hospital_name,last_updated_on,Version,hospital_location,hospital_address,license_number|MA,"To the best of its knowledge and belief, the hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date indicated.",,,,,,,,,,,,,,,,,,,,
"Southcoast Hospitals Group, Inc.",11/1/2024,2.0.0,St. Luke's Hospital,"101 Page St, New Bedford, MA 02740",V113,TRUE,,,,,,,,,,,,,,,,,,,,
description,code|1,code|1|type,code|2,code|2|type,code|3,code|3|type,code|4,code|4|type,setting,drug_unit_of_measurement,drug_type_of_measurement,standard_charge|gross,standard_charge|discounted_cash,payer_name,plan_name,modifiers,standard_charge|negotiated_dollar,standard_charge|negotiated_percentage,standard_charge|negotiated_algorithm,estimated_amount,standard_charge|min,standard_charge|max,standard_charge|methodology,additional_generic_notes,,
HC Semi-Private Unit,PX-12100001,CDM,12100001,LOCAL,121,RC,,,inpatient,,,1577,1103.9,AETNA [1000108],AETNA [100010801],,,77.2,,1217.444,525.9295,1261.6,percent of total billed charges,,,
HC Med/Surg Stepdown,PX-12100003,CDM,12100003,LOCAL,121,RC,,,inpatient,,,2423,1696.1,AETNA [1000108],AETNA [100010801],,,77.2,,1870.556,808.0705,1938.4,percent of total billed charges,,,
HC Maternity Unit,PX-12200001,CDM,12200001,LOCAL,122,RC,,,inpatient,,,2193,1535.1,AETNA [1000108],AETNA [100010801],,,77.2,,1692.996,731.3655,1754.4,percent of total billed charges,,,
HC Pediatric Semi-Private Unit,PX-12300001,CDM,12300001,LOCAL,123,RC,,,inpatient,,,3323,2326.1,AETNA [1000108],AETNA [100010801],,,77.2,,2565.356,1108.2205,2658.4,percent of total billed charges,,,
HC S.E. Rehab Semi-Private Unit,PX-12800001,CDM,12800001,LOCAL,128,RC,,,inpatient,,,1783,1248.1,AETNA [1000108],AETNA [100010801],,,77.2,,1376.476,594.6305,2483,percent of total billed charges,,,
HC Nursery,PX-17000001,CDM,17000001,LOCAL,170,RC,,,inpatient,,,1333,933.1,AETNA [1000108],AETNA [100010801],,,77.2,,1029.076,444.5555,1066.4,percent of total billed charges,,,
HC Nursery Boarder,PX-17900001,CDM,17900001,LOCAL,179,RC,,,inpatient,,,1195,836.5,AETNA [1000108],AETNA [100010801],,,77.2,,922.54,398.5325,956,percent of total billed charges,,,
HC Icu/Ccu Unit,PX-20000001,CDM,20000001,LOCAL,200,RC,,,inpatient,,,4009,2806.3,AETNA [1000108],AETNA [100010801],,,77.2,,3094.948,1337.0015,3207.2,percent of total billed charges,,,
HC Icu Surgical Unit,PX-20100001,CDM,20100001,LOCAL,201,RC,,,inpatient,,,3646,2552.2,AETNA [1000108],AETNA [100010801],,,77.2,,2814.712,1215.941,2916.8,percent of total billed charges,,,
HC Telemetry Unit,PX-20600001,CDM,20600001,LOCAL,206,RC,,,inpatient,,,2015,1410.5,AETNA [1000108],AETNA [100010801],,,77.2,,1555.58,672.0025,1612,percent of total billed charges,,,
HC Trauma,PX-20800001,CDM,20800001,LOCAL,208,RC,,,inpatient,,,4810,3367,AETNA [1000108],AETNA [100010801],,,77.2,,3713.32,1604.135,3848,percent of total billed charges,,,
HC Onc. Vad Kit,PX-27000020,CDM,27000020,LOCAL,270,RC,,,inpatient,,,90,63,AETNA [1000108],AETNA [100010801],,,77.2,,69.48,20.205,72,percent of total billed charges,,,
HC Imed Pump for Lvl II,PX-27000021,CDM,27000021,LOCAL,270,RC,,,inpatient,,,118,82.6,AETNA [1000108],AETNA [100010801],,,77.2,,91.096,26.491,94.4,percent of total billed charges,,,
HC Imed Pump,PX-27000022,CDM,27000022,LOCAL,270,RC,,,inpatient,,,113,79.1,AETNA [1000108],AETNA [100010801],,,77.2,,87.236,25.3685,90.4,percent of total billed charges,,,
HC Local Anesth Supplies,PX-27000023,CDM,27000023,LOCAL,270,RC,,,inpatient,,,80,56,AETNA [1000108],AETNA [100010801],,,77.2,,61.76,17.96,64,percent of total billed charges,,,
HC Periop O2,PX-27000044,CDM,27000044,LOCAL,270,RC,,,inpatient,,,79,55.3,AETNA [1000108],AETNA [100010801],,,77.2,,60.988,17.7355,63.2,percent of total billed charges,,,
HC Bone Bx Kit,PX-27000050,CDM,27000050,LOCAL,270,RC,,,inpatient,,,267,186.9,AETNA [1000108],AETNA [100010801],,,77.2,,206.124,59.9415,213.6,percent of total billed charges,,,
HC Kit Portex Nerve Block,PX-27000051,CDM,27000051,LOCAL,270,RC,,,inpatient,,,90,63,AETNA [1000108],AETNA [100010801],,,77.2,,69.48,20.205,72,percent of total billed charges,,,
HC Cannister Vac W/O Gel Ats,PX-27000052,CDM,27000052,LOCAL,270,RC,,,inpatient,,,282,197.4,AETNA [1000108],AETNA [100010801],,,77.2,,217.704,63.309,225.6,percent of total billed charges,,,
HC Dressing Kci Small 5/Cs,PX-27000053,CDM,27000053,LOCAL,270,RC,,,inpatient,,,268,187.6,AETNA [1000108],AETNA [100010801],,,77.2,,206.896,60.166,214.4,percent of total billed charges,,,
HC Cannister W/Gel Ats,PX-27000054,CDM,27000054,LOCAL,270,RC,,,inpatient,,,283,198.1,AETNA [1000108],AETNA [100010801],,,77.2,,218.476,63.5335,226.4,percent of total billed charges,,,
HC Compression Stocking A6530,PX-27000055,CDM,27000055,LOCAL,270,RC,,,inpatient,,,285,199.5,AETNA [1000108],AETNA [100010801],,,77.2,,220.02,63.9825,228,percent of total billed charges,,,
HC Custom Molded Insert,PX-27000056,CDM,27000056,LOCAL,270,RC,,,inpatient,,,287,200.9,AETNA [1000108],AETNA [100010801],,,77.2,,221.564,64.4315,229.6,percent of total billed charges,,,
HC Dressing Kci Medium 10/Cs,PX-27000057,CDM,27000057,LOCAL,270,RC,,,inpatient,,,307,214.9,AETNA [1000108],AETNA [100010801],,,77.2,,237.004,68.9215,245.6,percent of total billed charges,,,
HC Surgical Boot/Shoe L3260,PX-27000058,CDM,27000058,LOCAL,270,RC,,,inpatient,,,423,296.1,AETNA [1000108],AETNA [100010801],,,77.2,,326.556,94.9635,338.4,percent of total billed charges,,,
HC Vaccum Assisted Closure Pump,PX-27000059,CDM,27000059,LOCAL,270,RC,,,inpatient,,,438,306.6,AETNA [1000108],AETNA [100010801],,,77.2,,338.136,98.331,350.4,percent of total billed charges,,,
HC Ortho Wedge Shoe,PX-27000060,CDM,27000060,LOCAL,270,RC,,,inpatient,,,529,370.3,AETNA [1000108],AETNA [100010801],,,77.2,,408.388,118.7605,423.2,percent of total billed charges,,,
HC Foot Pressure Support A9283,PX-27000061,CDM,27000061,LOCAL,270,RC,,,inpatient,,,529,370.3,AETNA [1000108],AETNA [100010801],,,77.2,,408.388,118.7605,423.2,percent of total billed charges,,,
HC Sensor Nicom,PX-27000062,CDM,27000062,LOCAL,270,RC,,,inpatient,,,816,571.2,AETNA [1000108],AETNA [100010801],,,77.2,,629.952,183.192,652.8,percent of total billed charges,,,
HC 6 Channel Pneumogram,PX-27000063,CDM,27000063,LOCAL,270,RC,,,inpatient,,,3884,2718.8,AETNA [1000108],AETNA [100010801],,,77.2,,2998.448,871.958,3107.2,percent of total billed charges,,,
HC Pneumogram 4-Channel,PX-27000064,CDM,27000064,LOCAL,270,RC,,,inpatient,,,4891,3423.7,AETNA [1000108],AETNA [100010801],,,77.2,,3775.852,1098.0295,3912.8,percent of total billed charges,,,
HC Pad Artic Gel Large,PX-27000065,CDM,27000065,LOCAL,270,RC,,,inpatient,,,5242,3669.4,AETNA [1000108],AETNA [100010801],,,77.2,,4046.824,1176.829,4193.6,percent of total billed charges,,,
HC Pneumogram 6- Channel,PX-27000066,CDM,27000066,LOCAL,270,RC,,,inpatient,,,5466,3826.2,AETNA [1000108],AETNA [100010801],,,77.2,,4219.752,1227.117,4372.8,percent of total billed charges,,,
HC Therapy Polar Cooler,PX-27000068,CDM,27000068,LOCAL,270,RC,,,inpatient,,,667,466.9,AETNA [1000108],AETNA [100010801],,,77.2,,514.924,149.7415,533.6,percent of total billed charges,,,
HC Liner Foam Permanently Med,PX-27000069,CDM,27000069,LOCAL,270,RC,,,inpatient,,,353,247.1,AETNA [1000108],AETNA [100010801],,,77.2,,272.516,79.2485,282.4,percent of total billed charges,,,
HC Dressing Kci Vac Small,PX-27000070,CDM,27000070,LOCAL,270,RC,,,inpatient,,,327,228.9,AETNA [1000108],AETNA [100010801],,,77.2,,252.444,73.4115,261.6,percent of total billed charges,,,
HC Dressing Kci Vac Large,PX-27000071,CDM,27000071,LOCAL,270,RC,,,inpatient,,,390,273,AETNA [1000108],AETNA [100010801],,,77.2,,301.08,87.555,312,percent of total billed charges,,,
HC Developmental Aides,PX-27000072,CDM,27000072,LOCAL,270,RC,,,inpatient,,,707,494.9,AETNA [1000108],AETNA [100010801],,,77.2,,545.804,158.7215,565.6,percent of total billed charges,,,
"HC Ez Reacher 30"" Suction",PX-27100004,CDM,27100004,LOCAL,271,RC,,,inpatient,,,144,100.8,AETNA [1000108],AETNA [100010801],,,77.2,,111.168,32.328,122.0544,percent of total billed charges,,,
HC Support Bra Ez-on Med 958,PX-27100005,CDM,27100005,LOCAL,271,RC,,,inpatient,,,262,183.4,AETNA [1000108],AETNA [100010801],,,77.2,,202.264,58.819,222.0712,percent of total billed charges,,,
HC Support Bra Ez-on Lrg 958,PX-27100006,CDM,27100006,LOCAL,271,RC,,,inpatient,,,272,190.4,AETNA [1000108],AETNA [100010801],,,77.2,,209.984,61.064,230.5472,percent of total billed charges,,,
HC Support Bra Ez-on X-Lrg 958,PX-27100007,CDM,27100007,LOCAL,271,RC,,,inpatient,,,306,214.2,AETNA [1000108],AETNA [100010801],,,77.2,,236.232,68.697,259.3656,percent of total billed charges,,,
HC Support Bra Ez-on Queen,PX-27100008,CDM,27100008,LOCAL,271,RC,,,inpatient,,,377,263.9,AETNA [1000108],AETNA [100010801],,,77.2,,291.044,84.6365,319.5452,percent of total billed charges,,,
HC Bra Ez-on Super Queen,PX-27100009,CDM,27100009,LOCAL,271,RC,,,inpatient,,,471,329.7,AETNA [1000108],AETNA [100010801],,,77.2,,363.612,105.7395,399.2196,percent of total billed charges,,,
HC Gradient Com Stocking,PX-27100010,CDM,27100010,LOCAL,271,RC,,,inpatient,,,490,343,AETNA [1000108],AETNA [100010801],,,77.2,,378.28,110.005,415.324,percent of total billed charges,,,
HC Kit Flexi Seal Fecal,PX-27100011,CDM,27100011,LOCAL,271,RC,,,inpatient,,,939,657.3,AETNA [1000108],AETNA [100010801],,,77.2,,724.908,210.8055,795.8964,percent of total billed charges,,,
HC Port Power Loc Access Kit,PX-27200054,CDM,27200054,LOCAL,272,RC,,,inpatient,,,88,61.6,AETNA [1000108],AETNA [100010801],,,77.2,,67.936,19.756,74.5888,percent of total billed charges,,,
HC Dressing Kci Vac White Lg,PX-27200055,CDM,27200055,LOCAL,272,RC,,,inpatient,,,95,66.5,AETNA [1000108],AETNA [100010801],,,77.2,,73.34,21.3275,80.522,percent of total billed charges,,,
HC Sheath Brite Tip 11cm,PX-27200056,CDM,27200056,LOCAL,272,RC,,,inpatient,,,108,75.6,AETNA [1000108],AETNA [100010801],,,77.2,,83.376,24.246,91.5408,percent of total billed charges,,,
HC Kit Refill Syncromed Sys. Pain,PX-27200057,CDM,27200057,LOCAL,272,RC,,,inpatient,,,128,89.6,AETNA [1000108],AETNA [100010801],,,77.2,,98.816,28.736,108.4928,percent of total billed charges,,,
HC Sock Fracture,PX-27200058,CDM,27200058,LOCAL,272,RC,,,inpatient,,,193,135.1,AETNA [1000108],AETNA [100010801],,,77.2,,148.996,43.3285,163.5868,percent of total billed charges,,,
HC Tube Gastrostomy Replacement,PX-27200059,CDM,27200059,LOCAL,272,RC,,,inpatient,,,195,136.5,AETNA [1000108],AETNA [100010801],,,77.2,,150.54,43.7775,165.282,percent of total billed charges,,,
HC Mod of Depth Shoe,PX-27200060,CDM,27200060,LOCAL,272,RC,,,inpatient,,,225,157.5,AETNA [1000108],AETNA [100010801],,,77.2,,173.7,50.5125,190.71,percent of total billed charges,,,
HC Catheter Broncho 39l,PX-27200061,CDM,27200061,LOCAL,272,RC,,,inpatient,,,349,244.3,AETNA [1000108],AETNA [100010801],,,77.2,,269.428,78.3505,295.8124,percent of total billed charges,,,
HC Catheter Bronch 35 Left 95892,PX-27200062,CDM,27200062,LOCAL,272,RC,,,inpatient,,,349,244.3,AETNA [1000108],AETNA [100010801],,,77.2,,269.428,78.3505,295.8124,percent of total billed charges,,,
HC Endo-Bronch Tube 37fr Left,PX-27200063,CDM,27200063,LOCAL,272,RC,,,inpatient,,,349,244.3,AETNA [1000108],AETNA [100010801],,,77.2,,269.428,78.3505,295.8124,percent of total billed charges,,,
HC Tube Endo Bronch #35 Left,PX-27200064,CDM,27200064,LOCAL,272,RC,,,inpatient,,,349,244.3,AETNA [1000108],AETNA [100010801],,,77.2,,269.428,78.3505,295.8124,percent of total billed charges,,,
HC Endo Bronch Tube #39,PX-27200065,CDM,27200065,LOCAL,272,RC,,,inpatient,,,349,244.3,AETNA [1000108],AETNA [100010801],,,77.2,,269.428,78.3505,295.8124,percent of total billed charges,,,
HC Catheter Broncho 41l,PX-27200066,CDM,27200066,LOCAL,272,RC,,,inpatient,,,349,244.3,AETNA [1000108],AETNA [100010801],,,77.2,,269.428,78.3505,295.8124,percent of total billed charges,,,
HC Kit Arterial Line Arrow,PX-27200067,CDM,27200067,LOCAL,272,RC,,,inpatient,,,349,244.3,AETNA [1000108],AETNA [100010801],,,77.2,,269.428,78.3505,295.8124,percent of total billed charges,,,
HC Cassette Kci Veralink,PX-27200068,CDM,27200068,LOCAL,272,RC,,,inpatient,,,357,249.9,AETNA [1000108],AETNA [100010801],,,77.2,,275.604,80.1465,302.5932,percent of total billed charges,,,
HC Shiley Trach Tube 6lpc,PX-27200069,CDM,27200069,LOCAL,272,RC,,,inpatient,,,357,249.9,AETNA [1000108],AETNA [100010801],,,77.2,,275.604,80.1465,302.5932,percent of total billed charges,,,
HC Tube Trach Shiley 8lpc,PX-27200070,CDM,27200070,LOCAL,272,RC,,,inpatient,,,357,249.9,AETNA [1000108],AETNA [100010801],,,77.2,,275.604,80.1465,302.5932,percent of total billed charges,,,
HC Catheter Single 4fr Bard,PX-27200071,CDM,27200071,LOCAL,272,RC,,,inpatient,,,374,261.8,AETNA [1000108],AETNA [100010801],,,77.2,,288.728,83.963,317.0024,percent of total billed charges,,,
HC Bivona #7 Trach Uncuffed,PX-27200072,CDM,27200072,LOCAL,272,RC,,,inpatient,,,396,277.2,AETNA [1000108],AETNA [100010801],,,77.2,,305.712,88.902,335.6496,percent of total billed charges,,,
HC Retractor C Section Large,PX-27200073,CDM,27200073,LOCAL,272,RC,,,inpatient,,,402,281.4,AETNA [1000108],AETNA [100010801],,,77.2,,310.344,90.249,340.7352,percent of total billed charges,,,
HC Midline 4fr Bd#384308,PX-27200074,CDM,27200074,LOCAL,272,RC,,,inpatient,,,409,286.3,AETNA [1000108],AETNA [100010801],,,77.2,,315.748,91.8205,346.6684,percent of total billed charges,,,
HC Transducer Triple W/Vamp Pls,PX-27200075,CDM,27200075,LOCAL,272,RC,,,inpatient,,,418,292.6,AETNA [1000108],AETNA [100010801],,,77.2,,322.696,93.841,354.2968,percent of total billed charges,,,
HC B Pleurx Drainage Kit,PX-27200076,CDM,27200076,LOCAL,272,RC,,,inpatient,,,417,291.9,AETNA [1000108],AETNA [100010801],,,77.2,,321.924,93.6165,353.4492,percent of total billed charges,,,
HC Catheter Swan Ganz J Pacing,PX-27200078,CDM,27200078,LOCAL,272,RC,,,inpatient,,,446,312.2,AETNA [1000108],AETNA [100010801],,,77.2,,344.312,100.127,378.0296,percent of total billed charges,,,
HC Tube Trach Distal Xlt 5.0,PX-27200079,CDM,27200079,LOCAL,272,RC,,,inpatient,,,451,315.7,AETNA [1000108],AETNA [100010801],,,77.2,,348.172,101.2495,382.2676,percent of total billed charges,,,
HC Tube Trach Distal Xlt 6.0,PX-27200080,CDM,27200080,LOCAL,272,RC,,,inpatient,,,466,326.2,AETNA [1000108],AETNA [100010801],,,77.2,,359.752,104.617,394.9816,percent of total billed charges,,,
HC Tube Trach 8 Cuff Non X Long,PX-27200081,CDM,27200081,LOCAL,272,RC,,,inpatient,,,466,326.2,AETNA [1000108],AETNA [100010801],,,77.2,,359.752,104.617,394.9816,percent of total billed charges,,,
HC Sling Sam Pelvic Medium,PX-27200082,CDM,27200082,LOCAL,272,RC,,,inpatient,,,470,329,AETNA [1000108],AETNA [100010801],,,77.2,,362.84,105.515,398.372,percent of total billed charges,,,
HC Set Tube Kaci Veratrac Duo,PX-27200083,CDM,27200083,LOCAL,272,RC,,,inpatient,,,488,341.6,AETNA [1000108],AETNA [100010801],,,77.2,,376.736,109.556,413.6288,percent of total billed charges,,,
HC Retractor C Section Xlarge,PX-27200084,CDM,27200084,LOCAL,272,RC,,,inpatient,,,516,361.2,AETNA [1000108],AETNA [100010801],,,77.2,,398.352,115.842,437.3616,percent of total billed charges,,,
HC Kit Mini 4fr Single Lumen,PX-27200085,CDM,27200085,LOCAL,272,RC,,,inpatient,,,519,363.3,AETNA [1000108],AETNA [100010801],,,77.2,,400.668,116.5155,439.9044,percent of total billed charges,,,
HC Trach Bivona Tis 6id,PX-27200086,CDM,27200086,LOCAL,272,RC,,,inpatient,,,523,366.1,AETNA [1000108],AETNA [100010801],,,77.2,,403.756,117.4135,443.2948,percent of total billed charges,,,
HC Pack C Section Custom Disp,PX-27200087,CDM,27200087,LOCAL,272,RC,,,inpatient,,,541,378.7,AETNA [1000108],AETNA [100010801],,,77.2,,417.652,121.4545,458.5516,percent of total billed charges,,,
HC Trach Bivona Tts 8mm,PX-27200088,CDM,27200088,LOCAL,272,RC,,,inpatient,,,541,378.7,AETNA [1000108],AETNA [100010801],,,77.2,,417.652,121.4545,458.5516,percent of total billed charges,,,
HC Trach Bivona 7.5 X 10,PX-27200089,CDM,27200089,LOCAL,272,RC,,,inpatient,,,556,389.2,AETNA [1000108],AETNA [100010801],,,77.2,,429.232,124.822,471.2656,percent of total billed charges,,,
HC Tube Feeding Mic Key 14f 1.7,PX-27200091,CDM,27200091,LOCAL,272,RC,,,inpatient,,,674,471.8,AETNA [1000108],AETNA [100010801],,,77.2,,520.328,151.313,571.2824,percent of total billed charges,,,
HC Kit Mic-Key G Feeding 16-3.5,PX-27200092,CDM,27200092,LOCAL,272,RC,,,inpatient,,,694,485.8,AETNA [1000108],AETNA [100010801],,,77.2,,535.768,155.803,588.2344,percent of total billed charges,,,
HC Kit Mic-Key G Feeding 24-3.5,PX-27200093,CDM,27200093,LOCAL,272,RC,,,inpatient,,,694,485.8,AETNA [1000108],AETNA [100010801],,,77.2,,535.768,155.803,588.2344,percent of total billed charges,,,
HC Mic Key G Tube 20fr 3.5cm,PX-27200094,CDM,27200094,LOCAL,272,RC,,,inpatient,,,694,485.8,AETNA [1000108],AETNA [100010801],,,77.2,,535.768,155.803,588.2344,percent of total billed charges,,,
HC Device Support Foot,PX-27200095,CDM,27200095,LOCAL,272,RC,,,inpatient,,,703,492.1,AETNA [1000108],AETNA [100010801],,,77.2,,542.716,157.8235,595.8628,percent of total billed charges,,,
HC Catheter 4 Fr Mid Line,PX-27200096,CDM,27200096,LOCAL,272,RC,,,inpatient,,,719,503.3,AETNA [1000108],AETNA [100010801],,,77.2,,555.068,161.4155,609.4244,percent of total billed charges,,,
HC Tcc Size 3,PX-27200097,CDM,27200097,LOCAL,272,RC,,,inpatient,,,722,505.4,AETNA [1000108],AETNA [100010801],,,77.2,,557.384,162.089,611.9672,percent of total billed charges,,,
HC Femostop Gold Compress Sys,PX-27200098,CDM,27200098,LOCAL,272,RC,,,inpatient,,,731,511.7,AETNA [1000108],AETNA [100010801],,,77.2,,564.332,164.1095,619.5956,percent of total billed charges,,,
HC Dot Poly Midline 4fr Sl Full,PX-27200099,CDM,27200099,LOCAL,272,RC,,,inpatient,,,765,535.5,AETNA [1000108],AETNA [100010801],,,77.2,,590.58,171.7425,648.414,percent of total billed charges,,,
HC Powerwand 5fr 10cm,PX-27200100,CDM,27200100,LOCAL,272,RC,,,inpatient,,,776,543.2,AETNA [1000108],AETNA [100010801],,,77.2,,599.072,174.212,657.7376,percent of total billed charges,,,
HC Powerwand Single Sterile 5fr,PX-27200101,CDM,27200101,LOCAL,272,RC,,,inpatient,,,776,543.2,AETNA [1000108],AETNA [100010801],,,77.2,,599.072,174.212,657.7376,percent of total billed charges,,,
HC Needle Intraosseous Pd 15g,PX-27200102,CDM,27200102,LOCAL,272,RC,,,inpatient,,,845,591.5,AETNA [1000108],AETNA [100010801],,,77.2,,652.34,189.7025,716.222,percent of total billed charges,,,
HC Needle Intraosseous Ad 15g,PX-27200103,CDM,27200103,LOCAL,272,RC,,,inpatient,,,845,591.5,AETNA [1000108],AETNA [100010801],,,77.2,,652.34,189.7025,716.222,percent of total billed charges,,,
HC Needle Intraosseous,PX-27200104,CDM,27200104,LOCAL,272,RC,,,inpatient,,,845,591.5,AETNA [1000108],AETNA [100010801],,,77.2,,652.34,189.7025,716.222,percent of total billed charges,,,
HC Kit Triple Lumen Cath 7 X 6,PX-27200105,CDM,27200105,LOCAL,272,RC,,,inpatient,,,895,626.5,AETNA [1000108],AETNA [100010801],,,77.2,,690.94,200.9275,758.602,percent of total billed charges,,,
HC Multi Lumen Cvc Kit Toh Cust,PX-27200106,CDM,27200106,LOCAL,272,RC,,,inpatient,,,895,626.5,AETNA [1000108],AETNA [100010801],,,77.2,,690.94,200.9275,758.602,percent of total billed charges,,,
HC Pad Zoll Aed Cprd Access Kit,PX-27200107,CDM,27200107,LOCAL,272,RC,,,inpatient,,,827,578.9,AETNA [1000108],AETNA [100010801],,,77.2,,638.444,185.6615,700.9652,percent of total billed charges,,,
HC Kit Flexi Seal Fecal,PX-27200108,CDM,27200108,LOCAL,272,RC,,,inpatient,,,939,657.3,AETNA [1000108],AETNA [100010801],,,77.2,,724.908,210.8055,795.8964,percent of total billed charges,,,
HC Powerwand Quick Kit 5fr,PX-27200109,CDM,27200109,LOCAL,272,RC,,,inpatient,,,979,685.3,AETNA [1000108],AETNA [100010801],,,77.2,,755.788,219.7855,829.8004,percent of total billed charges,,,
HC Mahurkar Dual Lumen Subclav Ca,PX-27200110,CDM,27200110,LOCAL,272,RC,,,inpatient,,,1581,1106.7,AETNA [1000108],AETNA [100010801],,,77.2,,1220.532,354.9345,1340.0556,percent of total billed charges,,,
HC Catheter With Curved Extension,PX-27200111,CDM,27200111,LOCAL,272,RC,,,inpatient,,,1581,1106.7,AETNA [1000108],AETNA [100010801],,,77.2,,1220.532,354.9345,1340.0556,percent of total billed charges,,,
HC Set Cath Cricothyroidotomy,PX-27200112,CDM,27200112,LOCAL,272,RC,,,inpatient,,,1136,795.2,AETNA [1000108],AETNA [100010801],,,77.2,,876.992,255.032,962.8736,percent of total billed charges,,,
HC Rusch Quick Trac Small 2.0,PX-27200113,CDM,27200113,LOCAL,272,RC,,,inpatient,,,1269,888.3,AETNA [1000108],AETNA [100010801],,,77.2,,979.668,284.8905,1075.6044,percent of total billed charges,,,
HC Set Prism Prewarm M100'2,PX-27200114,CDM,27200114,LOCAL,272,RC,,,inpatient,,,1319,923.3,AETNA [1000108],AETNA [100010801],,,77.2,,1018.268,296.1155,1117.9844,percent of total billed charges,,,
HC Set Prismaflex M100's,PX-27200115,CDM,27200115,LOCAL,272,RC,,,inpatient,,,1399,979.3,AETNA [1000108],AETNA [100010801],,,77.2,,1080.028,314.0755,1185.7924,percent of total billed charges,,,
HC Bakri Postpartum Balloon,PX-27200116,CDM,27200116,LOCAL,272,RC,,,inpatient,,,1408,985.6,AETNA [1000108],AETNA [100010801],,,77.2,,1086.976,316.096,1193.4208,percent of total billed charges,,,
HC Flo Trac Sensor Mhd6,PX-27200117,CDM,27200117,LOCAL,272,RC,,,inpatient,,,2027,1418.9,AETNA [1000108],AETNA [100010801],,,77.2,,1564.844,455.0615,1718.0852,percent of total billed charges,,,
HC Pad Universal Artic Gel,PX-27200118,CDM,27200118,LOCAL,272,RC,,,inpatient,,,2219,1553.3,AETNA [1000108],AETNA [100010801],,,77.2,,1713.068,498.1655,1880.8244,percent of total billed charges,,,
HC Cath Presep 8.5 Oximetry,PX-27200119,CDM,27200119,LOCAL,272,RC,,,inpatient,,,2602,1821.4,AETNA [1000108],AETNA [100010801],,,77.2,,2008.744,584.149,2205.4552,percent of total billed charges,,,
HC Set Cricothyrotomy Cath,PX-27200120,CDM,27200120,LOCAL,272,RC,,,inpatient,,,2943,2060.1,AETNA [1000108],AETNA [100010801],,,77.2,,2271.996,660.7035,2494.4868,percent of total billed charges,,,
HC Pad Artic Gel Small,PX-27200121,CDM,27200121,LOCAL,272,RC,,,inpatient,,,5565,3895.5,AETNA [1000108],AETNA [100010801],,,77.2,,4296.18,1249.3425,4716.894,percent of total billed charges,,,
HC Pad Gel Artic Medium,PX-27200122,CDM,27200122,LOCAL,272,RC,,,inpatient,,,5512,3858.4,AETNA [1000108],AETNA [100010801],,,77.2,,4255.264,1237.444,4671.9712,percent of total billed charges,,,
HC Rhino G2 Blue,PX-27200123,CDM,27200123,LOCAL,272,RC,,,inpatient,,,4120,2884,AETNA [1000108],AETNA [100010801],,,77.2,,3180.64,924.94,3492.112,percent of total billed charges,,,
HC Pad Artic Gel Lrg,PX-27200124,CDM,27200124,LOCAL,272,RC,,,inpatient,,,5512,3858.4,AETNA [1000108],AETNA [100010801],,,77.2,,4255.264,1237.444,4671.9712,percent of total billed charges,,,
HC Bag External Drainage Collect,PX-27200125,CDM,27200125,LOCAL,272,RC,,,inpatient,,,1349,944.3,AETNA [1000108],AETNA [100010801],,,77.2,,1041.428,302.8505,1143.4124,percent of total billed charges,,,
HC Catheter Thoracic 28fr,PX-27200126,CDM,27200126,LOCAL,272,RC,,,inpatient,,,39,27.3,AETNA [1000108],AETNA [100010801],,,77.2,,30.108,8.7555,33.0564,percent of total billed charges,,,
HC Tube Endo Bronch Left 37,PX-27200127,CDM,27200127,LOCAL,272,RC,,,inpatient,,,349,244.3,AETNA [1000108],AETNA [100010801],,,77.2,,269.428,78.3505,295.8124,percent of total billed charges,,,
HC Electrode Temporary Pacing 6,PX-27200128,CDM,27200128,LOCAL,272,RC,,,inpatient,,,1238,866.6,AETNA [1000108],AETNA [100010801],,,77.2,,955.736,277.931,1049.3288,percent of total billed charges,,,
HC Set Pneumothorax,PX-27200129,CDM,27200129,LOCAL,272,RC,,,inpatient,,,1113,779.1,AETNA [1000108],AETNA [100010801],,,77.2,,859.236,249.8685,943.3788,percent of total billed charges,,,
HC System External Drainage III,PX-27200130,CDM,27200130,LOCAL,272,RC,,,inpatient,,,1887,1320.9,AETNA [1000108],AETNA [100010801],,,77.2,,1456.764,423.6315,1599.4212,percent of total billed charges,,,
HC Electrode Temporary Pacing 5,PX-27200131,CDM,27200131,LOCAL,272,RC,,,inpatient,,,1097,767.9,AETNA [1000108],AETNA [100010801],,,77.2,,846.884,246.2765,929.8172,percent of total billed charges,,,
HC Tray Tru Close Thoracic Vent,PX-27200132,CDM,27200132,LOCAL,272,RC,,,inpatient,,,1504,1052.8,AETNA [1000108],AETNA [100010801],,,77.2,,1161.088,337.648,1274.7904,percent of total billed charges,,,
HC Tube Trach Flex Laser 6.0 Mm,PX-27200133,CDM,27200133,LOCAL,272,RC,,,inpatient,,,319,223.3,AETNA [1000108],AETNA [100010801],,,77.2,,246.268,71.6155,270.3844,percent of total billed charges,,,
HC Pack Cesarean Custom,PX-27200134,CDM,27200134,LOCAL,272,RC,,,inpatient,,,462,323.4,AETNA [1000108],AETNA [100010801],,,77.2,,356.664,103.719,391.5912,percent of total billed charges,,,
HC Hemostat Instat 1gm,PX-27200135,CDM,27200135,LOCAL,272,RC,,,inpatient,,,1077,753.9,AETNA [1000108],AETNA [100010801],,,77.2,,831.444,241.7865,912.8652,percent of total billed charges,,,
HC Tube Trach Distal Xlt 7.0,PX-27200136,CDM,27200136,LOCAL,272,RC,,,inpatient,,,486,340.2,AETNA [1000108],AETNA [100010801],,,77.2,,375.192,109.107,411.9336,percent of total billed charges,,,
HC Surgicel 2 X 14 #1951,PX-27200137,CDM,27200137,LOCAL,272,RC,,,inpatient,,,447,312.9,AETNA [1000108],AETNA [100010801],,,77.2,,345.084,100.3515,378.8772,percent of total billed charges,,,
HC Ligator Saeed Sx Shoot,PX-27200138,CDM,27200138,LOCAL,272,RC,,,inpatient,,,1332,932.4,AETNA [1000108],AETNA [100010801],,,77.2,,1028.304,299.034,1129.0032,percent of total billed charges,,,
HC Cath Swan Ganz 7.5 Vip Port,PX-27200139,CDM,27200139,LOCAL,272,RC,,,inpatient,,,297,207.9,AETNA [1000108],AETNA [100010801],,,77.2,,229.284,66.6765,251.7372,percent of total billed charges,,,
HC Cath Multilumen Access,PX-27200140,CDM,27200140,LOCAL,272,RC,,,inpatient,,,537,375.9,AETNA [1000108],AETNA [100010801],,,77.2,,414.564,120.5565,455.1612,percent of total billed charges,,,
HC Trach Bivona Tts 7mm,PX-27200141,CDM,27200141,LOCAL,272,RC,,,inpatient,,,565,395.5,AETNA [1000108],AETNA [100010801],,,77.2,,436.18,126.8425,478.894,percent of total billed charges,,,
HC Kit Pleurx Drainage W Bottle,PX-27200142,CDM,27200142,LOCAL,272,RC,,,inpatient,,,417,291.9,AETNA [1000108],AETNA [100010801],,,77.2,,321.924,93.6165,353.4492,percent of total billed charges,,,
HC Retractor Wound Alexis Lrg,PX-27200143,CDM,27200143,LOCAL,272,RC,,,inpatient,,,412,288.4,AETNA [1000108],AETNA [100010801],,,77.2,,318.064,92.494,349.2112,percent of total billed charges,,,
HC Unit Cold Therapy Deroyal,PX-27200144,CDM,27200144,LOCAL,272,RC,,,inpatient,,,691,483.7,AETNA [1000108],AETNA [100010801],,,77.2,,533.452,155.1295,585.6916,percent of total billed charges,,,
HC Dressing Kci Vac Silver Med,PX-27200145,CDM,27200145,LOCAL,272,RC,,,inpatient,,,506,354.2,AETNA [1000108],AETNA [100010801],,,77.2,,390.632,113.597,428.8856,percent of total billed charges,,,
HC Kit Midline Cath 20ga X 20cm,PX-27200146,CDM,27200146,LOCAL,272,RC,,,inpatient,,,424,296.8,AETNA [1000108],AETNA [100010801],,,77.2,,327.328,95.188,359.3824,percent of total billed charges,,,
HC Cath Mahurkar 3 Lumen 12x20,PX-27200147,CDM,27200147,LOCAL,272,RC,,,inpatient,,,594,415.8,AETNA [1000108],AETNA [100010801],,,77.2,,458.568,133.353,503.4744,percent of total billed charges,,,
HC Retractor Alexis Wound Xlg,PX-27200148,CDM,27200148,LOCAL,272,RC,,,inpatient,,,529,370.3,AETNA [1000108],AETNA [100010801],,,77.2,,408.388,118.7605,448.3804,percent of total billed charges,,,
HC Surgiflo Hemostatic Matrix,PX-27200149,CDM,27200149,LOCAL,272,RC,,,inpatient,,,906,634.2,AETNA [1000108],AETNA [100010801],,,77.2,,699.432,203.397,767.9256,percent of total billed charges,,,
HC Kit Monitoring Press Abviser,PX-27200150,CDM,27200150,LOCAL,272,RC,,,inpatient,,,648,453.6,AETNA [1000108],AETNA [100010801],,,77.2,,500.256,145.476,549.2448,percent of total billed charges,,,
HC Tray Fuhrman Pleural Drain,PX-27200151,CDM,27200151,LOCAL,272,RC,,,inpatient,,,990,693,AETNA [1000108],AETNA [100010801],,,77.2,,764.28,222.255,839.124,percent of total billed charges,,,
HC Kit Cath Triple Lumen 20cm,PX-27200152,CDM,27200152,LOCAL,272,RC,,,inpatient,,,865,605.5,AETNA [1000108],AETNA [100010801],,,77.2,,667.78,194.1925,733.174,percent of total billed charges,,,
HC Dressing Kci Simplace Med,PX-27200153,CDM,27200153,LOCAL,272,RC,,,inpatient,,,433,303.1,AETNA [1000108],AETNA [100010801],,,77.2,,334.276,97.2085,367.0108,percent of total billed charges,,,
HC Tube Non Balloon Replace Peg,PX-27200154,CDM,27200154,LOCAL,272,RC,,,inpatient,,,394,275.8,AETNA [1000108],AETNA [100010801],,,77.2,,304.168,88.453,333.9544,percent of total billed charges,,,
HC Cath 12fr Hp Triple Lumen,PX-27200155,CDM,27200155,LOCAL,272,RC,,,inpatient,,,606,424.2,AETNA [1000108],AETNA [100010801],,,77.2,,467.832,136.047,513.6456,percent of total billed charges,,,
HC Cath Pneumothorax Ak01500,PX-27200156,CDM,27200156,LOCAL,272,RC,,,inpatient,,,700,490,AETNA [1000108],AETNA [100010801],,,77.2,,540.4,157.15,593.32,percent of total billed charges,,,
HC Kit Cranial Access 826614,PX-27200158,CDM,27200158,LOCAL,272,RC,,,inpatient,,,2205,1543.5,AETNA [1000108],AETNA [100010801],,,77.2,,1702.26,495.0225,1868.958,percent of total billed charges,,,
"HC Sensor Flotrac W Vamp 60""",PX-27200159,CDM,27200159,LOCAL,272,RC,,,inpatient,,,1336,935.2,AETNA [1000108],AETNA [100010801],,,77.2,,1031.392,299.932,1132.3936,percent of total billed charges,,,
HC Trach Lg 4.0 Quick Rusch,PX-27200160,CDM,27200160,LOCAL,272,RC,,,inpatient,,,1094,765.8,AETNA [1000108],AETNA [100010801],,,77.2,,844.568,245.603,927.2744,percent of total billed charges,,,
HC Tray Pericardiocentesis Stra,PX-27200161,CDM,27200161,LOCAL,272,RC,,,inpatient,,,1188,831.6,AETNA [1000108],AETNA [100010801],,,77.2,,917.136,266.706,1006.9488,percent of total billed charges,,,
HC Trocar Endo Ethicon 12 512sd,PX-27200162,CDM,27200162,LOCAL,272,RC,,,inpatient,,,1154,807.8,AETNA [1000108],AETNA [100010801],,,77.2,,890.888,259.073,978.1304,percent of total billed charges,,,
HC Tube Laryngectomy 12mm Metal,PX-27200163,CDM,27200163,LOCAL,272,RC,,,inpatient,,,1154,807.8,AETNA [1000108],AETNA [100010801],,,77.2,,890.888,259.073,978.1304,percent of total billed charges,,,
HC Tray Midline CT 4f 20cm Single,PX-27200164,CDM,27200164,LOCAL,272,RC,,,inpatient,,,785,549.5,AETNA [1000108],AETNA [100010801],,,77.2,,606.02,176.2325,665.366,percent of total billed charges,,,
HC Tray Midline CT 5f 20cm Dual,PX-27200165,CDM,27200165,LOCAL,272,RC,,,inpatient,,,779,545.3,AETNA [1000108],AETNA [100010801],,,77.2,,601.388,174.8855,660.2804,percent of total billed charges,,,
HC Mahurkar Triple Lumen Cath Tray #16,PX-27200166,CDM,27200166,LOCAL,272,RC,,,inpatient,,,1191,833.7,AETNA [1000108],AETNA [100010801],,,77.2,,919.452,267.3795,1009.4916,percent of total billed charges,,,
HC Mahurkar Triple Lumen Cath Tray #20,PX-27200167,CDM,27200167,LOCAL,272,RC,,,inpatient,,,983,688.1,AETNA [1000108],AETNA [100010801],,,77.2,,758.876,220.6835,833.1908,percent of total billed charges,,,
HC Compartment Pressure Monitoring Kit,PX-27200168,CDM,27200168,LOCAL,272,RC,,,inpatient,,,457,319.9,AETNA [1000108],AETNA [100010801],,,77.2,,352.804,102.5965,387.3532,percent of total billed charges,,,
HC Kit Perc Sheath Introducer 8.5,PX-27200169,CDM,27200169,LOCAL,272,RC,,,inpatient,,,471,329.7,AETNA [1000108],AETNA [100010801],,,77.2,,363.612,105.7395,399.2196,percent of total billed charges,,,
HC Cath Arrow Cvc Kit Latex Free,PX-27200170,CDM,27200170,LOCAL,272,RC,,,inpatient,,,465,325.5,AETNA [1000108],AETNA [100010801],,,77.2,,358.98,104.3925,394.134,percent of total billed charges,,,
HC Electrode Temporary Pacing 4,PX-27200171,CDM,27200171,LOCAL,272,RC,,,inpatient,,,823,576.1,AETNA [1000108],AETNA [100010801],,,77.2,,635.356,184.7635,697.5748,percent of total billed charges,,,
HC Catheter Bipolar Pacing 5,PX-27200172,CDM,27200172,LOCAL,272,RC,,,inpatient,,,619,433.3,AETNA [1000108],AETNA [100010801],,,77.2,,477.868,138.9655,524.6644,percent of total billed charges,,,
HC Set Emergency Pneumothorax,PX-27200173,CDM,27200173,LOCAL,272,RC,,,inpatient,,,795,556.5,AETNA [1000108],AETNA [100010801],,,77.2,,613.74,178.4775,673.842,percent of total billed charges,,,
HC Kit Pneumothorax,PX-27200174,CDM,27200174,LOCAL,272,RC,,,inpatient,,,722,505.4,AETNA [1000108],AETNA [100010801],,,77.2,,557.384,162.089,611.9672,percent of total billed charges,,,
HC Impella Purge Cassette,PX-27200175,CDM,27200175,LOCAL,272,RC,,,inpatient,,,245,171.5,AETNA [1000108],AETNA [100010801],,,77.2,,189.14,55.0025,207.662,percent of total billed charges,,,
HC Tray Midline CT 4f 20cm Singl,PX-27200176,CDM,27200176,LOCAL,272,RC,,,inpatient,,,954,667.8,AETNA [1000108],AETNA [100010801],,,77.2,,736.488,214.173,808.6104,percent of total billed charges,,,
HC Tray Midline CT 5f 20cm Dual F,PX-27200177,CDM,27200177,LOCAL,272,RC,,,inpatient,,,1154,807.8,AETNA [1000108],AETNA [100010801],,,77.2,,890.888,259.073,978.1304,percent of total billed charges,,,
HC Kit Microez Mst Nitinol 4.5 7c,PX-27200178,CDM,27200178,LOCAL,272,RC,,,inpatient,,,497,347.9,AETNA [1000108],AETNA [100010801],,,77.2,,383.684,111.5765,421.2572,percent of total billed charges,,,
HC Kit Microez Mst 5f Nsx,PX-27200179,CDM,27200179,LOCAL,272,RC,,,inpatient,,,251,175.7,AETNA [1000108],AETNA [100010801],,,77.2,,193.772,56.3495,212.7476,percent of total billed charges,,,
HC Electrode One Step Cpr Adult,PX-27200180,CDM,27200180,LOCAL,272,RC,,,inpatient,,,408,285.6,AETNA [1000108],AETNA [100010801],,,77.2,,314.976,91.596,345.8208,percent of total billed charges,,,
HC Electrode One Step Pediatric,PX-27200181,CDM,27200181,LOCAL,272,RC,,,inpatient,,,447,312.9,AETNA [1000108],AETNA [100010801],,,77.2,,345.084,100.3515,378.8772,percent of total billed charges,,,
HC Ambu® Ascopetm 4 Broncho Large (5.8/2.8),PX-27200196,CDM,27200196,LOCAL,272,RC,,,inpatient,,,359,251.3,AETNA [1000108],AETNA [100010801],,,77.2,,277.148,80.5955,304.2884,percent of total billed charges,,,
HC Ambu® Ascopetm 4 Broncho Regular (5.0/2.2),PX-27200197,CDM,27200197,LOCAL,272,RC,,,inpatient,,,312,218.4,AETNA [1000108],AETNA [100010801],,,77.2,,240.864,70.044,264.4512,percent of total billed charges,,,
HC Ambu® Ascopetm 4 Broncho Slim (3.8/1.2),PX-27200198,CDM,27200198,LOCAL,272,RC,,,inpatient,,,312,218.4,AETNA [1000108],AETNA [100010801],,,77.2,,240.864,70.044,264.4512,percent of total billed charges,,,
HC Tray Pneumothorax Turkel 9 Cm Sys,PX-27200199,CDM,27200199,LOCAL,272,RC,,,inpatient,,,622,435.4,AETNA [1000108],AETNA [100010801],,,77.2,,480.184,139.639,527.2072,percent of total billed charges,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400003,CDM,27400003,LOCAL,274,RC,,,inpatient,,,552,386.4,AETNA [1000108],AETNA [100010801],,,77.2,,426.144,123.924,467.8752,percent of total billed charges,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400005,CDM,27400005,LOCAL,274,RC,,,inpatient,,,1221,854.7,AETNA [1000108],AETNA [100010801],,,77.2,,942.612,274.1145,1034.9196,percent of total billed charges,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400008,CDM,27400008,LOCAL,274,RC,,,inpatient,,,3772,2640.4,AETNA [1000108],AETNA [100010801],,,77.2,,2911.984,846.814,3197.1472,percent of total billed charges,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400012,CDM,27400012,LOCAL,274,RC,,,inpatient,,,1954,1367.8,AETNA [1000108],AETNA [100010801],,,77.2,,1508.488,438.673,1656.2104,percent of total billed charges,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400015,CDM,27400015,LOCAL,274,RC,,,inpatient,,,3806,2664.2,AETNA [1000108],AETNA [100010801],,,77.2,,2938.232,854.447,3225.9656,percent of total billed charges,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400030,CDM,27400030,LOCAL,274,RC,,,inpatient,,,661,462.7,AETNA [1000108],AETNA [100010801],,,77.2,,510.292,148.3945,560.2636,percent of total billed charges,,,
HC Brace Knee Enhanced Trom,PX-27400038,CDM,27400038,LOCAL,274,RC,,,inpatient,,,570,399,AETNA [1000108],AETNA [100010801],,,77.2,,440.04,127.965,483.132,percent of total billed charges,,,
HC Brace Enhanced Trom Donjoy,PX-27400039,CDM,27400039,LOCAL,274,RC,,,inpatient,,,570,399,AETNA [1000108],AETNA [100010801],,,77.2,,440.04,127.965,483.132,percent of total billed charges,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400047,CDM,27400047,LOCAL,274,RC,,,inpatient,,,3385,2369.5,AETNA [1000108],AETNA [100010801],,,77.2,,2613.22,759.9325,2869.126,percent of total billed charges,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400050,CDM,27400050,LOCAL,274,RC,,,inpatient,,,3185,2229.5,AETNA [1000108],AETNA [100010801],,,77.2,,2458.82,715.0325,2699.606,percent of total billed charges,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400107,CDM,27400107,LOCAL,274,RC,,,inpatient,,,380,266,AETNA [1000108],AETNA [100010801],,,77.2,,293.36,85.31,322.088,percent of total billed charges,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400117,CDM,27400117,LOCAL,274,RC,,,inpatient,,,779,545.3,AETNA [1000108],AETNA [100010801],,,77.2,,601.388,174.8855,660.2804,percent of total billed charges,,,
HC Add. to Lower Extremity L2210,PX-27400184,CDM,27400184,LOCAL,274,RC,,,inpatient,,,330,231,AETNA [1000108],AETNA [100010801],,,77.2,,254.76,74.085,279.708,percent of total billed charges,,,
HC Lift Elevation Heel & Sole,PX-27400185,CDM,27400185,LOCAL,274,RC,,,inpatient,,,382,267.4,AETNA [1000108],AETNA [100010801],,,77.2,,294.904,85.759,323.7832,percent of total billed charges,,,
HC Add. Lower Extremity Orthosis,PX-27400186,CDM,27400186,LOCAL,274,RC,,,inpatient,,,448,313.6,AETNA [1000108],AETNA [100010801],,,77.2,,345.856,100.576,379.7248,percent of total billed charges,,,
HC Depth Shoe A5500,PX-27400187,CDM,27400187,LOCAL,274,RC,,,inpatient,,,473,331.1,AETNA [1000108],AETNA [100010801],,,77.2,,365.156,106.1885,400.9148,percent of total billed charges,,,
HC Compression Stocking A6533,PX-27400188,CDM,27400188,LOCAL,274,RC,,,inpatient,,,502,351.4,AETNA [1000108],AETNA [100010801],,,77.2,,387.544,112.699,425.4952,percent of total billed charges,,,
HC Collar L0172,PX-27400189,CDM,27400189,LOCAL,274,RC,,,inpatient,,,658,460.6,AETNA [1000108],AETNA [100010801],,,77.2,,507.976,147.721,557.7208,percent of total billed charges,,,
HC Ko Elastic Knee Joint L1820,PX-27400190,CDM,27400190,LOCAL,274,RC,,,inpatient,,,661,462.7,AETNA [1000108],AETNA [100010801],,,77.2,,510.292,148.3945,560.2636,percent of total billed charges,,,
HC Procedure Ortho Shoe/L3649,PX-27400191,CDM,27400191,LOCAL,274,RC,,,inpatient,,,703,492.1,AETNA [1000108],AETNA [100010801],,,77.2,,542.716,157.8235,595.8628,percent of total billed charges,,,
HC Air Cast Boot L4386,PX-27400192,CDM,27400192,LOCAL,274,RC,,,inpatient,,,745,521.5,AETNA [1000108],AETNA [100010801],,,77.2,,575.14,167.2525,631.462,percent of total billed charges,,,
HC Static Afa L4396,PX-27400193,CDM,27400193,LOCAL,274,RC,,,inpatient,,,785,549.5,AETNA [1000108],AETNA [100010801],,,77.2,,606.02,176.2325,665.366,percent of total billed charges,,,
HC Brace Tlso,PX-27400194,CDM,27400194,LOCAL,274,RC,,,inpatient,,,901,630.7,AETNA [1000108],AETNA [100010801],,,77.2,,695.572,202.2745,763.6876,percent of total billed charges,,,
HC Lumbar Corsette L0450,PX-27400195,CDM,27400195,LOCAL,274,RC,,,inpatient,,,915,640.5,AETNA [1000108],AETNA [100010801],,,77.2,,706.38,205.4175,775.554,percent of total billed charges,,,
HC Brace Warm and Form,PX-27400196,CDM,27400196,LOCAL,274,RC,,,inpatient,,,1117,781.9,AETNA [1000108],AETNA [100010801],,,77.2,,862.324,250.7665,946.7692,percent of total billed charges,,,
HC Afo L1940,PX-27400197,CDM,27400197,LOCAL,274,RC,,,inpatient,,,2560,1792,AETNA [1000108],AETNA [100010801],,,77.2,,1976.32,574.72,2169.856,percent of total billed charges,,,
HC Ankle Foot Orthosis L1940,PX-27400198,CDM,27400198,LOCAL,274,RC,,,inpatient,,,2560,1792,AETNA [1000108],AETNA [100010801],,,77.2,,1976.32,574.72,2169.856,percent of total billed charges,,,
HC POS OP Knee Brace L1832,PX-27400199,CDM,27400199,LOCAL,274,RC,,,inpatient,,,2974,2081.8,AETNA [1000108],AETNA [100010801],,,77.2,,2295.928,667.663,2520.7624,percent of total billed charges,,,
HC Afo Plastic L1960,PX-27400200,CDM,27400200,LOCAL,274,RC,,,inpatient,,,3011,2107.7,AETNA [1000108],AETNA [100010801],,,77.2,,2324.492,675.9695,2552.1236,percent of total billed charges,,,
HC Ankle/Foot Orthosis Afo,PX-27400201,CDM,27400201,LOCAL,274,RC,,,inpatient,,,3011,2107.7,AETNA [1000108],AETNA [100010801],,,77.2,,2324.492,675.9695,2552.1236,percent of total billed charges,,,
HC Left Afo Brace/Atlantic Pros,PX-27400202,CDM,27400202,LOCAL,274,RC,,,inpatient,,,3165,2215.5,AETNA [1000108],AETNA [100010801],,,77.2,,2443.38,710.5425,2682.654,percent of total billed charges,,,
HC Afo L1932,PX-27400203,CDM,27400203,LOCAL,274,RC,,,inpatient,,,3418,2392.6,AETNA [1000108],AETNA [100010801],,,77.2,,2638.696,767.341,2897.0968,percent of total billed charges,,,
HC Ankle Foot Orthosis L1970,PX-27400204,CDM,27400204,LOCAL,274,RC,,,inpatient,,,3462,2423.4,AETNA [1000108],AETNA [100010801],,,77.2,,2672.664,777.219,2934.3912,percent of total billed charges,,,
HC Back Brace Tlso Lo486,PX-27400205,CDM,27400205,LOCAL,274,RC,,,inpatient,,,6597,4617.9,AETNA [1000108],AETNA [100010801],,,77.2,,5092.884,1481.0265,5591.6172,percent of total billed charges,,,
HC Cervical Collar L0172,PX-27400206,CDM,27400206,LOCAL,274,RC,,,inpatient,,,658,460.6,AETNA [1000108],AETNA [100010801],,,77.2,,507.976,147.721,557.7208,percent of total billed charges,,,
HC Philly Collar No Extension,PX-27400207,CDM,27400207,LOCAL,274,RC,,,inpatient,,,658,460.6,AETNA [1000108],AETNA [100010801],,,77.2,,507.976,147.721,557.7208,percent of total billed charges,,,
HC Cervical Collar 2/Piece L0174,PX-27400208,CDM,27400208,LOCAL,274,RC,,,inpatient,,,1232,862.4,AETNA [1000108],AETNA [100010801],,,77.2,,951.104,276.584,1044.2432,percent of total billed charges,,,
HC Lumbar Orthosis L0627,PX-27400209,CDM,27400209,LOCAL,274,RC,,,inpatient,,,1750,1225,AETNA [1000108],AETNA [100010801],,,77.2,,1351,392.875,1483.3,percent of total billed charges,,,
HC Lso Sagoro Rigid Frame L0631,PX-27400210,CDM,27400210,LOCAL,274,RC,,,inpatient,,,3933,2753.1,AETNA [1000108],AETNA [100010801],,,77.2,,3036.276,882.9585,3333.6108,percent of total billed charges,,,
HC Lso Sagittal Coronal L0637,PX-27400211,CDM,27400211,LOCAL,274,RC,,,inpatient,,,4114,2879.8,AETNA [1000108],AETNA [100010801],,,77.2,,3176.008,923.593,3487.0264,percent of total billed charges,,,
HC Hip Abduction Orthosis L1686,PX-27400212,CDM,27400212,LOCAL,274,RC,,,inpatient,,,4461,3122.7,AETNA [1000108],AETNA [100010801],,,77.2,,3443.892,1001.4945,3781.1436,percent of total billed charges,,,
HC Knee Orthosis L1830,PX-27400213,CDM,27400213,LOCAL,274,RC,,,inpatient,,,466,326.2,AETNA [1000108],AETNA [100010801],,,77.2,,359.752,104.617,394.9816,percent of total billed charges,,,
HC Knee Orthosis L1832,PX-27400214,CDM,27400214,LOCAL,274,RC,,,inpatient,,,2974,2081.8,AETNA [1000108],AETNA [100010801],,,77.2,,2295.928,667.663,2520.7624,percent of total billed charges,,,
HC Knee Orthosis L1832,PX-27400215,CDM,27400215,LOCAL,274,RC,,,inpatient,,,2974,2081.8,AETNA [1000108],AETNA [100010801],,,77.2,,2295.928,667.663,2520.7624,percent of total billed charges,,,
HC Knee Osthosis L1832,PX-27400216,CDM,27400216,LOCAL,274,RC,,,inpatient,,,2974,2081.8,AETNA [1000108],AETNA [100010801],,,77.2,,2295.928,667.663,2520.7624,percent of total billed charges,,,
HC Afo L1930,PX-27400217,CDM,27400217,LOCAL,274,RC,,,inpatient,,,1062,743.4,AETNA [1000108],AETNA [100010801],,,77.2,,819.864,238.419,900.1512,percent of total billed charges,,,
HC Adj. Dorsal Splint L1930,PX-27400218,CDM,27400218,LOCAL,274,RC,,,inpatient,,,1062,743.4,AETNA [1000108],AETNA [100010801],,,77.2,,819.864,238.419,900.1512,percent of total billed charges,,,
HC L'nard Boot L1930,PX-27400219,CDM,27400219,LOCAL,274,RC,,,inpatient,,,1062,743.4,AETNA [1000108],AETNA [100010801],,,77.2,,819.864,238.419,900.1512,percent of total billed charges,,,
HC Hip Adj Ext L2624,PX-27400220,CDM,27400220,LOCAL,274,RC,,,inpatient,,,1445,1011.5,AETNA [1000108],AETNA [100010801],,,77.2,,1115.54,324.4025,1224.782,percent of total billed charges,,,
HC Bk Soft Interface L2820,PX-27400221,CDM,27400221,LOCAL,274,RC,,,inpatient,,,448,313.6,AETNA [1000108],AETNA [100010801],,,77.2,,345.856,100.576,379.7248,percent of total billed charges,,,
HC Lift Elevation L3332,PX-27400222,CDM,27400222,LOCAL,274,RC,,,inpatient,,,347,242.9,AETNA [1000108],AETNA [100010801],,,77.2,,267.884,77.9015,294.1172,percent of total billed charges,,,
HC Wrist Hand/Finger Ortho L3807,PX-27400223,CDM,27400223,LOCAL,274,RC,,,inpatient,,,1065,745.5,AETNA [1000108],AETNA [100010801],,,77.2,,822.18,239.0925,902.694,percent of total billed charges,,,
HC Wrist Cockup Nonmolded L3908,PX-27400224,CDM,27400224,LOCAL,274,RC,,,inpatient,,,353,247.1,AETNA [1000108],AETNA [100010801],,,77.2,,272.516,79.2485,299.2028,percent of total billed charges,,,
HC Orthosis Upper Limb Hum. Frac,PX-27400225,CDM,27400225,LOCAL,274,RC,,,inpatient,,,1413,989.1,AETNA [1000108],AETNA [100010801],,,77.2,,1090.836,317.2185,1197.6588,percent of total billed charges,,,
HC Walking Boot L4360,PX-27400226,CDM,27400226,LOCAL,274,RC,,,inpatient,,,1290,903,AETNA [1000108],AETNA [100010801],,,77.2,,995.88,289.605,1093.404,percent of total billed charges,,,
HC Walking Boot Prefab L4360,PX-27400227,CDM,27400227,LOCAL,274,RC,,,inpatient,,,1290,903,AETNA [1000108],AETNA [100010801],,,77.2,,995.88,289.605,1093.404,percent of total billed charges,,,
HC Walking Boot L4360,PX-27400228,CDM,27400228,LOCAL,274,RC,,,inpatient,,,2135,1494.5,AETNA [1000108],AETNA [100010801],,,77.2,,1648.22,479.3075,1809.626,percent of total billed charges,,,
HC Cam Walker L4386,PX-27400229,CDM,27400229,LOCAL,274,RC,,,inpatient,,,745,521.5,AETNA [1000108],AETNA [100010801],,,77.2,,575.14,167.2525,631.462,percent of total billed charges,,,
HC Bk Stump Shrinker L8440,PX-27400230,CDM,27400230,LOCAL,274,RC,,,inpatient,,,262,183.4,AETNA [1000108],AETNA [100010801],,,77.2,,202.264,58.819,222.0712,percent of total billed charges,,,
HC Stump Shrinker L8440,PX-27400231,CDM,27400231,LOCAL,274,RC,,,inpatient,,,262,183.4,AETNA [1000108],AETNA [100010801],,,77.2,,202.264,58.819,222.0712,percent of total billed charges,,,
HC Liner Foam Permanently Lg,PX-27400232,CDM,27400232,LOCAL,274,RC,,,inpatient,,,353,247.1,AETNA [1000108],AETNA [100010801],,,77.2,,272.516,79.2485,299.2028,percent of total billed charges,,,
HC Kit Electrode Pacing,PX-27500027,CDM,27500027,LOCAL,275,RC,,,inpatient,,,1286,900.2,AETNA [1000108],AETNA [100010801],,,77.2,,992.792,288.707,1090.0136,percent of total billed charges,,,
HC Medical/Surgical Supplies: Other Implants,PX-27800095,CDM,27800095,LOCAL,278,RC,,,inpatient,,,649,454.3,AETNA [1000108],AETNA [100010801],,,77.2,,501.028,145.7005,550.0924,percent of total billed charges,,,
HC Leg Post Rigid Brace/Sc Ortho,PX-27800096,CDM,27800096,LOCAL,278,RC,,,inpatient,,,758,530.6,AETNA [1000108],AETNA [100010801],,,77.2,,585.176,170.171,642.4808,percent of total billed charges,,,
HC Kit Picc 4fr per-Q Poly Cath,PX-27800097,CDM,27800097,LOCAL,278,RC,,,inpatient,,,1063,744.1,AETNA [1000108],AETNA [100010801],,,77.2,,820.636,238.6435,900.9988,percent of total billed charges,,,
HC Floseal Matrix Hemostatic,PX-27800098,CDM,27800098,LOCAL,278,RC,,,inpatient,,,1093,765.1,AETNA [1000108],AETNA [100010801],,,77.2,,843.796,245.3785,926.4268,percent of total billed charges,,,
HC Kit Picc 5fr per-Q Poly Cath,PX-27800099,CDM,27800099,LOCAL,278,RC,,,inpatient,,,1217,851.9,AETNA [1000108],AETNA [100010801],,,77.2,,939.524,273.2165,1031.5292,percent of total billed charges,,,
HC Tray Power Picc Dual 5f,PX-27800100,CDM,27800100,LOCAL,278,RC,,,inpatient,,,1355,948.5,AETNA [1000108],AETNA [100010801],,,77.2,,1046.06,304.1975,1148.498,percent of total billed charges,,,
HC Tray Power Picc Single 4f,PX-27800101,CDM,27800101,LOCAL,278,RC,,,inpatient,,,1398,978.6,AETNA [1000108],AETNA [100010801],,,77.2,,1079.256,313.851,1184.9448,percent of total billed charges,,,
HC Tray Power Picc Triple 5fr,PX-27800102,CDM,27800102,LOCAL,278,RC,,,inpatient,,,1474,1031.8,AETNA [1000108],AETNA [100010801],,,77.2,,1137.928,330.913,1249.3624,percent of total billed charges,,,
HC Tray Power Picc Triple 6f,PX-27800103,CDM,27800103,LOCAL,278,RC,,,inpatient,,,1499,1049.3,AETNA [1000108],AETNA [100010801],,,77.2,,1157.228,336.5255,1270.5524,percent of total billed charges,,,
HC Sepafilm/5x6,PX-27800104,CDM,27800104,LOCAL,278,RC,,,inpatient,,,1773,1241.1,AETNA [1000108],AETNA [100010801],,,77.2,,1368.756,398.0385,1502.7948,percent of total billed charges,,,
HC 3cg Power Picc Max 4fr Sl,PX-27800105,CDM,27800105,LOCAL,278,RC,,,inpatient,,,1585,1109.5,AETNA [1000108],AETNA [100010801],,,77.2,,1223.62,355.8325,1343.446,percent of total billed charges,,,
HC 3cg Power Picc Max 5fr Dl,PX-27800106,CDM,27800106,LOCAL,278,RC,,,inpatient,,,1636,1145.2,AETNA [1000108],AETNA [100010801],,,77.2,,1262.992,367.282,1386.6736,percent of total billed charges,,,
HC 3cg Power Picc Max 6fr Tl,PX-27800107,CDM,27800107,LOCAL,278,RC,,,inpatient,,,1749,1224.3,AETNA [1000108],AETNA [100010801],,,77.2,,1350.228,392.6505,1482.4524,percent of total billed charges,,,
HC Valve Passy Muir Aqua,PX-27800108,CDM,27800108,LOCAL,278,RC,,,inpatient,,,474,331.8,AETNA [1000108],AETNA [100010801],,,77.2,,365.928,106.413,401.7624,percent of total billed charges,,,
HC Passy Muir Valve - Clear,PX-27800113,CDM,27800113,LOCAL,278,RC,,,inpatient,,,474,331.8,AETNA [1000108],AETNA [100010801],,,77.2,,365.928,106.413,401.7624,percent of total billed charges,,,
HC Valve Passy Muir Purple,PX-27800114,CDM,27800114,LOCAL,278,RC,,,inpatient,,,474,331.8,AETNA [1000108],AETNA [100010801],,,77.2,,365.928,106.413,401.7624,percent of total billed charges,,,
HC Liner Foam Permanently X-Lg,PX-27800115,CDM,27800115,LOCAL,278,RC,,,inpatient,,,328,229.6,AETNA [1000108],AETNA [100010801],,,77.2,,253.216,73.636,278.0128,percent of total billed charges,,,
HC Tube Trach Proximal Xlt 7.0,PX-27800117,CDM,27800117,LOCAL,278,RC,,,inpatient,,,486,340.2,AETNA [1000108],AETNA [100010801],,,77.2,,375.192,109.107,411.9336,percent of total billed charges,,,
HC Barrier Seprafilm 3x5in,PX-27800118,CDM,27800118,LOCAL,278,RC,,,inpatient,,,1773,1241.1,AETNA [1000108],AETNA [100010801],,,77.2,,1368.756,398.0385,1502.7948,percent of total billed charges,,,
HC Tube Feeding Low Profile 20f,PX-27800119,CDM,27800119,LOCAL,278,RC,,,inpatient,,,694,485.8,AETNA [1000108],AETNA [100010801],,,77.2,,535.768,155.803,588.2344,percent of total billed charges,,,
HC Valve Speaking White #005,PX-27800121,CDM,27800121,LOCAL,278,RC,,,inpatient,,,474,331.8,AETNA [1000108],AETNA [100010801],,,77.2,,365.928,106.413,401.7624,percent of total billed charges,,,
HC Tray Percu Introducer 8.5fr,PX-27800122,CDM,27800122,LOCAL,278,RC,,,inpatient,,,475,332.5,AETNA [1000108],AETNA [100010801],,,77.2,,366.7,106.6375,402.61,percent of total billed charges,,,
HC Basket Zerotip Airway Retriv,PX-27800125,CDM,27800125,LOCAL,278,RC,,,inpatient,,,1710,1197,AETNA [1000108],AETNA [100010801],,,77.2,,1320.12,383.895,1449.396,percent of total billed charges,,,
HC Indwelling Prosthesis 20fr 8mm,PX-27800126,CDM,27800126,LOCAL,278,RC,,,inpatient,,,1327,928.9,AETNA [1000108],AETNA [100010801],,,77.2,,1024.444,297.9115,1124.7652,percent of total billed charges,,,
HC Indwelling Prosthesis 2.0,PX-27800127,CDM,27800127,LOCAL,278,RC,,,inpatient,,,1327,928.9,AETNA [1000108],AETNA [100010801],,,77.2,,1024.444,297.9115,1124.7652,percent of total billed charges,,,
HC Prosthesis Blom - 8mm,PX-27800128,CDM,27800128,LOCAL,278,RC,,,inpatient,,,1300,910,AETNA [1000108],AETNA [100010801],,,77.2,,1003.6,291.85,1101.88,percent of total billed charges,,,
HC Drug Collection,PX-30000005,CDM,30000005,LOCAL,300,RC,,,inpatient,,,32,22.4,AETNA [1000108],AETNA [100010801],,,77.2,,24.704,7.184,27.1232,percent of total billed charges,,,
HC Cardiac Mnr Thoracic Prcd,PX-36000003,CDM,36000003,LOCAL,360,RC,,,inpatient,,,142,99.4,AETNA [1000108],AETNA [100010801],,,77.2,,109.624,31.879,120.3592,percent of total billed charges,,,
HC Non-Pump Open Heart Other,PX-36000004,CDM,36000004,LOCAL,360,RC,,,inpatient,,,157,109.9,AETNA [1000108],AETNA [100010801],,,77.2,,121.204,35.2465,133.0732,percent of total billed charges,,,
HC Pump Procedure,PX-36000005,CDM,36000005,LOCAL,360,RC,,,inpatient,,,152,106.4,AETNA [1000108],AETNA [100010801],,,77.2,,117.344,34.124,128.8352,percent of total billed charges,,,
HC Non Pump Procedure,PX-36000006,CDM,36000006,LOCAL,360,RC,,,inpatient,,,208,145.6,AETNA [1000108],AETNA [100010801],,,77.2,,160.576,46.696,176.3008,percent of total billed charges,,,
HC Sub Minor Proc,PX-36000014,CDM,36000014,LOCAL,360,RC,,,inpatient,,,60,42,AETNA [1000108],AETNA [100010801],,,77.2,,46.32,13.47,50.856,percent of total billed charges,,,
HC Pain Mgmt Proc,PX-36000015,CDM,36000015,LOCAL,360,RC,,,inpatient,,,75,52.5,AETNA [1000108],AETNA [100010801],,,77.2,,57.9,16.8375,63.57,percent of total billed charges,,,
HC Endoscopy,PX-36000016,CDM,36000016,LOCAL,360,RC,,,inpatient,,,60,42,AETNA [1000108],AETNA [100010801],,,77.2,,46.32,13.47,50.856,percent of total billed charges,,,
HC Minor Proc,PX-36000017,CDM,36000017,LOCAL,360,RC,,,inpatient,,,75,52.5,AETNA [1000108],AETNA [100010801],,,77.2,,57.9,16.8375,63.57,percent of total billed charges,,,
HC Major Proc,PX-36000019,CDM,36000019,LOCAL,360,RC,,,inpatient,,,99,69.3,AETNA [1000108],AETNA [100010801],,,77.2,,76.428,22.2255,83.9124,percent of total billed charges,,,
HC Intensive Major Procedure,PX-36000020,CDM,36000020,LOCAL,360,RC,,,inpatient,,,140,98,AETNA [1000108],AETNA [100010801],,,77.2,,108.08,31.43,118.664,percent of total billed charges,,,
HC Ercp,PX-36000021,CDM,36000021,LOCAL,360,RC,,,inpatient,,,138,96.6,AETNA [1000108],AETNA [100010801],,,77.2,,106.536,30.981,116.9688,percent of total billed charges,,,
HC Cardiac Maj Thoracic Prcd,PX-36000022,CDM,36000022,LOCAL,360,RC,,,inpatient,,,159,111.3,AETNA [1000108],AETNA [100010801],,,77.2,,122.748,35.6955,134.7684,percent of total billed charges,,,
HC Anesthesia Block,PX-37000001,CDM,37000001,LOCAL,370,RC,,,inpatient,,,700,490,AETNA [1000108],AETNA [100010801],,,77.2,,540.4,157.15,593.32,percent of total billed charges,,,
HC Anesthesia Spinal,PX-37000002,CDM,37000002,LOCAL,370,RC,,,inpatient,,,850,595,AETNA [1000108],AETNA [100010801],,,77.2,,656.2,190.825,720.46,percent of total billed charges,,,
HC Anesthesia General Minor,PX-37000003,CDM,37000003,LOCAL,370,RC,,,inpatient,,,1662,1163.4,AETNA [1000108],AETNA [100010801],,,77.2,,1283.064,373.119,1408.7112,percent of total billed charges,,,
HC Anesthesia Epidural,PX-37000004,CDM,37000004,LOCAL,370,RC,,,inpatient,,,950,665,AETNA [1000108],AETNA [100010801],,,77.2,,733.4,213.275,805.22,percent of total billed charges,,,
HC Anesthesia General Major,PX-37000005,CDM,37000005,LOCAL,370,RC,,,inpatient,,,2924,2046.8,AETNA [1000108],AETNA [100010801],,,77.2,,2257.328,656.438,2478.3824,percent of total billed charges,,,
HC Anesthesia Gen/Epi,PX-37000006,CDM,37000006,LOCAL,370,RC,,,inpatient,,,1200,840,AETNA [1000108],AETNA [100010801],,,77.2,,926.4,269.4,1017.12,percent of total billed charges,,,
HC Anesthesia General Intensive,PX-37000007,CDM,37000007,LOCAL,370,RC,,,inpatient,,,4262,2983.4,AETNA [1000108],AETNA [100010801],,,77.2,,3290.264,956.819,3612.4712,percent of total billed charges,,,
HC Anesthesia General Cvs Bypass Pump,PX-37000008,CDM,37000008,LOCAL,370,RC,,,inpatient,,,9166,6416.2,AETNA [1000108],AETNA [100010801],,,77.2,,7076.152,2057.767,7769.1016,percent of total billed charges,,,
HC Anesthesia Mac,PX-37000009,CDM,37000009,LOCAL,370,RC,,,inpatient,,,1200,840,AETNA [1000108],AETNA [100010801],,,77.2,,926.4,269.4,1017.12,percent of total billed charges,,,
HC Endo Level I,PX-49000001,CDM,49000001,LOCAL,490,RC,,,inpatient,,,3749,2624.3,AETNA [1000108],AETNA [100010801],,,77.2,,2894.228,841.6505,3177.6524,percent of total billed charges,,,
HC Endo Level II,PX-49000002,CDM,49000002,LOCAL,490,RC,,,inpatient,,,5356,3749.2,AETNA [1000108],AETNA [100010801],,,77.2,,4134.832,1202.422,4539.7456,percent of total billed charges,,,
HC Endo Level III,PX-49000003,CDM,49000003,LOCAL,490,RC,,,inpatient,,,9641,6748.7,AETNA [1000108],AETNA [100010801],,,77.2,,7442.852,2164.4045,8171.7116,percent of total billed charges,,,
HC Recovery Room,PX-71000001,CDM,71000001,LOCAL,710,RC,,,inpatient,,,25,17.5,AETNA [1000108],AETNA [100010801],,,77.2,,19.3,5.6125,21.19,percent of total billed charges,,,
HC Second Stage Recovery per Minute,PX-71000002,CDM,71000002,LOCAL,710,RC,,,inpatient,,,22,15.4,AETNA [1000108],AETNA [100010801],,,77.2,,16.984,4.939,18.6472,percent of total billed charges,,,
HC Recovery - Sub Minor Proc,PX-71000003,CDM,71000003,LOCAL,710,RC,,,inpatient,,,23,16.1,AETNA [1000108],AETNA [100010801],,,77.2,,17.756,5.1635,19.4948,percent of total billed charges,,,
HC Recovery Rm - Minor Procedure,PX-71000004,CDM,71000004,LOCAL,710,RC,,,inpatient,,,28,19.6,AETNA [1000108],AETNA [100010801],,,77.2,,21.616,6.286,23.7328,percent of total billed charges,,,
HC Recovery Rm,PX-71000005,CDM,71000005,LOCAL,710,RC,,,inpatient,,,29,20.3,AETNA [1000108],AETNA [100010801],,,77.2,,22.388,6.5105,24.5804,percent of total billed charges,,,
HC Recovery Rm - Major Procedure,PX-71000006,CDM,71000006,LOCAL,710,RC,,,inpatient,,,33,23.1,AETNA [1000108],AETNA [100010801],,,77.2,,25.476,7.4085,27.9708,percent of total billed charges,,,
HC Recovery Rm - Intensive Major,PX-71000007,CDM,71000007,LOCAL,710,RC,,,inpatient,,,38,26.6,AETNA [1000108],AETNA [100010801],,,77.2,,29.336,8.531,32.2088,percent of total billed charges,,,
HC Extended Recovery Overnight,PX-71000009,CDM,71000009,LOCAL,710,RC,,,inpatient,,,1500,1050,AETNA [1000108],AETNA [100010801],,,77.2,,1158,336.75,1271.4,percent of total billed charges,,,
HC Observation Nursing Time,PX-76200006,CDM,76200006,LOCAL,762,RC,,,inpatient,,,101,70.7,AETNA [1000108],AETNA [100010801],,,77.2,,77.972,22.6745,6652,percent of total billed charges,,,
HC Tandem Dialysis,PX-80100001,CDM,80100001,LOCAL,801,RC,,,inpatient,,,1142,799.4,AETNA [1000108],AETNA [100010801],,,77.2,,881.624,256.379,967.9592,percent of total billed charges,,,
HC Single Dialysis,PX-80100002,CDM,80100002,LOCAL,801,RC,,,inpatient,,,1142,799.4,AETNA [1000108],AETNA [100010801],,,77.2,,881.624,256.379,967.9592,percent of total billed charges,,,
HC Unscheduled/Emergent Dialysis,PX-80100003,CDM,80100003,LOCAL,801,RC,,,inpatient,,,1142,799.4,AETNA [1000108],AETNA [100010801],,,77.2,,881.624,256.379,967.9592,percent of total billed charges,,,
HC Weekend/Holiday Dialysis,PX-80100004,CDM,80100004,LOCAL,801,RC,,,inpatient,,,1142,799.4,AETNA [1000108],AETNA [100010801],,,77.2,,881.624,256.379,967.9592,percent of total billed charges,,,
HC Capd per:Exchange,PX-80300001,CDM,80300001,LOCAL,803,RC,,,inpatient,,,569,398.3,AETNA [1000108],AETNA [100010801],,,77.2,,439.268,127.7405,482.2844,percent of total billed charges,,,
HC Ccpd ER,PX-80400001,CDM,80400001,LOCAL,804,RC,,,inpatient,,,569,398.3,AETNA [1000108],AETNA [100010801],,,77.2,,439.268,127.7405,482.2844,percent of total billed charges,,,
HC Ccpd,PX-80400002,CDM,80400002,LOCAL,804,RC,,,inpatient,,,1142,799.4,AETNA [1000108],AETNA [100010801],,,77.2,,881.624,256.379,967.9592,percent of total billed charges,,,
HC Dietary Services per 15 Mins,PX-99000006,CDM,99000006,LOCAL,990,RC,,,inpatient,,,29,20.3,AETNA [1000108],AETNA [100010801],,,77.2,,22.388,6.5105,24.5804,percent of total billed charges,,,
HC Hearing Aid Batteries,PX-99000034,CDM,99000034,LOCAL,479,RC,,,inpatient,,,7,4.9,AETNA [1000108],AETNA [100010801],,,77.2,,5.404,1.5715,163,percent of total billed charges,,,
HC Hearing Aid Tune Up,PX-99000037,CDM,99000037,LOCAL,479,RC,,,inpatient,,,43,30.1,AETNA [1000108],AETNA [100010801],,,77.2,,33.196,9.6535,163,percent of total billed charges,,,
HC Hearing Aid Fit,PX-99000038,CDM,99000038,LOCAL,479,RC,,,inpatient,,,171,119.7,AETNA [1000108],AETNA [100010801],,,77.2,,132.012,38.3895,163,percent of total billed charges,,,
HC Full Trauma No Notification,PX-45000633,CDM,TR450,LOCAL,450,RC,,,inpatient,,,10370,7259,AETNA [1000108],AETNA [100010801],,,77.2,,8005.64,399.86,9291.52,percent of total billed charges,,,
HC Partial Trauma No Notification,PX-45000634,CDM,TR450,LOCAL,450,RC,,,inpatient,,,7029,4920.3,AETNA [1000108],AETNA [100010801],,,77.2,,5426.388,399.86,6297.984,percent of total billed charges,,,
Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face- Mouth And Neck With Major O.R. Procedures,3,MS-DRG,,,,,,,inpatient,,,404600.26,283220.182,AETNA [1000108],AETNA [100010801],,,77.2,,312351.4007,7771.48,434261.5728,percent of total billed charges,,,
Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face- Mouth And Neck Without Major O.R. Procedures,4,MS-DRG,,,,,,,inpatient,,,379341.67,265539.169,AETNA [1000108],AETNA [100010801],,,77.2,,292851.7692,7771.48,303473.336,percent of total billed charges,,,
Tracheostomy For Face- Mouth And Neck Diagnoses Or Laryngectomy With McC,11,MS-DRG,,,,,,,inpatient,,,57485.95,40240.165,AETNA [1000108],AETNA [100010801],,,77.2,,44379.1534,7771.48,109336.4384,percent of total billed charges,,,
Tracheostomy For Face- Mouth And Neck Diagnoses Or Laryngectomy With Cc,12,MS-DRG,,,,,,,inpatient,,,82266.47,57586.529,AETNA [1000108],AETNA [100010801],,,77.2,,63509.71484,7771.48,83151.2976,percent of total billed charges,,,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With McC Or Chemotherapy Implant Or Epilepsy With Neurostimulator,23,MS-DRG,,,,,,,inpatient,,,82526.76,57768.732,AETNA [1000108],AETNA [100010801],,,77.2,,63710.65872,7771.48,115600.0408,percent of total billed charges,,,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without McC,24,MS-DRG,,,,,,,inpatient,,,54359.41,38051.587,AETNA [1000108],AETNA [100010801],,,77.2,,41965.46452,7771.48,77031.5696,percent of total billed charges,,,
Craniotomy And Endovascular Intracranial Procedures With McC,25,MS-DRG,,,,,,,inpatient,,,91861.46,64303.022,AETNA [1000108],AETNA [100010801],,,77.2,,70917.04712,7771.48,90620.608,percent of total billed charges,,,
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,,,inpatient,,,74058,51840.6,AETNA [1000108],AETNA [100010801],,,77.2,,57172.776,7771.48,61975.4176,percent of total billed charges,,,
Craniotomy And Endovascular Intracranial Procedures Without Cc/McC,27,MS-DRG,,,,,,,inpatient,,,61484.65,43039.255,AETNA [1000108],AETNA [100010801],,,77.2,,47466.1498,7771.48,50003.4464,percent of total billed charges,,,
Spinal Procedures With McC,28,MS-DRG,,,,,,,inpatient,,,148126.56,103688.592,AETNA [1000108],AETNA [100010801],,,77.2,,114353.7043,7771.48,123186.8824,percent of total billed charges,,,
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,inpatient,,,74991.36,52493.952,AETNA [1000108],AETNA [100010801],,,77.2,,57893.32992,7771.48,68016.116,percent of total billed charges,,,
Spinal Procedures Without Cc/McC,30,MS-DRG,,,,,,,inpatient,,,28580.9,20006.63,AETNA [1000108],AETNA [100010801],,,77.2,,22064.4548,7771.48,45091.4528,percent of total billed charges,,,
Ventricular Shunt Procedures With McC,31,MS-DRG,,,,,,,inpatient,,,61588.79,43112.153,AETNA [1000108],AETNA [100010801],,,77.2,,47546.54588,7771.48,84912.2392,percent of total billed charges,,,
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,,,inpatient,,,117340.84,82138.588,AETNA [1000108],AETNA [100010801],,,77.2,,90587.12848,7771.48,93872.672,percent of total billed charges,,,
Ventricular Shunt Procedures Without Cc/McC,33,MS-DRG,,,,,,,inpatient,,,50092.67,35064.869,AETNA [1000108],AETNA [100010801],,,77.2,,38671.54124,7771.48,40074.136,percent of total billed charges,,,
Carotid Artery Stent Procedures With McC,34,MS-DRG,,,,,,,inpatient,,,80412.35,56288.645,AETNA [1000108],AETNA [100010801],,,77.2,,62078.3342,7771.48,78796.564,percent of total billed charges,,,
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,inpatient,,,59060.84,41342.588,AETNA [1000108],AETNA [100010801],,,77.2,,45594.96848,7771.48,47248.672,percent of total billed charges,,,
Carotid Artery Stent Procedures Without Cc/McC,36,MS-DRG,,,,,,,inpatient,,,55590.26,38913.182,AETNA [1000108],AETNA [100010801],,,77.2,,42915.68072,7771.48,44472.208,percent of total billed charges,,,
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,inpatient,,,47239.38,33067.566,AETNA [1000108],AETNA [100010801],,,77.2,,36468.80136,7771.48,37791.504,percent of total billed charges,,,
Extracranial Procedures Without Cc/McC,39,MS-DRG,,,,,,,inpatient,,,40302.61,28211.827,AETNA [1000108],AETNA [100010801],,,77.2,,31113.61492,7771.48,32242.088,percent of total billed charges,,,
Peripheral- Cranial Nerve And Other Nervous System Procedures With McC,40,MS-DRG,,,,,,,inpatient,,,42423.5,29696.45,AETNA [1000108],AETNA [100010801],,,77.2,,32750.942,7771.48,76431.7552,percent of total billed charges,,,
Peripheral- Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator,41,MS-DRG,,,,,,,inpatient,,,29478.8,20635.16,AETNA [1000108],AETNA [100010801],,,77.2,,22757.6336,7771.48,45768.2704,percent of total billed charges,,,
Peripheral- Cranial Nerve And Other Nervous System Procedures Without Cc/McC,42,MS-DRG,,,,,,,inpatient,,,40958.56,28670.992,AETNA [1000108],AETNA [100010801],,,77.2,,31620.00832,7771.48,35613.98,percent of total billed charges,,,
Spinal Disorders And Injuries With Cc/McC,52,MS-DRG,,,,,,,inpatient,,,14188.67,9932.069,AETNA [1000108],AETNA [100010801],,,77.2,,10953.65324,4731.921445,40779.2736,percent of total billed charges,,,
Spinal Disorders And Injuries Without Cc/McC,53,MS-DRG,,,,,,,inpatient,,,42918.11,30042.677,AETNA [1000108],AETNA [100010801],,,77.2,,33132.78092,7771.48,34334.488,percent of total billed charges,,,
Nervous System Neoplasms With McC,54,MS-DRG,,,,,,,inpatient,,,16507.92,11555.544,AETNA [1000108],AETNA [100010801],,,77.2,,12744.11424,5505.39132,30377.7624,percent of total billed charges,,,
Nervous System Neoplasms Without McC,55,MS-DRG,,,,,,,inpatient,,,15148.1,10603.67,AETNA [1000108],AETNA [100010801],,,77.2,,11694.3332,5051.89135,22105.9976,percent of total billed charges,,,
Degenerative Nervous System Disorders With McC,56,MS-DRG,,,,,,,inpatient,,,32807.03,22964.921,AETNA [1000108],AETNA [100010801],,,77.2,,25327.02716,7771.48,50741.056,percent of total billed charges,,,
Degenerative Nervous System Disorders Without McC,57,MS-DRG,,,,,,,inpatient,,,21955.44,15368.808,AETNA [1000108],AETNA [100010801],,,77.2,,16949.59968,7322.13924,27046.3608,percent of total billed charges,,,
Multiple Sclerosis And Cerebellar Ataxia With McC,58,MS-DRG,,,,,,,inpatient,,,18732.22,13112.554,AETNA [1000108],AETNA [100010801],,,77.2,,14461.27384,6247.19537,37401.2648,percent of total billed charges,,,
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,inpatient,,,30559.84,21391.888,AETNA [1000108],AETNA [100010801],,,77.2,,23592.19648,7771.48,24793.004,percent of total billed charges,,,
Multiple Sclerosis And Cerebellar Ataxia Without Cc/McC,60,MS-DRG,,,,,,,inpatient,,,18686.21,13080.347,AETNA [1000108],AETNA [100010801],,,77.2,,14425.75412,6231.851035,18083.5936,percent of total billed charges,,,
Ischemic Stroke- Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With McC,61,MS-DRG,,,,,,,inpatient,,,81185.85,56830.095,AETNA [1000108],AETNA [100010801],,,77.2,,62675.4762,7771.48,64948.68,percent of total billed charges,,,
Ischemic Stroke- Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc,62,MS-DRG,,,,,,,inpatient,,,55465.6,38825.92,AETNA [1000108],AETNA [100010801],,,77.2,,42819.4432,7771.48,44372.48,percent of total billed charges,,,
Ischemic Stroke- Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/McC,63,MS-DRG,,,,,,,inpatient,,,65826.61,46078.627,AETNA [1000108],AETNA [100010801],,,77.2,,50818.14292,7771.48,52661.288,percent of total billed charges,,,
Intracranial Hemorrhage Or Cerebral Infarction With McC,64,MS-DRG,,,,,,,inpatient,,,31988.78,22392.146,AETNA [1000108],AETNA [100010801],,,77.2,,24695.33816,7771.48,40307.1224,percent of total billed charges,,,
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,inpatient,,,20095.65,14066.955,AETNA [1000108],AETNA [100010801],,,77.2,,15513.8418,6701.899275,20608.488,percent of total billed charges,,,
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/McC,66,MS-DRG,,,,,,,inpatient,,,17438.35,12206.845,AETNA [1000108],AETNA [100010801],,,77.2,,13462.4062,5143.64,13950.68,percent of total billed charges,,,
Nonspecific Cva And Precerebral Occlusion Without Infarction With McC,67,MS-DRG,,,,,,,inpatient,,,38053.25,26637.275,AETNA [1000108],AETNA [100010801],,,77.2,,29377.109,7771.48,30442.6,percent of total billed charges,,,
Nonspecific Cva And Precerebral Occlusion Without Infarction Without McC,68,MS-DRG,,,,,,,inpatient,,,27888.66,19522.062,AETNA [1000108],AETNA [100010801],,,77.2,,21530.04552,6429.37,22310.928,percent of total billed charges,,,
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,inpatient,,,17825.05,12477.535,AETNA [1000108],AETNA [100010801],,,77.2,,13760.9386,5687.74,16215.2528,percent of total billed charges,,,
Nonspecific Cerebrovascular Disorders With McC,70,MS-DRG,,,,,,,inpatient,,,36237.19,25366.033,AETNA [1000108],AETNA [100010801],,,77.2,,27975.11068,7771.48,35233.0168,percent of total billed charges,,,
Nonspecific Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,inpatient,,,26346.94,18442.858,AETNA [1000108],AETNA [100010801],,,77.2,,20339.83768,7313.53,21354.2032,percent of total billed charges,,,
Cranial And Peripheral Nerve Disorders With McC,73,MS-DRG,,,,,,,inpatient,,,24367.12,17056.984,AETNA [1000108],AETNA [100010801],,,77.2,,18811.41664,7771.48,31318.012,percent of total billed charges,,,
Cranial And Peripheral Nerve Disorders Without McC,74,MS-DRG,,,,,,,inpatient,,,24431.87,17102.309,AETNA [1000108],AETNA [100010801],,,77.2,,18861.40364,7368.52,21123.1936,percent of total billed charges,,,
Viral Meningitis With Cc/McC,75,MS-DRG,,,,,,,inpatient,,,38318.52,26822.964,AETNA [1000108],AETNA [100010801],,,77.2,,29581.89744,7771.48,34902.7136,percent of total billed charges,,,
Viral Meningitis Without Cc/McC,76,MS-DRG,,,,,,,inpatient,,,18360.72,12852.504,AETNA [1000108],AETNA [100010801],,,77.2,,14174.47584,6123.30012,18580.0616,percent of total billed charges,,,
Hypertensive Encephalopathy With McC,77,MS-DRG,,,,,,,inpatient,,,24086.79,16860.753,AETNA [1000108],AETNA [100010801],,,77.2,,18595.00188,7771.48,31332.1968,percent of total billed charges,,,
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,,,inpatient,,,18407.7,12885.39,AETNA [1000108],AETNA [100010801],,,77.2,,14210.7444,6138.96795,20219.4192,percent of total billed charges,,,
Nontraumatic Stupor And Coma With McC,80,MS-DRG,,,,,,,inpatient,,,17643.44,12350.408,AETNA [1000108],AETNA [100010801],,,77.2,,13620.73568,5884.08724,40280.7792,percent of total billed charges,,,
Traumatic Stupor And Coma >1 Hour With McC,82,MS-DRG,,,,,,,inpatient,,,45789.39,32052.573,AETNA [1000108],AETNA [100010801],,,77.2,,35349.40908,7771.48,47014.5064,percent of total billed charges,,,
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,inpatient,,,24521.38,17164.966,AETNA [1000108],AETNA [100010801],,,77.2,,18930.50536,7771.48,28173.0392,percent of total billed charges,,,
Traumatic Stupor And Coma >1 Hour Without Cc/McC,84,MS-DRG,,,,,,,inpatient,,,12382.21,8667.547,AETNA [1000108],AETNA [100010801],,,77.2,,9559.06612,4129.467035,19372.384,percent of total billed charges,,,
Traumatic Stupor And Coma <1 Hour With McC,85,MS-DRG,,,,,,,inpatient,,,44820.5,31374.35,AETNA [1000108],AETNA [100010801],,,77.2,,34601.426,7771.48,45916.1976,percent of total billed charges,,,
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,inpatient,,,22755.94,15929.158,AETNA [1000108],AETNA [100010801],,,77.2,,17567.58568,7589.10599,26578.2624,percent of total billed charges,,,
Traumatic Stupor And Coma <1 Hour Without Cc/McC,87,MS-DRG,,,,,,,inpatient,,,19756.53,13829.571,AETNA [1000108],AETNA [100010801],,,77.2,,15252.04116,6241.25,17913.376,percent of total billed charges,,,
Concussion With McC,88,MS-DRG,,,,,,,inpatient,,,61939.59,43357.713,AETNA [1000108],AETNA [100010801],,,77.2,,47817.36348,7771.48,49551.672,percent of total billed charges,,,
Concussion With Cc,89,MS-DRG,,,,,,,inpatient,,,38694.98,27086.486,AETNA [1000108],AETNA [100010801],,,77.2,,29872.52456,7678.2,30955.984,percent of total billed charges,,,
Other Disorders Of Nervous System With McC,91,MS-DRG,,,,,,,inpatient,,,27946.92,19562.844,AETNA [1000108],AETNA [100010801],,,77.2,,21575.02224,7771.48,36937.2192,percent of total billed charges,,,
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,inpatient,,,23877.59,16714.313,AETNA [1000108],AETNA [100010801],,,77.2,,18433.49948,7134.82,21455.5232,percent of total billed charges,,,
Other Disorders Of Nervous System Without Cc/McC,93,MS-DRG,,,,,,,inpatient,,,19087.94,13361.558,AETNA [1000108],AETNA [100010801],,,77.2,,14735.88968,5653.01,15994.3752,percent of total billed charges,,,
Bacterial And Tuberculous Infections Of Nervous System With McC,94,MS-DRG,,,,,,,inpatient,,,86655,60658.5,AETNA [1000108],AETNA [100010801],,,77.2,,66897.66,7771.48,73931.1776,percent of total billed charges,,,
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,,,inpatient,,,61521.3,43064.91,AETNA [1000108],AETNA [100010801],,,77.2,,47494.4436,7771.48,49217.04,percent of total billed charges,,,
Bacterial And Tuberculous Infections Of Nervous System Without Cc/McC,96,MS-DRG,,,,,,,inpatient,,,33095.5,23166.85,AETNA [1000108],AETNA [100010801],,,77.2,,25549.726,7771.48,48572.808,percent of total billed charges,,,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With McC,97,MS-DRG,,,,,,,inpatient,,,90065.06,63045.542,AETNA [1000108],AETNA [100010801],,,77.2,,69530.22632,7771.48,72642.3872,percent of total billed charges,,,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,inpatient,,,23740.04,16618.028,AETNA [1000108],AETNA [100010801],,,77.2,,18327.31088,7771.48,43954.6424,percent of total billed charges,,,
Seizures With McC,100,MS-DRG,,,,,,,inpatient,,,22104.14,15472.898,AETNA [1000108],AETNA [100010801],,,77.2,,17064.39608,7371.73069,40228.0928,percent of total billed charges,,,
Seizures Without McC,101,MS-DRG,,,,,,,inpatient,,,15944.38,11161.066,AETNA [1000108],AETNA [100010801],,,77.2,,12309.06136,5317.45073,18675.3024,percent of total billed charges,,,
Headaches With McC,102,MS-DRG,,,,,,,inpatient,,,25624.62,17937.234,AETNA [1000108],AETNA [100010801],,,77.2,,19782.20664,7771.48,23494.0816,percent of total billed charges,,,
Headaches Without McC,103,MS-DRG,,,,,,,inpatient,,,20277.76,14194.432,AETNA [1000108],AETNA [100010801],,,77.2,,15654.43072,5992.35,17228.4528,percent of total billed charges,,,
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,,,inpatient,,,26970.92,18879.644,AETNA [1000108],AETNA [100010801],,,77.2,,20821.55024,7771.48,31022.1576,percent of total billed charges,,,
Neurological Eye Disorders,123,MS-DRG,,,,,,,inpatient,,,18842.87,13190.009,AETNA [1000108],AETNA [100010801],,,77.2,,14546.69564,5537.24,16276.0448,percent of total billed charges,,,
Sinus And Mastoid Procedures With Cc/McC,135,MS-DRG,,,,,,,inpatient,,,60852.06,42596.442,AETNA [1000108],AETNA [100010801],,,77.2,,46977.79032,7771.48,48854.4776,percent of total billed charges,,,
Mouth Procedures Without Cc/McC,138,MS-DRG,,,,,,,inpatient,,,12689.7,8882.79,AETNA [1000108],AETNA [100010801],,,77.2,,9796.4484,4232.01495,16484.764,percent of total billed charges,,,
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,inpatient,,,50999.49,35699.643,AETNA [1000108],AETNA [100010801],,,77.2,,39371.60628,7771.48,43533.1512,percent of total billed charges,,,
Major Head And Neck Procedures Without Cc/McC,142,MS-DRG,,,,,,,inpatient,,,31036.34,21725.438,AETNA [1000108],AETNA [100010801],,,77.2,,23960.05448,7771.48,31861.0872,percent of total billed charges,,,
Other Ear- Nose- Mouth And Throat O.R. Procedures With McC,143,MS-DRG,,,,,,,inpatient,,,146130.64,102291.448,AETNA [1000108],AETNA [100010801],,,77.2,,112812.8541,7771.48,116904.512,percent of total billed charges,,,
Other Ear- Nose- Mouth And Throat O.R. Procedures With Cc,144,MS-DRG,,,,,,,inpatient,,,29177.65,20424.355,AETNA [1000108],AETNA [100010801],,,77.2,,22525.1458,7771.48,35595.7424,percent of total billed charges,,,
Ear- Nose- Mouth And Throat Malignancy With Cc,147,MS-DRG,,,,,,,inpatient,,,20455.22,14318.654,AETNA [1000108],AETNA [100010801],,,77.2,,15791.42984,6821.81587,25222.6008,percent of total billed charges,,,
Ear- Nose- Mouth And Throat Malignancy Without Cc/McC,148,MS-DRG,,,,,,,inpatient,,,18282.89,12798.023,AETNA [1000108],AETNA [100010801],,,77.2,,14114.39108,5689.187157,16225.3848,percent of total billed charges,,,
Dysequilibrium,149,MS-DRG,,,,,,,inpatient,,,21458.09,15020.663,AETNA [1000108],AETNA [100010801],,,77.2,,16565.64548,5321.63,17166.472,percent of total billed charges,,,
Epistaxis With McC,150,MS-DRG,,,,,,,inpatient,,,36459.7,25521.79,AETNA [1000108],AETNA [100010801],,,77.2,,28146.8884,7771.48,29167.76,percent of total billed charges,,,
Epistaxis Without McC,151,MS-DRG,,,,,,,inpatient,,,17762.28,12433.596,AETNA [1000108],AETNA [100010801],,,77.2,,13712.48016,5332.48243,15360.112,percent of total billed charges,,,
Otitis Media And Uri With McC,152,MS-DRG,,,,,,,inpatient,,,22895.06,16026.542,AETNA [1000108],AETNA [100010801],,,77.2,,17674.98632,7635.50251,22993.5608,percent of total billed charges,,,
Otitis Media And Uri Without McC,153,MS-DRG,,,,,,,inpatient,,,11257.92,7880.544,AETNA [1000108],AETNA [100010801],,,77.2,,8691.11424,3754.51632,14421.8888,percent of total billed charges,,,
Other Ear- Nose- Mouth And Throat Diagnoses With McC,154,MS-DRG,,,,,,,inpatient,,,33108.79,23176.153,AETNA [1000108],AETNA [100010801],,,77.2,,25559.98588,7771.48,32953.3168,percent of total billed charges,,,
Other Ear- Nose- Mouth And Throat Diagnoses With Cc,155,MS-DRG,,,,,,,inpatient,,,14149.33,9904.531,AETNA [1000108],AETNA [100010801],,,77.2,,10923.28276,4718.801555,18918.4704,percent of total billed charges,,,
Other Ear- Nose- Mouth And Throat Diagnoses Without Cc/McC,156,MS-DRG,,,,,,,inpatient,,,3168.14,2217.698,AETNA [1000108],AETNA [100010801],,,77.2,,2445.80408,1056.57469,13625.5136,percent of total billed charges,,,
Dental And Oral Diseases With McC,157,MS-DRG,,,,,,,inpatient,,,25823.75,18076.625,AETNA [1000108],AETNA [100010801],,,77.2,,19935.935,7771.48,33180.2736,percent of total billed charges,,,
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,inpatient,,,17794.61,12456.227,AETNA [1000108],AETNA [100010801],,,77.2,,13737.43892,5934.502435,19058.292,percent of total billed charges,,,
Dental And Oral Diseases Without Cc/McC,159,MS-DRG,,,,,,,inpatient,,,15217,10651.9,AETNA [1000108],AETNA [100010801],,,77.2,,11747.524,4744.97,13366.1344,percent of total billed charges,,,
Major Chest Procedures With McC,163,MS-DRG,,,,,,,inpatient,,,128830.68,90181.476,AETNA [1000108],AETNA [100010801],,,77.2,,99457.28496,7771.48,103064.544,percent of total billed charges,,,
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,inpatient,,,83811.85,58668.295,AETNA [1000108],AETNA [100010801],,,77.2,,64702.7482,7771.48,67049.48,percent of total billed charges,,,
Major Chest Procedures Without Cc/McC,165,MS-DRG,,,,,,,inpatient,,,63087.07,44160.949,AETNA [1000108],AETNA [100010801],,,77.2,,48703.21804,7771.48,50469.656,percent of total billed charges,,,
Other Respiratory System O.R. Procedures With McC,166,MS-DRG,,,,,,,inpatient,,,68518.66,47963.062,AETNA [1000108],AETNA [100010801],,,77.2,,52896.40552,7771.48,78036.664,percent of total billed charges,,,
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,inpatient,,,50504.64,35353.248,AETNA [1000108],AETNA [100010801],,,77.2,,38989.58208,7771.48,40403.712,percent of total billed charges,,,
Other Respiratory System O.R. Procedures Without Cc/McC,168,MS-DRG,,,,,,,inpatient,,,36816.23,25771.361,AETNA [1000108],AETNA [100010801],,,77.2,,28422.12956,7771.48,29452.984,percent of total billed charges,,,
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,inpatient,,,76600.57,53620.399,AETNA [1000108],AETNA [100010801],,,77.2,,59135.64004,7771.48,62178.0576,percent of total billed charges,,,
Pulmonary Embolism With McC Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,inpatient,,,27323.68,19126.576,AETNA [1000108],AETNA [100010801],,,77.2,,21093.88096,7771.48,28554.0024,percent of total billed charges,,,
Pulmonary Embolism Without McC,176,MS-DRG,,,,,,,inpatient,,,16280.09,11396.063,AETNA [1000108],AETNA [100010801],,,77.2,,12568.22948,5429.410015,16505.028,percent of total billed charges,,,
Respiratory Infections And Inflammations With McC,177,MS-DRG,,,,,,,inpatient,,,30316.04,21221.228,AETNA [1000108],AETNA [100010801],,,77.2,,23403.98288,7771.48,32756.756,percent of total billed charges,,,
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,inpatient,,,21346.77,14942.739,AETNA [1000108],AETNA [100010801],,,77.2,,16479.70644,7119.147795,20103.9144,percent of total billed charges,,,
Respiratory Infections And Inflammations Without Cc/McC,179,MS-DRG,,,,,,,inpatient,,,20533.98,14373.786,AETNA [1000108],AETNA [100010801],,,77.2,,15852.23256,6302.75,16427.184,percent of total billed charges,,,
Respiratory Neoplasms With McC,180,MS-DRG,,,,,,,inpatient,,,24678.76,17275.132,AETNA [1000108],AETNA [100010801],,,77.2,,19052.00272,7771.48,35415.3928,percent of total billed charges,,,
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,inpatient,,,15915.05,11140.535,AETNA [1000108],AETNA [100010801],,,77.2,,12286.4186,5307.669175,22497.0928,percent of total billed charges,,,
Major Chest Trauma With McC,183,MS-DRG,,,,,,,inpatient,,,30366.68,21256.676,AETNA [1000108],AETNA [100010801],,,77.2,,23443.07696,7771.48,32163.0208,percent of total billed charges,,,
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,inpatient,,,23252.15,16276.505,AETNA [1000108],AETNA [100010801],,,77.2,,17950.6598,7520.46,21641.952,percent of total billed charges,,,
Major Chest Trauma Without Cc/McC,185,MS-DRG,,,,,,,inpatient,,,26254.04,18377.828,AETNA [1000108],AETNA [100010801],,,77.2,,20268.11888,5597.297704,21003.232,percent of total billed charges,,,
Pleural Effusion With McC,186,MS-DRG,,,,,,,inpatient,,,23322.86,16326.002,AETNA [1000108],AETNA [100010801],,,77.2,,18005.24792,7771.48,32017.12,percent of total billed charges,,,
Pleural Effusion With Cc,187,MS-DRG,,,,,,,inpatient,,,25224.41,17657.087,AETNA [1000108],AETNA [100010801],,,77.2,,19473.24452,7468.37,20343.0296,percent of total billed charges,,,
Pleural Effusion Without Cc/McC,188,MS-DRG,,,,,,,inpatient,,,14227.72,9959.404,AETNA [1000108],AETNA [100010801],,,77.2,,10983.79984,4744.94462,14875.8024,percent of total billed charges,,,
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,inpatient,,,23597.45,16518.215,AETNA [1000108],AETNA [100010801],,,77.2,,18217.2314,7771.48,25076.7,percent of total billed charges,,,
Chronic Obstructive Pulmonary Disease With McC,190,MS-DRG,,,,,,,inpatient,,,20380.17,14266.119,AETNA [1000108],AETNA [100010801],,,77.2,,15733.49124,6796.786695,22762.5512,percent of total billed charges,,,
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,inpatient,,,18415.04,12890.528,AETNA [1000108],AETNA [100010801],,,77.2,,14216.41088,6141.41584,17408.8024,percent of total billed charges,,,
Chronic Obstructive Pulmonary Disease Without Cc/McC,192,MS-DRG,,,,,,,inpatient,,,15021,10514.7,AETNA [1000108],AETNA [100010801],,,77.2,,11596.212,5009.5035,13114.8608,percent of total billed charges,,,
Simple Pneumonia And Pleurisy With McC,193,MS-DRG,,,,,,,inpatient,,,24854.58,17398.206,AETNA [1000108],AETNA [100010801],,,77.2,,19187.73576,7771.48,26703.8992,percent of total billed charges,,,
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,inpatient,,,16852.25,11796.575,AETNA [1000108],AETNA [100010801],,,77.2,,13009.937,5620.225375,16616.48,percent of total billed charges,,,
Simple Pneumonia And Pleurisy Without Cc/McC,195,MS-DRG,,,,,,,inpatient,,,11327.34,7929.138,AETNA [1000108],AETNA [100010801],,,77.2,,8744.70648,3777.66789,12620.4192,percent of total billed charges,,,
Interstitial Lung Disease With McC,196,MS-DRG,,,,,,,inpatient,,,25824.88,18077.416,AETNA [1000108],AETNA [100010801],,,77.2,,19936.80736,7771.48,38181.4288,percent of total billed charges,,,
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,inpatient,,,14747.43,10323.201,AETNA [1000108],AETNA [100010801],,,77.2,,11385.01596,4918.267905,20059.3336,percent of total billed charges,,,
Interstitial Lung Disease Without Cc/McC,198,MS-DRG,,,,,,,inpatient,,,102750.94,71925.658,AETNA [1000108],AETNA [100010801],,,77.2,,79323.72568,5370.829997,82200.752,percent of total billed charges,,,
Pneumothorax With McC,199,MS-DRG,,,,,,,inpatient,,,30942.21,21659.547,AETNA [1000108],AETNA [100010801],,,77.2,,23887.38612,7771.48,35770.0128,percent of total billed charges,,,
Pneumothorax With Cc,200,MS-DRG,,,,,,,inpatient,,,23899.07,16729.349,AETNA [1000108],AETNA [100010801],,,77.2,,18450.08204,7771.48,22440.3536,percent of total billed charges,,,
Pneumothorax Without Cc/McC,201,MS-DRG,,,,,,,inpatient,,,14142.03,9899.421,AETNA [1000108],AETNA [100010801],,,77.2,,10917.64716,4716.367005,13716.7016,percent of total billed charges,,,
Bronchitis And Asthma With Cc/McC,202,MS-DRG,,,,,,,inpatient,,,14008.78,9806.146,AETNA [1000108],AETNA [100010801],,,77.2,,10814.77816,4671.92813,19589.2088,percent of total billed charges,,,
Bronchitis And Asthma Without Cc/McC,203,MS-DRG,,,,,,,inpatient,,,8434.66,5904.262,AETNA [1000108],AETNA [100010801],,,77.2,,6511.55752,2812.95911,14109.8232,percent of total billed charges,,,
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,inpatient,,,19382.31,13567.617,AETNA [1000108],AETNA [100010801],,,77.2,,14963.14332,5734.05,16432.0776,percent of total billed charges,,,
Other Respiratory System Diagnoses With McC,205,MS-DRG,,,,,,,inpatient,,,29471.66,20630.162,AETNA [1000108],AETNA [100010801],,,77.2,,22752.12152,7771.48,38252.3528,percent of total billed charges,,,
Other Respiratory System Diagnoses Without McC,206,MS-DRG,,,,,,,inpatient,,,18289.13,12802.391,AETNA [1000108],AETNA [100010801],,,77.2,,14119.20836,6099.424855,18355.1312,percent of total billed charges,,,
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,inpatient,,,153413.76,107389.632,AETNA [1000108],AETNA [100010801],,,77.2,,118435.4227,7771.48,131061.4728,percent of total billed charges,,,
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,inpatient,,,60056.19,42039.333,AETNA [1000108],AETNA [100010801],,,77.2,,46363.37868,7771.48,54390.6024,percent of total billed charges,,,
Other Heart Assist System Implant,215,MS-DRG,,,,,,,inpatient,,,163000.7,114100.49,AETNA [1000108],AETNA [100010801],,,77.2,,125836.5404,7771.48,214680.8688,percent of total billed charges,,,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/McC,218,MS-DRG,,,,,,,inpatient,,,144438.6,101107.02,AETNA [1000108],AETNA [100010801],,,77.2,,111506.5992,7771.48,120552.5624,percent of total billed charges,,,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/McC,221,MS-DRG,,,,,,,inpatient,,,282573.82,197801.674,AETNA [1000108],AETNA [100010801],,,77.2,,218146.989,7771.48,226059.056,percent of total billed charges,,,
Other Cardiothoracic Procedures With McC,228,MS-DRG,,,,,,,inpatient,,,215439.26,150807.482,AETNA [1000108],AETNA [100010801],,,77.2,,166319.1087,7771.48,172351.408,percent of total billed charges,,,
Coronary Bypass With Cardiac Catheterization Or Open Ablation With McC,233,MS-DRG,,,,,,,inpatient,,,335724.2,235006.94,AETNA [1000108],AETNA [100010801],,,77.2,,259179.0824,7771.48,268579.36,percent of total billed charges,,,
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without McC,234,MS-DRG,,,,,,,inpatient,,,168474.77,117932.339,AETNA [1000108],AETNA [100010801],,,77.2,,130062.5224,7771.48,134779.816,percent of total billed charges,,,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With McC,239,MS-DRG,,,,,,,inpatient,,,57370.89,40159.623,AETNA [1000108],AETNA [100010801],,,77.2,,44290.32708,7771.48,102059.636,percent of total billed charges,,,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,inpatient,,,51903.54,36332.478,AETNA [1000108],AETNA [100010801],,,77.2,,40069.53288,7771.48,59008.768,percent of total billed charges,,,
Permanent Cardiac Pacemaker Implant With McC,242,MS-DRG,,,,,,,inpatient,,,86942.73,60859.911,AETNA [1000108],AETNA [100010801],,,77.2,,67119.78756,7771.48,69554.184,percent of total billed charges,,,
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,inpatient,,,65531.01,45871.707,AETNA [1000108],AETNA [100010801],,,77.2,,50589.93972,7771.48,52424.808,percent of total billed charges,,,
Permanent Cardiac Pacemaker Implant Without Cc/McC,244,MS-DRG,,,,,,,inpatient,,,63411.07,44387.749,AETNA [1000108],AETNA [100010801],,,77.2,,48953.34604,7771.48,50728.856,percent of total billed charges,,,
Aicd Generator Procedures,245,MS-DRG,,,,,,,inpatient,,,15907.12,11134.984,AETNA [1000108],AETNA [100010801],,,77.2,,12280.29664,5305.02452,99020.036,percent of total billed charges,,,
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without McC,251,MS-DRG,,,,,,,inpatient,,,55424.98,38797.486,AETNA [1000108],AETNA [100010801],,,77.2,,42788.08456,7771.48,44339.984,percent of total billed charges,,,
Other Vascular Procedures With McC,252,MS-DRG,,,,,,,inpatient,,,85181.97,59627.379,AETNA [1000108],AETNA [100010801],,,77.2,,65760.48084,7771.48,69509.5728,percent of total billed charges,,,
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,inpatient,,,82797.33,57958.131,AETNA [1000108],AETNA [100010801],,,77.2,,63919.53876,7771.48,66237.864,percent of total billed charges,,,
Other Vascular Procedures Without Cc/McC,254,MS-DRG,,,,,,,inpatient,,,61488.65,43042.055,AETNA [1000108],AETNA [100010801],,,77.2,,47469.2378,7771.48,49190.92,percent of total billed charges,,,
Upper Limb And Toe Amputation For Circulatory System Disorders With McC,255,MS-DRG,,,,,,,inpatient,,,163135.56,114194.892,AETNA [1000108],AETNA [100010801],,,77.2,,125940.6523,7771.48,130508.448,percent of total billed charges,,,
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,inpatient,,,13744.76,9621.332,AETNA [1000108],AETNA [100010801],,,77.2,,10610.95472,4583.87746,34319.1104,percent of total billed charges,,,
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/McC,257,MS-DRG,,,,,,,inpatient,,,13802.75,9661.925,AETNA [1000108],AETNA [100010801],,,77.2,,10655.723,4603.217125,18073.4616,percent of total billed charges,,,
Cardiac Pacemaker Device Replacement Without McC,259,MS-DRG,,,,,,,inpatient,,,51584.98,36109.486,AETNA [1000108],AETNA [100010801],,,77.2,,39823.60456,7771.48,41267.984,percent of total billed charges,,,
Cardiac Pacemaker Revision Except Device Replacement With McC,260,MS-DRG,,,,,,,inpatient,,,218275.68,152792.976,AETNA [1000108],AETNA [100010801],,,77.2,,168508.825,7771.48,174620.544,percent of total billed charges,,,
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,inpatient,,,57651.04,40355.728,AETNA [1000108],AETNA [100010801],,,77.2,,44506.60288,7771.48,46120.832,percent of total billed charges,,,
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,inpatient,,,28475.53,19932.871,AETNA [1000108],AETNA [100010801],,,77.2,,21983.10916,7771.48,70820.6536,percent of total billed charges,,,
Aortic And Heart Assist Procedures Except Pulsation Balloon With McC,268,MS-DRG,,,,,,,inpatient,,,101907.56,71335.292,AETNA [1000108],AETNA [100010801],,,77.2,,78672.63632,7771.48,135104.1408,percent of total billed charges,,,
Aortic And Heart Assist Procedures Except Pulsation Balloon Without McC,269,MS-DRG,,,,,,,inpatient,,,145888.49,102121.943,AETNA [1000108],AETNA [100010801],,,77.2,,112625.9143,7771.48,116710.792,percent of total billed charges,,,
Other Major Cardiovascular Procedures With McC,270,MS-DRG,,,,,,,inpatient,,,185659.89,129961.923,AETNA [1000108],AETNA [100010801],,,77.2,,143329.4351,7771.48,148527.912,percent of total billed charges,,,
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,inpatient,,,127626.27,89338.389,AETNA [1000108],AETNA [100010801],,,77.2,,98527.48044,7771.48,102101.016,percent of total billed charges,,,
Other Major Cardiovascular Procedures Without Cc/McC,272,MS-DRG,,,,,,,inpatient,,,104134.1,72893.87,AETNA [1000108],AETNA [100010801],,,77.2,,80391.5252,7771.48,83307.28,percent of total billed charges,,,
Percutaneous And Other Intracardiac Procedures Without McC,274,MS-DRG,,,,,,,inpatient,,,98959.28,69271.496,AETNA [1000108],AETNA [100010801],,,77.2,,76396.56416,7771.48,79167.424,percent of total billed charges,,,
Cardiac Defibrillator Implant With Cardiac Catheterization And McC,275,MS-DRG,,,,,,,inpatient,,,167450.04,117215.028,AETNA [1000108],AETNA [100010801],,,77.2,,129271.4309,7771.48,143195.556,percent of total billed charges,,,
Cardiac Defibrillator Implant Without McC,277,MS-DRG,,,,,,,inpatient,,,278318.05,194822.635,AETNA [1000108],AETNA [100010801],,,77.2,,214861.5346,7771.48,222654.44,percent of total billed charges,,,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With McC,278,MS-DRG,,,,,,,inpatient,,,130044.83,91031.381,AETNA [1000108],AETNA [100010801],,,77.2,,100394.6088,7771.48,104035.864,percent of total billed charges,,,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without McC,279,MS-DRG,,,,,,,inpatient,,,135336.66,94735.662,AETNA [1000108],AETNA [100010801],,,77.2,,104479.9015,7771.48,108269.328,percent of total billed charges,,,
Acute Myocardial Infarction- Discharged Alive With McC,280,MS-DRG,,,,,,,inpatient,,,31571.18,22099.826,AETNA [1000108],AETNA [100010801],,,77.2,,24372.95096,7771.48,33263.356,percent of total billed charges,,,
Acute Myocardial Infarction- Discharged Alive With Cc,281,MS-DRG,,,,,,,inpatient,,,22298.62,15609.034,AETNA [1000108],AETNA [100010801],,,77.2,,17214.53464,6744.11,18679.3552,percent of total billed charges,,,
Acute Myocardial Infarction- Discharged Alive Without Cc/McC,282,MS-DRG,,,,,,,inpatient,,,15726.17,11008.319,AETNA [1000108],AETNA [100010801],,,77.2,,12140.60324,5244.677695,14693.4264,percent of total billed charges,,,
Acute Myocardial Infarction- Expired With McC,283,MS-DRG,,,,,,,inpatient,,,47695.81,33387.067,AETNA [1000108],AETNA [100010801],,,77.2,,36821.16532,7771.48,39624.2256,percent of total billed charges,,,
Acute Myocardial Infarction- Expired With Cc,284,MS-DRG,,,,,,,inpatient,,,30935.67,21654.969,AETNA [1000108],AETNA [100010801],,,77.2,,23882.33724,5312.22,24748.536,percent of total billed charges,,,
Circulatory Disorders Except Ami- With Cardiac Catheterization With McC,286,MS-DRG,,,,,,,inpatient,,,48769.97,34138.979,AETNA [1000108],AETNA [100010801],,,77.2,,37650.41684,7771.48,44850.3112,percent of total billed charges,,,
Circulatory Disorders Except Ami- With Cardiac Catheterization Without McC,287,MS-DRG,,,,,,,inpatient,,,33854.25,23697.975,AETNA [1000108],AETNA [100010801],,,77.2,,26135.481,7771.48,27083.4,percent of total billed charges,,,
Acute And Subacute Endocarditis With McC,288,MS-DRG,,,,,,,inpatient,,,36276.49,25393.543,AETNA [1000108],AETNA [100010801],,,77.2,,28005.45028,7771.48,55347.0632,percent of total billed charges,,,
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,inpatient,,,34648,24253.6,AETNA [1000108],AETNA [100010801],,,77.2,,26748.256,7771.48,31948.2224,percent of total billed charges,,,
Heart Failure And Shock With McC,291,MS-DRG,,,,,,,inpatient,,,22051.33,15435.931,AETNA [1000108],AETNA [100010801],,,77.2,,17023.62676,7354.118555,26442.4936,percent of total billed charges,,,
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,inpatient,,,17435.09,12204.563,AETNA [1000108],AETNA [100010801],,,77.2,,13459.88948,5814.602515,17453.3832,percent of total billed charges,,,
Cardiac Arrest- Unexplained With McC,296,MS-DRG,,,,,,,inpatient,,,34260.06,23982.042,AETNA [1000108],AETNA [100010801],,,77.2,,26448.76632,7771.48,33198.5112,percent of total billed charges,,,
Peripheral Vascular Disorders With McC,299,MS-DRG,,,,,,,inpatient,,,30642.24,21449.568,AETNA [1000108],AETNA [100010801],,,77.2,,23655.80928,7771.48,32781.0728,percent of total billed charges,,,
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,inpatient,,,19909.9,13936.93,AETNA [1000108],AETNA [100010801],,,77.2,,15370.4428,6639.95165,21692.612,percent of total billed charges,,,
Peripheral Vascular Disorders Without Cc/McC,301,MS-DRG,,,,,,,inpatient,,,15022.69,10515.883,AETNA [1000108],AETNA [100010801],,,77.2,,11597.51668,5010.067115,14454.3112,percent of total billed charges,,,
Atherosclerosis With McC,302,MS-DRG,,,,,,,inpatient,,,19965.6,13975.92,AETNA [1000108],AETNA [100010801],,,77.2,,15413.4432,6658.5276,23571.0848,percent of total billed charges,,,
Atherosclerosis Without McC,303,MS-DRG,,,,,,,inpatient,,,16291.73,11404.211,AETNA [1000108],AETNA [100010801],,,77.2,,12577.21556,4894.02,13625.5136,percent of total billed charges,,,
Hypertension With McC,304,MS-DRG,,,,,,,inpatient,,,26689.62,18682.734,AETNA [1000108],AETNA [100010801],,,77.2,,20604.38664,7771.48,23806.1472,percent of total billed charges,,,
Hypertension Without McC,305,MS-DRG,,,,,,,inpatient,,,17122.11,11985.477,AETNA [1000108],AETNA [100010801],,,77.2,,13218.26892,5343.34,15212.1848,percent of total billed charges,,,
Cardiac Congenital And Valvular Disorders With McC,306,MS-DRG,,,,,,,inpatient,,,18809.29,13166.503,AETNA [1000108],AETNA [100010801],,,77.2,,14520.77188,6272.898215,30343.3136,percent of total billed charges,,,
Cardiac Congenital And Valvular Disorders Without McC,307,MS-DRG,,,,,,,inpatient,,,16249.07,11374.349,AETNA [1000108],AETNA [100010801],,,77.2,,12544.28204,5419.064845,18770.5432,percent of total billed charges,,,
Cardiac Arrhythmia And Conduction Disorders With McC,308,MS-DRG,,,,,,,inpatient,,,21486.31,15040.417,AETNA [1000108],AETNA [100010801],,,77.2,,16587.43132,7165.684385,24438.384,percent of total billed charges,,,
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,inpatient,,,15843.59,11090.513,AETNA [1000108],AETNA [100010801],,,77.2,,12231.25148,5283.837265,14981.1752,percent of total billed charges,,,
Cardiac Arrhythmia And Conduction Disorders Without Cc/McC,310,MS-DRG,,,,,,,inpatient,,,13559.61,9491.727,AETNA [1000108],AETNA [100010801],,,77.2,,10468.01892,4040.24,11337.708,percent of total billed charges,,,
Angina Pectoris,311,MS-DRG,,,,,,,inpatient,,,18298.95,12809.265,AETNA [1000108],AETNA [100010801],,,77.2,,14126.7894,5043.07,14639.16,percent of total billed charges,,,
Syncope And Collapse,312,MS-DRG,,,,,,,inpatient,,,18654.24,13057.968,AETNA [1000108],AETNA [100010801],,,77.2,,14401.07328,6057.47,17656.0232,percent of total billed charges,,,
Chest Pain,313,MS-DRG,,,,,,,inpatient,,,18746.43,13122.501,AETNA [1000108],AETNA [100010801],,,77.2,,14472.24396,5215.27,14997.144,percent of total billed charges,,,
Other Circulatory System Diagnoses With McC,314,MS-DRG,,,,,,,inpatient,,,33351.93,23346.351,AETNA [1000108],AETNA [100010801],,,77.2,,25747.68996,7771.48,43636.4976,percent of total billed charges,,,
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,inpatient,,,17192.63,12034.841,AETNA [1000108],AETNA [100010801],,,77.2,,13272.71036,5733.742105,19500.0472,percent of total billed charges,,,
Other Circulatory System Diagnoses Without Cc/McC,316,MS-DRG,,,,,,,inpatient,,,16812.59,11768.813,AETNA [1000108],AETNA [100010801],,,77.2,,12979.31948,5422.92,13832.2064,percent of total billed charges,,,
Percutaneous Cardiovascular Procedures With Intraluminal Device With McC Or 4+ Arteries/Intraluminal Devices,321,MS-DRG,,,,,,,inpatient,,,107897.8,75528.46,AETNA [1000108],AETNA [100010801],,,77.2,,83297.1016,7771.48,86318.24,percent of total billed charges,,,
Percutaneous Cardiovascular Procedures With Intraluminal Device Without McC,322,MS-DRG,,,,,,,inpatient,,,85234.32,59664.024,AETNA [1000108],AETNA [100010801],,,77.2,,65800.89504,7771.48,68187.456,percent of total billed charges,,,
Coronary Intravascular Lithotripsy With Intraluminal Device With McC,323,MS-DRG,,,,,,,inpatient,,,110878.49,77614.943,AETNA [1000108],AETNA [100010801],,,77.2,,85598.19428,7771.48,88702.792,percent of total billed charges,,,
Coronary Intravascular Lithotripsy With Intraluminal Device Without McC,324,MS-DRG,,,,,,,inpatient,,,99829.51,69880.657,AETNA [1000108],AETNA [100010801],,,77.2,,77068.38172,7771.48,79863.608,percent of total billed charges,,,
Stomach- Esophageal And Duodenal Procedures With McC,326,MS-DRG,,,,,,,inpatient,,,70344.55,49241.185,AETNA [1000108],AETNA [100010801],,,77.2,,54305.9926,7771.48,102914.7768,percent of total billed charges,,,
Stomach- Esophageal And Duodenal Procedures With Cc,327,MS-DRG,,,,,,,inpatient,,,76692.68,53684.876,AETNA [1000108],AETNA [100010801],,,77.2,,59206.74896,7771.48,61354.144,percent of total billed charges,,,
Stomach- Esophageal And Duodenal Procedures Without Cc/McC,328,MS-DRG,,,,,,,inpatient,,,58306.69,40814.683,AETNA [1000108],AETNA [100010801],,,77.2,,45012.76468,7771.48,46645.352,percent of total billed charges,,,
Major Small And Large Bowel Procedures With McC,329,MS-DRG,,,,,,,inpatient,,,92091.01,64463.707,AETNA [1000108],AETNA [100010801],,,77.2,,71094.25972,7771.48,93046.2088,percent of total billed charges,,,
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,inpatient,,,66292.87,46405.009,AETNA [1000108],AETNA [100010801],,,77.2,,51178.09564,7771.48,53034.296,percent of total billed charges,,,
Major Small And Large Bowel Procedures Without Cc/McC,331,MS-DRG,,,,,,,inpatient,,,44944.36,31461.052,AETNA [1000108],AETNA [100010801],,,77.2,,34697.04592,7771.48,35955.488,percent of total billed charges,,,
Rectal Resection With McC,332,MS-DRG,,,,,,,inpatient,,,65516.56,45861.592,AETNA [1000108],AETNA [100010801],,,77.2,,50578.78432,7771.48,70285.684,percent of total billed charges,,,
Rectal Resection With Cc,333,MS-DRG,,,,,,,inpatient,,,51060.47,35742.329,AETNA [1000108],AETNA [100010801],,,77.2,,39418.68284,7771.48,43063.0264,percent of total billed charges,,,
Peritoneal Adhesiolysis With McC,335,MS-DRG,,,,,,,inpatient,,,76073.75,53251.625,AETNA [1000108],AETNA [100010801],,,77.2,,58728.935,7771.48,73434.7096,percent of total billed charges,,,
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,inpatient,,,39391.39,27573.973,AETNA [1000108],AETNA [100010801],,,77.2,,30410.15308,7771.48,42805.6736,percent of total billed charges,,,
Peritoneal Adhesiolysis Without Cc/McC,337,MS-DRG,,,,,,,inpatient,,,43856.45,30699.515,AETNA [1000108],AETNA [100010801],,,77.2,,33857.1794,7771.48,35085.16,percent of total billed charges,,,
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,inpatient,,,22777.13,15943.991,AETNA [1000108],AETNA [100010801],,,77.2,,17583.94436,7596.172855,30177.1488,percent of total billed charges,,,
Minor Small And Large Bowel Procedures Without Cc/McC,346,MS-DRG,,,,,,,inpatient,,,25360.83,17752.581,AETNA [1000108],AETNA [100010801],,,77.2,,19578.56076,7771.48,25232.7328,percent of total billed charges,,,
Anal And Stomal Procedures With McC,347,MS-DRG,,,,,,,inpatient,,,33046.94,23132.858,AETNA [1000108],AETNA [100010801],,,77.2,,25512.23768,7771.48,47956.7824,percent of total billed charges,,,
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,inpatient,,,21678.05,15174.635,AETNA [1000108],AETNA [100010801],,,77.2,,16735.4546,7229.629675,25508.3232,percent of total billed charges,,,
Anal And Stomal Procedures Without Cc/McC,349,MS-DRG,,,,,,,inpatient,,,20851.83,14596.281,AETNA [1000108],AETNA [100010801],,,77.2,,16097.61276,6954.085305,17850.5576,percent of total billed charges,,,
Inguinal And Femoral Hernia Procedures With McC,350,MS-DRG,,,,,,,inpatient,,,123839.74,86687.818,AETNA [1000108],AETNA [100010801],,,77.2,,95604.27928,7771.48,99071.792,percent of total billed charges,,,
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,inpatient,,,41444.06,29010.842,AETNA [1000108],AETNA [100010801],,,77.2,,31994.81432,7771.48,33155.248,percent of total billed charges,,,
Inguinal And Femoral Hernia Procedures Without Cc/McC,352,MS-DRG,,,,,,,inpatient,,,27314.17,19119.919,AETNA [1000108],AETNA [100010801],,,77.2,,21086.53924,7771.48,22341.06,percent of total billed charges,,,
Hernia Procedures Except Inguinal And Femoral With McC,353,MS-DRG,,,,,,,inpatient,,,60356.38,42249.466,AETNA [1000108],AETNA [100010801],,,77.2,,46595.12536,7771.48,59430.2592,percent of total billed charges,,,
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,inpatient,,,30185.36,21129.752,AETNA [1000108],AETNA [100010801],,,77.2,,23303.09792,7771.48,34471.0904,percent of total billed charges,,,
Hernia Procedures Except Inguinal And Femoral Without Cc/McC,355,MS-DRG,,,,,,,inpatient,,,34745.89,24322.123,AETNA [1000108],AETNA [100010801],,,77.2,,26823.82708,7771.48,27796.712,percent of total billed charges,,,
Other Digestive System O.R. Procedures With McC,356,MS-DRG,,,,,,,inpatient,,,122041.99,85429.393,AETNA [1000108],AETNA [100010801],,,77.2,,94216.41628,7771.48,97633.592,percent of total billed charges,,,
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,inpatient,,,40025.14,28017.598,AETNA [1000108],AETNA [100010801],,,77.2,,30899.40808,7771.48,45632.5016,percent of total billed charges,,,
Other Digestive System O.R. Procedures Without Cc/McC,358,MS-DRG,,,,,,,inpatient,,,22899.78,16029.846,AETNA [1000108],AETNA [100010801],,,77.2,,17678.63016,7637.07663,27457.72,percent of total billed charges,,,
Major Esophageal Disorders With McC,368,MS-DRG,,,,,,,inpatient,,,52357.14,36649.998,AETNA [1000108],AETNA [100010801],,,77.2,,40419.71208,7771.48,41885.712,percent of total billed charges,,,
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,inpatient,,,25013.89,17509.723,AETNA [1000108],AETNA [100010801],,,77.2,,19310.72308,7771.48,20620.6464,percent of total billed charges,,,
Major Gastrointestinal Disorders And Peritoneal Infections With McC,371,MS-DRG,,,,,,,inpatient,,,31663.98,22164.786,AETNA [1000108],AETNA [100010801],,,77.2,,24444.59256,7771.48,35427.5512,percent of total billed charges,,,
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,inpatient,,,22657.22,15860.054,AETNA [1000108],AETNA [100010801],,,77.2,,17491.37384,7435.09,20857.7352,percent of total billed charges,,,
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/McC,373,MS-DRG,,,,,,,inpatient,,,16862.96,11804.072,AETNA [1000108],AETNA [100010801],,,77.2,,13018.20512,5379.51,14697.4792,percent of total billed charges,,,
Digestive Malignancy With McC,374,MS-DRG,,,,,,,inpatient,,,35452.33,24816.631,AETNA [1000108],AETNA [100010801],,,77.2,,27369.19876,7771.48,42787.436,percent of total billed charges,,,
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,inpatient,,,28899.99,20229.993,AETNA [1000108],AETNA [100010801],,,77.2,,22310.79228,7771.48,24898.3768,percent of total billed charges,,,
Digestive Malignancy Without Cc/McC,376,MS-DRG,,,,,,,inpatient,,,13461.5,9423.05,AETNA [1000108],AETNA [100010801],,,77.2,,10392.278,4489.41025,17891.0856,percent of total billed charges,,,
Gastrointestinal Hemorrhage With McC,377,MS-DRG,,,,,,,inpatient,,,36368.06,25457.642,AETNA [1000108],AETNA [100010801],,,77.2,,28076.14232,7771.48,36841.9784,percent of total billed charges,,,
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,inpatient,,,26039.38,18227.566,AETNA [1000108],AETNA [100010801],,,77.2,,20102.40136,7186.19,20831.504,percent of total billed charges,,,
Gastrointestinal Hemorrhage Without Cc/McC,379,MS-DRG,,,,,,,inpatient,,,12685.62,8879.934,AETNA [1000108],AETNA [100010801],,,77.2,,9793.29864,4230.65427,12900.0624,percent of total billed charges,,,
Complicated Peptic Ulcer With McC,380,MS-DRG,,,,,,,inpatient,,,33309.68,23316.776,AETNA [1000108],AETNA [100010801],,,77.2,,25715.07296,7771.48,38994.0152,percent of total billed charges,,,
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,inpatient,,,25551.79,17886.253,AETNA [1000108],AETNA [100010801],,,77.2,,19725.98188,7667.34,22069.5224,percent of total billed charges,,,
Uncomplicated Peptic Ulcer With McC,383,MS-DRG,,,,,,,inpatient,,,17337.01,12135.907,AETNA [1000108],AETNA [100010801],,,77.2,,13384.17172,5781.892835,25617.7488,percent of total billed charges,,,
Uncomplicated Peptic Ulcer Without McC,384,MS-DRG,,,,,,,inpatient,,,17367.77,12157.439,AETNA [1000108],AETNA [100010801],,,77.2,,13407.91844,5792.151295,17621.5744,percent of total billed charges,,,
Inflammatory Bowel Disease With McC,385,MS-DRG,,,,,,,inpatient,,,26393.7,18475.59,AETNA [1000108],AETNA [100010801],,,77.2,,20375.9364,7771.48,32922.9208,percent of total billed charges,,,
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,inpatient,,,16705.38,11693.766,AETNA [1000108],AETNA [100010801],,,77.2,,12896.55336,5571.24423,20109.9936,percent of total billed charges,,,
Inflammatory Bowel Disease Without Cc/McC,387,MS-DRG,,,,,,,inpatient,,,12511.84,8758.288,AETNA [1000108],AETNA [100010801],,,77.2,,9659.14048,4172.69864,13582.9592,percent of total billed charges,,,
Gastrointestinal Obstruction With McC,388,MS-DRG,,,,,,,inpatient,,,25855.59,18098.913,AETNA [1000108],AETNA [100010801],,,77.2,,19960.51548,7771.48,29788.08,percent of total billed charges,,,
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,inpatient,,,16977.78,11884.446,AETNA [1000108],AETNA [100010801],,,77.2,,13106.84616,5662.08963,16245.6488,percent of total billed charges,,,
Gastrointestinal Obstruction Without Cc/McC,390,MS-DRG,,,,,,,inpatient,,,12959.35,9071.545,AETNA [1000108],AETNA [100010801],,,77.2,,10004.6182,4215.34,11086.4344,percent of total billed charges,,,
Esophagitis- Gastroenteritis And Miscellaneous Digestive Disorders With McC,391,MS-DRG,,,,,,,inpatient,,,20838.16,14586.712,AETNA [1000108],AETNA [100010801],,,77.2,,16087.05952,6949.52636,26037.2136,percent of total billed charges,,,
Esophagitis- Gastroenteritis And Miscellaneous Digestive Disorders Without McC,392,MS-DRG,,,,,,,inpatient,,,16987.8,11891.46,AETNA [1000108],AETNA [100010801],,,77.2,,13114.5816,5530.73,15811.9992,percent of total billed charges,,,
Other Digestive System Diagnoses With McC,393,MS-DRG,,,,,,,inpatient,,,37534.54,26274.178,AETNA [1000108],AETNA [100010801],,,77.2,,28976.66488,7771.48,33555.1576,percent of total billed charges,,,
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,inpatient,,,23011.57,16108.099,AETNA [1000108],AETNA [100010801],,,77.2,,17764.93204,6791.14,19074.5032,percent of total billed charges,,,
Other Digestive System Diagnoses Without Cc/McC,395,MS-DRG,,,,,,,inpatient,,,17300.89,12110.623,AETNA [1000108],AETNA [100010801],,,77.2,,13356.28708,4700.83,13840.712,percent of total billed charges,,,
Appendix Procedures With McC,397,MS-DRG,,,,,,,inpatient,,,61991.24,43393.868,AETNA [1000108],AETNA [100010801],,,77.2,,47857.23728,7771.48,50206.0864,percent of total billed charges,,,
Appendix Procedures With Cc,398,MS-DRG,,,,,,,inpatient,,,56760.43,39732.301,AETNA [1000108],AETNA [100010801],,,77.2,,43819.05196,7771.48,45408.344,percent of total billed charges,,,
Appendix Procedures Without Cc/McC,399,MS-DRG,,,,,,,inpatient,,,27586.47,19310.529,AETNA [1000108],AETNA [100010801],,,77.2,,21296.75484,7771.48,22778.7624,percent of total billed charges,,,
Pancreas- Liver And Shunt Procedures With McC,405,MS-DRG,,,,,,,inpatient,,,46019.16,32213.412,AETNA [1000108],AETNA [100010801],,,77.2,,35526.79152,7771.48,110001.0976,percent of total billed charges,,,
Pancreas- Liver And Shunt Procedures With Cc,406,MS-DRG,,,,,,,inpatient,,,55926.32,39148.424,AETNA [1000108],AETNA [100010801],,,77.2,,43175.11904,7771.48,56905.3648,percent of total billed charges,,,
Pancreas- Liver And Shunt Procedures Without Cc/McC,407,MS-DRG,,,,,,,inpatient,,,51764.06,36234.842,AETNA [1000108],AETNA [100010801],,,77.2,,39961.85432,7771.48,43275.7984,percent of total billed charges,,,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,inpatient,,,23884.65,16719.255,AETNA [1000108],AETNA [100010801],,,77.2,,18438.9498,7771.48,42479.4232,percent of total billed charges,,,
Laparoscopic Cholecystectomy Without C.D.E. With McC,417,MS-DRG,,,,,,,inpatient,,,63968.01,44777.607,AETNA [1000108],AETNA [100010801],,,77.2,,49383.30372,7771.48,51174.408,percent of total billed charges,,,
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,inpatient,,,44129.12,30890.384,AETNA [1000108],AETNA [100010801],,,77.2,,34067.68064,7771.48,35303.296,percent of total billed charges,,,
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/McC,419,MS-DRG,,,,,,,inpatient,,,36100.79,25270.553,AETNA [1000108],AETNA [100010801],,,77.2,,27869.80988,7771.48,28880.632,percent of total billed charges,,,
Hepatobiliary Diagnostic Procedures With McC,420,MS-DRG,,,,,,,inpatient,,,75254.61,52678.227,AETNA [1000108],AETNA [100010801],,,77.2,,58096.55892,7771.48,71515.7088,percent of total billed charges,,,
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,,,inpatient,,,37061.98,25943.386,AETNA [1000108],AETNA [100010801],,,77.2,,28611.84856,7771.48,33182.3,percent of total billed charges,,,
Hepatobiliary Diagnostic Procedures Without Cc/McC,422,MS-DRG,,,,,,,inpatient,,,34064.62,23845.234,AETNA [1000108],AETNA [100010801],,,77.2,,26297.88664,7771.48,29773.8952,percent of total billed charges,,,
Other Hepatobiliary Or Pancreas O.R. Procedures With McC,423,MS-DRG,,,,,,,inpatient,,,81747.41,57223.187,AETNA [1000108],AETNA [100010801],,,77.2,,63109.00052,7771.48,82415.7144,percent of total billed charges,,,
Cirrhosis And Alcoholic Hepatitis With McC,432,MS-DRG,,,,,,,inpatient,,,29574.59,20702.213,AETNA [1000108],AETNA [100010801],,,77.2,,22831.58348,7771.48,39699.2024,percent of total billed charges,,,
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,inpatient,,,21623.94,15136.758,AETNA [1000108],AETNA [100010801],,,77.2,,16693.68168,7211.58399,21676.4008,percent of total billed charges,,,
Cirrhosis And Alcoholic Hepatitis Without Cc/McC,434,MS-DRG,,,,,,,inpatient,,,14349.7,10044.79,AETNA [1000108],AETNA [100010801],,,77.2,,11077.9684,4483.05,14111.8496,percent of total billed charges,,,
Malignancy Of Hepatobiliary System Or Pancreas With McC,435,MS-DRG,,,,,,,inpatient,,,41847.14,29292.998,AETNA [1000108],AETNA [100010801],,,77.2,,32305.99208,7771.48,36971.668,percent of total billed charges,,,
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,inpatient,,,20489.14,14342.398,AETNA [1000108],AETNA [100010801],,,77.2,,15817.61608,6833.12819,22849.6864,percent of total billed charges,,,
Disorders Of Pancreas Except Malignancy With McC,438,MS-DRG,,,,,,,inpatient,,,28902.5,20231.75,AETNA [1000108],AETNA [100010801],,,77.2,,22312.73,7771.48,33715.2432,percent of total billed charges,,,
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,inpatient,,,16481.74,11537.218,AETNA [1000108],AETNA [100010801],,,77.2,,12723.90328,5496.66029,17431.0928,percent of total billed charges,,,
Disorders Of Pancreas Except Malignancy Without Cc/McC,440,MS-DRG,,,,,,,inpatient,,,15295.1,10706.57,AETNA [1000108],AETNA [100010801],,,77.2,,11807.8172,4383.92,12464.3864,percent of total billed charges,,,
Disorders Of Liver Except Malignancy- Cirrhosis Or Alcoholic Hepatitis With McC,441,MS-DRG,,,,,,,inpatient,,,34043.85,23830.695,AETNA [1000108],AETNA [100010801],,,77.2,,26281.8522,7771.48,38305.0392,percent of total billed charges,,,
Disorders Of Liver Except Malignancy- Cirrhosis Or Alcoholic Hepatitis With Cc,442,MS-DRG,,,,,,,inpatient,,,21274.77,14892.339,AETNA [1000108],AETNA [100010801],,,77.2,,16424.12244,6740.49,19579.0768,percent of total billed charges,,,
Disorders Of Liver Except Malignancy- Cirrhosis Or Alcoholic Hepatitis Without Cc/McC,443,MS-DRG,,,,,,,inpatient,,,11297.88,7908.516,AETNA [1000108],AETNA [100010801],,,77.2,,8721.96336,3767.84298,14237.4864,percent of total billed charges,,,
Disorders Of The Biliary Tract With McC,444,MS-DRG,,,,,,,inpatient,,,39694.28,27785.996,AETNA [1000108],AETNA [100010801],,,77.2,,30643.98416,7771.48,34134.708,percent of total billed charges,,,
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,inpatient,,,32558.38,22790.866,AETNA [1000108],AETNA [100010801],,,77.2,,25135.06936,7771.48,26046.704,percent of total billed charges,,,
Disorders Of The Biliary Tract Without Cc/McC,446,MS-DRG,,,,,,,inpatient,,,33146.93,23202.851,AETNA [1000108],AETNA [100010801],,,77.2,,25589.42996,5905.53,26517.544,percent of total billed charges,,,
Combined Anterior And Posterior Spinal Fusion With McC,453,MS-DRG,,,,,,,inpatient,,,126551.26,88585.882,AETNA [1000108],AETNA [100010801],,,77.2,,97697.57272,7771.48,101241.008,percent of total billed charges,,,
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,,,inpatient,,,108469.17,75928.419,AETNA [1000108],AETNA [100010801],,,77.2,,83738.19924,7771.48,86775.336,percent of total billed charges,,,
Combined Anterior And Posterior Spinal Fusion Without Cc/McC,455,MS-DRG,,,,,,,inpatient,,,115580.93,80906.651,AETNA [1000108],AETNA [100010801],,,77.2,,89228.47796,7771.48,92464.744,percent of total billed charges,,,
Spinal Fusion Except Cervical With Spinal Curvature- Malignancy- Infection Or Extensive Fusions With Cc,457,MS-DRG,,,,,,,inpatient,,,143333.97,100333.779,AETNA [1000108],AETNA [100010801],,,77.2,,110653.8248,7771.48,116295.096,percent of total billed charges,,,
Spinal Fusion Except Cervical With McC,459,MS-DRG,,,,,,,inpatient,,,98009.72,68606.804,AETNA [1000108],AETNA [100010801],,,77.2,,75663.50384,7771.48,78407.776,percent of total billed charges,,,
Spinal Fusion Except Cervical Without McC,460,MS-DRG,,,,,,,inpatient,,,99867.86,69907.502,AETNA [1000108],AETNA [100010801],,,77.2,,77097.98792,7771.48,79894.288,percent of total billed charges,,,
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With McC,461,MS-DRG,,,,,,,inpatient,,,327456.17,229219.319,AETNA [1000108],AETNA [100010801],,,77.2,,252796.1632,7771.48,261964.936,percent of total billed charges,,,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With McC,463,MS-DRG,,,,,,,inpatient,,,128878.42,90214.894,AETNA [1000108],AETNA [100010801],,,77.2,,99494.14024,7771.48,109439.7848,percent of total billed charges,,,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With Cc,464,MS-DRG,,,,,,,inpatient,,,40970.26,28679.182,AETNA [1000108],AETNA [100010801],,,77.2,,31629.04072,7771.48,59750.4304,percent of total billed charges,,,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Without Cc/McC,465,MS-DRG,,,,,,,inpatient,,,35885.97,25120.179,AETNA [1000108],AETNA [100010801],,,77.2,,27703.96884,7771.48,35176.2776,percent of total billed charges,,,
Revision Of Hip Or Knee Replacement With McC,466,MS-DRG,,,,,,,inpatient,,,84828.36,59379.852,AETNA [1000108],AETNA [100010801],,,77.2,,65487.49392,7771.48,103230.8952,percent of total billed charges,,,
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,inpatient,,,72170.88,50519.616,AETNA [1000108],AETNA [100010801],,,77.2,,55715.91936,7771.48,69402.1736,percent of total billed charges,,,
Revision Of Hip Or Knee Replacement Without Cc/McC,468,MS-DRG,,,,,,,inpatient,,,88973.4,62281.38,AETNA [1000108],AETNA [100010801],,,77.2,,68687.4648,7771.48,71178.72,percent of total billed charges,,,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With McC Or Total Ankle Replacement,469,MS-DRG,,,,,,,inpatient,,,112079.98,78455.986,AETNA [1000108],AETNA [100010801],,,77.2,,86525.74456,7771.48,89663.984,percent of total billed charges,,,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without McC,470,MS-DRG,,,,,,,inpatient,,,49135.63,34394.941,AETNA [1000108],AETNA [100010801],,,77.2,,37932.70636,7771.48,39308.504,percent of total billed charges,,,
Cervical Spinal Fusion With McC,471,MS-DRG,,,,,,,inpatient,,,68213.66,47749.562,AETNA [1000108],AETNA [100010801],,,77.2,,52660.94552,7771.48,98422.248,percent of total billed charges,,,
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,inpatient,,,62194.58,43536.206,AETNA [1000108],AETNA [100010801],,,77.2,,48014.21576,7771.48,58704.808,percent of total billed charges,,,
Cervical Spinal Fusion Without Cc/McC,473,MS-DRG,,,,,,,inpatient,,,60389.67,42272.769,AETNA [1000108],AETNA [100010801],,,77.2,,46620.82524,7771.48,48311.736,percent of total billed charges,,,
Amputation For Musculoskeletal System And Connective Tissue Disorders With McC,474,MS-DRG,,,,,,,inpatient,,,118369.6,82858.72,AETNA [1000108],AETNA [100010801],,,77.2,,91381.3312,7771.48,94695.68,percent of total billed charges,,,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,inpatient,,,42743.34,29920.338,AETNA [1000108],AETNA [100010801],,,77.2,,32997.85848,7771.48,43711.4744,percent of total billed charges,,,
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/McC,476,MS-DRG,,,,,,,inpatient,,,10865.65,7605.955,AETNA [1000108],AETNA [100010801],,,77.2,,8388.2818,3623.694275,23567.032,percent of total billed charges,,,
Biopsies Of Musculoskeletal System And Connective Tissue With McC,477,MS-DRG,,,,,,,inpatient,,,79298.26,55508.782,AETNA [1000108],AETNA [100010801],,,77.2,,61218.25672,7771.48,69683.8432,percent of total billed charges,,,
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,inpatient,,,43683.25,30578.275,AETNA [1000108],AETNA [100010801],,,77.2,,33723.469,7771.48,47385.3376,percent of total billed charges,,,
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/McC,479,MS-DRG,,,,,,,inpatient,,,48180.79,33726.553,AETNA [1000108],AETNA [100010801],,,77.2,,37195.56988,7771.48,38544.632,percent of total billed charges,,,
Hip And Femur Procedures Except Major Joint With McC,480,MS-DRG,,,,,,,inpatient,,,63845.68,44691.976,AETNA [1000108],AETNA [100010801],,,77.2,,49288.86496,7771.48,59596.424,percent of total billed charges,,,
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,inpatient,,,51147.69,35803.383,AETNA [1000108],AETNA [100010801],,,77.2,,39486.01668,7771.48,42045.7736,percent of total billed charges,,,
Hip And Femur Procedures Except Major Joint Without Cc/McC,482,MS-DRG,,,,,,,inpatient,,,37492.92,26245.044,AETNA [1000108],AETNA [100010801],,,77.2,,28944.53424,7771.48,32146.8096,percent of total billed charges,,,
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,inpatient,,,82685.37,57879.759,AETNA [1000108],AETNA [100010801],,,77.2,,63833.10564,7771.48,66148.296,percent of total billed charges,,,
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,inpatient,,,54953.11,38467.177,AETNA [1000108],AETNA [100010801],,,77.2,,42423.80092,7771.48,43962.488,percent of total billed charges,,,
Knee Procedures With Principal Diagnosis Of Infection Without Cc/McC,487,MS-DRG,,,,,,,inpatient,,,28558.04,19990.628,AETNA [1000108],AETNA [100010801],,,77.2,,22046.80688,7771.48,32019.1464,percent of total billed charges,,,
Knee Procedures Without Principal Diagnosis Of Infection With Cc/McC,488,MS-DRG,,,,,,,inpatient,,,29907.22,20935.054,AETNA [1000108],AETNA [100010801],,,77.2,,23088.37384,7771.48,39824.8392,percent of total billed charges,,,
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/McC,489,MS-DRG,,,,,,,inpatient,,,28726.07,20108.249,AETNA [1000108],AETNA [100010801],,,77.2,,22176.52604,7771.48,25098.9904,percent of total billed charges,,,
Lower Extremity And Humerus Procedures Except Hip- Foot And Femur With McC,492,MS-DRG,,,,,,,inpatient,,,73476.69,51433.683,AETNA [1000108],AETNA [100010801],,,77.2,,56724.00468,7771.48,71957.464,percent of total billed charges,,,
Lower Extremity And Humerus Procedures Except Hip- Foot And Femur With Cc,493,MS-DRG,,,,,,,inpatient,,,59232.47,41462.729,AETNA [1000108],AETNA [100010801],,,77.2,,45727.46684,7771.48,48653.864,percent of total billed charges,,,
Lower Extremity And Humerus Procedures Except Hip- Foot And Femur Without Cc/McC,494,MS-DRG,,,,,,,inpatient,,,55024.26,38516.982,AETNA [1000108],AETNA [100010801],,,77.2,,42478.72872,7771.48,44019.408,percent of total billed charges,,,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/McC,497,MS-DRG,,,,,,,inpatient,,,25582.79,17907.953,AETNA [1000108],AETNA [100010801],,,77.2,,19749.91388,7771.48,27214.552,percent of total billed charges,,,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/McC,498,MS-DRG,,,,,,,inpatient,,,53889.53,37722.671,AETNA [1000108],AETNA [100010801],,,77.2,,41602.71716,7771.48,51160.5208,percent of total billed charges,,,
Soft Tissue Procedures With McC,500,MS-DRG,,,,,,,inpatient,,,39746.36,27822.452,AETNA [1000108],AETNA [100010801],,,77.2,,30684.18992,7771.48,64206.484,percent of total billed charges,,,
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,inpatient,,,35413.37,24789.359,AETNA [1000108],AETNA [100010801],,,77.2,,27339.12164,7771.48,36169.2136,percent of total billed charges,,,
Soft Tissue Procedures Without Cc/McC,502,MS-DRG,,,,,,,inpatient,,,46820.44,32774.308,AETNA [1000108],AETNA [100010801],,,77.2,,36145.37968,7771.48,37456.352,percent of total billed charges,,,
Foot Procedures With McC,503,MS-DRG,,,,,,,inpatient,,,139085.96,97360.172,AETNA [1000108],AETNA [100010801],,,77.2,,107374.3611,7771.48,111268.768,percent of total billed charges,,,
Foot Procedures With Cc,504,MS-DRG,,,,,,,inpatient,,,58509.52,40956.664,AETNA [1000108],AETNA [100010801],,,77.2,,45169.34944,7771.48,46807.616,percent of total billed charges,,,
Foot Procedures Without Cc/McC,505,MS-DRG,,,,,,,inpatient,,,18215.65,12750.955,AETNA [1000108],AETNA [100010801],,,77.2,,14062.4818,6074.919275,35575.4784,percent of total billed charges,,,
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,inpatient,,,34935.4,24454.78,AETNA [1000108],AETNA [100010801],,,77.2,,26970.1288,7771.48,30375.736,percent of total billed charges,,,
Major Shoulder Or Elbow Joint Procedures With Cc/McC,507,MS-DRG,,,,,,,inpatient,,,46308.19,32415.733,AETNA [1000108],AETNA [100010801],,,77.2,,35749.92268,7771.48,39273.6584,percent of total billed charges,,,
Major Shoulder Or Elbow Joint Procedures Without Cc/McC,508,MS-DRG,,,,,,,inpatient,,,21924.51,15347.157,AETNA [1000108],AETNA [100010801],,,77.2,,16925.72172,7311.824085,26152.7184,percent of total billed charges,,,
Arthroscopy,509,MS-DRG,,,,,,,inpatient,,,27294.99,19106.493,AETNA [1000108],AETNA [100010801],,,77.2,,21071.73228,7771.48,35593.716,percent of total billed charges,,,
Shoulder- Elbow Or Forearm Procedures- Except Major Joint Procedures With McC,510,MS-DRG,,,,,,,inpatient,,,62572,43800.4,AETNA [1000108],AETNA [100010801],,,77.2,,48305.584,7771.48,57914.512,percent of total billed charges,,,
Shoulder- Elbow Or Forearm Procedures- Except Major Joint Procedures With Cc,511,MS-DRG,,,,,,,inpatient,,,55415.55,38790.885,AETNA [1000108],AETNA [100010801],,,77.2,,42780.8046,7771.48,44332.44,percent of total billed charges,,,
Shoulder- Elbow Or Forearm Procedures- Except Major Joint Procedures Without Cc/McC,512,MS-DRG,,,,,,,inpatient,,,47238.2,33066.74,AETNA [1000108],AETNA [100010801],,,77.2,,36467.8904,7771.48,37790.56,percent of total billed charges,,,
Hand Or Wrist Procedures- Except Major Thumb Or Joint Procedures With Cc/McC,513,MS-DRG,,,,,,,inpatient,,,43600.38,30520.266,AETNA [1000108],AETNA [100010801],,,77.2,,33659.49336,7771.48,34880.304,percent of total billed charges,,,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With McC,515,MS-DRG,,,,,,,inpatient,,,49277.7,34494.39,AETNA [1000108],AETNA [100010801],,,77.2,,38042.3844,7771.48,62660.3408,percent of total billed charges,,,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,inpatient,,,53176.69,37223.683,AETNA [1000108],AETNA [100010801],,,77.2,,41052.40468,7771.48,42541.352,percent of total billed charges,,,
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/McC,517,MS-DRG,,,,,,,inpatient,,,52111.68,36478.176,AETNA [1000108],AETNA [100010801],,,77.2,,40230.21696,7771.48,41689.344,percent of total billed charges,,,
Back And Neck Procedures Except Spinal Fusion With McC Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,inpatient,,,37618.21,26332.747,AETNA [1000108],AETNA [100010801],,,77.2,,29041.25812,7771.48,72622.1232,percent of total billed charges,,,
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,inpatient,,,45454.66,31818.262,AETNA [1000108],AETNA [100010801],,,77.2,,35090.99752,7771.48,39954.5288,percent of total billed charges,,,
Back And Neck Procedures Except Spinal Fusion Without Cc/McC,520,MS-DRG,,,,,,,inpatient,,,30414.64,21290.248,AETNA [1000108],AETNA [100010801],,,77.2,,23480.10208,7771.48,29040.3384,percent of total billed charges,,,
Hip Replacement With Principal Diagnosis Of Hip Fracture With McC,521,MS-DRG,,,,,,,inpatient,,,66299.82,46409.874,AETNA [1000108],AETNA [100010801],,,77.2,,51183.46104,7771.48,59061.4544,percent of total billed charges,,,
Hip Replacement With Principal Diagnosis Of Hip Fracture Without McC,522,MS-DRG,,,,,,,inpatient,,,59172.56,41420.792,AETNA [1000108],AETNA [100010801],,,77.2,,45681.21632,7771.48,47338.048,percent of total billed charges,,,
Fractures Of Femur With McC,533,MS-DRG,,,,,,,inpatient,,,15534.08,10873.856,AETNA [1000108],AETNA [100010801],,,77.2,,11992.30976,5180.61568,30898.5472,percent of total billed charges,,,
Fractures Of Femur Without McC,534,MS-DRG,,,,,,,inpatient,,,23461.3,16422.91,AETNA [1000108],AETNA [100010801],,,77.2,,18112.1236,5705.828554,18769.04,percent of total billed charges,,,
Fractures Of Hip And Pelvis With McC,535,MS-DRG,,,,,,,inpatient,,,19899.42,13929.594,AETNA [1000108],AETNA [100010801],,,77.2,,15362.35224,6636.45657,26949.0936,percent of total billed charges,,,
Fractures Of Hip And Pelvis Without McC,536,MS-DRG,,,,,,,inpatient,,,17540.07,12278.049,AETNA [1000108],AETNA [100010801],,,77.2,,13540.93404,5582.83,16432.0776,percent of total billed charges,,,
Sprains- Strains- And Dislocations Of Hip- Pelvis And Thigh With Cc/McC,537,MS-DRG,,,,,,,inpatient,,,18243.05,12770.135,AETNA [1000108],AETNA [100010801],,,77.2,,14083.6346,6084.057175,18620.5896,percent of total billed charges,,,
Sprains- Strains- And Dislocations Of Hip- Pelvis And Thigh Without Cc/McC,538,MS-DRG,,,,,,,inpatient,,,12750.59,8925.413,AETNA [1000108],AETNA [100010801],,,77.2,,9843.45548,4252.321765,13607.276,percent of total billed charges,,,
Osteomyelitis With McC,539,MS-DRG,,,,,,,inpatient,,,15126.14,10588.298,AETNA [1000108],AETNA [100010801],,,77.2,,11677.38008,5044.56769,40987.9928,percent of total billed charges,,,
Osteomyelitis With Cc,540,MS-DRG,,,,,,,inpatient,,,18734.75,13114.325,AETNA [1000108],AETNA [100010801],,,77.2,,14463.227,6248.039125,26229.7216,percent of total billed charges,,,
Osteomyelitis Without Cc/McC,541,MS-DRG,,,,,,,inpatient,,,13958.41,9770.887,AETNA [1000108],AETNA [100010801],,,77.2,,10775.89252,4655.129735,17726.9472,percent of total billed charges,,,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With McC,542,MS-DRG,,,,,,,inpatient,,,18971.85,13280.295,AETNA [1000108],AETNA [100010801],,,77.2,,14646.2682,6327.111975,37790.3336,percent of total billed charges,,,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,inpatient,,,20157.83,14110.481,AETNA [1000108],AETNA [100010801],,,77.2,,15561.84476,6722.636305,21496.0512,percent of total billed charges,,,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/McC,544,MS-DRG,,,,,,,inpatient,,,15770.25,11039.175,AETNA [1000108],AETNA [100010801],,,77.2,,12174.633,5259.378375,15313.5048,percent of total billed charges,,,
Connective Tissue Disorders With McC,545,MS-DRG,,,,,,,inpatient,,,29219.27,20453.489,AETNA [1000108],AETNA [100010801],,,77.2,,22557.27644,7771.48,51201.0488,percent of total billed charges,,,
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,inpatient,,,19656.15,13759.305,AETNA [1000108],AETNA [100010801],,,77.2,,15174.5478,6555.326025,23459.6328,percent of total billed charges,,,
Connective Tissue Disorders Without Cc/McC,547,MS-DRG,,,,,,,inpatient,,,8610.08,6027.056,AETNA [1000108],AETNA [100010801],,,77.2,,6646.98176,2871.46168,15120.9968,percent of total billed charges,,,
Septic Arthritis With Cc,549,MS-DRG,,,,,,,inpatient,,,46061.25,32242.875,AETNA [1000108],AETNA [100010801],,,77.2,,35559.285,7771.48,36849,percent of total billed charges,,,
Medical Back Problems With McC,551,MS-DRG,,,,,,,inpatient,,,27883.52,19518.464,AETNA [1000108],AETNA [100010801],,,77.2,,21526.07744,7771.48,34576.4632,percent of total billed charges,,,
Medical Back Problems Without McC,552,MS-DRG,,,,,,,inpatient,,,22361.84,15653.288,AETNA [1000108],AETNA [100010801],,,77.2,,17263.34048,6815.74,19530.4432,percent of total billed charges,,,
Bone Diseases And Arthropathies With McC,553,MS-DRG,,,,,,,inpatient,,,13901.34,9730.938,AETNA [1000108],AETNA [100010801],,,77.2,,10731.83448,4636.09689,26470.8632,percent of total billed charges,,,
Bone Diseases And Arthropathies Without McC,554,MS-DRG,,,,,,,inpatient,,,18962.8,13273.96,AETNA [1000108],AETNA [100010801],,,77.2,,14639.2816,5718.85,16912.3344,percent of total billed charges,,,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without McC,556,MS-DRG,,,,,,,inpatient,,,20178.82,14125.174,AETNA [1000108],AETNA [100010801],,,77.2,,15578.04904,5833.89,16545.556,percent of total billed charges,,,
Tendonitis- Myositis And Bursitis With McC,557,MS-DRG,,,,,,,inpatient,,,32769.21,22938.447,AETNA [1000108],AETNA [100010801],,,77.2,,25297.83012,7771.48,31403.1208,percent of total billed charges,,,
Tendonitis- Myositis And Bursitis Without McC,558,MS-DRG,,,,,,,inpatient,,,15272.59,10690.813,AETNA [1000108],AETNA [100010801],,,77.2,,11790.43948,5093.408765,17504.0432,percent of total billed charges,,,
Aftercare- Musculoskeletal System And Connective Tissue With McC,559,MS-DRG,,,,,,,inpatient,,,16267.53,11387.271,AETNA [1000108],AETNA [100010801],,,77.2,,12558.53316,5425.221255,37612.0104,percent of total billed charges,,,
Aftercare- Musculoskeletal System And Connective Tissue With Cc,560,MS-DRG,,,,,,,inpatient,,,15449.56,10814.692,AETNA [1000108],AETNA [100010801],,,77.2,,11927.06032,5152.42826,23076.6432,percent of total billed charges,,,
Aftercare- Musculoskeletal System And Connective Tissue Without Cc/McC,561,MS-DRG,,,,,,,inpatient,,,9300.65,6510.455,AETNA [1000108],AETNA [100010801],,,77.2,,7180.1018,3101.766775,16567.8464,percent of total billed charges,,,
Fracture- Sprain- Strain And Dislocation Except Femur- Hip- Pelvis And Thigh With McC,562,MS-DRG,,,,,,,inpatient,,,32385.67,22669.969,AETNA [1000108],AETNA [100010801],,,77.2,,25001.73724,7771.48,29660.4168,percent of total billed charges,,,
Fracture- Sprain- Strain And Dislocation Except Femur- Hip- Pelvis And Thigh Without McC,563,MS-DRG,,,,,,,inpatient,,,24167.6,16917.32,AETNA [1000108],AETNA [100010801],,,77.2,,18657.3872,6300.58,19334.08,percent of total billed charges,,,
Other Musculoskeletal System And Connective Tissue Diagnoses With McC,564,MS-DRG,,,,,,,inpatient,,,25802.93,18062.051,AETNA [1000108],AETNA [100010801],,,77.2,,19919.86196,7771.48,31798.2688,percent of total billed charges,,,
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,inpatient,,,22006.13,15404.291,AETNA [1000108],AETNA [100010801],,,77.2,,16988.73236,7280.97,20661.1744,percent of total billed charges,,,
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/McC,566,MS-DRG,,,,,,,inpatient,,,6764.1,4734.87,AETNA [1000108],AETNA [100010801],,,77.2,,5221.8852,2255.82735,15157.472,percent of total billed charges,,,
Skin Debridement With McC,570,MS-DRG,,,,,,,inpatient,,,33594.41,23516.087,AETNA [1000108],AETNA [100010801],,,77.2,,25934.88452,7771.48,61002.7456,percent of total billed charges,,,
Skin Debridement With Cc,571,MS-DRG,,,,,,,inpatient,,,26173.08,18321.156,AETNA [1000108],AETNA [100010801],,,77.2,,20205.61776,7771.48,33938.1472,percent of total billed charges,,,
Skin Graft For Skin Ulcer Or Cellulitis With McC,573,MS-DRG,,,,,,,inpatient,,,229287.37,160501.159,AETNA [1000108],AETNA [100010801],,,77.2,,177009.8496,7771.48,183429.896,percent of total billed charges,,,
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,inpatient,,,76990.64,53893.448,AETNA [1000108],AETNA [100010801],,,77.2,,59436.77408,7771.48,70208.6808,percent of total billed charges,,,
Other Skin- Subcutaneous Tissue And Breast Procedures With McC,579,MS-DRG,,,,,,,inpatient,,,44370,31059,AETNA [1000108],AETNA [100010801],,,77.2,,34253.64,7771.48,66042.4024,percent of total billed charges,,,
Other Skin- Subcutaneous Tissue And Breast Procedures With Cc,580,MS-DRG,,,,,,,inpatient,,,32530.15,22771.105,AETNA [1000108],AETNA [100010801],,,77.2,,25113.2758,7771.48,35926.0456,percent of total billed charges,,,
Other Skin- Subcutaneous Tissue And Breast Procedures Without Cc/McC,581,MS-DRG,,,,,,,inpatient,,,34001.93,23801.351,AETNA [1000108],AETNA [100010801],,,77.2,,26249.48996,7771.48,29161.9224,percent of total billed charges,,,
Mastectomy For Malignancy Without Cc/McC,583,MS-DRG,,,,,,,inpatient,,,26986.11,18890.277,AETNA [1000108],AETNA [100010801],,,77.2,,20833.27692,7771.48,33283.62,percent of total billed charges,,,
Breast Biopsy- Local Excision And Other Breast Procedures With Cc/McC,584,MS-DRG,,,,,,,inpatient,,,15783.7,11048.59,AETNA [1000108],AETNA [100010801],,,77.2,,12185.0164,5263.86395,41486.4872,percent of total billed charges,,,
Skin Ulcers With McC,592,MS-DRG,,,,,,,inpatient,,,11607.65,8125.355,AETNA [1000108],AETNA [100010801],,,77.2,,8961.1058,3871.151275,41666.8368,percent of total billed charges,,,
Skin Ulcers With Cc,593,MS-DRG,,,,,,,inpatient,,,11196.69,7837.683,AETNA [1000108],AETNA [100010801],,,77.2,,8643.84468,3734.096115,24774.7664,percent of total billed charges,,,
Skin Ulcers Without Cc/McC,594,MS-DRG,,,,,,,inpatient,,,9029.64,6320.748,AETNA [1000108],AETNA [100010801],,,77.2,,6970.88208,3011.38494,17196.0304,percent of total billed charges,,,
Major Skin Disorders With McC,595,MS-DRG,,,,,,,inpatient,,,27847.46,19493.222,AETNA [1000108],AETNA [100010801],,,77.2,,21498.23912,7771.48,42858.36,percent of total billed charges,,,
Major Skin Disorders Without McC,596,MS-DRG,,,,,,,inpatient,,,30386.11,21270.277,AETNA [1000108],AETNA [100010801],,,77.2,,23458.07692,7157.25,24308.888,percent of total billed charges,,,
Malignant Breast Disorders With McC,597,MS-DRG,,,,,,,inpatient,,,49956.04,34969.228,AETNA [1000108],AETNA [100010801],,,77.2,,38566.06288,7771.48,39964.832,percent of total billed charges,,,
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,inpatient,,,27430.15,19201.105,AETNA [1000108],AETNA [100010801],,,77.2,,21176.0758,7771.48,21944.12,percent of total billed charges,,,
Non-Malignant Breast Disorders With Cc/McC,600,MS-DRG,,,,,,,inpatient,,,13956.43,9769.501,AETNA [1000108],AETNA [100010801],,,77.2,,10774.36396,4654.469405,19396.7008,percent of total billed charges,,,
Non-Malignant Breast Disorders Without Cc/McC,601,MS-DRG,,,,,,,inpatient,,,9383.02,6568.114,AETNA [1000108],AETNA [100010801],,,77.2,,7243.69144,3129.23717,12148.268,percent of total billed charges,,,
Cellulitis With McC,602,MS-DRG,,,,,,,inpatient,,,27986.19,19590.333,AETNA [1000108],AETNA [100010801],,,77.2,,21605.33868,7771.48,29775.9216,percent of total billed charges,,,
Cellulitis Without McC,603,MS-DRG,,,,,,,inpatient,,,16886.67,11820.669,AETNA [1000108],AETNA [100010801],,,77.2,,13036.50924,5631.704445,17850.5576,percent of total billed charges,,,
Trauma To The Skin- Subcutaneous Tissue And Breast With McC,604,MS-DRG,,,,,,,inpatient,,,38556.84,26989.788,AETNA [1000108],AETNA [100010801],,,77.2,,29765.88048,7771.48,30845.472,percent of total billed charges,,,
Trauma To The Skin- Subcutaneous Tissue And Breast Without McC,605,MS-DRG,,,,,,,inpatient,,,21359.36,14951.552,AETNA [1000108],AETNA [100010801],,,77.2,,16489.42592,6578.42,18717.8568,percent of total billed charges,,,
Minor Skin Disorders With McC,606,MS-DRG,,,,,,,inpatient,,,6185.67,4329.969,AETNA [1000108],AETNA [100010801],,,77.2,,4775.33724,2062.920945,32627.0664,percent of total billed charges,,,
Minor Skin Disorders Without McC,607,MS-DRG,,,,,,,inpatient,,,19860.65,13902.455,AETNA [1000108],AETNA [100010801],,,77.2,,15332.4218,5973.54,17514.1752,percent of total billed charges,,,
Adrenal And Pituitary Procedures With Cc/McC,614,MS-DRG,,,,,,,inpatient,,,37769.13,26438.391,AETNA [1000108],AETNA [100010801],,,77.2,,29157.76836,7771.48,46177.6032,percent of total billed charges,,,
Adrenal And Pituitary Procedures Without Cc/McC,615,MS-DRG,,,,,,,inpatient,,,58015.91,40611.137,AETNA [1000108],AETNA [100010801],,,77.2,,44788.28252,7771.48,46412.728,percent of total billed charges,,,
Amputation Of Lower Limb For Endocrine- Nutritional And Metabolic Disorders With McC,616,MS-DRG,,,,,,,inpatient,,,66449.27,46514.489,AETNA [1000108],AETNA [100010801],,,77.2,,51298.83644,7771.48,78318.3336,percent of total billed charges,,,
Amputation Of Lower Limb For Endocrine- Nutritional And Metabolic Disorders With Cc,617,MS-DRG,,,,,,,inpatient,,,29882.58,20917.806,AETNA [1000108],AETNA [100010801],,,77.2,,23069.35176,7771.48,39154.1008,percent of total billed charges,,,
Amputation Of Lower Limb For Endocrine- Nutritional And Metabolic Disorders Without Cc/McC,618,MS-DRG,,,,,,,inpatient,,,10245.69,7171.983,AETNA [1000108],AETNA [100010801],,,77.2,,7909.67268,3416.937615,25228.68,percent of total billed charges,,,
Skin Grafts And Wound Debridement For Endocrine- Nutritional And Metabolic Disorders With McC,622,MS-DRG,,,,,,,inpatient,,,103303.17,72312.219,AETNA [1000108],AETNA [100010801],,,77.2,,79750.04724,7771.48,82642.536,percent of total billed charges,,,
Skin Grafts And Wound Debridement For Endocrine- Nutritional And Metabolic Disorders With Cc,623,MS-DRG,,,,,,,inpatient,,,20666.05,14466.235,AETNA [1000108],AETNA [100010801],,,77.2,,15954.1906,6892.127675,38785.296,percent of total billed charges,,,
Thyroid- Parathyroid And Thyroglossal Procedures With Cc,626,MS-DRG,,,,,,,inpatient,,,27302.86,19112.002,AETNA [1000108],AETNA [100010801],,,77.2,,21077.80792,7771.48,30582.4288,percent of total billed charges,,,
Thyroid- Parathyroid And Thyroglossal Procedures Without Cc/McC,627,MS-DRG,,,,,,,inpatient,,,31328.53,21929.971,AETNA [1000108],AETNA [100010801],,,77.2,,24185.62516,7771.48,25670.4352,percent of total billed charges,,,
Other Endocrine- Nutritional And Metabolic O.R. Procedures With McC,628,MS-DRG,,,,,,,inpatient,,,48752.32,34126.624,AETNA [1000108],AETNA [100010801],,,77.2,,37636.79104,7771.48,79967.8232,percent of total billed charges,,,
Other Endocrine- Nutritional And Metabolic O.R. Procedures With Cc,629,MS-DRG,,,,,,,inpatient,,,41481.26,29036.882,AETNA [1000108],AETNA [100010801],,,77.2,,32023.53272,7771.48,45596.0264,percent of total billed charges,,,
Diabetes With McC,637,MS-DRG,,,,,,,inpatient,,,33585.6,23509.92,AETNA [1000108],AETNA [100010801],,,77.2,,25928.0832,7771.48,29510.4632,percent of total billed charges,,,
Diabetes With Cc,638,MS-DRG,,,,,,,inpatient,,,16607.1,11624.97,AETNA [1000108],AETNA [100010801],,,77.2,,12820.6812,5538.46785,18586.1408,percent of total billed charges,,,
Diabetes Without Cc/McC,639,MS-DRG,,,,,,,inpatient,,,15715.82,11001.074,AETNA [1000108],AETNA [100010801],,,77.2,,12132.61304,4408.52,12697.4224,percent of total billed charges,,,
Miscellaneous Disorders Of Nutrition- Metabolism- Fluids And Electrolytes With McC,640,MS-DRG,,,,,,,inpatient,,,19706.61,13794.627,AETNA [1000108],AETNA [100010801],,,77.2,,15213.50292,6572.154435,26912.6184,percent of total billed charges,,,
Miscellaneous Disorders Of Nutrition- Metabolism- Fluids And Electrolytes Without McC,641,MS-DRG,,,,,,,inpatient,,,15211.2,10647.84,AETNA [1000108],AETNA [100010801],,,77.2,,11743.0464,5072.9352,15836.316,percent of total billed charges,,,
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,inpatient,,,44600.9,31220.63,AETNA [1000108],AETNA [100010801],,,77.2,,34431.8948,7771.48,35680.72,percent of total billed charges,,,
Endocrine Disorders With McC,643,MS-DRG,,,,,,,inpatient,,,24319.36,17023.552,AETNA [1000108],AETNA [100010801],,,77.2,,18774.54592,7771.48,33583.5272,percent of total billed charges,,,
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,inpatient,,,18127.98,12689.586,AETNA [1000108],AETNA [100010801],,,77.2,,13994.80056,6045.68133,20942.844,percent of total billed charges,,,
Endocrine Disorders Without Cc/McC,645,MS-DRG,,,,,,,inpatient,,,13087.48,9161.236,AETNA [1000108],AETNA [100010801],,,77.2,,10103.53456,4364.67458,15785.656,percent of total billed charges,,,
Major Bladder Procedures With McC,653,MS-DRG,,,,,,,inpatient,,,74103.71,51872.597,AETNA [1000108],AETNA [100010801],,,77.2,,57208.06412,7771.48,112955.5888,percent of total billed charges,,,
Major Bladder Procedures With Cc,654,MS-DRG,,,,,,,inpatient,,,32847.58,22993.306,AETNA [1000108],AETNA [100010801],,,77.2,,25358.33176,7771.48,57182.9816,percent of total billed charges,,,
Kidney And Ureter Procedures For Neoplasm With McC,656,MS-DRG,,,,,,,inpatient,,,74882.24,52417.568,AETNA [1000108],AETNA [100010801],,,77.2,,57809.08928,7771.48,66014.0328,percent of total billed charges,,,
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,inpatient,,,35825.52,25077.864,AETNA [1000108],AETNA [100010801],,,77.2,,27657.30144,7771.48,37042.592,percent of total billed charges,,,
Kidney And Ureter Procedures For Neoplasm Without Cc/McC,658,MS-DRG,,,,,,,inpatient,,,45531.4,31871.98,AETNA [1000108],AETNA [100010801],,,77.2,,35150.2408,7771.48,36425.12,percent of total billed charges,,,
Kidney And Ureter Procedures For Non-Neoplasm With McC,659,MS-DRG,,,,,,,inpatient,,,43577.66,30504.362,AETNA [1000108],AETNA [100010801],,,77.2,,33641.95352,7771.48,52366.2288,percent of total billed charges,,,
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,inpatient,,,27744.56,19421.192,AETNA [1000108],AETNA [100010801],,,77.2,,21418.80032,7771.48,27151.7336,percent of total billed charges,,,
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/McC,661,MS-DRG,,,,,,,inpatient,,,23214.29,16250.003,AETNA [1000108],AETNA [100010801],,,77.2,,17921.43188,7701.35,20803.0224,percent of total billed charges,,,
Minor Bladder Procedures With McC,662,MS-DRG,,,,,,,inpatient,,,26200.57,18340.399,AETNA [1000108],AETNA [100010801],,,77.2,,20226.84004,7771.48,63211.5216,percent of total billed charges,,,
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,inpatient,,,51470.37,36029.259,AETNA [1000108],AETNA [100010801],,,77.2,,39735.12564,7771.48,41176.296,percent of total billed charges,,,
Minor Bladder Procedures Without Cc/McC,664,MS-DRG,,,,,,,inpatient,,,21663.46,15164.422,AETNA [1000108],AETNA [100010801],,,77.2,,16724.19112,7224.76391,21881.0672,percent of total billed charges,,,
Prostatectomy With McC,665,MS-DRG,,,,,,,inpatient,,,440302,308211.4,AETNA [1000108],AETNA [100010801],,,77.2,,339913.144,7771.48,352241.6,percent of total billed charges,,,
Prostatectomy With Cc,666,MS-DRG,,,,,,,inpatient,,,21861.75,15303.225,AETNA [1000108],AETNA [100010801],,,77.2,,16877.271,7290.893625,33378.8608,percent of total billed charges,,,
Prostatectomy Without Cc/McC,667,MS-DRG,,,,,,,inpatient,,,16201.02,11340.714,AETNA [1000108],AETNA [100010801],,,77.2,,12507.18744,5403.04017,20825.3128,percent of total billed charges,,,
Transurethral Procedures With McC,668,MS-DRG,,,,,,,inpatient,,,48931.22,34251.854,AETNA [1000108],AETNA [100010801],,,77.2,,37774.90184,7771.48,59091.8504,percent of total billed charges,,,
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,inpatient,,,33035.66,23124.962,AETNA [1000108],AETNA [100010801],,,77.2,,25503.52952,7771.48,31358.54,percent of total billed charges,,,
Transurethral Procedures Without Cc/McC,670,MS-DRG,,,,,,,inpatient,,,33732.79,23612.953,AETNA [1000108],AETNA [100010801],,,77.2,,26041.71388,7065.36,26986.232,percent of total billed charges,,,
Other Kidney And Urinary Tract Procedures With McC,673,MS-DRG,,,,,,,inpatient,,,60478,42334.6,AETNA [1000108],AETNA [100010801],,,77.2,,46689.016,7771.48,84906.16,percent of total billed charges,,,
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,inpatient,,,73440.29,51408.203,AETNA [1000108],AETNA [100010801],,,77.2,,56695.90388,7771.48,58752.232,percent of total billed charges,,,
Renal Failure With McC,682,MS-DRG,,,,,,,inpatient,,,25189.25,17632.475,AETNA [1000108],AETNA [100010801],,,77.2,,19446.101,7771.48,30436.528,percent of total billed charges,,,
Renal Failure With Cc,683,MS-DRG,,,,,,,inpatient,,,17753.72,12427.604,AETNA [1000108],AETNA [100010801],,,77.2,,13705.87184,5920.86562,18012.6696,percent of total billed charges,,,
Renal Failure Without Cc/McC,684,MS-DRG,,,,,,,inpatient,,,9135.38,6394.766,AETNA [1000108],AETNA [100010801],,,77.2,,7052.51336,3046.64923,12310.38,percent of total billed charges,,,
Kidney And Urinary Tract Neoplasms With McC,686,MS-DRG,,,,,,,inpatient,,,27497.1,19247.97,AETNA [1000108],AETNA [100010801],,,77.2,,21227.7612,7771.48,38209.7984,percent of total billed charges,,,
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,inpatient,,,25492.34,17844.638,AETNA [1000108],AETNA [100010801],,,77.2,,19680.08648,7581.24,21329.8864,percent of total billed charges,,,
Kidney And Urinary Tract Infections With McC,689,MS-DRG,,,,,,,inpatient,,,20757.97,14530.579,AETNA [1000108],AETNA [100010801],,,77.2,,16025.15284,6922.782995,23716.9856,percent of total billed charges,,,
Kidney And Urinary Tract Infections Without McC,690,MS-DRG,,,,,,,inpatient,,,16632.65,11642.855,AETNA [1000108],AETNA [100010801],,,77.2,,12840.4058,5546.988775,16263.8864,percent of total billed charges,,,
Urinary Stones With McC,693,MS-DRG,,,,,,,inpatient,,,4007.39,2805.173,AETNA [1000108],AETNA [100010801],,,77.2,,3093.70508,1336.464565,29794.1592,percent of total billed charges,,,
Urinary Stones Without McC,694,MS-DRG,,,,,,,inpatient,,,15019.62,10513.734,AETNA [1000108],AETNA [100010801],,,77.2,,11595.14664,5009.04327,15834.2896,percent of total billed charges,,,
Kidney And Urinary Tract Signs And Symptoms With McC,695,MS-DRG,,,,,,,inpatient,,,29850.37,20895.259,AETNA [1000108],AETNA [100010801],,,77.2,,23044.48564,7771.48,23880.296,percent of total billed charges,,,
Kidney And Urinary Tract Signs And Symptoms Without McC,696,MS-DRG,,,,,,,inpatient,,,12055.26,8438.682,AETNA [1000108],AETNA [100010801],,,77.2,,9306.66072,4020.42921,14016.6088,percent of total billed charges,,,
Other Kidney And Urinary Tract Diagnoses With McC,698,MS-DRG,,,,,,,inpatient,,,25421.96,17795.372,AETNA [1000108],AETNA [100010801],,,77.2,,19625.75312,7771.48,34061.7576,percent of total billed charges,,,
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,inpatient,,,18359.1,12851.37,AETNA [1000108],AETNA [100010801],,,77.2,,14173.2252,6122.75985,20665.2272,percent of total billed charges,,,
Other Kidney And Urinary Tract Diagnoses Without Cc/McC,700,MS-DRG,,,,,,,inpatient,,,8380.95,5866.665,AETNA [1000108],AETNA [100010801],,,77.2,,6470.0934,2795.046825,14065.2424,percent of total billed charges,,,
Major Male Pelvic Procedures Without Cc/McC,708,MS-DRG,,,,,,,inpatient,,,55574.17,38901.919,AETNA [1000108],AETNA [100010801],,,77.2,,42903.25924,7771.48,44459.336,percent of total billed charges,,,
Penis Procedures With Cc/McC,709,MS-DRG,,,,,,,inpatient,,,18738.26,13116.782,AETNA [1000108],AETNA [100010801],,,77.2,,14465.93672,6249.20971,45533.208,percent of total billed charges,,,
Transurethral Prostatectomy With Cc/McC,713,MS-DRG,,,,,,,inpatient,,,28299.1,19809.37,AETNA [1000108],AETNA [100010801],,,77.2,,21846.9052,7771.48,29299.7176,percent of total billed charges,,,
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/McC,717,MS-DRG,,,,,,,inpatient,,,29999.37,20999.559,AETNA [1000108],AETNA [100010801],,,77.2,,23159.51364,7771.48,37597.8256,percent of total billed charges,,,
Malignancy- Male Reproductive System With Cc,723,MS-DRG,,,,,,,inpatient,,,3972.81,2780.967,AETNA [1000108],AETNA [100010801],,,77.2,,3067.00932,1324.932135,22754.4456,percent of total billed charges,,,
Benign Prostatic Hypertrophy Without McC,726,MS-DRG,,,,,,,inpatient,,,40258.34,28180.838,AETNA [1000108],AETNA [100010801],,,77.2,,31079.43848,5378.07,32206.672,percent of total billed charges,,,
Inflammation Of The Male Reproductive System With McC,727,MS-DRG,,,,,,,inpatient,,,22656.48,15859.536,AETNA [1000108],AETNA [100010801],,,77.2,,17490.80256,7555.93608,29773.8952,percent of total billed charges,,,
Inflammation Of The Male Reproductive System Without McC,728,MS-DRG,,,,,,,inpatient,,,13639.47,9547.629,AETNA [1000108],AETNA [100010801],,,77.2,,10529.67084,4548.763245,16557.7144,percent of total billed charges,,,
Other Male Reproductive System Diagnoses With Cc/McC,729,MS-DRG,,,,,,,inpatient,,,16117.99,11282.593,AETNA [1000108],AETNA [100010801],,,77.2,,12443.08828,5375.349665,22306.6112,percent of total billed charges,,,
Other Male Reproductive System Diagnoses Without Cc/McC,730,MS-DRG,,,,,,,inpatient,,,5959.58,4171.706,AETNA [1000108],AETNA [100010801],,,77.2,,4600.79576,1987.51993,12298.2216,percent of total billed charges,,,
Uterine And Adnexa Procedures For Non-Malignancy With Cc/McC,742,MS-DRG,,,,,,,inpatient,,,28503.79,19952.653,AETNA [1000108],AETNA [100010801],,,77.2,,22004.92588,7771.48,37014.2224,percent of total billed charges,,,
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/McC,743,MS-DRG,,,,,,,inpatient,,,26776.68,18743.676,AETNA [1000108],AETNA [100010801],,,77.2,,20671.59696,7771.48,24288.4304,percent of total billed charges,,,
D&C- Conization- Laparoscopy And Tubal Interruption With Cc/McC,744,MS-DRG,,,,,,,inpatient,,,42207.27,29545.089,AETNA [1000108],AETNA [100010801],,,77.2,,32584.01244,7771.48,39593.8296,percent of total billed charges,,,
D&C- Conization- Laparoscopy And Tubal Interruption Without Cc/McC,745,MS-DRG,,,,,,,inpatient,,,41300.62,28910.434,AETNA [1000108],AETNA [100010801],,,77.2,,31884.07864,7771.48,33040.496,percent of total billed charges,,,
Vagina- Cervix And Vulva Procedures With Cc/McC,746,MS-DRG,,,,,,,inpatient,,,54026.22,37818.354,AETNA [1000108],AETNA [100010801],,,77.2,,41708.24184,7771.48,43220.976,percent of total billed charges,,,
Vagina- Cervix And Vulva Procedures Without Cc/McC,747,MS-DRG,,,,,,,inpatient,,,14150.78,9905.546,AETNA [1000108],AETNA [100010801],,,77.2,,10924.40216,4719.28513,19354.1464,percent of total billed charges,,,
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,,,inpatient,,,71661.69,50163.183,AETNA [1000108],AETNA [100010801],,,77.2,,55322.82468,7771.48,57329.352,percent of total billed charges,,,
Other Female Reproductive System O.R. Procedures With Cc/McC,749,MS-DRG,,,,,,,inpatient,,,40397.2,28278.04,AETNA [1000108],AETNA [100010801],,,77.2,,31186.6384,7771.48,52451.3376,percent of total billed charges,,,
Malignancy- Female Reproductive System With McC,754,MS-DRG,,,,,,,inpatient,,,31179.58,21825.706,AETNA [1000108],AETNA [100010801],,,77.2,,24070.63576,7771.48,36661.6288,percent of total billed charges,,,
Malignancy- Female Reproductive System With Cc,755,MS-DRG,,,,,,,inpatient,,,7660.86,5362.602,AETNA [1000108],AETNA [100010801],,,77.2,,5914.18392,2554.89681,22495.0664,percent of total billed charges,,,
Malignancy- Female Reproductive System Without Cc/McC,756,MS-DRG,,,,,,,inpatient,,,11168.92,7818.244,AETNA [1000108],AETNA [100010801],,,77.2,,8622.40624,3724.83482,19350.0936,percent of total billed charges,,,
Infections- Female Reproductive System With Cc,758,MS-DRG,,,,,,,inpatient,,,20130.99,14091.693,AETNA [1000108],AETNA [100010801],,,77.2,,15541.12428,6713.685165,20655.0952,percent of total billed charges,,,
Infections- Female Reproductive System Without Cc/McC,759,MS-DRG,,,,,,,inpatient,,,18187.49,12731.243,AETNA [1000108],AETNA [100010801],,,77.2,,14040.74228,4943.22,14549.992,percent of total billed charges,,,
Menstrual And Other Female Reproductive System Disorders With Cc/McC,760,MS-DRG,,,,,,,inpatient,,,19375.46,13562.822,AETNA [1000108],AETNA [100010801],,,77.2,,14957.85512,6461.71591,19970.172,percent of total billed charges,,,
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,inpatient,,,14024.34,9817.038,AETNA [1000108],AETNA [100010801],,,77.2,,10826.79048,4677.11739,22215.4232,percent of total billed charges,,,
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,inpatient,,,9265.92,6486.144,AETNA [1000108],AETNA [100010801],,,77.2,,7153.29024,3090.18432,28156.828,percent of total billed charges,,,
Abortion With D&C- Aspiration Curettage Or Hysterotomy,770,MS-DRG,,,,,,,inpatient,,,25214.53,17650.171,AETNA [1000108],AETNA [100010801],,,77.2,,19465.61716,6425.75,21802.0376,percent of total billed charges,,,
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,inpatient,,,8836.34,6185.438,AETNA [1000108],AETNA [100010801],,,77.2,,6821.65448,2946.91939,14456.3376,percent of total billed charges,,,
Cesarean Section With Sterilization With McC,783,MS-DRG,,,,,,,inpatient,,,17734.56,12414.192,AETNA [1000108],AETNA [100010801],,,77.2,,13691.08032,5914.47576,37326.288,percent of total billed charges,,,
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,inpatient,,,18719.59,13103.713,AETNA [1000108],AETNA [100010801],,,77.2,,14451.52348,6242.983265,21945.912,percent of total billed charges,,,
Cesarean Section With Sterilization Without Cc/McC,785,MS-DRG,,,,,,,inpatient,,,17648.18,12353.726,AETNA [1000108],AETNA [100010801],,,77.2,,13624.39496,5885.66803,17728.9736,percent of total billed charges,,,
Cesarean Section Without Sterilization With McC,786,MS-DRG,,,,,,,inpatient,,,21072.73,14750.911,AETNA [1000108],AETNA [100010801],,,77.2,,16268.14756,7027.755455,32742.5712,percent of total billed charges,,,
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,inpatient,,,18455.52,12918.864,AETNA [1000108],AETNA [100010801],,,77.2,,14247.66144,6154.91592,21516.3152,percent of total billed charges,,,
Cesarean Section Without Sterilization Without Cc/McC,788,MS-DRG,,,,,,,inpatient,,,17822.26,12475.582,AETNA [1000108],AETNA [100010801],,,77.2,,13758.78472,5943.72371,18338.92,percent of total billed charges,,,
Neonates- Died Or Transferred To Another Acute Care Facility,789,MS-DRG,,,,,,,inpatient,,,6500.45,4550.315,AETNA [1000108],AETNA [100010801],,,77.2,,5018.3474,2167.900075,36529.9128,percent of total billed charges,,,
Extreme Immaturity Or Respiratory Distress Syndrome- Neonate,790,MS-DRG,,,,,,,inpatient,,,71335.38,49934.766,AETNA [1000108],AETNA [100010801],,,77.2,,55070.91336,7771.48,120469.48,percent of total billed charges,,,
Prematurity With Major Problems,791,MS-DRG,,,,,,,inpatient,,,39411.64,27588.148,AETNA [1000108],AETNA [100010801],,,77.2,,30425.78608,7771.48,82273.8664,percent of total billed charges,,,
Prematurity Without Major Problems,792,MS-DRG,,,,,,,inpatient,,,10975.85,7683.095,AETNA [1000108],AETNA [100010801],,,77.2,,8473.3562,3660.445975,49642.7472,percent of total billed charges,,,
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,inpatient,,,8093.71,5665.597,AETNA [1000108],AETNA [100010801],,,77.2,,6248.34412,2699.252285,84513.0384,percent of total billed charges,,,
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,inpatient,,,5349.51,3744.657,AETNA [1000108],AETNA [100010801],,,77.2,,4129.82172,1784.061585,29913.7168,percent of total billed charges,,,
Normal Newborn,795,MS-DRG,,,,,,,inpatient,,,4927.51,3449.257,AETNA [1000108],AETNA [100010801],,,77.2,,3804.03772,1378.34,7947.23,percent of total billed charges,,,
Vaginal Delivery With Sterilization And/Or D&C With McC,796,MS-DRG,,,,,,,inpatient,,,17976.19,12583.333,AETNA [1000108],AETNA [100010801],,,77.2,,13877.61868,5995.059365,25869.0224,percent of total billed charges,,,
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,inpatient,,,23001.33,16100.931,AETNA [1000108],AETNA [100010801],,,77.2,,17757.02676,6655.835261,19619.6048,percent of total billed charges,,,
Vaginal Delivery With Sterilization And/Or D&C Without Cc/McC,798,MS-DRG,,,,,,,inpatient,,,14819.75,10373.825,AETNA [1000108],AETNA [100010801],,,77.2,,11440.847,4942.386625,19619.6048,percent of total billed charges,,,
Splenic Procedures With McC,799,MS-DRG,,,,,,,inpatient,,,81427.43,56999.201,AETNA [1000108],AETNA [100010801],,,77.2,,62861.97596,7771.48,96345.188,percent of total billed charges,,,
Splenic Procedures Without Cc/McC,801,MS-DRG,,,,,,,inpatient,,,60652.11,42456.477,AETNA [1000108],AETNA [100010801],,,77.2,,46823.42892,7771.48,48521.688,percent of total billed charges,,,
Other O.R. Procedures Of The Blood And Blood Forming Organs With McC,802,MS-DRG,,,,,,,inpatient,,,94944.09,66460.863,AETNA [1000108],AETNA [100010801],,,77.2,,73296.83748,7771.48,75955.272,percent of total billed charges,,,
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/McC,804,MS-DRG,,,,,,,inpatient,,,22075,15452.5,AETNA [1000108],AETNA [100010801],,,77.2,,17041.9,7362.0125,22401.852,percent of total billed charges,,,
Vaginal Delivery Without Sterilization Or D&C With McC,805,MS-DRG,,,,,,,inpatient,,,13956.78,9769.746,AETNA [1000108],AETNA [100010801],,,77.2,,10774.63416,4654.58613,20221.4456,percent of total billed charges,,,
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,inpatient,,,13483.61,9438.527,AETNA [1000108],AETNA [100010801],,,77.2,,10409.34692,4496.783935,14661.004,percent of total billed charges,,,
Vaginal Delivery Without Sterilization Or D&C Without Cc/McC,807,MS-DRG,,,,,,,inpatient,,,13157.23,9210.061,AETNA [1000108],AETNA [100010801],,,77.2,,10157.38156,4387.936205,12912.2208,percent of total billed charges,,,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With McC,808,MS-DRG,,,,,,,inpatient,,,31882.27,22317.589,AETNA [1000108],AETNA [100010801],,,77.2,,24613.11244,7771.48,46412.6656,percent of total billed charges,,,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With Cc,809,MS-DRG,,,,,,,inpatient,,,26642.66,18649.862,AETNA [1000108],AETNA [100010801],,,77.2,,20568.13352,7771.48,25096.964,percent of total billed charges,,,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders Without Cc/McC,810,MS-DRG,,,,,,,inpatient,,,85706.42,59994.494,AETNA [1000108],AETNA [100010801],,,77.2,,66165.35624,6951.04,68565.136,percent of total billed charges,,,
Red Blood Cell Disorders With McC,811,MS-DRG,,,,,,,inpatient,,,33080.94,23156.658,AETNA [1000108],AETNA [100010801],,,77.2,,25538.48568,7771.48,28507.3952,percent of total billed charges,,,
Red Blood Cell Disorders Without McC,812,MS-DRG,,,,,,,inpatient,,,21914.25,15339.975,AETNA [1000108],AETNA [100010801],,,77.2,,16917.801,6364.97,18701.6456,percent of total billed charges,,,
Coagulation Disorders,813,MS-DRG,,,,,,,inpatient,,,31592.62,22114.834,AETNA [1000108],AETNA [100010801],,,77.2,,24389.50264,7771.48,31366.6456,percent of total billed charges,,,
Reticuloendothelial And Immunity Disorders With McC,814,MS-DRG,,,,,,,inpatient,,,15313.53,10719.471,AETNA [1000108],AETNA [100010801],,,77.2,,11822.04516,5107.062255,42357.8392,percent of total billed charges,,,
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,inpatient,,,14949.63,10464.741,AETNA [1000108],AETNA [100010801],,,77.2,,11541.11436,4985.701605,20590.2504,percent of total billed charges,,,
Other Antepartum Diagnoses With O.R. Procedures With McC,817,MS-DRG,,,,,,,inpatient,,,35079.77,24555.839,AETNA [1000108],AETNA [100010801],,,77.2,,27081.58244,7771.48,51371.2664,percent of total billed charges,,,
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,inpatient,,,56068.99,39248.293,AETNA [1000108],AETNA [100010801],,,77.2,,43285.26028,7771.48,44855.192,percent of total billed charges,,,
Other Antepartum Diagnoses With O.R. Procedures Without Cc/McC,819,MS-DRG,,,,,,,inpatient,,,15513.53,10859.471,AETNA [1000108],AETNA [100010801],,,77.2,,11976.44516,5173.762255,16545.556,percent of total billed charges,,,
Lymphoma And Leukemia With Major O.R. Procedures With McC,820,MS-DRG,,,,,,,inpatient,,,86514.51,60560.157,AETNA [1000108],AETNA [100010801],,,77.2,,66789.20172,7771.48,117974.9816,percent of total billed charges,,,
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,inpatient,,,70253.02,49177.114,AETNA [1000108],AETNA [100010801],,,77.2,,54235.33144,7771.48,56202.416,percent of total billed charges,,,
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/McC,822,MS-DRG,,,,,,,inpatient,,,27823.59,19476.513,AETNA [1000108],AETNA [100010801],,,77.2,,21479.81148,7771.48,23173.9104,percent of total billed charges,,,
Lymphoma And Non-Acute Leukemia With Other Procedures With McC,823,MS-DRG,,,,,,,inpatient,,,49236.57,34465.599,AETNA [1000108],AETNA [100010801],,,77.2,,38010.63204,7771.48,94819.3088,percent of total billed charges,,,
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/McC,825,MS-DRG,,,,,,,inpatient,,,56788.87,39752.209,AETNA [1000108],AETNA [100010801],,,77.2,,43841.00764,7771.48,45431.096,percent of total billed charges,,,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With McC,826,MS-DRG,,,,,,,inpatient,,,115032.85,80522.995,AETNA [1000108],AETNA [100010801],,,77.2,,88805.3602,7771.48,96764.6528,percent of total billed charges,,,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without Cc/McC,828,MS-DRG,,,,,,,inpatient,,,37373.35,26161.345,AETNA [1000108],AETNA [100010801],,,77.2,,28852.2262,7771.48,32479.1392,percent of total billed charges,,,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/McC,829,MS-DRG,,,,,,,inpatient,,,26899.5,18829.65,AETNA [1000108],AETNA [100010801],,,77.2,,20766.414,7771.48,62486.0704,percent of total billed charges,,,
Other Antepartum Diagnoses Without O.R. Procedures With McC,831,MS-DRG,,,,,,,inpatient,,,8108.51,5675.957,AETNA [1000108],AETNA [100010801],,,77.2,,6259.76972,2704.188085,23321.8376,percent of total billed charges,,,
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,inpatient,,,9811.14,6867.798,AETNA [1000108],AETNA [100010801],,,77.2,,7574.20008,3272.01519,15143.2872,percent of total billed charges,,,
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/McC,833,MS-DRG,,,,,,,inpatient,,,8494.15,5945.905,AETNA [1000108],AETNA [100010801],,,77.2,,6557.4838,2832.799025,10533.2272,percent of total billed charges,,,
Acute Leukemia Without Major O.R. Procedures With McC,834,MS-DRG,,,,,,,inpatient,,,33540.42,23478.294,AETNA [1000108],AETNA [100010801],,,77.2,,25893.20424,7771.48,111997.1016,percent of total billed charges,,,
Acute Leukemia Without Major O.R. Procedures With Cc,835,MS-DRG,,,,,,,inpatient,,,15922.85,11145.995,AETNA [1000108],AETNA [100010801],,,77.2,,12292.4402,5310.270475,43279.8512,percent of total billed charges,,,
Lymphoma And Non-Acute Leukemia With McC,840,MS-DRG,,,,,,,inpatient,,,35119.86,24583.902,AETNA [1000108],AETNA [100010801],,,77.2,,27112.53192,7771.48,64630.0016,percent of total billed charges,,,
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,inpatient,,,17465.46,12225.822,AETNA [1000108],AETNA [100010801],,,77.2,,13483.33512,5824.73091,31771.9256,percent of total billed charges,,,
Lymphoma And Non-Acute Leukemia Without Cc/McC,842,MS-DRG,,,,,,,inpatient,,,22518.92,15763.244,AETNA [1000108],AETNA [100010801],,,77.2,,17384.60624,7510.05982,21313.6752,percent of total billed charges,,,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With McC,843,MS-DRG,,,,,,,inpatient,,,21080.37,14756.259,AETNA [1000108],AETNA [100010801],,,77.2,,16274.04564,7030.303395,38361.7784,percent of total billed charges,,,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,inpatient,,,11557.79,8090.453,AETNA [1000108],AETNA [100010801],,,77.2,,8922.61388,3854.522965,24217.5064,percent of total billed charges,,,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/McC,845,MS-DRG,,,,,,,inpatient,,,13919.38,9743.566,AETNA [1000108],AETNA [100010801],,,77.2,,10745.76136,4642.11323,16954.8888,percent of total billed charges,,,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With McC,846,MS-DRG,,,,,,,inpatient,,,22506.34,15754.438,AETNA [1000108],AETNA [100010801],,,77.2,,17374.89448,7505.86439,51746.1504,percent of total billed charges,,,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,inpatient,,,14849.65,10394.755,AETNA [1000108],AETNA [100010801],,,77.2,,11463.9298,4952.358275,25747.4384,percent of total billed charges,,,
Infectious And Parasitic Diseases With O.R. Procedures With McC,853,MS-DRG,,,,,,,inpatient,,,91139.43,63797.601,AETNA [1000108],AETNA [100010801],,,77.2,,70359.63996,7771.48,101350.396,percent of total billed charges,,,
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,inpatient,,,41334.13,28933.891,AETNA [1000108],AETNA [100010801],,,77.2,,31909.94836,7771.48,40491.5248,percent of total billed charges,,,
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/McC,855,MS-DRG,,,,,,,inpatient,,,41292.75,28904.925,AETNA [1000108],AETNA [100010801],,,77.2,,31878.003,7771.48,33034.2,percent of total billed charges,,,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With McC,856,MS-DRG,,,,,,,inpatient,,,65177.47,45624.229,AETNA [1000108],AETNA [100010801],,,77.2,,50317.00684,7771.48,91416.9832,percent of total billed charges,,,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,inpatient,,,33908.27,23735.789,AETNA [1000108],AETNA [100010801],,,77.2,,26177.18444,7771.48,44153.2296,percent of total billed charges,,,
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/McC,858,MS-DRG,,,,,,,inpatient,,,18266.15,12786.305,AETNA [1000108],AETNA [100010801],,,77.2,,14101.4678,6091.761025,26108.1376,percent of total billed charges,,,
Postoperative And Post-Traumatic Infections With McC,862,MS-DRG,,,,,,,inpatient,,,32409.02,22686.314,AETNA [1000108],AETNA [100010801],,,77.2,,25019.76344,7771.48,37257.3904,percent of total billed charges,,,
Postoperative And Post-Traumatic Infections Without McC,863,MS-DRG,,,,,,,inpatient,,,26972.96,18881.072,AETNA [1000108],AETNA [100010801],,,77.2,,20823.12512,7071.87,21578.368,percent of total billed charges,,,
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,inpatient,,,18759.94,13131.958,AETNA [1000108],AETNA [100010801],,,77.2,,14482.67368,6256.43999,18195.0456,percent of total billed charges,,,
Viral Illness With McC,865,MS-DRG,,,,,,,inpatient,,,22475.35,15732.745,AETNA [1000108],AETNA [100010801],,,77.2,,17350.9702,7495.529225,29907.6376,percent of total billed charges,,,
Viral Illness Without McC,866,MS-DRG,,,,,,,inpatient,,,13589.18,9512.426,AETNA [1000108],AETNA [100010801],,,77.2,,10490.84696,4531.99153,17927.5608,percent of total billed charges,,,
Other Infectious And Parasitic Diseases Diagnoses With McC,867,MS-DRG,,,,,,,inpatient,,,29124.07,20386.849,AETNA [1000108],AETNA [100010801],,,77.2,,22483.78204,7771.48,43450.0688,percent of total billed charges,,,
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,inpatient,,,22783.92,15948.744,AETNA [1000108],AETNA [100010801],,,77.2,,17589.18624,7598.43732,21277.2,percent of total billed charges,,,
Other Infectious And Parasitic Diseases Diagnoses Without Cc/McC,869,MS-DRG,,,,,,,inpatient,,,6491.58,4544.106,AETNA [1000108],AETNA [100010801],,,77.2,,5011.49976,2164.94193,14579.948,percent of total billed charges,,,
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,inpatient,,,165811.55,116068.085,AETNA [1000108],AETNA [100010801],,,77.2,,128006.5166,7771.48,140966.516,percent of total billed charges,,,
Septicemia Or Severe Sepsis Without Mv >96 Hours With McC,871,MS-DRG,,,,,,,inpatient,,,32860.99,23002.693,AETNA [1000108],AETNA [100010801],,,77.2,,25368.68428,7771.48,39764.0472,percent of total billed charges,,,
Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC,872,MS-DRG,,,,,,,inpatient,,,22133.41,15493.387,AETNA [1000108],AETNA [100010801],,,77.2,,17086.99252,7381.492235,20892.184,percent of total billed charges,,,
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,,,inpatient,,,167914.64,117540.248,AETNA [1000108],AETNA [100010801],,,77.2,,129630.1021,7771.48,134331.712,percent of total billed charges,,,
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,inpatient,,,22889.31,16022.517,AETNA [1000108],AETNA [100010801],,,77.2,,17670.54732,6248.48,19425.0704,percent of total billed charges,,,
Depressive Neuroses,881,MS-DRG,,,,,,,inpatient,,,44762.95,31334.065,AETNA [1000108],AETNA [100010801],,,77.2,,34556.9974,5798.441546,35810.36,percent of total billed charges,,,
Neuroses Except Depressive,882,MS-DRG,,,,,,,inpatient,,,10863.25,7604.275,AETNA [1000108],AETNA [100010801],,,77.2,,8386.429,3622.893875,19491.9416,percent of total billed charges,,,
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,inpatient,,,35747.4,25023.18,AETNA [1000108],AETNA [100010801],,,77.2,,27596.9928,7771.48,33842.9064,percent of total billed charges,,,
Psychoses,885,MS-DRG,,,,,,,inpatient,,,20082.8,14057.96,AETNA [1000108],AETNA [100010801],,,77.2,,15503.9216,6697.6138,28562.108,percent of total billed charges,,,
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,inpatient,,,10508,7355.6,AETNA [1000108],AETNA [100010801],,,77.2,,8112.176,3504.418,36402.2496,percent of total billed charges,,,
Alcohol- Drug Abuse Or Dependence- Left Ama,894,MS-DRG,,,,,,,inpatient,,,15836.23,11085.361,AETNA [1000108],AETNA [100010801],,,77.2,,12225.56956,3961.38,12668.984,percent of total billed charges,,,
Alcohol- Drug Abuse Or Dependence Without Rehabilitation Therapy With McC,896,MS-DRG,,,,,,,inpatient,,,35553.78,24887.646,AETNA [1000108],AETNA [100010801],,,77.2,,27447.51816,7771.48,36086.1312,percent of total billed charges,,,
Alcohol- Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC,897,MS-DRG,,,,,,,inpatient,,,18541.81,12979.267,AETNA [1000108],AETNA [100010801],,,77.2,,14314.27732,5972.81,17876.9008,percent of total billed charges,,,
Wound Debridements For Injuries With McC,901,MS-DRG,,,,,,,inpatient,,,46387.19,32471.033,AETNA [1000108],AETNA [100010801],,,77.2,,35810.91068,7771.48,89773.5728,percent of total billed charges,,,
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,inpatient,,,59864.86,41905.402,AETNA [1000108],AETNA [100010801],,,77.2,,46215.67192,7771.48,47891.888,percent of total billed charges,,,
Wound Debridements For Injuries Without Cc/McC,903,MS-DRG,,,,,,,inpatient,,,13693.85,9585.695,AETNA [1000108],AETNA [100010801],,,77.2,,10571.6522,4566.898975,24701.816,percent of total billed charges,,,
Skin Grafts For Injuries With Cc/McC,904,MS-DRG,,,,,,,inpatient,,,114417.1,80091.97,AETNA [1000108],AETNA [100010801],,,77.2,,88330.0012,7771.48,91533.68,percent of total billed charges,,,
Hand Procedures For Injuries,906,MS-DRG,,,,,,,inpatient,,,51389.12,35972.384,AETNA [1000108],AETNA [100010801],,,77.2,,39672.40064,7771.48,44224.1536,percent of total billed charges,,,
Other O.R. Procedures For Injuries With McC,907,MS-DRG,,,,,,,inpatient,,,48914.02,34239.814,AETNA [1000108],AETNA [100010801],,,77.2,,37761.62344,7771.48,80721.644,percent of total billed charges,,,
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,inpatient,,,44494.39,31146.073,AETNA [1000108],AETNA [100010801],,,77.2,,34349.66908,7771.48,40872.488,percent of total billed charges,,,
Other O.R. Procedures For Injuries Without Cc/McC,909,MS-DRG,,,,,,,inpatient,,,14125.93,9888.151,AETNA [1000108],AETNA [100010801],,,77.2,,10905.21796,4710.997655,25698.8048,percent of total billed charges,,,
Traumatic Injury With McC,913,MS-DRG,,,,,,,inpatient,,,57017.38,39912.166,AETNA [1000108],AETNA [100010801],,,77.2,,44017.41736,7771.48,45613.904,percent of total billed charges,,,
Traumatic Injury Without McC,914,MS-DRG,,,,,,,inpatient,,,28970.93,20279.651,AETNA [1000108],AETNA [100010801],,,77.2,,22365.55796,6429.37,23176.744,percent of total billed charges,,,
Allergic Reactions With McC,915,MS-DRG,,,,,,,inpatient,,,42664.44,29865.108,AETNA [1000108],AETNA [100010801],,,77.2,,32936.94768,7771.48,35214.7792,percent of total billed charges,,,
Allergic Reactions Without McC,916,MS-DRG,,,,,,,inpatient,,,12818.09,8972.663,AETNA [1000108],AETNA [100010801],,,77.2,,9895.56548,4274.833015,13455.296,percent of total billed charges,,,
Poisoning And Toxic Effects Of Drugs With McC,917,MS-DRG,,,,,,,inpatient,,,41573.69,29101.583,AETNA [1000108],AETNA [100010801],,,77.2,,32094.88868,7771.48,33258.952,percent of total billed charges,,,
Poisoning And Toxic Effects Of Drugs Without McC,918,MS-DRG,,,,,,,inpatient,,,19845.67,13891.969,AETNA [1000108],AETNA [100010801],,,77.2,,15320.85724,5723.92,17921.4816,percent of total billed charges,,,
Complications Of Treatment With McC,919,MS-DRG,,,,,,,inpatient,,,48229.35,33760.545,AETNA [1000108],AETNA [100010801],,,77.2,,37233.0582,7771.48,38583.48,percent of total billed charges,,,
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,inpatient,,,20650.21,14455.147,AETNA [1000108],AETNA [100010801],,,77.2,,15941.96212,6886.845035,20584.1712,percent of total billed charges,,,
Complications Of Treatment Without Cc/McC,921,MS-DRG,,,,,,,inpatient,,,18737.44,13116.208,AETNA [1000108],AETNA [100010801],,,77.2,,14465.30368,5002.55,14989.952,percent of total billed charges,,,
Other Injury- Poisoning And Toxic Effect Diagnoses With McC,922,MS-DRG,,,,,,,inpatient,,,42436.37,29705.459,AETNA [1000108],AETNA [100010801],,,77.2,,32760.87764,7771.48,34229.9488,percent of total billed charges,,,
Other Injury- Poisoning And Toxic Effect Diagnoses Without McC,923,MS-DRG,,,,,,,inpatient,,,18119.88,12683.916,AETNA [1000108],AETNA [100010801],,,77.2,,13988.54736,6042.97998,20665.2272,percent of total billed charges,,,
Non-Extensive Burns,935,MS-DRG,,,,,,,inpatient,,,6946.99,4862.893,AETNA [1000108],AETNA [100010801],,,77.2,,5363.07628,2316.821165,44505.8232,percent of total billed charges,,,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,inpatient,,,22686.24,15880.368,AETNA [1000108],AETNA [100010801],,,77.2,,17513.77728,7565.86104,42783.3832,percent of total billed charges,,,
Signs And Symptoms With McC,947,MS-DRG,,,,,,,inpatient,,,29399.47,20579.629,AETNA [1000108],AETNA [100010801],,,77.2,,22696.39084,7771.48,26061.5304,percent of total billed charges,,,
Signs And Symptoms Without McC,948,MS-DRG,,,,,,,inpatient,,,16042.18,11229.526,AETNA [1000108],AETNA [100010801],,,77.2,,12384.56296,5350.06703,16099.748,percent of total billed charges,,,
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,inpatient,,,5109.91,3576.937,AETNA [1000108],AETNA [100010801],,,77.2,,3944.85052,1704.154985,11487.6616,percent of total billed charges,,,
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,,,inpatient,,,149455.54,104618.878,AETNA [1000108],AETNA [100010801],,,77.2,,115379.6769,7771.48,138360.5656,percent of total billed charges,,,
Limb Reattachment- Hip And Femur Procedures For Multiple Significant Trauma,956,MS-DRG,,,,,,,inpatient,,,64530.82,45171.574,AETNA [1000108],AETNA [100010801],,,77.2,,49817.79304,7771.48,77453.0608,percent of total billed charges,,,
Other O.R. Procedures For Multiple Significant Trauma With McC,957,MS-DRG,,,,,,,inpatient,,,104697.23,73288.061,AETNA [1000108],AETNA [100010801],,,77.2,,80826.26156,7771.48,151244.4168,percent of total billed charges,,,
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,inpatient,,,68495.96,47947.172,AETNA [1000108],AETNA [100010801],,,77.2,,52878.88112,7771.48,83274.908,percent of total billed charges,,,
Other Multiple Significant Trauma With McC,963,MS-DRG,,,,,,,inpatient,,,43017.73,30112.411,AETNA [1000108],AETNA [100010801],,,77.2,,33209.68756,7771.48,55049.1824,percent of total billed charges,,,
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,inpatient,,,32958.94,23071.258,AETNA [1000108],AETNA [100010801],,,77.2,,25444.30168,7771.48,30400.0528,percent of total billed charges,,,
Hiv With Major Related Condition With McC,974,MS-DRG,,,,,,,inpatient,,,42445.87,29712.109,AETNA [1000108],AETNA [100010801],,,77.2,,32768.21164,7771.48,60508.304,percent of total billed charges,,,
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,,,inpatient,,,19415.36,13590.752,AETNA [1000108],AETNA [100010801],,,77.2,,14988.65792,6475.02256,28801.2232,percent of total billed charges,,,
Hiv With Major Related Condition Without Cc/McC,976,MS-DRG,,,,,,,inpatient,,,36673.45,25671.415,AETNA [1000108],AETNA [100010801],,,77.2,,28311.9034,6867.108649,29338.76,percent of total billed charges,,,
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,inpatient,,,53209.61,37246.727,AETNA [1000108],AETNA [100010801],,,77.2,,41077.81892,7771.48,42567.688,percent of total billed charges,,,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC,981,MS-DRG,,,,,,,inpatient,,,96543.58,67580.506,AETNA [1000108],AETNA [100010801],,,77.2,,74531.64376,7771.48,96341.1352,percent of total billed charges,,,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,inpatient,,,54470.12,38129.084,AETNA [1000108],AETNA [100010801],,,77.2,,42050.93264,7771.48,49616.404,percent of total billed charges,,,
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/McC,983,MS-DRG,,,,,,,inpatient,,,18703.75,13092.625,AETNA [1000108],AETNA [100010801],,,77.2,,14439.295,6237.700625,33802.3784,percent of total billed charges,,,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC,987,MS-DRG,,,,,,,inpatient,,,51141.58,35799.106,AETNA [1000108],AETNA [100010801],,,77.2,,39481.29976,7771.48,70984.792,percent of total billed charges,,,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,inpatient,,,31104,21772.8,AETNA [1000108],AETNA [100010801],,,77.2,,24012.288,7771.48,34773.024,percent of total billed charges,,,
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,,,inpatient,,,13700.33,9590.231,AETNA [1000108],AETNA [100010801],,,77.2,,10576.65476,4569.060055,10960.264,percent of total billed charges,,,
Ungroupable,999,MS-DRG,,,,,,,inpatient,,,28509.33,19956.531,AETNA [1000108],AETNA [100010801],,,77.2,,22009.20276,7771.48,22807.464,percent of total billed charges,,,
HC Fine Needle Aspiration Bx W/O Img Gdn Ea Addl,PX-36900722,CDM,10004,CPT,369,RC,,,outpatient,,,79,55.3,AETNA [1000108],AETNA [100010801],,,76.8,,60.672,17.7355,1592,percent of total billed charges,,,
HC Fine Needle Aspiration Bx W/US Gdn 1st Lesion,PX-36900723,CDM,10005,CPT,369,RC,,,outpatient,,,2116,1481.2,AETNA [1000108],AETNA [100010801],,,76.8,,1625.09,399.86,2141,percent of total billed charges,,,
HC Fine Needle Aspiration Bx W/US Gdn Ea Addl,PX-36900724,CDM,10006,CPT,369,RC,,,outpatient,,,258,180.6,AETNA [1000108],AETNA [100010801],,,76.8,,198.14,57.921,1592,percent of total billed charges,,,
HC Fine Needle Aspiration W/O Imaging Guidance,PX-36900674,CDM,10021,CPT,369,RC,,,outpatient,,,871,609.7,AETNA [1000108],AETNA [100010801],,,76.8,,668.93,195.5395,1592,percent of total billed charges,,,
HC Image-Guided Catheter Fluid Collection Drainage,PX-36900043,CDM,10030,CPT,369,RC,,,outpatient,,,692,484.4,AETNA [1000108],AETNA [100010801],,,76.8,,531.46,155.354,2141,percent of total billed charges,,,
HC Plcmt of Soft Tissue Loc Device(S)- Perc- First Lesion,PX-36900637,CDM,10035,CPT,369,RC,,,outpatient,,,1860,1302,AETNA [1000108],AETNA [100010801],,,76.8,,1428.48,291.227805,2141,percent of total billed charges,,,
HC Plmt Sft Tiss Loclzj Dev Perq Each Addl Lesion,PX-36900889,CDM,10036,CPT,369,RC,,,outpatient,,,130,91,AETNA [1000108],AETNA [100010801],,,76.8,,99.84,29.185,1592,percent of total billed charges,,,
HC Drain Skin Abscess Simple,PX-36900044,CDM,10060,CPT,369,RC,,,outpatient,,,922,645.4,AETNA [1000108],AETNA [100010801],,,76.8,,708.1,206.989,1592,percent of total billed charges,,,
HC Drain Skin Abscess Complic,PX-36900045,CDM,10061,CPT,369,RC,,,outpatient,,,922,645.4,AETNA [1000108],AETNA [100010801],,,76.8,,708.1,206.989,1592,percent of total billed charges,,,
HC Drainage of Hematoma/Fluid,PX-36900048,CDM,10140,CPT,369,RC,,,outpatient,,,4838,3386.6,AETNA [1000108],AETNA [100010801],,,76.8,,3715.58,399.86,3715.584,percent of total billed charges,,,
HC Puncture Drainage of Lesion,PX-36100003,CDM,10160,CPT,361,RC,,,outpatient,,,916,641.2,AETNA [1000108],AETNA [100010801],,,76.8,,703.49,205.642,1592,percent of total billed charges,,,
HC Puncture Drainage of Lesion,PX-36900049,CDM,10160,CPT,369,RC,,,outpatient,,,916,641.2,AETNA [1000108],AETNA [100010801],,,76.8,,703.49,205.642,1592,percent of total billed charges,,,
HC Complex Drainage- Wound,PX-36900050,CDM,10180,CPT,369,RC,,,outpatient,,,8640,6048,AETNA [1000108],AETNA [100010801],,,76.8,,6635.52,399.86,6635.52,percent of total billed charges,,,
HC Debridement- Infected Skin- Up to 10% Bsa,PX-36900606,CDM,11000,CPT,369,RC,,,outpatient,,,1174,821.8,AETNA [1000108],AETNA [100010801],,,76.8,,901.63,263.563,1592,percent of total billed charges,,,
HC Debridement- Infected Skin- Ea Add 10% Bsa,PX-36900607,CDM,11001,CPT,369,RC,,,outpatient,,,53,37.1,AETNA [1000108],AETNA [100010801],,,76.8,,40.7,11.8985,1592,percent of total billed charges,,,
HC Debride Necrotic Skin/ Tissue- Genit & Perinm,PX-36900608,CDM,11004,CPT,369,RC,,,outpatient,,,2036,1425.2,AETNA [1000108],AETNA [100010801],,,76.8,,1563.65,399.86,2998,percent of total billed charges,,,
HC Dbrdmt Skn Subq T/M/F Necro Infctj Abdl Wall,PX-36900876,CDM,11005,CPT,369,RC,,,outpatient,,,2001,1400.7,AETNA [1000108],AETNA [100010801],,,76.8,,1536.77,399.86,2998,percent of total billed charges,,,
HC Dbrdmt Skn Subq T/M/F Necro Infctj Gent/Abdl,PX-36900877,CDM,11006,CPT,369,RC,,,outpatient,,,1815,1270.5,AETNA [1000108],AETNA [100010801],,,76.8,,1393.92,399.86,2998,percent of total billed charges,,,
HC Removal Prosthetic Matrl Abdl Wall for Infection,PX-36900878,CDM,11008,CPT,369,RC,,,outpatient,,,706,494.2,AETNA [1000108],AETNA [100010801],,,76.8,,542.21,158.497,3914,percent of total billed charges,,,
HC Dbrdmt W/Rmvl Fm Fx&/Dislc Skin&Subq Tissus,PX-36900743,CDM,11010,CPT,369,RC,,,outpatient,,,2113,1479.1,AETNA [1000108],AETNA [100010801],,,76.8,,1622.78,399.86,2141,percent of total billed charges,,,
HC Dbrdmt W/Rmvl Fm Fx&/Dislc Skn Subq T/M/F Musc,PX-36900773,CDM,11011,CPT,369,RC,,,outpatient,,,2197,1537.9,AETNA [1000108],AETNA [100010801],,,76.8,,1687.3,399.86,2141,percent of total billed charges,,,
HC Dbrdmt Fx&/Dislc Subq T/M/F Bone,PX-36900744,CDM,11012,CPT,369,RC,,,outpatient,,,9022,6315.4,AETNA [1000108],AETNA [100010801],,,76.8,,6928.9,399.86,6928.896,percent of total billed charges,,,
HC Debridement- Skin- Sub-Q Tissue-=<20 Sq Cm,PX-36900052,CDM,11042,CPT,369,RC,,,outpatient,,,1018,712.6,AETNA [1000108],AETNA [100010801],,,76.8,,781.82,228.541,1592,percent of total billed charges,,,
HC Debridement- Skin- Sub-Q Tissue-Muscle-=<20 Sq Cm,PX-36900053,CDM,11043,CPT,369,RC,,,outpatient,,,1065,745.5,AETNA [1000108],AETNA [100010801],,,76.8,,817.92,239.0925,1592,percent of total billed charges,,,
HC Debridement- Skin- Sub-Q Tissue-Muscle-Bone-=<20 Sq Cm,PX-36900054,CDM,11044,CPT,369,RC,,,outpatient,,,2829,1980.3,AETNA [1000108],AETNA [100010801],,,76.8,,2172.67,399.86,2477.315575,percent of total billed charges,,,
HC Debridement- Skin- Sub-Q Tissue-Each Add 20 Sq Cm,PX-36900055,CDM,11045,CPT,369,RC,,,outpatient,,,1203,842.1,AETNA [1000108],AETNA [100010801],,,76.8,,923.9,270.0735,1592,percent of total billed charges,,,
HC Debridement- Skin- Sub-Q Tissue-Muscle-Each Add 20 Sq Cm,PX-36900056,CDM,11046,CPT,369,RC,,,outpatient,,,1203,842.1,AETNA [1000108],AETNA [100010801],,,76.8,,923.9,270.0735,1592,percent of total billed charges,,,
HC Debridement- Skin- Sub-Q Tissue-Muscle-Bone-Each Add 20 Sq Cm,PX-36900057,CDM,11047,CPT,369,RC,,,outpatient,,,1910,1337,AETNA [1000108],AETNA [100010801],,,76.8,,1466.88,399.86,1592,percent of total billed charges,,,
HC Trim Nail(S),PX-36900064,CDM,11719,CPT,369,RC,,,outpatient,,,347,242.9,AETNA [1000108],AETNA [100010801],,,76.8,,266.5,62.19,1592,percent of total billed charges,,,
HC Debridement of Nail(S)- 1-5,PX-36900065,CDM,11720,CPT,369,RC,,,outpatient,,,347,242.9,AETNA [1000108],AETNA [100010801],,,76.8,,266.5,66.75974,1592,percent of total billed charges,,,
HC Debridement Nail Any Method 6/>,PX-36900791,CDM,11721,CPT,369,RC,,,outpatient,,,212,148.4,AETNA [1000108],AETNA [100010801],,,76.8,,162.82,47.594,1592,percent of total billed charges,,,
HC Removal of Nail Plate,PX-36900067,CDM,11730,CPT,369,RC,,,outpatient,,,431,301.7,AETNA [1000108],AETNA [100010801],,,76.8,,331.01,96.7595,1592,percent of total billed charges,,,
HC Avulsion Nail Plate Partial/Comp Simple Ea Addl,PX-36900831,CDM,11732,CPT,369,RC,,,outpatient,,,139,97.3,AETNA [1000108],AETNA [100010801],,,76.8,,106.75,31.2055,1592,percent of total billed charges,,,
HC Evacuation Subungual Hematoma,PX-36900832,CDM,11740,CPT,369,RC,,,outpatient,,,159,111.3,AETNA [1000108],AETNA [100010801],,,76.8,,122.11,35.6955,1592,percent of total billed charges,,,
HC Removal of Nail Bed,PX-36900069,CDM,11750,CPT,369,RC,,,outpatient,,,1914,1339.8,AETNA [1000108],AETNA [100010801],,,76.8,,1469.95,399.86,1592,percent of total billed charges,,,
HC Biopsy Nail Unit Separate Procedure,PX-36900763,CDM,11755,CPT,369,RC,,,outpatient,,,2197,1537.9,AETNA [1000108],AETNA [100010801],,,76.8,,1687.3,399.86,2141,percent of total billed charges,,,
HC Repair Nail Bed,PX-36900833,CDM,11760,CPT,369,RC,,,outpatient,,,909,636.3,AETNA [1000108],AETNA [100010801],,,76.8,,698.11,113.876282,1592,percent of total billed charges,,,
HC Wedge Excision Skin Nail Fold,PX-36900834,CDM,11765,CPT,369,RC,,,outpatient,,,1377,963.9,AETNA [1000108],AETNA [100010801],,,76.8,,1057.54,156.65,1592,percent of total billed charges,,,
HC Resuperf Wnd Body <2.5cm,PX-36900070,CDM,12001,CPT,369,RC,,,outpatient,,,505,353.5,AETNA [1000108],AETNA [100010801],,,76.8,,387.84,113.3725,1592,percent of total billed charges,,,
HC Resup Npterf Wnd Body 2.6-7.5 Cm,PX-36900071,CDM,12002,CPT,369,RC,,,outpatient,,,505,353.5,AETNA [1000108],AETNA [100010801],,,76.8,,387.84,113.3725,1592,percent of total billed charges,,,
HC Resuperf Wnd Body 7.6-12.5 Cm,PX-36900072,CDM,12004,CPT,369,RC,,,outpatient,,,445,311.5,AETNA [1000108],AETNA [100010801],,,76.8,,341.76,99.9025,1592,percent of total billed charges,,,
HC Resuperf Wnd Body 12.6-20 Cm,PX-36900839,CDM,12005,CPT,369,RC,,,outpatient,,,513,359.1,AETNA [1000108],AETNA [100010801],,,76.8,,393.98,115.1685,1592,percent of total billed charges,,,
HC Resuperf Wnd Body 20.1-30 Cm,PX-36900840,CDM,12006,CPT,369,RC,,,outpatient,,,648,453.6,AETNA [1000108],AETNA [100010801],,,76.8,,497.66,145.476,1592,percent of total billed charges,,,
HC Resuperf Wnd Body >30 Cm,PX-36900841,CDM,12007,CPT,369,RC,,,outpatient,,,425,297.5,AETNA [1000108],AETNA [100010801],,,76.8,,326.4,95.4125,1592,percent of total billed charges,,,
HC Simple Repair F/E/E/N/L/M 2.5cm/<,PX-36900758,CDM,12011,CPT,369,RC,,,outpatient,,,329,230.3,AETNA [1000108],AETNA [100010801],,,76.8,,252.67,73.8605,1592,percent of total billed charges,,,
HC Resuperf Wnd Face 2.6-5 Cm,PX-36900842,CDM,12013,CPT,369,RC,,,outpatient,,,400,280,AETNA [1000108],AETNA [100010801],,,76.8,,307.2,89.8,1592,percent of total billed charges,,,
HC Resuperf Wnd Face 5.1-7.5 Cm,PX-36900843,CDM,12014,CPT,369,RC,,,outpatient,,,479,335.3,AETNA [1000108],AETNA [100010801],,,76.8,,367.87,107.5355,1592,percent of total billed charges,,,
HC Resuperf Wnd Face 7.6-12.5 Cm,PX-36900844,CDM,12015,CPT,369,RC,,,outpatient,,,633,443.1,AETNA [1000108],AETNA [100010801],,,76.8,,486.14,142.1085,1592,percent of total billed charges,,,
HC Resuperf Wnd Face 12.6-20 Cm,PX-36900845,CDM,12016,CPT,369,RC,,,outpatient,,,779,545.3,AETNA [1000108],AETNA [100010801],,,76.8,,598.27,174.8855,1592,percent of total billed charges,,,
HC Simple Repair Suprfcl Wnds F/E/E/N/L/Mucs Membrnes;20.1-30.0 Cm,PX-36900846,CDM,12017,CPT,369,RC,,,outpatient,,,555,388.5,AETNA [1000108],AETNA [100010801],,,76.8,,426.24,124.5975,1592,percent of total billed charges,,,
HC Simple Repair Suprfcl Wnds F/E/E/N/L/Mucs Membrnes;Over 30.0 Cm,PX-36900847,CDM,12018,CPT,369,RC,,,outpatient,,,448,313.6,AETNA [1000108],AETNA [100010801],,,76.8,,344.06,100.576,1592,percent of total billed charges,,,
HC Closure Superf Wnd Dehis Simple,PX-36900848,CDM,12020,CPT,369,RC,,,outpatient,,,1377,963.9,AETNA [1000108],AETNA [100010801],,,76.8,,1057.54,309.1365,1592,percent of total billed charges,,,
HC Closure Superf Wnd Dehis W Packing,PX-36900849,CDM,12021,CPT,369,RC,,,outpatient,,,809,566.3,AETNA [1000108],AETNA [100010801],,,76.8,,621.31,181.6205,1592,percent of total billed charges,,,
HC Repair Intermediate S/a/T/E 2.5 Cm/<,PX-36900757,CDM,12031,CPT,369,RC,,,outpatient,,,891,623.7,AETNA [1000108],AETNA [100010801],,,76.8,,684.29,200.0295,1592,percent of total billed charges,,,
HC Layr Clos Wnd Trunk-Arm-Leg 2.6-7.5 Cm,PX-36900850,CDM,12032,CPT,369,RC,,,outpatient,,,505,353.5,AETNA [1000108],AETNA [100010801],,,76.8,,387.84,113.3725,1592,percent of total billed charges,,,
HC Layr Clos Wnd Trunk-Arm-Leg 7.6-12.5 Cm,PX-36900851,CDM,12034,CPT,369,RC,,,outpatient,,,685,479.5,AETNA [1000108],AETNA [100010801],,,76.8,,526.08,153.7825,1592,percent of total billed charges,,,
HC Layr Clos Wnd Trunk-Arm-Leg 12.6-20 Cm,PX-36900852,CDM,12035,CPT,369,RC,,,outpatient,,,685,479.5,AETNA [1000108],AETNA [100010801],,,76.8,,526.08,153.7825,1592,percent of total billed charges,,,
HC Layr Clos Wnd Trunk-Arm-Leg 20.1-30 Cm,PX-36900853,CDM,12036,CPT,369,RC,,,outpatient,,,649,454.3,AETNA [1000108],AETNA [100010801],,,76.8,,498.43,145.7005,1592,percent of total billed charges,,,
HC Layr Clos Wnd Trunk-Arm-Leg >30 Cm,PX-36900854,CDM,12037,CPT,369,RC,,,outpatient,,,4504,3152.8,AETNA [1000108],AETNA [100010801],,,76.8,,3459.07,399.86,3459.072,percent of total billed charges,,,
HC Repair Intermediate N/H/F/Xtrnl Gent 2.5cm/<,PX-36900756,CDM,12041,CPT,369,RC,,,outpatient,,,634,443.8,AETNA [1000108],AETNA [100010801],,,76.8,,486.91,142.333,1592,percent of total billed charges,,,
HC Repair Intermediate Neck/Hand/Feet/Xtrnl Gent 2.6-7.5 Cm,PX-36900806,CDM,12042,CPT,369,RC,,,outpatient,,,633,443.1,AETNA [1000108],AETNA [100010801],,,76.8,,486.14,142.1085,1592,percent of total billed charges,,,
HC Layr Clos Wnd Rest Body 7.6-12.5 Cm,PX-36900855,CDM,12044,CPT,369,RC,,,outpatient,,,623,436.1,AETNA [1000108],AETNA [100010801],,,76.8,,478.46,139.8635,1592,percent of total billed charges,,,
HC Layr Clos Wnd Rest Body 12.6-20 Cm,PX-36900856,CDM,12045,CPT,369,RC,,,outpatient,,,627,438.9,AETNA [1000108],AETNA [100010801],,,76.8,,481.54,140.7615,1592,percent of total billed charges,,,
HC Layr Clos Wnd Rest Body 20.1-30 Cm,PX-36900857,CDM,12046,CPT,369,RC,,,outpatient,,,1056,739.2,AETNA [1000108],AETNA [100010801],,,76.8,,811.01,237.072,2141,percent of total billed charges,,,
HC Repair Intermediate N/H/F/Xtrnl Gent >30.0 Cm,PX-36900858,CDM,12047,CPT,369,RC,,,outpatient,,,5238,3666.6,AETNA [1000108],AETNA [100010801],,,76.8,,4022.78,399.86,4022.784,percent of total billed charges,,,
HC Repair Intermediate F/E/E/N/L&/Muc 2.5 Cm/<,PX-36900755,CDM,12051,CPT,369,RC,,,outpatient,,,891,623.7,AETNA [1000108],AETNA [100010801],,,76.8,,684.29,200.0295,1592,percent of total billed charges,,,
HC Layr Clos Wnd Face-Facial 2.5-5 Cm,PX-36900859,CDM,12052,CPT,369,RC,,,outpatient,,,596,417.2,AETNA [1000108],AETNA [100010801],,,76.8,,457.73,133.802,1592,percent of total billed charges,,,
HC Layr Clos Wnd Face-Facial 5.1-7.5 Cm,PX-36900860,CDM,12053,CPT,369,RC,,,outpatient,,,663,464.1,AETNA [1000108],AETNA [100010801],,,76.8,,509.18,148.8435,1592,percent of total billed charges,,,
HC Layr Clos Wnd Face-Facial 7.6-12.5 Cm,PX-36900861,CDM,12054,CPT,369,RC,,,outpatient,,,652,456.4,AETNA [1000108],AETNA [100010801],,,76.8,,500.74,146.374,1592,percent of total billed charges,,,
HC Layr Clos Wnd Face-Facial 12.6-20 Cm,PX-36900862,CDM,12055,CPT,369,RC,,,outpatient,,,749,524.3,AETNA [1000108],AETNA [100010801],,,76.8,,575.23,168.1505,1592,percent of total billed charges,,,
HC Layr Clos Wnd Face-Facial 20.1-30 Cm,PX-36900863,CDM,12056,CPT,369,RC,,,outpatient,,,1419,993.3,AETNA [1000108],AETNA [100010801],,,76.8,,1089.79,318.5655,1592,percent of total billed charges,,,
HC Repair Intermediate F/E/E/N/L&/Muc >30.0 Cm,PX-36900864,CDM,12057,CPT,369,RC,,,outpatient,,,1132,792.4,AETNA [1000108],AETNA [100010801],,,76.8,,869.38,254.134,1592,percent of total billed charges,,,
HC Repair Complex Trunk 1.1-2.5 Cm,PX-36900788,CDM,13100,CPT,369,RC,,,outpatient,,,1831,1281.7,AETNA [1000108],AETNA [100010801],,,76.8,,1406.21,399.86,1592,percent of total billed charges,,,
HC Recmpl Wnd Trunk 2.6-7.5 Cm,PX-36900865,CDM,13101,CPT,369,RC,,,outpatient,,,1090,763,AETNA [1000108],AETNA [100010801],,,76.8,,837.12,244.705,1592,percent of total billed charges,,,
HC Rep-Skin-Trunk-Cmplx-+5 Cm/<,PX-36900866,CDM,13102,CPT,369,RC,,,outpatient,,,250,175,AETNA [1000108],AETNA [100010801],,,76.8,,192,56.125,1592,percent of total billed charges,,,
HC Repair Complex Scalp/Arm/Leg 1.1-2.5 Cm,PX-36900754,CDM,13120,CPT,369,RC,,,outpatient,,,1761,1232.7,AETNA [1000108],AETNA [100010801],,,76.8,,1352.45,395.3445,1592,percent of total billed charges,,,
HC Recmpl Wnd Scalp-Extr 2.6-7.5 Cm,PX-36900867,CDM,13121,CPT,369,RC,,,outpatient,,,735,514.5,AETNA [1000108],AETNA [100010801],,,76.8,,564.48,165.0075,1592,percent of total billed charges,,,
HC Rep-Skin-Scalp/Extrem+5 Cm/<,PX-36900868,CDM,13122,CPT,369,RC,,,outpatient,,,305,213.5,AETNA [1000108],AETNA [100010801],,,76.8,,234.24,68.4725,1592,percent of total billed charges,,,
HC Repair Complex F/C/C/M/N/Ax/G/H/F 1.1-2.5 Cm,PX-36900753,CDM,13131,CPT,369,RC,,,outpatient,,,1145,801.5,AETNA [1000108],AETNA [100010801],,,76.8,,879.36,257.0525,1592,percent of total billed charges,,,
HC Recmpl Wnd Head-Fac-Hand 2.6-7.5 Cm,PX-36900869,CDM,13132,CPT,369,RC,,,outpatient,,,723,506.1,AETNA [1000108],AETNA [100010801],,,76.8,,555.26,162.3135,1592,percent of total billed charges,,,
HC Repr-Face-Genital-Hand-Ft+5 Cmcm/<,PX-36900870,CDM,13133,CPT,369,RC,,,outpatient,,,578,404.6,AETNA [1000108],AETNA [100010801],,,76.8,,443.9,129.761,1592,percent of total billed charges,,,
HC Repair Complex Eyelid/Nose/Ear/Lip 1.1-2.5 Cm,PX-36900752,CDM,13151,CPT,369,RC,,,outpatient,,,1761,1232.7,AETNA [1000108],AETNA [100010801],,,76.8,,1352.45,395.3445,1592,percent of total billed charges,,,
HC Recmpl Wnd Lid-Nos-Ear 2.5-7.5 Cm,PX-36900871,CDM,13152,CPT,369,RC,,,outpatient,,,743,520.1,AETNA [1000108],AETNA [100010801],,,76.8,,570.62,166.8035,1592,percent of total billed charges,,,
HC Repr-Eyelid-Nose-Ear-Lip+5 Cm,PX-36900872,CDM,13153,CPT,369,RC,,,outpatient,,,462,323.4,AETNA [1000108],AETNA [100010801],,,76.8,,354.82,103.719,1592,percent of total billed charges,,,
HC Secd Clos Surg Wnd Exten/Complic,PX-36900873,CDM,13160,CPT,369,RC,,,outpatient,,,4504,3152.8,AETNA [1000108],AETNA [100010801],,,76.8,,3459.07,399.86,3459.072,percent of total billed charges,,,
HC Dressing Change Under Anesthesia,PX-36900774,CDM,15852,CPT,369,RC,,,outpatient,,,1831,1281.7,AETNA [1000108],AETNA [100010801],,,76.8,,1406.21,108.7,1592,percent of total billed charges,,,
HC Exc Coccyx/Ulcer W Suture,PX-36900598,CDM,15920,CPT,369,RC,,,outpatient,,,3425,2397.5,AETNA [1000108],AETNA [100010801],,,76.8,,2630.4,399.86,4341.777195,percent of total billed charges,,,
HC Exc Sacr Press Ulc W Pri Suture,PX-36900599,CDM,15931,CPT,369,RC,,,outpatient,,,7558,5290.6,AETNA [1000108],AETNA [100010801],,,76.8,,5804.54,399.86,5804.544,percent of total billed charges,,,
HC Exc Sacr Press Ulc W Flap Clos,PX-36900600,CDM,15934,CPT,369,RC,,,outpatient,,,9536,6675.2,AETNA [1000108],AETNA [100010801],,,76.8,,7323.65,399.86,7323.648,percent of total billed charges,,,
HC Exc Sacr Press Ulc W Musc Flap Clo,PX-36900601,CDM,15936,CPT,369,RC,,,outpatient,,,5831,4081.7,AETNA [1000108],AETNA [100010801],,,76.8,,4478.21,399.86,4478.208,percent of total billed charges,,,
HC Exc Isch Pres Ulc W Prim Clos,PX-36900602,CDM,15940,CPT,369,RC,,,outpatient,,,7558,5290.6,AETNA [1000108],AETNA [100010801],,,76.8,,5804.54,399.86,5804.544,percent of total billed charges,,,
HC Exc Isch Pres Ulc W Flap Clos,PX-36900603,CDM,15944,CPT,369,RC,,,outpatient,,,5831,4081.7,AETNA [1000108],AETNA [100010801],,,76.8,,4478.21,399.86,5481.863562,percent of total billed charges,,,
HC Exc Isch Pres Ulc Bone Myocut Flap,PX-36900604,CDM,15946,CPT,369,RC,,,outpatient,,,9536,6675.2,AETNA [1000108],AETNA [100010801],,,76.8,,7323.65,399.86,7323.648,percent of total billed charges,,,
HC Exc Troc Pres Ulc W Prim Clos,PX-36900605,CDM,15950,CPT,369,RC,,,outpatient,,,7558,5290.6,AETNA [1000108],AETNA [100010801],,,76.8,,5804.54,399.86,5804.544,percent of total billed charges,,,
HC Initial Tx 1st Degree Burn Local Tx,PX-36900591,CDM,16000,CPT,369,RC,,,outpatient,,,393,275.1,AETNA [1000108],AETNA [100010801],,,76.8,,301.82,88.2285,1592,percent of total billed charges,,,
HC Dress/Debrid Small Burn No Anes,PX-36900090,CDM,16020,CPT,369,RC,,,outpatient,,,812,568.4,AETNA [1000108],AETNA [100010801],,,76.8,,623.62,182.294,1592,percent of total billed charges,,,
HC Dress/Debrid Med Burn No Anesth,PX-36900091,CDM,16025,CPT,369,RC,,,outpatient,,,812,568.4,AETNA [1000108],AETNA [100010801],,,76.8,,623.62,182.294,1592,percent of total billed charges,,,
HC Dress/Debrid Large Burn No Anesth,PX-36900092,CDM,16030,CPT,369,RC,,,outpatient,,,845,591.5,AETNA [1000108],AETNA [100010801],,,76.8,,648.96,189.7025,1592,percent of total billed charges,,,
HC Escharotomy Each Additional Incision,PX-36900883,CDM,16036,CPT,369,RC,,,outpatient,,,670,469,AETNA [1000108],AETNA [100010801],,,76.8,,514.56,150.415,2998,percent of total billed charges,,,
HC Destruc Cut/Vasc 10-50 Sqcm,PX-36900094,CDM,17107,CPT,369,RC,,,outpatient,,,1763,1234.1,AETNA [1000108],AETNA [100010801],,,76.8,,1353.98,395.7935,1592,percent of total billed charges,,,
HC Punc/Aspir Breast Cyst,PX-36900096,CDM,19000,CPT,369,RC,,,outpatient,,,1637,1145.9,AETNA [1000108],AETNA [100010801],,,76.8,,1257.22,367.5065,2141,percent of total billed charges,,,
HC Puct/Aspir Breast Cyst-Each Addn,PX-36900097,CDM,19001,CPT,369,RC,,,outpatient,,,60,42,AETNA [1000108],AETNA [100010801],,,76.8,,46.08,13.47,1592,percent of total billed charges,,,
HC Bx Breast W Device 1st Lesion Stereotactic Guide,PX-36900099,CDM,19081,CPT,369,RC,,,outpatient,,,4317,3021.9,AETNA [1000108],AETNA [100010801],,,76.8,,3315.46,399.86,3315.456,percent of total billed charges,,,
HC Bx Breast W Device Addl Lesion Stereotact Guide,PX-36900100,CDM,19082,CPT,369,RC,,,outpatient,,,3998,2798.6,AETNA [1000108],AETNA [100010801],,,76.8,,3070.46,399.86,3070.464,percent of total billed charges,,,
HC Bx Breast W Device 1st Lesion Ultrasound Guide,PX-36900101,CDM,19083,CPT,369,RC,,,outpatient,,,3271,2289.7,AETNA [1000108],AETNA [100010801],,,76.8,,2512.13,399.86,2998,percent of total billed charges,,,
HC Bx Breast W Device Addl Lesion Ultrasound Guide,PX-36900102,CDM,19084,CPT,369,RC,,,outpatient,,,2336,1635.2,AETNA [1000108],AETNA [100010801],,,76.8,,1794.05,399.86,1794.048,percent of total billed charges,,,
HC Bx Breast W Device 1st Lesion Magnetic Res Guide,PX-36900103,CDM,19085,CPT,369,RC,,,outpatient,,,5120,3584,AETNA [1000108],AETNA [100010801],,,76.8,,3932.16,399.86,3932.16,percent of total billed charges,,,
HC Bx Breast W Device Addl Lesion Magnet Res Guide,PX-36900104,CDM,19086,CPT,369,RC,,,outpatient,,,2232,1562.4,AETNA [1000108],AETNA [100010801],,,76.8,,1714.18,399.86,1714.176,percent of total billed charges,,,
HC Perq Device Placemt Breast Loc 1st Les W Guidnce,PX-36900106,CDM,19281,CPT,369,RC,,,outpatient,,,915,640.5,AETNA [1000108],AETNA [100010801],,,76.8,,702.72,108.7,2998,percent of total billed charges,,,
HC Perq Device Placemt Breast Loc Ea Les W Guidnce,PX-36900107,CDM,19282,CPT,369,RC,,,outpatient,,,880,616,AETNA [1000108],AETNA [100010801],,,76.8,,675.84,197.56,1592,percent of total billed charges,,,
HC Perq Breast Loc Device Placemt 1st Strtctc Guid,PX-36900108,CDM,19283,CPT,369,RC,,,outpatient,,,2116,1481.2,AETNA [1000108],AETNA [100010801],,,76.8,,1625.09,108.7,2141,percent of total billed charges,,,
HC Perq Breast Loc Device Placemt Ea Lesion Strtctc,PX-36900109,CDM,19284,CPT,369,RC,,,outpatient,,,84,58.8,AETNA [1000108],AETNA [100010801],,,76.8,,64.51,18.858,1592,percent of total billed charges,,,
HC Perq Breast Loc Device Placemt 1st Lesio US Imag,PX-36900110,CDM,19285,CPT,369,RC,,,outpatient,,,1175,822.5,AETNA [1000108],AETNA [100010801],,,76.8,,902.4,108.7,2141,percent of total billed charges,,,
HC Perq Breast Loc Device Placemt Each Les US Image,PX-36900111,CDM,19286,CPT,369,RC,,,outpatient,,,274,191.8,AETNA [1000108],AETNA [100010801],,,76.8,,210.43,61.513,1592,percent of total billed charges,,,
HC Perq Breast Loc Device Placemt 1st Lesio MR Guid,PX-36900112,CDM,19287,CPT,369,RC,,,outpatient,,,2116,1481.2,AETNA [1000108],AETNA [100010801],,,76.8,,1625.09,108.7,2141,percent of total billed charges,,,
HC Place Postop Breast Cath for Rad,PX-36900114,CDM,19296,CPT,369,RC,,,outpatient,,,14045,9831.5,AETNA [1000108],AETNA [100010801],,,76.8,,10786.56,399.86,14403.82399,percent of total billed charges,,,
HC Muscle Biopsy,PX-36900115,CDM,20200,CPT,369,RC,,,outpatient,,,3700,2590,AETNA [1000108],AETNA [100010801],,,76.8,,2841.6,399.86,2998,percent of total billed charges,,,
HC Biopsy Muscle Deep,PX-36900764,CDM,20205,CPT,369,RC,,,outpatient,,,9022,6315.4,AETNA [1000108],AETNA [100010801],,,76.8,,6928.9,399.86,6928.896,percent of total billed charges,,,
HC Needle Biopsy-Muscle,PX-36900116,CDM,20206,CPT,369,RC,,,outpatient,,,3700,2590,AETNA [1000108],AETNA [100010801],,,76.8,,2841.6,399.86,2998,percent of total billed charges,,,
HC Bone Biopsy-Trocar/Needle Superf,PX-36900117,CDM,20220,CPT,369,RC,,,outpatient,,,3847,2692.9,AETNA [1000108],AETNA [100010801],,,76.8,,2954.5,399.86,2954.496,percent of total billed charges,,,
HC Bone Biopsy-Trocar/Needle Deep,PX-36900118,CDM,20225,CPT,369,RC,,,outpatient,,,3700,2590,AETNA [1000108],AETNA [100010801],,,76.8,,2841.6,399.86,2998,percent of total billed charges,,,
HC Biopsy Bone Open Superficial,PX-36900770,CDM,20240,CPT,369,RC,,,outpatient,,,9022,6315.4,AETNA [1000108],AETNA [100010801],,,76.8,,6928.9,399.86,6928.896,percent of total billed charges,,,
HC Biopsy Bone Open Deep,PX-36900769,CDM,20245,CPT,369,RC,,,outpatient,,,9022,6315.4,AETNA [1000108],AETNA [100010801],,,76.8,,6928.9,399.86,6928.896,percent of total billed charges,,,
HC Inject Sinus Tract for Dx W Xray,PX-36900120,CDM,20501,CPT,369,RC,,,outpatient,,,1451,1015.7,AETNA [1000108],AETNA [100010801],,,76.8,,1114.37,235.074116,1592,percent of total billed charges,,,
HC Removal Foreign Body Muscle/Tendon Sheath Simple,PX-36900749,CDM,20520,CPT,369,RC,,,outpatient,,,5218,3652.6,AETNA [1000108],AETNA [100010801],,,76.8,,4007.42,399.86,4007.424,percent of total billed charges,,,
HC Rmvl Foreign Body Muscle/Tendon Sheath Deep/Comp,PX-36900748,CDM,20525,CPT,369,RC,,,outpatient,,,5793,4055.1,AETNA [1000108],AETNA [100010801],,,76.8,,4449.02,399.86,4449.024,percent of total billed charges,,,
HC Injection of Tendon Sheath,PX-36900693,CDM,20550,CPT,369,RC,,,outpatient,,,823,576.1,AETNA [1000108],AETNA [100010801],,,76.8,,632.06,184.7635,1592,percent of total billed charges,,,
HC Injection Single Tendon Origin/Insertion,PX-36900793,CDM,20551,CPT,369,RC,,,outpatient,,,903,632.1,AETNA [1000108],AETNA [100010801],,,76.8,,693.5,202.7235,1592,percent of total billed charges,,,
HC Inject Trigger Point- 1 or 2,PX-36900123,CDM,20552,CPT,369,RC,,,outpatient,,,658,460.6,AETNA [1000108],AETNA [100010801],,,76.8,,505.34,147.721,1592,percent of total billed charges,,,
HC Drain/Inject Small Joint/Bursa,PX-36100004,CDM,20600,CPT,361,RC,,,outpatient,,,714,499.8,AETNA [1000108],AETNA [100010801],,,76.8,,548.35,160.293,1592,percent of total billed charges,,,
HC Drain/Inject Small Joint/Bursa,PX-36900125,CDM,20600,CPT,369,RC,,,outpatient,,,714,499.8,AETNA [1000108],AETNA [100010801],,,76.8,,548.35,160.293,1592,percent of total billed charges,,,
HC Arthrocnt Aspir&/Inj Small Jt/Bursaw/US Rec Rprt,PX-36900787,CDM,20604,CPT,369,RC,,,outpatient,,,938,656.6,AETNA [1000108],AETNA [100010801],,,76.8,,720.38,210.581,1592,percent of total billed charges,,,
HC Drain/Inject Intermediate Joint/Bursa,PX-36100005,CDM,20605,CPT,361,RC,,,outpatient,,,753,527.1,AETNA [1000108],AETNA [100010801],,,76.8,,578.3,169.0485,1592,percent of total billed charges,,,
HC Drain/Inject Intermediate Joint/Bursa,PX-36900126,CDM,20605,CPT,369,RC,,,outpatient,,,753,527.1,AETNA [1000108],AETNA [100010801],,,76.8,,578.3,169.0485,1592,percent of total billed charges,,,
HC Arthrocentesis Aspir&/Inj Interm Jt/Burs W/US,PX-36100030,CDM,20606,CPT,361,RC,,,outpatient,,,1844,1290.8,AETNA [1000108],AETNA [100010801],,,76.8,,1416.19,399.86,2141,percent of total billed charges,,,
HC Drain/Inject Large Joint/Bursa,PX-36100006,CDM,20610,CPT,361,RC,,,outpatient,,,658,460.6,AETNA [1000108],AETNA [100010801],,,76.8,,505.34,147.721,1592,percent of total billed charges,,,
HC Drain/Inject Large Joint/Bursa,PX-36900127,CDM,20610,CPT,369,RC,,,outpatient,,,658,460.6,AETNA [1000108],AETNA [100010801],,,76.8,,505.34,147.721,1592,percent of total billed charges,,,
HC Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US,PX-36100031,CDM,20611,CPT,361,RC,,,outpatient,,,784,548.8,AETNA [1000108],AETNA [100010801],,,76.8,,602.11,176.008,1592,percent of total billed charges,,,
HC Ablate- Bone Tumor(S) Perq,PX-36900128,CDM,20982,CPT,369,RC,,,outpatient,,,16473,11531.1,AETNA [1000108],AETNA [100010801],,,76.8,,12651.26,399.86,20110.10933,percent of total billed charges,,,
HC Biopsy Soft Tissue Neck/Chest,PX-36900130,CDM,21550,CPT,369,RC,,,outpatient,,,4796,3357.2,AETNA [1000108],AETNA [100010801],,,76.8,,3683.33,399.86,3683.328,percent of total billed charges,,,
HC Vertebroplasty Each Addl Cervicothor/Lumbosacral,PX-36900134,CDM,22512,CPT,369,RC,,,outpatient,,,1695,1186.5,AETNA [1000108],AETNA [100010801],,,76.8,,1301.76,380.5275,1592,percent of total billed charges,,,
HC Biopsy Soft Tissue Shoulder Superficial,PX-36900138,CDM,23065,CPT,369,RC,,,outpatient,,,2502,1751.4,AETNA [1000108],AETNA [100010801],,,76.8,,1921.54,399.86,2477.315575,percent of total billed charges,,,
HC Inj Proc Shoulder Arthrography/CT/MRI,PX-36900139,CDM,23350,CPT,369,RC,,,outpatient,,,1114,779.8,AETNA [1000108],AETNA [100010801],,,76.8,,855.55,235.074116,1592,percent of total billed charges,,,
HC Clsd Tx Shoulder Dislc W/Manipulation W/O Anes,PX-36900581,CDM,23650,CPT,369,RC,,,outpatient,,,735,514.5,AETNA [1000108],AETNA [100010801],,,76.8,,564.48,165.0075,1592,percent of total billed charges,,,
HC Clsd Tx Shoulder Dislc W/Manipulation Req Anes,PX-36900582,CDM,23655,CPT,369,RC,,,outpatient,,,3604,2522.8,AETNA [1000108],AETNA [100010801],,,76.8,,2767.87,399.86,2998,percent of total billed charges,,,
HC I&D Upper Arm/Elbow Deep Abscess/Hematoma,PX-36900784,CDM,23930,CPT,369,RC,,,outpatient,,,5218,3652.6,AETNA [1000108],AETNA [100010801],,,76.8,,4007.42,399.86,4341.777195,percent of total billed charges,,,
HC Incision&Drainage Upper Arm/Elbow Bursa,PX-36900751,CDM,23931,CPT,369,RC,,,outpatient,,,3342,2339.4,AETNA [1000108],AETNA [100010801],,,76.8,,2566.66,399.86,2998,percent of total billed charges,,,
HC Biopsy Soft Tissue Upper Arm/Elbow Superficial,PX-36900768,CDM,24065,CPT,369,RC,,,outpatient,,,5218,3652.6,AETNA [1000108],AETNA [100010801],,,76.8,,4007.42,399.86,4007.424,percent of total billed charges,,,
HC Biopsy Soft Tissue Upper Arm/Elbow Area Deep,PX-36900767,CDM,24066,CPT,369,RC,,,outpatient,,,9022,6315.4,AETNA [1000108],AETNA [100010801],,,76.8,,6928.9,399.86,6928.896,percent of total billed charges,,,
HC Injection for Elbow Arthrogram,PX-36900143,CDM,24220,CPT,369,RC,,,outpatient,,,1224,856.8,AETNA [1000108],AETNA [100010801],,,76.8,,940.03,274.788,1592,percent of total billed charges,,,
HC I&D Forearm&/Wrist Deep Abscess/Hematoma,PX-36900782,CDM,25028,CPT,369,RC,,,outpatient,,,9952,6966.4,AETNA [1000108],AETNA [100010801],,,76.8,,7643.14,399.86,7643.136,percent of total billed charges,,,
HC Incision & Drainage Forearm&/Wrist Bursa,PX-36900783,CDM,25031,CPT,369,RC,,,outpatient,,,4983,3488.1,AETNA [1000108],AETNA [100010801],,,76.8,,3826.94,399.86,3826.944,percent of total billed charges,,,
HC Incision Deep Bone Cortex Forearm&/Wrist,PX-36900785,CDM,25035,CPT,369,RC,,,outpatient,,,21621,15134.7,AETNA [1000108],AETNA [100010801],,,76.8,,16604.93,399.86,16604.928,percent of total billed charges,,,
HC Arthrt Rdcrpl/Midcarpl Jt W/Expl Drg/Rmvl FB,PX-36900778,CDM,25040,CPT,369,RC,,,outpatient,,,9952,6966.4,AETNA [1000108],AETNA [100010801],,,76.8,,7643.14,399.86,7643.136,percent of total billed charges,,,
HC Biopsy Soft Tissue Forearm&/Wrist Superficial,PX-36900766,CDM,25065,CPT,369,RC,,,outpatient,,,5218,3652.6,AETNA [1000108],AETNA [100010801],,,76.8,,4007.42,399.86,4007.424,percent of total billed charges,,,
HC Biopsy Soft Tissue Forearm&/Wrist Deep,PX-36900765,CDM,25066,CPT,369,RC,,,outpatient,,,9022,6315.4,AETNA [1000108],AETNA [100010801],,,76.8,,6928.9,399.86,6928.896,percent of total billed charges,,,
HC Injection for Wrist Arthrogram,PX-36900149,CDM,25246,CPT,369,RC,,,outpatient,,,1660,1162,AETNA [1000108],AETNA [100010801],,,76.8,,1274.88,235.074116,1592,percent of total billed charges,,,
HC Cltx Dstl Rdl Fx/Epiphysl Sep W/Manj When Perf,PX-36900792,CDM,25605,CPT,369,RC,,,outpatient,,,2563,1794.1,AETNA [1000108],AETNA [100010801],,,76.8,,1968.38,399.86,2455.793921,percent of total billed charges,,,
HC Drainage Finger Abscess Complicated,PX-36900750,CDM,26011,CPT,369,RC,,,outpatient,,,2563,1794.1,AETNA [1000108],AETNA [100010801],,,76.8,,1968.38,399.86,2998,percent of total billed charges,,,
HC Drainage Tendon Sheath Digit&/Palm Each,PX-36900781,CDM,26020,CPT,369,RC,,,outpatient,,,9952,6966.4,AETNA [1000108],AETNA [100010801],,,76.8,,7643.14,399.86,7643.136,percent of total billed charges,,,
HC Drainage of Palmar Bursa Single Bursa,PX-36900780,CDM,26025,CPT,369,RC,,,outpatient,,,9952,6966.4,AETNA [1000108],AETNA [100010801],,,76.8,,7643.14,399.86,7643.136,percent of total billed charges,,,
HC Drainage of Palmar Bursa Multiple Bursa,PX-36900779,CDM,26030,CPT,369,RC,,,outpatient,,,9952,6966.4,AETNA [1000108],AETNA [100010801],,,76.8,,7643.14,399.86,7643.136,percent of total billed charges,,,
HC Incision Bone Cortex Hand/Finger,PX-36900786,CDM,26034,CPT,369,RC,,,outpatient,,,4983,3488.1,AETNA [1000108],AETNA [100010801],,,76.8,,3826.94,399.86,3826.944,percent of total billed charges,,,
HC Arthrt Expl Drg/Rmvl Loose/FB Carp/Mtcrpl Jt,PX-36900775,CDM,26070,CPT,369,RC,,,outpatient,,,4983,3488.1,AETNA [1000108],AETNA [100010801],,,76.8,,3826.94,399.86,3826.944,percent of total billed charges,,,
HC Arthrt Expl Drg/Rmvl Loose/FB Mtcarphlngl Jt Ea,PX-36900777,CDM,26075,CPT,369,RC,,,outpatient,,,9952,6966.4,AETNA [1000108],AETNA [100010801],,,76.8,,7643.14,399.86,7643.136,percent of total billed charges,,,
HC Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea,PX-36900776,CDM,26080,CPT,369,RC,,,outpatient,,,4983,3488.1,AETNA [1000108],AETNA [100010801],,,76.8,,3826.94,399.86,3826.944,percent of total billed charges,,,
HC Bx Soft Tissues-Pelv/Hip-Superficl,PX-36900160,CDM,27040,CPT,369,RC,,,outpatient,,,3700,2590,AETNA [1000108],AETNA [100010801],,,76.8,,2841.6,399.86,2841.6,percent of total billed charges,,,
HC Bx Soft Tissues-Pelv/Hip-Deep,PX-36900161,CDM,27041,CPT,369,RC,,,outpatient,,,3700,2590,AETNA [1000108],AETNA [100010801],,,76.8,,2841.6,399.86,2841.6,percent of total billed charges,,,
HC Injection Hip Arthrogram,PX-36900162,CDM,27093,CPT,369,RC,,,outpatient,,,1589,1112.3,AETNA [1000108],AETNA [100010801],,,76.8,,1220.35,235.074116,1592,percent of total billed charges,,,
HC Closed Rx Prox/Neck Femur Fx-Manip,PX-36900886,CDM,27232,CPT,369,RC,,,outpatient,,,3499,2449.3,AETNA [1000108],AETNA [100010801],,,76.8,,2687.23,399.86,2998,percent of total billed charges,,,
HC Cltx Hip Dislocation Traumatic W/O Anesthesia,PX-36900583,CDM,27250,CPT,369,RC,,,outpatient,,,902,631.4,AETNA [1000108],AETNA [100010801],,,76.8,,692.74,202.499,1592,percent of total billed charges,,,
HC Cltx Hip Dislocation Traumatic Req Anesthesia,PX-36900584,CDM,27252,CPT,369,RC,,,outpatient,,,2848,1993.6,AETNA [1000108],AETNA [100010801],,,76.8,,2187.26,399.86,2455.793921,percent of total billed charges,,,
HC Cltx Post Hip Arthrp Dislc W/O Anes,PX-36900585,CDM,27265,CPT,369,RC,,,outpatient,,,671,469.7,AETNA [1000108],AETNA [100010801],,,76.8,,515.33,150.6395,1592,percent of total billed charges,,,
HC Cltx Post Hip Arthrp Dislc Req Anes,PX-36900586,CDM,27266,CPT,369,RC,,,outpatient,,,2045,1431.5,AETNA [1000108],AETNA [100010801],,,76.8,,1570.56,399.86,2998,percent of total billed charges,,,
HC Unlisted Procedure Pelvis/Hip Joint,PX-36900700,CDM,27299,CPT,369,RC,,,outpatient,,,715,500.5,AETNA [1000108],AETNA [100010801],,,76.8,,549.12,160.5175,1592,percent of total billed charges,,,
HC I&D Deep Absc Bursa/Hematoma Thigh/Knee Region,PX-36900814,CDM,27301,CPT,369,RC,,,outpatient,,,7663,5364.1,AETNA [1000108],AETNA [100010801],,,76.8,,5885.18,399.86,5885.184,percent of total billed charges,,,
HC Injection Knee Arthrography,PX-36900731,CDM,27369,CPT,369,RC,,,outpatient,,,1446,1012.2,AETNA [1000108],AETNA [100010801],,,76.8,,1110.53,324.627,1592,percent of total billed charges,,,
HC Injection for Ankle Arthrogram,PX-36900167,CDM,27648,CPT,369,RC,,,outpatient,,,834,583.8,AETNA [1000108],AETNA [100010801],,,76.8,,640.51,187.233,1592,percent of total billed charges,,,
HC Closed Tx Bimalleolar Ankle Fracture W/Manj,PX-36900880,CDM,27810,CPT,369,RC,,,outpatient,,,3663,2564.1,AETNA [1000108],AETNA [100010801],,,76.8,,2813.18,292.65,2813.184,percent of total billed charges,,,
HC Application Cast Shoulder Hand Long Arm,PX-36900741,CDM,29065,CPT,369,RC,,,outpatient,,,664,464.8,AETNA [1000108],AETNA [100010801],,,76.8,,509.95,149.068,1592,percent of total billed charges,,,
HC Application Cast Elbow Finger Short Arm,PX-36900739,CDM,29075,CPT,369,RC,,,outpatient,,,893,625.1,AETNA [1000108],AETNA [100010801],,,76.8,,685.82,200.4785,1592,percent of total billed charges,,,
HC Application Cast Hand & Lower Forearm Gauntlet,PX-36900740,CDM,29085,CPT,369,RC,,,outpatient,,,491,343.7,AETNA [1000108],AETNA [100010801],,,76.8,,377.09,110.2295,1592,percent of total billed charges,,,
HC Application Cast Finger,PX-36900771,CDM,29086,CPT,369,RC,,,outpatient,,,511,357.7,AETNA [1000108],AETNA [100010801],,,76.8,,392.45,114.7195,1592,percent of total billed charges,,,
HC Application Long Arm Splint Shoulder Hand,PX-36900759,CDM,29105,CPT,369,RC,,,outpatient,,,453,317.1,AETNA [1000108],AETNA [100010801],,,76.8,,347.9,101.6985,1592,percent of total billed charges,,,
HC Application Short Arm Splint Forearm-Hand Static,PX-36900576,CDM,29125,CPT,369,RC,,,outpatient,,,354,247.8,AETNA [1000108],AETNA [100010801],,,76.8,,271.87,79.473,1592,percent of total billed charges,,,
HC Application Short Arm Splint Dynamic,PX-36900577,CDM,29126,CPT,369,RC,,,outpatient,,,354,247.8,AETNA [1000108],AETNA [100010801],,,76.8,,271.87,79.473,1592,percent of total billed charges,,,
HC Application Finger Splint Static,PX-36900579,CDM,29130,CPT,369,RC,,,outpatient,,,221,154.7,AETNA [1000108],AETNA [100010801],,,76.8,,169.73,49.6145,1592,percent of total billed charges,,,
HC Application Finger Splint Dynamic,PX-36900580,CDM,29131,CPT,369,RC,,,outpatient,,,218,152.6,AETNA [1000108],AETNA [100010801],,,76.8,,167.42,48.941,1592,percent of total billed charges,,,
HC Strapping Shoulder,PX-36900761,CDM,29240,CPT,369,RC,,,outpatient,,,405,283.5,AETNA [1000108],AETNA [100010801],,,76.8,,311.04,90.9225,1592,percent of total billed charges,,,
HC Strapping Elbow/Wrist,PX-36900760,CDM,29260,CPT,369,RC,,,outpatient,,,122,85.4,AETNA [1000108],AETNA [100010801],,,76.8,,93.7,27.389,1592,percent of total billed charges,,,
HC Strapping Hand/Finger,PX-36900790,CDM,29280,CPT,369,RC,,,outpatient,,,122,85.4,AETNA [1000108],AETNA [100010801],,,76.8,,93.7,27.389,1592,percent of total billed charges,,,
HC Application Short Leg Cast Below Knee-Toe,PX-36900818,CDM,29405,CPT,369,RC,,,outpatient,,,699,489.3,AETNA [1000108],AETNA [100010801],,,76.8,,536.83,156.9255,1592,percent of total billed charges,,,
HC Application Long Leg Splint Thigh Ankle/Toes,PX-36900737,CDM,29505,CPT,369,RC,,,outpatient,,,554,387.8,AETNA [1000108],AETNA [100010801],,,76.8,,425.47,124.373,1592,percent of total billed charges,,,
HC Application Short Leg Splint Calf Foot,PX-36900578,CDM,29515,CPT,369,RC,,,outpatient,,,354,247.8,AETNA [1000108],AETNA [100010801],,,76.8,,271.87,79.473,1592,percent of total billed charges,,,
HC Ctrl Nosebleed-Anter-Simple,PX-36900181,CDM,30901,CPT,369,RC,,,outpatient,,,347,242.9,AETNA [1000108],AETNA [100010801],,,76.8,,266.5,77.9015,1592,percent of total billed charges,,,
HC PR Control Nasal Hemorrhage Anterior Simple,PX-96000041,CDM,30901,CPT,960,RC,,,outpatient,,,347,242.9,AETNA [1000108],AETNA [100010801],,,76.8,,266.5,77.9015,1592,percent of total billed charges,,,
HC Control Nasal Hemorrhage Anterior Complex,PX-36900745,CDM,30903,CPT,369,RC,,,outpatient,,,289,202.3,AETNA [1000108],AETNA [100010801],,,76.8,,221.95,64.8805,1592,percent of total billed charges,,,
HC PR Control Nasal Hemorrhage Anterior Complex,PX-96000042,CDM,30903,CPT,960,RC,,,outpatient,,,289,202.3,AETNA [1000108],AETNA [100010801],,,76.8,,221.95,64.8805,1592,percent of total billed charges,,,
HC Ctrl Nsl Hemrrg Pst Nasal Packs&/Cautery 1st,PX-36900746,CDM,30905,CPT,369,RC,,,outpatient,,,486,340.2,AETNA [1000108],AETNA [100010801],,,76.8,,373.25,109.107,1592,percent of total billed charges,,,
HC Ctrl Nsl Hemrrg Pst Nasal Packs&/Cautery Subsq,PX-36900747,CDM,30906,CPT,369,RC,,,outpatient,,,510,357,AETNA [1000108],AETNA [100010801],,,76.8,,391.68,114.495,1592,percent of total billed charges,,,
HC Insert Emergency Endotrach Airway,PX-36100007,CDM,31500,CPT,361,RC,,,outpatient,,,544,380.8,AETNA [1000108],AETNA [100010801],,,76.8,,417.79,122.128,1592,percent of total billed charges,,,
HC Insert Emergency Endotrach Airway,PX-36900182,CDM,31500,CPT,369,RC,,,outpatient,,,544,380.8,AETNA [1000108],AETNA [100010801],,,76.8,,417.79,122.128,1592,percent of total billed charges,,,
HC PR Intubation Endotracheal Emergency Procedure,PX-96000038,CDM,31500,CPT,960,RC,,,outpatient,,,544,380.8,AETNA [1000108],AETNA [100010801],,,76.8,,417.79,122.128,1592,percent of total billed charges,,,
HC Trach Tube Change,PX-36900183,CDM,31502,CPT,369,RC,,,outpatient,,,615,430.5,AETNA [1000108],AETNA [100010801],,,76.8,,472.32,138.0675,1592,percent of total billed charges,,,
HC Laryngoscopy-Flex Fiber-Diagnostic,PX-36900185,CDM,31575,CPT,369,RC,,,outpatient,,,371,259.7,AETNA [1000108],AETNA [100010801],,,76.8,,284.93,83.2895,1592,percent of total billed charges,,,
HC Bronchoscopy-Diagnostic,PX-36900187,CDM,31622,CPT,369,RC,,,outpatient,,,3151,2205.7,AETNA [1000108],AETNA [100010801],,,76.8,,2419.97,399.86,2998,percent of total billed charges,,,
HC Bronchoscopy-Diagnostic W Brush,PX-36900188,CDM,31623,CPT,369,RC,,,outpatient,,,3150,2205,AETNA [1000108],AETNA [100010801],,,76.8,,2419.2,399.86,2998,percent of total billed charges,,,
HC Brnchsc W/Brncl Alveolar Lavage,PX-36900896,CDM,31624,CPT,369,RC,,,outpatient,,,3935,2754.5,AETNA [1000108],AETNA [100010801],,,76.8,,3022.08,399.86,3022.08,percent of total billed charges,,,
HC Bronchoscopy-Biopsy,PX-36900189,CDM,31625,CPT,369,RC,,,outpatient,,,3271,2289.7,AETNA [1000108],AETNA [100010801],,,76.8,,2512.13,399.86,2998,percent of total billed charges,,,
HC Needle Biopsy Pleura,PX-36900190,CDM,32400,CPT,369,RC,,,outpatient,,,3700,2590,AETNA [1000108],AETNA [100010801],,,76.8,,2841.6,399.86,2998,percent of total billed charges,,,
HC Core Needle Bx Lung/Mediastinum Perq W/Img,PX-36900808,CDM,32408,CPT,369,RC,,,outpatient,,,4594,3215.8,AETNA [1000108],AETNA [100010801],,,76.8,,3528.19,399.86,3528.192,percent of total billed charges,,,
HC Insertion Indwelling Tunneled Pleural Catheter,PX-36900192,CDM,32550,CPT,369,RC,,,outpatient,,,8367,5856.9,AETNA [1000108],AETNA [100010801],,,76.8,,6425.86,399.86,6425.856,percent of total billed charges,,,
HC Tube Thoracostomy Includes Water Seal,PX-36100008,CDM,32551,CPT,361,RC,,,outpatient,,,1951,1365.7,AETNA [1000108],AETNA [100010801],,,76.8,,1498.37,399.86,2447.133941,percent of total billed charges,,,
HC Tube Thoracostomy Includes Water Seal,PX-36900193,CDM,32551,CPT,369,RC,,,outpatient,,,1951,1365.7,AETNA [1000108],AETNA [100010801],,,76.8,,1498.37,399.86,2447.133941,percent of total billed charges,,,
HC Tube Thoracostomy Includes Water Seal,PX-36900573,CDM,32551,CPT,369,RC,,,outpatient,,,1951,1365.7,AETNA [1000108],AETNA [100010801],,,76.8,,1498.37,399.86,2447.133941,percent of total billed charges,,,
HC PR Tube Thoracostomy Includes Water Seal,PX-96000039,CDM,32551,CPT,960,RC,,,outpatient,,,1951,1365.7,AETNA [1000108],AETNA [100010801],,,76.8,,1498.37,399.86,2447.133941,percent of total billed charges,,,
HC Removal of Indwelling Tunneled Pleural Catheter With Cuff,PX-36900194,CDM,32552,CPT,369,RC,,,outpatient,,,2265,1585.5,AETNA [1000108],AETNA [100010801],,,76.8,,1739.52,399.86,2141,percent of total billed charges,,,
HC Perc Place Intra-Thoracic Interstit Rad Therapy Guide- 1/Mult,PX-36900195,CDM,32553,CPT,369,RC,,,outpatient,,,4198,2938.6,AETNA [1000108],AETNA [100010801],,,76.8,,3224.06,399.86,3224.064,percent of total billed charges,,,
HC Thoracentesis Needle/Cath Pleura W/O Imaging,PX-36900196,CDM,32554,CPT,369,RC,,,outpatient,,,1874,1311.8,AETNA [1000108],AETNA [100010801],,,76.8,,1439.23,399.86,2141,percent of total billed charges,,,
HC Thoracentesis Needle/Cath Pleura W/Imaging,PX-36100001,CDM,32555,CPT,361,RC,,,outpatient,,,1636,1145.2,AETNA [1000108],AETNA [100010801],,,76.8,,1256.45,367.282,2141,percent of total billed charges,,,
HC Thoracentesis Needle/Cath Pleura W/Imaging,PX-36900197,CDM,32555,CPT,369,RC,,,outpatient,,,1636,1145.2,AETNA [1000108],AETNA [100010801],,,76.8,,1256.45,367.282,2141,percent of total billed charges,,,
HC Perq Drainage Pleura Insert Cath W/O Imaging,PX-36900742,CDM,32556,CPT,369,RC,,,outpatient,,,2896,2027.2,AETNA [1000108],AETNA [100010801],,,76.8,,2224.13,399.86,2998,percent of total billed charges,,,
HC Perq Drainage Pleura Insert Cath W/Imaging,PX-36900198,CDM,32557,CPT,369,RC,,,outpatient,,,1882,1317.4,AETNA [1000108],AETNA [100010801],,,76.8,,1445.38,399.86,2447.133941,percent of total billed charges,,,
HC PR Instlj via Chest Tube/Cath Agent for Pleurodesis,PX-96000040,CDM,32560,CPT,960,RC,,,outpatient,,,2265,1585.5,AETNA [1000108],AETNA [100010801],,,76.8,,1739.52,399.86,1739.52,percent of total billed charges,,,
HC Instlj via Ch Tube/Cath Agent Fbrnlysis 1st Day,PX-36900826,CDM,32561,CPT,369,RC,,,outpatient,,,1421,994.7,AETNA [1000108],AETNA [100010801],,,76.8,,1091.33,319.0145,2141,percent of total billed charges,,,
HC Instlj Ch Tube/Cath Agent Fbrnlysis Sbsq Day,PX-36900827,CDM,32562,CPT,369,RC,,,outpatient,,,1421,994.7,AETNA [1000108],AETNA [100010801],,,76.8,,1091.33,319.0145,2141,percent of total billed charges,,,
HC Pericardiocentesis W/Img Guidance When Performed,PX-36100034,CDM,33016,CPT,361,RC,,,outpatient,,,5537,3875.9,AETNA [1000108],AETNA [100010801],,,76.8,,4252.42,399.86,4252.416,percent of total billed charges,,,
HC Pericardiocentesis W/Img Guidance When Performed,PX-36900797,CDM,33016,CPT,369,RC,,,outpatient,,,5537,3875.9,AETNA [1000108],AETNA [100010801],,,76.8,,4252.42,399.86,4252.416,percent of total billed charges,,,
HC Inser Hart Pacer Xvenous Atrial,PX-36900204,CDM,33206,CPT,369,RC,,,outpatient,,,27344,19140.8,AETNA [1000108],AETNA [100010801],,,76.8,,21000.19,399.86,21000.192,percent of total billed charges,,,
HC Inser Hart Pacer Xvenous Ventr,PX-36900205,CDM,33207,CPT,369,RC,,,outpatient,,,36767,25736.9,AETNA [1000108],AETNA [100010801],,,76.8,,28237.06,399.86,28237.056,percent of total billed charges,,,
HC Inser Hart Pacer Xvenous Atr/Ventr,PX-36900206,CDM,33208,CPT,369,RC,,,outpatient,,,27344,19140.8,AETNA [1000108],AETNA [100010801],,,76.8,,21000.19,399.86,21000.192,percent of total billed charges,,,
HC Inser Heart Temp Pacer One Chmbr,PX-36900207,CDM,33210,CPT,369,RC,,,outpatient,,,21456,15019.2,AETNA [1000108],AETNA [100010801],,,76.8,,16478.21,399.86,16478.208,percent of total billed charges,,,
HC Insert Pulse Gener One Chmbr,PX-36900209,CDM,33212,CPT,369,RC,,,outpatient,,,21456,15019.2,AETNA [1000108],AETNA [100010801],,,76.8,,16478.21,399.86,16478.208,percent of total billed charges,,,
HC Insert Pulse Gener Dual Chmbr,PX-36900210,CDM,33213,CPT,369,RC,,,outpatient,,,27344,19140.8,AETNA [1000108],AETNA [100010801],,,76.8,,21000.19,399.86,21000.192,percent of total billed charges,,,
HC Upgrade of Pacemaker System,PX-36900211,CDM,33214,CPT,369,RC,,,outpatient,,,27344,19140.8,AETNA [1000108],AETNA [100010801],,,76.8,,21000.19,399.86,21000.192,percent of total billed charges,,,
HC Reposition Transvenous Electrode,PX-36900212,CDM,33215,CPT,369,RC,,,outpatient,,,4029,2820.3,AETNA [1000108],AETNA [100010801],,,76.8,,3094.27,399.86,4870.452937,percent of total billed charges,,,
HC Revise Electrode-Pacing-Dual,PX-36900215,CDM,33217,CPT,369,RC,,,outpatient,,,21456,15019.2,AETNA [1000108],AETNA [100010801],,,76.8,,16478.21,399.86,16478.208,percent of total billed charges,,,
HC Reeletrode-Pacing-Single,PX-36900216,CDM,33218,CPT,369,RC,,,outpatient,,,9056,6339.2,AETNA [1000108],AETNA [100010801],,,76.8,,6955.01,399.86,6955.008,percent of total billed charges,,,
HC Reelectrode-Pacing-Dual,PX-36900217,CDM,33220,CPT,369,RC,,,outpatient,,,9056,6339.2,AETNA [1000108],AETNA [100010801],,,76.8,,6955.01,399.86,6955.008,percent of total billed charges,,,
HC Ins Pacemaker Pulse Gen Only W/Exist Mult Leads,PX-36900218,CDM,33221,CPT,369,RC,,,outpatient,,,48979,34285.3,AETNA [1000108],AETNA [100010801],,,76.8,,37615.87,399.86,37615.872,percent of total billed charges,,,
HC Relocation of Skin Pocket for Pacemaker,PX-36900219,CDM,33222,CPT,369,RC,,,outpatient,,,4504,3152.8,AETNA [1000108],AETNA [100010801],,,76.8,,3459.07,399.86,3459.072,percent of total billed charges,,,
HC Relocate Skin Pocket Cardioverter-Defibrillator,PX-36900220,CDM,33223,CPT,369,RC,,,outpatient,,,2716,1901.2,AETNA [1000108],AETNA [100010801],,,76.8,,2085.89,399.86,2998,percent of total billed charges,,,
HC Insrt Pacing Elect-W/Attach Prev Device,PX-36900221,CDM,33224,CPT,369,RC,,,outpatient,,,27344,19140.8,AETNA [1000108],AETNA [100010801],,,76.8,,21000.19,399.86,21000.192,percent of total billed charges,,,
HC Insj Eltrd Car Ven Sys Tm Insj Cvdfb/Pm Pls Gen,PX-36900222,CDM,33225,CPT,369,RC,,,outpatient,,,7571,5299.7,AETNA [1000108],AETNA [100010801],,,76.8,,5814.53,399.86,6364,percent of total billed charges,,,
HC Reposit Prev Implanted Cardiac Electrode,PX-36900223,CDM,33226,CPT,369,RC,,,outpatient,,,3644,2550.8,AETNA [1000108],AETNA [100010801],,,76.8,,2798.59,399.86,4870.452937,percent of total billed charges,,,
HC Remvl Perm Pm Plse Gen W/Repl Plse Gen Sngl Lead,PX-36900224,CDM,33227,CPT,369,RC,,,outpatient,,,17786,12450.2,AETNA [1000108],AETNA [100010801],,,76.8,,13659.65,399.86,13659.648,percent of total billed charges,,,
HC Remvl Perm Pm Pls Gen W/Repl Plse Gen 2 Lead Sys,PX-36900225,CDM,33228,CPT,369,RC,,,outpatient,,,19652,13756.4,AETNA [1000108],AETNA [100010801],,,76.8,,15092.74,399.86,16316.30039,percent of total billed charges,,,
HC Remvl Perm Pm Pls Gen W/Repl Plse Gen Mult Lead,PX-36900226,CDM,33229,CPT,369,RC,,,outpatient,,,22582,15807.4,AETNA [1000108],AETNA [100010801],,,76.8,,17342.98,399.86,29773.2518,percent of total billed charges,,,
HC Ins Pacng Cvdfb Pls Gen Only W/Exist Dual Leads,PX-36900227,CDM,33230,CPT,369,RC,,,outpatient,,,67496,47247.2,AETNA [1000108],AETNA [100010801],,,76.8,,51836.93,399.86,51836.928,percent of total billed charges,,,
HC Ins Pacng Cvdfb Pls Gen Only W/Exist Multi Leads,PX-36900228,CDM,33231,CPT,369,RC,,,outpatient,,,64998,45498.6,AETNA [1000108],AETNA [100010801],,,76.8,,49918.46,399.86,50269.54813,percent of total billed charges,,,
HC Remv Perm Pacer Generator,PX-36900229,CDM,33233,CPT,369,RC,,,outpatient,,,21456,15019.2,AETNA [1000108],AETNA [100010801],,,76.8,,16478.21,399.86,16478.208,percent of total billed charges,,,
HC Remv Transven Pacer Electrode-1 Lead,PX-36900230,CDM,33234,CPT,369,RC,,,outpatient,,,9056,6339.2,AETNA [1000108],AETNA [100010801],,,76.8,,6955.01,399.86,6955.008,percent of total billed charges,,,
HC Remv Transven Pacer Electrode-2 Lead,PX-36900231,CDM,33235,CPT,369,RC,,,outpatient,,,9056,6339.2,AETNA [1000108],AETNA [100010801],,,76.8,,6955.01,399.86,6955.008,percent of total billed charges,,,
HC Rmv Pulse Generator-Sngl/Dual,PX-36900233,CDM,33241,CPT,369,RC,,,outpatient,,,9028,6319.6,AETNA [1000108],AETNA [100010801],,,76.8,,6933.5,399.86,6933.504,percent of total billed charges,,,
HC Rmv Pacer/Electrd-Transven Extrct,PX-36900234,CDM,33244,CPT,369,RC,,,outpatient,,,9056,6339.2,AETNA [1000108],AETNA [100010801],,,76.8,,6955.01,399.86,6955.008,percent of total billed charges,,,
HC Insert Electrd Leads/Repostion,PX-36900235,CDM,33249,CPT,369,RC,,,outpatient,,,86384,60468.8,AETNA [1000108],AETNA [100010801],,,76.8,,66342.91,399.86,66342.912,percent of total billed charges,,,
HC Rem Pac Cvdfb Plse Gen &Repl Plse Gen Sngl Lead,PX-36900236,CDM,33262,CPT,369,RC,,,outpatient,,,63006,44104.2,AETNA [1000108],AETNA [100010801],,,76.8,,48388.61,399.86,48388.608,percent of total billed charges,,,
HC Rem Pac Cvdfb Plse Gen &Repl Plse Gen Dual Lead,PX-36900237,CDM,33263,CPT,369,RC,,,outpatient,,,65752,46026.4,AETNA [1000108],AETNA [100010801],,,76.8,,50497.54,399.86,50497.536,percent of total billed charges,,,
HC Rem Pac Cvdfb Pls Gen &Repl Plse Gen Multi Lead,PX-36900238,CDM,33264,CPT,369,RC,,,outpatient,,,65752,46026.4,AETNA [1000108],AETNA [100010801],,,76.8,,50497.54,399.86,50497.536,percent of total billed charges,,,
HC Replace Aortic Valve Perq Femoral Artry Approach,PX-36900544,CDM,33361,CPT,369,RC,,,outpatient,,,27728,19409.6,AETNA [1000108],AETNA [100010801],,,76.8,,21295.1,399.86,21295.104,percent of total billed charges,,,
HC Replace Aortic Valve Openfemoral Artery Approach,PX-36900545,CDM,33362,CPT,369,RC,,,outpatient,,,29393,20575.1,AETNA [1000108],AETNA [100010801],,,76.8,,22573.82,399.86,24913.5068,percent of total billed charges,,,
HC Replace Aortic Valve Open Axillry Artry Approach,PX-36900546,CDM,33363,CPT,369,RC,,,outpatient,,,27728,19409.6,AETNA [1000108],AETNA [100010801],,,76.8,,21295.1,399.86,21295.104,percent of total billed charges,,,
HC Replace Aortic Valve Open Iliac Artery Approach,PX-36900547,CDM,33364,CPT,369,RC,,,outpatient,,,29393,20575.1,AETNA [1000108],AETNA [100010801],,,76.8,,22573.82,399.86,22573.824,percent of total billed charges,,,
HC Replace Aortic Valve Open Transaortic Approach,PX-36900548,CDM,33365,CPT,369,RC,,,outpatient,,,29393,20575.1,AETNA [1000108],AETNA [100010801],,,76.8,,22573.82,399.86,22573.824,percent of total billed charges,,,
HC Transcatheter Transapical Replacemt Aortic Valve,PX-36900549,CDM,33366,CPT,369,RC,,,outpatient,,,29393,20575.1,AETNA [1000108],AETNA [100010801],,,76.8,,22573.82,399.86,24913.5068,percent of total billed charges,,,
HC Replace Aortic Valve W/Byp Prq Art/Venous Apprch,PX-36900550,CDM,33367,CPT,369,RC,,,outpatient,,,27728,19409.6,AETNA [1000108],AETNA [100010801],,,76.8,,21295.1,399.86,23502.2528,percent of total billed charges,,,
HC Replace Aortic Valve W/Byp Open Art/Venous Aprch,PX-36900551,CDM,33368,CPT,369,RC,,,outpatient,,,29393,20575.1,AETNA [1000108],AETNA [100010801],,,76.8,,22573.82,399.86,24913.5068,percent of total billed charges,,,
HC Replace Aorta Valve W/Byp Cntrl Art/Venous Aprch,PX-36900552,CDM,33369,CPT,369,RC,,,outpatient,,,29393,20575.1,AETNA [1000108],AETNA [100010801],,,76.8,,22573.82,399.86,24913.5068,percent of total billed charges,,,
HC Endovasc Taa Reincl Subcl,PX-36900241,CDM,33880,CPT,369,RC,,,outpatient,,,6951,4865.7,AETNA [1000108],AETNA [100010801],,,76.8,,5338.37,399.86,5338.368,percent of total billed charges,,,
HC Endovasc Taa Rew/O Subcl,PX-36900242,CDM,33881,CPT,369,RC,,,outpatient,,,5970,4179,AETNA [1000108],AETNA [100010801],,,76.8,,4584.96,399.86,4584.96,percent of total billed charges,,,
HC Insert Endovasc Prosth- Taa,PX-36900243,CDM,33883,CPT,369,RC,,,outpatient,,,4420,3094,AETNA [1000108],AETNA [100010801],,,76.8,,3394.56,399.86,3746.392,percent of total billed charges,,,
HC Endovasc Prosth- Taa- Ea Add,PX-36900244,CDM,33884,CPT,369,RC,,,outpatient,,,1649,1154.3,AETNA [1000108],AETNA [100010801],,,76.8,,1266.43,370.2005,2998,percent of total billed charges,,,
HC Endovasc Dist Extens Taa Prosth- Delayed,PX-36900245,CDM,33886,CPT,369,RC,,,outpatient,,,3820,2674,AETNA [1000108],AETNA [100010801],,,76.8,,2933.76,399.86,3237.832,percent of total billed charges,,,
HC Car-Car Bypass Grft W/ Endovas Taa Repair,PX-36900247,CDM,33891,CPT,369,RC,,,outpatient,,,4194,2935.8,AETNA [1000108],AETNA [100010801],,,76.8,,3220.99,399.86,3220.992,percent of total billed charges,,,
HC Remove Pul Art Emboli No Bypass,PX-36900248,CDM,33915,CPT,369,RC,,,outpatient,,,1800,1260,AETNA [1000108],AETNA [100010801],,,76.8,,1382.4,399.86,2998,percent of total billed charges,,,
HC Insert Intra-Aortic Balloon Asst Device,PX-36900249,CDM,33967,CPT,369,RC,,,outpatient,,,2513,1759.1,AETNA [1000108],AETNA [100010801],,,76.8,,1929.98,399.86,6913,percent of total billed charges,,,
HC Rmv Aortic Balloon Device,PX-36900250,CDM,33968,CPT,369,RC,,,outpatient,,,139,97.3,AETNA [1000108],AETNA [100010801],,,76.8,,106.75,31.2055,6913,percent of total billed charges,,,
HC Insj Perq Vad W/Rs&I L Hrt Arterial Access Only,PX-36900251,CDM,33990,CPT,369,RC,,,outpatient,,,4109,2876.3,AETNA [1000108],AETNA [100010801],,,76.8,,3155.71,399.86,3155.712,percent of total billed charges,,,
HC Removal Perq Left Hrt Vad Artl/Artl&Ven Sep Insj,PX-36900252,CDM,33992,CPT,369,RC,,,outpatient,,,4188,2931.6,AETNA [1000108],AETNA [100010801],,,76.8,,3216.38,399.86,3549.7488,percent of total billed charges,,,
HC Repositioning Perq R/L Vad W/Img Gdn Sep Insj,PX-36900253,CDM,33993,CPT,369,RC,,,outpatient,,,4188,2931.6,AETNA [1000108],AETNA [100010801],,,76.8,,3216.38,399.86,3549.7488,percent of total billed charges,,,
HC Insj Perq Vad W/Rs&I R Heart Venous Access Only,PX-36900809,CDM,33995,CPT,369,RC,,,outpatient,,,4109,2876.3,AETNA [1000108],AETNA [100010801],,,76.8,,3155.71,399.86,3155.712,percent of total billed charges,,,
HC Removal Perq R Heart Vad Venous Cannula Sep Insj,PX-36900810,CDM,33997,CPT,369,RC,,,outpatient,,,4188,2931.6,AETNA [1000108],AETNA [100010801],,,76.8,,3216.38,293.5896,3216.384,percent of total billed charges,,,
HC Cardiac Surg Procedure Unlist,PX-36900254,CDM,33999,CPT,369,RC,,,outpatient,,,1770,1239,AETNA [1000108],AETNA [100010801],,,76.8,,1359.36,397.365,2141,percent of total billed charges,,,
HC Cardiac Surg Procedure Unlist,PX-36900635,CDM,33999,CPT,369,RC,,,outpatient,,,1770,1239,AETNA [1000108],AETNA [100010801],,,76.8,,1359.36,397.365,2141,percent of total billed charges,,,
HC Remv Art Clot Axill-Brach-Arm Incis,PX-36900255,CDM,34101,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA [1000108],AETNA [100010801],,,76.8,,9631.49,399.86,9631.488,percent of total billed charges,,,
HC Remv Art Clot Arm-Arm Incis,PX-36900256,CDM,34111,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA [1000108],AETNA [100010801],,,76.8,,9631.49,399.86,9631.488,percent of total billed charges,,,
HC Remv Art Clot Iliac-Pop-Leg Incis,PX-36900257,CDM,34201,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA [1000108],AETNA [100010801],,,76.8,,9631.49,399.86,9631.488,percent of total billed charges,,,
HC Remv Art Clot Low Leg-Leg Incis,PX-36900258,CDM,34203,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA [1000108],AETNA [100010801],,,76.8,,9631.49,399.86,9631.488,percent of total billed charges,,,
HC Aaa Repair-Iliac Artery Occlsn Device,PX-36900264,CDM,34808,CPT,369,RC,,,outpatient,,,152,106.4,AETNA [1000108],AETNA [100010801],,,76.8,,116.74,34.124,2998,percent of total billed charges,,,
HC Aaa Repr-Expose Femoral Art-Groin Incis,PX-36900265,CDM,34812,CPT,369,RC,,,outpatient,,,238,166.6,AETNA [1000108],AETNA [100010801],,,76.8,,182.78,53.431,2998,percent of total billed charges,,,
HC Aaa Repair- Femoral-Femoral Graft,PX-36900266,CDM,34813,CPT,369,RC,,,outpatient,,,167,116.9,AETNA [1000108],AETNA [100010801],,,76.8,,128.26,37.4915,2998,percent of total billed charges,,,
HC Aaa Repr-Expose Iliac Art-Abd Incis- Unilat,PX-36900267,CDM,34820,CPT,369,RC,,,outpatient,,,337,235.9,AETNA [1000108],AETNA [100010801],,,76.8,,258.82,75.6565,2998,percent of total billed charges,,,
HC Open Iliac Art Exp W/Conduit-Unilat,PX-36900270,CDM,34833,CPT,369,RC,,,outpatient,,,447,312.9,AETNA [1000108],AETNA [100010801],,,76.8,,343.3,100.3515,2998,percent of total billed charges,,,
HC Open Brach Art Exp-Endovas Pros-Unilat,PX-36900271,CDM,34834,CPT,369,RC,,,outpatient,,,218,152.6,AETNA [1000108],AETNA [100010801],,,76.8,,167.42,48.941,2998,percent of total billed charges,,,
HC Thrombectomy a-V Graft- Exc Hemodialysis,PX-36900278,CDM,35875,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA [1000108],AETNA [100010801],,,76.8,,9631.49,399.86,9631.488,percent of total billed charges,,,
HC Place Needle in Vein,PX-36900279,CDM,36000,CPT,369,RC,,,outpatient,,,343,240.1,AETNA [1000108],AETNA [100010801],,,76.8,,263.42,77.0035,1592,percent of total billed charges,,,
HC Injection Rx Extremity Pseudoaneurysm,PX-36900280,CDM,36002,CPT,369,RC,,,outpatient,,,775,542.5,AETNA [1000108],AETNA [100010801],,,76.8,,595.2,173.9875,2141,percent of total billed charges,,,
HC Injection Proc-Extremity-Venography,PX-36900281,CDM,36005,CPT,369,RC,,,outpatient,,,258,180.6,AETNA [1000108],AETNA [100010801],,,76.8,,198.14,57.921,1592,percent of total billed charges,,,
HC Place Cath in Vein-Svc-Ivc,PX-36900282,CDM,36010,CPT,369,RC,,,outpatient,,,541,378.7,AETNA [1000108],AETNA [100010801],,,76.8,,415.49,121.4545,1592,percent of total billed charges,,,
HC Place Cath in Vein-Select,PX-36900283,CDM,36011,CPT,369,RC,,,outpatient,,,773,541.1,AETNA [1000108],AETNA [100010801],,,76.8,,593.66,173.5385,1592,percent of total billed charges,,,
HC Place Cath in Vein-Subselect,PX-36900284,CDM,36012,CPT,369,RC,,,outpatient,,,909,636.3,AETNA [1000108],AETNA [100010801],,,76.8,,698.11,204.0705,1592,percent of total billed charges,,,
HC Place Cath in Rt Hrt-Main Pulm Art,PX-36900285,CDM,36013,CPT,369,RC,,,outpatient,,,8331,5831.7,AETNA [1000108],AETNA [100010801],,,76.8,,6398.21,399.86,6398.208,percent of total billed charges,,,
HC Place Cath in Lt/Rt Pulm Art,PX-36900286,CDM,36014,CPT,369,RC,,,outpatient,,,721,504.7,AETNA [1000108],AETNA [100010801],,,76.8,,553.73,161.8645,1592,percent of total billed charges,,,
HC Place Cath in Subsegmt Pulm Art,PX-36900287,CDM,36015,CPT,369,RC,,,outpatient,,,1662,1163.4,AETNA [1000108],AETNA [100010801],,,76.8,,1276.42,373.119,1592,percent of total billed charges,,,
HC Place Cath Carot/Vert Art,PX-36900288,CDM,36100,CPT,369,RC,,,outpatient,,,628,439.6,AETNA [1000108],AETNA [100010801],,,76.8,,482.3,140.986,1592,percent of total billed charges,,,
HC Place Cath Extrem Artery,PX-36900290,CDM,36140,CPT,369,RC,,,outpatient,,,340,238,AETNA [1000108],AETNA [100010801],,,76.8,,261.12,76.33,1592,percent of total billed charges,,,
HC Place Cath Aorta via Translumbar,PX-36900293,CDM,36160,CPT,369,RC,,,outpatient,,,2609,1826.3,AETNA [1000108],AETNA [100010801],,,76.8,,2003.71,399.86,2003.712,percent of total billed charges,,,
HC Place Cath Aorta,PX-36900294,CDM,36200,CPT,369,RC,,,outpatient,,,721,504.7,AETNA [1000108],AETNA [100010801],,,76.8,,553.73,161.8645,1592,percent of total billed charges,,,
HC Place Cath Selective Art-Neck,PX-36900295,CDM,36215,CPT,369,RC,,,outpatient,,,1030,721,AETNA [1000108],AETNA [100010801],,,76.8,,791.04,231.235,1592,percent of total billed charges,,,
HC Place Cath Subselect Art-Neck,PX-36900296,CDM,36216,CPT,369,RC,,,outpatient,,,568,397.6,AETNA [1000108],AETNA [100010801],,,76.8,,436.22,127.516,1592,percent of total billed charges,,,
HC Place Cath Subsubselect Art-Neck,PX-36900297,CDM,36217,CPT,369,RC,,,outpatient,,,1545,1081.5,AETNA [1000108],AETNA [100010801],,,76.8,,1186.56,346.8525,1592,percent of total billed charges,,,
HC Place Cath Addn Subselec Art-Neck,PX-36900298,CDM,36218,CPT,369,RC,,,outpatient,,,109,76.3,AETNA [1000108],AETNA [100010801],,,76.8,,83.71,24.4705,1592,percent of total billed charges,,,
HC Nonslctv Cath Thor Aorta Angio Intr/Xtrcranl Art,PX-36900299,CDM,36221,CPT,369,RC,,,outpatient,,,9691,6783.7,AETNA [1000108],AETNA [100010801],,,76.8,,7442.69,399.86,7442.688,percent of total billed charges,,,
HC Slctv Cath Carotid/Innom Art Angio Xtrcranl Art,PX-36900300,CDM,36222,CPT,369,RC,,,outpatient,,,9691,6783.7,AETNA [1000108],AETNA [100010801],,,76.8,,7442.69,399.86,7442.688,percent of total billed charges,,,
HC Slctv Cath Carotid/Innom Art Angio Intrcranl Art,PX-36900301,CDM,36223,CPT,369,RC,,,outpatient,,,9141,6398.7,AETNA [1000108],AETNA [100010801],,,76.8,,7020.29,399.86,8396.844904,percent of total billed charges,,,
HC Slctv Cath Intrnl Carotid Art Angio Intrcrnl Art,PX-36900302,CDM,36224,CPT,369,RC,,,outpatient,,,15847,11092.9,AETNA [1000108],AETNA [100010801],,,76.8,,12170.5,399.86,12170.496,percent of total billed charges,,,
HC Slctv Cath Subclavian Art Angio Vertebral Artery,PX-36900303,CDM,36225,CPT,369,RC,,,outpatient,,,9141,6398.7,AETNA [1000108],AETNA [100010801],,,76.8,,7020.29,399.86,7020.288,percent of total billed charges,,,
HC Slctv Cath Vertebral Art Angio Vertebral Artery,PX-36900304,CDM,36226,CPT,369,RC,,,outpatient,,,15847,11092.9,AETNA [1000108],AETNA [100010801],,,76.8,,12170.5,399.86,12170.496,percent of total billed charges,,,
HC Slctv Cath Xtrnl Carotid Angio Xtrnl Carotd Circ,PX-36900305,CDM,36227,CPT,369,RC,,,outpatient,,,515,360.5,AETNA [1000108],AETNA [100010801],,,76.8,,395.52,115.6175,1592,percent of total billed charges,,,
HC Slctv Cath Intrcrnl Brnch Angio Intrl Carot/Vert,PX-36900306,CDM,36228,CPT,369,RC,,,outpatient,,,612,428.4,AETNA [1000108],AETNA [100010801],,,76.8,,470.02,137.394,1592,percent of total billed charges,,,
HC Place Cath Select Art-Abd/Pel,PX-36900307,CDM,36245,CPT,369,RC,,,outpatient,,,1107,774.9,AETNA [1000108],AETNA [100010801],,,76.8,,850.18,248.5215,1592,percent of total billed charges,,,
HC Place Cath Subselect Art-Abd/Pel,PX-36900308,CDM,36246,CPT,369,RC,,,outpatient,,,1236,865.2,AETNA [1000108],AETNA [100010801],,,76.8,,949.25,277.482,1592,percent of total billed charges,,,
HC Place Cath Subsubselect Art-Abd/Pel,PX-36900309,CDM,36247,CPT,369,RC,,,outpatient,,,1442,1009.4,AETNA [1000108],AETNA [100010801],,,76.8,,1107.46,323.729,1592,percent of total billed charges,,,
HC Place Cath Addn Subsel Art-Abd/Pel,PX-36900310,CDM,36248,CPT,369,RC,,,outpatient,,,258,180.6,AETNA [1000108],AETNA [100010801],,,76.8,,198.14,57.921,1592,percent of total billed charges,,,
HC Slctv Cath 1stord W/WO Art Punct/Fluoro/S&I Uni,PX-36900311,CDM,36251,CPT,369,RC,,,outpatient,,,9430,6601,AETNA [1000108],AETNA [100010801],,,76.8,,7242.24,399.86,7242.24,percent of total billed charges,,,
HC Slctv Cath 1stord W/WO Art Punct/Fluor/S&I Bilat,PX-36900312,CDM,36252,CPT,369,RC,,,outpatient,,,9430,6601,AETNA [1000108],AETNA [100010801],,,76.8,,7242.24,399.86,7242.24,percent of total billed charges,,,
HC Supslctv Cath 2nd+Ord Renl&Acces Artery/S&I Uni,PX-36900313,CDM,36253,CPT,369,RC,,,outpatient,,,9430,6601,AETNA [1000108],AETNA [100010801],,,76.8,,7242.24,399.86,8396.844904,percent of total billed charges,,,
HC Supslctv Cath 2nd+Ord Renl&Acces Arter/S&I Bilat,PX-36900314,CDM,36254,CPT,369,RC,,,outpatient,,,9430,6601,AETNA [1000108],AETNA [100010801],,,76.8,,7242.24,399.86,7242.24,percent of total billed charges,,,
Vnpnxr <3 Years Phys/Qhp Skill Other Vein,PX-36900875,CDM,36406,CPT,369,RC,,,outpatient,,,24,16.8,AETNA [1000108],AETNA [100010801],,,76.8,,18.43,5.388,416.02,percent of total billed charges,,,
HC Blood Transfusion Service,PX-39100001,CDM,36430,CPT,391,RC,,,outpatient,,,923,646.1,AETNA [1000108],AETNA [100010801],,,,,,207.2135,1592,other,Rev 391 at $0,,
HC Injection; Spider Veins-Limb/Trunk,PX-36900315,CDM,36468,CPT,369,RC,,,outpatient,,,909,636.3,AETNA [1000108],AETNA [100010801],,,76.8,,698.11,156.65,1592,percent of total billed charges,,,
HC Injection Therapy Vein-One Vein,PX-36900316,CDM,36470,CPT,369,RC,,,outpatient,,,909,636.3,AETNA [1000108],AETNA [100010801],,,76.8,,698.11,204.0705,1592,percent of total billed charges,,,
HC Injection Therapy Vein-Mult Veins,PX-36900317,CDM,36471,CPT,369,RC,,,outpatient,,,383,268.1,AETNA [1000108],AETNA [100010801],,,76.8,,294.14,85.9835,1592,percent of total billed charges,,,
HC Endovenous Rf- 1st Vein,PX-36900318,CDM,36475,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,6623.08,percent of total billed charges,,,
HC Endovenous Rf- Vein Add-On,PX-36900319,CDM,36476,CPT,369,RC,,,outpatient,,,1797,1257.9,AETNA [1000108],AETNA [100010801],,,76.8,,1380.1,399.86,1592,percent of total billed charges,,,
HC Endovenous Laser- 1st Vein,PX-36900320,CDM,36478,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,5781.504,percent of total billed charges,,,
HC Endovenous Laser Vein Addon,PX-36900321,CDM,36479,CPT,369,RC,,,outpatient,,,1797,1257.9,AETNA [1000108],AETNA [100010801],,,76.8,,1380.1,399.86,1592,percent of total billed charges,,,
HC Percut Portal Vein Cath,PX-36900322,CDM,36481,CPT,369,RC,,,outpatient,,,915,640.5,AETNA [1000108],AETNA [100010801],,,76.8,,702.72,205.4175,1592,percent of total billed charges,,,
HC Venous Select Sampling W Cath,PX-36900323,CDM,36500,CPT,369,RC,,,outpatient,,,412,288.4,AETNA [1000108],AETNA [100010801],,,76.8,,316.42,92.494,1592,percent of total billed charges,,,
HC Cathj Umbilical Vein Dx/Ther Nb,PX-36900588,CDM,36510,CPT,369,RC,,,outpatient,,,773,541.1,AETNA [1000108],AETNA [100010801],,,76.8,,593.66,173.5385,1592,percent of total billed charges,,,
HC Ther Apheresis-Platelets,PX-36900553,CDM,36513,CPT,369,RC,,,outpatient,,,1337,935.9,AETNA [1000108],AETNA [100010801],,,76.8,,1026.82,300.1565,2081.64,percent of total billed charges,,,
HC Ther Apheresis-Plasma Pheresis,PX-36900324,CDM,36514,CPT,369,RC,,,outpatient,,,4919,3443.3,AETNA [1000108],AETNA [100010801],,,76.8,,3777.79,399.86,3777.792,percent of total billed charges,,,
HC Insert Non-Tunnel Cv Cath < 5 Y/O,PX-36100009,CDM,36555,CPT,361,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,5781.504,percent of total billed charges,,,
HC Insert Non-Tunnel Cv Cath < 5 Y/O,PX-36900325,CDM,36555,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,5781.504,percent of total billed charges,,,
HC Insert Non-Tunnel Cv Cath,PX-36100010,CDM,36556,CPT,361,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,6012.672,percent of total billed charges,,,
HC Insert Non-Tunnel Cv Cath,PX-36900326,CDM,36556,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,6012.672,percent of total billed charges,,,
HC PR Insj Non-Tunneled Central Venous Cath Age 5 Yr/>,PX-96000046,CDM,36556,CPT,960,RC,,,outpatient,,,7829,5480.3,AETNA [1000108],AETNA [100010801],,,76.8,,6012.67,399.86,6012.672,percent of total billed charges,,,
HC Insert Tunneled Cv Cath W/O Port or Pump < 5 Y/O,PX-36100011,CDM,36557,CPT,361,RC,,,outpatient,,,12541,8778.7,AETNA [1000108],AETNA [100010801],,,76.8,,9631.49,399.86,9631.488,percent of total billed charges,,,
HC Insert Tunneled Cv Cath W/O Port or Pump < 5 Y/O,PX-36900327,CDM,36557,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA [1000108],AETNA [100010801],,,76.8,,9631.49,399.86,9631.488,percent of total billed charges,,,
HC Insert Tunneled Cv Cath W/O Port or Pump,PX-36100012,CDM,36558,CPT,361,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,5781.504,percent of total billed charges,,,
HC Insert Tunneled Cv Cath W/O Port or Pump,PX-36900328,CDM,36558,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,5781.504,percent of total billed charges,,,
HC Insert Tunneled Cv Cath With Port <5 Y/O,PX-36100013,CDM,36560,CPT,361,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,5781.504,percent of total billed charges,,,
HC Insert Tunneled Cv Cath With Port <5 Y/O,PX-36900329,CDM,36560,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,5781.504,percent of total billed charges,,,
HC Insert Tunneled Cv Cath With Port,PX-36100014,CDM,36561,CPT,361,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,5781.504,percent of total billed charges,,,
HC Insert Tunneled Cv Cath With Port,PX-36900330,CDM,36561,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,5781.504,percent of total billed charges,,,
HC Insert Tunneled Cv Cath With Pump,PX-36100015,CDM,36563,CPT,361,RC,,,outpatient,,,12541,8778.7,AETNA [1000108],AETNA [100010801],,,76.8,,9631.49,399.86,9631.488,percent of total billed charges,,,
HC Insert Tunneled Cv Cath With Pump,PX-36900331,CDM,36563,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA [1000108],AETNA [100010801],,,76.8,,9631.49,399.86,9631.488,percent of total billed charges,,,
HC Insert Tunneled Cv Cath W 2 Access Sites- W/O Pump or Port,PX-36900332,CDM,36565,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,5781.504,percent of total billed charges,,,
HC Insert Tunneled Cv Cath W 2 Access Sites- W/ Pump or Port,PX-36900333,CDM,36566,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA [1000108],AETNA [100010801],,,76.8,,9631.49,399.86,9631.488,percent of total billed charges,,,
HC Insert Picc W/O Sub-Q Port <5 Y/O,PX-36900334,CDM,36568,CPT,369,RC,,,outpatient,,,3698,2588.6,AETNA [1000108],AETNA [100010801],,,76.8,,2840.06,399.86,2840.064,percent of total billed charges,,,
HC Insert Picc W/O Sub-Q Port,PX-36900335,CDM,36569,CPT,369,RC,,,outpatient,,,3698,2588.6,AETNA [1000108],AETNA [100010801],,,76.8,,2840.06,399.86,2953.728,percent of total billed charges,,,
HC PR Insj Prph Cvc W/O Subq Port/Pmp Age 5 Yr/>,PX-96000047,CDM,36569,CPT,960,RC,,,outpatient,,,3846,2692.2,AETNA [1000108],AETNA [100010801],,,76.8,,2953.73,399.86,2953.728,percent of total billed charges,,,
HC Insert Picc W/ Sub-Q Port <5 Y/O,PX-36900336,CDM,36570,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,5781.504,percent of total billed charges,,,
HC Insert Picc W/ Sub-Q Port,PX-36900337,CDM,36571,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,5781.504,percent of total billed charges,,,
HC Repair Cv Cath W/O Subq Port or Pump,PX-36900338,CDM,36575,CPT,369,RC,,,outpatient,,,1421,994.7,AETNA [1000108],AETNA [100010801],,,76.8,,1091.33,319.0145,2141,percent of total billed charges,,,
HC Repair Cv Cath W Subq Port or Pump,PX-36900339,CDM,36576,CPT,369,RC,,,outpatient,,,3698,2588.6,AETNA [1000108],AETNA [100010801],,,76.8,,2840.06,399.86,2840.064,percent of total billed charges,,,
HC Replace Cv Cath- Catheter Only W Subq Pump or Port,PX-36900340,CDM,36578,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,5781.504,percent of total billed charges,,,
HC Replace Cv Cath- Complete- Non-Tunneled- W/O Subq Port or Pump,PX-36900341,CDM,36580,CPT,369,RC,,,outpatient,,,3698,2588.6,AETNA [1000108],AETNA [100010801],,,76.8,,2840.06,399.86,2840.064,percent of total billed charges,,,
HC Replace Cv Cath- Complete- Tunneled- W/O Subq Port or Pump,PX-36900342,CDM,36581,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,5781.504,percent of total billed charges,,,
HC Replace Cv Cath- Complete- Non-Tunneled- W Subq Port or Pump,PX-36900343,CDM,36582,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,5781.504,percent of total billed charges,,,
HC Replace Cv Cath- Complete- Tunneled- W Subq Port or Pump,PX-36900344,CDM,36583,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA [1000108],AETNA [100010801],,,76.8,,9631.49,399.86,9631.488,percent of total billed charges,,,
HC Replace Picc W/O Port or Pump,PX-36900345,CDM,36584,CPT,369,RC,,,outpatient,,,3698,2588.6,AETNA [1000108],AETNA [100010801],,,76.8,,2840.06,399.86,2840.064,percent of total billed charges,,,
HC Replace Picc W Port or Pump,PX-36900346,CDM,36585,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,5781.504,percent of total billed charges,,,
HC Removal Tunneled Cv Cath W/O Subq Port or Pump,PX-36900347,CDM,36589,CPT,369,RC,,,outpatient,,,1421,994.7,AETNA [1000108],AETNA [100010801],,,76.8,,1091.33,319.0145,2141,percent of total billed charges,,,
HC Removal Tunneled Cv Cath W Subq Port or Pump,PX-36900348,CDM,36590,CPT,369,RC,,,outpatient,,,3698,2588.6,AETNA [1000108],AETNA [100010801],,,76.8,,2840.06,399.86,2998,percent of total billed charges,,,
HC Collect Blood From Implant Venous Access Device,PX-76100001,CDM,36591,CPT,761,RC,,,outpatient,,,160,112,AETNA [1000108],AETNA [100010801],,,76.8,,122.88,35.92,1592,percent of total billed charges,,,
HC Collect Blood From Catheter Venous Nos,PX-36900349,CDM,36592,CPT,369,RC,,,outpatient,,,125,87.5,AETNA [1000108],AETNA [100010801],,,76.8,,96,28.0625,1592,percent of total billed charges,,,
HC Declot of Cent Venous Catheter,PX-36900350,CDM,36593,CPT,369,RC,,,outpatient,,,806,564.2,AETNA [1000108],AETNA [100010801],,,76.8,,619.01,180.947,1592,percent of total billed charges,,,
HC Mech Remov Pericath Obstr Cv Dev via Ven Access,PX-36900351,CDM,36595,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,5781.504,percent of total billed charges,,,
HC Mech Remov Intralum Obstr Cv Dev Thru Lumen,PX-36900352,CDM,36596,CPT,369,RC,,,outpatient,,,3698,2588.6,AETNA [1000108],AETNA [100010801],,,76.8,,2840.06,399.86,2840.064,percent of total billed charges,,,
HC Reposition Venous Catheter,PX-36900353,CDM,36597,CPT,369,RC,,,outpatient,,,3698,2588.6,AETNA [1000108],AETNA [100010801],,,76.8,,2840.06,399.86,2840.064,percent of total billed charges,,,
HC Contrast Inj Cent Ven Cath- Inc Flouro,PX-36900354,CDM,36598,CPT,369,RC,,,outpatient,,,406,284.2,AETNA [1000108],AETNA [100010801],,,76.8,,311.81,91.147,1592,percent of total billed charges,,,
HC Withdrawal of Arterial Blood,PX-36900355,CDM,36600,CPT,369,RC,,,outpatient,,,297,207.9,AETNA [1000108],AETNA [100010801],,,76.8,,228.1,66.6765,1592,percent of total billed charges,,,
HC Insert Cath-Art-Percut-Shortterm,PX-36900356,CDM,36620,CPT,369,RC,,,outpatient,,,309,216.3,AETNA [1000108],AETNA [100010801],,,76.8,,237.31,69.3705,1592,percent of total billed charges,,,
HC Catheterization Umbilical Newborn Art Dx/Therapy,PX-36900836,CDM,36660,CPT,369,RC,,,outpatient,,,10702,7491.4,AETNA [1000108],AETNA [100010801],,,76.8,,8219.14,399.86,9071.0152,percent of total billed charges,,,
HC Placement Needle Intraosseous Infusion,PX-36900592,CDM,36680,CPT,369,RC,,,outpatient,,,568,397.6,AETNA [1000108],AETNA [100010801],,,76.8,,436.22,127.516,1592,percent of total billed charges,,,
HC PR Placement Needle Intraosseous Infusion,PX-96000050,CDM,36680,CPT,960,RC,,,outpatient,,,568,397.6,AETNA [1000108],AETNA [100010801],,,76.8,,436.22,127.516,1592,percent of total billed charges,,,
HC Insert Cannula-Vein-Vein,PX-36900358,CDM,36800,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA [1000108],AETNA [100010801],,,76.8,,9631.49,399.86,9631.488,percent of total billed charges,,,
HC Revise Av Fistula-W/O Thrombectomy,PX-36900359,CDM,36832,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA [1000108],AETNA [100010801],,,76.8,,9631.49,399.86,9631.488,percent of total billed charges,,,
HC Insert Transven Intrahep Portosys Shunt,PX-36900361,CDM,37182,CPT,369,RC,,,outpatient,,,4120,2884,AETNA [1000108],AETNA [100010801],,,76.8,,3164.16,399.86,5756,percent of total billed charges,,,
HC Revis Transven Intrahep Portosys Shunt,PX-36900362,CDM,37183,CPT,369,RC,,,outpatient,,,13035,9124.5,AETNA [1000108],AETNA [100010801],,,76.8,,10010.88,399.86,18955.84,percent of total billed charges,,,
HC Prim Perc Mech Thrombectomy- Arterial,PX-36900363,CDM,37184,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA [1000108],AETNA [100010801],,,76.8,,20286.72,399.86,26793.51305,percent of total billed charges,,,
HC Prim Perc Mech Thrombectomy- Arterial Ea Add,PX-36900364,CDM,37185,CPT,369,RC,,,outpatient,,,824,576.8,AETNA [1000108],AETNA [100010801],,,76.8,,632.83,184.988,4800.911611,percent of total billed charges,,,
HC Sec Perc Mech Thrombect- Arterial- W Other Proc,PX-36900365,CDM,37186,CPT,369,RC,,,outpatient,,,1236,865.2,AETNA [1000108],AETNA [100010801],,,76.8,,949.25,277.482,8164.18419,percent of total billed charges,,,
HC Percut Mech Thrombectomy- Venous,PX-36900366,CDM,37187,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA [1000108],AETNA [100010801],,,76.8,,20286.72,399.86,20286.72,percent of total billed charges,,,
HC Percut Mech Thrombectomy- Venous- Repeat,PX-36900367,CDM,37188,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,6788.57,percent of total billed charges,,,
HC Ins Intrvas Vc Filtr W/WO Vas Acs Vsl Selxn Rs&I,PX-36900368,CDM,37191,CPT,369,RC,,,outpatient,,,14030,9821,AETNA [1000108],AETNA [100010801],,,76.8,,10775.04,399.86,10775.04,percent of total billed charges,,,
HC Repsng Intrvas Vc Filtr W/WO Acs Vsl Selxn Rs&I,PX-36900369,CDM,37192,CPT,369,RC,,,outpatient,,,9628,6739.6,AETNA [1000108],AETNA [100010801],,,76.8,,7394.3,399.86,7394.304,percent of total billed charges,,,
HC Rtrvl Intrvas Vc Filtr W/WO Acs Vsl Selxn Rs&I,PX-36900370,CDM,37193,CPT,369,RC,,,outpatient,,,9998,6998.6,AETNA [1000108],AETNA [100010801],,,76.8,,7678.46,399.86,7678.464,percent of total billed charges,,,
HC Thrombolysis Cerebral IV Infusion,PX-36900762,CDM,37195,CPT,369,RC,,,outpatient,,,613,429.1,AETNA [1000108],AETNA [100010801],,,76.8,,470.78,137.6185,1592,percent of total billed charges,,,
HC Prq Transcatheter Rtrvl Intrvas FB With Imaging,PX-36900371,CDM,37197,CPT,369,RC,,,outpatient,,,8825,6177.5,AETNA [1000108],AETNA [100010801],,,76.8,,6777.6,399.86,6777.6,percent of total billed charges,,,
HC Transcatheter Biopsy,PX-36900372,CDM,37200,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA [1000108],AETNA [100010801],,,76.8,,9631.49,399.86,9631.488,percent of total billed charges,,,
HC Thrombolysis Arterial Infusion W/Imaging Init Tx,PX-36900374,CDM,37211,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA [1000108],AETNA [100010801],,,76.8,,9631.49,399.86,9631.488,percent of total billed charges,,,
HC Thrombolysis Venous Infusion W/Imaging Init Tx,PX-36900375,CDM,37212,CPT,369,RC,,,outpatient,,,3239,2267.3,AETNA [1000108],AETNA [100010801],,,76.8,,2487.55,399.86,4870.452937,percent of total billed charges,,,
HC Thrombolysis Art/Venous Infsn W/Image Subsq Tx,PX-36900376,CDM,37213,CPT,369,RC,,,outpatient,,,7224,5056.8,AETNA [1000108],AETNA [100010801],,,76.8,,5548.03,399.86,5548.032,percent of total billed charges,,,
HC Cessation Thrombolytic Thrpy W/Catheter Removal,PX-36900377,CDM,37214,CPT,369,RC,,,outpatient,,,7224,5056.8,AETNA [1000108],AETNA [100010801],,,76.8,,5548.03,399.86,5548.032,percent of total billed charges,,,
HC Transcath Stent- Cca W/Eps,PX-36900378,CDM,37215,CPT,369,RC,,,outpatient,,,553,387.1,AETNA [1000108],AETNA [100010801],,,76.8,,424.7,124.1485,2998,percent of total billed charges,,,
HC Revascularize Iliac Artery-Angioplasty- Initial Vessel,PX-36900379,CDM,37220,CPT,369,RC,,,outpatient,,,15994,11195.8,AETNA [1000108],AETNA [100010801],,,76.8,,12283.39,399.86,12283.392,percent of total billed charges,,,
HC Revascularize Iliac Artery-Angioplasty/Stent- Initial Vessel,PX-36900380,CDM,37221,CPT,369,RC,,,outpatient,,,16597,11617.9,AETNA [1000108],AETNA [100010801],,,76.8,,12746.5,399.86,18955.84,percent of total billed charges,,,
HC Revascularize Iliac Artery-Angioplasty- Ea Add Vessel,PX-36900381,CDM,37222,CPT,369,RC,,,outpatient,,,15818,11072.6,AETNA [1000108],AETNA [100010801],,,76.8,,12148.22,399.86,12148.224,percent of total billed charges,,,
HC Revascularize Iliac Artery-Angioplasty/Stent- Ea Add Vessel,PX-36900382,CDM,37223,CPT,369,RC,,,outpatient,,,16216,11351.2,AETNA [1000108],AETNA [100010801],,,76.8,,12453.89,399.86,12453.888,percent of total billed charges,,,
HC Revascularize Fem/Pop Artery-Angioplasty,PX-36900383,CDM,37224,CPT,369,RC,,,outpatient,,,16599,11619.3,AETNA [1000108],AETNA [100010801],,,76.8,,12748.03,399.86,12748.032,percent of total billed charges,,,
HC Revascularize Fem/Pop Artery-Angioplasty/Atherectomy,PX-36900384,CDM,37225,CPT,369,RC,,,outpatient,,,34070,23849,AETNA [1000108],AETNA [100010801],,,76.8,,26165.76,399.86,26793.51305,percent of total billed charges,,,
HC Revascularize Fem/Pop Artery-Angioplasty/Stent,PX-36900385,CDM,37226,CPT,369,RC,,,outpatient,,,32579,22805.3,AETNA [1000108],AETNA [100010801],,,76.8,,25020.67,399.86,25020.672,percent of total billed charges,,,
HC Revascularize Fem/Pop Artery-Angioplasty/Stent/Atherectomy,PX-36900386,CDM,37227,CPT,369,RC,,,outpatient,,,59005,41303.5,AETNA [1000108],AETNA [100010801],,,76.8,,45315.84,399.86,45315.84,percent of total billed charges,,,
HC Revascularize Tibial/Peron Artery-Angioplasty Initial,PX-36900387,CDM,37228,CPT,369,RC,,,outpatient,,,15999,11199.3,AETNA [1000108],AETNA [100010801],,,76.8,,12287.23,399.86,16809.6787,percent of total billed charges,,,
HC Revascularize Tibial/Peron Artery-Angioplasty/Atherectomy Initial,PX-36900388,CDM,37229,CPT,369,RC,,,outpatient,,,34866,24406.2,AETNA [1000108],AETNA [100010801],,,76.8,,26777.09,399.86,26793.51305,percent of total billed charges,,,
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent Initial,PX-36900389,CDM,37230,CPT,369,RC,,,outpatient,,,34070,23849,AETNA [1000108],AETNA [100010801],,,76.8,,26165.76,399.86,26793.51305,percent of total billed charges,,,
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent/Atherectomy Init,PX-36900390,CDM,37231,CPT,369,RC,,,outpatient,,,58146,40702.2,AETNA [1000108],AETNA [100010801],,,76.8,,44656.13,399.86,44656.128,percent of total billed charges,,,
HC Revascularize Tibial/Peron Artery-Angioplasty Ea Add,PX-36900391,CDM,37232,CPT,369,RC,,,outpatient,,,16052,11236.4,AETNA [1000108],AETNA [100010801],,,76.8,,12327.94,399.86,12327.936,percent of total billed charges,,,
HC Revascularize Tibial/Peron Artery-Angioplasty/Atherectomy Ea Add,PX-36900392,CDM,37233,CPT,369,RC,,,outpatient,,,33576,23503.2,AETNA [1000108],AETNA [100010801],,,76.8,,25786.37,399.86,25786.368,percent of total billed charges,,,
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent Ea Add,PX-36900393,CDM,37234,CPT,369,RC,,,outpatient,,,16052,11236.4,AETNA [1000108],AETNA [100010801],,,76.8,,12327.94,399.86,12327.936,percent of total billed charges,,,
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent/Atherectomy Ea Add,PX-36900394,CDM,37235,CPT,369,RC,,,outpatient,,,15818,11072.6,AETNA [1000108],AETNA [100010801],,,76.8,,12148.22,399.86,12148.224,percent of total billed charges,,,
HC Open/Perq Placement Intravascular Stent Initial,PX-36900395,CDM,37236,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA [1000108],AETNA [100010801],,,76.8,,20286.72,399.86,20286.72,percent of total billed charges,,,
HC Open/Perq Placement Intravascular Stent Ea Addl,PX-36900396,CDM,37237,CPT,369,RC,,,outpatient,,,3978,2784.6,AETNA [1000108],AETNA [100010801],,,76.8,,3055.1,399.86,4532,percent of total billed charges,,,
HC Open/Perq Placement Intravascular Stent Same 1st,PX-36900397,CDM,37238,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA [1000108],AETNA [100010801],,,76.8,,20286.72,399.86,20286.72,percent of total billed charges,,,
HC Open/Perq Placemt Intravasc Stent Same Ea Addl,PX-36900398,CDM,37239,CPT,369,RC,,,outpatient,,,3978,2784.6,AETNA [1000108],AETNA [100010801],,,76.8,,3055.1,399.86,4532,percent of total billed charges,,,
HC Vascular Embolization or Occlusion Venous Rs&I,PX-36900399,CDM,37241,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA [1000108],AETNA [100010801],,,76.8,,20286.72,399.86,20286.72,percent of total billed charges,,,
HC Vascular Embolization or Occlusion Arterial Rs&I,PX-36900400,CDM,37242,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA [1000108],AETNA [100010801],,,76.8,,20286.72,399.86,26793.51305,percent of total billed charges,,,
HC Vascular Embolize/Occlude Organ Tumor Infarct,PX-36900401,CDM,37243,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA [1000108],AETNA [100010801],,,76.8,,20286.72,399.86,20286.72,percent of total billed charges,,,
HC Vascular Embolization or Occlusion Hemorrhage,PX-36100016,CDM,37244,CPT,361,RC,,,outpatient,,,26415,18490.5,AETNA [1000108],AETNA [100010801],,,76.8,,20286.72,399.86,20286.72,percent of total billed charges,,,
HC Vascular Embolization or Occlusion Hemorrhage,PX-36900402,CDM,37244,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA [1000108],AETNA [100010801],,,76.8,,20286.72,399.86,20286.72,percent of total billed charges,,,
HC Temporal Artery Ligatn or Bx,PX-36900554,CDM,37609,CPT,369,RC,,,outpatient,,,4643,3250.1,AETNA [1000108],AETNA [100010801],,,76.8,,3565.82,399.86,3565.824,percent of total billed charges,,,
HC Phleb Veins - Extrem - to 20,PX-36900405,CDM,37765,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,5781.504,percent of total billed charges,,,
HC Phleb Veins - Extrem 20+,PX-36900406,CDM,37766,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,5781.504,percent of total billed charges,,,
HC Injection for Spleen X-Ray,PX-36900408,CDM,38200,CPT,369,RC,,,outpatient,,,381,266.7,AETNA [1000108],AETNA [100010801],,,76.8,,292.61,85.5345,1592,percent of total billed charges,,,
HC Bone Marrow; Aspiration Only,PX-36100017,CDM,38220,CPT,361,RC,,,outpatient,,,1973,1381.1,AETNA [1000108],AETNA [100010801],,,76.8,,1515.26,399.86,2477.315575,percent of total billed charges,,,
HC Bone Marrow; Aspiration Only,PX-36900409,CDM,38220,CPT,369,RC,,,outpatient,,,1973,1381.1,AETNA [1000108],AETNA [100010801],,,76.8,,1515.26,399.86,2477.315575,percent of total billed charges,,,
HC Bone Marrow Bx- Needle/Trocar,PX-36100018,CDM,38221,CPT,361,RC,,,outpatient,,,1972,1380.4,AETNA [1000108],AETNA [100010801],,,76.8,,1514.5,399.86,2477.315575,percent of total billed charges,,,
HC Bone Marrow Bx- Needle/Trocar,PX-36900410,CDM,38221,CPT,369,RC,,,outpatient,,,1972,1380.4,AETNA [1000108],AETNA [100010801],,,76.8,,1514.5,399.86,2477.315575,percent of total billed charges,,,
HC Dx Bone Marrow Bx & Aspir,PX-36100032,CDM,38222,CPT,361,RC,,,outpatient,,,4653,3257.1,AETNA [1000108],AETNA [100010801],,,76.8,,3573.5,399.86,4341.777195,percent of total billed charges,,,
HC Dx Bone Marrow Bx & Aspir,PX-36900703,CDM,38222,CPT,369,RC,,,outpatient,,,4653,3257.1,AETNA [1000108],AETNA [100010801],,,76.8,,3573.5,399.86,4341.777195,percent of total billed charges,,,
HC Needle Biopsy- Lymph Node(S),PX-36900411,CDM,38505,CPT,369,RC,,,outpatient,,,1973,1381.1,AETNA [1000108],AETNA [100010801],,,76.8,,1515.26,399.86,2998,percent of total billed charges,,,
HC Injection for Lymphatic Xray,PX-36900412,CDM,38790,CPT,369,RC,,,outpatient,,,500,350,AETNA [1000108],AETNA [100010801],,,76.8,,384,112.25,1592,percent of total billed charges,,,
HC Identify Sentinel Node,PX-36900413,CDM,38792,CPT,369,RC,,,outpatient,,,540,378,AETNA [1000108],AETNA [100010801],,,76.8,,414.72,121.23,1592,percent of total billed charges,,,
HC Biopsy of Floor of Mouth,PX-36900555,CDM,41108,CPT,369,RC,,,outpatient,,,2598,1818.6,AETNA [1000108],AETNA [100010801],,,76.8,,1995.26,399.86,2477.315575,percent of total billed charges,,,
HC Biopsy Salivary Gland-Needle,PX-36900414,CDM,42400,CPT,369,RC,,,outpatient,,,1637,1145.9,AETNA [1000108],AETNA [100010801],,,76.8,,1257.22,367.5065,2141,percent of total billed charges,,,
HC Injection for Salivary X-Ray,PX-36900415,CDM,42550,CPT,369,RC,,,outpatient,,,424,296.8,AETNA [1000108],AETNA [100010801],,,76.8,,325.63,95.188,1592,percent of total billed charges,,,
HC Dilation/Cath of Salivary Duct,PX-36900416,CDM,42660,CPT,369,RC,,,outpatient,,,533,373.1,AETNA [1000108],AETNA [100010801],,,76.8,,409.34,119.6585,1592,percent of total billed charges,,,
HC Inc/Drain Peritonsil Abscess,PX-36900812,CDM,42700,CPT,369,RC,,,outpatient,,,685,479.5,AETNA [1000108],AETNA [100010801],,,76.8,,526.08,153.7825,1592,percent of total billed charges,,,
HC Placement Ng/Og Tube by Physician,PX-36900423,CDM,43752,CPT,369,RC,,,outpatient,,,325,227.5,AETNA [1000108],AETNA [100010801],,,76.8,,249.6,72.9625,1592,percent of total billed charges,,,
HC PR Naso/Oro-Gastric Tube Plmt Req Phys&Fluor Gdnce,PX-96000043,CDM,43752,CPT,960,RC,,,outpatient,,,325,227.5,AETNA [1000108],AETNA [100010801],,,76.8,,249.6,72.9625,1592,percent of total billed charges,,,
HC Gastric Intubatj & Aspiraj W/Phys Skill/Lavage,PX-36900575,CDM,43753,CPT,369,RC,,,outpatient,,,579,405.3,AETNA [1000108],AETNA [100010801],,,76.8,,444.67,129.9855,1592,percent of total billed charges,,,
HC Reposition Gastric Feeding Tube Thru Duodenum,PX-36900425,CDM,43761,CPT,369,RC,,,outpatient,,,496,347.2,AETNA [1000108],AETNA [100010801],,,76.8,,380.93,111.352,1592,percent of total billed charges,,,
HC Perq Replacement Gtube Not Req Revj Gstrst Trc,PX-36100033,CDM,43762,CPT,361,RC,,,outpatient,,,879,615.3,AETNA [1000108],AETNA [100010801],,,76.8,,675.07,197.3355,1592,percent of total billed charges,,,
HC Perq Replacement Gtube Not Req Revj Gstrst Trc,PX-36900727,CDM,43762,CPT,369,RC,,,outpatient,,,879,615.3,AETNA [1000108],AETNA [100010801],,,76.8,,675.07,197.3355,1592,percent of total billed charges,,,
HC Intro Long GI Tube,PX-36900427,CDM,44500,CPT,369,RC,,,outpatient,,,1673,1171.1,AETNA [1000108],AETNA [100010801],,,76.8,,1284.86,375.5885,2998,percent of total billed charges,,,
HC Drainage of Pelvic Abscess,PX-36900428,CDM,45000,CPT,369,RC,,,outpatient,,,2727,1908.9,AETNA [1000108],AETNA [100010801],,,76.8,,2094.34,399.86,4005.9,percent of total billed charges,,,
HC Drainage of Deep Rectal Abscess,PX-36900429,CDM,45020,CPT,369,RC,,,outpatient,,,6425,4497.5,AETNA [1000108],AETNA [100010801],,,76.8,,4934.4,399.86,4934.4,percent of total billed charges,,,
HC I&D Ischiorectal&/Perirectal Abscess Spx,PX-36900738,CDM,46040,CPT,369,RC,,,outpatient,,,3716,2601.2,AETNA [1000108],AETNA [100010801],,,76.8,,2853.89,399.86,2998,percent of total billed charges,,,
HC Needle Biopsy Liver,PX-36900430,CDM,47000,CPT,369,RC,,,outpatient,,,3700,2590,AETNA [1000108],AETNA [100010801],,,76.8,,2841.6,399.86,2998,percent of total billed charges,,,
HC Needle Biopsy Liver-W Othr Proc,PX-36900431,CDM,47001,CPT,369,RC,,,outpatient,,,972,680.4,AETNA [1000108],AETNA [100010801],,,76.8,,746.5,218.214,1592,percent of total billed charges,,,
HC Ablat-Open-1+ Liver Tumor(S)-Percut Rf,PX-36900433,CDM,47382,CPT,369,RC,,,outpatient,,,13307,9314.9,AETNA [1000108],AETNA [100010801],,,76.8,,10219.78,399.86,10219.776,percent of total billed charges,,,
HC Cholecystostomy-Percutaneous- Complete,PX-36900434,CDM,47490,CPT,369,RC,,,outpatient,,,8367,5856.9,AETNA [1000108],AETNA [100010801],,,76.8,,6425.86,399.86,6425.856,percent of total billed charges,,,
HC Biliary Endoscopy Percut-Dil Strict,PX-36900443,CDM,47555,CPT,369,RC,,,outpatient,,,8367,5856.9,AETNA [1000108],AETNA [100010801],,,76.8,,6425.86,399.86,6425.856,percent of total billed charges,,,
HC Biliary Endoscopy Percut-Dil+Stent,PX-36900444,CDM,47556,CPT,369,RC,,,outpatient,,,13307,9314.9,AETNA [1000108],AETNA [100010801],,,76.8,,10219.78,399.86,15728.70471,percent of total billed charges,,,
HC Needle Biopsy of Pancreas,PX-36900446,CDM,48102,CPT,369,RC,,,outpatient,,,3700,2590,AETNA [1000108],AETNA [100010801],,,76.8,,2841.6,399.86,2998,percent of total billed charges,,,
HC Anast Panc Cyst-Bowel-Direct,PX-36900447,CDM,48520,CPT,369,RC,,,outpatient,,,1740,1218,AETNA [1000108],AETNA [100010801],,,76.8,,1336.32,390.63,2998,percent of total billed charges,,,
HC Exploratory Laparotomy Celiotomy W/WO Biopsy Spx,PX-36900881,CDM,49000,CPT,369,RC,,,outpatient,,,8564,5994.8,AETNA [1000108],AETNA [100010801],,,76.8,,6577.15,399.86,6577.152,percent of total billed charges,,,
HC Reopening Recent Laparotomy,PX-36900882,CDM,49002,CPT,369,RC,,,outpatient,,,8564,5994.8,AETNA [1000108],AETNA [100010801],,,76.8,,6577.15,399.86,6577.152,percent of total billed charges,,,
HC Abdom Paracentesis Dx/Ther W/O Imaging Guidance,PX-36900448,CDM,49082,CPT,369,RC,,,outpatient,,,925,647.5,AETNA [1000108],AETNA [100010801],,,76.8,,710.4,207.6625,2998,percent of total billed charges,,,
HC Abdom Paracentesis Dx/Ther W Imaging Guidance,PX-36100002,CDM,49083,CPT,361,RC,,,outpatient,,,1635,1144.5,AETNA [1000108],AETNA [100010801],,,76.8,,1255.68,367.0575,2998,percent of total billed charges,,,
HC Abdom Paracentesis Dx/Ther W Imaging Guidance,PX-36900449,CDM,49083,CPT,369,RC,,,outpatient,,,1635,1144.5,AETNA [1000108],AETNA [100010801],,,76.8,,1255.68,367.0575,2998,percent of total billed charges,,,
HC Percut Biopsy- Abdominal Mass,PX-36900450,CDM,49180,CPT,369,RC,,,outpatient,,,3700,2590,AETNA [1000108],AETNA [100010801],,,76.8,,2841.6,399.86,2998,percent of total billed charges,,,
HC Remove Peritoneal Foreign Body,PX-36900451,CDM,49402,CPT,369,RC,,,outpatient,,,8367,5856.9,AETNA [1000108],AETNA [100010801],,,76.8,,6425.86,399.86,6425.856,percent of total billed charges,,,
HC Image-Guide Fluid Collxn Drainage Cath Visc Perq,PX-36900452,CDM,49405,CPT,369,RC,,,outpatient,,,2870,2009,AETNA [1000108],AETNA [100010801],,,76.8,,2204.16,399.86,2998,percent of total billed charges,,,
HC Img-Guide Fluid Collxn Drainag Cath Periton Perq,PX-36900453,CDM,49406,CPT,369,RC,,,outpatient,,,2647,1852.9,AETNA [1000108],AETNA [100010801],,,76.8,,2032.9,399.86,2998,percent of total billed charges,,,
HC Insertion Tunnel Intraperitoneal Cath W Image Guidance,PX-36900455,CDM,49418,CPT,369,RC,,,outpatient,,,7964,5574.8,AETNA [1000108],AETNA [100010801],,,76.8,,6116.35,399.86,6116.352,percent of total billed charges,,,
HC Removal Tunneled Intraperitoneal Catheter,PX-36900456,CDM,49422,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,5781.504,percent of total billed charges,,,
HC Drainage Catheter Exchange,PX-36900457,CDM,49423,CPT,369,RC,,,outpatient,,,4271,2989.7,AETNA [1000108],AETNA [100010801],,,76.8,,3280.13,399.86,3280.128,percent of total billed charges,,,
HC Contrast Inj-Abscess/Cyst via Cath Tube,PX-36900458,CDM,49424,CPT,369,RC,,,outpatient,,,491,343.7,AETNA [1000108],AETNA [100010801],,,76.8,,377.09,110.2295,1592,percent of total billed charges,,,
HC Insert Gastrostomy Tube Percutaneous,PX-36900460,CDM,49440,CPT,369,RC,,,outpatient,,,4271,2989.7,AETNA [1000108],AETNA [100010801],,,76.8,,3280.13,399.86,3280.128,percent of total billed charges,,,
HC Convert Gastrostomy-Gastro-Jejunostomy Tube Percutaneous,PX-36900461,CDM,49446,CPT,369,RC,,,outpatient,,,4271,2989.7,AETNA [1000108],AETNA [100010801],,,76.8,,3280.13,399.86,3280.128,percent of total billed charges,,,
HC Replace Gastrostomy/Cecostomy Tube Percutaneous,PX-36100019,CDM,49450,CPT,361,RC,,,outpatient,,,1644,1150.8,AETNA [1000108],AETNA [100010801],,,76.8,,1262.59,369.078,2998,percent of total billed charges,,,
HC Replace Gastrostomy/Cecostomy Tube Percutaneous,PX-36900462,CDM,49450,CPT,369,RC,,,outpatient,,,1644,1150.8,AETNA [1000108],AETNA [100010801],,,76.8,,1262.59,369.078,2998,percent of total billed charges,,,
HC Replace Duodenostomy/Jejunostomy Tube Percutaneous,PX-36100020,CDM,49451,CPT,361,RC,,,outpatient,,,1692,1184.4,AETNA [1000108],AETNA [100010801],,,76.8,,1299.46,379.854,2998,percent of total billed charges,,,
HC Replace Duodenostomy/Jejunostomy Tube Percutaneous,PX-36900463,CDM,49451,CPT,369,RC,,,outpatient,,,1692,1184.4,AETNA [1000108],AETNA [100010801],,,76.8,,1299.46,379.854,2998,percent of total billed charges,,,
HC Replacement Gastro-Jejunostomy Tube Percutaneous,PX-36100021,CDM,49452,CPT,361,RC,,,outpatient,,,2617,1831.9,AETNA [1000108],AETNA [100010801],,,76.8,,2009.86,399.86,2998,percent of total billed charges,,,
HC Replacement Gastro-Jejunostomy Tube Percutaneous,PX-36900464,CDM,49452,CPT,369,RC,,,outpatient,,,2617,1831.9,AETNA [1000108],AETNA [100010801],,,76.8,,2009.86,399.86,2998,percent of total billed charges,,,
HC Obstructive Material Removal From GI Tube,PX-36900465,CDM,49460,CPT,369,RC,,,outpatient,,,2128,1489.6,AETNA [1000108],AETNA [100010801],,,76.8,,1634.3,399.86,2998,percent of total billed charges,,,
HC Contrast Injection Percutaneouos Radiologic Eval GI Tube,PX-36900466,CDM,49465,CPT,369,RC,,,outpatient,,,606,424.2,AETNA [1000108],AETNA [100010801],,,76.8,,465.41,136.047,1592,percent of total billed charges,,,
CEPHALEXIN 250 MG/5ML ORAL SUSR,RX-9502,CDM,50000,HCPCS,259,RC,68180-0441-01,NDC,outpatient,100,ML,50.29,35.203,AETNA [1000108],AETNA [100010801],,,76.8,,38.62,1.160665,416.02,percent of total billed charges,,,
CEPHALEXIN 250 MG/5ML ORAL SUSR,RX-9502,CDM,50000,HCPCS,259,RC,99999-0002-84,NDC,outpatient,10,ML,5.17,3.619,AETNA [1000108],AETNA [100010801],,,76.8,,3.97,1.160665,416.02,percent of total billed charges,,,
HC Biopsy of Kidney-Percutaneous,PX-36900467,CDM,50200,CPT,369,RC,,,outpatient,,,3700,2590,AETNA [1000108],AETNA [100010801],,,76.8,,2841.6,399.86,2998,percent of total billed charges,,,
HC Change Ureter Stent- Percut,PX-36900468,CDM,50382,CPT,369,RC,,,outpatient,,,4709,3296.3,AETNA [1000108],AETNA [100010801],,,76.8,,3616.51,399.86,4179.83,percent of total billed charges,,,
HC Remove Ureter Stent- Percut,PX-36900469,CDM,50384,CPT,369,RC,,,outpatient,,,4709,3296.3,AETNA [1000108],AETNA [100010801],,,76.8,,3616.51,399.86,3616.512,percent of total billed charges,,,
HC Change Ext Transneph Ureter Stent W/ Fluoro,PX-36900470,CDM,50387,CPT,369,RC,,,outpatient,,,4709,3296.3,AETNA [1000108],AETNA [100010801],,,76.8,,3616.51,399.86,3616.512,percent of total billed charges,,,
HC Remove Renal Tube W/Fluoro,PX-36900471,CDM,50389,CPT,369,RC,,,outpatient,,,1513,1059.1,AETNA [1000108],AETNA [100010801],,,76.8,,1161.98,339.6685,2141,percent of total billed charges,,,
HC Percut Drain/Inject Renal Cyst,PX-36900472,CDM,50390,CPT,369,RC,,,outpatient,,,726,508.2,AETNA [1000108],AETNA [100010801],,,76.8,,557.57,162.987,2141,percent of total billed charges,,,
HC Instll Rx Agnt Into Rnal Tub,PX-36900473,CDM,50391,CPT,369,RC,,,outpatient,,,533,373.1,AETNA [1000108],AETNA [100010801],,,76.8,,409.34,119.6585,1592,percent of total billed charges,,,
HC Measure Kidney Pressure Thru Tube,PX-36900478,CDM,50396,CPT,369,RC,,,outpatient,,,1513,1059.1,AETNA [1000108],AETNA [100010801],,,76.8,,1161.98,334.48,2141,percent of total billed charges,,,
HC Plmt Nephrostomy Cath Prq New Access Rs&I,PX-36900659,CDM,50432,CPT,369,RC,,,outpatient,,,5502,3851.4,AETNA [1000108],AETNA [100010801],,,76.8,,4225.54,399.86,4225.536,percent of total billed charges,,,
HC Renal Endoscopy-Remv FB/Stone,PX-36900480,CDM,50561,CPT,369,RC,,,outpatient,,,11603,8122.1,AETNA [1000108],AETNA [100010801],,,76.8,,8911.1,399.86,8911.104,percent of total billed charges,,,
HC Perc Radiofreq Ablate Renal Tumor,PX-36900481,CDM,50592,CPT,369,RC,,,outpatient,,,13307,9314.9,AETNA [1000108],AETNA [100010801],,,76.8,,10219.78,399.86,10219.776,percent of total billed charges,,,
HC Inject Indwell Cath-Ureter X-Ray,PX-36900482,CDM,50684,CPT,369,RC,,,outpatient,,,374,261.8,AETNA [1000108],AETNA [100010801],,,76.8,,287.23,83.963,1592,percent of total billed charges,,,
HC Change of Ureterostomy Tube via Ileal Conduit,PX-36900483,CDM,50688,CPT,369,RC,,,outpatient,,,4709,3296.3,AETNA [1000108],AETNA [100010801],,,76.8,,3616.51,399.86,3616.512,percent of total billed charges,,,
HC Inject Retrograde/Conduit X-Ray,PX-36900484,CDM,50690,CPT,369,RC,,,outpatient,,,533,373.1,AETNA [1000108],AETNA [100010801],,,76.8,,409.34,119.6585,1592,percent of total billed charges,,,
HC Ureter Endoscopy Thru Ureterostomy W Biopsy,PX-36900485,CDM,50955,CPT,369,RC,,,outpatient,,,11603,8122.1,AETNA [1000108],AETNA [100010801],,,76.8,,8911.1,399.86,8911.104,percent of total billed charges,,,
HC Ureter Endoscopy Thru Ureterostomy Remv FB or Calculus,PX-36900486,CDM,50961,CPT,369,RC,,,outpatient,,,11603,8122.1,AETNA [1000108],AETNA [100010801],,,76.8,,8911.1,399.86,8911.104,percent of total billed charges,,,
HC Aspiration Bladder Needle,PX-36100022,CDM,51100,CPT,361,RC,,,outpatient,,,699,489.3,AETNA [1000108],AETNA [100010801],,,76.8,,536.83,156.9255,1592,percent of total billed charges,,,
HC Aspiration Bladder Needle,PX-36900488,CDM,51100,CPT,369,RC,,,outpatient,,,699,489.3,AETNA [1000108],AETNA [100010801],,,76.8,,536.83,156.9255,1592,percent of total billed charges,,,
HC Aspiration Bladder Trocar/Intracatheter,PX-36100023,CDM,51101,CPT,361,RC,,,outpatient,,,2419,1693.3,AETNA [1000108],AETNA [100010801],,,76.8,,1857.79,179.53,2998,percent of total billed charges,,,
HC Aspiration Bladder Trocar/Intracatheter,PX-36900489,CDM,51101,CPT,369,RC,,,outpatient,,,2419,1693.3,AETNA [1000108],AETNA [100010801],,,76.8,,1857.79,179.53,2998,percent of total billed charges,,,
HC Aspiration Bladder Insert Suprapubic Catheter,PX-36100024,CDM,51102,CPT,361,RC,,,outpatient,,,4709,3296.3,AETNA [1000108],AETNA [100010801],,,76.8,,3616.51,399.86,3616.512,percent of total billed charges,,,
HC Aspiration Bladder Insert Suprapubic Catheter,PX-36900490,CDM,51102,CPT,369,RC,,,outpatient,,,4709,3296.3,AETNA [1000108],AETNA [100010801],,,76.8,,3616.51,399.86,3616.512,percent of total billed charges,,,
HC Injection for Bladder X-Ray,PX-36900491,CDM,51600,CPT,369,RC,,,outpatient,,,1455,1018.5,AETNA [1000108],AETNA [100010801],,,76.8,,1117.44,235.074116,1592,percent of total billed charges,,,
HC Inject for Retrograde Urethocysto,PX-36900492,CDM,51610,CPT,369,RC,,,outpatient,,,976,683.2,AETNA [1000108],AETNA [100010801],,,76.8,,749.57,219.112,1592,percent of total billed charges,,,
HC Bldr Irrigation Smpl Lavage &/Instlj,PX-36900732,CDM,51700,CPT,369,RC,,,outpatient,,,879,615.3,AETNA [1000108],AETNA [100010801],,,76.8,,675.07,197.3355,1592,percent of total billed charges,,,
HC Insert-Non-Indwelling Bladder Catheter,PX-36900494,CDM,51701,CPT,369,RC,,,outpatient,,,389,272.3,AETNA [1000108],AETNA [100010801],,,76.8,,298.75,87.3305,1592,percent of total billed charges,,,
HC Insert-Temp Indwelling Blad Cath-Simple,PX-36900495,CDM,51702,CPT,369,RC,,,outpatient,,,391,273.7,AETNA [1000108],AETNA [100010801],,,76.8,,300.29,87.7795,1592,percent of total billed charges,,,
HC Insert-Temp Indwelling Blad Cath-Comp,PX-36900496,CDM,51703,CPT,369,RC,,,outpatient,,,354,247.8,AETNA [1000108],AETNA [100010801],,,76.8,,271.87,79.473,1592,percent of total billed charges,,,
HC Change of Bladder Tube-Simple,PX-36900497,CDM,51705,CPT,369,RC,,,outpatient,,,456,319.2,AETNA [1000108],AETNA [100010801],,,76.8,,350.21,102.372,1592,percent of total billed charges,,,
HC Emg Stds Anal/Urtl Sphnctr Oth/Thn Ndl,PX-36900667,CDM,51784,CPT,369,RC,,,outpatient,,,475,332.5,AETNA [1000108],AETNA [100010801],,,76.8,,364.8,106.6375,1592,percent of total billed charges,,,
HC Meas Post-Voiding Residual Urine&/Bladder Cap,PX-36900733,CDM,51798,CPT,369,RC,,,outpatient,,,212,148.4,AETNA [1000108],AETNA [100010801],,,76.8,,162.82,47.594,1592,percent of total billed charges,,,
HC Cysto/Ureteroscopy-Tx Ureter Strict,PX-36900500,CDM,52344,CPT,369,RC,,,outpatient,,,8086,5660.2,AETNA [1000108],AETNA [100010801],,,76.8,,6210.05,399.86,6210.048,percent of total billed charges,,,
HC Circumcision Age >28 Days,PX-36900772,CDM,54161,CPT,369,RC,,,outpatient,,,6599,4619.3,AETNA [1000108],AETNA [100010801],,,76.8,,5068.03,399.86,5068.032,percent of total billed charges,,,
HC Irrigation Corpora Cavernosa Priapism,PX-36900736,CDM,54220,CPT,369,RC,,,outpatient,,,591,413.7,AETNA [1000108],AETNA [100010801],,,76.8,,453.89,120.28264,1592,percent of total billed charges,,,
HC Biopsy of Prostate-Needle/Punch,PX-36900501,CDM,55700,CPT,369,RC,,,outpatient,,,4709,3296.3,AETNA [1000108],AETNA [100010801],,,76.8,,3616.51,399.86,3616.512,percent of total billed charges,,,
HC I&D of Vulva/Perineum Abscess,PX-36900502,CDM,56405,CPT,369,RC,,,outpatient,,,829,580.3,AETNA [1000108],AETNA [100010801],,,76.8,,636.67,186.1105,1592,percent of total billed charges,,,
HC PR Colporrhaphy- Suture Vaginal Injury- Non-OB,PX-36900795,CDM,57200,CPT,369,RC,,,outpatient,,,5013,3509.1,AETNA [1000108],AETNA [100010801],,,76.8,,3849.98,399.86,4777.053449,percent of total billed charges,,,
HC Cath/Inject Hysterosalpingogram,PX-36900505,CDM,58340,CPT,369,RC,,,outpatient,,,1092,764.4,AETNA [1000108],AETNA [100010801],,,76.8,,838.66,235.074116,1592,percent of total billed charges,,,
HC Reopen Fallopian Tube-Transcerv Cath,PX-36900506,CDM,58345,CPT,369,RC,,,outpatient,,,6900,4830,AETNA [1000108],AETNA [100010801],,,76.8,,5299.2,399.86,5299.2,percent of total billed charges,,,
HC Fetal Non-Stress Test,PX-92000003,CDM,59025,CPT,920,RC,,,outpatient,,,490,343,AETNA [1000108],AETNA [100010801],,,76.8,,376.32,110.005,416.02,percent of total billed charges,,,
HC PR Vaginal Delivery Only,PX-96000044,CDM,59409,CPT,960,RC,,,outpatient,,,3062,2143.4,AETNA [1000108],AETNA [100010801],,,76.8,,2351.62,399.86,4777.053449,percent of total billed charges,,,
HC PR Delivery Placenta Separate Procedure,PX-96000045,CDM,59414,CPT,960,RC,,,outpatient,,,7176,5023.2,AETNA [1000108],AETNA [100010801],,,76.8,,5511.17,399.86,5511.168,percent of total billed charges,,,
HC Biopsy of Thyroid-Percut,PX-36900512,CDM,60100,CPT,369,RC,,,outpatient,,,1514,1059.8,AETNA [1000108],AETNA [100010801],,,76.8,,1162.75,339.893,2141,percent of total billed charges,,,
HC Endocrine Surgery Proc Unlisted,PX-36900513,CDM,60699,CPT,369,RC,,,outpatient,,,6035,4224.5,AETNA [1000108],AETNA [100010801],,,76.8,,4634.88,399.86,11413.04,percent of total billed charges,,,
HC Brain Shunt Tube/Reserv Injectn,PX-36900514,CDM,61070,CPT,369,RC,,,outpatient,,,1885,1319.5,AETNA [1000108],AETNA [100010801],,,76.8,,1447.68,399.86,2141,percent of total billed charges,,,
HC Endovasc Temp Balloon Occlus-Head/Nck,PX-36900515,CDM,61623,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA [1000108],AETNA [100010801],,,76.8,,20286.72,399.86,20286.72,percent of total billed charges,,,
HC Perm Occlusion/Embolization-Percut-Cns,PX-36900516,CDM,61624,CPT,369,RC,,,outpatient,,,533,373.1,AETNA [1000108],AETNA [100010801],,,76.8,,409.34,119.6585,5756,percent of total billed charges,,,
HC Percut Cath Occlusn Non Cns Lesn,PX-36900517,CDM,61626,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA [1000108],AETNA [100010801],,,76.8,,20286.72,399.86,20286.72,percent of total billed charges,,,
HC Percut Aspiration Vertebral Disc,PX-36900518,CDM,62267,CPT,369,RC,,,outpatient,,,1637,1145.9,AETNA [1000108],AETNA [100010801],,,76.8,,1257.22,367.5065,2141,percent of total billed charges,,,
HC Spinal Puncture-Lumbar-Diagnostic,PX-36100025,CDM,62270,CPT,361,RC,,,outpatient,,,915,640.5,AETNA [1000108],AETNA [100010801],,,76.8,,702.72,205.4175,2141,percent of total billed charges,,,
HC Spinal Puncture-Lumbar-Diagnostic,PX-36900519,CDM,62270,CPT,369,RC,,,outpatient,,,915,640.5,AETNA [1000108],AETNA [100010801],,,76.8,,702.72,205.4175,2141,percent of total billed charges,,,
HC PR Spinal Puncture Lumbar Diagnostic,PX-96000051,CDM,62270,CPT,960,RC,,,outpatient,,,915,640.5,AETNA [1000108],AETNA [100010801],,,76.8,,702.72,205.4175,2141,percent of total billed charges,,,
HC Spinal Puncture-Therapeutic Drainage,PX-36100026,CDM,62272,CPT,361,RC,,,outpatient,,,1256,879.2,AETNA [1000108],AETNA [100010801],,,76.8,,964.61,281.972,2141,percent of total billed charges,,,
HC Spinal Puncture-Therapeutic Drainage,PX-36900520,CDM,62272,CPT,369,RC,,,outpatient,,,1256,879.2,AETNA [1000108],AETNA [100010801],,,76.8,,964.61,281.972,2141,percent of total billed charges,,,
HC Inj-Lumb Epidur-Blood/Clot Patch,PX-36900521,CDM,62273,CPT,369,RC,,,outpatient,,,915,640.5,AETNA [1000108],AETNA [100010801],,,76.8,,702.72,205.4175,2141,percent of total billed charges,,,
HC Inject-Myelography &/or CT Scan-Spinal,PX-36900522,CDM,62284,CPT,369,RC,,,outpatient,,,1312,918.4,AETNA [1000108],AETNA [100010801],,,76.8,,1007.62,294.544,1592,percent of total billed charges,,,
HC Diskectomy-Percutaneous Lumbar,PX-36900523,CDM,62287,CPT,369,RC,,,outpatient,,,6304,4412.8,AETNA [1000108],AETNA [100010801],,,76.8,,4841.47,399.86,6224.0876,percent of total billed charges,,,
HC Inject Diskogram-Lumbar-Ea Level,PX-36900524,CDM,62290,CPT,369,RC,,,outpatient,,,1256,879.2,AETNA [1000108],AETNA [100010801],,,76.8,,964.61,281.972,1592,percent of total billed charges,,,
HC Inj-Cerv/Thorac-for Diskography,PX-36900525,CDM,62291,CPT,369,RC,,,outpatient,,,1107,774.9,AETNA [1000108],AETNA [100010801],,,76.8,,850.18,248.5215,1592,percent of total billed charges,,,
HC Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/O Img Gdn,PX-36900884,CDM,62322,CPT,369,RC,,,outpatient,,,2586,1810.2,AETNA [1000108],AETNA [100010801],,,76.8,,1986.05,399.86,2141,percent of total billed charges,,,
HC Elec Anlys Implt Ithcl/Edrl Pmp W/Repr Phys/Qhp,PX-36900526,CDM,62370,CPT,369,RC,,,outpatient,,,821,574.7,AETNA [1000108],AETNA [100010801],,,76.8,,630.53,155.844464,1592,percent of total billed charges,,,
HC Inject Nerv Blck-Trigeminal,PX-36900609,CDM,64400,CPT,369,RC,,,outpatient,,,891,623.7,AETNA [1000108],AETNA [100010801],,,76.8,,684.29,200.0295,1592,percent of total billed charges,,,
HC Inject Nerv Blck-Great Occiptl,PX-36900611,CDM,64405,CPT,369,RC,,,outpatient,,,1634,1143.8,AETNA [1000108],AETNA [100010801],,,76.8,,1254.91,323.2601,1592,percent of total billed charges,,,
HC Inject Nerv Blck-Vagus Nerve,PX-36900612,CDM,64408,CPT,369,RC,,,outpatient,,,877,613.9,AETNA [1000108],AETNA [100010801],,,76.8,,673.54,196.8865,1592,percent of total billed charges,,,
HC Inj-Anes Agent-Brachial Plexus-Single,PX-36900616,CDM,64415,CPT,369,RC,,,outpatient,,,1544,1080.8,AETNA [1000108],AETNA [100010801],,,76.8,,1185.79,346.628,2141,percent of total billed charges,,,
HC Inj-Anes Agent-Brachial Plexus-Cont Inf,PX-36900617,CDM,64416,CPT,369,RC,,,outpatient,,,2785,1949.5,AETNA [1000108],AETNA [100010801],,,76.8,,2138.88,399.86,2141,percent of total billed charges,,,
HC Inject Nerv Blck-Axillary Nerv,PX-36900618,CDM,64417,CPT,369,RC,,,outpatient,,,1544,1080.8,AETNA [1000108],AETNA [100010801],,,76.8,,1185.79,346.628,2141,percent of total billed charges,,,
HC Inject Nerv Blck-Suprascap N.,PX-36900619,CDM,64418,CPT,369,RC,,,outpatient,,,1544,1080.8,AETNA [1000108],AETNA [100010801],,,76.8,,1185.79,346.628,2141,percent of total billed charges,,,
HC Inject Nerv Blck-Intercostal-One,PX-36900620,CDM,64420,CPT,369,RC,,,outpatient,,,1382,967.4,AETNA [1000108],AETNA [100010801],,,76.8,,1061.38,310.259,2141,percent of total billed charges,,,
HC Inject Nerv Blck-Intercost-Multpl,PX-36900621,CDM,64421,CPT,369,RC,,,outpatient,,,2785,1949.5,AETNA [1000108],AETNA [100010801],,,76.8,,2138.88,399.86,2141,percent of total billed charges,,,
HC Inject Nerv Blck-Ilioingu/Iliohyp,PX-36900622,CDM,64425,CPT,369,RC,,,outpatient,,,1544,1080.8,AETNA [1000108],AETNA [100010801],,,76.8,,1185.79,346.628,2141,percent of total billed charges,,,
HC Inject Nerv Blck-Pudendal,PX-36100029,CDM,64430,CPT,361,RC,,,outpatient,,,2785,1949.5,AETNA [1000108],AETNA [100010801],,,76.8,,2138.88,399.86,2141,percent of total billed charges,,,
HC Inject Nerv Blck-Pudendal,PX-36900623,CDM,64430,CPT,369,RC,,,outpatient,,,2785,1949.5,AETNA [1000108],AETNA [100010801],,,76.8,,2138.88,399.86,2141,percent of total billed charges,,,
HC Inject Nerv Blck-Paracervical,PX-36900624,CDM,64435,CPT,369,RC,,,outpatient,,,1544,1080.8,AETNA [1000108],AETNA [100010801],,,76.8,,1185.79,346.628,2141,percent of total billed charges,,,
HC Inj-Anes Agent-Sciatic Nerve-Single,PX-36900625,CDM,64445,CPT,369,RC,,,outpatient,,,2785,1949.5,AETNA [1000108],AETNA [100010801],,,76.8,,2138.88,399.86,2141,percent of total billed charges,,,
HC Inj-Anes Agent-Sciatic Nerve-Cont Inf,PX-36900626,CDM,64446,CPT,369,RC,,,outpatient,,,2785,1949.5,AETNA [1000108],AETNA [100010801],,,76.8,,2138.88,399.86,2141,percent of total billed charges,,,
HC Inj-Anes Agent-Femoral Nerve-Single,PX-36900627,CDM,64447,CPT,369,RC,,,outpatient,,,1544,1080.8,AETNA [1000108],AETNA [100010801],,,76.8,,1185.79,346.628,2141,percent of total billed charges,,,
HC Inj-Anes Agent-Femoral Nerve-Cont Inf,PX-36900628,CDM,64448,CPT,369,RC,,,outpatient,,,6090,4263,AETNA [1000108],AETNA [100010801],,,76.8,,4677.12,399.86,4677.12,percent of total billed charges,,,
HC N Block Inj- Lumbar Plexus,PX-36900629,CDM,64449,CPT,369,RC,,,outpatient,,,2785,1949.5,AETNA [1000108],AETNA [100010801],,,76.8,,2138.88,399.86,2141,percent of total billed charges,,,
HC Inject Nerv Blck-Othr Periph Nerv,PX-36900630,CDM,64450,CPT,369,RC,,,outpatient,,,1634,1143.8,AETNA [1000108],AETNA [100010801],,,76.8,,1254.91,366.833,2141,percent of total billed charges,,,
HC Njx Aa&/Strd Plantar Common Digital Nerves,PX-36900835,CDM,64455,CPT,369,RC,,,outpatient,,,825,577.5,AETNA [1000108],AETNA [100010801],,,76.8,,633.6,185.2125,1592,percent of total billed charges,,,
HC Inject Anes/Steroid Foramen Cerv/Thoracic W Img Guide -1 Level,PX-36900631,CDM,64479,CPT,369,RC,,,outpatient,,,2785,1949.5,AETNA [1000108],AETNA [100010801],,,76.8,,2138.88,399.86,2141,percent of total billed charges,,,
HC Inject Anes/Steroid Foramen Cerv/Thoracic W Img Guide -Ea Add Level,PX-36900632,CDM,64480,CPT,369,RC,,,outpatient,,,230,161,AETNA [1000108],AETNA [100010801],,,76.8,,176.64,51.635,1592,percent of total billed charges,,,
HC Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level,PX-36100027,CDM,64483,CPT,361,RC,,,outpatient,,,1693,1185.1,AETNA [1000108],AETNA [100010801],,,76.8,,1300.22,380.0785,2141,percent of total billed charges,,,
HC Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level,PX-36900531,CDM,64483,CPT,369,RC,,,outpatient,,,1693,1185.1,AETNA [1000108],AETNA [100010801],,,76.8,,1300.22,380.0785,2141,percent of total billed charges,,,
HC Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl,PX-36900532,CDM,64484,CPT,369,RC,,,outpatient,,,416,291.2,AETNA [1000108],AETNA [100010801],,,76.8,,319.49,93.392,1592,percent of total billed charges,,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- 1st Level,PX-36100028,CDM,64490,CPT,361,RC,,,outpatient,,,1693,1185.1,AETNA [1000108],AETNA [100010801],,,76.8,,1300.22,380.0785,2141,percent of total billed charges,,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- 1st Level,PX-36900533,CDM,64490,CPT,369,RC,,,outpatient,,,1693,1185.1,AETNA [1000108],AETNA [100010801],,,76.8,,1300.22,380.0785,2141,percent of total billed charges,,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- 2nd Level,PX-36900633,CDM,64491,CPT,369,RC,,,outpatient,,,221,154.7,AETNA [1000108],AETNA [100010801],,,76.8,,169.73,49.6145,1592,percent of total billed charges,,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- Add Level,PX-36900634,CDM,64492,CPT,369,RC,,,outpatient,,,224,156.8,AETNA [1000108],AETNA [100010801],,,76.8,,172.03,50.288,1592,percent of total billed charges,,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Lumbar/Sac- 1st Level,PX-36900536,CDM,64493,CPT,369,RC,,,outpatient,,,1693,1185.1,AETNA [1000108],AETNA [100010801],,,76.8,,1300.22,380.0785,2141,percent of total billed charges,,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Lumbar/Sac- 2nd Level,PX-36900537,CDM,64494,CPT,369,RC,,,outpatient,,,1693,1185.1,AETNA [1000108],AETNA [100010801],,,76.8,,1300.22,380.0785,1592,percent of total billed charges,,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Lumbar/Sac- Add Level,PX-36900538,CDM,64495,CPT,369,RC,,,outpatient,,,54,37.8,AETNA [1000108],AETNA [100010801],,,76.8,,41.47,12.123,1592,percent of total billed charges,,,
HC Inject Nerv Blck-Celiac Plexus,PX-36900539,CDM,64530,CPT,369,RC,,,outpatient,,,2165,1515.5,AETNA [1000108],AETNA [100010801],,,76.8,,1662.72,399.86,2141,percent of total billed charges,,,
HC Unlisted Procedure Nervous System,PX-36100035,CDM,64999,CPT,361,RC,,,outpatient,,,687,480.9,AETNA [1000108],AETNA [100010801],,,76.8,,527.62,154.2315,1592,percent of total billed charges,,,
HC Unlisted Procedure Nervous System,PX-36900829,CDM,64999,CPT,369,RC,,,outpatient,,,687,480.9,AETNA [1000108],AETNA [100010801],,,76.8,,527.62,154.2315,1592,percent of total billed charges,,,
HC Removal Impacted Cerumen Using Irrigation/Lavage- Unilateral,PX-36900636,CDM,69209,CPT,369,RC,,,outpatient,,,205,143.5,AETNA [1000108],AETNA [100010801],,,76.8,,157.44,46.0225,1592,percent of total billed charges,,,
HC Removal Impacted Cerumen Instrumentation Unilat,PX-36900540,CDM,69210,CPT,369,RC,,,outpatient,,,305,213.5,AETNA [1000108],AETNA [100010801],,,76.8,,234.24,66.75974,1592,percent of total billed charges,,,
HC X-Ray Eye for Foreign Body,PX-32000004,CDM,70030,CPT,320,RC,,,outpatient,,,271,189.7,AETNA [1000108],AETNA [100010801],,,76.8,,208.13,60.8395,416.02,percent of total billed charges,,,
HC X-Ray Jaw <4 Vw,PX-32000005,CDM,70100,CPT,320,RC,,,outpatient,,,595,416.5,AETNA [1000108],AETNA [100010801],,,76.8,,456.96,71.24,456.96,percent of total billed charges,,,
HC X-Ray Jaw 4+ Vw,PX-32000006,CDM,70110,CPT,320,RC,,,outpatient,,,489,342.3,AETNA [1000108],AETNA [100010801],,,76.8,,375.55,76.026473,416.02,percent of total billed charges,,,
HC X-Ray Mastoids <3 Vw,PX-32000007,CDM,70120,CPT,320,RC,,,outpatient,,,384,268.8,AETNA [1000108],AETNA [100010801],,,76.8,,294.91,86.208,416.02,percent of total billed charges,,,
HC X-Ray Mastoids 3+ Vw,PX-32000008,CDM,70130,CPT,320,RC,,,outpatient,,,295,206.5,AETNA [1000108],AETNA [100010801],,,76.8,,226.56,66.2275,416.02,percent of total billed charges,,,
HC X-Ray Facial Bones <3 Vw,PX-32000009,CDM,70140,CPT,320,RC,,,outpatient,,,336,235.2,AETNA [1000108],AETNA [100010801],,,76.8,,258.05,71.24,416.02,percent of total billed charges,,,
HC X-Ray Facial Bones 3+ Vw,PX-32000010,CDM,70150,CPT,320,RC,,,outpatient,,,252,176.4,AETNA [1000108],AETNA [100010801],,,76.8,,193.54,56.574,416.02,percent of total billed charges,,,
HC X-Ray Nasal Bones,PX-32000011,CDM,70160,CPT,320,RC,,,outpatient,,,319,223.3,AETNA [1000108],AETNA [100010801],,,76.8,,244.99,71.24,416.02,percent of total billed charges,,,
HC X-Ray Orbits,PX-32000012,CDM,70200,CPT,320,RC,,,outpatient,,,328,229.6,AETNA [1000108],AETNA [100010801],,,76.8,,251.9,73.636,416.02,percent of total billed charges,,,
HC X-Ray Sinuses <3 Vw,PX-32000013,CDM,70210,CPT,320,RC,,,outpatient,,,328,229.6,AETNA [1000108],AETNA [100010801],,,76.8,,251.9,71.24,416.02,percent of total billed charges,,,
HC X-Ray Sinuses 3+ Vw,PX-32000014,CDM,70220,CPT,320,RC,,,outpatient,,,444,310.8,AETNA [1000108],AETNA [100010801],,,76.8,,340.99,71.24,416.02,percent of total billed charges,,,
HC X-Ray Exam Sella,PX-32000015,CDM,70240,CPT,320,RC,,,outpatient,,,262,183.4,AETNA [1000108],AETNA [100010801],,,76.8,,201.22,58.819,416.02,percent of total billed charges,,,
HC X-Ray Skull <4 Vw,PX-32000016,CDM,70250,CPT,320,RC,,,outpatient,,,352,246.4,AETNA [1000108],AETNA [100010801],,,76.8,,270.34,76.026473,416.02,percent of total billed charges,,,
HC X-Ray Skull 4+ Vw,PX-32000017,CDM,70260,CPT,320,RC,,,outpatient,,,419,293.3,AETNA [1000108],AETNA [100010801],,,76.8,,321.79,76.026473,416.02,percent of total billed charges,,,
HC X-Ray Teeth Single,PX-32000018,CDM,70300,CPT,320,RC,,,outpatient,,,241,168.7,AETNA [1000108],AETNA [100010801],,,76.8,,185.09,54.1045,416.02,percent of total billed charges,,,
HC X-Ray Tmj Unilat,PX-32000019,CDM,70328,CPT,320,RC,,,outpatient,,,241,168.7,AETNA [1000108],AETNA [100010801],,,76.8,,185.09,54.1045,416.02,percent of total billed charges,,,
HC X-Ray Tmj Bilat,PX-32000020,CDM,70330,CPT,320,RC,,,outpatient,,,716,501.2,AETNA [1000108],AETNA [100010801],,,76.8,,549.89,71.24,549.888,percent of total billed charges,,,
HC MRI- Tmj,PX-61000008,CDM,70336,CPT,610,RC,,,outpatient,,,2588,1811.6,AETNA [1000108],AETNA [100010801],,,76.8,,1987.58,267.439885,1987.584,percent of total billed charges,,,
HC Panoramic X-Ray of Jaws,PX-32000022,CDM,70355,CPT,320,RC,,,outpatient,,,241,168.7,AETNA [1000108],AETNA [100010801],,,76.8,,185.09,54.1045,416.02,percent of total billed charges,,,
HC X-Ray Neck Soft Tissue,PX-32000023,CDM,70360,CPT,320,RC,,,outpatient,,,232,162.4,AETNA [1000108],AETNA [100010801],,,76.8,,178.18,52.084,416.02,percent of total billed charges,,,
HC X-Ray Salivary Gland,PX-32000025,CDM,70380,CPT,320,RC,,,outpatient,,,262,183.4,AETNA [1000108],AETNA [100010801],,,76.8,,201.22,58.819,416.02,percent of total billed charges,,,
HC X-Ray Sialogram,PX-32000026,CDM,70390,CPT,320,RC,,,outpatient,,,537,375.9,AETNA [1000108],AETNA [100010801],,,76.8,,412.42,120.5565,646.6965,percent of total billed charges,,,
HC CT Scan-Head/Brain-W/O Contrast Matl,PX-35000002,CDM,70450,CPT,350,RC,,,outpatient,,,1070,749,AETNA [1000108],AETNA [100010801],,,76.8,,821.76,89.81,821.76,percent of total billed charges,,,
HC CT Scan Head Contrast,PX-35000003,CDM,70460,CPT,350,RC,,,outpatient,,,1333,933.1,AETNA [1000108],AETNA [100010801],,,76.8,,1023.74,124.33,1023.744,percent of total billed charges,,,
CT Head/Brain W/O & W/Contrast Material,PX-35000004,CDM,70470,CPT,350,RC,,,outpatient,,,1615,1130.5,AETNA [1000108],AETNA [100010801],,,76.8,,1240.32,153.75,1240.32,percent of total billed charges,,,
HC CT Scan-Orbit/Sella/Post Fossa/Ear-W/O,PX-35000005,CDM,70480,CPT,350,RC,,,outpatient,,,657,459.9,AETNA [1000108],AETNA [100010801],,,76.8,,504.58,96.160741,575,percent of total billed charges,,,
HC CT Scan Skull Contrast,PX-35000006,CDM,70481,CPT,350,RC,,,outpatient,,,774,541.8,AETNA [1000108],AETNA [100010801],,,76.8,,594.43,173.763,667.43,percent of total billed charges,,,
CT Orbit Sella/Post Fossa/Ear W/O & W/Contr Matr,PX-35000007,CDM,70482,CPT,350,RC,,,outpatient,,,1619,1133.3,AETNA [1000108],AETNA [100010801],,,76.8,,1243.39,200.53123,1243.392,percent of total billed charges,,,
HC CT Scan-Maxillofacial Area-W/O Contrast,PX-35000008,CDM,70486,CPT,350,RC,,,outpatient,,,1200,840,AETNA [1000108],AETNA [100010801],,,76.8,,921.6,96.160741,921.6,percent of total billed charges,,,
HC CT Scan- Face/Jaw Contrast,PX-35000009,CDM,70487,CPT,350,RC,,,outpatient,,,1321,924.7,AETNA [1000108],AETNA [100010801],,,76.8,,1014.53,200.53123,1014.528,percent of total billed charges,,,
CT Maxillofacial W/O & W/Contrast Material,PX-35000010,CDM,70488,CPT,350,RC,,,outpatient,,,1158,810.6,AETNA [1000108],AETNA [100010801],,,76.8,,889.34,200.53123,889.344,percent of total billed charges,,,
HC CT Scan-Soft Tissue Neck-W/O Contrast,PX-35000011,CDM,70490,CPT,350,RC,,,outpatient,,,514,359.8,AETNA [1000108],AETNA [100010801],,,76.8,,394.75,96.160741,575,percent of total billed charges,,,
HC CT Neck Tissue Contrast,PX-35000012,CDM,70491,CPT,350,RC,,,outpatient,,,1482,1037.4,AETNA [1000108],AETNA [100010801],,,76.8,,1138.18,194.55,1138.176,percent of total billed charges,,,
CT Soft Tissue Neck W/O & W/Contrast Material,PX-35000014,CDM,70492,CPT,350,RC,,,outpatient,,,1755,1228.5,AETNA [1000108],AETNA [100010801],,,76.8,,1347.84,200.53123,1347.84,percent of total billed charges,,,
CT Angiography Head W/Contrast/Noncontrast,PX-35000013,CDM,70496,CPT,350,RC,,,outpatient,,,1330,931,AETNA [1000108],AETNA [100010801],,,76.8,,1021.44,200.53123,1021.44,percent of total billed charges,,,
CT Angiography Neck W/Contrast/Noncontrast,PX-35000015,CDM,70498,CPT,350,RC,,,outpatient,,,1157,809.9,AETNA [1000108],AETNA [100010801],,,76.8,,888.58,200.53123,888.576,percent of total billed charges,,,
HC MRI- Face- Neck,PX-61000009,CDM,70540,CPT,610,RC,,,outpatient,,,5081,3556.7,AETNA [1000108],AETNA [100010801],,,76.8,,3902.21,237.688956,3902.208,percent of total billed charges,,,
HC MRI- Face- Neck W/Contrast,PX-61000010,CDM,70542,CPT,610,RC,,,outpatient,,,2710,1897,AETNA [1000108],AETNA [100010801],,,76.8,,2081.28,365.99,2081.28,percent of total billed charges,,,
MRI Orbit Face & Neck W/O & W/Contrast Matrl,PX-61000011,CDM,70543,CPT,610,RC,,,outpatient,,,1692,1184.4,AETNA [1000108],AETNA [100010801],,,76.8,,1299.46,379.854,1299.456,percent of total billed charges,,,
HC MR Angio- Head,PX-61000012,CDM,70544,CPT,610,RC,,,outpatient,,,2279,1595.3,AETNA [1000108],AETNA [100010801],,,76.8,,1750.27,267.439885,1750.272,percent of total billed charges,,,
HC MR Angio- Head W/Contrast,PX-61000013,CDM,70545,CPT,610,RC,,,outpatient,,,2279,1595.3,AETNA [1000108],AETNA [100010801],,,76.8,,1750.27,374.62,1750.272,percent of total billed charges,,,
Mra Head W/O & W/Contrast Material,PX-61000014,CDM,70546,CPT,610,RC,,,outpatient,,,2279,1595.3,AETNA [1000108],AETNA [100010801],,,76.8,,1750.27,301.425681,1750.272,percent of total billed charges,,,
HC MR Angio- Neck,PX-61000015,CDM,70547,CPT,610,RC,,,outpatient,,,2182,1527.4,AETNA [1000108],AETNA [100010801],,,76.8,,1675.78,267.439885,1675.776,percent of total billed charges,,,
HC MR Angio- Neck W/Contrast,PX-61000016,CDM,70548,CPT,610,RC,,,outpatient,,,2469,1728.3,AETNA [1000108],AETNA [100010801],,,76.8,,1896.19,399.86,1896.192,percent of total billed charges,,,
Mra Neck W/O &W/Contrast Material,PX-61000017,CDM,70549,CPT,610,RC,,,outpatient,,,2534,1773.8,AETNA [1000108],AETNA [100010801],,,76.8,,1946.11,301.425681,1946.112,percent of total billed charges,,,
HC MRI Brain,PX-61000018,CDM,70551,CPT,610,RC,,,outpatient,,,2090,1463,AETNA [1000108],AETNA [100010801],,,76.8,,1605.12,188.66,1605.12,percent of total billed charges,,,
HC MRI Brain Contrast,PX-61000019,CDM,70552,CPT,610,RC,,,outpatient,,,5255,3678.5,AETNA [1000108],AETNA [100010801],,,76.8,,4035.84,268.7,4035.84,percent of total billed charges,,,
MRI Brain Brain Stem W/O W/Contrast Material,PX-61000020,CDM,70553,CPT,610,RC,,,outpatient,,,2668,1867.6,AETNA [1000108],AETNA [100010801],,,76.8,,2049.02,307.14,2049.024,percent of total billed charges,,,
HC X-Ray Exam Chest 1 View,PX-32000245,CDM,71045,CPT,320,RC,,,outpatient,,,214,149.8,AETNA [1000108],AETNA [100010801],,,76.8,,164.35,48.043,416.02,percent of total billed charges,,,
HC X-Ray Exam Chest 2 Views,PX-32000246,CDM,71046,CPT,320,RC,,,outpatient,,,232,162.4,AETNA [1000108],AETNA [100010801],,,76.8,,178.18,52.084,416.02,percent of total billed charges,,,
HC X-Ray Exam Chest 3 Views,PX-32000247,CDM,71047,CPT,320,RC,,,outpatient,,,245,171.5,AETNA [1000108],AETNA [100010801],,,76.8,,188.16,55.0025,416.02,percent of total billed charges,,,
HC X-Ray Exam Chest 4+ Views,PX-32000248,CDM,71048,CPT,320,RC,,,outpatient,,,410,287,AETNA [1000108],AETNA [100010801],,,76.8,,314.88,76.026473,416.02,percent of total billed charges,,,
HC X-Ray Ribs- Chest 3+ Vw,PX-32000036,CDM,71101,CPT,320,RC,,,outpatient,,,484,338.8,AETNA [1000108],AETNA [100010801],,,76.8,,371.71,76.026473,416.02,percent of total billed charges,,,
HC X-Ray Ribs- Chest 4+ Vw,PX-32000038,CDM,71111,CPT,320,RC,,,outpatient,,,562,393.4,AETNA [1000108],AETNA [100010801],,,76.8,,431.62,76.026473,431.616,percent of total billed charges,,,
HC X-Ray Sternum 2+ Vw,PX-32000039,CDM,71120,CPT,320,RC,,,outpatient,,,358,250.6,AETNA [1000108],AETNA [100010801],,,76.8,,274.94,71.24,416.02,percent of total billed charges,,,
HC X-Ray Sterno-Clavicluar Jt,PX-32000040,CDM,71130,CPT,320,RC,,,outpatient,,,250,175,AETNA [1000108],AETNA [100010801],,,76.8,,192,56.125,416.02,percent of total billed charges,,,
HC Diagnostic Computed Tomography Thorax W/O Cntrst,PX-35000016,CDM,71250,CPT,350,RC,,,outpatient,,,1388,971.6,AETNA [1000108],AETNA [100010801],,,76.8,,1065.98,96.160741,1065.984,percent of total billed charges,,,
HC Diagnostic Computed Tomography Thorax W/Contrast,PX-35000017,CDM,71260,CPT,350,RC,,,outpatient,,,1624,1136.8,AETNA [1000108],AETNA [100010801],,,76.8,,1247.23,195.34,1247.232,percent of total billed charges,,,
HC Diagnostic Computed Tomography Thorax C-/C+,PX-35000018,CDM,71270,CPT,350,RC,,,outpatient,,,1982,1387.4,AETNA [1000108],AETNA [100010801],,,76.8,,1522.18,200.53123,1522.176,percent of total billed charges,,,
HC Computed Tomography Thorax Lw Dose Lng Ca Scr C-,PX-35000070,CDM,71271,CPT,350,RC,,,outpatient,,,264,184.8,AETNA [1000108],AETNA [100010801],,,76.8,,202.75,59.268,575,percent of total billed charges,,,
CT Angiography Chest W/Contrast/Noncontrast,PX-35000019,CDM,71275,CPT,350,RC,,,outpatient,,,1592,1114.4,AETNA [1000108],AETNA [100010801],,,76.8,,1222.66,200.53123,1222.656,percent of total billed charges,,,
HC MRI- Chest,PX-61000023,CDM,71550,CPT,610,RC,,,outpatient,,,1979,1385.3,AETNA [1000108],AETNA [100010801],,,76.8,,1519.87,237.688956,1519.872,percent of total billed charges,,,
HC MRI- Chest- W/Contrast,PX-61000024,CDM,71551,CPT,610,RC,,,outpatient,,,3128,2189.6,AETNA [1000108],AETNA [100010801],,,76.8,,2402.3,399.86,2402.304,percent of total billed charges,,,
MRI Chest W/O & W/Contrast Material,PX-61000025,CDM,71552,CPT,610,RC,,,outpatient,,,1547,1082.9,AETNA [1000108],AETNA [100010801],,,76.8,,1188.1,347.3015,1288.93,percent of total billed charges,,,
HC MR Angio Chest (Mra) W/Contrast,PX-61000026,CDM,71555,CPT,610,RC,,,outpatient,,,2367,1656.9,AETNA [1000108],AETNA [100010801],,,76.8,,1817.86,301.425681,1817.856,percent of total billed charges,,,
HC MR Angio Chest (Mra) Without Contrast,PX-61000071,CDM,71555,CPT,610,RC,,,outpatient,,,2367,1656.9,AETNA [1000108],AETNA [100010801],,,76.8,,1817.86,301.425681,1817.856,percent of total billed charges,,,
HC MR Angio Chest (Mra) W/Without Contrast,PX-61000072,CDM,71555,CPT,610,RC,,,outpatient,,,2367,1656.9,AETNA [1000108],AETNA [100010801],,,76.8,,1817.86,301.425681,1817.856,percent of total billed charges,,,
HC X-Ray Spine One View,PX-32000042,CDM,72020,CPT,320,RC,,,outpatient,,,251,175.7,AETNA [1000108],AETNA [100010801],,,76.8,,192.77,56.3495,416.02,percent of total billed charges,,,
HC Radex Spine Cervical 2 or 3 Views,PX-32000043,CDM,72040,CPT,320,RC,,,outpatient,,,296,207.2,AETNA [1000108],AETNA [100010801],,,76.8,,227.33,66.452,416.02,percent of total billed charges,,,
HC Radex Spine Cervical 4 or 5 Views,PX-32000044,CDM,72050,CPT,320,RC,,,outpatient,,,300,210,AETNA [1000108],AETNA [100010801],,,76.8,,230.4,67.35,416.02,percent of total billed charges,,,
HC Radex Spine Cervical 6 or More Views,PX-32000045,CDM,72052,CPT,320,RC,,,outpatient,,,300,210,AETNA [1000108],AETNA [100010801],,,76.8,,230.4,67.35,416.02,percent of total billed charges,,,
HC X-Ray Thoracic Spine 2 Vw,PX-32000046,CDM,72070,CPT,320,RC,,,outpatient,,,252,176.4,AETNA [1000108],AETNA [100010801],,,76.8,,193.54,56.574,416.02,percent of total billed charges,,,
HC X-Ray Thoracic Spine+Swim 3 Vw,PX-32000047,CDM,72072,CPT,320,RC,,,outpatient,,,283,198.1,AETNA [1000108],AETNA [100010801],,,76.8,,217.34,63.5335,416.02,percent of total billed charges,,,
HC X-Ray Thoracic Spine 4 Vw,PX-32000048,CDM,72074,CPT,320,RC,,,outpatient,,,306,214.2,AETNA [1000108],AETNA [100010801],,,76.8,,235.01,68.697,416.02,percent of total billed charges,,,
HC X-Ray Thor-Lumb Sp 2 Vw,PX-32000049,CDM,72080,CPT,320,RC,,,outpatient,,,357,249.9,AETNA [1000108],AETNA [100010801],,,76.8,,274.18,71.24,416.02,percent of total billed charges,,,
HC X-Ray Exam Entire Spi 1 Vw,PX-32000233,CDM,72081,CPT,320,RC,,,outpatient,,,241,168.7,AETNA [1000108],AETNA [100010801],,,76.8,,185.09,54.1045,416.02,percent of total billed charges,,,
HC X-Ray Exam Entire Spi 2/3 Vw,PX-32000234,CDM,72082,CPT,320,RC,,,outpatient,,,385,269.5,AETNA [1000108],AETNA [100010801],,,76.8,,295.68,86.4325,416.02,percent of total billed charges,,,
HC X-Ray Exam Entire Spi 4/5 Vw,PX-32000235,CDM,72083,CPT,320,RC,,,outpatient,,,757,529.9,AETNA [1000108],AETNA [100010801],,,76.8,,581.38,119.991125,581.376,percent of total billed charges,,,
HC X-Ray Exam Entire Spi 6/> Vw,PX-32000236,CDM,72084,CPT,320,RC,,,outpatient,,,757,529.9,AETNA [1000108],AETNA [100010801],,,76.8,,581.38,76.026473,581.376,percent of total billed charges,,,
HC X-Ray Lumbar Spine 2/3 Vw,PX-32000051,CDM,72100,CPT,320,RC,,,outpatient,,,235,164.5,AETNA [1000108],AETNA [100010801],,,76.8,,180.48,52.7575,416.02,percent of total billed charges,,,
HC X-Ray Lumbar Spine 4 Vw,PX-32000052,CDM,72110,CPT,320,RC,,,outpatient,,,323,226.1,AETNA [1000108],AETNA [100010801],,,76.8,,248.06,72.5135,416.02,percent of total billed charges,,,
HC X-Ray Lumbar Spine 6+ Vw,PX-32000053,CDM,72114,CPT,320,RC,,,outpatient,,,602,421.4,AETNA [1000108],AETNA [100010801],,,76.8,,462.34,76.026473,462.336,percent of total billed charges,,,
HC X-Ray Lumbar Spine Flex/Exten,PX-32000232,CDM,72120,CPT,320,RC,,,outpatient,,,411,287.7,AETNA [1000108],AETNA [100010801],,,76.8,,315.65,92.2695,416.02,percent of total billed charges,,,
HC CT Scan-Cervical Spine-W/O Contrast,PX-35000020,CDM,72125,CPT,350,RC,,,outpatient,,,1359,951.3,AETNA [1000108],AETNA [100010801],,,76.8,,1043.71,96.160741,1043.712,percent of total billed charges,,,
HC CT Scan Cerv Spine Contrast,PX-35000021,CDM,72126,CPT,350,RC,,,outpatient,,,1556,1089.2,AETNA [1000108],AETNA [100010801],,,76.8,,1195.01,196.52,1195.008,percent of total billed charges,,,
CT Cervical Spine W/O &W/Contrast Material,PX-35000022,CDM,72127,CPT,350,RC,,,outpatient,,,2239,1567.3,AETNA [1000108],AETNA [100010801],,,76.8,,1719.55,200.53123,1719.552,percent of total billed charges,,,
HC CT Scan-Thoracic Spine-W/O Contrast,PX-35000023,CDM,72128,CPT,350,RC,,,outpatient,,,909,636.3,AETNA [1000108],AETNA [100010801],,,76.8,,698.11,96.160741,698.112,percent of total billed charges,,,
HC CT Scan Dorsal Sp Contrast,PX-35000024,CDM,72129,CPT,350,RC,,,outpatient,,,1037,725.9,AETNA [1000108],AETNA [100010801],,,76.8,,796.42,196.52,796.416,percent of total billed charges,,,
CT Thoracic Spine W/O & W/Contrast Material,PX-35000025,CDM,72130,CPT,350,RC,,,outpatient,,,2219,1553.3,AETNA [1000108],AETNA [100010801],,,76.8,,1704.19,200.53123,1704.192,percent of total billed charges,,,
HC CT Scan-Lumbar Spine-W/O Contrast,PX-35000026,CDM,72131,CPT,350,RC,,,outpatient,,,688,481.6,AETNA [1000108],AETNA [100010801],,,76.8,,528.38,96.160741,575,percent of total billed charges,,,
HC CT Scan Lumbar Sp Contrast,PX-35000027,CDM,72132,CPT,350,RC,,,outpatient,,,1427,998.9,AETNA [1000108],AETNA [100010801],,,76.8,,1095.94,195.73,1095.936,percent of total billed charges,,,
CT Lumbar Spine W/O & W/Contrast Material,PX-35000028,CDM,72133,CPT,350,RC,,,outpatient,,,1377,963.9,AETNA [1000108],AETNA [100010801],,,76.8,,1057.54,200.53123,1057.536,percent of total billed charges,,,
HC MRI- Cerv Spine,PX-61000027,CDM,72141,CPT,610,RC,,,outpatient,,,2115,1480.5,AETNA [1000108],AETNA [100010801],,,76.8,,1624.32,185.92,1624.32,percent of total billed charges,,,
HC MRI- Cerv Spine Contrast,PX-61000028,CDM,72142,CPT,610,RC,,,outpatient,,,3043,2130.1,AETNA [1000108],AETNA [100010801],,,76.8,,2337.02,270.27,2337.024,percent of total billed charges,,,
HC MRI- Dorsal Spine,PX-61000029,CDM,72146,CPT,610,RC,,,outpatient,,,2222,1555.4,AETNA [1000108],AETNA [100010801],,,76.8,,1706.5,185.92,1706.496,percent of total billed charges,,,
HC MRI- Dorsal Spine Contrast,PX-61000030,CDM,72147,CPT,610,RC,,,outpatient,,,2843,1990.1,AETNA [1000108],AETNA [100010801],,,76.8,,2183.42,266.73,2183.424,percent of total billed charges,,,
HC MRI- Lumbar Spine,PX-61000031,CDM,72148,CPT,610,RC,,,outpatient,,,2651,1855.7,AETNA [1000108],AETNA [100010801],,,76.8,,2035.97,185.92,2035.968,percent of total billed charges,,,
HC MRI- Lumbar Spine Contrast,PX-61000032,CDM,72149,CPT,610,RC,,,outpatient,,,2645,1851.5,AETNA [1000108],AETNA [100010801],,,76.8,,2031.36,265.17,2031.36,percent of total billed charges,,,
MRI Spinal Canal Cervical W/O & W/Contr Matrl,PX-61000033,CDM,72156,CPT,610,RC,,,outpatient,,,3124,2186.8,AETNA [1000108],AETNA [100010801],,,76.8,,2399.23,307.53,2399.232,percent of total billed charges,,,
MRI Spinal Canal Thoracic W/O & W/Contr Matrl,PX-61000034,CDM,72157,CPT,610,RC,,,outpatient,,,2833,1983.1,AETNA [1000108],AETNA [100010801],,,76.8,,2175.74,307.93,2175.744,percent of total billed charges,,,
MRI Spinal Canal Lumbar W/O & W/Contr Matrl,PX-61000035,CDM,72158,CPT,610,RC,,,outpatient,,,3181,2226.7,AETNA [1000108],AETNA [100010801],,,76.8,,2443.01,305.58,2443.008,percent of total billed charges,,,
HC X-Ray Pelvis 1/2 Vw,PX-32000054,CDM,72170,CPT,320,RC,,,outpatient,,,287,200.9,AETNA [1000108],AETNA [100010801],,,76.8,,220.42,64.4315,416.02,percent of total billed charges,,,
CT Angiography Pelvis W/Contrast/Noncontrast,PX-35000029,CDM,72191,CPT,350,RC,,,outpatient,,,1269,888.3,AETNA [1000108],AETNA [100010801],,,76.8,,974.59,200.53123,974.592,percent of total billed charges,,,
HC CT Scan-Pelvis-W/O Contrast,PX-35000030,CDM,72192,CPT,350,RC,,,outpatient,,,1368,957.6,AETNA [1000108],AETNA [100010801],,,76.8,,1050.62,96.160741,1050.624,percent of total billed charges,,,
HC CT Scan of Pelvis Contrast,PX-35000031,CDM,72193,CPT,350,RC,,,outpatient,,,1561,1092.7,AETNA [1000108],AETNA [100010801],,,76.8,,1198.85,195.33,1198.848,percent of total billed charges,,,
CT Pelvis W/O & W/Contrast Material,PX-35000032,CDM,72194,CPT,350,RC,,,outpatient,,,1902,1331.4,AETNA [1000108],AETNA [100010801],,,76.8,,1460.74,200.53123,1460.736,percent of total billed charges,,,
HC MRI- Pelvis- W/O Contrast,PX-61000036,CDM,72195,CPT,610,RC,,,outpatient,,,2241,1568.7,AETNA [1000108],AETNA [100010801],,,76.8,,1721.09,237.688956,1721.088,percent of total billed charges,,,
HC MRI- Pelvis W/Contrast,PX-61000037,CDM,72196,CPT,610,RC,,,outpatient,,,2850,1995,AETNA [1000108],AETNA [100010801],,,76.8,,2188.8,372.27,2188.8,percent of total billed charges,,,
MRI Pelvis W/O & W/Contrast Material,PX-61000038,CDM,72197,CPT,610,RC,,,outpatient,,,2753,1927.1,AETNA [1000108],AETNA [100010801],,,76.8,,2114.3,399.547552,2114.304,percent of total billed charges,,,
HC MR Angio Pelvis(Mra) W/Contrast,PX-61000039,CDM,72198,CPT,610,RC,,,outpatient,,,2908,2035.6,AETNA [1000108],AETNA [100010801],,,76.8,,2233.34,399.86,2233.344,percent of total billed charges,,,
HC MR Angio Pelvis(Mra) Without Contrast,PX-61000073,CDM,72198,CPT,610,RC,,,outpatient,,,2710,1897,AETNA [1000108],AETNA [100010801],,,76.8,,2081.28,399.86,2233.344,percent of total billed charges,,,
HC MR Angio Pelvis(Mra) W/Without Contrast,PX-61000074,CDM,72198,CPT,610,RC,,,outpatient,,,1826,1278.2,AETNA [1000108],AETNA [100010801],,,76.8,,1402.37,399.86,2233.344,percent of total billed charges,,,
HC X-Ray Sacroiliac Jts 3+ Vw,PX-32000056,CDM,72202,CPT,320,RC,,,outpatient,,,443,310.1,AETNA [1000108],AETNA [100010801],,,76.8,,340.22,76.026473,416.02,percent of total billed charges,,,
HC X-Ray Sacrum/Coccyx 2+ Vw,PX-32000057,CDM,72220,CPT,320,RC,,,outpatient,,,336,235.2,AETNA [1000108],AETNA [100010801],,,76.8,,258.05,71.24,416.02,percent of total billed charges,,,
HC Myelography Cerv Spine,PX-32000058,CDM,72240,CPT,320,RC,,,outpatient,,,1478,1034.6,AETNA [1000108],AETNA [100010801],,,76.8,,1135.1,331.811,2051.3855,percent of total billed charges,,,
HC Myelography Thorax Spine,PX-32000059,CDM,72255,CPT,320,RC,,,outpatient,,,1823,1276.1,AETNA [1000108],AETNA [100010801],,,76.8,,1400.06,399.86,2051.3855,percent of total billed charges,,,
HC Myelography Lumbar Spine,PX-32000060,CDM,72265,CPT,320,RC,,,outpatient,,,1760,1232,AETNA [1000108],AETNA [100010801],,,76.8,,1351.68,395.12,2051.3855,percent of total billed charges,,,
HC Myelography of Entire Spine,PX-32000061,CDM,72270,CPT,320,RC,,,outpatient,,,1823,1276.1,AETNA [1000108],AETNA [100010801],,,76.8,,1400.06,399.86,2051.3855,percent of total billed charges,,,
HC X-Ray-C/T-Disk-Superv/Interpret,PX-32000062,CDM,72285,CPT,320,RC,,,outpatient,,,4306,3014.2,AETNA [1000108],AETNA [100010801],,,76.8,,3307.01,399.86,4977.9345,percent of total billed charges,,,
HC Discography Lumbar Spine,PX-32000064,CDM,72295,CPT,320,RC,,,outpatient,,,4306,3014.2,AETNA [1000108],AETNA [100010801],,,76.8,,3307.01,399.86,4977.9345,percent of total billed charges,,,
HC X-Ray Clavicle,PX-32000065,CDM,73000,CPT,320,RC,,,outpatient,,,170,119,AETNA [1000108],AETNA [100010801],,,76.8,,130.56,38.165,416.02,percent of total billed charges,,,
HC X-Ray Scapula,PX-32000066,CDM,73010,CPT,320,RC,,,outpatient,,,306,214.2,AETNA [1000108],AETNA [100010801],,,76.8,,235.01,68.697,416.02,percent of total billed charges,,,
HC X-Ray Shoulder 1 Vw,PX-32000067,CDM,73020,CPT,320,RC,,,outpatient,,,256,179.2,AETNA [1000108],AETNA [100010801],,,76.8,,196.61,57.472,416.02,percent of total billed charges,,,
HC X-Ray Shoulder 2+ Vw,PX-32000068,CDM,73030,CPT,320,RC,,,outpatient,,,139,97.3,AETNA [1000108],AETNA [100010801],,,76.8,,106.75,31.2055,416.02,percent of total billed charges,,,
HC Arthrogram of Shoulder,PX-32000069,CDM,73040,CPT,320,RC,,,outpatient,,,1690,1183,AETNA [1000108],AETNA [100010801],,,76.8,,1297.92,379.405,1297.92,percent of total billed charges,,,
HC X-Ray Ac Jts,PX-32000070,CDM,73050,CPT,320,RC,,,outpatient,,,323,226.1,AETNA [1000108],AETNA [100010801],,,76.8,,248.06,71.24,416.02,percent of total billed charges,,,
HC X-Ray Humerus,PX-32000071,CDM,73060,CPT,320,RC,,,outpatient,,,178,124.6,AETNA [1000108],AETNA [100010801],,,76.8,,136.7,39.961,416.02,percent of total billed charges,,,
HC X-Ray Elbow 2 Vw,PX-32000072,CDM,73070,CPT,320,RC,,,outpatient,,,171,119.7,AETNA [1000108],AETNA [100010801],,,76.8,,131.33,38.3895,416.02,percent of total billed charges,,,
HC X-Ray Elbow 3+ Vw,PX-32000073,CDM,73080,CPT,320,RC,,,outpatient,,,129,90.3,AETNA [1000108],AETNA [100010801],,,76.8,,99.07,28.9605,416.02,percent of total billed charges,,,
HC Arthrogram of Elbow,PX-32000074,CDM,73085,CPT,320,RC,,,outpatient,,,1331,931.7,AETNA [1000108],AETNA [100010801],,,76.8,,1022.21,298.8095,1022.208,percent of total billed charges,,,
HC X-Ray Forearm 2 Vw,PX-32000075,CDM,73090,CPT,320,RC,,,outpatient,,,225,157.5,AETNA [1000108],AETNA [100010801],,,76.8,,172.8,50.5125,416.02,percent of total billed charges,,,
HC X-Ray Arm- Infant,PX-32000076,CDM,73092,CPT,320,RC,,,outpatient,,,368,257.6,AETNA [1000108],AETNA [100010801],,,76.8,,282.62,76.026473,416.02,percent of total billed charges,,,
HC X-Ray Wrist 2 Vw,PX-32000077,CDM,73100,CPT,320,RC,,,outpatient,,,190,133,AETNA [1000108],AETNA [100010801],,,76.8,,145.92,42.655,416.02,percent of total billed charges,,,
HC X-Ray Wrist 3+ Vw,PX-32000078,CDM,73110,CPT,320,RC,,,outpatient,,,241,168.7,AETNA [1000108],AETNA [100010801],,,76.8,,185.09,54.1045,416.02,percent of total billed charges,,,
HC Arthrogram of Wrist,PX-32000079,CDM,73115,CPT,320,RC,,,outpatient,,,1722,1205.4,AETNA [1000108],AETNA [100010801],,,76.8,,1322.5,237.819698,1322.496,percent of total billed charges,,,
HC X-Ray Hand 2 Vw,PX-32000080,CDM,73120,CPT,320,RC,,,outpatient,,,306,214.2,AETNA [1000108],AETNA [100010801],,,76.8,,235.01,68.697,416.02,percent of total billed charges,,,
HC X-Ray Hand 3+ Vw,PX-32000081,CDM,73130,CPT,320,RC,,,outpatient,,,236,165.2,AETNA [1000108],AETNA [100010801],,,76.8,,181.25,52.982,416.02,percent of total billed charges,,,
HC X-Ray Exam of Finger(S),PX-32000082,CDM,73140,CPT,320,RC,,,outpatient,,,129,90.3,AETNA [1000108],AETNA [100010801],,,76.8,,99.07,28.9605,416.02,percent of total billed charges,,,
HC CT Scan-Upper Extremity-W/O Contrast,PX-35000034,CDM,73200,CPT,350,RC,,,outpatient,,,959,671.3,AETNA [1000108],AETNA [100010801],,,76.8,,736.51,96.160741,736.512,percent of total billed charges,,,
HC CT Scan of Arm Contrast,PX-35000035,CDM,73201,CPT,350,RC,,,outpatient,,,1388,971.6,AETNA [1000108],AETNA [100010801],,,76.8,,1065.98,193.37,1065.984,percent of total billed charges,,,
CT Upper Extremity W/O & W/Contrast Material,PX-35000036,CDM,73202,CPT,350,RC,,,outpatient,,,1961,1372.7,AETNA [1000108],AETNA [100010801],,,76.8,,1506.05,200.53123,1506.048,percent of total billed charges,,,
CT Angiography Upper Extremity,PX-35000037,CDM,73206,CPT,350,RC,,,outpatient,,,1345,941.5,AETNA [1000108],AETNA [100010801],,,76.8,,1032.96,200.53123,1032.96,percent of total billed charges,,,
HC MRI- Upper Extremity W/O Contrast,PX-61000040,CDM,73218,CPT,610,RC,,,outpatient,,,2888,2021.6,AETNA [1000108],AETNA [100010801],,,76.8,,2217.98,237.688956,2217.984,percent of total billed charges,,,
HC MRI- Upper Extremity W/Contrast,PX-61000041,CDM,73219,CPT,610,RC,,,outpatient,,,2936,2055.2,AETNA [1000108],AETNA [100010801],,,76.8,,2254.85,371.09,2254.848,percent of total billed charges,,,
HC MRI Ext Upp No Jnt W-W/O,PX-61000042,CDM,73220,CPT,610,RC,,,outpatient,,,3144,2200.8,AETNA [1000108],AETNA [100010801],,,76.8,,2414.59,399.547552,2414.592,percent of total billed charges,,,
MRI Any Jt Upper Extremity W/O Contrast Matrl,PX-61000043,CDM,73221,CPT,610,RC,,,outpatient,,,3039,2127.3,AETNA [1000108],AETNA [100010801],,,76.8,,2333.95,204.76,2333.952,percent of total billed charges,,,
HC MRI- Joint Upper Extrem W/Contrast,PX-61000044,CDM,73222,CPT,610,RC,,,outpatient,,,3144,2200.8,AETNA [1000108],AETNA [100010801],,,76.8,,2414.59,340.49,2414.592,percent of total billed charges,,,
MRI Any Jt Upper Extremity W/O & W/Contr Matrl,PX-61000045,CDM,73223,CPT,610,RC,,,outpatient,,,3060,2142,AETNA [1000108],AETNA [100010801],,,76.8,,2350.08,399.547552,2350.08,percent of total billed charges,,,
HC X-Ray Exam Hip Uni 1 View,PX-32000237,CDM,73501,CPT,320,RC,,,outpatient,,,222,155.4,AETNA [1000108],AETNA [100010801],,,76.8,,170.5,49.839,416.02,percent of total billed charges,,,
HC X-Ray Exam Hip Uni 2-3 Views,PX-32000238,CDM,73502,CPT,320,RC,,,outpatient,,,222,155.4,AETNA [1000108],AETNA [100010801],,,76.8,,170.5,49.839,416.02,percent of total billed charges,,,
HC X-Ray Exam Hip Uni 4/> Views,PX-32000239,CDM,73503,CPT,320,RC,,,outpatient,,,385,269.5,AETNA [1000108],AETNA [100010801],,,76.8,,295.68,86.4325,416.02,percent of total billed charges,,,
HC X-Ray Exam Hips Bi 2 Views,PX-32000240,CDM,73521,CPT,320,RC,,,outpatient,,,385,269.5,AETNA [1000108],AETNA [100010801],,,76.8,,295.68,86.4325,416.02,percent of total billed charges,,,
HC X-Ray Exam Hips Bi 5/> Views,PX-32000242,CDM,73523,CPT,320,RC,,,outpatient,,,757,529.9,AETNA [1000108],AETNA [100010801],,,76.8,,581.38,76.026473,581.376,percent of total billed charges,,,
HC Arthrogram of Hip,PX-32000086,CDM,73525,CPT,320,RC,,,outpatient,,,1616,1131.2,AETNA [1000108],AETNA [100010801],,,76.8,,1241.09,237.819698,1241.088,percent of total billed charges,,,
HC X-Ray Exam of Femur 1,PX-32000243,CDM,73551,CPT,320,RC,,,outpatient,,,213,149.1,AETNA [1000108],AETNA [100010801],,,76.8,,163.58,47.8185,416.02,percent of total billed charges,,,
HC X-Ray Exam of Femur 2/>,PX-32000244,CDM,73552,CPT,320,RC,,,outpatient,,,241,168.7,AETNA [1000108],AETNA [100010801],,,76.8,,185.09,54.1045,416.02,percent of total billed charges,,,
HC X-Ray Knee 1 or 2 View,PX-32000090,CDM,73560,CPT,320,RC,,,outpatient,,,213,149.1,AETNA [1000108],AETNA [100010801],,,76.8,,163.58,47.8185,416.02,percent of total billed charges,,,
HC X-Ray Knee 3 View,PX-32000091,CDM,73562,CPT,320,RC,,,outpatient,,,232,162.4,AETNA [1000108],AETNA [100010801],,,76.8,,178.18,52.084,416.02,percent of total billed charges,,,
HC X-Ray Knee 4+ View,PX-32000092,CDM,73564,CPT,320,RC,,,outpatient,,,260,182,AETNA [1000108],AETNA [100010801],,,76.8,,199.68,58.37,416.02,percent of total billed charges,,,
HC X-Ray Knee Bilat Standing,PX-32000093,CDM,73565,CPT,320,RC,,,outpatient,,,394,275.8,AETNA [1000108],AETNA [100010801],,,76.8,,302.59,71.24,416.02,percent of total billed charges,,,
HC Arthrogram of Knee Joint,PX-32000094,CDM,73580,CPT,320,RC,,,outpatient,,,1704,1192.8,AETNA [1000108],AETNA [100010801],,,76.8,,1308.67,382.548,1308.672,percent of total billed charges,,,
HC X-Ray Tib + Fib- 2vw,PX-32000095,CDM,73590,CPT,320,RC,,,outpatient,,,199,139.3,AETNA [1000108],AETNA [100010801],,,76.8,,152.83,44.6755,416.02,percent of total billed charges,,,
HC X-Ray Leg- Infant,PX-32000096,CDM,73592,CPT,320,RC,,,outpatient,,,231,161.7,AETNA [1000108],AETNA [100010801],,,76.8,,177.41,51.8595,416.02,percent of total billed charges,,,
HC X-Ray Ankle 2 Vw,PX-32000097,CDM,73600,CPT,320,RC,,,outpatient,,,137,95.9,AETNA [1000108],AETNA [100010801],,,76.8,,105.22,30.7565,416.02,percent of total billed charges,,,
HC X-Ray Ankle 3+ Vw,PX-32000098,CDM,73610,CPT,320,RC,,,outpatient,,,130,91,AETNA [1000108],AETNA [100010801],,,76.8,,99.84,29.185,416.02,percent of total billed charges,,,
HC Arthrogram of Ankle,PX-32000099,CDM,73615,CPT,320,RC,,,outpatient,,,1221,854.7,AETNA [1000108],AETNA [100010801],,,76.8,,937.73,237.819698,1020.2995,percent of total billed charges,,,
HC X-Ray Foot 2 Vw,PX-32000100,CDM,73620,CPT,320,RC,,,outpatient,,,158,110.6,AETNA [1000108],AETNA [100010801],,,76.8,,121.34,35.471,416.02,percent of total billed charges,,,
HC X-Ray Foot 3+ Vw,PX-32000101,CDM,73630,CPT,320,RC,,,outpatient,,,164,114.8,AETNA [1000108],AETNA [100010801],,,76.8,,125.95,36.818,416.02,percent of total billed charges,,,
HC X-Ray Heel,PX-32000102,CDM,73650,CPT,320,RC,,,outpatient,,,234,163.8,AETNA [1000108],AETNA [100010801],,,76.8,,179.71,52.533,416.02,percent of total billed charges,,,
HC X-Ray Toe(S),PX-32000103,CDM,73660,CPT,320,RC,,,outpatient,,,192,134.4,AETNA [1000108],AETNA [100010801],,,76.8,,147.46,43.104,416.02,percent of total billed charges,,,
HC CT Scan-Lower Extremity-W/O Contrast,PX-35000038,CDM,73700,CPT,350,RC,,,outpatient,,,968,677.6,AETNA [1000108],AETNA [100010801],,,76.8,,743.42,96.160741,743.424,percent of total billed charges,,,
HC CT Scan of Leg Contrast,PX-35000039,CDM,73701,CPT,350,RC,,,outpatient,,,987,690.9,AETNA [1000108],AETNA [100010801],,,76.8,,758.02,196.51,758.016,percent of total billed charges,,,
CT Lower Extremity W/O & W/Contrast Matrl,PX-35000040,CDM,73702,CPT,350,RC,,,outpatient,,,1903,1332.1,AETNA [1000108],AETNA [100010801],,,76.8,,1461.5,200.53123,1461.504,percent of total billed charges,,,
CT Angiography Lower Extremity,PX-35000041,CDM,73706,CPT,350,RC,,,outpatient,,,1176,823.2,AETNA [1000108],AETNA [100010801],,,76.8,,903.17,200.53123,903.168,percent of total billed charges,,,
HC MRI- Lower Extrem,PX-61000046,CDM,73718,CPT,610,RC,,,outpatient,,,2836,1985.2,AETNA [1000108],AETNA [100010801],,,76.8,,2178.05,237.688956,2178.048,percent of total billed charges,,,
HC MRI- Lower Extrem W/Contrast,PX-61000047,CDM,73719,CPT,610,RC,,,outpatient,,,2396,1677.2,AETNA [1000108],AETNA [100010801],,,76.8,,1840.13,372.66,1840.128,percent of total billed charges,,,
HC MRI- Lower Extr- W/O Contrast F/U by Contrast,PX-61000048,CDM,73720,CPT,610,RC,,,outpatient,,,3060,2142,AETNA [1000108],AETNA [100010801],,,76.8,,2350.08,399.547552,2350.08,percent of total billed charges,,,
HC MRI Lower Extrem Jt- W/O Contrast,PX-61000049,CDM,73721,CPT,610,RC,,,outpatient,,,3008,2105.6,AETNA [1000108],AETNA [100010801],,,76.8,,2310.14,205.15,2310.144,percent of total billed charges,,,
HC MRI- Joint of Leg W/Contrast,PX-61000050,CDM,73722,CPT,610,RC,,,outpatient,,,3018,2112.6,AETNA [1000108],AETNA [100010801],,,76.8,,2317.82,345.98,2317.824,percent of total billed charges,,,
MRI Any Jt Lower Extrem W/O & W/Contrast Matrl,PX-61000051,CDM,73723,CPT,610,RC,,,outpatient,,,3098,2168.6,AETNA [1000108],AETNA [100010801],,,76.8,,2379.26,399.547552,2379.264,percent of total billed charges,,,
HC MR Angio Lower Extrem (Mra) W/Contrast,PX-61000052,CDM,73725,CPT,610,RC,,,outpatient,,,2710,1897,AETNA [1000108],AETNA [100010801],,,76.8,,2081.28,399.86,2290.176,percent of total billed charges,,,
HC MR Angio Lower Extrem (Mra) Without Contrast,PX-61000075,CDM,73725,CPT,610,RC,,,outpatient,,,2710,1897,AETNA [1000108],AETNA [100010801],,,76.8,,2081.28,399.86,2290.176,percent of total billed charges,,,
HC MR Angio Lower Extrem (Mra) W/Without Contrast,PX-61000076,CDM,73725,CPT,610,RC,,,outpatient,,,2982,2087.4,AETNA [1000108],AETNA [100010801],,,76.8,,2290.18,399.86,2290.176,percent of total billed charges,,,
HC X-Ray Exam Abdomen 1 View,PX-32000249,CDM,74018,CPT,320,RC,,,outpatient,,,232,162.4,AETNA [1000108],AETNA [100010801],,,76.8,,178.18,52.084,416.02,percent of total billed charges,,,
HC X-Ray Exam Abdomen 2 Views,PX-32000250,CDM,74019,CPT,320,RC,,,outpatient,,,443,310.1,AETNA [1000108],AETNA [100010801],,,76.8,,340.22,76.026473,416.02,percent of total billed charges,,,
HC X-Ray Exam Abdomen 3+ Views,PX-32000251,CDM,74021,CPT,320,RC,,,outpatient,,,410,287,AETNA [1000108],AETNA [100010801],,,76.8,,314.88,92.045,416.02,percent of total billed charges,,,
HC CT Scan-Abdomen-W/O Contrast,PX-35000042,CDM,74150,CPT,350,RC,,,outpatient,,,1449,1014.3,AETNA [1000108],AETNA [100010801],,,76.8,,1112.83,96.160741,1112.832,percent of total billed charges,,,
HC CT Scan of Abdomen Contrast,PX-35000043,CDM,74160,CPT,350,RC,,,outpatient,,,1586,1110.2,AETNA [1000108],AETNA [100010801],,,76.8,,1218.05,194.55,1218.048,percent of total billed charges,,,
CT Abdomen W/O & W/Contrast Material,PX-35000044,CDM,74170,CPT,350,RC,,,outpatient,,,2058,1440.6,AETNA [1000108],AETNA [100010801],,,76.8,,1580.54,200.53123,1580.544,percent of total billed charges,,,
HC CT Angio Abd&Plvis Cntrst Mtrl W/WO Cntrst Imges,PX-35000045,CDM,74174,CPT,350,RC,,,outpatient,,,2581,1806.7,AETNA [1000108],AETNA [100010801],,,76.8,,1982.21,329.339098,1982.208,percent of total billed charges,,,
CT Angiography Abdomen W/Contrast/Noncontrast,PX-35000046,CDM,74175,CPT,350,RC,,,outpatient,,,1355,948.5,AETNA [1000108],AETNA [100010801],,,76.8,,1040.64,200.53123,1040.64,percent of total billed charges,,,
HC CT Scan-Abdoment and Pelvis-W/O Contrast,PX-35000047,CDM,74176,CPT,350,RC,,,outpatient,,,1368,957.6,AETNA [1000108],AETNA [100010801],,,76.8,,1050.62,142.38,1050.624,percent of total billed charges,,,
HC CT Scan-Abdoment and Pelvis-W Contrast,PX-35000048,CDM,74177,CPT,350,RC,,,outpatient,,,1971,1379.7,AETNA [1000108],AETNA [100010801],,,76.8,,1513.73,204.61123,1513.728,percent of total billed charges,,,
CT Abdomen & Pelvis W/O Contrst 1/> Body Re,PX-35000049,CDM,74178,CPT,350,RC,,,outpatient,,,2122,1485.4,AETNA [1000108],AETNA [100010801],,,76.8,,1629.7,204.61123,1629.696,percent of total billed charges,,,
HC MRI- Abdomen (MRI),PX-61000053,CDM,74181,CPT,610,RC,,,outpatient,,,2357,1649.9,AETNA [1000108],AETNA [100010801],,,76.8,,1810.18,237.688956,1810.176,percent of total billed charges,,,
HC MRI- Abdomen W/Contrast,PX-61000054,CDM,74182,CPT,610,RC,,,outpatient,,,5081,3556.7,AETNA [1000108],AETNA [100010801],,,76.8,,3902.21,399.547552,3902.208,percent of total billed charges,,,
MRI Abdomen W/O & W/Contrast Material,PX-61000055,CDM,74183,CPT,610,RC,,,outpatient,,,2698,1888.6,AETNA [1000108],AETNA [100010801],,,76.8,,2072.06,399.547552,2072.064,percent of total billed charges,,,
HC MR Angio Abdomen (Mra) W/Contrast,PX-61000056,CDM,74185,CPT,610,RC,,,outpatient,,,2446,1712.2,AETNA [1000108],AETNA [100010801],,,76.8,,1878.53,301.425681,1878.528,percent of total billed charges,,,
HC MR Angio Abdomen (Mra) Without Contrast,PX-61000077,CDM,74185,CPT,610,RC,,,outpatient,,,2446,1712.2,AETNA [1000108],AETNA [100010801],,,76.8,,1878.53,301.425681,1878.528,percent of total billed charges,,,
HC MR Angio Abdomen (Mra) W/Without Contrast,PX-61000078,CDM,74185,CPT,610,RC,,,outpatient,,,2446,1712.2,AETNA [1000108],AETNA [100010801],,,76.8,,1878.53,301.425681,1878.528,percent of total billed charges,,,
HC Esophagram,PX-32000107,CDM,74220,CPT,320,RC,,,outpatient,,,981,686.7,AETNA [1000108],AETNA [100010801],,,76.8,,753.41,76.026473,753.408,percent of total billed charges,,,
HC Swallowing Fcn-W/Cine &/or Video,PX-32000108,CDM,74230,CPT,320,RC,,,outpatient,,,874,611.8,AETNA [1000108],AETNA [100010801],,,76.8,,671.23,128.66,671.232,percent of total billed charges,,,
HC Remove Esophagus Obstruction,PX-32000109,CDM,74235,CPT,320,RC,,,outpatient,,,1157,809.9,AETNA [1000108],AETNA [100010801],,,76.8,,888.58,259.7465,888.576,percent of total billed charges,,,
HC Xray Upper GI Tract,PX-32000110,CDM,74240,CPT,320,RC,,,outpatient,,,916,641.2,AETNA [1000108],AETNA [100010801],,,76.8,,703.49,200.53123,703.488,percent of total billed charges,,,
HC Xray Upper GI Air Contrast,PX-32000113,CDM,74246,CPT,320,RC,,,outpatient,,,865,605.5,AETNA [1000108],AETNA [100010801],,,76.8,,664.32,194.1925,664.32,percent of total billed charges,,,
HC X-Ray-Small Bowel-W/Mult Serial Films,PX-32000116,CDM,74250,CPT,320,RC,,,outpatient,,,2949,2064.3,AETNA [1000108],AETNA [100010801],,,76.8,,2264.83,128.66,2264.832,percent of total billed charges,,,
HC X-Ray Small Bowel Enteroclysis,PX-32000117,CDM,74251,CPT,320,RC,,,outpatient,,,1182,827.4,AETNA [1000108],AETNA [100010801],,,76.8,,907.78,183.14,907.776,percent of total billed charges,,,
HC X-Ray Colon Contrast,PX-32000118,CDM,74270,CPT,320,RC,,,outpatient,,,1071,749.7,AETNA [1000108],AETNA [100010801],,,76.8,,822.53,200.53123,822.528,percent of total billed charges,,,
HC X-Ray Colon Air Contrast,PX-32000119,CDM,74280,CPT,320,RC,,,outpatient,,,1758,1230.6,AETNA [1000108],AETNA [100010801],,,76.8,,1350.14,200.53123,1350.144,percent of total billed charges,,,
HC X-Ray Oper Cholangiogram,PX-32000123,CDM,74300,CPT,320,RC,,,outpatient,,,1336,935.2,AETNA [1000108],AETNA [100010801],,,76.8,,1026.05,145.12362,1026.048,percent of total billed charges,,,
HC X-Ray Oper Cholangio Addnl Set,PX-32000124,CDM,74301,CPT,320,RC,,,outpatient,,,289,202.3,AETNA [1000108],AETNA [100010801],,,76.8,,221.95,64.8805,416.02,percent of total billed charges,,,
HC X-Ray Bile/Pancreas Endoscopy,PX-32000129,CDM,74330,CPT,320,RC,,,outpatient,,,1038,726.6,AETNA [1000108],AETNA [100010801],,,76.8,,797.18,145.12362,797.184,percent of total billed charges,,,
HC X-Ray Introductn GI Tube,PX-32000130,CDM,74340,CPT,320,RC,,,outpatient,,,872,610.4,AETNA [1000108],AETNA [100010801],,,76.8,,669.7,195.08,669.696,percent of total billed charges,,,
HC X-Ray Guide Enteroclysis Tube,PX-32000131,CDM,74355,CPT,320,RC,,,outpatient,,,2913,2039.1,AETNA [1000108],AETNA [100010801],,,76.8,,2237.18,260.23,2237.184,percent of total billed charges,,,
HC X-Ray Guide- GI Dilation,PX-32000132,CDM,74360,CPT,320,RC,,,outpatient,,,631,441.7,AETNA [1000108],AETNA [100010801],,,76.8,,484.61,141.6595,484.608,percent of total billed charges,,,
HC Percut Transhepat Dilat-Bile Duct Strict,PX-32000133,CDM,74363,CPT,320,RC,,,outpatient,,,2462,1723.4,AETNA [1000108],AETNA [100010801],,,76.8,,1890.82,399.86,1890.816,percent of total billed charges,,,
HC X-Ray IV Pyelogram (Ivp),PX-32000134,CDM,74400,CPT,320,RC,,,outpatient,,,599,419.3,AETNA [1000108],AETNA [100010801],,,76.8,,460.03,134.4755,499.422,percent of total billed charges,,,
HC X-Ray IV Pyelogram+Tomography,PX-32000136,CDM,74415,CPT,320,RC,,,outpatient,,,2078,1454.6,AETNA [1000108],AETNA [100010801],,,76.8,,1595.9,200.53123,1595.904,percent of total billed charges,,,
HC X-Ray Retrograde Pyelogram,PX-32000137,CDM,74420,CPT,320,RC,,,outpatient,,,1189,832.3,AETNA [1000108],AETNA [100010801],,,76.8,,913.15,237.819698,1020.2995,percent of total billed charges,,,
HC Antegrade Urography Radiological Supvj & Interpj,PX-32000138,CDM,74425,CPT,320,RC,,,outpatient,,,2829,1980.3,AETNA [1000108],AETNA [100010801],,,76.8,,2172.67,399.86,2172.672,percent of total billed charges,,,
HC X-Ray Cystogram- Min 3 View,PX-32000139,CDM,74430,CPT,320,RC,,,outpatient,,,1189,832.3,AETNA [1000108],AETNA [100010801],,,76.8,,913.15,237.819698,1020.2995,percent of total billed charges,,,
HC X-Ray Urethrocystogram,PX-32000140,CDM,74450,CPT,320,RC,,,outpatient,,,762,533.4,AETNA [1000108],AETNA [100010801],,,76.8,,585.22,171.069,646.6965,percent of total billed charges,,,
HC X-Ray Urethrocystogram+Voiding,PX-32000141,CDM,74455,CPT,320,RC,,,outpatient,,,762,533.4,AETNA [1000108],AETNA [100010801],,,76.8,,585.22,171.069,646.6965,percent of total billed charges,,,
HC X-Ray Renal Cyst Xlumbar+Contrst,PX-32000142,CDM,74470,CPT,320,RC,,,outpatient,,,542,379.4,AETNA [1000108],AETNA [100010801],,,76.8,,416.26,121.679,1393.3385,percent of total billed charges,,,
HC X-Ray Guide- Gu Dilation,PX-32000145,CDM,74485,CPT,320,RC,,,outpatient,,,3417,2391.9,AETNA [1000108],AETNA [100010801],,,76.8,,2624.26,399.86,5136.771,percent of total billed charges,,,
HC X-Ray Hysterosalpingogram,PX-32000146,CDM,74740,CPT,320,RC,,,outpatient,,,1695,1186.5,AETNA [1000108],AETNA [100010801],,,76.8,,1301.76,237.819698,1301.76,percent of total billed charges,,,
HC X-Ray Xcerv Cath Fallopian Tube,PX-32000147,CDM,74742,CPT,320,RC,,,outpatient,,,1270,889,AETNA [1000108],AETNA [100010801],,,76.8,,975.36,285.115,975.36,percent of total billed charges,,,
HC Cardiac MRI Morphology & Function W/O Contrast,PX-61000057,CDM,75557,CPT,610,RC,,,outpatient,,,2222,1555.4,AETNA [1000108],AETNA [100010801],,,76.8,,1706.5,88.902,1706.496,percent of total billed charges,,,
HC PR Cardiac MRI Morphology & Function W/O Contrast,PX-97200020,CDM,75557,CPT,972,RC,,,outpatient,,,396,277.2,AETNA [1000108],AETNA [100010801],,,76.8,,304.13,88.902,1706.496,percent of total billed charges,,,
HC Cardiac MRI W/W/O Contrast & Further Seq,PX-61000059,CDM,75561,CPT,610,RC,,,outpatient,,,2644,1850.8,AETNA [1000108],AETNA [100010801],,,76.8,,2030.59,102.5965,2030.592,percent of total billed charges,,,
HC PR Cardiac MRI W/W/O Contrast & Further Seq,PX-97200021,CDM,75561,CPT,972,RC,,,outpatient,,,457,319.9,AETNA [1000108],AETNA [100010801],,,76.8,,350.98,102.5965,2030.592,percent of total billed charges,,,
HC Cardiac MRI for Velocity Flow Mapping,PX-61000061,CDM,75565,CPT,610,RC,,,outpatient,,,222,155.4,AETNA [1000108],AETNA [100010801],,,76.8,,170.5,9.2045,836,percent of total billed charges,,,
HC PR Cardiac MRI for Velocity Flow Mapping,PX-97200022,CDM,75565,CPT,972,RC,,,outpatient,,,41,28.7,AETNA [1000108],AETNA [100010801],,,76.8,,31.49,9.2045,836,percent of total billed charges,,,
HC CT Heart W/O Contrast Quant Eval Coronary Calcium,PX-35000052,CDM,75571,CPT,350,RC,,,outpatient,,,264,184.8,AETNA [1000108],AETNA [100010801],,,76.8,,202.75,19.0825,575,percent of total billed charges,,,
HC PR CT Heart W/O Contrast Quant Eval Coronary Calcium,PX-97200023,CDM,75571,CPT,972,RC,,,outpatient,,,85,59.5,AETNA [1000108],AETNA [100010801],,,76.8,,65.28,19.0825,575,percent of total billed charges,,,
HC CT Heart Contrast Eval Cardiac Struct/Morph,PX-35000053,CDM,75572,CPT,350,RC,,,outpatient,,,872,610.4,AETNA [1000108],AETNA [100010801],,,76.8,,669.7,58.819,669.696,percent of total billed charges,,,
HC PR CT Heart Contrast Eval Cardiac Struct/Morph,PX-97200024,CDM,75572,CPT,972,RC,,,outpatient,,,262,183.4,AETNA [1000108],AETNA [100010801],,,76.8,,201.22,58.819,669.696,percent of total billed charges,,,
HC CT Heart Contrast Eval Cardiac Struct/Morph- Congen Heart Disease,PX-35000054,CDM,75573,CPT,350,RC,,,outpatient,,,1016,711.2,AETNA [1000108],AETNA [100010801],,,76.8,,780.29,58.819,780.288,percent of total billed charges,,,
HC PR CT Heart Contrast Eval Cardiac Struct/Morph- Congen Heart Disease,PX-97200025,CDM,75573,CPT,972,RC,,,outpatient,,,262,183.4,AETNA [1000108],AETNA [100010801],,,76.8,,201.22,58.819,780.288,percent of total billed charges,,,
HC CT Angio Hrt Cornry Art/Bypass Grfts Contrst 3d Post,PX-35000055,CDM,75574,CPT,350,RC,,,outpatient,,,1073,751.1,AETNA [1000108],AETNA [100010801],,,76.8,,824.06,57.921,824.064,percent of total billed charges,,,
HC PR CT Angio Hrt Cornry Art/Bypass Grfts Contrst 3d Post,PX-97200026,CDM,75574,CPT,972,RC,,,outpatient,,,258,180.6,AETNA [1000108],AETNA [100010801],,,76.8,,198.14,57.921,824.064,percent of total billed charges,,,
HC N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp,PX-48000097,CDM,75580,CPT,480,RC,,,outpatient,,,2856,1999.2,AETNA [1000108],AETNA [100010801],,,76.8,,2193.41,399.86,2536.61118,percent of total billed charges,,,
HC Angio Aortogram Thoracic,PX-32000148,CDM,75600,CPT,320,RC,,,outpatient,,,3155,2208.5,AETNA [1000108],AETNA [100010801],,,76.8,,2423.04,399.86,8249.769,percent of total billed charges,,,
HC Angio Aortogram Thor Serial,PX-32000149,CDM,75605,CPT,320,RC,,,outpatient,,,12541,8778.7,AETNA [1000108],AETNA [100010801],,,76.8,,9631.49,399.86,14233.715,percent of total billed charges,,,
HC Angio Aortogram Abd Serial,PX-32000150,CDM,75625,CPT,320,RC,,,outpatient,,,5654,3957.8,AETNA [1000108],AETNA [100010801],,,76.8,,4342.27,399.86,8249.769,percent of total billed charges,,,
HC Angio Aortobifemoral W Cath,PX-32000151,CDM,75630,CPT,320,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,8249.769,percent of total billed charges,,,
Cta Abdl Aorta&Bi Iliofem W/Contrast&Postp,PX-35000056,CDM,75635,CPT,350,RC,,,outpatient,,,1721,1204.7,AETNA [1000108],AETNA [100010801],,,76.8,,1321.73,200.53123,1321.728,percent of total billed charges,,,
HC Angio Spinal Selectv,PX-32000153,CDM,75705,CPT,320,RC,,,outpatient,,,11403,7982.1,AETNA [1000108],AETNA [100010801],,,76.8,,8757.5,399.86,14233.715,percent of total billed charges,,,
HC Angio Extremity Unilat,PX-32000154,CDM,75710,CPT,320,RC,,,outpatient,,,6489,4542.3,AETNA [1000108],AETNA [100010801],,,76.8,,4983.55,399.86,8249.769,percent of total billed charges,,,
HC Angio Extermity Bilat,PX-32000155,CDM,75716,CPT,320,RC,,,outpatient,,,7162,5013.4,AETNA [1000108],AETNA [100010801],,,76.8,,5500.42,399.86,8249.769,percent of total billed charges,,,
HC Angio Visceral Selectv/Subselec,PX-32000156,CDM,75726,CPT,320,RC,,,outpatient,,,9831,6881.7,AETNA [1000108],AETNA [100010801],,,76.8,,7550.21,399.86,14233.715,percent of total billed charges,,,
HC Angio Adrenal Unilat Select,PX-32000157,CDM,75731,CPT,320,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,8249.769,percent of total billed charges,,,
HC Angio Adrenal Bilat Select,PX-32000158,CDM,75733,CPT,320,RC,,,outpatient,,,6665,4665.5,AETNA [1000108],AETNA [100010801],,,76.8,,5118.72,399.86,8249.769,percent of total billed charges,,,
HC Angio Pelvis,PX-32000159,CDM,75736,CPT,320,RC,,,outpatient,,,11403,7982.1,AETNA [1000108],AETNA [100010801],,,76.8,,8757.5,399.86,14233.715,percent of total billed charges,,,
HC Angio Pulmon Unilat Select,PX-32000160,CDM,75741,CPT,320,RC,,,outpatient,,,6665,4665.5,AETNA [1000108],AETNA [100010801],,,76.8,,5118.72,399.86,8249.769,percent of total billed charges,,,
HC Angio Pulmon Bilat Select,PX-32000161,CDM,75743,CPT,320,RC,,,outpatient,,,7162,5013.4,AETNA [1000108],AETNA [100010801],,,76.8,,5500.42,399.86,8249.769,percent of total billed charges,,,
HC Angio Pulmon Bilat Nonselec,PX-32000162,CDM,75746,CPT,320,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,8249.769,percent of total billed charges,,,
HC Angio Intern Mammary,PX-32000163,CDM,75756,CPT,320,RC,,,outpatient,,,6665,4665.5,AETNA [1000108],AETNA [100010801],,,76.8,,5118.72,399.86,8249.769,percent of total billed charges,,,
HC Angio Ea Addnl Selectv Vessel,PX-32000164,CDM,75774,CPT,320,RC,,,outpatient,,,3538,2476.6,AETNA [1000108],AETNA [100010801],,,76.8,,2717.18,399.86,2717.184,percent of total billed charges,,,
HC Nonvascular Shuntogram,PX-32000166,CDM,75809,CPT,320,RC,,,outpatient,,,411,287.7,AETNA [1000108],AETNA [100010801],,,76.8,,315.65,92.2695,416.02,percent of total billed charges,,,
HC Venogram Splenoportogram,PX-32000167,CDM,75810,CPT,320,RC,,,outpatient,,,7698,5388.6,AETNA [1000108],AETNA [100010801],,,76.8,,5912.06,399.86,8249.769,percent of total billed charges,,,
HC Venogram Extrem Unilat,PX-32000168,CDM,75820,CPT,320,RC,,,outpatient,,,3212,2248.4,AETNA [1000108],AETNA [100010801],,,76.8,,2466.82,399.86,4120.349,percent of total billed charges,,,
HC Venogram Extrem Bilat,PX-32000169,CDM,75822,CPT,320,RC,,,outpatient,,,2940,2058,AETNA [1000108],AETNA [100010801],,,76.8,,2257.92,399.86,4120.349,percent of total billed charges,,,
HC Venogram Infer Vena Cava,PX-32000170,CDM,75825,CPT,320,RC,,,outpatient,,,5987,4190.9,AETNA [1000108],AETNA [100010801],,,76.8,,4598.02,399.86,8249.769,percent of total billed charges,,,
HC Venogram Super Vena Cava,PX-32000171,CDM,75827,CPT,320,RC,,,outpatient,,,2874,2011.8,AETNA [1000108],AETNA [100010801],,,76.8,,2207.23,399.86,4120.349,percent of total billed charges,,,
HC Venogram Renal Unilat,PX-32000172,CDM,75831,CPT,320,RC,,,outpatient,,,6489,4542.3,AETNA [1000108],AETNA [100010801],,,76.8,,4983.55,399.86,8249.769,percent of total billed charges,,,
HC Venogram Renal Bilat,PX-32000173,CDM,75833,CPT,320,RC,,,outpatient,,,6665,4665.5,AETNA [1000108],AETNA [100010801],,,76.8,,5118.72,399.86,8249.769,percent of total billed charges,,,
HC Venogram Adrenal Unilat,PX-32000174,CDM,75840,CPT,320,RC,,,outpatient,,,7698,5388.6,AETNA [1000108],AETNA [100010801],,,76.8,,5912.06,399.86,8249.769,percent of total billed charges,,,
HC Venogram Adrenal Bilat,PX-32000175,CDM,75842,CPT,320,RC,,,outpatient,,,11403,7982.1,AETNA [1000108],AETNA [100010801],,,76.8,,8757.5,399.86,14233.715,percent of total billed charges,,,
HC Venogram Sinus/Jugular,PX-32000176,CDM,75860,CPT,320,RC,,,outpatient,,,6665,4665.5,AETNA [1000108],AETNA [100010801],,,76.8,,5118.72,399.86,8249.769,percent of total billed charges,,,
HC Venogram Super Sag Sinus,PX-32000177,CDM,75870,CPT,320,RC,,,outpatient,,,4428,3099.6,AETNA [1000108],AETNA [100010801],,,76.8,,3400.7,399.86,8249.769,percent of total billed charges,,,
HC Venogram Epidural,PX-32000178,CDM,75872,CPT,320,RC,,,outpatient,,,4428,3099.6,AETNA [1000108],AETNA [100010801],,,76.8,,3400.7,399.86,3400.704,percent of total billed charges,,,
HC Venogram Orbital,PX-32000179,CDM,75880,CPT,320,RC,,,outpatient,,,1638,1146.6,AETNA [1000108],AETNA [100010801],,,76.8,,1257.98,367.731,1602.0655,percent of total billed charges,,,
HC Percut Xhepatic Porto+Dynamic,PX-32000180,CDM,75885,CPT,320,RC,,,outpatient,,,7698,5388.6,AETNA [1000108],AETNA [100010801],,,76.8,,5912.06,399.86,8249.769,percent of total billed charges,,,
HC Percut Xhepatic Portogram,PX-32000181,CDM,75887,CPT,320,RC,,,outpatient,,,7528,5269.6,AETNA [1000108],AETNA [100010801],,,76.8,,5781.5,399.86,8249.769,percent of total billed charges,,,
HC Venogram Hepatic W Hemodynamics,PX-32000182,CDM,75889,CPT,320,RC,,,outpatient,,,5272,3690.4,AETNA [1000108],AETNA [100010801],,,76.8,,4048.9,399.86,8249.769,percent of total billed charges,,,
HC Venogram Hepatic,PX-32000183,CDM,75891,CPT,320,RC,,,outpatient,,,6665,4665.5,AETNA [1000108],AETNA [100010801],,,76.8,,5118.72,399.86,8249.769,percent of total billed charges,,,
HC Venous Sampling by Catheter,PX-32000184,CDM,75893,CPT,320,RC,,,outpatient,,,11403,7982.1,AETNA [1000108],AETNA [100010801],,,76.8,,8757.5,399.86,14233.715,percent of total billed charges,,,
HC Transcatheter Rx Embolizatn,PX-32000185,CDM,75894,CPT,320,RC,,,outpatient,,,2536,1775.2,AETNA [1000108],AETNA [100010801],,,76.8,,1947.65,145.12362,1947.648,percent of total billed charges,,,
HC Angrph Cath F-Up Std Tcat Other Than Thrombylsis,PX-32000187,CDM,75898,CPT,320,RC,,,outpatient,,,3747,2622.9,AETNA [1000108],AETNA [100010801],,,76.8,,2877.7,260.23,8249.769,percent of total billed charges,,,
HC Remove-Obst Matl-Cva Dev via Sep Ven Acc,PX-32000188,CDM,75901,CPT,320,RC,,,outpatient,,,4773,3341.1,AETNA [1000108],AETNA [100010801],,,76.8,,3665.66,260.23,3665.664,percent of total billed charges,,,
HC Remove-Obst Matl-Cva Device via Lumen,PX-32000189,CDM,75902,CPT,320,RC,,,outpatient,,,471,329.7,AETNA [1000108],AETNA [100010801],,,76.8,,361.73,105.7395,416.02,percent of total billed charges,,,
HC Endovasc Repair Thor Aorta Incl Subclavian,PX-32000195,CDM,75956,CPT,320,RC,,,outpatient,,,1446,1012.2,AETNA [1000108],AETNA [100010801],,,76.8,,1110.53,324.627,1110.528,percent of total billed charges,,,
HC Endovasc Repair Thor Aorta Excl Subclavian,PX-32000196,CDM,75957,CPT,320,RC,,,outpatient,,,1312,918.4,AETNA [1000108],AETNA [100010801],,,76.8,,1007.62,294.544,1007.616,percent of total billed charges,,,
HC Proximal Extens Durng Endovasc Rethor Aorta,PX-32000197,CDM,75958,CPT,320,RC,,,outpatient,,,845,591.5,AETNA [1000108],AETNA [100010801],,,76.8,,648.96,189.7025,648.96,percent of total billed charges,,,
HC Delayed Prox Extens Endovasc Rethor Aorta,PX-32000198,CDM,75959,CPT,320,RC,,,outpatient,,,744,520.8,AETNA [1000108],AETNA [100010801],,,76.8,,571.39,167.028,571.392,percent of total billed charges,,,
HC Vascular Biopsy,PX-32000203,CDM,75970,CPT,320,RC,,,outpatient,,,2918,2042.6,AETNA [1000108],AETNA [100010801],,,76.8,,2241.02,145.12362,2241.024,percent of total billed charges,,,
HC Change Percut Tube/Drain Cath W Contrast Monit,PX-32000207,CDM,75984,CPT,320,RC,,,outpatient,,,2885,2019.5,AETNA [1000108],AETNA [100010801],,,76.8,,2215.68,145.12362,2215.68,percent of total billed charges,,,
HC Rad Guided-Percut Drainage-W/Cath Place,PX-32000208,CDM,75989,CPT,320,RC,,,outpatient,,,888,621.6,AETNA [1000108],AETNA [100010801],,,76.8,,681.98,145.12362,681.984,percent of total billed charges,,,
HC Rad Guided-Percut Drainage-W/Cath Place,PX-35000057,CDM,75989,CPT,350,RC,,,outpatient,,,888,621.6,AETNA [1000108],AETNA [100010801],,,76.8,,681.98,145.12362,681.984,percent of total billed charges,,,
HC Fluoroscopy Spx Up to 1 Hour Phys/Qhp Time,PX-32000209,CDM,76000,CPT,320,RC,,,outpatient,,,997,697.9,AETNA [1000108],AETNA [100010801],,,76.8,,765.7,195.08,765.696,percent of total billed charges,,,
HC X-Ray Nose-Rectum Child F.B.,PX-32000210,CDM,76010,CPT,320,RC,,,outpatient,,,340,238,AETNA [1000108],AETNA [100010801],,,76.8,,261.12,71.24,416.02,percent of total billed charges,,,
HC X-Ray Fistula-Abscess-Sinus Tract,PX-32000211,CDM,76080,CPT,320,RC,,,outpatient,,,1950,1365,AETNA [1000108],AETNA [100010801],,,76.8,,1497.6,237.819698,1497.6,percent of total billed charges,,,
HC X-Ray Exam- Breast Specimen,PX-32000212,CDM,76098,CPT,320,RC,,,outpatient,,,984,688.8,AETNA [1000108],AETNA [100010801],,,76.8,,755.71,220.908,1393.3385,percent of total billed charges,,,
HC Cine/Videoradiology-Exc Where Spec Incl,PX-32000214,CDM,76120,CPT,320,RC,,,outpatient,,,382,267.4,AETNA [1000108],AETNA [100010801],,,76.8,,293.38,85.759,416.02,percent of total billed charges,,,
HC 3d Rendering W/Interp & Postprocess Supervision,PX-35000058,CDM,76376,CPT,350,RC,,,outpatient,,,352,246.4,AETNA [1000108],AETNA [100010801],,,76.8,,270.34,79.024,836,percent of total billed charges,,,
HC 3d Rendering W/Interp & Postprocess Supervision,PX-40200003,CDM,76376,CPT,402,RC,,,outpatient,,,352,246.4,AETNA [1000108],AETNA [100010801],,,76.8,,270.34,79.024,836,percent of total billed charges,,,
HC 3d Rendering W/Interp & Postprocess Supervision,PX-61000062,CDM,76376,CPT,610,RC,,,outpatient,,,352,246.4,AETNA [1000108],AETNA [100010801],,,76.8,,270.34,79.024,836,percent of total billed charges,,,
HC 3d Rendering W/Interp&Postproc Diff Work Station,PX-35000059,CDM,76377,CPT,350,RC,,,outpatient,,,422,295.4,AETNA [1000108],AETNA [100010801],,,76.8,,324.1,94.739,836,percent of total billed charges,,,
HC 3d Rendering W/Interp&Postproc Diff Work Station,PX-40200004,CDM,76377,CPT,402,RC,,,outpatient,,,422,295.4,AETNA [1000108],AETNA [100010801],,,76.8,,324.1,94.739,836,percent of total billed charges,,,
HC 3d Rendering W/Interp&Postproc Diff Work Station,PX-61000063,CDM,76377,CPT,610,RC,,,outpatient,,,422,295.4,AETNA [1000108],AETNA [100010801],,,76.8,,324.1,94.739,836,percent of total billed charges,,,
HC CT Scan-Limited/Localized F/U Study,PX-35000060,CDM,76380,CPT,350,RC,,,outpatient,,,928,649.6,AETNA [1000108],AETNA [100010801],,,76.8,,712.7,71.24,712.704,percent of total billed charges,,,
HC MRI Spectroscopy,PX-61000064,CDM,76390,CPT,610,RC,,,outpatient,,,2218,1552.6,AETNA [1000108],AETNA [100010801],,,76.8,,1703.42,81.08,1703.424,percent of total billed charges,,,
HC Magnetic Resonance Elastography,PX-61000090,CDM,76391,CPT,610,RC,,,outpatient,,,842,589.4,AETNA [1000108],AETNA [100010801],,,76.8,,646.66,189.029,836,percent of total billed charges,,,
HC Unlisted CT Procedure,PX-35000061,CDM,76497,CPT,350,RC,,,outpatient,,,229,160.3,AETNA [1000108],AETNA [100010801],,,76.8,,175.87,51.4105,575,percent of total billed charges,,,
HC US- Head- Real Time,PX-40200005,CDM,76506,CPT,402,RC,,,outpatient,,,433,303.1,AETNA [1000108],AETNA [100010801],,,76.8,,332.54,97.2085,416.02,percent of total billed charges,,,
HC US- Head/Neck Tissues-Real Time,PX-40200006,CDM,76536,CPT,402,RC,,,outpatient,,,444,310.8,AETNA [1000108],AETNA [100010801],,,76.8,,340.99,99.678,416.02,percent of total billed charges,,,
HC US- Chest-Real Time,PX-40200007,CDM,76604,CPT,402,RC,,,outpatient,,,417,291.9,AETNA [1000108],AETNA [100010801],,,76.8,,320.26,93.6165,416.02,percent of total billed charges,,,
HC US Breast Uni Real Time With Image Complete,PX-40200056,CDM,76641,CPT,402,RC,,,outpatient,,,385,269.5,AETNA [1000108],AETNA [100010801],,,76.8,,295.68,86.4325,416.02,percent of total billed charges,,,
HC US Breast Uni Real Time With Image Limited,PX-40200055,CDM,76642,CPT,402,RC,,,outpatient,,,353,247.1,AETNA [1000108],AETNA [100010801],,,76.8,,271.1,71.24,416.02,percent of total billed charges,,,
HC US- Abdom-B-Scan &/or Real Time-Complete,PX-40200009,CDM,76700,CPT,402,RC,,,outpatient,,,461,322.7,AETNA [1000108],AETNA [100010801],,,76.8,,354.05,103.4945,416.02,percent of total billed charges,,,
HC US- Abdomen Limited,PX-40200010,CDM,76705,CPT,402,RC,,,outpatient,,,341,238.7,AETNA [1000108],AETNA [100010801],,,76.8,,261.89,76.5545,416.02,percent of total billed charges,,,
HC Ultrasound Exam Aaa Screen,PX-40200002,CDM,76706,CPT,402,RC,,,outpatient,,,261,182.7,AETNA [1000108],AETNA [100010801],,,76.8,,200.45,58.5945,416.02,percent of total billed charges,,,
HC US-Retroperit- B-Scan/Real Time-Complete,PX-40200011,CDM,76770,CPT,402,RC,,,outpatient,,,368,257.6,AETNA [1000108],AETNA [100010801],,,76.8,,282.62,82.616,416.02,percent of total billed charges,,,
HC US- Retroperitnl Abd- Ltd,PX-40200012,CDM,76775,CPT,402,RC,,,outpatient,,,345,241.5,AETNA [1000108],AETNA [100010801],,,76.8,,264.96,77.4525,416.02,percent of total billed charges,,,
HC US- Spinal Canal & Contents,PX-40200014,CDM,76800,CPT,402,RC,,,outpatient,,,595,416.5,AETNA [1000108],AETNA [100010801],,,76.8,,456.96,119.991125,456.96,percent of total billed charges,,,
HC US- OB < 14 Wks- Single Fetus,PX-40200015,CDM,76801,CPT,402,RC,,,outpatient,,,289,202.3,AETNA [1000108],AETNA [100010801],,,76.8,,221.95,64.8805,416.02,percent of total billed charges,,,
HC US- OB < 14 Wks- Add'l Fetus,PX-40200016,CDM,76802,CPT,402,RC,,,outpatient,,,224,156.8,AETNA [1000108],AETNA [100010801],,,76.8,,172.03,50.288,416.02,percent of total billed charges,,,
HC US- OB >/= 14 Wks- Sngl Fetus,PX-40200017,CDM,76805,CPT,402,RC,,,outpatient,,,421,294.7,AETNA [1000108],AETNA [100010801],,,76.8,,323.33,94.5145,416.02,percent of total billed charges,,,
HC US- OB >/= 14 Wks- Addl Fetus,PX-40200018,CDM,76810,CPT,402,RC,,,outpatient,,,713,499.1,AETNA [1000108],AETNA [100010801],,,76.8,,547.58,157.086513,547.584,percent of total billed charges,,,
HC US-Preg Uter-Fet & Mat-+ Detl Fet Exm,PX-40200019,CDM,76811,CPT,402,RC,,,outpatient,,,725,507.5,AETNA [1000108],AETNA [100010801],,,76.8,,556.8,162.7625,646.6965,percent of total billed charges,,,
HC US-Preg Uter-Fet & Mat-+ Detl Fet-Addl,PX-40200020,CDM,76812,CPT,402,RC,,,outpatient,,,240,168,AETNA [1000108],AETNA [100010801],,,76.8,,184.32,53.88,416.02,percent of total billed charges,,,
HC US-Pregnant Uterus-Limited- 1/> Fetuses,PX-40200021,CDM,76815,CPT,402,RC,,,outpatient,,,303,212.1,AETNA [1000108],AETNA [100010801],,,76.8,,232.7,68.0235,416.02,percent of total billed charges,,,
HC US-Pregnant Uterus-F/U-Transabd App,PX-40200022,CDM,76816,CPT,402,RC,,,outpatient,,,600,420,AETNA [1000108],AETNA [100010801],,,76.8,,460.8,119.991125,460.8,percent of total billed charges,,,
HC US-Pregnant Uterus-Transvaginal,PX-40200023,CDM,76817,CPT,402,RC,,,outpatient,,,355,248.5,AETNA [1000108],AETNA [100010801],,,76.8,,272.64,79.6975,416.02,percent of total billed charges,,,
HC Fetal Biophysical Profile,PX-40200024,CDM,76818,CPT,402,RC,,,outpatient,,,439,307.3,AETNA [1000108],AETNA [100010801],,,76.8,,337.15,98.5555,416.02,percent of total billed charges,,,
HC Fetal Biophys Prof-W/O Nst,PX-40200025,CDM,76819,CPT,402,RC,,,outpatient,,,358,250.6,AETNA [1000108],AETNA [100010801],,,76.8,,274.94,80.371,416.02,percent of total billed charges,,,
HC Doppler Fetal Umbilical Artery,PX-40200026,CDM,76820,CPT,402,RC,,,outpatient,,,290,203,AETNA [1000108],AETNA [100010801],,,76.8,,222.72,65.105,416.02,percent of total billed charges,,,
HC US-Pregnant Uterus-Limited- 1/> Fetuses,PX-40200028,CDM,76827,CPT,402,RC,,,outpatient,,,578,404.6,AETNA [1000108],AETNA [100010801],,,76.8,,443.9,119.991125,443.904,percent of total billed charges,,,
HC Sono Fetal Hrt Doppl F/U,PX-40200029,CDM,76828,CPT,402,RC,,,outpatient,,,146,102.2,AETNA [1000108],AETNA [100010801],,,76.8,,112.13,32.777,416.02,percent of total billed charges,,,
HC Echography-Transvaginal,PX-40200030,CDM,76830,CPT,402,RC,,,outpatient,,,365,255.5,AETNA [1000108],AETNA [100010801],,,76.8,,280.32,81.9425,416.02,percent of total billed charges,,,
HC Sono Exam- Hysterosonography,PX-40200031,CDM,76831,CPT,402,RC,,,outpatient,,,1006,704.2,AETNA [1000108],AETNA [100010801],,,76.8,,772.61,199.512292,772.608,percent of total billed charges,,,
HC Echo-Pelvic (Nonobstetric),PX-40200032,CDM,76856,CPT,402,RC,,,outpatient,,,361,252.7,AETNA [1000108],AETNA [100010801],,,76.8,,277.25,81.0445,416.02,percent of total billed charges,,,
HC Sono Pelvis Limited,PX-40200033,CDM,76857,CPT,402,RC,,,outpatient,,,332,232.4,AETNA [1000108],AETNA [100010801],,,76.8,,254.98,74.534,416.02,percent of total billed charges,,,
HC Echo-Scrotum & Contents,PX-40200034,CDM,76870,CPT,402,RC,,,outpatient,,,457,319.9,AETNA [1000108],AETNA [100010801],,,76.8,,350.98,102.5965,416.02,percent of total billed charges,,,
HC Echo-Transrectal,PX-40200035,CDM,76872,CPT,402,RC,,,outpatient,,,401,280.7,AETNA [1000108],AETNA [100010801],,,76.8,,307.97,90.0245,416.02,percent of total billed charges,,,
HC Echo-Transrectal-Prostate Vol,PX-40200036,CDM,76873,CPT,402,RC,,,outpatient,,,273,191.1,AETNA [1000108],AETNA [100010801],,,76.8,,209.66,61.2885,416.02,percent of total billed charges,,,
HC US-Extremity-Nonvascular-Real-Time Image-Complete,PX-40200037,CDM,76881,CPT,402,RC,,,outpatient,,,400,280,AETNA [1000108],AETNA [100010801],,,76.8,,307.2,89.8,416.02,percent of total billed charges,,,
HC US-Extremity-Nonvascular-Real-Time Image-Limited,PX-40200038,CDM,76882,CPT,402,RC,,,outpatient,,,253,177.1,AETNA [1000108],AETNA [100010801],,,76.8,,194.3,56.7985,416.02,percent of total billed charges,,,
HC US Inft Hips R-T Img Dynamic Req Phys/Qhp Manj,PX-40200039,CDM,76885,CPT,402,RC,,,outpatient,,,412,288.4,AETNA [1000108],AETNA [100010801],,,76.8,,316.42,71.24,416.02,percent of total billed charges,,,
HC US Inft Hips R-T Img Lmtd Static Phys/Qhp Manj,PX-40200040,CDM,76886,CPT,402,RC,,,outpatient,,,412,288.4,AETNA [1000108],AETNA [100010801],,,76.8,,316.42,71.24,416.02,percent of total billed charges,,,
HC US Guid-Comp Repair-Pseudo-Aneur/Av Fist,PX-40200041,CDM,76936,CPT,402,RC,,,outpatient,,,681,476.7,AETNA [1000108],AETNA [100010801],,,76.8,,523.01,152.8845,775.5705,percent of total billed charges,,,
HC US Guide- Vascular Access,PX-40200042,CDM,76937,CPT,402,RC,,,outpatient,,,251,175.7,AETNA [1000108],AETNA [100010801],,,76.8,,192.77,56.3495,416.02,percent of total billed charges,,,
HC US Guide- Tissue Ablation,PX-40200043,CDM,76940,CPT,402,RC,,,outpatient,,,460,322,AETNA [1000108],AETNA [100010801],,,76.8,,353.28,103.27,416.02,percent of total billed charges,,,
HC Sono Guide Needle Biopsy,PX-40200044,CDM,76942,CPT,402,RC,,,outpatient,,,868,607.6,AETNA [1000108],AETNA [100010801],,,76.8,,666.62,166.37,666.624,percent of total billed charges,,,
HC Sono Guide Amniocentesis,PX-40200045,CDM,76946,CPT,402,RC,,,outpatient,,,354,247.8,AETNA [1000108],AETNA [100010801],,,76.8,,271.87,79.473,416.02,percent of total billed charges,,,
HC US Guid-Comp Repair-Pseudo-Aneur/Av Fist,PX-40200048,CDM,76998,CPT,402,RC,,,outpatient,,,604,422.8,AETNA [1000108],AETNA [100010801],,,76.8,,463.87,135.598,463.872,percent of total billed charges,,,
HC Fluoroguide Cntrl Ven Access-Place-Replace-Remove,PX-32000217,CDM,77001,CPT,320,RC,,,outpatient,,,521,364.7,AETNA [1000108],AETNA [100010801],,,76.8,,400.13,116.9645,416.02,percent of total billed charges,,,
HC Fluoroscopic Guidance Needle Placement,PX-32000218,CDM,77002,CPT,320,RC,,,outpatient,,,318,222.6,AETNA [1000108],AETNA [100010801],,,76.8,,244.22,71.391,416.02,percent of total billed charges,,,
HC Fluorscopic Guidance Spinal Injection,PX-32000219,CDM,77003,CPT,320,RC,,,outpatient,,,518,362.6,AETNA [1000108],AETNA [100010801],,,76.8,,397.82,116.291,416.02,percent of total billed charges,,,
HC CT Guidance Stereotactic Localization,PX-35000062,CDM,77011,CPT,350,RC,,,outpatient,,,1801,1260.7,AETNA [1000108],AETNA [100010801],,,76.8,,1383.17,399.86,1383.168,percent of total billed charges,,,
HC CT Guidance Needle Placement,PX-35000063,CDM,77012,CPT,350,RC,,,outpatient,,,1747,1222.9,AETNA [1000108],AETNA [100010801],,,76.8,,1341.7,63.344499,1341.696,percent of total billed charges,,,
HC CT Guidance Tissue Ablation,PX-35000064,CDM,77013,CPT,350,RC,,,outpatient,,,1755,1228.5,AETNA [1000108],AETNA [100010801],,,76.8,,1347.84,63.344499,1347.84,percent of total billed charges,,,
HC CT Guidance Placement Rad Therapy Fields,PX-35000065,CDM,77014,CPT,350,RC,,,outpatient,,,623,436.1,AETNA [1000108],AETNA [100010801],,,76.8,,478.46,139.8635,575,percent of total billed charges,,,
HC MRI Guidance Needle Placement,PX-61000066,CDM,77021,CPT,610,RC,,,outpatient,,,3092,2164.4,AETNA [1000108],AETNA [100010801],,,76.8,,2374.66,399.86,2374.656,percent of total billed charges,,,
HC MRI Breast Without Contrast Material Unilateral,PX-61000083,CDM,77046,CPT,610,RC,,,outpatient,,,842,589.4,AETNA [1000108],AETNA [100010801],,,76.8,,646.66,189.029,836,percent of total billed charges,,,
HC MRI Breast Without Contrast Material Bilateral,PX-61000086,CDM,77047,CPT,610,RC,,,outpatient,,,842,589.4,AETNA [1000108],AETNA [100010801],,,76.8,,646.66,189.029,836,percent of total billed charges,,,
HC MRI Breast With Contrast W/Cad Unilateral,PX-61000084,CDM,77048,CPT,610,RC,,,outpatient,,,2118,1482.6,AETNA [1000108],AETNA [100010801],,,76.8,,1626.62,399.547552,1936.896,percent of total billed charges,,,
HC MRI Breast W/Out&With Contrast W/Cad Unilateral,PX-61000085,CDM,77048,CPT,610,RC,,,outpatient,,,2522,1765.4,AETNA [1000108],AETNA [100010801],,,76.8,,1936.9,399.547552,1936.896,percent of total billed charges,,,
HC MRI Breast With Contrast W/Cad Bilateral,PX-61000087,CDM,77049,CPT,610,RC,,,outpatient,,,2788,1951.6,AETNA [1000108],AETNA [100010801],,,76.8,,2141.18,399.547552,2548.224,percent of total billed charges,,,
HC MRI Breast W/Out&With Contrast W/Cad Bilateral,PX-61000088,CDM,77049,CPT,610,RC,,,outpatient,,,3318,2322.6,AETNA [1000108],AETNA [100010801],,,76.8,,2548.22,399.547552,2548.224,percent of total billed charges,,,
HC Digital Breast Tomosynthesis Unilateral,PX-40100006,CDM,77061,CPT,401,RC,,,outpatient,,,321,224.7,AETNA [1000108],AETNA [100010801],,,76.8,,246.53,72.0645,416.02,percent of total billed charges,,,
HC Digital Breast Tomosynthesis Bilateral,PX-40100007,CDM,77062,CPT,401,RC,,,outpatient,,,393,275.1,AETNA [1000108],AETNA [100010801],,,76.8,,301.82,88.2285,416.02,percent of total billed charges,,,
HC Screening Digital Breast Tomosynthesis Bi,PX-40300004,CDM,77063,CPT,403,RC,,,outpatient,,,202,141.4,AETNA [1000108],AETNA [100010801],,,76.8,,155.14,22.99364,416.02,percent of total billed charges,,,
HC Dx Mammo Incl Cad Uni,PX-40100008,CDM,77065,CPT,401,RC,,,outpatient,,,393,275.1,AETNA [1000108],AETNA [100010801],,,76.8,,301.82,88.2285,416.02,percent of total billed charges,,,
HC Dx Mammo Incl Cad Bi,PX-40100009,CDM,77066,CPT,401,RC,,,outpatient,,,466,326.2,AETNA [1000108],AETNA [100010801],,,76.8,,357.89,90.800319,416.02,percent of total billed charges,,,
HC Scr Mammo Bi Incl Cad,PX-40300005,CDM,77067,CPT,403,RC,,,outpatient,,,466,326.2,AETNA [1000108],AETNA [100010801],,,76.8,,357.89,90.800319,416.02,percent of total billed charges,,,
HC Manual Appl Stress Pfrmd Phys/Qhp Joint Films,PX-32000222,CDM,77071,CPT,320,RC,,,outpatient,,,262,183.4,AETNA [1000108],AETNA [100010801],,,76.8,,201.22,58.819,416.02,percent of total billed charges,,,
HC X-Rays for Bone Age,PX-32000223,CDM,77072,CPT,320,RC,,,outpatient,,,218,152.6,AETNA [1000108],AETNA [100010801],,,76.8,,167.42,48.941,416.02,percent of total billed charges,,,
HC X-Rays- Bone Length Studies,PX-32000224,CDM,77073,CPT,320,RC,,,outpatient,,,502,351.4,AETNA [1000108],AETNA [100010801],,,76.8,,385.54,76.026473,416.02,percent of total billed charges,,,
HC X-Rays- Bone Survey- Limited,PX-32000225,CDM,77074,CPT,320,RC,,,outpatient,,,502,351.4,AETNA [1000108],AETNA [100010801],,,76.8,,385.54,112.699,416.02,percent of total billed charges,,,
HC X-Rays- Bone Survey Complete,PX-32000226,CDM,77075,CPT,320,RC,,,outpatient,,,502,351.4,AETNA [1000108],AETNA [100010801],,,76.8,,385.54,112.699,416.02,percent of total billed charges,,,
HC X-Rays- Bone Survey- Infant,PX-32000227,CDM,77076,CPT,320,RC,,,outpatient,,,502,351.4,AETNA [1000108],AETNA [100010801],,,76.8,,385.54,76.026473,416.02,percent of total billed charges,,,
HC Dexa-Bone Density- 1 + Site- Axial Skeleton,PX-32000228,CDM,77080,CPT,320,RC,,,outpatient,,,575,402.5,AETNA [1000108],AETNA [100010801],,,76.8,,441.6,119.991125,441.6,percent of total billed charges,,,
HC Dexa-Bone Density- 1 + Site- Appendiculr Skeltn,PX-32000229,CDM,77081,CPT,320,RC,,,outpatient,,,114,79.8,AETNA [1000108],AETNA [100010801],,,76.8,,87.55,25.593,416.02,percent of total billed charges,,,
HC MRI- Bone Marrow,PX-61000070,CDM,77084,CPT,610,RC,,,outpatient,,,2406,1684.2,AETNA [1000108],AETNA [100010801],,,76.8,,1847.81,267.439885,1847.808,percent of total billed charges,,,
HC Tbs Techl Prep&Transmis Data Alys Pfrmd Elsewhr,PX-32000262,CDM,77090,CPT,320,RC,,,outpatient,,,248,173.6,AETNA [1000108],AETNA [100010801],,,76.8,,190.46,55.676,416.02,percent of total billed charges,,,
HC Tbs Technical Calculation Only,PX-32000263,CDM,77091,CPT,320,RC,,,outpatient,,,248,173.6,AETNA [1000108],AETNA [100010801],,,76.8,,190.46,55.676,416.02,percent of total billed charges,,,
HC Thyroid Uptake Single/Multiple Quant Measurement,PX-34100001,CDM,78012,CPT,341,RC,,,outpatient,,,935,654.5,AETNA [1000108],AETNA [100010801],,,76.8,,718.08,209.9075,1076.394,percent of total billed charges,,,
HC Thyroid Imaging With Vascular Flow,PX-34100002,CDM,78013,CPT,341,RC,,,outpatient,,,633,443.1,AETNA [1000108],AETNA [100010801],,,76.8,,486.14,142.1085,1076.394,percent of total billed charges,,,
HC Thyroid Uptake W/Blood Flow Sngle/Mult Quan Meas,PX-34100003,CDM,78014,CPT,341,RC,,,outpatient,,,982,687.4,AETNA [1000108],AETNA [100010801],,,76.8,,754.18,220.459,1076.394,percent of total billed charges,,,
HC Thyroid Met Imaging Body,PX-34100005,CDM,78018,CPT,341,RC,,,outpatient,,,1049,734.3,AETNA [1000108],AETNA [100010801],,,76.8,,805.63,235.5005,1397.122,percent of total billed charges,,,
HC Thyroid Met Uptake,PX-34100006,CDM,78020,CPT,341,RC,,,outpatient,,,171,119.7,AETNA [1000108],AETNA [100010801],,,76.8,,131.33,38.3895,416.02,percent of total billed charges,,,
HC Parathyroid Planar Imaging,PX-34100007,CDM,78070,CPT,341,RC,,,outpatient,,,1575,1102.5,AETNA [1000108],AETNA [100010801],,,76.8,,1209.6,353.5875,1209.6,percent of total billed charges,,,
HC Parathyroid Planar Imaging W/WO Subtraction,PX-34100008,CDM,78071,CPT,341,RC,,,outpatient,,,1357,949.9,AETNA [1000108],AETNA [100010801],,,76.8,,1042.18,304.6465,1076.394,percent of total billed charges,,,
HC Parathyroid Imaging W/Tomographic Spect & CT,PX-34100009,CDM,78072,CPT,341,RC,,,outpatient,,,1898,1328.6,AETNA [1000108],AETNA [100010801],,,76.8,,1457.66,358.69,1457.664,percent of total billed charges,,,
HC Adrenal Nuclear Imaging,PX-34100010,CDM,78075,CPT,341,RC,,,outpatient,,,2974,2081.8,AETNA [1000108],AETNA [100010801],,,76.8,,2284.03,399.86,3675.6585,percent of total billed charges,,,
HC Bone Marrow Imaging- Ltd,PX-34100011,CDM,78102,CPT,341,RC,,,outpatient,,,1403,982.1,AETNA [1000108],AETNA [100010801],,,76.8,,1077.5,314.9735,1077.504,percent of total billed charges,,,
HC Bone Marrow Imaging- Mult,PX-34100012,CDM,78103,CPT,341,RC,,,outpatient,,,1403,982.1,AETNA [1000108],AETNA [100010801],,,76.8,,1077.5,314.9735,1077.504,percent of total billed charges,,,
HC Bone Marrow Imaging- Body,PX-34100013,CDM,78104,CPT,341,RC,,,outpatient,,,659,461.3,AETNA [1000108],AETNA [100010801],,,76.8,,506.11,147.9455,1076.394,percent of total billed charges,,,
HC Spleen Imaging,PX-34100015,CDM,78185,CPT,341,RC,,,outpatient,,,971,679.7,AETNA [1000108],AETNA [100010801],,,76.8,,745.73,217.9895,1076.394,percent of total billed charges,,,
HC Lymphatics & Lymph Glands Imaging,PX-34100016,CDM,78195,CPT,341,RC,,,outpatient,,,1071,749.7,AETNA [1000108],AETNA [100010801],,,76.8,,822.53,240.4395,1397.122,percent of total billed charges,,,
HC Liver Imaging,PX-34100017,CDM,78201,CPT,341,RC,,,outpatient,,,2228,1559.6,AETNA [1000108],AETNA [100010801],,,76.8,,1711.1,399.86,2239.93036,percent of total billed charges,,,
HC Liver and Spleen Imaging,PX-34100021,CDM,78215,CPT,341,RC,,,outpatient,,,1205,843.5,AETNA [1000108],AETNA [100010801],,,76.8,,925.44,270.5225,1076.394,percent of total billed charges,,,
HC Hepatobiliary Syst Imaging Including Gallbladder,PX-34100023,CDM,78226,CPT,341,RC,,,outpatient,,,1384,968.8,AETNA [1000108],AETNA [100010801],,,76.8,,1062.91,310.708,1076.394,percent of total billed charges,,,
HC Hepatobil Syst Imag Inc Gb W/Pharma Intervenj,PX-34100024,CDM,78227,CPT,341,RC,,,outpatient,,,1384,968.8,AETNA [1000108],AETNA [100010801],,,76.8,,1062.91,310.708,1397.122,percent of total billed charges,,,
HC Serial Salivary Imaging,PX-34100025,CDM,78231,CPT,341,RC,,,outpatient,,,788,551.6,AETNA [1000108],AETNA [100010801],,,76.8,,605.18,176.906,1076.394,percent of total billed charges,,,
HC Gastroesophageal Reflux Exam,PX-34100027,CDM,78262,CPT,341,RC,,,outpatient,,,1043,730.1,AETNA [1000108],AETNA [100010801],,,76.8,,801.02,234.1535,1076.394,percent of total billed charges,,,
HC Gastric Emptying Study,PX-34100028,CDM,78264,CPT,341,RC,,,outpatient,,,838,586.6,AETNA [1000108],AETNA [100010801],,,76.8,,643.58,188.131,1076.394,percent of total billed charges,,,
HC Acute GI Blood Loss Imaging,PX-34100031,CDM,78278,CPT,341,RC,,,outpatient,,,2079,1455.3,AETNA [1000108],AETNA [100010801],,,76.8,,1596.67,399.86,1596.672,percent of total billed charges,,,
HC Bowel Imaging,PX-34100032,CDM,78290,CPT,341,RC,,,outpatient,,,893,625.1,AETNA [1000108],AETNA [100010801],,,76.8,,685.82,200.4785,1076.394,percent of total billed charges,,,
HC Leveen/Shunt Patency Exam,PX-34100033,CDM,78291,CPT,341,RC,,,outpatient,,,954,667.8,AETNA [1000108],AETNA [100010801],,,76.8,,732.67,214.173,1076.394,percent of total billed charges,,,
HC Bone Imaging- Limited Area,PX-34100034,CDM,78300,CPT,341,RC,,,outpatient,,,962,673.4,AETNA [1000108],AETNA [100010801],,,76.8,,738.82,215.969,1076.394,percent of total billed charges,,,
HC Bone Imaging- Multiple Areas,PX-34100035,CDM,78305,CPT,341,RC,,,outpatient,,,1098,768.6,AETNA [1000108],AETNA [100010801],,,76.8,,843.26,246.501,1076.394,percent of total billed charges,,,
HC Bone Imaging- Whole Body,PX-34100036,CDM,78306,CPT,341,RC,,,outpatient,,,893,625.1,AETNA [1000108],AETNA [100010801],,,76.8,,685.82,200.4785,1076.394,percent of total billed charges,,,
HC Bone Imaging- 3 Phase,PX-34100037,CDM,78315,CPT,341,RC,,,outpatient,,,956,669.2,AETNA [1000108],AETNA [100010801],,,76.8,,734.21,214.622,1076.394,percent of total billed charges,,,
HC Myocardial Spect Single Study at Rest or Stress,PX-34100040,CDM,78451,CPT,341,RC,,,outpatient,,,4510,3157,AETNA [1000108],AETNA [100010801],,,76.8,,3463.68,399.86,3675.6585,percent of total billed charges,,,
HC Myocardial Spect Multiple Studies,PX-34100041,CDM,78452,CPT,341,RC,,,outpatient,,,4510,3157,AETNA [1000108],AETNA [100010801],,,76.8,,3463.68,399.86,3675.6585,percent of total billed charges,,,
HC Myocardial Perfusion Planar 1 Study Rest/Stress,PX-34100042,CDM,78453,CPT,341,RC,,,outpatient,,,3900,2730,AETNA [1000108],AETNA [100010801],,,76.8,,2995.2,399.86,3675.6585,percent of total billed charges,,,
HC Myocardial Perfusion Planar Multiple Studies,PX-34100043,CDM,78454,CPT,341,RC,,,outpatient,,,3900,2730,AETNA [1000108],AETNA [100010801],,,76.8,,2995.2,399.86,3675.6585,percent of total billed charges,,,
HC Gated Heart- Planar Single,PX-34100048,CDM,78472,CPT,341,RC,,,outpatient,,,1586,1110.2,AETNA [1000108],AETNA [100010801],,,76.8,,1218.05,356.057,1218.048,percent of total billed charges,,,
HC Heart Image- Spect,PX-34100050,CDM,78494,CPT,341,RC,,,outpatient,,,1671,1169.7,AETNA [1000108],AETNA [100010801],,,76.8,,1283.33,375.1395,1283.328,percent of total billed charges,,,
HC Pulmonary Ventilation Imaging,PX-34100052,CDM,78579,CPT,341,RC,,,outpatient,,,767,536.9,AETNA [1000108],AETNA [100010801],,,76.8,,589.06,172.1915,1076.394,percent of total billed charges,,,
HC Lung Perfusion Imaging,PX-34100053,CDM,78580,CPT,341,RC,,,outpatient,,,640,448,AETNA [1000108],AETNA [100010801],,,76.8,,491.52,143.68,1076.394,percent of total billed charges,,,
HC Pulmonary Ventilation & Perfusion Imaging,PX-34100054,CDM,78582,CPT,341,RC,,,outpatient,,,946,662.2,AETNA [1000108],AETNA [100010801],,,76.8,,726.53,212.377,1397.122,percent of total billed charges,,,
HC Quant Differential Pulm Perfusion W/WO Imaging,PX-34100055,CDM,78597,CPT,341,RC,,,outpatient,,,902,631.4,AETNA [1000108],AETNA [100010801],,,76.8,,692.74,202.499,1076.394,percent of total billed charges,,,
HC Quant Diff Pulm Prfusion & Ventlaj W/WO Imaging,PX-34100056,CDM,78598,CPT,341,RC,,,outpatient,,,1499,1049.3,AETNA [1000108],AETNA [100010801],,,76.8,,1151.23,336.5255,1397.122,percent of total billed charges,,,
HC Brain Imaging < 4 Static Views W Vascular Flow,PX-34100058,CDM,78601,CPT,341,RC,,,outpatient,,,2704,1892.8,AETNA [1000108],AETNA [100010801],,,76.8,,2076.67,399.86,2076.672,percent of total billed charges,,,
HC Brain Imaging Min 4 Static Views W Vascular Flow,PX-34100059,CDM,78606,CPT,341,RC,,,outpatient,,,1589,1112.3,AETNA [1000108],AETNA [100010801],,,76.8,,1220.35,356.7305,1397.122,percent of total billed charges,,,
HC Brain Imaging Pet Metabolic,PX-40400003,CDM,78608,CPT,404,RC,,,outpatient,,,4890,3423,AETNA [1000108],AETNA [100010801],,,76.8,,3755.52,399.86,3755.52,percent of total billed charges,,,
HC CSF Fluid Scan Cisternography,PX-34100061,CDM,78630,CPT,341,RC,,,outpatient,,,2570,1799,AETNA [1000108],AETNA [100010801],,,76.8,,1973.76,399.86,1973.76,percent of total billed charges,,,
HC CSF Shunt Evaluation,PX-34100062,CDM,78645,CPT,341,RC,,,outpatient,,,916,641.2,AETNA [1000108],AETNA [100010801],,,76.8,,703.49,205.642,1397.122,percent of total billed charges,,,
HC CSF Leakage Detection & Localization,PX-34100063,CDM,78650,CPT,341,RC,,,outpatient,,,3215,2250.5,AETNA [1000108],AETNA [100010801],,,76.8,,2469.12,399.86,3675.6585,percent of total billed charges,,,
HC Renal Imaging- Static,PX-34100064,CDM,78700,CPT,341,RC,,,outpatient,,,1292,904.4,AETNA [1000108],AETNA [100010801],,,76.8,,992.26,290.054,1076.394,percent of total billed charges,,,
HC Renal Flow/Funct Imaging,PX-34100065,CDM,78707,CPT,341,RC,,,outpatient,,,1210,847,AETNA [1000108],AETNA [100010801],,,76.8,,929.28,271.645,1397.122,percent of total billed charges,,,
HC Renal Flow/Funct Image-Pharm Rx,PX-34100066,CDM,78708,CPT,341,RC,,,outpatient,,,899,629.3,AETNA [1000108],AETNA [100010801],,,76.8,,690.43,201.8255,1397.122,percent of total billed charges,,,
HC Testicular Imaging & Flow,PX-34100069,CDM,78761,CPT,341,RC,,,outpatient,,,845,591.5,AETNA [1000108],AETNA [100010801],,,76.8,,648.96,189.7025,1076.394,percent of total billed charges,,,
HC Tumor Imaging- Limited Area,PX-34100070,CDM,78800,CPT,341,RC,,,outpatient,,,867,606.9,AETNA [1000108],AETNA [100010801],,,76.8,,665.86,194.6415,1076.394,percent of total billed charges,,,
HC Tumor Imaging- Whole Body- Single Day,PX-34100072,CDM,78802,CPT,341,RC,,,outpatient,,,3124,2186.8,AETNA [1000108],AETNA [100010801],,,76.8,,2399.23,399.86,3675.6585,percent of total billed charges,,,
HC Tumor Imaging Spect,PX-34100073,CDM,78803,CPT,341,RC,,,outpatient,,,2419,1693.3,AETNA [1000108],AETNA [100010801],,,76.8,,1857.79,399.86,3675.6585,percent of total billed charges,,,
HC Tumor Imaging- Whole Body- 2 or More Days,PX-34100074,CDM,78804,CPT,341,RC,,,outpatient,,,2916,2041.2,AETNA [1000108],AETNA [100010801],,,76.8,,2239.49,399.86,3675.6585,percent of total billed charges,,,
HC Inject Radiopharm Non-Imaging Localization- IV,PX-34100080,CDM,78808,CPT,341,RC,,,outpatient,,,1227,858.9,AETNA [1000108],AETNA [100010801],,,76.8,,942.34,275.4615,1076.394,percent of total billed charges,,,
HC Pet Imaging CT for Attenuation Limited Area,PX-40400004,CDM,78814,CPT,404,RC,,,outpatient,,,5186,3630.2,AETNA [1000108],AETNA [100010801],,,76.8,,3982.85,399.86,3982.848,percent of total billed charges,,,
HC Pet Imaging CT Attenuation Skull Base Mid-Thigh,PX-40400005,CDM,78815,CPT,404,RC,,,outpatient,,,6904,4832.8,AETNA [1000108],AETNA [100010801],,,76.8,,5302.27,399.86,5302.272,percent of total billed charges,,,
HC Pet Imaging for CT Attenuation Whole Body,PX-40400006,CDM,78816,CPT,404,RC,,,outpatient,,,7705,5393.5,AETNA [1000108],AETNA [100010801],,,76.8,,5917.44,399.86,5917.44,percent of total billed charges,,,
HC Rp Loclzj Tum Spect W/CT 1 Area 1 Day Imaging,PX-34100081,CDM,78830,CPT,341,RC,,,outpatient,,,4318,3022.6,AETNA [1000108],AETNA [100010801],,,76.8,,3316.22,399.86,3675.6585,percent of total billed charges,,,
HC Rp Loclzj Tum Spect 2 Area 1d Img/1 Area Img>2+D,PX-34100082,CDM,78831,CPT,341,RC,,,outpatient,,,4318,3022.6,AETNA [1000108],AETNA [100010801],,,76.8,,3316.22,399.86,3675.6585,percent of total billed charges,,,
HC Rp Loclzj Tum Spect CT 2area 1d Img/1 AR Img>2+D,PX-34100083,CDM,78832,CPT,341,RC,,,outpatient,,,4899,3429.3,AETNA [1000108],AETNA [100010801],,,76.8,,3762.43,399.86,4124.5085,percent of total billed charges,,,
HC Radiopharmaceutical Quantification Meas 1 Area,PX-34100084,CDM,78835,CPT,341,RC,,,outpatient,,,203,142.1,AETNA [1000108],AETNA [100010801],,,76.8,,155.9,45.5735,416.02,percent of total billed charges,,,
HC Nuclear Therapy- Oral,PX-34200001,CDM,79005,CPT,342,RC,,,outpatient,,,782,547.4,AETNA [1000108],AETNA [100010801],,,76.8,,600.58,175.559,691.5815,percent of total billed charges,,,
HC Urinalysis- Auto- W/O Scope,PX-30000067,CDM,81003,CPT,300,RC,,,outpatient,,,32,22.4,AETNA [1000108],AETNA [100010801],,,76.8,,24.58,2.29,24.576,percent of total billed charges,,,
HC Urine Pregnancy Test,PX-30000713,CDM,81025,CPT,300,RC,,,outpatient,,,28,19.6,AETNA [1000108],AETNA [100010801],,,76.8,,21.5,6.286,21.504,percent of total billed charges,,,
HC Molecular Pathology Procedure Level 4,PX-30000097,CDM,81403,CPT,300,RC,,,outpatient,,,716,501.2,AETNA [1000108],AETNA [100010801],,,76.8,,549.89,160.742,549.888,percent of total billed charges,,,
HC Blood Occult-by Peroxid- Feces- 1-3 Simult- Non Ca Screen,PX-30000715,CDM,82272,CPT,300,RC,,,outpatient,,,24,16.8,AETNA [1000108],AETNA [100010801],,,76.8,,18.43,3.33,18.432,percent of total billed charges,,,
HC Glucose Blood Test,PX-30000221,CDM,82962,CPT,300,RC,,,outpatient,,,45,31.5,AETNA [1000108],AETNA [100010801],,,76.8,,34.56,2.4,34.56,percent of total billed charges,,,
HC Bone Marrow-Smear Interpretation,PX-31000012,CDM,85097,CPT,310,RC,,,outpatient,,,1038,726.6,AETNA [1000108],AETNA [100010801],,,76.8,,797.18,39.73,1313.895373,percent of total billed charges,,,
HC Coagulation Time- Activated,PX-30000417,CDM,85347,CPT,300,RC,,,outpatient,,,80,56,AETNA [1000108],AETNA [100010801],,,76.8,,61.44,4.35,61.44,percent of total billed charges,,,
HC Hgb/Rbcs Fetal Fetomaternal Hemrrg Rosette,PX-30000732,CDM,85461,CPT,300,RC,,,outpatient,,,32,22.4,AETNA [1000108],AETNA [100010801],,,76.8,,24.58,6.78,24.576,percent of total billed charges,,,
HC Sickling RBC Reduction,PX-30000730,CDM,85660,CPT,300,RC,,,outpatient,,,25,17.5,AETNA [1000108],AETNA [100010801],,,76.8,,19.2,5.6125,19.2,percent of total billed charges,,,
HC Platelet Antibodies,PX-30000453,CDM,86022,CPT,300,RC,,,outpatient,,,128,89.6,AETNA [1000108],AETNA [100010801],,,76.8,,98.3,18.77,98.304,percent of total billed charges,,,
HC Cold Agglutinin Screen,PX-30000465,CDM,86156,CPT,300,RC,,,outpatient,,,158,110.6,AETNA [1000108],AETNA [100010801],,,76.8,,121.34,6.51,121.344,percent of total billed charges,,,
HC Cold Agglutinin- Titer,PX-30000466,CDM,86157,CPT,300,RC,,,outpatient,,,29,20.3,AETNA [1000108],AETNA [100010801],,,76.8,,22.27,6.5105,24.43,percent of total billed charges,,,
HC Leukocyte Phagocytosis,PX-30000866,CDM,86344,CPT,300,RC,,,outpatient,,,33,23.1,AETNA [1000108],AETNA [100010801],,,76.8,,25.34,7.4085,25.344,percent of total billed charges,,,
HC Cmv Antibody,PX-30000526,CDM,86644,CPT,300,RC,,,outpatient,,,155,108.5,AETNA [1000108],AETNA [100010801],,,76.8,,119.04,14.71,119.04,percent of total billed charges,,,
HC Hla Typing- a-B-or C /Single,PX-30000582,CDM,86812,CPT,300,RC,,,outpatient,,,252,176.4,AETNA [1000108],AETNA [100010801],,,76.8,,193.54,26.37,193.536,percent of total billed charges,,,
HC Hla Typing Dr/Dq Single Antigen,PX-30000731,CDM,86816,CPT,300,RC,,,outpatient,,,124,86.8,AETNA [1000108],AETNA [100010801],,,76.8,,95.23,27.838,95.232,percent of total billed charges,,,
HC Hla Typing- Dr/Dq-Multi Antgn,PX-30000584,CDM,86817,CPT,300,RC,,,outpatient,,,287,200.9,AETNA [1000108],AETNA [100010801],,,76.8,,220.42,64.4315,241.472,percent of total billed charges,,,
HC RBC Antibody Screen,PX-30000585,CDM,86850,CPT,300,RC,,,outpatient,,,99,69.3,AETNA [1000108],AETNA [100010801],,,76.8,,76.03,6.25,92.88556,percent of total billed charges,,,
HC RBC Antibody Elution,PX-30000586,CDM,86860,CPT,300,RC,,,outpatient,,,358,250.6,AETNA [1000108],AETNA [100010801],,,76.8,,274.94,2.072,274.944,percent of total billed charges,,,
HC RBC Antibody Identification,PX-30000587,CDM,86870,CPT,300,RC,,,outpatient,,,501,350.7,AETNA [1000108],AETNA [100010801],,,76.8,,384.77,2.842,549.235176,percent of total billed charges,,,
HC Antihuman Globulin Dir Ea Antiserum,PX-30000588,CDM,86880,CPT,300,RC,,,outpatient,,,117,81.9,AETNA [1000108],AETNA [100010801],,,76.8,,89.86,5.5,93.463636,percent of total billed charges,,,
HC Antihuman Globulin Indir Qual Ea Reagent Cell,PX-30000589,CDM,86885,CPT,300,RC,,,outpatient,,,357,249.9,AETNA [1000108],AETNA [100010801],,,76.8,,274.18,5.85,274.176,percent of total billed charges,,,
HC Antihuman Globulin Indirect Ea Antibody Titer,PX-30000590,CDM,86886,CPT,300,RC,,,outpatient,,,357,249.9,AETNA [1000108],AETNA [100010801],,,76.8,,274.18,5.29,274.176,percent of total billed charges,,,
HC Blood Typing- Abo,PX-30000592,CDM,86900,CPT,300,RC,,,outpatient,,,208,145.6,AETNA [1000108],AETNA [100010801],,,76.8,,159.74,3.05,195.186327,percent of total billed charges,,,
HC Blood Typing- Rh (D),PX-30000593,CDM,86901,CPT,300,RC,,,outpatient,,,85,59.5,AETNA [1000108],AETNA [100010801],,,76.8,,65.28,3.05,65.28,percent of total billed charges,,,
HC Blood Type Antigen Donor Reagent Serum- Ea Antigen,PX-30000594,CDM,86902,CPT,300,RC,,,outpatient,,,628,439.6,AETNA [1000108],AETNA [100010801],,,76.8,,482.3,3.91,549.235176,percent of total billed charges,,,
HC Blood Typing Antigen Screen Patient Serum/Unit,PX-30000718,CDM,86904,CPT,300,RC,,,outpatient,,,311,217.7,AETNA [1000108],AETNA [100010801],,,76.8,,238.85,9.71,238.848,percent of total billed charges,,,
HC Blood Typing- RBC Antigens,PX-30000595,CDM,86905,CPT,300,RC,,,outpatient,,,628,439.6,AETNA [1000108],AETNA [100010801],,,76.8,,482.3,3.91,549.235176,percent of total billed charges,,,
HC Blood Typing Serologic Rh Phenotyping Complete,PX-30000719,CDM,86906,CPT,300,RC,,,outpatient,,,284,198.8,AETNA [1000108],AETNA [100010801],,,76.8,,218.11,7.91,218.112,percent of total billed charges,,,
HC Compatibility Test-Spin Tech,PX-30000596,CDM,86920,CPT,300,RC,,,outpatient,,,355,248.5,AETNA [1000108],AETNA [100010801],,,76.8,,272.64,2.31,272.64,percent of total billed charges,,,
HC Compatibility Test-Incub Tech,PX-30000597,CDM,86921,CPT,300,RC,,,outpatient,,,357,249.9,AETNA [1000108],AETNA [100010801],,,76.8,,274.18,2.072,274.176,percent of total billed charges,,,
HC Compatibility Test-Antiglob Tech,PX-30000598,CDM,86922,CPT,300,RC,,,outpatient,,,357,249.9,AETNA [1000108],AETNA [100010801],,,76.8,,274.18,2.45,274.176,percent of total billed charges,,,
HC Compatibility Test- Electronic,PX-30000599,CDM,86923,CPT,300,RC,,,outpatient,,,357,249.9,AETNA [1000108],AETNA [100010801],,,76.8,,274.18,1.862,274.176,percent of total billed charges,,,
HC Plasma- Fresh Frozen,PX-30000600,CDM,86927,CPT,300,RC,,,outpatient,,,312,218.4,AETNA [1000108],AETNA [100010801],,,76.8,,239.62,1.302,263.69806,percent of total billed charges,,,
HC Blood Product/Irradiation,PX-39100002,CDM,86945,CPT,391,RC,,,outpatient,,,116,81.2,AETNA [1000108],AETNA [100010801],,,,,,1.932,416.02,other,Rev 391 at $0,,
HC Pretx RBC Antibody Incubat W/Chem Agnts/Drugs Ea,PX-30000729,CDM,86970,CPT,300,RC,,,outpatient,,,110,77,AETNA [1000108],AETNA [100010801],,,76.8,,84.48,1.932,93.463636,percent of total billed charges,,,
HC Pretx RBC Antibody Incubat W/Enzymes Each,PX-30000726,CDM,86971,CPT,300,RC,,,outpatient,,,560,392,AETNA [1000108],AETNA [100010801],,,76.8,,430.08,1.54,499.62884,percent of total billed charges,,,
HC Pretx RBC Antibody Incubat W/Density Grad Sep,PX-30000727,CDM,86972,CPT,300,RC,,,outpatient,,,358,250.6,AETNA [1000108],AETNA [100010801],,,76.8,,274.94,2.702,274.944,percent of total billed charges,,,
HC Pretx Serum RBC Antibody Incubation Drugs Each,PX-30000725,CDM,86975,CPT,300,RC,,,outpatient,,,358,250.6,AETNA [1000108],AETNA [100010801],,,76.8,,274.94,2.072,608.812631,percent of total billed charges,,,
HC Pretx Serum RBC Antibody Identification Dilution,PX-30000724,CDM,86976,CPT,300,RC,,,outpatient,,,311,217.7,AETNA [1000108],AETNA [100010801],,,76.8,,238.85,2.31,238.848,percent of total billed charges,,,
HC Pretx Serum RBC Antb ID Incubation Inhibitors Ea,PX-30000734,CDM,86977,CPT,300,RC,,,outpatient,,,509,356.3,AETNA [1000108],AETNA [100010801],,,76.8,,390.91,2.31,416.02,percent of total billed charges,,,
HC RBC Pretreatment-Serum Inhib,PX-39100003,CDM,86977,CPT,391,RC,,,outpatient,,,509,356.3,AETNA [1000108],AETNA [100010801],,,,,,2.31,416.02,other,Rev 391 at $0,,
HC Pretx Serum RBC Antibody ID Diffial Each Absrpj,PX-30000723,CDM,86978,CPT,300,RC,,,outpatient,,,311,217.7,AETNA [1000108],AETNA [100010801],,,76.8,,238.85,2.31,238.848,percent of total billed charges,,,
HC Unlisted Transfusion Medicine Procedure,PX-30000728,CDM,86999,CPT,300,RC,,,outpatient,,,299,209.3,AETNA [1000108],AETNA [100010801],,,76.8,,229.63,1.68,229.632,percent of total billed charges,,,
HC Strep a Assay W/Optic,PX-30000714,CDM,87880,CPT,300,RC,,,outpatient,,,52,36.4,AETNA [1000108],AETNA [100010801],,,76.8,,39.94,11.674,39.936,percent of total billed charges,,,
HC Sperm Isolation- Simple,PX-31000079,CDM,89260,CPT,310,RC,,,outpatient,,,210,147,AETNA [1000108],AETNA [100010801],,,76.8,,161.28,47.145,416.02,percent of total billed charges,,,
HC Sperm Isolation- Complex,PX-30000709,CDM,89261,CPT,300,RC,,,outpatient,,,152,106.4,AETNA [1000108],AETNA [100010801],,,76.8,,116.74,34.124,116.736,percent of total billed charges,,,
HC Semen Analysis-Volume- Count- Motility- Diff,PX-30000711,CDM,89320,CPT,300,RC,,,outpatient,,,58,40.6,AETNA [1000108],AETNA [100010801],,,76.8,,44.54,12.32,44.544,percent of total billed charges,,,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4202-01,NDC,outpatient,1,ML,650.46,455.322,AETNA [1000108],AETNA [100010801],,,76.8,,499.55,139.93,1690.176,percent of total billed charges,,,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4203-02,NDC,outpatient,5,ML,2200.75,1540.525,AETNA [1000108],AETNA [100010801],,,76.8,,1690.18,139.93,1690.176,percent of total billed charges,,,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4202-02,NDC,outpatient,1,ML,650.46,455.322,AETNA [1000108],AETNA [100010801],,,76.8,,499.55,139.93,1690.176,percent of total billed charges,,,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4203-01,NDC,outpatient,5,ML,2200.75,1540.525,AETNA [1000108],AETNA [100010801],,,76.8,,1690.18,139.93,1690.176,percent of total billed charges,,,
RABIES IMMUNE GLOBULIN 300 UNIT/ML IJ SOLN,RX-142826,CDM,90375,HCPCS,636,RC,13533-0318-10,NDC,outpatient,1,ML,1554.22,1087.954,AETNA [1000108],AETNA [100010801],,,76.8,,1193.64,287.71,7105.5744,percent of total billed charges,,,
RABIES IMMUNE GLOBULIN 300 UNIT/ML IJ SOLN,RX-142826,CDM,90375,HCPCS,636,RC,13533-0318-01,NDC,outpatient,1,ML,1554.22,1087.954,AETNA [1000108],AETNA [100010801],,,76.8,,1193.64,287.71,7105.5744,percent of total billed charges,,,
RABIES IMMUNE GLOBULIN 1500 UNIT/5ML IJ SOLN,RX-142827,CDM,90375,HCPCS,636,RC,13533-0318-05,NDC,outpatient,5,ML,7771.09,5439.763,AETNA [1000108],AETNA [100010801],,,76.8,,5968.2,287.71,7105.5744,percent of total billed charges,,,
RABIES IMMUNE GLOBULIN 1500 UNIT/5ML IJ SOLN,RX-142827,CDM,90375,HCPCS,636,RC,13533-0318-50,NDC,outpatient,5,ML,7771.09,5439.763,AETNA [1000108],AETNA [100010801],,,76.8,,5968.2,287.71,7105.5744,percent of total billed charges,,,
RABIES IMMUNE GLOBULIN 900 UNIT/3ML IJ SOLN,RX-150138,CDM,90375,HCPCS,636,RC,13533-0318-03,NDC,outpatient,3,ML,4662.66,3263.862,AETNA [1000108],AETNA [100010801],,,76.8,,3580.92,287.71,7105.5744,percent of total billed charges,,,
RABIES IMMUNE GLOBULIN 900 UNIT/3ML IJ SOLN,RX-150138,CDM,90375,HCPCS,636,RC,13533-0318-30,NDC,outpatient,3,ML,4662.66,3263.862,AETNA [1000108],AETNA [100010801],,,76.8,,3580.92,287.71,7105.5744,percent of total billed charges,,,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-20,NDC,outpatient,2,ML,1850.42,1295.294,AETNA [1000108],AETNA [100010801],,,76.8,,1421.12,287.71,7105.5744,percent of total billed charges,,,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-02,NDC,outpatient,2,ML,1850.42,1295.294,AETNA [1000108],AETNA [100010801],,,76.8,,1421.12,287.71,7105.5744,percent of total billed charges,,,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-10,NDC,outpatient,10,ML,9252.05,6476.435,AETNA [1000108],AETNA [100010801],,,76.8,,7105.57,287.71,7105.5744,percent of total billed charges,,,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-11,NDC,outpatient,10,ML,9252.05,6476.435,AETNA [1000108],AETNA [100010801],,,76.8,,7105.57,287.71,7105.5744,percent of total billed charges,,,
PALIVIZUMAB 50 MG/0.5ML IM SOLN,RX-108060,CDM,90378,HCPCS,636,RC,66658-0230-01,NDC,outpatient,0.5,ML,5025.03,3517.521,AETNA [1000108],AETNA [100010801],,,76.8,,3859.22,389.10344,4791.979,percent of total billed charges,,,
RHO D IMMUNE GLOBULIN 1500 UNIT/2ML IJ SOSY,RX-129748,CDM,90384,HCPCS,636,RC,44206-0300-01,NDC,outpatient,2,ML,207.1,144.97,AETNA [1000108],AETNA [100010801],,,76.8,,159.05,0.5,416.02,percent of total billed charges,,,
RHO D IMMUNE GLOBULIN 1500 UNIT/2ML IJ SOSY,RX-129748,CDM,90384,HCPCS,636,RC,44206-0300-10,NDC,outpatient,2,ML,207.1,144.97,AETNA [1000108],AETNA [100010801],,,76.8,,159.05,0.5,416.02,percent of total billed charges,,,
RHO D IMMUNE GLOBULIN 1500 UNIT/2ML IJ SOSY,RX-129748,CDM,90384,HCPCS,636,RC,44206-0300-90,NDC,outpatient,2,ML,78.48,54.936,AETNA [1000108],AETNA [100010801],,,76.8,,60.27,0.5,416.02,percent of total billed charges,,,
HC Immuniz Admin-1 Single/Comb Vac/Toxoid,PX-77100004,CDM,90471,CPT,771,RC,,,outpatient,,,193,135.1,AETNA [1000108],AETNA [100010801],,,76.8,,148.22,43.3285,416.02,percent of total billed charges,,,
HC Immuniz-Admin-Each Addl,PX-77100008,CDM,90472,CPT,771,RC,,,outpatient,,,73,51.1,AETNA [1000108],AETNA [100010801],,,76.8,,56.06,16.3885,416.02,percent of total billed charges,,,
HC Admn Sarscov2 Vacc 1 Dose,PX-77100044,CDM,90480,CPT,771,RC,,,outpatient,,,111,77.7,AETNA [1000108],AETNA [100010801],,,76.8,,85.25,24.9195,416.02,percent of total billed charges,,,
MENINGOCOCCAL B RECOMB OMV ADJ IM SUSY,RX-129389,CDM,90620,HCPCS,636,RC,58160-0976-20,NDC,outpatient,0.5,ML,874.41,612.087,AETNA [1000108],AETNA [100010801],,,76.8,,671.55,0.5,671.54688,percent of total billed charges,,,
MENINGOCOCCAL B RECOMB OMV ADJ IM SUSY,RX-129389,CDM,90620,HCPCS,636,RC,58160-0976-02,NDC,outpatient,0.5,ML,874.41,612.087,AETNA [1000108],AETNA [100010801],,,76.8,,671.55,0.5,671.54688,percent of total billed charges,,,
HEPATITIS A VACCINE 1440 EL U/ML IM SUSP,RX-91034,CDM,90632,HCPCS,636,RC,58160-0826-43,NDC,outpatient,1,ML,337.61,236.327,AETNA [1000108],AETNA [100010801],,,76.8,,259.28,70.48,416.02,percent of total billed charges,,,
HEPATITIS A VACCINE 1440 EL U/ML IM SUSP,RX-91034,CDM,90632,HCPCS,636,RC,58160-0826-52,NDC,outpatient,1,ML,337.61,236.327,AETNA [1000108],AETNA [100010801],,,76.8,,259.28,70.48,416.02,percent of total billed charges,,,
HEPATITIS A VACCINE 720 EL U/0.5ML IM SUSP,RX-91033,CDM,90633,HCPCS,636,RC,58160-0825-43,NDC,outpatient,0.5,ML,155.01,108.507,AETNA [1000108],AETNA [100010801],,,76.8,,119.05,34.799745,416.02,percent of total billed charges,,,
HEPATITIS A VACCINE 720 EL U/0.5ML IM SUSP,RX-91033,CDM,90633,HCPCS,636,RC,58160-0825-52,NDC,outpatient,0.5,ML,155.01,108.507,AETNA [1000108],AETNA [100010801],,,76.8,,119.05,34.799745,416.02,percent of total billed charges,,,
HAEMOPHILUS B POLYSAC CONJ VAC IM SOLR,RX-11931,CDM,90648,HCPCS,636,RC,49281-0545-03,NDC,outpatient,1,UN,49.34,34.538,AETNA [1000108],AETNA [100010801],,,76.8,,37.89,11.07683,416.02,percent of total billed charges,,,
HAEMOPHILUS B POLYSAC CONJ VAC IM SOLR,RX-11931,CDM,90648,HCPCS,636,RC,49281-0547-58,NDC,outpatient,1,UN,49.34,34.538,AETNA [1000108],AETNA [100010801],,,76.8,,37.89,11.07683,416.02,percent of total billed charges,,,
HPV 9-VALENT RECOMB VACCINE IM SUSY,RX-129114,CDM,90651,HCPCS,636,RC,00006-4121-02,NDC,outpatient,0.5,ML,1147.17,803.019,AETNA [1000108],AETNA [100010801],,,76.8,,881.03,0.5,881.02656,percent of total billed charges,,,
HPV 9-VALENT RECOMB VACCINE IM SUSY,RX-129114,CDM,90651,HCPCS,636,RC,00006-4121-01,NDC,outpatient,0.5,ML,1147.17,803.019,AETNA [1000108],AETNA [100010801],,,76.8,,881.03,0.5,881.02656,percent of total billed charges,,,
INFLUENZA VAC SUBUNIT QUAD 0.5 ML IM SUSY,RX-135284,CDM,90674,HCPCS,636,RC,70461-0323-04,NDC,outpatient,0.5,ML,94.26,65.982,AETNA [1000108],AETNA [100010801],,,76.8,,72.39,0.5,416.02,percent of total billed charges,,,
INFLUENZA VAC SUBUNIT QUAD 0.5 ML IM SUSY,RX-135284,CDM,90674,HCPCS,636,RC,70461-0323-03,NDC,outpatient,0.5,ML,94.26,65.982,AETNA [1000108],AETNA [100010801],,,76.8,,72.39,0.5,416.02,percent of total billed charges,,,
RABIES VACCINE WRAPPER,RX-4080220,CDM,90675,HCPCS,636,RC,49281-0252-51,NDC,outpatient,1,UN,1713.57,1199.499,AETNA [1000108],AETNA [100010801],,,76.8,,1316.02,91.911626,1316.02176,percent of total billed charges,,,
RABIES VACCINE WRAPPER,RX-4080220,CDM,90675,HCPCS,636,RC,50632-0010-01,NDC,outpatient,1,UN,1460.49,1022.343,AETNA [1000108],AETNA [100010801],,,76.8,,1121.66,91.911626,1316.02176,percent of total billed charges,,,
RABIES VACCINE WRAPPER,RX-4080220,CDM,90675,HCPCS,636,RC,50632-0013-01,NDC,outpatient,1,UN,1460.49,1022.343,AETNA [1000108],AETNA [100010801],,,76.8,,1121.66,91.911626,1316.02176,percent of total billed charges,,,
PNEUMOCOCCAL 20-VAL CONJ VACC 0.5 ML IM SUSY,RX-156044,CDM,90677,HCPCS,636,RC,00005-2000-02,NDC,outpatient,0.5,ML,1098.4,768.88,AETNA [1000108],AETNA [100010801],,,76.8,,843.57,0.5,843.5712,percent of total billed charges,,,
INFLUENZA VAC A&B SA ADJ QUAD 0.5 ML IM PRSY,RX-150230,CDM,90694,HCPCS,636,RC,70461-0123-04,NDC,outpatient,0.5,ML,241.68,169.176,AETNA [1000108],AETNA [100010801],,,76.8,,185.61,0.5,416.02,percent of total billed charges,,,
INFLUENZA VAC A&B SA ADJ QUAD 0.5 ML IM PRSY,RX-150230,CDM,90694,HCPCS,636,RC,70461-0123-03,NDC,outpatient,0.5,ML,241.68,169.176,AETNA [1000108],AETNA [100010801],,,76.8,,185.61,0.5,416.02,percent of total billed charges,,,
DIPHTH-ACELL PERTUSSIS-TETANUS 15-23-5 LF-MCG/0.5 IM SUSP,RX-140528,CDM,90700,HCPCS,636,RC,49281-0286-10,NDC,outpatient,0.5,ML,107.51,75.257,AETNA [1000108],AETNA [100010801],,,76.8,,82.57,24.135995,416.02,percent of total billed charges,,,
DIPHTH-ACELL PERTUSSIS-TETANUS 15-23-5 LF-MCG/0.5 IM SUSP,RX-140528,CDM,90700,HCPCS,636,RC,49281-0286-58,NDC,outpatient,0.5,ML,107.51,75.257,AETNA [1000108],AETNA [100010801],,,76.8,,82.57,24.135995,416.02,percent of total billed charges,,,
MEASLES- MUMPS & RUBELLA VAC IJ SOLR,RX-148019,CDM,90707,HCPCS,636,RC,00006-4681-01,NDC,outpatient,1,UN,362.53,253.771,AETNA [1000108],AETNA [100010801],,,76.8,,278.42,54.47,416.02,percent of total billed charges,,,
MEASLES- MUMPS & RUBELLA VAC IJ SOLR,RX-148019,CDM,90707,HCPCS,636,RC,00006-4681-00,NDC,outpatient,1,UN,362.53,253.771,AETNA [1000108],AETNA [100010801],,,76.8,,278.42,54.47,416.02,percent of total billed charges,,,
POLIOVIRUS VACCINE INACTIVATED IJ INJ,RX-108127,CDM,90713,HCPCS,636,RC,49281-0860-78,NDC,outpatient,0.5,ML,163.66,114.562,AETNA [1000108],AETNA [100010801],,,76.8,,125.69,25.298577,416.02,percent of total billed charges,,,
POLIOVIRUS VACCINE INACTIVATED IJ INJ,RX-108127,CDM,90713,HCPCS,636,RC,49281-0860-10,NDC,outpatient,0.5,ML,163.66,114.562,AETNA [1000108],AETNA [100010801],,,76.8,,125.69,25.298577,416.02,percent of total billed charges,,,
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,49281-0400-10,NDC,outpatient,0.5,ML,187.93,131.551,AETNA [1000108],AETNA [100010801],,,76.8,,144.33,25.298577,416.02,percent of total billed charges,,,
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,49281-0400-58,NDC,outpatient,0.5,ML,187.93,131.551,AETNA [1000108],AETNA [100010801],,,76.8,,144.33,25.298577,416.02,percent of total billed charges,,,
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,58160-0842-11,NDC,outpatient,0.5,ML,193.78,135.646,AETNA [1000108],AETNA [100010801],,,76.8,,148.82,25.298577,416.02,percent of total billed charges,,,
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,58160-0842-01,NDC,outpatient,0.5,ML,193.78,135.646,AETNA [1000108],AETNA [100010801],,,76.8,,148.82,25.298577,416.02,percent of total billed charges,,,
VARICELLA VIRUS VACCINE LIVE 1350 PFU/0.5ML SC INJ,RX-113088,CDM,90716,HCPCS,636,RC,00006-4827-00,NDC,outpatient,1,UN,737.12,515.984,AETNA [1000108],AETNA [100010801],,,76.8,,566.11,0.5,566.10816,percent of total billed charges,,,
VARICELLA VIRUS VACCINE LIVE 1350 PFU/0.5ML SC INJ,RX-113088,CDM,90716,HCPCS,636,RC,00006-4827-01,NDC,outpatient,1,UN,737.12,515.984,AETNA [1000108],AETNA [100010801],,,76.8,,566.11,0.5,566.10816,percent of total billed charges,,,
DTAP-HEPATITIS B RECOMB-IPV IM SUSY,RX-158218,CDM,90723,HCPCS,636,RC,58160-0811-52,NDC,outpatient,0.5,ML,392.47,274.729,AETNA [1000108],AETNA [100010801],,,76.8,,301.42,0.5,416.02,percent of total billed charges,,,
DTAP-HEPATITIS B RECOMB-IPV IM SUSY,RX-158218,CDM,90723,HCPCS,636,RC,58160-0811-43,NDC,outpatient,0.5,ML,392.47,274.729,AETNA [1000108],AETNA [100010801],,,76.8,,301.42,0.5,416.02,percent of total billed charges,,,
MENINGOCOCCAL A C Y&W-135 OLIG IM SOLN,RX-161800,CDM,90734,HCPCS,636,RC,58160-0827-03,NDC,outpatient,0.5,ML,640.81,448.567,AETNA [1000108],AETNA [100010801],,,76.8,,492.14,0.5,492.14208,percent of total billed charges,,,
MENINGOCOCCAL A C Y&W-135 OLIG IM SOLN,RX-161800,CDM,90734,HCPCS,636,RC,58160-0827-30,NDC,outpatient,0.5,ML,640.81,448.567,AETNA [1000108],AETNA [100010801],,,76.8,,492.14,0.5,492.14208,percent of total billed charges,,,
HEPATITIS B VAC RECOMB ADJ 20 MCG/0.5ML IM SOSY,RX-143904,CDM,90739,HCPCS,636,RC,43528-0003-01,NDC,outpatient,0.5,ML,537.53,376.271,AETNA [1000108],AETNA [100010801],,,76.8,,412.82,0.5,416.02,percent of total billed charges,,,
HEPATITIS B VAC RECOMB ADJ 20 MCG/0.5ML IM SOSY,RX-143904,CDM,90739,HCPCS,636,RC,43528-0003-05,NDC,outpatient,0.5,ML,537.53,376.271,AETNA [1000108],AETNA [100010801],,,76.8,,412.82,0.5,416.02,percent of total billed charges,,,
HC Esophageal Motility Study- Manometry,PX-92000004,CDM,91010,CPT,920,RC,,,outpatient,,,1126,788.2,AETNA [1000108],AETNA [100010801],,,76.8,,864.77,252.787,1055.807021,percent of total billed charges,,,
HC Gerd Tst W/ Mucos Ph Electrod,PX-92000007,CDM,91035,CPT,920,RC,,,outpatient,,,1775,1242.5,AETNA [1000108],AETNA [100010801],,,76.8,,1363.2,398.4875,1363.2,percent of total billed charges,,,
HC GI Trc Img Intraluminal Esophagus-Ileum W/I&R,PX-75000005,CDM,91110,CPT,750,RC,,,outpatient,,,3922,2745.4,AETNA [1000108],AETNA [100010801],,,76.8,,3012.1,399.86,3012.096,percent of total billed charges,,,
HC GI Imag Intraluminal Esophagus-Ileum W/I&R,PX-92000008,CDM,91110,CPT,920,RC,,,outpatient,,,3922,2745.4,AETNA [1000108],AETNA [100010801],,,76.8,,3012.1,399.86,3012.096,percent of total billed charges,,,
HC Rectal Sesation Tone & Compliance Test,PX-36900666,CDM,91120,CPT,369,RC,,,outpatient,,,752,526.4,AETNA [1000108],AETNA [100010801],,,76.8,,577.54,168.824,1592,percent of total billed charges,,,
HC Anal Pressure Record,PX-36900541,CDM,91122,CPT,369,RC,,,outpatient,,,1360,952,AETNA [1000108],AETNA [100010801],,,76.8,,1044.48,305.32,1592,percent of total billed charges,,,
COVID-19 MRNA VACC (MODERNA) 50 MCG/0.5ML IM SUSY,RX-165852,CDM,91322,HCPCS,636,RC,80777-0102-93,NDC,outpatient,0.5,ML,492.72,344.904,AETNA [1000108],AETNA [100010801],,,76.8,,378.41,0.5,417.629472,percent of total billed charges,,,
COVID-19 MRNA VACC (MODERNA) 50 MCG/0.5ML IM SUSY,RX-165852,CDM,91322,HCPCS,636,RC,80777-0102-01,NDC,outpatient,0.5,ML,492.72,344.904,AETNA [1000108],AETNA [100010801],,,76.8,,378.41,0.5,417.629472,percent of total billed charges,,,
HC Eye Photography,PX-92000009,CDM,92285,CPT,920,RC,,,outpatient,,,80,56,AETNA [1000108],AETNA [100010801],,,76.8,,61.44,17.96,416.02,percent of total billed charges,,,
HC Caloric Vestibular Test Bilateral- Bithermal,PX-47100041,CDM,92537,CPT,471,RC,,,outpatient,,,1270,889,AETNA [1000108],AETNA [100010801],,,76.8,,975.36,163,975.36,percent of total billed charges,,,
HC Caloric Vestibular Test Bilateral- Monothermal,PX-47100042,CDM,92538,CPT,471,RC,,,outpatient,,,882,617.4,AETNA [1000108],AETNA [100010801],,,76.8,,677.38,163,677.376,percent of total billed charges,,,
HC Vestibular Eval Nystag Fovl&Perph Stim Oscil Tracking,PX-47000010,CDM,92540,CPT,470,RC,,,outpatient,,,550,385,AETNA [1000108],AETNA [100010801],,,76.8,,422.4,123.475,422.4,percent of total billed charges,,,
HC Spontaneous Nystagmus Test,PX-47000011,CDM,92541,CPT,470,RC,,,outpatient,,,155,108.5,AETNA [1000108],AETNA [100010801],,,76.8,,119.04,34.7975,416.02,percent of total billed charges,,,
HC Positional Nystagmus Test,PX-47000012,CDM,92542,CPT,470,RC,,,outpatient,,,155,108.5,AETNA [1000108],AETNA [100010801],,,76.8,,119.04,34.7975,416.02,percent of total billed charges,,,
HC Optokinetic Nystagmus Test- Bidirec- Foveal- Periph- W Record,PX-47000014,CDM,92544,CPT,470,RC,,,outpatient,,,155,108.5,AETNA [1000108],AETNA [100010801],,,76.8,,119.04,34.7975,416.02,percent of total billed charges,,,
HC Oscillating Tracking Test,PX-47000015,CDM,92545,CPT,470,RC,,,outpatient,,,696,487.2,AETNA [1000108],AETNA [100010801],,,76.8,,534.53,142.97,534.528,percent of total billed charges,,,
HC Supplemental Electrical Test,PX-47100012,CDM,92547,CPT,471,RC,,,outpatient,,,225,157.5,AETNA [1000108],AETNA [100010801],,,76.8,,172.8,50.5125,416.02,percent of total billed charges,,,
HC Tympanometry and Reflex Threshold Measurements,PX-47100013,CDM,92550,CPT,471,RC,,,outpatient,,,269,188.3,AETNA [1000108],AETNA [100010801],,,76.8,,206.59,60.3905,416.02,percent of total billed charges,,,
HC Pure Tone Audiometry- Air,PX-47100014,CDM,92552,CPT,471,RC,,,outpatient,,,230,161,AETNA [1000108],AETNA [100010801],,,76.8,,176.64,51.635,416.02,percent of total billed charges,,,
HC Audiometry- Air & Bone,PX-47100015,CDM,92553,CPT,471,RC,,,outpatient,,,295,206.5,AETNA [1000108],AETNA [100010801],,,76.8,,226.56,61.17,416.02,percent of total billed charges,,,
HC Speech Threshold Audiometry,PX-47100016,CDM,92555,CPT,471,RC,,,outpatient,,,144,100.8,AETNA [1000108],AETNA [100010801],,,76.8,,110.59,32.328,416.02,percent of total billed charges,,,
HC Speech Audiometry- Complete,PX-47100017,CDM,92556,CPT,471,RC,,,outpatient,,,132,92.4,AETNA [1000108],AETNA [100010801],,,76.8,,101.38,29.634,416.02,percent of total billed charges,,,
HC Comprehensive Hearing Test,PX-47100018,CDM,92557,CPT,471,RC,,,outpatient,,,519,363.3,AETNA [1000108],AETNA [100010801],,,76.8,,398.59,116.5155,416.02,percent of total billed charges,,,
HC Evoked Otoacoustic Emissions Screen Auto Analys,PX-47100047,CDM,92558,CPT,471,RC,,,outpatient,,,35,24.5,AETNA [1000108],AETNA [100010801],,,76.8,,26.88,7.8575,416.02,percent of total billed charges,,,
HC Stenger Test- Pure Tone,PX-47100020,CDM,92565,CPT,471,RC,,,outpatient,,,95,66.5,AETNA [1000108],AETNA [100010801],,,76.8,,72.96,21.3275,416.02,percent of total billed charges,,,
HC Tympanometry,PX-47100021,CDM,92567,CPT,471,RC,,,outpatient,,,125,87.5,AETNA [1000108],AETNA [100010801],,,76.8,,96,28.0625,416.02,percent of total billed charges,,,
HC Acoustic Immit Test Tympanometry/Acoust Reflex/Decay,PX-47100023,CDM,92570,CPT,471,RC,,,outpatient,,,359,251.3,AETNA [1000108],AETNA [100010801],,,76.8,,275.71,80.5955,416.02,percent of total billed charges,,,
HC Visual Audiometry (Vra),PX-47100027,CDM,92579,CPT,471,RC,,,outpatient,,,500,350,AETNA [1000108],AETNA [100010801],,,76.8,,384,112.25,416.02,percent of total billed charges,,,
HC Conditioning Play Audiometry,PX-47100028,CDM,92582,CPT,471,RC,,,outpatient,,,511,357.7,AETNA [1000108],AETNA [100010801],,,76.8,,392.45,114.7195,416.02,percent of total billed charges,,,
HC Select Picture Audiometry,PX-47100029,CDM,92583,CPT,471,RC,,,outpatient,,,114,79.8,AETNA [1000108],AETNA [100010801],,,76.8,,87.55,25.593,416.02,percent of total billed charges,,,
HC Evoked Auditory Test-Limited,PX-47100032,CDM,92587,CPT,471,RC,,,outpatient,,,624,436.8,AETNA [1000108],AETNA [100010801],,,76.8,,479.23,128.12716,479.602522,percent of total billed charges,,,
HC Hearing Aid Check- One Ear,PX-47100036,CDM,92592,CPT,471,RC,,,outpatient,,,116,81.2,AETNA [1000108],AETNA [100010801],,,76.8,,89.09,26.042,416.02,percent of total billed charges,,,
HC Hearing Aid Check- Both Ears,PX-47100038,CDM,92593,CPT,471,RC,,,outpatient,,,162,113.4,AETNA [1000108],AETNA [100010801],,,76.8,,124.42,36.369,416.02,percent of total billed charges,,,
HC Auditory Function- 60 Min,PX-47100039,CDM,92620,CPT,471,RC,,,outpatient,,,729,510.3,AETNA [1000108],AETNA [100010801],,,76.8,,559.87,84.99,559.872,percent of total billed charges,,,
HC Auditory Function- + 15 Min,PX-47100040,CDM,92621,CPT,471,RC,,,outpatient,,,122,85.4,AETNA [1000108],AETNA [100010801],,,76.8,,93.7,20.01,416.02,percent of total billed charges,,,
HC Aep Threshold Estimation Mlt Frequencies I&R,PX-47100043,CDM,92652,CPT,471,RC,,,outpatient,,,863,604.1,AETNA [1000108],AETNA [100010801],,,76.8,,662.78,128.12716,662.784,percent of total billed charges,,,
HC Aep Neurodiagnostic Interpretation and Report,PX-47100044,CDM,92653,CPT,471,RC,,,outpatient,,,863,604.1,AETNA [1000108],AETNA [100010801],,,76.8,,662.78,128.12716,662.784,percent of total billed charges,,,
HC Prq Trluml Coronary Angioplasty One Art/Branch,PX-48100012,CDM,92920,CPT,481,RC,,,outpatient,,,17563,12294.1,AETNA [1000108],AETNA [100010801],,,76.8,,13488.38,399.86,13488.384,percent of total billed charges,,,
HC Prq Trluml Coronary Angioplasty Addl Branch,PX-48100013,CDM,92921,CPT,481,RC,,,outpatient,,,17563,12294.1,AETNA [1000108],AETNA [100010801],,,76.8,,13488.38,399.86,13488.384,percent of total billed charges,,,
HC Prq Trluml Coronary Angio/Atherect One Art/Brnch,PX-48100014,CDM,92924,CPT,481,RC,,,outpatient,,,33484,23438.8,AETNA [1000108],AETNA [100010801],,,76.8,,25715.71,399.86,25715.712,percent of total billed charges,,,
HC Prq Trluml Coronary Angio/Atherec Addl Art/Brnch,PX-48100015,CDM,92925,CPT,481,RC,,,outpatient,,,32854,22997.8,AETNA [1000108],AETNA [100010801],,,76.8,,25231.87,399.86,25231.872,percent of total billed charges,,,
HC Prq Trluml Coronary Stent W/Angio One Art/Brnch,PX-48100016,CDM,92928,CPT,481,RC,,,outpatient,,,32584,22808.8,AETNA [1000108],AETNA [100010801],,,76.8,,25024.51,399.86,25024.512,percent of total billed charges,,,
HC Prq Trluml Coronary Stent W/Angio Addl Art/Brnch,PX-48100017,CDM,92929,CPT,481,RC,,,outpatient,,,26673,18671.1,AETNA [1000108],AETNA [100010801],,,76.8,,20484.86,399.86,20484.864,percent of total billed charges,,,
HC Prq Trluml Coronry Stent/Ath/Angio One Art/Brnch,PX-48100018,CDM,92933,CPT,481,RC,,,outpatient,,,33887,23720.9,AETNA [1000108],AETNA [100010801],,,76.8,,26025.22,399.86,26793.51305,percent of total billed charges,,,
HC Prq Trluml Coronary Stent/Ath/Angio Addl Branch,PX-48100019,CDM,92934,CPT,481,RC,,,outpatient,,,26169,18318.3,AETNA [1000108],AETNA [100010801],,,76.8,,20097.79,399.86,20097.792,percent of total billed charges,,,
HC Prq Trluml Coronary Byp Grft Revasc One Vessel,PX-48100020,CDM,92937,CPT,481,RC,,,outpatient,,,26673,18671.1,AETNA [1000108],AETNA [100010801],,,76.8,,20484.86,399.86,20484.864,percent of total billed charges,,,
HC Prq Trluml Coronary Byp Grft Revasc Addl Vessel,PX-48100021,CDM,92938,CPT,481,RC,,,outpatient,,,26169,18318.3,AETNA [1000108],AETNA [100010801],,,76.8,,20097.79,399.86,20097.792,percent of total billed charges,,,
HC Prq Trluml Coronry Chronic Occlus Revasc One Vsl,PX-48100023,CDM,92943,CPT,481,RC,,,outpatient,,,25667,17966.9,AETNA [1000108],AETNA [100010801],,,76.8,,19712.26,399.86,19712.256,percent of total billed charges,,,
HC Prq Trluml Coronry Chrnic Occlus Revasc Addl Vsl,PX-48100024,CDM,92944,CPT,481,RC,,,outpatient,,,26169,18318.3,AETNA [1000108],AETNA [100010801],,,76.8,,20097.79,399.86,20097.792,percent of total billed charges,,,
HC Heart/Lung Resuscitation (Cpr),PX-48000001,CDM,92950,CPT,480,RC,,,outpatient,,,1034,723.8,AETNA [1000108],AETNA [100010801],,,76.8,,794.11,232.133,997.822944,percent of total billed charges,,,
HC PR Cardiopulmonary Resuscitation,PX-96000048,CDM,92950,CPT,960,RC,,,outpatient,,,1034,723.8,AETNA [1000108],AETNA [100010801],,,76.8,,794.11,232.133,997.822944,percent of total billed charges,,,
HC Temporary External Pacing,PX-48000002,CDM,92953,CPT,480,RC,,,outpatient,,,1302,911.4,AETNA [1000108],AETNA [100010801],,,76.8,,999.94,292.299,999.936,percent of total billed charges,,,
HC Cardioversion- Elective;Extern,PX-48000003,CDM,92960,CPT,480,RC,,,outpatient,,,2006,1404.2,AETNA [1000108],AETNA [100010801],,,76.8,,1540.61,399.86,1540.608,percent of total billed charges,,,
HC PR Cardioversion Elective Arrhythmia External,PX-96000049,CDM,92960,CPT,960,RC,,,outpatient,,,2006,1404.2,AETNA [1000108],AETNA [100010801],,,76.8,,1540.61,399.86,1540.608,percent of total billed charges,,,
HC Prq Transluminal Coronary Mechanicl Thrombectomy,PX-48000005,CDM,92973,CPT,480,RC,,,outpatient,,,773,541.1,AETNA [1000108],AETNA [100010801],,,76.8,,593.66,173.5385,593.664,percent of total billed charges,,,
HC Intrav Optcl Chernce Tmgrphy W/S&I Intl Vesl,PX-36900031,CDM,92978,CPT,369,RC,,,outpatient,,,2785,1949.5,AETNA [1000108],AETNA [100010801],,,76.8,,2138.88,145.12362,2138.88,percent of total billed charges,,,
HC Intravasc US-Heart-1st Vessel,PX-48100025,CDM,92978,CPT,481,RC,,,outpatient,,,2785,1949.5,AETNA [1000108],AETNA [100010801],,,76.8,,2138.88,145.12362,2138.88,percent of total billed charges,,,
HC Intrav Optcal Cohrnce Tmgrphy W/S&I Adl Vesl,PX-36900032,CDM,92979,CPT,369,RC,,,outpatient,,,755,528.5,AETNA [1000108],AETNA [100010801],,,76.8,,579.84,169.4975,1592,percent of total billed charges,,,
HC Intravasc Coronary Sono-Addn Vessel,PX-48100026,CDM,92979,CPT,481,RC,,,outpatient,,,755,528.5,AETNA [1000108],AETNA [100010801],,,76.8,,579.84,169.4975,1592,percent of total billed charges,,,
HC Percut Aortic Valvuloplasty,PX-48100027,CDM,92986,CPT,481,RC,,,outpatient,,,17231,12061.7,AETNA [1000108],AETNA [100010801],,,76.8,,13233.41,399.86,13233.408,percent of total billed charges,,,
HC Percut Mitral Valvuloplasty,PX-48100028,CDM,92987,CPT,481,RC,,,outpatient,,,17231,12061.7,AETNA [1000108],AETNA [100010801],,,76.8,,13233.41,399.86,16809.6787,percent of total billed charges,,,
HC Percut Pulmonary Valvuloplasty,PX-48100029,CDM,92990,CPT,481,RC,,,outpatient,,,17231,12061.7,AETNA [1000108],AETNA [100010801],,,76.8,,13233.41,399.86,16809.6787,percent of total billed charges,,,
HC Electrocardiogram- Tracing,PX-73000001,CDM,93005,CPT,730,RC,,,outpatient,,,157,109.9,AETNA [1000108],AETNA [100010801],,,76.8,,120.58,25.49469,416.02,percent of total billed charges,,,
HC PR Electrocardiogram Report,PX-98500001,CDM,93010,CPT,985,RC,,,outpatient,,,28,19.6,AETNA [1000108],AETNA [100010801],,,76.8,,21.5,6.286,416.02,percent of total billed charges,,,
HC Cardiac Stress Tst-Tracing Only,PX-48200001,CDM,93017,CPT,482,RC,,,outpatient,,,485,339.5,AETNA [1000108],AETNA [100010801],,,76.8,,372.48,108.8825,479.602522,percent of total billed charges,,,
HC Rhythm Ecg- Tracing,PX-73000003,CDM,93041,CPT,730,RC,,,outpatient,,,120,84,AETNA [1000108],AETNA [100010801],,,76.8,,92.16,25.49469,416.02,percent of total billed charges,,,
HC PR Rhythm Ecg 1-3 Leads Interpretation & Reprt On,PX-98500004,CDM,93042,CPT,985,RC,,,outpatient,,,22,15.4,AETNA [1000108],AETNA [100010801],,,76.8,,16.9,4.939,416.02,percent of total billed charges,,,
HC Ext Ecg Record Contin 48 Hr- Record,PX-73100001,CDM,93225,CPT,731,RC,,,outpatient,,,433,303.1,AETNA [1000108],AETNA [100010801],,,76.8,,332.54,84.459332,416.02,percent of total billed charges,,,
HC Ext Ecg Record Contin 48 Hr- Scan Analysis W Report,PX-73100002,CDM,93226,CPT,731,RC,,,outpatient,,,318,222.6,AETNA [1000108],AETNA [100010801],,,76.8,,244.22,66.75974,416.02,percent of total billed charges,,,
HC PR Xtrnl Ecg Continuous Rhythm W/I&R Up to 48 Hrs,PX-98500002,CDM,93227,CPT,985,RC,,,outpatient,,,63,44.1,AETNA [1000108],AETNA [100010801],,,76.8,,48.38,14.1435,416.02,percent of total billed charges,,,
HC Prgrmg Dev Eval 1 Lead Pm/Ldls Pm 1 Car Chmbr IP,PX-48000087,CDM,93279,CPT,480,RC,,,outpatient,,,118,82.6,AETNA [1000108],AETNA [100010801],,,76.8,,90.62,26.491,416.02,percent of total billed charges,,,
HC Program Eval Implantable in Persn Dual Ld Pacer,PX-92000010,CDM,93280,CPT,920,RC,,,outpatient,,,1217,851.9,AETNA [1000108],AETNA [100010801],,,76.8,,934.66,41.157815,934.656,percent of total billed charges,,,
HC Program Eval Implantable in Prsn Multi Ld Pacer,PX-48000088,CDM,93281,CPT,480,RC,,,outpatient,,,118,82.6,AETNA [1000108],AETNA [100010801],,,76.8,,90.62,26.491,416.02,percent of total billed charges,,,
HC Prgrmng Dev Eval Implantable in Persn 1 Ld Dfb,PX-48000089,CDM,93282,CPT,480,RC,,,outpatient,,,118,82.6,AETNA [1000108],AETNA [100010801],,,76.8,,90.62,26.491,416.02,percent of total billed charges,,,
HC Progrm Eval Implantable in Prsn Dual L Card/Dfb,PX-48000009,CDM,93283,CPT,480,RC,,,outpatient,,,1878,1314.6,AETNA [1000108],AETNA [100010801],,,76.8,,1442.3,41.157815,1442.304,percent of total billed charges,,,
HC Prgrmg Eval Implantable in Person Multi Lead Dfb,PX-48000090,CDM,93284,CPT,480,RC,,,outpatient,,,118,82.6,AETNA [1000108],AETNA [100010801],,,76.8,,90.62,26.491,416.02,percent of total billed charges,,,
HC Prgrmg Dev Eval Scrms Phys/Qhp in Person,PX-48000091,CDM,93285,CPT,480,RC,,,outpatient,,,118,82.6,AETNA [1000108],AETNA [100010801],,,76.8,,90.62,26.491,416.02,percent of total billed charges,,,
HC Interrogation Eval in Person 1/Dual/Mlt Lead Pm,PX-48000010,CDM,93288,CPT,480,RC,,,outpatient,,,224,156.8,AETNA [1000108],AETNA [100010801],,,76.8,,172.03,41.157815,416.02,percent of total billed charges,,,
HC Interrog Eval F2f 1/Dual/Mlt Leads Impltbl Dfb,PX-48000086,CDM,93289,CPT,480,RC,,,outpatient,,,118,82.6,AETNA [1000108],AETNA [100010801],,,76.8,,90.62,26.491,416.02,percent of total billed charges,,,
HC Interrogation Evaluation in Person Ilr System,PX-92000011,CDM,93291,CPT,920,RC,,,outpatient,,,248,173.6,AETNA [1000108],AETNA [100010801],,,76.8,,190.46,23.39896,416.02,percent of total billed charges,,,
Rem Interrog Pm/Ldls Pm/Ids <90 D Tech Review,PX-48000085,CDM,93296,CPT,480,RC,,,outpatient,,,118,82.6,AETNA [1000108],AETNA [100010801],,,76.8,,90.62,26.491,416.02,percent of total billed charges,,,
HC Echo Xthoracic-Cong Anom-Complete,PX-48000014,CDM,93303,CPT,480,RC,,,outpatient,,,1337,935.9,AETNA [1000108],AETNA [100010801],,,76.8,,1026.82,54.1045,1223.3,percent of total billed charges,,,
HC PR Echo Xthoracic-Cong Anom-Complete,PX-96000009,CDM,93303,CPT,960,RC,,,outpatient,,,241,168.7,AETNA [1000108],AETNA [100010801],,,76.8,,185.09,54.1045,1223.3,percent of total billed charges,,,
HC Echo Xthoracic-Cong Anom-Limited,PX-48000015,CDM,93304,CPT,480,RC,,,outpatient,,,1303,912.1,AETNA [1000108],AETNA [100010801],,,76.8,,1000.7,281.81,1040.64,percent of total billed charges,,,
HC PR Echo Xthoracic-Cong Anom-Limited,PX-96000010,CDM,93304,CPT,960,RC,,,outpatient,,,1355,948.5,AETNA [1000108],AETNA [100010801],,,76.8,,1040.64,281.81,1040.64,percent of total billed charges,,,
HC Echo Heart Xthoracic-Complete W Doppler W/Contrast,PX-48000016,CDM,93306,CPT,480,RC,,,outpatient,,,1347,942.9,AETNA [1000108],AETNA [100010801],,,76.8,,1034.5,54.1045,1034.496,percent of total billed charges,,,
HC Echo Heart Xthoracic-Complete W Doppler W/O Contrast,PX-48000068,CDM,93306,CPT,480,RC,,,outpatient,,,1347,942.9,AETNA [1000108],AETNA [100010801],,,76.8,,1034.5,54.1045,1034.496,percent of total billed charges,,,
HC PR Echo Heart Xthoracic-Complete W Doppler,PX-96000036,CDM,93306,CPT,960,RC,,,outpatient,,,241,168.7,AETNA [1000108],AETNA [100010801],,,76.8,,185.09,54.1045,1034.496,percent of total billed charges,,,
HC Echo Heart Xthoracic-Complete- W/O Doppler W/Contrast,PX-48000017,CDM,93307,CPT,480,RC,,,outpatient,,,1228,859.6,AETNA [1000108],AETNA [100010801],,,76.8,,943.1,267.439885,943.104,percent of total billed charges,,,
HC Echo Heart Xthoracic-Complete- W/O Doppler W/O Contrast,PX-48000063,CDM,93307,CPT,480,RC,,,outpatient,,,1228,859.6,AETNA [1000108],AETNA [100010801],,,76.8,,943.1,267.439885,943.104,percent of total billed charges,,,
HC Echo Heart Xthoracic-Limited W/Contrast,PX-48000018,CDM,93308,CPT,480,RC,,,outpatient,,,561,392.7,AETNA [1000108],AETNA [100010801],,,76.8,,430.85,125.9445,465.66,percent of total billed charges,,,
HC Echo Heart Xthoracic-Limited W/O Contrast,PX-48000065,CDM,93308,CPT,480,RC,,,outpatient,,,561,392.7,AETNA [1000108],AETNA [100010801],,,76.8,,430.85,125.9445,465.66,percent of total billed charges,,,
HC PR Echo Heart Xthoracic-Limited,PX-96000037,CDM,93308,CPT,960,RC,,,outpatient,,,561,392.7,AETNA [1000108],AETNA [100010801],,,76.8,,430.85,125.9445,465.66,percent of total billed charges,,,
HC Echo Heart-Transesophageal-Complete W/Contrast,PX-48000019,CDM,93312,CPT,480,RC,,,outpatient,,,1764,1234.8,AETNA [1000108],AETNA [100010801],,,76.8,,1354.75,224.549385,1354.752,percent of total billed charges,,,
HC Echo Heart-Transesophageal-Complete W/O Contrast,PX-48000064,CDM,93312,CPT,480,RC,,,outpatient,,,1764,1234.8,AETNA [1000108],AETNA [100010801],,,76.8,,1354.75,224.549385,1354.752,percent of total billed charges,,,
HC Echo R-T 2d W/Probe Placement Only,PX-48000083,CDM,93313,CPT,480,RC,,,outpatient,,,1501,1050.7,AETNA [1000108],AETNA [100010801],,,76.8,,1152.77,336.9745,1152.768,percent of total billed charges,,,
HC 3d Echo Img&Pst-Pxessing Tee/Tte Cgen Car Anomal,PX-48000084,CDM,93319,CPT,480,RC,,,outpatient,,,352,246.4,AETNA [1000108],AETNA [100010801],,,76.8,,270.34,79.024,416.02,percent of total billed charges,,,
HC Doppler Echo Heart-Complete,PX-48000020,CDM,93320,CPT,480,RC,,,outpatient,,,323,226.1,AETNA [1000108],AETNA [100010801],,,76.8,,248.06,72.5135,416.02,percent of total billed charges,,,
HC Doppler Echo Heart-Limited-F/U,PX-48000021,CDM,93321,CPT,480,RC,,,outpatient,,,384,268.8,AETNA [1000108],AETNA [100010801],,,76.8,,294.91,86.208,416.02,percent of total billed charges,,,
HC Doppler Color Flow Velocity Map,PX-48000022,CDM,93325,CPT,480,RC,,,outpatient,,,744,520.8,AETNA [1000108],AETNA [100010801],,,76.8,,571.39,135.906309,571.392,percent of total billed charges,,,
HC Echo Heart Xthoracic- Stress/Rest W/Contrast,PX-48000023,CDM,93350,CPT,480,RC,,,outpatient,,,1384,968.8,AETNA [1000108],AETNA [100010801],,,76.8,,1062.91,224.549385,1062.912,percent of total billed charges,,,
HC Echo Heart Xthoracic- Stress/Rest W/O Contrast,PX-48000066,CDM,93350,CPT,480,RC,,,outpatient,,,1384,968.8,AETNA [1000108],AETNA [100010801],,,76.8,,1062.91,224.549385,1062.912,percent of total billed charges,,,
HC Echo Tthrc R-T 2d W/WO M-Mode Rest&Strs Cont Ecg W/Contrast,PX-48000024,CDM,93351,CPT,480,RC,,,outpatient,,,1785,1249.5,AETNA [1000108],AETNA [100010801],,,76.8,,1370.88,224.549385,1370.88,percent of total billed charges,,,
HC Echo Tthrc R-T 2d W/WO M-Mode Rest&Strs Cont Ecg W/O Contrast,PX-48000067,CDM,93351,CPT,480,RC,,,outpatient,,,1785,1249.5,AETNA [1000108],AETNA [100010801],,,76.8,,1370.88,224.549385,1370.88,percent of total billed charges,,,
HC Echo Tee Guid Tcat Icar/Vessel Structural Intvn,PX-48000052,CDM,93355,CPT,480,RC,,,outpatient,,,778,544.6,AETNA [1000108],AETNA [100010801],,,76.8,,597.5,174.661,597.504,percent of total billed charges,,,
HC Myocrd Strain Img Speckle Trck Assmt Myocrd Mech,PX-48000480,CDM,93356,CPT,480,RC,,,outpatient,,,1077,753.9,AETNA [1000108],AETNA [100010801],,,76.8,,827.14,241.7865,827.136,percent of total billed charges,,,
HC Right Heart Cath O2 Saturation & Cardiac Output,PX-48100030,CDM,93451,CPT,481,RC,,,outpatient,,,9177,6423.9,AETNA [1000108],AETNA [100010801],,,76.8,,7047.94,399.86,7870.4,percent of total billed charges,,,
HC Cath Place/Coronary Angio- Img Super/Interp,PX-48100031,CDM,93454,CPT,481,RC,,,outpatient,,,10988,7691.6,AETNA [1000108],AETNA [100010801],,,76.8,,8438.78,399.86,8438.784,percent of total billed charges,,,
HC Cath Place/Coronary Angio- Img Super/Interp- Bypass Angio,PX-48100032,CDM,93455,CPT,481,RC,,,outpatient,,,10988,7691.6,AETNA [1000108],AETNA [100010801],,,76.8,,8438.78,399.86,8438.784,percent of total billed charges,,,
HC Cath Place/Coronary Angio- Img Super/Interp-W Right Heart Cath,PX-48100033,CDM,93456,CPT,481,RC,,,outpatient,,,10988,7691.6,AETNA [1000108],AETNA [100010801],,,76.8,,8438.78,399.86,8438.784,percent of total billed charges,,,
HC Cath Place/Coron Angio- Img Super/Interp- Bypass Angio-W R Heart Cath,PX-48100034,CDM,93457,CPT,481,RC,,,outpatient,,,9755,6828.5,AETNA [1000108],AETNA [100010801],,,76.8,,7491.84,399.86,7870.4,percent of total billed charges,,,
HC Cath Place/Coron Angio- Img Super/Interp-W Left Heart Ventriculography,PX-48100035,CDM,93458,CPT,481,RC,,,outpatient,,,9755,6828.5,AETNA [1000108],AETNA [100010801],,,76.8,,7491.84,399.86,7870.4,percent of total billed charges,,,
HC Cath Place/Coron Angio- Img Super/Interp- Bypass Angio-W L Hrt Ventric,PX-48100036,CDM,93459,CPT,481,RC,,,outpatient,,,10988,7691.6,AETNA [1000108],AETNA [100010801],,,76.8,,8438.78,399.86,8438.784,percent of total billed charges,,,
HC Cath Place/Coron Angio- Img Super/Interp-R&L Hrt Cath- L Hrt Ventric,PX-48100037,CDM,93460,CPT,481,RC,,,outpatient,,,10988,7691.6,AETNA [1000108],AETNA [100010801],,,76.8,,8438.78,399.86,8438.784,percent of total billed charges,,,
HC Cath Place/Cor Ang-Img Supr/Intrp-Bypass Ang- R&L Cath- L Hrt Ventric,PX-48100038,CDM,93461,CPT,481,RC,,,outpatient,,,10988,7691.6,AETNA [1000108],AETNA [100010801],,,76.8,,8438.78,399.86,8438.784,percent of total billed charges,,,
HC Left Heart Cath by Transeptal Puncture,PX-48100039,CDM,93462,CPT,481,RC,,,outpatient,,,10365,7255.5,AETNA [1000108],AETNA [100010801],,,76.8,,7960.32,399.86,7960.32,percent of total billed charges,,,
HC Insert/Place Flow Direct Cath,PX-36900885,CDM,93503,CPT,369,RC,,,outpatient,,,2998,2098.6,AETNA [1000108],AETNA [100010801],,,76.8,,2302.46,399.86,2532.39,percent of total billed charges,,,
HC Insert/Place Flow Direct Cath,PX-48000025,CDM,93503,CPT,480,RC,,,outpatient,,,2998,2098.6,AETNA [1000108],AETNA [100010801],,,76.8,,2302.46,399.86,2532.39,percent of total billed charges,,,
HC Inject Select Cor Angio During Congenital Heart Cath,PX-48100044,CDM,93563,CPT,481,RC,,,outpatient,,,2542,1779.4,AETNA [1000108],AETNA [100010801],,,76.8,,1952.26,399.86,1952.256,percent of total billed charges,,,
HC Inject Select Cor/Graft Angio During Congenital Heart Cath,PX-48100045,CDM,93564,CPT,481,RC,,,outpatient,,,1018,712.6,AETNA [1000108],AETNA [100010801],,,76.8,,781.82,228.541,1592,percent of total billed charges,,,
HC Inject Select Left Vent/Atrial Angio During Heart Cath,PX-48100046,CDM,93565,CPT,481,RC,,,outpatient,,,510,357,AETNA [1000108],AETNA [100010801],,,76.8,,391.68,114.495,1592,percent of total billed charges,,,
HC Inject Select Right Vent/Atrial Angio During Heart Cath,PX-48100047,CDM,93566,CPT,481,RC,,,outpatient,,,1018,712.6,AETNA [1000108],AETNA [100010801],,,76.8,,781.82,228.541,1592,percent of total billed charges,,,
HC Inject Supravalvular Aortography During Heart Cath,PX-48100048,CDM,93567,CPT,481,RC,,,outpatient,,,1498,1048.6,AETNA [1000108],AETNA [100010801],,,76.8,,1150.46,235.074116,1592,percent of total billed charges,,,
HC Heart Flow Reserv Measure-Init Vessl,PX-48000026,CDM,93571,CPT,480,RC,,,outpatient,,,6936,4855.2,AETNA [1000108],AETNA [100010801],,,76.8,,5326.85,399.86,5638.7,percent of total billed charges,,,
HC Heart Flow Reserv Measure-Addn Vessl,PX-48000027,CDM,93572,CPT,480,RC,,,outpatient,,,2051,1435.7,AETNA [1000108],AETNA [100010801],,,76.8,,1575.17,399.86,1575.168,percent of total billed charges,,,
HC Perc Clos-Cong Interatrial Commun W/Impl,PX-48100049,CDM,93580,CPT,481,RC,,,outpatient,,,53254,37277.8,AETNA [1000108],AETNA [100010801],,,76.8,,40899.07,399.86,40899.072,percent of total billed charges,,,
HC Perc Closure-Cong Vsd W/Implant,PX-48100050,CDM,93581,CPT,481,RC,,,outpatient,,,53254,37277.8,AETNA [1000108],AETNA [100010801],,,76.8,,40899.07,399.86,40899.072,percent of total billed charges,,,
HC Percutan Transcath Closure Pat Duct Arteriosus,PX-36900556,CDM,93582,CPT,369,RC,,,outpatient,,,52790,36953,AETNA [1000108],AETNA [100010801],,,76.8,,40542.72,399.86,40542.72,percent of total billed charges,,,
HC Percutan Transcath Closure Pat Duct Arteriosus,PX-48100051,CDM,93582,CPT,481,RC,,,outpatient,,,52790,36953,AETNA [1000108],AETNA [100010801],,,76.8,,40542.72,399.86,40542.72,percent of total billed charges,,,
HC Percutaneous Transcatheter Septal Reduction Ther,PX-48100055,CDM,93583,CPT,481,RC,,,outpatient,,,16899,11829.3,AETNA [1000108],AETNA [100010801],,,76.8,,12978.43,399.86,12978.432,percent of total billed charges,,,
HC Heart Pacing- Mapping,PX-48000042,CDM,93631,CPT,480,RC,,,outpatient,,,8496,5947.2,AETNA [1000108],AETNA [100010801],,,76.8,,6524.93,399.86,6909.98,percent of total billed charges,,,
HC Eval Cardiovert Leads-Initial,PX-48000043,CDM,93640,CPT,480,RC,,,outpatient,,,5892,4124.4,AETNA [1000108],AETNA [100010801],,,76.8,,4525.06,399.86,4525.056,percent of total billed charges,,,
HC Eval Cardiovert Leads/Puls Gen,PX-48000044,CDM,93641,CPT,480,RC,,,outpatient,,,3075,2152.5,AETNA [1000108],AETNA [100010801],,,76.8,,2361.6,399.86,2361.6,percent of total billed charges,,,
HC Electrophys Eval-Cardioverter,PX-48000045,CDM,93642,CPT,480,RC,,,outpatient,,,3083,2158.1,AETNA [1000108],AETNA [100010801],,,76.8,,2367.74,399.86,2367.744,percent of total billed charges,,,
HC Tilt Table Evaluation,PX-48000049,CDM,93660,CPT,480,RC,,,outpatient,,,3083,2158.1,AETNA [1000108],AETNA [100010801],,,76.8,,2367.74,399.86,2367.744,percent of total billed charges,,,
HC Intracard Echo- Ther/Dx Intervent,PX-48000050,CDM,93662,CPT,480,RC,,,outpatient,,,7689,5382.3,AETNA [1000108],AETNA [100010801],,,76.8,,5905.15,399.86,10671.09667,percent of total billed charges,,,
HC Analyze Pacer Sys,PX-48000051,CDM,93724,CPT,480,RC,,,outpatient,,,1217,851.9,AETNA [1000108],AETNA [100010801],,,76.8,,934.66,73.54,934.656,percent of total billed charges,,,
HC Outpatient Cardiac Rehab W/O Cont Ecg Monitor,PX-94300002,CDM,93797,CPT,943,RC,,,outpatient,,,255,178.5,AETNA [1000108],AETNA [100010801],,,76.8,,195.84,57.2475,416.02,percent of total billed charges,,,
HC Outpatient Cardiac Rehab W/Cont Ecg Monitoring,PX-94300003,CDM,93798,CPT,943,RC,,,outpatient,,,271,189.7,AETNA [1000108],AETNA [100010801],,,76.8,,208.13,60.8395,416.02,percent of total billed charges,,,
HC Duplex Scan Extracranial-Bilat,PX-92100008,CDM,93880,CPT,921,RC,,,outpatient,,,915,640.5,AETNA [1000108],AETNA [100010801],,,76.8,,702.72,199.512292,702.72,percent of total billed charges,,,
HC Duplex Scan Extracranial-Limited,PX-92100010,CDM,93882,CPT,921,RC,,,outpatient,,,915,640.5,AETNA [1000108],AETNA [100010801],,,76.8,,702.72,119.991125,702.72,percent of total billed charges,,,
HC Transcran Doppler Intracran Art,PX-92100011,CDM,93886,CPT,921,RC,,,outpatient,,,1137,795.9,AETNA [1000108],AETNA [100010801],,,76.8,,873.22,255.2565,873.216,percent of total billed charges,,,
HC Transcran Doppler Intracran-Limited,PX-92100013,CDM,93888,CPT,921,RC,,,outpatient,,,428,299.6,AETNA [1000108],AETNA [100010801],,,76.8,,328.7,96.086,686,percent of total billed charges,,,
HC Transcran Doppl Intracran- Vasoreact,PX-92100015,CDM,93890,CPT,921,RC,,,outpatient,,,952,666.4,AETNA [1000108],AETNA [100010801],,,76.8,,731.14,213.724,731.136,percent of total billed charges,,,
HC Non-Invas Physiologic Std Extremity Art 1-2 Level,PX-92100017,CDM,93922,CPT,921,RC,,,outpatient,,,915,640.5,AETNA [1000108],AETNA [100010801],,,76.8,,702.72,135.906309,702.72,percent of total billed charges,,,
HC Non-Invasive Physiologic Study Extremity 3 Levels,PX-92100019,CDM,93923,CPT,921,RC,,,outpatient,,,701,490.7,AETNA [1000108],AETNA [100010801],,,76.8,,538.37,121.132463,686,percent of total billed charges,,,
HC Non-Invasive Lower Extrem Art Stress/Rest- Complete-Bilateral,PX-92100020,CDM,93924,CPT,921,RC,,,outpatient,,,915,640.5,AETNA [1000108],AETNA [100010801],,,76.8,,702.72,135.906309,775.5705,percent of total billed charges,,,
HC Duplex Lo Extrem Art Bilat,PX-92100022,CDM,93925,CPT,921,RC,,,outpatient,,,915,640.5,AETNA [1000108],AETNA [100010801],,,76.8,,702.72,199.512292,702.72,percent of total billed charges,,,
HC Duplex Lo Extrem Art Unilat/Ltd,PX-92100024,CDM,93926,CPT,921,RC,,,outpatient,,,441,308.7,AETNA [1000108],AETNA [100010801],,,76.8,,338.69,99.0045,686,percent of total billed charges,,,
HC Duplex Up Extrem Art Bilat,PX-92100025,CDM,93930,CPT,921,RC,,,outpatient,,,842,589.4,AETNA [1000108],AETNA [100010801],,,76.8,,646.66,135.906309,686,percent of total billed charges,,,
HC Duplex Up Extrem Art Bilat,PX-92100026,CDM,93930,CPT,921,RC,,,outpatient,,,842,589.4,AETNA [1000108],AETNA [100010801],,,76.8,,646.66,135.906309,686,percent of total billed charges,,,
HC Duplex Up Extrem Art Unilat/Ltd,PX-92100028,CDM,93931,CPT,921,RC,,,outpatient,,,915,640.5,AETNA [1000108],AETNA [100010801],,,76.8,,702.72,119.991125,702.72,percent of total billed charges,,,
HC Duplex Extrem Venous-Bilat,PX-92100031,CDM,93970,CPT,921,RC,,,outpatient,,,758,530.6,AETNA [1000108],AETNA [100010801],,,76.8,,582.14,170.171,686,percent of total billed charges,,,
HC Duplex Extrem Venous-Bilat,PX-92100032,CDM,93970,CPT,921,RC,,,outpatient,,,758,530.6,AETNA [1000108],AETNA [100010801],,,76.8,,582.14,170.171,686,percent of total billed charges,,,
HC Duplex Extrem Venous-Uni or Ltd,PX-92100034,CDM,93971,CPT,921,RC,,,outpatient,,,915,640.5,AETNA [1000108],AETNA [100010801],,,76.8,,702.72,119.991125,702.72,percent of total billed charges,,,
HC Duplex Abd/Pel Vasc Study-Complete,PX-92100036,CDM,93975,CPT,921,RC,,,outpatient,,,816,571.2,AETNA [1000108],AETNA [100010801],,,76.8,,626.69,183.192,686,percent of total billed charges,,,
HC Duplex Abd/Pel Vasc Study-Limitd,PX-92100037,CDM,93976,CPT,921,RC,,,outpatient,,,418,292.6,AETNA [1000108],AETNA [100010801],,,76.8,,321.02,93.841,686,percent of total billed charges,,,
HC Duplex Large Vessel(S)-Complete,PX-92100039,CDM,93978,CPT,921,RC,,,outpatient,,,915,640.5,AETNA [1000108],AETNA [100010801],,,76.8,,702.72,199.512292,702.72,percent of total billed charges,,,
HC Duplex Large Vessel(S)-Limited,PX-92100041,CDM,93979,CPT,921,RC,,,outpatient,,,387,270.9,AETNA [1000108],AETNA [100010801],,,76.8,,297.22,86.8815,686,percent of total billed charges,,,
HC Duplex Hemodialysis Access,PX-92100042,CDM,93990,CPT,921,RC,,,outpatient,,,614,429.8,AETNA [1000108],AETNA [100010801],,,76.8,,471.55,119.991125,686,percent of total billed charges,,,
HC Breathing Capacity Test,PX-46000002,CDM,94010,CPT,460,RC,,,outpatient,,,295,206.5,AETNA [1000108],AETNA [100010801],,,76.8,,226.56,66.2275,416.02,percent of total billed charges,,,
HC Eval of Bronchospasm,PX-46000003,CDM,94060,CPT,460,RC,,,outpatient,,,446,312.2,AETNA [1000108],AETNA [100010801],,,76.8,,342.53,100.127,479.602522,percent of total billed charges,,,
HC Eval of Bronchospasm-Prolonged,PX-46000004,CDM,94070,CPT,460,RC,,,outpatient,,,925,647.5,AETNA [1000108],AETNA [100010801],,,76.8,,710.4,163,710.4,percent of total billed charges,,,
HC Xers Tst Brncspsm Pre&Post Spmtry&Pls Ox W/Ecg,PX-46000023,CDM,94617,CPT,460,RC,,,outpatient,,,392,274.4,AETNA [1000108],AETNA [100010801],,,76.8,,301.06,88.004,416.02,percent of total billed charges,,,
HC Pulmonary Stress Testing,PX-46000022,CDM,94618,CPT,460,RC,,,outpatient,,,392,274.4,AETNA [1000108],AETNA [100010801],,,76.8,,301.06,88.004,416.02,percent of total billed charges,,,
HC Xers Tst Brncspsm Pre&Post Spmtry&Pls Ox WO /Ecg,PX-46000024,CDM,94619,CPT,460,RC,,,outpatient,,,182,127.4,AETNA [1000108],AETNA [100010801],,,76.8,,139.78,40.859,416.02,percent of total billed charges,,,
HC Inhal Rx- Airway Obst/Dx Sputum Induct,PX-41000006,CDM,94640,CPT,410,RC,,,outpatient,,,494,345.8,AETNA [1000108],AETNA [100010801],,,76.8,,379.39,59.92,416.02,percent of total billed charges,,,
HC Plethysmography Lung Volumes W/WO Airway Resist,PX-46000012,CDM,94726,CPT,460,RC,,,outpatient,,,446,312.2,AETNA [1000108],AETNA [100010801],,,76.8,,342.53,98.67,479.602522,percent of total billed charges,,,
HC Gas Dilut/Washout Lung Vol W/WO Distrib Vent&Vol,PX-46000013,CDM,94727,CPT,460,RC,,,outpatient,,,295,206.5,AETNA [1000108],AETNA [100010801],,,76.8,,226.56,66.2275,416.02,percent of total billed charges,,,
HC Diffusing Capacity,PX-46000014,CDM,94729,CPT,460,RC,,,outpatient,,,265,185.5,AETNA [1000108],AETNA [100010801],,,76.8,,203.52,59.4925,416.02,percent of total billed charges,,,
HC Noninvasv Oxygen Satur;Single,PX-46000015,CDM,94760,CPT,460,RC,,,outpatient,,,54,37.8,AETNA [1000108],AETNA [100010801],,,76.8,,41.47,12.123,416.02,percent of total billed charges,,,
HC Noninvasv Oxygen Satur-Multiple,PX-46000016,CDM,94761,CPT,460,RC,,,outpatient,,,90,63,AETNA [1000108],AETNA [100010801],,,76.8,,69.12,20.205,416.02,percent of total billed charges,,,
HC Car Seat/Bed Test Initial 60 Mins,PX-46000019,CDM,94780,CPT,460,RC,,,outpatient,,,194,135.8,AETNA [1000108],AETNA [100010801],,,76.8,,148.99,43.553,416.02,percent of total billed charges,,,
HC Car Seat/Bed Test Each Addl 30 Min,PX-46000020,CDM,94781,CPT,460,RC,,,outpatient,,,194,135.8,AETNA [1000108],AETNA [100010801],,,76.8,,148.99,43.553,416.02,percent of total billed charges,,,
HC Pulmonary Service/Procedure,PX-41000002,CDM,94799,CPT,410,RC,,,outpatient,,,367,256.9,AETNA [1000108],AETNA [100010801],,,76.8,,281.86,22.74,416.02,percent of total billed charges,,,
HC Eeg W/O Video by Tech 2-12 Hr Unmonitored,PX-74000012,CDM,95705,CPT,740,RC,,,outpatient,,,827,578.9,AETNA [1000108],AETNA [100010801],,,76.8,,635.14,185.6615,635.136,percent of total billed charges,,,
HC Eeg W/O Video by Tech 2-12 Hr Intermittent Mntr,PX-74000013,CDM,95706,CPT,740,RC,,,outpatient,,,827,578.9,AETNA [1000108],AETNA [100010801],,,76.8,,635.14,185.6615,635.136,percent of total billed charges,,,
HC Eeg W/O Video by Tech 2-12hr Continuous R-T Mntr,PX-74000014,CDM,95707,CPT,740,RC,,,outpatient,,,827,578.9,AETNA [1000108],AETNA [100010801],,,76.8,,635.14,185.6615,635.136,percent of total billed charges,,,
HC Eeg W/O Vid by Tech Ea Incr 12-26hr Unmonitored,PX-74000011,CDM,95708,CPT,740,RC,,,outpatient,,,1649,1154.3,AETNA [1000108],AETNA [100010801],,,76.8,,1266.43,370.2005,1266.432,percent of total billed charges,,,
HC Eeg W/O Vid by Tech Ea Incr 12-26 Hr Intmt Mntr,PX-74000015,CDM,95709,CPT,740,RC,,,outpatient,,,1585,1109.5,AETNA [1000108],AETNA [100010801],,,76.8,,1217.28,355.8325,1217.28,percent of total billed charges,,,
HC Eeg W/O Vid Tech Ea Incr 12-26 Hr Cont R-T Mntr,PX-74000016,CDM,95710,CPT,740,RC,,,outpatient,,,1585,1109.5,AETNA [1000108],AETNA [100010801],,,76.8,,1217.28,355.8325,1217.28,percent of total billed charges,,,
HC Electroencephalogram Extend Monitoring 41-60 Min,PX-74000008,CDM,95812,CPT,740,RC,,,outpatient,,,812,568.4,AETNA [1000108],AETNA [100010801],,,76.8,,623.62,182.294,623.616,percent of total billed charges,,,
HC Eeg >1 Hr,PX-74000002,CDM,95813,CPT,740,RC,,,outpatient,,,958,670.6,AETNA [1000108],AETNA [100010801],,,76.8,,735.74,215.071,735.744,percent of total billed charges,,,
HC Eeg-W/Awake & Drowsy Record,PX-74000003,CDM,95816,CPT,740,RC,,,outpatient,,,701,490.7,AETNA [1000108],AETNA [100010801],,,76.8,,538.37,157.3745,538.368,percent of total billed charges,,,
HC Eeg-W/Awake & Asleep Record,PX-74000004,CDM,95819,CPT,740,RC,,,outpatient,,,786,550.2,AETNA [1000108],AETNA [100010801],,,76.8,,603.65,176.457,603.648,percent of total billed charges,,,
HC Eeg-Coma/Sleep Record Only,PX-74000005,CDM,95822,CPT,740,RC,,,outpatient,,,675,472.5,AETNA [1000108],AETNA [100010801],,,76.8,,518.4,151.5375,518.4,percent of total billed charges,,,
HC Eeg Eval Cerebral Death,PX-74000006,CDM,95824,CPT,740,RC,,,outpatient,,,675,472.5,AETNA [1000108],AETNA [100010801],,,76.8,,518.4,151.5375,829.50194,percent of total billed charges,,,
HC Needle Emg Ea Extremity W/Paraspinl Area Limited,PX-92200011,CDM,95885,CPT,922,RC,,,outpatient,,,332,232.4,AETNA [1000108],AETNA [100010801],,,76.8,,254.98,14.817,570,percent of total billed charges,,,
HC PR Needle Emg Ea Extremity W/Paraspinl Area Limited,PX-96000021,CDM,95885,CPT,960,RC,,,outpatient,,,66,46.2,AETNA [1000108],AETNA [100010801],,,76.8,,50.69,14.817,570,percent of total billed charges,,,
HC Needle Emg Ea Extremty W/Paraspinl Area Complete,PX-92200012,CDM,95886,CPT,922,RC,,,outpatient,,,332,232.4,AETNA [1000108],AETNA [100010801],,,76.8,,254.98,30.083,570,percent of total billed charges,,,
HC PR Needle Emg Ea Extremty W/Paraspinl Area Complete,PX-96000022,CDM,95886,CPT,960,RC,,,outpatient,,,134,93.8,AETNA [1000108],AETNA [100010801],,,76.8,,102.91,30.083,570,percent of total billed charges,,,
HC Needle Emg Nonextremty Mscles W/Nerve Conduction,PX-92200013,CDM,95887,CPT,922,RC,,,outpatient,,,180,126,AETNA [1000108],AETNA [100010801],,,76.8,,138.24,20.4295,570,percent of total billed charges,,,
HC PR Needle Emg Nonextremty Mscles W/Nerve Conduction,PX-96000023,CDM,95887,CPT,960,RC,,,outpatient,,,91,63.7,AETNA [1000108],AETNA [100010801],,,76.8,,69.89,20.4295,570,percent of total billed charges,,,
HC Nerve Conduction Studies 1-2 Studies,PX-92200028,CDM,95907,CPT,922,RC,,,outpatient,,,760,532,AETNA [1000108],AETNA [100010801],,,76.8,,583.68,94.4,583.68,percent of total billed charges,,,
HC Motor &/Sens 7-8 Nrv Cndj Preconf Eltrode Limb,PX-92200017,CDM,95910,CPT,922,RC,,,outpatient,,,696,487.2,AETNA [1000108],AETNA [100010801],,,76.8,,534.53,94.4,570,percent of total billed charges,,,
HC PR Motor &/Sens 7-8 Nrv Cndj Preconf Eltrode Limb,PX-96000027,CDM,95910,CPT,960,RC,,,outpatient,,,724,506.8,AETNA [1000108],AETNA [100010801],,,76.8,,556.03,94.4,570,percent of total billed charges,,,
HC Ionm Remote/Nearby/>1 Patient in or per Hour,PX-92000015,CDM,95941,CPT,920,RC,,,outpatient,,,879,615.3,AETNA [1000108],AETNA [100010801],,,76.8,,675.07,197.3355,675.072,percent of total billed charges,,,
HC Eeg Digital Anylysis,PX-74000010,CDM,95957,CPT,740,RC,,,outpatient,,,696,487.2,AETNA [1000108],AETNA [100010801],,,76.8,,534.53,156.252,534.528,percent of total billed charges,,,
HC IV Inf- Hydration- 31 Min to 1 Hr,PX-26000001,CDM,96360,CPT,260,RC,,,outpatient,,,334,233.8,AETNA [1000108],AETNA [100010801],,,76.8,,256.51,74.983,416.02,percent of total billed charges,,,
HC IV Inf- Hydration- Each Add'l Hr,PX-26000002,CDM,96361,CPT,260,RC,,,outpatient,,,89,62.3,AETNA [1000108],AETNA [100010801],,,76.8,,68.35,19.9805,585.854902,percent of total billed charges,,,
HC IV Inf- Therapy - Init to 1 Hr (Spec Drug),PX-26000003,CDM,96365,CPT,260,RC,,,outpatient,,,418,292.6,AETNA [1000108],AETNA [100010801],,,76.8,,321.02,93.841,416.02,percent of total billed charges,,,
HC IV Inf- Therapy- Each Add Hr (Spec Drug),PX-26000004,CDM,96366,CPT,260,RC,,,outpatient,,,132,92.4,AETNA [1000108],AETNA [100010801],,,76.8,,101.38,29.634,585.854902,percent of total billed charges,,,
HC IV Infusion- Therap/Proph/Diagnost-Add Infusion-1st Hour,PX-26000005,CDM,96367,CPT,260,RC,,,outpatient,,,183,128.1,AETNA [1000108],AETNA [100010801],,,76.8,,140.54,41.0835,416.02,percent of total billed charges,,,
HC IV Infusion- Therap/Proph/Diagnost-Concurrent Infusion,PX-26000006,CDM,96368,CPT,260,RC,,,outpatient,,,109,76.3,AETNA [1000108],AETNA [100010801],,,76.8,,83.71,24.4705,416.02,percent of total billed charges,,,
HC Therapeutic Prophylactic/Dx Injection Subq/Im,PX-26000007,CDM,96372,CPT,260,RC,,,outpatient,,,162,113.4,AETNA [1000108],AETNA [100010801],,,76.8,,124.42,16.16,416.02,percent of total billed charges,,,
HC Injection-Therap/Proph/Diagnost- Intra-Arterial,PX-26000008,CDM,96373,CPT,260,RC,,,outpatient,,,334,233.8,AETNA [1000108],AETNA [100010801],,,76.8,,256.51,74.983,416.02,percent of total billed charges,,,
HC IV Push- Initial,PX-26000009,CDM,96374,CPT,260,RC,,,outpatient,,,309,216.3,AETNA [1000108],AETNA [100010801],,,76.8,,237.31,69.3705,416.02,percent of total billed charges,,,
HC IV Push- Ea Add Seq- of New Sub Drug,PX-26000010,CDM,96375,CPT,260,RC,,,outpatient,,,105,73.5,AETNA [1000108],AETNA [100010801],,,76.8,,80.64,23.5725,416.02,percent of total billed charges,,,
HC Injection-Therap/Proph/Diagnost- IV Push- Ea Add- Same Drug,PX-26000011,CDM,96376,CPT,260,RC,,,outpatient,,,303,212.1,AETNA [1000108],AETNA [100010801],,,76.8,,232.7,68.0235,416.02,percent of total billed charges,,,
HC Chemother-Non-Hormone Anti-Neopl- Sub-Q/Im,PX-33100001,CDM,96401,CPT,331,RC,,,outpatient,,,222,155.4,AETNA [1000108],AETNA [100010801],,,76.8,,170.5,49.839,416.02,percent of total billed charges,,,
HC Chemother- IV Push- Sngl Drug,PX-33100003,CDM,96409,CPT,331,RC,,,outpatient,,,691,483.7,AETNA [1000108],AETNA [100010801],,,76.8,,530.69,155.1295,530.688,percent of total billed charges,,,
HC Chemother- IV Infusion- 1 Hr,PX-33500001,CDM,96413,CPT,335,RC,,,outpatient,,,724,506.8,AETNA [1000108],AETNA [100010801],,,76.8,,556.03,162.538,556.032,percent of total billed charges,,,
HC Chemother- IV Infusion- Ea Add Hr,PX-33500002,CDM,96415,CPT,335,RC,,,outpatient,,,187,130.9,AETNA [1000108],AETNA [100010801],,,76.8,,143.62,41.9815,585.854902,percent of total billed charges,,,
HC Chemother-Ia Push Technique,PX-33100006,CDM,96420,CPT,331,RC,,,outpatient,,,668,467.6,AETNA [1000108],AETNA [100010801],,,76.8,,513.02,70.143083,517.481916,percent of total billed charges,,,
HC Chemother-Cns-W/Lumbar Puncture,PX-33100005,CDM,96450,CPT,331,RC,,,outpatient,,,657,459.9,AETNA [1000108],AETNA [100010801],,,76.8,,504.58,147.4965,585.854902,percent of total billed charges,,,
HC Ultraviolet Light Therapy,PX-94000005,CDM,96900,CPT,940,RC,,,outpatient,,,530,371,AETNA [1000108],AETNA [100010801],,,76.8,,407.04,34.385146,416.02,percent of total billed charges,,,
HC Mechanical Traction Therapy,PX-42100004,CDM,97012,CPT,421,RC,,,outpatient,,,245,171.5,AETNA [1000108],AETNA [100010801],,,76.8,,188.16,14.38,416.02,percent of total billed charges,,,
HC Electric Stimulation Therapy,PX-42100005,CDM,97014,CPT,421,RC,,,outpatient,,,123,86.1,AETNA [1000108],AETNA [100010801],,,76.8,,94.46,27.6135,416.02,percent of total billed charges,,,
HC Electrical Stimulation,PX-42100010,CDM,97032,CPT,421,RC,,,outpatient,,,123,86.1,AETNA [1000108],AETNA [100010801],,,76.8,,94.46,14.73,416.02,percent of total billed charges,,,
HC Electric Current Therapy,PX-42100011,CDM,97033,CPT,421,RC,,,outpatient,,,185,129.5,AETNA [1000108],AETNA [100010801],,,76.8,,142.08,20.02,416.02,percent of total billed charges,,,
HC Ultrasound Therapy,PX-42000005,CDM,97035,CPT,420,RC,,,outpatient,,,115,80.5,AETNA [1000108],AETNA [100010801],,,76.8,,88.32,14.44,416.02,percent of total billed charges,,,
HC Ultrasound Therapy,PX-42100013,CDM,97035,CPT,421,RC,,,outpatient,,,115,80.5,AETNA [1000108],AETNA [100010801],,,76.8,,88.32,14.44,416.02,percent of total billed charges,,,
HC Therapeutic Exercises,PX-42000006,CDM,97110,CPT,420,RC,,,outpatient,,,197,137.9,AETNA [1000108],AETNA [100010801],,,76.8,,151.3,30.33,416.02,percent of total billed charges,,,
HC Therapeutic Exercises,PX-42100014,CDM,97110,CPT,421,RC,,,outpatient,,,197,137.9,AETNA [1000108],AETNA [100010801],,,76.8,,151.3,30.33,416.02,percent of total billed charges,,,
HC Neuromusc Reeducat-1+ Areas- Ea 15 Min,PX-42000007,CDM,97112,CPT,420,RC,,,outpatient,,,115,80.5,AETNA [1000108],AETNA [100010801],,,76.8,,88.32,25.8175,416.02,percent of total billed charges,,,
HC Neuromusc Reeducat-1+ Areas- Ea 15 Min,PX-42100015,CDM,97112,CPT,421,RC,,,outpatient,,,115,80.5,AETNA [1000108],AETNA [100010801],,,76.8,,88.32,25.8175,416.02,percent of total billed charges,,,
HC Gait Training Therapy,PX-42100017,CDM,97116,CPT,421,RC,,,outpatient,,,115,80.5,AETNA [1000108],AETNA [100010801],,,76.8,,88.32,25.8175,416.02,percent of total billed charges,,,
HC Manual Ther Tech-1+Regions-Ea 15 Min,PX-42000008,CDM,97140,CPT,420,RC,,,outpatient,,,140,98,AETNA [1000108],AETNA [100010801],,,76.8,,107.52,27.89,416.02,percent of total billed charges,,,
HC Manual Ther Tech-1+Regions-Ea 15 Min,PX-42100018,CDM,97140,CPT,421,RC,,,outpatient,,,140,98,AETNA [1000108],AETNA [100010801],,,76.8,,107.52,27.89,416.02,percent of total billed charges,,,
HC Group Therapeutic Procedures,PX-42000009,CDM,97150,CPT,420,RC,,,outpatient,,,130,91,AETNA [1000108],AETNA [100010801],,,76.8,,99.84,18.56,416.02,percent of total billed charges,,,
HC Group Therapeutic Procedures,PX-42300001,CDM,97150,CPT,423,RC,,,outpatient,,,130,91,AETNA [1000108],AETNA [100010801],,,76.8,,99.84,18.56,416.02,percent of total billed charges,,,
HC Pt Eval Low Complex,PX-42400003,CDM,97161,CPT,424,RC,,,outpatient,,,260,182,AETNA [1000108],AETNA [100010801],,,76.8,,199.68,58.37,416.02,percent of total billed charges,,,
HC Pt Eval Mod Complex,PX-42400004,CDM,97162,CPT,424,RC,,,outpatient,,,260,182,AETNA [1000108],AETNA [100010801],,,76.8,,199.68,58.37,416.02,percent of total billed charges,,,
HC Pt Eval High Complex,PX-42400005,CDM,97163,CPT,424,RC,,,outpatient,,,260,182,AETNA [1000108],AETNA [100010801],,,76.8,,199.68,58.37,416.02,percent of total billed charges,,,
HC Pt Re-Eval Est Plan Care,PX-42400006,CDM,97164,CPT,424,RC,,,outpatient,,,231,161.7,AETNA [1000108],AETNA [100010801],,,76.8,,177.41,51.8595,416.02,percent of total billed charges,,,
HC Therapeut Actvity Direct Pt Contact Each 15 Min,PX-42100019,CDM,97530,CPT,421,RC,,,outpatient,,,115,80.5,AETNA [1000108],AETNA [100010801],,,76.8,,88.32,25.8175,416.02,percent of total billed charges,,,
HC Self-Care/Home Mgmt Training Each 15 Minutes,PX-42100020,CDM,97535,CPT,421,RC,,,outpatient,,,115,80.5,AETNA [1000108],AETNA [100010801],,,76.8,,88.32,25.8175,416.02,percent of total billed charges,,,
HC Orthotic Mgmt and Training- Each 15 Min,PX-42100027,CDM,97760,CPT,421,RC,,,outpatient,,,115,80.5,AETNA [1000108],AETNA [100010801],,,76.8,,88.32,25.8175,416.02,percent of total billed charges,,,
HC Prosthetic Training- Each 15 Min,PX-42100028,CDM,97761,CPT,421,RC,,,outpatient,,,104,72.8,AETNA [1000108],AETNA [100010801],,,76.8,,79.87,23.348,416.02,percent of total billed charges,,,
HC Med Nutr Ther- 1st- Indiv- Ea 15 Min,PX-94200006,CDM,97802,CPT,942,RC,,,outpatient,,,182,127.4,AETNA [1000108],AETNA [100010801],,,76.8,,139.78,34.45,416.02,percent of total billed charges,,,
HC Med Nutr Ther- Subsq- Indiv- Ea 15 Min,PX-94200007,CDM,97803,CPT,942,RC,,,outpatient,,,106,74.2,AETNA [1000108],AETNA [100010801],,,76.8,,81.41,23.797,416.02,percent of total billed charges,,,
HC Med Nutr Ther- Group- Ea 30 Min,PX-94200008,CDM,97804,CPT,942,RC,,,outpatient,,,52,36.4,AETNA [1000108],AETNA [100010801],,,76.8,,39.94,11.674,416.02,percent of total billed charges,,,
HC Mod Sed Same Phys/Qhp <5 Yrs,PX-37000019,CDM,99151,CPT,370,RC,,,outpatient,,,230,161,AETNA [1000108],AETNA [100010801],,,76.8,,176.64,51.635,416.02,percent of total billed charges,,,
HC Mod Sed Same Phys/Qhp 5/>Yrs,PX-37000020,CDM,99152,CPT,370,RC,,,outpatient,,,240,168,AETNA [1000108],AETNA [100010801],,,76.8,,184.32,53.88,416.02,percent of total billed charges,,,
HC Mod Sed Same Phys/Qhp Ea,PX-37000021,CDM,99153,CPT,370,RC,,,outpatient,,,240,168,AETNA [1000108],AETNA [100010801],,,76.8,,184.32,53.88,416.02,percent of total billed charges,,,
HC Mod Sed Oth Phys/Qhp <5 Yrs,PX-37000022,CDM,99155,CPT,370,RC,,,outpatient,,,361,252.7,AETNA [1000108],AETNA [100010801],,,76.8,,277.25,81.0445,416.02,percent of total billed charges,,,
HC Mod Sed Oth Phys/Qhp 5/>Yrs,PX-37000023,CDM,99156,CPT,370,RC,,,outpatient,,,240,168,AETNA [1000108],AETNA [100010801],,,76.8,,184.32,53.88,416.02,percent of total billed charges,,,
HC Mod Sed Other Phys/Qhp Ea,PX-37000024,CDM,99157,CPT,370,RC,,,outpatient,,,330,231,AETNA [1000108],AETNA [100010801],,,76.8,,253.44,74.085,416.02,percent of total billed charges,,,
HC Phlebotomy,PX-94000006,CDM,99195,CPT,940,RC,,,outpatient,,,312,218.4,AETNA [1000108],AETNA [100010801],,,76.8,,239.62,70.044,416.02,percent of total billed charges,,,
HC Office/Outpatient New Sf Mdm 15-29 Minutes,PX-51000025,CDM,99202,CPT,510,RC,,,outpatient,,,387,270.9,AETNA [1000108],AETNA [100010801],,,,,,82.56,416.02,other,E&M in Hospital/Facility,,
HC Office/Outpatient New Low Mdm 30-44 Minutes,PX-51000026,CDM,99203,CPT,510,RC,,,outpatient,,,573,401.1,AETNA [1000108],AETNA [100010801],,,,,,126.37,473.871,other,E&M in Hospital/Facility,,
HC Office/Outpatient New Moderate Mdm 45-59 Minutes,PX-51000027,CDM,99204,CPT,510,RC,,,outpatient,,,838,586.6,AETNA [1000108],AETNA [100010801],,,,,,179.35,693.026,other,E&M in Hospital/Facility,,
HC Office/Outpatient New High Mdm 60-74 Minutes,PX-51000028,CDM,99205,CPT,510,RC,,,outpatient,,,1192,834.4,AETNA [1000108],AETNA [100010801],,,,,,146.954008,985.784,other,E&M in Hospital/Facility,,
HC Office/Outpatient Est Pt May Not Req Phys/Qhp,PX-51000029,CDM,99211,CPT,510,RC,,,outpatient,,,287,200.9,AETNA [1000108],AETNA [100010801],,,,,,18.1184,416.02,other,E&M in Hospital/Facility,,
HC Office/Outpatient Est Pt May Not Req Phys/Qhp,PX-76100002,CDM,99211,CPT,761,RC,,,outpatient,,,287,200.9,AETNA [1000108],AETNA [100010801],,,,,,18.1184,416.02,other,E&M in Hospital/Facility,,
HC Office/Outpatient Est Pt May Not Req Phys/Qhp,PX-94200014,CDM,99211,CPT,942,RC,,,outpatient,,,287,200.9,AETNA [1000108],AETNA [100010801],,,76.8,,220.42,18.1184,416.02,percent of total billed charges,,,
HC Office/Outpatient Established Sf Mdm 10-19 Min,PX-51000030,CDM,99212,CPT,510,RC,,,outpatient,,,394,275.8,AETNA [1000108],AETNA [100010801],,,,,,50.2428,416.02,other,E&M in Hospital/Facility,,
HC Office/Outpatient Established Sf Mdm 10-19 Min,PX-94200015,CDM,99212,CPT,942,RC,,,outpatient,,,394,275.8,AETNA [1000108],AETNA [100010801],,,76.8,,302.59,50.2428,416.02,percent of total billed charges,,,
HC PR Office/Outpatient Established Sf Mdm 10-19 Min,PX-98800012,CDM,99212,CPT,988,RC,,,outpatient,,,373,261.1,AETNA [1000108],AETNA [100010801],,,76.8,,286.46,50.2428,416.02,percent of total billed charges,,,
HC Office/Outpatient Established Low Mdm 20-29 Min,PX-51000031,CDM,99213,CPT,510,RC,,,outpatient,,,431,301.7,AETNA [1000108],AETNA [100010801],,,,,,90.68,416.02,other,E&M in Hospital/Facility,,
HC Office/Outpatient Established Low Mdm 20-29 Min,PX-94200016,CDM,99213,CPT,942,RC,,,outpatient,,,431,301.7,AETNA [1000108],AETNA [100010801],,,76.8,,331.01,90.68,416.02,percent of total billed charges,,,
HC Office/Outpatient Established Mod Mdm 30-39 Min,PX-51000032,CDM,99214,CPT,510,RC,,,outpatient,,,467,326.9,AETNA [1000108],AETNA [100010801],,,,,,104.8415,416.02,other,E&M in Hospital/Facility,,
HC Office/Outpatient Established Mod Mdm 30-39 Min,PX-94200020,CDM,99214,CPT,942,RC,,,outpatient,,,467,326.9,AETNA [1000108],AETNA [100010801],,,76.8,,358.66,104.8415,416.02,percent of total billed charges,,,
HC Office/Outpatient Established High Mdm 40-54 Min,PX-51000033,CDM,99215,CPT,510,RC,,,outpatient,,,829,580.3,AETNA [1000108],AETNA [100010801],,,,,,169.273,685.583,other,E&M in Hospital/Facility,,
HC Office/Outpatient Established High Mdm 40-54 Min,PX-94200021,CDM,99215,CPT,942,RC,,,outpatient,,,754,527.8,AETNA [1000108],AETNA [100010801],,,76.8,,579.07,169.273,685.583,percent of total billed charges,,,
HC Critical Care Ill/Injured Patient Init 30-74 Min,PX-76000001,CDM,99291,CPT,760,RC,,,outpatient,,,3157,2209.9,AETNA [1000108],AETNA [100010801],,,76.8,,2424.58,318.748996,2424.576,percent of total billed charges,,,
HC PR Critical Care Ill/Injured Patient Init 30-74 Min,PX-96000052,CDM,99291,CPT,960,RC,,,outpatient,,,3157,2209.9,AETNA [1000108],AETNA [100010801],,,76.8,,2424.58,318.748996,2424.576,percent of total billed charges,,,
HC Critical Care Ill/Injured Patient Addl 30 Min,PX-76000002,CDM,99292,CPT,760,RC,,,outpatient,,,911,637.7,AETNA [1000108],AETNA [100010801],,,76.8,,699.65,204.5195,699.648,percent of total billed charges,,,
HC PR Critical Care Ill/Injured Patient Addl 30 Min,PX-96000053,CDM,99292,CPT,960,RC,,,outpatient,,,911,637.7,AETNA [1000108],AETNA [100010801],,,76.8,,699.65,204.5195,699.648,percent of total billed charges,,,
HC Tobacco Use Cessation Intermediate 3-10 Minutes,PX-94200022,CDM,99406,CPT,942,RC,,,outpatient,,,214,149.8,AETNA [1000108],AETNA [100010801],,,76.8,,164.35,31.31797,416.02,percent of total billed charges,,,
HC Tobacco Use Cessation Intensive >10 Minutes,PX-94200025,CDM,99407,CPT,942,RC,,,outpatient,,,214,149.8,AETNA [1000108],AETNA [100010801],,,76.8,,164.35,31.31797,416.02,percent of total billed charges,,,
TPN ELECTROLYTES IV CONC,RX-110242,CDM,25000001,HCPCS,250,RC,00409-5779-01,NDC,outpatient,20,ML,32.85,22.995,AETNA [1000108],AETNA [100010801],,,76.8,,25.23,0.74534,528.0548,percent of total billed charges,,,
PHENYLEPHRINE INTRACAVERNOSAL IN NS 100 MCG/ML SYRINGE,RX-141326,CDM,25000001,HCPCS,250,RC,70092-1046-46,NDC,outpatient,10,ML,24.79,17.353,AETNA [1000108],AETNA [100010801],,,76.8,,19.04,0.74534,528.0548,percent of total billed charges,,,
PHENYLEPHRINE INTRACAVERNOSAL IN NS 100 MCG/ML SYRINGE,RX-141326,CDM,25000001,HCPCS,250,RC,99999-0003-10,NDC,outpatient,10,ML,15.37,10.759,AETNA [1000108],AETNA [100010801],,,76.8,,11.8,0.74534,528.0548,percent of total billed charges,,,
PHENYLEPHRINE INTRACAVERNOSAL IN NS 100 MCG/ML SYRINGE,RX-141326,CDM,25000001,HCPCS,250,RC,70004-0810-11,NDC,outpatient,5,ML,23.81,16.667,AETNA [1000108],AETNA [100010801],,,76.8,,18.29,0.74534,528.0548,percent of total billed charges,,,
TALC 4 G PL POWD,RX-142785,CDM,25000001,HCPCS,250,RC,62327-0444-04,NDC,outpatient,1,UN,623,436.1,AETNA [1000108],AETNA [100010801],,,76.8,,478.46,0.74534,528.0548,percent of total billed charges,,,
TALC 4 G PL POWD,RX-142785,CDM,25000001,HCPCS,250,RC,62327-0444-44,NDC,outpatient,1,UN,623,436.1,AETNA [1000108],AETNA [100010801],,,76.8,,478.46,0.74534,528.0548,percent of total billed charges,,,
HYPERLYTE-CR IV CONC,RX-150262,CDM,25000001,HCPCS,250,RC,00409-5779-01,NDC,outpatient,20,ML,32.85,22.995,AETNA [1000108],AETNA [100010801],,,76.8,,25.23,0.74534,528.0548,percent of total billed charges,,,
HYPERLYTE-CR IV CONC,RX-150262,CDM,25000001,HCPCS,250,RC,00409-5779-11,NDC,outpatient,20,ML,32.85,22.995,AETNA [1000108],AETNA [100010801],,,76.8,,25.23,0.74534,528.0548,percent of total billed charges,,,
CLINIMIX E/DEXTROSE (8/14) 8 % IV SOLN,RX-152282,CDM,25000001,HCPCS,250,RC,00338-0202-06,NDC,outpatient,1000,ML,162.85,113.995,AETNA [1000108],AETNA [100010801],,,76.8,,125.07,0.74534,528.0548,percent of total billed charges,,,
CLINIMIX E/DEXTROSE (8/14) 8 % IV SOLN,RX-152282,CDM,25000001,HCPCS,250,RC,00338-0202-01,NDC,outpatient,1000,ML,162.85,113.995,AETNA [1000108],AETNA [100010801],,,76.8,,125.07,0.74534,528.0548,percent of total billed charges,,,
CLINIMIX E/DEXTROSE (8/14) 8 % IV SOLN,RX-152282,CDM,25000001,HCPCS,250,RC,00338-0206-04,NDC,outpatient,2000,ML,283,198.1,AETNA [1000108],AETNA [100010801],,,76.8,,217.34,0.74534,528.0548,percent of total billed charges,,,
CLINIMIX E/DEXTROSE (8/14) 8 % IV SOLN,RX-152282,CDM,25000001,HCPCS,250,RC,00338-0206-01,NDC,outpatient,2000,ML,283,198.1,AETNA [1000108],AETNA [100010801],,,76.8,,217.34,0.74534,528.0548,percent of total billed charges,,,
CLINIMIX E/DEXTROSE (8/10) 8 % IV SOLN,RX-152283,CDM,25000001,HCPCS,250,RC,00338-0210-01,NDC,outpatient,1000,ML,153.95,107.765,AETNA [1000108],AETNA [100010801],,,76.8,,118.23,0.74534,528.0548,percent of total billed charges,,,
CLINIMIX E/DEXTROSE (8/10) 8 % IV SOLN,RX-152283,CDM,25000001,HCPCS,250,RC,00338-0210-06,NDC,outpatient,1000,ML,153.95,107.765,AETNA [1000108],AETNA [100010801],,,76.8,,118.23,0.74534,528.0548,percent of total billed charges,,,
CLINIMIX E/DEXTROSE (8/10) 8 % IV SOLN,RX-152283,CDM,25000001,HCPCS,250,RC,00338-0214-01,NDC,outpatient,2000,ML,238.5,166.95,AETNA [1000108],AETNA [100010801],,,76.8,,183.17,0.74534,528.0548,percent of total billed charges,,,
CLINIMIX E/DEXTROSE (8/10) 8 % IV SOLN,RX-152283,CDM,25000001,HCPCS,250,RC,00338-0214-04,NDC,outpatient,2000,ML,238.5,166.95,AETNA [1000108],AETNA [100010801],,,76.8,,183.17,0.74534,528.0548,percent of total billed charges,,,
CLINIMIX/DEXTROSE (8/14) 8 % IV SOLN,RX-152285,CDM,25000001,HCPCS,250,RC,00338-0184-01,NDC,outpatient,2000,ML,274.1,191.87,AETNA [1000108],AETNA [100010801],,,76.8,,210.51,0.74534,528.0548,percent of total billed charges,,,
CLINIMIX/DEXTROSE (8/14) 8 % IV SOLN,RX-152285,CDM,25000001,HCPCS,250,RC,00338-0184-04,NDC,outpatient,2000,ML,274.1,191.87,AETNA [1000108],AETNA [100010801],,,76.8,,210.51,0.74534,528.0548,percent of total billed charges,,,
CLINIMIX/DEXTROSE (8/10) 8 % IV SOLN,RX-152286,CDM,25000001,HCPCS,250,RC,00338-0194-04,NDC,outpatient,2000,ML,229.6,160.72,AETNA [1000108],AETNA [100010801],,,76.8,,176.33,0.74534,528.0548,percent of total billed charges,,,
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML IV SOLN,RX-156196,CDM,25000001,HCPCS,250,RC,00517-9302-01,NDC,outpatient,1,ML,76.19,53.333,AETNA [1000108],AETNA [100010801],,,76.8,,58.51,0.74534,528.0548,percent of total billed charges,,,
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML IV SOLN,RX-156196,CDM,25000001,HCPCS,250,RC,00517-9302-25,NDC,outpatient,1,ML,76.19,53.333,AETNA [1000108],AETNA [100010801],,,76.8,,58.51,0.74534,528.0548,percent of total billed charges,,,
FAT EMULS PLANT BASE(SOY/OLIV) 20 % IV EMUL,RX-156373,CDM,25000001,HCPCS,250,RC,00338-9540-07,NDC,outpatient,500,ML,69.4,48.58,AETNA [1000108],AETNA [100010801],,,76.8,,53.3,0.74534,528.0548,percent of total billed charges,,,
FAT EMULS PLANT BASE(SOY/OLIV) 20 % IV EMUL,RX-156373,CDM,25000001,HCPCS,250,RC,00338-9540-02,NDC,outpatient,250,ML,57.17,40.019,AETNA [1000108],AETNA [100010801],,,76.8,,43.91,0.74534,528.0548,percent of total billed charges,,,
FAT EMULS PLANT BASE(SOY/OLIV) 20 % IV EMUL,RX-156373,CDM,25000001,HCPCS,250,RC,00338-9540-06,NDC,outpatient,250,ML,57.17,40.019,AETNA [1000108],AETNA [100010801],,,76.8,,43.91,0.74534,528.0548,percent of total billed charges,,,
FAT EMULS PLANT BASE(SOY/OLIV) 20 % IV EMUL,RX-156373,CDM,25000001,HCPCS,250,RC,00338-9540-03,NDC,outpatient,500,ML,69.4,48.58,AETNA [1000108],AETNA [100010801],,,76.8,,53.3,0.74534,528.0548,percent of total billed charges,,,
PRISMASOL BGK 4/0/1.2 32-4-1.2 MEQ/L EC SOLN,RX-156745,CDM,25000001,HCPCS,250,RC,24571-0114-06,NDC,outpatient,5000,ML,294.88,206.416,AETNA [1000108],AETNA [100010801],,,76.8,,226.47,0.74534,528.0548,percent of total billed charges,,,
MORPHINE SULFATE 100 MG IN D5W 100 ML PREMIX,RX-166979,CDM,25000001,HCPCS,250,RC,99999-0003-25,NDC,outpatient,100,ML,48.85,34.195,AETNA [1000108],AETNA [100010801],,,76.8,,37.52,0.74534,528.0548,percent of total billed charges,,,
ALUMINUM POTASSIUM SULFATE POWD,RX-21429,CDM,25000001,HCPCS,250,RC,24357-0300-30,NDC,outpatient,10,GR,267.27,187.089,AETNA [1000108],AETNA [100010801],,,76.8,,205.26,0.74534,528.0548,percent of total billed charges,,,
TROPHAMINE 10 % IV SOLN,RX-25798,CDM,25000001,HCPCS,250,RC,00264-1933-10,NDC,outpatient,500,ML,198.45,138.915,AETNA [1000108],AETNA [100010801],,,76.8,,152.41,0.74534,528.0548,percent of total billed charges,,,
GENTAMICIN IV SYRINGE 4 MG/ML (PEDIATRIC),RX-400058,CDM,25000001,HCPCS,250,RC,99999-0000-52,NDC,outpatient,10,ML,50.94,35.658,AETNA [1000108],AETNA [100010801],,,76.8,,39.12,0.74534,528.0548,percent of total billed charges,,,
GENTAMICIN IV SYRINGE 4 MG/ML (PEDIATRIC),RX-400058,CDM,25000001,HCPCS,250,RC,99999-0001-20,NDC,outpatient,5,ML,36.18,25.326,AETNA [1000108],AETNA [100010801],,,76.8,,27.79,0.74534,528.0548,percent of total billed charges,,,
AMINOCAPROIC ACID INFUSION (OPEN HEART),RX-400081,CDM,25000001,HCPCS,250,RC,99999-0000-86,NDC,outpatient,150,ML,97.97,68.579,AETNA [1000108],AETNA [100010801],,,76.8,,75.24,0.74534,528.0548,percent of total billed charges,,,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,25000001,HCPCS,250,RC,00338-0043-04,NDC,outpatient,1000,ML,26.28,18.396,AETNA [1000108],AETNA [100010801],,,76.8,,20.18,0.74534,528.0548,percent of total billed charges,,,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,25000001,HCPCS,250,RC,00338-0043-03,NDC,outpatient,500,ML,23.71,16.597,AETNA [1000108],AETNA [100010801],,,76.8,,18.21,0.74534,528.0548,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % IV SOLN FOR COMPOUNDING,RX-4080675,CDM,25000001,HCPCS,250,RC,00338-0049-31,NDC,outpatient,50,ML,6.43,4.501,AETNA [1000108],AETNA [100010801],,,76.8,,4.94,0.74534,528.0548,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % IV SOLN FOR COMPOUNDING,RX-4080675,CDM,25000001,HCPCS,250,RC,00409-4888-02,NDC,outpatient,10,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.74534,528.0548,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % IV SOLN FOR COMPOUNDING,RX-4080675,CDM,25000001,HCPCS,250,RC,00409-4888-12,NDC,outpatient,10,ML,9.82,6.874,AETNA [1000108],AETNA [100010801],,,76.8,,7.54,0.74534,528.0548,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % IV SOLN FOR COMPOUNDING,RX-4080675,CDM,25000001,HCPCS,250,RC,63323-0186-10,NDC,outpatient,10,ML,3.71,2.597,AETNA [1000108],AETNA [100010801],,,76.8,,2.85,0.74534,528.0548,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % IV SOLN FOR COMPOUNDING,RX-4080675,CDM,25000001,HCPCS,250,RC,00409-4888-10,NDC,outpatient,10,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.74534,528.0548,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % IV SOLN FOR COMPOUNDING,RX-4080675,CDM,25000001,HCPCS,250,RC,63323-0186-01,NDC,outpatient,10,ML,3.71,2.597,AETNA [1000108],AETNA [100010801],,,76.8,,2.85,0.74534,528.0548,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % IV SOLN FOR COMPOUNDING,RX-4080675,CDM,25000001,HCPCS,250,RC,00409-4888-01,NDC,outpatient,10,ML,9.82,6.874,AETNA [1000108],AETNA [100010801],,,76.8,,7.54,0.74534,528.0548,percent of total billed charges,,,
STERILE WATER FOR INJECTION COMPOUNDING ONLY,RX-4080705,CDM,25000001,HCPCS,250,RC,00409-4887-99,NDC,outpatient,100,ML,13.88,9.716,AETNA [1000108],AETNA [100010801],,,76.8,,10.66,0.74534,528.0548,percent of total billed charges,,,
STERILE WATER FOR INJECTION COMPOUNDING ONLY,RX-4080705,CDM,25000001,HCPCS,250,RC,00409-4887-10,NDC,outpatient,10,ML,3.6,2.52,AETNA [1000108],AETNA [100010801],,,76.8,,2.76,0.74534,528.0548,percent of total billed charges,,,
STERILE WATER FOR INJECTION COMPOUNDING ONLY,RX-4080705,CDM,25000001,HCPCS,250,RC,00409-4887-25,NDC,outpatient,100,ML,13.88,9.716,AETNA [1000108],AETNA [100010801],,,76.8,,10.66,0.74534,528.0548,percent of total billed charges,,,
STERILE WATER FOR INJECTION COMPOUNDING ONLY,RX-4080705,CDM,25000001,HCPCS,250,RC,63323-0185-20,NDC,outpatient,20,ML,7,4.9,AETNA [1000108],AETNA [100010801],,,76.8,,5.38,0.74534,528.0548,percent of total billed charges,,,
STERILE WATER FOR INJECTION COMPOUNDING ONLY,RX-4080705,CDM,25000001,HCPCS,250,RC,00338-0013-04,NDC,outpatient,1000,ML,10.28,7.196,AETNA [1000108],AETNA [100010801],,,76.8,,7.9,0.74534,528.0548,percent of total billed charges,,,
STERILE WATER FOR INJECTION COMPOUNDING ONLY,RX-4080705,CDM,25000001,HCPCS,250,RC,00409-4887-23,NDC,outpatient,20,ML,4.84,3.388,AETNA [1000108],AETNA [100010801],,,76.8,,3.72,0.74534,528.0548,percent of total billed charges,,,
STERILE WATER FOR INJECTION COMPOUNDING ONLY,RX-4080705,CDM,25000001,HCPCS,250,RC,00409-4887-17,NDC,outpatient,10,ML,3.6,2.52,AETNA [1000108],AETNA [100010801],,,76.8,,2.76,0.74534,528.0548,percent of total billed charges,,,
STERILE WATER FOR INJECTION COMPOUNDING ONLY,RX-4080705,CDM,25000001,HCPCS,250,RC,00409-4887-20,NDC,outpatient,20,ML,4.84,3.388,AETNA [1000108],AETNA [100010801],,,76.8,,3.72,0.74534,528.0548,percent of total billed charges,,,
STERILE WATER FOR INJECTION COMPOUNDING ONLY,RX-4080705,CDM,25000001,HCPCS,250,RC,63323-0185-10,NDC,outpatient,10,ML,4.07,2.849,AETNA [1000108],AETNA [100010801],,,76.8,,3.13,0.74534,528.0548,percent of total billed charges,,,
SUGAMMADEX SODIUM 100 MG/ML IV SOLN WRAPPER,RX-4080830,CDM,25000001,HCPCS,250,RC,00006-5423-02,NDC,outpatient,2,ML,533.12,373.184,AETNA [1000108],AETNA [100010801],,,76.8,,409.44,0.74534,528.0548,percent of total billed charges,,,
SUGAMMADEX SODIUM 100 MG/ML IV SOLN WRAPPER,RX-4080830,CDM,25000001,HCPCS,250,RC,00006-5423-12,NDC,outpatient,2,ML,533.12,373.184,AETNA [1000108],AETNA [100010801],,,76.8,,409.44,0.74534,528.0548,percent of total billed charges,,,
DEXMEDETOMIDINE HCL IN NACL 4 MCG/ML IV SOLN WRAPPER,RX-4080915,CDM,25000001,HCPCS,250,RC,00338-9557-12,NDC,outpatient,100,ML,89.43,62.601,AETNA [1000108],AETNA [100010801],,,76.8,,68.68,0.74534,528.0548,percent of total billed charges,,,
DILTIAZEM 100 MG IN 100 ML D5W BATCHED INFUSION,RX-4080938,CDM,25000001,HCPCS,250,RC,99999-0000-30,NDC,outpatient,100,ML,48.09,33.663,AETNA [1000108],AETNA [100010801],,,76.8,,36.93,0.74534,528.0548,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % CRRT SOLN,RX-4081079,CDM,25000001,HCPCS,250,RC,00338-0049-04,NDC,outpatient,1000,ML,21.14,14.798,AETNA [1000108],AETNA [100010801],,,76.8,,16.24,0.74534,528.0548,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % CRRT SOLN,RX-4081079,CDM,25000001,HCPCS,250,RC,00338-0049-03,NDC,outpatient,500,ML,23.71,16.597,AETNA [1000108],AETNA [100010801],,,76.8,,18.21,0.74534,528.0548,percent of total billed charges,,,
FAMOTIDINE IN NS (NEO/PEDI) SYRINGE 0.4 MG/ML,RX-4081338,CDM,25000001,HCPCS,250,RC,00338-5197-41,NDC,outpatient,50,ML,24.23,16.961,AETNA [1000108],AETNA [100010801],,,76.8,,18.61,0.74534,528.0548,percent of total billed charges,,,
PANTOPRAZOLE 80 MG/100 ML BOLUS/LOADING DOSE PREMIX,RX-4081495,CDM,25000001,HCPCS,250,RC,99999-0004-21,NDC,outpatient,100,ML,36.56,25.592,AETNA [1000108],AETNA [100010801],,,76.8,,28.08,0.74534,528.0548,percent of total billed charges,,,
CARDIOPLEGIA SOLN HIGH POTASSIUM 60 MEQ + MG 65 MEQ IN 500 ML OF NS,RX-4081526,CDM,25000001,HCPCS,250,RC,99999-0004-32,NDC,outpatient,500,ML,78.75,55.125,AETNA [1000108],AETNA [100010801],,,76.8,,60.48,0.74534,528.0548,percent of total billed charges,,,
VANCOMYCIN INTRAOSSEOUS 500 MG/50 ML NS SYR,RX-4081621,CDM,25000001,HCPCS,250,RC,99999-0004-52,NDC,outpatient,50,ML,33.99,23.793,AETNA [1000108],AETNA [100010801],,,76.8,,26.1,0.74534,528.0548,percent of total billed charges,,,
TRAVASOL 10 % IV SOLN,RX-8074,CDM,25000001,HCPCS,250,RC,00338-0644-04,NDC,outpatient,1000,ML,78.3,54.81,AETNA [1000108],AETNA [100010801],,,76.8,,60.13,0.74534,528.0548,percent of total billed charges,,,
TRAVASOL 10 % IV SOLN,RX-8074,CDM,25000001,HCPCS,250,RC,00338-0644-06,NDC,outpatient,2000,ML,122.8,85.96,AETNA [1000108],AETNA [100010801],,,76.8,,94.31,0.74534,528.0548,percent of total billed charges,,,
ZINC OXIDE 16 % EX OINT,RX-109467,CDM,25900001,HCPCS,259,RC,62103-0333-04,NDC,outpatient,113,GR,20.62,14.434,AETNA [1000108],AETNA [100010801],,,76.8,,15.84,0.222255,1203.778472,percent of total billed charges,,,
GLYCOPYRROLATE-FORMOTEROL 9-4.8 MCG/ACT IN AERO,RX-135283,CDM,25900001,HCPCS,259,RC,00310-4600-12,NDC,outpatient,10.7,GR,1420.22,994.154,AETNA [1000108],AETNA [100010801],,,76.8,,1090.73,0.222255,1203.778472,percent of total billed charges,,,
MULTIVITAMINS PLUS IRON CHILD 18 MG ORAL CHEW,RX-138485,CDM,25900001,HCPCS,259,RC,16500-0599-20,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,1203.778472,percent of total billed charges,,,
MULTIVITAMINS PLUS IRON CHILD 18 MG ORAL CHEW,RX-138485,CDM,25900001,HCPCS,259,RC,16500-0079-09,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,1203.778472,percent of total billed charges,,,
DAKINS (FULL STRENGTH) 0.5 % EX SOLN,RX-148710,CDM,25900001,HCPCS,259,RC,39328-0062-50,NDC,outpatient,473,ML,44.21,30.947,AETNA [1000108],AETNA [100010801],,,76.8,,33.95,0.222255,1203.778472,percent of total billed charges,,,
DAKINS (FULL STRENGTH) 0.5 % EX SOLN,RX-148710,CDM,25900001,HCPCS,259,RC,00436-0946-16,NDC,outpatient,473,ML,52.63,36.841,AETNA [1000108],AETNA [100010801],,,76.8,,40.42,0.222255,1203.778472,percent of total billed charges,,,
HYDROCORTISONE (PERIANAL) 2.5 % EX CREA,RX-150300,CDM,25900001,HCPCS,259,RC,10631-0407-01,NDC,outpatient,28.35,GR,38.36,26.852,AETNA [1000108],AETNA [100010801],,,76.8,,29.46,0.222255,1203.778472,percent of total billed charges,,,
HYDROCORTISONE (PERIANAL) 2.5 % EX CREA,RX-150300,CDM,25900001,HCPCS,259,RC,62559-0431-30,NDC,outpatient,30,GR,76.9,53.83,AETNA [1000108],AETNA [100010801],,,76.8,,59.06,0.222255,1203.778472,percent of total billed charges,,,
HYDROCORTISONE (PERIANAL) 2.5 % EX CREA,RX-150300,CDM,25900001,HCPCS,259,RC,64980-0324-30,NDC,outpatient,30,GR,25.77,18.039,AETNA [1000108],AETNA [100010801],,,76.8,,19.79,0.222255,1203.778472,percent of total billed charges,,,
HYDROCORTISONE (PERIANAL) 2.5 % EX CREA,RX-150300,CDM,25900001,HCPCS,259,RC,69315-0312-28,NDC,outpatient,28,GR,33.65,23.555,AETNA [1000108],AETNA [100010801],,,76.8,,25.84,0.222255,1203.778472,percent of total billed charges,,,
PRAMOXINE HCL (PERIANAL) 1 % EX FOAM,RX-150306,CDM,25900001,HCPCS,259,RC,51862-0180-15,NDC,outpatient,15,GR,166.95,116.865,AETNA [1000108],AETNA [100010801],,,76.8,,128.22,0.222255,1203.778472,percent of total billed charges,,,
HYDROCORT-PRAMOXINE (PERIANAL) 1-1 % EX FOAM,RX-150328,CDM,25900001,HCPCS,259,RC,00037-6822-10,NDC,outpatient,10,GR,761.13,532.791,AETNA [1000108],AETNA [100010801],,,76.8,,584.55,0.222255,1203.778472,percent of total billed charges,,,
PRIMAQUINE PHOSPHATE 26.3 (15 BASE) MG ORAL TABS,RX-155613,CDM,25900001,HCPCS,259,RC,76385-0102-01,NDC,outpatient,1,UN,5.96,4.172,AETNA [1000108],AETNA [100010801],,,76.8,,4.58,0.222255,1203.778472,percent of total billed charges,,,
ZANAMIVIR 5 MG/ACT IN AEPB,RX-160595,CDM,25900001,HCPCS,259,RC,00173-0681-01,NDC,outpatient,20,UN,240.22,168.154,AETNA [1000108],AETNA [100010801],,,76.8,,184.49,0.222255,1203.778472,percent of total billed charges,,,
DIPHENHYDRAMINE-ZINC ACETATE 2-0.1 % EX CREA,RX-16299,CDM,25900001,HCPCS,259,RC,45802-0358-03,NDC,outpatient,28,GR,4.62,3.234,AETNA [1000108],AETNA [100010801],,,76.8,,3.55,0.222255,1203.778472,percent of total billed charges,,,
GLYCERIN (LIQUID) 2.8 G RE SUPP,RX-163739,CDM,25900001,HCPCS,259,RC,00132-0190-12,NDC,outpatient,4,ML,3,2.1,AETNA [1000108],AETNA [100010801],,,76.8,,2.3,0.222255,1203.778472,percent of total billed charges,,,
FERROUS SULFATE 300 (60 FE) MG/5ML ORAL SOLN,RX-165823,CDM,25900001,HCPCS,259,RC,63739-0157-10,NDC,outpatient,5,ML,6.5,4.55,AETNA [1000108],AETNA [100010801],,,76.8,,4.99,0.222255,1203.778472,percent of total billed charges,,,
FERROUS SULFATE 300 (60 FE) MG/5ML ORAL SOLN,RX-165823,CDM,25900001,HCPCS,259,RC,63739-0157-70,NDC,outpatient,5,ML,6.5,4.55,AETNA [1000108],AETNA [100010801],,,76.8,,4.99,0.222255,1203.778472,percent of total billed charges,,,
FERROUS SULFATE 300 (60 FE) MG/5ML ORAL SOLN,RX-165823,CDM,25900001,HCPCS,259,RC,00121-0530-05,NDC,outpatient,5,ML,13.51,9.457,AETNA [1000108],AETNA [100010801],,,76.8,,10.38,0.222255,1203.778472,percent of total billed charges,,,
PSYLLIUM 25 % ORAL PACK,RX-166710,CDM,25900001,HCPCS,259,RC,37000-0023-04,NDC,outpatient,1,UN,2.18,1.526,AETNA [1000108],AETNA [100010801],,,76.8,,1.67,0.222255,1203.778472,percent of total billed charges,,,
PSYLLIUM 25 % ORAL PACK,RX-166710,CDM,25900001,HCPCS,259,RC,37000-0023-10,NDC,outpatient,1,UN,2.18,1.526,AETNA [1000108],AETNA [100010801],,,76.8,,1.67,0.222255,1203.778472,percent of total billed charges,,,
ASTROGLIDE EX GEL,RX-23759,CDM,25900001,HCPCS,259,RC,15594-0010-07,NDC,outpatient,66.5,GR,20.13,14.091,AETNA [1000108],AETNA [100010801],,,76.8,,15.46,0.222255,1203.778472,percent of total billed charges,,,
CORN STARCH EX POWD,RX-28839,CDM,25900001,HCPCS,259,RC,00316-0233-25,NDC,outpatient,71,GR,13.91,9.737,AETNA [1000108],AETNA [100010801],,,76.8,,10.68,0.222255,1203.778472,percent of total billed charges,,,
GLYCERIN (LAXATIVE) 5.4 GM/DOSE RE ENEM,RX-37495,CDM,25900001,HCPCS,259,RC,00132-0185-01,NDC,outpatient,7.5,ML,3.54,2.478,AETNA [1000108],AETNA [100010801],,,76.8,,2.72,0.222255,1203.778472,percent of total billed charges,,,
GLYCERIN (LAXATIVE) 5.4 GM/DOSE RE ENEM,RX-37495,CDM,25900001,HCPCS,259,RC,00132-0185-82,NDC,outpatient,7.5,ML,3.54,2.478,AETNA [1000108],AETNA [100010801],,,76.8,,2.72,0.222255,1203.778472,percent of total billed charges,,,
HYOSCYAMINE SULFATE 0.125 MG/ML ORAL SOLN,RX-3782,CDM,25900001,HCPCS,259,RC,54838-0506-15,NDC,outpatient,15,ML,121.96,85.372,AETNA [1000108],AETNA [100010801],,,76.8,,93.67,0.222255,1203.778472,percent of total billed charges,,,
HYOSCYAMINE SULFATE 0.125 MG/ML ORAL SOLN,RX-3782,CDM,25900001,HCPCS,259,RC,39328-0047-15,NDC,outpatient,15,ML,86.71,60.697,AETNA [1000108],AETNA [100010801],,,76.8,,66.59,0.222255,1203.778472,percent of total billed charges,,,
GENTAMICIN FORTIFIED EYE SOLUTION 14 MG/ML,RX-4080014,CDM,25900001,HCPCS,259,RC,99999-0001-32,NDC,outpatient,7,ML,17.67,12.369,AETNA [1000108],AETNA [100010801],,,76.8,,13.57,0.222255,1203.778472,percent of total billed charges,,,
LACTULOSE ENEMA IN STERILE WATER 1000 ML,RX-4080406,CDM,25900001,HCPCS,259,RC,,,outpatient,1000,ML,16.47,11.529,AETNA [1000108],AETNA [100010801],,,76.8,,12.65,0.222255,1203.778472,percent of total billed charges,,,
LACTULOSE ENEMA IN SODIUM CHLORIDE 0.9 % 1000 ML,RX-4080407,CDM,25900001,HCPCS,259,RC,99999-0001-00,NDC,outpatient,1000,ML,16.47,11.529,AETNA [1000108],AETNA [100010801],,,76.8,,12.65,0.222255,1203.778472,percent of total billed charges,,,
WITCH HAZEL-GLYCERIN EX PADS WRAPPER,RX-4080503,CDM,25900001,HCPCS,259,RC,50289-3250-01,NDC,outpatient,40,UN,9.62,6.734,AETNA [1000108],AETNA [100010801],,,76.8,,7.39,0.222255,1203.778472,percent of total billed charges,,,
LIDOCAINE HCL 2 % EX GEL UROJET,RX-4080776,CDM,25900001,HCPCS,259,RC,76329-3015-05,NDC,outpatient,20,ML,33.02,23.114,AETNA [1000108],AETNA [100010801],,,76.8,,25.36,0.222255,1203.778472,percent of total billed charges,,,
LIDOCAINE HCL 2 % EX GEL UROJET,RX-4080776,CDM,25900001,HCPCS,259,RC,76329-3013-05,NDC,outpatient,10,ML,24.12,16.884,AETNA [1000108],AETNA [100010801],,,76.8,,18.52,0.222255,1203.778472,percent of total billed charges,,,
LIDOCAINE HCL 2 % EX GEL UROJET,RX-4080776,CDM,25900001,HCPCS,259,RC,76329-3011-05,NDC,outpatient,5,ML,18.29,12.803,AETNA [1000108],AETNA [100010801],,,76.8,,14.05,0.222255,1203.778472,percent of total billed charges,,,
LIDOCAINE HCL 2 % EX GEL UROJET,RX-4080776,CDM,25900001,HCPCS,259,RC,76329-3012-05,NDC,outpatient,5,ML,18.29,12.803,AETNA [1000108],AETNA [100010801],,,76.8,,14.05,0.222255,1203.778472,percent of total billed charges,,,
CLONIDINE NEONATAL SUSPENSION 5 MCG/ML,RX-4080796,CDM,25900001,HCPCS,259,RC,99999-0001-04,NDC,outpatient,1,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,1203.778472,percent of total billed charges,,,
VANCOMYCIN 50 MG/ML ORAL SOLN WRAPPER,RX-4081075,CDM,25900001,HCPCS,259,RC,99999-0000-64,NDC,outpatient,2.5,ML,10.08,7.056,AETNA [1000108],AETNA [100010801],,,76.8,,7.74,0.222255,1203.778472,percent of total billed charges,,,
VANCOMYCIN 50 MG/ML ORAL SOLN WRAPPER,RX-4081075,CDM,25900001,HCPCS,259,RC,65628-0206-05,NDC,outpatient,2.5,ML,10.08,7.056,AETNA [1000108],AETNA [100010801],,,76.8,,7.74,0.222255,1203.778472,percent of total billed charges,,,
OXYMETAZOLINE HCL 0.05 % NA SOLN,RX-5943,CDM,25900001,HCPCS,259,RC,41100-0015-11,NDC,outpatient,15,ML,31.71,22.197,AETNA [1000108],AETNA [100010801],,,76.8,,24.35,0.222255,1203.778472,percent of total billed charges,,,
OXYMETAZOLINE HCL 0.05 % NA SOLN,RX-5943,CDM,25900001,HCPCS,259,RC,41100-0811-23,NDC,outpatient,15,ML,25.17,17.619,AETNA [1000108],AETNA [100010801],,,76.8,,19.33,0.222255,1203.778472,percent of total billed charges,,,
OXYMETAZOLINE HCL 0.05 % NA SOLN,RX-5943,CDM,25900001,HCPCS,259,RC,49348-0130-27,NDC,outpatient,30,ML,16.69,11.683,AETNA [1000108],AETNA [100010801],,,76.8,,12.82,0.222255,1203.778472,percent of total billed charges,,,
OXYMETAZOLINE HCL 0.05 % NA SOLN,RX-5943,CDM,25900001,HCPCS,259,RC,00904-7006-35,NDC,outpatient,15,ML,6.41,4.487,AETNA [1000108],AETNA [100010801],,,76.8,,4.92,0.222255,1203.778472,percent of total billed charges,,,
SULFUR PRECIPITATED POWD,RX-7576,CDM,25900001,HCPCS,259,RC,38779-0098-08,NDC,outpatient,500,GR,142.38,99.666,AETNA [1000108],AETNA [100010801],,,76.8,,109.35,0.222255,1203.778472,percent of total billed charges,,,
DISCONTINUED BRAND PRODUCT - PROAIR HFA 108 (90 BASE) MCG/ACT IN AERS (ALBUTEROL),RX-76821,CDM,25900001,HCPCS,259,RC,00093-3174-31,NDC,outpatient,8.5,GR,117.83,82.481,AETNA [1000108],AETNA [100010801],,,76.8,,90.49,0.222255,1203.778472,percent of total billed charges,,,
DISCONTINUED BRAND PRODUCT - PROAIR HFA 108 (90 BASE) MCG/ACT IN AERS (ALBUTEROL),RX-76821,CDM,25900001,HCPCS,259,RC,00173-0682-24,NDC,outpatient,8,GR,92.49,64.743,AETNA [1000108],AETNA [100010801],,,76.8,,71.03,0.222255,1203.778472,percent of total billed charges,,,
DISCONTINUED BRAND PRODUCT - PROAIR HFA 108 (90 BASE) MCG/ACT IN AERS (ALBUTEROL),RX-76821,CDM,25900001,HCPCS,259,RC,66993-0019-68,NDC,outpatient,18,GR,146.67,102.669,AETNA [1000108],AETNA [100010801],,,76.8,,112.64,0.222255,1203.778472,percent of total billed charges,,,
DESMOPRESSIN ACE REFRIGERATED 0.01 % NA SOLN,RX-9749,CDM,25900001,HCPCS,259,RC,55566-2400-00,NDC,outpatient,2.5,ML,1134.27,793.989,AETNA [1000108],AETNA [100010801],,,76.8,,871.12,0.222255,1203.778472,percent of total billed charges,,,
HC Onc. Vad Kit,PX-27000020,CDM,27000020,LOCAL,270,RC,,,outpatient,,,90,63,AETNA [1000108],AETNA [100010801],,,76.8,,69.12,20.205,72,percent of total billed charges,,,
HC Imed Pump for Lvl II,PX-27000021,CDM,27000021,LOCAL,270,RC,,,outpatient,,,118,82.6,AETNA [1000108],AETNA [100010801],,,76.8,,90.62,26.491,94.4,percent of total billed charges,,,
HC Imed Pump,PX-27000022,CDM,27000022,LOCAL,270,RC,,,outpatient,,,113,79.1,AETNA [1000108],AETNA [100010801],,,76.8,,86.78,25.3685,90.4,percent of total billed charges,,,
HC Local Anesth Supplies,PX-27000023,CDM,27000023,LOCAL,270,RC,,,outpatient,,,80,56,AETNA [1000108],AETNA [100010801],,,76.8,,61.44,17.96,64,percent of total billed charges,,,
HC Periop O2,PX-27000044,CDM,27000044,LOCAL,270,RC,,,outpatient,,,79,55.3,AETNA [1000108],AETNA [100010801],,,76.8,,60.67,17.7355,63.2,percent of total billed charges,,,
HC Bone Bx Kit,PX-27000050,CDM,27000050,LOCAL,270,RC,,,outpatient,,,267,186.9,AETNA [1000108],AETNA [100010801],,,76.8,,205.06,59.9415,213.6,percent of total billed charges,,,
HC Kit Portex Nerve Block,PX-27000051,CDM,27000051,LOCAL,270,RC,,,outpatient,,,90,63,AETNA [1000108],AETNA [100010801],,,76.8,,69.12,20.205,72,percent of total billed charges,,,
HC Cannister Vac W/O Gel Ats,PX-27000052,CDM,27000052,LOCAL,270,RC,,,outpatient,,,282,197.4,AETNA [1000108],AETNA [100010801],,,76.8,,216.58,63.309,225.6,percent of total billed charges,,,
HC Dressing Kci Small 5/Cs,PX-27000053,CDM,27000053,LOCAL,270,RC,,,outpatient,,,268,187.6,AETNA [1000108],AETNA [100010801],,,76.8,,205.82,60.166,214.4,percent of total billed charges,,,
HC Cannister W/Gel Ats,PX-27000054,CDM,27000054,LOCAL,270,RC,,,outpatient,,,283,198.1,AETNA [1000108],AETNA [100010801],,,76.8,,217.34,63.5335,226.4,percent of total billed charges,,,
HC Compression Stocking A6530,PX-27000055,CDM,27000055,LOCAL,270,RC,,,outpatient,,,285,199.5,AETNA [1000108],AETNA [100010801],,,76.8,,218.88,63.9825,228,percent of total billed charges,,,
HC Custom Molded Insert,PX-27000056,CDM,27000056,LOCAL,270,RC,,,outpatient,,,287,200.9,AETNA [1000108],AETNA [100010801],,,76.8,,220.42,64.4315,229.6,percent of total billed charges,,,
HC Dressing Kci Medium 10/Cs,PX-27000057,CDM,27000057,LOCAL,270,RC,,,outpatient,,,307,214.9,AETNA [1000108],AETNA [100010801],,,76.8,,235.78,68.9215,245.6,percent of total billed charges,,,
HC Surgical Boot/Shoe L3260,PX-27000058,CDM,27000058,LOCAL,270,RC,,,outpatient,,,423,296.1,AETNA [1000108],AETNA [100010801],,,76.8,,324.86,94.9635,338.4,percent of total billed charges,,,
HC Vaccum Assisted Closure Pump,PX-27000059,CDM,27000059,LOCAL,270,RC,,,outpatient,,,438,306.6,AETNA [1000108],AETNA [100010801],,,76.8,,336.38,98.331,350.4,percent of total billed charges,,,
HC Ortho Wedge Shoe,PX-27000060,CDM,27000060,LOCAL,270,RC,,,outpatient,,,529,370.3,AETNA [1000108],AETNA [100010801],,,76.8,,406.27,118.7605,423.2,percent of total billed charges,,,
HC Foot Pressure Support A9283,PX-27000061,CDM,27000061,LOCAL,270,RC,,,outpatient,,,529,370.3,AETNA [1000108],AETNA [100010801],,,76.8,,406.27,118.7605,423.2,percent of total billed charges,,,
HC Sensor Nicom,PX-27000062,CDM,27000062,LOCAL,270,RC,,,outpatient,,,816,571.2,AETNA [1000108],AETNA [100010801],,,76.8,,626.69,183.192,652.8,percent of total billed charges,,,
HC 6 Channel Pneumogram,PX-27000063,CDM,27000063,LOCAL,270,RC,,,outpatient,,,3884,2718.8,AETNA [1000108],AETNA [100010801],,,76.8,,2982.91,871.958,3107.2,percent of total billed charges,,,
HC Pneumogram 4-Channel,PX-27000064,CDM,27000064,LOCAL,270,RC,,,outpatient,,,4891,3423.7,AETNA [1000108],AETNA [100010801],,,76.8,,3756.29,1098.0295,3912.8,percent of total billed charges,,,
HC Pad Artic Gel Large,PX-27000065,CDM,27000065,LOCAL,270,RC,,,outpatient,,,5242,3669.4,AETNA [1000108],AETNA [100010801],,,76.8,,4025.86,1176.829,4193.6,percent of total billed charges,,,
HC Pneumogram 6- Channel,PX-27000066,CDM,27000066,LOCAL,270,RC,,,outpatient,,,5466,3826.2,AETNA [1000108],AETNA [100010801],,,76.8,,4197.89,1227.117,4372.8,percent of total billed charges,,,
HC Therapy Polar Cooler,PX-27000068,CDM,27000068,LOCAL,270,RC,,,outpatient,,,667,466.9,AETNA [1000108],AETNA [100010801],,,76.8,,512.26,149.7415,533.6,percent of total billed charges,,,
HC Liner Foam Permanently Med,PX-27000069,CDM,27000069,LOCAL,270,RC,,,outpatient,,,353,247.1,AETNA [1000108],AETNA [100010801],,,76.8,,271.1,79.2485,282.4,percent of total billed charges,,,
HC Dressing Kci Vac Small,PX-27000070,CDM,27000070,LOCAL,270,RC,,,outpatient,,,327,228.9,AETNA [1000108],AETNA [100010801],,,76.8,,251.14,73.4115,261.6,percent of total billed charges,,,
HC Dressing Kci Vac Large,PX-27000071,CDM,27000071,LOCAL,270,RC,,,outpatient,,,390,273,AETNA [1000108],AETNA [100010801],,,76.8,,299.52,87.555,312,percent of total billed charges,,,
HC Developmental Aides,PX-27000072,CDM,27000072,LOCAL,270,RC,,,outpatient,,,707,494.9,AETNA [1000108],AETNA [100010801],,,76.8,,542.98,158.7215,565.6,percent of total billed charges,,,
"HC Ez Reacher 30"" Suction",PX-27100004,CDM,27100004,LOCAL,271,RC,,,outpatient,,,144,100.8,AETNA [1000108],AETNA [100010801],,,76.8,,110.59,32.328,122.0544,percent of total billed charges,,,
HC Support Bra Ez-on Med 958,PX-27100005,CDM,27100005,LOCAL,271,RC,,,outpatient,,,262,183.4,AETNA [1000108],AETNA [100010801],,,76.8,,201.22,58.819,222.0712,percent of total billed charges,,,
HC Support Bra Ez-on Lrg 958,PX-27100006,CDM,27100006,LOCAL,271,RC,,,outpatient,,,272,190.4,AETNA [1000108],AETNA [100010801],,,76.8,,208.9,61.064,230.5472,percent of total billed charges,,,
HC Support Bra Ez-on X-Lrg 958,PX-27100007,CDM,27100007,LOCAL,271,RC,,,outpatient,,,306,214.2,AETNA [1000108],AETNA [100010801],,,76.8,,235.01,68.697,259.3656,percent of total billed charges,,,
HC Support Bra Ez-on Queen,PX-27100008,CDM,27100008,LOCAL,271,RC,,,outpatient,,,377,263.9,AETNA [1000108],AETNA [100010801],,,76.8,,289.54,84.6365,319.5452,percent of total billed charges,,,
HC Bra Ez-on Super Queen,PX-27100009,CDM,27100009,LOCAL,271,RC,,,outpatient,,,471,329.7,AETNA [1000108],AETNA [100010801],,,76.8,,361.73,105.7395,399.2196,percent of total billed charges,,,
HC Gradient Com Stocking,PX-27100010,CDM,27100010,LOCAL,271,RC,,,outpatient,,,490,343,AETNA [1000108],AETNA [100010801],,,76.8,,376.32,110.005,415.324,percent of total billed charges,,,
HC Kit Flexi Seal Fecal,PX-27100011,CDM,27100011,LOCAL,271,RC,,,outpatient,,,939,657.3,AETNA [1000108],AETNA [100010801],,,76.8,,721.15,210.8055,795.8964,percent of total billed charges,,,
HC Port Power Loc Access Kit,PX-27200054,CDM,27200054,LOCAL,272,RC,,,outpatient,,,88,61.6,AETNA [1000108],AETNA [100010801],,,76.8,,67.58,19.756,74.5888,percent of total billed charges,,,
HC Dressing Kci Vac White Lg,PX-27200055,CDM,27200055,LOCAL,272,RC,,,outpatient,,,95,66.5,AETNA [1000108],AETNA [100010801],,,76.8,,72.96,21.3275,80.522,percent of total billed charges,,,
HC Sheath Brite Tip 11cm,PX-27200056,CDM,27200056,LOCAL,272,RC,,,outpatient,,,108,75.6,AETNA [1000108],AETNA [100010801],,,76.8,,82.94,24.246,91.5408,percent of total billed charges,,,
HC Kit Refill Syncromed Sys. Pain,PX-27200057,CDM,27200057,LOCAL,272,RC,,,outpatient,,,128,89.6,AETNA [1000108],AETNA [100010801],,,76.8,,98.3,28.736,108.4928,percent of total billed charges,,,
HC Sock Fracture,PX-27200058,CDM,27200058,LOCAL,272,RC,,,outpatient,,,193,135.1,AETNA [1000108],AETNA [100010801],,,76.8,,148.22,43.3285,163.5868,percent of total billed charges,,,
HC Tube Gastrostomy Replacement,PX-27200059,CDM,27200059,LOCAL,272,RC,,,outpatient,,,195,136.5,AETNA [1000108],AETNA [100010801],,,76.8,,149.76,43.7775,165.282,percent of total billed charges,,,
HC Mod of Depth Shoe,PX-27200060,CDM,27200060,LOCAL,272,RC,,,outpatient,,,225,157.5,AETNA [1000108],AETNA [100010801],,,76.8,,172.8,50.5125,190.71,percent of total billed charges,,,
HC Catheter Broncho 39l,PX-27200061,CDM,27200061,LOCAL,272,RC,,,outpatient,,,349,244.3,AETNA [1000108],AETNA [100010801],,,76.8,,268.03,78.3505,295.8124,percent of total billed charges,,,
HC Catheter Bronch 35 Left 95892,PX-27200062,CDM,27200062,LOCAL,272,RC,,,outpatient,,,349,244.3,AETNA [1000108],AETNA [100010801],,,76.8,,268.03,78.3505,295.8124,percent of total billed charges,,,
HC Endo-Bronch Tube 37fr Left,PX-27200063,CDM,27200063,LOCAL,272,RC,,,outpatient,,,349,244.3,AETNA [1000108],AETNA [100010801],,,76.8,,268.03,78.3505,295.8124,percent of total billed charges,,,
HC Tube Endo Bronch #35 Left,PX-27200064,CDM,27200064,LOCAL,272,RC,,,outpatient,,,349,244.3,AETNA [1000108],AETNA [100010801],,,76.8,,268.03,78.3505,295.8124,percent of total billed charges,,,
HC Endo Bronch Tube #39,PX-27200065,CDM,27200065,LOCAL,272,RC,,,outpatient,,,349,244.3,AETNA [1000108],AETNA [100010801],,,76.8,,268.03,78.3505,295.8124,percent of total billed charges,,,
HC Catheter Broncho 41l,PX-27200066,CDM,27200066,LOCAL,272,RC,,,outpatient,,,349,244.3,AETNA [1000108],AETNA [100010801],,,76.8,,268.03,78.3505,295.8124,percent of total billed charges,,,
HC Kit Arterial Line Arrow,PX-27200067,CDM,27200067,LOCAL,272,RC,,,outpatient,,,349,244.3,AETNA [1000108],AETNA [100010801],,,76.8,,268.03,78.3505,295.8124,percent of total billed charges,,,
HC Cassette Kci Veralink,PX-27200068,CDM,27200068,LOCAL,272,RC,,,outpatient,,,357,249.9,AETNA [1000108],AETNA [100010801],,,76.8,,274.18,80.1465,302.5932,percent of total billed charges,,,
HC Shiley Trach Tube 6lpc,PX-27200069,CDM,27200069,LOCAL,272,RC,,,outpatient,,,357,249.9,AETNA [1000108],AETNA [100010801],,,76.8,,274.18,80.1465,302.5932,percent of total billed charges,,,
HC Tube Trach Shiley 8lpc,PX-27200070,CDM,27200070,LOCAL,272,RC,,,outpatient,,,357,249.9,AETNA [1000108],AETNA [100010801],,,76.8,,274.18,80.1465,302.5932,percent of total billed charges,,,
HC Catheter Single 4fr Bard,PX-27200071,CDM,27200071,LOCAL,272,RC,,,outpatient,,,374,261.8,AETNA [1000108],AETNA [100010801],,,76.8,,287.23,83.963,317.0024,percent of total billed charges,,,
HC Bivona #7 Trach Uncuffed,PX-27200072,CDM,27200072,LOCAL,272,RC,,,outpatient,,,396,277.2,AETNA [1000108],AETNA [100010801],,,76.8,,304.13,88.902,335.6496,percent of total billed charges,,,
HC Retractor C Section Large,PX-27200073,CDM,27200073,LOCAL,272,RC,,,outpatient,,,402,281.4,AETNA [1000108],AETNA [100010801],,,76.8,,308.74,90.249,340.7352,percent of total billed charges,,,
HC Midline 4fr Bd#384308,PX-27200074,CDM,27200074,LOCAL,272,RC,,,outpatient,,,409,286.3,AETNA [1000108],AETNA [100010801],,,76.8,,314.11,91.8205,346.6684,percent of total billed charges,,,
HC Transducer Triple W/Vamp Pls,PX-27200075,CDM,27200075,LOCAL,272,RC,,,outpatient,,,418,292.6,AETNA [1000108],AETNA [100010801],,,76.8,,321.02,93.841,354.2968,percent of total billed charges,,,
HC B Pleurx Drainage Kit,PX-27200076,CDM,27200076,LOCAL,272,RC,,,outpatient,,,417,291.9,AETNA [1000108],AETNA [100010801],,,76.8,,320.26,93.6165,353.4492,percent of total billed charges,,,
HC Catheter Swan Ganz J Pacing,PX-27200078,CDM,27200078,LOCAL,272,RC,,,outpatient,,,446,312.2,AETNA [1000108],AETNA [100010801],,,76.8,,342.53,100.127,378.0296,percent of total billed charges,,,
HC Tube Trach Distal Xlt 5.0,PX-27200079,CDM,27200079,LOCAL,272,RC,,,outpatient,,,451,315.7,AETNA [1000108],AETNA [100010801],,,76.8,,346.37,101.2495,382.2676,percent of total billed charges,,,
HC Tube Trach Distal Xlt 6.0,PX-27200080,CDM,27200080,LOCAL,272,RC,,,outpatient,,,466,326.2,AETNA [1000108],AETNA [100010801],,,76.8,,357.89,104.617,394.9816,percent of total billed charges,,,
HC Tube Trach 8 Cuff Non X Long,PX-27200081,CDM,27200081,LOCAL,272,RC,,,outpatient,,,466,326.2,AETNA [1000108],AETNA [100010801],,,76.8,,357.89,104.617,394.9816,percent of total billed charges,,,
HC Sling Sam Pelvic Medium,PX-27200082,CDM,27200082,LOCAL,272,RC,,,outpatient,,,470,329,AETNA [1000108],AETNA [100010801],,,76.8,,360.96,105.515,398.372,percent of total billed charges,,,
HC Set Tube Kaci Veratrac Duo,PX-27200083,CDM,27200083,LOCAL,272,RC,,,outpatient,,,488,341.6,AETNA [1000108],AETNA [100010801],,,76.8,,374.78,109.556,413.6288,percent of total billed charges,,,
HC Retractor C Section Xlarge,PX-27200084,CDM,27200084,LOCAL,272,RC,,,outpatient,,,516,361.2,AETNA [1000108],AETNA [100010801],,,76.8,,396.29,115.842,437.3616,percent of total billed charges,,,
HC Kit Mini 4fr Single Lumen,PX-27200085,CDM,27200085,LOCAL,272,RC,,,outpatient,,,519,363.3,AETNA [1000108],AETNA [100010801],,,76.8,,398.59,116.5155,439.9044,percent of total billed charges,,,
HC Trach Bivona Tis 6id,PX-27200086,CDM,27200086,LOCAL,272,RC,,,outpatient,,,523,366.1,AETNA [1000108],AETNA [100010801],,,76.8,,401.66,117.4135,443.2948,percent of total billed charges,,,
HC Pack C Section Custom Disp,PX-27200087,CDM,27200087,LOCAL,272,RC,,,outpatient,,,541,378.7,AETNA [1000108],AETNA [100010801],,,76.8,,415.49,121.4545,458.5516,percent of total billed charges,,,
HC Trach Bivona Tts 8mm,PX-27200088,CDM,27200088,LOCAL,272,RC,,,outpatient,,,541,378.7,AETNA [1000108],AETNA [100010801],,,76.8,,415.49,121.4545,458.5516,percent of total billed charges,,,
HC Trach Bivona 7.5 X 10,PX-27200089,CDM,27200089,LOCAL,272,RC,,,outpatient,,,556,389.2,AETNA [1000108],AETNA [100010801],,,76.8,,427.01,124.822,471.2656,percent of total billed charges,,,
HC Tube Feeding Mic Key 14f 1.7,PX-27200091,CDM,27200091,LOCAL,272,RC,,,outpatient,,,674,471.8,AETNA [1000108],AETNA [100010801],,,76.8,,517.63,151.313,571.2824,percent of total billed charges,,,
HC Kit Mic-Key G Feeding 16-3.5,PX-27200092,CDM,27200092,LOCAL,272,RC,,,outpatient,,,694,485.8,AETNA [1000108],AETNA [100010801],,,76.8,,532.99,155.803,588.2344,percent of total billed charges,,,
HC Kit Mic-Key G Feeding 24-3.5,PX-27200093,CDM,27200093,LOCAL,272,RC,,,outpatient,,,694,485.8,AETNA [1000108],AETNA [100010801],,,76.8,,532.99,155.803,588.2344,percent of total billed charges,,,
HC Mic Key G Tube 20fr 3.5cm,PX-27200094,CDM,27200094,LOCAL,272,RC,,,outpatient,,,694,485.8,AETNA [1000108],AETNA [100010801],,,76.8,,532.99,155.803,588.2344,percent of total billed charges,,,
HC Device Support Foot,PX-27200095,CDM,27200095,LOCAL,272,RC,,,outpatient,,,703,492.1,AETNA [1000108],AETNA [100010801],,,76.8,,539.9,157.8235,595.8628,percent of total billed charges,,,
HC Catheter 4 Fr Mid Line,PX-27200096,CDM,27200096,LOCAL,272,RC,,,outpatient,,,719,503.3,AETNA [1000108],AETNA [100010801],,,76.8,,552.19,161.4155,609.4244,percent of total billed charges,,,
HC Tcc Size 3,PX-27200097,CDM,27200097,LOCAL,272,RC,,,outpatient,,,722,505.4,AETNA [1000108],AETNA [100010801],,,76.8,,554.5,162.089,611.9672,percent of total billed charges,,,
HC Femostop Gold Compress Sys,PX-27200098,CDM,27200098,LOCAL,272,RC,,,outpatient,,,731,511.7,AETNA [1000108],AETNA [100010801],,,76.8,,561.41,164.1095,619.5956,percent of total billed charges,,,
HC Dot Poly Midline 4fr Sl Full,PX-27200099,CDM,27200099,LOCAL,272,RC,,,outpatient,,,765,535.5,AETNA [1000108],AETNA [100010801],,,76.8,,587.52,171.7425,648.414,percent of total billed charges,,,
HC Powerwand 5fr 10cm,PX-27200100,CDM,27200100,LOCAL,272,RC,,,outpatient,,,776,543.2,AETNA [1000108],AETNA [100010801],,,76.8,,595.97,174.212,657.7376,percent of total billed charges,,,
HC Powerwand Single Sterile 5fr,PX-27200101,CDM,27200101,LOCAL,272,RC,,,outpatient,,,776,543.2,AETNA [1000108],AETNA [100010801],,,76.8,,595.97,174.212,657.7376,percent of total billed charges,,,
HC Needle Intraosseous Pd 15g,PX-27200102,CDM,27200102,LOCAL,272,RC,,,outpatient,,,845,591.5,AETNA [1000108],AETNA [100010801],,,76.8,,648.96,189.7025,716.222,percent of total billed charges,,,
HC Needle Intraosseous Ad 15g,PX-27200103,CDM,27200103,LOCAL,272,RC,,,outpatient,,,845,591.5,AETNA [1000108],AETNA [100010801],,,76.8,,648.96,189.7025,716.222,percent of total billed charges,,,
HC Needle Intraosseous,PX-27200104,CDM,27200104,LOCAL,272,RC,,,outpatient,,,845,591.5,AETNA [1000108],AETNA [100010801],,,76.8,,648.96,189.7025,716.222,percent of total billed charges,,,
HC Kit Triple Lumen Cath 7 X 6,PX-27200105,CDM,27200105,LOCAL,272,RC,,,outpatient,,,895,626.5,AETNA [1000108],AETNA [100010801],,,76.8,,687.36,200.9275,758.602,percent of total billed charges,,,
HC Multi Lumen Cvc Kit Toh Cust,PX-27200106,CDM,27200106,LOCAL,272,RC,,,outpatient,,,895,626.5,AETNA [1000108],AETNA [100010801],,,76.8,,687.36,200.9275,758.602,percent of total billed charges,,,
HC Pad Zoll Aed Cprd Access Kit,PX-27200107,CDM,27200107,LOCAL,272,RC,,,outpatient,,,827,578.9,AETNA [1000108],AETNA [100010801],,,76.8,,635.14,185.6615,700.9652,percent of total billed charges,,,
HC Kit Flexi Seal Fecal,PX-27200108,CDM,27200108,LOCAL,272,RC,,,outpatient,,,939,657.3,AETNA [1000108],AETNA [100010801],,,76.8,,721.15,210.8055,795.8964,percent of total billed charges,,,
HC Powerwand Quick Kit 5fr,PX-27200109,CDM,27200109,LOCAL,272,RC,,,outpatient,,,979,685.3,AETNA [1000108],AETNA [100010801],,,76.8,,751.87,219.7855,829.8004,percent of total billed charges,,,
HC Mahurkar Dual Lumen Subclav Ca,PX-27200110,CDM,27200110,LOCAL,272,RC,,,outpatient,,,1581,1106.7,AETNA [1000108],AETNA [100010801],,,76.8,,1214.21,354.9345,1340.0556,percent of total billed charges,,,
HC Catheter With Curved Extension,PX-27200111,CDM,27200111,LOCAL,272,RC,,,outpatient,,,1581,1106.7,AETNA [1000108],AETNA [100010801],,,76.8,,1214.21,354.9345,1340.0556,percent of total billed charges,,,
HC Set Cath Cricothyroidotomy,PX-27200112,CDM,27200112,LOCAL,272,RC,,,outpatient,,,1136,795.2,AETNA [1000108],AETNA [100010801],,,76.8,,872.45,255.032,962.8736,percent of total billed charges,,,
HC Rusch Quick Trac Small 2.0,PX-27200113,CDM,27200113,LOCAL,272,RC,,,outpatient,,,1269,888.3,AETNA [1000108],AETNA [100010801],,,76.8,,974.59,284.8905,1075.6044,percent of total billed charges,,,
HC Set Prism Prewarm M100'2,PX-27200114,CDM,27200114,LOCAL,272,RC,,,outpatient,,,1319,923.3,AETNA [1000108],AETNA [100010801],,,76.8,,1012.99,296.1155,1117.9844,percent of total billed charges,,,
HC Set Prismaflex M100's,PX-27200115,CDM,27200115,LOCAL,272,RC,,,outpatient,,,1399,979.3,AETNA [1000108],AETNA [100010801],,,76.8,,1074.43,314.0755,1185.7924,percent of total billed charges,,,
HC Bakri Postpartum Balloon,PX-27200116,CDM,27200116,LOCAL,272,RC,,,outpatient,,,1408,985.6,AETNA [1000108],AETNA [100010801],,,76.8,,1081.34,316.096,1193.4208,percent of total billed charges,,,
HC Flo Trac Sensor Mhd6,PX-27200117,CDM,27200117,LOCAL,272,RC,,,outpatient,,,2027,1418.9,AETNA [1000108],AETNA [100010801],,,76.8,,1556.74,455.0615,1718.0852,percent of total billed charges,,,
HC Pad Universal Artic Gel,PX-27200118,CDM,27200118,LOCAL,272,RC,,,outpatient,,,2219,1553.3,AETNA [1000108],AETNA [100010801],,,76.8,,1704.19,498.1655,1880.8244,percent of total billed charges,,,
HC Cath Presep 8.5 Oximetry,PX-27200119,CDM,27200119,LOCAL,272,RC,,,outpatient,,,2602,1821.4,AETNA [1000108],AETNA [100010801],,,76.8,,1998.34,584.149,2205.4552,percent of total billed charges,,,
HC Set Cricothyrotomy Cath,PX-27200120,CDM,27200120,LOCAL,272,RC,,,outpatient,,,2943,2060.1,AETNA [1000108],AETNA [100010801],,,76.8,,2260.22,660.7035,2494.4868,percent of total billed charges,,,
HC Pad Artic Gel Small,PX-27200121,CDM,27200121,LOCAL,272,RC,,,outpatient,,,5565,3895.5,AETNA [1000108],AETNA [100010801],,,76.8,,4273.92,1249.3425,4716.894,percent of total billed charges,,,
HC Pad Gel Artic Medium,PX-27200122,CDM,27200122,LOCAL,272,RC,,,outpatient,,,5512,3858.4,AETNA [1000108],AETNA [100010801],,,76.8,,4233.22,1237.444,4671.9712,percent of total billed charges,,,
HC Rhino G2 Blue,PX-27200123,CDM,27200123,LOCAL,272,RC,,,outpatient,,,4120,2884,AETNA [1000108],AETNA [100010801],,,76.8,,3164.16,924.94,3492.112,percent of total billed charges,,,
HC Pad Artic Gel Lrg,PX-27200124,CDM,27200124,LOCAL,272,RC,,,outpatient,,,5512,3858.4,AETNA [1000108],AETNA [100010801],,,76.8,,4233.22,1237.444,4671.9712,percent of total billed charges,,,
HC Bag External Drainage Collect,PX-27200125,CDM,27200125,LOCAL,272,RC,,,outpatient,,,1349,944.3,AETNA [1000108],AETNA [100010801],,,76.8,,1036.03,302.8505,1143.4124,percent of total billed charges,,,
HC Catheter Thoracic 28fr,PX-27200126,CDM,27200126,LOCAL,272,RC,,,outpatient,,,39,27.3,AETNA [1000108],AETNA [100010801],,,76.8,,29.95,8.7555,33.0564,percent of total billed charges,,,
HC Tube Endo Bronch Left 37,PX-27200127,CDM,27200127,LOCAL,272,RC,,,outpatient,,,349,244.3,AETNA [1000108],AETNA [100010801],,,76.8,,268.03,78.3505,295.8124,percent of total billed charges,,,
HC Electrode Temporary Pacing 6,PX-27200128,CDM,27200128,LOCAL,272,RC,,,outpatient,,,1238,866.6,AETNA [1000108],AETNA [100010801],,,76.8,,950.78,277.931,1049.3288,percent of total billed charges,,,
HC Set Pneumothorax,PX-27200129,CDM,27200129,LOCAL,272,RC,,,outpatient,,,1113,779.1,AETNA [1000108],AETNA [100010801],,,76.8,,854.78,249.8685,943.3788,percent of total billed charges,,,
HC System External Drainage III,PX-27200130,CDM,27200130,LOCAL,272,RC,,,outpatient,,,1887,1320.9,AETNA [1000108],AETNA [100010801],,,76.8,,1449.22,423.6315,1599.4212,percent of total billed charges,,,
HC Electrode Temporary Pacing 5,PX-27200131,CDM,27200131,LOCAL,272,RC,,,outpatient,,,1097,767.9,AETNA [1000108],AETNA [100010801],,,76.8,,842.5,246.2765,929.8172,percent of total billed charges,,,
HC Tray Tru Close Thoracic Vent,PX-27200132,CDM,27200132,LOCAL,272,RC,,,outpatient,,,1504,1052.8,AETNA [1000108],AETNA [100010801],,,76.8,,1155.07,337.648,1274.7904,percent of total billed charges,,,
HC Tube Trach Flex Laser 6.0 Mm,PX-27200133,CDM,27200133,LOCAL,272,RC,,,outpatient,,,319,223.3,AETNA [1000108],AETNA [100010801],,,76.8,,244.99,71.6155,270.3844,percent of total billed charges,,,
HC Pack Cesarean Custom,PX-27200134,CDM,27200134,LOCAL,272,RC,,,outpatient,,,462,323.4,AETNA [1000108],AETNA [100010801],,,76.8,,354.82,103.719,391.5912,percent of total billed charges,,,
HC Hemostat Instat 1gm,PX-27200135,CDM,27200135,LOCAL,272,RC,,,outpatient,,,1077,753.9,AETNA [1000108],AETNA [100010801],,,76.8,,827.14,241.7865,912.8652,percent of total billed charges,,,
HC Tube Trach Distal Xlt 7.0,PX-27200136,CDM,27200136,LOCAL,272,RC,,,outpatient,,,486,340.2,AETNA [1000108],AETNA [100010801],,,76.8,,373.25,109.107,411.9336,percent of total billed charges,,,
HC Surgicel 2 X 14 #1951,PX-27200137,CDM,27200137,LOCAL,272,RC,,,outpatient,,,447,312.9,AETNA [1000108],AETNA [100010801],,,76.8,,343.3,100.3515,378.8772,percent of total billed charges,,,
HC Ligator Saeed Sx Shoot,PX-27200138,CDM,27200138,LOCAL,272,RC,,,outpatient,,,1332,932.4,AETNA [1000108],AETNA [100010801],,,76.8,,1022.98,299.034,1129.0032,percent of total billed charges,,,
HC Cath Swan Ganz 7.5 Vip Port,PX-27200139,CDM,27200139,LOCAL,272,RC,,,outpatient,,,297,207.9,AETNA [1000108],AETNA [100010801],,,76.8,,228.1,66.6765,251.7372,percent of total billed charges,,,
HC Cath Multilumen Access,PX-27200140,CDM,27200140,LOCAL,272,RC,,,outpatient,,,537,375.9,AETNA [1000108],AETNA [100010801],,,76.8,,412.42,120.5565,455.1612,percent of total billed charges,,,
HC Trach Bivona Tts 7mm,PX-27200141,CDM,27200141,LOCAL,272,RC,,,outpatient,,,565,395.5,AETNA [1000108],AETNA [100010801],,,76.8,,433.92,126.8425,478.894,percent of total billed charges,,,
HC Kit Pleurx Drainage W Bottle,PX-27200142,CDM,27200142,LOCAL,272,RC,,,outpatient,,,417,291.9,AETNA [1000108],AETNA [100010801],,,76.8,,320.26,93.6165,353.4492,percent of total billed charges,,,
HC Retractor Wound Alexis Lrg,PX-27200143,CDM,27200143,LOCAL,272,RC,,,outpatient,,,412,288.4,AETNA [1000108],AETNA [100010801],,,76.8,,316.42,92.494,349.2112,percent of total billed charges,,,
HC Unit Cold Therapy Deroyal,PX-27200144,CDM,27200144,LOCAL,272,RC,,,outpatient,,,691,483.7,AETNA [1000108],AETNA [100010801],,,76.8,,530.69,155.1295,585.6916,percent of total billed charges,,,
HC Dressing Kci Vac Silver Med,PX-27200145,CDM,27200145,LOCAL,272,RC,,,outpatient,,,506,354.2,AETNA [1000108],AETNA [100010801],,,76.8,,388.61,113.597,428.8856,percent of total billed charges,,,
HC Kit Midline Cath 20ga X 20cm,PX-27200146,CDM,27200146,LOCAL,272,RC,,,outpatient,,,424,296.8,AETNA [1000108],AETNA [100010801],,,76.8,,325.63,95.188,359.3824,percent of total billed charges,,,
HC Cath Mahurkar 3 Lumen 12x20,PX-27200147,CDM,27200147,LOCAL,272,RC,,,outpatient,,,594,415.8,AETNA [1000108],AETNA [100010801],,,76.8,,456.19,133.353,503.4744,percent of total billed charges,,,
HC Retractor Alexis Wound Xlg,PX-27200148,CDM,27200148,LOCAL,272,RC,,,outpatient,,,529,370.3,AETNA [1000108],AETNA [100010801],,,76.8,,406.27,118.7605,448.3804,percent of total billed charges,,,
HC Surgiflo Hemostatic Matrix,PX-27200149,CDM,27200149,LOCAL,272,RC,,,outpatient,,,906,634.2,AETNA [1000108],AETNA [100010801],,,76.8,,695.81,203.397,767.9256,percent of total billed charges,,,
HC Kit Monitoring Press Abviser,PX-27200150,CDM,27200150,LOCAL,272,RC,,,outpatient,,,648,453.6,AETNA [1000108],AETNA [100010801],,,76.8,,497.66,145.476,549.2448,percent of total billed charges,,,
HC Tray Fuhrman Pleural Drain,PX-27200151,CDM,27200151,LOCAL,272,RC,,,outpatient,,,990,693,AETNA [1000108],AETNA [100010801],,,76.8,,760.32,222.255,839.124,percent of total billed charges,,,
HC Kit Cath Triple Lumen 20cm,PX-27200152,CDM,27200152,LOCAL,272,RC,,,outpatient,,,865,605.5,AETNA [1000108],AETNA [100010801],,,76.8,,664.32,194.1925,733.174,percent of total billed charges,,,
HC Dressing Kci Simplace Med,PX-27200153,CDM,27200153,LOCAL,272,RC,,,outpatient,,,433,303.1,AETNA [1000108],AETNA [100010801],,,76.8,,332.54,97.2085,367.0108,percent of total billed charges,,,
HC Tube Non Balloon Replace Peg,PX-27200154,CDM,27200154,LOCAL,272,RC,,,outpatient,,,394,275.8,AETNA [1000108],AETNA [100010801],,,76.8,,302.59,88.453,333.9544,percent of total billed charges,,,
HC Cath 12fr Hp Triple Lumen,PX-27200155,CDM,27200155,LOCAL,272,RC,,,outpatient,,,606,424.2,AETNA [1000108],AETNA [100010801],,,76.8,,465.41,136.047,513.6456,percent of total billed charges,,,
HC Cath Pneumothorax Ak01500,PX-27200156,CDM,27200156,LOCAL,272,RC,,,outpatient,,,700,490,AETNA [1000108],AETNA [100010801],,,76.8,,537.6,157.15,593.32,percent of total billed charges,,,
HC Kit Cranial Access 826614,PX-27200158,CDM,27200158,LOCAL,272,RC,,,outpatient,,,2205,1543.5,AETNA [1000108],AETNA [100010801],,,76.8,,1693.44,495.0225,1868.958,percent of total billed charges,,,
"HC Sensor Flotrac W Vamp 60""",PX-27200159,CDM,27200159,LOCAL,272,RC,,,outpatient,,,1336,935.2,AETNA [1000108],AETNA [100010801],,,76.8,,1026.05,299.932,1132.3936,percent of total billed charges,,,
HC Trach Lg 4.0 Quick Rusch,PX-27200160,CDM,27200160,LOCAL,272,RC,,,outpatient,,,1094,765.8,AETNA [1000108],AETNA [100010801],,,76.8,,840.19,245.603,927.2744,percent of total billed charges,,,
HC Tray Pericardiocentesis Stra,PX-27200161,CDM,27200161,LOCAL,272,RC,,,outpatient,,,1188,831.6,AETNA [1000108],AETNA [100010801],,,76.8,,912.38,266.706,1006.9488,percent of total billed charges,,,
HC Trocar Endo Ethicon 12 512sd,PX-27200162,CDM,27200162,LOCAL,272,RC,,,outpatient,,,1154,807.8,AETNA [1000108],AETNA [100010801],,,76.8,,886.27,259.073,978.1304,percent of total billed charges,,,
HC Tube Laryngectomy 12mm Metal,PX-27200163,CDM,27200163,LOCAL,272,RC,,,outpatient,,,1154,807.8,AETNA [1000108],AETNA [100010801],,,76.8,,886.27,259.073,978.1304,percent of total billed charges,,,
HC Tray Midline CT 4f 20cm Single,PX-27200164,CDM,27200164,LOCAL,272,RC,,,outpatient,,,785,549.5,AETNA [1000108],AETNA [100010801],,,76.8,,602.88,176.2325,665.366,percent of total billed charges,,,
HC Tray Midline CT 5f 20cm Dual,PX-27200165,CDM,27200165,LOCAL,272,RC,,,outpatient,,,779,545.3,AETNA [1000108],AETNA [100010801],,,76.8,,598.27,174.8855,660.2804,percent of total billed charges,,,
HC Mahurkar Triple Lumen Cath Tray #16,PX-27200166,CDM,27200166,LOCAL,272,RC,,,outpatient,,,1191,833.7,AETNA [1000108],AETNA [100010801],,,76.8,,914.69,267.3795,1009.4916,percent of total billed charges,,,
HC Mahurkar Triple Lumen Cath Tray #20,PX-27200167,CDM,27200167,LOCAL,272,RC,,,outpatient,,,983,688.1,AETNA [1000108],AETNA [100010801],,,76.8,,754.94,220.6835,833.1908,percent of total billed charges,,,
HC Compartment Pressure Monitoring Kit,PX-27200168,CDM,27200168,LOCAL,272,RC,,,outpatient,,,457,319.9,AETNA [1000108],AETNA [100010801],,,76.8,,350.98,102.5965,387.3532,percent of total billed charges,,,
HC Kit Perc Sheath Introducer 8.5,PX-27200169,CDM,27200169,LOCAL,272,RC,,,outpatient,,,471,329.7,AETNA [1000108],AETNA [100010801],,,76.8,,361.73,105.7395,399.2196,percent of total billed charges,,,
HC Cath Arrow Cvc Kit Latex Free,PX-27200170,CDM,27200170,LOCAL,272,RC,,,outpatient,,,465,325.5,AETNA [1000108],AETNA [100010801],,,76.8,,357.12,104.3925,394.134,percent of total billed charges,,,
HC Electrode Temporary Pacing 4,PX-27200171,CDM,27200171,LOCAL,272,RC,,,outpatient,,,823,576.1,AETNA [1000108],AETNA [100010801],,,76.8,,632.06,184.7635,697.5748,percent of total billed charges,,,
HC Catheter Bipolar Pacing 5,PX-27200172,CDM,27200172,LOCAL,272,RC,,,outpatient,,,619,433.3,AETNA [1000108],AETNA [100010801],,,76.8,,475.39,138.9655,524.6644,percent of total billed charges,,,
HC Set Emergency Pneumothorax,PX-27200173,CDM,27200173,LOCAL,272,RC,,,outpatient,,,795,556.5,AETNA [1000108],AETNA [100010801],,,76.8,,610.56,178.4775,673.842,percent of total billed charges,,,
HC Kit Pneumothorax,PX-27200174,CDM,27200174,LOCAL,272,RC,,,outpatient,,,722,505.4,AETNA [1000108],AETNA [100010801],,,76.8,,554.5,162.089,611.9672,percent of total billed charges,,,
HC Impella Purge Cassette,PX-27200175,CDM,27200175,LOCAL,272,RC,,,outpatient,,,245,171.5,AETNA [1000108],AETNA [100010801],,,76.8,,188.16,55.0025,207.662,percent of total billed charges,,,
HC Tray Midline CT 4f 20cm Singl,PX-27200176,CDM,27200176,LOCAL,272,RC,,,outpatient,,,954,667.8,AETNA [1000108],AETNA [100010801],,,76.8,,732.67,214.173,808.6104,percent of total billed charges,,,
HC Tray Midline CT 5f 20cm Dual F,PX-27200177,CDM,27200177,LOCAL,272,RC,,,outpatient,,,1154,807.8,AETNA [1000108],AETNA [100010801],,,76.8,,886.27,259.073,978.1304,percent of total billed charges,,,
HC Kit Microez Mst Nitinol 4.5 7c,PX-27200178,CDM,27200178,LOCAL,272,RC,,,outpatient,,,497,347.9,AETNA [1000108],AETNA [100010801],,,76.8,,381.7,111.5765,421.2572,percent of total billed charges,,,
HC Kit Microez Mst 5f Nsx,PX-27200179,CDM,27200179,LOCAL,272,RC,,,outpatient,,,251,175.7,AETNA [1000108],AETNA [100010801],,,76.8,,192.77,56.3495,212.7476,percent of total billed charges,,,
HC Electrode One Step Cpr Adult,PX-27200180,CDM,27200180,LOCAL,272,RC,,,outpatient,,,408,285.6,AETNA [1000108],AETNA [100010801],,,76.8,,313.34,91.596,345.8208,percent of total billed charges,,,
HC Electrode One Step Pediatric,PX-27200181,CDM,27200181,LOCAL,272,RC,,,outpatient,,,447,312.9,AETNA [1000108],AETNA [100010801],,,76.8,,343.3,100.3515,378.8772,percent of total billed charges,,,
HC Ambu® Ascopetm 4 Broncho Large (5.8/2.8),PX-27200196,CDM,27200196,LOCAL,272,RC,,,outpatient,,,359,251.3,AETNA [1000108],AETNA [100010801],,,76.8,,275.71,80.5955,304.2884,percent of total billed charges,,,
HC Ambu® Ascopetm 4 Broncho Regular (5.0/2.2),PX-27200197,CDM,27200197,LOCAL,272,RC,,,outpatient,,,312,218.4,AETNA [1000108],AETNA [100010801],,,76.8,,239.62,70.044,264.4512,percent of total billed charges,,,
HC Ambu® Ascopetm 4 Broncho Slim (3.8/1.2),PX-27200198,CDM,27200198,LOCAL,272,RC,,,outpatient,,,312,218.4,AETNA [1000108],AETNA [100010801],,,76.8,,239.62,70.044,264.4512,percent of total billed charges,,,
HC Tray Pneumothorax Turkel 9 Cm Sys,PX-27200199,CDM,27200199,LOCAL,272,RC,,,outpatient,,,622,435.4,AETNA [1000108],AETNA [100010801],,,76.8,,477.7,139.639,527.2072,percent of total billed charges,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400003,CDM,27400003,LOCAL,274,RC,,,outpatient,,,552,386.4,AETNA [1000108],AETNA [100010801],,,76.8,,423.94,123.924,467.8752,percent of total billed charges,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400005,CDM,27400005,LOCAL,274,RC,,,outpatient,,,1221,854.7,AETNA [1000108],AETNA [100010801],,,76.8,,937.73,274.1145,1034.9196,percent of total billed charges,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400008,CDM,27400008,LOCAL,274,RC,,,outpatient,,,3772,2640.4,AETNA [1000108],AETNA [100010801],,,76.8,,2896.9,846.814,3197.1472,percent of total billed charges,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400012,CDM,27400012,LOCAL,274,RC,,,outpatient,,,1954,1367.8,AETNA [1000108],AETNA [100010801],,,76.8,,1500.67,438.673,1656.2104,percent of total billed charges,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400015,CDM,27400015,LOCAL,274,RC,,,outpatient,,,3806,2664.2,AETNA [1000108],AETNA [100010801],,,76.8,,2923.01,854.447,3225.9656,percent of total billed charges,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400030,CDM,27400030,LOCAL,274,RC,,,outpatient,,,661,462.7,AETNA [1000108],AETNA [100010801],,,76.8,,507.65,148.3945,560.2636,percent of total billed charges,,,
HC Brace Knee Enhanced Trom,PX-27400038,CDM,27400038,LOCAL,274,RC,,,outpatient,,,570,399,AETNA [1000108],AETNA [100010801],,,76.8,,437.76,127.965,483.132,percent of total billed charges,,,
HC Brace Enhanced Trom Donjoy,PX-27400039,CDM,27400039,LOCAL,274,RC,,,outpatient,,,570,399,AETNA [1000108],AETNA [100010801],,,76.8,,437.76,127.965,483.132,percent of total billed charges,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400047,CDM,27400047,LOCAL,274,RC,,,outpatient,,,3385,2369.5,AETNA [1000108],AETNA [100010801],,,76.8,,2599.68,759.9325,2869.126,percent of total billed charges,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400050,CDM,27400050,LOCAL,274,RC,,,outpatient,,,3185,2229.5,AETNA [1000108],AETNA [100010801],,,76.8,,2446.08,715.0325,2699.606,percent of total billed charges,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400107,CDM,27400107,LOCAL,274,RC,,,outpatient,,,380,266,AETNA [1000108],AETNA [100010801],,,76.8,,291.84,85.31,322.088,percent of total billed charges,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400117,CDM,27400117,LOCAL,274,RC,,,outpatient,,,779,545.3,AETNA [1000108],AETNA [100010801],,,76.8,,598.27,174.8855,660.2804,percent of total billed charges,,,
HC Add. to Lower Extremity L2210,PX-27400184,CDM,27400184,LOCAL,274,RC,,,outpatient,,,330,231,AETNA [1000108],AETNA [100010801],,,76.8,,253.44,74.085,279.708,percent of total billed charges,,,
HC Lift Elevation Heel & Sole,PX-27400185,CDM,27400185,LOCAL,274,RC,,,outpatient,,,382,267.4,AETNA [1000108],AETNA [100010801],,,76.8,,293.38,85.759,323.7832,percent of total billed charges,,,
HC Add. Lower Extremity Orthosis,PX-27400186,CDM,27400186,LOCAL,274,RC,,,outpatient,,,448,313.6,AETNA [1000108],AETNA [100010801],,,76.8,,344.06,100.576,379.7248,percent of total billed charges,,,
HC Depth Shoe A5500,PX-27400187,CDM,27400187,LOCAL,274,RC,,,outpatient,,,473,331.1,AETNA [1000108],AETNA [100010801],,,76.8,,363.26,106.1885,400.9148,percent of total billed charges,,,
HC Compression Stocking A6533,PX-27400188,CDM,27400188,LOCAL,274,RC,,,outpatient,,,502,351.4,AETNA [1000108],AETNA [100010801],,,76.8,,385.54,112.699,425.4952,percent of total billed charges,,,
HC Collar L0172,PX-27400189,CDM,27400189,LOCAL,274,RC,,,outpatient,,,658,460.6,AETNA [1000108],AETNA [100010801],,,76.8,,505.34,147.721,557.7208,percent of total billed charges,,,
HC Ko Elastic Knee Joint L1820,PX-27400190,CDM,27400190,LOCAL,274,RC,,,outpatient,,,661,462.7,AETNA [1000108],AETNA [100010801],,,76.8,,507.65,148.3945,560.2636,percent of total billed charges,,,
HC Procedure Ortho Shoe/L3649,PX-27400191,CDM,27400191,LOCAL,274,RC,,,outpatient,,,703,492.1,AETNA [1000108],AETNA [100010801],,,76.8,,539.9,157.8235,595.8628,percent of total billed charges,,,
HC Air Cast Boot L4386,PX-27400192,CDM,27400192,LOCAL,274,RC,,,outpatient,,,745,521.5,AETNA [1000108],AETNA [100010801],,,76.8,,572.16,167.2525,631.462,percent of total billed charges,,,
HC Static Afa L4396,PX-27400193,CDM,27400193,LOCAL,274,RC,,,outpatient,,,785,549.5,AETNA [1000108],AETNA [100010801],,,76.8,,602.88,176.2325,665.366,percent of total billed charges,,,
HC Brace Tlso,PX-27400194,CDM,27400194,LOCAL,274,RC,,,outpatient,,,901,630.7,AETNA [1000108],AETNA [100010801],,,76.8,,691.97,202.2745,763.6876,percent of total billed charges,,,
HC Lumbar Corsette L0450,PX-27400195,CDM,27400195,LOCAL,274,RC,,,outpatient,,,915,640.5,AETNA [1000108],AETNA [100010801],,,76.8,,702.72,205.4175,775.554,percent of total billed charges,,,
HC Brace Warm and Form,PX-27400196,CDM,27400196,LOCAL,274,RC,,,outpatient,,,1117,781.9,AETNA [1000108],AETNA [100010801],,,76.8,,857.86,250.7665,946.7692,percent of total billed charges,,,
HC Afo L1940,PX-27400197,CDM,27400197,LOCAL,274,RC,,,outpatient,,,2560,1792,AETNA [1000108],AETNA [100010801],,,76.8,,1966.08,574.72,2169.856,percent of total billed charges,,,
HC Ankle Foot Orthosis L1940,PX-27400198,CDM,27400198,LOCAL,274,RC,,,outpatient,,,2560,1792,AETNA [1000108],AETNA [100010801],,,76.8,,1966.08,574.72,2169.856,percent of total billed charges,,,
HC POS OP Knee Brace L1832,PX-27400199,CDM,27400199,LOCAL,274,RC,,,outpatient,,,2974,2081.8,AETNA [1000108],AETNA [100010801],,,76.8,,2284.03,667.663,2520.7624,percent of total billed charges,,,
HC Afo Plastic L1960,PX-27400200,CDM,27400200,LOCAL,274,RC,,,outpatient,,,3011,2107.7,AETNA [1000108],AETNA [100010801],,,76.8,,2312.45,675.9695,2552.1236,percent of total billed charges,,,
HC Ankle/Foot Orthosis Afo,PX-27400201,CDM,27400201,LOCAL,274,RC,,,outpatient,,,3011,2107.7,AETNA [1000108],AETNA [100010801],,,76.8,,2312.45,675.9695,2552.1236,percent of total billed charges,,,
HC Left Afo Brace/Atlantic Pros,PX-27400202,CDM,27400202,LOCAL,274,RC,,,outpatient,,,3165,2215.5,AETNA [1000108],AETNA [100010801],,,76.8,,2430.72,710.5425,2682.654,percent of total billed charges,,,
HC Afo L1932,PX-27400203,CDM,27400203,LOCAL,274,RC,,,outpatient,,,3418,2392.6,AETNA [1000108],AETNA [100010801],,,76.8,,2625.02,767.341,2897.0968,percent of total billed charges,,,
HC Ankle Foot Orthosis L1970,PX-27400204,CDM,27400204,LOCAL,274,RC,,,outpatient,,,3462,2423.4,AETNA [1000108],AETNA [100010801],,,76.8,,2658.82,777.219,2934.3912,percent of total billed charges,,,
HC Back Brace Tlso Lo486,PX-27400205,CDM,27400205,LOCAL,274,RC,,,outpatient,,,6597,4617.9,AETNA [1000108],AETNA [100010801],,,76.8,,5066.5,1481.0265,5591.6172,percent of total billed charges,,,
HC Cervical Collar L0172,PX-27400206,CDM,27400206,LOCAL,274,RC,,,outpatient,,,658,460.6,AETNA [1000108],AETNA [100010801],,,76.8,,505.34,147.721,557.7208,percent of total billed charges,,,
HC Philly Collar No Extension,PX-27400207,CDM,27400207,LOCAL,274,RC,,,outpatient,,,658,460.6,AETNA [1000108],AETNA [100010801],,,76.8,,505.34,147.721,557.7208,percent of total billed charges,,,
HC Cervical Collar 2/Piece L0174,PX-27400208,CDM,27400208,LOCAL,274,RC,,,outpatient,,,1232,862.4,AETNA [1000108],AETNA [100010801],,,76.8,,946.18,276.584,1044.2432,percent of total billed charges,,,
HC Lumbar Orthosis L0627,PX-27400209,CDM,27400209,LOCAL,274,RC,,,outpatient,,,1750,1225,AETNA [1000108],AETNA [100010801],,,76.8,,1344,392.875,1483.3,percent of total billed charges,,,
HC Lso Sagoro Rigid Frame L0631,PX-27400210,CDM,27400210,LOCAL,274,RC,,,outpatient,,,3933,2753.1,AETNA [1000108],AETNA [100010801],,,76.8,,3020.54,882.9585,3333.6108,percent of total billed charges,,,
HC Lso Sagittal Coronal L0637,PX-27400211,CDM,27400211,LOCAL,274,RC,,,outpatient,,,4114,2879.8,AETNA [1000108],AETNA [100010801],,,76.8,,3159.55,923.593,3487.0264,percent of total billed charges,,,
HC Hip Abduction Orthosis L1686,PX-27400212,CDM,27400212,LOCAL,274,RC,,,outpatient,,,4461,3122.7,AETNA [1000108],AETNA [100010801],,,76.8,,3426.05,1001.4945,3781.1436,percent of total billed charges,,,
HC Knee Orthosis L1830,PX-27400213,CDM,27400213,LOCAL,274,RC,,,outpatient,,,466,326.2,AETNA [1000108],AETNA [100010801],,,76.8,,357.89,104.617,394.9816,percent of total billed charges,,,
HC Knee Orthosis L1832,PX-27400214,CDM,27400214,LOCAL,274,RC,,,outpatient,,,2974,2081.8,AETNA [1000108],AETNA [100010801],,,76.8,,2284.03,667.663,2520.7624,percent of total billed charges,,,
HC Knee Orthosis L1832,PX-27400215,CDM,27400215,LOCAL,274,RC,,,outpatient,,,2974,2081.8,AETNA [1000108],AETNA [100010801],,,76.8,,2284.03,667.663,2520.7624,percent of total billed charges,,,
HC Knee Osthosis L1832,PX-27400216,CDM,27400216,LOCAL,274,RC,,,outpatient,,,2974,2081.8,AETNA [1000108],AETNA [100010801],,,76.8,,2284.03,667.663,2520.7624,percent of total billed charges,,,
HC Afo L1930,PX-27400217,CDM,27400217,LOCAL,274,RC,,,outpatient,,,1062,743.4,AETNA [1000108],AETNA [100010801],,,76.8,,815.62,238.419,900.1512,percent of total billed charges,,,
HC Adj. Dorsal Splint L1930,PX-27400218,CDM,27400218,LOCAL,274,RC,,,outpatient,,,1062,743.4,AETNA [1000108],AETNA [100010801],,,76.8,,815.62,238.419,900.1512,percent of total billed charges,,,
HC L'nard Boot L1930,PX-27400219,CDM,27400219,LOCAL,274,RC,,,outpatient,,,1062,743.4,AETNA [1000108],AETNA [100010801],,,76.8,,815.62,238.419,900.1512,percent of total billed charges,,,
HC Hip Adj Ext L2624,PX-27400220,CDM,27400220,LOCAL,274,RC,,,outpatient,,,1445,1011.5,AETNA [1000108],AETNA [100010801],,,76.8,,1109.76,324.4025,1224.782,percent of total billed charges,,,
HC Bk Soft Interface L2820,PX-27400221,CDM,27400221,LOCAL,274,RC,,,outpatient,,,448,313.6,AETNA [1000108],AETNA [100010801],,,76.8,,344.06,100.576,379.7248,percent of total billed charges,,,
HC Lift Elevation L3332,PX-27400222,CDM,27400222,LOCAL,274,RC,,,outpatient,,,347,242.9,AETNA [1000108],AETNA [100010801],,,76.8,,266.5,77.9015,294.1172,percent of total billed charges,,,
HC Wrist Hand/Finger Ortho L3807,PX-27400223,CDM,27400223,LOCAL,274,RC,,,outpatient,,,1065,745.5,AETNA [1000108],AETNA [100010801],,,76.8,,817.92,239.0925,902.694,percent of total billed charges,,,
HC Wrist Cockup Nonmolded L3908,PX-27400224,CDM,27400224,LOCAL,274,RC,,,outpatient,,,353,247.1,AETNA [1000108],AETNA [100010801],,,76.8,,271.1,79.2485,299.2028,percent of total billed charges,,,
HC Orthosis Upper Limb Hum. Frac,PX-27400225,CDM,27400225,LOCAL,274,RC,,,outpatient,,,1413,989.1,AETNA [1000108],AETNA [100010801],,,76.8,,1085.18,317.2185,1197.6588,percent of total billed charges,,,
HC Walking Boot L4360,PX-27400226,CDM,27400226,LOCAL,274,RC,,,outpatient,,,1290,903,AETNA [1000108],AETNA [100010801],,,76.8,,990.72,289.605,1093.404,percent of total billed charges,,,
HC Walking Boot Prefab L4360,PX-27400227,CDM,27400227,LOCAL,274,RC,,,outpatient,,,1290,903,AETNA [1000108],AETNA [100010801],,,76.8,,990.72,289.605,1093.404,percent of total billed charges,,,
HC Walking Boot L4360,PX-27400228,CDM,27400228,LOCAL,274,RC,,,outpatient,,,2135,1494.5,AETNA [1000108],AETNA [100010801],,,76.8,,1639.68,479.3075,1809.626,percent of total billed charges,,,
HC Cam Walker L4386,PX-27400229,CDM,27400229,LOCAL,274,RC,,,outpatient,,,745,521.5,AETNA [1000108],AETNA [100010801],,,76.8,,572.16,167.2525,631.462,percent of total billed charges,,,
HC Bk Stump Shrinker L8440,PX-27400230,CDM,27400230,LOCAL,274,RC,,,outpatient,,,262,183.4,AETNA [1000108],AETNA [100010801],,,76.8,,201.22,58.819,222.0712,percent of total billed charges,,,
HC Stump Shrinker L8440,PX-27400231,CDM,27400231,LOCAL,274,RC,,,outpatient,,,262,183.4,AETNA [1000108],AETNA [100010801],,,76.8,,201.22,58.819,222.0712,percent of total billed charges,,,
HC Liner Foam Permanently Lg,PX-27400232,CDM,27400232,LOCAL,274,RC,,,outpatient,,,353,247.1,AETNA [1000108],AETNA [100010801],,,76.8,,271.1,79.2485,299.2028,percent of total billed charges,,,
HC Kit Electrode Pacing,PX-27500027,CDM,27500027,LOCAL,275,RC,,,outpatient,,,1286,900.2,AETNA [1000108],AETNA [100010801],,,76.8,,987.65,288.707,1090.0136,percent of total billed charges,,,
HC Medical/Surgical Supplies: Other Implants,PX-27800095,CDM,27800095,LOCAL,278,RC,,,outpatient,,,649,454.3,AETNA [1000108],AETNA [100010801],,,76.8,,498.43,145.7005,550.0924,percent of total billed charges,,,
HC Leg Post Rigid Brace/Sc Ortho,PX-27800096,CDM,27800096,LOCAL,278,RC,,,outpatient,,,758,530.6,AETNA [1000108],AETNA [100010801],,,76.8,,582.14,170.171,642.4808,percent of total billed charges,,,
HC Kit Picc 4fr per-Q Poly Cath,PX-27800097,CDM,27800097,LOCAL,278,RC,,,outpatient,,,1063,744.1,AETNA [1000108],AETNA [100010801],,,76.8,,816.38,238.6435,900.9988,percent of total billed charges,,,
HC Floseal Matrix Hemostatic,PX-27800098,CDM,27800098,LOCAL,278,RC,,,outpatient,,,1093,765.1,AETNA [1000108],AETNA [100010801],,,76.8,,839.42,245.3785,926.4268,percent of total billed charges,,,
HC Kit Picc 5fr per-Q Poly Cath,PX-27800099,CDM,27800099,LOCAL,278,RC,,,outpatient,,,1217,851.9,AETNA [1000108],AETNA [100010801],,,76.8,,934.66,273.2165,1031.5292,percent of total billed charges,,,
HC Tray Power Picc Dual 5f,PX-27800100,CDM,27800100,LOCAL,278,RC,,,outpatient,,,1355,948.5,AETNA [1000108],AETNA [100010801],,,76.8,,1040.64,304.1975,1148.498,percent of total billed charges,,,
HC Tray Power Picc Single 4f,PX-27800101,CDM,27800101,LOCAL,278,RC,,,outpatient,,,1398,978.6,AETNA [1000108],AETNA [100010801],,,76.8,,1073.66,313.851,1184.9448,percent of total billed charges,,,
HC Tray Power Picc Triple 5fr,PX-27800102,CDM,27800102,LOCAL,278,RC,,,outpatient,,,1474,1031.8,AETNA [1000108],AETNA [100010801],,,76.8,,1132.03,330.913,1249.3624,percent of total billed charges,,,
HC Tray Power Picc Triple 6f,PX-27800103,CDM,27800103,LOCAL,278,RC,,,outpatient,,,1499,1049.3,AETNA [1000108],AETNA [100010801],,,76.8,,1151.23,336.5255,1270.5524,percent of total billed charges,,,
HC Sepafilm/5x6,PX-27800104,CDM,27800104,LOCAL,278,RC,,,outpatient,,,1773,1241.1,AETNA [1000108],AETNA [100010801],,,76.8,,1361.66,398.0385,1502.7948,percent of total billed charges,,,
HC 3cg Power Picc Max 4fr Sl,PX-27800105,CDM,27800105,LOCAL,278,RC,,,outpatient,,,1585,1109.5,AETNA [1000108],AETNA [100010801],,,76.8,,1217.28,355.8325,1343.446,percent of total billed charges,,,
HC 3cg Power Picc Max 5fr Dl,PX-27800106,CDM,27800106,LOCAL,278,RC,,,outpatient,,,1636,1145.2,AETNA [1000108],AETNA [100010801],,,76.8,,1256.45,367.282,1386.6736,percent of total billed charges,,,
HC 3cg Power Picc Max 6fr Tl,PX-27800107,CDM,27800107,LOCAL,278,RC,,,outpatient,,,1749,1224.3,AETNA [1000108],AETNA [100010801],,,76.8,,1343.23,392.6505,1482.4524,percent of total billed charges,,,
HC Valve Passy Muir Aqua,PX-27800108,CDM,27800108,LOCAL,278,RC,,,outpatient,,,474,331.8,AETNA [1000108],AETNA [100010801],,,76.8,,364.03,106.413,401.7624,percent of total billed charges,,,
HC Passy Muir Valve - Clear,PX-27800113,CDM,27800113,LOCAL,278,RC,,,outpatient,,,474,331.8,AETNA [1000108],AETNA [100010801],,,76.8,,364.03,106.413,401.7624,percent of total billed charges,,,
HC Valve Passy Muir Purple,PX-27800114,CDM,27800114,LOCAL,278,RC,,,outpatient,,,474,331.8,AETNA [1000108],AETNA [100010801],,,76.8,,364.03,106.413,401.7624,percent of total billed charges,,,
HC Liner Foam Permanently X-Lg,PX-27800115,CDM,27800115,LOCAL,278,RC,,,outpatient,,,328,229.6,AETNA [1000108],AETNA [100010801],,,76.8,,251.9,73.636,278.0128,percent of total billed charges,,,
HC Tube Trach Proximal Xlt 7.0,PX-27800117,CDM,27800117,LOCAL,278,RC,,,outpatient,,,486,340.2,AETNA [1000108],AETNA [100010801],,,76.8,,373.25,109.107,411.9336,percent of total billed charges,,,
HC Barrier Seprafilm 3x5in,PX-27800118,CDM,27800118,LOCAL,278,RC,,,outpatient,,,1773,1241.1,AETNA [1000108],AETNA [100010801],,,76.8,,1361.66,398.0385,1502.7948,percent of total billed charges,,,
HC Tube Feeding Low Profile 20f,PX-27800119,CDM,27800119,LOCAL,278,RC,,,outpatient,,,694,485.8,AETNA [1000108],AETNA [100010801],,,76.8,,532.99,155.803,588.2344,percent of total billed charges,,,
HC Valve Speaking White #005,PX-27800121,CDM,27800121,LOCAL,278,RC,,,outpatient,,,474,331.8,AETNA [1000108],AETNA [100010801],,,76.8,,364.03,106.413,401.7624,percent of total billed charges,,,
HC Tray Percu Introducer 8.5fr,PX-27800122,CDM,27800122,LOCAL,278,RC,,,outpatient,,,475,332.5,AETNA [1000108],AETNA [100010801],,,76.8,,364.8,106.6375,402.61,percent of total billed charges,,,
HC Basket Zerotip Airway Retriv,PX-27800125,CDM,27800125,LOCAL,278,RC,,,outpatient,,,1710,1197,AETNA [1000108],AETNA [100010801],,,76.8,,1313.28,383.895,1449.396,percent of total billed charges,,,
HC Indwelling Prosthesis 20fr 8mm,PX-27800126,CDM,27800126,LOCAL,278,RC,,,outpatient,,,1327,928.9,AETNA [1000108],AETNA [100010801],,,76.8,,1019.14,297.9115,1124.7652,percent of total billed charges,,,
HC Indwelling Prosthesis 2.0,PX-27800127,CDM,27800127,LOCAL,278,RC,,,outpatient,,,1327,928.9,AETNA [1000108],AETNA [100010801],,,76.8,,1019.14,297.9115,1124.7652,percent of total billed charges,,,
HC Prosthesis Blom - 8mm,PX-27800128,CDM,27800128,LOCAL,278,RC,,,outpatient,,,1300,910,AETNA [1000108],AETNA [100010801],,,76.8,,998.4,291.85,1101.88,percent of total billed charges,,,
HC Drug Collection,PX-30000005,CDM,30000005,LOCAL,300,RC,,,outpatient,,,32,22.4,AETNA [1000108],AETNA [100010801],,,76.8,,24.58,7.184,27.1232,percent of total billed charges,,,
HC Cardiac Mnr Thoracic Prcd,PX-36000003,CDM,36000003,LOCAL,360,RC,,,outpatient,,,142,99.4,AETNA [1000108],AETNA [100010801],,,76.8,,109.06,31.879,120.3592,percent of total billed charges,,,
HC Non-Pump Open Heart Other,PX-36000004,CDM,36000004,LOCAL,360,RC,,,outpatient,,,157,109.9,AETNA [1000108],AETNA [100010801],,,76.8,,120.58,35.2465,133.0732,percent of total billed charges,,,
HC Pump Procedure,PX-36000005,CDM,36000005,LOCAL,360,RC,,,outpatient,,,152,106.4,AETNA [1000108],AETNA [100010801],,,76.8,,116.74,34.124,128.8352,percent of total billed charges,,,
HC Non Pump Procedure,PX-36000006,CDM,36000006,LOCAL,360,RC,,,outpatient,,,208,145.6,AETNA [1000108],AETNA [100010801],,,76.8,,159.74,46.696,176.3008,percent of total billed charges,,,
HC Sub Minor Proc,PX-36000014,CDM,36000014,LOCAL,360,RC,,,outpatient,,,60,42,AETNA [1000108],AETNA [100010801],,,76.8,,46.08,13.47,50.856,percent of total billed charges,,,
HC Pain Mgmt Proc,PX-36000015,CDM,36000015,LOCAL,360,RC,,,outpatient,,,75,52.5,AETNA [1000108],AETNA [100010801],,,76.8,,57.6,16.8375,63.57,percent of total billed charges,,,
HC Endoscopy,PX-36000016,CDM,36000016,LOCAL,360,RC,,,outpatient,,,60,42,AETNA [1000108],AETNA [100010801],,,76.8,,46.08,13.47,50.856,percent of total billed charges,,,
HC Minor Proc,PX-36000017,CDM,36000017,LOCAL,360,RC,,,outpatient,,,75,52.5,AETNA [1000108],AETNA [100010801],,,76.8,,57.6,16.8375,63.57,percent of total billed charges,,,
HC Major Proc,PX-36000019,CDM,36000019,LOCAL,360,RC,,,outpatient,,,99,69.3,AETNA [1000108],AETNA [100010801],,,76.8,,76.03,22.2255,83.9124,percent of total billed charges,,,
HC Intensive Major Procedure,PX-36000020,CDM,36000020,LOCAL,360,RC,,,outpatient,,,140,98,AETNA [1000108],AETNA [100010801],,,76.8,,107.52,31.43,118.664,percent of total billed charges,,,
HC Ercp,PX-36000021,CDM,36000021,LOCAL,360,RC,,,outpatient,,,138,96.6,AETNA [1000108],AETNA [100010801],,,76.8,,105.98,30.981,116.9688,percent of total billed charges,,,
HC Cardiac Maj Thoracic Prcd,PX-36000022,CDM,36000022,LOCAL,360,RC,,,outpatient,,,159,111.3,AETNA [1000108],AETNA [100010801],,,76.8,,122.11,35.6955,134.7684,percent of total billed charges,,,
HC Anesthesia Block,PX-37000001,CDM,37000001,LOCAL,370,RC,,,outpatient,,,700,490,AETNA [1000108],AETNA [100010801],,,76.8,,537.6,157.15,593.32,percent of total billed charges,,,
HC Anesthesia Spinal,PX-37000002,CDM,37000002,LOCAL,370,RC,,,outpatient,,,850,595,AETNA [1000108],AETNA [100010801],,,76.8,,652.8,190.825,720.46,percent of total billed charges,,,
HC Anesthesia General Minor,PX-37000003,CDM,37000003,LOCAL,370,RC,,,outpatient,,,1662,1163.4,AETNA [1000108],AETNA [100010801],,,76.8,,1276.42,373.119,1408.7112,percent of total billed charges,,,
HC Anesthesia Epidural,PX-37000004,CDM,37000004,LOCAL,370,RC,,,outpatient,,,950,665,AETNA [1000108],AETNA [100010801],,,76.8,,729.6,213.275,805.22,percent of total billed charges,,,
HC Anesthesia General Major,PX-37000005,CDM,37000005,LOCAL,370,RC,,,outpatient,,,2924,2046.8,AETNA [1000108],AETNA [100010801],,,76.8,,2245.63,656.438,2478.3824,percent of total billed charges,,,
HC Anesthesia Gen/Epi,PX-37000006,CDM,37000006,LOCAL,370,RC,,,outpatient,,,1200,840,AETNA [1000108],AETNA [100010801],,,76.8,,921.6,269.4,1017.12,percent of total billed charges,,,
HC Anesthesia General Intensive,PX-37000007,CDM,37000007,LOCAL,370,RC,,,outpatient,,,4262,2983.4,AETNA [1000108],AETNA [100010801],,,76.8,,3273.22,956.819,3612.4712,percent of total billed charges,,,
HC Anesthesia General Cvs Bypass Pump,PX-37000008,CDM,37000008,LOCAL,370,RC,,,outpatient,,,9166,6416.2,AETNA [1000108],AETNA [100010801],,,76.8,,7039.49,2057.767,7769.1016,percent of total billed charges,,,
HC Anesthesia Mac,PX-37000009,CDM,37000009,LOCAL,370,RC,,,outpatient,,,1200,840,AETNA [1000108],AETNA [100010801],,,76.8,,921.6,269.4,1017.12,percent of total billed charges,,,
HC Endo Level I,PX-49000001,CDM,49000001,LOCAL,490,RC,,,outpatient,,,3749,2624.3,AETNA [1000108],AETNA [100010801],,,76.8,,2879.23,841.6505,3177.6524,percent of total billed charges,,,
HC Endo Level II,PX-49000002,CDM,49000002,LOCAL,490,RC,,,outpatient,,,5356,3749.2,AETNA [1000108],AETNA [100010801],,,76.8,,4113.41,1202.422,4539.7456,percent of total billed charges,,,
HC Endo Level III,PX-49000003,CDM,49000003,LOCAL,490,RC,,,outpatient,,,9641,6748.7,AETNA [1000108],AETNA [100010801],,,76.8,,7404.29,2164.4045,8171.7116,percent of total billed charges,,,
HC Recovery Room,PX-71000001,CDM,71000001,LOCAL,710,RC,,,outpatient,,,25,17.5,AETNA [1000108],AETNA [100010801],,,76.8,,19.2,5.6125,21.19,percent of total billed charges,,,
HC Second Stage Recovery per Minute,PX-71000002,CDM,71000002,LOCAL,710,RC,,,outpatient,,,22,15.4,AETNA [1000108],AETNA [100010801],,,76.8,,16.9,4.939,18.6472,percent of total billed charges,,,
HC Recovery - Sub Minor Proc,PX-71000003,CDM,71000003,LOCAL,710,RC,,,outpatient,,,23,16.1,AETNA [1000108],AETNA [100010801],,,76.8,,17.66,5.1635,19.4948,percent of total billed charges,,,
HC Recovery Rm - Minor Procedure,PX-71000004,CDM,71000004,LOCAL,710,RC,,,outpatient,,,28,19.6,AETNA [1000108],AETNA [100010801],,,76.8,,21.5,6.286,23.7328,percent of total billed charges,,,
HC Recovery Rm,PX-71000005,CDM,71000005,LOCAL,710,RC,,,outpatient,,,29,20.3,AETNA [1000108],AETNA [100010801],,,76.8,,22.27,6.5105,24.5804,percent of total billed charges,,,
HC Recovery Rm - Major Procedure,PX-71000006,CDM,71000006,LOCAL,710,RC,,,outpatient,,,33,23.1,AETNA [1000108],AETNA [100010801],,,76.8,,25.34,7.4085,27.9708,percent of total billed charges,,,
HC Recovery Rm - Intensive Major,PX-71000007,CDM,71000007,LOCAL,710,RC,,,outpatient,,,38,26.6,AETNA [1000108],AETNA [100010801],,,76.8,,29.18,8.531,32.2088,percent of total billed charges,,,
HC Extended Recovery Overnight,PX-71000009,CDM,71000009,LOCAL,710,RC,,,outpatient,,,1500,1050,AETNA [1000108],AETNA [100010801],,,76.8,,1152,336.75,1271.4,percent of total billed charges,,,
HC Observation Nursing Time,PX-76200006,CDM,76200006,LOCAL,762,RC,,,outpatient,,,101,70.7,AETNA [1000108],AETNA [100010801],,,76.8,,77.57,22.6745,6652,percent of total billed charges,,,
HC Tandem Dialysis,PX-80100001,CDM,80100001,LOCAL,801,RC,,,outpatient,,,1142,799.4,AETNA [1000108],AETNA [100010801],,,76.8,,877.06,256.379,967.9592,percent of total billed charges,,,
HC Single Dialysis,PX-80100002,CDM,80100002,LOCAL,801,RC,,,outpatient,,,1142,799.4,AETNA [1000108],AETNA [100010801],,,76.8,,877.06,256.379,967.9592,percent of total billed charges,,,
HC Unscheduled/Emergent Dialysis,PX-80100003,CDM,80100003,LOCAL,801,RC,,,outpatient,,,1142,799.4,AETNA [1000108],AETNA [100010801],,,76.8,,877.06,256.379,967.9592,percent of total billed charges,,,
HC Weekend/Holiday Dialysis,PX-80100004,CDM,80100004,LOCAL,801,RC,,,outpatient,,,1142,799.4,AETNA [1000108],AETNA [100010801],,,76.8,,877.06,256.379,967.9592,percent of total billed charges,,,
HC Capd per:Exchange,PX-80300001,CDM,80300001,LOCAL,803,RC,,,outpatient,,,569,398.3,AETNA [1000108],AETNA [100010801],,,76.8,,436.99,127.7405,482.2844,percent of total billed charges,,,
HC Ccpd ER,PX-80400001,CDM,80400001,LOCAL,804,RC,,,outpatient,,,569,398.3,AETNA [1000108],AETNA [100010801],,,76.8,,436.99,127.7405,482.2844,percent of total billed charges,,,
HC Ccpd,PX-80400002,CDM,80400002,LOCAL,804,RC,,,outpatient,,,1142,799.4,AETNA [1000108],AETNA [100010801],,,76.8,,877.06,256.379,967.9592,percent of total billed charges,,,
HC Dietary Services per 15 Mins,PX-99000006,CDM,99000006,LOCAL,990,RC,,,outpatient,,,29,20.3,AETNA [1000108],AETNA [100010801],,,76.8,,22.27,6.5105,24.5804,percent of total billed charges,,,
HC Hearing Aid Batteries,PX-99000034,CDM,99000034,LOCAL,479,RC,,,outpatient,,,7,4.9,AETNA [1000108],AETNA [100010801],,,76.8,,5.38,1.5715,163,percent of total billed charges,,,
HC Hearing Aid Tune Up,PX-99000037,CDM,99000037,LOCAL,479,RC,,,outpatient,,,43,30.1,AETNA [1000108],AETNA [100010801],,,76.8,,33.02,9.6535,163,percent of total billed charges,,,
HC Hearing Aid Fit,PX-99000038,CDM,99000038,LOCAL,479,RC,,,outpatient,,,171,119.7,AETNA [1000108],AETNA [100010801],,,76.8,,131.33,38.3895,163,percent of total billed charges,,,
HC Arterial Stent- Xcranial Vertebral/ Thoracic Carotid- 1st Vessel,PX-36900026,CDM,0075T,CPT,369,RC,,,outpatient,,,774,541.8,AETNA [1000108],AETNA [100010801],,,76.8,,594.43,173.763,2998,percent of total billed charges,,,
HC Arterial Stent- Xcranial Vertebral/ Thoracic Carotid- Ea Add,PX-36900027,CDM,0076T,CPT,369,RC,,,outpatient,,,161,112.7,AETNA [1000108],AETNA [100010801],,,76.8,,123.65,36.1445,2998,percent of total billed charges,,,
HC Transluminal Peripheral Atherectomy- Renal Artery,PX-36900028,CDM,0234T,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA [1000108],AETNA [100010801],,,76.8,,20286.72,399.86,22389.354,percent of total billed charges,,,
HC Transluminal Peripheral Atherectomy- Visceral Artery- Each,PX-36900029,CDM,0235T,CPT,369,RC,,,outpatient,,,735,514.5,AETNA [1000108],AETNA [100010801],,,76.8,,564.48,165.0075,2998,percent of total billed charges,,,
BONE BX OSTEO SITE 11G 10CM -,SUP-G36211,CDM,A4215,HCPCS,272,RC,,,outpatient,,,1924.08,1346.856,AETNA [1000108],AETNA [100010801],,,76.8,,1477.69,0.1,1477.69344,percent of total billed charges,,,
CATHETER COUDE 24FR 5CC -,SUP-1524C,CDM,A4340,HCPCS,270,RC,,,outpatient,,,45.92,32.144,AETNA [1000108],AETNA [100010801],,,76.8,,35.27,10.30904,416.02,percent of total billed charges,,,
SILICONE CATHETER FOLEY 24FR 5CC -,SUP-8887605247,CDM,A4344,HCPCS,270,RC,,,outpatient,,,17.15,12.005,AETNA [1000108],AETNA [100010801],,,76.8,,13.17,3.850175,416.02,percent of total billed charges,,,
CATH FOLEY 18FR 5ML BLN 3W DOVER LTX 16IN LUB -,SUP-2718,CDM,A4346,HCPCS,272,RC,,,outpatient,,,39.16,27.412,AETNA [1000108],AETNA [100010801],,,76.8,,30.07,4.025285,416.02,percent of total billed charges,,,
CATHETER FOLEY 22FR 30CC 3-WAY -,SUP-2822,CDM,A4346,HCPCS,272,RC,,,outpatient,,,41.84,29.288,AETNA [1000108],AETNA [100010801],,,76.8,,32.13,4.025285,416.02,percent of total billed charges,,,
CATHETER FOLEY 24FR 30CC 3-WAY -,SUP-2824,CDM,A4346,HCPCS,272,RC,,,outpatient,,,17.93,12.551,AETNA [1000108],AETNA [100010801],,,76.8,,13.77,4.025285,416.02,percent of total billed charges,,,
CATH FOLEY SIL 3W 30CC 22FR -,SUP-8887665225,CDM,A4346,HCPCS,272,RC,,,outpatient,,,41.84,29.288,AETNA [1000108],AETNA [100010801],,,76.8,,32.13,4.025285,416.02,percent of total billed charges,,,
SLING ORTHO ARM SM -,SUP-8023-01,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,AETNA [1000108],AETNA [100010801],,,76.8,,19.54,2.98585,416.02,percent of total billed charges,,,
SLING DEROYAL ARM MEDIUM -,SUP-8023-02,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,AETNA [1000108],AETNA [100010801],,,76.8,,19.54,2.98585,416.02,percent of total billed charges,,,
SLING DEROYAL ARM LARGE -,SUP-8023-03,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,AETNA [1000108],AETNA [100010801],,,76.8,,19.54,2.98585,416.02,percent of total billed charges,,,
SLING ORTHO ARM XL -,SUP-8023-04,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,AETNA [1000108],AETNA [100010801],,,76.8,,19.54,2.98585,416.02,percent of total billed charges,,,
SLING ARM MED STRP -,SUP-TX9901-43,CDM,A4565,HCPCS,270,RC,,,outpatient,,,13.3,9.31,AETNA [1000108],AETNA [100010801],,,76.8,,10.21,2.98585,416.02,percent of total billed charges,,,
HC Tissue Marker,PX-27800092,CDM,A4648,HCPCS,278,RC,,,outpatient,,,418,292.6,AETNA [1000108],AETNA [100010801],,,76.8,,321.02,39.325665,1791.14496,percent of total billed charges,,,
NEEDLE BRST LOC 20GAX3CM CM MRKNG STD MRKNG CANN ON WIRE -,SUP-253030,CDM,A4648,HCPCS,278,RC,,,outpatient,,,271.33,189.931,AETNA [1000108],AETNA [100010801],,,76.8,,208.38,39.325665,1791.14496,percent of total billed charges,,,
MARKER BRSTBIO 3MM 17GA INCONEL 625 ULTRA CLP -,SUP-862017,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,AETNA [1000108],AETNA [100010801],,,76.8,,286.8,39.325665,1791.14496,percent of total billed charges,,,
MARKER BRSTBIO 17GA TI ULTRA CLP II US -,SUP-863017,CDM,A4648,HCPCS,278,RC,,,outpatient,,,1097.2,768.04,AETNA [1000108],AETNA [100010801],,,76.8,,842.65,39.325665,1791.14496,percent of total billed charges,,,
INSTRUMENT BX 18GA/17GA/INTRO ACHIEVE AUTO 11CM SFT TIS -,SUP-CA1811,CDM,A4648,HCPCS,278,RC,,,outpatient,,,497.49,348.243,AETNA [1000108],AETNA [100010801],,,76.8,,382.07,39.325665,1791.14496,percent of total billed charges,,,
IDENTIFIER BIOPSY SITE FOR CELERO 12 THIRD SHAPE -,SUP-CELEROMARK-2S,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,AETNA [1000108],AETNA [100010801],,,76.8,,286.8,39.325665,1791.14496,percent of total billed charges,,,
NEEDLE BRST LOC KOPANS 20GAX5CM BVL CUT TIP MOD REINF TIP -,SUP-DKBL-20-5.0-A,CDM,A4648,HCPCS,278,RC,,,outpatient,,,175.17,122.619,AETNA [1000108],AETNA [100010801],,,76.8,,134.53,39.325665,1791.14496,percent of total billed charges,,,
NEEDLE BRST LOC KOPANS 20GAX7CM BVL CUT TIP MOD REINF TIP -,SUP-DKBL-20-7.0-A,CDM,A4648,HCPCS,278,RC,,,outpatient,,,175.17,122.619,AETNA [1000108],AETNA [100010801],,,76.8,,134.53,39.325665,1791.14496,percent of total billed charges,,,
NEEDLE BRST LOC KOPANS 20GAX9CM BVL CUT TIP MOD REINF TIP -,SUP-DKBL-20-9.0-A,CDM,A4648,HCPCS,278,RC,,,outpatient,,,175.17,122.619,AETNA [1000108],AETNA [100010801],,,76.8,,134.53,39.325665,1791.14496,percent of total billed charges,,,
NEEDLE 18GA X 20CM FUSIONCOIL WITH 1 X 5MM FIDUCIAL MARKER -,SUP-MTCTXFC1051820,CDM,A4648,HCPCS,278,RC,,,outpatient,,,752.72,526.904,AETNA [1000108],AETNA [100010801],,,76.8,,578.09,39.325665,1791.14496,percent of total billed charges,,,
MARKERS CIVCO FIDUCIAL 30CM -,SUP-MTNW887835,CDM,A4648,HCPCS,278,RC,,,outpatient,,,1129.01,790.307,AETNA [1000108],AETNA [100010801],,,76.8,,867.08,39.325665,1791.14496,percent of total billed charges,,,
MARKER BRSTBIO TI SCUR MRK MINI CORK -,SUP-SMARK-CELERO,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,AETNA [1000108],AETNA [100010801],,,76.8,,286.8,39.325665,1791.14496,percent of total billed charges,,,
MARKER BRSTBIO TI SECURMARK TOP HAT SHP -,SUP-SMARK-CELERO-2S,CDM,A4648,HCPCS,278,RC,,,outpatient,,,481.1,336.77,AETNA [1000108],AETNA [100010801],,,76.8,,369.48,39.325665,1791.14496,percent of total billed charges,,,
MARKER BRSTBIO TI SCUR MRK MINI CORK -,SUP-SMARK-EVIVA-13,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,AETNA [1000108],AETNA [100010801],,,76.8,,286.8,39.325665,1791.14496,percent of total billed charges,,,
MARKER BRSTBIO TI SECURMARK -,SUP-SMARK-EVIVA-2S-13,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,AETNA [1000108],AETNA [100010801],,,76.8,,286.8,39.325665,1791.14496,percent of total billed charges,,,
SCOUT 5CM DELIVERY NEEDLE AND REFLECTOR SSR05-01 -,SUP-SSR05-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,39.325665,1791.14496,percent of total billed charges,,,
SCOUT 10CM DELIVERY NEEDLE AND REFLECTOR -,SUP-SSR10-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,39.325665,1791.14496,percent of total billed charges,,,
SCOUT 7.5CM DELIVERY NEEDLE AND REFLECTOR -,SUP-SSR75-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,39.325665,1791.14496,percent of total billed charges,,,
REFLECTOR AND DELIVERY SYSTEM SINGLE HAND 16G 7.5 CM -,SUP-SSR75S-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,39.325665,1791.14496,percent of total billed charges,,,
IDENTIFIER BIOPSY SITE ATEC TRIMARK INTRODUCER SHEATH MARKER -,SUP-TRIMARK TD-2S-13-MR,CDM,A4648,HCPCS,278,RC,,,outpatient,,,371.98,260.386,AETNA [1000108],AETNA [100010801],,,76.8,,285.68,39.325665,1791.14496,percent of total billed charges,,,
EXPANDER BRST 500ML BIOCELL RND NATRLL 13CMX13.5CM 5.7CM -,SUP-133FV-13,CDM,A4649,HCPCS,272,RC,,,outpatient,,,4986.7,3490.69,AETNA [1000108],AETNA [100010801],,,76.8,,3829.79,14.186155,5948.3904,percent of total billed charges,,,
EXPANDER TISSUE SMOOTH 600CC NATRELLE FULL HEIGHT -,SUP-133S-FV-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,14.186155,5948.3904,percent of total billed charges,,,
EXPANDER TISSUE NATRELLE SMOOTH 650CC -,SUP-133S-FX-14-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,14.186155,5948.3904,percent of total billed charges,,,
NATRELLE INSPIRA TISSUE EXPANDER 800CC -,SUP-133S-FX-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,14.186155,5948.3904,percent of total billed charges,,,
TISSUE EXPANDER 400CC NATRELLE SMOOTH MOD HEIGHT EXTRA PROT -,SUP-133S-MX-12-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,14.186155,5948.3904,percent of total billed charges,,,
TISSUE EXPANDER 500CC NATRELLE SMOOTH MOD HEIGHT EXTRA PROT -,SUP-133S-MX-13-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,14.186155,5948.3904,percent of total billed charges,,,
TISSUE EXPANDER 600CC NATRELLE -,SUP-133S-MX-14-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,14.186155,5948.3904,percent of total billed charges,,,
EXPANDER TISSUE NATRELLE SMOOTH 700CC -,SUP-133S-MX-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,14.186155,5948.3904,percent of total billed charges,,,
EXPANDER TISSUE SMOOTH 400CC SHORT HT EXTRA PROJ NATRELLE -,SUP-133S-SX-13-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5903.4,4132.38,AETNA [1000108],AETNA [100010801],,,76.8,,4533.81,14.186155,5948.3904,percent of total billed charges,,,
EXPANDER TISSUE SMOOTH 650CC HEIGHT EXTRA PROJ NATRELLE -,SUP-133S-SX-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,14.186155,5948.3904,percent of total billed charges,,,
EXPANDER TISS 250ML SHRT H -,SUP-133SV-12,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA [1000108],AETNA [100010801],,,76.8,,4057.94,14.186155,5948.3904,percent of total billed charges,,,
EXPANDER BRST UNIV NATRLL -,SUP-30-000003,CDM,A4649,HCPCS,272,RC,,,outpatient,,,63.19,44.233,AETNA [1000108],AETNA [100010801],,,76.8,,48.53,14.186155,5948.3904,percent of total billed charges,,,
EXPANDER BREAST TISSUE CPX4 450CC -,SUP-350-9213,CDM,A4649,HCPCS,272,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,14.186155,5948.3904,percent of total billed charges,,,
650CC CPX 4 BREAST TISSUE EXPANDER W/SUTURE TABS MED. HEIGHT -,SUP-350-9215,CDM,A4649,HCPCS,272,RC,,,outpatient,,,7745.3,5421.71,AETNA [1000108],AETNA [100010801],,,76.8,,5948.39,14.186155,5948.3904,percent of total billed charges,,,
EXPANDER TISSUE SMOOTH 800CC CPX 4 W/SUTURE TABS MED HT -,SUP-350-9216,CDM,A4649,HCPCS,272,RC,,,outpatient,,,7745.3,5421.71,AETNA [1000108],AETNA [100010801],,,76.8,,5948.39,14.186155,5948.3904,percent of total billed charges,,,
EXPANDER BRST 850ML BIOCELL RND NATRLL 16CMX16.5CM 6.8CM -,SUP-37-133800,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5835.5,4084.85,AETNA [1000108],AETNA [100010801],,,76.8,,4481.66,14.186155,5948.3904,percent of total billed charges,,,
EXPANDER BRST 600ML BIOCELL RND NATRLL 14CMX14.5CM 6.2CM -,SUP-67-133FV14,CDM,A4649,HCPCS,272,RC,,,outpatient,,,4986.7,3490.69,AETNA [1000108],AETNA [100010801],,,76.8,,3829.79,14.186155,5948.3904,percent of total billed charges,,,
SIZER IMPLANT NATRELLE INSPIRA 520CC FULL PROFILE -,SUP-MSZ-F520,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,14.186155,5948.3904,percent of total billed charges,,,
SIZER IMPLANT NATRELLE INSPIRA 560CC FULL PROFILE -,SUP-MSZ-F560,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,14.186155,5948.3904,percent of total billed charges,,,
SIZER IMPLANT NATRELLE INSPIRA 605CC FULL PROFILE -,SUP-MSZ-F605,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,14.186155,5948.3904,percent of total billed charges,,,
SIZER IMPLANT NATRELLE INSPIRA 695CC FULL PROFILE -,SUP-MSZ-F695,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,14.186155,5948.3904,percent of total billed charges,,,
SIZER IMPLANT NATRELLE INSPIRA 770CC FULL PROFILE -,SUP-MSZ-F770,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,14.186155,5948.3904,percent of total billed charges,,,
SIZER IMPLANT NATRELLE INSPIRA 275CC MODERATE PROFILE -,SUP-MSZ-M275,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,14.186155,5948.3904,percent of total billed charges,,,
SIZER IMPLANT NATRELLE INSPIRA 560CC MODERATE PROFILE -,SUP-MSZ-M560,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,14.186155,5948.3904,percent of total billed charges,,,
SIZER IMPLANT NATRELLE INSPIRA 600CC MODERATE PROFILE -,SUP-MSZ-M600,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,14.186155,5948.3904,percent of total billed charges,,,
SIZER IMPLANT NATRELLE INSPIRA 525CC EXTRA FULL PROFILE -,SUP-MSZ-X525,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,14.186155,5948.3904,percent of total billed charges,,,
SIZER IMPLANT NATRELLE INSPIRA 545CC EXTRA FULL PROFILE -,SUP-MSZ-X545,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,14.186155,5948.3904,percent of total billed charges,,,
SIZER IMPLANT NATRELLE INSPIRA 580CC EXTRA FULL PROFILE -,SUP-MSZ-X580,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,14.186155,5948.3904,percent of total billed charges,,,
SIZER IMPLANT NATRELLE INSPIRA 750CC XFULL PROFILE -,SUP-MSZ-X750,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,14.186155,5948.3904,percent of total billed charges,,,
SIZER IMPLANT NATRELLE INSPIRA 800CC EXTRA FULL PROFILE -,SUP-MSZ-X800,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,14.186155,5948.3904,percent of total billed charges,,,
SIZER IMPLANT NATRELLE INSPIRA 745CC FULL PROFILE -,SUP-SCF-745,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,14.186155,5948.3904,percent of total billed charges,,,
DRESSING WND 2X2IN PURACOL + HI GEL INTGRTY COLL LF -,SUP-MSC8622EP,CDM,A6021,HCPCS,270,RC,,,outpatient,,,32.97,23.079,AETNA [1000108],AETNA [100010801],,,76.8,,25.32,7.401765,416.02,percent of total billed charges,,,
DRESSING BURN PURACOL PLUS 2X2 AG SILVER  COLLAGEN -,SUP-MSC8722EP,CDM,A6021,HCPCS,270,RC,,,outpatient,,,43.41,30.387,AETNA [1000108],AETNA [100010801],,,76.8,,33.34,7.401765,416.02,percent of total billed charges,,,
SHEETING SILASTIC 4.625X5.625IN SIL GEL HYPAL SLFADH LPRO -,SUP-NC15462,CDM,A6025,HCPCS,272,RC,,,outpatient,,,180.14,126.098,AETNA [1000108],AETNA [100010801],,,76.8,,138.35,11.99,416.02,percent of total billed charges,,,
DRESSING KALTOSTAT CA ALGIN 3X4.75IN ABSB -,SUP-168212,CDM,A6196,HCPCS,270,RC,,,outpatient,,,14.44,10.108,AETNA [1000108],AETNA [100010801],,,76.8,,11.09,1.708445,416.02,percent of total billed charges,,,
DRESSING XTRA HYDROFIBER AQUACEL 2X2IN -,SUP-420671,CDM,A6196,HCPCS,270,RC,,,outpatient,,,8.66,6.062,AETNA [1000108],AETNA [100010801],,,76.8,,6.65,1.708445,416.02,percent of total billed charges,,,
DRESSING ALGIN 2X2IN SQ NADH HI ABSB F/MOD TO HVY DRN -,SUP-MSC7022EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,7.61,5.327,AETNA [1000108],AETNA [100010801],,,76.8,,5.84,1.708445,416.02,percent of total billed charges,,,
DRESSING MAXORB 4X4IN EXTRA -,SUP-MSC7044EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,14.23,9.961,AETNA [1000108],AETNA [100010801],,,76.8,,10.93,1.708445,416.02,percent of total billed charges,,,
DRESSING WND 1X12IN FLT ROPE HI ABSORBENT1 F/WND MAXORB XTR -,SUP-MSC7112EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,20.07,14.049,AETNA [1000108],AETNA [100010801],,,76.8,,15.41,1.708445,416.02,percent of total billed charges,,,
DRESSING MAXORB AG 2X2IN ALGIN SILVER -,SUP-MSC9422EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,18.37,12.859,AETNA [1000108],AETNA [100010801],,,76.8,,14.11,1.708445,416.02,percent of total billed charges,,,
DRESSING GERMC AQUACEL AG EXTRA 4X4IN SLVR STRL -,SUP-420674,CDM,A6197,HCPCS,270,RC,,,outpatient,,,18.13,12.691,AETNA [1000108],AETNA [100010801],,,76.8,,13.92,4.070185,416.02,percent of total billed charges,,,
DRESSING AQUACEL 4 X 5 -,SUP-420674,CDM,A6197,HCPCS,270,RC,,,outpatient,,,18.13,12.691,AETNA [1000108],AETNA [100010801],,,76.8,,13.92,4.070185,416.02,percent of total billed charges,,,
DRESSING AQUACEL AG  2X2IN SQ HYDROFIBER SILVER -,SUP-422297,CDM,A6197,HCPCS,270,RC,,,outpatient,,,27.75,19.425,AETNA [1000108],AETNA [100010801],,,76.8,,21.31,4.070185,416.02,percent of total billed charges,,,
DRESSING AQUACEL AG 6X6IN HYDROFIBER -,SUP-422298,CDM,A6197,HCPCS,270,RC,,,outpatient,,,112.45,78.715,AETNA [1000108],AETNA [100010801],,,76.8,,86.36,4.070185,416.02,percent of total billed charges,,,
DRESSING MAXORB EXTRA AG 4X4 SILVER -,SUP-MSC9445EP,CDM,A6197,HCPCS,270,RC,,,outpatient,,,34.72,24.304,AETNA [1000108],AETNA [100010801],,,76.8,,26.66,4.070185,416.02,percent of total billed charges,,,
DRESSING ALGINATE SILVER 4X4.75IN CA ANTMIC NADH NWVN FLT -,SUP-MSC9445EP,CDM,A6197,HCPCS,270,RC,,,outpatient,,,34.27,23.989,AETNA [1000108],AETNA [100010801],,,76.8,,26.32,4.070185,416.02,percent of total billed charges,,,
DRESSING ALGIN AQUACL HYDROFIBER 0.75X18IN NADH CONFRM NWVN -,SUP-403770,CDM,A6199,HCPCS,270,RC,,,outpatient,,,22.99,16.093,AETNA [1000108],AETNA [100010801],,,76.8,,17.66,4.3553,416.02,percent of total billed charges,,,
DRESSING ALGIN AQUACL HYDROFIBER 0.75X18IN NADH CONFRM NWVN -,SUP-403770,CDM,A6199,HCPCS,270,RC,,,outpatient,,,19.4,13.58,AETNA [1000108],AETNA [100010801],,,76.8,,14.9,4.3553,416.02,percent of total billed charges,,,
DRESSING AQUACEL AG ROPE .75X18 IN -,SUP-422300,CDM,A6199,HCPCS,270,RC,,,outpatient,,,59.94,41.958,AETNA [1000108],AETNA [100010801],,,76.8,,46.03,4.3553,416.02,percent of total billed charges,,,
DRESSING SILVERLON 4 X 10 -,SUP-ID-410,CDM,A6206,HCPCS,272,RC,,,outpatient,,,169.8,118.86,AETNA [1000108],AETNA [100010801],,,76.8,,130.41,5.23,416.02,percent of total billed charges,,,
DRESSING ACTICOAT 4X5 -,SUP-66800405,CDM,A6207,HCPCS,272,RC,,,outpatient,,,81.2,56.84,AETNA [1000108],AETNA [100010801],,,76.8,,62.36,9.98576,416.02,percent of total billed charges,,,
DRESSING ACTICOAT 4X4 -,SUP-66800406,CDM,A6207,HCPCS,272,RC,,,outpatient,,,44.48,31.136,AETNA [1000108],AETNA [100010801],,,76.8,,34.16,9.98576,416.02,percent of total billed charges,,,
DRESSING ALLEVYN NONADHESIVE 2X2 NO BORDER -,SUP-66027643,CDM,A6209,HCPCS,272,RC,,,outpatient,,,14.63,10.241,AETNA [1000108],AETNA [100010801],,,76.8,,11.24,2.94544,416.02,percent of total billed charges,,,
DRESSING FOAM 4x4 BORDERLESS -,SUP-66927637,CDM,A6209,HCPCS,272,RC,,,outpatient,,,13.12,9.184,AETNA [1000108],AETNA [100010801],,,76.8,,10.08,2.94544,416.02,percent of total billed charges,,,
"DRESSING HYDROFERA 2.5"" X 2.5"" -",SUP-HLST-HBRT2525,CDM,A6209,HCPCS,272,RC,,,outpatient,,,268.12,187.684,AETNA [1000108],AETNA [100010801],,,76.8,,205.92,2.94544,416.02,percent of total billed charges,,,
HYDROFERA BLUE READY TRANSFER 2.5 X 2.5 -,SUP-HLST-HRBS2214,CDM,A6209,HCPCS,272,RC,,,outpatient,,,26.78,18.746,AETNA [1000108],AETNA [100010801],,,76.8,,20.57,2.94544,416.02,percent of total billed charges,,,
HYDROFERA BLUE READY TRANSFER 4 X 5 -,SUP-HBRS4520,CDM,A6210,HCPCS,272,RC,,,outpatient,,,40.63,28.441,AETNA [1000108],AETNA [100010801],,,76.8,,31.2,9.121435,416.02,percent of total billed charges,,,
HYDROFERA BLUE READY TRANSFER 4 X 5 -,SUP-HLST-HRBT4050,CDM,A6210,HCPCS,272,RC,,,outpatient,,,416.5,291.55,AETNA [1000108],AETNA [100010801],,,76.8,,319.87,9.121435,416.02,percent of total billed charges,,,
HYDROFERA BLUE READY TRANSFER 8 X 8 -,SUP-HLST-HRBS8820,CDM,A6211,HCPCS,272,RC,,,outpatient,,,92.17,64.519,AETNA [1000108],AETNA [100010801],,,76.8,,70.79,20.692165,416.02,percent of total billed charges,,,
DRESSING OPTIFOAM AG 3.5 X 6 -,SUP-412010,CDM,A6212,HCPCS,270,RC,,,outpatient,,,109.06,76.342,AETNA [1000108],AETNA [100010801],,,,,,1.79151,416.02,other,Supplies A-Codes,,
DRESSING OPTIFOAM AG 3.5 X 10 -,SUP-412011,CDM,A6212,HCPCS,270,RC,,,outpatient,,,139.34,97.538,AETNA [1000108],AETNA [100010801],,,,,,1.79151,416.02,other,Supplies A-Codes,,
BANDAGE ADH 4X4IN ALLEVYN -,SUP-66800270,CDM,A6212,HCPCS,270,RC,,,outpatient,,,12.57,8.799,AETNA [1000108],AETNA [100010801],,,,,,1.79151,416.02,other,Supplies A-Codes,,
BANDAGE ADH 4X4IN ALLEVYN -,SUP-66800270,CDM,A6212,HCPCS,270,RC,,,outpatient,,,18.72,13.104,AETNA [1000108],AETNA [100010801],,,,,,1.79151,416.02,other,Supplies A-Codes,,
DRESSING FOAM VERSATILE 2 1/8IN X 4 3/4IN SILICONE ADHESIVE -,SUP-66800836,CDM,A6212,HCPCS,270,RC,,,outpatient,,,7.98,5.586,AETNA [1000108],AETNA [100010801],,,,,,1.79151,416.02,other,Supplies A-Codes,,
"DRESSING FOAMING ALLEYN GENTLE BORDER LITE 5.5CM X 12CM"" -",SUP-66800836,CDM,A6212,HCPCS,270,RC,,,outpatient,,,8.42,5.894,AETNA [1000108],AETNA [100010801],,,,,,1.79151,416.02,other,Supplies A-Codes,,
DRESSING ALLEVYN LIFE 5 1/16IN x 5 1/16IN -,SUP-66801068,CDM,A6212,HCPCS,270,RC,,,outpatient,,,14.24,9.968,AETNA [1000108],AETNA [100010801],,,,,,1.79151,416.02,other,Supplies A-Codes,,
DRESSING OPTIFOAM AG 3.5 X 14 -,SUP-412012,CDM,A6213,HCPCS,270,RC,,,outpatient,,,148.97,104.279,AETNA [1000108],AETNA [100010801],,,76.8,,114.41,9.206745,416.02,percent of total billed charges,,,
DRESSING FOAM SACRUM 9.4 X 8.4CM LRG -,SUP-423270,CDM,A6213,HCPCS,270,RC,,,outpatient,,,41.01,28.707,AETNA [1000108],AETNA [100010801],,,76.8,,31.5,9.206745,416.02,percent of total billed charges,,,
DRESSING MEPORE 2.5 X 3 -,SUP-670800,CDM,A6219,HCPCS,270,RC,,,outpatient,,,0.55,0.385,AETNA [1000108],AETNA [100010801],,,,,,0.04041,416.02,other,Supplies A-Codes,,
TOWEL ABSORBENT STER 7550 -,SUP-7550,CDM,A6219,HCPCS,270,RC,,,outpatient,,,4,2.8,AETNA [1000108],AETNA [100010801],,,,,,0.04041,416.02,other,Supplies A-Codes,,
DRESSING WND 2X2IN ADH ISLND NWVN BRDR WTRPRF BK STRL SQ LF -,SUP-MSC3222,CDM,A6219,HCPCS,270,RC,,,outpatient,,,0.18,0.126,AETNA [1000108],AETNA [100010801],,,,,,0.04041,416.02,other,Supplies A-Codes,,
DRESSING BORDERED 4X4IN ADH ISLAND NWVN -,SUP-MSC3244,CDM,A6219,HCPCS,270,RC,,,outpatient,,,2.39,1.673,AETNA [1000108],AETNA [100010801],,,,,,0.04041,416.02,other,Supplies A-Codes,,
DRESSING PETRO ADPTC 3X3IN OIL EMUL NADH GZE CELLU-ACET -,SUP-2012,CDM,A6222,HCPCS,272,RC,,,outpatient,,,14.03,9.821,AETNA [1000108],AETNA [100010801],,,,,,0.52533,416.02,other,Gauze Dressings,,
DRESSING ADAPTIC 3INX3IN 7.6CMx7.6CM NON-ADHERING -,SUP-2012,CDM,A6222,HCPCS,272,RC,,,outpatient,,,14.03,9.821,AETNA [1000108],AETNA [100010801],,,,,,0.52533,416.02,other,Gauze Dressings,,
DRESSING XEROFORM 1X8 -,SUP-212,CDM,A6222,HCPCS,272,RC,,,outpatient,,,3.03,2.121,AETNA [1000108],AETNA [100010801],,,,,,0.52533,416.02,other,Gauze Dressings,,
DRESSING XEROFORM 2 X 2 -,SUP-214,CDM,A6222,HCPCS,272,RC,,,outpatient,,,2.34,1.638,AETNA [1000108],AETNA [100010801],,,,,,0.52533,416.02,other,Gauze Dressings,,
DRESSING MESALT RIBBON 3/4x39 IN DEBRIDE 0.75x39 IN ABSB -,SUP-285299,CDM,A6222,HCPCS,272,RC,,,outpatient,,,10.93,7.651,AETNA [1000108],AETNA [100010801],,,,,,0.52533,416.02,other,Gauze Dressings,,
DRESSING MESALT 3x3 IN GAUZE -,SUP-285780,CDM,A6222,HCPCS,272,RC,,,outpatient,,,4.67,3.269,AETNA [1000108],AETNA [100010801],,,,,,0.52533,416.02,other,Gauze Dressings,,
DRESSING WND 1.6 X 2.4IN CUTIMED SORBACT SWB PRIM STRL LF -,SUP-7216412,CDM,A6222,HCPCS,272,RC,,,outpatient,,,21.89,15.323,AETNA [1000108],AETNA [100010801],,,,,,0.52533,416.02,other,Gauze Dressings,,
DRESSING ADAPTIC 3X8 -,SUP-2013,CDM,A6223,HCPCS,272,RC,,,outpatient,,,4.43,3.101,AETNA [1000108],AETNA [100010801],,,,,,0.698195,416.02,other,Gauze Dressings,,
DRESSING PETRO VASELINE 1X36IN STRL 1-PLY IMPREG NADH LPRO -,SUP-205-12-A,CDM,A6223,HCPCS,272,RC,,,outpatient,,,3.11,2.177,AETNA [1000108],AETNA [100010801],,,,,,0.698195,416.02,other,Gauze Dressings,,
DRESSING XEROFORM 5IN X 9IN -,SUP-213,CDM,A6223,HCPCS,272,RC,,,outpatient,,,4.32,3.024,AETNA [1000108],AETNA [100010801],,,,,,0.698195,416.02,other,Gauze Dressings,,
DRESSING XEROFORM 5IN X 9IN -,SUP-213,CDM,A6223,HCPCS,272,RC,,,outpatient,,,4.32,3.024,AETNA [1000108],AETNA [100010801],,,,,,0.698195,416.02,other,Gauze Dressings,,
GAUZE VASELINE 1 X 36 -,SUP-8884412600,CDM,A6223,HCPCS,272,RC,,,outpatient,,,3.15,2.205,AETNA [1000108],AETNA [100010801],,,,,,0.698195,416.02,other,Gauze Dressings,,
DRESSING PETRO VASELINE 1X36IN OCL NADH STRIP STRL IMPREG -,SUP-8884412600,CDM,A6223,HCPCS,272,RC,,,outpatient,,,3.15,2.205,AETNA [1000108],AETNA [100010801],,,,,,0.698195,416.02,other,Gauze Dressings,,
DRESSING ADAPTIC 3X8 -,SUP-JOHN-2013,CDM,A6223,HCPCS,272,RC,,,outpatient,,,26.74,18.718,AETNA [1000108],AETNA [100010801],,,,,,0.698195,416.02,other,Gauze Dressings,,
GAUZE VASELINE 3IN X 18IN -,SUP-207-12-A,CDM,A6224,HCPCS,272,RC,,,outpatient,,,5.13,3.591,AETNA [1000108],AETNA [100010801],,,,,,0.801465,416.02,other,Gauze Dressings,,
GAUZE VASELINE 3IN X 18IN -,SUP-207-12-A,CDM,A6224,HCPCS,272,RC,,,outpatient,,,5.13,3.591,AETNA [1000108],AETNA [100010801],,,,,,0.801465,416.02,other,Gauze Dressings,,
"GAUZE VASELINE 3"" X 36"" -",SUP-425600,CDM,A6224,HCPCS,272,RC,,,outpatient,,,7.26,5.082,AETNA [1000108],AETNA [100010801],,,,,,0.801465,416.02,other,Gauze Dressings,,
GAUZE PETRO 3X36IN VASELINE -,SUP-8884415600,CDM,A6224,HCPCS,272,RC,,,outpatient,,,3.57,2.499,AETNA [1000108],AETNA [100010801],,,,,,0.801465,416.02,other,Gauze Dressings,,
GAUZE VASELINE 1/2 X 72 -,SUP-8884421600,CDM,A6224,HCPCS,272,RC,,,outpatient,,,5.95,4.165,AETNA [1000108],AETNA [100010801],,,,,,0.801465,416.02,other,Gauze Dressings,,
DRESSING HYDROCOLLOID DUODERM 2X4IN XTRA THIN -,SUP-187900,CDM,A6234,HCPCS,272,RC,,,outpatient,,,4.07,2.849,AETNA [1000108],AETNA [100010801],,,76.8,,3.13,0.913715,416.02,percent of total billed charges,,,
DRESSING DUODERM EXTRA THIN 4X4 -,SUP-187955,CDM,A6234,HCPCS,272,RC,,,outpatient,,,6.71,4.697,AETNA [1000108],AETNA [100010801],,,76.8,,5.15,0.913715,416.02,percent of total billed charges,,,
DRESSING HYDROCOLLOID DUODERM 4X4IN XTRA THIN -,SUP-187955,CDM,A6234,HCPCS,272,RC,,,outpatient,,,4.49,3.143,AETNA [1000108],AETNA [100010801],,,76.8,,3.45,0.913715,416.02,percent of total billed charges,,,
DRESSING WND XTHN 4X4IN DDRM STRL CONFRM NADH HYDRCL SQ -,SUP-187955,CDM,A6234,HCPCS,272,RC,,,outpatient,,,6.73,4.711,AETNA [1000108],AETNA [100010801],,,76.8,,5.17,0.913715,416.02,percent of total billed charges,,,
DRESSING HYDRCL XTHN 4X6IN DDRM CGF STRL XTHN CONFRM NADH -,SUP-187902,CDM,A6235,HCPCS,270,RC,,,outpatient,,,11.92,8.344,AETNA [1000108],AETNA [100010801],,,76.8,,9.15,2.67604,416.02,percent of total billed charges,,,
DRESSING DUODERM 4 X 4 THICK -,SUP-187660,CDM,A6237,HCPCS,272,RC,,,outpatient,,,9.64,6.748,AETNA [1000108],AETNA [100010801],,,76.8,,7.4,1.659055,416.02,percent of total billed charges,,,
DRESSING WND 4X4IN DDRM SGNL STRL CONFRM ADH ABSB WTRPRF -,SUP-403326,CDM,A6237,HCPCS,272,RC,,,outpatient,,,11.11,7.777,AETNA [1000108],AETNA [100010801],,,76.8,,8.53,1.659055,416.02,percent of total billed charges,,,
DRESSING HYDROCOLLOID DUODERM 4X4IN -,SUP-403326,CDM,A6237,HCPCS,272,RC,,,outpatient,,,7.39,5.173,AETNA [1000108],AETNA [100010801],,,76.8,,5.68,1.659055,416.02,percent of total billed charges,,,
DRESSING HYDRCL 6X7IN DUADERM CGF STRL -,SUP-187974,CDM,A6238,HCPCS,270,RC,,,outpatient,,,42.72,29.904,AETNA [1000108],AETNA [100010801],,,76.8,,32.81,4.600005,416.02,percent of total billed charges,,,
DRESSING WND 14X14CM DDRM SGNL STRL CONFRM ADH ABSB WTRPRF -,SUP-403327,CDM,A6238,HCPCS,270,RC,,,outpatient,,,20.49,14.343,AETNA [1000108],AETNA [100010801],,,76.8,,15.74,4.600005,416.02,percent of total billed charges,,,
DRESSING WND 15X18CM DDRM SGNL STRL CONFRM ADH ABSB WTRPRF -,SUP-403332,CDM,A6238,HCPCS,270,RC,,,outpatient,,,21.79,15.253,AETNA [1000108],AETNA [100010801],,,76.8,,16.73,4.600005,416.02,percent of total billed charges,,,
CREAM TRIAD HYDROPHILLIC WOUND DRESSING -,SUP-1964-A,CDM,A6240,HCPCS,270,RC,,,outpatient,,,31.57,22.099,AETNA [1000108],AETNA [100010801],,,76.8,,24.25,7.087465,416.02,percent of total billed charges,,,
DRESSING HYDRCL 1.6IN TENDRWT STRL ACT CVTY LF -,SUP-MSC8401,CDM,A6242,HCPCS,270,RC,,,outpatient,,,16.34,11.438,AETNA [1000108],AETNA [100010801],,,76.8,,12.55,3.66833,416.02,percent of total billed charges,,,
DRESSING DEBRIDE 3X3IN PLYACRL PLYMR GL CVTY PAD TENDRWT ACT -,SUP-MSC8403Z,CDM,A6242,HCPCS,270,RC,,,outpatient,,,22.7,15.89,AETNA [1000108],AETNA [100010801],,,76.8,,17.43,3.66833,416.02,percent of total billed charges,,,
DRESSING GEL 30GM DDRM HYDACTV NADH FIL HYDRCL HYDACTV -,SUP-187987,CDM,A6248,HCPCS,272,RC,,,outpatient,,,13.91,9.737,AETNA [1000108],AETNA [100010801],,,76.8,,10.68,3.122795,416.02,percent of total billed charges,,,
DRESSING SILVASORB GEL 0.25OZ  SILVER ABSB ANTMIC -,SUP-MSC93025EP,CDM,A6248,HCPCS,272,RC,,,outpatient,,,34.03,23.821,AETNA [1000108],AETNA [100010801],,,76.8,,26.14,3.122795,416.02,percent of total billed charges,,,
SURGICAL DRESSING SILK 6 X 8IN -,SUP-NON4313,CDM,A6255,HCPCS,270,RC,,,outpatient,,,8.82,6.174,AETNA [1000108],AETNA [100010801],,,76.8,,6.77,1.98009,416.02,percent of total billed charges,,,
DRESSING TEGADERM 1.75X1.75IN TRANPARENT FILM -,SUP-1622-W,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.17,0.819,AETNA [1000108],AETNA [100010801],,,,,,0.262665,416.02,other,Supplies A-Codes,,
DRESSING TEGADERM 3 X 3 -,SUP-1624-W,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.17,0.819,AETNA [1000108],AETNA [100010801],,,,,,0.262665,416.02,other,Supplies A-Codes,,
DRESSING TRANSP 2.375X2.75IN TEGADERM OCL PIC FRM STYL -,SUP-1624-W,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.17,0.819,AETNA [1000108],AETNA [100010801],,,,,,0.262665,416.02,other,Supplies A-Codes,,
DRESSING TEAGDERM IV 2.75X3.25IN -,SUP-1633,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.63,1.141,AETNA [1000108],AETNA [100010801],,,,,,0.262665,416.02,other,Supplies A-Codes,,
DRESSING TEGADERM IV 3.5X4.5IN TRANSPARENT -,SUP-1655,CDM,A6257,HCPCS,270,RC,,,outpatient,,,5.37,3.759,AETNA [1000108],AETNA [100010801],,,,,,0.262665,416.02,other,Supplies A-Codes,,
DRESSING TRANSPARENT 4IN X 4.25IN -,SUP-1626,CDM,A6258,HCPCS,270,RC,,,outpatient,,,3.38,2.366,AETNA [1000108],AETNA [100010801],,,76.8,,2.6,0.75881,416.02,percent of total billed charges,,,
DRESSING TRANSP 4X4.75IN TEGADERM OCL ORIG FRM STYL PLYSTR -,SUP-1626,CDM,A6258,HCPCS,270,RC,,,outpatient,,,3.38,2.366,AETNA [1000108],AETNA [100010801],,,76.8,,2.6,0.75881,416.02,percent of total billed charges,,,
DRESSING TEGADERM 4X5 -,SUP-1626-W,CDM,A6258,HCPCS,270,RC,,,outpatient,,,3.53,2.471,AETNA [1000108],AETNA [100010801],,,76.8,,2.71,0.75881,416.02,percent of total billed charges,,,
DRESSING TEGADERM 15X20CM -,SUP-1628,CDM,A6258,HCPCS,270,RC,,,outpatient,,,6.97,4.879,AETNA [1000108],AETNA [100010801],,,76.8,,5.35,0.75881,416.02,percent of total billed charges,,,
DRESSING TRANSP 4X6.125IN TEGADERM OCL WND FRM STYL ADLT -,SUP-1689,CDM,A6258,HCPCS,270,RC,,,outpatient,,,10.58,7.406,AETNA [1000108],AETNA [100010801],,,76.8,,8.13,0.75881,416.02,percent of total billed charges,,,
DRESSING TEGADERM 20CM X 30CM -,SUP-1629,CDM,A6259,HCPCS,272,RC,,,outpatient,,,9.86,6.902,AETNA [1000108],AETNA [100010801],,,76.8,,7.57,2.21357,416.02,percent of total billed charges,,,
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7020-38,NDC,outpatient,10,ML,102.5,71.75,AETNA [1000108],AETNA [100010801],,,76.8,,78.72,4.17,416.02,percent of total billed charges,,,
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7025-40,NDC,outpatient,10,ML,100.57,70.399,AETNA [1000108],AETNA [100010801],,,76.8,,77.24,4.17,416.02,percent of total billed charges,,,
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7030-42,NDC,outpatient,10,ML,100.56,70.392,AETNA [1000108],AETNA [100010801],,,76.8,,77.23,4.17,416.02,percent of total billed charges,,,
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7015-46,NDC,outpatient,10,ML,100.56,70.392,AETNA [1000108],AETNA [100010801],,,76.8,,77.23,4.17,416.02,percent of total billed charges,,,
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7015-48,NDC,outpatient,10,ML,100.56,70.392,AETNA [1000108],AETNA [100010801],,,76.8,,77.23,4.17,416.02,percent of total billed charges,,,
GADOTERATE MEGLUMINE 1 MMOL/2 ML IV SOLN WRAPPER,RX-4080731,CDM,A9575,HCPCS,636,RC,67684-2000-00,NDC,outpatient,20,ML,136.25,95.375,AETNA [1000108],AETNA [100010801],,,76.8,,104.64,0.12,416.02,percent of total billed charges,,,
7 HOLE SUPERIOR MIDSHAFT CLAVICLE RIGHT PLATE -,SUP-0000000215,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,AETNA [1000108],AETNA [100010801],,,76.8,,2961.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEADLESS 4.0 FIXOS X 26MM -,SUP-0000000215,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA [1000108],AETNA [100010801],,,76.8,,1722.1,0.518595,35041.66656,percent of total billed charges,,,
CAGE ANCHORED APACHE 5MM -,SUP-0000006784,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,0.518595,35041.66656,percent of total billed charges,,,
CABLE ORTHO CBL-RDY COCR 635MM -,SUP-00022320418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2083.36,1458.352,AETNA [1000108],AETNA [100010801],,,76.8,,1600.02,0.518595,35041.66656,percent of total billed charges,,,
PIN IM 4.8X222MM RUSH SS -,SUP-00080200103,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.68,514.976,AETNA [1000108],AETNA [100010801],,,76.8,,565,0.518595,35041.66656,percent of total billed charges,,,
PIN IM 3.2X127MM RUSH SS -,SUP-00080300104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,AETNA [1000108],AETNA [100010801],,,76.8,,481.92,0.518595,35041.66656,percent of total billed charges,,,
PIN IM 3.2X140MM RUSH SS -,SUP-00080300105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,AETNA [1000108],AETNA [100010801],,,76.8,,481.92,0.518595,35041.66656,percent of total billed charges,,,
PIN IM 3.2X165MM RUSH SS -,SUP-00080300107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,AETNA [1000108],AETNA [100010801],,,76.8,,481.92,0.518595,35041.66656,percent of total billed charges,,,
PIN IM 3.2X191MM RUSH SS -,SUP-00080300109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,AETNA [1000108],AETNA [100010801],,,76.8,,481.92,0.518595,35041.66656,percent of total billed charges,,,
PIN IM SZ 3L 3.2X241MM RUSH SS -,SUP-00080300113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,AETNA [1000108],AETNA [100010801],,,76.8,,481.92,0.518595,35041.66656,percent of total billed charges,,,
PIN IM 3.2X254MM RUSH SS -,SUP-00080300114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,AETNA [1000108],AETNA [100010801],,,76.8,,481.92,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X18MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS POR -,SUP-00104223018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X24MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS POR -,SUP-00104223024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X30MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-00104223030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN CANC 4.5X33MM PROTASUL-64 WF TM ANTMC SHLDR STRL -,SUP-00104223033,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN CANC 4.5X36MM PROTASUL-64 WF TM ANTMC SHLDR STRL -,SUP-00104223036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X42MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-00104223042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X48MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-00104223048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
FILLER TY I COLL CA PHOS 5ML PST COPIOS DBASC -,SUP-00110302005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3752.36,2626.652,AETNA [1000108],AETNA [100010801],,,76.8,,2881.81,0.518595,35041.66656,percent of total billed charges,,,
FILLER TY I COLL CA PHOS 10ML PST COPIOS DBASC -,SUP-00110302010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6279,4395.3,AETNA [1000108],AETNA [100010801],,,76.8,,4822.27,0.518595,35041.66656,percent of total billed charges,,,
CEMENT BN PLYMTHL MTHCRYLT 40GM PLC R HVISC -,SUP-00111214001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,396.78,277.746,AETNA [1000108],AETNA [100010801],,,76.8,,304.73,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 40X3MM ANCHR XLPE GLOBAL STRL -,SUP-00113640026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9421.68,6595.176,AETNA [1000108],AETNA [100010801],,,76.8,,7235.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX10MM CANN 7.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA [1000108],AETNA [100010801],,,76.8,,871.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX10MM CANN 1/2 5MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA [1000108],AETNA [100010801],,,76.8,,820.67,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX12MM CANN 9.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA [1000108],AETNA [100010801],,,76.8,,871.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX12MM CANN 1/3 5MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA [1000108],AETNA [100010801],,,76.8,,820.67,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3MMX16MM CANN 1/2 8MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114701631,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,AETNA [1000108],AETNA [100010801],,,76.8,,822.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX16MM CANN 13.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA [1000108],AETNA [100010801],,,76.8,,871.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3MMX19MM CANN 1/3 6.3MM THRD SD/ST HX REVCT FLUT -,SUP-00114701930,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,AETNA [1000108],AETNA [100010801],,,76.8,,822.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANN 3.0MM X 20MM 1/3 TH -,SUP-00114702030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,AETNA [1000108],AETNA [100010801],,,76.8,,822.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3MMX21MM CANN 1/3 7MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,AETNA [1000108],AETNA [100010801],,,76.8,,822.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3MMX24MM CANN 1/2 12MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702431,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,AETNA [1000108],AETNA [100010801],,,76.8,,822.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3MMX26MM CANN 1/2 13MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702631,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,AETNA [1000108],AETNA [100010801],,,76.8,,822.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3MMX28MM CANN 1/2 14MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702831,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,AETNA [1000108],AETNA [100010801],,,76.8,,822.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX28MM CANN 9.3MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114702835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA [1000108],AETNA [100010801],,,76.8,,871.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX28MM CANN 1/3 9.3MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114702840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.27,795.389,AETNA [1000108],AETNA [100010801],,,76.8,,872.66,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX28MM CANN 1/2 14MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114702841,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.27,795.389,AETNA [1000108],AETNA [100010801],,,76.8,,872.66,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3MMX30MM CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,AETNA [1000108],AETNA [100010801],,,76.8,,822.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX30MM CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA [1000108],AETNA [100010801],,,76.8,,820.67,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX30MM CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT. -,SUP-00114703041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA [1000108],AETNA [100010801],,,76.8,,820.67,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA [1000108],AETNA [100010801],,,76.8,,820.67,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX34MM CANN 1/3 11.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA [1000108],AETNA [100010801],,,76.8,,871.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX34MM CANN 1/3 11.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA [1000108],AETNA [100010801],,,76.8,,820.67,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX34MM CANN 1/3 17MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703441,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.27,795.389,AETNA [1000108],AETNA [100010801],,,76.8,,872.66,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX36MM CANN 1/3 12MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA [1000108],AETNA [100010801],,,76.8,,871.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX36MM CANN 1/3 12MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA [1000108],AETNA [100010801],,,76.8,,820.67,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX36MM CANN 1/3 18MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703641,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA [1000108],AETNA [100010801],,,76.8,,820.67,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX38MM CANN 1/3 12.7MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA [1000108],AETNA [100010801],,,76.8,,820.67,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX38MM CANN 1/3 19MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703841,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA [1000108],AETNA [100010801],,,76.8,,820.67,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3MMX40MM CANN 1/3 13.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,AETNA [1000108],AETNA [100010801],,,76.8,,822.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX40MM CANN 1/3 13.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA [1000108],AETNA [100010801],,,76.8,,871.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X40MM CANN 1/3 13.3MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA [1000108],AETNA [100010801],,,76.8,,820.67,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX40MM CANN 1/3 20MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA [1000108],AETNA [100010801],,,76.8,,820.67,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX42MM CANN 1/3 39.5MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA [1000108],AETNA [100010801],,,76.8,,820.67,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX44MM CANN 14.7MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA [1000108],AETNA [100010801],,,76.8,,871.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX44MM CANN 1/3 14.7MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA [1000108],AETNA [100010801],,,76.8,,820.67,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX44MM CANN 1/2 22MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704441,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA [1000108],AETNA [100010801],,,76.8,,820.67,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5MMX45MM CANN 16MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114704555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,AETNA [1000108],AETNA [100010801],,,76.8,,864.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5MMX45MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114704556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,AETNA [1000108],AETNA [100010801],,,76.8,,864.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX46MM CANN 15.3MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA [1000108],AETNA [100010801],,,76.8,,871.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX46MM CANN 43.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA [1000108],AETNA [100010801],,,76.8,,871.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX46MM CANN 1/3 15.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA [1000108],AETNA [100010801],,,76.8,,820.67,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX46MM CANN 1/2 23MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704641,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA [1000108],AETNA [100010801],,,76.8,,820.67,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX48MM CANN 16MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA [1000108],AETNA [100010801],,,76.8,,871.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX48MM CANN 1/3 16MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA [1000108],AETNA [100010801],,,76.8,,820.67,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX50MM CANN 16.7MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114705035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA [1000108],AETNA [100010801],,,76.8,,871.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX50MM CANN 1/3 16.7MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114705040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA [1000108],AETNA [100010801],,,76.8,,820.67,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5MMX50MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,AETNA [1000108],AETNA [100010801],,,76.8,,864.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5MMX50MM CANN 45.3MM FT SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705057,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,AETNA [1000108],AETNA [100010801],,,76.8,,864.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MMX50MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114705065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA [1000108],AETNA [100010801],,,76.8,,981.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5MMX55MM CANN 16MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,AETNA [1000108],AETNA [100010801],,,76.8,,864.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5MMX55MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,AETNA [1000108],AETNA [100010801],,,76.8,,864.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MMX55MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114705565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA [1000108],AETNA [100010801],,,76.8,,981.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5MMX60MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114706056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,AETNA [1000108],AETNA [100010801],,,76.8,,864.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MMX60MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA [1000108],AETNA [100010801],,,76.8,,981.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MMX60MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA [1000108],AETNA [100010801],,,76.8,,981.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5MMX65MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114706556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,AETNA [1000108],AETNA [100010801],,,76.8,,864.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MMX65MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA [1000108],AETNA [100010801],,,76.8,,981.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MMX65MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA [1000108],AETNA [100010801],,,76.8,,981.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MMX70MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA [1000108],AETNA [100010801],,,76.8,,981.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MMX70MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA [1000108],AETNA [100010801],,,76.8,,981.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7.5MMX70MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7.5MMX70MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MMX75MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA [1000108],AETNA [100010801],,,76.8,,981.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MMX75MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA [1000108],AETNA [100010801],,,76.8,,981.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7.5MMX75MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7.5MMX75MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5MMX80MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114708056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,AETNA [1000108],AETNA [100010801],,,76.8,,864.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MMX80MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA [1000108],AETNA [100010801],,,76.8,,981.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MMX80MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA [1000108],AETNA [100010801],,,76.8,,981.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7.5MMX80MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7.5MMX80MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7.5MMX80MM CANN 74.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114708077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,,,
GUIDEPIN ORTHO 1.6MMX6IN P/T TROC TIP -,SUP-00114708400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,AETNA [1000108],AETNA [100010801],,,76.8,,83.08,0.518595,35041.66656,percent of total billed charges,,,
GUIDEPIN ORTHO 1.25MMX6IN P/T TROC TIP -,SUP-00114708500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,AETNA [1000108],AETNA [100010801],,,76.8,,83.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5MMX85MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114708556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,AETNA [1000108],AETNA [100010801],,,76.8,,864.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MMX85MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA [1000108],AETNA [100010801],,,76.8,,981.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MMX85MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA [1000108],AETNA [100010801],,,76.8,,981.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7.5MMX85MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7.5MMX85MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7.5MMX85MM CANN 79.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114708577,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,,,
GUIDEPIN ORTHO 2.4MMX9IN P/T TROC TIP -,SUP-00114708700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,AETNA [1000108],AETNA [100010801],,,76.8,,83.08,0.518595,35041.66656,percent of total billed charges,,,
GUIDEPIN ORTHO 3.2MMX9IN P/T TROC TIP -,SUP-00114708800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,AETNA [1000108],AETNA [100010801],,,76.8,,83.08,0.518595,35041.66656,percent of total billed charges,,,
GUIDEPIN ORTHO 1.6MMX9IN SMTH SHFT TROC TIP -,SUP-00114709000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,70.98,49.686,AETNA [1000108],AETNA [100010801],,,76.8,,54.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MMX90MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA [1000108],AETNA [100010801],,,76.8,,981.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7.5MMX90MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7.5MMX90MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7.5MMX90MM CANN 84.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114709077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,,,
GUIDEPIN ORTHO 2.4MMX9IN SMTH SHFT TROC TIP -,SUP-00114709100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,147.14,102.998,AETNA [1000108],AETNA [100010801],,,76.8,,113,0.518595,35041.66656,percent of total billed charges,,,
GUIDEPIN ORTHO 3.2MMX9IN SMTH SHFT TROC TIP -,SUP-00114709200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,147.04,102.928,AETNA [1000108],AETNA [100010801],,,76.8,,112.93,0.518595,35041.66656,percent of total billed charges,,,
GUIDEPIN ORTHO 1.6MMX6IN SMTH SHFT TROC TIP -,SUP-00114709400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,70.95,49.665,AETNA [1000108],AETNA [100010801],,,76.8,,54.49,0.518595,35041.66656,percent of total billed charges,,,
WASHER ORTHO 3MM -,SUP-00114709500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,AETNA [1000108],AETNA [100010801],,,76.8,,186.11,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MMX95MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA [1000108],AETNA [100010801],,,76.8,,981.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MMX95MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA [1000108],AETNA [100010801],,,76.8,,981.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7.5MMX95MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7.5MMX95MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7.5MMX95MM CANN 89.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114709577,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,,,
WASHER ORTHO F/3.5/4MM CANN SCR NS -,SUP-00114709600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,AETNA [1000108],AETNA [100010801],,,76.8,,186.11,0.518595,35041.66656,percent of total billed charges,,,
WASHER ORTHO F/4.5MM CANN SCR SS NS -,SUP-00114709700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,AETNA [1000108],AETNA [100010801],,,76.8,,186.11,0.518595,35041.66656,percent of total billed charges,,,
WASHER ORTHO F/5.5MM/7.5MM CANN SCR SS RND NS -,SUP-00114709800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,AETNA [1000108],AETNA [100010801],,,76.8,,186.11,0.518595,35041.66656,percent of total billed charges,,,
GUIDEPIN ORTHO 3.2MMX12IN P/T TROC TIP -,SUP-00114709901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,AETNA [1000108],AETNA [100010801],,,76.8,,83.08,0.518595,35041.66656,percent of total billed charges,,,
GUIDEPIN ORTHO 3.2MM 30CM -,SUP-00114709902,CDM,C1713,HCPCS,278,RC,,,outpatient,,,155.78,109.046,AETNA [1000108],AETNA [100010801],,,76.8,,119.64,0.518595,35041.66656,percent of total billed charges,,,
GUIDEPIN ORTHO 3.2MMX12IN SMTH SHFT DRILL TIP -,SUP-00114709903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,155.74,109.018,AETNA [1000108],AETNA [100010801],,,76.8,,119.61,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MMX100MM CANN 16MM THRD SD/ST 4.5MM HX REVCT FLUT -,SUP-00114710065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA [1000108],AETNA [100010801],,,76.8,,981.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW Z CANN PT 32 6.5 X 100 -,SUP-00114710066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA [1000108],AETNA [100010801],,,76.8,,981.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7.5MMX100MM CANN FT SD/ST 5MM HX REVCT FLUT BIODUR 108 -,SUP-00114710077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MMX105MM CANN 16MM THRD SD/ST 4.5MM HX REVCT FLUT -,SUP-00114710565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA [1000108],AETNA [100010801],,,76.8,,981.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7.5MMX105MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114710575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1399.33,979.531,AETNA [1000108],AETNA [100010801],,,76.8,,1074.69,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7.5MMX105MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114710576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7.5MMX110MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7.5MMX110MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7.5MMX115MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7.5MMX115MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7.5MMX120MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114712075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.25MM 2.5MM THRD MINI 10MM HRBRT MINI TIV STRL -,SUP-00115001000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2142.36,1499.652,AETNA [1000108],AETNA [100010801],,,76.8,,1645.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.25MM 2.5MM THRD MINI 16MM HRBRT MINI TIV STRL -,SUP-00115001600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2142.36,1499.652,AETNA [1000108],AETNA [100010801],,,76.8,,1645.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5MM 2.1MM THRD 14MM CANN HRBRT/WPL TIV STRL -,SUP-00115201400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2555.05,1788.535,AETNA [1000108],AETNA [100010801],,,76.8,,1962.28,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3X5MM DIA THRD MINI 18MM CANN LAG HRBRT/WPL TIV STRL -,SUP-00115201800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2555.05,1788.535,AETNA [1000108],AETNA [100010801],,,76.8,,1962.28,0.518595,35041.66656,percent of total billed charges,,,
GUIDEPIN ORTHO 3.2MMX23CM THRD TROC TIP FRLCK STRL -,SUP-00118102000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.84,81.788,AETNA [1000108],AETNA [100010801],,,76.8,,89.73,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 12.7MM THRD VFX2 LAG 17MM S/T SS 130MM -,SUP-00119300557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1749.27,1224.489,AETNA [1000108],AETNA [100010801],,,76.8,,1343.44,0.518595,35041.66656,percent of total billed charges,,,
GUIDEPIN ORTHO 3.2MM TM -,SUP-00119703200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.19,908.033,AETNA [1000108],AETNA [100010801],,,76.8,,996.24,0.518595,35041.66656,percent of total billed charges,,,
ROD FEM HIP 10MM TM TIV 25MM THRD -,SUP-00119710010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14101.97,9871.379,AETNA [1000108],AETNA [100010801],,,76.8,,10830.31,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN NCB 80MM 4HL CONTR LCK PROTASUL-64 STRL -,SUP-00202262104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5884.73,4119.311,AETNA [1000108],AETNA [100010801],,,76.8,,4519.47,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN NCB 117MM 7HL CONTR LCK PROTASUL-64 STRL -,SUP-00202262107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7175.97,5023.179,AETNA [1000108],AETNA [100010801],,,76.8,,5511.14,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X24MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X26MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X30MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X32MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,605.85,424.095,AETNA [1000108],AETNA [100010801],,,76.8,,465.29,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X36MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,605.85,424.095,AETNA [1000108],AETNA [100010801],,,76.8,,465.29,0.518595,35041.66656,percent of total billed charges,,,
CAP LCK NCB NS -,SUP-00203150300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,930.39,651.273,AETNA [1000108],AETNA [100010801],,,76.8,,714.54,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X24MM NLCKG CORT NCB ST TMX NS -,SUP-00203155024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX26MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX28MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX30MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX32MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX34MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX36MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X38MM NLCKG CORT NCB ST TMX NS -,SUP-00203155038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX40MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX42MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX44MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX46MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX50MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X32MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,778.91,545.237,AETNA [1000108],AETNA [100010801],,,76.8,,598.2,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X44MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,778.91,545.237,AETNA [1000108],AETNA [100010801],,,76.8,,598.2,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X46MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,778.91,545.237,AETNA [1000108],AETNA [100010801],,,76.8,,598.2,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X50MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.68,514.976,AETNA [1000108],AETNA [100010801],,,76.8,,565,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN NCB 93MM 5HL LCK TI -,SUP-00203262005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5979.97,4185.979,AETNA [1000108],AETNA [100010801],,,76.8,,4592.62,0.518595,35041.66656,percent of total billed charges,,,
STAPLE INTNL 19MMX15.9MM LF -,SUP-00222901300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,294.26,205.982,AETNA [1000108],AETNA [100010801],,,76.8,,225.99,0.518595,35041.66656,percent of total billed charges,,,
DEVICE ORTHO 23MM LNG CBL-RDY GTR TROCH TIV 121MM STRL -,SUP-00223200205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9554.89,6688.423,AETNA [1000108],AETNA [100010801],,,76.8,,7338.16,0.518595,35041.66656,percent of total billed charges,,,
CABLE ORTHO 1.8MM CBL-RDY COCR 914MM STRL -,SUP-00223200228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2397.84,1678.488,AETNA [1000108],AETNA [100010801],,,76.8,,1841.54,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 305MM 4.5MM 10HL SS STRL -,SUP-00223200302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4354.7,3048.29,AETNA [1000108],AETNA [100010801],,,76.8,,3344.41,0.518595,35041.66656,percent of total billed charges,,,
CABLE PLATE 1.8MM CBL-RDY BN SS 610MM STRL -,SUP-00223200318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1493.73,1045.611,AETNA [1000108],AETNA [100010801],,,76.8,,1147.18,0.518595,35041.66656,percent of total billed charges,,,
CABLE SURG 1.8MM X 635MM CBL-RDY CRLGE SS -,SUP-00223200418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2083.36,1458.352,AETNA [1000108],AETNA [100010801],,,76.8,,1600.02,0.518595,35041.66656,percent of total billed charges,,,
CABLE FX 1.3MM CBL-RDY SS 889MM STRL -,SUP-00223201113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1788.55,1251.985,AETNA [1000108],AETNA [100010801],,,76.8,,1373.61,0.518595,35041.66656,percent of total billed charges,,,
ORTHOPEDIC CBL-RDY GRP 65MM PIN -,SUP-00223205021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2708.43,1895.901,AETNA [1000108],AETNA [100010801],,,76.8,,2080.07,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX12MM LCK CORT ST FA SS NS -,SUP-00234801235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA [1000108],AETNA [100010801],,,76.8,,172.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX18MM LCK CORT ST FA SS NS -,SUP-00234801835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA [1000108],AETNA [100010801],,,76.8,,172.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX20MM LCK CORT ST FA SS NS -,SUP-00234802035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA [1000108],AETNA [100010801],,,76.8,,172.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX22MM LCK CORT ST FA SS NS -,SUP-00234802235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA [1000108],AETNA [100010801],,,76.8,,172.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX26MM LCK CORT ST FA SS NS -,SUP-00234802635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA [1000108],AETNA [100010801],,,76.8,,172.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX30MM LCK CORT ST FA SS NS -,SUP-00234803035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA [1000108],AETNA [100010801],,,76.8,,172.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX34MM LCK CORT ST FA SS NS -,SUP-00234803435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA [1000108],AETNA [100010801],,,76.8,,172.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX40MM LCK CORT ST FA SS NS -,SUP-00234804035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA [1000108],AETNA [100010801],,,76.8,,172.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX100MM LCK CORT ST FA SS NS -,SUP-00234810035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA [1000108],AETNA [100010801],,,76.8,,172.85,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 132MM 2.7/3.5MM 8HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235701708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3823.64,2676.548,AETNA [1000108],AETNA [100010801],,,76.8,,2936.56,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 80MM 2.7/3.5MM 4HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235701804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3310.29,2317.203,AETNA [1000108],AETNA [100010801],,,76.8,,2542.3,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 106MM 6HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235701806,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3540.4,2478.28,AETNA [1000108],AETNA [100010801],,,76.8,,2719.03,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 114MM 3.5MM 6HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235800104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6389.13,4472.391,AETNA [1000108],AETNA [100010801],,,76.8,,4906.85,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 129MM 7HL FX-ANG LCK NS -,SUP-00235800907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.68,2924.376,AETNA [1000108],AETNA [100010801],,,76.8,,3208.46,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 77MM 3HL LCK SS NS -,SUP-00235801203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3788.26,2651.782,AETNA [1000108],AETNA [100010801],,,76.8,,2909.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX12MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX14MM LCK NCANN P/T ST CNCL SS NS -,SUP-00235901426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,328.92,230.244,AETNA [1000108],AETNA [100010801],,,76.8,,252.61,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX14MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX14MM LCK NCANN P/T ST SS NS -,SUP-00235901438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,AETNA [1000108],AETNA [100010801],,,76.8,,481.92,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX16MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX16MM LCK NCANN P/T ST CNCL SS NS -,SUP-00235901638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,AETNA [1000108],AETNA [100010801],,,76.8,,481.92,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X18MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X30MM LCK NCANN FT ST SS NS -,SUP-00235903035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X32MM LCK NCANN FT ST SS NS -,SUP-00235903235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X36MM LCK NCANN FT ST SS NS -,SUP-00235903635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X38MM LCK NCANN FT ST SS NS -,SUP-00235903835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X40MM LCK NCANN FT ST SS NS -,SUP-00235904035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X42MM LCK NCANN FT ST SS NS -,SUP-00235904235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X44MM LCK NCANN FT ST SS NS -,SUP-00235904435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X46MM LCK NCANN FT ST SS NS -,SUP-00235904635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X48MM LCK NCANN FT ST SS NS -,SUP-00235904835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X50MM LCK NCANN FT ST SS NS -,SUP-00235905035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA [1000108],AETNA [100010801],,,76.8,,498.5,0.518595,35041.66656,percent of total billed charges,,,
SCRW 14MM CASPAR PIN F/DSTRCT -,SUP-0024-LDR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
GUIDEPIN ORTHO 3.2X444MM -,SUP-00281001175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
STAPLE INTNL 22MMX9.5MM COCR LF -,SUP-00406000100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.27,530.089,AETNA [1000108],AETNA [100010801],,,76.8,,581.58,0.518595,35041.66656,percent of total billed charges,,,
STAPLE INTNL 25MMX9.5MM COCR LF -,SUP-00406000200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.27,530.089,AETNA [1000108],AETNA [100010801],,,76.8,,581.58,0.518595,35041.66656,percent of total billed charges,,,
PIN FX 3.2MM BGLNI/FLTW THRD TIP -,SUP-00430400800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,379.28,265.496,AETNA [1000108],AETNA [100010801],,,76.8,,291.29,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.5MM THRD 7MM CORT FT ST HEX HEAD SS NS -,SUP-00481500701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.5MM THRD 8MM CORT FT ST HEX HEAD SS NS -,SUP-00481500801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.5MM THRD 9MM CORT FT ST HEX HEAD SS NS -,SUP-00481500901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.5MM THRD 14MM CORT FT ST HEX HEAD SS NS -,SUP-00481501401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.5MM THRD 16MM CORT FT ST HEX HEAD SS NS -,SUP-00481501601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.5MM THRD 20MM CORT FT ST HEX HEAD SS NS -,SUP-00481502001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2MM THRD 6MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482000603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA [1000108],AETNA [100010801],,,76.8,,116.34,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2MM THRD 8MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482000803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA [1000108],AETNA [100010801],,,76.8,,116.34,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2MM THRD 10MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA [1000108],AETNA [100010801],,,76.8,,116.34,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2MM THRD 10MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA [1000108],AETNA [100010801],,,76.8,,116.34,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2MM THRD 12MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA [1000108],AETNA [100010801],,,76.8,,116.34,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2MM THRD 12MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA [1000108],AETNA [100010801],,,76.8,,116.34,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2MM THRD 14MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA [1000108],AETNA [100010801],,,76.8,,116.34,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2MM THRD 14MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA [1000108],AETNA [100010801],,,76.8,,116.34,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2MM THRD 16MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA [1000108],AETNA [100010801],,,76.8,,116.34,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2MM THRD 16MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA [1000108],AETNA [100010801],,,76.8,,116.34,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2MM THRD 18MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA [1000108],AETNA [100010801],,,76.8,,116.34,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2MM THRD 22MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482002201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA [1000108],AETNA [100010801],,,76.8,,116.34,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MM THRD 6MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00482700601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MM THRD 8MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00482700801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MM THRD 10MM LCK CORT FT NON- ST 2.5MM SM HEX RCESS -,SUP-00482701000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,128.9,90.23,AETNA [1000108],AETNA [100010801],,,76.8,,99,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MM THRD 10MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MM THRD 12MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MM THRD 14MM CORT FT ST 2.5MM SM HEX RCESS -,SUP-00482701401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MM THRD 16MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MM THRD 18MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,147.33,103.131,AETNA [1000108],AETNA [100010801],,,76.8,,113.15,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MM THRD 20MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482702001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MM THRD 26MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482702601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MMX10MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482801002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,AETNA [1000108],AETNA [100010801],,,76.8,,515.12,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MMX12MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482801202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,AETNA [1000108],AETNA [100010801],,,76.8,,515.12,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MMX12MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482801202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MMX14MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482801402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,AETNA [1000108],AETNA [100010801],,,76.8,,515.12,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MMX16MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482801602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,AETNA [1000108],AETNA [100010801],,,76.8,,515.12,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MMX18MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482801802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,AETNA [1000108],AETNA [100010801],,,76.8,,515.12,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MMX20MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482802002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,AETNA [1000108],AETNA [100010801],,,76.8,,515.12,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MMX22MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482802202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,AETNA [1000108],AETNA [100010801],,,76.8,,515.12,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MMX26MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482802602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,AETNA [1000108],AETNA [100010801],,,76.8,,515.12,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MMX28MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482802802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,AETNA [1000108],AETNA [100010801],,,76.8,,515.12,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MMX30MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482803002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,AETNA [1000108],AETNA [100010801],,,76.8,,515.12,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX16MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483501601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA [1000108],AETNA [100010801],,,76.8,,122.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX16MM LCK CORT 6MM P/T NON- ST 2.5MM SM HEX RCESS -,SUP-00483501604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX20MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA [1000108],AETNA [100010801],,,76.8,,122.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX20MM LCK CORT 6MM P/T NON- ST 2.5MM SM HEX RCESS -,SUP-00483502004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX22MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA [1000108],AETNA [100010801],,,76.8,,122.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX22MM LCK CORT 6MM P/T NON- ST 2.5MM SM HEX RCESS -,SUP-00483502204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX24MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483502404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX26MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA [1000108],AETNA [100010801],,,76.8,,122.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX26MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483502604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX28MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA [1000108],AETNA [100010801],,,76.8,,122.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX28MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483502804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX30MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483503001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA [1000108],AETNA [100010801],,,76.8,,122.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX30MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483503004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN CORT 3.5MM 32MM SS NS FT S/T LOCK 2.5MM SM HEX -,SUP-00483503201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA [1000108],AETNA [100010801],,,76.8,,122.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX34MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483503401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA [1000108],AETNA [100010801],,,76.8,,122.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX34MM LCK CORT 12MM P/T NON- ST 2.5MM SM HEX -,SUP-00483503404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX45MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483504501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA [1000108],AETNA [100010801],,,76.8,,122.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX45MM LCK CORT 12MM P/T NON- ST 2.5MM SM HEX -,SUP-00483504504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX50MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483505001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA [1000108],AETNA [100010801],,,76.8,,122.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX55MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483505501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA [1000108],AETNA [100010801],,,76.8,,122.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX12MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484001200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA [1000108],AETNA [100010801],,,76.8,,99.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX12MM CANC 5MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA [1000108],AETNA [100010801],,,76.8,,99.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX14MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484001400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA [1000108],AETNA [100010801],,,76.8,,99.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX14MM CANC 5MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA [1000108],AETNA [100010801],,,76.8,,99.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX16MM LCK CANC FT 2.5MM SM HEX RCESS SS NS -,SUP-00484001600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA [1000108],AETNA [100010801],,,76.8,,99.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX16MM CANC 6MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA [1000108],AETNA [100010801],,,76.8,,99.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX18MM LCK CANC FT 2.5MM SM HEX RCESS SS NS -,SUP-00484001800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA [1000108],AETNA [100010801],,,76.8,,99.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX18MM CANC 7MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA [1000108],AETNA [100010801],,,76.8,,99.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX20MM LCK CANC FT 2.5MM SM HEX RCESS SS NS -,SUP-00484002000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA [1000108],AETNA [100010801],,,76.8,,99.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX22MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484002200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA [1000108],AETNA [100010801],,,76.8,,99.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX24MM CANC 10MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484002401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA [1000108],AETNA [100010801],,,76.8,,99.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX26MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484002600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA [1000108],AETNA [100010801],,,76.8,,99.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX28MM CANC 14MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484002801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA [1000108],AETNA [100010801],,,76.8,,99.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX30MM CANC 14MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484003001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA [1000108],AETNA [100010801],,,76.8,,99.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX34MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484003400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA [1000108],AETNA [100010801],,,76.8,,99.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX38MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484003800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA [1000108],AETNA [100010801],,,76.8,,99.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX40MM CANC 14MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484004001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA [1000108],AETNA [100010801],,,76.8,,99.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX50MM CANC 15MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484005001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA [1000108],AETNA [100010801],,,76.8,,99.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MM THRD 36MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484503601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MM THRD 38MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484503801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MM THRD 40MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MM THRD 40MM CORT 20.5MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00484504008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,194.77,136.339,AETNA [1000108],AETNA [100010801],,,76.8,,149.58,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MM THRD 42MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MM THRD 44MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MM THRD 46MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MM THRD 50MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484505001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MM THRD 50MM CORT 24.5MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00484505008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,194.77,136.339,AETNA [1000108],AETNA [100010801],,,76.8,,149.58,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MM THRD 55MM CORT 26.5MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00484505508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,194.77,136.339,AETNA [1000108],AETNA [100010801],,,76.8,,149.58,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MM THRD 58MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484505801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MM THRD 60MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484506001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MM THRD 45MM CANC 32MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486504502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA [1000108],AETNA [100010801],,,76.8,,172.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MM THRD 50MM CANC 16MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486505001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA [1000108],AETNA [100010801],,,76.8,,172.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MM THRD 50MM CANC 32MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486505002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA [1000108],AETNA [100010801],,,76.8,,172.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MM THRD 55MM CANC 32MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486505502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA [1000108],AETNA [100010801],,,76.8,,172.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MM THRD 60MM CANC FT 3.5MM LRG HEX RCESS SS NS -,SUP-00486506000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA [1000108],AETNA [100010801],,,76.8,,172.85,0.518595,35041.66656,percent of total billed charges,,,
WASHER ORTHO 4X7MM SM 2.7/3.5/4.0MM SS RND FLT NS -,SUP-00490004051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA [1000108],AETNA [100010801],,,76.8,,106.38,0.518595,35041.66656,percent of total billed charges,,,
WASHER ORTHO 13MM LRG 4.5/6.5MM RND FLT NS -,SUP-00490006551,CDM,C1713,HCPCS,278,RC,,,outpatient,,,207.73,145.411,AETNA [1000108],AETNA [100010801],,,76.8,,159.54,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 21MM 2MM SS L-SHP OB R MINI FRAG NS -,SUP-00492000210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,386.57,270.599,AETNA [1000108],AETNA [100010801],,,76.8,,296.89,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 23MM 4HL 2MM SS STR MINI FRAG NS -,SUP-00492000402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,389.49,272.643,AETNA [1000108],AETNA [100010801],,,76.8,,299.13,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 32MM 2.7MM SS T-SHP MINI FRAG NS -,SUP-00492700304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.52,254.464,AETNA [1000108],AETNA [100010801],,,76.8,,279.18,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 31MM 4HL 1MM SS 1/4 TBLR MINI FRAG NS CLLR -,SUP-00492700403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,432.72,302.904,AETNA [1000108],AETNA [100010801],,,76.8,,332.33,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 104MM 3.5MM 4HL SS CLVRLF SM FRAG NS -,SUP-00493500416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1493.73,1045.611,AETNA [1000108],AETNA [100010801],,,76.8,,1147.18,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 61MM 5HL SS SM 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500503,CDM,C1713,HCPCS,278,RC,,,outpatient,,,406.82,284.774,AETNA [1000108],AETNA [100010801],,,76.8,,312.44,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 73MM 3.5MM 6HL COMPR SS SM FRAG NS -,SUP-00493500600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,800.56,560.392,AETNA [1000108],AETNA [100010801],,,76.8,,614.83,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 73MM 6HL SS SM 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.09,296.863,AETNA [1000108],AETNA [100010801],,,76.8,,325.7,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 85MM 3.5MM 7HL COMPR SS SM FRAG NS -,SUP-00493500700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,822.21,575.547,AETNA [1000108],AETNA [100010801],,,76.8,,631.46,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 85MM 7HL SS SM 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.09,296.863,AETNA [1000108],AETNA [100010801],,,76.8,,325.7,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 97MM 3.5MM 8HL 1.1MM COMPR SS SM FRAG NS -,SUP-00493500800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 97MM 3.5MM 8HL SS 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,454.37,318.059,AETNA [1000108],AETNA [100010801],,,76.8,,348.96,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 109MM 3.5MM 9HL 1.1MM COMPR SS SM FRAG NS -,SUP-00493500900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,887.1,620.97,AETNA [1000108],AETNA [100010801],,,76.8,,681.29,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 121MM 3.5MM 10HL 1.1MM COMPR SS SM FRAG NS -,SUP-00493501000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,908.74,636.118,AETNA [1000108],AETNA [100010801],,,76.8,,697.91,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 74MM 3.5MM HLX3/5 HD/SHFT 1.5MM SS T-SHP OBLQ SM -,SUP-00493503505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1100.65,770.455,AETNA [1000108],AETNA [100010801],,,76.8,,845.3,0.518595,35041.66656,percent of total billed charges,,,
"PLATE Z ""T"" 4 HOLE 3.5MM -",SUP-00493504404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,714.03,499.821,AETNA [1000108],AETNA [100010801],,,76.8,,548.38,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 68MM 3.5MM UNIV LCK SYS 5HL LCK SS 1/3 TBLR NS -,SUP-00493600503,CDM,C1713,HCPCS,278,RC,,,outpatient,,,952.04,666.428,AETNA [1000108],AETNA [100010801],,,76.8,,731.17,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 94MM 3.5MM UNIV LCK SYS 7HL LCK SS 1/3 TBLR NS -,SUP-00493600703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1016.92,711.844,AETNA [1000108],AETNA [100010801],,,76.8,,780.99,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 107MM 3.5MM UNIV LCK SYS 8HL LCK SS 1/3 TBLR NS -,SUP-00493600803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.22,742.154,AETNA [1000108],AETNA [100010801],,,76.8,,814.25,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 105MM 3.5MM UNIV LCK SYS 8HL CONTR LCK DL COMPR SS -,SUP-00493600807,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1867.15,1307.005,AETNA [1000108],AETNA [100010801],,,76.8,,1433.97,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 105MM 3.5MM UNIV LCK SYS 8HL RECON LCK SS NS -,SUP-00493600813,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2566.79,1796.753,AETNA [1000108],AETNA [100010801],,,76.8,,1971.29,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 133MM 3.5MM UNIV LCK SYS 10HL LCK SS 1/3 TBLR LRG -,SUP-00493601003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.81,757.267,AETNA [1000108],AETNA [100010801],,,76.8,,830.83,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 116MM 4.5MM 6HL SHFT SS T-SHP LRG FRAG NS -,SUP-00494500604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1316.86,921.802,AETNA [1000108],AETNA [100010801],,,76.8,,1011.35,0.518595,35041.66656,percent of total billed charges,,,
PLATE Z 4.5 COMP B 12 HOLE -,SUP-00494501201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1356.19,949.333,AETNA [1000108],AETNA [100010801],,,76.8,,1041.55,0.518595,35041.66656,percent of total billed charges,,,
KT MIXER BNCMNT VAC MX 35ML LNG CQ/NOZ FNL CHRCL FLTR SUCT -,SUP-00504903501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,811.07,567.749,AETNA [1000108],AETNA [100010801],,,76.8,,622.9,0.518595,35041.66656,percent of total billed charges,,,
KT MIXER BNCMNT VAC MX 45ML LNG CQ/NOZ FNL CHRCL FLTR SUCT -,SUP-00504904501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,905.01,633.507,AETNA [1000108],AETNA [100010801],,,76.8,,695.05,0.518595,35041.66656,percent of total billed charges,,,
WIRE PACK .028 SPADE TIP -,SUP-00505004100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,49.89,34.923,AETNA [1000108],AETNA [100010801],,,76.8,,38.32,0.518595,35041.66656,percent of total billed charges,,,
GRAFT HUM TIS 11MM CHONDROFIX OSTCHND LF -,SUP-00560402011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15111.91,10578.337,AETNA [1000108],AETNA [100010801],,,76.8,,11605.95,0.518595,35041.66656,percent of total billed charges,,,
GRAFT BN 15MM CHONDROFIX LF -,SUP-00560402015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15891.64,11124.148,AETNA [1000108],AETNA [100010801],,,76.8,,12204.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW 48MM HD UNICMPT SS F/HI FLEX SYS -,SUP-00579104100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.77,258.139,AETNA [1000108],AETNA [100010801],,,76.8,,283.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW 48MM HD UNICMPT SS F/HI FLEX SYS -,SUP-00579104100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
HOLDER IMPL HDLS 48MM SS GOLD F/UNICMPT HI FLEX KN SPCR BLCK -,SUP-00579104200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEX HEAD 3.5MM -,SUP-00-5901-035-27,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEX HEAD 3.5MM X 48MM -,SUP-00-5901-035-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA [1000108],AETNA [100010801],,,76.8,,1750.44,0.518595,35041.66656,percent of total billed charges,,,
SCREW FLEX LCK -,SUP-00595409000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,,,
EXTENSION STM MG2 PS TIV ALY PLG TAPR KN -,SUP-00596009900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,0.518595,35041.66656,percent of total billed charges,,,
GUIDE SURG NEXGEN F/UNICMPT KN ARTHPL TIB PT SPEC INST HI.. -,SUP-00597000001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,,,
GUIDE SURG NEXGEN F/UNICMPT KN ARTHPL TIB PT SPEC INST HI -,SUP-00597000002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,,,
GUIDEPIN ORTHO PERSONA CRUCIF RCESS -,SUP-00597000025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,,,
BASEPLATE TIB SZ1 58/40MM KN STM NEXGEN TIV ALY PMMA UHMWPE -,SUP-00598002701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,0.518595,35041.66656,percent of total billed charges,,,
COMP TIBPLT SZ2 62/41MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598002702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,0.518595,35041.66656,percent of total billed charges,,,
COMP TIBPLT SZ3 66/42MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598003701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8452.1,5916.47,AETNA [1000108],AETNA [100010801],,,76.8,,6491.21,0.518595,35041.66656,percent of total billed charges,,,
COMP TIBPLT SZ3 66/42MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598003701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,0.518595,35041.66656,percent of total billed charges,,,
COMP TIBPLT SZ4 66/46MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598003702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,0.518595,35041.66656,percent of total billed charges,,,
COMP TIBPLT SZ5 74/46MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598004701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,0.518595,35041.66656,percent of total billed charges,,,
COMP TIBPLT SZ6 74/50MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598004702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,0.518595,35041.66656,percent of total billed charges,,,
COMP TIBPLT SZ7 82/51MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598005701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW AUG 48MM TIV HX HD F/ARTHPL NEXGEN STRL DIST FEM KN -,SUP-00598304048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,76.8,,358.5,0.518595,35041.66656,percent of total billed charges,,,
COMP TIBTRY SZ3 66/42MM KN CMNT STM WDG NEXGEN TIV PMMA CR -,SUP-00598800300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10515.22,7360.654,AETNA [1000108],AETNA [100010801],,,76.8,,8075.69,0.518595,35041.66656,percent of total billed charges,,,
COMP TIBTRY SZ4 66/46MM KN CMNT STM WDG NEXGEN TIV PMMA CR -,SUP-00598800400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10515.22,7360.654,AETNA [1000108],AETNA [100010801],,,76.8,,8075.69,0.518595,35041.66656,percent of total billed charges,,,
COMP TIBTRY SZ5 74/46MM KN CMNT STM WDG NEXGEN TIV PMMA CR -,SUP-00598800500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10515.22,7360.654,AETNA [1000108],AETNA [100010801],,,76.8,,8075.69,0.518595,35041.66656,percent of total billed charges,,,
DEVICE 11X4X11MM TM-S 7DG TM -,SUP-00610101041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10526.36,7368.452,AETNA [1000108],AETNA [100010801],,,76.8,,8084.24,0.518595,35041.66656,percent of total billed charges,,,
SPACER 11X14X29MM VBR-11 TM -,SUP-00611100292,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15891.64,11124.148,AETNA [1000108],AETNA [100010801],,,76.8,,12204.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW ACTB 6.5X15MM TRILOGY TIV CNTRSNK HEAD ST -,SUP-00625006515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE SELF TAPPED 6.5 X 20 -,SUP-00-6250-065-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,,,
BONE SCREW 6.5X25 SELF-TAP -,SUP-00-6250-065-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE SELF TAP 6.5 X 30 -,SUP-00-6250-065-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,76.8,,403.32,0.518595,35041.66656,percent of total billed charges,,,
SCREW ACTB 6.5X35MM TRILOGY TIV CNTRSNK HEAD ST -,SUP-00625006535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE 6.5 X 40 SELF TAP -,SUP-00625006540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,,,
SCREW ACTB 6.5X40MM TRILOGY TIV CNTRSNK HEAD ST -,SUP-00625006540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE 6.5X40 SELF-TAP -,SUP-00-6250-065-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,,,
BONE SCREW 6.5 X 50MM SELF TAP -,SUP-00625006550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE 6.5 X 50 SELF-TAP -,SUP-00-6250-065-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,,,
LINER 56 X 32  TRILOGY LONGEVITY CONSTRAINED -,SUP-00-6334-056-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14191.09,9933.763,AETNA [1000108],AETNA [100010801],,,76.8,,10898.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW HGP ACETABULAR CUP BONE SLF TP 6.5 X 20 -,SUP-00662406520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,,,
SCREW HGPAETABULAR CUP BONE SLF TP 6.5 X 30 -,SUP-00662406530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,,,
SUBSTITUTE BVN SPNG 1ML STRIP FIL COPIOS 10X20MM 5MM -,SUP-00700582001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1934.68,1354.276,AETNA [1000108],AETNA [100010801],,,76.8,,1485.83,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 2MMX45CM TRIMAX NANCY TI ALY E CAP -,SUP-00800620450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1462.94,1024.058,AETNA [1000108],AETNA [100010801],,,76.8,,1123.54,0.518595,35041.66656,percent of total billed charges,,,
PLUG ACTB DOME HL HIP CONTIN -,SUP-00875700001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,379.28,265.496,AETNA [1000108],AETNA [100010801],,,76.8,,291.29,0.518595,35041.66656,percent of total billed charges,,,
HEAD BIOLOX OPT FEM 32MM/+3.5MM DELTA -,SUP-00-8777-032-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8566.51,5996.557,AETNA [1000108],AETNA [100010801],,,76.8,,6579.08,0.518595,35041.66656,percent of total billed charges,,,
SIDUS STEM-FREE SHOULDER HUMERAL ANCHOR M -,SUP-01.04555.120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19121.95,13385.365,AETNA [1000108],AETNA [100010801],,,76.8,,14685.66,0.518595,35041.66656,percent of total billed charges,,,
G7 ACETABULAR SCREW 6.5MM / 20L -,SUP-010000997,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,,,
G7 SCREW 6.5MM X 30MM -,SUP-010000999,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,,,
G7 ACETABULAR SCREW 6.5MM / 35L -,SUP-010001000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,,,
G7 SCREW 6.5MM X 40MM -,SUP-010001001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,,,
ENDOBUTTON 013186 -,SUP-013186,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.2,778.54,AETNA [1000108],AETNA [100010801],,,76.8,,854.17,0.518595,35041.66656,percent of total billed charges,,,
BASE SLDR GFT F/ACL /PCL GRAFTMS II -,SUP-014950,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3100.9,2170.63,AETNA [1000108],AETNA [100010801],,,76.8,,2381.49,0.518595,35041.66656,percent of total billed charges,,,
NAIL FLEXIBLE PRE CURVED 1.50MM X 300MM -,SUP-0194-1500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,AETNA [1000108],AETNA [100010801],,,76.8,,842.48,0.518595,35041.66656,percent of total billed charges,,,
NAIL FLEXIBLE PRE CURVED 1.75MM X 300MM -,SUP-0194-1750S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.66,795.662,AETNA [1000108],AETNA [100010801],,,76.8,,872.95,0.518595,35041.66656,percent of total billed charges,,,
NAIL FLEXIBLE PRE CURVED 2.25MM X 300MM -,SUP-0194-2250S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1104.62,773.234,AETNA [1000108],AETNA [100010801],,,76.8,,848.35,0.518595,35041.66656,percent of total billed charges,,,
NAIL FLEXIBLE PRE CURVED 2.5MM X 450MM -,SUP-0194-2500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.59,822.213,AETNA [1000108],AETNA [100010801],,,76.8,,902.09,0.518595,35041.66656,percent of total billed charges,,,
NAIL FLEXIBLE PRE CURVED 3.5MM X 450MM -,SUP-0194-3500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1240.32,868.224,AETNA [1000108],AETNA [100010801],,,76.8,,952.57,0.518595,35041.66656,percent of total billed charges,,,
NAIL FLEXIBLE PRE CURVED 4.0MM X 450MM -,SUP-0194-4000S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1276.36,893.452,AETNA [1000108],AETNA [100010801],,,76.8,,980.24,0.518595,35041.66656,percent of total billed charges,,,
NAIL FLEXIBLE PRE-CURVED 2.25 X 300MM -,SUP-0195-2250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1104.62,773.234,AETNA [1000108],AETNA [100010801],,,76.8,,848.35,0.518595,35041.66656,percent of total billed charges,,,
NAIL FLEXIBLE PRE CURVED 2.5 X 450MM -,SUP-0195-2500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.59,822.213,AETNA [1000108],AETNA [100010801],,,76.8,,902.09,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN LCP 158MM 3.5MM 6HL FA LC CONTR LCK COMPR SS TAPR -,SUP-02.104.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5487.49,3841.243,AETNA [1000108],AETNA [100010801],,,76.8,,4214.39,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN_VA-LCP 45MM 2.4MM HLX6/2 HD/SHFT CLMNX2 VAR ANG LCK -,SUP-02.111.621,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5084.31,3559.017,AETNA [1000108],AETNA [100010801],,,76.8,,3904.75,0.518595,35041.66656,percent of total billed charges,,,
2.7/3.5 VA ANTEROLAT DSTL TIB PL/10 H/RT -,SUP-02.118.208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10401.04,7280.728,AETNA [1000108],AETNA [100010801],,,76.8,,7988,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7 METAPHYSEA SLF-TPNG T8 SD REC/48 -,SUP-02.118.548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,76.8,,604.98,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7 METAPHYSEA SLF-TPNG T8 SD REC/50 -,SUP-02.118.550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,76.8,,604.98,0.518595,35041.66656,percent of total billed charges,,,
2.7 VA LOCKING ANT PATELLA PL SS CORE SILE -,SUP-02.137.003S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11077.74,7754.418,AETNA [1000108],AETNA [100010801],,,76.8,,8507.7,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7 VA LOCKING SLF-TPNG T8 SD REC 10 -,SUP-02.211.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA [1000108],AETNA [100010801],,,76.8,,946.46,0.518595,35041.66656,percent of total billed charges,,,
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 12 -,SUP-02.211.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA [1000108],AETNA [100010801],,,76.8,,946.46,0.518595,35041.66656,percent of total billed charges,,,
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 16 -,SUP-02.211.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA [1000108],AETNA [100010801],,,76.8,,946.46,0.518595,35041.66656,percent of total billed charges,,,
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 18 -,SUP-02.211.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA [1000108],AETNA [100010801],,,76.8,,946.46,0.518595,35041.66656,percent of total billed charges,,,
2.7 VA LCKNG SCR SLF-TPNG T8 SD REC 36 -,SUP-02.211.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA [1000108],AETNA [100010801],,,76.8,,946.46,0.518595,35041.66656,percent of total billed charges,,,
2.7 VA LCKING SCR SLF-TPNG T8 SD REC 38 -,SUP-02.211.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA [1000108],AETNA [100010801],,,76.8,,946.46,0.518595,35041.66656,percent of total billed charges,,,
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 40 -,SUP-02.211.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA [1000108],AETNA [100010801],,,76.8,,946.46,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7 VA LCKING SLF-TPNG T8 SD REC 42 -,SUP-02.211.042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA [1000108],AETNA [100010801],,,76.8,,946.46,0.518595,35041.66656,percent of total billed charges,,,
2.7 VA LCKNG SCR SLF-TPING T8 SD REC 46 -,SUP-02.211.046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA [1000108],AETNA [100010801],,,76.8,,946.46,0.518595,35041.66656,percent of total billed charges,,,
2.7MM VA LCKNG SCREW SLF-TPNG WITH T8 60MM -,SUP-02.211.060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,AETNA [1000108],AETNA [100010801],,,76.8,,1050.26,0.518595,35041.66656,percent of total billed charges,,,
PLATE FUSION CLOVERLEAF SHORT 2.4/2.7 VA-LCP -,SUP-02.211.250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8683.22,6078.254,AETNA [1000108],AETNA [100010801],,,76.8,,6668.71,0.518595,35041.66656,percent of total billed charges,,,
CAP FEM NCB LCK -,SUP-0203150300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,930.39,651.273,AETNA [1000108],AETNA [100010801],,,76.8,,714.54,0.518595,35041.66656,percent of total billed charges,,,
PRESSURIZER BNCMNT PROX FEM MED -,SUP-0206-545-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.66,71.862,AETNA [1000108],AETNA [100010801],,,76.8,,78.84,0.518595,35041.66656,percent of total billed charges,,,
FEM PRESSURIZING SEAL - MED -,SUP-0206-546-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.66,71.862,AETNA [1000108],AETNA [100010801],,,76.8,,78.84,0.518595,35041.66656,percent of total billed charges,,,
SCREW INTFR CANN BIOSTEON 7X23MM FT BABSRB WDG SHP HAP PLLA -,SUP-0234-010-161,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,AETNA [1000108],AETNA [100010801],,,76.8,,996.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW INTFR CANN BIOSTEON 8X28MM FT BABSRB WDG SHP HAP PLLA -,SUP-0234-010-167,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,AETNA [1000108],AETNA [100010801],,,76.8,,996.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW INTFR BIOSTEON 10X35MM INTFR HAP PLLA -,SUP-0234-010-178,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,AETNA [1000108],AETNA [100010801],,,76.8,,996.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW CROSS TITANIUM 8MM X 60MM -,SUP-0234500160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,885.69,619.983,AETNA [1000108],AETNA [100010801],,,76.8,,680.21,0.518595,35041.66656,percent of total billed charges,,,
SYNFLATE BALLOON MED -,SUP-03.804.701S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
DEVICE TK TI KNOT 5MM -,SUP-030404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1161.17,812.819,AETNA [1000108],AETNA [100010801],,,76.8,,891.78,0.518595,35041.66656,percent of total billed charges,,,
PLATE FUSION 2.4/2.7MM TI VA-LCP TMT -,SUP-04.211.266,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7524.61,5267.227,AETNA [1000108],AETNA [100010801],,,76.8,,5778.9,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN MATRIXRIB 17HL PRCONT TI NS ROSE RD -,SUP-04.501.006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7312.41,5118.687,AETNA [1000108],AETNA [100010801],,,76.8,,5615.93,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN MATRIXRIB 18HL 1.5MM PRCONT LCK TI NS LBLU -,SUP-04.501.007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8297.02,5807.914,AETNA [1000108],AETNA [100010801],,,76.8,,6372.11,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN MATRIXRIB 18HL PRCONT LCK TI NS ROSE RD -,SUP-04.501.008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7312.41,5118.687,AETNA [1000108],AETNA [100010801],,,76.8,,5615.93,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN MATRIXRIB 8HL PRCONT TI UNIV NS GOLD -,SUP-04.501.009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5653.01,3957.107,AETNA [1000108],AETNA [100010801],,,76.8,,4341.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.9X10MM LCK MATRIXRIB ST TI NS GOLD.. -,SUP-04.501.020.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1309.22,916.454,AETNA [1000108],AETNA [100010801],,,76.8,,1005.48,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.9X10MM LCK MATRIXRIB ST TI NS GOLD. -,SUP-04.501.020.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1147.03,802.921,AETNA [1000108],AETNA [100010801],,,76.8,,880.92,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.9X12MM LCK MATRIXRIB ST TI NS GOLD -,SUP-04.501.022.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1309.22,916.454,AETNA [1000108],AETNA [100010801],,,76.8,,1005.48,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.9X14MM LCK MATRIXRIB ST TI NS GOLD -,SUP-04.501.024.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1150.21,805.147,AETNA [1000108],AETNA [100010801],,,76.8,,883.36,0.518595,35041.66656,percent of total billed charges,,,
IMPLANT ZERO-P IMP 8MM LORDOTIC STERILE -,SUP-04.617.128S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11510.3,8057.21,AETNA [1000108],AETNA [100010801],,,76.8,,8839.91,0.518595,35041.66656,percent of total billed charges,,,
IMPLANT ZERO-P IMP 9MM LORDOTIC STERILE -,SUP-04.617.129S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11510.3,8057.21,AETNA [1000108],AETNA [100010801],,,76.8,,8839.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 3.0MM X 14MM TI CERVICAL SPINE -,SUP-04.617.814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,76.8,,806.63,0.518595,35041.66656,percent of total billed charges,,,
KT BONE CMNT SPINEPLEX -,SUP-0406-202-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1455.25,1018.675,AETNA [1000108],AETNA [100010801],,,76.8,,1117.63,0.518595,35041.66656,percent of total billed charges,,,
CEMENT BN 20GM VERTAPLEX DMSTC DUEL -,SUP-0406-402-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1853.05,1297.135,AETNA [1000108],AETNA [100010801],,,76.8,,1423.14,0.518595,35041.66656,percent of total billed charges,,,
PCD SYSTEM-LONG 90DEG TUBE W/VERTAPLEX -,SUP-0507-486-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2470.55,1729.385,AETNA [1000108],AETNA [100010801],,,76.8,,1897.38,0.518595,35041.66656,percent of total billed charges,,,
PCD PREC SYS LONG TUBE W/VHV -,SUP-0507-586-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2470.55,1729.385,AETNA [1000108],AETNA [100010801],,,76.8,,1897.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 8X70MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-05080000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,,,
KT BONE CMNT AUTOPLEX STRL -,SUP-0605-687-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3912.53,2738.771,AETNA [1000108],AETNA [100010801],,,76.8,,3004.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANNULATED TI 6.5X 110MM,SUP-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.94,757.358,AETNA [1000108],AETNA [100010801],,,76.8,,830.93,0.518595,35041.66656,percent of total billed charges,,,
GUIDEPIN ORTHO 2MM -,SUP-1007-1200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,AETNA [1000108],AETNA [100010801],,,76.8,,398.84,0.518595,35041.66656,percent of total billed charges,,,
SUSTAIN SPACE SMALL - 11MM -,SUP-101.111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
SUSTAIN SPACER SMALL NARROW 11MM -,SUP-101.711,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE ROD 5.5 X 250MM -,SUP-10-1025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X14MM CORT/CANC SS NS F/DMD CRPL FUSION PLATE -,SUP-1011602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,651.19,455.833,AETNA [1000108],AETNA [100010801],,,76.8,,500.11,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X16MM CORT/CANC SS NS F/DMD CRPL FUSION PLATE -,SUP-1011603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,651.19,455.833,AETNA [1000108],AETNA [100010801],,,76.8,,500.11,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X18MM CORT/CANC SS NS F/DMD CRPL FUSION PLATE -,SUP-1011604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,651.19,455.833,AETNA [1000108],AETNA [100010801],,,76.8,,500.11,0.518595,35041.66656,percent of total billed charges,,,
SET SCREW -,SUP-1020-00-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.0 PLY 3.5 X 24MM SYMPHONY -,SUP-1020-035-124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X100MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA [1000108],AETNA [100010801],,,76.8,,830.44,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.0 PLY 3.5 X 14MM SYMPHONY -,SUP-1020-35-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.0 PLY 3.5 X 16MM SYMPHONY -,SUP-1020-35-116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.0 PLY 3.5 X 18MM SYMPHONY -,SUP-1020-35-118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
4.0 PLY SCREW 3.5 X 20 -,SUP-102035120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.0 PLY 4.0 X 14MM SYMPHONY -,SUP-102040114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
ROD TI 4.0 X 070 LOR -,SUP-102064070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA [1000108],AETNA [100010801],,,76.8,,528.79,0.518595,35041.66656,percent of total billed charges,,,
ROD TI 4.0 X 075 LOR -,SUP-102064075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA [1000108],AETNA [100010801],,,76.8,,528.79,0.518595,35041.66656,percent of total billed charges,,,
TI 4.0 X 090 LOR ROD -,SUP-102064090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA [1000108],AETNA [100010801],,,76.8,,528.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X65MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA [1000108],AETNA [100010801],,,76.8,,887.29,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X75MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA [1000108],AETNA [100010801],,,76.8,,887.29,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X85MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA [1000108],AETNA [100010801],,,76.8,,887.29,0.518595,35041.66656,percent of total billed charges,,,
SPACER 12X8X27MM LUCENT LRDTC CRV PEEK -,SUP-10227-008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,AETNA [1000108],AETNA [100010801],,,76.8,,11962.4,0.518595,35041.66656,percent of total billed charges,,,
SPACER 12X9X27MM LUCENT LRDTC CRV PEEK -,SUP-10227-009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,AETNA [1000108],AETNA [100010801],,,76.8,,11962.4,0.518595,35041.66656,percent of total billed charges,,,
SPACER 12X11X27MM LUCENT LRDTC CRV PEEK -,SUP-10227-011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11695.95,8187.165,AETNA [1000108],AETNA [100010801],,,76.8,,8982.49,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN F /FUSSION SS SM NS -,SUP-1024002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7238.14,5066.698,AETNA [1000108],AETNA [100010801],,,76.8,,5558.89,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUT ULFX MICROMITE SZ2-0 2.7MM BRD PLYSTR -,SUP-10301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1633.77,1143.639,AETNA [1000108],AETNA [100010801],,,76.8,,1254.74,0.518595,35041.66656,percent of total billed charges,,,
CHIP CANCELLOUS BONE 5CC 1-8 C -,SUP-103015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,AETNA [1000108],AETNA [100010801],,,76.8,,854.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW CREO AMP 5.5 X 50MM -,SUP-1067.1550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,,,
SCREW CREO AMP 5.5 X 45MM MOD CAN -,SUP-1067.4545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,,,
SCREW MODULAR CANNULATED 6.5 X 40MM CREO AMP -,SUP-1067.4640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,,,
ROD CURVED TIT ALLOY 4.75MM X 35MM -,SUP-1067.7035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,AETNA [1000108],AETNA [100010801],,,76.8,,851.44,0.518595,35041.66656,percent of total billed charges,,,
ROD CURVED TIT ALLOY 4.75MM X 40MM -,SUP-1067.7040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,AETNA [1000108],AETNA [100010801],,,76.8,,851.44,0.518595,35041.66656,percent of total billed charges,,,
ONLAY LYOPLANT 7.5 X 7.5CM -,SUP-1067040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4108.41,2875.887,AETNA [1000108],AETNA [100010801],,,76.8,,3155.26,0.518595,35041.66656,percent of total billed charges,,,
FILLER 10ML OSTEOSPONGE -,SUP-109510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4081.77,2857.239,AETNA [1000108],AETNA [100010801],,,76.8,,3134.8,0.518595,35041.66656,percent of total billed charges,,,
FILLER CANC TRBCLR DBM 15ML CHP OSTEOSPONGE ELAS OSTCONDC -,SUP-109515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA [1000108],AETNA [100010801],,,76.8,,4074.24,0.518595,35041.66656,percent of total billed charges,,,
FILLER DEMIN CANC BN 5ML CHP OSTEOSPONGE ELAS OSTCONDC -,SUP-109550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,,,
GRAFT DEMIN CANC BN BLCK 14MM OSTEOSPONGE ELAS OSTCONDC -,SUP-109614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3437.28,2406.096,AETNA [1000108],AETNA [100010801],,,76.8,,2639.83,0.518595,35041.66656,percent of total billed charges,,,
SUBSTITUTE CORT FBR 10CC 3DEMIN -,SUP-109760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW T15 LP CORT 3.5 X 20MM NS -,SUP-110017720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW T15 LP CORT 3.5 X 22MM NS -,SUP-110017722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW T15 LP CORT 3.5 X 24MM NS -,SUP-110017724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW T15 LP CORT 3.5 X 26MM NS -,SUP-110017726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW T15 LP CORT 3.5 X 30MM NS -,SUP-110017730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW T15 LP CORT 3.5 X 32MM NS -,SUP-110017732,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW T15 LP CORT 3.5 X 34MM NS -,SUP-110017734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW T15 LOW PROFILE CORT 3.5 X 36MM NS -,SUP-110017736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW T15 LOW PROFILE CORT 3.5  X 38MM NS -,SUP-110017738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW T15 LOW PROFILE CORT 3.5 X 40MM NS -,SUP-110017740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW T15 LP CORT 3.5 X 44 NS -,SUP-110017744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW T15 MD 3.5 X 28MM NS -,SUP-110018028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA [1000108],AETNA [100010801],,,76.8,,887.29,0.518595,35041.66656,percent of total billed charges,,,
SCREW T15 LOCK MULTIDIRECTIONAL 3.5 X 34MM NS -,SUP-110018034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA [1000108],AETNA [100010801],,,76.8,,887.29,0.518595,35041.66656,percent of total billed charges,,,
SCREW T15 MULTIDDIRECTIONAL 3.5 X 38MM NS SILVER -,SUP-110018038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA [1000108],AETNA [100010801],,,76.8,,887.29,0.518595,35041.66656,percent of total billed charges,,,
SCREW T15 MULTIDIRECTIONAL 3.5 X 40MM NS SILVER -,SUP-110018040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA [1000108],AETNA [100010801],,,76.8,,887.29,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE T15 MULTIDIRECTIONAL 3.5 X 42MM NS SILVER -,SUP-110018042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA [1000108],AETNA [100010801],,,76.8,,887.29,0.518595,35041.66656,percent of total billed charges,,,
SCREW T15MD 3.5 X 46MM NS -,SUP-110018046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA [1000108],AETNA [100010801],,,76.8,,887.29,0.518595,35041.66656,percent of total billed charges,,,
SCREW T15 MD 3.5 X 52MM NS -,SUP-110018052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA [1000108],AETNA [100010801],,,76.8,,887.29,0.518595,35041.66656,percent of total billed charges,,,
3.2MM PEG 20MM -,SUP-110025320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA [1000108],AETNA [100010801],,,76.8,,564.64,0.518595,35041.66656,percent of total billed charges,,,
3.2MM PEG 24MM -,SUP-110025324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA [1000108],AETNA [100010801],,,76.8,,564.64,0.518595,35041.66656,percent of total billed charges,,,
PEG FIXATION 3.2 X 26MM -,SUP-110025326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA [1000108],AETNA [100010801],,,76.8,,564.64,0.518595,35041.66656,percent of total billed charges,,,
PEG FIXATION 3.2 X 28MM -,SUP-110025328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA [1000108],AETNA [100010801],,,76.8,,564.64,0.518595,35041.66656,percent of total billed charges,,,
3.2MM PEGS 30MM -,SUP-110025330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA [1000108],AETNA [100010801],,,76.8,,564.64,0.518595,35041.66656,percent of total billed charges,,,
PEG 3.2 X 32 -,SUP-110025332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA [1000108],AETNA [100010801],,,76.8,,564.64,0.518595,35041.66656,percent of total billed charges,,,
PEGS 3.2MM X 34MM -,SUP-110025334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA [1000108],AETNA [100010801],,,76.8,,564.64,0.518595,35041.66656,percent of total billed charges,,,
PEG 3.2 X 36MM -,SUP-110025336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA [1000108],AETNA [100010801],,,76.8,,564.64,0.518595,35041.66656,percent of total billed charges,,,
PEG 3.2MM X 38MM -,SUP-110025338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA [1000108],AETNA [100010801],,,76.8,,564.64,0.518595,35041.66656,percent of total billed charges,,,
PEG 3.5 X 40MM -,SUP-110025340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA [1000108],AETNA [100010801],,,76.8,,564.64,0.518595,35041.66656,percent of total billed charges,,,
PEG 3.2 X 42 -,SUP-110025342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA [1000108],AETNA [100010801],,,76.8,,564.64,0.518595,35041.66656,percent of total billed charges,,,
PEG 3.2MM X 44MM -,SUP-110025344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA [1000108],AETNA [100010801],,,76.8,,564.64,0.518595,35041.66656,percent of total billed charges,,,
PEG 3.2 X 46MM -,SUP-110025346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA [1000108],AETNA [100010801],,,76.8,,564.64,0.518595,35041.66656,percent of total billed charges,,,
PEG 3.2 X 50MM -,SUP-110025350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA [1000108],AETNA [100010801],,,76.8,,564.64,0.518595,35041.66656,percent of total billed charges,,,
PEG 3.2 X 52MM -,SUP-110025352,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA [1000108],AETNA [100010801],,,76.8,,564.64,0.518595,35041.66656,percent of total billed charges,,,
PEG 3.2MM X 54MM -,SUP-110025354,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA [1000108],AETNA [100010801],,,76.8,,564.64,0.518595,35041.66656,percent of total billed charges,,,
PEG 3.2 X 56 -,SUP-110025356,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA [1000108],AETNA [100010801],,,76.8,,564.64,0.518595,35041.66656,percent of total billed charges,,,
PEG 3.2 X 58MM -,SUP-110025358,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA [1000108],AETNA [100010801],,,76.8,,564.64,0.518595,35041.66656,percent of total billed charges,,,
3.2MM PEG 60MM -,SUP-110025360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA [1000108],AETNA [100010801],,,76.8,,564.64,0.518595,35041.66656,percent of total billed charges,,,
PEG 3.2 X 65MM -,SUP-110025365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA [1000108],AETNA [100010801],,,76.8,,564.64,0.518595,35041.66656,percent of total billed charges,,,
PLATE PRX HUM LO LT 3H 73MM -,SUP-110030100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6671.57,4670.099,AETNA [1000108],AETNA [100010801],,,76.8,,5123.77,0.518595,35041.66656,percent of total billed charges,,,
PRX HUM LO PLT LT 7H 133MM -,SUP-110030102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8021.16,5614.812,AETNA [1000108],AETNA [100010801],,,76.8,,6160.25,0.518595,35041.66656,percent of total billed charges,,,
PRX HUM HI PLTLT 3H 80MM -,SUP-110030300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6569.71,4598.797,AETNA [1000108],AETNA [100010801],,,76.8,,5045.54,0.518595,35041.66656,percent of total billed charges,,,
PRX HUM HI PLT RT 3H 80MM -,SUP-110030400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6569.71,4598.797,AETNA [1000108],AETNA [100010801],,,76.8,,5045.54,0.518595,35041.66656,percent of total billed charges,,,
PLATE PRX HUM HI RT 4H 90MM -,SUP-110030401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6824.35,4777.045,AETNA [1000108],AETNA [100010801],,,76.8,,5241.1,0.518595,35041.66656,percent of total billed charges,,,
REFOBACIN BONE CEMENT R 1X14 US -,SUP-110034355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,76.8,,806.63,0.518595,35041.66656,percent of total billed charges,,,
COMPR NANO 7IN STEINMANN PIN -,SUP-110045821,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3246.32,2272.424,AETNA [1000108],AETNA [100010801],,,76.8,,2493.17,0.518595,35041.66656,percent of total billed charges,,,
GRAFT PLATE CANOPY INLINE 7MM -,SUP-1102.1007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,,,
SCREW FIXATION VARIABLE ANGLE -,SUP-111655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1457.21,1020.047,AETNA [1000108],AETNA [100010801],,,76.8,,1119.14,0.518595,35041.66656,percent of total billed charges,,,
CAP SPIN CREO 5.5MM -,SUP-1119.0000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,,,
CREO THREADED LOCKING CAP -,SUP-1119.0010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,,,
CONNECTOR CROSS 38-50 LONG 5.5 CREO -,SUP-1119.0039,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
CREO 5.5 CROSS CONNECTOR 48-60MM LONG -,SUP-1119.0046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
TULIP HEAD FOR CORTICAL SCREW -,SUP-1119.0100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,,,
CONNECTOR CREO 5.5 LOW PROFILE CROSS  21.5-25MM LONG -,SUP-1119.0221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
CREO 5.5 LOW PROFILE CROSS CONN- 24.5-31MM LONG -,SUP-1119.0224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL 5.5-4.5X25MM MOD CREO AMP -,SUP-1119.1325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
5.5-4.5 X 30MM CREO MCS SCREW -,SUP-1119.1330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5 4.5 X 35MM CORTICAL MODULAR CREO AMP -,SUP-1119.1335,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL 6.0-5.0 X 30ML -,SUP-1119.1430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
6.0-5.0 X 35MM CORTICAL SCREW -,SUP-1119.1435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORITICAL 6.5-5.5X35MM -,SUP-1119.1535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL 6.5-5.5X35MM -,SUP-1119.1535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
ROD 5.5 X 35 TITANIUM ALLOY -,SUP-1119.5035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,,,
ROD STRAIGHT 5.5MM X 40 -,SUP-1119.5040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,,,
ROD TITANIUM ALLOY 5.5 X 45 STRAIGHT -,SUP-1119.5045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,,,
ROD 150MM -,SUP-1119.5150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN CREO 5.5X35MM CRV TI ALY THORLUM -,SUP-1119.7035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,,,
5.5MM CURVED ROD TITANIUM ALLOY 40MM LENGTH -,SUP-1119.7040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,,,
ROD CREO 5.5X40MM -,SUP-1119.7040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,,,
ROD CURVED 5.5MM TITANIUM ALLOY 45MM LENGTH -,SUP-1119.7045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN CREO 5.5X50MM CRV TI ALY THORLUM -,SUP-1119.7050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN CREO 5.5X55MM CRV TI ALY THORLUM -,SUP-1119.7055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,,,
ROD CURVED 5.5MM TITANIUM ALLOY 60MM LENGTH -,SUP-1119.7060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,,,
ROD 5.5MM CURVED TIT ALLOY 65MM -,SUP-1119.7065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,,,
ROD CURVED 5.5MM TITANIUM ALLOY 70MM LENGTH -,SUP-1119.7070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,,,
ROD CURVED 5.5MM TITANIUM ALLOY 80MM LENGTH -,SUP-1119.7080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,,,
SCREW LCK EXPLOR TI ALY -,SUP-11-210099,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,AETNA [1000108],AETNA [100010801],,,76.8,,725.97,0.518595,35041.66656,percent of total billed charges,,,
PELVIC ARRAY -,SUP-112230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5393.06,3775.142,AETNA [1000108],AETNA [100010801],,,76.8,,4141.87,0.518595,35041.66656,percent of total billed charges,,,
STEM TPR DIST SPR 14 X 150MM ARCOS -,SUP-11-300814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,AETNA [1000108],AETNA [100010801],,,76.8,,11360.71,0.518595,35041.66656,percent of total billed charges,,,
STEM TPR DIST SPR 16 X 150MM ARCOS -,SUP-11-300816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,AETNA [1000108],AETNA [100010801],,,76.8,,11360.71,0.518595,35041.66656,percent of total billed charges,,,
CAP LOCKING CREO MIS -,SUP-1134.0010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,,,
TULIP MODULAR POLYAXIAL 30MM REDUCTION CREO MIS -,SUP-1134.0100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,,,
ROD CURVED 5.5MM X 50MM TITANIUM ALLOY CREO MIS -,SUP-1134.7050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,,,
HEAD MOD 36MM COCR STD -,SUP-11-363662,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,0.518595,35041.66656,percent of total billed charges,,,
COMP 44MM GLOBAL AP SHLDR 3MM XLPE PG -,SUP-1136-41-026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8667.95,6067.565,AETNA [1000108],AETNA [100010801],,,76.8,,6656.99,0.518595,35041.66656,percent of total billed charges,,,
COMP 52MM GLOBAL AP SHLDR 3MM XLPE PG -,SUP-1136-43-026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10652.6,7456.82,AETNA [1000108],AETNA [100010801],,,76.8,,8181.2,0.518595,35041.66656,percent of total billed charges,,,
MITRIS RESILIA MITRAL VALVE 25MM -,SUP-11400M25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,AETNA [1000108],AETNA [100010801],,,76.8,,24238.46,0.518595,35041.66656,percent of total billed charges,,,
MITRIS RESILIA MITRAL VALVE 27MM -,SUP-11400M27,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,AETNA [1000108],AETNA [100010801],,,76.8,,24238.46,0.518595,35041.66656,percent of total billed charges,,,
MITRIS RESILIA MITRAL VALVE 29MM -,SUP-11400M29,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,AETNA [1000108],AETNA [100010801],,,76.8,,24238.46,0.518595,35041.66656,percent of total billed charges,,,
MITRIS RESILIA MITRAL VALVE 31MM -,SUP-11400M31,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,AETNA [1000108],AETNA [100010801],,,76.8,,24238.46,0.518595,35041.66656,percent of total billed charges,,,
THUMBSCREW FOR C501 ROCHE CUVETTE -,SUP-11406701001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,140.74,98.518,AETNA [1000108],AETNA [100010801],,,76.8,,108.09,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7.5MMX100MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT NS. -,SUP-1147-100-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7.5MMX100MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUTNS.. -,SUP-1147-100-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,,,
GUIDEPIN ORTHO 3.2X353MM THRD -,SUP-115163,CDM,C1713,HCPCS,278,RC,,,outpatient,,,307.85,215.495,AETNA [1000108],AETNA [100010801],,,76.8,,236.43,0.518595,35041.66656,percent of total billed charges,,,
SCREW COMP RVS CONTROL 6.5 X 20MM ST -,SUP-115380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW COMP RVS CONTROL 6.5 X 30MM ST -,SUP-115382,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X35MM CORT RVRS CNTRL 3.5MM HEX DRV HEX HEAD TI ALY -,SUP-115383,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
COMP RVS CNTRL 6.5 X 20MM ST/RST -,SUP-115394,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
COMP RVS CNTRL 6.5 X 25MM ST/RST -,SUP-115395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X25MM CORT RVRS CNTRL 3.5MM HEX DRV HEX HEAD TI ALY -,SUP-115395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
6.5 X 30MM CENTRAL SCREW -,SUP-115396,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
REVERSE CENTRAL SHOULDER SCREW 3.5MM X 35MM -,SUP-115397,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
COMP RVS CNTRL 6.5 X 40MM ST/RST -,SUP-115398,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
COMP RVS CNTRL 6.5 X 45MM ST/RST -,SUP-115399,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
SPACER ANT THORLUM VERT 14MMX15-18MMH XPAND 0DG SM 12MM OPN -,SUP-116.101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14881.7,10417.19,AETNA [1000108],AETNA [100010801],,,76.8,,11429.15,0.518595,35041.66656,percent of total billed charges,,,
SPACER ANT THORLUM VERT 21X23MMX37-46MM XPAND 0DG MED OPN TI -,SUP-116.207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16864.45,11805.115,AETNA [1000108],AETNA [100010801],,,76.8,,12951.9,0.518595,35041.66656,percent of total billed charges,,,
SPACER ANT THORLUM VERT 21X23MMX49-70MM XPAND 0DG MED OPN TI -,SUP-116.208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16864.45,11805.115,AETNA [1000108],AETNA [100010801],,,76.8,,12951.9,0.518595,35041.66656,percent of total billed charges,,,
CATH ANGIOPLASTIC MARINER BERENSTEIN 4FR 100CM -,SUP-11714016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA [1000108],AETNA [100010801],,,76.8,,241.99,0.518595,35041.66656,percent of total billed charges,,,
SING HEAD OPEN LAT CONN 5.5-6.0 HEAD-5.5-6.35 OPEN 12MM WIDE -,SUP-1175.9214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7265.73,5086.011,AETNA [1000108],AETNA [100010801],,,76.8,,5580.08,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN MOUNTAINEER 3.5-5.5X420MM CRV TI OCT LVL1 NS -,SUP-1183-11-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR LD SWIFT- LOCK SPIN CRD MECH LCK -,SUP-1192,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM-THRD -,SUP-121107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,AETNA [1000108],AETNA [100010801],,,76.8,,2695.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM THRD_ -,SUP-121108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,AETNA [1000108],AETNA [100010801],,,76.8,,2695.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM THRD- -,SUP-121109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,AETNA [1000108],AETNA [100010801],,,76.8,,2695.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM THRD. -,SUP-121110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,AETNA [1000108],AETNA [100010801],,,76.8,,2695.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW 19MM COMPR LAG AMBI CLASSIC IMHS 21MM THRD STD 3.5MM -,SUP-121116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,781.07,546.749,AETNA [1000108],AETNA [100010801],,,76.8,,599.86,0.518595,35041.66656,percent of total billed charges,,,
12MM ROD -,SUP-12-1120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X25MM CANN 19MM THRD SD/ST REVCT FLUT SS -,SUP-121625,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X30MM CANN 16MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X35MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121627,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X40MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X45MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121629,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X50MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X55MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121631,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X60MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X65MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121633,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X70MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X75MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X80MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X85MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121637,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X90MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5 CANNULATED 9.5 -,SUP-121639,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X100MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X105MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121641,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X110MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X115MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121643,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X120MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,,,
WASHER ORTHO 6.5X12.7MM F/7MM CANN BN SCR RND STRL -,SUP-121680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.23,451.661,AETNA [1000108],AETNA [100010801],,,76.8,,495.54,0.518595,35041.66656,percent of total billed charges,,,
SCREW ACTB 6.5X30MM GRIFTON PINNCL LCK TI FOAM DOME ST -,SUP-1217-30-500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,537.46,376.222,AETNA [1000108],AETNA [100010801],,,76.8,,412.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX10MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX12MM CANN 5MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX14MM CANN 5MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX16MM CANN 6MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX18MM CANN 7MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX22MM CANN 9MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX24MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX26MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX28MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX30MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121830,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX32MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX34MM CANN 14MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121834,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX36MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121836,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX38MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121838,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX40MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX42MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121842,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX44MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121844,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX46MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX48MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121848,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX50MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121850,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX52MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121852,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX54MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121854,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX56MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121856,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX58MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121858,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANNULATED 4.0M X 60M -,SUP-121860,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX65MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX70MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121870,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA [1000108],AETNA [100010801],,,76.8,,1780.85,0.518595,35041.66656,percent of total billed charges,,,
30MM CROSSLINK -,SUP-12-2052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
CATALYST R1 6.5MM CENTER SCREW AND CAP SIZE 30 -,SUP-1230-7508-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,,,
CATALYST R1 4.5MM LOCKING SCREW SIZE 20 -,SUP-1230-7511-003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
CATALYST R1 4.5MM LOCKING SCREW SIZE 24 -,SUP-1230-7511-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
CATALYST R1 GLENOSPHERE LOCKING SCREW IMPLANT -,SUP-1230-7515-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
LINER INSERT MDM X3 22.2MM ID X 36MM OD X 36C -,SUP-1236-2-242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,0.518595,35041.66656,percent of total billed charges,,,
ENDCAP SPIN REVERE -,SUP-124.000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,,,
REV LOW PROF ADJ T-CONN 29 X 34 -,SUP-124.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X25MM REVERE DBL LD THRD POLYAX F/5.5MM TI -,SUP-124.051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X30MM REVERE DL HEAD THRD POLYAX F/5.5MM TI -,SUP-124.052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI -,SUP-124.053,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X35MM REVERE DEFRM MONOAX -,SUP-124.263,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X40MM REVERE DEFRM MONOAX -,SUP-124.264,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7.5X35MM REVERE DEFRM MONOAX -,SUP-124.273,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X30MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.443,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
4.5MM REVERE PEDICLE SCREW 45MM -,SUP-124.445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5X30MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.452,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.453,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5X40MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.454,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5X45MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5X50MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.456,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5X55MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.457,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X30MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.462,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.463,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X40MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.464,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X45MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X50MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.466,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X55MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.467,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X60MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.468,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X65MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.469,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7.5X40MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.474,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN REVERE DEFRM 5.5X100MM STR TI LPRO THORLUM NTHRD -,SUP-124.510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
5.5MM STRAIGHT ROD 125MM -,SUP-124.512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN REVERE DEFRM 5.5X150MM STR TI LPRO THORLUM NTHRD -,SUP-124.515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
5.5MM STRAIGHT ROD 400MM -,SUP-124.520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
ROD STRAIGHT 5.5 X 500 -,SUP-124.521,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN REVERE DEFRM 5.5X45MM STR TI LPRO THORLUM NTHRD LCK -,SUP-124.545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN REVERE DEFRM 5.5X85MM STR TI LPRO THORLUM NTHRD LCK -,SUP-124.585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
5.5MM CURVED ROD 125MM -,SUP-124.612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN REVERE DEFRM 5.5X35MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN REVERE DEFRM 5.5X40MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN REVERE DEFRM 5.5X45MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN REVERE DEFRM 5.5X50MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN REVERE DEFRM 5.5X55MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN REVERE DEFRM 5.5X60MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN REVERE DEFRM 5.5X65MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN REVERE DEFRM 5.5X75MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6MM DL OD 35MM REVERE POLYAX CORT/CANC F/5.5MM TI ALY -,SUP-124.762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6MM DL OD 40MM REVERE POLYAX CORT/CANC F/5.5MM TI ALY -,SUP-124.763,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
CONNECTOR ROD REVERE 5.5MM VARIABLE CROSS 38MM-50MM -,SUP-124.984,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3327.48,2329.236,AETNA [1000108],AETNA [100010801],,,76.8,,2555.5,0.518595,35041.66656,percent of total billed charges,,,
5.5MM CLOSED OFFSET CONNECTOR 5.5MM ROD 30MM -,SUP-124.993,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,AETNA [1000108],AETNA [100010801],,,76.8,,1567.25,0.518595,35041.66656,percent of total billed charges,,,
ELIMINATOR ACTB THRD POS STP F/CUP DURALOC -,SUP-1246-03-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
OSTEOAMP GRANULES 1CC -,SUP-12600201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2340.97,1638.679,AETNA [1000108],AETNA [100010801],,,76.8,,1797.86,0.518595,35041.66656,percent of total billed charges,,,
OSTEOAMP GRANULES 5CC -,SUP-12600401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4725.27,3307.689,AETNA [1000108],AETNA [100010801],,,76.8,,3629.01,0.518595,35041.66656,percent of total billed charges,,,
OSTEOAMP GRANULES 10CC -,SUP-12600501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7875.46,5512.822,AETNA [1000108],AETNA [100010801],,,76.8,,6048.35,0.518595,35041.66656,percent of total billed charges,,,
OSTEOAMP GRANULES 2-4MM (5CC) -,SUP-12700401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4587.68,3211.376,AETNA [1000108],AETNA [100010801],,,76.8,,3523.34,0.518595,35041.66656,percent of total billed charges,,,
GUIDEPIN ORTHO 1.3MMX15CM THRD TROC TIP -,SUP-128047,CDM,C1713,HCPCS,278,RC,,,outpatient,,,305.64,213.948,AETNA [1000108],AETNA [100010801],,,76.8,,234.73,0.518595,35041.66656,percent of total billed charges,,,
STAPLE BN FX XS COCR -,SUP-128690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2676.59,1873.613,AETNA [1000108],AETNA [100010801],,,76.8,,2055.62,0.518595,35041.66656,percent of total billed charges,,,
STAPLE BN FX SM COCR -,SUP-128692,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2676.59,1873.613,AETNA [1000108],AETNA [100010801],,,76.8,,2055.62,0.518595,35041.66656,percent of total billed charges,,,
RESTRICTOR BNCMNT FMCNL 25MM BUCK -,SUP-129419,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1159.24,811.468,AETNA [1000108],AETNA [100010801],,,76.8,,890.3,0.518595,35041.66656,percent of total billed charges,,,
UNITED HIP SYSTEM FULL XPE CUP 36MM X 54MM -,SUP-1302-3654,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA [1000108],AETNA [100010801],,,76.8,,7414.12,0.518595,35041.66656,percent of total billed charges,,,
STAPLE SPIN RSTRL SM TI -,SUP-131.001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4759.68,3331.776,AETNA [1000108],AETNA [100010801],,,76.8,,3655.43,0.518595,35041.66656,percent of total billed charges,,,
STAPLE SPIN CDL SM TI -,SUP-131.002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4759.68,3331.776,AETNA [1000108],AETNA [100010801],,,76.8,,3655.43,0.518595,35041.66656,percent of total billed charges,,,
STAPLE SPIN ANT VERT SM TI -,SUP-131.011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3413.41,2389.387,AETNA [1000108],AETNA [100010801],,,76.8,,2621.5,0.518595,35041.66656,percent of total billed charges,,,
CONNECTOR SPIN REVERE DL CX 15MM TI -,SUP-131.115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
CONNECTOR SPIN CX TI -,SUP-131.116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.5X35MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,AETNA [1000108],AETNA [100010801],,,76.8,,725.97,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.5X40MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,AETNA [1000108],AETNA [100010801],,,76.8,,725.97,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.5X18MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,AETNA [1000108],AETNA [100010801],,,76.8,,725.97,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.5X24MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,AETNA [1000108],AETNA [100010801],,,76.8,,725.97,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN TMX 12.9MMX43.7MM COMPR HI STRGTH 2D CONTR LCK Y -,SUP-1312-17-003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2534.99,1774.493,AETNA [1000108],AETNA [100010801],,,76.8,,1946.87,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN F 3 13MMX42.7MM HI FLEX 3D CONTR LCK NS RT -,SUP-131217100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2778.47,1944.929,AETNA [1000108],AETNA [100010801],,,76.8,,2133.86,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN F 3 13MMX42.7MM HI FLEX 3D CONTR LCK NS LT -,SUP-131217101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2778.47,1944.929,AETNA [1000108],AETNA [100010801],,,76.8,,2133.86,0.518595,35041.66656,percent of total billed charges,,,
WASHER ORTHO 3.5MM ALPS F/ELB PLATE SYS NS -,SUP-131218000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA [1000108],AETNA [100010801],,,76.8,,322.65,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X14MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA [1000108],AETNA [100010801],,,76.8,,322.65,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X16MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA [1000108],AETNA [100010801],,,76.8,,322.65,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X28MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA [1000108],AETNA [100010801],,,76.8,,322.65,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X30MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA [1000108],AETNA [100010801],,,76.8,,322.65,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X36MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA [1000108],AETNA [100010801],,,76.8,,322.65,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X40MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA [1000108],AETNA [100010801],,,76.8,,322.65,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X44MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA [1000108],AETNA [100010801],,,76.8,,322.65,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X48MM NLCKG CORT ALPS TRNCT SQ DRV TMX NS -,SUP-131218048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA [1000108],AETNA [100010801],,,76.8,,322.65,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X50MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA [1000108],AETNA [100010801],,,76.8,,322.65,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X60MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA [1000108],AETNA [100010801],,,76.8,,322.65,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X70MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA [1000108],AETNA [100010801],,,76.8,,322.65,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN ALPS 10.7X85MM 9HL 2.4MM CONTR LCK TMX ANTMC -,SUP-131218203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN ALPS 17.5X29MM 1.5MM CONTR LCK TMX SM ANTMC NS -,SUP-131218400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3637.79,2546.453,AETNA [1000108],AETNA [100010801],,,76.8,,2793.82,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN SM -,SUP-1312-18-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4024.48,2817.136,AETNA [1000108],AETNA [100010801],,,76.8,,3090.8,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN ALPS 81X10IN 10HL CONTR LCK COMPR TMX SM ANTMC NS -,SUP-131218600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,AETNA [1000108],AETNA [100010801],,,76.8,,3629.77,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN ALPS 10.7X154MM 17HL 2.5MM CONTR LCK COMPR TMX LNG -,SUP-131218607,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4481.66,3137.162,AETNA [1000108],AETNA [100010801],,,76.8,,3441.91,0.518595,35041.66656,percent of total billed charges,,,
WASHER ORTHO 2.5MM ALPS THRD -,SUP-131220025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,76.8,,188.21,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN ALPS 2.5MM PRCONT LCK COMPR TMX T-SHP ANTMC NS -,SUP-131220152,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2353.42,1647.394,AETNA [1000108],AETNA [100010801],,,76.8,,1807.43,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN ALPS 2.5MM PRCONT LCK COMPR TMX SM T-SHP ANTMC NS -,SUP-131220157,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2099,1469.3,AETNA [1000108],AETNA [100010801],,,76.8,,1612.03,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN ALPS 2.5MM PRCONT LCK COMPR TMX STR ANTMC NS -,SUP-131220251,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2448.83,1714.181,AETNA [1000108],AETNA [100010801],,,76.8,,1880.7,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN ALPS 27.6MMX73.8MM 2.5MM 1.65MM PRCONT LCK COMPR -,SUP-131220252,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2448.83,1714.181,AETNA [1000108],AETNA [100010801],,,76.8,,1880.7,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN ALPS 19.5MMX71.8MM 2.5MM 1.65MM PRCONT LCK COMPR -,SUP-131220253,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2448.83,1714.181,AETNA [1000108],AETNA [100010801],,,76.8,,1880.7,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.5X11MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,76.8,,403.32,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.5X14MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,76.8,,403.32,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.5X15MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220415,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,76.8,,403.32,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.5X16MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,76.8,,403.32,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.5X12MM NLCKG CORT ALPS ST MULDIR MODULAR SQ DRV TMX -,SUP-131220512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,76.8,,403.32,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.5X14MM NLCKG CORT ALPS ST MULDIR MODULAR SQ DRV TMX -,SUP-131220514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,76.8,,403.32,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.5X15MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,76.8,,403.32,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.5X16MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,76.8,,403.32,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.5X18MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,76.8,,403.32,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.5X20MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,76.8,,403.32,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.7X18MM LCK SMTH DVR -,SUP-131227118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X20MM LCK CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X22MM LCK CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X14MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA [1000108],AETNA [100010801],,,76.8,,322.65,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X15MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227215,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA [1000108],AETNA [100010801],,,76.8,,322.65,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X16MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA [1000108],AETNA [100010801],,,76.8,,322.65,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X26MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227226,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA [1000108],AETNA [100010801],,,76.8,,322.65,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN DVR 24X85MM F/CROSSLOCK DIST RAD PLATE SYS LNG LCK -,SUP-131812090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4558.06,3190.642,AETNA [1000108],AETNA [100010801],,,76.8,,3500.59,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN MARS 5.5X45MM CRV CONE TIP TI ANT LMBR -,SUP-132.145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4334.79,3034.353,AETNA [1000108],AETNA [100010801],,,76.8,,3329.12,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN MARS 5.5X50MM CRV CONE TIP TI ANT LMBR -,SUP-132.150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN MARS 5.5X55MM CRV CONE TIP TI ANT LMBR -,SUP-132.155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4334.79,3034.353,AETNA [1000108],AETNA [100010801],,,76.8,,3329.12,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN MARS 5.5X60MM CRV CONE TIP TI ANT LMBR -,SUP-132.160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,0.518595,35041.66656,percent of total billed charges,,,
SCREW REVIEVE 2.2MM X 6MM SELF TAPPING -,SUP-136.506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1235.02,864.514,AETNA [1000108],AETNA [100010801],,,76.8,,948.5,0.518595,35041.66656,percent of total billed charges,,,
FEMORAL HEAD BIOLOX 32MM +5 12 -,SUP-1365-32-720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5432.32,3802.624,AETNA [1000108],AETNA [100010801],,,76.8,,4172.02,0.518595,35041.66656,percent of total billed charges,,,
FEMORAL HEAD BIOLOX DELTA TS CERAMIC  36MM +1.5 12/14 TAPER -,SUP-1365-36-710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5432.32,3802.624,AETNA [1000108],AETNA [100010801],,,76.8,,4172.02,0.518595,35041.66656,percent of total billed charges,,,
CERAMIC FEMORAL HEAD 40MM X 1.5 BIOLOX DELTA TS -,SUP-1365-40-710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,0.518595,35041.66656,percent of total billed charges,,,
FORTIFY I 12MM UPPER ENDPLATE 12 X 14MM 0 DEG -,SUP-137.300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,AETNA [1000108],AETNA [100010801],,,76.8,,2753.49,0.518595,35041.66656,percent of total billed charges,,,
FORTIFY I 12MM UPPER ENDPLATE 12 X 14MM 3.5 DEG -,SUP-137.301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,AETNA [1000108],AETNA [100010801],,,76.8,,2753.49,0.518595,35041.66656,percent of total billed charges,,,
FORTIFY I 12MM LOWER ENDPLATE 12 X 14MM 0 DEG -,SUP-137.350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,AETNA [1000108],AETNA [100010801],,,76.8,,2753.49,0.518595,35041.66656,percent of total billed charges,,,
FORTIFY I 12MM LOWER ENDPLAE 12 X 14MM 3.5 DEG -,SUP-137.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,AETNA [1000108],AETNA [100010801],,,76.8,,2753.49,0.518595,35041.66656,percent of total billed charges,,,
FORTIFY I 12MM LOWER ENDPLATE 12 X 14MM 3.5 DEG -,SUP-137.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,AETNA [1000108],AETNA [100010801],,,76.8,,2753.49,0.518595,35041.66656,percent of total billed charges,,,
KT BONE CMNT 2.5% GENT40 GM CEMEX GENTA RX STRL -,SUP-1400-AG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,0.518595,35041.66656,percent of total billed charges,,,
GUIDEPIN ORTHO 3.2MM STNMN 14IN THRD -,SUP-14012-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,213.27,149.289,AETNA [1000108],AETNA [100010801],,,76.8,,163.79,0.518595,35041.66656,percent of total billed charges,,,
GUIDEPIN ORTHO 3.2MMX9IN THRD -,SUP-140129,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X52MM CORT VERSANAIL FT ST NON-DRV END SLD HEX HEAD -,SUP-14022-52,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA [1000108],AETNA [100010801],,,76.8,,241.99,0.518595,35041.66656,percent of total billed charges,,,
SCREW AUTOFIX 2.0 X 10MM -,SUP-141-2010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,,,
SCREW  AUTOFIX 2.0 X 12MM -,SUP-141-2012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,,,
AUTOFIX HEADLESS SCREW 2.0 X 13 -,SUP-141-2013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,,,
SCREW AUTOFIX HEADLESS 2.0 X 13 -,SUP-141-2013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,AETNA [1000108],AETNA [100010801],,,76.8,,954.6,0.518595,35041.66656,percent of total billed charges,,,
SCREW AUTOFIX HEADLESS 2.0 X 14 -,SUP-141-2014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANNULATED 2.0 X 15MM -,SUP-141-2015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,,,
SCREW AUTOFIX 2.0 X 16 -,SUP-141-2016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,AETNA [1000108],AETNA [100010801],,,76.8,,954.6,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2X17MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD MOD -,SUP-1412017,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,AETNA [1000108],AETNA [100010801],,,76.8,,954.6,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2X18MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD MOD -,SUP-141-2018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,AETNA [1000108],AETNA [100010801],,,76.8,,954.6,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANNULATED 2.0 X 19MM -,SUP-141-2019,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,,,
SCREW AUTOFIX COMPRESSION 2.0 X 20MM -,SUP-141-2020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,,,
SCREW AUTOFIX 2.0 X 21MM -,SUP-141-2021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,,,
SCREW AUTOFIX 2.5 X 23MM -,SUP-141-2023,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,,,
SCREW AUTOFIX 2.5 X 24MM -,SUP-141-2024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,AETNA [1000108],AETNA [100010801],,,76.8,,954.6,0.518595,35041.66656,percent of total billed charges,,,
AUTOFIX SCREW 2.0 X 25MM -,SUP-141-2025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,,,
SCREW AUTOFIX 2.0 X 26MM -,SUP-141-2026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,,,
SCREW AUTOFIX 2.5 X 28MM -,SUP-141-2028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,,,
AUTOFIX 2.0 X 29MM SCREW -,SUP-141-2029,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,,,
SCREW AUTOFIX COMPRESSION 2.0 X 30MM -,SUP-141-2030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,,,
SCREW AUTOFIX 2.5 X 10 -,SUP-141-2510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,,,
SCREW AUTOFIX HEADLESS 2.5 X 14 -,SUP-141-2514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANNULATED 25 X 15MM -,SUP-141-2515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,,,
AUTOFIX 2.0/2.5 16MM -,SUP-141-2516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEADLESS 2.5 X 17MM -,SUP-141-2517,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,,,
SCREW AUTOFIX 2.5 X 18MM -,SUP-141-2518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,,,
SCREW AUTOFIX 2.5 X 19 -,SUP-141-2519,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,,,
SCREW AUTOFIX 2.5 X 21MM -,SUP-141-2521,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,,,
AUTOFIX 2.0/2.5 23MM -,SUP-141-2523,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5X24MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD -,SUP-1412524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,AETNA [1000108],AETNA [100010801],,,76.8,,954.6,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEADLESS 2.5 X 25MM -,SUP-141-2525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEADLESS 2.5 X 26MM -,SUP-141-2526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,AETNA [1000108],AETNA [100010801],,,76.8,,954.6,0.518595,35041.66656,percent of total billed charges,,,
AUTOFIX 2.5/2.5 27MM -,SUP-141-2527,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,AETNA [1000108],AETNA [100010801],,,76.8,,954.6,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEADLESS 2.5 X 28MM -,SUP-141-2528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,AETNA [1000108],AETNA [100010801],,,76.8,,954.6,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5X30MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD -,SUP-141-2529,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5X30MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD -,SUP-1412530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE 2.5MM 30MM AUTOFIX STAINLESS STEEL T7 FOOT ANKLE -,SUP-141-2530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA [1000108],AETNA [100010801],,,76.8,,954.55,0.518595,35041.66656,percent of total billed charges,,,
WASHER ORTHO 8MM TI -,SUP-14191,CDM,C1713,HCPCS,278,RC,,,outpatient,,,175.05,122.535,AETNA [1000108],AETNA [100010801],,,76.8,,134.44,0.518595,35041.66656,percent of total billed charges,,,
SCREW 8X100MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA [1000108],AETNA [100010801],,,76.8,,1196.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW 8X105MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA [1000108],AETNA [100010801],,,76.8,,1196.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW 8X110MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA [1000108],AETNA [100010801],,,76.8,,1196.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW 8X40MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA [1000108],AETNA [100010801],,,76.8,,1196.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW 8X45MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA [1000108],AETNA [100010801],,,76.8,,1196.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW 8X50MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA [1000108],AETNA [100010801],,,76.8,,1196.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW 8X55MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA [1000108],AETNA [100010801],,,76.8,,1196.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW 8X60MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA [1000108],AETNA [100010801],,,76.8,,1196.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW 8X65MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA [1000108],AETNA [100010801],,,76.8,,1196.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW 8X70MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA [1000108],AETNA [100010801],,,76.8,,1196.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW 8X75MM CANN LAG CANC ACE THRD SD/ST CUT FLUTX4 TMX NS -,SUP-14192-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA [1000108],AETNA [100010801],,,76.8,,1196.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW 8X85MM CANN LAG CANC ACE 24MM THRD SD/ST CUT FLUTX4 -,SUP-14192-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA [1000108],AETNA [100010801],,,76.8,,1196.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW 8X90MM CANN LAG CANC ACE 24MM THRD SD/ST CUT FLUTX4 -,SUP-14192-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA [1000108],AETNA [100010801],,,76.8,,1196.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW 8X95MM CANN LAG CANC ACE 24MM THRD SD/ST CUT FLUTX4 -,SUP-14192-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA [1000108],AETNA [100010801],,,76.8,,1196.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X100MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X105MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X110MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X115MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X120MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X25MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X30MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X35MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X40MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X45MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X50MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X55MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X60MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X65MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X70MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X75MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X80MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X85MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X90MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X95MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X100MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X105MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT -,SUP-14197-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X110MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT -,SUP-14197-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X40MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X45MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X50MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X55MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X60MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X65MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X70MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X75MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X80MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X85MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X90MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X95MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,,,
PRECISION PIN TM TAPERED D3.2/3.9X450MM -,SUP-1420-0065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X20MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X22MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X24MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X26MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X28MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X30MM CANNULATEDLAG CORT FT TMX NS -,SUP-14200-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X32MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X34MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X36MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X38MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X40MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X42MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X44MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X46MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X48MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X50MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X55MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X60MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X65MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X70MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X36MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-14223036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X30MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14250-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X32MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X34MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X36MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X38MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X40MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X42MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X44MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X46MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14250-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X48MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14250-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X50MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X55MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X60MM CANN LAG CORT 20MM FT SD/ST BIOCMPT TMX NS -,SUP-14250-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X65MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X70MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,,,
WASHER ORTHO F/4.5-5.0MM CANN SCR SYS FLT -,SUP-14260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,504.67,353.269,AETNA [1000108],AETNA [100010801],,,76.8,,387.59,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 10HL 100DG TBLR -,SUP-14355-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,557.3,390.11,AETNA [1000108],AETNA [100010801],,,76.8,,428.01,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN ALPS 9.2X49MM 3.5MM 4HL 1.3MM LCK TI 100DG ANG TBLR -,SUP-143554,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,AETNA [1000108],AETNA [100010801],,,76.8,,376.43,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN ALPS 9.2X73MM 3.5MM 6HL LCK COMPR TMX ANTMC THRD HL -,SUP-143556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA [1000108],AETNA [100010801],,,76.8,,457.09,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN ALPS 9.2X85MM 3.5MM 7HL LCK TI ANTMC NS -,SUP-143557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA [1000108],AETNA [100010801],,,76.8,,457.09,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN ALPS 9.2X97MM 3.5MM 8HL LCK TI 100DG ANG TBLR ANTMC -,SUP-143558,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA [1000108],AETNA [100010801],,,76.8,,457.09,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X14MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA [1000108],AETNA [100010801],,,76.8,,833.52,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X16MM CANC -,SUP-14376-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,977.89,684.523,AETNA [1000108],AETNA [100010801],,,76.8,,751.02,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X24MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA [1000108],AETNA [100010801],,,76.8,,833.52,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X34MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-1437634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA [1000108],AETNA [100010801],,,76.8,,833.52,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X40MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA [1000108],AETNA [100010801],,,76.8,,833.52,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X42MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA [1000108],AETNA [100010801],,,76.8,,833.52,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X44MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA [1000108],AETNA [100010801],,,76.8,,833.52,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X46MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA [1000108],AETNA [100010801],,,76.8,,833.52,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X48MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA [1000108],AETNA [100010801],,,76.8,,833.52,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X50MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA [1000108],AETNA [100010801],,,76.8,,833.52,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X55MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA [1000108],AETNA [100010801],,,76.8,,833.52,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X60MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA [1000108],AETNA [100010801],,,76.8,,833.52,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X65MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA [1000108],AETNA [100010801],,,76.8,,833.52,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X70MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA [1000108],AETNA [100010801],,,76.8,,833.52,0.518595,35041.66656,percent of total billed charges,,,
BONE PIN- 4 x 110MM- STERILE (2 Pack) -,SUP-144110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,AETNA [1000108],AETNA [100010801],,,76.8,,494.15,0.518595,35041.66656,percent of total billed charges,,,
BONE PIN- 4 x 140MM- STERILE (2 Pack) -,SUP-144140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,AETNA [1000108],AETNA [100010801],,,76.8,,494.15,0.518595,35041.66656,percent of total billed charges,,,
BONE PIN- 4 x 170MM- STERILE (2 Pack) -,SUP-144170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,AETNA [1000108],AETNA [100010801],,,76.8,,494.15,0.518595,35041.66656,percent of total billed charges,,,
SPACER ANT CERV 14X6X12MM SOLITAIRE 12DG LRDTC S/MED -,SUP-14-520506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12505.38,8753.766,AETNA [1000108],AETNA [100010801],,,76.8,,9604.13,0.518595,35041.66656,percent of total billed charges,,,
SPACER ANT CERV 14X7X12MM SOLITAIRE 12DG LRDTC S/MED -,SUP-14-520507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12505.38,8753.766,AETNA [1000108],AETNA [100010801],,,76.8,,9604.13,0.518595,35041.66656,percent of total billed charges,,,
SPACER ANT CERV 14X9X12MM SOLITAIRE 12DG LRDTC S/MED -,SUP-14-520509,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12505.38,8753.766,AETNA [1000108],AETNA [100010801],,,76.8,,9604.13,0.518595,35041.66656,percent of total billed charges,,,
SPACER 10X27X8MM ZYSTON 6DG LRDTC CRV TAPR -,SUP-14-533128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,AETNA [1000108],AETNA [100010801],,,76.8,,10978.6,0.518595,35041.66656,percent of total billed charges,,,
SPACER 10X25X7MM ZYSTON STR CNVX -,SUP-14-534067,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,AETNA [1000108],AETNA [100010801],,,76.8,,10978.6,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE 3.5MM X46MM CANNULATED -,SUP-148.146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,AETNA [1000108],AETNA [100010801],,,76.8,,1884.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.2X13MM PROVIDENCE SD FX-ANG -,SUP-150.013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.2MM X 14MM -,SUP-150.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN PROVIDENCE 12MM 4HL LVL1 TI LCK -,SUP-150.112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN PROVIDENCE 14MM 4HL LVL1 TI LCK -,SUP-150.114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN PROVIDENCE 16MM 4HL LVL1 TI LCK -,SUP-150.116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN PROVIDENCE 18MM 4HL LVL1 TI LCK -,SUP-150.118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
ANTERIOR CERVICAL PLATE 1-LEVEL -,SUP-150.120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
PLATE ANTERIOR CERVICAL 1-LEVEL 22MM PROV -,SUP-150.122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
PLATE ANTERIOR CERVICAL 24MM 1 LEVEL PROVIDENCE -,SUP-150.124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
ANTERIOR CERVICAL PLATE 14MM LORD -,SUP-150.134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN PROVIDENCE 28MM 6HL LVL2 TI LCK -,SUP-150.228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN PROVIDENCE 30MM 6HL LVL2 TI LCK -,SUP-150.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN PROVIDENCE 32MM 6HL LVL2 TI LCK -,SUP-150.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN PROVIDENCE 34MM 6HL LVL2 TI LCK -,SUP-150.234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN PROVIDENCE 36MM 6HL LVL2 TI LCK -,SUP-150.236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,,,
PLATE CERVICAL ANTERIOR 2-LEVEL 38MM -,SUP-150.238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN PROVIDENCE 45MM 8HL LVL3 TI LCK -,SUP-150.345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN PROVIDENCE 48MM 8HL LVL3 TI LCK -,SUP-150.348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN PROVIDENCE 51MM 8HL LVL3 TI LCK -,SUP-150.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN PROVIDENCE 54MM 8HL LVL3 TI LCK -,SUP-150.354,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN PROVIDENCE 57MM 8HL LVL3 TI LCK -,SUP-150.357,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
PROVIDENCE ANTERIOR CERVICAL PLATE 3-LVL 60MM -,SUP-150.360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
ANTERIOR CERVICAL PLATE 4-LEVEL 69MM -,SUP-150.469,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW PROV 4.6MM FIXED ANGLE SELF DRILL 14MM -,SUP-150.514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.6X16MM PROVIDENCE ST FA TI ALY -,SUP-150.536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.6X18MM PROVIDENCE SD FA TI ALY -,SUP-150.538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.2X12MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.2X13MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.613,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.2X14MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.2X15MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.2X16MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW SELF DRILLING 4.6MM X 12MM VAR ANGLE PROV -,SUP-150.712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.6X13MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.713,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.6X14MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.6X16MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW SELF DRILLING 4.2MM X 12MM VAR ANGLE PROV -,SUP-150.812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
PROVIDENCE 4.2MM VARIABLE ANGLE SCREW SELF-TAP 14MM -,SUP-150.814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW PROVIDENCE 4.6MM VARIABLE ANGLE 16MM SELF TAPPING -,SUP-150.816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW PROVIDENCE 4.2MM VARIABLE ANGLE - 20MM -,SUP-150.820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
TRNSCONN 4.6X12MM PROVIDENCE ST VAR ANG TI ANT CERV -,SUP-150.912,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.6X14MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.914,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.6X15MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.915,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.6X16MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.916,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.6X18MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.918,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW SELF TAPPING 4.6 X 20 VAR ANGLE PROV -,SUP-150.920,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
OSS POLY LOCK PIN -,SUP-150478,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1865.78,1306.046,AETNA [1000108],AETNA [100010801],,,76.8,,1432.92,0.518595,35041.66656,percent of total billed charges,,,
FORTIFY 12MM CORE HEIGHT 21-29MM -,SUP-151.052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA [1000108],AETNA [100010801],,,76.8,,14257.92,0.518595,35041.66656,percent of total billed charges,,,
FORTIFY 12MM CORE HEIGHT 25-37MM -,SUP-151.053,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA [1000108],AETNA [100010801],,,76.8,,14257.92,0.518595,35041.66656,percent of total billed charges,,,
CORE FORTIFY 012MM HEIGHT 33-53MM -,SUP-151.054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA [1000108],AETNA [100010801],,,76.8,,14257.92,0.518595,35041.66656,percent of total billed charges,,,
ENDPLATE UPPER 012MM 12X14 FOOTPRINT 3.5 DEG -,SUP-151.323,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,,,
ENDPLATE LOWER 012MM 12 X 14 FOOTPRINT 7 DEG FORTIFY -,SUP-151.374,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,,,
SYSTEM CLENCH STAPEL 9MM X 7MM -,SUP-152-30907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,,,
SYSTEM CLENCH STAPLE 15MM X 12MM -,SUP-152-31512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,,,
SYSTEM CLENCH STAPLE 18MM X 18MM -,SUP-152-31818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,0.518595,35041.66656,percent of total billed charges,,,
STAPLE CLENCH 15MM X 12MM -,SUP-152-41512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW BED F/PROC STRECHER UPR FRM ASMB -,SUP-16042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.68,1.876,AETNA [1000108],AETNA [100010801],,,76.8,,2.06,0.518595,35041.66656,percent of total billed charges,,,
PLATE OSS RS NON MOD LONG 59 -,SUP-161022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20050.2,14035.14,AETNA [1000108],AETNA [100010801],,,76.8,,15398.55,0.518595,35041.66656,percent of total billed charges,,,
PIN FX STNMN 2MMX9IN SMTH SGL END PLN DMD PT NS -,SUP-1620-609NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21.41,14.987,AETNA [1000108],AETNA [100010801],,,76.8,,16.44,0.518595,35041.66656,percent of total billed charges,,,
PIN FX STNMN 2.4MMX9IN SMTH SGL END PLN DMD PT NS -,SUP-1624-609NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21.41,14.987,AETNA [1000108],AETNA [100010801],,,76.8,,16.44,0.518595,35041.66656,percent of total billed charges,,,
PIN FX STNMN 4.8MMX9IN SMTH SGL END PLN DMD PT NS -,SUP-1648-609X,CDM,C1713,HCPCS,278,RC,,,outpatient,,,29.18,20.426,AETNA [1000108],AETNA [100010801],,,76.8,,22.41,0.518595,35041.66656,percent of total billed charges,,,
TIBIAL INSERT PS SZ 6 13MM -,SUP-166-5613,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,0.518595,35041.66656,percent of total billed charges,,,
SHELL ACETABULAR ESCALADE 46MM -,SUP-170-0146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,0.518595,35041.66656,percent of total billed charges,,,
ESCALADE EXL LINER +1 28 X 46MM -,SUP-170-2846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,,,
EXPANSION BOLT RECONSTRUCTION PROSTHESIS -,SUP-172-947/38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,AETNA [1000108],AETNA [100010801],,,76.8,,854.87,0.518595,35041.66656,percent of total billed charges,,,
MESH SURG 17X22X50MM OVL TI HARMS -,SUP-1741-48-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17992.27,12594.589,AETNA [1000108],AETNA [100010801],,,76.8,,13818.06,0.518595,35041.66656,percent of total billed charges,,,
MESH SURG 17X22X70MM OVL TI HARMS -,SUP-1741-49,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20248.85,14174.195,AETNA [1000108],AETNA [100010801],,,76.8,,15551.12,0.518595,35041.66656,percent of total billed charges,,,
MESH SURG 22X28X70MM OVL TI HARMS -,SUP-1741-52-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20248.85,14174.195,AETNA [1000108],AETNA [100010801],,,76.8,,15551.12,0.518595,35041.66656,percent of total billed charges,,,
MESH SURG 22X28X90MM OVL TI HARMS -,SUP-1741-53-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,24291.37,17003.959,AETNA [1000108],AETNA [100010801],,,76.8,,18655.77,0.518595,35041.66656,percent of total billed charges,,,
MESH SURG 26X33X50MM OVL TI HARMS -,SUP-1741-54-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17992.27,12594.589,AETNA [1000108],AETNA [100010801],,,76.8,,13818.06,0.518595,35041.66656,percent of total billed charges,,,
MESH SURG 26X33X70MM OVL TI HARMS -,SUP-1741-55-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21889.99,15322.993,AETNA [1000108],AETNA [100010801],,,76.8,,16811.51,0.518595,35041.66656,percent of total billed charges,,,
WASHER SPIN TI POLY IEXP -,SUP-1754-91-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,,,
NUT SPIN TI BOLT SWVL LCK IEXP -,SUP-1754-91-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,543.24,380.268,AETNA [1000108],AETNA [100010801],,,76.8,,417.21,0.518595,35041.66656,percent of total billed charges,,,
CAGE 50MM RND 10MM SGL LVL TI -,SUP-1760-10-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17292.37,12104.659,AETNA [1000108],AETNA [100010801],,,76.8,,13280.54,0.518595,35041.66656,percent of total billed charges,,,
CAGE 50MM RND 12MM SGL LVL TI -,SUP-1760-12-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17292.37,12104.659,AETNA [1000108],AETNA [100010801],,,76.8,,13280.54,0.518595,35041.66656,percent of total billed charges,,,
CAGE 90MM RND 12MM SGL LVL TI -,SUP-1760-12-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18873.18,13211.226,AETNA [1000108],AETNA [100010801],,,76.8,,14494.6,0.518595,35041.66656,percent of total billed charges,,,
CAGE 50MM RND 14MM SGL LVL TI -,SUP-1760-14-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17292.37,12104.659,AETNA [1000108],AETNA [100010801],,,76.8,,13280.54,0.518595,35041.66656,percent of total billed charges,,,
CAGE 90MM RND 14MM SGL LVL TI -,SUP-1760-14-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19307.6,13515.32,AETNA [1000108],AETNA [100010801],,,76.8,,14828.24,0.518595,35041.66656,percent of total billed charges,,,
CAGE 50MM RND 16MM SGL LVL TI -,SUP-1760-16-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16483.86,11538.702,AETNA [1000108],AETNA [100010801],,,76.8,,12659.6,0.518595,35041.66656,percent of total billed charges,,,
MESH ROUND 16MM X 90MM SPN -,SUP-1760-16-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19754.09,13827.863,AETNA [1000108],AETNA [100010801],,,76.8,,15171.14,0.518595,35041.66656,percent of total billed charges,,,
MESH SURG 12X23MM DIA 12X14MM OVL TRPZD TI HARMS -,SUP-1762-02-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10345.35,7241.745,AETNA [1000108],AETNA [100010801],,,76.8,,7945.23,0.518595,35041.66656,percent of total billed charges,,,
NUT ORTHO DOME TI SWVL F/MONARCH SPN SYS -,SUP-1770-91-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,481.97,337.379,AETNA [1000108],AETNA [100010801],,,76.8,,370.15,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN SKNLC 47MM LVL2 TI LPRO -,SUP-1796-02-047,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6079.53,4255.671,AETNA [1000108],AETNA [100010801],,,76.8,,4669.08,0.518595,35041.66656,percent of total billed charges,,,
SET SCREW SPIN EXPEDIUM TI POST PDCL THORLUM SQ THRD -,SUP-1797-02-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
SET SCREW SPIN EXPEDIUM TI POST PDCL THORLUM SQ THRD -,SUP-1797-02-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,AETNA [1000108],AETNA [100010801],,,76.8,,542.24,0.518595,35041.66656,percent of total billed charges,,,
VIPER TI SAI POLY 8X90MM -,SUP-179704890,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7.5X45MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7.5X50MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-179712050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7.5X65MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.35X20MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.35X25MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.35X30MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.35X35MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.35X40MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5 X 25MM POLYAXIAL SI -,SUP-179712525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X40MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X45MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X50MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6X30MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6X35MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6X55MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7X35MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-735,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7X45MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-745,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7X50MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7X55MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
EXP TI POLY SCREW 8 X 40MM -,SUP-179712840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW POLYAXIAL 8MM X 65MM -,SUP-179712865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN EXPEDIUM 5.5X480MM HEX END TI POST PDCL THORLUM -,SUP-179762480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN EXPEDIUM 5.5X35MM CRV TI POST PDCL THORLUM PRELRD -,SUP-1797-71-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA [1000108],AETNA [100010801],,,76.8,,528.79,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN EXPEDIUM 5.5X40MM CRV TI POST PDCL THORLUM PRELRD -,SUP-1797-71-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA [1000108],AETNA [100010801],,,76.8,,528.79,0.518595,35041.66656,percent of total billed charges,,,
ROD PRE-LODOSED W/LINE 65MM -,SUP-179771065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA [1000108],AETNA [100010801],,,76.8,,528.79,0.518595,35041.66656,percent of total billed charges,,,
ROD PRE-LORDOSED 75MM W/LINE -,SUP-179771075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA [1000108],AETNA [100010801],,,76.8,,528.79,0.518595,35041.66656,percent of total billed charges,,,
ROD PRE-LORDOSED W/LINE 85MM -,SUP-179771085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA [1000108],AETNA [100010801],,,76.8,,528.79,0.518595,35041.66656,percent of total billed charges,,,
CONNECTOR 20MM EXPEDIUM LAT OFST OPN F/10MM TI -,SUP-1797-92-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA [1000108],AETNA [100010801],,,76.8,,1933.62,0.518595,35041.66656,percent of total billed charges,,,
CONNECTOR 50MM EXPEDIUM LAT OFST OPN F/5.5MM TI -,SUP-1797-92-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA [1000108],AETNA [100010801],,,76.8,,1933.62,0.518595,35041.66656,percent of total billed charges,,,
CONNECTOR 20MM EXPEDIUM OPN F/5.5MM TI ILC -,SUP-1797-97-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X42MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-49-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X46MM TMX CANN RDC HEAD -,SUP-1802-49-046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X30MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA [1000108],AETNA [100010801],,,76.8,,860.41,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X32MM CANN -,SUP-1802-53-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA [1000108],AETNA [100010801],,,76.8,,860.41,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X34MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA [1000108],AETNA [100010801],,,76.8,,860.41,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X36MM CANN -,SUP-1802-53-036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA [1000108],AETNA [100010801],,,76.8,,860.41,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X38MM CANN -,SUP-1802-53-038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA [1000108],AETNA [100010801],,,76.8,,860.41,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X40MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA [1000108],AETNA [100010801],,,76.8,,860.41,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X42MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA [1000108],AETNA [100010801],,,76.8,,860.41,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X44MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA [1000108],AETNA [100010801],,,76.8,,860.41,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X50MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA [1000108],AETNA [100010801],,,76.8,,860.41,0.518595,35041.66656,percent of total billed charges,,,
COMP SCR 5MM CANN LAG P/T SD/ST TMX 55MM -,SUP-1802-53-055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA [1000108],AETNA [100010801],,,76.8,,860.41,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X60MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA [1000108],AETNA [100010801],,,76.8,,860.41,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X65MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA [1000108],AETNA [100010801],,,76.8,,860.41,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X70MM CANN LAG CANC P/T SD/ST SM HEAD TMX -,SUP-1802-53-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA [1000108],AETNA [100010801],,,76.8,,860.41,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X75MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA [1000108],AETNA [100010801],,,76.8,,860.41,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X80MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA [1000108],AETNA [100010801],,,76.8,,860.41,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5MMSMX85MM CANN LAG CANC PARTIALY THRD SD/ST RDC HEAD -,SUP-1802-53-085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA [1000108],AETNA [100010801],,,76.8,,860.41,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X90MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA [1000108],AETNA [100010801],,,76.8,,860.41,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5MMSMX95MM CANNULATEDLAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA [1000108],AETNA [100010801],,,76.8,,860.41,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X100MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA [1000108],AETNA [100010801],,,76.8,,860.41,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.75X15MM LCK CMPRHNSV RVRS FX TI ALY HAP CTD BLU -,SUP-180500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.75X20MM NLCKG CMPRHNSV RVRS FX TI ALY HAP CTD GOLD -,SUP-180508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.75X25MM NLCKG CMPRHNSV RVRS FX TI ALY HAP CTD GOLD -,SUP-180509,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.75X15MM LCK CORT FX 3.5MM HEX HEAD TI ALY HAP CTD -,SUP-180550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
4.75 X 20MM FIXED LOCKING SCREW 3.5MM HEX -,SUP-180551,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
COMP LK SCR 3.5 HEX 4.75 X 25 ST -,SUP-180552,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW COMP LK 3.5 HEX 4.75 X 30 ST -,SUP-180553,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW COMP LK 3.5 HEX 4.75 X 35 ST -,SUP-180554,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
COMP LK SCR 3.5 HEX 4.75 X 40 ST -,SUP-180555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.75X15MM NLCKG CORT VAR ANG 3.5MM HEX HEAD TI ALY HAP -,SUP-180557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.75X20MM NLCKG CORT VAR ANG 3.5MM HEX HEAD TI ALY HAP -,SUP-180558,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.75X25MM NLCKG CORT VAR ANG 3.5MM HEX HEAD TI ALY HAP -,SUP-180559,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
COMP NLK SCREW 3.5 HEX 4.75 X 30 ST -,SUP-180560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.75X35MM NLCKG CMPRHNSV 3.5MM HX HEX HEAD TMX HAP CTD -,SUP-180561,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
K-WIRE- STERILE 3 x 285MM -,SUP-1806-0050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,459.86,321.902,AETNA [1000108],AETNA [100010801],,,76.8,,353.17,0.518595,35041.66656,percent of total billed charges,,,
STRYKER PLATE -,SUP-1806-0150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,793.85,555.695,AETNA [1000108],AETNA [100010801],,,76.8,,609.68,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10X320MM VERSANAIL CANN FEM TI ALY -,SUP-1813-10-320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7410.02,5187.014,AETNA [1000108],AETNA [100010801],,,76.8,,5690.9,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 13X400MM VERSANAIL CANN RT TROCH FEM TI ALY -,SUP-1814-13-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10160.14,7112.098,AETNA [1000108],AETNA [100010801],,,76.8,,7802.99,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 7X220MM VERSANAIL CANN HUM TI ALY -,SUP-1817-07-221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,AETNA [1000108],AETNA [100010801],,,76.8,,5260.66,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 8X200MM VERSANAIL CANN HUM TI ALY -,SUP-1817-08-201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,AETNA [1000108],AETNA [100010801],,,76.8,,5260.66,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 9X260MM VERSANAIL CANN HUM TI ALY -,SUP-1817-09-261,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,AETNA [1000108],AETNA [100010801],,,76.8,,5260.66,0.518595,35041.66656,percent of total billed charges,,,
T2 ANKLE COMPRESSION SCREW -,SUP-1818-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1161.6,813.12,AETNA [1000108],AETNA [100010801],,,76.8,,892.11,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10X150MM VERSANAIL CANN PROX HUM SS -,SUP-1818-10-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7282.7,5097.89,AETNA [1000108],AETNA [100010801],,,76.8,,5593.11,0.518595,35041.66656,percent of total billed charges,,,
NAIL T2 ANKLE ARTHRODESIS LEFT -,SUP-1818-1020S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,AETNA [1000108],AETNA [100010801],,,76.8,,12095.56,0.518595,35041.66656,percent of total billed charges,,,
T2 ANKLE NAIL 11x200MM LEFT -,SUP-1818-1120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,AETNA [1000108],AETNA [100010801],,,76.8,,12095.56,0.518595,35041.66656,percent of total billed charges,,,
T2 ANKLE ARTHRODESIS NAIL LEFT 11X300MM -,SUP-1818-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,AETNA [1000108],AETNA [100010801],,,76.8,,12095.56,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 12X200MM T2 CANN LT ANKL TI ALY BIOMECH -,SUP-1818-1220S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,AETNA [1000108],AETNA [100010801],,,76.8,,12095.56,0.518595,35041.66656,percent of total billed charges,,,
T2 ANKLE ARTHRODESIS NAIL RIGHT 11 X 150MM -,SUP-1819-1115S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,AETNA [1000108],AETNA [100010801],,,76.8,,12095.56,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 12X200MM T2 CANN RT ANKL TI ALY BIOMECH -,SUP-1819-1220S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,AETNA [1000108],AETNA [100010801],,,76.8,,12095.56,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.8MMX20MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-35-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA [1000108],AETNA [100010801],,,76.8,,241.99,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X24MM CORT 3.5MM HX NS F/2.9MM DRLBT -,SUP-1819-35-024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA [1000108],AETNA [100010801],,,76.8,,241.99,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X30MM CORT 3.5MM HX NS F/2.9MM DRLBT -,SUP-1819-35-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA [1000108],AETNA [100010801],,,76.8,,241.99,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.8MMX30MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.8MMX32MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 4.8MMX42MM 3.6MM HX NS -,SUP-1819-48-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.8MMX44MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.8MMX46MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.8MMX50MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X24MM ELLIPSE POLYAX TI -,SUP-182.224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MM X 26MM ELLIPSE POLYAXIAL SHOULDER -,SUP-182.226,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X28MM ELLIPSE POLYAX TI. -,SUP-182.228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X30MM ELLIPSE POLYAX TI. -,SUP-182.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X32MM ELLIPSE POLYAX TI -,SUP-182.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X34MM ELLIPSE POLYAX TI -,SUP-182.234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X10MM ELLIPSE POLYAX TI -,SUP-182.310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X12MM ELLIPSE POLYAX TI -,SUP-182.312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X14MM ELLIPSE POLYAX TI -,SUP-182.314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW ELLIPSE POLYAXIAL 3.5MM X 16MM -,SUP-182.316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X18MM ELLIPSE POLYAX TI -,SUP-182.318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X20MM ELLIPSE POLYAX TI -,SUP-182.320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X22MM ELLIPSE POLYAX TI -,SUP-182.322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X26MM ELLIPSE POLYAX TI -,SUP-182.326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X28MM ELLIPSE POLYAX TI -,SUP-182.328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X30MM ELLIPSE POLYAX TI -,SUP-182.330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X10MM ELLIPSE POLYAX TI -,SUP-182.410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X12MM ELLIPSE POLYAX TI -,SUP-182.412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X14MM ELLIPSE POLYAX TI -,SUP-182.414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
4.0MM ELLIPSE POLYAXIAL SCREW 16MM -,SUP-182.416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X18MM ELLIPSE POLYAX TI -,SUP-182.418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X20MM ELLIPSE POLYAX TI -,SUP-182.420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X22MM ELLIPSE POLYAX TI -,SUP-182.422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X24MM ELLIPSE POLYAX TI -,SUP-182.424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X26MM ELLIPSE POLYAX TI -,SUP-182.426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW ELLIPSE POLYAXIAL 4.0 X 28MM -,SUP-182.428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
ELLIPSE LOCKING CAP -,SUP-182.500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,,,
HOOK SPIN INLN ELLIPSE -,SUP-182.501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA [1000108],AETNA [100010801],,,76.8,,1933.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW ELLIPSE POLYAXIAL 4.5 X 20 -,SUP-182.520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X22MM ELLIPSE POLYAX TI -,SUP-182.522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X24MM ELLIPSE POLYAX TI -,SUP-182.524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X26MM ELLIPSE POLYAX TI -,SUP-182.526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW ELLIPSE POLYAXIAL 4.5 X 28 -,SUP-182.528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW ELLIPSE POLYAXIAL 4.5 X 30 -,SUP-182.530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
ROD TO ROD CLAMP CT TO CT 7MM -,SUP-182.741,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA [1000108],AETNA [100010801],,,76.8,,1933.62,0.518595,35041.66656,percent of total billed charges,,,
ROD TO ROD CLAMP CT TO CT 9MM -,SUP-182.770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA [1000108],AETNA [100010801],,,76.8,,1933.62,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN ELLIPSE 6.35X80MM TI POST OCT -,SUP-182.801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA [1000108],AETNA [100010801],,,76.8,,528.79,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN ELLIPSE 6.35X120MM TI POST OCT -,SUP-182.802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA [1000108],AETNA [100010801],,,76.8,,528.79,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN ELLIPSE 3.5X240MM TI POST OCT -,SUP-182.803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA [1000108],AETNA [100010801],,,76.8,,528.79,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN ELLIPSE 3.5X40MM TI POST OCT -,SUP-182.804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA [1000108],AETNA [100010801],,,76.8,,528.79,0.518595,35041.66656,percent of total billed charges,,,
ENDCAP SPIN ELLIPSE T-SHP HD-TO-HD -,SUP-182.900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,,,
NUT SPIN ELLIPSE F/HD-TO-HD TRANSV CONN T-SHP -,SUP-182.901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,,,
TRNSCONN 27-33MM ELLIPSE HD-TO-HD F/3.5MM T-SHP POST OCT -,SUP-182.912,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
TRNSCONN 26-46MM ELLIPSE F/3.5MM CRV POST OCT -,SUP-182.924,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
PLATE OCPTL SM ELLIPSE -,SUP-182.950,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,AETNA [1000108],AETNA [100010801],,,76.8,,5866.91,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 8MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0828S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA [1000108],AETNA [100010801],,,76.8,,3388.14,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 8MMSTDX300MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0830S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA [1000108],AETNA [100010801],,,76.8,,3388.14,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 8MMSTDX315MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0831S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA [1000108],AETNA [100010801],,,76.8,,3388.14,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 8MMSTDX330MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0833S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA [1000108],AETNA [100010801],,,76.8,,3388.14,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 8MMSTDX360MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0836S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA [1000108],AETNA [100010801],,,76.8,,3388.14,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 8MMSTDX390MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0839S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA [1000108],AETNA [100010801],,,76.8,,3388.14,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1028S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA [1000108],AETNA [100010801],,,76.8,,3388.14,0.518595,35041.66656,percent of total billed charges,,,
TIBIAL NAIL 10 X 390MM -,SUP-1822-1039S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA [1000108],AETNA [100010801],,,76.8,,3388.14,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1128S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA [1000108],AETNA [100010801],,,76.8,,3388.14,0.518595,35041.66656,percent of total billed charges,,,
T2 STD. TIBIAL NAIL 11MM X 300MM -,SUP-1822-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA [1000108],AETNA [100010801],,,76.8,,3388.14,0.518595,35041.66656,percent of total billed charges,,,
TIBIAL NAIL 11 X 375MM -,SUP-1822-1137S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA [1000108],AETNA [100010801],,,76.8,,3388.14,0.518595,35041.66656,percent of total billed charges,,,
11 X 390MM TIBIA NAIL -,SUP-1822-1139S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA [1000108],AETNA [100010801],,,76.8,,3388.14,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 12MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1228S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA [1000108],AETNA [100010801],,,76.8,,3388.14,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 12MMSTDX315MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1231S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA [1000108],AETNA [100010801],,,76.8,,3388.14,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 12MMSTDX345MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA [1000108],AETNA [100010801],,,76.8,,3388.14,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 12MMSTDX360MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA [1000108],AETNA [100010801],,,76.8,,3388.14,0.518595,35041.66656,percent of total billed charges,,,
T2 TIBIAL NAIL SYSTEM  12 X 390MM -,SUP-1822-1239S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA [1000108],AETNA [100010801],,,76.8,,3388.14,0.518595,35041.66656,percent of total billed charges,,,
SCREW 8MM COMPR T2 CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1825-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.67,530.369,AETNA [1000108],AETNA [100010801],,,76.8,,581.89,0.518595,35041.66656,percent of total billed charges,,,
SCREW 8X5MM COMPR T2 CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1825-0005S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.67,530.369,AETNA [1000108],AETNA [100010801],,,76.8,,581.89,0.518595,35041.66656,percent of total billed charges,,,
NAIL SYS T2 FEMUR A/R 010 X 340MM -,SUP-1825-1034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10X360MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1038S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11X280MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1128S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11X320MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1132S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11X340MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11X400MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1140S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1144S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 12X280MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1228S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 12X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1230S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 12X360MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 12X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1238S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 12X420MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1242S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 12X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1244S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 13X180MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1318S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 13X240MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1324S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 13X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1330S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 13X340MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1334S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 13X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1338S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 13X400MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 13X420MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1342S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 13X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1344S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 14X240MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1424S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 14X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1430S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 14X320MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1432S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 14X340MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1434S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 14X360MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1436S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 14X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1438S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 14X400MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 14X420MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1442S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 14X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1444S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA [1000108],AETNA [100010801],,,76.8,,3527.32,0.518595,35041.66656,percent of total billed charges,,,
CAP ORTHO 8X4MM TI E CAP PROT -,SUP-1826-0003S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,771.97,540.379,AETNA [1000108],AETNA [100010801],,,76.8,,592.87,0.518595,35041.66656,percent of total billed charges,,,
T2 SUPRACONDYLAR NAIL 9X340MM -,SUP-1826-0934S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,,,
T2 SUPRACONDYLAR NAIL 9X380MM -,SUP-1826-0938S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1020S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,,,
SUPRACONDYLAR NAIL 10 X 320 -,SUP-1826-1032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10MMLNGX340MM T2 CANN SPRACON TI BIOMECH -,SUP-1826-1034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10MMLNGX360MM T2 CANN SPRACON TI BIOMECH -,SUP-1826-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,,,
NAIL SUPRACONDYLAR 10MM X 400MM -,SUP-1826-1040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11MMLNGX240MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1124S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11MMLNGX320MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1132S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,,,
SUPRACONDYLAR NAIL 11 X 360MM -,SUP-1826-1136S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,,,
NAIL SUPRACONDYLAR 11 X 380 -,SUP-1826-1138S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,,,
NAIL SUPRACONDYLAR 11 X 420 -,SUP-1826-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 12MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1220S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 12MMLNGX280MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1228S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 12MMLNGX300MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1230S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 12MMLNGX320MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1232S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 12MM X 340MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,,,
NAIL SUPRACONDYLAR 12 X 360 -,SUP-1826-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,,,
T2 SUPRACONDYLAR NAIL 12X400MM -,SUP-1826-1240S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 13MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 13MMLNGX300MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1330S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 13MMLNGX340MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1334S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,,,
NAIL SUPRACONDYLAR 13MM X 360MM -,SUP-1826-1336S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 13MMLNGX380MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1338S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 13MMLNGX400MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 13MMLNGX420MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1342S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,,,
NAIL SUPRACONDYLAR 14 X 380 -,SUP-1826-1438S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA [1000108],AETNA [100010801],,,76.8,,5080.74,0.518595,35041.66656,percent of total billed charges,,,
NAIL FEMORAL 10 X 360 -,SUP-1828-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5072.64,3550.848,AETNA [1000108],AETNA [100010801],,,76.8,,3895.79,0.518595,35041.66656,percent of total billed charges,,,
NAIL FEMORAL 11 X 340MM -,SUP-1828-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5072.64,3550.848,AETNA [1000108],AETNA [100010801],,,76.8,,3895.79,0.518595,35041.66656,percent of total billed charges,,,
NAIL FEMORAL 11 X 400 -,SUP-1828-1140S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5072.64,3550.848,AETNA [1000108],AETNA [100010801],,,76.8,,3895.79,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 13X740MM T2 CANN RT KN TI ALY BIOMECH -,SUP-1829-1374S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,28428.72,19900.104,AETNA [1000108],AETNA [100010801],,,76.8,,21833.26,0.518595,35041.66656,percent of total billed charges,,,
WASHER ORTHO 10MM TI ALY SQ STRL -,SUP-1830-0009S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,718.87,503.209,AETNA [1000108],AETNA [100010801],,,76.8,,552.09,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 7X210MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0721S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,AETNA [1000108],AETNA [100010801],,,76.8,,3826.53,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 7X220MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0722S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,AETNA [1000108],AETNA [100010801],,,76.8,,3826.53,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 7X240MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0724S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,AETNA [1000108],AETNA [100010801],,,76.8,,3826.53,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 8X240MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0824S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,AETNA [1000108],AETNA [100010801],,,76.8,,3826.53,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 8X250MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0825S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,AETNA [1000108],AETNA [100010801],,,76.8,,3826.53,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 8X280MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0828S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,AETNA [1000108],AETNA [100010801],,,76.8,,3826.53,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 9X210MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0921S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,AETNA [1000108],AETNA [100010801],,,76.8,,3826.53,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 9X220MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0922S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,AETNA [1000108],AETNA [100010801],,,76.8,,3826.53,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 9X240MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0924S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,AETNA [1000108],AETNA [100010801],,,76.8,,3826.53,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 9X250MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0925S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,AETNA [1000108],AETNA [100010801],,,76.8,,3826.53,0.518595,35041.66656,percent of total billed charges,,,
ENDCAP ORTHO 6MM STD TI T2 STRL -,SUP-1832-0003S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,725,507.5,AETNA [1000108],AETNA [100010801],,,76.8,,556.8,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 8MMLNGX150MM T2 CANN LT PROX HUM TI ALY -,SUP-1832-1035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6798.89,4759.223,AETNA [1000108],AETNA [100010801],,,76.8,,5221.55,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 8MMLNGX240MM T2 CANN LT PROX HUM TI ALY BIOMECH -,SUP-1832-2824S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,AETNA [1000108],AETNA [100010801],,,76.8,,4744.37,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 8MMLNGX260MM T2 CANN LT PROX HUM TI ALY BIOMECH -,SUP-1832-2826S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,AETNA [1000108],AETNA [100010801],,,76.8,,4744.37,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 8MMLNGX220MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3822S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,AETNA [1000108],AETNA [100010801],,,76.8,,4744.37,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11MMLNGX240MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3824S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,AETNA [1000108],AETNA [100010801],,,76.8,,4744.37,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 8MMLNGX260MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3826S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,AETNA [1000108],AETNA [100010801],,,76.8,,4744.37,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11MMLNGX280MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3828S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,AETNA [1000108],AETNA [100010801],,,76.8,,4744.37,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE 3.6MM VAR SELF-TAPPING 14MM -,SUP-184.114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE 3.6MM VAR SELF-TAPPING 16MM -,SUP-184.116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 9MM 1.5M RAD 340MM T2 RECON CANN LT FEM TI ALY RECON -,SUP-1843-0934S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,AETNA [1000108],AETNA [100010801],,,76.8,,5311.5,0.518595,35041.66656,percent of total billed charges,,,
T2 RECON NAIL R1.5- RIGHT 9 X 360MM X 125DG -,SUP-1845-0936S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,AETNA [1000108],AETNA [100010801],,,76.8,,5311.5,0.518595,35041.66656,percent of total billed charges,,,
T2 RECON NAIL R1.5- RIGHT 9 X 380MM X 125DG -,SUP-1845-0938S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,AETNA [1000108],AETNA [100010801],,,76.8,,5311.5,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10MM 1.5M RAD 360MM T2 RECON CANN RT FEM TI ALY -,SUP-1845-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,AETNA [1000108],AETNA [100010801],,,76.8,,5311.5,0.518595,35041.66656,percent of total billed charges,,,
NAIL T2 RECON R1 11MM X 420MM X 125 -,SUP-1845-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,AETNA [1000108],AETNA [100010801],,,76.8,,5311.5,0.518595,35041.66656,percent of total billed charges,,,
ENDCAP SPIN REVERE THORLUM NTHRD REVOLVE -,SUP-185.000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN REVOLVE 5.5X80MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN REVOLVE 5.5X90MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN REVOLVE 5.5X100MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN REVOLVE 5.5X110MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5X30MM REVOLVE POLYAX TI -,SUP-185.452,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5X35MM REVOLVE POLYAX TI -,SUP-185.453,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5X40MM REVOLVE POLYAX TI -,SUP-185.454,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5X45MM REVOLVE POLYAX TI -,SUP-185.455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5X50MM REVOLVE POLYAX TI -,SUP-185.456,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5X55MM REVOLVE POLYAX TI -,SUP-185.457,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X30MM REVOLVE POLYAX TI -,SUP-185.462,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X35MM REVOLVE POLYAX TI -,SUP-185.463,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X40MM REVOLVE POLYAX TI -,SUP-185.464,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X45MM REVOLVE POLYAX TI -,SUP-185.465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X50MM REVOLVE POLYAX TI -,SUP-185.466,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
FEMORAL NAIL RIGHT 9 X 360MM -,SUP-1851-0936S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6489.92,4542.944,AETNA [1000108],AETNA [100010801],,,76.8,,4984.26,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10X380MM T2 CANN RT GTR TROCH FEM TI ALY RECON -,SUP-1851-1038S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6489.92,4542.944,AETNA [1000108],AETNA [100010801],,,76.8,,4984.26,0.518595,35041.66656,percent of total billed charges,,,
CABLE SINGLE LOOP TITANIUM WITH CRIMP -,SUP-186.200S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2978.98,2085.286,AETNA [1000108],AETNA [100010801],,,76.8,,2287.86,0.518595,35041.66656,percent of total billed charges,,,
SPACER 28X8MM LPRD 5DG LRDTC BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,AETNA [1000108],AETNA [100010801],,,76.8,,7699.28,0.518595,35041.66656,percent of total billed charges,,,
CAGE 28X9MM LPRD 5DG LRDTC BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,AETNA [1000108],AETNA [100010801],,,76.8,,7699.28,0.518595,35041.66656,percent of total billed charges,,,
SPACER 28X7MM LPRD PRLL BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,AETNA [1000108],AETNA [100010801],,,76.8,,7699.28,0.518595,35041.66656,percent of total billed charges,,,
SPACER 28X9MM LPRD PRLL BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,AETNA [1000108],AETNA [100010801],,,76.8,,7699.28,0.518595,35041.66656,percent of total billed charges,,,
SPACER 28X11MM LPRD PRLL BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,AETNA [1000108],AETNA [100010801],,,76.8,,7699.28,0.518595,35041.66656,percent of total billed charges,,,
SCREW SET INNER MIS -,SUP-186715000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
SET SCREW SPIN VIPER 2 TI PDCL SQ THRD SGL INNIE -,SUP-1867-15-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6X35MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6X35MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6X40MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6X40MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6 X 45 POLYAXIAL CANNULA -,SUP-186715645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6X45MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6X50MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6X50MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6X55MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7X40MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7X50MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X55MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X40MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6X30MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6X40MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6X45MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW TI CORT FIX 6X50MM -,SUP-186731650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW TI CORT FIX 6X55MM -,SUP-186731655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6X35MM VIPER 2 DBL LD THRD CANN ULTRA TI -,SUP-1867-60-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6X40MM VIPER 2 DBL LD THRD CANN ULTRA TI -,SUP-1867-60-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN VIPER 5.5X35MM CRV PREBNT TI F/MN INV SURG NS -,SUP-1867-62-635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN VIPER 5.5X40MM CRV PREBNT TI F/MN INV SURG NS -,SUP-1867-62-640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN VIPER 2  - 5.5 X 35MM LORDOTIC -,SUP-186788035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN VIPER 2 5.5X35MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN VIPER 2 5.5X40MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN VIPER 2 5.5X45MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN VIPER 2 5.5X50MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,,,
TRNSCONN REVERE ADDITION RD-TO-RD F/5.5MM PRLL -,SUP-1867-88-055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN VIPER 2 5.5X65MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,,,
ROD VIPER 2 LORDOTIC 75MM -,SUP-186788075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,,,
ROD LORDOTIC 80MM VIPER2 -,SUP-186788080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,,,
ROD LORDOTIC 90MM VIPER2 -,SUP-186788090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN SKYLINE 16X12MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN SKYLINE 16X14MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN SKYLINE 16X16MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN SKYLINE 16X18MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN SKYLINE 16X20MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN SKYLINE 16X22MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN SKYLINE 16X24MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN SKYLINE 16X26MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
SKY 1 LEVEL PLATE 28MM -,SUP-1868-01-028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN SKYLINE 16X30MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
PLATE 28MM SKYLINE 2 LEVEL TI -,SUP-186802028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN SKYLINE 16X30MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN SKYLINE 16X32MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN SKYLINE 16X34MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN SKYLINE 16X36MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN SKYLINE 16X40MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN SKYLINE 16X42MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN SKYLINE 16X44MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN SKYLINE 16X45MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN SKYLINE 16X48MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN SKYLINE 16X51MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN SKYLINE 16X54MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN SKYLINE 16X57MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-057,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X12MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL BLU -,SUP-1868-50-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X14MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL GOLD -,SUP-1868-50-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X16MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL MAG -,SUP-1868-50-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X18MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL -,SUP-1868-50-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X12MM SKYLINE ST VAR ANG HX LOBE HEAD TI STRL BLU -,SUP-1868-52-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X14MM SKYLINE ST VAR ANG HX LOBE HEAD TI STRL GOLD -,SUP-1868-52-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X16MM SKYLINE ST VAR ANG HX LOBE HEAD TI STRL MAG -,SUP-1868-52-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW SKY VARIABLE S-T 18MM TI -,SUP-186852018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X12MM SKYLINE ST VAR ANG OVSZ HX LOBE HEAD TI STRL -,SUP-1868-54-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X14MM SKYLINE ST VAR ANG OVSZ HX LOBE HEAD TI STRL -,SUP-1868-54-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X16MM SKYLINE ST VAR ANG OVSZ HX LOBE HEAD TI STRL -,SUP-1868-54-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X14MM SKYLINE ST FA CNSTRN OVSZ HX LOBE HEAD TI -,SUP-1868-64-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
IMPLANT COUGAR SM 12MM 5 DEG -,SUP-187105112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,AETNA [1000108],AETNA [100010801],,,76.8,,10550.86,0.518595,35041.66656,percent of total billed charges,,,
COUGAR IMPLANT MED 14MM 50DEG -,SUP-187105214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,AETNA [1000108],AETNA [100010801],,,76.8,,10550.86,0.518595,35041.66656,percent of total billed charges,,,
SPACER 14MM COUGAR 10DG SM CFRP -,SUP-1871-10-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,AETNA [1000108],AETNA [100010801],,,76.8,,10550.86,0.518595,35041.66656,percent of total billed charges,,,
COUGAR IMPLANT MED 14MM 10DEG -,SUP-187110214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,AETNA [1000108],AETNA [100010801],,,76.8,,10550.86,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN EXPEDIUM 5.5X70MM STR TI ANT PCUT NS -,SUP-1877-03-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA [1000108],AETNA [100010801],,,76.8,,528.79,0.518595,35041.66656,percent of total billed charges,,,
BULLETT CONCORD 9 X 7 X 23 -,SUP-187823107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
CAGE 9X8X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
CAGE 9X9X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
CAGE 9X10X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
CAGE 9X8X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
CAGE 9X9X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-187823409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
CAGE 9X9X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
CAGE 9X10X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
CAGE 9X11X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
CAGE 9X12X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
CAGE 11X12X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
CONCORDE BUL LOR 11X13X23 5DG -,SUP-187823513,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
CAGE 9X7X27MM CONCORDE -,SUP-187827107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
CAGE 9X7X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
CAGE 9X8X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
CAGE 9X9X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
CAGE 9X10X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
CAGE 11X12X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
CAGE 9X8X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-27-408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
CAGE 9X9X27MM CONCORDE 5DG LRDTC BLLT NOSE STNT LPRO CFRP -,SUP-1878-27-409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
CAGE 9X10X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-27-410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
CONCORDE BUL LOR 9 X 11 X 27 -,SUP-187827411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
CAGE 9X11X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-27-411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
CAGE 11X12X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-187827512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
CAGE 9X7X23MM CONCORDE PRLL CFRP -,SUP-1879-23-107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14828.79,10380.153,AETNA [1000108],AETNA [100010801],,,76.8,,11388.51,0.518595,35041.66656,percent of total billed charges,,,
CAGE 11X13X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1879-27-513,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
CONNECTOR SPIN MOUNTAINEER LAT OFST TI -,SUP-1883-12-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA [1000108],AETNA [100010801],,,76.8,,1933.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X10MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X12MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X18MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X26MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X12MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X22MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X24MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X26MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X12MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X16MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X20MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X22MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X26MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X22MM MOUNTAINEER MINI POLYAX TAPR TI STRL BLU SHNK -,SUP-1883-19-422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X26MM MOUNTAINEER MINI POLYAX TAPR TI STRL BLU SHNK -,SUP-1883-19-426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X50MM MOUNTAINEER MINI POLYAX TAPR TI STRL BLU SHNK -,SUP-1883-19-450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.35X20MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.35X25MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.35X30MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.35X35MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.35X40MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X20MM MOUNTAINEER MINI POLYAX SHNK TAPR TI STRL -,SUP-1883-20-320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X28MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X32MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X34MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X36MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X38MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X40MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
XCONN 21MM MOUNTAINEER HD-TO-HD TI OCT -,SUP-1883-41-021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X12MM MOUNTAINEER MINI POLYAX TI STRL -,SUP-188362012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,AETNA [1000108],AETNA [100010801],,,76.8,,2181.53,0.518595,35041.66656,percent of total billed charges,,,
PLATE OC 37MM -,SUP-188362037,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA [1000108],AETNA [100010801],,,76.8,,14257.92,0.518595,35041.66656,percent of total billed charges,,,
MNTR OC PLATE LARGE -,SUP-188362045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA [1000108],AETNA [100010801],,,76.8,,14257.92,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.25X8MM MOUNTAINEER MINI POLYAX TI STRL -,SUP-188362108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,AETNA [1000108],AETNA [100010801],,,76.8,,2181.53,0.518595,35041.66656,percent of total billed charges,,,
MNTR OC PREBENT ROD 3.5X120 -,SUP-188363200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,921.93,645.351,AETNA [1000108],AETNA [100010801],,,76.8,,708.04,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN SKYLINE 34MM LVL2 PRELRD TI VSBL GFT SITE -,SUP-1888-02-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5856.72,4099.704,AETNA [1000108],AETNA [100010801],,,76.8,,4497.96,0.518595,35041.66656,percent of total billed charges,,,
CAGE ANTLAT 33-46MMH X-MESH 0DG MED TI -,SUP-1889-01-033,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20402.94,14282.058,AETNA [1000108],AETNA [100010801],,,76.8,,15669.46,0.518595,35041.66656,percent of total billed charges,,,
CAGE 0DG ANTLAT 51-71MM X-MESH MED TI -,SUP-1889-01-051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22445.09,15711.563,AETNA [1000108],AETNA [100010801],,,76.8,,17237.83,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X35MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,820.98,574.686,AETNA [1000108],AETNA [100010801],,,76.8,,630.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X40MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,812.82,568.974,AETNA [1000108],AETNA [100010801],,,76.8,,624.25,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X45MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,812.82,568.974,AETNA [1000108],AETNA [100010801],,,76.8,,624.25,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X55MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,812.82,568.974,AETNA [1000108],AETNA [100010801],,,76.8,,624.25,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X60MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,820.98,574.686,AETNA [1000108],AETNA [100010801],,,76.8,,630.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X65MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,820.98,574.686,AETNA [1000108],AETNA [100010801],,,76.8,,630.51,0.518595,35041.66656,percent of total billed charges,,,
SFX-5.5 TI LAT SIZE F4 -,SUP-189401104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,,,
DEPUY SPINE SFX F5 CROSSLINK -,SUP-189401105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,,,
CONNECTOR SZ F6 EXPEDIUM SFX FX F/5.5MM TI MDL -,SUP-1894-01-206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,,,
CONNECTOR SZ F7 EXPEDIUM SFX FX F/5.5MM TI MDL -,SUP-1894-01-207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,,,
CONNECTOR SPIN EXPEDIUM CX TI -,SUP-1894-01-209,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,,,
SFX 5.5 TI LAT SIZE A2 -,SUP-189401302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,,,
CONNECTOR SZ A4 EXPEDIUM SFX F/5.5MM TI MDL NS -,SUP-1894-01-404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,,,
CONNECTOR SZ A5 EXPEDIUM SFX F/5.5MM TI MDL NS -,SUP-1894-01-405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,,,
CONNECTOR SZ A6 EXPEDIUM SFX F/5.5MM TI MDL NS -,SUP-1894-01-406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,,,
SCREW T2 CONDYLE 5MM X 50MM -,SUP-1895-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,AETNA [1000108],AETNA [100010801],,,76.8,,633.65,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X60MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,AETNA [1000108],AETNA [100010801],,,76.8,,633.65,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X75MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,AETNA [1000108],AETNA [100010801],,,76.8,,633.65,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X80MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,AETNA [1000108],AETNA [100010801],,,76.8,,633.65,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X85MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,AETNA [1000108],AETNA [100010801],,,76.8,,633.65,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X20MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4020S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,AETNA [1000108],AETNA [100010801],,,76.8,,585.03,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X22MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4022S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,AETNA [1000108],AETNA [100010801],,,76.8,,589.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X26MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,AETNA [1000108],AETNA [100010801],,,76.8,,585.03,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X28MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4028S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,AETNA [1000108],AETNA [100010801],,,76.8,,589.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X30MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,AETNA [1000108],AETNA [100010801],,,76.8,,589.74,0.518595,35041.66656,percent of total billed charges,,,
T2 F/T LOCKING SCREW 4MM X 32MM -,SUP-1896-4032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,AETNA [1000108],AETNA [100010801],,,76.8,,589.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X36MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,AETNA [1000108],AETNA [100010801],,,76.8,,589.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X38MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4038S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,AETNA [1000108],AETNA [100010801],,,76.8,,589.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X45MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,AETNA [1000108],AETNA [100010801],,,76.8,,585.03,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X55MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,AETNA [1000108],AETNA [100010801],,,76.8,,585.03,0.518595,35041.66656,percent of total billed charges,,,
SCREW T2 F/T LOCK 5 X 30 -,SUP-1896-5030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA [1000108],AETNA [100010801],,,76.8,,577.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5MMX32.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA [1000108],AETNA [100010801],,,76.8,,577.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW T2 F/T LOCK 5 X 35 -,SUP-1896-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA [1000108],AETNA [100010801],,,76.8,,577.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5MMX37.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA [1000108],AETNA [100010801],,,76.8,,577.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW T2 F/T LOCK 5 X 40 -,SUP-1896-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA [1000108],AETNA [100010801],,,76.8,,577.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5MMX42.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA [1000108],AETNA [100010801],,,76.8,,577.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW T2 F/T LOCK 5 X 45 -,SUP-1896-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA [1000108],AETNA [100010801],,,76.8,,577.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5MMX47.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5047S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA [1000108],AETNA [100010801],,,76.8,,577.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW T2 F/T LOCK 5 X 50 -,SUP-1896-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA [1000108],AETNA [100010801],,,76.8,,577.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5MMX52.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5052S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA [1000108],AETNA [100010801],,,76.8,,577.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW T2 F/T LOCK 5 X 55 -,SUP-1896-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA [1000108],AETNA [100010801],,,76.8,,577.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5MMX57.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5057S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA [1000108],AETNA [100010801],,,76.8,,577.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW T2 F/T LOCK 5 X 60 -,SUP-1896-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA [1000108],AETNA [100010801],,,76.8,,577.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW T2 F/T LOCK 5 X 65 -,SUP-1896-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA [1000108],AETNA [100010801],,,76.8,,577.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW T2 F/T LOCK 5 X 70 -,SUP-1896-5070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA [1000108],AETNA [100010801],,,76.8,,577.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW T2 F/T LOCK 5 X 75 -,SUP-1896-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA [1000108],AETNA [100010801],,,76.8,,577.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X80MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA [1000108],AETNA [100010801],,,76.8,,577.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X85MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA [1000108],AETNA [100010801],,,76.8,,577.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X90MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA [1000108],AETNA [100010801],,,76.8,,577.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X100MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA [1000108],AETNA [100010801],,,76.8,,577.19,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN UNIPLATE 2 36MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-02-036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN UNIPLATE 2 38MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-02-038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.6X12MM UNIPLATE ST CANC TI BLU -,SUP-1897-06-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.6X13MM UNIPLATE ST CANC TI BLU -,SUP-1897-06-013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.6X14MM UNIPLATE ST CANC TI GOLD -,SUP-189706014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE 14MM UNIPLATE SPINE CERVICAL ANTERIOR SELF -,SUP-1897-06-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1293.32,905.324,AETNA [1000108],AETNA [100010801],,,76.8,,993.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.6X15MM UNIPLATE ST CANC TI LBLU -,SUP-1897-06-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.6X18MM UNIPLATE ST CANC TI LBLU -,SUP-1897-06-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.2MMX14MM UNIPLATE OVSZ CANC TI GOLD -,SUP-1897-06-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.2MMX18MM UNIPLATE ST CANC TI GOLD -,SUP-1897-06-118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.6X12MM UNIPLATE SD CANC TI BLU -,SUP-1897-07-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.6X13MM UNIPLATE SD CANC TI VIOL -,SUP-1897-07-013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.6X15MM UNIPLATE SD CANC TI LBLU -,SUP-1897-07-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN UNIPLATE 2 14MM LVL1 PRELRD TI NRW MDLN NO- BND -,SUP-189721014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN UNIPLATE 2 16MM LVL1 PRELRD TI NRW MDLN NO- BND -,SUP-189721016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN UNIPLATE 2 28MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-22-028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN UNIPLATE 2 32MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-22-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN UNIPLATE 2 34MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-22-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW T2 RECON LAG 6.5MM X 75MM -,SUP-1897-6075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,AETNA [1000108],AETNA [100010801],,,76.8,,743.45,0.518595,35041.66656,percent of total billed charges,,,
SCREW T2 RECON LAG 6.5MM X 80MM -,SUP-1897-6080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,AETNA [1000108],AETNA [100010801],,,76.8,,743.45,0.518595,35041.66656,percent of total billed charges,,,
SCREW LAG T2 RECON SYSTEM 6.5 X 85 -,SUP-1897-6085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,AETNA [1000108],AETNA [100010801],,,76.8,,743.45,0.518595,35041.66656,percent of total billed charges,,,
SCREW LAG BONE T2 RECON SYSTEM 6.5 X 90 -,SUP-1897-6090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,AETNA [1000108],AETNA [100010801],,,76.8,,743.45,0.518595,35041.66656,percent of total billed charges,,,
SCREW LAG T2 RECON 6.5MM X 100MM -,SUP-1897-6100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,AETNA [1000108],AETNA [100010801],,,76.8,,743.45,0.518595,35041.66656,percent of total billed charges,,,
LEVEL 1 PLATE 20MM -,SUP-19-0120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
CALBIBER SPACER 10 X 22MM- 10-15MM -,SUP-194.222,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,AETNA [1000108],AETNA [100010801],,,76.8,,11976.65,0.518595,35041.66656,percent of total billed charges,,,
SCREW SEMI CONST DRILL 4.0 X 14 -,SUP-19-6514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2MMX6MM LCK COMPR CORT LCP FT STD CRUCIF RCESS SS NS -,SUP-201.006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,93.36,65.352,AETNA [1000108],AETNA [100010801],,,76.8,,71.7,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.4MMX10MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,AETNA [1000108],AETNA [100010801],,,76.8,,347.3,0.518595,35041.66656,percent of total billed charges,,,
CLIP ANEUR 2.4MMX12MM SS LCP ST -,SUP-201.762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,AETNA [1000108],AETNA [100010801],,,76.8,,347.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.4MMX13MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.763,CDM,C1713,HCPCS,278,RC,,,outpatient,,,411.37,287.959,AETNA [1000108],AETNA [100010801],,,76.8,,315.93,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.4MMX14MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.764,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,AETNA [1000108],AETNA [100010801],,,76.8,,347.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.4MMX18MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.768,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,AETNA [1000108],AETNA [100010801],,,76.8,,347.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.4MMX22MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.772,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,AETNA [1000108],AETNA [100010801],,,76.8,,347.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2X10MM LCK COMPR LCP THRD ST FA T6 STRDRV RCESS SS NS -,SUP-201.880,CDM,C1713,HCPCS,278,RC,,,outpatient,,,830.26,581.182,AETNA [1000108],AETNA [100010801],,,76.8,,637.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MMX10MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,328.22,229.754,AETNA [1000108],AETNA [100010801],,,76.8,,252.07,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MMX12MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,328.22,229.754,AETNA [1000108],AETNA [100010801],,,76.8,,252.07,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MMX26MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA [1000108],AETNA [100010801],,,76.8,,52.65,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MMX28MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA [1000108],AETNA [100010801],,,76.8,,52.65,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MMX30MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA [1000108],AETNA [100010801],,,76.8,,52.65,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MMX32MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA [1000108],AETNA [100010801],,,76.8,,52.65,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MMX34MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA [1000108],AETNA [100010801],,,76.8,,52.65,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MMX36MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA [1000108],AETNA [100010801],,,76.8,,52.65,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MMX38MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA [1000108],AETNA [100010801],,,76.8,,52.65,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MMX40MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA [1000108],AETNA [100010801],,,76.8,,52.65,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MMX45MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA [1000108],AETNA [100010801],,,76.8,,52.65,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MMX50MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA [1000108],AETNA [100010801],,,76.8,,52.65,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MMX55MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA [1000108],AETNA [100010801],,,76.8,,52.65,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X10MM LCK COMPR LCP THRD ST T8 STRDRV RCESS SS NS -,SUP-202.210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,886.92,620.844,AETNA [1000108],AETNA [100010801],,,76.8,,681.15,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X30MM LCK COMPR LCP THRD ST T8 STRDRV RCESS SS NS -,SUP-202.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.01,516.607,AETNA [1000108],AETNA [100010801],,,76.8,,566.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X40MM LCK COMPR LCP THRD ST T8 STRDRV RCESS SS NS -,SUP-202.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.01,516.607,AETNA [1000108],AETNA [100010801],,,76.8,,566.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3X14MM CANN LNG THRD SD/ST CRUCIF RCESS SS NS -,SUP-202.714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1530.52,1071.364,AETNA [1000108],AETNA [100010801],,,76.8,,1175.44,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X16MM LCK COMPR CORT LCP FT ST T8 STRDRV RCESS SS -,SUP-202.876,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,AETNA [1000108],AETNA [100010801],,,76.8,,332.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X18MM LCK COMPR CORT LCP FT ST T8 STRDRV RCESS SS -,SUP-202.878,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,AETNA [1000108],AETNA [100010801],,,76.8,,332.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTEX SLF TPNG 2.7 X 20MM T8 SD REC -,SUP-202.880,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,AETNA [1000108],AETNA [100010801],,,76.8,,332.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X24MM LCK COMPR CORT LCP FT ST T8 STRDRV RCESS SS -,SUP-202.884,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,AETNA [1000108],AETNA [100010801],,,76.8,,332.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTEX SLF TPNG 2.7 X 26MM T8 SD REC -,SUP-202.886,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,AETNA [1000108],AETNA [100010801],,,76.8,,332.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTEX SLF TPNG 2.7 X 28MM T8 SD REC -,SUP-202.888,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,AETNA [1000108],AETNA [100010801],,,76.8,,332.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTEX SLF TPNG 2.7 X 30MM T8 SD REC -,SUP-202.890,CDM,C1713,HCPCS,278,RC,,,outpatient,,,577.67,404.369,AETNA [1000108],AETNA [100010801],,,76.8,,443.65,0.518595,35041.66656,percent of total billed charges,,,
BODY PHOENIX SHRT OPN BD -,SUP-20-2070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
BODY STD PHOENIX OPN BD POST PDCL F/MN INV FX SYS -,SUP-20-2090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
6.5 X 40MM CANCELLOUS BONE SCREW -,SUP-2030-6540-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW ACTB 6.5X55MM OMNIFIT -,SUP-2030-6555-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW ACTB 6.5X60MM OMNIFIT -,SUP-2030-6560-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X10MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X12MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X14MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,192.56,134.792,AETNA [1000108],AETNA [100010801],,,76.8,,147.89,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X16MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX18MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX20MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX22MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX24MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX26MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX28MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX32MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX34MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX36MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX38MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX40MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX45MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X50MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X28MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X30MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X32MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X34MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X36MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X38MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA [1000108],AETNA [100010801],,,76.8,,151.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X14MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA [1000108],AETNA [100010801],,,76.8,,241.99,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X20MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA [1000108],AETNA [100010801],,,76.8,,241.99,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X22MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA [1000108],AETNA [100010801],,,76.8,,241.99,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X24MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA [1000108],AETNA [100010801],,,76.8,,241.99,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X26MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA [1000108],AETNA [100010801],,,76.8,,241.99,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X28MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA [1000108],AETNA [100010801],,,76.8,,241.99,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X32MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA [1000108],AETNA [100010801],,,76.8,,241.99,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X34MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.834,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA [1000108],AETNA [100010801],,,76.8,,241.99,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X48MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.848,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA [1000108],AETNA [100010801],,,76.8,,241.99,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN PHOENIX 35MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN PHOENIX 40MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN PHOENIX 45MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN PHOENIX 50MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN PHOENIX 55MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN PHOENIX 70MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN PHOENIX 75MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX10MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX12MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX14MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.61,257.327,AETNA [1000108],AETNA [100010801],,,76.8,,282.32,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX16MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.61,257.327,AETNA [1000108],AETNA [100010801],,,76.8,,282.32,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX18MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.61,257.327,AETNA [1000108],AETNA [100010801],,,76.8,,282.32,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX22MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX24MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX26MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX30MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX35MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX40MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX45MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX50MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX55MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX60MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,,,
FEM PRESSURIZING SEAL - SMALL -,SUP-206-545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,101.12,70.784,AETNA [1000108],AETNA [100010801],,,76.8,,77.66,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X10MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X12MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X14MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X16MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X18MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X20MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X22MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X24MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X26MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X28MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X30MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,157.55,110.285,AETNA [1000108],AETNA [100010801],,,76.8,,121,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X40MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X45MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X50MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA [1000108],AETNA [100010801],,,76.8,,124.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX34MM LCK CANN LCP LNG THRD SD/ST 2.5MM SM HEX SCKT -,SUP-207.734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,AETNA [1000108],AETNA [100010801],,,76.8,,1066.54,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7MMX35MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,AETNA [1000108],AETNA [100010801],,,76.8,,1914.29,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7MMX40MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,AETNA [1000108],AETNA [100010801],,,76.8,,1914.29,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7MMX45MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,AETNA [1000108],AETNA [100010801],,,76.8,,1914.29,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7MMX50MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,AETNA [1000108],AETNA [100010801],,,76.8,,1914.29,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7MMX70MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,AETNA [1000108],AETNA [100010801],,,76.8,,1914.29,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7MMX75MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,AETNA [1000108],AETNA [100010801],,,76.8,,1914.29,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X95MM LCK CANN 32MM THRD SD/ST REVCT FLUT 4MM LRG -,SUP-208.441,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1770.37,1239.259,AETNA [1000108],AETNA [100010801],,,76.8,,1359.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7MMX45MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,AETNA [1000108],AETNA [100010801],,,76.8,,1914.29,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7MMX50MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,AETNA [1000108],AETNA [100010801],,,76.8,,1914.29,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7MMX55MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,AETNA [1000108],AETNA [100010801],,,76.8,,1914.29,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7MMX80MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,AETNA [1000108],AETNA [100010801],,,76.8,,1914.29,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7X32MM CANN -,SUP-209.750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7.3X75MM LCK CANN THRD SD/ST REVCT FLUT HEX SCKT -,SUP-209.875,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1710.52,1197.364,AETNA [1000108],AETNA [100010801],,,76.8,,1313.68,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUT SQA + THRDR TAB TI NTNL -,SUP-210.309,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2065.07,1445.549,AETNA [1000108],AETNA [100010801],,,76.8,,1585.97,0.518595,35041.66656,percent of total billed charges,,,
SUBSTITUTE TCP 1.2ML FOAM PK VITOSS RESRB COMPR RSIS -,SUP-2102-1401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1579.18,1105.426,AETNA [1000108],AETNA [100010801],,,76.8,,1212.81,0.518595,35041.66656,percent of total billed charges,,,
VITOSS BIOACTIVE PACK 2.5CC -,SUP-2102-1602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3430.26,2401.182,AETNA [1000108],AETNA [100010801],,,76.8,,2634.44,0.518595,35041.66656,percent of total billed charges,,,
VITOSS BA2X FOAM PACK 1.2CC -,SUP-2102-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2600.96,1820.672,AETNA [1000108],AETNA [100010801],,,76.8,,1997.54,0.518595,35041.66656,percent of total billed charges,,,
VITOSS BA2X FOAM PK BONE GRAFT 1.2CC -,SUP-2102-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2600.96,1820.672,AETNA [1000108],AETNA [100010801],,,76.8,,1997.54,0.518595,35041.66656,percent of total billed charges,,,
VITOSS BA2X BONE GRAFT 2.5CC -,SUP-2102-2102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4015.89,2811.123,AETNA [1000108],AETNA [100010801],,,76.8,,3084.2,0.518595,35041.66656,percent of total billed charges,,,
VITOSS BA2X BONE GRAFT 5CC -,SUP-2102-2105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6693.85,4685.695,AETNA [1000108],AETNA [100010801],,,76.8,,5140.88,0.518595,35041.66656,percent of total billed charges,,,
VITOSS BA2X BONE GRAFT 10CC -,SUP-2102-2110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10931.81,7652.267,AETNA [1000108],AETNA [100010801],,,76.8,,8395.63,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.4MMX12MM CANN 0.5IN LNG THRD SD/ST T8 STRDRV RCESS -,SUP-211.812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1577.85,1104.495,AETNA [1000108],AETNA [100010801],,,76.8,,1211.79,0.518595,35041.66656,percent of total billed charges,,,
CANNULATED SCREW 2.4mm X15mm -,SUP-211.815,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,AETNA [1000108],AETNA [100010801],,,76.8,,1066.54,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANNULATED 2.4MM X17MM L -,SUP-211.817,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1431.14,1001.798,AETNA [1000108],AETNA [100010801],,,76.8,,1099.12,0.518595,35041.66656,percent of total billed charges,,,
2.4MM CANN SCREW LONG 19MM -,SUP-211.819,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1431.14,1001.798,AETNA [1000108],AETNA [100010801],,,76.8,,1099.12,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX55MM LCK COMPR LCP FT ST SS NS GRN -,SUP-212.123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,813.98,569.786,AETNA [1000108],AETNA [100010801],,,76.8,,625.14,0.518595,35041.66656,percent of total billed charges,,,
BONE PIN- 3.2 x 110MM- STERILE (2 Pack) -,SUP-213524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,AETNA [1000108],AETNA [100010801],,,76.8,,494.15,0.518595,35041.66656,percent of total billed charges,,,
BONE PIN- 3.2 x 140MM- STERILE (2 Pack) -,SUP-213527,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,AETNA [1000108],AETNA [100010801],,,76.8,,494.15,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX16MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA [1000108],AETNA [100010801],,,76.8,,272.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX28MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA [1000108],AETNA [100010801],,,76.8,,272.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX30MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA [1000108],AETNA [100010801],,,76.8,,272.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX32MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA [1000108],AETNA [100010801],,,76.8,,272.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX36MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA [1000108],AETNA [100010801],,,76.8,,272.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX38MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA [1000108],AETNA [100010801],,,76.8,,272.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX40MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA [1000108],AETNA [100010801],,,76.8,,272.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX46MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA [1000108],AETNA [100010801],,,76.8,,272.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX50MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA [1000108],AETNA [100010801],,,76.8,,272.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX52MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA [1000108],AETNA [100010801],,,76.8,,272.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX56MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA [1000108],AETNA [100010801],,,76.8,,272.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX34MM LCK CANN P/T SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1518.59,1063.013,AETNA [1000108],AETNA [100010801],,,76.8,,1166.28,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX42MM LCK CANN P/T SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1518.59,1063.013,AETNA [1000108],AETNA [100010801],,,76.8,,1166.28,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX44MM LCK CANN P/T SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1518.59,1063.013,AETNA [1000108],AETNA [100010801],,,76.8,,1166.28,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX40MM LCK CANN FT SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1562.32,1093.624,AETNA [1000108],AETNA [100010801],,,76.8,,1199.86,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX44MM LCK CANN FT SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1562.32,1093.624,AETNA [1000108],AETNA [100010801],,,76.8,,1199.86,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX50MM LCK CANN FT SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1562.32,1093.624,AETNA [1000108],AETNA [100010801],,,76.8,,1199.86,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MMX40MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-216.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,AETNA [1000108],AETNA [100010801],,,76.8,,238.63,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MMX55MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,AETNA [1000108],AETNA [100010801],,,76.8,,238.63,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MMX60MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,AETNA [1000108],AETNA [100010801],,,76.8,,238.63,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MMX65MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,AETNA [1000108],AETNA [100010801],,,76.8,,238.63,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MMX70MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,AETNA [1000108],AETNA [100010801],,,76.8,,238.63,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MMX75MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,AETNA [1000108],AETNA [100010801],,,76.8,,238.63,0.518595,35041.66656,percent of total billed charges,,,
PLATE 9MM SHRT FASTFLAP 2HL STR 1.6MM NEURO SYS STRL -,SUP-218-0022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.42,222.194,AETNA [1000108],AETNA [100010801],,,76.8,,243.78,0.518595,35041.66656,percent of total billed charges,,,
PLATE CRNL 22MM 5HL 0.5MM STR FAST FLAP 1.6MM NEURO SYS TI -,SUP-218-0030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,868.25,607.775,AETNA [1000108],AETNA [100010801],,,76.8,,666.82,0.518595,35041.66656,percent of total billed charges,,,
PLATE CRANFC MED FST-FLP MSH 5HL TI BUR HL GRV SHNT 1.6MM -,SUP-218-0069,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA [1000108],AETNA [100010801],,,76.8,,1055.15,0.518595,35041.66656,percent of total billed charges,,,
PLATE CRNL LNG 2HL 0.25MM STR FAST FLAP 1.6MM NEURO SYS TI -,SUP-218-0093,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.8,316.96,AETNA [1000108],AETNA [100010801],,,76.8,,347.75,0.518595,35041.66656,percent of total billed charges,,,
PLATE CRNL 22MM LRG 0.25MM FAST FLAP BUR HL CVR 1.6MM NEURO -,SUP-218-0095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1077.06,753.942,AETNA [1000108],AETNA [100010801],,,76.8,,827.18,0.518595,35041.66656,percent of total billed charges,,,
PLATE CRANFC 90X90MM FST-FLP OSTFRM MSH TI PREFRM 1.6MM -,SUP-218-2006-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6545.95,4582.165,AETNA [1000108],AETNA [100010801],,,76.8,,5027.29,0.518595,35041.66656,percent of total billed charges,,,
WASHER ORTHO 10MM F/4.5MM CANN SCR RND NS -,SUP-219.910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,218.81,153.167,AETNA [1000108],AETNA [100010801],,,76.8,,168.05,0.518595,35041.66656,percent of total billed charges,,,
WASHER ORTHO 13MM F/6.5MM CANC LRG BN SCR RND NS -,SUP-219.990,CDM,C1713,HCPCS,278,RC,,,outpatient,,,223.19,156.233,AETNA [1000108],AETNA [100010801],,,76.8,,171.41,0.518595,35041.66656,percent of total billed charges,,,
ACCELFIX LUMBAR EXPANDABLE CAGE 8 22 X 11 X 8MM -,SUP-2211-0808S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19669.62,13768.734,AETNA [1000108],AETNA [100010801],,,76.8,,15106.27,0.518595,35041.66656,percent of total billed charges,,,
ACCELFIX EXPANDABLE LUMBAR CAGE 15 22 X 11 X 8 -,SUP-2211-0815S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19669.62,13768.734,AETNA [1000108],AETNA [100010801],,,76.8,,15106.27,0.518595,35041.66656,percent of total billed charges,,,
CAGE ACCELFIX LUMB EXPAND 8 DEG 22 X 11 X 12 -,SUP-2211-1208S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,AETNA [1000108],AETNA [100010801],,,76.8,,11976.65,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUT HEALIX ADVANCE 4.5MM MUL-THRD BCRL RAPIDE -,SUP-222.295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1643.16,1150.212,AETNA [1000108],AETNA [100010801],,,76.8,,1261.95,0.518595,35041.66656,percent of total billed charges,,,
SUTURE ORTHOCORD #2 MO-7 36IN BRD BLU VIOL 223114 1/2CIR MPK -,SUP-223.114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.04,210.028,AETNA [1000108],AETNA [100010801],,,76.8,,230.43,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN LC-DCP 11X77MM 3.5MM 6HL LC BSC LCK DCP SS SM NS -,SUP-223.560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2413.05,1689.135,AETNA [1000108],AETNA [100010801],,,76.8,,1853.22,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN LC-DCP 11X90MM 3.5MM 7HL LC BSC LCK DCP SS SM NS -,SUP-223.570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2504.49,1753.143,AETNA [1000108],AETNA [100010801],,,76.8,,1923.45,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN LC-DCP 11X103MM 3.5MM 8HL LC BSC DCP SS SM NS -,SUP-223.580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2631.7,1842.19,AETNA [1000108],AETNA [100010801],,,76.8,,2021.15,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN LC-DCP 11X116MM 3.5MM 9HL LC BSC LCK DCP SS SM NS -,SUP-223.590,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2466.96,1726.872,AETNA [1000108],AETNA [100010801],,,76.8,,1894.63,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN LC-DCP 11X129MM 3.5MM 10HL LC BSC LCK DCP SS SM NS -,SUP-223.600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2542.16,1779.512,AETNA [1000108],AETNA [100010801],,,76.8,,1952.38,0.518595,35041.66656,percent of total billed charges,,,
GUIDEPIN ORTHO BRKWY 2.5MM GLOBAL APG + -,SUP-2230-00-019,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1126.16,788.312,AETNA [1000108],AETNA [100010801],,,76.8,,864.89,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN LC-DCP 13.5X155MM 12HL 4.2MM LC COMPR SS 3.5MM BRD -,SUP-225.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2321.62,1625.134,AETNA [1000108],AETNA [100010801],,,76.8,,1783,0.518595,35041.66656,percent of total billed charges,,,
SUBSTITUTE DEMIN CANC TISS 0.75ML G2 DIVERTED MRSL VOID FIL -,SUP-227005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1139.61,797.727,AETNA [1000108],AETNA [100010801],,,76.8,,875.22,0.518595,35041.66656,percent of total billed charges,,,
SUBSTITUTE G2 TISS 0.5ML STRIP PREFL ATF STR TUBE -,SUP-227010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,846.08,592.256,AETNA [1000108],AETNA [100010801],,,76.8,,649.79,0.518595,35041.66656,percent of total billed charges,,,
KT ORTHO MILAGRO FEM -,SUP-232.300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2199.71,1539.797,AETNA [1000108],AETNA [100010801],,,76.8,,1689.38,0.518595,35041.66656,percent of total billed charges,,,
END CAP LOWER EXTREMITY 8 +0MM -,SUP-2330-0000S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1195.26,836.682,AETNA [1000108],AETNA [100010801],,,76.8,,917.96,0.518595,35041.66656,percent of total billed charges,,,
T2 ALFPHA COMPRESSION SCREW FEMUR 5.5 -,SUP-2330-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1333.08,933.156,AETNA [1000108],AETNA [100010801],,,76.8,,1023.81,0.518595,35041.66656,percent of total billed charges,,,
END CAP GT/PF T2 ALPHA 013 +10 -,SUP-2330-0010S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1195.26,836.682,AETNA [1000108],AETNA [100010801],,,76.8,,917.96,0.518595,35041.66656,percent of total billed charges,,,
NAIL FEMORAL GT LEFT 11 X 320MM -,SUP-2331-1132S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,AETNA [1000108],AETNA [100010801],,,76.8,,7478.28,0.518595,35041.66656,percent of total billed charges,,,
FEMORAL NAIL GT- LEFT Ã˜11X420MM -,SUP-2331-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9735.49,6814.843,AETNA [1000108],AETNA [100010801],,,76.8,,7476.86,0.518595,35041.66656,percent of total billed charges,,,
FEMORAL NAIL GT LEFT 13 X 400MM -,SUP-2331-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10095.65,7066.955,AETNA [1000108],AETNA [100010801],,,76.8,,7753.46,0.518595,35041.66656,percent of total billed charges,,,
FEMORAL NAIL GT RT 10 X 360 -,SUP-2333-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12776.73,8943.711,AETNA [1000108],AETNA [100010801],,,76.8,,9812.53,0.518595,35041.66656,percent of total billed charges,,,
FEMORAL NAIL GT RIGHT 10 X 420MM -,SUP-2333-1042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,AETNA [1000108],AETNA [100010801],,,76.8,,7478.28,0.518595,35041.66656,percent of total billed charges,,,
NAIL INTRAMEDULLARY T2 ALPHA FEMUR ANTEGRADE SYSTEM 11 X 380 -,SUP-2333-1138S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,AETNA [1000108],AETNA [100010801],,,76.8,,7478.28,0.518595,35041.66656,percent of total billed charges,,,
FEMORAL NAIL GT RIGHT 11 X 420MM -,SUP-2333-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,AETNA [1000108],AETNA [100010801],,,76.8,,7478.28,0.518595,35041.66656,percent of total billed charges,,,
FEMORAL NAIL GT RIGHT 11 X 440MM -,SUP-2333-1144S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,AETNA [1000108],AETNA [100010801],,,76.8,,7478.28,0.518595,35041.66656,percent of total billed charges,,,
FEMORAL NAIL GT RIGHT 13MM X 400MM -,SUP-2333-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10095.65,7066.955,AETNA [1000108],AETNA [100010801],,,76.8,,7753.46,0.518595,35041.66656,percent of total billed charges,,,
FEMORAL NAIL RETROGRADE D10X360MM -,SUP-2339-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,AETNA [1000108],AETNA [100010801],,,76.8,,7821.9,0.518595,35041.66656,percent of total billed charges,,,
FEMORAL NAIL RETROGRADE D10X400MM -,SUP-2339-1040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,AETNA [1000108],AETNA [100010801],,,76.8,,7821.9,0.518595,35041.66656,percent of total billed charges,,,
SYS FEMUR RETROGRADE NAIL 11 X 200MM T2 ALPHA SHORT -,SUP-2339-1120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,AETNA [1000108],AETNA [100010801],,,76.8,,7821.9,0.518595,35041.66656,percent of total billed charges,,,
FEMORAL NAIL RETROGRADE 11 X 300MM -,SUP-2339-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,AETNA [1000108],AETNA [100010801],,,76.8,,7821.9,0.518595,35041.66656,percent of total billed charges,,,
NAIL T2 FEMUR ALPHA RETROGRADE 11 X 340MM -,SUP-2339-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,AETNA [1000108],AETNA [100010801],,,76.8,,7821.9,0.518595,35041.66656,percent of total billed charges,,,
FEMORAL NAIL RETROGRADE D11X380MM -,SUP-2339-1138S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,AETNA [1000108],AETNA [100010801],,,76.8,,7821.9,0.518595,35041.66656,percent of total billed charges,,,
FEMORAL NAIL RETROGRADE 12 X 340MM -,SUP-2339-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10561.63,7393.141,AETNA [1000108],AETNA [100010801],,,76.8,,8111.33,0.518595,35041.66656,percent of total billed charges,,,
T2 ALPA FEMUR NAIL RETROGRADE 12 X 360 -,SUP-2339-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10559.77,7391.839,AETNA [1000108],AETNA [100010801],,,76.8,,8109.9,0.518595,35041.66656,percent of total billed charges,,,
FEMORAL NAIL RETROGRADE 13X340MM -,SUP-2339-1334S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10561.63,7393.141,AETNA [1000108],AETNA [100010801],,,76.8,,8111.33,0.518595,35041.66656,percent of total billed charges,,,
FEMORAL NAIL RETROGRADE D13X360MM -,SUP-2339-1336S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10559.77,7391.839,AETNA [1000108],AETNA [100010801],,,76.8,,8109.9,0.518595,35041.66656,percent of total billed charges,,,
SCREW INTFR CANN 8X23MM THRD BABSRB PLLA -,SUP-234-010-162,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,AETNA [1000108],AETNA [100010801],,,76.8,,996.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW INTFR CANN BIOSTEON 7X28MM 1MM CANN FLLY BLNT THRD -,SUP-234-010-164,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,AETNA [1000108],AETNA [100010801],,,76.8,,996.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW INTFR CANN BIOSTEON 8X28MM BABSRB WDG SHP HAP PLLA -,SUP-234-010-165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,AETNA [1000108],AETNA [100010801],,,76.8,,996.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW INTFR CANN 9X28MM THRD BABSRB PLLA -,SUP-234-010-166,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,AETNA [1000108],AETNA [100010801],,,76.8,,996.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW INTFR CANN BIOSTEON 11X35MM 1MM CANN FLLY BLNT THRD -,SUP-234-010-179,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,AETNA [1000108],AETNA [100010801],,,76.8,,996.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW INTFR CANN BIOSTEON 12X35MM 1MM CANN FLLY BLNT THRD -,SUP-234-010-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2187.89,1531.523,AETNA [1000108],AETNA [100010801],,,76.8,,1680.3,0.518595,35041.66656,percent of total billed charges,,,
COMPRESSION SCREW TIBIA 5.5 -,SUP-2341-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1333.08,933.156,AETNA [1000108],AETNA [100010801],,,76.8,,1023.81,0.518595,35041.66656,percent of total billed charges,,,
END CAP TIBIA T2 ALPHA 11.5 X +5MM -,SUP-2341-0005S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,AETNA [1000108],AETNA [100010801],,,76.8,,997.34,0.518595,35041.66656,percent of total billed charges,,,
END CAP TIBIA T2 ALPHA 11.5 X 10MM -,SUP-2341-0010S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,AETNA [1000108],AETNA [100010801],,,76.8,,997.34,0.518595,35041.66656,percent of total billed charges,,,
END CAP TIBIA T2 ALPHA 11.5 X 15MM -,SUP-2341-0015S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,AETNA [1000108],AETNA [100010801],,,76.8,,997.34,0.518595,35041.66656,percent of total billed charges,,,
GUIDEPIN ENDO VERSITOMIC SHP MEM ALY TECH FLXB -,SUP-234-108-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2166.31,1516.417,AETNA [1000108],AETNA [100010801],,,76.8,,1663.73,0.518595,35041.66656,percent of total billed charges,,,
GUIDEPIN ENDO VERSITOMIC FLXB -,SUP-234-108-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2187.89,1531.523,AETNA [1000108],AETNA [100010801],,,76.8,,1680.3,0.518595,35041.66656,percent of total billed charges,,,
TIBIAL NAIL 9 X 285MM -,SUP-2341-0928S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,,,
TIBIAL NAIL T2 ALPHA 9 X 300 -,SUP-2341-0930S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,,,
TIBIAL NAIL T2 09 X 315MM -,SUP-2341-0931S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,,,
NAIL TIBIAL 9 X 330 T2 ALPHA -,SUP-2341-0933S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,,,
TIBIAL NAIL 9 X 345 -,SUP-2341-0934S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,,,
TIBIAL NAIL 9 X 360 -,SUP-2341-0936S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,,,
TIBIAL NAIL 9 X 375 -,SUP-2341-0937S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,,,
TIBIAL NAIL 9 X 390MM -,SUP-2341-0939S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,,,
TIBIAL NAIL 10X285MM -,SUP-2341-1028S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10764.14,7534.898,AETNA [1000108],AETNA [100010801],,,76.8,,8266.86,0.518595,35041.66656,percent of total billed charges,,,
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM 10 X 300 -,SUP-2341-1030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,,,
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM 10 X 315 -,SUP-2341-1031S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,,,
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM -,SUP-2341-1033S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,,,
T2 ALPHA TIBIA NAIL 10X345MM SYS -,SUP-2341-1034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,,,
NAIL TIBIAL 10 X 360 T2 ALPHA -,SUP-2341-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,,,
NAIL TIBIAL 10 X 375MM T2 ALPHA -,SUP-2341-1037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,,,
NAIL TIBIAL 10 X 390 T2 ALPHA -,SUP-2341-1039S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,,,
NAIL TIBIAL T2 ALPHA 11 X 300MM -,SUP-2341-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,,,
NAIL TIBIAL T2 11 X 315 -,SUP-2341-1131S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,,,
TIBIAL NAIL 11 X 330 -,SUP-2341-1133S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,,,
NAIL SYSTEM T2 ALPHA TIBIA 11 X 345MM -,SUP-2341-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,,,
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM -,SUP-2341-1136S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,,,
TIBIAL NAIL T2 ALPHA 11 X 375 -,SUP-2341-1137S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,,,
T2 ALPHA TIBIA NAIL 11 X 390MM -,SUP-2341-1139S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA [1000108],AETNA [100010801],,,76.8,,6526.93,0.518595,35041.66656,percent of total billed charges,,,
NAIL TIBIAL T2 ALPHA 12 X 315MM -,SUP-2341-1231S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,AETNA [1000108],AETNA [100010801],,,76.8,,6769.76,0.518595,35041.66656,percent of total billed charges,,,
NAIL TIBIAL T2 ALPHA 12 X 330MM -,SUP-2341-1233S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,AETNA [1000108],AETNA [100010801],,,76.8,,6769.76,0.518595,35041.66656,percent of total billed charges,,,
T2 ALPHA TIBIA SYSTEM TIBIAL NAIL -,SUP-2341-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,AETNA [1000108],AETNA [100010801],,,76.8,,6769.76,0.518595,35041.66656,percent of total billed charges,,,
T2 ALPHA TIBIAL NAIL 12 X 380MM -,SUP-2341-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10764.1,7534.87,AETNA [1000108],AETNA [100010801],,,76.8,,8266.83,0.518595,35041.66656,percent of total billed charges,,,
TIBIAL NAIL 12 X 375MM -,SUP-2341-1237S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,AETNA [1000108],AETNA [100010801],,,76.8,,6769.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 8X50MM -,SUP-234500150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,885.69,619.983,AETNA [1000108],AETNA [100010801],,,76.8,,680.21,0.518595,35041.66656,percent of total billed charges,,,
LOCKING SCREW 5 X 25MM -,SUP-2360-5025S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,,,
LOCKING SCREW 5 X 27.5MM -,SUP-2360-5027S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 5X32MM -,SUP-2360-5032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,,,
SCREW IMN SYSTEM LOCKING SCREW 5 X 35 -,SUP-2360-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,,,
IMN LOCKING SCREW 5 X 37.5MM -,SUP-2360-5037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,,,
IMN SCREW SYSTEM LOCKING SCREW 5 X 40 -,SUP-2360-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 5X42MM -,SUP-2360-5042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,,,
LOCKING SCREW 05 X 45MM -,SUP-2360-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,,,
IMN LOCKING SCREW 5X47.5MM -,SUP-2360-5047S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,,,
IMN LCK SCREW 5X50 -,SUP-2360-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,,,
IMN LCK SCREW 5X52 -,SUP-2360-5052S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,,,
SCREW LCK STRYKER 5 X 55 -,SUP-2360-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,,,
IMN LOCKING SCREW 5X57.5MM -,SUP-2360-5057S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,,,
IMN LOCKING SCREW 0.5 X 60MM -,SUP-2360-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1836.62,1285.634,AETNA [1000108],AETNA [100010801],,,76.8,,1410.52,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING SYS IMN 5 X 60MM -,SUP-2360-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,,,
IMN LOCKING SCREW 0.5 X 65MM -,SUP-2360-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 5 X 70MM -,SUP-2360-5070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE T2 ALPHA IMN LOCKING  0.5 X 75MM -,SUP-2360-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING SYS IMN 5 X 65MM -,SUP-2360-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 5 X 85 -,SUP-2360-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 5 X 90 -,SUP-2360-5090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,,,
SCREW IMN T2 ALPHA LOCKING  5MM X 95MM -,SUP-2360-5095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING SYS IMN 5 X 100MM -,SUP-2360-5100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA [1000108],AETNA [100010801],,,76.8,,1009.55,0.518595,35041.66656,percent of total billed charges,,,
ADVANCED LOCKING SCREW 5X30MM -,SUP-2361-5030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA [1000108],AETNA [100010801],,,76.8,,1194.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW ADVANCED LOCKING 5MM X 32.5MM -,SUP-2361-5032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA [1000108],AETNA [100010801],,,76.8,,1194.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW ADVANCED LOCKING 5 X 35 -,SUP-2361-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA [1000108],AETNA [100010801],,,76.8,,1194.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING ADVANCED IMN 05 X 37.5MM -,SUP-2361-5037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA [1000108],AETNA [100010801],,,76.8,,1194.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING ADVANCED IMN 05 X 40MM -,SUP-2361-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA [1000108],AETNA [100010801],,,76.8,,1194.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW ADVANCED LOCKING 5MM X 42.5MM -,SUP-2361-5042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA [1000108],AETNA [100010801],,,76.8,,1194.78,0.518595,35041.66656,percent of total billed charges,,,
ADVANCED LOCKING SCREW 5MM X 45MM -,SUP-2361-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA [1000108],AETNA [100010801],,,76.8,,1194.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW IMN LCK 5 X 45 -,SUP-2361-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA [1000108],AETNA [100010801],,,76.8,,1194.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW ADVANCED LOCKING 5MM X 47.5MM -,SUP-2361-5047S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA [1000108],AETNA [100010801],,,76.8,,1194.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING ADVANCED 5X50MM -,SUP-2361-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA [1000108],AETNA [100010801],,,76.8,,1194.78,0.518595,35041.66656,percent of total billed charges,,,
ADVANCED LOCKING SCREW 5MM X 52.5MM -,SUP-2361-5052S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA [1000108],AETNA [100010801],,,76.8,,1194.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW ADVANCED LOCKING 5MM X 55MM -,SUP-2361-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA [1000108],AETNA [100010801],,,76.8,,1194.78,0.518595,35041.66656,percent of total billed charges,,,
ADVANCED LOCKING SCREW 5 X 57.5MM -,SUP-2361-5057S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA [1000108],AETNA [100010801],,,76.8,,1194.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X60MM IMN ADVANCED LOCKING -,SUP-2361-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA [1000108],AETNA [100010801],,,76.8,,1194.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW ADVANCED LOCKING 5MM X 65MM -,SUP-2361-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA [1000108],AETNA [100010801],,,76.8,,1194.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW ADVANCED LOCKING 5MM X 70MM -,SUP-2361-5070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA [1000108],AETNA [100010801],,,76.8,,1194.78,0.518595,35041.66656,percent of total billed charges,,,
ADVANCED LOCKING SCREW 5 X 57MM -,SUP-2361-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA [1000108],AETNA [100010801],,,76.8,,1194.78,0.518595,35041.66656,percent of total billed charges,,,
ADVANCED LOCKING SCREW 5 X 80 -,SUP-2361-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA [1000108],AETNA [100010801],,,76.8,,1194.78,0.518595,35041.66656,percent of total billed charges,,,
IMN ADVANCED LOCKING SCREW 5MM X 85MM -,SUP-2361-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA [1000108],AETNA [100010801],,,76.8,,1194.78,0.518595,35041.66656,percent of total billed charges,,,
ADVANCED LOCKING SCREW 5 X 90MM -,SUP-2361-5090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1553.05,1087.135,AETNA [1000108],AETNA [100010801],,,76.8,,1192.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW IMN LOCKING 5MM X 95MM -,SUP-2361-5095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA [1000108],AETNA [100010801],,,76.8,,1194.78,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN LCP 83MM 4/5MM 4HL BSC LCK COMPR SS LRG T-SHP NS -,SUP-240.141,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3467.5,2427.25,AETNA [1000108],AETNA [100010801],,,76.8,,2663.04,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN STERNAL TALON 14MM D FT PLATE LEGX2 SGL TI SM STRL -,SUP-24-009-14-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,AETNA [1000108],AETNA [100010801],,,76.8,,4094.28,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN STERNAL TALON SGL LEGX2 BIOCMPT TI SM STRL -,SUP-24-009-17-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,AETNA [1000108],AETNA [100010801],,,76.8,,4094.28,0.518595,35041.66656,percent of total billed charges,,,
FOOT PLATE BN STERNAL TALON SGL VRSN TI 17MM MED STRL LEGX2 -,SUP-24-010-17-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,AETNA [1000108],AETNA [100010801],,,76.8,,4094.28,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN STERNAL TALON 20MM D LEGX2 SGL TI MED STRL -,SUP-24-010-20-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,AETNA [1000108],AETNA [100010801],,,76.8,,4094.28,0.518595,35041.66656,percent of total billed charges,,,
FOOT PLATE XL 12X20MM STERNAL TALON SGL -,SUP-24-012-20-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,AETNA [1000108],AETNA [100010801],,,76.8,,4094.28,0.518595,35041.66656,percent of total billed charges,,,
STERNAL SCREW 2.3 -,SUP-24-023-09-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,AETNA [1000108],AETNA [100010801],,,76.8,,243.11,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X11MM LCK DRL-FR MAXDRIVE THREADLOCK TS SLF RET TI -,SUP-24-023-11-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,AETNA [1000108],AETNA [100010801],,,76.8,,243.11,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X13MM LCK DRL-FR MAXDRIVE THREADLOCK TS SLF RET TI -,SUP-24-023-13-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,AETNA [1000108],AETNA [100010801],,,76.8,,243.11,0.518595,35041.66656,percent of total billed charges,,,
STERNAL SCREW 2.3 X 15MM -,SUP-24-023-15-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,AETNA [1000108],AETNA [100010801],,,76.8,,243.11,0.518595,35041.66656,percent of total billed charges,,,
2.3MM SELF DRILLING STERNAL SCREWS -,SUP-24-023-17-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,AETNA [1000108],AETNA [100010801],,,76.8,,243.11,0.518595,35041.66656,percent of total billed charges,,,
PLATE LEVEL 1 THORACIC STERNAL LKG STR 2.3MM SCRW 20 HL -,SUP-24-025-07-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3118.62,2183.034,AETNA [1000108],AETNA [100010801],,,76.8,,2395.1,0.518595,35041.66656,percent of total billed charges,,,
STERNAL PLATE LOCK 6-HOLE 1.8 -,SUP-24-025-42-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2398.48,1678.936,AETNA [1000108],AETNA [100010801],,,76.8,,1842.03,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 8HL 1.8MM LCK TI X-SHP -,SUP-24-025-44-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2224.88,1557.416,AETNA [1000108],AETNA [100010801],,,76.8,,1708.71,0.518595,35041.66656,percent of total billed charges,,,
4 HOLE STRAIGHT -,SUP-24-025-48-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2155.98,1509.186,AETNA [1000108],AETNA [100010801],,,76.8,,1655.79,0.518595,35041.66656,percent of total billed charges,,,
PLATE LEVEL ONE THORACIC STERNAL LKG STR W/2.3MM SCREW -,SUP-24-025-50-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2580.02,1806.014,AETNA [1000108],AETNA [100010801],,,76.8,,1981.46,0.518595,35041.66656,percent of total billed charges,,,
9 HOLE Y PLATE -,SUP-24-025-52-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2613.77,1829.639,AETNA [1000108],AETNA [100010801],,,76.8,,2007.38,0.518595,35041.66656,percent of total billed charges,,,
PLATE 4 HOLE ANGLE -,SUP-24-025-59-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1906.85,1334.795,AETNA [1000108],AETNA [100010801],,,76.8,,1464.46,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN LC-DCP 10X50MM 3.5MM 3HL HD/SHFT LC DCP SS T-SHP RT -,SUP-241.130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,781.42,546.994,AETNA [1000108],AETNA [100010801],,,76.8,,600.13,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN LC-DCP 11X64MM 3.5MM HLX3/5 HD/SHFT LC DCP SS T-SHP -,SUP-241.150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,944.22,660.954,AETNA [1000108],AETNA [100010801],,,76.8,,725.16,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN LC-DCP 10X53MM 3.5MM 3HL HD/SHFT LC LCK DCP SS -,SUP-241.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1176.71,823.697,AETNA [1000108],AETNA [100010801],,,76.8,,903.71,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN LC-DCP 10X63MM 3.5MM 0.75HL HD/SHFT LC LCK DCP SS -,SUP-241.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1296.45,907.515,AETNA [1000108],AETNA [100010801],,,76.8,,995.67,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN LC-DCP 10X75MM 3.5MM HLX3/5 HD/SHFT LC LCK DCP SS -,SUP-241.250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1282.72,897.904,AETNA [1000108],AETNA [100010801],,,76.8,,985.13,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN LC-DCP 9X25MM 3.5MM 2HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,AETNA [1000108],AETNA [100010801],,,76.8,,880.57,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN LC-DCP 9X49MM 3.5MM 4HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA [1000108],AETNA [100010801],,,76.8,,946.46,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN LC-DCP 9X61MM 3.5MM 5HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA [1000108],AETNA [100010801],,,76.8,,946.46,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN LCP 9X57MM 2.7/3.5MM 5HL CONTR LCK COMPR SS SM 1/3 -,SUP-241.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1594.13,1115.891,AETNA [1000108],AETNA [100010801],,,76.8,,1224.29,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN LC-DCP 9X85MM 3.5MM 7HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1268.14,887.698,AETNA [1000108],AETNA [100010801],,,76.8,,973.93,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN LC-DCP 9X97MM 3.5MM 8HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1315.85,921.095,AETNA [1000108],AETNA [100010801],,,76.8,,1010.57,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN LC-DCP 9X121MM 3.5MM 10HL LC DCP SS SM MINI 1/3 -,SUP-241.400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,AETNA [1000108],AETNA [100010801],,,76.8,,1050.26,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN LCP 9X117MM 2.7/3.5MM 10HL CONTR LCK COMPR SS SM -,SUP-241.401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1745.19,1221.633,AETNA [1000108],AETNA [100010801],,,76.8,,1340.31,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN LCP 15MM D 3.5MM 5HL PRCONT LCK COMPR SS HOOK STRL -,SUP-241-085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4546.38,3182.466,AETNA [1000108],AETNA [100010801],,,76.8,,3491.62,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN LCP 6.3X49MM 2.4MM 0.75HL HD/SHFT FA CONTR LCK -,SUP-242.507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2479.52,1735.664,AETNA [1000108],AETNA [100010801],,,76.8,,1904.27,0.518595,35041.66656,percent of total billed charges,,,
SPACER TNDN 6X24MM SILASTIC PLYSTR COR SWN-HNT STRL -,SUP-24270006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7240.26,5068.182,AETNA [1000108],AETNA [100010801],,,76.8,,5560.52,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 82MM 3.5MM 7HL RECON SS STR NS -,SUP-245.170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3397.89,2378.523,AETNA [1000108],AETNA [100010801],,,76.8,,2609.58,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN LC-DCP 94MM 3.5MM 8HL RECON DCP SS STR NS -,SUP-245.181,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3544.7,2481.29,AETNA [1000108],AETNA [100010801],,,76.8,,2722.33,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN LC-DCP 106MM 3.5MM 9HL RECON DCP SS STR NS -,SUP-245.190,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3738.04,2616.628,AETNA [1000108],AETNA [100010801],,,76.8,,2870.81,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 53MM 2MM HLX2/8 HD/SHFT 1.2MM RECON SS T-SHP NS -,SUP-247.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1616.65,1131.655,AETNA [1000108],AETNA [100010801],,,76.8,,1241.59,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN LCP 54MM 2MM 7HL RECON LCK COMPR SS NS -,SUP-247.349,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4745.36,3321.752,AETNA [1000108],AETNA [100010801],,,76.8,,3644.44,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN LCP 44MM 2.4MM 5HL RECON ADPR LCK COMPR SS STR NS -,SUP-247.375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2573.19,1801.233,AETNA [1000108],AETNA [100010801],,,76.8,,1976.21,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN LCP 36MM 2.4MM 4HL RECON LCK COMPR SS STR NS -,SUP-249.674,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2496.8,1747.76,AETNA [1000108],AETNA [100010801],,,76.8,,1917.54,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN LCP 59MM 2.4MM 7HL RECON LCK COMPR SS STR NS -,SUP-249.679,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3862.17,2703.519,AETNA [1000108],AETNA [100010801],,,76.8,,2966.15,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN LCP 58MM 2.7MM 6HL RECON LCK COMPR SS STR NS -,SUP-249.682,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3247.51,2273.257,AETNA [1000108],AETNA [100010801],,,76.8,,2494.09,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN LCP 67MM 2.7MM 7HL RECON LCK COMPR SS STR NS -,SUP-249.683,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2544.54,1781.178,AETNA [1000108],AETNA [100010801],,,76.8,,1954.21,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN LCP 32MM 2.7MM 0.66HL HD/SHFT RECON LCK COMPR SS -,SUP-249.685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,AETNA [1000108],AETNA [100010801],,,76.8,,3629.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCK -,SUP-250-1001-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,,,
SCREW 8.5MM SHTH INTRAFIX PEEK PP NS F/ACL FX -,SUP-254.683,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,0.518595,35041.66656,percent of total billed charges,,,
SCREW LCK CRNMXF 2.3X11MM CROSS-DRIVE TI ALY -,SUP-25-773-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,0.518595,35041.66656,percent of total billed charges,,,
CAGE 7 MWX8MMX21MM TRAXIS PEEK/ TI -,SUP-2601070921,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,AETNA [1000108],AETNA [100010801],,,76.8,,11962.4,0.518595,35041.66656,percent of total billed charges,,,
CAGE VERT 25MM VUE 7MM/9MM LD /TRAILING DIA SGL LVL PEEK -,SUP-2601070925,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,AETNA [1000108],AETNA [100010801],,,76.8,,11962.4,0.518595,35041.66656,percent of total billed charges,,,
CAGE 9X21X9MM TRAXIS VUE 9MM/9MM DIA LD /TRAILING DIA SGL -,SUP-2601090921,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,AETNA [1000108],AETNA [100010801],,,76.8,,11962.4,0.518595,35041.66656,percent of total billed charges,,,
GUIDE DRILL POR F/KN ARTHPL -,SUP-261-0060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,,,
USTAR II KNEE CEMENTED STR STEM RHS 17X125 -,SUP-2715-3117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA [1000108],AETNA [100010801],,,76.8,,6046.17,0.518595,35041.66656,percent of total billed charges,,,
BLADE IM NAIL 12.5X105MM SS HLCL NS F /LCP DHS -,SUP-282.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2284.52,1599.164,AETNA [1000108],AETNA [100010801],,,76.8,,1754.51,0.518595,35041.66656,percent of total billed charges,,,
BLADE IM NAIL 12.5X120MM SS HLCL NS F /LCP DHS -,SUP-282.243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2277.41,1594.187,AETNA [1000108],AETNA [100010801],,,76.8,,1749.05,0.518595,35041.66656,percent of total billed charges,,,
ORTHOFIX CAGE 6.5 -,SUP-28-2180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA [1000108],AETNA [100010801],,,76.8,,13259.87,0.518595,35041.66656,percent of total billed charges,,,
ORTHOFIX CAGE 8.5 -,SUP-28-2182,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA [1000108],AETNA [100010801],,,76.8,,13259.87,0.518595,35041.66656,percent of total billed charges,,,
ORTHOFIX CAGE 6.5 X 24 XP -,SUP-28-3140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA [1000108],AETNA [100010801],,,76.8,,13259.87,0.518595,35041.66656,percent of total billed charges,,,
CAGE XP LORDOTIC 8.5 -,SUP-28-3142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA [1000108],AETNA [100010801],,,76.8,,13259.87,0.518595,35041.66656,percent of total billed charges,,,
ORTHOFIX FORZA XP CAGE 10.5H X 10W X 24L -,SUP-28-3144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA [1000108],AETNA [100010801],,,76.8,,13259.87,0.518595,35041.66656,percent of total billed charges,,,
ORTHOFIX 12H EXPANDABLE CAGE -,SUP-28-3146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA [1000108],AETNA [100010801],,,76.8,,13259.87,0.518595,35041.66656,percent of total billed charges,,,
EXPANDABLE CAGE 6.5MMX10MM WIDE X28MM -,SUP-28-3180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA [1000108],AETNA [100010801],,,76.8,,13259.87,0.518595,35041.66656,percent of total billed charges,,,
CAGE FORZA XP ORTHOFIX 10.5MM -,SUP-28-3184,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA [1000108],AETNA [100010801],,,76.8,,13259.87,0.518595,35041.66656,percent of total billed charges,,,
ORTHOFIX HYPERLORDOTIC CAGE 8.5 -,SUP-28-4142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA [1000108],AETNA [100010801],,,76.8,,13259.87,0.518595,35041.66656,percent of total billed charges,,,
CAGE 10.5HL HYPER XP -,SUP-28-4144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA [1000108],AETNA [100010801],,,76.8,,13259.87,0.518595,35041.66656,percent of total billed charges,,,
ORTHOFIX CAGE 12.5 X 24. HL -,SUP-28-4146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA [1000108],AETNA [100010801],,,76.8,,13259.87,0.518595,35041.66656,percent of total billed charges,,,
USTAR II KNEE SEGMENT PART RHS 25MM -,SUP-2915-1025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22014.38,15410.066,AETNA [1000108],AETNA [100010801],,,76.8,,16907.04,0.518595,35041.66656,percent of total billed charges,,,
SPACER VERT 22X8MM CAP STN VERTSTCK PEEK -,SUP-2960822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,AETNA [1000108],AETNA [100010801],,,76.8,,10265.7,0.518595,35041.66656,percent of total billed charges,,,
SPACER VERT 26X8MM CAP STN VERTSTCK PEEK -,SUP-2960826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20245.95,14172.165,AETNA [1000108],AETNA [100010801],,,76.8,,15548.89,0.518595,35041.66656,percent of total billed charges,,,
SPACER VERT 22X10MM CAP STN VERTSTCK 8DG PEEK -,SUP-2961022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,AETNA [1000108],AETNA [100010801],,,76.8,,10265.7,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X12MM LCK ACU-LOC 2 HXLB DRIVE F/VOLAR DIST RAD -,SUP-30-0234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,822.74,575.918,AETNA [1000108],AETNA [100010801],,,76.8,,631.86,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X14MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,76.8,,694.6,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X18MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0237,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,76.8,,694.6,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X20MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,76.8,,694.6,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X22MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0239,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,76.8,,694.6,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X24MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,76.8,,694.6,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X26MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0241,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,76.8,,694.6,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X30MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,76.8,,694.6,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X32MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,76.8,,694.6,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X36MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0246,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,76.8,,694.6,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X45MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0249,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,76.8,,694.6,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X22MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0262,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,AETNA [1000108],AETNA [100010801],,,76.8,,412.28,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X24MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0263,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,AETNA [1000108],AETNA [100010801],,,76.8,,412.28,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X26MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0264,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,AETNA [1000108],AETNA [100010801],,,76.8,,412.28,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X32MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0267,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,AETNA [1000108],AETNA [100010801],,,76.8,,412.28,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X40MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0271,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,AETNA [1000108],AETNA [100010801],,,76.8,,412.28,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X45MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0272,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,AETNA [1000108],AETNA [100010801],,,76.8,,412.28,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X50MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0273,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,AETNA [1000108],AETNA [100010801],,,76.8,,542.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X55MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0274,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,AETNA [1000108],AETNA [100010801],,,76.8,,542.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3X40MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0294,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,76.8,,694.6,0.518595,35041.66656,percent of total billed charges,,,
SCREW Ti SET 8X17.5MM -,SUP-3003-0822S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,858.1,600.67,AETNA [1000108],AETNA [100010801],,,76.8,,659.02,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X14MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0327,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,76.8,,694.6,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X16MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,76.8,,694.6,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X18MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0329,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,76.8,,694.6,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X20MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,76.8,,694.6,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X22MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0331,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,76.8,,694.6,0.518595,35041.66656,percent of total billed charges,,,
CAP END +10MM TI GAMMA3 -,SUP-3005-1110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,858.1,600.67,AETNA [1000108],AETNA [100010801],,,76.8,,659.02,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.7X45MM ACUTRAK 2 NS -,SUP-30-0645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,AETNA [1000108],AETNA [100010801],,,76.8,,2053.2,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.7X50MM ACUTRAK 2 NS -,SUP-30-0650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,AETNA [1000108],AETNA [100010801],,,76.8,,2053.2,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.3X26MM LCK POLARUS 3 HXLB DRV TI STRL -,SUP-3011-43026-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,AETNA [1000108],AETNA [100010801],,,76.8,,846.97,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.3X46MM HXLB -,SUP-3011-43046-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,AETNA [1000108],AETNA [100010801],,,76.8,,846.97,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.6MM/4.5MM DIA TIP/BK END 20MM CANN HDLS BIOTRAK -,SUP-3017-0009-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3465.92,2426.144,AETNA [1000108],AETNA [100010801],,,76.8,,2661.83,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.6MM/4.6MM DIA TIP/BK END 22MM CANN HDLS BIOTRAK -,SUP-3017-0010-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3465.92,2426.144,AETNA [1000108],AETNA [100010801],,,76.8,,2661.83,0.518595,35041.66656,percent of total billed charges,,,
SPACER THORLUM VERT 10X26X8MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
SPACER THORLUM VERT 10X26X9MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
SPACER THORLUM VERT 10X26X10MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
SPACER THORLUM VERT 10X26X11MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
SPACER THORLUM VERT 10X26X12MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
SPACER THORLUM VERT 8X22X8MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.078,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
SPACER THORLUM VERT 8X22X9MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.079,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
SPACER THORLUM VERT 8X22X10MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
SPACER THORLUM VERT 8X22X11MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.081,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
SPACER THORLUM VERT 8X22X12MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
SPACER THORLUM VERT 8X22X13MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.083,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
SPACER THORLUM VERT 10X22X8MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.088,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
SPACER THORLUM VERT 10X22X9MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.089,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
SPACER THORLUM VERT 10X22X10MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
SPACER THORLUM VERT 10X22X11MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.091,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
SPACER THORLUM VERT 10X22X12MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.092,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
SPACER THORLUM VERT 10X22X13MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.093,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
SPACER THORLUM VERT 10X22X15MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
SPACER THORLUM VERT 12X26X10MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.970,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
SPACER THORLUM VERT 12X26X17MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.977,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
LAG SCREW TI 10.5 X 75mm -,SUP-3060-0075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA [1000108],AETNA [100010801],,,76.8,,1670.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW GAMMA3 LAG TI 10.5X80 -,SUP-3060-0080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA [1000108],AETNA [100010801],,,76.8,,1670.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW GAMMA3 LAG Ti 10.5X85 -,SUP-3060-0085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA [1000108],AETNA [100010801],,,76.8,,1670.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 90MM -,SUP-3060-0090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA [1000108],AETNA [100010801],,,76.8,,1670.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW GAMMA3 LAG Ti 10.5X95 -,SUP-3060-0095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA [1000108],AETNA [100010801],,,76.8,,1670.36,0.518595,35041.66656,percent of total billed charges,,,
GAMMA3 LAG SCREW TI 10.5X100 -,SUP-3060-0100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA [1000108],AETNA [100010801],,,76.8,,1670.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW GAMMA3 LAG T1 10.5X105 -,SUP-3060-0105S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA [1000108],AETNA [100010801],,,76.8,,1670.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 110MM -,SUP-3060-0110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA [1000108],AETNA [100010801],,,76.8,,1670.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 115MM -,SUP-3060-0115S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA [1000108],AETNA [100010801],,,76.8,,1670.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 120MM -,SUP-3060-0120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA [1000108],AETNA [100010801],,,76.8,,1670.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 125MM -,SUP-3060-0125S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA [1000108],AETNA [100010801],,,76.8,,1670.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 130MM -,SUP-3060-0130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA [1000108],AETNA [100010801],,,76.8,,1670.36,0.518595,35041.66656,percent of total billed charges,,,
U-BLADE SET TI 10.5 X 95MM -,SUP-3066-0095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2850.17,1995.119,AETNA [1000108],AETNA [100010801],,,76.8,,2188.93,0.518595,35041.66656,percent of total billed charges,,,
GRAFT DBM 1ML PTTY OSTEOSELECT VOID FIL OSTCONDC -,SUP-309010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,,,
OSTEOSELECT 2.5CC -,SUP-309025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1749.17,1224.419,AETNA [1000108],AETNA [100010801],,,76.8,,1343.36,0.518595,35041.66656,percent of total billed charges,,,
SUBSTITUTE DBM 5ML PTTY OSTEOSELECT VOID FIL OSTCONDC -,SUP-309050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,0.518595,35041.66656,percent of total billed charges,,,
SUBSTITUTE DBM 10ML PTTY OSTEOSELECT -,SUP-309100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,0.518595,35041.66656,percent of total billed charges,,,
SPACER RADIOLUCENT 7MM CANOPY -,SUP-3102.6007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,0.518595,35041.66656,percent of total billed charges,,,
5CC BIO4 VIABLE BONE MATRIX -,SUP-3102-2105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8594.1,6015.87,AETNA [1000108],AETNA [100010801],,,76.8,,6600.27,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 15.5/11X180MM GAMMA3 LT TROCH FEM TI BIOMECH STRGTH -,SUP-3120-1180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4598.63,3219.041,AETNA [1000108],AETNA [100010801],,,76.8,,3531.75,0.518595,35041.66656,percent of total billed charges,,,
TROCHANTERIC NAIL KIT 10X170MMX125DG -,SUP-3125-0170S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5413.56,3789.492,AETNA [1000108],AETNA [100010801],,,76.8,,4157.61,0.518595,35041.66656,percent of total billed charges,,,
NAIL GAMMA3 TROCHANTARIC 180 -,SUP-3125-1180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4598.63,3219.041,AETNA [1000108],AETNA [100010801],,,76.8,,3531.75,0.518595,35041.66656,percent of total billed charges,,,
KIT TROCHANTERIC KIT 11X180 SF -,SUP-3130-1180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4598.63,3219.041,AETNA [1000108],AETNA [100010801],,,76.8,,3531.75,0.518595,35041.66656,percent of total billed charges,,,
DRILL BIT RINGLOC + QUICK CONNECT 3.2MM X 20MM -,SUP-31-323220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,76.8,,380.91,0.518595,35041.66656,percent of total billed charges,,,
EQUINOXE SHLDR -,SUP-320-15-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,AETNA [1000108],AETNA [100010801],,,76.8,,6192.84,0.518595,35041.66656,percent of total billed charges,,,
SCREW LCK COMPR EQUINOXE F/RVRS BALL/SCKT SURG -,SUP-320-15-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
SET SCREW INTNL FX EQUINOXE SHLDR RVRS TRQ DEFINING LCK -,SUP-320-20-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,AETNA [1000108],AETNA [100010801],,,76.8,,1119.47,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X22MM LCK COMPR EQUINOXE BLK F/RVRS BALL/SCKT SURG -,SUP-320-20-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X34MM LCK COMPR EQUINOXE RD F/RVRS BALL/SCKT SURG -,SUP-320-20-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
LONG NAIL GAMMA KIT 11X300 RIG -,SUP-3225-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA [1000108],AETNA [100010801],,,76.8,,5394.49,0.518595,35041.66656,percent of total billed charges,,,
LONG GAMMA NAIL 11X320 RIGHT -,SUP-3225-0320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA [1000108],AETNA [100010801],,,76.8,,5394.49,0.518595,35041.66656,percent of total billed charges,,,
NAIL KIT LONG R2.0 TI RT. GAMM -,SUP-3225-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA [1000108],AETNA [100010801],,,76.8,,5394.49,0.518595,35041.66656,percent of total billed charges,,,
LONG GAMMA NAIL 11X380 RIGHT -,SUP-3225-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA [1000108],AETNA [100010801],,,76.8,,5394.49,0.518595,35041.66656,percent of total billed charges,,,
LONG GAMMA NAIL 11X400 RIGHT -,SUP-3225-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA [1000108],AETNA [100010801],,,76.8,,5394.49,0.518595,35041.66656,percent of total billed charges,,,
LONG GAMMA NAIL 11X420 RIGHT -,SUP-3225-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA [1000108],AETNA [100010801],,,76.8,,5394.49,0.518595,35041.66656,percent of total billed charges,,,
NAIL LONG RT GAMMA3 KIT 11MM X -,SUP-3225-0440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA [1000108],AETNA [100010801],,,76.8,,5394.49,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 15MM/13MM DIA P/D 2MM RAD LNG 340MM GAMMA3 RT TROCH -,SUP-3225-3340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,AETNA [1000108],AETNA [100010801],,,76.8,,5738.49,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX16MM CANN ASNIS III 8MM P/T SD/ST REVCT FLUT SS NS -,SUP-325016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA [1000108],AETNA [100010801],,,76.8,,646.25,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX24MM CANN ASNIS III 8MM P/T SD/ST REVCT FLUT SS NS -,SUP-325024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA [1000108],AETNA [100010801],,,76.8,,646.25,0.518595,35041.66656,percent of total billed charges,,,
SCREW PT CANN ASNIS 4.0 X 28 -,SUP-325028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA [1000108],AETNA [100010801],,,76.8,,646.25,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX30MM CANN ASNIS III 10MM P/T SD/ST REVCT FLUT SS -,SUP-325030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA [1000108],AETNA [100010801],,,76.8,,646.25,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX32MM CANN ASNIS III 11MM P/T SD/ST REVCT FLUT SS -,SUP-325032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA [1000108],AETNA [100010801],,,76.8,,646.25,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX34MM CANN ASNIS III 11.5MM P/T SD/ST REVCT FLUT SS -,SUP-325034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA [1000108],AETNA [100010801],,,76.8,,646.25,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX34MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-325034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA [1000108],AETNA [100010801],,,76.8,,646.25,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX36MM CANN ASNIS III 12MM P/T SD/ST REVCT FLUT SS -,SUP-325036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA [1000108],AETNA [100010801],,,76.8,,646.25,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX38MM CANN ASNIS III 13MM P/T SD/ST REVCT FLUT SS -,SUP-325038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA [1000108],AETNA [100010801],,,76.8,,646.25,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX40MM CANN ASNIS III 13.5MM P/T SD/ST REVCT FLUT SS -,SUP-325040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA [1000108],AETNA [100010801],,,76.8,,646.25,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX42MM CANN ASNIS III 14MM P/T SD/ST REVCT FLUT SS -,SUP-325042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA [1000108],AETNA [100010801],,,76.8,,646.25,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX44MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325044S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA [1000108],AETNA [100010801],,,76.8,,646.25,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX46MM CANN ASNIS III 15.5MM P/T SD/ST REVCT FLUT SS -,SUP-325046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA [1000108],AETNA [100010801],,,76.8,,646.25,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX46MM CANN ASNIS III 0.33IN P/T SD/ST REVCT FLUT SS -,SUP-325046S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA [1000108],AETNA [100010801],,,76.8,,646.25,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX48MM CANN ASNIS III 16MM P/T SD/ST REVCT FLUT SS -,SUP-325048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA [1000108],AETNA [100010801],,,76.8,,646.25,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX50MM CANN ASNIS III 17MM P/T SD/ST REVCT FLUT SS -,SUP-325050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA [1000108],AETNA [100010801],,,76.8,,646.25,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX55MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA [1000108],AETNA [100010801],,,76.8,,646.25,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-325060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA [1000108],AETNA [100010801],,,76.8,,646.25,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX60MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA [1000108],AETNA [100010801],,,76.8,,646.25,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX70MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA [1000108],AETNA [100010801],,,76.8,,646.25,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANNULATED 4.0 X 32 -,SUP-325232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,AETNA [1000108],AETNA [100010801],,,76.8,,777.37,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X42MM CANN FT -,SUP-325242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,AETNA [1000108],AETNA [100010801],,,76.8,,777.37,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X44MM CANN FT -,SUP-325244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,AETNA [1000108],AETNA [100010801],,,76.8,,777.37,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5MMX70MM CANN ASNIS III 23.5MM P/T SD/ST REVCT FLUT SS -,SUP-325470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA [1000108],AETNA [100010801],,,76.8,,711.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANNULATED 5.0 X 60MM -,SUP-325660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,AETNA [1000108],AETNA [100010801],,,76.8,,854.13,0.518595,35041.66656,percent of total billed charges,,,
ASNIS III SS CANNULATED SCR 5 X 70MM -,SUP-325670S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA [1000108],AETNA [100010801],,,76.8,,711.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW SS CANN 6.5 X 70MM ASNIS -,SUP-326070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X75MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X80MM CANN ASNIS III P/T SD/ST REVCT FLUT SS NS -,SUP-326080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X80MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X85MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X85MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X90MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X90MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS 6.5MM 95MM -,SUP-326095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X95MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS 6.5MM 100MM -,SUP-326100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X100MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X105MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326105S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS 6.5 X 110 -,SUP-326110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X110MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X115MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326115S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X120MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,,,
SCREW S.S. TL40 6.5 X 55 -,SUP-326255,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,,,
6.5MM PARTIALLY THREADED 40MM SCREW 60MM LENGTH -,SUP-326260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,,,
SCREW S.S. TL40 6.5 X 70 -,SUP-326270,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MMX75MM CANN ASNIS III 40MM THRD SD/ST REVCT FLUT -,SUP-326275,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MMX80MM CANN ASNIS III 40MM THRD SD/ST REVCT FLUT -,SUP-326280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS CAN 6.5 X 85 -,SUP-326285,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS CAN 6.5 X 90 -,SUP-326290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS CAN 6.5 X 95 -,SUP-326295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS CAN 6.5 X 95 -,SUP-326295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.94,757.358,AETNA [1000108],AETNA [100010801],,,76.8,,830.93,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS CAN 6.5 X 100 -,SUP-326300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,,,
SCREW S.S. TL40 6.5 X 110 -,SUP-326310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,,,
SCREW S.S. TL40 6.5 X 115 -,SUP-326315,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,,,
SCREW S.S. TL40 6.5 X 120 -,SUP-326320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1196.43,837.501,AETNA [1000108],AETNA [100010801],,,76.8,,918.86,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 80 -,SUP-326480S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 85 -,SUP-326485S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANNULATED FULLY THREADED 6.5 X 90MM -,SUP-326490S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS III SS CANNULATED 6.5X95MM -,SUP-326495S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS III SS CANNULATED 6.5X100MM -,SUP-326500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS III SS CANNULATED 6.5X105MM -,SUP-326505S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS III SS CANNULATED 6.5X110MM -,SUP-326510S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS III SS CANNULATED 6.5X115MM -,SUP-326515S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS III SS CANNULATED 6.5X120MM -,SUP-326520S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS III SS CANNULATED 6.5X125MM -,SUP-326525S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS III SS CANNULATED 6.5X130MM -,SUP-326530S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS III CANN 8.0 X 70MM -,SUP-326670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,AETNA [1000108],AETNA [100010801],,,76.8,,893.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW S.S. TL25 8.0 X 75 -,SUP-326675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,AETNA [1000108],AETNA [100010801],,,76.8,,893.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS 8.0 X 80MM -,SUP-326680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,AETNA [1000108],AETNA [100010801],,,76.8,,893.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS CANNULATED 8.0 X 85MM -,SUP-326685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,AETNA [1000108],AETNA [100010801],,,76.8,,893.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW 8MMX90MM CANN ASNIS III 25MM P/T SD/ST REVCT FLUT SS -,SUP-326690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,AETNA [1000108],AETNA [100010801],,,76.8,,893.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW 8MMX95MM CANN ASNIS III 25MM P/T SD/ST REVCT FLUT SS -,SUP-326695,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,AETNA [1000108],AETNA [100010801],,,76.8,,893.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANNULATED PARTIALLY THREADED 8MM X 95MM TL25MM -,SUP-326695S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,AETNA [1000108],AETNA [100010801],,,76.8,,893.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW 8MMX100MM CANN ASNIS III 25MM P/T SD/ST REVCT FLUT SS -,SUP-326700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,AETNA [1000108],AETNA [100010801],,,76.8,,893.62,0.518595,35041.66656,percent of total billed charges,,,
8 x 105MM ASNIS SCREW -,SUP-326705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,AETNA [1000108],AETNA [100010801],,,76.8,,893.62,0.518595,35041.66656,percent of total billed charges,,,
8 X 110MM ASNIS SCREW -,SUP-326710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,AETNA [1000108],AETNA [100010801],,,76.8,,893.62,0.518595,35041.66656,percent of total billed charges,,,
C/M 16MM & 25MM PLUG WITH NOZZLE -,SUP-32810503800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1313.46,919.422,AETNA [1000108],AETNA [100010801],,,76.8,,1008.74,0.518595,35041.66656,percent of total billed charges,,,
LONG NAIL KIT LEFT 300mm -,SUP-3325-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA [1000108],AETNA [100010801],,,76.8,,5394.49,0.518595,35041.66656,percent of total billed charges,,,
NAIL LONG KIT 11X320MMX125 GAM -,SUP-3325-0320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA [1000108],AETNA [100010801],,,76.8,,5394.49,0.518595,35041.66656,percent of total billed charges,,,
NAIL GAMMA LGN LEFT 11X360 -,SUP-3325-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA [1000108],AETNA [100010801],,,76.8,,5394.49,0.518595,35041.66656,percent of total billed charges,,,
NAIL LONG GAMMA3 11X380 LFT -,SUP-3325-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA [1000108],AETNA [100010801],,,76.8,,5394.49,0.518595,35041.66656,percent of total billed charges,,,
LONG GAMMA NAIL 11X400 LEFT -,SUP-3325-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA [1000108],AETNA [100010801],,,76.8,,5394.49,0.518595,35041.66656,percent of total billed charges,,,
LONG GAMMA NAIL 11X420 LEFT -,SUP-3325-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA [1000108],AETNA [100010801],,,76.8,,5394.49,0.518595,35041.66656,percent of total billed charges,,,
LONG GAMMA NAIL 11X440 LEFT -,SUP-3325-0440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA [1000108],AETNA [100010801],,,76.8,,5394.49,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 13MMLNGX340MM GAMMA3 LT TROCH FEM TI BIOMECH STRGTH -,SUP-3325-3340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,AETNA [1000108],AETNA [100010801],,,76.8,,5738.49,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN OPLS 2HL STD BRL COMPR SDE 130DG ANG -,SUP-3362-1-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA [1000108],AETNA [100010801],,,76.8,,2351.29,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 130DG ANG -,SUP-3362-1-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA [1000108],AETNA [100010801],,,76.8,,2351.29,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN OPLS 2HL STD BRL COMPR SDE 135DG ANG KYLS -,SUP-3362-1-102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA [1000108],AETNA [100010801],,,76.8,,2351.29,0.518595,35041.66656,percent of total billed charges,,,
PLATE HIP COMP 135-5-HOLE -,SUP-3362-1-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA [1000108],AETNA [100010801],,,76.8,,2351.29,0.518595,35041.66656,percent of total billed charges,,,
PLATE HIP OMEGA 135 6 HOLE - OBSOLETE DO NOT USE -,SUP-3362-1-106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA [1000108],AETNA [100010801],,,76.8,,2351.29,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN OPLS SLOTX2 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA [1000108],AETNA [100010801],,,76.8,,2351.29,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA [1000108],AETNA [100010801],,,76.8,,2351.29,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN OPLS SLOTX5 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA [1000108],AETNA [100010801],,,76.8,,2351.29,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN OPLS SLOTX6 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA [1000108],AETNA [100010801],,,76.8,,2351.29,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN OPLS SLOTX8 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,AETNA [1000108],AETNA [100010801],,,76.8,,2750.55,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN OPLS SLOTX3 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-303,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA [1000108],AETNA [100010801],,,76.8,,2351.29,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA [1000108],AETNA [100010801],,,76.8,,2351.29,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN OPLS SLOTX5 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-305,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2896.15,2027.305,AETNA [1000108],AETNA [100010801],,,76.8,,2224.24,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN OPLS SLOTX6 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2896.15,2027.305,AETNA [1000108],AETNA [100010801],,,76.8,,2224.24,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN OPLS SLOTX8 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,AETNA [1000108],AETNA [100010801],,,76.8,,2750.55,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN OPLS SLOTX10 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,AETNA [1000108],AETNA [100010801],,,76.8,,2750.55,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 150DG ANG -,SUP-3362-1-404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA [1000108],AETNA [100010801],,,76.8,,2351.29,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN OPLS SLOTX8 STD BRL COMPR SDE 150DG ANG -,SUP-3362-1-408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,AETNA [1000108],AETNA [100010801],,,76.8,,2750.55,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN OPLS SLOTX10 STD BRL COMPR SDE 150DG ANG -,SUP-3362-1-410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3570.95,2499.665,AETNA [1000108],AETNA [100010801],,,76.8,,2742.49,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN OPLS SLOTX12 25.4MM BRL 98DG ANG PRE- KY -,SUP-3362-2-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4883.15,3418.205,AETNA [1000108],AETNA [100010801],,,76.8,,3750.26,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN OMG SLOTX4 STD BRL COMPR 130DG ANG KYLS -,SUP-3362-3-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA [1000108],AETNA [100010801],,,76.8,,2351.29,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN OMG SLOTX2 STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA [1000108],AETNA [100010801],,,76.8,,2351.29,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN OMG SLOTX3 STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-103,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA [1000108],AETNA [100010801],,,76.8,,2351.29,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN OPLS 4HL STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA [1000108],AETNA [100010801],,,76.8,,2351.29,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN OMG SLOTX6 STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA [1000108],AETNA [100010801],,,76.8,,2351.29,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN OMG SLOTX5 STD BRL COMPR 140DG ANG KYLS -,SUP-3362-3-205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA [1000108],AETNA [100010801],,,76.8,,2351.29,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 50MM -,SUP-3362-5-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,AETNA [1000108],AETNA [100010801],,,76.8,,1129.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 55MM -,SUP-3362-5-055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1205.86,844.102,AETNA [1000108],AETNA [100010801],,,76.8,,926.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 60MM -,SUP-3362-5-060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1205.86,844.102,AETNA [1000108],AETNA [100010801],,,76.8,,926.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 65MM -,SUP-3362-5-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,AETNA [1000108],AETNA [100010801],,,76.8,,1129.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 70MM -,SUP-3362-5-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,AETNA [1000108],AETNA [100010801],,,76.8,,1129.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 75MM -,SUP-3362-5-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,AETNA [1000108],AETNA [100010801],,,76.8,,1129.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 80MM -,SUP-3362-5-080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,AETNA [1000108],AETNA [100010801],,,76.8,,1129.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 90MM -,SUP-3362-5-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,AETNA [1000108],AETNA [100010801],,,76.8,,1129.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 95MM -,SUP-3362-5-095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,AETNA [1000108],AETNA [100010801],,,76.8,,1129.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 100MM -,SUP-3362-5-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,AETNA [1000108],AETNA [100010801],,,76.8,,1129.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 105MM -,SUP-3362-5-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,AETNA [1000108],AETNA [100010801],,,76.8,,1129.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X10MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X12MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X14MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X16MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X18MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X20MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X22MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X24MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X26MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X28MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X30MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X32MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X34MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X36MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X38MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X40MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X42MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X44MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X45MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X46MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X48MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X50MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X55MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X60MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X65MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X70MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5 X 75 CORTICAL -,SUP-338675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,AETNA [1000108],AETNA [100010801],,,76.8,,103.7,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X80MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,AETNA [1000108],AETNA [100010801],,,76.8,,103.7,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL 3.5MM X 85MM -,SUP-338685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,AETNA [1000108],AETNA [100010801],,,76.8,,103.7,0.518595,35041.66656,percent of total billed charges,,,
SCREW SELF TAP CORTICAL 3.5 X 115MM -,SUP-338715,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,AETNA [1000108],AETNA [100010801],,,76.8,,103.7,0.518595,35041.66656,percent of total billed charges,,,
SCREW SELF TAP CORTICAL 3.5 X 120MM -,SUP-338720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,AETNA [1000108],AETNA [100010801],,,76.8,,103.7,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X14MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV CUT -,SUP-340614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX16MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX18MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX20MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX22MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX24MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX26MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX28MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX30MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX34MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,AETNA [1000108],AETNA [100010801],,,76.8,,123.72,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX34MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX36MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,AETNA [1000108],AETNA [100010801],,,76.8,,123.72,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX36MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX38MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,AETNA [1000108],AETNA [100010801],,,76.8,,123.72,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX38MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX40MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX40MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,AETNA [1000108],AETNA [100010801],,,76.8,,123.72,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX42MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX42MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,AETNA [1000108],AETNA [100010801],,,76.8,,123.72,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX44MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX44MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,AETNA [1000108],AETNA [100010801],,,76.8,,123.72,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX46MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,AETNA [1000108],AETNA [100010801],,,76.8,,123.72,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX48MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX48MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,AETNA [1000108],AETNA [100010801],,,76.8,,123.72,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX50MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL 4.5 X 52 -,SUP-340652,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL 4.5 X 54 -,SUP-340654,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX55MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX56MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340656,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX58MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340658,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,AETNA [1000108],AETNA [100010801],,,76.8,,123.72,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL 4.5 X 60MM -,SUP-340660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX65MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA [1000108],AETNA [100010801],,,76.8,,123.69,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX75MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,AETNA [1000108],AETNA [100010801],,,76.8,,123.72,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MMX35MM MATTA CANC OMEGA3 SPS 16MM P/T 3.5MM HEX -,SUP-341035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,AETNA [1000108],AETNA [100010801],,,76.8,,109.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MMX40MM MATTA CANC OMEGA3 SPS 16MM P/T 3.5MM HEX -,SUP-341040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,AETNA [1000108],AETNA [100010801],,,76.8,,109.79,0.518595,35041.66656,percent of total billed charges,,,
SPACER KIKO CORPECTOMY SMALL 12 X 14 0 DEG 21MM -,SUP-342.721,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11547.43,8083.201,AETNA [1000108],AETNA [100010801],,,76.8,,8868.43,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB. -,SUP-3420-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11MMX320MM RT TI BIOMECH STRGTH STAB 120DG ANG -,SUP-3420-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11MMX340MM RT TI BIOMECH STRGTH STAB 120DG ANG -,SUP-3420-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MMX80MM MATTA CANC OMEGA3 SPS 32MM P/T 3.5MM HEX -,SUP-342080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,AETNA [1000108],AETNA [100010801],,,76.8,,109.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MMX85MM MATTA CANC OMEGA3 SPS 32MM P/T 3.5MM HEX -,SUP-342085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,AETNA [1000108],AETNA [100010801],,,76.8,,109.79,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10MMX300MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10MMX320MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10MMX340MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10MMX360MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB. -,SUP-3425-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10MMX380MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10MMX400MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,,,
LONG NAIL 10MM X 420MM X 125 DEGREES -,SUP-3425-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11MMX300MM GAMMA3 RT HIP TI BIOMECH STRGTH STAB -,SUP-3425-1300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11MMX320MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11MMX340MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11MMX360MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11MMX380MM GAMMA3 RT TI BIOMECH STRGTH STAB -,SUP-3425-1380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11MMX400MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANCL FT 6.5 X 20 -,SUP-343020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,AETNA [1000108],AETNA [100010801],,,76.8,,109.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANCL FT 6.5 X 25 -,SUP-343025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,AETNA [1000108],AETNA [100010801],,,76.8,,109.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANCL FT 6.5 X 30 -,SUP-343030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,AETNA [1000108],AETNA [100010801],,,76.8,,109.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANCL FT 6.5 X 40 -,SUP-343040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,AETNA [1000108],AETNA [100010801],,,76.8,,109.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MMX85MM MATTA CANC OMEGA3 SPS FT 3.5MM HEX DRV CUT -,SUP-343085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,AETNA [1000108],AETNA [100010801],,,76.8,,109.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX10MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX12MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX14MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX16MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX18MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX20MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX22MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX24MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX26MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX28MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX30MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX32MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX34MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX36MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX38MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW CNCL LCK 4.0 X 40 -,SUP-345440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX45MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX50MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX55MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX60MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX65MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX75MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345475,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,AETNA [1000108],AETNA [100010801],,,76.8,,118.26,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX80MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,AETNA [1000108],AETNA [100010801],,,76.8,,118.26,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX90MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,AETNA [1000108],AETNA [100010801],,,76.8,,118.26,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX10MM LCK CANC AXSOS SPS 5MM P/T ST 2.5MM HEX DRV -,SUP-345510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX14MM LCK CANC AXSOS SPS 6MM P/T ST 2.5MM HEX DRV -,SUP-345514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX18MM LCK CANC AXSOS SPS 6MM P/T ST 2.5MM HEX DRV -,SUP-345518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX34MM LCK CANC AXSOS SPS 14MM P/T ST 2.5MM HEX DRV -,SUP-345534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX36MM LCK CANC AXSOS SPS 14MM P/T ST 2.5MM HEX DRV -,SUP-345536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX38MM LCK CANC AXSOS SPS 14MM P/T ST 2.5MM HEX DRV -,SUP-345538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX40MM LCK CANC AXSOS SPS P/T ST 2.5MM HEX DRV CUT -,SUP-345540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX45MM LCK CANC AXSOS SPS 15MM P/T ST 2.5MM HEX DRV -,SUP-345545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX50MM LCK CANC AXSOS SPS 15MM P/T ST 2.5MM HEX DRV -,SUP-345550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX55MM LCK CANC AXSOS SPS 16MM P/T ST 2.5MM HEX DRV -,SUP-345555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX60MM LCK CANC AXSOS SPS 16MM P/T ST 2.5MM HEX DRV -,SUP-345560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX70MM LCK CANC AXSOS SPS P/T ST 2.5MM HEX DRV CUT -,SUP-345570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA [1000108],AETNA [100010801],,,76.8,,78.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX80MM LCK CANC AXSOS SPS P/T ST 2.5MM HEX DRV CUT -,SUP-345580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,AETNA [1000108],AETNA [100010801],,,76.8,,118.26,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MMX8MM CORT AXSOS ISO SPS FT ST 2.5MM HEX DRV CUT -,SUP-349608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,AETNA [1000108],AETNA [100010801],,,76.8,,114.59,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL 2.7 X 14MM -,SUP-349614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,AETNA [1000108],AETNA [100010801],,,76.8,,114.59,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MMX16MM CORT AXSOS ISO SPS FT ST 2.5MM HEX DRV CUT -,SUP-349616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,AETNA [1000108],AETNA [100010801],,,76.8,,114.59,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MMX18MM CORT AXSOS ISO SPS FT ST 2.5MM HEX DRV CUT -,SUP-349618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,AETNA [1000108],AETNA [100010801],,,76.8,,114.59,0.518595,35041.66656,percent of total billed charges,,,
CORTEX SCREW SELF TAPPING STEEL 2.7MM X 60MM -,SUP-349660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,127.9,89.53,AETNA [1000108],AETNA [100010801],,,76.8,,98.23,0.518595,35041.66656,percent of total billed charges,,,
ASSEMBLY CBL CRLGE TI CBL LOCK SPRCBL ISO-ELAS -,SUP-35-100-1010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2597.25,1818.075,AETNA [1000108],AETNA [100010801],,,76.8,,1994.69,0.518595,35041.66656,percent of total billed charges,,,
CABLE ORTHO SUPERCABLE 1.5MM CERVICAL CERCLAGE -,SUP-35-100-1040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2477.71,1734.397,AETNA [1000108],AETNA [100010801],,,76.8,,1902.88,0.518595,35041.66656,percent of total billed charges,,,
PLATE KINAMED 2 HOLE SUPERCABLE -,SUP-35-200-1020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8377.66,5864.362,AETNA [1000108],AETNA [100010801],,,76.8,,6434.04,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN SPRCBL 190MM 4HL TI TROCH GRP -,SUP-35-200-1030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10233.03,7163.121,AETNA [1000108],AETNA [100010801],,,76.8,,7858.97,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11MMX340MM GAMMA3 LT TI 120DG ANG -,SUP-3520-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11MMX360MM GAMMA3 LT TI 120DG ANG -,SUP-3520-1360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11MMX380MM GAMMA3 LT TI 120DG ANG -,SUP-3520-1380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,,,
CABLE ORTHO SUPER CBL TI PLATE 6HL -,SUP-35-220-1010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5831.26,4081.882,AETNA [1000108],AETNA [100010801],,,76.8,,4478.41,0.518595,35041.66656,percent of total billed charges,,,
CABLE-PLATE 8 HOLE STRAIGHT -,SUP-35-220-2010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7363.34,5154.338,AETNA [1000108],AETNA [100010801],,,76.8,,5655.05,0.518595,35041.66656,percent of total billed charges,,,
SUPERCABLE GRIP AND PLATE 10 HOLE STRAIGHT -,SUP-35-220-3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9661.23,6762.861,AETNA [1000108],AETNA [100010801],,,76.8,,7419.82,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN SPRCBL 290MM 10HL TI TROCH GRP -,SUP-35-220-3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10530.07,7371.049,AETNA [1000108],AETNA [100010801],,,76.8,,8087.09,0.518595,35041.66656,percent of total billed charges,,,
GRIP AND PLATE SYSTEM COMPRESSION BONE SCREW 4.5X12MM -,SUP-35-230-4512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,250.91,175.637,AETNA [1000108],AETNA [100010801],,,76.8,,192.7,0.518595,35041.66656,percent of total billed charges,,,
SUPERCABLE GRIP AND PLATE SYS COP BONE SCREW 4.5 X 14MM -,SUP-35-230-4514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,250.91,175.637,AETNA [1000108],AETNA [100010801],,,76.8,,192.7,0.518595,35041.66656,percent of total billed charges,,,
GRIP AND PLATE COMPRESSION BONE SCREW 4.5 X 16MM -,SUP-35-230-4516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,250.91,175.637,AETNA [1000108],AETNA [100010801],,,76.8,,192.7,0.518595,35041.66656,percent of total billed charges,,,
SUPERCABLE BONE SCREW 4.5 X 30 -,SUP-35-230-4530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,AETNA [1000108],AETNA [100010801],,,76.8,,210.62,0.518595,35041.66656,percent of total billed charges,,,
SUPERCABLE BONE SCREW 4.5 X 32 -,SUP-35-230-4532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,AETNA [1000108],AETNA [100010801],,,76.8,,210.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE SUPERCABLE GRIP AND PLATE COMP  4.5 X 34 -,SUP-35-230-4534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,AETNA [1000108],AETNA [100010801],,,76.8,,210.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X36MM COMPR SPRCBL F/GRP PLATE SYS -,SUP-35-230-4536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,AETNA [1000108],AETNA [100010801],,,76.8,,210.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X38MM COMPR SPRCBL F/GRP PLATE SYS -,SUP-35-230-4538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,AETNA [1000108],AETNA [100010801],,,76.8,,210.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X40MM COMPR SPRCBL F/GRP PLATE SYS -,SUP-35-230-4540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,AETNA [1000108],AETNA [100010801],,,76.8,,210.62,0.518595,35041.66656,percent of total billed charges,,,
GRIP AND PLATE SYS COMP BONE SCREW 4.5MM X 45MM -,SUP-35-230-4545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,AETNA [1000108],AETNA [100010801],,,76.8,,210.62,0.518595,35041.66656,percent of total billed charges,,,
KINAMED SUPERCABLE SCREW -,SUP-35-230-4550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,AETNA [1000108],AETNA [100010801],,,76.8,,210.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X12MM LCK SPRCBL F/GRP PLATE SYS -,SUP-35-234-5012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,AETNA [1000108],AETNA [100010801],,,76.8,,811.12,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X16MM LCK SPRCBL F/GRP PLATE SYS -,SUP-35-234-5016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,AETNA [1000108],AETNA [100010801],,,76.8,,811.12,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X18MM LCK SPRCBL F/GRP PLATE SYS -,SUP-35-234-5018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,AETNA [1000108],AETNA [100010801],,,76.8,,811.12,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE SUPERCABLE GRIP AND PLATE LOCK 5 X 20 -,SUP-35-234-5020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,AETNA [1000108],AETNA [100010801],,,76.8,,811.12,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10MMX300MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10MMX340MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10MMX380MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,,,
"NAIL LONG KIT R1.5 TI LEFT 010 X 125"" -",SUP-3525-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11MMX420MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11MMX440MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11MMX300MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11MMX320MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11MMX340MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11MMX380MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,,,
"NAIL LONG KIT R15 TI 011 X 400MM X 125"" LEFT GAMMAX3 SYS -",SUP-3525-1400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11MMX400MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,,,
NAIL LONG KIT R1 5 TI LEFT -,SUP-3525-1420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,,,
GAMMA LONG NAIL KIT R1.5 LEFT 11X440MM -,SUP-3525-1440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB. -,SUP-3530-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,,,
DBM PUTTY - OSTEOSELECT 2.5CC -,SUP-359025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1749.17,1224.419,AETNA [1000108],AETNA [100010801],,,76.8,,1343.36,0.518595,35041.66656,percent of total billed charges,,,
DBM PUTTY - OSTEOSELECT 5CC -,SUP-359050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,0.518595,35041.66656,percent of total billed charges,,,
DBM PUTTY - OSTEOSELECT 10CC -,SUP-359100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,0.518595,35041.66656,percent of total billed charges,,,
PIN FX STNMN 2.8X230MM SMTH TROC PNT 3-SDE SHNK SS -,SUP-3611-3-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13.5,9.45,AETNA [1000108],AETNA [100010801],,,76.8,,10.37,0.518595,35041.66656,percent of total billed charges,,,
SET SCREW -,SUP-36-2001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,,,
TULIP BODY -,SUP-36-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
REDUCTION HEAD -,SUP-36-2103,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW JANUS ORTHOFIX 4.5 X 30 -,SUP-36-2430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5MM X 35 ORTHOFIX -,SUP-36-2535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW JANUS ORTHOFIX 5.5 X 40 -,SUP-36-2540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
SREW ORTHOFIX FIREBIRD 5.5 X 45MM -,SUP-36-2545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MM X 30MM ORTHOFIX -,SUP-36-2630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW JANUS 6.5X35MM ORTHOFIX -,SUP-36-2635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW JANUS ORTHOFIX 6.5 X 40 -,SUP-36-2640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW JANUS CANN 5.5 X 35 -,SUP-36-3535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW JANUS CANN 5.5 X 40 -,SUP-36-3540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW JANUS CANN 5.5 X 45 -,SUP-36-3545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW JANUS CANN 65 X 35 -,SUP-36-3635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW JANUS CANN 65 X 45 -,SUP-36-3645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5 X 25MM ORTHOFIX -,SUP-36-4425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW JANUS 4.5 X 30MM FENESTRATE ORTHOFIX -,SUP-36-4430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW JANUS 4.5 X 35MM FENESTRATE ORTHOFIX -,SUP-36-4435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW JANUS ORTHOFIX 6.5 X 30MM -,SUP-36-4630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW JANUS ORTHOFIX 6.5 X 35MM -,SUP-36-4635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
SPACER ACDF COLONIAL 12 X 14 X 6MM 7 DEGREE -,SUP-365.406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SPACER ACDF COLONIAL 12 X 14 X 8MM 7 DEGREE -,SUP-365.408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X10MM LCK AXSOS ST T20 DRV SS NS -,SUP-370110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,AETNA [1000108],AETNA [100010801],,,76.8,,563.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X12MM LCK AXSOS ST T20 DRV SS NS -,SUP-370112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,AETNA [1000108],AETNA [100010801],,,76.8,,563.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X14MM LCK AXSOS ST.T20 DRV SS NS -,SUP-370114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,AETNA [1000108],AETNA [100010801],,,76.8,,563.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X16MM LCK AXSOS ST T20 DRV SS NS -,SUP-370116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,AETNA [1000108],AETNA [100010801],,,76.8,,563.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X14MM LCK AXSOS ST-T20 DRV SS NS -,SUP-370118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,AETNA [1000108],AETNA [100010801],,,76.8,,563.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X14MM LCK AXSOS ST..T20 DRV SS NS -,SUP-370120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,AETNA [1000108],AETNA [100010801],,,76.8,,563.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X14MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.17,457.219,AETNA [1000108],AETNA [100010801],,,76.8,,501.63,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X26MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA [1000108],AETNA [100010801],,,76.8,,566.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X28MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA [1000108],AETNA [100010801],,,76.8,,566.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X30MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA [1000108],AETNA [100010801],,,76.8,,566.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X32MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA [1000108],AETNA [100010801],,,76.8,,566.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X34MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA [1000108],AETNA [100010801],,,76.8,,566.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X36MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA [1000108],AETNA [100010801],,,76.8,,566.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X40MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA [1000108],AETNA [100010801],,,76.8,,566.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X44MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA [1000108],AETNA [100010801],,,76.8,,566.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X65MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA [1000108],AETNA [100010801],,,76.8,,566.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X70MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA [1000108],AETNA [100010801],,,76.8,,566.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X75MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA [1000108],AETNA [100010801],,,76.8,,566.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X80MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA [1000108],AETNA [100010801],,,76.8,,566.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X85MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370385,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA [1000108],AETNA [100010801],,,76.8,,566.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X90MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA [1000108],AETNA [100010801],,,76.8,,566.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X95MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA [1000108],AETNA [100010801],,,76.8,,566.88,0.518595,35041.66656,percent of total billed charges,,,
CABLE ORTHO 1.6MM DLMLS HIP SS BEAD SM SLV -,SUP-3704-0-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,AETNA [1000108],AETNA [100010801],,,76.8,,1228.32,0.518595,35041.66656,percent of total billed charges,,,
CABLE/SLEEVE FX 0.2MM DLMLS SS BEAD -,SUP-3704-0-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,AETNA [1000108],AETNA [100010801],,,76.8,,1228.32,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN DLMLS 165MM 4.5MM 5HL RECON SC SS BRD GROOVEX6 -,SUP-3704-3-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,AETNA [1000108],AETNA [100010801],,,76.8,,1928.57,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN DLMLS F/RECON TRMA 7HL GROOVEX8 RECON COMPR SS -,SUP-3704-3-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,AETNA [1000108],AETNA [100010801],,,76.8,,1928.57,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN DLMLS 254MM 4.5MM 9HL RECON SC SS BRD GROOVEX10 -,SUP-3704-3-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,AETNA [1000108],AETNA [100010801],,,76.8,,1928.57,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN DLMLS 305MM 4.5MM 11HL RECON SC SS GROOVEX12 -,SUP-3704-3-130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,AETNA [1000108],AETNA [100010801],,,76.8,,1928.57,0.518595,35041.66656,percent of total billed charges,,,
CABLE ORTHO 2MM HIP SS -,SUP-3704-8-240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,AETNA [1000108],AETNA [100010801],,,76.8,,1228.32,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS -,SUP-370528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,AETNA [1000108],AETNA [100010801],,,76.8,,423.03,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS. -,SUP-370532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,AETNA [1000108],AETNA [100010801],,,76.8,,423.03,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS- -,SUP-370538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,AETNA [1000108],AETNA [100010801],,,76.8,,423.03,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS_ -,SUP-370540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,AETNA [1000108],AETNA [100010801],,,76.8,,423.03,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS.NS -,SUP-370542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,AETNA [1000108],AETNA [100010801],,,76.8,,423.03,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS.. -,SUP-370544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,AETNA [1000108],AETNA [100010801],,,76.8,,423.03,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS -,SUP-370546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,AETNA [1000108],AETNA [100010801],,,76.8,,423.03,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS__ -,SUP-370570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,AETNA [1000108],AETNA [100010801],,,76.8,,423.03,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS-- -,SUP-370575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,AETNA [1000108],AETNA [100010801],,,76.8,,423.03,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X28MM LCK AXSOS ST T15 DRV-SS NS -,SUP-370585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,AETNA [1000108],AETNA [100010801],,,76.8,,423.03,0.518595,35041.66656,percent of total billed charges,,,
SCREW LCK ST 3.0 X 10 -,SUP-371010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,301.9,211.33,AETNA [1000108],AETNA [100010801],,,76.8,,231.86,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3X16MM LCK AXSOS -,SUP-371016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,301.9,211.33,AETNA [1000108],AETNA [100010801],,,76.8,,231.86,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X14MM LCK AXSOS ST.T20 DRV SS NS DIST LAT PERIART -,SUP-371314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCK 5.0 X 16 -,SUP-371316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X14MM LCK AXSOS ST_T20 DRV SS NS DIST LAT PERIART -,SUP-371318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X14MM LCK AXSOS ST T20 DRV SS NS DIST LAT PERIART -,SUP-371320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X22MM LCK AXSOS ST T20 DRV SS NS -,SUP-371322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X26MM LCK AXSOS ST T20 DRV SS NS -,SUP-371326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X28MM LCK AXSOS ST T20 DRV SS NS -,SUP-371328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCK 5.0 X 30 -,SUP-371330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X32MM LCK AXSOS ST T20 DRV SS NS -,SUP-371332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X34MM LCK AXSOS ST T20 DRV SS NS -,SUP-371334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X36MM LCK AXSOS ST T20 DRV SS NS -,SUP-371336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X38MM LCK AXSOS ST T20 DRV SS NS -,SUP-371338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X40MM LCK AXSOS ST T20 DRV SS NS -,SUP-371340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X42MM LCK AXSOS ST T20 DRV SS NS -,SUP-371342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X44MM LCK AXSOS ST T20 DRV SS NS -,SUP-371344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X46MM LCK AXSOS ST T20 DRV SS NS -,SUP-371346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X48MM LCK AXSOS ST T20 DRV SS NS -,SUP-371348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X50MM LCK AXSOS ST T20 DRV SS NS -,SUP-371350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X60MM LCK AXSOS ST T20 DRV SS NS -,SUP-371360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X70MM LCK AXSOS ST T20 DRV SS NS -,SUP-371370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X75MM LCK AXSOS ST T20 DRV SS NS -,SUP-371375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X80MM LCK AXSOS ST T20 DRV SS NS -,SUP-371380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X90MM LCK AXSOS ST T20 DRV SS NS -,SUP-371390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X95MM LCK AXSOS ST T20 DRV SS NS -,SUP-371395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,76.8,,535.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW LCK 4.0 X 14 -,SUP-371514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X16MM LCK AXSOS ST T15 DRV SS NS -,SUP-371516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X20MM LCK AXSOS ST T15 DRV SS NS -,SUP-371520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X22MM LCK AXSOS ST T15 DRV SS NS -,SUP-371522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X24MM LCK AXSOS ST T15 DRV SS NS -,SUP-371524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X26MM LCK AXSOS ST T15 DRV SS NS -,SUP-371526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X28MM LCK AXSOS ST_T15 DRV SS NS PERIART -,SUP-371528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X30MM LCK AXSOS ST T15 DRV SS NS -,SUP-371530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X28MM LCK AXSOS ST.T15 DRV SS NS PERIART -,SUP-371532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X34MM LCK AXSOS ST T15 DRV SS NS -,SUP-371534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X36MM LCK AXSOS ST T15 DRV SS NS -,SUP-371536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X28MM LCK AXSOS ST-T15 DRV SS NS PERIART -,SUP-371538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS.PERIART -,SUP-371542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS_PERIART -,SUP-371544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS-PERIART -,SUP-371546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X48MM LCK AXSOS ST T15 DRV SS NS -,SUP-371548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X50MM LCK AXSOS ST T15 DRV SS NS -,SUP-371550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X55MM LCK AXSOS ST T15 DRV SS NS -,SUP-371555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X60MM LCK AXSOS ST T15 DRV SS NS -,SUP-371560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X65MM LCK AXSOS ST T15 DRV SS NS -,SUP-371565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X28MM-LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X28MM.LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X80MM LCK AXSOS ST T15 DRV SS NS -,SUP-371580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X28MM_LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X95MM LCK AXSOS ST T15 DRV SS NS -,SUP-371595,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA [1000108],AETNA [100010801],,,76.8,,482.19,0.518595,35041.66656,percent of total billed charges,,,
GUIDEPIN ORTHO 2.4MM -,SUP-373-0224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,,,
BIT DRILL 6MM BN -,SUP-3815-1-660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,371.28,259.896,AETNA [1000108],AETNA [100010801],,,76.8,,285.14,0.518595,35041.66656,percent of total billed charges,,,
SPACER THORLUM 12X14X6MM COALITION 0DG -,SUP-384.006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,0.518595,35041.66656,percent of total billed charges,,,
SPACER THORLUM 12X14X8MM COALITION 0DG -,SUP-384.008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,0.518595,35041.66656,percent of total billed charges,,,
GUIDEPIN ORTHO 2.8MMX23CM THRD TIP -,SUP-3861-0-628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,82.92,58.044,AETNA [1000108],AETNA [100010801],,,76.8,,63.68,0.518595,35041.66656,percent of total billed charges,,,
WASHER ORTHO 13MM ASNIS III 6.5/8.0MM SS RND NS -,SUP-390016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,182.99,128.093,AETNA [1000108],AETNA [100010801],,,76.8,,140.54,0.518595,35041.66656,percent of total billed charges,,,
WASHER ORTHO 4MM ASNIS III F/4MM BN SCR SS RND NS -,SUP-390018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,132.57,92.799,AETNA [1000108],AETNA [100010801],,,76.8,,101.81,0.518595,35041.66656,percent of total billed charges,,,
WASHER ORTHO 4.1MM ASNIS III F/9MM BN SCR SS RND NS -,SUP-390019,CDM,C1713,HCPCS,278,RC,,,outpatient,,,145.64,101.948,AETNA [1000108],AETNA [100010801],,,76.8,,111.85,0.518595,35041.66656,percent of total billed charges,,,
REDUCTION PIN 4.5MM DIA 150MM -,SUP-390082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,624.75,437.325,AETNA [1000108],AETNA [100010801],,,76.8,,479.81,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUT 5.5MM ZIP PEEK #2 SUT FORCE FIB NDL -,SUP-3910-200-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,AETNA [1000108],AETNA [100010801],,,76.8,,955.08,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUT 5.5MM ZIP PEEK #2 SUTX2 FORCE FIB -,SUP-3910-200-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,AETNA [1000108],AETNA [100010801],,,76.8,,955.08,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUT 5.5MM ZIP PEEK #2 SUTX2 FORCE FIB -,SUP-3910-200-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,AETNA [1000108],AETNA [100010801],,,76.8,,1176.45,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUT 6.5MM ZIP PEEK #2 SUTX2 FORCE FIB 1/2CIR TAPR NDL -,SUP-3910-200-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,AETNA [1000108],AETNA [100010801],,,76.8,,955.08,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUT 6.5MM ZIP PEEK #2 SUTX2 FORCE FIB -,SUP-3910-200-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,AETNA [1000108],AETNA [100010801],,,76.8,,955.08,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUT INTRALINE 4.5MM HA/PLLA COMP BIOSTEON SUTX2 W/O -,SUP-3910-200-080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2648.5,1853.95,AETNA [1000108],AETNA [100010801],,,76.8,,2034.05,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUT TWINLOOP 3.5MM ZIP PEEK #2 SUT FORCE FIB -,SUP-3910-400-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1151.37,805.959,AETNA [1000108],AETNA [100010801],,,76.8,,884.25,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUT TWINLOOP 3.5MM ZIP PEEK #2 SUTX2 FORCE FIB EYLT -,SUP-3910-400-235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2055.64,1438.948,AETNA [1000108],AETNA [100010801],,,76.8,,1578.73,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUT ICONIX 2.3MM PILOT HL 3 STRN #2 FORCE FIB PLYSTR -,SUP-3910-500-532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2376.27,1663.389,AETNA [1000108],AETNA [100010801],,,76.8,,1824.98,0.518595,35041.66656,percent of total billed charges,,,
CAP PROT STRL F/2.5MM K-WR -,SUP-392.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5.72,4.004,AETNA [1000108],AETNA [100010801],,,76.8,,4.39,0.518595,35041.66656,percent of total billed charges,,,
CAP ORTHO -,SUP-393.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11.67,8.169,AETNA [1000108],AETNA [100010801],,,76.8,,8.96,0.518595,35041.66656,percent of total billed charges,,,
CAP PROT F/11MM CFBR EXTFIX ROD -,SUP-394.970,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5.02,3.514,AETNA [1000108],AETNA [100010801],,,76.8,,3.86,0.518595,35041.66656,percent of total billed charges,,,
CAP PROT F/4.0MM CRBN FIBRE BAR ROD BLK -,SUP-394.990,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5.43,3.801,AETNA [1000108],AETNA [100010801],,,76.8,,4.17,0.518595,35041.66656,percent of total billed charges,,,
CAP PROT NS F/4MM FX PIN YEL -,SUP-394.991,CDM,C1713,HCPCS,278,RC,,,outpatient,,,28.24,19.768,AETNA [1000108],AETNA [100010801],,,76.8,,21.69,0.518595,35041.66656,percent of total billed charges,,,
HYDROSET HA BONE SUB 3CC -,SUP-397003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4410.87,3087.609,AETNA [1000108],AETNA [100010801],,,76.8,,3387.55,0.518595,35041.66656,percent of total billed charges,,,
HYDROSET BONE SUB 15CC -,SUP-397015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17072.08,11950.456,AETNA [1000108],AETNA [100010801],,,76.8,,13111.36,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 150MM POLARUS 3 PROX HUM LCK -,SUP-4001-1015R-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10270.16,7189.112,AETNA [1000108],AETNA [100010801],,,76.8,,7887.48,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3X90MM COMPR DL -TRAK CUT FLUT TI ALY NS -,SUP-40-0137,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6336.29,4435.403,AETNA [1000108],AETNA [100010801],,,76.8,,4866.27,0.518595,35041.66656,percent of total billed charges,,,
SUBSTITUTE CANC 30ML CHP FRZDR VOID FIL 1.7-10MM -,SUP-400150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1681.8,1177.26,AETNA [1000108],AETNA [100010801],,,76.8,,1291.62,0.518595,35041.66656,percent of total billed charges,,,
GRAFT HUM TIS WDG FRZDR 10-17 MMX14-20MM TRCORT ILC CRST -,SUP-400405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4361,3052.7,AETNA [1000108],AETNA [100010801],,,76.8,,3349.25,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTEX TI SLF TPNG 2.4 X 10 T8 SD REC -,SUP-401.760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,656.44,459.508,AETNA [1000108],AETNA [100010801],,,76.8,,504.15,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTEX TI SLF TPNG 2.4 X 14 T8 SD REC -,SUP-401.764,CDM,C1713,HCPCS,278,RC,,,outpatient,,,656.44,459.508,AETNA [1000108],AETNA [100010801],,,76.8,,504.15,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTEX TI SLF TPNG 2.4 X 30 T8 SD REC -,SUP-401.780,CDM,C1713,HCPCS,278,RC,,,outpatient,,,656.44,459.508,AETNA [1000108],AETNA [100010801],,,76.8,,504.15,0.518595,35041.66656,percent of total billed charges,,,
PLATE SMALL CALCANEOUS FOOT -,SUP-40-10102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2915.48,2040.836,AETNA [1000108],AETNA [100010801],,,76.8,,2239.09,0.518595,35041.66656,percent of total billed charges,,,
PLATE CALCANEUS SMALL STANDARD -,SUP-40-10112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2915.48,2040.836,AETNA [1000108],AETNA [100010801],,,76.8,,2239.09,0.518595,35041.66656,percent of total billed charges,,,
PLATE CALCANEUS STANDARD LARGE -,SUP-40-10116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2915.48,2040.836,AETNA [1000108],AETNA [100010801],,,76.8,,2239.09,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 36MM 2.7MM 4HL RECON POLYAX LCK TI NS -,SUP-40-15011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2418.35,1692.845,AETNA [1000108],AETNA [100010801],,,76.8,,1857.29,0.518595,35041.66656,percent of total billed charges,,,
CURVED PLATE 5 HOLES RIGHT -,SUP-40-15012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.07,1837.549,AETNA [1000108],AETNA [100010801],,,76.8,,2016.05,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 49MM 2.7MM 6HL RECON POLYAX LCK TI NS -,SUP-40-15014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2657.78,1860.446,AETNA [1000108],AETNA [100010801],,,76.8,,2041.18,0.518595,35041.66656,percent of total billed charges,,,
H-PLATE SMALL -,SUP-40-15021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2050.76,1435.532,AETNA [1000108],AETNA [100010801],,,76.8,,1574.98,0.518595,35041.66656,percent of total billed charges,,,
PLATE MED-H -,SUP-40-15022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2610.76,1827.532,AETNA [1000108],AETNA [100010801],,,76.8,,2005.06,0.518595,35041.66656,percent of total billed charges,,,
PLATE LARGE -,SUP-40-15023,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2451.75,1716.225,AETNA [1000108],AETNA [100010801],,,76.8,,1882.94,0.518595,35041.66656,percent of total billed charges,,,
RECTANGLE PLATE SZ 1 -,SUP-40-15032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2451.75,1716.225,AETNA [1000108],AETNA [100010801],,,76.8,,1882.94,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 48MM 2.7/3.5MM 5HL 1MM RECON POLYAX LCK TI -,SUP-40-15041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2439.24,1707.468,AETNA [1000108],AETNA [100010801],,,76.8,,1873.34,0.518595,35041.66656,percent of total billed charges,,,
VARIAX FOOT PLATE -,SUP-40-15042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2547.84,1783.488,AETNA [1000108],AETNA [100010801],,,76.8,,1956.74,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 51MM 2.7/3.5MM 6HL 1MM RECON POLYAX LCK TI -,SUP-40-15062,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2785.68,1949.976,AETNA [1000108],AETNA [100010801],,,76.8,,2139.4,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 35MM 2.7MM 4HL RECON POLYAX LCK TI NS -,SUP-40-15081,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1737.5,1216.25,AETNA [1000108],AETNA [100010801],,,76.8,,1334.4,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2MMX8MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2MMX9MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2MMX10MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2MMX11MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2MMX12MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2MMX13MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2MMX14MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2MMX15MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2MMX16MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2MMX18MM CANN ASNIS 5MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2MMX20MM CANN ASNIS 5MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2MMX22MM CANN ASNIS 5MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2MMX24MM CANN ASNIS 6MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2MMX26MM CANN ASNIS 6MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2MMX28MM CANN ASNIS 6MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 28.5MM 2MM 2HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,AETNA [1000108],AETNA [100010801],,,76.8,,1339.25,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 60MM 2MM 4HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1910.88,1337.616,AETNA [1000108],AETNA [100010801],,,76.8,,1467.56,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 72MM 2MM 5HL 2MM PRCONT POLYAX TI STR SMRTLC -,SUP-40-20805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,AETNA [1000108],AETNA [100010801],,,76.8,,1339.25,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 84MM 2MM 6HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20806,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,AETNA [1000108],AETNA [100010801],,,76.8,,1339.25,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 96MM 2MM 7HL 2MM PRCONT POLYAX TI STR SMRTLC -,SUP-40-20807,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,AETNA [1000108],AETNA [100010801],,,76.8,,1339.25,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 108MM 2MM 8HL 2MM PRCONT POLYAX TI STR -,SUP-40-20808,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,AETNA [1000108],AETNA [100010801],,,76.8,,1339.25,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 132MM 2MM 10HL 2MM PRCONT POLYAX TI STR -,SUP-40-20810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1812.72,1268.904,AETNA [1000108],AETNA [100010801],,,76.8,,1392.17,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 156MM 2MM 12HL 2MM PRCONT POLYAX TI STR -,SUP-40-20812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2549.91,1784.937,AETNA [1000108],AETNA [100010801],,,76.8,,1958.33,0.518595,35041.66656,percent of total billed charges,,,
WASHER ORTHO 2MM ASNIS MICRO F/CANN SCR SYS NS -,SUP-40-20900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,304.88,213.416,AETNA [1000108],AETNA [100010801],,,76.8,,234.15,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 77MM 2MM 3HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.1,1787.87,AETNA [1000108],AETNA [100010801],,,76.8,,1961.55,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 89MM 2MM 4HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.1,1787.87,AETNA [1000108],AETNA [100010801],,,76.8,,1961.55,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 101MM 2MM 5HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.1,1787.87,AETNA [1000108],AETNA [100010801],,,76.8,,1961.55,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 113MM 2MM 6HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2388.81,1672.167,AETNA [1000108],AETNA [100010801],,,76.8,,1834.61,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 125MM 2MM 7HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2591.95,1814.365,AETNA [1000108],AETNA [100010801],,,76.8,,1990.62,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 137MM 2MM 8HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20908,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2591.95,1814.365,AETNA [1000108],AETNA [100010801],,,76.8,,1990.62,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 149MM 2MM 9HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20909,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2591.95,1814.365,AETNA [1000108],AETNA [100010801],,,76.8,,1990.62,0.518595,35041.66656,percent of total billed charges,,,
TOTAL JNT SUBCHONDROPLASTY -,SUP-402201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11788.78,8252.146,AETNA [1000108],AETNA [100010801],,,76.8,,9053.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X14MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA [1000108],AETNA [100010801],,,76.8,,253.46,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X16MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA [1000108],AETNA [100010801],,,76.8,,253.46,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X18MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA [1000108],AETNA [100010801],,,76.8,,253.46,0.518595,35041.66656,percent of total billed charges,,,
SCREW NON-LOCKING 2.7 X 20MM -,SUP-40-27020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA [1000108],AETNA [100010801],,,76.8,,253.46,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X22MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA [1000108],AETNA [100010801],,,76.8,,253.46,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X24MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA [1000108],AETNA [100010801],,,76.8,,253.46,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X26MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA [1000108],AETNA [100010801],,,76.8,,253.46,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X28MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA [1000108],AETNA [100010801],,,76.8,,253.46,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE T7 2.7 X 38MM -,SUP-40-27038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA [1000108],AETNA [100010801],,,76.8,,253.46,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE T7 2.7 X 40 -,SUP-40-27040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA [1000108],AETNA [100010801],,,76.8,,253.46,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE T7 2.7 X 45MM -,SUP-40-27045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA [1000108],AETNA [100010801],,,76.8,,253.46,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X12MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-2761,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA [1000108],AETNA [100010801],,,76.8,,558.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X10MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA [1000108],AETNA [100010801],,,76.8,,558.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X16MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA [1000108],AETNA [100010801],,,76.8,,558.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X18MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA [1000108],AETNA [100010801],,,76.8,,558.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X20MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA [1000108],AETNA [100010801],,,76.8,,558.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X22MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA [1000108],AETNA [100010801],,,76.8,,558.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X24MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA [1000108],AETNA [100010801],,,76.8,,558.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X26MM LCK -,SUP-4027626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA [1000108],AETNA [100010801],,,76.8,,558.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X28MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA [1000108],AETNA [100010801],,,76.8,,558.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3MMX8MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3MMX10MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3MMX12MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3MMX13MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3MMX14MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3MMX15MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3MMX16MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3MMX17MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3MMX18MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.48,659.036,AETNA [1000108],AETNA [100010801],,,76.8,,723.06,0.518595,35041.66656,percent of total billed charges,,,
MICRO ASNIS SCREW 3.0MM X 18MM -,SUP-40-30118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3MMX19MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30119,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3MMX20MM CANN ASNIS THRD REVCT FLUT TI NS PUR -,SUP-40-30120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3MMX22MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3MMX24MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3MMX26MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3MMX28MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3MMX30MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3MMX32MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3MMX34MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,,,
3.0 MICRO ASNIS SCREW -,SUP-40-30134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3MMX36MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3MMX40MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA [1000108],AETNA [100010801],,,76.8,,723.01,0.518595,35041.66656,percent of total billed charges,,,
WASHER ORTHO 3MM ASNIS MICRO F/CANN SCR SYS NS -,SUP-40-30900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,339.01,237.307,AETNA [1000108],AETNA [100010801],,,76.8,,260.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X10MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X12MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X14MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X16MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X18MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X20MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X22MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X24MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X26MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X28MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X30MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X32MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X34MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X36MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X38MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X40MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X42MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X44MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X46MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X48MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X50MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X55MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X60MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X65MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X70MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA [1000108],AETNA [100010801],,,76.8,,282.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X10MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA [1000108],AETNA [100010801],,,76.8,,558.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X12MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA [1000108],AETNA [100010801],,,76.8,,558.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X14MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA [1000108],AETNA [100010801],,,76.8,,558.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X16MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA [1000108],AETNA [100010801],,,76.8,,558.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X18MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA [1000108],AETNA [100010801],,,76.8,,558.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X20MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA [1000108],AETNA [100010801],,,76.8,,558.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X22MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA [1000108],AETNA [100010801],,,76.8,,558.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X24MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA [1000108],AETNA [100010801],,,76.8,,558.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X26MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA [1000108],AETNA [100010801],,,76.8,,558.27,0.518595,35041.66656,percent of total billed charges,,,
3.5MM LOCKING 28MM SCREW -,SUP-40-35628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA [1000108],AETNA [100010801],,,76.8,,558.27,0.518595,35041.66656,percent of total billed charges,,,
3.5MM LOCKING 34MM SCREW -,SUP-40-35634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA [1000108],AETNA [100010801],,,76.8,,558.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X40MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA [1000108],AETNA [100010801],,,76.8,,558.27,0.518595,35041.66656,percent of total billed charges,,,
WASHER ORTHO F/3.5MM BN SCR -,SUP-40-35900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,376.01,263.207,AETNA [1000108],AETNA [100010801],,,76.8,,288.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX28MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,AETNA [1000108],AETNA [100010801],,,76.8,,122.11,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX36MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.836,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,AETNA [1000108],AETNA [100010801],,,76.8,,122.11,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX38MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.838,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,AETNA [1000108],AETNA [100010801],,,76.8,,122.11,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX55MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.855,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,AETNA [1000108],AETNA [100010801],,,76.8,,122.11,0.518595,35041.66656,percent of total billed charges,,,
SCREW EXHAL SZ 8-32X.375 -,SUP-4-072623-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6.48,4.536,AETNA [1000108],AETNA [100010801],,,76.8,,4.98,0.518595,35041.66656,percent of total billed charges,,,
GUIDEPIN ORTHO 2.4MMX23CM -,SUP-410236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,407.52,285.264,AETNA [1000108],AETNA [100010801],,,76.8,,312.98,0.518595,35041.66656,percent of total billed charges,,,
SET SCREWS MARINER SPINE -,SUP-41-1010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,,,
POLYAXIAL HEAD G2 -,SUP-41-3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,,,
HEAD SCREW SEASPINE MARINER POLY EXTEND -,SUP-41-4010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,,,
30MM OFFSET -,SUP-41-4130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA [1000108],AETNA [100010801],,,76.8,,1933.62,0.518595,35041.66656,percent of total billed charges,,,
PLUG CEMENT SMALL DIA 10MM -,SUP-414994,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA [1000108],AETNA [100010801],,,76.8,,976.99,0.518595,35041.66656,percent of total billed charges,,,
PLUG CEMENT SMALL DIA 12MM -,SUP-414995,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA [1000108],AETNA [100010801],,,76.8,,976.99,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE SCREW 5.5 X 30MM -,SUP-41-5530-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,0.518595,35041.66656,percent of total billed charges,,,
MARINER SOLD SCREW 5.5 X35MM -,SUP-41-5535-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,0.518595,35041.66656,percent of total billed charges,,,
SCREW SEASPINE MARINER SOLID 5.5MM X 35MM -,SUP-41-5535-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE SCREW 5.5 X 40 -,SUP-41-5540-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5 X 45MM -,SUP-41-5545-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,0.518595,35041.66656,percent of total billed charges,,,
SCREW SEASPINE MARINER SOLID 6.5MM X 35MM -,SUP-41-6535-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE SCREW 6.5 X 45MM -,SUP-41-6545-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7.5 X 70MM -,SUP-41-7570-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,0.518595,35041.66656,percent of total billed charges,,,
GUIDEPIN ORTHO TRUMATCH RT -,SUP-420901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6242.92,4370.044,AETNA [1000108],AETNA [100010801],,,76.8,,4794.56,0.518595,35041.66656,percent of total billed charges,,,
GUIDEPIN ORTHO TRUMATCH LT -,SUP-420902,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4990.94,3493.658,AETNA [1000108],AETNA [100010801],,,76.8,,3833.04,0.518595,35041.66656,percent of total billed charges,,,
GUIDEPIN SZ5 ATTUNE TRUMATCH LT KN -,SUP-420945,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,AETNA [1000108],AETNA [100010801],,,76.8,,7473.78,0.518595,35041.66656,percent of total billed charges,,,
PLATE CRANFC 100X100MM MATRIXNEURO LPRO MSH 0.6MM TI SQ -,SUP-421.534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8428.58,5900.006,AETNA [1000108],AETNA [100010801],,,76.8,,6473.15,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X26MM LCK CANN SD 3.5MM HEX RCESS CNCL HEAD TI NS -,SUP-422.392,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1537.15,1076.005,AETNA [1000108],AETNA [100010801],,,76.8,,1180.53,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X55MM LCK CANN SD 3.5MM HEX RCESS CNCL HEAD TI NS -,SUP-422.394,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1515.94,1061.158,AETNA [1000108],AETNA [100010801],,,76.8,,1164.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X65MM LCK CANN SD 3.5MM HEX RCESS CNCL HEAD TI NS -,SUP-422.395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1515.94,1061.158,AETNA [1000108],AETNA [100010801],,,76.8,,1164.24,0.518595,35041.66656,percent of total billed charges,,,
BEARING FIXED ASF UC 14MM PLY R 4-11 EF PERSONA -,SUP-42-5212-005-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,0.518595,35041.66656,percent of total billed charges,,,
SYSTEM KNEE PERSONA ASF UC 35MM PLY R 7-12 GH 9.0 THICKNESS -,SUP-42-5400-000-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,AETNA [1000108],AETNA [100010801],,,76.8,,1607.96,0.518595,35041.66656,percent of total billed charges,,,
PLATE CURVED PELVIC R 108MM/L58.5MM/4HOLE -,SUP-425604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,AETNA [1000108],AETNA [100010801],,,76.8,,3424.93,0.518595,35041.66656,percent of total billed charges,,,
PLATE CURV PELV R 108MM L74.5MM 5 HOLE -,SUP-425605,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,AETNA [1000108],AETNA [100010801],,,76.8,,3424.93,0.518595,35041.66656,percent of total billed charges,,,
PLATE 8 HOLE -,SUP-425608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,AETNA [1000108],AETNA [100010801],,,76.8,,3349.16,0.518595,35041.66656,percent of total billed charges,,,
10 HOLE PLATE -,SUP-425610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,AETNA [1000108],AETNA [100010801],,,76.8,,3349.16,0.518595,35041.66656,percent of total billed charges,,,
PLATE CURV. PELV 108MM/L186.5MM/12H -,SUP-425612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,AETNA [1000108],AETNA [100010801],,,76.8,,3689.93,0.518595,35041.66656,percent of total billed charges,,,
PLATE PELV CURV R 108MM L218.5MM 14HOLE -,SUP-425614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,AETNA [1000108],AETNA [100010801],,,76.8,,3689.93,0.518595,35041.66656,percent of total billed charges,,,
PLATE PELV CURV R 108MM L250.5MM 16 HOLE -,SUP-425616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5273.81,3691.667,AETNA [1000108],AETNA [100010801],,,76.8,,4050.29,0.518595,35041.66656,percent of total billed charges,,,
PLATE PELV CURV R 108MM L282.5MM 18H -,SUP-425618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5273.81,3691.667,AETNA [1000108],AETNA [100010801],,,76.8,,4050.29,0.518595,35041.66656,percent of total billed charges,,,
PLATE PELV CURV R 108MM L314.5MM 20H -,SUP-425620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5273.81,3691.667,AETNA [1000108],AETNA [100010801],,,76.8,,4050.29,0.518595,35041.66656,percent of total billed charges,,,
PLATE SYMPYSIS -,SUP-425654,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,AETNA [1000108],AETNA [100010801],,,76.8,,3424.93,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 10.5MMX74.5MM F/3.5MM/4.5MM SCR 4HL MATTA SS 88MM -,SUP-425655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,AETNA [1000108],AETNA [100010801],,,76.8,,3424.93,0.518595,35041.66656,percent of total billed charges,,,
PLATE 6 HOLE R88 PELVIS -,SUP-425656,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,AETNA [1000108],AETNA [100010801],,,76.8,,3349.16,0.518595,35041.66656,percent of total billed charges,,,
PLATE 8HOLE R88 -,SUP-425658,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,AETNA [1000108],AETNA [100010801],,,76.8,,3349.16,0.518595,35041.66656,percent of total billed charges,,,
PLATE PELV CURVED R 88MM/L154.5MM/10H -,SUP-425660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,AETNA [1000108],AETNA [100010801],,,76.8,,3349.16,0.518595,35041.66656,percent of total billed charges,,,
PLATE R88 12 HOLE -,SUP-425662,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,AETNA [1000108],AETNA [100010801],,,76.8,,3689.93,0.518595,35041.66656,percent of total billed charges,,,
PLATE R88 CURVED 218.5 14 HOLE -,SUP-425664,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,AETNA [1000108],AETNA [100010801],,,76.8,,3689.93,0.518595,35041.66656,percent of total billed charges,,,
PLATE 16 HOLE R88 PELVIS -,SUP-425666,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,AETNA [1000108],AETNA [100010801],,,76.8,,3689.93,0.518595,35041.66656,percent of total billed charges,,,
PLATE PELV CURV R 88MM L282.5 18H -,SUP-425668,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,AETNA [1000108],AETNA [100010801],,,76.8,,3689.93,0.518595,35041.66656,percent of total billed charges,,,
PLATE PELV CURV R 88MM L314.5MM 20H -,SUP-425670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,AETNA [1000108],AETNA [100010801],,,76.8,,3689.93,0.518595,35041.66656,percent of total billed charges,,,
PLATE PELV STRAIGHT L 26.5MM -,SUP-425702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4046.3,2832.41,AETNA [1000108],AETNA [100010801],,,76.8,,3107.56,0.518595,35041.66656,percent of total billed charges,,,
PELVIC PLATE -,SUP-425753,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4676.37,3273.459,AETNA [1000108],AETNA [100010801],,,76.8,,3591.45,0.518595,35041.66656,percent of total billed charges,,,
PLATE STRT ACET L 46.5MM 14 HOLE -,SUP-425754,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4676.37,3273.459,AETNA [1000108],AETNA [100010801],,,76.8,,3591.45,0.518595,35041.66656,percent of total billed charges,,,
PLATE STRAIGHT ACET L 70.5M 6 HOLE -,SUP-425756,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4571.81,3200.267,AETNA [1000108],AETNA [100010801],,,76.8,,3511.15,0.518595,35041.66656,percent of total billed charges,,,
PLATE 8HOLE FLEX -,SUP-425758,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4571.81,3200.267,AETNA [1000108],AETNA [100010801],,,76.8,,3511.15,0.518595,35041.66656,percent of total billed charges,,,
PLATE 10 HOLE FLEX -,SUP-425760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4571.81,3200.267,AETNA [1000108],AETNA [100010801],,,76.8,,3511.15,0.518595,35041.66656,percent of total billed charges,,,
PLATE STRT ACET L 142.5MM 12 HOLE -,SUP-425762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5044.63,3531.241,AETNA [1000108],AETNA [100010801],,,76.8,,3874.28,0.518595,35041.66656,percent of total billed charges,,,
PLATE SYMPHYSIS 4 HOLE -,SUP-425794,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6110.34,4277.238,AETNA [1000108],AETNA [100010801],,,76.8,,4692.74,0.518595,35041.66656,percent of total billed charges,,,
PLATE PRO SUPRAPECTINEAL QLS LEFT -,SUP-425912S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.77,7018.039,AETNA [1000108],AETNA [100010801],,,76.8,,7699.79,0.518595,35041.66656,percent of total billed charges,,,
INFRAPECTINEAL PLATE SMALL QLS LEFT -,SUP-425932S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8017.17,5612.019,AETNA [1000108],AETNA [100010801],,,76.8,,6157.19,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN AXSOS 45MM 4MM 3HL LCK COMPR SS WAIST SM FRAG NS -,SUP-427003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,557.83,390.481,AETNA [1000108],AETNA [100010801],,,76.8,,428.41,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN AXSOS 71MM 4MM 5HL LCK COMPR SS WAIST SM FRAG NS -,SUP-427005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,716.54,501.578,AETNA [1000108],AETNA [100010801],,,76.8,,550.3,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN AXSOS 97MM 4MM 7HL LCK COMPR SS WAIST RND TAPR END -,SUP-427007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,716.54,501.578,AETNA [1000108],AETNA [100010801],,,76.8,,550.3,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN AXSOS 110MM 4MM 8HL LCK COMPR SS WAIST RND TAPR END -,SUP-427008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,795.89,557.123,AETNA [1000108],AETNA [100010801],,,76.8,,611.24,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN AXSOS 123MM 4MM 9HL LCK COMPR SS WAIST SM FRAG STRL -,SUP-427009S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,795.89,557.123,AETNA [1000108],AETNA [100010801],,,76.8,,611.24,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN AXSOS 136MM 4MM 10HL LCK COMPR SS WAIST RND TAPR -,SUP-427010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,795.89,557.123,AETNA [1000108],AETNA [100010801],,,76.8,,611.24,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN AXSOS 266MM 4MM 20HL LCK COMPR SS WAIST SM FRAG NS -,SUP-427020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.32,779.324,AETNA [1000108],AETNA [100010801],,,76.8,,855.03,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN AXSOS 48MM 4MM 4HL RECON LCK COMPR SS SM FRAG NS -,SUP-427034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1836.09,1285.263,AETNA [1000108],AETNA [100010801],,,76.8,,1410.12,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN AXSOS 60MM 4MM 5HL RECON LCK COMPR SS SM FRAG NS -,SUP-427035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1836.09,1285.263,AETNA [1000108],AETNA [100010801],,,76.8,,1410.12,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN AXSOS 72MM 4MM 6HL RECON LCK COMPR SS ADLT SM FRAG -,SUP-427036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2071.44,1450.008,AETNA [1000108],AETNA [100010801],,,76.8,,1590.87,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN AXSOS 96MM 4MM 8HL RECON LCK COMPR SS ADLT SM FRAG -,SUP-427038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2298.3,1608.81,AETNA [1000108],AETNA [100010801],,,76.8,,1765.09,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN AXSOS 76MM 3MM 6HL LCK SS 1/3 TBLR SM FRAG NS -,SUP-427066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,669.86,468.902,AETNA [1000108],AETNA [100010801],,,76.8,,514.45,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN AXSOS 89MM 3MM 8HL LCK SS 1/3 TBLR SM FRAG NS -,SUP-427068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,725.87,508.109,AETNA [1000108],AETNA [100010801],,,76.8,,557.47,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN AXSOS 169MM 5MM 9HL LCK COMPR SS NRW WAIST BSC FRAG -,SUP-427109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,898.59,629.013,AETNA [1000108],AETNA [100010801],,,76.8,,690.12,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN AXSOS 223MM 5MM 12HL LCK COMPR SS NRW WAIST BSC -,SUP-427112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1075.97,753.179,AETNA [1000108],AETNA [100010801],,,76.8,,826.34,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN AXSOS 259MM 5MM 14HL LCK COMPR SS NRW WAIST BSC -,SUP-427114S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1075.97,753.179,AETNA [1000108],AETNA [100010801],,,76.8,,826.34,0.518595,35041.66656,percent of total billed charges,,,
PLATE WSTD CMP BRD HL8 -,SUP-427138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN AXSOS 173MM 5MM 9HL LCK COMPR SS BRD WAIST BSC FRAG -,SUP-427139S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN AXSOS 263MM 5MM 14HL LCK COMPR SS BRD WAIST BSC ST -,SUP-427144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1159.75,811.825,AETNA [1000108],AETNA [100010801],,,76.8,,890.69,0.518595,35041.66656,percent of total billed charges,,,
GRAFT HUM TIS HEMI FRZN 10-10.5 MMX8-13CM PTLR TNDN 30-75MM -,SUP-430007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11007.78,7705.446,AETNA [1000108],AETNA [100010801],,,76.8,,8453.98,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 10X60MM F/3.5MM/4MM SCR 5HL SHFT 2.8MM RECON -,SUP-430105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.67,1007.769,AETNA [1000108],AETNA [100010801],,,76.8,,1105.67,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 25MM 3MM 2HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,234.51,164.157,AETNA [1000108],AETNA [100010801],,,76.8,,180.1,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 38MM 3MM 3HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,234.51,164.157,AETNA [1000108],AETNA [100010801],,,76.8,,180.1,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 64MM 3MM 5HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,289.01,202.307,AETNA [1000108],AETNA [100010801],,,76.8,,221.96,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 77MM 3MM 6HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,289.01,202.307,AETNA [1000108],AETNA [100010801],,,76.8,,221.96,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 90MM 3MM 7HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.42,222.194,AETNA [1000108],AETNA [100010801],,,76.8,,243.78,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 103MM 3MM 8HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,355.35,248.745,AETNA [1000108],AETNA [100010801],,,76.8,,272.91,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 129MM 3MM 10HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,355.35,248.745,AETNA [1000108],AETNA [100010801],,,76.8,,272.91,0.518595,35041.66656,percent of total billed charges,,,
MESH TITANIUM 6X6 - DISCONTINUED DO NOT USE -,SUP-43-1022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,AETNA [1000108],AETNA [100010801],,,76.8,,3533.18,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 10X49MM F/3.5MM/4.5MM SCR 0.75HL HD/SHFT 1.2MM SS -,SUP-431024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,634.85,444.395,AETNA [1000108],AETNA [100010801],,,76.8,,487.56,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 10X66MM F/3.5MM/4.5MM SCR HLX3/6 HD/SHFT 1.2MM SS -,SUP-431026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,871.75,610.225,AETNA [1000108],AETNA [100010801],,,76.8,,669.5,0.518595,35041.66656,percent of total billed charges,,,
MOLD CMNT SPCR 48MM SIL SS STAGEONE STRL -,SUP-431181,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5199.96,3639.972,AETNA [1000108],AETNA [100010801],,,76.8,,3993.57,0.518595,35041.66656,percent of total billed charges,,,
HIP HEAD CEMENT MOLD 52MM -,SUP-431182,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5199.96,3639.972,AETNA [1000108],AETNA [100010801],,,76.8,,3993.57,0.518595,35041.66656,percent of total billed charges,,,
SHOULDER MOLD 12STD 54 X 21 X 64 -,SUP-431412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11946.58,8362.606,AETNA [1000108],AETNA [100010801],,,76.8,,9174.97,0.518595,35041.66656,percent of total billed charges,,,
60MM FEMORAL KNEE CEMENT MOLD -,SUP-432160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8413.73,5889.611,AETNA [1000108],AETNA [100010801],,,76.8,,6461.74,0.518595,35041.66656,percent of total billed charges,,,
MOLD BNCMNT FEM 65MM SIL STAGEONE STRL -,SUP-432165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8413.73,5889.611,AETNA [1000108],AETNA [100010801],,,76.8,,6461.74,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 158MM 4.5MM 10HL RECON SS -,SUP-432210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1420.32,994.224,AETNA [1000108],AETNA [100010801],,,76.8,,1090.81,0.518595,35041.66656,percent of total billed charges,,,
PLATE RECON HL 4.5 X 14 HOLE -,SUP-432214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.92,1168.944,AETNA [1000108],AETNA [100010801],,,76.8,,1282.5,0.518595,35041.66656,percent of total billed charges,,,
PLATE T 6 HOLE L=111MM -,SUP-433106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.57,778.799,AETNA [1000108],AETNA [100010801],,,76.8,,854.45,0.518595,35041.66656,percent of total billed charges,,,
70MM TIBIAL KNEE CEMENT MOLD -,SUP-433170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4530.53,3171.371,AETNA [1000108],AETNA [100010801],,,76.8,,3479.45,0.518595,35041.66656,percent of total billed charges,,,
MOLD BNCMNT TIB 75MM SIL STAGEONE STRL -,SUP-433175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4530.53,3171.371,AETNA [1000108],AETNA [100010801],,,76.8,,3479.45,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN AXSOS 86MM 4MM 3HL CONTR LCK SS NS 1STRN/PK -,SUP-437123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5167.49,3617.243,AETNA [1000108],AETNA [100010801],,,76.8,,3968.63,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN AXSOS 112MM 4MM 5HL CONTR LCK SS NS -,SUP-437125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5167.49,3617.243,AETNA [1000108],AETNA [100010801],,,76.8,,3968.63,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN AXSOS 95MM 4MM HLX2/5 SHFT/METPHYSL CONTR LCK SS NS -,SUP-437302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,AETNA [1000108],AETNA [100010801],,,76.8,,3466.69,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN AXSOS 121MM 4MM HLX4/5 SHFT/METPHYSL CONTR LT TIB -,SUP-437304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,AETNA [1000108],AETNA [100010801],,,76.8,,3466.69,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN AXSOS 147MM 4MM HLX6/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,AETNA [1000108],AETNA [100010801],,,76.8,,3466.69,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN AXSOS 121MM 4MM HLX4/5 SHFT/METPHYSL CONTR RT TIB -,SUP-437324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,AETNA [1000108],AETNA [100010801],,,76.8,,3466.69,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN AXSOS 173MM 4MM HLX8/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,AETNA [1000108],AETNA [100010801],,,76.8,,3466.69,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN AXSOS 97MM 4MM HLX4/3 SHFT/METPHYSL CONTR LCK SS -,SUP-437424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4738,3316.6,AETNA [1000108],AETNA [100010801],,,76.8,,3638.78,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN AXSOS 166MM 5MM HLX6/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5434.02,3803.814,AETNA [1000108],AETNA [100010801],,,76.8,,4173.33,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN AXSOS 202MM 5MM HLX8/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,AETNA [1000108],AETNA [100010801],,,76.8,,4191.58,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN AXSOS 238MM 5MM HLX10/5 SHFT/METPHYSL CONTR LCK SS. -,SUP-437510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,AETNA [1000108],AETNA [100010801],,,76.8,,4191.58,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN AXSOS 310MM 5MM HLX14/5 SHFT/METPHYSL CONTR LCK SS- -,SUP-437514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,AETNA [1000108],AETNA [100010801],,,76.8,,4191.58,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN AXSOS 238MM 5MM HLX10/5 SHFT/METPHYSL CONTR LCK SS- -,SUP-437530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,AETNA [1000108],AETNA [100010801],,,76.8,,4191.58,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN AXSOS 310MM 5MM HLX14/5 SHFT/METPHYSL CONTR LCK SS. -,SUP-437534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,AETNA [1000108],AETNA [100010801],,,76.8,,4191.58,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN AXSOS 343MM 5MM HLX16/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,AETNA [1000108],AETNA [100010801],,,76.8,,4191.58,0.518595,35041.66656,percent of total billed charges,,,
LINER 32X49MM EPSLN STD DRSUL PRIM HOOD -,SUP-4377-32-049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3174.71,2222.297,AETNA [1000108],AETNA [100010801],,,76.8,,2438.18,0.518595,35041.66656,percent of total billed charges,,,
SET SCREW SPIN STD FIREBIRD TI -,SUP-44-2001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,,,
FIREBIRD TOP LOADING HEAD -,SUP-44-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
ORTHOFIX 4.5 X 30 SCREW -,SUP-44-5430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
ORTHOFIX SCREW 4.5 X 35 -,SUP-44-5435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
ORTHOFIX SCREW 4.5 X 40 -,SUP-44-5440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
ORTHOFIX SCREW 4.5 X 45 -,SUP-44-5445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
ORTHOFIX SCREW 5.5 X 30 -,SUP-44-5530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
ORTHOFIX SCREW 5.5 X 35 -,SUP-44-5535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
ORTHOFIX SCREW 5.5 X 40 -,SUP-44-5540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
ORTHOFIX SCREW 5.5 X 45 -,SUP-44-5545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
ORTHOFIX SCREW 6.5 X 30 -,SUP-44-5630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
6.5 X 35 SHANK -,SUP-44-5635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
6.5 X 40 SHANK -,SUP-44-5640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
6.5 X 45 SHANK -,SUP-44-5645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
7.5 X 40 SHANK -,SUP-44-5740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW FIREBIRD ORTHOFIX 7.5 X 45 -,SUP-44-5745,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
ORTHOFIX SCREW 7.5 X 50 -,SUP-44-5750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
ORTHOFIX SCREW 6.5 X 35 -,SUP-44-6535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
ORTHOFIX SCREW 6.5 X 40 -,SUP-44-6540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
WASHER 3.5 -,SUP-45-35900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,139.05,97.335,AETNA [1000108],AETNA [100010801],,,76.8,,106.79,0.518595,35041.66656,percent of total billed charges,,,
MICROCOIL EMBL 4MMX 5CML AZUR DTCH 18 -,SUP-45-480405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3570.95,2499.665,AETNA [1000108],AETNA [100010801],,,76.8,,2742.49,0.518595,35041.66656,percent of total billed charges,,,
IMPLANT PHALANX 2MM PRO- TOE VO 13MM 10DG ANG -,SUP-45712010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,0.518595,35041.66656,percent of total billed charges,,,
MINI STICK MAX 5FR X 10CM -,SUP-45-756,CDM,C1713,HCPCS,278,RC,,,outpatient,,,431.21,301.847,AETNA [1000108],AETNA [100010801],,,76.8,,331.17,0.518595,35041.66656,percent of total billed charges,,,
COUNTERSINK FOR SCREWS 02.7/3.5mm AO FITTING -,SUP-45-80040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,516.4,361.48,AETNA [1000108],AETNA [100010801],,,76.8,,396.6,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3X12MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115401200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,AETNA [1000108],AETNA [100010801],,,76.8,,1237.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3X16MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115401600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,AETNA [1000108],AETNA [100010801],,,76.8,,1237.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3X18MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115401800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,AETNA [1000108],AETNA [100010801],,,76.8,,1237.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3X20MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115402000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,AETNA [1000108],AETNA [100010801],,,76.8,,1237.76,0.518595,35041.66656,percent of total billed charges,,,
SPACER SYSTEM CONSTRUX MINI PEEK -,SUP-47-3009SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2X10MM CORT SM HX DRV -,SUP-4820-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.04,88.228,AETNA [1000108],AETNA [100010801],,,76.8,,96.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX24MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-48-3502-41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA [1000108],AETNA [100010801],,,76.8,,122.96,0.518595,35041.66656,percent of total billed charges,,,
COUPLING DELTA ROD TO ROD MULTI 05/8/11 5MM PIN -,SUP-4922-1-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4759.25,3331.475,AETNA [1000108],AETNA [100010801],,,76.8,,3655.1,0.518595,35041.66656,percent of total billed charges,,,
CLAMP 5 HOLE PIN -,SUP-4922-2-020-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3516.77,2461.739,AETNA [1000108],AETNA [100010801],,,76.8,,2700.88,0.518595,35041.66656,percent of total billed charges,,,
ROD VECTRAN COATED 11MM X 100MM CARBON CONN -,SUP-4922-8-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1854.96,1298.472,AETNA [1000108],AETNA [100010801],,,76.8,,1424.61,0.518595,35041.66656,percent of total billed charges,,,
WIRE BOLT SHORT -,SUP-4933-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,750.96,525.672,AETNA [1000108],AETNA [100010801],,,76.8,,576.74,0.518595,35041.66656,percent of total billed charges,,,
WIRE BOLT MEDIUM -,SUP-4933-1-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,750.96,525.672,AETNA [1000108],AETNA [100010801],,,76.8,,576.74,0.518595,35041.66656,percent of total billed charges,,,
WIRE BOLT ADAPTER SHORT -,SUP-4933-1-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1798.46,1258.922,AETNA [1000108],AETNA [100010801],,,76.8,,1381.22,0.518595,35041.66656,percent of total billed charges,,,
M8 CONNECTING NUT -,SUP-4933-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,199.56,139.692,AETNA [1000108],AETNA [100010801],,,76.8,,153.26,0.518595,35041.66656,percent of total billed charges,,,
POST EXTERNAL FIXATION SHORT L44 MM OD8 MM HOFFMANN -,SUP-4933-1-644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,819.23,573.461,AETNA [1000108],AETNA [100010801],,,76.8,,629.17,0.518595,35041.66656,percent of total billed charges,,,
BOLT FOR RING -,SUP-4933-1-702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,220.56,154.392,AETNA [1000108],AETNA [100010801],,,76.8,,169.39,0.518595,35041.66656,percent of total billed charges,,,
WASHER YELLOW 2MM -,SUP-4933-1-711,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.1,249.97,AETNA [1000108],AETNA [100010801],,,76.8,,274.25,0.518595,35041.66656,percent of total billed charges,,,
CARBON FIBER FULL RING 210MM -,SUP-4933-5-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10863.87,7604.709,AETNA [1000108],AETNA [100010801],,,76.8,,8343.45,0.518595,35041.66656,percent of total billed charges,,,
CARBON FIBER OPEN RING 180MM -,SUP-4933-6-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9858.39,6900.873,AETNA [1000108],AETNA [100010801],,,76.8,,7571.24,0.518595,35041.66656,percent of total billed charges,,,
CARBON FIBER OPEN RING 210MM -,SUP-4933-6-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9316.66,6521.662,AETNA [1000108],AETNA [100010801],,,76.8,,7155.19,0.518595,35041.66656,percent of total billed charges,,,
WIRE WITH OLIVE 1.8 X 450 -,SUP-4933-8-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,850.74,595.518,AETNA [1000108],AETNA [100010801],,,76.8,,653.37,0.518595,35041.66656,percent of total billed charges,,,
K-WIRE 2.0 OLIVE -,SUP-4933-8-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,887.5,621.25,AETNA [1000108],AETNA [100010801],,,76.8,,681.6,0.518595,35041.66656,percent of total billed charges,,,
HII COMPACT MRI PERIARTICULAR PIN CLAMP -,SUP-4941-2-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1539.11,1077.377,AETNA [1000108],AETNA [100010801],,,76.8,,1182.04,0.518595,35041.66656,percent of total billed charges,,,
SYNMESH 15MM DIA 8MM HEIGHT ROUND CAGE -,SUP-495.361,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9527.78,6669.446,AETNA [1000108],AETNA [100010801],,,76.8,,7317.34,0.518595,35041.66656,percent of total billed charges,,,
END RING 10MM DIAM / 0 DEG -,SUP-495.384,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1024.04,716.828,AETNA [1000108],AETNA [100010801],,,76.8,,786.46,0.518595,35041.66656,percent of total billed charges,,,
SYNMESH 10MM DIAM 20MM HEIGHT -,SUP-495.603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9664.94,6765.458,AETNA [1000108],AETNA [100010801],,,76.8,,7422.67,0.518595,35041.66656,percent of total billed charges,,,
SCREW CRNMXF UPR FACE 1.2X5MM UNIVERSAL NEURO II ST TI NS -,SUP-50-12005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,372.97,261.079,AETNA [1000108],AETNA [100010801],,,76.8,,286.44,0.518595,35041.66656,percent of total billed charges,,,
SCREW CRNMXF UPR FACE 1.2X10MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-12010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,372.97,261.079,AETNA [1000108],AETNA [100010801],,,76.8,,286.44,0.518595,35041.66656,percent of total billed charges,,,
SCREW CRNMXF UPR FACE 1.2X12MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-12012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,372.97,261.079,AETNA [1000108],AETNA [100010801],,,76.8,,286.44,0.518595,35041.66656,percent of total billed charges,,,
SCREW CRNMXF UPR FACE 1.2X3MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-12903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,417.55,292.285,AETNA [1000108],AETNA [100010801],,,76.8,,320.68,0.518595,35041.66656,percent of total billed charges,,,
PIN WND CLSR 200MM -,SUP-5014-5-200S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,680.36,476.252,AETNA [1000108],AETNA [100010801],,,76.8,,522.52,0.518595,35041.66656,percent of total billed charges,,,
CANC HALF-PIN 5MM SHAFT 6MM X 250 THREAD -,SUP-5015-7-250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,AETNA [1000108],AETNA [100010801],,,76.8,,432.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW CRNMXF MIDFC 1.7X6MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-17006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.31,222.117,AETNA [1000108],AETNA [100010801],,,76.8,,243.69,0.518595,35041.66656,percent of total billed charges,,,
SCREW CRNMXF MIDFC 1.7X8MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-17008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.31,222.117,AETNA [1000108],AETNA [100010801],,,76.8,,243.69,0.518595,35041.66656,percent of total billed charges,,,
SCREW CRNMXF MIDFC 1.7X10MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-17010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.31,222.117,AETNA [1000108],AETNA [100010801],,,76.8,,243.69,0.518595,35041.66656,percent of total billed charges,,,
SCREW ER CRNMXF MIDFC 1.7X4MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-17304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,441.77,309.239,AETNA [1000108],AETNA [100010801],,,76.8,,339.28,0.518595,35041.66656,percent of total billed charges,,,
SCREW LCK CRNMXF MIDFC 1.7X4MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-17504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,416.09,291.263,AETNA [1000108],AETNA [100010801],,,76.8,,319.56,0.518595,35041.66656,percent of total billed charges,,,
SCREW LCK CRNMXF MIDFC 1.7X5MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-17505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,416.09,291.263,AETNA [1000108],AETNA [100010801],,,76.8,,319.56,0.518595,35041.66656,percent of total billed charges,,,
HALF PIN FX APEX 5MM SS HA CTD SD/TAP180MML 50MM THRD -,SUP-5017-5-180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,642.67,449.869,AETNA [1000108],AETNA [100010801],,,76.8,,493.57,0.518595,35041.66656,percent of total billed charges,,,
SCREW CRNMXF MIDFC 1.7X3MM CX PIN HD UNIVERSAL NEURO II SD -,SUP-50-17903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,356.29,249.403,AETNA [1000108],AETNA [100010801],,,76.8,,273.63,0.518595,35041.66656,percent of total billed charges,,,
SCREW CRNMXF MIDFC 1.7X4MM CX PIN HD UNIVERSAL NEURO II ST. -,SUP-50-17904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,356.29,249.403,AETNA [1000108],AETNA [100010801],,,76.8,,273.63,0.518595,35041.66656,percent of total billed charges,,,
PIN EXTFIX 5X150MM SS APEX 40MM THRD SD/ST -,SUP-5018-5-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,AETNA [1000108],AETNA [100010801],,,76.8,,432.76,0.518595,35041.66656,percent of total billed charges,,,
HALFPIN EXTFIX 5X150MM SS APEX 50MM THRD SD/ST -,SUP-5018-6-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,AETNA [1000108],AETNA [100010801],,,76.8,,432.76,0.518595,35041.66656,percent of total billed charges,,,
PIN EXTFIX 5X50MM HLF SS APEX 180MM THRD SD -,SUP-5018-6-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,AETNA [1000108],AETNA [100010801],,,76.8,,432.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW CRNMXF MIDFC 1.9X3MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-19003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,348.64,244.048,AETNA [1000108],AETNA [100010801],,,76.8,,267.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW CRNMXF MAND 2X4MM CX PIN HD UNIVERSAL NEURO II ST TI -,SUP-50-20404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.62,210.434,AETNA [1000108],AETNA [100010801],,,76.8,,230.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW CRNMXF MAND 2X6MM CX PIN HD UNIVERSAL NEURO II ST TI -,SUP-50-20406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.62,210.434,AETNA [1000108],AETNA [100010801],,,76.8,,230.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW CRNMXF MAND 2X8MM CX PIN HD UNIVERSAL NEURO II ST TI -,SUP-50-20408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.62,210.434,AETNA [1000108],AETNA [100010801],,,76.8,,230.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW LCK CRNMXF MAND 2X12MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-20512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,551.06,385.742,AETNA [1000108],AETNA [100010801],,,76.8,,423.21,0.518595,35041.66656,percent of total billed charges,,,
SCREW LCK CRNMXF MAND 2X14MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-20514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,551.06,385.742,AETNA [1000108],AETNA [100010801],,,76.8,,423.21,0.518595,35041.66656,percent of total billed charges,,,
SCREW LCK CRNMXF MAND 2X16MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-20516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,551.06,385.742,AETNA [1000108],AETNA [100010801],,,76.8,,423.21,0.518595,35041.66656,percent of total billed charges,,,
SCREW SELF DRILLING LOCKING 2 X 6MM -,SUP-50-20596,CDM,C1713,HCPCS,278,RC,,,outpatient,,,830.96,581.672,AETNA [1000108],AETNA [100010801],,,76.8,,638.18,0.518595,35041.66656,percent of total billed charges,,,
PIN EXTFIX 6X200MM HLF SS APEX 70MM THRD SD/ST -,SUP-5021-8-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,AETNA [1000108],AETNA [100010801],,,76.8,,432.76,0.518595,35041.66656,percent of total billed charges,,,
PIN EXTFIX 4X120MM SS APEX 30MM THRD SD/ST -,SUP-5023-3-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,AETNA [1000108],AETNA [100010801],,,76.8,,350.25,0.518595,35041.66656,percent of total billed charges,,,
SCREW CRNMXF MAND 2.3X16MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-23416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.43,257.201,AETNA [1000108],AETNA [100010801],,,76.8,,282.19,0.518595,35041.66656,percent of total billed charges,,,
PIN EXTFIX 4X120MM HLF SS APEX 35MM THRD SD/ST -,SUP-5023-5-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,AETNA [1000108],AETNA [100010801],,,76.8,,350.25,0.518595,35041.66656,percent of total billed charges,,,
PIN EXTFIX 4X150MM HLF SS APEX 50MM THRD SD/ST -,SUP-5023-6-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,AETNA [1000108],AETNA [100010801],,,76.8,,350.25,0.518595,35041.66656,percent of total billed charges,,,
PIN EXTFIX 4X180MM SS HLF PIN APEX 50MM THRD SD/ST -,SUP-5023-6-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,AETNA [1000108],AETNA [100010801],,,76.8,,350.25,0.518595,35041.66656,percent of total billed charges,,,
PIN HYBRID APEX -,SUP-5026-8-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,591.79,414.253,AETNA [1000108],AETNA [100010801],,,76.8,,454.49,0.518595,35041.66656,percent of total billed charges,,,
CAP EXTFIX 5MM HOFFMN XPRESS 40MM THRD F/PIN TIP -,SUP-5027-1-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17.15,12.005,AETNA [1000108],AETNA [100010801],,,76.8,,13.17,0.518595,35041.66656,percent of total billed charges,,,
SCREW ER CRNMXF MAND 2.7X12MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-27412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,416.21,291.347,AETNA [1000108],AETNA [100010801],,,76.8,,319.65,0.518595,35041.66656,percent of total billed charges,,,
SCREW LCK CRNMXF MAND 2.7X10MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-27510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,708.49,495.943,AETNA [1000108],AETNA [100010801],,,76.8,,544.12,0.518595,35041.66656,percent of total billed charges,,,
ROD CONNECTING VECTRAN COATED CARBON 8MM X 400MM -,SUP-5028-8-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1100.81,770.567,AETNA [1000108],AETNA [100010801],,,76.8,,845.42,0.518595,35041.66656,percent of total billed charges,,,
TRANSFIX PIN 4X300MM -,SUP-5030-4-300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,AETNA [1000108],AETNA [100010801],,,76.8,,402.37,0.518595,35041.66656,percent of total billed charges,,,
APEX TRANSFIX 4 X 250 PIN 5 X 50 THR -,SUP-5030-5-250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,AETNA [1000108],AETNA [100010801],,,76.8,,402.37,0.518595,35041.66656,percent of total billed charges,,,
PIN EXTFIX 3X100MM TRNSFX SS APEX 25MM THRD SD/ST F/BILAT -,SUP-5038-2-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,329.79,230.853,AETNA [1000108],AETNA [100010801],,,76.8,,253.28,0.518595,35041.66656,percent of total billed charges,,,
PIN EXTFIX 3X200MM TRNSFX SS APEX -,SUP-5045-5-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,AETNA [1000108],AETNA [100010801],,,76.8,,402.37,0.518595,35041.66656,percent of total billed charges,,,
ROD HII COMPACT MRI CONNECTING 5MM X 65MM -,SUP-5048-5-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,AETNA [1000108],AETNA [100010801],,,76.8,,311.18,0.518595,35041.66656,percent of total billed charges,,,
HII COMPACT MRI CONNECTING ROD 5MM X 100MM -,SUP-5048-5-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,AETNA [1000108],AETNA [100010801],,,76.8,,311.18,0.518595,35041.66656,percent of total billed charges,,,
HII COMPACT MRI CONNECTING ROD 5MM X 150MM -,SUP-5048-5-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,AETNA [1000108],AETNA [100010801],,,76.8,,311.18,0.518595,35041.66656,percent of total billed charges,,,
ROD HII COMPACT MRI CONNECTING 5MM X 200MM -,SUP-5048-5-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,AETNA [1000108],AETNA [100010801],,,76.8,,311.18,0.518595,35041.66656,percent of total billed charges,,,
PIN TRANSFIXING 300MM 5/6 -,SUP-5050-4-300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,AETNA [1000108],AETNA [100010801],,,76.8,,402.37,0.518595,35041.66656,percent of total billed charges,,,
PIN EXTFIX 5MM/4X300MM TRNSFX SS APEX 50MM THRD SD/ST -,SUP-5050-5-250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,623.82,436.674,AETNA [1000108],AETNA [100010801],,,76.8,,479.09,0.518595,35041.66656,percent of total billed charges,,,
BLADE SAW 13X90MM OSCIL/SGTL 0.89MM -,SUP-506123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,460.97,322.679,AETNA [1000108],AETNA [100010801],,,76.8,,354.02,0.518595,35041.66656,percent of total billed charges,,,
PIN EXTFIX 2X45MM SS APEX 20MM THRD ST -,SUP-5065-4-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,297.76,208.432,AETNA [1000108],AETNA [100010801],,,76.8,,228.68,0.518595,35041.66656,percent of total billed charges,,,
CARBON CONNECTING ROD 3MMX120MM -,SUP-5079-6-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,290.23,203.161,AETNA [1000108],AETNA [100010801],,,76.8,,222.9,0.518595,35041.66656,percent of total billed charges,,,
HALFPIN EXTFIX 2X45MM SS U THRD DBL HLCL FLUT APEX 12MM P/T -,SUP-5080-2-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,346.77,242.739,AETNA [1000108],AETNA [100010801],,,76.8,,266.32,0.518595,35041.66656,percent of total billed charges,,,
PIN 2MM X 45MM HALF HOFFMANN II APEX STAINLESS STEEL MICRO -,SUP-5080-2-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,346.77,242.739,AETNA [1000108],AETNA [100010801],,,76.8,,266.32,0.518595,35041.66656,percent of total billed charges,,,
SCREW POLY THRD 4.5X25MM CREO -,SUP-5119.1327,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW POLY THRD 5.5 4.5X30MM CREO -,SUP-5119.1330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
CREO 5.5 4.5MM X 40MM POLYAXIAL SCREW -,SUP-5119.1340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW CREO 5.5 4.5MM X 45MM POLYAXIAL -,SUP-5119.1345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5 X 40 POLYAXIAL CREO -,SUP-5119.1440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
CREO THREADED 5.0 X 45MM POLYAXIAL SCREW -,SUP-5119.1447,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5 X 35 POLYAXIAL CREO -,SUP-5119.1535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5 X 40 POLYAXIAL CREO -,SUP-5119.1540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5X45MM CREO THRD PRASMB F/5.5MM TI STRL -,SUP-5119.1545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
CREO THREADED 5.5 X 45MM POLYAXIAL SCREW -,SUP-5119.1547,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW POLYAXIAL 5.5 X 50 -,SUP-5119.1550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW POLYAXIAL 5.5 6.5 X 30 CREO -,SUP-5119.1630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X35MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.1635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X40MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.1640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X45MM CREO THRD PRASMB F/5.5MM TI STRL -,SUP-5119.1645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW POLYAXIAL CREO 6.5 X 50 -,SUP-5119.1650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
CREO 5.5 6.5 X 60MM POLYAXIAL SCREW -,SUP-5119.1660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5-5.5X30MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5-5.5X35MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3337,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL CREO 5.5- 6.0-5.0X25MM -,SUP-5119.3427,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6-5X30MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.3432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6-5X35MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.3437,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5-6.5X30MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5-6.5X35MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3537,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW CREO 5.5 5.5MM X 45MM CORTICAL -,SUP-5119.3547,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SPACER CERV 14X6X12MM MOSAIC PEEK-OPTIMA -,SUP-51412-206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,AETNA [1000108],AETNA [100010801],,,76.8,,9410.23,0.518595,35041.66656,percent of total billed charges,,,
SPACER CERV 14X7X12MM MOSAIC PEEK-OPTIMA -,SUP-51412-207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11436.04,8005.228,AETNA [1000108],AETNA [100010801],,,76.8,,8782.88,0.518595,35041.66656,percent of total billed charges,,,
UNITED HIP CANCELLOUS LOCKING SCREW 6.5MM X 15MM -,SUP-5208-1015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,,,
UNITED CANCELLOUS LOCKING SCREW 6.5 X 20 -,SUP-5208-1020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,,,
UNITED CANCELLOUS LOCKING SCREW 6.5 X 25 -,SUP-5208-1025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,,,
UNITED CANCELLOUS LOCKING SCREW 6.5 X 30 -,SUP-5208-1030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,,,
UNITED HIP CANCELLOUS LOCKING SCREW 6.5MM X 35MM -,SUP-5208-1035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,,,
UNITED CANCELLOUS LOCKING SCREW 6.5 X 45 -,SUP-5208-1045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,,,
ROD FIREBIRD 40MM ORTHOFIX -,SUP-52-2040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
ORTHOFIX NXG 70 ROD -,SUP-52-2070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
ORTHOFIX 80MM ROD -,SUP-52-2080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
90MM TI ROD STRAIGHT -,SUP-52-2090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
100MM TI ROD STRAIGHT -,SUP-52-2100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
NXG 110MM ROD -,SUP-52-2110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
ROD FIREBIRD 120MM TI STRAIGHT ORTHOFIX -,SUP-52-2120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
ROD FIREBIRD STRAIGHT 140MM TI ORTHOFIX -,SUP-52-2140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
ROD 160MM NXG DIA 5.5MM TI ORTHOFIX -,SUP-52-2160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
ORTHOFIX ROD 180 -,SUP-52-2180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
ORTHOFIX ROD 200MM -,SUP-52-2200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
ROD HEX TITANIUM 400MM -,SUP-52-2450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
ROD 35MM ORTHOFIX -,SUP-52-6035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
40MM ROD TI CURVED -,SUP-52-6040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
ROD 45MM ORTHOFIX -,SUP-52-6045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
ORTHOFIX ROD 50MM -,SUP-52-6050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW ACTB 6.5X12MM OSTLOK -,SUP-5260-5-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW ACTB 6.5X14MM OSTLOK -,SUP-5260-5-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW ACTB 6.5X18MM OSTLOK -,SUP-5260-5-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW ACTB 6.5X30MM OSTLOK -,SUP-5260-5-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW ACTB 6.5X35MM OSTLOK -,SUP-5260-5-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW ACTB 6.5X40MM OSTLOK -,SUP-5260-5-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW ACTB 6.5 X 45MM OSTLOK -,SUP-5260-5-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW ACTB 6.5X50MM OSTLOK -,SUP-5260-5-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
ORTHOFIX ROD 55MM -,SUP-52-6055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
ORTHOFIX NXG 60MM ROD -,SUP-52-6060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
ORTHOFIX NXG 65MM ROD -,SUP-52-6065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
ORTHOFIX 70MM ROD -,SUP-52-6070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
ORTHOFIX 75MM ROD -,SUP-52-6075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
ORTHOFIX 80 ROD -,SUP-52-6080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
OPEN CONNCETOR 5.5 - 5.5 -,SUP-52-6805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,,,
PLATE CRANFC 12MM BAR UNIV NEURO III LPRO 2HL TI STR 1.5MM -,SUP-53-05212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,705.92,494.144,AETNA [1000108],AETNA [100010801],,,76.8,,542.15,0.518595,35041.66656,percent of total billed charges,,,
PLATE CRANFC 2HL 16MM BAR STR UNIV NEURO III 1.5MM TI NS -,SUP-53-05216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,844.97,591.479,AETNA [1000108],AETNA [100010801],,,76.8,,648.94,0.518595,35041.66656,percent of total billed charges,,,
PLATE CRANFC 4HL 28MM BAR 3D BX UNIV NEURO III 1.5MM TI NS -,SUP-53-05228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.88,735.616,AETNA [1000108],AETNA [100010801],,,76.8,,807.08,0.518595,35041.66656,percent of total billed charges,,,
PLATE CRANFC LRG 2HL 3D BX LEIBINGER UNIV NEURO 2 1.5MM TI -,SUP-53-05240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1443.7,1010.59,AETNA [1000108],AETNA [100010801],,,76.8,,1108.76,0.518595,35041.66656,percent of total billed charges,,,
PLATE CRANFC 6MM BAR 4HL STR LEIBINGER UNIV NEURO 2 1.5MM TI -,SUP-53-05406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,702.42,491.694,AETNA [1000108],AETNA [100010801],,,76.8,,539.46,0.518595,35041.66656,percent of total billed charges,,,
COVER CRANFC 7MM UNIV NEURO III LPRO TI -,SUP-53-05507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1211.85,848.295,AETNA [1000108],AETNA [100010801],,,76.8,,930.7,0.518595,35041.66656,percent of total billed charges,,,
COVER CRANFC 10MM UNIVERSAL NEURO II LPRO TI NS -,SUP-53-05510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1211.85,848.295,AETNA [1000108],AETNA [100010801],,,76.8,,930.7,0.518595,35041.66656,percent of total billed charges,,,
COVER CRANFC 14MM UNIVERSAL NEURO II LPRO TI NS -,SUP-53-05514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1211.85,848.295,AETNA [1000108],AETNA [100010801],,,76.8,,930.7,0.518595,35041.66656,percent of total billed charges,,,
COVER CRANFC 20MM UNIVERSAL NEURO II LPRO TI NS -,SUP-53-05520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1338.06,936.642,AETNA [1000108],AETNA [100010801],,,76.8,,1027.63,0.518595,35041.66656,percent of total billed charges,,,
PLATE CRANFC 8MM UNIV NEURO III LPRO 6HL TI DBL Y 1.5MM NS -,SUP-53-05608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1331.38,931.966,AETNA [1000108],AETNA [100010801],,,76.8,,1022.5,0.518595,35041.66656,percent of total billed charges,,,
PLATE STR LP GAP SMALL -,SUP-53-05612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1587.66,1111.362,AETNA [1000108],AETNA [100010801],,,76.8,,1219.32,0.518595,35041.66656,percent of total billed charges,,,
PLATE STR LP GAP LARGE -,SUP-53-05622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1748.42,1223.894,AETNA [1000108],AETNA [100010801],,,76.8,,1342.79,0.518595,35041.66656,percent of total billed charges,,,
PLATE CRANFC 4HL X-SHP LEIBINGER UNIV NEURO 2 1.5MM TI NS -,SUP-53-05630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1344.26,940.982,AETNA [1000108],AETNA [100010801],,,76.8,,1032.39,0.518595,35041.66656,percent of total billed charges,,,
PLATE CRANFC 8HL STR LEIBINGER UNIV NEURO 2 1.5MM TI NS W/O -,SUP-53-05804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.28,665.896,AETNA [1000108],AETNA [100010801],,,76.8,,730.58,0.518595,35041.66656,percent of total billed charges,,,
PLATE CRANFC 12MM 2HL UNIV NEURO III XTR RGD TI NS -,SUP-53-06212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,597.33,418.131,AETNA [1000108],AETNA [100010801],,,76.8,,458.75,0.518595,35041.66656,percent of total billed charges,,,
NAIL SFT TIS BIO- ABSB LPRO 1.5X20MM PLYLC ACD PLYMR KN -,SUP-531520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,798.11,558.677,AETNA [1000108],AETNA [100010801],,,76.8,,612.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.7X5MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17005E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,AETNA [1000108],AETNA [100010801],,,76.8,,338.47,0.518595,35041.66656,percent of total billed charges,,,
SCREW LCK 1.7 X 06 -,SUP-53-17006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,518.32,362.824,AETNA [1000108],AETNA [100010801],,,76.8,,398.07,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.7X8MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,AETNA [1000108],AETNA [100010801],,,76.8,,338.47,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.7X9MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,AETNA [1000108],AETNA [100010801],,,76.8,,338.47,0.518595,35041.66656,percent of total billed charges,,,
SCREW LCK 1.7 X 10 -,SUP-53-17010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.83,308.581,AETNA [1000108],AETNA [100010801],,,76.8,,338.56,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.7X12MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,AETNA [1000108],AETNA [100010801],,,76.8,,338.47,0.518595,35041.66656,percent of total billed charges,,,
SCREW LCK 1.7 X 16 -,SUP-53-17016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,AETNA [1000108],AETNA [100010801],,,76.8,,338.47,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.7X16MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX -,SUP-53-20616E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2X18MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX NS -,SUP-53-20618E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2X20MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX NS -,SUP-53-20620E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2X22MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX NS -,SUP-53-20622E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.7X24MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX -,SUP-53-20624E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.7X26MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX. -,SUP-53-20626E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X6MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA [1000108],AETNA [100010801],,,76.8,,340.09,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X8MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA [1000108],AETNA [100010801],,,76.8,,340.09,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X9MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA [1000108],AETNA [100010801],,,76.8,,340.09,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X10MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA [1000108],AETNA [100010801],,,76.8,,340.09,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X11MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23011E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA [1000108],AETNA [100010801],,,76.8,,340.09,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X12MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA [1000108],AETNA [100010801],,,76.8,,340.09,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X13MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23013E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA [1000108],AETNA [100010801],,,76.8,,340.09,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X16MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA [1000108],AETNA [100010801],,,76.8,,340.09,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X18MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23018E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA [1000108],AETNA [100010801],,,76.8,,340.09,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 2.3MM X 20MM -,SUP-53-23020E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.88,310.016,AETNA [1000108],AETNA [100010801],,,76.8,,340.13,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 2.3 X 24 -,SUP-53-23024E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA [1000108],AETNA [100010801],,,76.8,,340.09,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 2.3 X 26 -,SUP-53-23026E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA [1000108],AETNA [100010801],,,76.8,,340.09,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X10MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23210E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X14MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23214E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X16MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23216E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X18MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23218E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X20MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23220E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X22MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23222E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X24MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23224E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X26MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23226E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X28MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23228E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X30MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23230E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X32MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23232E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X34MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23234E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X36MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23236E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X38MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23238E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X10MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23610E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X12MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23612E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X14MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT. -,SUP-53-23614E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X16MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23616E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X18MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT. -,SUP-53-23618E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X20MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23620E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X22MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23622E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X24MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23624E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X26MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23626E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X28MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23628E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X30MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23630E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X32MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23632E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X34MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23634E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X36MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23636E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X38MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23638E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X16MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27116E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,AETNA [1000108],AETNA [100010801],,,76.8,,341.7,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X18MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27118E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,AETNA [1000108],AETNA [100010801],,,76.8,,341.7,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X20MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27120E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,AETNA [1000108],AETNA [100010801],,,76.8,,341.7,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X22MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27122E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,AETNA [1000108],AETNA [100010801],,,76.8,,341.7,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X24MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27124E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,AETNA [1000108],AETNA [100010801],,,76.8,,341.7,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X26MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27126E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,AETNA [1000108],AETNA [100010801],,,76.8,,341.7,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X10MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27210E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,,,
SCREW NON LOCK 2.7 X 12MM -,SUP-53-27212E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,,,
SCREW NON LOCK 2.7 X 14 -,SUP-53-27214E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X16MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27216E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X18MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27218E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X20MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27220E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X22MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27222E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X24MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27224E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X25MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27226E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X10MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27610E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X12MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27612E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X14MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27614E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X16MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27616E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X18MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27618E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X20MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27620E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 2.7 X 22 -,SUP-53-27622E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X24MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27624E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X26MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27626E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA [1000108],AETNA [100010801],,,76.8,,351.33,0.518595,35041.66656,percent of total billed charges,,,
PLATE MSH CRANFC MIDFC MICRO 60X120MM 0.1MM MLBL 1.2MM TI NS -,SUP-54-00261,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3755.99,2629.193,AETNA [1000108],AETNA [100010801],,,76.8,,2884.6,0.518595,35041.66656,percent of total billed charges,,,
MICRO/MESH 120 X 120 X .2MM / GOLD -,SUP-54-00270,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8602.59,6021.813,AETNA [1000108],AETNA [100010801],,,76.8,,6606.79,0.518595,35041.66656,percent of total billed charges,,,
MICRO/MESH 120 X 60 X .2MM / GOLD -,SUP-54-00271,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6438.15,4506.705,AETNA [1000108],AETNA [100010801],,,76.8,,4944.5,0.518595,35041.66656,percent of total billed charges,,,
BLUE DYNAMIC MESH  90X90MM 0.3MM MLBL 1.7MM TI NS -,SUP-54-00346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2066.2,1446.34,AETNA [1000108],AETNA [100010801],,,76.8,,1586.84,0.518595,35041.66656,percent of total billed charges,,,
LOCKING SCREW 3.5MM T15 L40MM -,SUP-541540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1621.95,1135.365,AETNA [1000108],AETNA [100010801],,,76.8,,1245.66,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 60MMX1.5MM 2.7MM ANTMC POLYAX TI SMRTLC RT -,SUP-54-25290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,AETNA [1000108],AETNA [100010801],,,76.8,,3196.47,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 60MMX1.5MM 2.7MM ANTMC POLYAX TI SMRTLC LT -,SUP-54-25291,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,AETNA [1000108],AETNA [100010801],,,76.8,,3196.47,0.518595,35041.66656,percent of total billed charges,,,
PLATE WIDE DORSAL RIGHT -,SUP-54-25292,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,AETNA [1000108],AETNA [100010801],,,76.8,,3196.47,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 60MMX1.5MM 2.7MM ANTMC POLYAX TI W SMRTLC -,SUP-54-25293,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,AETNA [1000108],AETNA [100010801],,,76.8,,3196.47,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 81MMX1.5MM 2.7MM ANTMC POLYAX TI XLNG SMRTLC -,SUP-54-25295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4270.06,2989.042,AETNA [1000108],AETNA [100010801],,,76.8,,3279.41,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 56MM 2.7MM 9HL 2MM ANTMC POLYAX TI SMRTLC -,SUP-54-25374,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,AETNA [1000108],AETNA [100010801],,,76.8,,3136.93,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 76MM 2.7MM 2MM ANTMC POLYAX TI LNG NRW LT -,SUP-54-25375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,AETNA [1000108],AETNA [100010801],,,76.8,,3622.18,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 56MM 2.7MM 11HL ANTMC POLYAX TI STD SMRTLC -,SUP-54-25376,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,AETNA [1000108],AETNA [100010801],,,76.8,,3136.93,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 76MM 2.7MM 13HL 2MM ANTMC POLYAX TI STD LNG -,SUP-54-25377,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,AETNA [1000108],AETNA [100010801],,,76.8,,3622.18,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 56MM 2.7MM 9HL ANTMC POLYAX TI STD SMRTLC -,SUP-54-25384,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,AETNA [1000108],AETNA [100010801],,,76.8,,3136.93,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 76MM 2.7MM 2MM ANTMC POLYAX TI LNG NRW RT -,SUP-54-25385,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,AETNA [1000108],AETNA [100010801],,,76.8,,3622.18,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 56MM 2.7MM STD ANTMC TI SMRTLC -,SUP-54-25386,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,AETNA [1000108],AETNA [100010801],,,76.8,,3136.93,0.518595,35041.66656,percent of total billed charges,,,
PLATE VOLAR 76MM L 14 HOLE 2MM H STAN LONG RT -,SUP-54-25387,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,AETNA [1000108],AETNA [100010801],,,76.8,,3622.18,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 53MM 2.7MM 2MM POLYAX TI MED/SHRT UNIV XLN -,SUP-54-25394,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3450.36,2415.252,AETNA [1000108],AETNA [100010801],,,76.8,,2649.88,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 53MM 2.7MM 2MM POLYAX TI SHRT UNIV STD -,SUP-54-25396,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3450.36,2415.252,AETNA [1000108],AETNA [100010801],,,76.8,,2649.88,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 53MM 2.7MM 2MM POLYAX TI SHRT UNIV W SMRTLC -,SUP-54-25398,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3450.36,2415.252,AETNA [1000108],AETNA [100010801],,,76.8,,2649.88,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 44MM 2.7MM 1MM ANTMC POLYAX TI SHRT NRW CLMN -,SUP-54-25400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,AETNA [1000108],AETNA [100010801],,,76.8,,2336.03,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 57MM 2.7MM ANTMC POLYAX TI LNG CLMN SMRTLC -,SUP-54-25401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,AETNA [1000108],AETNA [100010801],,,76.8,,2336.03,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 40MMX1MM FRAG SPEC POLYAX TI SHRT SMRTLC -,SUP-54-25402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,AETNA [1000108],AETNA [100010801],,,76.8,,2336.03,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 40MMX1MM 2.7MM FRAG SPEC POLYAX TI SHRT -,SUP-54-25403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,AETNA [1000108],AETNA [100010801],,,76.8,,2336.03,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 53MMX1MM FRAG SPEC POLYAX TI LNG SMRTLC -,SUP-54-25405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,AETNA [1000108],AETNA [100010801],,,76.8,,2336.03,0.518595,35041.66656,percent of total billed charges,,,
PLATE 2.7 X 189 15 HOLE -,SUP-54-25420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7093.08,4965.156,AETNA [1000108],AETNA [100010801],,,76.8,,5447.49,0.518595,35041.66656,percent of total billed charges,,,
PLATE 2.7 145 11 HOLES -,SUP-54-25424S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7093.08,4965.156,AETNA [1000108],AETNA [100010801],,,76.8,,5447.49,0.518595,35041.66656,percent of total billed charges,,,
PLATE 2.7MM XXL VOLAR L100MM 8 HOLE -,SUP-54-25428S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6203.58,4342.506,AETNA [1000108],AETNA [100010801],,,76.8,,4764.35,0.518595,35041.66656,percent of total billed charges,,,
PLATE VOLAR XXL 7MM -,SUP-54-25442S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7093.08,4965.156,AETNA [1000108],AETNA [100010801],,,76.8,,5447.49,0.518595,35041.66656,percent of total billed charges,,,
PLATE 2.7MM XXL VOLAR NARROW 8 HOLE -,SUP-54-25444S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6203.58,4342.506,AETNA [1000108],AETNA [100010801],,,76.8,,4764.35,0.518595,35041.66656,percent of total billed charges,,,
PLATE 8 HOLES / 100MM / 2.7MM XXL -,SUP-54-25446S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6203.58,4342.506,AETNA [1000108],AETNA [100010801],,,76.8,,4764.35,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 3HL XSH NRW -,SUP-54-25573,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,AETNA [1000108],AETNA [100010801],,,76.8,,3351.6,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 8HL XSH -,SUP-54-25583,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,AETNA [1000108],AETNA [100010801],,,76.8,,3351.6,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN XSH -,SUP-54-25673,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,AETNA [1000108],AETNA [100010801],,,76.8,,3351.6,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 2X56MM 11HL INTMD ANTMC SHRT NS -,SUP-54-25674,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,AETNA [1000108],AETNA [100010801],,,76.8,,3351.6,0.518595,35041.66656,percent of total billed charges,,,
PLATE INT LNG LEFT 14 HOLE -,SUP-54-25677,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4468.42,3127.894,AETNA [1000108],AETNA [100010801],,,76.8,,3431.75,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX F/DIST RAD SYS 10HL INTMD XSH -,SUP-54-25683,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,AETNA [1000108],AETNA [100010801],,,76.8,,3351.6,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 11HL INTMD SHRT -,SUP-54-25684,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,AETNA [1000108],AETNA [100010801],,,76.8,,3351.6,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 14HL INTMD LNG -,SUP-54-25687,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4468.42,3127.894,AETNA [1000108],AETNA [100010801],,,76.8,,3431.75,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX F/DIST RAD SYS 10HL STD XSH -,SUP-54-25773,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,AETNA [1000108],AETNA [100010801],,,76.8,,3351.6,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 10HL STD XSH -,SUP-54-25783,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,AETNA [1000108],AETNA [100010801],,,76.8,,3351.6,0.518595,35041.66656,percent of total billed charges,,,
RESTRICTOR BNCMNT FEM SZ3 13.25MM UHMWPE -,SUP-5460-14-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1026.96,718.872,AETNA [1000108],AETNA [100010801],,,76.8,,788.71,0.518595,35041.66656,percent of total billed charges,,,
RESTRICTOR BNCMNT FEM SZ3 15.75MM UHMWPE -,SUP-5460-16-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1150.21,805.147,AETNA [1000108],AETNA [100010801],,,76.8,,883.36,0.518595,35041.66656,percent of total billed charges,,,
RESTRICTOR FMCNL BNCMNT SZ5 18.25MM UHMWPE HIP -,SUP-5460-18-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1070.7,749.49,AETNA [1000108],AETNA [100010801],,,76.8,,822.3,0.518595,35041.66656,percent of total billed charges,,,
PLATE HYBRID MMP -,SUP-55-02950,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1731.83,1212.281,AETNA [1000108],AETNA [100010801],,,76.8,,1330.05,0.518595,35041.66656,percent of total billed charges,,,
PLATE CRANFC UPR FACE 18HL 3D SHP UNIVERSAL NEURO II MLBL -,SUP-55-04218,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2608.27,1825.789,AETNA [1000108],AETNA [100010801],,,76.8,,2003.15,0.518595,35041.66656,percent of total billed charges,,,
PLATE CRANFC UPR FACE HLX2X2 3D UNIVERSAL NEURO II MLBL -,SUP-55-04231,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.51,834.757,AETNA [1000108],AETNA [100010801],,,76.8,,915.85,0.518595,35041.66656,percent of total billed charges,,,
PLATE CRANFC UPR FACE HLX6X2 0.5MM 3D UNIV 2 MLBL 1.2MM TI -,SUP-55-04233,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2146.54,1502.578,AETNA [1000108],AETNA [100010801],,,76.8,,1648.54,0.518595,35041.66656,percent of total billed charges,,,
PLATE UPR FACE 7HL 0.5MM DBL Y UNIVERSAL NEURO II MLBL 1.2MM -,SUP-55-04240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1128.37,789.859,AETNA [1000108],AETNA [100010801],,,76.8,,866.59,0.518595,35041.66656,percent of total billed charges,,,
PLATE CRANFC UPR FACE 24HL 0.5MM STR UNIV 2 MLBL 1.2MM TI NS -,SUP-55-04424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2500,1750,AETNA [1000108],AETNA [100010801],,,76.8,,1920,0.518595,35041.66656,percent of total billed charges,,,
PLATE CRANFC MIDFC 20HL 0.55MM UNIV 2 MLBL 1.7MM TI NS BLU -,SUP-55-04720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2468.01,1727.607,AETNA [1000108],AETNA [100010801],,,76.8,,1895.43,0.518595,35041.66656,percent of total billed charges,,,
PLATE CRANFC MIDFC 24HL 0.55MM STR UNIV 2 MLBL CNDSD 1.7MM -,SUP-55-04724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.85,1788.395,AETNA [1000108],AETNA [100010801],,,76.8,,1962.12,0.518595,35041.66656,percent of total billed charges,,,
PLATE CRANFC MIDFC 7HL 0.6MM UNIVERSAL NEURO II STD 1.7MM TI -,SUP-55-05164,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.58,742.406,AETNA [1000108],AETNA [100010801],,,76.8,,814.53,0.518595,35041.66656,percent of total billed charges,,,
PLATE ORBT MIDFC 6HL CRV LEIBINGER UNIV 2 STD 1.7MM TI NS -,SUP-55-05188,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1255.9,879.13,AETNA [1000108],AETNA [100010801],,,76.8,,964.53,0.518595,35041.66656,percent of total billed charges,,,
PLATE LCK CRANFC MIDFC HL 2X2 0.8MM 3D SHP UNIVERSAL NEURO -,SUP-55-05731,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1390.43,973.301,AETNA [1000108],AETNA [100010801],,,76.8,,1067.85,0.518595,35041.66656,percent of total billed charges,,,
PLATE CRANFC UPR FACE 8HL STR UNIVERSAL NEURO II STD 1.2MM -,SUP-55-06208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1389.47,972.629,AETNA [1000108],AETNA [100010801],,,76.8,,1067.11,0.518595,35041.66656,percent of total billed charges,,,
PLATE CRANFC UPR FACE HLX2X2 3D SHP UNIVERSAL NEURO II STD -,SUP-55-06231,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.43,785.001,AETNA [1000108],AETNA [100010801],,,76.8,,861.26,0.518595,35041.66656,percent of total billed charges,,,
3D PLATE 6 X 2 HL UPPERFACE -,SUP-55-06233,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2014.51,1410.157,AETNA [1000108],AETNA [100010801],,,76.8,,1547.14,0.518595,35041.66656,percent of total billed charges,,,
3D PLATE 6 X 6 HL UPPERFACE -,SUP-55-06235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4305.34,3013.738,AETNA [1000108],AETNA [100010801],,,76.8,,3306.5,0.518595,35041.66656,percent of total billed charges,,,
PLT/7 HOLE DOUBLE Y UPPERFACE -,SUP-55-06240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1022.23,715.561,AETNA [1000108],AETNA [100010801],,,76.8,,785.07,0.518595,35041.66656,percent of total billed charges,,,
PLATE MIDFC 4HL STR UNIVERSAL NEURO II STD 1.7MM TI NS BAR -,SUP-55-06704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.58,457.506,AETNA [1000108],AETNA [100010801],,,76.8,,501.95,0.518595,35041.66656,percent of total billed charges,,,
PLATE CRANFC MIDFC 8HL STR UNIVERSAL NEURO II STD 1.7MM TI -,SUP-55-06708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1319.35,923.545,AETNA [1000108],AETNA [100010801],,,76.8,,1013.26,0.518595,35041.66656,percent of total billed charges,,,
PLATE MIDFC 24HL STR UNIVERSAL NEURO II STD 1.7MM TI NS BAR -,SUP-55-06724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2527.07,1768.949,AETNA [1000108],AETNA [100010801],,,76.8,,1940.79,0.518595,35041.66656,percent of total billed charges,,,
PLATE STR 2 X 2 3D -,SUP-55-06731,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1207.72,845.404,AETNA [1000108],AETNA [100010801],,,76.8,,927.53,0.518595,35041.66656,percent of total billed charges,,,
PLATE MIDFC 10HL UNIVERSAL NEURO II STD 1.7MM TI NS BAR GOLD -,SUP-55-06750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1390.43,973.301,AETNA [1000108],AETNA [100010801],,,76.8,,1067.85,0.518595,35041.66656,percent of total billed charges,,,
PLATE MIDFC 4HL CRV UNIVERSAL NEURO II STD 1.7MM TI NS GOLD -,SUP-55-06754,CDM,C1713,HCPCS,278,RC,,,outpatient,,,804.35,563.045,AETNA [1000108],AETNA [100010801],,,76.8,,617.74,0.518595,35041.66656,percent of total billed charges,,,
PLATE RT CRANFC MIDFC 2MM 5HL 0.6MM LEIBINGER UNIVERSAL -,SUP-55-06761,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1100.48,770.336,AETNA [1000108],AETNA [100010801],,,76.8,,845.17,0.518595,35041.66656,percent of total billed charges,,,
PLATE RT CRANFC MIDFC 5MM 5HL 0.6MM UNIVERSAL NEURO II STD -,SUP-55-06763,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1133.97,793.779,AETNA [1000108],AETNA [100010801],,,76.8,,870.89,0.518595,35041.66656,percent of total billed charges,,,
PLATE LCK MAND MINI 4HL 1MM STR UNIVERSAL NEURO II 2MM TI NS -,SUP-55-10504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,513.89,359.723,AETNA [1000108],AETNA [100010801],,,76.8,,394.67,0.518595,35041.66656,percent of total billed charges,,,
PLATE LCK MAND MINI 6HL 8MM STR UNIVERSAL NEURO II 2MM TI NS -,SUP-55-10507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.51,834.757,AETNA [1000108],AETNA [100010801],,,76.8,,915.85,0.518595,35041.66656,percent of total billed charges,,,
CAGE 10MM VUSION TS -,SUP-551-5210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,0.518595,35041.66656,percent of total billed charges,,,
PLATE CRANFC MAND 4HL STR UNIVERSAL NEURO II RECON FX 2MM TI -,SUP-55-15505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1918.09,1342.663,AETNA [1000108],AETNA [100010801],,,76.8,,1473.09,0.518595,35041.66656,percent of total billed charges,,,
PLT/FRACTURE 6 HOLES W. BAR -,SUP-55-15507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2440.83,1708.581,AETNA [1000108],AETNA [100010801],,,76.8,,1874.56,0.518595,35041.66656,percent of total billed charges,,,
CAGE 10 X 9 X 25 -,SUP-551-7410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,0.518595,35041.66656,percent of total billed charges,,,
INSERT TIB BEARING SZ2 9MM TRIATHLON X3 CR ARTCSURF -,SUP-5530-C-209,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
BEARING TIB INSERT CS 9MM SZ1 TRIATHLON X3 -,SUP-5531-G-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,0.518595,35041.66656,percent of total billed charges,,,
BEARING TIB INSERT CS 10MM SZ 1TRIATHLON X3 -,SUP-5531-G-110-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,0.518595,35041.66656,percent of total billed charges,,,
BEARING TIB INSERT CS 11MM SZ 1 TRIATHLON X3 -,SUP-5531-G-111-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,0.518595,35041.66656,percent of total billed charges,,,
INSERT TIBIAL BEARING  SZ. 5 / 11MM TYPE CS -,SUP-5531-G-511-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,0.518595,35041.66656,percent of total billed charges,,,
TIBIAL BEARING INSERT SZ.7 / CS / 11MM -,SUP-5531-G-711-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,0.518595,35041.66656,percent of total billed charges,,,
TIBIAL BEARING INSERT SZ.8 CS 9MM TRIATHLON X3 -,SUP-5531-G-809-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,0.518595,35041.66656,percent of total billed charges,,,
9MM INSERT TRIAL PS#3 -,SUP-5532-T-309,CDM,C1713,HCPCS,278,RC,,,outpatient,,,728.5,509.95,AETNA [1000108],AETNA [100010801],,,76.8,,559.49,0.518595,35041.66656,percent of total billed charges,,,
COMPONENT TIBIAL TRITANIUM SZ 1 TRIATHLON -,SUP-5536-B-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA [1000108],AETNA [100010801],,,76.8,,4726.12,0.518595,35041.66656,percent of total billed charges,,,
ORTHOFIX CROSSLINK 25 -,SUP-55-5325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,,,
CONNECTOR ROD FIREBIRD 45MM CROSSLINK ORTHOFIX -,SUP-55-5345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,,,
4.5MM PERIPHERAL SCREW 16MM -,SUP-5572-4516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,AETNA [1000108],AETNA [100010801],,,76.8,,1872.56,0.518595,35041.66656,percent of total billed charges,,,
4.5MM PERIPHERAL SCREW 24MM -,SUP-5572-4524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,AETNA [1000108],AETNA [100010801],,,76.8,,1872.56,0.518595,35041.66656,percent of total billed charges,,,
4.5MM PERIPHERAL SCREW 36MM -,SUP-5572-4536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,AETNA [1000108],AETNA [100010801],,,76.8,,1872.56,0.518595,35041.66656,percent of total billed charges,,,
6.5MM CENTER SCREW 32MM -,SUP-5573-6532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4573.49,3201.443,AETNA [1000108],AETNA [100010801],,,76.8,,3512.44,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX MODULAR TRIATH -,SUP-5575-X-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,AETNA [1000108],AETNA [100010801],,,76.8,,1506.19,0.518595,35041.66656,percent of total billed charges,,,
BONESCREW AXS ST 1.2 X 3MM 5P -,SUP-56-12003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,AETNA [1000108],AETNA [100010801],,,76.8,,440.95,0.518595,35041.66656,percent of total billed charges,,,
BONESCREW - AXS ST 1.2 X 4MM 5P -,SUP-56-12004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,AETNA [1000108],AETNA [100010801],,,76.8,,440.95,0.518595,35041.66656,percent of total billed charges,,,
BONESCREW AXS SD 1.2 X 3MM 5P -,SUP-56-12903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,636.37,445.459,AETNA [1000108],AETNA [100010801],,,76.8,,488.73,0.518595,35041.66656,percent of total billed charges,,,
BONESCREW AXS SD 1.2 X 4MM 5P -,SUP-56-12904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,636.37,445.459,AETNA [1000108],AETNA [100010801],,,76.8,,488.73,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE ER AXS ST 1.4 3MM 5P -,SUP-56-14003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,593.3,415.31,AETNA [1000108],AETNA [100010801],,,76.8,,455.65,0.518595,35041.66656,percent of total billed charges,,,
BONESCREW AXS SD 1.7 X 4MM 5P -,SUP-56-17904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,AETNA [1000108],AETNA [100010801],,,76.8,,440.95,0.518595,35041.66656,percent of total billed charges,,,
BONESCREW AXS SD 1.7 X 6MM 5P -,SUP-56-17906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,AETNA [1000108],AETNA [100010801],,,76.8,,440.95,0.518595,35041.66656,percent of total billed charges,,,
GRAFT HUM TIS PTTY 1ML OSTEOSPARX SYR LF -,SUP-562-100-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,AETNA [1000108],AETNA [100010801],,,76.8,,761.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X30MM CORT FT ST HEX HEAD -,SUP-5645-1-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,AETNA [1000108],AETNA [100010801],,,76.8,,92.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X32MM CORT FT ST HEX HEAD -,SUP-5645-1-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,AETNA [1000108],AETNA [100010801],,,76.8,,92.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X44MM CORT FT ST HEX HEAD -,SUP-5645-1-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,AETNA [1000108],AETNA [100010801],,,76.8,,92.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X48MM CORT FT ST HEX HEAD -,SUP-5645-1-048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,AETNA [1000108],AETNA [100010801],,,76.8,,92.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X50MM CORT FT ST HEX HEAD -,SUP-5645-1-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,AETNA [1000108],AETNA [100010801],,,76.8,,92.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X52MM CORT FT ST HEX HEAD -,SUP-5645-1-052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,AETNA [1000108],AETNA [100010801],,,76.8,,92.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X54MM CORT FT ST HEX HEAD -,SUP-5645-1-054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,AETNA [1000108],AETNA [100010801],,,76.8,,92.81,0.518595,35041.66656,percent of total billed charges,,,
STEM EXTENSION CEMENTED 12X30MM -,SUP-565-1203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,AETNA [1000108],AETNA [100010801],,,76.8,,3406.06,0.518595,35041.66656,percent of total billed charges,,,
MESH HYBRID MEDIUM MALL 90 X 90 X .3 BLUE -,SUP-56-90344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7015.12,4910.584,AETNA [1000108],AETNA [100010801],,,76.8,,5387.61,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PROFYLE 0.55MM 1.2MM 4HL STD PRCONT NLCKG TI XS STR -,SUP-57-05101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,AETNA [1000108],AETNA [100010801],,,76.8,,685.64,0.518595,35041.66656,percent of total billed charges,,,
PLATE PRF 1.7 X 4 HL -,SUP-57-05202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,AETNA [1000108],AETNA [100010801],,,76.8,,685.64,0.518595,35041.66656,percent of total billed charges,,,
PLATE PRF 1.7 X 6 HL LT L -,SUP-57-05221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,AETNA [1000108],AETNA [100010801],,,76.8,,685.64,0.518595,35041.66656,percent of total billed charges,,,
PLATE HAND -,SUP-57-05240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,AETNA [1000108],AETNA [100010801],,,76.8,,685.64,0.518595,35041.66656,percent of total billed charges,,,
PLATE PRF 1.7 X 7 HL T -,SUP-57-05260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1028.42,719.894,AETNA [1000108],AETNA [100010801],,,76.8,,789.83,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PROFYLE 0.55MM 1.7MM 1HL PRX2 STD PRCONT NLCKG TI -,SUP-57-05285,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1307.9,915.53,AETNA [1000108],AETNA [100010801],,,76.8,,1004.47,0.518595,35041.66656,percent of total billed charges,,,
PLATE PRF 1.7 X 3 X 2 3D -,SUP-57-05291,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1307.9,915.53,AETNA [1000108],AETNA [100010801],,,76.8,,1004.47,0.518595,35041.66656,percent of total billed charges,,,
PLATE PRF 1.7 X 4X2 RP 3D -,SUP-57-05295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1307.9,915.53,AETNA [1000108],AETNA [100010801],,,76.8,,1004.47,0.518595,35041.66656,percent of total billed charges,,,
PLATE PRF 2.3 6 HL LT L -,SUP-57-10121,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2457.66,1720.362,AETNA [1000108],AETNA [100010801],,,76.8,,1887.48,0.518595,35041.66656,percent of total billed charges,,,
PLATE PRF 2.3 X 6 HL NRW T -,SUP-57-10140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2457.66,1720.362,AETNA [1000108],AETNA [100010801],,,76.8,,1887.48,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PROFYLE 1MM 2.3MM 7HL SHFT PRCONT VAR ANG NLCKG TI -,SUP-57-10170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2457.66,1720.362,AETNA [1000108],AETNA [100010801],,,76.8,,1887.48,0.518595,35041.66656,percent of total billed charges,,,
PLATE PRF 2.3 X 5HL ROT -,SUP-57-10185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2395.78,1677.046,AETNA [1000108],AETNA [100010801],,,76.8,,1839.96,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 1.5MM 1.7MM 10HL PRCONT VAR ANG TI SM NRW -,SUP-57-10310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,AETNA [1000108],AETNA [100010801],,,76.8,,1609.22,0.518595,35041.66656,percent of total billed charges,,,
PLATE 1.7 X 6 HL LT L -,SUP-57-10321,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,AETNA [1000108],AETNA [100010801],,,76.8,,1192.09,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 1MM 1.7MM 6HL PRCONT VAR ANG TI SM NRW T-SHP -,SUP-57-10340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,AETNA [1000108],AETNA [100010801],,,76.8,,1192.09,0.518595,35041.66656,percent of total billed charges,,,
PLATE 1.7 X 7 HL T -,SUP-57-10360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,AETNA [1000108],AETNA [100010801],,,76.8,,1609.22,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 1MM 1.7MM 5HL ROT PRCONT VAR ANG TI SM -,SUP-57-10380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,AETNA [1000108],AETNA [100010801],,,76.8,,1609.22,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 1MM 1.7MM HLX3X2 PRCONT VAR ANG TI SM 3D SHP -,SUP-57-10391,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,AETNA [1000108],AETNA [100010801],,,76.8,,1609.22,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PROFYLE 1MM 2.3MM 6HL PRCONT NLCKG COMPR TI MED STR -,SUP-57-10407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2921.69,2045.183,AETNA [1000108],AETNA [100010801],,,76.8,,2243.86,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PROFYLE 1MM 2.3MM 7HL PRCONT NLCKG COMPR TI MED Y -,SUP-57-10470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2921.69,2045.183,AETNA [1000108],AETNA [100010801],,,76.8,,2243.86,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PROFYLE 1.3MM 2.3MM 6HL SHFT PRCONT NLCKG COMPR TI -,SUP-57-13150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.06,784.742,AETNA [1000108],AETNA [100010801],,,76.8,,860.97,0.518595,35041.66656,percent of total billed charges,,,
PLATE HAND 2.3 LP 4 HOLE -,SUP-57-13402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,AETNA [1000108],AETNA [100010801],,,76.8,,853.85,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PROFYLE 1.3MM 2.3MM 5HL PRCONT NLCKG COMPR TI LRG -,SUP-57-13405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,AETNA [1000108],AETNA [100010801],,,76.8,,853.85,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PROFYLE 1.3MM 2.3MM 6HL PRCONT NLCKG COMPR TI LRG -,SUP-57-13408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,AETNA [1000108],AETNA [100010801],,,76.8,,853.85,0.518595,35041.66656,percent of total billed charges,,,
PLATE T 1O HOLE NARROW COMPRESSION -,SUP-57-13442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,AETNA [1000108],AETNA [100010801],,,76.8,,853.85,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 1.5MM 2.3MM 4HL PRCONT VAR ANG TI MED STR -,SUP-57-15301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,AETNA [1000108],AETNA [100010801],,,76.8,,1192.09,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 1.5MM 2.3MM 4HL_PRCONT VAR ANG TI MED STR -,SUP-57-15302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,AETNA [1000108],AETNA [100010801],,,76.8,,1192.09,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 1.5MM 2.3MM 16HL PRCONT VAR ANG TI MED -,SUP-57-15316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,AETNA [1000108],AETNA [100010801],,,76.8,,1609.22,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 1.5MM 2.3MM 4HL PRCONT VAR ANG TI MED SMRTLC -,SUP-57-15340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,AETNA [1000108],AETNA [100010801],,,76.8,,1192.09,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 1.5MM 2.3MM 7HL PRCONT VAR ANG TI MED SMRTLC -,SUP-57-15370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,AETNA [1000108],AETNA [100010801],,,76.8,,1609.22,0.518595,35041.66656,percent of total billed charges,,,
PLATE PROFYLE 2.3 X 13 HL NRWZ -,SUP-57-15379,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,AETNA [1000108],AETNA [100010801],,,76.8,,1609.22,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 1.5MM 2.3MM 5HL PRCONT VAR ANG TI MED SMRTLC -,SUP-57-15385,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,AETNA [1000108],AETNA [100010801],,,76.8,,1609.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.2X5MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12005E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA [1000108],AETNA [100010801],,,76.8,,279.14,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.2X6MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA [1000108],AETNA [100010801],,,76.8,,279.14,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.2X7MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12007E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA [1000108],AETNA [100010801],,,76.8,,279.14,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.2X8MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA [1000108],AETNA [100010801],,,76.8,,279.14,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.2X14MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX -,SUP-58-12014E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA [1000108],AETNA [100010801],,,76.8,,279.14,0.518595,35041.66656,percent of total billed charges,,,
MIDFOOT FUSION U-PLATE MD LT ORTHOLOC -,SUP-5817002L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5793.06,4055.142,AETNA [1000108],AETNA [100010801],,,76.8,,4449.07,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.7X8MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA [1000108],AETNA [100010801],,,76.8,,279.14,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.7X9MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA [1000108],AETNA [100010801],,,76.8,,279.14,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.7X10MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA [1000108],AETNA [100010801],,,76.8,,279.14,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.7X11MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17011E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA [1000108],AETNA [100010801],,,76.8,,279.14,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.7X12MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA [1000108],AETNA [100010801],,,76.8,,279.14,0.518595,35041.66656,percent of total billed charges,,,
BONE SCREW 1.7 X 16MM STRYKER -,SUP-58-17016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA [1000108],AETNA [100010801],,,76.8,,279.14,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE 2.3 X 6 -,SUP-58-23006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA [1000108],AETNA [100010801],,,76.8,,280.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X8MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA [1000108],AETNA [100010801],,,76.8,,280.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X9MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA [1000108],AETNA [100010801],,,76.8,,280.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X10MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA [1000108],AETNA [100010801],,,76.8,,280.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X11MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23011E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA [1000108],AETNA [100010801],,,76.8,,280.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X12MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA [1000108],AETNA [100010801],,,76.8,,280.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X13MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23013E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA [1000108],AETNA [100010801],,,76.8,,280.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X14MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23014E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA [1000108],AETNA [100010801],,,76.8,,280.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW NL 2.3 X 15MM -,SUP-58-23015E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA [1000108],AETNA [100010801],,,76.8,,280.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X16MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA [1000108],AETNA [100010801],,,76.8,,280.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X20MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23020E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA [1000108],AETNA [100010801],,,76.8,,280.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X24MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23024E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA [1000108],AETNA [100010801],,,76.8,,280.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW EMERGENCY 2.5 X 6 -,SUP-58-25006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA [1000108],AETNA [100010801],,,76.8,,279.14,0.518595,35041.66656,percent of total billed charges,,,
SCREW EMERGENCY 2.5 X 8MM CROSSPIN LEFT -,SUP-58-25008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA [1000108],AETNA [100010801],,,76.8,,279.14,0.518595,35041.66656,percent of total billed charges,,,
MTP FUSIOIN MEDIUM 0DG RT ORTHOLOC 3DI PLATING SYSTEM -,SUP-587220RT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5046.12,3532.284,AETNA [1000108],AETNA [100010801],,,76.8,,3875.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING LG HD 2.7 X 12MM ORTHOLOC 3DI PLATING SYS -,SUP-58802712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,AETNA [1000108],AETNA [100010801],,,76.8,,851.44,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING LG HD 2.7 14MM ORTHOLOCK 3DI PLATING SYS -,SUP-58802714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,AETNA [1000108],AETNA [100010801],,,76.8,,851.44,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING LG HD  2.7 X 16MM ORTHOLOCK 3DI PLATING SYS -,SUP-58802716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,AETNA [1000108],AETNA [100010801],,,76.8,,851.44,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOW PRO CORT 2.7 X 12MM ORTHOLOC SYS -,SUP-58812712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,AETNA [1000108],AETNA [100010801],,,76.8,,398.84,0.518595,35041.66656,percent of total billed charges,,,
LOW PRO CORT SCREW 2.7 X 14MM ORTHOLOC SYSTEM -,SUP-58812714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,AETNA [1000108],AETNA [100010801],,,76.8,,398.84,0.518595,35041.66656,percent of total billed charges,,,
LOW PRO CORT SCREW 2.7 X 16MM ORTHOLOC SYSTEM -,SUP-58812716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,AETNA [1000108],AETNA [100010801],,,76.8,,398.84,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOW PRO CORT 2.7 X 18MM ORTHOLOC SYS -,SUP-58812718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,AETNA [1000108],AETNA [100010801],,,76.8,,398.84,0.518595,35041.66656,percent of total billed charges,,,
LOW PRO CORT SCREW 3.5 X 12MM ORTHOLOC SYSTEM -,SUP-58813512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,,,
LOW PRO CORT SCREW 3.5 X 14MM ORTHOLOC SYSTEM -,SUP-58813514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,,,
LOW PRO CORT SCREW 3.5 X 16MM ORTHOLOC SYSTEM -,SUP-58813516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,,,
SCREW NON LOCKING 3.5 X 18 -,SUP-58813518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,,,
LOW-PRO CORT SCREW 3.5X22MM ORTHOLOC -,SUP-58813522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,,,
LOW-PRO CORT SCREW 3.5X28MM ORTHOLOC -,SUP-58813528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,,,
LOW-PRO CORT SCREW 3.5X34MM ORTHOLOC -,SUP-58813534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,,,
LOW-PRO CORT SCREW 3.5X38MM ORTHOLOC -,SUP-58813538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,,,
WASHER ORTHO F/1.2MM SCR TI RND FLT HEAD NS -,SUP-59-12049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.24,105.868,AETNA [1000108],AETNA [100010801],,,76.8,,116.15,0.518595,35041.66656,percent of total billed charges,,,
WASHER ORTHO F/1.7MM/1.9MM TI RND BN SCR TITIANIUM FLT EDGE -,SUP-59-17049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.24,105.868,AETNA [1000108],AETNA [100010801],,,76.8,,116.15,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X10MM CORT PROFYLE ST CX PIN HD TI GOLD -,SUP-59-23010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,AETNA [1000108],AETNA [100010801],,,76.8,,274.39,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 16MM -,SUP-59-23016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,AETNA [1000108],AETNA [100010801],,,76.8,,274.39,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 18MM -,SUP-59-23018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,AETNA [1000108],AETNA [100010801],,,76.8,,274.39,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 20MM -,SUP-59-23020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,AETNA [1000108],AETNA [100010801],,,76.8,,274.39,0.518595,35041.66656,percent of total billed charges,,,
WASHER ORTHO F/2.3MM SCR TI RND FLT HEAD NS -,SUP-59-23049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.24,105.868,AETNA [1000108],AETNA [100010801],,,76.8,,116.15,0.518595,35041.66656,percent of total billed charges,,,
SCREW 32.3MM COMPR OMEGA3 SS STRL -,SUP-596001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,329.09,230.363,AETNA [1000108],AETNA [100010801],,,76.8,,252.74,0.518595,35041.66656,percent of total billed charges,,,
STANDARD BARRELL HIP PLATE- 130DEG- 2 HOLES -,SUP-597002S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2817.14,1971.998,AETNA [1000108],AETNA [100010801],,,76.8,,2163.56,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN OMG 3 63MM 3HL STD BRL LCK COMPR SS 135DG ANG KY -,SUP-597023S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,AETNA [1000108],AETNA [100010801],,,76.8,,2163.19,0.518595,35041.66656,percent of total billed charges,,,
PLATE HIP STD BARREL 4 HOLE KEYED 135DEG -,SUP-597024S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,AETNA [1000108],AETNA [100010801],,,76.8,,2163.19,0.518595,35041.66656,percent of total billed charges,,,
HIP PLATE OMEGA 3 STD BARREL KEYED 135 DEG 6 HOLES -,SUP-597026S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,AETNA [1000108],AETNA [100010801],,,76.8,,2163.19,0.518595,35041.66656,percent of total billed charges,,,
PLATE HIP STD BARREL 3 HOLE KEYED 140DEG -,SUP-597043S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,AETNA [1000108],AETNA [100010801],,,76.8,,2163.19,0.518595,35041.66656,percent of total billed charges,,,
PLATE HIP STD BARREL 4 HOLE KEYED 145DEG -,SUP-597064S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,AETNA [1000108],AETNA [100010801],,,76.8,,2163.19,0.518595,35041.66656,percent of total billed charges,,,
PLATE EXTFIX STD 47MM SS HIP 135DG ANG OMEGA3 KYLS BRL -,SUP-597122S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,AETNA [1000108],AETNA [100010801],,,76.8,,2163.19,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN OMG 3 79MM 4HL STD BRL LCK COMPR SS 135DG ANG KYLS -,SUP-597124S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,AETNA [1000108],AETNA [100010801],,,76.8,,2163.19,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN OMG 3 95MM 5HL STD BRL LCK COMPR SS 150DG ANG KYLS -,SUP-597185S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,AETNA [1000108],AETNA [100010801],,,76.8,,2163.19,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN OMG 3 79MM 4HL SHRT BRL LCK COMPR SS 135DG ANG KYLS -,SUP-597264S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2470.03,1729.021,AETNA [1000108],AETNA [100010801],,,76.8,,1896.98,0.518595,35041.66656,percent of total billed charges,,,
CAGE ANT CERV 12MM BAK HOL CHMFR EDGE 8MM TI -,SUP-6000-0812-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,AETNA [1000108],AETNA [100010801],,,76.8,,10978.6,0.518595,35041.66656,percent of total billed charges,,,
DEVICE ANT CERV 12MM BAK/ C HOL CHMFR EDGE 10MM TI -,SUP-6000-1012-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,AETNA [1000108],AETNA [100010801],,,76.8,,10978.6,0.518595,35041.66656,percent of total billed charges,,,
GW ORTHO 2MM TOEMOTION MRH AXLE -,SUP-6007-1200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,AETNA [1000108],AETNA [100010801],,,76.8,,398.84,0.518595,35041.66656,percent of total billed charges,,,
PIN DSTRCT 12MM ASSURE -,SUP-601.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,396.78,277.746,AETNA [1000108],AETNA [100010801],,,76.8,,304.73,0.518595,35041.66656,percent of total billed charges,,,
ASNIS III CANN SCREW 5 X 28MM -,SUP-601628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA [1000108],AETNA [100010801],,,76.8,,711.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS TI 5.0 X 30MM -,SUP-601630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA [1000108],AETNA [100010801],,,76.8,,711.81,0.518595,35041.66656,percent of total billed charges,,,
ASNIS III CANN SCREW 5 X 32MM -,SUP-601632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA [1000108],AETNA [100010801],,,76.8,,711.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS III CANN P/T 5.0MM X 42MM -,SUP-601642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA [1000108],AETNA [100010801],,,76.8,,711.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS III CANN 5.0 X 44MM -,SUP-601644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA [1000108],AETNA [100010801],,,76.8,,711.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE ASNIS PT 5 X 46 -,SUP-601646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA [1000108],AETNA [100010801],,,76.8,,711.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS PT 5.0 X 48 -,SUP-601648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA [1000108],AETNA [100010801],,,76.8,,711.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5MMX50MM CANN ASNIS III 17MM P/T SD/ST REVCT FLUT TI -,SUP-601650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA [1000108],AETNA [100010801],,,76.8,,711.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5MMX55MM CANN ASNIS III 18.5MM P/T SD/ST REVCT FLUT TI -,SUP-601655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA [1000108],AETNA [100010801],,,76.8,,711.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5MMX75MM CANN ASNIS III 27MM P/T SD/ST REVCT FLUT TI -,SUP-601675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA [1000108],AETNA [100010801],,,76.8,,711.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5MMX80MM CANN ASNIS III 27MM P/T SD/ST REVCT FLUT TI -,SUP-601680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA [1000108],AETNA [100010801],,,76.8,,711.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW FULLY THREADED 5MM X 38MM -,SUP-601738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,AETNA [1000108],AETNA [100010801],,,76.8,,854.13,0.518595,35041.66656,percent of total billed charges,,,
SCREW FULLY THREADED 5MM X 40MM -,SUP-601740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,AETNA [1000108],AETNA [100010801],,,76.8,,854.13,0.518595,35041.66656,percent of total billed charges,,,
SCREW FT 5MM X 42MM TITANIUM CANNULATED -,SUP-601742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,AETNA [1000108],AETNA [100010801],,,76.8,,854.13,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS FT 5 X 44 -,SUP-601744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,AETNA [1000108],AETNA [100010801],,,76.8,,854.13,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANNULATED 5 X 50 -,SUP-601750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,AETNA [1000108],AETNA [100010801],,,76.8,,854.13,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANNULATED 5 X 55 -,SUP-601755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,AETNA [1000108],AETNA [100010801],,,76.8,,854.13,0.518595,35041.66656,percent of total billed charges,,,
SCREW FULLY THREADED 5 X 60 -,SUP-601760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,AETNA [1000108],AETNA [100010801],,,76.8,,854.13,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANN HEADED 5.0 X 65MM ASNIS -,SUP-601765,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,AETNA [1000108],AETNA [100010801],,,76.8,,854.13,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANNULATED 5MM X 70MM -,SUP-601770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,AETNA [1000108],AETNA [100010801],,,76.8,,854.13,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANN TI 6.5 X 60MM -,SUP-602660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,AETNA [1000108],AETNA [100010801],,,76.8,,880.57,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS TI TL20 6.5 X 65MM -,SUP-602665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,AETNA [1000108],AETNA [100010801],,,76.8,,880.57,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANN TI 6.5 X 70MM -,SUP-602670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,AETNA [1000108],AETNA [100010801],,,76.8,,880.57,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MMX75MM CANN ASNIS III 20MM THRD SD/ST HEX DRV -,SUP-602675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,AETNA [1000108],AETNA [100010801],,,76.8,,880.57,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANN TI 6.5 X 80MM -,SUP-602680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,AETNA [1000108],AETNA [100010801],,,76.8,,880.57,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MMX80MM CANN ASNIS III 20MM THRD SD/ST HEX DRV -,SUP-602680S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,AETNA [1000108],AETNA [100010801],,,76.8,,888.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANN ASNIS TI 6.5 X 85MM -,SUP-602685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,AETNA [1000108],AETNA [100010801],,,76.8,,880.57,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MMX90MM CANN ASNIS III 20MM THRD SD/ST HEX DRV NS -,SUP-602690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,AETNA [1000108],AETNA [100010801],,,76.8,,880.57,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MMX90MM CANN ASNIS III 20MM THRD SD/ST HEX DRV STRL -,SUP-602690S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,AETNA [1000108],AETNA [100010801],,,76.8,,888.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MMX95MM CANN ASNIS III 20MM THRD SD/ST HEX DRV NS -,SUP-602695,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,AETNA [1000108],AETNA [100010801],,,76.8,,880.57,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MMX95MM CANN ASNIS III 20MM THRD SD/ST HEX DRV STRL -,SUP-602695S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,AETNA [1000108],AETNA [100010801],,,76.8,,888.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MMX100MM CANN ASNIS III 20MM THRD SD/ST HEX DRV -,SUP-602700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA [1000108],AETNA [100010801],,,76.8,,872.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW TI CANNULATED 6.5 X 105MM ASNIS -,SUP-602705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA [1000108],AETNA [100010801],,,76.8,,872.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANNULATED TI 6.5X 110MM -,SUP-602710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA [1000108],AETNA [100010801],,,76.8,,872.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS TI TL20 6.5 X 115 -,SUP-602715,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA [1000108],AETNA [100010801],,,76.8,,872.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS TI TL40 6.5 X 60 -,SUP-602860,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA [1000108],AETNA [100010801],,,76.8,,872.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS TI TL40 6.5 X 65 -,SUP-602865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA [1000108],AETNA [100010801],,,76.8,,872.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS 6.5 X 70MM -,SUP-602870,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA [1000108],AETNA [100010801],,,76.8,,872.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS TI TL40 6.5 X 75MM -,SUP-602875,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA [1000108],AETNA [100010801],,,76.8,,872.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS TI CANNULATED 6.5 X 80MM -,SUP-602880,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA [1000108],AETNA [100010801],,,76.8,,872.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS TI TL40 6.5 X 85 -,SUP-602885,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA [1000108],AETNA [100010801],,,76.8,,872.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW TI 6.5 X 90MM ASNIS TL40 CANNULATED -,SUP-602890,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA [1000108],AETNA [100010801],,,76.8,,872.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS TI TL40 6.5 X 95 -,SUP-602895,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA [1000108],AETNA [100010801],,,76.8,,872.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS TI TL40 6.5 X 100 -,SUP-602900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA [1000108],AETNA [100010801],,,76.8,,872.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS TI CANNULATED 6.5 X 105MM -,SUP-602905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA [1000108],AETNA [100010801],,,76.8,,872.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX28MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE CAN TI 4.0 X 30MM -,SUP-604630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX32MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,,,
4.0 X 34MM ASNIS CANN SCREW -,SUP-604634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX34MM CANN ASNIS III 11.5MM P/T SD/ST REVCT FLUT TI -,SUP-604634S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE CAN PT 4.0 X 36 -,SUP-604636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX38MM CANN ASNIS III -,SUP-604638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX40MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX40MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY -,SUP-604640S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX42MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX44MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX46MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE CAN PT 4.0 X 48 -,SUP-604648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX50MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX50MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY -,SUP-604650S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX55MM CANN ASNIS III 18.5MM P/T SD/ST REVCT FLUT TI -,SUP-604655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX55MM CANN ASNIS III 18.5MM.P/T SD/ST REVCT FLUT TI -,SUP-604655S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT TI- -,SUP-604660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT TI- -,SUP-604660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT TI_ -,SUP-604660S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX65MM CANN ASNIS III 22MM P/T SD/ST REVCT FLUT TI -,SUP-604665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX65MM CANN ASNIS III 22MM P/T SD/ST REVCT FLUT TI -,SUP-604665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX70MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX70MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY -,SUP-604670S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX40MM CANN ASNIS III FT SD/ST REVCT FLUT TI ALY NS -,SUP-604740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS III TI 4.0 X 42MM -,SUP-604742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANN FT 4.0 X 44MM -,SUP-604744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MMX50MM CANN ASNIS III FT SD/ST REVCT FLUT TI ALY NS -,SUP-604750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW TI SELF TAP CORTICAL 2.7MM X 22MM -,SUP-605022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.06,81.242,AETNA [1000108],AETNA [100010801],,,76.8,,89.13,0.518595,35041.66656,percent of total billed charges,,,
SCREW TI SELF TAP CORTICAL 2.7MM X 26MM -,SUP-605026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.06,81.242,AETNA [1000108],AETNA [100010801],,,76.8,,89.13,0.518595,35041.66656,percent of total billed charges,,,
SCREW TI SELF TAP CORTICAL 2.7MM X 28MM -,SUP-605028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.06,81.242,AETNA [1000108],AETNA [100010801],,,76.8,,89.13,0.518595,35041.66656,percent of total billed charges,,,
SCREW TI ASNIS III CANNULATED 6.5 X 85MM -,SUP-606085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,AETNA [1000108],AETNA [100010801],,,76.8,,888.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 90 -,SUP-606090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,AETNA [1000108],AETNA [100010801],,,76.8,,888.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 95 -,SUP-606095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,AETNA [1000108],AETNA [100010801],,,76.8,,888.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANNULATED FULLY THREADED 6.5 X 100 -,SUP-606100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,AETNA [1000108],AETNA [100010801],,,76.8,,888.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANNULATED FULLY THREADED 6.5 X 110 -,SUP-606110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,AETNA [1000108],AETNA [100010801],,,76.8,,888.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANCELLOUS FT 4 X 14 -,SUP-607314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANCELLOUS FT 4.0 X 16 -,SUP-607316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X18MM CANC FT TI -,SUP-607318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANCELLOUS 4.0 X 20 -,SUP-607320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X22MM CANC FT TI -,SUP-607322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X24MM CANC FT TI -,SUP-607324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANCELLOUS 4.0 X 26MM -,SUP-607326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANCELLOUS 4.0 X 28MM -,SUP-607328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANCELLOUS 4.0 X 32MM -,SUP-607332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X34MM CANC FT TI -,SUP-607334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X36MM CANC FT TI -,SUP-607336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X38MM CANC FT TI -,SUP-607338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X40MM CANC FT TI -,SUP-607340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.0 X 42MM CANC FT TI -,SUP-607342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANN TI 4.0 X 48MM FULL -,SUP-607348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,,,
4.0 CANCELLOUS SCREW 50MM FULLY THREADED -,SUP-607350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANCELLOUS 4.0 X 50MM -,SUP-607350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.0 X 55MM CANC FT TI -,SUP-607355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X60MM CANC FT TI -,SUP-607360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X65MM CANC FT TI -,SUP-607365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X70MM CANC FT TI -,SUP-607370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANCELLOUS FT 4.0 X 14MM STRYKER -,SUP-607414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANCELLOUS PT 4 X 16 -,SUP-607416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANCELLOUS PT 4 X 20 -,SUP-607420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X36MM CANC 16MM THRD TI -,SUP-607436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X38MM CANC 16MM THRD TI -,SUP-607438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X44MM CANC 16MM THRD TI -,SUP-607444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X46MM CANC 16MM THRD TI -,SUP-607446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X50MM CANC 16MM THRD TI -,SUP-607450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X65MM CANC 16MM THRD TI -,SUP-607465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X70MM CANC 16MM THRD TI -,SUP-607470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANC 6.0MM X 20MM  FULL THREAD -,SUP-608020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA [1000108],AETNA [100010801],,,76.8,,175.66,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANCELLOUS 6 X 25 -,SUP-608025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA [1000108],AETNA [100010801],,,76.8,,175.66,0.518595,35041.66656,percent of total billed charges,,,
SCREW CAN FT 6.0 X 35 -,SUP-608035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA [1000108],AETNA [100010801],,,76.8,,175.66,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANCELLOUS 6.0 X 40MM -,SUP-608040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA [1000108],AETNA [100010801],,,76.8,,175.66,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6X45MM CANC FT TI -,SUP-608045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA [1000108],AETNA [100010801],,,76.8,,175.66,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.0MM X 50MM CANCELLOUS FULL THREAD -,SUP-608050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA [1000108],AETNA [100010801],,,76.8,,175.66,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6X60MM CANC FT TI -,SUP-608060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA [1000108],AETNA [100010801],,,76.8,,175.66,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL 3.5 X 60 FT -,SUP-608070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA [1000108],AETNA [100010801],,,76.8,,175.66,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6X75MM CANC FT TI -,SUP-608075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA [1000108],AETNA [100010801],,,76.8,,175.66,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6X80MM CANC FT TI -,SUP-608080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA [1000108],AETNA [100010801],,,76.8,,175.66,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANCELLOUS FT 6.0 X 85 -,SUP-608085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA [1000108],AETNA [100010801],,,76.8,,175.66,0.518595,35041.66656,percent of total billed charges,,,
SCREW CAN TL 16 6.0 X 35 -,SUP-608235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA [1000108],AETNA [100010801],,,76.8,,175.66,0.518595,35041.66656,percent of total billed charges,,,
SCREW CAN TL 16 6.0 X 75 -,SUP-608275,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA [1000108],AETNA [100010801],,,76.8,,175.66,0.518595,35041.66656,percent of total billed charges,,,
SCREW CAN TL 16 6.0 X 80 -,SUP-608280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA [1000108],AETNA [100010801],,,76.8,,175.66,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANCELLOUS 6.0MM 90MM -,SUP-608290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA [1000108],AETNA [100010801],,,76.8,,175.66,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6X70MM CANC 32MM THRD TI -,SUP-608470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA [1000108],AETNA [100010801],,,76.8,,175.66,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6X80MM CANC 32MM THRD TI -,SUP-608480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA [1000108],AETNA [100010801],,,76.8,,175.66,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6X85MM CANC 32MM THRD TI -,SUP-608485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA [1000108],AETNA [100010801],,,76.8,,175.66,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6MM CANCELLOUS TI 6.0MM L90 TL32MM -,SUP-608490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,304.82,213.374,AETNA [1000108],AETNA [100010801],,,76.8,,234.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS TI TL25 8.0 X 70MM -,SUP-611070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,AETNA [1000108],AETNA [100010801],,,76.8,,837.77,0.518595,35041.66656,percent of total billed charges,,,
CANNULATED SCREW 8.0 X 75MM TI -,SUP-611075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,AETNA [1000108],AETNA [100010801],,,76.8,,837.77,0.518595,35041.66656,percent of total billed charges,,,
8.0 X 80MM TI CANNULATED SCREW -,SUP-611080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,AETNA [1000108],AETNA [100010801],,,76.8,,837.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS TI TL25 8.0 X 85MM -,SUP-611085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,AETNA [1000108],AETNA [100010801],,,76.8,,837.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW ANSIS TI TL25 8.0 X 90MM -,SUP-611090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,AETNA [1000108],AETNA [100010801],,,76.8,,837.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X8MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X12MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X14MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X16MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X18MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
2.7 X 20MM LOCKING SCREW -,SUP-614520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X22MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING T10 2.7 X 24MM -,SUP-614524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X26MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7 LOCKING ST 28 -,SUP-614528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X30MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7 LOCKING ST 34 -,SUP-614534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X36MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X38MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X40MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X55MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X60MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X8MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X10MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X12MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X14MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X16MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X18MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X20MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X22MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X24MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X26MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 3.5 X 28MM -,SUP-614628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X30MM LOCKING -,SUP-614630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X32MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
36MM 3.5 LOCKING SCREW -,SUP-614636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5 LCK ST 38 -,SUP-614638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5 X 40MM LOCKING -,SUP-614640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X42MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X44MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5 LCK ST 48 -,SUP-614648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X50MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
PLATE OLECRANON LEFT 8 HOLE -,SUP-614655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA [1000108],AETNA [100010801],,,76.8,,3788.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 3.5 X 55MM T10 -,SUP-614655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X60MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 3.5 X 65MM -,SUP-614665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 3.5 X 70MM -,SUP-614670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X8MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X12MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X14MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X16MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X18MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X20MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X22MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X24MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7 NON LOCKING ST 26 -,SUP-614726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X32MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614732,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X34MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X36MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X38MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X40MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7 NONLCK ST 44 -,SUP-614744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7 NONLOCKING ST 46 -,SUP-614746,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X55MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE T10 2.7 X 60MM -,SUP-614760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X8MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614808,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X10MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X12MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X14MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X16MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X18MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X20MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X22MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X24MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X26MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X28MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X30MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614830,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X32MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X34MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614834,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X36MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614836,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5 NONLCK ST 38 -,SUP-614838,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X40MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X42MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614842,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5 X 44 NONLOCK -,SUP-614844,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
46MM 3.5 SCREW -,SUP-614846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5 NONLOCK ST 46 -,SUP-614846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE 3.5 X 48MM NON-LOCK -,SUP-614848,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X50MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614850,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X60MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614860,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5 NONLOCK ST 65 -,SUP-614865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X70MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614870,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
BONE CEMENT SIMPLEX -,SUP-6191-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,431.79,302.253,AETNA [1000108],AETNA [100010801],,,76.8,,331.61,0.518595,35041.66656,percent of total billed charges,,,
CEMENT BONE SIMPLEX P -,SUP-6191-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
BONE CEMENT SPEEDSET SIMPLEX P FULL DOSE -,SUP-6192-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,431.79,302.253,AETNA [1000108],AETNA [100010801],,,76.8,,331.61,0.518595,35041.66656,percent of total billed charges,,,
CEMENT SIMPLEX SPEED SET -,SUP-6192-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
CEMENT BONE SIMPLEX HV -,SUP-6194-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
CEMENT BONE SIMPLEX GENTAMICIN -,SUP-6195-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,,,
CEMENT BONE SIMPLEX TOBRAMYCIN -,SUP-6197-9-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
WASHER ORTHO ASNIS III F/6.5/8MM BN SCR TI RND -,SUP-619904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,157.55,110.285,AETNA [1000108],AETNA [100010801],,,76.8,,121,0.518595,35041.66656,percent of total billed charges,,,
WASHER ORTHO ASNIS III 4MM TI RND -,SUP-619905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,122.54,85.778,AETNA [1000108],AETNA [100010801],,,76.8,,94.11,0.518595,35041.66656,percent of total billed charges,,,
WASHER ORTHO 5MM ASNIS III 5MM TI RND -,SUP-619906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.64,107.548,AETNA [1000108],AETNA [100010801],,,76.8,,118,0.518595,35041.66656,percent of total billed charges,,,
WASHER FOR 2.3MM BONE SCREWS -,SUP-619915,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.91,88.837,AETNA [1000108],AETNA [100010801],,,76.8,,97.47,0.518595,35041.66656,percent of total billed charges,,,
Washer T8 & T10 Scrws 2.4/2.7/3.5 -,SUP-619920,CDM,C1713,HCPCS,278,RC,,,outpatient,,,124.4,87.08,AETNA [1000108],AETNA [100010801],,,76.8,,95.54,0.518595,35041.66656,percent of total billed charges,,,
WASHER 19 FOR SCREWS 6.5/8.0MM -,SUP-619990,CDM,C1713,HCPCS,278,RC,,,outpatient,,,882.25,617.575,AETNA [1000108],AETNA [100010801],,,76.8,,677.57,0.518595,35041.66656,percent of total billed charges,,,
STIMULAN 5CC -,SUP-620-005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,0.518595,35041.66656,percent of total billed charges,,,
STIMULAN 10CC -,SUP-620-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA [1000108],AETNA [100010801],,,76.8,,4726.12,0.518595,35041.66656,percent of total billed charges,,,
PLATE SPIN 12MM ASPEN -,SUP-6201-0012-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,AETNA [1000108],AETNA [100010801],,,76.8,,5866.91,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN ASPEN 14MM -,SUP-6211-0014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,26874.69,18812.283,AETNA [1000108],AETNA [100010801],,,76.8,,20639.76,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 10HL TI -,SUP-621410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7788.16,5451.712,AETNA [1000108],AETNA [100010801],,,76.8,,5981.31,0.518595,35041.66656,percent of total billed charges,,,
PLUG BONE H MED 25 -,SUP-6215-5-011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
MIS CALCANEAL PLATE S7 7 HOLES -,SUP-622102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,AETNA [1000108],AETNA [100010801],,,76.8,,5684.38,0.518595,35041.66656,percent of total billed charges,,,
MIS CALCANEAL PLATE M8 8 HOLE -,SUP-622104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,AETNA [1000108],AETNA [100010801],,,76.8,,5684.38,0.518595,35041.66656,percent of total billed charges,,,
INSERT 10 DEG POLYETHYLENE 32MM D TRIDENT X3 -,SUP-623-10-32D,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,0.518595,35041.66656,percent of total billed charges,,,
BONE SCREW 6.5X30 SELF-TAP -,SUP-6250-65-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,,,
ONE-THIRD TUBULAR PLATE 2 HOLE / L23MM -,SUP-626672,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1523.42,1066.394,AETNA [1000108],AETNA [100010801],,,76.8,,1169.99,0.518595,35041.66656,percent of total billed charges,,,
TUBULAR PLATE ONE-THIRD 4 HOLE -,SUP-626674,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,AETNA [1000108],AETNA [100010801],,,76.8,,1261.78,0.518595,35041.66656,percent of total billed charges,,,
ONE-THIRD TUBULAR PLATE 5 HOLE / L59MM -,SUP-626675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,AETNA [1000108],AETNA [100010801],,,76.8,,1261.78,0.518595,35041.66656,percent of total billed charges,,,
ONE-THIRD TUBULAR PLATE 6 HOLE / L71MM -,SUP-626676,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,AETNA [1000108],AETNA [100010801],,,76.8,,1261.78,0.518595,35041.66656,percent of total billed charges,,,
TUBULAR PLATE ONE-THIRD 6 HOLE -,SUP-626676S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,AETNA [1000108],AETNA [100010801],,,76.8,,1261.78,0.518595,35041.66656,percent of total billed charges,,,
ONE-THIRD TUBULAR PLATE 7 HOLE L83MM -,SUP-626677,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,AETNA [1000108],AETNA [100010801],,,76.8,,1261.78,0.518595,35041.66656,percent of total billed charges,,,
PLATE 8 HOLE -,SUP-626678,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,AETNA [1000108],AETNA [100010801],,,76.8,,1261.78,0.518595,35041.66656,percent of total billed charges,,,
PLATE TUBULAR HOLE 9 -,SUP-626679,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2203.63,1542.541,AETNA [1000108],AETNA [100010801],,,76.8,,1692.39,0.518595,35041.66656,percent of total billed charges,,,
PLATE TUBULAR HOLE 12 -,SUP-626682,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2203.63,1542.541,AETNA [1000108],AETNA [100010801],,,76.8,,1692.39,0.518595,35041.66656,percent of total billed charges,,,
PLATE TUBULAR 16HL -,SUP-626686,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2746.15,1922.305,AETNA [1000108],AETNA [100010801],,,76.8,,2109.04,0.518595,35041.66656,percent of total billed charges,,,
PLATE POLYAXIAL LKG TALO-NAVICULAR LONG T10 -,SUP-626762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4305.48,3013.836,AETNA [1000108],AETNA [100010801],,,76.8,,3306.61,0.518595,35041.66656,percent of total billed charges,,,
VARIAX NAVICULAR PLATE -,SUP-626881,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4186.99,2930.893,AETNA [1000108],AETNA [100010801],,,76.8,,3215.61,0.518595,35041.66656,percent of total billed charges,,,
POLYAXIAL LOCKING PLATE CUBOID (T8) -,SUP-626885,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.24,2762.368,AETNA [1000108],AETNA [100010801],,,76.8,,3030.71,0.518595,35041.66656,percent of total billed charges,,,
PLATE 3 HOLE SLIM -,SUP-626963,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5843.99,4090.793,AETNA [1000108],AETNA [100010801],,,76.8,,4488.18,0.518595,35041.66656,percent of total billed charges,,,
PLATE 6 HOLE SLIM -,SUP-626966,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5843.99,4090.793,AETNA [1000108],AETNA [100010801],,,76.8,,4488.18,0.518595,35041.66656,percent of total billed charges,,,
PLATE SLIM STRAIGHT 7 HOLE T8 -,SUP-626967,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5843.99,4090.793,AETNA [1000108],AETNA [100010801],,,76.8,,4488.18,0.518595,35041.66656,percent of total billed charges,,,
2 HOLE FOREFOOT PLATE -,SUP-626972,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,AETNA [1000108],AETNA [100010801],,,76.8,,5344.75,0.518595,35041.66656,percent of total billed charges,,,
PLATE BROAD 3 HOLE -,SUP-626973,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,AETNA [1000108],AETNA [100010801],,,76.8,,5344.75,0.518595,35041.66656,percent of total billed charges,,,
BROAD STRAIGHT PLATE 4 HOLE -,SUP-626974,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,AETNA [1000108],AETNA [100010801],,,76.8,,5344.75,0.518595,35041.66656,percent of total billed charges,,,
5 HOLE FOREFOOT PLATE -,SUP-626975,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,AETNA [1000108],AETNA [100010801],,,76.8,,5344.75,0.518595,35041.66656,percent of total billed charges,,,
6 HOLE BROAD Y-PLATE -,SUP-626976,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,AETNA [1000108],AETNA [100010801],,,76.8,,5344.75,0.518595,35041.66656,percent of total billed charges,,,
PLATE BROAD STRAIGHT T10 7 HOLE -,SUP-626977,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,AETNA [1000108],AETNA [100010801],,,76.8,,5344.75,0.518595,35041.66656,percent of total billed charges,,,
PLATE SLIM -,SUP-626982,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,AETNA [1000108],AETNA [100010801],,,76.8,,4916.47,0.518595,35041.66656,percent of total billed charges,,,
3-HOLE 4-PLATE- SLIM -,SUP-626983,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,AETNA [1000108],AETNA [100010801],,,76.8,,4916.47,0.518595,35041.66656,percent of total billed charges,,,
PLATE-Y 4 HOLE SLIM -,SUP-626984,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,AETNA [1000108],AETNA [100010801],,,76.8,,4916.47,0.518595,35041.66656,percent of total billed charges,,,
PLATE 5 HOLE SLIM Y -,SUP-626985,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,AETNA [1000108],AETNA [100010801],,,76.8,,4916.47,0.518595,35041.66656,percent of total billed charges,,,
BROAD Y PLATE 2 SHAFT HOLES -,SUP-626992,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,AETNA [1000108],AETNA [100010801],,,76.8,,5773.03,0.518595,35041.66656,percent of total billed charges,,,
BROAD Y PLATE 3 HOLE -,SUP-626993,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,AETNA [1000108],AETNA [100010801],,,76.8,,5773.03,0.518595,35041.66656,percent of total billed charges,,,
BROAD Y-PLATE- 3 SHAFT -,SUP-626993,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,AETNA [1000108],AETNA [100010801],,,76.8,,5773.03,0.518595,35041.66656,percent of total billed charges,,,
STRYKER PLATE -,SUP-626994,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,AETNA [1000108],AETNA [100010801],,,76.8,,5773.03,0.518595,35041.66656,percent of total billed charges,,,
VARIAX 2 FOREFOOT 5 HOLE PLATE -,SUP-626995,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,AETNA [1000108],AETNA [100010801],,,76.8,,5773.03,0.518595,35041.66656,percent of total billed charges,,,
PLATE BONE VARIAX BROAD Y 6 SHAFT HOLES T10 -,SUP-626996,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,AETNA [1000108],AETNA [100010801],,,76.8,,5773.03,0.518595,35041.66656,percent of total billed charges,,,
BROAD Y-PLATE- 7 SHAFT HOLES (T10) -,SUP-626997,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,AETNA [1000108],AETNA [100010801],,,76.8,,5773.03,0.518595,35041.66656,percent of total billed charges,,,
BROAD Y PLATE - 7 HOLES -,SUP-626997,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,AETNA [1000108],AETNA [100010801],,,76.8,,5773.03,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 3HL TI -,SUP-627203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,AETNA [1000108],AETNA [100010801],,,76.8,,5856.64,0.518595,35041.66656,percent of total billed charges,,,
4 HOLE PLATE HUMERUS -,SUP-627204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,AETNA [1000108],AETNA [100010801],,,76.8,,5856.64,0.518595,35041.66656,percent of total billed charges,,,
PLATE 5-HOLE -,SUP-627205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,AETNA [1000108],AETNA [100010801],,,76.8,,5856.64,0.518595,35041.66656,percent of total billed charges,,,
PLATE PROX LAT HUMERUS LEFT 6 HOLE L125MM -,SUP-627206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8796.54,6157.578,AETNA [1000108],AETNA [100010801],,,76.8,,6755.74,0.518595,35041.66656,percent of total billed charges,,,
PLATE PROXIMAL LATERAL HUMERUS 8 HOLE -,SUP-627208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9123.11,6386.177,AETNA [1000108],AETNA [100010801],,,76.8,,7006.55,0.518595,35041.66656,percent of total billed charges,,,
PLATE 12 HOLE LEFT PROX LAT HUMERAL -,SUP-627212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9529.9,6670.93,AETNA [1000108],AETNA [100010801],,,76.8,,7318.96,0.518595,35041.66656,percent of total billed charges,,,
PROXIMAL LATERAL HUMERUS PLATE -,SUP-627216S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10146.77,7102.739,AETNA [1000108],AETNA [100010801],,,76.8,,7792.72,0.518595,35041.66656,percent of total billed charges,,,
PLATE 3 HOLE PROXIMAL LATERAL HUMERUS -,SUP-627233,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,AETNA [1000108],AETNA [100010801],,,76.8,,5856.64,0.518595,35041.66656,percent of total billed charges,,,
4 HOLE PLATE RIGHT -,SUP-627234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,AETNA [1000108],AETNA [100010801],,,76.8,,5856.64,0.518595,35041.66656,percent of total billed charges,,,
PLATE BONE AXSOS 3 TI 6 HOLE HUMERUS RIGHT PROXIMAL LATERAL -,SUP-627236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8796.54,6157.578,AETNA [1000108],AETNA [100010801],,,76.8,,6755.74,0.518595,35041.66656,percent of total billed charges,,,
8 HOLE PLATE STRYKER -,SUP-627238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9123.11,6386.177,AETNA [1000108],AETNA [100010801],,,76.8,,7006.55,0.518595,35041.66656,percent of total billed charges,,,
10 HOLE PROXIMAL HUMERUS PLATE - RIGHT -,SUP-627240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9123.11,6386.177,AETNA [1000108],AETNA [100010801],,,76.8,,7006.55,0.518595,35041.66656,percent of total billed charges,,,
PLATE HUMERUS 12 HOLE RIGHT PR -,SUP-627242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9529.9,6670.93,AETNA [1000108],AETNA [100010801],,,76.8,,7318.96,0.518595,35041.66656,percent of total billed charges,,,
PROXIMAL LATERAL HUMERUS PLATE FOR RIGHT HUMERUS 14 HOLE -,SUP-627244S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10146.77,7102.739,AETNA [1000108],AETNA [100010801],,,76.8,,7792.72,0.518595,35041.66656,percent of total billed charges,,,
2 HOLE PLATE LEFT TIBIA -,SUP-627302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7207.59,5045.313,AETNA [1000108],AETNA [100010801],,,76.8,,5535.43,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 121MM 4HL -,SUP-627304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7356.55,5149.585,AETNA [1000108],AETNA [100010801],,,76.8,,5649.83,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 147MM 6HL -,SUP-627306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7509.33,5256.531,AETNA [1000108],AETNA [100010801],,,76.8,,5767.17,0.518595,35041.66656,percent of total billed charges,,,
PLATE 8 HOLE PROX LATERAL FOR LEFT TIBIA L173MM -,SUP-627308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7658.3,5360.81,AETNA [1000108],AETNA [100010801],,,76.8,,5881.57,0.518595,35041.66656,percent of total billed charges,,,
PLATE PROXIMAL LATERAL TIBIA FOR LEFT TIBIA 10 HOLE -,SUP-627310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8099.46,5669.622,AETNA [1000108],AETNA [100010801],,,76.8,,6220.39,0.518595,35041.66656,percent of total billed charges,,,
AXSOS 3 TI PROX LAT TIBIA LEFT 12 HOLE PLATE -,SUP-627312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8414.58,5890.206,AETNA [1000108],AETNA [100010801],,,76.8,,6462.4,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 95MM 2HL F-SHP RT TIB -,SUP-627332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7207.59,5045.313,AETNA [1000108],AETNA [100010801],,,76.8,,5535.43,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 4HL -,SUP-627334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7356.55,5149.585,AETNA [1000108],AETNA [100010801],,,76.8,,5649.83,0.518595,35041.66656,percent of total billed charges,,,
PLATE RIGHT HOLE 6 -,SUP-627336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8887.66,6221.362,AETNA [1000108],AETNA [100010801],,,76.8,,6825.72,0.518595,35041.66656,percent of total billed charges,,,
PLATE PROXIMAL MEDIAL TIBIA 8 HOLE RIGHT -,SUP-627338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7658.3,5360.81,AETNA [1000108],AETNA [100010801],,,76.8,,5881.57,0.518595,35041.66656,percent of total billed charges,,,
PLATE 10 HOLE RIGHT PROX LATERAL TIBIA -,SUP-627340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8099.46,5669.622,AETNA [1000108],AETNA [100010801],,,76.8,,6220.39,0.518595,35041.66656,percent of total billed charges,,,
PLATE RIGHT HOLE 12 -,SUP-627342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8252.25,5776.575,AETNA [1000108],AETNA [100010801],,,76.8,,6337.73,0.518595,35041.66656,percent of total billed charges,,,
PLATE RIGHT HOLE 14 -,SUP-627344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8414.58,5890.206,AETNA [1000108],AETNA [100010801],,,76.8,,6462.4,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 6HL LT DIST -,SUP-627406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7102.55,4971.785,AETNA [1000108],AETNA [100010801],,,76.8,,5454.76,0.518595,35041.66656,percent of total billed charges,,,
PLATE DIST RAD TIB 12 HOLE LFT -,SUP-627412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7996.33,5597.431,AETNA [1000108],AETNA [100010801],,,76.8,,6141.18,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 14HL TI -,SUP-627414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8206.41,5744.487,AETNA [1000108],AETNA [100010801],,,76.8,,6302.52,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN MED DST -,SUP-627434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6900.11,4830.077,AETNA [1000108],AETNA [100010801],,,76.8,,5299.28,0.518595,35041.66656,percent of total billed charges,,,
PLATE 6HL MDL/DIST RIGHT -,SUP-627436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7102.55,4971.785,AETNA [1000108],AETNA [100010801],,,76.8,,5454.76,0.518595,35041.66656,percent of total billed charges,,,
PLATE DIST MED TIB 8HOLE RIGHT -,SUP-627438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7304.99,5113.493,AETNA [1000108],AETNA [100010801],,,76.8,,5610.23,0.518595,35041.66656,percent of total billed charges,,,
PLATE DIST MEDIAL 10 HOLE RT -,SUP-627440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7788.16,5451.712,AETNA [1000108],AETNA [100010801],,,76.8,,5981.31,0.518595,35041.66656,percent of total billed charges,,,
PLATE DIST MED LKD 12 HOLE RT -,SUP-627442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7996.33,5597.431,AETNA [1000108],AETNA [100010801],,,76.8,,6141.18,0.518595,35041.66656,percent of total billed charges,,,
PLATE 14 HOLE RIGHT DISTAL MEDICAL PLATE -,SUP-627444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8206.41,5744.487,AETNA [1000108],AETNA [100010801],,,76.8,,6302.52,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 4HL TI RT DIST -,SUP-627454,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.44,5926.508,AETNA [1000108],AETNA [100010801],,,76.8,,6502.23,0.518595,35041.66656,percent of total billed charges,,,
PLATE BONE AXSOS 3 TITANIUM 127 MM TIBIAL LEFT DISTAL -,SUP-627456,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7802.17,5461.519,AETNA [1000108],AETNA [100010801],,,76.8,,5992.07,0.518595,35041.66656,percent of total billed charges,,,
PLATE 8 HOLE LEFT ANTEROLATERAL -,SUP-627458,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7975.32,5582.724,AETNA [1000108],AETNA [100010801],,,76.8,,6125.05,0.518595,35041.66656,percent of total billed charges,,,
SCREW DIST ANTERIORLATERAL TIBIA LFT 10HL 178MM -,SUP-627460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8370.53,5859.371,AETNA [1000108],AETNA [100010801],,,76.8,,6428.57,0.518595,35041.66656,percent of total billed charges,,,
PLATE TIBIA  14 HOLE LEFT L229MM DISTAL ANTEROLATERAL -,SUP-627464,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8724.98,6107.486,AETNA [1000108],AETNA [100010801],,,76.8,,6700.78,0.518595,35041.66656,percent of total billed charges,,,
PLATE 4 HOLE -,SUP-627484,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7631.05,5341.735,AETNA [1000108],AETNA [100010801],,,76.8,,5860.65,0.518595,35041.66656,percent of total billed charges,,,
PLATE 6 HOLE RIGHT ANT-LAT -,SUP-627486,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7802.17,5461.519,AETNA [1000108],AETNA [100010801],,,76.8,,5992.07,0.518595,35041.66656,percent of total billed charges,,,
PLATE TIBIA DISTAL ANTEROLATERAL RIGHT 8 HOLE L153MM -,SUP-627488,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7975.32,5582.724,AETNA [1000108],AETNA [100010801],,,76.8,,6125.05,0.518595,35041.66656,percent of total billed charges,,,
PLATE DISTAL ANTEROLAT TIBIA RIGHT 10 HOLE 178MM -,SUP-627490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8370.53,5859.371,AETNA [1000108],AETNA [100010801],,,76.8,,6428.57,0.518595,35041.66656,percent of total billed charges,,,
PLATE LKG COMP 11 HOLD L149MM X 4.0MM -,SUP-627511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5647.28,3953.096,AETNA [1000108],AETNA [100010801],,,76.8,,4337.11,0.518595,35041.66656,percent of total billed charges,,,
PLATE 12HOLE COMPRESSION -,SUP-627512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5647.28,3953.096,AETNA [1000108],AETNA [100010801],,,76.8,,4337.11,0.518595,35041.66656,percent of total billed charges,,,
PLATE 14 HOLE AXSOS STRAIGHT -,SUP-627514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5809.61,4066.727,AETNA [1000108],AETNA [100010801],,,76.8,,4461.78,0.518595,35041.66656,percent of total billed charges,,,
PLATE LOCKING COMPRESSION 18 HOLE L240MM 4.0MM -,SUP-627518S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6099.9,4269.93,AETNA [1000108],AETNA [100010801],,,76.8,,4684.72,0.518595,35041.66656,percent of total billed charges,,,
PLATE 7 HOLE NARROW COMPRESSION -,SUP-627537,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6619.37,4633.559,AETNA [1000108],AETNA [100010801],,,76.8,,5083.68,0.518595,35041.66656,percent of total billed charges,,,
PLATE 8 HOLE NARROW COMPRESSION -,SUP-627538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.27,4961.089,AETNA [1000108],AETNA [100010801],,,76.8,,5443.02,0.518595,35041.66656,percent of total billed charges,,,
PLATE 9 HOLE NARROW -,SUP-627539,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.27,4961.089,AETNA [1000108],AETNA [100010801],,,76.8,,5443.02,0.518595,35041.66656,percent of total billed charges,,,
PLATE 10 HOLE STRAIGHT -,SUP-627540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7348.91,5144.237,AETNA [1000108],AETNA [100010801],,,76.8,,5643.96,0.518595,35041.66656,percent of total billed charges,,,
PLATE STRAIGHT BROAD 9 HOLE COMPR 173 LENGTH -,SUP-627569,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.27,4961.089,AETNA [1000108],AETNA [100010801],,,76.8,,5443.02,0.518595,35041.66656,percent of total billed charges,,,
PLATE STRAIGHT BROAD 10 HOLE COMPRESSION -,SUP-627570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7348.91,5144.237,AETNA [1000108],AETNA [100010801],,,76.8,,5643.96,0.518595,35041.66656,percent of total billed charges,,,
PLATE LOCKING COMPRESSION BROAD 12 HOLE -,SUP-627572,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7348.91,5144.237,AETNA [1000108],AETNA [100010801],,,76.8,,5643.96,0.518595,35041.66656,percent of total billed charges,,,
PLATE 13 HOLE 5.0 COMPRESSION PLATE -,SUP-627573,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7518.88,5263.216,AETNA [1000108],AETNA [100010801],,,76.8,,5774.5,0.518595,35041.66656,percent of total billed charges,,,
PLATE BROAD 14 HOLE -,SUP-627574,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7518.88,5263.216,AETNA [1000108],AETNA [100010801],,,76.8,,5774.5,0.518595,35041.66656,percent of total billed charges,,,
DISTAL LATERAL FEMUR PLATE FOR LEFT FEMUR 4 HOLE -,SUP-627604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7824.24,5476.968,AETNA [1000108],AETNA [100010801],,,76.8,,6009.02,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 166MM 6HL LT DIST LAT FEM -,SUP-627606,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9329.8,6530.86,AETNA [1000108],AETNA [100010801],,,76.8,,7165.29,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 8HL LT -,SUP-627608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8189.22,5732.454,AETNA [1000108],AETNA [100010801],,,76.8,,6289.32,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 238MM 10HL LT DIST LAT FEM -,SUP-627610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8683.22,6078.254,AETNA [1000108],AETNA [100010801],,,76.8,,6668.71,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 12HL -,SUP-627612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8871.66,6210.162,AETNA [1000108],AETNA [100010801],,,76.8,,6813.43,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 343MM 16HL LT -,SUP-627616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9250.22,6475.154,AETNA [1000108],AETNA [100010801],,,76.8,,7104.17,0.518595,35041.66656,percent of total billed charges,,,
PLATE DISTAL FEMUR -,SUP-627618S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9623.69,6736.583,AETNA [1000108],AETNA [100010801],,,76.8,,7390.99,0.518595,35041.66656,percent of total billed charges,,,
DISTAL LATERAL FEMUR 4 HOLE -,SUP-627634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7824.24,5476.968,AETNA [1000108],AETNA [100010801],,,76.8,,6009.02,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 166MM 6HL DIST LAT FEM -,SUP-627636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8009.28,5606.496,AETNA [1000108],AETNA [100010801],,,76.8,,6151.13,0.518595,35041.66656,percent of total billed charges,,,
PLATE DISTAL LATERAL FEMUR -,SUP-627638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8189.22,5732.454,AETNA [1000108],AETNA [100010801],,,76.8,,6289.32,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 238MM 10HL RT DIST LAT FEM -,SUP-627640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8683.22,6078.254,AETNA [1000108],AETNA [100010801],,,76.8,,6668.71,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 274MM 12HL -,SUP-627642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8871.66,6210.162,AETNA [1000108],AETNA [100010801],,,76.8,,6813.43,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 343MM 16HL 1STRN/PK RT -,SUP-627646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9250.22,6475.154,AETNA [1000108],AETNA [100010801],,,76.8,,7104.17,0.518595,35041.66656,percent of total billed charges,,,
PLATE AXSOS 3 TI DISTAL LAT FEMUR RT 18 HOLE L379MM -,SUP-627648S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9623.69,6736.583,AETNA [1000108],AETNA [100010801],,,76.8,,7390.99,0.518595,35041.66656,percent of total billed charges,,,
PLATE TIBAL 4 HOLE LEFT/L71MM -,SUP-627704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.9,4447.73,AETNA [1000108],AETNA [100010801],,,76.8,,4879.8,0.518595,35041.66656,percent of total billed charges,,,
PLATE MEDIAL PROXIMAL TIBIAL 5 HOLES LEFT -,SUP-627705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6560.16,4592.112,AETNA [1000108],AETNA [100010801],,,76.8,,5038.2,0.518595,35041.66656,percent of total billed charges,,,
PLATE MEDIAL 6 HOLES STRYKER -,SUP-627706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6764.51,4735.157,AETNA [1000108],AETNA [100010801],,,76.8,,5195.14,0.518595,35041.66656,percent of total billed charges,,,
PLATE PROX MED TIBIA FOR LEFT TIBIA 8HOLE L-123MM -,SUP-627708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6966.95,4876.865,AETNA [1000108],AETNA [100010801],,,76.8,,5350.62,0.518595,35041.66656,percent of total billed charges,,,
PLATE 14 HOLE PROX MEDIAL FOR LEFT TIBIA L201MM -,SUP-627714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7866.47,5506.529,AETNA [1000108],AETNA [100010801],,,76.8,,6041.45,0.518595,35041.66656,percent of total billed charges,,,
PLATE PROXIMAL MEDIAL TIBIA FOR LEFT TIBIA 16 HOLE -,SUP-627716S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8278.98,5795.286,AETNA [1000108],AETNA [100010801],,,76.8,,6358.26,0.518595,35041.66656,percent of total billed charges,,,
LOCKED TIBIAL PLATE -,SUP-627734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.9,4447.73,AETNA [1000108],AETNA [100010801],,,76.8,,4879.8,0.518595,35041.66656,percent of total billed charges,,,
PLATE TIBIAL LATERAL 5 HOLE -,SUP-627735,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6560.16,4592.112,AETNA [1000108],AETNA [100010801],,,76.8,,5038.2,0.518595,35041.66656,percent of total billed charges,,,
PLATE PROX MED TIB RT 6 HL -,SUP-627736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6764.51,4735.157,AETNA [1000108],AETNA [100010801],,,76.8,,5195.14,0.518595,35041.66656,percent of total billed charges,,,
PROXIMAL MEDIA TIBIA 97MM LENGTH -,SUP-627736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6764.51,4735.157,AETNA [1000108],AETNA [100010801],,,76.8,,5195.14,0.518595,35041.66656,percent of total billed charges,,,
PLATE PROXIMAL MEDIAL TIBIA 8 HOLE RIGHT -,SUP-627738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8247.49,5773.243,AETNA [1000108],AETNA [100010801],,,76.8,,6334.07,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN AXSOS 10HL RT PROX MDL TIB COMPR -,SUP-627740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7438.67,5207.069,AETNA [1000108],AETNA [100010801],,,76.8,,5712.9,0.518595,35041.66656,percent of total billed charges,,,
PROXIMAL MEDIAL TIBIA PLATE FOR RT TIBIA 12 HOLE 175MM -,SUP-627742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7654.48,5358.136,AETNA [1000108],AETNA [100010801],,,76.8,,5878.64,0.518595,35041.66656,percent of total billed charges,,,
INTERPROSTHETIC FEMUR PLATE RIGHT 334MM -,SUP-627846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,27813.56,19469.492,AETNA [1000108],AETNA [100010801],,,76.8,,21360.81,0.518595,35041.66656,percent of total billed charges,,,
DISTAL FEMUR PLATE RIGHT 280MM -,SUP-627863,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19576.64,13703.648,AETNA [1000108],AETNA [100010801],,,76.8,,15034.86,0.518595,35041.66656,percent of total billed charges,,,
6 HOLE PLATE - LEFT -,SUP-628006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,AETNA [1000108],AETNA [100010801],,,76.8,,2961.38,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 88MM 7HL STD PRCONT VAR ANG TI ALY DECREASED -,SUP-628007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,AETNA [1000108],AETNA [100010801],,,76.8,,2961.38,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 99MM 8HL STD PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA [1000108],AETNA [100010801],,,76.8,,3290.59,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 122MM 10HL STD PRCONT VAR ANG TI ALY -,SUP-628010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA [1000108],AETNA [100010801],,,76.8,,3290.59,0.518595,35041.66656,percent of total billed charges,,,
PLATE SUPERIOR 7 HOLE RIGHT DECREASED -,SUP-628027,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,AETNA [1000108],AETNA [100010801],,,76.8,,2961.38,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 99MM 8HL STD PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA [1000108],AETNA [100010801],,,76.8,,3290.59,0.518595,35041.66656,percent of total billed charges,,,
PLATE VARIAX 99MM CLAVICLE RIGHT SUPERIOR DECREASED 8 HOLE -,SUP-628028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA [1000108],AETNA [100010801],,,76.8,,3290.59,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 99MM 6HL BRDG PRCONT VAR ANG TI ALY LT CLVCL -,SUP-628046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,AETNA [1000108],AETNA [100010801],,,76.8,,3616.79,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 122MM 8HL BRDG PRCONT VAR ANG TI ALY -,SUP-628048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,AETNA [1000108],AETNA [100010801],,,76.8,,3616.79,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 99MM 6HL BRDG PRCONT VAR ANG TI ALY RT CLCVL -,SUP-628066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,AETNA [1000108],AETNA [100010801],,,76.8,,3616.79,0.518595,35041.66656,percent of total billed charges,,,
PLATE BRIDGE 8 HOLE SUPERIOR D -,SUP-628068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,AETNA [1000108],AETNA [100010801],,,76.8,,3616.79,0.518595,35041.66656,percent of total billed charges,,,
PLATE 8 HOLE STRYKER -,SUP-628108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA [1000108],AETNA [100010801],,,76.8,,3290.59,0.518595,35041.66656,percent of total billed charges,,,
PLATE 10 HOLE STRYKER -,SUP-628110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA [1000108],AETNA [100010801],,,76.8,,3290.59,0.518595,35041.66656,percent of total billed charges,,,
PLATE CLAVICLE INC CURVED 8 HOLE -,SUP-628128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA [1000108],AETNA [100010801],,,76.8,,3290.59,0.518595,35041.66656,percent of total billed charges,,,
PLATE CLAVICLE IC 10 HOLE -,SUP-628130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA [1000108],AETNA [100010801],,,76.8,,3290.59,0.518595,35041.66656,percent of total billed charges,,,
PLATE 6 HOLE BRIDGE -,SUP-628166,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,AETNA [1000108],AETNA [100010801],,,76.8,,3616.79,0.518595,35041.66656,percent of total billed charges,,,
SUPERIOR LATERAL PLATE - 3 HOLE / LEFT -,SUP-628203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA [1000108],AETNA [100010801],,,76.8,,3290.59,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 98MM 5HL PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA [1000108],AETNA [100010801],,,76.8,,3290.59,0.518595,35041.66656,percent of total billed charges,,,
SUPERIOR LATERAL PLATES -,SUP-628207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4698.11,3288.677,AETNA [1000108],AETNA [100010801],,,76.8,,3608.15,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 86MM 4HL PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA [1000108],AETNA [100010801],,,76.8,,3290.59,0.518595,35041.66656,percent of total billed charges,,,
PLATE RIGHT LATERAL 5-HOLE #628225 -,SUP-628225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA [1000108],AETNA [100010801],,,76.8,,3290.59,0.518595,35041.66656,percent of total billed charges,,,
PLATE 7 HOLE LATERAL -,SUP-628227,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4698.11,3288.677,AETNA [1000108],AETNA [100010801],,,76.8,,3608.15,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 86MM 7HL PRCONT VAR ANG TI ALY UNIV SMRTLC -,SUP-628307,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA [1000108],AETNA [100010801],,,76.8,,3290.59,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 16MMX68MM PRCONT VAR ANG TI ALY LAT -,SUP-628525S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4480.35,3136.245,AETNA [1000108],AETNA [100010801],,,76.8,,3440.91,0.518595,35041.66656,percent of total billed charges,,,
HOOK PLATE 7 HOLE 16MM RIGHT -,SUP-628537S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4480.35,3136.245,AETNA [1000108],AETNA [100010801],,,76.8,,3440.91,0.518595,35041.66656,percent of total billed charges,,,
DISTAL LATERAL HUMERUS PLATE 4 HOLE 109MM -,SUP-629204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA [1000108],AETNA [100010801],,,76.8,,3341.08,0.518595,35041.66656,percent of total billed charges,,,
PLATE 8 HOLE LEFT LATERAL -,SUP-629208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA [1000108],AETNA [100010801],,,76.8,,3788.78,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 3HL RT DIST LAT HUM COMPR -,SUP-629223S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,AETNA [1000108],AETNA [100010801],,,76.8,,3030.74,0.518595,35041.66656,percent of total billed charges,,,
PLATE DISTAL LATERAL 4 HOLE 109MM -,SUP-629224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA [1000108],AETNA [100010801],,,76.8,,3341.08,0.518595,35041.66656,percent of total billed charges,,,
PLATE 12 HOLE RIGHT HUMERUS L203MM VARIAX DIST LATERAL -,SUP-629232S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA [1000108],AETNA [100010801],,,76.8,,3788.78,0.518595,35041.66656,percent of total billed charges,,,
PLATE HUMERUS DIST POST LATERAL LEFT 3 HOLE -,SUP-629243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,AETNA [1000108],AETNA [100010801],,,76.8,,3030.74,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 105MM 4HL PRCONT VAR ANG LCK TI ALY NS LT -,SUP-629244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA [1000108],AETNA [100010801],,,76.8,,3341.08,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 128MM 6HL SHFT PRCONT VAR ANG LCK TI ALY NS -,SUP-629246,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA [1000108],AETNA [100010801],,,76.8,,3341.08,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 150MM 8HL PRCONT VAR ANG LCK TI ALY NS LT -,SUP-629248,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA [1000108],AETNA [100010801],,,76.8,,3788.78,0.518595,35041.66656,percent of total billed charges,,,
PLATE DIST POST LATERAL HUMERUS 10 HOLE L173MM -,SUP-629250S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA [1000108],AETNA [100010801],,,76.8,,3788.78,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 105MM 4HL PRCONT VAR ANG LCK TI ALY NS RT -,SUP-629264,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA [1000108],AETNA [100010801],,,76.8,,3341.08,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 150MM 8HL PRCONT VAR ANG LCK TI ALY NS RT -,SUP-629268,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA [1000108],AETNA [100010801],,,76.8,,3788.78,0.518595,35041.66656,percent of total billed charges,,,
PLATE HUMERUS DISTAL POSTERIOR LATERAL 12 HOLE -,SUP-629272S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA [1000108],AETNA [100010801],,,76.8,,3788.78,0.518595,35041.66656,percent of total billed charges,,,
PLATE EXTENDED MEDIAL LEFT 3 HOLE -,SUP-629283,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,AETNA [1000108],AETNA [100010801],,,76.8,,3030.74,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 96MM 4HL PRCONT VAR ANG LCK TI ALY -,SUP-629284,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA [1000108],AETNA [100010801],,,76.8,,3341.08,0.518595,35041.66656,percent of total billed charges,,,
PLATE DISTAL MEDIAL HUMERUS 6 HOLE EXTEND -,SUP-629286,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA [1000108],AETNA [100010801],,,76.8,,3341.08,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 104MM 4HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA [1000108],AETNA [100010801],,,76.8,,3341.08,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 151MM 8HL SHFT PRCONT VAR ANG LCK TI ALY NS -,SUP-629308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA [1000108],AETNA [100010801],,,76.8,,3788.78,0.518595,35041.66656,percent of total billed charges,,,
PLATE DIST POST MEDIAL HUMERUS 12 HOLE L199MM -,SUP-629312S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA [1000108],AETNA [100010801],,,76.8,,3788.78,0.518595,35041.66656,percent of total billed charges,,,
DISTAL POSTERIOR MEDIAL HUMERUS PLATE FOR RT HUM 3 HOLE -,SUP-629323,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,AETNA [1000108],AETNA [100010801],,,76.8,,3030.74,0.518595,35041.66656,percent of total billed charges,,,
PLATE DIST POST MDL RIGHT 4 -,SUP-629324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA [1000108],AETNA [100010801],,,76.8,,3341.08,0.518595,35041.66656,percent of total billed charges,,,
PLATE DISTAL POSTERIOR MEDIAL 8 HOLE -,SUP-629328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA [1000108],AETNA [100010801],,,76.8,,3788.78,0.518595,35041.66656,percent of total billed charges,,,
PLATE DIST POST MEDIAL HUMERUS 12 HOLE L199MM -,SUP-629332S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA [1000108],AETNA [100010801],,,76.8,,3788.78,0.518595,35041.66656,percent of total billed charges,,,
PLATE OLECRARON LEFT 3 HOLE -,SUP-629343,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,AETNA [1000108],AETNA [100010801],,,76.8,,3030.74,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 89MM 4HL PRCONT VAR ANG LCK TI ALY NS LT -,SUP-629344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA [1000108],AETNA [100010801],,,76.8,,3341.08,0.518595,35041.66656,percent of total billed charges,,,
3 HOLE RIGHT PLATE -,SUP-629363,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,AETNA [1000108],AETNA [100010801],,,76.8,,3030.74,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 89MM 4HL PRCONT VAR ANG LCK TI ALY NS RT -,SUP-629364,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA [1000108],AETNA [100010801],,,76.8,,3341.08,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 113MM 6HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629366,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA [1000108],AETNA [100010801],,,76.8,,3341.08,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 137MM 8HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629368,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA [1000108],AETNA [100010801],,,76.8,,3788.78,0.518595,35041.66656,percent of total billed charges,,,
PLATE MEDIAL 3 HOLE -,SUP-629383,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,AETNA [1000108],AETNA [100010801],,,76.8,,3030.74,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 92MM 4HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629384,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA [1000108],AETNA [100010801],,,76.8,,3341.08,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 116MM 6HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629386,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA [1000108],AETNA [100010801],,,76.8,,3341.08,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 139MM 8HL LCK TI ALY NS -,SUP-629388,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA [1000108],AETNA [100010801],,,76.8,,3788.78,0.518595,35041.66656,percent of total billed charges,,,
PLATE DISTAL MEDIAL HUMERUS LEFT 10HOLE 163MM -,SUP-629390S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA [1000108],AETNA [100010801],,,76.8,,3788.78,0.518595,35041.66656,percent of total billed charges,,,
PLATE DISTAL MEDIAL HUMERUS 12 HOLE -,SUP-629392S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA [1000108],AETNA [100010801],,,76.8,,3788.78,0.518595,35041.66656,percent of total billed charges,,,
PLATE COMPRESSION NARROW STRAIGHT 4 HOLES -,SUP-629504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1289.93,902.951,AETNA [1000108],AETNA [100010801],,,76.8,,990.67,0.518595,35041.66656,percent of total billed charges,,,
PLATE COMPRESSION NARROW STRAIGHT 5 HOLES -,SUP-629505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,AETNA [1000108],AETNA [100010801],,,76.8,,1314.54,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 6 HOLE COM PR NRW STR -,SUP-629506S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,AETNA [1000108],AETNA [100010801],,,76.8,,1314.54,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 7HL COMPR NRW STR -,SUP-629507S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,AETNA [1000108],AETNA [100010801],,,76.8,,1314.54,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX COMPR TI ALY NRW STR 629508S STRL -,SUP-629508S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,AETNA [1000108],AETNA [100010801],,,76.8,,1928.94,0.518595,35041.66656,percent of total billed charges,,,
PLATE COMP 9 HOLE NARROW STR -,SUP-629509S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,AETNA [1000108],AETNA [100010801],,,76.8,,1928.94,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 10HL COMPR NRW STR -,SUP-629510S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,AETNA [1000108],AETNA [100010801],,,76.8,,1928.94,0.518595,35041.66656,percent of total billed charges,,,
PLATE COMPRESSION NARROW STRAIGHT 12 HOLES -,SUP-629512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,AETNA [1000108],AETNA [100010801],,,76.8,,2066.22,0.518595,35041.66656,percent of total billed charges,,,
14 HOLE NARROW COMPRESSION PLATE VARIAX -,SUP-629514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,AETNA [1000108],AETNA [100010801],,,76.8,,2066.22,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX COMPR TI ALY NRW STR 629527S STRL -,SUP-629527S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,AETNA [1000108],AETNA [100010801],,,76.8,,1314.54,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 7HL COMPR BRD STR -,SUP-629537S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,AETNA [1000108],AETNA [100010801],,,76.8,,1314.54,0.518595,35041.66656,percent of total billed charges,,,
COMPRESSION PLATE BROAD STRAIGHT 6 HOLES -,SUP-629546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,AETNA [1000108],AETNA [100010801],,,76.8,,1314.54,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 8HL COMPR NRW STR -,SUP-629548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,AETNA [1000108],AETNA [100010801],,,76.8,,1928.94,0.518595,35041.66656,percent of total billed charges,,,
COMPRESSION PLATE BROAD STRAIGHT 9 HOLES/L115MM -,SUP-629549S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2509.57,1756.699,AETNA [1000108],AETNA [100010801],,,76.8,,1927.35,0.518595,35041.66656,percent of total billed charges,,,
VARIAX COMPRESSION PLATE BROAD CURVED 9 HOLES -,SUP-629559,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,AETNA [1000108],AETNA [100010801],,,76.8,,1928.94,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN VARIAX 8HL COMPR BRD CRV -,SUP-629560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,AETNA [1000108],AETNA [100010801],,,76.8,,1928.94,0.518595,35041.66656,percent of total billed charges,,,
PLATE COMPRESSION BROAD CURVED 11 HOLES -,SUP-629561,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,AETNA [1000108],AETNA [100010801],,,76.8,,2066.22,0.518595,35041.66656,percent of total billed charges,,,
PLATE COMP VARIAX BROAD CURVED 10 HOLES -,SUP-629562,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,AETNA [1000108],AETNA [100010801],,,76.8,,2066.22,0.518595,35041.66656,percent of total billed charges,,,
PLATE SHORT BEND -,SUP-629589,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8642.06,6049.442,AETNA [1000108],AETNA [100010801],,,76.8,,6637.1,0.518595,35041.66656,percent of total billed charges,,,
PLATE PROFILE 2.0 4HOLE -,SUP-629604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1944.22,1360.954,AETNA [1000108],AETNA [100010801],,,76.8,,1493.16,0.518595,35041.66656,percent of total billed charges,,,
PLATE PROFILE 2.0 X L33MM 6 HOLE -,SUP-629606,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1944.22,1360.954,AETNA [1000108],AETNA [100010801],,,76.8,,1493.16,0.518595,35041.66656,percent of total billed charges,,,
PROFILE PLATE 2.0 54MM -,SUP-629610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1944.22,1360.954,AETNA [1000108],AETNA [100010801],,,76.8,,1493.16,0.518595,35041.66656,percent of total billed charges,,,
PROFILE PLATE 2.0 L108MM 20HOLES -,SUP-629620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,AETNA [1000108],AETNA [100010801],,,76.8,,1690.19,0.518595,35041.66656,percent of total billed charges,,,
PLATE NARROW LOCKING 2.0 4 HOLE -,SUP-629624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2488.21,1741.747,AETNA [1000108],AETNA [100010801],,,76.8,,1910.95,0.518595,35041.66656,percent of total billed charges,,,
PLATE NARROW LOCK 2.0 L34MM 6 HOLES -,SUP-629626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2488.21,1741.747,AETNA [1000108],AETNA [100010801],,,76.8,,1910.95,0.518595,35041.66656,percent of total billed charges,,,
PLATE 8 HOLE NARROW -,SUP-629628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2488.21,1741.747,AETNA [1000108],AETNA [100010801],,,76.8,,1910.95,0.518595,35041.66656,percent of total billed charges,,,
PLATE 2.0MM BROAD LOCKING 6 HOLES STRAIGHT -,SUP-629646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,AETNA [1000108],AETNA [100010801],,,76.8,,2088.4,0.518595,35041.66656,percent of total billed charges,,,
PLATE BROAD LOCKING 2.0 / 10 HOLE -,SUP-629650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,AETNA [1000108],AETNA [100010801],,,76.8,,2088.4,0.518595,35041.66656,percent of total billed charges,,,
PLATE PROFILE 8 HOLE 2.4 -,SUP-629666,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,AETNA [1000108],AETNA [100010801],,,76.8,,1690.19,0.518595,35041.66656,percent of total billed charges,,,
PLATE PROFILE 2.4 8HOLE -,SUP-629668,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,AETNA [1000108],AETNA [100010801],,,76.8,,1690.19,0.518595,35041.66656,percent of total billed charges,,,
PLATE VARIAX LOW PROFILE 2.4 X L66MM 10 HOLES -,SUP-629670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,AETNA [1000108],AETNA [100010801],,,76.8,,1690.19,0.518595,35041.66656,percent of total billed charges,,,
PLATE NARROW LOCK 2.4 X L28MM 4 HOLE -,SUP-629684,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,AETNA [1000108],AETNA [100010801],,,76.8,,2265.85,0.518595,35041.66656,percent of total billed charges,,,
6 HOLE NARROW PLATE -,SUP-629686,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,AETNA [1000108],AETNA [100010801],,,76.8,,2265.85,0.518595,35041.66656,percent of total billed charges,,,
PLATE 2.4MM 8 HOLE -,SUP-629688,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,AETNA [1000108],AETNA [100010801],,,76.8,,2265.85,0.518595,35041.66656,percent of total billed charges,,,
PLATE BONE VARIAX NARROW LOCK 2.4 L69MM 10 HOLE -,SUP-629690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,AETNA [1000108],AETNA [100010801],,,76.8,,2265.85,0.518595,35041.66656,percent of total billed charges,,,
PLATE 4 HOLE -,SUP-629704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,AETNA [1000108],AETNA [100010801],,,76.8,,2441.84,0.518595,35041.66656,percent of total billed charges,,,
PLATE BROAD LOCKING 2.4 6 HOLE -,SUP-629706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,AETNA [1000108],AETNA [100010801],,,76.8,,2441.84,0.518595,35041.66656,percent of total billed charges,,,
PLATE 8 HOLE STRAIGHT 2.4 -,SUP-629708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,AETNA [1000108],AETNA [100010801],,,76.8,,2441.84,0.518595,35041.66656,percent of total billed charges,,,
PLATE BONE VARIAX BROAD LOCK 2.4 L80MM 10HOLES -,SUP-629710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,AETNA [1000108],AETNA [100010801],,,76.8,,2441.84,0.518595,35041.66656,percent of total billed charges,,,
PLATE BROAD LOCKING 2.4 12 HOLE -,SUP-629712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,AETNA [1000108],AETNA [100010801],,,76.8,,2619.3,0.518595,35041.66656,percent of total billed charges,,,
PLATE 4 HOLE NARROW -,SUP-629724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,AETNA [1000108],AETNA [100010801],,,76.8,,2619.3,0.518595,35041.66656,percent of total billed charges,,,
PLATE 2.7 6 HOLE STRAIGHT -,SUP-629726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,AETNA [1000108],AETNA [100010801],,,76.8,,2619.3,0.518595,35041.66656,percent of total billed charges,,,
PLATE 8 HOLE -,SUP-629728,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,AETNA [1000108],AETNA [100010801],,,76.8,,2619.3,0.518595,35041.66656,percent of total billed charges,,,
PLATE 10 HOLE -,SUP-629730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,AETNA [1000108],AETNA [100010801],,,76.8,,2619.3,0.518595,35041.66656,percent of total billed charges,,,
PLATE STRAIGHT 10 HOLE -,SUP-629740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA [1000108],AETNA [100010801],,,76.8,,2795.29,0.518595,35041.66656,percent of total billed charges,,,
PLATE BROAD LOCK 2.7 L39MM 4 HOLE -,SUP-629744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA [1000108],AETNA [100010801],,,76.8,,2795.29,0.518595,35041.66656,percent of total billed charges,,,
PLATE 2.7 6 HOLE -,SUP-629746,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA [1000108],AETNA [100010801],,,76.8,,2795.29,0.518595,35041.66656,percent of total billed charges,,,
PLATE BROAD LOCK 2.7 X 73MM 8HL -,SUP-629748,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA [1000108],AETNA [100010801],,,76.8,,2795.29,0.518595,35041.66656,percent of total billed charges,,,
T-PLATE 2.7MM 3 X 10 -,SUP-629748,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA [1000108],AETNA [100010801],,,76.8,,2795.29,0.518595,35041.66656,percent of total billed charges,,,
PLATE BROAD LOCKING 2.7 10HOLE -,SUP-629750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA [1000108],AETNA [100010801],,,76.8,,2795.29,0.518595,35041.66656,percent of total billed charges,,,
PLATE 12 HOLE BROAD STRAIGHT -,SUP-629752,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3870.76,2709.532,AETNA [1000108],AETNA [100010801],,,76.8,,2972.74,0.518595,35041.66656,percent of total billed charges,,,
T-PLATE NARROW LOCKING 2.0 2 X 5 HOLE -,SUP-629770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,AETNA [1000108],AETNA [100010801],,,76.8,,2088.4,0.518595,35041.66656,percent of total billed charges,,,
NARROW LOCK T-PLATE 2.0 L62MM 2X10HOLES -,SUP-629771,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2716.41,1901.487,AETNA [1000108],AETNA [100010801],,,76.8,,2086.2,0.518595,35041.66656,percent of total billed charges,,,
PLATE NARROW LCK T 2.0 3X5 HOLE -,SUP-629772,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,AETNA [1000108],AETNA [100010801],,,76.8,,2088.4,0.518595,35041.66656,percent of total billed charges,,,
T-PLATE 2.4MM NARROW LOCKING 2 X 5 -,SUP-629776,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,AETNA [1000108],AETNA [100010801],,,76.8,,2441.84,0.518595,35041.66656,percent of total billed charges,,,
T-PLATE -,SUP-629777,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,AETNA [1000108],AETNA [100010801],,,76.8,,2441.84,0.518595,35041.66656,percent of total billed charges,,,
PLATE BONE VARIAX NARROW LOCK T-PLATE 2.4 L41MM 3X5 HOLES -,SUP-629778,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,AETNA [1000108],AETNA [100010801],,,76.8,,2441.84,0.518595,35041.66656,percent of total billed charges,,,
PLATE T 2.4 NARROW -,SUP-629779,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,AETNA [1000108],AETNA [100010801],,,76.8,,2441.84,0.518595,35041.66656,percent of total billed charges,,,
PLATE NARROW T 2.4 X L76MM 5X10 HOLES LKG -,SUP-629781,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,AETNA [1000108],AETNA [100010801],,,76.8,,2441.84,0.518595,35041.66656,percent of total billed charges,,,
PLATE NARROW LOCKING T 5 HOLE -,SUP-629782,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA [1000108],AETNA [100010801],,,76.8,,2795.29,0.518595,35041.66656,percent of total billed charges,,,
PLATE 10 HOLE -,SUP-629783,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA [1000108],AETNA [100010801],,,76.8,,2795.29,0.518595,35041.66656,percent of total billed charges,,,
PLATE AXSOS TITANIUM 5 HOLE -,SUP-629784,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA [1000108],AETNA [100010801],,,76.8,,2795.29,0.518595,35041.66656,percent of total billed charges,,,
PLATE NARROW LOCKING T  2.7 X 87MM 10HOLE -,SUP-629785,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA [1000108],AETNA [100010801],,,76.8,,2795.29,0.518595,35041.66656,percent of total billed charges,,,
PLATE T NARROW LOCK 2.7 L8 7MM X 5 X 10 HOLES -,SUP-629787,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA [1000108],AETNA [100010801],,,76.8,,2795.29,0.518595,35041.66656,percent of total billed charges,,,
PLATE 2.7 Y- PLATE -,SUP-629788,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4103.73,2872.611,AETNA [1000108],AETNA [100010801],,,76.8,,3151.66,0.518595,35041.66656,percent of total billed charges,,,
PLATE 2.7MM TRIANGLE -,SUP-629789,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4103.73,2872.611,AETNA [1000108],AETNA [100010801],,,76.8,,3151.66,0.518595,35041.66656,percent of total billed charges,,,
PLATE Y 2.4MM -,SUP-629790,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA [1000108],AETNA [100010801],,,76.8,,2795.29,0.518595,35041.66656,percent of total billed charges,,,
PLATE NARROW LOCK TRIANGLE 2.4 X 81MM 10 HOLE -,SUP-629791,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA [1000108],AETNA [100010801],,,76.8,,2795.29,0.518595,35041.66656,percent of total billed charges,,,
ANTERIOR TT PLATE LEFT -,SUP-630101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10381.67,7267.169,AETNA [1000108],AETNA [100010801],,,76.8,,7973.12,0.518595,35041.66656,percent of total billed charges,,,
ANTERIOR TT PLATE RIGHT -,SUP-630102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10381.67,7267.169,AETNA [1000108],AETNA [100010801],,,76.8,,7973.12,0.518595,35041.66656,percent of total billed charges,,,
IMPLANT FLEXBLOCK -,SUP-6314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7031.8,4922.26,AETNA [1000108],AETNA [100010801],,,76.8,,5400.42,0.518595,35041.66656,percent of total billed charges,,,
PIN FX 38MM TRIATH HD F/T/K SYS -,SUP-6541-4-515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,,,
ABC IM ROD TRIATHLON INSTRUMENTS -,SUP-6541-4-516E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2213.49,1549.443,AETNA [1000108],AETNA [100010801],,,76.8,,1699.96,0.518595,35041.66656,percent of total billed charges,,,
PIN FX 19MM TRIATH HD F/T/K SYS -,SUP-6541-4-575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,327.34,229.138,AETNA [1000108],AETNA [100010801],,,76.8,,251.4,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING T8 FULL THREAD 2.4 X 6 -,SUP-656006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING T8 FULL THREAD 2.4 X 7 -,SUP-656007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW LCK T8 FULL THREAD 2.4X8 -,SUP-656008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING T8 FULL THREAD 2.4 X 10 -,SUP-656010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 2.4 X 11 -,SUP-656011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW LCK T8 FII THRD 2.4 X 12 -,SUP-656012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING T8 FULL THREAD 2.4MM L14 -,SUP-656014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.4MM X 16MM LOCKING -,SUP-656016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING T8 FULL TRHEAD 2.4MM L 18MM -,SUP-656018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING T8 FULL THREAD 2.4 X 22 -,SUP-656022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING T8 FULL THREAD 2.4MM X 24MM -,SUP-656024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,,,
LOCKING SCREW T8 FULL THREAD 2.4MM X 26MM -,SUP-656026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING T8 FULL THREAD 2.4 X 28 -,SUP-656028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING T8 FULL THREAD 2.4 X 30 -,SUP-656030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING T8 FULL THREAD 2.4 X 32 -,SUP-656032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING T8 FULL THREAD 2.4 X 34 -,SUP-656034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING T8 FULL THREAD 2.4 X 36 -,SUP-656036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 2.4MM X 38MM -,SUP-656038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN T8 FULL THREAD 2.4X6 -,SUP-656106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN T8 FULL THREAD 2.4X7 -,SUP-656107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN T8 FULL THREAD 2.4X8 -,SUP-656108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN T8 FULL THREAD 2.4X9 -,SUP-656109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN T8 FULL THREAD 2.4X12 -,SUP-656112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN T8 FULL THREAD 2.4X14 -,SUP-656114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.4 X 15 NL -,SUP-656115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN T8 FULL THREAD 2.4X18 -,SUP-656118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN T8 FULL THREAD 2.4X20 -,SUP-656120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN T8 FULL THREAD 2.4X24 -,SUP-656124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN T8 FULL THREAD 2.4X26 -,SUP-656126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN T8 FULL THREAD 2.4X28 -,SUP-656128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN T8 FULL THREAD 2.4X30 -,SUP-656130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN T8 FULL THREAD 2.4X32 -,SUP-656132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN T8 FULL THREAD 2.4X34 -,SUP-656134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN T8 FULL THREAD 2.4X36 -,SUP-656136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN T8 FULL THREAD 2.4X38 -,SUP-656138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE T8  2.4MM X L40MM NL -,SUP-656140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW NON LOCKING 3.5 X 42 -,SUP-656142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW NON LOCKING 3.5 X 44 -,SUP-656144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN T8 FULL THREAD 2.4X48 -,SUP-656148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN T8 FULL THREAD 2.4X50 -,SUP-656150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE VARIAX T8 2.4MM L55MM -,SUP-656155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN T8 FULL THREAD 2.4X60 -,SUP-656160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 2.7MM X 6MM -,SUP-656306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING T8 FULL THREAD 2.7 X 7 -,SUP-656307,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1150.21,805.147,AETNA [1000108],AETNA [100010801],,,76.8,,883.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING T8 FULL THREAD 2.7X8 -,SUP-656308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 2.7MM X 9MM -,SUP-656309,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW LCK T8 FULL THREAD 2.7X10 -,SUP-656310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW LCK T8 2.7 X 11MM -,SUP-656311,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 2.7MM X 12MM -,SUP-656312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7 X 13 LOCKING -,SUP-656313,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 2.7MM X 14MM -,SUP-656314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW LCK T8 2.7 X 15MM -,SUP-656315,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 2.7MM X 16MM -,SUP-656316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 2.7MM X 18MM -,SUP-656318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 2.7MM X 20MM -,SUP-656320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 2.7MM X 22MM -,SUP-656322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 2.7MM X 24MM -,SUP-656324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 2.7MM X 26MM -,SUP-656326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 2.7MM X 22MM -,SUP-656328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7 X 3 LOCKING -,SUP-656330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 2.7MM X 32MM -,SUP-656332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 2.7 X 34 -,SUP-656334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 2.7MM X 36MM -,SUP-656336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 2.7MM X 38MM -,SUP-656338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 2.7MM X 40MM -,SUP-656340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 2.7 X 42 -,SUP-656342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 2.7MM X 44MM -,SUP-656344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 2.7 X 45 -,SUP-656345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 2.7MM X 50MM -,SUP-656350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA [1000108],AETNA [100010801],,,76.8,,413.62,0.518595,35041.66656,percent of total billed charges,,,
2.7MM X 55MM LOCKING SCREW -,SUP-656355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE VARIAX T8 2.7MM  X  L 60MM LOCKING -,SUP-656360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 2.7 X 70 -,SUP-656370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE VARIAX T8 2.7MM X L 75MM LOCKING SCREW -,SUP-656375S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,694.95,486.465,AETNA [1000108],AETNA [100010801],,,76.8,,533.72,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE VARIAX T8 2.7MM X L 80MM LOCKING -,SUP-656380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,694.95,486.465,AETNA [1000108],AETNA [100010801],,,76.8,,533.72,0.518595,35041.66656,percent of total billed charges,,,
SCREW T8 FULL THREAD NON LCK 2.7 X 6 -,SUP-656406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE VARIAX T8  7MM X 2.7MM -,SUP-656407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE T8 FULL THREAD 2.7MM X 9 -,SUP-656409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MM X 10MM NON LOCKING -,SUP-656410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE T8 2.7 X11MM -,SUP-656411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW N/L 2.7MM X 12MM -,SUP-656412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7 X 13 NL -,SUP-656413,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW N/L 2.7MM X 14MM -,SUP-656414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW NON LOCKING 2.7 X 15 -,SUP-656415,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW N/L 2.7MM X 16MM -,SUP-656416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW N/L 2.7MM X 18MM -,SUP-656418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7 X 20MM NLCKG FT T8 STRDRV RCESS -,SUP-656420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW NON-LOCKING 2.7MM X 22MM -,SUP-656422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW NON LOCKING 2.7 X 26MM -,SUP-656426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,,,
2.7MM NON LOCKING BONE SCREW 28MM -,SUP-656428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN T8 FLL THRD 2.7 X 30 -,SUP-656430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN T8 FLL THRD 2.7 X 32 -,SUP-656432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN T8 FLL THRD 2.7 X 34 -,SUP-656434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN T8 FLL THRD 2.7 X 36 -,SUP-656436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW NON LOCKING 2.7 X 38 -,SUP-656438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE T8 FULL THREAD 2.7 X 40 -,SUP-656440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW NON LOCKING 2.7 X 40 -,SUP-656440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW NON LOCKING 2.7MM X 42MM -,SUP-656442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW NON LOCKING 2.7 X 45 -,SUP-656445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW NON LOCKING 2.7 X 46 -,SUP-656446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN T8 FLL THRD 2.7 X 48MM -,SUP-656448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7 X 50 NL -,SUP-656450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7 X 55 NL -,SUP-656455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW NON LOCKING 2.7MM X 60MM -,SUP-656460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW NON LOCKING 2.7MM X 65MM -,SUP-656465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW NL 2.7 X 70 -,SUP-656470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE 2.7MM X 75MM T8 -,SUP-656475S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE VAIRAX T8 2.7MM X L 80MM -,SUP-656480S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING T10 FULL THREAD 2.7 X 8 -,SUP-657008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X12MM LCK FT T10 HX DRV -,SUP-657012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X14MM LCK FT T10 HX DRV -,SUP-657014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X16MM LCK FT T10 HX DRV -,SUP-657016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X20MM LCK FT T10 HX DRV -,SUP-657020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING T10 FULL 2.7 X 22 -,SUP-657022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING T10 FULL 2.7MM  X 22MM VARIAX -,SUP-657024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7 X 26 LOCKING -,SUP-657026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7 X 28 LOCKING -,SUP-657028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7 X 30 LOCKING -,SUP-657030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING T10 FULL 2.7 X 32 -,SUP-657032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
LOCKING SCREW T10 FULL THREAD 2.7MM L34MM -,SUP-657034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING T10 FULL 2.7 X 36 -,SUP-657036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7 X 38 LOCKING -,SUP-657038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MM X 40MM LOCKING -,SUP-657040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING T10 2.7 X 50 -,SUP-657050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING T10 2.7 X 55 -,SUP-657055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
LOCKING SCREW T10 FULL THREAD 2.7MM X 60MM -,SUP-657060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING T10 FULL THREAD 2.7 X 65 -,SUP-657065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING T10 FULL THREAD 2.7 X 70 -,SUP-657070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE T10 FULL THREAD 2.7 X 8 -,SUP-657108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X12MM FT T10 HX DRV -,SUP-657112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X14MM FT T10 HX DRV -,SUP-657114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X16MM FT T10 HX DRV -,SUP-657116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X18MM FT T10 HX DRV -,SUP-657118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X20MM FT T10 HX DRV -,SUP-657120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X22MM FT T10 HX DRV -,SUP-657122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE T10 FULL THREAD 2.7 X 26 -,SUP-657126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE T10 FULL THREAD 2.7 X 28 -,SUP-657128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
30MM BONE SCREW NONLOCKING 2.7MM -,SUP-657130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW NL 2.7 X 32 -,SUP-657132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW NL 2.7 X 34 -,SUP-657134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE T10 FULL THREAD 2.7MM /L36MM -,SUP-657136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW NL 2.7 X 38 -,SUP-657138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE T10 FULL THREAD 2.7MM /L40MM -,SUP-657140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE T10 FULL THREAD 2.7MM /L42MM -,SUP-657142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE T10 FULL THREAD 2.7mm / L44mm -,SUP-657144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE T10 FULL THREAD 2.7MM /L46MM -,SUP-657146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE T10 FULL THREAD 2.7mm / L48mm -,SUP-657148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE T10 FULL THREAD 2.7MM /L50MM -,SUP-657150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE T10 FULL THREAD 2.7MM /L55MM -,SUP-657155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE T10 FULL THREAD 2.7MM /L60MM -,SUP-657160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE T10 FULL THREAD 2.7 X 65 -,SUP-657165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE T10 FULL THREAD 2.7 X 70 -,SUP-657170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING T10 FULL THREAD 3.5 X 8 -,SUP-657308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X10MM LCK FT T10 HX DRV -,SUP-657310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE 3.5MM 12MM VARIAX T10 FULL THREAD LOCK NONSTERILE -,SUP-657312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X14MM LCK FT T10 HX DRV -,SUP-657314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X16MM LCK FT T10 HX DRV -,SUP-657316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X18MM LCK FT T10 HX DRV -,SUP-657318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING T10 3.5MM / L20MM FULL THREAD -,SUP-657320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 3.5 X 22 -,SUP-657322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING T10 3.5MM / L22MM FULL THREAD -,SUP-657322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 3.5 X 24 -,SUP-657324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 3.5 X 26 -,SUP-657326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 3.5 X 30 -,SUP-657330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 3.5 X 32 -,SUP-657332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 3.5 X 34 -,SUP-657334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 3.5 X 38 -,SUP-657338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING T10 FULL THREAD 3.5 X 40 -,SUP-657340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING T10 FULL THREAD 3.5 X 42 -,SUP-657342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 3.5 X 44 -,SUP-657344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 3.5 X 46 -,SUP-657346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING T10FULL THREAD 3.5MM X 48MM -,SUP-657348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING T10 FULL THREAD 3.5MM X 50MM -,SUP-657350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING T10 FULL THREAD 3.5 X 60 -,SUP-657360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING T10 FULL THREAD 3.5 X 65 -,SUP-657365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING T10 FULL THREAD 3.5 X 70 -,SUP-657370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE T10 FULL THREAD 3.5 X 8 -,SUP-657408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,AETNA [1000108],AETNA [100010801],,,76.8,,589.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE T10 FULL THREAD 3.5 X 8 -,SUP-657408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE T10 FULL THREAD 3.5MM /L10MM -,SUP-657410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5 NON LOCKING 12MM -,SUP-657412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MM X12MM NON LOCKING -,SUP-657412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X14MM FT T10 HX DRV -,SUP-657414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X16MM FT T10 HX DRV -,SUP-657416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X18MM FT T10 HX DRV -,SUP-657418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X20MM FT T10 HX DRV -,SUP-657420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW NON-LOCKING 3.5 MM X 22 -,SUP-657422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5 NON LOCK FT 24MM -,SUP-657424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5 NON LOCK FT 26MM -,SUP-657426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MM NONLOCKING FT 28MM -,SUP-657428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MM NONLOCKING FT 30MM -,SUP-657430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
VARIAX 305MM NON LOCKING SCREW  32MM -,SUP-657432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
3.5MM NON-LOCKING SCREW 34MM -,SUP-657434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
3.5MM NON-LOCKING SCREW 36MM -,SUP-657436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE T10 FULL THREAD 3.5 X 38 -,SUP-657438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW  BONE T10 FULL THREAD NON LOCKING 3.5 X 40 -,SUP-657440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE T10 FULL THREAD 3.5MM X 42MM -,SUP-657442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
VARIAX 3.5MM NON LOCKING SCREW 44MM -,SUP-657444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
BONE SCREW T10 FULL THREAD 3.5MM / L46MM -,SUP-657446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE T10FULL THREAD 3.5 X 48 -,SUP-657448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MM NONLOCKING FT 50MM -,SUP-657450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE T10 FULL THREAD 3.5 X 55 -,SUP-657455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE T10 FULL THREAD 3.5 X 60 -,SUP-657460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE T10 FULL THREAD 3.5 X 65 -,SUP-657465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE T10 FULL THREAD 3.5 X 70 -,SUP-657470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA [1000108],AETNA [100010801],,,76.8,,250.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW VARIAX LOCKING T6 2.0MM L8MM -,SUP-657608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING T6 2.0MM L9MM -,SUP-657609,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW VARIAX LOCKING T6 2.0MM L10MM -,SUP-657610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING T6 2.0MM L11MM -,SUP-657611,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.0MM  X 12MM LOCKING -,SUP-657612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING T6 2 X 14MM -,SUP-657614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW LCK T6 2.0 X 16MM -,SUP-657616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW LCK T6 2.0 X 18MM -,SUP-657618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2-0MM LOCKING 20MM LENGTH -,SUP-657620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW LCK T6 2.0 X 22MM -,SUP-657622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING T6 2.0 X 26MM -,SUP-657626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING VARIAX T6 2.0MM X L30MM -,SUP-657630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE 2.0M X L6MM T6 -,SUP-657706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW NONLCK 2.0 X 10MM -,SUP-657710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2 X 11 -,SUP-657711,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.0MM X 12MM NON LOCKING -,SUP-657712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.0MM X 14MM NON LOCKING -,SUP-657714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2 X 16 -,SUP-657716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW VARIAX 2.0 X 18 -,SUP-657718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.9 NON LOCKING 20MM LENGTH -,SUP-657720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW NON LOCKING 2 X 22 -,SUP-657722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE T6 2.0MM X L 24MM NON-LOCKING -,SUP-657724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE T6 2.0MM L26MM -,SUP-657726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.0MM NON LOCKING 28MM LENGTH -,SUP-657728,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE T6 2.0MM L30MM -,SUP-657730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE VARIAX T6 2.0MM X L34MM -,SUP-657734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW NON LOCKING 2 X 36 -,SUP-657736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE VARIAX T6 2.0MM X L38MM -,SUP-657738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA [1000108],AETNA [100010801],,,76.8,,248.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW FIXOS 4.0 30MM -,SUP-658030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA [1000108],AETNA [100010801],,,76.8,,1722.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEADLESS 4.0 FIXOS 38MM -,SUP-658038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA [1000108],AETNA [100010801],,,76.8,,1722.1,0.518595,35041.66656,percent of total billed charges,,,
4.0 FIXOS 46MM SCREW -,SUP-658046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA [1000108],AETNA [100010801],,,76.8,,1722.1,0.518595,35041.66656,percent of total billed charges,,,
4.0 FIXOS 48MM SCREW -,SUP-658048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA [1000108],AETNA [100010801],,,76.8,,1722.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEADLESS COMP. 7.0MM 50M -,SUP-658050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA [1000108],AETNA [100010801],,,76.8,,1722.1,0.518595,35041.66656,percent of total billed charges,,,
4.0 FIXOS 55MM SCREW -,SUP-658055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA [1000108],AETNA [100010801],,,76.8,,1722.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEADLESS LONG THREAD 7.0 X 70MM -,SUP-658070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA [1000108],AETNA [100010801],,,76.8,,1722.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEADLESS COMP. 7.0MM 75M -,SUP-658075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA [1000108],AETNA [100010801],,,76.8,,1722.1,0.518595,35041.66656,percent of total billed charges,,,
4.0 FIXOS SCREW 80MM -,SUP-658080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA [1000108],AETNA [100010801],,,76.8,,1722.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEADLESS 5 X 32 -,SUP-658132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA [1000108],AETNA [100010801],,,76.8,,1802.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW FIXOS 5.0 X 34MM -,SUP-658134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA [1000108],AETNA [100010801],,,76.8,,1802.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW FIXOS 5.0 X 36MM -,SUP-658136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA [1000108],AETNA [100010801],,,76.8,,1802.87,0.518595,35041.66656,percent of total billed charges,,,
HEADLESS COMPRESSION SCREW 5MM X 38MM -,SUP-658138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA [1000108],AETNA [100010801],,,76.8,,1802.87,0.518595,35041.66656,percent of total billed charges,,,
5.0 HEADLESS SCREW 44 MM -,SUP-658144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA [1000108],AETNA [100010801],,,76.8,,1802.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANNULATED 5.0 X 46MM FIXOS -,SUP-658146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA [1000108],AETNA [100010801],,,76.8,,1802.87,0.518595,35041.66656,percent of total billed charges,,,
5.0 FIXOS 48MM SCREW -,SUP-658148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA [1000108],AETNA [100010801],,,76.8,,1802.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANNULATED 5.0 X 55MM FI -,SUP-658155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA [1000108],AETNA [100010801],,,76.8,,1802.87,0.518595,35041.66656,percent of total billed charges,,,
HEADLESS COMPRESSION SCREW 5.0mm / L65mm -,SUP-658165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA [1000108],AETNA [100010801],,,76.8,,1802.87,0.518595,35041.66656,percent of total billed charges,,,
HEADLESS COMPRESSION SCREW 5.0mm / L70mm -,SUP-658170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2402.19,1681.533,AETNA [1000108],AETNA [100010801],,,76.8,,1844.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW FIXOS 5 X 70MM -,SUP-658170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA [1000108],AETNA [100010801],,,76.8,,1802.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE FIXOS 5 X 75 -,SUP-658175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA [1000108],AETNA [100010801],,,76.8,,1802.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW FIXOS 5 X 80 -,SUP-658180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA [1000108],AETNA [100010801],,,76.8,,1802.87,0.518595,35041.66656,percent of total billed charges,,,
HEADLESS COMPRESSION SCREW 7MM / L40MM ST -,SUP-658340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA [1000108],AETNA [100010801],,,76.8,,2621.06,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEADLESS COMP. 7.0MM 6.5 FIXOS -,SUP-658365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA [1000108],AETNA [100010801],,,76.8,,2621.06,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEADLESS COMP. 7.0MM 70M -,SUP-658370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA [1000108],AETNA [100010801],,,76.8,,2621.06,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEADLESS SHORT THREAD 7.0 X 75MM -,SUP-658375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA [1000108],AETNA [100010801],,,76.8,,2621.06,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEADLESS SHORT THREAD 7.0 X 90MM -,SUP-658390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA [1000108],AETNA [100010801],,,76.8,,2621.06,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEADLESS COMP. 7.0MM 12.5 FIXOS -,SUP-658425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA [1000108],AETNA [100010801],,,76.8,,2621.06,0.518595,35041.66656,percent of total billed charges,,,
HEADLESS COMPRESSION SCREW 7MM / L65MM ST -,SUP-658565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA [1000108],AETNA [100010801],,,76.8,,2621.06,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEADLESS LONG THREAD 7.0 X 70MM -,SUP-658570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA [1000108],AETNA [100010801],,,76.8,,2621.06,0.518595,35041.66656,percent of total billed charges,,,
HEADLESS COMPRESSION SCREW Ã˜7.0MM / L75MM LONG THREAD -,SUP-658575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA [1000108],AETNA [100010801],,,76.8,,2621.06,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7.0 FIXOS 80MM -,SUP-658580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA [1000108],AETNA [100010801],,,76.8,,2621.06,0.518595,35041.66656,percent of total billed charges,,,
HEADLESS COMPRESSION SCREW 7MM X 85MM LONG THREAD -,SUP-658585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA [1000108],AETNA [100010801],,,76.8,,2621.06,0.518595,35041.66656,percent of total billed charges,,,
HEADLESS COMPRESSION SCREW 7MM X25MM -,SUP-658625,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA [1000108],AETNA [100010801],,,76.8,,2621.06,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 8X20MM -,SUP-660H0820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 9X35MM -,SUP-660H0935,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X14MM LCK -,SUP-661014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X18MM LCK -,SUP-661018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X20MM LCK -,SUP-661020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X22MM LCK -,SUP-661022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X24MM LCK -,SUP-661024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X26MM LCK -,SUP-661026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X28MM LCK -,SUP-661028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X30MM LCK -,SUP-661030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X32MM LCK -,SUP-661032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X34MM LCK -,SUP-661034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X36MM LCK -,SUP-661036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X38MM LCK -,SUP-661038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X40MM LCK -,SUP-661040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1154.51,808.157,AETNA [1000108],AETNA [100010801],,,76.8,,886.66,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X42MM LCK -,SUP-661042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X44MM LCK -,SUP-661044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X46MM LCK -,SUP-661046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X48MM LCK -,SUP-661048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X50MM LCK -,SUP-661050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCK 4.0 X 55MM -,SUP-661055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X60MM LCK -,SUP-661060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X65MM LCK -,SUP-661065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X70MM LCK -,SUP-661070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X75MM LCK -,SUP-661075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X80MM LCK -,SUP-661080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X85MM LCK -,SUP-661085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X90MM LCK -,SUP-661090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X95MM LCK -,SUP-661095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA [1000108],AETNA [100010801],,,76.8,,643.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X14MM LCK -,SUP-661114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X16MM LCK -,SUP-661116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X18MM LCK -,SUP-661118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X20MM LCK -,SUP-661120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X22MM LCK -,SUP-661122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X24MM LCK -,SUP-661124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X26MM LCK -,SUP-661126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X28MM LCK -,SUP-661128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X30MM LCK -,SUP-661130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X32MM LCK -,SUP-661132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X34MM LCK -,SUP-661134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X36MM LCK -,SUP-661136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X38MM LCK -,SUP-661138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X40MM LCK -,SUP-661140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X42MM LCK -,SUP-661142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X44MM LCK -,SUP-661144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X46MM LCK -,SUP-661146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5 X 48MM LCK -,SUP-661148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X55MM LCK -,SUP-661155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X60MM LCK -,SUP-661160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,854.24,597.968,AETNA [1000108],AETNA [100010801],,,76.8,,656.06,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X65MM LCK -,SUP-661165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X70MM LCK -,SUP-661170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X75MM LCK -,SUP-661175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X80MM LCK -,SUP-661180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X85MM LCK -,SUP-661185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X90MM LCK -,SUP-661190,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X95MM LCK -,SUP-661195,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA [1000108],AETNA [100010801],,,76.8,,700.87,0.518595,35041.66656,percent of total billed charges,,,
LOCKING SCREW FLAT TIP 5.0MM T20 L10MM -,SUP-661210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2630.74,1841.518,AETNA [1000108],AETNA [100010801],,,76.8,,2020.41,0.518595,35041.66656,percent of total billed charges,,,
LOCKING SCREW FLAT TIP 5.0MM /T20 /L20 -,SUP-661220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2630.74,1841.518,AETNA [1000108],AETNA [100010801],,,76.8,,2020.41,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X8MM LCK ST PRPRSTHTC -,SUP-661308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,AETNA [1000108],AETNA [100010801],,,76.8,,812.01,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 5.0 X 10MM PERIP -,SUP-661310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,AETNA [1000108],AETNA [100010801],,,76.8,,812.01,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 5.0 X 12MM PERIP -,SUP-661312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,AETNA [1000108],AETNA [100010801],,,76.8,,812.01,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X14MM LCK ST PRPRSTHTC -,SUP-661314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,AETNA [1000108],AETNA [100010801],,,76.8,,812.01,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X16MM PERI- LCK AXSOS -,SUP-661316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,AETNA [1000108],AETNA [100010801],,,76.8,,812.01,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X16MM LCK ST PRPRSTHTC -,SUP-661316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,AETNA [1000108],AETNA [100010801],,,76.8,,812.01,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X18MM LCK ST PRPRSTHTC -,SUP-661318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,AETNA [1000108],AETNA [100010801],,,76.8,,812.01,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X20MM LCK ST PRPRSTHTC -,SUP-661320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,AETNA [1000108],AETNA [100010801],,,76.8,,812.01,0.518595,35041.66656,percent of total billed charges,,,
SCREW NON LOCKING 3.5 X 14MM -,SUP-661414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X18MM CORT TI -,SUP-661418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,,,
SCREW NON LOCKING 3.5 X 20MM -,SUP-661420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X22MM CORT TI -,SUP-661422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X24MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X26MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X28MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X30MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X32MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X34MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X36MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X38MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X40MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X42MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X44MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X46MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL 3.5 X 46 -,SUP-661447,CDM,C1713,HCPCS,278,RC,,,outpatient,,,239.99,167.993,AETNA [1000108],AETNA [100010801],,,76.8,,184.31,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X48MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X50MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X55MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X65MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X70MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X75MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661475,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X80MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X85MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X90MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTEX 3.5MM X 120MM -,SUP-661520S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA [1000108],AETNA [100010801],,,76.8,,145.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTEX TI 4.5 X 14MM -,SUP-661714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTEX SELF TAPPING 4.5 X 16 -,SUP-661716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORT 4.5 X 18 -,SUP-661718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL 4.5 X 20MM -,SUP-661720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X22MM CORT TI -,SUP-661722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORT 4.5 X 24 -,SUP-661724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORT 4.5 X 26 -,SUP-661726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORITCAL 4.5MM X 28MM -,SUP-661728,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X30MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X32MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661732,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X34MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X36MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X38MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X38MM LCK CORT VARIAX SELF TAPPING -,SUP-661738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X40MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X42MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X44MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X46MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661746,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X48MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661748,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X50MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X55MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X60MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X65MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661765,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X70MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X75MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661775,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X80MM CORT TI -,SUP-661780,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL 4.5 X 85 -,SUP-661785,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3MMX8IN ER CANC CORT VARIAX FT POLYAX ST T7 STRDRV -,SUP-661795,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA [1000108],AETNA [100010801],,,76.8,,155.95,0.518595,35041.66656,percent of total billed charges,,,
CABLE PLUG 5.0MM -,SUP-662202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1868.43,1307.901,AETNA [1000108],AETNA [100010801],,,76.8,,1434.95,0.518595,35041.66656,percent of total billed charges,,,
LOCKING SCREW 5.0MM /T20 / L24MM -,SUP-662324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,AETNA [1000108],AETNA [100010801],,,76.8,,1760.21,0.518595,35041.66656,percent of total billed charges,,,
LOCKING SCREW 5.0MM /T20 /L30MM -,SUP-662330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,AETNA [1000108],AETNA [100010801],,,76.8,,1760.21,0.518595,35041.66656,percent of total billed charges,,,
LOCKING SCREW 5.0MM /T20 / L40MM -,SUP-662340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,AETNA [1000108],AETNA [100010801],,,76.8,,1760.21,0.518595,35041.66656,percent of total billed charges,,,
LOCKING SCREW 5.0MM T20 L46MM -,SUP-662346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,AETNA [1000108],AETNA [100010801],,,76.8,,1614.8,0.518595,35041.66656,percent of total billed charges,,,
LOCKING SCREW 5.0MM T20 L50MM -,SUP-662350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,AETNA [1000108],AETNA [100010801],,,76.8,,1614.8,0.518595,35041.66656,percent of total billed charges,,,
LOCKING SCREW 5.0MM T20 L60MM -,SUP-662360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,AETNA [1000108],AETNA [100010801],,,76.8,,1614.8,0.518595,35041.66656,percent of total billed charges,,,
LOCKING SCREW 5.0MM /T20 / L65MM -,SUP-662365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,AETNA [1000108],AETNA [100010801],,,76.8,,1760.21,0.518595,35041.66656,percent of total billed charges,,,
LOCKING SCREW 5.0MM T20 L70MM -,SUP-662370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,AETNA [1000108],AETNA [100010801],,,76.8,,1614.8,0.518595,35041.66656,percent of total billed charges,,,
LOCKING SCREW 5.0MM /T20 / L75MM -,SUP-662375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,AETNA [1000108],AETNA [100010801],,,76.8,,1760.21,0.518595,35041.66656,percent of total billed charges,,,
LOCKING SCREW 5.0MM /T20 /L80MM -,SUP-662380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,AETNA [1000108],AETNA [100010801],,,76.8,,1760.21,0.518595,35041.66656,percent of total billed charges,,,
SCREW LCK 1.7 X 5 -,SUP-662505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,497.14,347.998,AETNA [1000108],AETNA [100010801],,,76.8,,381.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING T5 1.7MM X 9MM -,SUP-662509,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,AETNA [1000108],AETNA [100010801],,,76.8,,299.8,0.518595,35041.66656,percent of total billed charges,,,
LOCKING SCREW T5 1.7MM X 22MM -,SUP-662522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,497.14,347.998,AETNA [1000108],AETNA [100010801],,,76.8,,381.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE 1.7 X 6 -,SUP-662606,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,AETNA [1000108],AETNA [100010801],,,76.8,,299.8,0.518595,35041.66656,percent of total billed charges,,,
BONE SCREW T5 1.7MM X 8MM -,SUP-662608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,AETNA [1000108],AETNA [100010801],,,76.8,,299.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE 1.7 X 9 -,SUP-662609,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,AETNA [1000108],AETNA [100010801],,,76.8,,299.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.7 X 11 NON LOCKING -,SUP-662611,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,AETNA [1000108],AETNA [100010801],,,76.8,,299.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.7 X 15 -,SUP-662615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,AETNA [1000108],AETNA [100010801],,,76.8,,299.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.7 X 16 NL -,SUP-662616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,AETNA [1000108],AETNA [100010801],,,76.8,,299.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.7 X 18 NL -,SUP-662618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,AETNA [1000108],AETNA [100010801],,,76.8,,299.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW EMERGENCY 1.9 X 5 -,SUP-662705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,AETNA [1000108],AETNA [100010801],,,76.8,,299.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW EMERGENCY T5 1.9MM/L12MM 12 HOLE LEFT -,SUP-662712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,AETNA [1000108],AETNA [100010801],,,76.8,,299.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANNULATED 4.0MM X 38MM COMP -,SUP-663038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA [1000108],AETNA [100010801],,,76.8,,2983.89,0.518595,35041.66656,percent of total billed charges,,,
WASHER 5MM -,SUP-663101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,202.42,141.694,AETNA [1000108],AETNA [100010801],,,76.8,,155.46,0.518595,35041.66656,percent of total billed charges,,,
SCREW JFX CANNULATED 5 X 46MM -,SUP-663146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA [1000108],AETNA [100010801],,,76.8,,2983.89,0.518595,35041.66656,percent of total billed charges,,,
NAIL IMPCTR HD XTRCT SHRT 3.2X19MM DURACN -,SUP-6633-7-615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,376.53,263.571,AETNA [1000108],AETNA [100010801],,,76.8,,289.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW SOLID COMPRESSION 4.0MM X 36MM L -,SUP-663436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA [1000108],AETNA [100010801],,,76.8,,2983.89,0.518595,35041.66656,percent of total billed charges,,,
SCREW SOLID COMPRESSION 4.0MM X 38MM -,SUP-663438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA [1000108],AETNA [100010801],,,76.8,,2983.89,0.518595,35041.66656,percent of total billed charges,,,
COMPRESSION SCREW SOLID A 4.0MM/ L40MM -,SUP-663440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA [1000108],AETNA [100010801],,,76.8,,2983.89,0.518595,35041.66656,percent of total billed charges,,,
SCREW SOLID COMPRESSION 4 X 22 -,SUP-663442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA [1000108],AETNA [100010801],,,76.8,,2983.89,0.518595,35041.66656,percent of total billed charges,,,
4.0 SOLID COMPRESSION SCREW 48MM -,SUP-663448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA [1000108],AETNA [100010801],,,76.8,,2983.89,0.518595,35041.66656,percent of total billed charges,,,
SCREW SOLID COMPRESSION 4.0MM X L50MM -,SUP-663450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.32,2719.724,AETNA [1000108],AETNA [100010801],,,76.8,,2983.93,0.518595,35041.66656,percent of total billed charges,,,
SCREW SOLID COMPRESSION 5.0MM X 36MM L -,SUP-663536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA [1000108],AETNA [100010801],,,76.8,,2983.89,0.518595,35041.66656,percent of total billed charges,,,
SCREW SOLID COMP 5MM X 40MM -,SUP-663540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA [1000108],AETNA [100010801],,,76.8,,2983.89,0.518595,35041.66656,percent of total billed charges,,,
SCREW COMPRESSION 5 X 42 -,SUP-663542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA [1000108],AETNA [100010801],,,76.8,,2983.89,0.518595,35041.66656,percent of total billed charges,,,
5.0MM L 44MM COMPRESSION SCREW -,SUP-663544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA [1000108],AETNA [100010801],,,76.8,,2983.89,0.518595,35041.66656,percent of total billed charges,,,
COMPRESSION SCREW 5.0MM -,SUP-663546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA [1000108],AETNA [100010801],,,76.8,,2983.89,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5 X 48 MM SOLID -,SUP-663548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA [1000108],AETNA [100010801],,,76.8,,2983.89,0.518595,35041.66656,percent of total billed charges,,,
SCREW SOLID COMPRESSION 5.0MM X L50MM -,SUP-663550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA [1000108],AETNA [100010801],,,76.8,,2983.89,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 2.3MM X 16MM -,SUP-663716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,498.89,349.223,AETNA [1000108],AETNA [100010801],,,76.8,,383.15,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 2.3MM X 18MM -,SUP-663718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,498.89,349.223,AETNA [1000108],AETNA [100010801],,,76.8,,383.15,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE 2.3 X 8 -,SUP-663808,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,AETNA [1000108],AETNA [100010801],,,76.8,,301.14,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE 2.3  X 9 -,SUP-663809,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,AETNA [1000108],AETNA [100010801],,,76.8,,301.14,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE 2.3 X 10 -,SUP-663810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,AETNA [1000108],AETNA [100010801],,,76.8,,301.14,0.518595,35041.66656,percent of total billed charges,,,
SCREW NON LOCKING 2.3MM X 13MM -,SUP-663813,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,AETNA [1000108],AETNA [100010801],,,76.8,,301.14,0.518595,35041.66656,percent of total billed charges,,,
SCREW NON-LOCKING 2.3MM 16MM -,SUP-663816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,AETNA [1000108],AETNA [100010801],,,76.8,,301.14,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE 2.3 X 20 -,SUP-663820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,AETNA [1000108],AETNA [100010801],,,76.8,,301.14,0.518595,35041.66656,percent of total billed charges,,,
SCREW EMERGENCY  2.5 X 6 -,SUP-663906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,AETNA [1000108],AETNA [100010801],,,76.8,,301.14,0.518595,35041.66656,percent of total billed charges,,,
SCREW EMERGENCY 2.5 X 8 -,SUP-663908,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,AETNA [1000108],AETNA [100010801],,,76.8,,301.14,0.518595,35041.66656,percent of total billed charges,,,
CORTEX SCREW DIA 4.0MM L38MM -,SUP-666138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,AETNA [1000108],AETNA [100010801],,,76.8,,301.14,0.518595,35041.66656,percent of total billed charges,,,
CANLTD SCRW 16MM THREAD DIA 6.5MM L45MM -,SUP-666445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,AETNA [1000108],AETNA [100010801],,,76.8,,1756.14,0.518595,35041.66656,percent of total billed charges,,,
CANLTD SCREW 16MM THREAD DIA 6.5MM L50MM -,SUP-666450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,AETNA [1000108],AETNA [100010801],,,76.8,,1756.14,0.518595,35041.66656,percent of total billed charges,,,
CANLTD SCREW 16MM THREAD DIA 6.5MM L65MM -,SUP-666465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,AETNA [1000108],AETNA [100010801],,,76.8,,1756.14,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANNULATED 6.5 X 70 -,SUP-666470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,AETNA [1000108],AETNA [100010801],,,76.8,,1756.14,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANNULATED 6.5 X 80 -,SUP-666480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,AETNA [1000108],AETNA [100010801],,,76.8,,1756.14,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANNULATED 6.5 X 85 -,SUP-666485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,AETNA [1000108],AETNA [100010801],,,76.8,,1756.14,0.518595,35041.66656,percent of total billed charges,,,
SPACER MOLD LG FEMORAL 53A/P X 75M/L -,SUP-669-1075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6663.08,4664.156,AETNA [1000108],AETNA [100010801],,,76.8,,5117.25,0.518595,35041.66656,percent of total billed charges,,,
GRIP CBL 1.6MM DLMLS VITAL -,SUP-6704-0-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3931.1,2751.77,AETNA [1000108],AETNA [100010801],,,76.8,,3019.08,0.518595,35041.66656,percent of total billed charges,,,
CABLE ORTHO 1.6MM DLMLS VITAL MED GRP + 2 -,SUP-6704-0-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3931.1,2751.77,AETNA [1000108],AETNA [100010801],,,76.8,,3019.08,0.518595,35041.66656,percent of total billed charges,,,
GRIP LARGE W/2 CABLES DALL MIL -,SUP-6704-0-310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3931.1,2751.77,AETNA [1000108],AETNA [100010801],,,76.8,,3019.08,0.518595,35041.66656,percent of total billed charges,,,
CABLE ORTHO DLMLS 1.6MM VITAL BEAD SM SLV -,SUP-6704-0-420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,AETNA [1000108],AETNA [100010801],,,76.8,,1228.32,0.518595,35041.66656,percent of total billed charges,,,
CABLE ORTHO DLMLS 2MM VITAL MED SLV -,SUP-6704-0-510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,,,
DALL-MILES 2.0MM VIT BEADED CABLE/SLEEVE SET -,SUP-6704-0-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,AETNA [1000108],AETNA [100010801],,,76.8,,1228.32,0.518595,35041.66656,percent of total billed charges,,,
SET CABLE SLEEVE BEADED  2.0 D -,SUP-6704-0-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,AETNA [1000108],AETNA [100010801],,,76.8,,1228.32,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN DLMLS 100MM GRP VITAL MED 2MM CBLX2 -,SUP-6704-3-081,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4408.24,3085.768,AETNA [1000108],AETNA [100010801],,,76.8,,3385.53,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN DLMLS 150MM GRP VITAL MED 2MM CBLX2 -,SUP-6704-3-082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5744.68,4021.276,AETNA [1000108],AETNA [100010801],,,76.8,,4411.91,0.518595,35041.66656,percent of total billed charges,,,
PLATE TROC DLMLS 110MM GRP LRG W/2 CBS -,SUP-6704-3-091,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4408.24,3085.768,AETNA [1000108],AETNA [100010801],,,76.8,,3385.53,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN DLMLS 160MM GRP VITAL LRG 2MM CBLX2 -,SUP-6704-3-092,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5744.68,4021.276,AETNA [1000108],AETNA [100010801],,,76.8,,4411.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW CENTURION 3.5 X 12 -,SUP-69-3312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW CENTURION 3.5 X 18 -,SUP-69-3318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW CENTURION 3.5 X 12 -,SUP-69-3412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW CENTURION 4.0 X 14 -,SUP-69-3414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW CENTURION 4.0 X 30 -,SUP-69-3430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW CENTURION 4.5 X 30 -,SUP-69-3530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW CENTURION 5.0 X 30 -,SUP-69-3630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
STAPLE INTNL 12X23MM VITAL ELLISON LF -,SUP-6982-1-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1703.05,1192.135,AETNA [1000108],AETNA [100010801],,,76.8,,1307.94,0.518595,35041.66656,percent of total billed charges,,,
STAPLE INTNL 14X23MM VITAL ELLISON LF -,SUP-6982-2-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1602.87,1122.009,AETNA [1000108],AETNA [100010801],,,76.8,,1231,0.518595,35041.66656,percent of total billed charges,,,
GRAFT BONE I FACTOR 2.5CC ALLOGRAFT PUTTY SYRINGE -,SUP-700-025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA [1000108],AETNA [100010801],,,76.8,,4726.12,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 8HL STR -,SUP-70-0095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA [1000108],AETNA [100010801],,,76.8,,4853.24,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 8HL STR -,SUP-70-0096,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA [1000108],AETNA [100010801],,,76.8,,4853.24,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 3.5MM 9HL LCK TI NS RT -,SUP-70-0116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.27,4447.289,AETNA [1000108],AETNA [100010801],,,76.8,,4879.31,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 3.5MM 9HL LCK TI NS LT -,SUP-70-0117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.27,4447.289,AETNA [1000108],AETNA [100010801],,,76.8,,4879.31,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 2.3MM 16HL LCK TI NS -,SUP-70-0124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6989.87,4892.909,AETNA [1000108],AETNA [100010801],,,76.8,,5368.22,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 2.3MM 13HL LCK TI NS -,SUP-70-0126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.27,4447.289,AETNA [1000108],AETNA [100010801],,,76.8,,4879.31,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 8HL LT CLAV LPRO TI STR NS -,SUP-70-0286,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA [1000108],AETNA [100010801],,,76.8,,4853.24,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 8HL RT CLAV LPRO TI STR NS -,SUP-70-0287,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA [1000108],AETNA [100010801],,,76.8,,4853.24,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN F/ELB PLATE SYS 8HL LCK TI LRG NS -,SUP-70-0289,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA [1000108],AETNA [100010801],,,76.8,,4853.24,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN F/ELB PLATE SYS 10HL LCK TI NS -,SUP-70-0294,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA [1000108],AETNA [100010801],,,76.8,,4853.24,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN F/ELB PLATE SYS 6HL LCK TI NS LT CLVCL -,SUP-70-0296,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA [1000108],AETNA [100010801],,,76.8,,4853.24,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN F/ELB PLATE SYS 6HL LCK TI NS RT CLVCL -,SUP-70-0297,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA [1000108],AETNA [100010801],,,76.8,,4853.24,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 8HL LT CLAV NRW-PRFL TI STR NS -,SUP-70-0298,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA [1000108],AETNA [100010801],,,76.8,,4853.24,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 8HL RT CLAV NRW-PRFL TI STR NS -,SUP-70-0299,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA [1000108],AETNA [100010801],,,76.8,,4853.24,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 8HL CONTR LCK TI LRG NS LT -,SUP-70-0300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA [1000108],AETNA [100010801],,,76.8,,4853.24,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 8HL CONTR LCK TI LRG NS RT -,SUP-70-0301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA [1000108],AETNA [100010801],,,76.8,,4853.24,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 65MM 3HL CONTR LCK TI STD NS -,SUP-70-0302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6535.76,4575.032,AETNA [1000108],AETNA [100010801],,,76.8,,5019.46,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 110MM 7HL CONTR LCK TI STD NS -,SUP-70-0306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7414.27,5189.989,AETNA [1000108],AETNA [100010801],,,76.8,,5694.16,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 90MM 5HL TAP-LCK TI EXTEND NS -,SUP-70-0313,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6535.76,4575.032,AETNA [1000108],AETNA [100010801],,,76.8,,5019.46,0.518595,35041.66656,percent of total billed charges,,,
GUIDEPIN ORTHO 2MM ASNIS III THRD -,SUP-7007-1300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,AETNA [1000108],AETNA [100010801],,,76.8,,398.84,0.518595,35041.66656,percent of total billed charges,,,
K-WIRE ASNIS III 3.2 -,SUP-702463S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,505.08,353.556,AETNA [1000108],AETNA [100010801],,,76.8,,387.9,0.518595,35041.66656,percent of total billed charges,,,
IRON BENDING -,SUP-702901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.85,795.795,AETNA [1000108],AETNA [100010801],,,76.8,,873.1,0.518595,35041.66656,percent of total billed charges,,,
AXSOS 5.0 ADAPTOR NUT -,SUP-702977,CDM,C1713,HCPCS,278,RC,,,outpatient,,,559.11,391.377,AETNA [1000108],AETNA [100010801],,,76.8,,429.4,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOW PROFILE HEX 6.5 X 15 -,SUP-7030-6515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEX LOW PROFILE 6.5MM X 20MM -,SUP-7030-6520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MM LOW PROFILE HEX -,SUP-7030-6525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEX 6.5MM X 30MM LOW PROFILE -,SUP-7030-6530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEX 6.5MM X 35MM LOW PROFILE -,SUP-7030-6535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
6.5x40MM LOW PROFILE HEX SCREW -,SUP-7030-6540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
6.5X45MM LOW PROFILE HEX SCREW -,SUP-7030-6545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
6.5x50MM LOW PROFILE HEX SCREW -,SUP-7030-6550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOW PROFILE HEX 6.5MM x 55MM -,SUP-7030-6555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
IMPLANT HIP 7X35MM POR TI PLASM SPRY SCRILAC IFUSE STRL -,SUP-7035-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,AETNA [1000108],AETNA [100010801],,,76.8,,8355.14,0.518595,35041.66656,percent of total billed charges,,,
GUIDE WIRE WITH CALIBRATION 3.2MM X 230MM QUICK RELEASE -,SUP-705237,CDM,C1713,HCPCS,278,RC,,,outpatient,,,606.84,424.788,AETNA [1000108],AETNA [100010801],,,76.8,,466.05,0.518595,35041.66656,percent of total billed charges,,,
ELEVATOR PERIOSTEAL 6MM ROUND EDGE -,SUP-705294,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1361.01,952.707,AETNA [1000108],AETNA [100010801],,,76.8,,1045.26,0.518595,35041.66656,percent of total billed charges,,,
IMPLANT HIP 7X65MM POR TI PLASM SPRY SCRILAC IFUSE STRL -,SUP-7065-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,AETNA [1000108],AETNA [100010801],,,76.8,,8355.14,0.518595,35041.66656,percent of total billed charges,,,
PIN EXTFIX 3X120MM 16MM THRD COVE PNT -,SUP-71022001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,AETNA [1000108],AETNA [100010801],,,76.8,,1488.65,0.518595,35041.66656,percent of total billed charges,,,
PIN EXTFIX 3X120MM 22MM THRD COVE PNT -,SUP-71022002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,AETNA [1000108],AETNA [100010801],,,76.8,,1488.65,0.518595,35041.66656,percent of total billed charges,,,
PIN EXTFIX 3X120MM 28MM THRD COVE PNT -,SUP-71022003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,AETNA [1000108],AETNA [100010801],,,76.8,,1488.65,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X70MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X80MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X85MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X95MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X110MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X130MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA [1000108],AETNA [100010801],,,76.8,,2151.64,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 58MM 3.5MM 5HL RECON STR -,SUP-71140105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4158.44,2910.908,AETNA [1000108],AETNA [100010801],,,76.8,,3193.68,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 70MM 3.5MM 6HL RECON STR -,SUP-71140106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4651.85,3256.295,AETNA [1000108],AETNA [100010801],,,76.8,,3572.62,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 82MM 3.5MM 7HL RECON STR -,SUP-71140107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4446.01,3112.207,AETNA [1000108],AETNA [100010801],,,76.8,,3414.54,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 94MM 3.5MM 8HL RECON STR -,SUP-71140108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5084.1,3558.87,AETNA [1000108],AETNA [100010801],,,76.8,,3904.59,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 75MM 3.5MM 6HL SM T-SHP RT ANG -,SUP-71140406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2349.66,1644.762,AETNA [1000108],AETNA [100010801],,,76.8,,1804.54,0.518595,35041.66656,percent of total billed charges,,,
WASHER ORTHO 3.7X7MM SS -,SUP-71143107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,441.48,309.036,AETNA [1000108],AETNA [100010801],,,76.8,,339.06,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 87MM 9HL Y STRL TMPLT -,SUP-71144012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7101.27,4970.889,AETNA [1000108],AETNA [100010801],,,76.8,,5453.78,0.518595,35041.66656,percent of total billed charges,,,
TROCAR PIN GEN 1/8 X 3 -,SUP-71210002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.63,108.241,AETNA [1000108],AETNA [100010801],,,76.8,,118.76,0.518595,35041.66656,percent of total billed charges,,,
GUIDEPIN ORTHO 3MM GENESIS 12.5CM TROC TIP -,SUP-71210003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.63,108.241,AETNA [1000108],AETNA [100010801],,,76.8,,118.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MM MINI 16MM CORT TC-100 FT HEX HEAD SS -,SUP-71220016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,359.67,251.769,AETNA [1000108],AETNA [100010801],,,76.8,,276.23,0.518595,35041.66656,percent of total billed charges,,,
SCREW 15MM REF SPHER HEAD -,SUP-71332515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,811.07,567.749,AETNA [1000108],AETNA [100010801],,,76.8,,622.9,0.518595,35041.66656,percent of total billed charges,,,
SCREW 20MM REF SPER HEAD -,SUP-71332520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,811.07,567.749,AETNA [1000108],AETNA [100010801],,,76.8,,622.9,0.518595,35041.66656,percent of total billed charges,,,
CABLE ORTHO 2MM ACCORD COCR -,SUP-71340020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,977.36,684.152,AETNA [1000108],AETNA [100010801],,,76.8,,750.61,0.518595,35041.66656,percent of total billed charges,,,
INSERT PS LGN XLPE SZ 3-4 11MM -,SUP-71453247,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4520.12,3164.084,AETNA [1000108],AETNA [100010801],,,76.8,,3471.45,0.518595,35041.66656,percent of total billed charges,,,
ENDCAP ORTHO 0MM TRIGEN STRL -,SUP-71634000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2293.1,1605.17,AETNA [1000108],AETNA [100010801],,,76.8,,1761.1,0.518595,35041.66656,percent of total billed charges,,,
ENDCAP PROT 5MM TI STRL TRIGEN F/OB GYNAECOLOGICAL PROC TIB -,SUP-71634005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2293.1,1605.17,AETNA [1000108],AETNA [100010801],,,76.8,,1761.1,0.518595,35041.66656,percent of total billed charges,,,
ENDCAP ORTHO 20MM TRIGEN STRL -,SUP-71634020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2293.1,1605.17,AETNA [1000108],AETNA [100010801],,,76.8,,1761.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX25MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2401.07,1680.749,AETNA [1000108],AETNA [100010801],,,76.8,,1844.02,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX30MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA [1000108],AETNA [100010801],,,76.8,,1883.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX35MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642135,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA [1000108],AETNA [100010801],,,76.8,,1883.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX40MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA [1000108],AETNA [100010801],,,76.8,,1883.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX45MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA [1000108],AETNA [100010801],,,76.8,,1883.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX55MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA [1000108],AETNA [100010801],,,76.8,,1883.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MMX65MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA [1000108],AETNA [100010801],,,76.8,,1883.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5MMX20MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA [1000108],AETNA [100010801],,,76.8,,1883.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5MMX25MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA [1000108],AETNA [100010801],,,76.8,,1883.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5MMX35MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA [1000108],AETNA [100010801],,,76.8,,1883.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5MMX50MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA [1000108],AETNA [100010801],,,76.8,,1883.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5MMX60MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA [1000108],AETNA [100010801],,,76.8,,1883.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5MMX65MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642265,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA [1000108],AETNA [100010801],,,76.8,,1883.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5MMX75MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642275,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA [1000108],AETNA [100010801],,,76.8,,1883.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X35MM TRIGEN -,SUP-71645035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA [1000108],AETNA [100010801],,,76.8,,1883.51,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X45MM TRIGEN -,SUP-71645045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA [1000108],AETNA [100010801],,,76.8,,1883.51,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10X380MM TRIGEN TAN CANN LT TROCH FEM TI ALY ANTGRD -,SUP-71647238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15450.91,10815.637,AETNA [1000108],AETNA [100010801],,,76.8,,11866.3,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11.5X380MM TRIGEN TAN CANN LT TROCH FEM TI ALY -,SUP-71647338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15450.91,10815.637,AETNA [1000108],AETNA [100010801],,,76.8,,11866.3,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10X320MM TRIGEN META-NAIL CANN DIST FEM TI ALY RTRGD -,SUP-71653032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14208.35,9945.845,AETNA [1000108],AETNA [100010801],,,76.8,,10912.01,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 8.5X330MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655033,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA [1000108],AETNA [100010801],,,76.8,,10663.07,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 8.5X340MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA [1000108],AETNA [100010801],,,76.8,,10663.07,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 8.5X350MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA [1000108],AETNA [100010801],,,76.8,,10663.07,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10X280MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA [1000108],AETNA [100010801],,,76.8,,10663.07,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10X290MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655129,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA [1000108],AETNA [100010801],,,76.8,,10663.07,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10MMX30CM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA [1000108],AETNA [100010801],,,76.8,,10663.07,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10X310MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655131,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA [1000108],AETNA [100010801],,,76.8,,10663.07,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10X320MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA [1000108],AETNA [100010801],,,76.8,,10663.07,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10X340MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA [1000108],AETNA [100010801],,,76.8,,10663.07,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10X350MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655135,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA [1000108],AETNA [100010801],,,76.8,,10663.07,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10MMX37CM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655137,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA [1000108],AETNA [100010801],,,76.8,,10663.07,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11.5X300MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA [1000108],AETNA [100010801],,,76.8,,10663.07,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11.5X360MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA [1000108],AETNA [100010801],,,76.8,,10663.07,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11.5X390MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655239,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA [1000108],AETNA [100010801],,,76.8,,10663.07,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11.5MMX40CM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA [1000108],AETNA [100010801],,,76.8,,10663.07,0.518595,35041.66656,percent of total billed charges,,,
GUIDEPIN ORTHO 3.2MM TRIGEN 343MM THRD BRAD TIP -,SUP-71674130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1491.03,1043.721,AETNA [1000108],AETNA [100010801],,,76.8,,1145.11,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10X180MM TRIGEN INTERTAN 1.5 CANN TROCH FEM TI 125DG -,SUP-71675201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,AETNA [1000108],AETNA [100010801],,,76.8,,10026.89,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11.5X180MM TRIGEN INTERTAN 1.5 CANN TROCH FEM TI -,SUP-71675202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,AETNA [1000108],AETNA [100010801],,,76.8,,10026.89,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 13X180MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,AETNA [1000108],AETNA [100010801],,,76.8,,10026.89,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,AETNA [1000108],AETNA [100010801],,,76.8,,10026.89,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11.5X200MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,AETNA [1000108],AETNA [100010801],,,76.8,,10026.89,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 13X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,AETNA [1000108],AETNA [100010801],,,76.8,,10026.89,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10X180MM TRIGEN INTERTAN 1.5 CANN TROCH FEM TI 130DG -,SUP-71675207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,AETNA [1000108],AETNA [100010801],,,76.8,,10026.89,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11.5MM 180MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP -,SUP-71675208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,AETNA [1000108],AETNA [100010801],,,76.8,,10026.89,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 13X180MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71675209,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,AETNA [1000108],AETNA [100010801],,,76.8,,10026.89,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71675210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,AETNA [1000108],AETNA [100010801],,,76.8,,10026.89,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10X320MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP -,SUP-71675219,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10MMX32CM TRIGEN INTERTAN 1.5 CANN INTST HIP TI -,SUP-71675220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675222,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CAN LT INTS HIP TI LIME -,SUP-71675223,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI125 -,SUP-71675224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10X380MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10X400MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP -,SUP-71675227,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11.5X320MM TRIGEN INTERTAN 1.5 CANN RT INTS HIP TI.. -,SUP-71675242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71675244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11.5X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675245,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71675246,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI_ -,SUP-71675250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11.5X420MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675251,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI130 -,SUP-71675268,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 13X280MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 13X320MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 13MMX32CM TRIGEN INTERTAN 1.5 CANN INTST HIP TI -,SUP-71675408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 13X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 13X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 13X180MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71675412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 13X380MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675413,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 13X400MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675415,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 13X400MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 13X440MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10X320MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71676507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TIRSE -,SUP-71676510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71676511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676513,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10X380MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11.5X320MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI- -,SUP-71676552,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTS HIP TI.. -,SUP-71676553,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI- -,SUP-71676554,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11.5MMX36CM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71676555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11.5X360MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11.5X380MM TRIGEN INTERTAN 1.5 CANN LT INTST TI -,SUP-71676557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11.5MMX38CM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71676558,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11.5X400MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 13X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71676598,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 13X360MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 13X380MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71676602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA [1000108],AETNA [100010801],,,76.8,,13387.61,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 70MM/75MM -,SUP-71677075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,AETNA [1000108],AETNA [100010801],,,76.8,,4900.49,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 75MM/80MM -,SUP-71677080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,AETNA [1000108],AETNA [100010801],,,76.8,,4900.49,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 80MM/85MM -,SUP-71677085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,AETNA [1000108],AETNA [100010801],,,76.8,,4900.49,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 85MM/90MM -,SUP-71677090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,AETNA [1000108],AETNA [100010801],,,76.8,,4900.49,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 90MM/95MM -,SUP-71677095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,AETNA [1000108],AETNA [100010801],,,76.8,,4900.49,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI_ -,SUP-71677100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,AETNA [1000108],AETNA [100010801],,,76.8,,4900.49,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI- -,SUP-71677105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,AETNA [1000108],AETNA [100010801],,,76.8,,4900.49,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI.. -,SUP-71677110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,AETNA [1000108],AETNA [100010801],,,76.8,,4900.49,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI. -,SUP-71677115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,AETNA [1000108],AETNA [100010801],,,76.8,,4900.49,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 11MM TRIGEN INTERTAN LAG 100MM -,SUP-71678010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,AETNA [1000108],AETNA [100010801],,,76.8,,3936.21,0.518595,35041.66656,percent of total billed charges,,,
SCREW 11X110MM LAG TRIGEN INTERTAN -,SUP-71678011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,AETNA [1000108],AETNA [100010801],,,76.8,,3936.21,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 11X115MM TRIGEN INTERTAN SBTRCHNTRC TI -,SUP-71678015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,AETNA [1000108],AETNA [100010801],,,76.8,,3936.21,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 11MM TRIGEN INTERTAN LAG 85MM -,SUP-71678085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,AETNA [1000108],AETNA [100010801],,,76.8,,3936.21,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 11MM TRIGEN INTERTAN LAG 90MM -,SUP-71678090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,AETNA [1000108],AETNA [100010801],,,76.8,,3936.21,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 11MM TRIGEN INTERTAN LAG 95MM -,SUP-71678095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,AETNA [1000108],AETNA [100010801],,,76.8,,3936.21,0.518595,35041.66656,percent of total billed charges,,,
GUIDEPIN ORTHO 3.2MMX24.8CM THRD DRILL TIP -,SUP-71751147,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,AETNA [1000108],AETNA [100010801],,,76.8,,1488.65,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X20MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,AETNA [1000108],AETNA [100010801],,,76.8,,1508.39,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X22MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,AETNA [1000108],AETNA [100010801],,,76.8,,1508.39,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X24MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,AETNA [1000108],AETNA [100010801],,,76.8,,1508.39,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X30MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,AETNA [1000108],AETNA [100010801],,,76.8,,1508.39,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X24MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA [1000108],AETNA [100010801],,,76.8,,1824.28,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X26MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA [1000108],AETNA [100010801],,,76.8,,1824.28,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X30MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA [1000108],AETNA [100010801],,,76.8,,1824.28,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X32MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA [1000108],AETNA [100010801],,,76.8,,1824.28,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X34MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA [1000108],AETNA [100010801],,,76.8,,1824.28,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X36MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA [1000108],AETNA [100010801],,,76.8,,1824.28,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X38MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA [1000108],AETNA [100010801],,,76.8,,1824.28,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X40MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA [1000108],AETNA [100010801],,,76.8,,1824.28,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X42MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA [1000108],AETNA [100010801],,,76.8,,1824.28,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X44MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA [1000108],AETNA [100010801],,,76.8,,1824.28,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X46MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA [1000108],AETNA [100010801],,,76.8,,1824.28,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 8/ 7MMLNGX260MM TRIGEN CANN PROX HUM TI ALY -,SUP-71770826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,AETNA [1000108],AETNA [100010801],,,76.8,,10704.56,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 9/ 7.5MMLNGX240MM TRIGEN CANN PROX HUM TI ALY -,SUP-71770924,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,AETNA [1000108],AETNA [100010801],,,76.8,,10704.56,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10/ 8.5MMLNGX220MM TRIGEN CANN PROX HUM TI ALY -,SUP-71771022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,AETNA [1000108],AETNA [100010801],,,76.8,,10704.56,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10/ 8.5MMLNGX240MM TRIGEN CANN PROX HUM TI ALY -,SUP-71771024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,AETNA [1000108],AETNA [100010801],,,76.8,,10704.56,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 10/ 8.5MMLNGX280MM TRIGEN CANN PROX HUM TI ALY -,SUP-71771028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,AETNA [1000108],AETNA [100010801],,,76.8,,10704.56,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC 193MM 4.5MM 8HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16207.25,11345.075,AETNA [1000108],AETNA [100010801],,,76.8,,12447.17,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC 286MM 4.5MM 13HL CONTR SCALLP LCK SS BVL LT -,SUP-71800013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17251.71,12076.197,AETNA [1000108],AETNA [100010801],,,76.8,,13249.31,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC 342MM 4.5MM 16HL CONTR SCALLP LCK SS BVL LT -,SUP-71800016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17575.86,12303.102,AETNA [1000108],AETNA [100010801],,,76.8,,13498.26,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC 193MM 4.5MM 8HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16207.25,11345.075,AETNA [1000108],AETNA [100010801],,,76.8,,12447.17,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC 342MM 4.5MM 16HL CONTR SCALLP LCK SS BVL RT -,SUP-71800116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17575.86,12303.102,AETNA [1000108],AETNA [100010801],,,76.8,,13498.26,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC 94MM 4.5MM 4HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17341.75,12139.225,AETNA [1000108],AETNA [100010801],,,76.8,,13318.46,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC 130MM 4.5MM 6HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17575.86,12303.102,AETNA [1000108],AETNA [100010801],,,76.8,,13498.26,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 93MM 4.5MM 3HL CONTR SCALLP LCK BVL TIP -,SUP-71801603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17053.62,11937.534,AETNA [1000108],AETNA [100010801],,,76.8,,13097.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X10MM CORT PERILOC ST SS -,SUP-71804010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X12MM CORT PERILOC ST SS -,SUP-71804012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X14MM CORT PERILOC ST SS -,SUP-71804014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X16MM CORT PERILOC ST SS -,SUP-71804016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X18MM CORT PERILOC ST SS -,SUP-71804018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X20MM CORT PERILOC ST SS -,SUP-71804020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X24MM CORT PERILOC ST SS -,SUP-71804024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X32MM CORT PERILOC ST SS -,SUP-71804032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X34MM CORT PERILOC ST SS -,SUP-71804034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X36MM CORT PERILOC ST SS -,SUP-71804036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X38MM CORT PERILOC ST SS -,SUP-71804038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X40MM CORT PERILOC ST SS -,SUP-71804040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X50MM CORT PERILOC ST SS -,SUP-71804050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X55MM CORT PERILOC ST SS -,SUP-71804055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X60MM CORT PERILOC ST SS -,SUP-71804060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X12MM LCK CORT PERILOC ST SS -,SUP-71805012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1866.36,1306.452,AETNA [1000108],AETNA [100010801],,,76.8,,1433.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X20MM LCK CORT PERILOC ST SS -,SUP-71805020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1866.36,1306.452,AETNA [1000108],AETNA [100010801],,,76.8,,1433.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X14MM CANC PERILOC FT SS -,SUP-71805214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,496.09,347.263,AETNA [1000108],AETNA [100010801],,,76.8,,381,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X36MM CORT PERILOC ST SS -,SUP-71806036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X38MM CORT PERILOC ST SS -,SUP-71806038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X40MM CORT PERILOC ST SS -,SUP-71806040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X42MM NLCKG CORT PERILOC ST SS -,SUP-71806042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X46MM NLCKG CORT PERILOC ST SS -,SUP-71806046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X50MM NLCKG CORT PERILOC ST SS -,SUP-71806050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X70MM NLCKG CORT PERILOC ST SS -,SUP-71806070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X32MM LCK CORT PERILOC ST SS -,SUP-71807032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,AETNA [1000108],AETNA [100010801],,,76.8,,1705.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X34MM LCK CORT PERILOC ST SS PERIART -,SUP-71807034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,AETNA [1000108],AETNA [100010801],,,76.8,,1705.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X36MM LCK CORT PERILOC ST SS PERIART -,SUP-71807036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,AETNA [1000108],AETNA [100010801],,,76.8,,1705.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X38MM LCK CORT PERILOC ST SS -,SUP-71807038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,AETNA [1000108],AETNA [100010801],,,76.8,,1705.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X48MM LCK CORT PERILOC ST SS -,SUP-71807048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,AETNA [1000108],AETNA [100010801],,,76.8,,1705.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X56MM LCK CORT PERILOC ST SS -,SUP-71807056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,AETNA [1000108],AETNA [100010801],,,76.8,,1705.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X58MM LCK CORT PERILOC ST SS -,SUP-71807058,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,AETNA [1000108],AETNA [100010801],,,76.8,,1705.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X60MM LCK CORT PERILOC ST SS PERIART -,SUP-71807060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,AETNA [1000108],AETNA [100010801],,,76.8,,1705.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X74MM LCK CORT PERILOC ST SS -,SUP-71807074,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,AETNA [1000108],AETNA [100010801],,,76.8,,1705.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.7X65MM LCK CANN PERILOC FT SS -,SUP-71808065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA [1000108],AETNA [100010801],,,76.8,,2699.34,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC 193MM 4.5MM 13HL CONTR SCALLP LCK SS BVL -,SUP-71820008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12497.59,8748.313,AETNA [1000108],AETNA [100010801],,,76.8,,9598.15,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 230MM 4.5MM 10HL CONTR SCALLP LCK SS BVL TIP -,SUP-71820010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12767.71,8937.397,AETNA [1000108],AETNA [100010801],,,76.8,,9805.6,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC 98MM 3.5MM 6HL CONTR SCALLP LCK SS BVL TIP -,SUP-71820506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13524.05,9466.835,AETNA [1000108],AETNA [100010801],,,76.8,,10386.47,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 196MM 3.5MM 10HL CONTR SCALLP LCK BVL TIP -,SUP-71821010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15522.94,10866.058,AETNA [1000108],AETNA [100010801],,,76.8,,11921.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X34MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA [1000108],AETNA [100010801],,,76.8,,778.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X36MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA [1000108],AETNA [100010801],,,76.8,,778.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X40MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA [1000108],AETNA [100010801],,,76.8,,778.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X50MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA [1000108],AETNA [100010801],,,76.8,,778.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X55MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA [1000108],AETNA [100010801],,,76.8,,778.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X60MM LCK PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG -,SUP-71821160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA [1000108],AETNA [100010801],,,76.8,,778.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX6MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA [1000108],AETNA [100010801],,,76.8,,1409.67,0.518595,35041.66656,percent of total billed charges,,,
RETRACTOR EYELID DSMRS 1.12MMX5.5IN STN FNSH LID V. MUELLER -,SUP-71821208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA [1000108],AETNA [100010801],,,76.8,,1409.67,0.518595,35041.66656,percent of total billed charges,,,
RETRACTOR LNG ALLISON 12.25IN 2.125IN BLD SS F/CV V. MUELLER -,SUP-71821210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA [1000108],AETNA [100010801],,,76.8,,1409.67,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX12MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA [1000108],AETNA [100010801],,,76.8,,1409.67,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX14MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA [1000108],AETNA [100010801],,,76.8,,1409.67,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX16MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA [1000108],AETNA [100010801],,,76.8,,1409.67,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX18MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821218,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA [1000108],AETNA [100010801],,,76.8,,1409.67,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX22MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821222,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA [1000108],AETNA [100010801],,,76.8,,1409.67,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX24MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA [1000108],AETNA [100010801],,,76.8,,1409.67,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX26MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821226,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA [1000108],AETNA [100010801],,,76.8,,1409.67,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX28MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA [1000108],AETNA [100010801],,,76.8,,1409.67,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX30MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA [1000108],AETNA [100010801],,,76.8,,1409.67,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX34MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA [1000108],AETNA [100010801],,,76.8,,1409.67,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX36MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA [1000108],AETNA [100010801],,,76.8,,1409.67,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX40MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA [1000108],AETNA [100010801],,,76.8,,1409.67,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC 89MM 3.5MM 3HL CONTR LCK SS BVL TIP -,SUP-71821303,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14982.7,10487.89,AETNA [1000108],AETNA [100010801],,,76.8,,11506.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX6MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM STD -,SUP-71821306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA [1000108],AETNA [100010801],,,76.8,,274.52,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX8MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM STD -,SUP-71821308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA [1000108],AETNA [100010801],,,76.8,,274.52,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX10MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA [1000108],AETNA [100010801],,,76.8,,274.52,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX12MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA [1000108],AETNA [100010801],,,76.8,,274.52,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX14MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA [1000108],AETNA [100010801],,,76.8,,274.52,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX16MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA [1000108],AETNA [100010801],,,76.8,,274.52,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX18MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA [1000108],AETNA [100010801],,,76.8,,274.52,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX20MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA [1000108],AETNA [100010801],,,76.8,,274.52,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX22MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA [1000108],AETNA [100010801],,,76.8,,274.52,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX24MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA [1000108],AETNA [100010801],,,76.8,,274.52,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX26MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA [1000108],AETNA [100010801],,,76.8,,274.52,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX28MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA [1000108],AETNA [100010801],,,76.8,,274.52,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX32MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA [1000108],AETNA [100010801],,,76.8,,274.52,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX34MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA [1000108],AETNA [100010801],,,76.8,,274.52,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX36MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA [1000108],AETNA [100010801],,,76.8,,274.52,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX38MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA [1000108],AETNA [100010801],,,76.8,,274.52,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX40MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA [1000108],AETNA [100010801],,,76.8,,274.52,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX44MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA [1000108],AETNA [100010801],,,76.8,,274.52,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX46MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA [1000108],AETNA [100010801],,,76.8,,274.52,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX50MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA [1000108],AETNA [100010801],,,76.8,,274.52,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC 89MM 3.5MM 3HL CONTR LCK SS BVL TIP NS -,SUP-71821403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14982.7,10487.89,AETNA [1000108],AETNA [100010801],,,76.8,,11506.71,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC 115MM 3.5MM 5HL CONTR LCK SS BVL TIP -,SUP-71821405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15414.89,10790.423,AETNA [1000108],AETNA [100010801],,,76.8,,11838.64,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC 79MM 2.7/3.5MM 5HL CONTR LCK SS BVL TIP -,SUP-71821805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11921.33,8344.931,AETNA [1000108],AETNA [100010801],,,76.8,,9155.58,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5MMX10MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA [1000108],AETNA [100010801],,,76.8,,778.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5MMX12MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA [1000108],AETNA [100010801],,,76.8,,778.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5MMX14MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA [1000108],AETNA [100010801],,,76.8,,778.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5MMX16MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA [1000108],AETNA [100010801],,,76.8,,778.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX18MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA [1000108],AETNA [100010801],,,76.8,,778.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5MMX20MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA [1000108],AETNA [100010801],,,76.8,,778.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5MMX38MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA [1000108],AETNA [100010801],,,76.8,,778.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX40MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA [1000108],AETNA [100010801],,,76.8,,778.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X10MM LCK CORT PERILOC FT ST SS NS -,SUP-71822310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA [1000108],AETNA [100010801],,,76.8,,1006.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X12MM LCK CORT PERILOC FT ST SS NS -,SUP-71822312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA [1000108],AETNA [100010801],,,76.8,,1006.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X14MM LCK CORT PERILOC FT ST SS NS -,SUP-71822314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA [1000108],AETNA [100010801],,,76.8,,1006.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X16MM LCK CORT PERILOC FT ST SS NS -,SUP-71822316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA [1000108],AETNA [100010801],,,76.8,,1006.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X18MM LCK CORT PERILOC FT ST SS NS -,SUP-71822318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA [1000108],AETNA [100010801],,,76.8,,1006.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X20MM LCK CORT PERILOC FT ST SS NS -,SUP-71822320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA [1000108],AETNA [100010801],,,76.8,,1006.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X24MM LCK CORT PERILOC FT ST SS NS -,SUP-71822324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA [1000108],AETNA [100010801],,,76.8,,1006.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X28MM LCK CORT PERILOC FT ST SS NS -,SUP-71822328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA [1000108],AETNA [100010801],,,76.8,,1006.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X30MM LCK CORT PERILOC FT ST SS NS -,SUP-71822330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA [1000108],AETNA [100010801],,,76.8,,1006.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X36MM LCK CORT PERILOC FT ST SS NS -,SUP-71822336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA [1000108],AETNA [100010801],,,76.8,,1006.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X40MM LCK CORT PERILOC FT ST SS NS -,SUP-71822340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA [1000108],AETNA [100010801],,,76.8,,1006.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X45MM LCK CORT PERILOC FT ST SS NS -,SUP-71822345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA [1000108],AETNA [100010801],,,76.8,,1006.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X50MM LCK CORT PERILOC FT ST SS NS -,SUP-71822350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA [1000108],AETNA [100010801],,,76.8,,1006.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X60MM LCK CORT PERILOC FT ST SS NS -,SUP-71822360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1413.91,989.737,AETNA [1000108],AETNA [100010801],,,76.8,,1085.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5X10MM LCK CORT PERILOC FT ST SS -,SUP-71822410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,AETNA [1000108],AETNA [100010801],,,76.8,,1089.83,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5X12MM LCK CORT PERILOC FT ST SS -,SUP-71822412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,AETNA [1000108],AETNA [100010801],,,76.8,,1089.83,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5X14MM LCK CORT PERILOC FT ST SS -,SUP-71822414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,AETNA [1000108],AETNA [100010801],,,76.8,,1089.83,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5X16MM LCK CORT PERILOC FT ST SS -,SUP-71822416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,AETNA [1000108],AETNA [100010801],,,76.8,,1089.83,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5X18MM LCK CORT PERILOC FT ST SS -,SUP-71822418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,AETNA [1000108],AETNA [100010801],,,76.8,,1089.83,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5X20MM LCK CORT PERILOC FT ST SS -,SUP-71822420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,AETNA [1000108],AETNA [100010801],,,76.8,,1089.83,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5X22MM LCK CORT PERILOC FT ST SS -,SUP-71822422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,AETNA [1000108],AETNA [100010801],,,76.8,,1089.83,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5X24MM LCK CORT PERILOC FT ST SS -,SUP-71822424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,AETNA [1000108],AETNA [100010801],,,76.8,,1089.83,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5X26MM LCK CORT PERILOC FT ST SS -,SUP-71822426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,AETNA [1000108],AETNA [100010801],,,76.8,,1089.83,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 153MM 2.7MM 11HL CONTR SS BVL TIP -,SUP-71822511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14982.7,10487.89,AETNA [1000108],AETNA [100010801],,,76.8,,11506.71,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC 80MM 2.7/3.5MM 5HL CONTR LCK SS BVL TIP -,SUP-71822705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12245.47,8571.829,AETNA [1000108],AETNA [100010801],,,76.8,,9404.52,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC 81MM 6HL LCK SS CORNL BND -,SUP-71822906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14406.44,10084.508,AETNA [1000108],AETNA [100010801],,,76.8,,11064.15,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC 107MM 8HL LCK SS CORNL BND -,SUP-71822908,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15522.94,10866.058,AETNA [1000108],AETNA [100010801],,,76.8,,11921.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MMX10MM LCK CORT PERILOC VLP ST VAR ANG CP 2.5MM -,SUP-71823010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MMX12MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MMX14MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MMX16MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MMX18MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,,,
DIRECTOR ORAL NO. 2522 7.25IN V. MUELLER SS GZE LIG TUCKER -,SUP-71823020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MMX22MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MMX24MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MMX26MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MMX30MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MMX40MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MMX45MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MMX50MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MMX55MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA [1000108],AETNA [100010801],,,76.8,,282.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7MMX60MM LCK CORT PERILOC VLP ST FLUTX3 2.5MM STD HX -,SUP-71823060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,611.27,427.889,AETNA [1000108],AETNA [100010801],,,76.8,,469.46,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC 62MM 2.5MM 3HL STD HEAD LCK SS -,SUP-71823110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,AETNA [1000108],AETNA [100010801],,,76.8,,7919.83,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC 86MM 2.5MM 5HL STD HEAD LCK SS LT VOLAR -,SUP-71823112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9562.27,6693.589,AETNA [1000108],AETNA [100010801],,,76.8,,7343.82,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC 62MM 2.5MM 3HL HEAD LCK SS STD -,SUP-71823114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,AETNA [1000108],AETNA [100010801],,,76.8,,7919.83,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC 86MM 2.5MM 5HL STD HEAD LCK SS RT VOLAR -,SUP-71823116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9562.27,6693.589,AETNA [1000108],AETNA [100010801],,,76.8,,7343.82,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC 62MM 2.5MM 3HL W HEAD LCK SS LT VOLAR RADL -,SUP-71823118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,AETNA [1000108],AETNA [100010801],,,76.8,,7919.83,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC 62MM 2.5MM 3HL W HEAD LCK SS RT VOLAR RADL -,SUP-71823122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,AETNA [1000108],AETNA [100010801],,,76.8,,7919.83,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC 97MM 3.5MM 8HL LCK SS -,SUP-71823401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8830.28,6181.196,AETNA [1000108],AETNA [100010801],,,76.8,,6781.66,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC 109MM 3.5MM 6HL LCK SS LT CLVCL -,SUP-71823403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9036.11,6325.277,AETNA [1000108],AETNA [100010801],,,76.8,,6939.73,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC 109MM 3.5MM 6HL LCK SS RT CLVCL -,SUP-71823404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9036.11,6325.277,AETNA [1000108],AETNA [100010801],,,76.8,,6939.73,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC 81MM 2.7MM LCK SS -,SUP-71823407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9036.11,6325.277,AETNA [1000108],AETNA [100010801],,,76.8,,6939.73,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC 81MM 6HL LCK SS -,SUP-71823906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14406.44,10084.508,AETNA [1000108],AETNA [100010801],,,76.8,,11064.15,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X10MM NLCKG CORT PERILOC ST SS -,SUP-71824010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,AETNA [1000108],AETNA [100010801],,,76.8,,218.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X16MM NLCKG CORT PERILOC ST SS -,SUP-71824016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,AETNA [1000108],AETNA [100010801],,,76.8,,218.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X22MM NLCKG CORT PERILOC ST SS -,SUP-71824022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,AETNA [1000108],AETNA [100010801],,,76.8,,218.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X24MM NLCKG CORT PERILOC ST SS -,SUP-71824024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,AETNA [1000108],AETNA [100010801],,,76.8,,218.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X26MM NLCKG CORT PERILOC ST SS -,SUP-71824026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,AETNA [1000108],AETNA [100010801],,,76.8,,218.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X28MM NLCKG CORT PERILOC ST SS -,SUP-71824028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,AETNA [1000108],AETNA [100010801],,,76.8,,218.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X30MM NLCKG CORT PERILOC ST SS -,SUP-71824030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,AETNA [1000108],AETNA [100010801],,,76.8,,218.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X50MM NLCKG CORT PERILOC ST SS -,SUP-71824050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,AETNA [1000108],AETNA [100010801],,,76.8,,218.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X18MM LCK CORT PERILOC ST SS -,SUP-71825018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,AETNA [1000108],AETNA [100010801],,,76.8,,1105.63,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X22MM LCK CORT PERILOC ST SS -,SUP-71825022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,AETNA [1000108],AETNA [100010801],,,76.8,,1105.63,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X24MM LCK CORT PERILOC ST SS -,SUP-71825024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,AETNA [1000108],AETNA [100010801],,,76.8,,1105.63,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X26MM LCK CORT PERILOC ST SS -,SUP-71825026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,AETNA [1000108],AETNA [100010801],,,76.8,,1105.63,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X28MM LCK CORT PERILOC ST SS -,SUP-71825028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,AETNA [1000108],AETNA [100010801],,,76.8,,1105.63,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X30MM LCK CORT PERILOC ST SS -,SUP-71825030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,AETNA [1000108],AETNA [100010801],,,76.8,,1105.63,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X32MM LCK CORT PERILOC ST SS -,SUP-71825032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,AETNA [1000108],AETNA [100010801],,,76.8,,1105.63,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X34MM LCK CORT PERILOC ST SS -,SUP-71825034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,AETNA [1000108],AETNA [100010801],,,76.8,,1105.63,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X50MM LCK CORT PERILOC ST SS -,SUP-71825050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,AETNA [1000108],AETNA [100010801],,,76.8,,1184.6,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X55MM LCK CORT PERILOC ST SS -,SUP-71825055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,AETNA [1000108],AETNA [100010801],,,76.8,,1184.6,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X60MM LCK CORT PERILOC ST SS -,SUP-71825060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,AETNA [1000108],AETNA [100010801],,,76.8,,1184.6,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X65MM LCK CORT PERILOC ST SS -,SUP-71825065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,AETNA [1000108],AETNA [100010801],,,76.8,,1184.6,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X80MM LCK CORT PERILOC ST SS -,SUP-71825080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,AETNA [1000108],AETNA [100010801],,,76.8,,1184.6,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X10MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA [1000108],AETNA [100010801],,,76.8,,294.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X12MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA [1000108],AETNA [100010801],,,76.8,,294.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X16MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA [1000108],AETNA [100010801],,,76.8,,294.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X18MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825218,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA [1000108],AETNA [100010801],,,76.8,,294.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X36MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA [1000108],AETNA [100010801],,,76.8,,294.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X45MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825245,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA [1000108],AETNA [100010801],,,76.8,,294.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X50MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA [1000108],AETNA [100010801],,,76.8,,294.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X60MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA [1000108],AETNA [100010801],,,76.8,,294.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X65MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825265,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA [1000108],AETNA [100010801],,,76.8,,294.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X35MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825335,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA [1000108],AETNA [100010801],,,76.8,,294.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X40MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA [1000108],AETNA [100010801],,,76.8,,294.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X45MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA [1000108],AETNA [100010801],,,76.8,,294.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X55MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA [1000108],AETNA [100010801],,,76.8,,294.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X60MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA [1000108],AETNA [100010801],,,76.8,,294.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X26MM NLCKG CORT PERILOC ST SS -,SUP-71826026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,AETNA [1000108],AETNA [100010801],,,76.8,,245.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X30MM NLCKG CORT PERILOC ST SS -,SUP-71826030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,AETNA [1000108],AETNA [100010801],,,76.8,,245.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X34MM NLCKG CORT PERILOC ST SS -,SUP-71826034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,AETNA [1000108],AETNA [100010801],,,76.8,,245.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X40MM NLCKG CORT PERILOC ST SS -,SUP-71826040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,AETNA [1000108],AETNA [100010801],,,76.8,,245.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X44MM NLCKG CORT PERILOC ST SS -,SUP-71826044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,AETNA [1000108],AETNA [100010801],,,76.8,,245.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X48MM NLCKG CORT PERILOC ST SS -,SUP-71826048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,AETNA [1000108],AETNA [100010801],,,76.8,,245.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X52MM NLCKG CORT PERILOC ST SS -,SUP-71826052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,AETNA [1000108],AETNA [100010801],,,76.8,,245.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X60MM NLCKG CORT PERILOC ST SS -,SUP-71826060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,AETNA [1000108],AETNA [100010801],,,76.8,,245.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X68MM NLCKG CORT PERILOC ST SS -,SUP-71826068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,AETNA [1000108],AETNA [100010801],,,76.8,,245.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X72MM NLCKG CORT PERILOC ST SS -,SUP-71826072,CDM,C1713,HCPCS,278,RC,,,outpatient,,,594.29,416.003,AETNA [1000108],AETNA [100010801],,,76.8,,456.41,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X74MM NLCKG CORT PERILOC ST SS -,SUP-71826074,CDM,C1713,HCPCS,278,RC,,,outpatient,,,594.29,416.003,AETNA [1000108],AETNA [100010801],,,76.8,,456.41,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X10MM LCK CORT PERILOC ST SS -,SUP-71827010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X12MM LCK CORT PERILOC ST BLNT TIP SS -,SUP-71827012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X18MM LCK CORT PERILOC ST SS -,SUP-71827018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X20MM LCK CORT PERILOC ST SS -,SUP-71827020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X24MM LCK CORT PERILOC ST SS -,SUP-71827024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X26MM LCK CORT PERILOC ST SS -,SUP-71827026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X28MM LCK CORT PERILOC ST SS -,SUP-71827028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X30MM LCK CORT PERILOC ST SS -,SUP-71827030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X32MM LCK CORT PERILOC ST SS -,SUP-71827032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X34MM LCK CORT PERILOC ST SS -,SUP-71827034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X36MM LCK CORT PERILOC ST SS PROX FEM -,SUP-71827036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X40MM LCK CORT PERILOC ST SS -,SUP-71827040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X42MM LCK CORT PERILOC ST SS -,SUP-71827042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X46MM LCK CORT PERILOC ST SS -,SUP-71827046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X50MM LCK CORT PERILOC ST SS -,SUP-71827050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X52MM LCK CORT PERILOC ST SS -,SUP-71827052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X60MM LCK CORT PERILOC ST SS PROX FEM -,SUP-71827060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X66MM LCK CORT PERILOC ST SS -,SUP-71827066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X68MM LCK CORT PERILOC ST SS -,SUP-71827068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X70MM LCK CORT PERILOC ST SS -,SUP-71827070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1924.08,1346.856,AETNA [1000108],AETNA [100010801],,,76.8,,1477.69,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X70MM LCK CORT PERILOC ST SS -,SUP-71827070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X72MM LCK CORT PERILOC ST SS -,SUP-71827072,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X76MM LCK CORT PERILOC ST SS -,SUP-71827076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X80MM LCK CORT PERILOC ST SS -,SUP-71827080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X85MM LCK CORT PERILOC ST SS -,SUP-71827085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA [1000108],AETNA [100010801],,,76.8,,1480.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X90MM LCK CORT PERILOC ST SS -,SUP-71827090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1979.47,1385.629,AETNA [1000108],AETNA [100010801],,,76.8,,1520.23,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.7MMX20MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA [1000108],AETNA [100010801],,,76.8,,2699.34,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.7MMX25MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA [1000108],AETNA [100010801],,,76.8,,2699.34,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.7MMX35MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA [1000108],AETNA [100010801],,,76.8,,2699.34,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.7MMX40MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA [1000108],AETNA [100010801],,,76.8,,2699.34,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.7MMX45MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA [1000108],AETNA [100010801],,,76.8,,2699.34,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.7MMX50MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA [1000108],AETNA [100010801],,,76.8,,2699.34,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.7MMX55MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA [1000108],AETNA [100010801],,,76.8,,2699.34,0.518595,35041.66656,percent of total billed charges,,,
RETRACTOR UTR DE LEE UNIV 2INX2.75IN 9.5IN HNDL SS V.MUELLER -,SUP-71828060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA [1000108],AETNA [100010801],,,76.8,,2699.34,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.7MMX65MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA [1000108],AETNA [100010801],,,76.8,,2699.34,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.7MMX70MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA [1000108],AETNA [100010801],,,76.8,,2699.34,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.7MMX80MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA [1000108],AETNA [100010801],,,76.8,,2699.34,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.7MMX85MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA [1000108],AETNA [100010801],,,76.8,,2699.34,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC CONTR + 57MM 3.5MM 4HL LCK COMPR SS 1/3 -,SUP-71829004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2601.59,1821.113,AETNA [1000108],AETNA [100010801],,,76.8,,1998.02,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC CONTR + 82MM 3.5MM 6HL LCK COMPR SS 1/3 -,SUP-71829006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2601.59,1821.113,AETNA [1000108],AETNA [100010801],,,76.8,,1998.02,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC CONTR + 107MM 3.5MM 8HL LCK COMPR SS 1/3 -,SUP-71829008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2533.04,1773.128,AETNA [1000108],AETNA [100010801],,,76.8,,1945.37,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC 93MM F/3.5MM 6HL NLCKG COMPR SS 1/3 TBLR SM -,SUP-71829406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2395.93,1677.151,AETNA [1000108],AETNA [100010801],,,76.8,,1840.07,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 106MM 3.5MM 7HL NLCKG COMPR 1/3 TBLR SM FRAG -,SUP-71829407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2514.19,1759.933,AETNA [1000108],AETNA [100010801],,,76.8,,1930.9,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 50MM 4.33HL TBLR NS -,SUP-71829434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.31,800.317,AETNA [1000108],AETNA [100010801],,,76.8,,878.06,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 62MM 5.33HL TBLR NS -,SUP-71829435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.31,800.317,AETNA [1000108],AETNA [100010801],,,76.8,,878.06,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 74MM 6.33HL TBLR NS -,SUP-71829436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1064.29,745.003,AETNA [1000108],AETNA [100010801],,,76.8,,817.37,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 86MM 7.33HL TBLR NS -,SUP-71829437,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1064.29,745.003,AETNA [1000108],AETNA [100010801],,,76.8,,817.37,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 98MM 8.33HL TBLR NS -,SUP-71829438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1095.14,766.598,AETNA [1000108],AETNA [100010801],,,76.8,,841.07,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 122MM 10.33HL TBLR NS -,SUP-71829440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1095.14,766.598,AETNA [1000108],AETNA [100010801],,,76.8,,841.07,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 70MM 3.5MM 6HL RECON SM FRAG -,SUP-71829516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4693.02,3285.114,AETNA [1000108],AETNA [100010801],,,76.8,,3604.24,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 94MM 3.5MM 8HL RECON -,SUP-71829518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5145.85,3602.095,AETNA [1000108],AETNA [100010801],,,76.8,,3952.01,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC 96MM F/3.5MM SM MUL FRAG SYS 6HL LCK COMPR -,SUP-71829706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4528.9,3170.23,AETNA [1000108],AETNA [100010801],,,76.8,,3478.2,0.518595,35041.66656,percent of total billed charges,,,
SCR- SFTSLK-2.0 PKG.7X20 STER -,SUP-7207256,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,AETNA [1000108],AETNA [100010801],,,76.8,,959.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW SOFTSILK 2.0 7 X 25 -,SUP-7207257,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,AETNA [1000108],AETNA [100010801],,,76.8,,959.77,0.518595,35041.66656,percent of total billed charges,,,
SCR- SFTSLK-2.0 PKG.8X20 STER -,SUP-7207259,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,AETNA [1000108],AETNA [100010801],,,76.8,,959.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW SOFTSILK 2.0 8 X 25 -,SUP-7207260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,AETNA [1000108],AETNA [100010801],,,76.8,,959.77,0.518595,35041.66656,percent of total billed charges,,,
DEVICE SUT ARSCP ENDBTTN CL 30MM STRL LF -,SUP-7210082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,AETNA [1000108],AETNA [100010801],,,76.8,,1535.58,0.518595,35041.66656,percent of total billed charges,,,
DEVICE SUT ARSCP ENDBTTN CL 35MM STRL LF -,SUP-7210083,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,AETNA [1000108],AETNA [100010801],,,76.8,,1535.58,0.518595,35041.66656,percent of total billed charges,,,
DEVICE SUT ARSCP ENDBTTN CL 40MM STRL LF -,SUP-7210084,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,AETNA [1000108],AETNA [100010801],,,76.8,,1535.58,0.518595,35041.66656,percent of total billed charges,,,
BUTTONENDO CL BTB STER 45MM -,SUP-7210085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,AETNA [1000108],AETNA [100010801],,,76.8,,1535.58,0.518595,35041.66656,percent of total billed charges,,,
BUTTON ENDO 15MM CL -,SUP-7220-0146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.98,1373.386,AETNA [1000108],AETNA [100010801],,,76.8,,1506.8,0.518595,35041.66656,percent of total billed charges,,,
ULTRA FAST FIX CURVED -,SUP-7220-1494,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2143.15,1500.205,AETNA [1000108],AETNA [100010801],,,76.8,,1645.94,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUT FTPRNT 5.5MM ARSCP NABSB OUTR SHL INR PLG -,SUP-7220-1697,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2143.95,1500.765,AETNA [1000108],AETNA [100010801],,,76.8,,1646.55,0.518595,35041.66656,percent of total billed charges,,,
SCREW INTFR CANN BIOSURE 9X25MM ABSB TAPR PLLA HAP KN -,SUP-72201781,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1574.57,1102.199,AETNA [1000108],AETNA [100010801],,,76.8,,1209.27,0.518595,35041.66656,percent of total billed charges,,,
SUT ANCHOR OSTEORAPTOR  2.9 -,SUP-72201995,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2049.44,1434.608,AETNA [1000108],AETNA [100010801],,,76.8,,1573.97,0.518595,35041.66656,percent of total billed charges,,,
FAST-FIX 360 STRAIGHT -,SUP-72202467,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2543.73,1780.611,AETNA [1000108],AETNA [100010801],,,76.8,,1953.58,0.518595,35041.66656,percent of total billed charges,,,
FAST FIX 360 CVD NEEDLE -,SUP-72202468,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2543.73,1780.611,AETNA [1000108],AETNA [100010801],,,76.8,,1953.58,0.518595,35041.66656,percent of total billed charges,,,
FAST-FIX 360 REVERSE CURVED -,SUP-72202469,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2543.73,1780.611,AETNA [1000108],AETNA [100010801],,,76.8,,1953.58,0.518595,35041.66656,percent of total billed charges,,,
GUIDE DRILL SZ1.2 ENDBTTN CL ULTRA PAC -,SUP-7220-2799,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2118.19,1482.733,AETNA [1000108],AETNA [100010801],,,76.8,,1626.77,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUTURE 4.5MM HEALICOIL -,SUP-7220-3378,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2261.88,1583.316,AETNA [1000108],AETNA [100010801],,,76.8,,1737.12,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR HEALICOIL 4.75MM REGENE -,SUP-72203697,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3911.82,2738.274,AETNA [1000108],AETNA [100010801],,,76.8,,3004.28,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR HEALICOIL 4.75MM -,SUP-72203704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2249.43,1574.601,AETNA [1000108],AETNA [100010801],,,76.8,,1727.56,0.518595,35041.66656,percent of total billed charges,,,
SCREW EVOS 2.7MM X 17MM CTX -,SUP-72402717,CDM,C1713,HCPCS,278,RC,,,outpatient,,,400.46,280.322,AETNA [1000108],AETNA [100010801],,,76.8,,307.55,0.518595,35041.66656,percent of total billed charges,,,
SCREW EVOS 2.7MM X 24MM CTX -,SUP-72402724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,188.59,132.013,AETNA [1000108],AETNA [100010801],,,76.8,,144.84,0.518595,35041.66656,percent of total billed charges,,,
SCREW EVOS 3.5MM X 14MM CTX -,SUP-72403514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.9,95.13,AETNA [1000108],AETNA [100010801],,,76.8,,104.37,0.518595,35041.66656,percent of total billed charges,,,
SCREW EVOS 3.5MM X 15MM CTX -,SUP-72403515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,AETNA [1000108],AETNA [100010801],,,76.8,,221.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW EVOS 3.5MM X 16MM CTX -,SUP-72403516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,AETNA [1000108],AETNA [100010801],,,76.8,,221.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW EVOS 3.5MM X 17MM CTX -,SUP-72403517,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,AETNA [1000108],AETNA [100010801],,,76.8,,221.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW EVOS 3.5MM X 18MM CTX -,SUP-72403518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,AETNA [1000108],AETNA [100010801],,,76.8,,221.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW EVOS 2.7MM X 18MM LCK -,SUP-72412718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,598.38,418.866,AETNA [1000108],AETNA [100010801],,,76.8,,459.56,0.518595,35041.66656,percent of total billed charges,,,
SCREW EVOS 2.7MM X 19MM LCK -,SUP-72412719,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.55,802.585,AETNA [1000108],AETNA [100010801],,,76.8,,880.55,0.518595,35041.66656,percent of total billed charges,,,
SCREW EVOS 2.7MM X 20MM LCK -,SUP-72412720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.55,802.585,AETNA [1000108],AETNA [100010801],,,76.8,,880.55,0.518595,35041.66656,percent of total billed charges,,,
PLATE EVOS VOLAR 10H R STD 138MM -,SUP-72468210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8021.16,5614.812,AETNA [1000108],AETNA [100010801],,,76.8,,6160.25,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC VLP 64MM 3.5MM 4HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10840.85,7588.595,AETNA [1000108],AETNA [100010801],,,76.8,,8325.77,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC VLP 72MM 3.5MM 5HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8521.53,5965.071,AETNA [1000108],AETNA [100010801],,,76.8,,6544.54,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC VLP 47MM 3.5MM 3HL VAR ANG CONTR LCK SS -,SUP-7282-0303,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7945.19,5561.633,AETNA [1000108],AETNA [100010801],,,76.8,,6101.91,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC VLP 89MM 3.5MM 3HL VAR ANG CONTR LCK SS -,SUP-7282-0603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10840.85,7588.595,AETNA [1000108],AETNA [100010801],,,76.8,,8325.77,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC VLP 89MM 3.5MM 3HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10840.85,7588.595,AETNA [1000108],AETNA [100010801],,,76.8,,8325.77,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC VLP 62MM 3.5MM 5HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6051.52,4236.064,AETNA [1000108],AETNA [100010801],,,76.8,,4647.57,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC VLP 86MM 3.5MM 7HL 1.5-MM VAR ANG CONTR LCK -,SUP-7282-0807,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7163.02,5014.114,AETNA [1000108],AETNA [100010801],,,76.8,,5501.2,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC VLP 74MM 3.5MM 6HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6607.27,4625.089,AETNA [1000108],AETNA [100010801],,,76.8,,5074.38,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC VLP 86MM 3.5MM 7HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7163.02,5014.114,AETNA [1000108],AETNA [100010801],,,76.8,,5501.2,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC VLP 59MM 3.5MM 3HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-1003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7060.11,4942.077,AETNA [1000108],AETNA [100010801],,,76.8,,5422.16,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC VLP 71MM 3.5MM 4HL VAR ANG CONTR LCK SS LT -,SUP-7282-1004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7492.36,5244.652,AETNA [1000108],AETNA [100010801],,,76.8,,5754.13,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC VLP 83MM 3.5MM 5HL VAR ANG CONTR LCK SS LT -,SUP-7282-1005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7924.61,5547.227,AETNA [1000108],AETNA [100010801],,,76.8,,6086.1,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC VLP 107MM 3.5MM 7HL 2MM VAR ANG CONTR LCK -,SUP-7282-1007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8336.28,5835.396,AETNA [1000108],AETNA [100010801],,,76.8,,6402.26,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC VLP 131MM 3.5MM 9HL VAR ANG CONTR LCK SS LT -,SUP-7282-1009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8830.28,6181.196,AETNA [1000108],AETNA [100010801],,,76.8,,6781.66,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC VLP 59MM 3.5MM 3HL VAR ANG CONTR LCK SS -,SUP-7282-2003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6977.77,4884.439,AETNA [1000108],AETNA [100010801],,,76.8,,5358.93,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC VLP 71MM 3.5MM 4HL VAR ANG CONTR LCK SS -,SUP-7282-2004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7451.19,5215.833,AETNA [1000108],AETNA [100010801],,,76.8,,5722.51,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC VLP 83MM 3.5MM 5HL VAR ANG CONTR LCK SS RT -,SUP-7282-2005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7862.86,5504.002,AETNA [1000108],AETNA [100010801],,,76.8,,6038.68,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC VLP 131MM 3.5MM 9HL VAR ANG CONTR LCK SS RT -,SUP-7282-2009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8768.53,6137.971,AETNA [1000108],AETNA [100010801],,,76.8,,6734.23,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC VLP 62MM 3.5MM 5HL VAR ANG CONTR LCK SS -,SUP-7282-3005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2852.56,1996.792,AETNA [1000108],AETNA [100010801],,,76.8,,2190.77,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC VLP 74MM 3.5MM 6HL VAR ANG CONTR LCK SS -,SUP-7282-3006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3223.02,2256.114,AETNA [1000108],AETNA [100010801],,,76.8,,2475.28,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERILOC VLP 86MM 3.5MM 7HL VAR ANG CONTR LCK SS -,SUP-7282-3007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3570.33,2499.231,AETNA [1000108],AETNA [100010801],,,76.8,,2742.01,0.518595,35041.66656,percent of total billed charges,,,
SCREW LCK ORLMXLFCL 2.4X14MM STERNALOCK SD TI GOLD -,SUP-73-2414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,,,
SCREW LCK ORLMXLFCL 2.4X16MM STERNALOCK SD TI GOLD -,SUP-73-2416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,,,
SCREW LCK ORLMXLFCL 2.4X18MM STERNALOCK SD TI GOLD -,SUP-73-2418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,460.97,322.679,AETNA [1000108],AETNA [100010801],,,76.8,,354.02,0.518595,35041.66656,percent of total billed charges,,,
SCREW LCK ORLMXLFCL 2.4X20MM STERNALOCK SD TI GOLD -,SUP-73-2420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,460.97,322.679,AETNA [1000108],AETNA [100010801],,,76.8,,354.02,0.518595,35041.66656,percent of total billed charges,,,
PLATE ORLMXLFCL 8HL STERNALOCK 4HL BX TI BLU -,SUP-73-2622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2835.76,1985.032,AETNA [1000108],AETNA [100010801],,,76.8,,2177.86,0.518595,35041.66656,percent of total billed charges,,,
PLATE ORLMXLFCL 12HL STERNALOCK LDDR TI BLU -,SUP-73-2632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4401.63,3081.141,AETNA [1000108],AETNA [100010801],,,76.8,,3380.45,0.518595,35041.66656,percent of total billed charges,,,
PLATE ORLMXLFCL 12HL STERNALOCK W LDDR TI BLU -,SUP-73-2634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4401.63,3081.141,AETNA [1000108],AETNA [100010801],,,76.8,,3380.45,0.518595,35041.66656,percent of total billed charges,,,
PLATE STRNM 8HL JL SHP STERNALOCK BLU TI -,SUP-73-2645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4124.74,2887.318,AETNA [1000108],AETNA [100010801],,,76.8,,3167.8,0.518595,35041.66656,percent of total billed charges,,,
COMP JRNY II CR FEM OX NP LT SZ 6 -,SUP-74021166,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA [1000108],AETNA [100010801],,,76.8,,7670.76,0.518595,35041.66656,percent of total billed charges,,,
BASEPLATE TIBIA JOURNEY NP LT SZ 5 -,SUP-74022225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,AETNA [1000108],AETNA [100010801],,,76.8,,3519.77,0.518595,35041.66656,percent of total billed charges,,,
INSERT JOURNEY II CR XLPE RT SZ 5-6 9MM -,SUP-74025661,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
MESH CAGE 30MM H -,SUP-74-1030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA [1000108],AETNA [100010801],,,76.8,,8269.59,0.518595,35041.66656,percent of total billed charges,,,
CAGE NGAGE 16MM X 12MM CORPECT -,SUP-74-1216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA [1000108],AETNA [100010801],,,76.8,,8269.59,0.518595,35041.66656,percent of total billed charges,,,
CAGE N-GAGE TI 16 X 50MM -,SUP-74-1650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA [1000108],AETNA [100010801],,,76.8,,8269.59,0.518595,35041.66656,percent of total billed charges,,,
TONIER HUMERAL NAIL DISTAL SCREW 4.3MM X 20MM -,SUP-7424520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,AETNA [1000108],AETNA [100010801],,,76.8,,854.87,0.518595,35041.66656,percent of total billed charges,,,
TONIER HUMERAL NAIL DISTAL SCREW 4.3MM X 22MM -,SUP-7424522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,AETNA [1000108],AETNA [100010801],,,76.8,,854.87,0.518595,35041.66656,percent of total billed charges,,,
CAP END N-GAGE ZERO DEGREE -,SUP-74-5016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA [1000108],AETNA [100010801],,,76.8,,1160.17,0.518595,35041.66656,percent of total billed charges,,,
ENDCAP 2.5 DEG 10MM -,SUP-74-6010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA [1000108],AETNA [100010801],,,76.8,,1160.17,0.518595,35041.66656,percent of total billed charges,,,
CAP NPLATE 7.5 DEGREE -,SUP-74-6012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA [1000108],AETNA [100010801],,,76.8,,1160.17,0.518595,35041.66656,percent of total billed charges,,,
NUT LCK F/C IN ADVANCED IMPL SYS -,SUP-7642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.87,143.409,AETNA [1000108],AETNA [100010801],,,76.8,,157.34,0.518595,35041.66656,percent of total billed charges,,,
SET SCREW SPIN 6.35MM CD HORIZN LEGC SS -,SUP-7660000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,869.18,608.426,AETNA [1000108],AETNA [100010801],,,76.8,,667.53,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5X35MM FIREBIRD DBL LD THRD ST CANN TI GRN -,SUP-77-8535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5X40MM FIREBIRD DBL LD THRD ST CANN TI GRN -,SUP-77-8540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5X45MM FIREBIRD DBL LD THRD ST CANN GRN -,SUP-77-8545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X35MM FIREBIRD DBL LD THRD ST CANN TI GOLD -,SUP-77-8635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X40MM FIREBIRD DBL LD THRD ST CANN GOLD -,SUP-77-8640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X45MM FIREBIRD DBL LD THRD ST CANN TI GOLD -,SUP-77-8645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X50MM FIREBIRD DBL LD THRD ST CANN TI GOLD -,SUP-77-8650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
3.5MM COCR ROD- 240MM -,SUP-782.803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA [1000108],AETNA [100010801],,,76.8,,528.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW SET -,SUP-79-2003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,,,
CABLE SPIN 1.2MM TI DBL LOP INTGR CRIMPX2 STRL -,SUP-7925011S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1755.53,1228.871,AETNA [1000108],AETNA [100010801],,,76.8,,1348.25,0.518595,35041.66656,percent of total billed charges,,,
SUBSTITUTE CA PHOS HAP 5ML PTTY CMNT INJ HYDR ST SYNTH -,SUP-79-43905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6318.89,4423.223,AETNA [1000108],AETNA [100010801],,,76.8,,4852.91,0.518595,35041.66656,percent of total billed charges,,,
CEMENT BN CA PHOS HAP 10ML HYDR ST -,SUP-79-43910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10521.16,7364.812,AETNA [1000108],AETNA [100010801],,,76.8,,8080.25,0.518595,35041.66656,percent of total billed charges,,,
SUBSTITUTE CA PHOS HAP 15ML PTTY CMNT INJ HYDR ST SLF-SET -,SUP-79-43915,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15098.17,10568.719,AETNA [1000108],AETNA [100010801],,,76.8,,11595.39,0.518595,35041.66656,percent of total billed charges,,,
GUIDEPIN ORTHO 2.5MM HEMICAP -,SUP-8007-1200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,AETNA [1000108],AETNA [100010801],,,76.8,,398.84,0.518595,35041.66656,percent of total billed charges,,,
IMPLANT SHT CRANFC 50X76MM 0.85MM MEDPOR EMBD TI MSH F/RECON -,SUP-81020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5562.27,3893.589,AETNA [1000108],AETNA [100010801],,,76.8,,4271.82,0.518595,35041.66656,percent of total billed charges,,,
MESH TITAN SHEET MTB 76 X 50 X 1MM -,SUP-81027,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6586.43,4610.501,AETNA [1000108],AETNA [100010801],,,76.8,,5058.38,0.518595,35041.66656,percent of total billed charges,,,
IMPLANT PE SHT EMBD TI MSH CRANFC 50X76MM -,SUP-81029,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6345.33,4441.731,AETNA [1000108],AETNA [100010801],,,76.8,,4873.21,0.518595,35041.66656,percent of total billed charges,,,
IMPLANT SHT 76X100MM 1.5MM MEDPOR TITAN MAX F/CRANFC -,SUP-81040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10857.55,7600.285,AETNA [1000108],AETNA [100010801],,,76.8,,8338.6,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X12MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X14MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X16MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X18MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN SPIDER 20MM TMX -,SUP-814100003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA [1000108],AETNA [100010801],,,76.8,,457.09,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERI 70.1MM 5HL COMPR TMX TBLR BLLT -,SUP-814123005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,980.28,686.196,AETNA [1000108],AETNA [100010801],,,76.8,,752.86,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PE.R.I. 83.1MM 6HL COMP TIMEX 1/3 TBLR -,SUP-814123006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 95.5MM 7HL COMPR COMP TBLR BLLT-SHP -,SUP-814123007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA [1000108],AETNA [100010801],,,76.8,,833.52,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PERI 109.2MM 30MM COMPR TMX TBLR BLLT -,SUP-814123008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA [1000108],AETNA [100010801],,,76.8,,833.52,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PE.R.I. 122.2MM 9HL NLCKG PERMTR RDC COMP TBLR -,SUP-814123009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA [1000108],AETNA [100010801],,,76.8,,887.29,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 179.4MM 6HL LCK SHFT STRL -,SUP-814130106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,AETNA [1000108],AETNA [100010801],,,76.8,,5162.88,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN POLYAX 233.5MM 9HL LCK TMX STRL -,SUP-814131109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,AETNA [1000108],AETNA [100010801],,,76.8,,5162.88,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 287.6MM 12HL LCK SHFT -,SUP-814131112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,AETNA [1000108],AETNA [100010801],,,76.8,,5162.88,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN POLYAX 99.6MM 2HL PRCONT LCK TMX STRL -,SUP-814133002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,AETNA [1000108],AETNA [100010801],,,76.8,,5162.88,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 13MMSHRTX180MM AFFIXUS TROCH ANTGRD AN-ROT 125DG ANG -,SUP-814313180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7282.7,5097.89,AETNA [1000108],AETNA [100010801],,,76.8,,5593.11,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 10.5MM AFFIXUS CANN LAG THRD ST TMX 80MM -,SUP-814510080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3265.42,2285.794,AETNA [1000108],AETNA [100010801],,,76.8,,2507.84,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 10.5MM AFFIXUS CANN LAG THRD ST TMX 105MM -,SUP-814510105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3265.42,2285.794,AETNA [1000108],AETNA [100010801],,,76.8,,2507.84,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 13MMSHRTX180MM AFFIXUS TROCH ANTGRD AN-ROT 130DG ANG -,SUP-814513180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7282.7,5097.89,AETNA [1000108],AETNA [100010801],,,76.8,,5593.11,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X34MM CORT AFFIXUS VERSANAIL FT ST 3.5MM HX DRV SCKT -,SUP-814550034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA [1000108],AETNA [100010801],,,76.8,,887.29,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X40MM CORT AFFIXUS VERSANAIL FT ST 3.5MM HX DRV SCKT -,SUP-814550040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA [1000108],AETNA [100010801],,,76.8,,887.29,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X20MM CORT ALPS FT ST HX DRV TMX -,SUP-8150-36-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,134.21,93.947,AETNA [1000108],AETNA [100010801],,,76.8,,103.07,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X10MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X12MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X14MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X20MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X22MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X24MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X26MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X28MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X30MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X34MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X38MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X42MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X44MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X46MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X48MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X50MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X55MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X60MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X65MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,76.8,,295.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X26MM LCK SHFT CORT POLYAX FT POLYAX ST FA TMX NS -,SUP-815045526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA [1000108],AETNA [100010801],,,76.8,,618.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X28MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA [1000108],AETNA [100010801],,,76.8,,618.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X30MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA [1000108],AETNA [100010801],,,76.8,,618.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X32MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA [1000108],AETNA [100010801],,,76.8,,618.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X34MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA [1000108],AETNA [100010801],,,76.8,,618.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X36MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA [1000108],AETNA [100010801],,,76.8,,618.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X40MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA [1000108],AETNA [100010801],,,76.8,,618.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X45MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA [1000108],AETNA [100010801],,,76.8,,618.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X55MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA [1000108],AETNA [100010801],,,76.8,,618.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X60MM LCK CANC POLYAX FT POLYAX ST FA BLLT SHP TIP TI -,SUP-815304060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA [1000108],AETNA [100010801],,,76.8,,618.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X75MM LCK CANC POLYAX FT POLYAX ST FA BLLT SHP TIP TI -,SUP-815304075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA [1000108],AETNA [100010801],,,76.8,,618.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 8X70MM LCK DUAL CORE POLYAX FT POLYAX ST FA BLLT SHP -,SUP-815308070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA [1000108],AETNA [100010801],,,76.8,,1196.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW 8X75MM LCK DUAL CORE POLYAX FT POLYAX ST FA BLLT SHP -,SUP-815308075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA [1000108],AETNA [100010801],,,76.8,,1196.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X10MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X14MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X16MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X18MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X20MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X24MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X26MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X28MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X34MM CANC FT -,SUP-8153-41-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,278.62,195.034,AETNA [1000108],AETNA [100010801],,,76.8,,213.98,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X44MM LAG CANC FT -,SUP-8153-41-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,198.39,138.873,AETNA [1000108],AETNA [100010801],,,76.8,,152.36,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X50MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X55MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5X30MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA [1000108],AETNA [100010801],,,76.8,,618.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5X45MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA [1000108],AETNA [100010801],,,76.8,,618.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5X60MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA [1000108],AETNA [100010801],,,76.8,,618.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5X65MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA [1000108],AETNA [100010801],,,76.8,,618.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5X70MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA [1000108],AETNA [100010801],,,76.8,,618.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5X75MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA [1000108],AETNA [100010801],,,76.8,,618.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5X65MM NLCKG CANC POLYAX P/T POLYAX TI NS -,SUP-815455065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,AETNA [1000108],AETNA [100010801],,,76.8,,376.43,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X20MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X24MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X28MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X30MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X32MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA [1000108],AETNA [100010801],,,76.8,,241.99,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X36MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA [1000108],AETNA [100010801],,,76.8,,241.99,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X42MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA [1000108],AETNA [100010801],,,76.8,,241.99,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X46MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA [1000108],AETNA [100010801],,,76.8,,241.99,0.518595,35041.66656,percent of total billed charges,,,
LAG SCREW D10.5X85MM -,SUP-8160-0085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4287.05,3000.935,AETNA [1000108],AETNA [100010801],,,76.8,,3292.45,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X10MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X12MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X14MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X16MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X18MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X20MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORT LOCK 3.5 X 20MM NS -,SUP-816135020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X22MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW  CORT LOCK 3.5 X 22MM NS -,SUP-816135022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X24MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-8161-35-024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
3.5MM CORT LOCK SCREW 26MM NS -,SUP-816135026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X28MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
3.5MM CORTLOCK SCREW 30MM NS -,SUP-816135030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X30MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X32MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X34MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X36MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X38MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X40MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X42MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
3.5MM CORT LOCK SCREW 50MM NS -,SUP-816135050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORT LOCK 3.5 X 52MM NS -,SUP-816135052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 3.5 X 54 CORT NS -,SUP-816135054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X56MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X60MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X65MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X10MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X12MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X14MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X16MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X18MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X26MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X28MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X46MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X60MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X65MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X70MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,76.8,,645.3,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN ALPS 199MM 12HL PRCONT LCK COMPR TMX W ANTMC FST -,SUP-816200012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6798.89,4759.223,AETNA [1000108],AETNA [100010801],,,76.8,,5221.55,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN ALPS 77MM 6HL THRD LCK TMX ANTMC NS BLU -,SUP-816204006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,AETNA [1000108],AETNA [100010801],,,76.8,,1050.26,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN ALPS 92MM 7HL THRD LCK TMX ANTMC NS BLU -,SUP-816204007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN ALPS 103MM 8HL THRD LCK TMX ANTMC NS BLU -,SUP-816204008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1526.54,1068.578,AETNA [1000108],AETNA [100010801],,,76.8,,1172.38,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN ALPS 3.5MM 5HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1208.51,845.957,AETNA [1000108],AETNA [100010801],,,76.8,,928.14,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN ALPS 3.5MM 6HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1208.51,845.957,AETNA [1000108],AETNA [100010801],,,76.8,,928.14,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN ALPS HCP 3.5MM 7HL HYBRID LCK COMPR TMX THN ANTMC -,SUP-816235007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA [1000108],AETNA [100010801],,,76.8,,976.99,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN ALPS 3.5MM 8HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1335.73,935.011,AETNA [1000108],AETNA [100010801],,,76.8,,1025.84,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN ALPS 3.5MM 9HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1335.73,935.011,AETNA [1000108],AETNA [100010801],,,76.8,,1025.84,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN ALPS 3.5MM 12HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN ALPS 3HL PRCONT LCK TMX STD CRV ANTMC LT TIB -,SUP-816235703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5627.54,3939.278,AETNA [1000108],AETNA [100010801],,,76.8,,4321.95,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN ALPS 5HL PRCONT LCK TMX STD CRV ANTMC -,SUP-816235705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5678.47,3974.929,AETNA [1000108],AETNA [100010801],,,76.8,,4361.06,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN ALPS 3HL PRCONT LCK TMX STD CRV ANTMC RT TIB -,SUP-816235803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5627.54,3939.278,AETNA [1000108],AETNA [100010801],,,76.8,,4321.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X22MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA [1000108],AETNA [100010801],,,76.8,,830.44,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X26MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA [1000108],AETNA [100010801],,,76.8,,830.44,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X32MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA [1000108],AETNA [100010801],,,76.8,,830.44,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X50MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA [1000108],AETNA [100010801],,,76.8,,830.44,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X55MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA [1000108],AETNA [100010801],,,76.8,,830.44,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X56MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA [1000108],AETNA [100010801],,,76.8,,830.44,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X65MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA [1000108],AETNA [100010801],,,76.8,,830.44,0.518595,35041.66656,percent of total billed charges,,,
SPACER SPNL ANT CERV 13X15X6MM ALTA 5DG PEEK. -,SUP-8401-0506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,0.518595,35041.66656,percent of total billed charges,,,
PIN FX 1.3MM ABSB -,SUP-84-1052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1153.11,807.177,AETNA [1000108],AETNA [100010801],,,76.8,,885.59,0.518595,35041.66656,percent of total billed charges,,,
SPACER SPNL ANT CERV 13X15X6MM ALTA 5DG PEEK.. -,SUP-8411-0506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,0.518595,35041.66656,percent of total billed charges,,,
SPACER ANT CERV 13X15X7MM ALTA 5DG PEEK -,SUP-8411-0507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,0.518595,35041.66656,percent of total billed charges,,,
COVER LOCKING SHORELINE 8-12 MM STANDALONE GRAY -,SUP-85-2008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,,,
TEMP FIX PIN -,SUP-85-2100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,,,
LONG NAIL LEFT 13X340MM X 125 DEG -,SUP-8525-3340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13986.87,9790.809,AETNA [1000108],AETNA [100010801],,,76.8,,10741.92,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5 X 12MM SELF DRILLING -,SUP-85-3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5 X 14MM SELF DRILLING -,SUP-85-3014SD,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
GRAVITY SYNCHFIX SYNDESMOSIS #5 SUTURE -,SUP-86SYN005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4349.11,3044.377,AETNA [1000108],AETNA [100010801],,,76.8,,3340.12,0.518595,35041.66656,percent of total billed charges,,,
SPACER TRNSFRMNL POST LMBR 9X23X6MM FORZA 0DG STR BLLT NOSE -,SUP-89-1006SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,AETNA [1000108],AETNA [100010801],,,76.8,,8477.76,0.518595,35041.66656,percent of total billed charges,,,
SPACER TRNSFRMNL POST LMBR 9X23X8MM FORZA 0DG STR BLLT NOSE -,SUP-89-1008SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,AETNA [1000108],AETNA [100010801],,,76.8,,8477.76,0.518595,35041.66656,percent of total billed charges,,,
SPACER TRNSFRMNL POST LMBR 9X27X7MM FORZA 0DG CRV BLLT NOSE -,SUP-89-1707SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,AETNA [1000108],AETNA [100010801],,,76.8,,8477.76,0.518595,35041.66656,percent of total billed charges,,,
SPACER TRNSFRMNL POST LMBR 9X27X8MM FORZA 0DG CRV BLLT NOSE -,SUP-89-1708SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,AETNA [1000108],AETNA [100010801],,,76.8,,8477.76,0.518595,35041.66656,percent of total billed charges,,,
SPACER TRNSFRMNL POST LMBR 9X27X9MM FORZA 0DG CRV BLLT NOSE -,SUP-89-1709SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,AETNA [1000108],AETNA [100010801],,,76.8,,8477.76,0.518595,35041.66656,percent of total billed charges,,,
IMPLANT HUM TIS 9X27X7MM SZ0 FORZA STR -,SUP-89-3007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,AETNA [1000108],AETNA [100010801],,,76.8,,8477.76,0.518595,35041.66656,percent of total billed charges,,,
SPACER TRNSFRMNL POST LMBR 9X27X10MM FORZA 0DG STR BLLT NOSE -,SUP-89-3010SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,AETNA [1000108],AETNA [100010801],,,76.8,,8477.76,0.518595,35041.66656,percent of total billed charges,,,
BONE CEMENT HYDROSET XT INJECTABLE HA -,SUP-897003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5310.31,3717.217,AETNA [1000108],AETNA [100010801],,,76.8,,4078.32,0.518595,35041.66656,percent of total billed charges,,,
CEMENT BONE HYDROSET XT HA 5CC -,SUP-897005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8517.71,5962.397,AETNA [1000108],AETNA [100010801],,,76.8,,6541.6,0.518595,35041.66656,percent of total billed charges,,,
CEMENT BONE HYDROSET XT HA 10CC -,SUP-897010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14367.75,10057.425,AETNA [1000108],AETNA [100010801],,,76.8,,11034.43,0.518595,35041.66656,percent of total billed charges,,,
HYDROSET XT -,SUP-897015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20614.72,14430.304,AETNA [1000108],AETNA [100010801],,,76.8,,15832.1,0.518595,35041.66656,percent of total billed charges,,,
GRAFT BONE BIO4 VIABLE BONE MATRIX 2.5CC -,SUP-90174424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,AETNA [1000108],AETNA [100010801],,,76.8,,3666.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEADLESS COMPRESSION 2.5MM X 28MM TI -,SUP-90176298,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,AETNA [1000108],AETNA [100010801],,,76.8,,2731.49,0.518595,35041.66656,percent of total billed charges,,,
PIN FIXATION IJS 2.5MM X 50MM AXIS -,SUP-90176511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1918.78,1343.146,AETNA [1000108],AETNA [100010801],,,76.8,,1473.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW FREEFIX COMPRESSION 4.5MM X 18MM TI -,SUP-90176560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1009.46,706.622,AETNA [1000108],AETNA [100010801],,,76.8,,775.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW FREEFIX LOCKING 4.5MM X 14MM TI -,SUP-90176561,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA [1000108],AETNA [100010801],,,76.8,,830.44,0.518595,35041.66656,percent of total billed charges,,,
SCREW FREEFIX LOCKING 4.5MM X 16MM TI -,SUP-90176562,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA [1000108],AETNA [100010801],,,76.8,,830.44,0.518595,35041.66656,percent of total billed charges,,,
SCREW FREEFIX LOCKING 4.5MM X 18MM TI -,SUP-90176563,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA [1000108],AETNA [100010801],,,76.8,,830.44,0.518595,35041.66656,percent of total billed charges,,,
SCREW FREEFIX LOCKING 4.5MM X 20MM TI -,SUP-90176564,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA [1000108],AETNA [100010801],,,76.8,,830.44,0.518595,35041.66656,percent of total billed charges,,,
PLATE MIDSHAFT HUMERUS NARROW 172MM -,SUP-90176565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5334.71,3734.297,AETNA [1000108],AETNA [100010801],,,76.8,,4097.06,0.518595,35041.66656,percent of total billed charges,,,
PLATE FREEFIX 173MM ULNA MIDSHAFT -,SUP-90176755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA [1000108],AETNA [100010801],,,76.8,,4872.79,0.518595,35041.66656,percent of total billed charges,,,
PLATE FREEFIX DISTAL HUMERUS 85MM ASSEMBLED LAT HELICAL LEFT -,SUP-90176827,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,AETNA [1000108],AETNA [100010801],,,76.8,,7125.03,0.518595,35041.66656,percent of total billed charges,,,
SCREW FREEFIX COMPRESSION 3.5MM X 12MM TI -,SUP-90176828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,AETNA [1000108],AETNA [100010801],,,76.8,,846.97,0.518595,35041.66656,percent of total billed charges,,,
SCREW FREEFIX LOCKING 3.5MM X 10MM TI -,SUP-90176829,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.51,808.857,AETNA [1000108],AETNA [100010801],,,76.8,,887.43,0.518595,35041.66656,percent of total billed charges,,,
SCREW POLYAXIAL LOCKING 3.0MM X 34MM CANNULATED COCR -,SUP-90176830,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,AETNA [1000108],AETNA [100010801],,,76.8,,1127.61,0.518595,35041.66656,percent of total billed charges,,,
SCREW POLYAXIAL LOCKING 3.0MM X 50MM CANNULATED COCR -,SUP-90176831,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,AETNA [1000108],AETNA [100010801],,,76.8,,1127.61,0.518595,35041.66656,percent of total billed charges,,,
SCREW POLYAXIAL LOCKING 3.0MM X 60MM CANNULATED COCR -,SUP-90176832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,AETNA [1000108],AETNA [100010801],,,76.8,,1127.61,0.518595,35041.66656,percent of total billed charges,,,
SCREW POLYAXIAL LOCKING 3.0MM X 65MM CANNULATED COCR -,SUP-90176833,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,AETNA [1000108],AETNA [100010801],,,76.8,,1127.61,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEADLESS COMPRESSION 2.5MM X 20MM TI -,SUP-90176987,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,AETNA [1000108],AETNA [100010801],,,76.8,,2731.49,0.518595,35041.66656,percent of total billed charges,,,
ASSEMBLED FREE FIX DISTAL HUM PLATE LAT DIRECT 85MM RIGHT -,SUP-90178750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,AETNA [1000108],AETNA [100010801],,,76.8,,7125.03,0.518595,35041.66656,percent of total billed charges,,,
ASSEMBLED FREE FIX DISTAL HUM PLATE MED DIRECT 75MM RIGHT -,SUP-90178751,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8504.98,5953.486,AETNA [1000108],AETNA [100010801],,,76.8,,6531.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW FREEFIX COMPRESSION 3.5MM X 16MM TI -,SUP-90178752,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,AETNA [1000108],AETNA [100010801],,,76.8,,766.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW FREEFIX COMPRESSION 3.5MM X 28MM TI -,SUP-90178753,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,AETNA [1000108],AETNA [100010801],,,76.8,,766.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW FREEFIX LOCKING 3.5MM X 30MM TI -,SUP-90178754,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,AETNA [1000108],AETNA [100010801],,,76.8,,882.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW MULTI-THREAD LOCKING 2.7MM X 16MM TI -,SUP-90178756,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,AETNA [1000108],AETNA [100010801],,,76.8,,815.59,0.518595,35041.66656,percent of total billed charges,,,
SCREW MULTI-THREAD LOCKING 2.7MM X 24MM TI -,SUP-90178757,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,AETNA [1000108],AETNA [100010801],,,76.8,,815.59,0.518595,35041.66656,percent of total billed charges,,,
ASSEMBLED FREEFIX DIST HUM PLATE LAT DIRECT 85MM LEFT -,SUP-90178787,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,AETNA [1000108],AETNA [100010801],,,76.8,,7125.03,0.518595,35041.66656,percent of total billed charges,,,
DISTAL TROCHLEA COMPRESSION SCREW 3.5MM X 40MM TI -,SUP-90178788,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,0.518595,35041.66656,percent of total billed charges,,,
SCREW MULTI-THREAD LOCKING 2.7MM X 26MM TI -,SUP-90178789,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,AETNA [1000108],AETNA [100010801],,,76.8,,815.59,0.518595,35041.66656,percent of total billed charges,,,
SCREW MULTI-THREAD LOCKING 2.7MM X 42MM TI -,SUP-90178790,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,AETNA [1000108],AETNA [100010801],,,76.8,,815.59,0.518595,35041.66656,percent of total billed charges,,,
HIGH COMPRESSION LOCKING PEG 2.7MM X 24MM TI -,SUP-90178898,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,AETNA [1000108],AETNA [100010801],,,76.8,,555.68,0.518595,35041.66656,percent of total billed charges,,,
DRILL CANNULATED 3.7MM X 30MM -,SUP-90178926,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,0.518595,35041.66656,percent of total billed charges,,,
ASSEMBLY DOUBLE IJS -,SUP-90178927,CDM,C1713,HCPCS,278,RC,,,outpatient,,,27394.51,19176.157,AETNA [1000108],AETNA [100010801],,,76.8,,21038.98,0.518595,35041.66656,percent of total billed charges,,,
IJS-E AXIS PIN FEMALE 30MM COCR -,SUP-90178928,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,AETNA [1000108],AETNA [100010801],,,76.8,,1669.03,0.518595,35041.66656,percent of total billed charges,,,
THREADED HAND NAIL 4.5MM X 45MM TI -,SUP-90178982,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4258.41,2980.887,AETNA [1000108],AETNA [100010801],,,76.8,,3270.46,0.518595,35041.66656,percent of total billed charges,,,
KT SPINAL 4.5MMX30-40MM PEDICAL COMPR TRANSFACET W/SCREWX2 -,SUP-9045-02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9549,6684.3,AETNA [1000108],AETNA [100010801],,,76.8,,7333.63,0.518595,35041.66656,percent of total billed charges,,,
IMPLANT ELB JNT TOGGLELOC -,SUP-909854,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4344.34,3041.038,AETNA [1000108],AETNA [100010801],,,76.8,,3336.45,0.518595,35041.66656,percent of total billed charges,,,
PK VALVE F/INFECT FLD WST MGMT ULTRA QUAD CART -,SUP-91530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW CRNL 1.5X4MM STRDRV RCESS SD TI -,SUP-92-15904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,413.82,289.674,AETNA [1000108],AETNA [100010801],,,76.8,,317.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW CRNL 1.5X5MM STRDRV RCESS SD TI -,SUP-92-15905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,413.82,289.674,AETNA [1000108],AETNA [100010801],,,76.8,,317.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW CRNL 1.5X5MM STRDRV RCESS SD TI -,SUP-92-15905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,82.76,57.932,AETNA [1000108],AETNA [100010801],,,76.8,,63.56,0.518595,35041.66656,percent of total billed charges,,,
PLATE INSERT LOCKING 2.7MM -,SUP-940372,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,AETNA [1000108],AETNA [100010801],,,76.8,,2002.83,0.518595,35041.66656,percent of total billed charges,,,
PIN FX STNMN 2.8MMX9IN SMTH STRL F /THE VUEPASS PORTAL -,SUP-94152,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2711.63,1898.141,AETNA [1000108],AETNA [100010801],,,76.8,,2082.53,0.518595,35041.66656,percent of total billed charges,,,
PFC SIGMA DISTAL AUG COM CEMT SIZE 5 X 4MM RIGHT -,SUP-960901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,0.518595,35041.66656,percent of total billed charges,,,
PFC SIGMA DISTAL AUG COM CEMT SIZE 5 X 8MM RIGHT -,SUP-960903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,0.518595,35041.66656,percent of total billed charges,,,
TIBAL INSERT ROTATING PLATFORM (STAB) 5- 10MM -,SUP-962151,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,AETNA [1000108],AETNA [100010801],,,76.8,,3666.82,0.518595,35041.66656,percent of total billed charges,,,
INSERT TIBIAL ROTATING PLATFORM SZ 2.5MM X 20MM TCS -,SUP-96-2335,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,0.518595,35041.66656,percent of total billed charges,,,
5.0MM VARIABLE ANGLE EXTENSION ARM -,SUP-991088S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2160.48,1512.336,AETNA [1000108],AETNA [100010801],,,76.8,,1659.25,0.518595,35041.66656,percent of total billed charges,,,
CAP TOT JNT SM PLST -,SUP-9911186002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1043.01,730.107,AETNA [1000108],AETNA [100010801],,,76.8,,801.03,0.518595,35041.66656,percent of total billed charges,,,
IMPLANT HUM TIS CHP ALLOGRAFT CANC 15ML -,SUP-A00035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.87,918.309,AETNA [1000108],AETNA [100010801],,,76.8,,1007.52,0.518595,35041.66656,percent of total billed charges,,,
TEMPORARY TENSION BOLT -,SUP-A-2791.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.07,775.649,AETNA [1000108],AETNA [100010801],,,76.8,,851,0.518595,35041.66656,percent of total billed charges,,,
DRILL BIT AO FIXATION 1.2MM X 25MM X L81MM -,SUP-A-3230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1173.53,821.471,AETNA [1000108],AETNA [100010801],,,76.8,,901.27,0.518595,35041.66656,percent of total billed charges,,,
COUNTERSINK M 1.2/1.5 -,SUP-A-3310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1607.11,1124.977,AETNA [1000108],AETNA [100010801],,,76.8,,1234.26,0.518595,35041.66656,percent of total billed charges,,,
3.0 CCS COUNTERSINK- AO -,SUP-A-3938,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1978.15,1384.705,AETNA [1000108],AETNA [100010801],,,76.8,,1519.22,0.518595,35041.66656,percent of total billed charges,,,
HOOK PLATE1.5 2 HOLE 2 HOOKS T0.6 -,SUP-A-4200.40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2365.61,1655.927,AETNA [1000108],AETNA [100010801],,,76.8,,1816.79,0.518595,35041.66656,percent of total billed charges,,,
HOOK PLATE 4 HOLE 4 HOOKS T0.6 -,SUP-A-4200.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2632.76,1842.932,AETNA [1000108],AETNA [100010801],,,76.8,,2021.96,0.518595,35041.66656,percent of total billed charges,,,
IMPLANT HUM TIS STRIP 1X20CMX8MM H GRFTN MATRIX -,SUP-A42280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8571.82,6000.274,AETNA [1000108],AETNA [100010801],,,76.8,,6583.16,0.518595,35041.66656,percent of total billed charges,,,
PLATE M FIX 4 HOLE STRAIGHT -,SUP-A-4300.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2106.42,1474.494,AETNA [1000108],AETNA [100010801],,,76.8,,1617.73,0.518595,35041.66656,percent of total billed charges,,,
PLATE M FIX 6 HOLE STRAIGHT -,SUP-A-4300.03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.98,1080.086,AETNA [1000108],AETNA [100010801],,,76.8,,1185.01,0.518595,35041.66656,percent of total billed charges,,,
PLATE M FIX 16 H STRAIGHT -,SUP-A-4300.04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2571.75,1800.225,AETNA [1000108],AETNA [100010801],,,76.8,,1975.1,0.518595,35041.66656,percent of total billed charges,,,
PLATE M FIX 16 H CURVED -,SUP-A-4300.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2092.11,1464.477,AETNA [1000108],AETNA [100010801],,,76.8,,1606.74,0.518595,35041.66656,percent of total billed charges,,,
PLATE M FIX16 HOLE OFF SET -,SUP-A-4300.06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2700.17,1890.119,AETNA [1000108],AETNA [100010801],,,76.8,,2073.73,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN APTUS 10X27MM F/1.2MM/1.5MM FX SCR HLX3X5 TI T-SHP -,SUP-A-4300.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1852.52,1296.764,AETNA [1000108],AETNA [100010801],,,76.8,,1422.74,0.518595,35041.66656,percent of total billed charges,,,
PLATE M FIX 2/3 H RIGHT L -,SUP-A-4300.21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1852.52,1296.764,AETNA [1000108],AETNA [100010801],,,76.8,,1422.74,0.518595,35041.66656,percent of total billed charges,,,
PLATE M GD FIX 2X2 RECT LEA -,SUP-A-4300.51,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2632.23,1842.561,AETNA [1000108],AETNA [100010801],,,76.8,,2021.55,0.518595,35041.66656,percent of total billed charges,,,
PLATE FIXATION GOLD GRID 2 X 2-HOLE TAPAZOID -,SUP-A-4300.54,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2632.23,1842.561,AETNA [1000108],AETNA [100010801],,,76.8,,2021.55,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN APTUS 15MM F/1.2MM/1.5MM SCR HLX3X2 0.6MM GRID FX -,SUP-A-4300.55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2074.62,1452.234,AETNA [1000108],AETNA [100010801],,,76.8,,1593.31,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN HLX4X2 FA MED L-SHP GRID -,SUP-A-4300.64,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2156.24,1509.368,AETNA [1000108],AETNA [100010801],,,76.8,,1655.99,0.518595,35041.66656,percent of total billed charges,,,
GRID 5 X 2 HOLE TRAPAZOID -,SUP-A-4300.66,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.52,1855.364,AETNA [1000108],AETNA [100010801],,,76.8,,2035.6,0.518595,35041.66656,percent of total billed charges,,,
PLATE M CONDYLE 5 H PIN L -,SUP-A-4340.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2542.12,1779.484,AETNA [1000108],AETNA [100010801],,,76.8,,1952.35,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN APTUS F/1.2-1.5MM SCR 1HL HOOKX2 COMPR TI TRILOCK -,SUP-A-4340.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3184.74,2229.318,AETNA [1000108],AETNA [100010801],,,76.8,,2445.88,0.518595,35041.66656,percent of total billed charges,,,
PLATE APTUS TRILOCK PI 4 HOLE STRAIGHT IO 8 -,SUP-A-4350.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3757.14,2629.998,AETNA [1000108],AETNA [100010801],,,76.8,,2885.48,0.518595,35041.66656,percent of total billed charges,,,
PLATE M TRILOCK STR 4 HOLE -,SUP-A-4350.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2752.69,1926.883,AETNA [1000108],AETNA [100010801],,,76.8,,2114.07,0.518595,35041.66656,percent of total billed charges,,,
PLATE TRILOCK PI 3/5 HOLE T -,SUP-A-4350.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4001.57,2801.099,AETNA [1000108],AETNA [100010801],,,76.8,,3073.21,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN APTUS 11X25MM 0.8MM 8HL HND TRILOCK TI T-SHP -,SUP-A-4350.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4001.57,2801.099,AETNA [1000108],AETNA [100010801],,,76.8,,3073.21,0.518595,35041.66656,percent of total billed charges,,,
PLATE TRILOCK ROTATING 3 HOLE 1.2/1.5 -,SUP-A-4350.23,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4080.82,2856.574,AETNA [1000108],AETNA [100010801],,,76.8,,3134.07,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN APTUS 9X23MM F/1.2MM/1.5MM SCR FX/ROT 6HL 0.8MM VAR -,SUP-A-4350.23,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.67,2999.269,AETNA [1000108],AETNA [100010801],,,76.8,,3290.63,0.518595,35041.66656,percent of total billed charges,,,
PLATE M TRILOCK T 5/4 HL -,SUP-A-4350.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4152.43,2906.701,AETNA [1000108],AETNA [100010801],,,76.8,,3189.07,0.518595,35041.66656,percent of total billed charges,,,
LOCKING PLATE 1.5 BLUE -,SUP-A-4350.56,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3415.8,2391.06,AETNA [1000108],AETNA [100010801],,,76.8,,2623.33,0.518595,35041.66656,percent of total billed charges,,,
PLATE M TRILOCK GRID HL 4 X 2 -,SUP-A-4350.62,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4381.08,3066.756,AETNA [1000108],AETNA [100010801],,,76.8,,3364.67,0.518595,35041.66656,percent of total billed charges,,,
PLATE 1.2/1.5 TRILOCK GRID 5X2H TRAPZ T 0.8 -,SUP-A-4350.66,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4471.05,3129.735,AETNA [1000108],AETNA [100010801],,,76.8,,3433.77,0.518595,35041.66656,percent of total billed charges,,,
PLATE LOCKING TRILOCK BLUE 1.5 TRAPEZ 10.8 -,SUP-A-4350.80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3868.85,2708.195,AETNA [1000108],AETNA [100010801],,,76.8,,2971.28,0.518595,35041.66656,percent of total billed charges,,,
IMPLANT HUM TIS GRFTN DBM OTHBLND -,SUP-A44135,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5713.91,3999.737,AETNA [1000108],AETNA [100010801],,,76.8,,4388.28,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN APTUS 55MM F/2MM/2.3MM SCR 8HL COMPR TI STR TRILOCK -,SUP-A-4645.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2466.32,1726.424,AETNA [1000108],AETNA [100010801],,,76.8,,1894.13,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN APTUS 35MM F/2MM/2.3MM SCR HLX2X4 COMPR TI T-SHP -,SUP-A-4645.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2428.06,1699.642,AETNA [1000108],AETNA [100010801],,,76.8,,1864.75,0.518595,35041.66656,percent of total billed charges,,,
PLATE M COMP L 2/8 HOLE RIGHT -,SUP-A-4645.23,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2405.14,1683.598,AETNA [1000108],AETNA [100010801],,,76.8,,1847.15,0.518595,35041.66656,percent of total billed charges,,,
PLATE LOCKING 1.0MM THCK 2./2.3 STRAIGHT BLUE -,SUP-A-4650.03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7191.46,5034.022,AETNA [1000108],AETNA [100010801],,,76.8,,5523.04,0.518595,35041.66656,percent of total billed charges,,,
LOCKING PLATE 2.0/2.3 BLUE T-2/4 HOLE -,SUP-A-4650.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3100.24,2170.168,AETNA [1000108],AETNA [100010801],,,76.8,,2380.98,0.518595,35041.66656,percent of total billed charges,,,
PLATE TRILOCK 3/4 HOLE -,SUP-A-4650.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3100.24,2170.168,AETNA [1000108],AETNA [100010801],,,76.8,,2380.98,0.518595,35041.66656,percent of total billed charges,,,
"PLATE M LK ""Y"" 2/5 H -",SUP-A-4650.13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3199.53,2239.671,AETNA [1000108],AETNA [100010801],,,76.8,,2457.24,0.518595,35041.66656,percent of total billed charges,,,
PLATE L 2/4 HOLE RIGHT -,SUP-A-4650.21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3601.51,2521.057,AETNA [1000108],AETNA [100010801],,,76.8,,2765.96,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN APTUS 45MM F/2MM/2.3MM SCR 8HL 1MM GRID TI -,SUP-A-4650.67,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3910.86,2737.602,AETNA [1000108],AETNA [100010801],,,76.8,,3003.54,0.518595,35041.66656,percent of total billed charges,,,
PLATE BLUE LOCKING 2.0 /2.3 4 HOLE STRAIGHT -,SUP-A-4655.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4610.73,3227.511,AETNA [1000108],AETNA [100010801],,,76.8,,3541.04,0.518595,35041.66656,percent of total billed charges,,,
PLATE LOCKING T1.3MM 4 HOLE STRAIGHT 2.0/2.3 -,SUP-A-4655.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3973.88,2781.716,AETNA [1000108],AETNA [100010801],,,76.8,,3051.94,0.518595,35041.66656,percent of total billed charges,,,
PLATE BLUE 2.0 / 2.23 5 HOLE STRAIGHT -,SUP-A-4655.02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4308.93,3016.251,AETNA [1000108],AETNA [100010801],,,76.8,,3309.26,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN APTUS 32MM F/2MM/2.3MM SCR 5HL 1.3MM GRID TI STR -,SUP-A-4655.02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4294.08,3005.856,AETNA [1000108],AETNA [100010801],,,76.8,,3297.85,0.518595,35041.66656,percent of total billed charges,,,
PLATE TRILOCK 8 HOLE STRAIGHT 2 X 3 -,SUP-A-4655.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4971,3479.7,AETNA [1000108],AETNA [100010801],,,76.8,,3817.73,0.518595,35041.66656,percent of total billed charges,,,
PLATE TRILOCK STRAIGHT 8 HOLE 2.0/2.3 -,SUP-A-4655.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4969.72,3478.804,AETNA [1000108],AETNA [100010801],,,76.8,,3816.74,0.518595,35041.66656,percent of total billed charges,,,
PLATE TRILOCK 2.0/2.3 T 2/4 HOLE T1.3 -,SUP-A-4655.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5024.05,3516.835,AETNA [1000108],AETNA [100010801],,,76.8,,3858.47,0.518595,35041.66656,percent of total billed charges,,,
PLATE M TRILOCK T 2/4 HL -,SUP-A-4655.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5024.05,3516.835,AETNA [1000108],AETNA [100010801],,,76.8,,3858.47,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN APTUS 56MM 2.0/2.3MM 10HL 1.3MM GRID TI T-SHP -,SUP-A-4655.16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5311.37,3717.959,AETNA [1000108],AETNA [100010801],,,76.8,,4079.13,0.518595,35041.66656,percent of total billed charges,,,
2.0/2.3 TRILOCK PLATE 2/4 HOLE LEFT -,SUP-A-4655.20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4600.23,3220.161,AETNA [1000108],AETNA [100010801],,,76.8,,3532.98,0.518595,35041.66656,percent of total billed charges,,,
PLATE M TRILOCK L RT 2/4 HL -,SUP-A-4655.21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5024.05,3516.835,AETNA [1000108],AETNA [100010801],,,76.8,,3858.47,0.518595,35041.66656,percent of total billed charges,,,
PLATE M TRILOCK L LT 2/8 HL -,SUP-A-4655.22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4539.38,3177.566,AETNA [1000108],AETNA [100010801],,,76.8,,3486.24,0.518595,35041.66656,percent of total billed charges,,,
PLATE ROTATION 3/3 HOLE T 1.3 -,SUP-A-4655.24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4738.2,3316.74,AETNA [1000108],AETNA [100010801],,,76.8,,3638.94,0.518595,35041.66656,percent of total billed charges,,,
PLATE TRILOCK GRIDPI 4 X2H TRAPEZ -,SUP-A-4655.62,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5438.26,3806.782,AETNA [1000108],AETNA [100010801],,,76.8,,4176.58,0.518595,35041.66656,percent of total billed charges,,,
PLATE TRILOCK GRIDPI 5 X2 H TRAPEZ -,SUP-A-4655.66,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5679.32,3975.524,AETNA [1000108],AETNA [100010801],,,76.8,,4361.72,0.518595,35041.66656,percent of total billed charges,,,
PLATE 2.0 TRILOCK RADIAL HEAD RIM -,SUP-A-4656.68,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7432.09,5202.463,AETNA [1000108],AETNA [100010801],,,76.8,,5707.85,0.518595,35041.66656,percent of total billed charges,,,
2.0 TRILOCK RADIAL HEAD BUTTRESS -,SUP-A-4656.69,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7017.88,4912.516,AETNA [1000108],AETNA [100010801],,,76.8,,5389.73,0.518595,35041.66656,percent of total billed charges,,,
PLATE TRILOCK 4CF 2 X 2.3 -,SUP-A-4660.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7727.9,5409.53,AETNA [1000108],AETNA [100010801],,,76.8,,5935.03,0.518595,35041.66656,percent of total billed charges,,,
PLATE M BABYFOOT LONG RT -,SUP-A-4750.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5479,3835.3,AETNA [1000108],AETNA [100010801],,,76.8,,4207.87,0.518595,35041.66656,percent of total billed charges,,,
PLATE 2.5 ADAPT II TRILOCK DISTRAD L 10 H NARROW -,SUP-A-4750.101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5810.88,4067.616,AETNA [1000108],AETNA [100010801],,,76.8,,4462.76,0.518595,35041.66656,percent of total billed charges,,,
PLATE M ADAPTIVE II NARROW RT -,SUP-A-4750.102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7626.89,5338.823,AETNA [1000108],AETNA [100010801],,,76.8,,5857.45,0.518595,35041.66656,percent of total billed charges,,,
DISTAL RADIUS LOCKING PLATE RIGHT 12 NARROW-LONG -,SUP-A-4750.104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,AETNA [1000108],AETNA [100010801],,,76.8,,5027.61,0.518595,35041.66656,percent of total billed charges,,,
PLATE 2.5 ADAPTIVE II TRILOCK DISTRAD NARR LONG -,SUP-A-4750.104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8591.98,6014.386,AETNA [1000108],AETNA [100010801],,,76.8,,6598.64,0.518595,35041.66656,percent of total billed charges,,,
PLATE ADAPTIVE 2.5 X 12HL NRW LNG -,SUP-A-4750.104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6904.56,4833.192,AETNA [1000108],AETNA [100010801],,,76.8,,5302.7,0.518595,35041.66656,percent of total billed charges,,,
PLATE M ADAPTIVE II LT -,SUP-A-4750.105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7626.89,5338.823,AETNA [1000108],AETNA [100010801],,,76.8,,5857.45,0.518595,35041.66656,percent of total billed charges,,,
PLATE M ADAPTIVE II LT -,SUP-A-4750.105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5810.88,4067.616,AETNA [1000108],AETNA [100010801],,,76.8,,4462.76,0.518595,35041.66656,percent of total billed charges,,,
PLATE STD WATERSHED RIGHT ADAP -,SUP-A-4750.106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8008.43,5605.901,AETNA [1000108],AETNA [100010801],,,76.8,,6150.47,0.518595,35041.66656,percent of total billed charges,,,
ADAPTIVE II TRILOCK 2.5 DISTRAD. PLATE 13 HOLE -,SUP-A-4750.107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,AETNA [1000108],AETNA [100010801],,,76.8,,5027.61,0.518595,35041.66656,percent of total billed charges,,,
DISTAL RADIUS LOCKING PLATE RIGHT 13 LONG -,SUP-A-4750.108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8591.98,6014.386,AETNA [1000108],AETNA [100010801],,,76.8,,6598.64,0.518595,35041.66656,percent of total billed charges,,,
PLATE M ADAPTIVE II LONG RIGHT -,SUP-A-4750.108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,AETNA [1000108],AETNA [100010801],,,76.8,,5027.61,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN APTUS 28X52MM 2.5MM 14HL TI TRILOCK TECH -,SUP-A-4750.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,AETNA [1000108],AETNA [100010801],,,76.8,,4251.23,0.518595,35041.66656,percent of total billed charges,,,
PLATE 2.5 ADAPTIVE II DISTAL RADIUS LEFT WIDE LONG -,SUP-A-4750.111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,AETNA [1000108],AETNA [100010801],,,76.8,,5027.61,0.518595,35041.66656,percent of total billed charges,,,
PLATE 2.5 ADAPTIVE II TRILOCK DIST RAD 15H WIDE LONG -,SUP-A-4750.112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6234.44,4364.108,AETNA [1000108],AETNA [100010801],,,76.8,,4788.05,0.518595,35041.66656,percent of total billed charges,,,
DISTAL RADIUS CORRECTION PLATE WIDE -,SUP-A-4750.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,AETNA [1000108],AETNA [100010801],,,76.8,,4251.23,0.518595,35041.66656,percent of total billed charges,,,
PLATE M FPL LT -,SUP-A-4750.123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8106.46,5674.522,AETNA [1000108],AETNA [100010801],,,76.8,,6225.76,0.518595,35041.66656,percent of total billed charges,,,
PLATE MEDARTIS 14HL -,SUP-A-4750.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6904.56,4833.192,AETNA [1000108],AETNA [100010801],,,76.8,,5302.7,0.518595,35041.66656,percent of total billed charges,,,
PLATE ADAPTIVE 2.5 X 15 HOLE -,SUP-A-4750.15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7057.35,4940.145,AETNA [1000108],AETNA [100010801],,,76.8,,5420.04,0.518595,35041.66656,percent of total billed charges,,,
PLATE ADAPTIVE 2.5 X 16 HOLE -,SUP-A-4750.16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7057.35,4940.145,AETNA [1000108],AETNA [100010801],,,76.8,,5420.04,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN APTUS 22X62MM 2.5MM 12HL 1.6MM TI LNG NRW TRILOCK -,SUP-A-4750.19,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,AETNA [1000108],AETNA [100010801],,,76.8,,4251.23,0.518595,35041.66656,percent of total billed charges,,,
PLATE 2.5TRILOCK WR SPANNINGPI DOR. STRAIGHT 11 HOLE TL6-3.4 -,SUP-A-4750.193S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13227.56,9259.292,AETNA [1000108],AETNA [100010801],,,76.8,,10158.77,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN APTUS 23X44MM 2.5MM 10HL 1.6MM TI NRW TRILOCK TECH -,SUP-A-4750.31,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,AETNA [1000108],AETNA [100010801],,,76.8,,4251.23,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN APTUS 23X44MM 2.5MM 10HL TI SHRT NRW TRILOCK TECH -,SUP-A-4750.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,AETNA [1000108],AETNA [100010801],,,76.8,,4251.23,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN APTUS 30X64MM F/2.5MM FX 1.6MM LCK TI FRM -,SUP-A-4750.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5815.98,4071.186,AETNA [1000108],AETNA [100010801],,,76.8,,4466.67,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN APTUS 30X64MM F/2.5 TRILOCK SYS 1.6MM LCK TI -,SUP-A-4750.42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5815.98,4071.186,AETNA [1000108],AETNA [100010801],,,76.8,,4466.67,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN APTUS 49MM 2.5MM 6HL TI STR TRILOCK TECH -,SUP-A-4750.54,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4373.94,3061.758,AETNA [1000108],AETNA [100010801],,,76.8,,3359.19,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN APTUS 23X54MM 2.5MM 13HL TI TRILOCK TECH RT WRST -,SUP-A-4750.62,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,AETNA [1000108],AETNA [100010801],,,76.8,,4251.23,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN APTUS 23X68MM 2.5MM 15HL TI LNG TRILOCK TECH LT -,SUP-A-4750.64,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6307.43,4415.201,AETNA [1000108],AETNA [100010801],,,76.8,,4844.11,0.518595,35041.66656,percent of total billed charges,,,
WASHER BICONCAVE 2.5/2.8 -,SUP-A-4750.70/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,340.18,238.126,AETNA [1000108],AETNA [100010801],,,76.8,,261.26,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN APTUS 46MM 2.5MM 7HL VAR ANG CONTR TI Y -,SUP-A-4750.91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4323.36,3026.352,AETNA [1000108],AETNA [100010801],,,76.8,,3320.34,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN APTUS 67MM 2.5MM 10HL 1.6MM VAR ANG CONTR LCK TI Y -,SUP-A-4750.92,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4557.21,3190.047,AETNA [1000108],AETNA [100010801],,,76.8,,3499.94,0.518595,35041.66656,percent of total billed charges,,,
2.5 TRILOCK ULNA SHORTENING PLATE 10HL -,SUP-A-4750.95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9650.43,6755.301,AETNA [1000108],AETNA [100010801],,,76.8,,7411.53,0.518595,35041.66656,percent of total billed charges,,,
2.5 TRILOCK ULNA SHORTENING PLATE -,SUP-A-4750.95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9650.43,6755.301,AETNA [1000108],AETNA [100010801],,,76.8,,7411.53,0.518595,35041.66656,percent of total billed charges,,,
PLATE 2.5 TRILOCK WRIST FUSION PI SHORT BEND -,SUP-A-4760.02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11734.57,8214.199,AETNA [1000108],AETNA [100010801],,,76.8,,9012.15,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN APTUS 2.5MM 15HL LCK TI STR MULDIR TRILOCK -,SUP-A-4760.03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9292.66,6504.862,AETNA [1000108],AETNA [100010801],,,76.8,,7136.76,0.518595,35041.66656,percent of total billed charges,,,
PLATE STRAIGHT 2.5 TRILOCK TOTAL WRIST FUS -,SUP-A-4760.04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11159.79,7811.853,AETNA [1000108],AETNA [100010801],,,76.8,,8570.72,0.518595,35041.66656,percent of total billed charges,,,
2.5 TRILOCK TOTAL WRIST FUS PL LONG BEND 16HL T1.8-2.6 DRSL -,SUP-A-4760.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11734.57,8214.199,AETNA [1000108],AETNA [100010801],,,76.8,,9012.15,0.518595,35041.66656,percent of total billed charges,,,
2.5 TRILOCK TOTAL WRIST FUS PI SHORT BEND 16 HOLE T1.8-2.6 D -,SUP-A-4760.06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11734.57,8214.199,AETNA [1000108],AETNA [100010801],,,76.8,,9012.15,0.518595,35041.66656,percent of total billed charges,,,
PLATE 2.5 TRILOCK WRIST FUSION SHORT BEND 12 HOLE -,SUP-A-4760.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11462.03,8023.421,AETNA [1000108],AETNA [100010801],,,76.8,,8802.84,0.518595,35041.66656,percent of total billed charges,,,
PLATE TENSION 2.8 TRILOCK 6 HOLE OLECRANON -,SUP-A-4856.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5373.33,3761.331,AETNA [1000108],AETNA [100010801],,,76.8,,4126.72,0.518595,35041.66656,percent of total billed charges,,,
PLATE TRILOCK T1-6 OLECRANON 7H RIGHT -,SUP-A-4856.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5556.24,3889.368,AETNA [1000108],AETNA [100010801],,,76.8,,4267.19,0.518595,35041.66656,percent of total billed charges,,,
PLATE 2.8 TRILOC OLECRANON 7H LEFT -,SUP-A-4856.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5557.94,3890.558,AETNA [1000108],AETNA [100010801],,,76.8,,4268.5,0.518595,35041.66656,percent of total billed charges,,,
PLATE TRILOCK OLECRANON 2.8 7H STRAIGHT -,SUP-A-4856.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5306.27,3714.389,AETNA [1000108],AETNA [100010801],,,76.8,,4075.22,0.518595,35041.66656,percent of total billed charges,,,
TRILOCK PLATE 2.8 - 10H- RIGHT -,SUP-A-4856.13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5674.23,3971.961,AETNA [1000108],AETNA [100010801],,,76.8,,4357.81,0.518595,35041.66656,percent of total billed charges,,,
TRILOCK PLATE 10H STRAIGHT -,SUP-A-4856.15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5576.62,3903.634,AETNA [1000108],AETNA [100010801],,,76.8,,4282.84,0.518595,35041.66656,percent of total billed charges,,,
2.8 TRILOCK DIST HUM PL MEDIAL 17H L -,SUP-A-4856.29,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10465.7,7325.99,AETNA [1000108],AETNA [100010801],,,76.8,,8037.66,0.518595,35041.66656,percent of total billed charges,,,
PLATE 2.8 TRILOCK DIST HUM MEDIAL 12H R -,SUP-A-4856.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9692.45,6784.715,AETNA [1000108],AETNA [100010801],,,76.8,,7443.8,0.518595,35041.66656,percent of total billed charges,,,
TriLock Dist. Hum Pl. Medial- 10h- l -,SUP-A-4856.33,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9291.81,6504.267,AETNA [1000108],AETNA [100010801],,,76.8,,7136.11,0.518595,35041.66656,percent of total billed charges,,,
2.8 TRILOCK DIST HUM PL LATERAL 18H L -,SUP-A-4856.39,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9432.88,6603.016,AETNA [1000108],AETNA [100010801],,,76.8,,7244.45,0.518595,35041.66656,percent of total billed charges,,,
PLATE 2.8 TRILCK DIST HUM MEDIAL 10H LFT -,SUP-A-4856.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9692.45,6784.715,AETNA [1000108],AETNA [100010801],,,76.8,,7443.8,0.518595,35041.66656,percent of total billed charges,,,
PLATE M TRILOCK GRID H 2X2 -,SUP-A-4856.44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9291.81,6504.267,AETNA [1000108],AETNA [100010801],,,76.8,,7136.11,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 10HL 2.8MM TRILOCK TECH RT OLCRN -,SUP-A-4856-13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4323.36,3026.352,AETNA [1000108],AETNA [100010801],,,76.8,,3320.34,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 10HL 2.8MM TRILOCK TECH LT OLCRN -,SUP-A-4856-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5674.23,3971.961,AETNA [1000108],AETNA [100010801],,,76.8,,4357.81,0.518595,35041.66656,percent of total billed charges,,,
K-WIRES LNCET 150MM 1.8MM -,SUP-A-5042.51/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,247.99,173.593,AETNA [1000108],AETNA [100010801],,,76.8,,190.46,0.518595,35041.66656,percent of total billed charges,,,
1.1 K-WIRE- TROCAR- 2-END. 100MM -,SUP-A-5043.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,297.59,208.313,AETNA [1000108],AETNA [100010801],,,76.8,,228.55,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.2X4MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.2X5MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.2X6MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.2X7MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.2X8MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.2X9MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.2X10MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.2X11MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.2X12MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.2X14MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW M CORTEX 1.2 X 16MM -,SUP-A-5100.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.5X4MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.5X5MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.5X6MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW M CORTEX 1.5 X 07 -,SUP-A-5200.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW M CORTEX 1.5 X 07 -,SUP-A-5200.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW M CORTEX 1.5 X 08 -,SUP-A-5200.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.5X9MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.5X10MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.5X11MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.5X12MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.5X13MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.5X14MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.5X15MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.5X15MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI. -,SUP-A-5200.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTEX 1.5 X 16 MEDARTIS -,SUP-A-5200.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTEX 1.5 X 17MM CORTICAL HD4 -,SUP-A-5200.17/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.5X18MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.5X19MM CORT APTUS DBL THRD ST/RET HEXDRV 4 TI GOLD -,SUP-A-5200.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW M CORTEX 1.5 X 21 -,SUP-A-5200.21/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL 1.5 22MM HD4 -,SUP-A-5200.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW M CORTEX 1.5 X 24 -,SUP-A-5200.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE APTUS 1.5 SPEEDTIP 10MM HD4 PK/1 -,SUP-A-5210.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1076.56,753.592,AETNA [1000108],AETNA [100010801],,,76.8,,826.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE 1.5MM SPEEDTIP 14MM HD4 PK/1 -,SUP-A-5210.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1076.56,753.592,AETNA [1000108],AETNA [100010801],,,76.8,,826.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.5X4MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.5X5MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.5X6MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.5X7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.5 X 7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.5X8MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.5X9MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.5X10MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.5X11MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.5X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.5X13MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 1.5 X 16 -,SUP-A-5250.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.8,742.56,AETNA [1000108],AETNA [100010801],,,76.8,,814.69,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE CANNULATED COMPRESSION 10/4MM -,SUP-A-5281.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.7 CCS LONG THREAD 15/06MM 1/PKG -,SUP-A-5281.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.7 CCS LONG THREAD 16/07MM 1/PKG -,SUP-A-5281.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,,,
1.7 CCS LONG THREAD 18/07MM -,SUP-A-5281.18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.7CCS LONG THREAD 20/08MM -,SUP-A-5281.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.7 CCS FULLY THREADED 10MM 1/PKG -,SUP-A-5282.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.7CCS FULLY THREADED 13MM -,SUP-A-5282.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.7CCS FULLY THREADED 14MM -,SUP-A-5282.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,,,
CORTEX BONE SCREWS 1.8MM 06MM LENGTH GOLD -,SUP-A-5300.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,884,618.8,AETNA [1000108],AETNA [100010801],,,76.8,,678.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW M CORTEX 1.8 X 10 -,SUP-A-5300.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,654.69,458.283,AETNA [1000108],AETNA [100010801],,,76.8,,502.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2X4MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2X5MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2X6MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2X7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5400.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2X8MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2X9MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5400.09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2X10MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2X11MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2X13MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2X14MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5400.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2X15MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
2.0 CORTICAL SCREW 16MM -,SUP-A-5400.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.0 X 17MM MEDARTIS -,SUP-A-5400.17/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL 2.0 X 18MM HD6 -,SUP-A-5400.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW APTUS TI CORTEX BONE GOLD 2.0 X 19MM -,SUP-A-5400.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2X20MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
2.0 CORTICAL SCREW 24MM -,SUP-A-5400.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2X6MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5450.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2X7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2X8MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5450.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2X9MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2X10MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2X11MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,295.02,206.514,AETNA [1000108],AETNA [100010801],,,76.8,,226.58,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2X12MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2X13MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2X14MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW TRILOCK 2.0 X 14MM HD6 -,SUP-A-5450.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2X16MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
2.0 TRILOCK SCREW 18MM -,SUP-A-5450.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
2.0 TRILOCK SCREW 20MM -,SUP-A-5450.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.0 TRILOCK 20MM HD6 -,SUP-A-5450.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X5MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X6MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X7MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X8MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X9MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X10MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X11MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X12MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X13MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X14MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X18MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X19MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW M CORTEX 2.3 X 20 -,SUP-A-5500.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW M CORTEX 2.3 X 18 -,SUP-A-5500.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORT MEDARTIS 2.5 8MM -,SUP-A-5700.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5X10MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORT MEDARTIS 2.5 11MM -,SUP-A-5700.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5X12MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5X13MM NLCKG CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5700.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORT MEDARTIS 2.5 14MM -,SUP-A-5700.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW M CORT 2.5 X 15 -,SUP-A-5700.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
LOCKING SCREW 16 MM BLUE 2.5MM -,SUP-A-5700.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
NON LOCKING BONE SCREW 16MM -,SUP-A-5700.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORT MEDARTIS 2.5 16MM -,SUP-A-5700.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5X18MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
LOCKING SCREW 18MM BLUE 2.5MM -,SUP-A-5700.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
LOCKING SCREW 20MM BLUE 2.5 -,SUP-A-5700.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5X20MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5X22MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.85,662.095,AETNA [1000108],AETNA [100010801],,,76.8,,726.41,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5X24MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5X30MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,623.76,436.632,AETNA [1000108],AETNA [100010801],,,76.8,,479.05,0.518595,35041.66656,percent of total billed charges,,,
CORTEX GOLD NON LCK 2.5 32MM  SCREW -,SUP-A-5700.32/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW M CORT 2.5 X 34MM -,SUP-A-5700.34/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5X20MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5720.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5X22MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5720.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5X10MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
TRILOCK SCREW 2.5 12MM -,SUP-A-5750.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5X14MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5X16MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5X18MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCK MEDARTIS 2.5 18MM -,SUP-A-5750.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5X24MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5X26MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW BLUE 2.5 X 28 LOCKING -,SUP-A-5750.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW M LOCKING 2.5 X 30MM -,SUP-A-5750.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5X32MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.8,742.56,AETNA [1000108],AETNA [100010801],,,76.8,,814.69,0.518595,35041.66656,percent of total billed charges,,,
2.5 TRILOCK SCREW 34MM -,SUP-A-5750.34/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5 TRILOCK EXPRESS 14MM HD7 PK/1 -,SUP-A-5755.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1158.25,810.775,AETNA [1000108],AETNA [100010801],,,76.8,,889.54,0.518595,35041.66656,percent of total billed charges,,,
SILVER LOCKING SCREW 18MM -,SUP-A-5755.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1158.25,810.775,AETNA [1000108],AETNA [100010801],,,76.8,,889.54,0.518595,35041.66656,percent of total billed charges,,,
SILVER LOCKING SCREW 20MM -,SUP-A-5755.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1158.25,810.775,AETNA [1000108],AETNA [100010801],,,76.8,,889.54,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE APTUS 2.2 CANN COMP 10MM HD7 DISTAL THREAD 4MM -,SUP-A-5780.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE APTUS 2.2 CANN COMP 11MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE APTUS 2.2 CANN COMP 14MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE APTUS 2.2 CANN COMP 15MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE APTUS 2.2 CANN COMP 16MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANULATED COPR 17MM -,SUP-A-5780.17/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE APTUS 2.2 CANN COMP 19MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,,,
2.2 CANNULATED SCREW COMPRESSION 20MM -,SUP-A-5780.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.2 CANNULATED COMPR 26MM DISTAL THREAD 6MM -,SUP-A-5780.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANULATED COPR 27MM -,SUP-A-5780.27/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.2 CANNULATED COMPR 30MM DISTAL THREAD 6MM -,SUP-A-5780.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW MEDART CANN CMPR 2.2 X 22 -,SUP-A-5781.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW MEDART CANN CMPR 2.2 X 24MM -,SUP-A-5781.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANNULATED 2.2 COMPRESSION LONG THREAD 26MM -,SUP-A-5781.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW COMPR CANNULATED 2.2 X 28MM -,SUP-A-5781.28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,AETNA [1000108],AETNA [100010801],,,76.8,,1875.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW COMPR CANNULATED 2.2 X 30MM -,SUP-A-5781.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,AETNA [1000108],AETNA [100010801],,,76.8,,1875.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW MEDART CANN COMPR 2.2 X 32 -,SUP-A-5781.32/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA [1000108],AETNA [100010801],,,76.8,,1951.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW COMPR CANNULATED 2.2 X 36MM -,SUP-A-5781.36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,AETNA [1000108],AETNA [100010801],,,76.8,,1875.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW COMPR CANNULATED 2.2 X 38MM -,SUP-A-5781.38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,AETNA [1000108],AETNA [100010801],,,76.8,,1875.82,0.518595,35041.66656,percent of total billed charges,,,
2.8 CORTICAL SCREW 10MM HD7 -,SUP-A-5800.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
2.8 CORTICAL SCREW 12MM HD7 -,SUP-A-5800.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.8X16MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.8X18MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.8X20MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.8X22MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.8X24MM CORT -,SUP-A-5800.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,654.69,458.283,AETNA [1000108],AETNA [100010801],,,76.8,,502.8,0.518595,35041.66656,percent of total billed charges,,,
2.8 CORTICAL SCREW 26MM HD7 -,SUP-A-5800.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
2.8 CORTICAL SCREW 28MM -,SUP-A-5800.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
2.8 CORTICAL SCREW 30MM HD7 -,SUP-A-5800.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
2.8 CORTICAL SCREW 32MM HD7 -,SUP-A-5800.32/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
2.8  CORTICAL SCREW 38MM- HD7 -,SUP-A-5800.38/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.8 GOLD CORTEX BONE 40MM HD7 -,SUP-A-5800.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.8X45MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.45/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORITCAL 50MM HD7 2.8 -,SUP-A-5800.50/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.8X55MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.55/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW LAG 2.8 X 40 HD7 -,SUP-A-5830.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,654.69,458.283,AETNA [1000108],AETNA [100010801],,,76.8,,502.8,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.8X14MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW TRILOCK BLUE 2.8 LOCKING16MM HD7 -,SUP-A-5850.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.8X18MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.8X20MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.8X22MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW TRILOCK 2.8 X 24MM HD7 -,SUP-A-5850.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW TRILOCK BLUE 2.8 LOCKING 26MM HD7 -,SUP-A-5850.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
2.8 TRILOCK  SCREW 28MM HD7 -,SUP-A-5850.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW TRILOCK BLUE 2.8 LOCKING 30MM HD7 -,SUP-A-5850.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
2.8 TRILOCK SCREW 32MM- HD7 -,SUP-A-5850.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
2.8 TRILOCK SCREW 36MM- HD7 -,SUP-A-5850.36/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
2.8 TRILOCK SCREW 38MM HD7 -,SUP-A-5850.38/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
2.8 TRILOCK SCREW 40MM HD7 -,SUP-A-5850.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
2.8 TRILOCK SCREW 50MM- HD7 -,SUP-A-5850.50/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
2.8 TRILOCK SCREW 55MM- HD7 -,SUP-A-5850.55/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.8 TRILCK 55MM -,SUP-A-5850.55/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.8,742.56,AETNA [1000108],AETNA [100010801],,,76.8,,814.69,0.518595,35041.66656,percent of total billed charges,,,
2.8 TRILOCK SCREW 70MM HD7 -,SUP-A-5850.70/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANNULATED SPEED TIP 3MM X 15MM -,SUP-A-5880.15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2326.39,1628.473,AETNA [1000108],AETNA [100010801],,,76.8,,1786.67,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANN SPEED TIP 3MM X 20MM -,SUP-A-5880.20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2326.87,1628.809,AETNA [1000108],AETNA [100010801],,,76.8,,1787.04,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3X24MM CANN SPEEDTIP CCS S/T SD HEXDRIVE 10 TI -,SUP-A-5880.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,AETNA [1000108],AETNA [100010801],,,76.8,,2040,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3X26MM CANN SPEEDTIP CCS S/T SD HEXDRIVE 10 TI -,SUP-A-5880.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,AETNA [1000108],AETNA [100010801],,,76.8,,2040,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.0 CANN COMPR 40 -,SUP-A-5880.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,AETNA [1000108],AETNA [100010801],,,76.8,,2040,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3X26MM CANN SPEEDTIP CCS LNG THRD SD HEXDRIVE 10 TI -,SUP-A-5881.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,AETNA [1000108],AETNA [100010801],,,76.8,,2040,0.518595,35041.66656,percent of total billed charges,,,
3.0 CANNULATED COMPRSCREW28MM-HD10- DISTAL THREAD 9MM -,SUP-A-5881.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2326.39,1628.473,AETNA [1000108],AETNA [100010801],,,76.8,,1786.67,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3 X 30 CANN COMPR DISTAL THREAD -,SUP-A-5881.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,AETNA [1000108],AETNA [100010801],,,76.8,,2040,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3 X 36 CANN COMPR DISTAL THREAD -,SUP-A-5881.36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,AETNA [1000108],AETNA [100010801],,,76.8,,2040,0.518595,35041.66656,percent of total billed charges,,,
SCREW EXTFIX 6/5MM DIA 100/ 40MM CORT TAPR DYNFX THRD -,SUP-A6010040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW EXTFIX 6MM/5X150MM CORT TAPR DYNFX VISION 50MM THRD -,SUP-A6015050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW EXTFIX 6MM/5X180MM CORT TAPR DYNFX VISION 50MM THRD -,SUP-A6018050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANULATED COMPR 44MM -,SUP-A-8112.44/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1707.29,1195.103,AETNA [1000108],AETNA [100010801],,,76.8,,1311.2,0.518595,35041.66656,percent of total billed charges,,,
"PLATE M LK ""L"" 2/4 H LEFT -",SUP-AÂ€4650.20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3601.51,2521.057,AETNA [1000108],AETNA [100010801],,,76.8,,2765.96,0.518595,35041.66656,percent of total billed charges,,,
SYS BONE CMNT BIOCARTILAGE 3ML STRL -,SUP-ABS-1000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,AETNA [1000108],AETNA [100010801],,,76.8,,846.97,0.518595,35041.66656,percent of total billed charges,,,
BIOCARTILAGE KIT SMALL JOINT -,SUP-ABS-1000-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,AETNA [1000108],AETNA [100010801],,,76.8,,997.34,0.518595,35041.66656,percent of total billed charges,,,
FUNNEL BNCMNT BIOCARTILAGE -,SUP-ABS-1003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,163.38,114.366,AETNA [1000108],AETNA [100010801],,,76.8,,125.48,0.518595,35041.66656,percent of total billed charges,,,
BIOCARTILAGE 1CC -,SUP-ABS-1010-BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4678.52,3274.964,AETNA [1000108],AETNA [100010801],,,76.8,,3593.1,0.518595,35041.66656,percent of total billed charges,,,
TACKER ABSORBATACK 5MM 30X -,SUP-ABSTACK30X,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2266.08,1586.256,AETNA [1000108],AETNA [100010801],,,76.8,,1740.35,0.518595,35041.66656,percent of total billed charges,,,
WAVEFORM C INTERBODY 16 X 14 X 7MM 7 DEG 3D -,SUP-AC4-264077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE WAVEFORM C INTERBODY 16 X 14X 8MM 7 DEGREE 3D -,SUP-AC4-264087,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,0.518595,35041.66656,percent of total billed charges,,,
SCREW 24MM COMPR HDLS ACUTRAK ACUTWIST FLLY W THRD PTCH -,SUP-AI-0024-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,AETNA [1000108],AETNA [100010801],,,76.8,,1066.54,0.518595,35041.66656,percent of total billed charges,,,
SCREW 26MM COMPR HDLS ACUTRAK ACUTWIST FLLY W THRD PTCH -,SUP-AI-0026-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,AETNA [1000108],AETNA [100010801],,,76.8,,1066.54,0.518595,35041.66656,percent of total billed charges,,,
SCREW 28MM COMPR HDLS ACUTRAK ACUTWIST FLLY W THRD PTCH -,SUP-AI-0028-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,AETNA [1000108],AETNA [100010801],,,76.8,,1066.54,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4-5X25MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0025-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,AETNA [1000108],AETNA [100010801],,,76.8,,2002.83,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4-5X30MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0030-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,AETNA [1000108],AETNA [100010801],,,76.8,,2002.83,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4-5X35MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0035-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,AETNA [1000108],AETNA [100010801],,,76.8,,2002.83,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4-5X40MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0040-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,AETNA [1000108],AETNA [100010801],,,76.8,,2002.83,0.518595,35041.66656,percent of total billed charges,,,
SCREW 45MM ACUTRAK 4/5 -,SUP-AM-0045-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,AETNA [1000108],AETNA [100010801],,,76.8,,2002.83,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5-6.5X50MM CANN HDLS ACUTRAK + 3MM HX DRV TI ALY STRL -,SUP-AP-0050-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2410.87,1687.609,AETNA [1000108],AETNA [100010801],,,76.8,,1851.55,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5-6.5X60MM CANN HDLS ACUTRAK + 3MM HX DRV TI ALY STRL -,SUP-AP-0060-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2410.87,1687.609,AETNA [1000108],AETNA [100010801],,,76.8,,1851.55,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE PLATE 10MM -,SUP-AP1-110010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,0.518595,35041.66656,percent of total billed charges,,,
PLATE 12MM -,SUP-AP1-110012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE 13MM PLATE -,SUP-AP1-110013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE ADMIRAL 14MM PLATE -,SUP-AP1-110014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE ANTERIOR CERVICAL PLATE 16MM -,SUP-AP1-110016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,0.518595,35041.66656,percent of total billed charges,,,
PLATE 30MM -,SUP-AP1-200030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
ADMIRAL PLATE 36MM -,SUP-AP1-200036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE PLATE 28MM -,SUP-AP1-210028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,0.518595,35041.66656,percent of total billed charges,,,
PLATE ADMIRAL 32MM SEASPINE -,SUP-AP1-210032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,0.518595,35041.66656,percent of total billed charges,,,
PLATE ADMIRAL 36MM SPINE CERVICAL 2 LEVEL SEASPINE -,SUP-AP1-210036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE PLATE 54MM -,SUP-AP1-310054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,0.518595,35041.66656,percent of total billed charges,,,
SCREW ST 4 X 14 -,SUP-AP1-604014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,,,
ADMIRAL SCREW 4X14 -,SUP-AP1-614014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE SCREW 4 X 10 -,SUP-AP1-704010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
SCREW 12MM -,SUP-AP1-704012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
SCREW ADMIRA 4 X 14MM SPINE SELF TAP VARIABLE ANGLE SEASPINE -,SUP-AP1-704014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
SCREW ADMIRAL 4.3 X 12MM SEASPINE -,SUP-AP1-704312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
SCREW ADMIRAL 4.3 X 14MM SPINE SELF TAP VARIABLE ANGLE -,SUP-AP1-704314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
SCREW ADMIRAL 4 X 12MM SEASPINE -,SUP-AP1-714012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE SCREW 4MM X 14MM SD -,SUP-AP1-714014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
SCREW ADMIRAL 4 X 16MM SEASPINE -,SUP-AP1-714016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
4.0 X 14 FIX SCREW -,SUP-AP1-724014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6-7.5X70MM CANN HDLS ACUTRAK 6/7 4MM HX DRV TI ALY -,SUP-AP-6770-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,AETNA [1000108],AETNA [100010801],,,76.8,,2002.83,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6-7.5X75MM CANN HDLS ACUTRACK 6/7 4MM HX DRV TI ALY -,SUP-AP-6775-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,AETNA [1000108],AETNA [100010801],,,76.8,,2002.83,0.518595,35041.66656,percent of total billed charges,,,
PLATE PROXIMAL ULNA 73MM LEFT -,SUP-APL-PUP-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5428.08,3799.656,AETNA [1000108],AETNA [100010801],,,76.8,,4168.77,0.518595,35041.66656,percent of total billed charges,,,
PLATE PROXIMAL ULNA 108MM / LEFT -,SUP-APL-PUP-6HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6175.02,4322.514,AETNA [1000108],AETNA [100010801],,,76.8,,4742.42,0.518595,35041.66656,percent of total billed charges,,,
PLATE PROXIMAL ULNA 108MM / RIGHT -,SUP-APL-PUP-6HR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6175.02,4322.514,AETNA [1000108],AETNA [100010801],,,76.8,,4742.42,0.518595,35041.66656,percent of total billed charges,,,
PLATE BONE 151MM ULNA LEFT PROXIMAL -,SUP-APL-PUP-9HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6531.52,4572.064,AETNA [1000108],AETNA [100010801],,,76.8,,5016.21,0.518595,35041.66656,percent of total billed charges,,,
GUIDEPIN ARSCP 1.1MM BLNT TIP F/BIOINTF SCR -,SUP-AR-1249,CDM,C1713,HCPCS,278,RC,,,outpatient,,,122.54,85.778,AETNA [1000108],AETNA [100010801],,,76.8,,94.11,0.518595,35041.66656,percent of total billed charges,,,
GUIDEPIN ARSCP 2.4MM DRILL TIP F/BIOINTF SCR -,SUP-AR-1250L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,,,
DRILL SYSTEM FIXATION TIGHTROPE BTBT IB W/FLIPCUTTER III -,SUP-AR-1288BTBIB-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4816.94,3371.858,AETNA [1000108],AETNA [100010801],,,76.8,,3699.41,0.518595,35041.66656,percent of total billed charges,,,
DRILL TIGHTROPE RT IB W/FLIPCUTTER III -,SUP-AR-1288RTIB-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4477.42,3134.194,AETNA [1000108],AETNA [100010801],,,76.8,,3438.66,0.518595,35041.66656,percent of total billed charges,,,
FIBERTAG TIGHTROPE II IMPLANT W/ FLIPCUTTER III DRILL -,SUP-AR-1288RTT2-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,AETNA [1000108],AETNA [100010801],,,76.8,,3308.28,0.518595,35041.66656,percent of total billed charges,,,
FIBER TAG TIGHTROPE WITH FLIPCUTTER III -,SUP-AR-1288RTT-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,AETNA [1000108],AETNA [100010801],,,76.8,,3308.28,0.518595,35041.66656,percent of total billed charges,,,
GUIDEPIN ARSCP 2.4MM SUT EYE -,SUP-AR-1297L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,396.78,277.746,AETNA [1000108],AETNA [100010801],,,76.8,,304.73,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X10MM CORT FT SLD TI STRL F/OSTMY SYS -,SUP-AR-13120T-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X10MM CANN LAG CORT P/T ST SLD TI F/OSTMY SYS -,SUP-AR-13120T-10C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X12MM CANN LAG CORT P/T ST SLD TI F/OSTMY SYS -,SUP-AR-13120T-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X14MM CANN LAG CORT P/T ST SLD TI F/OSTMY SYS -,SUP-AR-13120T-14C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X16MM CANN LAG CORT P/T ST SLD TI STRL F/OSTMY SYS -,SUP-AR-13120T-16C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
NANO CORKSCREW FT TI W3-0 FW -,SUP-AR-1317FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUTURE MICRO CORKSCREW FT 2.2 X 4MM -,SUP-AR-1318FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA [1000108],AETNA [100010801],,,76.8,,1160.17,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 12.5MM OPN WDG SS -,SUP-AR-13200-12.5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 12.5MM TI SLP STRL -,SUP-AR-13200ST-12.5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUTURE TAK MICRO 2.4 X 6.5 BIOCOMPOSITE -,SUP-AR-1320BCNF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,AETNA [1000108],AETNA [100010801],,,76.8,,1323,0.518595,35041.66656,percent of total billed charges,,,
BB-TAK THREADED -,SUP-AR-13226T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,76.8,,380.91,0.518595,35041.66656,percent of total billed charges,,,
SUTURETAPE S-TAK ASSY 3.0 SINGLE LOADED -,SUP-AR-1322BCST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,0.518595,35041.66656,percent of total billed charges,,,
SUTURETAPE S-TAK ASSY 3.0 SINGLE LOADED -,SUP-AR-1322BCST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X45MM CANC HTO PLATE TI F/OSTMY SYS -,SUP-AR-13280-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5X50MM CANC HTO PLATE TI F/OSTMY SYS -,SUP-AR-13280-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,,,
GUIDEPIN ARSCP 2.4MM F/OSTM -,SUP-AR-13303-2.4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,215.9,151.13,AETNA [1000108],AETNA [100010801],,,76.8,,165.81,0.518595,35041.66656,percent of total billed charges,,,
GUIDEPIN SURG 3MM -,SUP-AR-13303-3.0,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,,,
SUBSTITUTE B TCP OPN WDG OSFERION 7MM 30MM -,SUP-AR-13370-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,0.518595,35041.66656,percent of total billed charges,,,
SUBSTITUTE B TCP WDG OSFERION 15X35MM -,SUP-AR-13370-4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X40MM CORT HTO PLATE TI F/OSTMY SYS -,SUP-AR-13380-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X46MM CORT HTO PLATE TI F/OSTMY SYS -,SUP-AR-13380-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUT IBALANCE 6.5X24MM HI TIB OPN PEEK -,SUP-AR-13401-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUT IBALANCE 6.5X28MM HI TIB OPN PEEK -,SUP-AR-13401-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SFT TIS CORT 4.5X38MM IBALANCE HTO -,SUP-AR-13402-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUT IBALANCE 4.5X40MM HI TIB OPN PEEK -,SUP-AR-13402-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUT IBALANCE HTO 4.5X48MM HI TIB OPN NABSB PEEK -,SUP-AR-13402-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,,,
PIN ARSCP FX 5X40MM PLLA FEM ABSB TRNSFX II F/ACL RECON -,SUP-AR-1351B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,AETNA [1000108],AETNA [100010801],,,76.8,,1176.45,0.518595,35041.66656,percent of total billed charges,,,
PIN ARSCP FX 5X50MM PLLA FEM ABSB TRNSFX II F/ACL RECON -,SUP-AR-1351LB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,AETNA [1000108],AETNA [100010801],,,76.8,,1176.45,0.518595,35041.66656,percent of total billed charges,,,
SCREW INTFR CANN 6X23MM RND HEAD STP TAPR BIOCMPS FEM DBL -,SUP-AR-1360C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA [1000108],AETNA [100010801],,,76.8,,956.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW SILK 7 X 20 NON SHEATHED -,SUP-AR-1370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.64,822.248,AETNA [1000108],AETNA [100010801],,,76.8,,902.12,0.518595,35041.66656,percent of total billed charges,,,
SCREW INTFR CANN 7X23MM ABSB SHTH RND HEAD STP TAPR BIOCMPS -,SUP-AR-1370B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,AETNA [1000108],AETNA [100010801],,,76.8,,636.34,0.518595,35041.66656,percent of total billed charges,,,
SCREW 7X23 BIOCOMPOSITE -,SUP-AR-1370C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA [1000108],AETNA [100010801],,,76.8,,956.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW INTFR CANN TIGHTROPE RT 7X28MM FT ABSB RND HEAD STP -,SUP-AR-1370TC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA [1000108],AETNA [100010801],,,76.8,,956.64,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN CONTR LOCK HTO 12.5MM A/P SLP WDG -,SUP-AR-13725-12.5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW 8X23MM BIO -,SUP-AR-1380C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA [1000108],AETNA [100010801],,,76.8,,956.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW INTFR CANN 8X28MM FT ABSB TAPR PLLA TIB KN STRL -,SUP-AR-1380TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,AETNA [1000108],AETNA [100010801],,,76.8,,636.34,0.518595,35041.66656,percent of total billed charges,,,
SCREW 8 X 25 -,SUP-AR-1381,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,,,
SCREW SILK 9 X 2O NON SHEATHED -,SUP-AR-1390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.64,822.248,AETNA [1000108],AETNA [100010801],,,76.8,,902.12,0.518595,35041.66656,percent of total billed charges,,,
SCREW INTFR CANN TIGHTROPE RT 9X23MM SHTH ABSB HEX HEAD PLLA -,SUP-AR-1390B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,AETNA [1000108],AETNA [100010801],,,76.8,,636.34,0.518595,35041.66656,percent of total billed charges,,,
SCREW 9 X 23 BIOCOMPOSITE -,SUP-AR-1390C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA [1000108],AETNA [100010801],,,76.8,,956.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW INTFR CANN 9X28MM FT ABSB TAPR BIOCMPS PLLA TIB KN -,SUP-AR-1390TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,AETNA [1000108],AETNA [100010801],,,76.8,,636.34,0.518595,35041.66656,percent of total billed charges,,,
SCREW SILK 9 X 25 NON SHEATHED -,SUP-AR-1391,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.64,822.248,AETNA [1000108],AETNA [100010801],,,76.8,,902.12,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN SUTUREPLATE 90MM 3HL POLYAX TI STRL -,SUP-AR-14003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA [1000108],AETNA [100010801],,,76.8,,4872.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW INTFR CANN 10X23MM ABSB SHTH PLLA TIB KN GRD STRL -,SUP-AR-1400B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,AETNA [1000108],AETNA [100010801],,,76.8,,636.34,0.518595,35041.66656,percent of total billed charges,,,
SCREW 10 X 23 BIOCOMPOSITE -,SUP-AR-1400C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA [1000108],AETNA [100010801],,,76.8,,956.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW INTFR CANN 10X28MM ABSB FT TAPR PLLA TIB KN STRL -,SUP-AR-1400TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,AETNA [1000108],AETNA [100010801],,,76.8,,636.34,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X18MM NLCKG CORT SUTUREPLATE TI STRL F/ARTHPL -,SUP-AR-14118NL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,262.58,183.806,AETNA [1000108],AETNA [100010801],,,76.8,,201.66,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X20MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA [1000108],AETNA [100010801],,,76.8,,501.9,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X22MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA [1000108],AETNA [100010801],,,76.8,,501.9,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X26MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA [1000108],AETNA [100010801],,,76.8,,501.9,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X26MM NLCKG CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14126NL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,262.58,183.806,AETNA [1000108],AETNA [100010801],,,76.8,,201.66,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X28MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA [1000108],AETNA [100010801],,,76.8,,501.9,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X32MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA [1000108],AETNA [100010801],,,76.8,,501.9,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X34MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA [1000108],AETNA [100010801],,,76.8,,501.9,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X36MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA [1000108],AETNA [100010801],,,76.8,,501.9,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X38MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA [1000108],AETNA [100010801],,,76.8,,501.9,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X40MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA [1000108],AETNA [100010801],,,76.8,,501.9,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X50MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA [1000108],AETNA [100010801],,,76.8,,501.9,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X28MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA [1000108],AETNA [100010801],,,76.8,,501.9,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X32MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA [1000108],AETNA [100010801],,,76.8,,501.9,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X38MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA [1000108],AETNA [100010801],,,76.8,,501.9,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X48MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14248,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA [1000108],AETNA [100010801],,,76.8,,501.9,0.518595,35041.66656,percent of total billed charges,,,
KIT TENODESIS SCREW 3X8 DISPOSABLE -,SUP-AR-1530DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
FOREFOOT IB IMPLANT SYS PEEK -,SUP-AR-1530P-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5920.38,4144.266,AETNA [1000108],AETNA [100010801],,,76.8,,4546.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW TENODESIS PEEK 3.5 X 8 -,SUP-AR-1530PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2146.7,1502.69,AETNA [1000108],AETNA [100010801],,,76.8,,1648.67,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4 X 10MM BIOTENODESIS -,SUP-AR-1540BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,AETNA [1000108],AETNA [100010801],,,76.8,,1404.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW TENODESIS PEEK 4X10 -,SUP-AR-1540PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,AETNA [1000108],AETNA [100010801],,,76.8,,1282.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW INTFR BIO-TENODESIS 4.75X15MM BABSRB BIOCMPS ANKL/FT -,SUP-AR-1547BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,AETNA [1000108],AETNA [100010801],,,76.8,,1404.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW TENODESIS PEEK 4.75X15MM INTERFERENCE -,SUP-AR-1547PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,AETNA [1000108],AETNA [100010801],,,76.8,,1282.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW TENODESIS PEEK  5.5 X 15 -,SUP-AR-1555PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,AETNA [1000108],AETNA [100010801],,,76.8,,1282.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW INTFR CANN BIO-TENODESIS 6.25X15MM BABSRB PEEK HND -,SUP-AR-1562BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,AETNA [1000108],AETNA [100010801],,,76.8,,1404.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW TENODESIS PEEK 6.25X15 -,SUP-AR-1562PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,AETNA [1000108],AETNA [100010801],,,76.8,,1282.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW INTFR CANN BIO-TENODESIS 7X23MM BABSRB PLLA HND WRST -,SUP-AR-1570BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,AETNA [1000108],AETNA [100010801],,,76.8,,1404.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW INTFR CANN BIO-TENODESIS 8X23MM BABSRB PLLA HND WRST -,SUP-AR-1580BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,AETNA [1000108],AETNA [100010801],,,76.8,,1404.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 9X20MM CORT RETROSCREW FT RTRGD RND HEAD PLLA STRL -,SUP-AR-1586RB-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1131.99,792.393,AETNA [1000108],AETNA [100010801],,,76.8,,869.37,0.518595,35041.66656,percent of total billed charges,,,
RETRO BUTTON 15MM -,SUP-AR-1588-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA [1000108],AETNA [100010801],,,76.8,,956.64,0.518595,35041.66656,percent of total billed charges,,,
RETRO BUTTON 20mm -,SUP-AR-1588-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA [1000108],AETNA [100010801],,,76.8,,956.64,0.518595,35041.66656,percent of total billed charges,,,
RETRO BUTTON 12mm/25 -,SUP-AR-1588-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA [1000108],AETNA [100010801],,,76.8,,956.64,0.518595,35041.66656,percent of total billed charges,,,
RETRO BUTTON 12MM/30MM -,SUP-AR-1588-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA [1000108],AETNA [100010801],,,76.8,,956.64,0.518595,35041.66656,percent of total billed charges,,,
SYS ARTHROSCOPIC FX BTB TIGHTROPE RT F/ACL RECON -,SUP-AR-1588BTB-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2358.72,1651.104,AETNA [1000108],AETNA [100010801],,,76.8,,1811.5,0.518595,35041.66656,percent of total billed charges,,,
TIGHTROPE II RT WITH DEPLOYING SUTURE -,SUP-AR-1588RT-2J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2464.73,1725.311,AETNA [1000108],AETNA [100010801],,,76.8,,1892.91,0.518595,35041.66656,percent of total billed charges,,,
FIXATION ACL TIGHTROPE RT -,SUP-AR-1588RT-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,AETNA [1000108],AETNA [100010801],,,76.8,,1506.19,0.518595,35041.66656,percent of total billed charges,,,
FIXATION TIGHTROPE RT DBL -,SUP-AR-1588RT-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,AETNA [1000108],AETNA [100010801],,,76.8,,1506.19,0.518595,35041.66656,percent of total billed charges,,,
ACL TIGHTROPE WITH FIBER TAG -,SUP-AR-1588RTT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,0.518595,35041.66656,percent of total billed charges,,,
FIXATION ACL FEM TIGHTROPE -,SUP-AR-1588T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,,,
TIGHTROPE ABS BUTTON 11MM -,SUP-AR-1588TB-3IB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,AETNA [1000108],AETNA [100010801],,,76.8,,911.85,0.518595,35041.66656,percent of total billed charges,,,
TIGHTROPE ABS BUTTON 14MM -,SUP-AR-1588TB-4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,AETNA [1000108],AETNA [100010801],,,76.8,,911.85,0.518595,35041.66656,percent of total billed charges,,,
TIGHTROPE ABS BUTTON ROUND CONCAVE 20MM -,SUP-AR-1588TB-5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,AETNA [1000108],AETNA [100010801],,,76.8,,911.85,0.518595,35041.66656,percent of total billed charges,,,
TIGHTROPE ABS BUTTON 20MM -,SUP-AR-1588TB-5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,AETNA [1000108],AETNA [100010801],,,76.8,,911.85,0.518595,35041.66656,percent of total billed charges,,,
IMPLANT TIGHTROPE ABS -,SUP-AR-1588TN,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,AETNA [1000108],AETNA [100010801],,,76.8,,824.56,0.518595,35041.66656,percent of total billed charges,,,
OPEN TIGHTROPE ABS -,SUP-AR-1588TN-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1131.99,792.393,AETNA [1000108],AETNA [100010801],,,76.8,,869.37,0.518595,35041.66656,percent of total billed charges,,,
IMPLANT FIXATION TIGHTROPE II ABS -,SUP-AR-1588TN-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA [1000108],AETNA [100010801],,,76.8,,1160.17,0.518595,35041.66656,percent of total billed charges,,,
TIGHTROPE II ABS- IMPLANT OPEN -,SUP-AR-1588TN-21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
ACL TIGHTROPE WITH FIBER TAG ABS -,SUP-AR-1588TNT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1775.67,1242.969,AETNA [1000108],AETNA [100010801],,,76.8,,1363.71,0.518595,35041.66656,percent of total billed charges,,,
TIGHTROPE BUTTON EXTENDER -,SUP-AR-1589RT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,0.518595,35041.66656,percent of total billed charges,,,
SCREW INTFR CANN BIO-TENODESIS 9X23MM BABSRB PLLA HND WRST -,SUP-AR-1590BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,AETNA [1000108],AETNA [100010801],,,76.8,,1404.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW INTFR BIO-TENODESIS 5.5X10MM BABSRB PEEK ANKL/FT HND -,SUP-AR-1655PS-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA [1000108],AETNA [100010801],,,76.8,,1160.17,0.518595,35041.66656,percent of total billed charges,,,
SCREW INTFR BIO-TENODESIS 5.5X12MM PEEK SHOLUDER ELB -,SUP-AR-1655PS-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA [1000108],AETNA [100010801],,,76.8,,1160.17,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SWIVELOCK  BIOCOMPOSITE 8MM X 19.5MM -,SUP-AR-1662BC-8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2305.72,1614.004,AETNA [1000108],AETNA [100010801],,,76.8,,1770.79,0.518595,35041.66656,percent of total billed charges,,,
SYSTEM LATERAL ANKLE RECON -,SUP-AR-1675BC-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA [1000108],AETNA [100010801],,,76.8,,5703.94,0.518595,35041.66656,percent of total billed charges,,,
SCREW INTFR CANN BIO-TENODESIS 8X12MM BABSRB PLLA SFT TIS -,SUP-AR-1680BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,AETNA [1000108],AETNA [100010801],,,76.8,,1404.42,0.518595,35041.66656,percent of total billed charges,,,
KIT IB BC W/CC FT AND JUMPSTART IMPLANT SYSTEM -,SUP-AR-1788J-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA [1000108],AETNA [100010801],,,76.8,,4872.79,0.518595,35041.66656,percent of total billed charges,,,
KIT IB BC W/CC FT AND JUMPSTART -,SUP-AR-1788J-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA [1000108],AETNA [100010801],,,76.8,,4872.79,0.518595,35041.66656,percent of total billed charges,,,
SWIVEL LOCK INTERNAL BRACE -,SUP-AR-1788J-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA [1000108],AETNA [100010801],,,76.8,,4872.79,0.518595,35041.66656,percent of total billed charges,,,
LOW PROFILE SCREW 1.0 X 6MM CORTICAL TI -,SUP-AR-18710-06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,,,
LOW PROFILE SCREW 1.0 X 7MM CORTICAL TI -,SUP-AR-18710-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOW PROFILE 2.4 X 10 CORTICAL -,SUP-AR-18724-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOW PROFILE 2.4 X 26 CORTICAL -,SUP-AR-18724-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,,,
T-PLATE 2.4MM 6 HOLE -,SUP-AR-18724P-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,,,
TISSUE TAK TENDON ANCHOR -,SUP-AR-19021TT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUTURE CORKSCREW FT 3.5X10MM -,SUP-AR-1915FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA [1000108],AETNA [100010801],,,76.8,,1160.17,0.518595,35041.66656,percent of total billed charges,,,
ARTHREX SUTURE ANCHCRKSCRW FT3.5X10MM -,SUP-AR-1915FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA [1000108],AETNA [100010801],,,76.8,,1160.17,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUT CRKSCR 3.5X12MM THRD TI #2 SUT -,SUP-AR-1915S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,76.8,,806.63,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUT CRKSCR 5X15MM ABSB -,SUP-AR-1920BF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1378.13,964.691,AETNA [1000108],AETNA [100010801],,,76.8,,1058.4,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUTURE CORKSCREW 5.0 -,SUP-AR-1920S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,76.8,,806.63,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUT PSHLK 4.5X24MM BIOCMPS -,SUP-AR-1922BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUT BIO-PSHLK 4.5MMX18.5MM ABSB SLF-PNCH PLLA TI TIP -,SUP-AR-1922BM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2067.2,1447.04,AETNA [1000108],AETNA [100010801],,,76.8,,1587.61,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR PUSHLOCK 2.9 X 15.5 BIO -,SUP-AR-1923BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR PUSHLOK PEEK 2.9X15.5 -,SUP-AR-1923PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,AETNA [1000108],AETNA [100010801],,,76.8,,1465.48,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUT CRKSCR 6.5MMX15.5MM THRD ST TI SZ2 GRN WHT SUT -,SUP-AR-1925S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,76.8,,806.63,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR CORKSCREW 6.5 FIBER 2 2 -,SUP-AR-1925SF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,76.8,,873.85,0.518595,35041.66656,percent of total billed charges,,,
BIO-PUSHLOCK COMPOSITE 3.5MM -,SUP-AR-1926BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUT PSHLK 3.5MMX19.5MM PEEK HNDL INSRTR DRIVER -,SUP-AR-1926PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,AETNA [1000108],AETNA [100010801],,,76.8,,1465.48,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUT CRKSCR FT 5.5MMX14.7MM ARSCP FT BABSRB BIOCMPS -,SUP-AR-1927BCF-3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1802.17,1261.519,AETNA [1000108],AETNA [100010801],,,76.8,,1384.07,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR 4.5 BIO-COMPOSITE -,SUP-AR-1927BCF-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,AETNA [1000108],AETNA [100010801],,,76.8,,1323,0.518595,35041.66656,percent of total billed charges,,,
6.5 BIOCOMPOSITE ANCHORS -,SUP-AR-1927BCF-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1775.67,1242.969,AETNA [1000108],AETNA [100010801],,,76.8,,1363.71,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR BIO CORKSCREW 5.5 -,SUP-AR-1927BCT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1881.68,1317.176,AETNA [1000108],AETNA [100010801],,,76.8,,1445.13,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR CORKSCREW 5.5 PEEK (BOX OF 5) -,SUP-AR-1927PSF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA [1000108],AETNA [100010801],,,76.8,,1160.17,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUT SUTAK 3MMX14.5MM ARSCP BIOCMPS ABSB #2 -,SUP-AR-1934BCF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1616.65,1131.655,AETNA [1000108],AETNA [100010801],,,76.8,,1241.59,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR BIOCOMPOSITE 3MM DBL -,SUP-AR-1934BCF-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,AETNA [1000108],AETNA [100010801],,,76.8,,1302.65,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUT SUTAK 2.4X12MM ARSCP BIOCMPS FIBERWIREX2 -,SUP-AR-1934BCF-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1616.65,1131.655,AETNA [1000108],AETNA [100010801],,,76.8,,1241.59,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUT SUTAK 2.4X12MM ARSCP BIOCMPS FIBERWIRE -,SUP-AR-1934BCF-24-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,AETNA [1000108],AETNA [100010801],,,76.8,,1302.65,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR BIOCOMPOSITE 3MM SING -,SUP-AR-1934BCT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1802.17,1261.519,AETNA [1000108],AETNA [100010801],,,76.8,,1384.07,0.518595,35041.66656,percent of total billed charges,,,
BIO SUTURE TAK DISPOSABLE -,SUP-AR-1934DS-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,933.6,653.52,AETNA [1000108],AETNA [100010801],,,76.8,,717,0.518595,35041.66656,percent of total billed charges,,,
KIT SUTURE TAK 3MM PERCUTANEOUS INSERTION -,SUP-AR-1934PI-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,76.8,,873.85,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR KNOTLESS SUT TAK 3MM BI -,SUP-AR-1938BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR PEEK SUT TAK 3MM KNOTLESS -,SUP-AR-1938PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,AETNA [1000108],AETNA [100010801],,,76.8,,1567.25,0.518595,35041.66656,percent of total billed charges,,,
IMPLANT DISTAL BICEP REPAIR 7 X 10MM -,SUP-AR-2260BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,0.518595,35041.66656,percent of total billed charges,,,
BUTTON SUT 2.6MM TI 12MM LF -,SUP-AR-2261,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
BUTTON SUT DOG BN LF -,SUP-AR-2270,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SWIVEL LOCK 5.5 -,SUP-AR-2323BCC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUT SWIVLK C 5.5MMX19.1MM ABSB CLSD EYLT PLLA -,SUP-AR-2323BSLC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1987.69,1391.383,AETNA [1000108],AETNA [100010801],,,76.8,,1526.55,0.518595,35041.66656,percent of total billed charges,,,
SWIVELOCK- SP BC KL 5.5MM -,SUP-AR-2323KBCSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUT SWIVLK 5.5MMX24.5MM SLF-PNCH PEEK -,SUP-AR2323PSLM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUT SWIVLK C 4.7MMX19.1MM CLSD EYLT BIOCMPS WHT/BLK -,SUP-AR-2324BCCTT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,AETNA [1000108],AETNA [100010801],,,76.8,,1913.27,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR BIO COMP SWIVELOCK SP 4 (MIN 5 EACH) -,SUP-AR-2324BCM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR BIO-SWIVELLOCK 4.75 -,SUP-AR-2324BCT-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR BIOCOMPOSITE SWIVEL W\FIBERTAPE -,SUP-AR-2324BCT-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SWIVELOCK  BIOCOMPOSITE 4.75MM X  22MM DOUBLE LOADED -,SUP-AR-2324BCT-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,0.518595,35041.66656,percent of total billed charges,,,
SWIVELOCK KNOTLESS 4.75MM BC -,SUP-AR-2324KBCC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,AETNA [1000108],AETNA [100010801],,,76.8,,1872.56,0.518595,35041.66656,percent of total billed charges,,,
KNOTLESS SWIVELOK 4.75MM BC W/TAPE -,SUP-AR-2324KBCCTT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2530.22,1771.154,AETNA [1000108],AETNA [100010801],,,76.8,,1943.21,0.518595,35041.66656,percent of total billed charges,,,
SWIVELOCK- SP BC KL 4.75MM -,SUP-AR-2324KBCSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUT BIO- SWIVLK SP 4.75MMX24.5MM SLF-PNCH PEEK TI -,SUP-AR-2324PSLM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,0.518595,35041.66656,percent of total billed charges,,,
BC SWIVELOCK 3.9 X 17.9 MM -,SUP-AR-2326BCC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,0.518595,35041.66656,percent of total billed charges,,,
KIT SPEEDBRIDGE SHOULDER -,SUP-AR-2600SBS-8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8106.04,5674.228,AETNA [1000108],AETNA [100010801],,,76.8,,6225.44,0.518595,35041.66656,percent of total billed charges,,,
PLATE DISTAL CLAVICLE 22 DEG RIGHT -,SUP-AR-2622DR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,,,
PLATE 8HL PRCONT SS LT CLVCL -,SUP-AR-2651CL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PRCONT SS RT CNTRL CLVCL -,SUP-AR-2653CR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN PRCONT SS LT CNTRL CLVCL -,SUP-AR-2654CL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,,,
PLATE CLAVICLE DISTAL SHOR LEFT SS -,SUP-AR-2656DL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,,,
PLATE CLAVICLE DISTAL SHORT RIGHT SS -,SUP-AR-2656DR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,,,
PLATE 8HL PRCONT SS RT CLVCL -,SUP-AR-2657DR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,,,
PLATE DISTAL CLAVICLE BUTTON -,SUP-AR-2658,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,,,
DISTAL CLAVICLE REPAIR ASSEMBLY -,SUP-AR-2658T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
SUTURE ANCHOR- BIOCOMPOSITE- HIP PUSHLOCK- SHORT 2.9 x 12.5 -,SUP-AR-2923BCH,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,0.518595,35041.66656,percent of total billed charges,,,
KIT DISPOSABLES FOR FIBERTAK SUTR ANCH -,SUP-AR-3600DC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,76.8,,873.85,0.518595,35041.66656,percent of total billed charges,,,
FIBERTAK WITH SUTURETAPE -,SUP-AR-3602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1881.68,1317.176,AETNA [1000108],AETNA [100010801],,,76.8,,1445.13,0.518595,35041.66656,percent of total billed charges,,,
2.6 FIBERTAK ANCHOR DOUBLE  LOADED -,SUP-AR-3632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,AETNA [1000108],AETNA [100010801],,,76.8,,1506.19,0.518595,35041.66656,percent of total billed charges,,,
FIBERTAK ANCHOR TRIPLE LOADED -,SUP-AR-3633,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,AETNA [1000108],AETNA [100010801],,,76.8,,1567.25,0.518595,35041.66656,percent of total billed charges,,,
SELF-PUNCHING TRIPLE LOADED FIBERTAK -,SUP-AR-3633SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,AETNA [1000108],AETNA [100010801],,,76.8,,1669.03,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR FIBERTAK KNOTLESS -,SUP-AR-3636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,0.518595,35041.66656,percent of total billed charges,,,
FIBERTAK SHOULDER 1.8 SELF BUNCHING -,SUP-AR-3636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,0.518595,35041.66656,percent of total billed charges,,,
FIBERTAK HIP 1.8 SELF BUNCHING -,SUP-AR-3636H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA [1000108],AETNA [100010801],,,76.8,,1933.62,0.518595,35041.66656,percent of total billed charges,,,
KNOTLESS 1.8 FIBERTAK W/ #2 SUTURE -,SUP-AR-3638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,0.518595,35041.66656,percent of total billed charges,,,
KNOTLESS HIP FIBERTAK SUTURE ANCHOR- CURVED -,SUP-AR-3638DHC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
KIT FIBERTAK KNOTLESS STRAIGHT DISPOSABLE -,SUP-AR-3638DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,,,
SP FBTAK RC TGRTPE WH/BLK & STTPE WH/BL -,SUP-AR-3652SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,AETNA [1000108],AETNA [100010801],,,76.8,,1913.27,0.518595,35041.66656,percent of total billed charges,,,
SP FBTAC RC RBRTPE BLU & STTPE WH/BLK -,SUP-AR-3652TSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,AETNA [1000108],AETNA [100010801],,,76.8,,1913.27,0.518595,35041.66656,percent of total billed charges,,,
SP FBTAC RC RBRTPE BLK/BLU & STTPE BLU -,SUP-AR-3652TTSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,AETNA [1000108],AETNA [100010801],,,76.8,,1913.27,0.518595,35041.66656,percent of total billed charges,,,
KL FBTK RC (WH/BLK)TT & (BLU)#2 MTS -,SUP-AR-3653SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2530.22,1771.154,AETNA [1000108],AETNA [100010801],,,76.8,,1943.21,0.518595,35041.66656,percent of total billed charges,,,
KL FBTK RC W/(BLU)FT & (W/BLK) #2 MTS -,SUP-AR-3653TSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2530.22,1771.154,AETNA [1000108],AETNA [100010801],,,76.8,,1943.21,0.518595,35041.66656,percent of total billed charges,,,
KNOTLESS TENSIONABLE FIBERTAK BICEP -,SUP-AR-3687,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,0.518595,35041.66656,percent of total billed charges,,,
ARTHROSCOPIC FX CHNDR -,SUP-AR-4005B-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,AETNA [1000108],AETNA [100010801],,,76.8,,542.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW VENTED BC IF 7 X 20MM -,SUP-AR-4020C-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW VENTED BC IF 8 X 20MM -,SUP-AR-4020C-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW VENTED BC IF 9 X 20MM -,SUP-AR-4020C-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW VENTED BC IF 10 X 20MM -,SUP-AR-4020C-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
ARTHREX PEEK SCREW 7 X 20MM FAST THREAD -,SUP-AR-4020P-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW ARTHREX PEEK 8 X 20MM FAST THREAD -,SUP-AR-4020P-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW ARTHREX PEEK 9 X 20MM FAST THREAD -,SUP-AR-4020P-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW ARTHREX PEEK 10 X 20MM FAST THREAD -,SUP-AR-4020P-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW VENTED BC IF 7 X 30MM -,SUP-AR-4030C-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW VENTED BC IF 8 X 30MM -,SUP-AR-4030C-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW VENTED BC IF 9 X 30MM -,SUP-AR-4030C-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW VENTED BC IF 10 X 30MM -,SUP-AR-4030C-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW VENTED BC IF 11 X 30MM -,SUP-AR-4030C-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
ARTHREX PEEK SCREW 7 X 30MM FAST THREAD -,SUP-AR-4030P-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW ARTHREX PEEK 8 X 20MM FAST THREAD -,SUP-AR-4030P-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW ARTHREX PEEK 9 X 30MM FAST THREAD -,SUP-AR-4030P-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW ARTHREX PEEK 10 X 30MM FAST THREAD -,SUP-AR-4030P-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
DEVICE SUT 1.5X5MM CRV C IN MNSCL 2-0 FIBERWIRE NDLX2 MINI -,SUP-AR-4500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA [1000108],AETNA [100010801],,,76.8,,1160.17,0.518595,35041.66656,percent of total billed charges,,,
KIT BIOCOMPOSITE MENISCAL ROOT REPAIR -,SUP-AR-4550BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,0.518595,35041.66656,percent of total billed charges,,,
FIBER STITCH CURVED -,SUP-AR-4570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUTURE FIBERSTITCH FIBERWIRE POLYESTER 24 D 2-0 CURVE -,SUP-AR-4570-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,0.518595,35041.66656,percent of total billed charges,,,
KIT ARTHROSCOPIC FIXATION FIBERSTITCH REVERSE CURVE -,SUP-AR-4570R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUTURE FIBERSTITCH STRAIGHT -,SUP-AR-4570S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,0.518595,35041.66656,percent of total billed charges,,,
SCREW INTFR BIOCMPRSN 3X18MM BABSRB HDLS PLLA KN TAPR STP -,SUP-AR-5025B-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,AETNA [1000108],AETNA [100010801],,,76.8,,1607.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW INTFR BIOCMPRSN 2.7X20MM BABSRB HDLS PLLA KN TAPR STP -,SUP-AR-5025B-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,AETNA [1000108],AETNA [100010801],,,76.8,,1607.96,0.518595,35041.66656,percent of total billed charges,,,
SCREW 8 X 28 BIOCOMPOSITE -,SUP-AR-5028C-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA [1000108],AETNA [100010801],,,76.8,,956.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 9X28 DELTA -,SUP-AR-5028C-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA [1000108],AETNA [100010801],,,76.8,,956.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 10 X 28 BIOCOMPOSITE -,SUP-AR-5028C-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA [1000108],AETNA [100010801],,,76.8,,956.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 11 X 28 DELTA -,SUP-AR-5028C-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA [1000108],AETNA [100010801],,,76.8,,956.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 9 X 35 DELTA -,SUP-AR-5035TC-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA [1000108],AETNA [100010801],,,76.8,,956.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 10 X 35 BIOCOMPOSITE -,SUP-AR-5035TC-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA [1000108],AETNA [100010801],,,76.8,,956.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 11 X 35 DELTA -,SUP-AR-5035TC-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA [1000108],AETNA [100010801],,,76.8,,956.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 12 X 35 BIOCOMPOSITE -,SUP-AR-5035TC-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA [1000108],AETNA [100010801],,,76.8,,956.64,0.518595,35041.66656,percent of total billed charges,,,
WIRE GUIDE 1.35MM DUAL TROCAR -,SUP-AR-5050-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,239.24,167.468,AETNA [1000108],AETNA [100010801],,,76.8,,183.74,0.518595,35041.66656,percent of total billed charges,,,
GRAFTBOLT TIBIAL 7MM -,SUP-AR-5100-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,AETNA [1000108],AETNA [100010801],,,76.8,,1607.96,0.518595,35041.66656,percent of total billed charges,,,
GRAFTBOLT TIBIAL 8MM -,SUP-AR-5100-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,AETNA [1000108],AETNA [100010801],,,76.8,,1607.96,0.518595,35041.66656,percent of total billed charges,,,
GRAFTBOLT TIBIAL 9MM -,SUP-AR-5100-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,AETNA [1000108],AETNA [100010801],,,76.8,,1607.96,0.518595,35041.66656,percent of total billed charges,,,
GRAFTBOLT TIBIAL 10MM -,SUP-AR-5100-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,AETNA [1000108],AETNA [100010801],,,76.8,,1607.96,0.518595,35041.66656,percent of total billed charges,,,
SUTURE ANCHOR- SWIVELOCK TENODESIS- PEEK -,SUP-AR-7324PSL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2969.43,2078.601,AETNA [1000108],AETNA [100010801],,,76.8,,2280.52,0.518595,35041.66656,percent of total billed charges,,,
LOW PROFILE SCREW TI 4.5 X 26MM -,SUP-AR-8545-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
LOW PROFILE SCREW TI 4.5 X 34MM -,SUP-AR-8545-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
LOW PROFILE SCREW TI 4.5 X 36MM -,SUP-AR-8545-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
LO-PRO LOCK SCREW TI 4.5 X 28MM -,SUP-AR-8545L-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,76.8,,873.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X55MM LCK -,SUP-AR-8545L-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,76.8,,873.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X60MM LCK -,SUP-AR-8545L-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,76.8,,873.85,0.518595,35041.66656,percent of total billed charges,,,
IMPLANT SYSTEM CPR MINI SCORPION DX -,SUP-AR-8690DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,0.518595,35041.66656,percent of total billed charges,,,
STAPLE BN FX QUICKFIX SM SS -,SUP-AR-8710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,,,
NITINOL COMPRESSION STAPLE- 9WX7L -,SUP-AR-8717-0907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,0.518595,35041.66656,percent of total billed charges,,,
NITINOL COMPRESSION STAPLE- 9WX10L -,SUP-AR-8717-0910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,0.518595,35041.66656,percent of total billed charges,,,
DYNANITE NITI STAPLE W/INSTRS 9WX10L -,SUP-AR-8717DS-0910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA [1000108],AETNA [100010801],,,76.8,,4872.79,0.518595,35041.66656,percent of total billed charges,,,
DYNANITE NITI STAPLE W/INSTRS 10W X 11L -,SUP-AR-8717DS-1110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA [1000108],AETNA [100010801],,,76.8,,4872.79,0.518595,35041.66656,percent of total billed charges,,,
DYNANITE NITI STAPLE W/INSTRS 11W X 15\12L -,SUP-AR-8717DS-111512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA [1000108],AETNA [100010801],,,76.8,,4872.79,0.518595,35041.66656,percent of total billed charges,,,
NITINOL COMP STAPLE 15W X 12L -,SUP-AR-8718-1512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA [1000108],AETNA [100010801],,,76.8,,4872.79,0.518595,35041.66656,percent of total billed charges,,,
STAPLER DYNAMITE NITI  W/INSTRS 13W X 10L -,SUP-AR-8718DS-1310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8042.38,5629.666,AETNA [1000108],AETNA [100010801],,,76.8,,6176.55,0.518595,35041.66656,percent of total billed charges,,,
DYN NITI STAPLE W/INSTRS 15W X 12L -,SUP-AR-8718DS-1512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8042.38,5629.666,AETNA [1000108],AETNA [100010801],,,76.8,,6176.55,0.518595,35041.66656,percent of total billed charges,,,
STAPLE 15W X 15L DYNANITE NITI W/INSTRS -,SUP-AR-8719DS-1515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,0.518595,35041.66656,percent of total billed charges,,,
DYN NITI STAPLE W/INSTRS 18W X 15L -,SUP-AR-8719DS-1815,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,0.518595,35041.66656,percent of total billed charges,,,
STAPLE DYNANITE NITI W/INSTRS 18W X 18L -,SUP-AR-8719DS-1818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,0.518595,35041.66656,percent of total billed charges,,,
DYNANITE NITI STAPLE WINSTRS 20W X 20L -,SUP-AR-8719DS-2020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,0.518595,35041.66656,percent of total billed charges,,,
QCKFIX SCRW TI CANN PT 2.0 X 10MM -,SUP-AR-8720-10PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,AETNA [1000108],AETNA [100010801],,,76.8,,627.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.4X12MM HD CORT QUICKFIX ST SLD STND ALONE TI STRL -,SUP-AR-8724-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOW PROFILE 2.4 X 14 CORTEX -,SUP-AR-8724-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,,,
LOW PROFILE SCREW 2.4 X 18MM CORTEX -,SUP-AR-8724-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,,,
SCREW QUICKFIX 2.4 X 18MM TI CANNULATED -,SUP-AR-8724-18PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,846.08,592.256,AETNA [1000108],AETNA [100010801],,,76.8,,649.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW QUICKFIX 2.4 X 22MM TI CANNULATED -,SUP-AR-8724-22PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,846.08,592.256,AETNA [1000108],AETNA [100010801],,,76.8,,649.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.4X24MM CANN QUICKFIX P/T T8 HXLB DRV TI F/CMPRHNSV -,SUP-AR-8724-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,,,
LOW PROFILE SCREW 2.4 X 32MM CORTEX -,SUP-AR-8724-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,,,
LOW PROFILE SCREW 2.4 X 36MM CORTEX -,SUP-AR-8724-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.4 X 8 VAL TI -,SUP-AR-8724V-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,AETNA [1000108],AETNA [100010801],,,76.8,,627.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.4 X 12 VAL TI -,SUP-AR-8724V-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,AETNA [1000108],AETNA [100010801],,,76.8,,627.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.4 X 16 VAL TI -,SUP-AR-8724V-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,AETNA [1000108],AETNA [100010801],,,76.8,,627.38,0.518595,35041.66656,percent of total billed charges,,,
2.4MM X 18MM V AL SCREW TI -,SUP-AR-8724V-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,AETNA [1000108],AETNA [100010801],,,76.8,,627.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW VAL TI 2.4MM X 18MM -,SUP-AR-8724V-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,AETNA [1000108],AETNA [100010801],,,76.8,,627.38,0.518595,35041.66656,percent of total billed charges,,,
2.4MM X 22MMV AL SCREW TI -,SUP-AR-8724V-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,AETNA [1000108],AETNA [100010801],,,76.8,,627.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW VAL KREULOCK TI 2.4X12 -,SUP-AR-8724VCL-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW VAL KREULOCK TI 2.4X16 -,SUP-AR-8724VCL-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW COMPRESSION FT 2.5MM MICRO X 8MM LGTH -,SUP-AR-8725-08H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5MMX14MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-14H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5MMX16MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-16H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5MMX18MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-18H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5MMX20MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-20H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW COMPR FT 2.5 MICRO 22MM -,SUP-AR-8725-22H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5MMX24MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-24H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5MMX26MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-26H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,,,
COMPR FT SCREW 2.5 MICRO 28MM LGTH -,SUP-AR-8725-28H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEADLESS MICRO 2.5X 30MM -,SUP-AR-8725-30H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,,,
COMPR FT SCREW 2.5 MICRO 32MM LGTH -,SUP-AR-8725-32H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW QUICKFIX TI CANC PT 3.0 X 12MM -,SUP-AR-8730-12PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX14MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8730-14H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3MMX14MM DUAL CORE QUICKFIX -,SUP-AR-8730-14PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
COMPR FT SCREW 3.5 MINI 16MM -,SUP-AR-8730-16H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3MMX16MM DUAL CORE QUICKFIX -,SUP-AR-8730-16PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
COMPR FT SCRW 3.5 MINI 18MM LGTH -,SUP-AR-8730-18H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3MMX18MM DUAL CORE QUICKFIX -,SUP-AR-8730-18PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
COMP SCREW 3.5 MINI 20MM -,SUP-AR-8730-20H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3MM X 20MM DUAL CORE QUICKFIX -,SUP-AR-8730-20PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
COMPR FT SCREW 3.5 MINI 22MM -,SUP-AR-8730-22H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3MMX22MM DUAL CORE QUICKFIX -,SUP-AR-8730-22PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW FT COMPR 3.5 X 24MM -,SUP-AR-8730-24H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3MMX24MM DUAL CORE QUICKFIX -,SUP-AR-8730-24PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW COMPR FT 3.5 X 26 MINI -,SUP-AR-8730-26H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3MMX26MM DUAL CORE QUICKFIX P/T SD/ST T10 HXLB DRV TI -,SUP-AR-8730-26PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW COMPR FT 3.5 MINI 28MM -,SUP-AR-8730-28H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW FT COMPR 3.5 X 30MM -,SUP-AR-8730-30H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.6MMX32MM COMPR HDLS QUICKFIX P/T SD/ST T10 HXLB DRV -,SUP-AR-8730-32H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,,,
COMPR FT SCREW 3.5 MINI 34MM LGTH -,SUP-AR-8730-34H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,,,
QCKFIX SCREW TI CANC PT 3.0 X 38MM -,SUP-AR-8730-38PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
LOW PROFILE SCREW CORTICAL 3.5MM X 14MM DRP -,SUP-AR-8735-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
LOW PROFILE SCREW CORTICAL 3.5MM X 16MM DRP -,SUP-AR-8735-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
LOW PROFILE SCREW CORTICAL 3.5MM X 18MM DRP -,SUP-AR-8735-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
3.5X32MM BEVELED FT SCREW -,SUP-AR-8735BV-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW BEVELED FT 3.5MM X40MM -,SUP-AR-8735BV-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5 X 44MM BEVELED FT -,SUP-AR-8735BV-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,,,
LOW PROFILE SCREW LOCKING 3.5MM X 16MM DRP -,SUP-AR-8735L-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,76.8,,380.91,0.518595,35041.66656,percent of total billed charges,,,
GUIDEWIRE 0.86MM W/ LASER LINE SS -,SUP-AR-8737-21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,87.53,61.271,AETNA [1000108],AETNA [100010801],,,76.8,,67.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW COMPR FT 4.0 STD 20MM LGTH -,SUP-AR-8740-20H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW COMPR FT 4.0 STD 22MM LGTH -,SUP-AR-8740-22H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,,,
COMPRESSION SCREW 4.0 24MM LENGTH -,SUP-AR-8740-24H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,,,
COMPRESSION SCREW 4.0 26MM LENGTH -,SUP-AR-8740-26H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,,,
COMPRESSION SCREW 4.0 28MM LENGTH -,SUP-AR-8740-28H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW COMPR FT 4.0 STD 30MM LGTH -,SUP-AR-8740-30H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW QUICKFIX TI CANN ST 4.0 X 38MM CANC -,SUP-AR-8740-38PTS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW QUICKFIX TI CANN 4.0 X 40MM ST CANC -,SUP-AR-8740-40PTS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,,,
4X46MM BEVELED FT SCREW -,SUP-AR-8740BV-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4 X 50MM BEVELED FT -,SUP-AR-8740BV-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4 X 52MM BEVELED FT -,SUP-AR-8740BV-52,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,,,
WASHER 7.0MM TI -,SUP-AR-8740W,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,76.8,,156.85,0.518595,35041.66656,percent of total billed charges,,,
GUIDEWIRE 1.6MM- 4MM BEVELED FT -,SUP-AR-8741-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,,,
GUIDEWIRE 1.6X150MM CAPITAL FRAG -,SUP-AR-8741-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,,,
SCREW COMPR FT 5.0 X 42MM -,SUP-AR-8750-42H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA [1000108],AETNA [100010801],,,76.8,,1933.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW COMPR FT 5.0 X 55MM -,SUP-AR-8750-55H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA [1000108],AETNA [100010801],,,76.8,,1933.62,0.518595,35041.66656,percent of total billed charges,,,
COMPR FT SCREW 7.0 XL 65MM LGTH -,SUP-AR-8770-65H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,AETNA [1000108],AETNA [100010801],,,76.8,,2548.17,0.518595,35041.66656,percent of total billed charges,,,
COMPR FT SCREW 7.0 XL 70MM LGTH -,SUP-AR-8770-70H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,AETNA [1000108],AETNA [100010801],,,76.8,,2548.17,0.518595,35041.66656,percent of total billed charges,,,
COMPR FT SCREW 7.0 XL 75MM LGTH -,SUP-AR-8770-75H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,AETNA [1000108],AETNA [100010801],,,76.8,,2548.17,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUT BIO-PSHLK 2.5X8MM KNTLS PLLA ABSB #2 FIBERWIRE -,SUP-AR-8825B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,AETNA [1000108],AETNA [100010801],,,76.8,,1465.48,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUTURE PEEK MINI PUSHLOCK -,SUP-AR-8825P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,AETNA [1000108],AETNA [100010801],,,76.8,,1465.48,0.518595,35041.66656,percent of total billed charges,,,
KREULOCK COMPRESSION SCREW SS 2.7 X 12MM -,SUP-AR-8827CL-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
KREULOCK COMPRESSION SCREW SS 2.7 X 14MM -,SUP-AR-8827CL-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
KREULOCK COMPRESSION SCREW SS 2.7 X 16MM -,SUP-AR-8827CL-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
KREULOCK COMPRESSION SCREW SS 2.7 X 18MM -,SUP-AR-8827CL-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
KREULOCK COMPRESSION SCREW SS 2.7 X 20MM -,SUP-AR-8827CL-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X10MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X12MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X18MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X20MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW LO-PRO LOCK SS 2.7 X 22 -,SUP-AR-8827L-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW LO-PRO LOCK 2.7 X 24 -,SUP-AR-8827L-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
CANCLUS SCREW FULLY THREADED SS 3 X 24MM -,SUP-AR-8830-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,76.8,,156.85,0.518595,35041.66656,percent of total billed charges,,,
LO-PRO SCREW TM SS 3.5 X 12MM CORT -,SUP-AR-8835-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,76.8,,156.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X14MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,76.8,,156.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X16MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,76.8,,156.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X18MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,76.8,,156.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X22MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,76.8,,156.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X26MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,76.8,,156.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X28MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,76.8,,156.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X30MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,76.8,,156.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X35MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,76.8,,156.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X45MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,76.8,,156.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X10MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X14MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X16MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X18MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X20MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X14MM NLCKG CANC TIGHTROPE FT SD T15 HXLB DRV SS -,SUP-AR-8840-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,76.8,,156.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X16MM NLCKG CANC TIGHTROPE FT SD T15 HXLB DRV SS -,SUP-AR-8840-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,76.8,,156.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X30MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X40MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X45MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X60MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X30MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X35MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X50MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X60MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,,,
PARS Suture Implant Kit w/ SutureTape -,SUP-AR-8862DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA [1000108],AETNA [100010801],,,76.8,,4872.79,0.518595,35041.66656,percent of total billed charges,,,
TIGHTROPE MINI 1.1MM -,SUP-AR-8914DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,AETNA [1000108],AETNA [100010801],,,76.8,,2548.17,0.518595,35041.66656,percent of total billed charges,,,
VOLAR DISTAL RAD PLT TI NARROW LT 3HOLE -,SUP-AR-8916VNL-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,,,
VOLAR DISTAL RAD PLT TI NARROW RT 3H -,SUP-AR-8916VNR-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,,,
IMPLANT MINI TIGHTROPE 1.1 - 0 -,SUP-AR-8919DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,AETNA [1000108],AETNA [100010801],,,76.8,,3281.46,0.518595,35041.66656,percent of total billed charges,,,
KT ARTHROSCOPIC FX TIGHTROPE ANKL 6.5MM RND BTN 3.5X10MM -,SUP-AR-8920CDS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,0.518595,35041.66656,percent of total billed charges,,,
KT ARTHROSCOPIC FX TIGHTROPE ANKL 3.5MM RND/10MM OBLNG BTN -,SUP-AR-8921CDS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,0.518595,35041.66656,percent of total billed charges,,,
TIGHTROPE XP KNOTLESS TITANIUM -,SUP-AR-8925T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA [1000108],AETNA [100010801],,,76.8,,4872.79,0.518595,35041.66656,percent of total billed charges,,,
TIGHTROPE KNOTLESS -,SUP-AR-8926SS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4986.7,3490.69,AETNA [1000108],AETNA [100010801],,,76.8,,3829.79,0.518595,35041.66656,percent of total billed charges,,,
BIO-COMP ACHILLE SPEEDBRIDGE -,SUP-AR-8928BCJ-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,AETNA [1000108],AETNA [100010801],,,76.8,,6502.49,0.518595,35041.66656,percent of total billed charges,,,
SYSTEM IMPLANT MPFL BIOCOMPOSITE -,SUP-AR-8929BC-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6310.83,4417.581,AETNA [1000108],AETNA [100010801],,,76.8,,4846.72,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2X10MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI COLR F -,SUP-AR-8930-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA [1000108],AETNA [100010801],,,76.8,,976.99,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2X11MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI MAG F -,SUP-AR-8930-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA [1000108],AETNA [100010801],,,76.8,,976.99,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2X12MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI BLU F -,SUP-AR-8930-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA [1000108],AETNA [100010801],,,76.8,,976.99,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2X13MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI GRN F -,SUP-AR-8930-13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA [1000108],AETNA [100010801],,,76.8,,976.99,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2X14MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI PUR F -,SUP-AR-8930-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA [1000108],AETNA [100010801],,,76.8,,976.99,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2X16MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI PUR F -,SUP-AR8930-16PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA [1000108],AETNA [100010801],,,76.8,,976.99,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2X20MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI PUR F -,SUP-AR-8930-20PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA [1000108],AETNA [100010801],,,76.8,,976.99,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3X12MM CANN CORT P/T TI -,SUP-AR-8933-12PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3X14MM CANN CORT P/T TI -,SUP-AR-8933-14PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,,,
LP SCREW 3 X 16MM CORTICAL MTP TI -,SUP-AR-8933-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3X16MM CANN CORT P/T TI -,SUP-AR-8933-16PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,,,
LO-PRO SCREW TI 3.0MM X 18MM CORT -,SUP-AR-8933-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3X18MM CANN CORT P/T TI -,SUP-AR-8933-18PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,,,
LO-PRO SCREW TI 3.0MM X 20MM CORT -,SUP-AR-8933-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,,,
LO-PRO SCREW TI 3.0MM X 22MM CORT -,SUP-AR-8933-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,,,
LO-PRO SCREW TI 3.0MM X 36MM CORT -,SUP-AR-8933-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3X14MM LCK CORT P/T TI BLU -,SUP-AR-8933L-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3X16MM LCK CORT P/T TI BLU -,SUP-AR-8933L-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
VAL KREULOCK SCREW TI 3 X 16 -,SUP-AR-8933VCL-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
VAL KREULOCK SCREW TI 3 X 18 -,SUP-AR-8933VCL-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
VAL KREULOCK SCREW TI 3 X 20 -,SUP-AR-8933VCL-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW VAL KREULOCK 3.0 X 22MM TI -,SUP-AR-8933VCL-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW VAL KREULOCK 3.0 X 26MM TI -,SUP-AR-8933VCL-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
SUTURETAPE S-TAK ASSY 3.0 DOUBLE LOADED -,SUP-AR-8934BCST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,0.518595,35041.66656,percent of total billed charges,,,
3.0 DOUBLE LOADED SUTURETAPE S-TAK ASSY -,SUP-AR-8934BCST-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA [1000108],AETNA [100010801],,,76.8,,1933.62,0.518595,35041.66656,percent of total billed charges,,,
LO-PRO SCREW TI 3.5MM X 12MM -,SUP-AR-8935-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
LO-PRO SCREW TI 3.5MM X 22MM -,SUP-AR-8935-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
LO-PRO SCREW TI 3.5MM X 24MM -,SUP-AR-8935-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW LO-PRO TI 3.5MM X 26MM -,SUP-AR-8935-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW LO-PRO TI 3.5MM X 30MM -,SUP-AR-8935-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
LO-PRO SCREW TI 3.5MM X 32MM -,SUP-AR-8935-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW LO-PRO TI 3.5MM X 34MM -,SUP-AR-8935-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
LO-PRO SCREW TI 3.5MM X 36MM -,SUP-AR-8935-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
LO-PRO SCREW TI 3.5MM X 38MM -,SUP-AR-8935-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
LO-PRO SCREW TI 3.5MM X 40MM -,SUP-AR-8935-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
LO-PRO SCREW TI 3.5MM X 42MM -,SUP-AR-8935-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
LO-PRO SCREW TI 3.5MM X 44MM -,SUP-AR-8935-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
LO-PRO SCREW TI 3.5MM X 46MM -,SUP-AR-8935-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
LO-PRO SCREW TI 3.5MM X 48MM -,SUP-AR-8935-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW KREULOCK TI 3.5 X 24MM -,SUP-AR-8935CL-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW KREULOCK TI 3.5 X 26 -,SUP-AR-8935CL-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
KREULOCK SCREW TI 3.5 X 28 -,SUP-AR-8935CL-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW KREULOCK TI 3.5 X 28MM -,SUP-AR-8935CL-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW KREULOCK TI 3.5 X 30 -,SUP-AR-8935CL-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW KREULOCK TI 3.5 X 32 -,SUP-AR-8935CL-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
KREULOCK SCREW TI 3.5 X 34 -,SUP-AR-8935CL-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
KREULOCK SCREW TI 3.5 X 36 -,SUP-AR-8935CL-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
LO-PRO LOCK SCREW TI 3.5MM X 12MM -,SUP-AR-8935L-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
LOCKING SCREW  TI 3.5MM X 14MM -,SUP-AR-8935L-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X24MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X26MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
LOCKING SCREW TITANIUM 3.5MM X 28MM -,SUP-AR-8935L-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING TITANIUM 3.5MM X 28MM -,SUP-AR-8935L-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X30MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X32MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
LOCKING SCREW TITANIUM 3.5MM X 34MM -,SUP-AR-8935L-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
LOCKING SCREW TITANIUM 3.5MM X 44MM -,SUP-AR-8935L-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
KIT ENDOSCOPIC BOSTROM REPAIR IMPLANT SYS -,SUP-AR-8936BC-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA [1000108],AETNA [100010801],,,76.8,,4726.12,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X30MM CANC FT SD TI STRL F/H-PLATE LPDS SURG -,SUP-AR-8940-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW LO-PRO TI 4.0MM X 36MM -,SUP-AR-8940-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X40MM CANC FT SD TI -,SUP-AR-8940-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,76.8,,268.88,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN TIGHTROPE 79MM F/SYNDSMS RPR 4HL SS BTRSS LT -,SUP-AR-8943BL-04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN TIGHTROPE 79MM F/SYNDSMS RPR 4HL SS BTRSS RT -,SUP-AR-8943BR-04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN TIGHTROPE 91MM F/SYNDSMS RPR 5HL SS BTRSS -,SUP-AR-8943BR-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN TIGHTROPE 104MM F/SYNDSMS RPR 6HL SS BTRSS -,SUP-AR-8943BR-06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,AETNA [1000108],AETNA [100010801],,,76.8,,2658.16,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN TIGHTROPE 61MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943H-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN TIGHTROPE F/DLTD LGMNT ATTCH AVULSION FX SYNDSMS -,SUP-AR-8943H-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN TIGHTROPE 47MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943T-04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN TIGHTROPE 72MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943T-06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA [1000108],AETNA [100010801],,,76.8,,976.99,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN TIGHTROPE 98MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943T-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1404.63,983.241,AETNA [1000108],AETNA [100010801],,,76.8,,1078.76,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN TIGHTROPE F/SYNDSMS AVULSION FX MGMT 10HL LCK SS -,SUP-AR-8943T-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1484.14,1038.898,AETNA [1000108],AETNA [100010801],,,76.8,,1139.82,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN TIGHTROPE 72MM F/SYNDSMS AVULSION FX MGMT 3HL SS -,SUP-AR-8943TH-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN TIGHTROPE F/SYNDSMS AVULSION FX MGMT 7HL LCK SS 1/3 -,SUP-AR-8943TH-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN TIGHTROPE 43MM TI BTRSS 3.5MM LPS SCR 2.4MM GW -,SUP-AR-8947DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.1,3045.07,AETNA [1000108],AETNA [100010801],,,76.8,,3340.88,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 7.5MM STP -,SUP-AR-8949-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,0.518595,35041.66656,percent of total billed charges,,,
LISFRANC PLATE MEDIUM LEFT TI -,SUP-AR-8951ML,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,,,
PLATE MEDIUM RIGHT TITANIUM LISFRANC -,SUP-AR-8951MR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,,,
LISFRANC PLATE SMALL RIGHT TI -,SUP-AR-8951SR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,,,
2.5MM 2HOLE L-PLATE TI 5H RT -,SUP-AR-8952ML-05R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,AETNA [1000108],AETNA [100010801],,,76.8,,3281.46,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 3MM 5HL TI STR -,SUP-AR-8952TS-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,,,
CALCFX PERCPLT STD ANTERIOR PROCESS L -,SUP-AR-8954ML-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,0.518595,35041.66656,percent of total billed charges,,,
PLATE LONG CALCANEUS RIGHT TUBEROSITY 3.5/4 MM PERCUTANEOUS -,SUP-AR-8954YR-L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,0.518595,35041.66656,percent of total billed charges,,,
BONE TAP CANNULATED 6.0MM -,SUP-AR-8956C-60T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,0.518595,35041.66656,percent of total billed charges,,,
PLATE LONG METATARSAL RIGHT HOOK -,SUP-AR-8956R-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,AETNA [1000108],AETNA [100010801],,,76.8,,4155.72,0.518595,35041.66656,percent of total billed charges,,,
PLATE 2 HOLE TITANIUM -,SUP-AR-8958-02S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,,,
ANTEROLATERAL PILON FUSION PLATE 5 HOLE LT -,SUP-AR-8963ALF-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12624.2,8836.94,AETNA [1000108],AETNA [100010801],,,76.8,,9695.39,0.518595,35041.66656,percent of total billed charges,,,
ANTEROLATERAL PILON FUSION PLATE 7H RT -,SUP-AR-8963ARF-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,AETNA [1000108],AETNA [100010801],,,76.8,,10265.7,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.7X65MM CANN 18MM THRD SD/ST TI -,SUP-AR-8967-1865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,,,
WASHER ORTHO 13MM TI -,SUP-AR-8967W,CDM,C1713,HCPCS,278,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,76.8,,358.5,0.518595,35041.66656,percent of total billed charges,,,
KIT DX SWIVELOCK SL 3.5X8.5MM -,SUP-AR-8978DS-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,AETNA [1000108],AETNA [100010801],,,76.8,,1119.47,0.518595,35041.66656,percent of total billed charges,,,
SWIVELOCK DX SL 3.5 X 8.5 -,SUP-AR-8978P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,0.518595,35041.66656,percent of total billed charges,,,
SYSTEM INTERNAL FIXATION FIBERLOCK SUSPENSION  3.5 X 8.5 -,SUP-AR-8988-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5889.19,4122.433,AETNA [1000108],AETNA [100010801],,,76.8,,4522.9,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUTURE FIBER TAK DX -,SUP-AR-8990ST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2464.73,1725.311,AETNA [1000108],AETNA [100010801],,,76.8,,1892.91,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR FIBERTAK DOUBLE-LOADED DX SUTURE -,SUP-AR-8990ST-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2878.72,2015.104,AETNA [1000108],AETNA [100010801],,,76.8,,2210.86,0.518595,35041.66656,percent of total billed charges,,,
DX FIBERTAK SUTURE ANCHOR #2 MTS W/NDL -,SUP-AR-8991,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,AETNA [1000108],AETNA [100010801],,,76.8,,2181.53,0.518595,35041.66656,percent of total billed charges,,,
SWIVELOCK DISP KIT NANO 2.5 X 7 -,SUP-AR-8998DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
NANO SWIVELOCK 2.5 X 7 WITH FORK EYELET -,SUP-AR-8998T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X45MM P/T TI F /5TH MTRSL JONES FX SYS -,SUP-AR-9045-45PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X55MM P/T TI GRN -,SUP-AR-9045-55PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,,,
LO-PRO SCREW PT THREADED TI 5.5MM X 40MM -,SUP-AR-9055-40PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,,,
LO-PRO SCRW PT THD TI 6.0MM X 40MM -,SUP-AR-9060-40PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCK GLENOID PERIPH -,SUP-AR-9145-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW CENTRAL NL 6.5 X 25MM -,SUP-AR-9165-25NL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,AETNA [1000108],AETNA [100010801],,,76.8,,761.82,0.518595,35041.66656,percent of total billed charges,,,
BC ACHILLES SPDBRG W/KL DX CC 3.9MM -,SUP-AR-9928BCK-DX,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10749.14,7524.398,AETNA [1000108],AETNA [100010801],,,76.8,,8255.34,0.518595,35041.66656,percent of total billed charges,,,
LP SCREW 3 X 18MM CORTICAL MTP TI -,SUP-AR-9933-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
LP SCREW 3 X 20MM CORTICAL MTP TI -,SUP-AR-9933-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW LP 3.0 X 22MM CORTICAL MTP TI -,SUP-AR-9933-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW LP 3.0 X 24MM CORTICAL MTP TI -,SUP-AR-9933-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
LP SCREW 3 X 16MM CORTICAL HYBRID MTP TI -,SUP-AR-9933HY-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
LOCK MED HOOK PLATE TI 3H -,SUP-AR-9943H-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,0.518595,35041.66656,percent of total billed charges,,,
MAXFORCE MTP PLATE PETITE 0-0 RIGHT -,SUP-AR-9944P-0R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,AETNA [1000108],AETNA [100010801],,,76.8,,6502.49,0.518595,35041.66656,percent of total billed charges,,,
PLATE MAXFORCE STD 5-5 RIGHT MTP -,SUP-AR-9944S-5R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,AETNA [1000108],AETNA [100010801],,,76.8,,6502.49,0.518595,35041.66656,percent of total billed charges,,,
SCREW 12.5MM CANN HDLS ACUTRAK STD TI ALY -,SUP-AT-1125-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,AETNA [1000108],AETNA [100010801],,,76.8,,1884.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.3-3.8X15MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI -,SUP-AT-1150-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,AETNA [1000108],AETNA [100010801],,,76.8,,1884.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.3-3.9MM 17.5MM CANN HDLS ACUTRAK FT ST STD 2MM HX -,SUP-AT-1175-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,AETNA [1000108],AETNA [100010801],,,76.8,,1884.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 20MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI ALY -,SUP-AT-1200-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,AETNA [1000108],AETNA [100010801],,,76.8,,1884.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.3-4.2MM 22.5MM CANN HDLS ACUTRAK FT ST STD 2MM HX -,SUP-AT-1225-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,AETNA [1000108],AETNA [100010801],,,76.8,,1884.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.3-4.4X25MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI -,SUP-AT-1250-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,AETNA [1000108],AETNA [100010801],,,76.8,,1884.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.3-4.5MM 27.5MM CANN HDLS ACUTRAK FT ST STD 2MM HX -,SUP-AT-1275-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,AETNA [1000108],AETNA [100010801],,,76.8,,1884.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.3-4.6X30MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI -,SUP-AT-1300-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,AETNA [1000108],AETNA [100010801],,,76.8,,1884.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5-2.8 MMX8MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA [1000108],AETNA [100010801],,,76.8,,2034.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5-2.8 MMX9MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA [1000108],AETNA [100010801],,,76.8,,2034.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5-2.8 MMX12MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA [1000108],AETNA [100010801],,,76.8,,2034.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5-2.8 MMX14MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA [1000108],AETNA [100010801],,,76.8,,2034.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5-2.8 MMX16MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA [1000108],AETNA [100010801],,,76.8,,2034.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5-2.8 MMX18MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA [1000108],AETNA [100010801],,,76.8,,2034.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5-2.8 MMX20MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA [1000108],AETNA [100010801],,,76.8,,2034.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5-2.8 MMX26MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA [1000108],AETNA [100010801],,,76.8,,2034.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5-2.8 MMX28MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA [1000108],AETNA [100010801],,,76.8,,2034.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5-3.6 MMX16MM CANN HDLS ACUTRAK 2 FT SLF CT 2MM HX -,SUP-AT2-M16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA [1000108],AETNA [100010801],,,76.8,,2034.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5-3.6 MMX22MM CANN HDLS ACUTRAK 2 FT SLF CT 2MM HX -,SUP-AT2-M22-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA [1000108],AETNA [100010801],,,76.8,,2034.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5-3.6 MMX24MM CANN HDLS ACUTRAK 2 FT SLF CT 2MM HX -,SUP-AT2-M24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA [1000108],AETNA [100010801],,,76.8,,2034.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4-4.1X16MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT STD -,SUP-AT2-S16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA [1000108],AETNA [100010801],,,76.8,,2034.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4-4.1X26MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT STD -,SUP-AT2-S26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA [1000108],AETNA [100010801],,,76.8,,2034.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4-4.1X34MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST CUT STD -,SUP-AT2-S34-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA [1000108],AETNA [100010801],,,76.8,,2034.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3-2.5X24MM CANN HDLS ACUTRAK FUSION FT ST 1.5MM/2MM -,SUP-ATF-240-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1966.49,1376.543,AETNA [1000108],AETNA [100010801],,,76.8,,1510.26,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3-3.5X32MM CANN HDLS ACUTRAK FUSION FT ST 1.5MM/2MM -,SUP-ATF-320-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1966.49,1376.543,AETNA [1000108],AETNA [100010801],,,76.8,,1510.26,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.8-3.2 MMX10MM CANN HDLS ACUTRAK FT ST 1.5MM HX DRV -,SUP-ATM-100-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,AETNA [1000108],AETNA [100010801],,,76.8,,1884.77,0.518595,35041.66656,percent of total billed charges,,,
UNIVERSAL CEMENT RESTRICOTR SM 18.5MM -,SUP-B000-0185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
RESTRICTOR CMNT UNIV 24MM OSTEONICS -,SUP-B000-0240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
RESTRICTOR CEMENT UNIVERSAL SMALL INSERTER -,SUP-B000-1185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
RESTRICTOR CMNT MED UNIV STRL -,SUP-B000-1240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
RESTRICTOR BNCMNT 11MM -,SUP-B0010110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
RESTRICTOR BNCMNT 15.5MM -,SUP-B0020125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
RESTRICTOR BNCMNT 14MM -,SUP-B0030140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5MMX110MM CANC DYNFX 50MM THRD TAPR -,SUP-B6011050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,76.8,,779.74,0.518595,35041.66656,percent of total billed charges,,,
SCREW EXTFIX 6/5MM DIA 130/ 60MM CORT/CANC TAPR DYNFX THRD -,SUP-B6013060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,485.47,339.829,AETNA [1000108],AETNA [100010801],,,76.8,,372.84,0.518595,35041.66656,percent of total billed charges,,,
SCREW TITAN REV SHOULDER LARGE -,SUP-BBS-0960-21LRG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,0.518595,35041.66656,percent of total billed charges,,,
REVERSE BODY SMALL AND REVERSCE BODY SCREW -,SUP-BBS-0960-21SML,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,0.518595,35041.66656,percent of total billed charges,,,
BALLOON 6FR PTA 200CM X 3MM X 120MM METACROSS -,SUP-BD-P30150ER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,0.518595,35041.66656,percent of total billed charges,,,
AFX2 BIFURCATED ENDOGRAFT SYSTEM -,SUP-BEA25-80/I13-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,AETNA [1000108],AETNA [100010801],,,76.8,,30123.13,0.518595,35041.66656,percent of total billed charges,,,
STENT BIFURCATED ENDOGRAFT AFX2  28MM X 80MM -I16-40 -,SUP-BEA28-80/I16-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,37002.53,25901.771,AETNA [1000108],AETNA [100010801],,,76.8,,28417.94,0.518595,35041.66656,percent of total billed charges,,,
PIN TRIMED VOLAR BUTT 20 -,SUP-BP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,,,
RSS BODY SCREW -,SUP-BSC-0960-021-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW TI F/TITAN MODLR SHLDR SYS -,SUP-BSW-0920-021-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,758.61,531.027,AETNA [1000108],AETNA [100010801],,,76.8,,582.61,0.518595,35041.66656,percent of total billed charges,,,
MIXER CEMENT KYPHON W  CEMENT -,SUP-C01B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,919.01,643.307,AETNA [1000108],AETNA [100010801],,,76.8,,705.8,0.518595,35041.66656,percent of total billed charges,,,
"K-WIRE PIN COVER .028"" -",SUP-C-028NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,AETNA [1000108],AETNA [100010801],,,76.8,,1.77,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X12MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-C03120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA [1000108],AETNA [100010801],,,76.8,,371.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X16MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-C03160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA [1000108],AETNA [100010801],,,76.8,,371.95,0.518595,35041.66656,percent of total billed charges,,,
"K-WIRE PIN COVER .035"" -",SUP-C-035NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,AETNA [1000108],AETNA [100010801],,,76.8,,1.77,0.518595,35041.66656,percent of total billed charges,,,
"K-WIRE PIN COVER .045"" -",SUP-C-045NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,AETNA [1000108],AETNA [100010801],,,76.8,,1.77,0.518595,35041.66656,percent of total billed charges,,,
"K-WIRE PIN COVER .054"" -",SUP-C-054NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,AETNA [1000108],AETNA [100010801],,,76.8,,1.77,0.518595,35041.66656,percent of total billed charges,,,
"K-WIRE PIN COVER .062"" -",SUP-C-062NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,AETNA [1000108],AETNA [100010801],,,76.8,,1.77,0.518595,35041.66656,percent of total billed charges,,,
EXTERNAL FX 0.375IN BALL COLR F/CAP VRS SZ K-WIRE -,SUP-C50-COL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.5,771.75,AETNA [1000108],AETNA [100010801],,,76.8,,846.72,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4X14MM LCK CANC ACU-LOC 2 HEX HEAD TI NS F/MAYO -,SUP-CA-4140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,542.66,379.862,AETNA [1000108],AETNA [100010801],,,76.8,,416.76,0.518595,35041.66656,percent of total billed charges,,,
GRAFT CANC 30ML CHP RDIGRF FRZDR CRSH VOID FIL 1-8MM -,SUP-CAN30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1984.24,1388.968,AETNA [1000108],AETNA [100010801],,,76.8,,1523.9,0.518595,35041.66656,percent of total billed charges,,,
EXPERT KNEE CAPITATED REVISION SYSTEM -,SUP-CAP PRICE,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21164.1,14814.87,AETNA [1000108],AETNA [100010801],,,76.8,,16254.03,0.518595,35041.66656,percent of total billed charges,,,
CEMENT CARTRIDGE CC02A CDS -,SUP-CC02A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,76.8,,403.32,0.518595,35041.66656,percent of total billed charges,,,
DISC CERVICAL SIZE 6MM LL M6 -,SUP-CDL-637L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,AETNA [1000108],AETNA [100010801],,,76.8,,13972.76,0.518595,35041.66656,percent of total billed charges,,,
CERVICAL DISC SIZE 6MM M6 ORTHOFIX -,SUP-CDM-625,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,AETNA [1000108],AETNA [100010801],,,76.8,,13972.76,0.518595,35041.66656,percent of total billed charges,,,
CERVICAL DISC 6 MEDIUM LONG ARTIFICIAL -,SUP-CDM-635L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,AETNA [1000108],AETNA [100010801],,,76.8,,13972.76,0.518595,35041.66656,percent of total billed charges,,,
CEMENT GUN AND BONE FILLER CDS2A SIZE 2 -,SUP-CDS2A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2361.37,1652.959,AETNA [1000108],AETNA [100010801],,,76.8,,1813.53,0.518595,35041.66656,percent of total billed charges,,,
EXCLUDER ILIAC 23MM X 10MM X 10CM 16FR BRANCH ENDO -,SUP-CEB231010A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31520.86,22064.602,AETNA [1000108],AETNA [100010801],,,76.8,,24208.02,0.518595,35041.66656,percent of total billed charges,,,
IMPLANT VARILIFT- C STND ALONE XPD -,SUP-CIC1-7.5-12-BP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5835.5,4084.85,AETNA [1000108],AETNA [100010801],,,76.8,,4481.66,0.518595,35041.66656,percent of total billed charges,,,
CAGE VARILIFT- C ST -,SUP-CIC1-9.0-12-BP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5835.5,4084.85,AETNA [1000108],AETNA [100010801],,,76.8,,4481.66,0.518595,35041.66656,percent of total billed charges,,,
KT SUTURE REM SUT PRB KNT PSHR/CTR INTRO CROSSFIX II DISP -,SUP-CM-8000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
DEVICE MENISCOTOME UP CRV STRONGER STF NDL HI STRGTH SUT -,SUP-CM-8002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,AETNA [1000108],AETNA [100010801],,,76.8,,1323,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR JK 2.9 SL WT/BL NS BK JUGGERKNOT -,SUP-CM-99329B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2067.2,1447.04,AETNA [1000108],AETNA [100010801],,,76.8,,1587.61,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR JK 2.9 BDL WT/BL NS BKLU BB JUGGERKNOT -,SUP-CM-99429B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2067.2,1447.04,AETNA [1000108],AETNA [100010801],,,76.8,,1587.61,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X12MM NLCKG CORT ACU-LOK 2 TI NS F/MAYO -,SUP-CO-2712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA [1000108],AETNA [100010801],,,76.8,,371.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X14MM NLCKG CORT ACU-LOK 2 TI NS F/MAYO -,SUP-CO-2714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA [1000108],AETNA [100010801],,,76.8,,371.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X16MM NLCKG CORT ACU-LOK 2 TI NS F/MAYO -,SUP-CO-2716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA [1000108],AETNA [100010801],,,76.8,,371.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X20MM NLCKG CORT ACU-LOC 2 TI NS F/MAYO -,SUP-CO-2720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA [1000108],AETNA [100010801],,,76.8,,371.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X22MM NLCKG CORT ACU-LOC 2 TI NS F/MAYO -,SUP-CO-2722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA [1000108],AETNA [100010801],,,76.8,,371.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X6MM NLCKG CORT ACU-LOK 2 TI NS -,SUP-CO-3060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA [1000108],AETNA [100010801],,,76.8,,371.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X10MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA [1000108],AETNA [100010801],,,76.8,,371.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X12MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA [1000108],AETNA [100010801],,,76.8,,371.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X14MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA [1000108],AETNA [100010801],,,76.8,,371.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X16MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA [1000108],AETNA [100010801],,,76.8,,371.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X24MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA [1000108],AETNA [100010801],,,76.8,,371.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X25MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA [1000108],AETNA [100010801],,,76.8,,371.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X26MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA [1000108],AETNA [100010801],,,76.8,,371.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X28MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA [1000108],AETNA [100010801],,,76.8,,371.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X30MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA [1000108],AETNA [100010801],,,76.8,,371.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X32MM NLCKG CORT ACU-LOC 2 POLARUS TI NS COLR -,SUP-CO-3320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA [1000108],AETNA [100010801],,,76.8,,371.95,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X12MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,76.8,,604.98,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X14MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,76.8,,604.98,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X16MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,76.8,,604.98,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.7X18MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,76.8,,604.98,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X8MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,76.8,,604.98,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X10MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,76.8,,604.98,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X12MM LCK CORT -,SUP-COL-3120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,76.8,,604.98,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X14MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,76.8,,604.98,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X20MM LCK CORT FT TI F/MAYO PLATE/MODULAR/UNIV SYS -,SUP-COL-3200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,76.8,,604.98,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X22MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,76.8,,604.98,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORITICAL LOCKING TI 3.5 X 13MM -,SUP-COLS -35130-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW GEMINUS CORTICAL LOCKING 3.5MM X 8MM TI -,SUP-COLS-35080-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL LOCKING 3.5 X 9 -,SUP-COLS-35090-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL LOCKING 3.5 X 10 -,SUP-COLS-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL LOCKING 3.5MM X 11MM -,SUP-COLS-35110-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL LOCKING 3.5MM X 12MM -,SUP-COLS-35120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW- CORTICAL LOCKING 3.5MM X 12MM -,SUP-COLS-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORT LOCKING 3.5MM X 15MM -,SUP-COLS-35150-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL LOCKING 3.5MM X 16MM -,SUP-COLS-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL LOCKING 3.5 X 18 -,SUP-COLS-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL LOCKING 3.5MM X 20MM TI -,SUP-COLS-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA [1000108],AETNA [100010801],,,76.8,,833.52,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL LOCKING 3.5 X 24 -,SUP-COLS-35240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA [1000108],AETNA [100010801],,,76.8,,833.52,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL LOCKING 3.5 X 26 -,SUP-COLS-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA [1000108],AETNA [100010801],,,76.8,,833.52,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X14MM CORT ACU-LOC 2 FT NTOGG TI NS F/UNIV SYS -,SUP-CO-N2314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA [1000108],AETNA [100010801],,,76.8,,501.9,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X22MM CORT ACU-LOC 2 FT NTOGG TI NS F/UNIV SYS -,SUP-CO-N2322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA [1000108],AETNA [100010801],,,76.8,,501.9,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X14MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA [1000108],AETNA [100010801],,,76.8,,501.9,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X16MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA [1000108],AETNA [100010801],,,76.8,,501.9,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X18MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA [1000108],AETNA [100010801],,,76.8,,501.9,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.3X20MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA [1000108],AETNA [100010801],,,76.8,,501.9,0.518595,35041.66656,percent of total billed charges,,,
RTR CROSS CONNECTOR -,SUP-CPF-CR 26 32-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
CROSS CONNECTOR 32-44 -,SUP-CPF-CR 32 44-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL 3.5 X 12 -,SUP-CPF-CS 35 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW CC PREFERRED ANGLE 3.5 X 14 -,SUP-CPF-CS 35 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW CC PREFERRED ANGLE 3.5 X 18 -,SUP-CPF-CS 35 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW CC PREFERRED ANGLE 3.5 X 20 -,SUP-CPF-CS 35 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
LARGE OFFSET -,SUP-CPF-LC 00 0L-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA [1000108],AETNA [100010801],,,76.8,,1933.62,0.518595,35041.66656,percent of total billed charges,,,
SCREW SPINEART ML PREFERRED ANGLE 4MM X 12MM -,SUP-CPF-MS 04 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW ML PREFERRED ANGLE SCRE 4 X 16 -,SUP-CPF-MS 04 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW ML PREFERRED ANGLE SCRE 4 X 18 -,SUP-CPF-MS 04 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW ML PREFERRED ANGLE 4 X 20 -,SUP-CPF-MS 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW ML PREFERRED ANGLE 4 X 24 -,SUP-CPF-MS 04 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SPINEART PERLA ML PREFERRED ANGLE SCREW 4 X 28 -,SUP-CPF-MS 04 28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW ML PREFERRED 3.5 X 12 -,SUP-CPF-MS 35 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW ML 35 X 14 -,SUP-CPF-MS 35 14S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW PERLA ML PREFERRED ANGLE 3.5MM X 16MM -,SUP-CPF-MS 35 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW ML PREFERRED 3.5 X 18 -,SUP-CPF-MS 35 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW ML 35 X 20 -,SUP-CPF-MS 35 20S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW ML 35 X 24 -,SUP-CPF-MS 35 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW SPINEART ML PREFERRED ANGLE 4MM X 14MM -,SUP-CPF-MS-04 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
CONNECTOR PARALLEL 3-3 -,SUP-CPF-PC 30 3C-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA [1000108],AETNA [100010801],,,76.8,,1933.62,0.518595,35041.66656,percent of total billed charges,,,
CONNECTOR PARALLEL 3-5 -,SUP-CPF-PC 3C 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA [1000108],AETNA [100010801],,,76.8,,1933.62,0.518595,35041.66656,percent of total billed charges,,,
ROD PERLA 90MM TI -,SUP-CPF-PF T0 90-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
PREBENT ROD COBALT CHROMIUM 45MM -,SUP-CPF-PR C0 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
ROD PREBENT TITANIUM 3.5 X 40MM -,SUP-CPF-PR T0 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
ROD 50MM -,SUP-CPF-PR T0 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
ROD 60MM PREBENT TITANIUM -,SUP-CPF-PR T0 60-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
PERLA PREBENT ROD TITANIUM 3.5 X 65MM -,SUP-CPF-PR T0 65-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
ROD 70MM -,SUP-CPF-PR T0 70-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
PERLA PREBENT ROD TITANIUM 3.5 X 75MM -,SUP-CPF-PR T0 75-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
ROD PREBENT TITANIUM 3.5 L80 -,SUP-CPF-PR T0 80-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
ROD 85MM -,SUP-CPF-PR T0 85-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
ROD 45MM -,SUP-CPF-PR TO 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
PREBENT TITANIUM ROD 3.5 X L12 PERLA -,SUP-CPF-PR TO 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
ROD PREBENT TITANIUM 55MM -,SUP-CPF-PR TO 55-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
ROD 60MM -,SUP-CPF-PR TO 60-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
PRE-BENT ROD 3.5 X 90MM -,SUP-CPF-PR TO 90-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
SCREW POLY PERLA 4 X 10MM -,SUP-CPF-PS 04 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
PERLA SCREW 12MM -,SUP-CPF-PS 04 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW POLYAXIAL PERLA 4MM X 12MM -,SUP-CPF-PS 04 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW POLYAXIAL 4MM X 14MM -,SUP-CPF-PS 04 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW POLYAXIAL 4 X 16 -,SUP-CPF-PS 04 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW POLY 4 X 18MM -,SUP-CPF-PS 04 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW POLYAXIAL PERLA 4MM X 20MM -,SUP-CPF-PS 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW POLY PERLA 4.0 X 24MM -,SUP-CPF-PS 04 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE PERLA 4MM X 32MM SPINE POLYAXIAL -,SUP-CPF-PS 04 32-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
PERLA POLYAXIAL SCREW 3.5 X 10MM -,SUP-CPF-PS 35 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW POLY 3.5 X 12MM PERLA -,SUP-CPF-PS 35 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW PERLA 3.5 X 14 -,SUP-CPF-PS 35 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
3.5 x 16MM POLY SCREW -,SUP-CPF-PS 35 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW POLY 3.5 X 18MM PERLA -,SUP-CPF-PS 35 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
PERLA POLYAXIAL SCREW 3.5 X 20MM -,SUP-CPF-PS 35 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
POLYAXIAL SCREW 3.5 X 24 -,SUP-CPF-PS 35 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW POLY PERLA 3.5MM X 28MM -,SUP-CPF-PS 35 28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
POLYAXIAL SCREW 3.5 X 12 -,SUP-CPF-PS 3512-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
POLYAXIAL SCREW 4.0 X 28 -,SUP-CPF-PS-0428-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
3.5 X 28 POLY SCREW -,SUP-CPF-PS-3528-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREWS SET PERLA -,SUP-CPF-SC 00 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,,,
SPINEART STRAIGHT ROD CHROMIUM 350MM -,SUP-CPF-SR C3 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
ROD TITANIUM 40MM -,SUP-CPF-SR CO 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
ROD TITANIUM 80MM -,SUP-CPF-SR T0 80-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
PERLA STRAIGHT ROD TITANIUM 03.5 L100 -,SUP-CPF-SR T1 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
ROD TI 120MM -,SUP-CPF-SR T1 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
ROD 240 -,SUP-CPF-SR T2 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
SMOOTH SHANK SCREW 4MM Z 20 -,SUP-CPF-SS 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW SS 3.5 X 20 -,SUP-CPF-SS 35 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW SS 3.5 X 22 -,SUP-CPF-SS 35 22-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW SS 3.5 X 24 -,SUP-CPF-SS 35 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREWS SS 3.5 X 26 -,SUP-CPF-SS 35 26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
3.5 x 28MM SMOOTH SHANK -,SUP-CPF-SS 35 28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW SS 3.5 X 34 -,SUP-CPF-SS 35 34-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
3.5 X 30MM POLY SCREW -,SUP-CPF-SS-35 30-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X12MM CORT DVR FT CRUCIF HEAD MAG -,SUP-CS12000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X16MM CORT DVR FT CRUCIF HEAD MAG -,SUP-CS16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X18MM CORT DVR FT CRUCIF HEAD MAG -,SUP-CS18000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,,,
GRAFT STRUT MATRGRF FRZDR 15X100MM -,SUP-CST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3457.04,2419.928,AETNA [1000108],AETNA [100010801],,,76.8,,2655.01,0.518595,35041.66656,percent of total billed charges,,,
BONE CEMENT CX01B XPEDE W MIXER US -,SUP-CX01B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1598.1,1118.67,AETNA [1000108],AETNA [100010801],,,76.8,,1227.34,0.518595,35041.66656,percent of total billed charges,,,
HEADLESS 3.0X40 SCREW -,SUP-D2N30040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.61,678.027,AETNA [1000108],AETNA [100010801],,,76.8,,743.89,0.518595,35041.66656,percent of total billed charges,,,
TORNIER LONG HUMERAL NAIL LEFT 7MM X 230MM -,SUP-DHN5796,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13273.98,9291.786,AETNA [1000108],AETNA [100010801],,,76.8,,10194.42,0.518595,35041.66656,percent of total billed charges,,,
PLATE DISTAL HUMERUS MEDIAL DIRECT 105MM -,SUP-DHPF-MDL-5HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,AETNA [1000108],AETNA [100010801],,,76.8,,7125.03,0.518595,35041.66656,percent of total billed charges,,,
PIN SCREW DISTRACTION 12MM -,SUP-DP-12-TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,145.88,102.116,AETNA [1000108],AETNA [100010801],,,76.8,,112.04,0.518595,35041.66656,percent of total billed charges,,,
PIN SCREW DISTRACTION 14MM -,SUP-DP-14-TY,CDM,C1713,HCPCS,278,RC,,,outpatient,,,145.88,102.116,AETNA [1000108],AETNA [100010801],,,76.8,,112.04,0.518595,35041.66656,percent of total billed charges,,,
ULNAR STEM 6.0MM 2CM EXT STEM -,SUP-DRUJ-IS260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9932.28,6952.596,AETNA [1000108],AETNA [100010801],,,76.8,,7627.99,0.518595,35041.66656,percent of total billed charges,,,
LOCKING RADIAL PLATE SZ 20-15MM ASSY -,SUP-DRUJ-LP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19433.84,13603.688,AETNA [1000108],AETNA [100010801],,,76.8,,14925.19,0.518595,35041.66656,percent of total billed charges,,,
14MM 3.5 LOCKING SCREW -,SUP-DRUJ-LSC14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,799.4,559.58,AETNA [1000108],AETNA [100010801],,,76.8,,613.94,0.518595,35041.66656,percent of total billed charges,,,
20MM 3.5 LOCKING SCREW -,SUP-DRUJ-LSC20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,799.4,559.58,AETNA [1000108],AETNA [100010801],,,76.8,,613.94,0.518595,35041.66656,percent of total billed charges,,,
22MM 3.5 LOCKING SCREW -,SUP-DRUJ-LSC22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,799.4,559.58,AETNA [1000108],AETNA [100010801],,,76.8,,613.94,0.518595,35041.66656,percent of total billed charges,,,
20MM 3.5 CORTICAL SCREW -,SUP-DRUJ-SC20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,636.02,445.214,AETNA [1000108],AETNA [100010801],,,76.8,,488.46,0.518595,35041.66656,percent of total billed charges,,,
SCREW DISTAL TROCHLEA COMP 3.5 X 45 TI -,SUP-DTCS-35045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,0.518595,35041.66656,percent of total billed charges,,,
SCREW DISTAL TROCHLEA COMP 3.5 X 50 -,SUP-DTCS-35050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN DVR 24.4MMX51.3MM 4HL STD SHRT NS LT -,SUP-DVRAL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,AETNA [1000108],AETNA [100010801],,,76.8,,2925.81,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN DVR ANTMC NRW -,SUP-DVRANR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3828.27,2679.789,AETNA [1000108],AETNA [100010801],,,76.8,,2940.11,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN DVR 21.6MMX48.9MM 4HL SHRT BTRSS NRW NS -,SUP-DVRANSL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,AETNA [1000108],AETNA [100010801],,,76.8,,2925.81,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN DVR 21.6MMX48.9MM 4HL SHRT NS -,SUP-DVRANSR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,AETNA [1000108],AETNA [100010801],,,76.8,,2925.81,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN DVR 24.4MMX51.3MM 4HL STD SHRT NS RT -,SUP-DVRAR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,AETNA [1000108],AETNA [100010801],,,76.8,,2925.81,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN DVR 24.4MMX51.3MM 4HL STD SHRT NS RT RADL -,SUP-DVRASR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,AETNA [1000108],AETNA [100010801],,,76.8,,2925.81,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN DVR 28.2MMX62.6MM 4HL W NS -,SUP-DVRAWL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,AETNA [1000108],AETNA [100010801],,,76.8,,2925.81,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN DVR 28.2MMX62.6MM 4HL W BTRSS NS -,SUP-DVRAWR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,AETNA [1000108],AETNA [100010801],,,76.8,,2925.81,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN DVR 24.4MMX89.5MM 4HL EXTEND XLNG BTRSS NS -,SUP-DVRAXL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,AETNA [1000108],AETNA [100010801],,,76.8,,2925.81,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN DVR 24.4MMX59.5MM 4HL NS LT -,SUP-DVR-L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,AETNA [1000108],AETNA [100010801],,,76.8,,2925.81,0.518595,35041.66656,percent of total billed charges,,,
TORNIER PERFORM REVERESED CTRSCREW 6.5MM X 25MM NON ST -,SUP-DWJ125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,AETNA [1000108],AETNA [100010801],,,76.8,,2658.16,0.518595,35041.66656,percent of total billed charges,,,
TORNIER PERFORM REVERSED PERIPSCREW 5.0MM X 14MM NON ST -,SUP-DWJ314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1144.91,801.437,AETNA [1000108],AETNA [100010801],,,76.8,,879.29,0.518595,35041.66656,percent of total billed charges,,,
TORNIER PERFORM REVERSED PERIPSCREW 5.0MM X 18MM NON ST -,SUP-DWJ318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1144.91,801.437,AETNA [1000108],AETNA [100010801],,,76.8,,879.29,0.518595,35041.66656,percent of total billed charges,,,
RESTRICTOR HUM CMNT 24MM F/TOT ELB PROS LTD -,SUP-EB0101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1166.11,816.277,AETNA [1000108],AETNA [100010801],,,76.8,,895.57,0.518595,35041.66656,percent of total billed charges,,,
RESTRICTOR CMNT TORNIER -,SUP-EBO101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1293.32,905.324,AETNA [1000108],AETNA [100010801],,,76.8,,993.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW ROMEO POLYAXIAL 6 X 40 -,SUP-ELL-PS 06 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X25MM SIGNTR POLYAX FX F /ROMEO PDCL SYS TI ALY -,SUP-ELL-PS0525-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X30MM SIGNTR POLYAX FX F /ROMEO PDCL SYS TI ALY -,SUP-ELL-PS0530-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW POLYAXIAL 5 X 35 -,SUP-ELL-PS0535-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW POLYAXIAL 6 X 30 -,SUP-ELL-PS0630-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6X35MM SIGNTR POLYAX FX F /ROMEO PDCL SYS TI ALY -,SUP-ELL-PS0635-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
ROD 30MM -,SUP-ELL-RD 00 30 S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
ROD ROMEO STRAIGHT HEX TIP 0.54 L240 -,SUP-ELL-RD 22 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
ROD SPIN ROMEO 5.4X50MM PREBNT TI LMBR SFT MLBL F/TRNSCONN -,SUP-ELL-RD0050-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
SET SCREW SPIN ROMEO2 -,SUP-ELL-SC 00 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,,,
GRAFT STENT 49E X 36MM X 36MM ENDURANT II AO EXT -,SUP-ETCF3636C49E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18052.61,12636.827,AETNA [1000108],AETNA [100010801],,,76.8,,13864.4,0.518595,35041.66656,percent of total billed charges,,,
STENT ENDURANT II GRAFT 16F X 16MM X 146MM LIMB -,SUP-ETLW1616C146E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,AETNA [1000108],AETNA [100010801],,,76.8,,17337.63,0.518595,35041.66656,percent of total billed charges,,,
GRAFT STENT ENDUR II LIMB ELTW1620C146E -,SUP-ETLW1620C146E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,AETNA [1000108],AETNA [100010801],,,76.8,,17337.63,0.518595,35041.66656,percent of total billed charges,,,
INFRAME IMPLANT 2.0MM X 32MM -,SUP-EXINF922032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,,,
INFRAME EXSOMED IMPLANT 2.0MM X 36MM -,SUP-EXINF922036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6972.89,4881.023,AETNA [1000108],AETNA [100010801],,,76.8,,5355.18,0.518595,35041.66656,percent of total billed charges,,,
INNATE IMPLANT 3.6MM X 35MM -,SUP-EXINN923635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,,,
NAIL INTRAMEDULLARY INNATE IMPLANT 3.6MM X 40MM -,SUP-EXINN923640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,,,
INNATE IMPLANT 3.6MM X 50MM -,SUP-EXINN923650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,,,
NAIL INTRAMEDULLARY INNATE IMPLANT 3.6MM X 55MM -,SUP-EXINN923655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,,,
NAIL INTRAMEDULLARY INNATE IMPLANT 4.5MM X 45MM -,SUP-EXINN924545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,,,
NAIL INNATE IMPLANT 4.5MM X 50MM -,SUP-EXINN924550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,,,
INNATE IMPLANT 4.5 X 55 -,SUP-EXINN924555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,,,
STRYKER EASY CLIP STAPLE -,SUP-EZ 20-20-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9747.74,6823.418,AETNA [1000108],AETNA [100010801],,,76.8,,7486.26,0.518595,35041.66656,percent of total billed charges,,,
EASYCLIP 15 X 15 X 15 -,SUP-EZ15-15-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8823.28,6176.296,AETNA [1000108],AETNA [100010801],,,76.8,,6776.28,0.518595,35041.66656,percent of total billed charges,,,
EASYCLIP FIXATION DEVICE 18 X 19 X 17 -,SUP-EZ18-19-17,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8823.28,6176.296,AETNA [1000108],AETNA [100010801],,,76.8,,6776.28,0.518595,35041.66656,percent of total billed charges,,,
EASYCLIP FIXATION DEVICE 20 X 20 X 20 -,SUP-EZ20-20-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9747.74,6823.418,AETNA [1000108],AETNA [100010801],,,76.8,,7486.26,0.518595,35041.66656,percent of total billed charges,,,
EASYCLIP 8 X 8 X 8MM -,SUP-EZM08-08-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6512.42,4558.694,AETNA [1000108],AETNA [100010801],,,76.8,,5001.54,0.518595,35041.66656,percent of total billed charges,,,
BONE FILLER DEVICE SIZE 3 -,SUP-F04B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,577.67,404.369,AETNA [1000108],AETNA [100010801],,,76.8,,443.65,0.518595,35041.66656,percent of total billed charges,,,
DEVICE BN FIL FEM SZ2 KYPHX EXP STRL -,SUP-F06A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,577.67,404.369,AETNA [1000108],AETNA [100010801],,,76.8,,443.65,0.518595,35041.66656,percent of total billed charges,,,
ORTHOFIX 8.5 CAGE -,SUP-F28-3182,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA [1000108],AETNA [100010801],,,76.8,,13259.87,0.518595,35041.66656,percent of total billed charges,,,
SHAFT FROZEN BISECTED FEM -,SUP-FBFS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4383.06,3068.142,AETNA [1000108],AETNA [100010801],,,76.8,,3366.19,0.518595,35041.66656,percent of total billed charges,,,
CLAMP CRANIAL 11MM CRANIOFIX -,SUP-FF490T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,695.9,487.13,AETNA [1000108],AETNA [100010801],,,76.8,,534.45,0.518595,35041.66656,percent of total billed charges,,,
CLAMP CRANIAL 16MM TITANIUM CRANIOFIX 2 -,SUP-FF491T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,862.41,603.687,AETNA [1000108],AETNA [100010801],,,76.8,,662.33,0.518595,35041.66656,percent of total billed charges,,,
CLAMP CRANIAL 20MM TITANIUM CRANIOFIX 2 -,SUP-FF492T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1035.56,724.892,AETNA [1000108],AETNA [100010801],,,76.8,,795.31,0.518595,35041.66656,percent of total billed charges,,,
SCREW FREEFIX  COMPRESSION 3.5MM X 20MM TI -,SUP-FFC-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,AETNA [1000108],AETNA [100010801],,,76.8,,766.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW FREEFIX COMPRESSION 3.5MM X 22MM TI -,SUP-FFC-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,AETNA [1000108],AETNA [100010801],,,76.8,,766.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW FREEFIX COMPRESSION 3.5MM X 24MM TI -,SUP-FFC-35240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,AETNA [1000108],AETNA [100010801],,,76.8,,766.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW FREEFIX COMPRESSION 4.5MM X 20MM TI -,SUP-FFC-45200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1009.46,706.622,AETNA [1000108],AETNA [100010801],,,76.8,,775.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW FREEFIX COMPRESSION 4.5MM X 20MM TI -,SUP-FFC-45240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1009.46,706.622,AETNA [1000108],AETNA [100010801],,,76.8,,775.27,0.518595,35041.66656,percent of total billed charges,,,
GRAFT HUMAN TISSUE FEMORAL HEAD 43MM -,SUP-FFH,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4839.09,3387.363,AETNA [1000108],AETNA [100010801],,,76.8,,3716.42,0.518595,35041.66656,percent of total billed charges,,,
GRAFT HUMAN TISSUE FEMORAL HEAD 43MM -,SUP-FFH,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4839.09,3387.363,AETNA [1000108],AETNA [100010801],,,76.8,,3716.42,0.518595,35041.66656,percent of total billed charges,,,
WEDGE FIBULA 18MM FROZEN -,SUP-FFIBW8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2636.84,1845.788,AETNA [1000108],AETNA [100010801],,,76.8,,2025.09,0.518595,35041.66656,percent of total billed charges,,,
SCREW FREEFIX LOCKING 3.5MM X 20MM TI -,SUP-FFL-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,AETNA [1000108],AETNA [100010801],,,76.8,,882.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW FREEFIX LOCKING 3.5MM X 22MM TI -,SUP-FFL-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,AETNA [1000108],AETNA [100010801],,,76.8,,882.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW FREEFIX LOCKING 3.5MM X 26MM TI -,SUP-FFL-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,AETNA [1000108],AETNA [100010801],,,76.8,,882.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW FREEFIX LOCKING 4.5MM 22MM TI -,SUP-FFL-45220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA [1000108],AETNA [100010801],,,76.8,,830.44,0.518595,35041.66656,percent of total billed charges,,,
PRESUTURED ALLOGRAFT -,SUP-FGL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9411.49,6588.043,AETNA [1000108],AETNA [100010801],,,76.8,,7228.02,0.518595,35041.66656,percent of total billed charges,,,
GRAFT HUM TIS SPCR FRZN FLEXIGRAFT MNSCS R/M LF -,SUP-FMNRM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14676.34,10273.438,AETNA [1000108],AETNA [100010801],,,76.8,,11271.43,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.5X8MM LCK FT TI ALPS -,SUP-FP08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.5X10MM LCK FT TI ALPS NS -,SUP-FP10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.5X11MM LCK FT TI ALPS NS -,SUP-FP11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.5X12MM LCK FT TI ALPS NS -,SUP-FP12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.5X13MM LCK FT TI ALPS NS -,SUP-FP13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.5X14MM LCK FT TI ALPS -,SUP-FP14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.5X15MM LCK FT TI ALPS -,SUP-FP15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.5X16MM LCK FT TI ALPS -,SUP-FP16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2X18MM LCK FT TI DVR NS -,SUP-FP18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.5X20MM LCK FT TI DVR NS -,SUP-FP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.5X22MM LCK FT TI F3 NS -,SUP-FP22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.5X24MM LCK FT TI ALPS -,SUP-FP24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.5X26MM LCK FT TI ALPS NS -,SUP-FP26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.5X28MM LCK FT TI ALPS -,SUP-FP28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.5X30MM LCK FT TI F3 NS -,SUP-FP30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,,,
GRAFT HUM TIS FRZN 230CM 7.5MM FLEXIGRAFT PRNS LONGUS TNDN -,SUP-FPLT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.1,4960.97,AETNA [1000108],AETNA [100010801],,,76.8,,5442.89,0.518595,35041.66656,percent of total billed charges,,,
ROD 120MM -,SUP-G100-5-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
ROD 200MM -,SUP-G100-5-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
ROD 400MM -,SUP-G100-5-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
ROD 6.0MM STRAIGHT -,SUP-G100-5-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
ROD 100MM -,SUP-G150-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
TIROD 200MM STRAIGHT -,SUP-G150-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
ROD 30MM -,SUP-G150-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA [1000108],AETNA [100010801],,,76.8,,528.79,0.518595,35041.66656,percent of total billed charges,,,
ROD 35MM -,SUP-G150-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
ROD 40MM CURVED -,SUP-G150-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
ROD CURVED 40MM -,SUP-G150-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
ROD 45MM -,SUP-G150-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
ROD CURVED 50MM -,SUP-G150-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
ROD 55MM -,SUP-G150-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
ROD CURVED 60MM -,SUP-G150-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
ROD 65MM GENESYS -,SUP-G15065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
ROD 70MM GENESYS -,SUP-G150-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
ROD 75MM -,SUP-G150-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
ROD 80MM GENESYS -,SUP-G150-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
ROD 85MM SPINAL -,SUP-G150-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
ROD 90MM -,SUP-G150-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
ROD 95MM -,SUP-G150-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
ROD 300MM GENESYS -,SUP-G300-5-300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,,,
CONNECTOR CROSS LINK LARGE -,SUP-G301-LRG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
CROSSLINK MED -,SUP-G301-MED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
CROSS LINK -,SUP-G301-SM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
27-35MM CC -,SUP-G301-XSM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
COIL MICRONESTER EMBOLIZATION 0.018 X 7CM X 6MM -,SUP-G52738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,916.1,641.27,AETNA [1000108],AETNA [100010801],,,76.8,,703.56,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEADLESS COMP. 4.0MM 36M -,SUP-G58036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA [1000108],AETNA [100010801],,,76.8,,1722.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL 5.5 X 30MM -,SUP-G700-55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL 6.5 X 35MM -,SUP-G700-65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5 X 30MM GENESYS -,SUP-G701-55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW PEDICLE 5.5 X 35MM TI LO -,SUP-G701-55-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW PEDICLE 5.5MM X 40MM -,SUP-G701-55-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW TI LOCK 5.5 X 45MM -,SUP-G701-55-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW PEDICLE 6.5 X 30MM -,SUP-G701-65-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW PEDICLE 6.5 X 35MM -,SUP-G701-65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW PEDICLE 6.5 X 40MM -,SUP-G701-65-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW TI LOCK 6.5 X 45MM -,SUP-G701-65-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
6.5 X 50MM PEDICLE SCREW -,SUP-G701-65-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW TI-LOCK 7.5 X 30MM -,SUP-G701-75-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW TI-LOCK 7.5 X 35MM -,SUP-G701-75-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW PEDICLE 7.5 X 40MM -,SUP-G701-75-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW TI-LOCK 7.5 X 45MM -,SUP-G701-75-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
7.5 X 50MM PEDICLE SCREW -,SUP-G701-75-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 8.5MM X 70MM -,SUP-G701-85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,,,
CROSSLINK -,SUP-G701-XSM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MM X 25MM -,SUP-G702-45-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5MM X 30MM -,SUP-G702-45-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL 5.0 X 25MM -,SUP-G702-50-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL 5.0 X 30MM NEW -,SUP-G702-50-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
CORTICAL SCREW 25 X 5.5MM -,SUP-G7025525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL 5.5 X 25 -,SUP-G702-55-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5 X 45 GENESYS -,SUP-G702-55-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL 6.5 X 40MM -,SUP-G702-65-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL 7.5 X 45 -,SUP-G702-75-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW 8.5MM X 45MM -,SUP-G710-85-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,,,
SCREW ILIAC 8.5 X 60 -,SUP-G710-85-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,,,
SCREW SPINE 8.5 X 70 -,SUP-G710-85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,,,
SCREW SPINE 8.5 X 80 -,SUP-G710-85-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,,,
SCREW HI TOP 6.5 X 35 -,SUP-G711-65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,,,
ILIAC 8.5 X 70 -,SUP-G741-85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,,,
OFFSET -,SUP-G780-21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA [1000108],AETNA [100010801],,,76.8,,1933.62,0.518595,35041.66656,percent of total billed charges,,,
OFFSET 61 -,SUP-G780-61,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,,,
CAP CIRCULAR TI LOCKING -,SUP-G826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
SCREW SET 8.5 -,SUP-G826-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
CAP LOCKING TI -,SUP-G828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,,,
SET CAPS -,SUP-G828-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,,,
CAGE 5MM SMALL -,SUP-GAC-05-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR APACHE CAGE 7MM -,SUP-GAC-07-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,0.518595,35041.66656,percent of total billed charges,,,
APACHE CAGE ANCHORED 8MM -,SUP-GAC-08 SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,0.518595,35041.66656,percent of total billed charges,,,
CAGE H8 -,SUP-GAC-08-SC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,0.518595,35041.66656,percent of total billed charges,,,
APACHE ANCHORED 8MM -,SUP-GAC-08-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,0.518595,35041.66656,percent of total billed charges,,,
CAGE 9MM -,SUP-GAC-09-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,0.518595,35041.66656,percent of total billed charges,,,
CAGE APACHE ANCHORED 10MM -,SUP-GAC-10SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,0.518595,35041.66656,percent of total billed charges,,,
APACHE ANCHORED 6MM -,SUP-GAC3D06-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,0.518595,35041.66656,percent of total billed charges,,,
APACHE ANCHOR LARGE -,SUP-GAC-LG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR MEDIUM -,SUP-GAC-MD,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SMALL -,SUP-GAC-SM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR GREEN XL -,SUP-GAC-XL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR XXL BROWN -,SUP-GAC-XXL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
PLATE BUTTRES 22MM -,SUP-GBP1-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9549,6684.3,AETNA [1000108],AETNA [100010801],,,76.8,,7333.63,0.518595,35041.66656,percent of total billed charges,,,
SCREW 22MM 5.5 -,SUP-GBP1-2255,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,0.518595,35041.66656,percent of total billed charges,,,
9mm CERVICAL PECK CAGE APACHE -,SUP-GCL-09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
CAGE SMALL APACHE 11MM -,SUP-GCL-11-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 12MM -,SUP-GCP10012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 14MM -,SUP-GCP10014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
SCREW 14MM RESCU -,SUP-GCP10014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,AETNA [1000108],AETNA [100010801],,,76.8,,761.82,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 16MM -,SUP-GCP10016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
PLATE 35MM -,SUP-GCP20035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,,,
PLATE BINARY 12MM -,SUP-GCP2-112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
PLATE 14MM -,SUP-GCP2-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
PLATE 16MM -,SUP-GCP2-116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
PLATE CERVICAL 49MM -,SUP-GCP2-349,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.75MM X 16MM BINARY AUGER TIP FIXED -,SUP-GCP2-AF316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREWS 3.75 X 14MM SCREWS -,SUP-GCP2-AV314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.75MM X 18MM BINARY AUGER TIP VAIABLE -,SUP-GCP2-AV318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREWS 4.25 X 12MM -,SUP-GCP2-AV412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW FIXED CERV 3.75 X 14MM -,SUP-GCSF37514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,AETNA [1000108],AETNA [100010801],,,76.8,,761.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW BN 14MM -,SUP-GCSV37514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,AETNA [1000108],AETNA [100010801],,,76.8,,761.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW VA 16MM -,SUP-GCSV37516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,AETNA [1000108],AETNA [100010801],,,76.8,,761.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW RESCUE 16MM -,SUP-GCSV42516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,AETNA [1000108],AETNA [100010801],,,76.8,,761.82,0.518595,35041.66656,percent of total billed charges,,,
APACHE ANCHOR 6MM -,SUP-GCV-06-SO,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,0.518595,35041.66656,percent of total billed charges,,,
CAGE APACHE 6MM -,SUP-GCV-06-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,0.518595,35041.66656,percent of total billed charges,,,
CAGE APACHE ANCHORED 8MM -,SUP-GCV-08-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,0.518595,35041.66656,percent of total billed charges,,,
CAGE APACHE ANCHORED 9MM -,SUP-GCV-09-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR LARGE -,SUP-GCV-LG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,AETNA [1000108],AETNA [100010801],,,76.8,,2841.48,0.518595,35041.66656,percent of total billed charges,,,
GUIDE PIN 2.0MM X 125MM -,SUP-GDW-890-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.44,297.108,AETNA [1000108],AETNA [100010801],,,76.8,,325.97,0.518595,35041.66656,percent of total billed charges,,,
6.5 X 40MM PEDICLE SCREW -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
CERVICAL APACHE CAGE 8MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
PLATE CERVICAL 2 LEVEL 32MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL 7.5 X 30MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW REDUCTION 6.5 X 30MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,,,
PLATE BINARY 2 LEVEL CERVICAL 30MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,,,
PLATE STANDARD 31MM -,SUP-GLP-131,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 22MM -,SUP-GLPV-55 22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,,,
ROD SPINE 60MM -,SUP-GM150-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA [1000108],AETNA [100010801],,,76.8,,528.79,0.518595,35041.66656,percent of total billed charges,,,
SET SCREW -,SUP-GM520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,0.518595,35041.66656,percent of total billed charges,,,
MODULAR CORT IMPLANT HEAD -,SUP-GM557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,,,
MODULAR LOCK SCREW -,SUP-GM820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,,,
PLATE DORSAL SPANNING SHORT -,SUP-GMN-DSP-160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6217.46,4352.222,AETNA [1000108],AETNA [100010801],,,76.8,,4775.01,0.518595,35041.66656,percent of total billed charges,,,
PLATE BONE GEMINUS TITANIUM DORSAL SPANNING LONG -,SUP-GMN-DSP-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6416.93,4491.851,AETNA [1000108],AETNA [100010801],,,76.8,,4928.2,0.518595,35041.66656,percent of total billed charges,,,
PLATE BONE GEMINUS TITANIUM RADIAL DISTAL DORSAL HOOK -,SUP-GMN-HP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2592.28,1814.596,AETNA [1000108],AETNA [100010801],,,76.8,,1990.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW PLATE BONE GEMINUS TITANIUM RADIAL DISTAL DORSAL HOOK -,SUP-GMN-HP-SCRW,CDM,C1713,HCPCS,278,RC,,,outpatient,,,566,396.2,AETNA [1000108],AETNA [100010801],,,76.8,,434.69,0.518595,35041.66656,percent of total billed charges,,,
ASSEMBLED GEMINUS VOLAR DISTAL RADIUS PLATE NARR 120MM LEFT -,SUP-GMN-LTN-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9969.16,6978.412,AETNA [1000108],AETNA [100010801],,,76.8,,7656.31,0.518595,35041.66656,percent of total billed charges,,,
PLATE DIST RAD NARR 3 HOLE LEFT GEMINUS VOLAR -,SUP-GMN-LTN-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,AETNA [1000108],AETNA [100010801],,,76.8,,3406.06,0.518595,35041.66656,percent of total billed charges,,,
PLATE NARROW DIS RAD 4 HOLE LEFT -,SUP-GMN-LTN-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA [1000108],AETNA [100010801],,,76.8,,3487.55,0.518595,35041.66656,percent of total billed charges,,,
PLATE VOLAR DIST RAD STANDARD 3 HL LEFT -,SUP-GMN-LTS-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,AETNA [1000108],AETNA [100010801],,,76.8,,3406.06,0.518595,35041.66656,percent of total billed charges,,,
PLATE GEMINUS VOLAR DISTAL RADIUS STANDARD 4 HOLE LEFT -,SUP-GMN-LTS-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA [1000108],AETNA [100010801],,,76.8,,3487.55,0.518595,35041.66656,percent of total billed charges,,,
PLATE ASSEMBLED GEMINUS VOLAR DIST RAD NARROW 120MM RIGHT -,SUP-GMN-RTN-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9969.16,6978.412,AETNA [1000108],AETNA [100010801],,,76.8,,7656.31,0.518595,35041.66656,percent of total billed charges,,,
PLATE VOLAR DISTAL RADIUS NARROW 3 HOLE RIGHT -,SUP-GMN-RTN-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,AETNA [1000108],AETNA [100010801],,,76.8,,3406.06,0.518595,35041.66656,percent of total billed charges,,,
DISTAL RADIUS PLATE- NARROW 4 HOLE RT. -,SUP-GMN-RTN-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA [1000108],AETNA [100010801],,,76.8,,3487.55,0.518595,35041.66656,percent of total billed charges,,,
PLATE VOLAR DIST RADIUS STD 3 HOLD RIGHTTI GEMINUS -,SUP-GMN-RTS-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,AETNA [1000108],AETNA [100010801],,,76.8,,3406.06,0.518595,35041.66656,percent of total billed charges,,,
PLATE DISTAL RADIUS VOLAR GEMINUS WIDE 4HL RIGHT -,SUP-GMN-RTW-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4621.72,3235.204,AETNA [1000108],AETNA [100010801],,,76.8,,3549.48,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5 X 30 -,SUP-GMSD 55 30-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5 X 45 -,SUP-GMSD 55 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL 4.5 X 30MM -,SUP-GMSD45-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5 X 35 -,SUP-GMSD-50 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL 5.0 X 30MM -,SUP-GMSD50-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL 5.0 X 35MM NEW -,SUP-GMSD50-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.0 X 4.0 -,SUP-GMSD50-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,,,
SCREW 55 X 35 -,SUP-GMSD-55 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL 5.5 X 30 -,SUP-GMSD55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,,,
CORTICAL MODULAR SCREW 5.5 X 35 -,SUP-GMSD55-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL 5.5 X 35 -,SUP-GMSD55-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL SPINE 5.5 X 40 -,SUP-GMSD55-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL 5.5 X 45 -,SUP-GMSD55-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL 6 X 35 -,SUP-GMSD-60 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL 6 X 30 -,SUP-GMSD60-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,,,
CORTICAL SCREW 6 X 35 -,SUP-GMSD60-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,,,
GENESYS CORTICAL SCREW 6.5MM X 35MM -,SUP-GMSD60-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,,,
SCREW MODULAR 6.0 x 40 -,SUP-GMSD60-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,,,
SCREW 65 X 35 -,SUP-GMSD-65 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORITCAL SPINE 6.5 X 35 -,SUP-GMSD65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL SPINE 6.5 X 40 -,SUP-GMSD65-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL 6.5 X 45 -,SUP-GMSD65-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,,,
SCREW GENESYS MODULAR 6.5 X 50MM -,SUP-GMSD65-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL 7.5 X 40 -,SUP-GMSD75-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL 75 X 45 -,SUP-GMSD75-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL 75 X 50 -,SUP-GMSD75-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL 8.5 X 70 -,SUP-GMSD85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5 X 30 -,SUP-GMSP55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.0 X 30 -,SUP-GMSP60-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,,,
2-PIECE PIN TIP SECTION-TROCAR TIP -,SUP-GSI209-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,571.83,400.281,AETNA [1000108],AETNA [100010801],,,76.8,,439.17,0.518595,35041.66656,percent of total billed charges,,,
2-PIECE PIN-TAIL SECTION 750MM W/TIP -,SUP-GSI210-02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,,,
2P PIN TAIL -,SUP-GSI210-02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,,,
350 TROCAR PIN -,SUP-GSI211-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,,,
SCREW 9.5 X 35 -,SUP-GSI-SDW09535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,AETNA [1000108],AETNA [100010801],,,76.8,,8355.14,0.518595,35041.66656,percent of total billed charges,,,
SCREW 9.5 X 40 -,SUP-GSI-SDW09540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,AETNA [1000108],AETNA [100010801],,,76.8,,8355.14,0.518595,35041.66656,percent of total billed charges,,,
SCREW 9.5 X 40 -,SUP-GSI-SDW09545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,AETNA [1000108],AETNA [100010801],,,76.8,,8355.14,0.518595,35041.66656,percent of total billed charges,,,
SCREW 9.5 X 60 SI SUAL THREAD WASHER HEAD -,SUP-GSI-SDW09560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,AETNA [1000108],AETNA [100010801],,,76.8,,8355.14,0.518595,35041.66656,percent of total billed charges,,,
POSTERIOR ALLOGRAFT 20MM -,SUP-GSPA-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,AETNA [1000108],AETNA [100010801],,,76.8,,8355.14,0.518595,35041.66656,percent of total billed charges,,,
APACHE ANCHOR 8MM -,SUP-GVC-08-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,0.518595,35041.66656,percent of total billed charges,,,
APACHE ANCHORED 9MM -,SUP-GVC-09-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,0.518595,35041.66656,percent of total billed charges,,,
GUIDE PIN 2.0MM X 150MM -,SUP-GW0920061501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,306.34,214.438,AETNA [1000108],AETNA [100010801],,,76.8,,235.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE CAN PT TI 4.0 X 26MM -,SUP-H00693,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE CAN PT TI 4.0 X 24MM -,SUP-H00693,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA [1000108],AETNA [100010801],,,76.8,,648.08,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X40MM CANC POLARUS FT CNTRSNK TI NS -,SUP-HCA-5140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,AETNA [1000108],AETNA [100010801],,,76.8,,989.2,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5X45MM CANC POLARUS FT CNTRSNK TI NS -,SUP-HCA-5145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,AETNA [1000108],AETNA [100010801],,,76.8,,989.2,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.3X35MM LCK CANC POLARUS FT TI STRL -,SUP-HCA-L5335-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,AETNA [1000108],AETNA [100010801],,,76.8,,1050.26,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.3X40MM LCK CANC POLARUS FT TI STRL -,SUP-HCA-L5340-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,AETNA [1000108],AETNA [100010801],,,76.8,,1050.26,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.3X45MM LCK CANC POLARUS FT TI STRL -,SUP-HCA-L5345-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,AETNA [1000108],AETNA [100010801],,,76.8,,1050.26,0.518595,35041.66656,percent of total billed charges,,,
PEG HIGH COMPRESSION LOCKING 2.7 X 18 -,SUP-HCLP-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,AETNA [1000108],AETNA [100010801],,,76.8,,555.68,0.518595,35041.66656,percent of total billed charges,,,
PEG HIGH COMPRESSION LOCKING 2.7MM  X 19MM TI -,SUP-HCLP-27190-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,AETNA [1000108],AETNA [100010801],,,76.8,,555.68,0.518595,35041.66656,percent of total billed charges,,,
PEG HIGH COMPRESSION LOCKING 2.7MM  X 20M TI -,SUP-HCLP-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,AETNA [1000108],AETNA [100010801],,,76.8,,555.68,0.518595,35041.66656,percent of total billed charges,,,
PEG HIGH COMPRESSION LOCKING 2.7MM  X 21M TI -,SUP-HCLP-27210-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,AETNA [1000108],AETNA [100010801],,,76.8,,555.68,0.518595,35041.66656,percent of total billed charges,,,
HIGH COMP PEG LCK 2.7 X 22 -,SUP-HCLP-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,AETNA [1000108],AETNA [100010801],,,76.8,,555.68,0.518595,35041.66656,percent of total billed charges,,,
HIGH COMPRESSION LOCKING PEG 2.7MM X 28MM TI -,SUP-HCLP-27280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,AETNA [1000108],AETNA [100010801],,,76.8,,555.68,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X20MM NLCKG CORT POLARUS TI STRL -,SUP-HCO3200-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,AETNA [1000108],AETNA [100010801],,,76.8,,989.2,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X25MM NLCKG CORT POLARUS TI STRL -,SUP-HCO3250-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,AETNA [1000108],AETNA [100010801],,,76.8,,989.2,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MMX32.5MM NLCKG CORT POLARUS TI STRL -,SUP-HCO3325-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,AETNA [1000108],AETNA [100010801],,,76.8,,989.2,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEADLESS COMP 2.5 X 14 -,SUP-HCS-25014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,AETNA [1000108],AETNA [100010801],,,76.8,,2731.49,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEADLESS COMP 2.5 X 16 -,SUP-HCS-25016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,AETNA [1000108],AETNA [100010801],,,76.8,,2731.49,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEADLESS COMPRESSION 2.5MM X 18MM -,SUP-HCS-25018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,AETNA [1000108],AETNA [100010801],,,76.8,,2731.49,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEADLESS COMP 2.5MM X 22MM TI -,SUP-HCS-25022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,AETNA [1000108],AETNA [100010801],,,76.8,,2731.49,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEADLESS COMP 2.5MM X 24MM TI -,SUP-HCS-25024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,AETNA [1000108],AETNA [100010801],,,76.8,,2731.49,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEADLESS COMP 2.5MM X 26MM TI -,SUP-HCS-25026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,AETNA [1000108],AETNA [100010801],,,76.8,,2731.49,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEADLESS COMPRESSION 2.5MM X 30MM -,SUP-HCS-25030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,AETNA [1000108],AETNA [100010801],,,76.8,,2731.49,0.518595,35041.66656,percent of total billed charges,,,
ROD IM 8X240MM POLARUS + CANN TAPR PRFL HUM TI STAB -,SUP-HR-0824-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9312.2,6518.54,AETNA [1000108],AETNA [100010801],,,76.8,,7151.77,0.518595,35041.66656,percent of total billed charges,,,
ROD IM 11X150MM POLARUS PROX HUM -,SUP-HR-L1115-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10452.97,7317.079,AETNA [1000108],AETNA [100010801],,,76.8,,8027.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEADED 2.5 X 12MM -,SUP-IC2512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA [1000108],AETNA [100010801],,,76.8,,1414.19,0.518595,35041.66656,percent of total billed charges,,,
2.5MM HEADED SCREW LENGTH 14MM -,SUP-IC2514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA [1000108],AETNA [100010801],,,76.8,,1414.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE MINI HEADED 2.5 X 18MM -,SUP-IC2518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA [1000108],AETNA [100010801],,,76.8,,1414.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5 HEADED 20MM LENGTH -,SUP-IC2520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA [1000108],AETNA [100010801],,,76.8,,1414.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEADED 2.5 X 22MM -,SUP-IC2522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA [1000108],AETNA [100010801],,,76.8,,1414.19,0.518595,35041.66656,percent of total billed charges,,,
2.5 MM HEADED 26MM LENGTH MINI CANN SCREW -,SUP-IC2526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA [1000108],AETNA [100010801],,,76.8,,1414.19,0.518595,35041.66656,percent of total billed charges,,,
MINI SET SCREW 2.5X28MM -,SUP-IC2528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA [1000108],AETNA [100010801],,,76.8,,1414.19,0.518595,35041.66656,percent of total billed charges,,,
2.5 MM HEADED 30MM LENGTH MINI CANN SCREW -,SUP-IC2530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA [1000108],AETNA [100010801],,,76.8,,1414.19,0.518595,35041.66656,percent of total billed charges,,,
3.0 X 10MM CANNULATED SCREW -,SUP-IC3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA [1000108],AETNA [100010801],,,76.8,,1414.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.0 HEADED 18MM -,SUP-IC3018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA [1000108],AETNA [100010801],,,76.8,,1414.19,0.518595,35041.66656,percent of total billed charges,,,
3.0MM HEADED 22MM LENGTH CANN SCREW -,SUP-IC3022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA [1000108],AETNA [100010801],,,76.8,,1414.19,0.518595,35041.66656,percent of total billed charges,,,
3.0MM HEADED 24MM LENGTH CANN SCREW -,SUP-IC3024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA [1000108],AETNA [100010801],,,76.8,,1414.19,0.518595,35041.66656,percent of total billed charges,,,
3.0MM HEADED 26MM LENGTH MINI CANN SCREW -,SUP-IC3026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA [1000108],AETNA [100010801],,,76.8,,1414.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3MM X 30MM -,SUP-IC3030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA [1000108],AETNA [100010801],,,76.8,,1414.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.0 HEADED 32MM LENGTH -,SUP-IC3032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA [1000108],AETNA [100010801],,,76.8,,1414.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.0MM HEADED 34MM LENGTH -,SUP-IC3034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA [1000108],AETNA [100010801],,,76.8,,1414.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.0MM HEADED 38MM LENGTH -,SUP-IC3038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA [1000108],AETNA [100010801],,,76.8,,1414.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEADED 3.0 X 40MM -,SUP-IC3040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA [1000108],AETNA [100010801],,,76.8,,1414.19,0.518595,35041.66656,percent of total billed charges,,,
4.0MM HEADED 20MM LENGTH MINI CANN SCREW -,SUP-IC4020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,AETNA [1000108],AETNA [100010801],,,76.8,,950.73,0.518595,35041.66656,percent of total billed charges,,,
4.0MM HEADED SCREW LENGTH 32MM -,SUP-IC4032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,AETNA [1000108],AETNA [100010801],,,76.8,,950.73,0.518595,35041.66656,percent of total billed charges,,,
4.0MM HEADED SCREW LENGTH 34MM -,SUP-IC4034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,AETNA [1000108],AETNA [100010801],,,76.8,,950.73,0.518595,35041.66656,percent of total billed charges,,,
4.0MM HEADED 36MM LENGTH MINI CANN SCREW -,SUP-IC4036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,AETNA [1000108],AETNA [100010801],,,76.8,,950.73,0.518595,35041.66656,percent of total billed charges,,,
4.0MM HEADED 38MM LENGTH MINI CANN SCREW -,SUP-IC4038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,AETNA [1000108],AETNA [100010801],,,76.8,,950.73,0.518595,35041.66656,percent of total billed charges,,,
4.0MM HEADED 40MM LENGTH MINI CANN SCREW -,SUP-IC4040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,AETNA [1000108],AETNA [100010801],,,76.8,,950.73,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE MINI 46MM X 4MM HEAD NONSTERILE -,SUP-IC4046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,AETNA [1000108],AETNA [100010801],,,76.8,,950.73,0.518595,35041.66656,percent of total billed charges,,,
4.0MM HEADED SCREW LENGTH 48MM -,SUP-IC4048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,AETNA [1000108],AETNA [100010801],,,76.8,,950.73,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE MINI 50MM X 4MM HEAD NONSTERILE -,SUP-IC4050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,AETNA [1000108],AETNA [100010801],,,76.8,,950.73,0.518595,35041.66656,percent of total billed charges,,,
INFLUX SPARC (IBM) 1CC -,SUP-IFLX-CM-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2597.25,1818.075,AETNA [1000108],AETNA [100010801],,,76.8,,1994.69,0.518595,35041.66656,percent of total billed charges,,,
INFLUX SPARC (IBM) 5CC -,SUP-IFLX-CM-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8530.44,5971.308,AETNA [1000108],AETNA [100010801],,,76.8,,6551.38,0.518595,35041.66656,percent of total billed charges,,,
HEADLESS SCREW 2.5X10MM -,SUP-IH2510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,,,
2.5MM HEADLESS SCREW LENGTH 20MM -,SUP-IH2520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,,,
2.5MM HEADLESS SCREW LENGTH 24MM -,SUP-IH2524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,,,
2.5MM HEADLESS SCREW LENGTH 26MM -,SUP-IH2526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,,,
2.5MM HEADLESS SCREW LENGTH  30MM -,SUP-IH2530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE MINI 2.5 X 36MM HEADLESS -,SUP-IH2536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,,,
3.0 X 14MM HEADLESS SCREW -,SUP-IH3014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.0 X 22MM HEADLESS -,SUP-IH3022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.0 X 24MM HEADLESS -,SUP-IH3024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.0 X 26MM HEADLESS -,SUP-IH3026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEADLESS 3.0MM X 30MM -,SUP-IH3030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,,,
3.0 X 32MM HEADLESS SCREW -,SUP-IH3032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,,,
3.0 X 34MM HEADLESS SCREW -,SUP-IH3034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEADLESS 3.0MM X 36MM -,SUP-IH3036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEADLESS 3.0MM X 38MM -,SUP-IH3038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEADLESS 3.0MM X 40MM -,SUP-IH3040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,,,
4.0MM HEADLESS SCREW LENGTH 32MM -,SUP-IH4032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEADLESS 4.0MM X 16MM X 36MM -,SUP-IH4036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEADLESS 4.0MM X 38MM -,SUP-IH4038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEADLESS 4.0MM X 40MM -,SUP-IH4040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEADLESS 4.0MM X 42MM -,SUP-IH4042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEADLESS 4.0MM X 46MM -,SUP-IH4046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEADLESS 4.0MM X 50MM -,SUP-IH4050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA [1000108],AETNA [100010801],,,76.8,,2217.46,0.518595,35041.66656,percent of total billed charges,,,
PIN AXIS 2.5MM X 40MM IJS-E -,SUP-IJS-EAP-25400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1727.96,1209.572,AETNA [1000108],AETNA [100010801],,,76.8,,1327.07,0.518595,35041.66656,percent of total billed charges,,,
PIN IJS-E AXIS 2.5MM X 45MM -,SUP-IJS-EAP-25450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1727.96,1209.572,AETNA [1000108],AETNA [100010801],,,76.8,,1327.07,0.518595,35041.66656,percent of total billed charges,,,
BLADE T10 DRIVER 4.0 SCREWS -,SUP-IS1108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,921.23,644.861,AETNA [1000108],AETNA [100010801],,,76.8,,707.5,0.518595,35041.66656,percent of total billed charges,,,
PK SCREW INTNL FX STRL CONTR -,SUP-JG303R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21.15,14.805,AETNA [1000108],AETNA [100010801],,,76.8,,16.24,0.518595,35041.66656,percent of total billed charges,,,
CAGE 28MMX10MM JULIET OL LD SHARING ANTMC PEEK -,SUP-JUL-OL 28 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
CAGE 7X28MM STR -,SUP-JUL-OX2807-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,0.518595,35041.66656,percent of total billed charges,,,
CAGE LUMBAR POSTERIOR TI L24 W8 H7 -,SUP-JUN-P6 24 07-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,0.518595,35041.66656,percent of total billed charges,,,
8 X 24 PLIF TITANIUM CAGE -,SUP-JUN-P6 24 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,0.518595,35041.66656,percent of total billed charges,,,
CAGE LUMBAR POSTERIOR TI L24 W8 H09 6 DEGREE NARROW JULIET -,SUP-JUN-P6 24 09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,0.518595,35041.66656,percent of total billed charges,,,
CAGE PLIF TI 24 X 8.5 X 10 -,SUP-JUN-P6 24 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,0.518595,35041.66656,percent of total billed charges,,,
LUMBAR POSTERIOR TI CAGE L24 W9 H11 -,SUP-JUN-P6 24 11-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,0.518595,35041.66656,percent of total billed charges,,,
CAGE 24 X 9 X 12 PLIF 6 DEGREE -,SUP-JUN-P6 24 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,0.518595,35041.66656,percent of total billed charges,,,
CAGE LUMBAR POSTERIOR TI 14 X 9 X 24 6DEG -,SUP-JUN-P6 24 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,0.518595,35041.66656,percent of total billed charges,,,
LUMBAR POSTERIOR TI CAGE L24 X W8 X H07 6 DEGREE -,SUP-JUN-P62407-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,0.518595,35041.66656,percent of total billed charges,,,
LUMBAR POSTERIOR TI CAGE L24 W8.5 H10 -,SUP-JUN-P62410-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,0.518595,35041.66656,percent of total billed charges,,,
CAGE POSTERIOR LUMBAR TI L24 X W9 X H11 6DEG JULIET -,SUP-JUN-P62411-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,0.518595,35041.66656,percent of total billed charges,,,
TITANIUM PLIF CAGE L24 X W9 X H12 6 DEGREE -,SUP-JUN-P62412-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,0.518595,35041.66656,percent of total billed charges,,,
LUMBAR POSTERIOR TI CAGE L24 W10.5 -,SUP-JUT PX 24 09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,0.518595,35041.66656,percent of total billed charges,,,
CAGE TRANSORAMINLA LUMBAR TI L30 W 10.5 -,SUP-JUT-T6 30 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,0.518595,35041.66656,percent of total billed charges,,,
CAGE LUMBAR TRANSFORAMINAL L30 W 10.5 -,SUP-JUT-T6 30 09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,0.518595,35041.66656,percent of total billed charges,,,
CAGE TRANSFORAMINAL LUMBAR TI CAGE L30 W 10.5 H10 -,SUP-JUT-T6 30 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,0.518595,35041.66656,percent of total billed charges,,,
CAGE TRANSFORAMINAL LUMBAR TI L30 W 10.5 H 11 -,SUP-JUT-T6 30 11-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,0.518595,35041.66656,percent of total billed charges,,,
CAGE TRANSFORAMINAL LUMBAR TI L30 W10.5 H12 6 DEG -,SUP-JUT-T6 30 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,0.518595,35041.66656,percent of total billed charges,,,
CAGE TRANSORAMINAL LUMBAR TI L 30 W 10.5 H 13 -,SUP-JUT-T6 30 13-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,0.518595,35041.66656,percent of total billed charges,,,
SYS BONE CMNT PARALLAX EZFLOW -,SUP-KP-CDS-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,,,
KT DEVICE PARALLAX CONTR -,SUP-KP-CTR-1508C-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7002.6,4901.82,AETNA [1000108],AETNA [100010801],,,76.8,,5378,0.518595,35041.66656,percent of total billed charges,,,
STENT ADVANIX BIL 10FR X 3CM DBL PIGTAIL -,SUP-M00532240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.44,231.308,AETNA [1000108],AETNA [100010801],,,76.8,,253.78,0.518595,35041.66656,percent of total billed charges,,,
DISK SPIN MOBI- C COCR MLYBDNM EPLT UHMWPE INLAY 13X15X5MM -,SUP-MB3355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,AETNA [1000108],AETNA [100010801],,,76.8,,16824.35,0.518595,35041.66656,percent of total billed charges,,,
PROSTHESIS CERV DISC 13 X 17 H -,SUP-MB3375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,AETNA [1000108],AETNA [100010801],,,76.8,,16824.35,0.518595,35041.66656,percent of total billed charges,,,
DISC SPIN MOBI- C COCR MLYBDNM EPLT UHMWPE INLAY 15X15X5MM -,SUP-MB3555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,AETNA [1000108],AETNA [100010801],,,76.8,,16824.35,0.518595,35041.66656,percent of total billed charges,,,
DISC SPIN MOBI- C PROS COCR MLYBDNM EPLT UHMWPE INLAY -,SUP-MB3576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,AETNA [1000108],AETNA [100010801],,,76.8,,16824.35,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE 40MM ROD -,SUP-MC1-200040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,,,
IMPLANT ROI-C 7MM 12 X 14MM LO -,SUP-MC1343P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,0.518595,35041.66656,percent of total billed charges,,,
CAGE CERV 10MM/7.2MM H A/P ROI- C LRDTC -,SUP-MC1426P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,0.518595,35041.66656,percent of total billed charges,,,
CAGE CERV 5MM/2.3MM H A/P ROI- C LRDTC -,SUP-MC1441P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,0.518595,35041.66656,percent of total billed charges,,,
CAGE CERV 6MM/3.1MM H A/P ROI- C LRDTC -,SUP-MC1442P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,0.518595,35041.66656,percent of total billed charges,,,
CAGE CERV 8MM/5.1MM H A/P ROI- C LRDTC -,SUP-MC1444P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,0.518595,35041.66656,percent of total billed charges,,,
CAGE CERV 9MM/6.1MM H A/P ROI- C LRDTC -,SUP-MC1445P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,0.518595,35041.66656,percent of total billed charges,,,
IMPLANT ROI-C LORDOSED 12X15.5 -,SUP-MC1454P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.8X22MM S3 MULDIR NS -,SUP-MD22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.8X24MM S3 MULDIR NS -,SUP-MD24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.8X26MM S3 MULDIR NS -,SUP-MD26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.8X28MM S3 MULDIR NS -,SUP-MD-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.8X28MM S3 MULDIR NS -,SUP-MD-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.8X30MM S3 MULDIR NS -,SUP-MD30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.8X32MM S3 MULDIR NS -,SUP-MD32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.8X34MM S3 MULDIR NS -,SUP-MD34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.8X36MM S3 MULDIR NS -,SUP-MD36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.8X38MM S3 MULDIR NS -,SUP-MD38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5MM X 40MM CANNULATED POLYAXIAL -,SUP-MPF-PX  55 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5MM X 35MM CANNULATED POLYAXIAL -,SUP-MPF-PX 55 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,0.518595,35041.66656,percent of total billed charges,,,
MIDSHAFT RADIUS PLATE 112MM -,SUP-MRP-112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5996.77,4197.739,AETNA [1000108],AETNA [100010801],,,76.8,,4605.52,0.518595,35041.66656,percent of total billed charges,,,
PLATE FREEFIX MIDSHAFT RADIUS 127MM -,SUP-MRP-127,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA [1000108],AETNA [100010801],,,76.8,,4654.41,0.518595,35041.66656,percent of total billed charges,,,
SIZER NATRELLE INSPIRA 325CC FULL -,SUP-MSZ-F325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,,,
SIZER NATRELLE INSPIRA 345CC FULL -,SUP-MSZ-F345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,,,
SIZER NATRELLE INSPIRA 450CC FULL -,SUP-MSZ-F450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,,,
SIZER NATRELLE INSPIRA 485CC FULL -,SUP-MSZ-F485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,,,
SIZER NATRELLE INSPIRA 330CC MODERATE -,SUP-MSZ-M330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,,,
SIZER NATRELLE INSPIRA 445CC MODERATE -,SUP-MSZ-M445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,,,
SIZER NATRELLE INSPIRA 485CC MODERATE -,SUP-MSZ-M485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,,,
SCREW MULTI-THREAD LOCKING 2.7MM X 18MM TI -,SUP-MTLS-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,AETNA [1000108],AETNA [100010801],,,76.8,,815.59,0.518595,35041.66656,percent of total billed charges,,,
SCREW MULTI-THREAD LOCKING 2.7MM X 20MM -,SUP-MTLS-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,AETNA [1000108],AETNA [100010801],,,76.8,,815.59,0.518595,35041.66656,percent of total billed charges,,,
SCREW MULTI-THREAD LOCKING 2.7 X 22 -,SUP-MTLS-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,AETNA [1000108],AETNA [100010801],,,76.8,,815.59,0.518595,35041.66656,percent of total billed charges,,,
SCREW MULTI THREAD LOCKING 2.7MM X 32MM TI -,SUP-MTLS-27320-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,AETNA [1000108],AETNA [100010801],,,76.8,,815.59,0.518595,35041.66656,percent of total billed charges,,,
SCREW MULTI THREADED LOCKING 3.0MM X 10MM TI -,SUP-MTLS-30100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,AETNA [1000108],AETNA [100010801],,,76.8,,654.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW MULTI THREADED LOCKING 3.0MM X 12MM TI -,SUP-MTLS-30120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,AETNA [1000108],AETNA [100010801],,,76.8,,654.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW MULTI THREADED LOCKING 3.0MM X 14MM TI -,SUP-MTLS-30140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,AETNA [1000108],AETNA [100010801],,,76.8,,654.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW MT LOCKING 3.5MM X 8MM TI -,SUP-MTLS-35080-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW MT LOCKING 3.5MM X 10MM TI -,SUP-MTLS-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW MT LOCKING 3.5MM X 12MM TI -,SUP-MTLS-35120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW MT LOCKING 3.5MM X 14MM TI -,SUP-MTLS-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW MT LOCKING 3.5MM X 16MM TI -,SUP-MTLS-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW MT LOCKING 3.5MM X 18MM TI -,SUP-MTLS-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW MT LOCKING 3.5MM X 20MM TI -,SUP-MTLS-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW MT LOCKING 3.5MM X 22MM TI -,SUP-MTLS-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW MT LOCKING 3.5MM X 24MM TI -,SUP-MTLS-35240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW MT LOCKING 3.5MM X 26MM TI -,SUP-MTLS-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW MT LOCKING 3.5MM X 28MM TI -,SUP-MTLS-35280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE LKG 3.5MM X 32MM MULTITHREAD TI -,SUP-MTLS-35320-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE TITANIUM MULTI-THREAD LOCKING 3.5 X 34 -,SUP-MTLS-35340-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW MULTI-THREAD LOCKING 3.5MM X 36MM TI -,SUP-MTLS-35360-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW MULTI-THREAD LOCKING 3.5MM X 38MM TI -,SUP-MTLS-35380-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE TITANIUM MULTI-THREAD LOCKING 3.5 X 40 -,SUP-MTLS-35400-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW MULTI THREAD LOCKING 3.5MM X 42MM TI -,SUP-MTLS-35420-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,AETNA [1000108],AETNA [100010801],,,76.8,,815.59,0.518595,35041.66656,percent of total billed charges,,,
SCREW MULTI-THREAD LOCKING 3.5MM X 55MM TI -,SUP-MTLS-35550-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW MULTI-THREAD COMPRESSION 3 X 10 -,SUP-MTNL-30100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,AETNA [1000108],AETNA [100010801],,,76.8,,654.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW MULTI THREAD COMP 3.0MM X 12MM TI -,SUP-MTNL-30120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,AETNA [1000108],AETNA [100010801],,,76.8,,654.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW MULTI-THREAD COMPRESSION 3.0MM X 16MM TI -,SUP-MTNL-30160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,AETNA [1000108],AETNA [100010801],,,76.8,,654.27,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE TITANIUM MULTI-THREAD LOCKING 3.5 X 10 -,SUP-MTNL-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW MT COMP 3.5MM X 14MM TI -,SUP-MTNL-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW MT COMP 3.5MM X 16MM TI -,SUP-MTNL-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW MT COMP 3.5MM X 18MM TI -,SUP-MTNL-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW MT COMP 3.5MM X 22MM TI -,SUP-MTNL-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW MT COMP 3.5MM X 40MM TI -,SUP-MTNL-35400-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW MULTI THREAD COMPRESSION 3.5MM X 42MM TI -,SUP-MTNL-35420-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,AETNA [1000108],AETNA [100010801],,,76.8,,761.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW MT COMP 3.5MM X 45MM TI -,SUP-MTNL-35450-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW MT COMP 3.5MM X 50MM TI -,SUP-MTNL-35500-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,,,
SCREW MT COMP 3.5MM X 60MM TI -,SUP-MTNL-35600-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA [1000108],AETNA [100010801],,,76.8,,878.33,0.518595,35041.66656,percent of total billed charges,,,
MIDSHAFT ULNA PLATE 97MM -,SUP-MUP-097,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5937.36,4156.152,AETNA [1000108],AETNA [100010801],,,76.8,,4559.89,0.518595,35041.66656,percent of total billed charges,,,
PLATE MIDSHAFT ULNA 112MM -,SUP-MUP-112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5996.77,4197.739,AETNA [1000108],AETNA [100010801],,,76.8,,4605.52,0.518595,35041.66656,percent of total billed charges,,,
MACROFORM NOVABONE 5CC -,SUP-NB1002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA [1000108],AETNA [100010801],,,76.8,,4074.24,0.518595,35041.66656,percent of total billed charges,,,
MACROFORM 5CC -,SUP-NB4305,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA [1000108],AETNA [100010801],,,76.8,,4074.24,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.8X20MM LCK S3 90DG ANG TI NS -,SUP-NL20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.8X24MM LCK S3 90DG ANG TI NS -,SUP-NL24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.8X26MM LCK S3 90DG ANG TI NS -,SUP-NL-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.8X28MM LCK S3 90DG ANG TI NS -,SUP-NL28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.8X30MM LCK S3 90DG ANG TI NS -,SUP-NL30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.8X32MM LCK S3 90DG ANG TI NS -,SUP-NL32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW LCK 90DG ST BN HND SHLDR -,SUP-NL-SS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,AETNA [1000108],AETNA [100010801],,,76.8,,376.43,0.518595,35041.66656,percent of total billed charges,,,
SCREW LCK 90DG ST BN HND SHLDR -,SUP-NL-SS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,408.45,285.915,AETNA [1000108],AETNA [100010801],,,76.8,,313.69,0.518595,35041.66656,percent of total billed charges,,,
PIN FX STNMN 18INX9IN DBL END TROC SMTH SS -,SUP-OM 71-0459,CDM,C1713,HCPCS,278,RC,,,outpatient,,,69.73,48.811,AETNA [1000108],AETNA [100010801],,,76.8,,53.55,0.518595,35041.66656,percent of total billed charges,,,
ARTHROSCOPIC FX MAGNUM2 ACC F/SHLDR FT/ANKL RPR HALLUX -,SUP-OM-1502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1106.83,774.781,AETNA [1000108],AETNA [100010801],,,76.8,,850.05,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUT MAG PI -,SUP-OM-4500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,0.518595,35041.66656,percent of total billed charges,,,
DEVICE SUT MAG 2 + SMARTSTITCH KNTLS -,SUP-OM-9026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,AETNA [1000108],AETNA [100010801],,,76.8,,2548.17,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SFT TIS 3.2MM KNTLS FX W/PERFECTPASSER MAGNUMWR SUT -,SUP-OM-9146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3079.23,2155.461,AETNA [1000108],AETNA [100010801],,,76.8,,2364.85,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SFT TIS 3.2MM PNCH MAG PI + -,SUP-OM-9147,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3079.23,2155.461,AETNA [1000108],AETNA [100010801],,,76.8,,2364.85,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2X14MM LCK SMTH TI DVR NS -,SUP-P14000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2X16MM LCK SMTH TI DVR NS -,SUP-P16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2X20MM LCK SMTH TI DVR NS -,SUP-P20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2X22MM LCK SMTH TI DVR NS -,SUP-P22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2X26MM LCK SMTH TI DVR NS -,SUP-P26000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,,,
SCREW POLYAXIAL LCK 2.5 X 10 CANNULATED COCR -,SUP-PALS-25100-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,AETNA [1000108],AETNA [100010801],,,76.8,,842.48,0.518595,35041.66656,percent of total billed charges,,,
SCREW POLYAXIAL LCK 2.5 X 16 CANNULATED COCR -,SUP-PALS-25160-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,AETNA [1000108],AETNA [100010801],,,76.8,,842.48,0.518595,35041.66656,percent of total billed charges,,,
SCREW POLYAXIAL LCK 2.5 X 22MM CANNULATED COCR -,SUP-PALS-25220-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,AETNA [1000108],AETNA [100010801],,,76.8,,842.48,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE GEMINUS POLY LOCKING 2.5MM X 24MM CANN COCR -,SUP-PALS-25240-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,AETNA [1000108],AETNA [100010801],,,76.8,,842.48,0.518595,35041.66656,percent of total billed charges,,,
SCREW POLYAXL LCK 2.5MM X 26MM CANN -,SUP-PALS-25260-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,AETNA [1000108],AETNA [100010801],,,76.8,,842.48,0.518595,35041.66656,percent of total billed charges,,,
SCREW POLYAXIAL LOCKING 3.0MM X 18MM CANNULATED -,SUP-PALS-30180-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,AETNA [1000108],AETNA [100010801],,,76.8,,1127.61,0.518595,35041.66656,percent of total billed charges,,,
SCREW POLYAXIAL LOCKING 3.0MM X 22MM CANNULATED -,SUP-PALS-30220-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,AETNA [1000108],AETNA [100010801],,,76.8,,1184.6,0.518595,35041.66656,percent of total billed charges,,,
SCREW POLYAXIAL LOCKING 3.0MM X 24MM CANN -,SUP-PALS-30240-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,AETNA [1000108],AETNA [100010801],,,76.8,,1184.6,0.518595,35041.66656,percent of total billed charges,,,
SCREW POLYAXAIL LCK 3.0 X 34 -,SUP-PALS-30340-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,AETNA [1000108],AETNA [100010801],,,76.8,,1184.6,0.518595,35041.66656,percent of total billed charges,,,
SCREW POLYAXIAL LOCKING 3.0MM X 55MM CANNULATED -,SUP-PALS-30550-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,AETNA [1000108],AETNA [100010801],,,76.8,,1127.61,0.518595,35041.66656,percent of total billed charges,,,
THREADED PEG CORTICAL NON-LOCKING 2.7MM X 10MM TI -,SUP-PANL-27140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,76.8,,873.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL NON LOCKING 2.7 X 16 -,SUP-PANL-27160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,76.8,,873.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW PEG THREADED CORTICAL NON-LOCKING 2.7MM X 18MM TI -,SUP-PANL-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,76.8,,873.85,0.518595,35041.66656,percent of total billed charges,,,
PEG THREADED CORTICAL NON-LOCKING 2.7MM X 20MM TI -,SUP-PANL-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,76.8,,873.85,0.518595,35041.66656,percent of total billed charges,,,
PEG THREADED CORTICAL NON-LOCKING 2.7MM X 22MM TI -,SUP-PANL-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,76.8,,873.85,0.518595,35041.66656,percent of total billed charges,,,
PEG THREADED CORTICAL NL 2.7MM X 26MM TI -,SUP-PANL-27260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,76.8,,873.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL NON LOCKING 3.5 X 9 -,SUP-PANL-35090-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL NON LOCKING 3.5 X 10 -,SUP-PANL-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL NON LOCKING 3.5MM X 11MM -,SUP-PANL-35110-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW- CORTICAL NON-LOCKING 3.5MM X 12MM -,SUP-PANL-35120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW NON-LOCK 3.5 X 13 POLY TI -,SUP-PANL-35130-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
PLATE ASSEMBLED PROTEAN FRAGMENT DOUBLE HOCKEY STICK -,SUP-PANL-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4596.25,3217.375,AETNA [1000108],AETNA [100010801],,,76.8,,3529.92,0.518595,35041.66656,percent of total billed charges,,,
SCREW NON-LOCK 3.5 X 14 POLY TI -,SUP-PANL-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW NON-LOCK 3.5 X 15 POLY TI -,SUP-PANL-35150-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW POLYAXIAL NON LOCKING 3.5MM X 16MM TI -,SUP-PANL-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW POLYAXIAL NON LOCKING 3.5MM X 18MM TI -,SUP-PANL-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW NON-LOCK 3.5 X 20 POLY TI -,SUP-PANL-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,AETNA [1000108],AETNA [100010801],,,76.8,,685.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW NON-LOCK 3.5 X 22 POLY TI -,SUP-PANL-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,AETNA [1000108],AETNA [100010801],,,76.8,,685.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL NON LCK 3.5MM X 26MM TI -,SUP-PANL-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,AETNA [1000108],AETNA [100010801],,,76.8,,685.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW POLYAXIAL NON LOCKING 3.5MM X 28MM TI -,SUP-PANL-35280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,AETNA [1000108],AETNA [100010801],,,76.8,,685.64,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MM X 10MM -,SUP-PC1-003510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5MM X 12MM -,SUP-PC1-003512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
NORTHSTAR 3.5 X 14 SCREW -,SUP-PC1-003514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE 3.5MM X 16MM SCREW -,SUP-PC1-003516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
NORTHSTAR SCREW 3.5 X 18 -,SUP-PC1-003518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
SCREW POLY SEASPINE 3.5 MM X 20 MM -,SUP-PC1-003520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE SCREW 3.5MM X 22MM -,SUP-PC1-003522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE SCREW 35 X 24 -,SUP-PC1-003524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE SCREW 3.5 X 26 -,SUP-PC1-003526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE SCREW 4MM X 10MM -,SUP-PC1-004010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE NORTHSTAR 4MM X 12MM SCREW -,SUP-PC1-004012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MM X 14MM SPINE POLYAXIAL -,SUP-PC1-004014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4MM X 16MM SPINE POLYAXIAL -,SUP-PC1004016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3007.62,2105.334,AETNA [1000108],AETNA [100010801],,,76.8,,2309.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW POLYAXIAL 4.0 X 16 SEASPINE -,SUP-PC1-004016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
SCREW SEASPINE 4.0 X 18 POLYAXIAL -,SUP-PC1-004018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
NORTHSTAR SCREW 4 X 20 -,SUP-PC1-004020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
SCREW SEASPINE 4.0 X 22 POLYAXIAL -,SUP-PC1-004022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
SCREW SEASPINE 4.0 X 24 POLYAXIAL -,SUP-PC1-004024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE SCREW 4MM X 26MM -,SUP-PC1-004026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE SCREW 4MM X 28MM -,SUP-PC1-004028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4 X 30 -,SUP-PC1-004030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE SCREW 4.0 X 34 -,SUP-PC1-004034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
CROSS LINK MED 3.5 -,SUP-PC1-013502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,,,
CROSSHOLE LARGE 3.5MM -,SUP-PC1-013503,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE MD CROSSLINK -,SUP-PC1-014002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE LARGE CROSSLINK -,SUP-PC1-014003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,,,
LATERAL OFFSET -,SUP-PC1-020015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE 0-0CONNECTOR -,SUP-PC1-023540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,,,
PARALLELL TOP LOADING 5.5 -,SUP-PC1-023560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE 0-C CONNECTOR -,SUP-PC1-063535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE SCREW 4.5MM X 24MM -,SUP-PC1-104524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE 4.5 X 26 NS#2 -,SUP-PC1-104526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE 5.5 X 26 NS#2 -,SUP-PC1-104526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE SCREW 4.5MM X 28MM -,SUP-PC1-104528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE SCREW 4.5 X 30 NS#2 -,SUP-PC1-104530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE SCREW 4.5 X 34 -,SUP-PC1-104534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE SCREW 3.5 X 24 SS -,SUP-PC1-203524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE SCREW 3.5 X 26 SS -,SUP-PC1-203526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE SCREW 3.5 X 18 -,SUP-PC1-203528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
3.5 X 30MM SMOOTH SHANK SCREW -,SUP-PC1-203530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE REDUCTION SCREW 3.5 X 14 -,SUP-PC1-303514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
SCREW SET OCCIPITOCERVICOTHORACIC FIXATION SYSTEM -,SUP-PC1-400000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE ROD OCC 3.5 X 170 -,SUP-PC1-503177,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,0.518595,35041.66656,percent of total billed charges,,,
ROD SPINAL100MM TITANIUM CONTOUR -,SUP-PC1-503500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE ROD -,SUP-PC1-503502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE 30MM ROD -,SUP-PC1-503530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,,,
ROD SPINAL 40MM -,SUP-PC1-503540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,,,
ROD 50MM -,SUP-PC1-503550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,,,
ROD SPINAL 60MM TITANIUM CONTOUR -,SUP-PC1-503560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,,,
ROD 70MM -,SUP-PC1-503570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,,,
ROD 80MM -,SUP-PC1-503580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE NORTHSTAR 90MM ROD -,SUP-PC1-503590,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE ROD 4 X 120MM -,SUP-PC1-504002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE ROD 4X200MM -,SUP-PC1-504003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE ROD 80MM -,SUP-PC1-504080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE ROD 4 X 120 -,SUP-PC1-514012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE TRAN ROD 3.5 X 5.5 -,SUP-PC1-523555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1166.11,816.277,AETNA [1000108],AETNA [100010801],,,76.8,,895.57,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE OCC PLATE -,SUP-PC1-700000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,0.518595,35041.66656,percent of total billed charges,,,
BONE CHIPS CANCELLOUS CRUSHED 1-8 MM 15 CC CHIP -,SUP-PCAN15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.36,804.552,AETNA [1000108],AETNA [100010801],,,76.8,,882.71,0.518595,35041.66656,percent of total billed charges,,,
SUBSTITUTE CANC 30ML CUBE RDIGRF PRESERVON CRSH VOID FIL -,SUP-PCANCUBE30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2148.98,1504.286,AETNA [1000108],AETNA [100010801],,,76.8,,1650.42,0.518595,35041.66656,percent of total billed charges,,,
0 PDS PLUS VIOLET 1 X 27 CT-1 -,SUP-PDP340H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18.26,12.782,AETNA [1000108],AETNA [100010801],,,76.8,,14.02,0.518595,35041.66656,percent of total billed charges,,,
NAVIO BONE PIN 4.0MM X 89 -,SUP-PFSD-01008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.46,508.522,AETNA [1000108],AETNA [100010801],,,76.8,,557.92,0.518595,35041.66656,percent of total billed charges,,,
SUBSTITUTE WDG MATRGRF PRESERVON 18MM -,SUP-PICW8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3831.09,2681.763,AETNA [1000108],AETNA [100010801],,,76.8,,2942.28,0.518595,35041.66656,percent of total billed charges,,,
LEG CONTRA EXCLUDER AAA ENDO 16MM X 18MM X 11.5CM 12FR -,SUP-PLC181200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA [1000108],AETNA [100010801],,,76.8,,15213.2,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN F/ELB PLATE SYS 16HL LCK TI LNG NS -,SUP-PL-LEM16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6824.35,4777.045,AETNA [1000108],AETNA [100010801],,,76.8,,5241.1,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN 11X84MM 7HL LCK TI CONGR NS PNK -,SUP-PL-LEM7,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6017.99,4212.593,AETNA [1000108],AETNA [100010801],,,76.8,,4621.82,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN ANCHORAGE 6HL PRCONT LCK TI GRN LT -,SUP-PLP10341,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,AETNA [1000108],AETNA [100010801],,,76.8,,3740.34,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN ANCHORAGE 6HL PRCONT LCK TI GRN RT -,SUP-PLP10342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,AETNA [1000108],AETNA [100010801],,,76.8,,3740.34,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN ANCHORAGE F /HALLUX VALGUS V1 8HL PRCONT LCK TI LNG -,SUP-PLP10462,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,AETNA [1000108],AETNA [100010801],,,76.8,,3740.34,0.518595,35041.66656,percent of total billed charges,,,
PLATE MTP 5-HOLE -,SUP-PLP11341,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,AETNA [1000108],AETNA [100010801],,,76.8,,3740.34,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN ANCHORAGE F /HALLUX VALGUS V2 5HL PRCONT LCK TI GRN -,SUP-PLP11342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,AETNA [1000108],AETNA [100010801],,,76.8,,3740.34,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN ANCHORAGE F/CX PLATE SYS 1.5MM TI THRD HL COLR -,SUP-PLP14341,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,AETNA [1000108],AETNA [100010801],,,76.8,,3951.13,0.518595,35041.66656,percent of total billed charges,,,
ANCHORAGE MTP CP PLATE RIGHT -,SUP-PLP14342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,AETNA [1000108],AETNA [100010801],,,76.8,,3951.13,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN ANCHORAGE F/CX PLATE SYS TI THRD HL GRN -,SUP-PLP14342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,AETNA [1000108],AETNA [100010801],,,76.8,,3951.13,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN ANCHORAGE F/LPDS FUSION 0MM STP PRCONT LCK TI YEL -,SUP-PLP20342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,AETNA [1000108],AETNA [100010801],,,76.8,,3740.34,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN ANCHORAGE F/LPDS FUSION 0MM STP PRCONT LCK TI CP -,SUP-PLP29371,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,AETNA [1000108],AETNA [100010801],,,76.8,,3951.13,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN ANCHORAGE 28MM 4HL PRCONT SYM LCK UTIL TI PNK -,SUP-PLP40280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4564.66,3195.262,AETNA [1000108],AETNA [100010801],,,76.8,,3505.66,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN POLARUS 4HL SLOTX3 TI LRG NS -,SUP-PL-PHGR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5967.06,4176.942,AETNA [1000108],AETNA [100010801],,,76.8,,4582.7,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3X10MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,AETNA [1000108],AETNA [100010801],,,76.8,,730.45,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3X12MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,AETNA [1000108],AETNA [100010801],,,76.8,,730.45,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3X14MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,AETNA [1000108],AETNA [100010801],,,76.8,,730.45,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3X16MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,AETNA [1000108],AETNA [100010801],,,76.8,,730.45,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3X18MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,AETNA [1000108],AETNA [100010801],,,76.8,,730.45,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3X20MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,AETNA [1000108],AETNA [100010801],,,76.8,,730.45,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X16MM LCK ANCHORAGE T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,AETNA [1000108],AETNA [100010801],,,76.8,,730.45,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3X10MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA [1000108],AETNA [100010801],,,76.8,,495.45,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3X12MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA [1000108],AETNA [100010801],,,76.8,,495.45,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3X14MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,657.84,460.488,AETNA [1000108],AETNA [100010801],,,76.8,,505.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3X16MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,657.84,460.488,AETNA [1000108],AETNA [100010801],,,76.8,,505.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3X18MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,657.84,460.488,AETNA [1000108],AETNA [100010801],,,76.8,,505.22,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3X20MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA [1000108],AETNA [100010801],,,76.8,,495.45,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3X22MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA [1000108],AETNA [100010801],,,76.8,,495.45,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3X24MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA [1000108],AETNA [100010801],,,76.8,,495.45,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X18MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA [1000108],AETNA [100010801],,,76.8,,495.45,0.518595,35041.66656,percent of total billed charges,,,
SCREW 3.5X24MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA [1000108],AETNA [100010801],,,76.8,,495.45,0.518595,35041.66656,percent of total billed charges,,,
ANCHORAGE STANDARD SCREW 3.5 X 26MM -,SUP-PLSS3526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA [1000108],AETNA [100010801],,,76.8,,495.45,0.518595,35041.66656,percent of total billed charges,,,
TROCAR CLOSURE SUTURE GRASPER -,SUP-PMI-TC-SG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,64.19,44.933,AETNA [1000108],AETNA [100010801],,,76.8,,49.3,0.518595,35041.66656,percent of total billed charges,,,
TEMPORARY FIXATION PIN ADMIRAL -,SUP-PN AP2-100506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,0.518595,35041.66656,percent of total billed charges,,,
PIN FIXATION -,SUP-PN0920051001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,233.4,163.38,AETNA [1000108],AETNA [100010801],,,76.8,,179.25,0.518595,35041.66656,percent of total billed charges,,,
PLATE ASSEMBLED PROTEAN CENTRAL COLUMN LEFT -,SUP-PRT-CCP-LT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4681.13,3276.791,AETNA [1000108],AETNA [100010801],,,76.8,,3595.11,0.518595,35041.66656,percent of total billed charges,,,
PROTEAN CORONOID PLATE RIGHT -,SUP-PRT-CRD-RT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5237.1,3665.97,AETNA [1000108],AETNA [100010801],,,76.8,,4022.09,0.518595,35041.66656,percent of total billed charges,,,
PLATE PROTEAN FRAG DIST ULNA -,SUP-PRT-FSP-DU,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5054.6,3538.22,AETNA [1000108],AETNA [100010801],,,76.8,,3881.93,0.518595,35041.66656,percent of total billed charges,,,
PLATE Y PROTEAN FRAGMENT -,SUP-PRT-FSP-YS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4596.25,3217.375,AETNA [1000108],AETNA [100010801],,,76.8,,3529.92,0.518595,35041.66656,percent of total billed charges,,,
DEVICE FIXATION SIZE 18 4FUSION -,SUP-QUA-4F-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11849.67,8294.769,AETNA [1000108],AETNA [100010801],,,76.8,,9100.55,0.518595,35041.66656,percent of total billed charges,,,
SCREW 12MM X 2.7MM FUCHSIA U PLUS LOCKING -,SUP-RBL1224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1070.7,749.49,AETNA [1000108],AETNA [100010801],,,76.8,,822.3,0.518595,35041.66656,percent of total billed charges,,,
SCREW 14MM X 2.7MM GOLD U PLUS LOCKING -,SUP-RBL1225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1070.7,749.49,AETNA [1000108],AETNA [100010801],,,76.8,,822.3,0.518595,35041.66656,percent of total billed charges,,,
PLATE 50MM UPLUS RIB -,SUP-RBL1301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6463.61,4524.527,AETNA [1000108],AETNA [100010801],,,76.8,,4964.05,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X50MM -,SUP-RFS-S4500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,76.8,,1200.88,0.518595,35041.66656,percent of total billed charges,,,
TRUNK IPSI EXCLUDER AAA ENDO 26MM X 14.5MM X 12CM 16FR -,SUP-RLT261412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,32100.6,22470.42,AETNA [1000108],AETNA [100010801],,,76.8,,24653.26,0.518595,35041.66656,percent of total billed charges,,,
SIZER SMOOTH ROUND MODERATE GEL XTRA 755 CC -,SUP-RSZSHPX755S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,AETNA [1000108],AETNA [100010801],,,76.8,,1323,0.518595,35041.66656,percent of total billed charges,,,
SIZER SMOOTH ROUND MODERATE GEL HP XTRA 790 CC -,SUP-RSZSHPX790S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,AETNA [1000108],AETNA [100010801],,,76.8,,1323,0.518595,35041.66656,percent of total billed charges,,,
NAIL IM 1.6MMX12.7MM SBFS SS -,SUP-SBFS062,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,AETNA [1000108],AETNA [100010801],,,76.8,,1465.48,0.518595,35041.66656,percent of total billed charges,,,
CAGE CERVICAL LORDOTIC ANT D12 W15 H08 -,SUP-SCA-AC LS 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA [1000108],AETNA [100010801],,,76.8,,6844.72,0.518595,35041.66656,percent of total billed charges,,,
SCREW CERVICAL 3 X 14MM -,SUP-SCA-CS 3014-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,0.518595,35041.66656,percent of total billed charges,,,
RSS 4.5MM STAR SCREW AND CAP 15MM L -,SUP-SCW-0961-046-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
RSS 4.5MM STAR SCREW AND CAP 20MM L -,SUP-SCW-0961-046-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
RSS 4.5MM STAR SCREW AND CAP 25MM L -,SUP-SCW-0961-046-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
RSS 4.5MM STAR SCREW AND CAP 30MM -,SUP-SCW-0961-046-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,0.518595,35041.66656,percent of total billed charges,,,
KIT IMPLANT 10 X 9MM SPEED 1.5 X 1.5MM -,SUP-SE-0910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4623.62,3236.534,AETNA [1000108],AETNA [100010801],,,76.8,,3550.94,0.518595,35041.66656,percent of total billed charges,,,
SPEED IMPLANT 11 X 08 X 08MM -,SUP-SE-1108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SPEED IMPLANT 11X10X10MM -,SUP-SE-1110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,0.518595,35041.66656,percent of total billed charges,,,
SPEED IMPLANT 15X15X15MM -,SUP-SE-1515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5690.99,3983.693,AETNA [1000108],AETNA [100010801],,,76.8,,4370.68,0.518595,35041.66656,percent of total billed charges,,,
STAPLE -,SUP-SE-1815,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SPEEDTITAM 18X15X15MM -,SUP-SE-1815TI,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7289.07,5102.349,AETNA [1000108],AETNA [100010801],,,76.8,,5598.01,0.518595,35041.66656,percent of total billed charges,,,
SPEED IMPLANT TI 18X18X18MM -,SUP-SE-1818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5690.99,3983.693,AETNA [1000108],AETNA [100010801],,,76.8,,4370.68,0.518595,35041.66656,percent of total billed charges,,,
SPEED COMPRESSION IMPLANT KIT 20X20X20 -,SUP-SE-2020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,AETNA [1000108],AETNA [100010801],,,76.8,,3666.82,0.518595,35041.66656,percent of total billed charges,,,
SPEED TITAN IMPLANT 20 X 20 X 20MM -,SUP-SE-2020TI,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5644.52,3951.164,AETNA [1000108],AETNA [100010801],,,76.8,,4334.99,0.518595,35041.66656,percent of total billed charges,,,
WASHER ORTHO -,SUP-SFCW,CDM,C1713,HCPCS,278,RC,,,outpatient,,,379.28,265.496,AETNA [1000108],AETNA [100010801],,,76.8,,291.29,0.518595,35041.66656,percent of total billed charges,,,
SCARLET AL-T BONE SCREW 5 X 25MM -,SUP-SJT-LS 50 25-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5X20MM CORT/CANC DVR FT HEX HEAD TI -,SUP-SP 20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,545.51,381.857,AETNA [1000108],AETNA [100010801],,,76.8,,418.95,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.5X10MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP10000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,,,
PEG 2.5X11MM NLCKG SCR CANC DVR FT ST HEX HEAD TI NS F/ANTMC -,SUP-SP11000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.5X12MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP12000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.5X13MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP13000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.5X14MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP14000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.5X15MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP15000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.5X16MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,AETNA [1000108],AETNA [100010801],,,76.8,,435.58,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.5X16MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.5X18MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP18000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.5X20MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.5X20MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,AETNA [1000108],AETNA [100010801],,,76.8,,435.58,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.5X22MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,AETNA [1000108],AETNA [100010801],,,76.8,,435.58,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.5X22MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.5X22MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,534.37,374.059,AETNA [1000108],AETNA [100010801],,,76.8,,410.4,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.5X24MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP24000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.5X26MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP26000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.5X34MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP34000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,,,
PEG SMOTH LOCKING 2 X 14 -,SUP-SPLS-20140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
PEG SMOOTH LOCKING 2 X 16 -,SUP-SPLS-20160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
PEG SMOOTH LOCKING TI GRAY 2.0MM X 17MM -,SUP-SPLS-20170-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
PEG SMOOTH LOCKING 2 X 18 -,SUP-SPLS-20180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
SMOOTH PEG LOCKING 2.0MM X 18MM TI -,SUP-SPLS-20180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
PEG SMOOTH LOCKING TI GRAY 2.0MM X 19MM -,SUP-SPLS-20190-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
PEG SMOOTH LOCKING 2 X 20 -,SUP-SPLS-20200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
PEG SMOOTH LOCKING TI GRAY 2.0MM X 21MM -,SUP-SPLS-20210-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
PEG SMOOTH LOCKING TI GRAY 2.0MM X 22MM -,SUP-SPLS-20220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN S3 16X71MM 16MM 3HL CONTR LCK SS SUT HL FST GUIDE -,SUP-SSPL3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5703.94,3992.758,AETNA [1000108],AETNA [100010801],,,76.8,,4380.63,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN S3 16X84MM 4HL CONTR LCK SS SUT HL FST GUIDE TECH -,SUP-SSPL4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5703.94,3992.758,AETNA [1000108],AETNA [100010801],,,76.8,,4380.63,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN S3 16X70MM 16MM 3HL CONTR LCK SS SUT HL FST GUIDE -,SUP-SSPR3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5703.94,3992.758,AETNA [1000108],AETNA [100010801],,,76.8,,4380.63,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN S3 16X150MM 8HL CONTR LCK SS SUT HL FST GUIDE TECH -,SUP-SSPR8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7359.1,5151.37,AETNA [1000108],AETNA [100010801],,,76.8,,5651.79,0.518595,35041.66656,percent of total billed charges,,,
SIZER IMPLANT NATR INSPIRA SIL 485CC SINGLE USE FULL PROFILE -,SUP-SSZ-F485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,AETNA [1000108],AETNA [100010801],,,76.8,,824.56,0.518595,35041.66656,percent of total billed charges,,,
SIZER IMPLANT NATR INSPIRA SIL 605CC SINGLE USE FULL PROFILE -,SUP-SSZ-F605,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,AETNA [1000108],AETNA [100010801],,,76.8,,824.56,0.518595,35041.66656,percent of total billed charges,,,
SIZER IMPLANT NATR INSPIRA SIL 650CC SINGLE USE FULL PROFILE -,SUP-SSZ-F650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,AETNA [1000108],AETNA [100010801],,,76.8,,824.56,0.518595,35041.66656,percent of total billed charges,,,
SIZER IMPLANT NATR INSPIRA SIL 695CC SINGLE USE FULL PROFILE -,SUP-SSZ-F695,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,AETNA [1000108],AETNA [100010801],,,76.8,,824.56,0.518595,35041.66656,percent of total billed charges,,,
SIZER IMPLANT NATR INSPIRA SIL 560CC SINGLE USE MOD PROFILE -,SUP-SSZ-M560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,AETNA [1000108],AETNA [100010801],,,76.8,,824.56,0.518595,35041.66656,percent of total billed charges,,,
SIZER IMPLANT NATR INSPIRA SIL 600CC SINGLE USE MOD PROFILE -,SUP-SSZ-M600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,AETNA [1000108],AETNA [100010801],,,76.8,,824.56,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 4MMSTDX20MM LCK SMTH TI S3 -,SUP-STP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA [1000108],AETNA [100010801],,,76.8,,457.09,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 4MMSTDX25MM LCK SMTH TI S3 NS -,SUP-STP25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA [1000108],AETNA [100010801],,,76.8,,457.09,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 4MMSTDX32.5MM LCK SMTH TI S3 -,SUP-STP325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA [1000108],AETNA [100010801],,,76.8,,457.09,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 4MMSTDX37.5MM LCK SMTH TI S3 NS -,SUP-STP375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA [1000108],AETNA [100010801],,,76.8,,457.09,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 4MMSTDX42.5MM LCK SMTH TI S3 NS -,SUP-STP425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA [1000108],AETNA [100010801],,,76.8,,457.09,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 4MMSTDX45MM LCK SMTH TI S3 -,SUP-STP45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA [1000108],AETNA [100010801],,,76.8,,457.09,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 4MMSTDX47.5MM LCK SMTH TI S3 NS -,SUP-STP475,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA [1000108],AETNA [100010801],,,76.8,,457.09,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 4MMSTDX50MM LCK SMTH TI S3 NS -,SUP-STP50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA [1000108],AETNA [100010801],,,76.8,,457.09,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 4MMSTDX40MM LCK THRD TI S3 NS -,SUP-STPT40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 4MMSTDX50MM LCK THRD TI S3 NS -,SUP-STPT50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,,,
ENDOSCOPIC FX SECURESTRAP W/12 ABSB STRP F/HRN RPR -,SUP-STRAP12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1878.06,1314.642,AETNA [1000108],AETNA [100010801],,,76.8,,1442.35,0.518595,35041.66656,percent of total billed charges,,,
SECURESTRAP 5MM ASORB STRAP -,SUP-STRAP25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2542.51,1779.757,AETNA [1000108],AETNA [100010801],,,76.8,,1952.65,0.518595,35041.66656,percent of total billed charges,,,
ASNIS III SS CANN SCREW 6.5 X 105MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA [1000108],AETNA [100010801],,,76.8,,861.05,0.518595,35041.66656,percent of total billed charges,,,
BONE SCREW T10 NON-LOCKING 2.7 X 30MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
BONE SCREW T8 FULLY THREADED 2.7 X 18MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,,,
BONE SCREW T8 FULLY THREADED 2.7 X 24MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA [1000108],AETNA [100010801],,,76.8,,241.18,0.518595,35041.66656,percent of total billed charges,,,
BONE SCREW T10 NON-LOCKING 2.7 X 70MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTEX 3.5 X 22MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,76.8,,143.4,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING FULLY THREADED T10 3.5 X 28MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
NAIL LONG R2.0 TI LEFT 13 X 320MM GAMMA -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,AETNA [1000108],AETNA [100010801],,,76.8,,5738.49,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING ST 3.5 X 46MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 2.3 X 15MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.88,310.016,AETNA [1000108],AETNA [100010801],,,76.8,,340.13,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING FULLY THREADED T10 3.5 X 20MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA [1000108],AETNA [100010801],,,76.8,,460.22,0.518595,35041.66656,percent of total billed charges,,,
WRIST FUSION PLATE STRAIGHT 120MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8642.06,6049.442,AETNA [1000108],AETNA [100010801],,,76.8,,6637.1,0.518595,35041.66656,percent of total billed charges,,,
WRIST FUSION PLATE STANDARD BEND 120MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8642.06,6049.442,AETNA [1000108],AETNA [100010801],,,76.8,,6637.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5MMX16MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,AETNA [1000108],AETNA [100010801],,,76.8,,1750.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5MMX20MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,AETNA [1000108],AETNA [100010801],,,76.8,,1750.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5MMX26MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,AETNA [1000108],AETNA [100010801],,,76.8,,1750.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2.5MMX30MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,AETNA [1000108],AETNA [100010801],,,76.8,,1750.76,0.518595,35041.66656,percent of total billed charges,,,
3-0 20CM STRATAFIX SPIRAL MONOCRYL PLUS UNDYED SH -,SUP-SXMP1B427,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.67,104.769,AETNA [1000108],AETNA [100010801],,,76.8,,114.95,0.518595,35041.66656,percent of total billed charges,,,
4-0 STRATAFIX SPIRAL MONOCRYL PLUS 45 X 45CM UNDYED PS-2 -,SUP-SXMP2B151,CDM,C1713,HCPCS,278,RC,,,outpatient,,,125.22,87.654,AETNA [1000108],AETNA [100010801],,,76.8,,96.17,0.518595,35041.66656,percent of total billed charges,,,
SUTURE STRATAFIX 2-0 CT-1 PDS VIOL 45CM -,SUP-SXPP1A403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,117.01,81.907,AETNA [1000108],AETNA [100010801],,,76.8,,89.86,0.518595,35041.66656,percent of total billed charges,,,
0 STRATAFIX SYMMETRIC PDS PLUS 23CM CT-1 -,SUP-SXPP1A425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.1,107.87,AETNA [1000108],AETNA [100010801],,,76.8,,118.35,0.518595,35041.66656,percent of total billed charges,,,
SUTURE STRATAFIX 0 CT-1 PDS VIOL 45CM -,SUP-SXPP1B407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.07,107.849,AETNA [1000108],AETNA [100010801],,,76.8,,118.33,0.518595,35041.66656,percent of total billed charges,,,
SUTURE STRATAFIX 3-0 SH SPIRAL PDS VIOLET 15CM -,SUP-SXPP1B420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,183.51,128.457,AETNA [1000108],AETNA [100010801],,,76.8,,140.94,0.518595,35041.66656,percent of total billed charges,,,
"SUTURE STRATAFIX SPIRAL PDS PLUS 2-0 9"" 23CM VIOLET CT-2 -",SUP-SXPP1B432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,155.78,109.046,AETNA [1000108],AETNA [100010801],,,76.8,,119.64,0.518595,35041.66656,percent of total billed charges,,,
SUT STRATAFIX 0 30CM SPIRAL PDS PLUS VIOLET CT-1 -,SUP-SXPP1B450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,157.03,109.921,AETNA [1000108],AETNA [100010801],,,76.8,,120.6,0.518595,35041.66656,percent of total billed charges,,,
SET HERNIA KUMAR T ANCHORS -,SUP-TA-008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,46.32,32.424,AETNA [1000108],AETNA [100010801],,,76.8,,35.57,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE REEF TA INTERBODY 9X28X8MM -,SUP-TA1-928088,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA [1000108],AETNA [100010801],,,76.8,,6844.72,0.518595,35041.66656,percent of total billed charges,,,
REEF TA INTERBODY 9 X 28 X 10MM 15DEG -,SUP-TA1-928105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA [1000108],AETNA [100010801],,,76.8,,6844.72,0.518595,35041.66656,percent of total billed charges,,,
REEF TA 9X 28 X 11MM INTERBODY -,SUP-TA1-928115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA [1000108],AETNA [100010801],,,76.8,,6844.72,0.518595,35041.66656,percent of total billed charges,,,
SEASPINE REEF TA INTERBODY 9X32X8MM -,SUP-TA1-932088,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA [1000108],AETNA [100010801],,,76.8,,6844.72,0.518595,35041.66656,percent of total billed charges,,,
INTERBODY 9X32X11 15DEG -,SUP-TA1-932115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA [1000108],AETNA [100010801],,,76.8,,6844.72,0.518595,35041.66656,percent of total billed charges,,,
PIN 70MM TENSION BAND -,SUP-TB-1570K,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1219.12,853.384,AETNA [1000108],AETNA [100010801],,,76.8,,936.28,0.518595,35041.66656,percent of total billed charges,,,
SCREW TROCHLEAR COMPRESSION FEMALE -,SUP-TCS-F,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1833.97,1283.779,AETNA [1000108],AETNA [100010801],,,76.8,,1408.49,0.518595,35041.66656,percent of total billed charges,,,
SCREW TROCHLEAR COMPRESSION LOCKING CAP -,SUP-TCS-LC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1303.92,912.744,AETNA [1000108],AETNA [100010801],,,76.8,,1001.41,0.518595,35041.66656,percent of total billed charges,,,
SCREW TROCHLEAR COMPRESSION MALE 60MM -,SUP-TCS-M-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,AETNA [1000108],AETNA [100010801],,,76.8,,846.97,0.518595,35041.66656,percent of total billed charges,,,
ROD 35MM -,SUP-TLF-5P T0 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
ROD 40MM -,SUP-TLF-5P T0 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
ROD 45MM -,SUP-TLF-5P T0 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
ROD PREBENT TITANIUM 50MM -,SUP-TLF-5P T0 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
PREBENT ROD TITANIUM 55MM -,SUP-TLF-5P T0 55-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
ROD 60MM -,SUP-TLF-5P T0 60-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
PERLA TL PREBENT ROD TITANIUM 90MM -,SUP-TLF-5P T0 90-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
ROD 5.5 X  70 -,SUP-TLF-5P TO 70-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
ROD PREBENT 6MM X 40MM -,SUP-TLF-6P T0 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5 X 35 -,SUP-TLF-CS 55 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
SCREW 5.5MM X 40MM -,SUP-TLF-CS 55 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
CORTICAL BONE SCREW 5.5 X 45 -,SUP-TLF-CS 55 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5MM X 30MM -,SUP-TLF-CS 65 30-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5 X 35 -,SUP-TLF-CS 65 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
SCEW 6.5 X 40 -,SUP-TLF-CS 65 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
SCREW 6.5 X 45 -,SUP-TLF-CS 65 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEAD -,SUP-TLF-MH PL 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,,,
REDUCTION HEAD -,SUP-TLF-MH RE 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW SET -,SUP-TLF-SC 00 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.5X10MM LCK LAG P/T TI DVR NS -,SUP-TP10000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.5X14MM TI DVR NS -,SUP-TP14000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.5X16MM TI DVR NS -,SUP-TP16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,AETNA [1000108],AETNA [100010801],,,76.8,,435.58,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.5X18MM TI DVR NS -,SUP-TP18000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.5X20MM P/T -,SUP-TP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,534.37,374.059,AETNA [1000108],AETNA [100010801],,,76.8,,410.4,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.5X20MM TI DVR NS -,SUP-TP20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,,,
PEG BN FX 2.5X28MM TI DVR NS -,SUP-TP28000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,76.8,,430.2,0.518595,35041.66656,percent of total billed charges,,,
THREADED PEG FLUTED LCK 2.3 X 20 -,SUP-TPFL-23200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,0.518595,35041.66656,percent of total billed charges,,,
PEG FIXATION LOCKING 2.3 X 10 TI -,SUP-TPLS-23100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA [1000108],AETNA [100010801],,,76.8,,551.2,0.518595,35041.66656,percent of total billed charges,,,
PEG THREADED LOCKING 2.3MM X 12MM TI -,SUP-TPLS-23120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA [1000108],AETNA [100010801],,,76.8,,551.2,0.518595,35041.66656,percent of total billed charges,,,
THREADED PEG- LOCKING- 2.3MM X 16MM -,SUP-TPLS-23160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA [1000108],AETNA [100010801],,,76.8,,551.2,0.518595,35041.66656,percent of total billed charges,,,
SCREW LCK TRH PEG 2.3 X 17MM -,SUP-TPLS-23170-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA [1000108],AETNA [100010801],,,76.8,,551.2,0.518595,35041.66656,percent of total billed charges,,,
THREADED PEG- LOCKING- 2.3MM X 18MM -,SUP-TPLS-23180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA [1000108],AETNA [100010801],,,76.8,,551.2,0.518595,35041.66656,percent of total billed charges,,,
PEG THREADED LOCKING 2.3MM X 19MM -,SUP-TPLS-23190-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA [1000108],AETNA [100010801],,,76.8,,551.2,0.518595,35041.66656,percent of total billed charges,,,
SCREW LCK TRH PEG 2.3 X 20MM -,SUP-TPLS-23200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA [1000108],AETNA [100010801],,,76.8,,551.2,0.518595,35041.66656,percent of total billed charges,,,
THREADED PEG- LOCKING 2.3MM X 21MM -,SUP-TPLS-23210-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA [1000108],AETNA [100010801],,,76.8,,551.2,0.518595,35041.66656,percent of total billed charges,,,
THREADED PEG LOCKING 2.3MM X 22MM -,SUP-TPLS-23220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA [1000108],AETNA [100010801],,,76.8,,551.2,0.518595,35041.66656,percent of total billed charges,,,
THREADED PEG- LOCKING 2.3MM X 23MM -,SUP-TPLS-23230-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA [1000108],AETNA [100010801],,,76.8,,551.2,0.518595,35041.66656,percent of total billed charges,,,
PEG THREADED LOCKING TI PINK 2.3MM X 24MM -,SUP-TPLS-23240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA [1000108],AETNA [100010801],,,76.8,,551.2,0.518595,35041.66656,percent of total billed charges,,,
THREADED PEG- LOCKING 2.3MM X 26MM -,SUP-TPLS-23260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA [1000108],AETNA [100010801],,,76.8,,551.2,0.518595,35041.66656,percent of total billed charges,,,
PEG THREADED 2.3 X 28 LOCKING -,SUP-TPLS-23280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA [1000108],AETNA [100010801],,,76.8,,551.2,0.518595,35041.66656,percent of total billed charges,,,
PEG TRHEADED NON-LOCKING 2.7MM X 10MM TI -,SUP-TPNL-27100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
PEG THREADES NON LOCKING 2.7 X 12 -,SUP-TPNL-27120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
PEG THREADED NON LOCKING 2.7MM X 14MM -,SUP-TPNL-27140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
PEG THREADES NON LOCKING 2.7 X 16 -,SUP-TPNL-27160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
PEG THREADED NON LOCKING 2.7 X 18 -,SUP-TPNL-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW NON-LCK TRH PEG 2.7 X 20MM -,SUP-TPNL-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
SCREW NON-LCK TRH PEG 2.7 X 22MM -,SUP-TPNL-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
PEG THREADED NON-LOCKING 2.7MM X 24MM -,SUP-TPNL-27240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
PEG THREADED NON-LOCKING 2.7MM X 26MM -,SUP-TPNL-27260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
PEG THREADED NON LOCKING 2.7MM X 28MM -,SUP-TPNL-27280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,76.8,,510.87,0.518595,35041.66656,percent of total billed charges,,,
SUBSTITUTE DBM 5ML PTTY OPTIUM FRZDR -,SUP-TPUT05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2696.31,1887.417,AETNA [1000108],AETNA [100010801],,,76.8,,2070.77,0.518595,35041.66656,percent of total billed charges,,,
CAGE CERVICAL LORDOTIC D12 W14 H07 -,SUP-TRY-CL 12 07-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
CERVICAL CAGE-LORDOTIC D12 W14 H08 -,SUP-TRY-CL 12 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
PLATE BONE 20MM 1-LEVEL SPINE CERVICAL -,SUP-TRY-CP 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
PLATE 22MM -,SUP-TRY-CP 04 22-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
PLATE 24MM 1-LEVEL -,SUP-TRY-CP 04 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
PLATE 26MM 1-LEVEL -,SUP-TRY-CP 04 26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
PLATE 2 LEVEL 36MM -,SUP-TRY-CP 06 36-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
PLATE 38MM 2-LEVEL -,SUP-TRY-CP 06 38-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,,,
PLATE 40MM 2 LEVEL -,SUP-TRY-CP 06 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,,,
PLATE 43MM 2-LEVEL -,SUP-TRY-CP 06 43-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
PLATE 46MM 2-LEVEL -,SUP-TRY-CP 06 46-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
SPINEART TRYPTIK 2- PLATE-52MM-3-LEVEL -,SUP-TRY-CP 08 52-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
PLATE 55MM 3-LEVEL -,SUP-TRY-CP 08 55-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,0.518595,35041.66656,percent of total billed charges,,,
PLATE TRYPTIK 58MM 3-LEVEL -,SUP-TRY-CP 08 58-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
PLATE 61MM 3-LEVEL -,SUP-TRY-CP 08 61-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
PLATE TRYPTIK 72MM 3 LEVEL -,SUP-TRY-CP 08 72-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,0.518595,35041.66656,percent of total billed charges,,,
SCREW 12MM SELF DRILLING POLYAXIAL -,SUP-TRY-PD 40 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW SELF-DRILLING POLYAXIAL 4 X 14 -,SUP-TRY-PD 40 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW SELF-DRILLING POLYAXIAL 4 X 16 -,SUP-TRY-PD 40 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW SELF DRILLING POLYAXIAL 4.5 X 16 -,SUP-TRY-PD 45 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,AETNA [1000108],AETNA [100010801],,,76.8,,761.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW SELF TAPPING 4 X 14 -,SUP-TRY-PS 40 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
SCREW TRYPTIK SELF-TAPPING 4 X 16 -,SUP-TRY-PS 40 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,0.518595,35041.66656,percent of total billed charges,,,
STENT GRAFT 28 X 14 X 140MM OVATION ILIAC LIMB -,SUP-TV-IL1428140-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,AETNA [1000108],AETNA [100010801],,,76.8,,17252.08,0.518595,35041.66656,percent of total billed charges,,,
GUIDEPIN ORTHO THRD DRILL TIP -,SUP-U000-0200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,AETNA [1000108],AETNA [100010801],,,76.8,,1176.45,0.518595,35041.66656,percent of total billed charges,,,
ANCHOR SUT 2.3MM FIBERWIREX2 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,AETNA [1000108],AETNA [100010801],,,76.8,,1323,0.518595,35041.66656,percent of total billed charges,,,
ANCHORAGE LAPIDUS PLATING LS 0 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,AETNA [1000108],AETNA [100010801],,,76.8,,3740.34,0.518595,35041.66656,percent of total billed charges,,,
ANCHORAGE LISFRANC PLATING MED -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,AETNA [1000108],AETNA [100010801],,,76.8,,3740.34,0.518595,35041.66656,percent of total billed charges,,,
FEMORAL AUGMENT DISTAL SZ3 12M -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,AETNA [1000108],AETNA [100010801],,,76.8,,3836.31,0.518595,35041.66656,percent of total billed charges,,,
LOCKING PLATE 6 HOLE 2.0/2.3 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4600.23,3220.161,AETNA [1000108],AETNA [100010801],,,76.8,,3532.98,0.518595,35041.66656,percent of total billed charges,,,
PLATE DIST POST LAT HUMERAL 6H -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA [1000108],AETNA [100010801],,,76.8,,3341.08,0.518595,35041.66656,percent of total billed charges,,,
PLATE M ADAPTIVE II 2.5 TRI DI -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5810.88,4067.616,AETNA [1000108],AETNA [100010801],,,76.8,,4462.76,0.518595,35041.66656,percent of total billed charges,,,
LO-PRO MTP PLT TM CONTRDSHTLTI -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,AETNA [1000108],AETNA [100010801],,,76.8,,3281.46,0.518595,35041.66656,percent of total billed charges,,,
PLATE SUPERIOR 6H INCREASED -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,AETNA [1000108],AETNA [100010801],,,76.8,,3616.79,0.518595,35041.66656,percent of total billed charges,,,
PLATE WSTD CMP BRD 16 HOLE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.44,869.708,AETNA [1000108],AETNA [100010801],,,76.8,,954.19,0.518595,35041.66656,percent of total billed charges,,,
NAIL LONG LT TI 11X400 130 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,,,
NAIL LONG R1/5 RT 11 X 440MM X -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA [1000108],AETNA [100010801],,,76.8,,5627.96,0.518595,35041.66656,percent of total billed charges,,,
NAIL TI LNG RT 15 X 440MM X1 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,AETNA [1000108],AETNA [100010801],,,76.8,,5738.49,0.518595,35041.66656,percent of total billed charges,,,
LOCKING COMP BROAD 16 HOLE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.44,869.708,AETNA [1000108],AETNA [100010801],,,76.8,,954.19,0.518595,35041.66656,percent of total billed charges,,,
NAIL FLEXIBLE 2.0MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA [1000108],AETNA [100010801],,,76.8,,820.67,0.518595,35041.66656,percent of total billed charges,,,
PLATE GRIP TRICHANTERIC W/2 CA -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7111.03,4977.721,AETNA [1000108],AETNA [100010801],,,76.8,,5461.27,0.518595,35041.66656,percent of total billed charges,,,
PLATE RT ANTERIOR ANKLE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8806.3,6164.41,AETNA [1000108],AETNA [100010801],,,76.8,,6763.24,0.518595,35041.66656,percent of total billed charges,,,
PLATE SCREW GAP 6.5MM 30MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,663.67,464.569,AETNA [1000108],AETNA [100010801],,,76.8,,509.7,0.518595,35041.66656,percent of total billed charges,,,
SCREW ANCHORAGE 3.0 X 28MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA [1000108],AETNA [100010801],,,76.8,,495.45,0.518595,35041.66656,percent of total billed charges,,,
SCREW ANCHORAGE LOCK 3.5 X 14 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,AETNA [1000108],AETNA [100010801],,,76.8,,730.45,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS CANN TI 5.0 X 60MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA [1000108],AETNA [100010801],,,76.8,,711.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS III SS CANN 5 X 38 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA [1000108],AETNA [100010801],,,76.8,,711.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS III SS CANN 5 X 46 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA [1000108],AETNA [100010801],,,76.8,,711.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW AUTOFIX 2.5 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,AETNA [1000108],AETNA [100010801],,,76.8,,954.6,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE T10 2.7 X 48MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTEX T8 2.4MM X 8MM SE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL 5.5 X 30MM GENE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,,,
NAIL FLEXIBLE 1.5MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,AETNA [1000108],AETNA [100010801],,,76.8,,842.48,0.518595,35041.66656,percent of total billed charges,,,
NAIL FLEXIBLE 2.5MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.59,822.213,AETNA [1000108],AETNA [100010801],,,76.8,,902.09,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING SILVER 2.5 X 16M -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA [1000108],AETNA [100010801],,,76.8,,887.29,0.518595,35041.66656,percent of total billed charges,,,
SCREW TRILOCK 2.8 X 34MM HD7 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
PLATE 10 HOLE LOCKING COMPR BR -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,0.518595,35041.66656,percent of total billed charges,,,
PLATE 6 HOLE CURVED -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,AETNA [1000108],AETNA [100010801],,,76.8,,3349.16,0.518595,35041.66656,percent of total billed charges,,,
PLATE 6 HOLE STRAIGHT -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,AETNA [1000108],AETNA [100010801],,,76.8,,3424.93,0.518595,35041.66656,percent of total billed charges,,,
SCREW 1.2 X 12MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA [1000108],AETNA [100010801],,,76.8,,279.14,0.518595,35041.66656,percent of total billed charges,,,
PLATE BROAD 7 HOLE VARIAX COMP -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,AETNA [1000108],AETNA [100010801],,,76.8,,1314.54,0.518595,35041.66656,percent of total billed charges,,,
PLATE CERVICAL 2 LEVEL 30MM GE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,0.518595,35041.66656,percent of total billed charges,,,
PLATE DIAMOND FUSION LARGE NON -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7238.14,5066.698,AETNA [1000108],AETNA [100010801],,,76.8,,5558.89,0.518595,35041.66656,percent of total billed charges,,,
PLATE SCREW GAP 6.5MM 20MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,663.67,464.569,AETNA [1000108],AETNA [100010801],,,76.8,,509.7,0.518595,35041.66656,percent of total billed charges,,,
PLATE HUMERUS RT. 14 HOLE L218 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA [1000108],AETNA [100010801],,,76.8,,3788.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW ANCHORAGE 3.5MM X 20MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA [1000108],AETNA [100010801],,,76.8,,495.45,0.518595,35041.66656,percent of total billed charges,,,
SCREW ANCHORAGE LOCK 3.5 X 12 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,AETNA [1000108],AETNA [100010801],,,76.8,,730.45,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS 5.0MM 60MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA [1000108],AETNA [100010801],,,76.8,,711.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS TI 5.0 X 40MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA [1000108],AETNA [100010801],,,76.8,,711.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE 2.3 X 26 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA [1000108],AETNA [100010801],,,76.8,,280.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANN ASNIS III 5.0X 65MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA [1000108],AETNA [100010801],,,76.8,,711.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANN FT 4.0 X 40MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,AETNA [1000108],AETNA [100010801],,,76.8,,777.37,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORTICAL 5.5 X 40MM HIGH -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,,,
SCREW EMERGENCY 1.4 X 3 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA [1000108],AETNA [100010801],,,76.8,,279.14,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCK LP 4.5 X 46MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,76.8,,873.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 2.3 X 12MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA [1000108],AETNA [100010801],,,76.8,,279.14,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING T10 2.7 X 20MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW LP 5.5 X 55MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW M CORTEX 2.3 X 16MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA [1000108],AETNA [100010801],,,76.8,,691.91,0.518595,35041.66656,percent of total billed charges,,,
SCREW NON LOCK LP 4.5 X 30MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW NON LOCKING 3.5 X 55MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW PERIPH NL 4.5 X 30MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW S-FIX 2.5LG X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,AETNA [1000108],AETNA [100010801],,,76.8,,1750.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW TRILOCK 2.8 X 10MM HD7 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW ANCHORAGE 3.5MM X 14MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA [1000108],AETNA [100010801],,,76.8,,495.45,0.518595,35041.66656,percent of total billed charges,,,
SCREW ANCHORAGE LOCK 3.5 X 18 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,AETNA [1000108],AETNA [100010801],,,76.8,,730.45,0.518595,35041.66656,percent of total billed charges,,,
SCREW ANSIS 4.0 X 44MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA [1000108],AETNA [100010801],,,76.8,,646.25,0.518595,35041.66656,percent of total billed charges,,,
SCREW ANCHORAGE 3.5MM X 16MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA [1000108],AETNA [100010801],,,76.8,,495.45,0.518595,35041.66656,percent of total billed charges,,,
SCREW ANCHORAGE 3.5MM X 32MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA [1000108],AETNA [100010801],,,76.8,,495.45,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS 6.5MM X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.94,757.358,AETNA [1000108],AETNA [100010801],,,76.8,,830.93,0.518595,35041.66656,percent of total billed charges,,,
SCREW ASNIS TI 5.0 X 36MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA [1000108],AETNA [100010801],,,76.8,,711.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE T10 2.7 X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE 2.3 X 18MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA [1000108],AETNA [100010801],,,76.8,,280.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW BONE 3.5 X 46MM NON-LOCK -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA [1000108],AETNA [100010801],,,76.8,,264.71,0.518595,35041.66656,percent of total billed charges,,,
SCREW CANN ASNIS III 5.0X 70MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA [1000108],AETNA [100010801],,,76.8,,711.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW CORT HI-TOP 5.5 X 35MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEADLESS 2.5 X 12MM MICR -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCK LP 4.5 X 24MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,76.8,,873.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING T10 2.7 X 48MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW HEADLESS COMP. 4.0MM 32M -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA [1000108],AETNA [100010801],,,76.8,,1722.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW NON LOCKING 2.3 X 21MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,408.04,285.628,AETNA [1000108],AETNA [100010801],,,76.8,,313.37,0.518595,35041.66656,percent of total billed charges,,,
SCREW NON LOCKING 2.3 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA [1000108],AETNA [100010801],,,76.8,,280.75,0.518595,35041.66656,percent of total billed charges,,,
SCREW NON-LOCK LP 4.5 X 24MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW NON-LOCK LP 4.5 X 28MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW LCK ST 2.7 X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA [1000108],AETNA [100010801],,,76.8,,513.38,0.518595,35041.66656,percent of total billed charges,,,
SCREW LO-PRO PT 5MM X 50MM THR -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCK LP 4.5 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,76.8,,873.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCK LP 4.5 X 26MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,76.8,,873.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCK LP 4.5 X 32MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,76.8,,873.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCK LP 4.5 X 44MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,76.8,,873.85,0.518595,35041.66656,percent of total billed charges,,,
SCREW LOCKING 2.3 X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA [1000108],AETNA [100010801],,,76.8,,279.14,0.518595,35041.66656,percent of total billed charges,,,
SCREW T2 F/T LOCK 5 X 105MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA [1000108],AETNA [100010801],,,76.8,,577.19,0.518595,35041.66656,percent of total billed charges,,,
SCREW TRILOCK 2.8 X 12MM HD7 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA [1000108],AETNA [100010801],,,76.8,,1029.1,0.518595,35041.66656,percent of total billed charges,,,
SCREW VA 4.25 X 14MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,AETNA [1000108],AETNA [100010801],,,76.8,,761.82,0.518595,35041.66656,percent of total billed charges,,,
SCREW NON-LOCK LP 4.5 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.5,297.15,AETNA [1000108],AETNA [100010801],,,76.8,,326.02,0.518595,35041.66656,percent of total billed charges,,,
SCREW TI LOCK 5.5 X 35MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,0.518595,35041.66656,percent of total billed charges,,,
WASHER ORTHO -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,158.48,110.936,AETNA [1000108],AETNA [100010801],,,76.8,,121.71,0.518595,35041.66656,percent of total billed charges,,,
WIRE TEMP KIRSCH 1X100MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.71,106.197,AETNA [1000108],AETNA [100010801],,,76.8,,116.51,0.518595,35041.66656,percent of total billed charges,,,
PLATE BN ULTRA PIN -,SUP-UPP3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X23MM COMPR AEQUALIS REVERSED II ST NS F/BSPLT -,SUP-VDV223,CDM,C1713,HCPCS,278,RC,,,outpatient,,,980.28,686.196,AETNA [1000108],AETNA [100010801],,,76.8,,752.86,0.518595,35041.66656,percent of total billed charges,,,
SCREW 4.5X35MM COMPR AEQUALIS REVERSED II ST NS F/BSPLT -,SUP-VDV235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,AETNA [1000108],AETNA [100010801],,,76.8,,376.43,0.518595,35041.66656,percent of total billed charges,,,
"V-LOC 180 ABSORABLE RELOAD 2-0 6"" ES-9 TAPER -",SUP-VLOCA206L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,211.29,147.903,AETNA [1000108],AETNA [100010801],,,76.8,,162.27,0.518595,35041.66656,percent of total billed charges,,,
SUTURE V-LOC ABSORBABLE 2-0 8 IN FOR ENDOSTITCH -,SUP-VLOCA208L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,249.42,174.594,AETNA [1000108],AETNA [100010801],,,76.8,,191.55,0.518595,35041.66656,percent of total billed charges,,,
"SUT V-LOC 180 2-0 P-12 12""CLEAR -",SUP-VLOCL0015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.68,88.676,AETNA [1000108],AETNA [100010801],,,76.8,,97.29,0.518595,35041.66656,percent of total billed charges,,,
"V-LOC 0 ABS 12"" GS-21 GREEN -",SUP-VLOCL0316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,125.34,87.738,AETNA [1000108],AETNA [100010801],,,76.8,,96.26,0.518595,35041.66656,percent of total billed charges,,,
"V-LOC 2-0 ABS 18"" GS-21 GREEN -",SUP-VLOCL0325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,125.34,87.738,AETNA [1000108],AETNA [100010801],,,76.8,,96.26,0.518595,35041.66656,percent of total billed charges,,,
"V-LOC 0 ABS 18"" GS-21 GREEN -",SUP-VLOCL0326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,130.1,91.07,AETNA [1000108],AETNA [100010801],,,76.8,,99.92,0.518595,35041.66656,percent of total billed charges,,,
"SUT V-LOC 180 0 GS-21 9"" GREEN -",SUP-VLOCL0346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,124.81,87.367,AETNA [1000108],AETNA [100010801],,,76.8,,95.85,0.518595,35041.66656,percent of total billed charges,,,
"V-LOC 3-0 ABS 6"" V-20 GREEN -",SUP-VLOCL0604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.66,927.962,AETNA [1000108],AETNA [100010801],,,76.8,,1018.11,0.518595,35041.66656,percent of total billed charges,,,
"V-LOC 180 GREEN 12"" V-20 TAPER -",SUP-VLOCL0614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,AETNA [1000108],AETNA [100010801],,,76.8,,92.22,0.518595,35041.66656,percent of total billed charges,,,
"SUTURE VLOC 9"" 1/2 CIRCLE 26MM -",SUP-VLOCL0644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,AETNA [1000108],AETNA [100010801],,,76.8,,92.22,0.518595,35041.66656,percent of total billed charges,,,
"SUT V-LOC 180 3-0 CV-23 6"" GREEN -",SUP-VLOCL0804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,AETNA [1000108],AETNA [100010801],,,76.8,,92.22,0.518595,35041.66656,percent of total billed charges,,,
"SUT V-LOC 180 3-0 CV-23 12"" GREEN -",SUP-VLOCL0814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,AETNA [1000108],AETNA [100010801],,,76.8,,92.22,0.518595,35041.66656,percent of total billed charges,,,
"V-LOC 2-0 ABS 9"" GS-22 GREEN -",SUP-VLOCL2145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,AETNA [1000108],AETNA [100010801],,,76.8,,92.22,0.518595,35041.66656,percent of total billed charges,,,
"V-LOC 3-0 ABS 18"" P-14 UNDYED -",SUP-VLOCM0124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.68,88.676,AETNA [1000108],AETNA [100010801],,,76.8,,97.29,0.518595,35041.66656,percent of total billed charges,,,
"V-LOC 3-0 ABS  6"" CV-23 VIOLET -",SUP-VLOCM0804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,AETNA [1000108],AETNA [100010801],,,76.8,,92.22,0.518595,35041.66656,percent of total billed charges,,,
"V-LOC 3-0 ABS 18"" P-17 UNDYED -",SUP-VLOCM1824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.68,88.676,AETNA [1000108],AETNA [100010801],,,76.8,,97.29,0.518595,35041.66656,percent of total billed charges,,,
SUT V-LOC 90 2-0 GS-22 TAPER 12IN VIOLET -,SUP-VLOCM2115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,136.19,95.333,AETNA [1000108],AETNA [100010801],,,76.8,,104.59,0.518595,35041.66656,percent of total billed charges,,,
"SUTURE V-LOC 0 NON-ABS 6"" GS-21 BLUE -",SUP-VLOCN0306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,90.79,63.553,AETNA [1000108],AETNA [100010801],,,76.8,,69.73,0.518595,35041.66656,percent of total billed charges,,,
"V-LOC 2-0 PBT NON-ABS 6"" V-20 BLUE -",SUP-VLOCN0605,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1309.01,916.307,AETNA [1000108],AETNA [100010801],,,76.8,,1005.32,0.518595,35041.66656,percent of total billed charges,,,
"V-LOC 2-0 NON-ABS 12"" V-20 BLUE -",SUP-VLOCN0615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,AETNA [1000108],AETNA [100010801],,,76.8,,92.22,0.518595,35041.66656,percent of total billed charges,,,
VLOC PBT 1 BLU 12 GS-22 -,SUP-VLOCN2117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,131.58,92.106,AETNA [1000108],AETNA [100010801],,,76.8,,101.05,0.518595,35041.66656,percent of total billed charges,,,
VLOC PBT 0 BLU 9 GS-22 NON-ABS -,SUP-VLOCN2146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,131.58,92.106,AETNA [1000108],AETNA [100010801],,,76.8,,101.05,0.518595,35041.66656,percent of total billed charges,,,
GRAFT VALLIANT STENT 20F 31 X 90 NACION THORACIC -,SUP-VNMC3131C90TU,CDM,C1713,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,AETNA [1000108],AETNA [100010801],,,76.8,,35041.67,0.518595,35041.66656,percent of total billed charges,,,
PK CAP PROT 0.375IN PIN BALL W-SRS F/0.045IN K-WR XTRNFXTR -,SUP-W045-YL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,256.74,179.718,AETNA [1000108],AETNA [100010801],,,76.8,,197.18,0.518595,35041.66656,percent of total billed charges,,,
PIN BALL JURGAN .045 YELLOW -,SUP-W045-YL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,AETNA [1000108],AETNA [100010801],,,76.8,,32.86,0.518595,35041.66656,percent of total billed charges,,,
PIN BALL JURGAN .062 GREEN -,SUP-W062-GN,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,AETNA [1000108],AETNA [100010801],,,76.8,,32.86,0.518595,35041.66656,percent of total billed charges,,,
PK CAP PROT 0.375IN PIN HEAD JRGN PIN BALL W-SRS F/.0938IN -,SUP-W332-CR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,AETNA [1000108],AETNA [100010801],,,76.8,,32.86,0.518595,35041.66656,percent of total billed charges,,,
PK CAP PROT 0.375IN PIN HEAD JRGN PIN BALL W-SRS F/.0781IN -,SUP-W564-BL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,AETNA [1000108],AETNA [100010801],,,76.8,,32.86,0.518595,35041.66656,percent of total billed charges,,,
PK CAP PROT 0.375IN PIN HEAD JRGN PIN BALL W-SRS F/.0781IN -,SUP-W564-BL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,256.74,179.718,AETNA [1000108],AETNA [100010801],,,76.8,,197.18,0.518595,35041.66656,percent of total billed charges,,,
WASHER INSIDE 2.7MM OUTSIDE 5MM -,SUP-WBTN-2750-T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.27,240.989,AETNA [1000108],AETNA [100010801],,,76.8,,264.4,0.518595,35041.66656,percent of total billed charges,,,
WASHER BUTTON BRONZE -,SUP-WBTN-HCLP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.93,224.651,AETNA [1000108],AETNA [100010801],,,76.8,,246.47,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2MMX12MM NCANN TWST-OFF W- FX FIXOS MICROTHREADED -,SUP-WS12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,AETNA [1000108],AETNA [100010801],,,76.8,,1750.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW 13MM NCANN TWST-OFF W- FX FIXOS MICROTHREADED -,SUP-WS13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,AETNA [1000108],AETNA [100010801],,,76.8,,1750.76,0.518595,35041.66656,percent of total billed charges,,,
SNAP OFF SCREW DIAM 2.1 LG.14 -,SUP-WS14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,AETNA [1000108],AETNA [100010801],,,76.8,,1750.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2MMX15MM NCANN W- FX FIXOS MICROTHREADED SD/ST/RM -,SUP-WS15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,AETNA [1000108],AETNA [100010801],,,76.8,,1750.76,0.518595,35041.66656,percent of total billed charges,,,
SCREW 2MMX16MM NCANN W- FX FIXOS MICROTHREADED SD/ST/RM -,SUP-WS16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,AETNA [1000108],AETNA [100010801],,,76.8,,1750.76,0.518595,35041.66656,percent of total billed charges,,,
ORTHO 0.35MM -,SUP-WSO906ST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.7,81.69,AETNA [1000108],AETNA [100010801],,,76.8,,89.63,0.518595,35041.66656,percent of total billed charges,,,
WOUND MATRIX 6 LAYER 10CM X 15CM 150SQCM -,SUP-WSX1015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16411.46,11488.022,AETNA [1000108],AETNA [100010801],,,76.8,,12604,0.518595,35041.66656,percent of total billed charges,,,
PK PIN BALL PIN BALL PROT REFL 0.125IN 0.1094X.125IN F/3MM -,SUP-X003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,AETNA [1000108],AETNA [100010801],,,76.8,,32.86,0.518595,35041.66656,percent of total billed charges,,,
SUTURE MONODERM QUILL 3-0 MONO CLR YA-1023Q 30CMX30CM L BARB -,SUP-YA-1023Q,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.56,90.692,AETNA [1000108],AETNA [100010801],,,76.8,,99.5,0.518595,35041.66656,percent of total billed charges,,,
SUTURE MONODERM QUILL #0 MONO CLR YA-1029Q 36CMX36CM L BARB -,SUP-YA-1029Q,CDM,C1713,HCPCS,278,RC,,,outpatient,,,136.04,95.228,AETNA [1000108],AETNA [100010801],,,76.8,,104.48,0.518595,35041.66656,percent of total billed charges,,,
GUIDEWIRE HI-TORQUE CONNECT 250FT -,SUP-1012595,CDM,C1714,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes,,
EARLY ACCESSORY DROP OFF FEE -,SUP-10595-10169,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes,,
K-WIRE GAMMA 3.2 X 450MM -,SUP-1210-6451S,CDM,C1714,HCPCS,272,RC,,,outpatient,,,478.7,335.09,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes,,
SCREWDRIVER FLEXIBLE GAMMA -,SUP-1320-0233,CDM,C1714,HCPCS,272,RC,,,outpatient,,,2438.28,1706.796,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes,,
LEE RT ANG BRONCHUS CLAMP 9 39MM JAW -,SUP-320200,CDM,C1714,HCPCS,272,RC,,,outpatient,,,779.26,545.482,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes,,
PROBE BALL TIP 3MM TIP PEDICLE SCREW D344 -,SUP-3603-00-TE,CDM,C1714,HCPCS,272,RC,,,outpatient,,,601.01,420.707,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes,,
"KWIRE SINGLE POINT STST 150MM X .045"" -",SUP-451-1045,CDM,C1714,HCPCS,272,RC,,,outpatient,,,152.76,106.932,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes,,
10X30CM PICO14 DRESSING KIT -,SUP-66022043,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1562.06,1093.442,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes,,
HOLDER/POSITIOINER PLATE 1.2/1.55 FOR INSTRUMENT -,SUP-A-2350,CDM,C1714,HCPCS,272,RC,,,outpatient,,,4147.65,2903.355,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes,,
HOLDER/POSITIOINER PLATE 2.0/2.3 FOR INSTRUMENT -,SUP-A-2650,CDM,C1714,HCPCS,272,RC,,,outpatient,,,4147.65,2903.355,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes,,
KIT FIBERTAK KNOTLESS CURVED DISPOSABLE -,SUP-AR-3638DC,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes,,
B CROSSTELLAÂ® RX PTA Balloon Dilatation Cath 6mm x 150mm -,SUP-BD-F60150LR,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes,,
BALLOON R2P CROSTELLA  RX- 200cm- 6mm x 150mm -,SUP-BD-Q60150ER,CDM,C1714,HCPCS,272,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes,,
CATH BLNOCC 1.3MM 5FR SHTH 146CM 20CM LUM C RSSR 14S RX -,SUP-CRU14S,CDM,C1714,HCPCS,272,RC,,,outpatient,,,9315.58,6520.906,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes,,
CATH BLNOCC 1.1MM 5FR SHTH 146CM C RSSR 14P OTW PERIPH -,SUP-CRUO14PA,CDM,C1714,HCPCS,272,RC,,,outpatient,,,9315.58,6520.906,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes,,
CATH PTCA 0.05IN C RSSR S6 156CM RECANALIZATION PERIPH 5FR -,SUP-CRUS6A,CDM,C1714,HCPCS,272,RC,,,outpatient,,,9315.58,6520.906,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes,,
DRILL KIT FOR CONTINUOUS COMPRESSION -,SUP-DK-265C,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1863.92,1304.744,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes,,
INTERSTIM BELT FIXATION LARGE SCS PH -,SUP-FP9000L,CDM,C1714,HCPCS,272,RC,,,outpatient,,,233.4,163.38,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes,,
DILATOR COONS -,SUP-G04051,CDM,C1714,HCPCS,272,RC,,,outpatient,,,102.05,71.435,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes,,
CATH ANG 5FR DAV 100CM ADVANTG BRD VSCR -,SUP-G08581,CDM,C1714,HCPCS,272,RC,,,outpatient,,,151.7,106.19,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes,,
BALLOON EXTRACTOR PRO XL RETREIVAL 9-12 -,SUP-M00547130,CDM,C1714,HCPCS,272,RC,,,outpatient,,,612.32,428.624,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes,,
SET DELIVERY SIROS -,SUP-SIR-10300,CDM,C1714,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes,,
BLADE HOOK DISSECTING SYNERGY HARMONIC -,SUP-SNGHK,CDM,C1714,HCPCS,272,RC,,,outpatient,,,2781.64,1947.148,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes,,
SUTURE 3-0 MONO PLUS 16 X 16CM UNDYED -,SUP-SXMP2B402,CDM,C1714,HCPCS,272,RC,,,outpatient,,,166.17,116.319,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes,,
DRESSING KCI VERAFLO CLEANSE CHOICE LARGE -,SUP-ULTVCC05LG,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1428.85,1000.195,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes,,
DRESSING NEG PRSS SM 10X7.5X3.3CM VAC GRANUFOAM -,SUP-XF-DSMF1,CDM,C1714,HCPCS,272,RC,,,outpatient,,,163.38,114.366,AETNA [1000108],AETNA [100010801],,,,,,22.910225,6679.27086,other,272 with C codes,,
NEEDLE BRCHTX 18GAX20CM ULTRA-SHRP TIP PLSH SURF PRELD BN -,SUP-818205,CDM,C1715,CPT,272,RC,,,outpatient,,,84.61,59.227,AETNA [1000108],AETNA [100010801],,,,,,18.994945,416.02,other,272 with C codes,,
CURRENT DR RF 2207-36 AICD -,SUP-2207-36,CDM,C1721,HCPCS,275,RC,,,outpatient,,,44309.79,31016.853,AETNA [1000108],AETNA [100010801],,,76.8,,34029.92,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR LUMAX 740 DR-T 2CHMBR CARD IMPL W/HOME MNTR -,SUP-365606,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30837.5,21586.25,AETNA [1000108],AETNA [100010801],,,76.8,,23683.2,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR ILESTO DR-T DF-1 2CHMBR HI ENRG CARD IMPL W/TI -,SUP-383562,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25644.47,17951.129,AETNA [1000108],AETNA [100010801],,,76.8,,19694.95,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR ILESTO DR-T DF-4 2CHMBR HI ENRG CARD IMPL W/TI -,SUP-383564,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25644.47,17951.129,AETNA [1000108],AETNA [100010801],,,76.8,,19694.95,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR ITREVIA 7 DR-T DF-4 2CHMBR CARD IMPL W/TI -,SUP-392426,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25644.47,17951.129,AETNA [1000108],AETNA [100010801],,,76.8,,19694.95,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR CRNT + DR DF-4 2CHMBR RR V- PCNG RDC 50X74MM -,SUP-CD2211-36Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,AETNA [1000108],AETNA [100010801],,,76.8,,23755.2,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR FORTIFY DR DF-1 2CHMBR 40X74MM 14MM 35ML 76GM -,SUP-CD2231-40,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,AETNA [1000108],AETNA [100010801],,,76.8,,23755.2,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR FORTIFY DR DF-4 2CHMBR RR V- PCNG RDC 40X71MM -,SUP-CD2231-40Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,AETNA [1000108],AETNA [100010801],,,76.8,,23755.2,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR FORTIFY ASSURA DR DF-1 TELEM 2CHMBR 40X74MM -,SUP-CD2257-40,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,AETNA [1000108],AETNA [100010801],,,76.8,,23755.2,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR FORTIFY ASSURA DR DF-4 TELEM 2CHMBR 40X71MM -,SUP-CD2257-40Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,AETNA [1000108],AETNA [100010801],,,76.8,,23755.2,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR ELLIPSE DR DF-1 IS-1 CONN 2CHMBR DEFT RESPONSE -,SUP-CD2311-36,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,AETNA [1000108],AETNA [100010801],,,76.8,,23755.2,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR ELLIPSE DR DF-4 2CHMBR DEFT RESPONSE RF TELEM -,SUP-CD2311-36Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,AETNA [1000108],AETNA [100010801],,,76.8,,23755.2,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR FORTIFY ASSURA DR DF-4 2CHMBR CARD IMPL 40C -,SUP-CD2357-40C,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,AETNA [1000108],AETNA [100010801],,,76.8,,26377.15,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR FORTIFY ASSURA DR DF-4 2CHMBR CARD IMP 40Q -,SUP-CD2357-40Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,AETNA [1000108],AETNA [100010801],,,76.8,,26377.15,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR ELLIPSE VR IS-1 DF-1 2CHMBR 51X68MM 12MM 31ML -,SUP-CD2411-36C,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,AETNA [1000108],AETNA [100010801],,,76.8,,26377.15,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR ELLIPSE ASSURA DR DF-4 2CHMBR CARD IMPL -,SUP-CD2411-36Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,AETNA [1000108],AETNA [100010801],,,76.8,,26377.15,399.86,37344.8064,percent of total billed charges,,,
ENTRANT ICD CDDRA300Q -,SUP-CDDRA300Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37130,25991,AETNA [1000108],AETNA [100010801],,,76.8,,28515.84,399.86,37344.8064,percent of total billed charges,,,
ENTRANT DR ICD DF1 CONNECTOR REF: CDDRA300T -,SUP-CDDRA300T,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37130,25991,AETNA [1000108],AETNA [100010801],,,76.8,,28515.84,399.86,37344.8064,percent of total billed charges,,,
GALLANT ICD CDDRA500Q -,SUP-CDDRA500Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,26150.2,18305.14,AETNA [1000108],AETNA [100010801],,,76.8,,20083.35,399.86,37344.8064,percent of total billed charges,,,
GALLANT DR ICD DF1 CONNECTOR REF: CDDRA500T -,SUP-CDDRA500T,CDM,C1721,HCPCS,275,RC,,,outpatient,,,26150.2,18305.14,AETNA [1000108],AETNA [100010801],,,76.8,,20083.35,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR INOGEN DF-1 SGL-CHMBR 5.23X7.14X0.99 CM D -,SUP-D013,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25975.04,18182.528,AETNA [1000108],AETNA [100010801],,,76.8,,19948.83,399.86,37344.8064,percent of total billed charges,,,
DYNAGEN MINI ICD DR D022 -,SUP-D022,CDM,C1721,HCPCS,275,RC,,,outpatient,,,36747.56,25723.292,AETNA [1000108],AETNA [100010801],,,76.8,,28222.13,399.86,37344.8064,percent of total billed charges,,,
ICD MOMENTUM EO DR D121 -,SUP-D121,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25903.5,18132.45,AETNA [1000108],AETNA [100010801],,,76.8,,19893.89,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR D142 INOGEN MUL PRGM OPTN EXTEND LNGVT DR DF-4 -,SUP-D142,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25091.86,17564.302,AETNA [1000108],AETNA [100010801],,,76.8,,19270.55,399.86,37344.8064,percent of total billed charges,,,
DYNAGEN D153 EL ICD -DF-1 -,SUP-D153,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25091.86,17564.302,AETNA [1000108],AETNA [100010801],,,76.8,,19270.55,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR CONSULTA DF-4 CARD IMPL -,SUP-D204TRM,CDM,C1721,HCPCS,275,RC,,,outpatient,,,48626.05,34038.235,AETNA [1000108],AETNA [100010801],,,76.8,,37344.81,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR SECURA DR 2CHMBR RR V- PCNG RDC 51X64MM 15MM -,SUP-D224DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,35700.82,24990.574,AETNA [1000108],AETNA [100010801],,,76.8,,27418.23,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR SECURA VR SGL-CHMBR RR V- PCNG RDC 51X64MM -,SUP-D224VRC,CDM,C1721,HCPCS,275,RC,,,outpatient,,,31901.76,22331.232,AETNA [1000108],AETNA [100010801],,,76.8,,24500.55,399.86,37344.8064,percent of total billed charges,,,
ICD DUAL VIGILANT EL DR DF4 MRI CONDITIONAL -,SUP-D233,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25903.5,18132.45,AETNA [1000108],AETNA [100010801],,,76.8,,19893.89,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR MAXIMO II DR WRLS TELEM 2CHMBR RR V- PCNG RDC -,SUP-D284DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34217.29,23952.103,AETNA [1000108],AETNA [100010801],,,76.8,,26278.88,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR PROTECTA XT DR DF-1 IS-1 CONN 2CHMBR RR -,SUP-D314DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37579.81,26305.867,AETNA [1000108],AETNA [100010801],,,76.8,,28861.29,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR PROTECTA DR DF-1 IS-1 CONN 2CHMBR RR V- PCNG -,SUP-D334DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32749.43,22924.601,AETNA [1000108],AETNA [100010801],,,76.8,,25151.56,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR PROTECTA DR DF-4 2CHMBR CARD IMPL -,SUP-D334DRM,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32749.43,22924.601,AETNA [1000108],AETNA [100010801],,,76.8,,25151.56,399.86,37344.8064,percent of total billed charges,,,
ICD PERCIVA DR D401 -,SUP-D401,CDM,C1721,HCPCS,275,RC,,,outpatient,,,27894.37,19526.059,AETNA [1000108],AETNA [100010801],,,76.8,,21422.88,399.86,37344.8064,percent of total billed charges,,,
ICD PERCIVA DR DF4 D413 MRI CONDITIONAL -,SUP-D413,CDM,C1721,HCPCS,275,RC,,,outpatient,,,27894.37,19526.059,AETNA [1000108],AETNA [100010801],,,76.8,,21422.88,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR EVERA S DR DF-1 2CHMBR CARD IMPL -,SUP-DDBC3D1,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32071,22449.7,AETNA [1000108],AETNA [100010801],,,76.8,,24630.53,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR EVERA S DR DF-4 2CHMBR CARD IMPL -,SUP-DDBC3D4,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32071,22449.7,AETNA [1000108],AETNA [100010801],,,76.8,,24630.53,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR EVERA MRI XT DR SURSCN DF-4 CARD IMPL -,SUP-DDMB1D1,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37251.7,26076.19,AETNA [1000108],AETNA [100010801],,,76.8,,28609.31,399.86,37344.8064,percent of total billed charges,,,
EVERA MRI S DR SURESCAN MODEL DDMC3D1 -,SUP-DDMC3D1,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34784.7,24349.29,AETNA [1000108],AETNA [100010801],,,76.8,,26714.65,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR EVERA 2CHMBR CARD IMPL -,SUP-DDMC3D4,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34784.7,24349.29,AETNA [1000108],AETNA [100010801],,,76.8,,26714.65,399.86,37344.8064,percent of total billed charges,,,
ICD DUAL COBALT DR MRI REF: DDPB3D4 -,SUP-DDPB3D4,CDM,C1721,HCPCS,275,RC,,,outpatient,,,38485.2,26939.64,AETNA [1000108],AETNA [100010801],,,76.8,,29556.63,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR OVATIO CARD 6550 -,SUP-DR6550,CDM,C1721,HCPCS,275,RC,,,outpatient,,,45639.5,31947.65,AETNA [1000108],AETNA [100010801],,,76.8,,35051.14,399.86,37344.8064,percent of total billed charges,,,
DYNAGEN CRT-D G151 -,SUP-G151,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32897.45,23028.215,AETNA [1000108],AETNA [100010801],,,76.8,,25265.24,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR VITALITY II DR IS-1 DF-1 2CHMBR V- PCNG RDC -,SUP-T167,CDM,C1721,HCPCS,275,RC,,,outpatient,,,43197.17,30238.019,AETNA [1000108],AETNA [100010801],,,76.8,,33175.43,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR VITALITY HE IS-1 DF-1 2CHMBR 66MMX82.6MM -,SUP-T180,CDM,C1721,HCPCS,275,RC,,,outpatient,,,41877.33,29314.131,AETNA [1000108],AETNA [100010801],,,76.8,,32161.79,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR PARADYM RF VR IMPL 9250 -,SUP-TDF011U,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25661.73,17963.211,AETNA [1000108],AETNA [100010801],,,76.8,,19708.21,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR SQ-RX DF-1 SGL-CHMBR 65.5MMX78.2MMX15.7MM D -,SUP-1010,CDM,C1722,HCPCS,275,RC,,,outpatient,,,46873,32811.1,AETNA [1000108],AETNA [100010801],,,76.8,,35998.46,399.86,35998.464,percent of total billed charges,,,
DEFIBRILLATOR CRNT VR RF SGL-CHMBR VNTRC PCNG CARD IMPL -,SUP-1207/36,CDM,C1722,HCPCS,275,RC,,,outpatient,,,37656.29,26359.403,AETNA [1000108],AETNA [100010801],,,76.8,,28920.03,399.86,35998.464,percent of total billed charges,,,
DEFIBRILLATOR LUMAX 540 VR-T IS-1 CONN SGL-CHMBR RR 55X66MM -,SUP-360348,CDM,C1722,HCPCS,275,RC,,,outpatient,,,30895.47,21626.829,AETNA [1000108],AETNA [100010801],,,76.8,,23727.72,399.86,35998.464,percent of total billed charges,,,
DEFIBRILLATOR LUMAX 740 VR-T SGL-CHMBR CARD IMPL W/HOME MNTR -,SUP-365609,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28370.5,19859.35,AETNA [1000108],AETNA [100010801],,,76.8,,21788.54,399.86,35998.464,percent of total billed charges,,,
DEFIBRILLATOR LUMAX 740 VR-T DX CARD IMPL CELL GSM HOME MNTR -,SUP-372419,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28370.5,19859.35,AETNA [1000108],AETNA [100010801],,,76.8,,21788.54,399.86,35998.464,percent of total billed charges,,,
DEFIBRILLATOR ILESTO VR-T SGL-CHMBR CARD IMPL -,SUP-383578,CDM,C1722,HCPCS,275,RC,,,outpatient,,,30837.5,21586.25,AETNA [1000108],AETNA [100010801],,,76.8,,23683.2,399.86,35998.464,percent of total billed charges,,,
DEFIBRILLATOR ILESTO VR SGL-CHMBR HI ENRG CARD IMPL W/TI -,SUP-383580,CDM,C1722,HCPCS,275,RC,,,outpatient,,,30837.5,21586.25,AETNA [1000108],AETNA [100010801],,,76.8,,23683.2,399.86,35998.464,percent of total billed charges,,,
DEFIBRILLATOR ILESTO DX HI ENRG CARD IMPL W/TI LANDLINE HOME -,SUP-383594,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35737.63,25016.341,AETNA [1000108],AETNA [100010801],,,76.8,,27446.5,399.86,35998.464,percent of total billed charges,,,
DEFIBRILLATOR ITREVIA 7 VR-T DX HI ENRG CARD IMPL -,SUP-393037,CDM,C1722,HCPCS,275,RC,,,outpatient,,,24694.67,17286.269,AETNA [1000108],AETNA [100010801],,,76.8,,18965.51,399.86,35998.464,percent of total billed charges,,,
DEVICE HI ENRG CARD IMPL TI -,SUP-393041,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35737.63,25016.341,AETNA [1000108],AETNA [100010801],,,76.8,,27446.5,399.86,35998.464,percent of total billed charges,,,
ICD INTICA NEO 7 VR-T DX REF:429559 -,SUP-429559,CDM,C1722,HCPCS,275,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,399.86,35998.464,percent of total billed charges,,,
DEFIBRILLATOR EMBLEM S SQ-1 CONN 83.1MMX69.1MMX12.7MM D -,SUP-A209,CDM,C1722,HCPCS,275,RC,,,outpatient,,,46873,32811.1,AETNA [1000108],AETNA [100010801],,,76.8,,35998.46,399.86,35998.464,percent of total billed charges,,,
S-ICD Emblem MRI A219 -,SUP-A219,CDM,C1722,HCPCS,275,RC,,,outpatient,,,44406,31084.2,AETNA [1000108],AETNA [100010801],,,76.8,,34103.81,399.86,35998.464,percent of total billed charges,,,
DEFIBRILLATOR CRNT + VR SJ-4 CONN SGL-CHMBR 50X74MM 14MM -,SUP-CD1211-36Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,AETNA [1000108],AETNA [100010801],,,76.8,,21741.18,399.86,35998.464,percent of total billed charges,,,
DEFIBRILLATOR FORTIFY VR DF-1 SGL-CHMBR 40X73MM 14MM 35ML -,SUP-CD1231-40,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,AETNA [1000108],AETNA [100010801],,,76.8,,21741.18,399.86,35998.464,percent of total billed charges,,,
DEFIBRILLATOR FORTIFY VR DF-4 ATP TERM AUTOMATICITY -,SUP-CD1231-40Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,AETNA [1000108],AETNA [100010801],,,76.8,,21741.18,399.86,35998.464,percent of total billed charges,,,
DEFIBRILLATOR FORTIFY ASSURA VR DF-1 TELEM SGL-CHMBR 40X73MM -,SUP-CD1257-40,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,AETNA [1000108],AETNA [100010801],,,76.8,,21741.18,399.86,35998.464,percent of total billed charges,,,
DEFIBRILLATOR FORTIFY ASSURA VR DF-4 SGL-CHMBR RF TELEM -,SUP-CD1257-40Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,AETNA [1000108],AETNA [100010801],,,76.8,,21741.18,399.86,35998.464,percent of total billed charges,,,
DEFIBRILLATOR ELLIPSE VR DF-1 IS-1 CONN SGL-CHMBR DEFT -,SUP-CD1311-36,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,AETNA [1000108],AETNA [100010801],,,76.8,,21741.18,399.86,35998.464,percent of total billed charges,,,
DEFIBRILLATOR ELLIPSE VR DF-4 DF-1 IS-1 CONN SGL-CHMBR DEFT -,SUP-CD1311-36Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,25163.4,17614.38,AETNA [1000108],AETNA [100010801],,,76.8,,19325.49,399.86,35998.464,percent of total billed charges,,,
DEFIBRILLATOR FORTIFY ASSURA VR DF-1 IS-1 CONN SGL-CHMBR -,SUP-CD1357-40C,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,AETNA [1000108],AETNA [100010801],,,76.8,,25664.26,399.86,35998.464,percent of total billed charges,,,
DEFIBRILLATOR FORTIFY ASSURA VR DF-4 SGL-CHMBR 40X71MM 14MM -,SUP-CD1357-40Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,AETNA [1000108],AETNA [100010801],,,76.8,,25664.26,399.86,35998.464,percent of total billed charges,,,
DEFIBRILLATOR ELLIPSE VR IS-1 DF-1 SGL-CHMBR 51X68MM 12MM -,SUP-CD1411-36C,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,AETNA [1000108],AETNA [100010801],,,76.8,,25664.26,399.86,35998.464,percent of total billed charges,,,
DEFIBRILLATOR ELLIPSE VR-ICD MRLN DF-4 SGL-CHMBR -,SUP-CD1411-36Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,AETNA [1000108],AETNA [100010801],,,76.8,,25664.26,399.86,35998.464,percent of total billed charges,,,
ENTRANT ICD CDVRA300Q -,SUP-CDVRA300Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35273.5,24691.45,AETNA [1000108],AETNA [100010801],,,76.8,,27090.05,399.86,35998.464,percent of total billed charges,,,
ENTRANT VR ICD DF1 CONNECTOR REF: CDVRA300T -,SUP-CDVRA300T,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35273.5,24691.45,AETNA [1000108],AETNA [100010801],,,76.8,,27090.05,399.86,35998.464,percent of total billed charges,,,
GALLANT ICD CDVRA500Q -,SUP-CDVRA500Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36201.75,25341.225,AETNA [1000108],AETNA [100010801],,,76.8,,27802.94,399.86,35998.464,percent of total billed charges,,,
GALLANT VR ICD DF1 CONNECTOR REF: CDVRA500T -,SUP-CDVRA500T,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36201.75,25341.225,AETNA [1000108],AETNA [100010801],,,76.8,,27802.94,399.86,35998.464,percent of total billed charges,,,
DEFIBRILLATOR INOGEN DF-1 SGL-CHMBR 5.23X7.14X0.99 CM D. -,SUP-D011,CDM,C1722,HCPCS,275,RC,,,outpatient,,,26643.6,18650.52,AETNA [1000108],AETNA [100010801],,,76.8,,20462.28,399.86,35998.464,percent of total billed charges,,,
ICD MOMENTUM EL VR D120 -,SUP-D120,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36573.05,25601.135,AETNA [1000108],AETNA [100010801],,,76.8,,28088.1,399.86,35998.464,percent of total billed charges,,,
DEFIBRILLATOR INOGEN EXTEND LNGVT 5.37X7.36X0.99IN 68.9G -,SUP-D140,CDM,C1722,HCPCS,275,RC,,,outpatient,,,34746.25,24322.375,AETNA [1000108],AETNA [100010801],,,76.8,,26685.12,399.86,35998.464,percent of total billed charges,,,
DYNAGEN EL ICD VR MODEL D151 -,SUP-D151,CDM,C1722,HCPCS,275,RC,,,outpatient,,,34746.25,24322.375,AETNA [1000108],AETNA [100010801],,,76.8,,26685.12,399.86,35998.464,percent of total billed charges,,,
DEFIBRILLATOR SECURA DR DF-4 2CHMBR CARD IMPL -,SUP-D204DRM,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35700.82,24990.574,AETNA [1000108],AETNA [100010801],,,76.8,,27418.23,399.86,35998.464,percent of total billed charges,,,
DEFIBRILLATOR SECURA VR DF-4 SGL-CHMBR CARD IMPL -,SUP-D204VRM,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31901.76,22331.232,AETNA [1000108],AETNA [100010801],,,76.8,,24500.55,399.86,35998.464,percent of total billed charges,,,
ICD VIGILANT EO VR DF4 D232 MRI CONDITIONAL -,SUP-D232,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36573.05,25601.135,AETNA [1000108],AETNA [100010801],,,76.8,,28088.1,399.86,35998.464,percent of total billed charges,,,
DEFIBRILLATOR PROTECTA VR DF-1 IS-1 CONN SGL-CHMBR RR -,SUP-D334VRG,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28710.95,20097.665,AETNA [1000108],AETNA [100010801],,,76.8,,22050.01,399.86,35998.464,percent of total billed charges,,,
DEFIBRILLATOR PROTECTA VR DF-4 SGL-CHMBR CARD IMPL -,SUP-D334VRM,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28710.95,20097.665,AETNA [1000108],AETNA [100010801],,,76.8,,22050.01,399.86,35998.464,percent of total billed charges,,,
ICD SINGLE PERCIVA VR REF: D400 -,SUP-D400,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36573.05,25601.135,AETNA [1000108],AETNA [100010801],,,76.8,,28088.1,399.86,35998.464,percent of total billed charges,,,
ICD PERCIVA VR DF4 D142 MRI CONDITIONAL -,SUP-D412,CDM,C1722,HCPCS,275,RC,,,outpatient,,,25827.02,18078.914,AETNA [1000108],AETNA [100010801],,,76.8,,19835.15,399.86,35998.464,percent of total billed charges,,,
ICD RESONATE EL VR -,SUP-D432,CDM,C1722,HCPCS,275,RC,,,outpatient,,,29019.32,20313.524,AETNA [1000108],AETNA [100010801],,,76.8,,22286.84,399.86,35998.464,percent of total billed charges,,,
COBALT XT DR MRI ICD REF: DDPA2D4 -,SUP-DDPA2D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,41837.85,29286.495,AETNA [1000108],AETNA [100010801],,,76.8,,32131.47,399.86,35998.464,percent of total billed charges,,,
DEFIBRILLATOR EVERA S VR DF-1 SGL-CHMBR CARD IMPL -,SUP-DVBC3D1,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28617.2,20032.04,AETNA [1000108],AETNA [100010801],,,76.8,,21978.01,399.86,35998.464,percent of total billed charges,,,
DEFIBRILLATOR EVERA S VR DF-4 SGL-CHMBR CARD IMPL -,SUP-DVBC3D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28617.2,20032.04,AETNA [1000108],AETNA [100010801],,,76.8,,21978.01,399.86,35998.464,percent of total billed charges,,,
VISIA AF MRI VR ICD DVFB1D1 -,SUP-DVFB1D1,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,AETNA [1000108],AETNA [100010801],,,76.8,,24441.06,399.86,35998.464,percent of total billed charges,,,
ICD VISIA AF MRI SURESCAN VR -,SUP-DVFB1D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,AETNA [1000108],AETNA [100010801],,,76.8,,24441.06,399.86,35998.464,percent of total billed charges,,,
DEFIBRILLATOR CARDIAC VISIA AF MRI SURESCAN DVFC3D1 -,SUP-DVFC3D1,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,AETNA [1000108],AETNA [100010801],,,76.8,,24441.06,399.86,35998.464,percent of total billed charges,,,
DEFIBRILLATOR EVERA MRI XT DR SURSCN DF-4 CARD IMPL -,SUP-DVMB1D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,AETNA [1000108],AETNA [100010801],,,76.8,,24441.06,399.86,35998.464,percent of total billed charges,,,
EXPLANT TRUNCATED BLADE 56MM -,SUP-00-7053-056-10,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes,,
C 0.9M .014IN OTW TURBO ELITE -,SUP-410-152,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes,,
C 1.4M .014IN OTW TURBO ELITE -,SUP-414-151,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes,,
"2.0mm .018"" TURBO ELITE LASER -",SUP-420-006,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes,,
C 2.3M .018IN OTW TURBO ELITE -,SUP-423-001,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes,,
C 7FR LASER GUIDE 2.0MM TURBO -,SUP-423-050,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12234.34,8564.038,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes,,
DEVICE ATHRCMY STEALTH 360 1.5MM MICRO CRWN 145CM SHFT DMD -,SUP-DBE-150,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12605.64,8823.948,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes,,
CATH ATHRCMY DIAMONDBACK 360 1.25MM CROWN 135CM SHAFT -,SUP-DBEC-125,CDM,C1724,HCPCS,272,RC,,,outpatient,,,14833.44,10383.408,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes,,
DEVICE ATHRCMY PREDATOR 360 2MM CRWN DMD CTD SLD ART -,SUP-DBG-SCT30-200,CDM,C1724,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes,,
DEVICE ARTHREC 1.25 SOLID -,SUP-DBP-125MICRO145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes,,
SYSTEM ATHERECTOMY DBP-125MICRO145 -,SUP-DBP-125MICRO145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes,,
DEVICE ARTHREC STEALTH 1.25S -,SUP-DBP-125SOLID145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes,,
DEVICE ARTHREC STEALTH 1.50MM 5F -,SUP-DBP-150SOLID145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes,,
DBP-200SOLID145 -,SUP-DBP-200SOLID145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes,,
CATH ATHRCMY DIAMONDBACK 360 1.50MM X 145CM SOLID -,SUP-DBP-EX-150SOL145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,14462.14,10123.498,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes,,
ROTAPRO ADVANCER 1.25MM -,SUP-H749394671250,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7999.94,5599.958,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes,,
ROTAPRO ADVANCER 1.5MM -,SUP-H749394671500,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7999.94,5599.958,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes,,
ROTAPRO ADVANCER 1.75MM -,SUP-H749394671750,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes,,
ROTAPRO ADVANCER 2.0MM -,SUP-H749394672000,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes,,
ROTAPRO ADVANCER 2.25MM -,SUP-H749394672250,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes,,
ROTAPRO ADVANCER 2.38MM -,SUP-H749394672380,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes,,
ROTAPRO ADVANCER 2.5MM -,SUP-H749394672500,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes,,
ROTAPRO ADVANCER 2.15MM -,SUP-H7494672150,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes,,
CATH ATHRCMY ROTLNK + 1.25MM BUR 0.58IN SHTH 135CM TFLN PTFE -,SUP-H802227680020,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4502.88,3152.016,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes,,
BURR ROTALINK 1.50MM 0.58IN SHTH 135CM EXCHGL -,SUP-H802227680030,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4953.17,3467.219,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes,,
CATH ATHRCMY ROTLNK + 1.75MM BUR 0.58IN SHTH 135CM EXCHGL -,SUP-H802227680040,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4953.17,3467.219,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes,,
CATH ATHRCMY ROTLNK + 2MM BUR 0.58IN SHTH 135CM EXCHGL ROT -,SUP-H802227680050,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4502.88,3152.016,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes,,
CATH ATHRCMY ROTLNK 2.15MM BUR 0.58IN SHTH 135CM TFLN PTFE -,SUP-H802227680150,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4502.88,3152.016,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes,,
PHOENIX 1.8MM X130CM -,SUP-P18130,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes,,
1.8MM PHOENIX 149CM -,SUP-P18149K,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes,,
PHOENIX 2.2MM X 130CM -,SUP-P22130K,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes,,
PHOENIX ARTHERECTOMY 2.4MM 7FR -,SUP-P22149K,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes,,
ARTHERECTOMY JTSTRM 1.85MM -,SUP-PV3118F,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12754.16,8927.912,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes,,
ARTHERECTOMY JTSTRM 2.1/3MM -,SUP-PV31300,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12624.2,8836.94,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes,,
CATH ARTHERECTOMY JTSTRM 2.4/3.4MM LT -,SUP-PV41340,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12624.2,8836.94,AETNA [1000108],AETNA [100010801],,,,,,399.86,10635.57648,other,272 with C codes,,
CATHETER BALLOON VALVULOPLASTY  22MX4.5CMX110CM -,SUP-00224512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATHETER BALLOON VALAVULOPLASTY 20MMX4.5X110CM TRUE DILATION -,SUP-0204511,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATHETER BALLOON VALVULOPLASTY 21MMX4.5CMX110CM TRUE DILATIO -,SUP-0214512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATHETER BALLOON VALVULOPLASTY 23MMX4.5CMX120CM TRUE DILATIO -,SUP-0234512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATHETER BALLOON VALVULOPLASTY 24MMX4.5CMX110CM TRUE DILAT -,SUP-0244512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATHETER TRUE DILATATION 25MM X 4.5CM REF: 0254513 -,SUP-0254513,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATHETER TRUE DILATION 26MM -,SUP-0264513,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATHETER BALLOON VALVULOPLASTY 28MMX4.5CMX110CM TRUE DILAT -,SUP-0284514,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH IABP LINEAR 7.5FR 40CC -,SUP-0684-00-0480-01,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4203.6,2942.52,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATHETER IABP 7.5FR 40CC SENSATION PLUS -,SUP-0684-00-0568-01U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4524.1,3166.87,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATHETER IABP 8FR 50CC SENSATION PLUS -,SUP-0684-00-0576-01U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4524.1,3166.87,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
GAIA FIRST 190CM MICRO J,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
GAIA THIRD 190CM MICRO J,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
GAIA SECOND 190CM MICRO J,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
RG3 330CM,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X18MM PWRSL 143CM RX F/PTCA COR HYDRCT 0.024IN GW -,SUP-1005527-18,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1086.6,760.62,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X15MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008189-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
4MM X 20MM X 135CM VIATRAC 14 PLUS BALLOON -,SUP-1008189-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ABBOTT VIATRAC BALLOON 4.5 X 20 X 135 -,SUP-1008191-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5X20MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008193-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ABBOTT VIATRAC BALLOON 5.5 X 20 X 135 -,SUP-1008195-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6X20MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008197-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6X40MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008197-40,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH CV 4.5X20MM VIATRAC LF -,SUP-10081991-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ABBOTT VIATRAC BALLOON 6.5 X 20 X 135 -,SUP-1008199-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 7X20MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008201-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.2X6MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012268-06U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON MINI TREK RX 1.20MM X 08MM REF: 1012268-08U -,SUP-1012268-08U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.2X12MM MINI TREK II RX UL-LPRO NC COR HYDRCT -,SUP-1012268-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.2X12MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012268-12U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON MINI TREK RX 1.20MM X 15MM REF: 1012268-15U -,SUP-1012268-15U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.2X20MM MINI TREK II RX UL-LPRO NC COR HYDRCT -,SUP-1012268-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.2X20MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012268-20U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.5X8MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.5X12MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.5X15MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.5X20MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X8MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X12MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X15MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X20MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X25MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X30MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X30MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON TREK RX 2.75MM X 08MM REF: 1012273-08 -,SUP-1012273-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON TREK RX 2.75MM X 12MM REF: 1012273-12 -,SUP-1012273-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON TREK RX 2.75MM X 20MM REF: 1012273-20 -,SUP-1012273-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X30MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON TREK RX 4.0MM X 8MM REF: 1012278-08 -,SUP-1012278-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012278-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON TREK RX 4.0MM X 15MM REF: 1012278-15 -,SUP-1012278-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON TREK RX 4.0MM X 20MM REF: 1012278-20 -,SUP-1012278-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012278-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X30MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012278-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4.5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012279-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON TREK RX 4.5MM X 15MM REF: 1012279-15 -,SUP-1012279-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012280-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON TREK RX 5.0MM X 15MM REF: 1012280-15 -,SUP-1012280-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.2X6MM MINI TREK II OTW UL-LPRO NC COR HYDRCT CTD -,SUP-1012401-06Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.2X8MM MINI TREK II OTW UL-LPRO NC COR HYDRCT CTD -,SUP-1012401-08Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.2X12MM MINI TREK II OTW UL-LPRO NC COR HYDRCT -,SUP-1012401-12Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.2X15MM MINI TREK II OTW UL-LPRO NC COR HYDRCT -,SUP-1012401-15Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.2X20MM MINI TREK II OTW UL-LPRO NC COR HYDRCT -,SUP-1012401-20Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.5X8MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.5X12MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.5X15MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.5X20MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X8MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012403-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X12MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X15MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X20MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X30MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X30MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012407-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X30MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X12MM NC TREK OTW SM-PRFL NC COR RND TIP HYDRCT -,SUP-1012433-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.75X15MM NC TREK OTW SM-PRFL NC COR RND TIP -,SUP-1012436-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.5X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X25MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.75X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.75X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.75X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.75X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.75X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X25MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X12 MM NC TREK RX ULLPRO NC COR RND TIP HYDRCT -,SUP-1012450-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X25MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.75X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.75X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.75X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.75X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
2.0MM X 60 MM X 150CM ARMADA 18 BALLOON OTW -,SUP-1013463-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA BALLOON 2.5MM X 40MM X 150CM -,SUP-1013464-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 18 2.5 X 200 X 150 -,SUP-1013464-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA BALLOON 2.5MM X 80MM X 150CM -,SUP-1013464-80,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA BALLOON .018 3MM X 60MM X 150CM -,SUP-1013465-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1155.33,808.731,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA BALLOON .018 3.0MM X 80MM X 150CM -,SUP-1013465-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA BALLOON .018 3.0MM X 100MM X 150CM -,SUP-1013465-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATHETER ARMADA 18 3.0MM X 120MM X 150CM -,SUP-1013465-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATHETER ARMADA 18 PTA -,SUP-1013465-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA BALLOON .018 3 X 200 X 150 -,SUP-1013465-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 18 4 X 20MM -,SUP-1013466-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
4MM X 40MM X 150CM ARMADA 18 BALLOON -,SUP-1013466-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
4MM X 60MM X 150CM ARMADA 18 -,SUP-1013466-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 4MM X 80MM X 150CM 18 -,SUP-1013466-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON ARMADA 4 X 150 X 150MM -,SUP-1013466-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 18 BALLOON 5MM X 20MM -,SUP-1013468-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
5mm x 40mm armada 18 -,SUP-1013468-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
5mm x 60mm Armada 18 Balloon -,SUP-1013468-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 18 BALLOON 5MM X 80MM -,SUP-1013468-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B ARMADA .018 5MM X 100MM -,SUP-1013468-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA BALLOON 5 MM X 150MM -,SUP-1013468-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA BALLOON 5MM X 200MM -,SUP-1013468-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 18 BALLOON 6 X 20MM -,SUP-1013470-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
6MM X 40MM X 150CM ARMADA 18 BALLOON -,SUP-1013470-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 18 B 6MM X 60MM X 150CM -,SUP-1013470-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 018 6MM X 80 MM -,SUP-1013470-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 6MM X 100MM 18 BALLOON -,SUP-1013470-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 6MM X 150MM 0.018 -,SUP-1013470-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 6MM X 200MM 0.018 -,SUP-1013470-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON TREK RX 3.75MM X 8MM REF: 1012277-08 -,SUP-102277-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 1.50MM X 8MM REF: 1400150-08 -,SUP-1400150-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 1.50MM X 12MM REF: 1400150-12 -,SUP-1400150-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 1.50MM X 15MM REF: 1400150-15 -,SUP-1400150-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 1.50MM X 20MM REF: 1400150-20 -,SUP-1400150-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 2.00MM X 8MM REF: 1400200-08 -,SUP-1400200-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 2.00MM X 12MM REF: 1400200-12 -,SUP-1400200-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 2.00MM X 15MM REF: 1400200-15 -,SUP-1400200-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 2.00MM X 20MM REF: 1400200-20 -,SUP-1400200-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 2.25MM X 08MM REF: 1400225-08 -,SUP-1400225-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 2.25MM X 12MM REF: 1400225-12 -,SUP-1400225-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 2.25MM X 15MM REF: 1400225-15 -,SUP-1400225-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 2.25MM X 20MM REF: 1400225-20 -,SUP-1400225-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 2.50MM X 8MM REF: 1400250-08 -,SUP-1400250-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 2.50MM X 12MM REF: 1400250-12 -,SUP-1400250-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 2.50MM X 15MM REF: 1400250-15 -,SUP-1400250-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 2.50MM X 20MM REF: 1400250-20 -,SUP-1400250-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 2.75MM X 8MM REF: 1400275-08 -,SUP-1400275-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 2.75MM X 12MM REF: 1400275-12 -,SUP-1400275-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 2.75MM X 15MM REF: 1400275-15 -,SUP-1400275-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 2.75MM X 20MM REF: 1400275-20 -,SUP-1400275-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 3.00MM X 8MM REF: 1400300-08 -,SUP-1400300-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 3.00MM X 15MM REF: 1400300-15 -,SUP-1400300-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 3.00MM X 20MM REF: 1400300-20 -,SUP-1400300-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 3.25MM X 8MM REF: 1400325-08 -,SUP-1400325-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 3.25MM X 12MM REF: 1400325-12 -,SUP-1400325-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 3.25MM X 15MM REF: 1400325-15 -,SUP-1400325-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 3.25MM X 20MM REF: 1400325-20 -,SUP-1400325-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 3.50MM X 8MM REF: 1400350-08 -,SUP-1400350-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 3.50MM X 12MM REF: 1400350-12 -,SUP-1400350-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 3.50MM X 15MM REF: 1400350-15 -,SUP-1400350-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 3.50MM X 20MM REF: 1400350-20 -,SUP-1400350-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 3.75MM X 12MM REF: 1400375-12 -,SUP-1400375-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 3.75MM X 20MM REF: 1400375-20 -,SUP-1400375-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 4.00MM X 8MM REF: 1400400-08 -,SUP-1400400-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 4.00MM X 12MM REF: 1400400-12 -,SUP-1400400-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 4.00MM X 15MM REF: 1400400-15 -,SUP-1400400-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 4.00MM X 20MM REF: 1400400-20 -,SUP-1400400-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 4.50MM X 8MM REF: 1400450-08 -,SUP-1400450-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 4.50MM X 12MM REF: 1400450-12 -,SUP-1400450-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 4.50MM X 20MM REF: 1400450-20 -,SUP-1400450-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 5.00MM X 12MM REF: 1400500-12 -,SUP-1400500-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 5.00MM X 15MM REF: 1400500-15 -,SUP-1400500-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 5.50MM X 12MM REF: 1400550-12 -,SUP-1400550-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 5.50MM X 15MM REF: 1400550-15 -,SUP-1400550-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 6.00MM X 12MM REF: 1400600-12 -,SUP-1400600-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 6.00MM X 15MM REF: 1400600-15 -,SUP-1400600-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH BLNOCC 15MM LRG 23X71X2.5CM ENDOCATH LPRO PLYISPRN -,SUP-20-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X20MM 2.7CM ANGIOSCULPT XL 137CM OTW F/PTCA -,SUP-2039-2520,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X20MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2076-4020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X40MM ANGIOSCULPT XL 137CM OTW -,SUP-2076-4040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5X40MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2076-5040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6X40MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2076-6040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6X20MM ANGIOSCULPT XL 90CM OTW F/PTCA SEM-COM -,SUP-2092-6020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATHETER SAPPHIRE II PRO L5 MM 5F -,SUP-210-053-5UU,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATHETER SAPPHIRE II PRO L15 MM 5F -,SUP-210-153-5UU,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X40MM ANGIOSCULPT XL 155CM OTW F/PTCA SEM-COM -,SUP-2155-2540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR TAPR -,SUP-2200-2006-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X10MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2010-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2015-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.0X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2020-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2506-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X10MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2510-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2515-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2520-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR TAPR -,SUP-2200-3006-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X10MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3010-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3015-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.0X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3020-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3506-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X10MM ANGIOSCULPT 137CM RX F /PTCA SEM-COM COR -,SUP-2200-3510-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3515-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3520-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5X100MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2237-50100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6X100MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2237-60100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B ANGIOSCULPT 7MM X 40MM -,SUP-2333-7040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6X100MM STERLNG 135CM OTW COAX SEM-COM PERIPH TAPR -,SUP-39032-60101,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATHETER PCA 4MM X 30MM x 145CM COYOTE ES M -,SUP-39135-40301,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 14MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-1440L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATHETER DILATION16MM X 4MM -,SUP-417-1640L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 18MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-1840L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 20MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-2040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 22MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-2240L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 25MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-2540L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 12MMX4CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-2040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3MMX4CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-3040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3MMX8CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-3080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4MMX10CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-4000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4MMX2CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-4020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
MIRROR SURG 16.4MMX7.625IN LRYNG HEX HNDL V. MUELLER -,SUP-419-4040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4MMX6CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-4060L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5MMX10CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-5000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 8MMX8CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-8080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-5040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5MM 5FR SHFT 6CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-5060L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5MM 5FR SHFT 8CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-5080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6MM 5FR SHFT 6FR SHTH 10CM POWERFLX P3 110CM OTW -,SUP-420-6000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6MM 5FR SHFT 5FR SHTH 2CM POWERFLX P3 110CM OTW -,SUP-420-6020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-6040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6MM 5FR SHFT 6CM POWERFLX P3 80CM OTW F/PTA PERIPH -,SUP-420-6060S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6MM 5FR SHFT 8CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-6080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 7MM 5FR SHFT 10CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-7000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 7MM 5FR SHFT 2CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-7020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 7MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-7040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 8MM 5FR SHFT 6FR SHTH 2CM POWERFLX P3 110CM OTW -,SUP-420-8020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 8MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-8040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4MMX2CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-4020W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4MMX3CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-4030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
RETRACTOR RGNL 6IN DBL END STN FNSH SS DLCT V. MUELLER NS -,SUP-424-5030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6MMX3CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-6030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 7MMX3CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-7030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH DIL 3MM 4FR SHTH 4CM BLN 150CM F/PTA -,SUP-425-3004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3MMX4CM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-3004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X120MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X40MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-4004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5X40MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-5004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5X100MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-5010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5MMX28CM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-5028X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1696.16,1187.312,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5MMX6CM SAVVY 120CM OTW COAX MOD PRSS PERIPH TAPR -,SUP-435-506L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1155.51,808.857,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4MMX22CM SAVVY LONG 120CM OTW COAX MOD PRSS PERIPH -,SUP-436-4022L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1420.53,994.371,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4MMX22CM SAVVY LONG 150CM OTW COAX MOD PRSS PERIPH -,SUP-436-4022X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1420.53,994.371,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0302S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0402S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4MMX4CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0404S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X220MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0422X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5MMX2CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0502S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0504S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5X60MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5X100MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5X220MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0522X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6MMX2CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0602S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6MMX4CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0604S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6X100MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0610X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6X150MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0615X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,840.24,588.168,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 7X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0702S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 7X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0704S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 7X40MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0704X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 8X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0802S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 8X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0804S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 9X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0902S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 10X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-1004S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
TURNPIKE 150 CM MICRO CATH -,SUP-5643,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2859.63,2001.741,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 22MMX4CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-610462,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 25MMX4CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-610463,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 28MMX4CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-610465,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA BALLOON DILATAION 22X4X100 Z-MED II -,SUP-611761,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 30MMX2CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-611801,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 28MMX2CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-611803,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 25MMX3CM Z-MED 100CM LPRO COAX F/PTA HPRS PERIPH -,SUP-611816,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATHETER PTV 16MMX4CM TYSHAK II REF:611920 -,SUP-611920,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATHETER PTV 18MMX4CM TYSHAK II REF:611928 -,SUP-611928,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATHETER PTV 20MMX4CM TYSHAK II REF:611932 -,SUP-611932,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATHETER PTV 22MMX4CM TYSHAK II REF:611936 -,SUP-611936,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATHETER PTV 25MMX4CM TYSHAK II REF:611944 -,SUP-611944,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH GUID 0.07IN 6FR MPA-1 90CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-270-90,CDM,C1725,HCPCS,272,RC,,,outpatient,,,309.26,216.482,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X6MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R06350N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R10200N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10225N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10250N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10325N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10350N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R10400N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R12250N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R12300N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R12325N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.75X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R12350N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R12400N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R15250N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R15300N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R15325N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R15340N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R15400N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
C PIG 5FR 20/1CM MARKS -,SUP-7602-20M65SH,CDM,C1725,HCPCS,272,RC,,,outpatient,,,528.13,369.691,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X12MM EMPIRA 139CM RX F/PTCA SEM-COM -,SUP-85R12250S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X12MM EMPIRA 139CM RX F/PTCA SEM-COM DURALYN -,SUP-85R12300S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X12MM EMPIRA 139CM RX F/PTCA SEM-COM -,SUP-85R12325S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X15MM EMPIRA 139CM RX F/PTCA SEM-COM -,SUP-85R15250S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X15MM EMPIRA 139CM RX F/PTCA SEM-COM DURALYN -,SUP-85R15300S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 3.00MM X 12MM REF: 1400300-12 -,SUP-90176431,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 4.50MM X 15MM REF: 1400450-15 -,SUP-90176448,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON TREK RX 2.75MM X 15MM REF: 1012273-15 -,SUP-90176463,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON TREK RX 3.75MM X 12MM REF: 1012277-12 -,SUP-90176465,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON TREK RX 3.75MM X 15MM REF: 1012277-15 -,SUP-90176466,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC TREK NEO 3.75MM X 15MM REF: 1400375-15 -,SUP-90176697,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH ANG 6FR 18MM 70CM 3.5CM BLN AMPLATZER SZ LUMX3 FLXB -,SUP-9-SB-018,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH ANG 24MM 7FR 70CM 4.5CM BLN AMPLATZER SZ LUMX3 FLXB -,SUP-9-SB-024,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.5X20MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2015-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 14 1.5MM X 40MM X 150CM -,SUP-A2015-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X20MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X60MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X80MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X200MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2025-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND -,SUP-A2025-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X200MM ARMADA 14 150CM LPRO F/PTA PERIPH RND -,SUP-A2025-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X20MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X60MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X80MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B ARMADA 14 PTA C 3.0 X 200M -,SUP-A2030-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X60MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X80MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X200MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X40MM NANOCROSS ELITE 150CM OTW ULTRA LO XING -,SUP-AB14W030040150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2093.7,1465.59,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X80MM NANOCROSS ELITE 150CM OTW ULTRA LO XING -,SUP-AB14W030080150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2093.7,1465.59,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
4MM X 40MM STELLAREX DCB -,SUP-AB35SX040040135,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON ATLAS PTA CATHETER 16MMX 40MM X 120CM REF: AT120164 -,SUP-AT120164,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1966.49,1376.543,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B ATLAS 12MM X 4CM X 75CM -,SUP-AT-75124,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B ATLAS 14MM X 4CM X 75CM -,SUP-AT-75144,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B ATLAS 16MM X 4CM X 75CM -,SUP-AT-75164,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1966.49,1376.543,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B ATLAS 18MM X 4CM X 75CM -,SUP-AT75184,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1966.49,1376.543,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ATLAS BALLOON 20 X 40 -,SUP-AT75204,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2276.62,1593.634,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ATLAS BALLOON 24 X 40 -,SUP-AT75244,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2910.99,2037.693,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 26MMX4CM ATLAS 75CM OTW COAX ULTRA NC PERIPH 12FR -,SUP-AT-75264,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2826.21,1978.347,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ATLAS GOLD PTA DILATATION CATHETER 120CM -,SUP-ATG120164,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1913.48,1339.436,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH ATLAS GOLD PTA DILATATION 16 X 6 X 80MM - 8 FR -,SUP-ATG80166,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1913.48,1339.436,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 35  4.0MM X 20MM X 80CM -,SUP-B1040-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 35 4.0MM X 40MM X 80CM -,SUP-B1040-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
4MM X 80MM X 80CM ARMADA 35 BALLOON -,SUP-B1040-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON ARMADA 4MM X 80MM X 80CM -,SUP-B1040-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 5MM X 20MM X 80CM -,SUP-B1050-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B ARMADA 35 5MM X 40MM X 80CM -,SUP-B1050-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5X40MM ARMADA  .035 -,SUP-B1050-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 35 5MM X 60MM X 80CM -,SUP-B1050-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B ARMADA 35 5.0 X 80 X 80 PTA CATH -,SUP-B1050-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON ARMADA 5MM X 100MM X 80CM -,SUP-B1050-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 5MM X 120MM X 80CM -,SUP-B1050-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 6MMx40MMx80CM -,SUP-B1060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 35 6MM X 40MM X 80CM -,SUP-B1060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
6MM X 60MM X 80CM ARMADA 35 BALLOON -,SUP-B1060-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 35 6.0MM X 60MM X80CM -,SUP-B1060-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
6MM X 80MM X 80CM ARMADA 35 BALLOON -,SUP-B1060-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON ARMADA 6MM X 100MM X 80CM -,SUP-B1060-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 6 X 150 X 80 -,SUP-B1060-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON 35 ARMADA 7 X 20 X 80 PTA -,SUP-B1070-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA PTA 7MM X 40MM X 80CM -,SUP-B1070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA B  35  7.0X60X80 PTA -,SUP-B1070-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 35 7MM X 60MM X 80CM -,SUP-B1070-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B ARMADA 35 7MM X 80MM X 80CM -,SUP-B1070-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 35 7 X 80MM X 80CM -,SUP-B1070-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B ARMADA 35 7.0 X 100 X 80 PTA CATH -,SUP-B1070-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON ARMADA 7MM X 150MM X 80CM -,SUP-B1070-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 35 8MM X 20MM X 80CM -,SUP-B1080-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
8mm x 40mm x 80cm Armada 35 -,SUP-B1080-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
XARMADA 35 8.0MM X 40MM X 80C -,SUP-B1080-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 35 8mmx60mmX80cm -,SUP-B1080-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B ARMADA 35 8MM X 60MM ON 80MM -,SUP-B1080-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
8MM X 80MM X 80CM ARMADA 35 BALLOON -,SUP-B1080-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 35 8.0MM X 80MM X 80CM -,SUP-B1080-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
9MM X 20MM X 80CM ARMADA 35 BALLOON -,SUP-B1090-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 35 BALLOON 9 X 40MM X 80CM -,SUP-B1090-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
10MM X 20MM X 80CM ARMADA 35 BALLOON -,SUP-B1100-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
10.0MM X 40MM X 80 ARMADA 35 BALLOON -,SUP-B1100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 35 10.0MM X 40MM X 80CM -,SUP-B1100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
10MM X 60MM X 80CM ARMADA 35 BALLOON -,SUP-B1100-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 35 10MM 60MM X 80CM -,SUP-B1100-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
12MM X 20MM X 80CM ARMADA 35 BALLOON -,SUP-B1120-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 35 12.0MM X 40MM X 80CM -,SUP-B1120-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 35 12.0MM X 60MM X 80CM -,SUP-B1120-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 35 12 X 60MM X 80CM -,SUP-B1120-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 35 14.0MM X 20MM X 80CM -,SUP-B1140-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
14MM X 40MM X 80CM ARMADA 35 BALLOON -,SUP-B1140-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 35 14MM X 60MM X 80CM -,SUP-B1140-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
4MM X 20MM X 135CM ARMADA 35 BALLOON -,SUP-B2040-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
Armada 4 x 40 x 135 Balloon -,SUP-B2040-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 4MM X 60MM X 135CM -,SUP-B2040-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 35 4X100X135 -,SUP-B2040-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
5MM X 20MM X 135CM ARMADA 35 -,SUP-B2050-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
5MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2050-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
5MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2050-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA PTA 0.035MM X 5MM X 60MM X 135CM -,SUP-B2050-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA PTA .035  5MM X 80MM X 135CM -,SUP-B2050-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
5MMX100MMX135CM ARMADA 35 -,SUP-B2050-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
5MM X 200MM X 135CM ARMADA 35 BALLOON -,SUP-B2050-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
6MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA PTA 0.035 6MM X 40MM X 135CM -,SUP-B2060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
6MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2060-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 35 6MM 80MM 135CM -,SUP-B2060-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 35 6MM 100MM 135CM -,SUP-B2060-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
6mm x 150mm x 135cm ARMADA 35 -,SUP-B2060-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
6MM X 200MM X 135CM ARMADA 35 BALLOON -,SUP-B2060-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
7MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 35  BALLOON  7.0MM X 40MM X 135CM -,SUP-B2070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B ARMADA 35  7MM X 40MM X 135CM -,SUP-B2070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
7MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2070-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 35 7MM X 100MM BALLOON -,SUP-B2070-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
7MM X 200MM X 135CM ARMADA 35 BALLOON -,SUP-B2070-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 35 8MM X 20MM X 135CM -,SUP-B2080-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 35 8MM X 40MM X 135CM -,SUP-B2080-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 35  8MM X 60MM X 135CM -,SUP-B2080-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 8MM X 80MM 35 BALLOON -,SUP-B2080-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON 9MM X 20MM X 135CM CATH ARMADA 35 -,SUP-B2090-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
9MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2090-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA PTA CATHETER 9MM X 60MM X 135CM -,SUP-B2090-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA PTA 10MM X 20MM X 135CM -,SUP-B2100-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
10MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA PTA 10MM X 40MM X 135CM -,SUP-B2100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA PTA 10MM X 60MM X 135MM -,SUP-B2100-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 35 12MM X 40MM X 135CM -,SUP-B2120-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
12MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2120-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ARMADA 35 BALLOON DIAL CATH 14X20X135 -,SUP-B2140-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
14MM X 40MM X 135CM ARMADA 35 BALOON -,SUP-B2140-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH BALLOON DIL CROSPERIO RX 0.014 X 4.0MM X 150CM 4FR -,SUP-BD-B40150LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1229.72,860.804,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH BALLOON DILATION R2P PTA 4.0MM X 150MM CROSPERIO RX -,SUP-BD-B40150LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1229.72,860.804,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CROSTELLA RX PTA DIL CATH 3MM X 8MM X 150CM -,SUP-BD-F30080LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CROSSTELLA OTW 3MM X 200MM 150CM -,SUP-BD-F30200LW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH CROSTELLA BALLOON RX PTA 4.0MM X 40MM 150CM 4FR -,SUP-BD-F40040LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH CROSTELLA BALLOON RX PTA 5.0MM X 80MM 150CM 4FR -,SUP-BD-F50080LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CROSSTELLAÂ® RX PTA Balloon Dil Cath 5mm x 150mm -,SUP-BD-F50150LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON METACROS 5MM X 150 X .030 PTCA -,SUP-BD-P50150ER,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON R2P CROSTELLA RX 2MM X 40MM X 200CM -,SUP-BD-Q20040ER,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5X120MM CHOC 120CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CB1812050120OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X40MM CHOC 150CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CF1415025040OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X120MM CHOC 150CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CF1415025120OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X120MM CHOC 150CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CF1415030120OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 10MMX4CM CONQUST 75CM OTW COAX ULTRA NC PERIPH -,SUP-CQ-75104,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 12MMX4CM CONQUST 75CM OTW COAX ULTRA NC PERIPH -,SUP-CQ-75124,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1490.45,1043.315,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6MMX2CM CONQUST 75CM OTW COAX ULTRA NC PERIPH -,SUP-CQ-7562,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B CONQUEST 6 X 4 X 75 -,SUP-CQ-7564,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B CONQUEST 7 X 4 X 75 -,SUP-CQ-7574,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B CONQUEST 8 X 4 X 75 -,SUP-CQ-7584,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH BALLOON CHOLANGIOGRAPHY -,SUP-CS-01701,CDM,C1725,HCPCS,272,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON DILATATION CATH OTW TAKERU 1.5X6MM REF:DC-PY1506UA1 -,SUP-DC-PY1506UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU OTW 1.5X12MM REF: DC-PY1512UA1 -,SUP-DC-PY1512UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON DILATATION CATH OTW TAKERU 1.5X15MM REF:DC-PY1515UA1 -,SUP-DC-PY1515UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU OTW 1.5X20MM REF: DC-PY1520UA1 -,SUP-DC-PY1520UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU OTW 2.0X8MM REF: DC-PY2008UA2 -,SUP-DC-PY2008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU OTW 2.0X12MM REF: DC-PY2012UA2 -,SUP-DC-PY2012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON DILATATION CATH OTW TAKERU 2.0X15MM REF:DC-PY2015UA2 -,SUP-DC-PY2015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON DILATATION CATH OTW TAKERU 2.0X20MM REF:DC-PY2020UA2 -,SUP-DC-PY2020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU OTW 2.25X12MM REF: DC-PY2212UA2 -,SUP-DC-PY2212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU OTW 2.25X15MM REF: DC-PY2215UA2 -,SUP-DC-PY2215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU OTW 2.25X20MM REF: DC-PY2220UA2 -,SUP-DC-PY2220UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU OTW 2.5X8MM REF: DC-PY2508UA2 -,SUP-DC-PY2508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU OTW 2.5X15MM REF: DC-PY2515UA2 -,SUP-DC-PY2515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU OTW 2.5X20MM REF: DC-PY2520UA2 -,SUP-DC-PY2520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU OTW 3.0X8MM REF: DC-PY3008UA2 -,SUP-DC-PY3008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU OTW 3.0X12MM REF: DC-PY3012UA2 -,SUP-DC-PY3012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU OTW 3.0X15MM REF: DC-PY3015UA2 -,SUP-DC-PY3015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU OTW 3.0X20MM REF: DC-PY3020UA2 -,SUP-DC-PY3020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU OTW 3.5X8MM REF: DC-PY3508UA2 -,SUP-DC-PY3508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU OTW 3.5X12MM REF: DC-PY3512UA2 -,SUP-DC-PY3512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU OTW 3.5X15MM REF: DC-PY3515UA2 -,SUP-DC-PY3515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU OTW 3.5X20MM REF: DC-PY3520UA2 -,SUP-DC-PY3520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU OTW 4.0X8MM REF: DC-PY4008UA2 -,SUP-DC-PY4008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU OTW 4.0X12MM REF: DC-PY4012UA2 -,SUP-DC-PY4012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU OTW 4.0X20MM REF: DC-PY4020UA2 -,SUP-DC-PY4020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON DILATATION CATH RX TAKERU 1.5X6MM REF:DC-RY1506UA1 -,SUP-DC-RY1506UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX 1.5X12MM REF: DC-RY1512UA1 -,SUP-DC-RY1512UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON DILATATION CATH RX TAKERU 1.5X15MM REF:DC-RY1515UA1 -,SUP-DC-RY1515UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON DILATATION CATH RX TAKERU 1.5X20MM REF:DC-RY1520UA1 -,SUP-DC-RY1520UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX 2.0X8MM REF: DC-RY2008UA2 -,SUP-DC-RY2008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX 2.0X12MM REF: DC-RY2012UA2 -,SUP-DC-RY2012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON DILATATION CATH RX TAKERU 2.0X15MM REF:DC-RY2015UA2 -,SUP-DC-RY2015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON DILATATION CATH RX TAKERU 2.0X20MM REF:DC-RY2020UA2 -,SUP-DC-RY2020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX 2.25X12MM REF: DC-RY2212UA2 -,SUP-DC-RY2212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX 2.25X15MM REF: DC-RY2215UA2 -,SUP-DC-RY2215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX 2.5X8MM REF: DC-RY2508UA2 -,SUP-DC-RY2508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX 2.5X12MM REF: DC-RY2512UA2 -,SUP-DC-RY2512UA,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX 2.5X15MM REF: DC-RY2515UA2 -,SUP-DC-RY2515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX 2.5X20MM REF: DC-RY2520UA2 -,SUP-DC-RY2520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX 3.0X8MM REF: DC-RY3008UA2 -,SUP-DC-RY3008UA,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX 3.0X12MM REF: DC-RY3012UA2 -,SUP-DC-RY3012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX 3.0X15MM REF: DC-RY3015UA2 -,SUP-DC-RY3015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX 3.0X20MM REF: DC-RY3020UA2 -,SUP-DC-RY3020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX 3.5X8MM REF: DC-RY3508UA2 -,SUP-DC-RY3508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX 3.5X12MM REF: DC-RY3512UA2 -,SUP-DC-RY3512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX 3.5X15MM REF: DC-RY3515UA2 -,SUP-DC-RY3515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX 3.5X20MM REF: DC-RY3520UA2 -,SUP-DC-RY3520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX 4.0X8MM REF: DC-RY4008UA2 -,SUP-DC-RY4008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX 4.0X12MM REF: DC-RY4012UA2 -,SUP-DC-RY4012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX 4.0X15MM REF: DC-RY4015UA2 -,SUP-DC-RY4015UA,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX 4.0X20MM REF: DC-RY4020UA2 -,SUP-DC-RY4020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX NC 2.0X8MM REF: DC-RZ2008UA2 -,SUP-DC-RZ2008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX NC 2.0X12MM REF: DC-RZ2012UA2 -,SUP-DC-RZ2012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX NC 2.0X15MM REF: DC-RZ2015UA2 -,SUP-DC-RZ2015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX NC 2.0X21MM REF: DC-RZ2021UA2 -,SUP-DC-RZ2021UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX NC 2.25X8MM REF: DC-RZ2208UA2 -,SUP-DC-RZ2208UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX NC 2.25X12MM REF: DC-RZ2212UA2 -,SUP-DC-RZ2212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX NC 2.25X15MM REF: DC-RZ2215UA2 -,SUP-DC-RZ2215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX NC 2.25X21MM REF: DC-RZ2221UA2 -,SUP-DC-RZ2221UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX NC 2.5X8MM REF: DC-RZ2508UA2 -,SUP-DC-RZ2508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX NC 2.5X12MM REF: DC-RZ2512UA2 -,SUP-DC-RZ2512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX NC 2.5X15MM REF: DC-RZ2515UA2 -,SUP-DC-RZ2515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX NC 2.5X21MM REF: DC-RZ2521UA2 -,SUP-DC-RZ2521UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX NC 2.75X8MM REF: DC-RZ2708UA2 -,SUP-DC-RZ2708UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX NC 2.75X12MM REF: DC-RZ2712UA2 -,SUP-DC-RZ2712UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX NC 2.75X15MM REF: DC-RZ2715UA2 -,SUP-DC-RZ2715UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX NC 2.75X21MM REF: DC-RZ2721UA2 -,SUP-DC-RZ2721UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX NC 3.0X8MM REF: DC-RZ3008UA2 -,SUP-DC-RZ3008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX NC 3.0X12MM REF: DC-RZ3012UA2 -,SUP-DC-RZ3012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX NC 3.0X15MM REF: DC-RZ3015UA2 -,SUP-DC-RZ3015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX NC 3.0X21MM REF: DC-RZ3021UA2 -,SUP-DC-RZ3021UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX NC 3.25X8MM REF: DC-RZ3208UA2 -,SUP-DC-RZ3208UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX NC 3.25X12MM REF: DC-RZ3212UA2 -,SUP-DC-RZ3212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX NC 3.25X15MM REF: DC-RZ3215UA2 -,SUP-DC-RZ3215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX NC 3.25X21MM REF: DC-RZ3221UA2 -,SUP-DC-RZ3221UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX NC 3.5X08MM REF: DC-RZ3508UA2 -,SUP-DC-RZ3508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX NC 3.5X12MM REF: DC-RZ3512UA2 -,SUP-DC-RZ3512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX NC 3.5X15MM REF: DC-RZ3515UA2 -,SUP-DC-RZ3515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX NC 3.5X21MM REF: DC-RZ3521UA2 -,SUP-DC-RZ3521UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX NC 4.0X8MM REF: DC-RZ4008UA2 -,SUP-DC-RZ4008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX NC 4.0X12MM REF: DC-RZ4012UA2 -,SUP-DC-RZ4012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX NC 4.0X15MM REF: DC-RZ4015UA2 -,SUP-DC-RZ4015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU RX NC 4.0X21MM REF: DC-RZ4021UA2 -,SUP-DC-RZ4021UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATH TAKERU OTW 2.5X12MM REF: DC-PY2512UA2 -,SUP-D-PY2512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4MMX2CM DORADO 40CM OTW F/PTA ULTRA NC PERIPH 5FR -,SUP-DR4042,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1335.73,935.011,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 7MMX6CM DORADO 80CM OTW F/PTA ULTRA NC PERIPH 6FR -,SUP-DR8076,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1335.73,935.011,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP1506X EUPHORA RX -,SUP-EUP1506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP1512X EUPHORA RX -,SUP-EUP1512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP1515X EUPHORA RX -,SUP-EUP1515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP1520X EUPHORA RX -,SUP-EUP1520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP2006X EUPHORA RX -,SUP-EUP2006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP2010X EUPHORA RX -,SUP-EUP2010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP2012X EUPHORA RX -,SUP-EUP2012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP2015X EUPHORA RX -,SUP-EUP2015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP2020X EUPHORA RX -,SUP-EUP2020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP2025X EUPHORA RX -,SUP-EUP2025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP2030X EUPHORA RX -,SUP-EUP2030X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP22506X EUPHORA RX -,SUP-EUP22506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP22510X EUPHORA RX -,SUP-EUP22510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP22512X EUPHORA RX -,SUP-EUP22512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP22515X EUPHORA RX -,SUP-EUP22515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP22520X EUPHORA RX -,SUP-EUP22520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP22525X EUPHORA RX -,SUP-EUP22525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP2506X EUPHORA RX -,SUP-EUP2506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP2510X EUPHORA RX -,SUP-EUP2510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP2512X EUPHORA RX -,SUP-EUP2512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP2515X EUPHORA RX -,SUP-EUP2515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP2520X EUPHORA RX -,SUP-EUP2520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP2525X EUPHORA RX -,SUP-EUP2525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP2530X EUPHORA RX -,SUP-EUP2530X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP27506X EUPHORA RX -,SUP-EUP27506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP27510X EUPHORA RX -,SUP-EUP27510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP27512X EUPHORA RX -,SUP-EUP27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP27515X EUPHORA RX -,SUP-EUP27515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP27520X EUPHORA RX -,SUP-EUP27520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP27525X EUPHORA RX -,SUP-EUP27525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP3006X EUPHORA RX -,SUP-EUP3006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP3010X EUPHORA RX -,SUP-EUP3010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP3012X EUPHORA RX -,SUP-EUP3012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP3015X EUPHORA RX -,SUP-EUP3015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP3020X EUPHORA RX -,SUP-EUP3020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP3025X EUPHORA RX -,SUP-EUP3025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP3030X EUPHORA RX -,SUP-EUP3030X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP32506X EUPHORA RX -,SUP-EUP32506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP32510X EUPHORA RX -,SUP-EUP32510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP32512X EUPHORA RX -,SUP-EUP32512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP32515X EUPHORA RX -,SUP-EUP32515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP32520X EUPHORA RX -,SUP-EUP32520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP32525X EUPHORA RX -,SUP-EUP32525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP3506X EUPHORA RX -,SUP-EUP3506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP3510X EUPHORA RX -,SUP-EUP3510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP3512X EUPHORA RX -,SUP-EUP3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP3515X EUPHORA RX -,SUP-EUP3515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP3520X EUPHORA RX -,SUP-EUP3520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP3525X EUPHORA RX -,SUP-EUP3525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP3530X EUPHORA RX -,SUP-EUP3530X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP37506X EUPHORA RX -,SUP-EUP37506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP37510X EUPHORA RX -,SUP-EUP37510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP37512X EUPHORA RX -,SUP-EUP37512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP37515X EUPHORA RX -,SUP-EUP37515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP37520X EUPHORA RX -,SUP-EUP37520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP37525X EUPHORA RX -,SUP-EUP37525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP4006X EUPHORA RX -,SUP-EUP4006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP4010X EUPHORA RX -,SUP-EUP4010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP4012X EUPHORA RX -,SUP-EUP4012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP4015X EUPHORA RX -,SUP-EUP4015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP4020X EUPHORA RX -,SUP-EUP4020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP4025X EUPHORA RX -,SUP-EUP4025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EUP4030X EUPHORA RX -,SUP-EUP4030X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH BLNOCC 9FRX120CM CODA -,SUP-G03831,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2702.08,1891.456,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.5MMX4CM ADVANCE MICRO 14 150CM OTW UL-LPRO F/PTA -,SUP-G26614,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2289.76,1602.832,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2MMX12CM ADVANCE MICRO 14 150CM OTW UL-LPRO F/PTA -,SUP-G26641,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2289.76,1602.832,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6MMX2CM ADVANCE ATB 80CM OTW F/PTA MIN-CMPLNT -,SUP-G26895,CDM,C1725,HCPCS,272,RC,,,outpatient,,,705.98,494.186,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH DIL 4MMX12CM ADVANCE 18 LP 150CM LPRO F/PTA 4FR SHTH -,SUP-G30949,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30952,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5MMX15CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30955,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B 18LP ADVANCE 5MM X 15CM -,SUP-G30956,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ANGIOPLASTY 5 - 15 PTA -,SUP-G30956,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ANGIOPLASTY / PTA4-18-150-5-20 -,SUP-G30958,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30958,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH DIL 6MMX12CM ADVANCE 18 LP 150CM LPRO F/PTA 5FR SHTH -,SUP-G30961,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ANGIOPLASTY 6 - 15 PTA -,SUP-G30962,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30964,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 7MMX12CM ADVANCE 18 LP 150CM LPRO F/PTA 5FR SHTH -,SUP-G30967,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 7MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30970,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3MMX4CM ADVANCE 18LP 150CM LPRO F/PTA -,SUP-G34319,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
3X6X150 PTA ADVANCE CATH -,SUP-G34320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3MMX8CM ADVANCE 18LP -,SUP-G34321,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON ADVANCE .018 3MM X 10CM X 150CM -,SUP-G34322,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G34331,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G34336,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5MMX6CM ADVANCE 35LP 135CM LPRO PERIPH D-SHP -,SUP-G35532,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATHETER ADVANCED LOW PROFILE BALLOON 6MM X 20MM X 135CM -,SUP-G35536,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 7MMX20CM ADVANCE 35LP 135CM LPRO F/PTA -,SUP-G35540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 10MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G35546,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH ANG 5FRX80CM ADVANCE LPRO -,SUP-G35547,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
GW ENDO 0.035INX260CM ACROBAT CLBRT TIP -,SUP-G47614,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1038.63,727.041,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G49479,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50216,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50218,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50222,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50224,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5MMX10CM ADVANCE 18LP 135CM LUMX2 -,SUP-G50226,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4MMX4CM ADVANCE 18LP - USE 0141543 DISC. -,SUP-G50228,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50230,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50235,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50237,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50239,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50241,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 -,SUP-G50243,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50245,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50247,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50249,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50251,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50253,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 7MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50257,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 7MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50262,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 7MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50264,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2MMX2CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50313,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50314,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2MMX6CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50315,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50316,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50317,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50318,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50319,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50321,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1836.57,1285.599,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5MMX6CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50322,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50323,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50324,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50325,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ADVANCE 14 LP BALLOON CATHETER -,SUP-G50327,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50328,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3MMX4CM ADVANCE 14LP 60MM LPRO LUMX2 F/PTA SEM-COM -,SUP-G50329,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50330,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50332,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50333,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4MMX2CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50334,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50335,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4MMX6CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50336,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50337,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50338,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50339,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50340,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52251,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52253,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52254,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52257,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52258,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5MMX6CM ADVANCE 35LP 135CM LPRO PERIPH -,SUP-G52259,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52260,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52261,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5MMX14CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52263,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52265,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52266,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52267,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52268,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6MMX14CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 7MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52271,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 7MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52272,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 7MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52273,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 7MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52274,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 7MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52275,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 7MMX14CM ADVANCE 35LP 135CM LPRO F/PTA -,SUP-G52277,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 8MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52278,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 8MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52279,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 8MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52280,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 8MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52282,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 9MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52286,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 9MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52287,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 10MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52293,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 10MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52294,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 12MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52299,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 12MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
US PRE PP-CA-422 DIR BALLOON CATHER T3 20-23 -,SUP-G57885,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATHETER US PRE PP-CA-422 DIR BALLOON T3 20-23 -,SUP-G57887,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ADVANCE SERENITY 14 150-20-220 -,SUP-G57889,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATHETER BALLOON DILATATION ADVANCE SERENITY 14 2.5MM X10CM -,SUP-G57894,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CATHETER T3 20-23 -,SUP-G57896,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
DIRECT BALLOON CATHETERS T2 23-26 -,SUP-G57897,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATHETER US PRE PP-CA-422 DIR BALLOON  T3 20-23 -,SUP-G57900,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ADVANCE SERENITY 14 HYDROPHILIC PTA BALLOON DILA CATH 3 X 10 -,SUP-G57901,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ADVANCE SERENITY 14 HYDROPHILIC PTA BALLOON DILA CATH 3 X 22 -,SUP-G57903,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
US PRE PP-CA-422 DIR BALLOON CATHETER T3 20-23 150-40-20 -,SUP-G57911,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ADVANCE SERENITY 14 4MM x 100MM x 150CM -,SUP-G57915,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATHETER BALLOON DIR SERENITY 14 4MM X 15CM 150CM -,SUP-G57916,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATHETER US PRE PP-CA-422 DIR BALLOON  T3 20-23 -,SUP-G57917,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PIG 0.045IN 5FR PIG 125CM EXPO -,SUP-H749085262151,CDM,C1725,HCPCS,272,RC,,,outpatient,,,87.53,61.271,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.5X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP 0.014IN -,SUP-H7493895808200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.75X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP 0.014IN -,SUP-H7493895808300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP 0.014IN -,SUP-H7493895808400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.5X12MM APEX FLX UL-LPRO NC -,SUP-H7493895812150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.75X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.75X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.5X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.75X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.75X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.5X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.75X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.75X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X30MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895830250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,991.95,694.365,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.5X8MM APEX FLEX MONORAIL RX UL-LPRO NC -,SUP-H7493895908150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.75X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.5X12MM APEX FLEX MONORAIL RX UL-LPRO -,SUP-H7493895912150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.75X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.75X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.5X15MM APEX FLEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.75X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.75X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.5X20MM APEX FLEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.75X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.75X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B APEX MR  30MM X 2.50 MONORAIL RX -,SUP-H7493895930250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.0X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.5X8MM APEX OTW UL-LPRO F/PTCA OPTILEAP -,SUP-H7493896008150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.5X12MM APEX MONORAIL OTW UL-LPRO PSH -,SUP-H7493896012150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.5X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493896015150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.5X20MM APEX OTW UL-LPRO F/PTCA OPTILEAP -,SUP-H7493896020150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.5X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493896108150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.5X12MM APEX MONORAIL RX UL-LPRO PSH -,SUP-H7493896112150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.5X15MM APEX MONORAIL RX UL-LPRO -,SUP-H7493896115150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.5X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493896120150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
STERLING MONORAIL RAPID EXCHANGE 3 X 60 -,SUP-H74939031306010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON FG STERLING MR 4.5MM X 20MM X 135CM 4FR -,SUP-H74939031452010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2014.19,1409.933,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
STERLING MONORAIL .018 5X20X80CM 4F -,SUP-H74939031502080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6X20MM STERLNG MONORAIL 135CM RX LPRO COAX SEM-COM -,SUP-H74939031602010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH BALLOON STERLING 7.0MM X 40MM X 80CM 4FR FG MONORL -,SUP-H74939031704080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B STERLING OTW 10.0 X 60 135 -,SUP-H74939032106010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B STERLING OTW 10.0 X 80 135 -,SUP-H74939032108010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B STERLING OTW 4 X 10 X 135 39 -,SUP-H74939032401010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X220MM STERLNG 150CM OTW COAX SEM-COM PERIPH TAPR -,SUP-H74939032402210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B STERLING OTW 4.0 X 30 135 -,SUP-H74939032403010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B STERLING OTW 4 X 40 X 135 MA -,SUP-H74939032404010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B STERLING OTW 4.0 X 60 135 -,SUP-H74939032406010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1669.29,1168.503,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B STERLING OTW 4.0 X 80 135 -,SUP-H74939032408010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1669.29,1168.503,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B STERLING OTW 5 X 10 X 135 39 -,SUP-H74939032501010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B STERLING OTW 5.0 X 120 150 -,SUP-H74939032501210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B STERLING OTW 5.0 X 150 150 -,SUP-H74939032501510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B STERLING OTW 5.0 X 200 150 -,SUP-H74939032502110,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B STERLING OTW 5.0 X 220 150 -,SUP-H74939032502210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B STERLING OTW 5.0 X 30 135 -,SUP-H74939032503010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B STERLING OTW 5 X 4 X 135 390 -,SUP-H74939032504010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B STERLING OTW 5.0 X 60 135 -,SUP-H74939032506010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B STERLING OTW 5.0 X 80 135 -,SUP-H74939032508010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B STERLING OTW 6 X 10 X 135 39 -,SUP-H74939032601010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6X120MM 150CM -,SUP-H74939032601210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B STERLING OTW 6.0 X 150 150 -,SUP-H74939032601510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B STERLING OTW 6.0 X 200 150 -,SUP-H74939032602110,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B STERLING OTW 6.0 X 220 150 -,SUP-H7493903260221,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B STERLING OTW 6.0X30X135 -,SUP-H74939032603010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B STERLING OTW 6 X 4 X 135 390 -,SUP-H74939032604010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B STERLING OTW 6.0 X 80 135 -,SUP-H74939032608010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B STERLING OTW 7.0 X 100 135 -,SUP-H74939032701010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B STERLING OTW 7.0 X 120 150 -,SUP-H74939032701210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B STERLING OTW 7.0 X 150 150 -,SUP-H74939032701510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B STERLING OTW 7.0 X 200 150 -,SUP-H74939032702110,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B STERLING OTW 7.0 X 220 150 -,SUP-H74939032702210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B STERLING OTW 7.0 X 30 135 -,SUP-H74939032703010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B STERLING OTW 7.0 X 40 135 -,SUP-H74939032704010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B STERLING OTW 7.0 X 60 135 -,SUP-H74939032706010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B STERLING OTW 7.0 X 80 135 -,SUP-H74939032708010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B STERLING OTW 8.0 X 30 135 -,SUP-H74939032803010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B STERLING OTW 8.0 X 40 135 -,SUP-H74939032804010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B STERLING OTW 8.0 X 60 135 -,SUP-H74939032806010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B STERLING OTW 8.0 X 80 135 -,SUP-H74939032808010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B STERLING OTW 9.0 X 60 135 -,SUP-H74939032906010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B STERLING OTW 9.0 X 80 135 -,SUP-H74939032908010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.75X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.75X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4.5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912412200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.75X12MM NC QUANTM APEX MONORAIL UL-LPRO NC -,SUP-H7493912412270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X12MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912412320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.75X12MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912412370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X12MM NC QUANTM APEX MONORAIL RX UL -LPRO NC -,SUP-H7493912412400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4.5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912412450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912412500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.75X15MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912415270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X15MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912415320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.75X15MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912415370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4.5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912420200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.75X20MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912420270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X20MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912420320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.75X20MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912420370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4.5X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912420450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5 X 20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912430200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.75X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4732.06,3312.442,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.75X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.75X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.75X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4732.06,3312.442,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4.5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.75X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.75X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4.5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.75X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.75X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4.5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.75X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.75X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4.5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.75X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.75X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X40MM COYOTE ES MONORAIL 145CM RX SEM-COM PERIPH -,SUP-H74939134204010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON COYOTE 2.5MM X 40MM X 145CM  .014 -,SUP-H74939134254010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X20MM COYOTE ES 143CM OTW UL-LPRO SEM-COM PERIPH -,SUP-H74939134302010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X30MM COYOTE ES 144MM OTW UL-LPRO SEM-COM PERIPH -,SUP-H74939134303010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X40MM COYOTE ES 145CM OTW UL-LPRO SEM-COM PERIPH -,SUP-H74939134404010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.5X20MM COYOTE ES MONORAIL 143CM RX SEM-COM -,SUP-H74939135152010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X20MM COYOTE ES MONORAIL 143CM RX SEM-COM PERIPH -,SUP-H74939135202010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X20MM COYOTE ES MONORAIL 144CM RX SEM-COM PERIPH -,SUP-H74939135302010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X30MM COYOTE ES MONORAIL 145CM RX SEM-COM PERIPH -,SUP-H74939135303010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X40MM COYOTE ES MONORAIL 146CM RX SEM-COM PERIPH -,SUP-H74939135304010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X20MM COYOTE ES MONORAIL 144CM RX SEM-COM -,SUP-H74939135352010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X30MM COYOTE ES MONORAIL 145CM RX SEM-COM -,SUP-H74939135353010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X20MM COYOTE ES MONORAIL 144CM RX SEM-COM PERIPH -,SUP-H74939135402010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X30MM COYOTE ES MONORAIL 145CM RX SEM-COM PERIPH -,SUP-H74939135403010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X40MM COYOTE ES MONORAIL 146CM RX SEM-COM PERIPH -,SUP-H74939135404010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X100MM STERLNG SL 150CM OTW COAX SEM-COM PERIPH -,SUP-H74939148401510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 3.0 X 20 135CM -,SUP-H74939171030210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171030270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 3.0 X 40 135CM -,SUP-H74939171030410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
3MM X 40MM X 40CM MUSTANG -,SUP-H74939171030440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171030470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 3.0 X 60 135CM -,SUP-H74939171030610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
MUSTANG 3 X 60 X 75 -,SUP-H74939171030670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 3.0 X 80 135CM -,SUP-H74939171030810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 3.0 X 100 135C -,SUP-H74939171031010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 3.0 X 120 135C -,SUP-H74939171031210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 3.0 X 150 135C -,SUP-H74939171031510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 3.0 X 180 135C -,SUP-H74939171031810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 3.0 200 135CM -,SUP-H74939171032010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 4.0 X 20 135CM -,SUP-H74939171040210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171040270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 4.0 X 40 135CM -,SUP-H74939171040410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
MUSTANG 4MM X 40MM X 40CM -,SUP-H74939171040440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171040470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 4.0 X 60 135CM -,SUP-H74939171040610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171040670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 4.0 X 80 135CM -,SUP-H74939171040810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
MUSTANG 4MM X 80MM X 40CM -,SUP-H74939171040840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 4.0 X 100 135C -,SUP-H74939171041010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171041070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 4.0 X 120 135C -,SUP-H74939171041210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 4.0 X 150 135C -,SUP-H74939171041510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 4.0 X 180 135C -,SUP-H74939171041810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 4.0X200 135CM -,SUP-H74939171042010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 5.0 X 20 135CM -,SUP-H74939171050210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5X30MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 5.0 X 40 135CM -,SUP-H74939171050410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
MUSTANG 5MM X 40MM X 40 CM -,SUP-H74939171050440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 5.0 X 60 135CM -,SUP-H74939171050610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 5.0 X 80 135CM -,SUP-H74939171050810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
MUSTANG 5MM X 80MM X 40CM -,SUP-H74939171050840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 5.0 X 100 135C -,SUP-H74939171051010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171051070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 5.0 X 120 135C -,SUP-H74939171051210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 5.0 X 150 135C -,SUP-H74939171051510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 5.0 180 135CM -,SUP-H74939171051810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 5.0 200 135CM -,SUP-H74939171052010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 6.0 X 20 135CM -,SUP-H74939171060210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 6.0 X 40 135CM -,SUP-H74939171060410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6X40MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1079.48,755.636,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
MUSTANG 6MM X 40MM X 40CM -,SUP-H74939171060440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 6.0 X 60 135CM -,SUP-H74939171060610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 6.0 X 80 135CM -,SUP-H74939171060810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
6MM X 80MM X 40CM MUSTANG PTA -,SUP-H74939171060840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
MUSTANG 6MM X 80MM X 40CM -,SUP-H74939171060840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 6.0 X 100 135C -,SUP-H74939171061010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 6.0 X 120 135C -,SUP-H74939171061210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6X150MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171061510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6X150MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171061570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 6.0 180 135CM -,SUP-H74939171061810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6X200MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171062010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 7.0 X 20 135CM -,SUP-H74939171070210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 7X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 7.0 X 40 135cm -,SUP-H74939171070410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
7MM X 40MM X 40CM MUSTANG -,SUP-H74939171070440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 7X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 7.0 X 60 135CM -,SUP-H74939171070610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 7X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 7X80MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 7X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 7.0 X 100 135C -,SUP-H74939171071010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 7X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171071070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 7.0 X 120 135C -,SUP-H74939171071210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 7X150MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171071510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 7X150MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171071570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 7.0 180 135CM -,SUP-H74939171071810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 7X200MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171072010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 7X200MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171072070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 8.0 X 20 135CM -,SUP-H74939171080210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 8X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171080270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 8.0 X 40 135CM -,SUP-H74939171080410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
8MM X 40MM X 40CM MUSTANG -,SUP-H74939171080440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON MUSTANG 7.0MM X 80MM X 40CM -,SUP-H74939171080440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON MUSTANG 8MM X 40MM X 40CM -,SUP-H74939171080440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 8X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171080470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 8.0 X 60 135CM -,SUP-H74939171080610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 8.0 X 80 135CM -,SUP-H74939171080810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
8MM X 80MM X 40CM MUSTANG PTA -,SUP-H74939171080840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 8X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171080870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 8.0 X 100 135C -,SUP-H74939171081010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 8X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171081070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 8.0 X 120 135C -,SUP-H74939171081210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 8X150MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171081570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 8.0 180 135CM -,SUP-H74939171081810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 8X200MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171082010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 8X200MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171082070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 9.0 X 20 135CM -,SUP-H74939171090210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 9X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 9.0 X 40 135CM -,SUP-H74939171090410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 9X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 9X60MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 9X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 9.0 X 80 135CM -,SUP-H74939171090810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 9X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 10.0 X 20 135C -,SUP-H74939171100210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 10X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 10.0X40 135CM -,SUP-H74939171100410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
MUSTANG BALLOON 10MM X 40MM X 40CM -,SUP-H74939171100440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 10X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 10.0 X 60 135C -,SUP-H74939171100610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 10X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 10.0 X 80 135C -,SUP-H74939171100810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
MUSTANG 10MM X 80MM X 40CM -,SUP-H74939171100840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 10X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 12.0X20 135CM -,SUP-H74939171120210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 12X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171120270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 12.0X40 135CM -,SUP-H74939171120410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 12X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171120470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 12X60MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171120610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 12X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171120670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 12.0 X 80 135C -,SUP-H74939171120810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B MUSTANG PTA 12MM X 80MM 40CM -,SUP-H74939171120840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B CATH COYOTE OTW 1.5X40X150 -,SUP-H74939186150410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B CATH COYOTE OTW 2X60X150 -,SUP-H74939186200610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B CATH COYOTE OTW 2X80X150 -,SUP-H74939186200810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B CATH COYOTE OTW 2X100X150 -,SUP-H74939186201010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B CATH COYOTE OTW 2X120X150 -,SUP-H74939186201210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B CATH COYOTE OTW 2X220X150 -,SUP-H74939186202210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
COYOTE 2 X 220 -,SUP-H74939186202290,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B CATH COYOTE OTW 2.5X60X150 -,SUP-H74939186250610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B CATH COYOTE OTW 2.5X80X150 -,SUP-H74939186250810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B CATH COYOTE OW 2.5X100X150 -,SUP-H74939186251010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B CATH COYOTE OW 2.5X120X150 -,SUP-H74939186251210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B CATH COYOTE OW 2.5X220X150 -,SUP-H74939186252210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B CATH COYOTE OTW 3X60X150 -,SUP-H74939186300610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B CATH COYOTE OTW 3X80X150 -,SUP-H74939186300810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B CATH COYOTE OTW 3X100X150 -,SUP-H74939186301010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B CATH COYOTE OTW 3X120X150 -,SUP-H74939186301210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B CATH COYOTE OTW 3X150X150 -,SUP-H74939186301510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B CATH COYOTE OTW 3X220X150 -,SUP-H74939186302210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B CATH COYOTE OTW 3.5X60X150 -,SUP-H74939186350610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B CATH COYOTE OTW 3.5X80X150 -,SUP-H7493918635081,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1637.85,1146.495,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B CATH COYOTE OW 3.5X100X150 -,SUP-H74939186351010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B CATH COYOTE OW 3.5X120X150 -,SUP-H74939186351210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B CATH COYOTE OW 3.5X150X150 -,SUP-H74939186351510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B CATH COYOTE OW 3.5X220X150 -,SUP-H74939186352210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B CATH COYOTE OTW 4X60X150 -,SUP-H74939186400610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B CATH COYOTE OTW 4X80X150 -,SUP-H74939186400810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B CATH COYOTE OTW 4X100X150 -,SUP-H74939186401010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1637.85,1146.495,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B CATH COYOTE OTW 4X120X150 -,SUP-H74939186401210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1637.85,1146.495,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B CATH COYOTE OTW 4X150X150 -,SUP-H74939186401510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B CATH COYOTE OTW 4X220X150 -,SUP-H74939186402210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 1.20MM X 8MM -,SUP-H7493918908120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 1.50MM X 8MM -,SUP-H7493918908150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 2.00 MM X 8MM -,SUP-H7493918908200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 2.50 MM X 8MM -,SUP-H7493918908250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 2.75 MM X 8MM -,SUP-H7493918908270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 3.00 MM X 8MM -,SUP-H7493918908300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 3.25 MM X 8MM -,SUP-H7493918908320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 3.50 MM X 8MM -,SUP-H7493918908350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 3.75 MM X 8MM -,SUP-H7493918908370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 4.00MM X 8MM -,SUP-H7493918908400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 1.20MM X 12MM -,SUP-H7493918912120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 1.50MM X 12MM -,SUP-H7493918912150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 2.00 MM X 12 MM -,SUP-H7493918912200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 2.25 MM X 12MM -,SUP-H7493918912220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 2.50 MM X 12 MM -,SUP-H7493918912250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 2.75 MM X 12MM -,SUP-H7493918912270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 3.00 MM X 12MM -,SUP-H7493918912300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 3.25 MM X 12MM -,SUP-H7493918912320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 3.50 MM X 12MM -,SUP-H7493918912350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 3.75 MM X 12MM -,SUP-H7493918912370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 4.00MM X 12MM -,SUP-H7493918912400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 1.20MM X 15MM -,SUP-H7493918915120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 1.50MM X 15MM -,SUP-H7493918915150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 2.00 MM X 15 MM -,SUP-H7493918915200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 2.25 MM X 15MM -,SUP-H7493918915220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 2.50 MM X 15MM -,SUP-H7493918915250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 2.75 MM X 15MM -,SUP-H7493918915270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 3.00 MM X 15MM -,SUP-H7493918915300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 3.25 MM X 15MM -,SUP-H7493918915320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 3.50 MM X 15MM -,SUP-H7493918915350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 3.75 MM X 15MM -,SUP-H7493918915370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 4.00MM X 15MM -,SUP-H7493918915400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 1.20MM X 20MM -,SUP-H7493918920120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 1.50MM X 20MM -,SUP-H7493918920150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 2.00 MM X 20 MM -,SUP-H7493918920200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 2.25 MM X 20MM -,SUP-H7493918920220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 2.50 MM X 20 MM -,SUP-H7493918920250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 2.75 MM X 20MM -,SUP-H7493918920270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 3.00 MM X 20 MM -,SUP-H7493918920300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 3.25 MM X 20MM -,SUP-H7493918920320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 3.50 MM X 20MM -,SUP-H7493918920350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 3.75 MM X 20MM -,SUP-H7493918920370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 4.00MM X 20MM -,SUP-H7493918920400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 2.00 MM X 30MM -,SUP-H7493918930200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 2.25 MM X 30MM -,SUP-H7493918930220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 2.50 MM X 30MM -,SUP-H7493918930250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 2.75 MM X 30MM -,SUP-H7493918930270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 3.00 MM X 30MM -,SUP-H7493918930300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 3.25 MM X 30MM -,SUP-H7493918930320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 3.50 MM X 30MM -,SUP-H7493918930350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 3.75 MM X 30MM -,SUP-H7493918930370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE MR 4.00MM X 30MM -,SUP-H7493918930400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE PUSH MR 1.20MM X 8MM -,SUP-H7493919008120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE PUSH MR 1.50MM X 8MM -,SUP-H7493919008150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE PUSH MR 1.20MM X 12MM -,SUP-H7493919012120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE PUSH MR 1.50MM X 12MM -,SUP-H7493919012150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE PUSH MR 1.20MM X 15MM -,SUP-H7493919015120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE PUSH MR 1.50MM X 15MM -,SUP-H7493919015150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE PUSH MR 1.20MM X 20MM -,SUP-H7493919020120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE PUSH MR 1.50MM X 20MM -,SUP-H7493919020150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 1.20MM X 8MM -,SUP-H7493919108120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 1.50MM X 8MM -,SUP-H7493919108150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 2.00MM X 8MM -,SUP-H7493919108200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 2.25MM X 8MM -,SUP-H7493919108220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 2.50MM X 8MM -,SUP-H7493919108250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 2.75MM X 8MM -,SUP-H7493919108270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 3.00MM X 8MM -,SUP-H7493919108300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 3.25MM X 8MM -,SUP-H7493919108320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 3.50MM X 8MM -,SUP-H7493919108350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 3.75MM X 8MM -,SUP-H7493919108370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 4.00MM X 8MM -,SUP-H7493919108400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 1.20MM X 12MM -,SUP-H7493919112120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 1.50MM X 12MM -,SUP-H7493919112150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 2.00MM X 12MM -,SUP-H7493919112200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 2.25MM X 12MM -,SUP-H7493919112220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 2.50MM X 12MM -,SUP-H7493919112250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 2.75MM X 12MM -,SUP-H7493919112270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 3.00MM X 12MM -,SUP-H7493919112300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 3.25MM X 12MM -,SUP-H7493919112320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 3.50MM X 12MM -,SUP-H7493919112350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 3.75MM X 12MM -,SUP-H7493919112370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 4.00MM X 12MM -,SUP-H7493919112400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 1.20MM X 15MM -,SUP-H7493919115120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 1.50MM X 15MM -,SUP-H7493919115150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 2.00MM X 15MM -,SUP-H7493919115200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 2.25MM X 15MM -,SUP-H7493919115220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 2.50MM X 15MM -,SUP-H7493919115250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 2.75MM X 15MM -,SUP-H7493919115270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 3.00MM X 15MM -,SUP-H7493919115300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 3.25MM X 15MM -,SUP-H7493919115320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 3.50MM X 15MM -,SUP-H7493919115350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 3.75MM X 15MM -,SUP-H7493919115370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 4.00MM X 15MM -,SUP-H7493919115400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 1.20MM X 20MM -,SUP-H7493919120120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 1.50MM X 20MM -,SUP-H7493919120150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 2.25MM X 20MM -,SUP-H7493919120220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 2.50MM X 20MM -,SUP-H7493919120250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 2.75MM X 20MM -,SUP-H7493919120270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 3.00MM X 20MM -,SUP-H7493919120300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 3.25MM X 20MM -,SUP-H7493919120320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 3.50MM X 20MM -,SUP-H7493919120350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 3.75MM X 20MM -,SUP-H7493919120370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 4.00MM X 20MM -,SUP-H7493919120400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 2.00MM X 30MM -,SUP-H7493919130200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 2.00MM X 20MM -,SUP-H7493919130200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 2.25MM X 30MM -,SUP-H7493919130220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 2.50MM X 30MM -,SUP-H7493919130250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 2.75MM X 30MM -,SUP-H7493919130270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 3.00MM X 30MM -,SUP-H7493919130300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 3.25MM X 30MM -,SUP-H7493919130320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 3.50MM X 30MM -,SUP-H7493919130350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 3.75MM X 30MM -,SUP-H7493919130370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE OTW 4.00MM X 30MM -,SUP-H7493919130400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE PUSH OTW 1.20MM X 8MM -,SUP-H7493919208120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE PUSH OTW 1.50MM X 8MM -,SUP-H7493919208150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE PUSH OTW 1.20MM X 12MM -,SUP-H7493919212120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE PUSH OTW 1.50MM X 12MM -,SUP-H7493919212150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE PUSH OTW 1.20MM X 15MM -,SUP-H7493919215120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE PUSH OTW 1.50MM X 15MM -,SUP-H7493919215150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE PUSH OTW 1.20MM X 20MM -,SUP-H7493919220120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON EMERGE PUSH OTW 1.50MM X 20MM -,SUP-H7493919220150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CHARGER BALLOON 3 X 20 X 135 -,SUP-H74939206030210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CHARGER BALLOON 3 X 20 X 75 -,SUP-H74939206030270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CHARGER BALLOON 3MM X 40MM X 130CM -,SUP-H74939206030410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CHARGER BALLOON 3MM X 80MM X 135CM -,SUP-H74939206030810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
3MM X 100MM X 135CM CHARGER -,SUP-H74939206031010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CHARGER 3MM X 120MM -,SUP-H74939206031210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
3.0MM X 150MM X 135CM CHARGER BALLOON -,SUP-H74939206031510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CHARGER 3MM X 200MM X 135CM -,SUP-H74939206032010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CHARGER OTW 4 X 20MM X135CM BALLOON -,SUP-H74939206040210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
4MM X 20MM X 75CM CHARGER BALLOON -,SUP-H74939206040270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
PTA BALLOON 5F -,SUP-H74939206040670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CHARGER BALLOON 4MM X 80MM X 75CM -,SUP-H74939206040870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CHARGER 4MM X 100MM X 135CM -,SUP-H74939206041010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
4MM X 100MM X 75CM CHARGER BALLOON -,SUP-H74939206041070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CHARGER BALLOON 4MM X 150MM X 135CM -,SUP-H74939206041510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
5MM X 20MM X 75CM .035 CHARGER SHORT SHAFT -,SUP-H74939206050270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CHARGER 5MM X 40MM X 135CM -,SUP-H74939206050410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CHARGER BALLOON 5MM X 60MM X 135CM -,SUP-H74939206050610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CHARGER BALLOON 5MM X 80MM X 135CM -,SUP-H74939206050810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
5MM X 80MM X 75CM CHARGER BALLOON -,SUP-H74939206050870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CHARGER 5MM X 100MM X 135CM -,SUP-H74939206051010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CHARGER 5MM X 120MM X 135CM -,SUP-H74939206051210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CHARGER BALLOON 5 X 150MM -,SUP-H74939206051510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
5MM X 200MM X 135CM CHARGER -,SUP-H74939206052010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
6MM X 20MM X 135CM CHARGER -,SUP-H74939206060210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
6MM X 20MM X 75CM .035 CHARGER SHORT SHAFT -,SUP-H74939206060270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CHARGER BALLOON 6MM X 40MM X 135CM -,SUP-H74939206060410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CHARGER 6MM X 40MM X 75CM BALLOON -,SUP-H74939206060470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
6.0MM X 60MM X 75CM CHARGER -,SUP-H74939206060670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
6MM X 8MM X 135CM CHARGER -,SUP-H74939206060810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CHARGER 6.0MM X 80MM X 75CM -,SUP-H74939206060870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CHARGER BALLOON 6MM X 100MM X 135CM -,SUP-H74939206061010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CHARGER 6MM X 100MM X 75CM -,SUP-H74939206061070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CHARGER BALLOON 6MM X 150MM X 135CM -,SUP-H74939206061510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
7MM X 20MM X 135CM CHARGER -,SUP-H74939206070210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
7MM X 40MM X 135CM CHARGER BALLOON -,SUP-H74939206070410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
7MM X 40MM X 75CM CHARGER BALLOON -,SUP-H74939206070470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CHARGER 7MM X 80MM X 135CM -,SUP-H74939206070610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CHARGER BALLOON .035 7MM X 60MM X 75CM -,SUP-H74939206070670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
7MM X 80MM X 75CM CHARGER BALLOON -,SUP-H74939206070870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
7MM X 100MM X 135CM CHARGER BALLOON -,SUP-H74939206071010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
7MM X 100MM X 75CM CHARGER PTA -,SUP-H74939206071070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CHARGER BALLOON 8MM X 40MM X 135CM -,SUP-H74939206080410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CHARGER 8MM X 40MM X 75CM -,SUP-H74939206080470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
8MM X 60MM X 75CM CHARGER PTA -,SUP-H74939206080670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
8MM X 80MM X 135CM CHARGER BALLOON -,SUP-H74939206080810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
8.0MM X 80MM X 75CM CHARGER -,SUP-H74939206080870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CHARGER PTA 8MM X 100MM X 135CM -,SUP-H74939206081010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
8MM X 100MM X 75CM CHARGER PTA -,SUP-H74939206081070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CHARGER 8MM X 180MM X 135CM -,SUP-H74939206081810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
8.0MM X 200MM X 135XM CHARGER BALLOON -,SUP-H74939206082010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
9MM X 40MM X 135CM CHARGER BALLOON -,SUP-H74939206090410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
9MM X 40MM X 75CM CHARGER BALLOON -,SUP-H74939206090470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CHARGER 9MM X 60MM X 75CM -,SUP-H74939206090670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CHARGER OTW 10 X 20 BALLOON 135CM -,SUP-H74939206100210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CHARGER .035 10MM X 40MM X 135CM -,SUP-H74939206100410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
10MM X 40MM X 75CM CHARGER PTA -,SUP-H74939206100470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
10.0MM X 80MM X 75CM CHARGER BALLOON -,SUP-H74939206100870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
12MM X 20MM X 75CM CHARGER -,SUP-H74939206120270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
12MM X 40MM X 135CM CHARGER -,SUP-H74939206120410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
12MM X 40MM X 75CM CHARGER -,SUP-H74939206120470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CHARGER 12MM X 60MM X 75CM -,SUP-H74939206120670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CHARGER 12MM X 80MM X 75CM -,SUP-H74939206120870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 2.00MM x 6MM -,SUP-H7493926706200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 2.25MM x 6MM -,SUP-H7493926706220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 2.50MM x 6MM -,SUP-H7493926706250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 2.75MM x 6MM -,SUP-H7493926706270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 3.00MM x 6MM -,SUP-H7493926706300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 3.25MM x 6MM -,SUP-H7493926706320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 3.50MM x 6MM -,SUP-H7493926706350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 3.75MM x 6MM -,SUP-H7493926706370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 4.00MM X 6MM -,SUP-H7493926706400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 4.50MM x 6MM -,SUP-H7493926706450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 5.00MM x 6MM -,SUP-H7493926706500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 2.00MM x 8MM -,SUP-H7493926708200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 2.25MM x 8MM -,SUP-H7493926708220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 2.50MM x 8MM -,SUP-H7493926708250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 2.75MM x 8MM -,SUP-H7493926708270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 3.00MM x 8MM -,SUP-H7493926708300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 3.25MM x 8MM -,SUP-H7493926708320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 3.50MM x 8MM -,SUP-H7493926708350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 3.75MM x 8MM -,SUP-H7493926708370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 4.0 MM X 8 MM -,SUP-H7493926708400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 4.50MM x 8MM -,SUP-H7493926708450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 5.00MM x 8MM -,SUP-H7493926708500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 5.50MM x 8MM -,SUP-H7493926708550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 6.00MM x 8MM -,SUP-H7493926708600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 2.00MM X 12MM -,SUP-H7493926712200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 2.25MM x 12MM -,SUP-H7493926712220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 2.50 MM X 12 MM -,SUP-H7493926712250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 2.75MM x 12MM -,SUP-H7493926712270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 3.00MM x 12MM -,SUP-H7493926712300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 3.25MM x 12MM -,SUP-H7493926712320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 3.50MM x 12MM -,SUP-H7493926712350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 3.75MM x 12MM -,SUP-H7493926712370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 4.00MM x 12MM -,SUP-H7493926712400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 4.50MM x 12MM -,SUP-H7493926712450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 5.0 MM X 12 MM -,SUP-H7493926712500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 5.50MM x 12MM -,SUP-H7493926712550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 6.00MM x 12MM -,SUP-H7493926712600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 2.00MM x 15MM -,SUP-H7493926715200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 2.25MM x 15MM -,SUP-H7493926715220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 2.50 MM X 15 MM -,SUP-H7493926715250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 2.75MM x 15MM -,SUP-H7493926715270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 3.0 MM X 15 MM -,SUP-H7493926715300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 3.25MM x 15MM -,SUP-H7493926715320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 3.50MM x 15MM -,SUP-H7493926715350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 3.75MM x 15MM -,SUP-H7493926715370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 4.00MM X 15MM -,SUP-H7493926715400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 4.50MM x 15MM -,SUP-H7493926715450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 5.00MM x 15MM -,SUP-H7493926715500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 5.50MM x 15MM -,SUP-H7493926715550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 6.00MM x 15MM -,SUP-H7493926715600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 2.00MM x 20MM -,SUP-H7493926720200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 2.25MM x 20MM -,SUP-H7493926720220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 2.50 MM X 20 MM -,SUP-H7493926720250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 2.75MM x 20MM -,SUP-H7493926720270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 3.0 MM X 20 MM -,SUP-H7493926720300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 3.25MM x 20MM -,SUP-H7493926720320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 3.50MM x 20MM -,SUP-H7493926720350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 3.75MM x 20MM -,SUP-H7493926720370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 4.00MM x 20MM -,SUP-H7493926720400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 4.50MM x 20MM -,SUP-H7493926720450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 5.00MM x 20MM -,SUP-H7493926720500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 5.50MM x 20MM -,SUP-H7493926720550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 6.00MM x 20MM -,SUP-H7493926720600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 2.00MM x 30MM -,SUP-H7493926730200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 2.25MM x 30MM -,SUP-H7493926730220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 2.50MM x 30MM -,SUP-H7493926730250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 2.75MM x 30MM -,SUP-H7493926730270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 3.00MM x 30MM -,SUP-H7493926730300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 3.25MM x 30MM -,SUP-H7493926730320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 3.50MM x 30MM -,SUP-H7493926730350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 3.75MM x 30MM -,SUP-H7493926730370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE MR 4.00MM x 30MM -,SUP-H7493926730400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 2.00MM x 6MM -,SUP-H7493926806200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 2.25MM x 6MM -,SUP-H7493926806220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 2.50MM x 6MM -,SUP-H7493926806250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 2.75MM x 6MM -,SUP-H7493926806270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 3.00MM x 6MM -,SUP-H7493926806300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 3.25MM x 6MM -,SUP-H7493926806320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 3.50MM x 6MM -,SUP-H7493926806350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 3.75MM x 6MM -,SUP-H7493926806370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 4.00MM x 6MM -,SUP-H7493926806400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 4.50MM x 6MM -,SUP-H7493926806450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 5.00MM x 6MM -,SUP-H7493926806500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 2.00MM x 8MM -,SUP-H7493926808200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 2.25MM x 8MM -,SUP-H7493926808220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 2.50MM x 8MM -,SUP-H7493926808250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 2.75MM x 8MM -,SUP-H7493926808270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 3.00MM x 8MM -,SUP-H7493926808300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 3.25MM x 8MM -,SUP-H7493926808320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 3.50MM x 8MM -,SUP-H7493926808350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 3.75MM x 8MM -,SUP-H7493926808370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 4.00MM x 8MM -,SUP-H7493926808400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 4.50MM x 8MM -,SUP-H7493926808450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 5.00MM x 8MM -,SUP-H7493926808500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 5.50MM x 8MM -,SUP-H7493926808550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 6.00MM x 8MM -,SUP-H7493926808600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 2.00MM x 12MM -,SUP-H7493926812200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 2.25MM x 12MM -,SUP-H7493926812220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 2.50MM x 12MM -,SUP-H7493926812250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 2.75MM X 12MM -,SUP-H7493926812270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 3.00MM x 12MM -,SUP-H7493926812300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 3.25MM x 12MM -,SUP-H7493926812320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 3.50MM x 12MM -,SUP-H7493926812350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 3.75MM x 12MM -,SUP-H7493926812370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 4.00MM x 12MM -,SUP-H7493926812400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 4.50MM x 12MM -,SUP-H7493926812450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 5.00MM x 12MM -,SUP-H7493926812500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 5.50MM x 12MM -,SUP-H7493926812550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 6.00MM x 12MM -,SUP-H7493926812600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 2.00MM x 15MM -,SUP-H7493926815200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 2.25MM x 15MM -,SUP-H7493926815220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 2.50MM x 15MM -,SUP-H7493926815250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 2.75MM x 15MM -,SUP-H7493926815270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 3.00MM x 15MM -,SUP-H7493926815300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 3.25MM x 15MM -,SUP-H7493926815320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 3.50MM x 15MM -,SUP-H7493926815350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 3.75MM x 15MM -,SUP-H7493926815370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 4.00MM x 15MM -,SUP-H7493926815400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 4.50MM x 15MM -,SUP-H7493926815450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 5.00MM x 15MM -,SUP-H7493926815500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 5.50MM x 15MM -,SUP-H7493926815550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 6.00MM x 15MM -,SUP-H7493926815600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 2.00MM x 20MM -,SUP-H7493926820200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 2.25MM x 20MM -,SUP-H7493926820220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 2.50MM x 20MM -,SUP-H7493926820250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 2.75MM x 20MM -,SUP-H7493926820270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 3.00MM x 20MM -,SUP-H7493926820300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 3.25MM x 20MM -,SUP-H7493926820320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 3.50MM x 20MM -,SUP-H7493926820350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 3.75MM x 20MM -,SUP-H7493926820370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 4.00MM x 20MM -,SUP-H7493926820400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 4.50MM x 20MM -,SUP-H7493926820450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 5.00MM x 20MM -,SUP-H7493926820500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 5.50MM x 20MM -,SUP-H7493926820550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 6.00MM x 20MM -,SUP-H7493926820600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 2.00MM x 30MM -,SUP-H7493926830200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 2.25MM x 30MM -,SUP-H7493926830220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 2.50MM x 20MM -,SUP-H7493926830250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 2.75MM x 30MM -,SUP-H7493926830270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 3.00MM x 30MM -,SUP-H7493926830300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 3.25MM x 30MM -,SUP-H7493926830320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 3.50MM x 30MM -,SUP-H7493926830350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 3.75MM x 30MM -,SUP-H7493926830370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NC EMERGE OTW 4.00MM x 30MM -,SUP-H7493926830400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CUTTING 6MMX2.0MM WOLVERINE -,SUP-H74939401062000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CUTTING 6MMX2.5MM WOLVERINE -,SUP-H74939401062500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CUTTING 6MMX3.0MM WOLVERINE -,SUP-H74939401063000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CUTTING 6MMX3.5MM WOLVERINE -,SUP-H74939401063500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CUTTING 6MMX4.0MM WOLVERINE -,SUP-H74939401064000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CUTTING 10MMX2.0MM WOLVERINE -,SUP-H74939401102000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CUTTING 10MMX2.5MM WOLVERINE -,SUP-H74939401102500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CUTTING 10MMX3.0MM WOLVERINE -,SUP-H74939401103000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CUTTING 10MMX3.5MM WOLVERINE -,SUP-H74939401103500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CUTTING 10MMX4.0MM WOLVERINE -,SUP-H74939401104000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CUTTING 15MX2.00MM WOLVERINE -,SUP-H74939401152000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CUTTING 15MX2.50MM WOLVERINE -,SUP-H74939401152500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON CUTTING 15MMX3.0MM WOLVERINE -,SUP-H74939401153000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
RANGER GLOBAL DCB OTW 6.0 X 150MM 150CM -,SUP-H74939419601510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
RANGER DCB OTW  7.0MM x 40MM x 80CM -,SUP-H74939419700480,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT BLN -,SUP-H749CBM3200100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X6MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3225060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3225100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X6MM FLEXTOME CUT BLN MONORAIL 142CM RX -,SUP-H749CBM3250060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3250100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3250150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.75X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3275100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.75X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3275150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT BLN -,SUP-H749CBM3300100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT BLN -,SUP-H749CBM3300150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3325100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X15MM FLEXTOME CUT BLN MONORAIL 142CM RX -,SUP-H749CBM3325150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3350100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3350150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.75X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3375100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3200060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3200100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3225060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3225100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X15MM FLEXTOME BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3225150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3250060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3250100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X15MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3250150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.75X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3275100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.75X15MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3275150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3300060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X15MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3300150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3325100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X15MM FLEXTOME CUT BLN 142CM CUT BLN NC -,SUP-H749CBO3325150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN -,SUP-H749CBO3350100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH DX 2.4FR ID 3.4FR RND TIP 135CM CROSSBOSS XING MUL-WIRE -,SUP-H749M2000A0,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4648.07,3253.649,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH ANG 0.045IN 5FR FR4 125CM EXPO FUL-R WIRE BRD ROBST -,SUP-H759085262251,CDM,C1725,HCPCS,272,RC,,,outpatient,,,87.53,61.271,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATHETER IABP 7.5FR 40CC ULTRA FLEX REF: IAB-06840-U -,SUP-IAB-06840-U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATHETER IABP 8FR 40CC REDIGUARD REF: IAB-S840C -,SUP-IAB-S840C,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4010.16,2807.112,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
INFLATION KIT 30/30 BASIX -,SUP-IN4530,CDM,C1725,HCPCS,272,RC,,,outpatient,,,364.57,255.199,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5X220MM LUTONIX -,SUP-LX3513052205F,CDM,C1725,HCPCS,272,RC,,,outpatient,,,8063.6,5644.52,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
LUTONIX BALLOON 7MM X 80MM -,SUP-LX351307805F,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5305,3713.5,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
LUTONIX PTA 5MM X 60MM X 75CM -,SUP-LX3575560V,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
LUTONIX BALLOON 7 X 80 -,SUP-LX3575780V,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
LUTONIX 8 X 80 -,SUP-LX3575880V,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B XXL 14MM 4CM 75 14-514 -,SUP-M001145140,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B CATH XXL VASC 12 X 6 X 75CM -,SUP-M001145300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 14X60MM 2XL 75CM LPRO F/PTA PERIPH NYBAX LUB -,SUP-M001145320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON XXL 16 X 4 X 75 -,SUP-M001145530,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON XXL 16 X 4  5.8/120 -,SUP-M001145530,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 16X60MM 2XL 75CM LPRO PERIPH NYBAX LUB BIOSLD CTD -,SUP-M001145540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B CATH XXL 18MM X 4CM 120CM -,SUP-M001145580,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH DIL 18MM 8FR SHEA 0.037IN TIP 5.8FRX75CM 6CM BLN GALWAY -,SUP-M001145590,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X40MM ULTR-THN DMD 75CM F/PTA PERIPH 5FR SHTH -,SUP-M001164230,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6X20MM ULTR-THN DMD 75CM F/PTA PERIPH 5FR SHTH -,SUP-M001164570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 7X20MM ULTR-THN DMD 75CM F/PTA PERIPH 5FR SHTH -,SUP-M001164770,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B DUT 8MM 4CM 75CM  16-505 -,SUP-M001165050,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
AST-GN45 -,SUP-M001NC20000001,CDM,C1725,HCPCS,272,RC,,,outpatient,,,358.85,251.195,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 7X40MM POLAR 120CM COAX F/PTA CLD THRP PERIPH -,SUP-M001P740120010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2807.11,1964.977,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 7X60MM POLAR 120CM COAX F/PTA CLD THRP PERIPH -,SUP-M001P760120010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2807.11,1964.977,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 8X20MM POLAR 120CM COAX F/PTA CLD THRP PERIPH -,SUP-M001P820120010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
DEVICE INFL POLAR N2O -,SUP-M001PCIU400000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4927.28,3449.096,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X40MM POLAR 150CM COAX F/PTA CLD THRP PERIPH -,SUP-M001T3040150010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X40MM POLAR 150CM COAX F/PTA CLD THRP PERIPH -,SUP-M001T4040150010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
RETRACTOR ORTHO HHMN 18MMX9.25IN STN FNSH SS V. MUELLER -,SUP-M001T5040135010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6X40MM POLAR 135CM COAX F/PTA CLD THRP PERIPH -,SUP-M001T6040135010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATHETER  SHOCKWAVE M5+ IVL CATHETER 5.0X60MM -,SUP-M5PIVL5060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATHETER SHOCKWAVE 5.5 X 60 MM M5+ -,SUP-M5PIVL5560,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATHETER- SHOCKWAVE M5+ IVL CATHETER- 6.0X60MM -,SUP-M5PIVL6060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATHETER- SHOCKWAVE M5+ IVL CATHETER- 7.0X60MM -,SUP-M5PIVL7060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATHETER- SHOCKWAVE M5+ IVL CATHETER- 8.0X60MM -,SUP-M5PIVL8060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP2006X NCEUPHORA RX -,SUP-NCEUP2006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP2008X NCEUPHORA RX -,SUP-NCEUP2008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP2012X NCEUPHORA RX -,SUP-NCEUP2012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP2015X NCEUPHORA RX -,SUP-NCEUP2015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP2020X NCEUPHORA RX -,SUP-NCEUP2020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP22506X NCEUPHORA RX -,SUP-NCEUP22506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP22508X NCEUPHORA RX -,SUP-NCEUP22508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP22512X NCEUPHORA RX -,SUP-NCEUP22512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP22515X NCEUPHORA RX -,SUP-NCEUP22515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP22520X NCEUPHORA RX -,SUP-NCEUP22520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP2506X NCEUPHORA RX -,SUP-NCEUP2506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP2508X NCEUPHORA RX -,SUP-NCEUP2508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP2512X NCEUPHORA RX -,SUP-NCEUP2512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP2515X NCEUPHORA RX -,SUP-NCEUP2515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP2520X NCEUPHORA RX -,SUP-NCEUP2520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP2527X NCEUPHORA RX -,SUP-NCEUP2527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP27506X NCEUPHORA RX -,SUP-NCEUP27506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP27508X NCEUPHORA RX -,SUP-NCEUP27508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP27512X NCEUPHORA RX -,SUP-NCEUP27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP27515X NCEUPHORA RX -,SUP-NCEUP27515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP27520X NCEUPHORA RX -,SUP-NCEUP27520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP27527X NCEUPHORA RX -,SUP-NCEUP27527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP3006X NCEUPHORA RX -,SUP-NCEUP3006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP3008X NCEUPHORA RX -,SUP-NCEUP3008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP3012X NCEUPHORA RX -,SUP-NCEUP3012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP3015X NCEUPHORA RX -,SUP-NCEUP3015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP3020X NCEUPHORA RX -,SUP-NCEUP3020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP3027X NCEUPHORA RX -,SUP-NCEUP3027X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP32506X NCEUPHORA RX -,SUP-NCEUP32506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP32508X NCEUPHORA RX -,SUP-NCEUP32508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP32512X NCEUPHORA RX -,SUP-NCEUP32512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP32515X NCEUPHORA RX -,SUP-NCEUP32515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP32520X NCEUPHORA RX -,SUP-NCEUP32520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP32527X NCEUPHORA RX -,SUP-NCEUP32527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP3506X NCEUPHORA RX -,SUP-NCEUP3506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP3508X NCEUPHORA RX -,SUP-NCEUP3508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP3512X NCEUPHORA RX -,SUP-NCEUP3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP3515X NCEUPHORA RX -,SUP-NCEUP3515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP3520X NCEUPHORA RX -,SUP-NCEUP3520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP3527X NCEUPHORA RX -,SUP-NCEUP3527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP37506X NCEUPHORA RX -,SUP-NCEUP37506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP37508X NCEUPHORA RX -,SUP-NCEUP37508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP37512X NCEUPHORA RX -,SUP-NCEUP37512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP37515X NCEUPHORA RX -,SUP-NCEUP37515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP37520X NCEUPHORA RX -,SUP-NCEUP37520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP37527X NCEUPHORA RX -,SUP-NCEUP37527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP4006X NCEUPHORA RX -,SUP-NCEUP4006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP4008X NCEUPHORA RX -,SUP-NCEUP4008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP4012X NCEUPHORA RX -,SUP-NCEUP4012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP4015X NCEUPHORA RX -,SUP-NCEUP4015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP4020X NCEUPHORA RX -,SUP-NCEUP4020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP4027X NCEUPHORA RX -,SUP-NCEUP4027X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP4508X NCEUPHORA RX -,SUP-NCEUP4508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP4512X NCEUPHORA RX -,SUP-NCEUP4512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP4515X NCEUPHORA RX -,SUP-NCEUP4515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP4520X NCEUPHORA RX -,SUP-NCEUP4520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP5008X NCEUPHORA RX -,SUP-NCEUP5008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP5012X NCEUPHORA RX -,SUP-NCEUP5012,CDM,C1725,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
BALLOON NCEUP5015X NCEUPHORA RX -,SUP-NCEUP5015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X6MM NC STRMR 138CM OTW NC COR 3- FOLD FLCRM + -,SUP-NCS2506W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X11MM NC STRMR 138CM OTW NC COR 3- FOLD FLCRM + -,SUP-NCS2511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS2514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.75X6MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS27506W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.75X11MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM -,SUP-NCS27511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.75X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS27514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.75X16MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS27516W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X6MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS3006W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X11MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS3011W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS3014W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X16MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS3016W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X11MM NC STRMR 138CM OTW NC COR 5- FOLD FLCRM -,SUP-NCS32511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS32514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X11MM NC STRMR 138CM OTW NC COR 5- FOLD FLCRM + -,SUP-NCS3511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X16MM NC STRMR 138CM OTW NC COR 5- FOLD FLCRM + -,SUP-NCS3516W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.75X11MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS37511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.75X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS37514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X11MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS4011W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X16MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS4016W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X21MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS4021W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X6MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP2506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP2512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP2515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.75X6MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP27506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.75X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.75X21MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP27521X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X6MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT FLCRM -,SUP-NCSP3006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X21MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3021X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X12MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP32512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X15MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP32515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X27MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.75X12MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP37512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.75X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP37515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X21MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4021X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4.5X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5X15MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP5015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
PALADIN CAROTID PTA CATHETER WITH INTEGRATED EMB PRO -,SUP-PD-5520-140-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATHETER ADVANCE MICRO 14 ULTRA LOW PROFILE BALLOON -,SUP-PTA3-14-90-2.5-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2289.76,1602.832,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATHETER PTA BALLOON DILATION 18LP ADVANCE LP 2MM X 20CM -,SUP-PTA4-18-150-2-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4MMX10CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4MMX6CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-8,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
B CATH ADVANCE 18LP 5X10 150 -,SUP-PTA4-18-150-510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-5-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-5-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5MMX6CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-5-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6MMX10CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-6-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-6-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH ANG 4FR 0.018/ 150CM/6MM DIA 6CM ADVANCE RNL POPLT PTA -,SUP-PTA4-18-150-6-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 7MMX10CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-710,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 7MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 7MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 7MMX6CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 7MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-8,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 10MMX3CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-PTA5-35-135-103,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-PTA5-35-135-44,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-PTA5-35-13562.0,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 8MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-PTA5-35-135-8-8,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-PTAX4141702.520,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-PTAX414170312,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 26MM 12FRX2.5CM INOUE 70CM PVC 0.025IN GW COMP -,SUP-PTMC-26,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10025.1,7017.57,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 28MM 12FRX2.5CM INOUE 70CM PVC 0.025IN GW COMP -,SUP-PTMC-28,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10025.1,7017.57,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 30MM 12FRX2.5CM INOUE 70CM PVC 0.025IN GW COMP -,SUP-PTMC-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10025.1,7017.57,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
SHOCKWAVE 3.0 X 40MM IVL KIT -,SUP-S4IVLK3040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ADV SERENITY 14 HYDROPHILIC PTA BALL DIL CATH 2.5X60X150CM -,SUP-SER14-150-25-60,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ADVANCE SERENITY 14 HYDROPHILIC PTA BALLOON DIL CATH -,SUP-SER14-150-30-60,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.25X6MM SPRINTER LEGEND 152CM OTW SEM-COM COR -,SUP-SPL12506WL,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.25X6MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.25X10MM SPRINTER LEGEND 152CM OTW SEM-COM COR -,SUP-SPL12510WL,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.25X10MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.25X12MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.25X15MM SPRINTER LEGEND 152CM OTW SEM-COM COR -,SUP-SPL12515WL,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.25X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.5X6MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL15006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.5X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL15012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.5X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL15015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL20012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL20015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X20MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL20020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X6MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL22506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL22515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL25012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL25015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X20MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL25020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X25MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL25025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.75X12MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.75X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL27515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.75X20MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL27520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL30012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL30015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X20MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL30020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X12MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL40012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL40015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.5X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR1512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 1.5X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR1515W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2012W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2015W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X20MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2020W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X25MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2025W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.25X12MM SPRINTER 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR22512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X6MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2506W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2515W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5X20MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2520W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.75X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR27512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.75X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR27515W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3012W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3015W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3X20MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3020W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.25X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR32512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3.5X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR4015W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ENROUTE ENFLATE TRANSCAROTID RX BALLOON -,SUP-SR-4525-BC,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2008.89,1406.223,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
ENROUTE ENFLATE TRANSCAROTID RX BALLOON -,SUP-SR-5035-BC,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2008.89,1406.223,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH ANG 4FR STR 125CM TEMPO AQ SLCT BRD SHFT NO SH NYL -,SUP-SRD6667,CDM,C1725,HCPCS,272,RC,,,outpatient,,,269.58,188.706,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATHETER BALLOON TRUE FLOW 24 MM x 3.5CM REF: TF0243514 -,SUP-TF0243514,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6153.8,4307.66,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CABLE ADPTR IABP -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,344.79,241.353,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4X15MM 140CM OTW PERIPH -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4134.28,2893.996,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH SHEATH RITESITE C315H1802 -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2X15MM 140CM OTW PERIPH -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4134.28,2893.996,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2MMX2CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V142020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V142040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 2.5MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V142540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3MMX2CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V143020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3319.12,2323.384,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V143040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 3MMX6CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V143060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4MMX12CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V1840120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 4MMX8CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V184080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V185040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 5MMX6CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V185060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATH PTCA 6MMX12CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V1860120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
CATHETER PTV DILATATION 26MX4CM VIDA REF:VDA100264 -,SUP-VDA100264,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2802.82,1961.974,AETNA [1000108],AETNA [100010801],,,,,,19.650485,9184.66245,other,272 with C codes,,
DILATOR 6-30FR DIA TIP 30CM PE/PTFE -,SUP-118768,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1395.36,976.752,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
LEAD DEFIB IMPL BIPLR PERMNT PCNG ETAK RELIANCE G_59CM -,SUP-5843,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
KT MNMTRY BLN ADLT RCTL BLN -,SUP-A86-1070,CDM,C1726,HCPCS,272,RC,,,outpatient,,,52.52,36.764,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CATH DIL 6MMX16MM RELIEVA ULTIRRA SIN 2LUM SHFT ENDO F/IRR -,SUP-BC0616RU,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3728.49,2609.943,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CATH DIL 6MMX16MM RELIEVA SOLO PRO SIN 2LUM SHFT ENDO F/IRR -,SUP-BC0616SP,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3265.42,2285.794,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
KIT CATHETER SURGILUBE VINYL PEDIATRIC FEMALE OD8 FR SOFT LF -,SUP-CKF105L,CDM,C1726,HCPCS,272,RC,,,outpatient,,,18.96,13.272,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
KIT CATHETER SURGILUBE VINYL PEDIATRIC FEMALE OD8 FR SOFT LF -,SUP-CKF105L,CDM,C1726,HCPCS,272,RC,,,outpatient,,,18.99,13.293,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
TRAY URETHRAL 8FR FEMALE VINYL PVP URINE COLLECTION DEVICE -,SUP-CKF105L,CDM,C1726,HCPCS,272,RC,,,outpatient,,,18.15,12.705,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
BALLOON CERVICAL RIPENING W/STYLET -,SUP-G19891,CDM,C1726,HCPCS,272,RC,,,outpatient,,,243.61,170.527,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
IMPLANT PIP MCP SZ5 SWNSN SIL -,SUP-G470-0005,CDM,C1726,HCPCS,272,RC,,,outpatient,,,4413.76,3089.632,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
HURRICANE RX 4 X 4 -,SUP-G49219,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
HURRICANE RX 6 X 4 -,SUP-G49220,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
HURRICANE RX 8 X 4 -,SUP-G49221,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
HURRICANE RX 10 X 4 -,SUP-G49222,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CATH DIL 7FR CATH 7-5FR TIP 200CM 2CM BLN FUSION BIL TAPR -,SUP-G49571,CDM,C1726,HCPCS,272,RC,,,outpatient,,,676.86,473.802,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CATH DIL 8.5FR CATH 8.5-6FR TAPR 200CM 2CM BLN FUSION BIL -,SUP-G49572,CDM,C1726,HCPCS,272,RC,,,outpatient,,,676.86,473.802,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CATH DIL 7FR TAPR 200CM 2CM BLN FUSION BIL DOME TIP ENDO -,SUP-G49573,CDM,C1726,HCPCS,272,RC,,,outpatient,,,676.86,473.802,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CATH PTCA 6X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171061070,CDM,C1726,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
B CUTTING 5 X 2 X 135 -,SUP-M001PCB50201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
BALLOON 2CM PERIPHERAL CUTTING -,SUP-M001PCB50201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CATH PTCA 5MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-M001PCB50201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
PERIPHERAL CUTTING BALLOON  5MM X 2CM  50CM -,SUP-M001PCB5020500,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
B 6 X 2 X 135 CUTTING BAL -,SUP-M001PCB60201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
B CUTTING 7 X 2 X 135 -,SUP-M001PCB70201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CATH PTCA 7MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-M001PCB70201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CATH PTCA 7X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-M001PCB7020900,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
B CUTTING 8 X 2 X 135 -,SUP-M001PCB80201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CATH PTCA 8MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-M001PCB80201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CATH PTCA 8X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-M001PCB8020900,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CATH PTCA 1.5X3MM CUT BLN 140CM OTW PERIPH 0.018IN GW COMP -,SUP-M001PCBO3015140,CDM,C1726,HCPCS,272,RC,,,outpatient,,,4134.28,2893.996,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
B PERIPHERAL 6F 3.0X15X140 M00 -,SUP-M001PCBO3015140F0,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
B PER CUT OTW FLEX 4X15X140 M0 -,SUP-M001PCBO4015140F0,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CUTTING BALLOON 4MM X 1.5CM  X 135CM -,SUP-M001PCBO4015140F0,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CATH DIL 5.8FR 6MM BLN 180CM 4CM BLN HURRCN SS BIL RX ENDO -,SUP-M00545920,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CATH DIL 5.8FR 8MM BLN 180CM 4CM BLN HURRCN SS BIL RX ENDO -,SUP-M00545940,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CATHETER CHOLANGIOGRAM SPYGLASS 65CM CHOLANGIOSCOPY -,SUP-M00546780,CDM,C1726,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
DILATOR BLN 36-40.5-45FR OD BLN 75CM 5.5CM CRE ESPH WG ENDO -,SUP-M00550300,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1649.04,1154.328,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
DILATOR BLN 24-27-30FR OD BLN 75CM 3CM CRE ESPH WG ENDO -,SUP-M00550330,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1649.04,1154.328,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
DILATOR BLN 30-33-36FR OD BLN 75CM 3CM CRE ESPH WG ENDO -,SUP-M00550340,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1649.04,1154.328,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
DILATOR BALLOON 35MM RIGIFLEX -,SUP-M00554510,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3112.17,2178.519,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
DILATOR BLN 7.5FR 6-7-8 MMX180CM 5.5CM BLN CRE PEBAX ESPH FX -,SUP-M00556860,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CRE 8-10MM 8CM F/G -,SUP-M00558340,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CRE 10-12MM 8CM F/G -,SUP-M00558350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CRE 12-15MM 8CM F/G -,SUP-M00558360,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
DILATOR BLN 6FR 12-13.5-15 MMX180CM 8CM BLN CRE PEBAX ESPH -,SUP-M00558360,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CRE 15-18MM 8CM F/G -,SUP-M00558370,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
DILATOR BLN 6FR 18-19-20 MMX180CM 8CM BLN CRE PEBAX ESPH FX -,SUP-M00558380,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CRE 18-20MM 8CM F/G -,SUP-M00558380,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
DILATOR WIREGUIDED CRE 15-18 180CM -,SUP-M00558430,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
DILATOR BLN 7.5FR 10-11-12 MMX240CM 5.5CM BLN CRE PEBAX ESPH -,SUP-M00558470,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
DILATOR BLN 7.5FR 12-13.5-15 MMX240CM 5.5CM BLN CRE PEBAX -,SUP-M00558480,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
DILATOR WIREGUIDED CRE 8-10 180CM -,SUP-M00558610,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
DILATOR WIREGUIDED CRE 10-12 180CM -,SUP-M00558620,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
DILATOR WIREGUIDED CRE 12-15 180CM -,SUP-M00558630,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CRE PRO WIREGUIDED 6-7-8MM 240CM -,SUP-M00558660,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CRE PRO WIREGUIDE 8-9-10MM 240 -,SUP-M00558670,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CRE PRO WIREGUIDE 10-11-12MM 240 -,SUP-M00558680,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CRE PRO WIREGUIDE 12-13.5-15MM 240 -,SUP-M00558690,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
DILATOR BLN 7.5FR 15-16.5-18 MMX240CM 5.5CM BLN CRE PEBAX -,SUP-M00558700,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CRE PRO WIREGUIDE 15-16.5-18MM 240 -,SUP-M00558700,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CRE PRO WIREGUIDE 18-19-20MM 240 -,SUP-M00558710,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CATH BILIARY BALLOON DILATATION CRE 8-10 3CM -,SUP-M00558920,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1517,1061.9,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CATH BILIARY BALLOON DILATATION CRE 10-12 3CM -,SUP-M00558930,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1517,1061.9,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CATH BILIARY BALLOON DILATATION CRE 12-15 3CM -,SUP-M00558940,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1517,1061.9,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CATH NEPH DIL 7FR 30FR BLN LPRO NPHRMX LF MRKR STPCK 17CM -,SUP-M0062101170,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1232.21,862.547,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CATH NEPH 7FR 10MM NPHRMX LF MRKR PTFE SHTH STPCK INFL DVC -,SUP-M0062101180,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1347.23,943.061,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CATH NEPH DIL 7FR 30FR BLN LPRO NPHRMX LF MRKR STPCK 20CM -,SUP-M0062101440,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1303.92,912.744,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CATH URET 4MM BLN 12FR INFL 3FR SHFT 150CM HYDRPLS CTD SS -,SUP-M0062181100,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1434.32,1004.024,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
PASSPORT BALLOON CATH 2CM -,SUP-M0062181200,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1540.27,1078.189,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CATH URET 5.8FRX4MM OD BLN 12FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251000,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1208.3,845.81,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
URO-MAX 2Q 4CM BALLOON KIT -,SUP-M0062251010,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1252.72,876.904,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CATH URET 5.8FRX10MM OD BLN 30FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251050,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1170.62,819.434,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
UROMAX 2/Q CATH 6CM 15FR SINGLE -,SUP-M0062251070,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1170.62,819.434,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CATH UROMAX U2Q\8-8 SINGLE -,SUP-M0062251100,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1170.62,819.434,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
UROMAX 2/Q CATH 10CM 15FR -,SUP-M0062251160,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1252.72,876.904,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CATH URET 5.8FRX6MM OD BLN 15FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251360,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1464.74,1025.318,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CATH URET 5.8FRX6MM OD BLN 18FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251370,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1384.17,968.919,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
APPLICATOR ENDO BLN US F /BF-UC16F-OL8 LTX STRL -,SUP-MAJ-1351,CDM,C1726,HCPCS,272,RC,,,outpatient,,,191.19,133.833,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CUFF BLN ADLT ENDO US F -,SUP-MAJ-249,CDM,C1726,HCPCS,272,RC,,,outpatient,,,157.36,110.152,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CATH ESPH 4.2MMX1CM SPC HI-RESOLTN CHNLX36 MANOSCAN -,SUP-MSC-1286,CDM,C1726,HCPCS,272,RC,,,outpatient,,,25903.5,18132.45,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CATHETER HEMOSTATIC BALLOON NEXPOWDER -,SUP-NHS03,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CATH ATHRCMY PERIPH CUT BLN 4MMX140MM OTW PERIPH -,SUP-PCB04015140F,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CATH PTCA 6MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-PCB6020135,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CATH PTCA 7X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-PCB702090,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
CATH PTCA 8X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-PCB802090,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA [1000108],AETNA [100010801],,,,,,4.074675,18572.8095,other,272 with C codes,,
HERNIA BALLOON #OMS-PDBS2 -,SUP-OMS-PDBS2,CDM,C1727,HCPCS,272,RC,,,outpatient,,,1296.65,907.655,AETNA [1000108],AETNA [100010801],,,,,,291.097925,929.69805,other,272 with C codes,,
CATH BRCHTX MULTLUM 4-5CM CONTURA STRL -,SUP-B01245,CDM,C1728,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,AETNA [1000108],AETNA [100010801],,,,,,195.18479,8389.93965,other,272 with C codes,,
APPLICATOR BRCHTX MULTLUM 5-6CM BLN CONTURA STRL SUD -,SUP-B01256,CDM,C1728,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,AETNA [1000108],AETNA [100010801],,,,,,195.18479,8389.93965,other,272 with C codes,,
CATH BRCHTX 5-6CM CONTURAFLEX LF -,SUP-B13256,CDM,C1728,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,AETNA [1000108],AETNA [100010801],,,,,,195.18479,8389.93965,other,272 with C codes,,
CATH BRCHTX F/CVTY MNTN CONTURA -,SUP-B90012,CDM,C1728,HCPCS,272,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,,,,195.18479,8389.93965,other,272 with C codes,,
TRY APPLICATOR BRCHTX SAVI 6-1 -,SUP-SAVI-06,CDM,C1728,HCPCS,272,RC,,,outpatient,,,9468.15,6627.705,AETNA [1000108],AETNA [100010801],,,,,,195.18479,8389.93965,other,272 with C codes,,
APPLICATOR BRCHTX SGL-ENTRY MUL-CATH SAVI PREP -,SUP-SPC-01,CDM,C1728,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,195.18479,8389.93965,other,272 with C codes,,
CT/MR APPLICATOR W/BASE PLATE -,SUP-UNDEFINED,CDM,C1728,HCPCS,272,RC,,,outpatient,,,11701.45,8191.015,AETNA [1000108],AETNA [100010801],,,,,,195.18479,8389.93965,other,272 with C codes,,
DRAIN PENROSE19MM 30CM 32MM FLAT -,SUP-00000,CDM,C1729,HCPCS,272,RC,,,outpatient,,,4.14,2.898,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH NEPH PEZ 28FR EYEX2 PRPRTN HEAD LTX MSHRM SHP -,SUP-064028,CDM,C1729,HCPCS,272,RC,,,outpatient,,,44.17,30.919,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH NEPH MLCT 14FR WNGX4 LTX -,SUP-086014,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.82,46.074,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH MALECOT 18FR BARD -,SUP-086018,CDM,C1729,HCPCS,272,RC,,,outpatient,,,49.29,34.503,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH MALECOT 20FR BARD -,SUP-086020,CDM,C1729,HCPCS,272,RC,,,outpatient,,,49.29,34.503,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH MALECOT 22FR BARD -,SUP-086022,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.06,45.542,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH MALECOT 24FR BARD -,SUP-086024,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.07,45.549,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH MALECOT 34FR PROPORTIONATE HEAD LATEX -,SUP-086034,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.07,45.549,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH NEPH MLCT 38FR WNGX4 LTX -,SUP-086038,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.06,45.542,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH NEPH MLCT 40FR WNGX4 LTX -,SUP-086040,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.89,45.423,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
24FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14024,CDM,C1729,HCPCS,272,RC,,,outpatient,,,123.9,86.73,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
28FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14028,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
32 FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14032,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
36FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14036,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH DRN 10.2FRX25CM SDPRTX6 COOK-COPE TY LCK LOOP -,SUP-192550,CDM,C1729,HCPCS,272,RC,,,outpatient,,,429.81,300.867,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH DRN 16FRX25CM SDPRTX6 COOK-COPE TY LCK LOOP -,SUP-193581,CDM,C1729,HCPCS,272,RC,,,outpatient,,,609.7,426.79,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH BIL DRN 12FRX40CM SDPRTX32 MA C -LOC LCK LOOP -,SUP-228702,CDM,C1729,HCPCS,272,RC,,,outpatient,,,545.51,381.857,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH DRN 12 FR X 25CM J-CRV THAL-QUICK PVC SDPRTX3 -,SUP-228707,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH DRN 14FRX25CM SDPRTX6 MA C -LOC LCK LOOP -,SUP-228709,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
TUBE VACUTNR 4ML GRN CAP NAHEP SAFTY PLST PPR LBL STRL HG-FR -,SUP-367871,CDM,C1729,HCPCS,272,RC,,,outpatient,,,0.94,0.658,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
THORACENTESIS TRAY/P4340A -,SUP-4340A,CDM,C1729,HCPCS,272,RC,,,outpatient,,,176.04,123.228,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
TRY THORCNTS 14GAX2IN L INTRO NDLX4 3WAY STP C LOCK BTRFLY -,SUP-4341B,CDM,C1729,HCPCS,272,RC,,,outpatient,,,228.45,159.915,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH VNTRC DRN 80CM TUOHY NDL FX TAB BLNT NDL STRN RLF OPN -,SUP-464-20,CDM,C1729,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
THORACENTESIS 30IN TUBING 4653 -,SUP-4653-48,CDM,C1729,HCPCS,272,RC,,,outpatient,,,23.96,16.772,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
SYS VNTRC DRN 35CM DUET W/ICP LN NDL-FR PRTX3 DRP CHMBR TBG -,SUP-469-13,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1120.58,784.406,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
SYS BAG VNTRC DRN REPL 35CM INTLNK NDL-FR INJ SITE -,SUP-469-14,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1120.58,784.406,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
KIT CSF DRAINAGE W CATH -,SUP-46916,CDM,C1729,HCPCS,272,RC,,,outpatient,,,2091.05,1463.735,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATHETER PLEURAL PLEURX KIT -,SUP-50-7000B,CDM,C1729,HCPCS,272,RC,,,outpatient,,,3841.3,2688.91,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH WORD BARTHOLIN GLAND 10FR 5CM -,SUP-564000,CDM,C1729,HCPCS,272,RC,,,outpatient,,,104.15,72.905,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATHETER THORACIC 28F STRAIGHT -,SUP-8028,CDM,C1729,HCPCS,272,RC,,,outpatient,,,35.56,24.892,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATHETER THORACIC 32FR STERILE -,SUP-8032,CDM,C1729,HCPCS,272,RC,,,outpatient,,,35.05,24.535,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATHETER THORACIC 36F STRAIGHT -,SUP-8036,CDM,C1729,HCPCS,272,RC,,,outpatient,,,35.88,25.116,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATHETER THORACIC 24FR RT ANGL -,SUP-8124,CDM,C1729,HCPCS,272,RC,,,outpatient,,,57.26,40.082,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATHETER THORACIC  32F RT ANGLE -,SUP-8132,CDM,C1729,HCPCS,272,RC,,,outpatient,,,54.52,38.164,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
DRAIN CATH LUMBAR KTXTRN DRN 0.76MM 1.65MMX46CM -,SUP-82-1706,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1526.54,1068.578,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH VNTRC DRN 1.5MM BCTSL EVD SIL 0.15% CLNDMCN -,SUP-82-1745,CDM,C1729,HCPCS,272,RC,,,outpatient,,,2522.1,1765.47,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
DRAIN PENROSE 5/8 WND 0.625X12IN GRVTY  FLT LTX -,SUP-8888515007,CDM,C1729,HCPCS,272,RC,,,outpatient,,,223.25,156.275,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH TROCAR 12FR ARGYLE -,SUP-8888561027,CDM,C1729,HCPCS,272,RC,,,outpatient,,,106.84,74.788,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH TROCAR 20FR X 16 ARGYLE -,SUP-8888561043,CDM,C1729,HCPCS,272,RC,,,outpatient,,,78.42,54.894,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH TROCAR 28FR X 16 ARGYLE -,SUP-8888561068,CDM,C1729,HCPCS,272,RC,,,outpatient,,,110.81,77.567,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
KT DRN 20FRX10IN ARGYLE PVC GLVX2 PREP SWB /CUPX2 FEN DRAPE -,SUP-8888565036,CDM,C1729,HCPCS,272,RC,,,outpatient,,,192.93,135.051,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATHETER TROCAR KIT 28 FR NSQ -,SUP-8888565044,CDM,C1729,HCPCS,272,RC,,,outpatient,,,199.28,139.496,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH THORACIC 12FR MAR -,SUP-8888570507,CDM,C1729,HCPCS,272,RC,,,outpatient,,,55.61,38.927,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH THORACIC 16FR MAR -,SUP-8888570515,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.3,26.81,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATHETER THORACIC 16FR -,SUP-8888570515,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.3,26.81,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH THORACIC 20FR MAR -,SUP-8888570523,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.68,27.076,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
"CATHETER THORACIC 20FR X 20"" RADIOPAQUE 5 EYELETS -",SUP-8888570523,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.69,27.083,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH THORACIC 24FR MAR -,SUP-8888570531,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.18,27.426,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATHETER THORACIC 24FR -,SUP-8888570531,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.15,27.405,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH THORACIC 28FR MAR -,SUP-8888570549,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.44,27.608,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATHETER THORACIC 28FR -,SUP-8888570549,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.44,27.608,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH THORACIC 32FR MAR -,SUP-8888570556,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.85,27.895,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATHETER THORACIC 32FR -,SUP-8888570556,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.85,27.895,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH THORACIC 36FR MAR -,SUP-8888570564,CDM,C1729,HCPCS,272,RC,,,outpatient,,,40.24,28.168,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATHETER THORACIC 36FR -,SUP-8888570564,CDM,C1729,HCPCS,272,RC,,,outpatient,,,40.26,28.182,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH THORACIC 40FR MAR -,SUP-8888570572,CDM,C1729,HCPCS,272,RC,,,outpatient,,,40.63,28.441,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
TUBE CHEST RIGHT ANGLE 28 -,SUP-8888571042,CDM,C1729,HCPCS,272,RC,,,outpatient,,,77.11,53.977,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH THORCNTS 18FRX20IN LT VNTRC -,SUP-8888590216,CDM,C1729,HCPCS,272,RC,,,outpatient,,,193.84,135.688,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
KIT LUMBAR DRAINAGE CATH -,SUP-910121,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1076.58,753.606,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH DISTAL ATRIAL PERITONEAL SOPHYSA -,SUP-B905S,CDM,C1729,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATHETER VENTRICULAR STR 1.3 X 2.5 MM (INCL IN ITEM 0154508) -,SUP-BO19-10,CDM,C1729,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
TRAY CHEST TUBE 10FR THAL QUICK LUMX1 SDPRTX3 18GA ECHOTIP -,SUP-C-TQTSY-1000,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1096.98,767.886,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH PERFUS 12FR STR PVC -,SUP-EM012,CDM,C1729,HCPCS,272,RC,,,outpatient,,,263.92,184.744,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
EVACUATOR TBG UNIV ELLIK -,SUP-ET,CDM,C1729,HCPCS,272,RC,,,outpatient,,,74.71,52.297,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
BILIARY DRAINAGE CATH 8.5FR. -,SUP-G09497,CDM,C1729,HCPCS,272,RC,,,outpatient,,,545.51,381.857,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH BIL DRN 10.2FRX40CM MAC-LOC SDPRTX32 MA C -LOC LCK LOOP -,SUP-G09498,CDM,C1729,HCPCS,272,RC,,,outpatient,,,545.51,381.857,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH DRN 8.5FRX25CM LCK LOOP -,SUP-G09501,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH DRN 10FR NEPHROSTOMY TUBE -,SUP-G09502,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH MP DRAINAGE 10.2F 45CM UL -,SUP-G09766,CDM,C1729,HCPCS,272,RC,,,outpatient,,,554.27,387.989,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH DRN 12FRX45CM BND SDPRTX6 MA C -LOC LCK LOOP -,SUP-G09767,CDM,C1729,HCPCS,272,RC,,,outpatient,,,554.27,387.989,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH DRN 6FR UNIV 25CM CRV SDPRTX3 -,SUP-G10956,CDM,C1729,HCPCS,272,RC,,,outpatient,,,539.68,377.776,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
SET COLON DECOMPRESION 14FR -,SUP-G22181,CDM,C1729,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
Set Fuhrman Pleural Pneumopericardial Drainage -,SUP-G55723,CDM,C1729,HCPCS,272,RC,,,outpatient,,,711.87,498.309,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
Tray Fuhrman Pleural Pneumopericardial Drainage -,SUP-G55724,CDM,C1729,HCPCS,272,RC,,,outpatient,,,968.61,678.027,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
UNIV. LOOP DRAINAGE SET 10FR -,SUP-G55802,CDM,C1729,HCPCS,272,RC,,,outpatient,,,887.5,621.25,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
UNIV.  LOOP DRAINAGE SET 14FR X 30 -,SUP-G55804,CDM,C1729,HCPCS,272,RC,,,outpatient,,,887.5,621.25,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
ST UNIVERSA MALEOCOT16FRX22CM BLN SS NDL OBTR CON TUBE 3ML -,SUP-G55825,CDM,C1729,HCPCS,272,RC,,,outpatient,,,307.21,215.047,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
TRAY WAYNE PNEUMOTHORAX CATHETER 14.0 FR 29 CM -,SUP-G56537,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1250.92,875.644,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH PERC DRN 8FRX25CM STD LOOP TIP EXODUS LF -,SUP-H965101431,CDM,C1729,HCPCS,272,RC,,,outpatient,,,511.85,358.295,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH DRN 10FRX20CM EXODUS LF -,SUP-H965101511,CDM,C1729,HCPCS,272,RC,,,outpatient,,,511.85,358.295,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATHETER DRN 8FRX25CM EXODUS TIGHT TIP LOOP -,SUP-H965104031,CDM,C1729,HCPCS,272,RC,,,outpatient,,,537.4,376.18,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH DRN 10FRX25CM EXODUS TIGHT TIP LOOP -,SUP-H965104111,CDM,C1729,HCPCS,272,RC,,,outpatient,,,537.4,376.18,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH MULTIPURPOSE 14FR  25CM STD ;OOP W/MARKER BAND -,SUP-H965105621,CDM,C1729,HCPCS,272,RC,,,outpatient,,,2440.88,1708.616,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
SYSTEM EXTERNAL DRAINAGE WITHOUT VENTRICULAR CATH ACCUDRAIN -,SUP-INS8401,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1401.56,981.092,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH NEPH 14FR VTC -,SUP-M001245290,CDM,C1729,HCPCS,272,RC,,,outpatient,,,570.95,399.665,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH DRN 6FRX25CM PIGTL FOGARTY LOOP -,SUP-M001271380,CDM,C1729,HCPCS,272,RC,,,outpatient,,,468.26,327.782,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH DRN MP 10FR UNIV 30CM LCK PIGTL HUB LOCK CANN NTNL NAVR -,SUP-NNU10LPT,CDM,C1729,HCPCS,272,RC,,,outpatient,,,661.69,463.183,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
DRAIN SURG 30CM 12FR UNIV NTNL PIGTL MP -,SUP-NNU12LPT,CDM,C1729,HCPCS,272,RC,,,outpatient,,,661.69,463.183,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATH DRN MP 8FR UNIV 30CM NTNL LCK PIGTL HUB LOCK CANN NAVR -,SUP-NNU8LPT,CDM,C1729,HCPCS,272,RC,,,outpatient,,,661.69,463.183,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
KIT PERICARDIOCENTESIS 6F PIGTAIL CATH -,SUP-PC101,CDM,C1729,HCPCS,272,RC,,,outpatient,,,542.95,380.065,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
KT PERICRDCTS PIGTL 8.3FRX40CM ACC LF -,SUP-PC801,CDM,C1729,HCPCS,272,RC,,,outpatient,,,676.86,473.802,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
VALVE POLARIS ADJ 30-200 SHUNT WITH ITEM BO19-10 INCL -,SUP-SPVA-2010,CDM,C1729,HCPCS,272,RC,,,outpatient,,,14425.01,10097.507,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
CATHETER FIXATION SYSTEM 8F -,SUP-TFK-08,CDM,C1729,HCPCS,272,RC,,,outpatient,,,379.28,265.496,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
TRAY THORACENTESIS PARACENTESIS -,SUP-TPT1000SP,CDM,C1729,HCPCS,272,RC,,,outpatient,,,195.82,137.074,AETNA [1000108],AETNA [100010801],,,,,,0.21103,10342.73217,other,272 with C codes,,
ELECTRODE PCNG 5FRX110CM BIPLR NON- HEP BND -,SUP-006173P,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1018.79,713.153,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes,,
CATH QUAD  MARINR-MDT -,SUP-072322M,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1378.13,964.691,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes,,
CATH EP P- TY CRV 5FR 2-8-2MM SPC 110CM DECAPL MP POLEX10 -,SUP-1085122RT,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1505.34,1053.738,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes,,
CATH ACHIEVE ADVANCE 2ACH20 MAPPING -,SUP-2ACH20,CDM,C1730,HCPCS,272,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes,,
CATH ACHIEVE ADVANCE 2ACH20 REPROCESS MAPPING -,SUP-2ACH20,CDM,C1730,HCPCS,272,RC,,,outpatient,,,2983.75,2088.625,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes,,
CATH RESPONSE CRD -REPROC QUAD 6FR -,SUP-401226,CDM,C1730,HCPCS,272,RC,,,outpatient,,,185.14,129.598,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes,,
CATH EP RESPONSE CRD-SJM QUAD 6FR -,SUP-401226,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes,,
CATH EP RESPONSE JSN -SJM QUAD  6FR -,SUP-401227,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes,,
CATH RESPONSE JSN-REPROC 6FR -,SUP-401227,CDM,C1730,HCPCS,272,RC,,,outpatient,,,185.14,129.598,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes,,
CATH EP RESPONSE CRD-SJM  DECAPOLAR -,SUP-401305,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1081.3,756.91,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes,,
CATH EP RESPONSE CSL-SJM 6FR  DECAPOLAR  STEER -,SUP-401381,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes,,
CATH RESPONSE DEC CSL-REPROC -,SUP-401381,CDM,C1730,HCPCS,272,RC,,,outpatient,,,349.87,244.909,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes,,
CATH EP SPRM JSPHSN CRV 6FR 2-5-2MM ELCTRD SPC 120CM FX QDPL -,SUP-401451,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes,,
CATH EP LIVEWIRE MED SWEEP-REPROC DECAPOLAR -,SUP-401575,CDM,C1730,HCPCS,272,RC,,,outpatient,,,588.34,411.838,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes,,
CATH EP LIVEWIRE MED SWEEP-SJM DECAPOLAR -,SUP-401575,CDM,C1730,HCPCS,272,RC,,,outpatient,,,2056.59,1439.613,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes,,
CATH EP LIVEWIRE LRG SWP-SJM  QUAD STEERABLE  2-5-2 -,SUP-401606,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1876.38,1313.466,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes,,
CATH LIVEWIRE QUAD STEERABLE REPROC -,SUP-401606,CDM,C1730,HCPCS,272,RC,,,outpatient,,,593.19,415.233,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes,,
BIPOLAR PACING CATH BALLOON TIP 5 FR 110CM- PACEL REF:401763 -,SUP-401763,CDM,C1730,HCPCS,272,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes,,
CATH  LIVEWIRE 7F DUO SUPER LRG CURL-REPROC 2/10 -,SUP-401904,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1154.02,807.814,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes,,
CATH EP LIVEWIRE SUPER LRG CURL- SJM DECA 2-10-2 -,SUP-401904,CDM,C1730,HCPCS,272,RC,,,outpatient,,,4392.08,3074.456,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes,,
CATH LIVEWIRE MED CRL-REPROC 2-2-2 NO SPACE -,SUP-401908,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1591.63,1114.141,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes,,
CATH EP LIVEWIRE EXTRA LGE CURL-REPROC  DECAPL 2-5-2 -,SUP-401915,CDM,C1730,HCPCS,272,RC,,,outpatient,,,612.91,429.037,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes,,
CATH EP  LIVEWIRE EXTRA LGE CURL-SJM  DECAPL 2-5-2 -,SUP-401915,CDM,C1730,HCPCS,272,RC,,,outpatient,,,2258.01,1580.607,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes,,
CATH  LIVEWIRE DUO DEC SUPER LGE CURL-REPROC 2-8-2-60-2-8-2 -,SUP-401932,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1208.14,845.698,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes,,
CATH EP LIVEWIRE LRG SWP -SJM  QUAD STEER 5-5-5 NO SPACE -,SUP-401934,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1876.38,1313.466,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes,,
CATH EP LIVEWIRE LRG SWP -REPROC  QUAD STEER 5-5-5 NO SPACE -,SUP-401934,CDM,C1730,HCPCS,272,RC,,,outpatient,,,593.19,415.233,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes,,
CATH EP SUPREME CRD-2 -SJM QUAD -,SUP-402004,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes,,
CATH RESPONSE CRD-2 REPROC 6FR -,SUP-402004,CDM,C1730,HCPCS,272,RC,,,outpatient,,,193.84,135.688,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes,,
INQUIRY STEERABLE  SJM EP CATH 6FR -,SUP-81102,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes,,
CATH 20MM ACHIEVE MAPPING EP CRV 3.3FRX6MM SPC 165CM BIPLR -,SUP-990063020,CDM,C1730,HCPCS,272,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes,,
MEDIGUIDE LV CATH MED SWEEP MODEL D402058 -,SUP-D402058,CDM,C1730,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes,,
ADVISOR HD GRID MAPPING CATHETER D-AVHD-DF 16 REPRO -,SUP-D-AVHD-DF-16,CDM,C1730,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes,,
ADVISOR HD GRID MAPPING CATHETER D-AVHD-DF16 -,SUP-D-AVHD-DF-16,CDM,C1730,HCPCS,272,RC,,,outpatient,,,9090.65,6363.455,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes,,
EPSTAR CATHETER DCF-2-8-55-130 -,SUP-DCF-2-8-55-130,CDM,C1730,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes,,
CATHETER INQUIRY STEER 4 FR DEC 1110-4-2-M IBI-81530 -,SUP-IBI-81530,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes,,
CATH EP POLARISX270DG ANG 6FR 2.5-5-2.5MM SPC 105CM QDPL -,SUP-M0047003D0,CDM,C1730,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,,,,41.56393,6517.99605,other,272 with C codes,,
BLAZER DX -20 CATHETER SUPERLARGE CURVE -,SUP-20SL2860,CDM,C1731,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,,,,399.86,4619.19363,other,272 with C codes,,
CATH EP LIVEWIRE MED CURL-SJM  2-2-2 -,SUP-401908,CDM,C1731,HCPCS,272,RC,,,outpatient,,,4392.08,3074.456,AETNA [1000108],AETNA [100010801],,,,,,399.86,4619.19363,other,272 with C codes,,
CATH EP LIVEWIRE SUPER LGE CURL-SJM 2-8-2-60-2-8-2 -,SUP-401932,CDM,C1731,HCPCS,272,RC,,,outpatient,,,4596.25,3217.375,AETNA [1000108],AETNA [100010801],,,,,,399.86,4619.19363,other,272 with C codes,,
CATH EP REFLEXION SPIRAL SJM -,SUP-D402893,CDM,C1731,HCPCS,272,RC,,,outpatient,,,6442.39,4509.673,AETNA [1000108],AETNA [100010801],,,,,,399.86,4619.19363,other,272 with C codes,,
CATH ABLT BLAZER D X-20 SUPER LRG 7FR SHFT 2-10-2MM SPC -,SUP-M00420SL21020,CDM,C1731,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,,,,399.86,4619.19363,other,272 with C codes,,
CATH ACHIEVE ADVANCE 2ACH15 MAPPING -,SUP-2ACH15,CDM,C1732,HCPCS,272,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes,,
CATH ACHIEVE ADVANCE 2ACH15 REPROCESS MAPPING -,SUP-2ACH15,CDM,C1732,HCPCS,272,RC,,,outpatient,,,2983.75,2088.625,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes,,
CATH ACHIEVE ADVANCE 2ACH25  MAPPING -,SUP-2ACH25,CDM,C1732,HCPCS,272,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes,,
SOFTWARE MED ENSITE FUSION REGST MOD XPD F/SEG CT -,SUP-75-05772-001,CDM,C1732,HCPCS,272,RC,,,outpatient,,,27847.5,19493.25,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes,,
CATHETER PVAC GOLD - REF:990078 -,SUP-990078,CDM,C1732,HCPCS,272,RC,,,outpatient,,,25991,18193.7,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes,,
CATH ABLT THERMOCOOL SF CARTO XP D-F CRV 8FR 2-5-2MM SPC -,SUP-BNI35DFH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,11324.65,7927.255,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes,,
CATH ABLT THERMOCOOL SF NAV F-J CRV 8FR 2-5-2MM SPC 115CM -,SUP-BNI35FJH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,11324.65,7927.255,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes,,
CATH EP LASSO NAV ECO D-TYP CRV 7FR 4FR LOOP 25-15MM 2-6-2MM -,SUP-D134301,CDM,C1732,HCPCS,272,RC,,,outpatient,,,7257.24,5080.068,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes,,
CATH EP WEBSTER CS CS-D CRV 6FR 2-8-2MM SPC 115CM SGL-BRD -,SUP-D135303,CDM,C1732,HCPCS,272,RC,,,outpatient,,,2644.95,1851.465,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes,,
CATH EP WEBSTER CS CS-F CRV 6FR2MM TIP 2-8-2MM SPC 115CM FX -,SUP-D135304,CDM,C1732,HCPCS,272,RC,,,outpatient,,,2014.19,1409.933,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes,,
CATH ABLT NAVISTAR C F-TY CRV 7FR EP -,SUP-D17TCFLRT,CDM,C1732,HCPCS,272,RC,,,outpatient,,,7057.77,4940.439,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes,,
POLARX FIT BALLOON CATHETER ST REF:M004CRBS2060 -,SUP-M004CRBS2060,CDM,C1732,HCPCS,272,RC,,,outpatient,,,14852,10396.4,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes,,
POLARX FIT BALLOON CATHETER LT REF:M004CRBS2160 -,SUP-M004CRBS2160,CDM,C1732,HCPCS,272,RC,,,outpatient,,,14852,10396.4,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes,,
CATH POLARMAP CIRCULAR DX MAPPING CATHETER REF:M004CRBS7210 -,SUP-M004CRBS7210,CDM,C1732,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes,,
CATHETER INTELLANAV ST 7/110/2.5/7-4 QUAD STD -,SUP-M004R5031TH0,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes,,
CATHETER INTELLANAV ST K2 7/110/2.5/7-4 QUAD -,SUP-M004R5031THK20,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes,,
INTELLAMAP ORION CATHETER M004RC64S0 -,SUP-M004RC64S0,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes,,
CATH ABLT NAVISTAR THERMOCOOL D-CRV 8FR 2-5-2MM SPC 115CM -,SUP-NI75TCDH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes,,
CATH ABLT THERMOCOOL F-TY CRV 7.5FR 2-5-2MM SPC 115CM COOL -,SUP-NI75TCFH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes,,
CATH ABLT NAVISTAR C D-TYP CRV 7FR 1-7-4MM SPC 4MM TIP 115CM -,SUP-NS7TCDL174HS,CDM,C1732,HCPCS,272,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes,,
CATH ABLT NAVISTAR DS F-TY CRV 7FR 1-7-4MM SPC 8MM TIP 115CM -,SUP-NS7TCF8L174HS,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes,,
CATH ABLT NAVISTAR F-TY CRV 7FR 1-7-4MM SPC 4MM TIP 115CM -,SUP-NS7TCFL174HS,CDM,C1732,HCPCS,272,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,,,,399.86,19966.6575,other,272 with C codes,,
CATH ABLT FREEZOR 4MM TIP MDT -,SUP-207F3,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
CATH CRYABL FREEZOR MAX CRV 9FR 3-5-2MM SPC 90CM STEER BIDIR -,SUP-209F3,CDM,C1733,HCPCS,272,RC,,,outpatient,,,9124.6,6387.22,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
CATH ABLT FREEZOR XTRA 6MM 7FR 2-5-2MM SPC 108CM -,SUP-217F3,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
CATH ABLT FREEZOR XTRA LG CURVE 6MM 7FR REF:217F5 -,SUP-217F5,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
CATH CRYABL ARCTIC FRN 23MM STEER BIDIR EP -,SUP-2AF234,CDM,C1733,HCPCS,272,RC,,,outpatient,,,16337.2,11436.04,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
CATH CRYABL ARCTIC FRN 28MM STEER BIDIR EP -,SUP-2AF284,CDM,C1733,HCPCS,272,RC,,,outpatient,,,16337.2,11436.04,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
CATH ESPH ABLT 18MM 360DG ELCTRD ARRAY 85CM BARRX RF -,SUP-32041-18,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8339.46,5837.622,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
CATH PCNG 5FRX2.5CM SPC 110CM PACEL TEMP BIPLR 60DG CRV RT -,SUP-401775,CDM,C1733,HCPCS,272,RC,,,outpatient,,,513.48,359.436,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
CATH ABLT SAFIRE MED SWP 7FR 2-5-2MM SPC 115CM QDPL BIDIR -,SUP-402807,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3010.01,2107.007,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
CATH ABL SAFIRE LRG SWP 7FR -,SUP-402808,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3208.13,2245.691,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
CATH SAFIRE 7F 4MM SM CRL US -,SUP-402809,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3010.01,2107.007,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
CATH ABLT SAFIRE MED CURL 7FR 2-5-2MM SPC 115CM 7MM BIDIR -,SUP-402810,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3208.13,2245.691,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
CATH ABLT SAFIRE LRG CRV 7FR 2-5-2MM SPC 115CM QDPL BIDIR -,SUP-402811,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3208.13,2245.691,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
CATH ABLT SAFIRE LRG CRV 7FR 2-5-2MM 115CM 5MM QDPL BIDIR -,SUP-402817,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3232,2262.4,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
CATH SAFIRE TX  MED 7F 8 MM BI-DIR -,SUP-402839,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4501.88,3151.316,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
CATH SAFIRE TX  LRG  BI-DIR  7F 8MM -,SUP-402840,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4501.88,3151.316,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
FARAWAVE PFA CATHETER REF:41C601 -,SUP-41C601,CDM,C1733,HCPCS,272,RC,,,outpatient,,,25062.75,17543.925,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
FARAWAVE PFA CATHETER 35MM REF:41C602 -,SUP-41C602,CDM,C1733,HCPCS,272,RC,,,outpatient,,,25062.75,17543.925,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
CATHETER BARRX RFA EXPRESS RFA BALLOON -,SUP-64082,CDM,C1733,HCPCS,272,RC,,,outpatient,,,10218.18,7152.726,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
CATH ABLT THRP 7FR 2-5-2 MMMEDX110CM 4MM -,SUP-83365,CDM,C1733,HCPCS,272,RC,,,outpatient,,,2491.24,1743.868,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
CATH ABLT THRP 7FR 2-5-2 MMX110CM 4MM -,SUP-83366,CDM,C1733,HCPCS,272,RC,,,outpatient,,,2634.35,1844.045,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
CATH ABLT THRP 2-5-2 MMMEDX110CM DL -8 -,SUP-83371,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
CATH ABLT THRP 7FR MED 8MM DL -,SUP-83372,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3542.31,2479.617,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
CATH ABLT THRP DL -8 EXTEND REACH CRV 7FR 2-5-2MM SPC 110CM -,SUP-83374,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
CATHETER BARRX FOCAL 90 RFA 20MMX 13MM -,SUP-90-9100,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8492.24,5944.568,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
CATHETER BARRX FOCAL 90 RFA 40MM X 13MM -,SUP-90-9500,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7469.44,5228.608,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
CATH ABLT SAFIRE BLU LRG CURL DIST REACH CRV 7FR 2-5-2MM SPC -,SUP-A088109,CDM,C1733,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
CATH CRYABL ARCTIC FRN ADVANCED PRO 28MM STEER BIDIR EP -,SUP-AFAPRO28,CDM,C1733,HCPCS,272,RC,,,outpatient,,,16337.2,11436.04,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
FLEXABILITY SENSOR ENABLED BI DIR IRR CATH FJ CURVE -,SUP-A-FASE-FJ,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8190.92,5733.644,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
CATH 7F D/F BI-DIRECT CS REPROC -,SUP-BD710DF282RTS,CDM,C1733,HCPCS,272,RC,,,outpatient,,,1132.05,792.435,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
CATH ABLT WEBSTER EZ STEER D-F ASYM CRV 7FR 2-8-2MM SPC -,SUP-BD710DF282RTS,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3547.08,2482.956,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
CATH CV 7FRX3CM SIL CLSR FST LF ACC -,SUP-CF7-3-60,CDM,C1733,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
CATH ELCSURG 7FRX60CM RF FLXB CLSR FST -,SUP-CF7-7-60,CDM,C1733,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
AGILLIS NXT STEERABLE INTRO DUAL-REACH REF: I-V2-MED -,SUP-I-V2-MED,CDM,C1733,HCPCS,624,RC,,,outpatient,,,5.89,4.123,AETNA [1000108],AETNA [100010801],,,76.8,,4.52,1.322305,17969.99175,percent of total billed charges,,,
CATH ABLT BLAZER II STD CRV 7FRX2.5MM SPC 4MM TIP QDPL DIST -,SUP-M0045031TH0,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
CATH ABLT BLAZER II STD CRV 7FRX2.5MM SPC QDPL EXTEND DIST -,SUP-M0045086TL0,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
CATH ABLT BLAZER PRIM XP LRG CRV 8MM TIP QDPL EP -,SUP-M004P4500THK20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7427,5198.9,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
CATH ABLT BLAZER PRIM XP STD CRV STR 7FR 8FR TIP 2.5MM SPC -,SUP-M004P4790TH0,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7639.2,5347.44,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
CATH ABLT BLAZER PRIM XP LRG CRV 10mm  8FRX2.5MM SPC 110CM -,SUP-M004P4790THK20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7639.2,5347.44,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
CATH ABLT BLAZER PRIM HTD ASYM CRV 7FRX2.5MM SPC 110CM QDPL -,SUP-M004P5031THN40,CDM,C1733,HCPCS,272,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
CATH ABLT INTELLATIP MIFI XP STD CRV STR 7FR 8FR TIP 2.5MM -,SUP-M004PM45000,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
CATH ABLT INTELLATIP MIFI XP LRG CRV STR 7FR 8FR TIP 2.5MM -,SUP-M004PM4500K20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
CATHETER INTELLANAV MIFI OI 7.5/110/2.5.4.5 STD -,SUP-M004PMR96200,CDM,C1733,HCPCS,272,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
CATHETER INTELLANAV MIFI K2 OI 7.5/110/2.5/4.5 -,SUP-M004PMR9620K20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
PULSESELECT PFA LOOP CATHETER REF: PSCC100 -,SUP-PSCC100,CDM,C1733,HCPCS,272,RC,,,outpatient,,,23763.2,16634.24,AETNA [1000108],AETNA [100010801],,,,,,1.322305,17969.99175,other,272 with C codes,,
VOLT PFA CATHETER REF: P-SPI-DF8 -,SUP-VOLT PFA CATHETER REF: P-SPI-DF8,CDM,C1733,HCPCS,624,RC,,,outpatient,,,5.89,4.123,AETNA [1000108],AETNA [100010801],,,76.8,,4.52,1.322305,17969.99175,percent of total billed charges,,,
CATHETER 27CM GLIDEPATH LONG TERM HEMO -,SUP-5393270,CDM,C1750,HCPCS,278,RC,,,outpatient,,,2210.31,1547.217,AETNA [1000108],AETNA [100010801],,,76.8,,1697.52,12.50914,1945.83552,percent of total billed charges,,,
CATH HMDLYS HEMOSPLIT 14.5FRX31CM -,SUP-5733310,CDM,C1750,HCPCS,278,RC,,,outpatient,,,2390.53,1673.371,AETNA [1000108],AETNA [100010801],,,76.8,,1835.93,12.50914,1945.83552,percent of total billed charges,,,
CATH SHNT 1.2X2.5MM HLTR 65CM SIL RBR T-SHP 1PC -,SUP-82-1699,CDM,C1750,HCPCS,278,RC,,,outpatient,,,2533.64,1773.548,AETNA [1000108],AETNA [100010801],,,76.8,,1945.84,12.50914,1945.83552,percent of total billed charges,,,
CATH PERITONEALTENCKHOFF42CM -,SUP-8810888003,CDM,C1750,HCPCS,278,RC,,,outpatient,,,255.92,179.144,AETNA [1000108],AETNA [100010801],,,76.8,,196.55,12.50914,1945.83552,percent of total billed charges,,,
CATH TENCKHOFF 15FRX62CM -,SUP-8811313010,CDM,C1750,HCPCS,278,RC,,,outpatient,,,366.38,256.466,AETNA [1000108],AETNA [100010801],,,76.8,,281.38,12.50914,1945.83552,percent of total billed charges,,,
KIT CATHETER PERITONEAL DIALYSIS ARGYLE 62CM SILICONE CURLED -,SUP-8817278006,CDM,C1750,HCPCS,278,RC,,,outpatient,,,450.39,315.273,AETNA [1000108],AETNA [100010801],,,76.8,,345.9,12.50914,1945.83552,percent of total billed charges,,,
KT DLYS 60CM CURL STYL 60CM PREPERITONEIAL CUF CLMP ADPTR -,SUP-8817278010,CDM,C1750,HCPCS,278,RC,,,outpatient,,,537.58,376.306,AETNA [1000108],AETNA [100010801],,,76.8,,412.86,12.50914,1945.83552,percent of total billed charges,,,
KT HMDLYS PRMCTH 36CM SIL RBR LUMX2 -,SUP-8817748001,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1012.58,708.806,AETNA [1000108],AETNA [100010801],,,76.8,,777.66,12.50914,1945.83552,percent of total billed charges,,,
CATH HMDLYS MHRKR 11.5FRX16CM PU ACUTE LUMX2 ACC -,SUP-8817749001,CDM,C1750,HCPCS,278,RC,,,outpatient,,,923.47,646.429,AETNA [1000108],AETNA [100010801],,,76.8,,709.22,12.50914,1945.83552,percent of total billed charges,,,
CATH HMDLYS PALINDROME 14.5FRX19CM -,SUP-8888119360P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1259.4,881.58,AETNA [1000108],AETNA [100010801],,,76.8,,967.22,12.50914,1945.83552,percent of total billed charges,,,
KIT CATHETER PALINDROME 14.5FR X 19CM -,SUP-8888145014P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,AETNA [1000108],AETNA [100010801],,,76.8,,1044.6,12.50914,1945.83552,percent of total billed charges,,,
KIT CATHETER PALINDROME 14.5FR X 23CM -,SUP-8888145015P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,AETNA [1000108],AETNA [100010801],,,76.8,,1044.6,12.50914,1945.83552,percent of total billed charges,,,
KIT CATHETER PALINDROME 14.5FR X 28CM -,SUP-8888145016P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,AETNA [1000108],AETNA [100010801],,,76.8,,1044.6,12.50914,1945.83552,percent of total billed charges,,,
KIT CATHETER PALINDROME 14.5FR X 33CM -,SUP-8888145042P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,AETNA [1000108],AETNA [100010801],,,76.8,,1044.6,12.50914,1945.83552,percent of total billed charges,,,
STENCIL PERITONEAL DIALYSIS RITUS PRE-OPERATIVE -,SUP-8888412305,CDM,C1750,HCPCS,278,RC,,,outpatient,,,55.72,39.004,AETNA [1000108],AETNA [100010801],,,76.8,,42.79,12.50914,1945.83552,percent of total billed charges,,,
KIT CATHETER PERITONEAL DIALYSIS ARGYLE 62.5CM SILICONE -,SUP-8888413823,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1150.95,805.665,AETNA [1000108],AETNA [100010801],,,76.8,,883.93,12.50914,1945.83552,percent of total billed charges,,,
KT HMDLYS PALINDROME 15FRX43CM CRBTHN ACC -,SUP-8888541023P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1612.03,1128.421,AETNA [1000108],AETNA [100010801],,,76.8,,1238.04,12.50914,1945.83552,percent of total billed charges,,,
KT HMDLYS PALINDROME 15FRX48CM CRBTHN ACC -,SUP-8888541028P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1612.03,1128.421,AETNA [1000108],AETNA [100010801],,,76.8,,1238.04,12.50914,1945.83552,percent of total billed charges,,,
CATH TESIO LEFT BFL-6 -,SUP-BFL-6,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1595.45,1116.815,AETNA [1000108],AETNA [100010801],,,76.8,,1225.31,12.50914,1945.83552,percent of total billed charges,,,
CATH HMDLYS BFL TSO 10FR 22CM/25CM CUF -,SUP-BFR-6,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1690.86,1183.602,AETNA [1000108],AETNA [100010801],,,76.8,,1298.58,12.50914,1945.83552,percent of total billed charges,,,
ST HMDLYS TESIO 10FRX52CM PU LUMX2 INTRO NDL GW TUNNLER -,SUP-BFR-6E,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1881.68,1317.176,AETNA [1000108],AETNA [100010801],,,76.8,,1445.13,12.50914,1945.83552,percent of total billed charges,,,
CATH ARROW NEXT STEP 23CM HEMODIALYSIS -,SUP-CS-15232-X,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1436.44,1005.508,AETNA [1000108],AETNA [100010801],,,76.8,,1103.19,12.50914,1945.83552,percent of total billed charges,,,
CATH ARROW NEXT STEP 27CM HEMODIALSIS -,SUP-CS-15272-X,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1436.44,1005.508,AETNA [1000108],AETNA [100010801],,,76.8,,1103.19,12.50914,1945.83552,percent of total billed charges,,,
CATHETER KIT DIALYSIS 15FR ARROW -,SUP-CS-15282-SPM,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,12.50914,1945.83552,percent of total billed charges,,,
HC Try Cv Lumx3 5fr Triple Powerpicc Acc,PX-27200312,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1544,1080.8,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
HC Needle Provena 4fr Dl Picc 4fr Dl Max Barrier,PX-27200313,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1417,991.9,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
HC Needle Provena 4fr Dl Provena Midline Max Barrier,PX-27200314,CDM,C1751,HCPCS,272,RC,,,outpatient,,,967,676.9,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
HC Cath Cv Lumx2 4frx20 Cm Dual Mdln,PX-27200315,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1012,708.4,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
HC Needle Provena 3fr Sl Provena Midline Max Barrier,PX-27200316,CDM,C1751,CPT,272,RC,,,outpatient,,,831,581.7,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
KIT URETERAL IRIS INFRARED -,SUP-0220180518,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1863.01,1304.107,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
TRY CV LUMX2 9FRX90CM SIL PED HKMN LF ACC -,SUP-0600604,CDM,C1751,HCPCS,272,RC,,,outpatient,,,2291.14,1603.798,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH SWAN GANZ TD 6FR X 110 - 096F6P -,SUP-096F6P,CDM,C1751,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH GUIDE ECHELON 14 MICRO STR AIGHT REF:105-5092-150 -,SUP-105-5092-150,CDM,C1751,HCPCS,272,RC,,,outpatient,,,4838.16,3386.712,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
TRY CV LUMX1 4FR PU POWERPICC LF ACC SINGLE -,SUP-1174108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1252.61,876.827,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
5FR POWERPICC TRAY CV LUMX2 DBL PU  LF ACC -,SUP-1275108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1232.53,862.771,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH SWAN GANZ TD 7FR 131F7P -,SUP-131F7P,CDM,C1751,HCPCS,272,RC,,,outpatient,,,501.81,351.267,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATHETER IV JELCO PROTECTIV 24G X 3/4IN YELLOW -,SUP-305306,CDM,C1751,HCPCS,272,RC,,,outpatient,,,12.2,8.54,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATHETER IV WINGED HUB PEDI 24G X 5/8â€ PERIPHERAL RADIOPAQUE -,SUP-307300,CDM,C1751,HCPCS,272,RC,,,outpatient,,,11.94,8.358,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
TRY CV LUMX1 5FRX55CM PU POWERPICC LF ACC -,SUP-3175155,CDM,C1751,HCPCS,272,RC,,,outpatient,,,456.94,319.858,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH IV PROTECTIVE 22 X 1 -,SUP-326010,CDM,C1751,HCPCS,272,RC,,,outpatient,,,12.05,8.435,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH IV PROT 22GAX1IN FEP PLYMR SAFTY STR HUB WNG INDWL VPNT -,SUP-326010,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.66,7.462,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH IV PROT 24GAX.75IN FEP PLYMR SAFTY STR HUB WNG INDWL -,SUP-326310,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.68,7.476,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH IV PROTECTIVE 24 X 3/4 RA -,SUP-326310,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.68,7.476,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH IV PROT 20GAX1IN FEP PLYMR SAFTY STR HUB WNG INDWL VPNT -,SUP-326710,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.28,6.496,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH IV PROTECTIVE 20 X 1 -,SUP-326710,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.28,6.496,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH IV 14GA X 1.25 IN VIAVALVE -,SUP-3268,CDM,C1751,HCPCS,272,RC,,,outpatient,,,12.05,8.435,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
TRY CV LUMX2 5FRX55CM PU POWERPICC LF ACC -,SUP-3275335,CDM,C1751,HCPCS,272,RC,,,outpatient,,,602.11,421.477,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH IV ANGIOCATH 14 X 1.88 -,SUP-381167,CDM,C1751,HCPCS,272,RC,,,outpatient,,,22.71,15.897,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH IV 24G X .56 IN INSYTE BD -,SUP-381411,CDM,C1751,HCPCS,272,RC,,,outpatient,,,14.41,10.087,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH IV 20G X 1.88 IN INSYTE BD -,SUP-381437,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.86,6.902,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH IV INSYT AUTOGRD 20GAX48MM VIALON SAFTY WNG INDWL BLD -,SUP-381437,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.86,6.902,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH IV 14G X 1.75 IN INSYTE BD -,SUP-381467,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.87,6.909,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH IV 24G X .56 IN INSYTE BD -,SUP-381511,CDM,C1751,HCPCS,272,RC,,,outpatient,,,14.42,10.094,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH IV 22G x 1 IN INSYTE AUTOGUARD BC -,SUP-382523,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.12,7.084,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH IV 16G X 1.16 IN INSYTE BD -,SUP-382554,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.86,6.902,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH IV SAF-T-INTIMA 23GAX0.75IN VIALON SAFTY WNG INDWL -,SUP-383323,CDM,C1751,HCPCS,272,RC,,,outpatient,,,20.11,14.077,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH IV SAF-T-INTIMA 20GAX1IN VIALON SAFTY WNG INDWL SLFBNT -,SUP-383336,CDM,C1751,HCPCS,272,RC,,,outpatient,,,19.62,13.734,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH IV 24G X .75 IN NEXIVA BD -,SUP-383511,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH IV 22GA X 1 IN NEXIVA BD -,SUP-383512,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH IV 20GA X 1 IN NEXIVA BD -,SUP-383516,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH IV 18GA X 1.25 IN NEXIVA BD -,SUP-383519-A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
ST NEEDLE INFS 24GAX0.75IN NEXIVA SAFTY LRG BORE WNG DL PRT -,SUP-383531,CDM,C1751,HCPCS,272,RC,,,outpatient,,,31.28,21.896,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
KT ARTERIAL LN 20GAX20CM 1ST MI D CATH MDLN SFN -,SUP-384304,CDM,C1751,HCPCS,272,RC,,,outpatient,,,468.67,328.069,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATHETER IV 16 X 2 SFR -,SUP-4082,CDM,C1751,HCPCS,272,RC,,,outpatient,,,11.6,8.12,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH IV 14 X 2.25in JELCO -,SUP-4088,CDM,C1751,HCPCS,272,RC,,,outpatient,,,20.36,14.252,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
TRY MIDLINE CATH 4FR 18GA LUM LUMX1 LF -,SUP-4154108,CDM,C1751,HCPCS,272,RC,,,outpatient,,,526.32,368.424,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
TRY CV LUMX1 4FR PU LF ACC -,SUP-4154108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1151.36,805.952,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH IV INTROCAN SAFTY 20GAX1.75IN FEP POYMER SAFTY STR HUB -,SUP-4252527-02,CDM,C1751,HCPCS,272,RC,,,outpatient,,,7.39,5.173,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH IV INTROCAN SAFTY 18GAX2.5IN TFLN FEP PLYMR SAFTY STR -,SUP-4252561-02,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.22,6.454,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH CV 5FRX8CM POWERWAND PWR-INJ MDLN QCK CHRNFLX C -,SUP-72135,CDM,C1751,HCPCS,272,RC,,,outpatient,,,811.07,567.749,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
PICC LINE CHANGE KIT IVAD ACCE -,SUP-73240B,CDM,C1751,HCPCS,272,RC,,,outpatient,,,17.27,12.089,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
PORT INFS 8FR 1LUM -,SUP-7711802,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1505.34,1053.738,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH PA 8FRX110CM SWAN-GNZ C CMB VOL LUMX7 INJ PRT ANTMIC -,SUP-777HF8,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1446.77,1012.739,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
SWAN-GANZ VIP/ OXIMETRY THERMOD CATHETER -,SUP-782F75M,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1519.92,1063.944,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
KT IT F/LEGEND SYNCHROMED INFS PMP RPR -,SUP-8590-9,CDM,C1751,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
TRY CV LUMX1 4FRX60CM PU POLY P-Q-CTH LF ACC -,SUP-9154108,CDM,C1751,HCPCS,272,RC,,,outpatient,,,908.45,635.915,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
TRY CV LUMX1 4FR STD 55CM PU POWERPICC LF ACC -,SUP-9174108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1953.71,1367.597,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH CV 5FRX10CM POWERWAND PWR-INJ MDLN CHRNFLX C -,SUP-92006,CDM,C1751,HCPCS,272,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
TRY CV LUMX2 5FRX60CM PU POLY P-Q-CTH LF ACC -,SUP-9255108,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1040.96,728.672,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH PA 7.5FRX110CM SWAN-GNZ PCNG LUMX5 AMC THRMBSHLD HPCT -,SUP-931HF75,CDM,C1751,HCPCS,272,RC,,,outpatient,,,303.24,212.268,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
TRY CV LUMX3 6FR STD 55CM PU POWERPICC LF ACC -,SUP-9386108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,2085.78,1460.046,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH PA 8FRX110CM SWAN-GNZ A-V PCNG LUMX6 INJ PRT ANTMIC AMC -,SUP-991HF8,CDM,C1751,HCPCS,272,RC,,,outpatient,,,787.2,551.04,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
"ACCUCATH 22G 1.25"" BASIC KIT -",SUP-AC0221250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,133.27,93.289,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
KIT CATHETER ACCUCATH ACE 18G 2.25 BASIC -,SUP-AC1182250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,254.41,178.087,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
"ACCUCATH 20G 1.25"" BASIC KIT -",SUP-AC1201250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,133.27,93.289,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
ACCUCATH ACE 20G X 2.25IN BASIC KIT -,SUP-AC1202250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,254.41,178.087,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH PRSS MONTR BLN WDG 5FR -,SUP-AI-07124,CDM,C1751,HCPCS,272,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH A-LN BLN WDG LUMX2 6FRX110CM PA INDWL 1ML CTRL STRK SYR -,SUP-AI-07126,CDM,C1751,HCPCS,272,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH PA 6FRX110CM BLN -,SUP-AI-07365-NHL,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
ST ARTERIAL CATH 20GAX1.75IN SHRP SAFTY LF -,SUP-AK-04020-SPC,CDM,C1751,HCPCS,272,RC,,,outpatient,,,145.29,101.703,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
KT A-LN 20GAX5IN PA INDWL 0.25IN SPR STR SFT TIP JTP GW -,SUP-AK-04510-S,CDM,C1751,HCPCS,272,RC,,,outpatient,,,164.55,115.185,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
KIT CENTRAL VENOUS TWO LUMEN -,SUP-AK-11142-D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,568.91,398.237,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
KT CV LUMX2 4FRX8CM PU ARROW G+ARD LF ACC -,SUP-AK-25402,CDM,C1751,HCPCS,272,RC,,,outpatient,,,431.79,302.253,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
FEMORAL ARTERY CATH KIT  5FR REF: G58398 -,SUP-APM-5.0-35J-1-15-NY,CDM,C1751,HCPCS,272,RC,,,outpatient,,,259.07,181.349,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
KIT CATH TRIPLE LUMEN 20CM CEN -,SUP-ASK-45703-PSCH,CDM,C1751,HCPCS,272,RC,,,outpatient,,,847.94,593.558,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
KT CV MULTLUM 20CM ARROW G+ARD LF ACC -,SUP-ASK-45703-PSCH,CDM,C1751,HCPCS,272,RC,,,outpatient,,,847.94,593.558,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
KT CV LUMX3 7FRX16CM PU ARW HWS LF ACC -,SUP-CDC-12703-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,352.9,247.03,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
KT CV LUMX3 7FRX20CM PU ARW HWS LF ACC -,SUP-CDC-15703-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,408.63,286.041,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
KT CV LUMX1 16GAX20CM PU ARROW G+ARD LF ACC -,SUP-CDC-24301-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,395.61,276.927,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
KT CV LUMX1 16GAX20CM PU ARROW G+ARD LF ACC -,SUP-CDC-24301-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,395.61,276.927,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
ARROW PEDI CENTRAL LINE KIT 13CM -,SUP-CDC-24402-X1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,754.66,528.262,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
SWAN -GANZ TEMP PACR STR EDWARDS -,SUP-D97120F5,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1130.07,791.049,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
SWAN-GANZ BIPOLAR PACING CATH J-TIP 5 FR 90CM -,SUP-D97130F5,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1130.07,791.049,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH PERFUS 20FRX.25IN ACPT 6CM PRFX STR PVC -,SUP-E063,CDM,C1751,HCPCS,272,RC,,,outpatient,,,239.59,167.713,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
ST ARTERIAL CATH 18GAX4.25IN LF -,SUP-FA-04018,CDM,C1751,HCPCS,272,RC,,,outpatient,,,81.46,57.022,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CENTRAL VENOUS CATHETER TRAY 4.0FR -,SUP-G02138,CDM,C1751,HCPCS,272,RC,,,outpatient,,,245.65,171.955,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH INFS 3FR STR 135CM SLIP-CATH NYL SS HYDRCT 0.025IN GW -,SUP-G12044,CDM,C1751,HCPCS,272,RC,,,outpatient,,,283,198.1,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH INFS 3FR STR 150CM SLIP-CATH NYL SS HYDRCT 0.025IN GW -,SUP-G12045,CDM,C1751,HCPCS,272,RC,,,outpatient,,,283,198.1,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
KT BLOOD GS ART 182CM CHMBR IV SPK 3W STPCKX2 122IN PRESSMNT -,SUP-H965700361481,CDM,C1751,HCPCS,272,RC,,,outpatient,,,164.55,115.185,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH INFS 4FRX135CM 10CM INFS ACCESSPLUS VLV PEBAX OCL WIRE -,SUP-IS4-135-10,CDM,C1751,HCPCS,272,RC,,,outpatient,,,793.56,555.492,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH INFS 4FRX135CM 20CM INFS ACCESSPLUS VLV PEBAX OCL WIRE -,SUP-IS4-135-20,CDM,C1751,HCPCS,272,RC,,,outpatient,,,793.56,555.492,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
KT INTRAVENOUS CATH 20GAX8CM POWERGLIDE LF -,SUP-M020081,CDM,C1751,HCPCS,272,RC,,,outpatient,,,493.06,345.142,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
KT INTRAVENOUS CATH 20GAX10CM POWERGLIDE -,SUP-M020101,CDM,C1751,HCPCS,272,RC,,,outpatient,,,493.06,345.142,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH VASC ACCESS 3FR LUMX1 MDLN PU PRELD STYL INTRO GW SYR -,SUP-ML3S20FN,CDM,C1751,HCPCS,272,RC,,,outpatient,,,595.17,416.619,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH CV LUMX1 4FRX200CM SINGLE MDLN -,SUP-MLCT4S20FN,CDM,C1751,HCPCS,272,RC,,,outpatient,,,805.52,563.864,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH PICC LUMX1 6FR PWR PICC -,SUP-MR17036306MB,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1081.3,756.91,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
ARTERIAL CATHETERIZATION KIT 20G -,SUP-NA-04550-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,303.42,212.394,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH CV LUMX2 4FRX20 CM DUAL MDLN -,SUP-P4254108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,982.38,687.666,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH RADIAL ARTERY 20G -,SUP-RA-04020,CDM,C1751,HCPCS,272,RC,,,outpatient,,,55.96,39.172,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
CATH SET RADIAL ARTERY 20GX1.5 -,SUP-RA-04220,CDM,C1751,HCPCS,272,RC,,,outpatient,,,70.49,49.343,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
SET RAPID INFUSION 7FR CATHETER EXCHANGE -,SUP-RC-09700,CDM,C1751,HCPCS,272,RC,,,outpatient,,,61.73,43.211,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
SET RAPID INFUSION 8.5FR CATHETER EXCHANGE -,SUP-RC-09850,CDM,C1751,HCPCS,272,RC,,,outpatient,,,59.52,41.664,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
STYLET ELCSURG 6FRX12CM RF D MRKNG CLOSURERFS -,SUP-RFS2612,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1908.18,1335.726,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
TRY CV LUMX3 5FR TRIPLE  POWERPICC ACC -,SUP-S1385108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1499.41,1049.587,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
MULTI-LUMEN VENOUS CATH 8FR -,SUP-SS-14703,CDM,C1751,HCPCS,272,RC,,,outpatient,,,187.89,131.523,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
C 6FR TRIPLE LUMEN PICC -,SUP-UNDEFINED,CDM,C1751,HCPCS,272,RC,,,outpatient,,,669.86,468.902,AETNA [1000108],AETNA [100010801],,,,,,1.659055,3468.96072,other,272 with C codes,,
KT HMDLYS PWR TRIALYSIS 13FRX20CM LUMX3 SHRT TERM -,SUP-5603200,CDM,C1752,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,AETNA [1000108],AETNA [100010801],,,,,,80.92327,4457.91882,other,272 with C codes,,
TRY HMDLYS PWR TRIALYSIS 13FRX15CM PU ACUTE SHRT TERM LUMX3 -,SUP-5605150,CDM,C1752,HCPCS,272,RC,,,outpatient,,,6217.46,4352.222,AETNA [1000108],AETNA [100010801],,,,,,80.92327,4457.91882,other,272 with C codes,,
KT HMDLYS PWR -TRIALYSIS 13FRX20CM SHRT TERM LUMX3 ACC -,SUP-5605200,CDM,C1752,HCPCS,272,RC,,,outpatient,,,6217.46,4352.222,AETNA [1000108],AETNA [100010801],,,,,,80.92327,4457.91882,other,272 with C codes,,
KT HMDLYS PWR -TRIALYSIS 13FRX20CM SHRT TERM LUMX3 ACC -,SUP-5605200,CDM,C1752,HCPCS,272,RC,,,outpatient,,,1553.05,1087.135,AETNA [1000108],AETNA [100010801],,,,,,80.92327,4457.91882,other,272 with C codes,,
KT HMDLYS PWR -TRIALYSIS 13FRX15CM SHRT TERM LUMX3 ACC -,SUP-5613150,CDM,C1752,HCPCS,272,RC,,,outpatient,,,1372.83,960.981,AETNA [1000108],AETNA [100010801],,,,,,80.92327,4457.91882,other,272 with C codes,,
MAHUKAR CATH DUAL 19FR. -,SUP-8813793009,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,AETNA [1000108],AETNA [100010801],,,,,,80.92327,4457.91882,other,272 with C codes,,
MAHUKUR CATH DUAL 10 FR. -,SUP-8817146007,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,AETNA [1000108],AETNA [100010801],,,,,,80.92327,4457.91882,other,272 with C codes,,
KT HMDLYS MHRKR 11.5FR LNG EXTEND 16CM LUMX2 ACUTE ACC -,SUP-8830415001,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,AETNA [1000108],AETNA [100010801],,,,,,80.92327,4457.91882,other,272 with C codes,,
TRY HMDLYS MHRKR 11.5FRX24CM PU 1% 5ML LIDOCN LUMX2 ACC -,SUP-8831663001,CDM,C1752,HCPCS,272,RC,,,outpatient,,,443.65,310.555,AETNA [1000108],AETNA [100010801],,,,,,80.92327,4457.91882,other,272 with C codes,,
CATH MAHURKAR CURVED 12FR 16CM -,SUP-8888101002HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,553.17,387.219,AETNA [1000108],AETNA [100010801],,,,,,80.92327,4457.91882,other,272 with C codes,,
MAHURKER CATH DUAL 13.5 FR. -,SUP-8888135192,CDM,C1752,HCPCS,272,RC,,,outpatient,,,415.92,291.144,AETNA [1000108],AETNA [100010801],,,,,,80.92327,4457.91882,other,272 with C codes,,
MAHURKAR STRAIGHT CATH KIT 12FR -,SUP-8888221220,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,AETNA [1000108],AETNA [100010801],,,,,,80.92327,4457.91882,other,272 with C codes,,
TRY MHRKR ELITE ACUTE 12FRX20CM -,SUP-8888233420,CDM,C1752,HCPCS,272,RC,,,outpatient,,,859.55,601.685,AETNA [1000108],AETNA [100010801],,,,,,80.92327,4457.91882,other,272 with C codes,,
KT HMDLYS MHRKR 12FRX20CM PU LUMX3 ACUTE ACC -,SUP-8888340629HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,471.37,329.959,AETNA [1000108],AETNA [100010801],,,,,,80.92327,4457.91882,other,272 with C codes,,
KIT HEMODIALYSIS MAHURKAR 12FRX24CM PU LUMX3 ACUTE ACC -,SUP-8888340637HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,489.29,342.503,AETNA [1000108],AETNA [100010801],,,,,,80.92327,4457.91882,other,272 with C codes,,
KT HMDLYS MHRKR 12FRX16CM PU LUMX3 ACUTE ACC -,SUP-8888345611HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,471.37,329.959,AETNA [1000108],AETNA [100010801],,,,,,80.92327,4457.91882,other,272 with C codes,,
KT HEMODIALYSIS MHRKR TLC- C E 12FRX20CM LF -,SUP-8888345637,CDM,C1752,HCPCS,272,RC,,,outpatient,,,499.18,349.426,AETNA [1000108],AETNA [100010801],,,,,,80.92327,4457.91882,other,272 with C codes,,
KT HMDLYS 12FR PU LUMX3 ACUTE ACC CVD -,SUP-8888345637HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,471.37,329.959,AETNA [1000108],AETNA [100010801],,,,,,80.92327,4457.91882,other,272 with C codes,,
IVUS 0.014P RX CATHETER -,SUP-014R,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA [1000108],AETNA [100010801],,,,,,399.86,7720.4409,other,272 with C codes,,
CATH US 8FRX90CM ACUNAV 4W STEER -,SUP-10135936,CDM,C1753,HCPCS,272,RC,,,outpatient,,,10767.7,7537.39,AETNA [1000108],AETNA [100010801],,,,,,399.86,7720.4409,other,272 with C codes,,
CATH DRAGONFLY OPSTAR REF: 1014651 -,SUP-1014651,CDM,C1753,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,,,,399.86,7720.4409,other,272 with C codes,,
CATH US 5FR20MM IMG TAPR 150CM EAGLE EYE GOLD OTW COR PERIPH -,SUP-85900,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,AETNA [1000108],AETNA [100010801],,,,,,399.86,7720.4409,other,272 with C codes,,
CATH US EAGLE EYE PLATINUM REF: 85900P -,SUP-85900P,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,AETNA [1000108],AETNA [100010801],,,,,,399.86,7720.4409,other,272 with C codes,,
CATH US 5FR ID 20MM STR 150CM EAGLE EYE RX COR GLYDX PLTNM -,SUP-85900P,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,AETNA [1000108],AETNA [100010801],,,,,,399.86,7720.4409,other,272 with C codes,,
CATH US EAGLE EYE PLTNM SHORT TIP -,SUP-85900PST,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,AETNA [1000108],AETNA [100010801],,,,,,399.86,7720.4409,other,272 with C codes,,
CATH VISIONS PV 0.018 -,SUP-86700,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,,,,399.86,7720.4409,other,272 with C codes,,
C VOLCANO IVUS PV035 -,SUP-88901,CDM,C1753,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,,,,399.86,7720.4409,other,272 with C codes,,
CATH DX VIEWFLEXX ICE 4W -,SUP-D087031,CDM,C1753,HCPCS,272,RC,,,outpatient,,,8496.49,5947.543,AETNA [1000108],AETNA [100010801],,,,,,399.86,7720.4409,other,272 with C codes,,
CATH DX VIEWFLEX ECO ICE CATHERTER REPROC REF: D087031-R -,SUP-D087031-R,CDM,C1753,HCPCS,272,RC,,,outpatient,,,5544.79,3881.353,AETNA [1000108],AETNA [100010801],,,,,,399.86,7720.4409,other,272 with C codes,,
ECHO ATLANTIS ICE -,SUP-H749389790,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,399.86,7720.4409,other,272 with C codes,,
CATHETER OPTICROSS HD IVUS 5FR -,SUP-H74939352040,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3843.07,2690.149,AETNA [1000108],AETNA [100010801],,,,,,399.86,7720.4409,other,272 with C codes,,
CATHETER OPTICROSS HD IVUS 6FR -,SUP-H74939354080,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3843.07,2690.149,AETNA [1000108],AETNA [100010801],,,,,,399.86,7720.4409,other,272 with C codes,,
CATH US 9FR 9 MHZ 110CM ULTRA ICE IMG COR -,SUP-M00499000,CDM,C1753,HCPCS,272,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,,,,399.86,7720.4409,other,272 with C codes,,
CATH US 6FR CRV NDL 120CM PIONEER + TRPL BRD SHFT PERC -,SUP-PPLUS120,CDM,C1753,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,AETNA [1000108],AETNA [100010801],,,,,,399.86,7720.4409,other,272 with C codes,,
KIT EPIDURAL MINI BREVI-XL -,SUP-181-2340,CDM,C1755,HCPCS,278,RC,,,outpatient,,,481.1,336.77,AETNA [1000108],AETNA [100010801],,,76.8,,369.48,10.327,9046.79424,percent of total billed charges,,,
ST NEEDLE NRV BLCK CONTIPLEX -,SUP-331686,CDM,C1755,HCPCS,278,RC,,,outpatient,,,209.88,146.916,AETNA [1000108],AETNA [100010801],,,76.8,,161.19,10.327,9046.79424,percent of total billed charges,,,
TRAY EPIDURAL PERIFIX 17GA -,SUP-332079,CDM,C1755,HCPCS,278,RC,,,outpatient,,,140.22,98.154,AETNA [1000108],AETNA [100010801],,,76.8,,107.69,10.327,9046.79424,percent of total billed charges,,,
TRAY EPIDURAL WITH DURAPREP -,SUP-332215,CDM,C1755,HCPCS,278,RC,,,outpatient,,,192.5,134.75,AETNA [1000108],AETNA [100010801],,,76.8,,147.84,10.327,9046.79424,percent of total billed charges,,,
EPIDURAL CATHETER SET 20GA -,SUP-333540,CDM,C1755,HCPCS,278,RC,,,outpatient,,,46,32.2,AETNA [1000108],AETNA [100010801],,,76.8,,35.33,10.327,9046.79424,percent of total billed charges,,,
TRY EPDRL/SPIN CONT TUOHY WHITACRE 18GA PERISAFE 1% LIDOCN -,SUP-406048,CDM,C1755,HCPCS,278,RC,,,outpatient,,,114.89,80.423,AETNA [1000108],AETNA [100010801],,,76.8,,88.24,10.327,9046.79424,percent of total billed charges,,,
TRAY SPINAL LIDOCAINE 25GA X 3.5IN WHITACRE 0.75% HCL D8.25W -,SUP-406704,CDM,C1755,HCPCS,278,RC,,,outpatient,,,159.23,111.461,AETNA [1000108],AETNA [100010801],,,76.8,,122.29,10.327,9046.79424,percent of total billed charges,,,
LUMBAR PUNCTURE TRAY PEDI 22GA 1.5IN -,SUP-646,CDM,C1755,HCPCS,278,RC,,,outpatient,,,75.04,52.528,AETNA [1000108],AETNA [100010801],,,76.8,,57.63,10.327,9046.79424,percent of total billed charges,,,
TRAY LUMBAR PUNCTURE 20G -,SUP-648,CDM,C1755,HCPCS,278,RC,,,outpatient,,,92.06,64.442,AETNA [1000108],AETNA [100010801],,,76.8,,70.7,10.327,9046.79424,percent of total billed charges,,,
PASSER SURG SS HOL OBTR STRL -,SUP-8591-38,CDM,C1755,HCPCS,278,RC,,,outpatient,,,571.83,400.281,AETNA [1000108],AETNA [100010801],,,76.8,,439.17,10.327,9046.79424,percent of total billed charges,,,
KT IT 4FR CLSD TIP SIL MRKNG GW SPIN NDL ANCHR RLR -,SUP-8598A,CDM,C1755,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,10.327,9046.79424,percent of total billed charges,,,
KT IT SIL RBR CLSD TIP SIL MRKNG GW SPIN NDL ANCHR RLR -,SUP-8709SC,CDM,C1755,HCPCS,278,RC,,,outpatient,,,3150.84,2205.588,AETNA [1000108],AETNA [100010801],,,76.8,,2419.85,10.327,9046.79424,percent of total billed charges,,,
CATH IT 0.53MM 1.4MM/2.2MM SPIN/PMP SEG SIL RBR TRMBL CLSD -,SUP-8731SC,CDM,C1755,HCPCS,278,RC,,,outpatient,,,3150.84,2205.588,AETNA [1000108],AETNA [100010801],,,76.8,,2419.85,10.327,9046.79424,percent of total billed charges,,,
CATHETER INTRA MEDTRONIC -,SUP-8780,CDM,C1755,HCPCS,278,RC,,,outpatient,,,4430.74,3101.518,AETNA [1000108],AETNA [100010801],,,76.8,,3402.81,10.327,9046.79424,percent of total billed charges,,,
CATHETER INTRATHECAL  MEDTRONIC -,SUP-8781,CDM,C1755,HCPCS,278,RC,,,outpatient,,,4430.74,3101.518,AETNA [1000108],AETNA [100010801],,,76.8,,3402.81,10.327,9046.79424,percent of total billed charges,,,
PROCEDURE 20GA 3.5IN NDL SF-T + F/LP -,SUP-974,CDM,C1755,HCPCS,278,RC,,,outpatient,,,130.65,91.455,AETNA [1000108],AETNA [100010801],,,76.8,,100.34,10.327,9046.79424,percent of total billed charges,,,
PROCEDURE 20GA 3.5IN NDL SF-T + F/LP -,SUP-974,CDM,C1755,HCPCS,278,RC,,,outpatient,,,130.65,91.455,AETNA [1000108],AETNA [100010801],,,76.8,,100.34,10.327,9046.79424,percent of total billed charges,,,
KIT SINGLE SHOT EPIDURAL -,SUP-A4082-20,CDM,C1755,HCPCS,278,RC,,,outpatient,,,85.52,59.864,AETNA [1000108],AETNA [100010801],,,76.8,,65.68,10.327,9046.79424,percent of total billed charges,,,
KT NEEDLE NRV BLCK 20GA STIMUCATH CONT INSL 4CM -,SUP-AB-20604-KS,CDM,C1755,HCPCS,278,RC,,,outpatient,,,518.08,362.656,AETNA [1000108],AETNA [100010801],,,76.8,,397.89,10.327,9046.79424,percent of total billed charges,,,
ST NEEDLE NRV BLCK 20GA STIMUCATH CONT INSL -,SUP-AB-20604-S,CDM,C1755,HCPCS,278,RC,,,outpatient,,,369.64,258.748,AETNA [1000108],AETNA [100010801],,,76.8,,283.88,10.327,9046.79424,percent of total billed charges,,,
KT NEEDLE NRV BLCK 20GA STIMUCATH CONT INSL 8CM -,SUP-AB-20608-KS,CDM,C1755,HCPCS,278,RC,,,outpatient,,,256.13,179.291,AETNA [1000108],AETNA [100010801],,,76.8,,196.71,10.327,9046.79424,percent of total billed charges,,,
SPACEOAR KITS -,SUP-SO-2101,CDM,C1755,HCPCS,278,RC,,,outpatient,,,11779.68,8245.776,AETNA [1000108],AETNA [100010801],,,76.8,,9046.79,10.327,9046.79424,percent of total billed charges,,,
SPINAL -,SUP-UNDEFINED,CDM,C1755,HCPCS,278,RC,,,outpatient,,,80.87,56.609,AETNA [1000108],AETNA [100010801],,,76.8,,62.11,10.327,9046.79424,percent of total billed charges,,,
POWER PULSE KIT ANGIO JET Y SE -,SUP-104834-0020,CDM,C1757,HCPCS,272,RC,,,outpatient,,,214.56,150.192,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
SET POWER PULSE Y SPIKE ANGIO -,SUP-104834-0021,CDM,C1757,HCPCS,272,RC,,,outpatient,,,214.56,150.192,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
C ANGIOJET AVX -,SUP-105039-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,3746.49,2622.543,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
DISC INJ F/THRMB -,SUP-105040001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,5326.22,3728.354,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATH THRMB 5FRX140CM ANGIOJET XVG HYDRCT -,SUP-105042-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,6917.72,4842.404,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
THROMBECTOMY 16.5INX54INX25IN D ANGIOJET -,SUP-105650-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,85111.5,59578.05,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATH THRMB 4.2FR FETCH -,SUP-106127-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATH THRMB 4FRX135CM ANGIOJET SPIROFLEX RX CX-STRM TECH -,SUP-106553-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10062.52,7043.764,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATH THRMB 5FRX135CM ANGIOJET SPIROFLEXVG RX CX-STRM TECH -,SUP-106608-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10062.52,7043.764,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATH THRMB 6FRX90CM ANGIOJET SOLENT PROXI OTW SPRL CUT PROX -,SUP-109676-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10503.9,7352.73,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
6FR 120CM ANGIOJET SOLENT OMNI -,SUP-109681-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9202.73,6441.911,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
4FRX145CM ANGIOJET  SOLENT DISTA THROMBECTOMY SE -,SUP-111303-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11183.56,7828.492,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
ANGIOIJET ZELANTEDVT 8X105CM -,SUP-114610-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10452.1,7316.47,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATH FOGARTY 3FR EMB 3 / SHORT -,SUP-120403FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATH FOGARTY 4FR EMB 4 SHORT -,SUP-120404FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATH FOGARTY 2FR / EMB 2 SHORT -,SUP-120602FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,493.23,345.261,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATH FOGARTY 3FR / EMB 3 -,SUP-120803FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATH FOGARTY 4FR 9MM  EMB 4 -,SUP-120804F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,214.44,150.108,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATH EMBCMT 4FR 9MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120804FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATH EMBCMT 5FR 11MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120805FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATH EMBCMT 6FR 13MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120806FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATH EMBCMT 7FR 14MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120807FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
C FOGARTY 3FR 12TLW403F -,SUP-12TLW403F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
C FOGARTY 4FR 12TLW404F -,SUP-12TLW404F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
C FOGARTY 5F 40 CM -,SUP-12TLW405F35,CDM,C1757,HCPCS,272,RC,,,outpatient,,,567.98,397.586,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
C FOGARTY 6FR 40CM -,SUP-12TLW406F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATH FOGARTY THRU LUMEN 3 -,SUP-12TLW803F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
C FOGARTY 4 80CM -,SUP-12TLW804F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
C FOGARTY 5.5 80CM OTW -,SUP-12TLW805F35,CDM,C1757,HCPCS,272,RC,,,outpatient,,,567.98,397.586,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
C FOGARTY 6 80CM -,SUP-12TLW806F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,567.98,397.586,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATH EMBCMT 7FRX14MM/8FR INFL/DFLT BLN 80CM FOGARTY OTW -,SUP-12TLW807F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATH FOGARTY 6FR. ACC 6/10 -,SUP-1408010,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1347.12,942.984,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATH FOGARTY 6FR. / EMB 6 -,SUP-160246F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1992.72,1394.904,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATH THRMB 5.5FR 138CM PRONTO V4 LRG LUM LNGTDNL WIRE HYDRCT -,SUP-4005,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1765.07,1235.549,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATH PTCA 4MMX4CM SAVVY 120CM OTW COAX MOD PRSS PERIPH TAPR -,SUP-435-404L,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1155.51,808.857,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATH US 5.2FRX106CM 12CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-55112,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATH US 5.2FRX106CM 18CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-55118,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATH US 5.2FRX106CM 24CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-55124,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATH US 5.2FRX135CM 12CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56112,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATH US 5.2FRX135CM 30CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56130,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATH US 5.2FRX135CM 40CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56140,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATH US 5.2FRX135CM 50CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56150,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATH THRMB 0.066IN 6FRX140CM WKG PRONTO LP LPRO XTRCT HYDRCT -,SUP-5010,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1929.38,1350.566,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CLOT TRIEVER SHEATH -,SUP-50-101,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CLOTTRIEVER SHEATH 16FR X 15CM -,SUP-51-101,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
INDIGO CATHETER 5 + LARGE LUMEN ASPIRATION TUBING -,SUP-90178584,CDM,C1757,HCPCS,272,RC,,,outpatient,,,6599.42,4619.594,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
INDIGO CATHETER 6 + LARGE LUMEN ASPIRATION TUBING -,SUP-90178585,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9782.42,6847.694,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATH INFS 6FR 3-10 MMX80CM 10CM BLN TRELLIS OTW MULTLUM INFS -,SUP-BVT608010,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8891.18,6223.826,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATH THRMB 8FRX80CM 15CM TRELLIS INFS PTRN -,SUP-BVT808015,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8891.18,6223.826,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATH THRMB 8FRX80CM 30CM TRELLIS INFS PTRN -,SUP-BVT808030,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9145.82,6402.074,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATH INFS 8FR 5-16 MMX120CM 30CM BLN TRELLIS OTW MULTLUM -,SUP-BVT812030,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8891.18,6223.826,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATH THRMB 0.041IN/0.032IN ID 4.1FR/3.4FR P/D 150CM INDIGO -,SUP-CAT3,CDM,C1757,HCPCS,272,RC,,,outpatient,,,5114.02,3579.814,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATH THRMB 0.064IN/0.054IN ID 6FR/5FR P/D 132CM INDIGO -,SUP-CAT5,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4753.28,3327.296,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATH THRMB 6FRX135CM INDIGO -,SUP-CAT6,CDM,C1757,HCPCS,272,RC,,,outpatient,,,7936.28,5555.396,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
INDIGO CATHETER 7D PLUS DYNAMIC ASPIRATION TUBING -,SUP-CAT7DKIT,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9913.71,6939.597,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATH THRMB 8FRX115CM INDIGO -,SUP-CAT8XTORQ115,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10804.83,7563.381,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATHETER D + INDIGO LARGE LUMEN ASPIRATING TUBING -,SUP-CATD,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9913.71,6939.597,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
INDIGO CATHETER RX 140 CM + LG LUMEN ASPIRATION TUBING -,SUP-CATRXKIT,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8063.6,5644.52,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATHETER SILICONE EMBOLECTOMY 4FR 80CM -,SUP-E1801-48,CDM,C1757,HCPCS,272,RC,,,outpatient,,,811.07,567.749,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATHETER SILICONE EMBOLECTOMY 5FR 80CM -,SUP-E1801-58,CDM,C1757,HCPCS,272,RC,,,outpatient,,,811.07,567.749,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
EXCIPIO SV THROMBECTOMY DEVICE 8MM -,SUP-EXC-0940-165,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11101.87,7771.309,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATH EXPORT AP ASPIRATION 6F 0 -,SUP-EXPORTAP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATH PTCA 4MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50233,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATH EMBCMT 7FRX145CM EXPORT AP BRD ASPIR SFT TIP FLXB -,SUP-GEZ6200US7B,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
EKOS+ KIT 106CM 8 CM -,SUP-H74939605106080,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
DEVICE THROMBECTOMY EKOS+ 106CM X 2.62CM TREATMENT ZONE 12CM -,SUP-H74939605106120,CDM,C1757,HCPCS,272,RC,,,outpatient,,,13181.15,9226.805,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
EKOS+ KIT 106CM 16 CM -,SUP-H74939605106160,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
EKOS+ KIT 106CM 20 CM -,SUP-H74939605106200,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
EKOS+ KIT 135CM 20 CM -,SUP-H74939605135200,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
INDIGO CATHETER 12 115CM HTORQ -,SUP-LITNG12HTORQ115,CDM,C1757,HCPCS,272,RC,,,outpatient,,,25137.01,17595.907,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
INDIGO CATHETER 7 130CM XTORQ -,SUP-LITNG7XTORQ130,CDM,C1757,HCPCS,272,RC,,,outpatient,,,20681.41,14476.987,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
INDIGO CATHETER 8 115CM XTORQ -,SUP-LITNG8XTORQ115,CDM,C1757,HCPCS,272,RC,,,outpatient,,,21424.01,14996.807,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-5080-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-5120-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-6080-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-6120-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-6200-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
ACCESSORY KIT JETI NON STERILE DISPOSABLE -,SUP-WV1500,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
JETI CATHETER KIT 6FR -,SUP-WV6203A,CDM,C1757,HCPCS,272,RC,,,outpatient,,,12141.51,8499.057,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
JETI CATHETER KIT 8FR -,SUP-WV8803A,CDM,C1757,HCPCS,272,RC,,,outpatient,,,17109.5,11976.65,AETNA [1000108],AETNA [100010801],,,,,,48.14178,61024.9455,other,272 with C codes,,
CATH URETH 5FR TIGTL PU LF 70CM NPRT EYE FLXB OPN TIP -,SUP-0139005,CDM,C1758,HCPCS,272,RC,,,outpatient,,,549.07,384.349,AETNA [1000108],AETNA [100010801],,,,,,11.97932,751.60242,other,272 with C codes,,
CATH URETERAL POLLACK 5 70 -,SUP-021305,CDM,C1758,HCPCS,272,RC,,,outpatient,,,94.44,66.108,AETNA [1000108],AETNA [100010801],,,,,,11.97932,751.60242,other,272 with C codes,,
CATH FOLEY 6FR 2W LUBRI-SIL SIL LF PED -,SUP-175806N,CDM,C1758,HCPCS,272,RC,,,outpatient,,,146.07,102.249,AETNA [1000108],AETNA [100010801],,,,,,11.97932,751.60242,other,272 with C codes,,
CATH URET 6FRX70CM PVC OP-EN TIP LF PVC SOF-FLEX -,SUP-G15942,CDM,C1758,HCPCS,272,RC,,,outpatient,,,65.41,45.787,AETNA [1000108],AETNA [100010801],,,,,,11.97932,751.60242,other,272 with C codes,,
CATH URET 5FRX80CM VNYL LUMX1 LF BUSH SL CATHX2 CMN L/S -,SUP-G16746,CDM,C1758,HCPCS,272,RC,,,outpatient,,,1048.26,733.782,AETNA [1000108],AETNA [100010801],,,,,,11.97932,751.60242,other,272 with C codes,,
CATH ANG 5FR KMP 100CM SLIP-CATH BRD HYDRCT -,SUP-G28535,CDM,C1758,HCPCS,272,RC,,,outpatient,,,379.26,265.482,AETNA [1000108],AETNA [100010801],,,,,,11.97932,751.60242,other,272 with C codes,,
CATHETER ACCESS 6FR AXXCESS -,SUP-M0064001161,CDM,C1758,HCPCS,272,RC,,,outpatient,,,61.04,42.728,AETNA [1000108],AETNA [100010801],,,,,,11.97932,751.60242,other,272 with C codes,,
CATH 5FR X 70 CONE TIP BX/20 -,SUP-M0064002111,CDM,C1758,HCPCS,272,RC,,,outpatient,,,53.36,37.352,AETNA [1000108],AETNA [100010801],,,,,,11.97932,751.60242,other,272 with C codes,,
CATH DUAL LUMEN URETERAL -,SUP-M0064051000,CDM,C1758,HCPCS,272,RC,,,outpatient,,,384.35,269.045,AETNA [1000108],AETNA [100010801],,,,,,11.97932,751.60242,other,272 with C codes,,
CATHETER 5.5 S2 -,SUP-1000100,CDM,C1759,HCPCS,272,RC,,,outpatient,,,101147,70802.9,AETNA [1000108],AETNA [100010801],,,,,,399.86,72522.399,other,272 with C codes,,
CATH US 10FRX90CM 5.5-10 MHZ SOUNDSTAR NAV COR -,SUP-SNDSTR10,CDM,C1759,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,AETNA [1000108],AETNA [100010801],,,,,,399.86,72522.399,other,272 with C codes,,
DEVICE SUT -,SUP-123250101,CDM,C1760,HCPCS,278,RC,,,outpatient,,,116.7,81.69,AETNA [1000108],AETNA [100010801],,,76.8,,89.63,26.19915,3585.3312,percent of total billed charges,,,
CLOSURE PERCLOSE PROGLIDE 6F -,SUP-12673-03,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,76.8,,873.85,26.19915,3585.3312,percent of total billed charges,,,
PERCLOSE PROSTYLE -,SUP-12773-03,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,AETNA [1000108],AETNA [100010801],,,76.8,,854.87,26.19915,3585.3312,percent of total billed charges,,,
DEVICE VASC CLSR 56FR STARCLOSE SE -,SUP-14679-01,CDM,C1760,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,26.19915,3585.3312,percent of total billed charges,,,
STAR CLOSE SELF -,SUP-14679-01,CDM,C1760,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,26.19915,3585.3312,percent of total billed charges,,,
ANGIO SEAL STS VIP/PLUS 6FR -,SUP-610119,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,26.19915,3585.3312,percent of total billed charges,,,
ANGIO SEAL STS VIP/PLUS 8FR -,SUP-610121,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,26.19915,3585.3312,percent of total billed charges,,,
DEVICE VASC CLSR 6FR ANGIO-SEAL VIP -,SUP-610130,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,26.19915,3585.3312,percent of total billed charges,,,
DEVICE VASC CLSR 8FR ANGIO-SE  70CM -,SUP-610131,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,26.19915,3585.3312,percent of total billed charges,,,
VASCADE MVP - VENOUS VASCULAR CLOSURE SYSTEM 6-12F -,SUP-800-612C-10U,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,AETNA [1000108],AETNA [100010801],,,76.8,,997.34,26.19915,3585.3312,percent of total billed charges,,,
SYS ATRICLIP STD 40 -,SUP-ACH140,CDM,C1760,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,3585.3312,percent of total billed charges,,,
SYS ATRICLIP STD 45 -,SUP-ACH145,CDM,C1760,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,3585.3312,percent of total billed charges,,,
DEVICE VASC CLSR 5FR EXOSEAL -,SUP-EX500,CDM,C1760,HCPCS,278,RC,,,outpatient,,,933.6,653.52,AETNA [1000108],AETNA [100010801],,,76.8,,717,26.19915,3585.3312,percent of total billed charges,,,
DEVICE VASC CLSR 6FR EXOSEAL -,SUP-EX600,CDM,C1760,HCPCS,278,RC,,,outpatient,,,933.6,653.52,AETNA [1000108],AETNA [100010801],,,76.8,,717,26.19915,3585.3312,percent of total billed charges,,,
PAS-PORT PROXIMAL ANASTOMOSIS -,SUP-FG-000001-13,CDM,C1760,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,AETNA [1000108],AETNA [100010801],,,76.8,,3281.46,26.19915,3585.3312,percent of total billed charges,,,
CELT ACD 5FR CLOSURE DEVICE -,SUP-KCLT-05,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,26.19915,3585.3312,percent of total billed charges,,,
CELT ACD 6FR CLOSURE DEVICE -,SUP-KCLT-06,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,26.19915,3585.3312,percent of total billed charges,,,
CELT ACD 7FR CLOSURE DEVICE -,SUP-KCLT-07,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,26.19915,3585.3312,percent of total billed charges,,,
MYNX GRIP 5FR CLOSURE DEVICE M - MULTIPLES OF 10 ONLY -,SUP-M465MX50210C,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,76.8,,806.63,26.19915,3585.3312,percent of total billed charges,,,
DEVICE 6F/7F MYNX GRIP CLOSURE -,SUP-MX6721,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,AETNA [1000108],AETNA [100010801],,,76.8,,846.97,26.19915,3585.3312,percent of total billed charges,,,
DEVICE VASC CLSR 6FR MYNXGRIP -,SUP-MX6721,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,76.8,,806.63,26.19915,3585.3312,percent of total billed charges,,,
VENASEAL SYSTEM CLOSURE -,SUP-VS-404,CDM,C1760,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,AETNA [1000108],AETNA [100010801],,,76.8,,2658.16,26.19915,3585.3312,percent of total billed charges,,,
BALLOON SHOCKWAVE C2 + IVL CATHETER 2.5X12 REF: C2PIVL2512 -,SUP-C2PIVL2512,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,AETNA [1000108],AETNA [100010801],,,,,,399.86,14791.55236,other,272 with C codes,,
BALLOON SHOCKWAVE C2 + IVL CATHETER 3.0X12 REF: C2PIVL3012 -,SUP-C2PIVL3012,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,AETNA [1000108],AETNA [100010801],,,,,,399.86,14791.55236,other,272 with C codes,,
BALLOON SHOCKWAVE C2 + IVL CATHETER 3.5X12 REF: C2PIVL3512 -,SUP-C2PIVL3512,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,AETNA [1000108],AETNA [100010801],,,,,,399.86,14791.55236,other,272 with C codes,,
BALLOON SHOCKWAVE C2 + IVL CATHETER 4.0X12 REF: C2PIVL4012 -,SUP-C2PIVL4012,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,AETNA [1000108],AETNA [100010801],,,,,,399.86,14791.55236,other,272 with C codes,,
CATHETER  SHOCKWAVE L6 1VL- 8.0 X 30 MM -,SUP-L6IVL080030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,AETNA [1000108],AETNA [100010801],,,,,,399.86,14791.55236,other,272 with C codes,,
CATHETER  SHOCKWAVE L6 1VL- 9.0 X 30 MM -,SUP-L6IVL090030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,AETNA [1000108],AETNA [100010801],,,,,,399.86,14791.55236,other,272 with C codes,,
CATHETER  SHOCKWAVE L6 1VL- 10.0 X 30 MM -,SUP-L6IVL100030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,AETNA [1000108],AETNA [100010801],,,,,,399.86,14791.55236,other,272 with C codes,,
CATHETER  SHOCKWAVE L6 1VL- 12.0 X 30 MM -,SUP-L6IVL120030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,AETNA [1000108],AETNA [100010801],,,,,,399.86,14791.55236,other,272 with C codes,,
CATHETER SHOCKWAVE 6.5 X 60 MM M5+ -,SUP-M5PIVL6560,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,AETNA [1000108],AETNA [100010801],,,,,,399.86,14791.55236,other,272 with C codes,,
TENDON SEMITENINOSIS -,SUP-004023,CDM,C1762,HCPCS,278,RC,,,outpatient,,,5817.25,4072.075,AETNA [1000108],AETNA [100010801],,,76.8,,4467.65,315.339435,23049.35424,percent of total billed charges,,,
GRAFT HUM TIS NAT DENOVO LF -,SUP-00560600010,CDM,C1762,HCPCS,278,RC,,,outpatient,,,17339.71,12137.797,AETNA [1000108],AETNA [100010801],,,76.8,,13316.9,315.339435,23049.35424,percent of total billed charges,,,
ADVANCE NERVE GRAFT D 1-2MM X 15MM -,SUP-111215,CDM,C1762,HCPCS,278,RC,,,outpatient,,,8649.27,6054.489,AETNA [1000108],AETNA [100010801],,,76.8,,6642.64,315.339435,23049.35424,percent of total billed charges,,,
ADVANCE NERVE ALLOGRAFT -,SUP-111230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,AETNA [1000108],AETNA [100010801],,,76.8,,9005.3,315.339435,23049.35424,percent of total billed charges,,,
STRATTICE RECONSTRUCTIVE TISSUE MATRIX 16 X 20CM -,SUP-1620002,CDM,C1762,HCPCS,278,RC,,,outpatient,,,30012.18,21008.526,AETNA [1000108],AETNA [100010801],,,76.8,,23049.35,315.339435,23049.35424,percent of total billed charges,,,
STRATTICE RECONSTRUCTIVE TISSUE MATRIX 20 X 20CM -,SUP-2020002,CDM,C1762,HCPCS,278,RC,,,outpatient,,,24926.57,17448.599,AETNA [1000108],AETNA [100010801],,,76.8,,19143.61,315.339435,23049.35424,percent of total billed charges,,,
GRAFT HUM TIS SPORTSMED TIB IRRAD LF -,SUP-208002,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,315.339435,23049.35424,percent of total billed charges,,,
GRAFT HUM TIS SPORTSMED TIB TNDN POST TIB IRRAD LF -,SUP-208003,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,315.339435,23049.35424,percent of total billed charges,,,
AVANCE NERVE GRAFT 2MM DIAM / 30MM LENGTH -,SUP-211230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,AETNA [1000108],AETNA [100010801],,,76.8,,9005.3,315.339435,23049.35424,percent of total billed charges,,,
ADVANCE NERVE GRAFT 3-4MM X 30MM -,SUP-311230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,AETNA [1000108],AETNA [100010801],,,76.8,,9005.3,315.339435,23049.35424,percent of total billed charges,,,
AXOGEN ADVANCE NERVE GRAFT 3.4MM X 70MM -,SUP-311270,CDM,C1762,HCPCS,278,RC,,,outpatient,,,25322.66,17725.862,AETNA [1000108],AETNA [100010801],,,76.8,,19447.8,315.339435,23049.35424,percent of total billed charges,,,
NERVE GRAFT ADVANCED 4-5MM X 30MM -,SUP-411230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,AETNA [1000108],AETNA [100010801],,,76.8,,9005.3,315.339435,23049.35424,percent of total billed charges,,,
AXOGEN ADVANCE NERVE GRAFT 4.5MM X 70MM -,SUP-411270,CDM,C1762,HCPCS,278,RC,,,outpatient,,,25322.66,17725.862,AETNA [1000108],AETNA [100010801],,,76.8,,19447.8,315.339435,23049.35424,percent of total billed charges,,,
GRAFT HUM TIS FRZN 6-12 MMX20-38CM ANT TIB TNDN LF -,SUP-430335,CDM,C1762,HCPCS,278,RC,,,outpatient,,,8376.38,5863.466,AETNA [1000108],AETNA [100010801],,,76.8,,6433.06,315.339435,23049.35424,percent of total billed charges,,,
TENDON TIBIALIS POSTERIOR -,SUP-430343,CDM,C1762,HCPCS,278,RC,,,outpatient,,,8168.81,5718.167,AETNA [1000108],AETNA [100010801],,,76.8,,6273.65,315.339435,23049.35424,percent of total billed charges,,,
GRAFT HUM TIS FRZN 3-10 MMX26-38CM SEMITNDS TNDN LF -,SUP-430350,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,AETNA [1000108],AETNA [100010801],,,76.8,,5866.91,315.339435,23049.35424,percent of total billed charges,,,
GRAFT HUM TIS FRZN 3-10 MMX20-25.9CM ANT TIB TNDN LF -,SUP-430355,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,AETNA [1000108],AETNA [100010801],,,76.8,,5866.91,315.339435,23049.35424,percent of total billed charges,,,
IMPLANT HUM TIS PS 10MM TNDN ACH -,SUP-450200,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10971.92,7680.344,AETNA [1000108],AETNA [100010801],,,76.8,,8426.43,315.339435,23049.35424,percent of total billed charges,,,
GRAFT HUM TIS FRZDR 2X14CM IOPATCH TUTOPLAST FSCA LATA -,SUP-68021,CDM,C1762,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,315.339435,23049.35424,percent of total billed charges,,,
GRAFT HUM TIS DHYDR 1.5X1.5CM IOPATCH TUTOPLAST PROC -,SUP-68250,CDM,C1762,HCPCS,278,RC,,,outpatient,,,1404.63,983.241,AETNA [1000108],AETNA [100010801],,,76.8,,1078.76,315.339435,23049.35424,percent of total billed charges,,,
GRAFT HUM TIS PTCH DHYDR 1X3CM IOPATCH TUTOPLAST SCLR IRRAD -,SUP-68334,CDM,C1762,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,AETNA [1000108],AETNA [100010801],,,76.8,,2181.53,315.339435,23049.35424,percent of total billed charges,,,
GRAFT HTM NMSH SFT REGEN 5X5CM STD GRAFTJACKET ACLR DERM 1MM -,SUP-8600-5X05,CDM,C1762,HCPCS,278,RC,,,outpatient,,,9761.2,6832.84,AETNA [1000108],AETNA [100010801],,,76.8,,7496.6,315.339435,23049.35424,percent of total billed charges,,,
GRAFT HTM FRZDR SFT REGEN 2X4CM GRAFTJACKET COLL 1.5MM UND -,SUP-86MX-2X04,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10752.85,7526.995,AETNA [1000108],AETNA [100010801],,,76.8,,8258.19,315.339435,23049.35424,percent of total billed charges,,,
PATELLA TENDON W/ EXTENSION MECHANISM -,SUP-92-3300,CDM,C1762,HCPCS,278,RC,,,outpatient,,,26622.21,18635.547,AETNA [1000108],AETNA [100010801],,,76.8,,20445.86,315.339435,23049.35424,percent of total billed charges,,,
GRAFT HUM TIS SPLT THK VSNGRFT CRNA NON-IMMUNOGENIC XLNK -,SUP-C0301AL-90,CDM,C1762,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,AETNA [1000108],AETNA [100010801],,,76.8,,1607.96,315.339435,23049.35424,percent of total billed charges,,,
CORNEA HUMAN -,SUP-CORNEA,CDM,C1762,HCPCS,278,RC,,,outpatient,,,16467.16,11527.012,AETNA [1000108],AETNA [100010801],,,76.8,,12646.78,315.339435,23049.35424,percent of total billed charges,,,
IMPLANT HUM TIS BLCK AT -,SUP-FATB,CDM,C1762,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,315.339435,23049.35424,percent of total billed charges,,,
IMPLANT HUM TIS ALLOGRAFT BIOCLEANSE GRCLS TNDN FRZN -,SUP-FGRACILIS,CDM,C1762,HCPCS,278,RC,,,outpatient,,,5267.78,3687.446,AETNA [1000108],AETNA [100010801],,,76.8,,4045.66,315.339435,23049.35424,percent of total billed charges,,,
GRAFT HUM TIS FRZDR 30X150MM MED RDIGRF FSCA LATA LF -,SUP-FLM,CDM,C1762,HCPCS,278,RC,,,outpatient,,,4565.66,3195.962,AETNA [1000108],AETNA [100010801],,,76.8,,3506.43,315.339435,23049.35424,percent of total billed charges,,,
GRAFT HUM TIS SFT 230MM 7.5MM FLEXIGRAFT POST TIB TNDN FRZN -,SUP-FPOST.TIBIAL,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7087.1,4960.97,AETNA [1000108],AETNA [100010801],,,76.8,,5442.89,315.339435,23049.35424,percent of total billed charges,,,
FLEXIGRAFT QUADLINK-ZORC -,SUP-FQL,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10482.68,7337.876,AETNA [1000108],AETNA [100010801],,,76.8,,8050.7,315.339435,23049.35424,percent of total billed charges,,,
GRAFT HUM TIS HAMSTRING FRZN >150MM4MM-5.5MM DIA FLEXIGRAFT -,SUP-FROPE,CDM,C1762,HCPCS,278,RC,,,outpatient,,,3719.57,2603.699,AETNA [1000108],AETNA [100010801],,,76.8,,2856.63,315.339435,23049.35424,percent of total billed charges,,,
GRAFT HUM TIS HAMSTRING FRZN 160-250MM 4-6MM FLEXIGRAFT -,SUP-FSTP,CDM,C1762,HCPCS,278,RC,,,outpatient,,,3657.31,2560.117,AETNA [1000108],AETNA [100010801],,,76.8,,2808.81,315.339435,23049.35424,percent of total billed charges,,,
SLING TRNVAG RPLFRM COLL 5X10CM NABSB FEM FRZDR SLF-ANCHR -,SUP-M0068202450,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7456.11,5219.277,AETNA [1000108],AETNA [100010801],,,76.8,,5726.29,315.339435,23049.35424,percent of total billed charges,,,
SLING TRNVAG RPLFRM COLL 6X12CM NABSB FEM FRZDR SLF-ANCHR -,SUP-M0068202460,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7882.17,5517.519,AETNA [1000108],AETNA [100010801],,,76.8,,6053.51,315.339435,23049.35424,percent of total billed charges,,,
MACROFORM COMPOSITE NOVABONE 10CC -,SUP-NB1003,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,315.339435,23049.35424,percent of total billed charges,,,
NOVABONE BIOACTIVE BONE GRAFT 10CC LONG STRIP -,SUP-NB2310L,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,315.339435,23049.35424,percent of total billed charges,,,
NOVABONE 10CC STRIP -,SUP-NB2310S,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,315.339435,23049.35424,percent of total billed charges,,,
NOVABONE 2.5CC PUTTY -,SUP-NB2602,CDM,C1762,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,315.339435,23049.35424,percent of total billed charges,,,
NOVABONE 5CC PUTTY -,SUP-NB2605,CDM,C1762,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,315.339435,23049.35424,percent of total billed charges,,,
NOVABONE 10CC PUTTY SYRINGE -,SUP-NB2610,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,315.339435,23049.35424,percent of total billed charges,,,
GRAFT HUM TIS FRZN >=150MM TIB POST TNDN LF -,SUP-X30820,CDM,C1762,HCPCS,278,RC,,,outpatient,,,6302.34,4411.638,AETNA [1000108],AETNA [100010801],,,76.8,,4840.2,315.339435,23049.35424,percent of total billed charges,,,
IMPLANT BIO TISS 15X20CM RECT PRCN COLL MATRIX NXLNK XENMTRX -,SUP-1161520,CDM,C1763,HCPCS,278,RC,,,outpatient,,,31189.2,21832.44,AETNA [1000108],AETNA [100010801],,,76.8,,23953.31,270.120645,23953.3056,percent of total billed charges,,,
EPIDISK -,SUP-1417100,CDM,C1763,HCPCS,278,RC,,,outpatient,,,1203.21,842.247,AETNA [1000108],AETNA [100010801],,,76.8,,924.07,270.120645,23953.3056,percent of total billed charges,,,
IMPLANT COLL MEMBR 50X40MM GEISTLICH BIO-GIDE BILAYER RESRB -,SUP-20153,CDM,C1763,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,270.120645,23953.3056,percent of total billed charges,,,
SHEET MEDPOR 38 X 50 X 0.85 ORBITAL IMPLANT -,SUP-7210,CDM,C1763,HCPCS,278,RC,,,outpatient,,,2390.53,1673.371,AETNA [1000108],AETNA [100010801],,,76.8,,1835.93,270.120645,23953.3056,percent of total billed charges,,,
SUBSTITUTE CA SLPHT 5ML GRNL MIIGX3 RESRB SYNTH PREFL -,SUP-84XS-0405,CDM,C1763,HCPCS,278,RC,,,outpatient,,,7940.52,5558.364,AETNA [1000108],AETNA [100010801],,,76.8,,6098.32,270.120645,23953.3056,percent of total billed charges,,,
SUBSTITUTE CA SLPHT 5ML GRNL MIIGX3 RESRB SYNTH PREFL -,SUP-84XS-0405,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9145.82,6402.074,AETNA [1000108],AETNA [100010801],,,76.8,,7023.99,270.120645,23953.3056,percent of total billed charges,,,
GRID CRNL 106X97MM 6MM MEDPOR FLEXBLOCK -,SUP-9524,CDM,C1763,HCPCS,278,RC,,,outpatient,,,15136.27,10595.389,AETNA [1000108],AETNA [100010801],,,76.8,,11624.66,270.120645,23953.3056,percent of total billed charges,,,
NERVE PROTECTOR WRAP 2MM X 20MM -,SUP-AG0220,CDM,C1763,HCPCS,278,RC,,,outpatient,,,8118.77,5683.139,AETNA [1000108],AETNA [100010801],,,76.8,,6235.22,270.120645,23953.3056,percent of total billed charges,,,
NERVE PROTECTOR WRAP 3.5MM X 20MM -,SUP-AG0320,CDM,C1763,HCPCS,278,RC,,,outpatient,,,8118.77,5683.139,AETNA [1000108],AETNA [100010801],,,76.8,,6235.22,270.120645,23953.3056,percent of total billed charges,,,
NERVE WRAP AVANCE 3.5MM X 40MM -,SUP-AG0340,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9921.14,6944.798,AETNA [1000108],AETNA [100010801],,,76.8,,7619.44,270.120645,23953.3056,percent of total billed charges,,,
NERVE WRAP AVANCE 3.5MM X 40MM -,SUP-AG0340,CDM,C1763,HCPCS,278,RC,,,outpatient,,,10525.12,7367.584,AETNA [1000108],AETNA [100010801],,,76.8,,8083.29,270.120645,23953.3056,percent of total billed charges,,,
NERVE PROTECTOR 7MM X 40MM -,SUP-AG0740,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9442.16,6609.512,AETNA [1000108],AETNA [100010801],,,76.8,,7251.58,270.120645,23953.3056,percent of total billed charges,,,
NERVE PROTECTOR 7MM X 40MM - USE 0169678 -,SUP-AG0740,CDM,C1763,HCPCS,278,RC,,,outpatient,,,10121.64,7085.148,AETNA [1000108],AETNA [100010801],,,76.8,,7773.42,270.120645,23953.3056,percent of total billed charges,,,
AXOGUARD NERVE PROTECTOR 40MM 10MM -,SUP-AG1040,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9442.16,6609.512,AETNA [1000108],AETNA [100010801],,,76.8,,7251.58,270.120645,23953.3056,percent of total billed charges,,,
AXOGAURD NERVE CONNECTOR 2 X 15 -,SUP-AGX215,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,AETNA [1000108],AETNA [100010801],,,76.8,,5260.66,270.120645,23953.3056,percent of total billed charges,,,
AXOGAURD NERVE CONNECTOR D 3MM L 15MM -,SUP-AGX315,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,AETNA [1000108],AETNA [100010801],,,76.8,,5260.66,270.120645,23953.3056,percent of total billed charges,,,
AXOGAURD NERVE CONNECTOR D 4MM L 15MM -,SUP-AGX415,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,AETNA [1000108],AETNA [100010801],,,76.8,,5260.66,270.120645,23953.3056,percent of total billed charges,,,
CONNECTOR AXOGUARD NERVE D 5MM L 15MM -,SUP-AGX515,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,AETNA [1000108],AETNA [100010801],,,76.8,,5260.66,270.120645,23953.3056,percent of total billed charges,,,
PLUG ANAL FISTULA -,SUP-G53614,CDM,C1763,HCPCS,278,RC,,,outpatient,,,5071.58,3550.106,AETNA [1000108],AETNA [100010801],,,76.8,,3894.97,270.120645,23953.3056,percent of total billed charges,,,
IMPLANT GYN 17X70CM SYNTH UPHOLD LT -,SUP-M0068317170,CDM,C1763,HCPCS,278,RC,,,outpatient,,,8668.37,6067.859,AETNA [1000108],AETNA [100010801],,,76.8,,6657.31,270.120645,23953.3056,percent of total billed charges,,,
SURGICAL MATRIX THICK 10 X 20CM -,SUP-PSMT1020,CDM,C1763,HCPCS,278,RC,,,outpatient,,,20941.32,14658.924,AETNA [1000108],AETNA [100010801],,,76.8,,16082.93,270.120645,23953.3056,percent of total billed charges,,,
5 X 5CM 6 LAYER GENTRIX SURGICAL MATRIX DRESSING -,SUP-PSMX0505,CDM,C1763,HCPCS,278,RC,,,outpatient,,,3471.65,2430.155,AETNA [1000108],AETNA [100010801],,,76.8,,2666.23,270.120645,23953.3056,percent of total billed charges,,,
ROD TNDN 3X250MM PLYSTR COR SIL PSS KNOB END HNTR STRL STR -,SUP-PT300000,CDM,C1763,HCPCS,278,RC,,,outpatient,,,5254.07,3677.849,AETNA [1000108],AETNA [100010801],,,76.8,,4035.13,270.120645,23953.3056,percent of total billed charges,,,
ROD TNDN 5X250MM PLYSTR COR SIL PSS KNOB END HNTR STRL STR -,SUP-PT500000,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6315.07,4420.549,AETNA [1000108],AETNA [100010801],,,76.8,,4849.97,270.120645,23953.3056,percent of total billed charges,,,
ROD TNDN STD 4X245MM PLYSTR COR SIL PSS HNTR STRL STR -,SUP-TR400000,CDM,C1763,HCPCS,278,RC,,,outpatient,,,5254.07,3677.849,AETNA [1000108],AETNA [100010801],,,76.8,,4035.13,270.120645,23953.3056,percent of total billed charges,,,
WOUND MATRIX 6 LAYER 10 X 15 -,SUP-WSX1015,CDM,C1763,HCPCS,278,RC,,,outpatient,,,16411.46,11488.022,AETNA [1000108],AETNA [100010801],,,76.8,,12604,270.120645,23953.3056,percent of total billed charges,,,
RECORDER LOOP 2-AF BIOMONITOR -,SUP-398493,CDM,C1764,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,AETNA [1000108],AETNA [100010801],,,76.8,,11976.65,399.86,14243.66592,percent of total billed charges,,,
MONITOR CARD IMPL REVEAL XT 19X62MM TI 9ML 15GM -,SUP-9529,CDM,C1764,HCPCS,278,RC,,,outpatient,,,13348.24,9343.768,AETNA [1000108],AETNA [100010801],,,76.8,,10251.45,399.86,14243.66592,percent of total billed charges,,,
MONITOR CARD IMPL CNFRM 18.5MMX56.3MM 6.5ML 12GM FRZDR LRDTC -,SUP-DM2100,CDM,C1764,HCPCS,278,RC,,,outpatient,,,11346.93,7942.851,AETNA [1000108],AETNA [100010801],,,76.8,,8714.44,399.86,14243.66592,percent of total billed charges,,,
LOOP RECORDER NEXT GEN JOT DX REF: DM4500 -,SUP-DM4500,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA [1000108],AETNA [100010801],,,76.8,,13117.29,399.86,14243.66592,percent of total billed charges,,,
LOOP RECORDER ASSERT IQ3+ ICM REF: DM5300 -,SUP-DM5300,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA [1000108],AETNA [100010801],,,76.8,,13117.29,399.86,14243.66592,percent of total billed charges,,,
LOOP RECORDER ASSERT IQ EL+ ICM REF: DM5500 -,SUP-DM5500,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17636.75,12345.725,AETNA [1000108],AETNA [100010801],,,76.8,,13545.02,399.86,14243.66592,percent of total billed charges,,,
REVEAL LINQ ICM SYSTEM LOOP RECORDER MDT -,SUP-LINQSYS,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17246.89,12072.823,AETNA [1000108],AETNA [100010801],,,76.8,,13245.61,399.86,14243.66592,percent of total billed charges,,,
LOOP RECORDER REVEAL LINQ II SYSTEM REF: LNQ22SYS -,SUP-LNQ22SYS,CDM,C1764,HCPCS,278,RC,,,outpatient,,,18546.44,12982.508,AETNA [1000108],AETNA [100010801],,,76.8,,14243.67,399.86,14243.66592,percent of total billed charges,,,
LUX DX INSERTABLE CARDIAC MONITOR M301 -,SUP-M301,CDM,C1764,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA [1000108],AETNA [100010801],,,76.8,,12832.13,399.86,14243.66592,percent of total billed charges,,,
LUX -DX II+ INSERTABLE CARDIAC MONITOR REF: M312 -,SUP-M312,CDM,C1764,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA [1000108],AETNA [100010801],,,76.8,,12832.13,399.86,14243.66592,percent of total billed charges,,,
GELFILM OPTH -,SUP-0009-0297-03,CDM,C1765,HCPCS,278,RC,,,outpatient,,,1102.46,771.722,AETNA [1000108],AETNA [100010801],,,76.8,,846.69,247.50227,1378.95936,percent of total billed charges,,,
"BARRIER ADHESION SEPRAFILM 5 X 6"" -",SUP-430102,CDM,C1765,HCPCS,278,RC,,,outpatient,,,1691.39,1183.973,AETNA [1000108],AETNA [100010801],,,76.8,,1298.99,247.50227,1378.95936,percent of total billed charges,,,
BARRIER INTERCEED 3X4 -,SUP-4350,CDM,C1765,HCPCS,278,RC,,,outpatient,,,1795.52,1256.864,AETNA [1000108],AETNA [100010801],,,76.8,,1378.96,247.50227,1378.95936,percent of total billed charges,,,
FLEXCATH CONTOUR STERERABLE SHEATH REF:10FCC13 -,SUP-10FCC13,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,109.158635,4260.1272,other,272 with C codes,,
FLEXCATH CONTOUR STERRABLE SHEATH 10FRX20MM REF:10FCC20 -,SUP-10FCC20,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,109.158635,4260.1272,other,272 with C codes,,
FLEXCATH CONTOUR STEERABLE SHEATH 12FRx13MM REF:12FCC13 -,SUP-12FCC13,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,109.158635,4260.1272,other,272 with C codes,,
FLEXCATH CONTOUR STEERABLE SHEATH 12FRx20MM REF:12FCC20 -,SUP-12FCC20,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,109.158635,4260.1272,other,272 with C codes,,
FARADRIVE STEERABLE SHEATH REF: 21C602 -,SUP-21C602,CDM,C1766,HCPCS,272,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,,,,109.158635,4260.1272,other,272 with C codes,,
AGILIS SHEATH SMALL -SJM  8.5FRX91CM -,SUP-408309,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4139.92,2897.944,AETNA [1000108],AETNA [100010801],,,,,,109.158635,4260.1272,other,272 with C codes,,
SHEATH AGILIS SM- REPROC 8.5FR -,SUP-408309,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2639.83,1847.881,AETNA [1000108],AETNA [100010801],,,,,,109.158635,4260.1272,other,272 with C codes,,
AGILIS SHEATH  MED - SJM 8.5FR X 91CM -,SUP-408310,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4267.96,2987.572,AETNA [1000108],AETNA [100010801],,,,,,109.158635,4260.1272,other,272 with C codes,,
INTRO SHTH FLEXCATH ADVANCE 12FR -,SUP-4FC12,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,,,,109.158635,4260.1272,other,272 with C codes,,
CATH ABLT CARTO 3 XTRN REF -,SUP-CREFP6,CDM,C1766,HCPCS,272,RC,,,outpatient,,,486.23,340.361,AETNA [1000108],AETNA [100010801],,,,,,109.158635,4260.1272,other,272 with C codes,,
SHEATH AGILIS LGE- REPROC  8.5FR -,SUP-G408234,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2473.84,1731.688,AETNA [1000108],AETNA [100010801],,,,,,109.158635,4260.1272,other,272 with C codes,,
AGILIS SHEATH LRG CURL SFT 3MM J FNGR SJM -,SUP-G408324,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4172.48,2920.736,AETNA [1000108],AETNA [100010801],,,,,,109.158635,4260.1272,other,272 with C codes,,
SHEATH POLARSHEATH STEERABLE SHEATH REF:M004CRBS3150 -,SUP-M004CRBS3150,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,,,,109.158635,4260.1272,other,272 with C codes,,
AMULET STEERABLE DELIVERY SHEATH REF: STRBL-14F-075 -,SUP-STRBL-14F-075,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,,,,109.158635,4260.1272,other,272 with C codes,,
TOURGUIDE 7FR X 55CM -,SUP-TG0705509,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,,,,109.158635,4260.1272,other,272 with C codes,,
SHEATH 6.5 FR. 55CM -,SUP-UNDEFINED,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,,,,109.158635,4260.1272,other,272 with C codes,,
SHEATH GRAFT 7FR. 9MM 45CM -,SUP-UNDEFINED,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,,,,109.158635,4260.1272,other,272 with C codes,,
GENERATOR NEURSTM INTSTM TI 60MMX55MM SCRL NRV MRI-COND -,SUP-3023,CDM,C1767,HCPCS,278,RC,,,outpatient,,,36758.7,25731.09,AETNA [1000108],AETNA [100010801],,,76.8,,28230.68,399.86,39874.22976,percent of total billed charges,,,
INTERSTIM STIMULATOR EXTERNAL NEURO -,SUP-353101,CDM,C1767,HCPCS,278,RC,,,outpatient,,,1987.69,1391.383,AETNA [1000108],AETNA [100010801],,,76.8,,1526.55,399.86,39874.22976,percent of total billed charges,,,
PROCLAIM 5 ELITE -,SUP-3660ANS,CDM,C1767,HCPCS,278,RC,,,outpatient,,,40409.46,28286.622,AETNA [1000108],AETNA [100010801],,,76.8,,31034.47,399.86,39874.22976,percent of total billed charges,,,
NEUROSTIMULATOR PROCLAIM 5 -,SUP-3661,CDM,C1767,HCPCS,278,RC,,,outpatient,,,45984.88,32189.416,AETNA [1000108],AETNA [100010801],,,76.8,,35316.39,399.86,39874.22976,percent of total billed charges,,,
PROCLAIM 7 PULSE GENERATOR -,SUP-3663,CDM,C1767,HCPCS,278,RC,,,outpatient,,,44998.08,31498.656,AETNA [1000108],AETNA [100010801],,,76.8,,34558.53,399.86,39874.22976,percent of total billed charges,,,
PROCLAIM DRG IPG 5.3AHG MRI EIFU RED -,SUP-3664,CDM,C1767,HCPCS,278,RC,,,outpatient,,,51919.57,36343.699,AETNA [1000108],AETNA [100010801],,,76.8,,39874.23,399.86,39874.22976,percent of total billed charges,,,
DEVICE NEURSTM PRIM ADVANCED 2.6INX1.9IN PERC MRI-COND -,SUP-377-02,CDM,C1767,HCPCS,278,RC,,,outpatient,,,29604,20722.8,AETNA [1000108],AETNA [100010801],,,76.8,,22735.87,399.86,39874.22976,percent of total billed charges,,,
NEURSTM PRGM ITREL 60MMX55MM SPIN CRD PRIM CELL -,SUP-377-03,CDM,C1767,HCPCS,278,RC,,,outpatient,,,27012.08,18908.456,AETNA [1000108],AETNA [100010801],,,76.8,,20745.28,399.86,39874.22976,percent of total billed charges,,,
INS 977006 PAIN PC M -,SUP-977006,CDM,C1767,HCPCS,278,RC,,,outpatient,,,50457.55,35320.285,AETNA [1000108],AETNA [100010801],,,76.8,,38751.4,399.86,39874.22976,percent of total billed charges,,,
NEURSTM IMPL PRIM ADVANCED 65X49X15MM SPIN CRD MRI-COND -,SUP-9770-2,CDM,C1767,HCPCS,278,RC,,,outpatient,,,32564.4,22795.08,AETNA [1000108],AETNA [100010801],,,76.8,,25009.46,399.86,39874.22976,percent of total billed charges,,,
INTELLIS BATTERY #97715 -,SUP-97715,CDM,C1767,HCPCS,278,RC,,,outpatient,,,44376.4,31063.48,AETNA [1000108],AETNA [100010801],,,76.8,,34081.08,399.86,39874.22976,percent of total billed charges,,,
INTERSTIM X NEUROSTIMULATOR IMPLANT -,SUP-97800,CDM,C1767,HCPCS,278,RC,,,outpatient,,,26510.38,18557.266,AETNA [1000108],AETNA [100010801],,,76.8,,20359.97,399.86,39874.22976,percent of total billed charges,,,
PLEDGET FELT PTFE BARD 6 X 6IN -,SUP-007837,CDM,C1768,HCPCS,278,RC,,,outpatient,,,589.34,412.538,AETNA [1000108],AETNA [100010801],,,76.8,,452.61,51.089465,30693.4272,percent of total billed charges,,,
GRAFT HEMA MDV BIF 20 10 40 -,SUP-0085201,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,AETNA [1000108],AETNA [100010801],,,76.8,,2599.43,51.089465,30693.4272,percent of total billed charges,,,
GRAFT VASC 20MM 15CM HEMASHLD GOLD STR KNTD DBL VELR AOR BVN -,SUP-095120,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1996.38,1397.466,AETNA [1000108],AETNA [100010801],,,76.8,,1533.22,51.089465,30693.4272,percent of total billed charges,,,
GRAFT HEMA 16MM 30CM MDV -,SUP-095216,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2628.78,1840.146,AETNA [1000108],AETNA [100010801],,,76.8,,2018.9,51.089465,30693.4272,percent of total billed charges,,,
GRAFT HEMA 18MM 30CM MDV -,SUP-095218,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2628.78,1840.146,AETNA [1000108],AETNA [100010801],,,76.8,,2018.9,51.089465,30693.4272,percent of total billed charges,,,
GRAFT VASC 22MM 30CM HEMASHLD GOLD STR KNTD DBL VELR AOR BVN -,SUP-095222,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2628.78,1840.146,AETNA [1000108],AETNA [100010801],,,76.8,,2018.9,51.089465,30693.4272,percent of total billed charges,,,
GRAFT VASC 1X6CM GORE-TEX 0.6MM PTCH -,SUP-1702515006,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2581.34,1806.938,AETNA [1000108],AETNA [100010801],,,76.8,,1982.47,51.089465,30693.4272,percent of total billed charges,,,
GRAFT HEMASHIELD D:28MM L:30CM -,SUP-175428P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,AETNA [1000108],AETNA [100010801],,,76.8,,2112.05,51.089465,30693.4272,percent of total billed charges,,,
GRAFT VASC 32MM 32X30CM HEMASHLD PLTNM STR WVN AOR COLL -,SUP-175432P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,AETNA [1000108],AETNA [100010801],,,76.8,,2112.05,51.089465,30693.4272,percent of total billed charges,,,
GRAFT VASC 38MMX30CM HEMASHLD PLTNM FINESSE STR WVN AOR BVN -,SUP-175438P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,AETNA [1000108],AETNA [100010801],,,76.8,,2112.05,51.089465,30693.4272,percent of total billed charges,,,
GRAFT VASC 20MM THOR 10MM BRNCH 50CM HEMASHLD PLTNM STR 20CM -,SUP-175820P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5377.66,3764.362,AETNA [1000108],AETNA [100010801],,,76.8,,4130.04,51.089465,30693.4272,percent of total billed charges,,,
GRAFT VASC 26MM THOR 10MM/10MM/8MM/8MM ID BRNCH 50CM -,SUP-175926P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6299.92,4409.944,AETNA [1000108],AETNA [100010801],,,76.8,,4838.34,51.089465,30693.4272,percent of total billed charges,,,
GRAFT VASC 7X10CM GORE-HYBRID PRECLUDE 0.1MM MEMBR PERICARD -,SUP-1PCM001,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1812.77,1268.939,AETNA [1000108],AETNA [100010801],,,76.8,,1392.21,51.089465,30693.4272,percent of total billed charges,,,
GRAFT ATRIUM VXT 4 7 45CM  - DISCONTINUED DO NOT USE -,SUP-22115,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2091.84,1464.288,AETNA [1000108],AETNA [100010801],,,76.8,,1606.53,51.089465,30693.4272,percent of total billed charges,,,
KT INFL 20/20 PRIORITY PACK -,SUP-22297,CDM,C1768,HCPCS,278,RC,,,outpatient,,,227.57,159.299,AETNA [1000108],AETNA [100010801],,,76.8,,174.77,51.089465,30693.4272,percent of total billed charges,,,
GRAFT VASC 6MM 50CM FLIXENE STR GRAD WL REINF SFT WRP TNLR -,SUP-25058,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5114.4,3580.08,AETNA [1000108],AETNA [100010801],,,76.8,,3927.86,51.089465,30693.4272,percent of total billed charges,,,
GRAFT VASC 6MM 40CM FLIXENE STR GRAD WL REINF SFT WRP TNLR -,SUP-25061,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4720.98,3304.686,AETNA [1000108],AETNA [100010801],,,76.8,,3625.71,51.089465,30693.4272,percent of total billed charges,,,
GRAFT VASC 4-7MM 30CM FLIXENE STR REINF SFT-WRP TNLR ATTCH -,SUP-25098,CDM,C1768,HCPCS,278,RC,,,outpatient,,,9358.02,6550.614,AETNA [1000108],AETNA [100010801],,,76.8,,7186.96,51.089465,30693.4272,percent of total billed charges,,,
GRAFT FLIXENE GTW GW 4 7 35 -,SUP-25129,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6294.62,4406.234,AETNA [1000108],AETNA [100010801],,,76.8,,4834.27,51.089465,30693.4272,percent of total billed charges,,,
GRAFT VASC 8MM 80CM STR HEP FUSION BIOLINE CTD RNG SUPP -,SUP-503088B,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10403.74,7282.618,AETNA [1000108],AETNA [100010801],,,76.8,,7990.07,51.089465,30693.4272,percent of total billed charges,,,
VALVE AOR 6-30MM CRYOVALVE CONDT -,SUP-AV00,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39965.4,27975.78,AETNA [1000108],AETNA [100010801],,,76.8,,30693.43,51.089465,30693.4272,percent of total billed charges,,,
GRAFT STENT BIFURCATED -,SUP-BEA22-70/I16-30,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,AETNA [1000108],AETNA [100010801],,,76.8,,30123.13,51.089465,30693.4272,percent of total billed charges,,,
AFX2 BIFURCATED ENDOGRAFT SYSTEM -,SUP-BEA25-80/113-40,CDM,C1768,HCPCS,278,RC,,,outpatient,,,14944.83,10461.381,AETNA [1000108],AETNA [100010801],,,76.8,,11477.63,51.089465,30693.4272,percent of total billed charges,,,
GRAFT STENT BIFURCATED -,SUP-BEA25-80/I20-40,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,AETNA [1000108],AETNA [100010801],,,76.8,,30123.13,51.089465,30693.4272,percent of total billed charges,,,
GRAFT STENT 90MM 28MM 16MM AFX2 2 BRANCH MAIN BODY ILIAC LIM -,SUP-BEA28-90/I16-30,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,AETNA [1000108],AETNA [100010801],,,76.8,,30123.13,51.089465,30693.4272,percent of total billed charges,,,
GRAFT VASC 7X15CM CORMATRIX PERICARD COLL GRW FACT PRTN -,SUP-CMCV-003-402,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,51.089465,30693.4272,percent of total billed charges,,,
GRAFT DISTAFLO VASCULAR 6X70 -,SUP-DFM7006SC,CDM,C1768,HCPCS,278,RC,,,outpatient,,,30067.87,21047.509,AETNA [1000108],AETNA [100010801],,,76.8,,23092.12,51.089465,30693.4272,percent of total billed charges,,,
PATCH BOVINE 0.8 X 8CM DURAVESS PERICARDIAL -,SUP-DP08X8,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1126.45,788.515,AETNA [1000108],AETNA [100010801],,,76.8,,865.11,51.089465,30693.4272,percent of total billed charges,,,
PATCH BOVINE 2 X 9 DURAVESS PERICARDIUM -,SUP-DP2X9,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1655.24,1158.668,AETNA [1000108],AETNA [100010801],,,76.8,,1271.22,51.089465,30693.4272,percent of total billed charges,,,
GRAFT VASC 4-7MM 45CM ACUSEAL -,SUP-ECH470045A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6675.81,4673.067,AETNA [1000108],AETNA [100010801],,,76.8,,5127.02,51.089465,30693.4272,percent of total billed charges,,,
GRAFT ZENITH FLEX LEG 20X56 -,SUP-G55241,CDM,C1768,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA [1000108],AETNA [100010801],,,76.8,,12626.81,51.089465,30693.4272,percent of total billed charges,,,
GRAFT GORE PROPATEN 6 X 40 -,SUP-H060040A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4766.01,3336.207,AETNA [1000108],AETNA [100010801],,,76.8,,3660.3,51.089465,30693.4272,percent of total billed charges,,,
GRAFT GORE H470045A -,SUP-H470045A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5661.5,3963.05,AETNA [1000108],AETNA [100010801],,,76.8,,4348.03,51.089465,30693.4272,percent of total billed charges,,,
PROPATEN AXILLO BIFEMORAL VASC GRAFT -,SUP-HAX02A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,17306.29,12114.403,AETNA [1000108],AETNA [100010801],,,76.8,,13291.23,51.089465,30693.4272,percent of total billed charges,,,
GRAFT VASC 26X34MM SKRT 15CM CARDIOROOT 26MM SKRT 10MM CLLR -,SUP-HEWROOT0026,CDM,C1768,HCPCS,278,RC,,,outpatient,,,8640.74,6048.518,AETNA [1000108],AETNA [100010801],,,76.8,,6636.09,51.089465,30693.4272,percent of total billed charges,,,
GRAFT VASC 6MM 70CM HEMAGARD STR 0.49MM KNTD RVRS LOCKNIT -,SUP-HGK000670,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2112.2,1478.54,AETNA [1000108],AETNA [100010801],,,76.8,,1622.17,51.089465,30693.4272,percent of total billed charges,,,
GRAFT VASC PROPATEN 6 X 80 -,SUP-HT066080A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10957.06,7669.942,AETNA [1000108],AETNA [100010801],,,76.8,,8415.02,51.089465,30693.4272,percent of total billed charges,,,
PROPATEN VASCULAR GRAFT 7MM X 80CM -,SUP-HT076080A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10957.06,7669.942,AETNA [1000108],AETNA [100010801],,,76.8,,8415.02,51.089465,30693.4272,percent of total billed charges,,,
GRAFT PROPATEN 8 X 70 -,SUP-HT087080A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,11287.52,7901.264,AETNA [1000108],AETNA [100010801],,,76.8,,8668.82,51.089465,30693.4272,percent of total billed charges,,,
GRAFT FUSION BIOLINE 6 X 80 RING SUPPORTED -,SUP-M00201503086B0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10403.74,7282.618,AETNA [1000108],AETNA [100010801],,,76.8,,7990.07,51.089465,30693.4272,percent of total billed charges,,,
GRAFT CARDIOVASCULAR HEMASHIELD GOLD MDV BIF 14X7 40CM -,SUP-M002020851470,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,AETNA [1000108],AETNA [100010801],,,76.8,,2599.43,51.089465,30693.4272,percent of total billed charges,,,
GRAFT 16X8 40CM HEMA BIF MDV -,SUP-M002020851680,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,AETNA [1000108],AETNA [100010801],,,76.8,,2599.43,51.089465,30693.4272,percent of total billed charges,,,
GRAFT HEMA MDV BIF 18X9 40CM -,SUP-M002020851890,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,AETNA [1000108],AETNA [100010801],,,76.8,,2599.43,51.089465,30693.4272,percent of total billed charges,,,
GRAFT HEMA MDV BIF 22X11X40 -,SUP-M002020852210,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,AETNA [1000108],AETNA [100010801],,,76.8,,2599.43,51.089465,30693.4272,percent of total billed charges,,,
GRAFT HEMASHIELD D:6MM L:15CM GOLD -,SUP-M002020951060,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1879.03,1315.321,AETNA [1000108],AETNA [100010801],,,76.8,,1443.1,51.089465,30693.4272,percent of total billed charges,,,
GRAFT HEMASHIELD D:8MM L:15CM GOLD -,SUP-M002020951080,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1879.03,1315.321,AETNA [1000108],AETNA [100010801],,,76.8,,1443.1,51.089465,30693.4272,percent of total billed charges,,,
GRAFT HEMASHIELD D:10MM L:30CM GOLD -,SUP-M002020954100,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2538.41,1776.887,AETNA [1000108],AETNA [100010801],,,76.8,,1949.5,51.089465,30693.4272,percent of total billed charges,,,
GRAFT HEMASHIELD GOLD 10MM X 30CM -,SUP-M002020954100,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2538.41,1776.887,AETNA [1000108],AETNA [100010801],,,76.8,,1949.5,51.089465,30693.4272,percent of total billed charges,,,
GRAFT VASC 8MM 30CM HEMASHLD PLTNM STR WVN DBL VELR AOR BVN -,SUP-M00202175208P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2473.41,1731.387,AETNA [1000108],AETNA [100010801],,,76.8,,1899.58,51.089465,30693.4272,percent of total billed charges,,,
GRAFT HEMASHIELD 22MM X 30CM -,SUP-M00202175422P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2644.27,1850.989,AETNA [1000108],AETNA [100010801],,,76.8,,2030.8,51.089465,30693.4272,percent of total billed charges,,,
GRAFT HEMASHIELD D:24MM L:30CM -,SUP-M00202175424P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2644.27,1850.989,AETNA [1000108],AETNA [100010801],,,76.8,,2030.8,51.089465,30693.4272,percent of total billed charges,,,
GRAFT HEMASHIELD D:26MM L:30CM -,SUP-M00202175426P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,AETNA [1000108],AETNA [100010801],,,76.8,,2112.05,51.089465,30693.4272,percent of total billed charges,,,
GRAFT HEMASHIELD D:30MM L:30CM -,SUP-M00202175430P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,AETNA [1000108],AETNA [100010801],,,76.8,,2112.05,51.089465,30693.4272,percent of total billed charges,,,
GRAFT HEMASHIELD D:32MM L:30CM -,SUP-M00202175432P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,AETNA [1000108],AETNA [100010801],,,76.8,,2112.05,51.089465,30693.4272,percent of total billed charges,,,
PERICARDIUM PERIGUARD 6X8 -,SUP-PC0608SNBIO,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2602.81,1821.967,AETNA [1000108],AETNA [100010801],,,76.8,,1998.96,51.089465,30693.4272,percent of total billed charges,,,
PERICARDIUM PEROGIARD 8X14 -,SUP-PC0814SNBIO,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3079.33,2155.531,AETNA [1000108],AETNA [100010801],,,76.8,,2364.93,51.089465,30693.4272,percent of total billed charges,,,
GRAFT VASC 6MM 40CM GORE-TEX STR 30CM RNG SECT THNWL STRCH -,SUP-RRT06030040L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3933.78,2753.646,AETNA [1000108],AETNA [100010801],,,76.8,,3021.14,51.089465,30693.4272,percent of total billed charges,,,
GRAFT VASC 6MM 70CM GORE-TEX STR 60CM RNG SECT THNWL STRCH -,SUP-RRT06060070L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5648.76,3954.132,AETNA [1000108],AETNA [100010801],,,76.8,,4338.25,51.089465,30693.4272,percent of total billed charges,,,
GRAFT VASC 8MM 40CM GORE-TEX STR 30CM RNG SECT THNWL STRCH -,SUP-RRT08030040L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3933.78,2753.646,AETNA [1000108],AETNA [100010801],,,76.8,,3021.14,51.089465,30693.4272,percent of total billed charges,,,
GRAFT VASC 6MM 50CM GORE-TEX STR STD WL STRCH EPTFE -,SUP-S0605,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3403.86,2382.702,AETNA [1000108],AETNA [100010801],,,76.8,,2614.16,51.089465,30693.4272,percent of total billed charges,,,
GRAFT VASC 14X7MM 40CM GORE-TEX BIFUR THNWL STRCH EPTFE -,SUP-SBT1401D,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4303.42,3012.394,AETNA [1000108],AETNA [100010801],,,76.8,,3305.03,51.089465,30693.4272,percent of total billed charges,,,
GRAFT VASC 16X8MM 40CM GORE-TEX BIFUR THNWL STRCH -,SUP-SBT1601,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4000.61,2800.427,AETNA [1000108],AETNA [100010801],,,76.8,,3072.47,51.089465,30693.4272,percent of total billed charges,,,
STRETCH THIN WALL BIFURCATED GRAFT 16-8MM X 50CM -,SUP-SBT1602D,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5377.15,3764.005,AETNA [1000108],AETNA [100010801],,,76.8,,4129.65,51.089465,30693.4272,percent of total billed charges,,,
GRAFT VASC 8MM 40CM GORE-TEX STR THNWL STRCH LN REM RNG AOR -,SUP-SRRT08030040L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4387.31,3071.117,AETNA [1000108],AETNA [100010801],,,76.8,,3369.45,51.089465,30693.4272,percent of total billed charges,,,
GRAFT VASC 8MM 80CM GORE-TEX STR 70CM RNG SECT THNWL -,SUP-SRRT08070080L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,7032.31,4922.617,AETNA [1000108],AETNA [100010801],,,76.8,,5400.81,51.089465,30693.4272,percent of total billed charges,,,
GRAFT VASC 6MM 40CM GORE-TEX STR THNWL STRCH AOR EPTFE -,SUP-ST0604,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3232,2262.4,AETNA [1000108],AETNA [100010801],,,76.8,,2482.18,51.089465,30693.4272,percent of total billed charges,,,
GRAFT VASC 6MM 80CM GORE-TEX -,SUP-ST0608,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5330.46,3731.322,AETNA [1000108],AETNA [100010801],,,76.8,,4093.79,51.089465,30693.4272,percent of total billed charges,,,
AORTIC BODY ALTO TM ABDOMINAL STENT GRAFT -,SUP-TV-AB2080-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,AETNA [1000108],AETNA [100010801],,,76.8,,28135.64,51.089465,30693.4272,percent of total billed charges,,,
ALTO ABDOMINAL STENT GRAFT SYSTEM 23MM -,SUP-TV-AB2380-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,AETNA [1000108],AETNA [100010801],,,76.8,,28135.64,51.089465,30693.4272,percent of total billed charges,,,
ALTO ABDOMINAL STENT GRAFT SYSTEM 26MM -,SUP-TV-AB2680-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,AETNA [1000108],AETNA [100010801],,,76.8,,28135.64,51.089465,30693.4272,percent of total billed charges,,,
OVATION IX ABDOMINAL STENT GRAFT SYSTEM 29MM ALTO -,SUP-TV-AB2980-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,AETNA [1000108],AETNA [100010801],,,76.8,,28135.64,51.089465,30693.4272,percent of total billed charges,,,
ALTO ABDOMINAL STENT GRAFT SYSTEM 34MM -,SUP-TV-AB3480-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,AETNA [1000108],AETNA [100010801],,,76.8,,28135.64,51.089465,30693.4272,percent of total billed charges,,,
ILIAC GRAFT OVATION IX 10 X 160MM -,SUP-TV-IL1410160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,AETNA [1000108],AETNA [100010801],,,76.8,,17252.08,51.089465,30693.4272,percent of total billed charges,,,
GRAFT STENT TRIVASCULAR OVATION IX 12 X 140 ILIAC LIMB -,SUP-TV-IL1412140-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,AETNA [1000108],AETNA [100010801],,,76.8,,17252.08,51.089465,30693.4272,percent of total billed charges,,,
ILIAC GRAFT 14 X 100MM -,SUP-TV-IL1414100-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,AETNA [1000108],AETNA [100010801],,,76.8,,17252.08,51.089465,30693.4272,percent of total billed charges,,,
OVATION IX ILAC STENT GRAFT 14 X 160MM -,SUP-TV-IL1414160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,AETNA [1000108],AETNA [100010801],,,76.8,,17252.08,51.089465,30693.4272,percent of total billed charges,,,
OVATION IX ILIAC STENT GRAFT 18MM X 140MM -,SUP-TV-IL1418140-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,AETNA [1000108],AETNA [100010801],,,76.8,,17252.08,51.089465,30693.4272,percent of total billed charges,,,
GRAFT STENT OVATION IX ILIAC LIMB 18 X 160MM -,SUP-TV-IL1418160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,AETNA [1000108],AETNA [100010801],,,76.8,,17252.08,51.089465,30693.4272,percent of total billed charges,,,
OVATION IX 22 X 100MM -,SUP-TV-IL1422100-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,AETNA [1000108],AETNA [100010801],,,76.8,,17252.08,51.089465,30693.4272,percent of total billed charges,,,
GRAFT STENT TRIVASCULAR OVATION IX 28 X 120 ILIAC LIMB -,SUP-TV-IL1428120-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,AETNA [1000108],AETNA [100010801],,,76.8,,17252.08,51.089465,30693.4272,percent of total billed charges,,,
GRAFT STENT TRIVASCULAR OVATION IX 28 X 160 ILIAC LIMB -,SUP-TV-IL1428160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,AETNA [1000108],AETNA [100010801],,,76.8,,17252.08,51.089465,30693.4272,percent of total billed charges,,,
GRAFT HUM TIS VEIN CRYPRSR CRYOVEIN SAPHENOUS -,SUP-V010,CDM,C1768,HCPCS,278,RC,,,outpatient,,,30011.06,21007.742,AETNA [1000108],AETNA [100010801],,,76.8,,23048.49,51.089465,30693.4272,percent of total billed charges,,,
GRAFT VASC 6MM 50CM VENAFLO II STR CRBN IMPREG EPTFE CUF -,SUP-VL5006C,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6999.2,4899.44,AETNA [1000108],AETNA [100010801],,,76.8,,5375.39,51.089465,30693.4272,percent of total billed charges,,,
GRAFT VASC 6MM 80CM GORE-TEX THNWL LN EPTFE -,SUP-VT06080L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4621.23,3234.861,AETNA [1000108],AETNA [100010801],,,76.8,,3549.1,51.089465,30693.4272,percent of total billed charges,,,
GUIDEWIRE SPRING TIP REUSABLE MARKED -,SUP-000150,CDM,C1769,HCPCS,272,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.038INX260CM 3MM JTP TAPR FXCR STD PTFE-CTD 6CM -,SUP-00-8634,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.43,38.801,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW CATH 0.025IN GW LNR SS PTFE-CTD -,SUP-0684-00-0254-09,CDM,C1769,HCPCS,272,RC,,,outpatient,,,123.7,86.59,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX300CM HTORQ ALL STAR STR XTR SUPP INTMD -,SUP-1001741,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
HI-TORQUE SUPRACORE 35 (300cm) -,SUP-1002703-02,CDM,C1769,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.018INX190CM HTORQ STLCOR 18 STR FLXB SFT SS MICGLD -,SUP-1003281,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.018INX300CM HTORQ STLCOR 18 STR FLXB SFT SS MICGLD -,SUP-1003282,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX190CM HTORQ XIT 100XT STR SS/CTD 3CM 1.7GM -,SUP-1003309H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
SPARTA CORE 190CM ST -,SUP-1005202,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
SPARTACORE 14 WIRE (0.014IN- 300CM) -,SUP-1005203,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX190CM HTORQ SPARTACORE STR SFT SS SHFT -,SUP-1005205,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX300CM HTORQ SPARTACORE STR SFT SS SHFT -,SUP-1005206,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX190CM HTORQ  WHISPER MS STR SFT DURASTEEL -,SUP-1005357H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX300CM HTORQ WHISPER MS STR SFT DURASTEEL/ -,SUP-1005359H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX190CM HTORQ BAL MDWT UNIV STR RBN INTMD -,SUP-1009660,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDEWIRE HI-TORQUE BALANCE MIDDLEWEIGHT UNIVERSAL II 190CM -,SUP-1009664,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX190CM HTORQ PILOT 50 STR SFT DURASTEEL/ -,SUP-1010480-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX190CM HTORQ PILOT 150 STR STF DURASTEEL/ -,SUP-1010481-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX190CM HTORQ PILOT 200 STR DURASTEEL/ SS/CTD -,SUP-1010482-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX300CM HTORQ PILOT 50 STR SFT DURASTEEL/ -,SUP-1010483-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX300CM HTORQ PILOT 150 STR DURASTEEL/ SS/CTD -,SUP-1010484-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX300CM HTORQ PILOT 200 STR SFT DURASTEEL -,SUP-1010485-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
HI-TORQUE WHISPER GUIDE WIRE -,SUP-1011835H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX180CM ASAHI FIELDER F C STR XTR SUPP CTD 3CM -,SUP-1011895-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDEWIRE HI-TORQUE COMMAND 18 ST WORKHORSE 0.018IN x 210CM -,SUP-1013730,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.018INX300CM HTORQ COMMAND ES SS/NTNL/CTD 30CM -,SUP-1013731,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDEWIRE VERRATA 185 CM STRAIGHT TIP -,SUP-10185,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDEWIRE VERRATA 185 CM J-TIP -,SUP-10185J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDEWIRE VERRATA PLUS 185 CM J-TIP -,SUP-10185JP,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDEWIRE VERRATA 300 CM STRAIGHT TIP -,SUP-10300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDEWIRE VERRATA 300 CM J-TIP -,SUP-10300J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDEWIRE VERRATA PLUS 300 CM J-TIP -,SUP-10300JP,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDEWIRE VERRATA PLUS 300 CM STRAIGHT TIP -,SUP-10300P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
ST INTUB 11FRX110CM RTRGD 0.38IN STR/3MM J WG INTRO NDL SYR -,SUP-110-70-38J-110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1022.29,715.603,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INSHRTX182CM CHC STR SPR COIL HYDRCT SS -,SUP-12132-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,480.8,336.56,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDEWIRE ASAHI PROWATER 180 L -,SUP-12776-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX300CM ASAHI MIRACLEBROS 3 STR STEER FLXB SS -,SUP-14937-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW URO 0.38IN NTNL -,SUP-150NSA38,CDM,C1769,HCPCS,272,RC,,,outpatient,,,221.73,155.211,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW URO 0.038INX150CM NICORE NTNL HYDRCT STR STF COR -,SUP-150NSS38,CDM,C1769,HCPCS,272,RC,,,outpatient,,,221.73,155.211,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.009INX180CM ASAHI CONFIANZA PRO PTCA STR STEER -,SUP-20629-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDEWIRE VASCULAR HI-TORQUE COMMAND 0.014IN X 190CM -,SUP-2078174,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX300CM HTORQ COMMAND ES SS/NTNL/CTD 30CM -,SUP-2078175,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014IN/0.018IN DIA 145CM -,SUP-22260,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX190CM HTORQ FLPY II JTP RBN LGT SUPP SFT SS -,SUP-22339MJ,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX300CM HTORQ FLPY II STR RBN LGT SUPP SFT SS -,SUP-22359M,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX300CM HTORQ FLPY II JTP RBN LGT SUPP SFT SS -,SUP-22359MJ,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX300CM HTORQ WIGGLE STR RBN SS HYDRPHB -,SUP-22359M-W2,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX300CM HTORQ TRAV STR STD SHFT SS/CTD 3CM -,SUP-22379H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WIRE FLTR DLV BAREWIRE 0.014INX315CM SS COR PTFE-CTD -,SUP-22440-31,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX180CM RUNTHROUGH NS STR STEER EXTEND WIRE SS -,SUP-25-1011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX300CM RUNTHROUGH NS STR WIRE SS -,SUP-25-1013,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDE WIRE PTCA RUNTHROUGH NS HYPERCOAT 0.014X180CM -,SUP-25-3011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX150CM RUNTHROUGH NS STEER EXTEND WIRE SS -,SUP-25-9092,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.035INX260CM STR FXCR PTFE-CTD -,SUP-395369,CDM,C1769,HCPCS,272,RC,,,outpatient,,,218.81,153.167,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.035INX200CM STR FXCR PTFE-CTD -,SUP-395703,CDM,C1769,HCPCS,272,RC,,,outpatient,,,218.81,153.167,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC GUIDERIGHT 0.035INX150CM  3MM J REF:404570 -,SUP-404570,CDM,C1769,HCPCS,272,RC,,,outpatient,,,40.85,28.595,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDEWIRE GUIDERIGHT 3 MM J CURVE  L180 CM L5 CM OD.035 -,SUP-404571,CDM,C1769,HCPCS,272,RC,,,outpatient,,,43.76,30.632,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDEWIRE VASCULAR GUIDERIGHT J CURVE L260 CM L5 CM OD.35 -,SUP-404577,CDM,C1769,HCPCS,272,RC,,,outpatient,,,93.36,65.352,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDEWIRE VASCULAR GUIDERIGHT BENTSON L150 CM L15 CM OD.035 -,SUP-404843,CDM,C1769,HCPCS,272,RC,,,outpatient,,,54.27,37.989,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 190CM WHISPER VW HTORQ -,SUP-4483,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC WHISPER VW HTORQ -,SUP-4639,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDEWIRE EMERALD 0.35INx260CM J TIP  FLEX FIXED CORE PTFE -,SUP-502455,CDM,C1769,HCPCS,272,RC,,,outpatient,,,52.52,36.764,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.038INX150CM EMERLD 3MM JTP FXCR FLXB STD PTFE-CTD -,SUP-502-520,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.14,38.598,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.032INX150CM EMERLD 3MM JTP FXCR FLXB STD PTFE-CTD -,SUP-502-526,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.14,38.598,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.035INX150CM EMERLD STR FXCR FLXB STD PTFE-CTD 7CM -,SUP-502-542,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.14,38.598,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.035INX300CM STORQ ANG STEER 1PC COR SFT SGL OUTR -,SUP-503-356Y,CDM,C1769,HCPCS,272,RC,,,outpatient,,,404.37,283.059,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX300CM STBR + STR STEER S-SFT 3CM -,SUP-507-114X,CDM,C1769,HCPCS,272,RC,,,outpatient,,,349.22,244.454,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX300CM STBR XS STR STEER XTR SUPP SFT -,SUP-527-300E,CDM,C1769,HCPCS,272,RC,,,outpatient,,,560.16,392.112,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
PLATE LEFT ANTER LATERAL -,SUP-630111,CDM,C1769,HCPCS,272,RC,,,outpatient,,,10381.67,7267.169,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDEWIRE WARRIOR 200CM REF: 7388 -,SUP-7388,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1131.99,792.393,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDEWIRE R350 350CM REF: 7390 -,SUP-7390,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1367.53,957.271,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDEWIRE BANDIT 200CM REF: 7444 -,SUP-7444,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1131.99,792.393,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WIRE GUIDE .035X260 STIFF SUPER -,SUP-80129-406,CDM,C1769,HCPCS,272,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX300CM ASAHI PROWATER FLEX STR FLXB SPR COIL -,SUP-82358-02,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
"GUIDEWIRE 0.014"" X300CM PTCA STRAIGHT -",SUP-82902-02,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
PRESSURE GUIDEWIRE OMNIWIRE 185CM STRAIGHT TIP REF:89185 -,SUP-89185,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
PRESSURE GUIDEWIRE OMNIWIRE 185CM J-TIP REF:89185J -,SUP-89185J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.035INX260CM AMPLATZER MOD 1.5MM JTP NOODLEWIRE -,SUP-9-GW-002,CDM,C1769,HCPCS,272,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
EXTENSION GW ASAHI -,SUP-AG14900-0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,408.45,285.915,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDEWIRE VASCULAR MIRACLEBROS 6 L180 CM OD.014 IN STERILE L -,SUP-AG14M060,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDEWIRE ASAHI MIRACLEBROS 6 300CM DUPLICATE -,SUP-AG14M360,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
W VASC 0.014INX300CM ASAHI MIRACLEBROS 12 STR STEER FLXB SS -,SUP-AG14M370,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX300CM ASAHI CONFIANZA 9 STR XTR SUPP SPR -,SUP-AGH143390,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDEWIRE ASAHI PROWATER 300 CM .014 -,SUP-AGH146300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.009INX180CM ASAHI FIELDER F C PTCA JTP 1.2GM LD -,SUP-AGP1400-01J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.009INX190CM ASAHI FIELDER XT STR SPR COIL -,SUP-AGP140002,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.009INX300CM ASAHI FIELDER XT STR SPR COIL -,SUP-AGP140302,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDE WIRE ASAHI SION BLUE 180/190CM -,SUP-AHW14R004S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GAIA FIRST 190CM MICRO J -,SUP-AHW14R007P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GAIA SECOND 190CM MICRO J -,SUP-AHW14R008P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GAIA THIRD 190CM MICRO J -,SUP-AHW14R011P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX300CM ASAHI SOFT STR STEER COR-TO-TIP SS -,SUP-AHW14R304S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,490.14,343.098,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW GLADIUS MONGO190CM REF: AP14R023S -,SUP-AP14R023S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW FIELDER XT-A 190CM REF: APW14R009S -,SUP-APW14R009S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDE WIRE ASAHI SION BLACK 190CM STRAIGHT REF:APW14R010S -,SUP-APW14R010S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,566,396.2,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDE WIRE DOUBLE ENDED TROCAR .86MM -,SUP-AR-8737-39KD,CDM,C1769,HCPCS,272,RC,,,outpatient,,,175.05,122.535,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDE SPRING WIRE .018D 25CM -,SUP-AW-04018,CDM,C1769,HCPCS,272,RC,,,outpatient,,,53.92,37.744,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.018INX25CM 2FLX STR DBL END SPR WIRE SS -,SUP-AW-04018,CDM,C1769,HCPCS,272,RC,,,outpatient,,,53.92,37.744,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
"GUIDE SPRING WIRE .032"" -",SUP-AW-04432,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.08,38.556,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 175CM PRESSUREWIRE CERTUS SS NTNL PTFE-CTD -,SUP-C12008,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
PRESSUREWIRE X GUIDEWIRE 0.014INX175CM -,SUP-C12059,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 300CM PRESSUREWIRE CERTUS STEER CTD -,SUP-C12308,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
PRESSUREWIRE X GUIDEWIRE .014MMX300CM -,SUP-C12358,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.035INX260CM TIGRWRE ANG TAPR STEER FLXB FLPY SFT -,SUP-C405085,CDM,C1769,HCPCS,272,RC,,,outpatient,,,390.95,273.665,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.035INX180CM TIGRWRE ANG TAPR STEER FLXB FLPY SFT -,SUP-C405086,CDM,C1769,HCPCS,272,RC,,,outpatient,,,390.95,273.665,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
INTRO LAP 6MM SHTH 18GA 50CM -,SUP-C-LASS-6-10,CDM,C1769,HCPCS,272,RC,,,outpatient,,,431.79,302.253,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
ST CRICO MLKR 5MM PTFE XSTIF WG ENTRY NDLHLDR CUP GZE -,SUP-C-TCCSB-500-UNI,CDM,C1769,HCPCS,272,RC,,,outpatient,,,2450.49,1715.343,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
CPS EXCEL MEDIGUIDE MEDIUM GUIDEWIRE -,SUP-DS2M028,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
CPS EXCEL MEDIGUIDE STIFF GUIDEWIRE -,SUP-DS2M029,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
MEDIGUIDE GUIDEWIRE TORQUE CLIP -,SUP-DS2M030,CDM,C1769,HCPCS,272,RC,,,outpatient,,,408.45,285.915,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.035INX145CM STR 3MM JTP DBL END FLPY SS HEP -,SUP-G00362,CDM,C1769,HCPCS,272,RC,,,outpatient,,,93.3,65.31,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
W 15J .035 145CM x 15MM CURVE -,SUP-G00509,CDM,C1769,HCPCS,272,RC,,,outpatient,,,67.04,46.928,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.035INX145CM 3MM JTP CRV FXCR STD FLXB SS NO HEP -,SUP-G00511,CDM,C1769,HCPCS,272,RC,,,outpatient,,,67.04,46.928,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WIRE GUIDE .035 260 SAFE-T-J T -,SUP-G00517,CDM,C1769,HCPCS,272,RC,,,outpatient,,,104.97,73.479,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.035INX50CM 3MM NWTN JTP FNGR STR FXCR FLXB FLPY -,SUP-G00524,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.63,57.141,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WIRE GUIDE FIXED CORE 3MM J CURVED -,SUP-G00524,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.63,57.141,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.038INX145CM 3MM JTP FXCR FLXB SS HEP PTFE-CTD 6CM -,SUP-G00541,CDM,C1769,HCPCS,272,RC,,,outpatient,,,67.04,46.928,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WIRE GUIDE FIXED CORE STRAIGHT -,SUP-G00650,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.37,38.759,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
W BENTSON .035 145CM -,SUP-G00691,CDM,C1769,HCPCS,272,RC,,,outpatient,,,87.47,61.229,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.035INX180CM SAFE-T-J-TIP FXCR FLPY SS PTFE-CTD -,SUP-G00902,CDM,C1769,HCPCS,272,RC,,,outpatient,,,72.88,51.016,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
W .035 260 BENTSON TSFB-35-260 -,SUP-G01063,CDM,C1769,HCPCS,272,RC,,,outpatient,,,116.64,81.648,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.035INX260CM CRV RSN TIP FXCR FLPY W/OUT HEP -,SUP-G01253,CDM,C1769,HCPCS,272,RC,,,outpatient,,,104.97,73.479,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
THSCF 35 260 1.5 ROSEN 43700 -,SUP-G01253,CDM,C1769,HCPCS,272,RC,,,outpatient,,,104.97,73.479,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
W THSCF-35-180-1.5 ROSEN WIRE -,SUP-G01264,CDM,C1769,HCPCS,272,RC,,,outpatient,,,78.71,55.097,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WTSFB-35-180 BENTSON -,SUP-G01290,CDM,C1769,HCPCS,272,RC,,,outpatient,,,96.22,67.354,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.025INX180CM 3MM JTP FXCR STD FLXB SS HEP PTFE-CTD -,SUP-G01602,CDM,C1769,HCPCS,272,RC,,,outpatient,,,84.55,59.185,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WIRE GUIDE 0.032 IN X180CM SAFE T JTP PTFE-C  - G02335 -,SUP-G02335,CDM,C1769,HCPCS,272,RC,,,outpatient,,,84.55,59.185,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WIRE GUIDE 0.032 IN X260CM SAFE T J HEAVY DUTY - G03133 -,SUP-G03133,CDM,C1769,HCPCS,272,RC,,,outpatient,,,294.61,206.227,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WIRE AMPLATZ  0.035 INX145CM J CRV TIP XSTIF FLPY SS -,SUP-G03203,CDM,C1769,HCPCS,272,RC,,,outpatient,,,169.16,118.412,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WIRE AMPLATZ  0.025 IN X 145 OR 180 CM SAFE-T-J XTR-STF -,SUP-G03304,CDM,C1769,HCPCS,272,RC,,,outpatient,,,457.99,320.593,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.035INX180CM AMP STR XSTIF SS PTFE-CTD 7CM TAPR 3CM -,SUP-G03330,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.31,89.817,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WIRE AMPLATZ 0.032 IN X180CM JTP XSTIF FLPY SS PTFE-CTD -,SUP-G03584,CDM,C1769,HCPCS,272,RC,,,outpatient,,,125.39,87.773,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.038INX80CM AMP STR XSTIF FLPY SS PTFE-CTD 9.5CM -,SUP-G04003,CDM,C1769,HCPCS,272,RC,,,outpatient,,,148.73,104.111,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
SET CRIC MELKER 3.5MM 3.8CM -,SUP-G06245,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1139.28,797.496,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDEWIRE ROADRUNNER EXTRA SUP -,SUP-G07640,CDM,C1769,HCPCS,272,RC,,,outpatient,,,676.8,473.76,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 60CM NTNL -,SUP-G08427,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.18,167.426,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
W PMG-18SP-60-COPE-NT -,SUP-G08427,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.18,167.426,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
W PMG-18SP-COPE-NT -,SUP-G08733,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.18,167.426,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
COPE WIRE 60CM ST -,SUP-G09395,CDM,C1769,HCPCS,272,RC,,,outpatient,,,262.52,183.764,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.035INX180CM AMP STR ULTRA STF FLPY SS PTFE-CTD -,SUP-G09956,CDM,C1769,HCPCS,272,RC,,,outpatient,,,119.56,83.692,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
SHORT TAPER AMPLATZ WIRE 1CM -,SUP-G23639,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.31,89.817,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WIREGLIDE AMPLATZ EXTRA STIFF 0.035 X 180CM -,SUP-G23639,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.31,89.817,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WIRE UNIGLIDE ANG .018 260CM -,SUP-G30489,CDM,C1769,HCPCS,272,RC,,,outpatient,,,251.48,176.036,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WIRE UNIGLIDE ANG. .035 260CM -,SUP-G30492,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WIRE UNIGLIDE SIFF STR .035 260CM -,SUP-G30496,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.018INX260CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-G30500,CDM,C1769,HCPCS,272,RC,,,outpatient,,,269.57,188.699,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WIRE UNIGLIDE STR .018 260CM -,SUP-G30500,CDM,C1769,HCPCS,272,RC,,,outpatient,,,269.57,188.699,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WIRE UNIGLIDE STR .035 260CM -,SUP-G30502,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WIRE UNIGLIDE STIFF ANG .035 260CM -,SUP-G30506,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.035INX260CM LNDRQST STR XSTIF FLXB SS PTFE-CTD 4CM -,SUP-G31453,CDM,C1769,HCPCS,272,RC,,,outpatient,,,919.6,643.72,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW ENDO 0.035INX260CM TRACER METRO DRCT -,SUP-G31914,CDM,C1769,HCPCS,272,RC,,,outpatient,,,770.22,539.154,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
ACROBAT STR WIRE GUIDE 260 .03 -,SUP-G34265,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1042.19,729.533,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
SET GASTRONOMY ENTUIT START INIT PLCMT SM FOR 12/14FR -,SUP-G34442,CDM,C1769,HCPCS,272,RC,,,outpatient,,,551.35,385.945,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WIRE GUIDE HIWIRE HYDROPHILIC ANGLED 35 -,SUP-G36284,CDM,C1769,HCPCS,272,RC,,,outpatient,,,215.3,150.71,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WIRE HI .035 X 150CM STIFF ANGLED -,SUP-G36290,CDM,C1769,HCPCS,272,RC,,,outpatient,,,215.3,150.71,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WIRE HI .035 X 260CM STIFF STRAIGHT -,SUP-G36327,CDM,C1769,HCPCS,272,RC,,,outpatient,,,308.08,215.656,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WIRE GUIDE EX-STIFF 35-300 LUN -,SUP-G45408,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1025.79,718.053,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.035INX450CM ACROBAT 2 CTD -,SUP-G47616,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1038.63,727.041,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX190CM PRO-LT NTNL/PTFE-CTD/SS/PD 8CM TAPR -,SUP-G47736,CDM,C1769,HCPCS,272,RC,,,outpatient,,,339.6,237.72,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
LUNDERQUIST WIRE 0.035 x 180CM -,SUP-G49228,CDM,C1769,HCPCS,272,RC,,,outpatient,,,593.41,415.387,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WIRE METRO TRACER .035 X 600 -,SUP-G50660,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX190CM CTO MICROWIRE FLPY SS/PTFE-CTD/PLTNM -,SUP-G50788,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
CATH CTO 25 GRAM X 014 X 190CM -,SUP-G50789,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
W CTO 6G CMW-14-300-6G -,SUP-G50790,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
W CTO 12G CMW-14-300-12G -,SUP-G50791,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
W CTO 18G GUIDE WIRE -,SUP-G50792,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
W CTO 25G -,SUP-G50793,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX190CM HYDR ST MICRO FLPY SS/PTFE-CTD/PLTNM -,SUP-G52938,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1038.57,726.999,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX300CM HYDR ST MICRO FLPY SS/PTFE-CTD/PLTNM -,SUP-G52939,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1038.57,726.999,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.018INX180CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-G56141,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WIRE UNIGLIDE STR .018 180CM -,SUP-G56141,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WIRE UNIGLIDE STR .035 180CM -,SUP-G56150,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WIRE UNIGLIDE STIFF STR .035 180CM -,SUP-G56153,CDM,C1769,HCPCS,272,RC,,,outpatient,,,260.81,182.567,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
W GLIDE STIFF .035 180 STR -,SUP-G56153,CDM,C1769,HCPCS,272,RC,,,outpatient,,,308.15,215.705,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WIRE UNIGLIDE ANG .018 180CM -,SUP-G56160,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WIRE UNIGLIDE STR .035 260CM -,SUP-G56174,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WIRE UNIGLIDE STIFF ANG .035 180CM -,SUP-G56177,CDM,C1769,HCPCS,272,RC,,,outpatient,,,260.81,182.567,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GLIDEWIRE ADV .014 300CM ANG -,SUP-GA1430,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
W GLIDE ADVANTAGE 300 .018 -,SUP-GA1830,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1431.14,1001.798,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.035INX150CM GLIDEWIR ADVANTG ANG STF SHFT FLXB STD -,SUP-GA3501,CDM,C1769,HCPCS,272,RC,,,outpatient,,,933.6,653.52,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
W GLIDE ADVANTAGE 260 .035 -,SUP-GA3502,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.018INX300CM GLIDEWIR GOLD 45DG ANG FLXB -,SUP-GM1831,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1115.94,781.158,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.018INX300CM GLIDEWIR 70DG ANG GOLDBAND FLXB TIP -,SUP-GM1832,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1115.94,781.158,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDEWIRE .018/180 STRAIGHT -,SUP-GR1803,CDM,C1769,HCPCS,272,RC,,,outpatient,,,354.24,247.968,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GLIDEWIRE .018 150 ANGLED -,SUP-GR1805,CDM,C1769,HCPCS,272,RC,,,outpatient,,,354.24,247.968,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WIRE GLIDEWIRE 0.018INX180CM ANG STD FLXB -,SUP-GR1806,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.018INX260CM GLIDEWIR ANG STF SHFT STD FLXB -,SUP-GR1807,CDM,C1769,HCPCS,272,RC,,,outpatient,,,251.48,176.036,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
W GLIDE .035 180 STR -,SUP-GR3503,CDM,C1769,HCPCS,272,RC,,,outpatient,,,261.7,183.19,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WIRE GLIDE .035 260 STR -,SUP-GR3504,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.035INX150CM GLIDEWIR ANG STF SHFT STD FLXB -,SUP-GR3506,CDM,C1769,HCPCS,272,RC,,,outpatient,,,194.95,136.465,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WIRE GLIDE .035 180 ANG  GR3508 -,SUP-GR3508,CDM,C1769,HCPCS,272,RC,,,outpatient,,,261.7,183.19,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WIRE GLIDE .035 260 ANGLED -,SUP-GR3509,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.038INX180CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-GR3803,CDM,C1769,HCPCS,272,RC,,,outpatient,,,261.7,183.19,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.038INX260CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-GR3804,CDM,C1769,HCPCS,272,RC,,,outpatient,,,292.57,204.799,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDEWIRE VASCULAR GLIDEWIRE NITINOL STRAIGHT 260CM -,SUP-GS3504,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WIRE GLIDE 0.035 IN X 80 CM ANG STIFF -,SUP-GS3505,CDM,C1769,HCPCS,272,RC,,,outpatient,,,297.59,208.313,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WIRE GLIDE STIFF .035 180CM -,SUP-GS3508,CDM,C1769,HCPCS,272,RC,,,outpatient,,,260.81,182.567,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDEWIRE VASCULAR GLIDEWIRE NITINOL HYDROPHILIC ANGLE 260CM -,SUP-GS3509,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.035INX270CM LINEARGUIDEV ANG PTFE-CTD -,SUP-G-V210-3527A,CDM,C1769,HCPCS,272,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC VIPERWIRE .014IN TIP X 325CM -,SUP-GWC-12325LG-FLP,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC VIPERWIRE W/FLEX TIP .014IN TIP X 325CM -,SUP-GWC-12325LG-FT,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX300CM MLMN STR SUPER RAIL SUPP FLXB SPR COIL -,SUP-H74912120012,CDM,C1769,HCPCS,272,RC,,,outpatient,,,480.8,336.56,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDEWIRE MAILMAN 182CM STRAIGHT TIP 0.014 -,SUP-H74912136011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,480.8,336.56,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.14X190CM PLTNM + STR SUPER RAIL SUPP INTMD SPR -,SUP-H74917511,CDM,C1769,HCPCS,272,RC,,,outpatient,,,485.59,339.913,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.035INX300CM PLTNM + STR SUPER RAIL SUPP INTMD SPR -,SUP-H74917521,CDM,C1769,HCPCS,272,RC,,,outpatient,,,485.61,339.927,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.018INX300CM PLTNM + STR SUPER RAIL SUPP INTMD SPR -,SUP-H74917541,CDM,C1769,HCPCS,272,RC,,,outpatient,,,485.61,339.927,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX300CM VCT 14 CTRL WIRE STR SHRT TAPR ICE CTD -,SUP-H74939216730010,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
PRESSURE WIRE COMET II -,SUP-H74939359110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3926.81,2748.767,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDEWIRE SAFARI2  0.035 x 0275 CM XSMALL CURVE -,SUP-H74939406XS1,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3007.62,2105.334,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX330CM RTBLTR RTWR FLXB FLPY SS/CTD 2.2CM -,SUP-H74939462005,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1518.31,1062.817,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.009INX330CM RTWR 1.5MM RSN JTP CRV STF XTR SUPP -,SUP-H74939463005,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1518.31,1062.817,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX300CM VCT 14 12GM CTRL WIRE STR LNG TAPR -,SUP-H74939470300120,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1219.12,853.384,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX300CM VCT 14 18GM CTRL WIRE STR LNG TAPR -,SUP-H74939470300180,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1219.12,853.384,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX300CM VCT 14 25GM CTRL WIRE STR LNG TAPR -,SUP-H74939471300250,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX300CM VCT 14 30GM CTRL WIRE STR LNG TAPR -,SUP-H74939471300300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
COMET FFR WIRE 555111 -,SUP-H7495551110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3414.6,2390.22,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX300CM STINGRAY CTD CONN -,SUP-H749M3004A0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1625.29,1137.703,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX145CM STINGRAY CTD CONN -,SUP-H749M3010A0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,521.24,364.868,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX185CM STINGRAY CTD CONN -,SUP-H749M3012A0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1789.24,1252.468,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX180CM INTUITION STR SS SIL CTD -,SUP-INTU180SS,CDM,C1769,HCPCS,272,RC,,,outpatient,,,169.22,118.454,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WIRE GUIDE .035 260 INQWIRE REF: IQ35F260J3 -,SUP-IQ35F260J3,CDM,C1769,HCPCS,272,RC,,,outpatient,,,59.63,41.741,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDEWIRE AMPLATZ INQWIRE 0.035 X 71IN STRAIGHT SHORT TIP -,SUP-IQA511,CDM,C1769,HCPCS,272,RC,,,outpatient,,,255.63,178.941,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.035INX150CM ZIPWIRE STR STEER STF SHFT FLXB -,SUP-M00146306B1,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.24,167.468,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW AMPLATZ 0.035INX180CM J-TIP SUPER STIFF -,SUP-M001465011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
AMPLATZ WIRE SUPER STIFF  0.035 X 260 J -,SUP-M001465021,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.035IN X 260CM SUPER STIFF AMP STR SHRT TAPR FLXB -,SUP-M001465091,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
W AMPLATZ SS ST 35 145 BX/5 GU -,SUP-M001465231,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.035INX145CM SUPER STIFF AMP STR SHRT TAPR STD -,SUP-M001465241,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.035INX180CM SUPER STIFF AMP STR STD STEER SHFT -,SUP-M001465251,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
W AMPL SS EXCHANGE 260 STR -,SUP-M001465261,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
MAGIC TORQUE DLVR GW .035/315CM -,SUP-M001465301,CDM,C1769,HCPCS,272,RC,,,outpatient,,,805.23,563.661,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
W TORQUE 35 180 MAGIC 46-591 -,SUP-M001465911,CDM,C1769,HCPCS,272,RC,,,outpatient,,,443.46,310.422,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDEWIRE MAGIC TORQUE STRAIGHT 35-260 -,SUP-M001465921,CDM,C1769,HCPCS,272,RC,,,outpatient,,,443.46,310.422,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.018INX260CM PLTNM + SHRT TAPR STEER STF SHFT FLXB -,SUP-M001466050,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WIRE PLATINUM PLUS PTFE .014 X -,SUP-M001467120,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
W CON V18 8 200 46-852 -,SUP-M001468520,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDEWIRE V18 18 300    46-854 -,SUP-M001468540,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.018INX200CM 12CM V-18 CTRL WIRE STR STEER SFT SCTN -,SUP-M001468580,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.035INX150CM STRTR 3MM J FNGR STR FXCR STD SPR COIL -,SUP-M001491181,CDM,C1769,HCPCS,272,RC,,,outpatient,,,70.02,49.014,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
J WIRE 0.035 X 180CM -,SUP-M001491201,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.69,57.183,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.035INX260CM STRTR 3MM J FNGR STR FXCR STD SPR COIL -,SUP-M001491211,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.69,57.183,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.018INX190CM THRUWAY STR SHRT TAPR STEER SFT FLXB -,SUP-M001492791,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.018INX300CM THRUWAY STR SHRT TAPR STEER SFT FLXB -,SUP-M001492831,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
BSX THRUWAY 190CM 0.014 WIRE -,SUP-M001492921,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WIRE THRUWAY .014 X 300 STR -,SUP-M001492971,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.016INX180CM FATHOM 16 STR STEER NTNL ALY/PLTNM -,SUP-M001509100,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1563.65,1094.555,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW ENDO 0.035INX180CM JGWR -,SUP-M00515171,CDM,C1769,HCPCS,272,RC,,,outpatient,,,735.47,514.829,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
NOVAGOLD .018/260 -,SUP-M00552000,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1082.39,757.673,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW ENDO 0.035INX260CM HYD JGWR STF SHFT -,SUP-M00556061,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
DREAMWIRE .035/260 -,SUP-M00556100,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
DREAMWIRE .035/260 ANGLED -,SUP-M00556110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
DREAMWIRE .035/260 STIFF -,SUP-M00556120,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
DREAMWIRE .035/450 -,SUP-M00556140,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW ENDO 0.035IN STD 450CM DREAMWIRE HI-PRFRM DIST TIP -,SUP-M00556141,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
DREAMWIRE ANGLED 0.035 X 450CM -,SUP-M00556150,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW ENDO 0.035INX450CM DREAMWIRE HIPERF STF -,SUP-M00556161,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
JAGWIRE .038 / 260CM STRIAGHT -,SUP-M00556620,CDM,C1769,HCPCS,272,RC,,,outpatient,,,594.64,416.248,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
JAG-REVOLUTION WIRE .025/260 -,SUP-M00557000,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WIRE JAG REVOLUTION .025/450 -,SUP-M00557021,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
TUBE PEG 24FR ENDOVIVE LPRO PUL LF -,SUP-M00566480,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
"SPHINTEROTOME JAGTOME RX 44 0.35"" X 260CM -",SUP-M00573040,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1685.56,1179.892,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDEWIRE .038 -,SUP-M0066201010,CDM,C1769,HCPCS,272,RC,,,outpatient,,,65.06,45.542,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW URO 0.035INX150CM ZIPWIRE NTNL COR HYDRCT STR STD SHFT -,SUP-M006630205B1,CDM,C1769,HCPCS,272,RC,,,outpatient,,,219.51,153.657,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDEWIRE SENSOR .038 ANGLED -,SUP-M0066703021,CDM,C1769,HCPCS,272,RC,,,outpatient,,,241.45,169.015,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDEWIRE SENSOR -,SUP-M0066703091,CDM,C1769,HCPCS,272,RC,,,outpatient,,,230.6,161.42,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW URO 0.018IN X 150CM STD ZIPWIRE STRAIGHT -,SUP-M0066802001,CDM,C1769,HCPCS,272,RC,,,outpatient,,,298.43,208.901,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GLIDEWIRE STRAIGHT STIFF .035 SS -,SUP-M0066802221,CDM,C1769,HCPCS,272,RC,,,outpatient,,,302.94,212.058,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GLIDEWIRE STRAIGHT .038 SS -,SUP-M0066802251,CDM,C1769,HCPCS,272,RC,,,outpatient,,,302.94,212.058,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GLIDEWIRE ANGLED .038 SS STIFF -,SUP-M0066802261,CDM,C1769,HCPCS,272,RC,,,outpatient,,,302.94,212.058,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.018INX40CM SS -,SUP-MAK001,CDM,C1769,HCPCS,272,RC,,,outpatient,,,114.37,80.059,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.018INX40CM NTNL PLTNM -,SUP-MAK001N,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.37,89.859,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW METRO TRACER .035 X 480 -,SUP-METII-35-480,CDM,C1769,HCPCS,272,RC,,,outpatient,,,770.22,539.154,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDEWIRE W/NITREX .018 80CM STRAIGHT -,SUP-N180801,CDM,C1769,HCPCS,272,RC,,,outpatient,,,348.82,244.174,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014/ 0.008INX300CM ASTATO XS 20 STR TAPR PTFE-CTD -,SUP-PAGH143392,CDM,C1769,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.0180.0 13INX300CM ASTATO 30 STR PTFE-CTD 15CM 30GM -,SUP-PAGH18M371,CDM,C1769,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX300CM REGALIA XS 1 STR STF SHFT FLXB SPR -,SUP-PAGP140300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
TUBE JEJUNAL 12FR X 60CM PEG24 -,SUP-PEGJ-12-24,CDM,C1769,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
PHOENIX .014 FLOPPY TIP WIRE EXTRA SUPPORT -,SUP-PG14300XF,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
PIGTAIL WIRE PRO TRACK 175CM -,SUP-PTW-25-175,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1120.32,784.224,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WIRE DX 0.025IN BD PIGTL 230CM PROTRACK -,SUP-PTW-25-230,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1120.32,784.224,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
ILLUMINATION RELIEVA LUMA SENTRY -,SUP-SIS-100B,CDM,C1769,HCPCS,272,RC,,,outpatient,,,2273.91,1591.737,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDEWIRE 0.014 TCAR ENROUTE -,SUP-SR-014-GW,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WIRE SAFESEPT TRASEPTAL  0.014INX135CM -,SUP-SS-135,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1102.82,771.974,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
PK PROC CUST CARD CATHETERISATION LAB SLHSFR -,SUP-STLM004-13,CDM,C1769,HCPCS,272,RC,,,outpatient,,,288.66,202.062,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
DEVICE TRQ SGL HND F/0.010-0.038IN GW MUL-TRQ VISE STRL -,SUP-TD01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,38.34,26.838,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WIRE AMPLATZ 0.035 IN X 260CM CRV TIP XSTIF FLXB SS PTFE-CTD -,SUP-THSCF-025-260-3,CDM,C1769,HCPCS,272,RC,,,outpatient,,,166.24,116.368,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.032INX260CM AMP CRV JTP XSTIF FLPY SS PTFE-CTD 8CM -,SUP-THSCF322603AES,CDM,C1769,HCPCS,272,RC,,,outpatient,,,166.24,116.368,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.035INX145CM CRV RSN TIP FXCR FLXB FLPY SS PTFE-CTD -,SUP-THSCF351451.5R,CDM,C1769,HCPCS,272,RC,,,outpatient,,,78.71,55.097,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDE WIRE TORAY TRG-25230 -,SUP-TRG-25230,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.021INX180CM 3MM JTP FXCR FLXB SS PTFE-CTD 7CM TAPR -,SUP-TSCF-21-180-3BH,CDM,C1769,HCPCS,272,RC,,,outpatient,,,96.04,67.228,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.035INX180CM 3MM JTP FXCR FLXB SS HEP PTFE-CTD 6CM -,SUP-TSCF-35-180-3,CDM,C1769,HCPCS,272,RC,,,outpatient,,,72.88,51.016,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.035INX260CM LNDRQST FLXB LO SURF FRCTN EXTEND CRV -,SUP-TSCMG35260ELESD,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1025.79,718.053,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
WIRE GUIDE LUNDERQUIST .035 -,SUP-TSCMG35260LESDC,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1025.79,718.053,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC HTORQ WHISPER VW EDS -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
LOOP TIP WIRE GUIDE .035 X 480 -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1085.31,759.717,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
W MOVEABLE CORE 3J 035 145CM -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,151.71,106.197,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
W MOVEABLE CORE 1.5J 035 145CM -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,151.71,106.197,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDE WIRE VIPER .014 TIP -,SUP-VPR-GW-14,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GUIDE WIRE VIPER .017 335CM -,SUP-VPR-GW-FLEX18,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
GW VASC 0.014INX180CM ZINGER LS RSN JTP CRV LGT SUPP FRMG -,SUP-ZNGRLS180J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,169.22,118.454,AETNA [1000108],AETNA [100010801],,,,,,8.60733,7443.65739,other,272 with C codes,,
COIL MRI ENDORECTAL DISP BPX15 -,SUP-BPX 15,CDM,C1770,HCPCS,272,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,,,,144.095325,460.20645,other,272 with C codes,,
SYS SLING MALE VIRTUE -,SUP-50020,CDM,C1771,HCPCS,278,RC,,,outpatient,,,20164.56,14115.192,AETNA [1000108],AETNA [100010801],,,76.8,,15486.38,248.891925,15486.38208,percent of total billed charges,,,
SLING SINGLE INCISION ALTIS -,SUP-519650,CDM,C1771,HCPCS,278,RC,,,outpatient,,,6206.85,4344.795,AETNA [1000108],AETNA [100010801],,,76.8,,4766.86,248.891925,15486.38208,percent of total billed charges,,,
SYS SLING URETH ADVANCE MALE 3.55X36CM NABSB MSH NDLHLDRX2 -,SUP-720088-01,CDM,C1771,HCPCS,278,RC,,,outpatient,,,18026.62,12618.634,AETNA [1000108],AETNA [100010801],,,76.8,,13844.44,248.891925,15486.38208,percent of total billed charges,,,
MESH SURG MINI ARC SLNG -,SUP-720095-01,CDM,C1771,HCPCS,278,RC,,,outpatient,,,5623.3,3936.31,AETNA [1000108],AETNA [100010801],,,76.8,,4318.69,248.891925,15486.38208,percent of total billed charges,,,
MESH MINI ARC SLING PRECISE - DISCONTINUED -,SUP-720191-01,CDM,C1771,HCPCS,278,RC,,,outpatient,,,6578.45,4604.915,AETNA [1000108],AETNA [100010801],,,76.8,,5052.25,248.891925,15486.38208,percent of total billed charges,,,
PROSTHESIS PENL MONARCH + 1.1CMX35CM SAL FIL CYL NABSB -,SUP-724041-93,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4807.35,3365.145,AETNA [1000108],AETNA [100010801],,,76.8,,3692.04,248.891925,15486.38208,percent of total billed charges,,,
SLING GYN TVT PP 1.1X45CM URETH FEM MECH CUT -,SUP-810041B,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4965.48,3475.836,AETNA [1000108],AETNA [100010801],,,76.8,,3813.49,248.891925,15486.38208,percent of total billed charges,,,
KIT TRANS OBTURATOR W TAPE INC -,SUP-93-4001,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4720.05,3304.035,AETNA [1000108],AETNA [100010801],,,76.8,,3625,248.891925,15486.38208,percent of total billed charges,,,
ANCHORSURE SACROSPINOUS LIGAMENT FIXATION -,SUP-A-SURE,CDM,C1771,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,248.891925,15486.38208,percent of total billed charges,,,
NEOMEDIC ANCHORSURE ANCHOR SYSTEM 2 ANCHORS -,SUP-A-SURE02,CDM,C1771,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,AETNA [1000108],AETNA [100010801],,,76.8,,851.44,248.891925,15486.38208,percent of total billed charges,,,
SLING URETH PP NABSB FEM -,SUP-M006850200051,CDM,C1771,HCPCS,278,RC,,,outpatient,,,3571.91,2500.337,AETNA [1000108],AETNA [100010801],,,76.8,,2743.23,248.891925,15486.38208,percent of total billed charges,,,
SLING ADVANTAGE TRAN VAGINAL -,SUP-M0068502110,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4616.84,3231.788,AETNA [1000108],AETNA [100010801],,,76.8,,3545.73,248.891925,15486.38208,percent of total billed charges,,,
SLING GYN ADVANTG FIT PP TRNVAG MI D URETH FEM -,SUP-M0068502110,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4616.84,3231.788,AETNA [1000108],AETNA [100010801],,,76.8,,3545.73,248.891925,15486.38208,percent of total billed charges,,,
SLING LYNX MID URETHRAL SUPRAPUBIC BLUE SYSTEM -,SUP-M0068503010,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4439.29,3107.503,AETNA [1000108],AETNA [100010801],,,76.8,,3409.37,248.891925,15486.38208,percent of total billed charges,,,
SLING GYN OBTRYX II -,SUP-M0068505110,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4420,3094,AETNA [1000108],AETNA [100010801],,,76.8,,3394.56,248.891925,15486.38208,percent of total billed charges,,,
SLING GYN SOLYX SGL-INCS -,SUP-ML00001621,CDM,C1771,HCPCS,278,RC,,,outpatient,,,5030.63,3521.441,AETNA [1000108],AETNA [100010801],,,76.8,,3863.52,248.891925,15486.38208,percent of total billed charges,,,
PUMP IT 87.5MM 19.5MM 20ML 165/185 GM EMTY/FUL 0.22UM FLTR -,SUP-8637-20,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29090.86,20363.602,AETNA [1000108],AETNA [100010801],,,76.8,,22341.78,399.86,23012.49024,percent of total billed charges,,,
PUMP IT 87.5X26MM THK 40ML 175/215 GM EMTY/FUL 0.22UM FLTR -,SUP-8637-40,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29090.86,20363.602,AETNA [1000108],AETNA [100010801],,,76.8,,22341.78,399.86,23012.49024,percent of total billed charges,,,
PUMP 8667-20 SYNCHROMEDIII INFUSION 20ML -,SUP-8667-20,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29964.18,20974.926,AETNA [1000108],AETNA [100010801],,,76.8,,23012.49,399.86,23012.49024,percent of total billed charges,,,
PUMP 8667-40 SYNCHROMEDIII INFUSION 40ML -,SUP-8667-40,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29964.18,20974.926,AETNA [1000108],AETNA [100010801],,,76.8,,23012.49,399.86,23012.49024,percent of total billed charges,,,
TIGHTRAIL SUB-C  9FR 560-009 -,SUP-560-009,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7193.58,5035.506,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes,,
TIGHTRAIL SUB-C 11FR 560-011 -,SUP-560-011,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7830.18,5481.126,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes,,
TIGHTRAIL SUB-C 13FR 560-013 -,SUP-560-013,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7830.18,5481.126,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes,,
SHEATH CATH DLV 10FRX80CM AMPLATZER TORQVUE VASC 45DG ANG -,SUP-9-ATV10F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes,,
SHEATH CATH DLV 9FRX80CM AMPLATZER TORQVUE VASC 45DG ANG SFT -,SUP-9-EITV09F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes,,
SHEATH CATH DLV 12FRX80CM AMPLATZER TORQVUE VASC 45DG ANG -,SUP-9-EITV12F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes,,
SYSTEM AMPLATZER DELIVERY TORQVUE 9-ITV06F 180/80 -,SUP-9-ITV06F 180/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,3909.91,2736.937,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes,,
SHEATH CATH DLV 6FRX60CM AMPLATZER TORQVUE VASC 45DG ANG SFT -,SUP-9-ITV06F45/60,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes,,
SHEATH CATH DLV 7FRX80CM AMPLATZER TORQVUE VASC 180DG ANG -,SUP-9-ITV07F180/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes,,
SHEATH CATH DLV 7FRX80CM AMPLATZER TORQVUE VASC 45DG ANG SFT -,SUP-9-ITV07F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes,,
SHEATH CATH DLV AMPLATZER TORQVUE/TREVISIO VASC 45DG ANG SFT -,SUP-9-ITV08F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes,,
SHEATH CATH DLV 9FRX80CM AMPLATZER TORQVUE VASC 45DG ANG -,SUP-9-ITV09F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes,,
SHEATH CATH DLV 12FRX80CM AMPLATZER TORQVUE VASC 45DG ANG- -,SUP-9-ITV12F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes,,
AMPLATZER TALISMAN DELIVERY SHEATH 8F 80 -,SUP-9-TDS-08F45-80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes,,
AMPLATZER TALISMAN DELIVERY SHEATH 9FR 80 -,SUP-9-TDS-09F45-80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes,,
COMP LOADING SYS CLS-3000- 18F -,SUP-CLS-3000-18F-US,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2067.2,1447.04,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes,,
VALVE DEL SYS COMM 26/29/31 -,SUP-DCS-C4-18F-US,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes,,
CATH DELIVERY EVOLUT FX 23-29 REF: D-EVOLUTFX-2329 -,SUP-D-EVOLUTFX-2329,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes,,
CATH DELIVERY EVOLUT FX 34 REF: D-EVOLUTFX-34 -,SUP-D-EVOLUTFX-34,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes,,
CATH DELIVERY EVPROP2329US -,SUP-D-EVPROP2329US,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes,,
SNARE ENSNARE SYSTEM 9-15 120 -,SUP-EN2006015,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1779.27,1245.489,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes,,
SNARE ENSNARE 18 30 CM -,SUP-EN2007030,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes,,
SNARE VASC EN SNR 27-45MM 7FR CATH 120CM 3 PREFRM LOOP NTNL -,SUP-EN2007045,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2644.95,1851.465,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes,,
GTRS-200-RB RETREIVAL SET TULI -,SUP-G13287,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1590.1,1113.07,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes,,
EXTRACTION TOOL 13FR MANUAL CONTROL ROTATION DILATOR SHEATH -,SUP-G23747,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7285.21,5099.647,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes,,
SHEATH DILATOR 11FR EVOLUTION SHORTIE RL PERC -,SUP-G23749,CDM,C1773,HCPCS,272,RC,,,outpatient,,,5843.14,4090.198,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes,,
SNARE VASC EYE SNR 13MMX94CM FLSH PRT NTNL 16FR WRKSTN -,SUP-G26517,CDM,C1773,HCPCS,272,RC,,,outpatient,,,5674.23,3971.961,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes,,
SNARE VASC AMP GOOSENECK 15MM/6FR LOOP/CATH 120CM GOLD TUNG -,SUP-GN1500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes,,
SNARE EV AMP GOOSENECK 20X120MM GOLD TUNG NTNL 6FRX102CM -,SUP-GN2000,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes,,
SNARE VASC AMP GOOSENECK 25MM/6FR LOOP/CATH 120CM GOLD TUNG -,SUP-GN2500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes,,
KIT GOOSE NECK SNARE 25MM LOOP -,SUP-GN3000,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes,,
SNARE GOOSENECK GN3500 -,SUP-GN3500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes,,
SNARE AMPLATZ GN 5MM -,SUP-GN500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes,,
STYLET LD LIBERATOR 140CM -,SUP-LR-OFA01,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2639.4,1847.58,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes,,
CATHETER INTRODUCER AVEIR 50CM REF:LSN25501 -,SUP-LSN25501,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes,,
BASKET STONE SEGURA -,SUP-M0063801120,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1030.93,721.651,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes,,
SNARE ONE700 175CM 7MM LOOP -,SUP-ONE700,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2851.99,1996.393,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes,,
SNARE ONE701 200CM 7MM LOOP -,SUP-ONE701,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2959.88,2071.916,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes,,
SNARE VASC AMP GOOSENECK 7X175MM GOLD TUNG NTNL -,SUP-SK700,CDM,C1773,HCPCS,272,RC,,,outpatient,,,3126.44,2188.508,AETNA [1000108],AETNA [100010801],,,,,,231.443785,6420.62028,other,272 with C codes,,
HEAD FEM 12/ 1440MMX3.5MM NK TAPR -,SUP-00080184001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 40MM -,SUP-00080184002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 15X190MM WAGNER SL REVISN PROTASUL-100 POR CTD -,SUP-00100101915,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA [1000108],AETNA [100010801],,,76.8,,14257.92,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 18X225MM WAGNER SL REVISN PROTASUL-100 POR CTD -,SUP-00100102218,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA [1000108],AETNA [100010801],,,76.8,,14257.92,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 9MM PRFT ANTMC 110MM PROTASUL-100 UNCEM TAPR SHLDR -,SUP-00104201092,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA [1000108],AETNA [100010801],,,76.8,,8269.59,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 40X14MM -,SUP-00104212400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 44X16MM PROTASUL-21 WF ANTMCREM -,SUP-00104212440,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 46X16MM PROTASUL-21 WF ANTMC REM -,SUP-00104212460,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 48X17MM ANTMC SHLDR PROTASUL-21 REM -,SUP-00104212480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 50X18MM PROTASUL-21 WF ANTMC REM -,SUP-00104212500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,,,
COMP 24MM SM ANTMC SHLDR 16MM PE PG CMNT -,SUP-00104214340,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
COMP 28MM MED ANTMC SHLDR 19MM PE PG CMNT -,SUP-00104214370,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ3 39.68MM OFST 141MM AVENIR MULLER STD 56.11MM NK -,SUP-00106010003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ4 40.22MM OFST 147MM AVENIR MULLER STD 56.88MM NK -,SUP-00106010004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
STEM LAT AVENIR MUELLER SZ 4 -,SUP-00106010104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 12/14 TAPR M/L HIP -,SUP-00106010107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
WEDGE ANKL JNT OSSEOTI 15X15MM POR MTL -,SUP-00110003821,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8785.08,6149.556,AETNA [1000108],AETNA [100010801],,,76.8,,6746.94,9.170825,27238.33344,percent of total billed charges,,,
CEMENT BN PLYMTHL MTHCRYLT 40GM PLC R HVISC -,SUP-00111214001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,396.78,277.746,AETNA [1000108],AETNA [100010801],,,76.8,,304.73,9.170825,27238.33344,percent of total billed charges,,,
INTEGRAL SHORT GTR W/2 CABLES 23 X 53 -,SUP-00223200204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6861.23,4802.861,AETNA [1000108],AETNA [100010801],,,76.8,,5269.42,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 46X18MM BGLNI/FLTW STD ZML MODULAR OFST -,SUP-00430004618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,,,
COMP 40MM BGLNI/FLTW SHLDR UHMWPE SS PG -,SUP-00430008500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
COMP 46MM BGLNI/FLTW SHLDR UHMWPE SS PG -,SUP-00430008600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 40X18MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 40X21MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,,,
COMP 40MM 46MM ARTC SURF BGLNI/FLTW SHLDR UHMWPE SS PG -,SUP-00430204046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 46X15MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204615,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 46X17MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 46MM OFST MODULAR -,SUP-00430204618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 46X19MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 46X27MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204627,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,,,
COMP 46MM BGLNI/FLTW SHLDR W/52MM SS PG -,SUP-00430204652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
BF OFFSET HUM HEAD 18MM X 52MM -,SUP-00430205218,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 52X19MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430205219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 52X21MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430205221,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 10MM INTOP FLXB 130MM TM 42DG ANG NK SHLDR -,SUP-00434211013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,AETNA [1000108],AETNA [100010801],,,76.8,,8127.01,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 11MM INTOP FLXB 130MM TM 42DG ANG NK SHLDR -,SUP-00434211113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,AETNA [1000108],AETNA [100010801],,,76.8,,8127.01,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 6MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434810613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,AETNA [1000108],AETNA [100010801],,,76.8,,8127.01,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 8MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434810813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,AETNA [1000108],AETNA [100010801],,,76.8,,8127.01,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 9MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434810913,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,AETNA [1000108],AETNA [100010801],,,76.8,,8127.01,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 10MM TM 130MM 48DG ANG SHLDR -,SUP-00434811013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,AETNA [1000108],AETNA [100010801],,,76.8,,8127.01,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 11MM TM 130MM 48DG ANG SHLDR -,SUP-00434811113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,AETNA [1000108],AETNA [100010801],,,76.8,,8127.01,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 12MM TM 130MM 48DG ANG SHLDR -,SUP-00434811213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,AETNA [1000108],AETNA [100010801],,,76.8,,8127.01,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 13MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434811313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,AETNA [1000108],AETNA [100010801],,,76.8,,8127.01,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 12MM RVRS 130MM TM LPRO SHLDR -,SUP-00434901213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18477.37,12934.159,AETNA [1000108],AETNA [100010801],,,76.8,,14190.62,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 32X53MM EPSLN STD DRSL UHMWPE PRIM HD -,SUP-00437732053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 42MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500104200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 43MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500104300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 28X47-49MM VERSYS BIPLR UHMWPE -,SUP-00500104728,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 49MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500104900,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 28X50-52MM VERSYS BIPLR UHMWPE -,SUP-00500105028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 51MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 52MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 28X53-55MM VERSYS BIPLR UHMWPE -,SUP-00500105328,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 54MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 55MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 60MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500106000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT LMRL KN SZ2 27MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800227,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,AETNA [1000108],AETNA [100010801],,,76.8,,7587.86,9.170825,27238.33344,percent of total billed charges,,,
HALF BLOCK TRABECULAR TIBIAL AUGMENT RT LATERAL/LT MEDIAL -,SUP-00-5448-002-28,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10465.7,7325.99,AETNA [1000108],AETNA [100010801],,,76.8,,8037.66,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT RM/LL KN SZ2 37MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800237,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,AETNA [1000108],AETNA [100010801],,,76.8,,7587.86,9.170825,27238.33344,percent of total billed charges,,,
HALF BLOCK TRABECULAR TIBIAL AUGMENT LT LATERAL/RT MEDIAL -,SUP-00-5448-002-38,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10465.7,7325.99,AETNA [1000108],AETNA [100010801],,,76.8,,8037.66,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT LMRL KN SZ3 27MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800327,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,AETNA [1000108],AETNA [100010801],,,76.8,,7587.86,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT LMRL KN SZ3 26MM NEXGEN 5MM WDG FUL BLCK TM TIV PMMA -,SUP-00544800337,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,AETNA [1000108],AETNA [100010801],,,76.8,,7587.86,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT LMRL KN SZ5 27MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800527,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,AETNA [1000108],AETNA [100010801],,,76.8,,7587.86,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT RM/LL KN SZ5 37MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,AETNA [1000108],AETNA [100010801],,,76.8,,7587.86,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT KN 31MMMEDX31MM TM -,SUP-00545001331,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15863.61,11104.527,AETNA [1000108],AETNA [100010801],,,76.8,,12183.25,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT KN 36MM MED 25MMX36MM TM -,SUP-00545001336,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,AETNA [1000108],AETNA [100010801],,,76.8,,14371.98,9.170825,27238.33344,percent of total billed charges,,,
CONE TIBIAL TM LARGE 51 X 34 RIGHT -,SUP-00-5450-013-52,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,AETNA [1000108],AETNA [100010801],,,76.8,,14371.98,9.170825,27238.33344,percent of total billed charges,,,
CONE FEMORAL LT SM 30MM -,SUP-00545001730,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,AETNA [1000108],AETNA [100010801],,,76.8,,14371.98,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT RT DPHSL KN SZ30 SM TM -,SUP-00545001731,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,AETNA [1000108],AETNA [100010801],,,76.8,,14371.98,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT RT DPHSL KN SZ30 MED TM -,SUP-00545001831,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,AETNA [1000108],AETNA [100010801],,,76.8,,14371.98,9.170825,27238.33344,percent of total billed charges,,,
TM FEM DIAPHYSEAL CONE- 30 LARGE- RIGHT -,SUP-00-5450-019-31,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,AETNA [1000108],AETNA [100010801],,,76.8,,14371.98,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT KN SZ48 XS NEXGEN 15MM TM -,SUP-00545004801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19404.14,13582.898,AETNA [1000108],AETNA [100010801],,,76.8,,14902.38,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT TRAB METALTIB SZ 52-51MM FULL SMALL -,SUP-00-5450-052-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19404.14,13582.898,AETNA [1000108],AETNA [100010801],,,76.8,,14902.38,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT DIST KN SZ-D NEXGEN 5MM BLCK REVISN TM TIV -,SUP-00549003401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,AETNA [1000108],AETNA [100010801],,,76.8,,7587.86,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT KN SZ-D NEXGEN 5MM DIST BLCK REVISN TM TIV -,SUP-00549003410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,AETNA [1000108],AETNA [100010801],,,76.8,,7459.75,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT KN SZ-D NEXGEN 10MM BLCK REVISN TM TIV -,SUP-00549003420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,AETNA [1000108],AETNA [100010801],,,76.8,,7459.75,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT POST 5MM BLCK SZ-E NEXGEN BLCK REVISN TM TIV -,SUP-00549003501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,AETNA [1000108],AETNA [100010801],,,76.8,,7587.86,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT DIST KN SZ-E NEXGEN 5MM BLCK REVISN TM TIV -,SUP-00549003510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,AETNA [1000108],AETNA [100010801],,,76.8,,7459.75,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT KN SZ-E NEXGEN 10MM DIST BLCK REVISN TM TIV -,SUP-00549003520,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,AETNA [1000108],AETNA [100010801],,,76.8,,7459.75,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT POST KN SZ-F NEXGEN 5MM DIST BLCK REVISN TM TIV -,SUP-00549003601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,AETNA [1000108],AETNA [100010801],,,76.8,,7587.86,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT KN SZ-F NEXGEN 10MM POST BLCK REVISN TM TIV -,SUP-00549003602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,AETNA [1000108],AETNA [100010801],,,76.8,,7587.86,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT DIST KN SZ-F NEXGEN 5MM DIST BLCK REVISN TM TIV -,SUP-00549003610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,AETNA [1000108],AETNA [100010801],,,76.8,,7459.75,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-E MINUS NEXGEN GENDR SOL LT KN CR CMNT ZML PMMA -,SUP-00575001505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-E MINUS NEXGEN GENDR SOL LT KN CR CMNT COCR FLEX -,SUP-00575201505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,AETNA [1000108],AETNA [100010801],,,76.8,,7499.67,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-E MINUS NEXGEN GENDR SOL RT KN CR CMNT COCR FLEX -,SUP-00575201506,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,AETNA [1000108],AETNA [100010801],,,76.8,,7499.67,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-D NEXGEN LEGC GENDR SOL LT KN PS CMNT ZML FLEX -,SUP-00576401451,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-E NEXGEN LEGC GENDR SOL LT KN PS CMNT ZML FLEX -,SUP-00576401551,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-E NEXGEN LEGC GENDR SOL RT KN PS CMNT ZML FLEX -,SUP-00576401552,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-F NEXGEN LEGC GENDR SOL LT KN PS CMNT ZML FLEX -,SUP-00576401651,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBPLT SZ2 44/25MM LMRL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,AETNA [1000108],AETNA [100010801],,,76.8,,4209.51,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBPLT SZ3 47/27MM LMRL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,AETNA [1000108],AETNA [100010801],,,76.8,,4209.51,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBPLT SZ4 50/29MM LL/RM KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,AETNA [1000108],AETNA [100010801],,,76.8,,4209.51,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBPLT SZ5 53/31MM LMRL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,AETNA [1000108],AETNA [100010801],,,76.8,,4209.51,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBPLT SZ5 53/31MM RM/LL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,AETNA [1000108],AETNA [100010801],,,76.8,,4209.51,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-D 23/48MM NEXGEN LMRL CONDL UNICMPT ZML HI FLEX -,SUP-00584201401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,AETNA [1000108],AETNA [100010801],,,76.8,,6962.39,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-E 24/51.5MM NEXGEN LMRL CONDL UNICMPT ZML HI -,SUP-00584201501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,AETNA [1000108],AETNA [100010801],,,76.8,,6962.39,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-F 25/55.5MM NEXGEN LMRL CONDL UNICMPT ZML HI -,SUP-00584201601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,AETNA [1000108],AETNA [100010801],,,76.8,,6962.39,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-F 25/55.5MM NEXGEN LL/RM KN UNICMPT ZML HI FLEX -,SUP-00584201602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,AETNA [1000108],AETNA [100010801],,,76.8,,6962.39,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL SIZE G RM/LL -,SUP-00584201702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,AETNA [1000108],AETNA [100010801],,,76.8,,6962.39,9.170825,27238.33344,percent of total billed charges,,,
ARTICULAR SURFACE SIZE 2 11MM -,SUP-00584202211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,AETNA [1000108],AETNA [100010801],,,76.8,,2465.31,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 8MM UNICMPT ARTCSURF NET SHP KN-HI FLEX MLD -,SUP-00584202308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,9.170825,27238.33344,percent of total billed charges,,,
ARTICULAR SURFACE SIZE 5 8MM -,SUP-00584202508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,AETNA [1000108],AETNA [100010801],,,76.8,,2465.31,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ2 9MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3229.61,2260.727,AETNA [1000108],AETNA [100010801],,,76.8,,2480.34,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 8MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,AETNA [1000108],AETNA [100010801],,,76.8,,2465.31,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ4 8MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,AETNA [1000108],AETNA [100010801],,,76.8,,2465.31,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ4 10MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4521.46,3165.022,AETNA [1000108],AETNA [100010801],,,76.8,,3472.48,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5 8MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,AETNA [1000108],AETNA [100010801],,,76.8,,2465.31,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 32MM MED 19.5MM TM PMMA NEXGEN -,SUP-00587601019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16244.38,11371.066,AETNA [1000108],AETNA [100010801],,,76.8,,12475.68,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 29MM MICRO 10MM PEGX3 POR -,SUP-00587806129,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 32X10MM THK TM PMMA NEXGEN PRIM POR -,SUP-00587806532,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,,,
NEXGEN POROUS TM PATELLA 10MM X 32MM -,SUP-00-5878-065-32,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 38X10MM THK TM PMMA NEXGEN PRIM POR -,SUP-00-5878-065-41,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,,,
COMP TIB SZ C-H FEM 3 TIB 10X67/43MM NEXGEN PRFT CR MBLK -,SUP-00588604310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12109.95,8476.965,AETNA [1000108],AETNA [100010801],,,76.8,,9300.44,9.170825,27238.33344,percent of total billed charges,,,
COMP TIB SZ C-H FEM 5 TIB 10X75/47.5MM NEXGEN PRFT CR MBLK -,SUP-00588604510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10860.53,7602.371,AETNA [1000108],AETNA [100010801],,,76.8,,8340.89,9.170825,27238.33344,percent of total billed charges,,,
SCREW HEADED HEX 3.5MM X -,SUP-00-5901-035-33,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,AETNA [1000108],AETNA [100010801],,,76.8,,806.63,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ1 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,AETNA [1000108],AETNA [100010801],,,76.8,,9994.81,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ2 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT. -,SUP-00592601201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,AETNA [1000108],AETNA [100010801],,,76.8,,9994.81,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ2 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,AETNA [1000108],AETNA [100010801],,,76.8,,9994.81,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ3 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,AETNA [1000108],AETNA [100010801],,,76.8,,9994.81,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ3 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,AETNA [1000108],AETNA [100010801],,,76.8,,9994.81,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ4 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,AETNA [1000108],AETNA [100010801],,,76.8,,9994.81,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ4 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,AETNA [1000108],AETNA [100010801],,,76.8,,9994.81,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,AETNA [1000108],AETNA [100010801],,,76.8,,9994.81,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,AETNA [1000108],AETNA [100010801],,,76.8,,9994.81,9.170825,27238.33344,percent of total billed charges,,,
NEXTGEN CR FLEX PROLONG ART SURF C-H/1-2 SPUR- 14MM -,SUP-00-5952.021-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,,,
NEXGEN CR FLEX PROLONG  ART SURF -,SUP-00-5952-021-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ A-B/1-2 10MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596202010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ C-D/1-2 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596202212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ C-D SZ1-2 FEM 14MM NEXGEN PS ARTCSURF KN FLEX -,SUP-00596202214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ C-D/1-2 17MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596202217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ-E SZ1-2 FEM 10MM NEXGEN PS ARTCSURF KN FLEX FX -,SUP-00596202410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ E-F/3-4 10MM NEXGEN LEGACY ARTCSURF KN PS FLEX -,SUP-00596203210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ E-F/3-4 14MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596203214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ E-F/3-4 17MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596203217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,,,
NEXTGEN LPS-FLEX FIXED PROLONG ART SUR EF 3-4- 20MM -,SUP-00-5962-032-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ E-F/5-6 10MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ E-F/5-6 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ E-F/5-6 17MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ G-H/5-6 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ G-H/5-6 14MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ E-F/7-10 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596205112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-E 68/62.5MM NEXGEN LEGC RT KN PS CMNT ZML FLEX -,SUP-00596401552,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-F 72/65.5MM NEXGEN LEGC R/L KN PS CMNT ZML FLEX -,SUP-00596401652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-G 76.5/71.5MM NEXGEN LEGC L/L KN PS CMNT ZML -,SUP-00596401751,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-G 76.5/71.5MM NEXGEN LEGC R/L KN PS CMNT ZML -,SUP-00596401752,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ C-D/3-4 14MM NEXGEN LPS ARTCSURF NET SHP KN -,SUP-00596403012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-D NEXGEN LEGC LT KN PS CMNT TIV NPOR FLEX FX -,SUP-00596801451,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,AETNA [1000108],AETNA [100010801],,,76.8,,9980.54,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-F NEXGEN LEGC LT KN PS CMNT TIV NPOR FLEX FX -,SUP-00596801651,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,AETNA [1000108],AETNA [100010801],,,76.8,,9980.54,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-G NEXGEN LEGC RT KN PS CMNT TIV NPOR FLEX FX -,SUP-00596801752,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,AETNA [1000108],AETNA [100010801],,,76.8,,9980.54,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 29MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206529,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 32MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206532,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 35MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 38MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206538,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 29MM PRLNG NEXGEN ON ST -,SUP-00597206629,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 32MM PRLNG NEXGEN ON ST -,SUP-00597206632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,9.170825,27238.33344,percent of total billed charges,,,
PATELLA NEXGEN PROLONG ALLPOLY 35MM -,SUP-00597206635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 38MM PRLNG NEXGEN ON ST -,SUP-00597206638,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,9.170825,27238.33344,percent of total billed charges,,,
NEXGEN AC ART SURF 5-6 GREEN 12MM -,SUP-00597604012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT KN SZ3 NEXGEN 5MM CR PRCTD TIV PMMA -,SUP-00-5988-003-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5398.37,3778.859,AETNA [1000108],AETNA [100010801],,,76.8,,4145.95,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT L/R KN SZ4 NEXGEN 10MM HLF BLCK CR TIV PMMA -,SUP-00598800427,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5398.37,3778.859,AETNA [1000108],AETNA [100010801],,,76.8,,4145.95,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 11MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA [1000108],AETNA [100010801],,,76.8,,4654.41,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 12MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA [1000108],AETNA [100010801],,,76.8,,4654.41,9.170825,27238.33344,percent of total billed charges,,,
SCISSORS OPTH KNAPP 4IN SS CRV V. MUELLER MIRR FNSH S/S IRIS -,SUP-00-5988-010-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA [1000108],AETNA [100010801],,,76.8,,4654.41,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 16MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA [1000108],AETNA [100010801],,,76.8,,4654.41,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 18MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA [1000108],AETNA [100010801],,,76.8,,4654.41,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 20MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA [1000108],AETNA [100010801],,,76.8,,4654.41,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 16MM NEXGEN 155MM TIV ALY STR FEM/TBL KN -,SUP-00598801116,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA [1000108],AETNA [100010801],,,76.8,,4654.41,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 12.7MM NEXGEN 30MM TIV ALY STR FEM/TBL KN -,SUP-00598801212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA [1000108],AETNA [100010801],,,76.8,,4654.41,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 15MM NEXGEN 30MM TIV ALY STR FEM/TBL KN -,SUP-00598801215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA [1000108],AETNA [100010801],,,76.8,,4654.41,9.170825,27238.33344,percent of total billed charges,,,
SCISSORS OPTH STVNS 4IN SS STR V. MUELLER MIRR FNSH -,SUP-00598802011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,AETNA [1000108],AETNA [100010801],,,76.8,,6062.47,9.170825,27238.33344,percent of total billed charges,,,
SCOOP SURG SM 11IN SLVR PLT CMN DCT MLBL V. MUELLER -,SUP-00598802012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,AETNA [1000108],AETNA [100010801],,,76.8,,6062.47,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 13MM NEXGEN OFST 100MM TIV ALY FEM/TBL KN -,SUP-00598802013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,AETNA [1000108],AETNA [100010801],,,76.8,,6062.47,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 14MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,AETNA [1000108],AETNA [100010801],,,76.8,,6062.47,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 15MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,AETNA [1000108],AETNA [100010801],,,76.8,,6062.47,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 16MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,AETNA [1000108],AETNA [100010801],,,76.8,,6062.47,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 17MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,AETNA [1000108],AETNA [100010801],,,76.8,,6062.47,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 12MM NEXGEN OFST 155MM TIV ALY FEM/TBL KN -,SUP-00598802112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,AETNA [1000108],AETNA [100010801],,,76.8,,6062.47,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 11MM NEXGEN OFST 155MM TIV ALY FEM/TBL KN -,SUP-00598802115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,AETNA [1000108],AETNA [100010801],,,76.8,,6062.47,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT ANT KN SZ-D NEXGEN 5MM WDG BLCK TIV PMMA -,SUP-00599003431,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5398.37,3778.859,AETNA [1000108],AETNA [100010801],,,76.8,,4145.95,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-C 60/53.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401392,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,AETNA [1000108],AETNA [100010801],,,76.8,,23217.6,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-D 64/57.5MM NEXGEN LEGC LT CONDL KN CNSTRN -,SUP-00599401491,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,AETNA [1000108],AETNA [100010801],,,76.8,,23217.6,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-D 64/57.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401492,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,AETNA [1000108],AETNA [100010801],,,76.8,,23217.6,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-E 68/61.5MM NEXGEN LEGC LT CONDL KN CNSTRN -,SUP-00599401591,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,AETNA [1000108],AETNA [100010801],,,76.8,,23217.6,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-E 68/61.5MM NEXGEN LEGC RT KN REVISN CNSTRN -,SUP-00599401592,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,AETNA [1000108],AETNA [100010801],,,76.8,,23217.6,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-F 72/65.5MM NEXGEN LEGC LT KN REVISN CNSTRN -,SUP-00599401691,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,AETNA [1000108],AETNA [100010801],,,76.8,,23217.6,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-F 72/65.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401692,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,AETNA [1000108],AETNA [100010801],,,76.8,,23217.6,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-G 76.5/70.5MM NEXGEN LEGC LT KN REVISN CNSTRN -,SUP-00599401791,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,AETNA [1000108],AETNA [100010801],,,76.8,,23217.6,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-G 76.5/70.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401792,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,AETNA [1000108],AETNA [100010801],,,76.8,,23217.6,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ C-D/1-2 MICRO 10X58/40MM NEXGEN LEGC CNSTRN -,SUP-00599402210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA [1000108],AETNA [100010801],,,76.8,,8092.79,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ C-D/1-2 MICRO 12X58/40MM NEXGEN LEGC CNSTRN -,SUP-00599402212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA [1000108],AETNA [100010801],,,76.8,,8092.79,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ C-D/1-2 MICRO 14X58/40MM NEXGEN LEGC CNSTRN -,SUP-00599402214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA [1000108],AETNA [100010801],,,76.8,,8092.79,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB 0.5X20MM THK 58MM/40MM M/L A/P NEXGEN LEGC CNSTRN -,SUP-00599402220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA [1000108],AETNA [100010801],,,76.8,,8092.79,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ C-D/3-4 17X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA [1000108],AETNA [100010801],,,76.8,,8092.79,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ C-D/3-4 20X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA [1000108],AETNA [100010801],,,76.8,,8092.79,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ E-F/3-4 10X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA [1000108],AETNA [100010801],,,76.8,,8092.79,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ E-F/3-4 12X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA [1000108],AETNA [100010801],,,76.8,,8092.79,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ E-F/3-4 14X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA [1000108],AETNA [100010801],,,76.8,,8092.79,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ E-F SZ3-4 FEM 17MM 66MM/42MM M/L/A/P NEXGEN -,SUP-00599403217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA [1000108],AETNA [100010801],,,76.8,,8092.79,9.170825,27238.33344,percent of total billed charges,,,
NEXGEN LCCK ART SURF EF 3-4/STR YELLOW 20MM -,SUP-00599403220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9695.93,6787.151,AETNA [1000108],AETNA [100010801],,,76.8,,7446.47,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ E-F/5-6 10X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA [1000108],AETNA [100010801],,,76.8,,8092.79,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ E-F/5-6 14X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA [1000108],AETNA [100010801],,,76.8,,8092.79,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ E-F/5-6 17X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA [1000108],AETNA [100010801],,,76.8,,8092.79,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ E-F/5-6 20X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA [1000108],AETNA [100010801],,,76.8,,8092.79,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ-G 5-6 17X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA [1000108],AETNA [100010801],,,76.8,,8092.79,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ G-H/7-10 14X82/50MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599405014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA [1000108],AETNA [100010801],,,76.8,,8092.79,9.170825,27238.33344,percent of total billed charges,,,
TIBIA ALL POLY NEXGEN LPS SZ 8 BLUE 14MM FEM G H -,SUP-00599600814,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4638.69,3247.083,AETNA [1000108],AETNA [100010801],,,76.8,,3562.51,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 32X50MM TRILOGY 10DG TIV ALY UHMWPE 6.3MM PRIM -,SUP-00615405032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8097.55,5668.285,AETNA [1000108],AETNA [100010801],,,76.8,,6218.92,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 32X68MM TRILOGY 10DG TIV ALY UHMWPE 12.4MM PRIM -,SUP-00615406832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8097.55,5668.285,AETNA [1000108],AETNA [100010801],,,76.8,,6218.92,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 54MM TRILOGY PRIM MUL-HL TIV POR CTD SLD HMSPHR -,SUP-00620005420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6960.16,4872.112,AETNA [1000108],AETNA [100010801],,,76.8,,5345.4,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 44MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620204420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 48MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620204820,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 50MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620205020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 54MM PRIM MODULAR REVISN CLUS-HL TM TNTLM TIV SLD -,SUP-00620205422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 56MM PRIM MODULAR REVISN NO-HL TM TNTLM TIV SLD -,SUP-00620205620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 22X62MM TRILOGY PRIM MODULAR REVISN CLUS-HL TM -,SUP-00620206220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 68MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620206820,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 32X48MM XL TRILOGY 0DG STD LNGVT XLPE 5.3MM PRIM -,SUP-00630504832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 36X50MM TRILOGY 0DG STD LNGVT XLPE 6.8MM PRIM -,SUP-00630505036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 28X44MM TRILOGY 10DG ELEV RM LNGVT XLPE 5.2MM -,SUP-00631004428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 28X46MM TRILOGY 10DG ELEV RM LNGVT XLPE 6.3MM -,SUP-00631004628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 36X58MM XL TRILOGY 10DG STD LNGVT XLPE 8.9MM PRIM -,SUP-00631005836,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 32X62MM TRILOGY 10DG LNGVT XLPE 9.3MM PRIM -,SUP-00631006236,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 28X44MM TRILOGY 20DG ELEV RM LNGVT XLPE 5.2MM -,SUP-00632004428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 28X46MM TRILOGY 20DG ELEV RM LNGVT XLPE 6.3MM -,SUP-00632004628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 32X48MM TRILOGY 20DG ELEV RM LNGVT XLPE 5.3MM -,SUP-00632004832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 32X56MM TRILOGY 20DG ELEV RM LNGVT XLPE 6.4MM -,SUP-00632005632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 28X50MM TRILOGY LNGVT XLPE 7.2MM CNSTRN MODULAR -,SUP-00633405028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14191.09,9933.763,AETNA [1000108],AETNA [100010801],,,76.8,,10898.76,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 32X56MM TRILOGY LNGVT XLPE 6.4MM CNSTRN MODULAR -,SUP-00633405632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14191.09,9933.763,AETNA [1000108],AETNA [100010801],,,76.8,,10898.76,9.170825,27238.33344,percent of total billed charges,,,
TRABECULAR METAL REVISION SHELL 56MM -,SUP-00700005620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16582.26,11607.582,AETNA [1000108],AETNA [100010801],,,76.8,,12735.18,9.170825,27238.33344,percent of total billed charges,,,
BLADE EXPLANT TRUNCATED 60MM -,SUP-00705306010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
BLADE FULL EXPLANT 60MM -,SUP-00705306020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 6X111MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 TAPR -,SUP-00771100600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 10X119MM PRFT EXTEND OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 11X121MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 12.5X124MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 15X129MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM VERSYS 41MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM VERSYS 43MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM VERSYS 44MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM VERSYS 47MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM VERSYS 50MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781805000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM VERSYS 51MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781805100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM VERSYS 52MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781805200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,,,
ADAPTER HIP VERSYS ENPROS TIV TAPR. -,SUP-00781809901,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ11 120MM VERSYS LD/FX PRFT ZML CMNT HIP -,SUP-00783301100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ12 125MM VERSYS LD/FX PRFT ZML CMNT HIP -,SUP-00783301200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ14 135MM VERSYS LD/FX PRFT ZML CMNT HIP -,SUP-00783301400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,,,
NECK FEM SZ K2 KINECTIV M/L HIP MODULAR COCR -,SUP-00784802001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,AETNA [1000108],AETNA [100010801],,,76.8,,3324.58,9.170825,27238.33344,percent of total billed charges,,,
NECK FEM SZ S2 KINECTIV M/L HIP MODULAR COCR -,SUP-00784803001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,AETNA [1000108],AETNA [100010801],,,76.8,,3324.58,9.170825,27238.33344,percent of total billed charges,,,
NECK FEM SZ P2 KINECTIV M/L HIP MODULAR COCR STR 12/14 TAPR -,SUP-00784803101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,AETNA [1000108],AETNA [100010801],,,76.8,,3324.58,9.170825,27238.33344,percent of total billed charges,,,
KINECTIV MODULAR NECK G2 -,SUP-00784803201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4916.67,3441.669,AETNA [1000108],AETNA [100010801],,,76.8,,3776,9.170825,27238.33344,percent of total billed charges,,,
NECK FEM SZ R2 KINECTIV M/L HIP MODULAR COCR STR 12/14 TAPR -,SUP-00784804201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,AETNA [1000108],AETNA [100010801],,,76.8,,3324.58,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ13 130MM VERSYS ADVCT PRIM STD OFST NON V-LIGN -,SUP-00785001300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,,,
STEM VERSYS CMTD STD 14X135 -,SUP-00785001400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,,,
CENTRALIZER DIST FEM HIP 11MM VERSYS PMMA CMNT -,SUP-00785901100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,9.170825,27238.33344,percent of total billed charges,,,
CENTRALIZER DIST FEM HIP 13MM VERSYS PMMA CMNT -,SUP-00785901300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 14X135MM VERSYS PRIM EXTEND OFST TIV POR CTD FM -,SUP-00786201420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 16X145MM VERSYS PRIM STD OFST TIV POR CTD FM TAPR -,SUP-00786201600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 16X145MM VERSYS PRIM EXTEND OFST TIV POR CTD FM -,SUP-00786201620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 18X155MM VERSYS PRIM STD LRG OFST TIV POR CTD FM -,SUP-00786201830,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 20X155MM VERSYS PRIM EXTEND LRG OFST TIV POR CTD FM -,SUP-00786202050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 13X170MM VERSYS REVISN ZML CMNT CLCR HIP -,SUP-00787101360,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21520.55,15064.385,AETNA [1000108],AETNA [100010801],,,76.8,,16527.78,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 13X210MM VERSYS REVISN ZML CMNT CLCR HIP -,SUP-00-7871-013-61,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21520.55,15064.385,AETNA [1000108],AETNA [100010801],,,76.8,,16527.78,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ15 220MM VERSYS REVISN ZML CMNT CLCR HIP -,SUP-00787101561,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21520.55,15064.385,AETNA [1000108],AETNA [100010801],,,76.8,,16527.78,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM VERSYS 28X0MM NK ZML 12/14 TAPR STRL -,SUP-00801802802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM VERSYS 28MM +3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801802803,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM VERSYS 28MM +7MM NK ZML 12/14 TAPR STRL -,SUP-00801802814,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM VERSYS 32MM-3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM VERSYS 32MM +3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM VERSYS 32MM +7MM NK ZML 12/14 TAPR STRL -,SUP-00801803214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM VERSYS 36MM-3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM VERSYS 36X0MM NK ZML 12/14 TAPR STRL -,SUP-00801803602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM VERSYS 36MM +3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803603,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,,,
LINER ELEV RIM 32MM I.D. LONGE -,SUP-00875200832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 36X52MM II SHL CONTIN ELEV LNGVT XLPE 4.7MM F -,SUP-00875201036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,,,
RIM LINER 36MM SIZE JJ LONGEVITY HIGHLY CROSSLINKED POLY -,SUP-00-8752-011-36,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ EE 44MM CONTIN CLUS-HL TM TIV SNP FIT LCK GRV -,SUP-00875704401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ FF 46MM CONTIN MUL-HL TM TIV SNP FIT LCK GRV -,SUP-00875704602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ GG 48MM CONTIN CLUS-HL TM TIV SNP FIT LCK GRV -,SUP-00875704801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ HH 50MM CONTIN CLUS-HL TM TIV SNP FIT LCK GRV -,SUP-00875705001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ II LINER 52MM CONTIN CLUS-HL TM TIV SNP FIT -,SUP-00875705201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ II 52MM CONTIN MUL-HL TM TIV SNP FIT LCK GRV -,SUP-00875705202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ JJ LINER 54MM CONTIN MUL-HL TM TIV SNP FIT LCK -,SUP-00875705401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 28MMX-3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877502801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,,,
BIOLOX DELTA FEM HEAD 28MM +0MM -,SUP-00877502802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 32MM-3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 32MM +0MML NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 36MM-3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEMORAL 36MM CERAMIC -,SUP-00-8775-036-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 36MM +3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503603,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 36MM +7MM BIOLOX DELTA CER -,SUP-00-8775-036-04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,,,
BIOLOX DELTA OPTION FEM HEAD 28MM +0MM -,SUP-00-8777-028-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3150.84,2205.588,AETNA [1000108],AETNA [100010801],,,76.8,,2419.85,9.170825,27238.33344,percent of total billed charges,,,
BIOLOX OPTION HEAD 36/+3.5 TAPER 12/14 -,SUP-00-8777-036-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9780.3,6846.21,AETNA [1000108],AETNA [100010801],,,76.8,,7511.27,9.170825,27238.33344,percent of total billed charges,,,
BIOLOX OPTION HEAD XL 36/+7 TAPER 12/14 -,SUP-00-8777-036-04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9780.3,6846.21,AETNA [1000108],AETNA [100010801],,,76.8,,7511.27,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 28X44MM EE SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 28X46MM FF SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200728,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 32X48MM GG SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 32X50MM HH SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200932,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 36NN ID 52MM II SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885201036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 36X54MM JJ SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885201136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 22MMLNGX5.5MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902602300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 28MM SHRT +0MML NK ZML 6DG TAPR ANTMC STRL -,SUP-00902602800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 28MMMEDX+7MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902602900,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 28MMLNGX+14MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902603000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 32MMSHRTX3.5MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902603235,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,9.170825,27238.33344,percent of total billed charges,,,
HEAD 6DEGREE COCR FEM 36MM +3.5 S+ -,SUP-00-9026-036-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA [1000108],AETNA [100010801],,,76.8,,1750.44,9.170825,27238.33344,percent of total billed charges,,,
HEAD 6 DEGREE COCR FEM 36MM +7 M -,SUP-00-9026-036-07,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA [1000108],AETNA [100010801],,,76.8,,1750.44,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 15X185MM ZMR REVISN MODULAR TIV PLASM SPRY POR CTD -,SUP-00998201518,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14636.65,10245.655,AETNA [1000108],AETNA [100010801],,,76.8,,11240.95,9.170825,27238.33344,percent of total billed charges,,,
BODY HIP SZ A 17.7MM BD 40MM OFST ZMR REVISN MODULAR 45MM NK -,SUP-00999601745,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21253.21,14877.247,AETNA [1000108],AETNA [100010801],,,76.8,,16322.47,9.170825,27238.33344,percent of total billed charges,,,
STEM WAGNER REVISION 135 NK ANGLE 18MM X 265MM -,SUP-01.00102.618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA [1000108],AETNA [100010801],,,76.8,,14257.92,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB DURAM -,SUP-01.00214.152,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16626.81,11638.767,AETNA [1000108],AETNA [100010801],,,76.8,,12769.39,9.170825,27238.33344,percent of total billed charges,,,
CONE WAGNER 135 DEG X 21MM -,SUP-01.00561.321,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13856.92,9699.844,AETNA [1000108],AETNA [100010801],,,76.8,,10642.11,9.170825,27238.33344,percent of total billed charges,,,
SIDUS STEM-FREE SHOULDER HUMERAL HEAD 48-17 -,SUP-01.04555.480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,,,
STEM AVENIR STANDARD CEM 4 -,SUP-01.06010.204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,,,
STEM STD CEMENTED 7 TAPER 12/14 AVENIR -,SUP-01.06010.207,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,,,
AVENIR LATERAL STEM CEM 4 -,SUP-01.06010.304,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,,,
STEM AVENIR LATERAL CEM 8 -,SUP-01.06010.308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,,,
COMP RVRS 25MM BSPLT HA+ADPTR -,SUP-010000589,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,AETNA [1000108],AETNA [100010801],,,76.8,,5866.91,9.170825,27238.33344,percent of total billed charges,,,
SHELL G7 ACETABULAR PPS LTD 46B -,SUP-010000660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,9.170825,27238.33344,percent of total billed charges,,,
G7 PPS LTD ACET SHELL 48C -,SUP-010000661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,9.170825,27238.33344,percent of total billed charges,,,
G7 PPS LTD ACET SHELL 50D -,SUP-010000662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,9.170825,27238.33344,percent of total billed charges,,,
SHELL G7 ACETABULAR PPS LTD 52E -,SUP-010000663,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,9.170825,27238.33344,percent of total billed charges,,,
SHELL G7 ACET PPS LTD SHELL 54F -,SUP-010000664,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,9.170825,27238.33344,percent of total billed charges,,,
G7 PPS LTD ACET SHELL 56F -,SUP-010000665,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,9.170825,27238.33344,percent of total billed charges,,,
G7 PPS LTD ACET SHELL 60G -,SUP-010000667,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,9.170825,27238.33344,percent of total billed charges,,,
SHELL G7 PPS LTD ACET 46 B -,SUP-010000719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,,,
LINER G7 NEUTRAL ARCOMXL 32MM B -,SUP-010000729,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,,,
G7 NEUTRAL ARCOMXL LNR 36MM D -,SUP-010000739,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,,,
G7 NEUTRAL ARCOMXL LNR 36MM E -,SUP-010000740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,,,
LINER ARCOMXL G7 NEUTRAL 36MM F -,SUP-010000741,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,,,
G7 ACETABULAR LINER 36MM / G -,SUP-010000742,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,,,
G7 NEUTRAL ARCOMXL LNR 40MM G -,SUP-010000748,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,,,
G7 NEUTRAL E1 LINER 28MM C -,SUP-010000837,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
G7 NEUTRAL E1 LINER 32MM -,SUP-010000846,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
G7 NEUTRAL E1 LINER 32MM C -,SUP-010000847,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
G7 NEUTRAL E1 LINER 36MM D -,SUP-010000856,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
G7 NEUTRAL E1 LINER 36MM F -,SUP-010000858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
G7 FREEDOM CONST E1 LNR 36MM -,SUP-010000982,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,AETNA [1000108],AETNA [100010801],,,76.8,,10693.44,9.170825,27238.33344,percent of total billed charges,,,
G7 FREEDOM COSTR E1 LNR 36MM G -,SUP-010000985,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,AETNA [1000108],AETNA [100010801],,,76.8,,10693.44,9.170825,27238.33344,percent of total billed charges,,,
HEAD COCR FEM 40MM TYPE 1 +9MM -,SUP-010001032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,,,
COCR FEM HD 40MM TYPE 1 +6MM -,SUP-010001033,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEMORAL COCR 40MM TYPE 1 STD -,SUP-010001035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,,,
COCR FEM HD 40MM TYPE 1-3MM -,SUP-010001036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,,,
WAGNER SL REVISION STEM 135 NK ANGLE 15MM X 225MM -,SUP-0100102215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA [1000108],AETNA [100010801],,,76.8,,14257.92,9.170825,27238.33344,percent of total billed charges,,,
WAGNER SL REV STEM 135 NK ANGLE 14 X 265 -,SUP-0100102614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA [1000108],AETNA [100010801],,,76.8,,14257.92,9.170825,27238.33344,percent of total billed charges,,,
CONE WAGNER 125 DEG X 19MM -,SUP-0100561219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13856.92,9699.844,AETNA [1000108],AETNA [100010801],,,76.8,,10642.11,9.170825,27238.33344,percent of total billed charges,,,
ADAPTER ANTMC BGLNI 42 -,SUP-0104250042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,AETNA [1000108],AETNA [100010801],,,76.8,,2841.48,9.170825,27238.33344,percent of total billed charges,,,
AS B/F ADAPTOR 48 DEG -,SUP-0104250048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,AETNA [1000108],AETNA [100010801],,,76.8,,2841.48,9.170825,27238.33344,percent of total billed charges,,,
AC-CONNECTOR -,SUP-0104440000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,,,
STEM AVENIR 5 TAPER 12/14 MULL -,SUP-0106010005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
STEM AVENIR 6 TAPER 12/14 MULL -,SUP-0106010006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
MORSE TAPER HEAD +5 OFFSET WITH LFIT 32MM -,SUP-01-3205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
PLATE 2.7/3.5 VA ANTLAT DSTL TIB PL/10 H/LFT -,SUP-02.118.209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10401.04,7280.728,AETNA [1000108],AETNA [100010801],,,76.8,,7988,9.170825,27238.33344,percent of total billed charges,,,
BONE PREP KIT 21-1000 SFN -,SUP-0206-710-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,740.32,518.224,AETNA [1000108],AETNA [100010801],,,76.8,,568.57,9.170825,27238.33344,percent of total billed charges,,,
LOW FRICTION ION TREATMENT -,SUP-06-2200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
C-TAPER LFIT HEAD LOW FRI ION TREATMENT -,SUP-06-2205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 26X0MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-06-2600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEMORAL LFIT COCR +5 MM OFFSET C TAPER 26MM HIP -,SUP-06-2605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
C-TAPER LFIT HEAD LOW FRICTION SZ. 26MM / +10 -,SUP-06-2610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 28X0MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-062800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
C-TAPER LFIT HEAD LOW FRICTION SZ. 28MM / +10 -,SUP-06-2810,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 32X0MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-063200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 32MM-5MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-063299,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 36MM +0MML NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-063600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 40MM-2.5MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-064097,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,,,
STEM PLASMA SPRAY STD SIZE 2 TI6AI4V -,SUP-101-0002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,,,
HIP STEM PLASAM STD SZ 3 -,SUP-101-0003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ4 37MM OFST 110MM OVATN STD OFST 29MM 7MM M/L/A/P -,SUP-101-0004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ5 OVATN STD OFST TI PLASM SPRY CTD 12/14 TAPR -,SUP-101-0005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ6 38MM OFST 118MM OVATN STD OFST 31MM 9MM M/L/A/P -,SUP-101-0006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ7 32MM OFST 122MM OVATN STD OFST 32MM 10MM -,SUP-101-0007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ8 43MM OFST 126MM OVATN STD OFST 34MM 11MM -,SUP-101-0008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ9 44MM OFST 130MM OVATN STD OFST 36MM 13MM -,SUP-101-0009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ10 47MM OFST 134MM OVATN STD OFST 38MM 16MM -,SUP-101-0010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ5 44MM OFST 114MM OVATN EXTEND OFST 30MM 8MM -,SUP-101-1005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8233.36,5763.352,AETNA [1000108],AETNA [100010801],,,76.8,,6323.22,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ6 9/31X118MM OVATN EXTEND OFST 33MM LEG 44MM HZNT -,SUP-101-1006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ7 49MM OFST 122MM OVATN EXTEND OFST 32MM 10MM -,SUP-101-1007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ8 50MM OFST 126MM OVATN EXTEND OFST 34MM 11MM -,SUP-101-1008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ9 STD OVATN EXTEND OFST TI PLASM SPRY CTD 12/14 -,SUP-101-1009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ10 55MM OFST 134MM TI PLASM SPRY CTD HIP OVATN -,SUP-101-1010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,,,
SELF CENT HIP 41X28 RUST -,SUP-1035-41-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,,,
WIRE EXTFIX 1.8MM BAYNT PNT -,SUP-104.690,CDM,C1776,HCPCS,278,RC,,,outpatient,,,367.02,256.914,AETNA [1000108],AETNA [100010801],,,76.8,,281.87,9.170825,27238.33344,percent of total billed charges,,,
RING ACTB SZ23 TI HIP LCK LINER YEL RINGLOC STRL SUD -,SUP-1054-23,CDM,C1776,HCPCS,278,RC,,,outpatient,,,770.22,539.154,AETNA [1000108],AETNA [100010801],,,76.8,,591.53,9.170825,27238.33344,percent of total billed charges,,,
SPACER DIST HIP 10MM ACCOLADE C SZ SMALL -,SUP-1059-2310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,9.170825,27238.33344,percent of total billed charges,,,
SPACER FEM CMNT RNG STYL MED 12MM DIST F/STM 4/5 ACCOLADE -,SUP-1059-4512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,9.170825,27238.33344,percent of total billed charges,,,
RINGLOC + HIP SYSTEM SZ 21 -,SUP-106021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,945.27,661.689,AETNA [1000108],AETNA [100010801],,,76.8,,725.97,9.170825,27238.33344,percent of total billed charges,,,
SPACER DIST FEM HIP UNIV 8MM ACCOLADE CMNT -,SUP-1067-0008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,9.170825,27238.33344,percent of total billed charges,,,
SPACER DIST FEM HIP 9MM UNIV CMNT -,SUP-1067-0009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,9.170825,27238.33344,percent of total billed charges,,,
SPACER DIST FEM HIP 10MM UNIV CMNT -,SUP-1067-0010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,9.170825,27238.33344,percent of total billed charges,,,
SPACER DIST FEM HIP 11MM UNIV RECON CMNT -,SUP-1067-0011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,9.170825,27238.33344,percent of total billed charges,,,
SPACER DIST FEM HIP 12MM UNIV CMNT -,SUP-1067-0012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,9.170825,27238.33344,percent of total billed charges,,,
SPACER DIST FEM HIP 13MM UNIV CMNT -,SUP-1067-0013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,9.170825,27238.33344,percent of total billed charges,,,
SPACER DIST FEM HIP 14MM UNIV CMNT -,SUP-1067-0014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,9.170825,27238.33344,percent of total billed charges,,,
SPACER DIST FEM HIP 15MM UNIV CMNT -,SUP-1067-0015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,9.170825,27238.33344,percent of total billed charges,,,
OMNIFIT UNIVERSAL DISTAL CEMENT SPACER 16MM -,SUP-1067-0016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,9.170825,27238.33344,percent of total billed charges,,,
CEMENT SPACER UNIVERSAL DISTAL -,SUP-1067-0017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,9.170825,27238.33344,percent of total billed charges,,,
VARIO CUP 28MM X 47MM -,SUP-107-220/47,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5160.7,3612.49,AETNA [1000108],AETNA [100010801],,,76.8,,3963.42,9.170825,27238.33344,percent of total billed charges,,,
VARIO CUP 28MM X 48MM -,SUP-107-220/48,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5160.7,3612.49,AETNA [1000108],AETNA [100010801],,,76.8,,3963.42,9.170825,27238.33344,percent of total billed charges,,,
VARIO-CUP SYSTEM OUTER 50MM HEAD 28MM -,SUP-107-220/50,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5160.7,3612.49,AETNA [1000108],AETNA [100010801],,,76.8,,3963.42,9.170825,27238.33344,percent of total billed charges,,,
G7 OSSEOTI 3 HOLE SHELL 50MM D -,SUP-110010243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,AETNA [1000108],AETNA [100010801],,,76.8,,7984.44,9.170825,27238.33344,percent of total billed charges,,,
G7 OSSEOTI MULTIHOLE 50MM D -,SUP-110010263,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,AETNA [1000108],AETNA [100010801],,,76.8,,13493.7,9.170825,27238.33344,percent of total billed charges,,,
G7 MULTIHOLE 52MM -,SUP-110010264,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,AETNA [1000108],AETNA [100010801],,,76.8,,13493.7,9.170825,27238.33344,percent of total billed charges,,,
G7 OSSEOTI MULTIHOLE 54MM F -,SUP-110010265,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,AETNA [1000108],AETNA [100010801],,,76.8,,13493.7,9.170825,27238.33344,percent of total billed charges,,,
G7 OSSEOTI MULTIHOLE 56MM F -,SUP-110010266,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,AETNA [1000108],AETNA [100010801],,,76.8,,13493.7,9.170825,27238.33344,percent of total billed charges,,,
G7 OSSEO TI ACETABULAR SHELL 58MM / G -,SUP-110010267,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,AETNA [1000108],AETNA [100010801],,,76.8,,13493.7,9.170825,27238.33344,percent of total billed charges,,,
G7 OSSEO TI MULTIHOLE 60MM G -,SUP-110010268,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,AETNA [1000108],AETNA [100010801],,,76.8,,13493.7,9.170825,27238.33344,percent of total billed charges,,,
SHELL G7 OSSEO TI MULTIHOLE 62MM H -,SUP-110010269,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,AETNA [1000108],AETNA [100010801],,,76.8,,13493.7,9.170825,27238.33344,percent of total billed charges,,,
G7 OSSEO TI MULTIHOLE 64MM H -,SUP-110010270,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,AETNA [1000108],AETNA [100010801],,,76.8,,13493.7,9.170825,27238.33344,percent of total billed charges,,,
LINER G7 DUAL MOBILITY 38MM C -,SUP-110024461,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,9.170825,27238.33344,percent of total billed charges,,,
G7 DUAL MOBILITY LINER 42MM E -,SUP-110024463,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,9.170825,27238.33344,percent of total billed charges,,,
G7 DUAL MOBILITY LINER 44MM F -,SUP-110024464,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,9.170825,27238.33344,percent of total billed charges,,,
G7 DUAL MOBILITY LINER 50MM H -,SUP-110024466,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,9.170825,27238.33344,percent of total billed charges,,,
COMPR VRS GLEN PPS MIN TPR ADR -,SUP-110027734,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26395.72,18477.004,AETNA [1000108],AETNA [100010801],,,76.8,,20271.91,9.170825,27238.33344,percent of total billed charges,,,
PRX HUM LO PLT LT 4H 83MM -,SUP-110030101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6875.28,4812.696,AETNA [1000108],AETNA [100010801],,,76.8,,5280.22,9.170825,27238.33344,percent of total billed charges,,,
40MM VERSA-DIAL GLEN STD -,SUP-110030776,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,,,
40MM VERSA-DIAL GLEN +3 -,SUP-110030777,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,,,
BEARING VIVACIT-E DM 28 X 44MM -,SUP-110031012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,AETNA [1000108],AETNA [100010801],,,76.8,,3538.11,9.170825,27238.33344,percent of total billed charges,,,
BEARING VIVACIT-E DM 28 X 50MM -,SUP-110031015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,AETNA [1000108],AETNA [100010801],,,76.8,,3538.11,9.170825,27238.33344,percent of total billed charges,,,
VERSA-DIAL TAPER ADAPTOR 25MM -,SUP-110031378,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA [1000108],AETNA [100010801],,,76.8,,1147.96,9.170825,27238.33344,percent of total billed charges,,,
HMRL TRAY STD STD -,SUP-110031399,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA [1000108],AETNA [100010801],,,76.8,,4726.12,9.170825,27238.33344,percent of total billed charges,,,
TRAY HMRL STD SHOULDER REVERSE TI -,SUP-110031408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA [1000108],AETNA [100010801],,,76.8,,4726.12,9.170825,27238.33344,percent of total billed charges,,,
HMRLBEARING 36MM +3 PRLNG -,SUP-110031419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
HMRL BEARING 40MM STD PRLNG -,SUP-110031421,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
HMRL BEARING 36 MM STD VITE -,SUP-110031424,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA [1000108],AETNA [100010801],,,76.8,,4074.24,9.170825,27238.33344,percent of total billed charges,,,
HMRL BEARING 36 MM +3 VITE -,SUP-110031425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA [1000108],AETNA [100010801],,,76.8,,4074.24,9.170825,27238.33344,percent of total billed charges,,,
BEARING HUMERAL 40MM STD VITE -,SUP-110031427,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA [1000108],AETNA [100010801],,,76.8,,4074.24,9.170825,27238.33344,percent of total billed charges,,,
COMPR AUG BSPLT W ADP SM -,SUP-110032410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,9.170825,27238.33344,percent of total billed charges,,,
COMPR AUG BSPLT W ADP MD -,SUP-110032420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,9.170825,27238.33344,percent of total billed charges,,,
COMPR AUG BSPLT W ADP LG -,SUP-110032430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,9.170825,27238.33344,percent of total billed charges,,,
HMRL BEARING 36MM STD PRLNG -,SUP-11031418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
FREEDOM CONSTR HD 36MM T1 -,SUP-11-107016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7259.36,5081.552,AETNA [1000108],AETNA [100010801],,,76.8,,5575.19,9.170825,27238.33344,percent of total billed charges,,,
HEAD FREEDOM CONSTR 36MM T1 +9MM -,SUP-11-107021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7259.36,5081.552,AETNA [1000108],AETNA [100010801],,,76.8,,5575.19,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 6MM MAC PRIM RVRS CMPRHNSV 140MM COCR PLASM CTD -,SUP-11-113556,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,AETNA [1000108],AETNA [100010801],,,76.8,,7984.44,9.170825,27238.33344,percent of total billed charges,,,
PROXIMAL FEMORAL OMPONENT RHS LEFT -,SUP-1115-9110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22682.72,15877.904,AETNA [1000108],AETNA [100010801],,,76.8,,17420.33,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL CHECKPOINT STERILE -,SUP-111651,CDM,C1776,HCPCS,278,RC,,,outpatient,,,260.65,182.455,AETNA [1000108],AETNA [100010801],,,76.8,,200.18,9.170825,27238.33344,percent of total billed charges,,,
RINGLOC BIPOLAR 28X49MM -,SUP-11-165222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,,,
HEAD RADL SZ12 22MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6332.05,4432.435,AETNA [1000108],AETNA [100010801],,,76.8,,4863.01,9.170825,27238.33344,percent of total billed charges,,,
HEAD RADL SZ14 24MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA [1000108],AETNA [100010801],,,76.8,,4726.12,9.170825,27238.33344,percent of total billed charges,,,
STEM RADL SZ7 26MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7295.44,5106.808,AETNA [1000108],AETNA [100010801],,,76.8,,5602.9,9.170825,27238.33344,percent of total billed charges,,,
STEM RADL SZ8 28MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210063,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7507.64,5255.348,AETNA [1000108],AETNA [100010801],,,76.8,,5765.87,9.170825,27238.33344,percent of total billed charges,,,
STEM STR DIST ARCOS 23MM X 150MM TAPER -,SUP-11-300823,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,AETNA [1000108],AETNA [100010801],,,76.8,,11360.71,9.170825,27238.33344,percent of total billed charges,,,
STS DISTAL STEM 15 X 190MM -,SUP-11-300915,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,AETNA [1000108],AETNA [100010801],,,76.8,,11360.71,9.170825,27238.33344,percent of total billed charges,,,
DIST ARCOS 19 X 190MM SPL TPR -,SUP-11-300919,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,AETNA [1000108],AETNA [100010801],,,76.8,,11360.71,9.170825,27238.33344,percent of total billed charges,,,
CON ARCOS SZ A STD 60MM -,SUP-11-301301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,AETNA [1000108],AETNA [100010801],,,76.8,,22037.04,9.170825,27238.33344,percent of total billed charges,,,
CON ARCOS SZ A STD HI 50MM -,SUP-11-301310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,AETNA [1000108],AETNA [100010801],,,76.8,,22037.04,9.170825,27238.33344,percent of total billed charges,,,
ARCOS CON SIZE E HI 70MM -,SUP-11-301335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,AETNA [1000108],AETNA [100010801],,,76.8,,22037.04,9.170825,27238.33344,percent of total billed charges,,,
STANDARD CONE PROX BODY 80MM -,SUP-11-301342,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,AETNA [1000108],AETNA [100010801],,,76.8,,22037.04,9.170825,27238.33344,percent of total billed charges,,,
ARCOS CON SIZE B HI 80MM -,SUP-11-301352,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,AETNA [1000108],AETNA [100010801],,,76.8,,22037.04,9.170825,27238.33344,percent of total billed charges,,,
VERSA-DIAL 38 X 19 X 39 HUM HEAD -,SUP-113022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,,,
VERSA-DIAL 38X21X38 HUM HEAD -,SUP-113024,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 42MM 46X18MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,,,
VERSA DIAL 42 X 21 X 43 HUM HEAD -,SUP-113034,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 46X53MM 18MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 46X50MM 24MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 46X46MM 27MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 50MM 57X21MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 50X50MM 27MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113057,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,,,
MODULAR HEAD 54MM 21MM 64MM -,SUP-113063,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,,,
TAPER ADAPTER 54MM X 24MM -,SUP-113065,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM VERSA-DIAL 54X27X55 -,SUP-113067,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,,,
HUM HEAD VERSA-DIAL 58 X 24 X 64 -,SUP-113075,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE COMP FX HUM POS 8MM -,SUP-113576,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE COMP FX HUM POS 9MM -,SUP-113577,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,9.170825,27238.33344,percent of total billed charges,,,
POSTIONING SLEEVE COMP FX HUM 10MM -,SUP-113578,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE COMP FX HUM POS 11MM -,SUP-113579,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,9.170825,27238.33344,percent of total billed charges,,,
COMP FX HUM POS SLEEVE 12MM -,SUP-113580,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,9.170825,27238.33344,percent of total billed charges,,,
COMP FX HUM POS SLEEVE 13MM -,SUP-113581,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,9.170825,27238.33344,percent of total billed charges,,,
COMP PRIMARY STEM 9MM MICRO -,SUP-113609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,,,
COMP PRIMARY STEM 10MM MICRO -,SUP-113610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,,,
COMP PRIMARY STEM 11MM MICRO -,SUP-113611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,,,
COMP PRIMARY STEM 12MM MICRO -,SUP-113612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,,,
STEM COMP PRIMARY MICRO 13MM -,SUP-113613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,,,
STEM COMP PRIMARY MICRO 14MM -,SUP-113614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,,,
COMP PRIMARY STEM 15MM MICRO -,SUP-113615,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,,,
COMP PRIMARY STEM 17MM MICRO -,SUP-113617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,,,
COMP PRIMARY STEM 19MM MICRO -,SUP-113619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,,,
STEM COMP PRIMARY 5MM MINI -,SUP-113625,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,,,
STEM COMP PRIMARY 6MM MINI -,SUP-113626,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,,,
COMP PRIMARY STEM 7MM MINI -,SUP-113627,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,,,
STEM COMP PRIMARY 8MM MINI -,SUP-113628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,,,
COMPREHENSIVE HUMERAL STEM 9MM MINI -,SUP-113629,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,,,
POROUS PLASMA 10MM 83MM LONG -,SUP-113630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,,,
COMP PRIMARY STEM 11MM MINI -,SUP-113631,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,,,
COMPREHENSIVE HUMERAL STEM 12MM MINI -,SUP-113632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,,,
STEM COMP PRIMARY 13MM MINI -,SUP-113633,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,,,
STEM COMP PRIMARY 14MM MINI -,SUP-113634,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,,,
STEM COMP PRIMARY 15MM MINI -,SUP-113635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,,,
STEM COMP PRIMARY 16MM MINI -,SUP-113636,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,,,
HEAD MOD 36MM COCR 3MM -,SUP-11-363661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,,,
HEAD COCR MOD HD STD 36MM -,SUP-11-363662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,,,
HEAD 36MM COCR MOD +36MM -,SUP-11-363663,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,,,
STEM COMP PRIMARY 17MM MINI -,SUP-113637,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 7MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113647,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 8MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113648,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 12MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 15MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113655,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 16MM STD PRIM PRFT RVRS CMPRHNSV 122MM COCR PLASM -,SUP-113656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,9.170825,27238.33344,percent of total billed charges,,,
COMP MODULAR HYBRID SHLDR POST 4MM UHMWPE PG -,SUP-113951,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,9.170825,27238.33344,percent of total billed charges,,,
COMP SM MODULAR HYBRID SHLDR BS 4MM UHMWPE PG -,SUP-113952,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,,,
COMP MED MODULAR HYBRID SHLDR BS 4MM UHMWPE PG -,SUP-113954,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,,,
SPHERE GLND 36MM STD CMPRHNSV VERSA-DIAL RVRS HAP POR CTD -,SUP-115310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,,,
SPHERE GLND +3MM 36MM CMPRHNSV VERSA-DIAL RVRS HAP POR CTD -,SUP-115313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE 28MM CMPRHNSV SHLDR RVRS -,SUP-115330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,AETNA [1000108],AETNA [100010801],,,76.8,,5866.91,9.170825,27238.33344,percent of total billed charges,,,
TRY HUMERAL STD 44MM COCR SHLDR RVRS CMPRHNSV STRL SUD -,SUP-115370,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA [1000108],AETNA [100010801],,,76.8,,4726.12,9.170825,27238.33344,percent of total billed charges,,,
PIN INSRTR 24.5CM FRLCK F/VFX2 FEM FX SYS -,SUP-118001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,9.170825,27238.33344,percent of total billed charges,,,
KT BONE CMNT PREP-IM -,SUP-121010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3685.53,2579.871,AETNA [1000108],AETNA [100010801],,,76.8,,2830.49,9.170825,27238.33344,percent of total billed charges,,,
STEM COMPR 6MM HUM FRACT PPS -,SUP-12-113556,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,AETNA [1000108],AETNA [100010801],,,76.8,,7984.44,9.170825,27238.33344,percent of total billed charges,,,
COMPR 8MM HUM FRACT STEM PPS -,SUP-12-113558,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,AETNA [1000108],AETNA [100010801],,,76.8,,7984.44,9.170825,27238.33344,percent of total billed charges,,,
COMPR 10MM HUM FRACT STEM PPS -,SUP-12-113560,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,AETNA [1000108],AETNA [100010801],,,76.8,,7984.44,9.170825,27238.33344,percent of total billed charges,,,
COMPR 12NN HUM FRACT STEM PPS -,SUP-12-113562,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,AETNA [1000108],AETNA [100010801],,,76.8,,7984.44,9.170825,27238.33344,percent of total billed charges,,,
HEAD MODULAR CER BIOLOXD 28MM -3 NK -,SUP-12-115109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,,,
CER BIOLOXD MOD HD 28MM STD NK -,SUP-12-115110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,,,
CER BIOLOXD MOD HD 28MM +3 NK -,SUP-12-115111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,,,
CER BIOLOXD MOD HD 32MM-3NK -,SUP-12-115114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,,,
HEAD CERAMIC BIOLOX STANDARD NECK -,SUP-12-115115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,,,
CER BIOLOXD MOD HD 36MM STD NK -,SUP-12-115121,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,,,
CER BIOLOXD MOD HD 36MM +3 NK -,SUP-12-115122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,,,
CER BIOLOXD MOD HD 36MM +6 NK -,SUP-12-115123,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,,,
HEAD ENDO II MOD SIZE 49 -,SUP-12-139022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 54MM PINNCL NO-HL POR CTD LCK RNG SLD -,SUP-1217-01-054,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4847.45,3393.215,AETNA [1000108],AETNA [100010801],,,76.8,,3722.84,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 58MM PINNCL NO-HL POR CTD LCK RNG SLD -,SUP-1217-01-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4992.9,3495.03,AETNA [1000108],AETNA [100010801],,,76.8,,3834.55,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 60MM PINNCL NO-HL POR CTD LCK RNG SLD -,SUP-1217-01-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4992.9,3495.03,AETNA [1000108],AETNA [100010801],,,76.8,,3834.55,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 46MM PINNCL MUL-HL BANTAM POR CTD PLASM SPRY LCK -,SUP-1217-20-046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6137.89,4296.523,AETNA [1000108],AETNA [100010801],,,76.8,,4713.9,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 48MM PINNCL MUL-HL BANTAM PE POR CTD LCK RNG SLD -,SUP-1217-22-048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6215.13,4350.591,AETNA [1000108],AETNA [100010801],,,76.8,,4773.22,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 52MM PINNCL MUL-HL BANTAM SECT PE POR CTD LCK RNG -,SUP-1217-22-052,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4847.45,3393.215,AETNA [1000108],AETNA [100010801],,,76.8,,3722.84,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 54MM PINNCL MUL-HL BANTAM SECT PE POR CTD LCK RNG -,SUP-1217-22-054,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4706.3,3294.41,AETNA [1000108],AETNA [100010801],,,76.8,,3614.44,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 62MM PINNCL PRFT NO-HL GRIPTN -,SUP-1217-31-062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16040.16,11228.112,AETNA [1000108],AETNA [100010801],,,76.8,,12318.84,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 48MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,AETNA [1000108],AETNA [100010801],,,76.8,,3520.14,9.170825,27238.33344,percent of total billed charges,,,
CUP ACETABULAR 50MM -,SUP-1217-32-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,AETNA [1000108],AETNA [100010801],,,76.8,,3520.14,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 52MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-052,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10299.17,7209.419,AETNA [1000108],AETNA [100010801],,,76.8,,7909.76,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 54MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-054,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,AETNA [1000108],AETNA [100010801],,,76.8,,3520.14,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 56MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10299.17,7209.419,AETNA [1000108],AETNA [100010801],,,76.8,,7909.76,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 58MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10509.65,7356.755,AETNA [1000108],AETNA [100010801],,,76.8,,8071.41,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 60MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10299.17,7209.419,AETNA [1000108],AETNA [100010801],,,76.8,,7909.76,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 62MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,AETNA [1000108],AETNA [100010801],,,76.8,,3520.14,9.170825,27238.33344,percent of total billed charges,,,
LINER ACETABULAR PINNACLE 54 47 -,SUP-121854047,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13117.66,9182.362,AETNA [1000108],AETNA [100010801],,,76.8,,10074.36,9.170825,27238.33344,percent of total billed charges,,,
PINNACLE DM LINER 56 49 -,SUP-121856049,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13117.66,9182.362,AETNA [1000108],AETNA [100010801],,,76.8,,10074.36,9.170825,27238.33344,percent of total billed charges,,,
LINER DUR MAR +4 10D 36 X 54 -,SUP-122036554,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,AETNA [1000108],AETNA [100010801],,,76.8,,4155.72,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 32X50MM PINNCL NEUT ALTRX BLU -,SUP-1221-32-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 32X48MM PINNCL +4 10DG ALTRX BLU -,SUP-1221-32-148,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 32X50MM PINNCL +4 10DG ALTRX BLU -,SUP-1221-32-150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 36X58MM PINNCL NEUT ALTRX ORNG -,SUP-1221-36-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 36X52MM PINNCL +4 10DG ALTRX ORNG -,SUP-1221-36-152,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 36X54MM PINNCL +4 10DG ALTRX ORNG -,SUP-1221-36-154,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 36X56MM PINNCL +4 10DG ALTRX ORNG -,SUP-1221-36-156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 40X56MM PINNCL NEUT ALTRX -,SUP-1221-40-056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 40X58MM PINNCL NEUT ALTRX WHT -,SUP-1221-40-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 40X62MM PINNCL NEUT ALTRX -,SUP-1221-40-062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 40X56MM PINNCL LD +4 10DG ALTRX PNK -,SUP-1221-40-156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 40X58MM PINNCL LD +4 10DG ALTRX PNK -,SUP-1221-40-158,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
ALTRX +4 10D 40IDX620D -,SUP-1221-40-162,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
CATALYST R1 SHORT STEM HUMERAL SIZE 36S -,SUP-1230-7501-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,AETNA [1000108],AETNA [100010801],,,76.8,,9980.54,9.170825,27238.33344,percent of total billed charges,,,
CATALYST R1 POLY INSERT IMPLANT36 +0 -,SUP-1230-7504-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
CATALYST R1 POLY INSERT SIZE 36 +4 -,SUP-1230-7504-002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
CATALYST R1 STANDARD BASEPLATE IMPLANT -,SUP-1230-7506-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10674.88,7472.416,AETNA [1000108],AETNA [100010801],,,76.8,,8198.31,9.170825,27238.33344,percent of total billed charges,,,
CATALYST R1 GLENOSHERE SIZE 36 STD -,SUP-1230-7513-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9761.2,6832.84,AETNA [1000108],AETNA [100010801],,,76.8,,7496.6,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 52MM RESTOR ADM X3 PRFT MBL BRNG CMNTLS SLF-LCK -,SUP-1235-2-521,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 54MM RESTOR ADM X3 PRFT MBL BRNG CMNTLS SLF-LCK -,SUP-1235-2-541,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 60MM RESTOR ADM PRIM -,SUP-1235-2-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 28X48MM RESTOR ADM 0DG DURATION PE 6.9MM -,SUP-1235-2-848,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 28X54MM RESTOR ADM 0DG DURATION PE 9.9MM -,SUP-1235-2-854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 28X60MM RESTOR ADM 0DG DURATION PE 12.9MM -,SUP-1235-2-860,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 36X22.2MM RECON ADM MDM X3 UHMWPE PRIM ASYM -,SUP-1236-2-242,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 38X22.2MM RECON ADM MDM X3 UHMWPE PRIM ASYM -,SUP-1236-2-244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 28X48MM RESTOR ADM X3 PE 6.9MM REVISN -,SUP-1236-2-848,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,9.170825,27238.33344,percent of total billed charges,,,
INSERT RESTORATION ADM/MD/ 29MM X 28/48 SIZE 42E X3 -,SUP-1236-2-848,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,9.170825,27238.33344,percent of total billed charges,,,
INSERT RESTORATION ADM/MD/ 28MM X 28/52 SIZE 46F X3 -,SUP-1236-2-852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 28X52MM RESTOR ADM X3 PE 8.9MM REVISN -,SUP-1236-2-852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 28X54MM RESTOR ADM X3 PE 9.9MM REVISN -,SUP-1236-2-854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,9.170825,27238.33344,percent of total billed charges,,,
INSERT RESTORATION ADM/MDM 28MM X 52H X3 SZ 28/58MM -,SUP-1236-2-858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,9.170825,27238.33344,percent of total billed charges,,,
RES INSERT ADM/MDM 28MM SZ54I -,SUP-1236-2-860,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,9.170825,27238.33344,percent of total billed charges,,,
PROSTHESIS HEAD A 28MM NECK L S +3.5 TAPER 12/14 -,SUP-128-791/03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA [1000108],AETNA [100010801],,,76.8,,1750.44,9.170825,27238.33344,percent of total billed charges,,,
PROSTHESIS HEAD A 32MM MED 12/14 -,SUP-128-792/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA [1000108],AETNA [100010801],,,76.8,,1750.44,9.170825,27238.33344,percent of total billed charges,,,
PROSTHESIS HEAD A 36MM NECK L S -4 TAPER 12/14 -,SUP-128-793/01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA [1000108],AETNA [100010801],,,76.8,,1750.44,9.170825,27238.33344,percent of total billed charges,,,
PROSTHESIS HEAD A 36MM NECK M NECK LEN 0 TAPER 12/14 -,SUP-128-793/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA [1000108],AETNA [100010801],,,76.8,,1750.44,9.170825,27238.33344,percent of total billed charges,,,
PROSTHESIS HEAD A 36MM NECK LARGE +4 TAPER 12/14 -,SUP-128-793/03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA [1000108],AETNA [100010801],,,76.8,,1750.44,9.170825,27238.33344,percent of total billed charges,,,
LINK PROSTHESIS HEAD A CERAMIC 8MM -,SUP-128-793/04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA [1000108],AETNA [100010801],,,76.8,,1750.44,9.170825,27238.33344,percent of total billed charges,,,
PROSTHESIS HEAD A 40MM NECK M TAPER 12/14 -,SUP-128-794/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA [1000108],AETNA [100010801],,,76.8,,1750.44,9.170825,27238.33344,percent of total billed charges,,,
HEAD PROSTESIS B 24MM 12/14 M -,SUP-128-824/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA [1000108],AETNA [100010801],,,76.8,,1750.44,9.170825,27238.33344,percent of total billed charges,,,
PROSTHESIS HEAD B 28MM M NEC L 0 12/14 -,SUP-128-828/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA [1000108],AETNA [100010801],,,76.8,,1750.44,9.170825,27238.33344,percent of total billed charges,,,
PROSTHESIS HEAD B NECK XL +10.5 -,SUP-128-828/04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA [1000108],AETNA [100010801],,,76.8,,1750.44,9.170825,27238.33344,percent of total billed charges,,,
LINK PROSTHESIS HEAD B 36MM +4 -,SUP-128-836/03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA [1000108],AETNA [100010801],,,76.8,,1750.44,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ2.5 69.6/45.8MM KN CMNT STM SIGMA COCR PS -,SUP-1294-33-125,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,AETNA [1000108],AETNA [100010801],,,76.8,,8164.94,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ3 KN CMNT STM SIGMA COCR PS TCMPRTMNTL MBL -,SUP-1294-33-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,AETNA [1000108],AETNA [100010801],,,76.8,,8164.94,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ5 KN CMNT STM SIGMA COCR PS TCMPRTMNTL MBL -,SUP-1294-33-150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,AETNA [1000108],AETNA [100010801],,,76.8,,8164.94,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ6 KN CMNT STM SIGMA COCR PS TCMPRTMNTL MBL -,SUP-1294-33-160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,AETNA [1000108],AETNA [100010801],,,76.8,,8164.94,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ2.5 67/44MM KN CMNT SIGMA COCR PS REVISN MBL -,SUP-1294-35-125,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA [1000108],AETNA [100010801],,,76.8,,6844.72,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ3 70MM M/L 46MM A/P KN CMNT SIGMA COCR PS -,SUP-1294-35-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA [1000108],AETNA [100010801],,,76.8,,6844.72,9.170825,27238.33344,percent of total billed charges,,,
TIB TRAY ROT PLAT MBT REV SZ 4 -,SUP-129435140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA [1000108],AETNA [100010801],,,76.8,,6844.72,9.170825,27238.33344,percent of total billed charges,,,
REV MBT TIBIAL ROT PLAT TRAY SZ. 3 -,SUP-1294-35-315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA [1000108],AETNA [100010801],,,76.8,,6844.72,9.170825,27238.33344,percent of total billed charges,,,
REVISION MBT TIBIAL TRAY SZ. 4 / 15MM -,SUP-1294-35-415,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA [1000108],AETNA [100010801],,,76.8,,6844.72,9.170825,27238.33344,percent of total billed charges,,,
TRAY TIBIAL ROTATING PLAT MBT REV SZ 4 25MM THICK CEMENTED -,SUP-1294-35-425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA [1000108],AETNA [100010801],,,76.8,,6844.72,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE FEMORAL UNIV DISTAL PORUS 34MM -,SUP-1294-53-225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,AETNA [1000108],AETNA [100010801],,,76.8,,6649.16,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE UNIV FEMORAL 48MM FULL POROUS -,SUP-1294-53-246,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,AETNA [1000108],AETNA [100010801],,,76.8,,6649.16,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE TIB 29X29/26MM LCS COMPL MODULAR REVISN BEAR KN RP -,SUP-1294-54-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,AETNA [1000108],AETNA [100010801],,,76.8,,6649.16,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE TIB 37X37/27MM LCS COMPL MODULAR REVISN BEAR KN RP -,SUP-1294-54-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,AETNA [1000108],AETNA [100010801],,,76.8,,6649.16,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE TIB 45X45/27MM LCS COMPL MODULAR REVISN BEAR KN RP -,SUP-1294-54-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,AETNA [1000108],AETNA [100010801],,,76.8,,6649.16,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE METAPHYSEAL 53MM POUROUS MBT REV -,SUP-1294-54-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,AETNA [1000108],AETNA [100010801],,,76.8,,6649.16,9.170825,27238.33344,percent of total billed charges,,,
METAPHYSEAL SLEEVE POROUS -,SUP-1294-54-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,AETNA [1000108],AETNA [100010801],,,76.8,,6649.16,9.170825,27238.33344,percent of total billed charges,,,
METAPHYSEAL SLEEVE 29MM CEMENTED REV -,SUP-1294-54-140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,AETNA [1000108],AETNA [100010801],,,76.8,,6649.16,9.170825,27238.33344,percent of total billed charges,,,
UNITED HIP FULL XPE CUP I.D. 32MM O.D. 48MM -,SUP-1302-3248,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA [1000108],AETNA [100010801],,,76.8,,7414.12,9.170825,27238.33344,percent of total billed charges,,,
UNITED HIP FULL XPE CUP I.D. 32MM O.D. 50MM -,SUP-1302-3250,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA [1000108],AETNA [100010801],,,76.8,,7414.12,9.170825,27238.33344,percent of total billed charges,,,
UNITED HIP FULL XPE CUP I.D. 28MM O.D. 46MM -,SUP-1302-3846,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA [1000108],AETNA [100010801],,,76.8,,7414.12,9.170825,27238.33344,percent of total billed charges,,,
UNITED HIP LOCKING CAGE OD58MM LEFT -,SUP-1308-1158,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,AETNA [1000108],AETNA [100010801],,,76.8,,21466.72,9.170825,27238.33344,percent of total billed charges,,,
UNITED HIP LOCKING CAGE OD54MM RIGHT -,SUP-1308-1254,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,AETNA [1000108],AETNA [100010801],,,76.8,,21466.72,9.170825,27238.33344,percent of total billed charges,,,
UNITED HIP LOCKING CAGE OD 58MM RIGHT -,SUP-1308-1258,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,AETNA [1000108],AETNA [100010801],,,76.8,,21466.72,9.170825,27238.33344,percent of total billed charges,,,
UNITED HIP SYS LOCKING CAGE 62MM RIGHT -,SUP-1308-1262,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,AETNA [1000108],AETNA [100010801],,,76.8,,21466.72,9.170825,27238.33344,percent of total billed charges,,,
UNIPOLAR 42MM OD -,SUP-132-0042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,,,
HEAD SOLITUDE UNIPOLAR 43MM -,SUP-132-0043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,AETNA [1000108],AETNA [100010801],,,76.8,,1302.65,9.170825,27238.33344,percent of total billed charges,,,
UNIPOLAR 47MM -,SUP-132-0047,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,,,
UNIPOLAR 53MM SOLITUDE -,SUP-132-0053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,,,
UNIPOLAR SOLITUDE 55MM -,SUP-132-0055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,AETNA [1000108],AETNA [100010801],,,76.8,,1302.65,9.170825,27238.33344,percent of total billed charges,,,
UNIPOLAR 57MM -,SUP-132-0057,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,,,
ADAPTER SOLITUDE UNIPOLAR +0MM -,SUP-132-1200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,9.170825,27238.33344,percent of total billed charges,,,
ADAPTER +6MM 12/14 -,SUP-132-1206,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,9.170825,27238.33344,percent of total billed charges,,,
ADAPTER OFFSET 9MM 12/14 -,SUP-132-1209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,9.170825,27238.33344,percent of total billed charges,,,
COMP 3MM SOLITUDE OFST ADPTR UNIPL COCR 12/14 TAPR -,SUP-132-1230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,9.170825,27238.33344,percent of total billed charges,,,
SHELL BIPOLAR PIVOT 22 X 40 ACETABULAR -,SUP-133-2240,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,9.170825,27238.33344,percent of total billed charges,,,
PIVOT BIPOLAR 22 X 43MM BIPOLAR -,SUP-133-2243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM 22X44MM SHL OFST L CUP BIPLR TI COCR UHMWPE -,SUP-133-2244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM 28X46MM SHL OFST L CUP BIPLR TI COCR UHMWPE -,SUP-133-2846,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,9.170825,27238.33344,percent of total billed charges,,,
CUP BIPOLAR MOD COCR 28X47MM -,SUP-133-2847,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,9.170825,27238.33344,percent of total billed charges,,,
PIVOT BIPOLAR 28 X 49 -,SUP-133-2849,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,9.170825,27238.33344,percent of total billed charges,,,
PIVOT BIPOLAR 28 X 50MM -,SUP-133-2850,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,9.170825,27238.33344,percent of total billed charges,,,
BIPOLAR 28MM ID 51MM OD -,SUP-133-2851,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,9.170825,27238.33344,percent of total billed charges,,,
PIVOT BIPOLAR 28 X 52 BIPOLAR -,SUP-133-2852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,9.170825,27238.33344,percent of total billed charges,,,
SHELL BIPOLAR PIVOT 28MM X 53MM -,SUP-133-2853,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,9.170825,27238.33344,percent of total billed charges,,,
SHELL BIPOLAR PIVOT 28X54MM -,SUP-133-2854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,9.170825,27238.33344,percent of total billed charges,,,
PIVOT BIPOLAR 28 X 55 -,SUP-133-2855,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,9.170825,27238.33344,percent of total billed charges,,,
PIVOT BIPOLAR 28X56MM BIPOLAR -,SUP-133-2856,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,9.170825,27238.33344,percent of total billed charges,,,
PIVOT BIPOLAR 28MM X 57MM -,SUP-133-2857,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEMORAL CERAMIC 28MM -,SUP-136-2800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEMORAL CERAMIC DELTA 28MM 3 BIOLOX -,SUP-136-2830,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,,,
TAPERED SPACER ARTICUL/EZE -3 -,SUP-136308000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,AETNA [1000108],AETNA [100010801],,,76.8,,854.87,9.170825,27238.33344,percent of total billed charges,,,
SPACER HIP ARTICL/EZ MODULAR CATHCART UNIPL +0MML NK 12/14 -,SUP-1363-10-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1144.83,801.381,AETNA [1000108],AETNA [100010801],,,76.8,,879.23,9.170825,27238.33344,percent of total billed charges,,,
SPACER HIP ARTICL/EZ MODULAR CATHCART UNIPL +5MM NK 12/14 -,SUP-1363-12-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1144.83,801.381,AETNA [1000108],AETNA [100010801],,,76.8,,879.23,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL HEAD 32MM -3 CERAMIC 12/14 TAPER -,SUP-136-3230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 51MM UNIPL MODLR CATHCART BALL ORTHCNTRC DSGN -,SUP-1363-51-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1933.62,1353.534,AETNA [1000108],AETNA [100010801],,,76.8,,1485.02,9.170825,27238.33344,percent of total billed charges,,,
MODULAR CATHCART BALL 53MM OD -,SUP-136353000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,9.170825,27238.33344,percent of total billed charges,,,
HEAD 36MM +0 BIOLOX DELTA CERAMIC FEMORAL -,SUP-136-3600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM BIOLOX DELTA 36MM XL MODULAR -,SUP-136-3604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEMORAL 36MM +3 BIOLOX DELTA CERAMIC -,SUP-136-3613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEMORAL 36MM +6 CERAMIC 12/14 TAPER -,SUP-136-3616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEMORAL BIOLOX DELTA CERAMIC 36MM -3 -,SUP-136-3630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,,,
FERMORAL HEAD BIOLOX DELTA CERAMIC 36MM -6 -,SUP-136-3660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,,,
HEAD CERAMIC FEMORAL DELTA -,SUP-136-4000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 40MMMEDX-1MM NK BIOLOX DELTA 12/14 TAPR -,SUP-136-4002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2570.74,1799.518,AETNA [1000108],AETNA [100010801],,,76.8,,1974.33,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL HEAD CERAMIC 40MM +3 BIOLOX -,SUP-136-4013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL CERAMIC HEAD 40MM +9 -,SUP-136-4019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL HEAD CERAMIC 40MM -3 BIOLOX -,SUP-136-4030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,,,
ARTICUL/EZE BALL 28 +1.5 GR -,SUP-136511000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM ARTICL/EZ 28MMSTDX+8.5MM NK BIOLOX DELTA TS CERM -,SUP-1365-13-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,9.170825,27238.33344,percent of total billed charges,,,
ARTIUL/EZE BALL 28 +12 BLK -,SUP-136514000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4405.7,3083.99,AETNA [1000108],AETNA [100010801],,,76.8,,3383.58,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEMORAL BIOLOX DELTA 28MM +5 12/14 TAPER CERAMIC REV -,SUP-1365-28-720,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8563.54,5994.478,AETNA [1000108],AETNA [100010801],,,76.8,,6576.8,9.170825,27238.33344,percent of total billed charges,,,
ARTICUL/EZE BALL 22.225+4 NK -,SUP-136529000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4405.7,3083.99,AETNA [1000108],AETNA [100010801],,,76.8,,3383.58,9.170825,27238.33344,percent of total billed charges,,,
HEAD S-ROM M 36MM +0 -,SUP-136531000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL HEAD M-SPEC METAL 36MM +3 11/13 -,SUP-1365-32-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,9.170825,27238.33344,percent of total billed charges,,,
CERAMIC FEMORAL HEAD 32MM +0 11/13 TAPER -,SUP-1365-32-210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12117,8481.9,AETNA [1000108],AETNA [100010801],,,76.8,,9305.86,9.170825,27238.33344,percent of total billed charges,,,
HEAD BIOLOX DELTA CERAMIC FEMORAL 36MM -,SUP-1365-36-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4487.56,3141.292,AETNA [1000108],AETNA [100010801],,,76.8,,3446.45,9.170825,27238.33344,percent of total billed charges,,,
CERAMIC FEMORAL HEAD 40MM X +8.5 BIOLOX DELTA TS 12/14 TAPER -,SUP-1365-40-730,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,9.170825,27238.33344,percent of total billed charges,,,
CERAMIC FEMORAL HEAD 40MM +12 BIOLOX DELTA TS -,SUP-1365-40-740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM ARTICL/EZ 44MM +1.5MM NK COCR 12/14 TAPR CONTR -,SUP-1365-61-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,AETNA [1000108],AETNA [100010801],,,76.8,,2144.86,9.170825,27238.33344,percent of total billed charges,,,
CEMENTRALIZER 11.0 -,SUP-137620000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 22MM BIPLR COCR MODLR -,SUP-138-2200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL HEAD 22MM +3 COCR -,SUP-138-2203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL HEAD COCR 22MM -3 -,SUP-138-2230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM OVATN 28MM +0MML NK COCR 12/14 TAPR STRL -,SUP-138-2800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL HEAD 28MM +9 12/14 TAPER -,SUP-138-2809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEMORAL COCR 28MM -,SUP-138-2830,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM OVATN 36MM +0MML NK COCR 12/14 TAPR -,SUP-138-3600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL HEAD COCR 36MM +6 -,SUP-138-3606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL HEAD COCR 36MM +9 -,SUP-138-3609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM OVATN 36MM-3MM NK COCR 12/14 TAPR -,SUP-138-3630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL HEAD 40MM +3 -,SUP-138-4003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,,,
COCR FEMORAL HEAD -,SUP-138-4009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,,,
INSERT ENDO II TAPER STD 0MM T -,SUP-139247,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,9.170825,27238.33344,percent of total billed charges,,,
HEAD FRDM CNSTR 36MM T12/14 -6MM -,SUP-14-107016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7206.31,5044.417,AETNA [1000108],AETNA [100010801],,,76.8,,5534.45,9.170825,27238.33344,percent of total billed charges,,,
FRDM CNSTR HD 36MM T 12/14 - 14-107018 -,SUP-14-107018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7206.31,5044.417,AETNA [1000108],AETNA [100010801],,,76.8,,5534.45,9.170825,27238.33344,percent of total billed charges,,,
BAR ORTHO INTLOK TI ASCENT MAXIM L/R KN CR PRIM STRL -,SUP-141205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1136.02,795.214,AETNA [1000108],AETNA [100010801],,,76.8,,872.46,9.170825,27238.33344,percent of total billed charges,,,
TRAY TIBIAL ILOK PRI 79MM BIOMET -,SUP-141215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL PLATE 67MM -,SUP-141232,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,9.170825,27238.33344,percent of total billed charges,,,
TRAY COCR CRUCIATE 71MM CC BIOMET -,SUP-141233,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,9.170825,27238.33344,percent of total billed charges,,,
STEM HIP FINNED PRI 80 X 10MM BIOMET -,SUP-141316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
PIN FX STNMN 2MMX6IN SMTH PLN BAYNT PNT FA KN -,SUP-141796,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7206.31,5044.417,AETNA [1000108],AETNA [100010801],,,76.8,,5534.45,9.170825,27238.33344,percent of total billed charges,,,
STEM BMT SPLINED KNEE V2 12 X 40 -,SUP-148287,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,AETNA [1000108],AETNA [100010801],,,76.8,,6453.6,9.170825,27238.33344,percent of total billed charges,,,
STEM BMT SPLINED KNEE V2 14 X 40 -,SUP-148289,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,AETNA [1000108],AETNA [100010801],,,76.8,,6453.6,9.170825,27238.33344,percent of total billed charges,,,
SPLINED KNEE STEM V2 -,SUP-148291,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,AETNA [1000108],AETNA [100010801],,,76.8,,6453.6,9.170825,27238.33344,percent of total billed charges,,,
STEM BMT SPLINED KNEE V2 10 X 80 -,SUP-148300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,AETNA [1000108],AETNA [100010801],,,76.8,,6453.6,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 7MM PRSRVN RM/LL KN -,SUP-1498-11-306,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5824.89,4077.423,AETNA [1000108],AETNA [100010801],,,76.8,,4473.52,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 9.5MM PRSRVN RM/LL KN -,SUP-1498-11-308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5824.89,4077.423,AETNA [1000108],AETNA [100010801],,,76.8,,4473.52,9.170825,27238.33344,percent of total billed charges,,,
STEM OSS CEMENTED IM 9MM X 90MM -,SUP-150358,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9594.39,6716.073,AETNA [1000108],AETNA [100010801],,,76.8,,7368.49,9.170825,27238.33344,percent of total billed charges,,,
STEM OSS CEMENTED IM 12MM X 90MM -,SUP-150361,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9594.39,6716.073,AETNA [1000108],AETNA [100010801],,,76.8,,7368.49,9.170825,27238.33344,percent of total billed charges,,,
OSS CEMENTED IM STEM 13MM X 90MM -,SUP-150362,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9594.39,6716.073,AETNA [1000108],AETNA [100010801],,,76.8,,7368.49,9.170825,27238.33344,percent of total billed charges,,,
OSS CEMENTED IM STEM 13X150 -,SUP-150367,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10426.1,7298.27,AETNA [1000108],AETNA [100010801],,,76.8,,8007.24,9.170825,27238.33344,percent of total billed charges,,,
STEM OSS POUROUS IM 11.5MM X 90MM -,SUP-150382,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,AETNA [1000108],AETNA [100010801],,,76.8,,9444.45,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ3 ATTUNE LT KN CR CMNT -,SUP-1504-00-103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ9 ATTUNE LT KN CR CMNT -,SUP-1504-00-109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
OSS POROUS IM STEM 12.5 X 225 -,SUP-150402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,AETNA [1000108],AETNA [100010801],,,76.8,,9444.45,9.170825,27238.33344,percent of total billed charges,,,
OSS POROUS IM STEM 14.5 X 225 -,SUP-150403,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,AETNA [1000108],AETNA [100010801],,,76.8,,9444.45,9.170825,27238.33344,percent of total billed charges,,,
OSS POROUS IM STEM 18.5 X 225 -,SUP-150405,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,AETNA [1000108],AETNA [100010801],,,76.8,,9444.45,9.170825,27238.33344,percent of total billed charges,,,
OSS TIBAL POLY BEARING 14MM -,SUP-150411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7469.44,5228.608,AETNA [1000108],AETNA [100010801],,,76.8,,5736.53,9.170825,27238.33344,percent of total billed charges,,,
OSS TIBAL POLY BEARING 18MM -,SUP-150413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7469.44,5228.608,AETNA [1000108],AETNA [100010801],,,76.8,,5736.53,9.170825,27238.33344,percent of total billed charges,,,
PLATE OSS NON-MOD TIBAL SHORT 67MM -,SUP-150417,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19307.6,13515.32,AETNA [1000108],AETNA [100010801],,,76.8,,14828.24,9.170825,27238.33344,percent of total billed charges,,,
OSS MOD TIBAL BASEPLATE 71MM -,SUP-150422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20436.35,14305.445,AETNA [1000108],AETNA [100010801],,,76.8,,15695.12,9.170825,27238.33344,percent of total billed charges,,,
BLOCK OSS TIB 20 X 63/67 MR/LL -,SUP-150429,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,AETNA [1000108],AETNA [100010801],,,76.8,,5684.38,9.170825,27238.33344,percent of total billed charges,,,
BLOCK OSS TIB 20 X 63/67 MR/LR -,SUP-150430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,AETNA [1000108],AETNA [100010801],,,76.8,,5684.38,9.170825,27238.33344,percent of total billed charges,,,
REVISION CRS FEMORAL SZ 7 LEFT CEMENTED -,SUP-1504-40-107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24255.17,16978.619,AETNA [1000108],AETNA [100010801],,,76.8,,18627.97,9.170825,27238.33344,percent of total billed charges,,,
OSS FINN MOD PROX FMRL RT 7CM -,SUP-150457,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26939.64,18857.748,AETNA [1000108],AETNA [100010801],,,76.8,,20689.64,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT OSS LETSON MOD PROX FMRL R 7CM -,SUP-150459,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26939.64,18857.748,AETNA [1000108],AETNA [100010801],,,76.8,,20689.64,9.170825,27238.33344,percent of total billed charges,,,
OSS 3CM ELLIP DIAPHYSEAL SEG -,SUP-150461,CDM,C1776,HCPCS,278,RC,,,outpatient,,,35466.58,24826.606,AETNA [1000108],AETNA [100010801],,,76.8,,27238.33,9.170825,27238.33344,percent of total billed charges,,,
OSS POLY TIBIAL BUSHING -,SUP-150476,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2501.84,1751.288,AETNA [1000108],AETNA [100010801],,,76.8,,1921.41,9.170825,27238.33344,percent of total billed charges,,,
OSS POLY FEMORAL BUSHINGS 2PK -,SUP-150477,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1738.56,1216.992,AETNA [1000108],AETNA [100010801],,,76.8,,1335.21,9.170825,27238.33344,percent of total billed charges,,,
OSS AXLE -,SUP-150480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3399.09,2379.363,AETNA [1000108],AETNA [100010801],,,76.8,,2610.5,9.170825,27238.33344,percent of total billed charges,,,
OSS REINFORCED YOKE -,SUP-150493,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6994.11,4895.877,AETNA [1000108],AETNA [100010801],,,76.8,,5371.48,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL BASE FIXED BEARING -,SUP-1506-40-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12048.69,8434.083,AETNA [1000108],AETNA [100010801],,,76.8,,9253.39,9.170825,27238.33344,percent of total billed charges,,,
BASE TIBIAL REV RP SIZE 4 CEM -,SUP-1506-60-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18338.51,12836.957,AETNA [1000108],AETNA [100010801],,,76.8,,14083.98,9.170825,27238.33344,percent of total billed charges,,,
TIBIA SLV M/L ATUNE 29MM FULL POR -,SUP-1511-11-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13490.44,9443.308,AETNA [1000108],AETNA [100010801],,,76.8,,10360.66,9.170825,27238.33344,percent of total billed charges,,,
REVISED CEMENTED SYSTEM -,SUP-1512-14-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4423.31,3096.317,AETNA [1000108],AETNA [100010801],,,76.8,,3397.1,9.170825,27238.33344,percent of total billed charges,,,
STEM PRESSFIT STR ATUNE 16 X 60MM -,SUP-1513-16-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.93,4893.651,AETNA [1000108],AETNA [100010801],,,76.8,,5369.03,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 6MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-306,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5 10MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ6 6MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ9 7MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-907,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT FIXED BEARING POSTERIOR STABILIZED -,SUP-1516-40-412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,9.170825,27238.33344,percent of total billed charges,,,
TIBAL INSERT FIXED BEARING POST STAB 7X10MM -,SUP-1516-40-710,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,9.170825,27238.33344,percent of total billed charges,,,
INSERT PS RP SZ 5 ATTUNE 16MM -,SUP-1516-50-516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 41MM ATTUNE MDL DOME -,SUP-1518-20-041,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2364.02,1654.814,AETNA [1000108],AETNA [100010801],,,76.8,,1815.57,9.170825,27238.33344,percent of total billed charges,,,
AUG TIBIL UNIV ATUE SZ 3/4 X 5MM -,SUP-1523-03-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5835.5,4084.85,AETNA [1000108],AETNA [100010801],,,76.8,,4481.66,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ1 41MM OFST 120MM PROSTALAC HI OFST 26MM LEG COCR -,SUP-1541-06-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19493.25,13645.275,AETNA [1000108],AETNA [100010801],,,76.8,,14970.82,9.170825,27238.33344,percent of total billed charges,,,
CUP ACTB PROSTALAC CMNT PE 32X42MM -,SUP-1541-42-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3762.63,2633.841,AETNA [1000108],AETNA [100010801],,,76.8,,2889.7,9.170825,27238.33344,percent of total billed charges,,,
OXFORD PARTIAL KNEE SYM FIXED LATERAL TIBIAL LEFT -,SUP-154335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,AETNA [1000108],AETNA [100010801],,,76.8,,6306.92,9.170825,27238.33344,percent of total billed charges,,,
FIXED LATERAL TIBIAL COSTRUCT LEFT  (E3) -,SUP-154340,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,AETNA [1000108],AETNA [100010801],,,76.8,,6306.92,9.170825,27238.33344,percent of total billed charges,,,
OXF FIX LAT BRG E4 LEFT -,SUP-154341,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,AETNA [1000108],AETNA [100010801],,,76.8,,6306.92,9.170825,27238.33344,percent of total billed charges,,,
OXF FIX LAT BRG B3 RIGHT -,SUP-154355,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,AETNA [1000108],AETNA [100010801],,,76.8,,6306.92,9.170825,27238.33344,percent of total billed charges,,,
OXFORD FIX LAT BRG E5 RIGHT -,SUP-154372,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,AETNA [1000108],AETNA [100010801],,,76.8,,6306.92,9.170825,27238.33344,percent of total billed charges,,,
OXFORD FIX LAT BRG F3 RIGHT -,SUP-154375,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,AETNA [1000108],AETNA [100010801],,,76.8,,6306.92,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SM OXFORD KN UNICMPT COCR -,SUP-154600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA [1000108],AETNA [100010801],,,76.8,,6844.72,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM MED OXFORD KN UNICMPT COCR -,SUP-154601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9586.97,6710.879,AETNA [1000108],AETNA [100010801],,,76.8,,7362.79,9.170825,27238.33344,percent of total billed charges,,,
REVISION DISTAL FEMORAL AUGMENT SZ 7X4MM CEMENTED -,SUP-1547-07-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5135.24,3594.668,AETNA [1000108],AETNA [100010801],,,76.8,,3943.86,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ A LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154718,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ A R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ B LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154720,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ B R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154721,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ-C L/M PMA ARTC OXFORD TI NIOBM NTRD CTD UHMWP -,SUP-154722,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ-C LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154722,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ-C R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154723,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ-D LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154724,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ-D R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154725,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ-E R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154727,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,,,
REVISION POSTERIOR FEMORAL AUGMENT SZ 7X4MM -,SUP-1549-07-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5135.24,3594.668,AETNA [1000108],AETNA [100010801],,,76.8,,3943.86,9.170825,27238.33344,percent of total billed charges,,,
SUMMIT BASIC CEMENTED SZ 6 -,SUP-157006120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ4 OFST 12/14 TAPR W/ POROCOAT -,SUP-1570-11-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA [1000108],AETNA [100010801],,,76.8,,7328.57,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL STEM 12/14 TAPER / SZ 5 / 145MM -,SUP-1570-11-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA [1000108],AETNA [100010801],,,76.8,,7328.57,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ6 12/14 TAPER W/ PORCOAT -,SUP-1570-11-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA [1000108],AETNA [100010801],,,76.8,,7328.57,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL STEM 12/14 TAPER SZ7X155MM -,SUP-1570-11-135,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA [1000108],AETNA [100010801],,,76.8,,7328.57,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB XS OXFORD UNICMPT ANTMC BEAR LT FEM MNSCL KN -,SUP-159530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA [1000108],AETNA [100010801],,,76.8,,6844.72,9.170825,27238.33344,percent of total billed charges,,,
OXFORD KNEED RIGHT MEDIAL TIBIAL TRAY SZAA -,SUP-159532,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SM SZ4 PMA OXFORD UNICMPT ANTMC BRG LT MNSCL -,SUP-159541,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SM 5MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159542,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SM 6MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159543,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SM 9MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159546,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB MED 3MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159547,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB MED 4MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159548,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB MED 6MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159550,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB LRG 3MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159554,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB LRG 6MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159557,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB XL 4MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159562,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB XL 5MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159563,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SM 3MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159568,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SM 6MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159571,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SM 7MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159572,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SM 8MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159573,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SM 9MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159574,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB MED 3MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159575,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB MED 4MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159576,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
OXF ANAT BRG RT MD SZ 5 PMA -,SUP-159577,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB MED 6MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159578,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB MED 7MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159579,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB MED 8MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159580,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB LRG 3MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159582,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB LRG 4MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159583,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB LRG 5MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159584,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB LRG 6MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159585,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB XL 3MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL KN -,SUP-159589,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB XL 4MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL KN -,SUP-159590,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB XS 4MM OXFORD UNICMPT ANTMC ARTC BEAR LT MNSCL KN -,SUP-159791,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ5 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-05132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ6 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD. -,SUP-1601-06127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ6 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-06132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ7 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD. -,SUP-1601-07127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ7 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-07132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ8 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD. -,SUP-1601-08127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ8 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-08132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8806.3,6164.41,AETNA [1000108],AETNA [100010801],,,76.8,,6763.24,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ9 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-09127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,,,
HIP STEM SZ.9 34MM 142MM V40 -,SUP-1601-09132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,,,
HIP STEM SZ.10 34MM / 148MM -,SUP-1601-10132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ11 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-11132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB XS 4MM OXFORD UNIV ANTMC ARTC BEAR RT KN -,SUP-160791,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
OSS 3CM PROXIMAL TIBIAL SLEEVE -,SUP-161000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13099.46,9169.622,AETNA [1000108],AETNA [100010801],,,76.8,,10060.39,9.170825,27238.33344,percent of total billed charges,,,
OSS RS 3 CM RESURF FMRL-LT -,SUP-161006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26742.28,18719.596,AETNA [1000108],AETNA [100010801],,,76.8,,20538.07,9.170825,27238.33344,percent of total billed charges,,,
OSS RS 7 CM MOD SEG FMRL-RT -,SUP-161011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28518.52,19962.964,AETNA [1000108],AETNA [100010801],,,76.8,,21902.22,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE OSS RS 3 CM PROX TIBIAL -,SUP-161023,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13663.84,9564.688,AETNA [1000108],AETNA [100010801],,,76.8,,10493.83,9.170825,27238.33344,percent of total billed charges,,,
BUSHING OSS RS POLY FEM SET/2 -,SUP-161034,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3131.74,2192.218,AETNA [1000108],AETNA [100010801],,,76.8,,2405.18,9.170825,27238.33344,percent of total billed charges,,,
AXLE OSS RS -,SUP-161035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3399.09,2379.363,AETNA [1000108],AETNA [100010801],,,76.8,,2610.5,9.170825,27238.33344,percent of total billed charges,,,
SEGMENT OSS 3CM LG ELLIPT DIAPH -,SUP-161079,CDM,C1776,HCPCS,278,RC,,,outpatient,,,35466.58,24826.606,AETNA [1000108],AETNA [100010801],,,76.8,,27238.33,9.170825,27238.33344,percent of total billed charges,,,
MOD BEARING TIBIAL OSS RS 63MM -,SUP-161088,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21683.92,15178.744,AETNA [1000108],AETNA [100010801],,,76.8,,16653.25,9.170825,27238.33344,percent of total billed charges,,,
BEARING TIBIAL OSS RS 12MM LS -,SUP-161094,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,AETNA [1000108],AETNA [100010801],,,76.8,,4823.9,9.170825,27238.33344,percent of total billed charges,,,
BEARING TIBIAL OSS RS 16MM LS -,SUP-161096,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,AETNA [1000108],AETNA [100010801],,,76.8,,4823.9,9.170825,27238.33344,percent of total billed charges,,,
BEARING TIBIAL OSS RS 18MM LS -,SUP-161097,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,AETNA [1000108],AETNA [100010801],,,76.8,,4823.9,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT LT SZ 2 FEMORAL PS NONPOROUS -,SUP-161-1201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL PS RIGHT SZ 2 NON-POROUS -,SUP-161-1202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,,,
SEG OSS RS 8.5CM FMRL LEFT -,SUP-161124,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29722.42,20805.694,AETNA [1000108],AETNA [100010801],,,76.8,,22826.82,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ3 BAL KN LT PS NPOR -,SUP-161-1301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ3 BAL KN RT KN PS NPOR -,SUP-161-1302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ4 BAL KN LT KN PS NPOR -,SUP-161-1401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ4 BAL KN RT KN PS NPOR -,SUP-161-1402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT FEMORAL BALANCED KNEE COCR NONPOROUS 4N KNEE LEFT -,SUP-161-1405,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL PS NARROW RIGHT SZ 4 NON-POROUS -,SUP-161-1406,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 BAL KN LT KN PS NPOR -,SUP-161-1501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 BAL KN RT KN PS NPOR -,SUP-161-1502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL PS NARROW LEFT SZ 5 NON-POROUS -,SUP-161-1505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL PS NARROW RIGHT SZ 5 NON-POROUS -,SUP-161-1506,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ6 BAL KN LT KN PS NPOR -,SUP-161-1601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ6 BAL KN RT KN PS NPOR -,SUP-161-1602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ7 BAL KN LT KN PS NPOR -,SUP-161-1701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ7 BAL KN RT KN PS NPOR -,SUP-161-1702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,,,
RT SIZE 2 FEMORAL CR NONPOROUS -,SUP-161-3202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ4 BAL KN LT KN CR NPOR -,SUP-161-3401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 BAL KN LT KN CR NPOR -,SUP-161-3501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 BAL KN RT KN CR NPOR -,SUP-161-3502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ6 BAL KN LT KN CR NPOR -,SUP-161-3601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ6 BAL KN RT KN CR NPOR -,SUP-161-3602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM XS OXFORD KN TWN PG PRT CMNT COCR MLYBDNM ALY -,SUP-161467,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,AETNA [1000108],AETNA [100010801],,,76.8,,6192.84,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SM OXFORD KN TWN PG PRT CMNT COCR MLYBDNM ALY -,SUP-161468,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,AETNA [1000108],AETNA [100010801],,,76.8,,6192.84,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM MED OXFORD KN TWN PG PRT CMNT COCR MLYBDNM ALY -,SUP-161469,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,AETNA [1000108],AETNA [100010801],,,76.8,,6192.84,9.170825,27238.33344,percent of total billed charges,,,
TWIN PEGGED FEMORAL LRG KNEE -,SUP-161470,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,AETNA [1000108],AETNA [100010801],,,76.8,,6192.84,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ2 BAL KN NPOR -,SUP-162-1200A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ3 BAL KN NPOR -,SUP-162-1300A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ4 BAL KN NPOR -,SUP-162-1400A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ5 BAL KN NPOR -,SUP-162-1500A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ6 BAL KN NPOR -,SUP-162-1600A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL TRAY NONPOROUS SIZE 7 -,SUP-162-1700A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 11MM PS KN -,SUP-163-1311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5 8MM PS KN -,SUP-163-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5 13MM PS KN -,SUP-163-1513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ6 12MM PS KN -,SUP-163-1612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ2 13MM UL CONG KN -,SUP-163-3213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 11MM UL CONG KN -,SUP-163-3311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 16MM UL CONG KN -,SUP-163-3316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ4 9MM UL CONG KN PE -,SUP-163-3409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5 14MM UL CONG KN -,SUP-163-3514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2726.14,1908.298,AETNA [1000108],AETNA [100010801],,,76.8,,2093.68,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ6 10MM UL CONG KN -,SUP-163-3610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ6 11MM UL CONG KN -,SUP-163-3611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ6 14MM UL CONG KN -,SUP-163-3614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
MODULAR HEAD COMPONENT 32MM DIA HD 3MM NK -,SUP-163661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,,,
28MM DIA COCR MOD HD -,SUP-163665,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,,,
MODULAR HEAD COMPONENT 32MM -,SUP-163674,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,,,
PATELLA  29MM VITAMIN 3 -,SUP-164-5029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,,,
PATELLA 32MM VITAMIN E -,SUP-164-5032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,,,
PATELLA 35MM VITAMIN E -,SUP-164-5035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,,,
PATELLA 38MM VITAMIN E -,SUP-164-5038,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,,,
41MM PATELLA VITAMIN E -,SUP-164-5041,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL PS RIGHT SZ 4 NON-POROUS -,SUP-165-1402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL CR LEFT SZ 6 NON-POROUS -,SUP-165-3601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT PS SIZE 2 7MM VITAMIN E -,SUP-166-5207,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT BKS E-VITALIZE 9MM SZ 2 -,SUP-166-5209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT PS TIBIAL 10MM SIZE 2 V -,SUP-166-5210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT PS TIBIAL SIZE 2 11MM VITAMIN E -,SUP-166-5211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT PS VITAMIN E SIZE 2 12MM -,SUP-166-5212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT PS TIBIAL SIZE 3 7MM VITAMIN E -,SUP-166-5307,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL PS SIZE 3 8MM VITAMIN E -,SUP-166-5308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
SIZE 3 9MM TIBIAL INSERT PS VITAMIN E -,SUP-166-5309,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL PS SIZE 3 10MM VITAMIN E -,SUP-166-5310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT PS TIBIAL 10MM SIZE 3 V -,SUP-166-5310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL PS 11MM SIZE 3 V -,SUP-166-5311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL PS 12MM SIZE 3 V -,SUP-166-5312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL PS 13MM SIZE 3 V -,SUP-166-5313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT PS TIBIAL 14MM SIZE 3 V -,SUP-166-5314,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL PS 16MM SIZE 3 V -,SUP-166-5316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SIZE 3 18MM VIT E -,SUP-166-5318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SIZE 3 20MM -,SUP-166-5320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT PS VITAMIN E SZ4 7MM -,SUP-166-5407,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL PS 8MM SIZE 4 VITAMIN E -,SUP-166-5408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT PS TIBIAL 9MM SIZE 4 HI -,SUP-166-5409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT PS TIBIAL 10MM SIZE 4 V -,SUP-166-5410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL PS SIZE 4 10MM VITAMIN E -,SUP-166-5410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT PS VITAMIN E SZ 4 10MM -,SUP-166-5410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL PS 11MM SIZE 4 VITAMIN E -,SUP-166-5411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL PS 11MM SIZE 4 V -,SUP-166-5411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT PS TIBIAL 12MM SIZE 4 H -,SUP-166-5412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL PS SIZE 4 12MM VITAMIN E -,SUP-166-5412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT PS TIBIAL 13MM SIZE 4 H -,SUP-166-5413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL 14MM SIZE 4 HIGH -,SUP-166-5414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SIZE 4 16MM VIT E -,SUP-166-5416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT PS SIZE 4 18MM -,SUP-166-5418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT PS VIT 3 SIZE 4 20MM -,SUP-166-5420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT PS SIZE 5 7 MM VIT E -,SUP-166-5507,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIIAL PS SIZE 5 8MM VITAMIN E -,SUP-166-5508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT PS SIZE 5 9MM TIBIAL VITAMIN E -,SUP-166-5509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL PS 10MM SIZE 5 V -,SUP-166-5510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL PS SIZE 5 10MM VITAMIN E -,SUP-166-5510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL 11MM PS SIZE 5 HIGH FLEX VITAMIN E -,SUP-166-5511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL NONPOROUS SIZE 5 -,SUP-166-5511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL PS SIZE 5 12MM VITAMIN E -,SUP-166-5512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL PS 12MM SIZE 5 V -,SUP-166-5512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL PS 14MM SIZE 5 H -,SUP-166-5514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SIZE 5 16MM VIT E -,SUP-166-5516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SIZE 5 20MM -,SUP-166-5520,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SIZE 6 7MM -,SUP-166-5607,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SIZE 6 8MM VIT E -,SUP-166-5608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SZ 6 9MM PS -,SUP-166-5609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL PS 10MM SIZE 6 H -,SUP-166-5610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
SIZE 6 10MM TIBIAL INSERT PS VITAMIN E -,SUP-166-5610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL PS 11MM SIZE 6 VITAMIN E -,SUP-166-5611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SIZE 6 12MM VIT E -,SUP-166-5612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SIZE6 14MM VITAMIN E -,SUP-166-5614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT PS SZ 6 16MM VITAMN-E -,SUP-166-5616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,AETNA [1000108],AETNA [100010801],,,76.8,,3373.12,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT INSERT PS SIZE 7 10MM VIT E XLPE -,SUP-166-5710,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT CR SZ 5 10MM VITAMIN E -,SUP-166-6510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SZ 2 12MM VIT E -,SUP-166-7212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT UC SZ 3 9MM VIT-E -,SUP-166-7309,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SIZE 3 11MM VIT E XLPE -,SUP-166-7311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT UC SZ 4 8MM VIT E -,SUP-166-7408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SZ 4 9MM VIT E -,SUP-166-7409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT UC SIZE 4 10MM VIT E -,SUP-166-7410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SIZE 4 11MM VIT E -,SUP-166-7411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SIZE 4 12MM VIT E -,SUP-166-7412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SIZE 4 13MM -,SUP-166-7413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT UC SZ 4 14MM VIT E -,SUP-166-7414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SZ 5 7MM VIT E -,SUP-166-7507,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT UC SZ 5 8MM VITAMIN-E -,SUP-166-7508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL UC SZ 5 9MM E-VITALIZE KNEE -,SUP-166-7509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SIZE 5 10MM VIT E -,SUP-166-7510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT BKS E-VITALIZE 11MM SZ 5 -,SUP-166-7511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT UC SZ 5 12MM VIT-E -,SUP-166-7512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SIZE 5 13MM VITAMIN E -,SUP-166-7513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SIZE 5 14MM VIT E -,SUP-166-7514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT UC SIZE 5 16MM VIT-E -,SUP-166-7516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SIZE 6 10MM VIT E -,SUP-166-7610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SIZE 6 11MM VITAMIN E -,SUP-166-7611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SIZE 6 12MM VIT E -,SUP-166-7612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT UC SIZE 6 13MM VIT E -,SUP-166-7613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SIZE 6 14MM VIT E -,SUP-166-7614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SIZE 7 11MM VIT E -,SUP-166-7711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE HIP UNITRAX V40 UNIPL TI -,SUP-170000E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,9.170825,27238.33344,percent of total billed charges,,,
SHELL THREE HOLE 44MM -,SUP-170-0144,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 48MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0148,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4630.78,3241.546,AETNA [1000108],AETNA [100010801],,,76.8,,3556.44,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 50MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 52MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0152,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 56MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 58MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0158,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 60MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 62MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0162,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,,,
SHELL ESCALADE 68MM THREE HOLE -,SUP-170-0168,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACETABULAR LEGEND OD50 MM 3 HOLE -,SUP-170-0550,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,,,
POROUS ACET SHELL THREE HOLE 52MM OD -,SUP-170-0552,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,,,
POROUS ACETABULAR SHELL THREE-HOLE 54MM OD -,SUP-170-0554,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,,,
POROUS ACETABULAR SHELL THREE HOLE 56MM OD -,SUP-170-0556,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4630.78,3241.546,AETNA [1000108],AETNA [100010801],,,76.8,,3556.44,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 32MM X 52MM NEUTRAL HXLPE -,SUP-170-3252,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 36MM 52MM SHL ESCALADE +3 NEUT -,SUP-170-3652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 36MM 54MM SHL ESCALADE +1 NEUT -,SUP-170-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 36MM 56MM SHL ESCALADE +0 NEUT -,SUP-170-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 36MM 58MM SHL ESCALADE +0 NEUT -,SUP-170-3658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 36MM 60MM SHL ESCALADE +0 NEUT -,SUP-170-3660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 36X62MM ESCALDE +ODEG NEUT F/T/H ARTHPL -,SUP-170-3662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
LINER +3 NEUTRAL 40 X 56MM HXL -,SUP-170-4056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
LINER NEUTRAL +1 ESCALADE -,SUP-170-4058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 40X60MM ESCALDE +ODEG NEUT F/T/H ARTHPL -,SUP-170-4060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,AETNA [1000108],AETNA [100010801],,,76.8,,2841.48,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 40X62MM ESCALDE +ODEG NEUT F/T/H ARTHPL -,SUP-170-4062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
ACETABULAR LINER 36 X 52 +3 HOODED HXLPE -,SUP-171-3652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
LINER ACETABULAR 36 X 54 HOODED -,SUP-171-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 36X56MM ESCALDE +ODEG HD F/T/H ARTHPL -,SUP-171-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,AETNA [1000108],AETNA [100010801],,,76.8,,2841.48,9.170825,27238.33344,percent of total billed charges,,,
LINER 28MM ID 44MM OD NEUTRAL HXLPE -,SUP-172-2844,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
LINER 32MM ID 46MM OD NEUTRAL HXLPE -,SUP-172-3246,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
LINER 36MM ID 50MM OD NEUTRAL HXLPE -,SUP-172-3650,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
LINER 36MM ID 52MM OD NEUTRAL HXLPE -,SUP-172-3652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
LINER 36MM ID 54MM OD NEUTRAL HXLPE -,SUP-172-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
LINER 36MM ID 56MM OD NEUTRAL HXLPE -,SUP-172-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
LINER 36MM ID 58MM OD NEUTRAL HXLPE -,SUP-172-3658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
LINER 36MM ID 60MM OD NEUTRAL HXLPE -,SUP-172-3660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
LINER 36MM 64-70MM OD NEUTRAL -,SUP-172-3664,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
LINER 40MM ID 56MM OD NEUTRAL HXLPE -,SUP-172-4056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
LINER 40MM ID 58MM OD NEUTRAL HXLPE -,SUP-172-4058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
LINER 40MM ID 60MM OD NEUTRAL HXLPE -,SUP-172-4060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
STEM WITH MICROPOUROUS SUR 14MM X 12MM X 180CM -,SUP-172-918/14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA [1000108],AETNA [100010801],,,76.8,,12832.13,9.170825,27238.33344,percent of total billed charges,,,
STEM WITH MICROPOROUS SURGACE 14MM X 16MM L 180MM -,SUP-172-918/16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA [1000108],AETNA [100010801],,,76.8,,12832.13,9.170825,27238.33344,percent of total billed charges,,,
STEM WITH MICROPOROUS SURFACE 18MM X 16MM L180MM -,SUP-172-918/18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA [1000108],AETNA [100010801],,,76.8,,12832.13,9.170825,27238.33344,percent of total billed charges,,,
STEM FEMORAL LINK W/MICROPOROUS CEMTLESS 20MM X 18MM X 180MM -,SUP-172-918/20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA [1000108],AETNA [100010801],,,76.8,,12832.13,9.170825,27238.33344,percent of total billed charges,,,
LINK STEM WITH MICROP SUR 14MM X 16MM -,SUP-172-921/16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA [1000108],AETNA [100010801],,,76.8,,12832.13,9.170825,27238.33344,percent of total billed charges,,,
STEM WITH MICROPOROUS SURFACE 16 X 18 X 210 -,SUP-172-921/18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA [1000108],AETNA [100010801],,,76.8,,12832.13,9.170825,27238.33344,percent of total billed charges,,,
LINK STEM WITH MICROP SUR 14MM X 11MM X 120MM -,SUP-172-925/14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA [1000108],AETNA [100010801],,,76.8,,12832.13,9.170825,27238.33344,percent of total billed charges,,,
STEM WITH MICROPOROUS SURFACE 12.5MM X 16MM L 250MM -,SUP-172-925/16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA [1000108],AETNA [100010801],,,76.8,,12832.13,9.170825,27238.33344,percent of total billed charges,,,
STEM MICROPOROUS SURF 14.5MM X 18MM L 250MM CEMENTLESS -,SUP-172-925/18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA [1000108],AETNA [100010801],,,76.8,,12832.13,9.170825,27238.33344,percent of total billed charges,,,
SPACER PROXIMAL 20MM X 14MM COCRMO -,SUP-172-950/20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1484.14,1038.898,AETNA [1000108],AETNA [100010801],,,76.8,,1139.82,9.170825,27238.33344,percent of total billed charges,,,
LINK NECK SEGMENT WITHOUT COLLAR CEMLESS 65MM 126CCD -,SUP-172-964/26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,AETNA [1000108],AETNA [100010801],,,76.8,,15284.49,9.170825,27238.33344,percent of total billed charges,,,
NECK FEMORAL W/O COLLAR CEMENTLESS TILASTAN TI6AI-4V LINK -,SUP-172-964/35,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,AETNA [1000108],AETNA [100010801],,,76.8,,15284.49,9.170825,27238.33344,percent of total billed charges,,,
NECK SEGMENT WITHOUT COLLAR CEMENTLESS -,SUP-172-965/26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,AETNA [1000108],AETNA [100010801],,,76.8,,15284.49,9.170825,27238.33344,percent of total billed charges,,,
NECK SEGMENT XXL W/O COLLAR 65MM 12/14MM CEMENTLESS -,SUP-172-984/26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,AETNA [1000108],AETNA [100010801],,,76.8,,15284.49,9.170825,27238.33344,percent of total billed charges,,,
LINK NECK SEG XXL WITHOUT COLLAR CEMENLESS 65MM -,SUP-172-984/35,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,AETNA [1000108],AETNA [100010801],,,76.8,,15284.49,9.170825,27238.33344,percent of total billed charges,,,
LINER 36MM ID 50MM OD HOODED HXLPE -,SUP-173-3650,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,AETNA [1000108],AETNA [100010801],,,76.8,,2841.48,9.170825,27238.33344,percent of total billed charges,,,
LINER 36MM ID 54MM OD HOODED HXLPE -,SUP-173-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
LINER 36MM ID 56MM OD HOODED -,SUP-173-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,AETNA [1000108],AETNA [100010801],,,76.8,,2841.48,9.170825,27238.33344,percent of total billed charges,,,
LINER 36MM ID 58MM OD HOODED HXLPE -,SUP-173-3658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM ABC 36X0MM NK ALMN C-TAPR PRIM -,SUP-173600E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,,,
ASCENT ANT STBLZD TIBIAL BEARING 14 X 67 -,SUP-179822,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5551.15,3885.805,AETNA [1000108],AETNA [100010801],,,76.8,,4263.28,9.170825,27238.33344,percent of total billed charges,,,
COMP RESTORIS SZ 3 LEFT MAKO PATELLOFEMORAL COCRMO -,SUP-180403,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA [1000108],AETNA [100010801],,,76.8,,7414.12,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT RESTORIS MCK SIZE 4 LEFT PATELLOFEMORAL COCRMO -,SUP-180404,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA [1000108],AETNA [100010801],,,76.8,,7414.12,9.170825,27238.33344,percent of total billed charges,,,
COMP RESTORIS MCK PAT/FEM SZ 5 RIGHT COCRMO -,SUP-180415,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA [1000108],AETNA [100010801],,,76.8,,7414.12,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT FEMORAL RESTORIS MCK SIZE 1 LM/RL -,SUP-180501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT FEMORAL SZ 3 LM/RL RESTORIS MAKO COCRMO -,SUP-180503,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT FEMORAL SIZE 4 LM/RL RESTORIS MCK COCRMO -,SUP-180504,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT FEMORAL SZ 5 LM/RL RESTORIS MAKO COCRMO -,SUP-180505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT FEMORAL SZ 6 LM/RL RESTORIS MAKO COCRMO -,SUP-180506,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT FEMORAL SZ 1 RM/LL RESTORIS MAKO COCRMO -,SUP-180511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT FEM ONLAY SZ 3 RM/LL RESTORIS MAKO COCRMO -,SUP-180513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT FEMORAL SZ 4 RM/LL RESTORIS MAKO COCRMO -,SUP-180514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT FEMORAL RESTORIS MCK SZ 5 RM/LL COCRMO MAKO -,SUP-180515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT FEMORAL RESTORIS MCK SZ 6 RM/LL COCRMO MAKO -,SUP-180516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT FEM RESTORIS MCK SZ 7 RM/LL COCRMO -,SUP-180517,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIBIAL RESTORIS MCK ONLAY SIZE 2 LM/RL -,SUP-180602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIBIAL RESTORIS SZ 3 LM/RL T/6A/4V ONLAY MAKO -,SUP-180603,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE ONLAY TIBIAL SZ 4 LM/RL T/6A/4V RESTORIS MAKO -,SUP-180604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE ONLAY TIBIAL 5 LM/RL RESTORIS MCK -,SUP-180605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE ONLAY TIBIAL 6 LM/RL RESTORIS MCK -,SUP-180606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE ONLAY TIBIAL SZ 2 RM/LL Ti6AI4V RESTORIS MAKO -,SUP-180612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE ONLAY TIBIAL SIZE 3 RM/LL RESTORIS MCK TI6AI4V -,SUP-180613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE ONLAY TIBIAL SZ 4 RM/LL Ti6AI4V RESTORIS MAKO -,SUP-180614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIBIAL RESTORIS MCK SZ 5 RM/LL ONLAY MAKO TI6AI4V -,SUP-180615,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE ONLAY TIBIAL 6 RM/LL RESTORIS MCK -,SUP-180616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE ONLAY TIBIAL 7 RM/LL RESTORIS MCK TI6A14V -,SUP-180617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIBIAL RESTORIS MCK SZ 8 RM/LL TI6I4V -,SUP-180618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL SIZE 2 UNI X 8MM MAKO X3 ONLAY -,SUP-180732-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL MAKO X3 UNI ONLAY SIZE 2 X 8MM -,SUP-180732-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL MAKO X3 3 X 8 MM KNEE ONLAY -,SUP-180733-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,,,
INSERT ONLAY TIBIAL SZ 4 X 8MM MAKO X3 UNI -,SUP-180734-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL SIZE 4 X 8MM UNI ONLAY MAKO X3 -,SUP-180734-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL UNI ONLAY SIZE 4 X 9MM THKNS MAKO X3 -,SUP-180734-2,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL ONLAY SZ 5 X 8MM MAKO X3 UNI -,SUP-180735-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL ONLAY SZ 5 X 9MM MAKO X3 UNI -,SUP-180735-2,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,,,
INSERT ONLAY TIBIAL SZ 6 X 8MM MAKO X3 UNI -,SUP-180736-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL ONLAY SZ 6 X 8MM MAKO X3 UNI -,SUP-180736-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,,,
INSERT ONLAY TIBIAL SZ 7 X 8MM MAKO X3 UNI -,SUP-180737-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,,,
INSERT ONLAY TIBIAL MAKO X3 UNI SZ 8 X 8MM THKNS -,SUP-180738-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 28MM +0MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-18-2800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM 55MM VANGRD RT KN CR ANTMC CMNT COCR NPOR INTLOK -,SUP-183000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM 62.5MM VANGRD RT KN CR ANTMC CMNT COCR NPOR INTLOK -,SUP-183006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,,,
FEMUR CR INTERLOCK RIGHT 65MM VANGUARD -,SUP-183008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,,,
VANGUARD CR ILOK FEM-LT 62.5 -,SUP-183026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM 57.5MM VANGRD LT KN CR ANTMC CMNTLS TI POR -,SUP-183062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,AETNA [1000108],AETNA [100010801],,,76.8,,7499.67,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM 62.5MM VANGRD LT KN CR ANTMC CMNTLS TI POR -,SUP-183066,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,AETNA [1000108],AETNA [100010801],,,76.8,,7499.67,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM 70MM VANGRD LT KN CR ANTMC CMNTLS TI POR -,SUP-183072,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,AETNA [1000108],AETNA [100010801],,,76.8,,7499.67,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM 57.5MM VANGRD RT FEM OPN BX CMNT COCR -,SUP-183102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM 60MM VANGRD RT KN PS OPN BX CMNT COCR NPOR INTLOK -,SUP-183104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,,,
PS OPEN BOX FEMORAL - LEFT 62.5MM -,SUP-183126,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,,,
PLATE VN PS OPEN INTL FEM-LT 70 -,SUP-183132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 32MM +0MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 32MM +5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB 10X63/67MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-183520,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB 16X63/67MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-183526,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 36MM +0MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 36MM +5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB 12X63/67MM VANGRD PS MODULAR ARTC BEAR 0DG SLP KN -,SUP-183622,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 36MM -5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-18365,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 36MM +7.5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183675,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL BEARING 14MM X 63/67 MM -,SUP-183724,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,,,
BRIDGE VANGUARD PS+TIB 20 X63/67MM -,SUP-183730,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL BEARING 14MM X 71/75MM -,SUP-183744,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,,,
BRIDGE VNGD PS+TIB 24 X79/83MM -,SUP-183774,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,,,
VNGD SSK PSC TIB BRG 20 X 71/75 -,SUP-183890,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9735.49,6814.843,AETNA [1000108],AETNA [100010801],,,76.8,,7476.86,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 31MM STD 8MM TI SS UNMWPE PEGX3 VANGRD -,SUP-184764,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,9.170825,27238.33344,percent of total billed charges,,,
SERIES A ASYMMETRIC PAT 31X8 -,SUP-184792,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,9.170825,27238.33344,percent of total billed charges,,,
SERIES-A ASYMMETRICAL PATELLA 31MM / 8MM -,SUP-184792,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,9.170825,27238.33344,percent of total billed charges,,,
SERIES A ASYMMETRIC PAT 34X8.5 -,SUP-184793,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,9.170825,27238.33344,percent of total billed charges,,,
DRILL HEADLESS TROCAR PIN 75MM -,SUP-185086,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9557.26,6690.082,AETNA [1000108],AETNA [100010801],,,76.8,,7339.98,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL TRAY WITH TI LCK BAR AND SCREW -,SUP-185203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11606.84,8124.788,AETNA [1000108],AETNA [100010801],,,76.8,,8914.05,9.170825,27238.33344,percent of total billed charges,,,
OFFSET ADAPTER WITH SCREWS -,SUP-185210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4611.68,3228.176,AETNA [1000108],AETNA [100010801],,,76.8,,3541.77,9.170825,27238.33344,percent of total billed charges,,,
ADAPTER OFFSET BMT 360 TIB 6.0 -,SUP-185211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4611.68,3228.176,AETNA [1000108],AETNA [100010801],,,76.8,,3541.77,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT BMT 360 TIBIAL 7 X 5MM -,SUP-185223,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5321.98,3725.386,AETNA [1000108],AETNA [100010801],,,76.8,,4087.28,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT BMT 360 TIBIAL 71 X 15MM RL/LM -,SUP-185243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5321.98,3725.386,AETNA [1000108],AETNA [100010801],,,76.8,,4087.28,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT BMT 360 TIBIAL 71 X 15MM LL/RM -,SUP-185253,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5321.98,3725.386,AETNA [1000108],AETNA [100010801],,,76.8,,4087.28,9.170825,27238.33344,percent of total billed charges,,,
VNGD SSK 360 L FEMORAL R 67.5 -,SUP-185265,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29741.13,20818.791,AETNA [1000108],AETNA [100010801],,,76.8,,22841.19,9.170825,27238.33344,percent of total billed charges,,,
VNGD SSK 360 L FEMORAL 65MM -,SUP-185284,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29741.13,20818.791,AETNA [1000108],AETNA [100010801],,,76.8,,22841.19,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT VG 360 DIST FM 67.5 X 5 RL/LM -,SUP-185305,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT VG 360 DIST FM 67.5 X 5 LL/RM -,SUP-185325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT VG 360 UNIV PST FM 65 X 10 -,SUP-185424,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT VG 360 UNIV PST FM 67.5 X 10 -,SUP-185425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,,,
WING BMT 360 TIBIAL SM CRUCIATE -,SUP-185650,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,AETNA [1000108],AETNA [100010801],,,76.8,,3233.79,9.170825,27238.33344,percent of total billed charges,,,
VANGUARD ANT STBLZD BRG 12X67 -,SUP-189042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,,,
BRIDGE VANGUARD ANT STBLZD 14 X 67 -,SUP-189044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,,,
BRIDGE ANT TIBIAL STABILIZED10 X 71MM VANGD -,SUP-189060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE HIP UNIV TRIDENT PRIM ADPTR +0MML NK OFST BIOLOX -,SUP-19-0000T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,9.170825,27238.33344,percent of total billed charges,,,
ADAPTER UNIV C-TAPER +5MM SLEE -,SUP-19-0005T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,9.170825,27238.33344,percent of total billed charges,,,
UNIVERSAL C-TAPER +2.5MM ADAPTER SLEEVE -,SUP-19-0025T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,9.170825,27238.33344,percent of total billed charges,,,
UNITED HIP SYSTEM ISCHIAL FLANGE -,SUP-1908-5401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6459.37,4521.559,AETNA [1000108],AETNA [100010801],,,76.8,,4960.8,9.170825,27238.33344,percent of total billed charges,,,
STEM ECHO POR FEMORAL LAT NC 28 X 44MM -,SUP-192114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
BOLT LOCKING CONICAL PROX BODY CEMENTLESS 24 X 95 -,SUP-1975-24-095,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17895.36,12526.752,AETNA [1000108],AETNA [100010801],,,76.8,,13743.64,9.170825,27238.33344,percent of total billed charges,,,
STEM DISTAL TAPERED 15 X 190 STRAIGHT -,SUP-1976-15-190,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15238.52,10666.964,AETNA [1000108],AETNA [100010801],,,76.8,,11703.18,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ7 FNDTN LT KN CR TI NPOR -,SUP-201-01-107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
G7 LONGEVITY NEUTRIAL 32MM C -,SUP-20103203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,,,
G7 LONGEVITY NEUTRIAL 32MM D -,SUP-20103204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3174.71,2222.297,AETNA [1000108],AETNA [100010801],,,76.8,,2438.18,9.170825,27238.33344,percent of total billed charges,,,
SHELL G7 LONGEVITY NEUTRIAL 32MM D -,SUP-20103204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,,,
G7 LONGEVITY NEUTRIAL 32MM E -,SUP-20103205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,,,
G7 LONGEVITY NEUTRAL 36MM D -,SUP-20103604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,,,
G7 LONGEVITY NEUTRAL 36MM E -,SUP-20103605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,,,
G7 LONGEVITY NEUTRAL 36MM F -,SUP-20103606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,,,
G7 LONGEVITY NEUTRAL 36MM G -,SUP-20103607,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,,,
G7 LONGEVITY NEUTRAL 40MM F -,SUP-20104006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,,,
G7 LONGEVITY NEUTRAL 40MM G -,SUP-20104007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 FNDTN RT KN CR TI NPOR -,SUP-202-01-105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ7 FNDTN RT KN CR TI NPOR -,SUP-202-01-107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 28X58-60MM SHL OMNIFIT 10DG CROSSFIRE 13.1MM -,SUP-2041C-2858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4587.76,3211.432,AETNA [1000108],AETNA [100010801],,,76.8,,3523.4,9.170825,27238.33344,percent of total billed charges,,,
INSERT OMNIFIT SERIES II 20 DEGREE 32MM -,SUP-2042-3250,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3800.96,2660.672,AETNA [1000108],AETNA [100010801],,,76.8,,2919.14,9.170825,27238.33344,percent of total billed charges,,,
JIG TOT JNT RT TIB KN PERSONA ROT -,SUP-20-8070-002-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
JIG TOT JNT LT KN PERSONA PREF -,SUP-20-8070-010-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
GW ORTHO TM PT SPEC INST -,SUP-20-8075-001-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 28X58MM OSTEONICS 0DG BIPLR PE 5.8-10.4MM THK -,SUP-2099-2858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9662.67,6763.869,AETNA [1000108],AETNA [100010801],,,76.8,,7420.93,9.170825,27238.33344,percent of total billed charges,,,
USTAR KNEE SYS FEMORAL COMPONENT HINGED #3 LEFT -,SUP-2115-1330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,AETNA [1000108],AETNA [100010801],,,76.8,,21672.04,9.170825,27238.33344,percent of total billed charges,,,
USTAR II KNEE SYSTEM FEMORAL COMPONENT HINGED #4 LEFT -,SUP-2115-1340,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,AETNA [1000108],AETNA [100010801],,,76.8,,21672.04,9.170825,27238.33344,percent of total billed charges,,,
USTAR KNEE FEMORAL COMPONENT HINGED #5 LEFT -,SUP-2115-1350,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,AETNA [1000108],AETNA [100010801],,,76.8,,21672.04,9.170825,27238.33344,percent of total billed charges,,,
UNITED II KNEE FEMORAL COMPONENT HINGED #6 HINGED -,SUP-2115-1360,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,AETNA [1000108],AETNA [100010801],,,76.8,,21672.04,9.170825,27238.33344,percent of total billed charges,,,
URSTAR II KNEE SYSTEM FEMORAL COMPONENT HINGED #3 RIGHT -,SUP-2115-1430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,AETNA [1000108],AETNA [100010801],,,76.8,,21672.04,9.170825,27238.33344,percent of total billed charges,,,
USTAR II KNEE FEMORAL COMPONENT HINGED #5 RIGHT -,SUP-2115-1450,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,AETNA [1000108],AETNA [100010801],,,76.8,,21672.04,9.170825,27238.33344,percent of total billed charges,,,
USTAR II KNEE DISTAL FEMORAL COMPONENT RHS S LEFT -,SUP-2115-3310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30242.39,21169.673,AETNA [1000108],AETNA [100010801],,,76.8,,23226.16,9.170825,27238.33344,percent of total billed charges,,,
USTAR II KNEE DISTAL FEMORAL COMP RHS S RIGHT -,SUP-2115-3410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30242.39,21169.673,AETNA [1000108],AETNA [100010801],,,76.8,,23226.16,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ4 FNDTN LT KN PS TI NPOR -,SUP-213-01-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ8 FNDTN LT KN PS TI NPOR -,SUP-213-01-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ8 FNDTN RT KN PS TI NPOR -,SUP-214-01-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ12 FNDTN RT KN PS TI NPOR -,SUP-214-01-012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
IMPLANT  CUSTOM PFR KINEMATCH -,SUP-22-100-1001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19864.55,13905.185,AETNA [1000108],AETNA [100010801],,,76.8,,15255.97,9.170825,27238.33344,percent of total billed charges,,,
USTAR II TIBIAL BASEPLATE HINGED #1 -,SUP-2215-1410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,AETNA [1000108],AETNA [100010801],,,76.8,,10356.96,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIBIAL USTAR II HINGED 2 KNEE -,SUP-2215-1420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,AETNA [1000108],AETNA [100010801],,,76.8,,10356.96,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIBIAL SYSTEM USTAR II HINGED 3 -,SUP-2215-1430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,AETNA [1000108],AETNA [100010801],,,76.8,,10356.96,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIBIAL USTAR II HINGED 4 KNEE -,SUP-2215-1440,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,AETNA [1000108],AETNA [100010801],,,76.8,,10356.96,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT TIBIAL USTAR II KNEE PROXIMAL RHS S -,SUP-2215-3410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,34950.47,24465.329,AETNA [1000108],AETNA [100010801],,,76.8,,26841.96,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL KNEE USTAR II XPE SMALL 12MM -,SUP-2315-3211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,AETNA [1000108],AETNA [100010801],,,76.8,,5234.58,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL USTAR II KNEE XPE S 14MM -,SUP-2315-3212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,AETNA [1000108],AETNA [100010801],,,76.8,,5234.58,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL USTAR II KNEE XPE S 17MM -,SUP-2315-3213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,AETNA [1000108],AETNA [100010801],,,76.8,,5234.58,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL USTAR II XPE H20 SMALL 20MM -,SUP-2315-3214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,AETNA [1000108],AETNA [100010801],,,76.8,,5234.58,9.170825,27238.33344,percent of total billed charges,,,
USTAR II KNEE XPE TIBIAL INSERT M 17MM -,SUP-2315-3243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,AETNA [1000108],AETNA [100010801],,,76.8,,5234.58,9.170825,27238.33344,percent of total billed charges,,,
USTAR II KNEE XPE TIBIAL INSERT M 20MM -,SUP-2315-3244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,AETNA [1000108],AETNA [100010801],,,76.8,,5234.58,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL USTAR II KNEW XPE M 23MM -,SUP-2315-3245,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,AETNA [1000108],AETNA [100010801],,,76.8,,5234.58,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT FEMORAL U2 PSA COCR 5 4MM POSTERIOR SET -,SUP-2603-5051,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5852.48,4096.736,AETNA [1000108],AETNA [100010801],,,76.8,,4494.7,9.170825,27238.33344,percent of total billed charges,,,
AGUMENT FEMORAL U2 TOTAL KNEE SET DISTAL #5 12MM -,SUP-2603-5353,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5852.48,4096.736,AETNA [1000108],AETNA [100010801],,,76.8,,4494.7,9.170825,27238.33344,percent of total billed charges,,,
HEADED PIN 17-4 PH S.S. -,SUP-262-0520A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,9.170825,27238.33344,percent of total billed charges,,,
PS Insert Trial Size 2  14mm -,SUP-263-1214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 40X17MM COCR -,SUP-265 108,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9253.24,6477.268,AETNA [1000108],AETNA [100010801],,,76.8,,7106.49,9.170825,27238.33344,percent of total billed charges,,,
U2 TOTAL KNEE STRAIGHT STEM PSA 14MM X 75MM -,SUP-2703-5013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,AETNA [1000108],AETNA [100010801],,,76.8,,7719.24,9.170825,27238.33344,percent of total billed charges,,,
STEM TIBIAL U2 PSA TI STRAIGHT 16MM X 75MM KNEE -,SUP-2703-5014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,AETNA [1000108],AETNA [100010801],,,76.8,,7719.24,9.170825,27238.33344,percent of total billed charges,,,
U2 TOTAL KNEE SYSTEM STRAIGHT STEM PSA 22MM DIA 75MM STEM -,SUP-2703-5017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,AETNA [1000108],AETNA [100010801],,,76.8,,7719.24,9.170825,27238.33344,percent of total billed charges,,,
U2 TOTAL  KNEE STRAIGHT STEM PSA 24MM DIA 75MM STEM LENGTH -,SUP-2703-5018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,AETNA [1000108],AETNA [100010801],,,76.8,,7719.24,9.170825,27238.33344,percent of total billed charges,,,
U2 TOTAL KNEE STRAIGHT STEM PSA 12MM DIA 100MM STEM LENGTH -,SUP-2703-5022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,AETNA [1000108],AETNA [100010801],,,76.8,,7719.24,9.170825,27238.33344,percent of total billed charges,,,
STEM TIBIAL U2 PSA STRAIGHT 20MM X 150MM TOTAL KNEE -,SUP-2703-5056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,AETNA [1000108],AETNA [100010801],,,76.8,,7719.24,9.170825,27238.33344,percent of total billed charges,,,
USTAR II KNEE CEMENTED STRT STEM RHS NON COAT 9 X 100 -,SUP-2715-3009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA [1000108],AETNA [100010801],,,76.8,,6046.17,9.170825,27238.33344,percent of total billed charges,,,
USTAR II KNEE SYS CEMENTED STR STEM RHS NON-COAT 11X100 -,SUP-2715-3011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA [1000108],AETNA [100010801],,,76.8,,6046.17,9.170825,27238.33344,percent of total billed charges,,,
USTAR II KNEE CEMENTED STRAIGHT STEM RHS NON COATED 13 X 100 -,SUP-2715-3013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA [1000108],AETNA [100010801],,,76.8,,6046.17,9.170825,27238.33344,percent of total billed charges,,,
USTAR II KNEE CEMENTED STRT STEM RHS NON COATED 15 X 100 -,SUP-2715-3015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA [1000108],AETNA [100010801],,,76.8,,6046.17,9.170825,27238.33344,percent of total billed charges,,,
USTAR II KNEE CEMENTED STRAIGHT STEM RHS NON COAT 17X100 -,SUP-2715-3017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA [1000108],AETNA [100010801],,,76.8,,6046.17,9.170825,27238.33344,percent of total billed charges,,,
CEMENTED STRAIGHT STEM RHS COLLARLESS 9 X 125MM -,SUP-2715-3109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA [1000108],AETNA [100010801],,,76.8,,6046.17,9.170825,27238.33344,percent of total billed charges,,,
USTAR II KNEE CEMENTED STRAIGHT STEM RHS NON COATED 11X125 -,SUP-2715-3111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA [1000108],AETNA [100010801],,,76.8,,6046.17,9.170825,27238.33344,percent of total billed charges,,,
USTAR CEMENTED STRAIGHT STEM RHS NON COATED 13 X 125MM -,SUP-2715-3113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA [1000108],AETNA [100010801],,,76.8,,6046.17,9.170825,27238.33344,percent of total billed charges,,,
KNEE SYSTEM CEMENTED STRAIGHT STEM RHS NON COATED 15 X 125MM -,SUP-2715-3115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA [1000108],AETNA [100010801],,,76.8,,6046.17,9.170825,27238.33344,percent of total billed charges,,,
USTAR II KEE CEMENTED TIBIAL STEM 9MM X 20MM STEM LENG -,SUP-2715-5109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA [1000108],AETNA [100010801],,,76.8,,6046.17,9.170825,27238.33344,percent of total billed charges,,,
USTAR II KNEE CEMENTED TIBIAL STEM 9MM X 45MM STEM -,SUP-2715-5209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA [1000108],AETNA [100010801],,,76.8,,6046.17,9.170825,27238.33344,percent of total billed charges,,,
STEM TIBIAL USTAR II 9MM X 95MM KNEE CEMENT -,SUP-2715-5409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA [1000108],AETNA [100010801],,,76.8,,6046.17,9.170825,27238.33344,percent of total billed charges,,,
USTAR II KNEE TIBIAL STEM 12.5MM X 70MM -,SUP-2715-7312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,AETNA [1000108],AETNA [100010801],,,76.8,,7719.24,9.170825,27238.33344,percent of total billed charges,,,
USTAR II KNEE TIBIAL AUGMENT #2 10MM THICK -,SUP-2815-1022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5215.88,3651.116,AETNA [1000108],AETNA [100010801],,,76.8,,4005.8,9.170825,27238.33344,percent of total billed charges,,,
USTAR SEGMENT PART RHS 50MM LENGTH -,SUP-2915-1050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22014.38,15410.066,AETNA [1000108],AETNA [100010801],,,76.8,,16907.04,9.170825,27238.33344,percent of total billed charges,,,
USTAR II KNEE SEGMENT PART RHS 70MM LENGTH -,SUP-2915-1070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22014.38,15410.066,AETNA [1000108],AETNA [100010801],,,76.8,,16907.04,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 11MM 8.5MM MDL OFST PRIM PRFT EQUINOXE 110MM TI ALY -,SUP-300-01-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA [1000108],AETNA [100010801],,,76.8,,8269.59,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 15MM 9.5MM MDL OFST PRIM PRFT EQUINOXE 120MM TI ALY -,SUP-300-01-15,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA [1000108],AETNA [100010801],,,76.8,,8269.59,9.170825,27238.33344,percent of total billed charges,,,
PLATE BN EQUINOXE F/RVRS SYS ANTMC REPLICATOR TI ALY 4.5MM -,SUP-300-10-45,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4686.87,3280.809,AETNA [1000108],AETNA [100010801],,,76.8,,3599.52,9.170825,27238.33344,percent of total billed charges,,,
LINER G7 VIT E NEUTRAL 36MM E -,SUP-30103605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
LINER G7 VIT E NEUTRAL 36MM F -,SUP-30103606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
G7 VIT E HIGH WALL LNR 36MM D -,SUP-30123604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
LINER G7 VIT E HIGH WALL 36MM F -,SUP-30123606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
LINER G7 VIT E HIGH WALL 40MM H -,SUP-30124008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
LINER G7 VIT E +5MM 40MM H -,SUP-30154008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8963.33,6274.331,AETNA [1000108],AETNA [100010801],,,76.8,,6883.84,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 47MM SHRT 18MM EQUINOXE 1.5MM OFST COCR -,SUP-310-01-47,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7808.96,5466.272,AETNA [1000108],AETNA [100010801],,,76.8,,5997.28,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 53MM SHRT EQUINOXE -,SUP-310-21-53,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6472.1,4530.47,AETNA [1000108],AETNA [100010801],,,76.8,,4970.57,9.170825,27238.33344,percent of total billed charges,,,
COMP B MED EQUINOXE SHLDR PG -,SUP-314-02-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4010.16,2807.112,AETNA [1000108],AETNA [100010801],,,76.8,,3079.8,9.170825,27238.33344,percent of total billed charges,,,
SPHERE GLND 38MM EQUINOXE RVRS -,SUP-320-01-38,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,9.170825,27238.33344,percent of total billed charges,,,
TRY ADAPTER HUM WDG +0MM RVRS BALL SCKT EQUINOXE -,SUP-320-10-00,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,AETNA [1000108],AETNA [100010801],,,76.8,,6453.6,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 10MM FNDTN MODULAR REVISN 100MM TIB KN -,SUP-320-10-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
LINER HUM 38MM STD EQUINOXE -,SUP-320-38-00,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4559.17,3191.419,AETNA [1000108],AETNA [100010801],,,76.8,,3501.44,9.170825,27238.33344,percent of total billed charges,,,
LINER HUM 38MM STD RVRS EQUINOXE -,SUP-320-38-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4559.17,3191.419,AETNA [1000108],AETNA [100010801],,,76.8,,3501.44,9.170825,27238.33344,percent of total billed charges,,,
BLOCK CUT SZ4 10MM RM/LL FNDTN KN REVISN F/SPCR -,SUP-321-101-04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ4 RT KN STM FNDTN REVISN MODULAR NPOR -,SUP-322-01-104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA [1000108],AETNA [100010801],,,76.8,,6844.72,9.170825,27238.33344,percent of total billed charges,,,
BLOCK CUT SZ4 5MM RL/LM FNDTN KN REVISN F/SPCR -,SUP-322-05-104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,9.170825,27238.33344,percent of total billed charges,,,
BLOCK CUT SZ4 10MM RL/LM FNDTN KN REVISN F/SPCR -,SUP-322-10-104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ2 10.9MM FNDTN PS ARTC CONGR KN COMPR MLD -,SUP-360-09-510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ2 11MM FNDTN PS ARTC CONGR KN COMPR MLD UHMWPE -,SUP-360-11-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ2 13MM FNDTN PS ARTC CONGR KN COMPR MLD UHMWPE -,SUP-360-13-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB 4MM AXSOS LCK -,SUP-370002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,240.4,168.28,AETNA [1000108],AETNA [100010801],,,76.8,,184.63,9.170825,27238.33344,percent of total billed charges,,,
INSERT ORTHO 14X8.5MM DIA FEM LCK 5MM HL AXSOS NS -,SUP-370003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,274.83,192.381,AETNA [1000108],AETNA [100010801],,,76.8,,211.07,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ2 13MM FNDTN CR PRIM CNSTRN ARTC CONGR L/R KN -,SUP-385-13-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,,,
CENTRALIZER DIST HIP TI ALY -,SUP-400-03-002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 36MM +4MM NK BIOLOX DELTA CERM -,SUP-400-03-363,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4487.56,3141.292,AETNA [1000108],AETNA [100010801],,,76.8,,3446.45,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM BIOLOX DELTA 40MM NEUT CERM -,SUP-400-03-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,9.170825,27238.33344,percent of total billed charges,,,
COMP REV SHLDER 9 IN STEINMANN -,SUP-405800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,9.170825,27238.33344,percent of total billed charges,,,
SEASPINE TULIP HEADS -,SUP-41-1000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE HIP NEUT OFST UNIPL ANG -,SUP-411-00-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 46MM UNIPL -,SUP-411-00-146,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,AETNA [1000108],AETNA [100010801],,,76.8,,1302.65,9.170825,27238.33344,percent of total billed charges,,,
PLUG SMALL DIA CEMENT 8MM -,SUP-414993,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA [1000108],AETNA [100010801],,,76.8,,976.99,9.170825,27238.33344,percent of total billed charges,,,
KT THR SZ3 FEM 3 TIB RT HIP TRUMATCH -,SUP-420859,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,AETNA [1000108],AETNA [100010801],,,76.8,,7473.78,9.170825,27238.33344,percent of total billed charges,,,
KT TKR LT HIPERF 3T/3F -,SUP-420878,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,AETNA [1000108],AETNA [100010801],,,76.8,,7473.78,9.170825,27238.33344,percent of total billed charges,,,
KT TKR RT HIPERF -,SUP-420890,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,AETNA [1000108],AETNA [100010801],,,76.8,,7473.78,9.170825,27238.33344,percent of total billed charges,,,
FEMUR PERSONA CEMENTED CCR NARROW SIZE 5 R -,SUP-42500005802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,,,
FEMUR PERSONA CEMENTED NARROW PS LT SZ 6 -,SUP-42500006001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,,,
FEMUR PERSONA CEMENTED CCR NARROW SIZE 8 R -,SUP-42-5000-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT PSN FEM PS CMT CCR SZ 7 R STD -,SUP-42-5006-062-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT PSN FEM PS CCR STD SIZE 10 L -,SUP-42500606801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ3 PERSONA RT KN CR CMNT COCR NRW -,SUP-42-5020-054-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ6 PERSONA LT KN CR CMNT COCR NRW -,SUP-42-5020-060-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ7 PERSONA LT KN CR CMNT COCR NRW -,SUP-42-5020-062-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ7 PERSONA RT KN CR CMNT COCR NRW -,SUP-42-5020-062-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,,,
FEMUR PERSONA CEMENTED CR NARROW RT SZ 9 -,SUP-42502006602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,,,
FEMUR PERSONA CEMENTED KNEE CR   RT SZ10 -,SUP-42-5020-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 PERSONA LT KN CR CMNT COCR POR NRW -,SUP-42-5022-058-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ6 PERSONA LT KN CR CMNT COCR POR NRW -,SUP-42-5022-060-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,9.170825,27238.33344,percent of total billed charges,,,
FEMUR FEMORAL CR POR CCR NRW SIZE 6 RIGHT PERSONA -,SUP-42-5022-060-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ7 PERSONA RT KN CR CMNT COCR POR NRW -,SUP-42-5022-062-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,9.170825,27238.33344,percent of total billed charges,,,
COMP PSN FEM SZ 10 R CR CCR POR NRW -,SUP-42-5022-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ6 LEFT PERSONA KN CR STD CMNT CCR -,SUP-42-5026-060-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,,,
PERSONA FEMUR CMNT STD CCR SIZE 7 RIGHT -,SUP-42502606202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ8 PERSONA LT KN CR STD CMNT COCR NRW -,SUP-42-5026-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ8 RIGHT PERSONA KN CR STD CMNT COCR -,SUP-42-5026-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ10 PERSONA RT KN CR STD CMNT COCR NRW -,SUP-42-5026-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,,,
PSN FEM CR POR CCR STD SZ7 L -,SUP-42-5028-062-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ8 PERSONA LT KN CR STD COCR POR -,SUP-42-5028-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ8 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ9 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-066-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,9.170825,27238.33344,percent of total billed charges,,,
PERSONA KNEE SYSTEM FEMUR -,SUP-42-5028-068-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ10 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ11 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-070-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ12 R PERSONA RT KN CCR STD COCR POR -,SUP-42-5028-074-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,9.170825,27238.33344,percent of total billed charges,,,
PSN REV FEM CMT CCR STD SZ 5 R -,SUP-42-5046-058-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,33973.95,23781.765,AETNA [1000108],AETNA [100010801],,,76.8,,26091.99,9.170825,27238.33344,percent of total billed charges,,,
PSN REV FEM CMT CCR STD SZ 9 L -,SUP-42-5046-066-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,31746.15,22222.305,AETNA [1000108],AETNA [100010801],,,76.8,,24381.04,9.170825,27238.33344,percent of total billed charges,,,
PSN ASF CR 12MM PLY L 3-11 EF -,SUP-42-5110-005-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ8 139MM LNR PRFT LAT OFST CLLRLS 47.4MM NK TI POR -,SUP-425-11-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA [1000108],AETNA [100010801],,,76.8,,6029.88,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ13 148.5MM LNR PRFT LAT OFST CLLRLS 49.8MM NK TI -,SUP-425-11-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA [1000108],AETNA [100010801],,,76.8,,6029.88,9.170825,27238.33344,percent of total billed charges,,,
SYS PERSONA KNEE ASF UC 18MM PLY L-4-11 EF -,SUP-42-5112-005-18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,,,
PERSONA KNEE SYSTEM ARTICULAR SURFACE -,SUP-42-5112-006-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ C-D/3-9 10MM PERSONA CR ARTCSURF LT KN PE -,SUP-42-5120-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ C-D/3-9 11MM PERSONA CR ARTCSURF LT KN PE -,SUP-42-5120-004-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ C-D/3-9 12MM PERSONA CR ARTCSURF LT KN PE -,SUP-42-5120-004-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ E-F SZ3-11 FEM 10MM PERSONA ARTCSURF LT KN PE -,SUP-42-5120-005-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
PSN ASF CR 12MM VE L 3-11EF -,SUP-42-5120-005-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
PERSONA ARTICULAR SURFACE LEFT 11MM -,SUP-42-5121-007-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
PSN MC VE ASF L 12MM 12/GH -,SUP-42-5121-010-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ C-D SZ3-7 FEM 12MM PERSONA CR ARTCSURF LT KN -,SUP-42-5122-004-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
SURFACE ARTICULAR PERSONA VIVACIT-E 3-7 UC C-D 10MM KNEE LFT -,SUP-42512200410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
PERSONA ARTICULAR FIXED BEARING LEFT 16MM -,SUP-42512200516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
PERSONA ARTICULAR SURFACE 10MM -,SUP-42-5122-006-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
ARTICULAR SURFACE PERSONA LT 16MM -,SUP-42512600516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
PSN ASF CPS 14MM VE L 6-9 GH -,SUP-42-5126-009-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
PSN PK VE PLY- LM- SZ E- 8MM -,SUP-42-5182-005-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ7 PERSONA LT KN CR STD COCR POR -,SUP-42-5208-062-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,9.170825,27238.33344,percent of total billed charges,,,
PSN FEMORALASF UC 10MM POLY R 4-11 EF -,SUP-42-5212-00-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,,,
BEARING FIXED ASF UC 12MM PLY 3-7CD PERSONA -,SUP-42-5212-004-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,,,
BEARING FIXED ASF UC 12MM PLY R 4-11 EF PERSONA -,SUP-42-5212-005-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,,,
BEARING PSN ASF UC 10MM PLY R 7-12 GH -,SUP-42521200610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,,,
PSN ASF UC 12MM PLY R 7-12 GH -,SUP-42-5212-006-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA [1000108],AETNA [100010801],,,76.8,,2474.84,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ C-D SZ3-9 FEM 10MM PERSONA CR ARTCSURF RT KN -,SUP-42-5220-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ C-D/3-9 11MM PERSONA CR ARTCSURF RT KN PE -,SUP-42-5220-004-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ E-F/3-11 11MM PERSONA CR ARTCSURF RT KN PE -,SUP-42-5220-005-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
SURFACE ARTICULAR 10MM HEIGHT RIGHT -,SUP-42-5221-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
ARTICULAR SURFACE PERSONA MC VE RT 13MM -,SUP-42522100513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
ARTICULAR SURFACE PERSONA MC RT 10MM -,SUP-42522100810,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
ARTICULAR SURFACE RIGHT 10MM /SIZES E-F/CR 8-11 -,SUP-42-5221-008-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
ARTICULAR SURFACE PERSONA MC RT 11MM -,SUP-42-5221-008-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
SURFACE ARTICULAR PERSONA RIGHT 10MM X 12/GH MC VE ASF -,SUP-42-5221-010-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ C-D/3-7 10MM PERSONA ARTCSURF UL CONG RT KN PE -,SUP-42-5222-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ E-F 10MM PERSONA UL CONG ARTCSURF RT KN PE -,SUP-42-5222-005-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
HIGHLY CROSSLINKED POLY ARTICULAR FIXED BEARING -,SUP-42-5222-005-18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
VIVICIT-E PERSONA ASF UC 11MM 7 - 12GH -,SUP-42-5222-006-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
CD PERSONA ASF PS 16MM VE R 3-5 -,SUP-42522400416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL PSN ASF PS 13MM VE R 6-9 CD -,SUP-42-5224-005-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
PSN ASF CPS 14MM VE R 3-5CD -,SUP-42-5226-004-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
PERSONA HIGHLY CROSSLINKED POLY 6-9EF VE R -,SUP-42-5226-007-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
PERSONA HIGHLY CROSSLINKED POLYETHLENE 6-9EF -,SUP-42-5226-007-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,AETNA [1000108],AETNA [100010801],,,76.8,,4155.72,9.170825,27238.33344,percent of total billed charges,,,
PSN REV CCK ART SURF VE 12MM R 7-9+ CD -,SUP-42522800512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,9.170825,27238.33344,percent of total billed charges,,,
COMP TIB SZ-C PERSONA PEGX2 LT KN POR TM -,SUP-42-5300-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,,,
COMP TIB SZ-D PERSONA PEGX2 RT KN POR TM -,SUP-42-5300-067-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,,,
PSN TIB POR 2 PEG SZ E L -,SUP-42-5300-071-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,,,
COMP TIB SZ-F PERSONA PEGX2 RT KN POR TM -,SUP-42-5300-075-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,,,
PSN TIB POR 2 PEG SZ G L -,SUP-42-5300-079-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,,,
PSN TIB POR 2 PEG SZ G R -,SUP-42530007902,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,,,
PSN TIB POR 2 PEG SZ H R -,SUP-42-5300-083-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,,,
STEM TIB SZ-C 5DG PERSONA LT KN -,SUP-42-5320-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
STEM PERSONA ASF 16MM VE 3-5 R CD -,SUP-42532006402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
STEM TIB SZ-C 5DG PERSONA RT KN -,SUP-42-5320-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
STEM TIB 5DG SZ-D PERSONA LT KN -,SUP-42-5320-067-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
STEM TIB SZ-D 5DG PERSONA RT KN -,SUP-42-5320-067-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
STEM TIB 5DG SZ-E PERSONA LT KN -,SUP-42-5320-071-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
TIBIA PERSONA CEMENTED STEMMED RT SZ E -,SUP-42532007102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
NAT TIBIA CEME 5 DG SIZE F -,SUP-42-5320-075-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
STEM TIB SZ-F 5DG PERSONA RT KN -,SUP-42-5320-075-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
PSN PK CMT TIB- LM- SZ E -,SUP-42-5380-005-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT PATELLAR PERSONA ALL POLY PAT PLY 41MM -,SUP-42540000041,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,9.170825,27238.33344,percent of total billed charges,,,
DIA ALL POLY PAT PERSONA  29MM -,SUP-42540200029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 29MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-29,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 32MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-32,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 35MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-35,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 41MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-41,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ8 SHRT TAPR FIL TI POR CTD P-SQUARED HIP -,SUP-425-41-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA [1000108],AETNA [100010801],,,76.8,,7328.57,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ15 SHRT TAPR FIL TI POR CTD P-SQUARED HIP -,SUP-425-41-015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA [1000108],AETNA [100010801],,,76.8,,7328.57,9.170825,27238.33344,percent of total billed charges,,,
KEEL PSN REV TIB FIXED CMT SIZE C R -,SUP-42-5420-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11361.78,7953.246,AETNA [1000108],AETNA [100010801],,,76.8,,8725.85,9.170825,27238.33344,percent of total billed charges,,,
PSN REV TIB FIXED KEEL CMT SZ G L -,SUP-42-5420-079-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11361.78,7953.246,AETNA [1000108],AETNA [100010801],,,76.8,,8725.85,9.170825,27238.33344,percent of total billed charges,,,
AUG PSN REV FEM DISTAL SZ 5 5MM -,SUP-42-5566-058-05,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5602.08,3921.456,AETNA [1000108],AETNA [100010801],,,76.8,,4302.4,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTENSION PERSONA CEMETED TPRD 14MM X +30MM -,SUP-42557000114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,,,
PSN PK CMT FEM- LM- SZ 3 -,SUP-42-5580-003-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,AETNA [1000108],AETNA [100010801],,,76.8,,6192.84,9.170825,27238.33344,percent of total billed charges,,,
PSN PK CMT FEM- RM SZ.4 -,SUP-42558000402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,AETNA [1000108],AETNA [100010801],,,76.8,,6192.84,9.170825,27238.33344,percent of total billed charges,,,
PSN REV TAPERED SMOOTH STEM EXT 14 X 75MM -,SUP-42-5600-075-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8199.41,5739.587,AETNA [1000108],AETNA [100010801],,,76.8,,6297.15,9.170825,27238.33344,percent of total billed charges,,,
STEM PSN REV 6MM OFFSET EXT 10MM X 135MM -,SUP-42-5606-135-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11584.56,8109.192,AETNA [1000108],AETNA [100010801],,,76.8,,8896.94,9.170825,27238.33344,percent of total billed charges,,,
FEMUR PSN CR CMT TIN NRW SIZE 6R -,SUP-42-5720-060-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,AETNA [1000108],AETNA [100010801],,,76.8,,9980.54,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT FEMORAL PERSONA 7 KNEE -,SUP-42572606201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,AETNA [1000108],AETNA [100010801],,,76.8,,9980.54,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT PSN FEMORAL TIN STD SIZE 9L -,SUP-42-5726-066-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,AETNA [1000108],AETNA [100010801],,,76.8,,9980.54,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ8 109MM TAPR FIL PRFT LAT OFST 37MM NK TI POR CTD -,SUP-425-96-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA [1000108],AETNA [100010801],,,76.8,,7328.57,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ8 109MM TAPR FIL PRFT LAT OFST 42.5MM NK TI POR -,SUP-425-97-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA [1000108],AETNA [100010801],,,76.8,,7328.57,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ9 111MM TAPR FIL PRFT LAT OFST 42.5MM NK TI POR -,SUP-425-97-009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA [1000108],AETNA [100010801],,,76.8,,7328.57,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ12 LRG TAPR FIL PRFT LAT OFST TI POR COAT -,SUP-425-97-012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA [1000108],AETNA [100010801],,,76.8,,7328.57,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ13 117MM TAPR FIL PRFT LAT OFST 42.5MM NK TI POR -,SUP-425-97-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA [1000108],AETNA [100010801],,,76.8,,7328.57,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 13MM STD BGLNI/FLTW 130MM -,SUP-4300-13-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5470.69,3829.483,AETNA [1000108],AETNA [100010801],,,76.8,,4201.49,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 46X21MM BGLNI/FLTW ZML MODULAR OFST -,SUP-4302-46-21,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 48MM POR STRUCTURED TECH HMSPHR -,SUP-430-98-048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,AETNA [1000108],AETNA [100010801],,,76.8,,3520.14,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM STAGEONE SLCT 56MM SIL MODULAR SPCR STRL -,SUP-431183,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5199.96,3639.972,AETNA [1000108],AETNA [100010801],,,76.8,,3993.57,9.170825,27238.33344,percent of total billed charges,,,
ADAPTER STD STAGEONE CMNT MLD SPCR -,SUP-431186,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1636.53,1145.571,AETNA [1000108],AETNA [100010801],,,76.8,,1256.86,9.170825,27238.33344,percent of total billed charges,,,
HIP ADAPTER STD STAGEONE 6MM -,SUP-431188,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1428.48,999.936,AETNA [1000108],AETNA [100010801],,,76.8,,1097.07,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 15X155MM STG 1 HIP -,SUP-431193,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6510.3,4557.21,AETNA [1000108],AETNA [100010801],,,76.8,,4999.91,9.170825,27238.33344,percent of total billed charges,,,
HIP MOLD STEM W/REINF 13 X 200 -,SUP-431197,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6510.3,4557.21,AETNA [1000108],AETNA [100010801],,,76.8,,4999.91,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 12MM FNDTN CLLR FRG COCR CMNT 132DG ANG TAPR HIP -,SUP-450-01-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,9.170825,27238.33344,percent of total billed charges,,,
HEAD RADL 26MM 10.5MM EVOLVE PROLINE COCR MODULAR -,SUP-496H026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7999.94,5599.958,AETNA [1000108],AETNA [100010801],,,76.8,,6143.95,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 28MM SHRT -3.5MM NK COCR MODULAR -,SUP-497-28-035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ-G 62MM RIM TRIDENT PRIM MODULAR HAP CTD -,SUP-500-01-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ-C 48MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-48C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ-D 50MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ-D 52MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-52D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ-E 54MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ-E 56MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-56E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ-F 58MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,,,
SHELL SOLID BACK 60MM F -,SUP-500-03-60F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 48MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-5001-48,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,76.8,,915.92,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ-C 46MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-01-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ-C 48MM RIM TRIDENT PRIM MODULAR CLUS-HL. -,SUP-502-03-48C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 50MM TRIDENT PRIM MODULAR CLUS-HL X3 TRTNM LCK -,SUP-502-03-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ-D 52MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-03-52D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,,,
SHELL HEMISPHERICAL 54MM SZ-E RIM CLUSTER HOLE -,SUP-502-03-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ-E 56MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-03-56E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ-D 50MM RIM TRIDENT PRIM.MODULAR CLUS-HL -,SUP-502-03-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ-F 60MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-03-60F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ-D 50MM RIM TRIDENT PRIM MODULAR.CLUS-HL -,SUP-502-11-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,,,
ANATOMIC HEMISPHERICAL SHELL  56MM D RT -,SUP-504-02-56D-R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12514.18,8759.926,AETNA [1000108],AETNA [100010801],,,76.8,,9610.89,9.170825,27238.33344,percent of total billed charges,,,
HEMISPHERICAL SHELL ANATOMIC RESTORATION -,SUP-504-02-58D-L,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12514.18,8759.926,AETNA [1000108],AETNA [100010801],,,76.8,,9610.89,9.170825,27238.33344,percent of total billed charges,,,
HEMISPHERICAL SHELL 64MM -,SUP-504-02-64E-R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12514.18,8759.926,AETNA [1000108],AETNA [100010801],,,76.8,,9610.89,9.170825,27238.33344,percent of total billed charges,,,
INSERT HUM 4MM 32MM STD PE RVRS SCKT F/RSP STRL -,SUP-508-00-432,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4559.17,3191.419,AETNA [1000108],AETNA [100010801],,,76.8,,3501.44,9.170825,27238.33344,percent of total billed charges,,,
SHELL TRIDENT HEMISPHERICAL ACETABULAR 46MM C -,SUP-508-11-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,,,
SHELL HEMI ACETABULAR 48MM -,SUP-508-11-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ-D 50MM RIM TRIDENT PRIM MODULAR MUL-HL -,SUP-508-11-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,,,
ACETABULAR SHELL 52MM -,SUP-508-11-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ-E 54MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,AETNA [1000108],AETNA [100010801],,,76.8,,7746.62,9.170825,27238.33344,percent of total billed charges,,,
SHELL HEMISPHERICAL 56MM E TRI -,SUP-509-02-56E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,AETNA [1000108],AETNA [100010801],,,76.8,,7746.62,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ-F 58MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,AETNA [1000108],AETNA [100010801],,,76.8,,7746.62,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ-F 60MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-60F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,AETNA [1000108],AETNA [100010801],,,76.8,,7746.62,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ-G 62MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,AETNA [1000108],AETNA [100010801],,,76.8,,7746.62,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ-G 64MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-64G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,AETNA [1000108],AETNA [100010801],,,76.8,,7746.62,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ H LINER 66MM RIM TRIDENT REVISN MUL-HL -,SUP-509-02-66H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,AETNA [1000108],AETNA [100010801],,,76.8,,7746.62,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ H LINER 68MM RIM TRIDENT REVISN MUL-HL -,SUP-509-02-68H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,AETNA [1000108],AETNA [100010801],,,76.8,,7746.62,9.170825,27238.33344,percent of total billed charges,,,
TRIDENT TRITANIUM HEMI SHELL SZ 70MM -,SUP-509-02-70I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,AETNA [1000108],AETNA [100010801],,,76.8,,7746.62,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT ACTB 50MM RESTOR REVISN RECON HIP 15MM -,SUP-5096-5015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,AETNA [1000108],AETNA [100010801],,,76.8,,6346.72,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT ACTB 50MM RESTOR REVISN RECON HIP 20MM -,SUP-5096-5020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,AETNA [1000108],AETNA [100010801],,,76.8,,6346.72,9.170825,27238.33344,percent of total billed charges,,,
WEDGE AUGMENT RESTORATION ACET 54MM X 56MM X 15MM -,SUP-5096-5415,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,AETNA [1000108],AETNA [100010801],,,76.8,,6346.72,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT ACTB 58MM RESTOR REVISN RECON HIP -,SUP-5096-5815,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,AETNA [1000108],AETNA [100010801],,,76.8,,6346.72,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 6MM PRIM MBLK RVRS RSP 101MM CMNT 150DG ANG NK CYL -,SUP-510-00-006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19030.28,13321.196,AETNA [1000108],AETNA [100010801],,,76.8,,14615.26,9.170825,27238.33344,percent of total billed charges,,,
STEM TPRLC 133 FP TYPE 1 PPS SO 5.0 -,SUP-51-100050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
STEM TPRLC 133 FP TYPE 1 PPS SO 6.0 -,SUP-51-100060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
STEM TPRLC 133 FP TYPE1 PPS SO 7.0 -,SUP-51-100070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
STEM TPRLC 133 FP TYPE1 PPS SO 8.0 -,SUP-51-100080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
STEM FEMORAL TPRLC 133 FP PPS TYPE 1  6.0 H -,SUP-51-101060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
STEM TPRLC 133 FP PPS TYPE 1 HO 7.0 -,SUP-51-101070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
STEM TPRLC 133 FP PPS TYPE 1 HO 8.0 -,SUP-51-101080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
TPRLC XR FP TYPE 1 PPS 5 X 130MM -,SUP-51-102050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
TPRLC XR FP TYPE 1 PPS 6 X 132MM -,SUP-51-102060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
TPRLC XR FP TYPE 1 PPS 8 X 136MM -,SUP-51-102080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
STEM TPRLC 133 TYPE 1 PPS SO 9 X 137MM -,SUP-51-103090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
STEM TPRLC 133 TYPE 1 PPS SO 10 X 140MM -,SUP-51-103100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
STEM TPRLC 133 TYPE 1 PPS SO 11 X 142MM -,SUP-51-103110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
STEM TPRLC 133 T1 PPS SO 12 X 144MM -,SUP-51-103120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
STEM TPRLC 133 T1 PPS SO 13 X 146MM -,SUP-51-103130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
STEM TPRLC 133 T1 PPS SO 14 X 148MM -,SUP-51-103140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
STEM TPRLC 133 TYPE 1 PPS SO 15 X 150MM -,SUP-51-103150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
TAPERLOC 133 T1 9 X 137MM -,SUP-51-104090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
TPRLC 133 T1 PPS 11 X 142MM -,SUP-51-104110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
TPRLC 133 T1 PPS HO 13 X 146MM -,SUP-51-104130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
TPRLC TYPE 1 PPS HO 14 X 148MM FEM POR -,SUP-51-104140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
TPRLC TYPE 1 PPS HO 15 X 150MM FEM POR -,SUP-51-104150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
TPRLC 133 TYPE 1 PPS HO 16 X 152MM -,SUP-51-104160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
STEM TAPERLOC 133 T1 PPS HO 20 X 160MM -,SUP-51-104200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
STEM TAPERLOC 10 X 140MM COMP XR FEM POR T1 TAPER -,SUP-51-105100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
STEM TAPERLOC 11 X 142MM COMP XR 123 FEM POR T1 TAPER -,SUP-51-105110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
TPRLC 133 MP TYPE 1 PPS SO 11.0 -,SUP-51-106110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
TPRLC 133 MP TYPE1 PPS HO 9.0 -,SUP-51-107090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
TPRLC 133 MP TYPE1 PPS HO 14.0 -,SUP-51-107140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
TPRLC 133 MP TYPE1 PPS HO 16.0 -,SUP-51-107160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
TPRLC 133 MP TYPE1 PPS HO 17.0 -,SUP-51-107170,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
TPRL 133 MP TYPE1 PPS SO 4.0 -,SUP-51-108040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
TPRLC 133 MP T1 PPS SO 5X95MM -,SUP-51-108050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
TPRLC133 MP 6X97.5MM -,SUP-51-108060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
TPRLC 133 MP T1 PPS SO 8X101MM -,SUP-51-108080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
TLOC 133 MP SP T1 PPSHO 6X97.5 -,SUP-51-109060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
TLOC 133 MP SP T1 PPS HO 8X101 -,SUP-51-109080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA [1000108],AETNA [100010801],,,76.8,,6355.81,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM S-ROM 28MMSTDX+6MM NK COCR 11/13 TAPR MODULAR -,SUP-52-2029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4824.58,3377.206,AETNA [1000108],AETNA [100010801],,,76.8,,3705.28,9.170825,27238.33344,percent of total billed charges,,,
SCREW 2.3X12MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23212E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA [1000108],AETNA [100010801],,,76.8,,263.09,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 45X15MM -,SUP-5350-4515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6472.1,4530.47,AETNA [1000108],AETNA [100010801],,,76.8,,4970.57,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 12MM SOLAR 130MM TI SHLDR -,SUP-5351-4108,CDM,C1776,HCPCS,278,RC,,,outpatient,,,33064.27,23144.989,AETNA [1000108],AETNA [100010801],,,76.8,,25393.36,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 40X15MM OFST -,SUP-5352-4015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6472.1,4530.47,AETNA [1000108],AETNA [100010801],,,76.8,,4970.57,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ-D 46MM 47.8MM RIM TRIDENT PSL PRIM MODULAR HAP -,SUP-540-11-46D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ1 TRIATH LT KN CR CMNT -,SUP-5510-F-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ1 TRIATH RT KN CR CMNT -,SUP-5510-F-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ2 TRIATH LT KN CR CMNT -,SUP-5510-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ2 TRIATH RT KN CR CMNT -,SUP-5510-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ3 TRIATH LT KN CR CMNT -,SUP-5510-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ3 TRIATH RT KN CR CMNT -,SUP-5510-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ4 TRIATH LT KN CR CMNT -,SUP-5510-F-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ4 TRIATH RT KN CR CMNT -,SUP-5510-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 TRIATH LT KN CR CMNT -,SUP-5510-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 TRIATH RT KN CR CMNT -,SUP-5510-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ6 TRIATH LT KN CR CMNT -,SUP-5510-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ6 TRIATH RT KN CR CMNT -,SUP-5510-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ7 TRIATH LT KN CR CMNT -,SUP-5510-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ7 TRIATH RT KN CR CMNT -,SUP-5510-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ8 TRIATH LT KN CR CMNT -,SUP-5510-F-801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ1 59/53MM TRIATH RT KN TOTAL STABILIZED REVISN -,SUP-5512-F-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA [1000108],AETNA [100010801],,,76.8,,16247.78,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ2 62/56MM TRIATH LT KN TOTAL STABILIZED REVISN -,SUP-5512-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA [1000108],AETNA [100010801],,,76.8,,16247.78,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT FEMORAL TOTAL STABILIZER #2 RT TS -,SUP-5512-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA [1000108],AETNA [100010801],,,76.8,,16247.78,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ3 65/59MM TRIATH LT KN CRCTE STAB REVISN COCR -,SUP-5512-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA [1000108],AETNA [100010801],,,76.8,,16247.78,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ3 65/59MM TRIATH RT KN CRCTE STAB REVISN COCR -,SUP-5512-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA [1000108],AETNA [100010801],,,76.8,,16247.78,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ4 68/62MM TRIATH LT KN CRCTE STAB REVISN COCR -,SUP-5512-F-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA [1000108],AETNA [100010801],,,76.8,,16247.78,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ4 68/62MM TRIATH RT KN CRCTE STAB REVISN COCR -,SUP-5512-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA [1000108],AETNA [100010801],,,76.8,,16247.78,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 71/65MM TRIATH LT KN CRCTE STAB REVISN COCR -,SUP-5512-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA [1000108],AETNA [100010801],,,76.8,,16247.78,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 71/65MM TRIATH RT KN CRCTE STAB REVISN COCR -,SUP-5512-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA [1000108],AETNA [100010801],,,76.8,,16247.78,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ6 74/68MM TRIATH LT KN TOTAL STABILIZED REVISN -,SUP-5512-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA [1000108],AETNA [100010801],,,76.8,,16247.78,9.170825,27238.33344,percent of total billed charges,,,
TOTAL STABILIZER COMPONET FEMORAL -,SUP-5512-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA [1000108],AETNA [100010801],,,76.8,,16247.78,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ7 77/71MM TRIATH LT KN TOTAL STABILIZED REVISN -,SUP-5512-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA [1000108],AETNA [100010801],,,76.8,,16247.78,9.170825,27238.33344,percent of total billed charges,,,
STABILIZER TOTAL FEM COMP SZ 7 RIGHT TS TRIATHLON -,SUP-5512-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA [1000108],AETNA [100010801],,,76.8,,16247.78,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ8 80/75MM TRIATH RT KN TOTAL STABILIZED REVISN -,SUP-5512-F-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA [1000108],AETNA [100010801],,,76.8,,16247.78,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ1 TRIATH LT KN PS CMNT -,SUP-5515-F-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ2 TRIATH LT KN PS CMNT -,SUP-5515-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ2 TRIATH RT KN PS CMNT -,SUP-5515-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ3 TRIATH LT KN PS CMNT -,SUP-5515-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ3 TRIATH RT KN PS CMNT -,SUP-5515-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ4 TRIATH RT KN PS CMNT -,SUP-5515-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 TRIATH LT KN PS CMNT -,SUP-5515-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 TRIATH RT KN PS CMNT -,SUP-5515-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ6 TRIATH LT KN PS CMNT -,SUP-5515-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ6 TRIATH RT KN PS CMNT -,SUP-5515-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ7 TRIATH LT KN PS CMNT -,SUP-5515-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ7 TRIATH RT KN PS CMNT -,SUP-5515-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,,,
TRIATHLON PS FEM COMP SZ 8 CEMENTED -,SUP-5515-F-801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ8 TRIATH RT KN PS CMNT -,SUP-5515-F-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,9.170825,27238.33344,percent of total billed charges,,,
POSTERIOR STABILIZED FEMORAL -,SUP-5516-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
TRIATHLON CRUCLATE RETAINING FEMORAL SZ #1 LEFT CR -,SUP-5517-F-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
TRIATHLON CRUCLATE RETAINING FEMORAL SZ #1 RIGHT CR -,SUP-5517-F-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
TRIATHLON CR FEM COMPONENT - BEADED W/PA -,SUP-5517-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ2 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ3 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ3 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ4 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ4 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ6 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ6 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ7 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ7 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ8 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
TRIATHLON CRUCIATE RETAINING FEMORAL -,SUP-5517-F-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ1 KN CMNT TRIATH PRIM -,SUP-5520-B-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ2 KN CMNT TRIATH PRIM -,SUP-5520-B-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ3 KN CMNT TRIATH PRIM -,SUP-5520-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ4 KN CMNT TRIATH PRIM -,SUP-5520-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ5 KN CMNT TRIATH PRIM -,SUP-5520-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ6 KN CMNT TRIATH PRIM -,SUP-5520-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ7 KN CMNT TRIATH PRIM -,SUP-5520-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ8 KN CMNT TRIATH PRIM -,SUP-5520-B-800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ1 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ2 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ3 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL BASEPLATE TRIATHLON UNIV SIZE 4 -,SUP-5521-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ5 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ6 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ7 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ8 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ3 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ4 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ5 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ6 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ7 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ1 9MM TRIATH CR ARTC KN X3 -,SUP-5530-G-109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ1 11MM TRIATH CR ARTC KN X3 -,SUP-5530-G-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ1 13MM TRIATH CR ARTC KN X3 -,SUP-5530-G-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ1 16MM TRIATH CR ARTC KN X3 -,SUP-5530-G-116,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ1 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-119,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL BEARING INSERT CR SZ2 9MM -,SUP-5530-G-209-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ2 13MM TRIATH CR ARTC KN X3 -,SUP-5530-G-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ2 16MM TRIATH CR ARTC KN X3 -,SUP-5530-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ2 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL BEARING SZ 3 X 10MM CR X3 TRIATHLON -,SUP-5530-G-310-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL BEARING CR SZ4 9MM -,SUP-5530-G-409-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL BEARING CR SZ4 10MM TRIATHLON X3 -,SUP-5530-G-410-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL BEARING INSERT CR SZ4 11MM -,SUP-5530-G-411-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ4 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5 10MM TRIATH CR ARTCSURF KN X3 UHMWPE -,SUP-5530-G-510-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-519,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL BEARING SZ6 10MM TRIATH X3 CR -,SUP-5530-G-610-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ6 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBAL BEARING CR SZ 7 X 9MM TRIATHLON X3 -,SUP-5530-G-709-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBAL BEARING CR SZ 7 X 10MM TRIATHLON X3 -,SUP-5530-G-710-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ7 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ8 13MM TRIATH CR ARTC KN X3 -,SUP-5530-G-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ8 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-819,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
TRIATHALON INSERT CS #1 12MM X3 -,SUP-5531-G-112-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ2 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-209-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL BEARING CS SZ 2 X 10MM TRIATHLON X3 -,SUP-5531-G-210-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ2 11MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT BEARING TIBIAL CS SIZE 2 X 11MM TRIATHLON X3 -,SUP-5531-G-211-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL BEARING CS SZ 2 X 12MM TRIATHLON X3 -,SUP-5531-G-212-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ2 13MM TRIATH CS BEAR KN X3 -,SUP-5531-G-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TRIATHLON X3 TIBIAL BEARING SIZE 2 X 13MM CS -,SUP-5531-G-213-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ2 16MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-309-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 11MM TRIATH CS BEAR KN X3 -,SUP-5531-G-311-A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL BEARING INSERT  SZ.3 / CS / 12MM -,SUP-5531-G-312-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 13MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL BEARING CS SIZE 3 X 13MM TRIATHLON X3 -,SUP-5531-G-313-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 16MM TRIATH CS ARTCSURF KN X3 UHMWPE -,SUP-5531-G-316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 19MM TRIATH ARTCSURF KN X3 UHMWPE -,SUP-5531-G-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ4 9MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-409-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ4 11MM TRIATH CS BEAR X3 -,SUP-5531-G-411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ4 11MM TRIATH CS BEAR KN X3 -,SUP-5531-G-411-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ4 13MM TRIATH CS BEAR KN X3 -,SUP-5531-G-413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT BEARING TIBIAL CS SIZE 4 X 13MM TRIATHLON X3 -,SUP-5531-G-413-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ4 16MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ4 19MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL BEARING SZ 5 CS 9MM TRIATHLON X3 -,SUP-5531-G-509-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL BEARING INSERT  SZ. 5 / 10MM -,SUP-5531-G-510-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5 11MM TRIATH CS BEAR KN X3 -,SUP-5531-G-511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TRIATHLON X3 TIBIAL BEARING CS -,SUP-5531-G-512-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5 13MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
X3 TRIATHILON CS INS SIZE 5 13MM -,SUP-5531-G-513-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5 16MM TRIATH CS BEAR KN X3 -,SUP-5531-G-516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL BEARING CS SIZE 5 X 19MM TRIATHLON X3 -,SUP-5531-G-519-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ6 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-609-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ6 11MM TRIATH CONDL STAB BEAR KN -,SUP-5531-G-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ6 11MM TRIATH CONDL STAB BEAR CS X3 -,SUP-5531-G-611-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ6 13MM TRIATH CS BEAR KN X3 -,SUP-5531-G-613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ6 13MM TRIATH X3 CS BEAR X3 -,SUP-5531-G-613-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ6 16MM TRIATH ARTCSURF KN X3 UHMWPE -,SUP-5531-G-616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ6 19MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ7 9MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-709-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ7 11MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ7 13MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-713,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ7 16MM TRIATH CS BEAR KN X3 -,SUP-5531-G-716,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL TRIATHLON X3 SZ 7 16MM BEARING INSERT-CS -,SUP-5531-G-716-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ8 9MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
TRIATHLON TIBIAL BEARING INSERT - CS SZ8 11MM -,SUP-5531-G-811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ1 13MM TRIATH PS ARTC KN X3 -,SUP-5532-G-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ2 9MM TRIATH PS ARTC KN X3 -,SUP-5532-G-209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
TRIATHLON PS X3 TIBIAL INSERT -,SUP-5532-G-209-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ2 11MM TRIATH PS ARTCSURF KN X3 UHMWPE -,SUP-5532-G-211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB H TRTHLN PS 2-13MM -,SUP-5532-G-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ2 16MM TRIATH PS ARTC KN X3 -,SUP-5532-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ2 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL BEARING PS SZ 3 X 16MM TRIATHLON X3 -,SUP-5532-G-316-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL BEARING PS SZ 4 X 11MM TRIATHLON X3 -,SUP-5532-G-411-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ4 16MM TRIATH PS ARTCSURF KN X3 UHMWPE -,SUP-5532-G-416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ4 19MM TRIATH PS ARTC KN X3 -,SUP-5532-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ4 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5 22MM TRIATH PS ARTC KN X3 -,SUP-5532-G-522,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-525,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL BEARING INSERT TRI - PS SZ.6 / 9MM -,SUP-5532-G-609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ6 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-625,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ7 9MM TRIATH PS ARTC KN X3 -,SUP-5532-G-709,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ7 16MM TRIATH PS ARTC KN X3 -,SUP-5532-G-716,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL BEARING / SZ. 7  / 19MM -,SUP-5532-G-719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ7 22MM TRIATH PS ARTC KN X3 -,SUP-5532-G-722,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ7 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-725,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ8 9MM TRIATH PS ARTC KN X3 -,SUP-5532-G-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
TRIATHLON PS X3 TIBIAL INSERT SZ 8 -,SUP-5532-G-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT TIBIAL SIZE 2 X 16MM PS TRIATHLON ALL POLY -,SUP-5535-A-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA [1000108],AETNA [100010801],,,76.8,,4726.12,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT TIBIAL SIZE 5 X 9MM PS TRIATHLON ALL POLY -,SUP-5535-A-509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA [1000108],AETNA [100010801],,,76.8,,4726.12,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT TRIATHLON ALL POLY TIBIAL PS SIZE 5 13MM -,SUP-5535-A-513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA [1000108],AETNA [100010801],,,76.8,,4726.12,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT TRIATHLON ALL POLY TIBIAL PS SIZE 6 16MM -,SUP-5535-A-616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA [1000108],AETNA [100010801],,,76.8,,4726.12,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL COMPONENT TRITANIUM #2 -,SUP-5536-B-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA [1000108],AETNA [100010801],,,76.8,,4726.12,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ3 KN TRIATH TRTNM -,SUP-5536-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA [1000108],AETNA [100010801],,,76.8,,4726.12,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ4 KN TRIATH TRTNM -,SUP-5536-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA [1000108],AETNA [100010801],,,76.8,,4726.12,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ5 KN TRIATH TRTNM -,SUP-5536-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA [1000108],AETNA [100010801],,,76.8,,4726.12,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ6 KN TRIATH TRTNM -,SUP-5536-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA [1000108],AETNA [100010801],,,76.8,,4726.12,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ7 KN TRIATH TRTNM -,SUP-5536-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA [1000108],AETNA [100010801],,,76.8,,4726.12,9.170825,27238.33344,percent of total billed charges,,,
TRIATHLON TIBIAL COMPONENT -,SUP-5536-B-800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA [1000108],AETNA [100010801],,,76.8,,4726.12,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ1 19MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-119,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ2 11MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ2 10MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT TOTAL STABILIZER #2 19MM TS -,SUP-5537-G-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ2 22MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,,,
NO 3 TRIATHLON TS PLUS TIBIAL INSERT X3 POLY -,SUP-5537-G-309-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 19MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 22MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 25MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,,,
TOTAL STABILIZER+ TIBIAL INSERT -,SUP-5537-G-409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL TOTAL STABILIZER + SIZE 4 X 9MM TS TRIATH X3 -,SUP-5537-G-409-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT TRIATHLON X3 TOTAL STABILIZER SIZE F 11MM TS -,SUP-5537-G-411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ4 13MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ4 16MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,,,
NO 4 TRIATHLON TS PLUS TIBIAL INSERT X3 POLY 16MM -,SUP-5537-G-416-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ4 19MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ4 22MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ4 25MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ4 28MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL TOTAL STAB SIZE 5 X 16MM TS TRIATHLON X3 -,SUP-5537-G-516-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL TOTAL STABILIZER+ SIZE 5 X 19MM TRIATHLON X3 -,SUP-5537-G-519-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5 22MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-522,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5 28MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-528,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5 31MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-531,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ6 9MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ6 11MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ6 16MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ6 19MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ6 25MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-625,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,,,
TOTAL STABILIZER TIBIAL INSERT SZ7 -,SUP-5537-G-711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ7 16MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-716,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ8 22MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-822,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT RT DIST KN SZ1 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,AETNA [1000108],AETNA [100010801],,,76.8,,3592.92,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT LT DIST KN SZ2 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,AETNA [1000108],AETNA [100010801],,,76.8,,3592.92,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL DISTAL AUGMENT - RIGHT -,SUP-5540-A-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,AETNA [1000108],AETNA [100010801],,,76.8,,3592.92,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT LT DIST KN SZ4 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,AETNA [1000108],AETNA [100010801],,,76.8,,3592.92,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT RT DIST KN SZ4 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,AETNA [1000108],AETNA [100010801],,,76.8,,3592.92,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL DISTAL AUGMENT - RIGHT -,SUP-5540-A-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,AETNA [1000108],AETNA [100010801],,,76.8,,3592.92,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT RT DIST KN SZ8 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,AETNA [1000108],AETNA [100010801],,,76.8,,3592.92,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL DISTAL AUGMENT RIGHT #2 10MM -,SUP-5541-A-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA [1000108],AETNA [100010801],,,76.8,,3354.89,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT FEMORAL DISTAL LEFT TRIATHLON SIZE 3 10MM -,SUP-5541-A-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA [1000108],AETNA [100010801],,,76.8,,3354.89,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT LT DIST KN SZ4 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5541-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA [1000108],AETNA [100010801],,,76.8,,3354.89,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT LT DIST KN SZ5 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5541-A-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA [1000108],AETNA [100010801],,,76.8,,3354.89,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT FEMORAL DISTAL RIGHT SZ 7 X 5MM TRIATHLON -,SUP-5541-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA [1000108],AETNA [100010801],,,76.8,,3354.89,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT FEMORAL DISTAL RIGHT SZ 7 X 10MM TRIATHLON -,SUP-5541-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA [1000108],AETNA [100010801],,,76.8,,3354.89,9.170825,27238.33344,percent of total billed charges,,,
TRIATHLON FEMORAL DISTAL SUGMENT 15MM SIZE 4 LEFT -,SUP-5542-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4581.78,3207.246,AETNA [1000108],AETNA [100010801],,,76.8,,3518.81,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT FEMORAL DISTAL RIGHT SZ 7 X 15MM TRIATHLON -,SUP-5542-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4581.78,3207.246,AETNA [1000108],AETNA [100010801],,,76.8,,3518.81,9.170825,27238.33344,percent of total billed charges,,,
COMP SZ48 7MM REUNION ALLOGRAFT SHOLUDER PG -,SUP-5542-P-0048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
COMP SZ56 7MM REUNION ALLOGRAFT SHOLUDER PG -,SUP-5542-P-0056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT POST KN SZ1 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA [1000108],AETNA [100010801],,,76.8,,3354.89,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT POST KN SZ2 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA [1000108],AETNA [100010801],,,76.8,,3354.89,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT POST KN SZ3 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA [1000108],AETNA [100010801],,,76.8,,3354.89,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT POST KN SZ4 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA [1000108],AETNA [100010801],,,76.8,,3354.89,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT POST KN SZ5 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA [1000108],AETNA [100010801],,,76.8,,3354.89,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT POST KN SZ6 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA [1000108],AETNA [100010801],,,76.8,,3354.89,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT POST KN SZ7 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA [1000108],AETNA [100010801],,,76.8,,3354.89,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT POST KN SZ2 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA [1000108],AETNA [100010801],,,76.8,,3354.89,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT POST KN SZ3 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA [1000108],AETNA [100010801],,,76.8,,3354.89,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT POST KN SZ4 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA [1000108],AETNA [100010801],,,76.8,,3354.89,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT POST KN SZ5 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA [1000108],AETNA [100010801],,,76.8,,3354.89,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT POST KN SZ6 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA [1000108],AETNA [100010801],,,76.8,,3354.89,9.170825,27238.33344,percent of total billed charges,,,
HALF BLOCK TIBIAL AUGMENT SIZE 3 X 5MM TRIATHLON -,SUP-5545-A-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,AETNA [1000108],AETNA [100010801],,,76.8,,3443,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT RM/LL KN SZ3 TRIATH 5MM BLCK TOTAL STABILIZED AUG -,SUP-5545-A-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,AETNA [1000108],AETNA [100010801],,,76.8,,3443,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT LMRL KN SZ7 TRIATH 5MM BLCK TOTAL STABILIZED AUG -,SUP-5545-A-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,AETNA [1000108],AETNA [100010801],,,76.8,,3443,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT RM/LL KN SZ7 TRIATH 5MM BLCK TOTAL STABILIZED AUG -,SUP-5545-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,AETNA [1000108],AETNA [100010801],,,76.8,,3443,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT LMRL KN SZ1 TRIATH 10MM BLCK TOTAL STABILIZED AUG -,SUP-5546-A-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,AETNA [1000108],AETNA [100010801],,,76.8,,3363.73,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT RM/LL KN SZ1 TRIATH 10MM BLCK TOTAL STABILIZED AUG -,SUP-5546-A-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,AETNA [1000108],AETNA [100010801],,,76.8,,3363.73,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL AUGMENT HALF BLOCK -,SUP-5546-A-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,AETNA [1000108],AETNA [100010801],,,76.8,,3363.73,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL AUGMENT HALF BLOCK - 10MM -,SUP-5546-A-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,AETNA [1000108],AETNA [100010801],,,76.8,,3363.73,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT LMRL KN SZ3 TRIATH 10MM HLF BLCK TOTAL STABILIZED -,SUP-5546-A-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,AETNA [1000108],AETNA [100010801],,,76.8,,3363.73,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL AUGMENT HALF BLOCK / SZ.3 -,SUP-5546-A-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,AETNA [1000108],AETNA [100010801],,,76.8,,3363.73,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT LMRL KN SZ4 TRIATH 10MM HLF BLCK TOTAL STABILIZED -,SUP-5546-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,AETNA [1000108],AETNA [100010801],,,76.8,,3363.73,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT RM/LL KN SZ4 TRIATH 10MM HLF BLCK TOTAL STABILIZED -,SUP-5546-A-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,AETNA [1000108],AETNA [100010801],,,76.8,,3363.73,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL SYMMETRIC CONE AUGMENT SIZE A -,SUP-5549-A-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13500.17,9450.119,AETNA [1000108],AETNA [100010801],,,76.8,,10368.13,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL SYMMETRIC CONE AUGMENT -,SUP-5549-A-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13500.17,9450.119,AETNA [1000108],AETNA [100010801],,,76.8,,10368.13,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL SYMMETRIC CONE AUGMENT SIZE C -,SUP-5549-A-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13500.17,9450.119,AETNA [1000108],AETNA [100010801],,,76.8,,10368.13,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL CONE AUGMENT SZ 1&2 RT -,SUP-5549-A-322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15374.42,10762.094,AETNA [1000108],AETNA [100010801],,,76.8,,11807.55,9.170825,27238.33344,percent of total billed charges,,,
TRIATH TRITNUM CNTRLFEMCONE AUG SZ 3&4 LEFT -,SUP-5549-A-641,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15375.53,10762.871,AETNA [1000108],AETNA [100010801],,,76.8,,11808.41,9.170825,27238.33344,percent of total billed charges,,,
TRIATH TRITNUM CNTRLFEMCONE AUG SZ 3 & 4 RIGHT -,SUP-5549-A-642,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15375.53,10762.871,AETNA [1000108],AETNA [100010801],,,76.8,,11808.41,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT CENTRAL FEM CONE SZ 7&8 RIGHT TRIATHLON -,SUP-5549-A-672,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15375.53,10762.871,AETNA [1000108],AETNA [100010801],,,76.8,,11808.41,9.170825,27238.33344,percent of total billed charges,,,
PATELLA SYMMETRIC SZ S27MM X 8MM TRIATHLON X3 -,SUP-5550-G-278-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,AETNA [1000108],AETNA [100010801],,,76.8,,1669.03,9.170825,27238.33344,percent of total billed charges,,,
TRIATHLON SYMMETRIC X3 PATELLA -,SUP-5550-G-298-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,AETNA [1000108],AETNA [100010801],,,76.8,,1669.03,9.170825,27238.33344,percent of total billed charges,,,
TRIATHLON X3 SYMMETRIC PATELLA 31MM 9MM -,SUP-5550-G-319-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,AETNA [1000108],AETNA [100010801],,,76.8,,1669.03,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 33X9MM THK X3 TRIATH PRIM SYM -,SUP-5550-G-339,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,AETNA [1000108],AETNA [100010801],,,76.8,,1669.03,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 39X11MM THK X3 TRIATH PRIM SYM -,SUP-5550-G-391,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,AETNA [1000108],AETNA [100010801],,,76.8,,1669.03,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 29X9MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-299-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,AETNA [1000108],AETNA [100010801],,,76.8,,1669.03,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 32X10MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-320-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,AETNA [1000108],AETNA [100010801],,,76.8,,1669.03,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 35X10MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-350-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,AETNA [1000108],AETNA [100010801],,,76.8,,1669.03,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 38X11MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-381-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,,,
SINGLE RADIUS HUMERAL HEAD SIZE 44 19MM -,SUP-5552-E-4419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13563.59,9494.513,AETNA [1000108],AETNA [100010801],,,76.8,,10416.84,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 4MM OFST 52X17 REUNION -,SUP-5552-E-5217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 29X9MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-299,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 32X10MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 35X10MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-350,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 38X11MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-381,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,,,
PATELLA ASYMMETRIC A40/11MM -,SUP-5552-L-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 56MM STD REUNION SGL RAD -,SUP-5552-S-5622,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 32X10MM THK X3 PERIAPATITE TRIATH ASYM MTL BK -,SUP-5554-L-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 35X10MM THK X3 PERIAPATITE TRIATH ASYM MTL BK -,SUP-5554-L-350,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 38X11MM THK X3 PERIAPATITE ASYM BEADX3 MTL BK -,SUP-5554L381,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 40X11MM THK X3 PERIAPATITE ASYM BEADX3 MTL BK -,SUP-5554L401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND SZ1 12MM TRIATH TOTAL STABILIZED 50MM COCR FEM -,SUP-5560-S-112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,AETNA [1000108],AETNA [100010801],,,76.8,,3394.72,9.170825,27238.33344,percent of total billed charges,,,
STEM TOTAL KNEE 9MM X 100MM -,SUP-5560-S-209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,AETNA [1000108],AETNA [100010801],,,76.8,,3394.72,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND SZ2 12MM TRIATH TOTAL STABILIZED 100MM COCR FEM -,SUP-5560-S-212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,AETNA [1000108],AETNA [100010801],,,76.8,,3394.72,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND SZ2 15MM TRIATH TOTAL STABILIZED 50MM COCR FEM -,SUP-5560-S-215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,AETNA [1000108],AETNA [100010801],,,76.8,,3394.72,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND SZ3 12MM TRIATH TOTAL STABILIZED 50MM COCR FEM -,SUP-5560-S-312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,AETNA [1000108],AETNA [100010801],,,76.8,,3394.72,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 10MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA [1000108],AETNA [100010801],,,76.8,,3557.11,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 11MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA [1000108],AETNA [100010801],,,76.8,,3557.11,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 12MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA [1000108],AETNA [100010801],,,76.8,,3557.11,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 13MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA [1000108],AETNA [100010801],,,76.8,,3557.11,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 14MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA [1000108],AETNA [100010801],,,76.8,,3557.11,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 15MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA [1000108],AETNA [100010801],,,76.8,,3557.11,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 16MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA [1000108],AETNA [100010801],,,76.8,,3557.11,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 17MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA [1000108],AETNA [100010801],,,76.8,,3557.11,9.170825,27238.33344,percent of total billed charges,,,
FLUTED STEM 18MM / 100MM / TS -,SUP-5565-S-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA [1000108],AETNA [100010801],,,76.8,,3557.11,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 18MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA [1000108],AETNA [100010801],,,76.8,,3557.11,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 19MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA [1000108],AETNA [100010801],,,76.8,,3557.11,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 20MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA [1000108],AETNA [100010801],,,76.8,,3557.11,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 21MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA [1000108],AETNA [100010801],,,76.8,,3557.11,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 22MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA [1000108],AETNA [100010801],,,76.8,,3557.11,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 13MM TRIATH PRFT REVISN TOTAL STABILIZED 150MM -,SUP-5566-S-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4789.23,3352.461,AETNA [1000108],AETNA [100010801],,,76.8,,3678.13,9.170825,27238.33344,percent of total billed charges,,,
FLUTED STEM 14MM / 150MM / TS -,SUP-5566-S-014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4789.23,3352.461,AETNA [1000108],AETNA [100010801],,,76.8,,3678.13,9.170825,27238.33344,percent of total billed charges,,,
HUMERAL FRATURE STEM 7 X 113 -,SUP-5568-0007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,32158.29,22510.803,AETNA [1000108],AETNA [100010801],,,76.8,,24697.57,9.170825,27238.33344,percent of total billed charges,,,
REUNION RFX-HUMERAL FRACTURE STEM 9MM -,SUP-5568-0009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,31160.68,21812.476,AETNA [1000108],AETNA [100010801],,,76.8,,23931.4,9.170825,27238.33344,percent of total billed charges,,,
STEM HUMERAL FRACTURE 11MM X 123MM REUNION RFX -,SUP-5568-0011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,33766.02,23636.214,AETNA [1000108],AETNA [100010801],,,76.8,,25932.3,9.170825,27238.33344,percent of total billed charges,,,
HUMERAL CUP 36MM DIA X 4MM THK -,SUP-5570-3604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16968.41,11877.887,AETNA [1000108],AETNA [100010801],,,76.8,,13031.74,9.170825,27238.33344,percent of total billed charges,,,
ADAPTER FEM 2MM OFST TRIATH RECON KN REVISN TOTAL STABILIZED -,SUP-5570-S-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4348.4,3043.88,AETNA [1000108],AETNA [100010801],,,76.8,,3339.57,9.170825,27238.33344,percent of total billed charges,,,
ADAPTER FEM 4MM OFST TRIATH RECON KN REVISN TOTAL STABILIZED -,SUP-5570-S-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4348.4,3043.88,AETNA [1000108],AETNA [100010801],,,76.8,,3339.57,9.170825,27238.33344,percent of total billed charges,,,
ADAPTER FEM 6MM OFST TRIATH RECON KN REVISN TOTAL STABILIZED -,SUP-5570-S-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4348.4,3043.88,AETNA [1000108],AETNA [100010801],,,76.8,,3339.57,9.170825,27238.33344,percent of total billed charges,,,
EXTENDER STEM TRIATHLON 25MM LENGTH -,SUP-5571-S-025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4512.24,3158.568,AETNA [1000108],AETNA [100010801],,,76.8,,3465.4,9.170825,27238.33344,percent of total billed charges,,,
X3 HUMERAL INSERT 36MM X 4MM STANDARD -,SUP-5571-S-3604-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13571.02,9499.714,AETNA [1000108],AETNA [100010801],,,76.8,,10422.54,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE 28MM X 10.05MM -,SUP-5572-2802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18676.39,13073.473,AETNA [1000108],AETNA [100010801],,,76.8,,14343.47,9.170825,27238.33344,percent of total billed charges,,,
GLENOSPHERE 36MM DIA X 2MM THK CONCENTRIC -,SUP-5573-C-3602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16968.41,11877.887,AETNA [1000108],AETNA [100010801],,,76.8,,13031.74,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ2 TRIATH LMRL KN UNICMPT PRIM PRT RSRFC COCR -,SUP-5610-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ2 TRIATH RM/LL KN UNICMPT PRIM PRT RSRFC COCR -,SUP-5610-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL REVISION LEFT SZ 2 NON-POROUS -,SUP-561-1201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,AETNA [1000108],AETNA [100010801],,,76.8,,14029.79,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ3 BAL KN MODULAR REVISN RT KN -,SUP-561-1302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,AETNA [1000108],AETNA [100010801],,,76.8,,14029.79,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ4 BAL KN MODULAR REVISN LT KN -,SUP-561-1401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,AETNA [1000108],AETNA [100010801],,,76.8,,14029.79,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ4 BAL KN RT KN MODULAR REVISN SYS -,SUP-561-1402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,AETNA [1000108],AETNA [100010801],,,76.8,,14029.79,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 BAL KN LT KN MODULAR REVISN SYS -,SUP-561-1501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,AETNA [1000108],AETNA [100010801],,,76.8,,14029.79,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 BAL KN RT KN MODULAR REVISN SYS -,SUP-561-1502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,AETNA [1000108],AETNA [100010801],,,76.8,,14029.79,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ6 BAL KN LT KN MODULAR REVISN SYS -,SUP-561-1601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,AETNA [1000108],AETNA [100010801],,,76.8,,14029.79,9.170825,27238.33344,percent of total billed charges,,,
MODULAR FEMORAL LEFT SIZE 7 -,SUP-561-1701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,AETNA [1000108],AETNA [100010801],,,76.8,,14029.79,9.170825,27238.33344,percent of total billed charges,,,
MODULAR FEMORAL SIZE 7 -,SUP-561-1702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,AETNA [1000108],AETNA [100010801],,,76.8,,14029.79,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ3 27/47MM LMRL KN TRIATH COCR PRIM REVISN -,SUP-5620-B-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ3 27/47MM RM/LL KN TRIATH COCR PRIM REVISN -,SUP-5620-B-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ2 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,9.170825,27238.33344,percent of total billed charges,,,
TRAY TIBIAL REVISION SZ 2 NEUTRAL NON-POROUS -,SUP-562-1200A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ3 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL TRAY REVISION SZ 3 NEUTRAL NON-POROUS -,SUP-562-1300A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ4 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL TRAY REVISION SZ 4 NEUTRAL NON-POROUS -,SUP-562-1400A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ5 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL TRAY REVISION SZ 5 NEUTRAL NON-POROUS -,SUP-562-1500A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ6 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL TRAY SLOPED SIZE 5 MODULAR -,SUP-562-2500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9431.02,6601.714,AETNA [1000108],AETNA [100010801],,,76.8,,7243.02,9.170825,27238.33344,percent of total billed charges,,,
CONE TIBIAL CENTRAL 31MM -,SUP-562-7031,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12705.89,8894.123,AETNA [1000108],AETNA [100010801],,,76.8,,9758.12,9.170825,27238.33344,percent of total billed charges,,,
CONE TIBIAL CENTRAL 34MM -,SUP-562-7034,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12705.89,8894.123,AETNA [1000108],AETNA [100010801],,,76.8,,9758.12,9.170825,27238.33344,percent of total billed charges,,,
CONE TIBIAL CENTRAL 36MM -,SUP-562-7036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12705.89,8894.123,AETNA [1000108],AETNA [100010801],,,76.8,,9758.12,9.170825,27238.33344,percent of total billed charges,,,
CONE TIBIAL 25MM M-L 35MM A-P -,SUP-562-7135,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12223.2,8556.24,AETNA [1000108],AETNA [100010801],,,76.8,,9387.42,9.170825,27238.33344,percent of total billed charges,,,
CONE TIBIAL LARGE 47MM M/L 31MM A/P -,SUP-562-7247,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15108.2,10575.74,AETNA [1000108],AETNA [100010801],,,76.8,,11603.1,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 8MM TRIATH BEAR LMRL KN X3 UHMWPE -,SUP-5630-G-308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 8MM TRIATH BEAR RM/LL KN X3 UHMWPE -,SUP-5630-G-328,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 8MM CNSTRN -,SUP-563-1308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,AETNA [1000108],AETNA [100010801],,,76.8,,4178.54,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 10MM CNSTRN -,SUP-563-1310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 12MM CNSTRN -,SUP-563-1312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,AETNA [1000108],AETNA [100010801],,,76.8,,4178.54,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 14MM CNSTRN -,SUP-563-1314,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,AETNA [1000108],AETNA [100010801],,,76.8,,4178.54,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 16MM CNSTRN -,SUP-563-1316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,AETNA [1000108],AETNA [100010801],,,76.8,,4178.54,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 18MM CNSTRN -,SUP-563-1318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,AETNA [1000108],AETNA [100010801],,,76.8,,4155.72,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 20MM CNSTRN -,SUP-563-1320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,AETNA [1000108],AETNA [100010801],,,76.8,,4178.54,9.170825,27238.33344,percent of total billed charges,,,
SROM*ST XL 36+8LINK 18 X 13 X 255L -,SUP-563138L,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27357.55,19150.285,AETNA [1000108],AETNA [100010801],,,76.8,,21010.6,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL CK SZ 4 8MM -,SUP-563-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT CK SIZE 4 18MM -,SUP-563-1418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT CK SIZE 4 24MM -,SUP-563-1424,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,AETNA [1000108],AETNA [100010801],,,76.8,,4178.54,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5 8MM CNSTRN -,SUP-563-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5 10MM CNSTRN -,SUP-563-1510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,AETNA [1000108],AETNA [100010801],,,76.8,,4178.54,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5 12MM CNSTRN -,SUP-563-1512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,AETNA [1000108],AETNA [100010801],,,76.8,,4178.54,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT CK SIZE 6 8MM -,SUP-563-1608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,AETNA [1000108],AETNA [100010801],,,76.8,,4178.54,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ6 10MM CNSTRN -,SUP-563-1610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,AETNA [1000108],AETNA [100010801],,,76.8,,4178.54,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT CK SIZE 6 14MM -,SUP-563-1614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SZ 2 10MM -,SUP-563-2210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SZ 2 12MM -,SUP-563-2212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL REVISION CK SZ 2 14MM -,SUP-563-2214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SZ 2 18MM -,SUP-563-2218,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SZ 2 20MM -,SUP-563-2220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SZ 2 22MM -,SUP-563-2222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SZ 3 8MM -,SUP-563-2308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SZ 3 12MM -,SUP-563-2312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SZ 3 14MM -,SUP-563-2314,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SZ 3 18MM -,SUP-563-2318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL REV CK SZ 3 20MM -,SUP-563-2320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SZ 3 24MM -,SUP-563-2324,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SZ 4 8MM -,SUP-563-2408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SZ 4 10MM -,SUP-563-2410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SZ 4 12MM -,SUP-563-2412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SZ 4 14MM -,SUP-563-2414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SZ 4 16MM -,SUP-563-2416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SZ 4 18MM -,SUP-563-2418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SZ 4 22MM -,SUP-563-2422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SZ 5 10MM -,SUP-563-2510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SZ 5 12MM -,SUP-563-2512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SZ5 14MM -,SUP-563-2514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SZ 5 16MM -,SUP-563-2516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL REVISION CK SZ 6.8MM -,SUP-563-2608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SIZE 6 14MM -,SUP-563-2614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA [1000108],AETNA [100010801],,,76.8,,4139.43,9.170825,27238.33344,percent of total billed charges,,,
STEM 12MM X 50MM CEMENTED -,SUP-565-1205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,AETNA [1000108],AETNA [100010801],,,76.8,,3406.06,9.170825,27238.33344,percent of total billed charges,,,
STEM 12 X 80 CEMENTED -,SUP-565-1208,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,AETNA [1000108],AETNA [100010801],,,76.8,,3406.06,9.170825,27238.33344,percent of total billed charges,,,
STEM EXT CEMENTED 12MM X 110MM -,SUP-565-1211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,AETNA [1000108],AETNA [100010801],,,76.8,,3406.06,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTENSION CEMENTED 14MM X 30MM -,SUP-565-1403,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4481.66,3137.162,AETNA [1000108],AETNA [100010801],,,76.8,,3441.91,9.170825,27238.33344,percent of total billed charges,,,
STEM 14MM X 50MM CEMENTED -,SUP-565-1405,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,AETNA [1000108],AETNA [100010801],,,76.8,,3406.06,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 14MM BAL KN 80MM CMNT -,SUP-565-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4481.66,3137.162,AETNA [1000108],AETNA [100010801],,,76.8,,3441.91,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 10MM BAL KN 80MM FEM/TBL -,SUP-566-1008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,AETNA [1000108],AETNA [100010801],,,76.8,,3533.18,9.170825,27238.33344,percent of total billed charges,,,
STEM 10 X 150MM EXT FLUTED -,SUP-566-1015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,AETNA [1000108],AETNA [100010801],,,76.8,,3533.18,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 12MM BAL KN 80MM FEM/TBL -,SUP-566-1208,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA [1000108],AETNA [100010801],,,76.8,,3487.55,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 13MM BAL KN 80MM FEM/TBL -,SUP-566-1308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,AETNA [1000108],AETNA [100010801],,,76.8,,3533.18,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 13MM BAL KN 150MM FEM/TBL -,SUP-566-1315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,AETNA [1000108],AETNA [100010801],,,76.8,,3533.18,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 14MM BAL KN 80MM FEM/TBL -,SUP-566-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA [1000108],AETNA [100010801],,,76.8,,3487.55,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTENSION FLUTED 14 X 110 -,SUP-566-1411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA [1000108],AETNA [100010801],,,76.8,,3487.55,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 15MM BAL KN 80MM FEM/TBL -,SUP-566-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA [1000108],AETNA [100010801],,,76.8,,3487.55,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 16MM BAL KN 80MM FEM/TBL -,SUP-566-1608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA [1000108],AETNA [100010801],,,76.8,,3487.55,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 17MM BAL KN 80MM FEM/TBL -,SUP-566-1708,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA [1000108],AETNA [100010801],,,76.8,,3487.55,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTENSION FLUTED 17MM X 110MM -,SUP-566-1711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA [1000108],AETNA [100010801],,,76.8,,3487.55,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 18MM BAL KN 80MM FEM/TBL -,SUP-566-1808,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA [1000108],AETNA [100010801],,,76.8,,3487.55,9.170825,27238.33344,percent of total billed charges,,,
STEM 18MM X 110MM FLUTED -,SUP-566-1811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA [1000108],AETNA [100010801],,,76.8,,3487.55,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 20MM BAL KN 80MM FEM/TBL -,SUP-566-2008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA [1000108],AETNA [100010801],,,76.8,,3487.55,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTENSION FLUTED 20 X 110 -,SUP-566-2011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA [1000108],AETNA [100010801],,,76.8,,3487.55,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTENSION FLUTED 24 X 80MM -,SUP-566-2408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA [1000108],AETNA [100010801],,,76.8,,3487.55,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTENSION FLUTED 24 X 110MM -,SUP-566-2411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA [1000108],AETNA [100010801],,,76.8,,3487.55,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT RM/LL KN SZ3 BAL KN 5MM BLCK REVISN -,SUP-567-5103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,AETNA [1000108],AETNA [100010801],,,76.8,,3836.31,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL AUGMENT BLOCK 5MM RT LAT LT MED SIZE 4 -,SUP-567-5104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,AETNA [1000108],AETNA [100010801],,,76.8,,3836.31,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT RM/LL KN SZ3 BAL KN BLCK REVISN -,SUP-567-5203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,AETNA [1000108],AETNA [100010801],,,76.8,,3836.31,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL AUGMENT SZ 3 15MM BLOCK LT LATERAL RT MEDIAL -,SUP-567-7203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA [1000108],AETNA [100010801],,,76.8,,3797.19,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT DIST KN SZ3 BAL KN 4MM REVISN -,SUP-568-1304,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA [1000108],AETNA [100010801],,,76.8,,3797.19,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL AUGMENT DISTAL SIZE 3 8MM -,SUP-568-1308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA [1000108],AETNA [100010801],,,76.8,,3797.19,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT DIST KN SZ4 BAL KN 4MM REVISN -,SUP-568-1404,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,AETNA [1000108],AETNA [100010801],,,76.8,,3836.31,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT FEMORAL SZ 4 4MM DISTAL -,SUP-568-1404A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA [1000108],AETNA [100010801],,,76.8,,3797.19,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT DIST KN SZ4 BAL KN 8MM REVISN -,SUP-568-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,AETNA [1000108],AETNA [100010801],,,76.8,,3836.31,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL AUGMENT SZ 4 8MM DISTAL -,SUP-568-1408A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA [1000108],AETNA [100010801],,,76.8,,3797.19,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT DIST KN SZ5 BAL KN 4MM REVISN -,SUP-568-1504,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA [1000108],AETNA [100010801],,,76.8,,3797.19,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL AUGMENT SZ 5 4MM DISTAL -,SUP-568-1504A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA [1000108],AETNA [100010801],,,76.8,,3797.19,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL AUGMENT DISTA SIZE 5 8MM -,SUP-568-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,AETNA [1000108],AETNA [100010801],,,76.8,,3836.31,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL AUGMENT DISTAL 12MM -,SUP-568-1512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA [1000108],AETNA [100010801],,,76.8,,3797.19,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT DISTAL 4MM SIZE 6 -,SUP-568-1604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA [1000108],AETNA [100010801],,,76.8,,3797.19,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL AUGMENT SZ 6 8MM DISTAL -,SUP-568-1608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA [1000108],AETNA [100010801],,,76.8,,3797.19,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT POST KN SZ4 BAL KN 4MM REVISN -,SUP-568-2404,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA [1000108],AETNA [100010801],,,76.8,,3797.19,9.170825,27238.33344,percent of total billed charges,,,
FERMORAL AUGMENT POSTERIOR 4MM SIZE 6 -,SUP-568-2604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA [1000108],AETNA [100010801],,,76.8,,3797.19,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 14MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-5988-10-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4394.75,3076.325,AETNA [1000108],AETNA [100010801],,,76.8,,3375.17,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 14MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-5988-10-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA [1000108],AETNA [100010801],,,76.8,,4654.41,9.170825,27238.33344,percent of total billed charges,,,
EXTENSION STM 15X30MM -,SUP-5988-12-15,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4394.75,3076.325,AETNA [1000108],AETNA [100010801],,,76.8,,3375.17,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ0 33MM OFST 86MM ACCOLADE PRFT STD OFST 30MM NK -,SUP-6020-0030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ1 34MM OFST 110MM RECON ACCOLADE PRFT PRIM STD -,SUP-6020-0130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ2 35MM OFST 115MM ACCOLADE PRFT STD OFST 30MM NK -,SUP-6020-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ3 39MM OFST 120MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-0335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ4 40MM OFST 125MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ5 44MM OFST 130MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-0537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ2.5 36MM OFST 118MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-2530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ3.5 39MM OFST 124MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-3535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ4.5 41MM OFST 129MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-4535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ5.5 45MM OFST 133MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-5537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ0 +0MM 37MM OFST 86MM ACCOLADE PRFT EXTEND OFST -,SUP-6021-0030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ1 +0MM 38MM OFST 110MM ACCOLADE PRFT EXTEND OFST -,SUP-6021-0130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ2 39MM OFST 115MM ACCOLADE PRFT PRIM EXTEND OFST -,SUP-6021-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ3 43MM OFST 120MM ACCOLADE RECON PRFT PRIM HI -,SUP-6021-0335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ4 44MM OFST 125MM ACCOLADE RECON PRFT PRIM HI -,SUP-6021-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ5 48MM OFST 130MM ACCOLADE RECON PRFT PRIM EXTEND -,SUP-6021-0537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ2.5 40MM OFST 118MM ACCOLADE RECON PRFT PRIM -,SUP-6021-2530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ3.5 124MM RECON ACCOLADE PRFT PRIM EXTEND OFST -,SUP-6021-3535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ4.5 45MM OFST 130MM ACCOLADE RECON PRFT PRIM -,SUP-6021-4535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ5.5 49MM OFST 133MM ACCOLADE PRFT EXTEND OFST -,SUP-6021-5537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ4 OMNIFIT PRIM CLLR CMNT MDL CLCR HIP -,SUP-6034-0425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ6 30MM OFST 132MM SECUR-FIT PRFT PRIM 25MM -,SUP-6051-0625S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ7 35.1MM OFST 132MM SECUR-FIT MAX PRFT PRIM 30MM -,SUP-6051-0730S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ8 132MM RECON SECUR-FIT MAX PRFT PRIM TI HAP CTD -,SUP-6051-0830S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ9 40.8MM OFST 132MM SECUR-FIT MAX PRFT PRIM 35MM -,SUP-6051-0935S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ10 132MM RECON SECUR-FIT MAX PRFT PRIM TI HAP CTD -,SUP-6051-1035S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ11 132MM RECON SECUR-FIT MAX PRFT PRIM TI HAP CTD -,SUP-6051-1140S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ12 47.3MM OFST 132MM SECUR-FIT MAX PRFT PRIM 40MM -,SUP-6051-1240S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
HIP STEM SIZE 6 25MM C-TPR -,SUP-6052-0625S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ7 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-0730S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ8 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-0830S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ9 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-0935S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ10 127 DEG SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-1035S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ13 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-1340S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
STEM HIP SECUR-FIT PLUS MAX SZ 11 C-TPR 40MM X 170MM -,SUP-6054-1115S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
STEM HIP 127 DEG NECK ANGLE SZ 12 C-TPR 40MM X 170MM -,SUP-6054-1216S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
HIP STEM 127 DEG CEMENTED SZ 2 V40 TPR 30MM X 124MM ACCOLADE -,SUP-6057-0230D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,,,
STEM HIP ACCOLADE 127 DEG CEM NK 35MM SZ 3 V40 131MM LGTH -,SUP-6057-0335D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,,,
STEM HIP CEM SZ4 V40 TPR 35MM X 137MM 127 DEG -,SUP-6057-0435D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,,,
STEM HIP ACCOLADE 127 DEC CEM NK 37MM SZ 5 V40 145MM LGTH -,SUP-6057-0537D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,,,
STEM HIP ACCOLADE 127 DEG CEM NK 37MM SZ 6 V40 158MM LGTH -,SUP-6057-0637D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,,,
STEM HIP 127 DEG CEMENTED SZ 7 V40 TPR 40MM X 158MM ACCOLADE -,SUP-6057-0740D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,,,
STEM HIP 132 DEG SIZE 3 V40 X 35MM X 131MM CEM ACCOLADE C -,SUP-6058-0335D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,,,
STEM HIP 132 DEG CEMENTED SZ 4 V40 35MM X 137MM ACCOLADE -,SUP-6058-0435D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,,,
HIP STEM 132 DEG CEMENTED SZ 5 V40 TPR 37MM X 145MM -,SUP-6058-0537D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ10 42MM OFST 160MM OMNIFIT HFX RECON PRIM 35MM NK -,SUP-6070-1035A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ11 132MM OMNIFIT HFX PRIM COCR CMNT HIP -,SUP-6070-1140A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ5 35MM OFST 110MM RECON OMNIFIT HFX PRIM 25MM NK -,SUP-6076-0525A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ6 36MM OFST 120MM OMNIFIT HFX PRIM 25MM NK COCR -,SUP-6076-0625A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ7 41MM OFST 130MM OMNIFIT HFX PRIM 30MM NK COCR -,SUP-6076-0730A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ8 42MM OFST 140MM RECON OMNIFIT HFX PRIM 30MM NK -,SUP-6076-0830A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ2 +0MM 43MM OFST 120MM ACCOLADE HFX PRFT PRIM -,SUP-6077-0335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ4 +0MM 44MM OFST 125MM ACCOLADE HFX PRFT PRIM -,SUP-6077-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ5 +0MM 48MM OFST 130MM ACCOLADE HFX PRFT PRIM -,SUP-6077-0537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,,,
OMNIFIT CEMENTED LONG STEM RIGHT -,SUP-6088-0730-200R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17512.18,12258.526,AETNA [1000108],AETNA [100010801],,,76.8,,13449.35,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ4 33MM OFST 100MM OMNIFIT EON PRIM EXTEND OFST -,SUP-6097-0425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ5 8.9MM DIST TIP 39MM OFST 110MM OMNIFIT EON PRIM -,SUP-6097-0530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ6 9.6MM DIST TIP 40MM OFST 120MM OMNIFIT EON PRIM -,SUP-6097-0630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ7 10.4MM DIST TIP 45MM OFST 130MM OMNIFIT EON -,SUP-6097-0735,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ8 46MM OFST 135MM OMNIFIT EON PRIM EXTEND OFST -,SUP-6097-0835,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,,,
STEM HIP OMNIFIT EON PLUS SIZE 11 C-TPR 40MM X 150MM -,SUP-6097-1140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ5 8.9MM DIST TIP 35MM OFST 110MM OMNIFIT EON STD -,SUP-6098-0530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ6 9.6MM DIST TIP 36MM OFST 120MM OMNIFIT EON PRIM -,SUP-6098-0630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ7 9.6MM DIST TIP 41MM OFST 130MM OMNIFIT EON PRIM -,SUP-6098-0735,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ8 11.3MM DIST TIP 42MM OFST 135MM OMNIFIT EON STD -,SUP-6098-0835,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ9 46MM OFST 140MM OMNIFIT EON STD OFST 40MM NK -,SUP-6098-0940,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,,,
MODULAR CUP REPLACEMTN LOCK RING 54MM -,SUP-6201-54,CDM,C1776,HCPCS,278,RC,,,outpatient,,,816.9,571.83,AETNA [1000108],AETNA [100010801],,,76.8,,627.38,9.170825,27238.33344,percent of total billed charges,,,
TRABECULAR METAL LOCKING RING -,SUP-6201-56,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA [1000108],AETNA [100010801],,,76.8,,537.75,9.170825,27238.33344,percent of total billed charges,,,
SHELL MULTI HOLE TRABECULAR METAL 54MM -,SUP-6202-54-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9990.38,6993.266,AETNA [1000108],AETNA [100010801],,,76.8,,7672.61,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 36X58-60MM G SHL TRIDENT 0DG CROSSFIRE PRIM -,SUP-621-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 28X46-48MM D SHL TRIDENT 0DG NEUT X3 7.9MM PRIM -,SUP-623-00-28D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
INSERT 00 DEG X3 32MM ID TRIDENT -,SUP-623-00-32C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 32X44MM C SHL TRIDENT 0DG NEUT X3 4.9MM PRIM -,SUP-623-00-32C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
INSERT POLYETHLENE 0 DEG 32MM CODE D TRIDENT X3 -,SUP-623-00-32D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 32X54-56MM F SHL TRIDENT 0DG NEUT X3 9.9MM PRIM -,SUP-623-00-32F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
INSERT POLYETHLENE 0 DEG 36MM CODE D TRIDENT X3 -,SUP-623-00-36D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
INSERT POLYETHLENE 0 DEG 36MM CODE E TRIDENT X3 -,SUP-623-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
INSERT POLYETHLENE 0 DEG 36MM CODE F TRIDENT X3 -,SUP-623-00-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 36X54-56MM F SHL TRIDENT 0DG NEUT X3 7.9MM PRIM -,SUP-623-00-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 36X58-60MM G SHL TRIDENT 0DG NEUT X3 9.4MM PRIM -,SUP-623-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
INSERT POLY ZERO DEGREE 36MM X ALPHA G TRIDENT X3 -,SUP-623-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACET TRIDENT X3 0 DEG POLY 36MM H -,SUP-623-00-36H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
TRIDENT X3 0 DG POLYETTHYLENE INSERT 40MM SZ E RIM -,SUP-623-00-40E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
TRIDENT X3 0 DG  POLY INSERT 40MM SZ E -,SUP-623-00-40E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
INSERT 0 DEG POLYETHYLENE 40MM ALPHA CODE F TRIDENT X3 -,SUP-623-00-40F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 40X58-60MM G SHL TRIDENT 0DG X3 7.4MM PRIM -,SUP-623-00-40G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
INSERT POLY ZERO DEGREE 40MM X ALPHA G TRIDENT X3 -,SUP-623-00-40G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 40X62-64MM H SHL TRIDENT 0DG X3 9.1MM PRIM -,SUP-623-00-40H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
INSERT POLY ZERO DEGREE 40MM X ALPHA H TRIDENT X3 -,SUP-623-00-40H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
INSERT TRIDENT X3 0 D POLY 40MM ALPHA I -,SUP-623-00-40I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 44X54-56MM F SHL TRIDENT 0DG X3 3.8MM PRIM -,SUP-623-00-44F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 44X58-60MM G SHL TRIDENT 0DG X3 5.4MM PRIM -,SUP-623-00-44G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 44X62-64MM H SHL TRIDENT 0DG X3 7.1MM PRIM -,SUP-623-00-44H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
INSERT TRIDENT X3 0 DEGREE POLY 44MM ALPHA I -,SUP-623-00-44I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 22X42MM B SHL TRIDENT 10DG X3 8.8MM PRIM -,SUP-623-10-22B,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 32X54-56MM F SHL TRIDENT 10DG X3 9.9MM PRIM -,SUP-623-10-32F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 36X50-52MM E SHL TRIDENT 10DG X3 5.9MM PRIM -,SUP-623-10-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
INSERT 10 DEG POLYETHYLENE 36MM E TRIDENT X3 -,SUP-623-10-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
INSERT 10 DEG X3 36MM ID TRIDENT -,SUP-623-10-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 36X54-56MM F SHL TRIDENT 10DG X3 7.9MM PRIM -,SUP-623-10-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
INSERT 10 DEGREE POLY 36MM G TRIDENT X3 -,SUP-623-10-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 36X58-60MM G SHL TRIDENT 10DG X3 9.4MM PRIM -,SUP-623-10-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 36X66-68MM I SHL TRIDENT 10DG X3 12.7MM PRIM -,SUP-623-10-36I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
STEM DISTAL 19MM DIA CENTRALIZER-CEMENTED -,SUP-6259-8-180,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 32X50-52MM E SHL TRIDENT 0DG ALMN CERM PRIM -,SUP-625-OT-32E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA [1000108],AETNA [100010801],,,76.8,,4074.24,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 36MM D SHL RECON MDM CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-36C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,AETNA [1000108],AETNA [100010801],,,76.8,,3992.76,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 38MM D SHL MDM RECON CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-38D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,AETNA [1000108],AETNA [100010801],,,76.8,,3992.76,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 42MM E SHL RECON MDM CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-42E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,AETNA [1000108],AETNA [100010801],,,76.8,,3992.76,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 46MM F SHL RECON MDM CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-46F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,AETNA [1000108],AETNA [100010801],,,76.8,,3992.76,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 48MM G SHL MDM RECON CMNTLS COCR REVISN MODULAR -,SUP-626-00-48G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,AETNA [1000108],AETNA [100010801],,,76.8,,3992.76,9.170825,27238.33344,percent of total billed charges,,,
LINER MDM 52MM H CEMENTLESS -,SUP-626-00-52H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,AETNA [1000108],AETNA [100010801],,,76.8,,3992.76,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 22.2MMSTDX0MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-4-122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 26MM-3MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 26MM +4MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-226,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 26MM +8MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-326,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 26MM +12MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-426,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 26MM -3MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 40MM -4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 44MM -4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 22MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 26MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-126,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V40 28MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-128,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 36MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 40MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL HEAD LFIT V40 22.2MM +3MM -,SUP-6260-9-222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 26MM +4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-226,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 28MM +4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-228,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 40MM +4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-240,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 26MM +8MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-326,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 28MM +8MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-328,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 32MM +8MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-332,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 36MM +10MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-336,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 26MM +12MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-426,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V40 28MM +12MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL HEAD LFIT ANATOMIC V40 6.5MM X 16MM -,SUP-6260-9-440,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ15 47MM OFST 140MM PARTNERSHIP RELIANCE PF PRFT -,SUP-6265-2-005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ6 50MM OFST 150MM PARTNERSHIP RELIANCE PF PRFT -,SUP-6265-2-006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.170825,27238.33344,percent of total billed charges,,,
CENTRALIZER DIST HIP 13MM TY A -,SUP-6265-4-413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,601.24,420.868,AETNA [1000108],AETNA [100010801],,,76.8,,461.75,9.170825,27238.33344,percent of total billed charges,,,
CENTRALIZER DIST HIP 14MM TY A -,SUP-6265-4-414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,601.24,420.868,AETNA [1000108],AETNA [100010801],,,76.8,,461.75,9.170825,27238.33344,percent of total billed charges,,,
CENTRALIZER DIST HIP 15MM TY B -,SUP-6265-4-515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,601.24,420.868,AETNA [1000108],AETNA [100010801],,,76.8,,461.75,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ1 10X34MM OFST 115MM PARTNERSHIP CITNN PRFT PRIM -,SUP-6265-5101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ2 36MM OFST 120MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ4 44MM OFST 130MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ5 47MM OFST 135MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA [1000108],AETNA [100010801],,,76.8,,5703.94,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ0 9X34MM OFST 110MM PARTNERSHIP CITNN PRFT PRIM -,SUP-6265-5110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ1 34MM OFST 118MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ2 36MM OFST 120MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ3 40MM OFST 133MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ4 44MM OFST 130MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ5 47MM OFST 135MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
BODY PROX HIP 21MM STD RESTOR MODULAR REVISN BOLT CNCL -,SUP-6276-1-021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA [1000108],AETNA [100010801],,,76.8,,10675.05,9.170825,27238.33344,percent of total billed charges,,,
SYS HIP RESTORATION MODULAR SZ 21MM +0 HT V40 TPR -,SUP-6276-1-021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA [1000108],AETNA [100010801],,,76.8,,10675.05,9.170825,27238.33344,percent of total billed charges,,,
BODY PROX HIP 25MM STD RESTOR MODULAR REVISN BOLT CNCL -,SUP-6276-1-025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA [1000108],AETNA [100010801],,,76.8,,10675.05,9.170825,27238.33344,percent of total billed charges,,,
BODY PROX HIP 19MM RESTOR MODULAR REVISN BOLT +10MM NK CNCL -,SUP-6276-1-119,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA [1000108],AETNA [100010801],,,76.8,,10675.05,9.170825,27238.33344,percent of total billed charges,,,
BODY PROX HIP 21MM RESTOR MODULAR REVISN BOLT +11MM NK CNCL -,SUP-6276-1-121,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA [1000108],AETNA [100010801],,,76.8,,10675.05,9.170825,27238.33344,percent of total billed charges,,,
TIP SUCT ACORN STD V. MUELLER 1.0625IN SIL RBR -,SUP-6276-1-123,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA [1000108],AETNA [100010801],,,76.8,,10675.05,9.170825,27238.33344,percent of total billed charges,,,
MODULAR HIP SYSTEM RESTORATION 25MM X +10 X V40 TPR -,SUP-6276-1-125,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA [1000108],AETNA [100010801],,,76.8,,10675.05,9.170825,27238.33344,percent of total billed charges,,,
SYSTEM HIP MODULAR 27MM X +10 X V40 TPR RESTORAITON -,SUP-6276-1-127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA [1000108],AETNA [100010801],,,76.8,,10675.05,9.170825,27238.33344,percent of total billed charges,,,
BODY PROX HIP 19MM RESTOR MODULAR REVISN BOLT +20MM NK CNCL -,SUP-6276-1-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA [1000108],AETNA [100010801],,,76.8,,10675.05,9.170825,27238.33344,percent of total billed charges,,,
BODY PROX HIP 21MM RESTOR MODULAR REVISN BOLT +20MM NK CNCL -,SUP-6276-1-221,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA [1000108],AETNA [100010801],,,76.8,,10675.05,9.170825,27238.33344,percent of total billed charges,,,
BODY PROX HIP 25MM RESTOR MODULAR REVISN BOLT +10MM NK CNCL -,SUP-6276-1-225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA [1000108],AETNA [100010801],,,76.8,,10675.05,9.170825,27238.33344,percent of total billed charges,,,
BODY PROX HIP 19MM RESTOR MODULAR REVISN BOLT +30MM NK CNCL -,SUP-6276-1-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA [1000108],AETNA [100010801],,,76.8,,10675.05,9.170825,27238.33344,percent of total billed charges,,,
BODY PROX HIP 21MM RESTOR MODULAR REVISN BOLT +30MM NK CNCL -,SUP-6276-1-321,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA [1000108],AETNA [100010801],,,76.8,,10675.05,9.170825,27238.33344,percent of total billed charges,,,
BODY PROX HIP 23MM RESTOR MODULAR REVISN BOLT +30MM NK CNCL -,SUP-6276-1-323,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA [1000108],AETNA [100010801],,,76.8,,10675.05,9.170825,27238.33344,percent of total billed charges,,,
RESTORATION MODULAR HIP SYSTEM 25MM X 30 V40 -,SUP-6276-1-325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA [1000108],AETNA [100010801],,,76.8,,10675.05,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 14X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,AETNA [1000108],AETNA [100010801],,,76.8,,7648.77,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 15X155MM RESTOR REVISN MODULAR STR CNCL DIST HIP -,SUP-6276-7-015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,AETNA [1000108],AETNA [100010801],,,76.8,,7648.77,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 16X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,AETNA [1000108],AETNA [100010801],,,76.8,,7648.77,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 17X155MM RESTOR REVISN MODULAR STR CNCL DIST HIP -,SUP-6276-7-017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,AETNA [1000108],AETNA [100010801],,,76.8,,7648.77,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 18X155MM RESTOR REVISN MODULAR STR CNCL DIST HIP -,SUP-6276-7-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,AETNA [1000108],AETNA [100010801],,,76.8,,7648.77,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 19X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,AETNA [1000108],AETNA [100010801],,,76.8,,7648.77,9.170825,27238.33344,percent of total billed charges,,,
STEM HIP RESTORATION MODULAR 20MM X 155MM -,SUP-6276-7-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,AETNA [1000108],AETNA [100010801],,,76.8,,7648.77,9.170825,27238.33344,percent of total billed charges,,,
RESTORATION MODULAR HIP SYS 22MM X 155MM -,SUP-6276-7-022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,AETNA [1000108],AETNA [100010801],,,76.8,,7648.77,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 23X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-023,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,AETNA [1000108],AETNA [100010801],,,76.8,,7648.77,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 14X195MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10547.44,7383.208,AETNA [1000108],AETNA [100010801],,,76.8,,8100.43,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 14X195MM RESTOR REVISN MODULAR HIP -,SUP-6276-7-214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,AETNA [1000108],AETNA [100010801],,,76.8,,8549.42,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 15X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,AETNA [1000108],AETNA [100010801],,,76.8,,8549.42,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 16X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,AETNA [1000108],AETNA [100010801],,,76.8,,8549.42,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 19X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,AETNA [1000108],AETNA [100010801],,,76.8,,8549.42,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 21X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,AETNA [1000108],AETNA [100010801],,,76.8,,8549.42,9.170825,27238.33344,percent of total billed charges,,,
RESTORATION MODULAR HIP SYSTEM 21MM X 195MM -,SUP-6276-7-221,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,AETNA [1000108],AETNA [100010801],,,76.8,,8549.42,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 24X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-224,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,AETNA [1000108],AETNA [100010801],,,76.8,,8549.42,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 15X235MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11716.67,8201.669,AETNA [1000108],AETNA [100010801],,,76.8,,8998.4,9.170825,27238.33344,percent of total billed charges,,,
RESTORATION HIP STEM 235MM X 19MM -,SUP-6276-7-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11716.67,8201.669,AETNA [1000108],AETNA [100010801],,,76.8,,8998.4,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 22X235MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11716.67,8201.669,AETNA [1000108],AETNA [100010801],,,76.8,,8998.4,9.170825,27238.33344,percent of total billed charges,,,
SYS RESTORATION MOD HIP 18MM X 115MM -,SUP-6276-7-418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24628.33,17239.831,AETNA [1000108],AETNA [100010801],,,76.8,,18914.56,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM PCA 28X0MM NK COCR REVISN -,SUP-6280-0-136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM PCA 32MM +5MM NK COCR REVISN -,SUP-6280-0-232,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM PCA 36MM +5MM NK COCR REVISN -,SUP-6280-0-236,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM PCA 32MM +10MM NK COCR REVISN -,SUP-6280-0-332,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM PCA 36MM +10MM NK COCR REVISN -,SUP-6280-0-336,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 32X52-55MM DURATION 10DG UHMWPE PCA -,SUP-6299-7-525,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4020.85,2814.595,AETNA [1000108],AETNA [100010801],,,76.8,,3088.01,9.170825,27238.33344,percent of total billed charges,,,
LINEAR STANDARD TRILOGY ACETABULAR SYSTEM -,SUP-6305-50-36,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5260.44,3682.308,AETNA [1000108],AETNA [100010801],,,76.8,,4040.02,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB SZ P6 28X62-64MM SHL S12 +4 10DG CROSSFIRE CONGR -,SUP-6352-5-076,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4458.11,3120.677,AETNA [1000108],AETNA [100010801],,,76.8,,3423.83,9.170825,27238.33344,percent of total billed charges,,,
CROSSFIRE SYSTEM 12 POLYETHYLENE INSERT 10 -,SUP-6352-5-105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4458.11,3120.677,AETNA [1000108],AETNA [100010801],,,76.8,,3423.83,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR SM 9MM PE PEGX3 AVON RND DOME REVISN OFST -,SUP-6430-0-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4079.19,2855.433,AETNA [1000108],AETNA [100010801],,,76.8,,3132.82,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR MED 9.5MM PE PEGX3 AVON RND DOME REVISN OFST -,SUP-6430-0-030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4079.19,2855.433,AETNA [1000108],AETNA [100010801],,,76.8,,3132.82,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR LRG 10MM PE PEGX3 AVON RND DOME REVISN OFST -,SUP-6430-0-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4079.19,2855.433,AETNA [1000108],AETNA [100010801],,,76.8,,3132.82,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM XS 43.5MMX42.5MM AVON KN CMNT PEGX4 COCR -,SUP-6430-0-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14140.63,9898.441,AETNA [1000108],AETNA [100010801],,,76.8,,10860,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM MED 50.3MMX47.5MM AVON KN CMNT PEGX4 COCR -,SUP-6430-0-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14140.63,9898.441,AETNA [1000108],AETNA [100010801],,,76.8,,10860,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 36MM E SHL TRIDENT 0DG ELEV RM ECCT X3 PRIM -,SUP-643-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
TRIDENT ELEVATED RIM INSERT 36MM G -,SUP-643-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND XS KINEMAX PLUS PRFT REVISN MODULAR 80MM COCR -,SUP-6476-8-260,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3594.54,2516.178,AETNA [1000108],AETNA [100010801],,,76.8,,2760.61,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 14MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,AETNA [1000108],AETNA [100010801],,,76.8,,3377.52,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 16MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,AETNA [1000108],AETNA [100010801],,,76.8,,3377.52,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 19MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-645,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,AETNA [1000108],AETNA [100010801],,,76.8,,3377.52,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 23MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-665,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,AETNA [1000108],AETNA [100010801],,,76.8,,3377.52,9.170825,27238.33344,percent of total billed charges,,,
STEM TITANIUM FLUTED 16MM X 155MM -,SUP-6478-6-715,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,AETNA [1000108],AETNA [100010801],,,76.8,,3377.52,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 17MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-720,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,AETNA [1000108],AETNA [100010801],,,76.8,,3377.52,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 21MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,AETNA [1000108],AETNA [100010801],,,76.8,,3377.52,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 SM M LT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,AETNA [1000108],AETNA [100010801],,,76.8,,15765.47,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 SM M RT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,AETNA [1000108],AETNA [100010801],,,76.8,,15765.47,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 MED M LT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,AETNA [1000108],AETNA [100010801],,,76.8,,15765.47,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 LRG M RT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-131,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,AETNA [1000108],AETNA [100010801],,,76.8,,15765.47,9.170825,27238.33344,percent of total billed charges,,,
MRH KNEE FEMORAL DISTAL BLOCK MED 10MM -,SUP-6481-1-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3438.71,2407.097,AETNA [1000108],AETNA [100010801],,,76.8,,2640.93,9.170825,27238.33344,percent of total billed charges,,,
COMP TIB STD XS XL KN GMRS COCR MRH -,SUP-6481-2-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11254.62,7878.234,AETNA [1000108],AETNA [100010801],,,76.8,,8643.55,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL BEARING COMPONENT MRH -,SUP-6481-2-103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11254.62,7878.234,AETNA [1000108],AETNA [100010801],,,76.8,,8643.55,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ7 STD GMRS KN MODULAR REVISN BUSHNG COCR ROT HNG -,SUP-6481-2-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1628.47,1139.929,AETNA [1000108],AETNA [100010801],,,76.8,,1250.66,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ7 STD GMRS KN MODULAR REVISN AXLE COCR ROT HNG -,SUP-6481-2-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4454.42,3118.094,AETNA [1000108],AETNA [100010801],,,76.8,,3420.99,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB BEAR KN PE -,SUP-6481-2-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3005.95,2104.165,AETNA [1000108],AETNA [100010801],,,76.8,,2308.57,9.170825,27238.33344,percent of total billed charges,,,
MRH KNEE BUMPER INSERT 3 DEGREES -,SUP-6481-2-133,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3005.95,2104.165,AETNA [1000108],AETNA [100010801],,,76.8,,2308.57,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE TIB SZ4 MODULAR BMPR DIST KN ROT HNG DURATION -,SUP-6481-2-140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2514.7,1760.29,AETNA [1000108],AETNA [100010801],,,76.8,,1931.29,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ1 KN GMRS COCR MODULAR KLD ROT HNG -,SUP-6481-3-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12573.67,8801.569,AETNA [1000108],AETNA [100010801],,,76.8,,9656.58,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ2 SM KN GMRS COCR MODULAR KLD ROT HNG -,SUP-6481-3-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12573.67,8801.569,AETNA [1000108],AETNA [100010801],,,76.8,,9656.58,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ2 LRG KN GMRS COCR MODULAR KLD ROT HNG -,SUP-6481-3-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12573.67,8801.569,AETNA [1000108],AETNA [100010801],,,76.8,,9656.58,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ1-2 XS/SM 10MM PS ARTCSURF KN PE -,SUP-6481-3-210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,AETNA [1000108],AETNA [100010801],,,76.8,,3817.08,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ1-2 XS/SM 13MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,AETNA [1000108],AETNA [100010801],,,76.8,,3817.08,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ1-2 XS/SM 16MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,AETNA [1000108],AETNA [100010801],,,76.8,,3817.08,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ1-2 XS/SM 20MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,AETNA [1000108],AETNA [100010801],,,76.8,,3817.08,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB MED 2/ L2 13MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5011.74,3508.218,AETNA [1000108],AETNA [100010801],,,76.8,,3849.02,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB MED 2/ L2 24MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-324,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5011.74,3508.218,AETNA [1000108],AETNA [100010801],,,76.8,,3849.02,9.170825,27238.33344,percent of total billed charges,,,
KINEMATIC ROTATING HINGE KNEE XSM 8MM -,SUP-6485-2-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,AETNA [1000108],AETNA [100010801],,,76.8,,5064.41,9.170825,27238.33344,percent of total billed charges,,,
HINGE KNEE ROTATING SIZE XSM 11MM THKNS KINEMATIC -,SUP-6485-2-011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,AETNA [1000108],AETNA [100010801],,,76.8,,5064.41,9.170825,27238.33344,percent of total billed charges,,,
KINEMATIC ROTATING HINGE KNEE -,SUP-6485-2-016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,AETNA [1000108],AETNA [100010801],,,76.8,,5064.41,9.170825,27238.33344,percent of total billed charges,,,
KINEMATIC ROTATING  HINGE KNEE SM 8MM -,SUP-6485-2-108,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,AETNA [1000108],AETNA [100010801],,,76.8,,5064.41,9.170825,27238.33344,percent of total billed charges,,,
KINEMATIC ROTATING HINGE KNEE -,SUP-6485-2-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,AETNA [1000108],AETNA [100010801],,,76.8,,5064.41,9.170825,27238.33344,percent of total billed charges,,,
KINEMATIC ROTATING HINGE KNEE 16MM MEDIUM -,SUP-6485-2-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,AETNA [1000108],AETNA [100010801],,,76.8,,5064.41,9.170825,27238.33344,percent of total billed charges,,,
KINEMATIC ROTATING HINGE KNEE LARGE 21MM -,SUP-6485-2-321,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,AETNA [1000108],AETNA [100010801],,,76.8,,5064.41,9.170825,27238.33344,percent of total billed charges,,,
STEM STRAIGHT CEMENTED 10MM X 102MM -,SUP-6485-3-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA [1000108],AETNA [100010801],,,76.8,,8148.92,9.170825,27238.33344,percent of total billed charges,,,
STEM REPLACEMENT STRAIGHT CEMENTED 8MM X 102MM -,SUP-6485-3-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA [1000108],AETNA [100010801],,,76.8,,8148.92,9.170825,27238.33344,percent of total billed charges,,,
STEM REPLACEMENT STRAIGHT 9MM X 102MM -,SUP-6485-3-019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA [1000108],AETNA [100010801],,,76.8,,8148.92,9.170825,27238.33344,percent of total billed charges,,,
STEM CEMENTED STRAIGHT 11 X 127 -,SUP-6485-3-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA [1000108],AETNA [100010801],,,76.8,,8148.92,9.170825,27238.33344,percent of total billed charges,,,
STEM MRS STRAIGHT CEMENTED 13 X 127 -,SUP-6485-3-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA [1000108],AETNA [100010801],,,76.8,,8148.92,9.170825,27238.33344,percent of total billed charges,,,
STEM-REPLACEMENT CURVED CEMENTED 10MM X 102MM -,SUP-6485-3-310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA [1000108],AETNA [100010801],,,76.8,,8148.92,9.170825,27238.33344,percent of total billed charges,,,
STEM REPLACEMENT CURVED CEMENTED 8MM X 102MM -,SUP-6485-3-318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA [1000108],AETNA [100010801],,,76.8,,8148.92,9.170825,27238.33344,percent of total billed charges,,,
STEM REPLACEMENT CURVED CEMENTED -,SUP-6485-3-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA [1000108],AETNA [100010801],,,76.8,,8148.92,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 11MM LNG GMRS MODULAR 203MM TI HAP PLASM SPRY CTD -,SUP-6485-3-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14897,10427.9,AETNA [1000108],AETNA [100010801],,,76.8,,11440.9,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 17X203MM MRS MODULAR COCR POR CTD CMNT CRV DIST HIP -,SUP-6485-3-617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14897,10427.9,AETNA [1000108],AETNA [100010801],,,76.8,,11440.9,9.170825,27238.33344,percent of total billed charges,,,
MRS CURVED CEMENTED STEM 11MM X 127MM -,SUP-6485-3-811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA [1000108],AETNA [100010801],,,76.8,,8148.92,9.170825,27238.33344,percent of total billed charges,,,
MRS CURVED CEMENTED STEM 13MM X 127MM -,SUP-6485-3-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA [1000108],AETNA [100010801],,,76.8,,8148.92,9.170825,27238.33344,percent of total billed charges,,,
STEM CEMENTED STEM 15 X 127 -,SUP-6485-3-815,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA [1000108],AETNA [100010801],,,76.8,,8148.92,9.170825,27238.33344,percent of total billed charges,,,
STEM CEMENTED 17MM X 127MM CURVED -,SUP-6485-3-817,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA [1000108],AETNA [100010801],,,76.8,,8148.92,9.170825,27238.33344,percent of total billed charges,,,
GMRS PROXIMAL FEMORAL COMPONENT V40 -,SUP-6495-1-002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19014.24,13309.968,AETNA [1000108],AETNA [100010801],,,76.8,,14602.94,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT DISTAL FEMORAL SMALL LEFT 65MM -,SUP-6495-2-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27396.07,19177.249,AETNA [1000108],AETNA [100010801],,,76.8,,21040.18,9.170825,27238.33344,percent of total billed charges,,,
DISTAL FEMORAL COMPONENT SMALL RT 65MM -,SUP-6495-2-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27396.07,19177.249,AETNA [1000108],AETNA [100010801],,,76.8,,21040.18,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM STD 65MM GMRS LT DIST KN MODULAR COCR ROT HNG -,SUP-6495-2-030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27152.28,19006.596,AETNA [1000108],AETNA [100010801],,,76.8,,20852.95,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM STD 65MM GMRS RT DIST KN MODULAR COCR ROT HNG -,SUP-6495-2-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27152.28,19006.596,AETNA [1000108],AETNA [100010801],,,76.8,,20852.95,9.170825,27238.33344,percent of total billed charges,,,
BUSHING FOR SMALL DISTAL FEMUR -,SUP-6495-2-105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1672.63,1170.841,AETNA [1000108],AETNA [100010801],,,76.8,,1284.58,9.170825,27238.33344,percent of total billed charges,,,
AXLE GMRS -,SUP-6495-2-115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4462.74,3123.918,AETNA [1000108],AETNA [100010801],,,76.8,,3427.38,9.170825,27238.33344,percent of total billed charges,,,
INSERT FOR SMALL PROXIMAL TIBIAL COMPONENT 13MM -,SUP-6495-3-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,AETNA [1000108],AETNA [100010801],,,76.8,,3817.08,9.170825,27238.33344,percent of total billed charges,,,
INSERT FOR SMALL PROXIMAL TIBIAL COMPONENT 24MM -,SUP-6495-3-024,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,AETNA [1000108],AETNA [100010801],,,76.8,,3817.08,9.170825,27238.33344,percent of total billed charges,,,
PROXIMAL TIBIA GMRS SM 80MM -,SUP-6495-3-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27343.31,19140.317,AETNA [1000108],AETNA [100010801],,,76.8,,20999.66,9.170825,27238.33344,percent of total billed charges,,,
TIBIA PROXIMAL STD 80MM -,SUP-6495-3-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27343.31,19140.317,AETNA [1000108],AETNA [100010801],,,76.8,,20999.66,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL ROTATING COMPONENT SM -,SUP-6495-3-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11240.07,7868.049,AETNA [1000108],AETNA [100010801],,,76.8,,8632.37,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND GMRS REVISN MODULAR 30MM FEM KN -,SUP-6495-6-030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,AETNA [1000108],AETNA [100010801],,,76.8,,8823.8,9.170825,27238.33344,percent of total billed charges,,,
PIECE EXTENSION GMRS 40MM LENGTH -,SUP-6495-6-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,AETNA [1000108],AETNA [100010801],,,76.8,,8823.8,9.170825,27238.33344,percent of total billed charges,,,
GMRS EXTENSION PIECE 50MM -,SUP-6495-6-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,AETNA [1000108],AETNA [100010801],,,76.8,,8823.8,9.170825,27238.33344,percent of total billed charges,,,
EXTENSION PIECE GMRS -,SUP-6495-6-070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,AETNA [1000108],AETNA [100010801],,,76.8,,8823.8,9.170825,27238.33344,percent of total billed charges,,,
GMRS EXTENSION PIECE 120MM -,SUP-6495-6-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,AETNA [1000108],AETNA [100010801],,,76.8,,8823.8,9.170825,27238.33344,percent of total billed charges,,,
GRAFT HUM TIS 6X10CM TISSUEMEND COLL -,SUP-6495-9-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10181.42,7126.994,AETNA [1000108],AETNA [100010801],,,76.8,,7819.33,9.170825,27238.33344,percent of total billed charges,,,
HEAD DELTA CERAMIC FEMORAL 36/-3MM -,SUP-650-0660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,,,
HEAD DELTA CERAMIC FEMORAL 36/0MM -,SUP-650-0661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,,,
HEAD DELTA CERAMIC FEMORAL 36/+3MM -,SUP-650-0662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,,,
CERAMIC HEAD BIOLOX DELTA  OP HIP SYSTEM 28MM -,SUP-650-1055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,,,
HEAD CER BIOLOX D OPTION 28MM -,SUP-650-1055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,,,
HEAD CER BIOLOXD OPTION 36MM -,SUP-650-1057,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,,,
CER OPTION TYPE 1 TPR SLEEVE +3 -,SUP-650-1067,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,9.170825,27238.33344,percent of total billed charges,,,
+6MM NECK BIOLOCK OPTION HIP SYSTEM -,SUP-650-1068,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEMORAL G7 BIOLOX DELTA -3 MM OFFSET OD28 MM HIP -,SUP-650-1159,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL HEAD UNIVERSAL TAPER 28MM OD BIOLOX DELTA -,SUP-6519-1-028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL HEAD UNIVERSAL TAPER BIOLOX DELTA -,SUP-6519-1-032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 36MM UNIV +0MML NK BIOLOX DELTA CERM TAPR PRIM -,SUP-6519-1-036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEMORAL 40MM BIOLOX DELTA -,SUP-6519-1-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,,,
UNIVERSAL V40  -2.5MM ADAPTER SLEEVE (TI) -,SUP-6519-T-025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,AETNA [1000108],AETNA [100010801],,,76.8,,717,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE HIP UNIV V-40 RECON PRIM ADPTR +0MML NK OFST TI TAPR -,SUP-6519-T-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,AETNA [1000108],AETNA [100010801],,,76.8,,717,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE HIP +4MM OFST UNIV V-40 RECON PRIM ADPTR TI TAPR -,SUP-6519-T-204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,AETNA [1000108],AETNA [100010801],,,76.8,,717,9.170825,27238.33344,percent of total billed charges,,,
IMPACTOR SURG F/TIB INS TRIATH -,SUP-6541-4-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2125.24,1487.668,AETNA [1000108],AETNA [100010801],,,76.8,,1632.18,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 36MM-5MM NK ALMN PRIM -,SUP-6565-0-036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 32X0MM NK ALMN PRIM -,SUP-6565-0-132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 28MM -2.7MM OFST BIOLOX DELTA CERAMIC -,SUP-6570-0-028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 32MM -4MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 36MM -5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 28MM +0MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-128,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 32MM +0MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 36MM +0MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 28MM +4MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-228,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 32MM +4MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-232,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 36MM +5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-236,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 36MM -2.5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-436,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 36MM +2.5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-536,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 36MM +7.5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-736,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 36X54-56MM F SHL TRIDENT 0DG ECCT X3 PRIM -,SUP-663-00-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT KN SZ1 SM DURACN 10MM WDG BLCK REVISN VITAL -,SUP-6630-6-510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5255.98,3679.186,AETNA [1000108],AETNA [100010801],,,76.8,,4036.59,9.170825,27238.33344,percent of total billed charges,,,
DURACON TOTAL KNEE FULL FLAT TIBIAL WEDGE SM-2 10MM -,SUP-6630-6-515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5255.98,3679.186,AETNA [1000108],AETNA [100010801],,,76.8,,4036.59,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 32X46-48MM D SHL TRIDENT 10DG ECCT X3 16.8MM -,SUP-663-10-32D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 36X58-60MM G SHL TRIDENT 10DG ECCT X3 18.8MM -,SUP-663-10-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 36X62-64MM H SHL TRIDENT 10DG ECCT X3 20.4MM -,SUP-663-10-36H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
CK Insert Trial Sz 4 8mm -,SUP-663-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA [1000108],AETNA [100010801],,,76.8,,887.29,9.170825,27238.33344,percent of total billed charges,,,
CK Insert Trial Sz 5 16mm -,SUP-663-1516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA [1000108],AETNA [100010801],,,76.8,,887.29,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB LRG 9X77/53MM DURACN CR A/P LIP ARTC L/R KN -,SUP-6642-1-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3601.27,2520.889,AETNA [1000108],AETNA [100010801],,,76.8,,2765.78,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT A-P LIPPED DURACON XLGE 9MM -,SUP-6642-1-909,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3601.27,2520.889,AETNA [1000108],AETNA [100010801],,,76.8,,2765.78,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR XS PE DURACON DURATION ASYM -,SUP-6642-2-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR MED PE DURACON DURATION ASYM -,SUP-6642-2-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SM 11MMX45MM A/P DURACN CNSTRN ARTC L/R KN -,SUP-6642-9-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,AETNA [1000108],AETNA [100010801],,,76.8,,6510.64,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB LRG 9MMX55MM ARTCSURF L/R KN PE -,SUP-6642-9-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,AETNA [1000108],AETNA [100010801],,,76.8,,6510.64,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB LRG 11MMX55MM A/P DURACN CNSTRN ARTC L/R KN -,SUP-6642-9-811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,AETNA [1000108],AETNA [100010801],,,76.8,,6510.64,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB LRG 13MMX55MM A/P DURACN CNSTRN ARTC L/R KN -,SUP-6642-9-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,AETNA [1000108],AETNA [100010801],,,76.8,,6510.64,9.170825,27238.33344,percent of total billed charges,,,
TibAugSz1Trial20Â°WedgeLtLat/RtMed -,SUP-667-2201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,945.27,661.689,AETNA [1000108],AETNA [100010801],,,76.8,,725.97,9.170825,27238.33344,percent of total billed charges,,,
TibAugSz2Trial20Â°WedgeLtLat/RtMed -,SUP-667-2202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,945.27,661.689,AETNA [1000108],AETNA [100010801],,,76.8,,725.97,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ2 33MM OFST 99MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ3 35MM OFST 102MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ4 38MM OFST 105MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ5 35MM OFST 108MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ6 41MM OFST 111MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ7 46MM OFST 114MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0737,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,,,
STEM HIP ACCOLADE 132 SZ 8 -,SUP-6720-0837,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,,,
STEM HIP 132 DEG SZ #9 37MM X 120MM V40 ANGLE ACCOLADE II -,SUP-6720-0937,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,,,
NECK ANGLE HIP STEM SZ# 0 / 27MM / 93MM / V40 -,SUP-6721-0027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ1 34MM OFST 96MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ2 37MM OFST 99MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ3 30MM OFST 102MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ4 42MM OFST 105MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,,,
ACCOLADE II SZ5 35MM NECK ANGLE HIP STEM 108MM V40 -,SUP-6721-0535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ6 35MM OFST 111MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ7 50MM OFST 114MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0737,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ8 51MM OFST 117MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0837,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ9 53MM OFST 120MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0937,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ10 57MM OFST 123MM ACCOLADE II V40 PRFT PRIM -,SUP-6721-1040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SM 9MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4186.89,2930.823,AETNA [1000108],AETNA [100010801],,,76.8,,3215.53,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SM 11MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4186.89,2930.823,AETNA [1000108],AETNA [100010801],,,76.8,,3215.53,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SM 16MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-116,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4186.89,2930.823,AETNA [1000108],AETNA [100010801],,,76.8,,3215.53,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ2 16MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,AETNA [1000108],AETNA [100010801],,,76.8,,3915.57,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB LRG 9MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-309,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,AETNA [1000108],AETNA [100010801],,,76.8,,3915.57,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 11MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,AETNA [1000108],AETNA [100010801],,,76.8,,3915.57,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB LRG 16MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,AETNA [1000108],AETNA [100010801],,,76.8,,3915.57,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 22X50-52MM D SHL TRIDENT 0DG ECCT UHMWPE CNSTRN -,SUP-690-00-22D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,AETNA [1000108],AETNA [100010801],,,76.8,,7525.47,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 22X50-52MM E SHL TRIDENT 0DG ECCT UHMWPE CNSTRN -,SUP-690-00-22E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,AETNA [1000108],AETNA [100010801],,,76.8,,7525.47,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 22X54-56MM F SHL TRIDENT 0DG ECCT UHMWPE CNSTRN -,SUP-690-00-28F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,AETNA [1000108],AETNA [100010801],,,76.8,,7525.47,9.170825,27238.33344,percent of total billed charges,,,
TRIDENT 0 DG ACETABULAR INSERT SZ H -,SUP-690-00-32H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,AETNA [1000108],AETNA [100010801],,,76.8,,7525.47,9.170825,27238.33344,percent of total billed charges,,,
TRIDENT ALL POLY CONSTRAINED ACETABULAR INSERT -,SUP-69-2244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10027.4,7019.18,AETNA [1000108],AETNA [100010801],,,76.8,,7701.04,9.170825,27238.33344,percent of total billed charges,,,
ALL POLY CONSTRAINED INSERT 46MM -,SUP-69-2246,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10027.4,7019.18,AETNA [1000108],AETNA [100010801],,,76.8,,7701.04,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM UNITRAX 40MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM UNITRAX 42MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM UNITRAX 43MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM UNITRAX 46MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM UNITRAX 47MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-047,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE HIP UNITRAX V40 PRIM MODULAR UNIPL -4MM NK TAPR -,SUP-6942-6-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,76.8,,604.98,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE HIP UNITRAX V40 PRIM MODULAR UNIPL +0MML NK TAPR -,SUP-6942-6-065,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,76.8,,604.98,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE HIP UNITRAX V40 PRIM MODULAR UNIPL +8MM NK TAPR -,SUP-6942-6-075,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,76.8,,604.98,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE HIP UNITRAX C UNIPL -3MM NK C-TAPR -,SUP-6942-7-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,76.8,,604.98,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE HIP UNITRAX C UNIPL +0MML NK C-TAPR -,SUP-6942-7-065,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,76.8,,604.98,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE HIP UNITRAX C UNIPL +5MM NK C-TAPR -,SUP-6942-7-075,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,76.8,,604.98,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE HIP UNITRAX C UNIPL +10MM NK C-TAPR -,SUP-6942-7-085,CDM,C1776,HCPCS,278,RC,,,outpatient,,,810.6,567.42,AETNA [1000108],AETNA [100010801],,,76.8,,622.54,9.170825,27238.33344,percent of total billed charges,,,
STEM HIP HIGH OFFSET INSIGNIA SZ 4 X 36MM X 103MM -,SUP-7000-6604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,9.170825,27238.33344,percent of total billed charges,,,
SHELL CLUSTERHOLE ACET 46MM C TRIDENT TRITANIUM -,SUP-702-04-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,,,
TRIDENT IITRITANIUM CLUSTERHOLE 48MM D -,SUP-702-04-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,,,
SHELL TRIDENT II TRITANIUM CLUSTERHOLE ACETABULAR 50MM D -,SUP-702-04-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,,,
TRIDENT II TRITANIUM CLUSTERHOLE ACETABULAR SHELL -,SUP-702-04-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,,,
TRIDENT II TRITANIUM CLUSTERHOLE ACET SHELL 54MM -,SUP-702-04-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,,,
TRIDENT II TRITANIUM CLUSTERHOLE ACE SHELL 56MM F -,SUP-702-04-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,,,
TRIDENT II TRITANIUM CLUSTERHOLE ACE SHELL 58MM F -,SUP-702-04-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,,,
TRIDENT II TRITANIUM CLUST ACE SHELL SZ 60MM G -,SUP-702-04-60G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,,,
SHELL CLUSTERHOLE ACET SIZE 62MM G TRIDENT II TRITANIUM -,SUP-702-04-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACET 64MM H TRIDENT II TRIT CLUSTERHOLE -,SUP-702-04-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA [1000108],AETNA [100010801],,,76.8,,3503.85,9.170825,27238.33344,percent of total billed charges,,,
44MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-44B,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,,,
46MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,,,
48MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,9.170825,27238.33344,percent of total billed charges,,,
52MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,,,
54MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,,,
56MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,,,
58MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,,,
60MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-60G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,,,
62MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,,,
64MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,,,
66MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-66H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,,,
TRIDENT II TRITANIUM MULTIHOLE ACE SHELL 48MM D -,SUP-709-04-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,AETNA [1000108],AETNA [100010801],,,76.8,,8305.5,9.170825,27238.33344,percent of total billed charges,,,
SHELL TRIDENT II TITAN MLTHLE ACE SIZE 52MM E -,SUP-709-04-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,AETNA [1000108],AETNA [100010801],,,76.8,,8305.5,9.170825,27238.33344,percent of total billed charges,,,
SHELL TRIDENT II TRITANIUM MLTHOLE ACE 54MM E -,SUP-709-04-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,AETNA [1000108],AETNA [100010801],,,76.8,,8305.5,9.170825,27238.33344,percent of total billed charges,,,
TRIDENT II TRITANIUM MULTHL SHELL 56MM F -,SUP-709-04-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,AETNA [1000108],AETNA [100010801],,,76.8,,8305.5,9.170825,27238.33344,percent of total billed charges,,,
SHELL MULTIHOLE ACETABULAR 62MM X G TRIDENT II TRITANIUM -,SUP-709-04-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,AETNA [1000108],AETNA [100010801],,,76.8,,8305.5,9.170825,27238.33344,percent of total billed charges,,,
SHELL TRIDENT II TITANIUM 64MM H MULTIHOLE -,SUP-709-04-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,AETNA [1000108],AETNA [100010801],,,76.8,,8305.5,9.170825,27238.33344,percent of total billed charges,,,
SHELL MULTIHOLE ACET SZ 66MM H TRIDENT II TRITANIUM -,SUP-709-04-66H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,AETNA [1000108],AETNA [100010801],,,76.8,,8305.5,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACETABULAR 68MM ALPHA I MULTIHOLE TRIDENT II TRITANIUM -,SUP-709-04-68I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,AETNA [1000108],AETNA [100010801],,,76.8,,8305.5,9.170825,27238.33344,percent of total billed charges,,,
COMP ACTB 22X42MM SHL TANDEM AN-ROT BIPLR COCR UHMWPE MAX -,SUP-71322042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2755.51,1928.857,AETNA [1000108],AETNA [100010801],,,76.8,,2116.23,9.170825,27238.33344,percent of total billed charges,,,
REF XLPE 36 20 DEG 54-56F -,SUP-7133-3345,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9094.89,6366.423,AETNA [1000108],AETNA [100010801],,,76.8,,6984.88,9.170825,27238.33344,percent of total billed charges,,,
ACET LINER 36 X 58 R3 20 DEG XLPE -,SUP-71335758,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6230.19,4361.133,AETNA [1000108],AETNA [100010801],,,76.8,,4784.79,9.170825,27238.33344,percent of total billed charges,,,
COVER SCR HL HIP THRD R3 REFLC STRL -,SUP-71336500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,407.81,285.467,AETNA [1000108],AETNA [100010801],,,76.8,,313.2,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACETABULAR 58MM R3 MULTI HOLE -,SUP-71338668,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8734.15,6113.905,AETNA [1000108],AETNA [100010801],,,76.8,,6707.83,9.170825,27238.33344,percent of total billed charges,,,
OXINIUM HD 12/14 22MM +4 -,SUP-71342204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7011.09,4907.763,AETNA [1000108],AETNA [100010801],,,76.8,,5384.52,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 36MM +0MML NK OXNM 12/14 TAPR STRL -,SUP-71343600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8339.46,5837.622,AETNA [1000108],AETNA [100010801],,,76.8,,6404.71,9.170825,27238.33344,percent of total billed charges,,,
GNS II CMT TIB SIZE 2 LEFT -,SUP-71420162,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,AETNA [1000108],AETNA [100010801],,,76.8,,3519.77,9.170825,27238.33344,percent of total billed charges,,,
GNS II CMT TIBIAL SIZE 3 LEFT -,SUP-71420164,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,AETNA [1000108],AETNA [100010801],,,76.8,,3519.77,9.170825,27238.33344,percent of total billed charges,,,
GNS II CMT TIB SIZE 5 LEFT -,SUP-71420168,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,AETNA [1000108],AETNA [100010801],,,76.8,,3519.77,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ3 64/48MM RT KN CMNT GENESIS II NPOR -,SUP-71420182,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4286.44,3000.508,AETNA [1000108],AETNA [100010801],,,76.8,,3291.99,9.170825,27238.33344,percent of total billed charges,,,
GNS II CMT TIB SIZE 4 RIGHT -,SUP-71420184,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,AETNA [1000108],AETNA [100010801],,,76.8,,3519.77,9.170825,27238.33344,percent of total billed charges,,,
GNS II CMT TIB SIZE 6 RIGHT -,SUP-71420188,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,AETNA [1000108],AETNA [100010801],,,76.8,,3519.77,9.170825,27238.33344,percent of total billed charges,,,
GNSII CON INS SZ3-4 11MM -,SUP-71420524,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,AETNA [1000108],AETNA [100010801],,,76.8,,7887.73,9.170825,27238.33344,percent of total billed charges,,,
INSERT GENESIS II SZ 3-4 13MM -,SUP-71420526,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,AETNA [1000108],AETNA [100010801],,,76.8,,7887.73,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3-4 15MM 68-71MM M/L 48-50MM A/P GENESIS II -,SUP-71420528,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,AETNA [1000108],AETNA [100010801],,,76.8,,7887.73,9.170825,27238.33344,percent of total billed charges,,,
GNS II CON INS SZ 3-4 18MM -,SUP-71420530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,AETNA [1000108],AETNA [100010801],,,76.8,,7887.73,9.170825,27238.33344,percent of total billed charges,,,
GNS II CON INS SZ5-6 15MM -,SUP-71420542,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,9.170825,27238.33344,percent of total billed charges,,,
GNS II RESUR PAT 29MM -,SUP-71420574,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,9.170825,27238.33344,percent of total billed charges,,,
RESURF PAT GEN II 32MM -,SUP-71420576,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 35X9MM THK UHMWPE PEGX3 RSRFC GENESIS II -,SUP-71420578,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,AETNA [1000108],AETNA [100010801],,,76.8,,1282.3,9.170825,27238.33344,percent of total billed charges,,,
GNS II RESURF PAT 26MM -,SUP-71420580,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5-6 13MM 74-77MM M/L 52-54MM A/P GENESIS II PS -,SUP-71420834,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2502.77,1751.939,AETNA [1000108],AETNA [100010801],,,76.8,,1922.13,9.170825,27238.33344,percent of total billed charges,,,
LEGION CON ART INS 9MM SZ 1-2 -,SUP-71420959,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,9.170825,27238.33344,percent of total billed charges,,,
INSERT G2 CONST SZ1-2 11MM -,SUP-71420960,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,AETNA [1000108],AETNA [100010801],,,76.8,,2889.15,9.170825,27238.33344,percent of total billed charges,,,
INSERT ARTICULAR G2 CONST SIZE 1-2 13MM -,SUP-71420962,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,AETNA [1000108],AETNA [100010801],,,76.8,,7887.73,9.170825,27238.33344,percent of total billed charges,,,
COMP FEMORAL SIZE 4 RIGHT LEGI -,SUP-71420964,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ1-2 18MM 60-64MM M/L 42-45MM A/P GENESIS II -,SUP-71420966,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,9.170825,27238.33344,percent of total billed charges,,,
LGN HM ST 3-4 5MM LTMD-RTLA -,SUP-71421142,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6854.06,4797.842,AETNA [1000108],AETNA [100010801],,,76.8,,5263.92,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ3 LEGION LT KN CNSTRN REVISN OXNM -,SUP-71421163,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,AETNA [1000108],AETNA [100010801],,,76.8,,21700.55,9.170825,27238.33344,percent of total billed charges,,,
LGN OX CONSTRAINED FEM 4 LT -,SUP-71421164,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,AETNA [1000108],AETNA [100010801],,,76.8,,21700.55,9.170825,27238.33344,percent of total billed charges,,,
LGN OX CONSTRAINED FEM 6 LT -,SUP-71421166,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,AETNA [1000108],AETNA [100010801],,,76.8,,21700.55,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT FEMORAL SIZE 4 RIGHT -,SUP-71421174,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29666.87,20766.809,AETNA [1000108],AETNA [100010801],,,76.8,,22784.16,9.170825,27238.33344,percent of total billed charges,,,
LEGION OX CONSTRAINED FEM 5 RT -,SUP-71421175,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,AETNA [1000108],AETNA [100010801],,,76.8,,21700.55,9.170825,27238.33344,percent of total billed charges,,,
LEGION PS OIN FEM SZ3 RT -,SUP-71421203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA [1000108],AETNA [100010801],,,76.8,,7670.76,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ4 LEGION RT KN PS OXNM POR -,SUP-71421204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10489.23,7342.461,AETNA [1000108],AETNA [100010801],,,76.8,,8055.73,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 LEGION RT KN PS OXNM POR -,SUP-71421205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA [1000108],AETNA [100010801],,,76.8,,7670.76,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ6 LEGION PS OXIN RIGHT -,SUP-71421206,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA [1000108],AETNA [100010801],,,76.8,,7670.76,9.170825,27238.33344,percent of total billed charges,,,
LEGION PS OXIN FEM SZ4 LT -,SUP-71421214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA [1000108],AETNA [100010801],,,76.8,,7670.76,9.170825,27238.33344,percent of total billed charges,,,
LEGION PS OXIN FEM SZ6 LT -,SUP-71421216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA [1000108],AETNA [100010801],,,76.8,,7670.76,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 LEGION RT KN CR REVISN OXNM POR -,SUP-71421225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9893.85,6925.695,AETNA [1000108],AETNA [100010801],,,76.8,,7598.48,9.170825,27238.33344,percent of total billed charges,,,
LEGION CR OXIN FEM SZ6 RT -,SUP-71421226,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA [1000108],AETNA [100010801],,,76.8,,7670.76,9.170825,27238.33344,percent of total billed charges,,,
LEGION NARROW PS OXIN SZ 4N LT -,SUP-71421264,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA [1000108],AETNA [100010801],,,76.8,,7670.76,9.170825,27238.33344,percent of total billed charges,,,
LEGION NARROW PS OXIN SZ 6N LT -,SUP-71421266,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA [1000108],AETNA [100010801],,,76.8,,7670.76,9.170825,27238.33344,percent of total billed charges,,,
LEGION NARROW PS OXIN SZ 5N RT -,SUP-71421275,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,AETNA [1000108],AETNA [100010801],,,76.8,,7333.63,9.170825,27238.33344,percent of total billed charges,,,
LEGION NARROW PS OXIN SZ 6N RT -,SUP-71421276,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9574.46,6702.122,AETNA [1000108],AETNA [100010801],,,76.8,,7353.19,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3-4 13MM GENESIS II PS ARTC L/R KN-HI FLEX OXNM -,SUP-71421510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3539.59,2477.713,AETNA [1000108],AETNA [100010801],,,76.8,,2718.41,9.170825,27238.33344,percent of total billed charges,,,
GEN II PS HIGH FLEXION ARTICULAR INSERT SZ 5-6 13 -,SUP-71421517,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5975.55,4182.885,AETNA [1000108],AETNA [100010801],,,76.8,,4589.22,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT DIST KN SZ3 LEGION 10MM WDG BLCK -,SUP-71421658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA [1000108],AETNA [100010801],,,76.8,,3552.74,9.170825,27238.33344,percent of total billed charges,,,
WEDGE FEM LGN SCRW DIS SZ4 5MM -,SUP-71421661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,9.170825,27238.33344,percent of total billed charges,,,
LEGION SCREW DIS FEM WDG SZ5 5MM -,SUP-71421664,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6068.92,4248.244,AETNA [1000108],AETNA [100010801],,,76.8,,4660.93,9.170825,27238.33344,percent of total billed charges,,,
LEGION SCW LWDG S5 5D X 5P -,SUP-71421741,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8891.18,6223.826,AETNA [1000108],AETNA [100010801],,,76.8,,6828.43,9.170825,27238.33344,percent of total billed charges,,,
JUNI OX FB FEM SZ 3 LM RL -,SUP-71422343,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,AETNA [1000108],AETNA [100010801],,,76.8,,7613.94,9.170825,27238.33344,percent of total billed charges,,,
JUNI OX FB FEM SZ 5 LM RL -,SUP-71422345,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,AETNA [1000108],AETNA [100010801],,,76.8,,7613.94,9.170825,27238.33344,percent of total billed charges,,,
JUNI OX FB FEM SZ 7 LM RL -,SUP-71422347,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,AETNA [1000108],AETNA [100010801],,,76.8,,7613.94,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT FEMORAL JOURNEY OXINIUM SZ 5 RM LL -,SUP-71422355,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,AETNA [1000108],AETNA [100010801],,,76.8,,7613.94,9.170825,27238.33344,percent of total billed charges,,,
LGN RK/HK HEMI SZ 3-4 LL/RM 5MM -,SUP-71423420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8496.49,5947.543,AETNA [1000108],AETNA [100010801],,,76.8,,6525.3,9.170825,27238.33344,percent of total billed charges,,,
LGN RK/HK HEMI SZ 3-4 LM/RL 5MM -,SUP-71423432,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8496.49,5947.543,AETNA [1000108],AETNA [100010801],,,76.8,,6525.3,9.170825,27238.33344,percent of total billed charges,,,
LEGION REVISION TIBIAL BASEPLATE -,SUP-71424001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,AETNA [1000108],AETNA [100010801],,,76.8,,8677.37,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE REVISION LONG TIBIA SIZE 2 LT -,SUP-71424002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,AETNA [1000108],AETNA [100010801],,,76.8,,8677.37,9.170825,27238.33344,percent of total billed charges,,,
TIBIA BASE LGN REV SIZE 4 LT -,SUP-71424004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,AETNA [1000108],AETNA [100010801],,,76.8,,8677.37,9.170825,27238.33344,percent of total billed charges,,,
LGN REV TIBIA BASE SZ 5 LT -,SUP-71424005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,AETNA [1000108],AETNA [100010801],,,76.8,,8677.37,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIBIAL SIZE 2 RIGHT -,SUP-71424012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11863.04,8304.128,AETNA [1000108],AETNA [100010801],,,76.8,,9110.81,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ3 RT KN LEGION TI REVISN -,SUP-71424013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,AETNA [1000108],AETNA [100010801],,,76.8,,8677.37,9.170825,27238.33344,percent of total billed charges,,,
LEGION REV TIBIA BASE SZ 5 RT -,SUP-71424015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,AETNA [1000108],AETNA [100010801],,,76.8,,8677.37,9.170825,27238.33344,percent of total billed charges,,,
STEM PRESSFIT LONG 10MM X 120MM -,SUP-71424023,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,AETNA [1000108],AETNA [100010801],,,76.8,,4595.74,9.170825,27238.33344,percent of total billed charges,,,
LGN PRESSFIT STEM 12MM X 120MM -,SUP-71424025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,AETNA [1000108],AETNA [100010801],,,76.8,,4823.9,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 13MM LEGION PRFT REVISN 120MM TI FEM KN -,SUP-71424026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,AETNA [1000108],AETNA [100010801],,,76.8,,4595.74,9.170825,27238.33344,percent of total billed charges,,,
STEM STRAIGHT 14MM X 120MM LEG -,SUP-71424027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,AETNA [1000108],AETNA [100010801],,,76.8,,4823.9,9.170825,27238.33344,percent of total billed charges,,,
STEM LGN PRESSFIT 15MM X 120MM -,SUP-71424028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,AETNA [1000108],AETNA [100010801],,,76.8,,4823.9,9.170825,27238.33344,percent of total billed charges,,,
LGN PRESSFIT STEM 16MM X 120MM -,SUP-71424029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,AETNA [1000108],AETNA [100010801],,,76.8,,4595.74,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTENSION LEGION TI PRESSFIT 18MM X 120MM -,SUP-71424031,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,AETNA [1000108],AETNA [100010801],,,76.8,,4823.9,9.170825,27238.33344,percent of total billed charges,,,
LGN PRESSFIT STEM 11MM X 160MM -,SUP-71424044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,AETNA [1000108],AETNA [100010801],,,76.8,,4719.6,9.170825,27238.33344,percent of total billed charges,,,
STEM LGN PRESSFIT 12MM X 160MM -,SUP-71424045,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,AETNA [1000108],AETNA [100010801],,,76.8,,4719.6,9.170825,27238.33344,percent of total billed charges,,,
STEM LGN PRESSFIT 13MM X 160MM -,SUP-71424046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,AETNA [1000108],AETNA [100010801],,,76.8,,4719.6,9.170825,27238.33344,percent of total billed charges,,,
LGN PRESSFIT STEM 15MM X 160MM -,SUP-71424048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,AETNA [1000108],AETNA [100010801],,,76.8,,4719.6,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 16MM LEGION PRFT REVISN 160MM TI FEM KN -,SUP-71424049,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,AETNA [1000108],AETNA [100010801],,,76.8,,4719.6,9.170825,27238.33344,percent of total billed charges,,,
STEM LGN CEMENT 14MM X 160MM STRT -,SUP-71424206,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6527.27,4569.089,AETNA [1000108],AETNA [100010801],,,76.8,,5012.94,9.170825,27238.33344,percent of total billed charges,,,
LGN OFFSET COUPLER 2MM -,SUP-71424223,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6132.58,4292.806,AETNA [1000108],AETNA [100010801],,,76.8,,4709.82,9.170825,27238.33344,percent of total billed charges,,,
LGN OFFSET COUPLER 4MM -,SUP-71424225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6132.58,4292.806,AETNA [1000108],AETNA [100010801],,,76.8,,4709.82,9.170825,27238.33344,percent of total billed charges,,,
LGN CR HIGH FLEX XLPE SZ 3-4 9MM -,SUP-71453111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,AETNA [1000108],AETNA [100010801],,,76.8,,2889.15,9.170825,27238.33344,percent of total billed charges,,,
INSERT LEGION CR HIGH FLEX XLPE SZ 3-4 -,SUP-71453112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3-4 9MM LEGION CR KN XLPE -,SUP-71453146,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,AETNA [1000108],AETNA [100010801],,,76.8,,3666.82,9.170825,27238.33344,percent of total billed charges,,,
LGN PS HIGH FLEX XLPE SZ 1-2 10MM -,SUP-71453171,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,9.170825,27238.33344,percent of total billed charges,,,
LGN PS HIGH FLEX XLPE SZ 3-4 12MM -,SUP-71453174,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,9.170825,27238.33344,percent of total billed charges,,,
LGN PS HIGH FLEX XLPE SZ 1-2 15MM -,SUP-71453204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,AETNA [1000108],AETNA [100010801],,,76.8,,2889.15,9.170825,27238.33344,percent of total billed charges,,,
LGN PS HIGH FLEX XLPE SZ 3-4 9MM -,SUP-71453211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,AETNA [1000108],AETNA [100010801],,,76.8,,2889.15,9.170825,27238.33344,percent of total billed charges,,,
LEGION PS HIGH FLEX XLPE SZ 3-4 11MM -,SUP-71453212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,9.170825,27238.33344,percent of total billed charges,,,
LGN PS HIGH FLEX SLPE SZ 3-4 13MM -,SUP-71453213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,9.170825,27238.33344,percent of total billed charges,,,
LEGION PS HIGH FLEX XLPE SZ 3-4 15MM -,SUP-71453214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4308.51,3015.957,AETNA [1000108],AETNA [100010801],,,76.8,,3308.94,9.170825,27238.33344,percent of total billed charges,,,
LGN PS HIGH FLEX XLPE SZ 5-6 15MM -,SUP-71453224,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3-4 13MM PS KN LEGION XLPE -,SUP-71453248,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,9.170825,27238.33344,percent of total billed charges,,,
LGN XLPE DISHED ISRT SZ 5-6 15MM -,SUP-71453287,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,9.170825,27238.33344,percent of total billed charges,,,
JOURNEY PFJ IMPLANT X-SM LT -,SUP-71461010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,AETNA [1000108],AETNA [100010801],,,76.8,,10836.02,9.170825,27238.33344,percent of total billed charges,,,
JOURNEY PFJ IMPLANT X-SMALL RIGHT -,SUP-71461011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12604.89,8823.423,AETNA [1000108],AETNA [100010801],,,76.8,,9680.56,9.170825,27238.33344,percent of total billed charges,,,
JOURNEY PFJ IMPLANT SM LT -,SUP-71461012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,AETNA [1000108],AETNA [100010801],,,76.8,,10836.02,9.170825,27238.33344,percent of total billed charges,,,
JOURNEY PF IMPLANT SM RT -,SUP-71461013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,AETNA [1000108],AETNA [100010801],,,76.8,,10836.02,9.170825,27238.33344,percent of total billed charges,,,
SCREW 5MMX55MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642255,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA [1000108],AETNA [100010801],,,76.8,,1883.51,9.170825,27238.33344,percent of total billed charges,,,
UNIPL -,SUP-71701035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14184.25,9928.975,AETNA [1000108],AETNA [100010801],,,76.8,,10893.5,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 38X9MM THK GENESIS II REVISN PS -,SUP-71926225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,9.170825,27238.33344,percent of total billed charges,,,
GEN II 7.5MM RESUR PAT 26MM -,SUP-71932634,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,AETNA [1000108],AETNA [100010801],,,76.8,,1282.3,9.170825,27238.33344,percent of total billed charges,,,
GEN II 7.5MM RESUR PAT 29MM -,SUP-71932635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3366.62,2356.634,AETNA [1000108],AETNA [100010801],,,76.8,,2585.56,9.170825,27238.33344,percent of total billed charges,,,
LEGION REV TIB BASE W/JRNY LOCK SZ 5 -,SUP-71933571,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11863.04,8304.128,AETNA [1000108],AETNA [100010801],,,76.8,,9110.81,9.170825,27238.33344,percent of total billed charges,,,
CONE TIB LGN ID 18 SHORT -,SUP-71935386,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22278,15594.6,AETNA [1000108],AETNA [100010801],,,76.8,,17109.5,9.170825,27238.33344,percent of total billed charges,,,
WEDGE TIB LEGION CONE ID 20 SHORT -,SUP-71935387,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21210.51,14847.357,AETNA [1000108],AETNA [100010801],,,76.8,,16289.67,9.170825,27238.33344,percent of total billed charges,,,
LEGION TIB CONE ID 22 SHORT -,SUP-71935388,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21210.51,14847.357,AETNA [1000108],AETNA [100010801],,,76.8,,16289.67,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL CONE LEGION 18 LONG -,SUP-71935393,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22927.78,16049.446,AETNA [1000108],AETNA [100010801],,,76.8,,17608.54,9.170825,27238.33344,percent of total billed charges,,,
LEGION TIB CONE ID 22 LONG -,SUP-71935395,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21210.51,14847.357,AETNA [1000108],AETNA [100010801],,,76.8,,16289.67,9.170825,27238.33344,percent of total billed charges,,,
FEM CONE LGN ID 18MM LEFT -,SUP-71935400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22324.41,15627.087,AETNA [1000108],AETNA [100010801],,,76.8,,17145.15,9.170825,27238.33344,percent of total billed charges,,,
LEGION FEM CONE ID 20MM LEFT -,SUP-71935401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22324.41,15627.087,AETNA [1000108],AETNA [100010801],,,76.8,,17145.15,9.170825,27238.33344,percent of total billed charges,,,
LEGION FEM CONE ID 22MM LEFT -,SUP-71935402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22324.41,15627.087,AETNA [1000108],AETNA [100010801],,,76.8,,17145.15,9.170825,27238.33344,percent of total billed charges,,,
WEDGE FEMORAL LEGION CONE ID 18MM KNEE RIGHT -,SUP-71935407,CDM,C1776,HCPCS,278,RC,,,outpatient,,,23447.6,16413.32,AETNA [1000108],AETNA [100010801],,,76.8,,18007.76,9.170825,27238.33344,percent of total billed charges,,,
STEM FEMORAL ANTHOLOGY AFIT SO POR PL HA SZ7 -,SUP-71935567,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6009.5,4206.65,AETNA [1000108],AETNA [100010801],,,76.8,,4615.3,9.170825,27238.33344,percent of total billed charges,,,
SCROPIO-FLEX X3 TIBIAL BEARING INSERT CR SZ11 -,SUP-72-26-1110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,AETNA [1000108],AETNA [100010801],,,76.8,,3409.78,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 36X46-48MM D SHL TRIDENT 0DG NEUT X3 3.9MM PRIM -,SUP-723-00-36D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 36X50-52MM E SHL TRIDENT 0DG NEUT X3 5.9MM PRIM -,SUP-723-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 40X54-56MM G SHL TRIDENT 0DG X3 5.8MM PRIM -,SUP-723-00-40F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 28MM X 54MM RESTOR ADM/MDM X3 48G -,SUP-7236-2-854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ7 24X71/47MM 18X27MM SCORP CNSTRN TOTAL -,SUP-72-4-0724,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5828.45,4079.915,AETNA [1000108],AETNA [100010801],,,76.8,,4476.25,9.170825,27238.33344,percent of total billed charges,,,
PIN NONRIM SPEED 65 STERILE -,SUP-74013480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,128.37,89.859,AETNA [1000108],AETNA [100010801],,,76.8,,98.59,9.170825,27238.33344,percent of total billed charges,,,
PIN NONRIM SPEED 80 STERILE -,SUP-74013490,CDM,C1776,HCPCS,278,RC,,,outpatient,,,122.54,85.778,AETNA [1000108],AETNA [100010801],,,76.8,,94.11,9.170825,27238.33344,percent of total billed charges,,,
JOURNEY II CR FEM OX NP RT SZ. 4 -,SUP-74021154,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA [1000108],AETNA [100010801],,,76.8,,7670.76,9.170825,27238.33344,percent of total billed charges,,,
COMP JRNY II CR FEM OX NP LT SZ 4 -,SUP-74021164,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA [1000108],AETNA [100010801],,,76.8,,7670.76,9.170825,27238.33344,percent of total billed charges,,,
JRNY II BCS FEMORAL OXIN RT SZ 3 -,SUP-74022113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA [1000108],AETNA [100010801],,,76.8,,7670.76,9.170825,27238.33344,percent of total billed charges,,,
JOURNEY TIBIA BASE NP RT SZ 2 -,SUP-74022212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,AETNA [1000108],AETNA [100010801],,,76.8,,3519.77,9.170825,27238.33344,percent of total billed charges,,,
JOURNEY TIBIA BASE NP RT SZ 3 -,SUP-74022213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,AETNA [1000108],AETNA [100010801],,,76.8,,3519.77,9.170825,27238.33344,percent of total billed charges,,,
JOURNEY TIBA BASE NP RT SZ. 4 -,SUP-74022214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4218.31,2952.817,AETNA [1000108],AETNA [100010801],,,76.8,,3239.66,9.170825,27238.33344,percent of total billed charges,,,
JOURNEY TIBIA BASE NP LT SZ3 -,SUP-74022223,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,AETNA [1000108],AETNA [100010801],,,76.8,,3519.77,9.170825,27238.33344,percent of total billed charges,,,
JOURNEY BCS PAT RESRF RD 32 MM STD -,SUP-74024832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2017.9,1412.53,AETNA [1000108],AETNA [100010801],,,76.8,,1549.75,9.170825,27238.33344,percent of total billed charges,,,
JOURNEY II CR ISRT XLPE RT SZ 3-4 9MM -,SUP-74025631,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,9.170825,27238.33344,percent of total billed charges,,,
JRNY II ISRT XLPE DD LT SZ 3-4 9MM -,SUP-74025741,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,9.170825,27238.33344,percent of total billed charges,,,
JRNY II BCS XLPE ART ISRT SZ 1-2 RT 12MM -,SUP-74027214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,9.170825,27238.33344,percent of total billed charges,,,
JRNY II BCS XLPE ART ISRT SZ 5-6 LT 12MM -,SUP-74027264,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,AETNA [1000108],AETNA [100010801],,,76.8,,2889.15,9.170825,27238.33344,percent of total billed charges,,,
44MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-44B,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,,,
48MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,,,
50MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,,,
52MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,,,
54MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,,,
56MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,,,
58MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,,,
64MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,9.170825,27238.33344,percent of total billed charges,,,
POLARCUP XLPE INSERT 43/22 NON-CEM -,SUP-75018942,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4478.01,3134.607,AETNA [1000108],AETNA [100010801],,,76.8,,3439.11,9.170825,27238.33344,percent of total billed charges,,,
POLARCUP SHELL 43 CEMENTED -,SUP-75100451,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT DIST KN SZ7 SCORP 5MM WDG BLCK CMNT SPCR TOTAL -,SUP-75-1-0705,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4305.81,3014.067,AETNA [1000108],AETNA [100010801],,,76.8,,3306.86,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT POST KN SZ7 SCORP 5MM WDG BLCK SPCR TOTAL STABILIZED -,SUP-75-2-0705,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4305.81,3014.067,AETNA [1000108],AETNA [100010801],,,76.8,,3306.86,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL LEFT MEDIAL SZ 4 NON-POROUS -,SUP-761-1401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA [1000108],AETNA [100010801],,,76.8,,6844.72,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL LEFT MEDIAL SIZE 6 NON-POROUS -,SUP-761-1601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA [1000108],AETNA [100010801],,,76.8,,6844.72,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL TRAY LEFT MEDIAL SIZE 3 NON-POROUS -,SUP-762-3100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL TRAY LEFT MEDIAL SZ 4 NON-POROUS -,SUP-762-4100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,9.170825,27238.33344,percent of total billed charges,,,
INSERT TRIDENT X3 ECCENTRIC 0DEG 36MM -,SUP-763-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT LEFT MEDIAL SZ 4 7MM -,SUP-763-4071,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ7 66MM M/L 60-62MM A/P SCORP LT KN TOTAL -,SUP-76-4107L,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17711.12,12397.784,AETNA [1000108],AETNA [100010801],,,76.8,,13602.14,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL HEAD 12/14 COCR 36MM +3.5 -,SUP-8018-36-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,9.170825,27238.33344,percent of total billed charges,,,
HEAD 12/14 COCR FRDM 36MM X +6 -,SUP-802403605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7259.36,5081.552,AETNA [1000108],AETNA [100010801],,,76.8,,5575.19,9.170825,27238.33344,percent of total billed charges,,,
3.5MM CORT LOCK SCR 48MM NS -,SUP-816135048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,882.25,617.575,AETNA [1000108],AETNA [100010801],,,76.8,,677.57,9.170825,27238.33344,percent of total billed charges,,,
SPACER NO PROFILE 16 X 14 X 8MM 7IN STERILE SHORELINE -,SUP-85-0208-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9039.72,6327.804,AETNA [1000108],AETNA [100010801],,,76.8,,6942.5,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ4 76/51MM L/R KN PFC TI CR MODULAR + NPOR -,SUP-86-0124,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11851.9,8296.33,AETNA [1000108],AETNA [100010801],,,76.8,,9102.26,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ2 64/43MM L/R KN PFC SIG KLD NPOR -,SUP-86-4180,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,9.170825,27238.33344,percent of total billed charges,,,
STEM TAPER SIDMA 13 X 120 CEMENTED -,SUP-86-6498,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,,,
STEM TAPER 13 X 150 -,SUP-86-6499,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 12MM UNIV PFC PRFT MODULAR 75MM CMNT TIB KN -,SUP-86-7412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 14MM UNIV PFC PRFT MODULAR 75MM CMNT TIB KN -,SUP-86-7414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,,,
STEM UNIVERSAL FLUTED 75MM X 18MM -,SUP-86-7418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,,,
STEM UNIVERSAL FLUTED 75MM X 24MM -,SUP-86-7421,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,,,
STEM FLUTED 115 X 16MM -,SUP-86-7430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,,,
STEM UNIVERSAL FLUTED 115MM X 18MM -,SUP-86-7432,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,,,
STEM UNIVERSAL FLUTED 115MM X 20MM -,SUP-86-7433,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,,,
STEM RADIAL ALIGN TITANIUM 11MM X 0MM -,SUP-90176510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10481.8,7337.26,AETNA [1000108],AETNA [100010801],,,76.8,,8050.02,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 28X48-50MM X-ALT 0DG NEUT STD HXLPE 6MM NON- HD F -,SUP-931-28-248,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 36X52-54MM X-ALT 0DG NEUT STD HXLPE 6MM HD F /FMP -,SUP-932-36-252,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ2.5 63/59MM SIGMA FB RT KN CR CMNT COCR NPOR -,SUP-96-0018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7199.14,5039.398,AETNA [1000108],AETNA [100010801],,,76.8,,5528.94,9.170825,27238.33344,percent of total billed charges,,,
SIGMA TC3 FEM RT SZ2 -,SUP-96-0087,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA [1000108],AETNA [100010801],,,76.8,,7414.12,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL TC3 CEMENTED SIGMA SIZE 5 RIGHT -,SUP-96-0090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA [1000108],AETNA [100010801],,,76.8,,7414.12,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL TC3 CEMENTED SIGMA SIZE 2.5 RIGHT -,SUP-96-0092,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA [1000108],AETNA [100010801],,,76.8,,7414.12,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 32MM XS UHMWPE PEGX3 PFC SIG OVL DOME -,SUP-96-0100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 38MM STD UHMWPE PEGX3 PFC SIG OVL DOME -,SUP-96-0102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 41MM LRG UHMWPE PEGX3 PFC SIG OVL DOME -,SUP-96-0103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,9.170825,27238.33344,percent of total billed charges,,,
ADAPTER FEM 5DG PFC SIGMA TC3 KN REVISN CMNT TI -,SUP-96-0781,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8615.53,6030.871,AETNA [1000108],AETNA [100010801],,,76.8,,6616.73,9.170825,27238.33344,percent of total billed charges,,,
BOLT FEMORAL ADAPTER +2/-2 OFF -,SUP-96-0784,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1623.81,1136.667,AETNA [1000108],AETNA [100010801],,,76.8,,1247.09,9.170825,27238.33344,percent of total billed charges,,,
DISTAL AUGMENT SIZE 2 4MM RIGHT -,SUP-96-0821,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,9.170825,27238.33344,percent of total billed charges,,,
DISTAL AUGMENT SIZE 2 8MM RIGHT -,SUP-96-0823,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,9.170825,27238.33344,percent of total billed charges,,,
DISTAL AUGMENT SIZE 2.5 8MM RIGHT -,SUP-96-0843,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,9.170825,27238.33344,percent of total billed charges,,,
DISTAL  AUGMENT  COMBO  SIZE 2.5 16MM RIGHT -,SUP-96-0852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT FEM SZ4 PFC SIG POST KN WDG/BLCK 4MM COCR -,SUP-96-0886,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,9.170825,27238.33344,percent of total billed charges,,,
COMBO PFC SIGMA POST AUG CEMENTED SIZE 5 X 8MM -,SUP-960908,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,9.170825,27238.33344,percent of total billed charges,,,
COMBO PFC SIGMA DIST AUG CEMENTED SIZE 6 X 12MM LEFT -,SUP-96-0909,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,9.170825,27238.33344,percent of total billed charges,,,
COMBO PFC SIGMA DIST AUG CEMENTED SIZE 6 X 16MM LEFT -,SUP-96-0911,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5 10MM 74MM/47MM M/L/A/P PFC SIG PS ARTCSURF -,SUP-96-2051,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,AETNA [1000108],AETNA [100010801],,,76.8,,3666.82,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT ROTATING PLTFRM SIZE 3 X 12.5MM -,SUP-96-2132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,AETNA [1000108],AETNA [100010801],,,76.8,,3666.82,9.170825,27238.33344,percent of total billed charges,,,
TIBAL INSERT ROT PLAT STAB SZ4 12.5MM -,SUP-96-2142,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,AETNA [1000108],AETNA [100010801],,,76.8,,3666.82,9.170825,27238.33344,percent of total billed charges,,,
TIBAL INSERT ROTATING PLATFORM (STAB) 4- 20MM -,SUP-96-2145,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,AETNA [1000108],AETNA [100010801],,,76.8,,3666.82,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT ROT PLTFRM TC3 SZ 2 12.5MM -,SUP-96-2322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT ROTATING PLATFORM SIZE 2 20MM -,SUP-96-2325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT ROTATING PLATFORM TC3 SZ 12.5 -,SUP-96-2332,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT ROTATING PLTFRM SZ3 30MM -,SUP-96-2348,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT TC3 RP S4 12.5 -,SUP-96-2352,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL PLATFORM TCS SZ 5 GVF 22.5MM -,SUP-96-2366,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ3 8MM KN PFC SIG UHMWPE CR POST LIP -,SUP-96-2540,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6645.51,4651.857,AETNA [1000108],AETNA [100010801],,,76.8,,5103.75,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5 15X89/55MM PFC SIG PS TCMPRTMNTL BEAR ARTC -,SUP-97-0473,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM UNIPL COCR POR -,SUP-98000100400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12559.22,8791.454,AETNA [1000108],AETNA [100010801],,,76.8,,9645.48,9.170825,27238.33344,percent of total billed charges,,,
KT THR PRFT SUMMIT -,SUP-98-0001-006-00,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12559.22,8791.454,AETNA [1000108],AETNA [100010801],,,76.8,,9645.48,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB LRG VIVACIT VIT-E XLNK PE CNSTRN F/T/H ARTHPL -,SUP-98000125053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21605.69,15123.983,AETNA [1000108],AETNA [100010801],,,76.8,,16593.17,9.170825,27238.33344,percent of total billed charges,,,
KT THR PRIM KINECTIV -,SUP-98000132001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21605.69,15123.983,AETNA [1000108],AETNA [100010801],,,76.8,,16593.17,9.170825,27238.33344,percent of total billed charges,,,
KT THR PERSONA -,SUP-98-0002-415-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21605.69,15123.983,AETNA [1000108],AETNA [100010801],,,76.8,,16593.17,9.170825,27238.33344,percent of total billed charges,,,
SYS TKR PRIM CONSTRUT -,SUP-98000600000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20654.23,14457.961,AETNA [1000108],AETNA [100010801],,,76.8,,15862.45,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 10MM PFC SIG MODULAR CS STAB ANTMC KN POR CTD -,SUP-98-6061,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,,,
LINK NECK SEGMENT WITHOUTH COLLAR 12/14MM 126 DEG 65MM -,SUP-99-0984/30,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19311.31,13517.917,AETNA [1000108],AETNA [100010801],,,76.8,,14831.09,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE HIP +5MM 12/14 TAPR ASR UNIPL -,SUP-9998-00-315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1022.29,715.603,AETNA [1000108],AETNA [100010801],,,76.8,,785.12,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE HIP +8MM 12/14 TAPR ASR ADPR UNIPL -,SUP-9998-00-318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,9.170825,27238.33344,percent of total billed charges,,,
RADIAL HEAD 22MM -,SUP-ALN-RH1-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9803.64,6862.548,AETNA [1000108],AETNA [100010801],,,76.8,,7529.2,9.170825,27238.33344,percent of total billed charges,,,
HEAD RADIAL 20MM -,SUP-ALN-RHI-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9803.64,6862.548,AETNA [1000108],AETNA [100010801],,,76.8,,7529.2,9.170825,27238.33344,percent of total billed charges,,,
RADIAL HEAD 24MM -,SUP-ALN-RHI-240,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9803.64,6862.548,AETNA [1000108],AETNA [100010801],,,76.8,,7529.2,9.170825,27238.33344,percent of total billed charges,,,
STEM 8MM X 0MM -,SUP-ALN-RST-0800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,AETNA [1000108],AETNA [100010801],,,76.8,,7460.75,9.170825,27238.33344,percent of total billed charges,,,
STEM 8MM X 2MM -,SUP-ALN-RST-0802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,AETNA [1000108],AETNA [100010801],,,76.8,,7460.75,9.170825,27238.33344,percent of total billed charges,,,
RADAIL STEM ALIGN 9MM X 0MM -,SUP-ALN-RST-0900,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,AETNA [1000108],AETNA [100010801],,,76.8,,7460.75,9.170825,27238.33344,percent of total billed charges,,,
STEM 10MM X 0MM -,SUP-ALN-RST-1000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,AETNA [1000108],AETNA [100010801],,,76.8,,7460.75,9.170825,27238.33344,percent of total billed charges,,,
PACKAGED RADIAL STEM 11MM X 2MM -,SUP-ALN-RST-1102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,AETNA [1000108],AETNA [100010801],,,76.8,,7460.75,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT KN 7DG 8DG XL LRG 9.83 MDL OPN 78-88MM 88-96 MM -,SUP-AR-13400L-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,AETNA [1000108],AETNA [100010801],,,76.8,,6192.84,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT KN 11DG 12DG XL LRG 14.13 MDL OPN 78-88MM 88-96 MM -,SUP-AR-13400L-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,AETNA [1000108],AETNA [100010801],,,76.8,,6192.84,9.170825,27238.33344,percent of total billed charges,,,
PIP DART PEEK 10 DEGREE 2.5X30MM -,SUP-AR-4154PS-3010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,AETNA [1000108],AETNA [100010801],,,76.8,,2181.53,9.170825,27238.33344,percent of total billed charges,,,
IMPLANT PIP 3MM PEEK 30MM 10DG ANG -,SUP-AR-4155PS-3010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,AETNA [1000108],AETNA [100010801],,,76.8,,2181.53,9.170825,27238.33344,percent of total billed charges,,,
SCREW 7X12 PROSTOP ARTHROEREISIS -,SUP-AR-4207-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA [1000108],AETNA [100010801],,,76.8,,4872.79,9.170825,27238.33344,percent of total billed charges,,,
SCREW 8 X 14 MM PROSTOP SFT THRD -,SUP-AR-4208-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6154.44,4308.108,AETNA [1000108],AETNA [100010801],,,76.8,,4726.61,9.170825,27238.33344,percent of total billed charges,,,
SCREW 9X14 PROSTOP ARTHROEREISIS -,SUP-AR-4209-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA [1000108],AETNA [100010801],,,76.8,,4872.79,9.170825,27238.33344,percent of total billed charges,,,
SCREW 10X14MM PROSTOP SFT THRD CNCL TI F /ARTHROEREISIS -,SUP-AR-4210-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA [1000108],AETNA [100010801],,,76.8,,4872.79,9.170825,27238.33344,percent of total billed charges,,,
SCREW 11X16MM PROSTOP SFT THRD CNCL TI F /ARTHROEREISIS -,SUP-AR-4211-16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA [1000108],AETNA [100010801],,,76.8,,4872.79,9.170825,27238.33344,percent of total billed charges,,,
SCREW 12X16 PROSTOP ARTHROEREISI S -,SUP-AR-4212-16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA [1000108],AETNA [100010801],,,76.8,,4872.79,9.170825,27238.33344,percent of total billed charges,,,
"GUIDE WIRE .045"" X 5.91"" -",SUP-AR-8933K,CDM,C1776,HCPCS,278,RC,,,outpatient,,,40.85,28.595,AETNA [1000108],AETNA [100010801],,,76.8,,31.37,9.170825,27238.33344,percent of total billed charges,,,
STEM HUMERAL UNIVERS  SZ 6 -,SUP-AR-9100-06P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13645.28,9551.696,AETNA [1000108],AETNA [100010801],,,76.8,,10479.58,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 10MM UNIVERS II 148MM SHLDR -,SUP-AR-9100-10P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13645.28,9551.696,AETNA [1000108],AETNA [100010801],,,76.8,,10479.58,9.170825,27238.33344,percent of total billed charges,,,
GLENOID UNIV BASEPLATE SMALL -,SUP-AR-9120-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7278.46,5094.922,AETNA [1000108],AETNA [100010801],,,76.8,,5589.86,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 54X23MM UNIVERS II ECCT -,SUP-AR-9154-23P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA [1000108],AETNA [100010801],,,76.8,,5703.94,9.170825,27238.33344,percent of total billed charges,,,
ANATOEMIC PROSTHESIS 17MM -,SUP-AR-9500-170,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,AETNA [1000108],AETNA [100010801],,,76.8,,2548.17,9.170825,27238.33344,percent of total billed charges,,,
ANATOEMIC PROSTHESIS 18.5MM -,SUP-AR-9500-185,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,AETNA [1000108],AETNA [100010801],,,76.8,,2548.17,9.170825,27238.33344,percent of total billed charges,,,
ANATOEMIC PROSTHESIS 20MM -,SUP-AR-9500-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,AETNA [1000108],AETNA [100010801],,,76.8,,2548.17,9.170825,27238.33344,percent of total billed charges,,,
ANATOEMIC PROSTHESIS 21.5 MM -,SUP-AR-9500-215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,AETNA [1000108],AETNA [100010801],,,76.8,,2548.17,9.170825,27238.33344,percent of total billed charges,,,
RESTRICTOR CEMENT REV 30MM -,SUP-B000-0300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA [1000108],AETNA [100010801],,,76.8,,448.13,9.170825,27238.33344,percent of total billed charges,,,
REVERSE BODY STANDARD AND REVERSE BODY SCREW -,SUP-BBS-0960-21STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,9.170825,27238.33344,percent of total billed charges,,,
TSS PRIMARY PROXIMAL BODY 2.5 08STD -,SUP-BOD-0923-020-08STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,AETNA [1000108],AETNA [100010801],,,76.8,,4826.76,9.170825,27238.33344,percent of total billed charges,,,
BODY TSS PRIMARY PROXIMAL 10 LRG -,SUP-BOD-0923-020-10LRG,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,AETNA [1000108],AETNA [100010801],,,76.8,,4826.76,9.170825,27238.33344,percent of total billed charges,,,
BODY TSS PRIMARY PROXIMAL 10 STD -,SUP-BOD-0923-020-10STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,AETNA [1000108],AETNA [100010801],,,76.8,,4826.76,9.170825,27238.33344,percent of total billed charges,,,
BODY TSS PRIMARY PROXIMAL 2.5 X 12 STD -,SUP-BOD-0923-020-12STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,AETNA [1000108],AETNA [100010801],,,76.8,,4826.76,9.170825,27238.33344,percent of total billed charges,,,
BODY HUM LRG 40MM TI PROX GFT TITAN F/MODULAR SHLDR SYS -,SUP-BOD-0923-020-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6836.57,4785.599,AETNA [1000108],AETNA [100010801],,,76.8,,5250.49,9.170825,27238.33344,percent of total billed charges,,,
BODY TSS PRIMARY PROX 2.5 14 LRG -,SUP-BOD-0923-020-14LRG,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,AETNA [1000108],AETNA [100010801],,,76.8,,4826.76,9.170825,27238.33344,percent of total billed charges,,,
TSS PRIMARY PROXIMAL BODY 2.5 14STD -,SUP-BOD-0923-020-14STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,AETNA [1000108],AETNA [100010801],,,76.8,,4826.76,9.170825,27238.33344,percent of total billed charges,,,
TSS FRACTURE BODY 2.5 08LRG -,SUP-BOD-0923-021-08LRG,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,AETNA [1000108],AETNA [100010801],,,76.8,,4826.76,9.170825,27238.33344,percent of total billed charges,,,
TSS FRACTURE BODY 2.5 08STD -,SUP-BOD-0923-021-08STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,AETNA [1000108],AETNA [100010801],,,76.8,,4826.76,9.170825,27238.33344,percent of total billed charges,,,
ULNAR STEM 5.0MM 2CM EXT STEM -,SUP-DRUJ-IS250,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9932.28,6952.596,AETNA [1000108],AETNA [100010801],,,76.8,,7627.99,9.170825,27238.33344,percent of total billed charges,,,
AEQREVSD FX/ADAPTER LATRLZD HMRL INSRT 36MM 9MM -,SUP-DWD861,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8929.38,6250.566,AETNA [1000108],AETNA [100010801],,,76.8,,6857.76,9.170825,27238.33344,percent of total billed charges,,,
AEQUALIS REVERSED FX STEM 11MM X 130MM -,SUP-DWD903,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24223.61,16956.527,AETNA [1000108],AETNA [100010801],,,76.8,,18603.73,9.170825,27238.33344,percent of total billed charges,,,
TORNIER PERFORM REVERSED STANDARD GLENOSPHERE DIA 36MM -,SUP-DWJ012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15178.74,10625.118,AETNA [1000108],AETNA [100010801],,,76.8,,11657.27,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB SZ23 36MM MAX-ROM RINGLOC +3 HW E1 -,SUP-EP108323,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,9.170825,27238.33344,percent of total billed charges,,,
BEARING E1 44-36 STD HMRL -,SUP-EP-115393,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA [1000108],AETNA [100010801],,,76.8,,4074.24,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB 10X71/75MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-EP-183540,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB 12X71/75MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-EP-183542,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB 18MMX67MM M/L VANGRD ANT STAB MODULAR ARTC BEAR -,SUP-EP-189048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,9.170825,27238.33344,percent of total billed charges,,,
ACT ARTIC E1 HIP BRG 28X42MM -,SUP-EP-200148,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,AETNA [1000108],AETNA [100010801],,,76.8,,3538.11,9.170825,27238.33344,percent of total billed charges,,,
ACT ARTIC E1 HIP BRG 28X44MM -,SUP-EP-200150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,AETNA [1000108],AETNA [100010801],,,76.8,,3538.11,9.170825,27238.33344,percent of total billed charges,,,
ACT ARTIC E1 HIP BRG 28 X 50MM -,SUP-EP-200156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,AETNA [1000108],AETNA [100010801],,,76.8,,3538.11,9.170825,27238.33344,percent of total billed charges,,,
IMPLANT TOE JOINT PRIMUS SIZE 40 -,SUP-FGT-40T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6915.85,4841.095,AETNA [1000108],AETNA [100010801],,,76.8,,5311.37,9.170825,27238.33344,percent of total billed charges,,,
RSS GLENOID BASEPLATE-S -,SUP-GBP-0961-094-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,9.170825,27238.33344,percent of total billed charges,,,
TSS PEGGED GLENOID XS -,SUP-GLN-0920-030-00P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9802.32,6861.624,AETNA [1000108],AETNA [100010801],,,76.8,,7528.18,9.170825,27238.33344,percent of total billed charges,,,
GLENOID TSS PEGGED S -,SUP-GLN-0920-030-01P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4010.16,2807.112,AETNA [1000108],AETNA [100010801],,,76.8,,3079.8,9.170825,27238.33344,percent of total billed charges,,,
TSS PEGGED GLENOID S -,SUP-GLN-0920-030-01P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9802.32,6861.624,AETNA [1000108],AETNA [100010801],,,76.8,,7528.18,9.170825,27238.33344,percent of total billed charges,,,
TSS PEGGED GLENOID -,SUP-GLN-0920-030-02P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9802.32,6861.624,AETNA [1000108],AETNA [100010801],,,76.8,,7528.18,9.170825,27238.33344,percent of total billed charges,,,
TSS PEGGED GLENOID L -,SUP-GLN-0920-030-03P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4010.16,2807.112,AETNA [1000108],AETNA [100010801],,,76.8,,3079.8,9.170825,27238.33344,percent of total billed charges,,,
GLENDOID S FIN-LOCK -,SUP-GLN-0926-030-01A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5882.18,4117.526,AETNA [1000108],AETNA [100010801],,,76.8,,4517.51,9.170825,27238.33344,percent of total billed charges,,,
RSS GLENOSPHERE CONCENTRIC -S 2MM -,SUP-GLS-0961-02C-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,9.170825,27238.33344,percent of total billed charges,,,
RSS GLENOSPHERE CONCENTRIC -S 5MM -,SUP-GLS-0961-05C-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,9.170825,27238.33344,percent of total billed charges,,,
TSS PEGGED GLENOID XS -,SUP-GN092003000P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10292.44,7204.708,AETNA [1000108],AETNA [100010801],,,76.8,,7904.59,9.170825,27238.33344,percent of total billed charges,,,
KEY SURG 26MM F /UHR ACTB HEAD REM -,SUP-HIUHRK26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1195.26,836.682,AETNA [1000108],AETNA [100010801],,,76.8,,917.96,9.170825,27238.33344,percent of total billed charges,,,
BASE PLATE ASSEMBLY IJS-E -,SUP-IJS-ELB-BPA,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21316.33,14921.431,AETNA [1000108],AETNA [100010801],,,76.8,,16370.94,9.170825,27238.33344,percent of total billed charges,,,
STANDARD POLY LINER +0 -,SUP-LNR-0960-00S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA [1000108],AETNA [100010801],,,76.8,,5703.94,9.170825,27238.33344,percent of total billed charges,,,
RSS HXL LINER STANDARD +35 -,SUP-LNR-0960-191-3S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA [1000108],AETNA [100010801],,,76.8,,5703.94,9.170825,27238.33344,percent of total billed charges,,,
RSS HXL LINER STANDARD +65 -,SUP-LNR-0960-191-6S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA [1000108],AETNA [100010801],,,76.8,,5703.94,9.170825,27238.33344,percent of total billed charges,,,
RSS HXL LINER STANDARD +9S -,SUP-LNR-0960-191-9S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA [1000108],AETNA [100010801],,,76.8,,5703.94,9.170825,27238.33344,percent of total billed charges,,,
RSS HXL LINER STANDARD +OS -,SUP-LNR-0960-191-OS,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA [1000108],AETNA [100010801],,,76.8,,5703.94,9.170825,27238.33344,percent of total billed charges,,,
RSS HXL LINER RETENTIVE +6R -,SUP-LNR-0960-192-6R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA [1000108],AETNA [100010801],,,76.8,,5703.94,9.170825,27238.33344,percent of total billed charges,,,
SYSTEM GREAT TOE MOVEMENT PROX PHALANX HEMI -,SUP-MGT-890-20PPH,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10627.83,7439.481,AETNA [1000108],AETNA [100010801],,,76.8,,8162.17,9.170825,27238.33344,percent of total billed charges,,,
SYS MOVEMENT GREAT TOE SIZE 40 HEMI PROX PHALANX -,SUP-MGT89040PPH,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10627.83,7439.481,AETNA [1000108],AETNA [100010801],,,76.8,,8162.17,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 44X19MM TITAN 2.5 ECCT COCR -,SUP-MHH-0920-010-4419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6991.01,4893.707,AETNA [1000108],AETNA [100010801],,,76.8,,5369.1,9.170825,27238.33344,percent of total billed charges,,,
TSS COCR ECCENTRIC HEAD 2.5 40 X 15MM -,SUP-MHH-0923-010-4015E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA [1000108],AETNA [100010801],,,76.8,,5369.06,9.170825,27238.33344,percent of total billed charges,,,
TSS COCR CONCENTRIC HEAD 2.5 44 X 19MM -,SUP-MHH-0923-010-4419C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA [1000108],AETNA [100010801],,,76.8,,5369.06,9.170825,27238.33344,percent of total billed charges,,,
HEAD TSS COCR ECCENTRIC 2.5 44 X 19MM -,SUP-MHH-0923-010-4419E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA [1000108],AETNA [100010801],,,76.8,,5369.06,9.170825,27238.33344,percent of total billed charges,,,
CONCENTRIC HEAD TSS COCR 2.5 46 X 14MM -,SUP-MHH-0923-010-4614C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA [1000108],AETNA [100010801],,,76.8,,5369.06,9.170825,27238.33344,percent of total billed charges,,,
TSS COCR ECCENTRIC HEAD 2.5 46 X 14MM -,SUP-MHH-0923-010-4614E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA [1000108],AETNA [100010801],,,76.8,,5369.06,9.170825,27238.33344,percent of total billed charges,,,
HEAD CONCENTRIC TSS COCR 2.5 46MM X 17MM -,SUP-MHH-0923-010-4617C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA [1000108],AETNA [100010801],,,76.8,,5369.06,9.170825,27238.33344,percent of total billed charges,,,
HEAD TSS COCR ECCENTRIC 2.5 46 X 17MM -,SUP-MHH-0923-010-4617E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA [1000108],AETNA [100010801],,,76.8,,5369.06,9.170825,27238.33344,percent of total billed charges,,,
TSS COCR CONCENTRIC HEAD 2.5 46 X 20MM -,SUP-MHH-0923-010-4620C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA [1000108],AETNA [100010801],,,76.8,,5369.06,9.170825,27238.33344,percent of total billed charges,,,
TSS COCR CONCENTRIC HEAD 2.5 48 X 18MM -,SUP-MHH-0923-010-4818C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA [1000108],AETNA [100010801],,,76.8,,5369.06,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM COCR CONC 2.5 X 48 X 21MM TSS -,SUP-MHH-0923-010-4821C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA [1000108],AETNA [100010801],,,76.8,,5369.06,9.170825,27238.33344,percent of total billed charges,,,
HEAD TSS COCR ECCENTRIC 2.5 48 X 21MM -,SUP-MHH-0923-010-4821E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA [1000108],AETNA [100010801],,,76.8,,5369.06,9.170825,27238.33344,percent of total billed charges,,,
TSS COCR CONCENTRIC HEAD 2.5 50 X 19MM -,SUP-MHH-0923-010-5019C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA [1000108],AETNA [100010801],,,76.8,,5369.06,9.170825,27238.33344,percent of total billed charges,,,
TSS COCR CONCENTRIC HEAD 2.5 50 X 22MM -,SUP-MHH-0923-010-5022C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA [1000108],AETNA [100010801],,,76.8,,5369.06,9.170825,27238.33344,percent of total billed charges,,,
HEAD TSS COCR CONCENTRIC 2.5 52 X 20MM -,SUP-MHH-0923-010-5220C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA [1000108],AETNA [100010801],,,76.8,,5369.06,9.170825,27238.33344,percent of total billed charges,,,
IMPLANT SZ30 -,SUP-MHT-30,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6017.99,4212.593,AETNA [1000108],AETNA [100010801],,,76.8,,4621.82,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT LT SIZE 7 FEMORAL CR NONPOROUS COCR -,SUP-ORTHO DEV,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEMORAL 36MM +3 BIOLOX DELTA -,SUP-ORTHO DEV,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL PS 8MM SIZE 5 VITAMIN E -,SUP-ORTHO DEV,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
STEM PLASMA SPRAY STD SIZE 11 -,SUP-ORTHO DEVELOPMENT,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,9.170825,27238.33344,percent of total billed charges,,,
COMP TIB SZ1 STRIDE LL/RM -,SUP-PFSI-00001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,AETNA [1000108],AETNA [100010801],,,76.8,,3527.97,9.170825,27238.33344,percent of total billed charges,,,
COMP TIB SZ2 STRIDE LL/RM -,SUP-PFSI-00003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,AETNA [1000108],AETNA [100010801],,,76.8,,3527.97,9.170825,27238.33344,percent of total billed charges,,,
COMP TIB SZ2 STRIDE RL/LM -,SUP-PFSI-00004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,AETNA [1000108],AETNA [100010801],,,76.8,,3527.97,9.170825,27238.33344,percent of total billed charges,,,
STRIDE TIBIA BASEPLATE SIZE 3 RM/LL -,SUP-PFSI00005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,AETNA [1000108],AETNA [100010801],,,76.8,,3527.97,9.170825,27238.33344,percent of total billed charges,,,
COMP TIB SZ3 STRIDE LL/RM -,SUP-PFSI-00005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,AETNA [1000108],AETNA [100010801],,,76.8,,3308.28,9.170825,27238.33344,percent of total billed charges,,,
COMP TIB SZ3 STRIDE RL/LM -,SUP-PFSI-00006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,AETNA [1000108],AETNA [100010801],,,76.8,,3527.97,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBIAL STRIDE SZ 4 RMLL -,SUP-PFSI00007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,AETNA [1000108],AETNA [100010801],,,76.8,,3527.97,9.170825,27238.33344,percent of total billed charges,,,
STRIDE TIBIA BASEPLATE SZ. 4 LM/RL -,SUP-PFSI00008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,AETNA [1000108],AETNA [100010801],,,76.8,,3527.97,9.170825,27238.33344,percent of total billed charges,,,
COMP TIB SZ4 STRIDE RL/LM -,SUP-PFSI-00008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,AETNA [1000108],AETNA [100010801],,,76.8,,3527.97,9.170825,27238.33344,percent of total billed charges,,,
COMP TIB SZ5 STRIDE LL/RM -,SUP-PFSI-00009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5156.46,3609.522,AETNA [1000108],AETNA [100010801],,,76.8,,3960.16,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL 8MM SIZE A -,SUP-PFSI00021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,AETNA [1000108],AETNA [100010801],,,76.8,,1999.3,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ A 9MM -,SUP-PFSI-00022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,AETNA [1000108],AETNA [100010801],,,76.8,,1999.3,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ B 8MM -,SUP-PFSI00027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,AETNA [1000108],AETNA [100010801],,,76.8,,1999.3,9.170825,27238.33344,percent of total billed charges,,,
STRIDE POLY INSERT SZ. B 8MM -,SUP-PFSI00027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,AETNA [1000108],AETNA [100010801],,,76.8,,1999.3,9.170825,27238.33344,percent of total billed charges,,,
STRIDE POLY INSERT TIB SZ-C 8MM -,SUP-PFSI00033,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,AETNA [1000108],AETNA [100010801],,,76.8,,1999.3,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ1 STRIDE LL/RM -,SUP-PFSI-00052,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,AETNA [1000108],AETNA [100010801],,,76.8,,7699.28,9.170825,27238.33344,percent of total billed charges,,,
STRIDE FEMUR SZ. 3 LM/RL -,SUP-PFSI00055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10492.44,7344.708,AETNA [1000108],AETNA [100010801],,,76.8,,8058.19,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ3 STRIDE LL/RM -,SUP-PFSI00056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10492.44,7344.708,AETNA [1000108],AETNA [100010801],,,76.8,,8058.19,9.170825,27238.33344,percent of total billed charges,,,
STRIDE FEMUR SIZE 4 RM/LL -,SUP-PFSI00058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10492.44,7344.708,AETNA [1000108],AETNA [100010801],,,76.8,,8058.19,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 STRIDE LL/RM -,SUP-PFSI-00060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,AETNA [1000108],AETNA [100010801],,,76.8,,7699.28,9.170825,27238.33344,percent of total billed charges,,,
COMP COMPREHESIVE MODULAR HYBRID REGNREX SHLDR POST -,SUP-PT-113950,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 9MM LNG REUNION COCR HAP CTD SHLDR -,SUP-R53514509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,AETNA [1000108],AETNA [100010801],,,76.8,,5866.91,9.170825,27238.33344,percent of total billed charges,,,
SPACER KN 46MM FEM MODHD ANTBTC REMEDY -,SUP-RHHDSM,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8093.31,5665.317,AETNA [1000108],AETNA [100010801],,,76.8,,6215.66,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM MED MODULAR -,SUP-RHSTMD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM REFLEX HYBRID 32MM +2.5MM NK COCR C-TAPR PRIM LFRIC -,SUP-S1400HH32,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
C-TAPER LFIT INTER HEAD 28MM +2.5 -,SUP-S-1400-HH82,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
C-TAPER HEAD +7.5 OFFSET LFIT SZ. 28MM / +7.5 -,SUP-S-1400-HH84,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,9.170825,27238.33344,percent of total billed charges,,,
PEG 4 MOD GLEN SZ 2 -,SUP-SAGL2042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,9.170825,27238.33344,percent of total billed charges,,,
4 PEG MOD GLEN SZ 3 -,SUP-SAGL2043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,9.170825,27238.33344,percent of total billed charges,,,
PEG 4 MOD GLEN SZ 4 -,SUP-SAGL2044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,9.170825,27238.33344,percent of total billed charges,,,
PEG 4 MOD GLEN SZ5 -,SUP-SAGL2045,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT 4 PEG MOD GLEN LT AUG SZ 2 -,SUP-SAGL2142,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,AETNA [1000108],AETNA [100010801],,,76.8,,7333.63,9.170825,27238.33344,percent of total billed charges,,,
4 PEG MOD GLEN LT AUG SZ 3 -,SUP-SAGL2143,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,AETNA [1000108],AETNA [100010801],,,76.8,,7333.63,9.170825,27238.33344,percent of total billed charges,,,
PEG 4 MOD GLEN LT AUG SZ 5 -,SUP-SAGL2145,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,AETNA [1000108],AETNA [100010801],,,76.8,,7333.63,9.170825,27238.33344,percent of total billed charges,,,
4 PEG MOD GLEN RT AUG SZ 2 -,SUP-SAGL2242,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,AETNA [1000108],AETNA [100010801],,,76.8,,7333.63,9.170825,27238.33344,percent of total billed charges,,,
4 PEG MOD GLEN RT AUG SZ 3 -,SUP-SAGL2243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,AETNA [1000108],AETNA [100010801],,,76.8,,7333.63,9.170825,27238.33344,percent of total billed charges,,,
4 PEG MOD GLEN RT AUG SZ 4 -,SUP-SAGL2244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,AETNA [1000108],AETNA [100010801],,,76.8,,7333.63,9.170825,27238.33344,percent of total billed charges,,,
PEG 4 MOD GLEN RT AUG SZ 5 -,SUP-SAGL2245,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,AETNA [1000108],AETNA [100010801],,,76.8,,7333.63,9.170825,27238.33344,percent of total billed charges,,,
MODULAR POST PPS -,SUP-SAGP0001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,,,
MODULAR POST TM -,SUP-SAGP0002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 10MM SHLDR -,SUP-SEM092002510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA [1000108],AETNA [100010801],,,76.8,,4872.11,9.170825,27238.33344,percent of total billed charges,,,
OXINIUM LEGION PS-SPC FEMUR LEFT SIZE 5 -,SUP-SMITH & NE,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9155.58,6408.906,AETNA [1000108],AETNA [100010801],,,76.8,,7031.49,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 16.7MM PROX 10MM DIST SM 150MM INTSPC HI RELS 25MM -,SUP-SPC0022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12735.59,8914.913,AETNA [1000108],AETNA [100010801],,,76.8,,9780.93,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 10.5MM/21.9MM DIA P/D MED/SHRT 156MM INTSPC HI RELS -,SUP-SPC0122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12364.29,8655.003,AETNA [1000108],AETNA [100010801],,,76.8,,9495.77,9.170825,27238.33344,percent of total billed charges,,,
SPACER THR CMNT XL 54MM HIP REVISN INTSPC -,SUP-SPC0421,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11101.87,7771.309,AETNA [1000108],AETNA [100010801],,,76.8,,8526.24,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 10.5MM/21.9MM DIA P/D MED LNG 271MM INTSPC HI RELS -,SUP-SPC0422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,AETNA [1000108],AETNA [100010801],,,76.8,,10265.7,9.170825,27238.33344,percent of total billed charges,,,
SPACER THR CMNT LNG STM 60MM HIP REVISN INTSPC -,SUP-SPC0522,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,AETNA [1000108],AETNA [100010801],,,76.8,,10265.7,9.170825,27238.33344,percent of total billed charges,,,
SMART TOE INTRAMEDULLARY ARTHRODEAL 11MM -,SUP-ST0XS-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6409.29,4486.503,AETNA [1000108],AETNA [100010801],,,76.8,,4922.33,9.170825,27238.33344,percent of total billed charges,,,
TSS PRESS FIT STEM SZ. O7 -,SUP-STEM-0920-025-07,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA [1000108],AETNA [100010801],,,76.8,,4872.11,9.170825,27238.33344,percent of total billed charges,,,
TSS PRESS FIT STEM SIZE 08 -,SUP-STEM-0920-025-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA [1000108],AETNA [100010801],,,76.8,,4872.11,9.170825,27238.33344,percent of total billed charges,,,
TSS PRESS FIT HUM STEM SIZE 09 -,SUP-STEM-0920-025-09,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA [1000108],AETNA [100010801],,,76.8,,4872.11,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 12MM PRFT TITAN -,SUP-STEM-0920-025-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA [1000108],AETNA [100010801],,,76.8,,4872.11,9.170825,27238.33344,percent of total billed charges,,,
TSS PRESS FIT STEM SZ 10 -,SUP-STEM-0920-025-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA [1000108],AETNA [100010801],,,76.8,,4872.11,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 11MM PRFT TITAN -,SUP-STEM-0920-025-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA [1000108],AETNA [100010801],,,76.8,,4872.11,9.170825,27238.33344,percent of total billed charges,,,
STEM PRESS FIT TSS SZ 12 -,SUP-STEM-0920-025-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA [1000108],AETNA [100010801],,,76.8,,4872.11,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 13MM PRFT TITAN -,SUP-STEM-0920-025-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA [1000108],AETNA [100010801],,,76.8,,4872.11,9.170825,27238.33344,percent of total billed charges,,,
TSS PRESS FIT STEM SZ 14 -,SUP-STEM-0920-025-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA [1000108],AETNA [100010801],,,76.8,,4872.11,9.170825,27238.33344,percent of total billed charges,,,
STEM PRESS FIT TSS SZ 15 -,SUP-STEM-0920-025-15,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA [1000108],AETNA [100010801],,,76.8,,4872.11,9.170825,27238.33344,percent of total billed charges,,,
TSS PRESS FIT STEM SIZE 16 -,SUP-STEM-0920-025-16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA [1000108],AETNA [100010801],,,76.8,,4872.11,9.170825,27238.33344,percent of total billed charges,,,
TSS CEMENTED STEM SZ 08 -,SUP-STEM-0950-025-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA [1000108],AETNA [100010801],,,76.8,,4872.11,9.170825,27238.33344,percent of total billed charges,,,
INSERT ECCENTRIC CUP 10' X 36MM X3 CODE E TRIDENT -,SUP-STRYKER,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA [1000108],AETNA [100010801],,,76.8,,3153.13,9.170825,27238.33344,percent of total billed charges,,,
WEDGE ACETABULAR AUGMENT 54MM X 56MM X 15MM -,SUP-STRYKER,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,AETNA [1000108],AETNA [100010801],,,76.8,,6346.72,9.170825,27238.33344,percent of total billed charges,,,
COMP VRSDL GLNSPR 36MM TI -,SUP-TI-115310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,9.170825,27238.33344,percent of total billed charges,,,
COMP ACTB 26X42MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-42-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,,,
COMP ACTB 26X43MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-43-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,,,
COMP ACTB 26X44MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-44-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,,,
COMP ACTB 26X45MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-45-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,,,
COMP ACTB 26X46MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-46-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,,,
COMP ACTB 26X47MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-47-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,,,
COMP ACTB 26X48MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-48-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,,,
COMP ACTB 26X50MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-50-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,,,
COMP ACTB 26X51MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-51-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,,,
COMP ACTB 26X52MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-52-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,,,
COMP ACTB 26X53MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-53-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,,,
COMP ACTB 26X54MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-54-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,,,
COMP ACTB 26X55MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-55-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,,,
COMP ACTB 26X56MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-56-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,,,
COMP ACTB 26X58MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-58-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT FEM DIST 12MM SIZE 4 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,AETNA [1000108],AETNA [100010801],,,76.8,,3836.31,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT TIBIAL HALF BLOCK #6 T -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,AETNA [1000108],AETNA [100010801],,,76.8,,3363.73,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE 3LT REV TIBIA LNG -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,AETNA [1000108],AETNA [100010801],,,76.8,,8677.37,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE MED GLENOID UNIVER -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7278.46,5094.922,AETNA [1000108],AETNA [100010801],,,76.8,,5589.86,9.170825,27238.33344,percent of total billed charges,,,
GLENOID REVERS 39 +4 LAT -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA [1000108],AETNA [100010801],,,76.8,,6844.72,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT LT MOD FEM SIZE 3 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,AETNA [1000108],AETNA [100010801],,,76.8,,14029.79,9.170825,27238.33344,percent of total billed charges,,,
CONE FEMORAL MEDIUM LEFT 30MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,AETNA [1000108],AETNA [100010801],,,76.8,,14371.98,9.170825,27238.33344,percent of total billed charges,,,
CONE PROX BODY SIZE 0 60MM TYP -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,AETNA [1000108],AETNA [100010801],,,76.8,,22037.04,9.170825,27238.33344,percent of total billed charges,,,
CONE TIBIAL 31 X 31 X 25MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,AETNA [1000108],AETNA [100010801],,,76.8,,14371.98,9.170825,27238.33344,percent of total billed charges,,,
CUP UNIVERS REVERS 39 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7575.54,5302.878,AETNA [1000108],AETNA [100010801],,,76.8,,5818.01,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT LGN OX FEMORAL 5LT C -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,AETNA [1000108],AETNA [100010801],,,76.8,,21700.55,9.170825,27238.33344,percent of total billed charges,,,
CUP PIVOT BIPOLAR 22 X 45MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,9.170825,27238.33344,percent of total billed charges,,,
GLENOID POLY WITH PEG SMALL -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,,,
HUMERAL HEAD UNIVERS 44/17 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA [1000108],AETNA [100010801],,,76.8,,5703.94,9.170825,27238.33344,percent of total billed charges,,,
GLENOID POLY WITH PEG LG -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,,,
HEAD 40 CER 16/18 TAPER BIOLOXD -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL #5 13MM TS -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,,,
INSERT HUMERAL M/39 +3 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,AETNA [1000108],AETNA [100010801],,,76.8,,3308.28,9.170825,27238.33344,percent of total billed charges,,,
STEM HIP MODULAR 12MM X 127MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10941.84,7659.288,AETNA [1000108],AETNA [100010801],,,76.8,,8403.33,9.170825,27238.33344,percent of total billed charges,,,
STEM STR DIST 21MM X 90MM TAPE -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,AETNA [1000108],AETNA [100010801],,,76.8,,11360.71,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL HALF BLOCK #6 5MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,AETNA [1000108],AETNA [100010801],,,76.8,,3443,9.170825,27238.33344,percent of total billed charges,,,
POSTERIOR FEM AUGMENT 8MM SZ 4 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,AETNA [1000108],AETNA [100010801],,,76.8,,3836.31,9.170825,27238.33344,percent of total billed charges,,,
STEM STR DIST 21MM X 150MM TAP -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,AETNA [1000108],AETNA [100010801],,,76.8,,11360.71,9.170825,27238.33344,percent of total billed charges,,,
STEM HIP MODULAR 13MM X 127MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10941.84,7659.288,AETNA [1000108],AETNA [100010801],,,76.8,,8403.33,9.170825,27238.33344,percent of total billed charges,,,
STEM UNIVERS SZ10 CAP COATED -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10546.34,7382.438,AETNA [1000108],AETNA [100010801],,,76.8,,8099.59,9.170825,27238.33344,percent of total billed charges,,,
STEM DIST CONICAL 21MM X 155MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,AETNA [1000108],AETNA [100010801],,,76.8,,7648.77,9.170825,27238.33344,percent of total billed charges,,,
TIB TRAY ROTATING REV  SZ 2 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA [1000108],AETNA [100010801],,,76.8,,6844.72,9.170825,27238.33344,percent of total billed charges,,,
TRIAL CONE MED 31 X 31 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2768.92,1938.244,AETNA [1000108],AETNA [100010801],,,76.8,,2126.53,9.170825,27238.33344,percent of total billed charges,,,
WEDGE ACET AUGMENT 46MM X 15MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,AETNA [1000108],AETNA [100010801],,,76.8,,6346.72,9.170825,27238.33344,percent of total billed charges,,,
TIBAL INSERT TOTAL STAB SZ.3 9 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA [1000108],AETNA [100010801],,,76.8,,6790.98,9.170825,27238.33344,percent of total billed charges,,,
TRIAL KNEE INSERT 3X12 PS ORTH -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,AETNA [1000108],AETNA [100010801],,,76.8,,717,9.170825,27238.33344,percent of total billed charges,,,
COMPR NANO HMRL PPS 36MM -,SUP-US-115736,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24134.5,16894.15,AETNA [1000108],AETNA [100010801],,,76.8,,18535.3,9.170825,27238.33344,percent of total billed charges,,,
COMPR NANO HMRL PPS 38MM -,SUP-US-115738,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24134.5,16894.15,AETNA [1000108],AETNA [100010801],,,76.8,,18535.3,9.170825,27238.33344,percent of total billed charges,,,
COMPR NANO HMRL PPS 40MM -,SUP-US-115740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24134.5,16894.15,AETNA [1000108],AETNA [100010801],,,76.8,,18535.3,9.170825,27238.33344,percent of total billed charges,,,
BEARING HUM 44-36MM XL STD RVRS CMPRHNSV ARCM -,SUP-XL115363,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
ARCOM XL 44-36 STD HMRL BRNG -,SUP-XL-115363,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
44MM X 36MM CURV HUMERAL BEARING -,SUP-XL-115364,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,9.170825,27238.33344,percent of total billed charges,,,
PERSONA FEMUR CEMENTED STD CCR SIZE 7 LEFT -,SUP-ZIMMER,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA [1000108],AETNA [100010801],,,76.8,,5133.54,9.170825,27238.33344,percent of total billed charges,,,
LEAD DEFIB IMPL BIPLR PERMNT PCNG ETAK RELIANCE 59CM 9FR -,SUP-0137,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,399.86,9966.28992,percent of total billed charges,,,
ENDOTAK RELIANCE S 64CM REF: 0138 -,SUP-0138,CDM,C1777,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,AETNA [1000108],AETNA [100010801],,,76.8,,7799.09,399.86,9966.28992,percent of total billed charges,,,
LEAD PCNG 64CM ETAK RELIANCE SG -,SUP-0181,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,399.86,9966.28992,percent of total billed charges,,,
ENDOTAK RELIANCE S 0272 59CM -,SUP-0272-59,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,399.86,9966.28992,percent of total billed charges,,,
ENDOTAK RELIANCE S 0273 64CM -,SUP-0273-64,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,399.86,9966.28992,percent of total billed charges,,,
LEAD ENDOTAK RELIANCE SINGLE C -,SUP-0292,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,399.86,9966.28992,percent of total billed charges,,,
LEAD DEFIB PCNG ETAK RELIANCE 59CM GORE-HYBRID ETFE CTD STRD -,SUP-0292-59,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,399.86,9966.28992,percent of total billed charges,,,
LEAD ICD RELIANCE 4-FRONT DEFIB -,SUP-0672-59,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,399.86,9966.28992,percent of total billed charges,,,
LEAD DEFIB IMPL LINOX SMRT S 65CM ECRD SIL INSL SGL COIL -,SUP-369818,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,AETNA [1000108],AETNA [100010801],,,76.8,,7673.61,399.86,9966.28992,percent of total billed charges,,,
LEAD DEFIB IMPL LINOX SMRT S 60CM ECRD SIL INSL SGL COIL -,SUP-375012,CDM,C1777,HCPCS,278,RC,,,outpatient,,,12976.94,9083.858,AETNA [1000108],AETNA [100010801],,,76.8,,9966.29,399.86,9966.28992,percent of total billed charges,,,
LEAD PCNG PROTEGO T FX -,SUP-379967,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,AETNA [1000108],AETNA [100010801],,,76.8,,7673.61,399.86,9966.28992,percent of total billed charges,,,
DEFIBRILLATOR PROTEGO S SGL COIL 75CM LD CARD IMPL -,SUP-379968,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,AETNA [1000108],AETNA [100010801],,,76.8,,7673.61,399.86,9966.28992,percent of total billed charges,,,
DEFIBRILLATOR PROTEGO S SGL COIL 60CM LD CARD IMPL -,SUP-379970,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,AETNA [1000108],AETNA [100010801],,,76.8,,7673.61,399.86,9966.28992,percent of total billed charges,,,
PLEXA PROMRI DF-1 S DS 65/15 -,SUP-414005,CDM,C1777,HCPCS,278,RC,,,outpatient,,,10734.28,7513.996,AETNA [1000108],AETNA [100010801],,,76.8,,8243.93,399.86,9966.28992,percent of total billed charges,,,
LEAD DEFIB TRIPLR SPRNT QUATTRO 58CM 8.6FRX12MM SPC RT ECRD -,SUP-6935-58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA [1000108],AETNA [100010801],,,76.8,,9125.07,399.86,9966.28992,percent of total billed charges,,,
LEAD DEFIB TRIPLR SPRNT QUATTRO 75CM 8.6FRX12MM SPC SIL -,SUP-6935M,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA [1000108],AETNA [100010801],,,76.8,,9125.07,399.86,9966.28992,percent of total billed charges,,,
LEAD DEFIB TRIPLR SPRNT QUATTRO 72CM 8.6FRX12MM SPC SIL -,SUP-6935M72,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA [1000108],AETNA [100010801],,,76.8,,9125.07,399.86,9966.28992,percent of total billed charges,,,
LEAD DEFIB UNIPL 58CM 7.5FR SUBQ SIL INSL SUT ON ANCHR SLV -,SUP-6996SQ58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,399.86,9966.28992,percent of total billed charges,,,
LEAD DEFIB TRUE BIPLR DURATA 60CM 7FR VNTRC OPTIM INSL STRD -,SUP-7122/60,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,399.86,9966.28992,percent of total billed charges,,,
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FR VNTRC OPTIM INSL STRD -,SUP-7122/65,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,399.86,9966.28992,percent of total billed charges,,,
LEAD DEFIB TRUE BIPLR DURATA 52CM 7FR VNTRC OPTIM INSL SGL. -,SUP-7122Q/52,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,399.86,9966.28992,percent of total billed charges,,,
LEAD DEFIB 7FRX58CM DURATA TRUE BIPLR HLCL TIP AV SGL SHOCK. -,SUP-7122Q/58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,399.86,9966.28992,percent of total billed charges,,,
LEAD DEFIB 7FRX65CM DURATA TRUE BIPLR HLCL TIP AV SGL SHOCK -,SUP-7122Q/65,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,399.86,9966.28992,percent of total billed charges,,,
LEAD DEFIB 8FR INTRO 58CM OPTISURE TRUE BIPLR SGL COIL -,SUP-LDA210Q/58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,399.86,9966.28992,percent of total billed charges,,,
LEAD DEFIB 8FR INTRO 65CM OPTISURE TRUE BIPLR SGL COIL -,SUP-LDA210Q-65,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,399.86,9966.28992,percent of total billed charges,,,
PK LEAD NEURSTM ACC -,SUP-30571SC,CDM,C1778,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,150.646235,34103.808,percent of total billed charges,,,
KT LEAD NEURSTM OCTRODE 60CM ACC -,SUP-3186,CDM,C1778,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,150.646235,34103.808,percent of total billed charges,,,
OCTRODE -,SUP-3189,CDM,C1778,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,150.646235,34103.808,percent of total billed charges,,,
LEAD NEURSTM PENTA 60CM PDL -,SUP-3228,CDM,C1778,HCPCS,278,RC,,,outpatient,,,14480.7,10136.49,AETNA [1000108],AETNA [100010801],,,76.8,,11121.18,150.646235,34103.808,percent of total billed charges,,,
KT LEAD NEURSTM LMTRD S-8 60CM ACC -,SUP-3286,CDM,C1778,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,150.646235,34103.808,percent of total billed charges,,,
KT 8MMX60CM LDX1 REVISN F/MDTRNC DEEP BRN STIM DBS -,SUP-3550-27,CDM,C1778,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,150.646235,34103.808,percent of total billed charges,,,
KT EXTENSION NEURSTM 40CM ACC -,SUP-3708140,CDM,C1778,HCPCS,278,RC,,,outpatient,,,3007.62,2105.334,AETNA [1000108],AETNA [100010801],,,76.8,,2309.85,150.646235,34103.808,percent of total billed charges,,,
KT LEAD NEURSTM PLTNM-IRDM ELCTRD 60CM STD ACC -,SUP-3777-60,CDM,C1778,HCPCS,278,RC,,,outpatient,,,7193.58,5035.506,AETNA [1000108],AETNA [100010801],,,76.8,,5524.67,150.646235,34103.808,percent of total billed charges,,,
KT LEAD NEURSTM 60CM PERC CMPCT ACC -,SUP-3778-60,CDM,C1778,HCPCS,278,RC,,,outpatient,,,7193.58,5035.506,AETNA [1000108],AETNA [100010801],,,76.8,,5524.67,150.646235,34103.808,percent of total billed charges,,,
KT LEAD NEURSTM PLTNM-IRDM ELCTRD PU SLVR COR 75CM PERC -,SUP-3778-75,CDM,C1778,HCPCS,278,RC,,,outpatient,,,7193.58,5035.506,AETNA [1000108],AETNA [100010801],,,76.8,,5524.67,150.646235,34103.808,percent of total billed charges,,,
LEAD PCNG 56CM TIP PISCES QUAD -,SUP-3887-56,CDM,C1778,HCPCS,278,RC,,,outpatient,,,4498.64,3149.048,AETNA [1000108],AETNA [100010801],,,76.8,,3454.96,150.646235,34103.808,percent of total billed charges,,,
KT LEAD NEURSTM SPEC FLRPLYMR PLTNM-IRDM SIL RBR PLYSTR PU -,SUP-3956530,CDM,C1778,HCPCS,278,RC,,,outpatient,,,17822.4,12475.68,AETNA [1000108],AETNA [100010801],,,76.8,,13687.6,150.646235,34103.808,percent of total billed charges,,,
KT LEAD NEURSTM SPEC 65CM SPIN CRD 5-6-5 LD ACC -,SUP-3956565,CDM,C1778,HCPCS,278,RC,,,outpatient,,,17822.4,12475.68,AETNA [1000108],AETNA [100010801],,,76.8,,13687.6,150.646235,34103.808,percent of total billed charges,,,
REACTIV8 IMPLANTABLE LEAD 45CM -,SUP-8145,CDM,C1778,HCPCS,278,RC,,,outpatient,,,11127.86,7789.502,AETNA [1000108],AETNA [100010801],,,76.8,,8546.2,150.646235,34103.808,percent of total billed charges,,,
STIMULATOR NERVE SPRINT ENDURA PNS SYSTEM -,SUP-9244-6001,CDM,C1778,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,AETNA [1000108],AETNA [100010801],,,76.8,,13972.76,150.646235,34103.808,percent of total billed charges,,,
STIMULATOR NERVE SPRINT EXTENSA PNS SYSTEM -,SUP-9288-6002,CDM,C1778,HCPCS,278,RC,,,outpatient,,,30075.3,21052.71,AETNA [1000108],AETNA [100010801],,,76.8,,23097.83,150.646235,34103.808,percent of total billed charges,,,
LEAD NEURSTM VECTRIS SURECAN 60CM PERC IMPL -,SUP-977A260,CDM,C1778,HCPCS,278,RC,,,outpatient,,,8347.95,5843.565,AETNA [1000108],AETNA [100010801],,,76.8,,6411.23,150.646235,34103.808,percent of total billed charges,,,
SYS PROGRAMMER NEURSTM VECTRIS SURSCN 75CM SPIN CRD CMPCT -,SUP-977A275,CDM,C1778,HCPCS,278,RC,,,outpatient,,,8347.95,5843.565,AETNA [1000108],AETNA [100010801],,,76.8,,6411.23,150.646235,34103.808,percent of total billed charges,,,
SURESCAN MRI -,SUP-977C165,CDM,C1778,HCPCS,278,RC,,,outpatient,,,20681.41,14476.987,AETNA [1000108],AETNA [100010801],,,76.8,,15883.32,150.646235,34103.808,percent of total billed charges,,,
LEAD SPECIFY SURESCAN MRI LEAD -,SUP-977C265,CDM,C1778,HCPCS,278,RC,,,outpatient,,,20681.41,14476.987,AETNA [1000108],AETNA [100010801],,,76.8,,15883.32,150.646235,34103.808,percent of total billed charges,,,
SURESCAN 2 X 8 PADDLE LEAD -,SUP-977C290,CDM,C1778,HCPCS,278,RC,,,outpatient,,,20681.41,14476.987,AETNA [1000108],AETNA [100010801],,,76.8,,15883.32,150.646235,34103.808,percent of total billed charges,,,
LEAD INTERSTIM MICRO 28CM SSMRI TINED -,SUP-978A128,CDM,C1778,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,AETNA [1000108],AETNA [100010801],,,76.8,,9410.23,150.646235,34103.808,percent of total billed charges,,,
INTERSTIM MRI LEAD KIT 2.16MM X 28CM -,SUP-978B128,CDM,C1778,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,AETNA [1000108],AETNA [100010801],,,76.8,,9410.23,150.646235,34103.808,percent of total billed charges,,,
LEAD NEUROSTIMULATOR INTERSTIM L41 CM TINE SSMRI -,SUP-978B133,CDM,C1778,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,AETNA [1000108],AETNA [100010801],,,76.8,,9410.23,150.646235,34103.808,percent of total billed charges,,,
FREEDOM 4A NEUROSTIMULATOR FR4A-TRL-A0 -,SUP-FR4A-TRL-A0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,150.646235,34103.808,percent of total billed charges,,,
FREEDOM 4A NEUROSTIMULATOR FR4A-TRL-B0 -,SUP-FR4A-TRL-B0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,150.646235,34103.808,percent of total billed charges,,,
FREEDOM-8A TRIAL KIT CH A US -,SUP-FR8A-TRL-A0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,150.646235,34103.808,percent of total billed charges,,,
FREEDOM 8A NEUROSTIMULATOR FR8A-TRL-B0 -,SUP-FR8A-TRL-B0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,150.646235,34103.808,percent of total billed charges,,,
KIT INTELLIS TRIAL LEAD 2 -,SUP-INTELTRIAL2,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,150.646235,34103.808,percent of total billed charges,,,
BLUE PERC LEAD KIT -,SUP-LEAD1058-70B,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,150.646235,34103.808,percent of total billed charges,,,
NEVRO 70CM SURGICAL LEAD KIT -,SUP-LEAD3005-70B,CDM,C1778,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,AETNA [1000108],AETNA [100010801],,,76.8,,7984.44,150.646235,34103.808,percent of total billed charges,,,
KT NEURSTM PRGMR PRECISN ACC -,SUP-M365SC550040,CDM,C1778,HCPCS,278,RC,,,outpatient,,,6196.24,4337.368,AETNA [1000108],AETNA [100010801],,,76.8,,4758.71,150.646235,34103.808,percent of total billed charges,,,
VECTRIS SURESCAN MRI COMPACT LEAD KIT 1 X 8 SC -,SUP-MEDTRONIC INC,CDM,C1778,HCPCS,278,RC,,,outpatient,,,8347.95,5843.565,AETNA [1000108],AETNA [100010801],,,76.8,,6411.23,150.646235,34103.808,percent of total billed charges,,,
SLIM TIP DRG -,SUP-MN10450-50A,CDM,C1778,HCPCS,278,RC,,,outpatient,,,9331.07,6531.749,AETNA [1000108],AETNA [100010801],,,76.8,,7166.26,150.646235,34103.808,percent of total billed charges,,,
SLIMTIP DRG 90A -,SUP-MN10450-90A,CDM,C1778,HCPCS,278,RC,,,outpatient,,,9509.36,6656.552,AETNA [1000108],AETNA [100010801],,,76.8,,7303.19,150.646235,34103.808,percent of total billed charges,,,
KIT NEUROSTIMULATOR TUNNEL TOOL -,SUP-MN15000,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2572.47,1800.729,AETNA [1000108],AETNA [100010801],,,76.8,,1975.66,150.646235,34103.808,percent of total billed charges,,,
FREEDOM -4A PNS SYSTEM -,SUP-Q4SP-1-US DW,CDM,C1778,HCPCS,278,RC,,,outpatient,,,40705.5,28493.85,AETNA [1000108],AETNA [100010801],,,76.8,,31261.82,150.646235,34103.808,percent of total billed charges,,,
FREEDOM -4A PNS SYSTEM -,SUP-Q4SP-2-US,CDM,C1778,HCPCS,278,RC,,,outpatient,,,44406,31084.2,AETNA [1000108],AETNA [100010801],,,76.8,,34103.81,150.646235,34103.808,percent of total billed charges,,,
COVEREDGE 32 MRI PADDLE LEAD 50CM -,SUP-SC-8436-50,CDM,C1778,HCPCS,278,RC,,,outpatient,,,29704,20792.8,AETNA [1000108],AETNA [100010801],,,76.8,,22812.67,150.646235,34103.808,percent of total billed charges,,,
TRIAL LEAD KIT -,SUP-TLEAD1058-70B,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,150.646235,34103.808,percent of total billed charges,,,
LEAD PCNG 9FRX12MM SPC AV + DX PERMNT BIPLR STRD ELUT TND FX -,SUP-1368,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,399.86,2035.392,percent of total billed charges,,,
LEAD PCNG 9FRX12MM SPC 52CM AV + DX PERMNT BIPLR STRD ELUT -,SUP-1368/52,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,399.86,2035.392,percent of total billed charges,,,
LEAD PCNG 9FRX12MM SPC 58CM AV + DX PERMNT BIPLR STRD ELUT -,SUP-1368/58,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,399.86,2035.392,percent of total billed charges,,,
PACING  LEAD TENDRIL STS 2088TC-65 -,SUP-2088TC-65,CDM,C1779,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,AETNA [1000108],AETNA [100010801],,,76.8,,1465.57,399.86,2035.392,percent of total billed charges,,,
LEAD PCNG 58CM SOLOX IMPL BIPLR ECRD SGL -PASS PSS FX -,SUP-333900,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,AETNA [1000108],AETNA [100010801],,,76.8,,1567.25,399.86,2035.392,percent of total billed charges,,,
MESH SURG LRG 5.4X7IN OVL PP EPTFE CMPSX KL NABSB PTCH -,SUP-0010202,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5029.22,3520.454,AETNA [1000108],AETNA [100010801],,,76.8,,3862.44,26.19915,15398.5536,percent of total billed charges,,,
MESH SURG SM 3.1X4.7IN OVL MONO PP PDS EPTFE VENTRIO PRT -,SUP-0010211,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3818.72,2673.104,AETNA [1000108],AETNA [100010801],,,76.8,,2932.78,26.19915,15398.5536,percent of total billed charges,,,
MESH SURG LRG 5.4X7IN OVL MONO PP PDS EPTFE VENTRIO PRT ABSB -,SUP-0010212,CDM,C1781,HCPCS,278,RC,,,outpatient,,,7123.55,4986.485,AETNA [1000108],AETNA [100010801],,,76.8,,5470.89,26.19915,15398.5536,percent of total billed charges,,,
MESH SURG 4.5IN LRG CIR MONO PP PDS EPTFE VENTRIO PRT ABSB -,SUP-0010214,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4340.04,3038.028,AETNA [1000108],AETNA [100010801],,,76.8,,3333.15,26.19915,15398.5536,percent of total billed charges,,,
MESH SURG MED 4.3X5.5IN OVL MONO PP PDS EPTFE VENTRIO PRT -,SUP-0010215,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5013.01,3509.107,AETNA [1000108],AETNA [100010801],,,76.8,,3849.99,26.19915,15398.5536,percent of total billed charges,,,
MESH SURG 8CM LRG 3.2X3.2IN CIR PP EPTFE VENTRALEX NABSB -,SUP-0010303,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4167.7,2917.39,AETNA [1000108],AETNA [100010801],,,76.8,,3200.79,26.19915,15398.5536,percent of total billed charges,,,
MESH PERFIX PLUG MED -,SUP-0112760,CDM,C1781,HCPCS,278,RC,,,outpatient,,,984.1,688.87,AETNA [1000108],AETNA [100010801],,,76.8,,755.79,26.19915,15398.5536,percent of total billed charges,,,
MESH PERFIX PLUG LRG -,SUP-0112770,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1660.12,1162.084,AETNA [1000108],AETNA [100010801],,,76.8,,1274.97,26.19915,15398.5536,percent of total billed charges,,,
MESH PLUG PERFIX X-LRG -,SUP-0112780,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1159.39,811.573,AETNA [1000108],AETNA [100010801],,,76.8,,890.41,26.19915,15398.5536,percent of total billed charges,,,
MESH 3DMAX DAVOL LRG LEFT -,SUP-0115311,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,AETNA [1000108],AETNA [100010801],,,76.8,,822.99,26.19915,15398.5536,percent of total billed charges,,,
MESH 3DMAX DAVOL X-LRG LEFT -,SUP-0115312,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1187.9,831.53,AETNA [1000108],AETNA [100010801],,,76.8,,912.31,26.19915,15398.5536,percent of total billed charges,,,
MESH 3DMAX DAVOL LRG RIGHT -,SUP-0115321,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,AETNA [1000108],AETNA [100010801],,,76.8,,822.99,26.19915,15398.5536,percent of total billed charges,,,
MESH 3DMAX DAVOL X-LRG RIGHT -,SUP-0115322,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1187.9,831.53,AETNA [1000108],AETNA [100010801],,,76.8,,912.31,26.19915,15398.5536,percent of total billed charges,,,
MESH MOD KUGEL 3.5 X 5 -,SUP-0115816,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,AETNA [1000108],AETNA [100010801],,,76.8,,1119.47,26.19915,15398.5536,percent of total billed charges,,,
MESH SURG 4X6IN ELLIP MONO PP EPTFE COMPOSIX E /X NABSB -,SUP-0123460,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2954.63,2068.241,AETNA [1000108],AETNA [100010801],,,76.8,,2269.16,26.19915,15398.5536,percent of total billed charges,,,
MESH ATRIUM 1 X 4 - DISC DO NOT USE -,SUP-1000104-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,116.7,81.69,AETNA [1000108],AETNA [100010801],,,76.8,,89.63,26.19915,15398.5536,percent of total billed charges,,,
MESH ATRIUM 2 X 4 -  DISC DO NOT USE -,SUP-1000204-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,128.37,89.859,AETNA [1000108],AETNA [100010801],,,76.8,,98.59,26.19915,15398.5536,percent of total billed charges,,,
MESH ATRIUM 6 X 6 - DO NOT USE DISCONTINUED -,SUP-1000606-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,163.38,114.366,AETNA [1000108],AETNA [100010801],,,76.8,,125.48,26.19915,15398.5536,percent of total billed charges,,,
MESH ATRIUM 6X6 - DISCONTINUED DO NOT USE -,SUP-1000606-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,163.38,114.366,AETNA [1000108],AETNA [100010801],,,76.8,,125.48,26.19915,15398.5536,percent of total billed charges,,,
MESH SURG 10X14IN PP KNTD PROLITE NABSB SHT -,SUP-1001014-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,478.47,334.929,AETNA [1000108],AETNA [100010801],,,76.8,,367.46,26.19915,15398.5536,percent of total billed charges,,,
MESH ATRIUM PRE SHAPED -,SUP-1010306-02,CDM,C1781,HCPCS,278,RC,,,outpatient,,,192.56,134.792,AETNA [1000108],AETNA [100010801],,,76.8,,147.89,26.19915,15398.5536,percent of total billed charges,,,
MESH SURG 20X30CM RECT EPTFE GORE-TEX PTCH -,SUP-1320030020,CDM,C1781,HCPCS,278,RC,,,outpatient,,,18928.87,13250.209,AETNA [1000108],AETNA [100010801],,,76.8,,14537.37,26.19915,15398.5536,percent of total billed charges,,,
MESH SURG 5X10CM EPTFE GORE-TEX PTCH -,SUP-1405010010,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1754.47,1228.129,AETNA [1000108],AETNA [100010801],,,76.8,,1347.43,26.19915,15398.5536,percent of total billed charges,,,
MESH SURG 10X15CM OVL EPTFE GORE-TEX PLG -,SUP-1410015010,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4014.93,2810.451,AETNA [1000108],AETNA [100010801],,,76.8,,3083.47,26.19915,15398.5536,percent of total billed charges,,,
IMPLANT ARTELON 0.3X16CM -,SUP-31052,CDM,C1781,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,AETNA [1000108],AETNA [100010801],,,76.8,,6502.49,26.19915,15398.5536,percent of total billed charges,,,
IMPLANT ARTELON 0.7X16CM -,SUP-31056,CDM,C1781,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,AETNA [1000108],AETNA [100010801],,,76.8,,7806.24,26.19915,15398.5536,percent of total billed charges,,,
MESH PROLENE 3D PATCH LRG -,SUP-3DPL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3399.12,2379.384,AETNA [1000108],AETNA [100010801],,,76.8,,2610.52,26.19915,15398.5536,percent of total billed charges,,,
MESH PROLENE 3D PATCH MED -,SUP-3DPM,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3399.12,2379.384,AETNA [1000108],AETNA [100010801],,,76.8,,2610.52,26.19915,15398.5536,percent of total billed charges,,,
MESH RESTORELLE 24CM X 4CM -,SUP-501420,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4419.28,3093.496,AETNA [1000108],AETNA [100010801],,,76.8,,3394.01,26.19915,15398.5536,percent of total billed charges,,,
MESH VENTRALEX ST SM 4.3CM -,SUP-5950007,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2292.25,1604.575,AETNA [1000108],AETNA [100010801],,,76.8,,1760.45,26.19915,15398.5536,percent of total billed charges,,,
MESH VENTRALEX ST MD 6.4CM -,SUP-5950008,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2488.78,1742.146,AETNA [1000108],AETNA [100010801],,,76.8,,1911.38,26.19915,15398.5536,percent of total billed charges,,,
MESH VENTRALEX ST LRG 8.0CM -,SUP-5950009,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3167.55,2217.285,AETNA [1000108],AETNA [100010801],,,76.8,,2432.68,26.19915,15398.5536,percent of total billed charges,,,
MESH SURG 3IN SM CIR MONO PP CO-KNTD VENTRALEX ST ECHO PS -,SUP-5950010,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3765.73,2636.011,AETNA [1000108],AETNA [100010801],,,76.8,,2892.08,26.19915,15398.5536,percent of total billed charges,,,
MESH SURG SM 3.1X4.7IN OVL MONO PP CO-KNTD VENTRALEX ST ECHO -,SUP-5950030,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4634.12,3243.884,AETNA [1000108],AETNA [100010801],,,76.8,,3559,26.19915,15398.5536,percent of total billed charges,,,
MESH SURG MED 4.3.X5.5IN OVL MONO PP CO-KNTD VENTRALEX ST -,SUP-5950040,CDM,C1781,HCPCS,278,RC,,,outpatient,,,6128.34,4289.838,AETNA [1000108],AETNA [100010801],,,76.8,,4706.57,26.19915,15398.5536,percent of total billed charges,,,
MESH SURG XL 8.7X10.7IN OVL MONO PP PTFE HYDRGL CO-KNTD -,SUP-5950080,CDM,C1781,HCPCS,278,RC,,,outpatient,,,12018.24,8412.768,AETNA [1000108],AETNA [100010801],,,76.8,,9230.01,26.19915,15398.5536,percent of total billed charges,,,
MESH SURG 4X6IN ELLIP MONO PP PTFE HYDRGL CO-KNTD -,SUP-5954460,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3720.86,2604.602,AETNA [1000108],AETNA [100010801],,,76.8,,2857.62,26.19915,15398.5536,percent of total billed charges,,,
MESH SURG 15CM MED RND ACCUMESH PSTN -,SUP-AMPPCO15X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3904.18,2732.926,AETNA [1000108],AETNA [100010801],,,76.8,,2998.41,26.19915,15398.5536,percent of total billed charges,,,
MESH SURG 20CM MED RND ACCUMESH PSTN -,SUP-AMPPCO20X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4655.67,3258.969,AETNA [1000108],AETNA [100010801],,,76.8,,3575.55,26.19915,15398.5536,percent of total billed charges,,,
MESH PARIETEX 15CM X 10CM RT -,SUP-AUTO-VTX1510,CDM,C1781,HCPCS,278,RC,,,outpatient,,,465.28,325.696,AETNA [1000108],AETNA [100010801],,,76.8,,357.34,26.19915,15398.5536,percent of total billed charges,,,
MESH DEXTILE MEDIUM LEFT 13 X 9CM ANATOMICAL -,SUP-DXT1309AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,76.8,,604.98,26.19915,15398.5536,percent of total billed charges,,,
MESH DEXTILE MEDIUM RIGHT 13 X 9CM ANATOMICAL -,SUP-DXT1309AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA [1000108],AETNA [100010801],,,76.8,,604.98,26.19915,15398.5536,percent of total billed charges,,,
MESH DEXTILE LARGE LEFT 15 X 10CM ANATOMICAL -,SUP-DXT1510AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,846.08,592.256,AETNA [1000108],AETNA [100010801],,,76.8,,649.79,26.19915,15398.5536,percent of total billed charges,,,
MESH DEXTILE LARGE RIGHT 15 X 10CM ANATOMICAL -,SUP-DXT1510AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,846.08,592.256,AETNA [1000108],AETNA [100010801],,,76.8,,649.79,26.19915,15398.5536,percent of total billed charges,,,
MESH DEXTILE XL LEFT 16 X 12CM ANATOMICAL -,SUP-DXT1612AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,76.8,,694.6,26.19915,15398.5536,percent of total billed charges,,,
MESH DEXTILE XL RIGHT 16 X 12CM ANATOMICAL -,SUP-DXT1612AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,76.8,,694.6,26.19915,15398.5536,percent of total billed charges,,,
PATCH BOVINE 0.8 X 8CM -,SUP-E0.8P8,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1160.81,812.567,AETNA [1000108],AETNA [100010801],,,76.8,,891.5,26.19915,15398.5536,percent of total billed charges,,,
PATCH BOVINE 2.0 X 9CM -,SUP-E2P9,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2008.89,1406.223,AETNA [1000108],AETNA [100010801],,,76.8,,1542.83,26.19915,15398.5536,percent of total billed charges,,,
GORE BIOABSORBABLE SYNTHETIC MESH 7CM X 10CM -,SUP-HH0710,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,15398.5536,percent of total billed charges,,,
MESH LAP PROGRIP 15 X 10 -,SUP-LPG1510,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1664.57,1165.199,AETNA [1000108],AETNA [100010801],,,76.8,,1278.39,26.19915,15398.5536,percent of total billed charges,,,
MESH PROGRIP ANATOM 15x10 L -,SUP-LPG1510AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1878.87,1315.209,AETNA [1000108],AETNA [100010801],,,76.8,,1442.97,26.19915,15398.5536,percent of total billed charges,,,
MESH PROGRIP ANATOM 15x10 R -,SUP-LPG1510AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1878.87,1315.209,AETNA [1000108],AETNA [100010801],,,76.8,,1442.97,26.19915,15398.5536,percent of total billed charges,,,
MESH PROGRIP LAPAROSCOPIC SELF-FIX 16 X 12 -,SUP-LPG1612,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1888.04,1321.628,AETNA [1000108],AETNA [100010801],,,76.8,,1450.01,26.19915,15398.5536,percent of total billed charges,,,
MESH PROGRIP ANATOM 16X12 L -,SUP-LPG1612AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2098.94,1469.258,AETNA [1000108],AETNA [100010801],,,76.8,,1611.99,26.19915,15398.5536,percent of total billed charges,,,
MESH PROGRIP ANATOMICAL RIGHT 16CM X 12CM -,SUP-LPG1612AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2098.94,1469.258,AETNA [1000108],AETNA [100010801],,,76.8,,1611.99,26.19915,15398.5536,percent of total billed charges,,,
UPSYLON TRADITIONAL Y MESH -,SUP-M0068318200,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4180.97,2926.679,AETNA [1000108],AETNA [100010801],,,76.8,,3210.98,26.19915,15398.5536,percent of total billed charges,,,
MESH PROCEED 6IN X 8IN -,SUP-PCDG1,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4886.8,3420.76,AETNA [1000108],AETNA [100010801],,,76.8,,3753.06,26.19915,15398.5536,percent of total billed charges,,,
MESH PROCEED 4IN X 6IN -,SUP-PCDN1,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2936.68,2055.676,AETNA [1000108],AETNA [100010801],,,76.8,,2255.37,26.19915,15398.5536,percent of total billed charges,,,
IMPLANT BIO TISS 10X15CM 3D RND PLYSTR PRCN COLL OPN SKRT -,SUP-PCO1510OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2440.67,1708.469,AETNA [1000108],AETNA [100010801],,,76.8,,1874.43,26.19915,15398.5536,percent of total billed charges,,,
IMPLANT PLYSTR PRCN COLL 10X15CM PRTX 1.7MM ABSB 3D RND KNTD -,SUP-PCO1510X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1920.48,1344.336,AETNA [1000108],AETNA [100010801],,,76.8,,1474.93,26.19915,15398.5536,percent of total billed charges,,,
IMPLANT BIO TISS 15CM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCO15X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2513.71,1759.597,AETNA [1000108],AETNA [100010801],,,76.8,,1930.53,26.19915,15398.5536,percent of total billed charges,,,
IMPLANT BIO TISS 15X20CM 3D RECT PLYSTR PRCN COLL KNTD PRTX -,SUP-PCO2015OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3387.39,2371.173,AETNA [1000108],AETNA [100010801],,,76.8,,2601.52,26.19915,15398.5536,percent of total billed charges,,,
IMPLANT BIO TISS 15X20CM 3D RND PLYSTR PRCN COLL KNTD PRTX -,SUP-PCO2015X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3237.25,2266.075,AETNA [1000108],AETNA [100010801],,,76.8,,2486.21,26.19915,15398.5536,percent of total billed charges,,,
MESH PARIETEX HEART SHAPED -,SUP-PCO2H1,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1862.49,1303.743,AETNA [1000108],AETNA [100010801],,,76.8,,1430.39,26.19915,15398.5536,percent of total billed charges,,,
MESH PARIETEX HORSE SHOE -,SUP-PCO2H3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1999.72,1399.804,AETNA [1000108],AETNA [100010801],,,76.8,,1535.78,26.19915,15398.5536,percent of total billed charges,,,
IMPLANT BIO TISS 20X30CM 3D RECT PLYSTR PRCN COLL KNTD PRTX -,SUP-PCO3020X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5125.65,3587.955,AETNA [1000108],AETNA [100010801],,,76.8,,3936.5,26.19915,15398.5536,percent of total billed charges,,,
PATCH VENTRAL PARITEX 4.6CM -,SUP-PCO4VP,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1712.49,1198.743,AETNA [1000108],AETNA [100010801],,,76.8,,1315.19,26.19915,15398.5536,percent of total billed charges,,,
PATCH VENTRAL PARITEX 6.6CM -,SUP-PCO6VP,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2052.19,1436.533,AETNA [1000108],AETNA [100010801],,,76.8,,1576.08,26.19915,15398.5536,percent of total billed charges,,,
IMPLANT BIO TISS 8CM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCO8OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2128.52,1489.964,AETNA [1000108],AETNA [100010801],,,76.8,,1634.7,26.19915,15398.5536,percent of total billed charges,,,
IMPLANT BIO TISS 8CM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCO8OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2365.35,1655.745,AETNA [1000108],AETNA [100010801],,,76.8,,1816.59,26.19915,15398.5536,percent of total billed charges,,,
PATCH VENTRAL PARITEX 8.6CM -,SUP-PCO8VP,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2635.99,1845.193,AETNA [1000108],AETNA [100010801],,,76.8,,2024.44,26.19915,15398.5536,percent of total billed charges,,,
IMPLANT BIO TISS 50MM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCOPM15H50,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2579.06,1805.342,AETNA [1000108],AETNA [100010801],,,76.8,,1980.72,26.19915,15398.5536,percent of total billed charges,,,
MESH PROLENE HERNIA SYSTEM LARGE -,SUP-PHSL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2038.93,1427.251,AETNA [1000108],AETNA [100010801],,,76.8,,1565.9,26.19915,15398.5536,percent of total billed charges,,,
MESH PROLENE HERNIA SYSTEM MEDIUM -,SUP-PHSM,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2038.93,1427.251,AETNA [1000108],AETNA [100010801],,,76.8,,1565.9,26.19915,15398.5536,percent of total billed charges,,,
MESH PARIENTENE PROGRIP 15CM X 9CM -,SUP-PP1509G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1083.58,758.506,AETNA [1000108],AETNA [100010801],,,76.8,,832.19,26.19915,15398.5536,percent of total billed charges,,,
MESH PARITENE MACROPOROUS 15 X 10 -,SUP-PPM1510X3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,223.71,156.597,AETNA [1000108],AETNA [100010801],,,76.8,,171.81,26.19915,15398.5536,percent of total billed charges,,,
MESH PARITENE MACROPOROUS 15 X 15 -,SUP-PPM1515X3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,259.54,181.678,AETNA [1000108],AETNA [100010801],,,76.8,,199.33,26.19915,15398.5536,percent of total billed charges,,,
MESH PARIETENE 20 X 20 -,SUP-PPM2020,CDM,C1781,HCPCS,278,RC,,,outpatient,,,301.09,210.763,AETNA [1000108],AETNA [100010801],,,76.8,,231.24,26.19915,15398.5536,percent of total billed charges,,,
MESH PARIETENE 30 X 30 -,SUP-PPM3030,CDM,C1781,HCPCS,278,RC,,,outpatient,,,563.14,394.198,AETNA [1000108],AETNA [100010801],,,76.8,,432.49,26.19915,15398.5536,percent of total billed charges,,,
MESH PARIETENE 45 X 30 -,SUP-PPM4530,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1191.23,833.861,AETNA [1000108],AETNA [100010801],,,76.8,,914.86,26.19915,15398.5536,percent of total billed charges,,,
DURASORB PTM 0616 6 X 16 -,SUP-PTM 0616,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,26.19915,15398.5536,percent of total billed charges,,,
DURASORB PTM1 025 10 X 25 -,SUP-PTM1025,CDM,C1781,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA [1000108],AETNA [100010801],,,76.8,,7414.12,26.19915,15398.5536,percent of total billed charges,,,
DURASORB PTM 2025 -,SUP-PTM2025,CDM,C1781,HCPCS,278,RC,,,outpatient,,,20050.2,14035.14,AETNA [1000108],AETNA [100010801],,,76.8,,15398.55,26.19915,15398.5536,percent of total billed charges,,,
MESH SURG 6X11CM RECT PLYSTR KNTD MERSILN NABSB SHT -,SUP-RMS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,992.11,694.477,AETNA [1000108],AETNA [100010801],,,76.8,,761.94,26.19915,15398.5536,percent of total billed charges,,,
MESH SYMBOTEX 25 X 20 0118362 -,SUP-SMY2520OS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,6454.57,4518.199,AETNA [1000108],AETNA [100010801],,,76.8,,4957.11,26.19915,15398.5536,percent of total billed charges,,,
MESH SYMBOTEX VENTRAL 12CM -,SUP-SYM12,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1989.6,1392.72,AETNA [1000108],AETNA [100010801],,,76.8,,1528.01,26.19915,15398.5536,percent of total billed charges,,,
MESH SYMBOTEX VENTRAL 15CM -,SUP-SYM15,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2490.4,1743.28,AETNA [1000108],AETNA [100010801],,,76.8,,1912.63,26.19915,15398.5536,percent of total billed charges,,,
MESH SYMBOTEX VENTRAL 15CM -,SUP-SYM15,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2571.48,1800.036,AETNA [1000108],AETNA [100010801],,,76.8,,1974.9,26.19915,15398.5536,percent of total billed charges,,,
MESH SYMBOTEX VENTRAL 15 X 10 NON SKIRTED -,SUP-SYM1510,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1808.74,1266.118,AETNA [1000108],AETNA [100010801],,,76.8,,1389.11,26.19915,15398.5536,percent of total billed charges,,,
MESH SYMBOTEX 15 X 10 -,SUP-SYM1510OS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2418.08,1692.656,AETNA [1000108],AETNA [100010801],,,76.8,,1857.09,26.19915,15398.5536,percent of total billed charges,,,
MESH SYMBOTEX 2012E -,SUP-SYM2012E,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2774.79,1942.353,AETNA [1000108],AETNA [100010801],,,76.8,,2131.04,26.19915,15398.5536,percent of total billed charges,,,
MESH SYMBOTEX 20 X 15 CM -,SUP-SYM2015,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2613.29,1829.303,AETNA [1000108],AETNA [100010801],,,76.8,,2007.01,26.19915,15398.5536,percent of total billed charges,,,
MESH SYMBOTEX 20 X 15 SKIRTED -,SUP-SYM2015OS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3726.15,2608.305,AETNA [1000108],AETNA [100010801],,,76.8,,2861.68,26.19915,15398.5536,percent of total billed charges,,,
MESH SURG 25X15CM ELLIP MONO PLYSTR COLL SYMBOTEX NABSB -,SUP-SYM2515E,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4592.69,3214.883,AETNA [1000108],AETNA [100010801],,,76.8,,3527.19,26.19915,15398.5536,percent of total billed charges,,,
MESH PARIETENE DS COMPOSITE 25CM X 20CM -,SUP-SYM2520,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4274.74,2992.318,AETNA [1000108],AETNA [100010801],,,76.8,,3283,26.19915,15398.5536,percent of total billed charges,,,
MESH SYMBOTEX 25 X 20 -,SUP-SYM2520,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4118.24,2882.768,AETNA [1000108],AETNA [100010801],,,76.8,,3162.81,26.19915,15398.5536,percent of total billed charges,,,
MESH SYMBOTEX 30 X 20 -,SUP-SYM3020,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5381.94,3767.358,AETNA [1000108],AETNA [100010801],,,76.8,,4133.33,26.19915,15398.5536,percent of total billed charges,,,
MESH SYMBOTEX COMPOSITE -,SUP-SYM3728,CDM,C1781,HCPCS,278,RC,,,outpatient,,,6391.04,4473.728,AETNA [1000108],AETNA [100010801],,,76.8,,4908.32,26.19915,15398.5536,percent of total billed charges,,,
Symbotexâ„¢ Composite Mesh- 42 x 32 cm -,SUP-SYM4232,CDM,C1781,HCPCS,278,RC,,,outpatient,,,7515.87,5261.109,AETNA [1000108],AETNA [100010801],,,76.8,,5772.19,26.19915,15398.5536,percent of total billed charges,,,
MESH SYMBOTEX VENTRAL 9CM -,SUP-SYM9,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1450.75,1015.525,AETNA [1000108],AETNA [100010801],,,76.8,,1114.18,26.19915,15398.5536,percent of total billed charges,,,
MESH SURG 10X15CM PLYSTR KNTD PRTX SHT -,SUP-TECT1510ADPL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,734.63,514.241,AETNA [1000108],AETNA [100010801],,,76.8,,564.2,26.19915,15398.5536,percent of total billed charges,,,
"MESH PARIETEX ANATOMICAL LEFT 6X4"" -",SUP-TECT1510AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,648.04,453.628,AETNA [1000108],AETNA [100010801],,,76.8,,497.69,26.19915,15398.5536,percent of total billed charges,,,
"MESH PARIETEX ANATOMICAL RIGHT 6X4"" -",SUP-TECT1510AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,648.04,453.628,AETNA [1000108],AETNA [100010801],,,76.8,,497.69,26.19915,15398.5536,percent of total billed charges,,,
MESH SURG 8X12CM MONO PLYSTR KNTD PRTX PROGRIP PRT -,SUP-TEM1208GL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1175.76,823.032,AETNA [1000108],AETNA [100010801],,,76.8,,902.98,26.19915,15398.5536,percent of total billed charges,,,
MESH SURG 8X12CM MONO PLYSTR KNTD PRTX PROGRIP PRT ABSB -,SUP-TEM1208GR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1175.76,823.032,AETNA [1000108],AETNA [100010801],,,76.8,,902.98,26.19915,15398.5536,percent of total billed charges,,,
MESH PARIETEX PROGRIP 15cm x 9cm -,SUP-TEM1509G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1083.58,758.506,AETNA [1000108],AETNA [100010801],,,76.8,,832.19,26.19915,15398.5536,percent of total billed charges,,,
MESH PARIETEX PROGRIP 15 X 15CM -,SUP-TEM1515G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1131.55,792.085,AETNA [1000108],AETNA [100010801],,,76.8,,869.03,26.19915,15398.5536,percent of total billed charges,,,
MESH PARIETEX PROGRIP 20X15 -,SUP-TEM2015G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1382.48,967.736,AETNA [1000108],AETNA [100010801],,,76.8,,1061.74,26.19915,15398.5536,percent of total billed charges,,,
MESH PARIETEX PROGRIP 30X15 -,SUP-TEM3015G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1925.62,1347.934,AETNA [1000108],AETNA [100010801],,,76.8,,1478.88,26.19915,15398.5536,percent of total billed charges,,,
MESH SURG 30X30CM 3D PLYSTR KNTD PRTX EASEGRIP SHT -,SUP-TET3030,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1054.85,738.395,AETNA [1000108],AETNA [100010801],,,76.8,,810.12,26.19915,15398.5536,percent of total billed charges,,,
MESH SURG 3X6IN RECT MONO PLGCPRN-25 PP KNTD ULTRAPRO PRT -,SUP-UMR3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,908.96,636.272,AETNA [1000108],AETNA [100010801],,,76.8,,698.08,26.19915,15398.5536,percent of total billed charges,,,
GRAFT HEMASHIELD 10MM X100CM G -,SUP-UNDEFINED,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2550.8,1785.56,AETNA [1000108],AETNA [100010801],,,76.8,,1959.01,26.19915,15398.5536,percent of total billed charges,,,
MESH VENTRIO XL 10 X 13 -,SUP-UNDEFINED,CDM,C1781,HCPCS,278,RC,,,outpatient,,,8233.36,5763.352,AETNA [1000108],AETNA [100010801],,,76.8,,6323.22,26.19915,15398.5536,percent of total billed charges,,,
MESH VICRYL WOVEN FLAT12IN x 12IN ABSORBABLE HERNIA REPAIR -,SUP-VWML,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4702.1,3291.47,AETNA [1000108],AETNA [100010801],,,76.8,,3611.21,26.19915,15398.5536,percent of total billed charges,,,
STENT DES 2.25X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332220,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,200.09685,4563.1488,percent of total billed charges,,,
STENT DES 2.5X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332250,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,200.09685,4563.1488,percent of total billed charges,,,
STENT DES 3X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332300,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,200.09685,4563.1488,percent of total billed charges,,,
STENT DES 3.5X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332350,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,200.09685,4563.1488,percent of total billed charges,,,
STENT DES 4X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332400,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,200.09685,4563.1488,percent of total billed charges,,,
STENT DES 2.75X38MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902338270,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,200.09685,4563.1488,percent of total billed charges,,,
STENT DES 3.5X38MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902338350,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,200.09685,4563.1488,percent of total billed charges,,,
STENT DES 4X38MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902338400,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,200.09685,4563.1488,percent of total billed charges,,,
IMPLANT BIO TISS 6.5CM 3D RND PLYSTR PRCN COLL KNTD PRTX -,SUP-PNP6X3,CDM,C1784,HCPCS,278,RC,,,outpatient,,,891.3,623.91,AETNA [1000108],AETNA [100010801],,,76.8,,684.52,200.09685,4563.1488,percent of total billed charges,,,
PACEMAKER UNIPL BIPLR INSGA I ULTRA 2CHMBR RR 10.8ML 25.4GM -,SUP-1290,CDM,C1785,HCPCS,275,RC,,,outpatient,,,21052.71,14736.897,AETNA [1000108],AETNA [100010801],,,76.8,,16168.48,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER UNIPL BIPLR EVIA 2CHMBR 44.5X53MM 6.5MM 12ML 25GM -,SUP-359529,CDM,C1785,HCPCS,275,RC,,,outpatient,,,11220.69,7854.483,AETNA [1000108],AETNA [100010801],,,76.8,,8617.49,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER UNIPL BIPLR EVIA 2CHMBR RR 44.5X53MM 6.5MM 12ML -,SUP-377848,CDM,C1785,HCPCS,275,RC,,,outpatient,,,14573.53,10201.471,AETNA [1000108],AETNA [100010801],,,76.8,,11192.47,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER IMPL ENTOVIS PROMRI 2CHMBR IS-1 CONN SR-T ACC -,SUP-404722,CDM,C1785,HCPCS,275,RC,,,outpatient,,,18565,12995.5,AETNA [1000108],AETNA [100010801],,,76.8,,14257.92,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER IMPL UNIPL VERITY ADX MS DR 2CHMBR RR 45X52MM 6MM -,SUP-5357M/S,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9332.85,6532.995,AETNA [1000108],AETNA [100010801],,,76.8,,7167.63,399.86,21372.62592,percent of total billed charges,,,
GENERATOR TEMP PLS 2CHMBR 5392 ACC -,SUP-5392KIT,CDM,C1785,HCPCS,275,RC,,,outpatient,,,27828.94,19480.258,AETNA [1000108],AETNA [100010801],,,76.8,,21372.63,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER IMPL UNIPL BIPLR VCT DR 2CHMBR RR V- PCNG RDC -,SUP-5810,CDM,C1785,HCPCS,275,RC,,,outpatient,,,13842.06,9689.442,AETNA [1000108],AETNA [100010801],,,76.8,,10630.7,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER IMPL UNIPL BIPLR VCT XL DR 2CHMBR RR V- PCNG RDC -,SUP-5816,CDM,C1785,HCPCS,275,RC,,,outpatient,,,13842.06,9689.442,AETNA [1000108],AETNA [100010801],,,76.8,,10630.7,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER IMPL UNIPL BIPLR ZPHR 2CHMBR RR 43X44MM 6MM 8.5ML -,SUP-5820,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9332.85,6532.995,AETNA [1000108],AETNA [100010801],,,76.8,,7167.63,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER IMPL UNIPL BIPLR ZPHR 2CHMBR RR 43X44MM 6MM 8.5ML -,SUP-5820,CDM,C1785,HCPCS,275,RC,,,outpatient,,,22278,15594.6,AETNA [1000108],AETNA [100010801],,,76.8,,17109.5,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER IMPL UNIPL BIPLR ZPHR DR 2CHMBR RR 44X52MM 6MM -,SUP-5826,CDM,C1785,HCPCS,275,RC,,,outpatient,,,18565,12995.5,AETNA [1000108],AETNA [100010801],,,76.8,,14257.92,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER IMPL SURSCN ADVISA 2CHMBR RR MUL-PRGM IS-1 CONN SR -,SUP-A2DR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16337.2,11436.04,AETNA [1000108],AETNA [100010801],,,76.8,,12546.97,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER IMPL UNIPL ADAPTA DR 2CHMBR RR 12ML 21GM IS-1 -,SUP-ADAPTADRK2,CDM,C1785,HCPCS,275,RC,,,outpatient,,,27828.94,19480.258,AETNA [1000108],AETNA [100010801],,,76.8,,21372.63,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER IMPL BIPLR ADAPT 2CHMBR RR 13.1ML 31.3GM IS-1 CONN -,SUP-ADDRL1,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16567.96,11597.572,AETNA [1000108],AETNA [100010801],,,76.8,,12724.19,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER IMPL UNIPL BIPLR ADAPTA 2CHMBR RR 42.9MMX44.7MM -,SUP-ADDRS1,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16567.96,11597.572,AETNA [1000108],AETNA [100010801],,,76.8,,12724.19,399.86,21372.62592,percent of total billed charges,,,
GENERATOR 2CHMBR -,SUP-DR2550,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16708.5,11695.95,AETNA [1000108],AETNA [100010801],,,76.8,,12832.13,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER ESSENTIO DR DYNMC ADJ TI ACC -,SUP-L101,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9341.91,6539.337,AETNA [1000108],AETNA [100010801],,,76.8,,7174.59,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER ESSENTIO DR MRI L111 -,SUP-L111,CDM,C1785,HCPCS,275,RC,,,outpatient,,,12460.83,8722.581,AETNA [1000108],AETNA [100010801],,,76.8,,9569.92,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER IMPL ESSENTIO EL DR 2CHMBR 4.45X5.88X0.75IN 29.1GM -,SUP-L121,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9341.91,6539.337,AETNA [1000108],AETNA [100010801],,,76.8,,7174.59,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER ACCOLADE DR -REF: L301 -,SUP-L301,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9442.9,6610.03,AETNA [1000108],AETNA [100010801],,,76.8,,7252.15,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER ACCOLADE MRI DR L311 -,SUP-L311,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10582.05,7407.435,AETNA [1000108],AETNA [100010801],,,76.8,,8127.01,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER IMPL UNIPL BIPLR ACCENT DR 2CHMBR RR WRLS TELEM -,SUP-PM2110,CDM,C1785,HCPCS,275,RC,,,outpatient,,,12438.55,8706.985,AETNA [1000108],AETNA [100010801],,,76.8,,9552.81,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER ENDURITY 2CHMBR 50X46MM 6MM 10.4ML 19GM IS-1 CONN -,SUP-PM2160,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10470.66,7329.462,AETNA [1000108],AETNA [100010801],,,76.8,,8041.47,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER IMPL ACCENT DR 2CHMBR RR 52X52MM 6MM 12.8ML 23GM -,SUP-PM2210,CDM,C1785,HCPCS,275,RC,,,outpatient,,,12438.55,8706.985,AETNA [1000108],AETNA [100010801],,,76.8,,9552.81,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER IMPL ASSURITY 2CHMBR RR 50X47MM 6MM 10.4ML 20GM -,SUP-PM2240,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10732.43,7512.701,AETNA [1000108],AETNA [100010801],,,76.8,,8242.51,399.86,21372.62592,percent of total billed charges,,,
ASSURITY MRI PACEMAKER DR-RF PM2272 -,SUP-PM2272,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10582.05,7407.435,AETNA [1000108],AETNA [100010801],,,76.8,,8127.01,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER IMPL BIPLR REVO 2CHMBR RR SURSCN PCNG -,SUP-REVOMRIPEEM,CDM,C1785,HCPCS,275,RC,,,outpatient,,,23622.66,16535.862,AETNA [1000108],AETNA [100010801],,,76.8,,18142.2,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER IMPL BIPLR REVO SURSCN 2CHMBR RR 45X51X8MM 12.7ML -,SUP-RVDR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,17439.96,12207.972,AETNA [1000108],AETNA [100010801],,,76.8,,13393.89,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER ALTRUA 20 DDDR MUL-PRGM 43X49X8MM 29.6GM 12.6ML -,SUP-S202,CDM,C1785,HCPCS,275,RC,,,outpatient,,,17451.1,12215.77,AETNA [1000108],AETNA [100010801],,,76.8,,13402.44,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER ALTRUA 20 MUL-PRGM 42X44X8MM 25.4GM 10.8ML IS-1 -,SUP-S203,CDM,C1785,HCPCS,275,RC,,,outpatient,,,14373.02,10061.114,AETNA [1000108],AETNA [100010801],,,76.8,,11038.48,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER BIPLR ALTRUA 60 2CHMBR RR 42X44MM 8MM 10.8ML -,SUP-S603,CDM,C1785,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,AETNA [1000108],AETNA [100010801],,,76.8,,11976.65,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER IMPL UNIPL BIPLR SENSIA 2CHMBR RR -,SUP-SEDR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10396.4,7277.48,AETNA [1000108],AETNA [100010801],,,76.8,,7984.44,399.86,21372.62592,percent of total billed charges,,,
GENERATOR VERSA DUAL CHAMBER -,SUP-UNDEFINED,CDM,C1785,HCPCS,275,RC,,,outpatient,,,20402.94,14282.058,AETNA [1000108],AETNA [100010801],,,76.8,,15669.46,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER ALTRUA 20 DR 2 LD -,SUP-UNDEFINED,CDM,C1785,HCPCS,275,RC,,,outpatient,,,19827.42,13879.194,AETNA [1000108],AETNA [100010801],,,76.8,,15227.46,399.86,21372.62592,percent of total billed charges,,,
VERSA DR VEDR01 -,SUP-VEDR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10396.4,7277.48,AETNA [1000108],AETNA [100010801],,,76.8,,7984.44,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER MRI AZURE XT DR SURESCAN -,SUP-W1DR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,18565,12995.5,AETNA [1000108],AETNA [100010801],,,76.8,,14257.92,399.86,21372.62592,percent of total billed charges,,,
Azure S DR MRI Surescan W3DR01 -,SUP-W3DR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16708.5,11695.95,AETNA [1000108],AETNA [100010801],,,76.8,,12832.13,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER BIPLR INSGA ULTRA SR SGL-CHMBR RR 10ML 23.4GM IS-1 -,SUP-1190,CDM,C1786,HCPCS,275,RC,,,outpatient,,,17451.1,12215.77,AETNA [1000108],AETNA [100010801],,,76.8,,13402.44,399.86,46489.17504,percent of total billed charges,,,
PACEMAKER RELAY INTMD UNIPL CARD 5MM -,SUP-293-03,CDM,C1786,HCPCS,275,RC,,,outpatient,,,16151.55,11306.085,AETNA [1000108],AETNA [100010801],,,76.8,,12404.39,399.86,46489.17504,percent of total billed charges,,,
PACEMAKER UNIPL BIPLR EVIA SR-T SGL-CHMBR RR 39X53MM 6.5MM -,SUP-359 533,CDM,C1786,HCPCS,275,RC,,,outpatient,,,10983.05,7688.135,AETNA [1000108],AETNA [100010801],,,76.8,,8434.98,399.86,46489.17504,percent of total billed charges,,,
PACEMAKER IMPL ENTOVIS SR-T PROMRI SGL-CHMBR ACC -,SUP-404723,CDM,C1786,HCPCS,275,RC,,,outpatient,,,10457.22,7320.054,AETNA [1000108],AETNA [100010801],,,76.8,,8031.14,399.86,46489.17504,percent of total billed charges,,,
GENERATOR IMPL VERF SGL-CHMBR -,SUP-5156,CDM,C1786,HCPCS,275,RC,,,outpatient,,,11792.49,8254.743,AETNA [1000108],AETNA [100010801],,,76.8,,9056.63,399.86,46489.17504,percent of total billed charges,,,
PACEMAKER IMPL UNIPL VERITY ADX MS DR SGL-CHMBR RR 42X52MM -,SUP-5157M/S,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8533.24,5973.268,AETNA [1000108],AETNA [100010801],,,76.8,,6553.53,399.86,46489.17504,percent of total billed charges,,,
PACEMAKER IMPL UNIPL BIPLR ZPHR SGL-CHMBR RR 41X44MM 6MM 8ML -,SUP-5620,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8533.24,5973.268,AETNA [1000108],AETNA [100010801],,,76.8,,6553.53,399.86,46489.17504,percent of total billed charges,,,
PACEMAKER IMPL UNIPL BIPLR ZPHR XL SR SGL-CHMBR RR 52X42MM -,SUP-5626,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8533.24,5973.268,AETNA [1000108],AETNA [100010801],,,76.8,,6553.53,399.86,46489.17504,percent of total billed charges,,,
PACEMAKER IMPL SURSCN ADVISA 1CHMBR IS-1 CONN SR -,SUP-A3SR01,CDM,C1786,HCPCS,275,RC,,,outpatient,,,14852,10396.4,AETNA [1000108],AETNA [100010801],,,76.8,,11406.34,399.86,46489.17504,percent of total billed charges,,,
PACEMAKER IMPL UNIPL ADAPTA SR SGL-CHMBR RR 7.5MM 11ML -,SUP-ADSR06,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9952.18,6966.526,AETNA [1000108],AETNA [100010801],,,76.8,,7643.27,399.86,46489.17504,percent of total billed charges,,,
GENERATOR PCMKR  SR SSIR -,SUP-ICV1122,CDM,C1786,HCPCS,275,RC,,,outpatient,,,12497.96,8748.572,AETNA [1000108],AETNA [100010801],,,76.8,,9598.43,399.86,46489.17504,percent of total billed charges,,,
ESSENTIO 4.45X4.81X0.75 CM D 13.2ML TI -,SUP-L100,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8899.67,6229.769,AETNA [1000108],AETNA [100010801],,,76.8,,6834.95,399.86,46489.17504,percent of total billed charges,,,
PACEMAKER ESSENTIO SR MRI -,SUP-L110,CDM,C1786,HCPCS,275,RC,,,outpatient,,,10901.37,7630.959,AETNA [1000108],AETNA [100010801],,,76.8,,8372.25,399.86,46489.17504,percent of total billed charges,,,
PACEMAKER ACCOLADE SR -REF: L300 -,SUP-L300,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,399.86,46489.17504,percent of total billed charges,,,
ACCOLADE MRI SR PACEMAKER L310 -,SUP-L310,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,399.86,46489.17504,percent of total billed charges,,,
PACEMAKER LEADLESS SINGLE AVEIR RV REF: LSP112V -,SUP-LSP112V,CDM,C1786,HCPCS,275,RC,,,outpatient,,,37130,25991,AETNA [1000108],AETNA [100010801],,,76.8,,28515.84,399.86,46489.17504,percent of total billed charges,,,
MICRA MDT TRANSCATHER PACING MICRA SYSTEM -,SUP-MC1VR01,CDM,C1786,HCPCS,275,RC,,,outpatient,,,26520.25,18564.175,AETNA [1000108],AETNA [100010801],,,76.8,,20367.55,399.86,46489.17504,percent of total billed charges,,,
MICRA AV TRANSCATHETER  MC1AVR1 -,SUP-MICRAAVTCPSYSTEM,CDM,C1786,HCPCS,275,RC,,,outpatient,,,38855.25,27198.675,AETNA [1000108],AETNA [100010801],,,76.8,,29840.83,399.86,46489.17504,percent of total billed charges,,,
TRANSCATHETER PACING SYSTEM INC:CAPSULEDELIV CATHINTROD -,SUP-MICRATCPSYSTEM,CDM,C1786,HCPCS,275,RC,,,outpatient,,,26520.25,18564.175,AETNA [1000108],AETNA [100010801],,,76.8,,20367.55,399.86,46489.17504,percent of total billed charges,,,
PACEMAKER IMPL UNIPL BIPLR ACCENT SR SGL-CHMBR RR WRLS TELEM -,SUP-PM1110,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9375.33,6562.731,AETNA [1000108],AETNA [100010801],,,76.8,,7200.25,399.86,46489.17504,percent of total billed charges,,,
PACEMAKER ENDURITY SGL-CHMBR 50X41X6MM 6MM 19GM 9.7ML IS-1 -,SUP-PM1160,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,399.86,46489.17504,percent of total billed charges,,,
PACEMAKER IMPL UNIPL BIPLR ACCENT SR SGL-CHMBR RR WRLS TELEM -,SUP-PM1210,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9375.33,6562.731,AETNA [1000108],AETNA [100010801],,,76.8,,7200.25,399.86,46489.17504,percent of total billed charges,,,
PACEMAKER IMPL ASSURITY SGL-CHMBR RR 50X47MM 6MM 10.4ML 20GM -,SUP-PM1240,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,76.8,,6681.75,399.86,46489.17504,percent of total billed charges,,,
ASSURITY MRI PACEMAKER SR-RF -,SUP-PM1272,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,399.86,46489.17504,percent of total billed charges,,,
PACEMAKER ALTRUA 40 SR SGL-CHMBR RR 42X42X8MM 10ML 23.4GM -,SUP-S401,CDM,C1786,HCPCS,275,RC,,,outpatient,,,12887.82,9021.474,AETNA [1000108],AETNA [100010801],,,76.8,,9897.85,399.86,46489.17504,percent of total billed charges,,,
SYS ADAPTER PCMKR F/SR -,SUP-UNDEFINED,CDM,C1786,HCPCS,275,RC,,,outpatient,,,23744.64,16621.248,AETNA [1000108],AETNA [100010801],,,76.8,,18235.88,399.86,46489.17504,percent of total billed charges,,,
DEFIBRILLATOR VIVA QUAD S CRTN -,SUP-VIVA QUAD S CRT-D,CDM,C1786,HCPCS,275,RC,,,outpatient,,,60532.78,42372.946,AETNA [1000108],AETNA [100010801],,,76.8,,46489.18,399.86,46489.17504,percent of total billed charges,,,
Azure S SR NRI SureScan W3SR01 -,SUP-W3SR01,CDM,C1786,HCPCS,275,RC,,,outpatient,,,16708.5,11695.95,AETNA [1000108],AETNA [100010801],,,76.8,,12832.13,399.86,46489.17504,percent of total billed charges,,,
GENERATOR PROCLAIM 7 ELITE -,SUP-3662,CDM,C1787,HCPCS,272,RC,,,outpatient,,,40409.46,28286.622,AETNA [1000108],AETNA [100010801],,,,,,399.86,28973.58282,other,272 with C codes,,
PROGRAMMER NEURSTM MYSTIM HNDHLD DVC -,SUP-377-44,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4606.91,3224.837,AETNA [1000108],AETNA [100010801],,,,,,399.86,28973.58282,other,272 with C codes,,
PROGRAMMER NEURSTM MYSTIM 2.2X3.7X1.1IN -,SUP-377-46,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4606.91,3224.837,AETNA [1000108],AETNA [100010801],,,,,,399.86,28973.58282,other,272 with C codes,,
PROGRAMMER NEURSTM IMMG-LN -,SUP-3852,CDM,C1787,HCPCS,272,RC,,,outpatient,,,2517.74,1762.418,AETNA [1000108],AETNA [100010801],,,,,,399.86,28973.58282,other,272 with C codes,,
PRODIGY 3856 -,SUP-3856,CDM,C1787,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,,,,399.86,28973.58282,other,272 with C codes,,
PROCLAIM DRG CONTROLLER LEAD -,SUP-7883,CDM,C1787,HCPCS,272,RC,,,outpatient,,,6212.96,4349.072,AETNA [1000108],AETNA [100010801],,,,,,399.86,28973.58282,other,272 with C codes,,
PROGRAMMER PATIENT 97740 -,SUP-97740,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4507.13,3154.991,AETNA [1000108],AETNA [100010801],,,,,,399.86,28973.58282,other,272 with C codes,,
CONTROLLER 97745NT INTELLIS PTM NONTRIAL -,SUP-97745NT,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4507.13,3154.991,AETNA [1000108],AETNA [100010801],,,,,,399.86,28973.58282,other,272 with C codes,,
INTERSTIM KIT COMM W/HANDSET GU US -,SUP-TH90Q01,CDM,C1787,HCPCS,272,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,,,,399.86,28973.58282,other,272 with C codes,,
PORT IMPLINFN NPWR 8FRX1.6MM ID 12.7MM X- PRT ISP PU LF -,SUP-0607540,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1620.15,1134.105,AETNA [1000108],AETNA [100010801],,,76.8,,1244.28,22.2704,1965.53472,percent of total billed charges,,,
PORT IMPLINFN NPWR 9.5FR CATH X- PRT PLST PRT LF MRI-COND -,SUP-0607675,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2417.77,1692.439,AETNA [1000108],AETNA [100010801],,,76.8,,1856.85,22.2704,1965.53472,percent of total billed charges,,,
PORT POWER LOW PROFILE 8F -,SUP-1708060,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2318.07,1622.649,AETNA [1000108],AETNA [100010801],,,76.8,,1780.28,22.2704,1965.53472,percent of total billed charges,,,
PORT IMPLINFN PWR INJ 6FR CATH PWR PRT TI LF 1LUM -,SUP-1716000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2242.11,1569.477,AETNA [1000108],AETNA [100010801],,,76.8,,1721.94,22.2704,1965.53472,percent of total billed charges,,,
PORT IMPLINFN PWR INJ 8FR CATH PWR PRT M R I ISP PU LF 1LUM -,SUP-1808000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2243.33,1570.331,AETNA [1000108],AETNA [100010801],,,76.8,,1722.88,22.2704,1965.53472,percent of total billed charges,,,
PORT POWER 8F #1808000 -,SUP-1808000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2243.33,1570.331,AETNA [1000108],AETNA [100010801],,,76.8,,1722.88,22.2704,1965.53472,percent of total billed charges,,,
PORT INFS 9FR CATH PWR PRT DUO M R I PLST LF LUMX2 -,SUP-1829500,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2559.29,1791.503,AETNA [1000108],AETNA [100010801],,,76.8,,1965.53,22.2704,1965.53472,percent of total billed charges,,,
KT NEEDLE INFS 20GAX1IN POWERLOC PRT ACCESS SAFTY YST NACL -,SUP-2672010,CDM,C1788,HCPCS,278,RC,,,outpatient,,,99.2,69.44,AETNA [1000108],AETNA [100010801],,,76.8,,76.19,22.2704,1965.53472,percent of total billed charges,,,
PORT INFS PWR INJ 8FR CATH PWR PRT VUE ISP PU CATH LF -,SUP-5608062,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1261.52,883.064,AETNA [1000108],AETNA [100010801],,,76.8,,968.85,22.2704,1965.53472,percent of total billed charges,,,
PORT INFS 8FR MRI-SF PWR SLIM -,SUP-5618000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1261.52,883.064,AETNA [1000108],AETNA [100010801],,,76.8,,968.85,22.2704,1965.53472,percent of total billed charges,,,
TRY CV LUMX2 9.5FRX60CM GRSHNG LF ACC -,SUP-7726952,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1902.88,1332.016,AETNA [1000108],AETNA [100010801],,,76.8,,1461.41,22.2704,1965.53472,percent of total billed charges,,,
CATH INFS PRT 6.6FR SMRT PRT CT TI /CARBOTHAN/ PU LPRO INJ -,SUP-CT66LTPD,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,22.2704,1965.53472,percent of total billed charges,,,
CATH INFS PRT 8FR SMRT PRT CT TI/SIL INJ -,SUP-CT75STSD,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,22.2704,1965.53472,percent of total billed charges,,,
CATH INFS PRT 8FR SMRT PRT CT FLUOROMAX TI/PU INJ -,SUP-CT80STPD,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA [1000108],AETNA [100010801],,,76.8,,956.64,22.2704,1965.53472,percent of total billed charges,,,
CATH INFS PRT 6.6FR MINI SMRT PRT CT TI /CARBOTHAN/ PU INJ -,SUP-H787CT66PTPD0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA [1000108],AETNA [100010801],,,76.8,,956.64,22.2704,1965.53472,percent of total billed charges,,,
SMARTPORT PLASTIC W/VORTEX TECH IF FILLED DETATCHED -,SUP-H787CT80LPPDVI0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,22.2704,1965.53472,percent of total billed charges,,,
CATH INFS PRT 9.6FR SMRT PRT CT FLUOROMAX TI/SIL INJ -,SUP-H787CT96STSD0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA [1000108],AETNA [100010801],,,76.8,,956.64,22.2704,1965.53472,percent of total billed charges,,,
CATH INFS PRT 12/11.4 FR DIA INTRO/CATH VORT LP TI SIL DL -,SUP-H787LVTX52130,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,AETNA [1000108],AETNA [100010801],,,76.8,,1282.3,22.2704,1965.53472,percent of total billed charges,,,
PORT IMPLINFN 8FR INTRO 7.2FR CATH VORT VX TI SIL LF -,SUP-H787P12355K0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA [1000108],AETNA [100010801],,,76.8,,873.85,22.2704,1965.53472,percent of total billed charges,,,
PORT VORTEX VASC 9.6 -,SUP-H787P5455K0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,AETNA [1000108],AETNA [100010801],,,76.8,,1119.47,22.2704,1965.53472,percent of total billed charges,,,
PORT XCELA PLUS POWER INDECTABLE 8F FILLED DETATCHED -,SUP-H965440320,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,22.2704,1965.53472,percent of total billed charges,,,
PORT INFS 8FR MED DIGNITY -,SUP-MRDP80AMS,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1404.63,983.241,AETNA [1000108],AETNA [100010801],,,76.8,,1078.76,22.2704,1965.53472,percent of total billed charges,,,
EXPANDER TISSUE SMOOTH 600CC NATRELLE FULL HT VAR -,SUP-133S-FV-14-T,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BRST 397ML 13.1CM NATRLL 4.2CM PRJCT -,SUP-15-397,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BRST 125ML SIL GEL MOD+ RND 8.9CM MEMORYGEL 2.8CM -,SUP-350-1251BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BRST SIL GEL MOD+ RND 150CC -,SUP-350-1501BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BRST 175ML SIL GEL MOD+ RND 10CM MEMORYGEL 3.1CM -,SUP-350-1751BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BRST 200ML SIL GEL MOD+ RND 10.5CM MEMORYGEL 3.2CM -,SUP-350-2001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BRST 350-420ML SAL MOD+ RND 12.1-11.7CM MENTOR -,SUP-350-2350,CDM,C1789,HCPCS,278,RC,,,outpatient,,,2597.25,1818.075,AETNA [1000108],AETNA [100010801],,,76.8,,1994.69,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BRST 250ML SIL GEL HPRO RND 10.5CM MEMORYGEL 4.3CM -,SUP-350-2504BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,AETNA [1000108],AETNA [100010801],,,76.8,,3409.78,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BRST 600ML SIL GEL MOD+ RND 15CM MEMORYGEL 4.6CM -,SUP-350-6001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4320.47,3024.329,AETNA [1000108],AETNA [100010801],,,76.8,,3318.12,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BRST 650ML SIL GEL MOD+ RND 15.4CM MEMORYGEL 4.7CM -,SUP-350-6501BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4320.47,3024.329,AETNA [1000108],AETNA [100010801],,,76.8,,3318.12,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BRST 650ML SIL GEL HPRO RND 14.4CM MEMORYGEL 5.7CM -,SUP-350-6504BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,AETNA [1000108],AETNA [100010801],,,76.8,,3409.78,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BRST 700ML SIL GEL MOD+ RND 15.8CM MEMORYGEL 4.9CM -,SUP-350-7001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4320.47,3024.329,AETNA [1000108],AETNA [100010801],,,76.8,,3318.12,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BRST 130ML SIL GEL MOD CLASS RND 9.6CM MEMORYGEL -,SUP-350-7130MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BRST 150ML SIL GEL MOD CLASS RND 10.3CM MEMORYGEL -,SUP-350-7150MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BRST SIL GEL MOD+ RND CLSSC 190CC -,SUP-350-7190MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BRST SIL GEL MOD+ RND CLSSC 215CC -,SUP-350-7215MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA [1000108],AETNA [100010801],,,76.8,,3226.46,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BRST 750ML SIL GEL MOD CLASS RND 16.1CM MEMORYGEL -,SUP-350-7501BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,261.9915,4400.1792,percent of total billed charges,,,
BREAST IMPLANT SMOOTH ROUND MODERATE 750CC -,SUP-350-7750MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,261.9915,4400.1792,percent of total billed charges,,,
BREAST IMPLANT SMOOTH ROUND MODERATE 800CC -,SUP-350-7800MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,76.8,,2933.15,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BRST 800ML SIL GEL HPRO RND 16.5CM MEMORYGEL 5.1CM -,SUP-350-8001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BRST 800ML SIL GEL HPRO RND 15.5CM MEMORYGEL 6CM -,SUP-350-8004BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,AETNA [1000108],AETNA [100010801],,,76.8,,3409.78,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BRST 330-350ML SIL SAL BIOCELL PTOTIC SHP NATRLL -,SUP-363LF-330,CDM,C1789,HCPCS,278,RC,,,outpatient,,,3628.24,2539.768,AETNA [1000108],AETNA [100010801],,,76.8,,2786.49,261.9915,4400.1792,percent of total billed charges,,,
NATRELLE SALINE FILLED SMOOTH ROUND IMLANTS 640CC -,SUP-68HP-600,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1637.85,1146.495,AETNA [1000108],AETNA [100010801],,,76.8,,1257.87,261.9915,4400.1792,percent of total billed charges,,,
NATRELLE SMOOTH ROUND SALINE IMPLANTS 68LP-225 -,SUP-68LP-225,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,261.9915,4400.1792,percent of total billed charges,,,
NATRELLE SMOOTH ROUND SALINE IMPLANTS 250CC -,SUP-68LP-250,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,261.9915,4400.1792,percent of total billed charges,,,
NATRELLE SMOOTH ROUND SALINE IMPLANTS 275CC -,SUP-68LP-275,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA [1000108],AETNA [100010801],,,76.8,,1221.24,261.9915,4400.1792,percent of total billed charges,,,
SIZER IMPLANT NATRELLE INSPIRA 295CC FULL PROFILE -,SUP-MSZ-F295,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,261.9915,4400.1792,percent of total billed charges,,,
SIZER NATRELLE INSPIRA 335CC FULL -,SUP-MSZ-F335,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,261.9915,4400.1792,percent of total billed charges,,,
SIZER IMPLANT NATRELLE INSPIRA 650CC FULL PROFILE -,SUP-MSZ-F650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,76.8,,896.26,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 200CC NATRELLE INSPIRA FULL -,SUP-SCF-200,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 240CC NATRELLE INSPIRA FULL -,SUP-SCF-240,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 265CC NATRELLE INSPIRA FULL -,SUP-SCF-265,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 295CC NATRELLE INSPIRA FULL -,SUP-SCF-295,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 335CC NATRELLE INSPIRA FULL -,SUP-SCF-335,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 345CC NATRELLE INSPIRA FULL -,SUP-SCF-345,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 365CC NATRELLE INSPIRA FULL -,SUP-SCF-365,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 385CC NATRELLE INSPIRA FULL -,SUP-SCF-385,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 415CC NATRELLE INSPIRA FULL -,SUP-SCF-415,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 450CC NATRELLE INSPIRA FULL -,SUP-SCF-450,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 485CC NATRELLE INSPIRA FULL -,SUP-SCF-485,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4787.23,3351.061,AETNA [1000108],AETNA [100010801],,,76.8,,3676.59,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 520CC NATRELLE INSPIRA FULL -,SUP-SCF-520,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 560CC NATRELLE INSPIRA FULL -,SUP-SCF-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 605CC NATRELLE INSPIRA FULL -,SUP-SCF-605,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5623.3,3936.31,AETNA [1000108],AETNA [100010801],,,76.8,,4318.69,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 650CC NATRELLE INSPIRA FULL -,SUP-SCF-650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHES GEL 695CC NATRELLE INSPIRA FULL -,SUP-SCF-695,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
NATRELLE INSPIRA COHESIVE IMPLANT 745 -,SUP-SCF-745,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
NATRELLE INSPIRA COHESIVE IMPLANT 770 -,SUP-SCF-770,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST 460CC NATRELLE SMOOTH ROUND -,SUP-SCL-460,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST 490CC SMOOTH COHESIVE LOW PLUS PROFILE -,SUP-SCLP-490,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST 540CC SMOOTH COHESIVE LOW PLUS PROFILE -,SUP-SCLP-540,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST 330CC NATRELLE SMOOTH ROUND -,SUP-SCM-330,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST 360CC NATRELLE SMOOTH ROUND -,SUP-SCM-360,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST 375CC NATRELLE SMOOTH ROUND -,SUP-SCM-375,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SILICONE 375CC NATRELLE INSPIRA STYLE MODERAT -,SUP-SCM-375,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST 405CC NATRELLE SMOOTH ROUND -,SUP-SCM-405,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHES 485CC NATRELLE INSPIRA MODERATE -,SUP-SCM-485,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 560CC NATRELLE INSPIRA MOD -,SUP-SCM-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 600CC NATRELLE INSPIRA MOD -,SUP-SCM-600,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 640CC NAT INSPIRA MOD -,SUP-SCM-640,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHES GEL 685CC NATRELLE INSPIRA MOD -,SUP-SCM-685,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHES GEL 755CC NATRELLE INSPIRA MOD -,SUP-SCM-755,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 340CC NATRELLE INSPIRA FULL -,SUP-SCX-340,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 375CC NATRELLE INSP EXTRA FUL -,SUP-SCX-375,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 525CC NATRELLE INSPIRA FULL -,SUP-SCX-525,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 545CC NATRELLE INSPIRA FULL -,SUP-SCX-545,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST 560CC SMOOTH COHESIVE NATRELLE INSPIRA FULL -,SUP-SCX-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST 580CC SMOOTH COHESIVE NATRELLE INSPIRA FULL -,SUP-SCX-580,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST 615CC SMOOTH COHESIVE NATRELLE INSPIRA FULL -,SUP-SCX-615,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 650CC NATRELLE INSP EX-FULL -,SUP-SCX-650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
NATRELLE INSPIRA COHESIVE IMPLANT 700 -,SUP-SCX-700,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
NATRELLE INSPIRA COHESIVE IMPLANT 750 -,SUP-SCX-750,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
NATRELLE INSPIRA COHESIVE IMPLANT 800CC -,SUP-SCX-800,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT SMOOTH HIGH PROFILE XTRA 755 CC -,SUP-SHPX755,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5211.63,3648.141,AETNA [1000108],AETNA [100010801],,,76.8,,4002.53,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT SMOOTH HIGH PROFILE XTRA 790 CC -,SUP-SHPX790,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5211.63,3648.141,AETNA [1000108],AETNA [100010801],,,76.8,,4002.53,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH FULL 450CC NATRELLE INSPIRA FULL -,SUP-SSF-450,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH FULL 520CC NATRELLE INSPIRA FULL -,SUP-SSF-520,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH FULL 560CC NATRELLE INSPIRA FULL -,SUP-SSF-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH FULL 650CC NATRELLE INSPIRA FULL -,SUP-SSF-650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH FULL 695CC NATRELLE INSPIRA FULL -,SUP-SSF-695,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH FULL 745CC NATRELLE INSPIRA FULL -,SUP-SSF-745,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH SOFT TOUCH 330CC NATRELLE INSPIRA MOD -,SUP-SSM-330,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH SOFT TOUCH 445CC NATRELLE INSPIRA MOD -,SUP-SSM-445,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH SOFT TOUCH 485CC NATRELLE INSPIRA MOD -,SUP-SSM-485,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH SOFT TOUCH 520CC NATRELLE INSPIRA MOD -,SUP-SSM-520,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST EXTRA FULL SOFT TOUCH 750CC -,SUP-SSX-750,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST EXTRA FULL SOFT TOUCH 800CC -,SUP-SSX-800,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA [1000108],AETNA [100010801],,,76.8,,3569.03,261.9915,4400.1792,percent of total billed charges,,,
PROSTHESIS PENL CL SPCTR MALE 9.5MMX12CM CNCLBL SNP FIT TIP -,SUP-720054-01,CDM,C1813,HCPCS,278,RC,,,outpatient,,,20421.5,14295.05,AETNA [1000108],AETNA [100010801],,,76.8,,15683.71,150.646235,27674.62656,percent of total billed charges,,,
PROSTHESIS PENL CL SPCTR MALE 9.5MMX16CM SIL PE TI SEG -,SUP-720054-02,CDM,C1813,HCPCS,278,RC,,,outpatient,,,21238.36,14866.852,AETNA [1000108],AETNA [100010801],,,76.8,,16311.06,150.646235,27674.62656,percent of total billed charges,,,
PROSTHESIS PENL AMS SPCTR MALE 12MMX20CM SIL PE TI SEG CYL -,SUP-720074-03,CDM,C1813,HCPCS,278,RC,,,outpatient,,,28358.17,19850.719,AETNA [1000108],AETNA [100010801],,,76.8,,21779.07,150.646235,27674.62656,percent of total billed charges,,,
PROSTHESIS PENL AMS 700 LGX 100CM SAL FIL INFL MOMNTRY SQZ -,SUP-720185-01,CDM,C1813,HCPCS,278,RC,,,outpatient,,,12122.95,8486.065,AETNA [1000108],AETNA [100010801],,,76.8,,9310.43,150.646235,27674.62656,percent of total billed charges,,,
AMS 800 PRESSURE REGULATION BALLOON -,SUP-72400024,CDM,C1813,HCPCS,278,RC,,,outpatient,,,12791.29,8953.903,AETNA [1000108],AETNA [100010801],,,76.8,,9823.71,150.646235,27674.62656,percent of total billed charges,,,
KT PROSTHESIS PENL URIN ARTF SPHNCR IMPL SAL FIL SCRT CYL -,SUP-724000-95,CDM,C1813,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,76.8,,515.35,150.646235,27674.62656,percent of total billed charges,,,
PUMP URIN SPHNCR AMS 800 MALE SIL CNCLD FLD-FIL W/O INHBZN -,SUP-724000-98,CDM,C1813,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,AETNA [1000108],AETNA [100010801],,,76.8,,11976.65,150.646235,27674.62656,percent of total billed charges,,,
PROSTHESIS PENL AMBICOR 11MM/12.5MM DIA FIL PMP 16CM SAL FIL -,SUP-72401451,CDM,C1813,HCPCS,278,RC,,,outpatient,,,31752.76,22226.932,AETNA [1000108],AETNA [100010801],,,76.8,,24386.12,150.646235,27674.62656,percent of total billed charges,,,
AMS AMBICOR PENILE PROTHESIS -,SUP-72401452,CDM,C1813,HCPCS,278,RC,,,outpatient,,,34352.98,24047.086,AETNA [1000108],AETNA [100010801],,,76.8,,26383.09,150.646235,27674.62656,percent of total billed charges,,,
AMS AMBICOR PENILE PROTHESIS 18CM X 14 MM -,SUP-72401454,CDM,C1813,HCPCS,278,RC,,,outpatient,,,31752.76,22226.932,AETNA [1000108],AETNA [100010801],,,76.8,,24386.12,150.646235,27674.62656,percent of total billed charges,,,
RESERVOIR PROS -,SUP-724014-77,CDM,C1813,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,AETNA [1000108],AETNA [100010801],,,76.8,,2548.17,150.646235,27674.62656,percent of total billed charges,,,
PROSTHESIS PENL AMS 700 LGX 65CM SAL FIL INFL MOMNTRY SQZ -,SUP-724041-55,CDM,C1813,HCPCS,278,RC,,,outpatient,,,12122.95,8486.065,AETNA [1000108],AETNA [100010801],,,76.8,,9310.43,150.646235,27674.62656,percent of total billed charges,,,
PROSTHESIS PENL AMS 700 CX MALE 100ML SAL FIL INFL CYL TIP -,SUP-72404156,CDM,C1813,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,AETNA [1000108],AETNA [100010801],,,76.8,,7499.67,150.646235,27674.62656,percent of total billed charges,,,
PROSTHESIS PENL PMP AMS 700 CX MALE SAL FIL INFL STRL -,SUP-724042-09,CDM,C1813,HCPCS,278,RC,,,outpatient,,,15498.06,10848.642,AETNA [1000108],AETNA [100010801],,,76.8,,11902.51,150.646235,27674.62656,percent of total billed charges,,,
18CM 700CX -,SUP-72404232,CDM,C1813,HCPCS,278,RC,,,outpatient,,,25200.41,17640.287,AETNA [1000108],AETNA [100010801],,,76.8,,19353.91,150.646235,27674.62656,percent of total billed charges,,,
PUMP AMS 700 12MM X 18CM CX MS PENILE -,SUP-72404232-10,CDM,C1813,HCPCS,278,RC,,,outpatient,,,31466.59,22026.613,AETNA [1000108],AETNA [100010801],,,76.8,,24166.34,150.646235,27674.62656,percent of total billed charges,,,
AMS 700 CX MS PUMP IZ 21CM -,SUP-72404233-12,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26705.28,18693.696,AETNA [1000108],AETNA [100010801],,,76.8,,20509.66,150.646235,27674.62656,percent of total billed charges,,,
PROSTHESIS PENL AMS 700 LGX 15MM CL INFL PRECNCT W/MS PMP -,SUP-724042-51,CDM,C1813,HCPCS,278,RC,,,outpatient,,,28543.19,19980.233,AETNA [1000108],AETNA [100010801],,,76.8,,21921.17,150.646235,27674.62656,percent of total billed charges,,,
PROSTHESIS PENL AMS 700 LGX 18CM SAL FIL INFL MOMNTRY SQZ -,SUP-72404252,CDM,C1813,HCPCS,278,RC,,,outpatient,,,36034.67,25224.269,AETNA [1000108],AETNA [100010801],,,76.8,,27674.63,150.646235,27674.62656,percent of total billed charges,,,
AMS 700 LGX MS PUMP IZ 21CM X 12MM -,SUP-72404253-12,CDM,C1813,HCPCS,278,RC,,,outpatient,,,32354.71,22648.297,AETNA [1000108],AETNA [100010801],,,76.8,,24848.42,150.646235,27674.62656,percent of total billed charges,,,
PROSTHESIS PENL AMS 700 CXR 14CM X 9.5MM -,SUP-72404262,CDM,C1813,HCPCS,278,RC,,,outpatient,,,25200.41,17640.287,AETNA [1000108],AETNA [100010801],,,76.8,,19353.91,150.646235,27674.62656,percent of total billed charges,,,
AMS CXR MS PUMP IZ -,SUP-72404264,CDM,C1813,HCPCS,278,RC,,,outpatient,,,32749.43,22924.601,AETNA [1000108],AETNA [100010801],,,76.8,,25151.56,150.646235,27674.62656,percent of total billed charges,,,
EXTENDER PENL AMS SPCTR 12MM/14MM DIA CL 3CM REAR TIP -,SUP-724043-23,CDM,C1813,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,AETNA [1000108],AETNA [100010801],,,76.8,,7613.94,150.646235,27674.62656,percent of total billed charges,,,
IMPLANT PENL RSVR CLPLST 75ML HYDRPHL CTD LKOUT VLV STRL -,SUP-90-9075K-LOC,CDM,C1813,HCPCS,278,RC,,,outpatient,,,5602.08,3921.456,AETNA [1000108],AETNA [100010801],,,76.8,,4302.4,150.646235,27674.62656,percent of total billed charges,,,
PROSTHESIS PENL TITAN 16CM HYDRPHL RST CTD CYL 3 PRT REFL -,SUP-90-9916SC,CDM,C1813,HCPCS,278,RC,,,outpatient,,,24505.8,17154.06,AETNA [1000108],AETNA [100010801],,,76.8,,18820.45,150.646235,27674.62656,percent of total billed charges,,,
PROSTHESIS PENL STD 18CM BIOFLEX/SIL MALE SCRT CL/PMP ST -,SUP-90-9918SNCOTR,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26752.17,18726.519,AETNA [1000108],AETNA [100010801],,,76.8,,20545.67,150.646235,27674.62656,percent of total billed charges,,,
PROSTHESIS PENL STD 20CM BIOFLEX/SIL MALE SCRT CL/PMP ST -,SUP-90-9920SCOTR,CDM,C1813,HCPCS,278,RC,,,outpatient,,,24505.8,17154.06,AETNA [1000108],AETNA [100010801],,,76.8,,18820.45,150.646235,27674.62656,percent of total billed charges,,,
KT PROSTHESIS PENL TITAN MALE NRW BS EXTEND ESSAY NDLX1 -,SUP-91-9480SNC,CDM,C1813,HCPCS,278,RC,,,outpatient,,,2507.14,1754.998,AETNA [1000108],AETNA [100010801],,,76.8,,1925.48,150.646235,27674.62656,percent of total billed charges,,,
PROSTHESIS PENL RSVR TITAN 75ML BIOFLEX SIL INFL SLF-CNTN -,SUP-ER8075,CDM,C1813,HCPCS,278,RC,,,outpatient,,,6938.94,4857.258,AETNA [1000108],AETNA [100010801],,,76.8,,5329.11,150.646235,27674.62656,percent of total billed charges,,,
ST PROSTHESIS PENL TITAN 18CM BIOFLEX SIL CYL INFL SLF-CNTN -,SUP-ES2918,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26956.38,18869.466,AETNA [1000108],AETNA [100010801],,,76.8,,20702.5,150.646235,27674.62656,percent of total billed charges,,,
ST PROSTHESIS TITAN 22CM BIOFLEX SIL TCH ZERO DG CL PMP -,SUP-ES2922,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26956.38,18869.466,AETNA [1000108],AETNA [100010801],,,76.8,,20702.5,150.646235,27674.62656,percent of total billed charges,,,
PROSTHESIS PENL TITAN 18CM 0DG ANG CYL INFL 1-TCH RELS -,SUP-ESR918,CDM,C1813,HCPCS,278,RC,,,outpatient,,,27550.46,19285.322,AETNA [1000108],AETNA [100010801],,,76.8,,21158.75,150.646235,27674.62656,percent of total billed charges,,,
ST UROLOGICAL PMP/CL TITAN 20CM BIOFLEX SIL 0DG ANG PENL -,SUP-ESR920,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26752.17,18726.519,AETNA [1000108],AETNA [100010801],,,76.8,,20545.67,150.646235,27674.62656,percent of total billed charges,,,
AMS AMBICOR 16CM X 14MM -,SUP-UNDEFINED,CDM,C1813,HCPCS,278,RC,,,outpatient,,,30531.59,21372.113,AETNA [1000108],AETNA [100010801],,,76.8,,23448.26,150.646235,27674.62656,percent of total billed charges,,,
PROSTHESIS PENL 3.5CM INFL SCRT INHBZN CONTINENCE -,SUP-720157-01,CDM,C1815,HCPCS,278,RC,,,outpatient,,,16337.2,11436.04,AETNA [1000108],AETNA [100010801],,,76.8,,12546.97,399.86,21443.91168,percent of total billed charges,,,
PUMP CORTIAL 700 PROSTHESIS -,SUP-72404127,CDM,C1815,HCPCS,278,RC,,,outpatient,,,26900.69,18830.483,AETNA [1000108],AETNA [100010801],,,76.8,,20659.73,399.86,21443.91168,percent of total billed charges,,,
SYS UROLOGICAL AMS 800 4CM CUF BLT W/IZ -,SUP-724041-30,CDM,C1815,HCPCS,278,RC,,,outpatient,,,27921.76,19545.232,AETNA [1000108],AETNA [100010801],,,76.8,,21443.91,399.86,21443.91168,percent of total billed charges,,,
PROSTHESIS PENL AMS 800 4.5CM SAL FIL CNCLD CYL SCRT INHBZN -,SUP-72404131,CDM,C1815,HCPCS,278,RC,,,outpatient,,,27921.76,19545.232,AETNA [1000108],AETNA [100010801],,,76.8,,21443.91,399.86,21443.91168,percent of total billed charges,,,
PROSTHESIS PENL AMS 800 5.0CM SAL FIL CNCLD CYL SCRT INHBZN -,SUP-72404132,CDM,C1815,HCPCS,278,RC,,,outpatient,,,26585.08,18609.556,AETNA [1000108],AETNA [100010801],,,76.8,,20417.34,399.86,21443.91168,percent of total billed charges,,,
PROSTHESIS PENL AMS 800 6.0CM SAL FIL ARTIF URINARY SPHINCTR -,SUP-72404134,CDM,C1815,HCPCS,278,RC,,,outpatient,,,25935.31,18154.717,AETNA [1000108],AETNA [100010801],,,76.8,,19918.32,399.86,21443.91168,percent of total billed charges,,,
OCCLUDERS FLO RESTER 1.5 -,SUP-50150,CDM,C1817,HCPCS,278,RC,,,outpatient,,,470.8,329.56,AETNA [1000108],AETNA [100010801],,,76.8,,361.57,99.62861,33156.48,percent of total billed charges,,,
OCCLUDERS FLO RESTER 2.5 -,SUP-50250,CDM,C1817,HCPCS,278,RC,,,outpatient,,,470.8,329.56,AETNA [1000108],AETNA [100010801],,,76.8,,361.57,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER VASC 2MM BLB 30MM INTNL VES FLO-RST DISP -,SUP-60200,CDM,C1817,HCPCS,278,RC,,,outpatient,,,443.78,310.646,AETNA [1000108],AETNA [100010801],,,76.8,,340.82,99.62861,33156.48,percent of total billed charges,,,
AMPLATZER AMULET 16MM WW REF: 9-ACP2-007-016 -,SUP-9-ACP2-007-016,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA [1000108],AETNA [100010801],,,76.8,,32209.15,99.62861,33156.48,percent of total billed charges,,,
AMPLATZER AMULET 18MM WW REF: 9-ACP2-007-018 -,SUP-9-ACP2-007-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA [1000108],AETNA [100010801],,,76.8,,32209.15,99.62861,33156.48,percent of total billed charges,,,
AMPLATZER AMULET 20 MM WW REF: 9-ACP2-007-020 -,SUP-9-ACP2-007-020,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA [1000108],AETNA [100010801],,,76.8,,32209.15,99.62861,33156.48,percent of total billed charges,,,
AMPLATZER AMULET 22 MM WW REF: 9-ACP2-007-022 -,SUP-9-ACP2-007-022,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA [1000108],AETNA [100010801],,,76.8,,32209.15,99.62861,33156.48,percent of total billed charges,,,
AMPLATZER AMULET 25 MM WW REF: 9-ACP2-010-025 -,SUP-9-ACP2-010-025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA [1000108],AETNA [100010801],,,76.8,,32209.15,99.62861,33156.48,percent of total billed charges,,,
AMPLATZER AMULET 28 MM WW REF: 9-ACP2-010-028 -,SUP-9-ACP2-010-028,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA [1000108],AETNA [100010801],,,76.8,,32209.15,99.62861,33156.48,percent of total billed charges,,,
AMPLATZER AMULET 31 MM WW REF: 9-ACP2-010-031 -,SUP-9-ACP2-010-031,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA [1000108],AETNA [100010801],,,76.8,,32209.15,99.62861,33156.48,percent of total billed charges,,,
AMPLATZER AMULET 34 MM WW REF: 9-ACP2-010-034 -,SUP-9-ACP2-010-034,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA [1000108],AETNA [100010801],,,76.8,,32209.15,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER AMPLATZER SEPTAL 5MM  REF: 9-ASD-005 -,SUP-9-ASD-005,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER AMPLATZER SEPTAL 6MM  REF: 9-ASD-006 -,SUP-9-ASD-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 08MM WST 16MM/20MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-008,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 10MM WST 18MM/22MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-010,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 11MM WST 21MM/25MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-011,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 12MM WST 22MM/26MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-012,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 13MM WST 23MM/27MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-013,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 14MM WST 24MM/28MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-014,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 15MM WST 25MM/29MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-015,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 16MM WST 26MM/30MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-016,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 18MM WST 28MM/32MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 19MM WST 28MM/32MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-019,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 20MM WST 30MM/34MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-020,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 22MM WST 32MM/36MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-022,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 24MM WST 34MM/38MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-024,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 26MM WST 36MM/40MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-026,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 28MM WST 38MM/42MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-028,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 30MM WST 40MM/44MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-030,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 32MM WST 42MM/46MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-032,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 34MM WST 44MM/50MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-034,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 36MM WST 46MM/52MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-036,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 18MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 25MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 30MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-030,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 35MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-035,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA [1000108],AETNA [100010801],,,76.8,,22490.44,99.62861,33156.48,percent of total billed charges,,,
GRAFT VASC 5MMX12.5MM AMPLATZER OCLR SE FUL CX-SECT CVRGLS -,SUP-9-AVP038-005,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,99.62861,33156.48,percent of total billed charges,,,
GRAFT VASC 6X11MM AMPLATZER PLG SE FUL CX-SECT CVRGLS LT ATR -,SUP-9-AVP038-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,99.62861,33156.48,percent of total billed charges,,,
GRAFT VASC 7MMX12.5MM AMPLATZER PLG OCLR SE FUL CX-SECT -,SUP-9-AVP038-007,CDM,C1817,HCPCS,278,RC,,,outpatient,,,5177.68,3624.376,AETNA [1000108],AETNA [100010801],,,76.8,,3976.46,99.62861,33156.48,percent of total billed charges,,,
PLUG VASCULAR AMPLATZER 6MM REF:09-AVP2-006 -,SUP-9-AVP2-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,AETNA [1000108],AETNA [100010801],,,76.8,,3233.79,99.62861,33156.48,percent of total billed charges,,,
PLUG VASCULAR AMPLATZER 8 -,SUP-9-AVP2-008,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,AETNA [1000108],AETNA [100010801],,,76.8,,3233.79,99.62861,33156.48,percent of total billed charges,,,
PLUG VASCULAR AMPLATZER 10 011 -,SUP-9-AVP2-010,CDM,C1817,HCPCS,278,RC,,,outpatient,,,3971.97,2780.379,AETNA [1000108],AETNA [100010801],,,76.8,,3050.47,99.62861,33156.48,percent of total billed charges,,,
PLUG VASCULAR AMPLATZER 12 -,SUP-9-AVP2-012,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,AETNA [1000108],AETNA [100010801],,,76.8,,3233.79,99.62861,33156.48,percent of total billed charges,,,
PLUG VASCULAR AMPLATZER 16 -,SUP-9-AVP2-016,CDM,C1817,HCPCS,278,RC,,,outpatient,,,3971.97,2780.379,AETNA [1000108],AETNA [100010801],,,76.8,,3050.47,99.62861,33156.48,percent of total billed charges,,,
PLUG VASCULAR AMPLATZER 18 -,SUP-9-AVP2-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,AETNA [1000108],AETNA [100010801],,,76.8,,3233.79,99.62861,33156.48,percent of total billed charges,,,
GRAFT VASC 22X6MM AMPLATZER PLG SE MUL-LOBE LT ATR NTNL -,SUP-9-AVP2-022,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER DCT 5MM/4MM DIA DSCND AOR/PA AMPLATZER NTNL INTRWVN -,SUP-9-PDA-003,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,AETNA [1000108],AETNA [100010801],,,76.8,,8540.5,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER DCT 6MM/4MM DIA DSCND AOR/PA AMPLATZER NTNL INTRWVN -,SUP-9-PDA-004,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,AETNA [1000108],AETNA [100010801],,,76.8,,8540.5,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER DCT 8MM/6MM DIA DSCND AOR/PA AMPLATZER NTNL INTRWVN -,SUP-9-PDA-005,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,AETNA [1000108],AETNA [100010801],,,76.8,,8540.5,99.62861,33156.48,percent of total billed charges,,,
10/8 AMPLATZER DUCT OCCLUDER -,SUP-9-PDA-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,AETNA [1000108],AETNA [100010801],,,76.8,,8540.5,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER VASC DCT 12MM/10MM DIA/DSCND/PULM AOR 7FRX8MM NTNL -,SUP-9-PDA-007,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,AETNA [1000108],AETNA [100010801],,,76.8,,8540.5,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER DUCT II AMPLATZER 3MMX4MM -,SUP-9-PDA2-03-04,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,AETNA [1000108],AETNA [100010801],,,76.8,,14620.07,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER DCT 5MM/4MM DIA WST/DISC AMPLATZER NTNL DBL DISC -,SUP-9-PDA2-05-04,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,AETNA [1000108],AETNA [100010801],,,76.8,,14620.07,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER DCT 5MM/6MM DIA WST/DISC AMPLATZER NTNL DBL DISC. -,SUP-9-PDA2-05-06,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,AETNA [1000108],AETNA [100010801],,,76.8,,14620.07,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER DUCT II AMPLATZER 6MMX4MM -,SUP-9-PDA2-06-04,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,AETNA [1000108],AETNA [100010801],,,76.8,,14620.07,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER DCT 5MM/11MM DIA WST/DISC AMPLATZER NTNL DBL DISC.. -,SUP-9-PDA2-06-06,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,AETNA [1000108],AETNA [100010801],,,76.8,,14620.07,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER DUCT II AMPLATZER 6MMX6MM -,SUP-9-PDA2-06-06,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,AETNA [1000108],AETNA [100010801],,,76.8,,14620.07,99.62861,33156.48,percent of total billed charges,,,
OCCULUDER AMPLATZER PFO 18MM -,SUP-9-PFO-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,AETNA [1000108],AETNA [100010801],,,76.8,,28501.59,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER AMPLATZER PFO 25MM -,SUP-9-PFO-025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,AETNA [1000108],AETNA [100010801],,,76.8,,28501.59,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER AMPLATZER PFO 35MM -,SUP-9-PFO-035,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,AETNA [1000108],AETNA [100010801],,,76.8,,28501.59,99.62861,33156.48,percent of total billed charges,,,
AMPLATZER TALISMAN PFO OCCLUDER 8FR 18MM REF:9-PFO-1818 -,SUP-9-PFO-1818,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,AETNA [1000108],AETNA [100010801],,,76.8,,28501.59,99.62861,33156.48,percent of total billed charges,,,
AMPLATZER TALISMAN PFO OCCLUDER 25-18MM -,SUP-9-PFO-2518,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,AETNA [1000108],AETNA [100010801],,,76.8,,28501.59,99.62861,33156.48,percent of total billed charges,,,
AMPLATZER TALISMAN PFO OCCLUDER 30-25MM -,SUP-9-PFO-3025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,AETNA [1000108],AETNA [100010801],,,76.8,,28501.59,99.62861,33156.48,percent of total billed charges,,,
TORQVUE SHEATH 12F 80CM 45X45 REF: 9-TV45X45-12F-080 -,SUP-9-TV45X45-12F-080,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4676.89,3273.823,AETNA [1000108],AETNA [100010801],,,76.8,,3591.85,99.62861,33156.48,percent of total billed charges,,,
CLOSURE DEVICE WATCHMAN FLEX 27MM -,SUP-M635WU0270,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA [1000108],AETNA [100010801],,,76.8,,32209.15,99.62861,33156.48,percent of total billed charges,,,
SHEATH WATCHMAN 21MM 12FR CLSR 75CM TRNSEPT -,SUP-M635WU21060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA [1000108],AETNA [100010801],,,76.8,,32209.15,99.62861,33156.48,percent of total billed charges,,,
SHEATH WATCHMAN 24MM 12FR CLSR 75CM  TRNSEPT -,SUP-M635WU24060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA [1000108],AETNA [100010801],,,76.8,,32209.15,99.62861,33156.48,percent of total billed charges,,,
SHEATH WATCHMAN 27MM 12FR CLSR 75CM  TRNSEPT -,SUP-M635WU27060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA [1000108],AETNA [100010801],,,76.8,,32209.15,99.62861,33156.48,percent of total billed charges,,,
SHEATH WATCHMAN 30MM 12FR CLSR 75CM TRNSEPT -,SUP-M635WU30060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA [1000108],AETNA [100010801],,,76.8,,32209.15,99.62861,33156.48,percent of total billed charges,,,
SHEATH WATCHMAN 33MM 12FR CLSR 75CM TRANSEPT -,SUP-M635WU33060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA [1000108],AETNA [100010801],,,76.8,,32209.15,99.62861,33156.48,percent of total billed charges,,,
CLOSURE DEVICE WATCHMAN FLEX 20MM -,SUP-M635WU50200,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA [1000108],AETNA [100010801],,,76.8,,32209.15,99.62861,33156.48,percent of total billed charges,,,
CLOSURE DEVICE WATCHMAN FLEX 31MM -,SUP-M635WU50310,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA [1000108],AETNA [100010801],,,76.8,,32209.15,99.62861,33156.48,percent of total billed charges,,,
CLOSURE DEVICE WATCHMAN FLEX 35MM -,SUP-M635WU50350,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA [1000108],AETNA [100010801],,,76.8,,32209.15,99.62861,33156.48,percent of total billed charges,,,
CLOSURE DEVICE WATCHMAN FLEX PRO 20MM REF:M635WU60200 -,SUP-M635WU60200,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,AETNA [1000108],AETNA [100010801],,,76.8,,33156.48,99.62861,33156.48,percent of total billed charges,,,
CLOSURE DEVICE WATCHMAN FLEX PRO 24MM REF:M635WU60240 -,SUP-M635WU60240,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,AETNA [1000108],AETNA [100010801],,,76.8,,33156.48,99.62861,33156.48,percent of total billed charges,,,
CLOSURE DEVICE WATCHMAN FLEX PRO 27MM REF:M635WU60270 -,SUP-M635WU60270,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,AETNA [1000108],AETNA [100010801],,,76.8,,33156.48,99.62861,33156.48,percent of total billed charges,,,
CLOSURE DEVICE WATCHMAN FLEX PRO 31MM REF:M635WU60310 -,SUP-M635WU60310,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,AETNA [1000108],AETNA [100010801],,,76.8,,33156.48,99.62861,33156.48,percent of total billed charges,,,
CLOSURE DEVICE WATCHMAN FLEX PRO 35MM REF:M635WU60350 -,SUP-M635WU60350,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,AETNA [1000108],AETNA [100010801],,,76.8,,33156.48,99.62861,33156.48,percent of total billed charges,,,
CLOSURE DEVICE WATCHMAN FLEX PRO 40MM REF:M635WU60400 -,SUP-M635WU60400,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,AETNA [1000108],AETNA [100010801],,,76.8,,33156.48,99.62861,33156.48,percent of total billed charges,,,
CLOSURE DEVICE WATCHMAN FLEX 24MM -,SUP-M63WU50240,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA [1000108],AETNA [100010801],,,76.8,,32209.15,99.62861,33156.48,percent of total billed charges,,,
TULOC LOCALIZATION WIRE 20G X 5CM -,SUP-271660,CDM,C1819,HCPCS,278,RC,,,outpatient,,,200.72,140.504,AETNA [1000108],AETNA [100010801],,,,,,45.06164,416.02,other,Implant Exclusions,,
TULOC LOCALIZATION WIRE 20G X 9CM -,SUP-271661,CDM,C1819,HCPCS,278,RC,,,outpatient,,,200.72,140.504,AETNA [1000108],AETNA [100010801],,,,,,45.06164,416.02,other,Implant Exclusions,,
TULOC PREMIUM LOCALIZATION WIRE 20G X 5CM -,SUP-271880,CDM,C1819,HCPCS,278,RC,,,outpatient,,,256.74,179.718,AETNA [1000108],AETNA [100010801],,,,,,45.06164,416.02,other,Implant Exclusions,,
TULOC PREMIUM LOCALIZATION WIRE 20G X 9CM -,SUP-271881,CDM,C1819,HCPCS,278,RC,,,outpatient,,,256.74,179.718,AETNA [1000108],AETNA [100010801],,,,,,45.06164,416.02,other,Implant Exclusions,,
ETERNA IMPLANTABLE PULSE GENERATOR -,SUP-32400,CDM,C1820,HCPCS,278,RC,,,outpatient,,,45639.5,31947.65,AETNA [1000108],AETNA [100010801],,,76.8,,35051.14,399.86,41625.59232,percent of total billed charges,,,
PRODIGY 3730 -,SUP-3730,CDM,C1820,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,399.86,41625.59232,percent of total billed charges,,,
SYS GENERATOR NEURSTM RSTOR ADVANCED PERC MUL-PRGM RCHG ACC -,SUP-377-13,CDM,C1820,HCPCS,278,RC,,,outpatient,,,31108.87,21776.209,AETNA [1000108],AETNA [100010801],,,76.8,,23891.61,399.86,41625.59232,percent of total billed charges,,,
NEURSTM IMPL RESTORESENSOR 2.1INX2.1IN PERC SMALLEST -,SUP-377-14,CDM,C1820,HCPCS,278,RC,,,outpatient,,,38238.5,26766.95,AETNA [1000108],AETNA [100010801],,,76.8,,29367.17,399.86,41625.59232,percent of total billed charges,,,
PRODIGY MRI -,SUP-3772,CDM,C1820,HCPCS,278,RC,,,outpatient,,,38929.26,27250.482,AETNA [1000108],AETNA [100010801],,,76.8,,29897.67,399.86,41625.59232,percent of total billed charges,,,
NEURSTM IMPL RESTORESENSOR SURSCN 9X54X54MM SPIN CRD RCHG -,SUP-97714,CDM,C1820,HCPCS,278,RC,,,outpatient,,,38238.5,26766.95,AETNA [1000108],AETNA [100010801],,,76.8,,29367.17,399.86,41625.59232,percent of total billed charges,,,
INTERSTIM MICRO MRI RECHARGEABLE NEUROSTIMULATOR -,SUP-97810,CDM,C1820,HCPCS,278,RC,,,outpatient,,,25644.47,17951.129,AETNA [1000108],AETNA [100010801],,,76.8,,19694.95,399.86,41625.59232,percent of total billed charges,,,
MICROSTIMULATOR INS 97810 RECHARGEABLE -,SUP-97810,CDM,C1820,HCPCS,278,RC,,,outpatient,,,25644.47,17951.129,AETNA [1000108],AETNA [100010801],,,76.8,,19694.95,399.86,41625.59232,percent of total billed charges,,,
KT GENERATOR NEURSTM PRECISN SPCTR -,SUP-M365SC1110020,CDM,C1820,HCPCS,278,RC,,,outpatient,,,54199.99,37939.993,AETNA [1000108],AETNA [100010801],,,76.8,,41625.59,399.86,41625.59232,percent of total billed charges,,,
VERTIFLEX SUPERION IDS-10MM -,SUP-101-9810,CDM,C1821,HCPCS,278,RC,,,outpatient,,,25619.7,17933.79,AETNA [1000108],AETNA [100010801],,,76.8,,19675.93,399.86,19675.9296,percent of total billed charges,,,
VERTIFLEX SUPERION IDS-12MM -,SUP-101-9812,CDM,C1821,HCPCS,278,RC,,,outpatient,,,25619.7,17933.79,AETNA [1000108],AETNA [100010801],,,76.8,,19675.93,399.86,19675.9296,percent of total billed charges,,,
VERTIFLEX SUPERION IDS -14MM -,SUP-101-9814,CDM,C1821,HCPCS,278,RC,,,outpatient,,,25619.7,17933.79,AETNA [1000108],AETNA [100010801],,,76.8,,19675.93,399.86,19675.9296,percent of total billed charges,,,
SPACER CERV 8X27MMX0.016IN ZYSTON -,SUP-14-533108,CDM,C1821,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,AETNA [1000108],AETNA [100010801],,,76.8,,9980.54,399.86,19675.9296,percent of total billed charges,,,
SPACER ANT CERV 19-25MMH FORTIFY OPTMZ FIT TI -,SUP-151.051,CDM,C1821,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA [1000108],AETNA [100010801],,,76.8,,14257.92,399.86,19675.9296,percent of total billed charges,,,
SPACER ANT CERV 15X18MM FTPRNT FORTIFY 7DG OPTMZ FIT TI -,SUP-151.334,CDM,C1821,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,399.86,19675.9296,percent of total billed charges,,,
SPACER ANT CERV 15X18MM FTPRNT FORTIFY 7DG OPTMZ FIT TI. -,SUP-151.384,CDM,C1821,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,399.86,19675.9296,percent of total billed charges,,,
MESH 14MM ROUND 30MM HGT -,SUP-176014030,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11221.61,7855.127,AETNA [1000108],AETNA [100010801],,,76.8,,8618.2,399.86,19675.9296,percent of total billed charges,,,
MESH SURG 23X27MM DIA 12X14MM OBLNG TRPZD TI HARMS -,SUP-1763-02-012,CDM,C1821,HCPCS,278,RC,,,outpatient,,,14854.78,10398.346,AETNA [1000108],AETNA [100010801],,,76.8,,11408.47,399.86,19675.9296,percent of total billed charges,,,
RISE SPACER 8 X 22MM- 7-13MM -,SUP-193.001,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA [1000108],AETNA [100010801],,,76.8,,13117.29,399.86,19675.9296,percent of total billed charges,,,
SPACER RISE 8 X 22MM 8-14MM 10 DEG -,SUP-193.021,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA [1000108],AETNA [100010801],,,76.8,,13117.29,399.86,19675.9296,percent of total billed charges,,,
SPACER RISE 10 X 22 7-13 -,SUP-193.101,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA [1000108],AETNA [100010801],,,76.8,,13117.29,399.86,19675.9296,percent of total billed charges,,,
SPACER RISE 10 X 26MM 7-14MM -,SUP-193.102,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA [1000108],AETNA [100010801],,,76.8,,13117.29,399.86,19675.9296,percent of total billed charges,,,
SPACER RISE 10 X 26MM 10-17MM -,SUP-193.112,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA [1000108],AETNA [100010801],,,76.8,,13117.29,399.86,19675.9296,percent of total billed charges,,,
RISE SPACER 10X22MM 8-14MM 10 DEGREES -,SUP-193.121,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA [1000108],AETNA [100010801],,,76.8,,13117.29,399.86,19675.9296,percent of total billed charges,,,
RISE SPACER 10MM X 26MM 8-15MM 10 DEGREES -,SUP-193.122,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA [1000108],AETNA [100010801],,,76.8,,13117.29,399.86,19675.9296,percent of total billed charges,,,
SPACER SPINAL RISE 10MM X 30MM 8-15MM 10 DEG -,SUP-193.123,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA [1000108],AETNA [100010801],,,76.8,,13117.29,399.86,19675.9296,percent of total billed charges,,,
RISE SPACER 10 X 26MM 10-17MM -,SUP-193.142,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA [1000108],AETNA [100010801],,,76.8,,13117.29,399.86,19675.9296,percent of total billed charges,,,
RISER SPACER 10X22MM- 9-15MM -,SUP-193.151,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA [1000108],AETNA [100010801],,,76.8,,13117.29,399.86,19675.9296,percent of total billed charges,,,
NORMANDY 12X14 30MM 10DEGREES -,SUP-250-1214-30-10,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19597.21,13718.047,AETNA [1000108],AETNA [100010801],,,76.8,,15050.66,399.86,19675.9296,percent of total billed charges,,,
CAGE 12X14 44-76 10 DEGREE -,SUP-250-1214-4410,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19597.21,13718.047,AETNA [1000108],AETNA [100010801],,,76.8,,15050.66,399.86,19675.9296,percent of total billed charges,,,
SPACER THORLUM VERT 12X26X12MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.972,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,399.86,19675.9296,percent of total billed charges,,,
SPACER SMALL 12 X 14 ZERO DEG 19MM NIKO CORPECTOMY -,SUP-342.719,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11547.43,8083.201,AETNA [1000108],AETNA [100010801],,,76.8,,8868.43,399.86,19675.9296,percent of total billed charges,,,
SPACER SPINAL NIKO PEEK 7 D D12 MM SMALL 14X15MM CORPECTOMY -,SUP-342.815,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11547.43,8083.201,AETNA [1000108],AETNA [100010801],,,76.8,,8868.43,399.86,19675.9296,percent of total billed charges,,,
SEASPINE 7H CAGE -,SUP-AC4-143077,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9901.25,6930.875,AETNA [1000108],AETNA [100010801],,,76.8,,7604.16,399.86,19675.9296,percent of total billed charges,,,
SEASPINE CAGE 16X14X6MM 7 DEGREE 3D INTERBODY -,SUP-AC4-264067,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,399.86,19675.9296,percent of total billed charges,,,
GENESYS 6H CAGE -,SUP-ACC804-06S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,399.86,19675.9296,percent of total billed charges,,,
CAGE 9 X 26 X 12 6-20 DEGREES -,SUP-ET1-102612,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19678.9,13775.23,AETNA [1000108],AETNA [100010801],,,76.8,,15113.4,399.86,19675.9296,percent of total billed charges,,,
SEASPINE 9 X 26 0-14 DEGREE LORDOTIC CAGE -,SUP-ET1-142608,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA [1000108],AETNA [100010801],,,76.8,,12832.13,399.86,19675.9296,percent of total billed charges,,,
SEASPINE 10H 17 DEGREE CAGE -,SUP-ET1-172610,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA [1000108],AETNA [100010801],,,76.8,,12832.13,399.86,19675.9296,percent of total billed charges,,,
CAGE EXPANDABLE SEASPINE 10H 9W 30L -,SUP-ET1-173010,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA [1000108],AETNA [100010801],,,76.8,,12832.13,399.86,19675.9296,percent of total billed charges,,,
SEASPINE 10-14MM 8 DEGREE CAGE -,SUP-ET1-382810,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA [1000108],AETNA [100010801],,,76.8,,12832.13,399.86,19675.9296,percent of total billed charges,,,
APACHE SPACER 8MM -,SUP-GAC-08SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,399.86,19675.9296,percent of total billed charges,,,
TITANIUM APACHE CAGE 5MM -,SUP-GAC3D-05SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,399.86,19675.9296,percent of total billed charges,,,
TITANIUM APACHE CAGE 6MM -,SUP-GAC3D-06SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,399.86,19675.9296,percent of total billed charges,,,
7MM CAGE APACHE -,SUP-GAC3D-07SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,399.86,19675.9296,percent of total billed charges,,,
CAGE TLIF 7MM X 30MM -,SUP-GP-07-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,399.86,19675.9296,percent of total billed charges,,,
CAGE APACHE PEEK SPACER 8 X 30 -,SUP-GP-08-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,399.86,19675.9296,percent of total billed charges,,,
CAGE 25 STRAIGHT 9MM -,SUP-GP-09,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,399.86,19675.9296,percent of total billed charges,,,
CAGE 9 X 30 -,SUP-GP-09-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,399.86,19675.9296,percent of total billed charges,,,
CAGE 10MM STANDARD PLIF -,SUP-GP-10,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,399.86,19675.9296,percent of total billed charges,,,
CAGE PEEK 30 X 10MM -,SUP-GP-10-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,399.86,19675.9296,percent of total billed charges,,,
CAGE APACHE 11MM -,SUP-GP-11,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,399.86,19675.9296,percent of total billed charges,,,
CAGE 8MM BI-CONVEX PLIF -,SUP-GPC2-08,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,399.86,19675.9296,percent of total billed charges,,,
CAGE 9MM CONVEX PLIF -,SUP-GPC2-09,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,399.86,19675.9296,percent of total billed charges,,,
SPACER PEEK 10 X 24 CONVEX -,SUP-GPC2-10,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,399.86,19675.9296,percent of total billed charges,,,
CAGE PEEK APACHE 11MM -,SUP-GPC2-11,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,399.86,19675.9296,percent of total billed charges,,,
SPINEART LUMBAR POSTERIOR TI CAGE L24 W10.5 H08 12 DEG -,SUP-JUT-PX 24 08-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,399.86,19675.9296,percent of total billed charges,,,
JULIET TI PO LUMBAR POSTERIOR TI CAGE L24 W10.5 H10 12DEG -,SUP-JUT-PX 24 10-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,399.86,19675.9296,percent of total billed charges,,,
CAGE LUMBAR POSTERIOR TI L24 W10.5 H11 12 DEG -,SUP-JUT-PX 24 11-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,399.86,19675.9296,percent of total billed charges,,,
CAGE LUMBAR POSTERIOR TI L24 W10.5 H12 -,SUP-JUT-PX 24 12-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,399.86,19675.9296,percent of total billed charges,,,
CAGE TRANSORAMINAL LUMBAR TI L 30 W 10.5 H 14 -,SUP-JUT-T6 30 14-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,399.86,19675.9296,percent of total billed charges,,,
TRANSFORMATIONAL LUMBAR TI CAGE L34 W10.5 H12 06 DEG -,SUP-JUT-T6 34 12-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,399.86,19675.9296,percent of total billed charges,,,
CAGE CERV 7MM/4.1MM H A/P ROI- C LRDTC -,SUP-MC1443P,CDM,C1821,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,399.86,19675.9296,percent of total billed charges,,,
CAGE CERV 10MM/7.1MM H A/P ROI- C LRDTC -,SUP-MC1446P,CDM,C1821,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,399.86,19675.9296,percent of total billed charges,,,
PATHLOC LUMBAR INTERBODY FUSION CAGE 12MM 15 DEGREES -,SUP-PT2211-0815S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19678.9,13775.23,AETNA [1000108],AETNA [100010801],,,76.8,,15113.4,399.86,19675.9296,percent of total billed charges,,,
SCARLET AL-T SECURED ANTERIOR CAGE SMALL H12 15' -,SUP-SCA-LS 15 12-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,399.86,19675.9296,percent of total billed charges,,,
CAGE 11MM LUCENT STR -,SUP-UNDEFINED,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11695.95,8187.165,AETNA [1000108],AETNA [100010801],,,76.8,,8982.49,399.86,19675.9296,percent of total billed charges,,,
NPG IMPLANT AND CHARGER -,SUP-HFX-D,CDM,C1822,HCPCS,278,RC,,,outpatient,,,60441.5,42309.05,AETNA [1000108],AETNA [100010801],,,76.8,,46419.07,399.86,46419.072,percent of total billed charges,,,
KIT BLUE LEAD 90CM WITH 5MM SPACING -,SUP-LEAD1058-90B,CDM,C1822,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,399.86,46419.072,percent of total billed charges,,,
IPG KIT -,SUP-NIPG2500,CDM,C1822,HCPCS,278,RC,,,outpatient,,,60441.5,42309.05,AETNA [1000108],AETNA [100010801],,,76.8,,46419.07,399.86,46419.072,percent of total billed charges,,,
NEVRO IPG KIT WITH NEW BATTERY -,SUP-NIPG3000,CDM,C1822,HCPCS,278,RC,,,outpatient,,,60441.5,42309.05,AETNA [1000108],AETNA [100010801],,,76.8,,46419.07,399.86,46419.072,percent of total billed charges,,,
STENT DES 4X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-10074400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3X15MM XIENCE V RX BE PRMNT 143CM EVEROL CMPLNT -,SUP-1009541-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT 2.8X16MM GRAFTMS RX 143CM SEM-COM HYDRCT -,SUP-1012580-16,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,AETNA [1000108],AETNA [100010801],,,76.8,,7806.24,232.64935,38052.27264,percent of total billed charges,,,
STENT 4X16MM GRAFTMS RX 143CM SEM-COM HYDRCT -,SUP-1012582-16,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,AETNA [1000108],AETNA [100010801],,,76.8,,7806.24,232.64935,38052.27264,percent of total billed charges,,,
STENT 4X26MM GRAFTMS RX 143CM SEM-COM HYDRCT -,SUP-1012582-26,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,AETNA [1000108],AETNA [100010801],,,76.8,,7806.24,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.25X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.25X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.25X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.25X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.25X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.25X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.25X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.25X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.25X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.25X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.25X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.25X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.25X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.25X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.5X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.5X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.5X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.5X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.5X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.5X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.5X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.5X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.25X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125225-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.25X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.25X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.25X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.25X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.25X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125275-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.25X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.25X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.25X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35644.8,24951.36,AETNA [1000108],AETNA [100010801],,,76.8,,27375.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.25X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.25X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,232.64935,38052.27264,percent of total billed charges,,,
STENT 3X19MM JOST GRAFTMS OTW BE 143CM SEM-COM HYDREX CTD -,SUP-12744-19,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,AETNA [1000108],AETNA [100010801],,,76.8,,7806.24,232.64935,38052.27264,percent of total billed charges,,,
STENT 4X19MM JOST GRAFTMS OTW BE 143CM SEM-COM HYDREX CTD -,SUP-12746-19,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,AETNA [1000108],AETNA [100010801],,,76.8,,7806.24,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.25X8MM XIENCE SKYPOINT -,SUP-1804225-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.25X12MM XIENCE SKYPOINT -,SUP-1804225-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.25X15MM XIENCE SKYPOINT -,SUP-1804225-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.25X18MM XIENCE SKYPOINT -,SUP-1804225-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.25X23MM XIENCE SKYPOINT -,SUP-1804225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.25X28MM XIENCE SKYPOINT -,SUP-1804225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.25X33MM XIENCE SKYPOINT -,SUP-1804225-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.25X38MM XIENCE SKYPOINT -,SUP-1804225-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X8MM XIENCE SKYPOINT -,SUP-1804250-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X12MM XIENCE SKYPOINT -,SUP-1804250-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X15MM XIENCE SKYPOINT -,SUP-1804250-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X18MM XIENCE SKYPOINT -,SUP-1804250-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X23MM XIENCE SKYPOINT -,SUP-1804250-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X28MM XIENCE SKYPOINT -,SUP-1804250-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X33MM XIENCE SKYPOINT -,SUP-1804250-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X38MM XIENCE SKYPOINT -,SUP-1804250-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X8MM XIENCE SKYPOINT -,SUP-1804275-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X12MM XIENCE SKYPOINT -,SUP-1804275-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X15MM XIENCE SKYPOINT -,SUP-1804275-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X18MM XIENCE SKYPOINT -,SUP-1804275-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X23MM XIENCE SKYPOINT -,SUP-1804275-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X28MM XIENCE SKYPOINT -,SUP-1804275-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X33MM XIENCE SKYPOINT -,SUP-1804275-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X38MM XIENCE SKYPOINT -,SUP-1804275-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.0X8MM XIENCE SKYPOINT -,SUP-1804300-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.0X12MM XIENCE SKYPOINT -,SUP-1804300-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.0X15MM XIENCE SKYPOINT -,SUP-1804300-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.0X18MM XIENCE SKYPOINT -,SUP-1804300-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.0X23MM XIENCE SKYPOINT -,SUP-1804300-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.0X28MM XIENCE SKYPOINT -,SUP-1804300-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.0X33MM XIENCE SKYPOINT -,SUP-1804300-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.0X38MM XIENCE SKYPOINT -,SUP-1804300-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.25X8MM XIENCE SKYPOINT -,SUP-1804325-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.25X12MM XIENCE SKYPOINT -,SUP-1804325-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.25X15MM XIENCE SKYPOINT -,SUP-1804325-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.25X18MM XIENCE SKYPOINT -,SUP-1804325-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.25X23MM XIENCE SKYPOINT -,SUP-1804325-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.25X28MM XIENCE SKYPOINT -,SUP-1804325-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.25X33MM XIENCE SKYPOINT -,SUP-1804325-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.25X38MM XIENCE SKYPOINT -,SUP-1804325-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.5X8MM XIENCE SKYPOINT -,SUP-1804350-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.5X12MM XIENCE SKYPOINT -,SUP-1804350-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.5X15MM XIENCE SKYPOINT -,SUP-1804350-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.5X18MM XIENCE SKYPOINT -,SUP-1804350-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.5X23MM XIENCE SKYPOINT -,SUP-1804350-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.5X28MM XIENCE SKYPOINT -,SUP-1804350-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.5X33MM XIENCE SKYPOINT -,SUP-1804350-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.5X38MM XIENCE SKYPOINT -,SUP-1804350-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4.0X8MM XIENCE SKYPOINT -,SUP-1804400-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4.0X12MM XIENCE SKYPOINT -,SUP-1804400-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4.0X15MM XIENCE SKYPOINT -,SUP-1804400-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4.0X18MM XIENCE SKYPOINT -,SUP-1804400-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4.0X23MM XIENCE SKYPOINT -,SUP-1804400-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4.0X28MM XIENCE SKYPOINT -,SUP-1804400-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4.0X33MM XIENCE SKYPOINT -,SUP-1804400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4.0X38MM XIENCE SKYPOINT -,SUP-1804400-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4.5 X12MM XIENCE SKYPOINT -,SUP-1804450-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4.5 X15MM XIENCE SKYPOINT -,SUP-1804450-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4.5 X18MM XIENCE SKYPOINT -,SUP-1804450-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4.5 X23MM XIENCE SKYPOINT -,SUP-1804450-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4.5 X28MM XIENCE SKYPOINT -,SUP-1804450-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4.5 X33MM XIENCE SKYPOINT -,SUP-1804450-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 5.0 X12MM XIENCE SKYPOINT -,SUP-1804500-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 5.0 X15MM XIENCE SKYPOINT -,SUP-1804500-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 5.0 X18MM XIENCE SKYPOINT -,SUP-1804500-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 5.0 X23MM XIENCE SKYPOINT -,SUP-1804500-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 5.0 X28MM XIENCE SKYPOINT -,SUP-1804500-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 5.0 X33MM XIENCE SKYPOINT -,SUP-1804500-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 30MM PROX 30MM DIST 25-27MM OD AOR 140MM ZENITH TX2 -,SUP-2TEG-2P-30-140-,CDM,C1874,HCPCS,278,RC,,,outpatient,,,29835.9,20885.13,AETNA [1000108],AETNA [100010801],,,76.8,,22913.97,232.64935,38052.27264,percent of total billed charges,,,
DETACHABLE COIL 4MM X 8MM -,SUP-36-152,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,AETNA [1000108],AETNA [100010801],,,76.8,,1607.96,232.64935,38052.27264,percent of total billed charges,,,
STENT PK PAPYRUS 2.5/15 -,SUP-434887,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,232.64935,38052.27264,percent of total billed charges,,,
STENT PK PAPYRUS 3.0/15 -,SUP-434888,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,232.64935,38052.27264,percent of total billed charges,,,
STENT PK PAPYRUS 3.5/15 -,SUP-434889,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,232.64935,38052.27264,percent of total billed charges,,,
STENT PK PAPYRUS 4.0/15 -,SUP-434890,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,232.64935,38052.27264,percent of total billed charges,,,
STENT PK PAPYRUS 4.5/15 -,SUP-434891,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,232.64935,38052.27264,percent of total billed charges,,,
STENT PK PAPYRUS 5.0/15 -,SUP-434892,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,232.64935,38052.27264,percent of total billed charges,,,
STENT PK PAPYRUS 2.5/20 -,SUP-434893,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,232.64935,38052.27264,percent of total billed charges,,,
STENT PK PAPYRUS 3.0/20 -,SUP-434894,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,232.64935,38052.27264,percent of total billed charges,,,
STENT PK PAPYRUS 3.5/20 -,SUP-434895,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,232.64935,38052.27264,percent of total billed charges,,,
STENT PK PAPYRUS 4.0/20 -,SUP-434896,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,232.64935,38052.27264,percent of total billed charges,,,
STENT PK PAPYRUS 4.5/20 -,SUP-434897,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,232.64935,38052.27264,percent of total billed charges,,,
STENT PK PAPYRUS 5.0/20 -,SUP-434898,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,232.64935,38052.27264,percent of total billed charges,,,
STENT PK PAPYRUS 3.0/26 -,SUP-434899,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,232.64935,38052.27264,percent of total billed charges,,,
STENT PK PAPYRUS 3.5/26 -,SUP-434900,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,232.64935,38052.27264,percent of total billed charges,,,
STENT PK PAPYRUS 4.0/26 -,SUP-434901,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,232.64935,38052.27264,percent of total billed charges,,,
STENT PK PAPYRUS 4.5/26 -,SUP-434902,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,232.64935,38052.27264,percent of total billed charges,,,
STENT PK PAPYRUS 5.0/26 -,SUP-434903,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,232.64935,38052.27264,percent of total billed charges,,,
COVERA VASCULAR COVERED STENT 6 x 60 Ref: AVFM06060 -,SUP-AVFM06060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA [1000108],AETNA [100010801],,,76.8,,8269.59,232.64935,38052.27264,percent of total billed charges,,,
COVERA VASCULAR COVERED STENT 7 X 80 8F -,SUP-AVFM07080,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA [1000108],AETNA [100010801],,,76.8,,8269.59,232.64935,38052.27264,percent of total billed charges,,,
COVERA 8MM X 40MM FLARED -,SUP-AVFM08040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA [1000108],AETNA [100010801],,,76.8,,8269.59,232.64935,38052.27264,percent of total billed charges,,,
COVERA 8MM X 60MM FLARED -,SUP-AVFM08060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA [1000108],AETNA [100010801],,,76.8,,8269.59,232.64935,38052.27264,percent of total billed charges,,,
STENT VASCULAR COVERA FLARE 8MM X 80MM -,SUP-AVFM08080,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA [1000108],AETNA [100010801],,,76.8,,8269.59,232.64935,38052.27264,percent of total billed charges,,,
COVERA STENT GRAFT 10 X 40 -,SUP-AVFM10040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA [1000108],AETNA [100010801],,,76.8,,8269.59,232.64935,38052.27264,percent of total billed charges,,,
COVERA VASCULAR COVERED STENT 6 x 40 Ref: AVSM06040 -,SUP-AVSM06040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA [1000108],AETNA [100010801],,,76.8,,8269.59,232.64935,38052.27264,percent of total billed charges,,,
COVERA AV STENT GRAFT 8MM X 60MM X 80MM -,SUP-AVSM08060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA [1000108],AETNA [100010801],,,76.8,,8269.59,232.64935,38052.27264,percent of total billed charges,,,
STENT COVERA AV GRAFT 8MM X 80MM X 80MM -,SUP-AVSM08080,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA [1000108],AETNA [100010801],,,76.8,,8269.59,232.64935,38052.27264,percent of total billed charges,,,
STENT COVERA AV GRAFT 10MM X 60MM 80CM STRAIGHT -,SUP-AVSM10060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA [1000108],AETNA [100010801],,,76.8,,8269.59,232.64935,38052.27264,percent of total billed charges,,,
VIABAHN BALLOON EXPANDABLE 7MM X 29MM STENT -,SUP-BXA072902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12468.25,8727.775,AETNA [1000108],AETNA [100010801],,,76.8,,9575.62,232.64935,38052.27264,percent of total billed charges,,,
BALLOON EXPANDABLE ENDOPROSTHESIS VIABAHN 8-11 7FR 29LGTH -,SUP-BXA082902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13199.72,9239.804,AETNA [1000108],AETNA [100010801],,,76.8,,10137.38,232.64935,38052.27264,percent of total billed charges,,,
BALLOON EXPANDABLE ENDOPROSTHESIS VIABAHN 8-11 7FR 39LGTH -,SUP-BXA083902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,AETNA [1000108],AETNA [100010801],,,76.8,,8383.66,232.64935,38052.27264,percent of total billed charges,,,
BALLOON EXPANDABLE ENDOPROSTHESIS VIABAHN 8-11 7FR 59 LGTH -,SUP-BXA085902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12468.25,8727.775,AETNA [1000108],AETNA [100010801],,,76.8,,9575.62,232.64935,38052.27264,percent of total billed charges,,,
STENT VIABAHN 11MM X 39CM GORE -,SUP-BXA113902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11844.47,8291.129,AETNA [1000108],AETNA [100010801],,,76.8,,9096.55,232.64935,38052.27264,percent of total billed charges,,,
VIABAHN BALLOON EXPANDABLE 1MM X 59MM STENT -,SUP-BXA115902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,AETNA [1000108],AETNA [100010801],,,76.8,,8383.66,232.64935,38052.27264,percent of total billed charges,,,
STENT VIABAHN VBX BALLOON EXPANDABLE ENDOPROSTHESIS 2 -,SUP-BXAL082901A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,AETNA [1000108],AETNA [100010801],,,76.8,,8383.66,232.64935,38052.27264,percent of total billed charges,,,
VIABAHN VBX BALLOON EXPANDABLE ENDOPROSTHESIS -,SUP-BXAL082902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,AETNA [1000108],AETNA [100010801],,,76.8,,8383.66,232.64935,38052.27264,percent of total billed charges,,,
STENT VIABAHN VBX 8MM X 39MM BALLOON EXPANDABLE -,SUP-BXAL083901A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,AETNA [1000108],AETNA [100010801],,,76.8,,8383.66,232.64935,38052.27264,percent of total billed charges,,,
VIABAHN VBX 8MM X 59MM BALLOON AXPANDABLE STENT -,SUP-BXAL085901A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,AETNA [1000108],AETNA [100010801],,,76.8,,8383.66,232.64935,38052.27264,percent of total billed charges,,,
VIABAHN VBX BALLOON EXPANDABLE ENDOPROSTHESIS -,SUP-BXAL085902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,AETNA [1000108],AETNA [100010801],,,76.8,,8383.66,232.64935,38052.27264,percent of total billed charges,,,
EXCLUDER CONFORM AAA EXT ENDO 26MM X 4.5CM 15FR -,SUP-CXA260005,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19511.82,13658.274,AETNA [1000108],AETNA [100010801],,,76.8,,14985.08,232.64935,38052.27264,percent of total billed charges,,,
STENT 3.5X15MM DRIVER OTW BE  143CM 0.014IN GW COMP -,SUP-DRV35015W,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 22X39MM ZENITH FLEX BIFUR MAIN BD EXTEND Z-TRAK -,SUP-ESBE-22-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,AETNA [1000108],AETNA [100010801],,,76.8,,8102.85,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 24X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-24-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,AETNA [1000108],AETNA [100010801],,,76.8,,8102.85,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 26X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-26-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,AETNA [1000108],AETNA [100010801],,,76.8,,8102.85,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 28MM DI 39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK -,SUP-ESBE-28-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,AETNA [1000108],AETNA [100010801],,,76.8,,8102.85,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 30X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-30-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,AETNA [1000108],AETNA [100010801],,,76.8,,8102.85,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 32X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-32-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,AETNA [1000108],AETNA [100010801],,,76.8,,8102.85,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 36X50MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-36-50-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,AETNA [1000108],AETNA [100010801],,,76.8,,8102.85,232.64935,38052.27264,percent of total billed charges,,,
GRAFT STENT ENDURANT 23MM -,SUP-ESBF2314C103E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,AETNA [1000108],AETNA [100010801],,,76.8,,27022.33,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 28/14X103MM ENDURANT IIS BIFUR STNT PRELD PROX -,SUP-ESBF2814C103E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,36592.73,25614.911,AETNA [1000108],AETNA [100010801],,,76.8,,28103.22,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 32/14X103MM ENDURANT IIS BIFUR STNT PRELD PROX -,SUP-ESBF3214C103E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,AETNA [1000108],AETNA [100010801],,,76.8,,27022.33,232.64935,38052.27264,percent of total billed charges,,,
CONVERTER EV 12MM DIST 24MM PROX 80MM ZENITH FLEX Z-TRAK -,SUP-ESC-24-12-80-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,AETNA [1000108],AETNA [100010801],,,76.8,,8780.03,232.64935,38052.27264,percent of total billed charges,,,
CONVERTER EV 28MMX12MMX80MM ZENITH FLEX Z-TRAK INTRO SYS -,SUP-ESC-28-12-80ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,AETNA [1000108],AETNA [100010801],,,76.8,,8780.03,232.64935,38052.27264,percent of total billed charges,,,
CONVERTER EV 32MMX12MMX80MM ZENITH FLEX Z-TRAK INTRO SYS -,SUP-ESC-32-12-80-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,AETNA [1000108],AETNA [100010801],,,76.8,,8780.03,232.64935,38052.27264,percent of total billed charges,,,
CONVERTER EV 36MMX12MMX82MM ZENITH FLEX Z-TRAK INTRO SYS -,SUP-ESC-36-12-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,AETNA [1000108],AETNA [100010801],,,76.8,,8780.03,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 18X55MM ZENITH AOR -,SUP-ESLE-18-55-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8246.09,5772.263,AETNA [1000108],AETNA [100010801],,,76.8,,6333,232.64935,38052.27264,percent of total billed charges,,,
SYS STENT ENDURANT II GRAFT BI -,SUP-ETBF2316C145E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,AETNA [1000108],AETNA [100010801],,,76.8,,27022.33,232.64935,38052.27264,percent of total billed charges,,,
STENT GRAFT ENDURANT II AORTIC EXTENSION 49E -,SUP-ETCF2323C49E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14726.69,10308.683,AETNA [1000108],AETNA [100010801],,,76.8,,11310.1,232.64935,38052.27264,percent of total billed charges,,,
STENT GRAFT ENDURANT II AO EXT -,SUP-ETCF2828C49E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15079.42,10555.594,AETNA [1000108],AETNA [100010801],,,76.8,,11580.99,232.64935,38052.27264,percent of total billed charges,,,
STEN GRAFT ENDURANT II AORTIC EXT 49E -,SUP-ETCF3232C49E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16783.13,11748.191,AETNA [1000108],AETNA [100010801],,,76.8,,12889.44,232.64935,38052.27264,percent of total billed charges,,,
STENT GRAFT ENDURANTII ILEXT -,SUP-ETEW1313C82E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16402.18,11481.526,AETNA [1000108],AETNA [100010801],,,76.8,,12596.87,232.64935,38052.27264,percent of total billed charges,,,
STENT GRAFT ENDUR II LIMB -,SUP-ETLW1610C156E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,AETNA [1000108],AETNA [100010801],,,76.8,,17337.63,232.64935,38052.27264,percent of total billed charges,,,
GRAFT STENT ENDUR II LIMB -,SUP-ETLW1610C199E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,22910.14,16037.098,AETNA [1000108],AETNA [100010801],,,76.8,,17594.99,232.64935,38052.27264,percent of total billed charges,,,
GRAFT STENT ENDUR IIS LIMB -,SUP-ETLW1610C93E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17372.2,12160.54,AETNA [1000108],AETNA [100010801],,,76.8,,13341.85,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 16/13X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1613C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17548.57,12283.999,AETNA [1000108],AETNA [100010801],,,76.8,,13477.3,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 16/13X156MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1613C156E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,24713.73,17299.611,AETNA [1000108],AETNA [100010801],,,76.8,,18980.14,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 16/16X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1616C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,18067.09,12646.963,AETNA [1000108],AETNA [100010801],,,76.8,,13875.53,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 16/16X82MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1616C82E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17280.3,12096.21,AETNA [1000108],AETNA [100010801],,,76.8,,13271.27,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 16/20X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1620C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17548.57,12283.999,AETNA [1000108],AETNA [100010801],,,76.8,,13477.3,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 16/20X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1620C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,18250.51,12775.357,AETNA [1000108],AETNA [100010801],,,76.8,,14016.39,232.64935,38052.27264,percent of total billed charges,,,
STENT GRAFT ENDUR II LIMB -,SUP-ETLW1624C156E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,AETNA [1000108],AETNA [100010801],,,76.8,,17337.63,232.64935,38052.27264,percent of total billed charges,,,
STENT GRAFT CONTRAL ENDURANT -,SUP-ETLW1624C93E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17372.2,12160.54,AETNA [1000108],AETNA [100010801],,,76.8,,13341.85,232.64935,38052.27264,percent of total billed charges,,,
STENT GRAFT ENDURANT II AUI -,SUP-ETUF2314C102E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,AETNA [1000108],AETNA [100010801],,,76.8,,27022.33,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 28/14X102MM ENDURANT II BIFUR STNT AOR ILC PRELD -,SUP-ETUF2814C102E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,AETNA [1000108],AETNA [100010801],,,76.8,,27022.33,232.64935,38052.27264,percent of total billed charges,,,
GRAFT STENT ENDURANT II 14MM X 36 X102MM -,SUP-ETUF3614C102E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,AETNA [1000108],AETNA [100010801],,,76.8,,27022.33,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 7MM 9FR CATH 50MM 120CM TOT 80CM DLV SYS FLAIR FLR -,SUP-FAF07050,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 8MM 9FR CATH 40MM 800CM TOT 80CM DLV SYS FLAIR FLR -,SUP-FAF08040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 7MM 9FR CATH 40MM 120CM TOT 80CM DLV SYS FLAIR STR -,SUP-FAS07040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9995.4,6996.78,AETNA [1000108],AETNA [100010801],,,76.8,,7676.47,232.64935,38052.27264,percent of total billed charges,,,
STENT ENPROS 10MM 9FR CATH 40MM FLUENCY+ 117CM TRACHBR SE -,SUP-FTL10040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9825.92,6878.144,AETNA [1000108],AETNA [100010801],,,76.8,,7546.31,232.64935,38052.27264,percent of total billed charges,,,
STENT ENPROS 7MM 8FR CATH 60MM FLUENCY+ 80CM TRACHBR SE -,SUP-FTM07060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10077.08,7053.956,AETNA [1000108],AETNA [100010801],,,76.8,,7739.2,232.64935,38052.27264,percent of total billed charges,,,
STENT ENPROS 8MM 9FR CATH 40MM FLUENCY+ 80CM TRACHBR SE -,SUP-FTM08040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10077.08,7053.956,AETNA [1000108],AETNA [100010801],,,76.8,,7739.2,232.64935,38052.27264,percent of total billed charges,,,
STENT ENPROS 12X54MM ZENITH AAA CNTRLAT ILC LEG WVN PLYSTR -,SUP-G12446,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,AETNA [1000108],AETNA [100010801],,,76.8,,8543.35,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 12MM IPSI LEG DIA 106MM DIST LEG 28MM DIST BD -,SUP-G32500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,AETNA [1000108],AETNA [100010801],,,76.8,,11206.73,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 30MM PROX 24-26MM OD AOR 94MM PROX BD ZENITH FEN -,SUP-G32533,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,AETNA [1000108],AETNA [100010801],,,76.8,,22091.69,232.64935,38052.27264,percent of total billed charges,,,
ZENITH FENESTRATED PROXIMAL BODY -,SUP-G32537,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7045.04,4931.528,AETNA [1000108],AETNA [100010801],,,76.8,,5410.59,232.64935,38052.27264,percent of total billed charges,,,
GRAFT CUST ZFEN-P 2-24-124-R -,SUP-G32540,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,AETNA [1000108],AETNA [100010801],,,76.8,,22091.69,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 28MM PROX 23-24MM OD AOR 124MM PROX BD ZENITH FEN -,SUP-G32542,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,AETNA [1000108],AETNA [100010801],,,76.8,,22091.69,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 30MM PROX 24-26MM OD AOR 124MM PROX BD ZENITH FEN -,SUP-G32543,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,AETNA [1000108],AETNA [100010801],,,76.8,,22091.69,232.64935,38052.27264,percent of total billed charges,,,
GRAFT ZENITH FEN PROXIMAL BODY - ZFEN-P-2-32-124-R -,SUP-G32544,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,AETNA [1000108],AETNA [100010801],,,76.8,,22091.69,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 36MM PROX 29-31MM OD AOR 122MM PROX BD ZENITH FEN -,SUP-G32548,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,AETNA [1000108],AETNA [100010801],,,76.8,,22091.69,232.64935,38052.27264,percent of total billed charges,,,
GRAFT ZENITH DISTAL BODY - ZFEN-12-28-91 -,SUP-G32554,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,AETNA [1000108],AETNA [100010801],,,76.8,,11206.73,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 24/12X113MM ZENITH RENU ANCLRY CNVTR H&L-B 1-SHOT -,SUP-G36155,CDM,C1874,HCPCS,278,RC,,,outpatient,,,24186.48,16930.536,AETNA [1000108],AETNA [100010801],,,76.8,,18575.22,232.64935,38052.27264,percent of total billed charges,,,
DRUG ELUTING STENT 80 PTX -,SUP-G38480,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,AETNA [1000108],AETNA [100010801],,,76.8,,6437.27,232.64935,38052.27264,percent of total billed charges,,,
S ZILVER PTX 6 X 120 X 125 DRU -,SUP-G38482,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9315.54,6520.878,AETNA [1000108],AETNA [100010801],,,76.8,,7154.33,232.64935,38052.27264,percent of total billed charges,,,
STENT PTX 7MM X 40MM -,SUP-G38486,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5487.45,3841.215,AETNA [1000108],AETNA [100010801],,,76.8,,4214.36,232.64935,38052.27264,percent of total billed charges,,,
DRUG ELUTING STENT 7 - 60 PTX -,SUP-G38487,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6981.34,4886.938,AETNA [1000108],AETNA [100010801],,,76.8,,5361.67,232.64935,38052.27264,percent of total billed charges,,,
DRUG ELUTING STENT 7 - 100 PTX -,SUP-G38489,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,AETNA [1000108],AETNA [100010801],,,76.8,,6437.27,232.64935,38052.27264,percent of total billed charges,,,
STENT ZILVER PTX 7MM X 120MM P -,SUP-G38490,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9315.54,6520.878,AETNA [1000108],AETNA [100010801],,,76.8,,7154.33,232.64935,38052.27264,percent of total billed charges,,,
STENT 8mm x 40mm PTX ZILVER -,SUP-G38495,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5487.45,3841.215,AETNA [1000108],AETNA [100010801],,,76.8,,4214.36,232.64935,38052.27264,percent of total billed charges,,,
STENT ZILVER 8MM X 80MM PTX DRUG ELUTING PERIP -,SUP-G38518,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,AETNA [1000108],AETNA [100010801],,,76.8,,6437.27,232.64935,38052.27264,percent of total billed charges,,,
STENT ZIV6-35-125-8-120-PTX -,SUP-G38532,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9315.54,6520.878,AETNA [1000108],AETNA [100010801],,,76.8,,7154.33,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 20X30MM ZENITH FLEX BIFUR ILC PLG H&L-B 1-SHOT -,SUP-G43055,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7775.01,5442.507,AETNA [1000108],AETNA [100010801],,,76.8,,5971.21,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 36MMX11.3CM ZENITH FLEX AAA BIFUR STNT 20FR DLV SYS -,SUP-G43357,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30491.16,21343.812,AETNA [1000108],AETNA [100010801],,,76.8,,23417.21,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 36MMX12MMX127MM ZENITH RENU ANCLRY CNVTR H&L-B -,SUP-G43366,CDM,C1874,HCPCS,278,RC,,,outpatient,,,23484.73,16439.311,AETNA [1000108],AETNA [100010801],,,76.8,,18036.27,232.64935,38052.27264,percent of total billed charges,,,
ZENITH TX2 DISSECTION ENDOVASCULAR GRAFT STRAIGHT COMPONENT -,SUP-G47454,CDM,C1874,HCPCS,278,RC,,,outpatient,,,49547.23,34683.061,AETNA [1000108],AETNA [100010801],,,76.8,,38052.27,232.64935,38052.27264,percent of total billed charges,,,
COMPONENT STRAIGHT ENDO GRAFT ZENITH TX2 DISSECTION -,SUP-G47457,CDM,C1874,HCPCS,278,RC,,,outpatient,,,43823.79,30676.653,AETNA [1000108],AETNA [100010801],,,76.8,,33656.67,232.64935,38052.27264,percent of total billed charges,,,
ZENITH FLEX AAA ENDOVASC GRAFT MAIN BODY -,SUP-G48403,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA [1000108],AETNA [100010801],,,76.8,,20098.51,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 24MM BD 20-21MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-G48408,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA [1000108],AETNA [100010801],,,76.8,,20098.51,232.64935,38052.27264,percent of total billed charges,,,
GRAFT ZENITH FLEX AAA ENDOVASCULAR BIFURC MAIN BODY -,SUP-G48409,CDM,C1874,HCPCS,278,RC,,,outpatient,,,34530.9,24171.63,AETNA [1000108],AETNA [100010801],,,76.8,,26519.73,232.64935,38052.27264,percent of total billed charges,,,
ENDOGRAFT 32-82 ZENITH FLEX -,SUP-G48427,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA [1000108],AETNA [100010801],,,76.8,,20098.51,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 36MM BD 29-32MM OD AOR 95MM ZENITH FLEX BIFUR MAIN -,SUP-G48428,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA [1000108],AETNA [100010801],,,76.8,,20098.51,232.64935,38052.27264,percent of total billed charges,,,
ZENITH FLEX AAA ENDOVASCULAR GRAFT 20FR -,SUP-G48429,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA [1000108],AETNA [100010801],,,76.8,,20098.51,232.64935,38052.27264,percent of total billed charges,,,
GRAFT ZEINTH 36X95MM ENDOVAS A -,SUP-G48432,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA [1000108],AETNA [100010801],,,76.8,,20098.51,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 36MM BD 29-32MM OD AOR 113MM ZENITH FLEX BIFUR MAIN -,SUP-G48433,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA [1000108],AETNA [100010801],,,76.8,,20098.51,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 14MM MAIN BD 37MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-G48454,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,AETNA [1000108],AETNA [100010801],,,76.8,,8543.35,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 22MM MAIN BD 39MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-G48472,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11454.61,8018.227,AETNA [1000108],AETNA [100010801],,,76.8,,8797.14,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 24MM MAIN BD 39MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-G48476,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11454.61,8018.227,AETNA [1000108],AETNA [100010801],,,76.8,,8797.14,232.64935,38052.27264,percent of total billed charges,,,
STENT COLONIC 18MM X 23MM X 12 -,SUP-G51183,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,232.64935,38052.27264,percent of total billed charges,,,
STENT ESOPHAGEAL EVOLUTION FULLY COVERED 20-25-8 -,SUP-G52225,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 38MM PROX 38MM DIST 33-34MM OD AOR 202MM ZENITH TX2 -,SUP-G53435,CDM,C1874,HCPCS,278,RC,,,outpatient,,,29835.9,20885.13,AETNA [1000108],AETNA [100010801],,,76.8,,22913.97,232.64935,38052.27264,percent of total billed charges,,,
GRAFT ZENITH FLES Z-TRAK AAA ENDOVASC MAIN BODY EXT -,SUP-G55213,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9273.14,6491.198,AETNA [1000108],AETNA [100010801],,,76.8,,7121.77,232.64935,38052.27264,percent of total billed charges,,,
ZENITH FLEX WITH SPIRAL Z ENDOVASCULAR GRAFT -,SUP-G55221,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA [1000108],AETNA [100010801],,,76.8,,12626.81,232.64935,38052.27264,percent of total billed charges,,,
GRAFT ZENITH FLEX LEG 13X56 -,SUP-G55231,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA [1000108],AETNA [100010801],,,76.8,,12626.81,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 16MM DIST 56MM ZENITH SPRL-Z CNTRLAT IPSI ILC LEG -,SUP-G55237,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA [1000108],AETNA [100010801],,,76.8,,12626.81,232.64935,38052.27264,percent of total billed charges,,,
GRAFT ZENITH FLEX LEG 16X74 14FR -,SUP-G55238,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA [1000108],AETNA [100010801],,,76.8,,12626.81,232.64935,38052.27264,percent of total billed charges,,,
GRAFT ZENITH FLEX LEG 20MM X 39MM -,SUP-G55240,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA [1000108],AETNA [100010801],,,76.8,,12626.81,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 24MM DIST 90MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-G55247,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA [1000108],AETNA [100010801],,,76.8,,12626.81,232.64935,38052.27264,percent of total billed charges,,,
GRAFT ZENITH 22 X 113 -,SUP-G55357,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30944.14,21660.898,AETNA [1000108],AETNA [100010801],,,76.8,,23765.1,232.64935,38052.27264,percent of total billed charges,,,
ZENITH RENU AAA ANCILLARY GRAFT CON 12MM X 28MM X 113MM -,SUP-G55376,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30944.14,21660.898,AETNA [1000108],AETNA [100010801],,,76.8,,23765.1,232.64935,38052.27264,percent of total billed charges,,,
ICAST COVERED STENT- 9MMX38MMX120CM -,SUP-G60511,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9841.79,6889.253,AETNA [1000108],AETNA [100010801],,,76.8,,7558.49,232.64935,38052.27264,percent of total billed charges,,,
SYNERGY II US MR 2.5X8 -,SUP-H493926008250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
SYNERGY II US MR 2.75X8 -,SUP-H493926008270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
SYNERGY II US MR 3.5X8 -,SUP-H7433926008350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X24MM TAXUS EXPR2 OTW BE PRMNT 135CM PACLIT -,SUP-H7493896824250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA [1000108],AETNA [100010801],,,76.8,,6844.72,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.5X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.25X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.5X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X16MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902316250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4X16MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902316400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X20MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902320270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3X20MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902320300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4X20MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902320400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.25X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.5X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.25X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.25X16MM ION MONORAIL RX BE PRMNT 144CM PACLIT -,SUP-H7493902416220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X16MM ION MONORAIL RX BE PRMNT 144CM PACLIT -,SUP-H7493902416270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3X20MM ION MONORAIL RX BE PRMNT 144CM PACLIT THN -,SUP-H7493902420300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3X28MM ION MONORAIL RX BE PRMNT 144CM PACLIT THN -,SUP-H7493902428300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X32MM ION MONORAIL RX BE PRMNT 144CM PACLIT THN -,SUP-H7493902432250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X32MM ION MONORAIL RX BE PRMNT 144CM PACLIT -,SUP-H7493902432270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.25X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.5X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.25X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.5X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.25X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.5X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.25X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.5X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.25X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.5X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.25X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.5X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.25X32MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911432220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X32MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911432250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.5X32MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911432350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.5X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.25X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SV -,SUP-H7493911608220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911608250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911608270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL WKHRS -,SUP-H7493911608300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911608400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.25X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911612250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.5X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911612400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.25X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.5X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911616400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.5X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911620400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.25X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.5X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911624400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.25X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911628250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.5X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911628400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.25X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911632250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.5X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911632400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.5X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911638250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911638270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911638300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3.5X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911638350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911638400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,232.64935,38052.27264,percent of total billed charges,,,
SYNERGY II US MR 2.25X8 -,SUP-H7493926008220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 2.25 X 8 -,SUP-H7493926008220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 2.50 X 8 -,SUP-H7493926008250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 2.75 X 8 -,SUP-H7493926008270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 3.00 X 8 -,SUP-H7493926008300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
SYNERGY II US MR 3.00X8 -,SUP-H7493926008300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 3.50 X 8 -,SUP-H7493926008350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
SYNERGY II US MR 4.0X8 -,SUP-H7493926008400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 4.00 X 8 -,SUP-H7493926008400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 2.25 X 12 -,SUP-H7493926012220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 2.50 X 12 -,SUP-H7493926012250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 2.75 X 12 -,SUP-H7493926012270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 3.00 X 12 -,SUP-H7493926012300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 3.50 X 12 -,SUP-H7493926012350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 4.00 X 12 -,SUP-H7493926012400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 2.25 X 16 -,SUP-H7493926016220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 2.50 X 16 -,SUP-H7493926016250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 2.75 X 16 -,SUP-H7493926016270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 3.00 X 16 -,SUP-H7493926016300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 3.50 X 16 -,SUP-H7493926016350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 4.00 X 16 -,SUP-H7493926016400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 2.25 X 20 -,SUP-H7493926020220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 2.50 X 24 -,SUP-H7493926020250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 2.50 X 28 -,SUP-H7493926020250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 2.50 X 20 -,SUP-H7493926020250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 2.75 X 20 -,SUP-H7493926020270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 3.00 X 20 -,SUP-H749392602030,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 3.50 X 20 -,SUP-H7493926020350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 4.00 X 20 -,SUP-H7493926020400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 2.25 X 24 -,SUP-H7493926024220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 2.75 X 24 -,SUP-H7493926024270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 3.00 X 24 -,SUP-H7493926024300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 3.50 X 24 -,SUP-H7493926024350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 4.00 X 24 -,SUP-H7493926024400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 2.25 X 28 -,SUP-H7493926028220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 2.75 X 28 -,SUP-H7493926028270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 3.00 X 28 -,SUP-H7493926028300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 3.50 X 28 -,SUP-H7493926028350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 4.00 X 28 -,SUP-H7493926028400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 2.50 X 32 -,SUP-H7493926032250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 2.75 X 32 -,SUP-H7493926032270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 3.00 X 32 -,SUP-H7493926032300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 3.50 X 32 -,SUP-H7493926032350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 4.00 X 32 -,SUP-H7493926032400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 2.25 X 38 -,SUP-H7493926038220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 2.50 X 38 -,SUP-H7493926038250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 2.75 X 38 -,SUP-H7493926038270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 3.00 X 38 -,SUP-H7493926038300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 3.50 X 38 -,SUP-H7493926038350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES MR 4.00 X 38 -,SUP-H7493926038400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 2.25 X 8 -,SUP-H7493926108220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 2.50 X 8 -,SUP-H7493926108250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 2.75 X 8 -,SUP-H7493926108270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 3.00 X 8 -,SUP-H7493926108300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 3.50 X 8 -,SUP-H7493926108350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 4.00 X 8 -,SUP-H7493926108400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 2.25 X 12 -,SUP-H7493926112220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 2.50 X 12 -,SUP-H7493926112250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 2.75 X 12 -,SUP-H7493926112270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 3.00 X 12 -,SUP-H7493926112300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 3.50 X 12 -,SUP-H7493926112350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 4.00 X 12 -,SUP-H7493926112400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 2.25 X 16 -,SUP-H7493926116220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 2.50 X 16 -,SUP-H7493926116250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 2.75 X 16 -,SUP-H7493926116270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 3.00 X 16 -,SUP-H7493926116300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 3.50 X 16 -,SUP-H7493926116350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 4.00 X 16 -,SUP-H7493926116400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 2.25 X 20 -,SUP-H7493926120220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 2.50 X 20 -,SUP-H7493926120250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 2.75 X 20 -,SUP-H7493926120270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 3.00 X 20 -,SUP-H7493926120300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 3.50 X 20 -,SUP-H7493926120350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 4.00 X 20 -,SUP-H7493926120400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 2.25 X 24 -,SUP-H7493926124220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 2.50 X 24 -,SUP-H7493926124250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 2.75 X 24 -,SUP-H7493926124270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 3.00 X 24 -,SUP-H7493926124300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 3.50 X 24 -,SUP-H7493926124350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 4.00 X 24 -,SUP-H7493926124400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 2.25 X 28 -,SUP-H7493926128220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 2.50 X 28 -,SUP-H7493926128250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 2.75 X 28 -,SUP-H7493926128270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 3.00 X 28 -,SUP-H7493926128300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 3.50 X 28 -,SUP-H7493926128350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 4.00 X 28 -,SUP-H7493926128400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 2.25 X 32 -,SUP-H7493926132220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 2.50 X 32 -,SUP-H7493926132250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 2.75 X 32 -,SUP-H7493926132270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 3.00 X 32 -,SUP-H7493926132300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 3.50 X 32 -,SUP-H7493926132350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 4.00 X 32 -,SUP-H7493926132400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 2.25 X 38 -,SUP-H7493926138220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 2.50 X 38 -,SUP-H7493926138250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 2.75 X 38 -,SUP-H7493926138270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 3.00 X 38 -,SUP-H7493926138300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 3.50 X 38 -,SUP-H7493926138350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY DES OTW 4.00 X 38 -,SUP-H7493926138400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
ELUVIA US 6MM X 40MM X 130CM -,SUP-H74939294600410,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,AETNA [1000108],AETNA [100010801],,,76.8,,6502.49,232.64935,38052.27264,percent of total billed charges,,,
ELUVIA US 6MM X 60MM X 130CM -,SUP-H74939294600610,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,232.64935,38052.27264,percent of total billed charges,,,
ELUVIA US 6MM X 80MM X 130CM -,SUP-H74939294600810,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,AETNA [1000108],AETNA [100010801],,,76.8,,7399.86,232.64935,38052.27264,percent of total billed charges,,,
ELUVIA US 6MM X 100MM X 130CM -,SUP-H74939294601010,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,AETNA [1000108],AETNA [100010801],,,76.8,,7399.86,232.64935,38052.27264,percent of total billed charges,,,
ELUVIA US 6MM X 120MM X 130CM -,SUP-H74939294601210,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10749.14,7524.398,AETNA [1000108],AETNA [100010801],,,76.8,,8255.34,232.64935,38052.27264,percent of total billed charges,,,
ELUVIA US 6X150 130 cm -,SUP-H74939294601510,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13719.54,9603.678,AETNA [1000108],AETNA [100010801],,,76.8,,10536.61,232.64935,38052.27264,percent of total billed charges,,,
ELUVIA 7MM x 40MM x 130CM -,SUP-H74939294700410,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,AETNA [1000108],AETNA [100010801],,,76.8,,6502.49,232.64935,38052.27264,percent of total billed charges,,,
ELUVIA 7MM x 60MM x 130CM -,SUP-H74939294700610,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,232.64935,38052.27264,percent of total billed charges,,,
ELUVIA DRUG-ELUTING VASCULAR STENT SYSTEM 7MM X 80MM X 130CM -,SUP-H74939294700810,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,AETNA [1000108],AETNA [100010801],,,76.8,,7399.86,232.64935,38052.27264,percent of total billed charges,,,
ELUVIA 7MM x 100MM x 130CM -,SUP-H74939294701010,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,AETNA [1000108],AETNA [100010801],,,76.8,,7399.86,232.64935,38052.27264,percent of total billed charges,,,
ELUVIA 7MM x 120MM x 130CM -,SUP-H74939294701210,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10749.14,7524.398,AETNA [1000108],AETNA [100010801],,,76.8,,8255.34,232.64935,38052.27264,percent of total billed charges,,,
ELUVIA US 7X150 130 cm -,SUP-H74939294701510,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13719.54,9603.678,AETNA [1000108],AETNA [100010801],,,76.8,,10536.61,232.64935,38052.27264,percent of total billed charges,,,
STENT PROMUS ELITE US MR 4.0 X 8MM -,SUP-H7493941208400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,232.64935,38052.27264,percent of total billed charges,,,
STENT PROMUS ELITE US MR 4.0 X 12MM -,SUP-H7493941212400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,232.64935,38052.27264,percent of total billed charges,,,
STENT PROMUS ELITE US MR 2.50 X 32MM -,SUP-H7493941232250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,232.64935,38052.27264,percent of total billed charges,,,
STENT PROMUS ELITE US MR 3.50 X 32MM -,SUP-H7493941232350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,232.64935,38052.27264,percent of total billed charges,,,
STENT PROMUS ELITE US MR 3.50 X 38MM -,SUP-H7493941238350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 2.25 X 8 -,SUP-H7493941808220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 2.50 X 8 -,SUP-H7493941808250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 2.75 X 8 -,SUP-H7493941808270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 3.0 X 8 -,SUP-H7493941808300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 3.5 X 8 -,SUP-H7493941808350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 4.0 X 8 -,SUP-H7493941808400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 2.25 X 12 -,SUP-H7493941812220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 2.50 X 12 -,SUP-H7493941812250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 2.75 X 12 -,SUP-H7493941812270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 3.0 X 12 -,SUP-H7493941812300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 3.5 X 12 -,SUP-H7493941812350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 4.0 X 12 -,SUP-H7493941812400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 4.5 X 12 -,SUP-H7493941812450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 5.0 X 12 -,SUP-H7493941812500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 2.25 X 16 -,SUP-H7493941816220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 2.50 X 16 -,SUP-H7493941816250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 2.75 X 16 -,SUP-H7493941816270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 3.0 X 16 -,SUP-H7493941816300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 3.5 X 16 -,SUP-H7493941816350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 4.0 X 16 -,SUP-H7493941816400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 4.5 X 16 -,SUP-H7493941816450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 5.0 X 16 -,SUP-H7493941816500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 2.25 X 20 -,SUP-H7493941820220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 2.50 X 20 -,SUP-H7493941820250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 2.75 X 20 -,SUP-H7493941820270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 3.0 X 20 -,SUP-H7493941820300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 3.5 X 20 -,SUP-H7493941820350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 4.0 X 20 -,SUP-H7493941820400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 4.5 X 20 -,SUP-H7493941820450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 5.0 X 20 -,SUP-H7493941820500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 2.25 X 24 -,SUP-H7493941824220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 2.50 X 24 -,SUP-H7493941824250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 2.75 X 24 -,SUP-H7493941824270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 3.0 X 24 -,SUP-H7493941824300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 3.5 X 24 -,SUP-H7493941824350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 4.0 X 24 -,SUP-H7493941824400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 4.5 X 24 -,SUP-H7493941824450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 5.0 X 24 -,SUP-H7493941824500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 2.25 X 28 -,SUP-H7493941828220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 2.50 X 28 -,SUP-H7493941828250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 2.75 X 28 -,SUP-H7493941828270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 3.0 X 28 -,SUP-H7493941828300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 3.5 X 28 -,SUP-H7493941828350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 4.0 X 28 -,SUP-H7493941828400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 4.5 X 28 -,SUP-H7493941828450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 5.0 X 28 -,SUP-H7493941828500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 2.25 X 32 -,SUP-H7493941832220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 2.50 X 32 -,SUP-H7493941832250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 2.75 X 32 -,SUP-H7493941832270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 3.0 X 32 -,SUP-H7493941832300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 3.5 X 32 -,SUP-H7493941832350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 4.0 X 32 -,SUP-H7493941832400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 4.5 X 32 -,SUP-H7493941832450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 5.0 X 32 -,SUP-H7493941832500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 2.25 X 38 -,SUP-H7493941838220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 2.50 X 38 -,SUP-H7493941838250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 2.75 X 38 -,SUP-H7493941838270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 3.0 X 38 -,SUP-H7493941838300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 3.5 X 38 -,SUP-H7493941838350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR 4.0 X 38 -,SUP-H7493941838400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR US 2.5 X 48MM REF:H7493941848250 -,SUP-H7493941848250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR US 2.75 X 48MM REF:H7493941848270 -,SUP-H7493941848270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR US 3 X 48MM REF:H7493941848300 -,SUP-H7493941848300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR US 3.5 X 48MM REF:H7493941848350 -,SUP-H7493941848350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,,,
STENT SYNERGY XD DES MR US 4 X 48MM REF:H7493941848400 -,SUP-H7493941848400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,,,
STENT S MEGATRON DES US MR 3.5 X 16MM REF:H7493942816350 -,SUP-H7493942816350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,,,
STENT S MEGATRON DES US MR 3.5 X 20MM REF:H7493942820350 -,SUP-H7493942820350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,,,
STENT S MEGATRON DES US MR 4 X 20MM REF:H7493942820400 -,SUP-H7493942820400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,,,
STENT S MEGATRON DES US MR 4.5 X 20MM REF:H7493942820450 -,SUP-H7493942820450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,,,
STENT S MEGATRON DES US MR 5 X 20MM REF:H7493942820500 -,SUP-H7493942820500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,,,
STENT S MEGATRON DES US MR 3.5 X 24MM REF:H7493942824350 -,SUP-H7493942824350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,,,
STENT S MEGATRON DES US MR 4 X 24MM REF:H7493942824400 -,SUP-H7493942824400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,,,
STENT S MEGATRON DES US MR 4.5 X 24MM REF:H7493942824450 -,SUP-H7493942824450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,,,
STENT S MEGATRON DES US MR 5 X 24MM REF:H7493942824500 -,SUP-H7493942824500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,,,
STENT S MEGATRON DES US MR 3.5 X 28MM REF:H7493942828350 -,SUP-H7493942828350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,,,
STENT S MEGATRON DES US MR 4.0 X 28MM REF:H7493942828400 -,SUP-H7493942828400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,,,
STENT S MEGATRON DES US MR 4.5 X 28MM REF:H7493942828450 -,SUP-H7493942828450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,,,
STENT S MEGATRON DES US MR 5.0 X 28MM REF:H7493942828500 -,SUP-H7493942828500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,,,
STENT S MEGATRON DES US MR 3.5 X 32MM REF:H7493942832350 -,SUP-H7493942832350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,,,
STENT S MEGATRON DES US MR 4.0 X 32MM REF:H7493942832400 -,SUP-H7493942832400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,,,
STENT S MEGATRON DES US MR 4.5 X 32MM REF:H7493942832450 -,SUP-H7493942832450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,,,
STENT S MEGATRON DES US MR 5.0 X 32MM REF:H7493942832500 -,SUP-H7493942832500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,232.64935,38052.27264,percent of total billed charges,,,
SYNERGY II US MR 2.25X12 -,SUP-H749396012220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,232.64935,38052.27264,percent of total billed charges,,,
STENT BIL 10X60MM 194CM CATH WALLSTNT SE UNCNTSTR CVR ENPROS -,SUP-H965431100,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7116.04,4981.228,AETNA [1000108],AETNA [100010801],,,76.8,,5465.12,232.64935,38052.27264,percent of total billed charges,,,
STENT BALLOON EXPANDABLE VASC COVERED -,SUP-LSMU0800737,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,232.64935,38052.27264,percent of total billed charges,,,
STENT LIFESTREAM 7MM X 58MM BALLOON EXP -,SUP-LSMU0800758,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,AETNA [1000108],AETNA [100010801],,,76.8,,10693.44,232.64935,38052.27264,percent of total billed charges,,,
LIFESTREAM BALLOON EP VASC COVERED STENT 80CM X 26MM -,SUP-LSMU0800826,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,232.64935,38052.27264,percent of total billed charges,,,
12MM X 38MM LIFE STREAM -,SUP-LSMU0801238,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,232.64935,38052.27264,percent of total billed charges,,,
STENT LIFESTREAM 5MM X 26MM -,SUP-LSMU1350526,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,AETNA [1000108],AETNA [100010801],,,76.8,,10693.44,232.64935,38052.27264,percent of total billed charges,,,
LIFESTREAM 12MM X 38MM X 80CM -,SUP-LSMU1350626,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,AETNA [1000108],AETNA [100010801],,,76.8,,10693.44,232.64935,38052.27264,percent of total billed charges,,,
FIBERED PLATINUM COIL 2 X 5MM -,SUP-M0013120211,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2243.7,1570.59,AETNA [1000108],AETNA [100010801],,,76.8,,1723.16,232.64935,38052.27264,percent of total billed charges,,,
FIBERED PLATNUM COIL 4 X 4MM -,SUP-M0013120221,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2243.7,1570.59,AETNA [1000108],AETNA [100010801],,,76.8,,1723.16,232.64935,38052.27264,percent of total billed charges,,,
DETACHABLE COIL 3MM X 6MM -,SUP-M001361500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2622.16,1835.512,AETNA [1000108],AETNA [100010801],,,76.8,,2013.82,232.64935,38052.27264,percent of total billed charges,,,
DETACHABLE COIL 6MM X 10MM -,SUP-M001361560,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,AETNA [1000108],AETNA [100010801],,,76.8,,1607.96,232.64935,38052.27264,percent of total billed charges,,,
PUSHER SURG ARSCP 0.016INX177CM VASC COIL 16 -,SUP-M0014012160,CDM,C1874,HCPCS,278,RC,,,outpatient,,,1036.3,725.41,AETNA [1000108],AETNA [100010801],,,76.8,,795.88,232.64935,38052.27264,percent of total billed charges,,,
STENT ESPH 18MM BD 13MM BD 23MM FLR 15CM POLYFLEX SE SIL LF -,SUP-M00514320,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8623.21,6036.247,AETNA [1000108],AETNA [100010801],,,76.8,,6622.63,232.64935,38052.27264,percent of total billed charges,,,
STENT ESPH 18MM 25/23MM OD P/D FLR 18.5FR CATH 10CM WALLFLX -,SUP-M00516700,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,AETNA [1000108],AETNA [100010801],,,76.8,,8143.89,232.64935,38052.27264,percent of total billed charges,,,
STENT ESPH 18MM 25/23MM OD P/D FLR 12CM WALLFLX SE BRD FLLY -,SUP-M00516710,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,AETNA [1000108],AETNA [100010801],,,76.8,,8143.89,232.64935,38052.27264,percent of total billed charges,,,
WALLFLEX ESOPHAGEAL FULLY COVERED 18 X 15 -,SUP-M00516720,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,AETNA [1000108],AETNA [100010801],,,76.8,,8143.89,232.64935,38052.27264,percent of total billed charges,,,
STENT ESPH 23MM 28/28MM OD P/D FLR 10CM WALLFLX SE BRD FLLY -,SUP-M00516730,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,AETNA [1000108],AETNA [100010801],,,76.8,,8143.89,232.64935,38052.27264,percent of total billed charges,,,
WALLFLEX ESOPHAGEAL FULLY COVERED 23 X 10 -,SUP-M00516730,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,AETNA [1000108],AETNA [100010801],,,76.8,,8143.89,232.64935,38052.27264,percent of total billed charges,,,
STENT ESPH 23MM 28/28MM OD P/D FLR 12CM WALLFLX SE BRD FLLY -,SUP-M00516740,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,AETNA [1000108],AETNA [100010801],,,76.8,,8143.89,232.64935,38052.27264,percent of total billed charges,,,
WALLFLEX ESOPHAGEAL FULLY COVERED 23 X 12 -,SUP-M00516740,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,AETNA [1000108],AETNA [100010801],,,76.8,,8143.89,232.64935,38052.27264,percent of total billed charges,,,
WALLFLEX ESOPHAGEAL FULLY COVERED 18 X 15 -,SUP-M00516750,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,AETNA [1000108],AETNA [100010801],,,76.8,,8143.89,232.64935,38052.27264,percent of total billed charges,,,
WALLFLEX ESOPHAGEAL PARTIALLY COVERED 18 X 10 -,SUP-M00516900,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,AETNA [1000108],AETNA [100010801],,,76.8,,7977.59,232.64935,38052.27264,percent of total billed charges,,,
STENT ESPH 18MM 23/23MM OD P/D FLR 10CM WALLFLX SE BRD FLLY -,SUP-M00516900,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9314.91,6520.437,AETNA [1000108],AETNA [100010801],,,76.8,,7153.85,232.64935,38052.27264,percent of total billed charges,,,
STENT ESPH 18MM 23/23MM OD P/D FLR 123MM WALLFLX SE BRD FLLY -,SUP-M00516910,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,AETNA [1000108],AETNA [100010801],,,76.8,,7977.59,232.64935,38052.27264,percent of total billed charges,,,
WALLFLEX ESOPHAGEAL PARTIALLY COVERED 18 X 12 -,SUP-M00516910,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,AETNA [1000108],AETNA [100010801],,,76.8,,7977.59,232.64935,38052.27264,percent of total billed charges,,,
WALLFLEX PC ESOPH STENT 23/28MM X 105MM -,SUP-M00516930,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,AETNA [1000108],AETNA [100010801],,,76.8,,7977.59,232.64935,38052.27264,percent of total billed charges,,,
WALLFLEX ESOPHAGEAL PARTIALLY COVERED 23 X 12 -,SUP-M00516940,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,AETNA [1000108],AETNA [100010801],,,76.8,,7977.59,232.64935,38052.27264,percent of total billed charges,,,
STENT AXIOS ELECTROCAUTERY-ENHANCED 15mm X 10mm -,SUP-M00553650,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17317.43,12122.201,AETNA [1000108],AETNA [100010801],,,76.8,,13299.79,232.64935,38052.27264,percent of total billed charges,,,
STENT CYST GASTROSTOMY AXIOS -,SUP-M00553650,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19659.22,13761.454,AETNA [1000108],AETNA [100010801],,,76.8,,15098.28,232.64935,38052.27264,percent of total billed charges,,,
STENT AXIOS 10 X 20 EE LO -,SUP-M00553660,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19659.22,13761.454,AETNA [1000108],AETNA [100010801],,,76.8,,15098.28,232.64935,38052.27264,percent of total billed charges,,,
STENT BIL 10X60MM WALLSTNT RX SE PRT CVR MTL 0.035IN GW COMP -,SUP-M00569710,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7266.24,5086.368,AETNA [1000108],AETNA [100010801],,,76.8,,5580.47,232.64935,38052.27264,percent of total billed charges,,,
STENT WALLFLEX BILIARY FULLY COVERED -,SUP-M00570350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,AETNA [1000108],AETNA [100010801],,,76.8,,7494.74,232.64935,38052.27264,percent of total billed charges,,,
S WALLFLEX BILI 10X40 RX COV -,SUP-M00570360,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,AETNA [1000108],AETNA [100010801],,,76.8,,7494.74,232.64935,38052.27264,percent of total billed charges,,,
STENT BIL 10X60MM WALLFLX RX SE FLLY CVR PLATINOL 0.035IN GW -,SUP-M00570370,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,AETNA [1000108],AETNA [100010801],,,76.8,,7494.74,232.64935,38052.27264,percent of total billed charges,,,
STENT BIL 10X80MM WALLFLX RX SE FLLY CVR PLATINOL 0.035IN GW -,SUP-M00570380,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,AETNA [1000108],AETNA [100010801],,,76.8,,7494.74,232.64935,38052.27264,percent of total billed charges,,,
STENT PARTIALLY COVERED 8 X 100 -,SUP-M00570730,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9639.76,6747.832,AETNA [1000108],AETNA [100010801],,,76.8,,7403.34,232.64935,38052.27264,percent of total billed charges,,,
STENT ULTRAFLEX 8 X 40 25MM TR -,SUP-M00576520,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,AETNA [1000108],AETNA [100010801],,,76.8,,9022.69,232.64935,38052.27264,percent of total billed charges,,,
STENT TRACHBR 10MM XPND 18FR COMPRESS 30MM ULFLX PRT CVR -,SUP-M00576530,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,AETNA [1000108],AETNA [100010801],,,76.8,,9022.69,232.64935,38052.27264,percent of total billed charges,,,
STENT RX COVRD 15 X 30 -,SUP-M00576550,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,AETNA [1000108],AETNA [100010801],,,76.8,,9022.69,232.64935,38052.27264,percent of total billed charges,,,
STENT RX COVRD 25 X 40 -,SUP-M00576560,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,AETNA [1000108],AETNA [100010801],,,76.8,,9022.69,232.64935,38052.27264,percent of total billed charges,,,
STENT CVRD ULTRAFLEX 14 X 40 -,SUP-M00576580,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,AETNA [1000108],AETNA [100010801],,,76.8,,9022.69,232.64935,38052.27264,percent of total billed charges,,,
STENT CVRD ULTRAFLEX 14 X 60 -,SUP-M00576590,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,AETNA [1000108],AETNA [100010801],,,76.8,,9022.69,232.64935,38052.27264,percent of total billed charges,,,
STENT TRACHBR 16MMX40MM ULFLX CVR DIST RELS SIL DIST RELS -,SUP-M00576610,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,AETNA [1000108],AETNA [100010801],,,76.8,,9022.69,232.64935,38052.27264,percent of total billed charges,,,
STENT ULTRAFLEX 16X45 -,SUP-M00576620,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,AETNA [1000108],AETNA [100010801],,,76.8,,9022.69,232.64935,38052.27264,percent of total billed charges,,,
STENT CVRD ULTRAFLEX 18 X 40 -,SUP-M00576640,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,AETNA [1000108],AETNA [100010801],,,76.8,,9022.69,232.64935,38052.27264,percent of total billed charges,,,
STENT CVRD ULTRAFLEX 20 X 40 -,SUP-M00576670,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11747.93,8223.551,AETNA [1000108],AETNA [100010801],,,76.8,,9022.41,232.64935,38052.27264,percent of total billed charges,,,
STENT CVRD ULTRAFLEX 20 X 80 -,SUP-M00576690,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,AETNA [1000108],AETNA [100010801],,,76.8,,9022.69,232.64935,38052.27264,percent of total billed charges,,,
STENT ESOPHAGEAL 23 X 150 ENDO -,SUP-MAXX-2315,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9175.53,6422.871,AETNA [1000108],AETNA [100010801],,,76.8,,7046.81,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  2.00 x 08MM -,SUP-ONYXNG20008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,AETNA [1000108],AETNA [100010801],,,76.8,,2291.52,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  2.00 x 12MM -,SUP-ONYXNG20012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,AETNA [1000108],AETNA [100010801],,,76.8,,2291.52,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  2.00 x 15MM -,SUP-ONYXNG20015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,AETNA [1000108],AETNA [100010801],,,76.8,,2291.52,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  2.00 x 18MM -,SUP-ONYXNG20018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,AETNA [1000108],AETNA [100010801],,,76.8,,2291.52,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  2.00 x 30MM -,SUP-ONYXNG20030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  2.25 x 08MM -,SUP-ONYXNG22508UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  2.25 x 12MM -,SUP-ONYXNG22512UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  2.25 x 15MM -,SUP-ONYXNG22515UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  2.25 x 18MM -,SUP-ONYXNG22518UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  2.25 x 22MM -,SUP-ONYXNG22522UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  2.25 x 26MM -,SUP-ONYXNG22526UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  2.25 x 30MM -,SUP-ONYXNG22530UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  2.25 x 34MM -,SUP-ONYXNG22534UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  2.25 x 38MM -,SUP-ONYXNG22538UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  2.50 x 08MM -,SUP-ONYXNG25008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  2.50 x 12MM -,SUP-ONYXNG25012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  2.50 x 15MM -,SUP-ONYXNG25015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  2.50 x 18MM -,SUP-ONYXNG25018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  2.50 x 22MM -,SUP-ONYXNG25022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  2.50 x 26MM -,SUP-ONYXNG25026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  2.50 x 30MM -,SUP-ONYXNG25030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  2.50 x 34MM -,SUP-ONYXNG25034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  2.50 x 38MM -,SUP-ONYXNG25038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  2.75 x 08MM -,SUP-ONYXNG27508UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  2.75 x 12MM -,SUP-ONYXNG27512UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  2.75 x 15MM -,SUP-ONYXNG27515UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  2.75 x 18MM -,SUP-ONYXNG27518UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  2.75 x 22MM -,SUP-ONYXNG27522UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  2.75 x 26MM -,SUP-ONYXNG27526UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  2.75 x 30MM -,SUP-ONYXNG27530UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  2.75 x 34MM -,SUP-ONYXNG27534UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  2.75 x 38MM -,SUP-ONYXNG27538UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  3.0 x 08MM -,SUP-ONYXNG30008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  3.0 x 12MM -,SUP-ONYXNG30012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  3.0 x 15MM -,SUP-ONYXNG30015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  3.0 x 18MM -,SUP-ONYXNG30018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  3.0 x 22MM -,SUP-ONYXNG30022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  3.0 x 26MM -,SUP-ONYXNG30026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  3.0 x 30MM -,SUP-ONYXNG30030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  3.0 x 34MM -,SUP-ONYXNG30034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  3.0 x 38MM -,SUP-ONYXNG30038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  3.5 x 08MM -,SUP-ONYXNG35008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  3.5 x 12MM -,SUP-ONYXNG35012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  3.5 x 15MM -,SUP-ONYXNG35015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  3.5 x 18MM -,SUP-ONYXNG35018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  3.5 x 22MM -,SUP-ONYXNG35022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  3.5 x 26MM -,SUP-ONYXNG35026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  3.5 x 30MM -,SUP-ONYXNG35030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  3.5 x 34MM -,SUP-ONYXNG35034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  3.5 x 38MM -,SUP-ONYXNG35038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  4.0 x 12MM -,SUP-ONYXNG40012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  4.0 x 15MM -,SUP-ONYXNG40015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  4.0 x 18MM -,SUP-ONYXNG40018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  4.0 x 22MM -,SUP-ONYXNG40022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  4.0 x 26MM -,SUP-ONYXNG40026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  4.0 x 30MM -,SUP-ONYXNG40030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  4.0 x 34MM -,SUP-ONYXNG40034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  4.0 x 38MM -,SUP-ONYXNG40038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  4.5 x 12MM -,SUP-ONYXNG45012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  4.5 x 15MM -,SUP-ONYXNG45015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  4.5 x 18MM -,SUP-ONYXNG45018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  4.5 x 22MM -,SUP-ONYXNG45022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  4.5 x 26MM -,SUP-ONYXNG45026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  4.5 x 30MM -,SUP-ONYXNG45030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  5.0 x 18MM -,SUP-ONYXNG50018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  5.0 x 22MM -,SUP-ONYXNG50022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT ONYX DES  5.0 x 30MM -,SUP-ONYXNG50030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,232.64935,38052.27264,percent of total billed charges,,,
STENT BIL 5X18MM 135CM PALMZ GENESIS RX BE TRNSHEP SS -,SUP-PG1850BAX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4882.72,3417.904,AETNA [1000108],AETNA [100010801],,,76.8,,3749.93,232.64935,38052.27264,percent of total billed charges,,,
EXCLUDER AAA ENDO EXTENDER 26MMX3.3CM 16FR -,SUP-PLA260300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13934.89,9754.423,AETNA [1000108],AETNA [100010801],,,76.8,,10702,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 32MM 27-29MM AOR 4.5CM EXCLDR AOR EXTEND LPRO SULS -,SUP-PLA320400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13934.89,9754.423,AETNA [1000108],AETNA [100010801],,,76.8,,10702,232.64935,38052.27264,percent of total billed charges,,,
EXCLUDER AAA ENDO EXTENDER 36MM X 4.5CM 18FR -,SUP-PLA360400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13934.89,9754.423,AETNA [1000108],AETNA [100010801],,,76.8,,10702,232.64935,38052.27264,percent of total billed charges,,,
EXCLUDER AAA ENDOPROSTHESIS L 16MM X 12MM X 14CM 12F -,SUP-PLC121400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA [1000108],AETNA [100010801],,,76.8,,15213.2,232.64935,38052.27264,percent of total billed charges,,,
EXCLUDER CONTRALATERAL LEG 16MM X 14.5MM X 10CM 12F -,SUP-PLC141000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA [1000108],AETNA [100010801],,,76.8,,15213.2,232.64935,38052.27264,percent of total billed charges,,,
GORE EXCLUDER AAA ENDOPROSTHESIS -,SUP-PLC141200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA [1000108],AETNA [100010801],,,76.8,,15213.2,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 13.5-14.5MM 16MM ILC 9.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PLC161000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA [1000108],AETNA [100010801],,,76.8,,15213.2,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 13.5-14.5MM 16MM ILC 11.5CM EXCLDR CNTRLAT LEG ILC -,SUP-PLC161200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA [1000108],AETNA [100010801],,,76.8,,15213.2,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 13.5-14.5MM 16MM ILC 13.5CM EXCLDR CNTRLAT LEG ILC -,SUP-PLC161400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA [1000108],AETNA [100010801],,,76.8,,15213.2,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EXCLUDER AAA ENDO CONTRA LEG 16 X 18 X 9.5CM 12FR -,SUP-PLC181000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA [1000108],AETNA [100010801],,,76.8,,15213.2,232.64935,38052.27264,percent of total billed charges,,,
EXCLUDER AAA ENDO CONTRA LEG 16MM X 20MM X 11.5CM 12FR -,SUP-PLC201200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA [1000108],AETNA [100010801],,,76.8,,15213.2,232.64935,38052.27264,percent of total billed charges,,,
EXCLUDER AAA ENDO CONTRA LEG 16 X 23 X 12 14FR -,SUP-PLC231200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA [1000108],AETNA [100010801],,,76.8,,15213.2,232.64935,38052.27264,percent of total billed charges,,,
EXCLUDER AAA ENDO CONTRA LEG 16MM X 23MM X 14CM 14FR -,SUP-PLC231400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA [1000108],AETNA [100010801],,,76.8,,15213.2,232.64935,38052.27264,percent of total billed charges,,,
GORE EXCLUDER AAA CONTRALATERAL LEG 16 X 27 X 100MM -,SUP-PLK271000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA [1000108],AETNA [100010801],,,76.8,,15213.2,232.64935,38052.27264,percent of total billed charges,,,
GORE VIATORR 10MM X 6CM -,SUP-PTB8106275,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17651.6,12356.12,AETNA [1000108],AETNA [100010801],,,76.8,,13556.43,232.64935,38052.27264,percent of total billed charges,,,
GORE VIATORR 10MM X 7CM -,SUP-PTB8107275,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17651.6,12356.12,AETNA [1000108],AETNA [100010801],,,76.8,,13556.43,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 10-11MM 12MM ILC 10CM EXCLDR CNTRLAT LEG LPRO SULS -,SUP-PXC121000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,AETNA [1000108],AETNA [100010801],,,76.8,,11976.65,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 12-13.5MM 14.5MM ILC 12CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC141200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,AETNA [1000108],AETNA [100010801],,,76.8,,11976.65,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 13.5-14.5 MM 6MMX11.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC161200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,AETNA [1000108],AETNA [100010801],,,76.8,,11976.65,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 16.5-18.5 MM 20MMX11.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC201200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,AETNA [1000108],AETNA [100010801],,,76.8,,11976.65,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 16.5-18.5 MM 20MMX13.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC201400-L,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,AETNA [1000108],AETNA [100010801],,,76.8,,11976.65,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 10MMX7CM EXCLDR ILC EXTEND LPRO SULS CNSTRCT SEAL -,SUP-PXL161007,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11510.3,8057.21,AETNA [1000108],AETNA [100010801],,,76.8,,8839.91,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 12MMX7CM EXCLDR ILC EXTEND LPRO SULS CNSTRCT SEAL -,SUP-PXL161207,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10953.35,7667.345,AETNA [1000108],AETNA [100010801],,,76.8,,8412.17,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 27-29/12-13.5MM 31/14.5MM DIA AOR/ILC 18CM EXCLDR -,SUP-RLT311413,CDM,C1874,HCPCS,278,RC,,,outpatient,,,32100.6,22470.42,AETNA [1000108],AETNA [100010801],,,76.8,,24653.26,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 2.75X18MM RESOLUT IN RX BE PRMNT 140CM ZOTARO -,SUP-RSINT27518UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30022W,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30026W,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 3X38MM RESOLUT IN RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT30038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,232.64935,38052.27264,percent of total billed charges,,,
STENT DES 4X38MM RESOLUT IN RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT40038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 22MM 18FR SHTH 8.2CM BIFUR -,SUP-TFFB-22-82,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30491.16,21343.812,AETNA [1000108],AETNA [100010801],,,76.8,,23417.21,232.64935,38052.27264,percent of total billed charges,,,
GRAFT 22X82 ZENITH ENDOVASC AA -,SUP-TFFB-22-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA [1000108],AETNA [100010801],,,76.8,,20098.51,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 22MM BD 18-19MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-22-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA [1000108],AETNA [100010801],,,76.8,,20098.51,232.64935,38052.27264,percent of total billed charges,,,
GRAFT ZENITH 24X82 ENDOVASC -,SUP-TFFB-24-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA [1000108],AETNA [100010801],,,76.8,,20098.51,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 26MM BD 22MM AOR 111MM ZENITH FLEX BIFUR MAIN BD -,SUP-TFFB-26-111-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA [1000108],AETNA [100010801],,,76.8,,20098.51,232.64935,38052.27264,percent of total billed charges,,,
GRAFT 26X82 ZEINTH ENDOV AAA -,SUP-TFFB-26-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA [1000108],AETNA [100010801],,,76.8,,20098.51,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 26MM BD 22MM AOR 96MM ZENITH FLEX BIFUR MAIN BD -,SUP-TFFB-26-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA [1000108],AETNA [100010801],,,76.8,,20098.51,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 28MM BD 23-24MM OD AOR 111MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-28-111-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA [1000108],AETNA [100010801],,,76.8,,20098.51,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 28MM BD 23-24MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-28-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA [1000108],AETNA [100010801],,,76.8,,20098.51,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 30MM BD 25-26MM OD AOR 11.1CM ZENITH FLEX BIFUR -,SUP-TFFB-30-111,CDM,C1874,HCPCS,278,RC,,,outpatient,,,31404.55,21983.185,AETNA [1000108],AETNA [100010801],,,76.8,,24118.69,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 30MM BD 25-26MM OD AOR 111MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-30-111-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA [1000108],AETNA [100010801],,,76.8,,20098.51,232.64935,38052.27264,percent of total billed charges,,,
GRAFT 30X82 ZEINTH ENDOVASC AB -,SUP-TFFB-30-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA [1000108],AETNA [100010801],,,76.8,,20098.51,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV ZENITH FLEX 30MM 20FRX9.6MM BIFUR MAIN BD EXTEND -,SUP-TFFB-30-96,CDM,C1874,HCPCS,278,RC,,,outpatient,,,29150.76,20405.532,AETNA [1000108],AETNA [100010801],,,76.8,,22387.78,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 30MM BD 25-26MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-30-96-2T,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA [1000108],AETNA [100010801],,,76.8,,20098.51,232.64935,38052.27264,percent of total billed charges,,,
COOK GRAFT TFFB-30-96-ZT -,SUP-TFFB-30-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA [1000108],AETNA [100010801],,,76.8,,20098.51,232.64935,38052.27264,percent of total billed charges,,,
STENT ENPROS 12X71MM ZENITH AAA CNTRLAT ILC LEG WVN PLYSTR -,SUP-TFLE-12-71,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,AETNA [1000108],AETNA [100010801],,,76.8,,8543.35,232.64935,38052.27264,percent of total billed charges,,,
STENT ENPROS 14X54MM ZENITH AAA CNTRLAT ILC LEG WVN PLYSTR -,SUP-TFLE-14-54,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,AETNA [1000108],AETNA [100010801],,,76.8,,8543.35,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 14MM MAIN 56MM LEG ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-TFLE-14-56-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11454.61,8018.227,AETNA [1000108],AETNA [100010801],,,76.8,,8797.14,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 14MM MAIN BD 73MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-TFLE-14-73,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,AETNA [1000108],AETNA [100010801],,,76.8,,8543.35,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 14X56MM ZENITH FLEX AAA Z-TRAK BIFUR ILC CNTRLAT -,SUP-TFLE-15-56,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,AETNA [1000108],AETNA [100010801],,,76.8,,8543.35,232.64935,38052.27264,percent of total billed charges,,,
STENT ENPROS 18MM 16FR SHTH 54MM ZENITH AAA CNTRLAT ILC LEG -,SUP-TFLE-18-54,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,AETNA [1000108],AETNA [100010801],,,76.8,,8543.35,232.64935,38052.27264,percent of total billed charges,,,
GRAFT ZENITH FLEX AAA 28X82M -,SUP-TTFB-28-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA [1000108],AETNA [100010801],,,76.8,,20098.51,232.64935,38052.27264,percent of total billed charges,,,
GRAFT STENT ENDUR IIS BIF BODY -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,AETNA [1000108],AETNA [100010801],,,76.8,,27022.33,232.64935,38052.27264,percent of total billed charges,,,
GORE VIATORR 10MM X 8CM -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16385.47,11469.829,AETNA [1000108],AETNA [100010801],,,76.8,,12584.04,232.64935,38052.27264,percent of total billed charges,,,
S VIABAHN 7MM X 7CM VIA VAS -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,AETNA [1000108],AETNA [100010801],,,76.8,,10265.7,232.64935,38052.27264,percent of total billed charges,,,
STENT ESOPHAGEAL 21X150 -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9175.53,6422.871,AETNA [1000108],AETNA [100010801],,,76.8,,7046.81,232.64935,38052.27264,percent of total billed charges,,,
STENT POLYFLEX AIRWAY 16X40 -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8267.48,5787.236,AETNA [1000108],AETNA [100010801],,,76.8,,6349.42,232.64935,38052.27264,percent of total billed charges,,,
VALIANT THORACIC CAPTIVA STENT GRAFT 26MM X 112MM 22FR -,SUP-VAMF2626C100TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,40668.87,28468.209,AETNA [1000108],AETNA [100010801],,,76.8,,31233.69,232.64935,38052.27264,percent of total billed charges,,,
STENT GRAFT VALIANT CAPTIVA WITH DELIVERY SYSTEM -,SUP-VAMF2828C100TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,40668.5,28467.95,AETNA [1000108],AETNA [100010801],,,76.8,,31233.41,232.64935,38052.27264,percent of total billed charges,,,
STENT ENPROS 5MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART. -,SUP-VBH051002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12063.54,8444.478,AETNA [1000108],AETNA [100010801],,,76.8,,9264.8,232.64935,38052.27264,percent of total billed charges,,,
STENT ENPROS 6MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART. -,SUP-VBH061002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12152.65,8506.855,AETNA [1000108],AETNA [100010801],,,76.8,,9333.24,232.64935,38052.27264,percent of total billed charges,,,
STENT ENPROS 6MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC_ART. -,SUP-VBH061502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13968.31,9777.817,AETNA [1000108],AETNA [100010801],,,76.8,,10727.66,232.64935,38052.27264,percent of total billed charges,,,
STENT ENPROS 7MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBH071002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12152.65,8506.855,AETNA [1000108],AETNA [100010801],,,76.8,,9333.24,232.64935,38052.27264,percent of total billed charges,,,
STENT ENPROS 8MMX10CM 120CM VIABAHN SE LPRO TIP TO HUB DPLY -,SUP-VBH081002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12152.65,8506.855,AETNA [1000108],AETNA [100010801],,,76.8,,9333.24,232.64935,38052.27264,percent of total billed charges,,,
STENT ENPROS 9MMX15CM 120CM VIABAHN SE LPRO TIP TO HUB DPLY -,SUP-VBH091502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13968.31,9777.817,AETNA [1000108],AETNA [100010801],,,76.8,,10727.66,232.64935,38052.27264,percent of total billed charges,,,
S 10MMX 5.0CM VIA VASC 120CM -,SUP-VBH100502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11785.06,8249.542,AETNA [1000108],AETNA [100010801],,,76.8,,9050.93,232.64935,38052.27264,percent of total billed charges,,,
STENT ENPROS 10MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBH101502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14495.55,10146.885,AETNA [1000108],AETNA [100010801],,,76.8,,11132.58,232.64935,38052.27264,percent of total billed charges,,,
GORE VIABAHN ENDOPROSTHESIS- 7MMX5CM 8FR 120CMCATH -,SUP-VBHR070502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12910.1,9037.07,AETNA [1000108],AETNA [100010801],,,76.8,,9914.96,232.64935,38052.27264,percent of total billed charges,,,
STENT ENPROS 8MM 8FR DVC 5CM GORE-HYBRID VIABAHN 120CM NTNL -,SUP-VBHR080502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12910.1,9037.07,AETNA [1000108],AETNA [100010801],,,76.8,,9914.96,232.64935,38052.27264,percent of total billed charges,,,
STENT ENPROS 6MMX5CM 120CM VIABAHN FEM ILC ART TIP TO HUB -,SUP-VBJ060502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11268.96,7888.272,AETNA [1000108],AETNA [100010801],,,76.8,,8654.56,232.64935,38052.27264,percent of total billed charges,,,
STENT ENPROS 6MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART. -,SUP-VBJ061502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14347.03,10042.921,AETNA [1000108],AETNA [100010801],,,76.8,,11018.52,232.64935,38052.27264,percent of total billed charges,,,
STENT ENPROS 6MMX25CM 120CM GORE-HYBRID VIABAHN SUPRFC FEM -,SUP-VBJ062502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,23555.27,16488.689,AETNA [1000108],AETNA [100010801],,,76.8,,18090.45,232.64935,38052.27264,percent of total billed charges,,,
STENT ENPROS 7MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJ071502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14347.03,10042.921,AETNA [1000108],AETNA [100010801],,,76.8,,11018.52,232.64935,38052.27264,percent of total billed charges,,,
STENT ENPROS 8MMX5CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJ080502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10923.65,7646.555,AETNA [1000108],AETNA [100010801],,,76.8,,8389.36,232.64935,38052.27264,percent of total billed charges,,,
STENT ENPROS 8MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJ081002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12445.98,8712.186,AETNA [1000108],AETNA [100010801],,,76.8,,9558.51,232.64935,38052.27264,percent of total billed charges,,,
STENT ENPROS 5MM 6FRX5CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR050502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11669.96,8168.972,AETNA [1000108],AETNA [100010801],,,76.8,,8962.53,232.64935,38052.27264,percent of total billed charges,,,
STENT ENPROS 5MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR051002A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12761.58,8933.106,AETNA [1000108],AETNA [100010801],,,76.8,,9800.89,232.64935,38052.27264,percent of total billed charges,,,
STENT ENPROS 5MMX15CM VIABAHN 120MM CATH -,SUP-VBJR051502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14885.42,10419.794,AETNA [1000108],AETNA [100010801],,,76.8,,11432,232.64935,38052.27264,percent of total billed charges,,,
STENT ENPROS 5MM 6FRX25CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR052502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,24297.87,17008.509,AETNA [1000108],AETNA [100010801],,,76.8,,18660.76,232.64935,38052.27264,percent of total billed charges,,,
STENT ENPROS 6MMX5CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR060502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13403.93,9382.751,AETNA [1000108],AETNA [100010801],,,76.8,,10294.22,232.64935,38052.27264,percent of total billed charges,,,
STENT ENPROS 6MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR061002A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,AETNA [1000108],AETNA [100010801],,,76.8,,10265.7,232.64935,38052.27264,percent of total billed charges,,,
STENT ENPROS 6MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR061502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14224.5,9957.15,AETNA [1000108],AETNA [100010801],,,76.8,,10924.42,232.64935,38052.27264,percent of total billed charges,,,
STENT ENPROS 6MM 6FRX25CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR062502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,23351.06,16345.742,AETNA [1000108],AETNA [100010801],,,76.8,,17933.61,232.64935,38052.27264,percent of total billed charges,,,
STENT ENPROS 7MM 7FRX5CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR070502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12226.91,8558.837,AETNA [1000108],AETNA [100010801],,,76.8,,9390.27,232.64935,38052.27264,percent of total billed charges,,,
STENT ENPROS 7MM 7FRX10CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR071002A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,AETNA [1000108],AETNA [100010801],,,76.8,,10265.7,232.64935,38052.27264,percent of total billed charges,,,
STENT ENPROS 7MMX25CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR072502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26414.28,18489.996,AETNA [1000108],AETNA [100010801],,,76.8,,20286.17,232.64935,38052.27264,percent of total billed charges,,,
VALIANT NAVION THORACIC STENT GRAFT SYSTEM -,SUP-VNMC2020C94TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,AETNA [1000108],AETNA [100010801],,,76.8,,35041.67,232.64935,38052.27264,percent of total billed charges,,,
THORACIC STENT GRAFT 94MM 25MM -,SUP-VNMC2525C94TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,AETNA [1000108],AETNA [100010801],,,76.8,,35041.67,232.64935,38052.27264,percent of total billed charges,,,
STENT GRAFT VALION NAVION THORACIC -,SUP-VNMC4040C55TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,AETNA [1000108],AETNA [100010801],,,76.8,,35041.67,232.64935,38052.27264,percent of total billed charges,,,
STENT GORE VIABIL 10MM X 6CM BILIARY -,SUP-VSWVN1006,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,232.64935,38052.27264,percent of total billed charges,,,
STENT GORE VIABIL 10MM X 8CM BILIARY -,SUP-VSWVN1008,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 28MM PROX BD DIA 94MM PROX BD ZENITH FEN INTNL -,SUP-ZFEN-9-2-28-94R,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,AETNA [1000108],AETNA [100010801],,,76.8,,22091.69,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 12MM IPSI LEG DIA 121MM DIST LEG 28MM DIST BD -,SUP-ZFEN-D-1228121C,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,AETNA [1000108],AETNA [100010801],,,76.8,,11206.73,232.64935,38052.27264,percent of total billed charges,,,
FENESTRATED DISTAL BODY -,SUP-ZFEN-D-12-2876C,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,AETNA [1000108],AETNA [100010801],,,76.8,,11206.73,232.64935,38052.27264,percent of total billed charges,,,
GRAFT HUM TIS FEN 26MM ZENITH EV PROX BD LF -,SUP-ZFEN-P-226124-R,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,AETNA [1000108],AETNA [100010801],,,76.8,,22091.69,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 36MM PROX 29-31MM OD AOR 107MM PROX BD ZENITH FEN -,SUP-ZFEN-P-2-36107R,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,AETNA [1000108],AETNA [100010801],,,76.8,,22091.69,232.64935,38052.27264,percent of total billed charges,,,
STENT VASC DES ZILVER PTX 6X100MM 125CM OTW SE PRELD -,SUP-ZISV6351256100,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,AETNA [1000108],AETNA [100010801],,,76.8,,6437.27,232.64935,38052.27264,percent of total billed charges,,,
STENT VASC DES ZILVER PTX 6X60MM 125CM OTW SE PRELD -,SUP-ZIV6-35-125660,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6981.34,4886.938,AETNA [1000108],AETNA [100010801],,,76.8,,5361.67,232.64935,38052.27264,percent of total billed charges,,,
STENT VASC DES ZILVER PTX 7X100MM 125CM OTW SE PRELD -,SUP-ZIV6351257100PT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7617.98,5332.586,AETNA [1000108],AETNA [100010801],,,76.8,,5850.61,232.64935,38052.27264,percent of total billed charges,,,
STENT VASC DES ZILVER PTX 7X80MM 125CM OTW SE PRELD -,SUP-ZIV635125780PTX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7617.98,5332.586,AETNA [1000108],AETNA [100010801],,,76.8,,5850.61,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 11MM DIST 56MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-ZSLE-11-56-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14387.88,10071.516,AETNA [1000108],AETNA [100010801],,,76.8,,11049.89,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 11MM DIST 74MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-ZSLE-11-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA [1000108],AETNA [100010801],,,76.8,,12626.81,232.64935,38052.27264,percent of total billed charges,,,
GRAFT ZENITH FLEX LEG 13X74 -,SUP-ZSLE-13-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA [1000108],AETNA [100010801],,,76.8,,12626.81,232.64935,38052.27264,percent of total billed charges,,,
GRAFT ZENITH AAA LEG 13X90MM -,SUP-ZSLE-13-90-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA [1000108],AETNA [100010801],,,76.8,,12626.81,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 16MMX90MM ZENITH SPRL -Z BIFUR CNTRLAT IPSI -,SUP-ZSLE-16-16-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA [1000108],AETNA [100010801],,,76.8,,12626.81,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 16MM DIST 39MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-ZSLE-16-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA [1000108],AETNA [100010801],,,76.8,,12626.81,232.64935,38052.27264,percent of total billed charges,,,
GRAFT ZENITH AAA LEG 20X74MM -,SUP-ZSLE-20-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA [1000108],AETNA [100010801],,,76.8,,12626.81,232.64935,38052.27264,percent of total billed charges,,,
GRAFT ZENITH AAA 24 X 56MM LEG -,SUP-ZSLE-24-56-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA [1000108],AETNA [100010801],,,76.8,,12626.81,232.64935,38052.27264,percent of total billed charges,,,
GRAFT EV 24MM 16FR ID 6MM INTRO SHTH 74MM ZENITH SPRL -Z -,SUP-ZSLE-24-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA [1000108],AETNA [100010801],,,76.8,,12626.81,232.64935,38052.27264,percent of total billed charges,,,
STENT 4.5X13MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003381-13,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 4.5X18MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003381-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 4.5X28MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003381-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 5X13MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003382-13,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 2X8MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 2X12MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 2X15MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 2X18MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 2X23MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 2X28MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.25X8MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.25X12MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.25X15MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.25X18MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.25X23MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.25X28MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.5X8MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.5X12MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.5X15MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.5X18MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.5X23MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.5X28MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.75X8MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007847-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.75X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007847-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.75X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007847-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 3X8MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 3X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 3X23MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 3X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 3.5X8MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 3.5X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 3.5X23MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 3.5X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 4X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007850-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 4X23MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007850-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 4X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007850-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.75X15MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010142-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.75X23MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010142-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 3X8MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010143-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 3X15MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010143-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT VISION OTW 3.5 X 15 -,SUP-1010144-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT VISION OTW 3.5 X 23 -,SUP-1010144-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 3.5X28MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010144-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 4X18MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010145-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 4X23MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010145-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 2X8MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 3.5X12MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 2X15MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 3.5X18MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 2X23MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 2X28MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.25X8MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.25X12MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.25X15MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.25X18MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.25X23MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.25X28MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.5X8MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.5X12MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.5X15MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.5X18MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.5X23MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC ACCULINK 5X20MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011337-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC ACCULINK 5X30MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011337-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC ACCULINK 5X40MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011337-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,26.19915,32197.7856,percent of total billed charges,,,
S RX ACCULINK 7.0MM X 30MM X 132CM -,SUP-1011339-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC ACCULINK 7X40MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011339-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,26.19915,32197.7856,percent of total billed charges,,,
6-8 mm X 30mm RX ACCULINK STENT -,SUP-1011343-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC ACCULINK 6-8X40MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011343-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,26.19915,32197.7856,percent of total billed charges,,,
ACCULINK STENT 7-10 X 40MM -,SUP-1011344-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 4X12MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011487-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 4X18MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011487-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 4.5X15MM 135CM DLV CATH HERCULINK ELITE RX BE -,SUP-1011490-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 5X15MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011493-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 5X18MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011493-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR SELF-EXPANDING 6.0MM X 100MM X 80CM -,SUP-1012528-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR SELF-EXPANDING 6.0MM X 20MM X 80CM -,SUP-1012528-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR SELF-EXPANDING 6.0MM X 30MM X 80CM -,SUP-1012528-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR SELF-EXPANDING 6.0MM X 40MM X 80CM -,SUP-1012528-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR SEL-EXPANDING 6.0MM X 60MM X 80CM -,SUP-1012528-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAT SELF-EXPANDING 6.0MM X 80MM X 80CM -,SUP-1012528-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 100MM X 80CM -,SUP-1012529-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 20MM X 80CM -,SUP-1012529-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 30MM X 80CM -,SUP-1012529-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 40MM X 80CM -,SUP-1012529-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 60MM X 80CM -,SUP-1012529-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 80MM X 80CM -,SUP-1012529-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
ABSOLUTE PRO 8 X 100MM X 80CM -,SUP-1012530-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCUALR SELF-EXPANDING 8.0MM X 20MM X 80CM -,SUP-1012530-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR SELF-EXPANDING 8.0MM X 30MM X 80CM -,SUP-1012530-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
ABSOLUTE PRO VASCULAR SELF-EXPANDING STENT SYS 8 X 40 -,SUP-1012530-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
ABSOLUTE PRO 8 X 60MM X 80CM -,SUP-1012530-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
ABSOLUTE PRO 8 X 80MM X 80CM -,SUP-1012530-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR SELF-EXPANDING 9.0MM X 100MM X 80CM -,SUP-1012531-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR SELF-EXPANDING 9.0MM 20MM X 80CM -,SUP-1012531-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR SELF-EXPANDING 9.0MM X 30MM X 80CM -,SUP-1012531-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR SELF-EXPANDING 9.0MM X 40MM X 80CM -,SUP-1012531-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR SELF-EXPANDING 9.0MM X 60MM X 80CM -,SUP-1012531-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR SELF-EXPANDING 9.0MM X 80MM X 80CM -,SUP-1012531-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 100MM X 80CM -,SUP-1012532-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 20MM X 80CM -,SUP-1012532-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 30MM X 80CM -,SUP-1012532-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT ABSOLUTE PRO 10 X 40MM X 80CM -,SUP-1012532-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC ABSOLUTE PRO 10X60CM -,SUP-1012532-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
ABSOLUTE PRO SELF EXPANDING STENT 10MM X 80MM C 80CM -,SUP-1012532-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC ABSOLUTE PRO 6X100MM 135CM OTW SE PRMNT -,SUP-1012534-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC ABSOLUTE PRO 6X40MM 135CM OTW SE PRMNT -,SUP-1012534-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC ABSOLUTE PRO 7.0X100MM 135CM -,SUP-1012535-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 20MM X 135CM -,SUP-1012535-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 30MM X 135CM -,SUP-1012535-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC ABSOLUTE PRO 7X40MM 135CM OTW SE PRMNT -,SUP-1012535-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC ABSOLUTE PRO 7X60MM 135CM OTW SE PRMNT -,SUP-1012535-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 80MM X 135CM -,SUP-1012535-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR SELF-EXPANDING 8.0MM X 100MM X 135CM -,SUP-1012536-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR SELF-EXPANDING 8.0MM X 20MM X 135CM -,SUP-1012536-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR SELF-EXPANDING 8.0MM X 30MM X 135CM -,SUP-1012536-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR SELF-EXPANDING 8.0MM X 40MM X 135CM -,SUP-1012536-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC ABSOLUTE PRO 8.0 X 60MM X 135CM -,SUP-1012536-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR SELF-EXPANDING 9.0MM X 100MM X 135CM -,SUP-1012537-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR SELF-EXPANDED 9.0MM X 40MM X 135CM -,SUP-1012537-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR SELF-EXPANDING 9.0MM X 80MM X 135CM -,SUP-1012537-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 100MM X 135CM -,SUP-1012538-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 20MM X 135CM -,SUP-1012538-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 30MM X 135CM -,SUP-1012538-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA [1000108],AETNA [100010801],,,76.8,,976.99,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 40MM X 135CM -,SUP-1012538-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 60MM X 135CM -,SUP-1012538-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 80MM X 135CM -,SUP-1012538-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA [1000108],AETNA [100010801],,,76.8,,1709.73,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR BALLOON-EXPANDABLE 6.0MM X 16MM X 80CM -,SUP-1012622-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC OMNILINK ELITE 6X19MM 80CM OTW BE PRMNT -,SUP-1012622-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC OMNILINK ELITE 6X29MM 80CM OTW BE PRMNT -,SUP-1012622-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC OMNILINK ELITE 6X39MM 80CM OTW BE PRMNT -,SUP-1012622-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC OMNILINK ELITE 6X59MM 80CM OTW BE PRMNT -,SUP-1012622-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 12MM X 80CM -,SUP-1012623-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 16MM X 80CM -,SUP-1012623-16,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC OMNILINK ELITE 7X19MM 80CM OTW BE PRMNT -,SUP-1012623-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC OMNILINK ELITE 7X29MM 80CM OTW BE PRMNT -,SUP-1012623-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC OMNILINK ELITE 7X39MM 80CM OTW BE PRMNT -,SUP-1012623-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC OMNILINK ELITE 7X59MM 80CM OTW BE PRMNT -,SUP-1012623-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC OMNILINK ELITE 8X19MM 80CM OTW BE PRMNT -,SUP-1012624-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC OMNILINK ELITE 8X29MM 80CM OTW BE PRMNT -,SUP-1012624-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC OMNILINK ELITE 8X39MM 80CM OTW BE PRMNT -,SUP-1012624-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC OMNILINK ELITE 8X59MM 80CM OTW BE PRMNT -,SUP-1012624-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC OMNILINK ELITE 9X19MM 80CM OTW BE PRMNT -,SUP-1012625-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC OMNILINK ELITE 9X29MM 80CM OTW BE PRMNT -,SUP-1012625-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC OMNILINK ELITE 9X39MM 80CM OTW BE PRMNT -,SUP-1012625-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC OMNILINK ELITE 9X59MM 80CM OTW BE PRMNT -,SUP-1012625-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC OMNILINK ELITE 10X19MM 80CM OTW BE PRMNT -,SUP-1012626-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC OMNILINK ELITE 10X29MM 80CM OTW BE PRMNT -,SUP-1012626-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC OMNILINK ELITE 10X39MM 80CM OTW BE PRMNT -,SUP-1012626-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC OMNILINK ELITE 10X59MM 80CM OTW BE PRMNT -,SUP-1012626-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR BALLOON-EXPANDABLE 6.0MM X 16MM X 135 -,SUP-1012629-16,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC OMNILINK ELITE 6X19MM 135CM OTW BE PRMNT -,SUP-1012629-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC OMNILINK ELITE 6X29MM 135CM OTW BE PRMNT -,SUP-1012629-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC OMNILINK ELITE 6X39MM 135CM OTW BE PRMNT -,SUP-1012629-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC OMNILINK ELITE 6X59MM 135CM OTW BE PRMNT -,SUP-1012629-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 12MM X 135CM -,SUP-1012630-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 16MM X 135CM -,SUP-1012630-16,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC OMNILINK ELITE 7X19MM 135CM OTW BE PRMNT -,SUP-1012630-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC OMNILINK ELITE 7X29MM 135CM OTW BE PRMNT -,SUP-1012630-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC OMNILINK ELITE 7X39MM 135CM OTW BE PRMNT -,SUP-1012630-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC OMNILINK ELITE 7X59MM 135CM OTW BE PRMNT -,SUP-1012630-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC OMNILINK ELITE 8X19MM 135CM OTW BE PRMNT -,SUP-1012631-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC OMNILINK ELITE 8X29MM 135CM OTW BE PRMNT -,SUP-1012631-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC OMNILINK ELITE 8X39MM 135CM OTW BE PRMNT -,SUP-1012631-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC OMNILINK ELITE 8X59MM 135CM OTW BE PRMNT -,SUP-1012631-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC OMNILINK ELITE 9X19MM 135CM OTW BE PRMNT -,SUP-1012632-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC OMNILINK ELITE 9X29MM 135CM OTW BE PRMNT -,SUP-1012632-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC OMNILINK ELITE 9X39MM 135CM OTW BE PRMNT -,SUP-1012632-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC OMNILINK ELITE 9X59MM 135CM OTW BE PRMNT -,SUP-1012632-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC OMNILINK ELITE 10X19MM 135CM OTW BE PRMNT -,SUP-1012633-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC OMNILINK ELITE 10X29MM 135CM OTW BE PRMNT -,SUP-1012633-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC OMNILINK ELITE 10X39MM 135CM OTW BE PRMNT -,SUP-1012633-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC OMNILINK ELITE 10X59MM 135CM OTW BE PRMNT -,SUP-1012633-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT 4X12MM JOST GRAFTMS OTW BE 143CM SEM-COM HYDREX CTD -,SUP-12746-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,AETNA [1000108],AETNA [100010801],,,76.8,,7806.24,26.19915,32197.7856,percent of total billed charges,,,
BIOMIMICS 3-D STENT 5MM X 60MM -,SUP-142122-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,26.19915,32197.7856,percent of total billed charges,,,
BIOMIMICS 3-D STENT 6MM X 60MM -,SUP-142122-02,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,26.19915,32197.7856,percent of total billed charges,,,
BIOMIMICS 3-D STENT 7MM X 60MM -,SUP-142122-03,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,26.19915,32197.7856,percent of total billed charges,,,
BIOMIMICS 3-D STENT 5MM X 80MM -,SUP-142122-05,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,26.19915,32197.7856,percent of total billed charges,,,
BIOMIMICS 3-D STENT 6MM X 80MM -,SUP-142122-06,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,26.19915,32197.7856,percent of total billed charges,,,
BIOMIMICS 3-D STENT 7MM X 80MM -,SUP-142122-07,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,26.19915,32197.7856,percent of total billed charges,,,
BIOMIMICS 3-D STENT 5MM X 100MM -,SUP-142122-09,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA [1000108],AETNA [100010801],,,76.8,,4074.24,26.19915,32197.7856,percent of total billed charges,,,
BIOMIMICS 3-D STENT 6MM X 100MM -,SUP-142122-10,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA [1000108],AETNA [100010801],,,76.8,,4074.24,26.19915,32197.7856,percent of total billed charges,,,
BIOMIMICS 3-D STENT 7MM X 100MM -,SUP-142122-11,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA [1000108],AETNA [100010801],,,76.8,,4074.24,26.19915,32197.7856,percent of total billed charges,,,
BIOMIMICS 3-D STENT 5MM X 125MM -,SUP-142122-13,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,26.19915,32197.7856,percent of total billed charges,,,
BIOMIMICS 3-D STENT 6MM X 125MM -,SUP-142122-14,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,26.19915,32197.7856,percent of total billed charges,,,
BIOMIMICS 3-D STENT 7MM X 125MM -,SUP-142122-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,26.19915,32197.7856,percent of total billed charges,,,
BIOMIMICS 3-D STENT 5MM X 150MM -,SUP-144700-05,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,26.19915,32197.7856,percent of total billed charges,,,
BIOMIMICS 3-D STENT 6MM X 150MM -,SUP-144700-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,26.19915,32197.7856,percent of total billed charges,,,
BIOMIMICS 3-D STENT 7MM X 150MM -,SUP-144700-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,76.8,,4400.18,26.19915,32197.7856,percent of total billed charges,,,
S BILIARY LD PMTD 8 X 37 X75 6 -,SUP-38046-84075,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 8X37MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38046-84075,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 9 X 25MM 75CM EXP LD -,SUP-38046-92075,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 10X25MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-12013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 10X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-16013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 6X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-63013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 7X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-76013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
S BILIARY EXPRESS 8X37X135CM L -,SUP-38047-84013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 8X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-38047-84013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
PULSAR 18 - 6 X 40 X 135 -,SUP-390724,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,AETNA [1000108],AETNA [100010801],,,76.8,,2144.86,26.19915,32197.7856,percent of total billed charges,,,
PULSAR 18 - 6 X 120 X 135 -,SUP-390728,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,AETNA [1000108],AETNA [100010801],,,76.8,,2144.86,26.19915,32197.7856,percent of total billed charges,,,
PULSAR 18 - 6 X 150 X 135 -,SUP-390729,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,AETNA [1000108],AETNA [100010801],,,76.8,,2144.86,26.19915,32197.7856,percent of total billed charges,,,
PULSAR 18  7X40X135  .018 -,SUP-390734,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,26.19915,32197.7856,percent of total billed charges,,,
S EPIC OTW 6 X 120 X 120 -,SUP-39200-06122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC EPIC 6X120MM 120CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-39200-06122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-XPD 7X118X120 -,SUP-39200-07122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC EPIC 7X120MM 163CM/120CM WKG CATH SE MTLC ILC -,SUP-39200-07122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-XPD 7X79X120 -,SUP-39200-07802,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC EPIC 7X80MM 120CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-39200-07802,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-XPD 9X40X120 -,SUP-39200-09402,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,,,
EPIC STENT 10MM X 40MM X 120CM -,SUP-39200-10402,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,26.19915,32197.7856,percent of total billed charges,,,
EPIC STENT 10MM X 60MM X 120CM -,SUP-39200-10602,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,,,
EPIC STENT 12MM X 60MM X 120CM -,SUP-39200-12602,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,,,
STENT ENPROS 24MM 11FR CATH 70MM WALLSTNT RP 100CM TOT 75CM -,SUP-40512,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,26.19915,32197.7856,percent of total billed charges,,,
STENT PULSAR - 18 T3 4/20/135 -,SUP-430477,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,76.8,,2914.81,26.19915,32197.7856,percent of total billed charges,,,
STENT PULSAR - 18 T3 4/40/135 -,SUP-430479,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,26.19915,32197.7856,percent of total billed charges,,,
STENT PULSAR - 18 T3 4/80/135 -,SUP-430481,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,26.19915,32197.7856,percent of total billed charges,,,
STENT PULSAR - 18 T3  5/80/135 -,SUP-430491,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,26.19915,32197.7856,percent of total billed charges,,,
STENT PULSAR - 18 T3 5/120/135 -,SUP-430493,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,26.19915,32197.7856,percent of total billed charges,,,
STENT PULSAR - 18 T3 5/200/135 -,SUP-430496,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,26.19915,32197.7856,percent of total billed charges,,,
STENT PULSAR - 18 T3 6/40/135 -,SUP-430499,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,26.19915,32197.7856,percent of total billed charges,,,
STENT PULSAR - 18 T3 6/80/135 -,SUP-430501,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,26.19915,32197.7856,percent of total billed charges,,,
STENT PULSAR - 18 T3 6/120/135 -,SUP-430503,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,26.19915,32197.7856,percent of total billed charges,,,
STENT PULSAR - 18 T3 6/150/135 -,SUP-430504,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,26.19915,32197.7856,percent of total billed charges,,,
STENT PULSAR - 18 T3 6/200/135 -,SUP-430506,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,26.19915,32197.7856,percent of total billed charges,,,
STENT PULSAR - 18 T3 7/120/135 -,SUP-430513,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,26.19915,32197.7856,percent of total billed charges,,,
STENT PULSAR - 18 T3 7/150/135 -,SUP-430514,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,26.19915,32197.7856,percent of total billed charges,,,
WRENCH SPLTY HX F /CPI -,SUP-6563,CDM,C1876,HCPCS,278,RC,,,outpatient,,,175.05,122.535,AETNA [1000108],AETNA [100010801],,,76.8,,134.44,26.19915,32197.7856,percent of total billed charges,,,
STENT URET 6FR 22-32CM INLAY OPTM PLYMR BLND DBL PIGTL TAPR -,SUP-788600,CDM,C1876,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,76.8,,492.94,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC XACT 7-9X40MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82086-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC XACT 7-9X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82087-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC XACT 9X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82088-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC XACT 9X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82089-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC XACT 6-8X40MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82090-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC XACT 6-8X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82091-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC XACT 8X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82092-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC XACT 8X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82093-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC XACT 7X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82094-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC XACT 7X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82095-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC XACT 10.8MM X 40MM X 136CM -,SUP-82096-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC XACT 10X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82098-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC XACT 10X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82099-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA [1000108],AETNA [100010801],,,76.8,,7480.3,26.19915,32197.7856,percent of total billed charges,,,
ABRE STENTS 16MM X 80MM -,SUP-AB9U16080090,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6896.5,4827.55,AETNA [1000108],AETNA [100010801],,,76.8,,5296.51,26.19915,32197.7856,percent of total billed charges,,,
ABRE STENTS 18MM X 100MM -,SUP-AB9U18100090,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6896.5,4827.55,AETNA [1000108],AETNA [100010801],,,76.8,,5296.51,26.19915,32197.7856,percent of total billed charges,,,
ABRE STENTS 18MM X 120MM -,SUP-AB9U18120090,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6896.5,4827.55,AETNA [1000108],AETNA [100010801],,,76.8,,5296.51,26.19915,32197.7856,percent of total billed charges,,,
COVERA AV STENT GRAFT 7MM X 60MM X 80MM -,SUP-AVSM07060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA [1000108],AETNA [100010801],,,76.8,,8269.59,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC SMART CONT 6X30MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06030ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC SMART CONT 6X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC SMART CONT 6X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC SMART CONT 6X80MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06080ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC SMART CONT 6X100MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06100ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC SMART CONT 6X120MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06120ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC SMART CONT 6X150MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06150ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC SMART CONT 7X30MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07030ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC SMART CONT 7X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC SMART CONT 7X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC SMART CONT 7X80MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07080ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC SMART CONT 7X100MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07100ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC SMART CONT 7X120MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07120ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC SMART CONT 7X150MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07150ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC SMART CONT 8X30MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08030ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC SMART CONT 8X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC SMART CONT 8X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC SMART CONT 8X80MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08080ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC SMART CONT 8X100MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08100ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC SMART CONT 8X120MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08120ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC SMART CONT 8X150MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08150ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC SMART CONT 10X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C10040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC SMART CONT 10X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C10060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA [1000108],AETNA [100010801],,,76.8,,2566.5,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 12X40MM 120CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-C12040MB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 12X60MM 120CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-C12060MB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 12X60MM 80CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-C12060SB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 6X100MM 130CM LIFESTENT SE HLCL NTNL 0.035IN GW -,SUP-EX061003CD,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9230.7,6461.49,AETNA [1000108],AETNA [100010801],,,76.8,,7089.18,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC LIFESTENT 6X150MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX061503CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,AETNA [1000108],AETNA [100010801],,,76.8,,5866.91,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC LIFESTENT 6X170MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX061703CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA [1000108],AETNA [100010801],,,76.8,,7170.66,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC LIFESTENT 6X200MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX062003CL,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,AETNA [1000108],AETNA [100010801],,,76.8,,7699.28,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC LIFESTENT 7X60MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX070603CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,26.19915,32197.7856,percent of total billed charges,,,
GRAFT EV 8MM 9FR CATH 40MM 120CM TOT 80CM DLV SYS FLAIR STR -,SUP-FAS08040,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11020.18,7714.126,AETNA [1000108],AETNA [100010801],,,76.8,,8463.5,26.19915,32197.7856,percent of total billed charges,,,
COIL MICRONESTER EMBOLIZATION 0.018 X 5CM X 3MM -,SUP-G23520,CDM,C1876,HCPCS,278,RC,,,outpatient,,,851.91,596.337,AETNA [1000108],AETNA [100010801],,,76.8,,654.27,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 5MM 7FR GUID CATH 30MM 125CM ZILVER 518 OTW SE -,SUP-G31351,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,,,
S ZILVER 518 5X40 125CM S-E ZI -,SUP-G31352,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 4X40MM 125CM ZILVER 518 OTW SE PRELD FLXB SLT TUBE -,SUP-G31439,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 8MM 6FRX40MM 80CM SE PRELD MTL NTNL 5FR SHTH MUL -,SUP-G32020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA [1000108],AETNA [100010801],,,76.8,,5215.03,26.19915,32197.7856,percent of total billed charges,,,
S ZILVER .035 125CM 5 X 60 -,SUP-G32033,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 8X80MM MTL SE 6FRX125CM PRELD DLV SYS NTNL 6FR -,SUP-G36025,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,76.8,,5540.97,26.19915,32197.7856,percent of total billed charges,,,
S ZILVER 518 5X80 125CM S-E -,SUP-G36048,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 14X30MM 80CM ZILVER 635 OTW SE PRELD FLXB SLT TUBE -,SUP-G36233,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 12MM 8FR GUID CATH 40MM 125CM ZILVER 635 OTW SE -,SUP-G36239,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,,,
12MM X 8CM ZILVER 635 STENT -,SUP-G36241,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 14MM 8FR GUID CATH 40MM 125CM ZILVER 635 OTW SE -,SUP-G36244,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 14X60MM 125CM ZILVER 635 OTW SE PRELD 0.035IN GW -,SUP-G36245,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 5X20MM 135CM FRMLA 418 BLN-XPD GUID CATH 5/6 FR -,SUP-G42956,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4034.03,2823.821,AETNA [1000108],AETNA [100010801],,,76.8,,3098.14,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 6X24MM 135CM FRMLA 418 OTW BE U STRUT TAPR 0.018IN -,SUP-G42962,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,AETNA [1000108],AETNA [100010801],,,76.8,,3696.12,26.19915,32197.7856,percent of total billed charges,,,
S ZILVER 518 VASC 6X40 125CM S -,SUP-G43771,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,,,
S ZILVER518 VASC 6X60 125CM -,SUP-G43772,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,,,
S ZILVER 518 VASC 6X80 125CM S -,SUP-G43773,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,,,
7x40x125 ZILVER STENT 0.018 -,SUP-G43776,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC ZILVER 518 7X80MM 125CM OTW SE 0.018IN/5FR -,SUP-G43778,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC ZILVER 518 8X60MM 125CM OTW SE 0.018IN/5FR -,SUP-G43782,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,,,
S ZILVER .035 125CM 6 X 60 012 -,SUP-G43822,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,,,
S ZILVER .035 125CM 6 X 80 012 -,SUP-G43823,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC ZILVER 635 7X30MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43825,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC ZILVER 635 7X40MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43826,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC ZILVER 635 7X60MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43827,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC ZILVER 635 7X80MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43828,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC ZILVER 635 8X30MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC ZILVER 635 8X40MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43831,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC ZILVER 635 8X60MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43832,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC ZILVER 635 8X80MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43833,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC ZILVER 635 10X40MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43841,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC ZILVER 635 10X60MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43842,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC ZILVER 635 10X80MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43843,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,,,
COIL NESTOR 3 X 5 -,SUP-G47334,CDM,C1876,HCPCS,278,RC,,,outpatient,,,577.61,404.327,AETNA [1000108],AETNA [100010801],,,76.8,,443.6,26.19915,32197.7856,percent of total billed charges,,,
COIL MICRONESTOR EMBOLIZATION .018 X 7CM X 4MM PLAT -,SUP-G47339,CDM,C1876,HCPCS,278,RC,,,outpatient,,,638.87,447.209,AETNA [1000108],AETNA [100010801],,,76.8,,490.65,26.19915,32197.7856,percent of total billed charges,,,
ZENITH DISSECTION ENDOVASCULAR STENT -,SUP-G47492,CDM,C1876,HCPCS,278,RC,,,outpatient,,,41924.2,29346.94,AETNA [1000108],AETNA [100010801],,,76.8,,32197.79,26.19915,32197.7856,percent of total billed charges,,,
ZENITH DISSECTION ENDOVASCULAR STENT -,SUP-G47493,CDM,C1876,HCPCS,278,RC,,,outpatient,,,41924.2,29346.94,AETNA [1000108],AETNA [100010801],,,76.8,,32197.79,26.19915,32197.7856,percent of total billed charges,,,
STENT ENDOVASCULAR DISSECTION ZENITH -,SUP-G47496,CDM,C1876,HCPCS,278,RC,,,outpatient,,,37318.31,26122.817,AETNA [1000108],AETNA [100010801],,,76.8,,28660.46,26.19915,32197.7856,percent of total billed charges,,,
STENT DUODENAL EVOLUTION CONTROL RELEASE 22-27-9 -,SUP-G48026,CDM,C1876,HCPCS,278,RC,,,outpatient,,,8886.94,6220.858,AETNA [1000108],AETNA [100010801],,,76.8,,6825.17,26.19915,32197.7856,percent of total billed charges,,,
S ZILVER .035 125CM 5 X 100 -,SUP-G50162,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 7MM 8FR GUID CATH LNG 100MM 125CM ZILVER FLEX 35 -,SUP-G50168,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 7MM 8FR GUID CATH LNG 120MM 125CM ZILVER FLEX 35 -,SUP-G50169,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 7X140MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-G50170,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 8X100MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-G50171,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 8MM 8FR GUID CATH LNG 140MM 125CM ZILVER FLEX 35 -,SUP-G50173,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 10X100MM 80CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-G50177,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,,,
Z STENT BILIARY 8 X 8 -,SUP-G50623,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA [1000108],AETNA [100010801],,,76.8,,4726.12,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC FRMLA 418 5X16MM 80CM OTW BE PRMNT -,SUP-G56609,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,AETNA [1000108],AETNA [100010801],,,76.8,,3696.12,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC FRMLA 418 5X20MM 80CM OTW BE PRMNT -,SUP-G56610,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,AETNA [1000108],AETNA [100010801],,,76.8,,3696.12,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC FRMLA 418 6X12MM 80CM OTW BE PRMNT -,SUP-G56611,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,AETNA [1000108],AETNA [100010801],,,76.8,,3696.12,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC FRMLA 418 6X16MM 80CM OTW BE PRMNT -,SUP-G56613,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,AETNA [1000108],AETNA [100010801],,,76.8,,3696.12,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC FRMLA 418 6X20MM 80CM OTW BE PRMNT -,SUP-G56614,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,AETNA [1000108],AETNA [100010801],,,76.8,,3696.12,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC FRMLA 418 7X16MM 80CM -,SUP-G56617,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,AETNA [1000108],AETNA [100010801],,,76.8,,3696.12,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC FRMLA 418 5X12MM 80CM OTW BE PRMNT -,SUP-G56631,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,AETNA [1000108],AETNA [100010801],,,76.8,,3696.12,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC FRMLA 414 5X20MM 80CM RX BE PRMNT 0.014IN/5FR/6FR -,SUP-G56950,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,AETNA [1000108],AETNA [100010801],,,76.8,,3373.12,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC FRMLA 414 5X16MM 135CM RX BE PRMNT -,SUP-G56958,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,AETNA [1000108],AETNA [100010801],,,76.8,,3373.12,26.19915,32197.7856,percent of total billed charges,,,
0.14 ZILVER 5MM X 120MM X 135CM -,SUP-G56966,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,AETNA [1000108],AETNA [100010801],,,76.8,,3373.12,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC FRMLA 414 5X20MM 135CM RX BE PRMNT -,SUP-G56969,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,AETNA [1000108],AETNA [100010801],,,76.8,,3373.12,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC FRMLA 414 6X12MM 135CM RX BE PRMNT -,SUP-G56970,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,AETNA [1000108],AETNA [100010801],,,76.8,,3373.12,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC FRMLA 414 6X16MM 135CM RX BE PRMNT -,SUP-G56971,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,AETNA [1000108],AETNA [100010801],,,76.8,,3373.12,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC FRMLA 414 6X20MM 135CM RX BE PRMNT -,SUP-G56972,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,AETNA [1000108],AETNA [100010801],,,76.8,,3373.12,26.19915,32197.7856,percent of total billed charges,,,
0.14 ZILVER 7MM X 160MM X 135CM -,SUP-G56974,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,AETNA [1000108],AETNA [100010801],,,76.8,,3373.12,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC FRMLA 414 7X20MM 135CM RX BE PRMNT -,SUP-G56975,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,AETNA [1000108],AETNA [100010801],,,76.8,,3373.12,26.19915,32197.7856,percent of total billed charges,,,
US PRE PP-CA-397 P&B BARE METAL STENT ZVT7-35-120-16-60 -,SUP-G57453,CDM,C1876,HCPCS,278,RC,,,outpatient,,,8016.87,5611.809,AETNA [1000108],AETNA [100010801],,,76.8,,6156.96,26.19915,32197.7856,percent of total billed charges,,,
SYS STENT VASCULAR ZILVER VENA 16MM 100MM 120CM VEIN OTW -,SUP-G57454,CDM,C1876,HCPCS,278,RC,,,outpatient,,,8016.87,5611.809,AETNA [1000108],AETNA [100010801],,,76.8,,6156.96,26.19915,32197.7856,percent of total billed charges,,,
VENOUS WALLSTENT 10X94X75CM -,SUP-H74912044109470,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,26.19915,32197.7856,percent of total billed charges,,,
VENOUS WALLSTENT 12X60X75CM -,SUP-H74912044126070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,26.19915,32197.7856,percent of total billed charges,,,
VENOUS WALLSTENT 12X90X75CM -,SUP-H74912044129070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,26.19915,32197.7856,percent of total billed charges,,,
VENOUS WALLSTENT 14X60X75CM -,SUP-H74912044146070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,26.19915,32197.7856,percent of total billed charges,,,
VENOUS WALLSTENT 14X90X75CM -,SUP-H74912044149070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,26.19915,32197.7856,percent of total billed charges,,,
VENOUS WALLSTENT 16X40X75CM -,SUP-H74912044164070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,26.19915,32197.7856,percent of total billed charges,,,
VENOUS WALLSTENT 16X60X75CM -,SUP-H74912044166070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,26.19915,32197.7856,percent of total billed charges,,,
VENOUS WALLSTENT 16X90X75CM -,SUP-H74912044169070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,26.19915,32197.7856,percent of total billed charges,,,
VENOUS WALLSTENT 18X40X75CM -,SUP-H74912044184070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,26.19915,32197.7856,percent of total billed charges,,,
VENOUS WALLSTENT 18X60X75CM -,SUP-H74912044186070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,26.19915,32197.7856,percent of total billed charges,,,
VENOUS WALLSTENT 18X90X75CM -,SUP-H74912044189070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,26.19915,32197.7856,percent of total billed charges,,,
VENOUS WALLSTENT 20X40X75CM -,SUP-H74912044204070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,26.19915,32197.7856,percent of total billed charges,,,
VENOUS WALLSTENT 20X55X75CM -,SUP-H74912044205570,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,26.19915,32197.7856,percent of total billed charges,,,
VENOUS WALLSTENT 20X80X75CM -,SUP-H74912044208070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,26.19915,32197.7856,percent of total billed charges,,,
VICI VENOUS STENT 12MM X60MM X 100CM -,SUP-H74912060100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,26.19915,32197.7856,percent of total billed charges,,,
VICI VENOUS STENT 14MM X 60MM X 100CM -,SUP-H74914060100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,26.19915,32197.7856,percent of total billed charges,,,
VICI VENOUS STENT 14MM X 90MM X 100CM -,SUP-H74914090100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,26.19915,32197.7856,percent of total billed charges,,,
VICI VENOUS STENT 16MM X 60MM X 100CM -,SUP-H74916060100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,26.19915,32197.7856,percent of total billed charges,,,
VICI VENOUS STENT 16MM X90MM X 100CM -,SUP-H74916090100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 6X14MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937911614150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
FG EXP SD RENAL-BILIARY 7.0mmX15mmX150cm -,SUP-H74937911715150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 4X19MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912419150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 5X19MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912519150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 6X18MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912618150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 7X19MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912719150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 10X37MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046104070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 10X57MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046106070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
S BIL EXPRESS PMTD  6X27X75 -,SUP-H74938046630750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 6X27MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046630750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,26.19915,32197.7856,percent of total billed charges,,,
S BILIARY LD PMTD 6X37X75 6FR -,SUP-H74938046640750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 6X37MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046640750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
S BILI LD PMTD 6 X 57 X 75 EXP -,SUP-H74938046660750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 6X57MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046660750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 7X27MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046730750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,26.19915,32197.7856,percent of total billed charges,,,
S BILIARY LD PMTD 7X37X75 40CM -,SUP-H74938046740750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
S  BILI LD PMTD 7 X 57 X 75 EX -,SUP-H74938046760750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
S EXPRESS B-I LD 8 X 27 X 75 P -,SUP-H74938046830750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 8X27MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046830750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,26.19915,32197.7856,percent of total billed charges,,,
BEACON 8MM X 37MM X 75CM  ILIAC STENT -,SUP-H74938046840750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
8 X 57 X 75CM EXPRESS STENT -,SUP-H74938046860750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
S BILI LD PMTD 8 X 57 X 75 EXP -,SUP-H74938046860750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 9X57MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046960750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 10X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047140130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 5X17MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047520130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 5X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047530130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 5X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047540130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 5X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047560130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 6X17MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047620130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 6X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047640130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 6X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047660130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 7X17MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047720130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 7X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047730130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 7X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047740130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
7 X 57MM EXPRESS ILIAC / BILIARY STENT 135CM -,SUP-H74938047760130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 8X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047830130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 8X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047860130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 9X25MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047920130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 9X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047940130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 9X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047960130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
STENT 3X16MM VERIFLEX OTW BE PRMNT LO XING THN STRUT HYDRCT -,SUP-H7493893516300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3294.06,2305.842,AETNA [1000108],AETNA [100010801],,,76.8,,2529.84,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-XPD 6X100X120 -,SUP-H74939200061020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-XPD 6X19X120 -,SUP-H74939200062020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-XPD 6X29X120 -,SUP-H74939200063020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-XPD 6X40X120 -,SUP-H74939200064020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-XPD 6X51X120 -,SUP-H74939200065020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-XPD 6X61X120 -,SUP-H74939200066020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-XPD 6X71X120 -,SUP-H74939200067020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-XPD 6X80X120 -,SUP-H74939200068020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-XPD 7X99X120 -,SUP-H74939200071020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-XPD 7X19X120 -,SUP-H74939200072020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-XPD 7X29X120 -,SUP-H74939200073020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-XPD 7X41X120 -,SUP-H74939200074020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-XPD 7X50X120 -,SUP-H74939200075020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-XPD 7X60X120 -,SUP-H74939200076020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-XPD 7X70X120 -,SUP-H74939200077020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-XPD 8X100X120 -,SUP-H74939200081020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-XPD 8X120X120 -,SUP-H74939200081220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-XPD 8X20X120 -,SUP-H74939200082020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-XPD 8X31X120 -,SUP-H74939200083020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-XPD 8X41X120 -,SUP-H74939200084020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-XPD 8X51X120 -,SUP-H74939200085020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-XPD 8X61X120 -,SUP-H74939200086020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-XPD 8X72X120 -,SUP-H74939200087020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-XPD 8X82X120 -,SUP-H74939200088020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-XPD 9X99X120 -,SUP-H74939200091020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-XPD 9X21X120 -,SUP-H74939200092020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-XPD 9X30X120 -,SUP-H74939200093020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-XPD 9X51X120 -,SUP-H74939200095020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-XPD 9X61X120 -,SUP-H74939200096020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-XPD 9X81X120 -,SUP-H74939200098020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-XPD 10X98X120 -,SUP-H74939200101020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-EXP 10X20X120 -,SUP-H74939200102020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-EXP 10X30X120 -,SUP-H74939200103020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-XPD 10X40X120 -,SUP-H74939200104020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-XPD 10X50X120 -,SUP-H74939200105020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC EPIC 10X60MM 120CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939200106020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-XPD 10X71X120 -,SUP-H74939200107020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA [1000108],AETNA [100010801],,,76.8,,3483.11,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-XPD 10X80X120 -,SUP-H74939200108020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-EXP 12X32X120 -,SUP-H74939200123020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-XPD 12X42X120 -,SUP-H74939200124020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-XPD 12X52X120 -,SUP-H74939200125020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA [1000108],AETNA [100010801],,,76.8,,4237.21,26.19915,32197.7856,percent of total billed charges,,,
S EPIC ILIAC S-XPD 12X61X120 -,SUP-H74939200126020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.2X8MM REBEL MR RX BE -,SUP-H7493927408220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.5X8MM REBEL MR RX BE -,SUP-H7493927408250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.75X8MM REBEL MR RX BE -,SUP-H7493927408270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 3X8MM REBEL MR RX BE -,SUP-H7493927408300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 3.5X8MM REBEL MR RX BE -,SUP-H7493927408350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 4X8MM REBEL MR RX BE -,SUP-H7493927408400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.25X12MM REBEL MR RX BE -,SUP-H7493927412220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.5X12MM REBEL MR RX BE -,SUP-H7493927412250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.75X12MM REBEL MR RX BE -,SUP-H7493927412270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 3X12MM REBEL MR RX BE -,SUP-H7493927412300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 3.5X12MM REBEL MR RX BE -,SUP-H7493927412350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 4X12MM REBEL MR RX BE -,SUP-H7493927412400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 4.5X12MM REBEL MR RX BE -,SUP-H7493927412450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.25X16MM REBEL MR RX BE -,SUP-H7493927416220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.5X16MM REBEL MR RX BE -,SUP-H7493927416250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.75X16MM REBEL MR RX BE -,SUP-H7493927416270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 3X16MM REBEL MR RX BE -,SUP-H7493927416300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 3.5X16MM REBEL MR RX BE -,SUP-H7493927416350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 4X16MM REBEL MR RX BE -,SUP-H7493927416400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 4.5X16MM REBEL MR RX BE -,SUP-H7493927416450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.25X20MM REBEL MR RX BE -,SUP-H7493927420220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.5X20MM REBEL MR RX BE -,SUP-H7493927420250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.75X20MM REBEL MR RX BE -,SUP-H7493927420270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 3X20MM REBEL MR RX BE -,SUP-H7493927420300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 3.5X20MM REBEL MR RX BE -,SUP-H7493927420350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 4X20MM REBEL MR RX BE -,SUP-H7493927420400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 4.5X20MM REBEL MR RX BE -,SUP-H7493927420450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.25X24MM REBEL MR RX BE -,SUP-H7493927424220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.5X24MM REBEL MR RX BE -,SUP-H7493927424250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.75X24MM REBEL MR RX BE -,SUP-H7493927424270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 3X24MM REBEL MR RX BE -,SUP-H7493927424300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 3.5X24MM REBEL MR RX BE -,SUP-H7493927424350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 4X24MM REBEL MR RX BE -,SUP-H7493927424400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 4.5X24MM REBEL MR RX BE -,SUP-H7493927424450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.25X28MM REBEL MR RX BE -,SUP-H7493927428220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.5X28MM REBEL MR RX BE -,SUP-H7493927428250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.75X28MM REBEL MR RX BE -,SUP-H7493927428270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 3X28MM REBEL MR RX BE -,SUP-H7493927428300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 3.5X28MM REBEL MR RX BE -,SUP-H7493927428350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 4X28MM REBEL MR RX BE -,SUP-H7493927428400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 4.5X28MM REBEL MR RX BE -,SUP-H7493927428450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.75X32MM REBEL MR RX BE -,SUP-H7493927432270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 3X32MM REBEL MR RX BE -,SUP-H7493927432300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 3.5X32MM REBEL MR RX BE -,SUP-H7493927432350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 4X32MM REBEL MR RX BE -,SUP-H7493927432400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 4.5X32MM REBEL MR RX BE -,SUP-H7493927432450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.25X8MM REBEL OTW BE -,SUP-H7493927508220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.5X8MM REBEL OTW BE -,SUP-H7493927508250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.75X8MM REBEL OTW BE -,SUP-H7493927508270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 3X8MM REBEL OTW BE -,SUP-H7493927508300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 3.5X8MM REBEL OTW BE -,SUP-H7493927508350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 4X8MM REBEL OTW BE -,SUP-H7493927508400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.25X12MM REBEL OTW BE -,SUP-H7493927512220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.5X12MM REBEL OTW BE -,SUP-H7493927512250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.75X12MM REBEL OTW BE -,SUP-H7493927512270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 3X12MM REBEL OTW BE -,SUP-H7493927512300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 3.5X12MM REBEL OTW BE -,SUP-H7493927512350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 4X12MM REBEL OTW BE -,SUP-H7493927512400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 4.5X12MM REBEL OTW BE -,SUP-H7493927512450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.25X16MM REBEL OTW BE -,SUP-H7493927516220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.5X16MM REBEL OTW BE -,SUP-H7493927516250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.75X16MM REBEL OTW BE -,SUP-H7493927516270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 3X16MM REBEL OTW BE -,SUP-H7493927516300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 3.5X16MM REBEL OTW BE -,SUP-H7493927516350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 4X16MM REBEL OTW BE -,SUP-H7493927516400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 4.5X16MM REBEL OTW BE -,SUP-H7493927516450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.25X20MM REBEL OTW BE -,SUP-H7493927520220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.5X20MM REBEL OTW BE -,SUP-H7493927520250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.75X20MM REBEL OTW BE -,SUP-H7493927520270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 3X20MM REBEL OTW BE -,SUP-H7493927520300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 3.5X20MM REBEL OTW BE -,SUP-H7493927520350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 4X20MM REBEL OTW BE -,SUP-H7493927520400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 4.5X20MM REBEL OTW BE -,SUP-H7493927520450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.25X24MM REBEL OTW BE -,SUP-H7493927524220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.5X24MM REBEL OTW BE -,SUP-H7493927524250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.75X24MM REBEL OTW BE -,SUP-H7493927524270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 3X24MM REBEL OTW BE -,SUP-H7493927524300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 3.5X24MM REBEL OTW BE -,SUP-H7493927524350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 4X24MM REBEL OTW BE -,SUP-H7493927524400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 4.5X24MM REBEL OTW BE -,SUP-H7493927524450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.25X28MM REBEL OTW BE -,SUP-H7493927528220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.5X28MM REBEL OTW BE -,SUP-H7493927528250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.75X28MM REBEL OTW BE -,SUP-H7493927528270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 3X28MM REBEL OTW BE -,SUP-H7493927528300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 3.5X28MM REBEL OTW BE -,SUP-H7493927528350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 4X28MM REBEL OTW BE -,SUP-H7493927528400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 4.5X28MM REBEL OTW BE -,SUP-H7493927528450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 2.75X32MM REBEL OTW BE -,SUP-H7493927532270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 3X32MM REBEL OTW BE -,SUP-H7493927532300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 3.5X32MM REBEL OTW BE -,SUP-H7493927532350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 4X32MM REBEL OTW BE -,SUP-H7493927532400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT 4.5X32MM REBEL OTW BE -,SUP-H7493927532450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC INNOVA 5X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293050230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC INNOVA 5X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC INNOVA 5X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC INNOVA 5X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC INNOVA 5X180MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC INNOVA 5X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293052030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9018.5,6312.95,AETNA [1000108],AETNA [100010801],,,76.8,,6926.21,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC INNOVA 5X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293054030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC INNOVA 5X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293056030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC INNOVA 5X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293058030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC INNOVA 6X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293060230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC INNOVA 6X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC INNOVA 6X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC INNOVA 6X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,AETNA [1000108],AETNA [100010801],,,76.8,,2181.53,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC INNOVA 6X180MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC INNOVA 6X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293062030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,AETNA [1000108],AETNA [100010801],,,76.8,,8540.5,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC INNOVA 6X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293064030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC INNOVA 6X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293066030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC INNOVA 6X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293068030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC INNOVA 7X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293070230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC INNOVA 7X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293071030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC INNOVA 7X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293071230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC INNOVA 7X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293071530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,AETNA [1000108],AETNA [100010801],,,76.8,,2181.53,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC INNOVA 7X180X130 SE ILC -,SUP-H74939293071830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC INNOVA 7X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293072030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,AETNA [1000108],AETNA [100010801],,,76.8,,8540.5,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC INNOVA 7X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293074030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC INNOVA 7X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293076030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC INNOVA 7X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293078030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC INNOVA 8X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293080230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC INNOVA 8X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293081030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC INNOVA 8X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293081230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC INNOVA 8X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293081530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,AETNA [1000108],AETNA [100010801],,,76.8,,2181.53,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC INNOVA 8X180X130 SE ILC -,SUP-H74939293081830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC INNOVA 8X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293082030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,AETNA [1000108],AETNA [100010801],,,76.8,,8540.5,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC INNOVA 8X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293084030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC INNOVA 8X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293086030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC INNOVA 8X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293088030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,76.8,,2108.2,26.19915,32197.7856,percent of total billed charges,,,
STENT ENPROS 22MM 10FR CATH 45MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965404510,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,26.19915,32197.7856,percent of total billed charges,,,
STENT ENPROS 22MM 10FR CATH 70MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965404520,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,26.19915,32197.7856,percent of total billed charges,,,
STENT ENPROS 24MM 11FR CATH 35MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965405100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,26.19915,32197.7856,percent of total billed charges,,,
STENT ENPROS 24MM 11FR CATH 45MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965405110,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA [1000108],AETNA [100010801],,,76.8,,3024.81,26.19915,32197.7856,percent of total billed charges,,,
WALLSTENT 24X70 X 75CM/11F UNI PLUS 1 -,SUP-H965405120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 2.25X8MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22508UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 2.25X8MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 2.25X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22512UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 2.25X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 2.25X14MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22514UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 2.25X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22518UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 2.25X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 2.25X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22522UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 2.25X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 2.25X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22526UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 2.25X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 2.5X8MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25008UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 2.5X8MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25008W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 2.5X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 2.5X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 2.5X14MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25014UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS #1 27IN INTGRTY MO-4 DTCH 140CM MONO GUT TAPR PNT -,SUP-INT25014W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 2.5X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 2.5X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 2.5X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 2.5X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 2.5X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 2.5X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 2.75X8MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27508UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 2.75X8MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 2.75X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27512UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 2.75X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 2.75X14MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27514UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 2.75X14MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27514W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 2.75X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27518UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 2.75X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 2.75X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27522UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 2.75X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 2.75X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27526UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 2.75X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 3X9MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30009UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 3X9MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 3X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 3X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 3X15MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30015UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 3X15MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 3X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 3X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 3X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 3X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 3X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 3X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 3X30MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30030UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 3X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 3.5X9MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35009UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 3.5X9MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 3.5X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 3.5X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 3.5X15MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35015UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 3.5X15MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 3.5X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 3.5X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 3.5X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 3.5X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 3.5X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 3.5X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 3.5X30MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35030UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 3.5X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 4X9MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40009UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 4X9MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 4X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 4X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 4X15MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40015UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 4X15MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 4X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 4X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 4X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 4X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 4X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 4X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 4X30MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40030UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 4X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,26.19915,32197.7856,percent of total billed charges,,,
STENT LIFESTREAM 7MM X 26MM X 80MM -,SUP-LSMU0800726,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,26.19915,32197.7856,percent of total billed charges,,,
STENT ENPROS 8MM 6FR CATH 80MM WALLSTNT RP 100CM TOT 75CM -,SUP-M001711300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7320.9,5124.63,AETNA [1000108],AETNA [100010801],,,76.8,,5622.45,26.19915,32197.7856,percent of total billed charges,,,
STENT ESPH 18MM BD 23MMX7CM ULFLX NON- CVR FLR END MTL LF -,SUP-M00514070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,76.8,,3391.45,26.19915,32197.7856,percent of total billed charges,,,
STENT DUOD 22MMX6CM WALLFLX 230CM DLV SYS TTS/ OTW NTNL FLR -,SUP-M00565010,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA [1000108],AETNA [100010801],,,76.8,,7447.31,26.19915,32197.7856,percent of total billed charges,,,
STENT WALLFLEX DUODENAL 22 X 60 -,SUP-M00565010,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA [1000108],AETNA [100010801],,,76.8,,7447.31,26.19915,32197.7856,percent of total billed charges,,,
STENT DUOD 22MMX9CM WALLFLX 230CM NON- CVR NTNL LF -,SUP-M00565020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA [1000108],AETNA [100010801],,,76.8,,7447.31,26.19915,32197.7856,percent of total billed charges,,,
STENT WALLFLEX DUODENAL 22 X 90 -,SUP-M00565020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA [1000108],AETNA [100010801],,,76.8,,7447.31,26.19915,32197.7856,percent of total billed charges,,,
STENT WALLFLEX DUODENAL 22 X 120 -,SUP-M00565030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA [1000108],AETNA [100010801],,,76.8,,7447.31,26.19915,32197.7856,percent of total billed charges,,,
STENT WALLFLEX COLONIC 25 X 60 -,SUP-M00565040,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA [1000108],AETNA [100010801],,,76.8,,7447.31,26.19915,32197.7856,percent of total billed charges,,,
STENT WALLFLEX COLONIC 25 X 90 -,SUP-M00565050,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA [1000108],AETNA [100010801],,,76.8,,7447.31,26.19915,32197.7856,percent of total billed charges,,,
STENT WALLFLEX COLONIC 25 X 120 -,SUP-M00565060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA [1000108],AETNA [100010801],,,76.8,,7447.31,26.19915,32197.7856,percent of total billed charges,,,
STENT WALLFLEX COLONIC 22 X 60 -,SUP-M00565100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA [1000108],AETNA [100010801],,,76.8,,7447.31,26.19915,32197.7856,percent of total billed charges,,,
STENT WALLFLEX COLONIC 22 X 90 -,SUP-M00565110,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA [1000108],AETNA [100010801],,,76.8,,7447.31,26.19915,32197.7856,percent of total billed charges,,,
STENT WALLFLEX COLONIC 22 X 120 -,SUP-M00565120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA [1000108],AETNA [100010801],,,76.8,,7447.31,26.19915,32197.7856,percent of total billed charges,,,
STENT ENPROS 10FR 20X60MM WALLSTNT 135CM HRP -,SUP-M00565620,CDM,C1876,HCPCS,278,RC,,,outpatient,,,116.7,81.69,AETNA [1000108],AETNA [100010801],,,76.8,,89.63,26.19915,32197.7856,percent of total billed charges,,,
STENT COLN 22MM BD 10FR CATH 6CM WALLSTNT 135CM CATH 160CM -,SUP-M00565640,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7434.26,5203.982,AETNA [1000108],AETNA [100010801],,,76.8,,5709.51,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 10X80MM WALLSTNT RX SE UNCVR MTL 0.035IN GW COMP -,SUP-M00569660,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6340.15,4438.105,AETNA [1000108],AETNA [100010801],,,76.8,,4869.24,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 8X80MM WALLFLX RX SE UNCVR PLATINOL 0.035IN GW -,SUP-M00570620,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,AETNA [1000108],AETNA [100010801],,,76.8,,5712.54,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 8X100MM WALLFLX RX SE NON- CVR PLATINOL 0.035IN GW -,SUP-M00570630,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,AETNA [1000108],AETNA [100010801],,,76.8,,5712.54,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 10X60MM WALLFLX RX SE NON- CVR PLATINOL 0.035IN GW -,SUP-M00570640,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,AETNA [1000108],AETNA [100010801],,,76.8,,5712.54,26.19915,32197.7856,percent of total billed charges,,,
CATH GUID 6FRX68CM ACUITY BREAK-AWAY COR CS-IC 130 -,SUP-M00570650,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,AETNA [1000108],AETNA [100010801],,,76.8,,5712.54,26.19915,32197.7856,percent of total billed charges,,,
WALLFLEX BILIARY RX UNCOVERED 10 X 80 -,SUP-M00570650,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,AETNA [1000108],AETNA [100010801],,,76.8,,5712.54,26.19915,32197.7856,percent of total billed charges,,,
WALLFLEX RX UNCOVERED BILIARY STENT 10MM X 100MM -,SUP-M00570660,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,AETNA [1000108],AETNA [100010801],,,76.8,,5712.54,26.19915,32197.7856,percent of total billed charges,,,
WALLFLEX BILIARY RX UNCOVERED 10 X 40 -,SUP-M00570890,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,AETNA [1000108],AETNA [100010801],,,76.8,,5712.54,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 14X60MM 120CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-N1460BB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,26.19915,32197.7856,percent of total billed charges,,,
STENT PULSAR - 18 T3 5/40/135 -,SUP-NO MANUFACTURE IN DICTIONARY,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,76.8,,2383.18,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 10X30MM PALMZ XL BE UNMT TRNSHEP CLSD CELLFLEX SEG -,SUP-P3110,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA [1000108],AETNA [100010801],,,76.8,,3552.74,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 5X15MM 135CM PALMZ BLU RX BE TRNSHEP COCR 0.014IN -,SUP-PB1550BAX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4882.72,3417.904,AETNA [1000108],AETNA [100010801],,,76.8,,3749.93,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 5X15MM 135CM PALMZ BLU OTW BE TRNSHEP COCR 0.018IN -,SUP-PB1550BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,AETNA [1000108],AETNA [100010801],,,76.8,,3237.46,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 6X18MM 80CM PALMZ BLU OTW BE TRNSHEP COCR 0.014IN -,SUP-PB1860BSS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,AETNA [1000108],AETNA [100010801],,,76.8,,3237.46,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 6X18MM 135CM PALMZ BLU OTW BE TRNSHEP COCR 0.018IN -,SUP-PB1860BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,AETNA [1000108],AETNA [100010801],,,76.8,,3237.46,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 6X24MM 135CM PALMZ BLU OTW BE TRNSHEP COCR 0.018IN -,SUP-PB2460BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,AETNA [1000108],AETNA [100010801],,,76.8,,3237.46,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 6X18MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG1860BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA [1000108],AETNA [100010801],,,76.8,,2936.81,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 6X18MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG1860BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA [1000108],AETNA [100010801],,,76.8,,2936.81,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 9X19MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG1990BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA [1000108],AETNA [100010801],,,76.8,,2936.81,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 6X24MM 135CM PALMZ GENESIS RX BE TRNSHEP SS -,SUP-PG2460BAX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4948.93,3464.251,AETNA [1000108],AETNA [100010801],,,76.8,,3800.78,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 6X24MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2460BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA [1000108],AETNA [100010801],,,76.8,,2936.81,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 8X24MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG2480BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA [1000108],AETNA [100010801],,,76.8,,2936.81,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 10X29MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2910BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA [1000108],AETNA [100010801],,,76.8,,2936.81,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 5X29MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG2950BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA [1000108],AETNA [100010801],,,76.8,,2936.81,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 5X30MM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW COMP -,SUP-PG2950BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA [1000108],AETNA [100010801],,,76.8,,2936.81,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 6X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2960BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA [1000108],AETNA [100010801],,,76.8,,2936.81,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 7X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2970BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA [1000108],AETNA [100010801],,,76.8,,2936.81,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 7X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN. -,SUP-PG2970BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 8X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN. -,SUP-PG2980BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA [1000108],AETNA [100010801],,,76.8,,2936.81,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 8X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN- -,SUP-PG2980BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA [1000108],AETNA [100010801],,,76.8,,3208.13,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 10X39MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3910BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA [1000108],AETNA [100010801],,,76.8,,2936.81,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 6X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3960BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA [1000108],AETNA [100010801],,,76.8,,2936.81,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 7X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3970BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA [1000108],AETNA [100010801],,,76.8,,2936.81,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 8X29MM 135CM PALMZ_GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3980BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA [1000108],AETNA [100010801],,,76.8,,2936.81,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 8X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3980BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA [1000108],AETNA [100010801],,,76.8,,2936.81,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 7X59MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG5970BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA [1000108],AETNA [100010801],,,76.8,,2936.81,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 7X59MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG5970BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA [1000108],AETNA [100010801],,,76.8,,2936.81,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 8X59MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG5980BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA [1000108],AETNA [100010801],,,76.8,,2936.81,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 6X79MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG7960BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA [1000108],AETNA [100010801],,,76.8,,2936.81,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 6X20MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506020120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 6X40MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 6X60MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 6X80MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506080120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 6X100MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506100120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 6X120MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506120120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 6X150MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506150120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 6X200MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506200120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,12141.51,8499.057,AETNA [1000108],AETNA [100010801],,,76.8,,9324.68,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 7X20MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507020120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 7X40MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 7X60MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 7X80MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507080120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 7X120MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507120120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 7X150MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507150120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 8X40MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3508040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 8X60MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3508060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 8X80MM 120CM EVERFLX SE SUPRFC FEM/PROX POPLT ART -,SUP-PRB3508080120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC EVERFLX 10X120MM 120CM SE 3-WV PEAK DSGN PRECISN -,SUP-PRB3508100120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 12X120MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT -,SUP-PRB3508120120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 8X150MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3508150120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 7X37MM 135CM VISI-PRO BE MNT SS 0.035IN/6FR -,SUP-PXB350737135,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 8X27MM 135CM VISI-PRO BE MNT SS 0.035IN/6FR -,SUP-PXB350827135,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 8X37MM 135CM VISI-PRO BE MNT SS 0.035IN/6FR -,SUP-PXB350837135,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,26.19915,32197.7856,percent of total billed charges,,,
STENT DES 2.25X8MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT DES 2.25X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT DES 2.25X14MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22514W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT DES 2.25X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT DES 2.25X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT DES 2.25X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT BMS 2.25X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22530W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT DES 2.5X8MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25008W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT DES 2.5X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT DES 2.5X14MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25014W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT DES 2.5X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT DES 2.5X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT DES 2.5X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT DES 2.5X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT DES 2.75X8MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT DES 2.75X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT DES 2.75X14MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27514W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT DES 2.75X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT DES 2.75X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT DES 2.75X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT DES 2.75X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27530W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT DES 3X9MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT30009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT DES 3X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT DES 3X15MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT DES 3X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT DES 3X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT DES 3.5X9MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT DES 3.5X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT DES 3.5X15MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT DES 3.5X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT DES 3.5X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT DES 3.5X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT DES 3.5X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT DES 4X9MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT40009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT DES 4X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT DES 4X15MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT DES 4X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT DES 4X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT DES 4X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT DES 4X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 4MM 6FR CATH 60MM 120CM SUPERA TRNSHEP -,SUP-S-04-060-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 5MM 6FR CATH 40MM 120CM SUPERA TRNSHEP -,SUP-S-05-040-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 5MM 6FR CATH 80MM 120CM SUPERA TRNSHEP -,SUP-S-05-080-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6599.42,4619.594,AETNA [1000108],AETNA [100010801],,,76.8,,5068.35,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 5MM 6FR CATH 100MM 120CM SUPERA TRNSHEP -,SUP-S-05-100-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6599.42,4619.594,AETNA [1000108],AETNA [100010801],,,76.8,,5068.35,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 6MM 6FR CATH 40MM 120CM SUPERA TRNSHEP -,SUP-S-06-040-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7617.98,5332.586,AETNA [1000108],AETNA [100010801],,,76.8,,5850.61,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 7MM 6FR CATH 60MM 120CM SUPERA TRNSHEP -,SUP-S-07-060-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA [1000108],AETNA [100010801],,,76.8,,5052.06,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 8X100MM 120CM SUPERA TRNSHEP -,SUP-S-08-100-120-G3,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6599.42,4619.594,AETNA [1000108],AETNA [100010801],,,76.8,,5068.35,26.19915,32197.7856,percent of total billed charges,,,
STENT PERIPHERAL 4.5MM X 20MM X 120CM  6F -,SUP-S-45-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,,,
STENT PERIPHERAL 4.5MM X 30MM X 120CM  6F -,SUP-S-45-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC SUPERA 4.5X40MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-45-040-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC SUPERA 4.5X60MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-45-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,,,
STENT PERIPHERAL 4.5MM X 80MM X 120CM  6F -,SUP-S-45-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,,,
STENT PERIPHERAL 4.5MM X 100MM X 120CM  6F -,SUP-S-45-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC SUPERA 4.5X120MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-45-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,,,
STENT PERIPHERAL 5MM X 20MM X 120CM  6F -,SUP-S-50-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,,,
STENT PERIPHERAL 5MM X 30MM X 120CM  6F -,SUP-S-50-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC SUPERA 5 X 60MM 120 -,SUP-S-50-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,,,
STENT  VASC SUPERA 5 X 80MM x 120 -,SUP-S-50-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,,,
5MM X 100MM X 120CM SUPERA STENT -,SUP-S-50-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,,,
5MM x 120MM x 120CM SUPERA STENT -,SUP-S-50-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC SUPERA 5.5X40MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-040-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC SUPERA 5.5X60MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC SUPERA 5.5X80MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,,,
SUPERA PERIPHERAL STENT SYSTEM 5.5MM X 100MM X 120CM -,SUP-S-55-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5495.98,3847.186,AETNA [1000108],AETNA [100010801],,,76.8,,4220.91,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC SUPERA 5.5X120MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC SUPERA 5.5X150MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-150-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,,,
STENT PERIPHERAL 6MM X 30MM X 120CM  6F -,SUP-S-60-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,,,
STENT SUPERA 6.0MM X 80 X 120CM -,SUP-S-60-080-120-P,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5920.38,4144.266,AETNA [1000108],AETNA [100010801],,,76.8,,4546.85,26.19915,32197.7856,percent of total billed charges,,,
STENT SUPERA 6MM X 80 X 120CM -,SUP-S-60-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,,,
S SUPERA 6.0MM X 100 X 120CM -,SUP-S-60-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,,,
S SUPERA 6.0MM X 120 X 120CM -,SUP-S-60-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,,,
S SUPERA 6.0MM X 150 X 120CM -,SUP-S-60-150-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,,,
STENT PERIPHERAL  6.5MM X 20MM X 120CM 6F -,SUP-S-65-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,,,
STENT PERIPHERAL 6.5MM X 30MM X 120CM  6F -,SUP-S-65-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC SUPERA 6.5X40MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-040-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC SUPERA 6.5X60MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC SUPERA 6.5X80MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC SUPERA 6.5X100MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC SUPERA 6.5X120MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC SUPERA 6.5X150MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-150-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,,,
STENT PERIPHERAL 7.0MM X 020MM X 120CM  6F -,SUP-S-70-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,,,
STENT PERIPHERAL 7.0MM X 030MM X 120CM  6F -,SUP-S-70-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,76.8,,3585.33,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 10X40MM 120CM PROTEGE GPS OTW SE PRMNT OPN LATTICE -,SUP-SERB651040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 10X60MM 120CM PROTEGE GPS OTW SE PRMNT OPN LATTICE -,SUP-SERB651060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 12X20MM 120CM PROTEGE GPS OTW SE PRMNT OPN LATTICE -,SUP-SERB651220120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,26.19915,32197.7856,percent of total billed charges,,,
7MM X 30MM TCAR STENT ENROUTE -,SUP-SR-0730-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,AETNA [1000108],AETNA [100010801],,,76.8,,7841.86,26.19915,32197.7856,percent of total billed charges,,,
7MM X 40MM STENT TCAR ENROUTE -,SUP-SR-0740-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,AETNA [1000108],AETNA [100010801],,,76.8,,7841.86,26.19915,32197.7856,percent of total billed charges,,,
8MM X 30MM STENT TCAR ENROUTE -,SUP-SR-0830-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,AETNA [1000108],AETNA [100010801],,,76.8,,7841.86,26.19915,32197.7856,percent of total billed charges,,,
8MM X 40MM STENT TCAR ENROUTE -,SUP-SR-0840-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,AETNA [1000108],AETNA [100010801],,,76.8,,7841.86,26.19915,32197.7856,percent of total billed charges,,,
9MM X 30MM STENT TCAR ENROUTE -,SUP-SR-0930-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,AETNA [1000108],AETNA [100010801],,,76.8,,7841.86,26.19915,32197.7856,percent of total billed charges,,,
9MM X 40MM STENT TCAR ENROUTE -,SUP-SR-0940-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,AETNA [1000108],AETNA [100010801],,,76.8,,7841.86,26.19915,32197.7856,percent of total billed charges,,,
ENROUTE TANSCAROTID STENT SYSTEM SR-1030-CS -,SUP-SR-1030-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,AETNA [1000108],AETNA [100010801],,,76.8,,7841.86,26.19915,32197.7856,percent of total billed charges,,,
ENROUTE TANSCAROTID STENT -,SUP-SR-1040-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,AETNA [1000108],AETNA [100010801],,,76.8,,7841.86,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC MISAGO 6MM X120MM X 200CM RX R -,SUP-SXR06120R,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC MISAGO 6X150MM 135CM SELF EXPANDING -,SUP-SXR06150R,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
GRAFT EV 14X40 ILC -,SUP-UNDEFINED,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 5X18 GENESIS AVIATOR -,SUP-UNDEFINED,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,26.19915,32197.7856,percent of total billed charges,,,
S BILI EXPRESS 5X15X150 -,SUP-UNDEFINED,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA [1000108],AETNA [100010801],,,76.8,,2089.87,26.19915,32197.7856,percent of total billed charges,,,
VENOUS 8F 10mm x 80 mm 120cm CATHETER LENGTH -,SUP-VENUM10080,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,26.19915,32197.7856,percent of total billed charges,,,
VENOVO VENOUS STENT 12MM X 60MM -,SUP-VENUM12060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,26.19915,32197.7856,percent of total billed charges,,,
16MM x 60MM x 80CM VENOVO STENT -,SUP-VENUM16060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,26.19915,32197.7856,percent of total billed charges,,,
VENOUS STENT 14MM x 100MM 120CM CATHETER LENGTH -,SUP-VENUM16080,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,26.19915,32197.7856,percent of total billed charges,,,
VENOVO VENOUS STENT 18MM X 100MM X 80CM -,SUP-VENUM18100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,26.19915,32197.7856,percent of total billed charges,,,
VENOUS STENT SYSTEM 18X 120MM 80CM CATH LENGTH -,SUP-VENUM18120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,26.19915,32197.7856,percent of total billed charges,,,
VENOVO 10FR 20MM X 60MM- 80CM CATHETER LENGTH -,SUP-VENUM20060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA [1000108],AETNA [100010801],,,76.8,,4563.15,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 4MMX6CM 125CM ZILVER 518 OTW SE PRELD SLT TUBE -,SUP-ZIB5-125-4.0-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 4MMX8CM 125CM ZILVER 518 OTW SE PRELD SLT TUBE -,SUP-ZIB5-125-4.0-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,,,
S ZILVER 518 5X60 125CM S-E -,SUP-ZIB5-125-5.0-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 12MM 8FR GUID CATH 60MM 125CM ZILVER 635 OTW SE -,SUP-ZIB6-125-12.060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,,,
S ZILVER .035 120CM 5 X 40 -,SUP-ZIB6-125-5.0-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,,,
S ZILVER .035 125CM 5 X 80 -,SUP-ZIB6-125-5.0-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 6X100MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-ZIB6-35-1256100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,,,
STENT BIL 6X140MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-ZIB6-35-1256140,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,,,
STENT ZILVER 6MM X 60MM X 125MM -,SUP-ZIV5-18-125-6-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,76.8,,3299.79,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC ZILVER 518 8X40MM 125CM OTW SE 0.018IN/5FR -,SUP-ZIV5-18-125-840,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC ZILVER 518 8X80MM 125CM OTW SE 0.018IN/5FR -,SUP-ZIV5-18-125-880,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA [1000108],AETNA [100010801],,,76.8,,4048.14,26.19915,32197.7856,percent of total billed charges,,,
S ZILVER 6 X 30 -,SUP-ZIV6-35-125-630,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,,,
STENT ZILVER 6 X 40 -,SUP-ZIV6-35-125-640,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA [1000108],AETNA [100010801],,,76.8,,3327.25,26.19915,32197.7856,percent of total billed charges,,,
STENT VASC DES ZILVER PTX 6X40MM 125CM OTW SE PRELD -,SUP-ZIV635125640PTX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5487.45,3841.215,AETNA [1000108],AETNA [100010801],,,76.8,,4214.36,26.19915,32197.7856,percent of total billed charges,,,
STENT 3.5X18MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010144-18,CDM,C1877,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,198.065125,7007.6928,percent of total billed charges,,,
CATH GUID 7FR AL 0.75 SH 100CM -,SUP-G782AL75,CDM,C1877,HCPCS,278,RC,,,outpatient,,,882.25,617.575,AETNA [1000108],AETNA [100010801],,,76.8,,677.57,198.065125,7007.6928,percent of total billed charges,,,
STENT ESPH 18MM 23/23MM OD P/D FLR 153MM WALLFLX SE BRD FLLY -,SUP-M00516920,CDM,C1877,HCPCS,278,RC,,,outpatient,,,9124.6,6387.22,AETNA [1000108],AETNA [100010801],,,76.8,,7007.69,198.065125,7007.6928,percent of total billed charges,,,
PALMAZ UNMOUNTED STENT DIA 1 -,SUP-P4010,CDM,C1877,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA [1000108],AETNA [100010801],,,76.8,,3552.74,198.065125,7007.6928,percent of total billed charges,,,
STENT BIL 10X59MM PALMZ GENESIS BE UNMT TRNSHEP SS 0.035IN -,SUP-PG5910B,CDM,C1877,HCPCS,278,RC,,,outpatient,,,3986.29,2790.403,AETNA [1000108],AETNA [100010801],,,76.8,,3061.47,198.065125,7007.6928,percent of total billed charges,,,
IMPLANT VOCAL CRD PST PROLARYN PLUS 1ML SYR -,SUP-8044M0K5,CDM,C1878,HCPCS,278,RC,,,outpatient,,,3246.32,2272.424,AETNA [1000108],AETNA [100010801],,,76.8,,2493.17,399.86,2621.49888,percent of total billed charges,,,
IMPLANT VOCAL CORD PROLARYN GEL 1CC NEEDLE -,SUP-8602M0K5,CDM,C1878,HCPCS,278,RC,,,outpatient,,,3413.41,2389.387,AETNA [1000108],AETNA [100010801],,,76.8,,2621.5,399.86,2621.49888,percent of total billed charges,,,
IMPLANT THYRPL MONT SZ9 SIL EAR FEM STRL -,SUP-MTF.09,CDM,C1878,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,AETNA [1000108],AETNA [100010801],,,76.8,,1404.42,399.86,2621.49888,percent of total billed charges,,,
KIT THYROPLASTY MALE -,SUP-MT-SPM,CDM,C1878,HCPCS,278,RC,,,outpatient,,,3308.38,2315.866,AETNA [1000108],AETNA [100010801],,,76.8,,2540.84,399.86,2621.49888,percent of total billed charges,,,
FILTER VASC BIRDS NEST 40MMX40CM SS VC MRKR -,SUP-178242,CDM,C1880,HCPCS,278,RC,,,outpatient,,,9467.05,6626.935,AETNA [1000108],AETNA [100010801],,,,,,174.22547,6153.5825,other,Implant Exclusions,,
FILTER EMBL PROT OPTEASE 6FR ID 8FR INTRO SHTH 55CM SLF CNTR -,SUP-466-F220A,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3189.03,2232.321,AETNA [1000108],AETNA [100010801],,,,,,174.22547,6153.5825,other,Implant Exclusions,,
FILTER OPTEASE FEMORAL 55CM -,SUP-466-F230AF,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3189.03,2232.321,AETNA [1000108],AETNA [100010801],,,,,,174.22547,6153.5825,other,Implant Exclusions,,
FILTER VASC BIRD S NEST 40MM 11FR CATH 12FR INTRO 75CM SS VC -,SUP-BNF-75-PB,CDM,C1880,HCPCS,278,RC,,,outpatient,,,9467.05,6626.935,AETNA [1000108],AETNA [100010801],,,,,,174.22547,6153.5825,other,Implant Exclusions,,
FILTER EMBL NAVALIGN CELECT 30X48MM FEM VC -,SUP-G03767,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,,,,174.22547,6153.5825,other,Implant Exclusions,,
FILTER CELECT VENA CAVA UNI -,SUP-G34505,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4773.95,3341.765,AETNA [1000108],AETNA [100010801],,,,,,174.22547,6153.5825,other,Implant Exclusions,,
VENA CAVA FILTER FEMORAL & JUG -,SUP-G34505,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4773.95,3341.765,AETNA [1000108],AETNA [100010801],,,,,,174.22547,6153.5825,other,Implant Exclusions,,
FILTER EMBL CELECT 30MM 7FR INTRO SHTH 48MM UNISET VC -,SUP-G52915,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA [1000108],AETNA [100010801],,,,,,174.22547,6153.5825,other,Implant Exclusions,,
FILTER EMBL GUNTHER TULIP 30X50MM FEM VC -,SUP-G52917,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3819.15,2673.405,AETNA [1000108],AETNA [100010801],,,,,,174.22547,6153.5825,other,Implant Exclusions,,
FILTER VASC NAVALIGN CELECT 30MM 7FR CATH UNIV 49MM UNISET -,SUP-IGTCFS651UNICEL,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4773.95,3341.765,AETNA [1000108],AETNA [100010801],,,,,,174.22547,6153.5825,other,Implant Exclusions,,
FILTER VASC GUNTHER TULIP 30MM 8.5FR INTRO SHTH 50MM PRELD -,SUP-IGTCFS-65-FEM,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,,,,174.22547,6153.5825,other,Implant Exclusions,,
FILTER VASC GUNTHER TULIP 30MM 8.5FR INTRO SHTH 50MM- -,SUP-IGTCFS-65-UNI,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,,,,174.22547,6153.5825,other,Implant Exclusions,,
FILTER VENA CAVA TULIP UNI GUNTHER -,SUP-IGTCFS-65-UNI,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3819.15,2673.405,AETNA [1000108],AETNA [100010801],,,,,,174.22547,6153.5825,other,Implant Exclusions,,
FILTER GREENFIELD JUG -,SUP-M001503000,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4249.67,2974.769,AETNA [1000108],AETNA [100010801],,,,,,174.22547,6153.5825,other,Implant Exclusions,,
FILTER GREENFIELD FEM -,SUP-M001503010,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4249.67,2974.769,AETNA [1000108],AETNA [100010801],,,,,,174.22547,6153.5825,other,Implant Exclusions,,
DILATOR VASC 18GA GW 0.038IN DILATOR 8/10/12 FR DIA SYR -,SUP-M001503500,CDM,C1880,HCPCS,278,RC,,,outpatient,,,776.06,543.242,AETNA [1000108],AETNA [100010801],,,,,,174.22547,6153.5825,other,Implant Exclusions,,
FILTER VASC MERIDIAN NTNL VC -,SUP-MD800F,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,,,,174.22547,6153.5825,other,Implant Exclusions,,
FILTER VASC MERIDIAN NTNL SBCLVN VC -,SUP-MD800J,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,,,,174.22547,6153.5825,other,Implant Exclusions,,
FILTER OPTEASE JUGULAR 55CM -,SUP-UNDEFINED,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3189.03,2232.321,AETNA [1000108],AETNA [100010801],,,,,,174.22547,6153.5825,other,Implant Exclusions,,
FILTER OPTEASE JUGULAR 90CM -,SUP-UNDEFINED,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,AETNA [1000108],AETNA [100010801],,,,,,174.22547,6153.5825,other,Implant Exclusions,,
DEFIBRILLATOR PRMT RF DF-1 2CHMBR 50X81MM 14MM 43ML 82GM -,SUP-3207-36,CDM,C1882,HCPCS,275,RC,,,outpatient,,,59022.98,41316.086,AETNA [1000108],AETNA [100010801],,,76.8,,45329.65,399.86,45329.64864,percent of total billed charges,,,
DEFIBRILLATOR LUMAX 540 HF-T DF-1 IS-1 CONN 3 CHMBR RR. -,SUP-360347,CDM,C1882,HCPCS,275,RC,,,outpatient,,,38238.5,26766.95,AETNA [1000108],AETNA [100010801],,,76.8,,29367.17,399.86,45329.64864,percent of total billed charges,,,
DEFIBRILLATOR LUMAX 740 HF-T BIVEN PCNG CARD IMPL W/HOME -,SUP-365608,CDM,C1882,HCPCS,275,RC,,,outpatient,,,40705.5,28493.85,AETNA [1000108],AETNA [100010801],,,76.8,,31261.82,399.86,45329.64864,percent of total billed charges,,,
DEFIBRILLATOR ILESTO HF-T DF-1 BIVEN PCNG RDC HI ENRG CARD -,SUP-383547,CDM,C1882,HCPCS,275,RC,,,outpatient,,,40705.5,28493.85,AETNA [1000108],AETNA [100010801],,,76.8,,31261.82,399.86,45329.64864,percent of total billed charges,,,
DEFIBRILLATOR ILESTO HF-T DF-4 BIVEN PCNG HI ENRG CARD IMPL -,SUP-383549,CDM,C1882,HCPCS,275,RC,,,outpatient,,,32036.46,22425.522,AETNA [1000108],AETNA [100010801],,,76.8,,24604,399.86,45329.64864,percent of total billed charges,,,
DEFIBRILLATOR LUMAX 740 HF-T CARD IMPL W/HOME MNTR MBL -,SUP-393803,CDM,C1882,HCPCS,275,RC,,,outpatient,,,39472,27630.4,AETNA [1000108],AETNA [100010801],,,76.8,,30314.5,399.86,45329.64864,percent of total billed charges,,,
DEFIB HI ENRG BIVEN CARD IMPL TI -,SUP-401662,CDM,C1882,HCPCS,275,RC,,,outpatient,,,34503.46,24152.422,AETNA [1000108],AETNA [100010801],,,76.8,,26498.66,399.86,45329.64864,percent of total billed charges,,,
DEFIBRILLATOR PRMT + DF-4 RR V- PCNG RDC 50X75MM 14MM 42ML -,SUP-CD3211-36Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,AETNA [1000108],AETNA [100010801],,,76.8,,27159.9,399.86,45329.64864,percent of total billed charges,,,
DEFIBRILLATOR UNIFY IS-1 CONN 40X79MM 14MM 36ML 78GM CARD -,SUP-CD3231-40,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,AETNA [1000108],AETNA [100010801],,,76.8,,27159.9,399.86,45329.64864,percent of total billed charges,,,
DEFIBRILLATOR UNIFY QUADRA DF-4 IS-4 IS-1 CONN 41X75MM 14MM -,SUP-CD3249-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43251.44,30276.008,AETNA [1000108],AETNA [100010801],,,76.8,,33217.11,399.86,45329.64864,percent of total billed charges,,,
DEFIBRILLATOR UNIFY ASSURA DF-1 IS-1 DF-4 BIVEN PCNG 40X79MM -,SUP-CD3257-40,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,AETNA [1000108],AETNA [100010801],,,76.8,,27159.9,399.86,45329.64864,percent of total billed charges,,,
DEFIBRILLATOR UNIFY ASSURA DF-4 TELEM 2CHMBR 40X73MM 14MM -,SUP-CD3257-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,AETNA [1000108],AETNA [100010801],,,76.8,,27159.9,399.86,45329.64864,percent of total billed charges,,,
DEFIBRILLATOR QUADRA ASSURA DF-1 BIVEN PCNG 41X83MM 14MM -,SUP-CD3265-40,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43251.44,30276.008,AETNA [1000108],AETNA [100010801],,,76.8,,33217.11,399.86,45329.64864,percent of total billed charges,,,
DEFIBRILLATOR QUADRA ASSURA DF-4 IS-4 IS-1 CONN BIVEN PCNG -,SUP-CD3265-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43251.44,30276.008,AETNA [1000108],AETNA [100010801],,,76.8,,33217.11,399.86,45329.64864,percent of total billed charges,,,
DEFIBRILLATOR UNIFY ASSURA CARD IMPL PARYLENE CTD -,SUP-CD3357-40C,CDM,C1882,HCPCS,275,RC,,,outpatient,,,29974.05,20981.835,AETNA [1000108],AETNA [100010801],,,76.8,,23020.07,399.86,45329.64864,percent of total billed charges,,,
UNIFY ASSURA NXGEN CRT-D 40 MEDIGUIDE -,SUP-CD3357-40C,CDM,C1882,HCPCS,275,RC,,,outpatient,,,47726.58,33408.606,AETNA [1000108],AETNA [100010801],,,76.8,,36654.01,399.86,45329.64864,percent of total billed charges,,,
DEFIBRILLATOR UNIFY ASSURA DF-4 CARD IMPL PARYLENE CTD CD -,SUP-CD3357-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,29974.05,20981.835,AETNA [1000108],AETNA [100010801],,,76.8,,23020.07,399.86,45329.64864,percent of total billed charges,,,
CRT-D 40 QUADRA ASSURA -,SUP-CD3365-40C CELL,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35225.31,24657.717,AETNA [1000108],AETNA [100010801],,,76.8,,27053.04,399.86,45329.64864,percent of total billed charges,,,
DEFIBRILLATOR QUADRA ASSURA DF-4 SGL/2CHMBR 41X75MM 14MM -,SUP-CD3365-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35225.31,24657.717,AETNA [1000108],AETNA [100010801],,,76.8,,27053.04,399.86,45329.64864,percent of total billed charges,,,
CRT-D QUADRA ASSURA MP CD3369-40C -,SUP-CD3369-40C,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,AETNA [1000108],AETNA [100010801],,,76.8,,25577.86,399.86,45329.64864,percent of total billed charges,,,
CRT-D QUADRA ASSURA MP DFR CON -,SUP-CD3369-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,AETNA [1000108],AETNA [100010801],,,76.8,,25577.86,399.86,45329.64864,percent of total billed charges,,,
ENTRANT CRT-D CDHFA300Q -,SUP-CDHFA300Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35771.5,25040.05,AETNA [1000108],AETNA [100010801],,,76.8,,27472.51,399.86,45329.64864,percent of total billed charges,,,
ENTRANT HF CRT-D DF1 CONNECTOR REF: CDHFA300T -,SUP-CDHFA300T,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35771.5,25040.05,AETNA [1000108],AETNA [100010801],,,76.8,,27472.51,399.86,45329.64864,percent of total billed charges,,,
GALLANT CRT-D CDHFA500Q -,SUP-CDHFA500Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,38238.5,26766.95,AETNA [1000108],AETNA [100010801],,,76.8,,29367.17,399.86,45329.64864,percent of total billed charges,,,
GALLANT HF CRT-D DF1 CONNECTOR REF: CDHFA500T -,SUP-CDHFA500T,CDM,C1882,HCPCS,275,RC,,,outpatient,,,38238.5,26766.95,AETNA [1000108],AETNA [100010801],,,76.8,,29367.17,399.86,45329.64864,percent of total billed charges,,,
DEFIBRILLATOR INOGEN MUL PRGM OPTN EXTEND LNGVT VR -,SUP-D141,CDM,C1882,HCPCS,275,RC,,,outpatient,,,28370.5,19859.35,AETNA [1000108],AETNA [100010801],,,76.8,,21788.54,399.86,45329.64864,percent of total billed charges,,,
DEFIBRILLATOR CONSULTA DF-1 IS-1 CONN WRLS TELEM 2CHMBR RR -,SUP-D224TRK,CDM,C1882,HCPCS,275,RC,,,outpatient,,,48626.05,34038.235,AETNA [1000108],AETNA [100010801],,,76.8,,37344.81,399.86,45329.64864,percent of total billed charges,,,
DEFIBRILLATOR PROTECTA DF-4 CARD IMPL -,SUP-D334TRM,CDM,C1882,HCPCS,275,RC,,,outpatient,,,39911.13,27937.791,AETNA [1000108],AETNA [100010801],,,76.8,,30651.75,399.86,45329.64864,percent of total billed charges,,,
EVERA MRI MRT XT DR DDMB1D4 -,SUP-DDMB1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,37251.7,26076.19,AETNA [1000108],AETNA [100010801],,,76.8,,28609.31,399.86,45329.64864,percent of total billed charges,,,
VIVA CARD IMPL -,SUP-DTBA1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50599.65,35419.755,AETNA [1000108],AETNA [100010801],,,76.8,,38860.53,399.86,45329.64864,percent of total billed charges,,,
DEFIBRILLATOR VIVA XT IS-1 DF-1 ADPTVCRT PHYCRV SMRTSHCK -,SUP-DTBA1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50599.65,35419.755,AETNA [1000108],AETNA [100010801],,,76.8,,38860.53,399.86,45329.64864,percent of total billed charges,,,
DEFIBRILLATOR VIVA S DF-4 IS-1 CONN SGL-CHMBR CARD IMPL -,SUP-DTBB1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,42839.46,29987.622,AETNA [1000108],AETNA [100010801],,,76.8,,32900.71,399.86,45329.64864,percent of total billed charges,,,
DEFIBRILLATOR VIVA S DF-4 IS-1 CONN SGL-CHMBR CARD IMPL. -,SUP-DTBB1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,42839.46,29987.622,AETNA [1000108],AETNA [100010801],,,76.8,,32900.71,399.86,45329.64864,percent of total billed charges,,,
DEFIB  VIVA QUAD S CRT-D DF-1 IS-4 CONN CARD IMPL -,SUP-DTBB1Q1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43172.5,30220.75,AETNA [1000108],AETNA [100010801],,,76.8,,33156.48,399.86,45329.64864,percent of total billed charges,,,
DEFIBRILLATOR VIVA QUAD S DF-4 IS-4 CONN CARD IMPL -,SUP-DTBB1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,42839.46,29987.622,AETNA [1000108],AETNA [100010801],,,76.8,,32900.71,399.86,45329.64864,percent of total billed charges,,,
CLARIA MRI CRT-D MODEL DTMA1D1 -,SUP-DTMA1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49006.96,34304.872,AETNA [1000108],AETNA [100010801],,,76.8,,37637.35,399.86,45329.64864,percent of total billed charges,,,
CLARIA MRI CRT-D DTMA1D1 -,SUP-DTMA1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49006.96,34304.872,AETNA [1000108],AETNA [100010801],,,76.8,,37637.35,399.86,45329.64864,percent of total billed charges,,,
CLARIA MRI CRT-D DTMA1D4 -,SUP-DTMA1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49006.96,34304.872,AETNA [1000108],AETNA [100010801],,,76.8,,37637.35,399.86,45329.64864,percent of total billed charges,,,
CLARIA MRI QUAD CRT-D DTMA1QQ -,SUP-DTMA1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50326.8,35228.76,AETNA [1000108],AETNA [100010801],,,76.8,,38650.98,399.86,45329.64864,percent of total billed charges,,,
CLARIA MRI QUAD CRT-D Model DTMA1QQ -,SUP-DTMA1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50326.8,35228.76,AETNA [1000108],AETNA [100010801],,,76.8,,38650.98,399.86,45329.64864,percent of total billed charges,,,
AMPLIA MRI CRT-D DTMB1D1 -,SUP-DTMB1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,47773.46,33441.422,AETNA [1000108],AETNA [100010801],,,76.8,,36690.02,399.86,45329.64864,percent of total billed charges,,,
CRTD DTMB1D1 AMPLIA MRI US DF1 -,SUP-DTMB1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,47773.46,33441.422,AETNA [1000108],AETNA [100010801],,,76.8,,36690.02,399.86,45329.64864,percent of total billed charges,,,
AMPLIA CRT-D MRI DEVICE -,SUP-DTMB1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,54249.33,37974.531,AETNA [1000108],AETNA [100010801],,,76.8,,41663.49,399.86,45329.64864,percent of total billed charges,,,
AMPLIA MRI QUAD CRT-D -,SUP-DTMB1Q1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,AETNA [1000108],AETNA [100010801],,,76.8,,37703.65,399.86,45329.64864,percent of total billed charges,,,
AMPLIA MRI QUAD CRT-D SURESCAN DTMB1Q1 -,SUP-DTMB1Q1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,AETNA [1000108],AETNA [100010801],,,76.8,,37703.65,399.86,45329.64864,percent of total billed charges,,,
AMPLIA CRT-D DTMB 1 QQ -,SUP-DTMB1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,AETNA [1000108],AETNA [100010801],,,76.8,,37703.65,399.86,45329.64864,percent of total billed charges,,,
ICD COBALT HF CRT-D MRI SURESCAN REF: DTPB2D1 -,SUP-DTPB2D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,48237.25,33766.075,AETNA [1000108],AETNA [100010801],,,76.8,,37046.21,399.86,45329.64864,percent of total billed charges,,,
COBALT HF QUAD CRTD REF: DTPB2QQ -,SUP-DTPB2QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,52793.8,36955.66,AETNA [1000108],AETNA [100010801],,,76.8,,40545.64,399.86,45329.64864,percent of total billed charges,,,
CROME MRI CRTD REF: DTPC2D4 -,SUP-DTPC2D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50240.46,35168.322,AETNA [1000108],AETNA [100010801],,,76.8,,38584.67,399.86,45329.64864,percent of total billed charges,,,
CRT-D MOMENTUM IS1 DF4 G124 -,SUP-G124,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,AETNA [1000108],AETNA [100010801],,,76.8,,25577.86,399.86,45329.64864,percent of total billed charges,,,
CRT-D MOMENTUM IS1 DF1 G125 -,SUP-G125,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,AETNA [1000108],AETNA [100010801],,,76.8,,25577.86,399.86,45329.64864,percent of total billed charges,,,
CRT-D MOMENTUM LV-1 G126 -,SUP-G126,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,AETNA [1000108],AETNA [100010801],,,76.8,,25577.86,399.86,45329.64864,percent of total billed charges,,,
CRT-D MOMENTUM X4 IS4-DF1 G138 -,SUP-G138,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,AETNA [1000108],AETNA [100010801],,,76.8,,25577.86,399.86,45329.64864,percent of total billed charges,,,
PACEMAKER INOGEN CARD -,SUP-G140,CDM,C1882,HCPCS,275,RC,,,outpatient,,,39225.3,27457.71,AETNA [1000108],AETNA [100010801],,,76.8,,30125.03,399.86,45329.64864,percent of total billed charges,,,
DEFIBRILLATOR INOGEN CARD -,SUP-G141,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,AETNA [1000108],AETNA [100010801],,,76.8,,24507.38,399.86,45329.64864,percent of total billed charges,,,
DEFIBRILLATOR INOGEN DF-1 SGL-CHMBR 5.37CMX8.08CMX0.99CM D -,SUP-G146,CDM,C1882,HCPCS,275,RC,,,outpatient,,,41692.3,29184.61,AETNA [1000108],AETNA [100010801],,,76.8,,32019.69,399.86,45329.64864,percent of total billed charges,,,
DEFIBRILLATOR INOGEN DF-4 5.37CMX8.08CMX0.99CM D 32ML CARD -,SUP-G148,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,AETNA [1000108],AETNA [100010801],,,76.8,,24507.38,399.86,45329.64864,percent of total billed charges,,,
DYNAGEN CRT-D MODEL G150 -,SUP-G150,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,AETNA [1000108],AETNA [100010801],,,76.8,,24507.38,399.86,45329.64864,percent of total billed charges,,,
DYNAGEN CRT-D G-154 DEFIBRILLATOR -,SUP-G154,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,AETNA [1000108],AETNA [100010801],,,76.8,,24507.38,399.86,45329.64864,percent of total billed charges,,,
CRT-D DYNAGEN X4 G156 -,SUP-G156,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33218.16,23252.712,AETNA [1000108],AETNA [100010801],,,76.8,,25511.55,399.86,45329.64864,percent of total billed charges,,,
CRT-D VIGILANT X4 IS4 DF4 MRI CONDITIONAL -,SUP-G247,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,AETNA [1000108],AETNA [100010801],,,76.8,,25577.86,399.86,45329.64864,percent of total billed charges,,,
COMPIA CRT-D MRI QUAD -,SUP-UNDEFINED,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,AETNA [1000108],AETNA [100010801],,,76.8,,37703.65,399.86,45329.64864,percent of total billed charges,,,
ANCHOR LD C IN 94IN LF ACC -,SUP-1194,CDM,C1883,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA [1000108],AETNA [100010801],,,76.8,,336.1,26.19915,3519.77472,percent of total billed charges,,,
KIT EXTENSION INTERSTIM 10CM S  - DISCONTINUED DO NOT USE -,SUP-3095-10,CDM,C1883,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,26.19915,3519.77472,percent of total billed charges,,,
KIT REVISION INTERSTIM -,SUP-3550-05,CDM,C1883,HCPCS,278,RC,,,outpatient,,,1079.48,755.636,AETNA [1000108],AETNA [100010801],,,76.8,,829.04,26.19915,3519.77472,percent of total billed charges,,,
KT EXTENSION NEURSTM INTSTM 60CM PERC MRI-COND INSL MULI- -,SUP-3708160,CDM,C1883,HCPCS,278,RC,,,outpatient,,,3007.62,2105.334,AETNA [1000108],AETNA [100010801],,,76.8,,2309.85,26.19915,3519.77472,percent of total billed charges,,,
LEAD ADPTR -,SUP-5866,CDM,C1883,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA [1000108],AETNA [100010801],,,76.8,,1017.7,26.19915,3519.77472,percent of total billed charges,,,
CABLE PCNG -,SUP-5867AS,CDM,C1883,HCPCS,278,RC,,,outpatient,,,116.7,81.69,AETNA [1000108],AETNA [100010801],,,76.8,,89.63,26.19915,3519.77472,percent of total billed charges,,,
EXTENDER LD UNIPL -,SUP-6981M,CDM,C1883,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,76.8,,739.42,26.19915,3519.77472,percent of total billed charges,,,
EXTENDER LD BIPLR MRI-COND -,SUP-6984M,CDM,C1883,HCPCS,278,RC,,,outpatient,,,1079.48,755.636,AETNA [1000108],AETNA [100010801],,,76.8,,829.04,26.19915,3519.77472,percent of total billed charges,,,
ADAPTER NEURSTM 27.4CM SPIN CRD 2X4 PCKT -,SUP-740-02,CDM,C1883,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,AETNA [1000108],AETNA [100010801],,,76.8,,3519.77,26.19915,3519.77472,percent of total billed charges,,,
FILTER EMBL PROT EMBOSHIELD NAV6 5MMX190CM WIRE UNCNTSTR -,SUP-22437-19,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,AETNA [1000108],AETNA [100010801],,,,,,399.86,5331.24633,other,272 with C codes,,
FILTER EMBL PROT EMBOSHIELD NAV6 7.2MMSMX190CM WIRE UNCNTSTR -,SUP-22438-19,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,AETNA [1000108],AETNA [100010801],,,,,,399.86,5331.24633,other,272 with C codes,,
FILTER EMBL PROT FLTWR EZ 3.2FRX190CM WIRE NTNL LOOP CRTD -,SUP-H749201001900,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6875.28,4812.696,AETNA [1000108],AETNA [100010801],,,,,,399.86,5331.24633,other,272 with C codes,,
FILTER EMBL PROT FLTWR EZ 3.2FRX300CM WIRE NTNL LOOP CRTD -,SUP-H749201003000,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7078.99,4955.293,AETNA [1000108],AETNA [100010801],,,,,,399.86,5331.24633,other,272 with C codes,,
EMBOLIC PROT FLTWR EZ 0.042IN 0.014 DIA GW 110U FLTR 190CM -,SUP-H749390711900,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7435.49,5204.843,AETNA [1000108],AETNA [100010801],,,,,,399.86,5331.24633,other,272 with C codes,,
FILTERWIRE EMBL EZ 2.25MM 3.5MMX300CM FEM VC -,SUP-H74939071300,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6457.03,4519.921,AETNA [1000108],AETNA [100010801],,,,,,399.86,5331.24633,other,272 with C codes,,
DEVICE EMBL PROT SPIDERFX 3MM FLTR BSKT 0.014IN GW 0.066IN -,SUP-SPD2US030320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,AETNA [1000108],AETNA [100010801],,,,,,399.86,5331.24633,other,272 with C codes,,
DEVICE EMBL PROT SPIDERFX 4MM FLTR BSKT 0.014IN GW 0.066IN -,SUP-SPD2US040320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,AETNA [1000108],AETNA [100010801],,,,,,399.86,5331.24633,other,272 with C codes,,
SPIDER FX 5MM 320 .014 EMBOLIC -,SUP-SPD2US050320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,AETNA [1000108],AETNA [100010801],,,,,,399.86,5331.24633,other,272 with C codes,,
SPIDER FX 6MM 320 .014 EMBOLIC -,SUP-SPD2US060320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,AETNA [1000108],AETNA [100010801],,,,,,399.86,5331.24633,other,272 with C codes,,
DEVICE EMBL PROT SPIDERFX 7MM FLTR BSKT 0.014IN GW 0.066IN -,SUP-SPD2US070320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,AETNA [1000108],AETNA [100010801],,,,,,399.86,5331.24633,other,272 with C codes,,
CATHETER LASER CORONARY ATHETECTOMY 0.9X80 ELACX-80 -,SUP-110-004,CDM,C1885,HCPCS,272,RC,,,outpatient,,,10588.78,7412.146,AETNA [1000108],AETNA [100010801],,,,,,399.86,7592.15526,other,272 with C codes,,
CATHETER 1.4MM ELCA CORONARY LASER ATHE -,SUP-114-009,CDM,C1885,HCPCS,272,RC,,,outpatient,,,10588.78,7412.146,AETNA [1000108],AETNA [100010801],,,,,,399.86,7592.15526,other,272 with C codes,,
C 1.7M .018IN OTW TURBO ELITE -,SUP-417-152,CDM,C1885,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,AETNA [1000108],AETNA [100010801],,,,,,399.86,7592.15526,other,272 with C codes,,
CATH ABLT 4MM 90DG 160CM BARRX ULTRA LNG LF -,SUP-90-9200,CDM,C1886,HCPCS,272,RC,,,outpatient,,,9419.88,6593.916,AETNA [1000108],AETNA [100010801],,,,,,399.86,7607.37,other,272 with C codes,,
CATHETER BRONCHIAL THERMOPLAST -,SUP-M005ATS25010,CDM,C1886,HCPCS,272,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,,,,399.86,7607.37,other,272 with C codes,,
CATH SHEATH RITESITE C315H40,SUP-,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
GUIDE 8F MARK 1 AL 2 -,SUP-34358-20,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
GUIDE 8F MARK 1 IM -,SUP-34358-26,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
LEAD PCNG 6.6FR 7FR INTRO 53CM TILDA HELIX ELECTRICALLY -,SUP-382889,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
LEAD PCNG 6.6FR 7FR INTRO 60CM TILDA HELIX ELECTRICALLY -,SUP-382895,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATHETER GUIDE 6FR X 85CM INTERNAL MAMMARY -,SUP-38969-122/H749389691220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 5FR IL-3.5 HEARTRAIL III NO SH COR SS FLTWR PTFE -,SUP-40-5370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 5FR IKARI RT 2 HEARTRAIL III NO SH COR SS FLTWR -,SUP-40-5382,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 6FR ID 0.081IN IL-3.5 100CM HEARTRAIL III LRG LUM -,SUP-40-6370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 6FR ID 0.081IN IL-4.5 100CM HEARTRAIL III LRG LUM -,SUP-40-6375,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
MICRO GUIDE CATH NHANCER RX REF: 451669 -,SUP-451669,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATHETER GUIDE -,SUP-490107,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH DX 0.039/0.026IN DIA P/D 45DG ANG TAPR 135CM QCK-CX -,SUP-518-032,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH DX 0.044/0.030IN DIA P/D 15MM SPC 45DG ANG TAPR 90CM -,SUP-518-033,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
C QUICKCROSS .018 150CM -,SUP-518-035,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH DX 0.063/0.050IN DIA P/D 15MM SPC 45DG ANG TAPR 90CM -,SUP-518-036,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
C QUICKCROSS .035 135CM -,SUP-518-037,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
C QUICKCROSS .035 150CM -,SUP-518-038,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
C 0.014-150CM QUICK CROSS -,SUP-518-065,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH DX 0.052/0.059IN DIA P/D 15MM SPC 45DG ANG TAPR 135CM -,SUP-518-081,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
C QUICK CROSS SEL .035 150CM -,SUP-518-083,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
C QUICK CROSS SEL .014 150 -,SUP-518-087,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
C QUICK CROSS SEL .018 150 -,SUP-518-093,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH DX 3FR ID 1.9FRX140CM TWN PASS RX LPRO LUMX2 COR PERIPH -,SUP-5200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2003.59,1402.513,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATHETER SUPERCROSS 45 ANGLED 0.014 X 130CM -,SUP-5302,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
SUPERCROSS 90 ANGLED TIP CATH -,SUP-5305,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2279.22,1595.454,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
MICRO GUIDE CATH SUPERCROSS 120 ANGLED TIP REF: 5306 -,SUP-5306,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2472.93,1731.051,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH ANG INFINITI 5FR JR4 REF: 534521T -,SUP-534521T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH ANG 5FR 145 PIGTL 110CM INFINITI REF: 534-552S -,SUP-534552S,CDM,C1887,HCPCS,272,RC,,,outpatient,,,43.47,30.429,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH ANG 5FR IMA CRV 100CM INFIN SLCT 3 STG BRD NBRD PROX -,SUP-534-560T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH ANG INFINITI 6FR JL4 REF: 534620T -,SUP-534620T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH ANG INFINITI 6FR JR4 REF: 534-621T -,SUP-534-621T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH ANG INFINITI 6FR AR MOD REF: 534648T -,SUP-534648T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH ANG INFINITI 6FR RCB REF: 534670T -,SUP-534670T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH ANG INFINITI 6FR LCB REF: 534672T -,SUP-534672T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
SHEATH GUID 5FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-54-54501,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH DX 6FR 145DG PIGTL 110CM LANGSTON BRD LUMX2 LO XING -,SUP-5540,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1088.81,762.167,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.056IN 5FRX100CM 2.5MM VISTA BRITE TIP SS PTFE -,SUP-556-002-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.056IN 5FR JL3.5 100CM VISTA BRITE TIP BRD -,SUP-556-002-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.056IN 5FR LT COR EBU 3.5 100CM 2.5MM VISTA BRITE -,SUP-556-054-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.056IN 5FR  XBLAD 3.5 LBT 100CM 2.5MM VISTA -,SUP-556-060-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.056IN 5FR BARB 100CM VISTA BRITE TIP BRD MUL-SEG -,SUP-556-174-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATHETER 6FRX150CM TRAPLINER REF:5566 -,SUP-5566,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3652.11,2556.477,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATHETER 7FRX150CM TRAPLINER REF:5567 -,SUP-5567,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3652.11,2556.477,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH DX 6FRX150CM GUIDELINER V2 RX COAX PERIPH -,SUP-5571,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2183.81,1528.667,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH DX 7FRX150CM GUIDELINER V2 RX COAX PERIPH -,SUP-5572,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2183.81,1528.667,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH DX 8FRX150CM GUIDELINER V2 RX COAX PERIPH -,SUP-5573,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2173.21,1521.247,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
TURNPIKE GOLD 135CM MICRO CATH -,SUP-5621,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3294.06,2305.842,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
TURNPIKE LP 135 ON MICRO CATHETER -,SUP-5638,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3771.46,2640.022,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
TURNPIKE LP 150CM MICRO CATH -,SUP-5639,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2931.24,2051.868,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATHETER TURNPIKE SPIRAL 135CM -,SUP-5640,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3771.46,2640.022,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.018IN 3.5FR SHFT 70CM 8MM VENTURE OTW CS PED -,SUP-5822,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3146.07,2202.249,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.088IN 8FR JL4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-588-823,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.088IN 8FR LT COR EBU3 100CM 2.5MM VISTA BRITE -,SUP-588-829,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.088IN 8FR JR4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-588-830,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.088IN 8FR JL3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-588-851,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID VISTA 8FR XB 3.5 -,SUP-588-882,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.088IN 8FR LT COR EBU 4 100CM 2.5MM VISTA BRIT -,SUP-588-894,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH DX 0.054IN 6FRX100CM 2CM PERFORM ULTMT 2 -,SUP-610038ULT2,CDM,C1887,HCPCS,272,RC,,,outpatient,,,140.74,98.518,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 130DG CRV ATTAIN SELECT COR STR 5.5FR INR CATH -,SUP-6248DEL,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATHETER ATTAIN SELECT REF: 6248V-130 -,SUP-6248V-130,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1284.84,899.388,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH 6248V-90 ATTAIN SELECT II -,SUP-6248V-90,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1284.84,899.388,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATHETER  CRDM Adaptor 6250V-EH -,SUP-6250V-EH,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATHETER ATTAIN COMMAND REF: 6250V-MPR -,SUP-6250V-MPR,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.96MM/MIN 2.4MM/MAX MPX COR 50CM ATTAIN COMMAND -,SUP-6250VMPX,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.07IN 6FR JL3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-002-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.07IN 6FR JL4 100CM VISTA BRITE TIP BRD -,SUP-670-004-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.07IN 6FR JL4 SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-005-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.07IN 6FR JL4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-014-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.07IN 6FR AL1 100CM .75MM SH VISTA BRITE TIP -,SUP-67003500,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.07IN 6FR ALC1 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-036-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.07IN 6FR ALC2 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-040-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.07IN 6FR  XB3 100CM 1.8MM VISTA BRITE TIP -,SUP-670-052-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.07IN 6FR XB 3 SH 100CM VISTA BRITE TIP -,SUP-670-053-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUIDING 6FR XB 3.5 VISTA -,SUP-670-054-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUIDING 6FR XB 3.5 VISTA LBT -,SUP-670-054-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,253.82,177.674,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.07IN 6FR LT COR EBU3.5 SH 100CM 2.5MM VISTA -,SUP-670-055-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.07IN 6FR XB4 100CM 2.5MM VISTA BRITE TIP -,SUP-670-056-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.07IN 6FR XB4.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-67005800,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.07IN 6FR XBLAD 3.5 100CM  VISTA BRITE -,SUP-670-060-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.07IN 6FR XBLAD 4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-062-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 6FR XBLAD 4.5 100CM VISTA BRITE TIP -,SUP-67006400,CDM,C1887,HCPCS,272,RC,,,outpatient,,,198.39,138.873,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.07IN 6FR XBLAD 3 100CM VISTA BRITE TIP -,SUP-670-066-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.07IN 6FR JR3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-080-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.07IN 6FR JR4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-67008200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.07IN 6FR JR4 55CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-082-55,CDM,C1887,HCPCS,272,RC,,,outpatient,,,355.35,248.745,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.07IN 6FR JR4 SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-083-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.07IN 6FR ARC1 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-67011000,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.07IN 6FR XBRCA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-126-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.07IN 6FR JEAN- FJL 100CM 2.5MM VISTA BRITE TIP -,SUP-670-166-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 6FR JFL LT REF: 670-166-00 -,SUP-670-166-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.07IN 6FR BARB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-174-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.07IN 6FR LCB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-180-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.07IN 6FR LCB 90CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-180-90,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.07IN 6FR RCB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-182-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.07IN 6FR RCB 90CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-182-90,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.07IN 6FR IMA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-190-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.07IN 6FR VERT 55CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-190-55,CDM,C1887,HCPCS,272,RC,,,outpatient,,,355.35,248.745,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.07IN 6FR IM SH REF: 670-191-00 -,SUP-670-191-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 6FR IM VB-1 100CM VISTA BRITE TIP -,SUP-67019200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,198.39,138.873,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.07IN 6FR RNL CRV 55CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-212-55,CDM,C1887,HCPCS,272,RC,,,outpatient,,,355.35,248.745,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.07IN 6FR HS 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-278-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.07IN 6FR HS SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-279-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.078IN 7FR JL4 100CM 2.5MM VISTA BRITE TIP BD -,SUP-778-004-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATHETER GUIDING 7FR JL 5 SH JUDKINS -,SUP-77800900,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUIDE 7FR AL2 REF: 778704000 -,SUP-77804000,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.078IN 7FR LT EBU LAD 3 100CM 2.5MM VISTA BRITE -,SUP-778-052-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.078IN 7FR XB 3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-054-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUIDING  7FR XB3.5 SH VIS -,SUP-778-055-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.078IN 7FR XB4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-056-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.078IN 7FR LT EBU LAD 4.5 100CM 2.5MM VISTA BRITE -,SUP-778-058-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUIDING 7FR XBLAD 3.5 100CM 2.5MM VISTA -,SUP-778-060-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.078IN 7FR LT COR EBU LAD 4 100CM 2.5MM VISTA -,SUP-778-062-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.078IN 7FR JR4 100CM 2.5MM VISTA BRITE BRD -,SUP-778-082-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.078IN 7FR JR4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-083-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.078IN 7FR ARC1 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-110-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.078IN 7FR ARC2 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-112-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.078IN 7FR RCB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-182-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.078IN 7FR IMA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-190-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.078IN 7FR MPA-1 COR 100CM 2.5MM VISTA BRITE TIP -,SUP-778-270-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.078IN 7FR HS 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-278-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.078IN 7FR HS SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-279-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH BLN OCCULSION 2.1FRX135CM ASAHI TORNUS SUPP CHRNC OTW -,SUP-82380-01,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH DX 2.6FRX135CM ASAHI TORNUS SUPP OTW THRD COR SS -,SUP-82381-01,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3795.33,2656.731,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATHETER CENTER POINT REF:9181 -,SUP-9181,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATHETER CENTER POINT REF:9182 -,SUP-9182,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATHETER CENTER POINT REF:9183 -,SUP-9183,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATHETER CENTER POINT REF:9184 -,SUP-9184,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH SHEATH RITESITE C315H2002 -,SUP-C315H2002,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH SHEATH RITESITE C315H4002 -,SUP-C315H4002,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH SHEATH C315HIS02 -,SUP-C315HIS02,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
HIS SHEATH DELIVERY SYSTEM C315HIS02 -,SUP-C315HIS02,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH SHEATH RITESITE C315J02 -,SUP-C315J02,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH SHEATH RITESITE C315S1002 -,SUP-C315S1002,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH SHEATH RITESITE C315S402 -,SUP-C315S402,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH SHEATH RITESITE C315S502 -,SUP-C315S502,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH ELCSURG 7FRX100CM RF FLXB CLSR FST -,SUP-CF7-7-100,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
GLIDECATH MG1 4F 125CM  LONG -,SUP-CG440,CDM,C1887,HCPCS,272,RC,,,outpatient,,,295.54,206.878,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
GLIDECATH MG2 4F 135CM  LONG -,SUP-CG441,CDM,C1887,HCPCS,272,RC,,,outpatient,,,295.54,206.878,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH ABLT CLSR FST 65CM PROC KT MIS-7F11 INTRO -,SUP-CPK6511,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1908.18,1335.726,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH ABLT CLSR FST 73CM PROC KT MIS-7F11 INTRO -,SUP-CPK8511,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1908.18,1335.726,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
ASAHI CARAVEL MICROCATHETER 150 CM -,SUP-CRV150-19P,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATHETER CORSAIR PRO XS 150CM REF: CSR150-21S -,SUP-CSR150-21S,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATHETER CORSAIR PRO 150CM CSR150-26P ASAHI -,SUP-CSR150-26P,CDM,C1887,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
"CATHETER CXI SUPPORT 4.OFR X 135CM STR TIP .035"" MAX GUIDEWR -",SUP-CXI-4.0-35-135-P-NS-O,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATHETER CPS LOCATOR 3D- SMALL REF:DS2C100-42 -,SUP-DS2C100-42,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATHETER CPS LOCATOR 3D- MEDIUM REF:DS2C200-42 -,SUP-DS2C200-42,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATHETER CPS LOCATOR 3D- LAGE REF:DS2C300-42 -,SUP-DS2C300-42,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATHETER AGILIS HISPRO DS3H010-38  BUNDLE -,SUP-DS3H010-38,CDM,C1887,HCPCS,272,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATHETER AGILIS HISPRO DS3H010-38 -,SUP-DS3H010-38,CDM,C1887,HCPCS,272,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH ANG 0.056IN 6FR AR1 100CM DXTERITY REF: DXT6AR10 -,SUP-DXT6AR10,CDM,C1887,HCPCS,272,RC,,,outpatient,,,9.92,6.944,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
RING TRANS-JUG ACCESS SET WITH 10fr -,SUP-G06541,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2542.11,1779.477,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
TRANSJUGLAR LIVER ACCESS SET R -,SUP-G06929,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2558.82,1791.174,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
BEACON TIP 5.0 FR ANGIOGRAPHIC CATHETER - C2 -,SUP-G08442,CDM,C1887,HCPCS,272,RC,,,outpatient,,,151.7,106.19,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATHETER RIM 5FR X 100CM -,SUP-G12870,CDM,C1887,HCPCS,272,RC,,,outpatient,,,758.49,530.943,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH DX 2.6FR STR 65CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G18367,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1051.93,736.351,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATHETER CXI SUPPORT -,SUP-G18368,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1051.93,736.351,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CXI-2.3-14-65-0 -,SUP-G18369,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH CXI 2.3FR X 65CM X 014 SU -,SUP-G18370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH CXI 2.3FR X 90CM X 014 SU -,SUP-G18371,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CXI-2.3-14-90-ANG -,SUP-G18372,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CXI-2.3-14-150-ANG -,SUP-G18376,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH DX 2.6FR ANG 150CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G50003,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH DX 2.6FR STR 90CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G50004,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH DX 3FR/1.9FR P/D STR 135CM CROSSCATH SUPP LUMX1 PERIPH -,SUP-G51573,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH DX 4.8FR/3.7FR P/D STR 90CM CROSSCATH SUPP LUMX1 PERIPH -,SUP-G51580,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH DX 4.8FR/3.7FR P/D STR 135CM CROSSCATH SUPP LUMX1 -,SUP-G51581,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH DX 3.4FR/2.2FR P/D STR 135CM CROSSCATH SUPP LUMX1 -,SUP-G51583,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH DX 4FR DAV 135CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G52543,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
C NAVICROSS ANG 150CM .035 -,SUP-G52545,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH DX 4FR DAV 150CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G52545,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATHETER CXI SUPPORT 4FR X 90CM STR TIP .035 MAX GUIDEWRE -,SUP-G52546,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH DX 4FR DAV 90CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G52547,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH ANG 90CM NAVICROSS -,SUP-G52547,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.07IN 7FR XBRCA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-G778126,CDM,C1887,HCPCS,272,RC,,,outpatient,,,882.25,617.575,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID RELIEVA FLEX SIN S-0 SFT DIST TIP ENDO -,SUP-GC000RF,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1961.19,1372.833,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID RELIEVA FLEX SIN F-70 C SFT DIST TIP ENDO -,SUP-GC070CRF,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1961.19,1372.833,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID RELIEVA FLEX SIN M-110 SFT DIST TIP ENDO -,SUP-GC110RF,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1961.19,1372.833,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH ANGIO IMPULSE 5FR FL3.5 REF:H74916391212 -,SUP-H74916391212,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATHETER 5FR FL4 IMPULSE REF:H74916391222 -,SUP-H74916391222,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH ANGIO IMPULSE 5FR AR1 REF:H74916391842 -,SUP-H74916391842,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH ANG 0.045IN 5FR AL1 100CM IMPULSE REF:H74916391962 -,SUP-H74916391962,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATHETER 5FR AL2 IMPULSE REF:H74916391982 -,SUP-H74916391982,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
ANGIO CATH PIG 6F IMPULSE -,SUP-H74916599412,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.070IN 6FR AL3 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934356210,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATHETER GUIDING 6FR Mach 1 AL .75 -,SUP-H74934356220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 6FR MACH 1 ML 3.5 REF: H749343565370 -,SUP-H749343565370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.081IN 7FR FL3 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934357050,CDM,C1887,HCPCS,272,RC,,,outpatient,,,306.51,214.557,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.081IN 7FR FL3.5 100CM MACH1 4X2 RND BRD LRG LUM -,SUP-H74934357060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 7FR IM 85CM MACH1 -,SUP-H749343571220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 7FR AL.75 100CM MACH1 REF:H74934357220 -,SUP-H74934357220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.081IN 7FR RCB 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934357240,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.081IN 7FR Q- TY CRV 4 100CM MACH1 4X2 RND BRD -,SUP-H749343572940,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.070IN 7FR Q4.5 MACH 1 -,SUP-H749343572950,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.081IN 7FR MP1 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934357380,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUIDE 7FR MP2 REF: H74934357390 -,SUP-H74934357390,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.081IN 7FR FR3.5 SH 100CM MACH1 2X2 RND BRD -,SUP-H74934357470,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.081IN 7FR FL4.5 100CM MACH1 2X2 RND BRD LRG LUM -,SUP-H74934357540,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.081IN 7FR CNTRLAT 3 100CM MACH1 2X2 RND BRD LRG -,SUP-H749343575730,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.081IN 7FR CLS 3.5 100CM MACH1 4X2 RND BRD LRG -,SUP-H749343575740,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.081IN 7FR VL3 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934357710,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.081IN 7FR VL3.5 100CM MACH1 4X2 RND BRD LRG LUM -,SUP-H74934357720,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.081IN 7FR FR4 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934357920,CDM,C1887,HCPCS,272,RC,,,outpatient,,,306.51,214.557,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.091IN 8FR FR3.5 100CM MACH1 2X2 RND BRD SD HOL -,SUP-H74934358010,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.091IN 8FR FR4 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934358020,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.091IN 8FR FL3.5 100CM MACH1 4X2 RND BRD LRG LUM -,SUP-H74934358060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.091IN 8FR FL4.5 100CM MACH1 2X2 RND BRD LRG LUM -,SUP-H74934358080,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID MACH1 8FR AL.75 SH  90CM - H749343581920 -,SUP-H749343581920,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.091IN 8FR LCB 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934358250,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.091IN 8FR FR4 100CM MACH1 4X2 RND BRD LRG LUM SH -,SUP-H74934358480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.070IN 6FR FR3.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969010,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.070IN 6FR FR4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969020,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.07IN 6FR FL3 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969050,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.07IN 6FR FL3.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.07IN 6FR FL4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969070,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.070IN 6FR FL4.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969080,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.070IN 6FR FEM HS 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H749389691410,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.070IN 6FR AR2 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969180,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.070IN 6FR AL1 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969190,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.070IN 6FR AL2 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.07IN 6FR FRC BYPS 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H74938969240,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.070IN 6FR LCB RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969250,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.070IN 6FR IMA RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969260,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.070IN 6FR FL4 ST RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H74938969290,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.070IN 6FR Q3.5 -,SUP-H749389692930,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.070IN 6FR Q4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389692940,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.070IN 6FR Q4.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389692950,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.07IN 6FR MP1 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969380,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.070IN 6FR FEM MP 2 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H74938969390,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.070IN 6FR HS RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969410,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.070IN 6FR IMA 90CM RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389694460,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.070IN 6FR RC 4 SC RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389694480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.070IN 6FR RC 3.5 SC RUNWAY 2X2 RND BRD LRG LUM -,SUP-H74938969460,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.070IN 6FR FR3.5 RUNWAY 2X2 RND BRD LRG LUM SH -,SUP-H74938969470,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.070IN 6FR FR4 RUNWAY 2X2 RND BRD LRG LUM SH FEM -,SUP-H74938969480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.070IN 6FR ART3 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389694960,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.070IN 6FR ART3.5 RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389694980,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.070IN 6FR ART3.5 RUNWAY 2X2 RND BRD LRG LUM SH -,SUP-H749389694990,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.070IN 6FR ART4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389695000,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.070IN 6FR FL 3.5 SH RUNWAY 2X2 RND BRD LRG -,SUP-H74938969520,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.070IN 6FR MUTA LT 3 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695360,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.070IN 6FR MUTA LT 3.5 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.070IN 6FR MUTA LT 4 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695380,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.070IN 6FR MUTA LT 4.5 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695390,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.07IN 6FR FEM CLS 3 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H749389695730,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.070IN 6FR CLS 3.5 RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389695740,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.070IN 6FR CLS 4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389695750,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.070IN 6FR CLS 3.5 RUNWAY 2X2 RND BRD LRG LUM SH -,SUP-H749389695780,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUIDE RUNWAY 6F CLS4 SH -,SUP-H749389695790,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.070IN 6FR KRT HZNT 3H RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389696480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.081IN 7FR VL3.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389696620,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.070IN 6FR FEM JL5 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H749389696640,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.07IN 6FR FEM AL1 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H74938969680,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.070IN 6FR VL3 RUNWAY -,SUP-H74938969710,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.070IN 6FR FL BK -UP 4 100CM RUNWAY 2X2 RND BRD -,SUP-H749389697160,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.070IN 6FR FR4 ST RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H74938969920,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.070IN 6FR MP1 125CM RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389699530,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
MICRO GUIDE CATH MAMBA FLEX 135 REF: H7493928713540 -,SUP-H7493928713540,CDM,C1887,HCPCS,272,RC,,,outpatient,,,5071.58,3550.106,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
STINGRAY LP BALLOON 3.2FR -,SUP-H749393120SR0,CDM,C1887,HCPCS,272,RC,,,outpatient,,,6490.48,4543.336,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
GUIDE EXTENSION CATHETER GUIDEZILLA II 6F -,SUP-H7493933515060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
GUIDE EXTENSION CATHETER GUIDEZILLA II 6F LONG -,SUP-H74939335150610,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
GUIDE EXTENSION CATHETER GUIDEZILLA II 7F -,SUP-H7493933515070,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
GUIDE EXTENSION CATHETER GUIDEZILLA II 8F -,SUP-H7493933515080,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH PTCA 135CM CROSSBOSS STINGRAY F/COR CTO -,SUP-H749M1000A0,CDM,C1887,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH ANG 4FR STR 65CM RADIFOCUS GLIDECATH DBL BRD SM-PRFL -,SUP-H787117140155,CDM,C1887,HCPCS,272,RC,,,outpatient,,,388.61,272.027,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
4FR GLIDECATH LONG 100CM STRAIGHT -,SUP-H787117140225,CDM,C1887,HCPCS,272,RC,,,outpatient,,,295.54,206.878,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH ANG 5FR ANG TAPR 65CM RADIFOCUS GLIDECATH SGL-BRD LRG -,SUP-H787117221045,CDM,C1887,HCPCS,272,RC,,,outpatient,,,388.61,272.027,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH ANG 5FR STR TAPR 65CM RADIFOCUS GLIDECATH SGL-BRD LRG -,SUP-H787117315025,CDM,C1887,HCPCS,272,RC,,,outpatient,,,388.61,272.027,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH ANG 4FR JB3 TIP 100CM TORCONNB ADVANTG BEACN BRD PERIPH -,SUP-HNBR4.0-35-100-P-NS-JB3,CDM,C1887,HCPCS,272,RC,,,outpatient,,,227.57,159.299,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.071IN 5FR EBU3.5 100CM LAUNCHR BRD LRG LUM DIST -,SUP-LA5EBU35,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 6FR 3D RIGHT LAUNCHR REF: LA63DRIGHT -,SUP-LA63DRIGHT,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.071IN 6FR AL1 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6AL10,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 6FR AL75 100CM LAUNCHR REF: LA6AL75 -,SUP-LA6AL75,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.071IN 6FR AR1 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6AR10,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.071IN 6FR BU LT EBU 3 100CM LAUNCHR BRD LRG LUM -,SUP-LA6EBU30,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.071IN 6FR BU LT EBU 3.5 100CM LAUNCHR BRD LRG -,SUP-LA6EBU35,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.071IN 6FR BU LT EBU 3.75 100CM LAUNCHR BRD LRG -,SUP-LA6EBU375,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.071IN 6FR BU LT EBU 4 100CM LAUNCHR BRD LRG LUM -,SUP-LA6EBU40,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.071IN 6FR EBU 4.5 100CM LAUNCHR -,SUP-LA6EBU45,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.071IN 6FR BYPS IMA 90CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6IMAD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.071IN 6FR STD JR4 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6JR40,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 7FR 3D RIGHT LAUNCHR REF: LA73DRIGHT -,SUP-LA73DRIGHT,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUIDE 7 FR AL.75 SH D REF: LA7AL75SHD -,SUP-LA7AL75SHD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.081IN 7FR COR EBU3.5 100CM LAUNCHR BRD LRG LUM -,SUP-LA7EBU35,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.081IN 7FR COR EBU4 100CM LAUNCHR BRD LRG LUM -,SUP-LA7EBU40,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.081IN 7FR EBU4.5 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA7EBU45,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 7FR JR4 90CM LAUNCHR -,SUP-LA7JR40D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,256.74,179.718,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
GUIDE 8F AL 1.0 SH 90CM -,SUP-LA8AL10D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
GUIDE 8F AL 2.0 90CM MICR CATH -,SUP-LA8AL20D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
GUIDE 8F AL .75 90CM CATH -,SUP-LA8AL75D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
GUIDE 8F EBU 3.5 90CM -,SUP-LA8EBU35D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
GUIDE 8F EBU 3.5 SH 90CM -,SUP-LA8EBU35D SHD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
GUIDE 8F EBU 4.0 90CM -,SUP-LA8EBU40D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
GUIDE 8F JL 4.0 90CM -,SUP-LA8JL40D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
GUIDE 8F JL 4.0 SH 90CM -,SUP-LA8JL40D SHD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 105CM 20CM -,SUP-M001181250,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2497.81,1748.467,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D C 1 130CM 20CM -,SUP-M001181310,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2497.81,1748.467,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 150CM 20CM STC-18 -,SUP-M001181370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2497.81,1748.467,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 130CM 20CM -,SUP-M001182520,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1981.8,1387.26,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 150CM 20CM -,SUP-M001182530,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2297.77,1608.439,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
C RENEGADE HI-FLO MICROCATH -,SUP-M001183030,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2589.9,1812.93,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
MICROCATH INTVN 0.021IN SWAN 130CM DIREXION HI-FLO -,SUP-M001195300,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3221.16,2254.812,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH MICRO DREXION HI FLO J TO -,SUP-M001195470,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2566.03,1796.221,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.081IN 7FR LIMA 55CM MACH1 4X2 RND BRD LRG LUM -,SUP-M001197620,CDM,C1887,HCPCS,272,RC,,,outpatient,,,560.22,392.154,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH GUID 0.091IN 8FR LIMA 55CM MACH1 RND BRD LRG LUM PERIPH -,SUP-M001198620,CDM,C1887,HCPCS,272,RC,,,outpatient,,,560.22,392.154,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH ANG 4FR PIGTL 65CM IMAGER II SLCT FLSH BRD TRQ TUNG -,SUP-M001315091,CDM,C1887,HCPCS,272,RC,,,outpatient,,,58.24,40.768,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH ANG 4FR PIGTL 90CM IMAGER II FLSH BRD TRQ MED-GLD CTD -,SUP-M001315111,CDM,C1887,HCPCS,272,RC,,,outpatient,,,58.24,40.768,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH ANG 4FR CNTRLAT 2 CRV 65CM IMAGER II SLCT BRD TRQ SDE -,SUP-M001316581,CDM,C1887,HCPCS,272,RC,,,outpatient,,,58.24,40.768,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
MICRO GUIDE CATH FINECROSS M3 2.5 Fr 130 CM REF: M3-1430 -,SUP-M3-1430,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
MICRO GUIDE CATH FINECROSS M3 2.5 Fr 150 CM REF: M3-1450 -,SUP-M3-1450,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
PROGREAT 2.0 70 DEGREE ANGLE  150CM -,SUP-MC*PC2015ZRA,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3652.11,2556.477,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
PROGREAT COAXIAL MICROCATHETER2.4 FR  150CM   DEGREE ANGLE -,SUP-MC*PE24151YV,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2673.44,1871.408,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
PROGREAT COAXIAL 2.8 FR  150CM   RO MARKER BAND -,SUP-MC*PE28151YV,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2673.44,1871.408,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
PROGREAT 2.4  70 DEGREE ANGLE  150CM -,SUP-MC*PV2415ZRA,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2061.89,1443.323,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
PROGREAT MICROCATHETER 2.4x150CM -,SUP-MCPV2415Y,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1749.17,1224.419,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATHETER NAVICROSS 018 65CM ANGLED STAINLESS STEEL -,SUP-NC18651,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATHETER NAVICROSS 018 90CM ANGLED STAINLESS STEEL -,SUP-NC18901,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
C NAVICROSS 135CM .035 STR T -,SUP-NC35130,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
C NAVICROSS 135CM .035 ANGLE -,SUP-NC35131,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH INTVN 12MM TIP STR TAPR 150CM NAVICROSS SUPP DBL BRD -,SUP-NC35150,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATHETER SUPPORT NAVICROSS 0.035 150CM ANGLED -,SUP-NC35151,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
SHEATH GUID 6FRX90CM PINNACLE -,SUP-RSC03,CDM,C1887,HCPCS,272,RC,,,outpatient,,,743.96,520.772,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
SHEATH GUID 6FRX90CM PINNCL DSTNTN VASC STR CRV GOLD COIL. -,SUP-RSC05,CDM,C1887,HCPCS,272,RC,,,outpatient,,,743.96,520.772,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
SHEATH GUID 6FRX90CM PINNCL DSTNTN VASC MP CRV GOLD COIL -,SUP-RSC07,CDM,C1887,HCPCS,272,RC,,,outpatient,,,743.96,520.772,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
SHEATH GUID 6FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL- -,SUP-RSR01,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
SHEATH GUID 7FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-RSR04,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
SHEATH GUID 7FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-RSR04,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
TIP GUIDE CATH RELIEVA SPIN SPND SIN S-0 SHP TIP BLN WND ORT -,SUP-RSS0,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1696.16,1187.312,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH DX TAPR 65CM TRAILBLAZER SUPP HYDRCT -,SUP-SC035065,CDM,C1887,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATHETER GUIDING 6FR X 125 JL 5 JUDKINS -,SUP-SM7361,CDM,C1887,HCPCS,272,RC,,,outpatient,,,882.25,617.575,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
SHEATH 6.5 FR X 55CM X 17MM -,SUP-TG0655517,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH SHEATH RITESITE C315H20 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH SHEATH RITESITE C315H2001 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH SHEATH RITESITE C315H4001 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH SHEATH RITESITE C315J -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH SHEATH RITESITE C315S4 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH SHEATH RITESITE C315S401 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH SHEATH RITESITE C315J01 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH SHEATH RITESITE C315S10 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH SHEATH RITESITE C315S5 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH SHEATH RITESITE C315H40 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH SHEATH RITESITE C315S1001 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH SHEATH RITESITE C315S501 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH SHEATH RITESITE C315G -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
COIL MICRO RENEGADE STR FIBER -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2297.77,1608.439,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH OCL 0.97MM 6FR SHTH 110CM WILDCAT FLSH OTW 2MM XING -,SUP-W400,CDM,C1887,HCPCS,272,RC,,,outpatient,,,6769.18,4738.426,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
CATH OCL 0.43MM 5FR SHTH 150CM KITTYCAT 2 OTW 1.7MM XING -,SUP-W550,CDM,C1887,HCPCS,272,RC,,,outpatient,,,6769.18,4738.426,AETNA [1000108],AETNA [100010801],,,,,,2.22704,7607.37,other,272 with C codes,,
TUBE PEG 20FR PONSKY NBR NON BALLOON REPLACEMENT -,SUP-000700,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1250.92,875.644,AETNA [1000108],AETNA [100010801],,,76.8,,960.71,9.77024,11406.336,percent of total billed charges,,,
TUBE JJUNO 16FRX108IN PVC/PLST 15ML BLN LUMX2 -,SUP-0042510,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1602.34,1121.638,AETNA [1000108],AETNA [100010801],,,76.8,,1230.6,9.77024,11406.336,percent of total billed charges,,,
TUBE GASTROSTOMY 14 FR -,SUP-0100-14LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,AETNA [1000108],AETNA [100010801],,,76.8,,167.11,9.77024,11406.336,percent of total billed charges,,,
TUBE GASTROSTOMY FEEDING 16 FR -,SUP-010016LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,220.33,154.231,AETNA [1000108],AETNA [100010801],,,76.8,,169.21,9.77024,11406.336,percent of total billed charges,,,
TUBE GASTROSTOMY 16FR -,SUP-0100-16LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,AETNA [1000108],AETNA [100010801],,,76.8,,167.11,9.77024,11406.336,percent of total billed charges,,,
TUBE GASTROSTOMY FEEDING 18FR -,SUP-0100-18,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,AETNA [1000108],AETNA [100010801],,,76.8,,167.11,9.77024,11406.336,percent of total billed charges,,,
MIC GASTROSTOMY TUBE 20 FR -,SUP-0100-20,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,AETNA [1000108],AETNA [100010801],,,76.8,,167.11,9.77024,11406.336,percent of total billed charges,,,
TUBE GASTROSTOMY FEEDING 20 FR -,SUP-0100-20,CDM,C1889,HCPCS,278,RC,,,outpatient,,,45.16,31.612,AETNA [1000108],AETNA [100010801],,,76.8,,34.68,9.77024,11406.336,percent of total billed charges,,,
TUBE GASTROSTOMY FEEDING 22 FR -,SUP-0100-22,CDM,C1889,HCPCS,278,RC,,,outpatient,,,225.87,158.109,AETNA [1000108],AETNA [100010801],,,76.8,,173.47,9.77024,11406.336,percent of total billed charges,,,
MIC GASTROSTOMY TUBE 24 FR -,SUP-0100-24,CDM,C1889,HCPCS,278,RC,,,outpatient,,,43.52,30.464,AETNA [1000108],AETNA [100010801],,,76.8,,33.42,9.77024,11406.336,percent of total billed charges,,,
TUBE GASTROSTOMY 26 FR -,SUP-0100-26,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,AETNA [1000108],AETNA [100010801],,,76.8,,167.11,9.77024,11406.336,percent of total billed charges,,,
TUBE JJUNO 12FR SIL MI C SECUR-LOK XTRN RETEN RNG -,SUP-0200-12LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,AETNA [1000108],AETNA [100010801],,,76.8,,610.84,9.77024,11406.336,percent of total billed charges,,,
TUBE JJUNO 14FR SIL 7-10ML BLN MI C SECUR-LOK XTRN RETEN RNG -,SUP-0200-14,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,AETNA [1000108],AETNA [100010801],,,76.8,,610.84,9.77024,11406.336,percent of total billed charges,,,
TUBE FEEDING JEJUNAL 16F -,SUP-0200-16,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,AETNA [1000108],AETNA [100010801],,,76.8,,610.84,9.77024,11406.336,percent of total billed charges,,,
TUBE JJUNO 18FR SIL 7-10ML BLN MIC-KEY SECUR-LOK XTRN RETEN -,SUP-0200-18,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,AETNA [1000108],AETNA [100010801],,,76.8,,610.84,9.77024,11406.336,percent of total billed charges,,,
TUBE JEJUNOSTOMY 22FR MIC SECUR-LOK SILICONE -,SUP-0200-22,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,AETNA [1000108],AETNA [100010801],,,76.8,,610.84,9.77024,11406.336,percent of total billed charges,,,
TUBE JJUNO 22FRX45CM SIL 7-10ML BLN MIC-KEY LPRO -,SUP-0250-22,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1221.18,854.826,AETNA [1000108],AETNA [100010801],,,76.8,,937.87,9.77024,11406.336,percent of total billed charges,,,
TUBE MIC JEJUNOSTOMY 14FR / DR. GLEESON -,SUP-0301-14,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1113.49,779.443,AETNA [1000108],AETNA [100010801],,,76.8,,855.16,9.77024,11406.336,percent of total billed charges,,,
TUBE NG 6FR SALEM SMP 60CM VYGON -,SUP-1340.06,CDM,C1889,HCPCS,278,RC,,,outpatient,,,79.12,55.384,AETNA [1000108],AETNA [100010801],,,76.8,,60.76,9.77024,11406.336,percent of total billed charges,,,
CONNECTOR CATHETER NYLON STRAIGHT 1.5 X 1.0 X 1.9 -,SUP-45103,CDM,C1889,HCPCS,278,RC,,,outpatient,,,481.1,336.77,AETNA [1000108],AETNA [100010801],,,76.8,,369.48,9.77024,11406.336,percent of total billed charges,,,
CONNECTOR CSF CATH STRAIGHT 3 WAY IMP 2 X 1.5 X 1.8 X 1.0 -,SUP-45105,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1359.53,951.671,AETNA [1000108],AETNA [100010801],,,76.8,,1044.12,9.77024,11406.336,percent of total billed charges,,,
AZUR 18D SYSTEM 4MM X 5CM -,SUP-45-480405,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3570.95,2499.665,AETNA [1000108],AETNA [100010801],,,76.8,,2742.49,9.77024,11406.336,percent of total billed charges,,,
AZUR CX 35D 4MM X 7C3 DETACHABLE -,SUP-45-750407,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,AETNA [1000108],AETNA [100010801],,,76.8,,3559.26,9.77024,11406.336,percent of total billed charges,,,
AZUR CX .035 5MM X 11CM DETACH -,SUP-45-750511,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,AETNA [1000108],AETNA [100010801],,,76.8,,3559.26,9.77024,11406.336,percent of total billed charges,,,
AZUR CX DETACH 035 6MMX17CM -,SUP-45-750617,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,AETNA [1000108],AETNA [100010801],,,76.8,,3559.26,9.77024,11406.336,percent of total billed charges,,,
AZUR CK DETACHABLE 035 8MM X 12CM -,SUP-45-750812,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,AETNA [1000108],AETNA [100010801],,,76.8,,3559.26,9.77024,11406.336,percent of total billed charges,,,
AZUR CX DETACH 035 8MMX24CM -,SUP-45-750824,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,AETNA [1000108],AETNA [100010801],,,76.8,,3559.26,9.77024,11406.336,percent of total billed charges,,,
AZUR CX DETACH 035 10MMX19CM -,SUP-45-751019,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,AETNA [1000108],AETNA [100010801],,,76.8,,3559.26,9.77024,11406.336,percent of total billed charges,,,
AZUR CX 35 DETACH 13MMX24CM CX COIL -,SUP-45-751324,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,AETNA [1000108],AETNA [100010801],,,76.8,,3559.26,9.77024,11406.336,percent of total billed charges,,,
AZUR CX 35D 16MM X 32 CM -,SUP-45-751632,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,AETNA [1000108],AETNA [100010801],,,76.8,,3559.26,9.77024,11406.336,percent of total billed charges,,,
AZUR CX 35D 20MM X 39 CM -,SUP-45-752039,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,AETNA [1000108],AETNA [100010801],,,76.8,,3559.26,9.77024,11406.336,percent of total billed charges,,,
AZUR CX DETACHABLE 018 6MM X 20CM -,SUP-45-780620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,9.77024,11406.336,percent of total billed charges,,,
AZUR CX DETACHABLE 018 7MM X 24CM -,SUP-45-780724,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,9.77024,11406.336,percent of total billed charges,,,
AZUR CX DETACHABLE 018 8MM X 28CM -,SUP-45-780828,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,9.77024,11406.336,percent of total billed charges,,,
COIL EMBOLIZATION POD 0.020IN 4MM 30CM FULLY DETACHABLE RESH -,SUP-90178538,CDM,C1889,HCPCS,278,RC,,,outpatient,,,8190.92,5733.644,AETNA [1000108],AETNA [100010801],,,76.8,,6290.63,9.77024,11406.336,percent of total billed charges,,,
KIT INTRO GASTROSTOMY FEED -,SUP-98432,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1149.84,804.888,AETNA [1000108],AETNA [100010801],,,76.8,,883.08,9.77024,11406.336,percent of total billed charges,,,
SENTINEL CEREBRAL PROTECTION SYSTEM REF: CMS15-10C-US -,SUP-CMS15-10C-US,CDM,C1889,HCPCS,278,RC,,,outpatient,,,14852,10396.4,AETNA [1000108],AETNA [100010801],,,76.8,,11406.34,9.77024,11406.336,percent of total billed charges,,,
COIL EMBOLIZATION NESTER MICROCOIL PLATINUM L3 CM OD2 MM . -,SUP-G47331,CDM,C1889,HCPCS,278,RC,,,outpatient,,,577.61,404.327,AETNA [1000108],AETNA [100010801],,,76.8,,443.6,9.77024,11406.336,percent of total billed charges,,,
14X14 NESTER COIL 0.035 -,SUP-G47347,CDM,C1889,HCPCS,278,RC,,,outpatient,,,705.98,494.186,AETNA [1000108],AETNA [100010801],,,76.8,,542.19,9.77024,11406.336,percent of total billed charges,,,
CATH COOK AIRWAY EXCHANGE 14FR 83CM. -,SUP-G57622,CDM,C1889,HCPCS,278,RC,,,outpatient,,,374.02,261.814,AETNA [1000108],AETNA [100010801],,,76.8,,287.25,9.77024,11406.336,percent of total billed charges,,,
SPACER BONE CERVICAL LOR 6MM -,SUP-LGAL906,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.77024,11406.336,percent of total billed charges,,,
SPACER BONE CERVICAL LOR 7MM -,SUP-LGAL907,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.77024,11406.336,percent of total billed charges,,,
SPACER BONE CERVICAL LOR 8MM -,SUP-LGAL908,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.77024,11406.336,percent of total billed charges,,,
SPACER BONE CERVICAL PAR 6MM -,SUP-LGAP906-P,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.77024,11406.336,percent of total billed charges,,,
SPACER BONE CERVICAL PAR 7MM -,SUP-LGAP907-P,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.77024,11406.336,percent of total billed charges,,,
SPACER BONE CERVICAL PAR 8MM -,SUP-LGAP908-P,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,9.77024,11406.336,percent of total billed charges,,,
CATHETER DELIVERY AVEIR REF:LSCD111 -,SUP-LSCD111,CDM,C1889,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA [1000108],AETNA [100010801],,,76.8,,5703.94,9.77024,11406.336,percent of total billed charges,,,
BASKET SPECIMEN RETRIEVAL ZERO TIP 0.8MM 12MM ENDOSCOPIC -,SUP-M00513200,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1398.8,979.16,AETNA [1000108],AETNA [100010801],,,76.8,,1074.28,9.77024,11406.336,percent of total billed charges,,,
PROBE BILIARY EHL -,SUP-M00546620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2273.91,1591.737,AETNA [1000108],AETNA [100010801],,,76.8,,1746.36,9.77024,11406.336,percent of total billed charges,,,
TUBE PEG 16FR ENDOVIVE LPRO PUL LF -,SUP-M00582060,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,AETNA [1000108],AETNA [100010801],,,76.8,,128.75,9.77024,11406.336,percent of total billed charges,,,
TUBE PEG 18FR ENDOVIVE LPRO PUL LF -,SUP-M00582070,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,AETNA [1000108],AETNA [100010801],,,76.8,,128.75,9.77024,11406.336,percent of total billed charges,,,
KIT BALLOON REPLACEMENT STRAIGHT BOLSTER 20FR -,SUP-M00582080,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,AETNA [1000108],AETNA [100010801],,,76.8,,128.75,9.77024,11406.336,percent of total billed charges,,,
KT TUBE PEG 24FR ENDOVIVE LPRO PUL LF -,SUP-M00582090,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,AETNA [1000108],AETNA [100010801],,,76.8,,128.75,9.77024,11406.336,percent of total billed charges,,,
KIT BALLOON REPLACEMENT RIGHT ANGLE BOLSTER 20FR -,SUP-M00582150,CDM,C1889,HCPCS,278,RC,,,outpatient,,,192.44,134.708,AETNA [1000108],AETNA [100010801],,,76.8,,147.79,9.77024,11406.336,percent of total billed charges,,,
TUBE PEG 24FR 3ML BLN SIL ENDOVIVE RT ANG LF -,SUP-M00582160,CDM,C1889,HCPCS,278,RC,,,outpatient,,,192.44,134.708,AETNA [1000108],AETNA [100010801],,,76.8,,147.79,9.77024,11406.336,percent of total billed charges,,,
WATCHMAN FXD CURVE ACCESS SYSTEM SGL US REF: M635TU80010 -,SUP-M635TU80010,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.77024,11406.336,percent of total billed charges,,,
WATCHMAN FXD CURVE ACCESS SYSTEM DBL US REF: M635TU80020 -,SUP-M635TU80020,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,9.77024,11406.336,percent of total billed charges,,,
TUBE PEG 14FR 5ML BALLON TRITON LTX -,SUP-PEG-14-BRT-TR1,CDM,C1889,HCPCS,278,RC,,,outpatient,,,233.4,163.38,AETNA [1000108],AETNA [100010801],,,76.8,,179.25,9.77024,11406.336,percent of total billed charges,,,
COIL EMBL 3MMX5CM RUBY MICRO CMPLX STD FRM FLLY DTCH RSHEATH -,SUP-RBY2C0305,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,AETNA [1000108],AETNA [100010801],,,76.8,,3629.77,9.77024,11406.336,percent of total billed charges,,,
COIL EMBL 3MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0320,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4769.23,3338.461,AETNA [1000108],AETNA [100010801],,,76.8,,3662.77,9.77024,11406.336,percent of total billed charges,,,
COIL EMBL 4MMX10CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0410,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA [1000108],AETNA [100010801],,,76.8,,3552.74,9.77024,11406.336,percent of total billed charges,,,
COIL EMBL 4MMX15CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0415,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA [1000108],AETNA [100010801],,,76.8,,3552.74,9.77024,11406.336,percent of total billed charges,,,
COIL EMBL 4MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0420,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA [1000108],AETNA [100010801],,,76.8,,3552.74,9.77024,11406.336,percent of total billed charges,,,
COIL EMBL 4MMX35CM RUBY CMPLX STD FRM FLLY DTCH RSHEATH -,SUP-RBY2C0435,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA [1000108],AETNA [100010801],,,76.8,,4530.55,9.77024,11406.336,percent of total billed charges,,,
COIL EMBL 5MMX12CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0512,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA [1000108],AETNA [100010801],,,76.8,,3552.74,9.77024,11406.336,percent of total billed charges,,,
COIL EMBL 5MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0520,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA [1000108],AETNA [100010801],,,76.8,,3552.74,9.77024,11406.336,percent of total billed charges,,,
COIL EMBL 5MMX30CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0530,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA [1000108],AETNA [100010801],,,76.8,,4530.55,9.77024,11406.336,percent of total billed charges,,,
COIL EMBL 6MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4769.23,3338.461,AETNA [1000108],AETNA [100010801],,,76.8,,3662.77,9.77024,11406.336,percent of total billed charges,,,
COIL EMBL 6MMX30CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0630,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,AETNA [1000108],AETNA [100010801],,,76.8,,4233.95,9.77024,11406.336,percent of total billed charges,,,
COIL EMBL 7MMX25CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0725,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA [1000108],AETNA [100010801],,,76.8,,3552.74,9.77024,11406.336,percent of total billed charges,,,
COIL EMBL 8MMX25CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0825,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA [1000108],AETNA [100010801],,,76.8,,3552.74,9.77024,11406.336,percent of total billed charges,,,
COIL EMBL 8MMX40CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0840,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,AETNA [1000108],AETNA [100010801],,,76.8,,4233.95,9.77024,11406.336,percent of total billed charges,,,
COIL EMBL 9MMX30CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0930,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA [1000108],AETNA [100010801],,,76.8,,4530.55,9.77024,11406.336,percent of total billed charges,,,
COIL EMBL 10MMX35CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1035,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA [1000108],AETNA [100010801],,,76.8,,4530.55,9.77024,11406.336,percent of total billed charges,,,
COIL EMBL 12MMX40CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1240,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA [1000108],AETNA [100010801],,,76.8,,4530.55,9.77024,11406.336,percent of total billed charges,,,
COIL EMBL 12MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1260,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA [1000108],AETNA [100010801],,,76.8,,4530.55,9.77024,11406.336,percent of total billed charges,,,
COIL EMBL 14MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1460,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,AETNA [1000108],AETNA [100010801],,,76.8,,4233.95,9.77024,11406.336,percent of total billed charges,,,
COIL EMBL 16MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1660,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,AETNA [1000108],AETNA [100010801],,,76.8,,4233.95,9.77024,11406.336,percent of total billed charges,,,
COIL EMBL 18MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1857,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA [1000108],AETNA [100010801],,,76.8,,4530.55,9.77024,11406.336,percent of total billed charges,,,
COIL EMBL 20MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C2060,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA [1000108],AETNA [100010801],,,76.8,,4530.55,9.77024,11406.336,percent of total billed charges,,,
COIL EMBL 24MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C2457,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA [1000108],AETNA [100010801],,,76.8,,4530.55,9.77024,11406.336,percent of total billed charges,,,
COIL EMBL 28MMX60CM RUBY MICRO CMPLX STD FRM FLLY -,SUP-RBY2C2860,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA [1000108],AETNA [100010801],,,76.8,,4530.55,9.77024,11406.336,percent of total billed charges,,,
COIL EMBL 32MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C3260,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA [1000108],AETNA [100010801],,,76.8,,4530.55,9.77024,11406.336,percent of total billed charges,,,
RUBYCOIL 36MM X 60MM STANDARD -,SUP-RBY2C3660,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA [1000108],AETNA [100010801],,,76.8,,4530.55,9.77024,11406.336,percent of total billed charges,,,
RUBYCOIL 40MM X 60MM STANDARD -,SUP-RBY2C4060,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA [1000108],AETNA [100010801],,,76.8,,4530.55,9.77024,11406.336,percent of total billed charges,,,
COIL EMBL 2MMX4CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH PLTNM -,SUP-RBY4C0204,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3814.43,2670.101,AETNA [1000108],AETNA [100010801],,,76.8,,2929.48,9.77024,11406.336,percent of total billed charges,,,
COIL EMBL 3MMX5CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH PLTNM -,SUP-RBY4C0305,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,AETNA [1000108],AETNA [100010801],,,76.8,,3629.77,9.77024,11406.336,percent of total billed charges,,,
COIL EMBL 3MMX15CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0315,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA [1000108],AETNA [100010801],,,76.8,,3552.74,9.77024,11406.336,percent of total billed charges,,,
COIL EMBL 4MMX6CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH PLTNM -,SUP-RBY4C0406,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,AETNA [1000108],AETNA [100010801],,,76.8,,3629.77,9.77024,11406.336,percent of total billed charges,,,
COIL EMBL 4MMX15CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0415,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA [1000108],AETNA [100010801],,,76.8,,3552.74,9.77024,11406.336,percent of total billed charges,,,
COIL EMBL 6MMX20CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA [1000108],AETNA [100010801],,,76.8,,3552.74,9.77024,11406.336,percent of total billed charges,,,
COIL EMBL 6MMX30CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0630,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA [1000108],AETNA [100010801],,,76.8,,4530.55,9.77024,11406.336,percent of total billed charges,,,
COIL EMBL 8MMX35CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0835,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA [1000108],AETNA [100010801],,,76.8,,4530.55,9.77024,11406.336,percent of total billed charges,,,
COIL EMBL 8MMX60CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0860,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,AETNA [1000108],AETNA [100010801],,,76.8,,4233.95,9.77024,11406.336,percent of total billed charges,,,
COIL EMBL 16MMX50CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C1650,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA [1000108],AETNA [100010801],,,76.8,,4530.55,9.77024,11406.336,percent of total billed charges,,,
RUBY COIL LP- 1 MM x 5 CM PERIPHERAL EMBOLIZATION COILS -,SUP-RBYLP0105,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,AETNA [1000108],AETNA [100010801],,,76.8,,3629.77,9.77024,11406.336,percent of total billed charges,,,
RUBY COIL LP- 2 MM x 10 CM PERIPHERAL EMBOLIZATION COILS -,SUP-RBYLP0210,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA [1000108],AETNA [100010801],,,76.8,,3552.74,9.77024,11406.336,percent of total billed charges,,,
RUBY COIL LP- 3 MM x 4 CM PERIPHERAL EMBOLIZATION COILS -,SUP-RBYLP0304,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,AETNA [1000108],AETNA [100010801],,,76.8,,3629.77,9.77024,11406.336,percent of total billed charges,,,
PENUMBRA RUBY POD 6MM X 50CM -,SUP-RBYPOD6,CDM,C1889,HCPCS,278,RC,,,outpatient,,,8190.92,5733.644,AETNA [1000108],AETNA [100010801],,,76.8,,6290.63,9.77024,11406.336,percent of total billed charges,,,
SPACE OAR VUE HYDROGEL -,SUP-SV-2101,CDM,C1889,HCPCS,278,RC,,,outpatient,,,12791.29,8953.903,AETNA [1000108],AETNA [100010801],,,76.8,,9823.71,9.77024,11406.336,percent of total billed charges,,,
INTRO SHTH 6FRX14CM J SHP TIP 12ML SYR DI-LOK DILATOR 18GA -,SUP-405104,CDM,C1892,HCPCS,272,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,,,,20.121935,3080.6622,other,272 with C codes,,
INTRO SHTH 7FRX14CM 0.038INX50CM JTP GW 18GA XTW NDL 12ML -,SUP-405108,CDM,C1892,HCPCS,272,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,,,,20.121935,3080.6622,other,272 with C codes,,
KT 12FR 18GAX14CM 0.38INX50CM GW CV 3MM JTP PEEL-AWAY -,SUP-405120,CDM,C1892,HCPCS,272,RC,,,outpatient,,,186.72,130.704,AETNA [1000108],AETNA [100010801],,,,,,20.121935,3080.6622,other,272 with C codes,,
INTRO SHTH 10.5FRX14CM 0.038INX50CM JTP GW 18GA XTW NDL 12ML -,SUP-405122,CDM,C1892,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,20.121935,3080.6622,other,272 with C codes,,
INTRO SHTH 8T-TW FR DIA 14CM 0.038INX50CM JTP GW 18GA XTW -,SUP-405129,CDM,C1892,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA [1000108],AETNA [100010801],,,,,,20.121935,3080.6622,other,272 with C codes,,
INTRO SHTH 8FRX14CM J SHP TIP 12ML SYR DI-LOK DILATOR 18GA -,SUP-405145,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,,,,20.121935,3080.6622,other,272 with C codes,,
INTRO LD 9FR PEEL-AWAY SHTH SGL-CHMBR -,SUP-405147,CDM,C1892,HCPCS,272,RC,,,outpatient,,,320.93,224.651,AETNA [1000108],AETNA [100010801],,,,,,20.121935,3080.6622,other,272 with C codes,,
INTRO SHTH 8FRX14CM 0.038IN GW DI- LOCK DILATOR -,SUP-405412,CDM,C1892,HCPCS,272,RC,,,outpatient,,,90.56,63.392,AETNA [1000108],AETNA [100010801],,,,,,20.121935,3080.6622,other,272 with C codes,,
INTRO SHTH 9FRX14CM 0.038IN GW DI- LOCK DILATOR -,SUP-405416,CDM,C1892,HCPCS,272,RC,,,outpatient,,,89.63,62.741,AETNA [1000108],AETNA [100010801],,,,,,20.121935,3080.6622,other,272 with C codes,,
TRANSDC TRANSTHORACIC BTRY PK VIEWMATE -,SUP-405422,CDM,C1892,HCPCS,272,RC,,,outpatient,,,175.05,122.535,AETNA [1000108],AETNA [100010801],,,,,,20.121935,3080.6622,other,272 with C codes,,
INTRO SHTH 11FRX14CM 0.038INX50CM JTP GW 18GA XTW NDL 12ML -,SUP-405424,CDM,C1892,HCPCS,272,RC,,,outpatient,,,175.05,122.535,AETNA [1000108],AETNA [100010801],,,,,,20.121935,3080.6622,other,272 with C codes,,
INTRO VASC 8FR SUPER SHTH INFS SDPRT -,SUP-CLS-1008,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,,,,20.121935,3080.6622,other,272 with C codes,,
INTRO VASC 8.5FR SUPER SHTH INFS SDPRT -,SUP-CLS-1008.5,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,,,,20.121935,3080.6622,other,272 with C codes,,
INTRO VASC 10.5FR SUPER SHTH INFS SDPRT -,SUP-CLS-1010.5,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,,,,20.121935,3080.6622,other,272 with C codes,,
INTRO VASC 8FR LNG SUPER SHTH INFS SDPRT -,SUP-CLS-2508,CDM,C1892,HCPCS,272,RC,,,outpatient,,,301.67,211.169,AETNA [1000108],AETNA [100010801],,,,,,20.121935,3080.6622,other,272 with C codes,,
CPS DIRECT MEDI GUIDE ENABLED OUT CATH  RIGHT -,SUP-DS2M044,CDM,C1892,HCPCS,272,RC,,,outpatient,,,4296.6,3007.62,AETNA [1000108],AETNA [100010801],,,,,,20.121935,3080.6622,other,272 with C codes,,
SET INTRODUCER PEEL-AWAY SAFE-T-J -,SUP-G04496,CDM,C1892,HCPCS,272,RC,,,outpatient,,,397.66,278.362,AETNA [1000108],AETNA [100010801],,,,,,20.121935,3080.6622,other,272 with C codes,,
SHEATH SAFE PRELUDE 6F 13CM LN -,SUP-PLS-1006,CDM,C1892,HCPCS,272,RC,,,outpatient,,,274.25,191.975,AETNA [1000108],AETNA [100010801],,,,,,20.121935,3080.6622,other,272 with C codes,,
INTRODUCER MERIT PRELUDE 9F 25CM -,SUP-PLS-2509,CDM,C1892,HCPCS,272,RC,,,outpatient,,,301.67,211.169,AETNA [1000108],AETNA [100010801],,,,,,20.121935,3080.6622,other,272 with C codes,,
INTRODUCER 9FR OPTISEAL -,SUP-UNDEFINED,CDM,C1892,HCPCS,272,RC,,,outpatient,,,379.28,265.496,AETNA [1000108],AETNA [100010801],,,,,,20.121935,3080.6622,other,272 with C codes,,
CATH GUID 7FR COR -,SUP-358735,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2448.83,1714.181,AETNA [1000108],AETNA [100010801],,,,,,165.054645,2224.9227,other,272 with C codes,,
INTRO  SL1  CURVE - SJM 8.5FRX 63CM -,SUP-406849,CDM,C1893,HCPCS,272,RC,,,outpatient,,,892.76,624.932,AETNA [1000108],AETNA [100010801],,,,,,165.054645,2224.9227,other,272 with C codes,,
INTRO GUID 8.5FRX60CM FAST-CATH SWARTZ TRNSEPT SAFL CRV -,SUP-406868,CDM,C1893,HCPCS,272,RC,,,outpatient,,,898.59,629.013,AETNA [1000108],AETNA [100010801],,,,,,165.054645,2224.9227,other,272 with C codes,,
INTRO GUID 8FRX60CM FAST-CATH SWARTZ TRNSEPT SAFL CRV -,SUP-406871,CDM,C1893,HCPCS,272,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,,,,165.054645,2224.9227,other,272 with C codes,,
INTRO GUID 8FRX60CM FAST-CATH SWARTZ TRNSEPT SEPT CRV -,SUP-406885,CDM,C1893,HCPCS,272,RC,,,outpatient,,,904.43,633.101,AETNA [1000108],AETNA [100010801],,,,,,165.054645,2224.9227,other,272 with C codes,,
INTRO SEPT CURVE-SJM  8.5FRX60CM -,SUP-406894,CDM,C1893,HCPCS,272,RC,,,outpatient,,,898.59,629.013,AETNA [1000108],AETNA [100010801],,,,,,165.054645,2224.9227,other,272 with C codes,,
INTRO  RAMP  CURVE - SJM 8.5FRX 63CM -,SUP-406965,CDM,C1893,HCPCS,272,RC,,,outpatient,,,735.21,514.647,AETNA [1000108],AETNA [100010801],,,,,,165.054645,2224.9227,other,272 with C codes,,
SHEATH GUIDE LAMP 45 407363 -,SUP-407363,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1015.29,710.703,AETNA [1000108],AETNA [100010801],,,,,,165.054645,2224.9227,other,272 with C codes,,
INTRODUCER CATHETER BRITE TIP RADIANZ GUIDING 6FR 110CM -,SUP-687280110,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1363.55,954.485,AETNA [1000108],AETNA [100010801],,,,,,165.054645,2224.9227,other,272 with C codes,,
INTRODUCER CATHETER BRITE TIP RADIANZ GUIDING 6FR 135CM -,SUP-687280135,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1363.55,954.485,AETNA [1000108],AETNA [100010801],,,,,,165.054645,2224.9227,other,272 with C codes,,
TRANSSEPTAL ACCESS STYSTEM ACQCROSS QX AG 71 CM REF: 900301 -,SUP-900301,CDM,C1893,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,,,,165.054645,2224.9227,other,272 with C codes,,
TRANSSEPTAL ACCESS STYSTEM ACQCROSS QX - FC 65CM REF: 900304 -,SUP-900304,CDM,C1893,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,,,,165.054645,2224.9227,other,272 with C codes,,
TRANSSEPTAL ACCESS STYSTEM ACQCROSS  WT 75CM REF: 900308 -,SUP-900308,CDM,C1893,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,AETNA [1000108],AETNA [100010801],,,,,,165.054645,2224.9227,other,272 with C codes,,
FLEXCATH CROSS FCC 65CM 10FR REF:900310 -,SUP-900310,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,,,,165.054645,2224.9227,other,272 with C codes,,
FLEXCATH CROSS FCC 65CM 12FR REF:900311 -,SUP-900311,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,,,,165.054645,2224.9227,other,272 with C codes,,
CATHETER CPS LOCATOR 3D- LAGE EXTRA LONG REF:DS2C300-45 -,SUP-DS2C300-45,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,,,,165.054645,2224.9227,other,272 with C codes,,
SHEATH GUID WORLEY RNL TLSCP GUIDE -,SUP-LVI7556207RE,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2464.73,1725.311,AETNA [1000108],AETNA [100010801],,,,,,165.054645,2224.9227,other,272 with C codes,,
TORFLEX TRANSSEPTAL GUIDING SH -,SUP-TF85-32-63-45,CDM,C1893,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,165.054645,2224.9227,other,272 with C codes,,
DILATOR VESSEL 5 FR 35 -,SUP-040037A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,23.34,16.338,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
MICINTRO VASC 4.5FRX50CM MICRO EZ FNL DSGN SMTH DILATOR PTFE -,SUP-0928945,CDM,C1894,HCPCS,272,RC,,,outpatient,,,205.74,144.018,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
MICINTRO VASC 5FRX50CM MICRO EZ FNL DSGN SMTH DILATOR PTFE -,SUP-0928950,CDM,C1894,HCPCS,272,RC,,,outpatient,,,213.56,149.492,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
MICINTRO VASC 6FRX50CM MICRO EZ SMTH DILATOR PTFE 7CM A BVL -,SUP-0928960,CDM,C1894,HCPCS,272,RC,,,outpatient,,,189.64,132.748,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH INTRO 6FRX10CM PINNCL TIF TIP PERIPH 0.038INX45CM SS -,SUP-10-2032,CDM,C1894,HCPCS,272,RC,,,outpatient,,,72.94,51.058,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO INFS 7FR PEEL-AWAY -,SUP-120089,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.83,253.281,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH INTRO 5FRX10CM GLIDESHEATH RADL STR GOLD COIL MRKR -,SUP-20 -1050,CDM,C1894,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH INTRO 6FRX10CM GLIDESHEATH RADL STR GOLD COIL MRKR -,SUP-20 -1060,CDM,C1894,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
S COOK 7FR X 6CM -,SUP-242381,CDM,C1894,HCPCS,272,RC,,,outpatient,,,170.73,119.511,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH INTRO 5FRX10CM GLIDESHEATH RADL STR CRV GOLD COIL -,SUP-30-1050,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.48,364.336,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH INTRO 6FRX10CM GLIDESHEATH RADL STR CRV GOLD COIL -,SUP-30-1060,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.48,364.336,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH INTRO 6FRX10CM GLIDESHEATH RADL  STR CRV GOLD COIL -,SUP-30-1065,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.48,364.336,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH GUID 0.110IN 8FRX62CM PREFACE MP ST TAPR PRFL -,SUP-301803MS,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO CATH 4FRX3.2CM INTRSYT-N PERC SHLD -,SUP-384011,CDM,C1894,HCPCS,272,RC,,,outpatient,,,234.57,164.199,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO CATH 1.9FRX1.9CM INTRSYT-N PERC SHLD -,SUP-384021,CDM,C1894,HCPCS,272,RC,,,outpatient,,,280.08,196.056,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
FORTRESS SHEATH 5FR x 45CM -,SUP-386591,CDM,C1894,HCPCS,272,RC,,,outpatient,,,102.7,71.89,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
FORTRESS SHEALTH 5FRx45CM -,SUP-386591,CDM,C1894,HCPCS,272,RC,,,outpatient,,,102.7,71.89,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 10FRX11CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-011M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
S BRITE TIP 10FR 11CM  RB -,SUP-401-011M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH BRITE TIP 4F 11CM -,SUP-401411M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH 5FR 11CM BRITE TIP -,SUP-401511M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH 5FR BRITE TIP 23CM -,SUP-401-523M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 5FRX55CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-555M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 6FRX5.5CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401605M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 6FRX5.5CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-605M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH 6FR 11CM BRITE TIP -,SUP-401-611M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 6FRX5.5CM X 23CM CANN BRT TIP PERC TAPR SMTH -,SUP-401-623M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH 6F 23CM BRITE TIP -,SUP-401-623M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 6FRX55CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-655M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH 7 FR 11CM BRITE TIP -,SUP-401-711M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH 7FR X 23CM BRITE TIP -,SUP-401-723M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 7FRX45CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-745M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH 8FR 11CM BRITE TIP -,SUP-401-811M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
S BRITE TIP 8FR 23CM RB -,SUP-401-823M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 8FRX45CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-845M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
S BRITE TIP 9FR X 11CM RB -,SUP-401-911M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHTH INTRO 11FR X 11CM CANN BRT -,SUP-402611X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,43.18,30.226,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 6FR STD L 11CM REF: 402656X -,SUP-402656X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,43.18,30.226,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 2MM ANCURE -,SUP-40320,CDM,C1894,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
HEMOSTASIS INTRODUCER FAST CATH 10FRX30CM REF: 406180 -,SUP-406180,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.77,253.239,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
HEMOSTASIS INTRODUCER FAST CATH 14FRX30CM REF: 406188 -,SUP-406188,CDM,C1894,HCPCS,272,RC,,,outpatient,,,385.11,269.577,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
FAST CATH DUO SHEATH 12F  12CM -,SUP-406301,CDM,C1894,HCPCS,272,RC,,,outpatient,,,140.04,98.028,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 7FRX12CM FAST-CATH CATH-LOCK PERC JTP STR SNP -,SUP-406702,CDM,C1894,HCPCS,272,RC,,,outpatient,,,62.26,43.582,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 8FRX12CM FAST-CATH CATH-LOCK PERC JTP STR SNP -,SUP-406706,CDM,C1894,HCPCS,272,RC,,,outpatient,,,105.03,73.521,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 4FRX12CM FAST-CATH CATH-LOCK PERC JTP STR SNP -,SUP-406709,CDM,C1894,HCPCS,272,RC,,,outpatient,,,105.03,73.521,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 8FRX60CM FAST-CATH TRNSEPT MLNS CRV SNP LOCK -,SUP-406805,CDM,C1894,HCPCS,272,RC,,,outpatient,,,501.81,351.267,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SR0 CURVE-SJM -,SUP-406853,CDM,C1894,HCPCS,272,RC,,,outpatient,,,898.59,629.013,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH AGILIS MED-REPROC  8.5X 71CM -,SUP-408310,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2473.84,1731.688,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 4FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-604X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 6FR MI D L 23CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-606D,CDM,C1894,HCPCS,272,RC,,,outpatient,,,93.36,65.352,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 7FR MI D L 23CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-607T,CDM,C1894,HCPCS,272,RC,,,outpatient,,,93.36,65.352,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH INTRODUCER AVANTI 7FR X 11 CM -,SUP-504-607X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 8FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-608X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 9FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-609X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 10FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504610X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 11FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-611X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 5MS FR DIA MI D L 23CM CANN AVANTI + PERC TAPR SS -,SUP-504-655T,CDM,C1894,HCPCS,272,RC,,,outpatient,,,103.57,72.499,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 5MS DIA STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-655X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 5MS DIA STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-655X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 6MS FR DIA MI D L 23CM CANN AVANTI + PERC TAPR SS -,SUP-504-656T,CDM,C1894,HCPCS,272,RC,,,outpatient,,,93.36,65.352,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 6FR STD L 11CM CANN AVANTI  PERC TAPR SS W/O -,SUP-504-656X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 6FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-656X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
MONITORING SHEATH 7 FR INTRO -,SUP-504-657X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 8MS DIA STD L 11CM CANN AVANTI PERC TAPR SS W/O -,SUP-504-658X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
TIGHTRAIL MINI 11FR 545-011 -,SUP-540-011,CDM,C1894,HCPCS,272,RC,,,outpatient,,,7193.58,5035.506,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
TIGHTRAIL MINI  9FR 545-009 -,SUP-545-009,CDM,C1894,HCPCS,272,RC,,,outpatient,,,7193.58,5035.506,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
TIGHTRAIL LONG  9FR 545-509 -,SUP-545-509,CDM,C1894,HCPCS,272,RC,,,outpatient,,,10121.94,7085.358,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
TIGHTRAIL LONG 11FR 545-511 -,SUP-545-511,CDM,C1894,HCPCS,272,RC,,,outpatient,,,10121.94,7085.358,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
TIGHTRAIL LONG 13FR 545-513 -,SUP-545-513,CDM,C1894,HCPCS,272,RC,,,outpatient,,,10121.94,7085.358,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH GUID 8FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-54-84501,CDM,C1894,HCPCS,272,RC,,,outpatient,,,609.76,426.832,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
GLIDESHEATH SLENDER 6FR X 10CM X .021CM SS GLIDEWIRE -,SUP-60-1060,CDM,C1894,HCPCS,272,RC,,,outpatient,,,353.02,247.114,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
GLIDESHEATH SLENDER A KIT 0.025 GW 6FR 10CM -,SUP-60-1065,CDM,C1894,HCPCS,272,RC,,,outpatient,,,619.97,433.979,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
GLIDESHEATH SLENDER A KIT 0.025 GW 7FR 10CM -,SUP-60-1075,CDM,C1894,HCPCS,272,RC,,,outpatient,,,619.97,433.979,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 7FRX11CM INPUT PS PERC 0.038IN GW COMP VES -,SUP-700-11,CDM,C1894,HCPCS,272,RC,,,outpatient,,,56.02,39.214,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRODUCER SET 11 FR - DISCONTINUED DO NOT USE -,SUP-7097,CDM,C1894,HCPCS,272,RC,,,outpatient,,,320.93,224.651,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
GLIDESHEATH SLENDER SS KIT 0.025 GW 6FR 10CM -,SUP-80-1065,CDM,C1894,HCPCS,272,RC,,,outpatient,,,353.02,247.114,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
GLIDESHEATH SLENDER SS KIT 0.025 GW 7FR 10CM -,SUP-80-1075,CDM,C1894,HCPCS,272,RC,,,outpatient,,,353.02,247.114,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
AMPLATZER DELIVERY SHEATH TORQVUE 2 5FR REF: 9-TV2-05F120 -,SUP-90176109,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
AMPLATZER DELIVERY SHEATH TORQVUE 2 6FR REF: 9-TV2-06F120 -,SUP-9-TV2-06F120,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
TORQVUE SHEATH 14F 80CM 45X45 REF: 9-TV45X45-14F-080 -,SUP-9-TV45X45-14F-080,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4676.89,3273.823,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
OBTURATOR VASC 8FR SHRT -,SUP-AO-09000,CDM,C1894,HCPCS,272,RC,,,outpatient,,,13.65,9.555,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
CATH PA 7FR X 110CM SWAN-GNZ LUMX4 PLYMR BLND -,SUP-C146F7,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2531.31,1771.917,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRODUCER SHEATH 8.5FR CATH-GARD PERC ARROW KIT -,SUP-CDC-09803-1A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,430.62,301.434,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
9FR. PERC SHEATH INTRO KIT -,SUP-CDC-09903-1A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,418.37,292.859,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 10FRX35CM SUPER ARROW-FLEX PERC SNP-LOCK MIN -,SUP-CL-07035,CDM,C1894,HCPCS,272,RC,,,outpatient,,,547.82,383.474,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 5FR SHTH 4.375IN SHTH 0.035-0.038IN GW HEMSTS VLV -,SUP-CL-07511,CDM,C1894,HCPCS,272,RC,,,outpatient,,,182.55,127.785,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 6FRX24CM SUPER ARROW-FLEX PERC 0.038IN GW COMP -,SUP-CL-07624,CDM,C1894,HCPCS,272,RC,,,outpatient,,,431.79,302.253,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 6FRX45CM SUPER ARROW-FLEX PERC ANTMIC SURF PU -,SUP-CL-07645,CDM,C1894,HCPCS,272,RC,,,outpatient,,,553.38,387.366,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 7FRX24CM SUPER ARROW-FLEX PERC INTGR HEMSTS -,SUP-CL-07724,CDM,C1894,HCPCS,272,RC,,,outpatient,,,379.08,265.356,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 7FRX45CM SUPER ARROW-FLEX PERC ANTMIC SURF PU -,SUP-CL-07745,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.82,364.574,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH CLASSICSHEATH 6FR STD 13CM CRV GRN CAP -,SUP-CLS-1006,CDM,C1894,HCPCS,272,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO VASC 7FR SAFESHEATH INFS SDPRT -,SUP-CLS-1007,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.77,253.239,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO VASC 10FR SUPER SHTH INFS SDPRT -,SUP-CLS-1010,CDM,C1894,HCPCS,272,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 5FRX11CM SUPER ARROW-FLEX PERC 0.035IN GW COMP -,SUP-CP-07511,CDM,C1894,HCPCS,272,RC,,,outpatient,,,148.79,104.153,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
DRYSEAL FLEX INTRODUCER SHEATH - 1233 -,SUP-DSF1233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3695.08,2586.556,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH INTRO 12FRX28CM DRYSEAL HYDRCT -,SUP-DSF1233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3695.08,2586.556,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH DRYSEAL INTRODUCER -,SUP-DSF1245,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4821.18,3374.826,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
DRYSEAL FLEX INTRODUCER SHEATH 14FR REF: DSF1433 -,SUP-DSF1433,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
GORE INTRODUCER SHEATH 16 -,SUP-DSF1633,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3695.08,2586.556,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
DRYSEAL SHEATH--16 FR X 65CM -,SUP-DSF1665,CDM,C1894,HCPCS,272,RC,,,outpatient,,,5780.33,4046.231,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
GORE INTRODUCER SHEATH 18 -,SUP-DSF1833,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
22FR X 33CM DRYSEAL SHEATH -,SUP-DSF2233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
GORE DRY SEAL SHEATH 22F X 33CM -,SUP-DSF2233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
22FR X 65CM DRYSEAL SHEATH -,SUP-DSF2265,CDM,C1894,HCPCS,272,RC,,,outpatient,,,5780.33,4046.231,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
GORE DRY SEAL SHEATH 26F X 33CM -,SUP-DSF2633,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH INTRO 18FRX28CM DRYSEAL HYDRCT -,SUP-DSL1828,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
URETHRAL ACCESS SHTH 9.5FR ID AQ HYDRCT TAPR LUMX1 DILATOR -,SUP-FUS-095045,CDM,C1894,HCPCS,272,RC,,,outpatient,,,774.6,542.22,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
URETHRAL ACCESS SHTH 14FRX28CM AQ HYDRCT FLEXOR TAPR LUMX1 -,SUP-FUS-120028,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
URETHRAL ACCESS SHTH 12FR ID HYDRCT LUMX1 DILATOR -,SUP-FUS-120035,CDM,C1894,HCPCS,272,RC,,,outpatient,,,762.34,533.638,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
URETHRAL ACCESS SHTH 12FRX45CM HYDRCT TAPR LUMX1 DILATOR -,SUP-FUS-120045,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
DILATOR VASCULAR 16FR 20CM REF G01212 -,SUP-G01212,CDM,C1894,HCPCS,272,RC,,,outpatient,,,49.54,34.678,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH MICROPUN TRANSTLS TIP 0.018INX40CM GW PEDAL -,SUP-G02972,CDM,C1894,HCPCS,272,RC,,,outpatient,,,349.52,244.664,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 16FRX30CM PEEL-AWAY 0.038IN GW COMP -,SUP-G02997,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO CATH 22FRX13CM PEEL-AWAY LNG COONS TAPR STR 0.038IN GW -,SUP-G04096,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.57,194.299,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 18FRX15.5CM PEEL-AWAY LNG COONS TAPR STR 20CM VES -,SUP-G06444,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 20FRX13CM PEEL-AWAY PERC STR 20CM VES DILATOR W/O -,SUP-G06445,CDM,C1894,HCPCS,272,RC,,,outpatient,,,273.6,191.52,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 24FRX13CM PEEL-AWAY PERC STR 20CM VES DILATOR W/O -,SUP-G06446,CDM,C1894,HCPCS,272,RC,,,outpatient,,,273.6,191.52,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 12FRX15.5CM PEEL-AWAY PERC STR 0.038IN GW COMP -,SUP-G06492,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 14FRX15.5CM PEEL-AWAY PERC STR 0.038IN GW COMP -,SUP-G06496,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SET INTRODUCER PEEL-AWAY .038IN 15.5CM 15FR -,SUP-G06497,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
RING TRANS-JUG ACCESS SET WITH 9Fr -,SUP-G06541,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2759.32,1931.524,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 4MM 12FRX13CM PERFORM JTP 0.038IN GW COMP -,SUP-G07369,CDM,C1894,HCPCS,272,RC,,,outpatient,,,293.56,205.492,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 2.9MM 8FRX13CM FLEXOR 0.038IN GW SM CHECK-FLO VLV -,SUP-G07856,CDM,C1894,HCPCS,272,RC,,,outpatient,,,243.44,170.408,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH CHECKFLO PERFORMA 10FRX30CM -,SUP-G08686,CDM,C1894,HCPCS,272,RC,,,outpatient,,,419.77,293.839,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRODUCER CHECK-FLO PERFORMER 12FR 30CM -,SUP-G08956,CDM,C1894,HCPCS,272,RC,,,outpatient,,,419.77,293.839,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRODUCER CHECK-FLO PERFORMER 14FR 30CM -,SUP-G08957,CDM,C1894,HCPCS,272,RC,,,outpatient,,,419.77,293.839,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
CHECK FLOW PERFORMER INTRODUCER 16FR 70CM REF:G09582 -,SUP-G09582,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRODUCER CHECK-FLO PERFORMER 16FR 30CM -,SUP-G09691,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SET INTRODUCER CHECK-FLO EXTRA LARGE 18FR 40CM -,SUP-G10626,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH GUID 2.2MM 6FRX45CM FLEXOR CHECK-FLO BLKN UP/ OVR -,SUP-G10634,CDM,C1894,HCPCS,272,RC,,,outpatient,,,313.51,219.457,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
S COOK 6FR X 6CM -,SUP-G10675,CDM,C1894,HCPCS,272,RC,,,outpatient,,,170.73,119.511,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SET INTRODUCER CATHETER NEFF 4/6FR -,SUP-G10797,CDM,C1894,HCPCS,272,RC,,,outpatient,,,513.42,359.394,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 5FRX9CM PEEL-AWAY MICROPUNCTURE DENNY MOD LCK -,SUP-G11566,CDM,C1894,HCPCS,272,RC,,,outpatient,,,465.11,325.577,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 6FRX9CM PEEL-AWAY PERC DENNY MOD 0.018IN GW COMP -,SUP-G11568,CDM,C1894,HCPCS,272,RC,,,outpatient,,,465.11,325.577,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 8FRX9CM PEEL-AWAY PERC DENNY MOD 0.038IN GW COMP -,SUP-G11570,CDM,C1894,HCPCS,272,RC,,,outpatient,,,375.77,263.039,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
VALVE CHECK-FLO 7F 55C RAABE K -,SUP-G11633,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH RAABE FLEXOR 7FR X 90CM -,SUP-G11634,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH GUID 7FRX70CM FLEXOR CHECK-FLO RAABE MOD STR 0.038IN -,SUP-G11635,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH GUID 6FRX70CM FLEXOR CHECK-FLO RAABE MOD STR 0.038IN -,SUP-G11636,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH GUID 2.9MM 8FRX70CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G11637,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH 6FR STRAIGHT FLEXOR -,SUP-G11638,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH GUID 2.2MM 6FRX55CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G11638,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
CHECK FLOW PERFORMER INTRODUCER 18FR X 30CM -,SUP-G11672,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
VALVE CHECK-FLO 8F 55C RAABE K -,SUP-G12242,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH 6FR 90CM RAABE KCFW-6.0 -,SUP-G12266,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH GUID 3.2MM 9FRX70CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G12606,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRODUCER CHECK-FLO PERFORMER 22FR 25CM -,SUP-G12831,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2364.02,1654.814,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH GUID 2.5MM 7FRX90CM FLEXOR SHTL SFT TIP HYDRCT -,SUP-G12835,CDM,C1894,HCPCS,272,RC,,,outpatient,,,611.39,427.973,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH GUID 1.9MM 5FRX55CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G13009,CDM,C1894,HCPCS,272,RC,,,outpatient,,,268.41,187.887,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH GUID 1.9MM 5FRX90CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G13069,CDM,C1894,HCPCS,272,RC,,,outpatient,,,348.58,244.006,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 5FRX70CM FLEXOR CHECK-FLO RAABE MOD STR 0.038IN -,SUP-G13091,CDM,C1894,HCPCS,272,RC,,,outpatient,,,268.41,187.887,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH 6FR. 80CM -,SUP-G13539,CDM,C1894,HCPCS,272,RC,,,outpatient,,,611.39,427.973,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
URETHRAL ACCESS SHTH 9.5FR ID HYDRCT TAPR LUMX1 DILATOR -,SUP-G19174,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
URETHRAL ACCESS SHTH 9.5FRX28CM AQ HYDRCT FLEXOR TAPR LUMX1 -,SUP-G19176,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH 20F X 25CM COOK -,SUP-G28999,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2364.02,1654.814,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 12FRX24CM PEEL-AWAY PERC CRV 0.038IN GW COMP 34CM -,SUP-G29839,CDM,C1894,HCPCS,272,RC,,,outpatient,,,689.99,482.993,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 14FRX24CM PEEL-AWAY CRV 0.038IN GW COMP 18GA 12ML -,SUP-G29840,CDM,C1894,HCPCS,272,RC,,,outpatient,,,689.99,482.993,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH GUID 2.5MM 7FRX45CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29885,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
5Fr. 45cm ANSEL SHEATH WITH ANGLE KCFW-5.0-18/38/45-RB-ANL1- -,SUP-G29981,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH GUID 1.9MM 5FRX45CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29981,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH GUID 1.9MM 5FRX90MM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29988,CDM,C1894,HCPCS,272,RC,,,outpatient,,,586.83,410.781,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH 6F ANSEL 90CM FLEXOR KC -,SUP-G29989,CDM,C1894,HCPCS,272,RC,,,outpatient,,,586.83,410.781,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH GUID 2.2MM 6FRX55MM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29996,CDM,C1894,HCPCS,272,RC,,,outpatient,,,420.18,294.126,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH GUID 2.2MM 6FRX55MM FLEXOR CHECK-FLO ANSEL MOD RNL -,SUP-G29997,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHUTTLE SELECT GUIDE SHEATH KS -,SUP-G31138,CDM,C1894,HCPCS,272,RC,,,outpatient,,,617.11,431.977,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH CHECKFLOW 3.4MM 10FRX40CM FLEXOR -,SUP-G32233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,385.81,270.067,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH GUID 4.1MM 12FRX40CM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-G32373,CDM,C1894,HCPCS,272,RC,,,outpatient,,,444.22,310.954,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SET MICROPUNCTURE 5.0F 10CM -,SUP-G36333,CDM,C1894,HCPCS,272,RC,,,outpatient,,,159.7,111.79,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH GUID 3.2MM 9FRX55CM FLEXOR CHECK-FLO RAABE MOD -,SUP-G36393,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
MICRO PUNCTURE  5FR X 10CM  0.018INX40CM -,SUP-G43870,CDM,C1894,HCPCS,272,RC,,,outpatient,,,191.21,133.847,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH 5F ANSEL 45CM ANLO -,SUP-G44153,CDM,C1894,HCPCS,272,RC,,,outpatient,,,300.62,210.434,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH 6F ANSEL 45CM -,SUP-G44154,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH MICROPUNCTURE TRANSTLS TIP 0.018INX40CM PLTNM TIP -,SUP-G47942,CDM,C1894,HCPCS,272,RC,,,outpatient,,,190.1,133.07,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
MICROPUNCTURE STIFF 4F NIT -,SUP-G48003,CDM,C1894,HCPCS,272,RC,,,outpatient,,,281.36,196.952,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
MICROPUNCTURE TRANSITIONLESS STIFFENED CANNULA ACCESS SET -,SUP-G48005,CDM,C1894,HCPCS,272,RC,,,outpatient,,,281.36,196.952,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
WIRE FOR  MICROPUNCTURE 0.018 IN X 40 CM PLTNM TIP -,SUP-G48007,CDM,C1894,HCPCS,272,RC,,,outpatient,,,281.36,196.952,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH GUID 1.5MM 4FRX45MM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-G48186,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH 4F ANSEL 90CM -,SUP-G48188,CDM,C1894,HCPCS,272,RC,,,outpatient,,,620.26,434.182,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH 5F 90 RB ANSEL KCF-5.0- -,SUP-G48189,CDM,C1894,HCPCS,272,RC,,,outpatient,,,620.26,434.182,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH 7F X 55CM ANSEL 1 -,SUP-G49043,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH GUID 2.9MM 8FRX45CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G49100,CDM,C1894,HCPCS,272,RC,,,outpatient,,,356.11,249.277,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH GUID 3.2MM 9FRX45MM FLEXOR CHECK-FLO ANSEL MOD ANL1 -,SUP-G49102,CDM,C1894,HCPCS,272,RC,,,outpatient,,,356.11,249.277,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH GUID 6FRX70CM FLEXOR 0.038IN GW COMP HYDRCT -,SUP-G56221,CDM,C1894,HCPCS,272,RC,,,outpatient,,,452.45,316.715,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH GUIDING 7FR x 70CM STRAIGHT -,SUP-G56222,CDM,C1894,HCPCS,272,RC,,,outpatient,,,452.45,316.715,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH GUID 2.2MM 6FRX70CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G56226,CDM,C1894,HCPCS,272,RC,,,outpatient,,,452.45,316.715,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH GUID 1.9MM 5FRX55CM FLEXOR CHECK-FLO ANSEL MOD STR. -,SUP-G56230,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH GUID 1.9MM 5FRX55CM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-G56235,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH 6F X 55 ANSEL 1 -,SUP-G56236,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH FLEXOR PARALLEL 9.5CM x 28CM - URETERAL -,SUP-G56429,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1012.66,708.862,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH FLEXOR PARALLEL 9.5FR x 45CM URETERAL -,SUP-G56431,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1012.66,708.862,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SET MICROPUNCTURE INTRODUCER 21G -,SUP-G84006,CDM,C1894,HCPCS,272,RC,,,outpatient,,,252.07,176.449,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH GUIDING DESTINATION SLENDER 105CM 6FR STRAIGHT -,SUP-GS-R6ST1C10W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1599.43,1119.601,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SYS SHEATH RTRVL 4FR BNTP EMBL PROT FLTWR EZ -,SUP-H749501001500,CDM,C1894,HCPCS,272,RC,,,outpatient,,,595.17,416.619,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
COAXIAL MICROINTRODUCER KIT 4FR -,SUP-H965457531,CDM,C1894,HCPCS,272,RC,,,outpatient,,,175.05,122.535,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO PERC 6FR SHTH INTROFLEX -,SUP-I500-F6,CDM,C1894,HCPCS,272,RC,,,outpatient,,,288.25,201.775,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 9FR STD INTROFLEX PERC W/O LIDOCN -,SUP-I505BF9C,CDM,C1894,HCPCS,272,RC,,,outpatient,,,243.32,170.324,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 5FRX10CM MICROPUNCTURE STF CANN COAX CATH PR -,SUP-JCD5.01810.0MPI,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.06,81.242,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
10fr 0.035 Flexer Guiding Sheath -,SUP-KCFW-10.0-35-RB-RTPS-100,CDM,C1894,HCPCS,272,RC,,,outpatient,,,641.79,449.253,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 2.2MM 6FRX30CM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-KCFW6.0-38-30RB,CDM,C1894,HCPCS,272,RC,,,outpatient,,,268.35,187.845,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO CATH 6FRX13CM SHTH FLEXOR NTPR 0.038IN GW VES DILATOR -,SUP-KCFW-6.0-38-RB,CDM,C1894,HCPCS,272,RC,,,outpatient,,,243.44,170.408,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO 4.5FRX5CM MICRO-ACCESS TEARAWAY 0.018INX4.CM MRK NTNL -,SUP-KIT-010-03,CDM,C1894,HCPCS,272,RC,,,outpatient,,,204.23,142.961,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
CATHETER RETRIEVAL AVEIR REF:LSCR111 -,SUP-LSCR111,CDM,C1894,HCPCS,272,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
LOADING SYSTEM ENVEO R  LS-MDT2-2629-US -,SUP-LS-MDT2-2629-US,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2067.2,1447.04,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
CATHETER INTRODUCER AVEIR 30CM REF:LSN25301 -,SUP-LSN25301,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 21GA ACCUSTICK II STF CANN -,SUP-M001207020,CDM,C1894,HCPCS,272,RC,,,outpatient,,,416.39,291.473,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH INTRO 8.5FRX60CM HEARTSPAN TRNSEPT 55DG CRV TAPR -,SUP-M0045660550,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1108.65,776.055,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH URET 11/13FRX36CM NAVIGATOR -,SUP-M0062502021,CDM,C1894,HCPCS,272,RC,,,outpatient,,,567.91,397.537,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH NAVIGATOR HD 11/13 X 28 -,SUP-M0062502210,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH NAVIGATOR HD 11 13 36 -,SUP-M0062502220,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH NAVIGATOR HD 11 13 46 -,SUP-M0062502230,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH NAVIGATOR HD 12 14 36 -,SUP-M0062502250,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH NAVIGATOR 12F/14F X 46CM -,SUP-M0062502260,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
ST DILATOR URETH 8-30FR OD 35CM 30CM SHTH TFLN-CT TAPR GRAD -,SUP-M0062601000,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1208.3,845.81,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
ST DILATOR URETH SHTH 8FR/10FR 70CM/35CM L PTFE TAPR LF -,SUP-M0062601200,CDM,C1894,HCPCS,272,RC,,,outpatient,,,280.31,196.217,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
URETHRAL ACCESS SHTH 34FR TAPR -,SUP-M0062601600,CDM,C1894,HCPCS,272,RC,,,outpatient,,,344.5,241.15,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
MICRO PUNCTURE 4FR X 10 CM NTNL 0.018X 40 -,SUP-MAK401NPD,CDM,C1894,HCPCS,272,RC,,,outpatient,,,91.84,64.288,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
MICRO PUNCTURE  5FR X 10CM  0.018INX40CM - MAK501N -,SUP-MAK501N,CDM,C1894,HCPCS,272,RC,,,outpatient,,,151.42,105.994,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
MICRA INTRO SHEATH HYDRO COAT -,SUP-MI2355A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
MICINTRO SHTH 7FRX7CM VENEFIT ECHGNC TIP 21GA -,SUP-MIS7F07,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
MICRO INTRO SHEATH 7F 11CM -,SUP-MIS-7F11,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH MICROPUNCTURE TRANSTLS TIP 0.018INX40CM PLTNM TIP -,SUP-MPIS-401-NT,CDM,C1894,HCPCS,272,RC,,,outpatient,,,190.1,133.07,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 4FR MICROPUNCTURE TRANSTLS TIP 0.018INX40CM PLTNM -,SUP-MPIS401PEDNTSST,CDM,C1894,HCPCS,272,RC,,,outpatient,,,197.05,137.935,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 5FRX10CM MICROPUNCTURE TRANSTLS TIP 0.018INX40CM -,SUP-MPIS-501-NT,CDM,C1894,HCPCS,272,RC,,,outpatient,,,191.21,133.847,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO ORTHO 4FR MICRO-STK NTNL WIRE -,SUP-MR190421,CDM,C1894,HCPCS,272,RC,,,outpatient,,,105.03,73.521,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 18FRX85CM PERFORM 0.038IN GW 97CM VES DILATOR -,SUP-RCFW18.0P3885RB,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 2.6MM 8FRX63CM PERFORM MLNS CRV 0.038IN GW COMP -,SUP-RCFW8.0-38-63,CDM,C1894,HCPCS,272,RC,,,outpatient,,,433.42,303.394,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH INTRO 6FRX10CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB602,CDM,C1894,HCPCS,272,RC,,,outpatient,,,152.29,106.603,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH INTRO 7FR X 10CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB702,CDM,C1894,HCPCS,272,RC,,,outpatient,,,152.29,106.603,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH INTRO 8FRX25CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB803,CDM,C1894,HCPCS,272,RC,,,outpatient,,,193.72,135.604,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH INTRO 9FRX10CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB902,CDM,C1894,HCPCS,272,RC,,,outpatient,,,152.29,106.603,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH INTRO 9FRX25CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB903,CDM,C1894,HCPCS,272,RC,,,outpatient,,,193.72,135.604,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH INTRO 5FRX10CM PINNCL PERIPH STR CRV 0.035IN GW COMP -,SUP-RSS501,CDM,C1894,HCPCS,272,RC,,,outpatient,,,63.43,44.401,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH 8FR 10CM PINNACLE -,SUP-RSS802,CDM,C1894,HCPCS,272,RC,,,outpatient,,,60.68,42.476,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH 9FR 10CM PINNACLE -,SUP-RSS901,CDM,C1894,HCPCS,272,RC,,,outpatient,,,63.43,44.401,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 14FRX28CM SENTRANT 0.035IN GW HYDRCT -,SUP-SENSH1428W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1108.65,776.055,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
INTRO SHTH 16FRX28CM SENTRANT 0.035IN GW COMP HYDRCT -,SUP-SENSH1628W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1123.71,786.597,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH 18FR MEDTRONIC -,SUP-SENSH1828W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1123.71,786.597,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH 20FR X 28CM MEDTRONIC -,SUP-SENSH2028W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1258.87,881.209,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
MICRO PUNCTURE  5FR X 10CM  0.018INX40CM STIFF- S-MAK501N -,SUP-S-MAK501N,CDM,C1894,HCPCS,272,RC,,,outpatient,,,210.06,147.042,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH NAVIGATOR 12F/14F X 28CM -,SUP-STRYKER INSTRUMENTS,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
9.5F SAFESHEATH PEEL AWAY HEMO -,SUP-UNDEFINED,CDM,C1894,HCPCS,272,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SHEATH INTRO 6FR BRT TIP -,SUP-UNDEFINED,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
CATAPULT US 5F 15CM STRAIGHT 5PK -,SUP-US-35015-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,519.32,363.524,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
CATAPULT US 5F 45CM STRAIGHT 5PK -,SUP-US-35045-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,636.02,445.214,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
CATAPULT US 5F 60CM STRAIGHT 5PK -,SUP-US-35060-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,694.37,486.059,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
CATAPULT US 5F 90CM STRAIGHT 5PK -,SUP-US-35090-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
TRANSEPTAL ACCESS SET VERSACROSS REF: VXSK0032 -,SUP-VXSK0032,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4630.78,3241.546,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
SET INTRODUCER CHECK-FLO EXTRA LARGE 20FR 40CM -,SUP-XVCFW-20.0-35-40,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2364.02,1654.814,AETNA [1000108],AETNA [100010801],,,,,,3.064425,7986.663,other,272 with C codes,,
LEAD DEFIB IMPL BIPLR PERMNT PCNG ETAK RELIANCE 59CM 8FR -,SUP-0157,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,399.86,13473.73824,percent of total billed charges,,,
LEAD DEFIB ETAK RELIANCE 59CM -,SUP-0275-59,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,AETNA [1000108],AETNA [100010801],,,76.8,,7799.09,399.86,13473.73824,percent of total billed charges,,,
LEAD DEFIB ETAK RELIANCE 64CM -,SUP-0276-64,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,AETNA [1000108],AETNA [100010801],,,76.8,,7799.09,399.86,13473.73824,percent of total billed charges,,,
LEAD DEFIB ENDOTAK RELIANCE G 64CM -,SUP-0286,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,399.86,13473.73824,percent of total billed charges,,,
LEAD DEFIB PCNG ETAK RELIANCE 64CM GORE-HYBRID ETFE CTD STRD -,SUP-0293-64,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10470.66,7329.462,AETNA [1000108],AETNA [100010801],,,76.8,,8041.47,399.86,13473.73824,percent of total billed charges,,,
LEAD DEFIB IMPL BIPLR ETAK RELIANCE 4- SITE 59CM RT ECRD -,SUP-0295,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,AETNA [1000108],AETNA [100010801],,,76.8,,7799.09,399.86,13473.73824,percent of total billed charges,,,
LEAD DEFIB IMPL BIPLR ETAK RELIANCE 4- SITE 64CM RT ECRD -,SUP-0296,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,AETNA [1000108],AETNA [100010801],,,76.8,,7799.09,399.86,13473.73824,percent of total billed charges,,,
LEAD RELIANCE 4-FRONT 0673 64 CM -,SUP-0673-64,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,76.8,,8554.75,399.86,13473.73824,percent of total billed charges,,,
LEAD DEFIB BIPLR PERMNT PCNG KENTROX SL 65CM 7.8FRX180MM SPC -,SUP-350054,CDM,C1895,HCPCS,278,RC,,,outpatient,,,14265.35,9985.745,AETNA [1000108],AETNA [100010801],,,76.8,,10955.79,399.86,13473.73824,percent of total billed charges,,,
LEAD DEFIB IMPL LINOX SMRT SD 65CM 18CM ECRD SIL INSL DL -,SUP-359067,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,AETNA [1000108],AETNA [100010801],,,76.8,,7673.61,399.86,13473.73824,percent of total billed charges,,,
LEAD PCNG 60MM LINOX SD IMPL BIPLR RV STRD ELUT ACT -,SUP-363303,CDM,C1895,HCPCS,278,RC,,,outpatient,,,14265.35,9985.745,AETNA [1000108],AETNA [100010801],,,76.8,,10955.79,399.86,13473.73824,percent of total billed charges,,,
LEAD DEFIB TRIPLR SPRNT QUATTRO 65CM 8.6FRX12MM SPC RT ECRD -,SUP-6935-65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA [1000108],AETNA [100010801],,,76.8,,9125.07,399.86,13473.73824,percent of total billed charges,,,
LEAD DEFIB 8.6FRX12MM SPC 55CM SPRNT QUATTRO TRIPLR STRD -,SUP-6935M55,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA [1000108],AETNA [100010801],,,76.8,,9125.07,399.86,13473.73824,percent of total billed charges,,,
LEAD DEFIB TRIPLR SPRNT QUATTRO 62CM 8.6FRX12MM SPC SIL -,SUP-6935M62,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA [1000108],AETNA [100010801],,,76.8,,9125.07,399.86,13473.73824,percent of total billed charges,,,
LEAD PCNG 8.6FRX12MM SPC 58CM SPRNT QUATTRO PERMNT QDPL -,SUP-6947-58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA [1000108],AETNA [100010801],,,76.8,,9125.07,399.86,13473.73824,percent of total billed charges,,,
LEAD PCNG 8.6FRX12MM SPC 65CM SPRNT QUATTRO PERMNT QDPL -,SUP-6947-65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA [1000108],AETNA [100010801],,,76.8,,9125.07,399.86,13473.73824,percent of total billed charges,,,
LEAD DEFIB QDPL SPRNT QUATTRO 55CM 8.6FRX12MM SPC RT ECRD -,SUP-6947M55,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA [1000108],AETNA [100010801],,,76.8,,9125.07,399.86,13473.73824,percent of total billed charges,,,
LEAD DEFIB QDPL SPRNT QUATTRO 62CM 8.6FRX12MM SPC RT ECRD -,SUP-6947M62,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA [1000108],AETNA [100010801],,,76.8,,9125.07,399.86,13473.73824,percent of total billed charges,,,
LEAD DEFIB QDPL SPRNT QUATTRO 72CM 8.6FRX12MM SPC RT ECRD -,SUP-6947M72,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA [1000108],AETNA [100010801],,,76.8,,9125.07,399.86,13473.73824,percent of total billed charges,,,
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FRX170MM SPC VNTRC OPTIM -,SUP-7120/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,399.86,13473.73824,percent of total billed charges,,,
LEAD DEFIB TRUE BIPLR DURATA 52CM 7FRX170MM SPC VNTRC OPTIM -,SUP-7120Q/52,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,399.86,13473.73824,percent of total billed charges,,,
LEAD DEFIB TRUE BIPLR DURATA 58CM 7FR VNTRC OPTIM INSL SGL -,SUP-7120Q/58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,399.86,13473.73824,percent of total billed charges,,,
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FR VNTRC OPTIM INSL SGL -,SUP-7120Q/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,399.86,13473.73824,percent of total billed charges,,,
LEAD DEFIBRILLATOR DURATA OPTIM L21 CM OD7 FR 2 COIL -,SUP-7121,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11031.32,7721.924,AETNA [1000108],AETNA [100010801],,,76.8,,8472.05,399.86,13473.73824,percent of total billed charges,,,
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FRX210MM SPC VNTRC OPTIM -,SUP-7121/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,399.86,13473.73824,percent of total billed charges,,,
LEAD DEFIB TRUE BIPLR DURATA 52CM 7FR VNTRC OPTIM INSL SGL -,SUP-7121Q/52,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,399.86,13473.73824,percent of total billed charges,,,
LEAD DEFIB DURATA IMPL -,SUP-7131,CDM,C1895,HCPCS,278,RC,,,outpatient,,,17543.93,12280.751,AETNA [1000108],AETNA [100010801],,,76.8,,13473.74,399.86,13473.73824,percent of total billed charges,,,
LEAD DEFIB TRUE BIPLR DURATA 58CM 17CM-TO-PROX COIL 7FR -,SUP-7170Q/58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,399.86,13473.73824,percent of total billed charges,,,
LEAD DEFIB TRUE BIPLR DURATA 58CM 21CM-TO-PROX COIL 7FR -,SUP-7171Q/58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA [1000108],AETNA [100010801],,,76.8,,7659.57,399.86,13473.73824,percent of total billed charges,,,
LEAD DEFIB 8FR INTRO 65CM OPTISURE TRUE BIPLR XTD-RETRAC -,SUP-LDA230Q/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,399.86,13473.73824,percent of total billed charges,,,
ELECTRODE DEFIB 12FR DIST TIP 9FR COIL 45CM Q-TRAK TRIPLR -,SUP-3400,CDM,C1896,HCPCS,278,RC,,,outpatient,,,14852,10396.4,AETNA [1000108],AETNA [100010801],,,76.8,,11406.34,399.86,11406.336,percent of total billed charges,,,
ELECTRODE DEFIB 12FR DIST TIP 45CM EMBLEM TRIPLR SUBQ DIST -,SUP-3401,CDM,C1896,HCPCS,278,RC,,,outpatient,,,14852,10396.4,AETNA [1000108],AETNA [100010801],,,76.8,,11406.34,399.86,11406.336,percent of total billed charges,,,
EMBLEM S-ICD LEAD 3501-45CM -,SUP-3501-45,CDM,C1896,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,AETNA [1000108],AETNA [100010801],,,76.8,,10836.02,399.86,11406.336,percent of total billed charges,,,
LEAD EPICARDIAC 5071 -,SUP-5071,CDM,C1896,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,AETNA [1000108],AETNA [100010801],,,76.8,,2053.2,399.86,11406.336,percent of total billed charges,,,
LEAD PCNG 58CM TRANSVENE IMPL UNIPL ECRD CS SVC -,SUP-6937A58,CDM,C1896,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA [1000108],AETNA [100010801],,,76.8,,3666.43,399.86,11406.336,percent of total billed charges,,,
OPTISURE DEFIBRILLATION LEAD DF1 SINGLE COIL LDA210-65 -,SUP-LDA210-65,CDM,C1896,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA [1000108],AETNA [100010801],,,76.8,,7556.7,399.86,11406.336,percent of total billed charges,,,
KT LEAD NEURSTM OCTRODE 60CM PERC ACC -,SUP-3086ANS,CDM,C1897,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA [1000108],AETNA [100010801],,,76.8,,2199.86,196.493625,28414.1568,percent of total billed charges,,,
KT LEAD NEURSTM 60CM PERC ACC 6MM -,SUP-3873-60,CDM,C1897,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA [1000108],AETNA [100010801],,,76.8,,2749.82,196.493625,28414.1568,percent of total billed charges,,,
KT LEAD NEURSTM 60CM PERC SUBCOMPACT ACC -,SUP-3875-60,CDM,C1897,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,AETNA [1000108],AETNA [100010801],,,76.8,,2658.16,196.493625,28414.1568,percent of total billed charges,,,
REACTIV8 IMPLANTABLE PULSE GENERATOR -,SUP-5100,CDM,C1897,HCPCS,278,RC,,,outpatient,,,36997.6,25898.32,AETNA [1000108],AETNA [100010801],,,76.8,,28414.16,196.493625,28414.1568,percent of total billed charges,,,
KT IT REVISN INTFC TRANSP STRN RLF SLVX2 NS RLR F/SULS PMP -,SUP-8578,CDM,C1897,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,196.493625,28414.1568,percent of total billed charges,,,
LEAD NEURSTM VECTRIS SURSCN 60CM PERC SPIN CRD MRI-COND -,SUP-977D260,CDM,C1897,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,AETNA [1000108],AETNA [100010801],,,76.8,,2925.81,196.493625,28414.1568,percent of total billed charges,,,
SLIM TIP DRG TRIAL LEAD KIT -,SUP-MN10350-50A,CDM,C1897,HCPCS,278,RC,,,outpatient,,,4874.15,3411.905,AETNA [1000108],AETNA [100010801],,,76.8,,3743.35,196.493625,28414.1568,percent of total billed charges,,,
SLIP TIP DRG -,SUP-MN10350-90A,CDM,C1897,HCPCS,278,RC,,,outpatient,,,4909.5,3436.65,AETNA [1000108],AETNA [100010801],,,76.8,,3770.5,196.493625,28414.1568,percent of total billed charges,,,
STIMWAVE NEUROSTIMULATOR RECEIVER KIT -,SUP-STQ4-RCV-A0,CDM,C1897,HCPCS,278,RC,,,outpatient,,,32936.92,23055.844,AETNA [1000108],AETNA [100010801],,,76.8,,25295.55,196.493625,28414.1568,percent of total billed charges,,,
PNS PERMANENT TINED RECEIVER KIT CHANNEL B -,SUP-STQ4-RCV-B0,CDM,C1897,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,76.8,,8148.48,196.493625,28414.1568,percent of total billed charges,,,
LEAD NRV STIM 50CM F/TRL -,SUP-UNDEFINED,CDM,C1897,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,196.493625,28414.1568,percent of total billed charges,,,
LEAD PCNG 8FR INTRO 58CM TENDRIL DX PERMNT BIPLR AV -,SUP-1388TC/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 1642T X 46 -,SUP-1642T/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 7FR INTRO 10MM SPC 52CM ISFLX PERMNT BIPLR STR AV -,SUP-1646T/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 1646T-58 ISFLX PERMNT BIPLR_STR AV -,SUP-1646T/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 46CM TENDRIL -,SUP-1688TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,39.298725,2053.20192,percent of total billed charges,,,
TENDRIL SDX 1688TC/46 -,SUP-1688TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,AETNA [1000108],AETNA [100010801],,,76.8,,1465.57,39.298725,2053.20192,percent of total billed charges,,,
LEAD TENDRIL 1688 TC/58 -,SUP-1688TC-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,AETNA [1000108],AETNA [100010801],,,76.8,,1465.57,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 6FR INTRO 10MM SPC 52CM TENDRILL SDX PERMNT BIPLR -,SUP-1788TC/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 6FR INTRO 10MM SPC 58CM TENDRILL SDX PERMNT BIPLR -,SUP-1788TC/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 7FR INTRO 10MM SPC 46CM TENDRILL ST PERMNT BIPLR -,SUP-1882TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,AETNA [1000108],AETNA [100010801],,,76.8,,1465.57,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 7FR INTRO 10MM SPC 52CM TENDRILL ST PERMNT BIPLR -,SUP-1882TC/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,AETNA [1000108],AETNA [100010801],,,76.8,,1465.57,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 6FR INTRO 10MM SPC 46CM TENDRILL ST PERMNT BIPLR -,SUP-1888TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,AETNA [1000108],AETNA [100010801],,,76.8,,1465.57,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 6FR INTRO 10MM SPC 52CM TENDRILL ST PERMNT BIPLR -,SUP-1888TC/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,AETNA [1000108],AETNA [100010801],,,76.8,,1465.57,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 6FR INTRO 10MM SPC 58CM TENDRILL ST PERMNT BIPLR -,SUP-1888TC/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,AETNA [1000108],AETNA [100010801],,,76.8,,1465.57,39.298725,2053.20192,percent of total billed charges,,,
LEAD ISOFLEX OPTIM J 1944-46CM -,SUP-1944/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 7FR INTRO 10MM SPC 52CM ISFLX PERMNT BIPLR J-SHP -,SUP-1944/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG ISOFLEX 1948-52 ISFLX PERMNT BIPLR STR AV. -,SUP-1948/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 7FR INTRO 10MM SPC 58CM ISFLX PERMNT BIPLR STR AV -,SUP-1948/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,39.298725,2053.20192,percent of total billed charges,,,
LEAD OPINSENSE  MODEL 1999-52 -,SUP-1999/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,39.298725,2053.20192,percent of total billed charges,,,
LEAD CATH DELIVERED 3830 69CM,SUP-2,CDM,C1898,HCPCS,275,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 6FRX46CM TENDRIL STS IMPL BIPLR RAV ACT SCR IN FX -,SUP-2088TC-46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 6FRX52CM TENDRIL STS IMPL BIPLR RAV ACT SCR IN FX -,SUP-2088TC-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 6FRX58CM TENDRIL STS IMPL BIPLR RAV ACT SCR IN FX -,SUP-2088TC-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 6.6FRX15MM SPC 60CM SELOX ST 60 PERMNT IMPL BIPLR -,SUP-346367,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,AETNA [1000108],AETNA [100010801],,,76.8,,1567.25,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 6.6FRX15MM SPC 53CM SELOX JT 53 PERMNT IMPL BIPLR -,SUP-346368,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,AETNA [1000108],AETNA [100010801],,,76.8,,1567.25,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 6.6FRX10MM SPC 45CM SETROX DX PERMNT IMPL BIPLR -,SUP-350973,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,AETNA [1000108],AETNA [100010801],,,76.8,,1567.25,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 7FRX10MM SPC 53CM SETROX DX PERMNT IMPL BIPLR HLCL -,SUP-350974,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,AETNA [1000108],AETNA [100010801],,,76.8,,1567.25,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 6.6FRX10MM SPC 60CM SETROX DX PERMNT IMPL BIPLR -,SUP-350975,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,AETNA [1000108],AETNA [100010801],,,76.8,,1567.25,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 6.6FR 7FR INTRO 53CM TILDA STR PSS FX -,SUP-382872,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,39.298725,2053.20192,percent of total billed charges,,,
LEAD CATH DELIVERED 3830 69 CM -,SUP-383069,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 52CM SELUTE PICOTIP COMPLIANCE PRACTITIONERS -,SUP-4064,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 5.7FRX10MM SPC 35CM CAP NOV PERMNT BIPLR AV STRD -,SUP-4076-35,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2570.74,1799.518,AETNA [1000108],AETNA [100010801],,,76.8,,1974.33,39.298725,2053.20192,percent of total billed charges,,,
LEAD PPM 45CM CAPSURE FIX NOVUS 4076-45 -,SUP-4076-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 5.7FRX10MM SPC 45CM CAP NOV IMPL BIPLR AV STRD -,SUP-4076-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 5.3FRX9MM SPC 52CM CPSR SP NOVUS PERMNT BIPLR AV -,SUP-4092-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 5.3FRX9MM SPC 58CM CPSR SP NOVUS PERMNT BIPLR AV -,SUP-4092-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 6.7FRX10MM SPC 53CM DEXTRUS PERMNT BIPLR HLCL TIP -,SUP-4136-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 6.7FRX10MM SPC 60CM DEXTRUS PERMNT BIPLR HLCL TIP -,SUP-4137,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA [1000108],AETNA [100010801],,,76.8,,1730.08,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 5.7FRX16MM SPC 58CM FNLN STRX PERMNT BIPLR STR -,SUP-4457,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 1.7X16MM SPC_45CM FINELINE II EZ STEROX PERMNT -,SUP-4469,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 1.7X16MM SPC 45CM FINELINE II EZ STEROX PERMNT -,SUP-4469-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 1.7X16MM SPC 52CM FINELINE II EZ STEROX PERMNT -,SUP-4470-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 1.7X16MM SPC 58CM FINELINE II EZ STEROX PERMNT -,SUP-4471,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 5.7FRX45CM FNLN STRX AJ PERMNT BIPLR JTP RA ECRD -,SUP-4479,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 5.7FRX52CM FNLN STRX AJ PERMNT BIPLR JTP RA ECRD -,SUP-4480-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 5.3FRX9MM SPC 45CM CPSR SP NOVUS PERMNT BIPLR JTP -,SUP-4592-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 5.3FR CPSR SP NOVUS J-SHP ATR BIPLR -,SUP-4592-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,39.298725,2053.20192,percent of total billed charges,,,
LEAD MEDTRONIC CAPSURE VDD-2 5038S-52 -,SUP-5038S-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,39.298725,2053.20192,percent of total billed charges,,,
LEAD MEDTRONIC CAPSURE VDD-2 5038S-58 -,SUP-5038S-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA [1000108],AETNA [100010801],,,76.8,,1831.86,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG EPCRD -,SUP-5071-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,AETNA [1000108],AETNA [100010801],,,76.8,,2053.2,39.298725,2053.20192,percent of total billed charges,,,
LEAD PPM 45CM CAPSUREFIX SURSCN NOVUS 5076-45 -,SUP-5076-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 6.2FRX10MM SPC 52CM CAPSUREFIX SURSCN NOVUS IMPL -,SUP-5076-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 6.2FR X10MM SPC 58CM CAPSUREFIX SURSCN NOVUS IMPL -,SUP-5076-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 6.2FRX10MM SPC 65CM CAPSUREFIX SURSCN NOVUS IMPL -,SUP-5076-65,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 7FRX45CM CPSR FX MRI BIPLR STR AV ACT SCR IN FX -,SUP-5086MRI-45CM,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 7FRX52CM CPSR FX MRI BIPLR STR AV ACT SCR IN FX -,SUP-5086MRI-52CM,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 7FRX58CM CAPSUREFIX BIPLR STR AV ACT SCR IN FX -,SUP-5086MRI-58CM,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,39.298725,2053.20192,percent of total billed charges,,,
LEAD MYOPORE BIPOLAR 511211 -,SUP-511211,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 35MM MYOPORE IMPL BIPLR EPCRD AV STRD ELUT ACT SCR -,SUP-511211,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 54CM MYOPORE IMPL BIPLR EPCRD AV STRD ELUT ACT SCR -,SUP-511212,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 7.2FRX53CM CAPSUREFIX PERMNT BIPLR J-SHP TIP ATR -,SUP-5568-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,39.298725,2053.20192,percent of total billed charges,,,
BIPOLAR TEMPORARY MYOCARDIAL PACING LEAD -,SUP-6495F,CDM,C1898,HCPCS,278,RC,,,outpatient,,,408.45,285.915,AETNA [1000108],AETNA [100010801],,,76.8,,313.69,39.298725,2053.20192,percent of total billed charges,,,
OIL MNRL F/EZ INS STYL -,SUP-6529,CDM,C1898,HCPCS,278,RC,,,outpatient,,,175.05,122.535,AETNA [1000108],AETNA [100010801],,,76.8,,134.44,39.298725,2053.20192,percent of total billed charges,,,
LEAD INGEVITY MRI 7731 52 CM P -,SUP-7731,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,39.298725,2053.20192,percent of total billed charges,,,
LEAD INGEVITY MRI 7732-59 ( PASSIVE ) -,SUP-7732,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,39.298725,2053.20192,percent of total billed charges,,,
LEAD INGEVITY MRI 7732 59 -,SUP-7732-59,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,39.298725,2053.20192,percent of total billed charges,,,
INGEVITY MRI  MODEL 7735-45 -,SUP-7735,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,39.298725,2053.20192,percent of total billed charges,,,
LEAD INGEVITY MRI 7736-52 ( PASSIVE J ) -,SUP-7736,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,39.298725,2053.20192,percent of total billed charges,,,
LEAD INGEVITY MRI 7740 -,SUP-7740,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,39.298725,2053.20192,percent of total billed charges,,,
LEAD INGEVITY MRI 7741 52CM -,SUP-7741,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,39.298725,2053.20192,percent of total billed charges,,,
LEAD INGEVITY MRI 7742 59CM -,SUP-7742,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,39.298725,2053.20192,percent of total billed charges,,,
INGEVITY + 7840-45cm -,SUP-7840,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,39.298725,2053.20192,percent of total billed charges,,,
INGEVITY + 7841/52 -,SUP-7841/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,39.298725,2053.20192,percent of total billed charges,,,
INGEVITY + 7842/59 LEAD -,SUP-7842/59,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA [1000108],AETNA [100010801],,,76.8,,1424.78,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG ELAFIX ATR -,SUP-ELAFIX P2 752,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2549.32,1784.524,AETNA [1000108],AETNA [100010801],,,76.8,,1957.88,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 7FRX52CM BIPLR ECRD THN TND -,SUP-ELAPASSP752,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 7FRX58CM BIPLR ECRD THN TND -,SUP-ELAPASSP758,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2549.32,1784.524,AETNA [1000108],AETNA [100010801],,,76.8,,1957.88,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 7FRX52CM BIPLR J-SHP ECRD THN TND -,SUP-ELAPASSPJ752,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA [1000108],AETNA [100010801],,,76.8,,1628.31,39.298725,2053.20192,percent of total billed charges,,,
TENDRIL MRI LEAD 46CM -,SUP-LPA1200M/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,39.298725,2053.20192,percent of total billed charges,,,
TENDRIL MRI LEAD- 52CM -,SUP-LPA1200M/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,39.298725,2053.20192,percent of total billed charges,,,
TENDRIL MRI LEAD- 58CM -,SUP-LPA1200M/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA [1000108],AETNA [100010801],,,76.8,,1396.28,39.298725,2053.20192,percent of total billed charges,,,
LEAD CATH DELIVERED 3830 59CM -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,39.298725,2053.20192,percent of total billed charges,,,
LEAD CATH DELIVERED 3830 74CM -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,39.298725,2053.20192,percent of total billed charges,,,
LEAD GENTR -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA [1000108],AETNA [100010801],,,76.8,,2035.39,39.298725,2053.20192,percent of total billed charges,,,
LEAD CATH DELIVERED 3830 49CM -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA [1000108],AETNA [100010801],,,76.8,,1791.14,39.298725,2053.20192,percent of total billed charges,,,
LEAD PCNG 7FR INTRO 20MM SPC 86CM QUICKFLEX PERMNT BIPLR -,SUP-1156T/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,AETNA [1000108],AETNA [100010801],,,76.8,,9410.23,399.86,9410.2272,percent of total billed charges,,,
LEAD PCNG 5FRX20MM SPC 75CM QUICKFLEX U BIPLR STYP CRV LH -,SUP-1258T/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,399.86,9410.2272,percent of total billed charges,,,
LEAD PCNG 5FRX20MM SPC 86CM QUICKFLEX U BIPLR STYP CRV LH -,SUP-1258T/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,399.86,9410.2272,percent of total billed charges,,,
LEAD PCNG 5FRX20MM SPC 92CM QUICKFLEX U BIPLR STYP CRV LH -,SUP-1258T/92,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,AETNA [1000108],AETNA [100010801],,,76.8,,4595.74,399.86,9410.2272,percent of total billed charges,,,
Lead Quartet 1456/75Q LV Lead -,SUP-1456/75Q,CDM,C1900,HCPCS,278,RC,,,outpatient,,,8445.56,5911.892,AETNA [1000108],AETNA [100010801],,,76.8,,6486.19,399.86,9410.2272,percent of total billed charges,,,
LEAD QUARTET 1456Q/86 LV LEAD -,SUP-1456/86Q,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA [1000108],AETNA [100010801],,,76.8,,6029.88,399.86,9410.2272,percent of total billed charges,,,
QUARTET LEAD DOUBLE BEND- 75 CM MODEL 1457Q/75 -,SUP-1457Q/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA [1000108],AETNA [100010801],,,76.8,,6029.88,399.86,9410.2272,percent of total billed charges,,,
QUARTET LEAD DOUBLE BEND-86CM MODEL 1457Q/86 -,SUP-1457Q/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA [1000108],AETNA [100010801],,,76.8,,6029.88,399.86,9410.2272,percent of total billed charges,,,
LEAD PCNG 7FR INTRO 75CMX16MM QRTT CRT STYP CRV LH LPRO -,SUP-1458Q/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA [1000108],AETNA [100010801],,,76.8,,6029.88,399.86,9410.2272,percent of total billed charges,,,
LEAD PCNG 7FR INTRO 86CMX16MM QRTT CRT STYP CRV LH LPRO -,SUP-1458Q/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA [1000108],AETNA [100010801],,,76.8,,6029.88,399.86,9410.2272,percent of total billed charges,,,
LEAD QUARTET 75 WIDE SPACING -,SUP-1458QL/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA [1000108],AETNA [100010801],,,76.8,,6029.88,399.86,9410.2272,percent of total billed charges,,,
LEAD QUARTET 1458QL 86 WIDE SPACING -,SUP-1458QL/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA [1000108],AETNA [100010801],,,76.8,,6029.88,399.86,9410.2272,percent of total billed charges,,,
LEAD PCNG 5.4FRX18MM SPC 77CM COROX PERMNT IMPL BIPLR HMSPHR -,SUP-355148,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5228.61,3660.027,AETNA [1000108],AETNA [100010801],,,76.8,,4015.57,399.86,9410.2272,percent of total billed charges,,,
LEAD SENTUS OTW QP L-75 -,SUP-386835,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA [1000108],AETNA [100010801],,,76.8,,6029.88,399.86,9410.2272,percent of total billed charges,,,
LEAD SENTUS OTW QP S-75 -,SUP-400719,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA [1000108],AETNA [100010801],,,76.8,,6029.88,399.86,9410.2272,percent of total billed charges,,,
LV LEAD SENTUS OTW QP L 75/49 -,SUP-408718,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA [1000108],AETNA [100010801],,,76.8,,6029.88,399.86,9410.2272,percent of total billed charges,,,
LV LEAD SENTUS OTW QP L 85/49 -,SUP-408719,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA [1000108],AETNA [100010801],,,76.8,,6029.88,399.86,9410.2272,percent of total billed charges,,,
LEAD PCNG 5FRX88CM ATTAIN PERMNT UNIPL CANTED LT VNTRC OTW -,SUP-4195-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,AETNA [1000108],AETNA [100010801],,,76.8,,7699.28,399.86,9410.2272,percent of total billed charges,,,
LEAD PCNG 4FRX21MM SPC 88CM ATTAIN PERMNT BIPLR ANG LT VNTRC -,SUP-4196-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,399.86,9410.2272,percent of total billed charges,,,
LEAD PCNG 5.3FRX21MM SPC 88CM ATTAIN ABILITY + IMPL BIPLR -,SUP-4296-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,76.8,,4889.09,399.86,9410.2272,percent of total billed charges,,,
LEAD ATTAIN PERFORMA LV REF:429878 -,SUP-429878,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,AETNA [1000108],AETNA [100010801],,,76.8,,7887.73,399.86,9410.2272,percent of total billed charges,,,
LEAD PCNG 5.3FRX21MM SPC 78CM ATTAIN PERFORM QDPL DBL CRV LT -,SUP-4298-78,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,AETNA [1000108],AETNA [100010801],,,76.8,,7841.86,399.86,9410.2272,percent of total billed charges,,,
LEAD ATTAIN PERFORM 4298-88 CM QDPL DBL CRV LT -,SUP-4298-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,399.86,9410.2272,percent of total billed charges,,,
LEAD ATTAIN PERFORMA QUAD LV  88 -,SUP-439888,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,399.86,9410.2272,percent of total billed charges,,,
LEAD PCNG 6FRX11MM SPC 80CM EASYTRAK 2 IMPL UNIPL BIPLR LT -,SUP-4542,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5585.1,3909.57,AETNA [1000108],AETNA [100010801],,,76.8,,4289.36,399.86,9410.2272,percent of total billed charges,,,
LEAD PCNG 6FRX11MM SPC 90CM EASYTRAK 2 IMPL UNIPL BIPLR LT -,SUP-4543,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5585.1,3909.57,AETNA [1000108],AETNA [100010801],,,76.8,,4289.36,399.86,9410.2272,percent of total billed charges,,,
LEAD PCNG 6FRX11MM SPC 90CM EASYTRAK 3 IMPL UNIPL BIPLR LT -,SUP-4549,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5585.1,3909.57,AETNA [1000108],AETNA [100010801],,,76.8,,4289.36,399.86,9410.2272,percent of total billed charges,,,
LEAD PCNG 4.5FRX90CM ACUITY IMPL UNIPL LT ECRD VNTRC SPRL FX -,SUP-4592,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,399.86,9410.2272,percent of total billed charges,,,
LEAD ATTAIN PERFORMA LV 4598-78 -,SUP-4598-78,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,399.86,9410.2272,percent of total billed charges,,,
LEAD ATTAIN PERFORMA LV 4598-88 -,SUP-4598-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA [1000108],AETNA [100010801],,,76.8,,7822.54,399.86,9410.2272,percent of total billed charges,,,
LEAD ACUITY X4 86CM STRAIGHT -,SUP-4671,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,399.86,9410.2272,percent of total billed charges,,,
LEAD ACUITY X4 95CM STRAIGHT -,SUP-4672-95,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,399.86,9410.2272,percent of total billed charges,,,
LV LEAD ACUTIY SPIRAL S MODEL 4674-86 -,SUP-4674,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,399.86,9410.2272,percent of total billed charges,,,
LEAD ACUITY X4 95CM SPIRAL S -,SUP-4675-95,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,399.86,9410.2272,percent of total billed charges,,,
LEAD ACUITY X4 86CM SPIRAL L -,SUP-4677,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,399.86,9410.2272,percent of total billed charges,,,
LEAD ACUITY X4 95CM SPIRAL L -,SUP-4678-95,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA [1000108],AETNA [100010801],,,76.8,,3911.27,399.86,9410.2272,percent of total billed charges,,,
LEAD ATTAIN STABILITY QUAD MRI SURESCAN LV LEAD REF:4798-88 -,SUP-4798-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10247.88,7173.516,AETNA [1000108],AETNA [100010801],,,76.8,,7870.37,399.86,9410.2272,percent of total billed charges,,,
LV LEAD SENTUS OTW QP S 75/49 MODEL 406081 -,SUP-706081,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA [1000108],AETNA [100010801],,,76.8,,6029.88,399.86,9410.2272,percent of total billed charges,,,
LEAD COROX OTW-L 85-BP -,SUP-UNDEFINED,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5228.61,3660.027,AETNA [1000108],AETNA [100010801],,,76.8,,4015.57,399.86,9410.2272,percent of total billed charges,,,
LEAD COROX OTW-L 75-BP -,SUP-UNDEFINED,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5228.61,3660.027,AETNA [1000108],AETNA [100010801],,,76.8,,4015.57,399.86,9410.2272,percent of total billed charges,,,
PROBE PERC SPIN 17GAX6IN -,SUP-0407-250-000,CDM,C2614,HCPCS,270,RC,,,outpatient,,,8309.75,5816.825,AETNA [1000108],AETNA [100010801],,,76.8,,6381.89,399.86,6381.888,percent of total billed charges,,,
SIR-SPHERES Y-90 RESIN MICROSPHERES -,SUP-SIR-Y001,CDM,C2616,HCPCS,278,RC,,,outpatient,,,44393.67,31075.569,AETNA [1000108],AETNA [100010801],,,76.8,,34094.34,399.86,42246.08608,percent of total billed charges,,,
STENT BLDR 14F/7FRX24CM RETROMAX + PERCUFLEX HYDRPLS CTD -,SUP-145-148,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1085.19,759.633,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT 6FR OPEN END -,SUP-160205,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT URET 8FRX80CM PERCUFLEX STR OPEN TIP -,SUP-160215,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
URINARY STENT 7FR CLOSED TIP -,SUP-160230,CDM,C2617,HCPCS,278,RC,,,outpatient,,,535.8,375.06,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT PANC 7FR PSHR CATH 5CM FREEMN -ALIPERT FLEX-STNT -,SUP-6521,CDM,C2617,HCPCS,278,RC,,,outpatient,,,320.93,224.651,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT PANC 7FRX9CM FREEMN FLX-STNT SGL PIGTL DBL XTRN FLNG -,SUP-6575,CDM,C2617,HCPCS,278,RC,,,outpatient,,,268.41,187.887,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT URET 4.7FRX26CM INLAY DBL PIGTL TAPR -,SUP-778426,CDM,C2617,HCPCS,278,RC,,,outpatient,,,396.78,277.746,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT BIL 10FRX5CM COTTON-LEUNG CRV TAPR PE -,SUP-CLSO 10-5,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT BIL 7FRX7CM COTTON-LEUNG CRV TAPR PE P/D FLP -,SUP-CLSO 7-7,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT BILIARY ZIMMON 8FR 12CM 0.035IN GW 3.2MM -,SUP-G21404,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT BIL 10FRX7CM COTTON-LEUNG CRV TAPR PE -,SUP-G21469,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT BIL 10FRX8CM COTTON-LEUNG CRV TAPR PE P/D FLP -,SUP-G21472,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT BIL 10FRX10CM COTTON-LEUNG CRV TAPR PE P/D FLP -,SUP-G21807,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT BILIARY ZIMMON 10-5 -,SUP-G21975,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT PANC 5FRX5CM ZIMMON SPRL SH PE PIGTL TAPR FLP LF MRI -,SUP-G22980,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT PANC 3FRX4CM ZIMMON SPRL SH PE PIGTL TAPR OPTN DCT FLP -,SUP-G24566,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT PANC 5FRX9CM GEENEN SPRL SH SOF-FLEX OFST PROX FLP LF -,SUP-G49666,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT PANC 5FR 7CM GEENEN SOF-FLEX NO INTERNAL FLAP -,SUP-G49670,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT PANC 5FR 9CM GEENEN SOF-FLEX NO INTERNAL FLAP -,SUP-G49671,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT BIL 7FRX5CM COMPASS BDS DBL PIGTL TAPR PLST 0.035IN GW -,SUP-G55519,CDM,C2617,HCPCS,278,RC,,,outpatient,,,414.29,290.003,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT PANC 5FR 3CM GEENEN SOF-FLEX NO INTERNAL FLAP -,SUP-GPSOS-SF-5-3,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT PANC 5FR 5CM GEENEN SOF-FLEX NO INTERNAL PLAP -,SUP-GPSOS-SF-5-5,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT URET 8FRX22CM PERCUFLEX DBL PIGTL FLXB STF -,SUP-M001245500,CDM,C2617,HCPCS,278,RC,,,outpatient,,,826.41,578.487,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT URET 6FRX22CM PERCUFLEX DBL PIGTL -,SUP-M001245730,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT URET 6FRX24CM PERCUFLEX DBL PIGTL -,SUP-M001245740,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT URET 6FRX26CM PERCUFLEX DBL PIGTL -,SUP-M001245750,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT URET 6FRX28CM PERCUFLEX DBL PIGTL -,SUP-M001245760,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT URET 8FRX26CM FLEXIMA DBL PIGTL -,SUP-M001274030,CDM,C2617,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT ADVANIX 7FR X 3CM DOUBLE PIGTAIL -,SUP-M00532160,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
ADVANIX DOUBLE PIGTAIL 7FR X 5CM -,SUP-M00532180,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
ADVANIX DOUBLE PIGTAIL 7FR X 7CM -,SUP-M00532190,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
ADVANIX DOUBLE PIGTAIL 7FR X 10CM -,SUP-M00532210,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
ADVANIX DOUBLE PIGTAIL 10FR X 5CM -,SUP-M00532260,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT BIL 10FRX5CM ADVANIX RX SGL DBL PIGTL PLST 4.2MM WKG -,SUP-M00532260,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
ADVANIX DOUBLE PIGTAIL 10FR X 7CM -,SUP-M00532270,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT BIL 10FRX15CM WALLSTNT DUOD BND PERCUFLEX -,SUP-M00533700,CDM,C2617,HCPCS,278,RC,,,outpatient,,,290.87,203.609,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT URET 8FRX22CM PERCUFLEX DBL PIGTL PSTNR -,SUP-M0061453800,CDM,C2617,HCPCS,278,RC,,,outpatient,,,441.13,308.791,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
SCISSORS SURG KAYE CRV 7.5IN SERR DSCT V. MUELLER LF -,SUP-M0061552310,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT URET 6FRX24CM POLARIS LOOP PERCUFLEX -,SUP-M0061552320,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT URET 6FRX26CM POLARIS LOOP PERCUFLEX -,SUP-M0061552330,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT URET 6FRX28CM POLARIS LOOP PERCUFLEX -,SUP-M0061552340,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT URET 8FRX26CM POLARIS LOOP PERCUFLEX -,SUP-M0061552530,CDM,C2617,HCPCS,278,RC,,,outpatient,,,836.51,585.557,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT URET 7FRX80CM PERCUFLEX STR LF -,SUP-M006160210,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT PERC PLUS 4.8 X 24 -,SUP-M0061752520,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT PERC PLUS 4.8 X 26 -,SUP-M0061752530,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT PERC PLUS 4.8 X 28 -,SUP-M0061752540,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT PERCUFLEX PLUS 6 X 22 -,SUP-M0061752610,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT PERCUFLEX PLUS 6 X 24 -,SUP-M0061752620,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT PERCUFLEX PLUS 6 X 26 -,SUP-M0061752630,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT PERCUFLEX PLUS 6 X 28 -,SUP-M0061752640,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT PERCUFLEX PLUS 6 X 30 -,SUP-M0061752650,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT PERCUFLEX PLUS 7FR X 24CM -,SUP-M0061752720,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT PERCUFLEX PLUS 7FR X 26CM -,SUP-M0061752730,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT PERCUFLEX PLUS 8 X 26 -,SUP-M0061752830,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT PERCUFLEX PLUS 8 X 28 NO -,SUP-M0061752840,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT URET 8FRX30CM PERCUFLEX DBL PIGTL TAPR -,SUP-M0061752850,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT URET 4.8FR 22-30CM CONTR VL PERCUFLEX DBL PIGTL TAPR -,SUP-M0061801550,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT URET 6FR 22-30CM CONTR VL PERCUFLEX DBL PIGTL TAPR -,SUP-M0061801560,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT URET CONTOUR 6 X 22 -,SUP-M0061802210,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT URET CONTOUR 6 X 28 -,SUP-M0061802240,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT URET 8FRX28CM PERCUFLEX TAPR LF -,SUP-M00618022440,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT URET CONTOUR 8 X 24 -,SUP-M0061802420,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT URET 6FRX22CM NTNL/PTFE DBL PIGTL -,SUP-M006190131090,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1073.17,751.219,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT URET 6FRX24CM NTNL/PTFE DBL PIGTL -,SUP-M006190132090,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1073.17,751.219,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT URET 6FRX22CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921310,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT URET 6FRX24CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921320,CDM,C2617,HCPCS,278,RC,,,outpatient,,,791.28,553.896,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT URET 6FRX26CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921330,CDM,C2617,HCPCS,278,RC,,,outpatient,,,791.28,553.896,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT URET 6FRX28CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921340,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT URET 8FRX22CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921510,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT URET 8FRX26CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921530,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT PANC 5FRX5CM ZIMMON SPRL SH PE PIGTL TAPR OPTN DCT FLP -,SUP-SPSOF-5-5,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT BIL 7FRX10CM ZIMMON DBL PIGTL TAPR PE -,SUP-ZSO-7-10,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
STENT BIL 7FRX7CM ZIMMON DBL PIGTL TAPR PE -,SUP-ZSO-7-7,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA [1000108],AETNA [100010801],,,,,,60.258045,734.3115,other,Implant Exclusions,,
PROBE CRYOSPHERE 11IN -,SUP-CRYOS,CDM,C2618,HCPCS,272,RC,,,outpatient,,,10397.8,7278.46,AETNA [1000108],AETNA [100010801],,,,,,399.86,7607.37,other,272 with C codes,,
PROBE CRYOSPHERE 18IN -,SUP-CRYOS-L,CDM,C2618,HCPCS,272,RC,,,outpatient,,,9468.15,6627.705,AETNA [1000108],AETNA [100010801],,,,,,399.86,7607.37,other,272 with C codes,,
ICEROD 1.5C X 90 NEEDLE -,SUP-FPRPR3533,CDM,C2618,HCPCS,272,RC,,,outpatient,,,8042.38,5629.666,AETNA [1000108],AETNA [100010801],,,,,,399.86,7607.37,other,272 with C codes,,
NEEDLE ICEROD CX 90 VL -,SUP-FPRPR3533,CDM,C2618,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,,,,399.86,7607.37,other,272 with C codes,,
NEEDLE ICEPEARL  2.1C X 90 -,SUP-FPRPR3601,CDM,C2618,HCPCS,272,RC,,,outpatient,,,8042.38,5629.666,AETNA [1000108],AETNA [100010801],,,,,,399.86,7607.37,other,272 with C codes,,
NEEDLE ICEFORCE 2.1 X 90 -,SUP-FPRPR3602,CDM,C2618,HCPCS,272,RC,,,outpatient,,,10610,7427,AETNA [1000108],AETNA [100010801],,,,,,399.86,7607.37,other,272 with C codes,,
PACEMAKER IMPL BIPLR ADAPTA VDD SGL-CHMBR RR 11.1ML 23.6GM -,SUP-ADVDD01,CDM,C2619,HCPCS,275,RC,,,outpatient,,,16567.96,11597.572,AETNA [1000108],AETNA [100010801],,,76.8,,12724.19,399.86,12724.19328,percent of total billed charges,,,
PACEMAKER IMPL EVIA HF-T TRI CHMBR 14ML 27GM IS-1 CONN -,SUP-377208,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25991,18193.7,AETNA [1000108],AETNA [100010801],,,76.8,,19961.09,399.86,24381.0432,percent of total billed charges,,,
PACEMAKER IMPL SYNCRA 15ML 26GM DR -,SUP-C2TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,AETNA [1000108],AETNA [100010801],,,76.8,,17109.5,399.86,24381.0432,percent of total billed charges,,,
PACEMAKER IMPL CONSULTA CRT-P SGL-CHMBR 15ML 26GM IS-1 CONN -,SUP-C4TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,AETNA [1000108],AETNA [100010801],,,76.8,,17109.5,399.86,24381.0432,percent of total billed charges,,,
PACEMAKER IMPL ANTHEM 2CHMBR RR 52X58MM 6MM 13.7ML 25GM IS-1 -,SUP-PM3210,CDM,C2621,HCPCS,275,RC,,,outpatient,,,19897.97,13928.579,AETNA [1000108],AETNA [100010801],,,76.8,,15281.64,399.86,24381.0432,percent of total billed charges,,,
PACEMAKER IMPL ALLURE RF 59X55MM 6MM 14ML 24GM IS-1 CONN -,SUP-PM3222,CDM,C2621,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,AETNA [1000108],AETNA [100010801],,,76.8,,11976.65,399.86,24381.0432,percent of total billed charges,,,
PACEMAKER IMPL QDPL ALLURE QUADRA RF 2CHMBR RR 59X56MM 6MM -,SUP-PM3242,CDM,C2621,HCPCS,275,RC,,,outpatient,,,20792.8,14554.96,AETNA [1000108],AETNA [100010801],,,76.8,,15968.87,399.86,24381.0432,percent of total billed charges,,,
CRT-PACER QUADRA ALLURE MP  RF -,SUP-PM3262,CDM,C2621,HCPCS,275,RC,,,outpatient,,,21813.88,15269.716,AETNA [1000108],AETNA [100010801],,,76.8,,16753.06,399.86,24381.0432,percent of total billed charges,,,
QUADRA ALLURE MP MRI PM3562 -,SUP-PM3562,CDM,C2621,HCPCS,275,RC,,,outpatient,,,20792.8,14554.96,AETNA [1000108],AETNA [100010801],,,76.8,,15968.87,399.86,24381.0432,percent of total billed charges,,,
PACEMAKER ALTRUA 60 49MMX43X8MM 12.1ML TI -,SUP-S606 DR EL,CDM,C2621,HCPCS,275,RC,,,outpatient,,,18193.7,12735.59,AETNA [1000108],AETNA [100010801],,,76.8,,13972.76,399.86,24381.0432,percent of total billed charges,,,
VALITUDE CRT-P U125 -,SUP-U125,CDM,C2621,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,AETNA [1000108],AETNA [100010801],,,76.8,,11976.65,399.86,24381.0432,percent of total billed charges,,,
CRT-P VALITUDE MODEL - U128 -,SUP-U128,CDM,C2621,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,AETNA [1000108],AETNA [100010801],,,76.8,,11976.65,399.86,24381.0432,percent of total billed charges,,,
VISIONIST CRT-P MODEL U226 BI-V PACEMAKER -,SUP-U226,CDM,C2621,HCPCS,275,RC,,,outpatient,,,27736.11,19415.277,AETNA [1000108],AETNA [100010801],,,76.8,,21301.33,399.86,24381.0432,percent of total billed charges,,,
CRT-P VISIONIST X4 - U228 -,SUP-U228,CDM,C2621,HCPCS,275,RC,,,outpatient,,,20313.82,14219.674,AETNA [1000108],AETNA [100010801],,,76.8,,15601.01,399.86,24381.0432,percent of total billed charges,,,
PACEMAKER IMPL INVIVE CRT-PS SMARTDELAY ALGORITHM RPM -,SUP-V172,CDM,C2621,HCPCS,275,RC,,,outpatient,,,31746.15,22222.305,AETNA [1000108],AETNA [100010801],,,76.8,,24381.04,399.86,24381.0432,percent of total billed charges,,,
PACEMAKER INTUA CARD -,SUP-V272,CDM,C2621,HCPCS,275,RC,,,outpatient,,,28590.1,20013.07,AETNA [1000108],AETNA [100010801],,,76.8,,21957.2,399.86,24381.0432,percent of total billed charges,,,
PACEMAKER PERCEPTA CRT-P MRI W1TR01 -,SUP-W1TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25991,18193.7,AETNA [1000108],AETNA [100010801],,,76.8,,19961.09,399.86,24381.0432,percent of total billed charges,,,
SOLARA CRT-P MRI W1TR03 -,SUP-W1TR03,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,AETNA [1000108],AETNA [100010801],,,76.8,,17109.5,399.86,24381.0432,percent of total billed charges,,,
PACEMAKER PERCEPTA QUAD CRT-P MRI W4TR01 -,SUP-W4TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25991,18193.7,AETNA [1000108],AETNA [100010801],,,76.8,,19961.09,399.86,24381.0432,percent of total billed charges,,,
PACEMAKER SERENA QUAD CRT-P MRI W4TR02 -,SUP-W4TR02,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25248.4,17673.88,AETNA [1000108],AETNA [100010801],,,76.8,,19390.77,399.86,24381.0432,percent of total billed charges,,,
SOLARA QUAD CRT-P MRI W4TR03 -,SUP-W4TR03,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,AETNA [1000108],AETNA [100010801],,,76.8,,17109.5,399.86,24381.0432,percent of total billed charges,,,
PROSTHESIS PENL CNCLBL 14MMX16CM ANG RGD CONN MIN SPR BK -,SUP-720056-02,CDM,C2622,HCPCS,278,RC,,,outpatient,,,24383.27,17068.289,AETNA [1000108],AETNA [100010801],,,76.8,,18726.35,399.86,23086.3872,percent of total billed charges,,,
IMPLANT PENL CL 12MMX12CM SIL PE TI SEG MALE CNCLBL SNP FIT -,SUP-720074-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,20421.5,14295.05,AETNA [1000108],AETNA [100010801],,,76.8,,15683.71,399.86,23086.3872,percent of total billed charges,,,
PROSTHESIS TACTRA 9.5MM X 14CM-23CM MALLEABLE -,SUP-720080-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,30060.4,21042.28,AETNA [1000108],AETNA [100010801],,,76.8,,23086.39,399.86,23086.3872,percent of total billed charges,,,
TACTRA 11CM MALLEABLE PROSTHESIS -,SUP-720081-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,30060.4,21042.28,AETNA [1000108],AETNA [100010801],,,76.8,,23086.39,399.86,23086.3872,percent of total billed charges,,,
TACTRA 13MM X 18CM-27CM MALLEABLE PROSTHESIS -,SUP-720082-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,28358.17,19850.719,AETNA [1000108],AETNA [100010801],,,76.8,,21779.07,399.86,23086.3872,percent of total billed charges,,,
IMPLANT PENL DURA 11 10MMX14CM CL HX WRNCH STRL -,SUP-720093-10,CDM,C2622,HCPCS,278,RC,,,outpatient,,,15579.75,10905.825,AETNA [1000108],AETNA [100010801],,,76.8,,11965.25,399.86,23086.3872,percent of total billed charges,,,
TIP PROS DURA II 10MMX1CM UNIV PENL STRL -,SUP-720093-12,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,AETNA [1000108],AETNA [100010801],,,76.8,,1848.14,399.86,23086.3872,percent of total billed charges,,,
TIP PROS DURA II 10MMX5CM PROX PENL STRL -,SUP-720093-16,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,AETNA [1000108],AETNA [100010801],,,76.8,,1848.14,399.86,23086.3872,percent of total billed charges,,,
TIP PROS DURA II 10MMX4CM DIST PENL STRL -,SUP-720093-23,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,AETNA [1000108],AETNA [100010801],,,76.8,,1848.14,399.86,23086.3872,percent of total billed charges,,,
TIP PROS DURA II 10MMX2CM UNIV PENL STRL -,SUP-720093-60,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,AETNA [1000108],AETNA [100010801],,,76.8,,1848.14,399.86,23086.3872,percent of total billed charges,,,
KT PROSTHESIS PENL 11MMX25CM MALE CYL MLBL TRMBL ADPR W/TAIL -,SUP-91-9511SC,CDM,C2622,HCPCS,278,RC,,,outpatient,,,20291.55,14204.085,AETNA [1000108],AETNA [100010801],,,76.8,,15583.91,399.86,23086.3872,percent of total billed charges,,,
BARD BALLOON LUTONIX .035 4.0 X 150MM -,SUP-BSLX3513041505F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8912.4,6238.68,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
CATH PTCA 6MMX130CM LUTONIX 60MM DRG CTD 0.035IN GW COMP -,SUP-BSLX351306605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
LUTONIX BALLOON 6MM X 80MM -,SUP-BSLX351306805F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,7214.8,5050.36,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
RANGER DCB OTW  4.0MM x 40MM x 135CM -,SUP-H74939419400410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
RANGER GLOBAL DCB OTW 4.0 X 80MM 135CM -,SUP-H74939419400810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
RANGER GLOBAL DCB OTW 4.0 X 100MM 135CM -,SUP-H74939419401010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
RANGER GLOBAL DCB OTW 4.0 X 150MM 150CM -,SUP-H74939419401510,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
RANGER GLOBAL DCB OTW 4.0 X 200MM 150CM -,SUP-H74939419402010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
RANGER GLOBAL DCB OTW 4.0 X 200MM 150CM -,SUP-H74939419500410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
RANGER GLOBAL DCB OTW 5.0 X 60MM 135CM -,SUP-H74939419500610,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
CATH BALLOON RANGER GLOBAL 5.0 X 80MM X 135CM GLOBAL DCB OTW -,SUP-H74939419500810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
RANGER GLOBAL DCB OTW 5.0 X 100MM 135CM -,SUP-H74939419501010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
RANGER GLOBAL DCB OTW 5.0 X 120MM 150CM -,SUP-H74939419501210,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5708.18,3995.726,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
RANGER GLOBAL DCB OTW 5.0 X 150MM 150CM -,SUP-H74939419501510,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
RANGER DCB OTW 5.0MM x 200MM x 150CM -,SUP-H74939419502010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
RANGER GLOBAL DCB OTW 5.0 X 200MM 90CM -,SUP-H74939419502090,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
RANGER GLOBAL DCB OTW 6.0 X 40MM 135CM -,SUP-H74939419600410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
RANGER GLOBAL DCB OTW 6.0 X 60MM 135CM -,SUP-H74939419600610,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
CATH BALLOON RANGER GLOBAL 6.0 X 80MM X 135CM GLOBAL DCB OTW -,SUP-H74939419600810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
RANGER GLOBAL DCB OTW 6.0 X 100MM 135CM -,SUP-H74939419601010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
RANGER GLOBAL DCB OTW 6.0 X 200MM 150CM -,SUP-H74939419602010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
RANGER GLOBAL DCB OTW 7.0 X 40MM 135CM -,SUP-H74939419700410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
RANGER GLOBAL DCB OTW 7.0 X 60MM 135CM -,SUP-H74939419700610,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
RANGER GLOBAL DCB OTW 7.0 X 80MM 135CM -,SUP-H74939419700810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
RANGER GLOBAL DCB OTW 7.0 X 100MM 135CM -,SUP-H74939419701010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
RANGER GLOBAL DCB OTW 7.0 X 150MM 150CM -,SUP-H74939419701510,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
RANGER GLOBAL DCB OTW 7.0 X 200MM 150CM -,SUP-H74939419702010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
LUTONIX 018 6 X 80MM -,SUP-LX181306805F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
CATH PTCA 4MMX130CM LUTONIX 40MM DRG CTD 0.035IN GW COMP -,SUP-LX351304405F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
CATH PTCA 4MMX130CM LUTONIX 60MM DRG CTD 0.035IN GW COMP -,SUP-LX351304605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
CATH PTCA 5MMX130CM LUTONIX 100MM DRG CTD 0.035IN GW COMP -,SUP-LX3513051005F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
CATH PTCA 5X150MM LUTONIX 130CM -,SUP-LX3513051505F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
CATH PTCA 5MMX130CM LUTONIX 60MM DRG CTD 0.035IN GW COMP -,SUP-LX351305605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
B LUTONIX 6MM X 100MM X 130 -,SUP-LX3513061005F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
CATH PTCA 6X150MM LUTONIX 130CM -,SUP-LX3513061505F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
LUTONIX BALLOON -,SUP-LX3513062205F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8700.2,6090.14,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
CATH PTCA LUTONIX 0.035 X 6.0MM X 130CM 6FR DRG CTD GW GROUP -,SUP-LX351306605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
CATH PTCA 6MMX130CM LUTONIX 80MM DRG CTD 0.035IN GW COMP -,SUP-LX351306805F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
LUTONIX BALLOON 7MM X 100MM X 130M -,SUP-LX3513071005F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
S LUTONIX 7 X 40 X 130 -,SUP-LX351307405F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
S LUTONIX 7 X 60 X 130 -,SUP-LX351307605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
BALLOON LUTONIX .035 X 10MM X 40MM -,SUP-LX35751040V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
BALLOON LUTONIX .035 X 10MM X 60MM -,SUP-LX35751060V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
LUTONIX 12MM X 40MMX 75CM -,SUP-LX35751240V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6896.5,4827.55,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
BALLOON LUTONIX .035  4.0MM X 40MM -,SUP-LX3575440V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
CATH LUTONIX BALLOON DILATATION 6MM 75CM 40MM PACLITAXEL LF -,SUP-LX3575640V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
CATH LUTONIX BALLOON DILATATION 6MM 75CM 60MM PACLITAXEL LF -,SUP-LX3575660V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
LUTONIX DCB BALLOON 6 X 80 X 75 -,SUP-LX3575680V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
BALLOON LUTONIX .035  7.0MM X 40MM -,SUP-LX3575740V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
BALLOON LUTONIX .035  4 X 60 X 75 -,SUP-LX3575760V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
BALLOON LUTONIX .035 X 8MM X 40MM X 75CM -,SUP-LX3575840V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
BALLOON LUTONIX  .035 8 X 60 X 75 -,SUP-LX3575860V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
BALLOON LUTONIX .035 9.0MM X 40MM X 75CM -,SUP-LX3575940V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA [1000108],AETNA [100010801],,,,,,399.86,6390.1908,other,272 with C codes,,
STENT NEPHURET 8.5FRX22CM ULTRATHANE COPE DBL PIGTL BND -,SUP-240735,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT NEPHURET 8.5FRX24CM ULTRATHANE COPE DBL PIGTL BND -,SUP-240736,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT NEPHURET 8.5FRX28 CM ULTRATHANE COPE DBL PIGTL BND -,SUP-244806,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT URET 4.7FRX24CM INLAY DBL PIGTL TAPR -,SUP-778424,CDM,C2625,HCPCS,278,RC,,,outpatient,,,396.78,277.746,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
8FR X 22 BARD OPTIMA INLAY URETERAL STENT -,SUP-778822,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
8FR X 24 BARD OPTIMA INLAY URETERAL STENT -,SUP-778824,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
8FR X 26 BARD OPTIMA INLAY URETERAL STENT -,SUP-778826,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
8FR X 28 BARD OPTIMA INLAY URETERAL STENT -,SUP-778828,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT URETERAL INLAY 6F 20 OPT -,SUP-788620,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT URETERAL INLAY 6F 22 OPT -,SUP-788622,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT URETERAL INLAY 6F 24 -,SUP-788624,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT URETERAL INLAY 6F 26 -,SUP-788626,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT URETERAL INLAY 6F 28 -,SUP-788628,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT URETERAL INLAY 6F 30 -,SUP-788630,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
BARD OPTIMA INLAY STENT 7 X 24 -,SUP-788724,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
BARD OPTIMA INLAY STENT 7 X 26 -,SUP-788726,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
BARD OPTIMA INLAY STENT 7 X 28 -,SUP-788728,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT BIL 7FRX5CM COTTON-LEUNG CRV TAPR PE P/D FLP PSH CATH -,SUP-CLBS-7-5,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT FANELLI BILIARY -,SUP-G13699,CDM,C2625,HCPCS,278,RC,,,outpatient,,,2999.5,2099.65,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT URET 7FRX75CM BNDR RT SOF-FLEX -,SUP-G14779,CDM,C2625,HCPCS,278,RC,,,outpatient,,,446.79,312.753,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT URET 7FRX75CM BNDR PTFE -,SUP-G14780,CDM,C2625,HCPCS,278,RC,,,outpatient,,,451.1,315.77,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT BILIARY DOUBLE PIGTAIL 7 X 7 -,SUP-G21396,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT BILIARY DOUBLE PIGTAIL 7 X 9 -,SUP-G21398,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT GEENAN PANCREATIC 7X7 -,SUP-G21479,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT GEENAN PANCREATIC 7X9 -,SUP-G21480,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT SET ZIMMON BILIARY 7-12 -,SUP-G21526,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT ZIMON BILIARY 7 X 15 -,SUP-G21529,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT ZIMMON DBL PIGTAIL 10X4 -,SUP-G21781,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT BIL 10MMX5CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN -,SUP-G25379,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT BIL 10MMX7CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN -,SUP-G25380,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT BIL 7MMX5CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN GW -,SUP-G25656,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT BIL 7MMX7CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN GW -,SUP-G25657,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT SOLUS DOUBLE PIGTAIL 10FR 3CM -,SUP-G25670,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT SOLUS DBL PIGTAIL 10 X 4 -,SUP-G25671,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT SOLUS DBL PIGTAIL 10 X 5 -,SUP-G25672,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT SOLUS DOUBLE PIGTAIL 10FR 1CM -,SUP-G26829,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT DBLE PIGTAIL 10F 1CM -,SUP-G26829,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT NEPHURET 10.2FRX22CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48162,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT NEPHURET 8.5FRX24CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48176,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT NEPHURET 8.5FRX26CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48180,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT NEPHURET 8.5FRX26CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48180,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
COMPASS BDS BILIARY STENT 7FR 15CM -,SUP-G58990,CDM,C2625,HCPCS,278,RC,,,outpatient,,,408.45,285.915,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT PANC 3FRX4CM GEENEN 170CM/320CM PSH/GUID CATH SPRL SH -,SUP-GEPD3-4,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
TUBE LRNCMY JCKSN SZ8 12MMX7CM OSDE V. MUELLER CRV MIRR FNSH -,SUP-GEPD3-5,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
CATH DRN 10FR NAVIFLEX RX -,SUP-M00533580,CDM,C2625,HCPCS,278,RC,,,outpatient,,,512.08,358.456,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT ADVANIX RX 7FR X 5CM PRELOADED -,SUP-M00534200,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT ADVANIX RX 7FR X 7CM PRELOADED -,SUP-M00534210,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT ADVANIX RX 7FR X 9CM PRELOADED -,SUP-M00534220,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT BIL 2.3MMX9CM ADVANIX RX PRELD DUOD BND PLST 3.2MM WKG -,SUP-M00534220,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT ADVANIX RX 7FR X 12CM PRELOADED -,SUP-M00534230,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT ADVANIX RX 10FR X 5CM PRELOADED -,SUP-M00534320,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT ADVANIX RX 10FR X 5CM PRELOADED -,SUP-M00534330,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT ADVANIX RX 10FR X 9CM PRELOADED -,SUP-M00534340,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT BIL 10FRX9CM ADVANIX RX PRELD DUOD BND PLST 4.2MM WKG -,SUP-M00534340,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT ADVANIX RX 10FR X 12CM PRELOADED -,SUP-M00534350,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT BIL 10FRX12CM ADVANIX RX PRELD DUOD BND PLST 4.2MM WKG -,SUP-M00534350,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT BIL 10FRX15CM ADVANIX RX PRELD DUOD BND PLST 4.2MM WKG -,SUP-M00534360,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT ADVANIX RX 10FR X 15CM -,SUP-M00534360,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT BIL 8.5FRX7CM ADVANIX RX PRELD CTR BND PLST 3.2MM WKG -,SUP-M00534630,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT BIL 8.5FRX9CM ADVANIX RX PRELD CTR BND PLST 3.2MM WKG -,SUP-M00534640,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT BIL 10FRX7CM ADVANIX RX PRELD CTR BND PLST 4.2MM WKG -,SUP-M00534690,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT BIL 10FRX12CM ADVANIX RX PRELD CTR BND PLST 4.2MM WKG -,SUP-M00534710,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT ADVANTIX 5X3 PANCREATIC NO LEADING BARB SINGLE PIGTAIL -,SUP-M00537390,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT ADVANTIX 5 X 4 PANCREATIC - NO LEADING BARB -,SUP-M00537400,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT ADVANTIX 5X5 PANCREATIC NO LEADING BARB SINGLE PIGTAIL -,SUP-M00537410,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT ADVANTIX 5 X 3 PANCREATIC -LEADING BARB -,SUP-M00537430,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT ADVANTIX 5 X 4 PANCREATIC -LEADING BARB -,SUP-M00537440,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT ADVANTIX 5X3 PANCREATIC NO LEADING BARB STRAIGHT -,SUP-M00537500,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT ADVANTIX 5X5 PANCREATIC NO LEADING BARB STRAIGHT -,SUP-M00537520,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT KIT PANCREATIC 5FR X 3CM -,SUP-M00537540,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
STENT BIL 7FRX4CM ZIMMON DBL PIGTL TAPR PE 170CM PSH CATH -,SUP-ZEBD-7-4,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,AETNA [1000108],AETNA [100010801],,,,,,89.07711,1949.675,other,Implant Exclusions,,
PAIN CONTROL DEVICE BEELINE -,SUP-UNDEFINED,CDM,C2626,HCPCS,278,RC,,,outpatient,,,758.55,530.985,AETNA [1000108],AETNA [100010801],,,76.8,,582.57,170.294475,582.5664,percent of total billed charges,,,
HC Cath Stamey Suprapubic 14,PX-27200045,CDM,C2627,HCPCS,272,RC,,,outpatient,,,306,214.2,AETNA [1000108],AETNA [100010801],,,,,,24.890315,416.02,other,272 with C codes,,
ST SUPRAPUBIC 12FRX25CM CONN TUBEX1/NDL OBTURATORX1/ 1W -,SUP-G14313,CDM,C2627,HCPCS,272,RC,,,outpatient,,,357.1,249.97,AETNA [1000108],AETNA [100010801],,,,,,24.890315,416.02,other,272 with C codes,,
CATHETER MALECOT DRAINAGE 14FR 30CM -,SUP-G55824,CDM,C2627,HCPCS,272,RC,,,outpatient,,,307.21,215.047,AETNA [1000108],AETNA [100010801],,,,,,24.890315,416.02,other,272 with C codes,,
LAWRENCE SUPRA-FOLEY 16F -,SUP-SF-S16-851,CDM,C2627,HCPCS,272,RC,,,outpatient,,,110.87,77.609,AETNA [1000108],AETNA [100010801],,,,,,24.890315,416.02,other,272 with C codes,,
OCCULSION BALLOON CATH 90CM BR -,SUP-590-001,CDM,C2628,HCPCS,272,RC,,,outpatient,,,4415.95,3091.165,AETNA [1000108],AETNA [100010801],,,,,,23.64434,10635.57648,other,272 with C codes,,
CATH OCL 6FRX10MM BLN ATTAIN COR -,SUP-6215,CDM,C2628,HCPCS,272,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,,,,23.64434,10635.57648,other,272 with C codes,,
CATHETER PRUITT OCCLUSION 3F 7MM 27CM -,SUP-E2103-36,CDM,C2628,HCPCS,272,RC,,,outpatient,,,1743.86,1220.702,AETNA [1000108],AETNA [100010801],,,,,,23.64434,10635.57648,other,272 with C codes,,
CATH ANG 5FR SHTH 135CM 3.75X20X1.5MM BLN ENTEER PERIPH -,SUP-ENB37520135,CDM,C2628,HCPCS,272,RC,,,outpatient,,,10273.24,7191.268,AETNA [1000108],AETNA [100010801],,,,,,23.64434,10635.57648,other,272 with C codes,,
CATHETER OCCLUSION ER-REBOA PLUS -,SUP-ER7232PLUS,CDM,C2628,HCPCS,272,RC,,,outpatient,,,14833.44,10383.408,AETNA [1000108],AETNA [100010801],,,,,,23.64434,10635.57648,other,272 with C codes,,
CATH HSG 5FRX30CM SIL 1ML BLN/SYR OPN TIP MRI-COND STRL SUD -,SUP-G17147,CDM,C2628,HCPCS,272,RC,,,outpatient,,,171.9,120.33,AETNA [1000108],AETNA [100010801],,,,,,23.64434,10635.57648,other,272 with C codes,,
B CODA-2-10.0-35-140-46 -,SUP-G23773,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2702.08,1891.456,AETNA [1000108],AETNA [100010801],,,,,,23.64434,10635.57648,other,272 with C codes,,
CODA BALLOON 46MM -,SUP-G23773,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2702.08,1891.456,AETNA [1000108],AETNA [100010801],,,,,,23.64434,10635.57648,other,272 with C codes,,
CATH URET 6.2FRX26CM LF W/HSG/SHG MLBL STYL -,SUP-J-UHSG-062026,CDM,C2628,HCPCS,272,RC,,,outpatient,,,105.32,73.724,AETNA [1000108],AETNA [100010801],,,,,,23.64434,10635.57648,other,272 with C codes,,
KIT CATHETER REBOA CONVENIENCE -,SUP-KT1835C,CDM,C2628,HCPCS,272,RC,,,outpatient,,,1192.61,834.827,AETNA [1000108],AETNA [100010801],,,,,,23.64434,10635.57648,other,272 with C codes,,
CATHETER BALLOON MOLDING OCCLUSION 10MM X 37MM 10FR -,SUP-MOB37,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2740.28,1918.196,AETNA [1000108],AETNA [100010801],,,,,,23.64434,10635.57648,other,272 with C codes,,
CATH OUTBACK RE-ENTRY 120CM -,SUP-OTB59120A,CDM,C2628,HCPCS,272,RC,,,outpatient,,,8021.16,5614.812,AETNA [1000108],AETNA [100010801],,,,,,23.64434,10635.57648,other,272 with C codes,,
Q50X STENT GRAFT BALLOON CATHETER -,SUP-Q50-100-X,CDM,C2628,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,,,,23.64434,10635.57648,other,272 with C codes,,
CATH GUID 8FR 10-46MM INFL 100CM RELIANT PU 12FR SHTH -,SUP-REL46,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2500.25,1750.175,AETNA [1000108],AETNA [100010801],,,,,,23.64434,10635.57648,other,272 with C codes,,
MICRO INTRO KIT 21G 4FR 7CM TCAR - MULT'S OF 10EA -,SUP-SR-4F21G7D-MP,CDM,C2628,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA [1000108],AETNA [100010801],,,,,,23.64434,10635.57648,other,272 with C codes,,
HSG CATHETER -,SUP-UNDEFINED,CDM,C2628,HCPCS,272,RC,,,outpatient,,,207.35,145.145,AETNA [1000108],AETNA [100010801],,,,,,23.64434,10635.57648,other,272 with C codes,,
CATH ABLT THRP COOL PATH MED CURL 7FR 2-5-2MM SPC 110CM QDPL -,SUP-A088047,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes,,
CATH ABLT THRP COOL PATH LRG CURL 7FR 2-5-2MM SPC 110CM QDPL -,SUP-A088049,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes,,
CATH ABLT SAFIRE BLU MED SWP DIST REACH CRV 7FR 2-5-2MM SPC -,SUP-A088106,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes,,
CATH ABLT SAFIRE BLU MED CURL DIST REACH CRV 7FR 2-5-2MM SPC -,SUP-A088107,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes,,
CATH ABLT SAFIRE BLU LRG SWP 7FR 2-5-2MM SPC LRG SWP 110CM -,SUP-A088108,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes,,
CATH ABLT SAFIRE BLU MED CURL DIST REACH CRV 7FR HGH TRQ -,SUP-A402871,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes,,
CATH ABLT SAFIRE BLU LRG CURL DIST REACH CRV HGH TRQ SHFT -,SUP-A402872,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes,,
CATH ABLT SAFIRE BLU MED CURL CRV EP DUO -,SUP-A700455,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes,,
CATH ABLT TACTICATH SE BI-D DF -,SUP-A-TCSE-DF,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10440.96,7308.672,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes,,
CATH ABLT TACTI SE BI-D FJ -,SUP-A-TCSE-FJ,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10440.96,7308.672,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes,,
CATH ABLT TACTIFLEX SE BID DF REF: A-TFSE-DF -,SUP-A-TFSE-DF,CDM,C2630,HCPCS,272,RC,,,outpatient,,,14387.88,10071.516,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes,,
CATH ABLT TACTIFLEX SE BID FJ REF: A-TFSE-FJ -,SUP-A-TFSE-FJ,CDM,C2630,HCPCS,272,RC,,,outpatient,,,14387.88,10071.516,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes,,
CATH ABLT THERMOCOOL SF F-J CRV 8FR 2-5-2MM SPC 115CM BIDIR -,SUP-BDI35FJRT,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7957.5,5570.25,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes,,
CATH ABLT THERMOCOOL SF B- CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131601,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes,,
CATH ABLT THERMOCOOL SF D-CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131602,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes,,
CATH ABLT THERMOCOOL SF F-CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131603,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes,,
CATH ABLT THERMOCOOL SF J-CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131604,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes,,
CATH ABLT THERMOCOOL SF CARTO XP F-TY CRV STEER UNI- DRCT -,SUP-D131803,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes,,
CATH ABLT THERMOCOOL SF CARTO XP J CRV STEER UNI- DRCT HTORQ -,SUP-D131804,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes,,
CATH ABLT CHILLI II STD CRV 7.5FRX2.5MM SPC 4MM TIP 110CM -,SUP-M00490310,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7151.14,5005.798,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes,,
CATH ABLT THRMCPL CRV 7.5FR LRG 110CM 2.5/2.5MM SPC -,SUP-M0049031K20,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7151.14,5005.798,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes,,
CATH ABLT TACTICATH 65 MM -,SUP-PN-004 065,CDM,C2630,HCPCS,272,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes,,
CATH ABLT TACTICATH 75MM -,SUP-PN-004075,CDM,C2630,HCPCS,272,RC,,,outpatient,,,11139,7797.3,AETNA [1000108],AETNA [100010801],,,,,,399.86,10316.10996,other,272 with C codes,,
DEVICE SUTCAP 12MM OPN ACCESS -,SUP-M0068311251,CDM,C2631,HCPCS,272,RC,,,outpatient,,,2073.95,1451.765,AETNA [1000108],AETNA [100010801],,,,,,399.86,1487.02215,other,272 with C codes,,
HC Mra- W/Dye- Upper Extremity,PX-61000005,CDM,C8934,CPT,610,RC,,,outpatient,,,2034,1423.8,AETNA [1000108],AETNA [100010801],,,76.8,,1562.11,399.86,1724.0184,percent of total billed charges,,,
HC Mra- W/O Dye- Upper Extr,PX-61000006,CDM,C8935,CPT,610,RC,,,outpatient,,,1745,1221.5,AETNA [1000108],AETNA [100010801],,,76.8,,1340.16,267.439885,1479.062,percent of total billed charges,,,
HC Mra- W/O&W/Dye- Upper Extr,PX-61000007,CDM,C8936,CPT,610,RC,,,outpatient,,,3036,2125.2,AETNA [1000108],AETNA [100010801],,,76.8,,2331.65,399.86,2573.3136,percent of total billed charges,,,
HC Cad Breast MRI,PX-61000089,CDM,C8937,HCPCS,610,RC,,,outpatient,,,344,240.8,AETNA [1000108],AETNA [100010801],,,76.8,,264.19,77.228,836,percent of total billed charges,,,
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML IJ SOLN,RX-155306,CDM,C9088,HCPCS,636,RC,47426-0301-02,NDC,outpatient,14,ML,1200.46,840.322,AETNA [1000108],AETNA [100010801],,,76.8,,921.95,0.71,921.95328,percent of total billed charges,,,
PANTOPRAZOLE SODIUM 40 MG IV SOLR,RX-26226,CDM,C9113,HCPCS,636,RC,55150-0202-10,NDC,outpatient,1,UN,7.54,5.278,AETNA [1000108],AETNA [100010801],,,76.8,,5.79,1.69273,416.02,percent of total billed charges,,,
PANTOPRAZOLE SODIUM 40 MG IV SOLR,RX-26226,CDM,C9113,HCPCS,636,RC,00008-0923-55,NDC,outpatient,1,UN,8.55,5.985,AETNA [1000108],AETNA [100010801],,,76.8,,6.57,1.69273,416.02,percent of total billed charges,,,
PANTOPRAZOLE SODIUM 40 MG IV SOLR,RX-26226,CDM,C9113,HCPCS,636,RC,00008-0923-51,NDC,outpatient,1,UN,8.55,5.985,AETNA [1000108],AETNA [100010801],,,76.8,,6.57,1.69273,416.02,percent of total billed charges,,,
PANTOPRAZOLE SODIUM 40 MG IV SOLR,RX-26226,CDM,C9113,HCPCS,636,RC,00008-0923-60,NDC,outpatient,1,UN,8.55,5.985,AETNA [1000108],AETNA [100010801],,,76.8,,6.57,1.69273,416.02,percent of total billed charges,,,
PANTOPRAZOLE SODIUM 40 MG IV SOLR,RX-26226,CDM,C9113,HCPCS,636,RC,55150-0202-00,NDC,outpatient,1,UN,7.54,5.278,AETNA [1000108],AETNA [100010801],,,76.8,,5.79,1.69273,416.02,percent of total billed charges,,,
COCAINE HCL 4 % EX SOLN,RX-1792,CDM,C9143,HCPCS,636,RC,70839-0362-04,NDC,outpatient,4,ML,1089.63,762.741,AETNA [1000108],AETNA [100010801],,,76.8,,836.84,1.4,836.83584,percent of total billed charges,,,
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-01,NDC,outpatient,50,ML,344.88,241.416,AETNA [1000108],AETNA [100010801],JW,,76.8,,264.87,3.39,416.02,percent of total billed charges,,,
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-10,NDC,outpatient,50,ML,360.88,252.616,AETNA [1000108],AETNA [100010801],,,76.8,,277.16,3.39,416.02,percent of total billed charges,,,
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-01,NDC,outpatient,50,ML,360.88,252.616,AETNA [1000108],AETNA [100010801],,,76.8,,277.16,3.39,416.02,percent of total billed charges,,,
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-10,NDC,outpatient,50,ML,344.88,241.416,AETNA [1000108],AETNA [100010801],JW,,76.8,,264.87,3.39,416.02,percent of total billed charges,,,
LACOSAMIDE 200 MG/20ML IV SOLN,RX-96972,CDM,C9254,HCPCS,636,RC,00131-1810-67,NDC,outpatient,20,ML,278.22,194.754,AETNA [1000108],AETNA [100010801],,,76.8,,213.67,0.31,416.02,percent of total billed charges,,,
LACOSAMIDE 200 MG/20ML IV SOLN,RX-96972,CDM,C9254,HCPCS,636,RC,72603-0140-02,NDC,outpatient,20,ML,100.4,70.28,AETNA [1000108],AETNA [100010801],,,76.8,,77.11,0.31,416.02,percent of total billed charges,,,
LACOSAMIDE 200 MG/20ML IV SOLN,RX-96972,CDM,C9254,HCPCS,636,RC,72603-0140-01,NDC,outpatient,20,ML,100.4,70.28,AETNA [1000108],AETNA [100010801],,,76.8,,77.11,0.31,416.02,percent of total billed charges,,,
BUPIVACAINE LIPOSOME 1.3 % IJ SUSP,RX-112781,CDM,C9290,HCPCS,636,RC,65250-0266-09,NDC,outpatient,20,ML,1495.03,1046.521,AETNA [1000108],AETNA [100010801],,,76.8,,1148.18,1.36,1148.18304,percent of total billed charges,,,
BUPIVACAINE LIPOSOME 1.3 % IJ SUSP,RX-112781,CDM,C9290,HCPCS,636,RC,65250-0266-20,NDC,outpatient,20,ML,1495.03,1046.521,AETNA [1000108],AETNA [100010801],,,76.8,,1148.18,1.36,1148.18304,percent of total billed charges,,,
CAP NERVE AXOGEN 2MM X 15MM -,SUP-AGT215,CDM,C9353,HCPCS,278,RC,,,outpatient,,,6688.54,4681.978,AETNA [1000108],AETNA [100010801],,,76.8,,5136.8,399.86,5136.79872,percent of total billed charges,,,
CAP NERVE AXOGEN 3MM X 15MM -,SUP-AGT315,CDM,C9353,HCPCS,278,RC,,,outpatient,,,6688.54,4681.978,AETNA [1000108],AETNA [100010801],,,76.8,,5136.8,399.86,5136.79872,percent of total billed charges,,,
CAP NERVE AXOGEN 4 X 15 -,SUP-AGT415,CDM,C9353,HCPCS,278,RC,,,outpatient,,,6688.54,4681.978,AETNA [1000108],AETNA [100010801],,,76.8,,5136.8,399.86,5136.79872,percent of total billed charges,,,
NEUROMATRIX 6.0MM DIAMETER 2.5CM LENGTH -,SUP-CNC6025,CDM,C9355,HCPCS,278,RC,,,outpatient,,,5756.22,4029.354,AETNA [1000108],AETNA [100010801],,,76.8,,4420.78,182.24,5164.04736,percent of total billed charges,,,
NEUROFLEX NERVE 4MM X 2.5CM -,SUP-CNCF4025,CDM,C9355,HCPCS,278,RC,,,outpatient,,,6724.02,4706.814,AETNA [1000108],AETNA [100010801],,,76.8,,5164.05,182.24,5164.04736,percent of total billed charges,,,
NEUROFLEX NERVE 6MM X 2.5CM -,SUP-CNCF6025,CDM,C9355,HCPCS,278,RC,,,outpatient,,,6724.02,4706.814,AETNA [1000108],AETNA [100010801],,,76.8,,5164.05,182.24,5164.04736,percent of total billed charges,,,
MESH SURGIMEND 5X6CM 1.0MM -,SUP-606-001-002,CDM,C9358,HCPCS,636,RC,,,outpatient,,,2525.06,1767.542,AETNA [1000108],AETNA [100010801],,,76.8,,1939.25,399.86,24858.15552,percent of total billed charges,,,
MESH SURGIMEND 5X6CM 1.0MM - C -,SUP-606-001-002,CDM,C9358,HCPCS,636,RC,,,outpatient,,,2525.06,1767.542,AETNA [1000108],AETNA [100010801],,,76.8,,1939.25,399.86,24858.15552,percent of total billed charges,,,
MESH SURGIMEND BOVINE 10 X 15CM -,SUP-606-001-006,CDM,C9358,HCPCS,636,RC,,,outpatient,,,9819.33,6873.531,AETNA [1000108],AETNA [100010801],,,76.8,,7541.25,399.86,24858.15552,percent of total billed charges,,,
IMPLANT NDNTR COLL 4X7CM SRGMND RECT -,SUP-606-001-013,CDM,C9358,HCPCS,636,RC,,,outpatient,,,2616.64,1831.648,AETNA [1000108],AETNA [100010801],,,76.8,,2009.58,399.86,24858.15552,percent of total billed charges,,,
SURGIMEND PRS 10CM X 20CM RECT -,SUP-606-004-102,CDM,C9358,HCPCS,636,RC,,,outpatient,,,16238.36,11366.852,AETNA [1000108],AETNA [100010801],,,76.8,,12471.06,399.86,24858.15552,percent of total billed charges,,,
MESH SURGIMEND 8CM X 16CM SEMI OVAL FENESTRAED -,SUP-606-004-103,CDM,C9358,HCPCS,636,RC,,,outpatient,,,10392.54,7274.778,AETNA [1000108],AETNA [100010801],,,76.8,,7981.47,399.86,24858.15552,percent of total billed charges,,,
GRAFT FTL BVN NDNTR COLL MATRIX 20X30CM SRGMND 2MM SHT RECT -,SUP-606-200-017,CDM,C9358,HCPCS,636,RC,,,outpatient,,,27546.57,19282.599,AETNA [1000108],AETNA [100010801],,,76.8,,21155.77,399.86,24858.15552,percent of total billed charges,,,
MESH SURGIMEND 3.0 13 X 25CM -,SUP-606-300-009,CDM,C9358,HCPCS,636,RC,,,outpatient,,,26387.33,18471.131,AETNA [1000108],AETNA [100010801],,,76.8,,20265.47,399.86,24858.15552,percent of total billed charges,,,
MESH SURGIMEND 20 X 30 X 3MM -,SUP-606-300-017,CDM,C9358,HCPCS,636,RC,,,outpatient,,,32367.39,22657.173,AETNA [1000108],AETNA [100010801],,,76.8,,24858.16,399.86,24858.15552,percent of total billed charges,,,
GENTRIX SURGICAL MATRIX HIATAL 7.5 X 6CM -,SUP-HIAT0706,CDM,C9358,HCPCS,636,RC,,,outpatient,,,4704.78,3293.346,AETNA [1000108],AETNA [100010801],,,76.8,,3613.27,399.86,24858.15552,percent of total billed charges,,,
MESH SURGIMEND 3.0 10 X 15CM -,SUP-603-300-006,CDM,C9360,HCPCS,636,RC,,,outpatient,,,12178.79,8525.153,AETNA [1000108],AETNA [100010801],,,76.8,,9353.31,399.86,41430.25152,percent of total billed charges,,,
MESH SURGIMEND 10 X 15CM 2.0 -,SUP-606-200-006,CDM,C9360,HCPCS,636,RC,,,outpatient,,,10364.84,7255.388,AETNA [1000108],AETNA [100010801],,,76.8,,7960.2,399.86,41430.25152,percent of total billed charges,,,
IMPLANT NDNTR COLL 13X20CM SRGMND RECT -,SUP-606-200-009,CDM,C9360,HCPCS,636,RC,,,outpatient,,,22457.19,15720.033,AETNA [1000108],AETNA [100010801],,,76.8,,17247.12,399.86,41430.25152,percent of total billed charges,,,
MESH SURGIMEND 25X40 X 3.0MM -,SUP-606-300-016,CDM,C9360,HCPCS,636,RC,,,outpatient,,,53945.64,37761.948,AETNA [1000108],AETNA [100010801],,,76.8,,41430.25,399.86,41430.25152,percent of total billed charges,,,
NEUROMEND12MM X 2.5CM -,SUP-CNW12025,CDM,C9361,HCPCS,636,RC,,,outpatient,,,6724.07,4706.849,AETNA [1000108],AETNA [100010801],,,76.8,,5164.09,177.26,5164.08576,percent of total billed charges,,,
NEUROMEND 4MM X 2.25CM -,SUP-CNW4025,CDM,C9361,HCPCS,636,RC,,,outpatient,,,6464.93,4525.451,AETNA [1000108],AETNA [100010801],,,76.8,,4965.07,177.26,5164.08576,percent of total billed charges,,,
IMPLANT BIO TISS 3X8CM 3D HYDR PRCN COLL MATRIX PERMACOL SHT -,SUP-P100308,CDM,C9364,HCPCS,636,RC,,,outpatient,,,2987.95,2091.565,AETNA [1000108],AETNA [100010801],,,76.8,,2294.75,18.39,18739.8144,percent of total billed charges,,,
MESH PERMACOL 5X10CM 1.0MM -,SUP-P100510,CDM,C9364,HCPCS,636,RC,,,outpatient,,,4648.41,3253.887,AETNA [1000108],AETNA [100010801],,,76.8,,3569.98,18.39,18739.8144,percent of total billed charges,,,
IMPLANT BIO TISS 10X10CM 3D HYDR PRCN DERM COLL PERMACOL SHT -,SUP-P101010,CDM,C9364,HCPCS,636,RC,,,outpatient,,,9294.36,6506.052,AETNA [1000108],AETNA [100010801],,,76.8,,7138.07,18.39,18739.8144,percent of total billed charges,,,
IMPLANT BIO TISS 15X20CM 3D HYDR PRCN COLL MATRIX PERMACOL -,SUP-P151520,CDM,C9364,HCPCS,636,RC,,,outpatient,,,24400.8,17080.56,AETNA [1000108],AETNA [100010801],,,76.8,,18739.81,18.39,18739.8144,percent of total billed charges,,,
SARILUMAB 200 MG/1.14ML SC SOAJ,RX-143091,CDM,C9399,HCPCS,636,RC,00024-5922-01,NDC,outpatient,1.14,ML,5813.71,4069.597,AETNA [1000108],AETNA [100010801],,,76.8,,4464.93,399.86,4927.700596,percent of total billed charges,,,
CANGRELOR TETRASODIUM 50 MG IV SOLR,RX-131579,CDM,C9460,HCPCS,636,RC,10122-0620-01,NDC,outpatient,1,UN,2428.93,1700.251,AETNA [1000108],AETNA [100010801],,,76.8,,1865.42,18.2,1865.41824,percent of total billed charges,,,
CANGRELOR TETRASODIUM 50 MG IV SOLR,RX-131579,CDM,C9460,HCPCS,636,RC,10122-0620-10,NDC,outpatient,1,UN,2428.93,1700.251,AETNA [1000108],AETNA [100010801],,,76.8,,1865.42,18.2,1865.41824,percent of total billed charges,,,
HC Perc Drug-El Cor Stent Sing,PX-48100003,CDM,C9600,CPT,481,RC,,,outpatient,,,32584,22808.8,AETNA [1000108],AETNA [100010801],,,76.8,,25024.51,399.86,25024.512,percent of total billed charges,,,
HC Perc Drug-El Cor Stent Bran,PX-48100004,CDM,C9601,CPT,481,RC,,,outpatient,,,33887,23720.9,AETNA [1000108],AETNA [100010801],,,76.8,,26025.22,399.86,26025.216,percent of total billed charges,,,
HC Perc D-E Cor Stent Ather S,PX-48100005,CDM,C9602,CPT,481,RC,,,outpatient,,,33887,23720.9,AETNA [1000108],AETNA [100010801],,,76.8,,26025.22,399.86,26793.51305,percent of total billed charges,,,
HC Perc D-E Cor Revasc T Cabg S,PX-48100007,CDM,C9604,CPT,481,RC,,,outpatient,,,33887,23720.9,AETNA [1000108],AETNA [100010801],,,76.8,,26025.22,399.86,26025.216,percent of total billed charges,,,
HC Perc D-E Cor Revasc T Cabg B,PX-48100008,CDM,C9605,CPT,481,RC,,,outpatient,,,33887,23720.9,AETNA [1000108],AETNA [100010801],,,76.8,,26025.22,399.86,26025.216,percent of total billed charges,,,
HC Perc D-E Cor Revasc Chro Sin,PX-48100010,CDM,C9607,CPT,481,RC,,,outpatient,,,33887,23720.9,AETNA [1000108],AETNA [100010801],,,76.8,,26025.22,399.86,26793.51305,percent of total billed charges,,,
HC Perc D-E Cor Revasc Chro Add,PX-48100011,CDM,C9608,CPT,481,RC,,,outpatient,,,33887,23720.9,AETNA [1000108],AETNA [100010801],,,76.8,,26025.22,399.86,26025.216,percent of total billed charges,,,
HC Admin Influenza Virus Vac,PX-77100001,CDM,G0008,CPT,771,RC,,,outpatient,,,193,135.1,AETNA [1000108],AETNA [100010801],,,76.8,,148.22,19.95,416.02,percent of total billed charges,,,
HC Immuniz-Admin-Each Addl,PX-77100005,CDM,G0008,CPT,771,RC,,,outpatient,,,215,150.5,AETNA [1000108],AETNA [100010801],,,76.8,,165.12,19.95,416.02,percent of total billed charges,,,
HC Admin Pneumococcal Vaccine,PX-77100002,CDM,G0009,CPT,771,RC,,,outpatient,,,193,135.1,AETNA [1000108],AETNA [100010801],,,76.8,,148.22,19.95,416.02,percent of total billed charges,,,
HC Immuniz-Admin-Each Addl,PX-77100006,CDM,G0009,CPT,771,RC,,,outpatient,,,215,150.5,AETNA [1000108],AETNA [100010801],,,76.8,,165.12,19.95,416.02,percent of total billed charges,,,
HC Admin Hepatitis B Vaccine,PX-77100003,CDM,G0010,CPT,771,RC,,,outpatient,,,193,135.1,AETNA [1000108],AETNA [100010801],,,76.8,,148.22,19.95,416.02,percent of total billed charges,,,
HC Immuniz-Admin-Each Addl,PX-77100007,CDM,G0010,CPT,771,RC,,,outpatient,,,215,150.5,AETNA [1000108],AETNA [100010801],,,76.8,,165.12,19.95,416.02,percent of total billed charges,,,
HC Inject for Sacroiliac Joint,PX-36900022,CDM,G0259,CPT,369,RC,,,outpatient,,,827,578.9,AETNA [1000108],AETNA [100010801],,,76.8,,635.14,185.6615,1592,percent of total billed charges,,,
HC Inj for Sacroiliac Jt Anesth,PX-36900023,CDM,G0260,CPT,369,RC,,,outpatient,,,1722,1205.4,AETNA [1000108],AETNA [100010801],,,76.8,,1322.5,386.589,2141,percent of total billed charges,,,
HC Occlusive Device in Vein Art,PX-48100001,CDM,G0269,CPT,481,RC,,,outpatient,,,202,141.4,AETNA [1000108],AETNA [100010801],,,76.8,,155.14,45.349,1592,percent of total billed charges,,,
HC Iliac Art Angio-Cardiac Cath,PX-32000003,CDM,G0278,CPT,320,RC,,,outpatient,,,113,79.1,AETNA [1000108],AETNA [100010801],,,76.8,,86.78,25.3685,416.02,percent of total billed charges,,,
HC Elec Stim Other Than Wound,PX-42000003,CDM,G0283,CPT,420,RC,,,outpatient,,,123,86.1,AETNA [1000108],AETNA [100010801],,,76.8,,94.46,12.01,416.02,percent of total billed charges,,,
HC Observation Time,PX-76200003,CDM,G0378,CPT,762,RC,,,outpatient,,,101,70.7,AETNA [1000108],AETNA [100010801],,,76.8,,77.57,22.6745,6652,percent of total billed charges,,,
HC Observation Carve-Out,PX-76200004,CDM,G0378,CPT,762,RC,,,outpatient,,,101,70.7,AETNA [1000108],AETNA [100010801],,,76.8,,77.57,22.6745,6652,percent of total billed charges,,,
HC Direct Refer Hospital Observ,PX-76200001,CDM,G0379,CPT,762,RC,,,outpatient,,,1442,1009.4,AETNA [1000108],AETNA [100010801],,,76.8,,1107.46,104.83,6652,percent of total billed charges,,,
HC PR Trauma Respons W/Hosp Criti,PX-68200001,CDM,G0390,HCPCS,682,RC,,,outpatient,,,10370,7259,AETNA [1000108],AETNA [100010801],,,76.8,,7964.16,399.86,7964.16,percent of total billed charges,,,
HC Full Trauma,PX-68200002,CDM,G0390,HCPCS,682,RC,,,outpatient,,,10370,7259,AETNA [1000108],AETNA [100010801],,,76.8,,7964.16,399.86,7964.16,percent of total billed charges,,,
HC Partial Trauma,PX-68200003,CDM,G0390,HCPCS,682,RC,,,outpatient,,,7029,4920.3,AETNA [1000108],AETNA [100010801],,,76.8,,5398.27,399.86,7964.16,percent of total billed charges,,,
HC Mod Sedat Endo Service >5yrs,PX-37000025,CDM,G0500,HCPCS,370,RC,,,outpatient,,,240,168,AETNA [1000108],AETNA [100010801],,,76.8,,184.32,53.88,416.02,percent of total billed charges,,,
HC Inter Devc Remote 30d,PX-48000092,CDM,G2066,HCPCS,480,RC,,,outpatient,,,118,82.6,AETNA [1000108],AETNA [100010801],,,76.8,,90.62,26.491,416.02,percent of total billed charges,,,
ABATACEPT 250 MG IV SOLR,RX-70287,CDM,J0129,HCPCS,636,RC,00003-2187-13,NDC,outpatient,1,UN,3823.57,2676.499,AETNA [1000108],AETNA [100010801],,,76.8,,2936.5,43.27,2936.50176,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0131,HCPCS,636,RC,36000-0306-60,NDC,outpatient,100,ML,53.83,37.681,AETNA [1000108],AETNA [100010801],,,76.8,,41.34,0.04,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0131,HCPCS,636,RC,67457-0940-10,NDC,outpatient,100,ML,44.93,31.451,AETNA [1000108],AETNA [100010801],,,76.8,,34.51,0.04,416.02,percent of total billed charges,,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0131,HCPCS,636,RC,67457-0940-10,NDC,outpatient,100,ML,44.93,31.451,AETNA [1000108],AETNA [100010801],,,76.8,,34.51,0.04,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0131,HCPCS,636,RC,36000-0306-60,NDC,outpatient,100,ML,53.83,37.681,AETNA [1000108],AETNA [100010801],,,76.8,,41.34,0.04,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0131,HCPCS,636,RC,67457-0940-10,NDC,outpatient,100,ML,44.93,31.451,AETNA [1000108],AETNA [100010801],,,76.8,,34.51,0.04,416.02,percent of total billed charges,,,
ACETYLCYSTEINE 200 MG/ML IV SOLN,RX-38303,CDM,J0132,HCPCS,636,RC,00574-0805-00,NDC,outpatient,30,ML,278.49,194.943,AETNA [1000108],AETNA [100010801],,,76.8,,213.88,0.57,416.02,percent of total billed charges,,,
ACETYLCYSTEINE 200 MG/ML IV SOLN,RX-38303,CDM,J0132,HCPCS,636,RC,00574-0805-30,NDC,outpatient,30,ML,278.49,194.943,AETNA [1000108],AETNA [100010801],,,76.8,,213.88,0.57,416.02,percent of total billed charges,,,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,55150-0154-10,NDC,outpatient,10,ML,11.47,8.029,AETNA [1000108],AETNA [100010801],,,76.8,,8.81,0.02,416.02,percent of total billed charges,,,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,55150-0155-20,NDC,outpatient,20,ML,19.14,13.398,AETNA [1000108],AETNA [100010801],,,76.8,,14.7,0.02,416.02,percent of total billed charges,,,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-10,NDC,outpatient,10,ML,8.9,6.23,AETNA [1000108],AETNA [100010801],,,76.8,,6.84,0.02,416.02,percent of total billed charges,,,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-09,NDC,outpatient,20,ML,18.52,12.964,AETNA [1000108],AETNA [100010801],,,76.8,,14.22,0.02,416.02,percent of total billed charges,,,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-20,NDC,outpatient,20,ML,18.52,12.964,AETNA [1000108],AETNA [100010801],,,76.8,,14.22,0.02,416.02,percent of total billed charges,,,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-03,NDC,outpatient,10,ML,8.9,6.23,AETNA [1000108],AETNA [100010801],,,76.8,,6.84,0.02,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,24.48,17.136,AETNA [1000108],AETNA [100010801],JW,,76.8,,18.8,0.04,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,40.48,28.336,AETNA [1000108],AETNA [100010801],,,76.8,,31.09,0.04,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,24.48,17.136,AETNA [1000108],AETNA [100010801],JW,,76.8,,18.8,0.04,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,40.48,28.336,AETNA [1000108],AETNA [100010801],,,76.8,,31.09,0.04,416.02,percent of total billed charges,,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,40.48,28.336,AETNA [1000108],AETNA [100010801],,,76.8,,31.09,0.04,416.02,percent of total billed charges,,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,24.48,17.136,AETNA [1000108],AETNA [100010801],JW,,76.8,,18.8,0.04,416.02,percent of total billed charges,,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,24.48,17.136,AETNA [1000108],AETNA [100010801],JW,,76.8,,18.8,0.04,416.02,percent of total billed charges,,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,40.48,28.336,AETNA [1000108],AETNA [100010801],,,76.8,,31.09,0.04,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,24.48,17.136,AETNA [1000108],AETNA [100010801],JW,,76.8,,18.8,0.04,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,40.48,28.336,AETNA [1000108],AETNA [100010801],,,76.8,,31.09,0.04,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,24.48,17.136,AETNA [1000108],AETNA [100010801],JW,,76.8,,18.8,0.04,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,40.48,28.336,AETNA [1000108],AETNA [100010801],,,76.8,,31.09,0.04,416.02,percent of total billed charges,,,
ADALIMUMAB 40 MG/0.8ML SC PSKT,RX-129739,CDM,J0135,HCPCS,636,RC,00074-3799-02,NDC,outpatient,1,UN,9266.62,6486.634,AETNA [1000108],AETNA [100010801],,,76.8,,7116.76,336.23,7116.76416,percent of total billed charges,,,
ADALIMUMAB 40 MG/0.8ML SC PNKT,RX-129742,CDM,J0135,HCPCS,636,RC,00074-4339-02,NDC,outpatient,1,UN,9266.62,6486.634,AETNA [1000108],AETNA [100010801],,,76.8,,7116.76,336.23,7116.76416,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,39.59,27.713,AETNA [1000108],AETNA [100010801],,,76.8,,30.41,0.05,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0136,HCPCS,636,RC,00264-4100-95,NDC,outpatient,100,ML,39.59,27.713,AETNA [1000108],AETNA [100010801],,,76.8,,30.41,0.05,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,23.59,16.513,AETNA [1000108],AETNA [100010801],JW,,76.8,,18.12,0.05,416.02,percent of total billed charges,,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,39.59,27.713,AETNA [1000108],AETNA [100010801],,,76.8,,30.41,0.05,416.02,percent of total billed charges,,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,23.59,16.513,AETNA [1000108],AETNA [100010801],JW,,76.8,,18.12,0.05,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0136,HCPCS,636,RC,00264-4100-95,NDC,outpatient,100,ML,39.59,27.713,AETNA [1000108],AETNA [100010801],,,76.8,,30.41,0.05,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,39.59,27.713,AETNA [1000108],AETNA [100010801],,,76.8,,30.41,0.05,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,23.59,16.513,AETNA [1000108],AETNA [100010801],JW,,76.8,,18.12,0.05,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,34.69,24.283,AETNA [1000108],AETNA [100010801],,,76.8,,26.64,0.05,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,18.69,13.083,AETNA [1000108],AETNA [100010801],JW,,76.8,,14.35,0.05,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,34.69,24.283,AETNA [1000108],AETNA [100010801],,,76.8,,26.64,0.05,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,18.69,13.083,AETNA [1000108],AETNA [100010801],JW,,76.8,,14.35,0.05,416.02,percent of total billed charges,,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,18.69,13.083,AETNA [1000108],AETNA [100010801],JW,,76.8,,14.35,0.05,416.02,percent of total billed charges,,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,18.69,13.083,AETNA [1000108],AETNA [100010801],JW,,76.8,,14.35,0.05,416.02,percent of total billed charges,,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,34.69,24.283,AETNA [1000108],AETNA [100010801],,,76.8,,26.64,0.05,416.02,percent of total billed charges,,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,34.69,24.283,AETNA [1000108],AETNA [100010801],,,76.8,,26.64,0.05,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,18.69,13.083,AETNA [1000108],AETNA [100010801],JW,,76.8,,14.35,0.05,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,34.69,24.283,AETNA [1000108],AETNA [100010801],,,76.8,,26.64,0.05,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,34.69,24.283,AETNA [1000108],AETNA [100010801],,,76.8,,26.64,0.05,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,18.69,13.083,AETNA [1000108],AETNA [100010801],JW,,76.8,,14.35,0.05,416.02,percent of total billed charges,,,
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,RX-15330,CDM,J0153,HCPCS,636,RC,67457-0857-30,NDC,outpatient,30,ML,821.94,575.358,AETNA [1000108],AETNA [100010801],,,76.8,,631.25,0.4,631.24992,percent of total billed charges,,,
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,RX-15330,CDM,J0153,HCPCS,636,RC,55150-0193-01,NDC,outpatient,30,ML,91.83,64.281,AETNA [1000108],AETNA [100010801],,,76.8,,70.53,0.4,631.24992,percent of total billed charges,,,
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,RX-15330,CDM,J0153,HCPCS,636,RC,16714-0997-01,NDC,outpatient,30,ML,109.72,76.804,AETNA [1000108],AETNA [100010801],,,76.8,,84.26,0.4,631.24992,percent of total billed charges,,,
ADENOSINE 6 MG/2ML IV SOLN,RX-38703,CDM,J0153,HCPCS,636,RC,67457-0855-00,NDC,outpatient,2,ML,24.68,17.276,AETNA [1000108],AETNA [100010801],,,76.8,,18.95,0.4,631.24992,percent of total billed charges,,,
ADENOSINE 6 MG/2ML IV SOLN,RX-38703,CDM,J0153,HCPCS,636,RC,67457-0855-02,NDC,outpatient,2,ML,24.68,17.276,AETNA [1000108],AETNA [100010801],,,76.8,,18.95,0.4,631.24992,percent of total billed charges,,,
EPINEPHRINE 0.15 MG/0.3ML IJ SOAJ,RX-124855,CDM,J0171,HCPCS,636,RC,49502-0101-01,NDC,outpatient,1,UN,616.75,431.725,AETNA [1000108],AETNA [100010801],,,76.8,,473.66,0.73,960.94464,percent of total billed charges,,,
EPINEPHRINE 0.15 MG/0.3ML IJ SOAJ,RX-124855,CDM,J0171,HCPCS,636,RC,49502-0501-02,NDC,outpatient,1,UN,1251.23,875.861,AETNA [1000108],AETNA [100010801],,,76.8,,960.94,0.73,960.94464,percent of total billed charges,,,
EPINEPHRINE 0.15 MG/0.3ML IJ SOAJ,RX-124855,CDM,J0171,HCPCS,636,RC,49502-0101-02,NDC,outpatient,1,UN,616.75,431.725,AETNA [1000108],AETNA [100010801],,,76.8,,473.66,0.73,960.94464,percent of total billed charges,,,
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,00115-1694-30,NDC,outpatient,1,UN,506.88,354.816,AETNA [1000108],AETNA [100010801],,,76.8,,389.28,0.73,960.94464,percent of total billed charges,,,
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,49502-0500-02,NDC,outpatient,1,UN,1251.23,875.861,AETNA [1000108],AETNA [100010801],,,76.8,,960.94,0.73,960.94464,percent of total billed charges,,,
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,00115-1694-49,NDC,outpatient,1,UN,506.88,354.816,AETNA [1000108],AETNA [100010801],,,76.8,,389.28,0.73,960.94464,percent of total billed charges,,,
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,49502-0102-01,NDC,outpatient,1,UN,616.75,431.725,AETNA [1000108],AETNA [100010801],,,76.8,,473.66,0.73,960.94464,percent of total billed charges,,,
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,49502-0102-02,NDC,outpatient,1,UN,616.75,431.725,AETNA [1000108],AETNA [100010801],,,76.8,,473.66,0.73,960.94464,percent of total billed charges,,,
EPINEPHRINE INFUSION PREMIX 1 MG IN 250 ML,RX-4080061,CDM,J0171,HCPCS,636,RC,99999-0001-65,NDC,outpatient,250,ML,83.79,58.653,AETNA [1000108],AETNA [100010801],,,76.8,,64.35,0.73,960.94464,percent of total billed charges,,,
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER,RX-4080099,CDM,J0171,HCPCS,636,RC,42023-0159-01,NDC,outpatient,1,ML,57.57,40.299,AETNA [1000108],AETNA [100010801],,,76.8,,44.21,0.73,960.94464,percent of total billed charges,,,
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER,RX-4080099,CDM,J0171,HCPCS,636,RC,42023-0159-25,NDC,outpatient,1,ML,57.57,40.299,AETNA [1000108],AETNA [100010801],,,76.8,,44.21,0.73,960.94464,percent of total billed charges,,,
EPINEPHRINE HCL 0.1 MG/ML IJ WRAPPER,RX-4080103,CDM,J0171,HCPCS,636,RC,76329-3318-01,NDC,outpatient,10,ML,42.5,29.75,AETNA [1000108],AETNA [100010801],,,76.8,,32.64,0.73,960.94464,percent of total billed charges,,,
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER FOR CODE NARRATOR,RX-4081384,CDM,J0171,HCPCS,636,RC,42023-0159-25,NDC,outpatient,1,ML,57.57,40.299,AETNA [1000108],AETNA [100010801],,,76.8,,44.21,0.73,960.94464,percent of total billed charges,,,
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER FOR CODE NARRATOR,RX-4081384,CDM,J0171,HCPCS,636,RC,42023-0159-01,NDC,outpatient,1,ML,57.57,40.299,AETNA [1000108],AETNA [100010801],,,76.8,,44.21,0.73,960.94464,percent of total billed charges,,,
EPINEPHRINE PF 1 MG/ML IJ SOLN,RX-140555,CDM,J0173,HCPCS,636,RC,54288-0103-10,NDC,outpatient,1,ML,35.98,25.186,AETNA [1000108],AETNA [100010801],,,76.8,,27.63,1.61,416.02,percent of total billed charges,,,
EPINEPHRINE PF 1 MG/ML IJ SOLN,RX-140555,CDM,J0173,HCPCS,636,RC,54288-0103-01,NDC,outpatient,1,ML,35.98,25.186,AETNA [1000108],AETNA [100010801],,,76.8,,27.63,1.61,416.02,percent of total billed charges,,,
AGALSIDASE BETA 35 MG IV SOLR,RX-35775,CDM,J0180,HCPCS,636,RC,58468-0040-01,NDC,outpatient,1,UN,20575.06,14402.542,AETNA [1000108],AETNA [100010801],,,76.8,,15801.65,215.38,15801.64608,percent of total billed charges,,,
AGALSIDASE BETA 5 MG IV SOLR,RX-38494,CDM,J0180,HCPCS,636,RC,58468-0041-01,NDC,outpatient,1,UN,2938.8,2057.16,AETNA [1000108],AETNA [100010801],,,76.8,,2257,215.38,15801.64608,percent of total billed charges,,,
ALGLUCOSIDASE ALFA 50 MG IV SOLR,RX-76353,CDM,J0221,HCPCS,636,RC,58468-0160-01,NDC,outpatient,1,UN,2661.83,1863.281,AETNA [1000108],AETNA [100010801],,,76.8,,2044.29,194.92,2044.28544,percent of total billed charges,,,
REMDESIVIR 100 MG IV SOLR,RX-150611,CDM,J0248,HCPCS,636,RC,61958-2901-02,NDC,outpatient,1,UN,1654.57,1158.199,AETNA [1000108],AETNA [100010801],,,76.8,,1270.71,5.51,1270.70976,percent of total billed charges,,,
ALPHA1-PROTEINASE INHIBITOR 1000 MG/20ML IV SOLN,RX-141646,CDM,J0256,HCPCS,636,RC,13533-0705-11,NDC,outpatient,1,UN,1462.8,1023.96,AETNA [1000108],AETNA [100010801],,,76.8,,1123.43,4.88,1606.272,percent of total billed charges,,,
ALPHA1-PROTEINASE INHIBITOR 1000 MG/20ML IV SOLN,RX-141646,CDM,J0256,HCPCS,636,RC,13533-0705-01,NDC,outpatient,1,UN,1462.8,1023.96,AETNA [1000108],AETNA [100010801],,,76.8,,1123.43,4.88,1606.272,percent of total billed charges,,,
ZEMAIRA 1000 MG IV SOLR,RX-36564,CDM,J0256,HCPCS,636,RC,00053-7201-02,NDC,outpatient,1,UN,2091.5,1464.05,AETNA [1000108],AETNA [100010801],,,76.8,,1606.27,4.88,1606.272,percent of total billed charges,,,
ALPROSTADIL 500 MCG/ML IJ SOLN,RX-9001,CDM,J0270,HCPCS,636,RC,00009-3169-01,NDC,outpatient,1,ML,564.52,395.164,AETNA [1000108],AETNA [100010801],,,76.8,,433.55,2.98,4260,percent of total billed charges,,,
ALPROSTADIL 500 MCG/ML IJ SOLN,RX-9001,CDM,J0270,HCPCS,636,RC,00009-3169-06,NDC,outpatient,1,ML,564.52,395.164,AETNA [1000108],AETNA [100010801],,,76.8,,433.55,2.98,4260,percent of total billed charges,,,
AMIKACIN SULFATE 500 MG/2ML IJ SOLN,RX-108131,CDM,J0278,HCPCS,636,RC,23155-0290-41,NDC,outpatient,2,ML,17.6,12.32,AETNA [1000108],AETNA [100010801],,,76.8,,13.52,0.77,416.02,percent of total billed charges,,,
AMIKACIN SULFATE 500 MG/2ML IJ SOLN,RX-108131,CDM,J0278,HCPCS,636,RC,23155-0290-31,NDC,outpatient,2,ML,17.6,12.32,AETNA [1000108],AETNA [100010801],,,76.8,,13.52,0.77,416.02,percent of total billed charges,,,
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5922-01,NDC,outpatient,20,ML,38.54,26.978,AETNA [1000108],AETNA [100010801],,,76.8,,29.6,4.51,416.02,percent of total billed charges,,,
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5922-16,NDC,outpatient,20,ML,38.54,26.978,AETNA [1000108],AETNA [100010801],,,76.8,,29.6,4.51,416.02,percent of total billed charges,,,
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5921-01,NDC,outpatient,10,ML,61.06,42.742,AETNA [1000108],AETNA [100010801],,,76.8,,46.89,4.51,416.02,percent of total billed charges,,,
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5921-16,NDC,outpatient,10,ML,61.06,42.742,AETNA [1000108],AETNA [100010801],,,76.8,,46.89,4.51,416.02,percent of total billed charges,,,
AMIODARONE HCL IN DEXTROSE 900-5 MG/500ML-% IV SOLN,RX-135815,CDM,J0282,HCPCS,636,RC,70092-1005-38,NDC,outpatient,500,ML,218.97,153.279,AETNA [1000108],AETNA [100010801],,,76.8,,168.17,0.46,416.02,percent of total billed charges,,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-01,NDC,outpatient,3,ML,9.41,6.587,AETNA [1000108],AETNA [100010801],,,76.8,,7.23,0.46,416.02,percent of total billed charges,,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-02,NDC,outpatient,9,ML,22.43,15.701,AETNA [1000108],AETNA [100010801],,,76.8,,17.23,0.46,416.02,percent of total billed charges,,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,00143-9875-25,NDC,outpatient,3,ML,3.58,2.506,AETNA [1000108],AETNA [100010801],,,76.8,,2.75,0.46,416.02,percent of total billed charges,,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-09,NDC,outpatient,9,ML,22.43,15.701,AETNA [1000108],AETNA [100010801],,,76.8,,17.23,0.46,416.02,percent of total billed charges,,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,00143-9875-01,NDC,outpatient,3,ML,3.58,2.506,AETNA [1000108],AETNA [100010801],,,76.8,,2.75,0.46,416.02,percent of total billed charges,,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-03,NDC,outpatient,3,ML,9.41,6.587,AETNA [1000108],AETNA [100010801],,,76.8,,7.23,0.46,416.02,percent of total billed charges,,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,67457-0153-00,NDC,outpatient,3,ML,16.55,11.585,AETNA [1000108],AETNA [100010801],,,76.8,,12.71,0.46,416.02,percent of total billed charges,,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,67457-0153-03,NDC,outpatient,3,ML,16.55,11.585,AETNA [1000108],AETNA [100010801],,,76.8,,12.71,0.46,416.02,percent of total billed charges,,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,67457-0153-18,NDC,outpatient,18,ML,55.43,38.801,AETNA [1000108],AETNA [100010801],,,76.8,,42.57,0.46,416.02,percent of total billed charges,,,
AMPHOTERICIN B 50 MG IV SOLR,RX-464,CDM,J0285,HCPCS,636,RC,39822-1055-05,NDC,outpatient,1,UN,155.22,108.654,AETNA [1000108],AETNA [100010801],,,76.8,,119.21,34.84689,416.02,percent of total billed charges,,,
AMPHOTERICIN B LIPID 5 MG/ML IV SUSP,RX-22981,CDM,J0287,HCPCS,636,RC,57665-0101-41,NDC,outpatient,20,ML,431.74,302.218,AETNA [1000108],AETNA [100010801],,,76.8,,331.58,11.13,416.02,percent of total billed charges,,,
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,RX-21900,CDM,J0289,HCPCS,636,RC,00469-3051-30,NDC,outpatient,1,UN,1268.66,888.062,AETNA [1000108],AETNA [100010801],,,76.8,,974.33,23.33,974.33088,percent of total billed charges,,,
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,RX-21900,CDM,J0289,HCPCS,636,RC,62756-0233-01,NDC,outpatient,1,UN,328.95,230.265,AETNA [1000108],AETNA [100010801],,,76.8,,252.63,23.33,974.33088,percent of total billed charges,,,
AMPICILLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080940,CDM,J0290,HCPCS,636,RC,25021-0136-10,NDC,outpatient,1,UN,10.62,7.434,AETNA [1000108],AETNA [100010801],,,76.8,,8.16,0.78,416.02,percent of total billed charges,,,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,65219-0016-01,NDC,outpatient,1,UN,5.52,3.864,AETNA [1000108],AETNA [100010801],,,76.8,,4.24,0.78,416.02,percent of total billed charges,,,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,00781-3407-78,NDC,outpatient,1,UN,4.29,3.003,AETNA [1000108],AETNA [100010801],,,76.8,,3.29,0.78,416.02,percent of total billed charges,,,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,00781-3407-95,NDC,outpatient,1,UN,4.29,3.003,AETNA [1000108],AETNA [100010801],,,76.8,,3.29,0.78,416.02,percent of total billed charges,,,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,67850-0024-00,NDC,outpatient,1,UN,8.62,6.034,AETNA [1000108],AETNA [100010801],,,76.8,,6.62,0.78,416.02,percent of total billed charges,,,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,67850-0024-10,NDC,outpatient,1,UN,8.62,6.034,AETNA [1000108],AETNA [100010801],,,76.8,,6.62,0.78,416.02,percent of total billed charges,,,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,65219-0016-10,NDC,outpatient,1,UN,5.52,3.864,AETNA [1000108],AETNA [100010801],,,76.8,,4.24,0.78,416.02,percent of total billed charges,,,
AMPICILLIN SODIUM 1 G IJ SOLR,RX-469,CDM,J0290,HCPCS,636,RC,25021-0136-10,NDC,outpatient,1,UN,10.62,7.434,AETNA [1000108],AETNA [100010801],,,76.8,,8.16,0.78,416.02,percent of total billed charges,,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,25021-0137-20,NDC,outpatient,1,UN,16.54,11.578,AETNA [1000108],AETNA [100010801],,,76.8,,12.7,0.78,416.02,percent of total billed charges,,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,44567-0103-10,NDC,outpatient,1,UN,45.23,31.661,AETNA [1000108],AETNA [100010801],,,76.8,,34.74,0.78,416.02,percent of total billed charges,,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,72485-0422-10,NDC,outpatient,1,UN,18.51,12.957,AETNA [1000108],AETNA [100010801],,,76.8,,14.22,0.78,416.02,percent of total billed charges,,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,65219-0020-03,NDC,outpatient,1,UN,32.57,22.799,AETNA [1000108],AETNA [100010801],,,76.8,,25.01,0.78,416.02,percent of total billed charges,,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,55150-0114-20,NDC,outpatient,1,UN,13.5,9.45,AETNA [1000108],AETNA [100010801],,,76.8,,10.37,0.78,416.02,percent of total billed charges,,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,65219-0020-23,NDC,outpatient,1,UN,32.57,22.799,AETNA [1000108],AETNA [100010801],,,76.8,,25.01,0.78,416.02,percent of total billed charges,,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,72485-0422-01,NDC,outpatient,1,UN,18.51,12.957,AETNA [1000108],AETNA [100010801],,,76.8,,14.22,0.78,416.02,percent of total billed charges,,,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,67850-0024-10,NDC,outpatient,1,UN,8.62,6.034,AETNA [1000108],AETNA [100010801],,,76.8,,6.62,0.78,416.02,percent of total billed charges,,,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,65219-0016-01,NDC,outpatient,1,UN,5.52,3.864,AETNA [1000108],AETNA [100010801],,,76.8,,4.24,0.78,416.02,percent of total billed charges,,,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,00781-3407-95,NDC,outpatient,1,UN,4.29,3.003,AETNA [1000108],AETNA [100010801],,,76.8,,3.29,0.78,416.02,percent of total billed charges,,,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,65219-0016-10,NDC,outpatient,1,UN,5.52,3.864,AETNA [1000108],AETNA [100010801],,,76.8,,4.24,0.78,416.02,percent of total billed charges,,,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,67850-0024-00,NDC,outpatient,1,UN,8.62,6.034,AETNA [1000108],AETNA [100010801],,,76.8,,6.62,0.78,416.02,percent of total billed charges,,,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,00781-3407-78,NDC,outpatient,1,UN,4.29,3.003,AETNA [1000108],AETNA [100010801],,,76.8,,3.29,0.78,416.02,percent of total billed charges,,,
AMPICILLIN-SULBACTAM SODIUM 15 (10-5) G IV SOLR,RX-105616,CDM,J0295,HCPCS,636,RC,00049-0024-28,NDC,outpatient,1,UN,84.11,58.877,AETNA [1000108],AETNA [100010801],,,76.8,,64.6,1.600685,416.02,percent of total billed charges,,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IV SOLR,RX-27283,CDM,J0295,HCPCS,636,RC,00409-2987-03,NDC,outpatient,1,UN,24.87,17.409,AETNA [1000108],AETNA [100010801],,,76.8,,19.1,1.600685,416.02,percent of total billed charges,,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IV SOLR,RX-27283,CDM,J0295,HCPCS,636,RC,00409-2987-23,NDC,outpatient,1,UN,24.87,17.409,AETNA [1000108],AETNA [100010801],,,76.8,,19.1,1.600685,416.02,percent of total billed charges,,,
AMPICILLIN-SULBACTAM 3 G 100 ML ADD-VANTAGE BAG,RX-400006,CDM,J0295,HCPCS,636,RC,99999-0003-15,NDC,outpatient,100,ML,43.51,30.457,AETNA [1000108],AETNA [100010801],,,76.8,,33.42,1.600685,416.02,percent of total billed charges,,,
AMPICILLIN-SULBACTAM 3 G 100 ML IVPB BATCHED,RX-4081206,CDM,J0295,HCPCS,636,RC,99999-0003-29,NDC,outpatient,100,ML,29.73,20.811,AETNA [1000108],AETNA [100010801],,,76.8,,22.83,1.600685,416.02,percent of total billed charges,,,
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR,RX-9083,CDM,J0295,HCPCS,636,RC,71288-0031-21,NDC,outpatient,1,UN,21.1,14.77,AETNA [1000108],AETNA [100010801],,,76.8,,16.2,1.600685,416.02,percent of total billed charges,,,
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR,RX-9083,CDM,J0295,HCPCS,636,RC,55150-0116-20,NDC,outpatient,1,UN,7.13,4.991,AETNA [1000108],AETNA [100010801],,,76.8,,5.48,1.600685,416.02,percent of total billed charges,,,
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR,RX-9083,CDM,J0295,HCPCS,636,RC,71288-0031-20,NDC,outpatient,1,UN,21.1,14.77,AETNA [1000108],AETNA [100010801],,,76.8,,16.2,1.600685,416.02,percent of total billed charges,,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,70594-0082-02,NDC,outpatient,1,UN,37.01,25.907,AETNA [1000108],AETNA [100010801],,,76.8,,28.42,1.600685,416.02,percent of total billed charges,,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,00641-6117-01,NDC,outpatient,1,UN,28.2,19.74,AETNA [1000108],AETNA [100010801],,,76.8,,21.66,1.600685,416.02,percent of total billed charges,,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,00641-6117-10,NDC,outpatient,1,UN,28.2,19.74,AETNA [1000108],AETNA [100010801],,,76.8,,21.66,1.600685,416.02,percent of total billed charges,,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,25021-0143-30,NDC,outpatient,1,UN,36.19,25.333,AETNA [1000108],AETNA [100010801],,,76.8,,27.79,1.600685,416.02,percent of total billed charges,,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,55150-0117-01,NDC,outpatient,1,UN,13.78,9.646,AETNA [1000108],AETNA [100010801],,,76.8,,10.58,1.600685,416.02,percent of total billed charges,,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,70594-0082-01,NDC,outpatient,1,UN,37.01,25.907,AETNA [1000108],AETNA [100010801],,,76.8,,28.42,1.600685,416.02,percent of total billed charges,,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,72485-0417-10,NDC,outpatient,1,UN,18.05,12.635,AETNA [1000108],AETNA [100010801],,,76.8,,13.86,1.600685,416.02,percent of total billed charges,,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,55150-0117-20,NDC,outpatient,1,UN,13.78,9.646,AETNA [1000108],AETNA [100010801],,,76.8,,10.58,1.600685,416.02,percent of total billed charges,,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,71288-0032-20,NDC,outpatient,1,UN,33.6,23.52,AETNA [1000108],AETNA [100010801],,,76.8,,25.8,1.600685,416.02,percent of total billed charges,,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,71288-0032-21,NDC,outpatient,1,UN,33.6,23.52,AETNA [1000108],AETNA [100010801],,,76.8,,25.8,1.600685,416.02,percent of total billed charges,,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,72485-0417-01,NDC,outpatient,1,UN,18.05,12.635,AETNA [1000108],AETNA [100010801],,,76.8,,13.86,1.600685,416.02,percent of total billed charges,,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,55150-0117-10,NDC,outpatient,1,UN,13.78,9.646,AETNA [1000108],AETNA [100010801],,,76.8,,10.58,1.600685,416.02,percent of total billed charges,,,
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,70092-1086-44,NDC,outpatient,5,ML,84.42,59.094,AETNA [1000108],AETNA [100010801],,,76.8,,64.83,0.82,416.02,percent of total billed charges,,,
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,69374-0920-05,NDC,outpatient,5,ML,14.14,9.898,AETNA [1000108],AETNA [100010801],,,76.8,,10.86,0.82,416.02,percent of total billed charges,,,
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,70004-0908-09,NDC,outpatient,5,ML,95.5,66.85,AETNA [1000108],AETNA [100010801],,,76.8,,73.34,0.82,416.02,percent of total billed charges,,,
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,70004-0910-09,NDC,outpatient,5,ML,31.6,22.12,AETNA [1000108],AETNA [100010801],,,76.8,,24.27,0.82,416.02,percent of total billed charges,,,
ANIDULAFUNGIN 100 MG IV SOLR,RX-88093,CDM,J0348,HCPCS,636,RC,00049-0116-28,NDC,outpatient,1,UN,139.38,97.566,AETNA [1000108],AETNA [100010801],,,76.8,,107.04,0.46,416.02,percent of total billed charges,,,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,00641-6231-01,NDC,outpatient,1,ML,12.17,8.519,AETNA [1000108],AETNA [100010801],,,76.8,,9.35,2.732165,416.02,percent of total billed charges,,,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,55150-0400-25,NDC,outpatient,1,ML,14.72,10.304,AETNA [1000108],AETNA [100010801],,,76.8,,11.3,2.732165,416.02,percent of total billed charges,,,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,63323-0614-00,NDC,outpatient,1,ML,14.49,10.143,AETNA [1000108],AETNA [100010801],,,76.8,,11.13,2.732165,416.02,percent of total billed charges,,,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,00641-6231-25,NDC,outpatient,1,ML,12.17,8.519,AETNA [1000108],AETNA [100010801],,,76.8,,9.35,2.732165,416.02,percent of total billed charges,,,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,55150-0400-01,NDC,outpatient,1,ML,14.72,10.304,AETNA [1000108],AETNA [100010801],,,76.8,,11.3,2.732165,416.02,percent of total billed charges,,,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,63323-0614-01,NDC,outpatient,1,ML,14.49,10.143,AETNA [1000108],AETNA [100010801],,,76.8,,11.13,2.732165,416.02,percent of total billed charges,,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,63323-0398-10,NDC,outpatient,1,UN,8.17,5.719,AETNA [1000108],AETNA [100010801],,,76.8,,6.27,1.834165,416.02,percent of total billed charges,,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70860-0100-10,NDC,outpatient,1,UN,13.9,9.73,AETNA [1000108],AETNA [100010801],,,76.8,,10.68,1.834165,416.02,percent of total billed charges,,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,55150-0174-10,NDC,outpatient,1,UN,9.22,6.454,AETNA [1000108],AETNA [100010801],,,76.8,,7.08,1.834165,416.02,percent of total billed charges,,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,63323-0398-01,NDC,outpatient,1,UN,8.17,5.719,AETNA [1000108],AETNA [100010801],,,76.8,,6.27,1.834165,416.02,percent of total billed charges,,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70436-0019-82,NDC,outpatient,1,UN,12.13,8.491,AETNA [1000108],AETNA [100010801],,,76.8,,9.32,1.834165,416.02,percent of total billed charges,,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,00069-3150-83,NDC,outpatient,1,UN,24.39,17.073,AETNA [1000108],AETNA [100010801],,,76.8,,18.73,1.834165,416.02,percent of total billed charges,,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70095-0025-02,NDC,outpatient,1,UN,8.79,6.153,AETNA [1000108],AETNA [100010801],,,76.8,,6.75,1.834165,416.02,percent of total billed charges,,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,00069-3150-84,NDC,outpatient,1,UN,24.39,17.073,AETNA [1000108],AETNA [100010801],,,76.8,,18.73,1.834165,416.02,percent of total billed charges,,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70095-0025-01,NDC,outpatient,1,UN,8.79,6.153,AETNA [1000108],AETNA [100010801],,,76.8,,6.75,1.834165,416.02,percent of total billed charges,,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70860-0100-41,NDC,outpatient,1,UN,13.9,9.73,AETNA [1000108],AETNA [100010801],,,76.8,,10.68,1.834165,416.02,percent of total billed charges,,,
AZITHROMYCIN 500 MG IN 250 ML NS PREMIX,RX-4080917,CDM,J0456,HCPCS,636,RC,99999-0001-37,NDC,outpatient,255,ML,46.12,32.284,AETNA [1000108],AETNA [100010801],,,76.8,,35.42,1.834165,416.02,percent of total billed charges,,,
AZTREONAM 1 G IJ SOLR 100 MG/ML,RX-4081004,CDM,J0457,HCPCS,636,RC,00409-0829-11,NDC,outpatient,1,UN,98.69,69.083,AETNA [1000108],AETNA [100010801],,,76.8,,75.79,1.97,416.02,percent of total billed charges,,,
AZTREONAM 1 G IJ SOLR 100 MG/ML,RX-4081004,CDM,J0457,HCPCS,636,RC,00409-0829-01,NDC,outpatient,1,UN,98.69,69.083,AETNA [1000108],AETNA [100010801],,,76.8,,75.79,1.97,416.02,percent of total billed charges,,,
AZTREONAM 1 G IJ SOLR 100 MG/ML,RX-4081004,CDM,J0457,HCPCS,636,RC,00003-2560-16,NDC,outpatient,1,UN,122.23,85.561,AETNA [1000108],AETNA [100010801],,,76.8,,93.87,1.97,416.02,percent of total billed charges,,,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,00003-2570-16,NDC,outpatient,1,UN,244.45,171.115,AETNA [1000108],AETNA [100010801],,,76.8,,187.74,1.97,416.02,percent of total billed charges,,,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,00409-0830-01,NDC,outpatient,1,UN,201.48,141.036,AETNA [1000108],AETNA [100010801],,,76.8,,154.74,1.97,416.02,percent of total billed charges,,,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,63323-0402-01,NDC,outpatient,1,UN,201.48,141.036,AETNA [1000108],AETNA [100010801],,,76.8,,154.74,1.97,416.02,percent of total billed charges,,,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,63323-0402-20,NDC,outpatient,1,UN,201.48,141.036,AETNA [1000108],AETNA [100010801],,,76.8,,154.74,1.97,416.02,percent of total billed charges,,,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,00409-0830-11,NDC,outpatient,1,UN,201.48,141.036,AETNA [1000108],AETNA [100010801],,,76.8,,154.74,1.97,416.02,percent of total billed charges,,,
AZTREONAM 1 G IJ SOLR,RX-9185,CDM,J0457,HCPCS,636,RC,00409-0829-01,NDC,outpatient,1,UN,98.69,69.083,AETNA [1000108],AETNA [100010801],,,76.8,,75.79,1.97,416.02,percent of total billed charges,,,
AZTREONAM 1 G IJ SOLR,RX-9185,CDM,J0457,HCPCS,636,RC,00003-2560-16,NDC,outpatient,1,UN,122.23,85.561,AETNA [1000108],AETNA [100010801],,,76.8,,93.87,1.97,416.02,percent of total billed charges,,,
AZTREONAM 1 G IJ SOLR,RX-9185,CDM,J0457,HCPCS,636,RC,00409-0829-11,NDC,outpatient,1,UN,98.69,69.083,AETNA [1000108],AETNA [100010801],,,76.8,,75.79,1.97,416.02,percent of total billed charges,,,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,63323-0402-20,NDC,outpatient,1,UN,201.48,141.036,AETNA [1000108],AETNA [100010801],,,76.8,,154.74,1.97,416.02,percent of total billed charges,,,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,00409-0830-01,NDC,outpatient,1,UN,201.48,141.036,AETNA [1000108],AETNA [100010801],,,76.8,,154.74,1.97,416.02,percent of total billed charges,,,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,00003-2570-16,NDC,outpatient,1,UN,244.45,171.115,AETNA [1000108],AETNA [100010801],,,76.8,,187.74,1.97,416.02,percent of total billed charges,,,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,00409-0830-11,NDC,outpatient,1,UN,201.48,141.036,AETNA [1000108],AETNA [100010801],,,76.8,,154.74,1.97,416.02,percent of total billed charges,,,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,63323-0402-01,NDC,outpatient,1,UN,201.48,141.036,AETNA [1000108],AETNA [100010801],,,76.8,,154.74,1.97,416.02,percent of total billed charges,,,
ATROPINE SULFATE 0.1 MG/ML IJ SOLN WRAPPER,RX-4080930,CDM,J0461,HCPCS,636,RC,76329-3340-01,NDC,outpatient,10,ML,42.72,29.904,AETNA [1000108],AETNA [100010801],,,76.8,,32.81,0.09,416.02,percent of total billed charges,,,
ATROPINE SULFATE 0.4 MG/ML IJ SOLN WRAPPER,RX-4080931,CDM,J0461,HCPCS,636,RC,00517-1004-01,NDC,outpatient,1,ML,19.31,13.517,AETNA [1000108],AETNA [100010801],,,76.8,,14.83,0.09,416.02,percent of total billed charges,,,
ATROPINE SULFATE 0.4 MG/ML IJ SOLN WRAPPER,RX-4080931,CDM,J0461,HCPCS,636,RC,00517-1004-25,NDC,outpatient,1,ML,19.31,13.517,AETNA [1000108],AETNA [100010801],,,76.8,,14.83,0.09,416.02,percent of total billed charges,,,
ATROPINE SULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4081335,CDM,J0461,HCPCS,636,RC,00517-1001-01,NDC,outpatient,1,ML,30.76,21.532,AETNA [1000108],AETNA [100010801],,,76.8,,23.62,0.09,416.02,percent of total billed charges,,,
ATROPINE SULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4081335,CDM,J0461,HCPCS,636,RC,00517-1001-25,NDC,outpatient,1,ML,30.76,21.532,AETNA [1000108],AETNA [100010801],,,76.8,,23.62,0.09,416.02,percent of total billed charges,,,
ATROPINE SULFATE 0.25 MG/5ML IJ SOSY,RX-729,CDM,J0461,HCPCS,636,RC,00409-9630-15,NDC,outpatient,5,ML,87.58,61.306,AETNA [1000108],AETNA [100010801],,,76.8,,67.26,0.09,416.02,percent of total billed charges,,,
ATROPINE SULFATE 0.25 MG/5ML IJ SOSY,RX-729,CDM,J0461,HCPCS,636,RC,00409-9630-05,NDC,outpatient,5,ML,87.58,61.306,AETNA [1000108],AETNA [100010801],,,76.8,,67.26,0.09,416.02,percent of total billed charges,,,
BACLOFEN 10000 MCG/20ML IT WRAPPER,RX-4081072,CDM,J0475,HCPCS,636,RC,66794-0155-01,NDC,outpatient,20,ML,794.33,556.031,AETNA [1000108],AETNA [100010801],,,76.8,,610.05,174.58,1359.95136,percent of total billed charges,,,
BACLOFEN 20000 MCG/20ML IT WRAPPER,RX-4081073,CDM,J0475,HCPCS,636,RC,66794-0156-02,NDC,outpatient,20,ML,1497.87,1048.509,AETNA [1000108],AETNA [100010801],,,76.8,,1150.36,174.58,1359.95136,percent of total billed charges,,,
BACLOFEN 40000 MCG/20ML IT WRAPPER,RX-4081074,CDM,J0475,HCPCS,636,RC,66794-0157-02,NDC,outpatient,20,ML,1770.77,1239.539,AETNA [1000108],AETNA [100010801],,,76.8,,1359.95,174.58,1359.95136,percent of total billed charges,,,
BACLOFEN 50 MCG/ML IT SOSY,RX-107798,CDM,J0476,HCPCS,636,RC,66794-0151-01,NDC,outpatient,1,ML,326.81,228.767,AETNA [1000108],AETNA [100010801],,,76.8,,250.99,40.38,416.02,percent of total billed charges,,,
BELIMUMAB 120 MG IV SOLR,RX-108842,CDM,J0490,HCPCS,636,RC,49401-0101-01,NDC,outpatient,1,UN,1753.47,1227.429,AETNA [1000108],AETNA [100010801],,,76.8,,1346.66,50.93,4488.66816,percent of total billed charges,,,
BELIMUMAB 400 MG IV SOLR,RX-108843,CDM,J0490,HCPCS,636,RC,49401-0102-01,NDC,outpatient,1,UN,5844.62,4091.234,AETNA [1000108],AETNA [100010801],,,76.8,,4488.67,50.93,4488.66816,percent of total billed charges,,,
DICYCLOMINE HCL 10 MG/ML IM SOLN,RX-2417,CDM,J0500,HCPCS,636,RC,14789-0010-07,NDC,outpatient,2,ML,41.12,28.784,AETNA [1000108],AETNA [100010801],,,76.8,,31.58,9.23144,416.02,percent of total billed charges,,,
DICYCLOMINE HCL 10 MG/ML IM SOLN,RX-2417,CDM,J0500,HCPCS,636,RC,58914-0080-52,NDC,outpatient,2,ML,345.64,241.948,AETNA [1000108],AETNA [100010801],,,76.8,,265.45,9.23144,416.02,percent of total billed charges,,,
DICYCLOMINE HCL 10 MG/ML IM SOLN,RX-2417,CDM,J0500,HCPCS,636,RC,14789-0010-02,NDC,outpatient,2,ML,41.12,28.784,AETNA [1000108],AETNA [100010801],,,76.8,,31.58,9.23144,416.02,percent of total billed charges,,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9233-05,NDC,outpatient,2,ML,97.73,68.411,AETNA [1000108],AETNA [100010801],,,76.8,,75.06,16.21,416.02,percent of total billed charges,,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9729-01,NDC,outpatient,2,ML,114.01,79.807,AETNA [1000108],AETNA [100010801],,,76.8,,87.56,16.21,416.02,percent of total billed charges,,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,68382-0860-02,NDC,outpatient,2,ML,102.98,72.086,AETNA [1000108],AETNA [100010801],,,76.8,,79.09,16.21,416.02,percent of total billed charges,,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9729-05,NDC,outpatient,2,ML,114.01,79.807,AETNA [1000108],AETNA [100010801],,,76.8,,87.56,16.21,416.02,percent of total billed charges,,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,68382-0860-10,NDC,outpatient,2,ML,102.98,72.086,AETNA [1000108],AETNA [100010801],,,76.8,,79.09,16.21,416.02,percent of total billed charges,,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9233-01,NDC,outpatient,2,ML,97.73,68.411,AETNA [1000108],AETNA [100010801],,,76.8,,75.06,16.21,416.02,percent of total billed charges,,,
PENICILLIN G BENZATHINE & PROC 1200000 UNIT/2ML IM SUSP,RX-108051,CDM,J0558,HCPCS,636,RC,60793-0600-10,NDC,outpatient,2,ML,908.68,636.076,AETNA [1000108],AETNA [100010801],,,76.8,,697.87,15.67,697.86624,percent of total billed charges,,,
PENICILLIN G BENZATHINE & PROC 1200000 UNIT/2ML IM SUSP,RX-108051,CDM,J0558,HCPCS,636,RC,60793-0600-02,NDC,outpatient,2,ML,908.68,636.076,AETNA [1000108],AETNA [100010801],,,76.8,,697.87,15.67,697.86624,percent of total billed charges,,,
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SUSY,RX-158171,CDM,J0561,HCPCS,636,RC,60793-0700-01,NDC,outpatient,1,ML,595.58,416.906,AETNA [1000108],AETNA [100010801],,,76.8,,457.41,20.17,1623.552,percent of total billed charges,,,
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SUSY,RX-158171,CDM,J0561,HCPCS,636,RC,60793-0700-10,NDC,outpatient,1,ML,595.58,416.906,AETNA [1000108],AETNA [100010801],,,76.8,,457.41,20.17,1623.552,percent of total billed charges,,,
PENICILLIN G BENZATHINE 1200000 UNIT/2ML IM SUSY,RX-158172,CDM,J0561,HCPCS,636,RC,60793-0701-10,NDC,outpatient,2,ML,1139.95,797.965,AETNA [1000108],AETNA [100010801],,,76.8,,875.48,20.17,1623.552,percent of total billed charges,,,
PENICILLIN G BENZATHINE 1200000 UNIT/2ML IM SUSY,RX-158172,CDM,J0561,HCPCS,636,RC,60793-0701-02,NDC,outpatient,2,ML,1139.95,797.965,AETNA [1000108],AETNA [100010801],,,76.8,,875.48,20.17,1623.552,percent of total billed charges,,,
PENICILLIN G BENZATHINE 2400000 UNIT/4ML IM SUSY,RX-162947,CDM,J0561,HCPCS,636,RC,60793-0702-04,NDC,outpatient,4,ML,2114,1479.8,AETNA [1000108],AETNA [100010801],,,76.8,,1623.55,20.17,1623.552,percent of total billed charges,,,
PENICILLIN G BENZATHINE 2400000 UNIT/4ML IM SUSY,RX-162947,CDM,J0561,HCPCS,636,RC,60793-0702-10,NDC,outpatient,4,ML,2114,1479.8,AETNA [1000108],AETNA [100010801],,,76.8,,1623.55,20.17,1623.552,percent of total billed charges,,,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,00781-3158-94,NDC,outpatient,1,UN,308.39,215.873,AETNA [1000108],AETNA [100010801],,,76.8,,236.84,0.17,416.02,percent of total billed charges,,,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,16729-0275-03,NDC,outpatient,1,UN,294.51,206.157,AETNA [1000108],AETNA [100010801],,,76.8,,226.18,0.17,416.02,percent of total billed charges,,,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,55150-0210-10,NDC,outpatient,1,UN,189.45,132.615,AETNA [1000108],AETNA [100010801],,,76.8,,145.5,0.17,416.02,percent of total billed charges,,,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,00781-3158-95,NDC,outpatient,1,UN,308.39,215.873,AETNA [1000108],AETNA [100010801],,,76.8,,236.84,0.17,416.02,percent of total billed charges,,,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,16729-0275-67,NDC,outpatient,1,UN,294.51,206.157,AETNA [1000108],AETNA [100010801],,,76.8,,226.18,0.17,416.02,percent of total billed charges,,,
ONABOTULINUMTOXINA 100 UNITS IJ SOLR,RX-100610,CDM,J0585,HCPCS,636,RC,00023-1145-01,NDC,outpatient,1,UN,1749.84,1224.888,AETNA [1000108],AETNA [100010801],,,76.8,,1343.88,6.15,1343.87712,percent of total billed charges,,,
BUPRENORPHINE HCL 0.3 MG/ML IJ SOLN,RX-9320,CDM,J0592,HCPCS,636,RC,42023-0179-05,NDC,outpatient,1,ML,53.16,37.212,AETNA [1000108],AETNA [100010801],,,76.8,,40.83,4.03,416.02,percent of total billed charges,,,
BUPRENORPHINE HCL 0.3 MG/ML IJ SOLN,RX-9320,CDM,J0592,HCPCS,636,RC,42023-0179-01,NDC,outpatient,1,ML,53.16,37.212,AETNA [1000108],AETNA [100010801],,,76.8,,40.83,4.03,416.02,percent of total billed charges,,,
BUTORPHANOL TARTRATE 2 MG/ML IJ SOLN,RX-9334,CDM,J0595,HCPCS,636,RC,00409-1626-01,NDC,outpatient,1,ML,29.94,20.958,AETNA [1000108],AETNA [100010801],,,76.8,,22.99,4.06,416.02,percent of total billed charges,,,
BUTORPHANOL TARTRATE 2 MG/ML IJ SOLN,RX-9334,CDM,J0595,HCPCS,636,RC,00409-1626-21,NDC,outpatient,1,ML,29.94,20.958,AETNA [1000108],AETNA [100010801],,,76.8,,22.99,4.06,416.02,percent of total billed charges,,,
EDETATE CALCIUM DISODIUM 1 GM/5ML IJ SOLN,RX-108094,CDM,J0600,HCPCS,250,RC,64980-0588-05,NDC,outpatient,5,ML,16465.83,11526.081,AETNA [1000108],AETNA [100010801],,,76.8,,12645.76,60.43,12645.75744,percent of total billed charges,,,
EDETATE CALCIUM DISODIUM 1 GM/5ML IJ SOLN,RX-108094,CDM,J0600,HCPCS,250,RC,64980-0588-51,NDC,outpatient,5,ML,16465.83,11526.081,AETNA [1000108],AETNA [100010801],,,76.8,,12645.76,60.43,12645.75744,percent of total billed charges,,,
CALCIUM GLUCONATE 10 % IV SOLN,RX-1312,CDM,J0612,HCPCS,636,RC,63323-0360-01,NDC,outpatient,10,ML,36.54,25.578,AETNA [1000108],AETNA [100010801],,,76.8,,28.06,0.04,416.02,percent of total billed charges,,,
CALCIUM GLUCONATE 10 % IV SOLN,RX-1312,CDM,J0612,HCPCS,636,RC,63323-0360-19,NDC,outpatient,10,ML,36.54,25.578,AETNA [1000108],AETNA [100010801],,,76.8,,28.06,0.04,416.02,percent of total billed charges,,,
CALCIUM GLUCONATE-NACL 1-0.8 GM/100ML-% IV SOLN,RX-156703,CDM,J0613,HCPCS,636,RC,44567-0622-01,NDC,outpatient,100,ML,37.38,26.166,AETNA [1000108],AETNA [100010801],,,76.8,,28.71,0.08,416.02,percent of total billed charges,,,
CALCIUM GLUCONATE-NACL 1-0.8 GM/100ML-% IV SOLN,RX-156703,CDM,J0613,HCPCS,636,RC,44567-0622-24,NDC,outpatient,100,ML,37.38,26.166,AETNA [1000108],AETNA [100010801],,,76.8,,28.71,0.08,416.02,percent of total billed charges,,,
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-01,NDC,outpatient,100,ML,53.38,37.366,AETNA [1000108],AETNA [100010801],,,76.8,,41,0.08,416.02,percent of total billed charges,,,
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-24,NDC,outpatient,100,ML,37.38,26.166,AETNA [1000108],AETNA [100010801],JW,,76.8,,28.71,0.08,416.02,percent of total billed charges,,,
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-01,NDC,outpatient,100,ML,37.38,26.166,AETNA [1000108],AETNA [100010801],JW,,76.8,,28.71,0.08,416.02,percent of total billed charges,,,
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-24,NDC,outpatient,100,ML,53.38,37.366,AETNA [1000108],AETNA [100010801],,,76.8,,41,0.08,416.02,percent of total billed charges,,,
CALCITONIN (SALMON) 200 UNIT/ML IJ SOLN,RX-9347,CDM,J0630,HCPCS,636,RC,67457-0675-02,NDC,outpatient,2,ML,2806.57,1964.599,AETNA [1000108],AETNA [100010801],,,76.8,,2155.45,399.86,2155.44576,percent of total billed charges,,,
CALCITONIN (SALMON) 200 UNIT/ML IJ SOLN,RX-9347,CDM,J0630,HCPCS,636,RC,42023-0205-01,NDC,outpatient,2,ML,2193.21,1535.247,AETNA [1000108],AETNA [100010801],,,76.8,,1684.39,399.86,2155.44576,percent of total billed charges,,,
LEUCOVORIN CALCIUM IM INJECTION,RX-4080923,CDM,J0640,HCPCS,636,RC,25021-0813-10,NDC,outpatient,50,ME,16.97,11.879,AETNA [1000108],AETNA [100010801],,,76.8,,13.03,2.68951,416.02,percent of total billed charges,,,
LEUCOVORIN CALCIUM 350 MG IJ SOLR,RX-4393,CDM,J0640,HCPCS,636,RC,00143-9552-01,NDC,outpatient,1,UN,106.72,74.704,AETNA [1000108],AETNA [100010801],,,76.8,,81.96,2.68951,416.02,percent of total billed charges,,,
LEUCOVORIN CALCIUM 50 MG IJ SOLR,RX-4394,CDM,J0640,HCPCS,636,RC,25021-0813-10,NDC,outpatient,50,ME,11.98,8.386,AETNA [1000108],AETNA [100010801],,,76.8,,9.2,2.68951,416.02,percent of total billed charges,,,
LEVOTHYROXINE SODIUM 100 MCG IV SOLR,RX-113060,CDM,J0651,HCPCS,250,RC,63323-0649-07,NDC,outpatient,1,UN,279.46,195.622,AETNA [1000108],AETNA [100010801],,,76.8,,214.63,4.2921885,416.02,percent of total billed charges,,,
LEVOTHYROXINE SODIUM 100 MCG IV SOLR,RX-113060,CDM,J0651,HCPCS,250,RC,63323-0885-12,NDC,outpatient,5,ML,293.44,205.408,AETNA [1000108],AETNA [100010801],,,76.8,,225.36,4.2921885,416.02,percent of total billed charges,,,
LEVOTHYROXINE SODIUM 100 MCG IV SOLR,RX-113060,CDM,J0651,HCPCS,250,RC,63323-0885-10,NDC,outpatient,5,ML,293.44,205.408,AETNA [1000108],AETNA [100010801],,,76.8,,225.36,4.2921885,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-18,NDC,outpatient,10,ML,8.79,6.153,AETNA [1000108],AETNA [100010801],,,76.8,,6.75,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-02,NDC,outpatient,30,ML,8.79,6.153,AETNA [1000108],AETNA [100010801],,,76.8,,6.75,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-19,NDC,outpatient,30,ML,8.79,6.153,AETNA [1000108],AETNA [100010801],,,76.8,,6.75,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1559-19,NDC,outpatient,30,ML,19.59,13.713,AETNA [1000108],AETNA [100010801],,,76.8,,15.05,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,55150-0167-10,NDC,outpatient,10,ML,10.85,7.595,AETNA [1000108],AETNA [100010801],,,76.8,,8.33,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,63323-0464-01,NDC,outpatient,10,ML,6.48,4.536,AETNA [1000108],AETNA [100010801],,,76.8,,4.98,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,63323-0464-17,NDC,outpatient,10,ML,6.48,4.536,AETNA [1000108],AETNA [100010801],,,76.8,,4.98,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00143-9330-01,NDC,outpatient,10,ML,7.82,5.474,AETNA [1000108],AETNA [100010801],,,76.8,,6.01,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,55150-0168-30,NDC,outpatient,30,ML,11.11,7.777,AETNA [1000108],AETNA [100010801],,,76.8,,8.53,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00143-9330-10,NDC,outpatient,10,ML,7.82,5.474,AETNA [1000108],AETNA [100010801],,,76.8,,6.01,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-01,NDC,outpatient,10,ML,8.79,6.153,AETNA [1000108],AETNA [100010801],,,76.8,,6.75,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1559-30,NDC,outpatient,30,ML,19.59,13.713,AETNA [1000108],AETNA [100010801],,,76.8,,15.05,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1162-01,NDC,outpatient,10,ML,10.08,7.056,AETNA [1000108],AETNA [100010801],,,76.8,,7.74,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1162-02,NDC,outpatient,30,ML,9.72,6.804,AETNA [1000108],AETNA [100010801],,,76.8,,7.46,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,63323-0466-01,NDC,outpatient,30,ML,9.57,6.699,AETNA [1000108],AETNA [100010801],,,76.8,,7.35,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1560-18,NDC,outpatient,10,ML,19.43,13.601,AETNA [1000108],AETNA [100010801],,,76.8,,14.92,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,63323-0466-37,NDC,outpatient,30,ML,9.57,6.699,AETNA [1000108],AETNA [100010801],,,76.8,,7.35,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1560-19,NDC,outpatient,30,ML,17.89,12.523,AETNA [1000108],AETNA [100010801],,,76.8,,13.74,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,55150-0170-30,NDC,outpatient,30,ML,12.34,8.638,AETNA [1000108],AETNA [100010801],,,76.8,,9.48,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,00409-1165-19,NDC,outpatient,30,ML,16.97,11.879,AETNA [1000108],AETNA [100010801],,,76.8,,13.03,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,00409-1165-02,NDC,outpatient,30,ML,16.97,11.879,AETNA [1000108],AETNA [100010801],,,76.8,,13.03,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,63323-0472-01,NDC,outpatient,30,ML,12.8,8.96,AETNA [1000108],AETNA [100010801],,,76.8,,9.83,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,63323-0472-37,NDC,outpatient,30,ML,12.8,8.96,AETNA [1000108],AETNA [100010801],,,76.8,,9.83,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL 0.25 % IJ SOLN,RX-1222,CDM,J0665,HCPCS,636,RC,63323-0465-57,NDC,outpatient,5,ML,5.5,3.85,AETNA [1000108],AETNA [100010801],,,76.8,,4.22,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL 0.25 % IJ SOLN,RX-1222,CDM,J0665,HCPCS,636,RC,63323-0465-01,NDC,outpatient,5,ML,5.5,3.85,AETNA [1000108],AETNA [100010801],,,76.8,,4.22,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL 0.5 % IJ SOLN,RX-1223,CDM,J0665,HCPCS,636,RC,00409-1163-01,NDC,outpatient,5,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL 0.5 % IJ SOLN,RX-1223,CDM,J0665,HCPCS,636,RC,00409-1163-18,NDC,outpatient,5,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE IN DEXTROSE 0.75-8.25 % IT SOLN,RX-9316,CDM,J0665,HCPCS,636,RC,00409-1761-18,NDC,outpatient,2,ML,20.36,14.252,AETNA [1000108],AETNA [100010801],,,76.8,,15.64,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE IN DEXTROSE 0.75-8.25 % IT SOLN,RX-9316,CDM,J0665,HCPCS,636,RC,00409-1761-10,NDC,outpatient,2,ML,20.36,14.252,AETNA [1000108],AETNA [100010801],,,76.8,,15.64,0.01,416.02,percent of total billed charges,,,
MEPIVACAINE HCL (PF) 2 % IJ SOLN,RX-105638,CDM,J0670,HCPCS,636,RC,63323-0294-01,NDC,outpatient,20,ML,27.95,19.565,AETNA [1000108],AETNA [100010801],,,76.8,,21.47,3.08,416.02,percent of total billed charges,,,
MEPIVACAINE HCL (PF) 2 % IJ SOLN,RX-105638,CDM,J0670,HCPCS,636,RC,63323-0294-27,NDC,outpatient,20,ML,27.95,19.565,AETNA [1000108],AETNA [100010801],,,76.8,,21.47,3.08,416.02,percent of total billed charges,,,
CEFAZOLIN IVPB 2 G IN 100 ML D4W PREMIX,RX-4080727,CDM,J0689,HCPCS,636,RC,00338-3508-41,NDC,outpatient,100,ML,42.74,29.918,AETNA [1000108],AETNA [100010801],,,76.8,,32.82,1.22,416.02,percent of total billed charges,,,
CEFAZOLIN IVPB 2 G IN 100 ML D4W PREMIX|DISCARDED DRUG NOT ADMINISTERED,RX-4080727,CDM,J0689,HCPCS,636,RC,00338-3508-41,NDC,outpatient,100,ML,26.74,18.718,AETNA [1000108],AETNA [100010801],JW,,76.8,,20.54,1.22,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,00143-9924-90,NDC,outpatient,1,UN,5.85,4.095,AETNA [1000108],AETNA [100010801],,,76.8,,4.49,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,25021-0101-10,NDC,outpatient,1,UN,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,44567-0707-25,NDC,outpatient,1,UN,7.84,5.488,AETNA [1000108],AETNA [100010801],,,76.8,,6.02,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,60505-6142-00,NDC,outpatient,1,UN,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,60505-6142-05,NDC,outpatient,1,UN,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 10 G IJ SOLR,RX-1446,CDM,J0690,HCPCS,636,RC,00143-9983-03,NDC,outpatient,1,UN,40.9,28.63,AETNA [1000108],AETNA [100010801],,,76.8,,31.41,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 10 G IJ SOLR,RX-1446,CDM,J0690,HCPCS,636,RC,00143-9983-91,NDC,outpatient,1,UN,40.9,28.63,AETNA [1000108],AETNA [100010801],,,76.8,,31.41,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 500 MG IJ SOLR,RX-1448,CDM,J0690,HCPCS,636,RC,44567-0706-25,NDC,outpatient,1,UN,4.28,2.996,AETNA [1000108],AETNA [100010801],,,76.8,,3.29,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 2 G IJ SOLR,RX-158156,CDM,J0690,HCPCS,636,RC,60505-6231-05,NDC,outpatient,1,UN,18.74,13.118,AETNA [1000108],AETNA [100010801],,,76.8,,14.39,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 2 G IJ SOLR,RX-158156,CDM,J0690,HCPCS,636,RC,60505-6231-00,NDC,outpatient,1,UN,18.74,13.118,AETNA [1000108],AETNA [100010801],,,76.8,,14.39,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 1 G IV SOLR ADD-VANTAGE,RX-27297,CDM,J0690,HCPCS,636,RC,00409-2585-01,NDC,outpatient,1,UN,12.17,8.519,AETNA [1000108],AETNA [100010801],,,76.8,,9.35,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 1 G IV SOLR ADD-VANTAGE,RX-27297,CDM,J0690,HCPCS,636,RC,00409-2585-11,NDC,outpatient,1,UN,12.17,8.519,AETNA [1000108],AETNA [100010801],,,76.8,,9.35,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,60505-6142-00,NDC,outpatient,1,UN,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,60505-6142-05,NDC,outpatient,1,UN,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,25021-0101-10,NDC,outpatient,1,UN,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,00143-9924-90,NDC,outpatient,1,UN,5.85,4.095,AETNA [1000108],AETNA [100010801],,,76.8,,4.49,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,44567-0707-25,NDC,outpatient,1,UN,7.84,5.488,AETNA [1000108],AETNA [100010801],,,76.8,,6.02,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,44567-0707-25,NDC,outpatient,1,UN,7.84,5.488,AETNA [1000108],AETNA [100010801],,,76.8,,6.02,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,60505-6142-00,NDC,outpatient,1,UN,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,60505-6142-05,NDC,outpatient,1,UN,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,00143-9924-90,NDC,outpatient,1,UN,5.85,4.095,AETNA [1000108],AETNA [100010801],,,76.8,,4.49,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,25021-0101-10,NDC,outpatient,1,UN,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 1 G 100 ML ADD-VANTAGE BAG,RX-4081138,CDM,J0690,HCPCS,636,RC,99999-0003-01,NDC,outpatient,100,ML,32.9,23.03,AETNA [1000108],AETNA [100010801],,,76.8,,25.27,0.74534,416.02,percent of total billed charges,,,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,00409-9566-10,NDC,outpatient,1,UN,16.63,11.641,AETNA [1000108],AETNA [100010801],,,76.8,,12.77,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,00409-9566-01,NDC,outpatient,1,UN,16.63,11.641,AETNA [1000108],AETNA [100010801],,,76.8,,12.77,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,25021-0121-20,NDC,outpatient,1,UN,17.97,12.579,AETNA [1000108],AETNA [100010801],,,76.8,,13.8,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,60505-6146-04,NDC,outpatient,1,UN,12,8.4,AETNA [1000108],AETNA [100010801],,,76.8,,9.22,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,44567-0240-10,NDC,outpatient,1,UN,23.44,16.408,AETNA [1000108],AETNA [100010801],,,76.8,,18,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,60505-6146-00,NDC,outpatient,1,UN,12,8.4,AETNA [1000108],AETNA [100010801],,,76.8,,9.22,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,00409-9735-01,NDC,outpatient,1,UN,25.5,17.85,AETNA [1000108],AETNA [100010801],,,76.8,,19.58,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,60505-6246-04,NDC,outpatient,1,UN,19.47,13.629,AETNA [1000108],AETNA [100010801],,,76.8,,14.95,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,00409-9735-10,NDC,outpatient,1,UN,25.5,17.85,AETNA [1000108],AETNA [100010801],,,76.8,,19.58,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,60505-6246-00,NDC,outpatient,1,UN,19.47,13.629,AETNA [1000108],AETNA [100010801],,,76.8,,14.95,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,70594-0090-02,NDC,outpatient,1,UN,40.3,28.21,AETNA [1000108],AETNA [100010801],,,76.8,,30.95,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,25021-0122-50,NDC,outpatient,1,UN,32.22,22.554,AETNA [1000108],AETNA [100010801],,,76.8,,24.74,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,44567-0241-10,NDC,outpatient,1,UN,40.3,28.21,AETNA [1000108],AETNA [100010801],,,76.8,,30.95,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,70594-0090-01,NDC,outpatient,1,UN,40.3,28.21,AETNA [1000108],AETNA [100010801],,,76.8,,30.95,1.22,416.02,percent of total billed charges,,,
CEFEPIME IVPB 1 G IN 100 ML NS COMPOUNDED,RX-4080828,CDM,J0692,HCPCS,636,RC,99999-0001-09,NDC,outpatient,100,ML,48.93,34.251,AETNA [1000108],AETNA [100010801],,,76.8,,37.58,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,44567-0241-10,NDC,outpatient,1,UN,40.3,28.21,AETNA [1000108],AETNA [100010801],,,76.8,,30.95,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,60505-6147-00,NDC,outpatient,1,UN,34.31,24.017,AETNA [1000108],AETNA [100010801],,,76.8,,26.35,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,00409-9735-10,NDC,outpatient,1,UN,25.5,17.85,AETNA [1000108],AETNA [100010801],,,76.8,,19.58,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,00409-9735-01,NDC,outpatient,1,UN,25.5,17.85,AETNA [1000108],AETNA [100010801],,,76.8,,19.58,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,70594-0090-02,NDC,outpatient,1,UN,40.3,28.21,AETNA [1000108],AETNA [100010801],,,76.8,,30.95,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,60505-6147-04,NDC,outpatient,1,UN,19.47,13.629,AETNA [1000108],AETNA [100010801],,,76.8,,14.95,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,70594-0090-01,NDC,outpatient,1,UN,40.3,28.21,AETNA [1000108],AETNA [100010801],,,76.8,,30.95,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,60505-6146-00,NDC,outpatient,1,UN,12,8.4,AETNA [1000108],AETNA [100010801],,,76.8,,9.22,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,00409-9566-10,NDC,outpatient,1,UN,16.63,11.641,AETNA [1000108],AETNA [100010801],,,76.8,,12.77,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,44567-0240-10,NDC,outpatient,1,UN,23.44,16.408,AETNA [1000108],AETNA [100010801],,,76.8,,18,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,25021-0121-20,NDC,outpatient,1,UN,17.97,12.579,AETNA [1000108],AETNA [100010801],,,76.8,,13.8,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,00409-9566-01,NDC,outpatient,1,UN,16.63,11.641,AETNA [1000108],AETNA [100010801],,,76.8,,12.77,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,60505-6146-04,NDC,outpatient,1,UN,12,8.4,AETNA [1000108],AETNA [100010801],,,76.8,,9.22,1.22,416.02,percent of total billed charges,,,
CEFOXITIN SODIUM-DEXTROSE 2-2.2 GM-%(50ML) IV SOLR,RX-144407,CDM,J0694,HCPCS,636,RC,00264-3125-11,NDC,outpatient,1,UN,147.33,103.131,AETNA [1000108],AETNA [100010801],,,76.8,,113.15,3.679555,416.02,percent of total billed charges,,,
CEFOXITIN IVPB 2 G IN 100 ML NS COMPOUNDED,RX-4080864,CDM,J0694,HCPCS,636,RC,99999-0001-16,NDC,outpatient,100,ML,46.14,32.298,AETNA [1000108],AETNA [100010801],,,76.8,,35.44,3.679555,416.02,percent of total billed charges,,,
CEFOXITIN SODIUM 1 G IV SOLR 1000 MG/10.5 ML,RX-4080998,CDM,J0694,HCPCS,636,RC,44567-0245-25,NDC,outpatient,1,UN,40.92,28.644,AETNA [1000108],AETNA [100010801],,,76.8,,31.43,3.679555,416.02,percent of total billed charges,,,
CEFOXITIN SODIUM 1 G IV SOLR 1000 MG/10.5 ML,RX-4080998,CDM,J0694,HCPCS,636,RC,25021-0109-10,NDC,outpatient,1,UN,16.39,11.473,AETNA [1000108],AETNA [100010801],,,76.8,,12.59,3.679555,416.02,percent of total billed charges,,,
CEFOXITIN SODIUM 2 G IV SOLR 2000 MG/11.1 ML,RX-4081009,CDM,J0694,HCPCS,636,RC,44567-0246-25,NDC,outpatient,1,UN,82.04,57.428,AETNA [1000108],AETNA [100010801],,,76.8,,63.01,3.679555,416.02,percent of total billed charges,,,
CEFOXITIN SODIUM 2 G IV SOLR 2000 MG/11.1 ML,RX-4081009,CDM,J0694,HCPCS,636,RC,25021-0110-20,NDC,outpatient,1,UN,30.34,21.238,AETNA [1000108],AETNA [100010801],,,76.8,,23.3,3.679555,416.02,percent of total billed charges,,,
CEFOXITIN SODIUM 1 G IV SOLR,RX-9461,CDM,J0694,HCPCS,636,RC,44567-0245-25,NDC,outpatient,1,UN,40.92,28.644,AETNA [1000108],AETNA [100010801],,,76.8,,31.43,3.679555,416.02,percent of total billed charges,,,
CEFOXITIN SODIUM 1 G IV SOLR,RX-9461,CDM,J0694,HCPCS,636,RC,25021-0109-10,NDC,outpatient,1,UN,16.39,11.473,AETNA [1000108],AETNA [100010801],,,76.8,,12.59,3.679555,416.02,percent of total billed charges,,,
CEFOXITIN SODIUM 2 G IV SOLR,RX-9463,CDM,J0694,HCPCS,636,RC,25021-0110-20,NDC,outpatient,1,UN,30.34,21.238,AETNA [1000108],AETNA [100010801],,,76.8,,23.3,3.679555,416.02,percent of total billed charges,,,
CEFOXITIN SODIUM 2 G IV SOLR,RX-9463,CDM,J0694,HCPCS,636,RC,44567-0246-25,NDC,outpatient,1,UN,82.04,57.428,AETNA [1000108],AETNA [100010801],,,76.8,,63.01,3.679555,416.02,percent of total billed charges,,,
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G IV SOLR,RX-129169,CDM,J0695,HCPCS,636,RC,67919-0030-01,NDC,outpatient,1,UN,652.32,456.624,AETNA [1000108],AETNA [100010801],,,76.8,,500.98,7.54,500.98176,percent of total billed charges,,,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,25021-0106-10,NDC,outpatient,1,UN,9.22,6.454,AETNA [1000108],AETNA [100010801],,,76.8,,7.08,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00143-9857-01,NDC,outpatient,1,UN,5.23,3.661,AETNA [1000108],AETNA [100010801],,,76.8,,4.02,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00143-9857-25,NDC,outpatient,1,UN,5.23,3.661,AETNA [1000108],AETNA [100010801],,,76.8,,4.02,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,44567-0701-25,NDC,outpatient,1,UN,4.75,3.325,AETNA [1000108],AETNA [100010801],,,76.8,,3.65,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00781-3208-95,NDC,outpatient,1,UN,17.99,12.593,AETNA [1000108],AETNA [100010801],,,76.8,,13.82,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00781-3208-85,NDC,outpatient,1,UN,17.99,12.593,AETNA [1000108],AETNA [100010801],,,76.8,,13.82,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,44567-0702-25,NDC,outpatient,1,UN,9.03,6.321,AETNA [1000108],AETNA [100010801],,,76.8,,6.94,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00143-9856-01,NDC,outpatient,1,UN,9.12,6.384,AETNA [1000108],AETNA [100010801],,,76.8,,7,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00143-9856-25,NDC,outpatient,1,UN,9.12,6.384,AETNA [1000108],AETNA [100010801],,,76.8,,7,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00781-3209-90,NDC,outpatient,1,UN,11.14,7.798,AETNA [1000108],AETNA [100010801],,,76.8,,8.56,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,25021-0107-20,NDC,outpatient,1,UN,18.72,13.104,AETNA [1000108],AETNA [100010801],,,76.8,,14.38,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00781-3209-95,NDC,outpatient,1,UN,11.14,7.798,AETNA [1000108],AETNA [100010801],,,76.8,,8.56,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00409-7332-11,NDC,outpatient,1,UN,6.94,4.858,AETNA [1000108],AETNA [100010801],,,76.8,,5.33,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00143-9857-01,NDC,outpatient,1,UN,5.23,3.661,AETNA [1000108],AETNA [100010801],,,76.8,,4.02,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00409-7332-01,NDC,outpatient,1,UN,6.94,4.858,AETNA [1000108],AETNA [100010801],,,76.8,,5.33,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00143-9857-25,NDC,outpatient,1,UN,5.23,3.661,AETNA [1000108],AETNA [100010801],,,76.8,,4.02,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00781-3208-85,NDC,outpatient,1,UN,17.99,12.593,AETNA [1000108],AETNA [100010801],,,76.8,,13.82,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,25021-0106-10,NDC,outpatient,1,UN,9.22,6.454,AETNA [1000108],AETNA [100010801],,,76.8,,7.08,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,44567-0701-25,NDC,outpatient,1,UN,4.75,3.325,AETNA [1000108],AETNA [100010801],,,76.8,,3.65,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00781-3208-95,NDC,outpatient,1,UN,17.99,12.593,AETNA [1000108],AETNA [100010801],,,76.8,,13.82,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00781-3209-90,NDC,outpatient,1,UN,11.14,7.798,AETNA [1000108],AETNA [100010801],,,76.8,,8.56,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00143-9856-01,NDC,outpatient,1,UN,9.12,6.384,AETNA [1000108],AETNA [100010801],,,76.8,,7,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00781-3209-95,NDC,outpatient,1,UN,11.14,7.798,AETNA [1000108],AETNA [100010801],,,76.8,,8.56,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00143-9856-25,NDC,outpatient,1,UN,9.12,6.384,AETNA [1000108],AETNA [100010801],,,76.8,,7,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,25021-0107-20,NDC,outpatient,1,UN,18.72,13.104,AETNA [1000108],AETNA [100010801],,,76.8,,14.38,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,44567-0702-25,NDC,outpatient,1,UN,9.03,6.321,AETNA [1000108],AETNA [100010801],,,76.8,,6.94,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00143-9859-25,NDC,outpatient,1,UN,4.32,3.024,AETNA [1000108],AETNA [100010801],,,76.8,,3.32,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00409-7337-01,NDC,outpatient,1,UN,3.47,2.429,AETNA [1000108],AETNA [100010801],,,76.8,,2.66,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00781-3206-85,NDC,outpatient,1,UN,6.33,4.431,AETNA [1000108],AETNA [100010801],,,76.8,,4.86,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00409-7337-11,NDC,outpatient,1,UN,3.47,2.429,AETNA [1000108],AETNA [100010801],,,76.8,,2.66,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00143-9859-01,NDC,outpatient,1,UN,4.32,3.024,AETNA [1000108],AETNA [100010801],,,76.8,,3.32,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00781-3206-95,NDC,outpatient,1,UN,6.33,4.431,AETNA [1000108],AETNA [100010801],,,76.8,,4.86,0.44,416.02,percent of total billed charges,,,
CEFUROXIME SODIUM 750 MG IJ SOLR,RX-1465,CDM,J0697,HCPCS,636,RC,00143-9979-90,NDC,outpatient,1,UN,12.5,8.75,AETNA [1000108],AETNA [100010801],,,76.8,,9.6,1.88,416.02,percent of total billed charges,,,
CEFUROXIME SODIUM 750 MG IJ SOLR,RX-1465,CDM,J0697,HCPCS,636,RC,25021-0118-10,NDC,outpatient,1,UN,9.6,6.72,AETNA [1000108],AETNA [100010801],,,76.8,,7.37,1.88,416.02,percent of total billed charges,,,
CEFUROXIME SODIUM 750 MG IJ SOLR,RX-1465,CDM,J0697,HCPCS,636,RC,00143-9979-22,NDC,outpatient,1,UN,12.5,8.75,AETNA [1000108],AETNA [100010801],,,76.8,,9.6,1.88,416.02,percent of total billed charges,,,
CEFUROXIME SODIUM 1.5 G IV SOLR,RX-27299,CDM,J0697,HCPCS,636,RC,00143-9977-22,NDC,outpatient,1,UN,21.64,15.148,AETNA [1000108],AETNA [100010801],,,76.8,,16.62,1.88,416.02,percent of total billed charges,,,
CEFUROXIME SODIUM 1.5 G IV SOLR,RX-27299,CDM,J0697,HCPCS,636,RC,00143-9977-90,NDC,outpatient,1,UN,21.64,15.148,AETNA [1000108],AETNA [100010801],,,76.8,,16.62,1.88,416.02,percent of total billed charges,,,
CEFUROXIME SODIUM 750 MG IJ SOLR 750 MG/8.3 ML,RX-4080994,CDM,J0697,HCPCS,636,RC,00143-9979-22,NDC,outpatient,1,UN,12.5,8.75,AETNA [1000108],AETNA [100010801],,,76.8,,9.6,1.88,416.02,percent of total billed charges,,,
CEFUROXIME SODIUM 750 MG IJ SOLR 750 MG/8.3 ML,RX-4080994,CDM,J0697,HCPCS,636,RC,00143-9979-90,NDC,outpatient,1,UN,12.5,8.75,AETNA [1000108],AETNA [100010801],,,76.8,,9.6,1.88,416.02,percent of total billed charges,,,
CEFUROXIME SODIUM 750 MG IJ SOLR 750 MG/8.3 ML,RX-4080994,CDM,J0697,HCPCS,636,RC,25021-0118-10,NDC,outpatient,1,UN,9.6,6.72,AETNA [1000108],AETNA [100010801],,,76.8,,7.37,1.88,416.02,percent of total billed charges,,,
CEFUROXIME SODIUM 1.5 G IJ SOLR IN 16 ML,RX-4081008,CDM,J0697,HCPCS,636,RC,00143-9977-22,NDC,outpatient,1,UN,21.64,15.148,AETNA [1000108],AETNA [100010801],,,76.8,,16.62,1.88,416.02,percent of total billed charges,,,
CEFUROXIME SODIUM 1.5 G IJ SOLR IN 16 ML,RX-4081008,CDM,J0697,HCPCS,636,RC,00143-9977-90,NDC,outpatient,1,UN,21.64,15.148,AETNA [1000108],AETNA [100010801],,,76.8,,16.62,1.88,416.02,percent of total billed charges,,,
BETAMETHASONE SOD PHOS & ACET 6 (3-3) MG/ML IJ SUSP,RX-9266,CDM,J0702,HCPCS,636,RC,78206-0118-01,NDC,outpatient,5,ML,170.75,119.525,AETNA [1000108],AETNA [100010801],,,76.8,,131.14,6.96,416.02,percent of total billed charges,,,
BETAMETHASONE SOD PHOS & ACET 6 (3-3) MG/ML IJ SUSP,RX-9266,CDM,J0702,HCPCS,636,RC,00517-0720-01,NDC,outpatient,5,ML,143.92,100.744,AETNA [1000108],AETNA [100010801],,,76.8,,110.53,6.96,416.02,percent of total billed charges,,,
CAFFEINE CITRATE 60 MG/3ML IV SOLN,RX-109034,CDM,J0706,HCPCS,636,RC,51754-0500-01,NDC,outpatient,3,ML,26.75,18.725,AETNA [1000108],AETNA [100010801],,,76.8,,20.54,1.65,416.02,percent of total billed charges,,,
CEFTAROLINE FOSAMIL 400 MG IV SOLR,RX-107670,CDM,J0712,HCPCS,636,RC,00456-0400-10,NDC,outpatient,1,UN,806.58,564.606,AETNA [1000108],AETNA [100010801],,,76.8,,619.45,3.89,619.45344,percent of total billed charges,,,
CEFTAROLINE FOSAMIL 400 MG IV SOLR,RX-107670,CDM,J0712,HCPCS,636,RC,00456-0400-01,NDC,outpatient,1,UN,806.58,564.606,AETNA [1000108],AETNA [100010801],,,76.8,,619.45,3.89,619.45344,percent of total billed charges,,,
CEFTAROLINE FOSAMIL 600 MG IV SOLR,RX-107671,CDM,J0712,HCPCS,636,RC,00456-0600-01,NDC,outpatient,1,UN,806.58,564.606,AETNA [1000108],AETNA [100010801],,,76.8,,619.45,3.89,619.45344,percent of total billed charges,,,
CEFTAROLINE FOSAMIL 600 MG IV SOLR,RX-107671,CDM,J0712,HCPCS,636,RC,00456-0600-10,NDC,outpatient,1,UN,806.58,564.606,AETNA [1000108],AETNA [100010801],,,76.8,,619.45,3.89,619.45344,percent of total billed charges,,,
CEFTAZIDIME 2 G IV SOLR,RX-27291,CDM,J0713,HCPCS,636,RC,44567-0236-10,NDC,outpatient,1,UN,23.52,16.464,AETNA [1000108],AETNA [100010801],,,76.8,,18.06,1.66,416.02,percent of total billed charges,,,
CEFTAZIDIME 2 G IV SOLR,RX-27291,CDM,J0713,HCPCS,636,RC,25021-0128-50,NDC,outpatient,1,UN,37.01,25.907,AETNA [1000108],AETNA [100010801],,,76.8,,28.42,1.66,416.02,percent of total billed charges,,,
CEFTAZIDIME 1 MG/ML IJ SOLR,RX-4080666,CDM,J0713,HCPCS,636,RC,00409-5082-16,NDC,outpatient,1,UN,14.25,9.975,AETNA [1000108],AETNA [100010801],,,76.8,,10.94,1.66,416.02,percent of total billed charges,,,
CEFTAZIDIME 1 G IJ SOLR 1000 MG/10.8 ML,RX-4081001,CDM,J0713,HCPCS,636,RC,00409-5082-16,NDC,outpatient,1,UN,14.25,9.975,AETNA [1000108],AETNA [100010801],,,76.8,,10.94,1.66,416.02,percent of total billed charges,,,
CEFTAZIDIME 2 G IJ SOLR 2000 MG/11.5 ML,RX-4081002,CDM,J0713,HCPCS,636,RC,25021-0128-50,NDC,outpatient,1,UN,37.01,25.907,AETNA [1000108],AETNA [100010801],,,76.8,,28.42,1.66,416.02,percent of total billed charges,,,
CEFTAZIDIME 1 G IJ SOLR,RX-9474,CDM,J0713,HCPCS,636,RC,00409-5082-11,NDC,outpatient,1,UN,14.25,9.975,AETNA [1000108],AETNA [100010801],,,76.8,,10.94,1.66,416.02,percent of total billed charges,,,
CEFTAZIDIME 1 G IJ SOLR,RX-9474,CDM,J0713,HCPCS,636,RC,00409-5082-16,NDC,outpatient,1,UN,14.25,9.975,AETNA [1000108],AETNA [100010801],,,76.8,,10.94,1.66,416.02,percent of total billed charges,,,
CEFTAZIDIME 1 G IJ SOLR,RX-9474,CDM,J0713,HCPCS,636,RC,44567-0235-25,NDC,outpatient,1,UN,13.87,9.709,AETNA [1000108],AETNA [100010801],,,76.8,,10.65,1.66,416.02,percent of total billed charges,,,
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G IV SOLR,RX-130403,CDM,J0714,HCPCS,636,RC,00456-2700-01,NDC,outpatient,1,UN,1625.76,1138.032,AETNA [1000108],AETNA [100010801],,,76.8,,1248.58,92.48,1248.58368,percent of total billed charges,,,
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G IV SOLR,RX-130403,CDM,J0714,HCPCS,636,RC,00456-2700-10,NDC,outpatient,1,UN,1625.76,1138.032,AETNA [1000108],AETNA [100010801],,,76.8,,1248.58,92.48,1248.58368,percent of total billed charges,,,
CLONIDINE HCL (ANALGESIA) 100 MCG/ML EP SOLN,RX-19333,CDM,J0735,HCPCS,636,RC,67457-0218-10,NDC,outpatient,10,ML,45.22,31.654,AETNA [1000108],AETNA [100010801],,,76.8,,34.73,10.15189,416.02,percent of total billed charges,,,
CLONIDINE HCL (ANALGESIA) 500 MCG/ML EP SOLN,RX-27113,CDM,J0735,HCPCS,636,RC,39822-2010-01,NDC,outpatient,10,ML,402.95,282.065,AETNA [1000108],AETNA [100010801],,,76.8,,309.47,10.15189,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE 150 MG/ML IJ WRAPPER,RX-4080195,CDM,J0736,HCPCS,636,RC,00009-0775-20,NDC,outpatient,4,ML,13.99,9.793,AETNA [1000108],AETNA [100010801],,,76.8,,10.74,1.61,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE 150 MG/ML IJ WRAPPER,RX-4080195,CDM,J0736,HCPCS,636,RC,00009-0775-26,NDC,outpatient,4,ML,13.99,9.793,AETNA [1000108],AETNA [100010801],,,76.8,,10.74,1.61,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0736,HCPCS,636,RC,00781-3288-91,NDC,outpatient,50,ML,48.27,33.789,AETNA [1000108],AETNA [100010801],,,76.8,,37.07,1.61,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0736,HCPCS,636,RC,00781-3288-09,NDC,outpatient,50,ML,48.27,33.789,AETNA [1000108],AETNA [100010801],,,76.8,,37.07,1.61,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-09,NDC,outpatient,50,ML,64.73,45.311,AETNA [1000108],AETNA [100010801],,,76.8,,49.71,1.61,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-09,NDC,outpatient,50,ML,48.73,34.111,AETNA [1000108],AETNA [100010801],JW,,76.8,,37.42,1.61,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-91,NDC,outpatient,50,ML,48.73,34.111,AETNA [1000108],AETNA [100010801],JW,,76.8,,37.42,1.61,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-91,NDC,outpatient,50,ML,64.73,45.311,AETNA [1000108],AETNA [100010801],,,76.8,,49.71,1.61,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0737,HCPCS,636,RC,00338-3410-24,NDC,outpatient,50,ML,30.91,21.637,AETNA [1000108],AETNA [100010801],,,76.8,,23.74,2.59,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0737,HCPCS,636,RC,00338-3410-50,NDC,outpatient,50,ML,30.91,21.637,AETNA [1000108],AETNA [100010801],,,76.8,,23.74,2.59,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-50,NDC,outpatient,50,ML,34.25,23.975,AETNA [1000108],AETNA [100010801],,,76.8,,26.3,2.59,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-50,NDC,outpatient,50,ML,34.25,23.975,AETNA [1000108],AETNA [100010801],,,76.8,,26.3,2.59,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-24,NDC,outpatient,50,ML,34.25,23.975,AETNA [1000108],AETNA [100010801],,,76.8,,26.3,2.59,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-24,NDC,outpatient,50,ML,18.25,12.775,AETNA [1000108],AETNA [100010801],JW,,76.8,,14.02,2.59,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-24,NDC,outpatient,50,ML,34.25,23.975,AETNA [1000108],AETNA [100010801],,,76.8,,26.3,2.59,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-50,NDC,outpatient,50,ML,18.25,12.775,AETNA [1000108],AETNA [100010801],JW,,76.8,,14.02,2.59,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-50,NDC,outpatient,50,ML,18.25,12.775,AETNA [1000108],AETNA [100010801],JW,,76.8,,14.02,2.59,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-24,NDC,outpatient,50,ML,18.25,12.775,AETNA [1000108],AETNA [100010801],JW,,76.8,,14.02,2.59,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-24,NDC,outpatient,50,ML,38.7,27.09,AETNA [1000108],AETNA [100010801],,,76.8,,29.72,2.59,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-50,NDC,outpatient,50,ML,38.7,27.09,AETNA [1000108],AETNA [100010801],,,76.8,,29.72,2.59,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-50,NDC,outpatient,50,ML,22.7,15.89,AETNA [1000108],AETNA [100010801],JW,,76.8,,17.43,2.59,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-24,NDC,outpatient,50,ML,22.7,15.89,AETNA [1000108],AETNA [100010801],JW,,76.8,,17.43,2.59,416.02,percent of total billed charges,,,
IMIPENEM-CILASTATIN 250 MG IV SOLR,RX-9602,CDM,J0743,HCPCS,636,RC,63323-0349-25,NDC,outpatient,1,UN,25.58,17.906,AETNA [1000108],AETNA [100010801],,,76.8,,19.65,5.74271,416.02,percent of total billed charges,,,
IMIPENEM-CILASTATIN 500 MG IV SOLR,RX-9603,CDM,J0743,HCPCS,636,RC,63323-0322-01,NDC,outpatient,1,UN,43.92,30.744,AETNA [1000108],AETNA [100010801],,,76.8,,33.73,5.74271,416.02,percent of total billed charges,,,
IMIPENEM-CILASTATIN 500 MG IV SOLR,RX-9603,CDM,J0743,HCPCS,636,RC,63323-0322-25,NDC,outpatient,1,UN,43.92,30.744,AETNA [1000108],AETNA [100010801],,,76.8,,33.73,5.74271,416.02,percent of total billed charges,,,
CIPROFLOXACIN IN D5W 200 MG/100ML IV SOLN,RX-108130,CDM,J0744,HCPCS,636,RC,00409-2300-24,NDC,outpatient,100,ML,26.8,18.76,AETNA [1000108],AETNA [100010801],,,76.8,,20.58,1.86,416.02,percent of total billed charges,,,
CIPROFLOXACIN IN D5W 200 MG/100ML IV SOLN,RX-108130,CDM,J0744,HCPCS,636,RC,00409-2300-01,NDC,outpatient,100,ML,26.8,18.76,AETNA [1000108],AETNA [100010801],,,76.8,,20.58,1.86,416.02,percent of total billed charges,,,
CIPROFLOXACIN IN D5W 400 MG/200ML IV SOLN,RX-108132,CDM,J0744,HCPCS,636,RC,25021-0114-87,NDC,outpatient,200,ML,42.7,29.89,AETNA [1000108],AETNA [100010801],,,76.8,,32.79,1.86,416.02,percent of total billed charges,,,
COLISTIMETHATE SODIUM (CBA) 150 MG IJ SOLR,RX-142413,CDM,J0770,HCPCS,636,RC,70594-0023-04,NDC,outpatient,1,UN,46.34,32.438,AETNA [1000108],AETNA [100010801],,,76.8,,35.59,10.40333,416.02,percent of total billed charges,,,
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,14789-0700-02,NDC,outpatient,2,ML,14.97,10.479,AETNA [1000108],AETNA [100010801],,,76.8,,11.5,3.01,416.02,percent of total billed charges,,,
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,00713-0351-02,NDC,outpatient,2,ML,13.73,9.611,AETNA [1000108],AETNA [100010801],,,76.8,,10.54,3.01,416.02,percent of total billed charges,,,
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,14789-0700-07,NDC,outpatient,2,ML,14.97,10.479,AETNA [1000108],AETNA [100010801],,,76.8,,11.5,3.01,416.02,percent of total billed charges,,,
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,00713-0351-09,NDC,outpatient,2,ML,15.66,10.962,AETNA [1000108],AETNA [100010801],,,76.8,,12.03,3.01,416.02,percent of total billed charges,,,
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,00713-0351-25,NDC,outpatient,2,ML,13.73,9.611,AETNA [1000108],AETNA [100010801],,,76.8,,10.54,3.01,416.02,percent of total billed charges,,,
COSYNTROPIN 0.25 MG IJ SOLR,RX-9686,CDM,J0834,HCPCS,636,RC,00781-3440-95,NDC,outpatient,1,UN,356.89,249.823,AETNA [1000108],AETNA [100010801],,,76.8,,274.09,16.61749,416.02,percent of total billed charges,,,
COSYNTROPIN 0.25 MG IJ SOLR,RX-9686,CDM,J0834,HCPCS,636,RC,00548-5900-00,NDC,outpatient,1,UN,74.02,51.814,AETNA [1000108],AETNA [100010801],,,76.8,,56.85,16.61749,416.02,percent of total billed charges,,,
COSYNTROPIN 0.25 MG IJ SOLR,RX-9686,CDM,J0834,HCPCS,636,RC,00781-3440-71,NDC,outpatient,1,UN,356.89,249.823,AETNA [1000108],AETNA [100010801],,,76.8,,274.09,16.61749,416.02,percent of total billed charges,,,
DAPTOMYCIN 500 MG IV SOLR,RX-36989,CDM,J0873,HCPCS,636,RC,70594-0034-01,NDC,outpatient,1,UN,65.78,46.046,AETNA [1000108],AETNA [100010801],,,76.8,,50.52,0.04,416.02,percent of total billed charges,,,
DALBAVANCIN HCL 500 MG IV SOLR,RX-125774,CDM,J0875,HCPCS,636,RC,57970-0100-01,NDC,outpatient,1,UN,2550.24,1785.168,AETNA [1000108],AETNA [100010801],,,76.8,,1958.58,14.7,4668.927562,percent of total billed charges,,,
DAPTOMYCIN 350 MG IV SOLR,RX-143414,CDM,J0878,HCPCS,636,RC,16729-0434-05,NDC,outpatient,1,UN,201.5,141.05,AETNA [1000108],AETNA [100010801],,,76.8,,154.75,0.03,416.02,percent of total billed charges,,,
DAPTOMYCIN 350 MG IV SOLR,RX-143414,CDM,J0878,HCPCS,636,RC,16729-0434-45,NDC,outpatient,1,UN,201.59,141.113,AETNA [1000108],AETNA [100010801],,,76.8,,154.82,0.03,416.02,percent of total billed charges,,,
DAPTOMYCIN 500 MG IV SOLR,RX-36989,CDM,J0878,HCPCS,636,RC,00143-9378-01,NDC,outpatient,1,UN,57.59,40.313,AETNA [1000108],AETNA [100010801],,,76.8,,44.23,0.03,416.02,percent of total billed charges,,,
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0883,HCPCS,636,RC,16729-0430-43,NDC,outpatient,50,ML,342.65,239.855,AETNA [1000108],AETNA [100010801],JW,,76.8,,263.16,1.35,1059.84,percent of total billed charges,,,
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0883,HCPCS,636,RC,16729-0430-43,NDC,outpatient,50,ML,358.65,251.055,AETNA [1000108],AETNA [100010801],,,76.8,,275.44,1.35,1059.84,percent of total billed charges,,,
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0883,HCPCS,636,RC,00143-9559-01,NDC,outpatient,50,ML,422.53,295.771,AETNA [1000108],AETNA [100010801],JW,,76.8,,324.5,1.35,1059.84,percent of total billed charges,,,
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0883,HCPCS,636,RC,25021-0414-50,NDC,outpatient,50,ML,317.29,222.103,AETNA [1000108],AETNA [100010801],JW,,76.8,,243.68,1.35,1059.84,percent of total billed charges,,,
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0883,HCPCS,636,RC,00143-9559-01,NDC,outpatient,50,ML,438.53,306.971,AETNA [1000108],AETNA [100010801],,,76.8,,336.79,1.35,1059.84,percent of total billed charges,,,
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0883,HCPCS,636,RC,25021-0414-50,NDC,outpatient,50,ML,333.29,233.303,AETNA [1000108],AETNA [100010801],,,76.8,,255.97,1.35,1059.84,percent of total billed charges,,,
ARGATROBAN 250 MG/2.5ML IV SOLN,RX-28947,CDM,J0883,HCPCS,636,RC,00143-9674-01,NDC,outpatient,2.5,ML,1380,966,AETNA [1000108],AETNA [100010801],,,76.8,,1059.84,1.35,1059.84,percent of total billed charges,,,
ARGATROBAN 250 MG/2.5ML IV SOLN,RX-28947,CDM,J0883,HCPCS,636,RC,00409-1140-01,NDC,outpatient,2.5,ML,226.15,158.305,AETNA [1000108],AETNA [100010801],,,76.8,,173.68,1.35,1059.84,percent of total billed charges,,,
ARGATROBAN 250 MG/2.5ML IV SOLN,RX-28947,CDM,J0883,HCPCS,636,RC,63323-0526-03,NDC,outpatient,2.5,ML,1328.82,930.174,AETNA [1000108],AETNA [100010801],,,76.8,,1020.53,1.35,1059.84,percent of total billed charges,,,
EPOETIN ALFA 10000 UNIT/ML IJ SOLN,RX-9938,CDM,J0885,HCPCS,636,RC,59676-0310-00,NDC,outpatient,1,ML,622.94,436.058,AETNA [1000108],AETNA [100010801],,,76.8,,478.42,6.88,478.41792,percent of total billed charges,,,
EPOETIN ALFA 10000 UNIT/ML IJ SOLN,RX-9938,CDM,J0885,HCPCS,636,RC,59676-0310-01,NDC,outpatient,1,ML,622.94,436.058,AETNA [1000108],AETNA [100010801],,,76.8,,478.42,6.88,478.41792,percent of total billed charges,,,
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,55513-0148-10,NDC,outpatient,1,ML,283.41,198.387,AETNA [1000108],AETNA [100010801],,,76.8,,217.66,6.88,478.41792,percent of total billed charges,,,
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,59676-0304-01,NDC,outpatient,1,ML,456.83,319.781,AETNA [1000108],AETNA [100010801],,,76.8,,350.85,6.88,478.41792,percent of total billed charges,,,
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,55513-0148-01,NDC,outpatient,1,ML,283.41,198.387,AETNA [1000108],AETNA [100010801],,,76.8,,217.66,6.88,478.41792,percent of total billed charges,,,
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,59676-0304-00,NDC,outpatient,1,ML,456.83,319.781,AETNA [1000108],AETNA [100010801],,,76.8,,350.85,6.88,478.41792,percent of total billed charges,,,
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0891,HCPCS,636,RC,16729-0430-11,NDC,outpatient,50,ML,358.65,251.055,AETNA [1000108],AETNA [100010801],,,76.8,,275.44,0.46,416.02,percent of total billed charges,,,
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0891,HCPCS,636,RC,16729-0430-11,NDC,outpatient,50,ML,342.65,239.855,AETNA [1000108],AETNA [100010801],JW,,76.8,,263.16,0.46,416.02,percent of total billed charges,,,
DECITABINE 50 MG IV SOLR,RX-76364,CDM,J0894,HCPCS,636,RC,16729-0224-05,NDC,outpatient,1,UN,335.38,234.766,AETNA [1000108],AETNA [100010801],,,76.8,,257.57,1.63,416.02,percent of total billed charges,,,
DEFEROXAMINE MESYLATE 500 MG IJ SOLR,RX-9723,CDM,J0895,HCPCS,636,RC,60505-6236-00,NDC,outpatient,1,UN,46.34,32.438,AETNA [1000108],AETNA [100010801],,,76.8,,35.59,6.78,416.02,percent of total billed charges,,,
DEFEROXAMINE MESYLATE 500 MG IJ SOLR,RX-9723,CDM,J0895,HCPCS,636,RC,60505-6236-06,NDC,outpatient,1,UN,46.34,32.438,AETNA [1000108],AETNA [100010801],,,76.8,,35.59,6.78,416.02,percent of total billed charges,,,
DENOSUMAB 120 MG/1.7ML SC SOLN,RX-106804,CDM,J0897,HCPCS,636,RC,55513-0730-01,NDC,outpatient,1.7,ML,8861.12,6202.784,AETNA [1000108],AETNA [100010801],,,76.8,,6805.34,24.19,6805.34016,percent of total billed charges,,,
DENOSUMAB 60 MG/ML SC SOSY,RX-146195,CDM,J0897,HCPCS,636,RC,55513-0710-01,NDC,outpatient,1,ML,4649.31,3254.517,AETNA [1000108],AETNA [100010801],,,76.8,,3570.67,24.19,6805.34016,percent of total billed charges,,,
METHYLPREDNISOLONE ACETATE 40 MG/ML IJ SUSP,RX-4995,CDM,J1030,HCPCS,636,RC,00009-3073-03,NDC,outpatient,1,ML,22.62,15.834,AETNA [1000108],AETNA [100010801],,,76.8,,17.37,5.07819,416.02,percent of total billed charges,,,
METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP,RX-4996,CDM,J1040,HCPCS,636,RC,70121-1574-01,NDC,outpatient,1,ML,25.95,18.165,AETNA [1000108],AETNA [100010801],,,76.8,,19.93,5.82353,416.02,percent of total billed charges,,,
METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP,RX-4996,CDM,J1040,HCPCS,636,RC,70121-1574-05,NDC,outpatient,1,ML,25.94,18.158,AETNA [1000108],AETNA [100010801],,,76.8,,19.92,5.82353,416.02,percent of total billed charges,,,
METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP,RX-4996,CDM,J1040,HCPCS,636,RC,00009-3475-03,NDC,outpatient,1,ML,34.96,24.472,AETNA [1000108],AETNA [100010801],,,76.8,,26.85,5.82353,416.02,percent of total billed charges,,,
TESTOSTERONE CYPIONATE 200 MG/ML IM SOLN,RX-7784,CDM,J1071,HCPCS,636,RC,00009-0417-01,NDC,outpatient,1,ML,41.92,29.344,AETNA [1000108],AETNA [100010801],,,76.8,,32.19,0.03,416.02,percent of total billed charges,,,
DEXAMETHASONE SOD PHOSPHATE PF 10 MG/ML IJ SOLN,RX-116345,CDM,J1100,HCPCS,636,RC,99999-0003-18,NDC,outpatient,1,ML,8.17,5.719,AETNA [1000108],AETNA [100010801],,,76.8,,6.27,0.11,416.02,percent of total billed charges,,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,63323-0165-01,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.11,416.02,percent of total billed charges,,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,67457-0423-12,NDC,outpatient,1,ML,3.69,2.583,AETNA [1000108],AETNA [100010801],,,76.8,,2.83,0.11,416.02,percent of total billed charges,,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,00641-6145-01,NDC,outpatient,1,ML,4.14,2.898,AETNA [1000108],AETNA [100010801],,,76.8,,3.18,0.11,416.02,percent of total billed charges,,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,00641-6145-25,NDC,outpatient,1,ML,4.14,2.898,AETNA [1000108],AETNA [100010801],,,76.8,,3.18,0.11,416.02,percent of total billed charges,,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,67457-0423-00,NDC,outpatient,1,ML,3.69,2.583,AETNA [1000108],AETNA [100010801],,,76.8,,2.83,0.11,416.02,percent of total billed charges,,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,55150-0237-01,NDC,outpatient,1,ML,4.01,2.807,AETNA [1000108],AETNA [100010801],,,76.8,,3.08,0.11,416.02,percent of total billed charges,,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,63323-0165-02,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.11,416.02,percent of total billed charges,,,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,00641-0367-21,NDC,outpatient,1,ML,6.11,4.277,AETNA [1000108],AETNA [100010801],,,76.8,,4.69,0.11,416.02,percent of total billed charges,,,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,70069-0021-25,NDC,outpatient,1,ML,8.17,5.719,AETNA [1000108],AETNA [100010801],,,76.8,,6.27,0.11,416.02,percent of total billed charges,,,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,63323-0506-01,NDC,outpatient,1,ML,6.99,4.893,AETNA [1000108],AETNA [100010801],,,76.8,,5.37,0.11,416.02,percent of total billed charges,,,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,70069-0021-01,NDC,outpatient,1,ML,8.17,5.719,AETNA [1000108],AETNA [100010801],,,76.8,,6.27,0.11,416.02,percent of total billed charges,,,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,00641-0367-25,NDC,outpatient,1,ML,6.11,4.277,AETNA [1000108],AETNA [100010801],,,76.8,,4.69,0.11,416.02,percent of total billed charges,,,
DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN,RX-9859,CDM,J1110,HCPCS,636,RC,81284-0411-00,NDC,outpatient,1,ML,179.49,125.643,AETNA [1000108],AETNA [100010801],,,76.8,,137.85,40.295505,416.02,percent of total billed charges,,,
DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN,RX-9859,CDM,J1110,HCPCS,636,RC,81284-0411-05,NDC,outpatient,1,ML,220.97,154.679,AETNA [1000108],AETNA [100010801],,,76.8,,169.7,40.295505,416.02,percent of total billed charges,,,
DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN,RX-9859,CDM,J1110,HCPCS,636,RC,81284-0411-10,NDC,outpatient,1,ML,179.49,125.643,AETNA [1000108],AETNA [100010801],,,76.8,,137.85,40.295505,416.02,percent of total billed charges,,,
ACETAZOLAMIDE SODIUM 500 MG IJ SOLR,RX-114,CDM,J1120,HCPCS,636,RC,00143-9503-01,NDC,outpatient,1,UN,178.94,125.258,AETNA [1000108],AETNA [100010801],,,76.8,,137.43,10.29108,416.02,percent of total billed charges,,,
ACETAZOLAMIDE SODIUM 500 MG IJ SOLR,RX-114,CDM,J1120,HCPCS,636,RC,23155-0313-31,NDC,outpatient,1,UN,45.84,32.088,AETNA [1000108],AETNA [100010801],,,76.8,,35.21,10.29108,416.02,percent of total billed charges,,,
ACETAZOLAMIDE SODIUM 500 MG IJ SOLR,RX-114,CDM,J1120,HCPCS,636,RC,67457-0853-50,NDC,outpatient,1,UN,164.43,115.101,AETNA [1000108],AETNA [100010801],,,76.8,,126.28,10.29108,416.02,percent of total billed charges,,,
DIGOXIN 0.25 MG/ML IJ SOLN,RX-2442,CDM,J1160,HCPCS,636,RC,00641-1410-31,NDC,outpatient,2,ML,14.62,10.234,AETNA [1000108],AETNA [100010801],,,76.8,,11.23,3.28219,416.02,percent of total billed charges,,,
DIGOXIN 0.25 MG/ML IJ SOLN,RX-2442,CDM,J1160,HCPCS,636,RC,00641-1410-35,NDC,outpatient,2,ML,14.62,10.234,AETNA [1000108],AETNA [100010801],,,76.8,,11.23,3.28219,416.02,percent of total billed charges,,,
DIGOXIN 0.1 MG/ML IJ SOLN,RX-9853,CDM,J1160,HCPCS,636,RC,70515-0263-10,NDC,outpatient,1,ML,449.39,314.573,AETNA [1000108],AETNA [100010801],,,76.8,,345.13,3.28219,416.02,percent of total billed charges,,,
DIGOXIN IMMUNE FAB 40 MG IV SOLR,RX-31432,CDM,J1162,HCPCS,636,RC,50633-0120-11,NDC,outpatient,1,UN,12197.8,8538.46,AETNA [1000108],AETNA [100010801],,,76.8,,9367.91,399.86,9367.9104,percent of total billed charges,,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,00641-0493-21,NDC,outpatient,2,ML,5.82,4.074,AETNA [1000108],AETNA [100010801],,,76.8,,4.47,0.44,416.02,percent of total billed charges,,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-10,NDC,outpatient,2,ML,10.45,7.315,AETNA [1000108],AETNA [100010801],,,76.8,,8.03,0.44,416.02,percent of total billed charges,,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-02,NDC,outpatient,2,ML,10.45,7.315,AETNA [1000108],AETNA [100010801],,,76.8,,8.03,0.44,416.02,percent of total billed charges,,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-30,NDC,outpatient,5,ML,10.7,7.49,AETNA [1000108],AETNA [100010801],,,76.8,,8.22,0.44,416.02,percent of total billed charges,,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,00641-0493-25,NDC,outpatient,2,ML,5.82,4.074,AETNA [1000108],AETNA [100010801],,,76.8,,4.47,0.44,416.02,percent of total billed charges,,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-05,NDC,outpatient,5,ML,10.7,7.49,AETNA [1000108],AETNA [100010801],,,76.8,,8.22,0.44,416.02,percent of total billed charges,,,
HYDROMORPHONE HCL PF 10 MG/ML IJ SOLN,RX-116809,CDM,J1170,HCPCS,636,RC,00703-0113-03,NDC,outpatient,10,ML,44.91,31.437,AETNA [1000108],AETNA [100010801],,,76.8,,34.49,2.507665,416.02,percent of total billed charges,,,
HYDROMORPHONE HCL PF 10 MG/ML IJ SOLN,RX-116809,CDM,J1170,HCPCS,636,RC,00703-0113-01,NDC,outpatient,10,ML,44.91,31.437,AETNA [1000108],AETNA [100010801],,,76.8,,34.49,2.507665,416.02,percent of total billed charges,,,
HYDROMORPHONE HCL PF 10 MG/ML IJ SOLN,RX-116809,CDM,J1170,HCPCS,636,RC,00409-2634-25,NDC,outpatient,10,ML,71.61,50.127,AETNA [1000108],AETNA [100010801],,,76.8,,55,2.507665,416.02,percent of total billed charges,,,
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,00409-1283-03,NDC,outpatient,1,ML,11.43,8.001,AETNA [1000108],AETNA [100010801],,,76.8,,8.78,2.507665,416.02,percent of total billed charges,,,
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,76045-0009-96,NDC,outpatient,0.5,ML,12.4,8.68,AETNA [1000108],AETNA [100010801],,,76.8,,9.52,2.507665,416.02,percent of total billed charges,,,
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,00409-1283-31,NDC,outpatient,1,ML,11.43,8.001,AETNA [1000108],AETNA [100010801],,,76.8,,8.78,2.507665,416.02,percent of total billed charges,,,
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,76045-0009-01,NDC,outpatient,1,ML,11.73,8.211,AETNA [1000108],AETNA [100010801],,,76.8,,9.01,2.507665,416.02,percent of total billed charges,,,
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,76045-0009-06,NDC,outpatient,0.5,ML,12.4,8.68,AETNA [1000108],AETNA [100010801],,,76.8,,9.52,2.507665,416.02,percent of total billed charges,,,
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,76045-0009-11,NDC,outpatient,1,ML,11.73,8.211,AETNA [1000108],AETNA [100010801],,,76.8,,9.01,2.507665,416.02,percent of total billed charges,,,
HYDROMORPHONE HCL 2 MG/ML IJ SOLN,RX-3758,CDM,J1170,HCPCS,636,RC,00641-6151-01,NDC,outpatient,1,ML,11.17,7.819,AETNA [1000108],AETNA [100010801],,,76.8,,8.58,2.507665,416.02,percent of total billed charges,,,
HYDROMORPHONE HCL 2 MG/ML IJ SOLN,RX-3758,CDM,J1170,HCPCS,636,RC,00641-6151-25,NDC,outpatient,1,ML,11.17,7.819,AETNA [1000108],AETNA [100010801],,,76.8,,8.58,2.507665,416.02,percent of total billed charges,,,
CONC DILAUDID 10 MG/ML PCA,RX-4080160,CDM,J1170,HCPCS,636,RC,99999-0000-95,NDC,outpatient,50,ML,267.65,187.355,AETNA [1000108],AETNA [100010801],,,76.8,,205.56,2.507665,416.02,percent of total billed charges,,,
DEXRAZOXANE HCL 500 MG IV SOLR,RX-146172,CDM,J1190,HCPCS,636,RC,51991-0942-98,NDC,outpatient,1,UN,575.66,402.962,AETNA [1000108],AETNA [100010801],,,76.8,,442.11,87.49,442.10688,percent of total billed charges,,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-01,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.74534,416.02,percent of total billed charges,,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,00641-0376-21,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.74534,416.02,percent of total billed charges,,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-00,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.74534,416.02,percent of total billed charges,,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-16,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.74534,416.02,percent of total billed charges,,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,00641-0376-25,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.74534,416.02,percent of total billed charges,,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-41,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.74534,416.02,percent of total billed charges,,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,72485-0101-01,NDC,outpatient,1,ML,4.75,3.325,AETNA [1000108],AETNA [100010801],,,76.8,,3.65,0.74534,416.02,percent of total billed charges,,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,72485-0101-25,NDC,outpatient,1,ML,4.75,3.325,AETNA [1000108],AETNA [100010801],,,76.8,,3.65,0.74534,416.02,percent of total billed charges,,,
CHLOROTHIAZIDE SODIUM 500 MG IV SOLR,RX-9526,CDM,J1205,HCPCS,636,RC,25021-0305-20,NDC,outpatient,1,UN,139.6,97.72,AETNA [1000108],AETNA [100010801],,,76.8,,107.21,31.3402,416.02,percent of total billed charges,,,
DIMETHYL SULFOXIDE 50 % IS SOLN,RX-9873,CDM,J1212,HCPCS,636,RC,67457-0177-50,NDC,outpatient,50,ML,1852.55,1296.785,AETNA [1000108],AETNA [100010801],,,76.8,,1422.76,399.86,1422.7584,percent of total billed charges,,,
METHADONE HCL 10 MG/ML IJ SOLN,RX-10546,CDM,J1230,HCPCS,636,RC,67457-0217-20,NDC,outpatient,20,ML,869.71,608.797,AETNA [1000108],AETNA [100010801],,,76.8,,667.94,9.763505,945.2928,percent of total billed charges,,,
METHADONE HCL 10 MG/ML IJ SOLN,RX-10546,CDM,J1230,HCPCS,636,RC,99999-0000-89,NDC,outpatient,1,ML,43.49,30.443,AETNA [1000108],AETNA [100010801],,,76.8,,33.4,9.763505,945.2928,percent of total billed charges,,,
METHADONE 10 MG/ML PCA,RX-4080162,CDM,J1230,HCPCS,636,RC,99999-0000-13,NDC,outpatient,50,ML,1230.85,861.595,AETNA [1000108],AETNA [100010801],,,76.8,,945.29,9.763505,945.2928,percent of total billed charges,,,
METHADONE 1 MG/ML IV INFUSION PREMIX,RX-4080178,CDM,J1230,HCPCS,636,RC,99999-0000-27,NDC,outpatient,200,ML,874.19,611.933,AETNA [1000108],AETNA [100010801],,,76.8,,671.38,9.763505,945.2928,percent of total billed charges,,,
DIPYRIDAMOLE 5 MG/ML IV SOLN,RX-9891,CDM,J1245,HCPCS,636,RC,00641-2569-44,NDC,outpatient,10,ML,75.79,53.053,AETNA [1000108],AETNA [100010801],,,76.8,,58.21,3.78,416.02,percent of total billed charges,,,
DIPYRIDAMOLE 5 MG/ML IV SOLN,RX-9891,CDM,J1245,HCPCS,636,RC,00641-2569-41,NDC,outpatient,10,ML,75.79,53.053,AETNA [1000108],AETNA [100010801],,,76.8,,58.21,3.78,416.02,percent of total billed charges,,,
DOBUTAMINE-DEXTROSE 1-5 MG/ML-% IV SOLN,RX-18314,CDM,J1250,HCPCS,636,RC,00338-1073-02,NDC,outpatient,250,ML,38.25,26.775,AETNA [1000108],AETNA [100010801],,,76.8,,29.38,4.15774,416.02,percent of total billed charges,,,
DOBUTAMINE-DEXTROSE 1-5 MG/ML-% IV SOLN,RX-18314,CDM,J1250,HCPCS,636,RC,00409-2346-32,NDC,outpatient,250,ML,52.72,36.904,AETNA [1000108],AETNA [100010801],,,76.8,,40.49,4.15774,416.02,percent of total billed charges,,,
DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN,RX-18315,CDM,J1250,HCPCS,636,RC,00338-1075-02,NDC,outpatient,250,ML,52.72,36.904,AETNA [1000108],AETNA [100010801],,,76.8,,40.49,4.15774,416.02,percent of total billed charges,,,
DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN,RX-18315,CDM,J1250,HCPCS,636,RC,00409-2347-31,NDC,outpatient,250,ML,72.74,50.918,AETNA [1000108],AETNA [100010801],,,76.8,,55.86,4.15774,416.02,percent of total billed charges,,,
DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN,RX-18315,CDM,J1250,HCPCS,636,RC,00409-2347-32,NDC,outpatient,250,ML,72.74,50.918,AETNA [1000108],AETNA [100010801],,,76.8,,55.86,4.15774,416.02,percent of total billed charges,,,
DOBUTAMINE 50 MG IN D5W 50 ML SYRINGE FROM PREMIX BAG (NEO/PED),RX-4081532,CDM,J1250,HCPCS,636,RC,99999-0004-34,NDC,outpatient,50,ML,24.49,17.143,AETNA [1000108],AETNA [100010801],,,76.8,,18.81,4.15774,416.02,percent of total billed charges,,,
DOBUTAMINE HCL 250 MG/20ML IV SOLN,RX-77318,CDM,J1250,HCPCS,636,RC,00143-9141-10,NDC,outpatient,20,ML,18.52,12.964,AETNA [1000108],AETNA [100010801],,,76.8,,14.22,4.15774,416.02,percent of total billed charges,,,
DOBUTAMINE HCL 250 MG/20ML IV SOLN,RX-77318,CDM,J1250,HCPCS,636,RC,00409-2344-01,NDC,outpatient,20,ML,27.59,19.313,AETNA [1000108],AETNA [100010801],,,76.8,,21.19,4.15774,416.02,percent of total billed charges,,,
DOBUTAMINE HCL 250 MG/20ML IV SOLN,RX-77318,CDM,J1250,HCPCS,636,RC,00143-9141-01,NDC,outpatient,20,ML,18.52,12.964,AETNA [1000108],AETNA [100010801],,,76.8,,14.22,4.15774,416.02,percent of total billed charges,,,
DOPAMINE-DEXTROSE 0.8-5 MG/ML-% IV SOLN,RX-14844,CDM,J1265,HCPCS,636,RC,00338-1005-02,NDC,outpatient,250,ML,41.59,29.113,AETNA [1000108],AETNA [100010801],,,76.8,,31.94,0.7,416.02,percent of total billed charges,,,
DOPAMINE-DEXTROSE 1.6-5 MG/ML-% IV SOLN,RX-14845,CDM,J1265,HCPCS,636,RC,00409-7809-11,NDC,outpatient,250,ML,50.49,35.343,AETNA [1000108],AETNA [100010801],,,76.8,,38.78,0.7,416.02,percent of total billed charges,,,
DOPAMINE-DEXTROSE 1.6-5 MG/ML-% IV SOLN,RX-14845,CDM,J1265,HCPCS,636,RC,00338-1007-02,NDC,outpatient,250,ML,48.27,33.789,AETNA [1000108],AETNA [100010801],,,76.8,,37.07,0.7,416.02,percent of total billed charges,,,
DOPAMINE-DEXTROSE 1.6-5 MG/ML-% IV SOLN,RX-14845,CDM,J1265,HCPCS,636,RC,00409-7809-22,NDC,outpatient,250,ML,50.49,35.343,AETNA [1000108],AETNA [100010801],,,76.8,,38.78,0.7,416.02,percent of total billed charges,,,
DOPAMINE HCL 40 MG/ML IV SOLN,RX-2595,CDM,J1265,HCPCS,636,RC,00409-9104-21,NDC,outpatient,10,ML,13.16,9.212,AETNA [1000108],AETNA [100010801],,,76.8,,10.11,0.7,416.02,percent of total billed charges,,,
DOPAMINE HCL 40 MG/ML IV SOLN,RX-2595,CDM,J1265,HCPCS,636,RC,00409-9104-20,NDC,outpatient,10,ML,13.16,9.212,AETNA [1000108],AETNA [100010801],,,76.8,,10.11,0.7,416.02,percent of total billed charges,,,
DOPAMINE 40 MG IN D5W 50 ML SYRINGE FROM PREMIX BAG (NEO/PED),RX-4081531,CDM,J1265,HCPCS,636,RC,99999-0004-33,NDC,outpatient,50,ML,21.92,15.344,AETNA [1000108],AETNA [100010801],,,76.8,,16.83,0.7,416.02,percent of total billed charges,,,
ECULIZUMAB 300 MG/30ML IV SOLN,RX-81696,CDM,J1300,HCPCS,636,RC,25682-0001-01,NDC,outpatient,30,ML,18003.46,12602.422,AETNA [1000108],AETNA [100010801],,,76.8,,13826.66,224.63,13826.65728,percent of total billed charges,,,
VELETRI 1.5 MG IV SOLR,RX-106514,CDM,J1325,HCPCS,636,RC,66215-0402-01,NDC,outpatient,1,UN,260.55,182.385,AETNA [1000108],AETNA [100010801],,,76.8,,200.1,15.86,416.02,percent of total billed charges,,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,16714-0889-10,NDC,outpatient,1,UN,129.15,90.405,AETNA [1000108],AETNA [100010801],,,76.8,,99.19,10.42,416.02,percent of total billed charges,,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,60505-6196-04,NDC,outpatient,1,UN,127.17,89.019,AETNA [1000108],AETNA [100010801],,,76.8,,97.67,10.42,416.02,percent of total billed charges,,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00409-3510-21,NDC,outpatient,1,UN,135.69,94.983,AETNA [1000108],AETNA [100010801],,,76.8,,104.21,10.42,416.02,percent of total billed charges,,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,16714-0889-01,NDC,outpatient,1,UN,129.15,90.405,AETNA [1000108],AETNA [100010801],,,76.8,,99.19,10.42,416.02,percent of total billed charges,,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00143-9398-10,NDC,outpatient,1,UN,100.74,70.518,AETNA [1000108],AETNA [100010801],,,76.8,,77.37,10.42,416.02,percent of total billed charges,,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,42023-0221-01,NDC,outpatient,1,UN,95.49,66.843,AETNA [1000108],AETNA [100010801],,,76.8,,73.34,10.42,416.02,percent of total billed charges,,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,42023-0221-10,NDC,outpatient,1,UN,95.49,66.843,AETNA [1000108],AETNA [100010801],,,76.8,,73.34,10.42,416.02,percent of total billed charges,,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00143-9398-01,NDC,outpatient,1,UN,100.74,70.518,AETNA [1000108],AETNA [100010801],,,76.8,,77.37,10.42,416.02,percent of total billed charges,,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00409-3510-22,NDC,outpatient,1,UN,135.69,94.983,AETNA [1000108],AETNA [100010801],,,76.8,,104.21,10.42,416.02,percent of total billed charges,,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,55150-0282-20,NDC,outpatient,1,UN,111.68,78.176,AETNA [1000108],AETNA [100010801],,,76.8,,85.77,10.42,416.02,percent of total billed charges,,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,60505-6196-00,NDC,outpatient,1,UN,127.17,89.019,AETNA [1000108],AETNA [100010801],,,76.8,,97.67,10.42,416.02,percent of total billed charges,,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00409-3510-21,NDC,outpatient,1,UN,135.69,94.983,AETNA [1000108],AETNA [100010801],,,76.8,,104.21,10.42,416.02,percent of total billed charges,,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,42023-0221-01,NDC,outpatient,1,UN,95.49,66.843,AETNA [1000108],AETNA [100010801],,,76.8,,73.34,10.42,416.02,percent of total billed charges,,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,60505-6196-00,NDC,outpatient,1,UN,127.17,89.019,AETNA [1000108],AETNA [100010801],,,76.8,,97.67,10.42,416.02,percent of total billed charges,,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00143-9398-10,NDC,outpatient,1,UN,100.74,70.518,AETNA [1000108],AETNA [100010801],,,76.8,,77.37,10.42,416.02,percent of total billed charges,,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00409-3510-22,NDC,outpatient,1,UN,135.69,94.983,AETNA [1000108],AETNA [100010801],,,76.8,,104.21,10.42,416.02,percent of total billed charges,,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00143-9398-01,NDC,outpatient,1,UN,100.74,70.518,AETNA [1000108],AETNA [100010801],,,76.8,,77.37,10.42,416.02,percent of total billed charges,,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,16714-0889-01,NDC,outpatient,1,UN,129.15,90.405,AETNA [1000108],AETNA [100010801],,,76.8,,99.19,10.42,416.02,percent of total billed charges,,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,55150-0282-20,NDC,outpatient,1,UN,111.68,78.176,AETNA [1000108],AETNA [100010801],,,76.8,,85.77,10.42,416.02,percent of total billed charges,,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,60505-6196-04,NDC,outpatient,1,UN,127.17,89.019,AETNA [1000108],AETNA [100010801],,,76.8,,97.67,10.42,416.02,percent of total billed charges,,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,16714-0889-10,NDC,outpatient,1,UN,129.15,90.405,AETNA [1000108],AETNA [100010801],,,76.8,,99.19,10.42,416.02,percent of total billed charges,,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,42023-0221-10,NDC,outpatient,1,UN,95.49,66.843,AETNA [1000108],AETNA [100010801],,,76.8,,73.34,10.42,416.02,percent of total billed charges,,,
ERYTHROMYCIN LACTOBIONATE 500 MG IV SOLR,RX-2903,CDM,J1364,HCPCS,636,RC,00409-6482-01,NDC,outpatient,1,UN,236.03,165.221,AETNA [1000108],AETNA [100010801],,,76.8,,181.27,52.988735,416.02,percent of total billed charges,,,
ERYTHROMYCIN LACTOBIONATE 500 MG IV SOLR,RX-2903,CDM,J1364,HCPCS,636,RC,00409-6482-11,NDC,outpatient,1,UN,236.03,165.221,AETNA [1000108],AETNA [100010801],,,76.8,,181.27,52.988735,416.02,percent of total billed charges,,,
ESTROGENS CONJUGATED 25 MG IJ SOLR,RX-9972,CDM,J1410,HCPCS,636,RC,00046-0749-05,NDC,outpatient,1,UN,1513.36,1059.352,AETNA [1000108],AETNA [100010801],,,76.8,,1162.26,339.74932,1162.26048,percent of total billed charges,,,
FERRIC CARBOXYMALTOSE 750 MG/15ML IV SOLN,RX-122648,CDM,J1439,HCPCS,636,RC,00517-0650-01,NDC,outpatient,15,ML,2478.29,1734.803,AETNA [1000108],AETNA [100010801],,,76.8,,1903.33,1.1,1903.32672,percent of total billed charges,,,
FLUCONAZOLE IN SODIUM CHLORIDE 200-0.9 MG/100ML-% IV SOLN,RX-10049,CDM,J1450,HCPCS,636,RC,25021-0184-82,NDC,outpatient,100,ML,36.03,25.221,AETNA [1000108],AETNA [100010801],,,76.8,,27.67,2.61,416.02,percent of total billed charges,,,
FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN,RX-10050,CDM,J1450,HCPCS,636,RC,00409-4688-12,NDC,outpatient,200,ML,35.54,24.878,AETNA [1000108],AETNA [100010801],,,76.8,,27.29,2.61,416.02,percent of total billed charges,,,
FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN,RX-10050,CDM,J1450,HCPCS,636,RC,00409-4688-16,NDC,outpatient,200,ML,35.54,24.878,AETNA [1000108],AETNA [100010801],,,76.8,,27.29,2.61,416.02,percent of total billed charges,,,
FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN,RX-10050,CDM,J1450,HCPCS,636,RC,69784-0003-06,NDC,outpatient,200,ML,35.58,24.906,AETNA [1000108],AETNA [100010801],,,76.8,,27.33,2.61,416.02,percent of total billed charges,,,
FLUCONAZOLE IVPB,RX-4080630,CDM,J1450,HCPCS,636,RC,99999-0001-23,NDC,outpatient,50,ML,23.46,16.422,AETNA [1000108],AETNA [100010801],,,76.8,,18.02,2.61,416.02,percent of total billed charges,,,
FOMEPIZOLE 1 GM/ML IV SOLN,RX-22185,CDM,J1451,HCPCS,636,RC,67457-0211-02,NDC,outpatient,1.5,ML,1680.9,1176.63,AETNA [1000108],AETNA [100010801],,,76.8,,1290.93,7.3781655,1590,percent of total billed charges,,,
FOMEPIZOLE 1 GM/ML IV SOLN,RX-22185,CDM,J1451,HCPCS,636,RC,70710-1478-01,NDC,outpatient,1.5,ML,2014.79,1410.353,AETNA [1000108],AETNA [100010801],,,76.8,,1547.36,7.3781655,1590,percent of total billed charges,,,
FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR,RX-106783,CDM,J1453,HCPCS,636,RC,00006-3061-00,NDC,outpatient,1,UN,1375.94,963.158,AETNA [1000108],AETNA [100010801],,,76.8,,1056.72,0.14,1056.72192,percent of total billed charges,,,
FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR,RX-106783,CDM,J1453,HCPCS,636,RC,00006-3061-01,NDC,outpatient,1,UN,1375.94,963.158,AETNA [1000108],AETNA [100010801],,,76.8,,1056.72,0.14,1056.72192,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0439-93,NDC,outpatient,400,ML,10769.52,7538.664,AETNA [1000108],AETNA [100010801],,,76.8,,8270.99,47.99,8270.99136,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0436-05,NDC,outpatient,100,ML,2692.38,1884.666,AETNA [1000108],AETNA [100010801],,,76.8,,2067.75,47.99,8270.99136,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0436-90,NDC,outpatient,100,ML,2692.38,1884.666,AETNA [1000108],AETNA [100010801],,,76.8,,2067.75,47.99,8270.99136,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0438-20,NDC,outpatient,200,ML,5384.76,3769.332,AETNA [1000108],AETNA [100010801],,,76.8,,4135.5,47.99,8270.99136,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0437-10,NDC,outpatient,100,ML,2692.38,1884.666,AETNA [1000108],AETNA [100010801],,,76.8,,2067.75,47.99,8270.99136,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0437-91,NDC,outpatient,100,ML,2692.38,1884.666,AETNA [1000108],AETNA [100010801],,,76.8,,2067.75,47.99,8270.99136,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0439-40,NDC,outpatient,400,ML,10769.52,7538.664,AETNA [1000108],AETNA [100010801],,,76.8,,8270.99,47.99,8270.99136,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) IM INJ,RX-15342,CDM,J1460,HCPCS,636,RC,13533-0335-04,NDC,outpatient,2,ML,422.8,295.96,AETNA [1000108],AETNA [100010801],,,76.8,,324.71,48.47,416.02,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) IM INJ,RX-15342,CDM,J1460,HCPCS,636,RC,13533-0335-40,NDC,outpatient,2,ML,422.8,295.96,AETNA [1000108],AETNA [100010801],,,76.8,,324.71,48.47,416.02,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-41,NDC,outpatient,400,ML,8399.24,5879.468,AETNA [1000108],AETNA [100010801],,,76.8,,6450.62,48.81,6450.61632,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-72,NDC,outpatient,100,ML,2099.81,1469.867,AETNA [1000108],AETNA [100010801],,,76.8,,1612.65,48.81,6450.61632,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-20,NDC,outpatient,100,ML,2099.81,1469.867,AETNA [1000108],AETNA [100010801],,,76.8,,1612.65,48.81,6450.61632,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-24,NDC,outpatient,200,ML,4199.62,2939.734,AETNA [1000108],AETNA [100010801],,,76.8,,3225.31,48.81,6450.61632,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-21,NDC,outpatient,100,ML,2099.81,1469.867,AETNA [1000108],AETNA [100010801],,,76.8,,1612.65,48.81,6450.61632,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-25,NDC,outpatient,200,ML,4199.62,2939.734,AETNA [1000108],AETNA [100010801],,,76.8,,3225.31,48.81,6450.61632,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-40,NDC,outpatient,400,ML,8399.24,5879.468,AETNA [1000108],AETNA [100010801],,,76.8,,6450.62,48.81,6450.61632,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-71,NDC,outpatient,100,ML,2099.81,1469.867,AETNA [1000108],AETNA [100010801],,,76.8,,1612.65,48.81,6450.61632,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD S/D  5 % IGA <=2.2,RX-4080223,CDM,J1566,HCPCS,636,RC,00944-2620-03,NDC,outpatient,5,GR,934.5,654.15,AETNA [1000108],AETNA [100010801],,,76.8,,717.7,77.77,1531.4,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD S/D  5 % IGA <= 1,RX-4080224,CDM,J1566,HCPCS,636,RC,00944-2658-04,NDC,outpatient,10,GR,1154.96,808.472,AETNA [1000108],AETNA [100010801],,,76.8,,887.01,77.77,1531.4,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD S/D  5 % IGA <= 1,RX-4080224,CDM,J1566,HCPCS,636,RC,00944-2656-03,NDC,outpatient,5,GR,577.48,404.236,AETNA [1000108],AETNA [100010801],,,76.8,,443.5,77.77,1531.4,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) OCTAGAM 5 % IV SOLN,RX-4080225,CDM,J1568,HCPCS,636,RC,68209-0843-04,NDC,outpatient,200,ML,1884.53,1319.171,AETNA [1000108],AETNA [100010801],,,76.8,,1447.32,44.12,1447.31904,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) OCTAGAM 5 % IV SOLN,RX-4080225,CDM,J1568,HCPCS,636,RC,68209-0843-03,NDC,outpatient,200,ML,1884.53,1319.171,AETNA [1000108],AETNA [100010801],,,76.8,,1447.32,44.12,1447.31904,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-09,NDC,outpatient,100,ML,2726.33,1908.431,AETNA [1000108],AETNA [100010801],,,76.8,,2093.82,46.03,6281.46432,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-11,NDC,outpatient,100,ML,2726.33,1908.431,AETNA [1000108],AETNA [100010801],,,76.8,,2093.82,46.03,6281.46432,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-12,NDC,outpatient,200,ML,5452.66,3816.862,AETNA [1000108],AETNA [100010801],,,76.8,,4187.64,46.03,6281.46432,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-04,NDC,outpatient,100,ML,2726.33,1908.431,AETNA [1000108],AETNA [100010801],,,76.8,,2093.82,46.03,6281.46432,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-02,NDC,outpatient,100,ML,2726.33,1908.431,AETNA [1000108],AETNA [100010801],,,76.8,,2093.82,46.03,6281.46432,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-05,NDC,outpatient,100,ML,2726.33,1908.431,AETNA [1000108],AETNA [100010801],,,76.8,,2093.82,46.03,6281.46432,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-07,NDC,outpatient,300,ML,8178.99,5725.293,AETNA [1000108],AETNA [100010801],,,76.8,,6281.46,46.03,6281.46432,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-08,NDC,outpatient,100,ML,2726.33,1908.431,AETNA [1000108],AETNA [100010801],,,76.8,,2093.82,46.03,6281.46432,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-13,NDC,outpatient,300,ML,8178.99,5725.293,AETNA [1000108],AETNA [100010801],,,76.8,,6281.46,46.03,6281.46432,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-03,NDC,outpatient,100,ML,2726.33,1908.431,AETNA [1000108],AETNA [100010801],,,76.8,,2093.82,46.03,6281.46432,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-06,NDC,outpatient,200,ML,5452.66,3816.862,AETNA [1000108],AETNA [100010801],,,76.8,,4187.64,46.03,6281.46432,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-10,NDC,outpatient,100,ML,2726.33,1908.431,AETNA [1000108],AETNA [100010801],,,76.8,,2093.82,46.03,6281.46432,percent of total billed charges,,,
GANCICLOVIR SODIUM 500 MG IV SOLR,RX-10101,CDM,J1570,HCPCS,636,RC,70436-0089-55,NDC,outpatient,1,UN,165.87,116.109,AETNA [1000108],AETNA [100010801],,,76.8,,127.39,36.41,416.02,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-03,NDC,outpatient,200,ML,2125.2,1487.64,AETNA [1000108],AETNA [100010801],,,76.8,,1632.15,48.52,3264.3072,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-04,NDC,outpatient,200,ML,2125.2,1487.64,AETNA [1000108],AETNA [100010801],,,76.8,,1632.15,48.52,3264.3072,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-00,NDC,outpatient,400,ML,4250.4,2975.28,AETNA [1000108],AETNA [100010801],,,76.8,,3264.31,48.52,3264.3072,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-08,NDC,outpatient,200,ML,2125.2,1487.64,AETNA [1000108],AETNA [100010801],,,76.8,,1632.15,48.52,3264.3072,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-05,NDC,outpatient,400,ML,4250.4,2975.28,AETNA [1000108],AETNA [100010801],,,76.8,,3264.31,48.52,3264.3072,percent of total billed charges,,,
GENTAMICIN 80 MG IN NS 50 ML IV SOLN PREMIX,RX-15911,CDM,J1580,HCPCS,636,RC,99999-0002-93,NDC,outpatient,50,ML,25.25,17.675,AETNA [1000108],AETNA [100010801],,,76.8,,19.39,1.23924,416.02,percent of total billed charges,,,
GENTAMICIN 80 MG IN NS 50 ML IV SOLN PREMIX,RX-15911,CDM,J1580,HCPCS,636,RC,00338-0509-41,NDC,outpatient,50,ML,25,17.5,AETNA [1000108],AETNA [100010801],,,76.8,,19.2,1.23924,416.02,percent of total billed charges,,,
GENTAMICIN SULFATE 10 MG/ML IJ SOLN,RX-3425,CDM,J1580,HCPCS,636,RC,63323-0173-01,NDC,outpatient,2,ML,9.88,6.916,AETNA [1000108],AETNA [100010801],,,76.8,,7.59,1.23924,416.02,percent of total billed charges,,,
GENTAMICIN SULFATE 10 MG/ML IJ SOLN,RX-3425,CDM,J1580,HCPCS,636,RC,63323-0173-02,NDC,outpatient,2,ML,9.88,6.916,AETNA [1000108],AETNA [100010801],,,76.8,,7.59,1.23924,416.02,percent of total billed charges,,,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,00409-1207-03,NDC,outpatient,2,ML,12.55,8.785,AETNA [1000108],AETNA [100010801],,,76.8,,9.64,1.23924,416.02,percent of total billed charges,,,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-20,NDC,outpatient,20,ML,102.62,71.834,AETNA [1000108],AETNA [100010801],,,76.8,,78.81,1.23924,416.02,percent of total billed charges,,,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-01,NDC,outpatient,2,ML,5.52,3.864,AETNA [1000108],AETNA [100010801],,,76.8,,4.24,1.23924,416.02,percent of total billed charges,,,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-02,NDC,outpatient,2,ML,5.52,3.864,AETNA [1000108],AETNA [100010801],,,76.8,,4.24,1.23924,416.02,percent of total billed charges,,,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,00409-1207-13,NDC,outpatient,2,ML,12.55,8.785,AETNA [1000108],AETNA [100010801],,,76.8,,9.64,1.23924,416.02,percent of total billed charges,,,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-03,NDC,outpatient,20,ML,102.62,71.834,AETNA [1000108],AETNA [100010801],,,76.8,,78.81,1.23924,416.02,percent of total billed charges,,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,70121-1394-01,NDC,outpatient,1,ML,17.13,11.991,AETNA [1000108],AETNA [100010801],,,76.8,,13.16,0.51,416.02,percent of total billed charges,,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,00143-9682-25,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.51,416.02,percent of total billed charges,,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,16714-0536-01,NDC,outpatient,1,ML,5.69,3.983,AETNA [1000108],AETNA [100010801],,,76.8,,4.37,0.51,416.02,percent of total billed charges,,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,16714-0536-25,NDC,outpatient,1,ML,5.69,3.983,AETNA [1000108],AETNA [100010801],,,76.8,,4.37,0.51,416.02,percent of total billed charges,,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,71288-0414-01,NDC,outpatient,1,ML,4.37,3.059,AETNA [1000108],AETNA [100010801],,,76.8,,3.36,0.51,416.02,percent of total billed charges,,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,00143-9682-01,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.51,416.02,percent of total billed charges,,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,71288-0414-03,NDC,outpatient,1,ML,4.37,3.059,AETNA [1000108],AETNA [100010801],,,76.8,,3.36,0.51,416.02,percent of total billed charges,,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,00517-4601-25,NDC,outpatient,1,ML,7.56,5.292,AETNA [1000108],AETNA [100010801],,,76.8,,5.81,0.51,416.02,percent of total billed charges,,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,70121-1394-05,NDC,outpatient,1,ML,17.13,11.991,AETNA [1000108],AETNA [100010801],,,76.8,,13.16,0.51,416.02,percent of total billed charges,,,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00548-5850-00,NDC,outpatient,1,UN,754.5,528.15,AETNA [1000108],AETNA [100010801],,,76.8,,579.46,90.641875,579.456,percent of total billed charges,,,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00597-0053-01,NDC,outpatient,1,UN,403.75,282.625,AETNA [1000108],AETNA [100010801],,,76.8,,310.08,90.641875,579.456,percent of total billed charges,,,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00597-0053-45,NDC,outpatient,1,UN,403.75,282.625,AETNA [1000108],AETNA [100010801],,,76.8,,310.08,90.641875,579.456,percent of total billed charges,,,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00597-0260-10,NDC,outpatient,1,UN,403.75,282.625,AETNA [1000108],AETNA [100010801],,,76.8,,310.08,90.641875,579.456,percent of total billed charges,,,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1611,HCPCS,636,RC,63323-0596-11,NDC,outpatient,1,UN,610.61,427.427,AETNA [1000108],AETNA [100010801],,,76.8,,468.95,101.41,468.94848,percent of total billed charges,,,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1611,HCPCS,636,RC,63323-0596-13,NDC,outpatient,1,UN,610.61,427.427,AETNA [1000108],AETNA [100010801],,,76.8,,468.95,101.41,468.94848,percent of total billed charges,,,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1611,HCPCS,636,RC,63323-0593-03,NDC,outpatient,1,UN,610.59,427.413,AETNA [1000108],AETNA [100010801],,,76.8,,468.93,101.41,468.94848,percent of total billed charges,,,
GRANISETRON HCL 1 MG/ML IV SOLN,RX-12552,CDM,J1626,HCPCS,636,RC,00143-9744-01,NDC,outpatient,1,ML,11.46,8.022,AETNA [1000108],AETNA [100010801],,,76.8,,8.8,0.28,416.02,percent of total billed charges,,,
GRANISETRON HCL 1 MG/ML IV SOLN,RX-12552,CDM,J1626,HCPCS,636,RC,00143-9744-10,NDC,outpatient,1,ML,11.46,8.022,AETNA [1000108],AETNA [100010801],,,76.8,,8.8,0.28,416.02,percent of total billed charges,,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,67457-0426-00,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.74534,416.02,percent of total billed charges,,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,76045-0737-10,NDC,outpatient,1,ML,15.64,10.948,AETNA [1000108],AETNA [100010801],,,76.8,,12.01,0.74534,416.02,percent of total billed charges,,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,00143-9501-01,NDC,outpatient,1,ML,7.22,5.054,AETNA [1000108],AETNA [100010801],,,76.8,,5.54,0.74534,416.02,percent of total billed charges,,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,00143-9501-25,NDC,outpatient,1,ML,7.22,5.054,AETNA [1000108],AETNA [100010801],,,76.8,,5.54,0.74534,416.02,percent of total billed charges,,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,63323-0474-00,NDC,outpatient,1,ML,3.76,2.632,AETNA [1000108],AETNA [100010801],,,76.8,,2.89,0.74534,416.02,percent of total billed charges,,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,76045-0737-01,NDC,outpatient,1,ML,15.64,10.948,AETNA [1000108],AETNA [100010801],,,76.8,,12.01,0.74534,416.02,percent of total billed charges,,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,63323-0474-01,NDC,outpatient,1,ML,3.76,2.632,AETNA [1000108],AETNA [100010801],,,76.8,,2.89,0.74534,416.02,percent of total billed charges,,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,67457-0426-12,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.74534,416.02,percent of total billed charges,,,
HEPARIN LOCK FLUSH 100 UNIT/ML IV SOLN WRAPPER,RX-4080200,CDM,J1642,HCPCS,636,RC,08290-3064-24,NDC,outpatient,5,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.02,416.02,percent of total billed charges,,,
HEPARIN LOCK FLUSH 100 UNIT/ML IV SOLN WRAPPER,RX-4080200,CDM,J1642,HCPCS,636,RC,64253-0333-35,NDC,outpatient,5,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.02,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,00409-2720-31,NDC,outpatient,10,ML,15.99,11.193,AETNA [1000108],AETNA [100010801],,,76.8,,12.28,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0276-02,NDC,outpatient,2,ML,21.8,15.26,AETNA [1000108],AETNA [100010801],,,76.8,,16.74,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-15,NDC,outpatient,10,ML,18.71,13.097,AETNA [1000108],AETNA [100010801],,,76.8,,14.37,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,71288-0400-02,NDC,outpatient,2,ML,19.86,13.902,AETNA [1000108],AETNA [100010801],,,76.8,,15.25,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,71288-0400-03,NDC,outpatient,2,ML,19.86,13.902,AETNA [1000108],AETNA [100010801],,,76.8,,15.25,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,00409-2720-02,NDC,outpatient,10,ML,15.99,11.193,AETNA [1000108],AETNA [100010801],,,76.8,,12.28,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-05,NDC,outpatient,10,ML,18.71,13.097,AETNA [1000108],AETNA [100010801],,,76.8,,14.37,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0920-11,NDC,outpatient,1,ML,3.83,2.681,AETNA [1000108],AETNA [100010801],,,76.8,,2.94,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0920-25,NDC,outpatient,1,ML,3.83,2.681,AETNA [1000108],AETNA [100010801],,,76.8,,2.94,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0931-28,NDC,outpatient,10,ML,10.28,7.196,AETNA [1000108],AETNA [100010801],,,76.8,,7.9,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0372-99,NDC,outpatient,1,ML,13.11,9.177,AETNA [1000108],AETNA [100010801],,,76.8,,10.07,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,25021-0400-10,NDC,outpatient,10,ML,16.81,11.767,AETNA [1000108],AETNA [100010801],,,76.8,,12.91,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0931-14,NDC,outpatient,10,ML,10.28,7.196,AETNA [1000108],AETNA [100010801],,,76.8,,7.9,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0385-10,NDC,outpatient,10,ML,19.64,13.748,AETNA [1000108],AETNA [100010801],,,76.8,,15.08,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0385-99,NDC,outpatient,10,ML,19.64,13.748,AETNA [1000108],AETNA [100010801],,,76.8,,15.08,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,25021-0400-01,NDC,outpatient,1,ML,5.04,3.528,AETNA [1000108],AETNA [100010801],,,76.8,,3.87,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0276-01,NDC,outpatient,2,ML,21.8,15.26,AETNA [1000108],AETNA [100010801],,,76.8,,16.74,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-33,NDC,outpatient,30,ML,21.77,15.239,AETNA [1000108],AETNA [100010801],,,76.8,,16.72,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-36,NDC,outpatient,30,ML,21.77,15.239,AETNA [1000108],AETNA [100010801],,,76.8,,16.72,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0372-12,NDC,outpatient,1,ML,13.11,9.177,AETNA [1000108],AETNA [100010801],,,76.8,,10.07,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 20000 UNIT/ML IJ SOLN,RX-10178,CDM,J1644,HCPCS,636,RC,63739-0986-11,NDC,outpatient,1,ML,33.86,23.702,AETNA [1000108],AETNA [100010801],,,76.8,,26,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 20000 UNIT/ML IJ SOLN,RX-10178,CDM,J1644,HCPCS,636,RC,63739-0986-25,NDC,outpatient,1,ML,33.86,23.702,AETNA [1000108],AETNA [100010801],,,76.8,,26,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,00409-2723-31,NDC,outpatient,1,ML,3.99,2.793,AETNA [1000108],AETNA [100010801],,,76.8,,3.06,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,00409-2723-02,NDC,outpatient,1,ML,3.99,2.793,AETNA [1000108],AETNA [100010801],,,76.8,,3.06,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,63739-0953-11,NDC,outpatient,1,ML,6.36,4.452,AETNA [1000108],AETNA [100010801],,,76.8,,4.88,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,63739-0953-25,NDC,outpatient,1,ML,6.36,4.452,AETNA [1000108],AETNA [100010801],,,76.8,,4.88,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,71288-0403-01,NDC,outpatient,1,ML,3.33,2.331,AETNA [1000108],AETNA [100010801],,,76.8,,2.56,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,71288-0403-02,NDC,outpatient,1,ML,3.33,2.331,AETNA [1000108],AETNA [100010801],,,76.8,,2.56,0.22,416.02,percent of total billed charges,,,
HEPARIN (PORCINE) IN NACL 25000-0.45 UT/250ML-% IV SOLN,RX-135728,CDM,J1644,HCPCS,636,RC,00409-7650-52,NDC,outpatient,250,ML,63.84,44.688,AETNA [1000108],AETNA [100010801],,,76.8,,49.03,0.22,416.02,percent of total billed charges,,,
HEPARIN (PORCINE) IN NACL 25000-0.45 UT/250ML-% IV SOLN,RX-135728,CDM,J1644,HCPCS,636,RC,00409-7650-62,NDC,outpatient,250,ML,63.84,44.688,AETNA [1000108],AETNA [100010801],,,76.8,,49.03,0.22,416.02,percent of total billed charges,,,
HEPARIN SOD (PORCINE) IN D5W 100 UNIT/ML IV SOLN,RX-24329,CDM,J1644,HCPCS,636,RC,00264-9587-20,NDC,outpatient,250,ML,77.19,54.033,AETNA [1000108],AETNA [100010801],,,76.8,,59.28,0.22,416.02,percent of total billed charges,,,
HEPARIN SOD (PORCINE) IN D5W 100 UNIT/ML IV SOLN,RX-24329,CDM,J1644,HCPCS,636,RC,63323-0523-74,NDC,outpatient,250,ML,44.93,31.451,AETNA [1000108],AETNA [100010801],,,76.8,,34.51,0.22,416.02,percent of total billed charges,,,
HEPARIN SOD (PORCINE) IN D5W 100 UNIT/ML IV SOLN,RX-24329,CDM,J1644,HCPCS,636,RC,63323-0523-01,NDC,outpatient,250,ML,44.93,31.451,AETNA [1000108],AETNA [100010801],,,76.8,,34.51,0.22,416.02,percent of total billed charges,,,
HEPARIN SOD (PORCINE) PREMIX 30000 UNITS IN 1L NS,RX-4080227,CDM,J1644,HCPCS,636,RC,70092-1281-08,NDC,outpatient,1000,ML,120.09,84.063,AETNA [1000108],AETNA [100010801],,,76.8,,92.23,0.22,416.02,percent of total billed charges,,,
HEPARIN SOD (PORCINE) PREMIX 30000 UNITS IN 1L NS,RX-4080227,CDM,J1644,HCPCS,636,RC,99999-0921-33,NDC,outpatient,1000,ML,91.43,64.001,AETNA [1000108],AETNA [100010801],,,76.8,,70.22,0.22,416.02,percent of total billed charges,,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00264-9872-10,NDC,outpatient,500,ML,33.8,23.66,AETNA [1000108],AETNA [100010801],,,76.8,,25.96,0.22,416.02,percent of total billed charges,,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00338-0424-18,NDC,outpatient,500,ML,28.85,20.195,AETNA [1000108],AETNA [100010801],,,76.8,,22.16,0.22,416.02,percent of total billed charges,,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-1005-01,NDC,outpatient,500,ML,33.99,23.793,AETNA [1000108],AETNA [100010801],,,76.8,,26.1,0.22,416.02,percent of total billed charges,,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-1005-20,NDC,outpatient,500,ML,33.99,23.793,AETNA [1000108],AETNA [100010801],,,76.8,,26.1,0.22,416.02,percent of total billed charges,,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-7620-03,NDC,outpatient,500,ML,33.99,23.793,AETNA [1000108],AETNA [100010801],,,76.8,,26.1,0.22,416.02,percent of total billed charges,,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,63323-0519-77,NDC,outpatient,500,ML,31.42,21.994,AETNA [1000108],AETNA [100010801],,,76.8,,24.13,0.22,416.02,percent of total billed charges,,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,99999-0001-81,NDC,outpatient,1000,ML,22.86,16.002,AETNA [1000108],AETNA [100010801],,,76.8,,17.56,0.22,416.02,percent of total billed charges,,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-7620-13,NDC,outpatient,500,ML,33.99,23.793,AETNA [1000108],AETNA [100010801],,,76.8,,26.1,0.22,416.02,percent of total billed charges,,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,63323-0519-02,NDC,outpatient,500,ML,31.42,21.994,AETNA [1000108],AETNA [100010801],,,76.8,,24.13,0.22,416.02,percent of total billed charges,,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,99999-0001-71,NDC,outpatient,500,ML,22,15.4,AETNA [1000108],AETNA [100010801],,,76.8,,16.9,0.22,416.02,percent of total billed charges,,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,99999-0002-94,NDC,outpatient,5,ML,16.13,11.291,AETNA [1000108],AETNA [100010801],,,76.8,,12.39,0.22,416.02,percent of total billed charges,,,
HEPARIN (PORCINE) IN NACL 25000-0.9 UT/250ML-% IV SOLN,RX-4081544,CDM,J1644,HCPCS,636,RC,99999-0003-31,NDC,outpatient,250,ML,42.73,29.911,AETNA [1000108],AETNA [100010801],,,76.8,,32.82,0.22,416.02,percent of total billed charges,,,
HEPARIN (PORCINE) IN NACL 25000-0.9 UT/250ML-% IV SOLN,RX-4081544,CDM,J1644,HCPCS,636,RC,99999-0003-32,NDC,outpatient,250,ML,30.4,21.28,AETNA [1000108],AETNA [100010801],,,76.8,,23.35,0.22,416.02,percent of total billed charges,,,
ENOXAPARIN SODIUM 30 MG/0.3ML IJ SOSY,RX-158184,CDM,J1650,HCPCS,636,RC,00548-5601-00,NDC,outpatient,0.3,ML,20.03,14.021,AETNA [1000108],AETNA [100010801],,,76.8,,15.38,0.57,416.02,percent of total billed charges,,,
ENOXAPARIN SODIUM 40 MG/0.4ML IJ SOSY,RX-158185,CDM,J1650,HCPCS,636,RC,00548-5602-00,NDC,outpatient,0.4,ML,26.7,18.69,AETNA [1000108],AETNA [100010801],,,76.8,,20.51,0.57,416.02,percent of total billed charges,,,
ENOXAPARIN SODIUM 60 MG/0.6ML IJ SOSY,RX-158186,CDM,J1650,HCPCS,636,RC,00548-5603-00,NDC,outpatient,0.6,ML,40.05,28.035,AETNA [1000108],AETNA [100010801],,,76.8,,30.76,0.57,416.02,percent of total billed charges,,,
ENOXAPARIN SODIUM 80 MG/0.8ML IJ SOSY,RX-158187,CDM,J1650,HCPCS,636,RC,00548-5604-00,NDC,outpatient,0.8,ML,53.4,37.38,AETNA [1000108],AETNA [100010801],,,76.8,,41.01,0.57,416.02,percent of total billed charges,,,
ENOXAPARIN SODIUM 100 MG/ML IJ SOSY,RX-158188,CDM,J1650,HCPCS,636,RC,00548-5605-00,NDC,outpatient,1,ML,66.75,46.725,AETNA [1000108],AETNA [100010801],,,76.8,,51.26,0.57,416.02,percent of total billed charges,,,
ENOXAPARIN SODIUM 120 MG/0.8ML IJ SOSY,RX-158189,CDM,J1650,HCPCS,636,RC,00548-5606-00,NDC,outpatient,0.8,ML,80.1,56.07,AETNA [1000108],AETNA [100010801],,,76.8,,61.52,0.57,416.02,percent of total billed charges,,,
ENOXAPARIN SODIUM 150 MG/ML IJ SOSY,RX-158190,CDM,J1650,HCPCS,636,RC,00548-5607-00,NDC,outpatient,1,ML,100.13,70.091,AETNA [1000108],AETNA [100010801],,,76.8,,76.9,0.57,416.02,percent of total billed charges,,,
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,67457-0583-00,NDC,outpatient,0.4,ML,146.14,102.298,AETNA [1000108],AETNA [100010801],,,76.8,,112.24,0.92,416.02,percent of total billed charges,,,
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,55150-0231-00,NDC,outpatient,0.4,ML,58.52,40.964,AETNA [1000108],AETNA [100010801],,,76.8,,44.94,0.92,416.02,percent of total billed charges,,,
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,55150-0231-10,NDC,outpatient,0.4,ML,58.52,40.964,AETNA [1000108],AETNA [100010801],,,76.8,,44.94,0.92,416.02,percent of total billed charges,,,
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,67457-0583-04,NDC,outpatient,0.4,ML,146.14,102.298,AETNA [1000108],AETNA [100010801],,,76.8,,112.24,0.92,416.02,percent of total billed charges,,,
FONDAPARINUX SODIUM 7.5 MG/0.6ML SC SOLN,RX-108028,CDM,J1652,HCPCS,636,RC,55111-0680-10,NDC,outpatient,0.6,ML,45.65,31.955,AETNA [1000108],AETNA [100010801],,,76.8,,35.06,0.92,416.02,percent of total billed charges,,,
FONDAPARINUX SODIUM 7.5 MG/0.6ML SC SOLN,RX-108028,CDM,J1652,HCPCS,636,RC,55111-0680-11,NDC,outpatient,0.6,ML,45.65,31.955,AETNA [1000108],AETNA [100010801],,,76.8,,35.06,0.92,416.02,percent of total billed charges,,,
FONDAPARINUX SODIUM 10 MG/0.8ML SC SOLN,RX-108029,CDM,J1652,HCPCS,636,RC,67457-0585-08,NDC,outpatient,0.8,ML,146.14,102.298,AETNA [1000108],AETNA [100010801],,,76.8,,112.24,0.92,416.02,percent of total billed charges,,,
FONDAPARINUX SODIUM 10 MG/0.8ML SC SOLN,RX-108029,CDM,J1652,HCPCS,636,RC,67457-0585-00,NDC,outpatient,0.8,ML,146.14,102.298,AETNA [1000108],AETNA [100010801],,,76.8,,112.24,0.92,416.02,percent of total billed charges,,,
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55111-0678-10,NDC,outpatient,0.5,ML,21,14.7,AETNA [1000108],AETNA [100010801],,,76.8,,16.13,0.92,416.02,percent of total billed charges,,,
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55150-0230-00,NDC,outpatient,0.5,ML,20.75,14.525,AETNA [1000108],AETNA [100010801],,,76.8,,15.94,0.92,416.02,percent of total billed charges,,,
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55150-0230-10,NDC,outpatient,0.5,ML,20.75,14.525,AETNA [1000108],AETNA [100010801],,,76.8,,15.94,0.92,416.02,percent of total billed charges,,,
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55111-0678-11,NDC,outpatient,0.5,ML,21,14.7,AETNA [1000108],AETNA [100010801],,,76.8,,16.13,0.92,416.02,percent of total billed charges,,,
TETANUS IMMUNE GLOBULIN 250 UNIT/ML IM SOSY,RX-156399,CDM,J1670,HCPCS,636,RC,13533-0634-02,NDC,outpatient,1,ML,1484.53,1039.171,AETNA [1000108],AETNA [100010801],,,76.8,,1140.12,333.276985,1140.11904,percent of total billed charges,,,
TETANUS IMMUNE GLOBULIN 250 UNIT/ML IM SOSY,RX-156399,CDM,J1670,HCPCS,636,RC,13533-0634-20,NDC,outpatient,1,ML,1484.53,1039.171,AETNA [1000108],AETNA [100010801],,,76.8,,1140.12,333.276985,1140.11904,percent of total billed charges,,,
HYDROCORTISONE SOD SUC (PF) 250 MG IJ SOLR,RX-160127,CDM,J1720,HCPCS,636,RC,00009-0013-05,NDC,outpatient,1,UN,153.4,107.38,AETNA [1000108],AETNA [100010801],,,76.8,,117.81,13.56878,416.02,percent of total billed charges,,,
HYDROCORTISONE SOD SUC (PF) 500 MG IJ SOLR,RX-160129,CDM,J1720,HCPCS,636,RC,00009-0016-12,NDC,outpatient,1,UN,308.7,216.09,AETNA [1000108],AETNA [100010801],,,76.8,,237.08,13.56878,416.02,percent of total billed charges,,,
HYDROCORTISONE NA SUCCINATE PF 100 MG IJ WRAPPER,RX-4080176,CDM,J1720,HCPCS,636,RC,00009-0011-04,NDC,outpatient,1,UN,83.69,58.583,AETNA [1000108],AETNA [100010801],,,76.8,,64.27,13.56878,416.02,percent of total billed charges,,,
HYDROCORTISONE NA SUCCINATE PF 100 MG IJ WRAPPER,RX-4080176,CDM,J1720,HCPCS,636,RC,00009-0825-01,NDC,outpatient,1,UN,60.44,42.308,AETNA [1000108],AETNA [100010801],,,76.8,,46.42,13.56878,416.02,percent of total billed charges,,,
IBANDRONATE SODIUM 3 MG/3ML IV SOLN,RX-110306,CDM,J1740,HCPCS,636,RC,60505-6097-00,NDC,outpatient,3,ML,291.8,204.26,AETNA [1000108],AETNA [100010801],,,76.8,,224.1,27.14,416.02,percent of total billed charges,,,
IBUTILIDE FUMARATE 1 MG/10ML IV SOLN,RX-100740,CDM,J1742,HCPCS,636,RC,00009-3794-01,NDC,outpatient,10,ML,380.26,266.182,AETNA [1000108],AETNA [100010801],,,76.8,,292.04,85.36837,416.02,percent of total billed charges,,,
INFLIXIMAB 100 MG IV SOLR,RX-23796,CDM,J1745,HCPCS,636,RC,57894-0030-01,NDC,outpatient,1,UN,3124.93,2187.451,AETNA [1000108],AETNA [100010801],,,76.8,,2399.95,32.22,2399.94624,percent of total billed charges,,,
IRON DEXTRAN 50 MG/ML IJ SOLN,RX-3990,CDM,J1750,HCPCS,636,RC,00023-6082-01,NDC,outpatient,2,ML,145.94,102.158,AETNA [1000108],AETNA [100010801],,,76.8,,112.08,17.18,416.02,percent of total billed charges,,,
IRON DEXTRAN 50 MG/ML IJ SOLN,RX-3990,CDM,J1750,HCPCS,636,RC,00023-6082-10,NDC,outpatient,2,ML,145.94,102.158,AETNA [1000108],AETNA [100010801],,,76.8,,112.08,17.18,416.02,percent of total billed charges,,,
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2310-01,NDC,outpatient,10,ML,278.93,195.251,AETNA [1000108],AETNA [100010801],,,76.8,,214.22,0.21,416.02,percent of total billed charges,,,
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2340-10,NDC,outpatient,5,ML,131.72,92.204,AETNA [1000108],AETNA [100010801],,,76.8,,101.16,0.21,416.02,percent of total billed charges,,,
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2310-05,NDC,outpatient,10,ML,278.93,195.251,AETNA [1000108],AETNA [100010801],,,76.8,,214.22,0.21,416.02,percent of total billed charges,,,
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2340-01,NDC,outpatient,5,ML,137.29,96.103,AETNA [1000108],AETNA [100010801],,,76.8,,105.44,0.21,416.02,percent of total billed charges,,,
DROPERIDOL 2.5 MG/ML IJ SOLN,RX-2654,CDM,J1790,HCPCS,636,RC,00517-9702-25,NDC,outpatient,2,ML,31.33,21.931,AETNA [1000108],AETNA [100010801],,,76.8,,24.06,3.83,416.02,percent of total billed charges,,,
DROPERIDOL 2.5 MG/ML IJ SOLN,RX-2654,CDM,J1790,HCPCS,636,RC,00517-9702-01,NDC,outpatient,2,ML,31.33,21.931,AETNA [1000108],AETNA [100010801],,,76.8,,24.06,3.83,416.02,percent of total billed charges,,,
PROPRANOLOL HCL 1 MG/ML IV SOLN,RX-29335,CDM,J1800,HCPCS,636,RC,63323-0604-00,NDC,outpatient,1,ML,8.17,5.719,AETNA [1000108],AETNA [100010801],,,76.8,,6.27,1.834165,416.02,percent of total billed charges,,,
PROPRANOLOL HCL 1 MG/ML IV SOLN,RX-29335,CDM,J1800,HCPCS,636,RC,63323-0604-01,NDC,outpatient,1,ML,8.17,5.719,AETNA [1000108],AETNA [100010801],,,76.8,,6.27,1.834165,416.02,percent of total billed charges,,,
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN,RX-29805,CDM,J1805,HCPCS,636,RC,67457-0657-25,NDC,outpatient,250,ML,426.52,298.564,AETNA [1000108],AETNA [100010801],,,76.8,,327.57,0.19,416.02,percent of total billed charges,,,
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN,RX-29805,CDM,J1805,HCPCS,636,RC,25021-0308-84,NDC,outpatient,250,ML,336.4,235.48,AETNA [1000108],AETNA [100010801],,,76.8,,258.36,0.19,416.02,percent of total billed charges,,,
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-29805,CDM,J1805,HCPCS,636,RC,25021-0308-84,NDC,outpatient,250,ML,320.4,224.28,AETNA [1000108],AETNA [100010801],JW,,76.8,,246.07,0.19,416.02,percent of total billed charges,,,
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-29805,CDM,J1805,HCPCS,636,RC,67457-0657-25,NDC,outpatient,250,ML,410.52,287.364,AETNA [1000108],AETNA [100010801],JW,,76.8,,315.28,0.19,416.02,percent of total billed charges,,,
ESMOLOL HCL 100 MG/10ML IV SOLN,RX-82085,CDM,J1805,HCPCS,636,RC,55150-0194-10,NDC,outpatient,10,ML,10.39,7.273,AETNA [1000108],AETNA [100010801],,,76.8,,7.98,0.19,416.02,percent of total billed charges,,,
ESMOLOL HCL 100 MG/10ML IV SOLN,RX-82085,CDM,J1805,HCPCS,636,RC,67457-0182-00,NDC,outpatient,10,ML,17.12,11.984,AETNA [1000108],AETNA [100010801],,,76.8,,13.15,0.19,416.02,percent of total billed charges,,,
ESMOLOL HCL 100 MG/10ML IV SOLN,RX-82085,CDM,J1805,HCPCS,636,RC,67457-0182-10,NDC,outpatient,10,ML,17.12,11.984,AETNA [1000108],AETNA [100010801],,,76.8,,13.15,0.19,416.02,percent of total billed charges,,,
ESMOLOL HCL 2500 MG/250ML IV SOLN,RX-142051,CDM,J1806,HCPCS,636,RC,44567-0811-10,NDC,outpatient,250,ML,430.97,301.679,AETNA [1000108],AETNA [100010801],,,76.8,,330.98,0.36,416.02,percent of total billed charges,,,
ESMOLOL HCL 2500 MG/250ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-142051,CDM,J1806,HCPCS,636,RC,44567-0811-10,NDC,outpatient,250,ML,414.97,290.479,AETNA [1000108],AETNA [100010801],JW,,76.8,,318.7,0.36,416.02,percent of total billed charges,,,
INTERFERON BETA-1B 0.3 MG SC KIT,RX-124318,CDM,J1830,HCPCS,636,RC,50419-0524-01,NDC,outpatient,1,UN,1865.02,1305.514,AETNA [1000108],AETNA [100010801],,,76.8,,1432.34,114.43,1432.33536,percent of total billed charges,,,
INTERFERON BETA-1B 0.3 MG SC KIT,RX-124318,CDM,J1830,HCPCS,636,RC,50419-0524-35,NDC,outpatient,1,UN,1865.02,1305.514,AETNA [1000108],AETNA [100010801],,,76.8,,1432.34,114.43,1432.33536,percent of total billed charges,,,
ISAVUCONAZONIUM SULFATE 372 MG IV SOLR,RX-130407,CDM,J1833,HCPCS,636,RC,00469-0420-01,NDC,outpatient,1,UN,1572.32,1100.624,AETNA [1000108],AETNA [100010801],,,76.8,,1207.54,1,1207.54176,percent of total billed charges,,,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-01,NDC,outpatient,100,ML,24.23,16.961,AETNA [1000108],AETNA [100010801],,,76.8,,18.61,0.02,416.02,percent of total billed charges,,,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,25021-0131-82,NDC,outpatient,100,ML,25.77,18.039,AETNA [1000108],AETNA [100010801],,,76.8,,19.79,0.02,416.02,percent of total billed charges,,,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,47335-0993-01,NDC,outpatient,100,ML,7.2,5.04,AETNA [1000108],AETNA [100010801],JW,,76.8,,5.53,0.02,416.02,percent of total billed charges,,,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,00338-1055-48,NDC,outpatient,100,ML,21.14,14.798,AETNA [1000108],AETNA [100010801],,,76.8,,16.24,0.02,416.02,percent of total billed charges,,,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,00338-1055-48,NDC,outpatient,100,ML,5.14,3.598,AETNA [1000108],AETNA [100010801],JW,,76.8,,3.95,0.02,416.02,percent of total billed charges,,,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-01,NDC,outpatient,100,ML,8.23,5.761,AETNA [1000108],AETNA [100010801],JW,,76.8,,6.32,0.02,416.02,percent of total billed charges,,,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-24,NDC,outpatient,100,ML,24.23,16.961,AETNA [1000108],AETNA [100010801],,,76.8,,18.61,0.02,416.02,percent of total billed charges,,,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,47335-0993-01,NDC,outpatient,100,ML,23.2,16.24,AETNA [1000108],AETNA [100010801],,,76.8,,17.82,0.02,416.02,percent of total billed charges,,,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-24,NDC,outpatient,100,ML,8.23,5.761,AETNA [1000108],AETNA [100010801],JW,,76.8,,6.32,0.02,416.02,percent of total billed charges,,,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,25021-0131-82,NDC,outpatient,100,ML,9.77,6.839,AETNA [1000108],AETNA [100010801],JW,,76.8,,7.5,0.02,416.02,percent of total billed charges,,,
METRONIDAZOLE IN NACL IVPB,RX-4080369,CDM,J1836,HCPCS,636,RC,99999-0001-74,NDC,outpatient,50,ML,20.37,14.259,AETNA [1000108],AETNA [100010801],,,76.8,,15.64,0.02,416.02,percent of total billed charges,,,
METRONIDAZOLE IV SYRINGE (PEDIATRIC),RX-40840043,CDM,J1836,HCPCS,636,RC,99999-0001-74,NDC,outpatient,50,ML,20.37,14.259,AETNA [1000108],AETNA [100010801],,,76.8,,15.64,0.02,416.02,percent of total billed charges,,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,63323-0162-01,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.55,416.02,percent of total billed charges,,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,00338-0072-25,NDC,outpatient,1,ML,3.57,2.499,AETNA [1000108],AETNA [100010801],,,76.8,,2.74,0.55,416.02,percent of total billed charges,,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,62332-0600-01,NDC,outpatient,1,ML,9.77,6.839,AETNA [1000108],AETNA [100010801],,,76.8,,7.5,0.55,416.02,percent of total billed charges,,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,72266-0118-01,NDC,outpatient,1,ML,4.8,3.36,AETNA [1000108],AETNA [100010801],,,76.8,,3.69,0.55,416.02,percent of total billed charges,,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,00409-3795-01,NDC,outpatient,1,ML,18.43,12.901,AETNA [1000108],AETNA [100010801],,,76.8,,14.15,0.55,416.02,percent of total billed charges,,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,00409-3795-19,NDC,outpatient,1,ML,18.43,12.901,AETNA [1000108],AETNA [100010801],,,76.8,,14.15,0.55,416.02,percent of total billed charges,,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,62332-0600-25,NDC,outpatient,1,ML,9.77,6.839,AETNA [1000108],AETNA [100010801],,,76.8,,7.5,0.55,416.02,percent of total billed charges,,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,63323-0162-00,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.55,416.02,percent of total billed charges,,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,72266-0118-25,NDC,outpatient,1,ML,4.8,3.36,AETNA [1000108],AETNA [100010801],,,76.8,,3.69,0.55,416.02,percent of total billed charges,,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,00409-2267-54,NDC,outpatient,40,ML,40.77,28.539,AETNA [1000108],AETNA [100010801],,,76.8,,31.31,0.24,416.02,percent of total billed charges,,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,00409-2339-34,NDC,outpatient,4,ML,35.3,24.71,AETNA [1000108],AETNA [100010801],,,76.8,,27.11,0.24,416.02,percent of total billed charges,,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,25021-0317-20,NDC,outpatient,20,ML,9.98,6.986,AETNA [1000108],AETNA [100010801],,,76.8,,7.66,0.24,416.02,percent of total billed charges,,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,72266-0102-01,NDC,outpatient,20,ML,12.14,8.498,AETNA [1000108],AETNA [100010801],,,76.8,,9.32,0.24,416.02,percent of total billed charges,,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,36000-0320-01,NDC,outpatient,4,ML,16.17,11.319,AETNA [1000108],AETNA [100010801],,,76.8,,12.42,0.24,416.02,percent of total billed charges,,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,36000-0320-10,NDC,outpatient,4,ML,16.17,11.319,AETNA [1000108],AETNA [100010801],,,76.8,,12.42,0.24,416.02,percent of total billed charges,,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,00409-2339-24,NDC,outpatient,4,ML,35.3,24.71,AETNA [1000108],AETNA [100010801],,,76.8,,27.11,0.24,416.02,percent of total billed charges,,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1921,HCPCS,636,RC,00143-9623-01,NDC,outpatient,40,ML,18.87,13.209,AETNA [1000108],AETNA [100010801],,,76.8,,14.49,1.24,416.02,percent of total billed charges,,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1921,HCPCS,636,RC,00143-9622-01,NDC,outpatient,20,ML,8.85,6.195,AETNA [1000108],AETNA [100010801],,,76.8,,6.8,1.24,416.02,percent of total billed charges,,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,72205-0101-07,NDC,outpatient,4,ML,12.36,8.652,AETNA [1000108],AETNA [100010801],,,76.8,,9.49,0.62,416.02,percent of total billed charges,,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6007-01,NDC,outpatient,10,ML,15.42,10.794,AETNA [1000108],AETNA [100010801],,,76.8,,11.84,0.62,416.02,percent of total billed charges,,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6008-10,NDC,outpatient,4,ML,14.21,9.947,AETNA [1000108],AETNA [100010801],,,76.8,,10.91,0.62,416.02,percent of total billed charges,,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0570-04,NDC,outpatient,4,ML,8.04,5.628,AETNA [1000108],AETNA [100010801],,,76.8,,6.17,0.62,416.02,percent of total billed charges,,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0572-01,NDC,outpatient,10,ML,8.64,6.048,AETNA [1000108],AETNA [100010801],,,76.8,,6.64,0.62,416.02,percent of total billed charges,,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,72205-0101-01,NDC,outpatient,4,ML,12.36,8.652,AETNA [1000108],AETNA [100010801],,,76.8,,9.49,0.62,416.02,percent of total billed charges,,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6008-01,NDC,outpatient,4,ML,14.21,9.947,AETNA [1000108],AETNA [100010801],,,76.8,,10.91,0.62,416.02,percent of total billed charges,,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0572-10,NDC,outpatient,10,ML,8.64,6.048,AETNA [1000108],AETNA [100010801],,,76.8,,6.64,0.62,416.02,percent of total billed charges,,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6007-10,NDC,outpatient,10,ML,15.42,10.794,AETNA [1000108],AETNA [100010801],,,76.8,,11.84,0.62,416.02,percent of total billed charges,,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0570-01,NDC,outpatient,4,ML,8.04,5.628,AETNA [1000108],AETNA [100010801],,,76.8,,6.17,0.62,416.02,percent of total billed charges,,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-32,NDC,outpatient,4,ML,4.75,3.325,AETNA [1000108],AETNA [100010801],,,76.8,,3.65,0.4,416.02,percent of total billed charges,,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-44,NDC,outpatient,10,ML,7.2,5.04,AETNA [1000108],AETNA [100010801],,,76.8,,5.53,0.4,416.02,percent of total billed charges,,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,36000-0283-25,NDC,outpatient,4,ML,5.41,3.787,AETNA [1000108],AETNA [100010801],,,76.8,,4.15,0.4,416.02,percent of total billed charges,,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,36000-0284-25,NDC,outpatient,10,ML,8.33,5.831,AETNA [1000108],AETNA [100010801],,,76.8,,6.4,0.4,416.02,percent of total billed charges,,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,00409-6102-04,NDC,outpatient,4,ML,9.24,6.468,AETNA [1000108],AETNA [100010801],,,76.8,,7.1,0.4,416.02,percent of total billed charges,,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-42,NDC,outpatient,4,ML,4.75,3.325,AETNA [1000108],AETNA [100010801],,,76.8,,3.65,0.4,416.02,percent of total billed charges,,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,25021-0311-10,NDC,outpatient,10,ML,7.25,5.075,AETNA [1000108],AETNA [100010801],,,76.8,,5.57,0.4,416.02,percent of total billed charges,,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,63323-0280-03,NDC,outpatient,4,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.4,416.02,percent of total billed charges,,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,63323-0280-26,NDC,outpatient,4,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.4,416.02,percent of total billed charges,,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,72603-0251-01,NDC,outpatient,4,ML,3.79,2.653,AETNA [1000108],AETNA [100010801],,,76.8,,2.91,0.4,416.02,percent of total billed charges,,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,70860-0302-04,NDC,outpatient,4,ML,4.94,3.458,AETNA [1000108],AETNA [100010801],,,76.8,,3.79,0.4,416.02,percent of total billed charges,,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,70860-0302-42,NDC,outpatient,4,ML,4.94,3.458,AETNA [1000108],AETNA [100010801],,,76.8,,3.79,0.4,416.02,percent of total billed charges,,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,71288-0203-05,NDC,outpatient,4,ML,3.66,2.562,AETNA [1000108],AETNA [100010801],,,76.8,,2.81,0.4,416.02,percent of total billed charges,,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,72603-0251-25,NDC,outpatient,4,ML,3.79,2.653,AETNA [1000108],AETNA [100010801],,,76.8,,2.91,0.4,416.02,percent of total billed charges,,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,00409-6102-18,NDC,outpatient,4,ML,9.24,6.468,AETNA [1000108],AETNA [100010801],,,76.8,,7.1,0.4,416.02,percent of total billed charges,,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-33,NDC,outpatient,10,ML,7.2,5.04,AETNA [1000108],AETNA [100010801],,,76.8,,5.53,0.4,416.02,percent of total billed charges,,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,63323-0280-04,NDC,outpatient,4,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.4,416.02,percent of total billed charges,,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,71288-0203-04,NDC,outpatient,4,ML,3.66,2.562,AETNA [1000108],AETNA [100010801],,,76.8,,2.81,0.4,416.02,percent of total billed charges,,,
LEUPROLIDE ACETATE 3.75 MG IM KIT,RX-13691,CDM,J1950,HCPCS,636,RC,00074-3641-03,NDC,outpatient,1,UN,4758.7,3331.09,AETNA [1000108],AETNA [100010801],,,76.8,,3654.68,399.86,10964.15232,percent of total billed charges,,,
LEUPROLIDE ACETATE (3 MONTH) 11.25 MG IM KIT,RX-21044,CDM,J1950,HCPCS,636,RC,00074-3663-03,NDC,outpatient,1,UN,14276.24,9993.368,AETNA [1000108],AETNA [100010801],,,76.8,,10964.15,399.86,10964.15232,percent of total billed charges,,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,14789-0220-10,NDC,outpatient,100,ML,48.49,33.943,AETNA [1000108],AETNA [100010801],,,76.8,,37.24,0.06,416.02,percent of total billed charges,,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,67457-0265-00,NDC,outpatient,100,ML,64.06,44.842,AETNA [1000108],AETNA [100010801],,,76.8,,49.2,0.06,416.02,percent of total billed charges,,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,70860-0603-82,NDC,outpatient,100,ML,63.62,44.534,AETNA [1000108],AETNA [100010801],,,76.8,,48.86,0.06,416.02,percent of total billed charges,,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,44567-0502-01,NDC,outpatient,100,ML,49.38,34.566,AETNA [1000108],AETNA [100010801],,,76.8,,37.92,0.06,416.02,percent of total billed charges,,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,67457-0265-10,NDC,outpatient,100,ML,64.06,44.842,AETNA [1000108],AETNA [100010801],,,76.8,,49.2,0.06,416.02,percent of total billed charges,,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,70860-0603-41,NDC,outpatient,100,ML,63.62,44.534,AETNA [1000108],AETNA [100010801],,,76.8,,48.86,0.06,416.02,percent of total billed charges,,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,14789-0220-08,NDC,outpatient,100,ML,48.49,33.943,AETNA [1000108],AETNA [100010801],,,76.8,,37.24,0.06,416.02,percent of total billed charges,,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,43598-0636-10,NDC,outpatient,100,ML,87.65,61.355,AETNA [1000108],AETNA [100010801],,,76.8,,67.32,0.06,416.02,percent of total billed charges,,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,43598-0636-52,NDC,outpatient,100,ML,87.65,61.355,AETNA [1000108],AETNA [100010801],,,76.8,,67.32,0.06,416.02,percent of total billed charges,,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,44567-0502-10,NDC,outpatient,100,ML,49.38,34.566,AETNA [1000108],AETNA [100010801],,,76.8,,37.92,0.06,416.02,percent of total billed charges,,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,00264-1009-90,NDC,outpatient,100,ML,43.15,30.205,AETNA [1000108],AETNA [100010801],,,76.8,,33.14,0.06,416.02,percent of total billed charges,,,
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,44567-0503-01,NDC,outpatient,100,ML,60.06,42.042,AETNA [1000108],AETNA [100010801],,,76.8,,46.13,0.06,416.02,percent of total billed charges,,,
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,44567-0503-10,NDC,outpatient,100,ML,60.06,42.042,AETNA [1000108],AETNA [100010801],,,76.8,,46.13,0.06,416.02,percent of total billed charges,,,
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,70860-0604-82,NDC,outpatient,100,ML,79.64,55.748,AETNA [1000108],AETNA [100010801],,,76.8,,61.16,0.06,416.02,percent of total billed charges,,,
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,70860-0604-41,NDC,outpatient,100,ML,79.64,55.748,AETNA [1000108],AETNA [100010801],,,76.8,,61.16,0.06,416.02,percent of total billed charges,,,
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,67457-0790-05,NDC,outpatient,5,ML,10.7,7.49,AETNA [1000108],AETNA [100010801],,,76.8,,8.22,0.06,416.02,percent of total billed charges,,,
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,00409-1886-22,NDC,outpatient,5,ML,6.38,4.466,AETNA [1000108],AETNA [100010801],,,76.8,,4.9,0.06,416.02,percent of total billed charges,,,
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,67457-0790-00,NDC,outpatient,5,ML,10.7,7.49,AETNA [1000108],AETNA [100010801],,,76.8,,8.22,0.06,416.02,percent of total billed charges,,,
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,00409-1886-02,NDC,outpatient,5,ML,6.38,4.466,AETNA [1000108],AETNA [100010801],,,76.8,,4.9,0.06,416.02,percent of total billed charges,,,
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,55150-0177-05,NDC,outpatient,5,ML,5.07,3.549,AETNA [1000108],AETNA [100010801],,,76.8,,3.89,0.06,416.02,percent of total billed charges,,,
LEVOFLOXACIN IN D5W 250 MG/50ML IV SOLN,RX-108118,CDM,J1956,HCPCS,636,RC,25021-0132-81,NDC,outpatient,50,ML,25.26,17.682,AETNA [1000108],AETNA [100010801],,,76.8,,19.4,0.92,416.02,percent of total billed charges,,,
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00143-9721-01,NDC,outpatient,100,ML,25.77,18.039,AETNA [1000108],AETNA [100010801],,,76.8,,19.79,0.92,416.02,percent of total billed charges,,,
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00143-9721-24,NDC,outpatient,100,ML,25.77,18.039,AETNA [1000108],AETNA [100010801],,,76.8,,19.79,0.92,416.02,percent of total billed charges,,,
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,25021-0132-82,NDC,outpatient,100,ML,26.28,18.396,AETNA [1000108],AETNA [100010801],,,76.8,,20.18,0.92,416.02,percent of total billed charges,,,
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00409-0528-23,NDC,outpatient,100,ML,28.85,20.195,AETNA [1000108],AETNA [100010801],,,76.8,,22.16,0.92,416.02,percent of total billed charges,,,
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00409-0528-25,NDC,outpatient,100,ML,28.85,20.195,AETNA [1000108],AETNA [100010801],,,76.8,,22.16,0.92,416.02,percent of total billed charges,,,
LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN,RX-108120,CDM,J1956,HCPCS,636,RC,00409-0528-35,NDC,outpatient,150,ML,32.2,22.54,AETNA [1000108],AETNA [100010801],,,76.8,,24.73,0.92,416.02,percent of total billed charges,,,
LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN,RX-108120,CDM,J1956,HCPCS,636,RC,00409-0528-31,NDC,outpatient,150,ML,32.2,22.54,AETNA [1000108],AETNA [100010801],,,76.8,,24.73,0.92,416.02,percent of total billed charges,,,
LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN,RX-108120,CDM,J1956,HCPCS,636,RC,25021-0132-83,NDC,outpatient,150,ML,33.74,23.618,AETNA [1000108],AETNA [100010801],,,76.8,,25.91,0.92,416.02,percent of total billed charges,,,
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,00143-9722-24,NDC,outpatient,50,ML,23.97,16.779,AETNA [1000108],AETNA [100010801],,,76.8,,18.41,0.92,416.02,percent of total billed charges,,,
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,63323-0355-50,NDC,outpatient,50,ML,45.6,31.92,AETNA [1000108],AETNA [100010801],,,76.8,,35.02,0.92,416.02,percent of total billed charges,,,
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,25021-0132-81,NDC,outpatient,50,ML,25.26,17.682,AETNA [1000108],AETNA [100010801],,,76.8,,19.4,0.92,416.02,percent of total billed charges,,,
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,36000-0046-24,NDC,outpatient,50,ML,26.54,18.578,AETNA [1000108],AETNA [100010801],,,76.8,,20.38,0.92,416.02,percent of total billed charges,,,
LIDOCAINE IN D5W 4-5 MG/ML-% IV SOLN,RX-14868,CDM,J2001,HCPCS,636,RC,00338-0409-03,NDC,outpatient,500,ML,42.7,29.89,AETNA [1000108],AETNA [100010801],,,76.8,,32.79,0.02,416.02,percent of total billed charges,,,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,00781-3433-46,NDC,outpatient,300,ML,100.11,70.077,AETNA [1000108],AETNA [100010801],,,76.8,,76.88,3.08,416.02,percent of total billed charges,,,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,63323-0713-03,NDC,outpatient,300,ML,49.38,34.566,AETNA [1000108],AETNA [100010801],,,76.8,,37.92,3.08,416.02,percent of total billed charges,,,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,00781-3433-95,NDC,outpatient,300,ML,100.11,70.077,AETNA [1000108],AETNA [100010801],,,76.8,,76.88,3.08,416.02,percent of total billed charges,,,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,63323-0713-13,NDC,outpatient,300,ML,49.38,34.566,AETNA [1000108],AETNA [100010801],,,76.8,,37.92,3.08,416.02,percent of total billed charges,,,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,55150-0242-51,NDC,outpatient,300,ML,53.38,37.366,AETNA [1000108],AETNA [100010801],,,76.8,,41,3.08,416.02,percent of total billed charges,,,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,57664-0683-31,NDC,outpatient,300,ML,46.71,32.697,AETNA [1000108],AETNA [100010801],,,76.8,,35.87,3.08,416.02,percent of total billed charges,,,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,57664-0683-57,NDC,outpatient,300,ML,46.71,32.697,AETNA [1000108],AETNA [100010801],,,76.8,,35.87,3.08,416.02,percent of total billed charges,,,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,00781-3433-95,NDC,outpatient,300,ML,100.11,70.077,AETNA [1000108],AETNA [100010801],,,76.8,,76.88,3.08,416.02,percent of total billed charges,,,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,57664-0683-31,NDC,outpatient,300,ML,46.71,32.697,AETNA [1000108],AETNA [100010801],,,76.8,,35.87,3.08,416.02,percent of total billed charges,,,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,55150-0242-51,NDC,outpatient,300,ML,53.38,37.366,AETNA [1000108],AETNA [100010801],,,76.8,,41,3.08,416.02,percent of total billed charges,,,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,57664-0683-57,NDC,outpatient,300,ML,46.71,32.697,AETNA [1000108],AETNA [100010801],,,76.8,,35.87,3.08,416.02,percent of total billed charges,,,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,63323-0713-13,NDC,outpatient,300,ML,49.38,34.566,AETNA [1000108],AETNA [100010801],,,76.8,,37.92,3.08,416.02,percent of total billed charges,,,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,00781-3433-46,NDC,outpatient,300,ML,100.11,70.077,AETNA [1000108],AETNA [100010801],,,76.8,,76.88,3.08,416.02,percent of total billed charges,,,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,63323-0713-03,NDC,outpatient,300,ML,49.38,34.566,AETNA [1000108],AETNA [100010801],,,76.8,,37.92,3.08,416.02,percent of total billed charges,,,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6207-01,NDC,outpatient,1,ML,5.04,3.528,AETNA [1000108],AETNA [100010801],,,76.8,,3.87,0.85,416.02,percent of total billed charges,,,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6044-25,NDC,outpatient,1,ML,4.94,3.458,AETNA [1000108],AETNA [100010801],,,76.8,,3.79,0.85,416.02,percent of total billed charges,,,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6207-25,NDC,outpatient,1,ML,5.04,3.528,AETNA [1000108],AETNA [100010801],,,76.8,,3.87,0.85,416.02,percent of total billed charges,,,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00409-1985-03,NDC,outpatient,1,ML,16.06,11.242,AETNA [1000108],AETNA [100010801],,,76.8,,12.33,0.85,416.02,percent of total billed charges,,,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00409-1985-30,NDC,outpatient,1,ML,16.06,11.242,AETNA [1000108],AETNA [100010801],,,76.8,,12.33,0.85,416.02,percent of total billed charges,,,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6044-01,NDC,outpatient,1,ML,4.94,3.458,AETNA [1000108],AETNA [100010801],,,76.8,,3.79,0.85,416.02,percent of total billed charges,,,
LORAZEPAM INFUSION PREMIX,RX-4080084,CDM,J2060,HCPCS,636,RC,SH408-0084-01,NDC,outpatient,100,ML,126.59,88.613,AETNA [1000108],AETNA [100010801],,,76.8,,97.22,0.85,416.02,percent of total billed charges,,,
MANNITOL 25 % IV SOLN,RX-4750,CDM,J2150,HCPCS,636,RC,00409-4031-01,NDC,outpatient,50,ML,10.28,7.196,AETNA [1000108],AETNA [100010801],,,76.8,,7.9,2.30786,416.02,percent of total billed charges,,,
MANNITOL 25 % IV SOLN,RX-4750,CDM,J2150,HCPCS,636,RC,00409-4031-16,NDC,outpatient,50,ML,10.28,7.196,AETNA [1000108],AETNA [100010801],,,76.8,,7.9,2.30786,416.02,percent of total billed charges,,,
MEPERIDINE 10 MG/ML PCA,RX-400415,CDM,J2175,HCPCS,636,RC,99999-0000-09,NDC,outpatient,50,ML,59.93,41.951,AETNA [1000108],AETNA [100010801],,,76.8,,46.03,2.386435,416.02,percent of total billed charges,,,
MEPERIDINE HCL 25 MG/ML IJ SOLN,RX-4903,CDM,J2175,HCPCS,636,RC,00641-6052-01,NDC,outpatient,1,ML,10.63,7.441,AETNA [1000108],AETNA [100010801],,,76.8,,8.16,2.386435,416.02,percent of total billed charges,,,
MEPERIDINE HCL 25 MG/ML IJ SOLN,RX-4903,CDM,J2175,HCPCS,636,RC,00641-6052-25,NDC,outpatient,1,ML,10.63,7.441,AETNA [1000108],AETNA [100010801],,,76.8,,8.16,2.386435,416.02,percent of total billed charges,,,
MEPERIDINE HCL 50 MG/ML IJ SOLN,RX-4904,CDM,J2175,HCPCS,636,RC,00641-6053-01,NDC,outpatient,1,ML,11.08,7.756,AETNA [1000108],AETNA [100010801],,,76.8,,8.51,2.386435,416.02,percent of total billed charges,,,
MEPERIDINE HCL 50 MG/ML IJ SOLN,RX-4904,CDM,J2175,HCPCS,636,RC,00641-6053-25,NDC,outpatient,1,ML,11.08,7.756,AETNA [1000108],AETNA [100010801],,,76.8,,8.51,2.386435,416.02,percent of total billed charges,,,
MEPOLIZUMAB 100 MG SC SOLR,RX-131231,CDM,J2182,HCPCS,636,RC,00173-0881-01,NDC,outpatient,1,UN,8145.21,5701.647,AETNA [1000108],AETNA [100010801],,,76.8,,6255.52,29.75,6255.52128,percent of total billed charges,,,
MEROPENEM 500 MG IV SOLR,RX-17379,CDM,J2185,HCPCS,636,RC,63323-0507-01,NDC,outpatient,1,UN,14.25,9.975,AETNA [1000108],AETNA [100010801],,,76.8,,10.94,0.35,416.02,percent of total billed charges,,,
MEROPENEM 500 MG IV SOLR,RX-17379,CDM,J2185,HCPCS,636,RC,63323-0507-20,NDC,outpatient,1,UN,14.25,9.975,AETNA [1000108],AETNA [100010801],,,76.8,,10.94,0.35,416.02,percent of total billed charges,,,
MEROPENEM 500 MG IV SOLR,RX-17379,CDM,J2185,HCPCS,636,RC,55150-0207-20,NDC,outpatient,1,UN,7.45,5.215,AETNA [1000108],AETNA [100010801],,,76.8,,5.72,0.35,416.02,percent of total billed charges,,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00409-1391-21,NDC,outpatient,1,UN,20.02,14.014,AETNA [1000108],AETNA [100010801],,,76.8,,15.38,0.35,416.02,percent of total billed charges,,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,55150-0208-30,NDC,outpatient,1,UN,17.23,12.061,AETNA [1000108],AETNA [100010801],,,76.8,,13.23,0.35,416.02,percent of total billed charges,,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00409-1391-22,NDC,outpatient,1,UN,20.02,14.014,AETNA [1000108],AETNA [100010801],,,76.8,,15.38,0.35,416.02,percent of total billed charges,,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00781-3098-94,NDC,outpatient,1,UN,48.95,34.265,AETNA [1000108],AETNA [100010801],,,76.8,,37.59,0.35,416.02,percent of total billed charges,,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00781-3098-95,NDC,outpatient,1,UN,48.95,34.265,AETNA [1000108],AETNA [100010801],,,76.8,,37.59,0.35,416.02,percent of total billed charges,,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,70121-1453-01,NDC,outpatient,1,UN,45.95,32.165,AETNA [1000108],AETNA [100010801],,,76.8,,35.29,0.35,416.02,percent of total billed charges,,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,70121-1453-07,NDC,outpatient,1,UN,45.95,32.165,AETNA [1000108],AETNA [100010801],,,76.8,,35.29,0.35,416.02,percent of total billed charges,,,
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,00517-0740-01,NDC,outpatient,1,ML,89.19,62.433,AETNA [1000108],AETNA [100010801],,,76.8,,68.5,15.18518,416.02,percent of total billed charges,,,
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,00517-0740-20,NDC,outpatient,1,ML,89.19,62.433,AETNA [1000108],AETNA [100010801],,,76.8,,68.5,15.18518,416.02,percent of total billed charges,,,
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,51991-0144-17,NDC,outpatient,1,ML,67.64,47.348,AETNA [1000108],AETNA [100010801],,,76.8,,51.95,15.18518,416.02,percent of total billed charges,,,
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,51991-0144-99,NDC,outpatient,1,ML,67.64,47.348,AETNA [1000108],AETNA [100010801],,,76.8,,51.95,15.18518,416.02,percent of total billed charges,,,
METHYLNALTREXONE BROMIDE 12 MG/0.6ML SC SOLN,RX-91651,CDM,J2212,HCPCS,636,RC,65649-0551-02,NDC,outpatient,0.6,ML,659.14,461.398,AETNA [1000108],AETNA [100010801],,,76.8,,506.22,1.07677,506.21952,percent of total billed charges,,,
MICAFUNGIN SODIUM 50 MG IV SOLR,RX-41144,CDM,J2248,HCPCS,636,RC,00469-3250-10,NDC,outpatient,1,UN,384.44,269.108,AETNA [1000108],AETNA [100010801],,,76.8,,295.25,0.29,590.53056,percent of total billed charges,,,
MICAFUNGIN SODIUM 50 MG IV SOLR,RX-41144,CDM,J2248,HCPCS,636,RC,70710-1724-01,NDC,outpatient,1,UN,160.37,112.259,AETNA [1000108],AETNA [100010801],,,76.8,,123.16,0.29,590.53056,percent of total billed charges,,,
MICAFUNGIN SODIUM 50 MG IV SOLR,RX-41144,CDM,J2248,HCPCS,636,RC,70710-1724-06,NDC,outpatient,1,UN,160.37,112.259,AETNA [1000108],AETNA [100010801],,,76.8,,123.16,0.29,590.53056,percent of total billed charges,,,
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,00469-3211-10,NDC,outpatient,1,UN,768.92,538.244,AETNA [1000108],AETNA [100010801],,,76.8,,590.53,0.29,590.53056,percent of total billed charges,,,
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,70710-1725-06,NDC,outpatient,1,UN,320.73,224.511,AETNA [1000108],AETNA [100010801],,,76.8,,246.32,0.29,590.53056,percent of total billed charges,,,
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,25021-0191-10,NDC,outpatient,1,UN,136.09,95.263,AETNA [1000108],AETNA [100010801],,,76.8,,104.52,0.29,590.53056,percent of total billed charges,,,
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,70710-1725-01,NDC,outpatient,1,UN,320.73,224.511,AETNA [1000108],AETNA [100010801],,,76.8,,246.32,0.29,590.53056,percent of total billed charges,,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,00409-2305-16,NDC,outpatient,2,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.13,416.02,percent of total billed charges,,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,23155-0600-31,NDC,outpatient,2,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.13,416.02,percent of total billed charges,,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-15,NDC,outpatient,2,ML,6.08,4.256,AETNA [1000108],AETNA [100010801],,,76.8,,4.67,0.13,416.02,percent of total billed charges,,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-18,NDC,outpatient,5,ML,13.45,9.415,AETNA [1000108],AETNA [100010801],,,76.8,,10.33,0.13,416.02,percent of total billed charges,,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-25,NDC,outpatient,5,ML,13.45,9.415,AETNA [1000108],AETNA [100010801],,,76.8,,10.33,0.13,416.02,percent of total billed charges,,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,00409-2305-17,NDC,outpatient,2,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.13,416.02,percent of total billed charges,,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,23155-0600-41,NDC,outpatient,2,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.13,416.02,percent of total billed charges,,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-12,NDC,outpatient,2,ML,6.08,4.256,AETNA [1000108],AETNA [100010801],,,76.8,,4.67,0.13,416.02,percent of total billed charges,,,
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2250,HCPCS,636,RC,70004-0411-59,NDC,outpatient,100,ML,159.16,111.412,AETNA [1000108],AETNA [100010801],,,76.8,,122.23,0.13,416.02,percent of total billed charges,,,
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2250,HCPCS,636,RC,99999-0001-46,NDC,outpatient,100,ML,75.72,53.004,AETNA [1000108],AETNA [100010801],,,76.8,,58.15,0.13,416.02,percent of total billed charges,,,
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00409-2308-21,NDC,outpatient,1,ML,3.95,2.765,AETNA [1000108],AETNA [100010801],,,76.8,,3.03,0.13,416.02,percent of total billed charges,,,
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00641-6060-01,NDC,outpatient,10,ML,8.07,5.649,AETNA [1000108],AETNA [100010801],,,76.8,,6.2,0.13,416.02,percent of total billed charges,,,
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00641-6060-10,NDC,outpatient,10,ML,8.07,5.649,AETNA [1000108],AETNA [100010801],,,76.8,,6.2,0.13,416.02,percent of total billed charges,,,
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00409-2308-01,NDC,outpatient,1,ML,3.95,2.765,AETNA [1000108],AETNA [100010801],,,76.8,,3.03,0.13,416.02,percent of total billed charges,,,
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2251,HCPCS,636,RC,44567-0611-01,NDC,outpatient,100,ML,77.41,54.187,AETNA [1000108],AETNA [100010801],,,76.8,,59.45,0.18,416.02,percent of total billed charges,,,
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2251,HCPCS,636,RC,44567-0611-10,NDC,outpatient,100,ML,77.41,54.187,AETNA [1000108],AETNA [100010801],,,76.8,,59.45,0.18,416.02,percent of total billed charges,,,
MILRINONE IN DEXTROSE 20 MG/100ML IV SOLN,RX-122186,CDM,J2260,HCPCS,636,RC,00143-9719-10,NDC,outpatient,100,ML,44.93,31.451,AETNA [1000108],AETNA [100010801],,,76.8,,34.51,1.41,416.02,percent of total billed charges,,,
MILRINONE IN DEXTROSE 20 MG/100ML IV SOLN,RX-122186,CDM,J2260,HCPCS,636,RC,00143-9719-01,NDC,outpatient,100,ML,44.93,31.451,AETNA [1000108],AETNA [100010801],,,76.8,,34.51,1.41,416.02,percent of total billed charges,,,
MILRINONE IN DEXTROSE 20 MG/100ML IV SOLN,RX-122186,CDM,J2260,HCPCS,636,RC,25021-0313-82,NDC,outpatient,100,ML,50.27,35.189,AETNA [1000108],AETNA [100010801],,,76.8,,38.61,1.41,416.02,percent of total billed charges,,,
MILRINONE LACTATE 10 MG/10ML IV SOLN,RX-122188,CDM,J2260,HCPCS,636,RC,00143-9710-10,NDC,outpatient,10,ML,16.45,11.515,AETNA [1000108],AETNA [100010801],,,76.8,,12.63,1.41,416.02,percent of total billed charges,,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00409-1891-01,NDC,outpatient,1,ML,9.04,6.328,AETNA [1000108],AETNA [100010801],,,76.8,,6.94,2.02948,416.02,percent of total billed charges,,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00641-6125-25,NDC,outpatient,1,ML,10.46,7.322,AETNA [1000108],AETNA [100010801],,,76.8,,8.03,2.02948,416.02,percent of total billed charges,,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00641-6125-01,NDC,outpatient,1,ML,10.46,7.322,AETNA [1000108],AETNA [100010801],,,76.8,,8.03,2.02948,416.02,percent of total billed charges,,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00409-1891-03,NDC,outpatient,1,ML,9.04,6.328,AETNA [1000108],AETNA [100010801],,,76.8,,6.94,2.02948,416.02,percent of total billed charges,,,
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2270,HCPCS,636,RC,00641-6127-25,NDC,outpatient,1,ML,10.68,7.476,AETNA [1000108],AETNA [100010801],,,76.8,,8.2,2.02948,416.02,percent of total billed charges,,,
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2270,HCPCS,636,RC,00641-6127-01,NDC,outpatient,1,ML,10.68,7.476,AETNA [1000108],AETNA [100010801],,,76.8,,8.2,2.02948,416.02,percent of total billed charges,,,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2270,HCPCS,636,RC,00409-1890-01,NDC,outpatient,1,ML,9.93,6.951,AETNA [1000108],AETNA [100010801],,,76.8,,7.63,2.02948,416.02,percent of total billed charges,,,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2270,HCPCS,636,RC,00409-1890-03,NDC,outpatient,1,ML,9.93,6.951,AETNA [1000108],AETNA [100010801],,,76.8,,7.63,2.02948,416.02,percent of total billed charges,,,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2270,HCPCS,636,RC,52533-0161-45,NDC,outpatient,1,ML,33.38,23.366,AETNA [1000108],AETNA [100010801],,,76.8,,25.64,2.02948,416.02,percent of total billed charges,,,
MORPHINE SULFATE 50 MG/ML IV SOLN,RX-27393,CDM,J2270,HCPCS,636,RC,00409-1134-05,NDC,outpatient,50,ML,115.7,80.99,AETNA [1000108],AETNA [100010801],,,76.8,,88.86,2.02948,416.02,percent of total billed charges,,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2272,HCPCS,636,RC,63323-0454-00,NDC,outpatient,1,ML,8.51,5.957,AETNA [1000108],AETNA [100010801],,,76.8,,6.54,1.816205,416.02,percent of total billed charges,,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2272,HCPCS,636,RC,76045-0005-10,NDC,outpatient,1,ML,8.79,6.153,AETNA [1000108],AETNA [100010801],,,76.8,,6.75,1.816205,416.02,percent of total billed charges,,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2272,HCPCS,636,RC,63323-0454-01,NDC,outpatient,1,ML,8.51,5.957,AETNA [1000108],AETNA [100010801],,,76.8,,6.54,1.816205,416.02,percent of total billed charges,,,
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2272,HCPCS,636,RC,63323-0451-01,NDC,outpatient,1,ML,9.36,6.552,AETNA [1000108],AETNA [100010801],,,76.8,,7.19,1.816205,416.02,percent of total billed charges,,,
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2272,HCPCS,636,RC,63323-0451-00,NDC,outpatient,1,ML,9.36,6.552,AETNA [1000108],AETNA [100010801],,,76.8,,7.19,1.816205,416.02,percent of total billed charges,,,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2272,HCPCS,636,RC,63323-0452-00,NDC,outpatient,1,ML,8.27,5.789,AETNA [1000108],AETNA [100010801],,,76.8,,6.35,1.816205,416.02,percent of total billed charges,,,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2272,HCPCS,636,RC,76045-0004-10,NDC,outpatient,1,ML,8.09,5.663,AETNA [1000108],AETNA [100010801],,,76.8,,6.21,1.816205,416.02,percent of total billed charges,,,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2272,HCPCS,636,RC,63323-0452-01,NDC,outpatient,1,ML,8.27,5.789,AETNA [1000108],AETNA [100010801],,,76.8,,6.35,1.816205,416.02,percent of total billed charges,,,
MORPHINE SULFATE (PF) 1 MG/ML IJ SOLN,RX-15852,CDM,J2274,HCPCS,636,RC,00641-6019-10,NDC,outpatient,10,ML,82.11,57.477,AETNA [1000108],AETNA [100010801],,,76.8,,63.06,10.46,1022.48448,percent of total billed charges,,,
MORPHINE SULFATE (PF) 1 MG/ML IJ SOLN,RX-15852,CDM,J2274,HCPCS,636,RC,00641-6019-01,NDC,outpatient,10,ML,82.11,57.477,AETNA [1000108],AETNA [100010801],,,76.8,,63.06,10.46,1022.48448,percent of total billed charges,,,
MORPHINE SULF MICROINFUSION PF 200 MG/20ML (10 MG/ML) IJ SOLN,RX-77009,CDM,J2274,HCPCS,636,RC,00641-6039-01,NDC,outpatient,20,ML,695.45,486.815,AETNA [1000108],AETNA [100010801],,,76.8,,534.11,10.46,1022.48448,percent of total billed charges,,,
MORPHINE SULF MICROINFUSION PF 500 MG/20ML (25 MG/ML) IJ SOLN,RX-77010,CDM,J2274,HCPCS,636,RC,00641-6040-01,NDC,outpatient,20,ML,1331.36,931.952,AETNA [1000108],AETNA [100010801],,,76.8,,1022.48,10.46,1022.48448,percent of total billed charges,,,
NALBUPHINE HCL 10 MG/ML IJ SOLN,RX-5339,CDM,J2300,HCPCS,636,RC,00409-1463-71,NDC,outpatient,1,ML,17.79,12.453,AETNA [1000108],AETNA [100010801],,,76.8,,13.66,2.72,416.02,percent of total billed charges,,,
NALBUPHINE HCL 10 MG/ML IJ SOLN,RX-5339,CDM,J2300,HCPCS,636,RC,00409-1463-01,NDC,outpatient,1,ML,17.79,12.453,AETNA [1000108],AETNA [100010801],,,76.8,,13.66,2.72,416.02,percent of total billed charges,,,
NITROGLYCERIN IN D5W 400-5 MCG/ML-% IV SOLN,RX-14895,CDM,J2305,HCPCS,636,RC,00338-1051-02,NDC,outpatient,250,ML,62.73,43.911,AETNA [1000108],AETNA [100010801],,,76.8,,48.18,1.3,416.02,percent of total billed charges,,,
NITROGLYCERIN IN D5W 400-5 MCG/ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-14895,CDM,J2305,HCPCS,636,RC,00338-1051-02,NDC,outpatient,250,ML,46.73,32.711,AETNA [1000108],AETNA [100010801],JW,,76.8,,35.89,1.3,416.02,percent of total billed charges,,,
NITROGLYCERIN IN D5W 100-5 MCG/ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-15858,CDM,J2305,HCPCS,636,RC,00338-1047-02,NDC,outpatient,250,ML,40.05,28.035,AETNA [1000108],AETNA [100010801],JW,,76.8,,30.76,1.3,416.02,percent of total billed charges,,,
NITROGLYCERIN IN D5W 100-5 MCG/ML-% IV SOLN,RX-15858,CDM,J2305,HCPCS,636,RC,00338-1047-02,NDC,outpatient,250,ML,56.05,39.235,AETNA [1000108],AETNA [100010801],,,76.8,,43.05,1.3,416.02,percent of total billed charges,,,
NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN,RX-15859,CDM,J2305,HCPCS,636,RC,99999-0004-40,NDC,outpatient,250,ML,45.49,31.843,AETNA [1000108],AETNA [100010801],,,76.8,,34.94,1.3,416.02,percent of total billed charges,,,
NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN,RX-15859,CDM,J2305,HCPCS,636,RC,00338-1049-02,NDC,outpatient,250,ML,58.28,40.796,AETNA [1000108],AETNA [100010801],,,76.8,,44.76,1.3,416.02,percent of total billed charges,,,
NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-15859,CDM,J2305,HCPCS,636,RC,00338-1049-02,NDC,outpatient,250,ML,42.28,29.596,AETNA [1000108],AETNA [100010801],JW,,76.8,,32.47,1.3,416.02,percent of total billed charges,,,
NITROGLYCERIN 5 MG/ML IV SOLN,RX-5599,CDM,J2305,HCPCS,636,RC,00517-4810-01,NDC,outpatient,10,ML,51.4,35.98,AETNA [1000108],AETNA [100010801],,,76.8,,39.48,1.3,416.02,percent of total billed charges,,,
NITROGLYCERIN 5 MG/ML IV SOLN,RX-5599,CDM,J2305,HCPCS,636,RC,00517-4810-25,NDC,outpatient,10,ML,51.4,35.98,AETNA [1000108],AETNA [100010801],,,76.8,,39.48,1.3,416.02,percent of total billed charges,,,
NALOXONE HCL 2 MG/2ML IJ SOSY,RX-136113,CDM,J2310,HCPCS,636,RC,76329-3369-01,NDC,outpatient,2,ML,42.08,29.456,AETNA [1000108],AETNA [100010801],,,76.8,,32.32,3.03075,416.02,percent of total billed charges,,,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,67457-0292-02,NDC,outpatient,1,ML,15.44,10.808,AETNA [1000108],AETNA [100010801],,,76.8,,11.86,3.03075,416.02,percent of total billed charges,,,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,00409-1215-21,NDC,outpatient,1,ML,63.16,44.212,AETNA [1000108],AETNA [100010801],,,76.8,,48.51,3.03075,416.02,percent of total billed charges,,,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,36000-0308-01,NDC,outpatient,1,ML,13.5,9.45,AETNA [1000108],AETNA [100010801],,,76.8,,10.37,3.03075,416.02,percent of total billed charges,,,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,36000-0308-10,NDC,outpatient,1,ML,13.5,9.45,AETNA [1000108],AETNA [100010801],,,76.8,,10.37,3.03075,416.02,percent of total billed charges,,,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,67457-0292-00,NDC,outpatient,1,ML,15.44,10.808,AETNA [1000108],AETNA [100010801],,,76.8,,11.86,3.03075,416.02,percent of total billed charges,,,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,00409-1215-01,NDC,outpatient,1,ML,63.16,44.212,AETNA [1000108],AETNA [100010801],,,76.8,,48.51,3.03075,416.02,percent of total billed charges,,,
OCTREOTIDE ACETATE 50 MCG/ML IJ SOLN,RX-91278,CDM,J2354,HCPCS,636,RC,67457-0239-00,NDC,outpatient,1,ML,17.58,12.306,AETNA [1000108],AETNA [100010801],,,76.8,,13.5,0.86,416.02,percent of total billed charges,,,
OCTREOTIDE ACETATE 50 MCG/ML IJ SOLN,RX-91278,CDM,J2354,HCPCS,636,RC,67457-0239-01,NDC,outpatient,1,ML,17.58,12.306,AETNA [1000108],AETNA [100010801],,,76.8,,13.5,0.86,416.02,percent of total billed charges,,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,23155-0688-31,NDC,outpatient,1,ML,11.88,8.316,AETNA [1000108],AETNA [100010801],,,76.8,,9.12,0.86,416.02,percent of total billed charges,,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,63323-0376-00,NDC,outpatient,1,ML,11.92,8.344,AETNA [1000108],AETNA [100010801],,,76.8,,9.15,0.86,416.02,percent of total billed charges,,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,00641-6175-10,NDC,outpatient,1,ML,7.84,5.488,AETNA [1000108],AETNA [100010801],,,76.8,,6.02,0.86,416.02,percent of total billed charges,,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,23155-0688-41,NDC,outpatient,1,ML,11.88,8.316,AETNA [1000108],AETNA [100010801],,,76.8,,9.12,0.86,416.02,percent of total billed charges,,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,63323-0376-01,NDC,outpatient,1,ML,11.92,8.344,AETNA [1000108],AETNA [100010801],,,76.8,,9.15,0.86,416.02,percent of total billed charges,,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,00641-6175-01,NDC,outpatient,1,ML,7.84,5.488,AETNA [1000108],AETNA [100010801],,,76.8,,6.02,0.86,416.02,percent of total billed charges,,,
OCTREOTIDE ACETATE 200 MCG/ML IJ SOLN,RX-91280,CDM,J2354,HCPCS,636,RC,00641-6177-01,NDC,outpatient,0.5,ML,25.17,17.619,AETNA [1000108],AETNA [100010801],,,76.8,,19.33,0.86,416.02,percent of total billed charges,,,
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,63323-0377-00,NDC,outpatient,1,ML,41.91,29.337,AETNA [1000108],AETNA [100010801],,,76.8,,32.19,0.86,416.02,percent of total billed charges,,,
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,63323-0377-01,NDC,outpatient,1,ML,41.91,29.337,AETNA [1000108],AETNA [100010801],,,76.8,,32.19,0.86,416.02,percent of total billed charges,,,
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,00641-6176-01,NDC,outpatient,1,ML,46.52,32.564,AETNA [1000108],AETNA [100010801],,,76.8,,35.73,0.86,416.02,percent of total billed charges,,,
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,00641-6176-10,NDC,outpatient,1,ML,46.52,32.564,AETNA [1000108],AETNA [100010801],,,76.8,,35.73,0.86,416.02,percent of total billed charges,,,
OMALIZUMAB 150 MG/ML SC SOSY,RX-144954,CDM,J2357,HCPCS,636,RC,50242-0215-01,NDC,outpatient,1,ML,3822.49,2675.743,AETNA [1000108],AETNA [100010801],,,76.8,,2935.67,38.29,2935.67232,percent of total billed charges,,,
OMALIZUMAB 75 MG/0.5ML SC SOSY,RX-144955,CDM,J2357,HCPCS,636,RC,50242-0214-01,NDC,outpatient,0.5,ML,1911.25,1337.875,AETNA [1000108],AETNA [100010801],,,76.8,,1467.84,38.29,2935.67232,percent of total billed charges,,,
OMALIZUMAB 150 MG SC SOLR,RX-36151,CDM,J2357,HCPCS,636,RC,50242-0040-62,NDC,outpatient,1,UN,3822.49,2675.743,AETNA [1000108],AETNA [100010801],,,76.8,,2935.67,38.29,2935.67232,percent of total billed charges,,,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00517-0955-01,NDC,outpatient,1,UN,115.66,80.962,AETNA [1000108],AETNA [100010801],,,76.8,,88.83,0.92,416.02,percent of total billed charges,,,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00781-9105-72,NDC,outpatient,1,UN,62.44,43.708,AETNA [1000108],AETNA [100010801],,,76.8,,47.95,0.92,416.02,percent of total billed charges,,,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00781-3159-72,NDC,outpatient,1,UN,62.44,43.708,AETNA [1000108],AETNA [100010801],,,76.8,,47.95,0.92,416.02,percent of total billed charges,,,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00002-7597-01,NDC,outpatient,1,UN,206.8,144.76,AETNA [1000108],AETNA [100010801],,,76.8,,158.82,0.92,416.02,percent of total billed charges,,,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,55150-0308-01,NDC,outpatient,1,UN,77.39,54.173,AETNA [1000108],AETNA [100010801],,,76.8,,59.44,0.92,416.02,percent of total billed charges,,,
ORPHENADRINE CITRATE 30 MG/ML IJ SOLN,RX-5886,CDM,J2360,HCPCS,636,RC,00641-6182-10,NDC,outpatient,2,ML,19.23,13.461,AETNA [1000108],AETNA [100010801],,,76.8,,14.77,4.317135,416.02,percent of total billed charges,,,
ORPHENADRINE CITRATE 30 MG/ML IJ SOLN,RX-5886,CDM,J2360,HCPCS,636,RC,00641-6182-01,NDC,outpatient,2,ML,19.23,13.461,AETNA [1000108],AETNA [100010801],,,76.8,,14.77,4.317135,416.02,percent of total billed charges,,,
PHENYLEPHRINE HCL 100 MCG/ML SYRINGE,RX-4080501,CDM,J2371,HCPCS,636,RC,70004-0810-12,NDC,outpatient,10,ML,25.28,17.696,AETNA [1000108],AETNA [100010801],,,76.8,,19.42,0.01,416.02,percent of total billed charges,,,
PHENYLEPHRINE HCL 100 MCG/ML SYRINGE,RX-4080501,CDM,J2371,HCPCS,636,RC,70092-1046-46,NDC,outpatient,10,ML,24.79,17.353,AETNA [1000108],AETNA [100010801],,,76.8,,19.04,0.01,416.02,percent of total billed charges,,,
PHENYLEPHRINE HCL 100 MCG/ML SYRINGE,RX-4080501,CDM,J2371,HCPCS,636,RC,70004-0810-11,NDC,outpatient,5,ML,23.81,16.667,AETNA [1000108],AETNA [100010801],,,76.8,,18.29,0.01,416.02,percent of total billed charges,,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,00781-3422-71,NDC,outpatient,1,ML,12.34,8.638,AETNA [1000108],AETNA [100010801],,,76.8,,9.48,0.01,416.02,percent of total billed charges,,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1578-01,NDC,outpatient,5,ML,19.7,13.79,AETNA [1000108],AETNA [100010801],,,76.8,,15.13,0.01,416.02,percent of total billed charges,,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1578-07,NDC,outpatient,5,ML,19.7,13.79,AETNA [1000108],AETNA [100010801],,,76.8,,15.13,0.01,416.02,percent of total billed charges,,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,25021-0315-01,NDC,outpatient,1,ML,3.42,2.394,AETNA [1000108],AETNA [100010801],,,76.8,,2.63,0.01,416.02,percent of total billed charges,,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70069-0801-25,NDC,outpatient,1,ML,6.49,4.543,AETNA [1000108],AETNA [100010801],,,76.8,,4.98,0.01,416.02,percent of total billed charges,,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1577-05,NDC,outpatient,1,ML,9.89,6.923,AETNA [1000108],AETNA [100010801],,,76.8,,7.6,0.01,416.02,percent of total billed charges,,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1577-01,NDC,outpatient,1,ML,9.89,6.923,AETNA [1000108],AETNA [100010801],,,76.8,,7.6,0.01,416.02,percent of total billed charges,,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,00781-3422-92,NDC,outpatient,1,ML,12.34,8.638,AETNA [1000108],AETNA [100010801],,,76.8,,9.48,0.01,416.02,percent of total billed charges,,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70069-0801-01,NDC,outpatient,1,ML,6.49,4.543,AETNA [1000108],AETNA [100010801],,,76.8,,4.98,0.01,416.02,percent of total billed charges,,,
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,00143-9209-01,NDC,outpatient,20,ML,51.18,35.826,AETNA [1000108],AETNA [100010801],,,76.8,,39.31,0.03,416.02,percent of total billed charges,,,
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,63323-0477-01,NDC,outpatient,20,ML,78.86,55.202,AETNA [1000108],AETNA [100010801],,,76.8,,60.56,0.03,416.02,percent of total billed charges,,,
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,00143-9209-10,NDC,outpatient,20,ML,51.18,35.826,AETNA [1000108],AETNA [100010801],,,76.8,,39.31,0.03,416.02,percent of total billed charges,,,
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,63323-0477-27,NDC,outpatient,20,ML,78.86,55.202,AETNA [1000108],AETNA [100010801],,,76.8,,60.56,0.03,416.02,percent of total billed charges,,,
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,00143-9210-01,NDC,outpatient,20,ML,54.03,37.821,AETNA [1000108],AETNA [100010801],,,76.8,,41.5,0.03,416.02,percent of total billed charges,,,
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,63323-0478-01,NDC,outpatient,20,ML,82.77,57.939,AETNA [1000108],AETNA [100010801],,,76.8,,63.57,0.03,416.02,percent of total billed charges,,,
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,00143-9210-10,NDC,outpatient,20,ML,54.03,37.821,AETNA [1000108],AETNA [100010801],,,76.8,,41.5,0.03,416.02,percent of total billed charges,,,
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,63323-0478-27,NDC,outpatient,20,ML,82.77,57.939,AETNA [1000108],AETNA [100010801],,,76.8,,63.57,0.03,416.02,percent of total billed charges,,,
NICARDIPINE HCL 2.5 MG/ML IV SOLN,RX-12370,CDM,J2404,HCPCS,636,RC,00143-9689-10,NDC,outpatient,10,ML,41.12,28.784,AETNA [1000108],AETNA [100010801],,,76.8,,31.58,0.54,416.02,percent of total billed charges,,,
NICARDIPINE HCL 2.5 MG/ML IV SOLN,RX-12370,CDM,J2404,HCPCS,636,RC,00143-9689-01,NDC,outpatient,10,ML,41.12,28.784,AETNA [1000108],AETNA [100010801],,,76.8,,31.58,0.54,416.02,percent of total billed charges,,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00641-6078-01,NDC,outpatient,2,ML,3.61,2.527,AETNA [1000108],AETNA [100010801],,,76.8,,2.77,0.09,416.02,percent of total billed charges,,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00641-6078-25,NDC,outpatient,2,ML,3.61,2.527,AETNA [1000108],AETNA [100010801],,,76.8,,2.77,0.09,416.02,percent of total billed charges,,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,23155-0547-31,NDC,outpatient,2,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.09,416.02,percent of total billed charges,,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,23155-0549-31,NDC,outpatient,20,ML,18.1,12.67,AETNA [1000108],AETNA [100010801],,,76.8,,13.9,0.09,416.02,percent of total billed charges,,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,60505-6130-00,NDC,outpatient,2,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.09,416.02,percent of total billed charges,,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00409-4755-03,NDC,outpatient,2,ML,6.09,4.263,AETNA [1000108],AETNA [100010801],,,76.8,,4.68,0.09,416.02,percent of total billed charges,,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,23155-0547-42,NDC,outpatient,2,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.09,416.02,percent of total billed charges,,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,60505-6130-05,NDC,outpatient,2,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.09,416.02,percent of total billed charges,,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00409-4755-18,NDC,outpatient,2,ML,6.09,4.263,AETNA [1000108],AETNA [100010801],,,76.8,,4.68,0.09,416.02,percent of total billed charges,,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,36000-0012-25,NDC,outpatient,2,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.09,416.02,percent of total billed charges,,,
PAMIDRONATE DISODIUM 30 MG/10ML IV SOLN,RX-32589,CDM,J2430,HCPCS,636,RC,67457-0430-10,NDC,outpatient,10,ML,36.81,25.767,AETNA [1000108],AETNA [100010801],,,76.8,,28.27,8.263845,416.02,percent of total billed charges,,,
PAMIDRONATE DISODIUM 30 MG/10ML IV SOLN,RX-32589,CDM,J2430,HCPCS,636,RC,61703-0324-18,NDC,outpatient,10,ML,46.42,32.494,AETNA [1000108],AETNA [100010801],,,76.8,,35.65,8.263845,416.02,percent of total billed charges,,,
PALONOSETRON HCL 0.25 MG/5ML IV SOLN,RX-36591,CDM,J2469,HCPCS,636,RC,55111-0694-07,NDC,outpatient,5,ML,25.1,17.57,AETNA [1000108],AETNA [100010801],,,76.8,,19.28,0.62,416.02,percent of total billed charges,,,
PALONOSETRON HCL 0.25 MG/5ML IV SOLN,RX-36591,CDM,J2469,HCPCS,636,RC,60505-6193-01,NDC,outpatient,5,ML,13.32,9.324,AETNA [1000108],AETNA [100010801],,,76.8,,10.23,0.62,416.02,percent of total billed charges,,,
PARICALCITOL 5 MCG/ML IV SOLN,RX-22960,CDM,J2501,HCPCS,636,RC,00074-1658-01,NDC,outpatient,1,ML,40.71,28.497,AETNA [1000108],AETNA [100010801],,,76.8,,31.27,0.5,416.02,percent of total billed charges,,,
PEGLOTICASE 8 MG/ML IV SOLN,RX-107664,CDM,J2507,HCPCS,636,RC,75987-0080-10,NDC,outpatient,1,ML,59467.57,41627.299,AETNA [1000108],AETNA [100010801],,,76.8,,45671.09,399.86,45671.09376,percent of total billed charges,,,
PENICILLIN G POT IN DEXTROSE 60000 UNIT/ML IV WRAPPER,RX-4080111,CDM,J2540,HCPCS,636,RC,00338-1025-41,NDC,outpatient,50,ML,55.67,38.969,AETNA [1000108],AETNA [100010801],,,76.8,,42.75,1.01,416.02,percent of total billed charges,,,
PENICILLIN G POTASSIUM 5000000 UNITS IJ SOLR,RX-6086,CDM,J2540,HCPCS,636,RC,44567-0311-10,NDC,outpatient,1,UN,17.93,12.551,AETNA [1000108],AETNA [100010801],,,76.8,,13.77,1.01,416.02,percent of total billed charges,,,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,00781-3114-91,NDC,outpatient,1,UN,30.55,21.385,AETNA [1000108],AETNA [100010801],,,76.8,,23.46,1.1,416.02,percent of total billed charges,,,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,44567-0803-10,NDC,outpatient,1,UN,27.96,19.572,AETNA [1000108],AETNA [100010801],,,76.8,,21.47,1.1,416.02,percent of total billed charges,,,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,00781-3114-95,NDC,outpatient,1,UN,30.55,21.385,AETNA [1000108],AETNA [100010801],,,76.8,,23.46,1.1,416.02,percent of total billed charges,,,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,55150-0121-50,NDC,outpatient,1,UN,18.43,12.901,AETNA [1000108],AETNA [100010801],,,76.8,,14.15,1.1,416.02,percent of total billed charges,,,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,72485-0404-10,NDC,outpatient,1,UN,18.51,12.957,AETNA [1000108],AETNA [100010801],,,76.8,,14.22,1.1,416.02,percent of total billed charges,,,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,72485-0404-01,NDC,outpatient,1,UN,18.51,12.957,AETNA [1000108],AETNA [100010801],,,76.8,,14.22,1.1,416.02,percent of total billed charges,,,
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,60505-6157-00,NDC,outpatient,1,UN,9.79,6.853,AETNA [1000108],AETNA [100010801],,,76.8,,7.52,1.1,416.02,percent of total billed charges,,,
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,64679-0056-02,NDC,outpatient,1,UN,13.78,9.646,AETNA [1000108],AETNA [100010801],,,76.8,,10.58,1.1,416.02,percent of total billed charges,,,
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,64679-0056-01,NDC,outpatient,1,UN,13.78,9.646,AETNA [1000108],AETNA [100010801],,,76.8,,10.58,1.1,416.02,percent of total billed charges,,,
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,55150-0120-30,NDC,outpatient,1,UN,12.91,9.037,AETNA [1000108],AETNA [100010801],,,76.8,,9.91,1.1,416.02,percent of total billed charges,,,
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,60505-6157-04,NDC,outpatient,1,UN,9.79,6.853,AETNA [1000108],AETNA [100010801],,,76.8,,7.52,1.1,416.02,percent of total billed charges,,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00409-3383-11,NDC,outpatient,1,UN,25.13,17.591,AETNA [1000108],AETNA [100010801],,,76.8,,19.3,1.1,416.02,percent of total billed charges,,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00781-3110-90,NDC,outpatient,1,UN,17.66,12.362,AETNA [1000108],AETNA [100010801],,,76.8,,13.56,1.1,416.02,percent of total billed charges,,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,44567-0801-10,NDC,outpatient,1,UN,14.21,9.947,AETNA [1000108],AETNA [100010801],,,76.8,,10.91,1.1,416.02,percent of total billed charges,,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,55150-0119-30,NDC,outpatient,1,UN,8.76,6.132,AETNA [1000108],AETNA [100010801],,,76.8,,6.73,1.1,416.02,percent of total billed charges,,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00781-3110-95,NDC,outpatient,1,UN,17.66,12.362,AETNA [1000108],AETNA [100010801],,,76.8,,13.56,1.1,416.02,percent of total billed charges,,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00409-3383-02,NDC,outpatient,1,UN,25.13,17.591,AETNA [1000108],AETNA [100010801],,,76.8,,19.3,1.1,416.02,percent of total billed charges,,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,60505-6156-00,NDC,outpatient,1,UN,7.94,5.558,AETNA [1000108],AETNA [100010801],,,76.8,,6.1,1.1,416.02,percent of total billed charges,,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,60505-6156-04,NDC,outpatient,1,UN,7.94,5.558,AETNA [1000108],AETNA [100010801],,,76.8,,6.1,1.1,416.02,percent of total billed charges,,,
PROMETHAZINE HCL 25 MG/ML IJ SOLN,RX-6618,CDM,J2550,HCPCS,636,RC,00641-1495-35,NDC,outpatient,1,ML,7.75,5.425,AETNA [1000108],AETNA [100010801],,,76.8,,5.95,1.739875,416.02,percent of total billed charges,,,
PROMETHAZINE HCL 25 MG/ML IJ SOLN,RX-6618,CDM,J2550,HCPCS,636,RC,00641-1495-31,NDC,outpatient,1,ML,7.75,5.425,AETNA [1000108],AETNA [100010801],,,76.8,,5.95,1.739875,416.02,percent of total billed charges,,,
PHENOBARBITAL SODIUM 130 MG/ML IJ SOLN,RX-6221,CDM,J2560,HCPCS,636,RC,00641-0477-21,NDC,outpatient,1,ML,155.87,109.109,AETNA [1000108],AETNA [100010801],,,76.8,,119.71,13.89655,416.02,percent of total billed charges,,,
PHENOBARBITAL SODIUM 130 MG/ML IJ SOLN,RX-6221,CDM,J2560,HCPCS,636,RC,00641-0477-25,NDC,outpatient,1,ML,155.87,109.109,AETNA [1000108],AETNA [100010801],,,76.8,,119.71,13.89655,416.02,percent of total billed charges,,,
PHENOBARBITAL SODIUM 65 MG/ML IJ SOLN,RX-6224,CDM,J2560,HCPCS,636,RC,00641-0476-25,NDC,outpatient,1,ML,61.9,43.33,AETNA [1000108],AETNA [100010801],,,76.8,,47.54,13.89655,416.02,percent of total billed charges,,,
PHENOBARBITAL SODIUM 65 MG/ML IJ SOLN,RX-6224,CDM,J2560,HCPCS,636,RC,00641-0476-21,NDC,outpatient,1,ML,61.9,43.33,AETNA [1000108],AETNA [100010801],,,76.8,,47.54,13.89655,416.02,percent of total billed charges,,,
OXYTOCIN 10 UNIT/ML IJ SOLN,RX-5944,CDM,J2590,HCPCS,636,RC,63323-0012-10,NDC,outpatient,0.3,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.74534,416.02,percent of total billed charges,,,
OXYTOCIN 10 UNIT/ML IJ SOLN,RX-5944,CDM,J2590,HCPCS,636,RC,42023-0116-25,NDC,outpatient,1,ML,7.42,5.194,AETNA [1000108],AETNA [100010801],,,76.8,,5.7,0.74534,416.02,percent of total billed charges,,,
OXYTOCIN 10 UNIT/ML IJ SOLN,RX-5944,CDM,J2590,HCPCS,636,RC,63323-0012-06,NDC,outpatient,0.3,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.74534,416.02,percent of total billed charges,,,
DESMOPRESSIN ACETATE 4 MCG/ML IJ SOLN WRAPPER,RX-4081353,CDM,J2597,HCPCS,636,RC,69918-0899-01,NDC,outpatient,1,ML,91.9,64.33,AETNA [1000108],AETNA [100010801],,,76.8,,70.58,5.42,416.02,percent of total billed charges,,,
DESMOPRESSIN ACETATE 4 MCG/ML IJ SOLN WRAPPER,RX-4081353,CDM,J2597,HCPCS,636,RC,69918-0899-10,NDC,outpatient,1,ML,91.9,64.33,AETNA [1000108],AETNA [100010801],,,76.8,,70.58,5.42,416.02,percent of total billed charges,,,
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-10,NDC,outpatient,100,ML,550.45,385.315,AETNA [1000108],AETNA [100010801],,,76.8,,422.75,1.62,422.7456,percent of total billed charges,,,
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-10,NDC,outpatient,100,ML,534.45,374.115,AETNA [1000108],AETNA [100010801],JW,,76.8,,410.46,1.62,422.7456,percent of total billed charges,,,
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-01,NDC,outpatient,100,ML,550.45,385.315,AETNA [1000108],AETNA [100010801],,,76.8,,422.75,1.62,422.7456,percent of total billed charges,,,
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-01,NDC,outpatient,100,ML,534.45,374.115,AETNA [1000108],AETNA [100010801],JW,,76.8,,410.46,1.62,422.7456,percent of total billed charges,,,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42023-0164-25,NDC,outpatient,1,ML,50.82,35.574,AETNA [1000108],AETNA [100010801],,,76.8,,39.03,1.62,422.7456,percent of total billed charges,,,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,55150-0370-25,NDC,outpatient,0.25,ML,21.94,15.358,AETNA [1000108],AETNA [100010801],,,76.8,,16.85,1.62,422.7456,percent of total billed charges,,,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42367-0570-87,NDC,outpatient,0.25,ML,175.83,123.081,AETNA [1000108],AETNA [100010801],,,76.8,,135.04,1.62,422.7456,percent of total billed charges,,,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,55150-0370-01,NDC,outpatient,0.25,ML,21.94,15.358,AETNA [1000108],AETNA [100010801],,,76.8,,16.85,1.62,422.7456,percent of total billed charges,,,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42367-0570-22,NDC,outpatient,0.25,ML,175.83,123.081,AETNA [1000108],AETNA [100010801],,,76.8,,135.04,1.62,422.7456,percent of total billed charges,,,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42023-0164-01,NDC,outpatient,1,ML,50.82,35.574,AETNA [1000108],AETNA [100010801],,,76.8,,39.03,1.62,422.7456,percent of total billed charges,,,
FLUPHENAZINE HCL 2.5 MG/ML IJ SOLN,RX-3216,CDM,J2679,HCPCS,636,RC,63323-0281-10,NDC,outpatient,0.5,ML,19.62,13.734,AETNA [1000108],AETNA [100010801],,,76.8,,15.07,4.40469,416.02,percent of total billed charges,,,
FLUPHENAZINE DECANOATE 25 MG/ML IJ SOLN,RX-3215,CDM,J2680,HCPCS,636,RC,63323-0272-05,NDC,outpatient,0.5,ML,32.89,23.023,AETNA [1000108],AETNA [100010801],,,76.8,,25.26,4.586535,416.02,percent of total billed charges,,,
FLUPHENAZINE DECANOATE 25 MG/ML IJ SOLN,RX-3215,CDM,J2680,HCPCS,636,RC,42023-0129-01,NDC,outpatient,0.5,ML,20.43,14.301,AETNA [1000108],AETNA [100010801],,,76.8,,15.69,4.586535,416.02,percent of total billed charges,,,
PROCAINAMIDE HCL 100 MG/ML IJ SOLN,RX-6562,CDM,J2690,HCPCS,636,RC,00409-1902-11,NDC,outpatient,1,ML,24.43,17.101,AETNA [1000108],AETNA [100010801],,,76.8,,18.76,5.484535,1082.90304,percent of total billed charges,,,
PROCAINAMIDE HCL 100 MG/ML IJ SOLN,RX-6562,CDM,J2690,HCPCS,636,RC,00409-1902-01,NDC,outpatient,1,ML,24.43,17.101,AETNA [1000108],AETNA [100010801],,,76.8,,18.76,5.484535,1082.90304,percent of total billed charges,,,
PROCAINAMIDE HCL 500 MG/ML IJ SOLN,RX-6563,CDM,J2690,HCPCS,636,RC,14789-0900-07,NDC,outpatient,2,ML,1410.03,987.021,AETNA [1000108],AETNA [100010801],,,76.8,,1082.9,5.484535,1082.90304,percent of total billed charges,,,
PROCAINAMIDE HCL 500 MG/ML IJ SOLN,RX-6563,CDM,J2690,HCPCS,636,RC,14789-0900-02,NDC,outpatient,2,ML,1410.03,987.021,AETNA [1000108],AETNA [100010801],,,76.8,,1082.9,5.484535,1082.90304,percent of total billed charges,,,
OXACILLIN SODIUM 10 G IV SOLR,RX-150085,CDM,J2700,HCPCS,636,RC,25021-0163-99,NDC,outpatient,1,UN,489.5,342.65,AETNA [1000108],AETNA [100010801],,,76.8,,375.94,0.87,416.02,percent of total billed charges,,,
OXACILLIN SODIUM 10 G IV SOLR,RX-150085,CDM,J2700,HCPCS,636,RC,55150-0129-99,NDC,outpatient,1,UN,150.46,105.322,AETNA [1000108],AETNA [100010801],,,76.8,,115.55,0.87,416.02,percent of total billed charges,,,
OXACILLIN SODIUM 10 G IV SOLR,RX-150085,CDM,J2700,HCPCS,636,RC,63323-0811-00,NDC,outpatient,1,UN,137.38,96.166,AETNA [1000108],AETNA [100010801],,,76.8,,105.51,0.87,416.02,percent of total billed charges,,,
OXACILLIN SODIUM 1 G IJ SOLR,RX-5924,CDM,J2700,HCPCS,636,RC,64679-0698-01,NDC,outpatient,1,UN,20.97,14.679,AETNA [1000108],AETNA [100010801],,,76.8,,16.1,0.87,416.02,percent of total billed charges,,,
OXACILLIN SODIUM 1 G IJ SOLR,RX-5924,CDM,J2700,HCPCS,636,RC,64679-0698-02,NDC,outpatient,1,UN,20.97,14.679,AETNA [1000108],AETNA [100010801],,,76.8,,16.1,0.87,416.02,percent of total billed charges,,,
OXACILLIN SODIUM 1 G IJ SOLR,RX-5924,CDM,J2700,HCPCS,636,RC,55150-0127-15,NDC,outpatient,1,UN,19.11,13.377,AETNA [1000108],AETNA [100010801],,,76.8,,14.68,0.87,416.02,percent of total billed charges,,,
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,63323-0812-20,NDC,outpatient,1,UN,25.17,17.619,AETNA [1000108],AETNA [100010801],,,76.8,,19.33,0.87,416.02,percent of total billed charges,,,
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,64679-0699-01,NDC,outpatient,1,UN,38.24,26.768,AETNA [1000108],AETNA [100010801],,,76.8,,29.37,0.87,416.02,percent of total billed charges,,,
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,64679-0699-02,NDC,outpatient,1,UN,38.24,26.768,AETNA [1000108],AETNA [100010801],,,76.8,,29.37,0.87,416.02,percent of total billed charges,,,
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,63323-0812-01,NDC,outpatient,1,UN,25.17,17.619,AETNA [1000108],AETNA [100010801],,,76.8,,19.33,0.87,416.02,percent of total billed charges,,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0209-10,NDC,outpatient,20,ML,9.98,6.986,AETNA [1000108],AETNA [100010801],,,76.8,,7.66,0.09,416.02,percent of total billed charges,,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0234-01,NDC,outpatient,50,ML,21.59,15.113,AETNA [1000108],AETNA [100010801],,,76.8,,16.58,0.09,416.02,percent of total billed charges,,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0234-20,NDC,outpatient,50,ML,21.59,15.113,AETNA [1000108],AETNA [100010801],,,76.8,,16.58,0.09,416.02,percent of total billed charges,,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-33,NDC,outpatient,50,ML,18.47,12.929,AETNA [1000108],AETNA [100010801],,,76.8,,14.18,0.09,416.02,percent of total billed charges,,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-54,NDC,outpatient,100,ML,36.94,25.858,AETNA [1000108],AETNA [100010801],,,76.8,,28.37,0.09,416.02,percent of total billed charges,,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,63323-0269-22,NDC,outpatient,20,ML,9.57,6.699,AETNA [1000108],AETNA [100010801],,,76.8,,7.35,0.09,416.02,percent of total billed charges,,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,63323-0269-29,NDC,outpatient,20,ML,9.57,6.699,AETNA [1000108],AETNA [100010801],,,76.8,,7.35,0.09,416.02,percent of total billed charges,,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0209-01,NDC,outpatient,20,ML,9.98,6.986,AETNA [1000108],AETNA [100010801],,,76.8,,7.66,0.09,416.02,percent of total billed charges,,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0248-01,NDC,outpatient,100,ML,43.17,30.219,AETNA [1000108],AETNA [100010801],,,76.8,,33.15,0.09,416.02,percent of total billed charges,,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0248-10,NDC,outpatient,100,ML,43.17,30.219,AETNA [1000108],AETNA [100010801],,,76.8,,33.15,0.09,416.02,percent of total billed charges,,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0690-10,NDC,outpatient,100,ML,32.93,23.051,AETNA [1000108],AETNA [100010801],,,76.8,,25.29,0.09,416.02,percent of total billed charges,,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0977-01,NDC,outpatient,50,ML,18.69,13.083,AETNA [1000108],AETNA [100010801],,,76.8,,14.35,0.09,416.02,percent of total billed charges,,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0977-20,NDC,outpatient,50,ML,18.69,13.083,AETNA [1000108],AETNA [100010801],,,76.8,,14.35,0.09,416.02,percent of total billed charges,,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,25021-0608-51,NDC,outpatient,100,ML,57.41,40.187,AETNA [1000108],AETNA [100010801],,,76.8,,44.09,0.09,416.02,percent of total billed charges,,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,43598-0548-21,NDC,outpatient,50,ML,20.47,14.329,AETNA [1000108],AETNA [100010801],,,76.8,,15.72,0.09,416.02,percent of total billed charges,,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-24,NDC,outpatient,100,ML,36.94,25.858,AETNA [1000108],AETNA [100010801],,,76.8,,28.37,0.09,416.02,percent of total billed charges,,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,25021-0608-20,NDC,outpatient,20,ML,10.49,7.343,AETNA [1000108],AETNA [100010801],,,76.8,,8.06,0.09,416.02,percent of total billed charges,,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,43598-0548-50,NDC,outpatient,50,ML,20.47,14.329,AETNA [1000108],AETNA [100010801],,,76.8,,15.72,0.09,416.02,percent of total billed charges,,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-53,NDC,outpatient,50,ML,18.47,12.929,AETNA [1000108],AETNA [100010801],,,76.8,,14.18,0.09,416.02,percent of total billed charges,,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0528-01,NDC,outpatient,20,ML,8.95,6.265,AETNA [1000108],AETNA [100010801],,,76.8,,6.87,0.09,416.02,percent of total billed charges,,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0528-10,NDC,outpatient,20,ML,9.98,6.986,AETNA [1000108],AETNA [100010801],,,76.8,,7.66,0.09,416.02,percent of total billed charges,,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0690-01,NDC,outpatient,100,ML,32.93,23.051,AETNA [1000108],AETNA [100010801],,,76.8,,25.29,0.09,416.02,percent of total billed charges,,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,25021-0608-50,NDC,outpatient,50,ML,28.71,20.097,AETNA [1000108],AETNA [100010801],,,76.8,,22.05,0.09,416.02,percent of total billed charges,,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0234-01,NDC,outpatient,50,ML,37.59,26.313,AETNA [1000108],AETNA [100010801],,,76.8,,28.87,0.09,416.02,percent of total billed charges,,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0248-01,NDC,outpatient,100,ML,59.17,41.419,AETNA [1000108],AETNA [100010801],,,76.8,,45.44,0.09,416.02,percent of total billed charges,,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0248-10,NDC,outpatient,100,ML,59.17,41.419,AETNA [1000108],AETNA [100010801],,,76.8,,45.44,0.09,416.02,percent of total billed charges,,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-24,NDC,outpatient,100,ML,52.94,37.058,AETNA [1000108],AETNA [100010801],,,76.8,,40.66,0.09,416.02,percent of total billed charges,,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0977-20,NDC,outpatient,50,ML,34.69,24.283,AETNA [1000108],AETNA [100010801],,,76.8,,26.64,0.09,416.02,percent of total billed charges,,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,25021-0608-50,NDC,outpatient,50,ML,44.71,31.297,AETNA [1000108],AETNA [100010801],,,76.8,,34.34,0.09,416.02,percent of total billed charges,,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,43598-0548-21,NDC,outpatient,50,ML,36.47,25.529,AETNA [1000108],AETNA [100010801],,,76.8,,28.01,0.09,416.02,percent of total billed charges,,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,43598-0548-50,NDC,outpatient,50,ML,36.47,25.529,AETNA [1000108],AETNA [100010801],,,76.8,,28.01,0.09,416.02,percent of total billed charges,,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0234-20,NDC,outpatient,50,ML,37.59,26.313,AETNA [1000108],AETNA [100010801],,,76.8,,28.87,0.09,416.02,percent of total billed charges,,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-53,NDC,outpatient,50,ML,34.47,24.129,AETNA [1000108],AETNA [100010801],,,76.8,,26.47,0.09,416.02,percent of total billed charges,,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0690-10,NDC,outpatient,100,ML,48.93,34.251,AETNA [1000108],AETNA [100010801],,,76.8,,37.58,0.09,416.02,percent of total billed charges,,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-33,NDC,outpatient,50,ML,34.47,24.129,AETNA [1000108],AETNA [100010801],,,76.8,,26.47,0.09,416.02,percent of total billed charges,,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-54,NDC,outpatient,100,ML,52.94,37.058,AETNA [1000108],AETNA [100010801],,,76.8,,40.66,0.09,416.02,percent of total billed charges,,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0690-01,NDC,outpatient,100,ML,48.93,34.251,AETNA [1000108],AETNA [100010801],,,76.8,,37.58,0.09,416.02,percent of total billed charges,,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0977-01,NDC,outpatient,50,ML,34.69,24.283,AETNA [1000108],AETNA [100010801],,,76.8,,26.64,0.09,416.02,percent of total billed charges,,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,25021-0608-51,NDC,outpatient,100,ML,73.41,51.387,AETNA [1000108],AETNA [100010801],,,76.8,,56.38,0.09,416.02,percent of total billed charges,,,
NEOSTIGMINE METHYLSULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4080613,CDM,J2710,HCPCS,636,RC,70121-1479-01,NDC,outpatient,10,ML,34.98,24.486,AETNA [1000108],AETNA [100010801],,,76.8,,26.86,0.43,416.02,percent of total billed charges,,,
NEOSTIGMINE METHYLSULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4080613,CDM,J2710,HCPCS,636,RC,70121-1479-07,NDC,outpatient,10,ML,34.98,24.486,AETNA [1000108],AETNA [100010801],,,76.8,,26.86,0.43,416.02,percent of total billed charges,,,
PROTAMINE SULFATE 10 MG/ML IV SOLN,RX-6677,CDM,J2720,HCPCS,636,RC,63323-0229-30,NDC,outpatient,25,ML,134.62,94.234,AETNA [1000108],AETNA [100010801],,,76.8,,103.39,0.95,416.02,percent of total billed charges,,,
PROTAMINE SULFATE 10 MG/ML IV SOLN,RX-6677,CDM,J2720,HCPCS,636,RC,63323-0229-05,NDC,outpatient,5,ML,44.82,31.374,AETNA [1000108],AETNA [100010801],,,76.8,,34.42,0.95,416.02,percent of total billed charges,,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-5255-02,NDC,outpatient,2,ML,4.14,2.898,AETNA [1000108],AETNA [100010801],,,76.8,,3.18,0.92943,416.02,percent of total billed charges,,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-5255-25,NDC,outpatient,2,ML,4.14,2.898,AETNA [1000108],AETNA [100010801],,,76.8,,3.18,0.92943,416.02,percent of total billed charges,,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00703-4502-04,NDC,outpatient,2,ML,17.23,12.061,AETNA [1000108],AETNA [100010801],,,76.8,,13.23,0.92943,416.02,percent of total billed charges,,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,76045-0101-20,NDC,outpatient,2,ML,9.08,6.356,AETNA [1000108],AETNA [100010801],,,76.8,,6.97,0.92943,416.02,percent of total billed charges,,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-3414-01,NDC,outpatient,2,ML,4.14,2.898,AETNA [1000108],AETNA [100010801],,,76.8,,3.18,0.92943,416.02,percent of total billed charges,,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-3414-18,NDC,outpatient,2,ML,4.14,2.898,AETNA [1000108],AETNA [100010801],,,76.8,,3.18,0.92943,416.02,percent of total billed charges,,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00703-4502-01,NDC,outpatient,2,ML,17.23,12.061,AETNA [1000108],AETNA [100010801],,,76.8,,13.23,0.92943,416.02,percent of total billed charges,,,
QUINUPRISTIN-DALFOPRISTIN 500 MG IV SOLR,RX-26335,CDM,J2770,HCPCS,636,RC,61570-0260-01,NDC,outpatient,1,UN,1916.14,1341.298,AETNA [1000108],AETNA [100010801],,,76.8,,1471.6,7.136465,1471.59552,percent of total billed charges,,,
QUINUPRISTIN-DALFOPRISTIN 500 MG IV SOLR,RX-26335,CDM,J2770,HCPCS,636,RC,61570-0260-10,NDC,outpatient,1,UN,1916.14,1341.298,AETNA [1000108],AETNA [100010801],,,76.8,,1471.6,7.136465,1471.59552,percent of total billed charges,,,
RASBURICASE 1.5 MG IV SOLR,RX-33591,CDM,J2783,HCPCS,636,RC,00024-5150-10,NDC,outpatient,1,UN,3073.12,2151.184,AETNA [1000108],AETNA [100010801],,,76.8,,2360.16,357.36,11800.75008,percent of total billed charges,,,
RASBURICASE 7.5 MG IV SOLR,RX-76868,CDM,J2783,HCPCS,636,RC,00024-5151-75,NDC,outpatient,1,UN,15365.56,10755.892,AETNA [1000108],AETNA [100010801],,,76.8,,11800.75,357.36,11800.75008,percent of total billed charges,,,
REGADENOSON 0.4 MG/5ML IV SOLN,RX-91408,CDM,J2785,HCPCS,636,RC,67457-0994-05,NDC,outpatient,5,ML,26.97,18.879,AETNA [1000108],AETNA [100010801],,,76.8,,20.71,2.88,455.8464,percent of total billed charges,,,
REGADENOSON 0.4 MG/5ML IV SOLN,RX-91408,CDM,J2785,HCPCS,636,RC,71288-0201-85,NDC,outpatient,5,ML,30.71,21.497,AETNA [1000108],AETNA [100010801],,,76.8,,23.59,2.88,455.8464,percent of total billed charges,,,
REGADENOSON 0.4 MG/5ML IV SOLN,RX-91408,CDM,J2785,HCPCS,636,RC,00469-6501-89,NDC,outpatient,5,ML,593.55,415.485,AETNA [1000108],AETNA [100010801],,,76.8,,455.85,2.88,455.8464,percent of total billed charges,,,
RHO D IMMUNE GLOBULIN 5000 UNIT/4.4ML IJ SOLN,RX-70574,CDM,J2792,HCPCS,636,RC,70257-0310-51,NDC,outpatient,4.4,ML,3912.94,2739.058,AETNA [1000108],AETNA [100010801],,,76.8,,3005.14,33.71,3005.13792,percent of total billed charges,,,
RHO D IMMUNE GLOBULIN 5000 UNIT/4.4ML IJ SOLN,RX-70574,CDM,J2792,HCPCS,636,RC,70257-0310-04,NDC,outpatient,4.4,ML,3912.94,2739.058,AETNA [1000108],AETNA [100010801],,,76.8,,3005.14,33.71,3005.13792,percent of total billed charges,,,
RISPERIDONE MICROSPHERES ER 37.5 MG IM SRER,RX-148032,CDM,J2794,HCPCS,636,RC,50458-0307-11,NDC,outpatient,1,UN,2304,1612.8,AETNA [1000108],AETNA [100010801],,,76.8,,1769.47,10.7,2359.38048,percent of total billed charges,,,
RISPERIDONE MICROSPHERES ER 50 MG IM SRER,RX-148033,CDM,J2794,HCPCS,636,RC,50458-0308-11,NDC,outpatient,1,UN,3072.11,2150.477,AETNA [1000108],AETNA [100010801],,,76.8,,2359.38,10.7,2359.38048,percent of total billed charges,,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-01,NDC,outpatient,20,ML,59.55,41.685,AETNA [1000108],AETNA [100010801],,,76.8,,45.73,0.06,416.02,percent of total billed charges,,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,70069-0064-01,NDC,outpatient,30,ML,20.21,14.147,AETNA [1000108],AETNA [100010801],,,76.8,,15.52,0.06,416.02,percent of total billed charges,,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,43066-0023-01,NDC,outpatient,30,ML,15.73,11.011,AETNA [1000108],AETNA [100010801],,,76.8,,12.08,0.06,416.02,percent of total billed charges,,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-20,NDC,outpatient,20,ML,59.55,41.685,AETNA [1000108],AETNA [100010801],,,76.8,,45.73,0.06,416.02,percent of total billed charges,,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,43066-0023-10,NDC,outpatient,30,ML,15.73,11.011,AETNA [1000108],AETNA [100010801],,,76.8,,12.08,0.06,416.02,percent of total billed charges,,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-35,NDC,outpatient,30,ML,20.56,14.392,AETNA [1000108],AETNA [100010801],,,76.8,,15.79,0.06,416.02,percent of total billed charges,,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,55150-0198-30,NDC,outpatient,30,ML,20.21,14.147,AETNA [1000108],AETNA [100010801],,,76.8,,15.52,0.06,416.02,percent of total billed charges,,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-11,NDC,outpatient,30,ML,20.56,14.392,AETNA [1000108],AETNA [100010801],,,76.8,,15.79,0.06,416.02,percent of total billed charges,,,
ROMIPLOSTIM 125 MCG SC SOLR,RX-148858,CDM,J2796,HCPCS,636,RC,55513-0223-01,NDC,outpatient,1,UN,3455.52,2418.864,AETNA [1000108],AETNA [100010801],,,76.8,,2653.84,95.47,5307.61728,percent of total billed charges,,,
ROMIPLOSTIM 250 MCG SC SOLR,RX-93566,CDM,J2796,HCPCS,636,RC,55513-0221-01,NDC,outpatient,1,UN,6910.96,4837.672,AETNA [1000108],AETNA [100010801],,,76.8,,5307.62,95.47,5307.61728,percent of total billed charges,,,
SILTUXIMAB 100 MG IV SOLR,RX-125552,CDM,J2860,HCPCS,636,RC,73090-0420-01,NDC,outpatient,1,UN,4143.92,2900.744,AETNA [1000108],AETNA [100010801],,,76.8,,3182.53,139.22,12730.14528,percent of total billed charges,,,
SILTUXIMAB 400 MG IV SOLR,RX-125553,CDM,J2860,HCPCS,636,RC,73090-0421-01,NDC,outpatient,1,UN,16575.71,11602.997,AETNA [1000108],AETNA [100010801],,,76.8,,12730.15,139.22,12730.14528,percent of total billed charges,,,
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00024-2792-10,NDC,outpatient,5,ML,35.83,25.081,AETNA [1000108],AETNA [100010801],,,76.8,,27.52,2.12,416.02,percent of total billed charges,,,
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00143-9570-10,NDC,outpatient,5,ML,61.68,43.176,AETNA [1000108],AETNA [100010801],,,76.8,,47.37,2.12,416.02,percent of total billed charges,,,
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00024-2792-01,NDC,outpatient,5,ML,35.83,25.081,AETNA [1000108],AETNA [100010801],,,76.8,,27.52,2.12,416.02,percent of total billed charges,,,
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00143-9570-01,NDC,outpatient,5,ML,61.68,43.176,AETNA [1000108],AETNA [100010801],,,76.8,,47.37,2.12,416.02,percent of total billed charges,,,
METHYLPREDNISOLONE SODIUM SUCC 40 MG IJ SOLR,RX-10580,CDM,J2920,HCPCS,636,RC,00009-0039-28,NDC,outpatient,1,UN,20.03,14.021,AETNA [1000108],AETNA [100010801],,,76.8,,15.38,4.24,416.02,percent of total billed charges,,,
METHYLPREDNISOLONE SODIUM SUCC 40 MG IJ SOLR,RX-10580,CDM,J2920,HCPCS,636,RC,00009-0039-30,NDC,outpatient,1,UN,20.03,14.021,AETNA [1000108],AETNA [100010801],,,76.8,,15.38,4.24,416.02,percent of total billed charges,,,
METHYLPREDNISOLONE SODIUM SUCC 1000 MG IJ SOLR,RX-10577,CDM,J2930,HCPCS,636,RC,00009-0698-01,NDC,outpatient,1,UN,79.04,55.328,AETNA [1000108],AETNA [100010801],,,76.8,,60.7,5.73,565.07136,percent of total billed charges,,,
METHYLPREDNISOLONE SODIUM SUCC 125 MG IJ SOLR,RX-10578,CDM,J2930,HCPCS,636,RC,00009-0047-22,NDC,outpatient,1,UN,31.87,22.309,AETNA [1000108],AETNA [100010801],,,76.8,,24.48,5.73,565.07136,percent of total billed charges,,,
METHYLPREDNISOLONE SODIUM SUCC 125 MG IJ SOLR,RX-10578,CDM,J2930,HCPCS,636,RC,00009-0047-25,NDC,outpatient,1,UN,31.87,22.309,AETNA [1000108],AETNA [100010801],,,76.8,,24.48,5.73,565.07136,percent of total billed charges,,,
METHYLPREDNISOLONE SODIUM SUCC 2000 MG IJ SOLR,RX-10579,CDM,J2930,HCPCS,636,RC,00009-0850-01,NDC,outpatient,1,UN,735.77,515.039,AETNA [1000108],AETNA [100010801],,,76.8,,565.07,5.73,565.07136,percent of total billed charges,,,
METHYLPREDNISOLONE SODIUM SUCC 500 MG IJ SOLR,RX-10581,CDM,J2930,HCPCS,636,RC,00009-0758-01,NDC,outpatient,1,UN,87,60.9,AETNA [1000108],AETNA [100010801],,,76.8,,66.82,5.73,565.07136,percent of total billed charges,,,
METHYLPREDNISOLONE SODIUM SUCC 1000 MG IJ ACT-O-VIAL,RX-4081056,CDM,J2930,HCPCS,636,RC,00009-0018-20,NDC,outpatient,1,UN,235.14,164.598,AETNA [1000108],AETNA [100010801],,,76.8,,180.59,5.73,565.07136,percent of total billed charges,,,
METHYLPREDNISOLONE SODIUM SUCC 500 MG IJ ACT-O-VIAL,RX-4081057,CDM,J2930,HCPCS,636,RC,00009-0003-02,NDC,outpatient,1,UN,180.85,126.595,AETNA [1000108],AETNA [100010801],,,76.8,,138.89,5.73,565.07136,percent of total billed charges,,,
ALTEPLASE 2 MG IJ SOLR,RX-31310,CDM,J2997,HCPCS,636,RC,50242-0041-64,NDC,outpatient,1,UN,725.13,507.591,AETNA [1000108],AETNA [100010801],,,76.8,,556.9,89.15,17236.24704,percent of total billed charges,,,
ALTEPLASE 2 MG IJ SOLR,RX-31310,CDM,J2997,HCPCS,636,RC,99999-0000-50,NDC,outpatient,2,ML,723.71,506.597,AETNA [1000108],AETNA [100010801],,,76.8,,555.81,89.15,17236.24704,percent of total billed charges,,,
ALTEPLASE 100 MG IV SOLR,RX-9002,CDM,J2997,HCPCS,636,RC,50242-0085-27,NDC,outpatient,1,UN,22443.03,15710.121,AETNA [1000108],AETNA [100010801],,,76.8,,17236.25,89.15,17236.24704,percent of total billed charges,,,
ALTEPLASE 50 MG IV SOLR,RX-9003,CDM,J2997,HCPCS,636,RC,50242-0044-13,NDC,outpatient,1,UN,11221.53,7855.071,AETNA [1000108],AETNA [100010801],,,76.8,,8618.14,89.15,17236.24704,percent of total billed charges,,,
STREPTOMYCIN SULFATE 1 G IM SOLR,RX-7508,CDM,J3000,HCPCS,636,RC,39822-0706-02,NDC,outpatient,1,UN,186.61,130.627,AETNA [1000108],AETNA [100010801],,,76.8,,143.32,31.57,416.02,percent of total billed charges,,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-13,NDC,outpatient,5,ML,9.41,6.587,AETNA [1000108],AETNA [100010801],,,76.8,,7.23,0.84,416.02,percent of total billed charges,,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-41,NDC,outpatient,50,ML,40.05,28.035,AETNA [1000108],AETNA [100010801],,,76.8,,30.76,0.84,416.02,percent of total billed charges,,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00641-6027-25,NDC,outpatient,2,ML,6.08,4.256,AETNA [1000108],AETNA [100010801],,,76.8,,4.67,0.84,416.02,percent of total billed charges,,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-02,NDC,outpatient,2,ML,7.42,5.194,AETNA [1000108],AETNA [100010801],,,76.8,,5.7,0.84,416.02,percent of total billed charges,,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-12,NDC,outpatient,2,ML,7.31,5.117,AETNA [1000108],AETNA [100010801],,,76.8,,5.61,0.84,416.02,percent of total billed charges,,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-22,NDC,outpatient,2,ML,7.31,5.117,AETNA [1000108],AETNA [100010801],,,76.8,,5.61,0.84,416.02,percent of total billed charges,,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00641-6027-01,NDC,outpatient,2,ML,6.08,4.256,AETNA [1000108],AETNA [100010801],,,76.8,,4.67,0.84,416.02,percent of total billed charges,,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-61,NDC,outpatient,50,ML,40.05,28.035,AETNA [1000108],AETNA [100010801],,,76.8,,30.76,0.84,416.02,percent of total billed charges,,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-05,NDC,outpatient,5,ML,9.41,6.587,AETNA [1000108],AETNA [100010801],,,76.8,,7.23,0.84,416.02,percent of total billed charges,,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-12,NDC,outpatient,2,ML,7.42,5.194,AETNA [1000108],AETNA [100010801],,,76.8,,5.7,0.84,416.02,percent of total billed charges,,,
TENECTEPLASE 50 MG IV KIT,RX-28530,CDM,J3101,HCPCS,636,RC,50242-0120-47,NDC,outpatient,1,UN,19380.84,13566.588,AETNA [1000108],AETNA [100010801],,,76.8,,14884.49,152.7,14884.48512,percent of total billed charges,,,
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,63323-0665-00,NDC,outpatient,1,ML,6.42,4.494,AETNA [1000108],AETNA [100010801],,,76.8,,4.93,1.358225,416.02,percent of total billed charges,,,
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,00143-9746-10,NDC,outpatient,1,ML,6.05,4.235,AETNA [1000108],AETNA [100010801],,,76.8,,4.65,1.358225,416.02,percent of total billed charges,,,
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,00143-9746-01,NDC,outpatient,1,ML,6.05,4.235,AETNA [1000108],AETNA [100010801],,,76.8,,4.65,1.358225,416.02,percent of total billed charges,,,
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,63323-0665-01,NDC,outpatient,1,ML,6.42,4.494,AETNA [1000108],AETNA [100010801],,,76.8,,4.93,1.358225,416.02,percent of total billed charges,,,
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,00641-1398-35,NDC,outpatient,2,ML,108.05,75.635,AETNA [1000108],AETNA [100010801],,,76.8,,82.98,14.63291,416.02,percent of total billed charges,,,
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,00641-1398-31,NDC,outpatient,2,ML,108.05,75.635,AETNA [1000108],AETNA [100010801],,,76.8,,82.98,14.63291,416.02,percent of total billed charges,,,
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,55150-0318-01,NDC,outpatient,1,ML,65.18,45.626,AETNA [1000108],AETNA [100010801],,,76.8,,50.06,14.63291,416.02,percent of total billed charges,,,
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,55150-0318-25,NDC,outpatient,1,ML,65.18,45.626,AETNA [1000108],AETNA [100010801],,,76.8,,50.06,14.63291,416.02,percent of total billed charges,,,
THYROTROPIN ALFA 0.9 MG IM SOLR,RX-156409,CDM,J3240,HCPCS,636,RC,58468-0030-02,NDC,outpatient,1,UN,5457.19,3820.033,AETNA [1000108],AETNA [100010801],,,76.8,,4191.12,399.86,4191.12192,percent of total billed charges,,,
TIGECYCLINE 50 MG IV SOLR,RX-41652,CDM,J3243,HCPCS,636,RC,55150-0228-10,NDC,outpatient,1,UN,119.66,83.762,AETNA [1000108],AETNA [100010801],,,76.8,,91.9,0.52,416.02,percent of total billed charges,,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-02,NDC,outpatient,250,ML,723.13,506.191,AETNA [1000108],AETNA [100010801],JW,,76.8,,555.36,3.83,567.65184,percent of total billed charges,,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0429-01,NDC,outpatient,100,ML,219.39,153.573,AETNA [1000108],AETNA [100010801],JW,,76.8,,168.49,3.83,567.65184,percent of total billed charges,,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0430-01,NDC,outpatient,250,ML,513.98,359.786,AETNA [1000108],AETNA [100010801],JW,,76.8,,394.74,3.83,567.65184,percent of total billed charges,,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-01,NDC,outpatient,100,ML,301.69,211.183,AETNA [1000108],AETNA [100010801],,,76.8,,231.7,3.83,567.65184,percent of total billed charges,,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0430-01,NDC,outpatient,250,ML,529.98,370.986,AETNA [1000108],AETNA [100010801],,,76.8,,407.02,3.83,567.65184,percent of total billed charges,,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0429-01,NDC,outpatient,100,ML,235.39,164.773,AETNA [1000108],AETNA [100010801],,,76.8,,180.78,3.83,567.65184,percent of total billed charges,,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-01,NDC,outpatient,100,ML,285.69,199.983,AETNA [1000108],AETNA [100010801],JW,,76.8,,219.41,3.83,567.65184,percent of total billed charges,,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-03,NDC,outpatient,100,ML,198.47,138.929,AETNA [1000108],AETNA [100010801],JW,,76.8,,152.42,3.83,567.65184,percent of total billed charges,,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-02,NDC,outpatient,250,ML,739.13,517.391,AETNA [1000108],AETNA [100010801],,,76.8,,567.65,3.83,567.65184,percent of total billed charges,,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-03,NDC,outpatient,100,ML,214.47,150.129,AETNA [1000108],AETNA [100010801],,,76.8,,164.71,3.83,567.65184,percent of total billed charges,,,
TRIMETHOBENZAMIDE HCL 100 MG/ML IM SOLN,RX-8178,CDM,J3250,HCPCS,636,RC,42023-0119-25,NDC,outpatient,2,ML,199.22,139.454,AETNA [1000108],AETNA [100010801],,,76.8,,153,44.72489,416.02,percent of total billed charges,,,
TOBRAMYCIN SULFATE 1.2 G IJ SOLR,RX-11565,CDM,J3260,HCPCS,636,RC,39822-0412-01,NDC,outpatient,1,UN,217.92,152.544,AETNA [1000108],AETNA [100010801],,,76.8,,167.36,0.882285,416.02,percent of total billed charges,,,
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,63323-0306-02,NDC,outpatient,2,ML,16.01,11.207,AETNA [1000108],AETNA [100010801],,,76.8,,12.3,0.882285,416.02,percent of total billed charges,,,
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,00409-3578-11,NDC,outpatient,2,ML,13.74,9.618,AETNA [1000108],AETNA [100010801],,,76.8,,10.55,0.882285,416.02,percent of total billed charges,,,
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,67457-0473-00,NDC,outpatient,2,ML,3.93,2.751,AETNA [1000108],AETNA [100010801],,,76.8,,3.02,0.882285,416.02,percent of total billed charges,,,
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,00409-3578-01,NDC,outpatient,2,ML,13.74,9.618,AETNA [1000108],AETNA [100010801],,,76.8,,10.55,0.882285,416.02,percent of total billed charges,,,
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,67457-0473-22,NDC,outpatient,2,ML,3.93,2.751,AETNA [1000108],AETNA [100010801],,,76.8,,3.02,0.882285,416.02,percent of total billed charges,,,
TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN,RX-97790,CDM,J3260,HCPCS,636,RC,67457-0428-30,NDC,outpatient,30,ML,45.26,31.682,AETNA [1000108],AETNA [100010801],,,76.8,,34.76,0.882285,416.02,percent of total billed charges,,,
TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN,RX-97790,CDM,J3260,HCPCS,636,RC,63323-0306-30,NDC,outpatient,30,ML,60.48,42.336,AETNA [1000108],AETNA [100010801],,,76.8,,46.45,0.882285,416.02,percent of total billed charges,,,
TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN,RX-97790,CDM,J3260,HCPCS,636,RC,67457-0428-00,NDC,outpatient,30,ML,45.26,31.682,AETNA [1000108],AETNA [100010801],,,76.8,,34.76,0.882285,416.02,percent of total billed charges,,,
TOCILIZUMAB 20 MG/ML IV WRAPPER,RX-4080174,CDM,J3262,HCPCS,636,RC,50242-0135-01,NDC,outpatient,4,ML,1422.05,995.435,AETNA [1000108],AETNA [100010801],,,76.8,,1092.13,5.91,5460.64128,percent of total billed charges,,,
TOCILIZUMAB 20 MG/ML IV WRAPPER,RX-4080174,CDM,J3262,HCPCS,636,RC,50242-0136-01,NDC,outpatient,10,ML,3555.08,2488.556,AETNA [1000108],AETNA [100010801],,,76.8,,2730.3,5.91,5460.64128,percent of total billed charges,,,
TOCILIZUMAB 20 MG/ML IV WRAPPER,RX-4080174,CDM,J3262,HCPCS,636,RC,50242-0137-01,NDC,outpatient,20,ML,7110.21,4977.147,AETNA [1000108],AETNA [100010801],,,76.8,,5460.64,5.91,5460.64128,percent of total billed charges,,,
TRIAMCINOLONE ACETONIDE 10 MG/ML IJ SUSP,RX-11584,CDM,J3301,HCPCS,636,RC,00003-0494-20,NDC,outpatient,5,ML,49.71,34.797,AETNA [1000108],AETNA [100010801],,,76.8,,38.18,0.9,416.02,percent of total billed charges,,,
TRIAMCINOLONE ACETONIDE 40 MG/ML IJ SUSP,RX-8120,CDM,J3301,HCPCS,636,RC,00003-0293-05,NDC,outpatient,1,ML,38.5,26.95,AETNA [1000108],AETNA [100010801],,,76.8,,29.57,0.9,416.02,percent of total billed charges,,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00409-1273-03,NDC,outpatient,2,ML,106.04,74.228,AETNA [1000108],AETNA [100010801],,,76.8,,81.44,5.25,416.02,percent of total billed charges,,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00641-6244-01,NDC,outpatient,2,ML,60.45,42.315,AETNA [1000108],AETNA [100010801],,,76.8,,46.43,5.25,416.02,percent of total billed charges,,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00641-6244-10,NDC,outpatient,2,ML,60.45,42.315,AETNA [1000108],AETNA [100010801],,,76.8,,46.43,5.25,416.02,percent of total billed charges,,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,69339-0136-03,NDC,outpatient,2,ML,63.74,44.618,AETNA [1000108],AETNA [100010801],,,76.8,,48.95,5.25,416.02,percent of total billed charges,,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00409-1273-32,NDC,outpatient,2,ML,106.04,74.228,AETNA [1000108],AETNA [100010801],,,76.8,,81.44,5.25,416.02,percent of total billed charges,,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,69339-0136-34,NDC,outpatient,2,ML,63.74,44.618,AETNA [1000108],AETNA [100010801],,,76.8,,48.95,5.25,416.02,percent of total billed charges,,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,76045-0204-00,NDC,outpatient,2,ML,59.63,41.741,AETNA [1000108],AETNA [100010801],,,76.8,,45.8,5.25,416.02,percent of total billed charges,,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,76045-0204-20,NDC,outpatient,2,ML,59.63,41.741,AETNA [1000108],AETNA [100010801],,,76.8,,45.8,5.25,416.02,percent of total billed charges,,,
VANCOMYCIN HCL IN DEXTROSE 750 MG/150ML IV SOLN,RX-108740,CDM,J3370,HCPCS,636,RC,00338-3580-48,NDC,outpatient,150,ML,49.93,34.951,AETNA [1000108],AETNA [100010801],,,76.8,,38.35,2.16,672.6528,percent of total billed charges,,,
VANCOMYCIN HCL IN DEXTROSE 750 MG/150ML IV SOLN,RX-108740,CDM,J3370,HCPCS,636,RC,99999-0000-88,NDC,outpatient,150,ML,35.17,24.619,AETNA [1000108],AETNA [100010801],,,76.8,,27.01,2.16,672.6528,percent of total billed charges,,,
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,70594-0048-01,NDC,outpatient,10,GR,267,186.9,AETNA [1000108],AETNA [100010801],,,76.8,,205.06,2.16,672.6528,percent of total billed charges,,,
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,67457-0342-10,NDC,outpatient,10,GR,875.85,613.095,AETNA [1000108],AETNA [100010801],,,76.8,,672.65,2.16,672.6528,percent of total billed charges,,,
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,25021-0158-99,NDC,outpatient,10,GR,205.59,143.913,AETNA [1000108],AETNA [100010801],,,76.8,,157.89,2.16,672.6528,percent of total billed charges,,,
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,63323-0314-61,NDC,outpatient,10,GR,107.34,75.138,AETNA [1000108],AETNA [100010801],,,76.8,,82.44,2.16,672.6528,percent of total billed charges,,,
VANCOMYCIN HCL IN DEXTROSE 500 MG/100ML IV SOLN,RX-11632,CDM,J3370,HCPCS,636,RC,00338-3551-48,NDC,outpatient,100,ML,52.94,37.058,AETNA [1000108],AETNA [100010801],,,76.8,,40.66,2.16,672.6528,percent of total billed charges,,,
VANCOMYCIN HCL IN NACL 750-0.9 MG/150ML-% IV SOLN,RX-134904,CDM,J3370,HCPCS,636,RC,00338-3582-01,NDC,outpatient,150,ML,73.41,51.387,AETNA [1000108],AETNA [100010801],,,76.8,,56.38,2.16,672.6528,percent of total billed charges,,,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,00143-9357-01,NDC,outpatient,1,UN,12.35,8.645,AETNA [1000108],AETNA [100010801],,,76.8,,9.48,2.16,672.6528,percent of total billed charges,,,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,00143-9357-10,NDC,outpatient,1,UN,12.35,8.645,AETNA [1000108],AETNA [100010801],,,76.8,,9.48,2.16,672.6528,percent of total billed charges,,,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,16714-0309-01,NDC,outpatient,1,UN,11.19,7.833,AETNA [1000108],AETNA [100010801],,,76.8,,8.59,2.16,672.6528,percent of total billed charges,,,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,67457-0340-01,NDC,outpatient,1,UN,16.63,11.641,AETNA [1000108],AETNA [100010801],,,76.8,,12.77,2.16,672.6528,percent of total billed charges,,,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,16714-0309-10,NDC,outpatient,1,UN,11.19,7.833,AETNA [1000108],AETNA [100010801],,,76.8,,8.59,2.16,672.6528,percent of total billed charges,,,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,67457-0340-00,NDC,outpatient,1,UN,16.63,11.641,AETNA [1000108],AETNA [100010801],,,76.8,,12.77,2.16,672.6528,percent of total billed charges,,,
VANCOMYCIN HCL 5 G IV SOLR,RX-144290,CDM,J3370,HCPCS,636,RC,00409-6509-01,NDC,outpatient,5,GR,364.64,255.248,AETNA [1000108],AETNA [100010801],,,76.8,,280.04,2.16,672.6528,percent of total billed charges,,,
VANCOMYCIN HCL 5 G IV SOLR,RX-144290,CDM,J3370,HCPCS,636,RC,67457-0341-05,NDC,outpatient,5,GR,361.57,253.099,AETNA [1000108],AETNA [100010801],,,76.8,,277.69,2.16,672.6528,percent of total billed charges,,,
VANCOMYCIN HCL 5 G IV SOLR,RX-144290,CDM,J3370,HCPCS,636,RC,25021-0157-99,NDC,outpatient,5,GR,81.22,56.854,AETNA [1000108],AETNA [100010801],,,76.8,,62.38,2.16,672.6528,percent of total billed charges,,,
VANCOMYCIN HCL 1.5 G IV SOLR,RX-145320,CDM,J3370,HCPCS,636,RC,00409-3515-01,NDC,outpatient,1,UN,51.81,36.267,AETNA [1000108],AETNA [100010801],,,76.8,,39.79,2.16,672.6528,percent of total billed charges,,,
VANCOMYCIN HCL 1.5 G IV SOLR,RX-145320,CDM,J3370,HCPCS,636,RC,00409-3515-11,NDC,outpatient,1,UN,51.81,36.267,AETNA [1000108],AETNA [100010801],,,76.8,,39.79,2.16,672.6528,percent of total billed charges,,,
VANCOMYCIN HCL 500 MG IV SOLR,RX-8443,CDM,J3370,HCPCS,636,RC,72611-0761-01,NDC,outpatient,1,UN,15.42,10.794,AETNA [1000108],AETNA [100010801],,,76.8,,11.84,2.16,672.6528,percent of total billed charges,,,
VANCOMYCIN HCL 500 MG IV SOLR,RX-8443,CDM,J3370,HCPCS,636,RC,72611-0761-10,NDC,outpatient,1,UN,15.42,10.794,AETNA [1000108],AETNA [100010801],,,76.8,,11.84,2.16,672.6528,percent of total billed charges,,,
VANCOMYCIN HCL IN DEXTROSE 1 GM/200ML IV SOLN,RX-92895,CDM,J3370,HCPCS,636,RC,00338-3552-48,NDC,outpatient,200,ML,52.27,36.589,AETNA [1000108],AETNA [100010801],,,76.8,,40.14,2.16,672.6528,percent of total billed charges,,,
VEDOLIZUMAB 300 MG IV SOLR,RX-125757,CDM,J3380,HCPCS,636,RC,64764-0300-20,NDC,outpatient,1,UN,23919.77,16743.839,AETNA [1000108],AETNA [100010801],,,76.8,,18370.38,22.26,18370.38336,percent of total billed charges,,,
HYDROXYZINE HCL 50 MG/ML IM SOLN,RX-3770,CDM,J3410,HCPCS,636,RC,00517-5601-25,NDC,outpatient,1,ML,82.29,57.603,AETNA [1000108],AETNA [100010801],,,76.8,,63.2,12.41,416.02,percent of total billed charges,,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,00641-6228-01,NDC,outpatient,0.5,ML,4.75,3.325,AETNA [1000108],AETNA [100010801],,,76.8,,3.65,0.88453,416.02,percent of total billed charges,,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,00641-6228-25,NDC,outpatient,0.5,ML,4.75,3.325,AETNA [1000108],AETNA [100010801],,,76.8,,3.65,0.88453,416.02,percent of total billed charges,,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,55150-0273-01,NDC,outpatient,0.5,ML,4.61,3.227,AETNA [1000108],AETNA [100010801],,,76.8,,3.54,0.88453,416.02,percent of total billed charges,,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,25021-0500-02,NDC,outpatient,0.5,ML,4.68,3.276,AETNA [1000108],AETNA [100010801],,,76.8,,3.59,0.88453,416.02,percent of total billed charges,,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,55150-0273-25,NDC,outpatient,0.5,ML,4.61,3.227,AETNA [1000108],AETNA [100010801],,,76.8,,3.54,0.88453,416.02,percent of total billed charges,,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,67457-0196-02,NDC,outpatient,0.5,ML,3.94,2.758,AETNA [1000108],AETNA [100010801],,,76.8,,3.03,0.88453,416.02,percent of total billed charges,,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,67457-0196-00,NDC,outpatient,0.5,ML,3.94,2.758,AETNA [1000108],AETNA [100010801],,,76.8,,3.03,0.88453,416.02,percent of total billed charges,,,
PYRIDOXINE HCL 100 MG/ML IJ SOLN,RX-6744,CDM,J3415,HCPCS,636,RC,63323-0180-01,NDC,outpatient,0.5,ML,20.17,14.119,AETNA [1000108],AETNA [100010801],,,76.8,,15.49,4.528165,416.02,percent of total billed charges,,,
PYRIDOXINE HCL 100 MG/ML IJ SOLN,RX-6744,CDM,J3415,HCPCS,636,RC,63323-0180-00,NDC,outpatient,0.5,ML,20.17,14.119,AETNA [1000108],AETNA [100010801],,,76.8,,15.49,4.528165,416.02,percent of total billed charges,,,
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,00143-9621-01,NDC,outpatient,1,ML,10.83,7.581,AETNA [1000108],AETNA [100010801],,,76.8,,8.32,1.15,416.02,percent of total billed charges,,,
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,63323-0044-00,NDC,outpatient,1,ML,6.18,4.326,AETNA [1000108],AETNA [100010801],,,76.8,,4.75,1.15,416.02,percent of total billed charges,,,
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,00143-9621-25,NDC,outpatient,1,ML,10.83,7.581,AETNA [1000108],AETNA [100010801],,,76.8,,8.32,1.15,416.02,percent of total billed charges,,,
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,63323-0044-01,NDC,outpatient,1,ML,6.18,4.326,AETNA [1000108],AETNA [100010801],,,76.8,,4.75,1.15,416.02,percent of total billed charges,,,
HYDROXOCOBALAMIN 5 G IV SOLR,RX-111437,CDM,J3424,HCPCS,250,RC,50633-0310-11,NDC,outpatient,1,UN,2471.2,1729.84,AETNA [1000108],AETNA [100010801],,,76.8,,1897.88,5.69,1897.8816,percent of total billed charges,,,
PHYTONADIONE 1 MG/0.5ML IJ SOLN WRAPPER,RX-4080206,CDM,J3430,HCPCS,636,RC,76329-1240-01,NDC,outpatient,0.5,ML,98.15,68.705,AETNA [1000108],AETNA [100010801],,,76.8,,75.38,2.51,416.02,percent of total billed charges,,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,43598-0405-11,NDC,outpatient,1,ML,78.97,55.279,AETNA [1000108],AETNA [100010801],,,76.8,,60.65,2.51,416.02,percent of total billed charges,,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,00409-9158-01,NDC,outpatient,1,ML,85.53,59.871,AETNA [1000108],AETNA [100010801],,,76.8,,65.69,2.51,416.02,percent of total billed charges,,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,00409-9158-31,NDC,outpatient,1,ML,85.53,59.871,AETNA [1000108],AETNA [100010801],,,76.8,,65.69,2.51,416.02,percent of total billed charges,,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,00409-9158-50,NDC,outpatient,1,ML,85.53,59.871,AETNA [1000108],AETNA [100010801],,,76.8,,65.69,2.51,416.02,percent of total billed charges,,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,69097-0708-31,NDC,outpatient,1,ML,82.7,57.89,AETNA [1000108],AETNA [100010801],,,76.8,,63.51,2.51,416.02,percent of total billed charges,,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,43598-0405-16,NDC,outpatient,1,ML,78.97,55.279,AETNA [1000108],AETNA [100010801],,,76.8,,60.65,2.51,416.02,percent of total billed charges,,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,69097-0708-96,NDC,outpatient,1,ML,82.7,57.89,AETNA [1000108],AETNA [100010801],,,76.8,,63.51,2.51,416.02,percent of total billed charges,,,
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,39822-1077-01,NDC,outpatient,1,UN,89.45,62.615,AETNA [1000108],AETNA [100010801],,,76.8,,68.7,0.78,416.02,percent of total billed charges,,,
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,70436-0029-80,NDC,outpatient,1,UN,78.41,54.887,AETNA [1000108],AETNA [100010801],,,76.8,,60.22,0.78,416.02,percent of total billed charges,,,
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,00049-3190-28,NDC,outpatient,1,UN,59.15,41.405,AETNA [1000108],AETNA [100010801],,,76.8,,45.43,0.78,416.02,percent of total billed charges,,,
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,00781-3416-94,NDC,outpatient,1,UN,325.92,228.144,AETNA [1000108],AETNA [100010801],,,76.8,,250.31,0.78,416.02,percent of total billed charges,,,
HYALURONIDASE HUMAN 15 UNIT/ML INJECTION SYRINGE,RX-4081350,CDM,J3473,HCPCS,636,RC,99999-0004-00,NDC,outpatient,1,ML,164.85,115.395,AETNA [1000108],AETNA [100010801],,,76.8,,126.6,0.36,416.02,percent of total billed charges,,,
HYALURONIDASE HUMAN 150 UNIT/ML IJ SOLN,RX-76338,CDM,J3473,HCPCS,636,RC,18657-0117-01,NDC,outpatient,1,ML,164.85,115.395,AETNA [1000108],AETNA [100010801],,,76.8,,126.6,0.36,416.02,percent of total billed charges,,,
HYALURONIDASE HUMAN 150 UNIT/ML IJ SOLN,RX-76338,CDM,J3473,HCPCS,636,RC,18657-0117-04,NDC,outpatient,1,ML,164.85,115.395,AETNA [1000108],AETNA [100010801],,,76.8,,126.6,0.36,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00264-4400-54,NDC,outpatient,100,ML,30.4,21.28,AETNA [1000108],AETNA [100010801],,,76.8,,23.35,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00409-6727-11,NDC,outpatient,100,ML,46.71,32.697,AETNA [1000108],AETNA [100010801],,,76.8,,35.87,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,63323-0108-00,NDC,outpatient,100,ML,26.28,18.396,AETNA [1000108],AETNA [100010801],,,76.8,,20.18,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,67457-0567-00,NDC,outpatient,100,ML,30.4,21.28,AETNA [1000108],AETNA [100010801],,,76.8,,23.35,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00409-6727-23,NDC,outpatient,100,ML,46.71,32.697,AETNA [1000108],AETNA [100010801],,,76.8,,35.87,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00338-1709-40,NDC,outpatient,100,ML,22.17,15.519,AETNA [1000108],AETNA [100010801],,,76.8,,17.03,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,63323-0108-01,NDC,outpatient,100,ML,26.28,18.396,AETNA [1000108],AETNA [100010801],,,76.8,,20.18,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,00409-6729-24,NDC,outpatient,50,ML,36.31,25.417,AETNA [1000108],AETNA [100010801],,,76.8,,27.89,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,44567-0420-00,NDC,outpatient,50,ML,43.82,30.674,AETNA [1000108],AETNA [100010801],,,76.8,,33.65,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,44567-0420-24,NDC,outpatient,50,ML,43.82,30.674,AETNA [1000108],AETNA [100010801],,,76.8,,33.65,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,67457-0553-00,NDC,outpatient,50,ML,33.74,23.618,AETNA [1000108],AETNA [100010801],,,76.8,,25.91,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,00409-6729-11,NDC,outpatient,50,ML,36.31,25.417,AETNA [1000108],AETNA [100010801],,,76.8,,27.89,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,25021-0612-81,NDC,outpatient,50,ML,24.74,17.318,AETNA [1000108],AETNA [100010801],,,76.8,,19,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,00338-1708-40,NDC,outpatient,50,ML,28.6,20.02,AETNA [1000108],AETNA [100010801],,,76.8,,21.96,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,63323-0106-02,NDC,outpatient,50,ML,32.45,22.715,AETNA [1000108],AETNA [100010801],,,76.8,,24.92,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,63323-0106-05,NDC,outpatient,50,ML,32.45,22.715,AETNA [1000108],AETNA [100010801],,,76.8,,24.92,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,47335-0992-01,NDC,outpatient,50,ML,28.85,20.195,AETNA [1000108],AETNA [100010801],,,76.8,,22.16,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 40 MG/ML SOLN WRAPPER,RX-4080721,CDM,J3475,HCPCS,636,RC,00409-2050-01,NDC,outpatient,500,ML,38.25,26.775,AETNA [1000108],AETNA [100010801],,,76.8,,29.38,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 40 MG/ML SOLN WRAPPER,RX-4080721,CDM,J3475,HCPCS,636,RC,00409-2050-20,NDC,outpatient,500,ML,38.25,26.775,AETNA [1000108],AETNA [100010801],,,76.8,,29.38,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 40 MG/ML SOLN WRAPPER,RX-4080721,CDM,J3475,HCPCS,636,RC,63323-0106-15,NDC,outpatient,500,ML,33.99,23.793,AETNA [1000108],AETNA [100010801],,,76.8,,26.1,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-11,NDC,outpatient,10,ML,6.53,4.571,AETNA [1000108],AETNA [100010801],,,76.8,,5.02,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-03,NDC,outpatient,2,ML,5.46,3.822,AETNA [1000108],AETNA [100010801],,,76.8,,4.19,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-04,NDC,outpatient,10,ML,6.53,4.571,AETNA [1000108],AETNA [100010801],,,76.8,,5.02,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0642-50,NDC,outpatient,2,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-01,NDC,outpatient,2,ML,5.46,3.822,AETNA [1000108],AETNA [100010801],,,76.8,,4.19,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0642-02,NDC,outpatient,50,ML,55.41,38.787,AETNA [1000108],AETNA [100010801],,,76.8,,42.55,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,99999-0002-95,NDC,outpatient,2,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.47,416.02,percent of total billed charges,,,
POTASSIUM CHLORIDE 10 MEQ/100ML IV SOLN,RX-11074,CDM,J3480,HCPCS,636,RC,00338-0709-48,NDC,outpatient,100,ML,26.8,18.76,AETNA [1000108],AETNA [100010801],,,76.8,,20.58,0.1,416.02,percent of total billed charges,,,
POTASSIUM CHLORIDE 10 MEQ/100ML IV SOLN,RX-11074,CDM,J3480,HCPCS,636,RC,00990-7074-26,NDC,outpatient,100,ML,36.92,25.844,AETNA [1000108],AETNA [100010801],,,76.8,,28.35,0.1,416.02,percent of total billed charges,,,
POTASSIUM CHLORIDE 20 MEQ/100ML IV SOLN,RX-11076,CDM,J3480,HCPCS,636,RC,00338-0705-48,NDC,outpatient,100,ML,26.8,18.76,AETNA [1000108],AETNA [100010801],,,76.8,,20.58,0.1,416.02,percent of total billed charges,,,
POTASSIUM CHLORIDE 20 MEQ/100ML IV SOLN,RX-11076,CDM,J3480,HCPCS,636,RC,00990-7075-26,NDC,outpatient,100,ML,37.81,26.467,AETNA [1000108],AETNA [100010801],,,76.8,,29.04,0.1,416.02,percent of total billed charges,,,
POTASSIUM CHLORIDE 20 MEQ/50ML IV SOLN,RX-11077,CDM,J3480,HCPCS,636,RC,00990-7077-14,NDC,outpatient,50,ML,37.59,26.313,AETNA [1000108],AETNA [100010801],,,76.8,,28.87,0.1,416.02,percent of total billed charges,,,
POTASSIUM CHLORIDE 20 MEQ/50ML IV SOLN,RX-11077,CDM,J3480,HCPCS,636,RC,00338-0703-41,NDC,outpatient,50,ML,26.28,18.396,AETNA [1000108],AETNA [100010801],,,76.8,,20.18,0.1,416.02,percent of total billed charges,,,
POTASSIUM CHLORIDE IN NACL 20-0.9 MEQ/L-% IV SOLN,RX-11081,CDM,J3480,HCPCS,636,RC,00338-0691-04,NDC,outpatient,1000,ML,26.28,18.396,AETNA [1000108],AETNA [100010801],,,76.8,,20.18,0.1,416.02,percent of total billed charges,,,
POTASSIUM CHLORIDE IN NACL 40-0.9 MEQ/L-% IV SOLN,RX-11082,CDM,J3480,HCPCS,636,RC,00338-0695-04,NDC,outpatient,1000,ML,31.42,21.994,AETNA [1000108],AETNA [100010801],,,76.8,,24.13,0.1,416.02,percent of total billed charges,,,
KCL IN NACL 0.9% 10 MEQ/100ML IV SOLN,RX-166975,CDM,J3480,HCPCS,636,RC,99999-0001-77,NDC,outpatient,100,ML,26.28,18.396,AETNA [1000108],AETNA [100010801],,,76.8,,20.18,0.1,416.02,percent of total billed charges,,,
POTASSIUM CHLORIDE IN NACL 20-0.45 MEQ/L-% IV SOLN,RX-36046,CDM,J3480,HCPCS,636,RC,00338-0704-34,NDC,outpatient,1000,ML,26.28,18.396,AETNA [1000108],AETNA [100010801],,,76.8,,20.18,0.1,416.02,percent of total billed charges,,,
POTASSIUM CHLORIDE IN NACL 20 MEQ/50ML IV SOLN,RX-4081006,CDM,J3480,HCPCS,636,RC,99999-0001-79,NDC,outpatient,50,ML,31.17,21.819,AETNA [1000108],AETNA [100010801],,,76.8,,23.94,0.1,416.02,percent of total billed charges,,,
POTASSIUM CHLORIDE IN NACL 20 MEQ/100ML IV SOLN,RX-4081007,CDM,J3480,HCPCS,636,RC,99999-0001-78,NDC,outpatient,100,ML,30.91,21.637,AETNA [1000108],AETNA [100010801],,,76.8,,23.74,0.1,416.02,percent of total billed charges,,,
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN,RX-6429,CDM,J3480,HCPCS,636,RC,63323-0965-02,NDC,outpatient,20,ML,6.48,4.536,AETNA [1000108],AETNA [100010801],,,76.8,,4.98,0.1,416.02,percent of total billed charges,,,
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN,RX-6429,CDM,J3480,HCPCS,636,RC,63323-0965-20,NDC,outpatient,20,ML,6.48,4.536,AETNA [1000108],AETNA [100010801],,,76.8,,4.98,0.1,416.02,percent of total billed charges,,,
POTASSIUM CL IN DEXTROSE 5% 20 MEQ/L IV SOLN,RX-9791,CDM,J3480,HCPCS,636,RC,00338-0683-04,NDC,outpatient,1000,ML,31.42,21.994,AETNA [1000108],AETNA [100010801],,,76.8,,24.13,0.1,416.02,percent of total billed charges,,,
KCL IN DEXTROSE-NACL 20-5-0.9 MEQ/L-%-% IV SOLN,RX-9795,CDM,J3480,HCPCS,636,RC,00264-7652-00,NDC,outpatient,1000,ML,38.25,26.775,AETNA [1000108],AETNA [100010801],,,76.8,,29.38,0.1,416.02,percent of total billed charges,,,
KCL IN DEXTROSE-NACL 20-5-0.9 MEQ/L-%-% IV SOLN,RX-9795,CDM,J3480,HCPCS,636,RC,00338-0803-04,NDC,outpatient,1000,ML,26.28,18.396,AETNA [1000108],AETNA [100010801],,,76.8,,20.18,0.1,416.02,percent of total billed charges,,,
KCL IN DEXTROSE-NACL 10-5-0.45 MEQ/L-%-% IV SOLN,RX-9799,CDM,J3480,HCPCS,636,RC,00338-0669-04,NDC,outpatient,1000,ML,31.42,21.994,AETNA [1000108],AETNA [100010801],,,76.8,,24.13,0.1,416.02,percent of total billed charges,,,
KCL IN DEXTROSE-NACL 10-5-0.45 MEQ/L-%-% IV SOLN,RX-9799,CDM,J3480,HCPCS,636,RC,00990-7993-09,NDC,outpatient,1000,ML,47.15,33.005,AETNA [1000108],AETNA [100010801],,,76.8,,36.21,0.1,416.02,percent of total billed charges,,,
KCL IN DEXTROSE-NACL 20-5-0.2 MEQ/L-%-% IV SOLN,RX-9800,CDM,J3480,HCPCS,636,RC,00264-7645-00,NDC,outpatient,1000,ML,47.15,33.005,AETNA [1000108],AETNA [100010801],,,76.8,,36.21,0.1,416.02,percent of total billed charges,,,
KCL IN DEXTROSE-NACL 20-5-0.2 MEQ/L-%-% IV SOLN,RX-9800,CDM,J3480,HCPCS,636,RC,00338-0663-04,NDC,outpatient,1000,ML,31.42,21.994,AETNA [1000108],AETNA [100010801],,,76.8,,24.13,0.1,416.02,percent of total billed charges,,,
KCL IN DEXTROSE-NACL 20-5-0.45 MEQ/L-%-% IV SOLN,RX-9801,CDM,J3480,HCPCS,636,RC,00338-0671-04,NDC,outpatient,1000,ML,26.28,18.396,AETNA [1000108],AETNA [100010801],,,76.8,,20.18,0.1,416.02,percent of total billed charges,,,
KCL IN DEXTROSE-NACL 40-5-0.45 MEQ/L-%-% IV SOLN,RX-9807,CDM,J3480,HCPCS,636,RC,00338-0675-04,NDC,outpatient,1000,ML,31.42,21.994,AETNA [1000108],AETNA [100010801],,,76.8,,24.13,0.1,416.02,percent of total billed charges,,,
ZIDOVUDINE 10 MG/ML IV SOLN,RX-11691,CDM,J3485,HCPCS,636,RC,49702-0213-01,NDC,outpatient,20,ML,126.03,88.221,AETNA [1000108],AETNA [100010801],,,76.8,,96.79,1.51,416.02,percent of total billed charges,,,
ZIDOVUDINE 10 MG/ML IV SOLN,RX-11691,CDM,J3485,HCPCS,636,RC,49702-0213-26,NDC,outpatient,20,ML,126.03,88.221,AETNA [1000108],AETNA [100010801],,,76.8,,96.79,1.51,416.02,percent of total billed charges,,,
ZIPRASIDONE MESYLATE 20 MG IM SOLR,RX-33175,CDM,J3486,HCPCS,636,RC,00049-3920-20,NDC,outpatient,1,UN,264.92,185.444,AETNA [1000108],AETNA [100010801],,,76.8,,203.46,7.43,416.02,percent of total billed charges,,,
ZIPRASIDONE MESYLATE 20 MG IM SOLR,RX-33175,CDM,J3486,HCPCS,636,RC,00049-3920-83,NDC,outpatient,1,UN,264.92,185.444,AETNA [1000108],AETNA [100010801],,,76.8,,203.46,7.43,416.02,percent of total billed charges,,,
ZOLEDRONIC ACID 4 MG/5ML IV CONC,RX-35640,CDM,J3489,HCPCS,636,RC,67457-0390-54,NDC,outpatient,5,ML,30.53,21.371,AETNA [1000108],AETNA [100010801],,,76.8,,23.45,6.47,416.02,percent of total billed charges,,,
ZOLEDRONIC ACID 5 MG/100ML IV SOLN,RX-81434,CDM,J3489,HCPCS,636,RC,67457-0619-10,NDC,outpatient,100,ML,182.43,127.701,AETNA [1000108],AETNA [100010801],,,76.8,,140.11,6.47,416.02,percent of total billed charges,,,
ZOLEDRONIC ACID 5 MG/100ML IV SOLN,RX-81434,CDM,J3489,HCPCS,636,RC,55111-0688-52,NDC,outpatient,100,ML,126.81,88.767,AETNA [1000108],AETNA [100010801],,,76.8,,97.39,6.47,416.02,percent of total billed charges,,,
IDARUCIZUMAB 2.5 GM/50ML IV SOLN,RX-132721,CDM,J3590,HCPCS,636,RC,00597-0197-05,NDC,outpatient,100,ML,13473.22,9431.254,AETNA [1000108],AETNA [100010801],,,76.8,,10347.43,399.86,10347.43296,percent of total billed charges,,,
SODIUM CHLORIDE 0.45 % IV SOLN,RX-7318,CDM,J7030,HCPCS,250,RC,00338-0043-03,NDC,outpatient,500,ML,23.71,16.597,AETNA [1000108],AETNA [100010801],,,76.8,,18.21,2.54,416.02,percent of total billed charges,,,
SODIUM CHLORIDE 0.45 % IV SOLN,RX-7318,CDM,J7030,HCPCS,250,RC,00338-0043-04,NDC,outpatient,1000,ML,26.28,18.396,AETNA [1000108],AETNA [100010801],,,76.8,,20.18,2.54,416.02,percent of total billed charges,,,
DEXTROSE-SODIUM CHLORIDE 5-0.9 % IV SOLN,RX-9815,CDM,J7042,HCPCS,636,RC,00338-0089-04,NDC,outpatient,1000,ML,26.28,18.396,AETNA [1000108],AETNA [100010801],,,76.8,,20.18,1.14,416.02,percent of total billed charges,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-02,NDC,outpatient,250,ML,22.43,15.701,AETNA [1000108],AETNA [100010801],,,76.8,,17.23,1.81,416.02,percent of total billed charges,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-03,NDC,outpatient,500,ML,23.71,16.597,AETNA [1000108],AETNA [100010801],,,76.8,,18.21,1.81,416.02,percent of total billed charges,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-31,NDC,outpatient,50,ML,22.43,15.701,AETNA [1000108],AETNA [100010801],,,76.8,,17.23,1.81,416.02,percent of total billed charges,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-11,NDC,outpatient,50,ML,22.43,15.701,AETNA [1000108],AETNA [100010801],,,76.8,,17.23,1.81,416.02,percent of total billed charges,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-38,NDC,outpatient,100,ML,22.17,15.519,AETNA [1000108],AETNA [100010801],,,76.8,,17.03,1.81,416.02,percent of total billed charges,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-41,NDC,outpatient,50,ML,22.94,16.058,AETNA [1000108],AETNA [100010801],,,76.8,,17.62,1.81,416.02,percent of total billed charges,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00409-7100-02,NDC,outpatient,250,ML,30.14,21.098,AETNA [1000108],AETNA [100010801],,,76.8,,23.15,1.81,416.02,percent of total billed charges,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,63323-0624-74,NDC,outpatient,250,ML,25,17.5,AETNA [1000108],AETNA [100010801],,,76.8,,19.2,1.81,416.02,percent of total billed charges,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-48,NDC,outpatient,100,ML,22.69,15.883,AETNA [1000108],AETNA [100010801],,,76.8,,17.43,1.81,416.02,percent of total billed charges,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00409-7100-04,NDC,outpatient,250,ML,30.14,21.098,AETNA [1000108],AETNA [100010801],,,76.8,,23.15,1.81,416.02,percent of total billed charges,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,63323-0624-04,NDC,outpatient,250,ML,25,17.5,AETNA [1000108],AETNA [100010801],,,76.8,,19.2,1.81,416.02,percent of total billed charges,,,
DEXTROSE 5 % IV PVC FREE SOLN,RX-4080550,CDM,J7060,HCPCS,636,RC,00338-6346-03,NDC,outpatient,500,ML,42.7,29.89,AETNA [1000108],AETNA [100010801],,,76.8,,32.79,1.81,416.02,percent of total billed charges,,,
DEXTROSE 5 % IV PVC FREE SOLN,RX-4080550,CDM,J7060,HCPCS,636,RC,00264-7510-10,NDC,outpatient,500,ML,33.99,23.793,AETNA [1000108],AETNA [100010801],,,76.8,,26.1,1.81,416.02,percent of total billed charges,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7070,HCPCS,636,RC,00338-0017-04,NDC,outpatient,1000,ML,21.14,14.798,AETNA [1000108],AETNA [100010801],,,76.8,,16.24,3.62,416.02,percent of total billed charges,,,
DEXTRAN 40 IN D5W 10 % IV SOLN,RX-9759,CDM,J7100,HCPCS,636,RC,00409-7418-03,NDC,outpatient,500,ML,116.13,81.291,AETNA [1000108],AETNA [100010801],,,76.8,,89.19,19.23,416.02,percent of total billed charges,,,
DEXTRAN 40 IN D5W 10 % IV SOLN,RX-9759,CDM,J7100,HCPCS,636,RC,00409-7418-13,NDC,outpatient,500,ML,116.13,81.291,AETNA [1000108],AETNA [100010801],,,76.8,,89.19,19.23,416.02,percent of total billed charges,,,
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00264-7750-20,NDC,outpatient,250,ML,33.8,23.66,AETNA [1000108],AETNA [100010801],,,76.8,,25.96,2.39,416.02,percent of total billed charges,,,
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00338-0117-02,NDC,outpatient,250,ML,22.43,15.701,AETNA [1000108],AETNA [100010801],,,76.8,,17.23,2.39,416.02,percent of total billed charges,,,
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00338-0117-04,NDC,outpatient,1000,ML,26.28,18.396,AETNA [1000108],AETNA [100010801],,,76.8,,20.18,2.39,416.02,percent of total billed charges,,,
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00338-0117-03,NDC,outpatient,500,ML,23.71,16.597,AETNA [1000108],AETNA [100010801],,,76.8,,18.21,2.39,416.02,percent of total billed charges,,,
DEXTROSE IN LACTATED RINGERS 5 % IV SOLN,RX-9788,CDM,J7121,HCPCS,636,RC,00338-0125-04,NDC,outpatient,1000,ML,26.28,18.396,AETNA [1000108],AETNA [100010801],,,76.8,,20.18,5.89986,416.02,percent of total billed charges,,,
PROTHROMBIN COMPLEX CONC HUMAN 500 UNITS IV KIT,RX-122122,CDM,J7168,HCPCS,636,RC,63833-0386-02,NDC,outpatient,1,UN,3022.2,2115.54,AETNA [1000108],AETNA [100010801],,,76.8,,2321.05,2.568211,4642.0992,percent of total billed charges,,,
PROTHROMBIN COMPLEX CONC HUMAN 1000 UNITS IV KIT,RX-125272,CDM,J7168,HCPCS,636,RC,63833-0387-02,NDC,outpatient,1,UN,6044.4,4231.08,AETNA [1000108],AETNA [100010801],,,76.8,,4642.1,2.568211,4642.0992,percent of total billed charges,,,
ANTIHEMOPHILIC FACTOR-VWF 500-500 UNITS IV KIT,RX-134441,CDM,J7183,HCPCS,636,RC,68982-0182-01,NDC,outpatient,1,UN,1449,1014.3,AETNA [1000108],AETNA [100010801],,,76.8,,1112.83,1.26,2225.664,percent of total billed charges,,,
ANTIHEMOPHILIC FACTOR-VWF 1000-1000 UNITS IV KIT,RX-134442,CDM,J7183,HCPCS,636,RC,68982-0182-02,NDC,outpatient,1,UN,2898,2028.6,AETNA [1000108],AETNA [100010801],,,76.8,,2225.66,1.26,2225.664,percent of total billed charges,,,
ANTIHEMOPHILIC FACTOR-VWF 250-600 UNITS IV SOLR,RX-70404,CDM,J7187,HCPCS,636,RC,63833-0615-02,NDC,outpatient,1,UN,1821.6,1275.12,AETNA [1000108],AETNA [100010801],,,76.8,,1398.99,1.23,3240,percent of total billed charges,,,
ANTIHEMOPHILIC FACTOR-VWF 250-600 UNITS IV SOLR,RX-70404,CDM,J7187,HCPCS,636,RC,63833-0625-01,NDC,outpatient,1,UN,1821.6,1275.12,AETNA [1000108],AETNA [100010801],,,76.8,,1398.99,1.23,3240,percent of total billed charges,,,
ANTIHEMOPHILIC FACTOR-VWF 500-1200 UNITS IV SOLR,RX-70405,CDM,J7187,HCPCS,636,RC,63833-0616-02,NDC,outpatient,1,UN,3643.2,2550.24,AETNA [1000108],AETNA [100010801],,,76.8,,2797.98,1.23,3240,percent of total billed charges,,,
ANTIHEMOPHILIC FACTOR-VWF 500-1200 UNITS IV SOLR,RX-70405,CDM,J7187,HCPCS,636,RC,63833-0626-01,NDC,outpatient,1,UN,3643.2,2550.24,AETNA [1000108],AETNA [100010801],,,76.8,,2797.98,1.23,3240,percent of total billed charges,,,
ANTIHEMOPHILIC FACTOR-VWF 1000-2400 UNITS IV SOLR,RX-70406,CDM,J7187,HCPCS,636,RC,63833-0617-02,NDC,outpatient,1,UN,3036,2125.2,AETNA [1000108],AETNA [100010801],,,76.8,,2331.65,1.23,3240,percent of total billed charges,,,
ANTIHEMOPHILIC FACTOR-VWF 1000-2400 UNITS IV SOLR,RX-70406,CDM,J7187,HCPCS,636,RC,63833-0627-01,NDC,outpatient,1,UN,3036,2125.2,AETNA [1000108],AETNA [100010801],,,76.8,,2331.65,1.23,3240,percent of total billed charges,,,
COAGULATION FACTOR VIIA RECOMB 1 MG IV SOLR,RX-92853,CDM,J7189,HCPCS,636,RC,00169-7211-11,NDC,outpatient,1,UN,6342.76,4439.932,AETNA [1000108],AETNA [100010801],,,76.8,,4871.24,2.13,24356.18304,percent of total billed charges,,,
COAGULATION FACTOR VIIA RECOMB 1 MG IV SOLR,RX-92853,CDM,J7189,HCPCS,636,RC,00169-7201-01,NDC,outpatient,1,UN,6342.76,4439.932,AETNA [1000108],AETNA [100010801],,,76.8,,4871.24,2.13,24356.18304,percent of total billed charges,,,
COAGULATION FACTOR VIIA RECOMB 2 MG IV SOLR,RX-92854,CDM,J7189,HCPCS,636,RC,00169-7202-01,NDC,outpatient,1,UN,12685.52,8879.864,AETNA [1000108],AETNA [100010801],,,76.8,,9742.48,2.13,24356.18304,percent of total billed charges,,,
COAGULATION FACTOR VIIA RECOMB 2 MG IV SOLR,RX-92854,CDM,J7189,HCPCS,636,RC,00169-7212-11,NDC,outpatient,1,UN,12685.52,8879.864,AETNA [1000108],AETNA [100010801],,,76.8,,9742.48,2.13,24356.18304,percent of total billed charges,,,
COAGULATION FACTOR VIIA RECOMB 5 MG IV SOLR,RX-92855,CDM,J7189,HCPCS,636,RC,00169-7205-01,NDC,outpatient,1,UN,31713.78,22199.646,AETNA [1000108],AETNA [100010801],,,76.8,,24356.18,2.13,24356.18304,percent of total billed charges,,,
ANTIHEMOPHILIC FACTOR VIII RAHF-PFM 500 UNITS IV SOLR,RX-76366,CDM,J7192,HCPCS,636,RC,00944-3052-02,NDC,outpatient,1,UN,1863,1304.1,AETNA [1000108],AETNA [100010801],,,76.8,,1430.78,1.25,2861.568,percent of total billed charges,,,
ANTIHEMOPHILIC FACTOR VIII RAHF-PFM 1000 UNITS IV SOLR,RX-76367,CDM,J7192,HCPCS,636,RC,00944-3053-02,NDC,outpatient,1,UN,3726,2608.2,AETNA [1000108],AETNA [100010801],,,76.8,,2861.57,1.25,2861.568,percent of total billed charges,,,
ANTITHROMBIN III (HUMAN) 500 UNITS IV SOLR,RX-9116,CDM,J7197,HCPCS,636,RC,13533-0606-12,NDC,outpatient,1,UN,4954.2,3467.94,AETNA [1000108],AETNA [100010801],,,76.8,,3804.83,3.35,3804.8256,percent of total billed charges,,,
ANTITHROMBIN III (HUMAN) 500 UNITS IV SOLR,RX-9116,CDM,J7197,HCPCS,636,RC,13533-0602-50,NDC,outpatient,1,UN,4954.2,3467.94,AETNA [1000108],AETNA [100010801],,,76.8,,3804.83,3.35,3804.8256,percent of total billed charges,,,
ANTIINHIBITOR COAGULANT CMPLX 2500 UNITS IV SOLR,RX-146201,CDM,J7198,HCPCS,636,RC,64193-0425-02,NDC,outpatient,1,UN,13869,9708.3,AETNA [1000108],AETNA [100010801],,,76.8,,10651.39,1.94,10651.392,percent of total billed charges,,,
SODIUM HYALURONATE (VISCOSUP) 25 MG/2.5ML IX SOSY,RX-127543,CDM,J7321,HCPCS,636,RC,89130-4444-01,NDC,outpatient,2.5,ML,1023.91,716.737,AETNA [1000108],AETNA [100010801],,,76.8,,786.36,73.22,786.36288,percent of total billed charges,,,
AZATHIOPRINE 50 MG ORAL TABS,RX-9183,CDM,J7500,HCPCS,259,RC,68084-0229-11,NDC,outpatient,1,UN,2.39,1.673,AETNA [1000108],AETNA [100010801],,,76.8,,1.84,0.536555,416.02,percent of total billed charges,,,
AZATHIOPRINE 50 MG ORAL TABS,RX-9183,CDM,J7500,HCPCS,259,RC,68084-0229-01,NDC,outpatient,1,UN,2.39,1.673,AETNA [1000108],AETNA [100010801],,,76.8,,1.84,0.536555,416.02,percent of total billed charges,,,
CYCLOSPORINE 50 MG/ML IV SOLN,RX-9705,CDM,J7516,HCPCS,636,RC,00574-0866-10,NDC,outpatient,5,ML,142.85,99.995,AETNA [1000108],AETNA [100010801],,,76.8,,109.71,15.32,416.02,percent of total billed charges,,,
MYCOPHENOLATE MOFETIL HCL 500 MG IV SOLR,RX-23968,CDM,J7519,HCPCS,636,RC,71288-0803-20,NDC,outpatient,1,UN,89.27,62.489,AETNA [1000108],AETNA [100010801],,,76.8,,68.56,0.52,416.02,percent of total billed charges,,,
MYCOPHENOLATE MOFETIL HCL 500 MG IV SOLR,RX-23968,CDM,J7519,HCPCS,636,RC,00004-0298-09,NDC,outpatient,1,UN,298.3,208.81,AETNA [1000108],AETNA [100010801],,,76.8,,229.09,0.52,416.02,percent of total billed charges,,,
METHACHOLINE CHLORIDE 100 MG IN SOLR,RX-27032,CDM,J7674,HCPCS,636,RC,64281-0100-00,NDC,outpatient,1,UN,341.28,238.896,AETNA [1000108],AETNA [100010801],,,76.8,,262.1,0.86,416.02,percent of total billed charges,,,
METHACHOLINE CHLORIDE 100 MG IN SOLR,RX-27032,CDM,J7674,HCPCS,636,RC,64281-0100-06,NDC,outpatient,1,UN,341.28,238.896,AETNA [1000108],AETNA [100010801],,,76.8,,262.1,0.86,416.02,percent of total billed charges,,,
ETOPOSIDE 50 MG ORAL CAPS,RX-10001,CDM,J8560,HCPCS,636,RC,00378-3266-32,NDC,outpatient,1,UN,309.74,216.818,AETNA [1000108],AETNA [100010801],,,76.8,,237.88,69.53663,416.02,percent of total billed charges,,,
ETOPOSIDE 50 MG ORAL CAPS,RX-10001,CDM,J8560,HCPCS,636,RC,00378-3266-94,NDC,outpatient,1,UN,309.74,216.818,AETNA [1000108],AETNA [100010801],,,76.8,,237.88,69.53663,416.02,percent of total billed charges,,,
MERCAPTOPURINE 50 MG ORAL TABS,RX-10531,CDM,J8999,HCPCS,259,RC,00054-4581-11,NDC,outpatient,1,UN,14.11,9.877,AETNA [1000108],AETNA [100010801],,,76.8,,10.84,0.370425,416.02,percent of total billed charges,,,
MERCAPTOPURINE 50 MG ORAL TABS,RX-10531,CDM,J8999,HCPCS,259,RC,00378-3547-52,NDC,outpatient,1,UN,4.39,3.073,AETNA [1000108],AETNA [100010801],,,76.8,,3.37,0.370425,416.02,percent of total billed charges,,,
BICALUTAMIDE 50 MG ORAL TABS,RX-15746,CDM,J8999,HCPCS,259,RC,16729-0023-10,NDC,outpatient,1,UN,2.86,2.002,AETNA [1000108],AETNA [100010801],,,76.8,,2.2,0.370425,416.02,percent of total billed charges,,,
ANASTROZOLE 1 MG ORAL TABS,RX-16205,CDM,J8999,HCPCS,259,RC,60687-0112-11,NDC,outpatient,1,UN,3.22,2.254,AETNA [1000108],AETNA [100010801],,,76.8,,2.47,0.370425,416.02,percent of total billed charges,,,
ANASTROZOLE 1 MG ORAL TABS,RX-16205,CDM,J8999,HCPCS,259,RC,60687-0112-21,NDC,outpatient,1,UN,3.22,2.254,AETNA [1000108],AETNA [100010801],,,76.8,,2.47,0.370425,416.02,percent of total billed charges,,,
MEGESTROL ACETATE 40 MG ORAL TABS,RX-4871,CDM,J8999,HCPCS,259,RC,64380-0159-01,NDC,outpatient,1,UN,1.65,1.155,AETNA [1000108],AETNA [100010801],,,76.8,,1.27,0.370425,416.02,percent of total billed charges,,,
MEGESTROL ACETATE 400 MG/10ML ORAL SUSP,RX-76824,CDM,J8999,HCPCS,259,RC,00121-0945-40,NDC,outpatient,10,ML,15.58,10.906,AETNA [1000108],AETNA [100010801],,,76.8,,11.97,0.370425,416.02,percent of total billed charges,,,
MEGESTROL ACETATE 400 MG/10ML ORAL SUSP,RX-76824,CDM,J8999,HCPCS,259,RC,99999-0003-95,NDC,outpatient,10,ML,8.73,6.111,AETNA [1000108],AETNA [100010801],,,76.8,,6.7,0.370425,416.02,percent of total billed charges,,,
MEGESTROL ACETATE 400 MG/10ML ORAL SUSP,RX-76824,CDM,J8999,HCPCS,259,RC,00121-0945-10,NDC,outpatient,10,ML,15.58,10.906,AETNA [1000108],AETNA [100010801],,,76.8,,11.97,0.370425,416.02,percent of total billed charges,,,
TAMOXIFEN CITRATE 10 MG ORAL TABS,RX-7711,CDM,J8999,HCPCS,259,RC,63739-0143-10,NDC,outpatient,1,UN,1.98,1.386,AETNA [1000108],AETNA [100010801],,,76.8,,1.52,0.370425,416.02,percent of total billed charges,,,
DOXORUBICIN HCL 2 MG/ML IV PUSH SOLN,RX-2616,CDM,J9000,HCPCS,636,RC,00069-3032-20,NDC,outpatient,25,ML,44.02,30.814,AETNA [1000108],AETNA [100010801],,,76.8,,33.81,2.5,525.12,percent of total billed charges,,,
DOXORUBICIN HCL 2 MG/ML IV PUSH SOLN,RX-2616,CDM,J9000,HCPCS,636,RC,00069-3030-20,NDC,outpatient,5,ML,19.68,13.776,AETNA [1000108],AETNA [100010801],,,76.8,,15.11,2.5,525.12,percent of total billed charges,,,
DOXORUBICIN HCL 2 MG/ML IV PUSH SOLN,RX-2616,CDM,J9000,HCPCS,636,RC,00069-3031-20,NDC,outpatient,10,ML,34.71,24.297,AETNA [1000108],AETNA [100010801],,,76.8,,26.66,2.5,525.12,percent of total billed charges,,,
DOXORUBICIN HCL 10 MG IV SOLR,RX-2617,CDM,J9000,HCPCS,636,RC,00143-9092-01,NDC,outpatient,1,UN,143.64,100.548,AETNA [1000108],AETNA [100010801],,,76.8,,110.32,2.5,525.12,percent of total billed charges,,,
DOXORUBICIN HCL 50 MG IV SOLR,RX-2619,CDM,J9000,HCPCS,636,RC,00143-9277-01,NDC,outpatient,1,UN,683.75,478.625,AETNA [1000108],AETNA [100010801],,,76.8,,525.12,2.5,525.12,percent of total billed charges,,,
ARSENIC TRIOXIDE 12 MG/6ML IV SOLN,RX-141420,CDM,J9017,HCPCS,636,RC,63459-0601-06,NDC,outpatient,6,ML,3082.97,2158.079,AETNA [1000108],AETNA [100010801],,,76.8,,2367.72,7.2,2367.72096,percent of total billed charges,,,
ARSENIC TRIOXIDE 12 MG/6ML IV SOLN,RX-141420,CDM,J9017,HCPCS,636,RC,63459-0601-11,NDC,outpatient,6,ML,3082.97,2158.079,AETNA [1000108],AETNA [100010801],,,76.8,,2367.72,7.2,2367.72096,percent of total billed charges,,,
AZACITIDINE 100 MG IJ SUSR,RX-78420,CDM,J9025,HCPCS,636,RC,43598-0305-62,NDC,outpatient,1,UN,83.86,58.702,AETNA [1000108],AETNA [100010801],,,76.8,,64.4,0.32,416.02,percent of total billed charges,,,
AZACITIDINE 100 MG IJ SUSR,RX-78420,CDM,J9025,HCPCS,636,RC,63323-0771-39,NDC,outpatient,1,UN,117.36,82.152,AETNA [1000108],AETNA [100010801],,,76.8,,90.13,0.32,416.02,percent of total billed charges,,,
BENDAMUSTINE HCL 5 MG/ML IV SOLR WRAPPER,RX-4080211,CDM,J9033,HCPCS,636,RC,63459-0391-20,NDC,outpatient,20,ML,2803.09,1962.163,AETNA [1000108],AETNA [100010801],,,76.8,,2152.77,5.43,2152.77312,percent of total billed charges,,,
BENDAMUSTINE HCL 5 MG/ML IV SOLR WRAPPER,RX-4080211,CDM,J9033,HCPCS,636,RC,63459-0390-08,NDC,outpatient,5,ML,889.43,622.601,AETNA [1000108],AETNA [100010801],,,76.8,,683.08,5.43,2152.77312,percent of total billed charges,,,
BENDAMUSTINE HCL 100 MG/4ML IV SOLN,RX-133070,CDM,J9034,HCPCS,636,RC,63459-0348-04,NDC,outpatient,4,ML,5078.48,3554.936,AETNA [1000108],AETNA [100010801],,,76.8,,3900.27,12.95,3900.27264,percent of total billed charges,,,
BEVACIZUMAB 25 MG/ML IV WRAPPER,RX-4080193,CDM,J9035,HCPCS,636,RC,50242-0061-01,NDC,outpatient,16,ML,9117,6381.9,AETNA [1000108],AETNA [100010801],,,76.8,,7001.86,72.7,7001.856,percent of total billed charges,,,
BEVACIZUMAB 25 MG/ML IV WRAPPER,RX-4080193,CDM,J9035,HCPCS,636,RC,50242-0060-01,NDC,outpatient,4,ML,2279.25,1595.475,AETNA [1000108],AETNA [100010801],,,76.8,,1750.46,72.7,7001.856,percent of total billed charges,,,
BLEOMYCIN SULFATE 30 UNITS IJ SOLR,RX-17012,CDM,J9040,HCPCS,636,RC,63323-0137-20,NDC,outpatient,1,UN,120.16,84.112,AETNA [1000108],AETNA [100010801],,,76.8,,92.28,14.931495,416.02,percent of total billed charges,,,
BLEOMYCIN SULFATE 15 UNITS IJ SOLR *TEST DOSE*,RX-9289,CDM,J9040,HCPCS,636,RC,16714-0886-01,NDC,outpatient,1,UN,66.51,46.557,AETNA [1000108],AETNA [100010801],,,76.8,,51.08,14.931495,416.02,percent of total billed charges,,,
BORTEZOMIB 3.5 MG IJ SOLR,RX-123070,CDM,J9041,HCPCS,636,RC,00143-9098-01,NDC,outpatient,1,UN,58.7,41.09,AETNA [1000108],AETNA [100010801],,,76.8,,45.08,1.57,905.322979,percent of total billed charges,,,
BORTEZOMIB 3.5 MG IJ SOLR,RX-123070,CDM,J9041,HCPCS,636,RC,10019-0991-01,NDC,outpatient,1,UN,147.6,103.32,AETNA [1000108],AETNA [100010801],,,76.8,,113.36,1.57,905.322979,percent of total billed charges,,,
BRENTUXIMAB VEDOTIN 50 MG IV SOLR,RX-111348,CDM,J9042,HCPCS,636,RC,51144-0050-01,NDC,outpatient,1,UN,32323.72,22626.604,AETNA [1000108],AETNA [100010801],,,76.8,,24824.62,221.96,24824.61696,percent of total billed charges,,,
CABAZITAXEL 60 MG/1.5ML IV SOLN,RX-105644,CDM,J9043,HCPCS,636,RC,00024-5824-11,NDC,outpatient,6,ML,39665.77,27766.039,AETNA [1000108],AETNA [100010801],,,76.8,,30463.31,206.03,30463.31136,percent of total billed charges,,,
CARBOPLATIN 10 MG/ML IV SOLN WRAPPER,RX-4080212,CDM,J9045,HCPCS,636,RC,00703-4248-01,NDC,outpatient,45,ML,63.71,44.597,AETNA [1000108],AETNA [100010801],,,76.8,,48.93,2.41,416.02,percent of total billed charges,,,
CARBOPLATIN 10 MG/ML IV SOLN WRAPPER,RX-4080212,CDM,J9045,HCPCS,636,RC,61703-0339-50,NDC,outpatient,45,ML,157.96,110.572,AETNA [1000108],AETNA [100010801],,,76.8,,121.31,2.41,416.02,percent of total billed charges,,,
CARFILZOMIB 60 MG IV SOLR,RX-117047,CDM,J9047,HCPCS,636,RC,76075-0101-01,NDC,outpatient,1,UN,8945.66,6261.962,AETNA [1000108],AETNA [100010801],,,76.8,,6870.27,47.04,6870.26688,percent of total billed charges,,,
CETUXIMAB 200 MG/100ML IV SOLN,RX-108072,CDM,J9055,HCPCS,636,RC,66733-0958-23,NDC,outpatient,100,ML,4373.8,3061.66,AETNA [1000108],AETNA [100010801],,,76.8,,3359.08,72.08,3359.0784,percent of total billed charges,,,
CETUXIMAB 100 MG/50ML IV SOLN,RX-37989,CDM,J9055,HCPCS,636,RC,66733-0948-23,NDC,outpatient,50,ML,2186.9,1530.83,AETNA [1000108],AETNA [100010801],,,76.8,,1679.54,72.08,3359.0784,percent of total billed charges,,,
CISPLATIN 1 MG/ML IV WRAPPER,RX-4080194,CDM,J9060,HCPCS,636,RC,00703-5748-11,NDC,outpatient,100,ML,67.89,47.523,AETNA [1000108],AETNA [100010801],,,76.8,,52.14,2.37,416.02,percent of total billed charges,,,
CLADRIBINE 1 MG/ML IV SOLN WRAPPER,RX-4080791,CDM,J9065,HCPCS,636,RC,63323-0140-10,NDC,outpatient,10,ML,347.72,243.404,AETNA [1000108],AETNA [100010801],,,76.8,,267.05,14.25,416.02,percent of total billed charges,,,
CYCLOPHOSPHAMIDE 1 G IJ SOLR,RX-38270,CDM,J9070,HCPCS,636,RC,00781-3244-94,NDC,outpatient,1,UN,1602.63,1121.841,AETNA [1000108],AETNA [100010801],,,76.8,,1230.82,17.09,1230.81984,percent of total billed charges,,,
CYCLOPHOSPHAMIDE 500 MG IJ SOLR,RX-38271,CDM,J9070,HCPCS,636,RC,00781-3233-94,NDC,outpatient,1,UN,1017.09,711.963,AETNA [1000108],AETNA [100010801],,,76.8,,781.13,17.09,1230.81984,percent of total billed charges,,,
CYCLOPHOSPHAMIDE 2 G IJ SOLR,RX-38280,CDM,J9070,HCPCS,636,RC,10019-0957-01,NDC,outpatient,1,UN,1524.13,1066.891,AETNA [1000108],AETNA [100010801],,,76.8,,1170.53,17.09,1230.81984,percent of total billed charges,,,
CYTARABINE (PF) 100 MG/ML IJ SOLN,RX-20156,CDM,J9100,HCPCS,636,RC,63323-0120-20,NDC,outpatient,20,ML,40.95,28.665,AETNA [1000108],AETNA [100010801],,,76.8,,31.45,0.77,416.02,percent of total billed charges,,,
CYTARABINE (PF) 100 MG/ML IJ SOLN,RX-20156,CDM,J9100,HCPCS,636,RC,61703-0319-22,NDC,outpatient,20,ML,53.29,37.303,AETNA [1000108],AETNA [100010801],,,76.8,,40.93,0.77,416.02,percent of total billed charges,,,
CYTARABINE (PF) 20 MG/ML IJ SOLN,RX-96982,CDM,J9100,HCPCS,636,RC,61703-0303-46,NDC,outpatient,50,ML,62.44,43.708,AETNA [1000108],AETNA [100010801],,,76.8,,47.95,0.77,416.02,percent of total billed charges,,,
CYTARABINE (PF) 20 MG/ML IJ SOLN,RX-96982,CDM,J9100,HCPCS,636,RC,61703-0305-38,NDC,outpatient,5,ML,16.81,11.767,AETNA [1000108],AETNA [100010801],,,76.8,,12.91,0.77,416.02,percent of total billed charges,,,
CYTARABINE (PF) 20 MG/ML IJ SOLN,RX-96982,CDM,J9100,HCPCS,636,RC,61703-0305-58,NDC,outpatient,5,ML,16.81,11.767,AETNA [1000108],AETNA [100010801],,,76.8,,12.91,0.77,416.02,percent of total billed charges,,,
CYTARABINE 20 MG/ML IJ SOLN,RX-9709,CDM,J9100,HCPCS,636,RC,61703-0304-36,NDC,outpatient,25,ML,34.67,24.269,AETNA [1000108],AETNA [100010801],,,76.8,,26.63,0.77,416.02,percent of total billed charges,,,
DACARBAZINE 200 MG IV SOLR,RX-2091,CDM,J9130,HCPCS,636,RC,00143-9245-01,NDC,outpatient,1,UN,16.44,11.508,AETNA [1000108],AETNA [100010801],,,76.8,,12.63,3.69078,416.02,percent of total billed charges,,,
DACARBAZINE 200 MG IV SOLR,RX-2091,CDM,J9130,HCPCS,636,RC,00143-9245-10,NDC,outpatient,1,UN,16.44,11.508,AETNA [1000108],AETNA [100010801],,,76.8,,12.63,3.69078,416.02,percent of total billed charges,,,
DEGARELIX ACETATE(240 MG DOSE) 120 MG/VIAL SC SOLR,RX-150086,CDM,J9155,HCPCS,636,RC,55566-8403-01,NDC,outpatient,1,UN,1744.22,1220.954,AETNA [1000108],AETNA [100010801],,,76.8,,1339.56,4.18,1339.56096,percent of total billed charges,,,
DEGARELIX ACETATE 80 MG SC SOLR,RX-96986,CDM,J9155,HCPCS,636,RC,55566-8303-01,NDC,outpatient,1,UN,1117.94,782.558,AETNA [1000108],AETNA [100010801],,,76.8,,858.58,4.18,1339.56096,percent of total billed charges,,,
DOCETAXEL 20 MG/ML IV CONC WRAPPER,RX-4080197,CDM,J9171,HCPCS,636,RC,16729-0267-65,NDC,outpatient,8,ML,615.8,431.06,AETNA [1000108],AETNA [100010801],,,76.8,,472.93,0.79,1115.136,percent of total billed charges,,,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,43066-0006-01,NDC,outpatient,8,ML,120.55,84.385,AETNA [1000108],AETNA [100010801],,,76.8,,92.58,0.79,1115.136,percent of total billed charges,,,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,66758-0050-02,NDC,outpatient,8,ML,726,508.2,AETNA [1000108],AETNA [100010801],,,76.8,,557.57,0.79,1115.136,percent of total billed charges,,,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,00409-0201-02,NDC,outpatient,2,ML,45.67,31.969,AETNA [1000108],AETNA [100010801],,,76.8,,35.07,0.79,1115.136,percent of total billed charges,,,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,66758-0050-01,NDC,outpatient,2,ML,181.5,127.05,AETNA [1000108],AETNA [100010801],,,76.8,,139.39,0.79,1115.136,percent of total billed charges,,,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,00409-0201-20,NDC,outpatient,16,ML,345.35,241.745,AETNA [1000108],AETNA [100010801],,,76.8,,265.23,0.79,1115.136,percent of total billed charges,,,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,66758-0050-03,NDC,outpatient,16,ML,1452,1016.4,AETNA [1000108],AETNA [100010801],,,76.8,,1115.14,0.79,1115.136,percent of total billed charges,,,
EPIRUBICIN HCL 2 MG/ML IV SOLN WRAPPER,RX-4080365,CDM,J9178,HCPCS,636,RC,00009-5091-01,NDC,outpatient,25,ML,112.35,78.645,AETNA [1000108],AETNA [100010801],,,76.8,,86.28,1.34,416.02,percent of total billed charges,,,
ERIBULIN MESYLATE 1 MG/2ML IV PUSH SOLN,RX-106773,CDM,J9179,HCPCS,636,RC,62856-0389-01,NDC,outpatient,2,ML,4032.6,2822.82,AETNA [1000108],AETNA [100010801],,,76.8,,3097.04,128.78,3097.0368,percent of total billed charges,,,
ETOPOSIDE 100 MG/5ML IV SOLN,RX-124543,CDM,J9181,HCPCS,636,RC,16729-0114-31,NDC,outpatient,5,ML,33.84,23.688,AETNA [1000108],AETNA [100010801],,,76.8,,25.99,0.7,416.02,percent of total billed charges,,,
ETOPOSIDE 100 MG/5ML IV SOLN,RX-124543,CDM,J9181,HCPCS,636,RC,16729-0114-08,NDC,outpatient,25,ML,169.25,118.475,AETNA [1000108],AETNA [100010801],,,76.8,,129.98,0.7,416.02,percent of total billed charges,,,
FLUDARABINE PHOSPHATE 25 MG/ML IV WRAPPER,RX-4080526,CDM,J9185,HCPCS,636,RC,25021-0242-02,NDC,outpatient,2,ML,278.39,194.873,AETNA [1000108],AETNA [100010801],,,76.8,,213.8,62.498555,604.75,percent of total billed charges,,,
FLUOROURACIL 50 MG/ML IV SOLN WRAPPER,RX-4080199,CDM,J9190,HCPCS,636,RC,16729-0276-11,NDC,outpatient,50,ML,99.65,69.755,AETNA [1000108],AETNA [100010801],,,76.8,,76.53,1.83,416.02,percent of total billed charges,,,
FLUOROURACIL 500 MG/10ML IV PUSH SOLN,RX-82200,CDM,J9190,HCPCS,636,RC,63323-0117-10,NDC,outpatient,10,ML,8.43,5.901,AETNA [1000108],AETNA [100010801],,,76.8,,6.47,1.83,416.02,percent of total billed charges,,,
FLUOROURACIL 500 MG/10ML IV PUSH SOLN,RX-82200,CDM,J9190,HCPCS,636,RC,63323-0117-00,NDC,outpatient,10,ML,8.43,5.901,AETNA [1000108],AETNA [100010801],,,76.8,,6.47,1.83,416.02,percent of total billed charges,,,
GEMCITABINE HCL 200 MG/5.26ML IV SOLN,RX-112786,CDM,J9201,HCPCS,636,RC,00409-0183-01,NDC,outpatient,5.26,ML,31.43,22.001,AETNA [1000108],AETNA [100010801],,,76.8,,24.14,2.79,416.02,percent of total billed charges,,,
GEMCITABINE HCL 1 GM/26.3ML IV SOLN,RX-112787,CDM,J9201,HCPCS,636,RC,00409-0181-01,NDC,outpatient,26.3,ML,133.66,93.562,AETNA [1000108],AETNA [100010801],,,76.8,,102.65,2.79,416.02,percent of total billed charges,,,
GEMCITABINE HCL 200 MG IV SOLR,RX-17121,CDM,J9201,HCPCS,636,RC,25021-0234-10,NDC,outpatient,1,UN,27.81,19.467,AETNA [1000108],AETNA [100010801],,,76.8,,21.36,2.79,416.02,percent of total billed charges,,,
GEMCITABINE HCL 1 G IV SOLR,RX-17122,CDM,J9201,HCPCS,636,RC,16714-0930-01,NDC,outpatient,1,UN,63.54,44.478,AETNA [1000108],AETNA [100010801],,,76.8,,48.8,2.79,416.02,percent of total billed charges,,,
GOSERELIN ACETATE 3.6 MG SC IMPL,RX-10137,CDM,J9202,HCPCS,636,RC,70720-0950-36,NDC,outpatient,1,UN,2706.82,1894.774,AETNA [1000108],AETNA [100010801],,,76.8,,2078.84,399.86,5828.5824,percent of total billed charges,,,
GOSERELIN ACETATE 10.8 MG SC IMPL,RX-16254,CDM,J9202,HCPCS,636,RC,70720-0951-30,NDC,outpatient,1,UN,7589.3,5312.51,AETNA [1000108],AETNA [100010801],,,76.8,,5828.58,399.86,5828.5824,percent of total billed charges,,,
IRINOTECAN HCL 20 MG/ML IV SOLN WRAPPER,RX-4080202,CDM,J9206,HCPCS,636,RC,60505-6128-01,NDC,outpatient,5,ML,26.29,18.403,AETNA [1000108],AETNA [100010801],,,76.8,,20.19,2.5,416.02,percent of total billed charges,,,
IRINOTECAN HCL 20 MG/ML IV SOLN WRAPPER,RX-4080202,CDM,J9206,HCPCS,636,RC,61703-0349-09,NDC,outpatient,5,ML,56.89,39.823,AETNA [1000108],AETNA [100010801],,,76.8,,43.69,2.5,416.02,percent of total billed charges,,,
IRINOTECAN HCL 20 MG/ML IV SOLN WRAPPER,RX-4080202,CDM,J9206,HCPCS,636,RC,61703-0349-16,NDC,outpatient,2,ML,43.49,30.443,AETNA [1000108],AETNA [100010801],,,76.8,,33.4,2.5,416.02,percent of total billed charges,,,
IXABEPILONE 15 MG IV SOLR,RX-88652,CDM,J9207,HCPCS,636,RC,70020-1910-01,NDC,outpatient,1,UN,5537.91,3876.537,AETNA [1000108],AETNA [100010801],,,76.8,,4253.11,122.55,12759.31392,percent of total billed charges,,,
IXABEPILONE 45 MG IV SOLR,RX-88653,CDM,J9207,HCPCS,636,RC,70020-1911-01,NDC,outpatient,1,UN,16613.69,11629.583,AETNA [1000108],AETNA [100010801],,,76.8,,12759.31,122.55,12759.31392,percent of total billed charges,,,
IFOSFAMIDE 1 G IV SOLR,RX-10248,CDM,J9208,HCPCS,636,RC,10019-0925-01,NDC,outpatient,1,UN,94.35,66.045,AETNA [1000108],AETNA [100010801],,,76.8,,72.46,21.181575,416.02,percent of total billed charges,,,
IFOSFAMIDE 1 G IV SOLR,RX-10248,CDM,J9208,HCPCS,636,RC,10019-0925-82,NDC,outpatient,1,UN,94.35,66.045,AETNA [1000108],AETNA [100010801],,,76.8,,72.46,21.181575,416.02,percent of total billed charges,,,
IFOSFAMIDE 3 G IV SOLR,RX-10249,CDM,J9208,HCPCS,636,RC,00338-3993-01,NDC,outpatient,1,UN,350.95,245.665,AETNA [1000108],AETNA [100010801],,,76.8,,269.53,21.181575,416.02,percent of total billed charges,,,
IFOSFAMIDE 3 G IV SOLR,RX-10249,CDM,J9208,HCPCS,636,RC,10019-0926-02,NDC,outpatient,1,UN,288.44,201.908,AETNA [1000108],AETNA [100010801],,,76.8,,221.52,21.181575,416.02,percent of total billed charges,,,
IFOSFAMIDE 3 G IV SOLR,RX-10249,CDM,J9208,HCPCS,636,RC,10019-0926-16,NDC,outpatient,1,UN,288.44,201.908,AETNA [1000108],AETNA [100010801],,,76.8,,221.52,21.181575,416.02,percent of total billed charges,,,
MESNA 100 MG/ML IV SOLN,RX-10537,CDM,J9209,HCPCS,636,RC,00338-1305-01,NDC,outpatient,10,ML,28.36,19.852,AETNA [1000108],AETNA [100010801],,,76.8,,21.78,1.67,416.02,percent of total billed charges,,,
MESNA 100 MG/ML IV SOLN,RX-10537,CDM,J9209,HCPCS,636,RC,63323-0733-11,NDC,outpatient,10,ML,222.31,155.617,AETNA [1000108],AETNA [100010801],,,76.8,,170.73,1.67,416.02,percent of total billed charges,,,
IDARUBICIN HCL 1 MG/ML IV SOLN WRAPPER,RX-4080583,CDM,J9211,HCPCS,636,RC,00013-2576-91,NDC,outpatient,5,ML,121.76,85.232,AETNA [1000108],AETNA [100010801],,,76.8,,93.51,27.33512,416.02,percent of total billed charges,,,
LEUPROLIDE ACETATE 7.5 MG IM KIT,RX-10392,CDM,J9217,HCPCS,636,RC,00074-3642-03,NDC,outpatient,1,UN,5670.76,3969.532,AETNA [1000108],AETNA [100010801],,,76.8,,4355.14,165.86,17420.48256,percent of total billed charges,,,
LEUPROLIDE ACETATE (3 MONTH) 22.5 MG IM KIT,RX-21045,CDM,J9217,HCPCS,636,RC,00074-3346-03,NDC,outpatient,1,UN,17012.14,11908.498,AETNA [1000108],AETNA [100010801],,,76.8,,13065.32,165.86,17420.48256,percent of total billed charges,,,
LEUPROLIDE ACETATE (4 MONTH) 30 MG IM KIT,RX-21108,CDM,J9217,HCPCS,636,RC,00074-3683-03,NDC,outpatient,1,UN,22682.92,15878.044,AETNA [1000108],AETNA [100010801],,,76.8,,17420.48,165.86,17420.48256,percent of total billed charges,,,
LEUPROLIDE ACETATE (4 MONTH) 30 MG SC KIT,RX-35236,CDM,J9217,HCPCS,636,RC,62935-0303-30,NDC,outpatient,1,UN,1549.29,1084.503,AETNA [1000108],AETNA [100010801],,,76.8,,1189.85,165.86,17420.48256,percent of total billed charges,,,
IPILIMUMAB 5 MG/ML IV SOLN WRAPPER,RX-4080201,CDM,J9228,HCPCS,636,RC,00003-2327-11,NDC,outpatient,10,ML,24402.93,17082.051,AETNA [1000108],AETNA [100010801],,,76.8,,18741.45,167.93,74965.60128,percent of total billed charges,,,
IPILIMUMAB 5 MG/ML IV SOLN WRAPPER,RX-4080201,CDM,J9228,HCPCS,636,RC,00003-2328-22,NDC,outpatient,40,ML,97611.46,68328.022,AETNA [1000108],AETNA [100010801],,,76.8,,74965.6,167.93,74965.60128,percent of total billed charges,,,
METHOTREXATE SODIUM 25 MG/ML IJ SOLN WRAPPER,RX-4080788,CDM,J9250,HCPCS,636,RC,61703-0350-38,NDC,outpatient,0.5,ML,3.4,2.38,AETNA [1000108],AETNA [100010801],,,76.8,,2.61,0.27,416.02,percent of total billed charges,,,
METHOTREXATE SODIUM 25 MG/ML IJ SOLN WRAPPER,RX-4080788,CDM,J9250,HCPCS,636,RC,61703-0350-37,NDC,outpatient,0.5,ML,3.4,2.38,AETNA [1000108],AETNA [100010801],,,76.8,,2.61,0.27,416.02,percent of total billed charges,,,
METHOTREXATE SODIUM (PF) 25 MG/ML IJ SOLN WRAPPER,RX-4080789,CDM,J9260,HCPCS,636,RC,00143-9519-01,NDC,outpatient,2,ML,6.58,4.606,AETNA [1000108],AETNA [100010801],,,76.8,,5.05,1.47721,416.02,percent of total billed charges,,,
METHOTREXATE SODIUM (PF) 25 MG/ML IJ SOLN WRAPPER,RX-4080789,CDM,J9260,HCPCS,636,RC,00143-9519-10,NDC,outpatient,2,ML,6.58,4.606,AETNA [1000108],AETNA [100010801],,,76.8,,5.05,1.47721,416.02,percent of total billed charges,,,
NELARABINE 5 MG/ML IV SOLN,RX-70267,CDM,J9261,HCPCS,636,RC,00078-0683-61,NDC,outpatient,50,ML,2241.96,1569.372,AETNA [1000108],AETNA [100010801],,,76.8,,1721.83,72.53,1721.82528,percent of total billed charges,,,
OXALIPLATIN 5 MG/ML IV SOLR WRAPPER,RX-4080205,CDM,J9263,HCPCS,636,RC,00703-3986-01,NDC,outpatient,20,ML,216.64,151.648,AETNA [1000108],AETNA [100010801],,,76.8,,166.38,0.06,416.02,percent of total billed charges,,,
OXALIPLATIN 5 MG/ML IV SOLR WRAPPER,RX-4080205,CDM,J9263,HCPCS,636,RC,67457-0469-10,NDC,outpatient,10,ML,50.32,35.224,AETNA [1000108],AETNA [100010801],,,76.8,,38.65,0.06,416.02,percent of total billed charges,,,
PACLITAXEL PROTEIN-BOUND PART 100 MG IV SUSR,RX-40475,CDM,J9264,HCPCS,636,RC,68817-0134-50,NDC,outpatient,1,UN,4383.41,3068.387,AETNA [1000108],AETNA [100010801],,,76.8,,3366.46,12.06,3366.45888,percent of total billed charges,,,
PACLITAXEL 6 MG/ML IV CONC WRAPPER,RX-4080637,CDM,J9267,HCPCS,636,RC,61703-0342-50,NDC,outpatient,50,ML,238.31,166.817,AETNA [1000108],AETNA [100010801],,,76.8,,183.02,0.1,416.02,percent of total billed charges,,,
PACLITAXEL 6 MG/ML IV CONC WRAPPER,RX-4080637,CDM,J9267,HCPCS,636,RC,63323-0763-50,NDC,outpatient,50,ML,433.61,303.527,AETNA [1000108],AETNA [100010801],,,76.8,,333.01,0.1,416.02,percent of total billed charges,,,
PENTOSTATIN 10 MG IV SOLR,RX-10910,CDM,J9268,HCPCS,636,RC,00409-0801-01,NDC,outpatient,1,UN,6377.89,4464.523,AETNA [1000108],AETNA [100010801],,,76.8,,4898.22,399.86,4898.21952,percent of total billed charges,,,
PEMBROLIZUMAB 25 MG/ML IV SOLN WRAPPER,RX-4080564,CDM,J9271,HCPCS,636,RC,00006-3026-02,NDC,outpatient,4,ML,16212.43,11348.701,AETNA [1000108],AETNA [100010801],,,76.8,,12451.15,54.81,12451.14624,percent of total billed charges,,,
MITOMYCIN 20 MG IV SOLR,RX-10630,CDM,J9280,HCPCS,636,RC,16729-0108-11,NDC,outpatient,1,UN,505.56,353.892,AETNA [1000108],AETNA [100010801],,,76.8,,388.27,42.51,2565.35808,percent of total billed charges,,,
MITOMYCIN 40 MG IV SOLR,RX-10631,CDM,J9280,HCPCS,636,RC,16729-0116-38,NDC,outpatient,1,UN,3340.2,2338.14,AETNA [1000108],AETNA [100010801],,,76.8,,2565.27,42.51,2565.35808,percent of total billed charges,,,
MITOMYCIN 40 MG IV SOLR,RX-10631,CDM,J9280,HCPCS,636,RC,00143-9280-01,NDC,outpatient,1,UN,3340.31,2338.217,AETNA [1000108],AETNA [100010801],,,76.8,,2565.36,42.51,2565.35808,percent of total billed charges,,,
MITOMYCIN 5 MG IV SOLR,RX-10632,CDM,J9280,HCPCS,636,RC,16729-0115-05,NDC,outpatient,1,UN,734.35,514.045,AETNA [1000108],AETNA [100010801],,,76.8,,563.98,42.51,2565.35808,percent of total billed charges,,,
MITOXANTRONE HCL 20 MG/10ML IV CONC,RX-93748,CDM,J9293,HCPCS,636,RC,61703-0343-18,NDC,outpatient,10,ML,279.99,195.993,AETNA [1000108],AETNA [100010801],,,76.8,,215.03,29.06,416.02,percent of total billed charges,,,
NIVOLUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080562,CDM,J9299,HCPCS,636,RC,00003-3734-13,NDC,outpatient,24,ML,21406.97,14984.879,AETNA [1000108],AETNA [100010801],,,76.8,,16440.55,30.46,16440.55296,percent of total billed charges,,,
NIVOLUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080562,CDM,J9299,HCPCS,636,RC,00003-3772-11,NDC,outpatient,4,ML,3567.83,2497.481,AETNA [1000108],AETNA [100010801],,,76.8,,2740.09,30.46,16440.55296,percent of total billed charges,,,
NIVOLUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080562,CDM,J9299,HCPCS,636,RC,00003-3774-12,NDC,outpatient,10,ML,8919.54,6243.678,AETNA [1000108],AETNA [100010801],,,76.8,,6850.21,30.46,16440.55296,percent of total billed charges,,,
OBINUTUZUMAB 1000 MG/40ML IV SOLN,RX-124650,CDM,J9301,HCPCS,636,RC,50242-0070-01,NDC,outpatient,40,ML,23571.67,16500.169,AETNA [1000108],AETNA [100010801],,,76.8,,18103.04,70.55,18103.04256,percent of total billed charges,,,
PANITUMUMAB 20 MG/ML IV SOLN WRAPPER,RX-4080216,CDM,J9303,HCPCS,636,RC,55513-0954-01,NDC,outpatient,5,ML,4571.26,3199.882,AETNA [1000108],AETNA [100010801],,,76.8,,3510.73,149.71,14042.8032,percent of total billed charges,,,
PANITUMUMAB 20 MG/ML IV SOLN WRAPPER,RX-4080216,CDM,J9303,HCPCS,636,RC,55513-0956-01,NDC,outpatient,20,ML,18284.9,12799.43,AETNA [1000108],AETNA [100010801],,,76.8,,14042.8,149.71,14042.8032,percent of total billed charges,,,
PEMETREXED DISODIUM 500 MG IV SOLR,RX-37894,CDM,J9305,HCPCS,636,RC,00002-7623-01,NDC,outpatient,1,UN,11216.1,7851.27,AETNA [1000108],AETNA [100010801],,,76.8,,8613.96,4.18,8613.9648,percent of total billed charges,,,
PEMETREXED DISODIUM 100 MG IV SOLR,RX-89350,CDM,J9305,HCPCS,636,RC,00002-7640-01,NDC,outpatient,1,UN,2243.22,1570.254,AETNA [1000108],AETNA [100010801],,,76.8,,1722.79,4.18,8613.9648,percent of total billed charges,,,
PERTUZUMAB 420 MG/14ML IV SOLN,RX-116596,CDM,J9306,HCPCS,636,RC,50242-0145-01,NDC,outpatient,14,ML,18666.61,13066.627,AETNA [1000108],AETNA [100010801],,,76.8,,14335.96,15.37,14335.95648,percent of total billed charges,,,
PRALATREXATE 20 MG/ML IV SOLN WRAPPER,RX-4080207,CDM,J9307,HCPCS,636,RC,72893-0003-01,NDC,outpatient,1,ML,20371.07,14259.749,AETNA [1000108],AETNA [100010801],,,76.8,,15644.98,356.51,15644.98176,percent of total billed charges,,,
RAMUCIRUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080567,CDM,J9308,HCPCS,636,RC,00002-7669-01,NDC,outpatient,10,ML,4084.74,2859.318,AETNA [1000108],AETNA [100010801],,,76.8,,3137.08,68.87,15685.39392,percent of total billed charges,,,
RAMUCIRUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080567,CDM,J9308,HCPCS,636,RC,00002-7678-01,NDC,outpatient,50,ML,20423.69,14296.583,AETNA [1000108],AETNA [100010801],,,76.8,,15685.39,68.87,15685.39392,percent of total billed charges,,,
RITUXIMAB 10 MG/ML IV SOLN WRAPPER,RX-4080719,CDM,J9312,HCPCS,636,RC,50242-0051-21,NDC,outpatient,10,ML,2687.03,1880.921,AETNA [1000108],AETNA [100010801],,,76.8,,2063.64,77.31,10318.18752,percent of total billed charges,,,
RITUXIMAB 10 MG/ML IV SOLN WRAPPER,RX-4080719,CDM,J9312,HCPCS,636,RC,50242-0053-06,NDC,outpatient,50,ML,13435.14,9404.598,AETNA [1000108],AETNA [100010801],,,76.8,,10318.19,77.31,10318.18752,percent of total billed charges,,,
STREPTOZOCIN 1 G IV SOLR,RX-11436,CDM,J9320,HCPCS,636,RC,00703-4636-01,NDC,outpatient,1,UN,1171.99,820.393,AETNA [1000108],AETNA [100010801],,,76.8,,900.09,223.44,900.08832,percent of total billed charges,,,
TEMSIROLIMUS 25 MG/ML IV SOLN,RX-82228,CDM,J9330,HCPCS,636,RC,00008-1179-01,NDC,outpatient,2.5,ML,5549.29,3884.503,AETNA [1000108],AETNA [100010801],,,76.8,,4261.85,32.21,4261.85472,percent of total billed charges,,,
TOPOTECAN HCL 1 MG/ML IV SOLN WRAPPER,RX-4080561,CDM,J9351,HCPCS,636,RC,16729-0151-31,NDC,outpatient,1,UN,263.29,184.303,AETNA [1000108],AETNA [100010801],,,76.8,,202.21,0.5,416.02,percent of total billed charges,,,
ADO-TRASTUZUMAB EMTANSINE 100 MG IV SOLR,RX-120086,CDM,J9354,HCPCS,636,RC,50242-0088-01,NDC,outpatient,1,UN,11130.41,7791.287,AETNA [1000108],AETNA [100010801],,,76.8,,8548.15,38.33,13677.02016,percent of total billed charges,,,
ADO-TRASTUZUMAB EMTANSINE 160 MG IV SOLR,RX-120087,CDM,J9354,HCPCS,636,RC,50242-0087-01,NDC,outpatient,1,UN,17808.62,12466.034,AETNA [1000108],AETNA [100010801],,,76.8,,13677.02,38.33,13677.02016,percent of total billed charges,,,
TRASTUZUMAB 21 MG/ML IV SOLR WRAPPER,RX-4080954,CDM,J9355,HCPCS,636,RC,50242-0132-01,NDC,outpatient,150,ME,4754.01,3327.807,AETNA [1000108],AETNA [100010801],,,76.8,,3651.08,77.94,3651.07968,percent of total billed charges,,,
TRASTUZUMAB 21 MG/ML IV SOLR WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080954,CDM,J9355,HCPCS,636,RC,50242-0132-01,NDC,outpatient,150,ME,4456.89,3119.823,AETNA [1000108],AETNA [100010801],JW,,76.8,,3422.89,77.94,3651.07968,percent of total billed charges,,,
VINBLASTINE SULFATE 1 MG/ML IV SOLN IV PUSH,RX-8594,CDM,J9360,HCPCS,636,RC,63323-0278-10,NDC,outpatient,10,ML,173.56,121.492,AETNA [1000108],AETNA [100010801],,,76.8,,133.29,3.95,416.02,percent of total billed charges,,,
VINCRISTINE SULFATE 1 MG/ML IV SOLN,RX-8597,CDM,J9370,HCPCS,636,RC,61703-0309-16,NDC,outpatient,2,ML,46.03,32.221,AETNA [1000108],AETNA [100010801],,,76.8,,35.35,7.49,416.02,percent of total billed charges,,,
VINCRISTINE SULFATE 1 MG/ML IV SOLN,RX-8597,CDM,J9370,HCPCS,636,RC,61703-0309-06,NDC,outpatient,2,ML,92.35,64.645,AETNA [1000108],AETNA [100010801],,,76.8,,70.92,7.49,416.02,percent of total billed charges,,,
VINORELBINE TARTRATE 10 MG/ML IV SOLN WRAPPER,RX-4080209,CDM,J9390,HCPCS,636,RC,25021-0204-05,NDC,outpatient,5,ML,163.03,114.121,AETNA [1000108],AETNA [100010801],,,76.8,,125.21,7.59,416.02,percent of total billed charges,,,
FULVESTRANT 250 MG/5ML IM SOSY,RX-160451,CDM,J9394,HCPCS,636,RC,63323-0715-01,NDC,outpatient,10,ML,518.07,362.649,AETNA [1000108],AETNA [100010801],,,76.8,,397.88,1.65,1060,percent of total billed charges,,,
FULVESTRANT 250 MG/5ML IM SOSY,RX-160451,CDM,J9394,HCPCS,636,RC,63323-0715-05,NDC,outpatient,10,ML,518.07,362.649,AETNA [1000108],AETNA [100010801],,,76.8,,397.88,1.65,1060,percent of total billed charges,,,
COLLAR CERV FOAM LARGE -,SUP-00273900400,CDM,L0120,HCPCS,274,RC,,,outpatient,,,175.05,122.535,AETNA [1000108],AETNA [100010801],,,76.8,,134.44,4.41367,416.02,percent of total billed charges,,,
COLLAR SM 20.5INX3.5IN SFT DENS BRTHBL STCKNT CVR FOAM/CTTN -,SUP-1018-02,CDM,L0120,HCPCS,274,RC,,,outpatient,,,22.99,16.093,AETNA [1000108],AETNA [100010801],,,76.8,,17.66,4.41367,416.02,percent of total billed charges,,,
COLLAR CERVICAL STAT MEDIUM -,SUP-1018-03,CDM,L0120,HCPCS,274,RC,,,outpatient,,,19.66,13.762,AETNA [1000108],AETNA [100010801],,,76.8,,15.1,4.41367,416.02,percent of total billed charges,,,
CERVICAL COLLAR XL SOFT 22x3.5 -,SUP-1050-24,CDM,L0120,HCPCS,274,RC,,,outpatient,,,23.75,16.625,AETNA [1000108],AETNA [100010801],,,76.8,,18.24,4.41367,416.02,percent of total billed charges,,,
COLLAR PHILADELPHIA CERVICAL SM TRACH 2PC 4.25IN X 10-13IN -,SUP-1044-11,CDM,L0172,HCPCS,274,RC,,,outpatient,,,126.85,88.795,AETNA [1000108],AETNA [100010801],,,76.8,,97.42,12.10504,416.02,percent of total billed charges,,,
COLLAR PHILADELPHIA CERVICAL MD TRACH 2PC 4.25IN X 13-16IN -,SUP-1044-12,CDM,L0172,HCPCS,274,RC,,,outpatient,,,126.85,88.795,AETNA [1000108],AETNA [100010801],,,76.8,,97.42,12.10504,416.02,percent of total billed charges,,,
COLLAR PHILADELPHIA CERVICAL LRG TRACH 2PC 4.25IN X 16-19IN -,SUP-1044-13,CDM,L0172,HCPCS,274,RC,,,outpatient,,,126.85,88.795,AETNA [1000108],AETNA [100010801],,,76.8,,97.42,12.10504,416.02,percent of total billed charges,,,
COLLAR CERVICAL RIGID MED TRACH 2PC 3.25IN X 13-16IN -,SUP-1113MPP,CDM,L0172,HCPCS,274,RC,,,outpatient,,,53.92,37.744,AETNA [1000108],AETNA [100010801],,,76.8,,41.41,12.10504,416.02,percent of total billed charges,,,
COLLAR CERVICAL RIGID SM TRACH 2PC 3.25IN X 10-13IN -,SUP-1113SPP,CDM,L0172,HCPCS,274,RC,,,outpatient,,,53.92,37.744,AETNA [1000108],AETNA [100010801],,,76.8,,41.41,12.10504,416.02,percent of total billed charges,,,
COLLAR PHILADELPHIA SM 3.25IN 10-13 IN -,SUP-79-83133,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.23,46.361,AETNA [1000108],AETNA [100010801],,,76.8,,50.86,12.10504,416.02,percent of total billed charges,,,
COLLAR PHILADELPHIA MD 3.25IN x 13-16 IN -,SUP-79-83135,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.23,46.361,AETNA [1000108],AETNA [100010801],,,76.8,,50.86,12.10504,416.02,percent of total billed charges,,,
COLLAR PHILADELPHIA LG 3.25IN x 16-19IN -,SUP-79-83137,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.23,46.361,AETNA [1000108],AETNA [100010801],,,76.8,,50.86,12.10504,416.02,percent of total billed charges,,,
COLLAR PHILADELPHIA SM 4.25IN x 10-13IN -,SUP-79-83143,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.46,46.522,AETNA [1000108],AETNA [100010801],,,76.8,,51.04,12.10504,416.02,percent of total billed charges,,,
COLLAR PHILADELPHIA LG 4.25IN x 16-19IN -,SUP-79-83147,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.46,46.522,AETNA [1000108],AETNA [100010801],,,76.8,,51.04,12.10504,416.02,percent of total billed charges,,,
KNEE SUPPORT- HINGED PULL UP- MEDIUM -,SUP-NE7711-73,CDM,L1820,HCPCS,274,RC,,,outpatient,,,136.07,95.249,AETNA [1000108],AETNA [100010801],,,76.8,,104.5,29.06826,416.02,percent of total billed charges,,,
KNEE SUPPORT HINGED PULL UP- LRG -,SUP-NE7711-74,CDM,L1820,HCPCS,274,RC,,,outpatient,,,129.48,90.636,AETNA [1000108],AETNA [100010801],,,76.8,,99.44,29.06826,416.02,percent of total billed charges,,,
SUPPORT KNEE HINGED PULL UP LARGE -,SUP-NE7711-74,CDM,L1820,HCPCS,274,RC,,,outpatient,,,136.13,95.291,AETNA [1000108],AETNA [100010801],,,76.8,,104.55,29.06826,416.02,percent of total billed charges,,,
KNEE SUPPORT HINGED PULL UP X-LRG -,SUP-NE7711-75,CDM,L1820,HCPCS,274,RC,,,outpatient,,,136.07,95.249,AETNA [1000108],AETNA [100010801],,,76.8,,104.5,29.06826,416.02,percent of total billed charges,,,
SUPPORT KNEE HINGED PULL UP X-LARGE -,SUP-NE7711-75,CDM,L1820,HCPCS,274,RC,,,outpatient,,,129.48,90.636,AETNA [1000108],AETNA [100010801],,,76.8,,99.44,29.06826,416.02,percent of total billed charges,,,
BRACE KNEE ENHANCED TROM - DONJOY -,SUP-11-9114-9,CDM,L1832,HCPCS,274,RC,,,outpatient,,,544.99,381.493,AETNA [1000108],AETNA [100010801],,,76.8,,418.55,110.03643,1222.676,percent of total billed charges,,,
KNEE BRACE HINGED TROM DONJOY -,SUP-11-9114-9,CDM,L1832,HCPCS,274,RC,,,outpatient,,,544.99,381.493,AETNA [1000108],AETNA [100010801],,,76.8,,418.55,110.03643,1222.676,percent of total billed charges,,,
BRACE KN POSTOP 18-26IN FIT UPTO 34IN THG 6IN ABV MI D PTLR -,SUP-75-7500-000,CDM,L1832,HCPCS,274,RC,,,outpatient,,,490.14,343.098,AETNA [1000108],AETNA [100010801],,,76.8,,376.43,110.03643,1222.676,percent of total billed charges,,,
ANKLE BRACE SPORTS ORTHOSIS LACE UP BOA SMALL -,SUP-AB3000-12,CDM,L1902,HCPCS,274,RC,,,outpatient,,,105.56,73.892,AETNA [1000108],AETNA [100010801],,,76.8,,81.07,23.579235,416.02,percent of total billed charges,,,
ANKLE BRACE SPORTS ORTHOSIS LACE UP BOA MEDIUM -,SUP-AB3000-14,CDM,L1902,HCPCS,274,RC,,,outpatient,,,105.03,73.521,AETNA [1000108],AETNA [100010801],,,76.8,,80.66,23.579235,416.02,percent of total billed charges,,,
BRACE ANKLE SPORTS ORTHOSIS LACE UP BOA LARGE -,SUP-AB3000-16,CDM,L1902,HCPCS,274,RC,,,outpatient,,,105.56,73.892,AETNA [1000108],AETNA [100010801],,,76.8,,81.07,23.579235,416.02,percent of total billed charges,,,
BRACE ANKLE- SPORTS ORTHOSIS LACE UP BOA- XL -,SUP-AB3000-18,CDM,L1902,HCPCS,274,RC,,,outpatient,,,111.45,78.015,AETNA [1000108],AETNA [100010801],,,76.8,,85.59,23.579235,416.02,percent of total billed charges,,,
SPLINT ORTHO LT ANKL/FT LRG SZ8-10 PLST CLSD HL MLD HK/LOP -,SUP-A508LL,CDM,L1930,HCPCS,274,RC,,,outpatient,,,180.48,126.336,AETNA [1000108],AETNA [100010801],,,76.8,,138.61,34.77954,420.504,percent of total billed charges,,,
SPLINT ORTHO LT ANKL/FT MED SZ8-10 PLST CLSD HL MLD HK/LOP -,SUP-A508LM,CDM,L1930,HCPCS,274,RC,,,outpatient,,,179.78,125.846,AETNA [1000108],AETNA [100010801],,,76.8,,138.07,34.77954,420.504,percent of total billed charges,,,
SPLINT ORTHO RT ANKL/FT LRG SZ8-10 MALE PLST CLSD HL MLD -,SUP-A508RL,CDM,L1930,HCPCS,274,RC,,,outpatient,,,180.48,126.336,AETNA [1000108],AETNA [100010801],,,76.8,,138.61,34.77954,420.504,percent of total billed charges,,,
SPLINT ORTHO RT ANKL/FT LRG SZ8-10 PLST CLSD HL MLD HK/LOP -,SUP-A508RM,CDM,L1930,HCPCS,274,RC,,,outpatient,,,175.28,122.696,AETNA [1000108],AETNA [100010801],,,76.8,,134.62,34.77954,420.504,percent of total billed charges,,,
SPLINT ORTHO RT ANKL/FT SM SZ3-6 FEM PLST CLSD HL MLD HK/LOP -,SUP-A508RS,CDM,L1930,HCPCS,274,RC,,,outpatient,,,226.22,158.354,AETNA [1000108],AETNA [100010801],,,76.8,,173.74,34.77954,420.504,percent of total billed charges,,,
AFO FOR FOOT AND ANKLE -,SUP-XEE64330,CDM,L1930,HCPCS,274,RC,,,outpatient,,,154.92,108.444,AETNA [1000108],AETNA [100010801],,,76.8,,118.98,34.77954,420.504,percent of total billed charges,,,
AFO FOR FOOT AND ANKLE -,SUP-XEE64331,CDM,L1930,HCPCS,274,RC,,,outpatient,,,154.92,108.444,AETNA [1000108],AETNA [100010801],,,76.8,,118.98,34.77954,420.504,percent of total billed charges,,,
SYS FOOT OTHTC SM PEGASSIST DARCO -,SUP-PW1,CDM,L3002,HCPCS,274,RC,,,outpatient,,,73.46,51.422,AETNA [1000108],AETNA [100010801],,,76.8,,56.42,16.49177,416.02,percent of total billed charges,,,
SYS FOOT OTHTC MED PEGASSIST DARCO -,SUP-PW2,CDM,L3002,HCPCS,274,RC,,,outpatient,,,73.46,51.422,AETNA [1000108],AETNA [100010801],,,76.8,,56.42,16.49177,416.02,percent of total billed charges,,,
SYS FOOT OTHTC XL PEGASSIST DARCO -,SUP-PW4,CDM,L3002,HCPCS,274,RC,,,outpatient,,,73.46,51.422,AETNA [1000108],AETNA [100010801],,,76.8,,56.42,16.49177,416.02,percent of total billed charges,,,
SHOE POSTOP SZ5-6.5 SM MALE RT/LT LACE-UP CLSR -,SUP-2020-01,CDM,L3260,HCPCS,274,RC,,,outpatient,,,31.86,22.302,AETNA [1000108],AETNA [100010801],,,76.8,,24.47,4.63817,482.28096,percent of total billed charges,,,
SHOE POSTOP SZ7-8.5 MED MALE RT/LT LACE-UP CLSR -,SUP-2020-02,CDM,L3260,HCPCS,274,RC,,,outpatient,,,31.86,22.302,AETNA [1000108],AETNA [100010801],,,76.8,,24.47,4.63817,482.28096,percent of total billed charges,,,
SHOE POSTOP SZ9-11 LRG MALE RT/LT LACE-UP CLSR -,SUP-2020-03,CDM,L3260,HCPCS,274,RC,,,outpatient,,,31.86,22.302,AETNA [1000108],AETNA [100010801],,,76.8,,24.47,4.63817,482.28096,percent of total billed charges,,,
SHOE POSTOP SZ4-6 SM FEM RT/LT LACE-UP CLSR -,SUP-2021-01,CDM,L3260,HCPCS,274,RC,,,outpatient,,,30.87,21.609,AETNA [1000108],AETNA [100010801],,,76.8,,23.71,4.63817,482.28096,percent of total billed charges,,,
SHOE POSTOP SZ6.5-8 MED FEM RT/LT LACE-UP CLSR -,SUP-2021-02,CDM,L3260,HCPCS,274,RC,,,outpatient,,,30.87,21.609,AETNA [1000108],AETNA [100010801],,,76.8,,23.71,4.63817,482.28096,percent of total billed charges,,,
SHOE POSTOP SZ8.5-10 LRG L/R ANKL OPN TOE CLSD HL CNVS RBR -,SUP-2021-03,CDM,L3260,HCPCS,274,RC,,,outpatient,,,30.87,21.609,AETNA [1000108],AETNA [100010801],,,76.8,,23.71,4.63817,482.28096,percent of total billed charges,,,
BOOT CAST SM 4.5X8.5IN CNVS FT RCKR SOLE NSLIP HK/LOP CLSR -,SUP-2035-02,CDM,L3260,HCPCS,274,RC,,,outpatient,,,27.25,19.075,AETNA [1000108],AETNA [100010801],,,76.8,,20.93,4.63817,482.28096,percent of total billed charges,,,
CAST SHOE MED CANVAS ROCKER -,SUP-2035-03,CDM,L3260,HCPCS,274,RC,,,outpatient,,,27.6,19.32,AETNA [1000108],AETNA [100010801],,,76.8,,21.2,4.63817,482.28096,percent of total billed charges,,,
SHOE CAST LRG 5.25X11.5IN CNVS FT RCKR SOLE NSLIP HK/LOP -,SUP-2035-04,CDM,L3260,HCPCS,274,RC,,,outpatient,,,27.25,19.075,AETNA [1000108],AETNA [100010801],,,76.8,,20.93,4.63817,482.28096,percent of total billed charges,,,
SURGICAL SHOE MENS XL -,SUP-5701024,CDM,L3260,HCPCS,274,RC,,,outpatient,,,39.56,27.692,AETNA [1000108],AETNA [100010801],,,76.8,,30.38,4.63817,482.28096,percent of total billed charges,,,
SHOE ORTHO ANKL SM SZ7.5-10 MSH CLSD HL CLSD TOE HK/LOP STRP -,SUP-92732502,CDM,L3260,HCPCS,274,RC,,,outpatient,,,221.73,155.211,AETNA [1000108],AETNA [100010801],,,76.8,,170.29,4.63817,482.28096,percent of total billed charges,,,
SHOE ORTHO ANKL MED SZ8.5-10 MALE MSH CLSD HL CLSD TOE -,SUP-92732503,CDM,L3260,HCPCS,274,RC,,,outpatient,,,214.44,150.108,AETNA [1000108],AETNA [100010801],,,76.8,,164.69,4.63817,482.28096,percent of total billed charges,,,
SHOE ORTHO ANKL LRG SZ10.5-12 MSH CLSD HL CLSD TOE HK/LOP -,SUP-92732504,CDM,L3260,HCPCS,274,RC,,,outpatient,,,214.44,150.108,AETNA [1000108],AETNA [100010801],,,76.8,,164.69,4.63817,482.28096,percent of total billed charges,,,
SHOE CAST SZ6-8 MALE SZ7.5-10 FEM SM FT DARCO HEELWEDGE -,SUP-92732602,CDM,L3260,HCPCS,274,RC,,,outpatient,,,116.41,81.487,AETNA [1000108],AETNA [100010801],,,76.8,,89.4,4.63817,482.28096,percent of total billed charges,,,
SHOE CAST SZ8.5-10 MALE 10.5-13 FEM MED FT DARCO HEELWEDGE -,SUP-92732603,CDM,L3260,HCPCS,274,RC,,,outpatient,,,124.52,87.164,AETNA [1000108],AETNA [100010801],,,76.8,,95.63,4.63817,482.28096,percent of total billed charges,,,
SHOE POST-OP NYLON RUBBER HOOK/LOOP MALE SMALL -,SUP-A152305,CDM,L3260,HCPCS,274,RC,,,outpatient,,,20.66,14.462,AETNA [1000108],AETNA [100010801],,,76.8,,15.87,4.63817,482.28096,percent of total billed charges,,,
POST OP SHOE NYLON RUBBER HOOK/LOOP MALE LRG -,SUP-A152307,CDM,L3260,HCPCS,274,RC,,,outpatient,,,22.29,15.603,AETNA [1000108],AETNA [100010801],,,76.8,,17.12,4.63817,482.28096,percent of total billed charges,,,
SHOE POSTOP MENS SM SIZES 6-8 MEDSURG -,SUP-MQM1B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,AETNA [1000108],AETNA [100010801],,,76.8,,48.05,4.63817,482.28096,percent of total billed charges,,,
SHOE POSTOP MENS MED SIZES 8.5-10 MEDSURG -,SUP-MQM2B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,AETNA [1000108],AETNA [100010801],,,76.8,,48.05,4.63817,482.28096,percent of total billed charges,,,
SHOE POSTOP MENS LG SIZES 10.5-12 MEDSURG -,SUP-MQM3B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,AETNA [1000108],AETNA [100010801],,,76.8,,48.05,4.63817,482.28096,percent of total billed charges,,,
SHOE POSTOP MENS XL SIZES 12.5-14 MEDSURG -,SUP-MQM4B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,AETNA [1000108],AETNA [100010801],,,76.8,,48.05,4.63817,482.28096,percent of total billed charges,,,
SHOE POSTOP WOMENS SM SIZES 4-6 MEDSURG -,SUP-MQW1B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,AETNA [1000108],AETNA [100010801],,,76.8,,48.05,4.63817,482.28096,percent of total billed charges,,,
SHOE POSTOP WOMENS MED SIZES 6.5- 8 MEDSURG -,SUP-MQW2B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,AETNA [1000108],AETNA [100010801],,,76.8,,48.05,4.63817,482.28096,percent of total billed charges,,,
SHOE POSTOP SZ6.5-8 FEM MED MEDSURG OPN TOE CLSD HL RCKR BTM -,SUP-MQW2B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,110.4,77.28,AETNA [1000108],AETNA [100010801],,,76.8,,84.79,4.63817,482.28096,percent of total billed charges,,,
SHOE POSTOP WOMENS LG SIZES  8.5 -10 MEDSURG -,SUP-MQW3B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,AETNA [1000108],AETNA [100010801],,,76.8,,48.05,4.63817,482.28096,percent of total billed charges,,,
SHOE DARCO SURGICAL MENS SMALL -,SUP-MSM1N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,28.47,19.929,AETNA [1000108],AETNA [100010801],,,76.8,,21.86,4.63817,482.28096,percent of total billed charges,,,
SHOES DARCO MENS MEDIUM -,SUP-MSM2N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,47.21,33.047,AETNA [1000108],AETNA [100010801],,,76.8,,36.26,4.63817,482.28096,percent of total billed charges,,,
SHOES DARCO MENS LARGE -,SUP-MSM3N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,48.55,33.985,AETNA [1000108],AETNA [100010801],,,76.8,,37.29,4.63817,482.28096,percent of total billed charges,,,
SHOES DARCO WOMENS SMALL -,SUP-MSW1N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,48.55,33.985,AETNA [1000108],AETNA [100010801],,,76.8,,37.29,4.63817,482.28096,percent of total billed charges,,,
SHOES DARCO WOMENS MEDIUM -,SUP-MSW2N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,28.47,19.929,AETNA [1000108],AETNA [100010801],,,76.8,,21.86,4.63817,482.28096,percent of total billed charges,,,
SHOES DARCO WOMENS LARGE -,SUP-MSW3N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,45.63,31.941,AETNA [1000108],AETNA [100010801],,,76.8,,35.04,4.63817,482.28096,percent of total billed charges,,,
BOOT CAST REG FT PD WVN TCC-EZ -,SUP-TCC21100,CDM,L3260,HCPCS,274,RC,,,outpatient,,,393.57,275.499,AETNA [1000108],AETNA [100010801],,,76.8,,302.26,4.63817,482.28096,percent of total billed charges,,,
BOOT CAST LRG FT PD WVN TCC-EZ -,SUP-TCC21114,CDM,L3260,HCPCS,274,RC,,,outpatient,,,444.34,311.038,AETNA [1000108],AETNA [100010801],,,76.8,,341.25,4.63817,482.28096,percent of total billed charges,,,
BOOT CAST LRG FT CHARCOT PD WVN TCC-EZ -,SUP-TCC21116,CDM,L3260,HCPCS,274,RC,,,outpatient,,,538.28,376.796,AETNA [1000108],AETNA [100010801],,,76.8,,413.4,4.63817,482.28096,percent of total billed charges,,,
SYS CAST 3IN FT CHARCOT PD WVN W/REGULARX2 BT TCC-EZ -,SUP-TCC23000,CDM,L3260,HCPCS,274,RC,,,outpatient,,,627.97,439.579,AETNA [1000108],AETNA [100010801],,,76.8,,482.28,4.63817,482.28096,percent of total billed charges,,,
SYS CAST SZ4 IN FT PD WVN W/2 REG BT TCC-EZ -,SUP-TCC24000,CDM,L3260,HCPCS,274,RC,,,outpatient,,,627.97,439.579,AETNA [1000108],AETNA [100010801],,,76.8,,482.28,4.63817,482.28096,percent of total billed charges,,,
IMMOBILIZER SHLDR LRG ELAS HUM CUF RB WRP -,SUP-00078300300,CDM,L3670,HCPCS,274,RC,,,outpatient,,,291.75,204.225,AETNA [1000108],AETNA [100010801],,,76.8,,224.06,3.81201,416.02,percent of total billed charges,,,
IMMOBILIZER SHLDR LRG ELAS HUM CUF CONTR RB WRP -,SUP-00078400300,CDM,L3670,HCPCS,274,RC,,,outpatient,,,233.4,163.38,AETNA [1000108],AETNA [100010801],,,76.8,,179.25,3.81201,416.02,percent of total billed charges,,,
IMMOBILIZER SHLDR SMALL ULTRASLING III BLACK -,SUP-11-0449-2,CDM,L3670,HCPCS,274,RC,,,outpatient,,,305.46,213.822,AETNA [1000108],AETNA [100010801],,,76.8,,234.59,3.81201,416.02,percent of total billed charges,,,
IMMOBILIZER SHLDR MED ULTRASLING III BLACK -,SUP-11-0449-3,CDM,L3670,HCPCS,274,RC,,,outpatient,,,305.46,213.822,AETNA [1000108],AETNA [100010801],,,76.8,,234.59,3.81201,416.02,percent of total billed charges,,,
SUPPORT RT SHLDR SM 11IN MSH FBRC ULSNG ER HUM CUF 15DEG -,SUP-11-1343-2-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,AETNA [1000108],AETNA [100010801],,,76.8,,271.52,3.81201,416.02,percent of total billed charges,,,
SUPPORT LT SHLDR ARM SM UPTO 11IN MSH FBRC ULSNG ER BRTHBL -,SUP-11-1344-2-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,AETNA [1000108],AETNA [100010801],,,76.8,,271.52,3.81201,416.02,percent of total billed charges,,,
SUPPORT LT SHLDR ARM LRG ABV 13IN MSH FBRC ULSNG ER BRTHBL -,SUP-11-1344-4-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,AETNA [1000108],AETNA [100010801],,,76.8,,271.52,3.81201,416.02,percent of total billed charges,,,
SUPPORT RT SHLDR SM 11IN MSH FBRC ULSNG ER HUM CUF 30DEG -,SUP-11-1345-2,CDM,L3670,HCPCS,274,RC,,,outpatient,,,371.22,259.854,AETNA [1000108],AETNA [100010801],,,76.8,,285.1,3.81201,416.02,percent of total billed charges,,,
SUPPORT RT SHLDR LRG 13-15IN MSH FBRC ULSNG ER HUM 30DEG -,SUP-11-1345-4-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,AETNA [1000108],AETNA [100010801],,,76.8,,271.52,3.81201,416.02,percent of total billed charges,,,
SUPPORT LT SHLDR LRG 13-15IN MSH FBRC ULSNG ER BRTHBL HUM -,SUP-11-1346-4-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,AETNA [1000108],AETNA [100010801],,,76.8,,271.52,3.81201,416.02,percent of total billed charges,,,
IMMOBILIZER SHLDR SLING MED 7IN X 17IN -,SUP-11630006,CDM,L3670,HCPCS,274,RC,,,outpatient,,,243.14,170.198,AETNA [1000108],AETNA [100010801],,,76.8,,186.73,3.81201,416.02,percent of total billed charges,,,
IMMOBILIZER SHLDR SLING LRG 7IN X 18IN -,SUP-11630007,CDM,L3670,HCPCS,274,RC,,,outpatient,,,243.14,170.198,AETNA [1000108],AETNA [100010801],,,76.8,,186.73,3.81201,416.02,percent of total billed charges,,,
IIMMOBILIZER SHOULDER VELPEAU M -,SUP-23-1872,CDM,L3670,HCPCS,274,RC,,,outpatient,,,29.7,20.79,AETNA [1000108],AETNA [100010801],,,76.8,,22.81,3.81201,416.02,percent of total billed charges,,,
IMMOBILIZER SHOULDER VELPEAU L -,SUP-23-1873-000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,29.7,20.79,AETNA [1000108],AETNA [100010801],,,76.8,,22.81,3.81201,416.02,percent of total billed charges,,,
IMMOBILIZER SHLDR SM PD WRST/HUM CUF SHLDR/WST STRP -,SUP-667110,CDM,L3670,HCPCS,274,RC,,,outpatient,,,343.1,240.17,AETNA [1000108],AETNA [100010801],,,76.8,,263.5,3.81201,416.02,percent of total billed charges,,,
IMMOBILIZER RT/LT SHLDR XS CTTN CLTH 6X12.5IN PCH CLSD/OPN -,SUP-9002-01,CDM,L3670,HCPCS,274,RC,,,outpatient,,,29.12,20.384,AETNA [1000108],AETNA [100010801],,,76.8,,22.36,3.81201,416.02,percent of total billed charges,,,
IMMOBILIZER SHOULDER UNIVERSAL -,SUP-9013-00,CDM,L3670,HCPCS,274,RC,,,outpatient,,,56.25,39.375,AETNA [1000108],AETNA [100010801],,,76.8,,43.2,3.81201,416.02,percent of total billed charges,,,
SHOULDER IMMOBILIZER W/FOAM SMALL -,SUP-A111015,CDM,L3670,HCPCS,274,RC,,,outpatient,,,19.02,13.314,AETNA [1000108],AETNA [100010801],,,76.8,,14.61,3.81201,416.02,percent of total billed charges,,,
SHOULDER IMMOBILIZER W/FOAM WAIST STRAP M -,SUP-A111016,CDM,L3670,HCPCS,274,RC,,,outpatient,,,19.02,13.314,AETNA [1000108],AETNA [100010801],,,76.8,,14.61,3.81201,416.02,percent of total billed charges,,,
IMMOBILIZER SHLDR X-LRG 9IN X 22.5IN -,SUP-A111018,CDM,L3670,HCPCS,274,RC,,,outpatient,,,16.98,11.886,AETNA [1000108],AETNA [100010801],,,76.8,,13.04,3.81201,416.02,percent of total billed charges,,,
IMMOBILIZER SHOULDER VELP XLG -,SUP-TX9023-04,CDM,L3670,HCPCS,274,RC,,,outpatient,,,31.1,21.77,AETNA [1000108],AETNA [100010801],,,76.8,,23.88,3.81201,416.02,percent of total billed charges,,,
SPLINT RT HND SM 6.5-7.25IN ALIFLEECE LINER THRMPLST DLX FIG -,SUP-5183,CDM,L3807,HCPCS,274,RC,,,outpatient,,,286.27,200.389,AETNA [1000108],AETNA [100010801],,,76.8,,219.86,31.76675,416.02,percent of total billed charges,,,
SPLINT RT HND LRG 8.25-9.25IN ALIFLEECE LINER THRMPLST DLX -,SUP-5187,CDM,L3807,HCPCS,274,RC,,,outpatient,,,284.4,199.08,AETNA [1000108],AETNA [100010801],,,76.8,,218.42,31.76675,416.02,percent of total billed charges,,,
SPLINT LT SM RST -,SUP-5812,CDM,L3807,HCPCS,274,RC,,,outpatient,,,273.08,191.156,AETNA [1000108],AETNA [100010801],,,76.8,,209.73,31.76675,416.02,percent of total billed charges,,,
SPLINT WRST MED POLY FOAM CCKUP -,SUP-A1601P,CDM,L3807,HCPCS,274,RC,,,outpatient,,,141.5,99.05,AETNA [1000108],AETNA [100010801],,,76.8,,108.67,31.76675,416.02,percent of total billed charges,,,
EXTERNAL FIX DIGIT WIDGET -,SUP-DWD-232,CDM,L3921,HCPCS,274,RC,,,outpatient,,,7002.6,4901.82,AETNA [1000108],AETNA [100010801],,,76.8,,5378,335.72,5377.9968,percent of total billed charges,,,
SPLINT THUMB SPICA RIGHT MED/LRG 3.5IN - 4.25IN -,SUP-340M/LR,CDM,L3924,HCPCS,274,RC,,,outpatient,,,68.27,47.789,AETNA [1000108],AETNA [100010801],,,76.8,,52.43,15.326615,416.02,percent of total billed charges,,,
THUMB SPLINT COMFORT COOL CMC LT MEDIUM -,SUP-348ML,CDM,L3924,HCPCS,274,RC,,,outpatient,,,92.66,64.862,AETNA [1000108],AETNA [100010801],,,76.8,,71.16,15.326615,416.02,percent of total billed charges,,,
THUMB SPLINT COMFORT COOL CMC RT MEDIUM -,SUP-348MR,CDM,L3924,HCPCS,274,RC,,,outpatient,,,92.66,64.862,AETNA [1000108],AETNA [100010801],,,76.8,,71.16,15.326615,416.02,percent of total billed charges,,,
LMB SPRING PIP EXTENSION ASSIST -,SUP-704103,CDM,L3925,HCPCS,274,RC,,,outpatient,,,89.16,62.412,AETNA [1000108],AETNA [100010801],,,76.8,,68.47,17.225885,416.02,percent of total billed charges,,,
SPLINT FINGER EXTENSION LMB SPRING SIZE A -,SUP-704200,CDM,L3925,HCPCS,274,RC,,,outpatient,,,76.73,53.711,AETNA [1000108],AETNA [100010801],,,76.8,,58.93,17.225885,416.02,percent of total billed charges,,,
SPLINT FINGER EXTENSION SPRING LMB SIZE C -,SUP-704202,CDM,L3925,HCPCS,274,RC,,,outpatient,,,76.79,53.753,AETNA [1000108],AETNA [100010801],,,76.8,,58.97,17.225885,416.02,percent of total billed charges,,,
BOOT WALKER LRG AIRCAST SZ10-13 MALE SZ11-15 FEM PED -,SUP-01EF-L,CDM,L4361,HCPCS,274,RC,,,outpatient,,,269.52,188.664,AETNA [1000108],AETNA [100010801],,,76.8,,206.99,50.613525,568.638,percent of total billed charges,,,
BOOT WALKER MED AIRCAST SZ7-10 MALE SZ8-11 FEM -,SUP-01EF-M,CDM,L4361,HCPCS,274,RC,,,outpatient,,,269.52,188.664,AETNA [1000108],AETNA [100010801],,,76.8,,206.99,50.613525,568.638,percent of total billed charges,,,
BOOT WALKER SM AIRCAST SZ4-7 MALE SZ5-8 FEM -,SUP-01F-S,CDM,L4361,HCPCS,274,RC,,,outpatient,,,263.86,184.702,AETNA [1000108],AETNA [100010801],,,76.8,,202.64,50.613525,568.638,percent of total billed charges,,,
BOOT WALKER XL AIRCAST SZ 13+ MALE SZ 15+ FEM -,SUP-01F-XL,CDM,L4361,HCPCS,274,RC,,,outpatient,,,263.86,184.702,AETNA [1000108],AETNA [100010801],,,76.8,,202.64,50.613525,568.638,percent of total billed charges,,,
BOOT WALKER LRG SHELL 10-13M/11-15F -,SUP-1175LPP,CDM,L4361,HCPCS,274,RC,,,outpatient,,,225.45,157.815,AETNA [1000108],AETNA [100010801],,,76.8,,173.15,50.613525,568.638,percent of total billed charges,,,
WALKER FULL SHELL 2 SHORT- SMALL -,SUP-15500047,CDM,L4361,HCPCS,274,RC,,,outpatient,,,274.6,192.22,AETNA [1000108],AETNA [100010801],,,76.8,,210.89,50.613525,568.638,percent of total billed charges,,,
WALKER- FULL SHELL 2 SHORT- MEDIUM -,SUP-15500048,CDM,L4361,HCPCS,274,RC,,,outpatient,,,249.74,174.818,AETNA [1000108],AETNA [100010801],,,76.8,,191.8,50.613525,568.638,percent of total billed charges,,,
WALKER FULL SHELL 2 SHORT LARGE -,SUP-1550049,CDM,L4361,HCPCS,274,RC,,,outpatient,,,234.33,164.031,AETNA [1000108],AETNA [100010801],,,76.8,,179.97,50.613525,568.638,percent of total billed charges,,,
BOOT ORTHO FT MED/L FLEECE LINER OPN TOE SEMI- FLXB SHL -,SUP-6963,CDM,L4394,HCPCS,274,RC,,,outpatient,,,127.09,88.963,AETNA [1000108],AETNA [100010801],,,76.8,,97.61,20.61,416.02,percent of total billed charges,,,
VALVE SPK 15X23MM PASSY-MUIR WHITE -,SUP-PMV 005,CDM,L8501,HCPCS,274,RC,,,outpatient,,,429.46,300.622,AETNA [1000108],AETNA [100010801],,,76.8,,329.83,52.37136,418.655068,percent of total billed charges,,,
VALVE SPK PASSY-MUIR PMV 15X22MM LPRO REUS FLEX AQUA -,SUP-PMV 007,CDM,L8501,HCPCS,274,RC,,,outpatient,,,493.93,345.751,AETNA [1000108],AETNA [100010801],,,76.8,,379.34,52.37136,418.655068,percent of total billed charges,,,
VALVE SPK/SWALW IN G 15X23MM PASSY-MUIR PMV 1W  CLEAR -,SUP-PMV 2000,CDM,L8501,HCPCS,274,RC,,,outpatient,,,429.46,300.622,AETNA [1000108],AETNA [100010801],,,76.8,,329.83,52.37136,418.655068,percent of total billed charges,,,
VALVE PASSY MUIR PURPLE SPEAK SWALLOW IN G 15X23MM PMV -,SUP-PMV 2001,CDM,L8501,HCPCS,274,RC,,,outpatient,,,429.46,300.622,AETNA [1000108],AETNA [100010801],,,76.8,,329.83,52.37136,418.655068,percent of total billed charges,,,
VALVE SPK SHILEY 0.66MM MINI STRL MONOKA PHONATE W/O O2 PRT -,SUP-SSV,CDM,L8501,HCPCS,274,RC,,,outpatient,,,233.28,163.296,AETNA [1000108],AETNA [100010801],,,76.8,,179.16,52.37136,418.655068,percent of total billed charges,,,
PROSTHESIS VOCAL CRD BLOM-SINGER CLASSIC 20FRX8MM INDWL STRL -,SUP-IN 2008-SO,CDM,L8509,HCPCS,274,RC,,,outpatient,,,1378.13,964.691,AETNA [1000108],AETNA [100010801],,,76.8,,1058.4,125.65,1058.40384,percent of total billed charges,,,
PROSTHESIS VOCAL CRD BLOM-SINGER 20FRX14MM INDWL STRL -,SUP-IN2014-SO,CDM,L8509,HCPCS,274,RC,,,outpatient,,,1378.13,964.691,AETNA [1000108],AETNA [100010801],,,76.8,,1058.4,125.65,1058.40384,percent of total billed charges,,,
IMPLANT BRST 600ML SIL GEL HPRO RND 14CM MEMORYGEL 5.6CM -,SUP-350-6004BC,CDM,L8600,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,AETNA [1000108],AETNA [100010801],,,76.8,,3409.78,399.86,3409.78176,percent of total billed charges,,,
BULKAMID URETHRAL BULKING SYSTEM -,SUP-50050,CDM,L8606,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA [1000108],AETNA [100010801],,,76.8,,3748.3,252.25,3748.3008,percent of total billed charges,,,
COAPTITE SYRINGE 1ML -,SUP-M0068903000,CDM,L8606,HCPCS,278,RC,,,outpatient,,,1975.44,1382.808,AETNA [1000108],AETNA [100010801],,,76.8,,1517.14,252.25,3748.3008,percent of total billed charges,,,
SPHERE EYE 18MM -,SUP-14254,CDM,L8610,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA [1000108],AETNA [100010801],,,76.8,,241.99,70.737705,686.06,percent of total billed charges,,,
IMPLANT OSS PRT WIET 1.14MM SHFT 3.25MMX5MM OFF-CTR HAP FLEX -,SUP-0516,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA [1000108],AETNA [100010801],,,76.8,,2016.54,60.258045,2016.5376,percent of total billed charges,,,
PROSTHESIS OSS PRT 4X5MM CTR HAP FLEX TI MLBL -,SUP-0550,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2565.44,1795.808,AETNA [1000108],AETNA [100010801],,,76.8,,1970.26,60.258045,2016.5376,percent of total billed charges,,,
MNP TOTAL TITANIUM .2 X 3.00MM -,SUP-1004434,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA [1000108],AETNA [100010801],,,76.8,,1933.62,60.258045,2016.5376,percent of total billed charges,,,
MNP TOTAL TITANIUM .2 X 3.5MM -,SUP-1004436,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA [1000108],AETNA [100010801],,,76.8,,1933.62,60.258045,2016.5376,percent of total billed charges,,,
OMEGA CONNECTOR 1.5MM X 8MMX0.5 -,SUP-1004930,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1219.12,853.384,AETNA [1000108],AETNA [100010801],,,76.8,,936.28,60.258045,2016.5376,percent of total billed charges,,,
PROSTHESIS OSS ASTN PLAS-PR MOD PORP 3MM FLNG DIA 1MM SHFT -,SUP-14-0063,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1300.05,910.035,AETNA [1000108],AETNA [100010801],,,76.8,,998.44,60.258045,2016.5376,percent of total billed charges,,,
PISTON OTO SCHKNT 0.8MMX4.25MM WIRE LOOP FLPLS SS -,SUP-14-0105,CDM,L8613,HCPCS,278,RC,,,outpatient,,,628.66,440.062,AETNA [1000108],AETNA [100010801],,,76.8,,482.81,60.258045,2016.5376,percent of total billed charges,,,
LOOP WIRE HOUSE TYPE .12 X 4.25 -,SUP-140184,CDM,L8613,HCPCS,278,RC,,,outpatient,,,346.6,242.62,AETNA [1000108],AETNA [100010801],,,76.8,,266.19,60.258045,2016.5376,percent of total billed charges,,,
LOOP WIRE HOUSE TYPE .12 X 4.0 -,SUP-140184,CDM,L8613,HCPCS,278,RC,,,outpatient,,,268.41,187.887,AETNA [1000108],AETNA [100010801],,,76.8,,206.14,60.258045,2016.5376,percent of total billed charges,,,
PISTON OTO RCHRD 0.6MMX3.50MM RBN LOOP FLPLS PLTNM -,SUP-14-0781,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,AETNA [1000108],AETNA [100010801],,,76.8,,779.21,60.258045,2016.5376,percent of total billed charges,,,
PISTON OTO RCHRD 0.6X4MM RBN LOOP FLPLS PLTNM -,SUP-14-0783,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,AETNA [1000108],AETNA [100010801],,,76.8,,779.21,60.258045,2016.5376,percent of total billed charges,,,
PISTON OTO RCHRD 0.6MMX4.25MM RBN LOOP FLPLS PLTNM -,SUP-14-0784,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,AETNA [1000108],AETNA [100010801],,,76.8,,779.21,60.258045,2016.5376,percent of total billed charges,,,
PISTON OTO RCHRD 0.8X4MM RBN LOOP FLPLS PLTNM -,SUP-14-0792,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1024.74,717.318,AETNA [1000108],AETNA [100010801],,,76.8,,787,60.258045,2016.5376,percent of total billed charges,,,
PISTON OTO RCHRD 0.8MMX4.5MM RBN LOOP FLPLS PLTNM -,SUP-14-0794,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,AETNA [1000108],AETNA [100010801],,,76.8,,779.21,60.258045,2016.5376,percent of total billed charges,,,
PLATE OSS MED 10MM POR HAP ATTIC DFCT -,SUP-14-0863,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1063.14,744.198,AETNA [1000108],AETNA [100010801],,,76.8,,816.49,60.258045,2016.5376,percent of total billed charges,,,
PLATE OSS 14MM LRG POR HAP ATTIC DFCT -,SUP-14-0864,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1072.41,750.687,AETNA [1000108],AETNA [100010801],,,76.8,,823.61,60.258045,2016.5376,percent of total billed charges,,,
PROSTHESIS OSS APLBM SM 2X2MM 1MM CANN HAP INCSTP -,SUP-14-0956,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2182.32,1527.624,AETNA [1000108],AETNA [100010801],,,76.8,,1676.02,60.258045,2016.5376,percent of total billed charges,,,
PROSTHESIS OSS PRT GLDNBRG 1.5MM 1.14MM FLLY CANN HAP EAR -,SUP-14-0963,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2038.36,1426.852,AETNA [1000108],AETNA [100010801],,,76.8,,1565.46,60.258045,2016.5376,percent of total billed charges,,,
PROSTHESIS OSS APLBM 2.5X3MM HAP INCUS -,SUP-14-0973,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2205.54,1543.878,AETNA [1000108],AETNA [100010801],,,76.8,,1693.85,60.258045,2016.5376,percent of total billed charges,,,
PROSTHESIS OSS RCHRD 0.4MM PSTN 1MM WELL 4.50MM CUP PED -,SUP-142152,CDM,L8613,HCPCS,278,RC,,,outpatient,,,761.58,533.106,AETNA [1000108],AETNA [100010801],,,76.8,,584.89,60.258045,2016.5376,percent of total billed charges,,,
Eclipse Flat Ribbon Piston .6MM X 4.50MM -,SUP-472-450,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1863.34,1304.338,AETNA [1000108],AETNA [100010801],,,76.8,,1431.05,60.258045,2016.5376,percent of total billed charges,,,
Eclipse Flat Ribbon Piston .6MM X 4.75MM -,SUP-472-475,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1863.34,1304.338,AETNA [1000108],AETNA [100010801],,,76.8,,1431.05,60.258045,2016.5376,percent of total billed charges,,,
Eclipse Flat Ribbon Piston .6MM X 5.00MM -,SUP-472-500,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1863.34,1304.338,AETNA [1000108],AETNA [100010801],,,76.8,,1431.05,60.258045,2016.5376,percent of total billed charges,,,
PROSTHESIS OSS UM TORP 2X10MM CTR TI ADJ -,SUP-7014-1044,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1852.68,1296.876,AETNA [1000108],AETNA [100010801],,,76.8,,1422.86,60.258045,2016.5376,percent of total billed charges,,,
PROSTHESIS OSS UM TORP 2X5MM CTR TI ADJ -,SUP-7014-1046,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1852.68,1296.876,AETNA [1000108],AETNA [100010801],,,76.8,,1422.86,60.258045,2016.5376,percent of total billed charges,,,
PISTON OSS SMRT 0.6X4MM WIRE LOOP FLPLS NTNL STPS ADLT -,SUP-70145926,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1601.92,1121.344,AETNA [1000108],AETNA [100010801],,,76.8,,1230.27,60.258045,2016.5376,percent of total billed charges,,,
PISTON OSS SMRT 0.6MMX4.25MM WIRE LOOP FLPLS NTNL STPS ADLT -,SUP-70145927,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1601.92,1121.344,AETNA [1000108],AETNA [100010801],,,76.8,,1230.27,60.258045,2016.5376,percent of total billed charges,,,
PISTON OSS SMRT 0.6MMX4.50MM WIRE LOOP FLPLS NTNL STPS ADLT -,SUP-70145928,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1601.92,1121.344,AETNA [1000108],AETNA [100010801],,,76.8,,1230.27,60.258045,2016.5376,percent of total billed charges,,,
DISTANCE PLATES REPLACEMENT 0.1 /0.2 /0.3 -,SUP-8000140,CDM,L8613,HCPCS,278,RC,,,outpatient,,,723.54,506.478,AETNA [1000108],AETNA [100010801],,,76.8,,555.68,60.258045,2016.5376,percent of total billed charges,,,
JOINT FINGER SWANSON 1 MCP FLEXIBLE STERILE W/O GROMMETS SIL -,SUP-4700001,CDM,L8630,HCPCS,278,RC,,,outpatient,,,4602.62,3221.834,AETNA [1000108],AETNA [100010801],,,76.8,,3534.81,399.86,3534.81216,percent of total billed charges,,,
IMPLANT PIP MCP SZ4 SWNSN SIL -,SUP-G470-0004,CDM,L8630,HCPCS,278,RC,,,outpatient,,,4413.76,3089.632,AETNA [1000108],AETNA [100010801],,,76.8,,3389.77,399.86,3534.81216,percent of total billed charges,,,
PROSTHESIS PENL TOROSA LRG SAL FIL CYL INFL PRECNCT SCRT -,SUP-450-1329,CDM,L8699,HCPCS,278,RC,,,outpatient,,,8471.02,5929.714,AETNA [1000108],AETNA [100010801],,,76.8,,6505.74,163.74581,6505.74336,percent of total billed charges,,,
PROSTHESIS TSTCLR 2.9CMX4.5IN -,SUP-96-450-1329,CDM,L8699,HCPCS,278,RC,,,outpatient,,,7002.6,4901.82,AETNA [1000108],AETNA [100010801],,,76.8,,5378,163.74581,6505.74336,percent of total billed charges,,,
LEAD ANCHOR KIT -,SUP-ACCK5300,CDM,L8699,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,163.74581,6505.74336,percent of total billed charges,,,
WEIGHT EYELID THN 0.6MM PLTNM 0.6GM SPHRCL CRV TAPR EDGE RND -,SUP-LL 6006,CDM,L8699,HCPCS,278,RC,,,outpatient,,,1749.17,1224.419,AETNA [1000108],AETNA [100010801],,,76.8,,1343.36,163.74581,6505.74336,percent of total billed charges,,,
UROLIFT ATC IMPLANT CARTRIDGE -,SUP-UL2ATC-C,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4986.7,3490.69,AETNA [1000108],AETNA [100010801],,,76.8,,3829.79,163.74581,6505.74336,percent of total billed charges,,,
IMPLANT CARTRIDGE UROLIFT -,SUP-UL2-C,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4350.1,3045.07,AETNA [1000108],AETNA [100010801],,,76.8,,3340.88,163.74581,6505.74336,percent of total billed charges,,,
IMPLANT UROLOGICAL UROLIFT 2 CARTRIDGE -,SUP-UL2-C,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,163.74581,6505.74336,percent of total billed charges,,,
KIT HANDLE UROLIFT DELIVERY HANDLE IMPLANT CARTRIDGE -,SUP-UL2-CHK,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,163.74581,6505.74336,percent of total billed charges,,,
IMPLANT HANDLE CARTRIDGE UROLIFT -,SUP-UL2-CHK,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA [1000108],AETNA [100010801],,,76.8,,3574.77,163.74581,6505.74336,percent of total billed charges,,,
HC Bebtelovimab Injection,PX-26000018,CDM,M0222,HCPCS,260,RC,,,outpatient,,,1455,1018.5,AETNA [1000108],AETNA [100010801],,,76.8,,1117.44,326.6475,1117.44,percent of total billed charges,,,
HC Cryoprecipitate Each Unit,PX-39000006,CDM,P9012,CPT,390,RC,,,outpatient,,,1227,858.9,AETNA [1000108],AETNA [100010801],,,76.8,,942.34,49.4,942.336,percent of total billed charges,,,
HC RBC Leukocytes Reduced,PX-39000007,CDM,P9016,CPT,390,RC,,,outpatient,,,551,385.7,AETNA [1000108],AETNA [100010801],,,76.8,,423.17,123.6995,423.168,percent of total billed charges,,,
HC Plasma 1 Donor Frz W/in 8 Hr,PX-39000008,CDM,P9017,CPT,390,RC,,,outpatient,,,379,265.3,AETNA [1000108],AETNA [100010801],,,76.8,,291.07,71.53,416.02,percent of total billed charges,,,
HC Red Blood Cells Unit,PX-39000009,CDM,P9021,CPT,390,RC,,,outpatient,,,471,329.7,AETNA [1000108],AETNA [100010801],,,76.8,,361.73,105.7395,416.02,percent of total billed charges,,,
HC Washed Red Blood Cells Unit,PX-39000010,CDM,P9022,CPT,390,RC,,,outpatient,,,1028,719.6,AETNA [1000108],AETNA [100010801],,,76.8,,789.5,163,871.3328,percent of total billed charges,,,
HC Platelets Leukocytes Reduced,PX-39000011,CDM,P9031,CPT,390,RC,,,outpatient,,,1397,977.9,AETNA [1000108],AETNA [100010801],,,76.8,,1072.9,136.61,1072.896,percent of total billed charges,,,
HC Platelets Leukoreduced Irrad,PX-39000012,CDM,P9033,CPT,390,RC,,,outpatient,,,1633,1143.1,AETNA [1000108],AETNA [100010801],,,76.8,,1254.14,163,1384.1308,percent of total billed charges,,,
HC Platelet Pheres Leukoreduced,PX-39000013,CDM,P9035,CPT,390,RC,,,outpatient,,,1233,863.1,AETNA [1000108],AETNA [100010801],,,76.8,,946.94,163,1119.53,percent of total billed charges,,,
HC Plate Pheres Leukoredu Irrad,PX-39000014,CDM,P9037,CPT,390,RC,,,outpatient,,,1624,1136.8,AETNA [1000108],AETNA [100010801],,,76.8,,1247.23,163,1476.21,percent of total billed charges,,,
HC RBC Deglycerolized,PX-39000015,CDM,P9039,CPT,390,RC,,,outpatient,,,2586,1810.2,AETNA [1000108],AETNA [100010801],,,76.8,,1986.05,163,2191.8936,percent of total billed charges,,,
HC RBC Leukoreduced Irradiated,PX-39000016,CDM,P9040,CPT,390,RC,,,outpatient,,,636,445.2,AETNA [1000108],AETNA [100010801],,,76.8,,488.45,142.782,598.2,percent of total billed charges,,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,44206-0310-25,NDC,outpatient,250,ML,199.57,139.699,AETNA [1000108],AETNA [100010801],,,76.8,,153.27,25.321355,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,44206-0310-90,NDC,outpatient,250,ML,199.57,139.699,AETNA [1000108],AETNA [100010801],,,76.8,,153.27,25.321355,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,68516-5214-03,NDC,outpatient,250,ML,168.42,117.894,AETNA [1000108],AETNA [100010801],,,76.8,,129.35,25.321355,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,76125-0790-26,NDC,outpatient,250,ML,171.75,120.225,AETNA [1000108],AETNA [100010801],,,76.8,,131.9,25.321355,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,00944-0495-06,NDC,outpatient,250,ML,112.79,78.953,AETNA [1000108],AETNA [100010801],,,76.8,,86.62,25.321355,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,68516-5214-01,NDC,outpatient,250,ML,168.42,117.894,AETNA [1000108],AETNA [100010801],,,76.8,,129.35,25.321355,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,76125-0790-25,NDC,outpatient,250,ML,171.75,120.225,AETNA [1000108],AETNA [100010801],,,76.8,,131.9,25.321355,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,00944-0495-05,NDC,outpatient,250,ML,112.79,78.953,AETNA [1000108],AETNA [100010801],,,76.8,,86.62,25.321355,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,68982-0623-03,NDC,outpatient,500,ML,363.1,254.17,AETNA [1000108],AETNA [100010801],,,76.8,,278.86,25.321355,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 5 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8982,CDM,P9045,HCPCS,636,RC,68982-0623-03,NDC,outpatient,500,ML,347.1,242.97,AETNA [1000108],AETNA [100010801],JW,,76.8,,266.57,25.321355,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-03,NDC,outpatient,50,ML,209.58,146.706,AETNA [1000108],AETNA [100010801],,,76.8,,160.96,7.294005,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-04,NDC,outpatient,100,ML,48.49,33.943,AETNA [1000108],AETNA [100010801],,,76.8,,37.24,7.294005,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,64208-2512-07,NDC,outpatient,100,ML,309.7,216.79,AETNA [1000108],AETNA [100010801],,,76.8,,237.85,7.294005,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-00,NDC,outpatient,100,ML,309.7,216.79,AETNA [1000108],AETNA [100010801],,,76.8,,237.85,7.294005,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-04,NDC,outpatient,100,ML,320.83,224.581,AETNA [1000108],AETNA [100010801],,,76.8,,246.4,7.294005,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-04,NDC,outpatient,100,ML,32.49,22.743,AETNA [1000108],AETNA [100010801],JW,,76.8,,24.95,7.294005,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,64208-2512-07,NDC,outpatient,100,ML,293.7,205.59,AETNA [1000108],AETNA [100010801],JW,,76.8,,225.56,7.294005,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-04,NDC,outpatient,100,ML,304.83,213.381,AETNA [1000108],AETNA [100010801],JW,,76.8,,234.11,7.294005,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-02,NDC,outpatient,100,ML,48.49,33.943,AETNA [1000108],AETNA [100010801],,,76.8,,37.24,7.294005,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-02,NDC,outpatient,100,ML,32.49,22.743,AETNA [1000108],AETNA [100010801],JW,,76.8,,24.95,7.294005,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-00,NDC,outpatient,100,ML,293.7,205.59,AETNA [1000108],AETNA [100010801],JW,,76.8,,225.56,7.294005,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-08,NDC,outpatient,100,ML,414.3,290.01,AETNA [1000108],AETNA [100010801],JW,,76.8,,318.18,7.294005,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-08,NDC,outpatient,100,ML,430.3,301.21,AETNA [1000108],AETNA [100010801],,,76.8,,330.47,7.294005,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-01,NDC,outpatient,50,ML,209.58,146.706,AETNA [1000108],AETNA [100010801],,,76.8,,160.96,7.294005,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-01,NDC,outpatient,50,ML,168.42,117.894,AETNA [1000108],AETNA [100010801],,,76.8,,129.35,7.294005,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-02,NDC,outpatient,100,ML,320.83,224.581,AETNA [1000108],AETNA [100010801],,,76.8,,246.4,7.294005,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-03,NDC,outpatient,50,ML,168.42,117.894,AETNA [1000108],AETNA [100010801],,,76.8,,129.35,7.294005,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-02,NDC,outpatient,100,ML,304.83,213.381,AETNA [1000108],AETNA [100010801],JW,,76.8,,234.11,7.294005,416.02,percent of total billed charges,,,
HC Platelets- Hla-M- L/R- Unit,PX-39000026,CDM,P9052,HCPCS,390,RC,,,outpatient,,,1807,1264.9,AETNA [1000108],AETNA [100010801],,,76.8,,1387.78,163,1698,percent of total billed charges,,,
HC RBC- Frz/Deg/Wsh- L/R- Irrad,PX-39000023,CDM,P9057,CPT,390,RC,,,outpatient,,,2062,1443.4,AETNA [1000108],AETNA [100010801],,,76.8,,1583.62,163,1747.7512,percent of total billed charges,,,
HC RBC- L/R- Cmv-Neg- Irrad,PX-39000024,CDM,P9058,CPT,390,RC,,,outpatient,,,1235,864.5,AETNA [1000108],AETNA [100010801],,,76.8,,948.48,163,1046.786,percent of total billed charges,,,
HC Plasma- Frz Between 8-24hour,PX-39000025,CDM,P9059,CPT,390,RC,,,outpatient,,,222,155.4,AETNA [1000108],AETNA [100010801],,,76.8,,170.5,49.839,416.02,percent of total billed charges,,,
HC Platelets- Pheresis- Pathogen-Reduced- Each Unit,PX-39000028,CDM,P9073,HCPCS,390,RC,,,outpatient,,,1626,1138.2,AETNA [1000108],AETNA [100010801],,,76.8,,1248.77,163,1265.41,percent of total billed charges,,,
HC Pathogen Test for Platelets,PX-30000897,CDM,P9100,HCPCS,300,RC,,,outpatient,,,89,62.3,AETNA [1000108],AETNA [100010801],,,76.8,,68.35,19.9805,416.02,percent of total billed charges,,,
FERUMOXYTOL 510 MG/17ML IV SOLN,RX-98312,CDM,Q0138,HCPCS,636,RC,59338-0775-01,NDC,outpatient,17,ML,945.71,661.997,AETNA [1000108],AETNA [100010801],,,76.8,,726.31,0.34,726.30528,percent of total billed charges,,,
ONDANSETRON HCL 4 MG ORAL TABS,RX-10778,CDM,Q0162,HCPCS,259,RC,00904-6551-61,NDC,outpatient,1,UN,1.57,1.099,AETNA [1000108],AETNA [100010801],,,76.8,,1.21,0.01,416.02,percent of total billed charges,,,
ONDANSETRON 4 MG ORAL TBDP,RX-27697,CDM,Q0162,HCPCS,259,RC,65862-0390-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.01,416.02,percent of total billed charges,,,
ONDANSETRON 4 MG ORAL TBDP,RX-27697,CDM,Q0162,HCPCS,259,RC,68462-0157-13,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.01,416.02,percent of total billed charges,,,
ONDANSETRON 4 MG ORAL TBDP,RX-27697,CDM,Q0162,HCPCS,259,RC,68462-0157-40,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.01,416.02,percent of total billed charges,,,
PROCHLORPERAZINE MALEATE 5 MG ORAL TABS,RX-6583,CDM,Q0164,HCPCS,259,RC,50268-0684-15,NDC,outpatient,1,UN,3.56,2.492,AETNA [1000108],AETNA [100010801],,,76.8,,2.73,0.35,416.02,percent of total billed charges,,,
PROCHLORPERAZINE MALEATE 5 MG ORAL TABS,RX-6583,CDM,Q0164,HCPCS,259,RC,50268-0684-11,NDC,outpatient,1,UN,3.56,2.492,AETNA [1000108],AETNA [100010801],,,76.8,,2.73,0.35,416.02,percent of total billed charges,,,
DRONABINOL 2.5 MG ORAL CAPS,RX-9904,CDM,Q0167,HCPCS,259,RC,60687-0375-11,NDC,outpatient,1,UN,18.82,13.174,AETNA [1000108],AETNA [100010801],,,76.8,,14.45,0.73,416.02,percent of total billed charges,,,
DRONABINOL 2.5 MG ORAL CAPS,RX-9904,CDM,Q0167,HCPCS,259,RC,60687-0375-21,NDC,outpatient,1,UN,18.82,13.174,AETNA [1000108],AETNA [100010801],,,76.8,,14.45,0.73,416.02,percent of total billed charges,,,
PROMETHAZINE HCL 25 MG ORAL TABS,RX-6622,CDM,Q0169,HCPCS,259,RC,00904-7304-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.09,416.02,percent of total billed charges,,,
PROMETHAZINE HCL 25 MG ORAL TABS,RX-6622,CDM,Q0169,HCPCS,259,RC,68382-0041-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.09,416.02,percent of total billed charges,,,
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,00069-6001-10,NDC,outpatient,10,ML,77.92,54.544,AETNA [1000108],AETNA [100010801],,,76.8,,59.84,2.55,416.02,percent of total billed charges,,,
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,00069-6001-21,NDC,outpatient,10,ML,77.92,54.544,AETNA [1000108],AETNA [100010801],,,76.8,,59.84,2.55,416.02,percent of total billed charges,,,
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,63323-0403-01,NDC,outpatient,2,ML,19.75,13.825,AETNA [1000108],AETNA [100010801],,,76.8,,15.17,2.55,416.02,percent of total billed charges,,,
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,63323-0403-02,NDC,outpatient,2,ML,19.75,13.825,AETNA [1000108],AETNA [100010801],,,76.8,,15.17,2.55,416.02,percent of total billed charges,,,
DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ,RX-27431,CDM,Q2050,HCPCS,636,RC,00338-0067-01,NDC,outpatient,25,ML,1408.44,985.908,AETNA [1000108],AETNA [100010801],,,76.8,,1081.68,87.98,1653.428703,percent of total billed charges,,,
DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ,RX-27431,CDM,Q2050,HCPCS,636,RC,47335-0050-40,NDC,outpatient,25,ML,1589.76,1112.832,AETNA [1000108],AETNA [100010801],,,76.8,,1220.94,87.98,1653.428703,percent of total billed charges,,,
HC Telehealth Originating Site Facility Fee,PX-78000001,CDM,Q3014,HCPCS,780,RC,,,outpatient,,,373,261.1,AETNA [1000108],AETNA [100010801],,,76.8,,286.46,83.7385,416.02,percent of total billed charges,,,
IMPLANT TY I COLL 1X1IN DURAMATRIX-ONLAY -,SUP-CDSLM11,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,1553.95,1087.765,AETNA [1000108],AETNA [100010801],,,76.8,,1193.43,348.861775,3862.93248,percent of total billed charges,,,
DURAMATRIX SUTURABLE 2 X 2 -,SUP-DMS22,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,2490.5,1743.35,AETNA [1000108],AETNA [100010801],,,76.8,,1912.7,348.861775,3862.93248,percent of total billed charges,,,
DURAMATRIX SUTURABLE  3x3 -,SUP-DMS33,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,4042.29,2829.603,AETNA [1000108],AETNA [100010801],,,76.8,,3104.48,348.861775,3862.93248,percent of total billed charges,,,
DURAMATRIX SUTURABLE 4 X 5 -,SUP-DMS45,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,5029.86,3520.902,AETNA [1000108],AETNA [100010801],,,76.8,,3862.93,348.861775,3862.93248,percent of total billed charges,,,
HC Skin Apligraf,PX-63600004,CDM,Q4101,HCPCS,636,RC,,,outpatient,,,8745,6121.5,AETNA [1000108],AETNA [100010801],,,76.8,,6716.16,30.42,6716.16,percent of total billed charges,,,
HC Matrix Wound Oasis by Sq Cm,PX-63600006,CDM,Q4102,HCPCS,636,RC,,,outpatient,,,65,45.5,AETNA [1000108],AETNA [100010801],,,76.8,,49.92,12.25,659.42016,percent of total billed charges,,,
DRESSING WND 3 X 3.5CM OASIS WND MATRIX -,SUP-8213-1000-33,CDM,Q4102,CPT,278,RC,,,outpatient,,,858.62,601.034,AETNA [1000108],AETNA [100010801],,,76.8,,659.42,12.25,659.42016,percent of total billed charges,,,
INTEGRA BILAYER MATRIX WOUND DRESSING 4 x 5 -,SUP-BMW4051,CDM,Q4104,HCPCS,278,RC,,,outpatient,,,24698.88,17289.216,AETNA [1000108],AETNA [100010801],,,76.8,,18968.74,48.96,24594.91584,percent of total billed charges,,,
MATRIX MESHED BILAYER 2X2 INTE -,SUP-MWM2021,CDM,Q4104,HCPCS,278,RC,,,outpatient,,,20440.07,14308.049,AETNA [1000108],AETNA [100010801],,,76.8,,15697.97,48.96,24594.91584,percent of total billed charges,,,
MATRIX MESH BILAYER 4 X 5 -,SUP-MWM4051,CDM,Q4104,HCPCS,278,RC,,,outpatient,,,32024.63,22417.241,AETNA [1000108],AETNA [100010801],,,76.8,,24594.92,48.96,24594.91584,percent of total billed charges,,,
HC Primatrix Mesh by Sq Cm,PX-63600008,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,186,130.2,AETNA [1000108],AETNA [100010801],,,76.8,,142.85,41.757,4074.24,percent of total billed charges,,,
PRIMATRIX 0.2 x 26.5 ROPE 3 UNITS/BOX -,SUP-607-001-009,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,2157.3,1510.11,AETNA [1000108],AETNA [100010801],,,76.8,,1656.81,41.757,4074.24,percent of total billed charges,,,
PRIMATRIX 2X2 MESHED -,SUP-607-005-220,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,2364.02,1654.814,AETNA [1000108],AETNA [100010801],,,76.8,,1815.57,41.757,4074.24,percent of total billed charges,,,
PRIMATRIX 3X3 MESHED -,SUP-607-005-330,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,2506.35,1754.445,AETNA [1000108],AETNA [100010801],,,76.8,,1924.88,41.757,4074.24,percent of total billed charges,,,
PRIMATRIX 4 X 4CM  MESH -,SUP-607-005-440,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,3074.46,2152.122,AETNA [1000108],AETNA [100010801],,,76.8,,2361.19,41.757,4074.24,percent of total billed charges,,,
PRIMATRIX 6 X 6 MESH -,SUP-607-005-660,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,5305,3713.5,AETNA [1000108],AETNA [100010801],,,76.8,,4074.24,41.757,4074.24,percent of total billed charges,,,
PRIMATRIX 4X4 AG -,SUP-UNDEFINED,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,41.757,4074.24,percent of total billed charges,,,
ALLODERM LARGE THK1.04-2.28 MM THICK L12 CM X W4 CM 48CM2 -,SUP-102050,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,5700.37,3990.259,AETNA [1000108],AETNA [100010801],,,76.8,,4377.88,31.11,14996.48256,percent of total billed charges,,,
ALLODERM LARGE THK2-2.8 MM THICK L12CM X W6CM 72CM2 -,SUP-151972,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,4655.67,3258.969,AETNA [1000108],AETNA [100010801],,,76.8,,3575.55,31.11,14996.48256,percent of total billed charges,,,
GRAFT SOFT TISSUE AXIS TUTOPLAST DERMIS 12CM X 8CM ALLODERM -,SUP-939812,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,10961.89,7673.323,AETNA [1000108],AETNA [100010801],,,76.8,,8418.73,31.11,14996.48256,percent of total billed charges,,,
ALLODERM CONTOUR LARGE PERF L21.5 CM X W10 230.05CM2 -,SUP-CL1519P,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,19526.67,13668.669,AETNA [1000108],AETNA [100010801],,,76.8,,14996.48,31.11,14996.48256,percent of total billed charges,,,
ALLODERM CONTOUR MED PERF THICK 19.3 CM X 9.6 CM 185.28CM2 -,SUP-CM1519P,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,15267.86,10687.502,AETNA [1000108],AETNA [100010801],,,76.8,,11725.72,31.11,14996.48256,percent of total billed charges,,,
ACELL MICROMATRIX POWDER 200MG -,SUP-MM0200,CDM,Q4118,HCPCS,278,RC,,,outpatient,,,2929.8,2050.86,AETNA [1000108],AETNA [100010801],,,76.8,,2250.09,2.5,8051.0208,percent of total billed charges,,,
ACELL MICRO MATRIX 500 MG -,SUP-MM0500,CDM,Q4118,HCPCS,278,RC,,,outpatient,,,5728.55,4009.985,AETNA [1000108],AETNA [100010801],,,76.8,,4399.53,2.5,8051.0208,percent of total billed charges,,,
ACELL MICRO MATRIX 1000 MG -,SUP-MM1000,CDM,Q4118,HCPCS,278,RC,,,outpatient,,,10483.1,7338.17,AETNA [1000108],AETNA [100010801],,,76.8,,8051.02,2.5,8051.0208,percent of total billed charges,,,
SURGICLOSE MICRO 38CM2 -,SUP-50205P04D0D,CDM,Q4121,HCPCS,636,RC,,,outpatient,,,8488,5941.6,AETNA [1000108],AETNA [100010801],,,76.8,,6518.78,46.98,6518.784,percent of total billed charges,,,
HC Matrix Wound Oasis Ultra by Sq Cm,PX-63600010,CDM,Q4124,HCPCS,636,RC,,,outpatient,,,61,42.7,AETNA [1000108],AETNA [100010801],,,76.8,,46.85,9.16,4034.304,percent of total billed charges,,,
HC Matrix Oasis Ultra 7 X 10,PX-63600014,CDM,Q4124,HCPCS,636,RC,,,outpatient,,,5253,3677.1,AETNA [1000108],AETNA [100010801],,,76.8,,4034.3,9.16,4034.304,percent of total billed charges,,,
GRAFT ARTHROFLEX DERMIS THK1.5MM 35MM X 35MM 12.25CM2 -,SUP-AFLEX100,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,7779.25,5445.475,AETNA [1000108],AETNA [100010801],,,76.8,,5974.46,209.5932,10851.38688,percent of total billed charges,,,
DERMIS DECELLULARIZED 35MM X 35MM X 2.0MM 12.25SQCM -,SUP-AFLEX200,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,11781.35,8246.945,AETNA [1000108],AETNA [100010801],,,76.8,,9048.08,209.5932,10851.38688,percent of total billed charges,,,
ARTHROFLEX 40MM X 70MM X 3.0 DERMIS DECELLULARIZED 28SQCM -,SUP-AFLEX301,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,14129.41,9890.587,AETNA [1000108],AETNA [100010801],,,76.8,,10851.39,209.5932,10851.38688,percent of total billed charges,,,
ARTHROFLEX 25 X 30 X 1MM 7.5SQCM -,SUP-AFLEX403,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,933.6,653.52,AETNA [1000108],AETNA [100010801],,,76.8,,717,209.5932,10851.38688,percent of total billed charges,,,
CONNECT PRE-SUTURED TENDON-ZORC 4.5 x 160MM -,SUP-FCON,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,5187.44,3631.208,AETNA [1000108],AETNA [100010801],,,76.8,,3983.95,209.5932,10851.38688,percent of total billed charges,,,
SURGICLOSE 7 X 10CM- 70SQCM -,SUP-50205N03D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,16121.85,11285.295,AETNA [1000108],AETNA [100010801],,,76.8,,12381.58,3.06,20434.45248,percent of total billed charges,,,
SURGICLOSE 6 X 8 MESHED 2:1 UP TO 86CM2 -,SUP-50205N18D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,10804.83,7563.381,AETNA [1000108],AETNA [100010801],,,76.8,,8298.11,3.06,20434.45248,percent of total billed charges,,,
SURGICLOSE MESHED 2:1 4X6 CM- 24SQCM -,SUP-50205N20D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,6934.7,4854.29,AETNA [1000108],AETNA [100010801],,,76.8,,5325.85,3.06,20434.45248,percent of total billed charges,,,
SURGICLOSE MESHED 7 X 20 -,SUP-50205N21D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,26607.36,18625.152,AETNA [1000108],AETNA [100010801],,,76.8,,20434.45,3.06,20434.45248,percent of total billed charges,,,
SURGICLOSE MICRO 95 CM2 -,SUP-50205P31D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,15965.9,11176.13,AETNA [1000108],AETNA [100010801],,,76.8,,12261.81,3.06,20434.45248,percent of total billed charges,,,
ACELL WOUND/BURN MATRIX 2 LAYER -,SUP-BMM0710,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,4509.25,3156.475,AETNA [1000108],AETNA [100010801],,,76.8,,3463.1,18.9,9453.0048,percent of total billed charges,,,
CYTAL BURN MATRIX -,SUP-BMM1015,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,8116.65,5681.655,AETNA [1000108],AETNA [100010801],,,76.8,,6233.59,18.9,9453.0048,percent of total billed charges,,,
CYTAL WOUND MATRIX 1 LAYER 3 X 7CM -,SUP-WS0307,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,853.08,597.156,AETNA [1000108],AETNA [100010801],,,76.8,,655.17,18.9,9453.0048,percent of total billed charges,,,
MATRIX WOUND ACELL GENTRIX 5M X 5CM 25CM2 3 LAYERS -,SUP-WSR0505,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,4118.77,2883.139,AETNA [1000108],AETNA [100010801],,,76.8,,3163.22,18.9,9453.0048,percent of total billed charges,,,
WOUND MATRIX CYTEL 3 LAYER 7 X 10CM -,SUP-WSR0710,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,8206.84,5744.788,AETNA [1000108],AETNA [100010801],,,76.8,,6302.85,18.9,9453.0048,percent of total billed charges,,,
WOUND MATRIX 3 LAYER 10 X 15CM -,SUP-WSR1015,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,12308.6,8616.02,AETNA [1000108],AETNA [100010801],,,76.8,,9453,18.9,9453.0048,percent of total billed charges,,,
ACELL WOUND MATRIX 6-LAYER MESH -,SUP-WSX0505,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,4869.99,3408.993,AETNA [1000108],AETNA [100010801],,,76.8,,3740.15,18.9,9453.0048,percent of total billed charges,,,
CYTAL WOUND MATRIX 6 LAYER 7 X 10CM -,SUP-WSX0710,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,9562.83,6693.981,AETNA [1000108],AETNA [100010801],,,76.8,,7344.25,18.9,9453.0048,percent of total billed charges,,,
HC Epifix- per Square Centimeter,PX-63600024,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,501,350.7,AETNA [1000108],AETNA [100010801],,,76.8,,384.77,112.4745,3643.99872,percent of total billed charges,,,
EPIFIX DISK 14MM -,SUP-GS-5140,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,1746.51,1222.557,AETNA [1000108],AETNA [100010801],,,76.8,,1341.32,112.4745,3643.99872,percent of total billed charges,,,
EPIFIX DISK 18MM -,SUP-GS-5180,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,3733.27,2613.289,AETNA [1000108],AETNA [100010801],,,76.8,,2867.15,112.4745,3643.99872,percent of total billed charges,,,
EPIFIX 2 X 2 CM -,SUP-GS-5220,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,4744.79,3321.353,AETNA [1000108],AETNA [100010801],,,76.8,,3644,112.4745,3643.99872,percent of total billed charges,,,
PURAPLY AM 2CMX2CM -,SUP-00000000000000000000000000000,CDM,Q4196,HCPCS,636,RC,,,outpatient,,,4057.9,2840.53,AETNA [1000108],AETNA [100010801],,,76.8,,3116.47,102.28,3422.3616,percent of total billed charges,,,
PURAPLY AM 2CMX4CM -,SUP-PURAPLYAM-COM 2X4,CDM,Q4196,HCPCS,636,RC,,,outpatient,,,4456.2,3119.34,AETNA [1000108],AETNA [100010801],,,76.8,,3422.36,102.28,3422.3616,percent of total billed charges,,,
FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY,RX-132201,CDM,Q5101,HCPCS,636,RC,61314-0318-01,NDC,outpatient,0.5,ML,603.11,422.177,AETNA [1000108],AETNA [100010801],,,76.8,,463.19,0.18,741.12768,percent of total billed charges,,,
FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY,RX-132201,CDM,Q5101,HCPCS,636,RC,61314-0318-10,NDC,outpatient,0.5,ML,603.14,422.198,AETNA [1000108],AETNA [100010801],,,76.8,,463.21,0.18,741.12768,percent of total billed charges,,,
FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY,RX-132201,CDM,Q5101,HCPCS,636,RC,61314-0318-05,NDC,outpatient,0.5,ML,603.14,422.198,AETNA [1000108],AETNA [100010801],,,76.8,,463.21,0.18,741.12768,percent of total billed charges,,,
FILGRASTIM-SNDZ 480 MCG/0.8ML IJ SOSY,RX-132202,CDM,Q5101,HCPCS,636,RC,61314-0326-05,NDC,outpatient,0.8,ML,965.01,675.507,AETNA [1000108],AETNA [100010801],,,76.8,,741.13,0.18,741.12768,percent of total billed charges,,,
FILGRASTIM-SNDZ 480 MCG/0.8ML IJ SOSY,RX-132202,CDM,Q5101,HCPCS,636,RC,61314-0326-10,NDC,outpatient,0.8,ML,965.01,675.507,AETNA [1000108],AETNA [100010801],,,76.8,,741.13,0.18,741.12768,percent of total billed charges,,,
INFLIXIMAB-DYYB 100 MG IV SOLR,RX-136637,CDM,Q5103,HCPCS,636,RC,00069-0809-01,NDC,outpatient,1,UN,1389.66,972.762,AETNA [1000108],AETNA [100010801],,,76.8,,1067.26,13.62,1653.428703,percent of total billed charges,,,
INFLIXIMAB-ABDA 100 MG IV SOLR,RX-139995,CDM,Q5104,HCPCS,636,RC,00006-4305-01,NDC,outpatient,1,UN,1902.38,1331.666,AETNA [1000108],AETNA [100010801],,,76.8,,1461.03,27.18,1653.428703,percent of total billed charges,,,
INFLIXIMAB-ABDA 100 MG IV SOLR,RX-139995,CDM,Q5104,HCPCS,636,RC,00006-4305-02,NDC,outpatient,1,UN,1902.38,1331.666,AETNA [1000108],AETNA [100010801],,,76.8,,1461.03,27.18,1653.428703,percent of total billed charges,,,
EPOETIN ALFA-EPBX 2000 UNIT/ML IJ SOLN,RX-143174,CDM,Q5106,HCPCS,636,RC,00069-1305-10,NDC,outpatient,1,ML,79.46,55.622,AETNA [1000108],AETNA [100010801],,,76.8,,61.03,7.5,416.02,percent of total billed charges,,,
EPOETIN ALFA-EPBX 2000 UNIT/ML IJ SOLN,RX-143174,CDM,Q5106,HCPCS,636,RC,00069-1305-01,NDC,outpatient,1,ML,79.46,55.622,AETNA [1000108],AETNA [100010801],,,76.8,,61.03,7.5,416.02,percent of total billed charges,,,
EPOETIN ALFA-EPBX 3000 UNIT/ML IJ SOLN,RX-143175,CDM,Q5106,HCPCS,636,RC,00069-1306-01,NDC,outpatient,1,ML,119.19,83.433,AETNA [1000108],AETNA [100010801],,,76.8,,91.54,7.5,416.02,percent of total billed charges,,,
EPOETIN ALFA-EPBX 3000 UNIT/ML IJ SOLN,RX-143175,CDM,Q5106,HCPCS,636,RC,00069-1306-10,NDC,outpatient,1,ML,119.19,83.433,AETNA [1000108],AETNA [100010801],,,76.8,,91.54,7.5,416.02,percent of total billed charges,,,
EPOETIN ALFA-EPBX 4000 UNIT/ML IJ SOLN,RX-143176,CDM,Q5106,HCPCS,636,RC,00069-1307-01,NDC,outpatient,1,ML,158.92,111.244,AETNA [1000108],AETNA [100010801],,,76.8,,122.05,7.5,416.02,percent of total billed charges,,,
EPOETIN ALFA-EPBX 4000 UNIT/ML IJ SOLN,RX-143176,CDM,Q5106,HCPCS,636,RC,00069-1307-10,NDC,outpatient,1,ML,158.92,111.244,AETNA [1000108],AETNA [100010801],,,76.8,,122.05,7.5,416.02,percent of total billed charges,,,
EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN,RX-143177,CDM,Q5106,HCPCS,636,RC,00069-1308-10,NDC,outpatient,1,ML,377.7,264.39,AETNA [1000108],AETNA [100010801],,,76.8,,290.07,7.5,416.02,percent of total billed charges,,,
EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN,RX-143177,CDM,Q5106,HCPCS,636,RC,00069-1308-01,NDC,outpatient,1,ML,377.7,264.39,AETNA [1000108],AETNA [100010801],,,76.8,,290.07,7.5,416.02,percent of total billed charges,,,
EPOETIN ALFA-EPBX 40000 UNIT/ML IJ SOLN,RX-143178,CDM,Q5106,HCPCS,636,RC,00069-1309-01,NDC,outpatient,0.05,ML,75.54,52.878,AETNA [1000108],AETNA [100010801],,,76.8,,58.01,7.5,416.02,percent of total billed charges,,,
EPOETIN ALFA-EPBX 40000 UNIT/ML IJ SOLN,RX-143178,CDM,Q5106,HCPCS,636,RC,00069-1309-04,NDC,outpatient,0.05,ML,75.54,52.878,AETNA [1000108],AETNA [100010801],,,76.8,,58.01,7.5,416.02,percent of total billed charges,,,
RITUXIMAB-ABBS 10 MG/ML IV SOLN WRAPPER,RX-4081244,CDM,Q5115,HCPCS,636,RC,63459-0103-10,NDC,outpatient,10,ML,1691.22,1183.854,AETNA [1000108],AETNA [100010801],,,76.8,,1298.86,33.59,7269.974281,percent of total billed charges,,,
RITUXIMAB-ABBS 10 MG/ML IV SOLN WRAPPER,RX-4081244,CDM,Q5115,HCPCS,636,RC,63459-0104-50,NDC,outpatient,50,ML,6662.37,4663.659,AETNA [1000108],AETNA [100010801],,,76.8,,5116.7,33.59,7269.974281,percent of total billed charges,,,
INFLIXIMAB-AXXQ 100 MG IV SOLR,RX-150921,CDM,Q5121,HCPCS,636,RC,55513-0670-01,NDC,outpatient,1,UN,2071.48,1450.036,AETNA [1000108],AETNA [100010801],,,76.8,,1590.9,21.29,1590.89664,percent of total billed charges,,,
MEDIA CONTR PRFLTRN LPD MICSPHR INJ SUSP VL DEFINITY -,SUP-DE16,CDM,Q9957,CPT,636,RC,,,outpatient,,,554.33,388.031,AETNA [1000108],AETNA [100010801],,,76.8,,425.73,40.92,438.4896,percent of total billed charges,,,
DEFINITY DE-4 -,SUP-DE4,CDM,Q9957,CPT,636,RC,,,outpatient,,,570.95,399.665,AETNA [1000108],AETNA [100010801],,,76.8,,438.49,40.92,438.4896,percent of total billed charges,,,
DIATRIZOATE MEGLUMINE & SODIUM 66-10 % ORAL SOLN,RX-9828,CDM,Q9963,HCPCS,636,RC,00270-0445-40,NDC,outpatient,7.5,ML,3.71,2.597,AETNA [1000108],AETNA [100010801],,,76.8,,2.85,0.22,416.02,percent of total billed charges,,,
IOHEXOL 180 MG/ML IJ SOLN,RX-10319,CDM,Q9965,HCPCS,636,RC,00407-1411-10,NDC,outpatient,3,ML,16.35,11.445,AETNA [1000108],AETNA [100010801],,,76.8,,12.56,1.56,416.02,percent of total billed charges,,,
IOHEXOL 180 MG/ML IJ SOLN,RX-10319,CDM,Q9965,HCPCS,636,RC,99999-0004-10,NDC,outpatient,3,ML,16.35,11.445,AETNA [1000108],AETNA [100010801],,,76.8,,12.56,1.56,416.02,percent of total billed charges,,,
IOPAMIDOL 41 % IJ SOLN,RX-10325,CDM,Q9966,HCPCS,636,RC,00270-1411-11,NDC,outpatient,10,ML,98.1,68.67,AETNA [1000108],AETNA [100010801],,,76.8,,75.34,0.38,416.02,percent of total billed charges,,,
IOHEXOL 240 MG/ML IJ SOLN,RX-119843,CDM,Q9966,HCPCS,636,RC,00407-1412-33,NDC,outpatient,10,ML,32.7,22.89,AETNA [1000108],AETNA [100010801],,,76.8,,25.11,0.38,416.02,percent of total billed charges,,,
IOHEXOL 240 MG/ML IJ SOLN,RX-119843,CDM,Q9966,HCPCS,636,RC,99999-0004-07,NDC,outpatient,10,ML,32.7,22.89,AETNA [1000108],AETNA [100010801],,,76.8,,25.11,0.38,416.02,percent of total billed charges,,,
IOHEXOL 240 MG/ML IJ SOLN,RX-119843,CDM,Q9966,HCPCS,636,RC,00407-1412-30,NDC,outpatient,10,ML,32.7,22.89,AETNA [1000108],AETNA [100010801],,,76.8,,25.11,0.38,416.02,percent of total billed charges,,,
IOPAMIDOL 61 % IJ SOLN,RX-10327,CDM,Q9967,HCPCS,636,RC,00270-1412-15,NDC,outpatient,15,ML,81.75,57.225,AETNA [1000108],AETNA [100010801],,,76.8,,62.78,0.14,416.02,percent of total billed charges,,,
IOPAMIDOL 76 % IV SOLN,RX-10328,CDM,Q9967,HCPCS,636,RC,00270-1316-35,NDC,outpatient,50,ML,272.5,190.75,AETNA [1000108],AETNA [100010801],,,76.8,,209.28,0.14,416.02,percent of total billed charges,,,
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-61,NDC,outpatient,5,ML,10.9,7.63,AETNA [1000108],AETNA [100010801],,,76.8,,8.37,0.14,416.02,percent of total billed charges,,,
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-63,NDC,outpatient,5,ML,10.9,7.63,AETNA [1000108],AETNA [100010801],,,76.8,,8.37,0.14,416.02,percent of total billed charges,,,
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-10,NDC,outpatient,5,ML,10.9,7.63,AETNA [1000108],AETNA [100010801],,,76.8,,8.37,0.14,416.02,percent of total billed charges,,,
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-58,NDC,outpatient,5,ML,10.9,7.63,AETNA [1000108],AETNA [100010801],,,76.8,,8.37,0.14,416.02,percent of total billed charges,,,
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-59,NDC,outpatient,5,ML,10.9,7.63,AETNA [1000108],AETNA [100010801],,,76.8,,8.37,0.14,416.02,percent of total billed charges,,,
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,99999-0004-09,NDC,outpatient,5,ML,10.9,7.63,AETNA [1000108],AETNA [100010801],,,76.8,,8.37,0.14,416.02,percent of total billed charges,,,
IOPAMIDOL 61 % IV SOLN,RX-27737,CDM,Q9967,HCPCS,636,RC,00270-1315-25,NDC,outpatient,30,ML,163.5,114.45,AETNA [1000108],AETNA [100010801],,,76.8,,125.57,0.14,416.02,percent of total billed charges,,,
IOVERSOL 68 % IJ SOLN,RX-39700,CDM,Q9967,HCPCS,636,RC,00019-1323-02,NDC,outpatient,20,ML,109,76.3,AETNA [1000108],AETNA [100010801],,,76.8,,83.71,0.14,416.02,percent of total billed charges,,,
ISOSULFAN BLUE 1 % SC SOLN,RX-10358,CDM,Q9968,HCPCS,636,RC,67457-0220-05,NDC,outpatient,5,ML,2840.8,1988.56,AETNA [1000108],AETNA [100010801],,,76.8,,2181.73,9.53,2181.7344,percent of total billed charges,,,
ISOSULFAN BLUE 1 % SC SOLN,RX-10358,CDM,Q9968,HCPCS,636,RC,67457-0220-00,NDC,outpatient,5,ML,2840.8,1988.56,AETNA [1000108],AETNA [100010801],,,76.8,,2181.73,9.53,2181.7344,percent of total billed charges,,,
ACETAMINOPHEN 160 MG/5ML ORAL SOLN,RX-100,CDM,S5000,HCPCS,259,RC,00121-1971-00,NDC,outpatient,650,ME,11.57,8.099,AETNA [1000108],AETNA [100010801],,,76.8,,8.89,0.222255,85118.57664,percent of total billed charges,,,
ACETAMINOPHEN 160 MG/5ML ORAL SOLN,RX-100,CDM,S5000,HCPCS,259,RC,81033-0002-30,NDC,outpatient,650,ME,11.57,8.099,AETNA [1000108],AETNA [100010801],,,76.8,,8.89,0.222255,85118.57664,percent of total billed charges,,,
ACETAMINOPHEN 160 MG/5ML ORAL SOLN,RX-100,CDM,S5000,HCPCS,259,RC,00121-1971-21,NDC,outpatient,650,ME,11.57,8.099,AETNA [1000108],AETNA [100010801],,,76.8,,8.89,0.222255,85118.57664,percent of total billed charges,,,
ACETAMINOPHEN 160 MG/5ML ORAL SOLN,RX-100,CDM,S5000,HCPCS,259,RC,81033-0002-20,NDC,outpatient,650,ME,11.57,8.099,AETNA [1000108],AETNA [100010801],,,76.8,,8.89,0.222255,85118.57664,percent of total billed charges,,,
FAMOTIDINE 40 MG/5ML ORAL SUSR,RX-10010,CDM,S5000,HCPCS,259,RC,70954-0316-10,NDC,outpatient,50,ML,117.71,82.397,AETNA [1000108],AETNA [100010801],,,76.8,,90.4,0.222255,85118.57664,percent of total billed charges,,,
FAMOTIDINE 40 MG/5ML ORAL SUSR,RX-10010,CDM,S5000,HCPCS,259,RC,99999-0004-18,NDC,outpatient,2.5,ML,4.86,3.402,AETNA [1000108],AETNA [100010801],,,76.8,,3.73,0.222255,85118.57664,percent of total billed charges,,,
FAMOTIDINE 20 MG ORAL TABS,RX-10011,CDM,S5000,HCPCS,259,RC,50268-0299-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
FAMOTIDINE 20 MG ORAL TABS,RX-10011,CDM,S5000,HCPCS,259,RC,00904-7193-06,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
FAMOTIDINE 20 MG ORAL TABS,RX-10011,CDM,S5000,HCPCS,259,RC,63739-0645-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
FAMOTIDINE 20 MG ORAL TABS,RX-10011,CDM,S5000,HCPCS,259,RC,50268-0299-15,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
FAMOTIDINE 20 MG ORAL TABS,RX-10011,CDM,S5000,HCPCS,259,RC,62332-0001-31,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
FELBAMATE 600 MG ORAL TABS,RX-10025,CDM,S5000,HCPCS,259,RC,72578-0057-16,NDC,outpatient,1,UN,5.99,4.193,AETNA [1000108],AETNA [100010801],,,76.8,,4.6,0.222255,85118.57664,percent of total billed charges,,,
FINASTERIDE 5 MG ORAL TABS,RX-10037,CDM,S5000,HCPCS,259,RC,00904-6830-61,NDC,outpatient,1,UN,2.18,1.526,AETNA [1000108],AETNA [100010801],,,76.8,,1.67,0.222255,85118.57664,percent of total billed charges,,,
FINASTERIDE 5 MG ORAL TABS,RX-10037,CDM,S5000,HCPCS,259,RC,00904-6830-06,NDC,outpatient,1,UN,1.66,1.162,AETNA [1000108],AETNA [100010801],,,76.8,,1.27,0.222255,85118.57664,percent of total billed charges,,,
FINASTERIDE 5 MG ORAL TABS,RX-10037,CDM,S5000,HCPCS,259,RC,60687-0428-01,NDC,outpatient,1,UN,2.29,1.603,AETNA [1000108],AETNA [100010801],,,76.8,,1.76,0.222255,85118.57664,percent of total billed charges,,,
FINASTERIDE 5 MG ORAL TABS,RX-10037,CDM,S5000,HCPCS,259,RC,60687-0428-11,NDC,outpatient,1,UN,2.29,1.603,AETNA [1000108],AETNA [100010801],,,76.8,,1.76,0.222255,85118.57664,percent of total billed charges,,,
FLECAINIDE ACETATE 100 MG ORAL TABS,RX-10041,CDM,S5000,HCPCS,259,RC,50268-0321-15,NDC,outpatient,1,UN,2.86,2.002,AETNA [1000108],AETNA [100010801],,,76.8,,2.2,0.222255,85118.57664,percent of total billed charges,,,
FLECAINIDE ACETATE 100 MG ORAL TABS,RX-10041,CDM,S5000,HCPCS,259,RC,00054-0011-21,NDC,outpatient,1,UN,2.98,2.086,AETNA [1000108],AETNA [100010801],,,76.8,,2.29,0.222255,85118.57664,percent of total billed charges,,,
FLECAINIDE ACETATE 100 MG ORAL TABS,RX-10041,CDM,S5000,HCPCS,259,RC,50268-0321-11,NDC,outpatient,1,UN,2.86,2.002,AETNA [1000108],AETNA [100010801],,,76.8,,2.2,0.222255,85118.57664,percent of total billed charges,,,
FLECAINIDE ACETATE 50 MG ORAL TABS,RX-10043,CDM,S5000,HCPCS,259,RC,50268-0320-15,NDC,outpatient,1,UN,3.66,2.562,AETNA [1000108],AETNA [100010801],,,76.8,,2.81,0.222255,85118.57664,percent of total billed charges,,,
FLECAINIDE ACETATE 50 MG ORAL TABS,RX-10043,CDM,S5000,HCPCS,259,RC,00054-0010-20,NDC,outpatient,1,UN,2.45,1.715,AETNA [1000108],AETNA [100010801],,,76.8,,1.88,0.222255,85118.57664,percent of total billed charges,,,
FLECAINIDE ACETATE 50 MG ORAL TABS,RX-10043,CDM,S5000,HCPCS,259,RC,50268-0320-11,NDC,outpatient,1,UN,3.66,2.562,AETNA [1000108],AETNA [100010801],,,76.8,,2.81,0.222255,85118.57664,percent of total billed charges,,,
FLUCONAZOLE 100 MG ORAL TABS,RX-10044,CDM,S5000,HCPCS,259,RC,68084-0728-11,NDC,outpatient,1,UN,4.94,3.458,AETNA [1000108],AETNA [100010801],,,76.8,,3.79,0.222255,85118.57664,percent of total billed charges,,,
FLUCONAZOLE 100 MG ORAL TABS,RX-10044,CDM,S5000,HCPCS,259,RC,68084-0728-01,NDC,outpatient,1,UN,4.94,3.458,AETNA [1000108],AETNA [100010801],,,76.8,,3.79,0.222255,85118.57664,percent of total billed charges,,,
FLUCONAZOLE 100 MG ORAL TABS,RX-10044,CDM,S5000,HCPCS,259,RC,00904-6500-61,NDC,outpatient,1,UN,4.03,2.821,AETNA [1000108],AETNA [100010801],,,76.8,,3.1,0.222255,85118.57664,percent of total billed charges,,,
FLUCONAZOLE 200 MG ORAL TABS,RX-10045,CDM,S5000,HCPCS,259,RC,00904-6501-61,NDC,outpatient,1,UN,6.68,4.676,AETNA [1000108],AETNA [100010801],,,76.8,,5.13,0.222255,85118.57664,percent of total billed charges,,,
VITAMIN D2 (ERGOCALCIFEROL) 1.25 MG (50000 UNITS) ORAL CAPS,RX-100493,CDM,S5000,HCPCS,259,RC,50268-0297-11,NDC,outpatient,1,UN,3.93,2.751,AETNA [1000108],AETNA [100010801],,,76.8,,3.02,0.222255,85118.57664,percent of total billed charges,,,
VITAMIN D2 (ERGOCALCIFEROL) 1.25 MG (50000 UNITS) ORAL CAPS,RX-100493,CDM,S5000,HCPCS,259,RC,64380-0737-06,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
VITAMIN D2 (ERGOCALCIFEROL) 1.25 MG (50000 UNITS) ORAL CAPS,RX-100493,CDM,S5000,HCPCS,259,RC,50268-0297-15,NDC,outpatient,1,UN,3.93,2.751,AETNA [1000108],AETNA [100010801],,,76.8,,3.02,0.222255,85118.57664,percent of total billed charges,,,
FLUCYTOSINE 500 MG ORAL CAPS,RX-10052,CDM,S5000,HCPCS,259,RC,42794-0010-08,NDC,outpatient,1,UN,233.01,163.107,AETNA [1000108],AETNA [100010801],,,76.8,,178.95,0.222255,85118.57664,percent of total billed charges,,,
FLUDROCORTISONE ACETATE 0.1 MG ORAL TABS,RX-10054,CDM,S5000,HCPCS,259,RC,00115-7033-01,NDC,outpatient,1,UN,2.43,1.701,AETNA [1000108],AETNA [100010801],,,76.8,,1.87,0.222255,85118.57664,percent of total billed charges,,,
FLUDROCORTISONE ACETATE 0.1 MG ORAL TABS,RX-10054,CDM,S5000,HCPCS,259,RC,50268-0330-11,NDC,outpatient,1,UN,2.26,1.582,AETNA [1000108],AETNA [100010801],,,76.8,,1.74,0.222255,85118.57664,percent of total billed charges,,,
FLUDROCORTISONE ACETATE 0.1 MG ORAL TABS,RX-10054,CDM,S5000,HCPCS,259,RC,50268-0330-15,NDC,outpatient,1,UN,2.26,1.582,AETNA [1000108],AETNA [100010801],,,76.8,,1.74,0.222255,85118.57664,percent of total billed charges,,,
FLUOROURACIL 5 % EX CREA,RX-10065,CDM,S5000,HCPCS,259,RC,16729-0542-35,NDC,outpatient,40,GR,458.18,320.726,AETNA [1000108],AETNA [100010801],,,76.8,,351.88,0.222255,85118.57664,percent of total billed charges,,,
FLUOROURACIL 5 % EX CREA,RX-10065,CDM,S5000,HCPCS,259,RC,51672-4118-06,NDC,outpatient,40,GR,108.41,75.887,AETNA [1000108],AETNA [100010801],,,76.8,,83.26,0.222255,85118.57664,percent of total billed charges,,,
FLUOXETINE HCL 10 MG ORAL CAPS,RX-10069,CDM,S5000,HCPCS,259,RC,16714-0720-02,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
FLUOXETINE HCL 20 MG ORAL CAPS,RX-10070,CDM,S5000,HCPCS,259,RC,00904-7346-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
FLURBIPROFEN SODIUM 0.03 % OP SOLN,RX-10080,CDM,S5000,HCPCS,259,RC,69292-0722-25,NDC,outpatient,2.5,ML,140.89,98.623,AETNA [1000108],AETNA [100010801],,,76.8,,108.2,0.222255,85118.57664,percent of total billed charges,,,
FLUVOXAMINE MALEATE 50 MG ORAL TABS,RX-10085,CDM,S5000,HCPCS,259,RC,60505-0165-01,NDC,outpatient,1,UN,1.63,1.141,AETNA [1000108],AETNA [100010801],,,76.8,,1.25,0.222255,85118.57664,percent of total billed charges,,,
FOSINOPRIL SODIUM 10 MG ORAL TABS,RX-10094,CDM,S5000,HCPCS,259,RC,69097-0856-05,NDC,outpatient,1,UN,1.76,1.232,AETNA [1000108],AETNA [100010801],,,76.8,,1.35,0.222255,85118.57664,percent of total billed charges,,,
RITONAVIR 100 MG ORAL TABS,RX-100995,CDM,S5000,HCPCS,259,RC,00074-2340-30,NDC,outpatient,1,UN,37.01,25.907,AETNA [1000108],AETNA [100010801],,,76.8,,28.42,0.222255,85118.57664,percent of total billed charges,,,
GLIPIZIDE 5 MG ORAL TABS,RX-10117,CDM,S5000,HCPCS,259,RC,00904-6637-61,NDC,outpatient,1,UN,1.21,0.847,AETNA [1000108],AETNA [100010801],,,76.8,,0.93,0.222255,85118.57664,percent of total billed charges,,,
GLIPIZIDE 5 MG ORAL TABS,RX-10117,CDM,S5000,HCPCS,259,RC,60505-0141-00,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
GLYBURIDE 2.5 MG ORAL TABS,RX-10126,CDM,S5000,HCPCS,259,RC,00093-8343-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
GLYCOPYRROLATE 1 MG ORAL TABS,RX-10130,CDM,S5000,HCPCS,259,RC,23155-0606-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
GUANFACINE HCL 1 MG ORAL TABS,RX-10149,CDM,S5000,HCPCS,259,RC,68094-0065-62,NDC,outpatient,1,UN,8.9,6.23,AETNA [1000108],AETNA [100010801],,,76.8,,6.84,0.222255,85118.57664,percent of total billed charges,,,
GUANFACINE HCL 1 MG ORAL TABS,RX-10149,CDM,S5000,HCPCS,259,RC,68094-0065-59,NDC,outpatient,1,UN,8.9,6.23,AETNA [1000108],AETNA [100010801],,,76.8,,6.84,0.222255,85118.57664,percent of total billed charges,,,
ACETAMINOPHEN 500 MG ORAL TABS,RX-102,CDM,S5000,HCPCS,259,RC,00904-6730-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
HYDROCORTISONE 5 MG ORAL TABS,RX-10209,CDM,S5000,HCPCS,259,RC,59762-0073-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
HYDROCORTISONE 5 MG ORAL TABS,RX-10209,CDM,S5000,HCPCS,259,RC,64380-0970-25,NDC,outpatient,1,UN,1.23,0.861,AETNA [1000108],AETNA [100010801],,,76.8,,0.94,0.222255,85118.57664,percent of total billed charges,,,
HYDROCORTISONE 100 MG/60ML RE ENEM,RX-10210,CDM,S5000,HCPCS,259,RC,62559-0138-07,NDC,outpatient,60,ML,88.11,61.677,AETNA [1000108],AETNA [100010801],,,76.8,,67.67,0.222255,85118.57664,percent of total billed charges,,,
HYDROCORTISONE 100 MG/60ML RE ENEM,RX-10210,CDM,S5000,HCPCS,259,RC,62559-0138-11,NDC,outpatient,60,ML,88.11,61.677,AETNA [1000108],AETNA [100010801],,,76.8,,67.67,0.222255,85118.57664,percent of total billed charges,,,
HYDROCORTISONE MICRONIZED POWD,RX-10217,CDM,S5000,HCPCS,259,RC,51552-0020-05,NDC,outpatient,100,GR,1580.42,1106.294,AETNA [1000108],AETNA [100010801],,,76.8,,1213.76,0.222255,85118.57664,percent of total billed charges,,,
HYDROXYCHLOROQUINE SULFATE 200 MG ORAL TABS,RX-10235,CDM,S5000,HCPCS,259,RC,68084-0269-01,NDC,outpatient,1,UN,4.87,3.409,AETNA [1000108],AETNA [100010801],,,76.8,,3.74,0.222255,85118.57664,percent of total billed charges,,,
HYDROXYCHLOROQUINE SULFATE 200 MG ORAL TABS,RX-10235,CDM,S5000,HCPCS,259,RC,68084-0269-11,NDC,outpatient,1,UN,4.87,3.409,AETNA [1000108],AETNA [100010801],,,76.8,,3.74,0.222255,85118.57664,percent of total billed charges,,,
HYDROXYCHLOROQUINE SULFATE 200 MG ORAL TABS,RX-10235,CDM,S5000,HCPCS,259,RC,00904-7046-61,NDC,outpatient,1,UN,3.27,2.289,AETNA [1000108],AETNA [100010801],,,76.8,,2.51,0.222255,85118.57664,percent of total billed charges,,,
HYDROXYUREA 500 MG ORAL CAPS,RX-10236,CDM,S5000,HCPCS,259,RC,68084-0284-01,NDC,outpatient,1,UN,3.02,2.114,AETNA [1000108],AETNA [100010801],,,76.8,,2.32,0.222255,85118.57664,percent of total billed charges,,,
HYDROXYUREA 500 MG ORAL CAPS,RX-10236,CDM,S5000,HCPCS,259,RC,68084-0284-11,NDC,outpatient,1,UN,3.02,2.114,AETNA [1000108],AETNA [100010801],,,76.8,,2.32,0.222255,85118.57664,percent of total billed charges,,,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,51672-2130-08,NDC,outpatient,120,ML,11.22,7.854,AETNA [1000108],AETNA [100010801],,,76.8,,8.62,0.222255,85118.57664,percent of total billed charges,,,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,59651-0032-47,NDC,outpatient,473,ML,67.36,47.152,AETNA [1000108],AETNA [100010801],,,76.8,,51.73,0.222255,85118.57664,percent of total billed charges,,,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,99999-0004-24,NDC,outpatient,5,ML,1.37,0.959,AETNA [1000108],AETNA [100010801],,,76.8,,1.05,0.222255,85118.57664,percent of total billed charges,,,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,00121-0914-05,NDC,outpatient,5,ML,2.5,1.75,AETNA [1000108],AETNA [100010801],,,76.8,,1.92,0.222255,85118.57664,percent of total billed charges,,,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,00121-0914-00,NDC,outpatient,5,ML,2.5,1.75,AETNA [1000108],AETNA [100010801],,,76.8,,1.92,0.222255,85118.57664,percent of total billed charges,,,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,68094-0494-59,NDC,outpatient,5,ML,2.54,1.778,AETNA [1000108],AETNA [100010801],,,76.8,,1.95,0.222255,85118.57664,percent of total billed charges,,,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,68094-0494-61,NDC,outpatient,5,ML,2.54,1.778,AETNA [1000108],AETNA [100010801],,,76.8,,1.95,0.222255,85118.57664,percent of total billed charges,,,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,68094-0494-62,NDC,outpatient,5,ML,2.59,1.813,AETNA [1000108],AETNA [100010801],,,76.8,,1.99,0.222255,85118.57664,percent of total billed charges,,,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,59651-0032-05,NDC,outpatient,5,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
INDIGOTINDISULFONATE SODIUM 8 MG/ML IJ SOLN,RX-10265,CDM,S5000,HCPCS,250,RC,81284-0315-00,NDC,outpatient,5,ML,1398.02,978.614,AETNA [1000108],AETNA [100010801],,,76.8,,1073.68,0.222255,85118.57664,percent of total billed charges,,,
INDIGOTINDISULFONATE SODIUM 8 MG/ML IJ SOLN,RX-10265,CDM,S5000,HCPCS,250,RC,81284-0315-05,NDC,outpatient,5,ML,1398.02,978.614,AETNA [1000108],AETNA [100010801],,,76.8,,1073.68,0.222255,85118.57664,percent of total billed charges,,,
INDOCYANINE GREEN 25 MG IV SOLR,RX-10266,CDM,S5000,HCPCS,250,RC,70100-0424-02,NDC,outpatient,1,UN,501.97,351.379,AETNA [1000108],AETNA [100010801],,,76.8,,385.51,0.222255,85118.57664,percent of total billed charges,,,
INDOCYANINE GREEN 25 MG IV SOLR,RX-10266,CDM,S5000,HCPCS,250,RC,70100-0424-01,NDC,outpatient,1,UN,501.97,351.379,AETNA [1000108],AETNA [100010801],,,76.8,,385.51,0.222255,85118.57664,percent of total billed charges,,,
INDOMETHACIN SODIUM 1 MG IV SOLR,RX-10267,CDM,S5000,HCPCS,250,RC,63323-0659-03,NDC,outpatient,1,UN,1192.43,834.701,AETNA [1000108],AETNA [100010801],,,76.8,,915.79,0.222255,85118.57664,percent of total billed charges,,,
INSULIN NPH (HUMAN) (ISOPHANE) 100 UNIT/ML SC SUSP,RX-10284,CDM,S5000,HCPCS,259,RC,00002-8315-01,NDC,outpatient,10,ML,61.5,43.05,AETNA [1000108],AETNA [100010801],,,76.8,,47.23,0.222255,85118.57664,percent of total billed charges,,,
INSULIN REGULAR HUMAN 100 UNIT/ML IJ SOLN,RX-10289,CDM,S5000,HCPCS,259,RC,00002-8215-01,NDC,outpatient,10,ML,61.5,43.05,AETNA [1000108],AETNA [100010801],,,76.8,,47.23,0.222255,85118.57664,percent of total billed charges,,,
ACETAMINOPHEN 120 MG RE SUPP,RX-103,CDM,S5000,HCPCS,259,RC,45802-0732-30,NDC,outpatient,1,UN,1.69,1.183,AETNA [1000108],AETNA [100010801],,,76.8,,1.3,0.222255,85118.57664,percent of total billed charges,,,
BETAMETHASONE VALERATE 0.1 % EX CREA,RX-1031,CDM,S5000,HCPCS,259,RC,00713-0326-15,NDC,outpatient,15,GR,50.4,35.28,AETNA [1000108],AETNA [100010801],,,76.8,,38.71,0.222255,85118.57664,percent of total billed charges,,,
BETAMETHASONE VALERATE 0.1 % EX CREA,RX-1031,CDM,S5000,HCPCS,259,RC,00472-0370-15,NDC,outpatient,15,GR,93.12,65.184,AETNA [1000108],AETNA [100010801],,,76.8,,71.52,0.222255,85118.57664,percent of total billed charges,,,
BETAMETHASONE VALERATE 0.1 % EX LOTN,RX-1032,CDM,S5000,HCPCS,259,RC,00168-0041-60,NDC,outpatient,60,ML,267,186.9,AETNA [1000108],AETNA [100010801],,,76.8,,205.06,0.222255,85118.57664,percent of total billed charges,,,
ISOSORBIDE MONONITRATE 20 MG ORAL TABS,RX-10357,CDM,S5000,HCPCS,259,RC,00228-2620-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ISRADIPINE 5 MG ORAL CAPS,RX-10363,CDM,S5000,HCPCS,259,RC,16252-0540-01,NDC,outpatient,1,UN,8.59,6.013,AETNA [1000108],AETNA [100010801],,,76.8,,6.6,0.222255,85118.57664,percent of total billed charges,,,
ITRACONAZOLE 100 MG ORAL CAPS,RX-10364,CDM,S5000,HCPCS,259,RC,16714-0743-02,NDC,outpatient,1,UN,5.65,3.955,AETNA [1000108],AETNA [100010801],,,76.8,,4.34,0.222255,85118.57664,percent of total billed charges,,,
KETOCONAZOLE 2 % EX CREA,RX-10368,CDM,S5000,HCPCS,259,RC,00168-0099-15,NDC,outpatient,15,GR,22.57,15.799,AETNA [1000108],AETNA [100010801],,,76.8,,17.33,0.222255,85118.57664,percent of total billed charges,,,
KETOROLAC TROMETHAMINE 10 MG ORAL TABS,RX-10371,CDM,S5000,HCPCS,259,RC,00093-0314-01,NDC,outpatient,1,UN,4.33,3.031,AETNA [1000108],AETNA [100010801],,,76.8,,3.33,0.222255,85118.57664,percent of total billed charges,,,
KETOROLAC TROMETHAMINE 10 MG ORAL TABS,RX-10371,CDM,S5000,HCPCS,259,RC,70710-1710-01,NDC,outpatient,1,UN,3.63,2.541,AETNA [1000108],AETNA [100010801],,,76.8,,2.79,0.222255,85118.57664,percent of total billed charges,,,
LABETALOL HCL 100 MG ORAL TABS,RX-10373,CDM,S5000,HCPCS,259,RC,60687-0439-01,NDC,outpatient,1,UN,1.32,0.924,AETNA [1000108],AETNA [100010801],,,76.8,,1.01,0.222255,85118.57664,percent of total billed charges,,,
LABETALOL HCL 100 MG ORAL TABS,RX-10373,CDM,S5000,HCPCS,259,RC,60687-0439-11,NDC,outpatient,1,UN,1.32,0.924,AETNA [1000108],AETNA [100010801],,,76.8,,1.01,0.222255,85118.57664,percent of total billed charges,,,
LABETALOL HCL 200 MG ORAL TABS,RX-10374,CDM,S5000,HCPCS,259,RC,60687-0450-01,NDC,outpatient,1,UN,1.81,1.267,AETNA [1000108],AETNA [100010801],,,76.8,,1.39,0.222255,85118.57664,percent of total billed charges,,,
LABETALOL HCL 200 MG ORAL TABS,RX-10374,CDM,S5000,HCPCS,259,RC,60687-0450-11,NDC,outpatient,1,UN,1.81,1.267,AETNA [1000108],AETNA [100010801],,,76.8,,1.39,0.222255,85118.57664,percent of total billed charges,,,
AMMONIUM LACTATE 12 % EX LOTN,RX-10380,CDM,S5000,HCPCS,259,RC,00904-5984-26,NDC,outpatient,226,GR,13.08,9.156,AETNA [1000108],AETNA [100010801],,,76.8,,10.05,0.222255,85118.57664,percent of total billed charges,,,
AMMONIUM LACTATE 12 % EX LOTN,RX-10380,CDM,S5000,HCPCS,259,RC,16864-0000-18,NDC,outpatient,225,GR,41.06,28.742,AETNA [1000108],AETNA [100010801],,,76.8,,31.53,0.222255,85118.57664,percent of total billed charges,,,
AMMONIUM LACTATE 12 % EX LOTN,RX-10380,CDM,S5000,HCPCS,259,RC,30781-7098-79,NDC,outpatient,225,GR,41.06,28.742,AETNA [1000108],AETNA [100010801],,,76.8,,31.53,0.222255,85118.57664,percent of total billed charges,,,
AMMONIUM LACTATE 12 % EX LOTN,RX-10380,CDM,S5000,HCPCS,259,RC,51672-1300-05,NDC,outpatient,225,GR,61.08,42.756,AETNA [1000108],AETNA [100010801],,,76.8,,46.91,0.222255,85118.57664,percent of total billed charges,,,
AMMONIUM LACTATE 12 % EX LOTN,RX-10380,CDM,S5000,HCPCS,259,RC,63044-0484-09,NDC,outpatient,225,GR,29.04,20.328,AETNA [1000108],AETNA [100010801],,,76.8,,22.3,0.222255,85118.57664,percent of total billed charges,,,
TAMSULOSIN HCL 0.4 MG ORAL CAPS,RX-103890,CDM,S5000,HCPCS,259,RC,68084-0299-11,NDC,outpatient,1,UN,1.04,0.728,AETNA [1000108],AETNA [100010801],,,76.8,,0.8,0.222255,85118.57664,percent of total billed charges,,,
TAMSULOSIN HCL 0.4 MG ORAL CAPS,RX-103890,CDM,S5000,HCPCS,259,RC,57237-0014-01,NDC,outpatient,1,UN,1.24,0.868,AETNA [1000108],AETNA [100010801],,,76.8,,0.95,0.222255,85118.57664,percent of total billed charges,,,
TAMSULOSIN HCL 0.4 MG ORAL CAPS,RX-103890,CDM,S5000,HCPCS,259,RC,72603-0115-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
TAMSULOSIN HCL 0.4 MG ORAL CAPS,RX-103890,CDM,S5000,HCPCS,259,RC,68084-0299-01,NDC,outpatient,1,UN,1.04,0.728,AETNA [1000108],AETNA [100010801],,,76.8,,0.8,0.222255,85118.57664,percent of total billed charges,,,
TAMSULOSIN HCL 0.4 MG ORAL CAPS,RX-103890,CDM,S5000,HCPCS,259,RC,63739-0567-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ACETAMINOPHEN 325 MG RE SUPP,RX-104,CDM,S5000,HCPCS,259,RC,51672-2116-02,NDC,outpatient,1,UN,2.7,1.89,AETNA [1000108],AETNA [100010801],,,76.8,,2.07,0.222255,85118.57664,percent of total billed charges,,,
ACETAMINOPHEN 325 MG RE SUPP,RX-104,CDM,S5000,HCPCS,259,RC,51672-2116-04,NDC,outpatient,1,UN,1.99,1.393,AETNA [1000108],AETNA [100010801],,,76.8,,1.53,0.222255,85118.57664,percent of total billed charges,,,
LEVOTHYROXINE SODIUM 88 MCG ORAL TABS,RX-10403,CDM,S5000,HCPCS,259,RC,42292-0038-20,NDC,outpatient,1,UN,2.39,1.673,AETNA [1000108],AETNA [100010801],,,76.8,,1.84,0.222255,85118.57664,percent of total billed charges,,,
LEVOTHYROXINE SODIUM 88 MCG ORAL TABS,RX-10403,CDM,S5000,HCPCS,259,RC,60687-0486-01,NDC,outpatient,1,UN,2.07,1.449,AETNA [1000108],AETNA [100010801],,,76.8,,1.59,0.222255,85118.57664,percent of total billed charges,,,
LEVOTHYROXINE SODIUM 88 MCG ORAL TABS,RX-10403,CDM,S5000,HCPCS,259,RC,60687-0486-11,NDC,outpatient,1,UN,2.07,1.449,AETNA [1000108],AETNA [100010801],,,76.8,,1.59,0.222255,85118.57664,percent of total billed charges,,,
LEVOTHYROXINE SODIUM 88 MCG ORAL TABS,RX-10403,CDM,S5000,HCPCS,259,RC,42292-0038-01,NDC,outpatient,1,UN,2.39,1.673,AETNA [1000108],AETNA [100010801],,,76.8,,1.84,0.222255,85118.57664,percent of total billed charges,,,
LEVOTHYROXINE SODIUM 112 MCG ORAL TABS,RX-10404,CDM,S5000,HCPCS,259,RC,42292-0039-01,NDC,outpatient,1,UN,2.79,1.953,AETNA [1000108],AETNA [100010801],,,76.8,,2.14,0.222255,85118.57664,percent of total billed charges,,,
LEVOTHYROXINE SODIUM 112 MCG ORAL TABS,RX-10404,CDM,S5000,HCPCS,259,RC,42292-0039-20,NDC,outpatient,1,UN,2.79,1.953,AETNA [1000108],AETNA [100010801],,,76.8,,2.14,0.222255,85118.57664,percent of total billed charges,,,
LEVOTHYROXINE SODIUM 112 MCG ORAL TABS,RX-10404,CDM,S5000,HCPCS,259,RC,69238-1835-01,NDC,outpatient,1,UN,1.64,1.148,AETNA [1000108],AETNA [100010801],,,76.8,,1.26,0.222255,85118.57664,percent of total billed charges,,,
LEVOTHYROXINE SODIUM 137 MCG ORAL TABS,RX-10405,CDM,S5000,HCPCS,259,RC,00074-3727-90,NDC,outpatient,1,UN,6.49,4.543,AETNA [1000108],AETNA [100010801],,,76.8,,4.98,0.222255,85118.57664,percent of total billed charges,,,
LEVOTHYROXINE SODIUM 137 MCG ORAL TABS,RX-10405,CDM,S5000,HCPCS,259,RC,00378-1823-77,NDC,outpatient,1,UN,2.29,1.603,AETNA [1000108],AETNA [100010801],,,76.8,,1.76,0.222255,85118.57664,percent of total billed charges,,,
LEVOTHYROXINE SODIUM 137 MCG ORAL TABS,RX-10405,CDM,S5000,HCPCS,259,RC,00527-3287-46,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LEVOTHYROXINE SODIUM 175 MCG ORAL TABS,RX-10406,CDM,S5000,HCPCS,259,RC,42292-0040-20,NDC,outpatient,1,UN,3.47,2.429,AETNA [1000108],AETNA [100010801],,,76.8,,2.66,0.222255,85118.57664,percent of total billed charges,,,
LEVOTHYROXINE SODIUM 175 MCG ORAL TABS,RX-10406,CDM,S5000,HCPCS,259,RC,42292-0040-01,NDC,outpatient,1,UN,3.47,2.429,AETNA [1000108],AETNA [100010801],,,76.8,,2.66,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00409-4713-12,NDC,outpatient,5,ML,4.55,3.185,AETNA [1000108],AETNA [100010801],,,76.8,,3.49,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,55150-0159-74,NDC,outpatient,5,ML,3.68,2.576,AETNA [1000108],AETNA [100010801],,,76.8,,2.83,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,55150-0163-30,NDC,outpatient,30,ML,6.17,4.319,AETNA [1000108],AETNA [100010801],,,76.8,,4.74,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-08,NDC,outpatient,10,ML,24.48,17.136,AETNA [1000108],AETNA [100010801],,,76.8,,18.8,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-57,NDC,outpatient,5,ML,6.46,4.522,AETNA [1000108],AETNA [100010801],,,76.8,,4.96,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00143-9595-25,NDC,outpatient,5,ML,7.61,5.327,AETNA [1000108],AETNA [100010801],,,76.8,,5.84,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00409-4279-02,NDC,outpatient,30,ML,13.42,9.394,AETNA [1000108],AETNA [100010801],,,76.8,,10.31,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00409-4279-16,NDC,outpatient,30,ML,13.42,9.394,AETNA [1000108],AETNA [100010801],,,76.8,,10.31,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00409-4713-26,NDC,outpatient,5,ML,4.55,3.185,AETNA [1000108],AETNA [100010801],,,76.8,,3.49,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-04,NDC,outpatient,2,ML,4.85,3.395,AETNA [1000108],AETNA [100010801],,,76.8,,3.72,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00409-4713-02,NDC,outpatient,5,ML,4.55,3.185,AETNA [1000108],AETNA [100010801],,,76.8,,3.49,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-27,NDC,outpatient,2,ML,4.85,3.395,AETNA [1000108],AETNA [100010801],,,76.8,,3.72,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-97,NDC,outpatient,10,ML,24.48,17.136,AETNA [1000108],AETNA [100010801],,,76.8,,18.8,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00143-9595-01,NDC,outpatient,5,ML,7.61,5.327,AETNA [1000108],AETNA [100010801],,,76.8,,5.84,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-09,NDC,outpatient,5,ML,6.46,4.522,AETNA [1000108],AETNA [100010801],,,76.8,,4.96,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-4282-12,NDC,outpatient,10,ML,10.34,7.238,AETNA [1000108],AETNA [100010801],,,76.8,,7.94,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,55150-0165-05,NDC,outpatient,5,ML,4.63,3.241,AETNA [1000108],AETNA [100010801],,,76.8,,3.56,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0495-27,NDC,outpatient,2,ML,8.69,6.083,AETNA [1000108],AETNA [100010801],,,76.8,,6.67,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0496-03,NDC,outpatient,10,ML,28.48,19.936,AETNA [1000108],AETNA [100010801],,,76.8,,21.87,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-2066-05,NDC,outpatient,5,ML,11.34,7.938,AETNA [1000108],AETNA [100010801],,,76.8,,8.71,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-4282-11,NDC,outpatient,2,ML,4.57,3.199,AETNA [1000108],AETNA [100010801],,,76.8,,3.51,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-2066-10,NDC,outpatient,5,ML,11.34,7.938,AETNA [1000108],AETNA [100010801],,,76.8,,8.71,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-4282-01,NDC,outpatient,2,ML,4.57,3.199,AETNA [1000108],AETNA [100010801],,,76.8,,3.51,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0495-07,NDC,outpatient,5,ML,6.46,4.522,AETNA [1000108],AETNA [100010801],,,76.8,,4.96,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0495-09,NDC,outpatient,2,ML,8.69,6.083,AETNA [1000108],AETNA [100010801],,,76.8,,6.67,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0496-97,NDC,outpatient,10,ML,28.48,19.936,AETNA [1000108],AETNA [100010801],,,76.8,,21.87,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00143-9594-01,NDC,outpatient,5,ML,7.61,5.327,AETNA [1000108],AETNA [100010801],,,76.8,,5.84,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00143-9594-25,NDC,outpatient,5,ML,7.61,5.327,AETNA [1000108],AETNA [100010801],,,76.8,,5.84,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-4282-02,NDC,outpatient,10,ML,10.34,7.238,AETNA [1000108],AETNA [100010801],,,76.8,,7.94,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-4282-25,NDC,outpatient,2,ML,4.57,3.199,AETNA [1000108],AETNA [100010801],,,76.8,,3.51,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,55150-0164-02,NDC,outpatient,2,ML,4.16,2.912,AETNA [1000108],AETNA [100010801],,,76.8,,3.19,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0495-04,NDC,outpatient,5,ML,6.46,4.522,AETNA [1000108],AETNA [100010801],,,76.8,,4.96,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE-EPINEPHRINE 0.5 %-1:200000 IJ SOLN,RX-10426,CDM,S5000,HCPCS,250,RC,00409-3177-01,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE-EPINEPHRINE 0.5 %-1:200000 IJ SOLN,RX-10426,CDM,S5000,HCPCS,250,RC,63323-0481-57,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE-EPINEPHRINE 0.5 %-1:200000 IJ SOLN,RX-10426,CDM,S5000,HCPCS,250,RC,63323-0481-01,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE-EPINEPHRINE 0.5 %-1:200000 IJ SOLN,RX-10426,CDM,S5000,HCPCS,250,RC,00409-3177-16,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,00409-3178-01,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,00409-3178-16,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,00409-3178-17,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,63323-0482-03,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,63323-0482-17,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,63323-0482-01,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,63323-0482-27,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,00409-3178-02,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE-EPINEPHRINE 1.5 %-1:200000 IJ SOLN,RX-10429,CDM,S5000,HCPCS,250,RC,63323-0488-07,NDC,outpatient,30,ML,30.31,21.217,AETNA [1000108],AETNA [100010801],,,76.8,,23.28,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE-EPINEPHRINE 1.5 %-1:200000 IJ SOLN,RX-10429,CDM,S5000,HCPCS,250,RC,63323-0488-37,NDC,outpatient,30,ML,30.31,21.217,AETNA [1000108],AETNA [100010801],,,76.8,,23.28,0.222255,85118.57664,percent of total billed charges,,,
BETHANECHOL CHLORIDE 10 MG ORAL TABS,RX-1043,CDM,S5000,HCPCS,259,RC,00832-0511-89,NDC,outpatient,1,UN,1.83,1.281,AETNA [1000108],AETNA [100010801],,,76.8,,1.41,0.222255,85118.57664,percent of total billed charges,,,
BETHANECHOL CHLORIDE 10 MG ORAL TABS,RX-1043,CDM,S5000,HCPCS,259,RC,00832-0511-01,NDC,outpatient,1,UN,1.83,1.281,AETNA [1000108],AETNA [100010801],,,76.8,,1.41,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN,RX-10430,CDM,S5000,HCPCS,250,RC,00409-3182-11,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN,RX-10430,CDM,S5000,HCPCS,250,RC,00409-3182-01,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN,RX-10430,CDM,S5000,HCPCS,250,RC,63323-0483-03,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN,RX-10430,CDM,S5000,HCPCS,250,RC,63323-0483-27,NDC,outpatient,1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN,RX-10431,CDM,S5000,HCPCS,250,RC,63323-0489-02,NDC,outpatient,20,ML,30.18,21.126,AETNA [1000108],AETNA [100010801],,,76.8,,23.18,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN,RX-10431,CDM,S5000,HCPCS,250,RC,00409-3183-01,NDC,outpatient,20,ML,16.35,11.445,AETNA [1000108],AETNA [100010801],,,76.8,,12.56,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN,RX-10431,CDM,S5000,HCPCS,250,RC,00409-3183-11,NDC,outpatient,20,ML,16.35,11.445,AETNA [1000108],AETNA [100010801],,,76.8,,12.56,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN,RX-10431,CDM,S5000,HCPCS,250,RC,63323-0489-17,NDC,outpatient,10,ML,19.13,13.391,AETNA [1000108],AETNA [100010801],,,76.8,,14.69,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN,RX-10431,CDM,S5000,HCPCS,250,RC,63323-0489-27,NDC,outpatient,20,ML,30.18,21.126,AETNA [1000108],AETNA [100010801],,,76.8,,23.18,0.222255,85118.57664,percent of total billed charges,,,
BETHANECHOL CHLORIDE 25 MG ORAL TABS,RX-1044,CDM,S5000,HCPCS,259,RC,00832-0512-89,NDC,outpatient,1,UN,2.51,1.757,AETNA [1000108],AETNA [100010801],,,76.8,,1.93,0.222255,85118.57664,percent of total billed charges,,,
BETHANECHOL CHLORIDE 25 MG ORAL TABS,RX-1044,CDM,S5000,HCPCS,259,RC,00832-0512-01,NDC,outpatient,1,UN,2.51,1.757,AETNA [1000108],AETNA [100010801],,,76.8,,1.93,0.222255,85118.57664,percent of total billed charges,,,
LIOTHYRONINE SODIUM 10 MCG/ML IV SOLN,RX-10442,CDM,S5000,HCPCS,250,RC,39822-0151-01,NDC,outpatient,1,ML,1739.29,1217.503,AETNA [1000108],AETNA [100010801],,,76.8,,1335.77,0.222255,85118.57664,percent of total billed charges,,,
LIOTHYRONINE SODIUM 5 MCG ORAL TABS,RX-10443,CDM,S5000,HCPCS,259,RC,00093-2179-01,NDC,outpatient,1,UN,2.45,1.715,AETNA [1000108],AETNA [100010801],,,76.8,,1.88,0.222255,85118.57664,percent of total billed charges,,,
LIOTHYRONINE SODIUM 5 MCG ORAL TABS,RX-10443,CDM,S5000,HCPCS,259,RC,68382-0582-01,NDC,outpatient,1,UN,2.45,1.715,AETNA [1000108],AETNA [100010801],,,76.8,,1.88,0.222255,85118.57664,percent of total billed charges,,,
LISINOPRIL 10 MG ORAL TABS,RX-10449,CDM,S5000,HCPCS,259,RC,00904-6798-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LISINOPRIL 10 MG ORAL TABS,RX-10449,CDM,S5000,HCPCS,259,RC,68180-0980-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LISINOPRIL 10 MG ORAL TABS,RX-10449,CDM,S5000,HCPCS,259,RC,68180-0980-03,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LISINOPRIL 5 MG ORAL TABS,RX-10451,CDM,S5000,HCPCS,259,RC,00904-6797-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LITHIUM CARBONATE ER 300 MG ORAL TBCR,RX-10454,CDM,S5000,HCPCS,259,RC,68084-0640-01,NDC,outpatient,1,UN,1.52,1.064,AETNA [1000108],AETNA [100010801],,,76.8,,1.17,0.222255,85118.57664,percent of total billed charges,,,
LITHIUM CARBONATE ER 300 MG ORAL TBCR,RX-10454,CDM,S5000,HCPCS,259,RC,68084-0640-11,NDC,outpatient,1,UN,1.52,1.064,AETNA [1000108],AETNA [100010801],,,76.8,,1.17,0.222255,85118.57664,percent of total billed charges,,,
LITHIUM CARBONATE ER 450 MG ORAL TBCR,RX-10455,CDM,S5000,HCPCS,259,RC,68084-0655-01,NDC,outpatient,1,UN,2.55,1.785,AETNA [1000108],AETNA [100010801],,,76.8,,1.96,0.222255,85118.57664,percent of total billed charges,,,
LITHIUM CARBONATE ER 450 MG ORAL TBCR,RX-10455,CDM,S5000,HCPCS,259,RC,68084-0655-11,NDC,outpatient,1,UN,2.55,1.785,AETNA [1000108],AETNA [100010801],,,76.8,,1.96,0.222255,85118.57664,percent of total billed charges,,,
LITHIUM CARBONATE ER 450 MG ORAL TBCR,RX-10455,CDM,S5000,HCPCS,259,RC,68462-0224-01,NDC,outpatient,1,UN,1,0.7,AETNA [1000108],AETNA [100010801],,,76.8,,0.77,0.222255,85118.57664,percent of total billed charges,,,
TRANEXAMIC ACID 650 MG ORAL TABS,RX-104576,CDM,S5000,HCPCS,259,RC,50268-0772-11,NDC,outpatient,1,UN,11.87,8.309,AETNA [1000108],AETNA [100010801],,,76.8,,9.12,0.222255,85118.57664,percent of total billed charges,,,
TRANEXAMIC ACID 650 MG ORAL TABS,RX-104576,CDM,S5000,HCPCS,259,RC,69918-0301-30,NDC,outpatient,1,UN,6.2,4.34,AETNA [1000108],AETNA [100010801],,,76.8,,4.76,0.222255,85118.57664,percent of total billed charges,,,
TRANEXAMIC ACID 650 MG ORAL TABS,RX-104576,CDM,S5000,HCPCS,259,RC,62559-0265-30,NDC,outpatient,1,UN,10.97,7.679,AETNA [1000108],AETNA [100010801],,,76.8,,8.42,0.222255,85118.57664,percent of total billed charges,,,
TRANEXAMIC ACID 650 MG ORAL TABS,RX-104576,CDM,S5000,HCPCS,259,RC,50268-0772-13,NDC,outpatient,1,UN,11.87,8.309,AETNA [1000108],AETNA [100010801],,,76.8,,9.12,0.222255,85118.57664,percent of total billed charges,,,
RIFAXIMIN 550 MG ORAL TABS,RX-104604,CDM,S5000,HCPCS,259,RC,65649-0303-03,NDC,outpatient,1,UN,223.91,156.737,AETNA [1000108],AETNA [100010801],,,76.8,,171.96,0.222255,85118.57664,percent of total billed charges,,,
RIFAXIMIN 550 MG ORAL TABS,RX-104604,CDM,S5000,HCPCS,259,RC,65649-0303-02,NDC,outpatient,1,UN,223.91,156.737,AETNA [1000108],AETNA [100010801],,,76.8,,171.96,0.222255,85118.57664,percent of total billed charges,,,
LORATADINE 10 MG ORAL TABS,RX-10466,CDM,S5000,HCPCS,259,RC,00904-6852-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LORATADINE 10 MG ORAL TABS,RX-10466,CDM,S5000,HCPCS,259,RC,51079-0246-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LORATADINE 10 MG ORAL TABS,RX-10466,CDM,S5000,HCPCS,259,RC,51079-0246-20,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
SIROLIMUS 0.5 MG ORAL TABS,RX-104764,CDM,S5000,HCPCS,259,RC,68382-0520-01,NDC,outpatient,1,UN,18.05,12.635,AETNA [1000108],AETNA [100010801],,,76.8,,13.86,0.222255,85118.57664,percent of total billed charges,,,
SIROLIMUS 0.5 MG ORAL TABS,RX-104764,CDM,S5000,HCPCS,259,RC,59762-1001-01,NDC,outpatient,1,UN,20.25,14.175,AETNA [1000108],AETNA [100010801],,,76.8,,15.55,0.222255,85118.57664,percent of total billed charges,,,
MAFENIDE ACETATE 85 MG/GM EX CREA,RX-10478,CDM,S5000,HCPCS,259,RC,16571-0723-60,NDC,outpatient,56.7,GR,282.85,197.995,AETNA [1000108],AETNA [100010801],,,76.8,,217.23,0.222255,85118.57664,percent of total billed charges,,,
CAFFEINE CITRATE 60 MG/3ML ORAL SOLN,RX-104787,CDM,S5000,HCPCS,259,RC,51754-0501-03,NDC,outpatient,3,ML,27.32,19.124,AETNA [1000108],AETNA [100010801],,,76.8,,20.98,0.222255,85118.57664,percent of total billed charges,,,
CAFFEINE CITRATE 60 MG/3ML ORAL SOLN,RX-104787,CDM,S5000,HCPCS,259,RC,63323-0406-01,NDC,outpatient,3,ML,31.83,22.281,AETNA [1000108],AETNA [100010801],,,76.8,,24.45,0.222255,85118.57664,percent of total billed charges,,,
CAFFEINE CITRATE 60 MG/3ML ORAL SOLN,RX-104787,CDM,S5000,HCPCS,259,RC,63323-0406-03,NDC,outpatient,3,ML,31.83,22.281,AETNA [1000108],AETNA [100010801],,,76.8,,24.45,0.222255,85118.57664,percent of total billed charges,,,
CAFFEINE CITRATE 60 MG/3ML ORAL SOLN,RX-104787,CDM,S5000,HCPCS,259,RC,25021-0602-03,NDC,outpatient,3,ML,26.44,18.508,AETNA [1000108],AETNA [100010801],,,76.8,,20.31,0.222255,85118.57664,percent of total billed charges,,,
MAGNESIUM OXIDE 140 MG ORAL CAPS,RX-10490,CDM,S5000,HCPCS,259,RC,60569-0495-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ACETAMINOPHEN 650 MG RE SUPP,RX-105,CDM,S5000,HCPCS,259,RC,45802-0730-30,NDC,outpatient,1,UN,1.95,1.365,AETNA [1000108],AETNA [100010801],,,76.8,,1.5,0.222255,85118.57664,percent of total billed charges,,,
ACETAMINOPHEN 650 MG RE SUPP,RX-105,CDM,S5000,HCPCS,259,RC,45802-0730-33,NDC,outpatient,1,UN,1.05,0.735,AETNA [1000108],AETNA [100010801],,,76.8,,0.81,0.222255,85118.57664,percent of total billed charges,,,
MEDIUM CHAIN TRIGLYCERIDES ORAL OIL,RX-10518,CDM,S5000,HCPCS,259,RC,41679-0365-03,NDC,outpatient,946,ML,46.31,32.417,AETNA [1000108],AETNA [100010801],,,76.8,,35.57,0.222255,85118.57664,percent of total billed charges,,,
MEDIUM CHAIN TRIGLYCERIDES ORAL OIL,RX-10518,CDM,S5000,HCPCS,259,RC,41679-0365-13,NDC,outpatient,946,ML,46.31,32.417,AETNA [1000108],AETNA [100010801],,,76.8,,35.57,0.222255,85118.57664,percent of total billed charges,,,
MEDIUM CHAIN TRIGLYCERIDES ORAL OIL,RX-10518,CDM,S5000,HCPCS,259,RC,99999-0003-04,NDC,outpatient,1,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
MEDIUM CHAIN TRIGLYCERIDES ORAL OIL,RX-10518,CDM,S5000,HCPCS,259,RC,99999-0003-05,NDC,outpatient,15,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
MESALAMINE ER 250 MG ORAL CPCR,RX-10533,CDM,S5000,HCPCS,259,RC,54092-0189-81,NDC,outpatient,1,UN,12.49,8.743,AETNA [1000108],AETNA [100010801],,,76.8,,9.59,0.222255,85118.57664,percent of total billed charges,,,
BROMOCRIPTINE MESYLATE 0.8 MG ORAL TABS,RX-105409,CDM,S5000,HCPCS,259,RC,68012-0258-20,NDC,outpatient,1,UN,23.23,16.261,AETNA [1000108],AETNA [100010801],,,76.8,,17.84,0.222255,85118.57664,percent of total billed charges,,,
METFORMIN HCL 500 MG ORAL TABS,RX-10544,CDM,S5000,HCPCS,259,RC,60687-0155-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
METFORMIN HCL 500 MG ORAL TABS,RX-10544,CDM,S5000,HCPCS,259,RC,00904-7162-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
METFORMIN HCL 500 MG ORAL TABS,RX-10544,CDM,S5000,HCPCS,259,RC,60687-0155-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LACOSAMIDE 10 MG/ML ORAL SOLN,RX-105482,CDM,S5000,HCPCS,259,RC,99999-0001-42,NDC,outpatient,20,ML,187.97,131.579,AETNA [1000108],AETNA [100010801],,,76.8,,144.36,0.222255,85118.57664,percent of total billed charges,,,
LACOSAMIDE 10 MG/ML ORAL SOLN,RX-105482,CDM,S5000,HCPCS,259,RC,00131-5410-72,NDC,outpatient,5,ML,47,32.9,AETNA [1000108],AETNA [100010801],,,76.8,,36.1,0.222255,85118.57664,percent of total billed charges,,,
METHENAMINE HIPPURATE 1 G ORAL TABS,RX-10549,CDM,S5000,HCPCS,259,RC,60687-0694-11,NDC,outpatient,1,UN,7.92,5.544,AETNA [1000108],AETNA [100010801],,,76.8,,6.08,0.222255,85118.57664,percent of total billed charges,,,
METHENAMINE HIPPURATE 1 G ORAL TABS,RX-10549,CDM,S5000,HCPCS,259,RC,60687-0694-21,NDC,outpatient,1,UN,7.92,5.544,AETNA [1000108],AETNA [100010801],,,76.8,,6.08,0.222255,85118.57664,percent of total billed charges,,,
METHIMAZOLE 5 MG ORAL TABS,RX-10553,CDM,S5000,HCPCS,259,RC,60687-0669-11,NDC,outpatient,1,UN,2.25,1.575,AETNA [1000108],AETNA [100010801],,,76.8,,1.73,0.222255,85118.57664,percent of total billed charges,,,
METHIMAZOLE 5 MG ORAL TABS,RX-10553,CDM,S5000,HCPCS,259,RC,23155-0070-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
METHIMAZOLE 5 MG ORAL TABS,RX-10553,CDM,S5000,HCPCS,259,RC,60687-0669-01,NDC,outpatient,1,UN,2.25,1.575,AETNA [1000108],AETNA [100010801],,,76.8,,1.73,0.222255,85118.57664,percent of total billed charges,,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-1746-70,NDC,outpatient,10,ML,17.38,12.166,AETNA [1000108],AETNA [100010801],,,76.8,,13.35,0.222255,85118.57664,percent of total billed charges,,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,63323-0468-02,NDC,outpatient,30,ML,28.84,20.188,AETNA [1000108],AETNA [100010801],,,76.8,,22.15,0.222255,85118.57664,percent of total billed charges,,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,63323-0468-17,NDC,outpatient,10,ML,18.16,12.712,AETNA [1000108],AETNA [100010801],,,76.8,,13.95,0.222255,85118.57664,percent of total billed charges,,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-1746-30,NDC,outpatient,30,ML,36.85,25.795,AETNA [1000108],AETNA [100010801],,,76.8,,28.3,0.222255,85118.57664,percent of total billed charges,,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-1746-71,NDC,outpatient,30,ML,36.85,25.795,AETNA [1000108],AETNA [100010801],,,76.8,,28.3,0.222255,85118.57664,percent of total billed charges,,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-9042-01,NDC,outpatient,10,ML,18.15,12.705,AETNA [1000108],AETNA [100010801],,,76.8,,13.94,0.222255,85118.57664,percent of total billed charges,,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-9042-11,NDC,outpatient,10,ML,18.15,12.705,AETNA [1000108],AETNA [100010801],,,76.8,,13.94,0.222255,85118.57664,percent of total billed charges,,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-1746-10,NDC,outpatient,10,ML,17.38,12.166,AETNA [1000108],AETNA [100010801],,,76.8,,13.35,0.222255,85118.57664,percent of total billed charges,,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,63323-0468-01,NDC,outpatient,10,ML,18.16,12.712,AETNA [1000108],AETNA [100010801],,,76.8,,13.95,0.222255,85118.57664,percent of total billed charges,,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,63323-0468-37,NDC,outpatient,30,ML,28.84,20.188,AETNA [1000108],AETNA [100010801],,,76.8,,22.15,0.222255,85118.57664,percent of total billed charges,,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,00409-9045-01,NDC,outpatient,10,ML,11.21,7.847,AETNA [1000108],AETNA [100010801],,,76.8,,8.61,0.222255,85118.57664,percent of total billed charges,,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-04,NDC,outpatient,10,ML,18.61,13.027,AETNA [1000108],AETNA [100010801],,,76.8,,14.29,0.222255,85118.57664,percent of total billed charges,,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-31,NDC,outpatient,30,ML,25.5,17.85,AETNA [1000108],AETNA [100010801],,,76.8,,19.58,0.222255,85118.57664,percent of total billed charges,,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-37,NDC,outpatient,30,ML,30.98,21.686,AETNA [1000108],AETNA [100010801],,,76.8,,23.79,0.222255,85118.57664,percent of total billed charges,,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,00409-9045-17,NDC,outpatient,30,ML,11.88,8.316,AETNA [1000108],AETNA [100010801],,,76.8,,9.12,0.222255,85118.57664,percent of total billed charges,,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,00409-9045-16,NDC,outpatient,30,ML,11.88,8.316,AETNA [1000108],AETNA [100010801],,,76.8,,9.12,0.222255,85118.57664,percent of total billed charges,,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-01,NDC,outpatient,30,ML,30.98,21.686,AETNA [1000108],AETNA [100010801],,,76.8,,23.79,0.222255,85118.57664,percent of total billed charges,,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,00409-9045-11,NDC,outpatient,10,ML,11.21,7.847,AETNA [1000108],AETNA [100010801],,,76.8,,8.61,0.222255,85118.57664,percent of total billed charges,,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-02,NDC,outpatient,30,ML,25.5,17.85,AETNA [1000108],AETNA [100010801],,,76.8,,19.58,0.222255,85118.57664,percent of total billed charges,,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-17,NDC,outpatient,10,ML,18.61,13.027,AETNA [1000108],AETNA [100010801],,,76.8,,14.29,0.222255,85118.57664,percent of total billed charges,,,
METHYLERGONOVINE MALEATE 0.2 MG ORAL TABS,RX-10572,CDM,S5000,HCPCS,259,RC,60687-0813-11,NDC,outpatient,1,UN,190.6,133.42,AETNA [1000108],AETNA [100010801],,,76.8,,146.38,0.222255,85118.57664,percent of total billed charges,,,
METHYLERGONOVINE MALEATE 0.2 MG ORAL TABS,RX-10572,CDM,S5000,HCPCS,259,RC,69238-1605-02,NDC,outpatient,1,UN,78.51,54.957,AETNA [1000108],AETNA [100010801],,,76.8,,60.3,0.222255,85118.57664,percent of total billed charges,,,
METHYLERGONOVINE MALEATE 0.2 MG ORAL TABS,RX-10572,CDM,S5000,HCPCS,259,RC,60687-0813-94,NDC,outpatient,1,UN,190.6,133.42,AETNA [1000108],AETNA [100010801],,,76.8,,146.38,0.222255,85118.57664,percent of total billed charges,,,
METHYLERGONOVINE MALEATE 0.2 MG ORAL TABS,RX-10572,CDM,S5000,HCPCS,259,RC,69238-1605-08,NDC,outpatient,1,UN,71.96,50.372,AETNA [1000108],AETNA [100010801],,,76.8,,55.27,0.222255,85118.57664,percent of total billed charges,,,
METOLAZONE 2.5 MG ORAL TABS,RX-10587,CDM,S5000,HCPCS,259,RC,51079-0023-20,NDC,outpatient,1,UN,11.25,7.875,AETNA [1000108],AETNA [100010801],,,76.8,,8.64,0.222255,85118.57664,percent of total billed charges,,,
METOLAZONE 2.5 MG ORAL TABS,RX-10587,CDM,S5000,HCPCS,259,RC,51079-0023-01,NDC,outpatient,1,UN,11.25,7.875,AETNA [1000108],AETNA [100010801],,,76.8,,8.64,0.222255,85118.57664,percent of total billed charges,,,
METOLAZONE 5 MG ORAL TABS,RX-10588,CDM,S5000,HCPCS,259,RC,51079-0024-20,NDC,outpatient,1,UN,12.79,8.953,AETNA [1000108],AETNA [100010801],,,76.8,,9.82,0.222255,85118.57664,percent of total billed charges,,,
METOLAZONE 5 MG ORAL TABS,RX-10588,CDM,S5000,HCPCS,259,RC,51079-0024-01,NDC,outpatient,1,UN,12.79,8.953,AETNA [1000108],AETNA [100010801],,,76.8,,9.82,0.222255,85118.57664,percent of total billed charges,,,
METRONIDAZOLE 0.75 % VA GEL,RX-10592,CDM,S5000,HCPCS,259,RC,16714-0557-01,NDC,outpatient,70,GR,66.67,46.669,AETNA [1000108],AETNA [100010801],,,76.8,,51.2,0.222255,85118.57664,percent of total billed charges,,,
MEXILETINE HCL 150 MG ORAL CAPS,RX-10595,CDM,S5000,HCPCS,259,RC,50742-0239-01,NDC,outpatient,1,UN,1.39,0.973,AETNA [1000108],AETNA [100010801],,,76.8,,1.07,0.222255,85118.57664,percent of total billed charges,,,
MEXILETINE HCL 150 MG ORAL CAPS,RX-10595,CDM,S5000,HCPCS,259,RC,62559-0820-01,NDC,outpatient,1,UN,1.38,0.966,AETNA [1000108],AETNA [100010801],,,76.8,,1.06,0.222255,85118.57664,percent of total billed charges,,,
MEXILETINE HCL 150 MG ORAL CAPS,RX-10595,CDM,S5000,HCPCS,259,RC,00093-8739-01,NDC,outpatient,1,UN,2.26,1.582,AETNA [1000108],AETNA [100010801],,,76.8,,1.74,0.222255,85118.57664,percent of total billed charges,,,
MEXILETINE HCL 200 MG ORAL CAPS,RX-10596,CDM,S5000,HCPCS,259,RC,00093-8740-01,NDC,outpatient,1,UN,3.1,2.17,AETNA [1000108],AETNA [100010801],,,76.8,,2.38,0.222255,85118.57664,percent of total billed charges,,,
MICONAZOLE NITRATE 2 % EX POWD,RX-10599,CDM,S5000,HCPCS,259,RC,53329-0169-79,NDC,outpatient,85,GR,16.27,11.389,AETNA [1000108],AETNA [100010801],,,76.8,,12.5,0.222255,85118.57664,percent of total billed charges,,,
MICONAZOLE NITRATE 2 % EX POWD,RX-10599,CDM,S5000,HCPCS,259,RC,11701-0038-16,NDC,outpatient,85,GR,25.73,18.011,AETNA [1000108],AETNA [100010801],,,76.8,,19.76,0.222255,85118.57664,percent of total billed charges,,,
MICROFIBRILLAR COLL HEMOSTAT EX PADS,RX-10605,CDM,S5000,HCPCS,259,RC,53276-1010-08,NDC,outpatient,1,UN,496.85,347.795,AETNA [1000108],AETNA [100010801],,,76.8,,381.58,0.222255,85118.57664,percent of total billed charges,,,
MICROFIBRILLAR COLL HEMOSTAT EX POWD,RX-10606,CDM,S5000,HCPCS,250,RC,53276-1010-02,NDC,outpatient,1,GR,993.69,695.583,AETNA [1000108],AETNA [100010801],,,76.8,,763.15,0.222255,85118.57664,percent of total billed charges,,,
ULIPRISTAL ACETATE 30 MG ORAL TABS,RX-106079,CDM,S5000,HCPCS,259,RC,73302-0456-01,NDC,outpatient,1,UN,159.36,111.552,AETNA [1000108],AETNA [100010801],,,76.8,,122.39,0.222255,85118.57664,percent of total billed charges,,,
MIDODRINE HCL 2.5 MG ORAL TABS,RX-10609,CDM,S5000,HCPCS,259,RC,00245-0211-11,NDC,outpatient,1,UN,1.99,1.393,AETNA [1000108],AETNA [100010801],,,76.8,,1.53,0.222255,85118.57664,percent of total billed charges,,,
MIDODRINE HCL 2.5 MG ORAL TABS,RX-10609,CDM,S5000,HCPCS,259,RC,00378-1901-01,NDC,outpatient,1,UN,2.12,1.484,AETNA [1000108],AETNA [100010801],,,76.8,,1.63,0.222255,85118.57664,percent of total billed charges,,,
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,63739-0145-10,NDC,outpatient,1,UN,1.05,0.735,AETNA [1000108],AETNA [100010801],,,76.8,,0.81,0.222255,85118.57664,percent of total billed charges,,,
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,00245-0212-89,NDC,outpatient,1,UN,2.4,1.68,AETNA [1000108],AETNA [100010801],,,76.8,,1.84,0.222255,85118.57664,percent of total billed charges,,,
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,51079-0453-01,NDC,outpatient,1,UN,1.17,0.819,AETNA [1000108],AETNA [100010801],,,76.8,,0.9,0.222255,85118.57664,percent of total billed charges,,,
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,00904-6818-61,NDC,outpatient,1,UN,2.24,1.568,AETNA [1000108],AETNA [100010801],,,76.8,,1.72,0.222255,85118.57664,percent of total billed charges,,,
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,51079-0453-20,NDC,outpatient,1,UN,1.17,0.819,AETNA [1000108],AETNA [100010801],,,76.8,,0.9,0.222255,85118.57664,percent of total billed charges,,,
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,00245-0212-01,NDC,outpatient,1,UN,2.4,1.68,AETNA [1000108],AETNA [100010801],,,76.8,,1.84,0.222255,85118.57664,percent of total billed charges,,,
NEOMYCIN-POLYMYXIN-DEXAMETH 3.5-10000-0.1 OP SUSP,RX-106248,CDM,S5000,HCPCS,259,RC,24208-0830-60,NDC,outpatient,5,ML,59.63,41.741,AETNA [1000108],AETNA [100010801],,,76.8,,45.8,0.222255,85118.57664,percent of total billed charges,,,
NEOMYCIN-POLYMYXIN-DEXAMETH 3.5-10000-0.1 OP OINT,RX-106249,CDM,S5000,HCPCS,259,RC,61314-0631-36,NDC,outpatient,3.5,GR,69.78,48.846,AETNA [1000108],AETNA [100010801],,,76.8,,53.59,0.222255,85118.57664,percent of total billed charges,,,
MISOPROSTOL 100 MCG ORAL TABS,RX-10628,CDM,S5000,HCPCS,259,RC,00025-1451-34,NDC,outpatient,1,UN,17.24,12.068,AETNA [1000108],AETNA [100010801],,,76.8,,13.24,0.222255,85118.57664,percent of total billed charges,,,
MISOPROSTOL 100 MCG ORAL TABS,RX-10628,CDM,S5000,HCPCS,259,RC,60687-0735-01,NDC,outpatient,1,UN,9.27,6.489,AETNA [1000108],AETNA [100010801],,,76.8,,7.12,0.222255,85118.57664,percent of total billed charges,,,
MISOPROSTOL 100 MCG ORAL TABS,RX-10628,CDM,S5000,HCPCS,259,RC,60687-0735-11,NDC,outpatient,1,UN,9.27,6.489,AETNA [1000108],AETNA [100010801],,,76.8,,7.12,0.222255,85118.57664,percent of total billed charges,,,
MISOPROSTOL 100 MCG ORAL TABS,RX-10628,CDM,S5000,HCPCS,259,RC,59762-5007-01,NDC,outpatient,1,UN,2.08,1.456,AETNA [1000108],AETNA [100010801],,,76.8,,1.6,0.222255,85118.57664,percent of total billed charges,,,
MISOPROSTOL 200 MCG ORAL TABS,RX-10629,CDM,S5000,HCPCS,259,RC,60687-0746-11,NDC,outpatient,1,UN,7.19,5.033,AETNA [1000108],AETNA [100010801],,,76.8,,5.52,0.222255,85118.57664,percent of total billed charges,,,
MISOPROSTOL 200 MCG ORAL TABS,RX-10629,CDM,S5000,HCPCS,259,RC,60687-0746-01,NDC,outpatient,1,UN,7.19,5.033,AETNA [1000108],AETNA [100010801],,,76.8,,5.52,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL (PF) 0.5 % IJ SOLN,RX-106363,CDM,S5000,HCPCS,250,RC,00409-4278-16,NDC,outpatient,50,ML,10.28,7.196,AETNA [1000108],AETNA [100010801],,,76.8,,7.9,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL (PF) 0.5 % IJ SOLN,RX-106363,CDM,S5000,HCPCS,250,RC,00409-4278-01,NDC,outpatient,50,ML,10.28,7.196,AETNA [1000108],AETNA [100010801],,,76.8,,7.9,0.222255,85118.57664,percent of total billed charges,,,
DABIGATRAN ETEXILATE MESYLATE 75 MG ORAL CAPS,RX-106490,CDM,S5000,HCPCS,259,RC,00597-0355-61,NDC,outpatient,1,UN,12.92,9.044,AETNA [1000108],AETNA [100010801],,,76.8,,9.92,0.222255,85118.57664,percent of total billed charges,,,
DABIGATRAN ETEXILATE MESYLATE 75 MG ORAL CAPS,RX-106490,CDM,S5000,HCPCS,259,RC,00597-0355-56,NDC,outpatient,1,UN,12.92,9.044,AETNA [1000108],AETNA [100010801],,,76.8,,9.92,0.222255,85118.57664,percent of total billed charges,,,
DABIGATRAN ETEXILATE MESYLATE 150 MG ORAL CAPS,RX-106491,CDM,S5000,HCPCS,259,RC,00597-0360-55,NDC,outpatient,1,UN,12.92,9.044,AETNA [1000108],AETNA [100010801],,,76.8,,9.92,0.222255,85118.57664,percent of total billed charges,,,
DABIGATRAN ETEXILATE MESYLATE 150 MG ORAL CAPS,RX-106491,CDM,S5000,HCPCS,259,RC,00597-0360-82,NDC,outpatient,1,UN,12.92,9.044,AETNA [1000108],AETNA [100010801],,,76.8,,9.92,0.222255,85118.57664,percent of total billed charges,,,
MORPHINE SULFATE (CONCENTRATE) 20 MG/ML ORAL SOLN,RX-10655,CDM,S5000,HCPCS,259,RC,00406-8003-30,NDC,outpatient,0.25,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
MORPHINE SULFATE (CONCENTRATE) 20 MG/ML ORAL SOLN,RX-10655,CDM,S5000,HCPCS,259,RC,99999-0002-18,NDC,outpatient,1,ML,2.33,1.631,AETNA [1000108],AETNA [100010801],,,76.8,,1.79,0.222255,85118.57664,percent of total billed charges,,,
MUPIROCIN 2 % EX OINT,RX-10674,CDM,S5000,HCPCS,259,RC,45802-0112-22,NDC,outpatient,22,GR,13.61,9.527,AETNA [1000108],AETNA [100010801],,,76.8,,10.45,0.222255,85118.57664,percent of total billed charges,,,
MUPIROCIN 2 % EX OINT,RX-10674,CDM,S5000,HCPCS,259,RC,68462-0180-22,NDC,outpatient,22,GR,18.61,13.027,AETNA [1000108],AETNA [100010801],,,76.8,,14.29,0.222255,85118.57664,percent of total billed charges,,,
MUPIROCIN 2 % EX OINT,RX-10674,CDM,S5000,HCPCS,259,RC,51672-1312-00,NDC,outpatient,22,GR,11.07,7.749,AETNA [1000108],AETNA [100010801],,,76.8,,8.5,0.222255,85118.57664,percent of total billed charges,,,
NABUMETONE 500 MG ORAL TABS,RX-10676,CDM,S5000,HCPCS,259,RC,60687-0630-11,NDC,outpatient,1,UN,3.85,2.695,AETNA [1000108],AETNA [100010801],,,76.8,,2.96,0.222255,85118.57664,percent of total billed charges,,,
NABUMETONE 500 MG ORAL TABS,RX-10676,CDM,S5000,HCPCS,259,RC,60687-0630-21,NDC,outpatient,1,UN,3.85,2.695,AETNA [1000108],AETNA [100010801],,,76.8,,2.96,0.222255,85118.57664,percent of total billed charges,,,
NABUMETONE 500 MG ORAL TABS,RX-10676,CDM,S5000,HCPCS,259,RC,00591-3670-01,NDC,outpatient,1,UN,1.2,0.84,AETNA [1000108],AETNA [100010801],,,76.8,,0.92,0.222255,85118.57664,percent of total billed charges,,,
NALTREXONE HCL 50 MG ORAL TABS,RX-10685,CDM,S5000,HCPCS,259,RC,68084-0291-11,NDC,outpatient,1,UN,8.68,6.076,AETNA [1000108],AETNA [100010801],,,76.8,,6.67,0.222255,85118.57664,percent of total billed charges,,,
NALTREXONE HCL 50 MG ORAL TABS,RX-10685,CDM,S5000,HCPCS,259,RC,00904-7036-04,NDC,outpatient,1,UN,7.95,5.565,AETNA [1000108],AETNA [100010801],,,76.8,,6.11,0.222255,85118.57664,percent of total billed charges,,,
NALTREXONE HCL 50 MG ORAL TABS,RX-10685,CDM,S5000,HCPCS,259,RC,00406-1170-03,NDC,outpatient,1,UN,4.49,3.143,AETNA [1000108],AETNA [100010801],,,76.8,,3.45,0.222255,85118.57664,percent of total billed charges,,,
NALTREXONE HCL 50 MG ORAL TABS,RX-10685,CDM,S5000,HCPCS,259,RC,68084-0291-21,NDC,outpatient,1,UN,8.68,6.076,AETNA [1000108],AETNA [100010801],,,76.8,,6.67,0.222255,85118.57664,percent of total billed charges,,,
NICARDIPINE HCL 20 MG ORAL CAPS,RX-10712,CDM,S5000,HCPCS,259,RC,62559-0205-90,NDC,outpatient,1,UN,35.49,24.843,AETNA [1000108],AETNA [100010801],,,76.8,,27.26,0.222255,85118.57664,percent of total billed charges,,,
NICARDIPINE HCL 20 MG ORAL CAPS,RX-10712,CDM,S5000,HCPCS,259,RC,68462-0120-90,NDC,outpatient,1,UN,18.98,13.286,AETNA [1000108],AETNA [100010801],,,76.8,,14.58,0.222255,85118.57664,percent of total billed charges,,,
NICARDIPINE HCL 30 MG ORAL CAPS,RX-10713,CDM,S5000,HCPCS,259,RC,68462-0121-90,NDC,outpatient,1,UN,27.58,19.306,AETNA [1000108],AETNA [100010801],,,76.8,,21.18,0.222255,85118.57664,percent of total billed charges,,,
NICARDIPINE HCL 30 MG ORAL CAPS,RX-10713,CDM,S5000,HCPCS,259,RC,42806-0502-09,NDC,outpatient,1,UN,24.73,17.311,AETNA [1000108],AETNA [100010801],,,76.8,,18.99,0.222255,85118.57664,percent of total billed charges,,,
NICOTINE POLACRILEX 2 MG MT GUM,RX-10717,CDM,S5000,HCPCS,259,RC,00536-3029-23,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
NICOTINE POLACRILEX 2 MG MT GUM,RX-10717,CDM,S5000,HCPCS,259,RC,00536-1362-23,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
NICOTINE POLACRILEX 4 MG MT GUM,RX-10718,CDM,S5000,HCPCS,259,RC,00536-1372-23,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
NICOTINE POLACRILEX 4 MG MT GUM,RX-10718,CDM,S5000,HCPCS,259,RC,00135-0242-08,NDC,outpatient,1,UN,2.37,1.659,AETNA [1000108],AETNA [100010801],,,76.8,,1.82,0.222255,85118.57664,percent of total billed charges,,,
NIMODIPINE 30 MG ORAL CAPS,RX-10722,CDM,S5000,HCPCS,259,RC,23155-0512-00,NDC,outpatient,1,UN,5.11,3.577,AETNA [1000108],AETNA [100010801],,,76.8,,3.92,0.222255,85118.57664,percent of total billed charges,,,
NIMODIPINE 30 MG ORAL CAPS,RX-10722,CDM,S5000,HCPCS,259,RC,23155-0512-11,NDC,outpatient,1,UN,5.11,3.577,AETNA [1000108],AETNA [100010801],,,76.8,,3.92,0.222255,85118.57664,percent of total billed charges,,,
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,50268-0625-15,NDC,outpatient,1,UN,7.34,5.138,AETNA [1000108],AETNA [100010801],,,76.8,,5.64,0.222255,85118.57664,percent of total billed charges,,,
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,00904-7137-61,NDC,outpatient,1,UN,6.96,4.872,AETNA [1000108],AETNA [100010801],,,76.8,,5.35,0.222255,85118.57664,percent of total billed charges,,,
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,16714-0439-01,NDC,outpatient,1,UN,7.17,5.019,AETNA [1000108],AETNA [100010801],,,76.8,,5.51,0.222255,85118.57664,percent of total billed charges,,,
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,50268-0625-11,NDC,outpatient,1,UN,7.34,5.138,AETNA [1000108],AETNA [100010801],,,76.8,,5.64,0.222255,85118.57664,percent of total billed charges,,,
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,60687-0633-01,NDC,outpatient,1,UN,9.67,6.769,AETNA [1000108],AETNA [100010801],,,76.8,,7.43,0.222255,85118.57664,percent of total billed charges,,,
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,60687-0633-11,NDC,outpatient,1,UN,9.67,6.769,AETNA [1000108],AETNA [100010801],,,76.8,,7.43,0.222255,85118.57664,percent of total billed charges,,,
BUPRENORPHINE 5 MCG/HR TD PTWK,RX-107660,CDM,S5000,HCPCS,259,RC,50742-0372-04,NDC,outpatient,1,UN,146.92,102.844,AETNA [1000108],AETNA [100010801],,,76.8,,112.83,0.222255,85118.57664,percent of total billed charges,,,
BUPRENORPHINE 5 MCG/HR TD PTWK,RX-107660,CDM,S5000,HCPCS,259,RC,50742-0372-01,NDC,outpatient,1,UN,146.92,102.844,AETNA [1000108],AETNA [100010801],,,76.8,,112.83,0.222255,85118.57664,percent of total billed charges,,,
BUPRENORPHINE 5 MCG/HR TD PTWK,RX-107660,CDM,S5000,HCPCS,259,RC,42858-0750-40,NDC,outpatient,1,UN,220.77,154.539,AETNA [1000108],AETNA [100010801],,,76.8,,169.55,0.222255,85118.57664,percent of total billed charges,,,
BUPRENORPHINE 10 MCG/HR TD PTWK,RX-107661,CDM,S5000,HCPCS,259,RC,00093-3657-21,NDC,outpatient,1,UN,232.52,162.764,AETNA [1000108],AETNA [100010801],,,76.8,,178.58,0.222255,85118.57664,percent of total billed charges,,,
BUPRENORPHINE 10 MCG/HR TD PTWK,RX-107661,CDM,S5000,HCPCS,259,RC,00093-3657-40,NDC,outpatient,1,UN,232.52,162.764,AETNA [1000108],AETNA [100010801],,,76.8,,178.58,0.222255,85118.57664,percent of total billed charges,,,
OLSALAZINE SODIUM 250 MG ORAL CAPS,RX-10773,CDM,S5000,HCPCS,259,RC,00037-6860-10,NDC,outpatient,1,UN,61.39,42.973,AETNA [1000108],AETNA [100010801],,,76.8,,47.15,0.222255,85118.57664,percent of total billed charges,,,
VALPROIC ACID 250 MG/5ML ORAL SOLN,RX-107838,CDM,S5000,HCPCS,259,RC,00121-4675-05,NDC,outpatient,5,ML,7.15,5.005,AETNA [1000108],AETNA [100010801],,,76.8,,5.49,0.222255,85118.57664,percent of total billed charges,,,
VALPROIC ACID 250 MG/5ML ORAL SOLN,RX-107838,CDM,S5000,HCPCS,259,RC,00121-4675-40,NDC,outpatient,5,ML,7.15,5.005,AETNA [1000108],AETNA [100010801],,,76.8,,5.49,0.222255,85118.57664,percent of total billed charges,,,
VALPROIC ACID 250 MG/5ML ORAL SOLN,RX-107838,CDM,S5000,HCPCS,259,RC,00121-4675-00,NDC,outpatient,5,ML,4.92,3.444,AETNA [1000108],AETNA [100010801],,,76.8,,3.78,0.222255,85118.57664,percent of total billed charges,,,
VALPROIC ACID 250 MG/5ML ORAL SOLN,RX-107838,CDM,S5000,HCPCS,259,RC,99999-0001-41,NDC,outpatient,5,ML,2.27,1.589,AETNA [1000108],AETNA [100010801],,,76.8,,1.74,0.222255,85118.57664,percent of total billed charges,,,
BISACODYL 5 MG ORAL TBEC,RX-1079,CDM,S5000,HCPCS,259,RC,00904-6407-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
BISACODYL 10 MG RE SUPP,RX-1080,CDM,S5000,HCPCS,259,RC,00574-7050-50,NDC,outpatient,1,UN,1.02,0.714,AETNA [1000108],AETNA [100010801],,,76.8,,0.78,0.222255,85118.57664,percent of total billed charges,,,
BISACODYL 10 MG RE SUPP,RX-1080,CDM,S5000,HCPCS,259,RC,58980-0415-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
BISACODYL 10 MG RE SUPP,RX-1080,CDM,S5000,HCPCS,259,RC,58980-0415-50,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
BISACODYL 10 MG RE SUPP,RX-1080,CDM,S5000,HCPCS,259,RC,81421-0021-03,NDC,outpatient,1,UN,3.38,2.366,AETNA [1000108],AETNA [100010801],,,76.8,,2.6,0.222255,85118.57664,percent of total billed charges,,,
BISACODYL 10 MG RE SUPP,RX-1080,CDM,S5000,HCPCS,259,RC,00574-7050-12,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
TESTOSTERONE 25 MG/2.5GM (1%) TD GEL,RX-108038,CDM,S5000,HCPCS,259,RC,64380-0151-01,NDC,outpatient,2.5,GR,13.58,9.506,AETNA [1000108],AETNA [100010801],,,76.8,,10.43,0.222255,85118.57664,percent of total billed charges,,,
TESTOSTERONE 25 MG/2.5GM (1%) TD GEL,RX-108038,CDM,S5000,HCPCS,259,RC,64380-0151-02,NDC,outpatient,2.5,GR,13.58,9.506,AETNA [1000108],AETNA [100010801],,,76.8,,10.43,0.222255,85118.57664,percent of total billed charges,,,
TESTOSTERONE 50 MG/5GM (1%) TD GEL,RX-108039,CDM,S5000,HCPCS,259,RC,00591-3524-26,NDC,outpatient,5,GR,13.67,9.569,AETNA [1000108],AETNA [100010801],,,76.8,,10.5,0.222255,85118.57664,percent of total billed charges,,,
TESTOSTERONE 50 MG/5GM (1%) TD GEL,RX-108039,CDM,S5000,HCPCS,259,RC,00591-3524-30,NDC,outpatient,5,GR,13.67,9.569,AETNA [1000108],AETNA [100010801],,,76.8,,10.5,0.222255,85118.57664,percent of total billed charges,,,
OXYCODONE HCL 100 MG/5ML ORAL CONC,RX-10812,CDM,S5000,HCPCS,259,RC,00406-8557-30,NDC,outpatient,30,ML,133.24,93.268,AETNA [1000108],AETNA [100010801],,,76.8,,102.33,0.222255,85118.57664,percent of total billed charges,,,
OXYCODONE HCL 100 MG/5ML ORAL CONC,RX-10812,CDM,S5000,HCPCS,259,RC,99999-0002-27,NDC,outpatient,1,ML,7.21,5.047,AETNA [1000108],AETNA [100010801],,,76.8,,5.54,0.222255,85118.57664,percent of total billed charges,,,
OXYCODONE HCL 5 MG/5ML ORAL SOLN,RX-10813,CDM,S5000,HCPCS,259,RC,64950-0354-55,NDC,outpatient,5,ML,8.79,6.153,AETNA [1000108],AETNA [100010801],,,76.8,,6.75,0.222255,85118.57664,percent of total billed charges,,,
OXYCODONE HCL 5 MG/5ML ORAL SOLN,RX-10813,CDM,S5000,HCPCS,259,RC,64950-0354-05,NDC,outpatient,5,ML,8.79,6.153,AETNA [1000108],AETNA [100010801],,,76.8,,6.75,0.222255,85118.57664,percent of total billed charges,,,
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,00904-6966-61,NDC,outpatient,1,UN,1.01,0.707,AETNA [1000108],AETNA [100010801],,,76.8,,0.78,0.222255,85118.57664,percent of total billed charges,,,
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,68084-0354-01,NDC,outpatient,1,UN,1.65,1.155,AETNA [1000108],AETNA [100010801],,,76.8,,1.27,0.222255,85118.57664,percent of total billed charges,,,
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,00406-0552-62,NDC,outpatient,1,UN,1.17,0.819,AETNA [1000108],AETNA [100010801],,,76.8,,0.9,0.222255,85118.57664,percent of total billed charges,,,
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,42858-0001-10,NDC,outpatient,1,UN,1,0.7,AETNA [1000108],AETNA [100010801],,,76.8,,0.77,0.222255,85118.57664,percent of total billed charges,,,
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,10702-0018-50,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,68084-0354-11,NDC,outpatient,1,UN,1.65,1.155,AETNA [1000108],AETNA [100010801],,,76.8,,1.27,0.222255,85118.57664,percent of total billed charges,,,
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,00406-0552-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,00406-0552-23,NDC,outpatient,1,UN,1.17,0.819,AETNA [1000108],AETNA [100010801],,,76.8,,0.9,0.222255,85118.57664,percent of total billed charges,,,
PAROXETINE HCL 20 MG ORAL TABS,RX-10855,CDM,S5000,HCPCS,259,RC,63739-0963-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
BISMUTH SUBCARBONATE POWD,RX-1086,CDM,S5000,HCPCS,259,RC,62991-2844-02,NDC,outpatient,100,GR,276.06,193.242,AETNA [1000108],AETNA [100010801],,,76.8,,212.01,0.222255,85118.57664,percent of total billed charges,,,
BISMUTH SUBSALICYLATE 262 MG/15ML ORAL SUSP,RX-1090,CDM,S5000,HCPCS,259,RC,37000-0475-08,NDC,outpatient,10,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
BISMUTH SUBSALICYLATE 262 MG/15ML ORAL SUSP,RX-1090,CDM,S5000,HCPCS,259,RC,99999-0001-91,NDC,outpatient,30,ML,2.01,1.407,AETNA [1000108],AETNA [100010801],,,76.8,,1.54,0.222255,85118.57664,percent of total billed charges,,,
PERMETHRIN 5 % EX CREA,RX-10917,CDM,S5000,HCPCS,259,RC,00472-0242-60,NDC,outpatient,60,GR,76.37,53.459,AETNA [1000108],AETNA [100010801],,,76.8,,58.65,0.222255,85118.57664,percent of total billed charges,,,
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,60687-0786-11,NDC,outpatient,1,UN,7.84,5.488,AETNA [1000108],AETNA [100010801],,,76.8,,6.02,0.222255,85118.57664,percent of total billed charges,,,
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,60687-0786-21,NDC,outpatient,1,UN,7.84,5.488,AETNA [1000108],AETNA [100010801],,,76.8,,6.02,0.222255,85118.57664,percent of total billed charges,,,
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,00310-0095-30,NDC,outpatient,1,UN,54.75,38.325,AETNA [1000108],AETNA [100010801],,,76.8,,42.05,0.222255,85118.57664,percent of total billed charges,,,
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,00378-1905-77,NDC,outpatient,1,UN,17.44,12.208,AETNA [1000108],AETNA [100010801],,,76.8,,13.39,0.222255,85118.57664,percent of total billed charges,,,
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,42571-0259-30,NDC,outpatient,1,UN,4.47,3.129,AETNA [1000108],AETNA [100010801],,,76.8,,3.43,0.222255,85118.57664,percent of total billed charges,,,
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,31722-0623-90,NDC,outpatient,1,UN,7.15,5.005,AETNA [1000108],AETNA [100010801],,,76.8,,5.49,0.222255,85118.57664,percent of total billed charges,,,
PHENOXYBENZAMINE HCL 10 MG ORAL CAPS,RX-10945,CDM,S5000,HCPCS,259,RC,66993-0066-02,NDC,outpatient,1,UN,73.53,51.471,AETNA [1000108],AETNA [100010801],,,76.8,,56.47,0.222255,85118.57664,percent of total billed charges,,,
PHENTOLAMINE MESYLATE 5 MG IJ SOLR,RX-10947,CDM,S5000,HCPCS,259,RC,00143-9564-10,NDC,outpatient,1,UN,1233.54,863.478,AETNA [1000108],AETNA [100010801],,,76.8,,947.36,0.222255,85118.57664,percent of total billed charges,,,
PHENTOLAMINE MESYLATE 5 MG IJ SOLR,RX-10947,CDM,S5000,HCPCS,259,RC,00143-9564-01,NDC,outpatient,1,UN,1208.89,846.223,AETNA [1000108],AETNA [100010801],,,76.8,,928.43,0.222255,85118.57664,percent of total billed charges,,,
LINAGLIPTIN 5 MG ORAL TABS,RX-109773,CDM,S5000,HCPCS,259,RC,00597-0140-61,NDC,outpatient,1,UN,56.14,39.298,AETNA [1000108],AETNA [100010801],,,76.8,,43.12,0.222255,85118.57664,percent of total billed charges,,,
RILPIVIRINE HCL 25 MG ORAL TABS,RX-109909,CDM,S5000,HCPCS,259,RC,59676-0278-01,NDC,outpatient,1,UN,209.04,146.328,AETNA [1000108],AETNA [100010801],,,76.8,,160.54,0.222255,85118.57664,percent of total billed charges,,,
PHENYTOIN 50 MG ORAL CHEW,RX-11018,CDM,S5000,HCPCS,259,RC,60687-0156-25,NDC,outpatient,1,UN,4.05,2.835,AETNA [1000108],AETNA [100010801],,,76.8,,3.11,0.222255,85118.57664,percent of total billed charges,,,
PHENYTOIN 50 MG ORAL CHEW,RX-11018,CDM,S5000,HCPCS,259,RC,00904-7199-07,NDC,outpatient,1,UN,3.73,2.611,AETNA [1000108],AETNA [100010801],,,76.8,,2.86,0.222255,85118.57664,percent of total billed charges,,,
PHENYTOIN 50 MG ORAL CHEW,RX-11018,CDM,S5000,HCPCS,259,RC,60687-0156-95,NDC,outpatient,1,UN,4.05,2.835,AETNA [1000108],AETNA [100010801],,,76.8,,3.11,0.222255,85118.57664,percent of total billed charges,,,
PHENYTOIN SODIUM EXTENDED 30 MG ORAL CAPS,RX-11019,CDM,S5000,HCPCS,259,RC,00071-3740-66,NDC,outpatient,1,UN,5.97,4.179,AETNA [1000108],AETNA [100010801],,,76.8,,4.58,0.222255,85118.57664,percent of total billed charges,,,
PHYTONADIONE 5 MG ORAL TABS,RX-11024,CDM,S5000,HCPCS,259,RC,60687-0381-11,NDC,outpatient,1,UN,227.6,159.32,AETNA [1000108],AETNA [100010801],,,76.8,,174.8,0.222255,85118.57664,percent of total billed charges,,,
PHYTONADIONE 5 MG ORAL TABS,RX-11024,CDM,S5000,HCPCS,259,RC,60687-0381-94,NDC,outpatient,1,UN,227.6,159.32,AETNA [1000108],AETNA [100010801],,,76.8,,174.8,0.222255,85118.57664,percent of total billed charges,,,
RIVAROXABAN 10 MG ORAL TABS,RX-110250,CDM,S5000,HCPCS,259,RC,50458-0580-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
RIVAROXABAN 10 MG ORAL TABS,RX-110250,CDM,S5000,HCPCS,259,RC,50458-0580-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
FIDAXOMICIN 200 MG ORAL TABS,RX-110360,CDM,S5000,HCPCS,259,RC,52015-0080-01,NDC,outpatient,1,UN,501.77,351.239,AETNA [1000108],AETNA [100010801],,,76.8,,385.36,0.222255,85118.57664,percent of total billed charges,,,
TICAGRELOR 90 MG ORAL TABS,RX-110427,CDM,S5000,HCPCS,259,RC,00186-0777-39,NDC,outpatient,1,UN,30.77,21.539,AETNA [1000108],AETNA [100010801],,,76.8,,23.63,0.222255,85118.57664,percent of total billed charges,,,
CALCIUM POLYCARBOPHIL 625 MG ORAL TABS,RX-11046,CDM,S5000,HCPCS,259,RC,00536-4306-05,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
CALCIUM POLYCARBOPHIL 625 MG ORAL TABS,RX-11046,CDM,S5000,HCPCS,259,RC,00904-2500-91,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
POLYSACCHARIDE IRON COMPLEX 150 MG ORAL CAPS,RX-11050,CDM,S5000,HCPCS,259,RC,00904-5395-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
POTASSIUM CITRATE ER 10 MEQ (1080 MG) ORAL TBCR,RX-11083,CDM,S5000,HCPCS,259,RC,00178-0610-01,NDC,outpatient,1,UN,7.92,5.544,AETNA [1000108],AETNA [100010801],,,76.8,,6.08,0.222255,85118.57664,percent of total billed charges,,,
POTASSIUM CITRATE ER 10 MEQ (1080 MG) ORAL TBCR,RX-11083,CDM,S5000,HCPCS,259,RC,68084-0850-32,NDC,outpatient,1,UN,8.47,5.929,AETNA [1000108],AETNA [100010801],,,76.8,,6.5,0.222255,85118.57664,percent of total billed charges,,,
POTASSIUM CITRATE ER 10 MEQ (1080 MG) ORAL TBCR,RX-11083,CDM,S5000,HCPCS,259,RC,68084-0850-33,NDC,outpatient,1,UN,8.47,5.929,AETNA [1000108],AETNA [100010801],,,76.8,,6.5,0.222255,85118.57664,percent of total billed charges,,,
OSELTAMIVIR PHOSPHATE 6 MG/ML ORAL SUSR,RX-110998,CDM,S5000,HCPCS,259,RC,68180-0678-01,NDC,outpatient,60,ML,26.7,18.69,AETNA [1000108],AETNA [100010801],,,76.8,,20.51,0.222255,85118.57664,percent of total billed charges,,,
OSELTAMIVIR PHOSPHATE 6 MG/ML ORAL SUSR,RX-110998,CDM,S5000,HCPCS,259,RC,27241-0139-09,NDC,outpatient,60,ML,35.52,24.864,AETNA [1000108],AETNA [100010801],,,76.8,,27.28,0.222255,85118.57664,percent of total billed charges,,,
OSELTAMIVIR PHOSPHATE 6 MG/ML ORAL SUSR,RX-110998,CDM,S5000,HCPCS,259,RC,99999-0000-41,NDC,outpatient,5,ML,52.63,36.841,AETNA [1000108],AETNA [100010801],,,76.8,,40.42,0.222255,85118.57664,percent of total billed charges,,,
OSELTAMIVIR PHOSPHATE 6 MG/ML ORAL SUSR,RX-110998,CDM,S5000,HCPCS,259,RC,00004-0822-05,NDC,outpatient,60,ML,624.52,437.164,AETNA [1000108],AETNA [100010801],,,76.8,,479.63,0.222255,85118.57664,percent of total billed charges,,,
PRAVASTATIN SODIUM 10 MG ORAL TABS,RX-11110,CDM,S5000,HCPCS,259,RC,00904-5891-61,NDC,outpatient,1,UN,1.35,0.945,AETNA [1000108],AETNA [100010801],,,76.8,,1.04,0.222255,85118.57664,percent of total billed charges,,,
PRAVASTATIN SODIUM 20 MG ORAL TABS,RX-11111,CDM,S5000,HCPCS,259,RC,00904-5892-61,NDC,outpatient,1,UN,2.3,1.61,AETNA [1000108],AETNA [100010801],,,76.8,,1.77,0.222255,85118.57664,percent of total billed charges,,,
PRAVASTATIN SODIUM 20 MG ORAL TABS,RX-11111,CDM,S5000,HCPCS,259,RC,51079-0458-20,NDC,outpatient,1,UN,2.39,1.673,AETNA [1000108],AETNA [100010801],,,76.8,,1.84,0.222255,85118.57664,percent of total billed charges,,,
PRAVASTATIN SODIUM 20 MG ORAL TABS,RX-11111,CDM,S5000,HCPCS,259,RC,51079-0458-01,NDC,outpatient,1,UN,2.39,1.673,AETNA [1000108],AETNA [100010801],,,76.8,,1.84,0.222255,85118.57664,percent of total billed charges,,,
PRIMIDONE 50 MG ORAL TABS,RX-11129,CDM,S5000,HCPCS,259,RC,68084-0202-11,NDC,outpatient,1,UN,2.64,1.848,AETNA [1000108],AETNA [100010801],,,76.8,,2.03,0.222255,85118.57664,percent of total billed charges,,,
PRIMIDONE 50 MG ORAL TABS,RX-11129,CDM,S5000,HCPCS,259,RC,68084-0202-01,NDC,outpatient,1,UN,2.64,1.848,AETNA [1000108],AETNA [100010801],,,76.8,,2.03,0.222255,85118.57664,percent of total billed charges,,,
PROCHLORPERAZINE 25 MG RE SUPP,RX-11138,CDM,S5000,HCPCS,259,RC,00574-7226-12,NDC,outpatient,1,UN,26.18,18.326,AETNA [1000108],AETNA [100010801],,,76.8,,20.11,0.222255,85118.57664,percent of total billed charges,,,
PROMETHAZINE HCL 12.5 MG RE SUPP,RX-11143,CDM,S5000,HCPCS,259,RC,00713-0536-12,NDC,outpatient,1,UN,43.38,30.366,AETNA [1000108],AETNA [100010801],,,76.8,,33.32,0.222255,85118.57664,percent of total billed charges,,,
PROMETHAZINE HCL 12.5 MG RE SUPP,RX-11143,CDM,S5000,HCPCS,259,RC,00713-0536-06,NDC,outpatient,1,UN,43.38,30.366,AETNA [1000108],AETNA [100010801],,,76.8,,33.32,0.222255,85118.57664,percent of total billed charges,,,
PROMETHAZINE HCL 25 MG RE SUPP,RX-11144,CDM,S5000,HCPCS,259,RC,00713-0526-12,NDC,outpatient,1,UN,43.38,30.366,AETNA [1000108],AETNA [100010801],,,76.8,,33.32,0.222255,85118.57664,percent of total billed charges,,,
PROPAFENONE HCL 150 MG ORAL TABS,RX-11146,CDM,S5000,HCPCS,259,RC,00591-0582-01,NDC,outpatient,1,UN,1.95,1.365,AETNA [1000108],AETNA [100010801],,,76.8,,1.5,0.222255,85118.57664,percent of total billed charges,,,
PROPAFENONE HCL 225 MG ORAL TABS,RX-11147,CDM,S5000,HCPCS,259,RC,00591-0583-01,NDC,outpatient,1,UN,1.32,0.924,AETNA [1000108],AETNA [100010801],,,76.8,,1.01,0.222255,85118.57664,percent of total billed charges,,,
PYRIDOSTIGMINE BROMIDE 60 MG ORAL TABS,RX-11239,CDM,S5000,HCPCS,259,RC,00904-6622-61,NDC,outpatient,1,UN,3.64,2.548,AETNA [1000108],AETNA [100010801],,,76.8,,2.8,0.222255,85118.57664,percent of total billed charges,,,
PYRIDOSTIGMINE BROMIDE 60 MG ORAL TABS,RX-11239,CDM,S5000,HCPCS,259,RC,68382-0659-06,NDC,outpatient,1,UN,1.59,1.113,AETNA [1000108],AETNA [100010801],,,76.8,,1.22,0.222255,85118.57664,percent of total billed charges,,,
PYRIDOSTIGMINE BROMIDE ER 180 MG ORAL TBCR,RX-11240,CDM,S5000,HCPCS,259,RC,47781-0335-30,NDC,outpatient,1,UN,71.76,50.232,AETNA [1000108],AETNA [100010801],,,76.8,,55.11,0.222255,85118.57664,percent of total billed charges,,,
PYRIMETHAMINE 25 MG ORAL TABS,RX-11246,CDM,S5000,HCPCS,259,RC,43598-0672-01,NDC,outpatient,1,UN,1019.51,713.657,AETNA [1000108],AETNA [100010801],,,76.8,,782.98,0.222255,85118.57664,percent of total billed charges,,,
POLIDOCANOL 1 % IV SOLN,RX-112481,CDM,S5000,HCPCS,250,RC,67850-0141-05,NDC,outpatient,2,ML,92.93,65.051,AETNA [1000108],AETNA [100010801],,,76.8,,71.37,0.222255,85118.57664,percent of total billed charges,,,
POLIDOCANOL 1 % IV SOLN,RX-112481,CDM,S5000,HCPCS,250,RC,67850-0141-00,NDC,outpatient,2,ML,92.93,65.051,AETNA [1000108],AETNA [100010801],,,76.8,,71.37,0.222255,85118.57664,percent of total billed charges,,,
RAMIPRIL 1.25 MG ORAL CAPS,RX-11258,CDM,S5000,HCPCS,259,RC,68382-0144-06,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
RAMIPRIL 5 MG ORAL CAPS,RX-11261,CDM,S5000,HCPCS,259,RC,57237-0224-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
RAMIPRIL 5 MG ORAL CAPS,RX-11261,CDM,S5000,HCPCS,259,RC,68382-0146-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
CLOBAZAM 10 MG ORAL TABS,RX-112703,CDM,S5000,HCPCS,259,RC,60687-0423-21,NDC,outpatient,1,UN,9.33,6.531,AETNA [1000108],AETNA [100010801],,,76.8,,7.17,0.222255,85118.57664,percent of total billed charges,,,
CLOBAZAM 10 MG ORAL TABS,RX-112703,CDM,S5000,HCPCS,259,RC,68180-0157-01,NDC,outpatient,1,UN,2.47,1.729,AETNA [1000108],AETNA [100010801],,,76.8,,1.9,0.222255,85118.57664,percent of total billed charges,,,
CLOBAZAM 10 MG ORAL TABS,RX-112703,CDM,S5000,HCPCS,259,RC,60687-0423-11,NDC,outpatient,1,UN,9.33,6.531,AETNA [1000108],AETNA [100010801],,,76.8,,7.17,0.222255,85118.57664,percent of total billed charges,,,
RIVAROXABAN 15 MG ORAL TABS,RX-112834,CDM,S5000,HCPCS,259,RC,50458-0578-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
RIVAROXABAN 15 MG ORAL TABS,RX-112834,CDM,S5000,HCPCS,259,RC,50458-0578-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
RIBAVIRIN 200 MG ORAL CAPS,RX-11286,CDM,S5000,HCPCS,259,RC,65862-0290-84,NDC,outpatient,1,UN,5.94,4.158,AETNA [1000108],AETNA [100010801],,,76.8,,4.56,0.222255,85118.57664,percent of total billed charges,,,
RIFABUTIN 150 MG ORAL CAPS,RX-11290,CDM,S5000,HCPCS,259,RC,59762-1350-01,NDC,outpatient,1,UN,47.58,33.306,AETNA [1000108],AETNA [100010801],,,76.8,,36.54,0.222255,85118.57664,percent of total billed charges,,,
RIFAMPIN 600 MG IV SOLR,RX-11291,CDM,S5000,HCPCS,250,RC,00068-0597-01,NDC,outpatient,1,UN,360.5,252.35,AETNA [1000108],AETNA [100010801],,,76.8,,276.86,0.222255,85118.57664,percent of total billed charges,,,
RIFAMPIN 600 MG IV SOLR,RX-11291,CDM,S5000,HCPCS,250,RC,67457-0445-60,NDC,outpatient,1,UN,242,169.4,AETNA [1000108],AETNA [100010801],,,76.8,,185.86,0.222255,85118.57664,percent of total billed charges,,,
RIFAMPIN 600 MG IV SOLR,RX-11291,CDM,S5000,HCPCS,250,RC,63323-0351-20,NDC,outpatient,1,UN,246.71,172.697,AETNA [1000108],AETNA [100010801],,,76.8,,189.47,0.222255,85118.57664,percent of total billed charges,,,
RIFAMPIN 150 MG ORAL CAPS,RX-11292,CDM,S5000,HCPCS,259,RC,60687-0575-11,NDC,outpatient,1,UN,10.17,7.119,AETNA [1000108],AETNA [100010801],,,76.8,,7.81,0.222255,85118.57664,percent of total billed charges,,,
RIFAMPIN 150 MG ORAL CAPS,RX-11292,CDM,S5000,HCPCS,259,RC,60687-0575-21,NDC,outpatient,1,UN,10.17,7.119,AETNA [1000108],AETNA [100010801],,,76.8,,7.81,0.222255,85118.57664,percent of total billed charges,,,
RIFAMPIN 300 MG ORAL CAPS,RX-11293,CDM,S5000,HCPCS,259,RC,60687-0586-01,NDC,outpatient,1,UN,6.25,4.375,AETNA [1000108],AETNA [100010801],,,76.8,,4.8,0.222255,85118.57664,percent of total billed charges,,,
RIFAMPIN 300 MG ORAL CAPS,RX-11293,CDM,S5000,HCPCS,259,RC,60687-0586-11,NDC,outpatient,1,UN,6.25,4.375,AETNA [1000108],AETNA [100010801],,,76.8,,4.8,0.222255,85118.57664,percent of total billed charges,,,
ACETAZOLAMIDE 250 MG ORAL TABS,RX-113,CDM,S5000,HCPCS,259,RC,60687-0619-01,NDC,outpatient,1,UN,9.15,6.405,AETNA [1000108],AETNA [100010801],,,76.8,,7.03,0.222255,85118.57664,percent of total billed charges,,,
ACETAZOLAMIDE 250 MG ORAL TABS,RX-113,CDM,S5000,HCPCS,259,RC,60687-0619-11,NDC,outpatient,1,UN,9.15,6.405,AETNA [1000108],AETNA [100010801],,,76.8,,7.03,0.222255,85118.57664,percent of total billed charges,,,
RACEPINEPHRINE HCL 2.25 % IN NEBU,RX-113082,CDM,S5000,HCPCS,259,RC,00487-5901-99,NDC,outpatient,1,UN,5.79,4.053,AETNA [1000108],AETNA [100010801],,,76.8,,4.45,0.222255,85118.57664,percent of total billed charges,,,
FIRST-OMEPRAZOLE 2 MG/ML ORAL SUSP,RX-113272,CDM,S5000,HCPCS,259,RC,65628-0070-03,NDC,outpatient,5,ML,27.75,19.425,AETNA [1000108],AETNA [100010801],,,76.8,,21.31,0.222255,85118.57664,percent of total billed charges,,,
FIRST-OMEPRAZOLE 2 MG/ML ORAL SUSP,RX-113272,CDM,S5000,HCPCS,259,RC,99999-9003-64,NDC,outpatient,5,ML,27.75,19.425,AETNA [1000108],AETNA [100010801],,,76.8,,21.31,0.222255,85118.57664,percent of total billed charges,,,
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,16714-0612-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,16714-0612-04,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,76282-0213-18,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,00904-6925-61,NDC,outpatient,1,UN,1.38,0.966,AETNA [1000108],AETNA [100010801],,,76.8,,1.06,0.222255,85118.57664,percent of total billed charges,,,
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,60687-0242-01,NDC,outpatient,1,UN,1.35,0.945,AETNA [1000108],AETNA [100010801],,,76.8,,1.04,0.222255,85118.57664,percent of total billed charges,,,
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,60687-0242-11,NDC,outpatient,1,UN,1.35,0.945,AETNA [1000108],AETNA [100010801],,,76.8,,1.04,0.222255,85118.57664,percent of total billed charges,,,
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,68180-0352-09,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LURASIDONE HCL 20 MG ORAL TABS,RX-113587,CDM,S5000,HCPCS,259,RC,63402-0302-30,NDC,outpatient,1,UN,165.29,115.703,AETNA [1000108],AETNA [100010801],,,76.8,,126.94,0.222255,85118.57664,percent of total billed charges,,,
LURASIDONE HCL 20 MG ORAL TABS,RX-113587,CDM,S5000,HCPCS,259,RC,67877-0638-30,NDC,outpatient,1,UN,1.86,1.302,AETNA [1000108],AETNA [100010801],,,76.8,,1.43,0.222255,85118.57664,percent of total billed charges,,,
LURASIDONE HCL 20 MG ORAL TABS,RX-113587,CDM,S5000,HCPCS,259,RC,16729-0346-10,NDC,outpatient,1,UN,5,3.5,AETNA [1000108],AETNA [100010801],,,76.8,,3.84,0.222255,85118.57664,percent of total billed charges,,,
SILVER NITRATE-POT NITRATE 75-25 % EX MISC,RX-11359,CDM,S5000,HCPCS,259,RC,12870-0001-01,NDC,outpatient,10,UN,28.31,19.817,AETNA [1000108],AETNA [100010801],,,76.8,,21.74,0.222255,85118.57664,percent of total billed charges,,,
SOD CITRATE-CITRIC ACID 500-334 MG/5ML ORAL SOLN,RX-11394,CDM,S5000,HCPCS,259,RC,00121-1190-30,NDC,outpatient,30,ML,19.63,13.741,AETNA [1000108],AETNA [100010801],,,76.8,,15.08,0.222255,85118.57664,percent of total billed charges,,,
SOD CITRATE-CITRIC ACID 500-334 MG/5ML ORAL SOLN,RX-11394,CDM,S5000,HCPCS,259,RC,00121-1190-00,NDC,outpatient,30,ML,19.63,13.741,AETNA [1000108],AETNA [100010801],,,76.8,,15.08,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % IR SOLN,RX-11403,CDM,S5000,HCPCS,250,RC,00338-0048-04,NDC,outpatient,1000,ML,15.82,11.074,AETNA [1000108],AETNA [100010801],,,76.8,,12.15,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % IR SOLN,RX-11403,CDM,S5000,HCPCS,250,RC,00338-0048-03,NDC,outpatient,500,ML,11.87,8.309,AETNA [1000108],AETNA [100010801],,,76.8,,9.12,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE (HYPERTONIC) 2 % OP SOLN,RX-11404,CDM,S5000,HCPCS,259,RC,24208-0276-15,NDC,outpatient,15,ML,65.35,45.745,AETNA [1000108],AETNA [100010801],,,76.8,,50.19,0.222255,85118.57664,percent of total billed charges,,,
SOTALOL HCL 80 MG ORAL TABS,RX-11421,CDM,S5000,HCPCS,259,RC,68084-0654-11,NDC,outpatient,1,UN,4.36,3.052,AETNA [1000108],AETNA [100010801],,,76.8,,3.35,0.222255,85118.57664,percent of total billed charges,,,
SOTALOL HCL 80 MG ORAL TABS,RX-11421,CDM,S5000,HCPCS,259,RC,68084-0654-01,NDC,outpatient,1,UN,4.36,3.052,AETNA [1000108],AETNA [100010801],,,76.8,,3.35,0.222255,85118.57664,percent of total billed charges,,,
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,29033-0003-05,NDC,outpatient,1,UN,1.06,0.742,AETNA [1000108],AETNA [100010801],,,76.8,,0.81,0.222255,85118.57664,percent of total billed charges,,,
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,51079-0753-01,NDC,outpatient,1,UN,1.48,1.036,AETNA [1000108],AETNA [100010801],,,76.8,,1.14,0.222255,85118.57664,percent of total billed charges,,,
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,59762-0401-05,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,62135-0436-90,NDC,outpatient,1,UN,16.45,11.515,AETNA [1000108],AETNA [100010801],,,76.8,,12.63,0.222255,85118.57664,percent of total billed charges,,,
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,00093-2210-01,NDC,outpatient,1,UN,1.34,0.938,AETNA [1000108],AETNA [100010801],,,76.8,,1.03,0.222255,85118.57664,percent of total billed charges,,,
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,51079-0753-20,NDC,outpatient,1,UN,1.48,1.036,AETNA [1000108],AETNA [100010801],,,76.8,,1.14,0.222255,85118.57664,percent of total billed charges,,,
TERBUTALINE SULFATE 2.5 MG ORAL TABS,RX-11508,CDM,S5000,HCPCS,259,RC,62559-0721-01,NDC,outpatient,1,UN,4.45,3.115,AETNA [1000108],AETNA [100010801],,,76.8,,3.42,0.222255,85118.57664,percent of total billed charges,,,
TERBUTALINE SULFATE 2.5 MG ORAL TABS,RX-11508,CDM,S5000,HCPCS,259,RC,00527-1318-01,NDC,outpatient,1,UN,19.38,13.566,AETNA [1000108],AETNA [100010801],,,76.8,,14.88,0.222255,85118.57664,percent of total billed charges,,,
TETRACAINE HCL 1 % IJ SOLN,RX-11517,CDM,S5000,HCPCS,250,RC,54288-0127-01,NDC,outpatient,2,ML,164.48,115.136,AETNA [1000108],AETNA [100010801],,,76.8,,126.32,0.222255,85118.57664,percent of total billed charges,,,
TETRACAINE HCL 1 % IJ SOLN,RX-11517,CDM,S5000,HCPCS,250,RC,54288-0127-10,NDC,outpatient,2,ML,164.48,115.136,AETNA [1000108],AETNA [100010801],,,76.8,,126.32,0.222255,85118.57664,percent of total billed charges,,,
THROMBIN 20000 UNITS EX KIT,RX-11544,CDM,S5000,HCPCS,250,RC,60793-0217-21,NDC,outpatient,1,UN,883.55,618.485,AETNA [1000108],AETNA [100010801],,,76.8,,678.57,0.222255,85118.57664,percent of total billed charges,,,
THROMBIN 20000 UNITS EX KIT,RX-11544,CDM,S5000,HCPCS,250,RC,60793-0217-22,NDC,outpatient,1,UN,883.55,618.485,AETNA [1000108],AETNA [100010801],,,76.8,,678.57,0.222255,85118.57664,percent of total billed charges,,,
THROMBIN 5000 UNITS EX SOLR,RX-11548,CDM,S5000,HCPCS,250,RC,60793-0215-05,NDC,outpatient,1,UN,195.76,137.032,AETNA [1000108],AETNA [100010801],,,76.8,,150.34,0.222255,85118.57664,percent of total billed charges,,,
TIMOLOL MALEATE 0.25 % OP SOLN,RX-11561,CDM,S5000,HCPCS,259,RC,60758-0802-05,NDC,outpatient,5,ML,11.17,7.819,AETNA [1000108],AETNA [100010801],,,76.8,,8.58,0.222255,85118.57664,percent of total billed charges,,,
TIMOLOL MALEATE 0.25 % OP SOLN,RX-11561,CDM,S5000,HCPCS,259,RC,64980-0513-05,NDC,outpatient,5,ML,10.28,7.196,AETNA [1000108],AETNA [100010801],,,76.8,,7.9,0.222255,85118.57664,percent of total billed charges,,,
TIMOLOL MALEATE 0.5 % OP SOLN,RX-11562,CDM,S5000,HCPCS,259,RC,60758-0801-05,NDC,outpatient,5,ML,22.48,15.736,AETNA [1000108],AETNA [100010801],,,76.8,,17.26,0.222255,85118.57664,percent of total billed charges,,,
TIMOLOL MALEATE 0.5 % OP SOLN,RX-11562,CDM,S5000,HCPCS,259,RC,64980-0514-05,NDC,outpatient,5,ML,21.94,15.358,AETNA [1000108],AETNA [100010801],,,76.8,,16.85,0.222255,85118.57664,percent of total billed charges,,,
TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OP OINT,RX-11566,CDM,S5000,HCPCS,259,RC,00078-0876-01,NDC,outpatient,3.5,GR,1115.32,780.724,AETNA [1000108],AETNA [100010801],,,76.8,,856.57,0.222255,85118.57664,percent of total billed charges,,,
TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OP SUSP,RX-11567,CDM,S5000,HCPCS,259,RC,24208-0295-25,NDC,outpatient,2.5,ML,173.64,121.548,AETNA [1000108],AETNA [100010801],,,76.8,,133.36,0.222255,85118.57664,percent of total billed charges,,,
TRIAMTERENE 50 MG ORAL CAPS,RX-11588,CDM,S5000,HCPCS,259,RC,59212-0002-01,NDC,outpatient,1,UN,60.49,42.343,AETNA [1000108],AETNA [100010801],,,76.8,,46.46,0.222255,85118.57664,percent of total billed charges,,,
TRIAMTERENE 50 MG ORAL CAPS,RX-11588,CDM,S5000,HCPCS,259,RC,66993-0831-02,NDC,outpatient,1,UN,36.58,25.606,AETNA [1000108],AETNA [100010801],,,76.8,,28.09,0.222255,85118.57664,percent of total billed charges,,,
TRIFLURIDINE 1 % OP SOLN,RX-11595,CDM,S5000,HCPCS,259,RC,61314-0044-75,NDC,outpatient,7.5,ML,948.02,663.614,AETNA [1000108],AETNA [100010801],,,76.8,,728.08,0.222255,85118.57664,percent of total billed charges,,,
POLYMYXIN B-TRIMETHOPRIM 10000-0.1 UNIT/ML-% OP SOLN,RX-11596,CDM,S5000,HCPCS,259,RC,24208-0315-10,NDC,outpatient,10,ML,47.84,33.488,AETNA [1000108],AETNA [100010801],,,76.8,,36.74,0.222255,85118.57664,percent of total billed charges,,,
POLYMYXIN B-TRIMETHOPRIM 10000-0.1 UNIT/ML-% OP SOLN,RX-11596,CDM,S5000,HCPCS,259,RC,61314-0628-10,NDC,outpatient,10,ML,43.88,30.716,AETNA [1000108],AETNA [100010801],,,76.8,,33.7,0.222255,85118.57664,percent of total billed charges,,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG ORAL TABS,RX-11599,CDM,S5000,HCPCS,259,RC,00904-2725-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
URSODIOL 300 MG ORAL CAPS,RX-11624,CDM,S5000,HCPCS,259,RC,60687-0100-01,NDC,outpatient,1,UN,15.37,10.759,AETNA [1000108],AETNA [100010801],,,76.8,,11.8,0.222255,85118.57664,percent of total billed charges,,,
URSODIOL 300 MG ORAL CAPS,RX-11624,CDM,S5000,HCPCS,259,RC,60687-0100-11,NDC,outpatient,1,UN,15.37,10.759,AETNA [1000108],AETNA [100010801],,,76.8,,11.8,0.222255,85118.57664,percent of total billed charges,,,
VECURONIUM BROMIDE 10 MG IV SOLR,RX-11634,CDM,S5000,HCPCS,250,RC,55150-0235-01,NDC,outpatient,1,UN,11.52,8.064,AETNA [1000108],AETNA [100010801],,,76.8,,8.85,0.222255,85118.57664,percent of total billed charges,,,
VECURONIUM BROMIDE 10 MG IV SOLR,RX-11634,CDM,S5000,HCPCS,250,RC,55150-0235-10,NDC,outpatient,1,UN,11.52,8.064,AETNA [1000108],AETNA [100010801],,,76.8,,8.85,0.222255,85118.57664,percent of total billed charges,,,
VECURONIUM BROMIDE 20 MG IV SOLR,RX-11635,CDM,S5000,HCPCS,250,RC,00143-9232-01,NDC,outpatient,1,UN,41.49,29.043,AETNA [1000108],AETNA [100010801],,,76.8,,31.86,0.222255,85118.57664,percent of total billed charges,,,
VECURONIUM BROMIDE 20 MG IV SOLR,RX-11635,CDM,S5000,HCPCS,250,RC,00143-9232-10,NDC,outpatient,1,UN,41.49,29.043,AETNA [1000108],AETNA [100010801],,,76.8,,31.86,0.222255,85118.57664,percent of total billed charges,,,
WARFARIN SODIUM 1 MG ORAL TABS,RX-11664,CDM,S5000,HCPCS,259,RC,00832-1211-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
WARFARIN SODIUM 1 MG ORAL TABS,RX-11664,CDM,S5000,HCPCS,259,RC,00832-1211-89,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
IPRATROPIUM-ALBUTEROL 20-100 MCG/ACT IN AERS,RX-116728,CDM,S5000,HCPCS,259,RC,00597-0024-02,NDC,outpatient,4,GR,2012.08,1408.456,AETNA [1000108],AETNA [100010801],,,76.8,,1545.28,0.222255,85118.57664,percent of total billed charges,,,
ZIDOVUDINE 100 MG ORAL CAPS,RX-11692,CDM,S5000,HCPCS,259,RC,65862-0107-01,NDC,outpatient,1,UN,6.23,4.361,AETNA [1000108],AETNA [100010801],,,76.8,,4.78,0.222255,85118.57664,percent of total billed charges,,,
ZIDOVUDINE 10 MG/ML ORAL SYRP,RX-11693,CDM,S5000,HCPCS,259,RC,,,outpatient,5,ML,3.1,2.17,AETNA [1000108],AETNA [100010801],,,76.8,,2.38,0.222255,85118.57664,percent of total billed charges,,,
ZOLPIDEM TARTRATE 5 MG ORAL TABS,RX-11701,CDM,S5000,HCPCS,259,RC,00904-6082-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LINACLOTIDE 145 MCG ORAL CAPS,RX-117352,CDM,S5000,HCPCS,259,RC,00456-1201-30,NDC,outpatient,1,UN,74.11,51.877,AETNA [1000108],AETNA [100010801],,,76.8,,56.92,0.222255,85118.57664,percent of total billed charges,,,
RIVASTIGMINE 13.3 MG/24HR TD PT24,RX-117356,CDM,S5000,HCPCS,259,RC,00378-9072-93,NDC,outpatient,1,UN,6.86,4.802,AETNA [1000108],AETNA [100010801],,,76.8,,5.27,0.222255,85118.57664,percent of total billed charges,,,
RIVASTIGMINE 13.3 MG/24HR TD PT24,RX-117356,CDM,S5000,HCPCS,259,RC,70710-1198-01,NDC,outpatient,1,UN,8.83,6.181,AETNA [1000108],AETNA [100010801],,,76.8,,6.78,0.222255,85118.57664,percent of total billed charges,,,
RIVASTIGMINE 13.3 MG/24HR TD PT24,RX-117356,CDM,S5000,HCPCS,259,RC,00378-9072-16,NDC,outpatient,1,UN,6.86,4.802,AETNA [1000108],AETNA [100010801],,,76.8,,5.27,0.222255,85118.57664,percent of total billed charges,,,
RIVASTIGMINE 13.3 MG/24HR TD PT24,RX-117356,CDM,S5000,HCPCS,259,RC,70710-1198-07,NDC,outpatient,1,UN,8.83,6.181,AETNA [1000108],AETNA [100010801],,,76.8,,6.78,0.222255,85118.57664,percent of total billed charges,,,
MORPHINE SULFATE ER 30 MG ORAL TBCR,RX-119007,CDM,S5000,HCPCS,259,RC,00406-8330-01,NDC,outpatient,1,UN,1.46,1.022,AETNA [1000108],AETNA [100010801],,,76.8,,1.12,0.222255,85118.57664,percent of total billed charges,,,
MORPHINE SULFATE ER 30 MG ORAL TBCR,RX-119007,CDM,S5000,HCPCS,259,RC,00406-8330-62,NDC,outpatient,1,UN,4.35,3.045,AETNA [1000108],AETNA [100010801],,,76.8,,3.34,0.222255,85118.57664,percent of total billed charges,,,
MORPHINE SULFATE ER 30 MG ORAL TBCR,RX-119007,CDM,S5000,HCPCS,259,RC,00406-8330-23,NDC,outpatient,1,UN,4.35,3.045,AETNA [1000108],AETNA [100010801],,,76.8,,3.34,0.222255,85118.57664,percent of total billed charges,,,
MORPHINE SULFATE ER 30 MG ORAL TBCR,RX-119007,CDM,S5000,HCPCS,259,RC,00904-6558-61,NDC,outpatient,1,UN,5.15,3.605,AETNA [1000108],AETNA [100010801],,,76.8,,3.96,0.222255,85118.57664,percent of total billed charges,,,
APIXABAN 2.5 MG ORAL TABS,RX-119040,CDM,S5000,HCPCS,259,RC,00003-0893-21,NDC,outpatient,1,UN,6.17,4.319,AETNA [1000108],AETNA [100010801],,,76.8,,4.74,0.222255,85118.57664,percent of total billed charges,,,
APIXABAN 2.5 MG ORAL TABS,RX-119040,CDM,S5000,HCPCS,259,RC,00003-0893-31,NDC,outpatient,1,UN,6.17,4.319,AETNA [1000108],AETNA [100010801],,,76.8,,4.74,0.222255,85118.57664,percent of total billed charges,,,
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,00703-2056-01,NDC,outpatient,10,ML,102.35,71.645,AETNA [1000108],AETNA [100010801],,,76.8,,78.6,0.222255,85118.57664,percent of total billed charges,,,
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,70069-0161-01,NDC,outpatient,10,ML,30.13,21.091,AETNA [1000108],AETNA [100010801],,,76.8,,23.14,0.222255,85118.57664,percent of total billed charges,,,
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,70069-0161-10,NDC,outpatient,10,ML,30.13,21.091,AETNA [1000108],AETNA [100010801],,,76.8,,23.14,0.222255,85118.57664,percent of total billed charges,,,
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,00703-2056-03,NDC,outpatient,10,ML,102.35,71.645,AETNA [1000108],AETNA [100010801],,,76.8,,78.6,0.222255,85118.57664,percent of total billed charges,,,
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,71288-0714-11,NDC,outpatient,10,ML,30.26,21.182,AETNA [1000108],AETNA [100010801],,,76.8,,23.24,0.222255,85118.57664,percent of total billed charges,,,
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,71288-0714-10,NDC,outpatient,10,ML,30.26,21.182,AETNA [1000108],AETNA [100010801],,,76.8,,23.24,0.222255,85118.57664,percent of total billed charges,,,
MORPHINE SULFATE ER 15 MG ORAL TBCR,RX-119246,CDM,S5000,HCPCS,259,RC,00406-8315-62,NDC,outpatient,1,UN,2.2,1.54,AETNA [1000108],AETNA [100010801],,,76.8,,1.69,0.222255,85118.57664,percent of total billed charges,,,
MORPHINE SULFATE ER 15 MG ORAL TBCR,RX-119246,CDM,S5000,HCPCS,259,RC,00406-8315-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
MORPHINE SULFATE ER 15 MG ORAL TBCR,RX-119246,CDM,S5000,HCPCS,259,RC,00406-8315-23,NDC,outpatient,1,UN,2.2,1.54,AETNA [1000108],AETNA [100010801],,,76.8,,1.69,0.222255,85118.57664,percent of total billed charges,,,
MORPHINE SULFATE ER 15 MG ORAL TBCR,RX-119246,CDM,S5000,HCPCS,259,RC,00228-4270-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
MORPHINE SULFATE ER 15 MG ORAL TBCR,RX-119246,CDM,S5000,HCPCS,259,RC,63304-0450-01,NDC,outpatient,1,UN,1.05,0.735,AETNA [1000108],AETNA [100010801],,,76.8,,0.81,0.222255,85118.57664,percent of total billed charges,,,
MORPHINE SULFATE ER 100 MG ORAL TBCR,RX-119248,CDM,S5000,HCPCS,259,RC,00406-8390-23,NDC,outpatient,1,UN,12.34,8.638,AETNA [1000108],AETNA [100010801],,,76.8,,9.48,0.222255,85118.57664,percent of total billed charges,,,
MORPHINE SULFATE ER 100 MG ORAL TBCR,RX-119248,CDM,S5000,HCPCS,259,RC,00406-8390-62,NDC,outpatient,1,UN,12.34,8.638,AETNA [1000108],AETNA [100010801],,,76.8,,9.48,0.222255,85118.57664,percent of total billed charges,,,
INFUVITE ADULT IV INJ,RX-119571,CDM,S5000,HCPCS,250,RC,54643-5650-09,NDC,outpatient,10,ML,3.96,2.772,AETNA [1000108],AETNA [100010801],,,76.8,,3.04,0.222255,85118.57664,percent of total billed charges,,,
INFUVITE ADULT IV INJ,RX-119571,CDM,S5000,HCPCS,250,RC,54643-5649-01,NDC,outpatient,10,ML,39.65,27.755,AETNA [1000108],AETNA [100010801],,,76.8,,30.45,0.222255,85118.57664,percent of total billed charges,,,
INFUVITE ADULT IV INJ,RX-119571,CDM,S5000,HCPCS,250,RC,54643-5650-02,NDC,outpatient,10,ML,3.96,2.772,AETNA [1000108],AETNA [100010801],,,76.8,,3.04,0.222255,85118.57664,percent of total billed charges,,,
INFUVITE ADULT IV INJ,RX-119571,CDM,S5000,HCPCS,250,RC,54643-5650-28,NDC,outpatient,10,ML,3.96,2.772,AETNA [1000108],AETNA [100010801],,,76.8,,3.04,0.222255,85118.57664,percent of total billed charges,,,
APIXABAN 5 MG ORAL TABS,RX-119614,CDM,S5000,HCPCS,259,RC,00003-0894-31,NDC,outpatient,1,UN,6.17,4.319,AETNA [1000108],AETNA [100010801],,,76.8,,4.74,0.222255,85118.57664,percent of total billed charges,,,
MESALAMINE 400 MG ORAL CPDR,RX-119913,CDM,S5000,HCPCS,259,RC,00023-5853-18,NDC,outpatient,1,UN,15.96,11.172,AETNA [1000108],AETNA [100010801],,,76.8,,12.26,0.222255,85118.57664,percent of total billed charges,,,
MESALAMINE 400 MG ORAL CPDR,RX-119913,CDM,S5000,HCPCS,259,RC,59762-0117-01,NDC,outpatient,1,UN,10.4,7.28,AETNA [1000108],AETNA [100010801],,,76.8,,7.99,0.222255,85118.57664,percent of total billed charges,,,
MESALAMINE 400 MG ORAL CPDR,RX-119913,CDM,S5000,HCPCS,259,RC,60687-0556-33,NDC,outpatient,1,UN,23.14,16.198,AETNA [1000108],AETNA [100010801],,,76.8,,17.77,0.222255,85118.57664,percent of total billed charges,,,
MESALAMINE 400 MG ORAL CPDR,RX-119913,CDM,S5000,HCPCS,259,RC,60687-0556-32,NDC,outpatient,1,UN,23.14,16.198,AETNA [1000108],AETNA [100010801],,,76.8,,17.77,0.222255,85118.57664,percent of total billed charges,,,
MECLIZINE HCL 12.5 MG ORAL TABS,RX-12024,CDM,S5000,HCPCS,259,RC,60687-0775-11,NDC,outpatient,1,UN,1.73,1.211,AETNA [1000108],AETNA [100010801],,,76.8,,1.33,0.222255,85118.57664,percent of total billed charges,,,
MECLIZINE HCL 12.5 MG ORAL TABS,RX-12024,CDM,S5000,HCPCS,259,RC,60687-0775-01,NDC,outpatient,1,UN,1.73,1.211,AETNA [1000108],AETNA [100010801],,,76.8,,1.33,0.222255,85118.57664,percent of total billed charges,,,
THEOPHYLLINE ER 300 MG ORAL TB12,RX-12098,CDM,S5000,HCPCS,259,RC,68462-0721-01,NDC,outpatient,1,UN,5.92,4.144,AETNA [1000108],AETNA [100010801],,,76.8,,4.55,0.222255,85118.57664,percent of total billed charges,,,
THEOPHYLLINE ER 300 MG ORAL TB12,RX-12098,CDM,S5000,HCPCS,259,RC,62332-0025-31,NDC,outpatient,1,UN,11.73,8.211,AETNA [1000108],AETNA [100010801],,,76.8,,9.01,0.222255,85118.57664,percent of total billed charges,,,
MEMANTINE HCL ER 14 MG ORAL CP24,RX-121474,CDM,S5000,HCPCS,259,RC,00456-3414-33,NDC,outpatient,1,UN,7.56,5.292,AETNA [1000108],AETNA [100010801],,,76.8,,5.81,0.222255,85118.57664,percent of total billed charges,,,
MEMANTINE HCL ER 21 MG ORAL CP24,RX-121475,CDM,S5000,HCPCS,259,RC,00456-3421-33,NDC,outpatient,1,UN,7.56,5.292,AETNA [1000108],AETNA [100010801],,,76.8,,5.81,0.222255,85118.57664,percent of total billed charges,,,
MEMANTINE HCL ER 28 MG ORAL CP24,RX-121476,CDM,S5000,HCPCS,259,RC,00456-3428-33,NDC,outpatient,1,UN,63.71,44.597,AETNA [1000108],AETNA [100010801],,,76.8,,48.93,0.222255,85118.57664,percent of total billed charges,,,
DOXYLAMINE-PYRIDOXINE 10-10 MG ORAL TBEC,RX-121504,CDM,S5000,HCPCS,259,RC,70505-0100-10,NDC,outpatient,1,UN,13.18,9.226,AETNA [1000108],AETNA [100010801],,,76.8,,10.12,0.222255,85118.57664,percent of total billed charges,,,
DOXYLAMINE-PYRIDOXINE 10-10 MG ORAL TBEC,RX-121504,CDM,S5000,HCPCS,259,RC,55494-0100-10,NDC,outpatient,1,UN,13.41,9.387,AETNA [1000108],AETNA [100010801],,,76.8,,10.3,0.222255,85118.57664,percent of total billed charges,,,
QUINIDINE GLUCONATE ER 324 MG ORAL TBCR,RX-12197,CDM,S5000,HCPCS,259,RC,53489-0141-01,NDC,outpatient,1,UN,24.15,16.905,AETNA [1000108],AETNA [100010801],,,76.8,,18.55,0.222255,85118.57664,percent of total billed charges,,,
VENLAFAXINE HCL 25 MG ORAL TABS,RX-12203,CDM,S5000,HCPCS,259,RC,68084-0896-25,NDC,outpatient,1,UN,3.98,2.786,AETNA [1000108],AETNA [100010801],,,76.8,,3.06,0.222255,85118.57664,percent of total billed charges,,,
VENLAFAXINE HCL 25 MG ORAL TABS,RX-12203,CDM,S5000,HCPCS,259,RC,68084-0896-95,NDC,outpatient,1,UN,3.98,2.786,AETNA [1000108],AETNA [100010801],,,76.8,,3.06,0.222255,85118.57664,percent of total billed charges,,,
VENLAFAXINE HCL 75 MG ORAL TABS,RX-12206,CDM,S5000,HCPCS,259,RC,57664-0395-88,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
VENLAFAXINE HCL 75 MG ORAL TABS,RX-12206,CDM,S5000,HCPCS,259,RC,68084-0856-01,NDC,outpatient,1,UN,3.02,2.114,AETNA [1000108],AETNA [100010801],,,76.8,,2.32,0.222255,85118.57664,percent of total billed charges,,,
VENLAFAXINE HCL 75 MG ORAL TABS,RX-12206,CDM,S5000,HCPCS,259,RC,68084-0856-11,NDC,outpatient,1,UN,3.02,2.114,AETNA [1000108],AETNA [100010801],,,76.8,,2.32,0.222255,85118.57664,percent of total billed charges,,,
VENLAFAXINE HCL 37.5 MG ORAL TABS,RX-12207,CDM,S5000,HCPCS,259,RC,68084-0844-01,NDC,outpatient,1,UN,2.34,1.638,AETNA [1000108],AETNA [100010801],,,76.8,,1.8,0.222255,85118.57664,percent of total billed charges,,,
VENLAFAXINE HCL 37.5 MG ORAL TABS,RX-12207,CDM,S5000,HCPCS,259,RC,68084-0844-11,NDC,outpatient,1,UN,2.34,1.638,AETNA [1000108],AETNA [100010801],,,76.8,,1.8,0.222255,85118.57664,percent of total billed charges,,,
DORNASE ALFA 2.5 MG/2.5ML IN SOLN,RX-12211,CDM,S5000,HCPCS,259,RC,50242-0100-39,NDC,outpatient,2.5,ML,560.63,392.441,AETNA [1000108],AETNA [100010801],,,76.8,,430.56,0.222255,85118.57664,percent of total billed charges,,,
DORNASE ALFA 2.5 MG/2.5ML IN SOLN,RX-12211,CDM,S5000,HCPCS,259,RC,50242-0100-40,NDC,outpatient,2.5,ML,560.63,392.441,AETNA [1000108],AETNA [100010801],,,76.8,,430.56,0.222255,85118.57664,percent of total billed charges,,,
IRON-VITAMIN C 65-125 MG ORAL TABS,RX-122332,CDM,S5000,HCPCS,259,RC,63736-0123-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
OXYCODONE HCL ER 10 MG ORAL T12A,RX-122363,CDM,S5000,HCPCS,259,RC,59011-0410-20,NDC,outpatient,1,UN,22.52,15.764,AETNA [1000108],AETNA [100010801],,,76.8,,17.3,0.222255,85118.57664,percent of total billed charges,,,
OXYCODONE HCL ER 20 MG ORAL T12A,RX-122366,CDM,S5000,HCPCS,259,RC,59011-0420-20,NDC,outpatient,1,UN,41.94,29.358,AETNA [1000108],AETNA [100010801],,,76.8,,32.21,0.222255,85118.57664,percent of total billed charges,,,
OXYCODONE HCL ER 20 MG ORAL T12A,RX-122366,CDM,S5000,HCPCS,259,RC,59011-0420-10,NDC,outpatient,1,UN,40.9,28.63,AETNA [1000108],AETNA [100010801],,,76.8,,31.41,0.222255,85118.57664,percent of total billed charges,,,
OXYCODONE HCL ER 40 MG ORAL T12A,RX-122368,CDM,S5000,HCPCS,259,RC,59011-0440-20,NDC,outpatient,1,UN,71.8,50.26,AETNA [1000108],AETNA [100010801],,,76.8,,55.14,0.222255,85118.57664,percent of total billed charges,,,
DOLUTEGRAVIR SODIUM 50 MG ORAL TABS,RX-122784,CDM,S5000,HCPCS,259,RC,49702-0228-13,NDC,outpatient,1,UN,324.81,227.367,AETNA [1000108],AETNA [100010801],,,76.8,,249.45,0.222255,85118.57664,percent of total billed charges,,,
LURASIDONE HCL 60 MG ORAL TABS,RX-122968,CDM,S5000,HCPCS,259,RC,65162-0082-03,NDC,outpatient,1,UN,1.48,1.036,AETNA [1000108],AETNA [100010801],,,76.8,,1.14,0.222255,85118.57664,percent of total billed charges,,,
LURASIDONE HCL 60 MG ORAL TABS,RX-122968,CDM,S5000,HCPCS,259,RC,16729-0348-10,NDC,outpatient,1,UN,5,3.5,AETNA [1000108],AETNA [100010801],,,76.8,,3.84,0.222255,85118.57664,percent of total billed charges,,,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,63323-0694-04,NDC,outpatient,4,ML,17.02,11.914,AETNA [1000108],AETNA [100010801],,,76.8,,13.07,0.222255,85118.57664,percent of total billed charges,,,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,63323-0694-22,NDC,outpatient,4,ML,17.02,11.914,AETNA [1000108],AETNA [100010801],,,76.8,,13.07,0.222255,85118.57664,percent of total billed charges,,,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,00517-7604-01,NDC,outpatient,4,ML,26.92,18.844,AETNA [1000108],AETNA [100010801],,,76.8,,20.67,0.222255,85118.57664,percent of total billed charges,,,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,00517-7604-25,NDC,outpatient,4,ML,26.92,18.844,AETNA [1000108],AETNA [100010801],,,76.8,,20.67,0.222255,85118.57664,percent of total billed charges,,,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,99999-0002-60,NDC,outpatient,3,ML,9.75,6.825,AETNA [1000108],AETNA [100010801],,,76.8,,7.49,0.222255,85118.57664,percent of total billed charges,,,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,00409-3308-03,NDC,outpatient,30,ML,57.68,40.376,AETNA [1000108],AETNA [100010801],,,76.8,,44.3,0.222255,85118.57664,percent of total billed charges,,,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,00409-3308-11,NDC,outpatient,30,ML,57.68,40.376,AETNA [1000108],AETNA [100010801],,,76.8,,44.3,0.222255,85118.57664,percent of total billed charges,,,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,63323-0690-22,NDC,outpatient,30,ML,25.77,18.039,AETNA [1000108],AETNA [100010801],,,76.8,,19.79,0.222255,85118.57664,percent of total billed charges,,,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,63323-0690-30,NDC,outpatient,30,ML,25.77,18.039,AETNA [1000108],AETNA [100010801],,,76.8,,19.79,0.222255,85118.57664,percent of total billed charges,,,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,99999-0002-61,NDC,outpatient,3,ML,9.75,6.825,AETNA [1000108],AETNA [100010801],,,76.8,,7.49,0.222255,85118.57664,percent of total billed charges,,,
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,66794-0230-42,NDC,outpatient,2,ML,21.6,15.12,AETNA [1000108],AETNA [100010801],,,76.8,,16.59,0.222255,85118.57664,percent of total billed charges,,,
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,70860-0605-03,NDC,outpatient,2,ML,9.94,6.958,AETNA [1000108],AETNA [100010801],,,76.8,,7.63,0.222255,85118.57664,percent of total billed charges,,,
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,71288-0505-03,NDC,outpatient,2,ML,11.79,8.253,AETNA [1000108],AETNA [100010801],,,76.8,,9.05,0.222255,85118.57664,percent of total billed charges,,,
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,66794-0230-02,NDC,outpatient,2,ML,21.6,15.12,AETNA [1000108],AETNA [100010801],,,76.8,,16.59,0.222255,85118.57664,percent of total billed charges,,,
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,70860-0605-41,NDC,outpatient,2,ML,9.94,6.958,AETNA [1000108],AETNA [100010801],,,76.8,,7.63,0.222255,85118.57664,percent of total billed charges,,,
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,71288-0505-02,NDC,outpatient,2,ML,11.79,8.253,AETNA [1000108],AETNA [100010801],,,76.8,,9.05,0.222255,85118.57664,percent of total billed charges,,,
CETIRIZINE HCL 5 MG/5ML ORAL SOLN,RX-124298,CDM,S5000,HCPCS,259,RC,51672-4070-08,NDC,outpatient,2.5,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
CETIRIZINE HCL 5 MG/5ML ORAL SOLN,RX-124298,CDM,S5000,HCPCS,259,RC,99999-0004-13,NDC,outpatient,5,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
TOBRAMYCIN 0.3 % OP SOLN,RX-124312,CDM,S5000,HCPCS,259,RC,70069-0131-01,NDC,outpatient,5,ML,22.25,15.575,AETNA [1000108],AETNA [100010801],,,76.8,,17.09,0.222255,85118.57664,percent of total billed charges,,,
TOBRAMYCIN 0.3 % OP SOLN,RX-124312,CDM,S5000,HCPCS,259,RC,61314-0643-05,NDC,outpatient,5,ML,42.15,29.505,AETNA [1000108],AETNA [100010801],,,76.8,,32.37,0.222255,85118.57664,percent of total billed charges,,,
EXENATIDE 5 MCG/0.02ML SC SOPN,RX-124738,CDM,S5000,HCPCS,259,RC,00310-6512-01,NDC,outpatient,1.2,ML,2102.55,1471.785,AETNA [1000108],AETNA [100010801],,,76.8,,1614.76,0.222255,85118.57664,percent of total billed charges,,,
EXENATIDE 10 MCG/0.04ML SC SOPN,RX-124739,CDM,S5000,HCPCS,259,RC,00310-6524-01,NDC,outpatient,2.4,ML,2102.55,1471.785,AETNA [1000108],AETNA [100010801],,,76.8,,1614.76,0.222255,85118.57664,percent of total billed charges,,,
LIRAGLUTIDE 18 MG/3ML SC SOPN,RX-124740,CDM,S5000,HCPCS,250,RC,00169-4060-12,NDC,outpatient,3,ML,1117.4,782.18,AETNA [1000108],AETNA [100010801],,,76.8,,858.16,0.222255,85118.57664,percent of total billed charges,,,
LIRAGLUTIDE 18 MG/3ML SC SOPN,RX-124740,CDM,S5000,HCPCS,250,RC,00169-4060-13,NDC,outpatient,3,ML,1117.41,782.187,AETNA [1000108],AETNA [100010801],,,76.8,,858.17,0.222255,85118.57664,percent of total billed charges,,,
ESTRADIOL 0.5 MG ORAL TABS,RX-12491,CDM,S5000,HCPCS,259,RC,00555-0899-02,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ESTRADIOL 0.5 MG ORAL TABS,RX-12491,CDM,S5000,HCPCS,259,RC,42806-0087-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
TOBRAMYCIN 0.3 % OP OINT,RX-125351,CDM,S5000,HCPCS,259,RC,00078-0813-01,NDC,outpatient,3.5,GR,1047.63,733.341,AETNA [1000108],AETNA [100010801],,,76.8,,804.58,0.222255,85118.57664,percent of total billed charges,,,
DIPHENHYDRAMINE HCL 12.5 MG/5ML ORAL LIQD,RX-12556,CDM,S5000,HCPCS,259,RC,00904-6985-20,NDC,outpatient,2.5,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,60687-0394-83,NDC,outpatient,2.5,ML,1.05,0.735,AETNA [1000108],AETNA [100010801],,,76.8,,0.81,0.222255,85118.57664,percent of total billed charges,,,
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,60687-0394-79,NDC,outpatient,2.5,ML,1.05,0.735,AETNA [1000108],AETNA [100010801],,,76.8,,0.81,0.222255,85118.57664,percent of total billed charges,,,
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,76204-0100-01,NDC,outpatient,2.5,ML,1.24,0.868,AETNA [1000108],AETNA [100010801],,,76.8,,0.95,0.222255,85118.57664,percent of total billed charges,,,
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,00378-7970-93,NDC,outpatient,2.5,ML,1.02,0.714,AETNA [1000108],AETNA [100010801],,,76.8,,0.78,0.222255,85118.57664,percent of total billed charges,,,
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,00487-9801-01,NDC,outpatient,2.5,ML,1.51,1.057,AETNA [1000108],AETNA [100010801],,,76.8,,1.16,0.222255,85118.57664,percent of total billed charges,,,
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,00487-9801-60,NDC,outpatient,2.5,ML,1.12,0.784,AETNA [1000108],AETNA [100010801],,,76.8,,0.86,0.222255,85118.57664,percent of total billed charges,,,
PHENYLEPHRINE-COCOA BUTTER 0.25-88.44 % RE SUPP,RX-125849,CDM,S5000,HCPCS,259,RC,00536-1186-12,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
CAFFEINE 200 MG ORAL TABS,RX-1259,CDM,S5000,HCPCS,259,RC,46017-0018-40,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
DANTROLENE SODIUM 250 MG IV SUSR,RX-126042,CDM,S5000,HCPCS,250,RC,42367-0540-32,NDC,outpatient,1,UN,5868.29,4107.803,AETNA [1000108],AETNA [100010801],,,76.8,,4506.85,0.222255,85118.57664,percent of total billed charges,,,
EMPAGLIFLOZIN 10 MG ORAL TABS,RX-126076,CDM,S5000,HCPCS,259,RC,00597-0152-30,NDC,outpatient,1,UN,55.29,38.703,AETNA [1000108],AETNA [100010801],,,76.8,,42.46,0.222255,85118.57664,percent of total billed charges,,,
EMPAGLIFLOZIN 10 MG ORAL TABS,RX-126076,CDM,S5000,HCPCS,259,RC,00597-0152-37,NDC,outpatient,1,UN,55.29,38.703,AETNA [1000108],AETNA [100010801],,,76.8,,42.46,0.222255,85118.57664,percent of total billed charges,,,
EMPAGLIFLOZIN 25 MG ORAL TABS,RX-126078,CDM,S5000,HCPCS,259,RC,00597-0153-37,NDC,outpatient,1,UN,55.29,38.703,AETNA [1000108],AETNA [100010801],,,76.8,,42.46,0.222255,85118.57664,percent of total billed charges,,,
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML IJ SOLN,RX-1262,CDM,S5000,HCPCS,250,RC,00517-2502-10,NDC,outpatient,2,ML,107.33,75.131,AETNA [1000108],AETNA [100010801],,,76.8,,82.43,0.222255,85118.57664,percent of total billed charges,,,
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML IJ SOLN,RX-1262,CDM,S5000,HCPCS,250,RC,00517-2502-01,NDC,outpatient,2,ML,107.33,75.131,AETNA [1000108],AETNA [100010801],,,76.8,,82.43,0.222255,85118.57664,percent of total billed charges,,,
TERBINAFINE HCL 250 MG ORAL TABS,RX-12724,CDM,S5000,HCPCS,259,RC,65862-0079-30,NDC,outpatient,1,UN,1.29,0.903,AETNA [1000108],AETNA [100010801],,,76.8,,0.99,0.222255,85118.57664,percent of total billed charges,,,
TRIAMTERENE-HCTZ 37.5-25 MG ORAL CAPS,RX-12729,CDM,S5000,HCPCS,259,RC,00781-2074-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
FAMOTIDINE IN NACL 20-0.9 MG/50ML-% IV SOLN,RX-12735,CDM,S5000,HCPCS,250,RC,00338-5197-41,NDC,outpatient,50,ML,24.23,16.961,AETNA [1000108],AETNA [100010801],,,76.8,,18.61,0.222255,85118.57664,percent of total billed charges,,,
PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML ORAL ELIX,RX-127530,CDM,S5000,HCPCS,259,RC,99999-0002-29,NDC,outpatient,5,ML,70.67,49.469,AETNA [1000108],AETNA [100010801],,,76.8,,54.27,0.222255,85118.57664,percent of total billed charges,,,
PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML ORAL ELIX,RX-127530,CDM,S5000,HCPCS,259,RC,75826-0127-05,NDC,outpatient,5,ML,13.49,9.443,AETNA [1000108],AETNA [100010801],,,76.8,,10.36,0.222255,85118.57664,percent of total billed charges,,,
PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML ORAL ELIX,RX-127530,CDM,S5000,HCPCS,259,RC,75826-0128-04,NDC,outpatient,5,ML,45.71,31.997,AETNA [1000108],AETNA [100010801],,,76.8,,35.11,0.222255,85118.57664,percent of total billed charges,,,
PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML ORAL ELIX,RX-127530,CDM,S5000,HCPCS,259,RC,75826-0127-04,NDC,outpatient,5,ML,13.49,9.443,AETNA [1000108],AETNA [100010801],,,76.8,,10.36,0.222255,85118.57664,percent of total billed charges,,,
PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML ORAL ELIX,RX-127530,CDM,S5000,HCPCS,259,RC,75826-0128-05,NDC,outpatient,5,ML,45.71,31.997,AETNA [1000108],AETNA [100010801],,,76.8,,35.11,0.222255,85118.57664,percent of total billed charges,,,
BUPRENORPHINE 7.5 MCG/HR TD PTWK,RX-127562,CDM,S5000,HCPCS,259,RC,42858-0353-40,NDC,outpatient,1,UN,309.07,216.349,AETNA [1000108],AETNA [100010801],,,76.8,,237.37,0.222255,85118.57664,percent of total billed charges,,,
PILOCARPINE HCL 5 MG ORAL TABS,RX-12803,CDM,S5000,HCPCS,259,RC,00527-1313-01,NDC,outpatient,1,UN,4.2,2.94,AETNA [1000108],AETNA [100010801],,,76.8,,3.23,0.222255,85118.57664,percent of total billed charges,,,
PILOCARPINE HCL 5 MG ORAL TABS,RX-12803,CDM,S5000,HCPCS,259,RC,68084-0928-25,NDC,outpatient,1,UN,10.51,7.357,AETNA [1000108],AETNA [100010801],,,76.8,,8.07,0.222255,85118.57664,percent of total billed charges,,,
PILOCARPINE HCL 5 MG ORAL TABS,RX-12803,CDM,S5000,HCPCS,259,RC,68084-0928-95,NDC,outpatient,1,UN,10.51,7.357,AETNA [1000108],AETNA [100010801],,,76.8,,8.07,0.222255,85118.57664,percent of total billed charges,,,
TIOTROPIUM BROMIDE MONOHYDRATE 2.5 MCG/ACT IN AERS,RX-128423,CDM,S5000,HCPCS,259,RC,00597-0100-51,NDC,outpatient,4,GR,308.39,215.873,AETNA [1000108],AETNA [100010801],,,76.8,,236.84,0.222255,85118.57664,percent of total billed charges,,,
PENTOSAN POLYSULFATE SODIUM 100 MG ORAL CAPS,RX-12912,CDM,S5000,HCPCS,259,RC,50458-0098-01,NDC,outpatient,1,UN,46.46,32.522,AETNA [1000108],AETNA [100010801],,,76.8,,35.68,0.222255,85118.57664,percent of total billed charges,,,
TACROLIMUS 1 MG ORAL CAPS,RX-12933,CDM,S5000,HCPCS,259,RC,51079-0818-20,NDC,outpatient,1,UN,4.95,3.465,AETNA [1000108],AETNA [100010801],,,76.8,,3.8,0.222255,85118.57664,percent of total billed charges,,,
TACROLIMUS 1 MG ORAL CAPS,RX-12933,CDM,S5000,HCPCS,259,RC,51079-0818-01,NDC,outpatient,1,UN,4.95,3.465,AETNA [1000108],AETNA [100010801],,,76.8,,3.8,0.222255,85118.57664,percent of total billed charges,,,
TACROLIMUS 1 MG ORAL CAPS,RX-12933,CDM,S5000,HCPCS,259,RC,00904-7097-61,NDC,outpatient,1,UN,4.43,3.101,AETNA [1000108],AETNA [100010801],,,76.8,,3.4,0.222255,85118.57664,percent of total billed charges,,,
DOMEBORO EX PACK,RX-129475,CDM,S5000,HCPCS,259,RC,57074-0001-77,NDC,outpatient,1,UN,2.6,1.82,AETNA [1000108],AETNA [100010801],,,76.8,,2,0.222255,85118.57664,percent of total billed charges,,,
DARUNAVIR-COBICISTAT 800-150 MG ORAL TABS,RX-129730,CDM,S5000,HCPCS,259,RC,59676-0575-30,NDC,outpatient,1,UN,354.92,248.444,AETNA [1000108],AETNA [100010801],,,76.8,,272.58,0.222255,85118.57664,percent of total billed charges,,,
PYRIDOSTIGMINE BROMIDE 10 MG/2ML IV SOLN,RX-129741,CDM,S5000,HCPCS,250,RC,00781-3040-72,NDC,outpatient,2,ML,130.52,91.364,AETNA [1000108],AETNA [100010801],,,76.8,,100.24,0.222255,85118.57664,percent of total billed charges,,,
PYRIDOSTIGMINE BROMIDE 10 MG/2ML IV SOLN,RX-129741,CDM,S5000,HCPCS,250,RC,00781-3040-95,NDC,outpatient,2,ML,130.52,91.364,AETNA [1000108],AETNA [100010801],,,76.8,,100.24,0.222255,85118.57664,percent of total billed charges,,,
SCOPOLAMINE 1 MG/3DAYS TD PT72,RX-129902,CDM,S5000,HCPCS,259,RC,10019-0553-04,NDC,outpatient,1,UN,23.54,16.478,AETNA [1000108],AETNA [100010801],,,76.8,,18.08,0.222255,85118.57664,percent of total billed charges,,,
SCOPOLAMINE 1 MG/3DAYS TD PT72,RX-129902,CDM,S5000,HCPCS,259,RC,10019-0553-90,NDC,outpatient,1,UN,23.54,16.478,AETNA [1000108],AETNA [100010801],,,76.8,,18.08,0.222255,85118.57664,percent of total billed charges,,,
SCOPOLAMINE 1 MG/3DAYS TD PT72,RX-129902,CDM,S5000,HCPCS,259,RC,50742-0505-01,NDC,outpatient,1,UN,42.28,29.596,AETNA [1000108],AETNA [100010801],,,76.8,,32.47,0.222255,85118.57664,percent of total billed charges,,,
SCOPOLAMINE 1 MG/3DAYS TD PT72,RX-129902,CDM,S5000,HCPCS,259,RC,50742-0505-24,NDC,outpatient,1,UN,23.2,16.24,AETNA [1000108],AETNA [100010801],,,76.8,,17.82,0.222255,85118.57664,percent of total billed charges,,,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,00143-9318-10,NDC,outpatient,4,ML,15.67,10.969,AETNA [1000108],AETNA [100010801],,,76.8,,12.03,0.222255,85118.57664,percent of total billed charges,,,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,00409-3375-14,NDC,outpatient,4,ML,23.45,16.415,AETNA [1000108],AETNA [100010801],,,76.8,,18.01,0.222255,85118.57664,percent of total billed charges,,,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,67457-0852-00,NDC,outpatient,4,ML,24.37,17.059,AETNA [1000108],AETNA [100010801],,,76.8,,18.72,0.222255,85118.57664,percent of total billed charges,,,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,00143-9318-01,NDC,outpatient,4,ML,15.67,10.969,AETNA [1000108],AETNA [100010801],,,76.8,,12.03,0.222255,85118.57664,percent of total billed charges,,,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,00409-3375-04,NDC,outpatient,4,ML,23.45,16.415,AETNA [1000108],AETNA [100010801],,,76.8,,18.01,0.222255,85118.57664,percent of total billed charges,,,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,70121-1576-01,NDC,outpatient,4,ML,19.72,13.804,AETNA [1000108],AETNA [100010801],,,76.8,,15.14,0.222255,85118.57664,percent of total billed charges,,,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,70121-1576-07,NDC,outpatient,4,ML,19.72,13.804,AETNA [1000108],AETNA [100010801],,,76.8,,15.14,0.222255,85118.57664,percent of total billed charges,,,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,25021-0316-04,NDC,outpatient,4,ML,19.53,13.671,AETNA [1000108],AETNA [100010801],,,76.8,,15,0.222255,85118.57664,percent of total billed charges,,,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,67457-0852-04,NDC,outpatient,4,ML,24.37,17.059,AETNA [1000108],AETNA [100010801],,,76.8,,18.72,0.222255,85118.57664,percent of total billed charges,,,
CALCIUM CARBONATE 600 MG ORAL TABS,RX-1302,CDM,S5000,HCPCS,259,RC,00904-3232-92,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
CALCIUM CARBONATE 600 MG ORAL TABS,RX-1302,CDM,S5000,HCPCS,259,RC,20555-0005-00,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE 4 % EX PTCH,RX-130376,CDM,S5000,HCPCS,259,RC,00536-1202-07,NDC,outpatient,1,UN,3.11,2.177,AETNA [1000108],AETNA [100010801],,,76.8,,2.39,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE 4 % EX PTCH,RX-130376,CDM,S5000,HCPCS,259,RC,41167-0058-40,NDC,outpatient,1,UN,6.13,4.291,AETNA [1000108],AETNA [100010801],,,76.8,,4.71,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE 4 % EX PTCH,RX-130376,CDM,S5000,HCPCS,259,RC,70512-0812-30,NDC,outpatient,1,UN,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,,,
DESVENLAFAXINE SUCCINATE ER 25 MG ORAL TB24,RX-130484,CDM,S5000,HCPCS,259,RC,59762-1210-03,NDC,outpatient,1,UN,2.76,1.932,AETNA [1000108],AETNA [100010801],,,76.8,,2.12,0.222255,85118.57664,percent of total billed charges,,,
DESVENLAFAXINE SUCCINATE ER 25 MG ORAL TB24,RX-130484,CDM,S5000,HCPCS,259,RC,68180-0604-06,NDC,outpatient,1,UN,2.56,1.792,AETNA [1000108],AETNA [100010801],,,76.8,,1.97,0.222255,85118.57664,percent of total billed charges,,,
CALCIUM CHLORIDE 10 % IV SOLN,RX-1306,CDM,S5000,HCPCS,250,RC,00409-4928-11,NDC,outpatient,10,ML,55.67,38.969,AETNA [1000108],AETNA [100010801],,,76.8,,42.75,0.222255,85118.57664,percent of total billed charges,,,
CALCIUM CHLORIDE 10 % IV SOLN,RX-1306,CDM,S5000,HCPCS,250,RC,00409-1631-40,NDC,outpatient,10,ML,41.92,29.344,AETNA [1000108],AETNA [100010801],,,76.8,,32.19,0.222255,85118.57664,percent of total billed charges,,,
CALCIUM CHLORIDE 10 % IV SOLN,RX-1306,CDM,S5000,HCPCS,250,RC,00409-1631-10,NDC,outpatient,10,ML,41.92,29.344,AETNA [1000108],AETNA [100010801],,,76.8,,32.19,0.222255,85118.57664,percent of total billed charges,,,
CALCIUM CHLORIDE 10 % IV SOLN,RX-1306,CDM,S5000,HCPCS,250,RC,00409-4928-34,NDC,outpatient,10,ML,55.67,38.969,AETNA [1000108],AETNA [100010801],,,76.8,,42.75,0.222255,85118.57664,percent of total billed charges,,,
CALCIUM CHLORIDE 10 % IV SOLN,RX-1306,CDM,S5000,HCPCS,250,RC,76329-3304-01,NDC,outpatient,10,ML,39.08,27.356,AETNA [1000108],AETNA [100010801],,,76.8,,30.01,0.222255,85118.57664,percent of total billed charges,,,
VERAPAMIL HCL ER 240 MG ORAL TBCR,RX-13073,CDM,S5000,HCPCS,259,RC,60687-0515-01,NDC,outpatient,1,UN,5.2,3.64,AETNA [1000108],AETNA [100010801],,,76.8,,3.99,0.222255,85118.57664,percent of total billed charges,,,
VERAPAMIL HCL ER 240 MG ORAL TBCR,RX-13073,CDM,S5000,HCPCS,259,RC,60687-0515-11,NDC,outpatient,1,UN,5.2,3.64,AETNA [1000108],AETNA [100010801],,,76.8,,3.99,0.222255,85118.57664,percent of total billed charges,,,
VERAPAMIL HCL ER 240 MG ORAL TBCR,RX-13073,CDM,S5000,HCPCS,259,RC,68462-0260-01,NDC,outpatient,1,UN,1.48,1.036,AETNA [1000108],AETNA [100010801],,,76.8,,1.14,0.222255,85118.57664,percent of total billed charges,,,
TIOTROPIUM BROMIDE-OLODATEROL 2.5-2.5 MCG/ACT IN AERS,RX-131078,CDM,S5000,HCPCS,259,RC,00597-0155-70,NDC,outpatient,4,GR,308.39,215.873,AETNA [1000108],AETNA [100010801],,,76.8,,236.84,0.222255,85118.57664,percent of total billed charges,,,
VITAMIN D3 10 MCG (400 UNIT) ORAL TABS,RX-13108,CDM,S5000,HCPCS,259,RC,50268-0863-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
VITAMIN D3 10 MCG (400 UNIT) ORAL TABS,RX-13108,CDM,S5000,HCPCS,259,RC,00904-5823-60,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
VITAMIN D3 10 MCG (400 UNIT) ORAL TABS,RX-13108,CDM,S5000,HCPCS,259,RC,50268-0863-15,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ELVITEG-COBIC-EMTRICIT-TENOFAF 150-150-200-10 MG ORAL TABS,RX-131233,CDM,S5000,HCPCS,259,RC,61958-1901-01,NDC,outpatient,1,UN,572.84,400.988,AETNA [1000108],AETNA [100010801],,,76.8,,439.94,0.222255,85118.57664,percent of total billed charges,,,
VALACYCLOVIR HCL 500 MG ORAL TABS,RX-13133,CDM,S5000,HCPCS,259,RC,00904-6565-61,NDC,outpatient,1,UN,4.32,3.024,AETNA [1000108],AETNA [100010801],,,76.8,,3.32,0.222255,85118.57664,percent of total billed charges,,,
VALACYCLOVIR HCL 500 MG ORAL TABS,RX-13133,CDM,S5000,HCPCS,259,RC,63739-0077-10,NDC,outpatient,1,UN,4,2.8,AETNA [1000108],AETNA [100010801],,,76.8,,3.07,0.222255,85118.57664,percent of total billed charges,,,
VALACYCLOVIR HCL 500 MG ORAL TABS,RX-13133,CDM,S5000,HCPCS,259,RC,68084-0215-11,NDC,outpatient,1,UN,4.3,3.01,AETNA [1000108],AETNA [100010801],,,76.8,,3.3,0.222255,85118.57664,percent of total billed charges,,,
VALACYCLOVIR HCL 500 MG ORAL TABS,RX-13133,CDM,S5000,HCPCS,259,RC,68084-0215-01,NDC,outpatient,1,UN,4.3,3.01,AETNA [1000108],AETNA [100010801],,,76.8,,3.3,0.222255,85118.57664,percent of total billed charges,,,
SACUBITRIL-VALSARTAN 24-26 MG ORAL TABS,RX-131630,CDM,S5000,HCPCS,259,RC,00078-0659-20,NDC,outpatient,1,UN,46.68,32.676,AETNA [1000108],AETNA [100010801],,,76.8,,35.85,0.222255,85118.57664,percent of total billed charges,,,
SACUBITRIL-VALSARTAN 49-51 MG ORAL TABS,RX-131631,CDM,S5000,HCPCS,259,RC,00078-0777-20,NDC,outpatient,1,UN,46.68,32.676,AETNA [1000108],AETNA [100010801],,,76.8,,35.85,0.222255,85118.57664,percent of total billed charges,,,
SACUBITRIL-VALSARTAN 97-103 MG ORAL TABS,RX-131632,CDM,S5000,HCPCS,259,RC,00078-0696-20,NDC,outpatient,1,UN,46.68,32.676,AETNA [1000108],AETNA [100010801],,,76.8,,35.85,0.222255,85118.57664,percent of total billed charges,,,
AMINOCAPROIC ACID 0.25 GM/ML ORAL SOLN,RX-131645,CDM,S5000,HCPCS,259,RC,99999-0001-90,NDC,outpatient,5,ML,202.39,141.673,AETNA [1000108],AETNA [100010801],,,76.8,,155.44,0.222255,85118.57664,percent of total billed charges,,,
VERAPAMIL HCL ER 120 MG ORAL TBCR,RX-13184,CDM,S5000,HCPCS,259,RC,68462-0292-01,NDC,outpatient,1,UN,1.05,0.735,AETNA [1000108],AETNA [100010801],,,76.8,,0.81,0.222255,85118.57664,percent of total billed charges,,,
BUPIVACAINE-EPINEPHRINE (PF) 0.75% -1:200000 IJ SOLN,RX-132205,CDM,S5000,HCPCS,250,RC,63323-0460-37,NDC,outpatient,30,ML,34.71,24.297,AETNA [1000108],AETNA [100010801],,,76.8,,26.66,0.222255,85118.57664,percent of total billed charges,,,
TICAGRELOR 60 MG ORAL TABS,RX-132286,CDM,S5000,HCPCS,259,RC,00186-0776-60,NDC,outpatient,1,UN,30.77,21.539,AETNA [1000108],AETNA [100010801],,,76.8,,23.63,0.222255,85118.57664,percent of total billed charges,,,
KETAMINE HCL 10 MG/ML IN NS IV SYRINGE,RX-132334,CDM,S5000,HCPCS,250,RC,69374-0982-55,NDC,outpatient,5,ML,26.7,18.69,AETNA [1000108],AETNA [100010801],,,76.8,,20.51,0.222255,85118.57664,percent of total billed charges,,,
KETAMINE HCL 10 MG/ML IN NS IV SYRINGE,RX-132334,CDM,S5000,HCPCS,250,RC,70092-9119-44,NDC,outpatient,5,ML,27.82,19.474,AETNA [1000108],AETNA [100010801],,,76.8,,21.37,0.222255,85118.57664,percent of total billed charges,,,
KETAMINE HCL 10 MG/ML IN NS IV SYRINGE,RX-132334,CDM,S5000,HCPCS,250,RC,70004-0430-09,NDC,outpatient,5,ML,28.93,20.251,AETNA [1000108],AETNA [100010801],,,76.8,,22.22,0.222255,85118.57664,percent of total billed charges,,,
KETAMINE HCL 10 MG/ML IN NS IV SYRINGE,RX-132334,CDM,S5000,HCPCS,250,RC,70092-1119-44,NDC,outpatient,5,ML,20.39,14.273,AETNA [1000108],AETNA [100010801],,,76.8,,15.66,0.222255,85118.57664,percent of total billed charges,,,
CALCIUM ACETATE (PHOS BINDER) 667 MG ORAL CAPS,RX-132734,CDM,S5000,HCPCS,259,RC,00904-7119-06,NDC,outpatient,1,UN,3.29,2.303,AETNA [1000108],AETNA [100010801],,,76.8,,2.53,0.222255,85118.57664,percent of total billed charges,,,
CALCIUM ACETATE (PHOS BINDER) 667 MG ORAL CAPS,RX-132734,CDM,S5000,HCPCS,259,RC,68084-0479-01,NDC,outpatient,1,UN,5.45,3.815,AETNA [1000108],AETNA [100010801],,,76.8,,4.19,0.222255,85118.57664,percent of total billed charges,,,
CALCIUM ACETATE (PHOS BINDER) 667 MG ORAL CAPS,RX-132734,CDM,S5000,HCPCS,259,RC,68084-0479-11,NDC,outpatient,1,UN,5.45,3.815,AETNA [1000108],AETNA [100010801],,,76.8,,4.19,0.222255,85118.57664,percent of total billed charges,,,
BUPRENORPHINE HCL 75 MCG BU FILM,RX-132950,CDM,S5000,HCPCS,259,RC,59385-0021-01,NDC,outpatient,1,UN,29.34,20.538,AETNA [1000108],AETNA [100010801],,,76.8,,22.53,0.222255,85118.57664,percent of total billed charges,,,
BUPRENORPHINE HCL 75 MCG BU FILM,RX-132950,CDM,S5000,HCPCS,259,RC,59385-0021-60,NDC,outpatient,1,UN,29.34,20.538,AETNA [1000108],AETNA [100010801],,,76.8,,22.53,0.222255,85118.57664,percent of total billed charges,,,
BUPRENORPHINE HCL 300 MCG BU FILM,RX-132952,CDM,S5000,HCPCS,259,RC,59385-0023-01,NDC,outpatient,1,UN,46.07,32.249,AETNA [1000108],AETNA [100010801],,,76.8,,35.38,0.222255,85118.57664,percent of total billed charges,,,
BUPRENORPHINE HCL 300 MCG BU FILM,RX-132952,CDM,S5000,HCPCS,259,RC,59385-0023-60,NDC,outpatient,1,UN,46.07,32.249,AETNA [1000108],AETNA [100010801],,,76.8,,35.38,0.222255,85118.57664,percent of total billed charges,,,
BUPRENORPHINE HCL 750 MCG BU FILM,RX-132955,CDM,S5000,HCPCS,259,RC,59385-0026-60,NDC,outpatient,1,UN,70.24,49.168,AETNA [1000108],AETNA [100010801],,,76.8,,53.94,0.222255,85118.57664,percent of total billed charges,,,
BUPRENORPHINE HCL 750 MCG BU FILM,RX-132955,CDM,S5000,HCPCS,259,RC,59385-0026-01,NDC,outpatient,1,UN,70.24,49.168,AETNA [1000108],AETNA [100010801],,,76.8,,53.94,0.222255,85118.57664,percent of total billed charges,,,
BUPRENORPHINE HCL 900 MCG BU FILM,RX-132956,CDM,S5000,HCPCS,259,RC,59385-0027-60,NDC,outpatient,1,UN,72.31,50.617,AETNA [1000108],AETNA [100010801],,,76.8,,55.53,0.222255,85118.57664,percent of total billed charges,,,
BUPRENORPHINE HCL 900 MCG BU FILM,RX-132956,CDM,S5000,HCPCS,259,RC,59385-0027-01,NDC,outpatient,1,UN,72.31,50.617,AETNA [1000108],AETNA [100010801],,,76.8,,55.53,0.222255,85118.57664,percent of total billed charges,,,
NALOXONE HCL 4 MG/0.1ML NA LIQD,RX-132964,CDM,S5000,HCPCS,259,RC,00093-2165-68,NDC,outpatient,1,UN,146.88,102.816,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.222255,85118.57664,percent of total billed charges,,,
NALOXONE HCL 4 MG/0.1ML NA LIQD,RX-132964,CDM,S5000,HCPCS,259,RC,00093-2165-19,NDC,outpatient,1,UN,146.88,102.816,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.222255,85118.57664,percent of total billed charges,,,
PRENATAL VITAMIN PLUS LOW IRON 27-1 MG ORAL TABS,RX-133380,CDM,S5000,HCPCS,259,RC,39328-0106-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
FAMCICLOVIR 500 MG ORAL TABS,RX-13358,CDM,S5000,HCPCS,259,RC,60505-3247-03,NDC,outpatient,1,UN,1.93,1.351,AETNA [1000108],AETNA [100010801],,,76.8,,1.48,0.222255,85118.57664,percent of total billed charges,,,
TRANEXAMIC ACID 1000 MG/10ML IV SOLN,RX-133831,CDM,S5000,HCPCS,250,RC,39822-1000-01,NDC,outpatient,10,ML,23.86,16.702,AETNA [1000108],AETNA [100010801],,,76.8,,18.32,0.222255,85118.57664,percent of total billed charges,,,
TRANEXAMIC ACID 1000 MG/10ML IV SOLN,RX-133831,CDM,S5000,HCPCS,250,RC,72485-0510-01,NDC,outpatient,10,ML,14.6,10.22,AETNA [1000108],AETNA [100010801],,,76.8,,11.21,0.222255,85118.57664,percent of total billed charges,,,
TRANEXAMIC ACID 1000 MG/10ML IV SOLN,RX-133831,CDM,S5000,HCPCS,250,RC,81284-0611-00,NDC,outpatient,10,ML,24.48,17.136,AETNA [1000108],AETNA [100010801],,,76.8,,18.8,0.222255,85118.57664,percent of total billed charges,,,
TRANEXAMIC ACID 1000 MG/10ML IV SOLN,RX-133831,CDM,S5000,HCPCS,250,RC,72485-0510-10,NDC,outpatient,10,ML,14.6,10.22,AETNA [1000108],AETNA [100010801],,,76.8,,11.21,0.222255,85118.57664,percent of total billed charges,,,
TRANEXAMIC ACID 1000 MG/10ML IV SOLN,RX-133831,CDM,S5000,HCPCS,250,RC,81284-0611-10,NDC,outpatient,10,ML,24.48,17.136,AETNA [1000108],AETNA [100010801],,,76.8,,18.8,0.222255,85118.57664,percent of total billed charges,,,
INSULIN REGULAR HUMAN (CONC) 500 UNIT/ML SC SOPN,RX-134373,CDM,S5000,HCPCS,259,RC,00002-8824-01,NDC,outpatient,3,ML,1168.7,818.09,AETNA [1000108],AETNA [100010801],,,76.8,,897.56,0.222255,85118.57664,percent of total billed charges,,,
INSULIN REGULAR HUMAN (CONC) 500 UNIT/ML SC SOPN,RX-134373,CDM,S5000,HCPCS,259,RC,00002-8824-27,NDC,outpatient,3,ML,1168.7,818.09,AETNA [1000108],AETNA [100010801],,,76.8,,897.56,0.222255,85118.57664,percent of total billed charges,,,
EMTRICITABINE-TENOFOVIR AF 200-25 MG ORAL TABS,RX-134420,CDM,S5000,HCPCS,259,RC,61958-2002-01,NDC,outpatient,1,UN,316.88,221.816,AETNA [1000108],AETNA [100010801],,,76.8,,243.36,0.222255,85118.57664,percent of total billed charges,,,
DILTIAZEM HCL-DEXTROSE 125-5 MG/125ML-% IV SOLN,RX-134429,CDM,S5000,HCPCS,250,RC,70004-0540-35,NDC,outpatient,125,ML,123.38,86.366,AETNA [1000108],AETNA [100010801],,,76.8,,94.76,0.222255,85118.57664,percent of total billed charges,,,
DILTIAZEM HCL-DEXTROSE 125-5 MG/125ML-% IV SOLN,RX-134429,CDM,S5000,HCPCS,250,RC,70092-1007-36,NDC,outpatient,125,ML,77.9,54.53,AETNA [1000108],AETNA [100010801],,,76.8,,59.83,0.222255,85118.57664,percent of total billed charges,,,
DILTIAZEM HCL-DEXTROSE 125-5 MG/125ML-% IV SOLN,RX-134429,CDM,S5000,HCPCS,250,RC,70092-1575-36,NDC,outpatient,125,ML,81.02,56.714,AETNA [1000108],AETNA [100010801],,,76.8,,62.22,0.222255,85118.57664,percent of total billed charges,,,
PSYLLIUM 400 MG ORAL CAPS,RX-134482,CDM,S5000,HCPCS,259,RC,37000-0405-14,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
CARBAMAZEPINE 100 MG ORAL CHEW,RX-1355,CDM,S5000,HCPCS,259,RC,00904-3854-61,NDC,outpatient,1,UN,1.65,1.155,AETNA [1000108],AETNA [100010801],,,76.8,,1.27,0.222255,85118.57664,percent of total billed charges,,,
CARBAMAZEPINE 100 MG ORAL CHEW,RX-1355,CDM,S5000,HCPCS,259,RC,60687-0479-01,NDC,outpatient,1,UN,1.69,1.183,AETNA [1000108],AETNA [100010801],,,76.8,,1.3,0.222255,85118.57664,percent of total billed charges,,,
CARBAMAZEPINE 100 MG ORAL CHEW,RX-1355,CDM,S5000,HCPCS,259,RC,60687-0479-11,NDC,outpatient,1,UN,1.69,1.183,AETNA [1000108],AETNA [100010801],,,76.8,,1.3,0.222255,85118.57664,percent of total billed charges,,,
CARBAMAZEPINE 100 MG/5ML ORAL SUSP,RX-1356,CDM,S5000,HCPCS,259,RC,99999-0001-92,NDC,outpatient,10,ML,6.06,4.242,AETNA [1000108],AETNA [100010801],,,76.8,,4.65,0.222255,85118.57664,percent of total billed charges,,,
METHYLENE BLUE (ANTIDOTE) 50 MG/10ML IV SOLN,RX-135699,CDM,S5000,HCPCS,250,RC,00517-0374-05,NDC,outpatient,10,ML,411.18,287.826,AETNA [1000108],AETNA [100010801],,,76.8,,315.79,0.222255,85118.57664,percent of total billed charges,,,
METHYLENE BLUE (ANTIDOTE) 50 MG/10ML IV SOLN,RX-135699,CDM,S5000,HCPCS,250,RC,00517-0374-01,NDC,outpatient,10,ML,411.18,287.826,AETNA [1000108],AETNA [100010801],,,76.8,,315.79,0.222255,85118.57664,percent of total billed charges,,,
CARBAMAZEPINE 200 MG ORAL TABS,RX-1357,CDM,S5000,HCPCS,259,RC,00904-6172-61,NDC,outpatient,1,UN,2.42,1.694,AETNA [1000108],AETNA [100010801],,,76.8,,1.86,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE-SODIUM BICARBONATE 1-8.4 % IJ SOSY,RX-135806,CDM,S5000,HCPCS,250,RC,70004-0725-05,NDC,outpatient,1,ML,19.02,13.314,AETNA [1000108],AETNA [100010801],,,76.8,,14.61,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE-SODIUM BICARBONATE 1-8.4 % IJ SOSY,RX-135806,CDM,S5000,HCPCS,250,RC,70092-1443-43,NDC,outpatient,1,ML,22.08,15.456,AETNA [1000108],AETNA [100010801],,,76.8,,16.96,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE-SODIUM BICARBONATE 1-8.4 % IJ SOSY,RX-135806,CDM,S5000,HCPCS,250,RC,99999-0003-11,NDC,outpatient,1.1,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,,,
VANCOMYCIN HCL IN NACL 0.9 % 1500 MG/250ML IV SOLN,RX-135845,CDM,S5000,HCPCS,250,RC,70004-0924-59,NDC,outpatient,280,ML,189.24,132.468,AETNA [1000108],AETNA [100010801],,,76.8,,145.34,0.222255,85118.57664,percent of total billed charges,,,
VANCOMYCIN HCL IN NACL 0.9 % 1500 MG/250ML IV SOLN,RX-135845,CDM,S5000,HCPCS,250,RC,99999-0001-84,NDC,outpatient,280,ML,33.42,23.394,AETNA [1000108],AETNA [100010801],,,76.8,,25.67,0.222255,85118.57664,percent of total billed charges,,,
VANCOMYCIN HCL IN NACL 0.9 % 1500 MG/250ML IV SOLN,RX-135845,CDM,S5000,HCPCS,250,RC,70092-9056-05,NDC,outpatient,280,ML,121.34,84.938,AETNA [1000108],AETNA [100010801],,,76.8,,93.19,0.222255,85118.57664,percent of total billed charges,,,
CARBAMIDE PEROXIDE 6.5 % OT SOLN,RX-1359,CDM,S5000,HCPCS,259,RC,00904-6627-35,NDC,outpatient,15,ML,6.35,4.445,AETNA [1000108],AETNA [100010801],,,76.8,,4.88,0.222255,85118.57664,percent of total billed charges,,,
CARBAMIDE PEROXIDE 6.5 % OT SOLN,RX-1359,CDM,S5000,HCPCS,259,RC,78112-0736-23,NDC,outpatient,15,ML,15.56,10.892,AETNA [1000108],AETNA [100010801],,,76.8,,11.95,0.222255,85118.57664,percent of total billed charges,,,
CARBAMIDE PEROXIDE 6.5 % OT SOLN,RX-1359,CDM,S5000,HCPCS,259,RC,78112-0736-21,NDC,outpatient,15,ML,17.89,12.523,AETNA [1000108],AETNA [100010801],,,76.8,,13.74,0.222255,85118.57664,percent of total billed charges,,,
METHOTREXATE SODIUM 2.5 MG ORAL TABS,RX-13594,CDM,S5000,HCPCS,259,RC,50268-0527-15,NDC,outpatient,1,UN,5.12,3.584,AETNA [1000108],AETNA [100010801],,,76.8,,3.93,0.222255,85118.57664,percent of total billed charges,,,
METHOTREXATE SODIUM 2.5 MG ORAL TABS,RX-13594,CDM,S5000,HCPCS,259,RC,50268-0527-11,NDC,outpatient,1,UN,5.12,3.584,AETNA [1000108],AETNA [100010801],,,76.8,,3.93,0.222255,85118.57664,percent of total billed charges,,,
METHOTREXATE SODIUM 2.5 MG ORAL TABS,RX-13594,CDM,S5000,HCPCS,259,RC,00054-8550-25,NDC,outpatient,1,UN,5.49,3.843,AETNA [1000108],AETNA [100010801],,,76.8,,4.22,0.222255,85118.57664,percent of total billed charges,,,
DEXMEDETOMIDINE HCL 1000 MCG/10ML IV SOLN,RX-136367,CDM,S5000,HCPCS,250,RC,44567-0601-04,NDC,outpatient,10,ML,205.59,143.913,AETNA [1000108],AETNA [100010801],,,76.8,,157.89,0.222255,85118.57664,percent of total billed charges,,,
MICONAZOLE NITRATE 2 % EX OINT,RX-13651,CDM,S5000,HCPCS,259,RC,53329-0172-10,NDC,outpatient,71,GR,15.17,10.619,AETNA [1000108],AETNA [100010801],,,76.8,,11.65,0.222255,85118.57664,percent of total billed charges,,,
MICONAZOLE NITRATE 2 % EX OINT,RX-13651,CDM,S5000,HCPCS,259,RC,11701-0067-23,NDC,outpatient,57,GR,25.88,18.116,AETNA [1000108],AETNA [100010801],,,76.8,,19.88,0.222255,85118.57664,percent of total billed charges,,,
VANCOMYCIN HCL IN NACL 0.9 % 1250 MG/250ML IV SOLN,RX-136649,CDM,S5000,HCPCS,250,RC,99999-0001-85,NDC,outpatient,275,ML,59.61,41.727,AETNA [1000108],AETNA [100010801],,,76.8,,45.78,0.222255,85118.57664,percent of total billed charges,,,
VANCOMYCIN HCL IN NACL 0.9 % 1250 MG/250ML IV SOLN,RX-136649,CDM,S5000,HCPCS,250,RC,70092-9054-05,NDC,outpatient,275,ML,111.55,78.085,AETNA [1000108],AETNA [100010801],,,76.8,,85.67,0.222255,85118.57664,percent of total billed charges,,,
VANCOMYCIN HCL IN NACL 0.9 % 1250 MG/250ML IV SOLN,RX-136649,CDM,S5000,HCPCS,250,RC,71506-0015-58,NDC,outpatient,275,ML,93.39,65.373,AETNA [1000108],AETNA [100010801],,,76.8,,71.72,0.222255,85118.57664,percent of total billed charges,,,
VANCOMYCIN HCL IN NACL 0.9 % 1250 MG/250ML IV SOLN,RX-136649,CDM,S5000,HCPCS,250,RC,70004-0923-59,NDC,outpatient,275,ML,170.02,119.014,AETNA [1000108],AETNA [100010801],,,76.8,,130.58,0.222255,85118.57664,percent of total billed charges,,,
GUAIFENESIN 100 MG/5ML ORAL LIQD,RX-13748,CDM,S5000,HCPCS,259,RC,00121-2232-00,NDC,outpatient,15,ML,6.68,4.676,AETNA [1000108],AETNA [100010801],,,76.8,,5.13,0.222255,85118.57664,percent of total billed charges,,,
GUAIFENESIN 100 MG/5ML ORAL LIQD,RX-13748,CDM,S5000,HCPCS,259,RC,00121-2232-15,NDC,outpatient,15,ML,6.68,4.676,AETNA [1000108],AETNA [100010801],,,76.8,,5.13,0.222255,85118.57664,percent of total billed charges,,,
DILTIAZEM HCL-SODIUM CHLORIDE 125-0.9 MG/125ML-% IV SOLN,RX-137908,CDM,S5000,HCPCS,250,RC,76154-0818-05,NDC,outpatient,125,ML,82.75,57.925,AETNA [1000108],AETNA [100010801],,,76.8,,63.55,0.222255,85118.57664,percent of total billed charges,,,
DILTIAZEM HCL-SODIUM CHLORIDE 125-0.9 MG/125ML-% IV SOLN,RX-137908,CDM,S5000,HCPCS,250,RC,99999-0003-40,NDC,outpatient,125,ML,51.6,36.12,AETNA [1000108],AETNA [100010801],,,76.8,,39.63,0.222255,85118.57664,percent of total billed charges,,,
OXYTOCIN-SODIUM CHLORIDE 30-0.9 UT/500ML-% IV SOLN,RX-137935,CDM,S5000,HCPCS,250,RC,70092-1068-07,NDC,outpatient,500,ML,106.3,74.41,AETNA [1000108],AETNA [100010801],,,76.8,,81.64,0.222255,85118.57664,percent of total billed charges,,,
OXYTOCIN-SODIUM CHLORIDE 30-0.9 UT/500ML-% IV SOLN,RX-137935,CDM,S5000,HCPCS,250,RC,70092-1552-07,NDC,outpatient,500,ML,97.53,68.271,AETNA [1000108],AETNA [100010801],,,76.8,,74.9,0.222255,85118.57664,percent of total billed charges,,,
LINACLOTIDE 72 MCG ORAL CAPS,RX-138008,CDM,S5000,HCPCS,259,RC,00456-1203-30,NDC,outpatient,1,UN,74.11,51.877,AETNA [1000108],AETNA [100010801],,,76.8,,56.92,0.222255,85118.57664,percent of total billed charges,,,
BACITRACIN ZINC 500 UNIT/GM EX OINT,RX-13818,CDM,S5000,HCPCS,259,RC,57896-0145-14,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
BACITRACIN ZINC 500 UNIT/GM EX OINT,RX-13818,CDM,S5000,HCPCS,259,RC,00536-1263-28,NDC,outpatient,28,GR,4.99,3.493,AETNA [1000108],AETNA [100010801],,,76.8,,3.83,0.222255,85118.57664,percent of total billed charges,,,
BACITRACIN ZINC 500 UNIT/GM EX OINT,RX-13818,CDM,S5000,HCPCS,259,RC,58980-0011-10,NDC,outpatient,28.35,GR,10.1,7.07,AETNA [1000108],AETNA [100010801],,,76.8,,7.76,0.222255,85118.57664,percent of total billed charges,,,
VANCOMYCIN HCL IN NACL 2-0.9 GM/500ML-% IV SOLN,RX-138299,CDM,S5000,HCPCS,250,RC,71506-0019-59,NDC,outpatient,540,ML,128.46,89.922,AETNA [1000108],AETNA [100010801],,,76.8,,98.66,0.222255,85118.57664,percent of total billed charges,,,
VANCOMYCIN HCL IN NACL 2-0.9 GM/500ML-% IV SOLN,RX-138299,CDM,S5000,HCPCS,250,RC,99999-0002-01,NDC,outpatient,540,ML,36.84,25.788,AETNA [1000108],AETNA [100010801],,,76.8,,28.29,0.222255,85118.57664,percent of total billed charges,,,
VANCOMYCIN HCL IN NACL 1.75-0.9 GM/500ML-% IV SOLN,RX-138322,CDM,S5000,HCPCS,250,RC,99999-0002-00,NDC,outpatient,535,ML,35.39,24.773,AETNA [1000108],AETNA [100010801],,,76.8,,27.18,0.222255,85118.57664,percent of total billed charges,,,
VANCOMYCIN HCL IN NACL 1.75-0.9 GM/500ML-% IV SOLN,RX-138322,CDM,S5000,HCPCS,250,RC,71506-0017-59,NDC,outpatient,535,ML,119.16,83.412,AETNA [1000108],AETNA [100010801],,,76.8,,91.51,0.222255,85118.57664,percent of total billed charges,,,
BENZOCAINE 20 % MT AERO,RX-138339,CDM,S5000,HCPCS,259,RC,00283-0679-02,NDC,outpatient,57,GR,120.74,84.518,AETNA [1000108],AETNA [100010801],,,76.8,,92.73,0.222255,85118.57664,percent of total billed charges,,,
PORACTANT ALFA 120 MG/1.5ML INTRATRACHEA SUSP,RX-138354,CDM,S5000,HCPCS,250,RC,10122-0510-01,NDC,outpatient,1.5,ML,1807.78,1265.446,AETNA [1000108],AETNA [100010801],,,76.8,,1388.38,0.222255,85118.57664,percent of total billed charges,,,
PORACTANT ALFA 240 MG/3ML INTRATRACHEA SUSP,RX-138355,CDM,S5000,HCPCS,250,RC,10122-0510-03,NDC,outpatient,3,ML,2153.49,1507.443,AETNA [1000108],AETNA [100010801],,,76.8,,1653.88,0.222255,85118.57664,percent of total billed charges,,,
COLESTIPOL HCL 1 G ORAL TABS,RX-13884,CDM,S5000,HCPCS,259,RC,00115-5211-16,NDC,outpatient,1,UN,4.6,3.22,AETNA [1000108],AETNA [100010801],,,76.8,,3.53,0.222255,85118.57664,percent of total billed charges,,,
COLESTIPOL HCL 1 G ORAL TABS,RX-13884,CDM,S5000,HCPCS,259,RC,60687-0715-11,NDC,outpatient,1,UN,12.93,9.051,AETNA [1000108],AETNA [100010801],,,76.8,,9.93,0.222255,85118.57664,percent of total billed charges,,,
COLESTIPOL HCL 1 G ORAL TABS,RX-13884,CDM,S5000,HCPCS,259,RC,00009-0450-03,NDC,outpatient,1,UN,9.24,6.468,AETNA [1000108],AETNA [100010801],,,76.8,,7.1,0.222255,85118.57664,percent of total billed charges,,,
COLESTIPOL HCL 1 G ORAL TABS,RX-13884,CDM,S5000,HCPCS,259,RC,59762-0450-01,NDC,outpatient,1,UN,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,,,
COLESTIPOL HCL 1 G ORAL TABS,RX-13884,CDM,S5000,HCPCS,259,RC,60687-0715-21,NDC,outpatient,1,UN,12.93,9.051,AETNA [1000108],AETNA [100010801],,,76.8,,9.93,0.222255,85118.57664,percent of total billed charges,,,
MORPHINE SULFATE 100 MG IN NACL 0.9 % 100 ML IV PREMIX,RX-138903,CDM,S5000,HCPCS,250,RC,99999-0003-24,NDC,outpatient,100,ML,48.85,34.195,AETNA [1000108],AETNA [100010801],,,76.8,,37.52,0.222255,85118.57664,percent of total billed charges,,,
MORPHINE SULFATE 100 MG IN NACL 0.9 % 100 ML IV PREMIX,RX-138903,CDM,S5000,HCPCS,250,RC,70092-1380-36,NDC,outpatient,100,ML,69.27,48.489,AETNA [1000108],AETNA [100010801],,,76.8,,53.2,0.222255,85118.57664,percent of total billed charges,,,
MORPHINE SULFATE 100 MG IN NACL 0.9 % 100 ML IV PREMIX,RX-138903,CDM,S5000,HCPCS,250,RC,70092-1130-36,NDC,outpatient,100,ML,83.73,58.611,AETNA [1000108],AETNA [100010801],,,76.8,,64.3,0.222255,85118.57664,percent of total billed charges,,,
DAPAGLIFLOZIN PROPANEDIOL 5 MG ORAL TABS,RX-138997,CDM,S5000,HCPCS,259,RC,00310-6205-30,NDC,outpatient,1,UN,54.15,37.905,AETNA [1000108],AETNA [100010801],,,76.8,,41.59,0.222255,85118.57664,percent of total billed charges,,,
DAPAGLIFLOZIN PROPANEDIOL 5 MG ORAL TABS,RX-138997,CDM,S5000,HCPCS,259,RC,66993-0456-30,NDC,outpatient,1,UN,54.61,38.227,AETNA [1000108],AETNA [100010801],,,76.8,,41.94,0.222255,85118.57664,percent of total billed charges,,,
DAPAGLIFLOZIN PROPANEDIOL 10 MG ORAL TABS,RX-138998,CDM,S5000,HCPCS,259,RC,66993-0457-30,NDC,outpatient,1,UN,57.77,40.439,AETNA [1000108],AETNA [100010801],,,76.8,,44.37,0.222255,85118.57664,percent of total billed charges,,,
DAPAGLIFLOZIN PROPANEDIOL 10 MG ORAL TABS,RX-138998,CDM,S5000,HCPCS,259,RC,00310-6210-39,NDC,outpatient,1,UN,54.15,37.905,AETNA [1000108],AETNA [100010801],,,76.8,,41.59,0.222255,85118.57664,percent of total billed charges,,,
OCUVITE-LUTEIN ORAL TABS,RX-139063,CDM,S5000,HCPCS,259,RC,00536-5090-08,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
OCUVITE-LUTEIN ORAL TABS,RX-139063,CDM,S5000,HCPCS,259,RC,24208-0387-62,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
SARILUMAB 200 MG/1.14ML SC SOSY,RX-139347,CDM,S5000,HCPCS,250,RC,00024-5910-00,NDC,outpatient,1.14,ML,5813.71,4069.597,AETNA [1000108],AETNA [100010801],,,76.8,,4464.93,0.222255,85118.57664,percent of total billed charges,,,
SARILUMAB 200 MG/1.14ML SC SOSY,RX-139347,CDM,S5000,HCPCS,250,RC,00024-5910-01,NDC,outpatient,1.14,ML,5813.71,4069.597,AETNA [1000108],AETNA [100010801],,,76.8,,4464.93,0.222255,85118.57664,percent of total billed charges,,,
CARISOPRODOL 350 MG ORAL TABS,RX-1395,CDM,S5000,HCPCS,259,RC,50228-0109-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LAMOTRIGINE 25 MG ORAL TABS,RX-13981,CDM,S5000,HCPCS,259,RC,00904-7007-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LAMOTRIGINE 25 MG ORAL TABS,RX-13981,CDM,S5000,HCPCS,259,RC,51672-4130-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LAMOTRIGINE 25 MG ORAL TABS,RX-13981,CDM,S5000,HCPCS,259,RC,68084-0318-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LAMOTRIGINE 25 MG ORAL TABS,RX-13981,CDM,S5000,HCPCS,259,RC,68084-0318-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LAMOTRIGINE 100 MG ORAL TABS,RX-13982,CDM,S5000,HCPCS,259,RC,68084-0319-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LAMOTRIGINE 100 MG ORAL TABS,RX-13982,CDM,S5000,HCPCS,259,RC,00904-7008-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LAMOTRIGINE 100 MG ORAL TABS,RX-13982,CDM,S5000,HCPCS,259,RC,51672-4131-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LAMOTRIGINE 100 MG ORAL TABS,RX-13982,CDM,S5000,HCPCS,259,RC,68084-0319-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
CALCIUM CARBONATE ANTACID 1250 MG/5ML ORAL SUSP,RX-140541,CDM,S5000,HCPCS,259,RC,00121-4766-05,NDC,outpatient,5,ML,9.19,6.433,AETNA [1000108],AETNA [100010801],,,76.8,,7.06,0.222255,85118.57664,percent of total billed charges,,,
DILTIAZEM HCL ER 60 MG ORAL CP12,RX-14100,CDM,S5000,HCPCS,259,RC,51079-0924-01,NDC,outpatient,1,UN,13.61,9.527,AETNA [1000108],AETNA [100010801],,,76.8,,10.45,0.222255,85118.57664,percent of total billed charges,,,
DILTIAZEM HCL ER 60 MG ORAL CP12,RX-14100,CDM,S5000,HCPCS,259,RC,51079-0924-20,NDC,outpatient,1,UN,13.61,9.527,AETNA [1000108],AETNA [100010801],,,76.8,,10.45,0.222255,85118.57664,percent of total billed charges,,,
DILTIAZEM HCL ER 90 MG ORAL CP12,RX-14101,CDM,S5000,HCPCS,259,RC,51079-0925-01,NDC,outpatient,1,UN,16,11.2,AETNA [1000108],AETNA [100010801],,,76.8,,12.29,0.222255,85118.57664,percent of total billed charges,,,
DILTIAZEM HCL ER 90 MG ORAL CP12,RX-14101,CDM,S5000,HCPCS,259,RC,51079-0925-20,NDC,outpatient,1,UN,16,11.2,AETNA [1000108],AETNA [100010801],,,76.8,,12.29,0.222255,85118.57664,percent of total billed charges,,,
KETOCONAZOLE 2 % EX SHAM,RX-14132,CDM,S5000,HCPCS,259,RC,45802-0465-64,NDC,outpatient,120,ML,53.4,37.38,AETNA [1000108],AETNA [100010801],,,76.8,,41.01,0.222255,85118.57664,percent of total billed charges,,,
BECLOMETHASONE DIPROP HFA 40 MCG/ACT IN AERB,RX-141345,CDM,S5000,HCPCS,259,RC,59310-0302-40,NDC,outpatient,10.6,GR,878.5,614.95,AETNA [1000108],AETNA [100010801],,,76.8,,674.69,0.222255,85118.57664,percent of total billed charges,,,
BECLOMETHASONE DIPROP HFA 80 MCG/ACT IN AERB,RX-141346,CDM,S5000,HCPCS,259,RC,59310-0304-80,NDC,outpatient,10.6,GR,1176.28,823.396,AETNA [1000108],AETNA [100010801],,,76.8,,903.38,0.222255,85118.57664,percent of total billed charges,,,
BICTEGRAVIR-EMTRICITAB-TENOFOV 50-200-25 MG ORAL TABS,RX-142007,CDM,S5000,HCPCS,259,RC,61958-2501-01,NDC,outpatient,1,UN,572.84,400.988,AETNA [1000108],AETNA [100010801],,,76.8,,439.94,0.222255,85118.57664,percent of total billed charges,,,
FLUCONAZOLE 40 MG/ML ORAL SUSR,RX-14233,CDM,S5000,HCPCS,259,RC,59762-5030-01,NDC,outpatient,35,ML,84.73,59.311,AETNA [1000108],AETNA [100010801],,,76.8,,65.07,0.222255,85118.57664,percent of total billed charges,,,
FLUCONAZOLE 40 MG/ML ORAL SUSR,RX-14233,CDM,S5000,HCPCS,259,RC,16714-0696-01,NDC,outpatient,35,ML,43.77,30.639,AETNA [1000108],AETNA [100010801],,,76.8,,33.62,0.222255,85118.57664,percent of total billed charges,,,
FLUCONAZOLE 40 MG/ML ORAL SUSR,RX-14233,CDM,S5000,HCPCS,259,RC,99999-0002-78,NDC,outpatient,5,ML,12.62,8.834,AETNA [1000108],AETNA [100010801],,,76.8,,9.69,0.222255,85118.57664,percent of total billed charges,,,
MAGNESIUM CHLORIDE 64 MG ORAL TBEC,RX-142395,CDM,S5000,HCPCS,259,RC,10006-0700-13,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
MAGNESIUM CHLORIDE 64 MG ORAL TBEC,RX-142395,CDM,S5000,HCPCS,259,RC,57896-0635-06,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
MAGNESIUM CHLORIDE 64 MG ORAL TBEC,RX-142395,CDM,S5000,HCPCS,259,RC,68585-0005-75,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
POTASSIUM IODIDE (EXPECTORANT) 1 GM/ML ORAL SOLN,RX-142406,CDM,S5000,HCPCS,259,RC,71740-0112-30,NDC,outpatient,0.25,ML,14.74,10.318,AETNA [1000108],AETNA [100010801],,,76.8,,11.32,0.222255,85118.57664,percent of total billed charges,,,
POTASSIUM IODIDE (EXPECTORANT) 1 GM/ML ORAL SOLN,RX-142406,CDM,S5000,HCPCS,259,RC,99999-0003-49,NDC,outpatient,1,ML,58.94,41.258,AETNA [1000108],AETNA [100010801],,,76.8,,45.27,0.222255,85118.57664,percent of total billed charges,,,
DARUN-COBIC-EMTRICIT-TENOFAF 800-150-200-10 MG ORAL TABS,RX-143657,CDM,S5000,HCPCS,259,RC,59676-0800-30,NDC,outpatient,1,UN,678.69,475.083,AETNA [1000108],AETNA [100010801],,,76.8,,521.23,0.222255,85118.57664,percent of total billed charges,,,
PIMAVANSERIN TARTRATE 34 MG ORAL CAPS,RX-143683,CDM,S5000,HCPCS,259,RC,63090-0340-30,NDC,outpatient,1,UN,740.93,518.651,AETNA [1000108],AETNA [100010801],,,76.8,,569.03,0.222255,85118.57664,percent of total billed charges,,,
SODIUM ZIRCONIUM CYCLOSILICATE 10 G ORAL PACK,RX-143885,CDM,S5000,HCPCS,259,RC,00310-1110-01,NDC,outpatient,1,UN,69.73,48.811,AETNA [1000108],AETNA [100010801],,,76.8,,53.55,0.222255,85118.57664,percent of total billed charges,,,
SODIUM ZIRCONIUM CYCLOSILICATE 10 G ORAL PACK,RX-143885,CDM,S5000,HCPCS,259,RC,00310-1110-39,NDC,outpatient,1,UN,69.73,48.811,AETNA [1000108],AETNA [100010801],,,76.8,,53.55,0.222255,85118.57664,percent of total billed charges,,,
CLONIDINE 0.1 MG/24HR TD PTWK,RX-144285,CDM,S5000,HCPCS,259,RC,00378-0871-16,NDC,outpatient,1,UN,58.96,41.272,AETNA [1000108],AETNA [100010801],,,76.8,,45.28,0.222255,85118.57664,percent of total billed charges,,,
CLONIDINE 0.1 MG/24HR TD PTWK,RX-144285,CDM,S5000,HCPCS,259,RC,52817-0610-04,NDC,outpatient,1,UN,36.6,25.62,AETNA [1000108],AETNA [100010801],,,76.8,,28.11,0.222255,85118.57664,percent of total billed charges,,,
CLONIDINE 0.1 MG/24HR TD PTWK,RX-144285,CDM,S5000,HCPCS,259,RC,00378-0871-99,NDC,outpatient,1,UN,58.96,41.272,AETNA [1000108],AETNA [100010801],,,76.8,,45.28,0.222255,85118.57664,percent of total billed charges,,,
CLONIDINE 0.2 MG/24HR TD PTWK,RX-144286,CDM,S5000,HCPCS,259,RC,00591-3509-54,NDC,outpatient,1,UN,89.34,62.538,AETNA [1000108],AETNA [100010801],,,76.8,,68.61,0.222255,85118.57664,percent of total billed charges,,,
CLONIDINE 0.2 MG/24HR TD PTWK,RX-144286,CDM,S5000,HCPCS,259,RC,51862-0454-01,NDC,outpatient,1,UN,43.76,30.632,AETNA [1000108],AETNA [100010801],,,76.8,,33.61,0.222255,85118.57664,percent of total billed charges,,,
CLONIDINE 0.2 MG/24HR TD PTWK,RX-144286,CDM,S5000,HCPCS,259,RC,00591-3509-04,NDC,outpatient,1,UN,89.34,62.538,AETNA [1000108],AETNA [100010801],,,76.8,,68.61,0.222255,85118.57664,percent of total billed charges,,,
CLONIDINE 0.2 MG/24HR TD PTWK,RX-144286,CDM,S5000,HCPCS,259,RC,82089-0102-34,NDC,outpatient,1,UN,502.38,351.666,AETNA [1000108],AETNA [100010801],,,76.8,,385.83,0.222255,85118.57664,percent of total billed charges,,,
CLONIDINE 0.2 MG/24HR TD PTWK,RX-144286,CDM,S5000,HCPCS,259,RC,51862-0454-04,NDC,outpatient,1,UN,43.76,30.632,AETNA [1000108],AETNA [100010801],,,76.8,,33.61,0.222255,85118.57664,percent of total billed charges,,,
CLONIDINE 0.3 MG/24HR TD PTWK,RX-144287,CDM,S5000,HCPCS,259,RC,00591-3510-04,NDC,outpatient,1,UN,122.13,85.491,AETNA [1000108],AETNA [100010801],,,76.8,,93.8,0.222255,85118.57664,percent of total billed charges,,,
CLONIDINE 0.3 MG/24HR TD PTWK,RX-144287,CDM,S5000,HCPCS,259,RC,00591-3510-54,NDC,outpatient,1,UN,122.13,85.491,AETNA [1000108],AETNA [100010801],,,76.8,,93.8,0.222255,85118.57664,percent of total billed charges,,,
RIVAROXABAN 2.5 MG ORAL TABS,RX-144544,CDM,S5000,HCPCS,259,RC,50458-0577-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
RIVAROXABAN 2.5 MG ORAL TABS,RX-144544,CDM,S5000,HCPCS,259,RC,50458-0577-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
DORZOLAMIDE HCL 2 % OP SOLN,RX-14471,CDM,S5000,HCPCS,259,RC,24208-0485-10,NDC,outpatient,10,ML,36.09,25.263,AETNA [1000108],AETNA [100010801],,,76.8,,27.72,0.222255,85118.57664,percent of total billed charges,,,
DORZOLAMIDE HCL 2 % OP SOLN,RX-14471,CDM,S5000,HCPCS,259,RC,42571-0141-26,NDC,outpatient,10,ML,151.26,105.882,AETNA [1000108],AETNA [100010801],,,76.8,,116.17,0.222255,85118.57664,percent of total billed charges,,,
DORZOLAMIDE HCL 2 % OP SOLN,RX-14471,CDM,S5000,HCPCS,259,RC,61314-0019-10,NDC,outpatient,10,ML,71.78,50.246,AETNA [1000108],AETNA [100010801],,,76.8,,55.13,0.222255,85118.57664,percent of total billed charges,,,
REVEFENACIN 175 MCG/3ML IN SOLN,RX-145104,CDM,S5000,HCPCS,259,RC,49502-0806-32,NDC,outpatient,3,ML,93.63,65.541,AETNA [1000108],AETNA [100010801],,,76.8,,71.91,0.222255,85118.57664,percent of total billed charges,,,
REVEFENACIN 175 MCG/3ML IN SOLN,RX-145104,CDM,S5000,HCPCS,259,RC,49502-0806-93,NDC,outpatient,3,ML,93.63,65.541,AETNA [1000108],AETNA [100010801],,,76.8,,71.91,0.222255,85118.57664,percent of total billed charges,,,
TERAZOSIN HCL 1 MG ORAL CAPS,RX-14550,CDM,S5000,HCPCS,259,RC,50268-0764-15,NDC,outpatient,1,UN,2.5,1.75,AETNA [1000108],AETNA [100010801],,,76.8,,1.92,0.222255,85118.57664,percent of total billed charges,,,
TERAZOSIN HCL 1 MG ORAL CAPS,RX-14550,CDM,S5000,HCPCS,259,RC,50268-0764-11,NDC,outpatient,1,UN,2.5,1.75,AETNA [1000108],AETNA [100010801],,,76.8,,1.92,0.222255,85118.57664,percent of total billed charges,,,
TERAZOSIN HCL 5 MG ORAL CAPS,RX-14553,CDM,S5000,HCPCS,259,RC,50268-0766-15,NDC,outpatient,1,UN,2.67,1.869,AETNA [1000108],AETNA [100010801],,,76.8,,2.05,0.222255,85118.57664,percent of total billed charges,,,
TERAZOSIN HCL 5 MG ORAL CAPS,RX-14553,CDM,S5000,HCPCS,259,RC,50268-0766-11,NDC,outpatient,1,UN,2.67,1.869,AETNA [1000108],AETNA [100010801],,,76.8,,2.05,0.222255,85118.57664,percent of total billed charges,,,
ABLYSINOL IA SOLN,RX-145979,CDM,S5000,HCPCS,250,RC,54288-0105-02,NDC,outpatient,5,ML,2091.2,1463.84,AETNA [1000108],AETNA [100010801],,,76.8,,1606.04,0.222255,85118.57664,percent of total billed charges,,,
ABLYSINOL IA SOLN,RX-145979,CDM,S5000,HCPCS,250,RC,54288-0105-15,NDC,outpatient,5,ML,2091.2,1463.84,AETNA [1000108],AETNA [100010801],,,76.8,,1606.04,0.222255,85118.57664,percent of total billed charges,,,
PYRIDOSTIGMINE BROMIDE 60 MG/5ML ORAL SOLN,RX-146239,CDM,S5000,HCPCS,259,RC,99999-0002-40,NDC,outpatient,5,ML,47,32.9,AETNA [1000108],AETNA [100010801],,,76.8,,36.1,0.222255,85118.57664,percent of total billed charges,,,
PYRIDOSTIGMINE BROMIDE 60 MG/5ML ORAL SOLN,RX-146239,CDM,S5000,HCPCS,259,RC,69238-1731-02,NDC,outpatient,473,ML,2201.68,1541.176,AETNA [1000108],AETNA [100010801],,,76.8,,1690.89,0.222255,85118.57664,percent of total billed charges,,,
VERAPAMIL HCL ER 180 MG ORAL TBCR,RX-14626,CDM,S5000,HCPCS,259,RC,75834-0158-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
INDOMETHACIN ER 75 MG ORAL CPCR,RX-14628,CDM,S5000,HCPCS,259,RC,68084-0411-11,NDC,outpatient,1,UN,9.29,6.503,AETNA [1000108],AETNA [100010801],,,76.8,,7.13,0.222255,85118.57664,percent of total billed charges,,,
INDOMETHACIN ER 75 MG ORAL CPCR,RX-14628,CDM,S5000,HCPCS,259,RC,68084-0411-21,NDC,outpatient,1,UN,9.29,6.503,AETNA [1000108],AETNA [100010801],,,76.8,,7.13,0.222255,85118.57664,percent of total billed charges,,,
TRAMADOL HCL 50 MG ORAL TABS,RX-14632,CDM,S5000,HCPCS,259,RC,60687-0795-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
TRAMADOL HCL 50 MG ORAL TABS,RX-14632,CDM,S5000,HCPCS,259,RC,00904-7179-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
TRAMADOL HCL 50 MG ORAL TABS,RX-14632,CDM,S5000,HCPCS,259,RC,00093-0058-05,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
TRAMADOL HCL 50 MG ORAL TABS,RX-14632,CDM,S5000,HCPCS,259,RC,29300-0355-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
TRAMADOL HCL 50 MG ORAL TABS,RX-14632,CDM,S5000,HCPCS,259,RC,60687-0795-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ACETIC ACID 5 % SOLN,RX-14702,CDM,S5000,HCPCS,259,RC,99999-0000-92,NDC,outpatient,60,ML,12.55,8.785,AETNA [1000108],AETNA [100010801],,,76.8,,9.64,0.222255,85118.57664,percent of total billed charges,,,
METFORMIN HCL 850 MG ORAL TABS,RX-14719,CDM,S5000,HCPCS,259,RC,60687-0143-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
METFORMIN HCL 850 MG ORAL TABS,RX-14719,CDM,S5000,HCPCS,259,RC,00904-7163-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
METFORMIN HCL 850 MG ORAL TABS,RX-14719,CDM,S5000,HCPCS,259,RC,60687-0143-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
GLYBURIDE MICRONIZED 1.5 MG ORAL TABS,RX-14777,CDM,S5000,HCPCS,259,RC,00093-8034-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
INSULIN REGULAR(HUMAN) IN NACL 100-0.9 UT/100ML-% IV SOLN,RX-147794,CDM,S5000,HCPCS,250,RC,00338-0126-12,NDC,outpatient,100,ML,98.33,68.831,AETNA [1000108],AETNA [100010801],,,76.8,,75.52,0.222255,85118.57664,percent of total billed charges,,,
TRANEXAMIC ACID-NACL 1000-0.7 MG/100ML-% IV SOLN,RX-147865,CDM,S5000,HCPCS,250,RC,51754-0108-03,NDC,outpatient,100,ML,46.71,32.697,AETNA [1000108],AETNA [100010801],,,76.8,,35.87,0.222255,85118.57664,percent of total billed charges,,,
TRANEXAMIC ACID-NACL 1000-0.7 MG/100ML-% IV SOLN,RX-147865,CDM,S5000,HCPCS,250,RC,51754-0108-01,NDC,outpatient,100,ML,46.71,32.697,AETNA [1000108],AETNA [100010801],,,76.8,,35.87,0.222255,85118.57664,percent of total billed charges,,,
DORZOLAMIDE HCL-TIMOLOL MAL PF 2-0.5 % OP SOLN,RX-147878,CDM,S5000,HCPCS,259,RC,82584-0604-30,NDC,outpatient,1,UN,14.17,9.919,AETNA [1000108],AETNA [100010801],,,76.8,,10.88,0.222255,85118.57664,percent of total billed charges,,,
DORZOLAMIDE HCL-TIMOLOL MAL PF 2-0.5 % OP SOLN,RX-147878,CDM,S5000,HCPCS,259,RC,82584-0604-01,NDC,outpatient,1,UN,14.17,9.919,AETNA [1000108],AETNA [100010801],,,76.8,,10.88,0.222255,85118.57664,percent of total billed charges,,,
TIZANIDINE HCL 2 MG ORAL TABS,RX-14792,CDM,S5000,HCPCS,259,RC,50268-0759-11,NDC,outpatient,1,UN,2.93,2.051,AETNA [1000108],AETNA [100010801],,,76.8,,2.25,0.222255,85118.57664,percent of total billed charges,,,
TIZANIDINE HCL 2 MG ORAL TABS,RX-14792,CDM,S5000,HCPCS,259,RC,50268-0759-15,NDC,outpatient,1,UN,2.93,2.051,AETNA [1000108],AETNA [100010801],,,76.8,,2.25,0.222255,85118.57664,percent of total billed charges,,,
TIZANIDINE HCL 4 MG ORAL TABS,RX-14793,CDM,S5000,HCPCS,259,RC,00904-6418-61,NDC,outpatient,1,UN,1.85,1.295,AETNA [1000108],AETNA [100010801],,,76.8,,1.42,0.222255,85118.57664,percent of total billed charges,,,
LANSOPRAZOLE 30 MG ORAL TBDD,RX-148035,CDM,S5000,HCPCS,259,RC,64764-0544-11,NDC,outpatient,1,UN,56.9,39.83,AETNA [1000108],AETNA [100010801],,,76.8,,43.7,0.222255,85118.57664,percent of total billed charges,,,
LANSOPRAZOLE 30 MG ORAL TBDD,RX-148035,CDM,S5000,HCPCS,259,RC,68382-0772-30,NDC,outpatient,1,UN,20.73,14.511,AETNA [1000108],AETNA [100010801],,,76.8,,15.92,0.222255,85118.57664,percent of total billed charges,,,
LANSOPRAZOLE 30 MG ORAL TBDD,RX-148035,CDM,S5000,HCPCS,259,RC,00378-6982-32,NDC,outpatient,1,UN,22.99,16.093,AETNA [1000108],AETNA [100010801],,,76.8,,17.66,0.222255,85118.57664,percent of total billed charges,,,
LANSOPRAZOLE 30 MG ORAL TBDD,RX-148035,CDM,S5000,HCPCS,259,RC,00378-6982-88,NDC,outpatient,1,UN,22.99,16.093,AETNA [1000108],AETNA [100010801],,,76.8,,17.66,0.222255,85118.57664,percent of total billed charges,,,
LANSOPRAZOLE 30 MG ORAL TBDD,RX-148035,CDM,S5000,HCPCS,259,RC,68382-0772-77,NDC,outpatient,1,UN,20.73,14.511,AETNA [1000108],AETNA [100010801],,,76.8,,15.92,0.222255,85118.57664,percent of total billed charges,,,
LOSARTAN POTASSIUM 25 MG ORAL TABS,RX-14823,CDM,S5000,HCPCS,259,RC,68084-0346-01,NDC,outpatient,1,UN,1.75,1.225,AETNA [1000108],AETNA [100010801],,,76.8,,1.34,0.222255,85118.57664,percent of total billed charges,,,
LOSARTAN POTASSIUM 25 MG ORAL TABS,RX-14823,CDM,S5000,HCPCS,259,RC,68084-0346-11,NDC,outpatient,1,UN,1.75,1.225,AETNA [1000108],AETNA [100010801],,,76.8,,1.34,0.222255,85118.57664,percent of total billed charges,,,
LOSARTAN POTASSIUM 50 MG ORAL TABS,RX-14824,CDM,S5000,HCPCS,259,RC,50268-0505-11,NDC,outpatient,1,UN,1.24,0.868,AETNA [1000108],AETNA [100010801],,,76.8,,0.95,0.222255,85118.57664,percent of total billed charges,,,
LOSARTAN POTASSIUM 50 MG ORAL TABS,RX-14824,CDM,S5000,HCPCS,259,RC,00904-7048-61,NDC,outpatient,1,UN,1.68,1.176,AETNA [1000108],AETNA [100010801],,,76.8,,1.29,0.222255,85118.57664,percent of total billed charges,,,
LOSARTAN POTASSIUM 50 MG ORAL TABS,RX-14824,CDM,S5000,HCPCS,259,RC,31722-0701-30,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LOSARTAN POTASSIUM 50 MG ORAL TABS,RX-14824,CDM,S5000,HCPCS,259,RC,31722-0701-90,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LOSARTAN POTASSIUM 50 MG ORAL TABS,RX-14824,CDM,S5000,HCPCS,259,RC,50268-0505-15,NDC,outpatient,1,UN,1.24,0.868,AETNA [1000108],AETNA [100010801],,,76.8,,0.95,0.222255,85118.57664,percent of total billed charges,,,
FOSFOMYCIN TROMETHAMINE 3 G ORAL PACK,RX-14825,CDM,S5000,HCPCS,259,RC,69097-0579-67,NDC,outpatient,1,UN,204.35,143.045,AETNA [1000108],AETNA [100010801],,,76.8,,156.94,0.222255,85118.57664,percent of total billed charges,,,
FOSFOMYCIN TROMETHAMINE 3 G ORAL PACK,RX-14825,CDM,S5000,HCPCS,259,RC,70700-0268-94,NDC,outpatient,1,UN,214.58,150.206,AETNA [1000108],AETNA [100010801],,,76.8,,164.8,0.222255,85118.57664,percent of total billed charges,,,
FOSFOMYCIN TROMETHAMINE 3 G ORAL PACK,RX-14825,CDM,S5000,HCPCS,259,RC,70700-0268-99,NDC,outpatient,1,UN,214.58,150.206,AETNA [1000108],AETNA [100010801],,,76.8,,164.8,0.222255,85118.57664,percent of total billed charges,,,
ATOVAQUONE 750 MG/5ML ORAL SUSP,RX-14953,CDM,S5000,HCPCS,259,RC,99999-0004-54,NDC,outpatient,5,ML,14.67,10.269,AETNA [1000108],AETNA [100010801],,,76.8,,11.27,0.222255,85118.57664,percent of total billed charges,,,
ATOVAQUONE 750 MG/5ML ORAL SUSP,RX-14953,CDM,S5000,HCPCS,259,RC,70748-0299-01,NDC,outpatient,210,ML,615.84,431.088,AETNA [1000108],AETNA [100010801],,,76.8,,472.97,0.222255,85118.57664,percent of total billed charges,,,
BACTERIOSTATIC WATER(BENZ ALC) IJ SOLN,RX-14979,CDM,S5000,HCPCS,250,RC,00409-3977-03,NDC,outpatient,30,ML,8.02,5.614,AETNA [1000108],AETNA [100010801],,,76.8,,6.16,0.222255,85118.57664,percent of total billed charges,,,
BACTERIOSTATIC WATER(BENZ ALC) IJ SOLN,RX-14979,CDM,S5000,HCPCS,250,RC,00409-3977-01,NDC,outpatient,30,ML,8.02,5.614,AETNA [1000108],AETNA [100010801],,,76.8,,6.16,0.222255,85118.57664,percent of total billed charges,,,
MOEXIPRIL HCL 7.5 MG ORAL TABS,RX-15025,CDM,S5000,HCPCS,259,RC,68462-0209-01,NDC,outpatient,1,UN,3.46,2.422,AETNA [1000108],AETNA [100010801],,,76.8,,2.66,0.222255,85118.57664,percent of total billed charges,,,
VITAMIN A 3 MG (10000 UT) ORAL CAPS,RX-150260,CDM,S5000,HCPCS,259,RC,00904-2085-60,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
VITAMIN A 3 MG (10000 UT) ORAL CAPS,RX-150260,CDM,S5000,HCPCS,259,RC,40093-0101-44,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
VITAMIN A 3 MG (10000 UT) ORAL CAPS,RX-150260,CDM,S5000,HCPCS,259,RC,40093-0140-03,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
HYDROCORT-PRAMOXINE (PERIANAL) 2.5-1 % EX CREA,RX-150325,CDM,S5000,HCPCS,259,RC,45802-0472-64,NDC,outpatient,30,GR,583,408.1,AETNA [1000108],AETNA [100010801],,,76.8,,447.74,0.222255,85118.57664,percent of total billed charges,,,
ACETIC ACID 3 % SOLN,RX-15091,CDM,S5000,HCPCS,259,RC,99999-0001-49,NDC,outpatient,60,ML,11.75,8.225,AETNA [1000108],AETNA [100010801],,,76.8,,9.02,0.222255,85118.57664,percent of total billed charges,,,
ACETIC ACID 3 % SOLN,RX-15091,CDM,S5000,HCPCS,259,RC,51552-0051-06,NDC,outpatient,500,ML,97.9,68.53,AETNA [1000108],AETNA [100010801],,,76.8,,75.19,0.222255,85118.57664,percent of total billed charges,,,
LOPERAMIDE HCL 1 MG/7.5ML ORAL SOLN,RX-150997,CDM,S5000,HCPCS,259,RC,68094-0129-59,NDC,outpatient,15,ML,10.55,7.385,AETNA [1000108],AETNA [100010801],,,76.8,,8.1,0.222255,85118.57664,percent of total billed charges,,,
LOPERAMIDE HCL 1 MG/7.5ML ORAL SOLN,RX-150997,CDM,S5000,HCPCS,259,RC,68094-0129-62,NDC,outpatient,15,ML,10.55,7.385,AETNA [1000108],AETNA [100010801],,,76.8,,8.1,0.222255,85118.57664,percent of total billed charges,,,
MYCOPHENOLATE MOFETIL 250 MG ORAL CAPS,RX-15113,CDM,S5000,HCPCS,259,RC,60687-0494-01,NDC,outpatient,1,UN,2.25,1.575,AETNA [1000108],AETNA [100010801],,,76.8,,1.73,0.222255,85118.57664,percent of total billed charges,,,
MYCOPHENOLATE MOFETIL 250 MG ORAL CAPS,RX-15113,CDM,S5000,HCPCS,259,RC,51079-0721-01,NDC,outpatient,1,UN,2.18,1.526,AETNA [1000108],AETNA [100010801],,,76.8,,1.67,0.222255,85118.57664,percent of total billed charges,,,
MYCOPHENOLATE MOFETIL 250 MG ORAL CAPS,RX-15113,CDM,S5000,HCPCS,259,RC,51079-0721-20,NDC,outpatient,1,UN,2.18,1.526,AETNA [1000108],AETNA [100010801],,,76.8,,1.67,0.222255,85118.57664,percent of total billed charges,,,
MYCOPHENOLATE MOFETIL 250 MG ORAL CAPS,RX-15113,CDM,S5000,HCPCS,259,RC,60687-0494-11,NDC,outpatient,1,UN,2.25,1.575,AETNA [1000108],AETNA [100010801],,,76.8,,1.73,0.222255,85118.57664,percent of total billed charges,,,
POLY-VI-SOL/IRON 11 MG/ML ORAL SOLN,RX-151638,CDM,S5000,HCPCS,259,RC,00087-0405-01,NDC,outpatient,0.5,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
POLY-VI-SOL/IRON 11 MG/ML ORAL SOLN,RX-151638,CDM,S5000,HCPCS,259,RC,99999-0001-69,NDC,outpatient,0.5,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
TACROLIMUS ER 1 MG ORAL TB24,RX-151676,CDM,S5000,HCPCS,259,RC,68992-3010-03,NDC,outpatient,1,UN,3.04,2.128,AETNA [1000108],AETNA [100010801],,,76.8,,2.33,0.222255,85118.57664,percent of total billed charges,,,
TACROLIMUS ER 0.75 MG ORAL TB24,RX-151678,CDM,S5000,HCPCS,259,RC,68992-3075-03,NDC,outpatient,1,UN,2.28,1.596,AETNA [1000108],AETNA [100010801],,,76.8,,1.75,0.222255,85118.57664,percent of total billed charges,,,
TACROLIMUS ER 4 MG ORAL TB24,RX-151679,CDM,S5000,HCPCS,259,RC,68992-3040-03,NDC,outpatient,1,UN,12.17,8.519,AETNA [1000108],AETNA [100010801],,,76.8,,9.35,0.222255,85118.57664,percent of total billed charges,,,
SENNOSIDES 8.8 MG/5ML ORAL SYRP,RX-15168,CDM,S5000,HCPCS,259,RC,00536-1266-59,NDC,outpatient,10,ML,1.5,1.05,AETNA [1000108],AETNA [100010801],,,76.8,,1.15,0.222255,85118.57664,percent of total billed charges,,,
SENNOSIDES 8.8 MG/5ML ORAL SYRP,RX-15168,CDM,S5000,HCPCS,259,RC,99999-0002-42,NDC,outpatient,10,ML,1.6,1.12,AETNA [1000108],AETNA [100010801],,,76.8,,1.23,0.222255,85118.57664,percent of total billed charges,,,
SENNOSIDES 8.8 MG/5ML ORAL SYRP,RX-15168,CDM,S5000,HCPCS,259,RC,00536-1266-10,NDC,outpatient,10,ML,1.5,1.05,AETNA [1000108],AETNA [100010801],,,76.8,,1.15,0.222255,85118.57664,percent of total billed charges,,,
SENNOSIDES 8.8 MG/5ML ORAL SYRP,RX-15168,CDM,S5000,HCPCS,259,RC,57896-0472-08,NDC,outpatient,5,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
SENNOSIDES 8.8 MG/5ML ORAL SYRP,RX-15168,CDM,S5000,HCPCS,259,RC,57896-0472-10,NDC,outpatient,10,ML,1.39,0.973,AETNA [1000108],AETNA [100010801],,,76.8,,1.07,0.222255,85118.57664,percent of total billed charges,,,
TRACE MINERALS CU-MN-SE-ZN 300-55-60-3000 MCG/ML IV SOLN,RX-151858,CDM,S5000,HCPCS,250,RC,00517-9305-01,NDC,outpatient,1,ML,93.05,65.135,AETNA [1000108],AETNA [100010801],,,76.8,,71.46,0.222255,85118.57664,percent of total billed charges,,,
TRACE MINERALS CU-MN-SE-ZN 300-55-60-3000 MCG/ML IV SOLN,RX-151858,CDM,S5000,HCPCS,250,RC,00517-9305-25,NDC,outpatient,1,ML,93.05,65.135,AETNA [1000108],AETNA [100010801],,,76.8,,71.46,0.222255,85118.57664,percent of total billed charges,,,
METHACHOLINE CHLORIDE IN KIT,RX-151916,CDM,S5000,HCPCS,259,RC,69374-0542-06,NDC,outpatient,18,ML,600.75,420.525,AETNA [1000108],AETNA [100010801],,,76.8,,461.38,0.222255,85118.57664,percent of total billed charges,,,
DICLOFENAC SODIUM 1 % EX GEL,RX-152701,CDM,S5000,HCPCS,259,RC,00536-1294-97,NDC,outpatient,100,GR,33.38,23.366,AETNA [1000108],AETNA [100010801],,,76.8,,25.64,0.222255,85118.57664,percent of total billed charges,,,
DICLOFENAC SODIUM 1 % EX GEL,RX-152701,CDM,S5000,HCPCS,259,RC,43598-0977-10,NDC,outpatient,100,GR,59.19,41.433,AETNA [1000108],AETNA [100010801],,,76.8,,45.46,0.222255,85118.57664,percent of total billed charges,,,
DICLOFENAC SODIUM 1 % EX GEL,RX-152701,CDM,S5000,HCPCS,259,RC,69097-0524-44,NDC,outpatient,100,GR,59.63,41.741,AETNA [1000108],AETNA [100010801],,,76.8,,45.8,0.222255,85118.57664,percent of total billed charges,,,
SUMATRIPTAN SUCCINATE 25 MG ORAL TABS,RX-15327,CDM,S5000,HCPCS,259,RC,65862-0146-36,NDC,outpatient,1,UN,1.72,1.204,AETNA [1000108],AETNA [100010801],,,76.8,,1.32,0.222255,85118.57664,percent of total billed charges,,,
DICLOFENAC SODIUM 50 MG ORAL TBEC,RX-15340,CDM,S5000,HCPCS,259,RC,16571-0202-10,NDC,outpatient,1,UN,1.23,0.861,AETNA [1000108],AETNA [100010801],,,76.8,,0.94,0.222255,85118.57664,percent of total billed charges,,,
DICLOFENAC SODIUM 50 MG ORAL TBEC,RX-15340,CDM,S5000,HCPCS,259,RC,61442-0102-01,NDC,outpatient,1,UN,1.24,0.868,AETNA [1000108],AETNA [100010801],,,76.8,,0.95,0.222255,85118.57664,percent of total billed charges,,,
DICLOFENAC SODIUM 50 MG ORAL TBEC,RX-15340,CDM,S5000,HCPCS,259,RC,00228-2550-11,NDC,outpatient,1,UN,1.63,1.141,AETNA [1000108],AETNA [100010801],,,76.8,,1.25,0.222255,85118.57664,percent of total billed charges,,,
DICLOFENAC SODIUM 50 MG ORAL TBEC,RX-15340,CDM,S5000,HCPCS,259,RC,60687-0606-01,NDC,outpatient,1,UN,2.07,1.449,AETNA [1000108],AETNA [100010801],,,76.8,,1.59,0.222255,85118.57664,percent of total billed charges,,,
DICLOFENAC SODIUM 50 MG ORAL TBEC,RX-15340,CDM,S5000,HCPCS,259,RC,60687-0606-11,NDC,outpatient,1,UN,2.07,1.449,AETNA [1000108],AETNA [100010801],,,76.8,,1.59,0.222255,85118.57664,percent of total billed charges,,,
DICLOFENAC SODIUM 75 MG ORAL TBEC,RX-15341,CDM,S5000,HCPCS,259,RC,16571-0201-06,NDC,outpatient,1,UN,1.46,1.022,AETNA [1000108],AETNA [100010801],,,76.8,,1.12,0.222255,85118.57664,percent of total billed charges,,,
AYR SALINE NASAL NA GEL,RX-15372,CDM,S5000,HCPCS,259,RC,00225-0525-47,NDC,outpatient,14.1,GR,10.92,7.644,AETNA [1000108],AETNA [100010801],,,76.8,,8.39,0.222255,85118.57664,percent of total billed charges,,,
AYR SALINE NASAL NA GEL,RX-15372,CDM,S5000,HCPCS,259,RC,05928-0000-99,NDC,outpatient,28.4,GR,22.75,15.925,AETNA [1000108],AETNA [100010801],,,76.8,,17.47,0.222255,85118.57664,percent of total billed charges,,,
RIMANTADINE HCL 100 MG ORAL TABS,RX-15440,CDM,S5000,HCPCS,259,RC,00115-1911-01,NDC,outpatient,1,UN,10.21,7.147,AETNA [1000108],AETNA [100010801],,,76.8,,7.84,0.222255,85118.57664,percent of total billed charges,,,
CHERRY ORAL SYRP,RX-1562,CDM,S5000,HCPCS,259,RC,00395-2662-16,NDC,outpatient,473,ML,78.58,55.006,AETNA [1000108],AETNA [100010801],,,76.8,,60.35,0.222255,85118.57664,percent of total billed charges,,,
FAT EMULSION PLANT BASED (SOY) 20 % IV EMUL,RX-156372,CDM,S5000,HCPCS,250,RC,00338-0519-13,NDC,outpatient,500,ML,73.85,51.695,AETNA [1000108],AETNA [100010801],,,76.8,,56.72,0.222255,85118.57664,percent of total billed charges,,,
FAT EMULSION PLANT BASED (SOY) 20 % IV EMUL,RX-156372,CDM,S5000,HCPCS,250,RC,00338-0519-09,NDC,outpatient,250,ML,59.39,41.573,AETNA [1000108],AETNA [100010801],,,76.8,,45.61,0.222255,85118.57664,percent of total billed charges,,,
AMANTADINE HCL 50 MG/5ML ORAL SOLN,RX-156382,CDM,S5000,HCPCS,259,RC,00121-0646-10,NDC,outpatient,10,ML,13.67,9.569,AETNA [1000108],AETNA [100010801],,,76.8,,10.5,0.222255,85118.57664,percent of total billed charges,,,
ALENDRONATE SODIUM 10 MG ORAL TABS,RX-15661,CDM,S5000,HCPCS,259,RC,16714-0631-01,NDC,outpatient,1,UN,1.72,1.204,AETNA [1000108],AETNA [100010801],,,76.8,,1.32,0.222255,85118.57664,percent of total billed charges,,,
SODIUM THIOSULFATE 250 MG/ML IV SOLN,RX-156724,CDM,S5000,HCPCS,250,RC,60267-0705-50,NDC,outpatient,50,ML,431.65,302.155,AETNA [1000108],AETNA [100010801],,,76.8,,331.51,0.222255,85118.57664,percent of total billed charges,,,
PRISMASOL BGK 0/2.5 32-2.5 MEQ/L EC SOLN,RX-156740,CDM,S5000,HCPCS,250,RC,24571-0108-06,NDC,outpatient,5000,ML,294.88,206.416,AETNA [1000108],AETNA [100010801],,,76.8,,226.47,0.222255,85118.57664,percent of total billed charges,,,
PRISMASOL BGK 4/2.5 32-4-2.5 MEQ/L EC SOLN,RX-156741,CDM,S5000,HCPCS,250,RC,24571-0105-06,NDC,outpatient,5000,ML,294.88,206.416,AETNA [1000108],AETNA [100010801],,,76.8,,226.47,0.222255,85118.57664,percent of total billed charges,,,
PRISMASOL BGK 2/0 32-2 MEQ/L EC SOLN,RX-156742,CDM,S5000,HCPCS,250,RC,24571-0102-06,NDC,outpatient,5000,ML,294.88,206.416,AETNA [1000108],AETNA [100010801],,,76.8,,226.47,0.222255,85118.57664,percent of total billed charges,,,
PRISMASOL BGK 2/3.5 32-2-3.5 MEQ/L EC SOLN,RX-156743,CDM,S5000,HCPCS,250,RC,24571-0103-06,NDC,outpatient,5000,ML,325.06,227.542,AETNA [1000108],AETNA [100010801],,,76.8,,249.65,0.222255,85118.57664,percent of total billed charges,,,
SOTALOL HCL 120 MG ORAL TABS,RX-15723,CDM,S5000,HCPCS,259,RC,00093-1060-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
SOTALOL HCL 120 MG ORAL TABS,RX-15723,CDM,S5000,HCPCS,259,RC,60505-0159-00,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
CALCITONIN (SALMON) 200 UNIT/ACT NA SOLN,RX-15738,CDM,S5000,HCPCS,259,RC,60505-0823-06,NDC,outpatient,3.7,ML,230.15,161.105,AETNA [1000108],AETNA [100010801],,,76.8,,176.76,0.222255,85118.57664,percent of total billed charges,,,
CALCITONIN (SALMON) 200 UNIT/ACT NA SOLN,RX-15738,CDM,S5000,HCPCS,259,RC,49884-0161-11,NDC,outpatient,3.7,ML,207.33,145.131,AETNA [1000108],AETNA [100010801],,,76.8,,159.23,0.222255,85118.57664,percent of total billed charges,,,
CARVEDILOL 6.25 MG ORAL TABS,RX-15747,CDM,S5000,HCPCS,259,RC,00904-6301-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
CARVEDILOL 12.5 MG ORAL TABS,RX-15749,CDM,S5000,HCPCS,259,RC,00904-6302-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
CARVEDILOL 12.5 MG ORAL TABS,RX-15749,CDM,S5000,HCPCS,259,RC,68382-0094-05,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
AZITHROMYCIN 200 MG/5ML ORAL SUSR,RX-15797,CDM,S5000,HCPCS,259,RC,59762-3120-01,NDC,outpatient,18.75,ML,76.85,53.795,AETNA [1000108],AETNA [100010801],,,76.8,,59.02,0.222255,85118.57664,percent of total billed charges,,,
AZITHROMYCIN 200 MG/5ML ORAL SUSR,RX-15797,CDM,S5000,HCPCS,259,RC,99999-0002-81,NDC,outpatient,6.25,ML,21.03,14.721,AETNA [1000108],AETNA [100010801],,,76.8,,16.15,0.222255,85118.57664,percent of total billed charges,,,
AZITHROMYCIN 200 MG/5ML ORAL SUSR,RX-15797,CDM,S5000,HCPCS,259,RC,00093-2026-23,NDC,outpatient,18.75,ML,62.17,43.519,AETNA [1000108],AETNA [100010801],,,76.8,,47.75,0.222255,85118.57664,percent of total billed charges,,,
DARUNAVIR 800 MG ORAL TABS,RX-158170,CDM,S5000,HCPCS,259,RC,59676-0566-30,NDC,outpatient,1,UN,310.53,217.371,AETNA [1000108],AETNA [100010801],,,76.8,,238.49,0.222255,85118.57664,percent of total billed charges,,,
INSULIN LISPRO 100 UNIT/ML IJ SOLN,RX-158181,CDM,S5000,HCPCS,259,RC,00024-5924-10,NDC,outpatient,10,ML,322.63,225.841,AETNA [1000108],AETNA [100010801],,,76.8,,247.78,0.222255,85118.57664,percent of total billed charges,,,
INSULIN LISPRO 100 UNIT/ML IJ SOLN,RX-158181,CDM,S5000,HCPCS,259,RC,00024-5926-05,NDC,outpatient,3,ML,50.03,35.021,AETNA [1000108],AETNA [100010801],,,76.8,,38.42,0.222255,85118.57664,percent of total billed charges,,,
INSULIN LISPRO 100 UNIT/ML IJ SOLN,RX-158181,CDM,S5000,HCPCS,259,RC,00002-7533-01,NDC,outpatient,3,ML,80.06,56.042,AETNA [1000108],AETNA [100010801],,,76.8,,61.49,0.222255,85118.57664,percent of total billed charges,,,
LAMIVUDINE 150 MG ORAL TABS,RX-15880,CDM,S5000,HCPCS,259,RC,00904-6583-04,NDC,outpatient,1,UN,21.27,14.889,AETNA [1000108],AETNA [100010801],,,76.8,,16.34,0.222255,85118.57664,percent of total billed charges,,,
LAMIVUDINE 150 MG ORAL TABS,RX-15880,CDM,S5000,HCPCS,259,RC,64380-0710-03,NDC,outpatient,1,UN,2.38,1.666,AETNA [1000108],AETNA [100010801],,,76.8,,1.83,0.222255,85118.57664,percent of total billed charges,,,
LAMIVUDINE 10 MG/ML ORAL SOLN,RX-15881,CDM,S5000,HCPCS,259,RC,54838-0566-70,NDC,outpatient,15,ML,23.1,16.17,AETNA [1000108],AETNA [100010801],,,76.8,,17.74,0.222255,85118.57664,percent of total billed charges,,,
ACARBOSE 50 MG ORAL TABS,RX-15895,CDM,S5000,HCPCS,259,RC,64380-0759-06,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
DAKINS (1/2 STRENGTH) 0.25 % EX SOLN,RX-15950,CDM,S5000,HCPCS,259,RC,00436-0936-16,NDC,outpatient,473,ML,52.63,36.841,AETNA [1000108],AETNA [100010801],,,76.8,,40.42,0.222255,85118.57664,percent of total billed charges,,,
NIRMATRELVIR&RITONAVIR 150/100 10 X 150 MG & 10 X 100MG ORAL TBPK,RX-159847,CDM,S5000,HCPCS,259,RC,00069-5317-02,NDC,outpatient,1,UN,571.55,400.085,AETNA [1000108],AETNA [100010801],,,76.8,,438.95,0.222255,85118.57664,percent of total billed charges,,,
NIRMATRELVIR&RITONAVIR 150/100 10 X 150 MG & 10 X 100MG ORAL TBPK,RX-159847,CDM,S5000,HCPCS,259,RC,00069-5317-20,NDC,outpatient,1,UN,3544.84,2481.388,AETNA [1000108],AETNA [100010801],,,76.8,,2722.44,0.222255,85118.57664,percent of total billed charges,,,
NIRMATRELVIR&RITONAVIR 300/100 20 X 150 MG & 10 X 100MG ORAL TBPK,RX-159848,CDM,S5000,HCPCS,259,RC,00069-5321-30,NDC,outpatient,1,UN,3544.84,2481.388,AETNA [1000108],AETNA [100010801],,,76.8,,2722.44,0.222255,85118.57664,percent of total billed charges,,,
NIRMATRELVIR&RITONAVIR 300/100 20 X 150 MG & 10 X 100MG ORAL TBPK,RX-159848,CDM,S5000,HCPCS,259,RC,00069-5321-03,NDC,outpatient,1,UN,571.55,400.085,AETNA [1000108],AETNA [100010801],,,76.8,,438.95,0.222255,85118.57664,percent of total billed charges,,,
METHADONE HCL 10 MG/ML ORAL CONC,RX-15996,CDM,S5000,HCPCS,259,RC,00406-0527-10,NDC,outpatient,0.5,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
METHADONE HCL 10 MG/ML ORAL CONC,RX-15996,CDM,S5000,HCPCS,259,RC,99999-0002-10,NDC,outpatient,10,ML,27.28,19.096,AETNA [1000108],AETNA [100010801],,,76.8,,20.95,0.222255,85118.57664,percent of total billed charges,,,
ESTROGENS CONJUGATED 0.625 MG/GM VA CREA,RX-160113,CDM,S5000,HCPCS,259,RC,00046-0872-21,NDC,outpatient,30,GR,1850.58,1295.406,AETNA [1000108],AETNA [100010801],,,76.8,,1421.25,0.222255,85118.57664,percent of total billed charges,,,
CALCIPOTRIENE 0.005 % EX CREA,RX-16034,CDM,S5000,HCPCS,259,RC,16714-0763-01,NDC,outpatient,60,GR,327.35,229.145,AETNA [1000108],AETNA [100010801],,,76.8,,251.4,0.222255,85118.57664,percent of total billed charges,,,
GLUCOSE 4 G ORAL CHEW,RX-16050,CDM,S5000,HCPCS,259,RC,56151-1610-51,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
GLUCOSE 4 G ORAL CHEW,RX-16050,CDM,S5000,HCPCS,259,RC,80681-0100-00,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
GLUCOSE 4 G ORAL CHEW,RX-16050,CDM,S5000,HCPCS,259,RC,56151-1610-11,NDC,outpatient,1,UN,3.58,2.506,AETNA [1000108],AETNA [100010801],,,76.8,,2.75,0.222255,85118.57664,percent of total billed charges,,,
DESMOPRESSIN ACETATE 0.2 MG ORAL TABS,RX-16053,CDM,S5000,HCPCS,259,RC,60687-0732-21,NDC,outpatient,1,UN,7.9,5.53,AETNA [1000108],AETNA [100010801],,,76.8,,6.07,0.222255,85118.57664,percent of total billed charges,,,
DESMOPRESSIN ACETATE 0.2 MG ORAL TABS,RX-16053,CDM,S5000,HCPCS,259,RC,23155-0490-01,NDC,outpatient,1,UN,1.27,0.889,AETNA [1000108],AETNA [100010801],,,76.8,,0.98,0.222255,85118.57664,percent of total billed charges,,,
DESMOPRESSIN ACETATE 0.2 MG ORAL TABS,RX-16053,CDM,S5000,HCPCS,259,RC,60687-0732-11,NDC,outpatient,1,UN,7.9,5.53,AETNA [1000108],AETNA [100010801],,,76.8,,6.07,0.222255,85118.57664,percent of total billed charges,,,
METHYLENE BLUE 1 % IV SOLN,RX-160649,CDM,S5000,HCPCS,250,RC,54288-0147-01,NDC,outpatient,10,ML,616.77,431.739,AETNA [1000108],AETNA [100010801],,,76.8,,473.68,0.222255,85118.57664,percent of total billed charges,,,
ACTIDOSE WITH SORBITOL 25 GM/120ML ORAL SUSP,RX-160655,CDM,S5000,HCPCS,259,RC,66689-0203-04,NDC,outpatient,120,ML,73.16,51.212,AETNA [1000108],AETNA [100010801],,,76.8,,56.19,0.222255,85118.57664,percent of total billed charges,,,
ACTIDOSE WITH SORBITOL 25 GM/120ML ORAL SUSP,RX-160655,CDM,S5000,HCPCS,259,RC,00574-0520-74,NDC,outpatient,120,ML,51.8,36.26,AETNA [1000108],AETNA [100010801],,,76.8,,39.78,0.222255,85118.57664,percent of total billed charges,,,
IPRATROPIUM BROMIDE 0.03 % NA SOLN,RX-16070,CDM,S5000,HCPCS,259,RC,00054-0045-44,NDC,outpatient,30,ML,160.2,112.14,AETNA [1000108],AETNA [100010801],,,76.8,,123.03,0.222255,85118.57664,percent of total billed charges,,,
IPRATROPIUM BROMIDE 0.03 % NA SOLN,RX-16070,CDM,S5000,HCPCS,259,RC,24208-0398-30,NDC,outpatient,30,ML,45.66,31.962,AETNA [1000108],AETNA [100010801],,,76.8,,35.07,0.222255,85118.57664,percent of total billed charges,,,
CALCIUM CARB-CHOLECALCIFEROL 600-5 MG-MCG ORAL TABS,RX-160700,CDM,S5000,HCPCS,259,RC,80681-0138-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
IPRATROPIUM BROMIDE 0.06 % NA SOLN,RX-16071,CDM,S5000,HCPCS,259,RC,00054-0046-41,NDC,outpatient,15,ML,147.99,103.593,AETNA [1000108],AETNA [100010801],,,76.8,,113.66,0.222255,85118.57664,percent of total billed charges,,,
IPRATROPIUM BROMIDE 0.06 % NA SOLN,RX-16071,CDM,S5000,HCPCS,259,RC,60505-0827-01,NDC,outpatient,15,ML,69.49,48.643,AETNA [1000108],AETNA [100010801],,,76.8,,53.37,0.222255,85118.57664,percent of total billed charges,,,
FAMCICLOVIR 250 MG ORAL TABS,RX-16081,CDM,S5000,HCPCS,259,RC,60505-3246-03,NDC,outpatient,1,UN,1.06,0.742,AETNA [1000108],AETNA [100010801],,,76.8,,0.81,0.222255,85118.57664,percent of total billed charges,,,
CALCIUM CITRATE-VITAMIN D 200-6.25 MG-MCG ORAL TABS,RX-160846,CDM,S5000,HCPCS,259,RC,16500-0535-03,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
CALCIUM CITRATE-VITAMIN D 200-6.25 MG-MCG ORAL TABS,RX-160846,CDM,S5000,HCPCS,259,RC,00536-3223-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
CALCIUM CITRATE-VITAMIN D 200-6.25 MG-MCG ORAL TABS,RX-160846,CDM,S5000,HCPCS,259,RC,16500-0535-02,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
RILUZOLE 50 MG ORAL TABS,RX-16124,CDM,S5000,HCPCS,259,RC,67877-0286-60,NDC,outpatient,1,UN,2.96,2.072,AETNA [1000108],AETNA [100010801],,,76.8,,2.27,0.222255,85118.57664,percent of total billed charges,,,
CALCITRIOL 1 MCG/ML ORAL SOLN,RX-16218,CDM,S5000,HCPCS,259,RC,00054-3120-41,NDC,outpatient,1,ML,24.45,17.115,AETNA [1000108],AETNA [100010801],,,76.8,,18.78,0.222255,85118.57664,percent of total billed charges,,,
CALCITRIOL 1 MCG/ML ORAL SOLN,RX-16218,CDM,S5000,HCPCS,259,RC,99999-0002-71,NDC,outpatient,1,ML,19.3,13.51,AETNA [1000108],AETNA [100010801],,,76.8,,14.82,0.222255,85118.57664,percent of total billed charges,,,
CALCITRIOL 1 MCG/ML ORAL SOLN,RX-16218,CDM,S5000,HCPCS,259,RC,63304-0241-59,NDC,outpatient,1,ML,19.3,13.51,AETNA [1000108],AETNA [100010801],,,76.8,,14.82,0.222255,85118.57664,percent of total billed charges,,,
CHLORDIAZEPOXIDE HCL 25 MG ORAL CAPS,RX-1623,CDM,S5000,HCPCS,259,RC,00555-0159-02,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
CHLORDIAZEPOXIDE HCL 25 MG ORAL CAPS,RX-1623,CDM,S5000,HCPCS,259,RC,51079-0141-20,NDC,outpatient,1,UN,2.52,1.764,AETNA [1000108],AETNA [100010801],,,76.8,,1.94,0.222255,85118.57664,percent of total billed charges,,,
CHLORDIAZEPOXIDE HCL 25 MG ORAL CAPS,RX-1623,CDM,S5000,HCPCS,259,RC,51079-0141-01,NDC,outpatient,1,UN,2.52,1.764,AETNA [1000108],AETNA [100010801],,,76.8,,1.94,0.222255,85118.57664,percent of total billed charges,,,
CHLORDIAZEPOXIDE HCL 5 MG ORAL CAPS,RX-1624,CDM,S5000,HCPCS,259,RC,51079-0374-20,NDC,outpatient,1,UN,2.65,1.855,AETNA [1000108],AETNA [100010801],,,76.8,,2.04,0.222255,85118.57664,percent of total billed charges,,,
CHLORDIAZEPOXIDE HCL 5 MG ORAL CAPS,RX-1624,CDM,S5000,HCPCS,259,RC,51079-0374-01,NDC,outpatient,1,UN,2.65,1.855,AETNA [1000108],AETNA [100010801],,,76.8,,2.04,0.222255,85118.57664,percent of total billed charges,,,
EUCERIN ORIGINAL HEALING EX CREA,RX-162713,CDM,S5000,HCPCS,259,RC,72140-0038-68,NDC,outpatient,57,GR,20.04,14.028,AETNA [1000108],AETNA [100010801],,,76.8,,15.39,0.222255,85118.57664,percent of total billed charges,,,
GLIMEPIRIDE 2 MG ORAL TABS,RX-16356,CDM,S5000,HCPCS,259,RC,55111-0321-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
GLIMEPIRIDE 2 MG ORAL TABS,RX-16356,CDM,S5000,HCPCS,259,RC,68084-0326-11,NDC,outpatient,1,UN,2.06,1.442,AETNA [1000108],AETNA [100010801],,,76.8,,1.58,0.222255,85118.57664,percent of total billed charges,,,
GLIMEPIRIDE 2 MG ORAL TABS,RX-16356,CDM,S5000,HCPCS,259,RC,68084-0326-01,NDC,outpatient,1,UN,2.06,1.442,AETNA [1000108],AETNA [100010801],,,76.8,,1.58,0.222255,85118.57664,percent of total billed charges,,,
CHLORPHENIRAMINE MALEATE 4 MG ORAL TABS,RX-1645,CDM,S5000,HCPCS,259,RC,00904-0012-59,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
CHLORPHENIRAMINE MALEATE 4 MG ORAL TABS,RX-1645,CDM,S5000,HCPCS,259,RC,00904-0012-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PHENYLEPH-SHARK LIV OIL-MO-PET 0.25-3-14-71.9 % RE OINT,RX-16462,CDM,S5000,HCPCS,259,RC,00573-2871-93,NDC,outpatient,28,GR,25.8,18.06,AETNA [1000108],AETNA [100010801],,,76.8,,19.81,0.222255,85118.57664,percent of total billed charges,,,
CHLORPROMAZINE HCL 10 MG ORAL TABS,RX-1653,CDM,S5000,HCPCS,259,RC,50268-0162-11,NDC,outpatient,1,UN,4.66,3.262,AETNA [1000108],AETNA [100010801],,,76.8,,3.58,0.222255,85118.57664,percent of total billed charges,,,
CHLORPROMAZINE HCL 10 MG ORAL TABS,RX-1653,CDM,S5000,HCPCS,259,RC,00904-7129-61,NDC,outpatient,1,UN,10.41,7.287,AETNA [1000108],AETNA [100010801],,,76.8,,7.99,0.222255,85118.57664,percent of total billed charges,,,
CHLORPROMAZINE HCL 10 MG ORAL TABS,RX-1653,CDM,S5000,HCPCS,259,RC,50268-0162-15,NDC,outpatient,1,UN,4.66,3.262,AETNA [1000108],AETNA [100010801],,,76.8,,3.58,0.222255,85118.57664,percent of total billed charges,,,
CHLORPROMAZINE HCL 100 MG ORAL TABS,RX-1654,CDM,S5000,HCPCS,259,RC,00904-7132-61,NDC,outpatient,1,UN,20.86,14.602,AETNA [1000108],AETNA [100010801],,,76.8,,16.02,0.222255,85118.57664,percent of total billed charges,,,
CHLORPROMAZINE HCL 100 MG ORAL TABS,RX-1654,CDM,S5000,HCPCS,259,RC,69238-1060-01,NDC,outpatient,1,UN,6.98,4.886,AETNA [1000108],AETNA [100010801],,,76.8,,5.36,0.222255,85118.57664,percent of total billed charges,,,
CHLORPROMAZINE HCL 25 MG ORAL TABS,RX-1656,CDM,S5000,HCPCS,259,RC,50268-0163-15,NDC,outpatient,1,UN,7.19,5.033,AETNA [1000108],AETNA [100010801],,,76.8,,5.52,0.222255,85118.57664,percent of total billed charges,,,
CHLORPROMAZINE HCL 25 MG ORAL TABS,RX-1656,CDM,S5000,HCPCS,259,RC,50268-0163-11,NDC,outpatient,1,UN,7.19,5.033,AETNA [1000108],AETNA [100010801],,,76.8,,5.52,0.222255,85118.57664,percent of total billed charges,,,
CHLORPROMAZINE HCL 25 MG ORAL TABS,RX-1656,CDM,S5000,HCPCS,259,RC,69238-1056-01,NDC,outpatient,1,UN,2.88,2.016,AETNA [1000108],AETNA [100010801],,,76.8,,2.21,0.222255,85118.57664,percent of total billed charges,,,
KETOTIFEN FUMARATE 0.035 % OP SOLN,RX-165824,CDM,S5000,HCPCS,259,RC,00065-4011-05,NDC,outpatient,5,ML,42.77,29.939,AETNA [1000108],AETNA [100010801],,,76.8,,32.85,0.222255,85118.57664,percent of total billed charges,,,
KETOTIFEN FUMARATE 0.035 % OP SOLN,RX-165824,CDM,S5000,HCPCS,259,RC,00536-1252-40,NDC,outpatient,5,ML,30.09,21.063,AETNA [1000108],AETNA [100010801],,,76.8,,23.11,0.222255,85118.57664,percent of total billed charges,,,
KETOTIFEN FUMARATE 0.035 % OP SOLN,RX-165824,CDM,S5000,HCPCS,259,RC,72485-0617-10,NDC,outpatient,5,ML,28.93,20.251,AETNA [1000108],AETNA [100010801],,,76.8,,22.22,0.222255,85118.57664,percent of total billed charges,,,
CHLORTHALIDONE 25 MG ORAL TABS,RX-1661,CDM,S5000,HCPCS,259,RC,51079-0058-20,NDC,outpatient,1,UN,7.86,5.502,AETNA [1000108],AETNA [100010801],,,76.8,,6.04,0.222255,85118.57664,percent of total billed charges,,,
CHLORTHALIDONE 25 MG ORAL TABS,RX-1661,CDM,S5000,HCPCS,259,RC,51079-0058-01,NDC,outpatient,1,UN,7.86,5.502,AETNA [1000108],AETNA [100010801],,,76.8,,6.04,0.222255,85118.57664,percent of total billed charges,,,
PAROXETINE HCL 10 MG ORAL TABS,RX-16632,CDM,S5000,HCPCS,259,RC,68084-0044-01,NDC,outpatient,1,UN,2.56,1.792,AETNA [1000108],AETNA [100010801],,,76.8,,1.97,0.222255,85118.57664,percent of total billed charges,,,
PAROXETINE HCL 10 MG ORAL TABS,RX-16632,CDM,S5000,HCPCS,259,RC,68084-0044-11,NDC,outpatient,1,UN,2.56,1.792,AETNA [1000108],AETNA [100010801],,,76.8,,1.97,0.222255,85118.57664,percent of total billed charges,,,
PAROXETINE HCL 10 MG ORAL TABS,RX-16632,CDM,S5000,HCPCS,259,RC,63739-0888-10,NDC,outpatient,1,UN,2.7,1.89,AETNA [1000108],AETNA [100010801],,,76.8,,2.07,0.222255,85118.57664,percent of total billed charges,,,
FERROUS SULFATE ER 45 MG ORAL TBCR,RX-167735,CDM,S5000,HCPCS,259,RC,10006-0730-13,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ACD FORMULA A 0.73-2.45-2.2 GM/100ML VI SOLN,RX-16825,CDM,S5000,HCPCS,250,RC,00942-0641-04,NDC,outpatient,1000,ML,60.15,42.105,AETNA [1000108],AETNA [100010801],,,76.8,,46.2,0.222255,85118.57664,percent of total billed charges,,,
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,50268-0524-15,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,68094-0110-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,77333-0516-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,77333-0516-25,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,20555-0036-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,50268-0524-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,68094-0110-59,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
HYOSCYAMINE SULFATE ER 0.375 MG ORAL TB12,RX-17010,CDM,S5000,HCPCS,259,RC,51525-0115-01,NDC,outpatient,1,UN,1.16,0.812,AETNA [1000108],AETNA [100010801],,,76.8,,0.89,0.222255,85118.57664,percent of total billed charges,,,
TRANDOLAPRIL 1 MG ORAL TABS,RX-17017,CDM,S5000,HCPCS,259,RC,68180-0566-01,NDC,outpatient,1,UN,2.46,1.722,AETNA [1000108],AETNA [100010801],,,76.8,,1.89,0.222255,85118.57664,percent of total billed charges,,,
SELEGILINE HCL 5 MG ORAL CAPS,RX-17280,CDM,S5000,HCPCS,259,RC,60505-0055-01,NDC,outpatient,1,UN,2.47,1.729,AETNA [1000108],AETNA [100010801],,,76.8,,1.9,0.222255,85118.57664,percent of total billed charges,,,
DERMAPHOR EX OINT,RX-17369,CDM,S5000,HCPCS,259,RC,72140-0031-47,NDC,outpatient,396,GR,61.68,43.176,AETNA [1000108],AETNA [100010801],,,76.8,,47.37,0.222255,85118.57664,percent of total billed charges,,,
DERMAPHOR EX OINT,RX-17369,CDM,S5000,HCPCS,259,RC,72140-0452-31,NDC,outpatient,50,GR,20.25,14.175,AETNA [1000108],AETNA [100010801],,,76.8,,15.55,0.222255,85118.57664,percent of total billed charges,,,
DERMAPHOR EX OINT,RX-17369,CDM,S5000,HCPCS,259,RC,61924-0184-04,NDC,outpatient,106,GR,13.68,9.576,AETNA [1000108],AETNA [100010801],,,76.8,,10.51,0.222255,85118.57664,percent of total billed charges,,,
RISPERIDONE 1 MG/ML ORAL SOLN,RX-17377,CDM,S5000,HCPCS,259,RC,27808-0002-01,NDC,outpatient,0.25,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
RISPERIDONE 1 MG/ML ORAL SOLN,RX-17377,CDM,S5000,HCPCS,259,RC,65162-0673-84,NDC,outpatient,0.25,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
RISPERIDONE 1 MG/ML ORAL SOLN,RX-17377,CDM,S5000,HCPCS,259,RC,99999-0003-81,NDC,outpatient,1,ML,4.12,2.884,AETNA [1000108],AETNA [100010801],,,76.8,,3.16,0.222255,85118.57664,percent of total billed charges,,,
AZITHROMYCIN 600 MG ORAL TABS,RX-17387,CDM,S5000,HCPCS,259,RC,62332-0253-30,NDC,outpatient,1,UN,1.72,1.204,AETNA [1000108],AETNA [100010801],,,76.8,,1.32,0.222255,85118.57664,percent of total billed charges,,,
CLINDAMYCIN HCL 150 MG ORAL CAPS,RX-1740,CDM,S5000,HCPCS,259,RC,00904-5959-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
NEVIRAPINE 200 MG ORAL TABS,RX-17403,CDM,S5000,HCPCS,259,RC,31722-0505-60,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE 1 % EX SOLN,RX-1742,CDM,S5000,HCPCS,259,RC,00168-0201-60,NDC,outpatient,60,ML,139.11,97.377,AETNA [1000108],AETNA [100010801],,,76.8,,106.84,0.222255,85118.57664,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE 1 % EX SOLN,RX-1742,CDM,S5000,HCPCS,259,RC,45802-0562-02,NDC,outpatient,60,ML,48.6,34.02,AETNA [1000108],AETNA [100010801],,,76.8,,37.32,0.222255,85118.57664,percent of total billed charges,,,
MIRTAZAPINE 15 MG ORAL TABS,RX-17466,CDM,S5000,HCPCS,259,RC,00904-6519-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
MIRTAZAPINE 15 MG ORAL TABS,RX-17466,CDM,S5000,HCPCS,259,RC,51079-0086-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
MIRTAZAPINE 15 MG ORAL TABS,RX-17466,CDM,S5000,HCPCS,259,RC,51079-0086-20,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
CANDIDA ALBICANS SKN TST ANTGN ID SOLN,RX-17524,CDM,S5000,HCPCS,250,RC,59584-0138-01,NDC,outpatient,0.1,ML,121.71,85.197,AETNA [1000108],AETNA [100010801],,,76.8,,93.47,0.222255,85118.57664,percent of total billed charges,,,
CLONIDINE HCL 0.1 MG ORAL TABS,RX-1755,CDM,S5000,HCPCS,259,RC,60687-0113-11,NDC,outpatient,1,UN,1.25,0.875,AETNA [1000108],AETNA [100010801],,,76.8,,0.96,0.222255,85118.57664,percent of total billed charges,,,
CLONIDINE HCL 0.1 MG ORAL TABS,RX-1755,CDM,S5000,HCPCS,259,RC,60687-0113-01,NDC,outpatient,1,UN,1.25,0.875,AETNA [1000108],AETNA [100010801],,,76.8,,0.96,0.222255,85118.57664,percent of total billed charges,,,
CLORAZEPATE DIPOTASSIUM 3.75 MG ORAL TABS,RX-1759,CDM,S5000,HCPCS,259,RC,13107-0319-01,NDC,outpatient,1,UN,4.43,3.101,AETNA [1000108],AETNA [100010801],,,76.8,,3.4,0.222255,85118.57664,percent of total billed charges,,,
CLOTRIMAZOLE 1 % EX CREA,RX-1767,CDM,S5000,HCPCS,259,RC,51672-2002-02,NDC,outpatient,30,GR,6.01,4.207,AETNA [1000108],AETNA [100010801],,,76.8,,4.62,0.222255,85118.57664,percent of total billed charges,,,
CLOTRIMAZOLE 1 % EX CREA,RX-1767,CDM,S5000,HCPCS,259,RC,45802-0434-11,NDC,outpatient,30,GR,10.42,7.294,AETNA [1000108],AETNA [100010801],,,76.8,,8,0.222255,85118.57664,percent of total billed charges,,,
CLOTRIMAZOLE 1 % EX SOLN,RX-1768,CDM,S5000,HCPCS,259,RC,51672-1260-03,NDC,outpatient,30,ML,97.86,68.502,AETNA [1000108],AETNA [100010801],,,76.8,,75.16,0.222255,85118.57664,percent of total billed charges,,,
CLOTRIMAZOLE 1 % VA CREA,RX-1769,CDM,S5000,HCPCS,259,RC,51672-2003-06,NDC,outpatient,45,GR,11.82,8.274,AETNA [1000108],AETNA [100010801],,,76.8,,9.08,0.222255,85118.57664,percent of total billed charges,,,
ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS,RX-17837,CDM,S5000,HCPCS,259,RC,00173-0682-24,NDC,outpatient,8,GR,92.49,64.743,AETNA [1000108],AETNA [100010801],,,76.8,,71.03,0.222255,85118.57664,percent of total billed charges,,,
ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS,RX-17837,CDM,S5000,HCPCS,259,RC,00093-3174-31,NDC,outpatient,8.5,GR,117.83,82.481,AETNA [1000108],AETNA [100010801],,,76.8,,90.49,0.222255,85118.57664,percent of total billed charges,,,
ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS,RX-17837,CDM,S5000,HCPCS,259,RC,66993-0019-68,NDC,outpatient,18,GR,146.67,102.669,AETNA [1000108],AETNA [100010801],,,76.8,,112.64,0.222255,85118.57664,percent of total billed charges,,,
BRIMONIDINE TARTRATE 0.2 % OP SOLN,RX-17881,CDM,S5000,HCPCS,259,RC,24208-0411-05,NDC,outpatient,5,ML,61.95,43.365,AETNA [1000108],AETNA [100010801],,,76.8,,47.58,0.222255,85118.57664,percent of total billed charges,,,
BRIMONIDINE TARTRATE 0.2 % OP SOLN,RX-17881,CDM,S5000,HCPCS,259,RC,71921-0185-05,NDC,outpatient,5,ML,41.12,28.784,AETNA [1000108],AETNA [100010801],,,76.8,,31.58,0.222255,85118.57664,percent of total billed charges,,,
BRIMONIDINE TARTRATE 0.2 % OP SOLN,RX-17881,CDM,S5000,HCPCS,259,RC,61314-0143-05,NDC,outpatient,5,ML,13.04,9.128,AETNA [1000108],AETNA [100010801],,,76.8,,10.01,0.222255,85118.57664,percent of total billed charges,,,
BRIMONIDINE TARTRATE 0.2 % OP SOLN,RX-17881,CDM,S5000,HCPCS,259,RC,70069-0231-01,NDC,outpatient,5,ML,7.26,5.082,AETNA [1000108],AETNA [100010801],,,76.8,,5.58,0.222255,85118.57664,percent of total billed charges,,,
B COMPLEX ORAL CAPS,RX-17882,CDM,S5000,HCPCS,259,RC,54629-0560-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
OLANZAPINE 5 MG ORAL TABS,RX-17936,CDM,S5000,HCPCS,259,RC,00904-6377-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
DEXAMETHASONE 1 MG/ML ORAL CONC,RX-17946,CDM,S5000,HCPCS,259,RC,00054-3176-44,NDC,outpatient,30,ML,90.92,63.644,AETNA [1000108],AETNA [100010801],,,76.8,,69.83,0.222255,85118.57664,percent of total billed charges,,,
ZAFIRLUKAST 20 MG ORAL TABS,RX-17960,CDM,S5000,HCPCS,259,RC,68084-0059-21,NDC,outpatient,1,UN,10.83,7.581,AETNA [1000108],AETNA [100010801],,,76.8,,8.32,0.222255,85118.57664,percent of total billed charges,,,
ZAFIRLUKAST 20 MG ORAL TABS,RX-17960,CDM,S5000,HCPCS,259,RC,68084-0059-11,NDC,outpatient,1,UN,10.83,7.581,AETNA [1000108],AETNA [100010801],,,76.8,,8.32,0.222255,85118.57664,percent of total billed charges,,,
AMMONIUM LACTATE 12 % EX CREA,RX-17997,CDM,S5000,HCPCS,259,RC,45802-0513-77,NDC,outpatient,140,GR,35.52,24.864,AETNA [1000108],AETNA [100010801],,,76.8,,27.28,0.222255,85118.57664,percent of total billed charges,,,
CODEINE SULFATE 15 MG ORAL TABS,RX-1801,CDM,S5000,HCPCS,259,RC,00054-0243-24,NDC,outpatient,1,UN,2.94,2.058,AETNA [1000108],AETNA [100010801],,,76.8,,2.26,0.222255,85118.57664,percent of total billed charges,,,
SENNA 8.6 MG ORAL TABS,RX-18138,CDM,S5000,HCPCS,259,RC,00904-7252-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
COLCHICINE 0.6 MG ORAL TABS,RX-1821,CDM,S5000,HCPCS,259,RC,42292-0054-03,NDC,outpatient,1,UN,13.56,9.492,AETNA [1000108],AETNA [100010801],,,76.8,,10.41,0.222255,85118.57664,percent of total billed charges,,,
COLCHICINE 0.6 MG ORAL TABS,RX-1821,CDM,S5000,HCPCS,259,RC,42292-0054-01,NDC,outpatient,1,UN,13.56,9.492,AETNA [1000108],AETNA [100010801],,,76.8,,10.41,0.222255,85118.57664,percent of total billed charges,,,
COLCHICINE 0.6 MG ORAL TABS,RX-1821,CDM,S5000,HCPCS,259,RC,65162-0710-09,NDC,outpatient,1,UN,2.83,1.981,AETNA [1000108],AETNA [100010801],,,76.8,,2.17,0.222255,85118.57664,percent of total billed charges,,,
BISOPROLOL FUMARATE 5 MG ORAL TABS,RX-18288,CDM,S5000,HCPCS,259,RC,29300-0126-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
BISOPROLOL-HYDROCHLOROTHIAZIDE 10-6.25 MG ORAL TABS,RX-18289,CDM,S5000,HCPCS,259,RC,10135-0742-30,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
BISOPROLOL-HYDROCHLOROTHIAZIDE 10-6.25 MG ORAL TABS,RX-18289,CDM,S5000,HCPCS,259,RC,29300-0189-01,NDC,outpatient,1,UN,2.16,1.512,AETNA [1000108],AETNA [100010801],,,76.8,,1.66,0.222255,85118.57664,percent of total billed charges,,,
BISOPROLOL-HYDROCHLOROTHIAZIDE 5-6.25 MG ORAL TABS,RX-18290,CDM,S5000,HCPCS,259,RC,29300-0188-01,NDC,outpatient,1,UN,2.18,1.526,AETNA [1000108],AETNA [100010801],,,76.8,,1.67,0.222255,85118.57664,percent of total billed charges,,,
BISOPROLOL-HYDROCHLOROTHIAZIDE 2.5-6.25 MG ORAL TABS,RX-18291,CDM,S5000,HCPCS,259,RC,68462-0878-30,NDC,outpatient,1,UN,1.61,1.127,AETNA [1000108],AETNA [100010801],,,76.8,,1.24,0.222255,85118.57664,percent of total billed charges,,,
BISOPROLOL-HYDROCHLOROTHIAZIDE 2.5-6.25 MG ORAL TABS,RX-18291,CDM,S5000,HCPCS,259,RC,29300-0187-01,NDC,outpatient,1,UN,2.03,1.421,AETNA [1000108],AETNA [100010801],,,76.8,,1.56,0.222255,85118.57664,percent of total billed charges,,,
TORSEMIDE 10 MG ORAL TABS,RX-18292,CDM,S5000,HCPCS,259,RC,50268-0755-15,NDC,outpatient,1,UN,1.14,0.798,AETNA [1000108],AETNA [100010801],,,76.8,,0.88,0.222255,85118.57664,percent of total billed charges,,,
TORSEMIDE 10 MG ORAL TABS,RX-18292,CDM,S5000,HCPCS,259,RC,50268-0755-11,NDC,outpatient,1,UN,1.14,0.798,AETNA [1000108],AETNA [100010801],,,76.8,,0.88,0.222255,85118.57664,percent of total billed charges,,,
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,50268-0756-11,NDC,outpatient,1,UN,1.5,1.05,AETNA [1000108],AETNA [100010801],,,76.8,,1.15,0.222255,85118.57664,percent of total billed charges,,,
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,00054-0077-29,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,50268-0756-15,NDC,outpatient,1,UN,1.5,1.05,AETNA [1000108],AETNA [100010801],,,76.8,,1.15,0.222255,85118.57664,percent of total billed charges,,,
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,68084-0539-11,NDC,outpatient,1,UN,1.28,0.896,AETNA [1000108],AETNA [100010801],,,76.8,,0.98,0.222255,85118.57664,percent of total billed charges,,,
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,00054-0077-25,NDC,outpatient,1,UN,1.1,0.77,AETNA [1000108],AETNA [100010801],,,76.8,,0.84,0.222255,85118.57664,percent of total billed charges,,,
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,68084-0539-01,NDC,outpatient,1,UN,1.28,0.896,AETNA [1000108],AETNA [100010801],,,76.8,,0.98,0.222255,85118.57664,percent of total billed charges,,,
TORSEMIDE 100 MG ORAL TABS,RX-18294,CDM,S5000,HCPCS,259,RC,50268-0757-15,NDC,outpatient,1,UN,1.64,1.148,AETNA [1000108],AETNA [100010801],,,76.8,,1.26,0.222255,85118.57664,percent of total billed charges,,,
TORSEMIDE 100 MG ORAL TABS,RX-18294,CDM,S5000,HCPCS,259,RC,31722-0532-01,NDC,outpatient,1,UN,2.32,1.624,AETNA [1000108],AETNA [100010801],,,76.8,,1.78,0.222255,85118.57664,percent of total billed charges,,,
TORSEMIDE 100 MG ORAL TABS,RX-18294,CDM,S5000,HCPCS,259,RC,50268-0757-11,NDC,outpatient,1,UN,1.64,1.148,AETNA [1000108],AETNA [100010801],,,76.8,,1.26,0.222255,85118.57664,percent of total billed charges,,,
GABAPENTIN 400 MG ORAL CAPS,RX-18307,CDM,S5000,HCPCS,259,RC,63739-0904-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
GABAPENTIN 400 MG ORAL CAPS,RX-18307,CDM,S5000,HCPCS,259,RC,00904-6667-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,00904-6666-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,45963-0556-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,60687-0591-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,16714-0662-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,60687-0591-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,63739-0903-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
GABAPENTIN 100 MG ORAL CAPS,RX-18309,CDM,S5000,HCPCS,259,RC,60687-0580-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
GABAPENTIN 100 MG ORAL CAPS,RX-18309,CDM,S5000,HCPCS,259,RC,60687-0580-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
GABAPENTIN 100 MG ORAL CAPS,RX-18309,CDM,S5000,HCPCS,259,RC,00904-6665-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
GABAPENTIN 100 MG ORAL CAPS,RX-18309,CDM,S5000,HCPCS,259,RC,63739-0902-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
RISPERIDONE 2 MG ORAL TABS,RX-18311,CDM,S5000,HCPCS,259,RC,00904-7363-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
RISPERIDONE 1 MG ORAL TABS,RX-18313,CDM,S5000,HCPCS,259,RC,00904-7362-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
RISPERIDONE 1 MG ORAL TABS,RX-18313,CDM,S5000,HCPCS,259,RC,42291-0910-60,NDC,outpatient,1,UN,11.7,8.19,AETNA [1000108],AETNA [100010801],,,76.8,,8.99,0.222255,85118.57664,percent of total billed charges,,,
BUPROPION HCL ER (SR) 100 MG ORAL TB12,RX-18385,CDM,S5000,HCPCS,259,RC,68084-0697-11,NDC,outpatient,1,UN,2.72,1.904,AETNA [1000108],AETNA [100010801],,,76.8,,2.09,0.222255,85118.57664,percent of total billed charges,,,
BUPROPION HCL ER (SR) 100 MG ORAL TB12,RX-18385,CDM,S5000,HCPCS,259,RC,68084-0697-01,NDC,outpatient,1,UN,2.72,1.904,AETNA [1000108],AETNA [100010801],,,76.8,,2.09,0.222255,85118.57664,percent of total billed charges,,,
BUPROPION HCL ER (SR) 150 MG ORAL TB12,RX-18386,CDM,S5000,HCPCS,259,RC,68084-0708-95,NDC,outpatient,1,UN,2.27,1.589,AETNA [1000108],AETNA [100010801],,,76.8,,1.74,0.222255,85118.57664,percent of total billed charges,,,
BUPROPION HCL ER (SR) 150 MG ORAL TB12,RX-18386,CDM,S5000,HCPCS,259,RC,68084-0708-25,NDC,outpatient,1,UN,2.27,1.589,AETNA [1000108],AETNA [100010801],,,76.8,,1.74,0.222255,85118.57664,percent of total billed charges,,,
REMIFENTANIL HCL 1 MG IV SOLR,RX-18398,CDM,S5000,HCPCS,250,RC,00143-9391-01,NDC,outpatient,1,UN,164.07,114.849,AETNA [1000108],AETNA [100010801],,,76.8,,126.01,0.222255,85118.57664,percent of total billed charges,,,
REMIFENTANIL HCL 1 MG IV SOLR,RX-18398,CDM,S5000,HCPCS,250,RC,63323-0723-01,NDC,outpatient,1,UN,164.48,115.136,AETNA [1000108],AETNA [100010801],,,76.8,,126.32,0.222255,85118.57664,percent of total billed charges,,,
REMIFENTANIL HCL 1 MG IV SOLR,RX-18398,CDM,S5000,HCPCS,250,RC,00143-9391-10,NDC,outpatient,1,UN,164.07,114.849,AETNA [1000108],AETNA [100010801],,,76.8,,126.01,0.222255,85118.57664,percent of total billed charges,,,
REMIFENTANIL HCL 1 MG IV SOLR,RX-18398,CDM,S5000,HCPCS,250,RC,63323-0723-03,NDC,outpatient,1,UN,164.48,115.136,AETNA [1000108],AETNA [100010801],,,76.8,,126.32,0.222255,85118.57664,percent of total billed charges,,,
CARVEDILOL 3.125 MG ORAL TABS,RX-18551,CDM,S5000,HCPCS,259,RC,00904-6300-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LATANOPROST 0.005 % OP SOLN,RX-18621,CDM,S5000,HCPCS,259,RC,24208-0463-25,NDC,outpatient,2.5,ML,46.77,32.739,AETNA [1000108],AETNA [100010801],,,76.8,,35.92,0.222255,85118.57664,percent of total billed charges,,,
LATANOPROST 0.005 % OP SOLN,RX-18621,CDM,S5000,HCPCS,259,RC,70069-0421-01,NDC,outpatient,2.5,ML,19.9,13.93,AETNA [1000108],AETNA [100010801],,,76.8,,15.28,0.222255,85118.57664,percent of total billed charges,,,
LATANOPROST 0.005 % OP SOLN,RX-18621,CDM,S5000,HCPCS,259,RC,59762-0333-02,NDC,outpatient,2.5,ML,18.92,13.244,AETNA [1000108],AETNA [100010801],,,76.8,,14.53,0.222255,85118.57664,percent of total billed charges,,,
LATANOPROST 0.005 % OP SOLN,RX-18621,CDM,S5000,HCPCS,259,RC,61314-0547-01,NDC,outpatient,2.5,ML,19.1,13.37,AETNA [1000108],AETNA [100010801],,,76.8,,14.67,0.222255,85118.57664,percent of total billed charges,,,
DONEPEZIL HCL 5 MG ORAL TABS,RX-18786,CDM,S5000,HCPCS,259,RC,00904-6477-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
NITROPRUSSIDE SODIUM 25 MG/ML IV SOLN,RX-18908,CDM,S5000,HCPCS,250,RC,43598-0587-23,NDC,outpatient,2,ML,87.58,61.306,AETNA [1000108],AETNA [100010801],,,76.8,,67.26,0.222255,85118.57664,percent of total billed charges,,,
NITROPRUSSIDE SODIUM 25 MG/ML IV SOLN,RX-18908,CDM,S5000,HCPCS,250,RC,67457-0839-02,NDC,outpatient,2,ML,53.45,37.415,AETNA [1000108],AETNA [100010801],,,76.8,,41.05,0.222255,85118.57664,percent of total billed charges,,,
NITROPRUSSIDE SODIUM 25 MG/ML IV SOLN,RX-18908,CDM,S5000,HCPCS,250,RC,72485-0105-01,NDC,outpatient,2,ML,69.91,48.937,AETNA [1000108],AETNA [100010801],,,76.8,,53.69,0.222255,85118.57664,percent of total billed charges,,,
LEVOFLOXACIN 250 MG ORAL TABS,RX-18918,CDM,S5000,HCPCS,259,RC,00904-6351-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LEVOFLOXACIN 500 MG ORAL TABS,RX-18919,CDM,S5000,HCPCS,259,RC,00904-6352-61,NDC,outpatient,1,UN,1.04,0.728,AETNA [1000108],AETNA [100010801],,,76.8,,0.8,0.222255,85118.57664,percent of total billed charges,,,
TOPIRAMATE 25 MG ORAL TABS,RX-18920,CDM,S5000,HCPCS,259,RC,68084-0342-11,NDC,outpatient,1,UN,1.38,0.966,AETNA [1000108],AETNA [100010801],,,76.8,,1.06,0.222255,85118.57664,percent of total billed charges,,,
TOPIRAMATE 25 MG ORAL TABS,RX-18920,CDM,S5000,HCPCS,259,RC,68084-0342-01,NDC,outpatient,1,UN,1.38,0.966,AETNA [1000108],AETNA [100010801],,,76.8,,1.06,0.222255,85118.57664,percent of total billed charges,,,
TOPIRAMATE 100 MG ORAL TABS,RX-18922,CDM,S5000,HCPCS,259,RC,68084-0344-01,NDC,outpatient,1,UN,2.19,1.533,AETNA [1000108],AETNA [100010801],,,76.8,,1.68,0.222255,85118.57664,percent of total billed charges,,,
TOPIRAMATE 100 MG ORAL TABS,RX-18922,CDM,S5000,HCPCS,259,RC,68084-0344-11,NDC,outpatient,1,UN,2.19,1.533,AETNA [1000108],AETNA [100010801],,,76.8,,1.68,0.222255,85118.57664,percent of total billed charges,,,
ATORVASTATIN CALCIUM 10 MG ORAL TABS,RX-19176,CDM,S5000,HCPCS,259,RC,00904-6290-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ATORVASTATIN CALCIUM 20 MG ORAL TABS,RX-19178,CDM,S5000,HCPCS,259,RC,00904-6291-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
AZELASTINE HCL 0.1 % NA SOLN,RX-19179,CDM,S5000,HCPCS,259,RC,60505-0833-05,NDC,outpatient,30,ML,24.97,17.479,AETNA [1000108],AETNA [100010801],,,76.8,,19.18,0.222255,85118.57664,percent of total billed charges,,,
CABERGOLINE 0.5 MG ORAL TABS,RX-19226,CDM,S5000,HCPCS,259,RC,23155-0823-73,NDC,outpatient,1,UN,8.36,5.852,AETNA [1000108],AETNA [100010801],,,76.8,,6.42,0.222255,85118.57664,percent of total billed charges,,,
CABERGOLINE 0.5 MG ORAL TABS,RX-19226,CDM,S5000,HCPCS,259,RC,50742-0118-08,NDC,outpatient,1,UN,13.91,9.737,AETNA [1000108],AETNA [100010801],,,76.8,,10.68,0.222255,85118.57664,percent of total billed charges,,,
CABERGOLINE 0.5 MG ORAL TABS,RX-19226,CDM,S5000,HCPCS,259,RC,59762-1005-01,NDC,outpatient,1,UN,22.17,15.519,AETNA [1000108],AETNA [100010801],,,76.8,,17.03,0.222255,85118.57664,percent of total billed charges,,,
PHENYLEPHRINE HCL 10 % OP SOLN,RX-19636,CDM,S5000,HCPCS,259,RC,70756-0614-30,NDC,outpatient,5,ML,178,124.6,AETNA [1000108],AETNA [100010801],,,76.8,,136.7,0.222255,85118.57664,percent of total billed charges,,,
BENZOCAINE 20 % MT GEL,RX-19691,CDM,S5000,HCPCS,259,RC,10310-0566-20,NDC,outpatient,11.9,GR,20.34,14.238,AETNA [1000108],AETNA [100010801],,,76.8,,15.62,0.222255,85118.57664,percent of total billed charges,,,
CARBACHOL 0.01 % IO SOLN,RX-19704,CDM,S5000,HCPCS,259,RC,00065-0023-15,NDC,outpatient,1.5,ML,66,46.2,AETNA [1000108],AETNA [100010801],,,76.8,,50.69,0.222255,85118.57664,percent of total billed charges,,,
DIAZOXIDE 50 MG/ML ORAL SUSP,RX-19713,CDM,S5000,HCPCS,259,RC,99999-0003-50,NDC,outpatient,1,ML,37.77,26.439,AETNA [1000108],AETNA [100010801],,,76.8,,29.01,0.222255,85118.57664,percent of total billed charges,,,
DIAZOXIDE 50 MG/ML ORAL SUSP,RX-19713,CDM,S5000,HCPCS,259,RC,00254-1010-19,NDC,outpatient,30,ML,1132.89,793.023,AETNA [1000108],AETNA [100010801],,,76.8,,870.06,0.222255,85118.57664,percent of total billed charges,,,
DICLOFENAC SODIUM 0.1 % OP SOLN,RX-19714,CDM,S5000,HCPCS,259,RC,24208-0457-05,NDC,outpatient,5,ML,46.46,32.522,AETNA [1000108],AETNA [100010801],,,76.8,,35.68,0.222255,85118.57664,percent of total billed charges,,,
DICLOFENAC SODIUM 0.1 % OP SOLN,RX-19714,CDM,S5000,HCPCS,259,RC,61314-0014-25,NDC,outpatient,2.5,ML,39.79,27.853,AETNA [1000108],AETNA [100010801],,,76.8,,30.56,0.222255,85118.57664,percent of total billed charges,,,
FLUOROMETHOLONE 0.25 % OP SUSP,RX-19722,CDM,S5000,HCPCS,259,RC,11980-0228-05,NDC,outpatient,5,ML,692.51,484.757,AETNA [1000108],AETNA [100010801],,,76.8,,531.85,0.222255,85118.57664,percent of total billed charges,,,
MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP,RX-19736,CDM,S5000,HCPCS,250,RC,00548-5400-00,NDC,outpatient,1,ML,75.65,52.955,AETNA [1000108],AETNA [100010801],,,76.8,,58.1,0.222255,85118.57664,percent of total billed charges,,,
MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP,RX-19736,CDM,S5000,HCPCS,250,RC,00009-0746-30,NDC,outpatient,1,ML,216.41,151.487,AETNA [1000108],AETNA [100010801],,,76.8,,166.2,0.222255,85118.57664,percent of total billed charges,,,
METHYLCELLULOSE (LAXATIVE) 500 MG ORAL TABS,RX-19740,CDM,S5000,HCPCS,259,RC,00135-0199-02,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
METHYLCELLULOSE (LAXATIVE) 500 MG ORAL TABS,RX-19740,CDM,S5000,HCPCS,259,RC,49348-0541-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
OFLOXACIN 0.3 % OP SOLN,RX-19746,CDM,S5000,HCPCS,259,RC,60505-0560-00,NDC,outpatient,5,ML,32.22,22.554,AETNA [1000108],AETNA [100010801],,,76.8,,24.74,0.222255,85118.57664,percent of total billed charges,,,
OFLOXACIN 0.3 % OP SOLN,RX-19746,CDM,S5000,HCPCS,259,RC,64980-0515-05,NDC,outpatient,5,ML,58.61,41.027,AETNA [1000108],AETNA [100010801],,,76.8,,45.01,0.222255,85118.57664,percent of total billed charges,,,
POVIDONE-IODINE 5 % OP SOLN,RX-19791,CDM,S5000,HCPCS,259,RC,00065-0411-30,NDC,outpatient,30,ML,45.26,31.682,AETNA [1000108],AETNA [100010801],,,76.8,,34.76,0.222255,85118.57664,percent of total billed charges,,,
NEOMYCIN-POLYMYXIN-PRAMOXINE 1 % EX CREA,RX-19880,CDM,S5000,HCPCS,259,RC,12547-0407-40,NDC,outpatient,14.2,GR,19.03,13.321,AETNA [1000108],AETNA [100010801],,,76.8,,14.62,0.222255,85118.57664,percent of total billed charges,,,
SERTRALINE HCL 25 MG ORAL TABS,RX-19882,CDM,S5000,HCPCS,259,RC,60687-0231-11,NDC,outpatient,1,UN,1.26,0.882,AETNA [1000108],AETNA [100010801],,,76.8,,0.97,0.222255,85118.57664,percent of total billed charges,,,
SERTRALINE HCL 25 MG ORAL TABS,RX-19882,CDM,S5000,HCPCS,259,RC,60687-0231-01,NDC,outpatient,1,UN,1.26,0.882,AETNA [1000108],AETNA [100010801],,,76.8,,0.97,0.222255,85118.57664,percent of total billed charges,,,
NELFINAVIR MESYLATE 250 MG ORAL TABS,RX-20032,CDM,S5000,HCPCS,259,RC,63010-0010-30,NDC,outpatient,1,UN,17.47,12.229,AETNA [1000108],AETNA [100010801],,,76.8,,13.42,0.222255,85118.57664,percent of total billed charges,,,
MESNA 400 MG ORAL TABS,RX-20077,CDM,S5000,HCPCS,259,RC,67108-3565-09,NDC,outpatient,1,UN,287.17,201.019,AETNA [1000108],AETNA [100010801],,,76.8,,220.55,0.222255,85118.57664,percent of total billed charges,,,
CYANOCOBALAMIN 100 MCG ORAL TABS,RX-2008,CDM,S5000,HCPCS,259,RC,50268-0852-15,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
CYANOCOBALAMIN 100 MCG ORAL TABS,RX-2008,CDM,S5000,HCPCS,259,RC,50268-0852-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
CYCLOBENZAPRINE HCL 10 MG ORAL TABS,RX-2017,CDM,S5000,HCPCS,259,RC,60687-0558-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
CYCLOBENZAPRINE HCL 10 MG ORAL TABS,RX-2017,CDM,S5000,HCPCS,259,RC,60687-0558-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
CYCLOPENTOLATE HCL 1 % OP SOLN,RX-2025,CDM,S5000,HCPCS,259,RC,24208-0735-06,NDC,outpatient,15,ML,121.82,85.274,AETNA [1000108],AETNA [100010801],,,76.8,,93.56,0.222255,85118.57664,percent of total billed charges,,,
CYCLOPENTOLATE HCL 1 % OP SOLN,RX-2025,CDM,S5000,HCPCS,259,RC,24208-0735-01,NDC,outpatient,2,ML,47.31,33.117,AETNA [1000108],AETNA [100010801],,,76.8,,36.33,0.222255,85118.57664,percent of total billed charges,,,
CYPROHEPTADINE HCL 4 MG ORAL TABS,RX-2033,CDM,S5000,HCPCS,259,RC,50268-0189-15,NDC,outpatient,1,UN,2.94,2.058,AETNA [1000108],AETNA [100010801],,,76.8,,2.26,0.222255,85118.57664,percent of total billed charges,,,
CYPROHEPTADINE HCL 4 MG ORAL TABS,RX-2033,CDM,S5000,HCPCS,259,RC,50268-0189-11,NDC,outpatient,1,UN,2.94,2.058,AETNA [1000108],AETNA [100010801],,,76.8,,2.26,0.222255,85118.57664,percent of total billed charges,,,
CYSTEINE HCL 50 MG/ML IV SOLN,RX-2034,CDM,S5000,HCPCS,250,RC,51754-1007-01,NDC,outpatient,10,ML,375.94,263.158,AETNA [1000108],AETNA [100010801],,,76.8,,288.72,0.222255,85118.57664,percent of total billed charges,,,
CYSTEINE HCL 50 MG/ML IV SOLN,RX-2034,CDM,S5000,HCPCS,250,RC,51754-1007-03,NDC,outpatient,10,ML,375.94,263.158,AETNA [1000108],AETNA [100010801],,,76.8,,288.72,0.222255,85118.57664,percent of total billed charges,,,
ANAGRELIDE HCL 0.5 MG ORAL CAPS,RX-20446,CDM,S5000,HCPCS,259,RC,00172-5241-60,NDC,outpatient,1,UN,3.43,2.401,AETNA [1000108],AETNA [100010801],,,76.8,,2.63,0.222255,85118.57664,percent of total billed charges,,,
ANAGRELIDE HCL 0.5 MG ORAL CAPS,RX-20446,CDM,S5000,HCPCS,259,RC,13668-0453-01,NDC,outpatient,1,UN,2.97,2.079,AETNA [1000108],AETNA [100010801],,,76.8,,2.28,0.222255,85118.57664,percent of total billed charges,,,
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,00143-9507-01,NDC,outpatient,20,ML,27.51,19.257,AETNA [1000108],AETNA [100010801],,,76.8,,21.13,0.222255,85118.57664,percent of total billed charges,,,
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,00143-9506-01,NDC,outpatient,10,ML,25.46,17.822,AETNA [1000108],AETNA [100010801],,,76.8,,19.55,0.222255,85118.57664,percent of total billed charges,,,
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,00143-9506-10,NDC,outpatient,10,ML,25.46,17.822,AETNA [1000108],AETNA [100010801],,,76.8,,19.55,0.222255,85118.57664,percent of total billed charges,,,
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,00143-9507-10,NDC,outpatient,20,ML,27.51,19.257,AETNA [1000108],AETNA [100010801],,,76.8,,21.13,0.222255,85118.57664,percent of total billed charges,,,
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,55150-0221-10,NDC,outpatient,10,ML,12.44,8.708,AETNA [1000108],AETNA [100010801],,,76.8,,9.55,0.222255,85118.57664,percent of total billed charges,,,
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,72266-0146-01,NDC,outpatient,10,ML,13.73,9.611,AETNA [1000108],AETNA [100010801],,,76.8,,10.54,0.222255,85118.57664,percent of total billed charges,,,
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,72266-0146-10,NDC,outpatient,10,ML,13.73,9.611,AETNA [1000108],AETNA [100010801],,,76.8,,10.54,0.222255,85118.57664,percent of total billed charges,,,
MELOXICAM 7.5 MG ORAL TABS,RX-20566,CDM,S5000,HCPCS,259,RC,50268-0525-15,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
MELOXICAM 7.5 MG ORAL TABS,RX-20566,CDM,S5000,HCPCS,259,RC,50268-0525-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PYRETHRINS-PIPERONYL BUTOXIDE 0.33-4 % EX LIQD,RX-20781,CDM,S5000,HCPCS,259,RC,49348-0443-34,NDC,outpatient,118,ML,21.53,15.071,AETNA [1000108],AETNA [100010801],,,76.8,,16.54,0.222255,85118.57664,percent of total billed charges,,,
MIGLITOL 25 MG ORAL TABS,RX-20799,CDM,S5000,HCPCS,259,RC,69367-0303-01,NDC,outpatient,1,UN,7.35,5.145,AETNA [1000108],AETNA [100010801],,,76.8,,5.64,0.222255,85118.57664,percent of total billed charges,,,
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,00143-9785-10,NDC,outpatient,5,ML,20.56,14.392,AETNA [1000108],AETNA [100010801],,,76.8,,15.79,0.222255,85118.57664,percent of total billed charges,,,
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,70860-0784-05,NDC,outpatient,5,ML,10.16,7.112,AETNA [1000108],AETNA [100010801],,,76.8,,7.8,0.222255,85118.57664,percent of total billed charges,,,
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,70860-0784-41,NDC,outpatient,5,ML,10.16,7.112,AETNA [1000108],AETNA [100010801],,,76.8,,7.8,0.222255,85118.57664,percent of total billed charges,,,
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,63323-0494-01,NDC,outpatient,5,ML,9.31,6.517,AETNA [1000108],AETNA [100010801],,,76.8,,7.15,0.222255,85118.57664,percent of total billed charges,,,
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,00143-9785-01,NDC,outpatient,5,ML,20.56,14.392,AETNA [1000108],AETNA [100010801],,,76.8,,15.79,0.222255,85118.57664,percent of total billed charges,,,
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,63323-0494-05,NDC,outpatient,5,ML,9.31,6.517,AETNA [1000108],AETNA [100010801],,,76.8,,7.15,0.222255,85118.57664,percent of total billed charges,,,
AZITHROMYCIN 250 MG ORAL TABS,RX-20943,CDM,S5000,HCPCS,259,RC,60687-0742-11,NDC,outpatient,1,UN,3.5,2.45,AETNA [1000108],AETNA [100010801],,,76.8,,2.69,0.222255,85118.57664,percent of total billed charges,,,
AZITHROMYCIN 250 MG ORAL TABS,RX-20943,CDM,S5000,HCPCS,259,RC,65862-0641-63,NDC,outpatient,1,UN,1.45,1.015,AETNA [1000108],AETNA [100010801],,,76.8,,1.11,0.222255,85118.57664,percent of total billed charges,,,
AZITHROMYCIN 250 MG ORAL TABS,RX-20943,CDM,S5000,HCPCS,259,RC,60687-0742-01,NDC,outpatient,1,UN,3.5,2.45,AETNA [1000108],AETNA [100010801],,,76.8,,2.69,0.222255,85118.57664,percent of total billed charges,,,
LEVOCARNITINE 200 MG/ML IV SOLN,RX-20954,CDM,S5000,HCPCS,250,RC,00143-9852-01,NDC,outpatient,5,ML,94.7,66.29,AETNA [1000108],AETNA [100010801],,,76.8,,72.73,0.222255,85118.57664,percent of total billed charges,,,
LEVOCARNITINE 200 MG/ML IV SOLN,RX-20954,CDM,S5000,HCPCS,250,RC,54482-0147-01,NDC,outpatient,5,ML,99.51,69.657,AETNA [1000108],AETNA [100010801],,,76.8,,76.42,0.222255,85118.57664,percent of total billed charges,,,
LEVOCARNITINE 200 MG/ML IV SOLN,RX-20954,CDM,S5000,HCPCS,250,RC,00143-9852-10,NDC,outpatient,5,ML,94.7,66.29,AETNA [1000108],AETNA [100010801],,,76.8,,72.73,0.222255,85118.57664,percent of total billed charges,,,
OLANZAPINE 2.5 MG ORAL TABS,RX-21057,CDM,S5000,HCPCS,259,RC,00904-6283-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
OXCARBAZEPINE 300 MG ORAL TABS,RX-21061,CDM,S5000,HCPCS,259,RC,60687-0722-01,NDC,outpatient,1,UN,2.53,1.771,AETNA [1000108],AETNA [100010801],,,76.8,,1.94,0.222255,85118.57664,percent of total billed charges,,,
OXCARBAZEPINE 300 MG ORAL TABS,RX-21061,CDM,S5000,HCPCS,259,RC,60687-0722-11,NDC,outpatient,1,UN,2.53,1.771,AETNA [1000108],AETNA [100010801],,,76.8,,1.94,0.222255,85118.57664,percent of total billed charges,,,
OXCARBAZEPINE 300 MG ORAL TABS,RX-21061,CDM,S5000,HCPCS,259,RC,62756-0184-88,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
CITALOPRAM HYDROBROMIDE 20 MG ORAL TABS,RX-21062,CDM,S5000,HCPCS,259,RC,00904-6085-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
AMPHETAMINE-DEXTROAMPHETAMINE 5 MG ORAL TABS,RX-21284,CDM,S5000,HCPCS,259,RC,42806-0339-01,NDC,outpatient,1,UN,1.83,1.281,AETNA [1000108],AETNA [100010801],,,76.8,,1.41,0.222255,85118.57664,percent of total billed charges,,,
PRAMIPEXOLE DIHYDROCHLORIDE 1 MG ORAL TABS,RX-21288,CDM,S5000,HCPCS,259,RC,60687-0592-11,NDC,outpatient,1,UN,3.34,2.338,AETNA [1000108],AETNA [100010801],,,76.8,,2.57,0.222255,85118.57664,percent of total billed charges,,,
PRAMIPEXOLE DIHYDROCHLORIDE 1 MG ORAL TABS,RX-21288,CDM,S5000,HCPCS,259,RC,60687-0592-21,NDC,outpatient,1,UN,3.34,2.338,AETNA [1000108],AETNA [100010801],,,76.8,,2.57,0.222255,85118.57664,percent of total billed charges,,,
PRAMIPEXOLE DIHYDROCHLORIDE 1.5 MG ORAL TABS,RX-21289,CDM,S5000,HCPCS,259,RC,68462-0334-90,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PRAMIPEXOLE DIHYDROCHLORIDE 0.25 MG ORAL TABS,RX-21290,CDM,S5000,HCPCS,259,RC,00904-6704-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PENTOXIFYLLINE ER 400 MG ORAL TBCR,RX-21300,CDM,S5000,HCPCS,259,RC,60505-0033-06,NDC,outpatient,1,UN,2.18,1.526,AETNA [1000108],AETNA [100010801],,,76.8,,1.67,0.222255,85118.57664,percent of total billed charges,,,
PENTOXIFYLLINE ER 400 MG ORAL TBCR,RX-21300,CDM,S5000,HCPCS,259,RC,00904-5448-61,NDC,outpatient,1,UN,1.11,0.777,AETNA [1000108],AETNA [100010801],,,76.8,,0.85,0.222255,85118.57664,percent of total billed charges,,,
DAPSONE 100 MG ORAL TABS,RX-2131,CDM,S5000,HCPCS,259,RC,70954-0136-10,NDC,outpatient,1,UN,5.05,3.535,AETNA [1000108],AETNA [100010801],,,76.8,,3.88,0.222255,85118.57664,percent of total billed charges,,,
DAPSONE 25 MG ORAL TABS,RX-2132,CDM,S5000,HCPCS,259,RC,70954-0135-10,NDC,outpatient,1,UN,4.35,3.045,AETNA [1000108],AETNA [100010801],,,76.8,,3.34,0.222255,85118.57664,percent of total billed charges,,,
LETROZOLE 2.5 MG ORAL TABS,RX-21509,CDM,S5000,HCPCS,259,RC,00078-0249-15,NDC,outpatient,1,UN,108.93,76.251,AETNA [1000108],AETNA [100010801],,,76.8,,83.66,0.222255,85118.57664,percent of total billed charges,,,
LETROZOLE 2.5 MG ORAL TABS,RX-21509,CDM,S5000,HCPCS,259,RC,59651-0180-30,NDC,outpatient,1,UN,1.55,1.085,AETNA [1000108],AETNA [100010801],,,76.8,,1.19,0.222255,85118.57664,percent of total billed charges,,,
CARMUSTINE IN POLIFEPROSAN 7.7 MG IL WAFR,RX-21672,CDM,S5000,HCPCS,250,RC,24338-0050-08,NDC,outpatient,8,UN,110831.48,77582.036,AETNA [1000108],AETNA [100010801],,,76.8,,85118.58,0.222255,85118.57664,percent of total billed charges,,,
ROPINIROLE HCL 0.25 MG ORAL TABS,RX-21688,CDM,S5000,HCPCS,259,RC,00904-6373-61,NDC,outpatient,1,UN,1.51,1.057,AETNA [1000108],AETNA [100010801],,,76.8,,1.16,0.222255,85118.57664,percent of total billed charges,,,
ROPINIROLE HCL 1 MG ORAL TABS,RX-21689,CDM,S5000,HCPCS,259,RC,00904-6374-61,NDC,outpatient,1,UN,1.76,1.232,AETNA [1000108],AETNA [100010801],,,76.8,,1.35,0.222255,85118.57664,percent of total billed charges,,,
ROPINIROLE HCL 2 MG ORAL TABS,RX-21690,CDM,S5000,HCPCS,259,RC,50268-0744-11,NDC,outpatient,1,UN,2.46,1.722,AETNA [1000108],AETNA [100010801],,,76.8,,1.89,0.222255,85118.57664,percent of total billed charges,,,
ROPINIROLE HCL 2 MG ORAL TABS,RX-21690,CDM,S5000,HCPCS,259,RC,50268-0744-15,NDC,outpatient,1,UN,2.46,1.722,AETNA [1000108],AETNA [100010801],,,76.8,,1.89,0.222255,85118.57664,percent of total billed charges,,,
QUETIAPINE FUMARATE 25 MG ORAL TABS,RX-21823,CDM,S5000,HCPCS,259,RC,00904-6638-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
QUETIAPINE FUMARATE 25 MG ORAL TABS,RX-21823,CDM,S5000,HCPCS,259,RC,60687-0327-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
QUETIAPINE FUMARATE 25 MG ORAL TABS,RX-21823,CDM,S5000,HCPCS,259,RC,60687-0327-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
QUETIAPINE FUMARATE 100 MG ORAL TABS,RX-21824,CDM,S5000,HCPCS,259,RC,00904-6640-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
TIAGABINE HCL 4 MG ORAL TABS,RX-21827,CDM,S5000,HCPCS,259,RC,62756-0224-83,NDC,outpatient,1,UN,16.11,11.277,AETNA [1000108],AETNA [100010801],,,76.8,,12.37,0.222255,85118.57664,percent of total billed charges,,,
IRBESARTAN 150 MG ORAL TABS,RX-21848,CDM,S5000,HCPCS,259,RC,31722-0730-90,NDC,outpatient,1,UN,1.91,1.337,AETNA [1000108],AETNA [100010801],,,76.8,,1.47,0.222255,85118.57664,percent of total billed charges,,,
IRBESARTAN 150 MG ORAL TABS,RX-21848,CDM,S5000,HCPCS,259,RC,33342-0048-10,NDC,outpatient,1,UN,1.15,0.805,AETNA [1000108],AETNA [100010801],,,76.8,,0.88,0.222255,85118.57664,percent of total billed charges,,,
CLOPIDOGREL BISULFATE 75 MG ORAL TABS,RX-22142,CDM,S5000,HCPCS,259,RC,00904-6294-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
RALOXIFENE HCL 60 MG ORAL TABS,RX-22143,CDM,S5000,HCPCS,259,RC,60687-0266-11,NDC,outpatient,1,UN,23.4,16.38,AETNA [1000108],AETNA [100010801],,,76.8,,17.97,0.222255,85118.57664,percent of total billed charges,,,
RALOXIFENE HCL 60 MG ORAL TABS,RX-22143,CDM,S5000,HCPCS,259,RC,60687-0266-21,NDC,outpatient,1,UN,23.4,16.38,AETNA [1000108],AETNA [100010801],,,76.8,,17.97,0.222255,85118.57664,percent of total billed charges,,,
DILTIAZEM HCL 100 MG IV SOLR,RX-22156,CDM,S5000,HCPCS,250,RC,00409-4350-13,NDC,outpatient,1,UN,40.12,28.084,AETNA [1000108],AETNA [100010801],,,76.8,,30.81,0.222255,85118.57664,percent of total billed charges,,,
DILTIAZEM HCL 100 MG IV SOLR,RX-22156,CDM,S5000,HCPCS,250,RC,00409-4350-03,NDC,outpatient,1,UN,40.12,28.084,AETNA [1000108],AETNA [100010801],,,76.8,,30.81,0.222255,85118.57664,percent of total billed charges,,,
TOBRAMYCIN 300 MG/5ML IN NEBU,RX-22240,CDM,S5000,HCPCS,259,RC,70756-0604-56,NDC,outpatient,5,ML,19.47,13.629,AETNA [1000108],AETNA [100010801],,,76.8,,14.95,0.222255,85118.57664,percent of total billed charges,,,
TOBRAMYCIN 300 MG/5ML IN NEBU,RX-22240,CDM,S5000,HCPCS,259,RC,68180-0962-04,NDC,outpatient,5,ML,27.71,19.397,AETNA [1000108],AETNA [100010801],,,76.8,,21.28,0.222255,85118.57664,percent of total billed charges,,,
TOBRAMYCIN 300 MG/5ML IN NEBU,RX-22240,CDM,S5000,HCPCS,259,RC,70756-0604-44,NDC,outpatient,5,ML,19.47,13.629,AETNA [1000108],AETNA [100010801],,,76.8,,14.95,0.222255,85118.57664,percent of total billed charges,,,
TOBRAMYCIN 300 MG/5ML IN NEBU,RX-22240,CDM,S5000,HCPCS,259,RC,68180-0962-56,NDC,outpatient,5,ML,27.71,19.397,AETNA [1000108],AETNA [100010801],,,76.8,,21.28,0.222255,85118.57664,percent of total billed charges,,,
MUPIROCIN CALCIUM 2 % EX CREA,RX-22251,CDM,S5000,HCPCS,259,RC,68462-0564-17,NDC,outpatient,15,GR,861.28,602.896,AETNA [1000108],AETNA [100010801],,,76.8,,661.46,0.222255,85118.57664,percent of total billed charges,,,
MUPIROCIN CALCIUM 2 % EX CREA,RX-22251,CDM,S5000,HCPCS,259,RC,51672-1370-01,NDC,outpatient,15,GR,62.62,43.834,AETNA [1000108],AETNA [100010801],,,76.8,,48.09,0.222255,85118.57664,percent of total billed charges,,,
OFLOXACIN 0.3 % OT SOLN,RX-22257,CDM,S5000,HCPCS,259,RC,70756-0609-15,NDC,outpatient,5,ML,31.29,21.903,AETNA [1000108],AETNA [100010801],,,76.8,,24.03,0.222255,85118.57664,percent of total billed charges,,,
OFLOXACIN 0.3 % OT SOLN,RX-22257,CDM,S5000,HCPCS,259,RC,24208-0410-05,NDC,outpatient,5,ML,214.49,150.143,AETNA [1000108],AETNA [100010801],,,76.8,,164.73,0.222255,85118.57664,percent of total billed charges,,,
LACTASE 3000 UNITS ORAL TABS,RX-22469,CDM,S5000,HCPCS,259,RC,77333-0430-50,NDC,outpatient,1,UN,1.55,1.085,AETNA [1000108],AETNA [100010801],,,76.8,,1.19,0.222255,85118.57664,percent of total billed charges,,,
LACTASE 3000 UNITS ORAL TABS,RX-22469,CDM,S5000,HCPCS,259,RC,00904-5224-52,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LACTASE 3000 UNITS ORAL TABS,RX-22469,CDM,S5000,HCPCS,259,RC,77333-0430-25,NDC,outpatient,1,UN,1.55,1.085,AETNA [1000108],AETNA [100010801],,,76.8,,1.19,0.222255,85118.57664,percent of total billed charges,,,
MONTELUKAST SODIUM 10 MG ORAL TABS,RX-22509,CDM,S5000,HCPCS,259,RC,00904-6808-61,NDC,outpatient,1,UN,1.44,1.008,AETNA [1000108],AETNA [100010801],,,76.8,,1.11,0.222255,85118.57664,percent of total billed charges,,,
MONTELUKAST SODIUM 10 MG ORAL TABS,RX-22509,CDM,S5000,HCPCS,259,RC,00904-6808-06,NDC,outpatient,1,UN,1.19,0.833,AETNA [1000108],AETNA [100010801],,,76.8,,0.91,0.222255,85118.57664,percent of total billed charges,,,
MONTELUKAST SODIUM 5 MG ORAL CHEW,RX-22510,CDM,S5000,HCPCS,259,RC,50268-0574-11,NDC,outpatient,1,UN,2.8,1.96,AETNA [1000108],AETNA [100010801],,,76.8,,2.15,0.222255,85118.57664,percent of total billed charges,,,
MONTELUKAST SODIUM 5 MG ORAL CHEW,RX-22510,CDM,S5000,HCPCS,259,RC,50268-0574-15,NDC,outpatient,1,UN,2.8,1.96,AETNA [1000108],AETNA [100010801],,,76.8,,2.15,0.222255,85118.57664,percent of total billed charges,,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML ORAL SUSP,RX-22560,CDM,S5000,HCPCS,259,RC,99999-0002-45,NDC,outpatient,20,ML,22.52,15.764,AETNA [1000108],AETNA [100010801],,,76.8,,17.3,0.222255,85118.57664,percent of total billed charges,,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML ORAL SUSP,RX-22560,CDM,S5000,HCPCS,259,RC,00121-0853-40,NDC,outpatient,20,ML,60.61,42.427,AETNA [1000108],AETNA [100010801],,,76.8,,46.55,0.222255,85118.57664,percent of total billed charges,,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML ORAL SUSP,RX-22560,CDM,S5000,HCPCS,259,RC,00121-0853-20,NDC,outpatient,20,ML,60.61,42.427,AETNA [1000108],AETNA [100010801],,,76.8,,46.55,0.222255,85118.57664,percent of total billed charges,,,
REPAGLINIDE 2 MG ORAL TABS,RX-22585,CDM,S5000,HCPCS,259,RC,65862-0672-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
REPAGLINIDE 1 MG ORAL TABS,RX-22586,CDM,S5000,HCPCS,259,RC,65862-0671-01,NDC,outpatient,1,UN,1.06,0.742,AETNA [1000108],AETNA [100010801],,,76.8,,0.81,0.222255,85118.57664,percent of total billed charges,,,
POTASSIUM CITRATE-CITRIC ACID 1100-334 MG/5ML ORAL SOLN,RX-22646,CDM,S5000,HCPCS,259,RC,60258-0003-16,NDC,outpatient,10,ML,5.88,4.116,AETNA [1000108],AETNA [100010801],,,76.8,,4.52,0.222255,85118.57664,percent of total billed charges,,,
POTASSIUM CITRATE-CITRIC ACID 1100-334 MG/5ML ORAL SOLN,RX-22646,CDM,S5000,HCPCS,259,RC,99999-0002-34,NDC,outpatient,15,ML,3.14,2.198,AETNA [1000108],AETNA [100010801],,,76.8,,2.41,0.222255,85118.57664,percent of total billed charges,,,
POTASSIUM CITRATE-CITRIC ACID 1100-334 MG/5ML ORAL SOLN,RX-22646,CDM,S5000,HCPCS,259,RC,00121-0676-16,NDC,outpatient,15,ML,3.61,2.527,AETNA [1000108],AETNA [100010801],,,76.8,,2.77,0.222255,85118.57664,percent of total billed charges,,,
URSODIOL 250 MG ORAL TABS,RX-22660,CDM,S5000,HCPCS,259,RC,60687-0527-11,NDC,outpatient,1,UN,6.99,4.893,AETNA [1000108],AETNA [100010801],,,76.8,,5.37,0.222255,85118.57664,percent of total billed charges,,,
URSODIOL 250 MG ORAL TABS,RX-22660,CDM,S5000,HCPCS,259,RC,60687-0527-21,NDC,outpatient,1,UN,6.99,4.893,AETNA [1000108],AETNA [100010801],,,76.8,,5.37,0.222255,85118.57664,percent of total billed charges,,,
URSODIOL 250 MG ORAL TABS,RX-22660,CDM,S5000,HCPCS,259,RC,00904-6890-04,NDC,outpatient,1,UN,10.99,7.693,AETNA [1000108],AETNA [100010801],,,76.8,,8.44,0.222255,85118.57664,percent of total billed charges,,,
URSODIOL 250 MG ORAL TABS,RX-22660,CDM,S5000,HCPCS,259,RC,68462-0473-01,NDC,outpatient,1,UN,2.31,1.617,AETNA [1000108],AETNA [100010801],,,76.8,,1.77,0.222255,85118.57664,percent of total billed charges,,,
DESIPRAMINE HCL 25 MG ORAL TABS,RX-2286,CDM,S5000,HCPCS,259,RC,50742-0113-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PAROXETINE HCL 10 MG/5ML ORAL SUSP,RX-22959,CDM,S5000,HCPCS,259,RC,70954-0319-10,NDC,outpatient,5,ML,32.69,22.883,AETNA [1000108],AETNA [100010801],,,76.8,,25.11,0.222255,85118.57664,percent of total billed charges,,,
PAROXETINE HCL 10 MG/5ML ORAL SUSP,RX-22959,CDM,S5000,HCPCS,259,RC,99999-0001-34,NDC,outpatient,10,ML,72.98,51.086,AETNA [1000108],AETNA [100010801],,,76.8,,56.05,0.222255,85118.57664,percent of total billed charges,,,
DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN,RX-22982,CDM,S5000,HCPCS,259,RC,65862-0946-01,NDC,outpatient,10,ML,89,62.3,AETNA [1000108],AETNA [100010801],,,76.8,,68.35,0.222255,85118.57664,percent of total billed charges,,,
DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN,RX-22982,CDM,S5000,HCPCS,259,RC,70069-0051-01,NDC,outpatient,10,ML,38.99,27.293,AETNA [1000108],AETNA [100010801],,,76.8,,29.94,0.222255,85118.57664,percent of total billed charges,,,
DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN,RX-22982,CDM,S5000,HCPCS,259,RC,24208-0486-10,NDC,outpatient,10,ML,45.62,31.934,AETNA [1000108],AETNA [100010801],,,76.8,,35.04,0.222255,85118.57664,percent of total billed charges,,,
DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN,RX-22982,CDM,S5000,HCPCS,259,RC,82584-0605-10,NDC,outpatient,10,ML,996.05,697.235,AETNA [1000108],AETNA [100010801],,,76.8,,764.97,0.222255,85118.57664,percent of total billed charges,,,
DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN,RX-22982,CDM,S5000,HCPCS,259,RC,71921-0226-10,NDC,outpatient,10,ML,45.39,31.773,AETNA [1000108],AETNA [100010801],,,76.8,,34.86,0.222255,85118.57664,percent of total billed charges,,,
AMOXICILLIN-POT CLAVULANATE 250-125 MG ORAL TABS,RX-22992,CDM,S5000,HCPCS,259,RC,42571-0160-30,NDC,outpatient,1,UN,9.65,6.755,AETNA [1000108],AETNA [100010801],,,76.8,,7.41,0.222255,85118.57664,percent of total billed charges,,,
AMOXICILLIN-POT CLAVULANATE 250-125 MG ORAL TABS,RX-22992,CDM,S5000,HCPCS,259,RC,00781-1874-31,NDC,outpatient,1,UN,6.58,4.606,AETNA [1000108],AETNA [100010801],,,76.8,,5.05,0.222255,85118.57664,percent of total billed charges,,,
CAPECITABINE 500 MG ORAL TABS,RX-22994,CDM,S5000,HCPCS,259,RC,16729-0073-29,NDC,outpatient,1,UN,1.65,1.155,AETNA [1000108],AETNA [100010801],,,76.8,,1.27,0.222255,85118.57664,percent of total billed charges,,,
CAPECITABINE 500 MG ORAL TABS,RX-22994,CDM,S5000,HCPCS,259,RC,00004-1101-50,NDC,outpatient,1,UN,195.05,136.535,AETNA [1000108],AETNA [100010801],,,76.8,,149.8,0.222255,85118.57664,percent of total billed charges,,,
RISEDRONATE SODIUM 30 MG ORAL TABS,RX-23015,CDM,S5000,HCPCS,259,RC,00093-3100-56,NDC,outpatient,1,UN,220.55,154.385,AETNA [1000108],AETNA [100010801],,,76.8,,169.38,0.222255,85118.57664,percent of total billed charges,,,
CAMPHOR-MENTHOL 0.5-0.5 % EX LOTN,RX-23063,CDM,S5000,HCPCS,259,RC,00536-1268-12,NDC,outpatient,222,ML,16.8,11.76,AETNA [1000108],AETNA [100010801],,,76.8,,12.9,0.222255,85118.57664,percent of total billed charges,,,
CAMPHOR-MENTHOL 0.5-0.5 % EX LOTN,RX-23063,CDM,S5000,HCPCS,259,RC,46122-0573-10,NDC,outpatient,222,ML,11.13,7.791,AETNA [1000108],AETNA [100010801],,,76.8,,8.55,0.222255,85118.57664,percent of total billed charges,,,
CLINISOL SF 15 % IV SOLN,RX-23068,CDM,S5000,HCPCS,250,RC,00338-0502-06,NDC,outpatient,2000,ML,211.8,148.26,AETNA [1000108],AETNA [100010801],,,76.8,,162.66,0.222255,85118.57664,percent of total billed charges,,,
CLINIMIX E/DEXTROSE (5/15) 5 % IV SOLN,RX-23165,CDM,S5000,HCPCS,250,RC,00338-1123-04,NDC,outpatient,2000,ML,211.8,148.26,AETNA [1000108],AETNA [100010801],,,76.8,,162.66,0.222255,85118.57664,percent of total billed charges,,,
CLINIMIX E/DEXTROSE (5/15) 5 % IV SOLN,RX-23165,CDM,S5000,HCPCS,250,RC,00338-1147-03,NDC,outpatient,1000,ML,122.8,85.96,AETNA [1000108],AETNA [100010801],,,76.8,,94.31,0.222255,85118.57664,percent of total billed charges,,,
DEXAMETHASONE 0.5 MG ORAL TABS,RX-2322,CDM,S5000,HCPCS,259,RC,00054-8179-25,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
CANDESARTAN CILEXETIL 4 MG ORAL TABS,RX-23229,CDM,S5000,HCPCS,259,RC,62332-0341-90,NDC,outpatient,1,UN,4.08,2.856,AETNA [1000108],AETNA [100010801],,,76.8,,3.13,0.222255,85118.57664,percent of total billed charges,,,
CANDESARTAN CILEXETIL 4 MG ORAL TABS,RX-23229,CDM,S5000,HCPCS,259,RC,33342-0114-07,NDC,outpatient,1,UN,5.64,3.948,AETNA [1000108],AETNA [100010801],,,76.8,,4.33,0.222255,85118.57664,percent of total billed charges,,,
CANDESARTAN CILEXETIL 16 MG ORAL TABS,RX-23231,CDM,S5000,HCPCS,259,RC,33342-0116-07,NDC,outpatient,1,UN,4.6,3.22,AETNA [1000108],AETNA [100010801],,,76.8,,3.53,0.222255,85118.57664,percent of total billed charges,,,
DEXAMETHASONE 1 MG ORAL TABS,RX-2324,CDM,S5000,HCPCS,259,RC,00054-8174-25,NDC,outpatient,1,UN,1.46,1.022,AETNA [1000108],AETNA [100010801],,,76.8,,1.12,0.222255,85118.57664,percent of total billed charges,,,
DEXAMETHASONE 4 MG ORAL TABS,RX-2327,CDM,S5000,HCPCS,259,RC,66993-0730-51,NDC,outpatient,1,UN,4.47,3.129,AETNA [1000108],AETNA [100010801],,,76.8,,3.43,0.222255,85118.57664,percent of total billed charges,,,
DEXAMETHASONE 4 MG ORAL TABS,RX-2327,CDM,S5000,HCPCS,259,RC,66993-0730-80,NDC,outpatient,1,UN,4.47,3.129,AETNA [1000108],AETNA [100010801],,,76.8,,3.43,0.222255,85118.57664,percent of total billed charges,,,
DEXAMETHASONE 4 MG ORAL TABS,RX-2327,CDM,S5000,HCPCS,259,RC,00054-8175-25,NDC,outpatient,1,UN,4.2,2.94,AETNA [1000108],AETNA [100010801],,,76.8,,3.23,0.222255,85118.57664,percent of total billed charges,,,
DEXAMETHASONE 6 MG ORAL TABS,RX-2328,CDM,S5000,HCPCS,259,RC,00054-8183-25,NDC,outpatient,1,UN,6.68,4.676,AETNA [1000108],AETNA [100010801],,,76.8,,5.13,0.222255,85118.57664,percent of total billed charges,,,
DEXAMETHASONE SODIUM PHOSPHATE 0.1 % OP SOLN,RX-2335,CDM,S5000,HCPCS,259,RC,24208-0720-02,NDC,outpatient,5,ML,228.82,160.174,AETNA [1000108],AETNA [100010801],,,76.8,,175.73,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE 4 % EX CREA,RX-23461,CDM,S5000,HCPCS,259,RC,00496-0882-05,NDC,outpatient,5,GR,12.51,8.757,AETNA [1000108],AETNA [100010801],,,76.8,,9.61,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE 4 % EX CREA,RX-23461,CDM,S5000,HCPCS,259,RC,39328-0024-30,NDC,outpatient,30,GR,40.32,28.224,AETNA [1000108],AETNA [100010801],,,76.8,,30.97,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE 4 % EX CREA,RX-23461,CDM,S5000,HCPCS,259,RC,00496-0882-06,NDC,outpatient,5,GR,12.51,8.757,AETNA [1000108],AETNA [100010801],,,76.8,,9.61,0.222255,85118.57664,percent of total billed charges,,,
DEXTROSE 10 % IV SOLN,RX-2357,CDM,S5000,HCPCS,250,RC,00338-0023-02,NDC,outpatient,250,ML,25,17.5,AETNA [1000108],AETNA [100010801],,,76.8,,19.2,0.222255,85118.57664,percent of total billed charges,,,
DEXTROSE 10 % IV SOLN,RX-2357,CDM,S5000,HCPCS,250,RC,00338-0023-04,NDC,outpatient,1000,ML,26.28,18.396,AETNA [1000108],AETNA [100010801],,,76.8,,20.18,0.222255,85118.57664,percent of total billed charges,,,
DEXTROSE 20 % IV SOLN,RX-2359,CDM,S5000,HCPCS,250,RC,00990-7935-19,NDC,outpatient,500,ML,62.73,43.911,AETNA [1000108],AETNA [100010801],,,76.8,,48.18,0.222255,85118.57664,percent of total billed charges,,,
DEXTROSE 250 MG/ML IV SOLN,RX-2361,CDM,S5000,HCPCS,250,RC,00409-1775-10,NDC,outpatient,10,ML,57.77,40.439,AETNA [1000108],AETNA [100010801],,,76.8,,44.37,0.222255,85118.57664,percent of total billed charges,,,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,69623-0201-39,NDC,outpatient,50,ML,93.45,65.415,AETNA [1000108],AETNA [100010801],,,76.8,,71.77,0.222255,85118.57664,percent of total billed charges,,,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-4902-64,NDC,outpatient,50,ML,59.41,41.587,AETNA [1000108],AETNA [100010801],,,76.8,,45.63,0.222255,85118.57664,percent of total billed charges,,,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-6648-02,NDC,outpatient,50,ML,19.02,13.314,AETNA [1000108],AETNA [100010801],,,76.8,,14.61,0.222255,85118.57664,percent of total billed charges,,,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,69374-0953-50,NDC,outpatient,50,ML,66.75,46.725,AETNA [1000108],AETNA [100010801],,,76.8,,51.26,0.222255,85118.57664,percent of total billed charges,,,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,76329-3302-01,NDC,outpatient,50,ML,66.31,46.417,AETNA [1000108],AETNA [100010801],,,76.8,,50.93,0.222255,85118.57664,percent of total billed charges,,,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-4902-34,NDC,outpatient,50,ML,59.41,41.587,AETNA [1000108],AETNA [100010801],,,76.8,,45.63,0.222255,85118.57664,percent of total billed charges,,,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-7517-16,NDC,outpatient,50,ML,31.82,22.274,AETNA [1000108],AETNA [100010801],,,76.8,,24.44,0.222255,85118.57664,percent of total billed charges,,,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-6648-16,NDC,outpatient,50,ML,19.02,13.314,AETNA [1000108],AETNA [100010801],,,76.8,,14.61,0.222255,85118.57664,percent of total billed charges,,,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-7517-66,NDC,outpatient,50,ML,58.08,40.656,AETNA [1000108],AETNA [100010801],,,76.8,,44.61,0.222255,85118.57664,percent of total billed charges,,,
EFAVIRENZ 200 MG ORAL CAPS,RX-23900,CDM,S5000,HCPCS,259,RC,64980-0407-09,NDC,outpatient,1,UN,33.64,23.548,AETNA [1000108],AETNA [100010801],,,76.8,,25.84,0.222255,85118.57664,percent of total billed charges,,,
DIAZEPAM 2 MG ORAL TABS,RX-2404,CDM,S5000,HCPCS,259,RC,00172-3925-60,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
DIAZEPAM 2 MG ORAL TABS,RX-2404,CDM,S5000,HCPCS,259,RC,51079-0284-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
DIAZEPAM 2 MG ORAL TABS,RX-2404,CDM,S5000,HCPCS,259,RC,51079-0284-20,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
DIAZEPAM 5 MG ORAL TABS,RX-2405,CDM,S5000,HCPCS,259,RC,51079-0285-20,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
DIAZEPAM 5 MG ORAL TABS,RX-2405,CDM,S5000,HCPCS,259,RC,51079-0285-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
MICONAZOLE NITRATE 4 % VA CREA,RX-24050,CDM,S5000,HCPCS,259,RC,63736-0442-01,NDC,outpatient,15,GR,44.73,31.311,AETNA [1000108],AETNA [100010801],,,76.8,,34.35,0.222255,85118.57664,percent of total billed charges,,,
DICLOXACILLIN SODIUM 250 MG ORAL CAPS,RX-2414,CDM,S5000,HCPCS,259,RC,59651-0565-01,NDC,outpatient,1,UN,2.33,1.631,AETNA [1000108],AETNA [100010801],,,76.8,,1.79,0.222255,85118.57664,percent of total billed charges,,,
DICLOXACILLIN SODIUM 250 MG ORAL CAPS,RX-2414,CDM,S5000,HCPCS,259,RC,00093-3123-01,NDC,outpatient,1,UN,2.5,1.75,AETNA [1000108],AETNA [100010801],,,76.8,,1.92,0.222255,85118.57664,percent of total billed charges,,,
MIDAZOLAM HCL 2 MG/ML ORAL SYRP,RX-24176,CDM,S5000,HCPCS,259,RC,68094-0764-59,NDC,outpatient,5,ML,21.65,15.155,AETNA [1000108],AETNA [100010801],,,76.8,,16.63,0.222255,85118.57664,percent of total billed charges,,,
MIDAZOLAM HCL 2 MG/ML ORAL SYRP,RX-24176,CDM,S5000,HCPCS,259,RC,68094-0764-62,NDC,outpatient,5,ML,21.65,15.155,AETNA [1000108],AETNA [100010801],,,76.8,,16.63,0.222255,85118.57664,percent of total billed charges,,,
DICYCLOMINE HCL 10 MG ORAL CAPS,RX-2418,CDM,S5000,HCPCS,259,RC,60687-0369-11,NDC,outpatient,1,UN,1.75,1.225,AETNA [1000108],AETNA [100010801],,,76.8,,1.34,0.222255,85118.57664,percent of total billed charges,,,
DICYCLOMINE HCL 10 MG ORAL CAPS,RX-2418,CDM,S5000,HCPCS,259,RC,60687-0369-01,NDC,outpatient,1,UN,1.75,1.225,AETNA [1000108],AETNA [100010801],,,76.8,,1.34,0.222255,85118.57664,percent of total billed charges,,,
DICYCLOMINE HCL 20 MG ORAL TABS,RX-2420,CDM,S5000,HCPCS,259,RC,60687-0380-11,NDC,outpatient,1,UN,1.8,1.26,AETNA [1000108],AETNA [100010801],,,76.8,,1.38,0.222255,85118.57664,percent of total billed charges,,,
DICYCLOMINE HCL 20 MG ORAL TABS,RX-2420,CDM,S5000,HCPCS,259,RC,60687-0380-01,NDC,outpatient,1,UN,1.8,1.26,AETNA [1000108],AETNA [100010801],,,76.8,,1.38,0.222255,85118.57664,percent of total billed charges,,,
SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG ORAL TABS,RX-24216,CDM,S5000,HCPCS,259,RC,60687-0622-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG ORAL TABS,RX-24216,CDM,S5000,HCPCS,259,RC,00536-1248-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG ORAL TABS,RX-24216,CDM,S5000,HCPCS,259,RC,60687-0622-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG ORAL TABS,RX-24216,CDM,S5000,HCPCS,259,RC,63739-0432-02,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ISOSORBIDE MONONITRATE ER 60 MG ORAL TAB,RX-24268,CDM,S5000,HCPCS,259,RC,00904-6450-61,NDC,outpatient,1,UN,1.31,0.917,AETNA [1000108],AETNA [100010801],,,76.8,,1.01,0.222255,85118.57664,percent of total billed charges,,,
TELMISARTAN 40 MG ORAL TABS,RX-24335,CDM,S5000,HCPCS,259,RC,00597-0040-37,NDC,outpatient,1,UN,19.23,13.461,AETNA [1000108],AETNA [100010801],,,76.8,,14.77,0.222255,85118.57664,percent of total billed charges,,,
HYDROCORTISONE-ACETIC ACID 1-2 % OT SOLN,RX-24385,CDM,S5000,HCPCS,259,RC,51672-3007-01,NDC,outpatient,10,ML,303.14,212.198,AETNA [1000108],AETNA [100010801],,,76.8,,232.81,0.222255,85118.57664,percent of total billed charges,,,
ABACAVIR SULFATE 300 MG ORAL TABS,RX-24438,CDM,S5000,HCPCS,259,RC,00378-4105-91,NDC,outpatient,1,UN,13.01,9.107,AETNA [1000108],AETNA [100010801],,,76.8,,9.99,0.222255,85118.57664,percent of total billed charges,,,
ABACAVIR SULFATE 300 MG ORAL TABS,RX-24438,CDM,S5000,HCPCS,259,RC,68084-0021-21,NDC,outpatient,1,UN,26.71,18.697,AETNA [1000108],AETNA [100010801],,,76.8,,20.51,0.222255,85118.57664,percent of total billed charges,,,
ABACAVIR SULFATE 300 MG ORAL TABS,RX-24438,CDM,S5000,HCPCS,259,RC,68084-0021-11,NDC,outpatient,1,UN,26.71,18.697,AETNA [1000108],AETNA [100010801],,,76.8,,20.51,0.222255,85118.57664,percent of total billed charges,,,
DIGOXIN 125 MCG ORAL TABS,RX-2444,CDM,S5000,HCPCS,259,RC,00904-5921-61,NDC,outpatient,1,UN,3.14,2.198,AETNA [1000108],AETNA [100010801],,,76.8,,2.41,0.222255,85118.57664,percent of total billed charges,,,
OXYBUTYNIN CHLORIDE ER 5 MG ORAL TB24,RX-24470,CDM,S5000,HCPCS,259,RC,00904-6570-61,NDC,outpatient,1,UN,5.08,3.556,AETNA [1000108],AETNA [100010801],,,76.8,,3.9,0.222255,85118.57664,percent of total billed charges,,,
OXYBUTYNIN CHLORIDE ER 5 MG ORAL TB24,RX-24470,CDM,S5000,HCPCS,259,RC,00904-6570-04,NDC,outpatient,1,UN,7.7,5.39,AETNA [1000108],AETNA [100010801],,,76.8,,5.91,0.222255,85118.57664,percent of total billed charges,,,
OXYBUTYNIN CHLORIDE ER 5 MG ORAL TB24,RX-24470,CDM,S5000,HCPCS,259,RC,68084-0480-01,NDC,outpatient,1,UN,4.79,3.353,AETNA [1000108],AETNA [100010801],,,76.8,,3.68,0.222255,85118.57664,percent of total billed charges,,,
OXYBUTYNIN CHLORIDE ER 5 MG ORAL TB24,RX-24470,CDM,S5000,HCPCS,259,RC,68084-0480-11,NDC,outpatient,1,UN,4.79,3.353,AETNA [1000108],AETNA [100010801],,,76.8,,3.68,0.222255,85118.57664,percent of total billed charges,,,
OXYBUTYNIN CHLORIDE ER 5 MG ORAL TB24,RX-24470,CDM,S5000,HCPCS,259,RC,63739-0548-33,NDC,outpatient,1,UN,5.24,3.668,AETNA [1000108],AETNA [100010801],,,76.8,,4.02,0.222255,85118.57664,percent of total billed charges,,,
CILOSTAZOL 100 MG ORAL TABS,RX-24474,CDM,S5000,HCPCS,259,RC,50268-0177-11,NDC,outpatient,1,UN,3.18,2.226,AETNA [1000108],AETNA [100010801],,,76.8,,2.44,0.222255,85118.57664,percent of total billed charges,,,
CILOSTAZOL 100 MG ORAL TABS,RX-24474,CDM,S5000,HCPCS,259,RC,50268-0177-15,NDC,outpatient,1,UN,3.18,2.226,AETNA [1000108],AETNA [100010801],,,76.8,,2.44,0.222255,85118.57664,percent of total billed charges,,,
CELECOXIB 100 MG ORAL CAPS,RX-24500,CDM,S5000,HCPCS,259,RC,00904-6502-61,NDC,outpatient,1,UN,3.56,2.492,AETNA [1000108],AETNA [100010801],,,76.8,,2.73,0.222255,85118.57664,percent of total billed charges,,,
CELECOXIB 100 MG ORAL CAPS,RX-24500,CDM,S5000,HCPCS,259,RC,60687-0436-01,NDC,outpatient,1,UN,3.16,2.212,AETNA [1000108],AETNA [100010801],,,76.8,,2.43,0.222255,85118.57664,percent of total billed charges,,,
CELECOXIB 100 MG ORAL CAPS,RX-24500,CDM,S5000,HCPCS,259,RC,60687-0436-11,NDC,outpatient,1,UN,3.16,2.212,AETNA [1000108],AETNA [100010801],,,76.8,,2.43,0.222255,85118.57664,percent of total billed charges,,,
CELECOXIB 200 MG ORAL CAPS,RX-24501,CDM,S5000,HCPCS,259,RC,00904-6503-61,NDC,outpatient,1,UN,5.49,3.843,AETNA [1000108],AETNA [100010801],,,76.8,,4.22,0.222255,85118.57664,percent of total billed charges,,,
CELECOXIB 200 MG ORAL CAPS,RX-24501,CDM,S5000,HCPCS,259,RC,60505-3849-01,NDC,outpatient,1,UN,2.67,1.869,AETNA [1000108],AETNA [100010801],,,76.8,,2.05,0.222255,85118.57664,percent of total billed charges,,,
ISOSORBIDE MONONITRATE ER 30 MG ORAL TB24,RX-24521,CDM,S5000,HCPCS,259,RC,00904-6449-61,NDC,outpatient,1,UN,1.08,0.756,AETNA [1000108],AETNA [100010801],,,76.8,,0.83,0.222255,85118.57664,percent of total billed charges,,,
MODAFINIL 100 MG ORAL TABS,RX-24702,CDM,S5000,HCPCS,259,RC,50268-0570-11,NDC,outpatient,1,UN,25.83,18.081,AETNA [1000108],AETNA [100010801],,,76.8,,19.84,0.222255,85118.57664,percent of total billed charges,,,
MODAFINIL 100 MG ORAL TABS,RX-24702,CDM,S5000,HCPCS,259,RC,68084-0621-11,NDC,outpatient,1,UN,21.38,14.966,AETNA [1000108],AETNA [100010801],,,76.8,,16.42,0.222255,85118.57664,percent of total billed charges,,,
MODAFINIL 100 MG ORAL TABS,RX-24702,CDM,S5000,HCPCS,259,RC,68084-0621-21,NDC,outpatient,1,UN,21.38,14.966,AETNA [1000108],AETNA [100010801],,,76.8,,16.42,0.222255,85118.57664,percent of total billed charges,,,
MODAFINIL 100 MG ORAL TABS,RX-24702,CDM,S5000,HCPCS,259,RC,00904-6791-04,NDC,outpatient,1,UN,21.38,14.966,AETNA [1000108],AETNA [100010801],,,76.8,,16.42,0.222255,85118.57664,percent of total billed charges,,,
MODAFINIL 100 MG ORAL TABS,RX-24702,CDM,S5000,HCPCS,259,RC,50268-0570-12,NDC,outpatient,1,UN,25.83,18.081,AETNA [1000108],AETNA [100010801],,,76.8,,19.84,0.222255,85118.57664,percent of total billed charges,,,
BELLADONNA ALKALOIDS-OPIUM 16.2-60 MG RE SUPP,RX-24731,CDM,S5000,HCPCS,259,RC,00574-7040-12,NDC,outpatient,1,UN,104.53,73.171,AETNA [1000108],AETNA [100010801],,,76.8,,80.28,0.222255,85118.57664,percent of total billed charges,,,
DILTIAZEM HCL 30 MG ORAL TABS,RX-2475,CDM,S5000,HCPCS,259,RC,00093-0318-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
DILTIAZEM HCL 30 MG ORAL TABS,RX-2475,CDM,S5000,HCPCS,259,RC,60687-0717-01,NDC,outpatient,1,UN,1.81,1.267,AETNA [1000108],AETNA [100010801],,,76.8,,1.39,0.222255,85118.57664,percent of total billed charges,,,
DILTIAZEM HCL 30 MG ORAL TABS,RX-2475,CDM,S5000,HCPCS,259,RC,60687-0717-11,NDC,outpatient,1,UN,1.81,1.267,AETNA [1000108],AETNA [100010801],,,76.8,,1.39,0.222255,85118.57664,percent of total billed charges,,,
DIMENHYDRINATE 50 MG ORAL TABS,RX-2485,CDM,S5000,HCPCS,259,RC,00904-2051-59,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
TACROLIMUS 0.5 MG ORAL CAPS,RX-24914,CDM,S5000,HCPCS,259,RC,00904-6623-61,NDC,outpatient,1,UN,2.82,1.974,AETNA [1000108],AETNA [100010801],,,76.8,,2.17,0.222255,85118.57664,percent of total billed charges,,,
LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU,RX-24915,CDM,S5000,HCPCS,259,RC,76204-0800-01,NDC,outpatient,3,ML,5.32,3.724,AETNA [1000108],AETNA [100010801],,,76.8,,4.09,0.222255,85118.57664,percent of total billed charges,,,
LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU,RX-24915,CDM,S5000,HCPCS,259,RC,76204-0800-11,NDC,outpatient,3,ML,5.32,3.724,AETNA [1000108],AETNA [100010801],,,76.8,,4.09,0.222255,85118.57664,percent of total billed charges,,,
LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU,RX-24915,CDM,S5000,HCPCS,259,RC,00093-4146-45,NDC,outpatient,3,ML,7.12,4.984,AETNA [1000108],AETNA [100010801],,,76.8,,5.47,0.222255,85118.57664,percent of total billed charges,,,
LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU,RX-24915,CDM,S5000,HCPCS,259,RC,00093-4146-56,NDC,outpatient,3,ML,7.12,4.984,AETNA [1000108],AETNA [100010801],,,76.8,,5.47,0.222255,85118.57664,percent of total billed charges,,,
LEVALBUTEROL HCL 1.25 MG/3ML IN NEBU,RX-24916,CDM,S5000,HCPCS,259,RC,76204-0900-01,NDC,outpatient,3,ML,5.47,3.829,AETNA [1000108],AETNA [100010801],,,76.8,,4.2,0.222255,85118.57664,percent of total billed charges,,,
LEVALBUTEROL HCL 1.25 MG/3ML IN NEBU,RX-24916,CDM,S5000,HCPCS,259,RC,76204-0900-11,NDC,outpatient,3,ML,5.47,3.829,AETNA [1000108],AETNA [100010801],,,76.8,,4.2,0.222255,85118.57664,percent of total billed charges,,,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,00378-8270-55,NDC,outpatient,3,ML,1.22,0.854,AETNA [1000108],AETNA [100010801],,,76.8,,0.94,0.222255,85118.57664,percent of total billed charges,,,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,47335-0703-52,NDC,outpatient,3,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,00378-8270-31,NDC,outpatient,3,ML,1.22,0.854,AETNA [1000108],AETNA [100010801],,,76.8,,0.94,0.222255,85118.57664,percent of total billed charges,,,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,60687-0395-79,NDC,outpatient,3,ML,1.02,0.714,AETNA [1000108],AETNA [100010801],,,76.8,,0.78,0.222255,85118.57664,percent of total billed charges,,,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,60687-0395-83,NDC,outpatient,3,ML,1.02,0.714,AETNA [1000108],AETNA [100010801],,,76.8,,0.78,0.222255,85118.57664,percent of total billed charges,,,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,47335-0703-48,NDC,outpatient,3,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,76204-0200-01,NDC,outpatient,3,ML,1.18,0.826,AETNA [1000108],AETNA [100010801],,,76.8,,0.91,0.222255,85118.57664,percent of total billed charges,,,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,00487-9501-01,NDC,outpatient,3,ML,1.41,0.987,AETNA [1000108],AETNA [100010801],,,76.8,,1.08,0.222255,85118.57664,percent of total billed charges,,,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,47335-0703-49,NDC,outpatient,3,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,76204-0200-60,NDC,outpatient,3,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL SUSR,RX-25005,CDM,S5000,HCPCS,259,RC,99999-0002-21,NDC,outpatient,2.5,ML,69.2,48.44,AETNA [1000108],AETNA [100010801],,,76.8,,53.15,0.222255,85118.57664,percent of total billed charges,,,
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL SUSR,RX-25005,CDM,S5000,HCPCS,259,RC,66689-0307-08,NDC,outpatient,160,ML,1111.44,778.008,AETNA [1000108],AETNA [100010801],,,76.8,,853.59,0.222255,85118.57664,percent of total billed charges,,,
DIPHENHYDRAMINE HCL 25 MG ORAL CAPS,RX-2509,CDM,S5000,HCPCS,259,RC,00904-7237-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
DIPHENHYDRAMINE HCL 12.5 MG/5ML ORAL SOLN,RX-2511,CDM,S5000,HCPCS,259,RC,00121-0489-05,NDC,outpatient,5,ML,15.4,10.78,AETNA [1000108],AETNA [100010801],,,76.8,,11.83,0.222255,85118.57664,percent of total billed charges,,,
DIPHENHYDRAMINE HCL 12.5 MG/5ML ORAL SOLN,RX-2511,CDM,S5000,HCPCS,259,RC,00121-0489-00,NDC,outpatient,5,ML,15.4,10.78,AETNA [1000108],AETNA [100010801],,,76.8,,11.83,0.222255,85118.57664,percent of total billed charges,,,
CIPROFLOXACIN HCL 250 MG ORAL TABS,RX-25118,CDM,S5000,HCPCS,259,RC,62135-0308-01,NDC,outpatient,1,UN,12.1,8.47,AETNA [1000108],AETNA [100010801],,,76.8,,9.29,0.222255,85118.57664,percent of total billed charges,,,
CIPROFLOXACIN HCL 250 MG ORAL TABS,RX-25118,CDM,S5000,HCPCS,259,RC,65862-0076-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
CIPROFLOXACIN HCL 250 MG ORAL TABS,RX-25118,CDM,S5000,HCPCS,259,RC,00143-9927-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
DIPHENOXYLATE-ATROPINE 2.5-0.025 MG ORAL TABS,RX-2516,CDM,S5000,HCPCS,259,RC,00406-1236-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
DIPHENOXYLATE-ATROPINE 2.5-0.025 MG ORAL TABS,RX-2516,CDM,S5000,HCPCS,259,RC,69315-0910-01,NDC,outpatient,1,UN,2.4,1.68,AETNA [1000108],AETNA [100010801],,,76.8,,1.84,0.222255,85118.57664,percent of total billed charges,,,
ALBUTEROL SULFATE 2 MG/5ML ORAL SYRP,RX-252,CDM,S5000,HCPCS,259,RC,99999-0003-98,NDC,outpatient,5,ML,1.34,0.938,AETNA [1000108],AETNA [100010801],,,76.8,,1.03,0.222255,85118.57664,percent of total billed charges,,,
ALBUTEROL SULFATE 2 MG/5ML ORAL SYRP,RX-252,CDM,S5000,HCPCS,259,RC,00472-0825-16,NDC,outpatient,5,ML,1.24,0.868,AETNA [1000108],AETNA [100010801],,,76.8,,0.95,0.222255,85118.57664,percent of total billed charges,,,
ALBUTEROL SULFATE 2 MG/5ML ORAL SYRP,RX-252,CDM,S5000,HCPCS,259,RC,70752-0102-12,NDC,outpatient,5,ML,1.91,1.337,AETNA [1000108],AETNA [100010801],,,76.8,,1.47,0.222255,85118.57664,percent of total billed charges,,,
DIPYRIDAMOLE 25 MG ORAL TABS,RX-2528,CDM,S5000,HCPCS,259,RC,64980-0133-01,NDC,outpatient,1,UN,5.27,3.689,AETNA [1000108],AETNA [100010801],,,76.8,,4.05,0.222255,85118.57664,percent of total billed charges,,,
ALBUTEROL SULFATE 2 MG ORAL TABS,RX-253,CDM,S5000,HCPCS,259,RC,68084-0949-25,NDC,outpatient,1,UN,27.72,19.404,AETNA [1000108],AETNA [100010801],,,76.8,,21.29,0.222255,85118.57664,percent of total billed charges,,,
ALBUTEROL SULFATE 2 MG ORAL TABS,RX-253,CDM,S5000,HCPCS,259,RC,68084-0949-95,NDC,outpatient,1,UN,27.72,19.404,AETNA [1000108],AETNA [100010801],,,76.8,,21.29,0.222255,85118.57664,percent of total billed charges,,,
DISOPYRAMIDE PHOSPHATE 100 MG ORAL CAPS,RX-2535,CDM,S5000,HCPCS,259,RC,00093-3127-01,NDC,outpatient,1,UN,5.28,3.696,AETNA [1000108],AETNA [100010801],,,76.8,,4.06,0.222255,85118.57664,percent of total billed charges,,,
DISULFIRAM 250 MG ORAL TABS,RX-2540,CDM,S5000,HCPCS,259,RC,47781-0607-30,NDC,outpatient,1,UN,7.69,5.383,AETNA [1000108],AETNA [100010801],,,76.8,,5.91,0.222255,85118.57664,percent of total billed charges,,,
POLYETHYLENE GLYCOL 3350 17 G ORAL PACK,RX-25424,CDM,S5000,HCPCS,259,RC,00904-6931-86,NDC,outpatient,1,UN,3.67,2.569,AETNA [1000108],AETNA [100010801],,,76.8,,2.82,0.222255,85118.57664,percent of total billed charges,,,
POLYETHYLENE GLYCOL 3350 17 G ORAL PACK,RX-25424,CDM,S5000,HCPCS,259,RC,62559-0157-10,NDC,outpatient,1,UN,3.43,2.401,AETNA [1000108],AETNA [100010801],,,76.8,,2.63,0.222255,85118.57664,percent of total billed charges,,,
POLYETHYLENE GLYCOL 3350 17 G ORAL PACK,RX-25424,CDM,S5000,HCPCS,259,RC,00904-6931-81,NDC,outpatient,1,UN,3.67,2.569,AETNA [1000108],AETNA [100010801],,,76.8,,2.82,0.222255,85118.57664,percent of total billed charges,,,
POLYETHYLENE GLYCOL 3350 17 G ORAL PACK,RX-25424,CDM,S5000,HCPCS,259,RC,62559-0157-17,NDC,outpatient,1,UN,3.43,2.401,AETNA [1000108],AETNA [100010801],,,76.8,,2.63,0.222255,85118.57664,percent of total billed charges,,,
DIVALPROEX SODIUM 125 MG ORAL TBEC,RX-2551,CDM,S5000,HCPCS,259,RC,60687-0211-21,NDC,outpatient,1,UN,3.46,2.422,AETNA [1000108],AETNA [100010801],,,76.8,,2.66,0.222255,85118.57664,percent of total billed charges,,,
DIVALPROEX SODIUM 125 MG ORAL TBEC,RX-2551,CDM,S5000,HCPCS,259,RC,60687-0211-11,NDC,outpatient,1,UN,3.46,2.422,AETNA [1000108],AETNA [100010801],,,76.8,,2.66,0.222255,85118.57664,percent of total billed charges,,,
RISPERIDONE 0.25 MG ORAL TABS,RX-25519,CDM,S5000,HCPCS,259,RC,68382-0112-14,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
RISPERIDONE 0.25 MG ORAL TABS,RX-25519,CDM,S5000,HCPCS,259,RC,68084-0270-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
RISPERIDONE 0.25 MG ORAL TABS,RX-25519,CDM,S5000,HCPCS,259,RC,68084-0270-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
DIVALPROEX SODIUM 250 MG ORAL TBEC,RX-2552,CDM,S5000,HCPCS,259,RC,68084-0776-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
DIVALPROEX SODIUM 250 MG ORAL TBEC,RX-2552,CDM,S5000,HCPCS,259,RC,68084-0776-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
RISPERIDONE 0.5 MG ORAL TABS,RX-25520,CDM,S5000,HCPCS,259,RC,00904-7361-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PIOGLITAZONE HCL 15 MG ORAL TABS,RX-25528,CDM,S5000,HCPCS,259,RC,60687-0391-11,NDC,outpatient,1,UN,3.42,2.394,AETNA [1000108],AETNA [100010801],,,76.8,,2.63,0.222255,85118.57664,percent of total billed charges,,,
PIOGLITAZONE HCL 15 MG ORAL TABS,RX-25528,CDM,S5000,HCPCS,259,RC,60687-0391-01,NDC,outpatient,1,UN,3.42,2.394,AETNA [1000108],AETNA [100010801],,,76.8,,2.63,0.222255,85118.57664,percent of total billed charges,,,
DIVALPROEX SODIUM 500 MG ORAL TBEC,RX-2553,CDM,S5000,HCPCS,259,RC,68084-0782-11,NDC,outpatient,1,UN,1.16,0.812,AETNA [1000108],AETNA [100010801],,,76.8,,0.89,0.222255,85118.57664,percent of total billed charges,,,
DIVALPROEX SODIUM 500 MG ORAL TBEC,RX-2553,CDM,S5000,HCPCS,259,RC,68084-0782-61,NDC,outpatient,1,UN,1.16,0.812,AETNA [1000108],AETNA [100010801],,,76.8,,0.89,0.222255,85118.57664,percent of total billed charges,,,
DIVALPROEX SODIUM 500 MG ORAL TBEC,RX-2553,CDM,S5000,HCPCS,259,RC,00904-6861-90,NDC,outpatient,1,UN,1.2,0.84,AETNA [1000108],AETNA [100010801],,,76.8,,0.92,0.222255,85118.57664,percent of total billed charges,,,
DOCUSATE SODIUM 100 MG ORAL CAPS,RX-2566,CDM,S5000,HCPCS,259,RC,00904-7280-60,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
DOCUSATE SODIUM 100 MG ORAL CAPS,RX-2566,CDM,S5000,HCPCS,259,RC,00904-7183-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
DOCUSATE SODIUM 100 MG ORAL CAPS,RX-2566,CDM,S5000,HCPCS,259,RC,00904-7280-80,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
IVERMECTIN 3 MG ORAL TABS,RX-25820,CDM,S5000,HCPCS,259,RC,00006-0032-20,NDC,outpatient,1,UN,19.14,13.398,AETNA [1000108],AETNA [100010801],,,76.8,,14.7,0.222255,85118.57664,percent of total billed charges,,,
IVERMECTIN 3 MG ORAL TABS,RX-25820,CDM,S5000,HCPCS,259,RC,42799-0806-01,NDC,outpatient,1,UN,14.59,10.213,AETNA [1000108],AETNA [100010801],,,76.8,,11.21,0.222255,85118.57664,percent of total billed charges,,,
DOXEPIN HCL 10 MG ORAL CAPS,RX-2608,CDM,S5000,HCPCS,259,RC,51079-0436-01,NDC,outpatient,1,UN,2.53,1.771,AETNA [1000108],AETNA [100010801],,,76.8,,1.94,0.222255,85118.57664,percent of total billed charges,,,
DOXEPIN HCL 10 MG ORAL CAPS,RX-2608,CDM,S5000,HCPCS,259,RC,00904-7052-61,NDC,outpatient,1,UN,2.19,1.533,AETNA [1000108],AETNA [100010801],,,76.8,,1.68,0.222255,85118.57664,percent of total billed charges,,,
DOXEPIN HCL 10 MG ORAL CAPS,RX-2608,CDM,S5000,HCPCS,259,RC,51079-0436-20,NDC,outpatient,1,UN,2.53,1.771,AETNA [1000108],AETNA [100010801],,,76.8,,1.94,0.222255,85118.57664,percent of total billed charges,,,
DOXEPIN HCL 100 MG ORAL CAPS,RX-2609,CDM,S5000,HCPCS,259,RC,51079-0651-20,NDC,outpatient,1,UN,6.84,4.788,AETNA [1000108],AETNA [100010801],,,76.8,,5.25,0.222255,85118.57664,percent of total billed charges,,,
DOXEPIN HCL 100 MG ORAL CAPS,RX-2609,CDM,S5000,HCPCS,259,RC,00378-6410-01,NDC,outpatient,1,UN,5.48,3.836,AETNA [1000108],AETNA [100010801],,,76.8,,4.21,0.222255,85118.57664,percent of total billed charges,,,
DOXEPIN HCL 100 MG ORAL CAPS,RX-2609,CDM,S5000,HCPCS,259,RC,51079-0651-01,NDC,outpatient,1,UN,6.84,4.788,AETNA [1000108],AETNA [100010801],,,76.8,,5.25,0.222255,85118.57664,percent of total billed charges,,,
DOXEPIN HCL 25 MG ORAL CAPS,RX-2611,CDM,S5000,HCPCS,259,RC,00378-3125-01,NDC,outpatient,1,UN,2.29,1.603,AETNA [1000108],AETNA [100010801],,,76.8,,1.76,0.222255,85118.57664,percent of total billed charges,,,
DOXEPIN HCL 25 MG ORAL CAPS,RX-2611,CDM,S5000,HCPCS,259,RC,51079-0437-01,NDC,outpatient,1,UN,2.89,2.023,AETNA [1000108],AETNA [100010801],,,76.8,,2.22,0.222255,85118.57664,percent of total billed charges,,,
DOXEPIN HCL 25 MG ORAL CAPS,RX-2611,CDM,S5000,HCPCS,259,RC,51079-0437-20,NDC,outpatient,1,UN,2.89,2.023,AETNA [1000108],AETNA [100010801],,,76.8,,2.22,0.222255,85118.57664,percent of total billed charges,,,
MUSCLE RUB 10-15 % EX CREA,RX-26210,CDM,S5000,HCPCS,259,RC,57896-0116-03,NDC,outpatient,85,GR,10.97,7.679,AETNA [1000108],AETNA [100010801],,,76.8,,8.42,0.222255,85118.57664,percent of total billed charges,,,
MUSCLE RUB 10-15 % EX CREA,RX-26210,CDM,S5000,HCPCS,259,RC,00536-1101-45,NDC,outpatient,85,GR,10.6,7.42,AETNA [1000108],AETNA [100010801],,,76.8,,8.14,0.222255,85118.57664,percent of total billed charges,,,
MUSCLE RUB 10-15 % EX CREA,RX-26210,CDM,S5000,HCPCS,259,RC,00536-1349-57,NDC,outpatient,85,GR,9.08,6.356,AETNA [1000108],AETNA [100010801],,,76.8,,6.97,0.222255,85118.57664,percent of total billed charges,,,
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,00143-9381-10,NDC,outpatient,1,UN,49.76,34.832,AETNA [1000108],AETNA [100010801],,,76.8,,38.22,0.222255,85118.57664,percent of total billed charges,,,
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,67457-0437-00,NDC,outpatient,1,UN,68.55,47.985,AETNA [1000108],AETNA [100010801],,,76.8,,52.65,0.222255,85118.57664,percent of total billed charges,,,
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,68382-0910-10,NDC,outpatient,1,UN,107.52,75.264,AETNA [1000108],AETNA [100010801],,,76.8,,82.58,0.222255,85118.57664,percent of total billed charges,,,
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,00143-9381-01,NDC,outpatient,1,UN,49.76,34.832,AETNA [1000108],AETNA [100010801],,,76.8,,38.22,0.222255,85118.57664,percent of total billed charges,,,
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,63323-0130-11,NDC,outpatient,1,UN,45.64,31.948,AETNA [1000108],AETNA [100010801],,,76.8,,35.05,0.222255,85118.57664,percent of total billed charges,,,
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,68382-0910-01,NDC,outpatient,1,UN,107.52,75.264,AETNA [1000108],AETNA [100010801],,,76.8,,82.58,0.222255,85118.57664,percent of total billed charges,,,
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,63323-0130-02,NDC,outpatient,1,UN,45.64,31.948,AETNA [1000108],AETNA [100010801],,,76.8,,35.05,0.222255,85118.57664,percent of total billed charges,,,
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,67457-0437-10,NDC,outpatient,1,UN,68.55,47.985,AETNA [1000108],AETNA [100010801],,,76.8,,52.65,0.222255,85118.57664,percent of total billed charges,,,
PANTOPRAZOLE SODIUM 40 MG ORAL TBEC,RX-26225,CDM,S5000,HCPCS,259,RC,35573-0428-51,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PANTOPRAZOLE SODIUM 40 MG ORAL TBEC,RX-26225,CDM,S5000,HCPCS,259,RC,51079-0051-20,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PANTOPRAZOLE SODIUM 40 MG ORAL TBEC,RX-26225,CDM,S5000,HCPCS,259,RC,00904-6474-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PANTOPRAZOLE SODIUM 40 MG ORAL TBEC,RX-26225,CDM,S5000,HCPCS,259,RC,35573-0428-80,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PANTOPRAZOLE SODIUM 40 MG ORAL TBEC,RX-26225,CDM,S5000,HCPCS,259,RC,51079-0051-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
DOXYCYCLINE HYCLATE 100 MG ORAL TABS,RX-2625,CDM,S5000,HCPCS,259,RC,00143-2112-50,NDC,outpatient,1,UN,1.07,0.749,AETNA [1000108],AETNA [100010801],,,76.8,,0.82,0.222255,85118.57664,percent of total billed charges,,,
DOXYCYCLINE HYCLATE 100 MG ORAL TABS,RX-2625,CDM,S5000,HCPCS,259,RC,00904-0430-06,NDC,outpatient,1,UN,5.29,3.703,AETNA [1000108],AETNA [100010801],,,76.8,,4.06,0.222255,85118.57664,percent of total billed charges,,,
DOXYCYCLINE HYCLATE 100 MG ORAL TABS,RX-2625,CDM,S5000,HCPCS,259,RC,62584-0693-11,NDC,outpatient,1,UN,4.84,3.388,AETNA [1000108],AETNA [100010801],,,76.8,,3.72,0.222255,85118.57664,percent of total billed charges,,,
DOXYCYCLINE HYCLATE 100 MG ORAL TABS,RX-2625,CDM,S5000,HCPCS,259,RC,62584-0693-21,NDC,outpatient,1,UN,4.84,3.388,AETNA [1000108],AETNA [100010801],,,76.8,,3.72,0.222255,85118.57664,percent of total billed charges,,,
CARBIDOPA-LEVODOPA ER 50-200 MG ORAL TBCR,RX-26371,CDM,S5000,HCPCS,259,RC,68084-0282-11,NDC,outpatient,1,UN,4.16,2.912,AETNA [1000108],AETNA [100010801],,,76.8,,3.19,0.222255,85118.57664,percent of total billed charges,,,
CARBIDOPA-LEVODOPA ER 50-200 MG ORAL TBCR,RX-26371,CDM,S5000,HCPCS,259,RC,68084-0282-01,NDC,outpatient,1,UN,4.16,2.912,AETNA [1000108],AETNA [100010801],,,76.8,,3.19,0.222255,85118.57664,percent of total billed charges,,,
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAPS,RX-26546,CDM,S5000,HCPCS,259,RC,31722-0632-31,NDC,outpatient,1,UN,4.28,2.996,AETNA [1000108],AETNA [100010801],,,76.8,,3.29,0.222255,85118.57664,percent of total billed charges,,,
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAPS,RX-26546,CDM,S5000,HCPCS,259,RC,64380-0799-01,NDC,outpatient,1,UN,8.24,5.768,AETNA [1000108],AETNA [100010801],,,76.8,,6.33,0.222255,85118.57664,percent of total billed charges,,,
ENTACAPONE 200 MG ORAL TABS,RX-26547,CDM,S5000,HCPCS,259,RC,60687-0188-11,NDC,outpatient,1,UN,18.43,12.901,AETNA [1000108],AETNA [100010801],,,76.8,,14.15,0.222255,85118.57664,percent of total billed charges,,,
ENTACAPONE 200 MG ORAL TABS,RX-26547,CDM,S5000,HCPCS,259,RC,60687-0188-21,NDC,outpatient,1,UN,18.43,12.901,AETNA [1000108],AETNA [100010801],,,76.8,,14.15,0.222255,85118.57664,percent of total billed charges,,,
ENTACAPONE 200 MG ORAL TABS,RX-26547,CDM,S5000,HCPCS,259,RC,27241-0049-10,NDC,outpatient,1,UN,2.4,1.68,AETNA [1000108],AETNA [100010801],,,76.8,,1.84,0.222255,85118.57664,percent of total billed charges,,,
EXEMESTANE 25 MG ORAL TABS,RX-26551,CDM,S5000,HCPCS,259,RC,59762-2858-01,NDC,outpatient,1,UN,6.65,4.655,AETNA [1000108],AETNA [100010801],,,76.8,,5.11,0.222255,85118.57664,percent of total billed charges,,,
LEVETIRACETAM 500 MG ORAL TABS,RX-26817,CDM,S5000,HCPCS,259,RC,00904-7124-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LEVETIRACETAM 500 MG ORAL TABS,RX-26817,CDM,S5000,HCPCS,259,RC,65862-0246-08,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
MOXIFLOXACIN HCL 400 MG ORAL TABS,RX-26854,CDM,S5000,HCPCS,259,RC,65862-0603-30,NDC,outpatient,1,UN,13.67,9.569,AETNA [1000108],AETNA [100010801],,,76.8,,10.5,0.222255,85118.57664,percent of total billed charges,,,
DOFETILIDE 125 MCG ORAL CAPS,RX-26965,CDM,S5000,HCPCS,259,RC,69452-0131-17,NDC,outpatient,1,UN,2.23,1.561,AETNA [1000108],AETNA [100010801],,,76.8,,1.71,0.222255,85118.57664,percent of total billed charges,,,
DOFETILIDE 125 MCG ORAL CAPS,RX-26965,CDM,S5000,HCPCS,259,RC,72205-0039-60,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
DOFETILIDE 125 MCG ORAL CAPS,RX-26965,CDM,S5000,HCPCS,259,RC,16729-0490-12,NDC,outpatient,1,UN,6.58,4.606,AETNA [1000108],AETNA [100010801],,,76.8,,5.05,0.222255,85118.57664,percent of total billed charges,,,
DOFETILIDE 250 MCG ORAL CAPS,RX-26966,CDM,S5000,HCPCS,259,RC,00904-6682-08,NDC,outpatient,1,UN,13.18,9.226,AETNA [1000108],AETNA [100010801],,,76.8,,10.12,0.222255,85118.57664,percent of total billed charges,,,
DOFETILIDE 250 MCG ORAL CAPS,RX-26966,CDM,S5000,HCPCS,259,RC,42291-0412-60,NDC,outpatient,1,UN,1.48,1.036,AETNA [1000108],AETNA [100010801],,,76.8,,1.14,0.222255,85118.57664,percent of total billed charges,,,
DOFETILIDE 250 MCG ORAL CAPS,RX-26966,CDM,S5000,HCPCS,259,RC,69452-0132-17,NDC,outpatient,1,UN,2.23,1.561,AETNA [1000108],AETNA [100010801],,,76.8,,1.71,0.222255,85118.57664,percent of total billed charges,,,
DOFETILIDE 500 MCG ORAL CAPS,RX-26967,CDM,S5000,HCPCS,259,RC,00904-6683-08,NDC,outpatient,1,UN,13.31,9.317,AETNA [1000108],AETNA [100010801],,,76.8,,10.22,0.222255,85118.57664,percent of total billed charges,,,
DOFETILIDE 500 MCG ORAL CAPS,RX-26967,CDM,S5000,HCPCS,259,RC,42291-0413-60,NDC,outpatient,1,UN,1.4,0.98,AETNA [1000108],AETNA [100010801],,,76.8,,1.08,0.222255,85118.57664,percent of total billed charges,,,
TERBINAFINE HCL 1 % EX CREA,RX-27023,CDM,S5000,HCPCS,259,RC,51672-2080-01,NDC,outpatient,15,GR,24.57,17.199,AETNA [1000108],AETNA [100010801],,,76.8,,18.87,0.222255,85118.57664,percent of total billed charges,,,
PREDNISOLONE ACETATE 0.12 % OP SUSP,RX-27038,CDM,S5000,HCPCS,259,RC,11980-0174-05,NDC,outpatient,5,ML,659.54,461.678,AETNA [1000108],AETNA [100010801],,,76.8,,506.53,0.222255,85118.57664,percent of total billed charges,,,
OXCARBAZEPINE 150 MG ORAL TABS,RX-27049,CDM,S5000,HCPCS,259,RC,60687-0711-01,NDC,outpatient,1,UN,1.81,1.267,AETNA [1000108],AETNA [100010801],,,76.8,,1.39,0.222255,85118.57664,percent of total billed charges,,,
OXCARBAZEPINE 150 MG ORAL TABS,RX-27049,CDM,S5000,HCPCS,259,RC,60687-0711-11,NDC,outpatient,1,UN,1.81,1.267,AETNA [1000108],AETNA [100010801],,,76.8,,1.39,0.222255,85118.57664,percent of total billed charges,,,
CHARCOAL ACTIVATED ORAL LIQD,RX-27099,CDM,S5000,HCPCS,259,RC,66689-0202-04,NDC,outpatient,120,ML,82.77,57.939,AETNA [1000108],AETNA [100010801],,,76.8,,63.57,0.222255,85118.57664,percent of total billed charges,,,
RISEDRONATE SODIUM 5 MG ORAL TABS,RX-27112,CDM,S5000,HCPCS,259,RC,33342-0107-07,NDC,outpatient,1,UN,11.13,7.791,AETNA [1000108],AETNA [100010801],,,76.8,,8.55,0.222255,85118.57664,percent of total billed charges,,,
NIACIN ER (ANTIHYPERLIPIDEMIC) 500 MG ORAL TBCR,RX-27181,CDM,S5000,HCPCS,259,RC,59651-0018-90,NDC,outpatient,1,UN,1.7,1.19,AETNA [1000108],AETNA [100010801],,,76.8,,1.31,0.222255,85118.57664,percent of total billed charges,,,
NIACIN ER (ANTIHYPERLIPIDEMIC) 500 MG ORAL TBCR,RX-27181,CDM,S5000,HCPCS,259,RC,47335-0539-81,NDC,outpatient,1,UN,1.02,0.714,AETNA [1000108],AETNA [100010801],,,76.8,,0.78,0.222255,85118.57664,percent of total billed charges,,,
MAGNESIUM SULFATE (LAXATIVE) ORAL GRAN,RX-27322,CDM,S5000,HCPCS,259,RC,70677-1210-01,NDC,outpatient,454,GR,8.09,5.663,AETNA [1000108],AETNA [100010801],,,76.8,,6.21,0.222255,85118.57664,percent of total billed charges,,,
MAGNESIUM SULFATE (LAXATIVE) ORAL GRAN,RX-27322,CDM,S5000,HCPCS,259,RC,49580-0394-04,NDC,outpatient,1814,GR,16.15,11.305,AETNA [1000108],AETNA [100010801],,,76.8,,12.4,0.222255,85118.57664,percent of total billed charges,,,
MAGNESIUM SULFATE (LAXATIVE) ORAL GRAN,RX-27322,CDM,S5000,HCPCS,259,RC,70677-0038-01,NDC,outpatient,454,GR,8.09,5.663,AETNA [1000108],AETNA [100010801],,,76.8,,6.21,0.222255,85118.57664,percent of total billed charges,,,
MINERAL OIL LIGHT OIL,RX-27386,CDM,S5000,HCPCS,259,RC,63323-0254-02,NDC,outpatient,2,ML,34.38,24.066,AETNA [1000108],AETNA [100010801],,,76.8,,26.4,0.222255,85118.57664,percent of total billed charges,,,
MINERAL OIL LIGHT OIL,RX-27386,CDM,S5000,HCPCS,259,RC,63323-0254-10,NDC,outpatient,10,ML,39.03,27.321,AETNA [1000108],AETNA [100010801],,,76.8,,29.98,0.222255,85118.57664,percent of total billed charges,,,
THEOPHYLLINE ER 100 MG ORAL CP24,RX-27418,CDM,S5000,HCPCS,259,RC,52244-0100-10,NDC,outpatient,1,UN,14.48,10.136,AETNA [1000108],AETNA [100010801],,,76.8,,11.12,0.222255,85118.57664,percent of total billed charges,,,
PENTAMIDINE ISETHIONATE 300 MG IJ SOLR,RX-27430,CDM,S5000,HCPCS,250,RC,63323-0113-10,NDC,outpatient,1,UN,686.14,480.298,AETNA [1000108],AETNA [100010801],,,76.8,,526.96,0.222255,85118.57664,percent of total billed charges,,,
DINOPROSTONE 10 MG VA INST,RX-27467,CDM,S5000,HCPCS,259,RC,55566-2800-01,NDC,outpatient,1,UN,2100.63,1470.441,AETNA [1000108],AETNA [100010801],,,76.8,,1613.28,0.222255,85118.57664,percent of total billed charges,,,
NITROGLYCERIN 0.1 MG/HR TD PT24,RX-27471,CDM,S5000,HCPCS,259,RC,00378-9102-16,NDC,outpatient,1,UN,2.47,1.729,AETNA [1000108],AETNA [100010801],,,76.8,,1.9,0.222255,85118.57664,percent of total billed charges,,,
NITROGLYCERIN 0.1 MG/HR TD PT24,RX-27471,CDM,S5000,HCPCS,259,RC,00378-9102-93,NDC,outpatient,1,UN,2.47,1.729,AETNA [1000108],AETNA [100010801],,,76.8,,1.9,0.222255,85118.57664,percent of total billed charges,,,
NITROGLYCERIN 0.2 MG/HR TD PT24,RX-27472,CDM,S5000,HCPCS,259,RC,00378-9104-16,NDC,outpatient,1,UN,2.2,1.54,AETNA [1000108],AETNA [100010801],,,76.8,,1.69,0.222255,85118.57664,percent of total billed charges,,,
NITROGLYCERIN 0.2 MG/HR TD PT24,RX-27472,CDM,S5000,HCPCS,259,RC,00378-9104-93,NDC,outpatient,1,UN,2.2,1.54,AETNA [1000108],AETNA [100010801],,,76.8,,1.69,0.222255,85118.57664,percent of total billed charges,,,
NITROGLYCERIN 0.3 MG/HR TD PT24,RX-27473,CDM,S5000,HCPCS,259,RC,50742-0515-30,NDC,outpatient,1,UN,217.89,152.523,AETNA [1000108],AETNA [100010801],,,76.8,,167.34,0.222255,85118.57664,percent of total billed charges,,,
NITROGLYCERIN 0.3 MG/HR TD PT24,RX-27473,CDM,S5000,HCPCS,259,RC,50742-0515-01,NDC,outpatient,1,UN,217.89,152.523,AETNA [1000108],AETNA [100010801],,,76.8,,167.34,0.222255,85118.57664,percent of total billed charges,,,
NITROGLYCERIN 0.4 MG/HR TD PT24,RX-27474,CDM,S5000,HCPCS,259,RC,00378-9112-93,NDC,outpatient,1,UN,2.77,1.939,AETNA [1000108],AETNA [100010801],,,76.8,,2.13,0.222255,85118.57664,percent of total billed charges,,,
NITROGLYCERIN 0.4 MG/HR TD PT24,RX-27474,CDM,S5000,HCPCS,259,RC,00378-9112-16,NDC,outpatient,1,UN,2.77,1.939,AETNA [1000108],AETNA [100010801],,,76.8,,2.13,0.222255,85118.57664,percent of total billed charges,,,
NITROGLYCERIN 0.4 MG/HR TD PT24,RX-27474,CDM,S5000,HCPCS,259,RC,43598-0894-30,NDC,outpatient,1,UN,9.32,6.524,AETNA [1000108],AETNA [100010801],,,76.8,,7.16,0.222255,85118.57664,percent of total billed charges,,,
NITROGLYCERIN 0.6 MG/HR TD PT24,RX-27475,CDM,S5000,HCPCS,259,RC,00378-9116-16,NDC,outpatient,1,UN,3.17,2.219,AETNA [1000108],AETNA [100010801],,,76.8,,2.43,0.222255,85118.57664,percent of total billed charges,,,
NITROGLYCERIN 0.6 MG/HR TD PT24,RX-27475,CDM,S5000,HCPCS,259,RC,00378-9116-93,NDC,outpatient,1,UN,3.17,2.219,AETNA [1000108],AETNA [100010801],,,76.8,,2.43,0.222255,85118.57664,percent of total billed charges,,,
FELODIPINE ER 2.5 MG ORAL TB24,RX-27489,CDM,S5000,HCPCS,259,RC,00603-3581-21,NDC,outpatient,1,UN,1.73,1.211,AETNA [1000108],AETNA [100010801],,,76.8,,1.33,0.222255,85118.57664,percent of total billed charges,,,
FELODIPINE ER 2.5 MG ORAL TB24,RX-27489,CDM,S5000,HCPCS,259,RC,13668-0132-01,NDC,outpatient,1,UN,1.96,1.372,AETNA [1000108],AETNA [100010801],,,76.8,,1.51,0.222255,85118.57664,percent of total billed charges,,,
FELODIPINE ER 2.5 MG ORAL TB24,RX-27489,CDM,S5000,HCPCS,259,RC,68462-0233-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
DM-GUAIFENESIN ER 30-600 MG ORAL TB12,RX-27543,CDM,S5000,HCPCS,259,RC,00536-1161-37,NDC,outpatient,1,UN,1.77,1.239,AETNA [1000108],AETNA [100010801],,,76.8,,1.36,0.222255,85118.57664,percent of total billed charges,,,
DM-GUAIFENESIN ER 30-600 MG ORAL TB12,RX-27543,CDM,S5000,HCPCS,259,RC,63824-0056-34,NDC,outpatient,1,UN,1.93,1.351,AETNA [1000108],AETNA [100010801],,,76.8,,1.48,0.222255,85118.57664,percent of total billed charges,,,
DIVALPROEX SODIUM 125 MG ORAL CSDR,RX-27631,CDM,S5000,HCPCS,259,RC,68084-0313-01,NDC,outpatient,1,UN,3.24,2.268,AETNA [1000108],AETNA [100010801],,,76.8,,2.49,0.222255,85118.57664,percent of total billed charges,,,
DIVALPROEX SODIUM 125 MG ORAL CSDR,RX-27631,CDM,S5000,HCPCS,259,RC,68084-0313-11,NDC,outpatient,1,UN,3.24,2.268,AETNA [1000108],AETNA [100010801],,,76.8,,2.49,0.222255,85118.57664,percent of total billed charges,,,
DIVALPROEX SODIUM 125 MG ORAL CSDR,RX-27631,CDM,S5000,HCPCS,259,RC,68382-0106-01,NDC,outpatient,1,UN,1.55,1.085,AETNA [1000108],AETNA [100010801],,,76.8,,1.19,0.222255,85118.57664,percent of total billed charges,,,
CARBAMAZEPINE ER 200 MG ORAL CP12,RX-27632,CDM,S5000,HCPCS,259,RC,50268-0171-11,NDC,outpatient,1,UN,7.06,4.942,AETNA [1000108],AETNA [100010801],,,76.8,,5.42,0.222255,85118.57664,percent of total billed charges,,,
CARBAMAZEPINE ER 200 MG ORAL CP12,RX-27632,CDM,S5000,HCPCS,259,RC,50268-0171-13,NDC,outpatient,1,UN,7.06,4.942,AETNA [1000108],AETNA [100010801],,,76.8,,5.42,0.222255,85118.57664,percent of total billed charges,,,
CARBAMAZEPINE ER 300 MG ORAL CP12,RX-27633,CDM,S5000,HCPCS,259,RC,66993-0409-32,NDC,outpatient,1,UN,5.66,3.962,AETNA [1000108],AETNA [100010801],,,76.8,,4.35,0.222255,85118.57664,percent of total billed charges,,,
CARBAMAZEPINE ER 100 MG ORAL TB12,RX-27634,CDM,S5000,HCPCS,259,RC,51672-4123-01,NDC,outpatient,1,UN,1.04,0.728,AETNA [1000108],AETNA [100010801],,,76.8,,0.8,0.222255,85118.57664,percent of total billed charges,,,
CARBAMAZEPINE ER 400 MG ORAL TB12,RX-27636,CDM,S5000,HCPCS,259,RC,51672-4125-01,NDC,outpatient,1,UN,2.24,1.568,AETNA [1000108],AETNA [100010801],,,76.8,,1.72,0.222255,85118.57664,percent of total billed charges,,,
ASPIRIN-DIPYRIDAMOLE ER 25-200 MG ORAL CP12,RX-27644,CDM,S5000,HCPCS,259,RC,68462-0405-60,NDC,outpatient,1,UN,2.36,1.652,AETNA [1000108],AETNA [100010801],,,76.8,,1.81,0.222255,85118.57664,percent of total billed charges,,,
ASPIRIN-DIPYRIDAMOLE ER 25-200 MG ORAL CP12,RX-27644,CDM,S5000,HCPCS,259,RC,49884-0007-02,NDC,outpatient,1,UN,22.19,15.533,AETNA [1000108],AETNA [100010801],,,76.8,,17.04,0.222255,85118.57664,percent of total billed charges,,,
NIFEDIPINE ER OSMOTIC RELEASE 60 MG ORAL TB24,RX-27659,CDM,S5000,HCPCS,259,RC,68084-0598-11,NDC,outpatient,1,UN,8.9,6.23,AETNA [1000108],AETNA [100010801],,,76.8,,6.84,0.222255,85118.57664,percent of total billed charges,,,
NIFEDIPINE ER OSMOTIC RELEASE 60 MG ORAL TB24,RX-27659,CDM,S5000,HCPCS,259,RC,68084-0598-01,NDC,outpatient,1,UN,8.9,6.23,AETNA [1000108],AETNA [100010801],,,76.8,,6.84,0.222255,85118.57664,percent of total billed charges,,,
NIFEDIPINE ER OSMOTIC RELEASE 90 MG ORAL TB24,RX-27660,CDM,S5000,HCPCS,259,RC,68084-0603-11,NDC,outpatient,1,UN,11.24,7.868,AETNA [1000108],AETNA [100010801],,,76.8,,8.63,0.222255,85118.57664,percent of total billed charges,,,
NIFEDIPINE ER OSMOTIC RELEASE 90 MG ORAL TB24,RX-27660,CDM,S5000,HCPCS,259,RC,62175-0262-37,NDC,outpatient,1,UN,9.51,6.657,AETNA [1000108],AETNA [100010801],,,76.8,,7.3,0.222255,85118.57664,percent of total billed charges,,,
NIFEDIPINE ER OSMOTIC RELEASE 90 MG ORAL TB24,RX-27660,CDM,S5000,HCPCS,259,RC,68084-0603-21,NDC,outpatient,1,UN,11.24,7.868,AETNA [1000108],AETNA [100010801],,,76.8,,8.63,0.222255,85118.57664,percent of total billed charges,,,
FLUORESCEIN SODIUM 1 MG OP STRP,RX-27663,CDM,S5000,HCPCS,259,RC,17238-0900-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
TROLAMINE SALICYLATE 10 % EX CREA,RX-27680,CDM,S5000,HCPCS,259,RC,41167-0057-24,NDC,outpatient,141,GR,30.75,21.525,AETNA [1000108],AETNA [100010801],,,76.8,,23.62,0.222255,85118.57664,percent of total billed charges,,,
DESMOPRESSIN ACE SPRAY REFRIG 0.01 % NA SOLN,RX-27770,CDM,S5000,HCPCS,259,RC,24208-0342-05,NDC,outpatient,5,ML,655.13,458.591,AETNA [1000108],AETNA [100010801],,,76.8,,503.14,0.222255,85118.57664,percent of total billed charges,,,
ZONISAMIDE 100 MG ORAL CAPS,RX-27780,CDM,S5000,HCPCS,259,RC,50268-0816-15,NDC,outpatient,1,UN,2.24,1.568,AETNA [1000108],AETNA [100010801],,,76.8,,1.72,0.222255,85118.57664,percent of total billed charges,,,
ZONISAMIDE 100 MG ORAL CAPS,RX-27780,CDM,S5000,HCPCS,259,RC,50268-0816-11,NDC,outpatient,1,UN,2.24,1.568,AETNA [1000108],AETNA [100010801],,,76.8,,1.72,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-02,NDC,outpatient,250,ML,22.43,15.701,AETNA [1000108],AETNA [100010801],,,76.8,,17.23,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-04,NDC,outpatient,1000,ML,21.14,14.798,AETNA [1000108],AETNA [100010801],,,76.8,,16.24,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-31,NDC,outpatient,50,ML,22.43,15.701,AETNA [1000108],AETNA [100010801],,,76.8,,17.23,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,,,outpatient,500,ML,21.14,14.798,AETNA [1000108],AETNA [100010801],,,76.8,,16.24,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-38,NDC,outpatient,100,ML,22.17,15.519,AETNA [1000108],AETNA [100010801],,,76.8,,17.03,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-48,NDC,outpatient,100,ML,22.69,15.883,AETNA [1000108],AETNA [100010801],,,76.8,,17.43,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00409-7101-67,NDC,outpatient,100,ML,25.77,18.039,AETNA [1000108],AETNA [100010801],,,76.8,,19.79,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00264-1800-32,NDC,outpatient,100,ML,28.85,20.195,AETNA [1000108],AETNA [100010801],,,76.8,,22.16,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-03,NDC,outpatient,500,ML,23.71,16.597,AETNA [1000108],AETNA [100010801],,,76.8,,18.21,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-41,NDC,outpatient,50,ML,22.94,16.058,AETNA [1000108],AETNA [100010801],,,76.8,,17.62,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-9543-02,NDC,outpatient,250,ML,25,17.5,AETNA [1000108],AETNA [100010801],,,76.8,,19.2,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-9543-04,NDC,outpatient,500,ML,26.7,18.69,AETNA [1000108],AETNA [100010801],,,76.8,,20.51,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00487-4301-10,NDC,outpatient,100,ML,28.85,20.195,AETNA [1000108],AETNA [100010801],,,76.8,,22.16,0.222255,85118.57664,percent of total billed charges,,,
VENLAFAXINE HCL ER 37.5 MG ORAL CP24,RX-27857,CDM,S5000,HCPCS,259,RC,68084-0698-11,NDC,outpatient,1,UN,2.07,1.449,AETNA [1000108],AETNA [100010801],,,76.8,,1.59,0.222255,85118.57664,percent of total billed charges,,,
VENLAFAXINE HCL ER 37.5 MG ORAL CP24,RX-27857,CDM,S5000,HCPCS,259,RC,68084-0698-01,NDC,outpatient,1,UN,2.07,1.449,AETNA [1000108],AETNA [100010801],,,76.8,,1.59,0.222255,85118.57664,percent of total billed charges,,,
VENLAFAXINE HCL ER 75 MG ORAL CP24,RX-27858,CDM,S5000,HCPCS,259,RC,68084-0709-11,NDC,outpatient,1,UN,2.26,1.582,AETNA [1000108],AETNA [100010801],,,76.8,,1.74,0.222255,85118.57664,percent of total billed charges,,,
VENLAFAXINE HCL ER 75 MG ORAL CP24,RX-27858,CDM,S5000,HCPCS,259,RC,00904-7077-61,NDC,outpatient,1,UN,1.54,1.078,AETNA [1000108],AETNA [100010801],,,76.8,,1.18,0.222255,85118.57664,percent of total billed charges,,,
VENLAFAXINE HCL ER 75 MG ORAL CP24,RX-27858,CDM,S5000,HCPCS,259,RC,68084-0709-01,NDC,outpatient,1,UN,2.26,1.582,AETNA [1000108],AETNA [100010801],,,76.8,,1.74,0.222255,85118.57664,percent of total billed charges,,,
NICOTINE 7 MG/24HR TD PT24,RX-27860,CDM,S5000,HCPCS,259,RC,43598-0446-74,NDC,outpatient,1,UN,4.78,3.346,AETNA [1000108],AETNA [100010801],,,76.8,,3.67,0.222255,85118.57664,percent of total billed charges,,,
NICOTINE 14 MG/24HR TD PT24,RX-27862,CDM,S5000,HCPCS,259,RC,43598-0447-74,NDC,outpatient,1,UN,5.28,3.696,AETNA [1000108],AETNA [100010801],,,76.8,,4.06,0.222255,85118.57664,percent of total billed charges,,,
NICOTINE 21 MG/24HR TD PT24,RX-27863,CDM,S5000,HCPCS,259,RC,00536-5896-33,NDC,outpatient,1,UN,7.5,5.25,AETNA [1000108],AETNA [100010801],,,76.8,,5.76,0.222255,85118.57664,percent of total billed charges,,,
NICOTINE 21 MG/24HR TD PT24,RX-27863,CDM,S5000,HCPCS,259,RC,00536-5896-88,NDC,outpatient,1,UN,7.5,5.25,AETNA [1000108],AETNA [100010801],,,76.8,,5.76,0.222255,85118.57664,percent of total billed charges,,,
NICOTINE 21 MG/24HR TD PT24,RX-27863,CDM,S5000,HCPCS,259,RC,43598-0448-28,NDC,outpatient,1,UN,5.25,3.675,AETNA [1000108],AETNA [100010801],,,76.8,,4.03,0.222255,85118.57664,percent of total billed charges,,,
NICOTINE 21 MG/24HR TD PT24,RX-27863,CDM,S5000,HCPCS,259,RC,43598-0448-74,NDC,outpatient,1,UN,4.94,3.458,AETNA [1000108],AETNA [100010801],,,76.8,,3.79,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE VISCOUS HCL 2 % MT SOLN,RX-27898,CDM,S5000,HCPCS,259,RC,00054-3500-49,NDC,outpatient,5,ML,2.23,1.561,AETNA [1000108],AETNA [100010801],,,76.8,,1.71,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE VISCOUS HCL 2 % MT SOLN,RX-27898,CDM,S5000,HCPCS,259,RC,62135-0712-42,NDC,outpatient,5,ML,20.16,14.112,AETNA [1000108],AETNA [100010801],,,76.8,,15.48,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE VISCOUS HCL 2 % MT SOLN,RX-27898,CDM,S5000,HCPCS,259,RC,72888-0125-26,NDC,outpatient,5,ML,2.5,1.75,AETNA [1000108],AETNA [100010801],,,76.8,,1.92,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE VISCOUS HCL 2 % MT SOLN,RX-27898,CDM,S5000,HCPCS,259,RC,99999-0002-05,NDC,outpatient,15,ML,60.48,42.336,AETNA [1000108],AETNA [100010801],,,76.8,,46.45,0.222255,85118.57664,percent of total billed charges,,,
FENTANYL 25 MCG/HR TD PT72,RX-27905,CDM,S5000,HCPCS,259,RC,47781-0424-11,NDC,outpatient,1,UN,17.49,12.243,AETNA [1000108],AETNA [100010801],,,76.8,,13.43,0.222255,85118.57664,percent of total billed charges,,,
FENTANYL 25 MCG/HR TD PT72,RX-27905,CDM,S5000,HCPCS,259,RC,47781-0424-47,NDC,outpatient,1,UN,17.49,12.243,AETNA [1000108],AETNA [100010801],,,76.8,,13.43,0.222255,85118.57664,percent of total billed charges,,,
FENTANYL 50 MCG/HR TD PT72,RX-27906,CDM,S5000,HCPCS,259,RC,00378-9122-16,NDC,outpatient,1,UN,37.78,26.446,AETNA [1000108],AETNA [100010801],,,76.8,,29.02,0.222255,85118.57664,percent of total billed charges,,,
FENTANYL 50 MCG/HR TD PT72,RX-27906,CDM,S5000,HCPCS,259,RC,47781-0426-11,NDC,outpatient,1,UN,25.49,17.843,AETNA [1000108],AETNA [100010801],,,76.8,,19.58,0.222255,85118.57664,percent of total billed charges,,,
FENTANYL 50 MCG/HR TD PT72,RX-27906,CDM,S5000,HCPCS,259,RC,47781-0426-47,NDC,outpatient,1,UN,25.49,17.843,AETNA [1000108],AETNA [100010801],,,76.8,,19.58,0.222255,85118.57664,percent of total billed charges,,,
FENTANYL 50 MCG/HR TD PT72,RX-27906,CDM,S5000,HCPCS,259,RC,00378-9122-98,NDC,outpatient,1,UN,37.78,26.446,AETNA [1000108],AETNA [100010801],,,76.8,,29.02,0.222255,85118.57664,percent of total billed charges,,,
FENTANYL 75 MCG/HR TD PT72,RX-27907,CDM,S5000,HCPCS,259,RC,47781-0427-47,NDC,outpatient,1,UN,37.66,26.362,AETNA [1000108],AETNA [100010801],,,76.8,,28.92,0.222255,85118.57664,percent of total billed charges,,,
FENTANYL 75 MCG/HR TD PT72,RX-27907,CDM,S5000,HCPCS,259,RC,47781-0427-11,NDC,outpatient,1,UN,37.66,26.362,AETNA [1000108],AETNA [100010801],,,76.8,,28.92,0.222255,85118.57664,percent of total billed charges,,,
FENTANYL 100 MCG/HR TD PT72,RX-27908,CDM,S5000,HCPCS,259,RC,00378-9124-16,NDC,outpatient,1,UN,93.74,65.618,AETNA [1000108],AETNA [100010801],,,76.8,,71.99,0.222255,85118.57664,percent of total billed charges,,,
FENTANYL 100 MCG/HR TD PT72,RX-27908,CDM,S5000,HCPCS,259,RC,00378-9124-98,NDC,outpatient,1,UN,93.74,65.618,AETNA [1000108],AETNA [100010801],,,76.8,,71.99,0.222255,85118.57664,percent of total billed charges,,,
EMPTY STERILIZED CONTAINER,RX-2795,CDM,S5000,HCPCS,250,RC,63323-0001-30,NDC,outpatient,1,UN,4.71,3.297,AETNA [1000108],AETNA [100010801],,,76.8,,3.62,0.222255,85118.57664,percent of total billed charges,,,
EMPTY STERILIZED CONTAINER,RX-2795,CDM,S5000,HCPCS,250,RC,63323-0001-10,NDC,outpatient,1,UN,3.99,2.793,AETNA [1000108],AETNA [100010801],,,76.8,,3.06,0.222255,85118.57664,percent of total billed charges,,,
SODIUM POLYSTYRENE SULFONATE 15 GM/60ML ORAL SUSP,RX-27999,CDM,S5000,HCPCS,259,RC,46287-0006-60,NDC,outpatient,60,ML,91.85,64.295,AETNA [1000108],AETNA [100010801],,,76.8,,70.54,0.222255,85118.57664,percent of total billed charges,,,
SERTRALINE HCL 20 MG/ML ORAL CONC,RX-28011,CDM,S5000,HCPCS,259,RC,99999-0003-51,NDC,outpatient,2.5,ML,10.37,7.259,AETNA [1000108],AETNA [100010801],,,76.8,,7.96,0.222255,85118.57664,percent of total billed charges,,,
SERTRALINE HCL 20 MG/ML ORAL CONC,RX-28011,CDM,S5000,HCPCS,259,RC,16714-0601-02,NDC,outpatient,2.5,ML,10.37,7.259,AETNA [1000108],AETNA [100010801],,,76.8,,7.96,0.222255,85118.57664,percent of total billed charges,,,
FE FUMARATE-B12-VIT C-FA-IFC ORAL CAPS,RX-28030,CDM,S5000,HCPCS,259,RC,51991-0635-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
BENZOCAINE-MENTHOL 20-0.5 % EX AERO,RX-28048,CDM,S5000,HCPCS,259,RC,16864-0680-02,NDC,outpatient,56,GR,17.7,12.39,AETNA [1000108],AETNA [100010801],,,76.8,,13.59,0.222255,85118.57664,percent of total billed charges,,,
BENZOCAINE-MENTHOL 20-0.5 % EX AERO,RX-28048,CDM,S5000,HCPCS,259,RC,16864-0680-01,NDC,outpatient,78,GR,22.91,16.037,AETNA [1000108],AETNA [100010801],,,76.8,,17.59,0.222255,85118.57664,percent of total billed charges,,,
ASPIRIN BUF(CACARB-MGCARB-MGO) 325 MG ORAL TABS,RX-28122,CDM,S5000,HCPCS,259,RC,00904-2015-59,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,55111-0262-81,NDC,outpatient,1,UN,3.06,2.142,AETNA [1000108],AETNA [100010801],,,76.8,,2.35,0.222255,85118.57664,percent of total billed charges,,,
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,60505-3275-00,NDC,outpatient,1,UN,1.9,1.33,AETNA [1000108],AETNA [100010801],,,76.8,,1.46,0.222255,85118.57664,percent of total billed charges,,,
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,00093-5245-65,NDC,outpatient,1,UN,2.89,2.023,AETNA [1000108],AETNA [100010801],,,76.8,,2.22,0.222255,85118.57664,percent of total billed charges,,,
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,33342-0083-07,NDC,outpatient,1,UN,3.81,2.667,AETNA [1000108],AETNA [100010801],,,76.8,,2.93,0.222255,85118.57664,percent of total billed charges,,,
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,55111-0262-79,NDC,outpatient,1,UN,3.06,2.142,AETNA [1000108],AETNA [100010801],,,76.8,,2.35,0.222255,85118.57664,percent of total billed charges,,,
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,00093-5245-19,NDC,outpatient,1,UN,2.89,2.023,AETNA [1000108],AETNA [100010801],,,76.8,,2.22,0.222255,85118.57664,percent of total billed charges,,,
OLANZAPINE 10 MG ORAL TBDP,RX-28160,CDM,S5000,HCPCS,259,RC,49884-0321-55,NDC,outpatient,1,UN,2.45,1.715,AETNA [1000108],AETNA [100010801],,,76.8,,1.88,0.222255,85118.57664,percent of total billed charges,,,
OLANZAPINE 10 MG ORAL TBDP,RX-28160,CDM,S5000,HCPCS,259,RC,49884-0321-52,NDC,outpatient,1,UN,2.45,1.715,AETNA [1000108],AETNA [100010801],,,76.8,,1.88,0.222255,85118.57664,percent of total billed charges,,,
LINEZOLID 600 MG ORAL TABS,RX-28224,CDM,S5000,HCPCS,259,RC,67877-0419-33,NDC,outpatient,1,UN,7.42,5.194,AETNA [1000108],AETNA [100010801],,,76.8,,5.7,0.222255,85118.57664,percent of total billed charges,,,
LINEZOLID 600 MG ORAL TABS,RX-28224,CDM,S5000,HCPCS,259,RC,67877-0419-84,NDC,outpatient,1,UN,7.42,5.194,AETNA [1000108],AETNA [100010801],,,76.8,,5.7,0.222255,85118.57664,percent of total billed charges,,,
LINEZOLID 600 MG ORAL TABS,RX-28224,CDM,S5000,HCPCS,259,RC,00904-6553-04,NDC,outpatient,1,UN,7.73,5.411,AETNA [1000108],AETNA [100010801],,,76.8,,5.94,0.222255,85118.57664,percent of total billed charges,,,
LINEZOLID 100 MG/5ML ORAL SUSR,RX-28225,CDM,S5000,HCPCS,259,RC,59762-1308-04,NDC,outpatient,150,ML,1694.12,1185.884,AETNA [1000108],AETNA [100010801],,,76.8,,1301.08,0.222255,85118.57664,percent of total billed charges,,,
LINEZOLID 100 MG/5ML ORAL SUSR,RX-28225,CDM,S5000,HCPCS,259,RC,99999-0002-85,NDC,outpatient,30,ML,340.43,238.301,AETNA [1000108],AETNA [100010801],,,76.8,,261.45,0.222255,85118.57664,percent of total billed charges,,,
PENTAMIDINE ISETHIONATE 300 MG IN SOLR,RX-28235,CDM,S5000,HCPCS,259,RC,63323-0877-15,NDC,outpatient,1,UN,686.24,480.368,AETNA [1000108],AETNA [100010801],,,76.8,,527.03,0.222255,85118.57664,percent of total billed charges,,,
RIVASTIGMINE TARTRATE 1.5 MG ORAL CAPS,RX-28278,CDM,S5000,HCPCS,259,RC,00904-7107-61,NDC,outpatient,1,UN,10.27,7.189,AETNA [1000108],AETNA [100010801],,,76.8,,7.89,0.222255,85118.57664,percent of total billed charges,,,
RIVASTIGMINE TARTRATE 3 MG ORAL CAPS,RX-28279,CDM,S5000,HCPCS,259,RC,55111-0353-60,NDC,outpatient,1,UN,2.6,1.82,AETNA [1000108],AETNA [100010801],,,76.8,,2,0.222255,85118.57664,percent of total billed charges,,,
INSULIN GLARGINE 100 UNIT/ML SC SOLN,RX-28282,CDM,S5000,HCPCS,259,RC,00088-2220-33,NDC,outpatient,10,ML,252.19,176.533,AETNA [1000108],AETNA [100010801],,,76.8,,193.68,0.222255,85118.57664,percent of total billed charges,,,
COLESEVELAM HCL 625 MG ORAL TABS,RX-28372,CDM,S5000,HCPCS,259,RC,60687-0385-25,NDC,outpatient,1,UN,13.08,9.156,AETNA [1000108],AETNA [100010801],,,76.8,,10.05,0.222255,85118.57664,percent of total billed charges,,,
COLESEVELAM HCL 625 MG ORAL TABS,RX-28372,CDM,S5000,HCPCS,259,RC,60687-0385-95,NDC,outpatient,1,UN,13.08,9.156,AETNA [1000108],AETNA [100010801],,,76.8,,10.05,0.222255,85118.57664,percent of total billed charges,,,
HYDROCODONE-ACETAMINOPHEN 10-325 MG ORAL TABS,RX-28384,CDM,S5000,HCPCS,259,RC,00406-0125-23,NDC,outpatient,1,UN,2,1.4,AETNA [1000108],AETNA [100010801],,,76.8,,1.54,0.222255,85118.57664,percent of total billed charges,,,
HYDROCODONE-ACETAMINOPHEN 10-325 MG ORAL TABS,RX-28384,CDM,S5000,HCPCS,259,RC,00406-0125-62,NDC,outpatient,1,UN,2,1.4,AETNA [1000108],AETNA [100010801],,,76.8,,1.54,0.222255,85118.57664,percent of total billed charges,,,
ESTRADIOL 0.05 MG/24HR TD PTWK,RX-28408,CDM,S5000,HCPCS,259,RC,00378-3350-16,NDC,outpatient,1,UN,65.95,46.165,AETNA [1000108],AETNA [100010801],,,76.8,,50.65,0.222255,85118.57664,percent of total billed charges,,,
ESTRADIOL 0.05 MG/24HR TD PTWK,RX-28408,CDM,S5000,HCPCS,259,RC,00378-3350-99,NDC,outpatient,1,UN,65.95,46.165,AETNA [1000108],AETNA [100010801],,,76.8,,50.65,0.222255,85118.57664,percent of total billed charges,,,
ESTRADIOL 0.1 MG/24HR TD PTWK,RX-28409,CDM,S5000,HCPCS,259,RC,00378-3352-16,NDC,outpatient,1,UN,65.26,45.682,AETNA [1000108],AETNA [100010801],,,76.8,,50.12,0.222255,85118.57664,percent of total billed charges,,,
ESTRADIOL 0.1 MG/24HR TD PTWK,RX-28409,CDM,S5000,HCPCS,259,RC,00378-3352-99,NDC,outpatient,1,UN,65.26,45.682,AETNA [1000108],AETNA [100010801],,,76.8,,50.12,0.222255,85118.57664,percent of total billed charges,,,
NIFEDIPINE ER OSMOTIC RELEASE 30 MG ORAL TB24,RX-28643,CDM,S5000,HCPCS,259,RC,68084-0597-11,NDC,outpatient,1,UN,5.37,3.759,AETNA [1000108],AETNA [100010801],,,76.8,,4.12,0.222255,85118.57664,percent of total billed charges,,,
NIFEDIPINE ER OSMOTIC RELEASE 30 MG ORAL TB24,RX-28643,CDM,S5000,HCPCS,259,RC,68084-0597-01,NDC,outpatient,1,UN,5.37,3.759,AETNA [1000108],AETNA [100010801],,,76.8,,4.12,0.222255,85118.57664,percent of total billed charges,,,
METHYLPHENIDATE HCL ER (OSM) 18 MG ORAL TBCR,RX-28750,CDM,S5000,HCPCS,259,RC,50458-0585-01,NDC,outpatient,1,UN,53.04,37.128,AETNA [1000108],AETNA [100010801],,,76.8,,40.73,0.222255,85118.57664,percent of total billed charges,,,
METHYLPHENIDATE HCL ER (OSM) 18 MG ORAL TBCR,RX-28750,CDM,S5000,HCPCS,259,RC,13811-0706-10,NDC,outpatient,1,UN,3.22,2.254,AETNA [1000108],AETNA [100010801],,,76.8,,2.47,0.222255,85118.57664,percent of total billed charges,,,
BUDESONIDE 0.25 MG/2ML IN SUSP,RX-28774,CDM,S5000,HCPCS,259,RC,00487-9601-01,NDC,outpatient,2,ML,17.76,12.432,AETNA [1000108],AETNA [100010801],,,76.8,,13.64,0.222255,85118.57664,percent of total billed charges,,,
BUDESONIDE 0.25 MG/2ML IN SUSP,RX-28774,CDM,S5000,HCPCS,259,RC,00186-1988-04,NDC,outpatient,2,ML,35.8,25.06,AETNA [1000108],AETNA [100010801],,,76.8,,27.49,0.222255,85118.57664,percent of total billed charges,,,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,69097-0319-53,NDC,outpatient,2,ML,12.55,8.785,AETNA [1000108],AETNA [100010801],,,76.8,,9.64,0.222255,85118.57664,percent of total billed charges,,,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,00093-6816-73,NDC,outpatient,2,ML,39.45,27.615,AETNA [1000108],AETNA [100010801],,,76.8,,30.3,0.222255,85118.57664,percent of total billed charges,,,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,00487-9701-01,NDC,outpatient,2,ML,14.93,10.451,AETNA [1000108],AETNA [100010801],,,76.8,,11.47,0.222255,85118.57664,percent of total billed charges,,,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,68180-0984-05,NDC,outpatient,2,ML,5.21,3.647,AETNA [1000108],AETNA [100010801],,,76.8,,4,0.222255,85118.57664,percent of total billed charges,,,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,69097-0319-32,NDC,outpatient,2,ML,12.55,8.785,AETNA [1000108],AETNA [100010801],,,76.8,,9.64,0.222255,85118.57664,percent of total billed charges,,,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,68180-0984-30,NDC,outpatient,2,ML,5.21,3.647,AETNA [1000108],AETNA [100010801],,,76.8,,4,0.222255,85118.57664,percent of total billed charges,,,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,00093-6816-45,NDC,outpatient,2,ML,39.45,27.615,AETNA [1000108],AETNA [100010801],,,76.8,,30.3,0.222255,85118.57664,percent of total billed charges,,,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,47335-0632-49,NDC,outpatient,1,ML,6.14,4.298,AETNA [1000108],AETNA [100010801],,,76.8,,4.72,0.222255,85118.57664,percent of total billed charges,,,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,69097-0319-86,NDC,outpatient,2,ML,8.61,6.027,AETNA [1000108],AETNA [100010801],,,76.8,,6.61,0.222255,85118.57664,percent of total billed charges,,,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,69097-0319-87,NDC,outpatient,2,ML,8.61,6.027,AETNA [1000108],AETNA [100010801],,,76.8,,6.61,0.222255,85118.57664,percent of total billed charges,,,
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,00168-0053-21,NDC,outpatient,28.35,GR,7.2,5.04,AETNA [1000108],AETNA [100010801],,,76.8,,5.53,0.222255,85118.57664,percent of total billed charges,,,
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,08080-4302-01,NDC,outpatient,30,ML,5.88,4.116,AETNA [1000108],AETNA [100010801],,,76.8,,4.52,0.222255,85118.57664,percent of total billed charges,,,
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,53329-0993-04,NDC,outpatient,113,GR,5.26,3.682,AETNA [1000108],AETNA [100010801],,,76.8,,4.04,0.222255,85118.57664,percent of total billed charges,,,
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,00168-0053-16,NDC,outpatient,453.6,GR,58.59,41.013,AETNA [1000108],AETNA [100010801],,,76.8,,45,0.222255,85118.57664,percent of total billed charges,,,
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,00521-2311-00,NDC,outpatient,52.5,GR,7.25,5.075,AETNA [1000108],AETNA [100010801],,,76.8,,5.57,0.222255,85118.57664,percent of total billed charges,,,
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,38779-3068-00,NDC,outpatient,30,GR,75.03,52.521,AETNA [1000108],AETNA [100010801],,,76.8,,57.62,0.222255,85118.57664,percent of total billed charges,,,
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,00521-2335-00,NDC,outpatient,390,GR,19.1,13.37,AETNA [1000108],AETNA [100010801],,,76.8,,14.67,0.222255,85118.57664,percent of total billed charges,,,
NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SUSP,RX-28810,CDM,S5000,HCPCS,259,RC,24208-0635-62,NDC,outpatient,10,ML,221.08,154.756,AETNA [1000108],AETNA [100010801],,,76.8,,169.79,0.222255,85118.57664,percent of total billed charges,,,
NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SUSP,RX-28810,CDM,S5000,HCPCS,259,RC,61314-0645-11,NDC,outpatient,10,ML,217.88,152.516,AETNA [1000108],AETNA [100010801],,,76.8,,167.33,0.222255,85118.57664,percent of total billed charges,,,
GLYCERIN LIQD,RX-28815,CDM,S5000,HCPCS,259,RC,00395-1031-96,NDC,outpatient,177,ML,23.63,16.541,AETNA [1000108],AETNA [100010801],,,76.8,,18.15,0.222255,85118.57664,percent of total billed charges,,,
MAGNESIUM HYDROXIDE 400 MG/5ML ORAL SUSP,RX-28836,CDM,S5000,HCPCS,259,RC,00121-0431-30,NDC,outpatient,30,ML,4.14,2.898,AETNA [1000108],AETNA [100010801],,,76.8,,3.18,0.222255,85118.57664,percent of total billed charges,,,
CYCLOSPORINE MODIFIED 25 MG ORAL CAPS,RX-28842,CDM,S5000,HCPCS,259,RC,00093-9018-65,NDC,outpatient,1,UN,1.84,1.288,AETNA [1000108],AETNA [100010801],,,76.8,,1.41,0.222255,85118.57664,percent of total billed charges,,,
CYCLOSPORINE MODIFIED 25 MG ORAL CAPS,RX-28842,CDM,S5000,HCPCS,259,RC,00093-9018-19,NDC,outpatient,1,UN,1.84,1.288,AETNA [1000108],AETNA [100010801],,,76.8,,1.41,0.222255,85118.57664,percent of total billed charges,,,
CYCLOSPORINE MODIFIED 100 MG ORAL CAPS,RX-28843,CDM,S5000,HCPCS,259,RC,00078-0248-15,NDC,outpatient,1,UN,46.19,32.333,AETNA [1000108],AETNA [100010801],,,76.8,,35.47,0.222255,85118.57664,percent of total billed charges,,,
CYCLOSPORINE MODIFIED 100 MG ORAL CAPS,RX-28843,CDM,S5000,HCPCS,259,RC,00078-0248-61,NDC,outpatient,1,UN,46.19,32.333,AETNA [1000108],AETNA [100010801],,,76.8,,35.47,0.222255,85118.57664,percent of total billed charges,,,
CYCLOSPORINE MODIFIED 100 MG/ML ORAL SOLN,RX-28844,CDM,S5000,HCPCS,259,RC,00172-7313-20,NDC,outpatient,50,ML,396.5,277.55,AETNA [1000108],AETNA [100010801],,,76.8,,304.51,0.222255,85118.57664,percent of total billed charges,,,
ERYTHROMYCIN 2 % EX SOLN,RX-2887,CDM,S5000,HCPCS,259,RC,45802-0038-46,NDC,outpatient,60,ML,71.56,50.092,AETNA [1000108],AETNA [100010801],,,76.8,,54.96,0.222255,85118.57664,percent of total billed charges,,,
ERYTHROMYCIN 5 MG/GM OP OINT,RX-2888,CDM,S5000,HCPCS,259,RC,00574-4024-50,NDC,outpatient,1,GR,31.37,21.959,AETNA [1000108],AETNA [100010801],,,76.8,,24.09,0.222255,85118.57664,percent of total billed charges,,,
ERYTHROMYCIN 5 MG/GM OP OINT,RX-2888,CDM,S5000,HCPCS,259,RC,00574-4024-11,NDC,outpatient,1,GR,31.37,21.959,AETNA [1000108],AETNA [100010801],,,76.8,,24.09,0.222255,85118.57664,percent of total billed charges,,,
ERYTHROMYCIN 5 MG/GM OP OINT,RX-2888,CDM,S5000,HCPCS,259,RC,48102-0057-11,NDC,outpatient,1,GR,40.3,28.21,AETNA [1000108],AETNA [100010801],,,76.8,,30.95,0.222255,85118.57664,percent of total billed charges,,,
ERYTHROMYCIN 5 MG/GM OP OINT,RX-2888,CDM,S5000,HCPCS,259,RC,24208-0910-19,NDC,outpatient,1,GR,31.03,21.721,AETNA [1000108],AETNA [100010801],,,76.8,,23.83,0.222255,85118.57664,percent of total billed charges,,,
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,68084-0975-01,NDC,outpatient,1,UN,4.25,2.975,AETNA [1000108],AETNA [100010801],,,76.8,,3.26,0.222255,85118.57664,percent of total billed charges,,,
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,68094-0005-59,NDC,outpatient,1,UN,2.33,1.631,AETNA [1000108],AETNA [100010801],,,76.8,,1.79,0.222255,85118.57664,percent of total billed charges,,,
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,68084-0975-11,NDC,outpatient,1,UN,4.25,2.975,AETNA [1000108],AETNA [100010801],,,76.8,,3.26,0.222255,85118.57664,percent of total billed charges,,,
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,00406-8515-23,NDC,outpatient,1,UN,2.43,1.701,AETNA [1000108],AETNA [100010801],,,76.8,,1.87,0.222255,85118.57664,percent of total billed charges,,,
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,00406-8515-62,NDC,outpatient,1,UN,2.43,1.701,AETNA [1000108],AETNA [100010801],,,76.8,,1.87,0.222255,85118.57664,percent of total billed charges,,,
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,68094-0005-61,NDC,outpatient,1,UN,2.33,1.631,AETNA [1000108],AETNA [100010801],,,76.8,,1.79,0.222255,85118.57664,percent of total billed charges,,,
ERYTHROMYCIN BASE 250 MG ORAL TBEC,RX-2891,CDM,S5000,HCPCS,259,RC,24338-0122-03,NDC,outpatient,1,UN,24.57,17.199,AETNA [1000108],AETNA [100010801],,,76.8,,18.87,0.222255,85118.57664,percent of total billed charges,,,
ERYTHROMYCIN BASE 250 MG ORAL TBEC,RX-2891,CDM,S5000,HCPCS,259,RC,13668-0586-30,NDC,outpatient,1,UN,21.71,15.197,AETNA [1000108],AETNA [100010801],,,76.8,,16.67,0.222255,85118.57664,percent of total billed charges,,,
NA HYALUR & NA CHOND-NA HYALUR 0.4-0.35 ML IO KIT,RX-28916,CDM,S5000,HCPCS,250,RC,08065-1831-35,NDC,outpatient,0.75,ML,867.31,607.117,AETNA [1000108],AETNA [100010801],,,76.8,,666.09,0.222255,85118.57664,percent of total billed charges,,,
LEVOFLOXACIN 750 MG ORAL TABS,RX-28964,CDM,S5000,HCPCS,259,RC,00904-6353-61,NDC,outpatient,1,UN,2.17,1.519,AETNA [1000108],AETNA [100010801],,,76.8,,1.67,0.222255,85118.57664,percent of total billed charges,,,
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5ML ORAL SUSR,RX-2899,CDM,S5000,HCPCS,259,RC,24338-0134-02,NDC,outpatient,100,ML,1005.7,703.99,AETNA [1000108],AETNA [100010801],,,76.8,,772.38,0.222255,85118.57664,percent of total billed charges,,,
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5ML ORAL SUSR,RX-2899,CDM,S5000,HCPCS,259,RC,99999-0002-77,NDC,outpatient,5,ML,50.87,35.609,AETNA [1000108],AETNA [100010801],,,76.8,,39.07,0.222255,85118.57664,percent of total billed charges,,,
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5ML ORAL SUSR,RX-2899,CDM,S5000,HCPCS,259,RC,75834-0295-01,NDC,outpatient,100,ML,494.4,346.08,AETNA [1000108],AETNA [100010801],,,76.8,,379.7,0.222255,85118.57664,percent of total billed charges,,,
METFORMIN HCL ER 500 MG ORAL TB24,RX-28995,CDM,S5000,HCPCS,259,RC,51224-0007-50,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
METFORMIN HCL ER 500 MG ORAL TB24,RX-28995,CDM,S5000,HCPCS,259,RC,70010-0491-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ALENDRONATE SODIUM 70 MG ORAL TABS,RX-29048,CDM,S5000,HCPCS,259,RC,16714-0633-01,NDC,outpatient,1,UN,2.67,1.869,AETNA [1000108],AETNA [100010801],,,76.8,,2.05,0.222255,85118.57664,percent of total billed charges,,,
ALENDRONATE SODIUM 35 MG ORAL TABS,RX-29072,CDM,S5000,HCPCS,259,RC,16714-0632-01,NDC,outpatient,1,UN,5.43,3.801,AETNA [1000108],AETNA [100010801],,,76.8,,4.17,0.222255,85118.57664,percent of total billed charges,,,
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,42192-0608-40,NDC,outpatient,6,ML,15.62,10.934,AETNA [1000108],AETNA [100010801],,,76.8,,12,0.222255,85118.57664,percent of total billed charges,,,
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,59762-5050-06,NDC,outpatient,6,ML,2.26,1.582,AETNA [1000108],AETNA [100010801],,,76.8,,1.74,0.222255,85118.57664,percent of total billed charges,,,
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,65162-0698-90,NDC,outpatient,473,ML,168.39,117.873,AETNA [1000108],AETNA [100010801],,,76.8,,129.32,0.222255,85118.57664,percent of total billed charges,,,
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,59762-5050-07,NDC,outpatient,470,ML,154.78,108.346,AETNA [1000108],AETNA [100010801],,,76.8,,118.87,0.222255,85118.57664,percent of total billed charges,,,
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,99999-0003-42,NDC,outpatient,6,ML,2.43,1.701,AETNA [1000108],AETNA [100010801],,,76.8,,1.87,0.222255,85118.57664,percent of total billed charges,,,
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,42192-0608-06,NDC,outpatient,6,ML,15.62,10.934,AETNA [1000108],AETNA [100010801],,,76.8,,12,0.222255,85118.57664,percent of total billed charges,,,
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,42192-0608-16,NDC,outpatient,470,ML,144.32,101.024,AETNA [1000108],AETNA [100010801],,,76.8,,110.84,0.222255,85118.57664,percent of total billed charges,,,
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,65162-0698-06,NDC,outpatient,6,ML,2.47,1.729,AETNA [1000108],AETNA [100010801],,,76.8,,1.9,0.222255,85118.57664,percent of total billed charges,,,
DILTIAZEM HCL ER COATED BEADS 120 MG ORAL CP24,RX-29270,CDM,S5000,HCPCS,259,RC,50742-0248-30,NDC,outpatient,1,UN,1.44,1.008,AETNA [1000108],AETNA [100010801],,,76.8,,1.11,0.222255,85118.57664,percent of total billed charges,,,
DILTIAZEM HCL ER COATED BEADS 120 MG ORAL CP24,RX-29270,CDM,S5000,HCPCS,259,RC,50742-0248-90,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
DILTIAZEM HCL ER COATED BEADS 120 MG ORAL CP24,RX-29270,CDM,S5000,HCPCS,259,RC,60687-0195-01,NDC,outpatient,1,UN,1.87,1.309,AETNA [1000108],AETNA [100010801],,,76.8,,1.44,0.222255,85118.57664,percent of total billed charges,,,
DILTIAZEM HCL ER COATED BEADS 120 MG ORAL CP24,RX-29270,CDM,S5000,HCPCS,259,RC,60687-0195-11,NDC,outpatient,1,UN,1.87,1.309,AETNA [1000108],AETNA [100010801],,,76.8,,1.44,0.222255,85118.57664,percent of total billed charges,,,
DILTIAZEM HCL ER COATED BEADS 120 MG ORAL CP24,RX-29270,CDM,S5000,HCPCS,259,RC,68682-0993-98,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
DILTIAZEM HCL ER COATED BEADS 180 MG ORAL CP24,RX-29272,CDM,S5000,HCPCS,259,RC,00904-7218-61,NDC,outpatient,1,UN,1.28,0.896,AETNA [1000108],AETNA [100010801],,,76.8,,0.98,0.222255,85118.57664,percent of total billed charges,,,
DILTIAZEM HCL ER COATED BEADS 180 MG ORAL CP24,RX-29272,CDM,S5000,HCPCS,259,RC,60687-0206-11,NDC,outpatient,1,UN,1.65,1.155,AETNA [1000108],AETNA [100010801],,,76.8,,1.27,0.222255,85118.57664,percent of total billed charges,,,
DILTIAZEM HCL ER COATED BEADS 180 MG ORAL CP24,RX-29272,CDM,S5000,HCPCS,259,RC,60687-0206-01,NDC,outpatient,1,UN,1.65,1.155,AETNA [1000108],AETNA [100010801],,,76.8,,1.27,0.222255,85118.57664,percent of total billed charges,,,
DILTIAZEM HCL ER COATED BEADS 180 MG ORAL CP24,RX-29272,CDM,S5000,HCPCS,259,RC,62037-0598-90,NDC,outpatient,1,UN,2.27,1.589,AETNA [1000108],AETNA [100010801],,,76.8,,1.74,0.222255,85118.57664,percent of total billed charges,,,
DILTIAZEM HCL ER COATED BEADS 240 MG ORAL CP24,RX-29274,CDM,S5000,HCPCS,259,RC,00904-7219-61,NDC,outpatient,1,UN,1.59,1.113,AETNA [1000108],AETNA [100010801],,,76.8,,1.22,0.222255,85118.57664,percent of total billed charges,,,
DILTIAZEM HCL ER COATED BEADS 240 MG ORAL CP24,RX-29274,CDM,S5000,HCPCS,259,RC,60687-0217-11,NDC,outpatient,1,UN,2.46,1.722,AETNA [1000108],AETNA [100010801],,,76.8,,1.89,0.222255,85118.57664,percent of total billed charges,,,
DILTIAZEM HCL ER COATED BEADS 240 MG ORAL CP24,RX-29274,CDM,S5000,HCPCS,259,RC,60687-0217-01,NDC,outpatient,1,UN,2.46,1.722,AETNA [1000108],AETNA [100010801],,,76.8,,1.89,0.222255,85118.57664,percent of total billed charges,,,
DILTIAZEM HCL ER COATED BEADS 300 MG ORAL CP24,RX-29276,CDM,S5000,HCPCS,259,RC,60687-0228-01,NDC,outpatient,1,UN,6.23,4.361,AETNA [1000108],AETNA [100010801],,,76.8,,4.78,0.222255,85118.57664,percent of total billed charges,,,
DILTIAZEM HCL ER COATED BEADS 300 MG ORAL CP24,RX-29276,CDM,S5000,HCPCS,259,RC,24979-0029-07,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
DILTIAZEM HCL ER COATED BEADS 300 MG ORAL CP24,RX-29276,CDM,S5000,HCPCS,259,RC,60687-0228-11,NDC,outpatient,1,UN,6.23,4.361,AETNA [1000108],AETNA [100010801],,,76.8,,4.78,0.222255,85118.57664,percent of total billed charges,,,
DOCOSANOL 10 % EX CREA,RX-29287,CDM,S5000,HCPCS,259,RC,00135-0300-01,NDC,outpatient,2,GR,72.76,50.932,AETNA [1000108],AETNA [100010801],,,76.8,,55.88,0.222255,85118.57664,percent of total billed charges,,,
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,00054-0079-28,NDC,outpatient,1,UN,1.72,1.204,AETNA [1000108],AETNA [100010801],,,76.8,,1.32,0.222255,85118.57664,percent of total billed charges,,,
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,50268-0102-11,NDC,outpatient,1,UN,5.8,4.06,AETNA [1000108],AETNA [100010801],,,76.8,,4.45,0.222255,85118.57664,percent of total billed charges,,,
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,50268-0102-13,NDC,outpatient,1,UN,5.8,4.06,AETNA [1000108],AETNA [100010801],,,76.8,,4.45,0.222255,85118.57664,percent of total billed charges,,,
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,60505-2575-07,NDC,outpatient,1,UN,1.09,0.763,AETNA [1000108],AETNA [100010801],,,76.8,,0.84,0.222255,85118.57664,percent of total billed charges,,,
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,65649-0101-02,NDC,outpatient,1,UN,26.86,18.802,AETNA [1000108],AETNA [100010801],,,76.8,,20.63,0.222255,85118.57664,percent of total billed charges,,,
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,72789-0149-69,NDC,outpatient,1,UN,1.89,1.323,AETNA [1000108],AETNA [100010801],,,76.8,,1.45,0.222255,85118.57664,percent of total billed charges,,,
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % EX CREA,RX-29424,CDM,S5000,HCPCS,259,RC,16714-0496-01,NDC,outpatient,15,GR,55.61,38.927,AETNA [1000108],AETNA [100010801],,,76.8,,42.71,0.222255,85118.57664,percent of total billed charges,,,
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % EX CREA,RX-29424,CDM,S5000,HCPCS,259,RC,00168-0258-15,NDC,outpatient,15,GR,71.29,49.903,AETNA [1000108],AETNA [100010801],,,76.8,,54.75,0.222255,85118.57664,percent of total billed charges,,,
NATEGLINIDE 60 MG ORAL TABS,RX-29437,CDM,S5000,HCPCS,259,RC,60687-0673-21,NDC,outpatient,1,UN,7.98,5.586,AETNA [1000108],AETNA [100010801],,,76.8,,6.13,0.222255,85118.57664,percent of total billed charges,,,
NATEGLINIDE 60 MG ORAL TABS,RX-29437,CDM,S5000,HCPCS,259,RC,60687-0673-11,NDC,outpatient,1,UN,7.98,5.586,AETNA [1000108],AETNA [100010801],,,76.8,,6.13,0.222255,85118.57664,percent of total billed charges,,,
MIRTAZAPINE 15 MG ORAL TBDP,RX-29531,CDM,S5000,HCPCS,259,RC,65862-0021-06,NDC,outpatient,1,UN,1.96,1.372,AETNA [1000108],AETNA [100010801],,,76.8,,1.51,0.222255,85118.57664,percent of total billed charges,,,
ZIPRASIDONE HCL 20 MG ORAL CAPS,RX-29778,CDM,S5000,HCPCS,259,RC,00904-6269-08,NDC,outpatient,1,UN,11.99,8.393,AETNA [1000108],AETNA [100010801],,,76.8,,9.21,0.222255,85118.57664,percent of total billed charges,,,
ZIPRASIDONE HCL 60 MG ORAL CAPS,RX-29780,CDM,S5000,HCPCS,259,RC,50268-0813-11,NDC,outpatient,1,UN,7.96,5.572,AETNA [1000108],AETNA [100010801],,,76.8,,6.11,0.222255,85118.57664,percent of total billed charges,,,
ZIPRASIDONE HCL 60 MG ORAL CAPS,RX-29780,CDM,S5000,HCPCS,259,RC,68084-0105-09,NDC,outpatient,1,UN,7.81,5.467,AETNA [1000108],AETNA [100010801],,,76.8,,6,0.222255,85118.57664,percent of total billed charges,,,
ZIPRASIDONE HCL 60 MG ORAL CAPS,RX-29780,CDM,S5000,HCPCS,259,RC,68084-0105-11,NDC,outpatient,1,UN,7.81,5.467,AETNA [1000108],AETNA [100010801],,,76.8,,6,0.222255,85118.57664,percent of total billed charges,,,
ZIPRASIDONE HCL 60 MG ORAL CAPS,RX-29780,CDM,S5000,HCPCS,259,RC,50268-0813-12,NDC,outpatient,1,UN,7.96,5.572,AETNA [1000108],AETNA [100010801],,,76.8,,6.11,0.222255,85118.57664,percent of total billed charges,,,
ZIPRASIDONE HCL 80 MG ORAL CAPS,RX-29781,CDM,S5000,HCPCS,259,RC,00781-2168-60,NDC,outpatient,1,UN,1.24,0.868,AETNA [1000108],AETNA [100010801],,,76.8,,0.95,0.222255,85118.57664,percent of total billed charges,,,
ZIPRASIDONE HCL 80 MG ORAL CAPS,RX-29781,CDM,S5000,HCPCS,259,RC,68084-0106-09,NDC,outpatient,1,UN,7.81,5.467,AETNA [1000108],AETNA [100010801],,,76.8,,6,0.222255,85118.57664,percent of total billed charges,,,
ZIPRASIDONE HCL 80 MG ORAL CAPS,RX-29781,CDM,S5000,HCPCS,259,RC,68084-0106-11,NDC,outpatient,1,UN,7.81,5.467,AETNA [1000108],AETNA [100010801],,,76.8,,6,0.222255,85118.57664,percent of total billed charges,,,
GALANTAMINE HYDROBROMIDE 4 MG ORAL TABS,RX-29806,CDM,S5000,HCPCS,259,RC,68084-0729-11,NDC,outpatient,1,UN,14.03,9.821,AETNA [1000108],AETNA [100010801],,,76.8,,10.78,0.222255,85118.57664,percent of total billed charges,,,
GALANTAMINE HYDROBROMIDE 4 MG ORAL TABS,RX-29806,CDM,S5000,HCPCS,259,RC,68084-0729-21,NDC,outpatient,1,UN,14.03,9.821,AETNA [1000108],AETNA [100010801],,,76.8,,10.78,0.222255,85118.57664,percent of total billed charges,,,
GALANTAMINE HYDROBROMIDE 4 MG ORAL TABS,RX-29806,CDM,S5000,HCPCS,259,RC,70436-0004-06,NDC,outpatient,1,UN,1.21,0.847,AETNA [1000108],AETNA [100010801],,,76.8,,0.93,0.222255,85118.57664,percent of total billed charges,,,
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,51079-0169-01,NDC,outpatient,1,UN,2.11,1.477,AETNA [1000108],AETNA [100010801],,,76.8,,1.62,0.222255,85118.57664,percent of total billed charges,,,
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,50742-0615-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,45963-0709-11,NDC,outpatient,1,UN,1.28,0.896,AETNA [1000108],AETNA [100010801],,,76.8,,0.98,0.222255,85118.57664,percent of total billed charges,,,
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,00904-6322-06,NDC,outpatient,1,UN,1.21,0.847,AETNA [1000108],AETNA [100010801],,,76.8,,0.93,0.222255,85118.57664,percent of total billed charges,,,
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,00904-6322-61,NDC,outpatient,1,UN,2.19,1.533,AETNA [1000108],AETNA [100010801],,,76.8,,1.68,0.222255,85118.57664,percent of total billed charges,,,
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,51079-0169-20,NDC,outpatient,1,UN,2.11,1.477,AETNA [1000108],AETNA [100010801],,,76.8,,1.62,0.222255,85118.57664,percent of total billed charges,,,
EYE STREAM OP SOLN,RX-2999,CDM,S5000,HCPCS,259,RC,00065-0530-01,NDC,outpatient,30,ML,81.97,57.379,AETNA [1000108],AETNA [100010801],,,76.8,,62.95,0.222255,85118.57664,percent of total billed charges,,,
METOPROLOL SUCCINATE ER 50 MG ORAL TAB,RX-30070,CDM,S5000,HCPCS,259,RC,00904-6323-61,NDC,outpatient,1,UN,2.29,1.603,AETNA [1000108],AETNA [100010801],,,76.8,,1.76,0.222255,85118.57664,percent of total billed charges,,,
METOPROLOL SUCCINATE ER 50 MG ORAL TAB,RX-30070,CDM,S5000,HCPCS,259,RC,51079-0170-20,NDC,outpatient,1,UN,1.9,1.33,AETNA [1000108],AETNA [100010801],,,76.8,,1.46,0.222255,85118.57664,percent of total billed charges,,,
METOPROLOL SUCCINATE ER 50 MG ORAL TAB,RX-30070,CDM,S5000,HCPCS,259,RC,51079-0170-01,NDC,outpatient,1,UN,1.9,1.33,AETNA [1000108],AETNA [100010801],,,76.8,,1.46,0.222255,85118.57664,percent of total billed charges,,,
METOPROLOL SUCCINATE ER 50 MG ORAL TAB,RX-30070,CDM,S5000,HCPCS,259,RC,68382-0565-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
METOPROLOL SUCCINATE ER 50 MG ORAL TAB,RX-30070,CDM,S5000,HCPCS,259,RC,50742-0616-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,50268-0542-11,NDC,outpatient,1,UN,2.35,1.645,AETNA [1000108],AETNA [100010801],,,76.8,,1.8,0.222255,85118.57664,percent of total billed charges,,,
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,50268-0542-15,NDC,outpatient,1,UN,2.35,1.645,AETNA [1000108],AETNA [100010801],,,76.8,,1.8,0.222255,85118.57664,percent of total billed charges,,,
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,51079-0171-03,NDC,outpatient,1,UN,5.81,4.067,AETNA [1000108],AETNA [100010801],,,76.8,,4.46,0.222255,85118.57664,percent of total billed charges,,,
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,51079-0171-01,NDC,outpatient,1,UN,5.81,4.067,AETNA [1000108],AETNA [100010801],,,76.8,,4.46,0.222255,85118.57664,percent of total billed charges,,,
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,60687-0413-01,NDC,outpatient,1,UN,3.08,2.156,AETNA [1000108],AETNA [100010801],,,76.8,,2.37,0.222255,85118.57664,percent of total billed charges,,,
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,00904-6324-61,NDC,outpatient,1,UN,2.66,1.862,AETNA [1000108],AETNA [100010801],,,76.8,,2.04,0.222255,85118.57664,percent of total billed charges,,,
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,60687-0413-11,NDC,outpatient,1,UN,3.08,2.156,AETNA [1000108],AETNA [100010801],,,76.8,,2.37,0.222255,85118.57664,percent of total billed charges,,,
VALGANCICLOVIR HCL 450 MG ORAL TABS,RX-30148,CDM,S5000,HCPCS,259,RC,63739-0357-33,NDC,outpatient,1,UN,93.6,65.52,AETNA [1000108],AETNA [100010801],,,76.8,,71.88,0.222255,85118.57664,percent of total billed charges,,,
VALGANCICLOVIR HCL 450 MG ORAL TABS,RX-30148,CDM,S5000,HCPCS,259,RC,68084-0965-25,NDC,outpatient,1,UN,121.31,84.917,AETNA [1000108],AETNA [100010801],,,76.8,,93.17,0.222255,85118.57664,percent of total billed charges,,,
VALGANCICLOVIR HCL 450 MG ORAL TABS,RX-30148,CDM,S5000,HCPCS,259,RC,68084-0965-95,NDC,outpatient,1,UN,121.31,84.917,AETNA [1000108],AETNA [100010801],,,76.8,,93.17,0.222255,85118.57664,percent of total billed charges,,,
CITALOPRAM HYDROBROMIDE 10 MG ORAL TABS,RX-30264,CDM,S5000,HCPCS,259,RC,00904-6084-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
OXCARBAZEPINE 300 MG/5ML ORAL SUSP,RX-30479,CDM,S5000,HCPCS,259,RC,68094-0123-62,NDC,outpatient,5,ML,23.66,16.562,AETNA [1000108],AETNA [100010801],,,76.8,,18.17,0.222255,85118.57664,percent of total billed charges,,,
OXCARBAZEPINE 300 MG/5ML ORAL SUSP,RX-30479,CDM,S5000,HCPCS,259,RC,00078-0357-52,NDC,outpatient,5,ML,39.3,27.51,AETNA [1000108],AETNA [100010801],,,76.8,,30.18,0.222255,85118.57664,percent of total billed charges,,,
OXCARBAZEPINE 300 MG/5ML ORAL SUSP,RX-30479,CDM,S5000,HCPCS,259,RC,99999-0002-25,NDC,outpatient,5,ML,33.09,23.163,AETNA [1000108],AETNA [100010801],,,76.8,,25.41,0.222255,85118.57664,percent of total billed charges,,,
OXCARBAZEPINE 300 MG/5ML ORAL SUSP,RX-30479,CDM,S5000,HCPCS,259,RC,68094-0123-59,NDC,outpatient,5,ML,23.66,16.562,AETNA [1000108],AETNA [100010801],,,76.8,,18.17,0.222255,85118.57664,percent of total billed charges,,,
MELATONIN 5 MG SL SUBL,RX-30511,CDM,S5000,HCPCS,259,RC,54629-0615-00,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
FERROUS SULFATE 325 (65 FE) MG ORAL TABS,RX-3074,CDM,S5000,HCPCS,259,RC,00904-7591-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
FERROUS SULFATE 325 (65 FE) MG ORAL TABS,RX-3074,CDM,S5000,HCPCS,259,RC,00904-7590-60,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
FERROUS SULFATE 325 (65 FE) MG ORAL TABS,RX-3074,CDM,S5000,HCPCS,259,RC,20555-0021-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,16714-0576-02,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,60687-0677-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,00904-7041-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,51079-0205-01,NDC,outpatient,1,UN,1.23,0.861,AETNA [1000108],AETNA [100010801],,,76.8,,0.94,0.222255,85118.57664,percent of total billed charges,,,
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,51079-0205-20,NDC,outpatient,1,UN,1.23,0.861,AETNA [1000108],AETNA [100010801],,,76.8,,0.94,0.222255,85118.57664,percent of total billed charges,,,
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,60687-0677-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,55111-0729-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ALLOPURINOL 300 MG ORAL TABS,RX-311,CDM,S5000,HCPCS,259,RC,51079-0206-20,NDC,outpatient,1,UN,1.68,1.176,AETNA [1000108],AETNA [100010801],,,76.8,,1.29,0.222255,85118.57664,percent of total billed charges,,,
ALLOPURINOL 300 MG ORAL TABS,RX-311,CDM,S5000,HCPCS,259,RC,00904-6572-61,NDC,outpatient,1,UN,1.71,1.197,AETNA [1000108],AETNA [100010801],,,76.8,,1.31,0.222255,85118.57664,percent of total billed charges,,,
ALLOPURINOL 300 MG ORAL TABS,RX-311,CDM,S5000,HCPCS,259,RC,51079-0206-01,NDC,outpatient,1,UN,1.68,1.176,AETNA [1000108],AETNA [100010801],,,76.8,,1.29,0.222255,85118.57664,percent of total billed charges,,,
FISH OIL 1000 MG ORAL CAPS,RX-3113,CDM,S5000,HCPCS,259,RC,77333-0308-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
FISH OIL 1000 MG ORAL CAPS,RX-3113,CDM,S5000,HCPCS,259,RC,77333-0308-25,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
AMOXICILLIN-POT CLAVULANATE 600-42.9 MG/5ML ORAL SUSR,RX-31177,CDM,S5000,HCPCS,259,RC,00143-9853-75,NDC,outpatient,75,ML,63.42,44.394,AETNA [1000108],AETNA [100010801],,,76.8,,48.71,0.222255,85118.57664,percent of total billed charges,,,
AMOXICILLIN-POT CLAVULANATE 600-42.9 MG/5ML ORAL SUSR,RX-31177,CDM,S5000,HCPCS,259,RC,99999-0002-82,NDC,outpatient,5,ML,8.55,5.985,AETNA [1000108],AETNA [100010801],,,76.8,,6.57,0.222255,85118.57664,percent of total billed charges,,,
VALSARTAN 160 MG ORAL TABS,RX-31210,CDM,S5000,HCPCS,259,RC,33342-0064-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
VALSARTAN 160 MG ORAL TABS,RX-31210,CDM,S5000,HCPCS,259,RC,60687-0634-01,NDC,outpatient,1,UN,4.62,3.234,AETNA [1000108],AETNA [100010801],,,76.8,,3.55,0.222255,85118.57664,percent of total billed charges,,,
VALSARTAN 160 MG ORAL TABS,RX-31210,CDM,S5000,HCPCS,259,RC,31722-0153-90,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
VALSARTAN 160 MG ORAL TABS,RX-31210,CDM,S5000,HCPCS,259,RC,60687-0634-11,NDC,outpatient,1,UN,4.62,3.234,AETNA [1000108],AETNA [100010801],,,76.8,,3.55,0.222255,85118.57664,percent of total billed charges,,,
BUDESONIDE 3 MG ORAL CPEP,RX-31576,CDM,S5000,HCPCS,259,RC,65162-0778-10,NDC,outpatient,1,UN,2.47,1.729,AETNA [1000108],AETNA [100010801],,,76.8,,1.9,0.222255,85118.57664,percent of total billed charges,,,
BUDESONIDE 3 MG ORAL CPEP,RX-31576,CDM,S5000,HCPCS,259,RC,00574-9855-10,NDC,outpatient,1,UN,2.52,1.764,AETNA [1000108],AETNA [100010801],,,76.8,,1.94,0.222255,85118.57664,percent of total billed charges,,,
ALBUTEROL SULFATE 0.63 MG/3ML IN NEBU,RX-31577,CDM,S5000,HCPCS,259,RC,00487-0301-01,NDC,outpatient,3,ML,2.43,1.701,AETNA [1000108],AETNA [100010801],,,76.8,,1.87,0.222255,85118.57664,percent of total billed charges,,,
ALBUTEROL SULFATE 0.63 MG/3ML IN NEBU,RX-31577,CDM,S5000,HCPCS,259,RC,76204-0010-55,NDC,outpatient,3,ML,1.98,1.386,AETNA [1000108],AETNA [100010801],,,76.8,,1.52,0.222255,85118.57664,percent of total billed charges,,,
ALBUTEROL SULFATE 1.25 MG/3ML IN NEBU,RX-31578,CDM,S5000,HCPCS,259,RC,00487-9904-01,NDC,outpatient,3,ML,2.43,1.701,AETNA [1000108],AETNA [100010801],,,76.8,,1.87,0.222255,85118.57664,percent of total billed charges,,,
ALBUTEROL SULFATE 1.25 MG/3ML IN NEBU,RX-31578,CDM,S5000,HCPCS,259,RC,00487-9904-25,NDC,outpatient,3,ML,2.43,1.701,AETNA [1000108],AETNA [100010801],,,76.8,,1.87,0.222255,85118.57664,percent of total billed charges,,,
AMPHETAMINE-DEXTROAMPHET ER 10 MG ORAL CP24,RX-31587,CDM,S5000,HCPCS,259,RC,00228-3059-11,NDC,outpatient,1,UN,12.55,8.785,AETNA [1000108],AETNA [100010801],,,76.8,,9.64,0.222255,85118.57664,percent of total billed charges,,,
AMPHETAMINE-DEXTROAMPHET ER 10 MG ORAL CP24,RX-31587,CDM,S5000,HCPCS,259,RC,64850-0511-01,NDC,outpatient,1,UN,2,1.4,AETNA [1000108],AETNA [100010801],,,76.8,,1.54,0.222255,85118.57664,percent of total billed charges,,,
AMPHETAMINE-DEXTROAMPHET ER 10 MG ORAL CP24,RX-31587,CDM,S5000,HCPCS,259,RC,70010-0030-01,NDC,outpatient,1,UN,3.45,2.415,AETNA [1000108],AETNA [100010801],,,76.8,,2.65,0.222255,85118.57664,percent of total billed charges,,,
UREA 40 % EX LOTN,RX-31683,CDM,S5000,HCPCS,259,RC,54295-0312-18,NDC,outpatient,226.8,GR,419.86,293.902,AETNA [1000108],AETNA [100010801],,,76.8,,322.45,0.222255,85118.57664,percent of total billed charges,,,
UREA 40 % EX LOTN,RX-31683,CDM,S5000,HCPCS,259,RC,81542-0201-08,NDC,outpatient,226.8,GR,454.17,317.919,AETNA [1000108],AETNA [100010801],,,76.8,,348.8,0.222255,85118.57664,percent of total billed charges,,,
TENOFOVIR DISOPROXIL FUMARATE 300 MG ORAL TABS,RX-31684,CDM,S5000,HCPCS,259,RC,61958-0401-01,NDC,outpatient,1,UN,180.36,126.252,AETNA [1000108],AETNA [100010801],,,76.8,,138.52,0.222255,85118.57664,percent of total billed charges,,,
FLUOCINONIDE 0.05 % EX CREA,RX-3187,CDM,S5000,HCPCS,259,RC,00093-0262-15,NDC,outpatient,15,GR,162.14,113.498,AETNA [1000108],AETNA [100010801],,,76.8,,124.52,0.222255,85118.57664,percent of total billed charges,,,
FLUOCINONIDE 0.05 % EX CREA,RX-3187,CDM,S5000,HCPCS,259,RC,51672-1386-01,NDC,outpatient,15,GR,35.32,24.724,AETNA [1000108],AETNA [100010801],,,76.8,,27.13,0.222255,85118.57664,percent of total billed charges,,,
FLUOCINONIDE 0.05 % EX OINT,RX-3189,CDM,S5000,HCPCS,259,RC,51672-1264-01,NDC,outpatient,15,GR,55.01,38.507,AETNA [1000108],AETNA [100010801],,,76.8,,42.25,0.222255,85118.57664,percent of total billed charges,,,
FLUOCINONIDE 0.05 % EX SOLN,RX-3190,CDM,S5000,HCPCS,259,RC,51672-1273-02,NDC,outpatient,20,ML,137.87,96.509,AETNA [1000108],AETNA [100010801],,,76.8,,105.88,0.222255,85118.57664,percent of total billed charges,,,
FLUOROMETHOLONE 0.1 % OP SUSP,RX-3208,CDM,S5000,HCPCS,259,RC,60758-0880-05,NDC,outpatient,5,ML,308.83,216.181,AETNA [1000108],AETNA [100010801],,,76.8,,237.18,0.222255,85118.57664,percent of total billed charges,,,
FLUPHENAZINE HCL 1 MG ORAL TABS,RX-3218,CDM,S5000,HCPCS,259,RC,00527-1788-01,NDC,outpatient,1,UN,6.6,4.62,AETNA [1000108],AETNA [100010801],,,76.8,,5.07,0.222255,85118.57664,percent of total billed charges,,,
FLUPHENAZINE HCL 2.5 MG ORAL TABS,RX-3220,CDM,S5000,HCPCS,259,RC,00527-1789-01,NDC,outpatient,1,UN,10.2,7.14,AETNA [1000108],AETNA [100010801],,,76.8,,7.83,0.222255,85118.57664,percent of total billed charges,,,
FLUPHENAZINE HCL 2.5 MG ORAL TABS,RX-3220,CDM,S5000,HCPCS,259,RC,70954-0274-10,NDC,outpatient,1,UN,2.47,1.729,AETNA [1000108],AETNA [100010801],,,76.8,,1.9,0.222255,85118.57664,percent of total billed charges,,,
FLUPHENAZINE HCL 5 MG ORAL TABS,RX-3221,CDM,S5000,HCPCS,259,RC,00527-1790-01,NDC,outpatient,1,UN,13.8,9.66,AETNA [1000108],AETNA [100010801],,,76.8,,10.6,0.222255,85118.57664,percent of total billed charges,,,
FLUPHENAZINE HCL 5 MG ORAL TABS,RX-3221,CDM,S5000,HCPCS,259,RC,69238-1680-01,NDC,outpatient,1,UN,6.45,4.515,AETNA [1000108],AETNA [100010801],,,76.8,,4.95,0.222255,85118.57664,percent of total billed charges,,,
FOLIC ACID 5 MG/ML IJ SOLN,RX-3232,CDM,S5000,HCPCS,250,RC,39822-1100-01,NDC,outpatient,0.2,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,,,
FOLIC ACID 5 MG/ML IJ SOLN,RX-3232,CDM,S5000,HCPCS,250,RC,63323-0184-10,NDC,outpatient,0.2,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,,,
FOLIC ACID 1 MG ORAL TABS,RX-3233,CDM,S5000,HCPCS,259,RC,00904-7224-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
FOLIC ACID 1 MG ORAL TABS,RX-3233,CDM,S5000,HCPCS,259,RC,60687-0681-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
FOLIC ACID 1 MG ORAL TABS,RX-3233,CDM,S5000,HCPCS,259,RC,60687-0681-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ALPRAZOLAM 0.25 MG ORAL TABS,RX-324,CDM,S5000,HCPCS,259,RC,00781-1061-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ALPRAZOLAM 0.25 MG ORAL TABS,RX-324,CDM,S5000,HCPCS,259,RC,65862-0676-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ALPRAZOLAM 0.5 MG ORAL TABS,RX-325,CDM,S5000,HCPCS,259,RC,00781-1077-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PAROXETINE HCL ER 12.5 MG ORAL TB24,RX-32631,CDM,S5000,HCPCS,259,RC,62175-0470-32,NDC,outpatient,1,UN,4.97,3.479,AETNA [1000108],AETNA [100010801],,,76.8,,3.82,0.222255,85118.57664,percent of total billed charges,,,
METHYLPHENIDATE HCL ER (OSM) 27 MG ORAL TBCR,RX-32654,CDM,S5000,HCPCS,259,RC,13811-0707-10,NDC,outpatient,1,UN,3.33,2.331,AETNA [1000108],AETNA [100010801],,,76.8,,2.56,0.222255,85118.57664,percent of total billed charges,,,
OLMESARTAN MEDOXOMIL 20 MG ORAL TABS,RX-32762,CDM,S5000,HCPCS,259,RC,00713-0861-30,NDC,outpatient,1,UN,39.98,27.986,AETNA [1000108],AETNA [100010801],,,76.8,,30.7,0.222255,85118.57664,percent of total billed charges,,,
OLMESARTAN MEDOXOMIL 20 MG ORAL TABS,RX-32762,CDM,S5000,HCPCS,259,RC,33342-0179-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
OLMESARTAN MEDOXOMIL 20 MG ORAL TABS,RX-32762,CDM,S5000,HCPCS,259,RC,68462-0437-30,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
RISEDRONATE SODIUM 35 MG ORAL TABS,RX-32895,CDM,S5000,HCPCS,259,RC,33342-0109-50,NDC,outpatient,1,UN,18.52,12.964,AETNA [1000108],AETNA [100010801],,,76.8,,14.22,0.222255,85118.57664,percent of total billed charges,,,
FUROSEMIDE 10 MG/ML ORAL SOLN,RX-3292,CDM,S5000,HCPCS,259,RC,68094-0756-59,NDC,outpatient,4,ML,7.04,4.928,AETNA [1000108],AETNA [100010801],,,76.8,,5.41,0.222255,85118.57664,percent of total billed charges,,,
FUROSEMIDE 10 MG/ML ORAL SOLN,RX-3292,CDM,S5000,HCPCS,259,RC,68094-0756-62,NDC,outpatient,4,ML,7.04,4.928,AETNA [1000108],AETNA [100010801],,,76.8,,5.41,0.222255,85118.57664,percent of total billed charges,,,
FUROSEMIDE 8 MG/ML ORAL SOLN,RX-3293,CDM,S5000,HCPCS,259,RC,68094-0867-59,NDC,outpatient,5,ML,7.04,4.928,AETNA [1000108],AETNA [100010801],,,76.8,,5.41,0.222255,85118.57664,percent of total billed charges,,,
FUROSEMIDE 8 MG/ML ORAL SOLN,RX-3293,CDM,S5000,HCPCS,259,RC,68094-0867-62,NDC,outpatient,5,ML,7.04,4.928,AETNA [1000108],AETNA [100010801],,,76.8,,5.41,0.222255,85118.57664,percent of total billed charges,,,
FUROSEMIDE 20 MG ORAL TABS,RX-3294,CDM,S5000,HCPCS,259,RC,00054-8297-25,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
FUROSEMIDE 20 MG ORAL TABS,RX-3294,CDM,S5000,HCPCS,259,RC,00904-7177-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
FUROSEMIDE 40 MG ORAL TABS,RX-3295,CDM,S5000,HCPCS,259,RC,51079-0073-20,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
FUROSEMIDE 40 MG ORAL TABS,RX-3295,CDM,S5000,HCPCS,259,RC,51079-0073-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
FUROSEMIDE 80 MG ORAL TABS,RX-3296,CDM,S5000,HCPCS,259,RC,00054-8301-25,NDC,outpatient,1,UN,2.07,1.449,AETNA [1000108],AETNA [100010801],,,76.8,,1.59,0.222255,85118.57664,percent of total billed charges,,,
FUROSEMIDE 80 MG ORAL TABS,RX-3296,CDM,S5000,HCPCS,259,RC,51079-0527-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
FUROSEMIDE 80 MG ORAL TABS,RX-3296,CDM,S5000,HCPCS,259,RC,51079-0527-20,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
AMPHETAMINE-DEXTROAMPHET ER 5 MG ORAL CP24,RX-33005,CDM,S5000,HCPCS,259,RC,54092-0381-01,NDC,outpatient,1,UN,29.29,20.503,AETNA [1000108],AETNA [100010801],,,76.8,,22.49,0.222255,85118.57664,percent of total billed charges,,,
VORICONAZOLE 200 MG ORAL TABS,RX-33009,CDM,S5000,HCPCS,259,RC,00904-7024-04,NDC,outpatient,1,UN,43.81,30.667,AETNA [1000108],AETNA [100010801],,,76.8,,33.65,0.222255,85118.57664,percent of total billed charges,,,
AMOXICILLIN-POT CLAVULANATE 500-125 MG ORAL TABS,RX-33227,CDM,S5000,HCPCS,259,RC,00781-1831-01,NDC,outpatient,1,UN,1.59,1.113,AETNA [1000108],AETNA [100010801],,,76.8,,1.22,0.222255,85118.57664,percent of total billed charges,,,
AMOXICILLIN-POT CLAVULANATE 875-125 MG ORAL TABS,RX-33228,CDM,S5000,HCPCS,259,RC,42571-0162-01,NDC,outpatient,1,UN,2.67,1.869,AETNA [1000108],AETNA [100010801],,,76.8,,2.05,0.222255,85118.57664,percent of total billed charges,,,
AMOXICILLIN-POT CLAVULANATE 875-125 MG ORAL TABS,RX-33228,CDM,S5000,HCPCS,259,RC,65862-0503-01,NDC,outpatient,1,UN,2.34,1.638,AETNA [1000108],AETNA [100010801],,,76.8,,1.8,0.222255,85118.57664,percent of total billed charges,,,
AMOXICILLIN-POT CLAVULANATE 875-125 MG ORAL TABS,RX-33228,CDM,S5000,HCPCS,259,RC,65862-0503-20,NDC,outpatient,1,UN,1.87,1.309,AETNA [1000108],AETNA [100010801],,,76.8,,1.44,0.222255,85118.57664,percent of total billed charges,,,
AMOXICILLIN-POT CLAVULANATE 875-125 MG ORAL TABS,RX-33228,CDM,S5000,HCPCS,259,RC,00143-9249-20,NDC,outpatient,1,UN,5.26,3.682,AETNA [1000108],AETNA [100010801],,,76.8,,4.04,0.222255,85118.57664,percent of total billed charges,,,
ESCITALOPRAM OXALATE 10 MG ORAL TABS,RX-33512,CDM,S5000,HCPCS,259,RC,68084-0617-01,NDC,outpatient,1,UN,1.04,0.728,AETNA [1000108],AETNA [100010801],,,76.8,,0.8,0.222255,85118.57664,percent of total billed charges,,,
ESCITALOPRAM OXALATE 10 MG ORAL TABS,RX-33512,CDM,S5000,HCPCS,259,RC,00904-6426-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ESCITALOPRAM OXALATE 10 MG ORAL TABS,RX-33512,CDM,S5000,HCPCS,259,RC,68084-0617-11,NDC,outpatient,1,UN,1.04,0.728,AETNA [1000108],AETNA [100010801],,,76.8,,0.8,0.222255,85118.57664,percent of total billed charges,,,
VALSARTAN 40 MG ORAL TABS,RX-33541,CDM,S5000,HCPCS,259,RC,31722-0151-30,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
VALSARTAN 40 MG ORAL TABS,RX-33541,CDM,S5000,HCPCS,259,RC,60687-0612-21,NDC,outpatient,1,UN,3.18,2.226,AETNA [1000108],AETNA [100010801],,,76.8,,2.44,0.222255,85118.57664,percent of total billed charges,,,
VALSARTAN 40 MG ORAL TABS,RX-33541,CDM,S5000,HCPCS,259,RC,60687-0612-11,NDC,outpatient,1,UN,3.18,2.226,AETNA [1000108],AETNA [100010801],,,76.8,,2.44,0.222255,85118.57664,percent of total billed charges,,,
GEMFIBROZIL 600 MG ORAL TABS,RX-3378,CDM,S5000,HCPCS,259,RC,60687-0224-11,NDC,outpatient,1,UN,1.15,0.805,AETNA [1000108],AETNA [100010801],,,76.8,,0.88,0.222255,85118.57664,percent of total billed charges,,,
GEMFIBROZIL 600 MG ORAL TABS,RX-3378,CDM,S5000,HCPCS,259,RC,60687-0224-01,NDC,outpatient,1,UN,1.15,0.805,AETNA [1000108],AETNA [100010801],,,76.8,,0.88,0.222255,85118.57664,percent of total billed charges,,,
METAXALONE 800 MG ORAL TABS,RX-33963,CDM,S5000,HCPCS,259,RC,00527-1435-01,NDC,outpatient,1,UN,2.54,1.778,AETNA [1000108],AETNA [100010801],,,76.8,,1.95,0.222255,85118.57664,percent of total billed charges,,,
DUTASTERIDE 0.5 MG ORAL CAPS,RX-34089,CDM,S5000,HCPCS,259,RC,42806-0549-09,NDC,outpatient,1,UN,1.7,1.19,AETNA [1000108],AETNA [100010801],,,76.8,,1.31,0.222255,85118.57664,percent of total billed charges,,,
EZETIMIBE 10 MG ORAL TABS,RX-34153,CDM,S5000,HCPCS,259,RC,51660-0200-90,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
EZETIMIBE 10 MG ORAL TABS,RX-34153,CDM,S5000,HCPCS,259,RC,60687-0373-21,NDC,outpatient,1,UN,18.75,13.125,AETNA [1000108],AETNA [100010801],,,76.8,,14.4,0.222255,85118.57664,percent of total billed charges,,,
EZETIMIBE 10 MG ORAL TABS,RX-34153,CDM,S5000,HCPCS,259,RC,00904-7103-04,NDC,outpatient,1,UN,18.36,12.852,AETNA [1000108],AETNA [100010801],,,76.8,,14.1,0.222255,85118.57664,percent of total billed charges,,,
EZETIMIBE 10 MG ORAL TABS,RX-34153,CDM,S5000,HCPCS,259,RC,60687-0373-11,NDC,outpatient,1,UN,18.75,13.125,AETNA [1000108],AETNA [100010801],,,76.8,,14.4,0.222255,85118.57664,percent of total billed charges,,,
GENTAMICIN SULFATE 0.1 % EX CREA,RX-3423,CDM,S5000,HCPCS,259,RC,45802-0056-35,NDC,outpatient,15,GR,170.02,119.014,AETNA [1000108],AETNA [100010801],,,76.8,,130.58,0.222255,85118.57664,percent of total billed charges,,,
GENTAMICIN SULFATE 0.1 % EX OINT,RX-3424,CDM,S5000,HCPCS,259,RC,45802-0046-35,NDC,outpatient,15,GR,132.44,92.708,AETNA [1000108],AETNA [100010801],,,76.8,,101.71,0.222255,85118.57664,percent of total billed charges,,,
GENTAMICIN SULFATE 0.3 % OP SOLN,RX-3428,CDM,S5000,HCPCS,259,RC,24208-0580-60,NDC,outpatient,5,ML,23.41,16.387,AETNA [1000108],AETNA [100010801],,,76.8,,17.98,0.222255,85118.57664,percent of total billed charges,,,
GENTAMICIN SULFATE 0.3 % OP SOLN,RX-3428,CDM,S5000,HCPCS,259,RC,61314-0633-05,NDC,outpatient,5,ML,21.99,15.393,AETNA [1000108],AETNA [100010801],,,76.8,,16.89,0.222255,85118.57664,percent of total billed charges,,,
ARIPIPRAZOLE 10 MG ORAL TABS,RX-34369,CDM,S5000,HCPCS,259,RC,60687-0179-01,NDC,outpatient,1,UN,22.5,15.75,AETNA [1000108],AETNA [100010801],,,76.8,,17.28,0.222255,85118.57664,percent of total billed charges,,,
ARIPIPRAZOLE 10 MG ORAL TABS,RX-34369,CDM,S5000,HCPCS,259,RC,60687-0179-11,NDC,outpatient,1,UN,22.5,15.75,AETNA [1000108],AETNA [100010801],,,76.8,,17.28,0.222255,85118.57664,percent of total billed charges,,,
ARIPIPRAZOLE 15 MG ORAL TABS,RX-34370,CDM,S5000,HCPCS,259,RC,27241-0054-03,NDC,outpatient,1,UN,2.88,2.016,AETNA [1000108],AETNA [100010801],,,76.8,,2.21,0.222255,85118.57664,percent of total billed charges,,,
ARIPIPRAZOLE 15 MG ORAL TABS,RX-34370,CDM,S5000,HCPCS,259,RC,60687-0191-11,NDC,outpatient,1,UN,27.24,19.068,AETNA [1000108],AETNA [100010801],,,76.8,,20.92,0.222255,85118.57664,percent of total billed charges,,,
ARIPIPRAZOLE 15 MG ORAL TABS,RX-34370,CDM,S5000,HCPCS,259,RC,60687-0191-21,NDC,outpatient,1,UN,27.24,19.068,AETNA [1000108],AETNA [100010801],,,76.8,,20.92,0.222255,85118.57664,percent of total billed charges,,,
ARIPIPRAZOLE 15 MG ORAL TABS,RX-34370,CDM,S5000,HCPCS,259,RC,63739-0078-33,NDC,outpatient,1,UN,22.38,15.666,AETNA [1000108],AETNA [100010801],,,76.8,,17.19,0.222255,85118.57664,percent of total billed charges,,,
DIVALPROEX SODIUM ER 250 MG ORAL TB24,RX-34418,CDM,S5000,HCPCS,259,RC,68084-0310-11,NDC,outpatient,1,UN,2.75,1.925,AETNA [1000108],AETNA [100010801],,,76.8,,2.11,0.222255,85118.57664,percent of total billed charges,,,
DIVALPROEX SODIUM ER 250 MG ORAL TB24,RX-34418,CDM,S5000,HCPCS,259,RC,68084-0310-01,NDC,outpatient,1,UN,2.75,1.925,AETNA [1000108],AETNA [100010801],,,76.8,,2.11,0.222255,85118.57664,percent of total billed charges,,,
ATOMOXETINE HCL 10 MG ORAL CAPS,RX-34444,CDM,S5000,HCPCS,259,RC,31722-0714-30,NDC,outpatient,1,UN,8.16,5.712,AETNA [1000108],AETNA [100010801],,,76.8,,6.27,0.222255,85118.57664,percent of total billed charges,,,
ATOMOXETINE HCL 10 MG ORAL CAPS,RX-34444,CDM,S5000,HCPCS,259,RC,55111-0519-30,NDC,outpatient,1,UN,7.25,5.075,AETNA [1000108],AETNA [100010801],,,76.8,,5.57,0.222255,85118.57664,percent of total billed charges,,,
ATOMOXETINE HCL 10 MG ORAL CAPS,RX-34444,CDM,S5000,HCPCS,259,RC,68462-0265-30,NDC,outpatient,1,UN,4.5,3.15,AETNA [1000108],AETNA [100010801],,,76.8,,3.46,0.222255,85118.57664,percent of total billed charges,,,
ATOMOXETINE HCL 10 MG ORAL CAPS,RX-34444,CDM,S5000,HCPCS,259,RC,35573-0415-30,NDC,outpatient,1,UN,14,9.8,AETNA [1000108],AETNA [100010801],,,76.8,,10.75,0.222255,85118.57664,percent of total billed charges,,,
ATOMOXETINE HCL 25 MG ORAL CAPS,RX-34446,CDM,S5000,HCPCS,259,RC,16714-0757-01,NDC,outpatient,1,UN,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,,,
ATOMOXETINE HCL 25 MG ORAL CAPS,RX-34446,CDM,S5000,HCPCS,259,RC,64980-0375-03,NDC,outpatient,1,UN,7.25,5.075,AETNA [1000108],AETNA [100010801],,,76.8,,5.57,0.222255,85118.57664,percent of total billed charges,,,
ATOMOXETINE HCL 40 MG ORAL CAPS,RX-34447,CDM,S5000,HCPCS,259,RC,00093-3545-56,NDC,outpatient,1,UN,17.9,12.53,AETNA [1000108],AETNA [100010801],,,76.8,,13.75,0.222255,85118.57664,percent of total billed charges,,,
ATOMOXETINE HCL 40 MG ORAL CAPS,RX-34447,CDM,S5000,HCPCS,259,RC,60687-0326-95,NDC,outpatient,1,UN,14.68,10.276,AETNA [1000108],AETNA [100010801],,,76.8,,11.27,0.222255,85118.57664,percent of total billed charges,,,
ATOMOXETINE HCL 40 MG ORAL CAPS,RX-34447,CDM,S5000,HCPCS,259,RC,68462-0268-30,NDC,outpatient,1,UN,2.91,2.037,AETNA [1000108],AETNA [100010801],,,76.8,,2.23,0.222255,85118.57664,percent of total billed charges,,,
ATOMOXETINE HCL 40 MG ORAL CAPS,RX-34447,CDM,S5000,HCPCS,259,RC,60687-0326-25,NDC,outpatient,1,UN,14.68,10.276,AETNA [1000108],AETNA [100010801],,,76.8,,11.27,0.222255,85118.57664,percent of total billed charges,,,
HYDROCODONE-ACETAMINOPHEN 5-325 MG ORAL TABS,RX-34505,CDM,S5000,HCPCS,259,RC,00406-0123-23,NDC,outpatient,1,UN,1.5,1.05,AETNA [1000108],AETNA [100010801],,,76.8,,1.15,0.222255,85118.57664,percent of total billed charges,,,
HYDROCODONE-ACETAMINOPHEN 5-325 MG ORAL TABS,RX-34505,CDM,S5000,HCPCS,259,RC,00406-0123-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
HYDROCODONE-ACETAMINOPHEN 5-325 MG ORAL TABS,RX-34505,CDM,S5000,HCPCS,259,RC,00406-0123-62,NDC,outpatient,1,UN,1.5,1.05,AETNA [1000108],AETNA [100010801],,,76.8,,1.15,0.222255,85118.57664,percent of total billed charges,,,
BUPRENORPHINE HCL 2 MG SL SUBL,RX-34711,CDM,S5000,HCPCS,259,RC,60687-0481-11,NDC,outpatient,1,UN,6.96,4.872,AETNA [1000108],AETNA [100010801],,,76.8,,5.35,0.222255,85118.57664,percent of total billed charges,,,
BUPRENORPHINE HCL 2 MG SL SUBL,RX-34711,CDM,S5000,HCPCS,259,RC,60687-0481-21,NDC,outpatient,1,UN,6.96,4.872,AETNA [1000108],AETNA [100010801],,,76.8,,5.35,0.222255,85118.57664,percent of total billed charges,,,
BUPRENORPHINE HCL 8 MG SL SUBL,RX-34712,CDM,S5000,HCPCS,259,RC,60687-0492-21,NDC,outpatient,1,UN,11.98,8.386,AETNA [1000108],AETNA [100010801],,,76.8,,9.2,0.222255,85118.57664,percent of total billed charges,,,
BUPRENORPHINE HCL 8 MG SL SUBL,RX-34712,CDM,S5000,HCPCS,259,RC,42858-0502-03,NDC,outpatient,1,UN,2.47,1.729,AETNA [1000108],AETNA [100010801],,,76.8,,1.9,0.222255,85118.57664,percent of total billed charges,,,
BUPRENORPHINE HCL 8 MG SL SUBL,RX-34712,CDM,S5000,HCPCS,259,RC,60687-0492-11,NDC,outpatient,1,UN,11.98,8.386,AETNA [1000108],AETNA [100010801],,,76.8,,9.2,0.222255,85118.57664,percent of total billed charges,,,
BUPRENORPHINE HCL-NALOXONE HCL 2-0.5 MG SL SUBL,RX-34713,CDM,S5000,HCPCS,259,RC,00054-0188-13,NDC,outpatient,1,UN,2.47,1.729,AETNA [1000108],AETNA [100010801],,,76.8,,1.9,0.222255,85118.57664,percent of total billed charges,,,
BUPRENORPHINE HCL-NALOXONE HCL 2-0.5 MG SL SUBL,RX-34713,CDM,S5000,HCPCS,259,RC,65162-0416-03,NDC,outpatient,1,UN,2.45,1.715,AETNA [1000108],AETNA [100010801],,,76.8,,1.88,0.222255,85118.57664,percent of total billed charges,,,
BUPRENORPHINE HCL-NALOXONE HCL 8-2 MG SL SUBL,RX-34714,CDM,S5000,HCPCS,259,RC,50268-0145-15,NDC,outpatient,1,UN,14.96,10.472,AETNA [1000108],AETNA [100010801],,,76.8,,11.49,0.222255,85118.57664,percent of total billed charges,,,
BUPRENORPHINE HCL-NALOXONE HCL 8-2 MG SL SUBL,RX-34714,CDM,S5000,HCPCS,259,RC,50268-0145-11,NDC,outpatient,1,UN,14.96,10.472,AETNA [1000108],AETNA [100010801],,,76.8,,11.49,0.222255,85118.57664,percent of total billed charges,,,
BUPRENORPHINE HCL-NALOXONE HCL 8-2 MG SL SUBL,RX-34714,CDM,S5000,HCPCS,259,RC,42858-0602-03,NDC,outpatient,1,UN,27,18.9,AETNA [1000108],AETNA [100010801],,,76.8,,20.74,0.222255,85118.57664,percent of total billed charges,,,
NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SOLN,RX-34814,CDM,S5000,HCPCS,259,RC,24208-0631-10,NDC,outpatient,10,ML,205.06,143.542,AETNA [1000108],AETNA [100010801],,,76.8,,157.49,0.222255,85118.57664,percent of total billed charges,,,
NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SOLN,RX-34814,CDM,S5000,HCPCS,259,RC,61314-0646-10,NDC,outpatient,10,ML,188.28,131.796,AETNA [1000108],AETNA [100010801],,,76.8,,144.6,0.222255,85118.57664,percent of total billed charges,,,
ROSUVASTATIN CALCIUM 10 MG ORAL TABS,RX-35134,CDM,S5000,HCPCS,259,RC,00904-6779-61,NDC,outpatient,1,UN,3.97,2.779,AETNA [1000108],AETNA [100010801],,,76.8,,3.05,0.222255,85118.57664,percent of total billed charges,,,
ROSUVASTATIN CALCIUM 10 MG ORAL TABS,RX-35134,CDM,S5000,HCPCS,259,RC,60687-0245-01,NDC,outpatient,1,UN,4.01,2.807,AETNA [1000108],AETNA [100010801],,,76.8,,3.08,0.222255,85118.57664,percent of total billed charges,,,
ROSUVASTATIN CALCIUM 10 MG ORAL TABS,RX-35134,CDM,S5000,HCPCS,259,RC,60687-0245-11,NDC,outpatient,1,UN,4.01,2.807,AETNA [1000108],AETNA [100010801],,,76.8,,3.08,0.222255,85118.57664,percent of total billed charges,,,
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,50268-0710-11,NDC,outpatient,1,UN,2.29,1.603,AETNA [1000108],AETNA [100010801],,,76.8,,1.76,0.222255,85118.57664,percent of total billed charges,,,
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,00904-6780-61,NDC,outpatient,1,UN,3.57,2.499,AETNA [1000108],AETNA [100010801],,,76.8,,2.74,0.222255,85118.57664,percent of total billed charges,,,
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,50268-0710-15,NDC,outpatient,1,UN,2.29,1.603,AETNA [1000108],AETNA [100010801],,,76.8,,1.76,0.222255,85118.57664,percent of total billed charges,,,
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,60687-0256-01,NDC,outpatient,1,UN,5.36,3.752,AETNA [1000108],AETNA [100010801],,,76.8,,4.12,0.222255,85118.57664,percent of total billed charges,,,
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,60687-0256-11,NDC,outpatient,1,UN,5.36,3.752,AETNA [1000108],AETNA [100010801],,,76.8,,4.12,0.222255,85118.57664,percent of total billed charges,,,
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,16714-0990-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
CYCLOSPORINE 0.05 % OP EMUL,RX-35209,CDM,S5000,HCPCS,259,RC,00023-9163-30,NDC,outpatient,1,UN,44.22,30.954,AETNA [1000108],AETNA [100010801],,,76.8,,33.96,0.222255,85118.57664,percent of total billed charges,,,
ALUMINUM HYDROXIDE GEL 320 MG/5ML ORAL SUSP,RX-353,CDM,S5000,HCPCS,259,RC,00536-0091-85,NDC,outpatient,5,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ALUMINUM HYDROXIDE GEL 320 MG/5ML ORAL SUSP,RX-353,CDM,S5000,HCPCS,259,RC,99999-0002-48,NDC,outpatient,30,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
GRISEOFULVIN ULTRAMICROSIZE 250 MG ORAL TABS,RX-3536,CDM,S5000,HCPCS,259,RC,00115-1725-01,NDC,outpatient,1,UN,20.98,14.686,AETNA [1000108],AETNA [100010801],,,76.8,,16.11,0.222255,85118.57664,percent of total billed charges,,,
OXYBUTYNIN 3.9 MG/24HR TD PTTW,RX-35495,CDM,S5000,HCPCS,259,RC,00023-6153-01,NDC,outpatient,1,UN,349.43,244.601,AETNA [1000108],AETNA [100010801],,,76.8,,268.36,0.222255,85118.57664,percent of total billed charges,,,
OXYBUTYNIN 3.9 MG/24HR TD PTTW,RX-35495,CDM,S5000,HCPCS,259,RC,00023-6153-08,NDC,outpatient,1,UN,349.43,244.601,AETNA [1000108],AETNA [100010801],,,76.8,,268.36,0.222255,85118.57664,percent of total billed charges,,,
OXYBUTYNIN 3.9 MG/24HR TD PTTW,RX-35495,CDM,S5000,HCPCS,259,RC,00023-9637-08,NDC,outpatient,1,UN,10.21,7.147,AETNA [1000108],AETNA [100010801],,,76.8,,7.84,0.222255,85118.57664,percent of total billed charges,,,
OXYBUTYNIN 3.9 MG/24HR TD PTTW,RX-35495,CDM,S5000,HCPCS,259,RC,00023-9637-01,NDC,outpatient,1,UN,10.21,7.147,AETNA [1000108],AETNA [100010801],,,76.8,,7.84,0.222255,85118.57664,percent of total billed charges,,,
RISPERIDONE 0.5 MG ORAL TBDP,RX-35686,CDM,S5000,HCPCS,259,RC,49884-0311-55,NDC,outpatient,1,UN,2.41,1.687,AETNA [1000108],AETNA [100010801],,,76.8,,1.85,0.222255,85118.57664,percent of total billed charges,,,
RISPERIDONE 0.5 MG ORAL TBDP,RX-35686,CDM,S5000,HCPCS,259,RC,49884-0311-52,NDC,outpatient,1,UN,2.41,1.687,AETNA [1000108],AETNA [100010801],,,76.8,,1.85,0.222255,85118.57664,percent of total billed charges,,,
RISPERIDONE 1 MG ORAL TBDP,RX-35687,CDM,S5000,HCPCS,259,RC,49884-0315-52,NDC,outpatient,1,UN,2.77,1.939,AETNA [1000108],AETNA [100010801],,,76.8,,2.13,0.222255,85118.57664,percent of total billed charges,,,
RISPERIDONE 1 MG ORAL TBDP,RX-35687,CDM,S5000,HCPCS,259,RC,49884-0315-55,NDC,outpatient,1,UN,2.77,1.939,AETNA [1000108],AETNA [100010801],,,76.8,,2.13,0.222255,85118.57664,percent of total billed charges,,,
MOXIFLOXACIN HCL 0.5 % OP SOLN,RX-35699,CDM,S5000,HCPCS,259,RC,00832-1410-03,NDC,outpatient,3,ML,113.88,79.716,AETNA [1000108],AETNA [100010801],,,76.8,,87.46,0.222255,85118.57664,percent of total billed charges,,,
MOXIFLOXACIN HCL 0.5 % OP SOLN,RX-35699,CDM,S5000,HCPCS,259,RC,72266-0158-01,NDC,outpatient,3,ML,45.03,31.521,AETNA [1000108],AETNA [100010801],,,76.8,,34.58,0.222255,85118.57664,percent of total billed charges,,,
METFORMIN HCL ER 750 MG ORAL TB24,RX-35771,CDM,S5000,HCPCS,259,RC,62756-0143-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
METFORMIN HCL ER 750 MG ORAL TB24,RX-35771,CDM,S5000,HCPCS,259,RC,67877-0414-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
METFORMIN HCL ER 750 MG ORAL TB24,RX-35771,CDM,S5000,HCPCS,259,RC,70010-0492-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
HALOPERIDOL 0.5 MG ORAL TABS,RX-3578,CDM,S5000,HCPCS,259,RC,51079-0733-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
HALOPERIDOL 0.5 MG ORAL TABS,RX-3578,CDM,S5000,HCPCS,259,RC,51079-0733-20,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
HALOPERIDOL 2 MG ORAL TABS,RX-3581,CDM,S5000,HCPCS,259,RC,00832-1530-11,NDC,outpatient,1,UN,1.81,1.267,AETNA [1000108],AETNA [100010801],,,76.8,,1.39,0.222255,85118.57664,percent of total billed charges,,,
HALOPERIDOL 2 MG ORAL TABS,RX-3581,CDM,S5000,HCPCS,259,RC,00378-0214-01,NDC,outpatient,1,UN,2.45,1.715,AETNA [1000108],AETNA [100010801],,,76.8,,1.88,0.222255,85118.57664,percent of total billed charges,,,
HALOPERIDOL 5 MG ORAL TABS,RX-3583,CDM,S5000,HCPCS,259,RC,51079-0736-20,NDC,outpatient,1,UN,1.41,0.987,AETNA [1000108],AETNA [100010801],,,76.8,,1.08,0.222255,85118.57664,percent of total billed charges,,,
HALOPERIDOL 5 MG ORAL TABS,RX-3583,CDM,S5000,HCPCS,259,RC,51079-0736-01,NDC,outpatient,1,UN,1.41,0.987,AETNA [1000108],AETNA [100010801],,,76.8,,1.08,0.222255,85118.57664,percent of total billed charges,,,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONC,RX-3585,CDM,S5000,HCPCS,259,RC,54838-0501-15,NDC,outpatient,0.5,ML,2.5,1.75,AETNA [1000108],AETNA [100010801],,,76.8,,1.92,0.222255,85118.57664,percent of total billed charges,,,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONC,RX-3585,CDM,S5000,HCPCS,259,RC,99999-0003-09,NDC,outpatient,0.5,ML,2.5,1.75,AETNA [1000108],AETNA [100010801],,,76.8,,1.92,0.222255,85118.57664,percent of total billed charges,,,
POTASSIUM CHLORIDE CRYS ER 10 MEQ ORAL TBCR,RX-35942,CDM,S5000,HCPCS,259,RC,63739-0972-10,NDC,outpatient,1,UN,1.14,0.798,AETNA [1000108],AETNA [100010801],,,76.8,,0.88,0.222255,85118.57664,percent of total billed charges,,,
POTASSIUM CHLORIDE CRYS ER 10 MEQ ORAL TBCR,RX-35942,CDM,S5000,HCPCS,259,RC,00245-5317-89,NDC,outpatient,1,UN,1.08,0.756,AETNA [1000108],AETNA [100010801],,,76.8,,0.83,0.222255,85118.57664,percent of total billed charges,,,
POTASSIUM CHLORIDE CRYS ER 10 MEQ ORAL TBCR,RX-35942,CDM,S5000,HCPCS,259,RC,00245-5317-01,NDC,outpatient,1,UN,1.08,0.756,AETNA [1000108],AETNA [100010801],,,76.8,,0.83,0.222255,85118.57664,percent of total billed charges,,,
POTASSIUM CHLORIDE CRYS ER 20 MEQ ORAL TBCR,RX-35943,CDM,S5000,HCPCS,259,RC,00245-5319-89,NDC,outpatient,1,UN,1.25,0.875,AETNA [1000108],AETNA [100010801],,,76.8,,0.96,0.222255,85118.57664,percent of total billed charges,,,
POTASSIUM CHLORIDE CRYS ER 20 MEQ ORAL TBCR,RX-35943,CDM,S5000,HCPCS,259,RC,00245-5319-01,NDC,outpatient,1,UN,1.25,0.875,AETNA [1000108],AETNA [100010801],,,76.8,,0.96,0.222255,85118.57664,percent of total billed charges,,,
POTASSIUM CHLORIDE CRYS ER 20 MEQ ORAL TBCR,RX-35943,CDM,S5000,HCPCS,259,RC,00832-5325-11,NDC,outpatient,1,UN,1.25,0.875,AETNA [1000108],AETNA [100010801],,,76.8,,0.96,0.222255,85118.57664,percent of total billed charges,,,
ATAZANAVIR SULFATE 150 MG ORAL CAPS,RX-36149,CDM,S5000,HCPCS,259,RC,42385-0920-60,NDC,outpatient,1,UN,11.33,7.931,AETNA [1000108],AETNA [100010801],,,76.8,,8.7,0.222255,85118.57664,percent of total billed charges,,,
ATAZANAVIR SULFATE 200 MG ORAL CAPS,RX-36150,CDM,S5000,HCPCS,259,RC,65862-0712-60,NDC,outpatient,1,UN,13.22,9.254,AETNA [1000108],AETNA [100010801],,,76.8,,10.15,0.222255,85118.57664,percent of total billed charges,,,
PREMASOL 10 % IV SOLN,RX-36160,CDM,S5000,HCPCS,250,RC,00338-1130-03,NDC,outpatient,500,ML,98.33,68.831,AETNA [1000108],AETNA [100010801],,,76.8,,75.52,0.222255,85118.57664,percent of total billed charges,,,
EMTRICITABINE 200 MG ORAL CAPS,RX-36252,CDM,S5000,HCPCS,259,RC,61958-0601-01,NDC,outpatient,1,UN,77.2,54.04,AETNA [1000108],AETNA [100010801],,,76.8,,59.29,0.222255,85118.57664,percent of total billed charges,,,
AMANTADINE HCL 100 MG ORAL CAPS,RX-364,CDM,S5000,HCPCS,259,RC,50268-0069-15,NDC,outpatient,1,UN,4.75,3.325,AETNA [1000108],AETNA [100010801],,,76.8,,3.65,0.222255,85118.57664,percent of total billed charges,,,
AMANTADINE HCL 100 MG ORAL CAPS,RX-364,CDM,S5000,HCPCS,259,RC,50268-0069-11,NDC,outpatient,1,UN,4.75,3.325,AETNA [1000108],AETNA [100010801],,,76.8,,3.65,0.222255,85118.57664,percent of total billed charges,,,
ARIPIPRAZOLE 5 MG ORAL TABS,RX-36438,CDM,S5000,HCPCS,259,RC,60687-0168-11,NDC,outpatient,1,UN,15.64,10.948,AETNA [1000108],AETNA [100010801],,,76.8,,12.01,0.222255,85118.57664,percent of total billed charges,,,
ARIPIPRAZOLE 5 MG ORAL TABS,RX-36438,CDM,S5000,HCPCS,259,RC,60687-0168-01,NDC,outpatient,1,UN,15.64,10.948,AETNA [1000108],AETNA [100010801],,,76.8,,12.01,0.222255,85118.57664,percent of total billed charges,,,
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % OT SUSP,RX-36576,CDM,S5000,HCPCS,259,RC,16714-0628-01,NDC,outpatient,7.5,ML,422.83,295.981,AETNA [1000108],AETNA [100010801],,,76.8,,324.73,0.222255,85118.57664,percent of total billed charges,,,
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % OT SUSP,RX-36576,CDM,S5000,HCPCS,259,RC,43598-0326-75,NDC,outpatient,7.5,ML,438.69,307.083,AETNA [1000108],AETNA [100010801],,,76.8,,336.91,0.222255,85118.57664,percent of total billed charges,,,
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % OT SUSP,RX-36576,CDM,S5000,HCPCS,259,RC,62756-0427-90,NDC,outpatient,7.5,ML,336.96,235.872,AETNA [1000108],AETNA [100010801],,,76.8,,258.79,0.222255,85118.57664,percent of total billed charges,,,
LEVETIRACETAM 100 MG/ML ORAL SOLN,RX-36590,CDM,S5000,HCPCS,259,RC,00121-4799-05,NDC,outpatient,5,ML,9.93,6.951,AETNA [1000108],AETNA [100010801],,,76.8,,7.63,0.222255,85118.57664,percent of total billed charges,,,
LEVETIRACETAM 100 MG/ML ORAL SOLN,RX-36590,CDM,S5000,HCPCS,259,RC,60687-0249-67,NDC,outpatient,5,ML,12.02,8.414,AETNA [1000108],AETNA [100010801],,,76.8,,9.23,0.222255,85118.57664,percent of total billed charges,,,
LEVETIRACETAM 100 MG/ML ORAL SOLN,RX-36590,CDM,S5000,HCPCS,259,RC,00121-4799-40,NDC,outpatient,5,ML,9.93,6.951,AETNA [1000108],AETNA [100010801],,,76.8,,7.63,0.222255,85118.57664,percent of total billed charges,,,
LEVETIRACETAM 100 MG/ML ORAL SOLN,RX-36590,CDM,S5000,HCPCS,259,RC,60687-0249-40,NDC,outpatient,5,ML,12.02,8.414,AETNA [1000108],AETNA [100010801],,,76.8,,9.23,0.222255,85118.57664,percent of total billed charges,,,
ROSUVASTATIN CALCIUM 5 MG ORAL TABS,RX-36612,CDM,S5000,HCPCS,259,RC,00904-6778-61,NDC,outpatient,1,UN,2.9,2.03,AETNA [1000108],AETNA [100010801],,,76.8,,2.23,0.222255,85118.57664,percent of total billed charges,,,
KETOROLAC TROMETHAMINE 0.4 % OP SOLN,RX-36631,CDM,S5000,HCPCS,259,RC,60758-0773-05,NDC,outpatient,5,ML,248.94,174.258,AETNA [1000108],AETNA [100010801],,,76.8,,191.19,0.222255,85118.57664,percent of total billed charges,,,
BUPROPION HCL ER (XL) 150 MG ORAL TB24,RX-36775,CDM,S5000,HCPCS,259,RC,00904-7084-04,NDC,outpatient,1,UN,5.27,3.689,AETNA [1000108],AETNA [100010801],,,76.8,,4.05,0.222255,85118.57664,percent of total billed charges,,,
BUPROPION HCL ER (XL) 150 MG ORAL TB24,RX-36775,CDM,S5000,HCPCS,259,RC,00904-7084-61,NDC,outpatient,1,UN,6.35,4.445,AETNA [1000108],AETNA [100010801],,,76.8,,4.88,0.222255,85118.57664,percent of total billed charges,,,
BUPROPION HCL ER (XL) 150 MG ORAL TB24,RX-36775,CDM,S5000,HCPCS,259,RC,16729-0443-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
DOCUSATE SODIUM 50 MG/5ML ORAL LIQD,RX-36962,CDM,S5000,HCPCS,259,RC,00121-1870-10,NDC,outpatient,10,ML,6.46,4.522,AETNA [1000108],AETNA [100010801],,,76.8,,4.96,0.222255,85118.57664,percent of total billed charges,,,
DOCUSATE SODIUM 50 MG/5ML ORAL LIQD,RX-36962,CDM,S5000,HCPCS,259,RC,99999-0001-96,NDC,outpatient,10,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
DOCUSATE SODIUM 50 MG/5ML ORAL LIQD,RX-36962,CDM,S5000,HCPCS,259,RC,00121-1870-00,NDC,outpatient,10,ML,6.46,4.522,AETNA [1000108],AETNA [100010801],,,76.8,,4.96,0.222255,85118.57664,percent of total billed charges,,,
DOCUSATE SODIUM 50 MG/5ML ORAL LIQD,RX-36962,CDM,S5000,HCPCS,259,RC,63739-0976-10,NDC,outpatient,10,ML,3.61,2.527,AETNA [1000108],AETNA [100010801],,,76.8,,2.77,0.222255,85118.57664,percent of total billed charges,,,
DOCUSATE SODIUM 50 MG/5ML ORAL LIQD,RX-36962,CDM,S5000,HCPCS,259,RC,63739-0976-01,NDC,outpatient,10,ML,3.61,2.527,AETNA [1000108],AETNA [100010801],,,76.8,,2.77,0.222255,85118.57664,percent of total billed charges,,,
THEOPHYLLINE ER 400 MG ORAL TB24,RX-36973,CDM,S5000,HCPCS,259,RC,29033-0001-01,NDC,outpatient,1,UN,5.44,3.808,AETNA [1000108],AETNA [100010801],,,76.8,,4.18,0.222255,85118.57664,percent of total billed charges,,,
THEOPHYLLINE ER 400 MG ORAL TB24,RX-36973,CDM,S5000,HCPCS,259,RC,42858-0701-01,NDC,outpatient,1,UN,3.89,2.723,AETNA [1000108],AETNA [100010801],,,76.8,,2.99,0.222255,85118.57664,percent of total billed charges,,,
PHENOL 1.4 % MT LIQD,RX-36976,CDM,S5000,HCPCS,259,RC,49348-0991-36,NDC,outpatient,177,ML,7.88,5.516,AETNA [1000108],AETNA [100010801],,,76.8,,6.05,0.222255,85118.57664,percent of total billed charges,,,
PHENOL 1.4 % MT LIQD,RX-36976,CDM,S5000,HCPCS,259,RC,00904-6305-21,NDC,outpatient,177,ML,7.09,4.963,AETNA [1000108],AETNA [100010801],,,76.8,,5.45,0.222255,85118.57664,percent of total billed charges,,,
PHENOL 1.4 % MT LIQD,RX-36976,CDM,S5000,HCPCS,259,RC,78112-0011-03,NDC,outpatient,177,ML,17.33,12.131,AETNA [1000108],AETNA [100010801],,,76.8,,13.31,0.222255,85118.57664,percent of total billed charges,,,
HYDRALAZINE HCL 10 MG ORAL TABS,RX-3698,CDM,S5000,HCPCS,259,RC,51079-0074-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
HYDRALAZINE HCL 10 MG ORAL TABS,RX-3698,CDM,S5000,HCPCS,259,RC,51079-0074-20,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ALFUZOSIN HCL ER 10 MG ORAL TB24,RX-36982,CDM,S5000,HCPCS,259,RC,29300-0155-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ALFUZOSIN HCL ER 10 MG ORAL TB24,RX-36982,CDM,S5000,HCPCS,259,RC,57237-0114-90,NDC,outpatient,1,UN,2,1.4,AETNA [1000108],AETNA [100010801],,,76.8,,1.54,0.222255,85118.57664,percent of total billed charges,,,
EPLERENONE 25 MG ORAL TABS,RX-36983,CDM,S5000,HCPCS,259,RC,51991-0877-33,NDC,outpatient,1,UN,1.68,1.176,AETNA [1000108],AETNA [100010801],,,76.8,,1.29,0.222255,85118.57664,percent of total billed charges,,,
EPLERENONE 25 MG ORAL TABS,RX-36983,CDM,S5000,HCPCS,259,RC,59762-1710-02,NDC,outpatient,1,UN,5.59,3.913,AETNA [1000108],AETNA [100010801],,,76.8,,4.29,0.222255,85118.57664,percent of total billed charges,,,
EPLERENONE 25 MG ORAL TABS,RX-36983,CDM,S5000,HCPCS,259,RC,60687-0451-11,NDC,outpatient,1,UN,18.55,12.985,AETNA [1000108],AETNA [100010801],,,76.8,,14.25,0.222255,85118.57664,percent of total billed charges,,,
EPLERENONE 25 MG ORAL TABS,RX-36983,CDM,S5000,HCPCS,259,RC,60687-0451-21,NDC,outpatient,1,UN,18.55,12.985,AETNA [1000108],AETNA [100010801],,,76.8,,14.25,0.222255,85118.57664,percent of total billed charges,,,
ZONISAMIDE 25 MG ORAL CAPS,RX-36987,CDM,S5000,HCPCS,259,RC,68462-0128-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,51079-0075-01,NDC,outpatient,1,UN,1.14,0.798,AETNA [1000108],AETNA [100010801],,,76.8,,0.88,0.222255,85118.57664,percent of total billed charges,,,
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,23155-0833-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,31722-0520-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,60687-0822-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,60687-0822-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,63739-0327-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,51079-0075-20,NDC,outpatient,1,UN,1.14,0.798,AETNA [1000108],AETNA [100010801],,,76.8,,0.88,0.222255,85118.57664,percent of total billed charges,,,
THERA M PLUS ORAL TABS,RX-37053,CDM,S5000,HCPCS,259,RC,00536-3445-08,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
THERA M PLUS ORAL TABS,RX-37053,CDM,S5000,HCPCS,259,RC,57896-0621-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,00591-3870-44,NDC,outpatient,1,UN,1.42,0.994,AETNA [1000108],AETNA [100010801],,,76.8,,1.09,0.222255,85118.57664,percent of total billed charges,,,
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,00904-6505-61,NDC,outpatient,1,UN,1.34,0.938,AETNA [1000108],AETNA [100010801],,,76.8,,1.03,0.222255,85118.57664,percent of total billed charges,,,
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,00591-3870-45,NDC,outpatient,1,UN,1.42,0.994,AETNA [1000108],AETNA [100010801],,,76.8,,1.09,0.222255,85118.57664,percent of total billed charges,,,
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,00832-1112-60,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,60687-0173-11,NDC,outpatient,1,UN,2.01,1.407,AETNA [1000108],AETNA [100010801],,,76.8,,1.54,0.222255,85118.57664,percent of total billed charges,,,
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,60687-0173-57,NDC,outpatient,1,UN,2.01,1.407,AETNA [1000108],AETNA [100010801],,,76.8,,1.54,0.222255,85118.57664,percent of total billed charges,,,
HYDROCHLOROTHIAZIDE 25 MG ORAL TABS,RX-3720,CDM,S5000,HCPCS,259,RC,60687-0593-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
HYDROCHLOROTHIAZIDE 25 MG ORAL TABS,RX-3720,CDM,S5000,HCPCS,259,RC,60687-0593-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
HYDROCORTISONE 1 % EX CREA,RX-3726,CDM,S5000,HCPCS,259,RC,00536-1277-80,NDC,outpatient,28,GR,5.24,3.668,AETNA [1000108],AETNA [100010801],,,76.8,,4.02,0.222255,85118.57664,percent of total billed charges,,,
HYDROCORTISONE 1 % EX CREA,RX-3726,CDM,S5000,HCPCS,259,RC,49348-0521-72,NDC,outpatient,28.4,GR,6.32,4.424,AETNA [1000108],AETNA [100010801],,,76.8,,4.85,0.222255,85118.57664,percent of total billed charges,,,
HYDROCORTISONE 1 % EX LOTN,RX-3728,CDM,S5000,HCPCS,259,RC,00096-0732-04,NDC,outpatient,120,ML,56.61,39.627,AETNA [1000108],AETNA [100010801],,,76.8,,43.48,0.222255,85118.57664,percent of total billed charges,,,
HYDROCORTISONE 1 % EX LOTN,RX-3728,CDM,S5000,HCPCS,259,RC,00394-0859-32,NDC,outpatient,114,ML,22.83,15.981,AETNA [1000108],AETNA [100010801],,,76.8,,17.53,0.222255,85118.57664,percent of total billed charges,,,
HYDROCORTISONE 1 % EX OINT,RX-3731,CDM,S5000,HCPCS,259,RC,00168-0020-31,NDC,outpatient,28.35,GR,18.05,12.635,AETNA [1000108],AETNA [100010801],,,76.8,,13.86,0.222255,85118.57664,percent of total billed charges,,,
HYDROCORTISONE 10 MG ORAL TABS,RX-3733,CDM,S5000,HCPCS,259,RC,59762-0074-01,NDC,outpatient,1,UN,1.14,0.798,AETNA [1000108],AETNA [100010801],,,76.8,,0.88,0.222255,85118.57664,percent of total billed charges,,,
HYDROCORTISONE 10 MG ORAL TABS,RX-3733,CDM,S5000,HCPCS,259,RC,60687-0582-01,NDC,outpatient,1,UN,6.08,4.256,AETNA [1000108],AETNA [100010801],,,76.8,,4.67,0.222255,85118.57664,percent of total billed charges,,,
HYDROCORTISONE 10 MG ORAL TABS,RX-3733,CDM,S5000,HCPCS,259,RC,60687-0582-11,NDC,outpatient,1,UN,6.08,4.256,AETNA [1000108],AETNA [100010801],,,76.8,,4.67,0.222255,85118.57664,percent of total billed charges,,,
HYDROCORTISONE ACETATE 25 MG RE SUPP,RX-3738,CDM,S5000,HCPCS,259,RC,10135-0751-12,NDC,outpatient,1,UN,7.8,5.46,AETNA [1000108],AETNA [100010801],,,76.8,,5.99,0.222255,85118.57664,percent of total billed charges,,,
HYDROCORTISONE ACETATE 25 MG RE SUPP,RX-3738,CDM,S5000,HCPCS,259,RC,00574-7090-12,NDC,outpatient,1,UN,5.54,3.878,AETNA [1000108],AETNA [100010801],,,76.8,,4.25,0.222255,85118.57664,percent of total billed charges,,,
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,42806-0270-98,NDC,outpatient,1,UN,3.48,2.436,AETNA [1000108],AETNA [100010801],,,76.8,,2.67,0.222255,85118.57664,percent of total billed charges,,,
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,00245-0036-89,NDC,outpatient,1,UN,3.71,2.597,AETNA [1000108],AETNA [100010801],,,76.8,,2.85,0.222255,85118.57664,percent of total billed charges,,,
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,49884-0466-65,NDC,outpatient,1,UN,2.84,1.988,AETNA [1000108],AETNA [100010801],,,76.8,,2.18,0.222255,85118.57664,percent of total billed charges,,,
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,00245-0036-60,NDC,outpatient,1,UN,3.71,2.597,AETNA [1000108],AETNA [100010801],,,76.8,,2.85,0.222255,85118.57664,percent of total billed charges,,,
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,42806-0270-95,NDC,outpatient,1,UN,3.48,2.436,AETNA [1000108],AETNA [100010801],,,76.8,,2.67,0.222255,85118.57664,percent of total billed charges,,,
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,49884-0466-63,NDC,outpatient,1,UN,2.84,1.988,AETNA [1000108],AETNA [100010801],,,76.8,,2.18,0.222255,85118.57664,percent of total billed charges,,,
CARBAMAZEPINE ER 100 MG ORAL CP12,RX-37567,CDM,S5000,HCPCS,259,RC,50268-0170-11,NDC,outpatient,1,UN,7.06,4.942,AETNA [1000108],AETNA [100010801],,,76.8,,5.42,0.222255,85118.57664,percent of total billed charges,,,
CARBAMAZEPINE ER 100 MG ORAL CP12,RX-37567,CDM,S5000,HCPCS,259,RC,50268-0170-13,NDC,outpatient,1,UN,7.06,4.942,AETNA [1000108],AETNA [100010801],,,76.8,,5.42,0.222255,85118.57664,percent of total billed charges,,,
BSS IO SOLN,RX-37579,CDM,S5000,HCPCS,259,RC,00065-0795-15,NDC,outpatient,15,ML,24.7,17.29,AETNA [1000108],AETNA [100010801],,,76.8,,18.97,0.222255,85118.57664,percent of total billed charges,,,
HYDROMORPHONE HCL 2 MG ORAL TABS,RX-3760,CDM,S5000,HCPCS,259,RC,42858-0301-01,NDC,outpatient,1,UN,1.14,0.798,AETNA [1000108],AETNA [100010801],,,76.8,,0.88,0.222255,85118.57664,percent of total billed charges,,,
HYDROMORPHONE HCL 2 MG ORAL TABS,RX-3760,CDM,S5000,HCPCS,259,RC,42858-0301-25,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
HYDROMORPHONE HCL 2 MG ORAL TABS,RX-3760,CDM,S5000,HCPCS,259,RC,60687-0579-11,NDC,outpatient,1,UN,1.27,0.889,AETNA [1000108],AETNA [100010801],,,76.8,,0.98,0.222255,85118.57664,percent of total billed charges,,,
HYDROMORPHONE HCL 2 MG ORAL TABS,RX-3760,CDM,S5000,HCPCS,259,RC,60687-0579-01,NDC,outpatient,1,UN,1.27,0.889,AETNA [1000108],AETNA [100010801],,,76.8,,0.98,0.222255,85118.57664,percent of total billed charges,,,
HYDROMORPHONE HCL 2 MG ORAL TABS,RX-3760,CDM,S5000,HCPCS,259,RC,00406-3243-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
HYDROMORPHONE HCL 4 MG ORAL TABS,RX-3761,CDM,S5000,HCPCS,259,RC,60687-0590-11,NDC,outpatient,1,UN,1.06,0.742,AETNA [1000108],AETNA [100010801],,,76.8,,0.81,0.222255,85118.57664,percent of total billed charges,,,
HYDROMORPHONE HCL 4 MG ORAL TABS,RX-3761,CDM,S5000,HCPCS,259,RC,42858-0234-01,NDC,outpatient,1,UN,17.03,11.921,AETNA [1000108],AETNA [100010801],,,76.8,,13.08,0.222255,85118.57664,percent of total billed charges,,,
HYDROMORPHONE HCL 4 MG ORAL TABS,RX-3761,CDM,S5000,HCPCS,259,RC,00406-3244-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
HYDROMORPHONE HCL 4 MG ORAL TABS,RX-3761,CDM,S5000,HCPCS,259,RC,60687-0590-01,NDC,outpatient,1,UN,1.06,0.742,AETNA [1000108],AETNA [100010801],,,76.8,,0.81,0.222255,85118.57664,percent of total billed charges,,,
METOPROLOL TARTRATE 25 MG ORAL TABS,RX-37637,CDM,S5000,HCPCS,259,RC,00378-0018-05,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
METOPROLOL TARTRATE 25 MG ORAL TABS,RX-37637,CDM,S5000,HCPCS,259,RC,62584-0265-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
METOPROLOL TARTRATE 25 MG ORAL TABS,RX-37637,CDM,S5000,HCPCS,259,RC,62584-0265-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
METOPROLOL TARTRATE 25 MG ORAL TABS,RX-37637,CDM,S5000,HCPCS,259,RC,51079-0255-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
METOPROLOL TARTRATE 25 MG ORAL TABS,RX-37637,CDM,S5000,HCPCS,259,RC,51079-0255-20,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
CLINDAMYCIN PALMITATE HCL 75 MG/5ML ORAL SOLR,RX-37642,CDM,S5000,HCPCS,259,RC,23155-0603-51,NDC,outpatient,100,ML,170.44,119.308,AETNA [1000108],AETNA [100010801],,,76.8,,130.9,0.222255,85118.57664,percent of total billed charges,,,
CLINDAMYCIN PALMITATE HCL 75 MG/5ML ORAL SOLR,RX-37642,CDM,S5000,HCPCS,259,RC,59762-0016-01,NDC,outpatient,100,ML,170.44,119.308,AETNA [1000108],AETNA [100010801],,,76.8,,130.9,0.222255,85118.57664,percent of total billed charges,,,
CLINDAMYCIN PALMITATE HCL 75 MG/5ML ORAL SOLR,RX-37642,CDM,S5000,HCPCS,259,RC,99999-0002-90,NDC,outpatient,10,ML,18.43,12.901,AETNA [1000108],AETNA [100010801],,,76.8,,14.15,0.222255,85118.57664,percent of total billed charges,,,
GLIPIZIDE ER 2.5 MG ORAL TB24,RX-37648,CDM,S5000,HCPCS,259,RC,60687-0768-11,NDC,outpatient,1,UN,4.6,3.22,AETNA [1000108],AETNA [100010801],,,76.8,,3.53,0.222255,85118.57664,percent of total billed charges,,,
GLIPIZIDE ER 2.5 MG ORAL TB24,RX-37648,CDM,S5000,HCPCS,259,RC,60687-0768-21,NDC,outpatient,1,UN,4.6,3.22,AETNA [1000108],AETNA [100010801],,,76.8,,3.53,0.222255,85118.57664,percent of total billed charges,,,
GLIPIZIDE ER 5 MG ORAL TB24,RX-37649,CDM,S5000,HCPCS,259,RC,68084-0111-11,NDC,outpatient,1,UN,2.4,1.68,AETNA [1000108],AETNA [100010801],,,76.8,,1.84,0.222255,85118.57664,percent of total billed charges,,,
GLIPIZIDE ER 5 MG ORAL TB24,RX-37649,CDM,S5000,HCPCS,259,RC,68084-0111-01,NDC,outpatient,1,UN,2.4,1.68,AETNA [1000108],AETNA [100010801],,,76.8,,1.84,0.222255,85118.57664,percent of total billed charges,,,
GUAIFENESIN ER 600 MG ORAL TB12,RX-37651,CDM,S5000,HCPCS,259,RC,00904-6718-39,NDC,outpatient,1,UN,2.32,1.624,AETNA [1000108],AETNA [100010801],,,76.8,,1.78,0.222255,85118.57664,percent of total billed charges,,,
GUAIFENESIN ER 600 MG ORAL TB12,RX-37651,CDM,S5000,HCPCS,259,RC,68084-0572-01,NDC,outpatient,1,UN,2.76,1.932,AETNA [1000108],AETNA [100010801],,,76.8,,2.12,0.222255,85118.57664,percent of total billed charges,,,
GUAIFENESIN ER 600 MG ORAL TB12,RX-37651,CDM,S5000,HCPCS,259,RC,68084-0572-11,NDC,outpatient,1,UN,2.76,1.932,AETNA [1000108],AETNA [100010801],,,76.8,,2.12,0.222255,85118.57664,percent of total billed charges,,,
GUAIFENESIN ER 600 MG ORAL TB12,RX-37651,CDM,S5000,HCPCS,259,RC,63824-0008-50,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
HYDROXYZINE HCL 10 MG/5ML ORAL SYRP,RX-3771,CDM,S5000,HCPCS,259,RC,54838-0502-80,NDC,outpatient,5,ML,2.88,2.016,AETNA [1000108],AETNA [100010801],,,76.8,,2.21,0.222255,85118.57664,percent of total billed charges,,,
HYDROXYZINE HCL 10 MG/5ML ORAL SYRP,RX-3771,CDM,S5000,HCPCS,259,RC,62135-0750-47,NDC,outpatient,5,ML,21.74,15.218,AETNA [1000108],AETNA [100010801],,,76.8,,16.7,0.222255,85118.57664,percent of total billed charges,,,
HYDROXYZINE HCL 10 MG/5ML ORAL SYRP,RX-3771,CDM,S5000,HCPCS,259,RC,99999-0002-50,NDC,outpatient,5,ML,1.16,0.812,AETNA [1000108],AETNA [100010801],,,76.8,,0.89,0.222255,85118.57664,percent of total billed charges,,,
HYDROXYZINE HCL 10 MG ORAL TABS,RX-3772,CDM,S5000,HCPCS,259,RC,63739-0483-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
HYDROXYZINE HCL 25 MG ORAL TABS,RX-3774,CDM,S5000,HCPCS,259,RC,63739-0486-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
HYDROXYZINE HCL 25 MG ORAL TABS,RX-3774,CDM,S5000,HCPCS,259,RC,00904-6617-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
HYDROXYZINE HCL 25 MG ORAL TABS,RX-3774,CDM,S5000,HCPCS,259,RC,60687-0675-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
HYDROXYZINE HCL 25 MG ORAL TABS,RX-3774,CDM,S5000,HCPCS,259,RC,60687-0675-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
TALC 5 G PL SUSR,RX-37812,CDM,S5000,HCPCS,259,RC,63256-0200-05,NDC,outpatient,1,UN,458.35,320.845,AETNA [1000108],AETNA [100010801],,,76.8,,352.01,0.222255,85118.57664,percent of total billed charges,,,
CINACALCET HCL 30 MG ORAL TABS,RX-38100,CDM,S5000,HCPCS,259,RC,60687-0525-11,NDC,outpatient,1,UN,64.87,45.409,AETNA [1000108],AETNA [100010801],,,76.8,,49.82,0.222255,85118.57664,percent of total billed charges,,,
CINACALCET HCL 30 MG ORAL TABS,RX-38100,CDM,S5000,HCPCS,259,RC,00904-7067-04,NDC,outpatient,1,UN,76.53,53.571,AETNA [1000108],AETNA [100010801],,,76.8,,58.78,0.222255,85118.57664,percent of total billed charges,,,
CINACALCET HCL 30 MG ORAL TABS,RX-38100,CDM,S5000,HCPCS,259,RC,55513-0073-30,NDC,outpatient,1,UN,75.45,52.815,AETNA [1000108],AETNA [100010801],,,76.8,,57.95,0.222255,85118.57664,percent of total billed charges,,,
CINACALCET HCL 30 MG ORAL TABS,RX-38100,CDM,S5000,HCPCS,259,RC,60687-0525-21,NDC,outpatient,1,UN,64.87,45.409,AETNA [1000108],AETNA [100010801],,,76.8,,49.82,0.222255,85118.57664,percent of total billed charges,,,
CINACALCET HCL 30 MG ORAL TABS,RX-38100,CDM,S5000,HCPCS,259,RC,70436-0007-04,NDC,outpatient,1,UN,1.94,1.358,AETNA [1000108],AETNA [100010801],,,76.8,,1.49,0.222255,85118.57664,percent of total billed charges,,,
ORPHENADRINE CITRATE ER 100 MG ORAL TB12,RX-38213,CDM,S5000,HCPCS,259,RC,43386-0480-24,NDC,outpatient,1,UN,2.27,1.589,AETNA [1000108],AETNA [100010801],,,76.8,,1.74,0.222255,85118.57664,percent of total billed charges,,,
PROPRANOLOL HCL ER 60 MG ORAL CP24,RX-38224,CDM,S5000,HCPCS,259,RC,00228-2778-11,NDC,outpatient,1,UN,6.75,4.725,AETNA [1000108],AETNA [100010801],,,76.8,,5.18,0.222255,85118.57664,percent of total billed charges,,,
PROPRANOLOL HCL ER 60 MG ORAL CP24,RX-38224,CDM,S5000,HCPCS,259,RC,42291-0522-01,NDC,outpatient,1,UN,1.68,1.176,AETNA [1000108],AETNA [100010801],,,76.8,,1.29,0.222255,85118.57664,percent of total billed charges,,,
PROPRANOLOL HCL ER 60 MG ORAL CP24,RX-38224,CDM,S5000,HCPCS,259,RC,62559-0530-01,NDC,outpatient,1,UN,2.1,1.47,AETNA [1000108],AETNA [100010801],,,76.8,,1.61,0.222255,85118.57664,percent of total billed charges,,,
PROPRANOLOL HCL ER 80 MG ORAL CP24,RX-38225,CDM,S5000,HCPCS,259,RC,00228-2779-11,NDC,outpatient,1,UN,8.57,5.999,AETNA [1000108],AETNA [100010801],,,76.8,,6.58,0.222255,85118.57664,percent of total billed charges,,,
PROPRANOLOL HCL ER 80 MG ORAL CP24,RX-38225,CDM,S5000,HCPCS,259,RC,00527-4117-37,NDC,outpatient,1,UN,1.14,0.798,AETNA [1000108],AETNA [100010801],,,76.8,,0.88,0.222255,85118.57664,percent of total billed charges,,,
PROPRANOLOL HCL ER 120 MG ORAL CP24,RX-38226,CDM,S5000,HCPCS,259,RC,42291-0524-01,NDC,outpatient,1,UN,2.42,1.694,AETNA [1000108],AETNA [100010801],,,76.8,,1.86,0.222255,85118.57664,percent of total billed charges,,,
PROPRANOLOL HCL ER 120 MG ORAL CP24,RX-38226,CDM,S5000,HCPCS,259,RC,00228-2780-11,NDC,outpatient,1,UN,10.29,7.203,AETNA [1000108],AETNA [100010801],,,76.8,,7.9,0.222255,85118.57664,percent of total billed charges,,,
LACTULOSE 10 GM/15ML ORAL SOLN,RX-38245,CDM,S5000,HCPCS,259,RC,00121-1154-00,NDC,outpatient,30,ML,4.94,3.458,AETNA [1000108],AETNA [100010801],,,76.8,,3.79,0.222255,85118.57664,percent of total billed charges,,,
LACTULOSE 10 GM/15ML ORAL SOLN,RX-38245,CDM,S5000,HCPCS,259,RC,99999-0001-83,NDC,outpatient,30,ML,2.16,1.512,AETNA [1000108],AETNA [100010801],,,76.8,,1.66,0.222255,85118.57664,percent of total billed charges,,,
LACTULOSE 10 GM/15ML ORAL SOLN,RX-38245,CDM,S5000,HCPCS,259,RC,45963-0439-30,NDC,outpatient,30,ML,2.01,1.407,AETNA [1000108],AETNA [100010801],,,76.8,,1.54,0.222255,85118.57664,percent of total billed charges,,,
LACTULOSE 10 GM/15ML ORAL SOLN,RX-38245,CDM,S5000,HCPCS,259,RC,45963-0439-65,NDC,outpatient,15,ML,1.01,0.707,AETNA [1000108],AETNA [100010801],,,76.8,,0.78,0.222255,85118.57664,percent of total billed charges,,,
LACTULOSE 10 GM/15ML ORAL SOLN,RX-38245,CDM,S5000,HCPCS,259,RC,00121-1154-30,NDC,outpatient,30,ML,4.94,3.458,AETNA [1000108],AETNA [100010801],,,76.8,,3.79,0.222255,85118.57664,percent of total billed charges,,,
CETIRIZINE HCL 5 MG ORAL CHEW,RX-38402,CDM,S5000,HCPCS,259,RC,00781-5283-64,NDC,outpatient,1,UN,12.96,9.072,AETNA [1000108],AETNA [100010801],,,76.8,,9.95,0.222255,85118.57664,percent of total billed charges,,,
CETIRIZINE HCL 5 MG ORAL CHEW,RX-38402,CDM,S5000,HCPCS,259,RC,00781-5283-06,NDC,outpatient,1,UN,12.96,9.072,AETNA [1000108],AETNA [100010801],,,76.8,,9.95,0.222255,85118.57664,percent of total billed charges,,,
IBUPROFEN 200 MG ORAL TABS,RX-3841,CDM,S5000,HCPCS,259,RC,00904-7914-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,00904-5853-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,67877-0319-05,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,60687-0446-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,60687-0446-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,67877-0319-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,00904-5853-60,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
IBUPROFEN 600 MG ORAL TABS,RX-3844,CDM,S5000,HCPCS,259,RC,00904-5854-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
INFUVITE PEDIATRIC IV SOLN,RX-38445,CDM,S5000,HCPCS,250,RC,54643-5646-09,NDC,outpatient,1,ML,15.58,10.906,AETNA [1000108],AETNA [100010801],,,76.8,,11.97,0.222255,85118.57664,percent of total billed charges,,,
INFUVITE PEDIATRIC IV SOLN,RX-38445,CDM,S5000,HCPCS,250,RC,54643-5646-01,NDC,outpatient,4,ML,53.96,37.772,AETNA [1000108],AETNA [100010801],,,76.8,,41.44,0.222255,85118.57664,percent of total billed charges,,,
IBUPROFEN 800 MG ORAL TABS,RX-3845,CDM,S5000,HCPCS,259,RC,00904-5855-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
FLUOXETINE HCL 20 MG/5ML ORAL SOLN,RX-38488,CDM,S5000,HCPCS,259,RC,00121-4721-05,NDC,outpatient,5,ML,14.38,10.066,AETNA [1000108],AETNA [100010801],,,76.8,,11.04,0.222255,85118.57664,percent of total billed charges,,,
IMIPRAMINE HCL 10 MG ORAL TABS,RX-3860,CDM,S5000,HCPCS,259,RC,69584-0425-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
IMIPRAMINE HCL 25 MG ORAL TABS,RX-3861,CDM,S5000,HCPCS,259,RC,69584-0426-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
NEOMYCIN-BACITRACIN ZN-POLYMYX 5-400-10000 OP OINT,RX-38701,CDM,S5000,HCPCS,259,RC,24208-0780-55,NDC,outpatient,3.5,GR,57.59,40.313,AETNA [1000108],AETNA [100010801],,,76.8,,44.23,0.222255,85118.57664,percent of total billed charges,,,
INDAPAMIDE 2.5 MG ORAL TABS,RX-3879,CDM,S5000,HCPCS,259,RC,00228-2571-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
INDAPAMIDE 2.5 MG ORAL TABS,RX-3879,CDM,S5000,HCPCS,259,RC,62559-0511-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
SELENIUM SULFIDE 1 % EX SHAM,RX-38961,CDM,S5000,HCPCS,259,RC,00536-1995-53,NDC,outpatient,207,ML,9.22,6.454,AETNA [1000108],AETNA [100010801],,,76.8,,7.08,0.222255,85118.57664,percent of total billed charges,,,
PEG 3350-KCL-NABCB-NACL-NASULF 240 G ORAL SOLR,RX-38965,CDM,S5000,HCPCS,259,RC,43386-0060-19,NDC,outpatient,4000,ML,53.4,37.38,AETNA [1000108],AETNA [100010801],,,76.8,,41.01,0.222255,85118.57664,percent of total billed charges,,,
INDOMETHACIN 25 MG ORAL CAPS,RX-3897,CDM,S5000,HCPCS,259,RC,50268-0430-15,NDC,outpatient,1,UN,1.4,0.98,AETNA [1000108],AETNA [100010801],,,76.8,,1.08,0.222255,85118.57664,percent of total billed charges,,,
INDOMETHACIN 25 MG ORAL CAPS,RX-3897,CDM,S5000,HCPCS,259,RC,50268-0430-11,NDC,outpatient,1,UN,1.4,0.98,AETNA [1000108],AETNA [100010801],,,76.8,,1.08,0.222255,85118.57664,percent of total billed charges,,,
INDOMETHACIN 50 MG RE SUPP,RX-3901,CDM,S5000,HCPCS,259,RC,69344-0102-33,NDC,outpatient,1,UN,1095.8,767.06,AETNA [1000108],AETNA [100010801],,,76.8,,841.57,0.222255,85118.57664,percent of total billed charges,,,
RIFAXIMIN 200 MG ORAL TABS,RX-39063,CDM,S5000,HCPCS,259,RC,65649-0301-03,NDC,outpatient,1,UN,43.55,30.485,AETNA [1000108],AETNA [100010801],,,76.8,,33.45,0.222255,85118.57664,percent of total billed charges,,,
AMILORIDE HCL 5 MG ORAL TABS,RX-391,CDM,S5000,HCPCS,259,RC,00574-0292-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
NYSTATIN 100000 UNIT/GM EX POWD,RX-39136,CDM,S5000,HCPCS,259,RC,00832-0465-15,NDC,outpatient,15,GR,37.52,26.264,AETNA [1000108],AETNA [100010801],,,76.8,,28.82,0.222255,85118.57664,percent of total billed charges,,,
NYSTATIN 100000 UNIT/GM EX POWD,RX-39136,CDM,S5000,HCPCS,259,RC,68308-0152-15,NDC,outpatient,15,GR,27.84,19.488,AETNA [1000108],AETNA [100010801],,,76.8,,21.38,0.222255,85118.57664,percent of total billed charges,,,
NYSTATIN 100000 UNIT/GM EX POWD,RX-39136,CDM,S5000,HCPCS,259,RC,68382-0370-01,NDC,outpatient,15,GR,31.18,21.826,AETNA [1000108],AETNA [100010801],,,76.8,,23.95,0.222255,85118.57664,percent of total billed charges,,,
NYSTATIN 100000 UNIT/GM EX POWD,RX-39136,CDM,S5000,HCPCS,259,RC,69315-0306-15,NDC,outpatient,15,GR,24.5,17.15,AETNA [1000108],AETNA [100010801],,,76.8,,18.82,0.222255,85118.57664,percent of total billed charges,,,
NYSTATIN 100000 UNIT/GM EX POWD,RX-39136,CDM,S5000,HCPCS,259,RC,16714-0769-01,NDC,outpatient,15,GR,25.04,17.528,AETNA [1000108],AETNA [100010801],,,76.8,,19.23,0.222255,85118.57664,percent of total billed charges,,,
EMTRICITABINE-TENOFOVIR DF 200-300 MG ORAL TABS,RX-39255,CDM,S5000,HCPCS,259,RC,61958-0701-01,NDC,outpatient,1,UN,265.08,185.556,AETNA [1000108],AETNA [100010801],,,76.8,,203.58,0.222255,85118.57664,percent of total billed charges,,,
DULOXETINE HCL 20 MG ORAL CPEP,RX-39275,CDM,S5000,HCPCS,259,RC,00904-7043-04,NDC,outpatient,1,UN,3.3,2.31,AETNA [1000108],AETNA [100010801],,,76.8,,2.53,0.222255,85118.57664,percent of total billed charges,,,
DULOXETINE HCL 20 MG ORAL CPEP,RX-39275,CDM,S5000,HCPCS,259,RC,60687-0723-21,NDC,outpatient,1,UN,3.39,2.373,AETNA [1000108],AETNA [100010801],,,76.8,,2.6,0.222255,85118.57664,percent of total billed charges,,,
DULOXETINE HCL 20 MG ORAL CPEP,RX-39275,CDM,S5000,HCPCS,259,RC,60687-0723-11,NDC,outpatient,1,UN,3.39,2.373,AETNA [1000108],AETNA [100010801],,,76.8,,2.6,0.222255,85118.57664,percent of total billed charges,,,
DULOXETINE HCL 30 MG ORAL CPEP,RX-39276,CDM,S5000,HCPCS,259,RC,60687-0734-01,NDC,outpatient,1,UN,3.41,2.387,AETNA [1000108],AETNA [100010801],,,76.8,,2.62,0.222255,85118.57664,percent of total billed charges,,,
DULOXETINE HCL 30 MG ORAL CPEP,RX-39276,CDM,S5000,HCPCS,259,RC,60687-0734-11,NDC,outpatient,1,UN,3.41,2.387,AETNA [1000108],AETNA [100010801],,,76.8,,2.62,0.222255,85118.57664,percent of total billed charges,,,
DULOXETINE HCL 30 MG ORAL CPEP,RX-39276,CDM,S5000,HCPCS,259,RC,57237-0018-90,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
DULOXETINE HCL 30 MG ORAL CPEP,RX-39276,CDM,S5000,HCPCS,259,RC,00904-7044-61,NDC,outpatient,1,UN,3.08,2.156,AETNA [1000108],AETNA [100010801],,,76.8,,2.37,0.222255,85118.57664,percent of total billed charges,,,
LEVALBUTEROL HCL 1.25 MG/0.5ML IN NEBU,RX-39278,CDM,S5000,HCPCS,259,RC,00378-6993-93,NDC,outpatient,1,UN,20.14,14.098,AETNA [1000108],AETNA [100010801],,,76.8,,15.47,0.222255,85118.57664,percent of total billed charges,,,
LEVALBUTEROL HCL 1.25 MG/0.5ML IN NEBU,RX-39278,CDM,S5000,HCPCS,259,RC,00378-6993-31,NDC,outpatient,1,UN,20.14,14.098,AETNA [1000108],AETNA [100010801],,,76.8,,15.47,0.222255,85118.57664,percent of total billed charges,,,
CEFDINIR 250 MG/5ML ORAL SUSR,RX-39522,CDM,S5000,HCPCS,259,RC,65862-0219-60,NDC,outpatient,60,ML,88.92,62.244,AETNA [1000108],AETNA [100010801],,,76.8,,68.29,0.222255,85118.57664,percent of total billed charges,,,
CEFDINIR 250 MG/5ML ORAL SUSR,RX-39522,CDM,S5000,HCPCS,259,RC,99999-0002-80,NDC,outpatient,6,ML,3.93,2.751,AETNA [1000108],AETNA [100010801],,,76.8,,3.02,0.222255,85118.57664,percent of total billed charges,,,
CEFDINIR 250 MG/5ML ORAL SUSR,RX-39522,CDM,S5000,HCPCS,259,RC,68180-0723-04,NDC,outpatient,60,ML,87.31,61.117,AETNA [1000108],AETNA [100010801],,,76.8,,67.05,0.222255,85118.57664,percent of total billed charges,,,
MESALAMINE ER 500 MG ORAL CPCR,RX-39575,CDM,S5000,HCPCS,259,RC,54092-0191-12,NDC,outpatient,1,UN,24.97,17.479,AETNA [1000108],AETNA [100010801],,,76.8,,19.18,0.222255,85118.57664,percent of total billed charges,,,
IODINE STRONG 5 % ORAL SOLN,RX-3961,CDM,S5000,HCPCS,259,RC,48433-0230-15,NDC,outpatient,14,ML,132.64,92.848,AETNA [1000108],AETNA [100010801],,,76.8,,101.87,0.222255,85118.57664,percent of total billed charges,,,
IODINE STRONG 5 % ORAL SOLN,RX-3961,CDM,S5000,HCPCS,259,RC,51552-0019-44,NDC,outpatient,14,ML,5.44,3.808,AETNA [1000108],AETNA [100010801],,,76.8,,4.18,0.222255,85118.57664,percent of total billed charges,,,
ACAMPROSATE CALCIUM 333 MG ORAL TBEC,RX-39720,CDM,S5000,HCPCS,259,RC,60687-0121-95,NDC,outpatient,1,UN,6.9,4.83,AETNA [1000108],AETNA [100010801],,,76.8,,5.3,0.222255,85118.57664,percent of total billed charges,,,
ACAMPROSATE CALCIUM 333 MG ORAL TBEC,RX-39720,CDM,S5000,HCPCS,259,RC,60687-0121-25,NDC,outpatient,1,UN,6.9,4.83,AETNA [1000108],AETNA [100010801],,,76.8,,5.3,0.222255,85118.57664,percent of total billed charges,,,
FLUMAZENIL 0.5 MG/5ML IV SOLN,RX-39744,CDM,S5000,HCPCS,250,RC,00143-9784-10,NDC,outpatient,5,ML,13.42,9.394,AETNA [1000108],AETNA [100010801],,,76.8,,10.31,0.222255,85118.57664,percent of total billed charges,,,
FLUMAZENIL 0.5 MG/5ML IV SOLN,RX-39744,CDM,S5000,HCPCS,250,RC,00143-9784-01,NDC,outpatient,5,ML,13.42,9.394,AETNA [1000108],AETNA [100010801],,,76.8,,10.31,0.222255,85118.57664,percent of total billed charges,,,
FLUMAZENIL 0.5 MG/5ML IV SOLN,RX-39744,CDM,S5000,HCPCS,250,RC,36000-0148-10,NDC,outpatient,5,ML,12.98,9.086,AETNA [1000108],AETNA [100010801],,,76.8,,9.97,0.222255,85118.57664,percent of total billed charges,,,
FLUMAZENIL 0.5 MG/5ML IV SOLN,RX-39744,CDM,S5000,HCPCS,250,RC,36000-0148-01,NDC,outpatient,5,ML,12.98,9.086,AETNA [1000108],AETNA [100010801],,,76.8,,9.97,0.222255,85118.57664,percent of total billed charges,,,
FLUMAZENIL 0.5 MG/5ML IV SOLN,RX-39744,CDM,S5000,HCPCS,250,RC,63323-0424-05,NDC,outpatient,5,ML,15.68,10.976,AETNA [1000108],AETNA [100010801],,,76.8,,12.04,0.222255,85118.57664,percent of total billed charges,,,
LEVOFLOXACIN 25 MG/ML ORAL SOLN,RX-39970,CDM,S5000,HCPCS,259,RC,99999-0002-53,NDC,outpatient,10,ML,37.07,25.949,AETNA [1000108],AETNA [100010801],,,76.8,,28.47,0.222255,85118.57664,percent of total billed charges,,,
LEVOFLOXACIN 25 MG/ML ORAL SOLN,RX-39970,CDM,S5000,HCPCS,259,RC,00527-1948-68,NDC,outpatient,10,ML,85.98,60.186,AETNA [1000108],AETNA [100010801],,,76.8,,66.03,0.222255,85118.57664,percent of total billed charges,,,
LANTHANUM CARBONATE 500 MG ORAL CHEW,RX-39975,CDM,S5000,HCPCS,259,RC,68180-0819-42,NDC,outpatient,1,UN,24.73,17.311,AETNA [1000108],AETNA [100010801],,,76.8,,18.99,0.222255,85118.57664,percent of total billed charges,,,
LANTHANUM CARBONATE 500 MG ORAL CHEW,RX-39975,CDM,S5000,HCPCS,259,RC,54092-0252-90,NDC,outpatient,1,UN,49.37,34.559,AETNA [1000108],AETNA [100010801],,,76.8,,37.92,0.222255,85118.57664,percent of total billed charges,,,
LANTHANUM CARBONATE 500 MG ORAL CHEW,RX-39975,CDM,S5000,HCPCS,259,RC,54092-0252-45,NDC,outpatient,1,UN,49.37,34.559,AETNA [1000108],AETNA [100010801],,,76.8,,37.92,0.222255,85118.57664,percent of total billed charges,,,
LANTHANUM CARBONATE 500 MG ORAL CHEW,RX-39975,CDM,S5000,HCPCS,259,RC,68180-0819-52,NDC,outpatient,1,UN,24.73,17.311,AETNA [1000108],AETNA [100010801],,,76.8,,18.99,0.222255,85118.57664,percent of total billed charges,,,
FENOFIBRATE 48 MG ORAL TABS,RX-40009,CDM,S5000,HCPCS,259,RC,51079-0599-01,NDC,outpatient,1,UN,4.01,2.807,AETNA [1000108],AETNA [100010801],,,76.8,,3.08,0.222255,85118.57664,percent of total billed charges,,,
FENOFIBRATE 48 MG ORAL TABS,RX-40009,CDM,S5000,HCPCS,259,RC,51079-0599-20,NDC,outpatient,1,UN,4.01,2.807,AETNA [1000108],AETNA [100010801],,,76.8,,3.08,0.222255,85118.57664,percent of total billed charges,,,
FENOFIBRATE 145 MG ORAL TABS,RX-40010,CDM,S5000,HCPCS,259,RC,51079-0608-20,NDC,outpatient,1,UN,10.74,7.518,AETNA [1000108],AETNA [100010801],,,76.8,,8.25,0.222255,85118.57664,percent of total billed charges,,,
FENOFIBRATE 145 MG ORAL TABS,RX-40010,CDM,S5000,HCPCS,259,RC,60687-0629-21,NDC,outpatient,1,UN,4.19,2.933,AETNA [1000108],AETNA [100010801],,,76.8,,3.22,0.222255,85118.57664,percent of total billed charges,,,
MAGIC MOUTHWASH ORAL SUSPENSION *HOSPITAL USE ONLY*,RX-400477,CDM,S5000,HCPCS,259,RC,65628-0050-01,NDC,outpatient,10,ML,19.54,13.678,AETNA [1000108],AETNA [100010801],,,76.8,,15.01,0.222255,85118.57664,percent of total billed charges,,,
MAGIC MOUTHWASH ORAL SUSPENSION *HOSPITAL USE ONLY*,RX-400477,CDM,S5000,HCPCS,259,RC,65628-0050-04,NDC,outpatient,5,ML,14,9.8,AETNA [1000108],AETNA [100010801],,,76.8,,10.75,0.222255,85118.57664,percent of total billed charges,,,
MAGIC MOUTHWASH ORAL SUSPENSION *HOSPITAL USE ONLY*,RX-400477,CDM,S5000,HCPCS,259,RC,99999-0000-82,NDC,outpatient,10,ML,19.54,13.678,AETNA [1000108],AETNA [100010801],,,76.8,,15.01,0.222255,85118.57664,percent of total billed charges,,,
MAGIC MOUTHWASH ORAL SUSPENSION *HOSPITAL USE ONLY*,RX-400477,CDM,S5000,HCPCS,259,RC,99999-0000-61,NDC,outpatient,180,ML,12.46,8.722,AETNA [1000108],AETNA [100010801],,,76.8,,9.57,0.222255,85118.57664,percent of total billed charges,,,
RIFAMPIN 10 MG/ML ORAL SUSPENSION,RX-400484,CDM,S5000,HCPCS,259,RC,99999-0001-44,NDC,outpatient,120,ML,34,23.8,AETNA [1000108],AETNA [100010801],,,76.8,,26.11,0.222255,85118.57664,percent of total billed charges,,,
METOPROLOL TARTRATE 12.5 MG ORAL SPLIT TABLET,RX-400503,CDM,S5000,HCPCS,259,RC,,,outpatient,12.5,ME,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
METOPROLOL TARTRATE 12.5 MG ORAL SPLIT TABLET,RX-400503,CDM,S5000,HCPCS,259,RC,99999-0002-12,NDC,outpatient,12.5,ME,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
METOPROLOL TARTRATE 12.5 MG ORAL SPLIT TABLET,RX-400503,CDM,S5000,HCPCS,259,RC,SH040-0403-01,NDC,outpatient,12.5,ME,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
CEFAZOLIN EYE DROPS 50 MG/ML 20 ML BOTTLE,RX-400598,CDM,S5000,HCPCS,259,RC,SH408-0378-01,NDC,outpatient,20,ML,18.41,12.887,AETNA [1000108],AETNA [100010801],,,76.8,,14.14,0.222255,85118.57664,percent of total billed charges,,,
MISOPROSTOL 25 MCG ORAL SPLIT TABS,RX-400620,CDM,S5000,HCPCS,259,RC,,,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
MISOPROSTOL 25 MCG ORAL SPLIT TABS,RX-400620,CDM,S5000,HCPCS,259,RC,SH040-0620-01,NDC,outpatient,1,UN,1.69,1.183,AETNA [1000108],AETNA [100010801],,,76.8,,1.3,0.222255,85118.57664,percent of total billed charges,,,
ISONIAZID 100 MG ORAL TABS,RX-4026,CDM,S5000,HCPCS,259,RC,00555-0066-02,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
AMINOCAPROIC ACID 250 MG/ML IV SOLN,RX-403,CDM,S5000,HCPCS,250,RC,00517-9120-25,NDC,outpatient,4,ML,8,5.6,AETNA [1000108],AETNA [100010801],,,76.8,,6.14,0.222255,85118.57664,percent of total billed charges,,,
AMINOCAPROIC ACID 250 MG/ML IV SOLN,RX-403,CDM,S5000,HCPCS,250,RC,00409-4346-16,NDC,outpatient,20,ML,18.34,12.838,AETNA [1000108],AETNA [100010801],,,76.8,,14.09,0.222255,85118.57664,percent of total billed charges,,,
AMINOCAPROIC ACID 250 MG/ML IV SOLN,RX-403,CDM,S5000,HCPCS,250,RC,00409-4346-73,NDC,outpatient,20,ML,18.34,12.838,AETNA [1000108],AETNA [100010801],,,76.8,,14.09,0.222255,85118.57664,percent of total billed charges,,,
AMINOCAPROIC ACID 250 MG/ML IV SOLN,RX-403,CDM,S5000,HCPCS,250,RC,00517-9120-01,NDC,outpatient,4,ML,8,5.6,AETNA [1000108],AETNA [100010801],,,76.8,,6.14,0.222255,85118.57664,percent of total billed charges,,,
ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN,RX-4034,CDM,S5000,HCPCS,250,RC,00548-9502-00,NDC,outpatient,5,ML,246.51,172.557,AETNA [1000108],AETNA [100010801],,,76.8,,189.32,0.222255,85118.57664,percent of total billed charges,,,
ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN,RX-4034,CDM,S5000,HCPCS,250,RC,14789-0015-07,NDC,outpatient,5,ML,1453.64,1017.548,AETNA [1000108],AETNA [100010801],,,76.8,,1116.4,0.222255,85118.57664,percent of total billed charges,,,
ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN,RX-4034,CDM,S5000,HCPCS,250,RC,14789-0015-05,NDC,outpatient,5,ML,1453.64,1017.548,AETNA [1000108],AETNA [100010801],,,76.8,,1116.4,0.222255,85118.57664,percent of total billed charges,,,
MESALAMINE 1000 MG RE SUPP,RX-40369,CDM,S5000,HCPCS,259,RC,69918-0560-30,NDC,outpatient,1,UN,7.56,5.292,AETNA [1000108],AETNA [100010801],,,76.8,,5.81,0.222255,85118.57664,percent of total billed charges,,,
MESALAMINE 1000 MG RE SUPP,RX-40369,CDM,S5000,HCPCS,259,RC,59762-0118-03,NDC,outpatient,1,UN,22.5,15.75,AETNA [1000108],AETNA [100010801],,,76.8,,17.28,0.222255,85118.57664,percent of total billed charges,,,
SOLIFENACIN SUCCINATE 5 MG ORAL TABS,RX-40392,CDM,S5000,HCPCS,259,RC,51248-0150-01,NDC,outpatient,1,UN,52.84,36.988,AETNA [1000108],AETNA [100010801],,,76.8,,40.58,0.222255,85118.57664,percent of total billed charges,,,
CYANOCOBALAMIN 500 MCG SL SUBL,RX-40518,CDM,S5000,HCPCS,259,RC,74312-0035-95,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
CYANOCOBALAMIN 500 MCG SL SUBL,RX-40518,CDM,S5000,HCPCS,259,RC,00743-1203-59,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ISOSORBIDE DINITRATE 10 MG ORAL TABS,RX-4064,CDM,S5000,HCPCS,259,RC,68084-0082-01,NDC,outpatient,1,UN,2.67,1.869,AETNA [1000108],AETNA [100010801],,,76.8,,2.05,0.222255,85118.57664,percent of total billed charges,,,
ISOSORBIDE DINITRATE 10 MG ORAL TABS,RX-4064,CDM,S5000,HCPCS,259,RC,68084-0082-11,NDC,outpatient,1,UN,2.67,1.869,AETNA [1000108],AETNA [100010801],,,76.8,,2.05,0.222255,85118.57664,percent of total billed charges,,,
ISOSORBIDE DINITRATE 20 MG ORAL TABS,RX-4065,CDM,S5000,HCPCS,259,RC,00904-6620-61,NDC,outpatient,1,UN,2.27,1.589,AETNA [1000108],AETNA [100010801],,,76.8,,1.74,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % IV PVC FREE SOLN,RX-4080010,CDM,S5000,HCPCS,250,RC,00264-1800-32,NDC,outpatient,100,ML,28.85,20.195,AETNA [1000108],AETNA [100010801],,,76.8,,22.16,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % IV PVC FREE SOLN,RX-4080010,CDM,S5000,HCPCS,250,RC,00264-7800-20,NDC,outpatient,250,ML,30.14,21.098,AETNA [1000108],AETNA [100010801],,,76.8,,23.15,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % IV PVC FREE SOLN,RX-4080010,CDM,S5000,HCPCS,250,RC,00264-7800-10,NDC,outpatient,500,ML,31.42,21.994,AETNA [1000108],AETNA [100010801],,,76.8,,24.13,0.222255,85118.57664,percent of total billed charges,,,
HYDROMORPHONE 100 MG/100 ML INFUSION,RX-4080055,CDM,S5000,HCPCS,250,RC,99999-0000-26,NDC,outpatient,100,ML,168.65,118.055,AETNA [1000108],AETNA [100010801],,,76.8,,129.52,0.222255,85118.57664,percent of total billed charges,,,
DILTIAZEM ADDVANTAGE INFUSION IN NS,RX-4080056,CDM,S5000,HCPCS,250,RC,99999-0000-00,NDC,outpatient,100,ML,54.5,38.15,AETNA [1000108],AETNA [100010801],,,76.8,,41.86,0.222255,85118.57664,percent of total billed charges,,,
FENTANYL INFUSION PREMIX 10 MCG/ML 250 ML,RX-4080065,CDM,S5000,HCPCS,250,RC,70004-0229-40,NDC,outpatient,250,ML,277.66,194.362,AETNA [1000108],AETNA [100010801],,,76.8,,213.24,0.222255,85118.57664,percent of total billed charges,,,
FENTANYL INFUSION PREMIX 10 MCG/ML 250 ML,RX-4080065,CDM,S5000,HCPCS,250,RC,99999-0001-54,NDC,outpatient,250,ML,37.36,26.152,AETNA [1000108],AETNA [100010801],,,76.8,,28.69,0.222255,85118.57664,percent of total billed charges,,,
FENTANYL INFUSION PREMIX 10 MCG/ML 250 ML,RX-4080065,CDM,S5000,HCPCS,250,RC,70092-1093-37,NDC,outpatient,250,ML,130.86,91.602,AETNA [1000108],AETNA [100010801],,,76.8,,100.5,0.222255,85118.57664,percent of total billed charges,,,
FENTANYL INFUSION PREMIX 10 MCG/ML 250 ML,RX-4080065,CDM,S5000,HCPCS,250,RC,70004-0202-40,NDC,outpatient,250,ML,236.1,165.27,AETNA [1000108],AETNA [100010801],,,76.8,,181.32,0.222255,85118.57664,percent of total billed charges,,,
KETAMINE INFUSION 500 MG IN 250 ML INFUSION,RX-4080078,CDM,S5000,HCPCS,250,RC,70004-0442-40,NDC,outpatient,250,ML,112.79,78.953,AETNA [1000108],AETNA [100010801],,,76.8,,86.62,0.222255,85118.57664,percent of total billed charges,,,
KETAMINE INFUSION 500 MG IN 250 ML INFUSION,RX-4080078,CDM,S5000,HCPCS,250,RC,99999-9990-03,NDC,outpatient,250,ML,37.81,26.467,AETNA [1000108],AETNA [100010801],,,76.8,,29.04,0.222255,85118.57664,percent of total billed charges,,,
MORPHINE INFUSION 250 MG IN D5W 250 ML PREMIX,RX-4080096,CDM,S5000,HCPCS,250,RC,99999-0001-61,NDC,outpatient,250,ML,35.02,24.514,AETNA [1000108],AETNA [100010801],,,76.8,,26.9,0.222255,85118.57664,percent of total billed charges,,,
FAMOTIDINE 10 MG/ML IJ WRAPPER,RX-4080100,CDM,S5000,HCPCS,250,RC,00641-6022-01,NDC,outpatient,2,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,,,
FAMOTIDINE 10 MG/ML IJ WRAPPER,RX-4080100,CDM,S5000,HCPCS,250,RC,67457-0433-00,NDC,outpatient,2,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,,,
FAMOTIDINE 10 MG/ML IJ WRAPPER,RX-4080100,CDM,S5000,HCPCS,250,RC,00641-6022-25,NDC,outpatient,2,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,,,
FAMOTIDINE 10 MG/ML IJ WRAPPER,RX-4080100,CDM,S5000,HCPCS,250,RC,67457-0433-22,NDC,outpatient,2,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,,,
ARTIFICIAL TEARS EYE SOLN WRAPPER,RX-4080101,CDM,S5000,HCPCS,259,RC,57896-0181-05,NDC,outpatient,15,ML,5.55,3.885,AETNA [1000108],AETNA [100010801],,,76.8,,4.26,0.222255,85118.57664,percent of total billed charges,,,
ARTIFICIAL TEARS EYE SOLN WRAPPER,RX-4080101,CDM,S5000,HCPCS,259,RC,00065-0426-36,NDC,outpatient,15,ML,27.17,19.019,AETNA [1000108],AETNA [100010801],,,76.8,,20.87,0.222255,85118.57664,percent of total billed charges,,,
NAFCILLIN SODIUM 1 G IJ WRAPPER,RX-4080106,CDM,S5000,HCPCS,250,RC,63323-0327-10,NDC,outpatient,1,UN,15.49,10.843,AETNA [1000108],AETNA [100010801],,,76.8,,11.9,0.222255,85118.57664,percent of total billed charges,,,
NAFCILLIN SODIUM 2 G IJ WRAPPER,RX-4080107,CDM,S5000,HCPCS,250,RC,44567-0222-10,NDC,outpatient,1,UN,90.46,63.322,AETNA [1000108],AETNA [100010801],,,76.8,,69.47,0.222255,85118.57664,percent of total billed charges,,,
NAFCILLIN SODIUM 2 G IJ WRAPPER,RX-4080107,CDM,S5000,HCPCS,250,RC,55150-0123-15,NDC,outpatient,1,UN,30.45,21.315,AETNA [1000108],AETNA [100010801],,,76.8,,23.39,0.222255,85118.57664,percent of total billed charges,,,
NAFCILLIN SODIUM 2 G IJ WRAPPER,RX-4080107,CDM,S5000,HCPCS,250,RC,63323-0328-20,NDC,outpatient,1,UN,24.64,17.248,AETNA [1000108],AETNA [100010801],,,76.8,,18.92,0.222255,85118.57664,percent of total billed charges,,,
NOREPINEPHRINE PREMIX 4 MG IN 250 ML NS,RX-4080110,CDM,S5000,HCPCS,250,RC,71266-5020-02,NDC,outpatient,250,ML,112.97,79.079,AETNA [1000108],AETNA [100010801],,,76.8,,86.76,0.222255,85118.57664,percent of total billed charges,,,
NOREPINEPHRINE PREMIX 4 MG IN 250 ML NS,RX-4080110,CDM,S5000,HCPCS,250,RC,70004-0781-40,NDC,outpatient,250,ML,123.78,86.646,AETNA [1000108],AETNA [100010801],,,76.8,,95.06,0.222255,85118.57664,percent of total billed charges,,,
NOREPINEPHRINE PREMIX 4 MG IN 250 ML NS,RX-4080110,CDM,S5000,HCPCS,250,RC,70092-1650-05,NDC,outpatient,250,ML,102.2,71.54,AETNA [1000108],AETNA [100010801],,,76.8,,78.49,0.222255,85118.57664,percent of total billed charges,,,
PHENYLEPHRINE IV PREMIX 40 MG IN 250 ML NS,RX-4080112,CDM,S5000,HCPCS,250,RC,42852-0838-25,NDC,outpatient,250,ML,158.85,111.195,AETNA [1000108],AETNA [100010801],,,76.8,,122,0.222255,85118.57664,percent of total billed charges,,,
PHENYLEPHRINE IV PREMIX 40 MG IN 250 ML NS,RX-4080112,CDM,S5000,HCPCS,250,RC,70004-0812-40,NDC,outpatient,250,ML,93.12,65.184,AETNA [1000108],AETNA [100010801],,,76.8,,71.52,0.222255,85118.57664,percent of total billed charges,,,
PHENYLEPHRINE IV PREMIX 40 MG IN 250 ML NS,RX-4080112,CDM,S5000,HCPCS,250,RC,70092-9170-05,NDC,outpatient,250,ML,146.26,102.382,AETNA [1000108],AETNA [100010801],,,76.8,,112.33,0.222255,85118.57664,percent of total billed charges,,,
PHENYLEPHRINE IV PREMIX 10 MG IN 250 ML NS,RX-4080113,CDM,S5000,HCPCS,250,RC,70004-0811-40,NDC,outpatient,250,ML,109.23,76.461,AETNA [1000108],AETNA [100010801],,,76.8,,83.89,0.222255,85118.57664,percent of total billed charges,,,
PHENYLEPHRINE IV PREMIX 10 MG IN 250 ML NS,RX-4080113,CDM,S5000,HCPCS,250,RC,71506-0010-58,NDC,outpatient,250,ML,88.76,62.132,AETNA [1000108],AETNA [100010801],,,76.8,,68.17,0.222255,85118.57664,percent of total billed charges,,,
VANCOMYCIN HCL IN DEXTROSE 1250 MG/250 ML IV SOLN,RX-4080122,CDM,S5000,HCPCS,250,RC,99999-0000-46,NDC,outpatient,275,ML,64.38,45.066,AETNA [1000108],AETNA [100010801],,,76.8,,49.44,0.222255,85118.57664,percent of total billed charges,,,
VANCOMYCIN HCL IN DEXTROSE 1500 MG/250 ML IV SOLN,RX-4080123,CDM,S5000,HCPCS,250,RC,99999-0000-47,NDC,outpatient,280,ML,80.8,56.56,AETNA [1000108],AETNA [100010801],,,76.8,,62.05,0.222255,85118.57664,percent of total billed charges,,,
CARDIOPLEGIA SOLN HIGH POTASSIUM 4:1 INDUCTION,RX-4080154,CDM,S5000,HCPCS,250,RC,72196-0101-01,NDC,outpatient,500,ML,673.36,471.352,AETNA [1000108],AETNA [100010801],,,76.8,,517.14,0.222255,85118.57664,percent of total billed charges,,,
CARDIOPLEGIA SOLN LOW POTASSION 4:1 REPERFUSATE,RX-4080155,CDM,S5000,HCPCS,250,RC,71285-0007-01,NDC,outpatient,238.75,ML,1537.64,1076.348,AETNA [1000108],AETNA [100010801],,,76.8,,1180.91,0.222255,85118.57664,percent of total billed charges,,,
CARDIOPLEGIA SOLN LOW POTASSIUM 4:1 MAINTENANCE,RX-4080156,CDM,S5000,HCPCS,250,RC,72196-0104-01,NDC,outpatient,1000,ML,1042.09,729.463,AETNA [1000108],AETNA [100010801],,,76.8,,800.33,0.222255,85118.57664,percent of total billed charges,,,
CONCENTRATED DILAUDID 1 MG/ML PCA,RX-4080157,CDM,S5000,HCPCS,250,RC,70004-0303-62,NDC,outpatient,50,ML,212.25,148.575,AETNA [1000108],AETNA [100010801],,,76.8,,163.01,0.222255,85118.57664,percent of total billed charges,,,
DILAUDID 0.2 MG/ML PCA (HYDROMORPHONE),RX-4080159,CDM,S5000,HCPCS,250,RC,70004-0300-62,NDC,outpatient,50,ML,69.63,48.741,AETNA [1000108],AETNA [100010801],,,76.8,,53.48,0.222255,85118.57664,percent of total billed charges,,,
PRISMASATE K 0/CA 3.5 CRRT SOLUTION,RX-4080163,CDM,S5000,HCPCS,250,RC,00000-1053-53,NDC,outpatient,5000,ML,188.44,131.908,AETNA [1000108],AETNA [100010801],,,76.8,,144.72,0.222255,85118.57664,percent of total billed charges,,,
FENTANYL 2 MCG/ML WITH BUPIVACAINE 0.125 % EPIDURAL,RX-4080168,CDM,S5000,HCPCS,250,RC,99999-0001-52,NDC,outpatient,100,ML,30.84,21.588,AETNA [1000108],AETNA [100010801],,,76.8,,23.69,0.222255,85118.57664,percent of total billed charges,,,
FENTANYL 2 MCG/ML WITH BUPIVACAINE 0.125 % EPIDURAL,RX-4080168,CDM,S5000,HCPCS,250,RC,70004-0231-64,NDC,outpatient,100,ML,109.23,76.461,AETNA [1000108],AETNA [100010801],,,76.8,,83.89,0.222255,85118.57664,percent of total billed charges,,,
FENTANYL 2 MCG/ML WITH BUPIVACAINE 0.125 % EPIDURAL,RX-4080168,CDM,S5000,HCPCS,250,RC,70092-1202-75,NDC,outpatient,100,ML,258.44,180.908,AETNA [1000108],AETNA [100010801],,,76.8,,198.48,0.222255,85118.57664,percent of total billed charges,,,
FENTANYL 2 MCG/ML WITH BUPIVACAINE 0.125 % EPIDURAL,RX-4080168,CDM,S5000,HCPCS,250,RC,70092-9202-75,NDC,outpatient,100,ML,251.94,176.358,AETNA [1000108],AETNA [100010801],,,76.8,,193.49,0.222255,85118.57664,percent of total billed charges,,,
FENTANYL 5 MCG/ML WITH BUPIVACAINE 0.075 % EPIDURAL,RX-4080169,CDM,S5000,HCPCS,250,RC,99999-0001-55,NDC,outpatient,100,ML,34.55,24.185,AETNA [1000108],AETNA [100010801],,,76.8,,26.53,0.222255,85118.57664,percent of total billed charges,,,
FENTANYL 3 MCG/ML WITH BUPIVACAINE 0.075 % EPIDURAL,RX-4080170,CDM,S5000,HCPCS,250,RC,99999-0000-03,NDC,outpatient,100,ML,67.18,47.026,AETNA [1000108],AETNA [100010801],,,76.8,,51.59,0.222255,85118.57664,percent of total billed charges,,,
FENTANYL CITRATE (PF) 0.05 MG/ML NASAL SOLUTION,RX-4080181,CDM,S5000,HCPCS,259,RC,00409-9094-12,NDC,outpatient,2,ML,6.33,4.431,AETNA [1000108],AETNA [100010801],,,76.8,,4.86,0.222255,85118.57664,percent of total billed charges,,,
FENTANYL CITRATE (PF) 0.05 MG/ML NASAL SOLUTION,RX-4080181,CDM,S5000,HCPCS,259,RC,00409-9094-22,NDC,outpatient,2,ML,6.33,4.431,AETNA [1000108],AETNA [100010801],,,76.8,,4.86,0.222255,85118.57664,percent of total billed charges,,,
MIDAZOLAM HCL 5 MG/ML NASAL SOLUTION,RX-4080183,CDM,S5000,HCPCS,250,RC,00409-2308-21,NDC,outpatient,1,ML,3.42,2.394,AETNA [1000108],AETNA [100010801],,,76.8,,2.63,0.222255,85118.57664,percent of total billed charges,,,
MIDAZOLAM HCL 5 MG/ML NASAL SOLUTION,RX-4080183,CDM,S5000,HCPCS,250,RC,00409-2308-01,NDC,outpatient,1,ML,3.42,2.394,AETNA [1000108],AETNA [100010801],,,76.8,,2.63,0.222255,85118.57664,percent of total billed charges,,,
NICARDIPINE HCL IN NACL 1 MG/10 ML IV SYRINGE,RX-4080192,CDM,S5000,HCPCS,250,RC,70004-0756-12,NDC,outpatient,10,ML,39.83,27.881,AETNA [1000108],AETNA [100010801],,,76.8,,30.59,0.222255,85118.57664,percent of total billed charges,,,
NICARDIPINE HCL IN NACL 1 MG/10 ML IV SYRINGE,RX-4080192,CDM,S5000,HCPCS,250,RC,99999-0001-50,NDC,outpatient,10,ML,10.7,7.49,AETNA [1000108],AETNA [100010801],,,76.8,,8.22,0.222255,85118.57664,percent of total billed charges,,,
DILTIAZEM HCL 5 MG/ML IV WRAPPER,RX-4080196,CDM,S5000,HCPCS,250,RC,00641-6014-10,NDC,outpatient,10,ML,22.61,15.827,AETNA [1000108],AETNA [100010801],,,76.8,,17.36,0.222255,85118.57664,percent of total billed charges,,,
DILTIAZEM HCL 5 MG/ML IV WRAPPER,RX-4080196,CDM,S5000,HCPCS,250,RC,00641-6014-01,NDC,outpatient,10,ML,22.61,15.827,AETNA [1000108],AETNA [100010801],,,76.8,,17.36,0.222255,85118.57664,percent of total billed charges,,,
DILTIAZEM HCL 5 MG/ML IV WRAPPER,RX-4080196,CDM,S5000,HCPCS,250,RC,00641-6013-10,NDC,outpatient,5,ML,14.35,10.045,AETNA [1000108],AETNA [100010801],,,76.8,,11.02,0.222255,85118.57664,percent of total billed charges,,,
DILTIAZEM HCL 5 MG/ML IV WRAPPER,RX-4080196,CDM,S5000,HCPCS,250,RC,00641-6013-01,NDC,outpatient,5,ML,14.35,10.045,AETNA [1000108],AETNA [100010801],,,76.8,,11.02,0.222255,85118.57664,percent of total billed charges,,,
NIFEDIPINE-LIDOCAINE 0.3%-1.5% OINT,RX-408020,CDM,S5000,HCPCS,259,RC,00000-0000-03,NDC,outpatient,30,GR,333.75,233.625,AETNA [1000108],AETNA [100010801],,,76.8,,256.32,0.222255,85118.57664,percent of total billed charges,,,
METOPROLOL TARTRATE 1 MG/ML IV SOLN WRAPPER,RX-4080203,CDM,S5000,HCPCS,250,RC,00409-1778-05,NDC,outpatient,5,ML,3.47,2.429,AETNA [1000108],AETNA [100010801],,,76.8,,2.66,0.222255,85118.57664,percent of total billed charges,,,
METOPROLOL TARTRATE 1 MG/ML IV SOLN WRAPPER,RX-4080203,CDM,S5000,HCPCS,250,RC,00409-1778-15,NDC,outpatient,5,ML,3.47,2.429,AETNA [1000108],AETNA [100010801],,,76.8,,2.66,0.222255,85118.57664,percent of total billed charges,,,
DIBUCAINE 1 % EX OINT WRAPPER,RX-4080210,CDM,S5000,HCPCS,259,RC,71399-2829-01,NDC,outpatient,28,GR,14.21,9.947,AETNA [1000108],AETNA [100010801],,,76.8,,10.91,0.222255,85118.57664,percent of total billed charges,,,
DIBUCAINE 1 % EX OINT WRAPPER,RX-4080210,CDM,S5000,HCPCS,259,RC,00536-1211-95,NDC,outpatient,28,GR,13.84,9.688,AETNA [1000108],AETNA [100010801],,,76.8,,10.63,0.222255,85118.57664,percent of total billed charges,,,
COCOA BUTTER STICK,RX-4080278,CDM,S5000,HCPCS,259,RC,07570-7011-00,NDC,outpatient,30,ML,4.41,3.087,AETNA [1000108],AETNA [100010801],,,76.8,,3.39,0.222255,85118.57664,percent of total billed charges,,,
CAPSAICIN 0.025 % EX CREAM WRAPPER,RX-4080289,CDM,S5000,HCPCS,259,RC,00536-2525-25,NDC,outpatient,60,GR,10.95,7.665,AETNA [1000108],AETNA [100010801],,,76.8,,8.41,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE-PRILOCAINE 2.5-2.5 % EX CREAM WRAPPER,RX-4080290,CDM,S5000,HCPCS,259,RC,00168-0357-55,NDC,outpatient,5,GR,29.95,20.965,AETNA [1000108],AETNA [100010801],,,76.8,,23,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE-PRILOCAINE 2.5-2.5 % EX CREAM WRAPPER,RX-4080290,CDM,S5000,HCPCS,259,RC,62332-0582-04,NDC,outpatient,5,GR,24.68,17.276,AETNA [1000108],AETNA [100010801],,,76.8,,18.95,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE-PRILOCAINE 2.5-2.5 % EX CREAM WRAPPER,RX-4080290,CDM,S5000,HCPCS,259,RC,62332-0582-31,NDC,outpatient,30,GR,87.18,61.026,AETNA [1000108],AETNA [100010801],,,76.8,,66.95,0.222255,85118.57664,percent of total billed charges,,,
NITROGLYCERIN IN D5W 2000 MCG/20 ML IV SYRINGE,RX-4080358,CDM,S5000,HCPCS,250,RC,SH408-0358-01,NDC,outpatient,20,ML,3.71,2.597,AETNA [1000108],AETNA [100010801],,,76.8,,2.85,0.222255,85118.57664,percent of total billed charges,,,
NITROGLYCERIN IN D5W 2000 MCG/20 ML IV SYRINGE,RX-4080358,CDM,S5000,HCPCS,250,RC,99999-0000-54,NDC,outpatient,20,ML,3.71,2.597,AETNA [1000108],AETNA [100010801],,,76.8,,2.85,0.222255,85118.57664,percent of total billed charges,,,
MULTIVITAMIN CHILDRENS ORAL CHEW WRAPPER,RX-4080360,CDM,S5000,HCPCS,259,RC,80681-0049-00,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
AMPHOTERICIN B EYE DROPS 0.2 MG/ML 10 ML BOTTLE,RX-4080376,CDM,S5000,HCPCS,259,RC,SH408-0376-01,NDC,outpatient,10,ML,61.86,43.302,AETNA [1000108],AETNA [100010801],,,76.8,,47.51,0.222255,85118.57664,percent of total billed charges,,,
ASPIRIN 1 MG/ML ORAL SUSPENSION 81 ML FOR ASA DESENSITIZATION,RX-4080380,CDM,S5000,HCPCS,259,RC,SH408-0380-01,NDC,outpatient,81,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
CEFTAZIDIME EYE DROPS 22.5 MG/ML SYRINGE,RX-4080386,CDM,S5000,HCPCS,259,RC,99999-0000-32,NDC,outpatient,1,ML,37.46,26.222,AETNA [1000108],AETNA [100010801],,,76.8,,28.77,0.222255,85118.57664,percent of total billed charges,,,
CLINDAMYCIN MOUTH WASH 3 MG/ML,RX-4080388,CDM,S5000,HCPCS,259,RC,99999-0000-33,NDC,outpatient,250,ML,10.02,7.014,AETNA [1000108],AETNA [100010801],,,76.8,,7.7,0.222255,85118.57664,percent of total billed charges,,,
LIDO 4%-EPI 0.05%-TETRACAINE 0.5% (LET) GEL 3 ML,RX-4080408,CDM,S5000,HCPCS,259,RC,70092-1135-44,NDC,outpatient,3,ML,49.22,34.454,AETNA [1000108],AETNA [100010801],,,76.8,,37.8,0.222255,85118.57664,percent of total billed charges,,,
LIDO 4%-EPI 0.05%-TETRACAINE 0.5% (LET) GEL 3 ML,RX-4080408,CDM,S5000,HCPCS,259,RC,88888-0926-28,NDC,outpatient,3,ML,22.25,15.575,AETNA [1000108],AETNA [100010801],,,76.8,,17.09,0.222255,85118.57664,percent of total billed charges,,,
LIDO 4%-EPI 0.05%-TETRACAINE 0.5% (LET) GEL 3 ML,RX-4080408,CDM,S5000,HCPCS,259,RC,69623-0801-14,NDC,outpatient,3,ML,35.6,24.92,AETNA [1000108],AETNA [100010801],,,76.8,,27.34,0.222255,85118.57664,percent of total billed charges,,,
LIDO 4%-EPI 0.05%-TETRACAINE 0.5% (LET) GEL 3 ML,RX-4080408,CDM,S5000,HCPCS,259,RC,99999-0003-19,NDC,outpatient,3,ML,14.57,10.199,AETNA [1000108],AETNA [100010801],,,76.8,,11.19,0.222255,85118.57664,percent of total billed charges,,,
MAG SULFATE-GLYCERIN-WATER ENEMA 180 ML,RX-4080412,CDM,S5000,HCPCS,259,RC,00000-0000-02,NDC,outpatient,180,ML,28.04,19.628,AETNA [1000108],AETNA [100010801],,,76.8,,21.53,0.222255,85118.57664,percent of total billed charges,,,
METOPROLOL TARTRATE ORAL SUSPENSION 1 MG/ML,RX-4080416,CDM,S5000,HCPCS,259,RC,99999-0003-46,NDC,outpatient,12.5,ML,1.93,1.351,AETNA [1000108],AETNA [100010801],,,76.8,,1.48,0.222255,85118.57664,percent of total billed charges,,,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,62135-0250-37,NDC,outpatient,240,ML,1184.42,829.094,AETNA [1000108],AETNA [100010801],,,76.8,,909.63,0.222255,85118.57664,percent of total billed charges,,,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,69238-2122-20,NDC,outpatient,20,ML,14.96,10.472,AETNA [1000108],AETNA [100010801],,,76.8,,11.49,0.222255,85118.57664,percent of total billed charges,,,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,99999-0002-35,NDC,outpatient,20,ML,13.44,9.408,AETNA [1000108],AETNA [100010801],,,76.8,,10.32,0.222255,85118.57664,percent of total billed charges,,,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,00121-0759-20,NDC,outpatient,20,ML,13.44,9.408,AETNA [1000108],AETNA [100010801],,,76.8,,10.32,0.222255,85118.57664,percent of total billed charges,,,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,00121-0885-16,NDC,outpatient,480,ML,1149.17,804.419,AETNA [1000108],AETNA [100010801],,,76.8,,882.56,0.222255,85118.57664,percent of total billed charges,,,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,99999-0002-36,NDC,outpatient,5,ML,2.94,2.058,AETNA [1000108],AETNA [100010801],,,76.8,,2.26,0.222255,85118.57664,percent of total billed charges,,,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,00121-0759-08,NDC,outpatient,237,ML,159.26,111.482,AETNA [1000108],AETNA [100010801],,,76.8,,122.31,0.222255,85118.57664,percent of total billed charges,,,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,42799-0815-01,NDC,outpatient,237,ML,151.87,106.309,AETNA [1000108],AETNA [100010801],,,76.8,,116.64,0.222255,85118.57664,percent of total billed charges,,,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,62135-0250-20,NDC,outpatient,20,ML,98.71,69.097,AETNA [1000108],AETNA [100010801],,,76.8,,75.81,0.222255,85118.57664,percent of total billed charges,,,
MORPHINE 0.4 MG/ML 1 ML NEONATAL ORAL SYRINGE,RX-4080423,CDM,S5000,HCPCS,259,RC,99999-0001-12,NDC,outpatient,1,ML,1.09,0.763,AETNA [1000108],AETNA [100010801],,,76.8,,0.84,0.222255,85118.57664,percent of total billed charges,,,
MORPHINE 0.4 MG/ML 1 ML NEONATAL ORAL SYRINGE,RX-4080423,CDM,S5000,HCPCS,259,RC,SH408-0423-01,NDC,outpatient,1,ML,1.09,0.763,AETNA [1000108],AETNA [100010801],,,76.8,,0.84,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE 1 MEQ/ML 1 ML ORAL SYRINGE,RX-4080424,CDM,S5000,HCPCS,259,RC,99999-0001-25,NDC,outpatient,1,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE-MINERAL OIL-GLYCERIN ENEMA,RX-4080430,CDM,S5000,HCPCS,259,RC,SH408-0430-01,NDC,outpatient,135,ML,9.22,6.454,AETNA [1000108],AETNA [100010801],,,76.8,,7.08,0.222255,85118.57664,percent of total billed charges,,,
POTASSIUM CHLORIDE 2 MEQ/1.5 ML ORAL SYRINGE,RX-4080432,CDM,S5000,HCPCS,259,RC,,,outpatient,1.5,ML,1.92,1.344,AETNA [1000108],AETNA [100010801],,,76.8,,1.47,0.222255,85118.57664,percent of total billed charges,,,
POTASSIUM CHLORIDE 2 MEQ/1.5 ML ORAL SYRINGE,RX-4080432,CDM,S5000,HCPCS,259,RC,99999-0001-26,NDC,outpatient,1.5,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
SPIRONOLACTONE 6 MG/3 ML ORAL SYRINGE,RX-4080435,CDM,S5000,HCPCS,259,RC,99999-0000-28,NDC,outpatient,3,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
CEFAZOLIN IVPB 2 G IN 100 ML NS PREMIX,RX-4080437,CDM,S5000,HCPCS,250,RC,99999-0000-45,NDC,outpatient,100,ML,47.78,33.446,AETNA [1000108],AETNA [100010801],,,76.8,,36.7,0.222255,85118.57664,percent of total billed charges,,,
VANCOMYCIN INTRACAMERAL INJECTION 10 MG/ML,RX-4080449,CDM,S5000,HCPCS,259,RC,SH408-0450-01,NDC,outpatient,0.1,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
VANCOMYCIN INTRACAMERAL INJECTION 10 MG/ML,RX-4080449,CDM,S5000,HCPCS,259,RC,SH408-0449-01,NDC,outpatient,2,ML,22.21,15.547,AETNA [1000108],AETNA [100010801],,,76.8,,17.06,0.222255,85118.57664,percent of total billed charges,,,
VANCOMYCIN EYE SOLUTION 25 MG/ML,RX-4080451,CDM,S5000,HCPCS,259,RC,SH408-0451-01,NDC,outpatient,20,ML,54.07,37.849,AETNA [1000108],AETNA [100010801],,,76.8,,41.53,0.222255,85118.57664,percent of total billed charges,,,
VANCOMYCIN EYE SOLUTION 50 MG/ML ,RX-4080452,CDM,S5000,HCPCS,259,RC,SH408-0452-01,NDC,outpatient,20,ML,54.07,37.849,AETNA [1000108],AETNA [100010801],,,76.8,,41.53,0.222255,85118.57664,percent of total billed charges,,,
WARFARIN SODIUM 0.5 MG ORAL SPLIT TABS,RX-4080479,CDM,S5000,HCPCS,259,RC,51672-4027-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
WARFARIN SODIUM 0.5 MG ORAL SPLIT TABS,RX-4080479,CDM,S5000,HCPCS,259,RC,76282-0327-01,NDC,outpatient,1,UN,1.15,0.805,AETNA [1000108],AETNA [100010801],,,76.8,,0.88,0.222255,85118.57664,percent of total billed charges,,,
WARFARIN SODIUM 0.5 MG ORAL SPLIT TABS,RX-4080479,CDM,S5000,HCPCS,259,RC,99999-0002-46,NDC,outpatient,0.5,ME,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
WARFARIN SODIUM 1.25 MG ORAL SPLIT TABS,RX-4080485,CDM,S5000,HCPCS,259,RC,51672-4029-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
WARFARIN SODIUM 1.25 MG ORAL SPLIT TABS,RX-4080485,CDM,S5000,HCPCS,259,RC,99999-0002-47,NDC,outpatient,1.25,ME,4.53,3.171,AETNA [1000108],AETNA [100010801],,,76.8,,3.48,0.222255,85118.57664,percent of total billed charges,,,
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,70004-0775-40,NDC,outpatient,250,ML,320.83,224.581,AETNA [1000108],AETNA [100010801],,,76.8,,246.4,0.222255,85118.57664,percent of total billed charges,,,
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,81298-9658-03,NDC,outpatient,250,ML,261.87,183.309,AETNA [1000108],AETNA [100010801],,,76.8,,201.12,0.222255,85118.57664,percent of total billed charges,,,
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,69374-0533-25,NDC,outpatient,250,ML,140.6,98.42,AETNA [1000108],AETNA [100010801],,,76.8,,107.98,0.222255,85118.57664,percent of total billed charges,,,
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,70092-1652-05,NDC,outpatient,250,ML,216.97,151.879,AETNA [1000108],AETNA [100010801],,,76.8,,166.63,0.222255,85118.57664,percent of total billed charges,,,
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,81298-9658-01,NDC,outpatient,250,ML,261.87,183.309,AETNA [1000108],AETNA [100010801],,,76.8,,201.12,0.222255,85118.57664,percent of total billed charges,,,
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,69374-0315-25,NDC,outpatient,250,ML,118.35,82.845,AETNA [1000108],AETNA [100010801],,,76.8,,90.89,0.222255,85118.57664,percent of total billed charges,,,
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,70092-1468-05,NDC,outpatient,250,ML,192.22,134.554,AETNA [1000108],AETNA [100010801],,,76.8,,147.62,0.222255,85118.57664,percent of total billed charges,,,
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,70004-0785-40,NDC,outpatient,250,ML,301.03,210.721,AETNA [1000108],AETNA [100010801],,,76.8,,231.19,0.222255,85118.57664,percent of total billed charges,,,
THIAMINE HCL 100 MG ORAL TABS WRAPPER,RX-4080502,CDM,S5000,HCPCS,259,RC,77333-0934-25,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
THIAMINE HCL 100 MG ORAL TABS WRAPPER,RX-4080502,CDM,S5000,HCPCS,259,RC,77333-0934-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
THIAMINE HCL 100 MG ORAL TABS WRAPPER,RX-4080502,CDM,S5000,HCPCS,259,RC,00904-7191-06,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
THIAMINE HCL 100 MG ORAL TABS WRAPPER,RX-4080502,CDM,S5000,HCPCS,259,RC,48433-0108-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
NEOSTIGMINE METHYLSULFATE 1 MG/ML SYRINGE,RX-4080506,CDM,S5000,HCPCS,250,RC,70004-0750-09,NDC,outpatient,5,ML,78.06,54.642,AETNA [1000108],AETNA [100010801],,,76.8,,59.95,0.222255,85118.57664,percent of total billed charges,,,
NEOSTIGMINE METHYLSULFATE 1 MG/ML SYRINGE,RX-4080506,CDM,S5000,HCPCS,250,RC,76045-0383-13,NDC,outpatient,3,ML,51.74,36.218,AETNA [1000108],AETNA [100010801],,,76.8,,39.74,0.222255,85118.57664,percent of total billed charges,,,
NEOSTIGMINE METHYLSULFATE 1 MG/ML SYRINGE,RX-4080506,CDM,S5000,HCPCS,250,RC,76045-0383-30,NDC,outpatient,3,ML,51.74,36.218,AETNA [1000108],AETNA [100010801],,,76.8,,39.74,0.222255,85118.57664,percent of total billed charges,,,
NEOSTIGMINE METHYLSULFATE 1 MG/ML SYRINGE,RX-4080506,CDM,S5000,HCPCS,250,RC,69374-0932-03,NDC,outpatient,3,ML,45.62,31.934,AETNA [1000108],AETNA [100010801],,,76.8,,35.04,0.222255,85118.57664,percent of total billed charges,,,
NEOSTIGMINE METHYLSULFATE 1 MG/ML SYRINGE,RX-4080506,CDM,S5000,HCPCS,250,RC,70092-1084-44,NDC,outpatient,5,ML,61.01,42.707,AETNA [1000108],AETNA [100010801],,,76.8,,46.86,0.222255,85118.57664,percent of total billed charges,,,
FERROUS GLUCONATE 324 MG ORAL TABS WRAPPER,RX-4080542,CDM,S5000,HCPCS,259,RC,00574-0508-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
FERROUS GLUCONATE 324 MG ORAL TABS WRAPPER,RX-4080542,CDM,S5000,HCPCS,259,RC,20555-0019-00,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ARTIFICIAL TEARS OP OINT WRAPPER,RX-4080546,CDM,S5000,HCPCS,259,RC,00065-0518-01,NDC,outpatient,3.5,GR,29.43,20.601,AETNA [1000108],AETNA [100010801],,,76.8,,22.6,0.222255,85118.57664,percent of total billed charges,,,
ARTIFICIAL TEARS OP OINT WRAPPER,RX-4080546,CDM,S5000,HCPCS,259,RC,10119-0022-39,NDC,outpatient,3.5,GR,30.17,21.119,AETNA [1000108],AETNA [100010801],,,76.8,,23.17,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE 1 % FOR PLEURODESIS,RX-4080551,CDM,S5000,HCPCS,250,RC,99999-0003-43,NDC,outpatient,50,ML,13.37,9.359,AETNA [1000108],AETNA [100010801],,,76.8,,10.27,0.222255,85118.57664,percent of total billed charges,,,
POTASSIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080554,CDM,S5000,HCPCS,250,RC,00409-7295-01,NDC,outpatient,15,ML,59.41,41.587,AETNA [1000108],AETNA [100010801],,,76.8,,45.63,0.222255,85118.57664,percent of total billed charges,,,
POTASSIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080554,CDM,S5000,HCPCS,250,RC,65219-0052-09,NDC,outpatient,5,ML,93.68,65.576,AETNA [1000108],AETNA [100010801],,,76.8,,71.95,0.222255,85118.57664,percent of total billed charges,,,
POTASSIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080554,CDM,S5000,HCPCS,250,RC,00409-7295-11,NDC,outpatient,15,ML,59.41,41.587,AETNA [1000108],AETNA [100010801],,,76.8,,45.63,0.222255,85118.57664,percent of total billed charges,,,
POTASSIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080554,CDM,S5000,HCPCS,250,RC,65219-0052-29,NDC,outpatient,5,ML,93.68,65.576,AETNA [1000108],AETNA [100010801],,,76.8,,71.95,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,00409-4888-01,NDC,outpatient,10,ML,9.82,6.874,AETNA [1000108],AETNA [100010801],,,76.8,,7.54,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,00409-4888-02,NDC,outpatient,10,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,00409-4888-10,NDC,outpatient,10,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,63323-0186-10,NDC,outpatient,10,ML,3.71,2.597,AETNA [1000108],AETNA [100010801],,,76.8,,2.85,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,63323-0186-01,NDC,outpatient,10,ML,3.71,2.597,AETNA [1000108],AETNA [100010801],,,76.8,,2.85,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,00409-4888-12,NDC,outpatient,10,ML,9.82,6.874,AETNA [1000108],AETNA [100010801],,,76.8,,7.54,0.222255,85118.57664,percent of total billed charges,,,
MENTHOL-ZINC OXIDE 0.44-20.625 % EX OINT WRAPPER,RX-4080556,CDM,S5000,HCPCS,259,RC,00799-0001-04,NDC,outpatient,113,GR,20.12,14.084,AETNA [1000108],AETNA [100010801],,,76.8,,15.45,0.222255,85118.57664,percent of total billed charges,,,
MENTHOL-ZINC OXIDE 0.44-20.625 % EX OINT WRAPPER,RX-4080556,CDM,S5000,HCPCS,259,RC,10135-0701-04,NDC,outpatient,113,GR,13.58,9.506,AETNA [1000108],AETNA [100010801],,,76.8,,10.43,0.222255,85118.57664,percent of total billed charges,,,
DILTIAZEM 100 MG ADDVANTAGE INFUSION IN D5W 100 ML,RX-4080558,CDM,S5000,HCPCS,250,RC,99999-0000-01,NDC,outpatient,100,ML,48.09,33.663,AETNA [1000108],AETNA [100010801],,,76.8,,36.93,0.222255,85118.57664,percent of total billed charges,,,
HIV POST EXPOSURE KIT,RX-4080559,CDM,S5000,HCPCS,259,RC,SH408-0559-01,NDC,outpatient,1,UN,1178.97,825.279,AETNA [1000108],AETNA [100010801],,,76.8,,905.45,0.222255,85118.57664,percent of total billed charges,,,
BUPIVACAINE 0.125 % IN 100 ML NS NERVE BLOCK CASSETTE,RX-4080570,CDM,S5000,HCPCS,250,RC,61553-0829-48,NDC,outpatient,100,ML,76.93,53.851,AETNA [1000108],AETNA [100010801],,,76.8,,59.08,0.222255,85118.57664,percent of total billed charges,,,
FENTANYL 3 MCG/ML WITH BUPIVACAINE 0.125 % EPIDURAL,RX-4080589,CDM,S5000,HCPCS,250,RC,99999-0000-04,NDC,outpatient,100,ML,79.95,55.965,AETNA [1000108],AETNA [100010801],,,76.8,,61.4,0.222255,85118.57664,percent of total billed charges,,,
VEIN GRAFT SOLUTION,RX-4080591,CDM,S5000,HCPCS,250,RC,99999-0000-07,NDC,outpatient,505.67,ML,73.5,51.45,AETNA [1000108],AETNA [100010801],,,76.8,,56.45,0.222255,85118.57664,percent of total billed charges,,,
FLECAINIDE ACETATE 20 MG/ML ORAL SUSP,RX-4080607,CDM,S5000,HCPCS,259,RC,99999-0003-52,NDC,outpatient,2.5,ML,2.45,1.715,AETNA [1000108],AETNA [100010801],,,76.8,,1.88,0.222255,85118.57664,percent of total billed charges,,,
HYOSCYAMINE SULFATE 0.125 MG SL SUBL WRAPPER,RX-4080632,CDM,S5000,HCPCS,259,RC,42192-0338-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
MESALAMINE 4 G RE ENEM WRAPPER,RX-4080640,CDM,S5000,HCPCS,259,RC,45802-0098-46,NDC,outpatient,60,ML,33.11,23.177,AETNA [1000108],AETNA [100010801],,,76.8,,25.43,0.222255,85118.57664,percent of total billed charges,,,
MESALAMINE 4 G RE ENEM WRAPPER,RX-4080640,CDM,S5000,HCPCS,259,RC,45802-0923-41,NDC,outpatient,60,ML,80.91,56.637,AETNA [1000108],AETNA [100010801],,,76.8,,62.14,0.222255,85118.57664,percent of total billed charges,,,
MESALAMINE 4 G RE ENEM WRAPPER,RX-4080640,CDM,S5000,HCPCS,259,RC,45802-0098-51,NDC,outpatient,60,ML,33.11,23.177,AETNA [1000108],AETNA [100010801],,,76.8,,25.43,0.222255,85118.57664,percent of total billed charges,,,
MAGNESIUM OXIDE 400 MG ORAL TABS WRAPPER,RX-4080641,CDM,S5000,HCPCS,259,RC,64980-0339-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
MAGNESIUM OXIDE 400 MG ORAL TABS WRAPPER,RX-4080641,CDM,S5000,HCPCS,259,RC,64980-0339-90,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
MAGNESIUM OXIDE 400 MG ORAL TABS WRAPPER,RX-4080641,CDM,S5000,HCPCS,259,RC,10006-0700-28,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
MAGNESIUM GLUCONATE 500 MG ORAL TABS WRAPPER,RX-4080642,CDM,S5000,HCPCS,259,RC,60258-0172-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
GI COCKTAIL SUSPENSION,RX-4080647,CDM,S5000,HCPCS,259,RC,99999-0000-39,NDC,outpatient,55,ML,82.33,57.631,AETNA [1000108],AETNA [100010801],,,76.8,,63.23,0.222255,85118.57664,percent of total billed charges,,,
CARDIOPLEGIA SOLN DEL NIDO,RX-4080676,CDM,S5000,HCPCS,250,RC,99999-0004-39,NDC,outpatient,1052.8,ML,113.01,79.107,AETNA [1000108],AETNA [100010801],,,76.8,,86.79,0.222255,85118.57664,percent of total billed charges,,,
EPINEPHRINE PF 10 MCG/ML 10 ML SYRINGE,RX-4080700,CDM,S5000,HCPCS,250,RC,70092-1512-46,NDC,outpatient,10,ML,20.96,14.672,AETNA [1000108],AETNA [100010801],,,76.8,,16.1,0.222255,85118.57664,percent of total billed charges,,,
EPINEPHRINE PF 10 MCG/ML 10 ML SYRINGE,RX-4080700,CDM,S5000,HCPCS,250,RC,70092-1617-46,NDC,outpatient,10,ML,31.42,21.994,AETNA [1000108],AETNA [100010801],,,76.8,,24.13,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % IV SOLN MINI-BAG 100 ML,RX-4080711,CDM,S5000,HCPCS,250,RC,00338-0553-18,NDC,outpatient,100,ML,29.37,20.559,AETNA [1000108],AETNA [100010801],,,76.8,,22.56,0.222255,85118.57664,percent of total billed charges,,,
HYDROCORTISONE ORAL SUSPENSION 2.5 MG/ML COMPOUNDED PRODUCT,RX-4080716,CDM,S5000,HCPCS,259,RC,99999-0000-80,NDC,outpatient,1,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
FLUDROCORTISONE ACETATE SUSP 0.2 MG/ML,RX-4080718,CDM,S5000,HCPCS,259,RC,99999-0000-81,NDC,outpatient,1,ML,4.96,3.472,AETNA [1000108],AETNA [100010801],,,76.8,,3.81,0.222255,85118.57664,percent of total billed charges,,,
ZINC OXIDE 40 % (BOUDREAUX'S) PASTE,RX-4080754,CDM,S5000,HCPCS,259,RC,62103-0323-02,NDC,outpatient,57,GR,14.72,10.304,AETNA [1000108],AETNA [100010801],,,76.8,,11.3,0.222255,85118.57664,percent of total billed charges,,,
ZINC OXIDE 40 % (BOUDREAUX'S) PASTE,RX-4080754,CDM,S5000,HCPCS,259,RC,74300-0000-71,NDC,outpatient,113,GR,26.15,18.305,AETNA [1000108],AETNA [100010801],,,76.8,,20.08,0.222255,85118.57664,percent of total billed charges,,,
NALOXONE INHALATION KIT - HOSPITAL USE ONLY,RX-4080774,CDM,S5000,HCPCS,259,RC,99999-0000-90,NDC,outpatient,1,UN,110.81,77.567,AETNA [1000108],AETNA [100010801],,,76.8,,85.1,0.222255,85118.57664,percent of total billed charges,,,
CISATRACURIUM BESYLATE 10 MG/ML IV SOLN WRAPPER,RX-4080786,CDM,S5000,HCPCS,250,RC,00409-1103-11,NDC,outpatient,20,ML,230.78,161.546,AETNA [1000108],AETNA [100010801],,,76.8,,177.24,0.222255,85118.57664,percent of total billed charges,,,
CISATRACURIUM BESYLATE 10 MG/ML IV SOLN WRAPPER,RX-4080786,CDM,S5000,HCPCS,250,RC,00409-1103-01,NDC,outpatient,20,ML,230.78,161.546,AETNA [1000108],AETNA [100010801],,,76.8,,177.24,0.222255,85118.57664,percent of total billed charges,,,
CEFAZOLIN IVPB 3 G IN 100 ML NS PREMIX,RX-4080801,CDM,S5000,HCPCS,250,RC,99999-0001-10,NDC,outpatient,130,ML,33.43,23.401,AETNA [1000108],AETNA [100010801],,,76.8,,25.67,0.222255,85118.57664,percent of total billed charges,,,
PERICAPSULAR MIXTURE INJECTION,RX-4080804,CDM,S5000,HCPCS,250,RC,70092-1433-50,NDC,outpatient,50,ML,216.36,151.452,AETNA [1000108],AETNA [100010801],,,76.8,,166.16,0.222255,85118.57664,percent of total billed charges,,,
PERICAPSULAR MIXTURE INJECTION,RX-4080804,CDM,S5000,HCPCS,250,RC,99999-0000-98,NDC,outpatient,50,ML,59.06,41.342,AETNA [1000108],AETNA [100010801],,,76.8,,45.36,0.222255,85118.57664,percent of total billed charges,,,
TRANEXAMIC ACID 5 % MOUTHWASH ORAL SUSPENSION,RX-4080811,CDM,S5000,HCPCS,259,RC,99999-0001-06,NDC,outpatient,169,ML,77.47,54.229,AETNA [1000108],AETNA [100010801],,,76.8,,59.5,0.222255,85118.57664,percent of total billed charges,,,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP *DYE FREE*,RX-4080831,CDM,S5000,HCPCS,259,RC,50580-0170-05,NDC,outpatient,5,ML,1.37,0.959,AETNA [1000108],AETNA [100010801],,,76.8,,1.05,0.222255,85118.57664,percent of total billed charges,,,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP *DYE FREE*,RX-4080831,CDM,S5000,HCPCS,259,RC,99999-0001-17,NDC,outpatient,5,ML,1.37,0.959,AETNA [1000108],AETNA [100010801],,,76.8,,1.05,0.222255,85118.57664,percent of total billed charges,,,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP *DYE FREE*,RX-4080831,CDM,S5000,HCPCS,259,RC,00045-0166-04,NDC,outpatient,120,ML,28.31,19.817,AETNA [1000108],AETNA [100010801],,,76.8,,21.74,0.222255,85118.57664,percent of total billed charges,,,
BABY BUTT BALM,RX-4080852,CDM,S5000,HCPCS,259,RC,99999-0001-13,NDC,outpatient,118.7,GR,70.96,49.672,AETNA [1000108],AETNA [100010801],,,76.8,,54.5,0.222255,85118.57664,percent of total billed charges,,,
ACETAZOLAMIDE 25 MG/ML SUSPENSION,RX-4080874,CDM,S5000,HCPCS,259,RC,99999-0001-21,NDC,outpatient,5,ML,10.93,7.651,AETNA [1000108],AETNA [100010801],,,76.8,,8.39,0.222255,85118.57664,percent of total billed charges,,,
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,68094-0120-61,NDC,outpatient,15,ML,7.68,5.376,AETNA [1000108],AETNA [100010801],,,76.8,,5.9,0.222255,85118.57664,percent of total billed charges,,,
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,68094-0120-59,NDC,outpatient,15,ML,7.68,5.376,AETNA [1000108],AETNA [100010801],,,76.8,,5.9,0.222255,85118.57664,percent of total billed charges,,,
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,00573-0513-30,NDC,outpatient,15,ML,2.32,1.624,AETNA [1000108],AETNA [100010801],,,76.8,,1.78,0.222255,85118.57664,percent of total billed charges,,,
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,00005-4344-62,NDC,outpatient,15,ML,2.09,1.463,AETNA [1000108],AETNA [100010801],,,76.8,,1.61,0.222255,85118.57664,percent of total billed charges,,,
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,00573-0513-15,NDC,outpatient,15,ML,2.32,1.624,AETNA [1000108],AETNA [100010801],,,76.8,,1.78,0.222255,85118.57664,percent of total billed charges,,,
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,69618-0008-58,NDC,outpatient,15,ML,2.55,1.785,AETNA [1000108],AETNA [100010801],,,76.8,,1.96,0.222255,85118.57664,percent of total billed charges,,,
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,99999-0002-20,NDC,outpatient,15,ML,2.01,1.407,AETNA [1000108],AETNA [100010801],,,76.8,,1.54,0.222255,85118.57664,percent of total billed charges,,,
FERRIC SUBSULFATE SOLN WRAPPER,RX-4080921,CDM,S5000,HCPCS,250,RC,38779-1284-08,NDC,outpatient,8,ML,2.35,1.645,AETNA [1000108],AETNA [100010801],,,76.8,,1.8,0.222255,85118.57664,percent of total billed charges,,,
FERRIC SUBSULFATE SOLN WRAPPER,RX-4080921,CDM,S5000,HCPCS,250,RC,10481-0112-02,NDC,outpatient,8,ML,9.33,6.531,AETNA [1000108],AETNA [100010801],,,76.8,,7.17,0.222255,85118.57664,percent of total billed charges,,,
FERRIC SUBSULFATE SOLN WRAPPER,RX-4080921,CDM,S5000,HCPCS,250,RC,10481-0112-08,NDC,outpatient,8,ML,47.67,33.369,AETNA [1000108],AETNA [100010801],,,76.8,,36.61,0.222255,85118.57664,percent of total billed charges,,,
FERRIC SUBSULFATE SOLN WRAPPER,RX-4080921,CDM,S5000,HCPCS,250,RC,49452-3081-02,NDC,outpatient,8,ML,2.35,1.645,AETNA [1000108],AETNA [100010801],,,76.8,,1.8,0.222255,85118.57664,percent of total billed charges,,,
SODIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080937,CDM,S5000,HCPCS,250,RC,63323-0170-05,NDC,outpatient,5,ML,35.56,24.892,AETNA [1000108],AETNA [100010801],,,76.8,,27.31,0.222255,85118.57664,percent of total billed charges,,,
SODIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080937,CDM,S5000,HCPCS,250,RC,63323-0881-01,NDC,outpatient,15,ML,169.35,118.545,AETNA [1000108],AETNA [100010801],,,76.8,,130.06,0.222255,85118.57664,percent of total billed charges,,,
SODIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080937,CDM,S5000,HCPCS,250,RC,63323-0881-16,NDC,outpatient,15,ML,169.35,118.545,AETNA [1000108],AETNA [100010801],,,76.8,,130.06,0.222255,85118.57664,percent of total billed charges,,,
SODIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080937,CDM,S5000,HCPCS,250,RC,63323-0884-01,NDC,outpatient,5,ML,79.73,55.811,AETNA [1000108],AETNA [100010801],,,76.8,,61.23,0.222255,85118.57664,percent of total billed charges,,,
SODIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080937,CDM,S5000,HCPCS,250,RC,63323-0884-06,NDC,outpatient,5,ML,79.73,55.811,AETNA [1000108],AETNA [100010801],,,76.8,,61.23,0.222255,85118.57664,percent of total billed charges,,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,43066-0007-10,NDC,outpatient,5,ML,8.46,5.922,AETNA [1000108],AETNA [100010801],,,76.8,,6.5,0.222255,85118.57664,percent of total billed charges,,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,63323-0426-02,NDC,outpatient,5,ML,7.05,4.935,AETNA [1000108],AETNA [100010801],,,76.8,,5.41,0.222255,85118.57664,percent of total billed charges,,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,67457-0228-02,NDC,outpatient,5,ML,6.84,4.788,AETNA [1000108],AETNA [100010801],,,76.8,,5.25,0.222255,85118.57664,percent of total billed charges,,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,00143-9250-01,NDC,outpatient,5,ML,10.46,7.322,AETNA [1000108],AETNA [100010801],,,76.8,,8.03,0.222255,85118.57664,percent of total billed charges,,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,25021-0662-05,NDC,outpatient,5,ML,11.88,8.316,AETNA [1000108],AETNA [100010801],,,76.8,,9.12,0.222255,85118.57664,percent of total billed charges,,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,55150-0225-05,NDC,outpatient,5,ML,9.23,6.461,AETNA [1000108],AETNA [100010801],,,76.8,,7.09,0.222255,85118.57664,percent of total billed charges,,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,39822-4200-05,NDC,outpatient,10,ML,22.61,15.827,AETNA [1000108],AETNA [100010801],,,76.8,,17.36,0.222255,85118.57664,percent of total billed charges,,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,39822-4200-06,NDC,outpatient,10,ML,22.61,15.827,AETNA [1000108],AETNA [100010801],,,76.8,,17.36,0.222255,85118.57664,percent of total billed charges,,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,55150-0226-10,NDC,outpatient,10,ML,18.46,12.922,AETNA [1000108],AETNA [100010801],,,76.8,,14.18,0.222255,85118.57664,percent of total billed charges,,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,72611-0756-01,NDC,outpatient,5,ML,24.17,16.919,AETNA [1000108],AETNA [100010801],,,76.8,,18.56,0.222255,85118.57664,percent of total billed charges,,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,72611-0756-10,NDC,outpatient,5,ML,24.17,16.919,AETNA [1000108],AETNA [100010801],,,76.8,,18.56,0.222255,85118.57664,percent of total billed charges,,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,00143-9250-10,NDC,outpatient,5,ML,10.46,7.322,AETNA [1000108],AETNA [100010801],,,76.8,,8.03,0.222255,85118.57664,percent of total billed charges,,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,63323-0426-05,NDC,outpatient,5,ML,7.05,4.935,AETNA [1000108],AETNA [100010801],,,76.8,,5.41,0.222255,85118.57664,percent of total billed charges,,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,66794-0228-41,NDC,outpatient,5,ML,6.84,4.788,AETNA [1000108],AETNA [100010801],,,76.8,,5.25,0.222255,85118.57664,percent of total billed charges,,,
AMIODARONE ORAL SUSPENSION 40 MG/ML,RX-4080970,CDM,S5000,HCPCS,259,RC,99999-0001-63,NDC,outpatient,10,ML,2.04,1.428,AETNA [1000108],AETNA [100010801],,,76.8,,1.57,0.222255,85118.57664,percent of total billed charges,,,
MORPHINE SULFATE 100 MG/100 ML IN D5W PF PREMIX,RX-4081012,CDM,S5000,HCPCS,250,RC,99999-0000-99,NDC,outpatient,100,ML,312.37,218.659,AETNA [1000108],AETNA [100010801],,,76.8,,239.9,0.222255,85118.57664,percent of total billed charges,,,
EPHEDRINE SULFATE 5 MG/ML IJ WRAPPER,RX-4081019,CDM,S5000,HCPCS,250,RC,42023-0243-01,NDC,outpatient,10,ML,42.55,29.785,AETNA [1000108],AETNA [100010801],,,76.8,,32.68,0.222255,85118.57664,percent of total billed charges,,,
EPHEDRINE SULFATE 5 MG/ML IJ WRAPPER,RX-4081019,CDM,S5000,HCPCS,250,RC,14789-0250-07,NDC,outpatient,10,ML,61.68,43.176,AETNA [1000108],AETNA [100010801],,,76.8,,47.37,0.222255,85118.57664,percent of total billed charges,,,
EPHEDRINE SULFATE 5 MG/ML IJ WRAPPER,RX-4081019,CDM,S5000,HCPCS,250,RC,14789-0250-10,NDC,outpatient,10,ML,61.68,43.176,AETNA [1000108],AETNA [100010801],,,76.8,,47.37,0.222255,85118.57664,percent of total billed charges,,,
INSULIN REGULAR 1 UNIT/ML INFUSION PREMIX,RX-4081020,CDM,S5000,HCPCS,250,RC,99999-0000-87,NDC,outpatient,100,ML,34.01,23.807,AETNA [1000108],AETNA [100010801],,,76.8,,26.12,0.222255,85118.57664,percent of total billed charges,,,
INSULIN REGULAR 1 UNIT/ML INFUSION PREMIX,RX-4081020,CDM,S5000,HCPCS,250,RC,00338-0126-12,NDC,outpatient,100,ML,98.33,68.831,AETNA [1000108],AETNA [100010801],,,76.8,,75.52,0.222255,85118.57664,percent of total billed charges,,,
DILTIAZEM 100 MG IN 100 ML NS BATCHED INFUSION,RX-4081050,CDM,S5000,HCPCS,250,RC,99999-0002-64,NDC,outpatient,100,ML,56.68,39.676,AETNA [1000108],AETNA [100010801],,,76.8,,43.53,0.222255,85118.57664,percent of total billed charges,,,
URSODIOL 50 MG/ML ORAL SUSPENSION,RX-4081064,CDM,S5000,HCPCS,259,RC,99999-0002-69,NDC,outpatient,1,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
BUPRENORPHINE-NALOXONE (SUBOXONE) SL FILM 8 MG-2 MG KIT,RX-4081171,CDM,S5000,HCPCS,259,RC,99999-0003-16,NDC,outpatient,1,UN,142.33,99.631,AETNA [1000108],AETNA [100010801],,,76.8,,109.31,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,00409-1323-05,NDC,outpatient,5,ML,19.63,13.741,AETNA [1000108],AETNA [100010801],,,76.8,,15.08,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,00409-1323-15,NDC,outpatient,5,ML,19.63,13.741,AETNA [1000108],AETNA [100010801],,,76.8,,15.08,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,00409-4903-11,NDC,outpatient,5,ML,17.92,12.544,AETNA [1000108],AETNA [100010801],,,76.8,,13.76,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,00409-4903-34,NDC,outpatient,5,ML,17.92,12.544,AETNA [1000108],AETNA [100010801],,,76.8,,13.76,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,63323-0208-05,NDC,outpatient,5,ML,7.41,5.187,AETNA [1000108],AETNA [100010801],,,76.8,,5.69,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,76329-3390-01,NDC,outpatient,5,ML,27.15,19.005,AETNA [1000108],AETNA [100010801],,,76.8,,20.85,0.222255,85118.57664,percent of total billed charges,,,
TRANEXAMIC ACID 100 MG/ML FOR INHALATION,RX-4081187,CDM,S5000,HCPCS,250,RC,39822-1000-01,NDC,outpatient,10,ML,23.86,16.702,AETNA [1000108],AETNA [100010801],,,76.8,,18.32,0.222255,85118.57664,percent of total billed charges,,,
TRANEXAMIC ACID 100 MG/ML FOR INHALATION,RX-4081187,CDM,S5000,HCPCS,250,RC,81284-0611-00,NDC,outpatient,10,ML,24.48,17.136,AETNA [1000108],AETNA [100010801],,,76.8,,18.8,0.222255,85118.57664,percent of total billed charges,,,
TRANEXAMIC ACID 100 MG/ML FOR INHALATION,RX-4081187,CDM,S5000,HCPCS,250,RC,72485-0510-01,NDC,outpatient,10,ML,12.64,8.848,AETNA [1000108],AETNA [100010801],,,76.8,,9.71,0.222255,85118.57664,percent of total billed charges,,,
TRANEXAMIC ACID 100 MG/ML FOR INHALATION,RX-4081187,CDM,S5000,HCPCS,250,RC,72485-0510-10,NDC,outpatient,10,ML,12.64,8.848,AETNA [1000108],AETNA [100010801],,,76.8,,9.71,0.222255,85118.57664,percent of total billed charges,,,
TRANEXAMIC ACID 100 MG/ML FOR INHALATION,RX-4081187,CDM,S5000,HCPCS,250,RC,81284-0611-10,NDC,outpatient,10,ML,24.48,17.136,AETNA [1000108],AETNA [100010801],,,76.8,,18.8,0.222255,85118.57664,percent of total billed charges,,,
MORPHINE SULFATE 100 MG/100 ML IN NS PF PREMIX,RX-4081195,CDM,S5000,HCPCS,250,RC,99999-0003-26,NDC,outpatient,100,ML,312.37,218.659,AETNA [1000108],AETNA [100010801],,,76.8,,239.9,0.222255,85118.57664,percent of total billed charges,,,
PANTOPRAZOLE 80 MG/100 ML INFUSION PREMIX,RX-4081208,CDM,S5000,HCPCS,250,RC,99999-0000-77,NDC,outpatient,100,ML,36.56,25.592,AETNA [1000108],AETNA [100010801],,,76.8,,28.08,0.222255,85118.57664,percent of total billed charges,,,
NICARDIPINE HCL 40 MG IN NACL 200 ML IV SOLN WRAPPER,RX-4081293,CDM,S5000,HCPCS,250,RC,00143-9633-01,NDC,outpatient,200,ML,242.06,169.442,AETNA [1000108],AETNA [100010801],,,76.8,,185.9,0.222255,85118.57664,percent of total billed charges,,,
NICARDIPINE HCL 40 MG IN NACL 200 ML IV SOLN WRAPPER,RX-4081293,CDM,S5000,HCPCS,250,RC,00143-9633-10,NDC,outpatient,200,ML,242.06,169.442,AETNA [1000108],AETNA [100010801],,,76.8,,185.9,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE 3 % IV ONCE,RX-4081432,CDM,S5000,HCPCS,250,RC,99999-0003-86,NDC,outpatient,100,ML,18.06,12.642,AETNA [1000108],AETNA [100010801],,,76.8,,13.87,0.222255,85118.57664,percent of total billed charges,,,
FAMOTIDINE IN NACL 20-0.9 MG/10 ML-% IV SOSY,RX-4081444,CDM,S5000,HCPCS,250,RC,99999-0003-96,NDC,outpatient,5,ML,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,,,
SODIUM HYALURONATE 10 MG/ML IO SOLN WRAPPER,RX-4081458,CDM,S5000,HCPCS,250,RC,05047-4508-38,NDC,outpatient,0.4,ML,397.92,278.544,AETNA [1000108],AETNA [100010801],,,76.8,,305.6,0.222255,85118.57664,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV *BATCHED*,RX-4081542,CDM,S5000,HCPCS,250,RC,99999-0004-35,NDC,outpatient,50,ML,157.29,110.103,AETNA [1000108],AETNA [100010801],,,76.8,,120.8,0.222255,85118.57664,percent of total billed charges,,,
NALOXONE HCL 4 MG/0.1ML NA LIQD FOR CODE NARRATOR,RX-4081549,CDM,S5000,HCPCS,259,RC,00093-2165-68,NDC,outpatient,1,UN,146.88,102.816,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.222255,85118.57664,percent of total billed charges,,,
NALOXONE HCL 4 MG/0.1ML NA LIQD FOR CODE NARRATOR,RX-4081549,CDM,S5000,HCPCS,259,RC,00093-2165-19,NDC,outpatient,1,UN,146.88,102.816,AETNA [1000108],AETNA [100010801],,,76.8,,112.8,0.222255,85118.57664,percent of total billed charges,,,
MORPHINE SULFATE 1 MG/ML 100 ML PCA,RX-4081551,CDM,S5000,HCPCS,250,RC,70092-1518-75,NDC,outpatient,100,ML,209.09,146.363,AETNA [1000108],AETNA [100010801],,,76.8,,160.58,0.222255,85118.57664,percent of total billed charges,,,
MORPHINE SULFATE 1 MG/ML 100 ML PCA,RX-4081551,CDM,S5000,HCPCS,250,RC,99999-0004-53,NDC,outpatient,100,ML,48.85,34.195,AETNA [1000108],AETNA [100010801],,,76.8,,37.52,0.222255,85118.57664,percent of total billed charges,,,
PRASUGREL HCL 10 MG TABS - OMNICELL CATH LAB USE ONLY,RX-4081602,CDM,S5000,HCPCS,259,RC,65162-0002-03,NDC,outpatient,0.5,UN,2.9,2.03,AETNA [1000108],AETNA [100010801],,,76.8,,2.23,0.222255,85118.57664,percent of total billed charges,,,
PRASUGREL HCL 10 MG TABS - OMNICELL CATH LAB USE ONLY,RX-4081602,CDM,S5000,HCPCS,259,RC,65862-0830-30,NDC,outpatient,0.5,UN,1,0.7,AETNA [1000108],AETNA [100010801],,,76.8,,0.77,0.222255,85118.57664,percent of total billed charges,,,
PRASUGREL HCL 10 MG TABS - OMNICELL CATH LAB USE ONLY,RX-4081602,CDM,S5000,HCPCS,259,RC,00378-5186-93,NDC,outpatient,0.5,UN,4.12,2.884,AETNA [1000108],AETNA [100010801],,,76.8,,3.16,0.222255,85118.57664,percent of total billed charges,,,
METHADONE 10 MG TABLET DISCHARGE KIT,RX-4081610,CDM,S5000,HCPCS,259,RC,99999-0004-50,NDC,outpatient,1,UN,6.15,4.305,AETNA [1000108],AETNA [100010801],,,76.8,,4.72,0.222255,85118.57664,percent of total billed charges,,,
PRISMASATE K 4/CA 2.5 CRRT SOLUTION,RX-40840045,CDM,S5000,HCPCS,250,RC,SH408-4045-01,NDC,outpatient,5000,ML,188.44,131.908,AETNA [1000108],AETNA [100010801],,,76.8,,144.72,0.222255,85118.57664,percent of total billed charges,,,
PRISMASATE K 2/CA 0 CRRT SOLUTION,RX-40840046,CDM,S5000,HCPCS,250,RC,SH408-4046-01,NDC,outpatient,5000,ML,188.44,131.908,AETNA [1000108],AETNA [100010801],,,76.8,,144.72,0.222255,85118.57664,percent of total billed charges,,,
BENZOCAINE-MENTHOL 6-10 MG MT LOZG,RX-41085,CDM,S5000,HCPCS,259,RC,78112-0011-06,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
BENZOCAINE-MENTHOL 6-10 MG MT LOZG,RX-41085,CDM,S5000,HCPCS,259,RC,78112-0012-66,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
GALANTAMINE HYDROBROMIDE ER 8 MG ORAL CP24,RX-41138,CDM,S5000,HCPCS,259,RC,63629-2364-01,NDC,outpatient,1,UN,6.03,4.221,AETNA [1000108],AETNA [100010801],,,76.8,,4.63,0.222255,85118.57664,percent of total billed charges,,,
GALANTAMINE HYDROBROMIDE ER 8 MG ORAL CP24,RX-41138,CDM,S5000,HCPCS,259,RC,47335-0835-83,NDC,outpatient,1,UN,5.27,3.689,AETNA [1000108],AETNA [100010801],,,76.8,,4.05,0.222255,85118.57664,percent of total billed charges,,,
IPRATROPIUM BROMIDE HFA 17 MCG/ACT IN AERS,RX-41142,CDM,S5000,HCPCS,259,RC,00597-0087-17,NDC,outpatient,12.9,GR,1940.98,1358.686,AETNA [1000108],AETNA [100010801],,,76.8,,1490.67,0.222255,85118.57664,percent of total billed charges,,,
ENTECAVIR 0.5 MG ORAL TABS,RX-41147,CDM,S5000,HCPCS,259,RC,00003-1611-12,NDC,outpatient,1,UN,197.48,138.236,AETNA [1000108],AETNA [100010801],,,76.8,,151.66,0.222255,85118.57664,percent of total billed charges,,,
ENTECAVIR 1 MG ORAL TABS,RX-41148,CDM,S5000,HCPCS,259,RC,65862-0842-30,NDC,outpatient,1,UN,8.95,6.265,AETNA [1000108],AETNA [100010801],,,76.8,,6.87,0.222255,85118.57664,percent of total billed charges,,,
FENTANYL 12 MCG/HR TD PT72,RX-41382,CDM,S5000,HCPCS,259,RC,00378-9119-16,NDC,outpatient,1,UN,50.62,35.434,AETNA [1000108],AETNA [100010801],,,76.8,,38.88,0.222255,85118.57664,percent of total billed charges,,,
FENTANYL 12 MCG/HR TD PT72,RX-41382,CDM,S5000,HCPCS,259,RC,47781-0423-11,NDC,outpatient,1,UN,21.37,14.959,AETNA [1000108],AETNA [100010801],,,76.8,,16.41,0.222255,85118.57664,percent of total billed charges,,,
FENTANYL 12 MCG/HR TD PT72,RX-41382,CDM,S5000,HCPCS,259,RC,00378-9119-98,NDC,outpatient,1,UN,50.62,35.434,AETNA [1000108],AETNA [100010801],,,76.8,,38.88,0.222255,85118.57664,percent of total billed charges,,,
FENTANYL 12 MCG/HR TD PT72,RX-41382,CDM,S5000,HCPCS,259,RC,47781-0423-47,NDC,outpatient,1,UN,21.37,14.959,AETNA [1000108],AETNA [100010801],,,76.8,,16.41,0.222255,85118.57664,percent of total billed charges,,,
PARICALCITOL 1 MCG ORAL CAPS,RX-41497,CDM,S5000,HCPCS,259,RC,49483-0687-03,NDC,outpatient,1,UN,4.45,3.115,AETNA [1000108],AETNA [100010801],,,76.8,,3.42,0.222255,85118.57664,percent of total billed charges,,,
PARICALCITOL 1 MCG ORAL CAPS,RX-41497,CDM,S5000,HCPCS,259,RC,65862-0936-30,NDC,outpatient,1,UN,5.24,3.668,AETNA [1000108],AETNA [100010801],,,76.8,,4.02,0.222255,85118.57664,percent of total billed charges,,,
LEVOCARNITINE 1 GM/10ML ORAL SOLN,RX-41623,CDM,S5000,HCPCS,259,RC,52817-0830-04,NDC,outpatient,1,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LEVOCARNITINE 1 GM/10ML ORAL SOLN,RX-41623,CDM,S5000,HCPCS,259,RC,99999-0002-52,NDC,outpatient,10,ML,6.37,4.459,AETNA [1000108],AETNA [100010801],,,76.8,,4.89,0.222255,85118.57664,percent of total billed charges,,,
SODIUM TETRADECYL SULFATE 3 % IV SOLN,RX-41793,CDM,S5000,HCPCS,250,RC,24201-0201-05,NDC,outpatient,0.5,ML,58.03,40.621,AETNA [1000108],AETNA [100010801],,,76.8,,44.57,0.222255,85118.57664,percent of total billed charges,,,
SODIUM TETRADECYL SULFATE 3 % IV SOLN,RX-41793,CDM,S5000,HCPCS,250,RC,24201-0201-01,NDC,outpatient,0.5,ML,58.03,40.621,AETNA [1000108],AETNA [100010801],,,76.8,,44.57,0.222255,85118.57664,percent of total billed charges,,,
SODIUM TETRADECYL SULFATE 3 % IV SOLN,RX-41793,CDM,S5000,HCPCS,250,RC,67457-0163-02,NDC,outpatient,0.5,ML,64.31,45.017,AETNA [1000108],AETNA [100010801],,,76.8,,49.39,0.222255,85118.57664,percent of total billed charges,,,
SODIUM TETRADECYL SULFATE 3 % IV SOLN,RX-41793,CDM,S5000,HCPCS,250,RC,67457-0163-00,NDC,outpatient,0.5,ML,58.19,40.733,AETNA [1000108],AETNA [100010801],,,76.8,,44.69,0.222255,85118.57664,percent of total billed charges,,,
OMEGA-3-ACID ETHYL ESTERS 1 G ORAL CAPS,RX-41822,CDM,S5000,HCPCS,259,RC,64380-0761-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE 5 % EX OINT,RX-41831,CDM,S5000,HCPCS,259,RC,65162-0918-38,NDC,outpatient,35.44,GR,50,35,AETNA [1000108],AETNA [100010801],,,76.8,,38.4,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE 5 % EX OINT,RX-41831,CDM,S5000,HCPCS,259,RC,64380-0789-32,NDC,outpatient,35.44,GR,61.67,43.169,AETNA [1000108],AETNA [100010801],,,76.8,,47.36,0.222255,85118.57664,percent of total billed charges,,,
SILDENAFIL CITRATE 20 MG ORAL TABS,RX-41832,CDM,S5000,HCPCS,259,RC,63739-0072-33,NDC,outpatient,1,UN,2.21,1.547,AETNA [1000108],AETNA [100010801],,,76.8,,1.7,0.222255,85118.57664,percent of total billed charges,,,
SILDENAFIL CITRATE 20 MG ORAL TABS,RX-41832,CDM,S5000,HCPCS,259,RC,00904-6671-04,NDC,outpatient,1,UN,2.21,1.547,AETNA [1000108],AETNA [100010801],,,76.8,,1.7,0.222255,85118.57664,percent of total billed charges,,,
METRONIDAZOLE 1 % EX GEL,RX-41899,CDM,S5000,HCPCS,259,RC,51672-4215-03,NDC,outpatient,60,GR,258.99,181.293,AETNA [1000108],AETNA [100010801],,,76.8,,198.9,0.222255,85118.57664,percent of total billed charges,,,
AVEENO SOOTHING BATH TREATMENT EX PACK,RX-41904,CDM,S5000,HCPCS,259,RC,08137-0036-40,NDC,outpatient,1,UN,2.74,1.918,AETNA [1000108],AETNA [100010801],,,76.8,,2.1,0.222255,85118.57664,percent of total billed charges,,,
RAMELTEON 8 MG ORAL TABS,RX-42064,CDM,S5000,HCPCS,259,RC,50268-0708-15,NDC,outpatient,1,UN,11.47,8.029,AETNA [1000108],AETNA [100010801],,,76.8,,8.81,0.222255,85118.57664,percent of total billed charges,,,
RAMELTEON 8 MG ORAL TABS,RX-42064,CDM,S5000,HCPCS,259,RC,50268-0708-11,NDC,outpatient,1,UN,11.47,8.029,AETNA [1000108],AETNA [100010801],,,76.8,,8.81,0.222255,85118.57664,percent of total billed charges,,,
RAMELTEON 8 MG ORAL TABS,RX-42064,CDM,S5000,HCPCS,259,RC,70010-0028-03,NDC,outpatient,1,UN,6.31,4.417,AETNA [1000108],AETNA [100010801],,,76.8,,4.85,0.222255,85118.57664,percent of total billed charges,,,
DICYCLOMINE HCL 10 MG/5ML ORAL SOLN,RX-42119,CDM,S5000,HCPCS,259,RC,99999-0003-12,NDC,outpatient,5,ML,5.06,3.542,AETNA [1000108],AETNA [100010801],,,76.8,,3.89,0.222255,85118.57664,percent of total billed charges,,,
DICYCLOMINE HCL 10 MG/5ML ORAL SOLN,RX-42119,CDM,S5000,HCPCS,259,RC,00054-0622-63,NDC,outpatient,5,ML,3.5,2.45,AETNA [1000108],AETNA [100010801],,,76.8,,2.69,0.222255,85118.57664,percent of total billed charges,,,
PREGABALIN 25 MG ORAL CAPS,RX-42162,CDM,S5000,HCPCS,259,RC,50228-0350-90,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PREGABALIN 25 MG ORAL CAPS,RX-42162,CDM,S5000,HCPCS,259,RC,60687-0473-01,NDC,outpatient,1,UN,1.96,1.372,AETNA [1000108],AETNA [100010801],,,76.8,,1.51,0.222255,85118.57664,percent of total billed charges,,,
PREGABALIN 25 MG ORAL CAPS,RX-42162,CDM,S5000,HCPCS,259,RC,60687-0473-11,NDC,outpatient,1,UN,1.96,1.372,AETNA [1000108],AETNA [100010801],,,76.8,,1.51,0.222255,85118.57664,percent of total billed charges,,,
PREGABALIN 50 MG ORAL CAPS,RX-42163,CDM,S5000,HCPCS,259,RC,00071-1013-41,NDC,outpatient,1,UN,45.77,32.039,AETNA [1000108],AETNA [100010801],,,76.8,,35.15,0.222255,85118.57664,percent of total billed charges,,,
PREGABALIN 50 MG ORAL CAPS,RX-42163,CDM,S5000,HCPCS,259,RC,00904-6992-61,NDC,outpatient,1,UN,2.3,1.61,AETNA [1000108],AETNA [100010801],,,76.8,,1.77,0.222255,85118.57664,percent of total billed charges,,,
PREGABALIN 50 MG ORAL CAPS,RX-42163,CDM,S5000,HCPCS,259,RC,72205-0012-90,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PREGABALIN 75 MG ORAL CAPS,RX-42164,CDM,S5000,HCPCS,259,RC,60687-0495-01,NDC,outpatient,1,UN,1.87,1.309,AETNA [1000108],AETNA [100010801],,,76.8,,1.44,0.222255,85118.57664,percent of total billed charges,,,
PREGABALIN 75 MG ORAL CAPS,RX-42164,CDM,S5000,HCPCS,259,RC,60687-0495-11,NDC,outpatient,1,UN,1.87,1.309,AETNA [1000108],AETNA [100010801],,,76.8,,1.44,0.222255,85118.57664,percent of total billed charges,,,
PREGABALIN 75 MG ORAL CAPS,RX-42164,CDM,S5000,HCPCS,259,RC,00904-7000-61,NDC,outpatient,1,UN,2.47,1.729,AETNA [1000108],AETNA [100010801],,,76.8,,1.9,0.222255,85118.57664,percent of total billed charges,,,
PREGABALIN 75 MG ORAL CAPS,RX-42164,CDM,S5000,HCPCS,259,RC,62332-0121-90,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PREGABALIN 75 MG ORAL CAPS,RX-42164,CDM,S5000,HCPCS,259,RC,00071-1014-41,NDC,outpatient,1,UN,45.77,32.039,AETNA [1000108],AETNA [100010801],,,76.8,,35.15,0.222255,85118.57664,percent of total billed charges,,,
PREGABALIN 100 MG ORAL CAPS,RX-42165,CDM,S5000,HCPCS,259,RC,62332-0122-90,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PREGABALIN 100 MG ORAL CAPS,RX-42165,CDM,S5000,HCPCS,259,RC,00904-7001-61,NDC,outpatient,1,UN,2.38,1.666,AETNA [1000108],AETNA [100010801],,,76.8,,1.83,0.222255,85118.57664,percent of total billed charges,,,
PREGABALIN 100 MG ORAL CAPS,RX-42165,CDM,S5000,HCPCS,259,RC,69238-1313-09,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PREGABALIN 150 MG ORAL CAPS,RX-42166,CDM,S5000,HCPCS,259,RC,00904-7002-61,NDC,outpatient,1,UN,2.56,1.792,AETNA [1000108],AETNA [100010801],,,76.8,,1.97,0.222255,85118.57664,percent of total billed charges,,,
PREGABALIN 150 MG ORAL CAPS,RX-42166,CDM,S5000,HCPCS,259,RC,00071-1016-41,NDC,outpatient,1,UN,45.77,32.039,AETNA [1000108],AETNA [100010801],,,76.8,,35.15,0.222255,85118.57664,percent of total billed charges,,,
KETAMINE HCL 10 MG/ML IJ SOLN,RX-4236,CDM,S5000,HCPCS,250,RC,42023-0113-10,NDC,outpatient,20,ML,41.57,29.099,AETNA [1000108],AETNA [100010801],,,76.8,,31.93,0.222255,85118.57664,percent of total billed charges,,,
KETAMINE HCL 100 MG/ML IJ SOLN,RX-4237,CDM,S5000,HCPCS,250,RC,42023-0115-10,NDC,outpatient,5,ML,53.45,37.415,AETNA [1000108],AETNA [100010801],,,76.8,,41.05,0.222255,85118.57664,percent of total billed charges,,,
KETAMINE HCL 50 MG/ML IJ SOLN,RX-4238,CDM,S5000,HCPCS,250,RC,00143-9508-01,NDC,outpatient,10,ML,23.23,16.261,AETNA [1000108],AETNA [100010801],,,76.8,,17.84,0.222255,85118.57664,percent of total billed charges,,,
KETAMINE HCL 50 MG/ML IJ SOLN,RX-4238,CDM,S5000,HCPCS,250,RC,00143-9508-10,NDC,outpatient,10,ML,23.23,16.261,AETNA [1000108],AETNA [100010801],,,76.8,,17.84,0.222255,85118.57664,percent of total billed charges,,,
AMITRIPTYLINE HCL 10 MG ORAL TABS,RX-432,CDM,S5000,HCPCS,259,RC,50268-0037-11,NDC,outpatient,1,UN,1.35,0.945,AETNA [1000108],AETNA [100010801],,,76.8,,1.04,0.222255,85118.57664,percent of total billed charges,,,
AMITRIPTYLINE HCL 10 MG ORAL TABS,RX-432,CDM,S5000,HCPCS,259,RC,50268-0037-15,NDC,outpatient,1,UN,1.35,0.945,AETNA [1000108],AETNA [100010801],,,76.8,,1.04,0.222255,85118.57664,percent of total billed charges,,,
AMITRIPTYLINE HCL 10 MG ORAL TABS,RX-432,CDM,S5000,HCPCS,259,RC,70756-0201-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
AMITRIPTYLINE HCL 25 MG ORAL TABS,RX-435,CDM,S5000,HCPCS,259,RC,60687-0433-01,NDC,outpatient,1,UN,1.4,0.98,AETNA [1000108],AETNA [100010801],,,76.8,,1.08,0.222255,85118.57664,percent of total billed charges,,,
AMITRIPTYLINE HCL 25 MG ORAL TABS,RX-435,CDM,S5000,HCPCS,259,RC,00781-1487-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
AMITRIPTYLINE HCL 25 MG ORAL TABS,RX-435,CDM,S5000,HCPCS,259,RC,60687-0433-11,NDC,outpatient,1,UN,1.4,0.98,AETNA [1000108],AETNA [100010801],,,76.8,,1.08,0.222255,85118.57664,percent of total billed charges,,,
DIGOXIN 0.05 MG/ML ORAL SOLN,RX-43556,CDM,S5000,HCPCS,259,RC,00054-0057-46,NDC,outpatient,60,ML,612.5,428.75,AETNA [1000108],AETNA [100010801],,,76.8,,470.4,0.222255,85118.57664,percent of total billed charges,,,
DIGOXIN 0.05 MG/ML ORAL SOLN,RX-43556,CDM,S5000,HCPCS,259,RC,99999-0004-03,NDC,outpatient,2.5,ML,25.53,17.871,AETNA [1000108],AETNA [100010801],,,76.8,,19.61,0.222255,85118.57664,percent of total billed charges,,,
AMITRIPTYLINE HCL 50 MG ORAL TABS,RX-436,CDM,S5000,HCPCS,259,RC,60687-0444-01,NDC,outpatient,1,UN,1.83,1.281,AETNA [1000108],AETNA [100010801],,,76.8,,1.41,0.222255,85118.57664,percent of total billed charges,,,
AMITRIPTYLINE HCL 50 MG ORAL TABS,RX-436,CDM,S5000,HCPCS,259,RC,60687-0444-11,NDC,outpatient,1,UN,1.83,1.281,AETNA [1000108],AETNA [100010801],,,76.8,,1.41,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL 4 % MT SOLN,RX-43717,CDM,S5000,HCPCS,259,RC,76329-6300-05,NDC,outpatient,4,ML,116.7,81.69,AETNA [1000108],AETNA [100010801],,,76.8,,89.63,0.222255,85118.57664,percent of total billed charges,,,
AMMONIA AROMATIC IN INHA,RX-439,CDM,S5000,HCPCS,259,RC,67777-0251-01,NDC,outpatient,1,UN,1.04,0.728,AETNA [1000108],AETNA [100010801],,,76.8,,0.8,0.222255,85118.57664,percent of total billed charges,,,
LEUCOVORIN CALCIUM 5 MG ORAL TABS,RX-4398,CDM,S5000,HCPCS,259,RC,00555-0484-02,NDC,outpatient,1,UN,5.35,3.745,AETNA [1000108],AETNA [100010801],,,76.8,,4.11,0.222255,85118.57664,percent of total billed charges,,,
LEUCOVORIN CALCIUM 5 MG ORAL TABS,RX-4398,CDM,S5000,HCPCS,259,RC,00054-8496-19,NDC,outpatient,1,UN,7.46,5.222,AETNA [1000108],AETNA [100010801],,,76.8,,5.73,0.222255,85118.57664,percent of total billed charges,,,
LEVOTHYROXINE SODIUM 25 MCG ORAL TABS,RX-4420,CDM,S5000,HCPCS,259,RC,51079-0444-01,NDC,outpatient,1,UN,2.38,1.666,AETNA [1000108],AETNA [100010801],,,76.8,,1.83,0.222255,85118.57664,percent of total billed charges,,,
LEVOTHYROXINE SODIUM 25 MCG ORAL TABS,RX-4420,CDM,S5000,HCPCS,259,RC,51079-0444-20,NDC,outpatient,1,UN,2.38,1.666,AETNA [1000108],AETNA [100010801],,,76.8,,1.83,0.222255,85118.57664,percent of total billed charges,,,
LEVOTHYROXINE SODIUM 25 MCG ORAL TABS,RX-4420,CDM,S5000,HCPCS,259,RC,60687-0453-01,NDC,outpatient,1,UN,1.54,1.078,AETNA [1000108],AETNA [100010801],,,76.8,,1.18,0.222255,85118.57664,percent of total billed charges,,,
LEVOTHYROXINE SODIUM 25 MCG ORAL TABS,RX-4420,CDM,S5000,HCPCS,259,RC,60687-0453-11,NDC,outpatient,1,UN,1.54,1.078,AETNA [1000108],AETNA [100010801],,,76.8,,1.18,0.222255,85118.57664,percent of total billed charges,,,
LEVOTHYROXINE SODIUM 50 MCG ORAL TABS,RX-4421,CDM,S5000,HCPCS,259,RC,00074-4552-11,NDC,outpatient,1,UN,6.49,4.543,AETNA [1000108],AETNA [100010801],,,76.8,,4.98,0.222255,85118.57664,percent of total billed charges,,,
LEVOTHYROXINE SODIUM 50 MCG ORAL TABS,RX-4421,CDM,S5000,HCPCS,259,RC,51079-0440-01,NDC,outpatient,1,UN,2.52,1.764,AETNA [1000108],AETNA [100010801],,,76.8,,1.94,0.222255,85118.57664,percent of total billed charges,,,
LEVOTHYROXINE SODIUM 50 MCG ORAL TABS,RX-4421,CDM,S5000,HCPCS,259,RC,60687-0464-11,NDC,outpatient,1,UN,1.67,1.169,AETNA [1000108],AETNA [100010801],,,76.8,,1.28,0.222255,85118.57664,percent of total billed charges,,,
LEVOTHYROXINE SODIUM 50 MCG ORAL TABS,RX-4421,CDM,S5000,HCPCS,259,RC,60687-0464-01,NDC,outpatient,1,UN,1.67,1.169,AETNA [1000108],AETNA [100010801],,,76.8,,1.28,0.222255,85118.57664,percent of total billed charges,,,
LEVOTHYROXINE SODIUM 50 MCG ORAL TABS,RX-4421,CDM,S5000,HCPCS,259,RC,51079-0440-20,NDC,outpatient,1,UN,2.52,1.764,AETNA [1000108],AETNA [100010801],,,76.8,,1.94,0.222255,85118.57664,percent of total billed charges,,,
LEVOTHYROXINE SODIUM 75 MCG ORAL TABS,RX-4422,CDM,S5000,HCPCS,259,RC,51079-0441-20,NDC,outpatient,1,UN,2.6,1.82,AETNA [1000108],AETNA [100010801],,,76.8,,2,0.222255,85118.57664,percent of total billed charges,,,
LEVOTHYROXINE SODIUM 75 MCG ORAL TABS,RX-4422,CDM,S5000,HCPCS,259,RC,51079-0441-01,NDC,outpatient,1,UN,2.6,1.82,AETNA [1000108],AETNA [100010801],,,76.8,,2,0.222255,85118.57664,percent of total billed charges,,,
LEVOTHYROXINE SODIUM 75 MCG ORAL TABS,RX-4422,CDM,S5000,HCPCS,259,RC,60687-0475-11,NDC,outpatient,1,UN,2.04,1.428,AETNA [1000108],AETNA [100010801],,,76.8,,1.57,0.222255,85118.57664,percent of total billed charges,,,
LEVOTHYROXINE SODIUM 75 MCG ORAL TABS,RX-4422,CDM,S5000,HCPCS,259,RC,60687-0475-01,NDC,outpatient,1,UN,2.04,1.428,AETNA [1000108],AETNA [100010801],,,76.8,,1.57,0.222255,85118.57664,percent of total billed charges,,,
LEVOTHYROXINE SODIUM 100 MCG ORAL TABS,RX-4423,CDM,S5000,HCPCS,259,RC,51079-0442-20,NDC,outpatient,1,UN,2.67,1.869,AETNA [1000108],AETNA [100010801],,,76.8,,2.05,0.222255,85118.57664,percent of total billed charges,,,
LEVOTHYROXINE SODIUM 100 MCG ORAL TABS,RX-4423,CDM,S5000,HCPCS,259,RC,00074-6624-11,NDC,outpatient,1,UN,6.49,4.543,AETNA [1000108],AETNA [100010801],,,76.8,,4.98,0.222255,85118.57664,percent of total billed charges,,,
LEVOTHYROXINE SODIUM 100 MCG ORAL TABS,RX-4423,CDM,S5000,HCPCS,259,RC,51079-0442-01,NDC,outpatient,1,UN,2.67,1.869,AETNA [1000108],AETNA [100010801],,,76.8,,2.05,0.222255,85118.57664,percent of total billed charges,,,
LEVOTHYROXINE SODIUM 125 MCG ORAL TABS,RX-4424,CDM,S5000,HCPCS,259,RC,51079-0443-20,NDC,outpatient,1,UN,3.14,2.198,AETNA [1000108],AETNA [100010801],,,76.8,,2.41,0.222255,85118.57664,percent of total billed charges,,,
LEVOTHYROXINE SODIUM 125 MCG ORAL TABS,RX-4424,CDM,S5000,HCPCS,259,RC,51079-0443-01,NDC,outpatient,1,UN,3.14,2.198,AETNA [1000108],AETNA [100010801],,,76.8,,2.41,0.222255,85118.57664,percent of total billed charges,,,
LEVOTHYROXINE SODIUM 150 MCG ORAL TABS,RX-4425,CDM,S5000,HCPCS,259,RC,60687-0530-01,NDC,outpatient,1,UN,2.51,1.757,AETNA [1000108],AETNA [100010801],,,76.8,,1.93,0.222255,85118.57664,percent of total billed charges,,,
LEVOTHYROXINE SODIUM 150 MCG ORAL TABS,RX-4425,CDM,S5000,HCPCS,259,RC,00074-7069-11,NDC,outpatient,1,UN,6.49,4.543,AETNA [1000108],AETNA [100010801],,,76.8,,4.98,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL 4 % EX SOLN,RX-4450,CDM,S5000,HCPCS,259,RC,00527-6004-80,NDC,outpatient,50,ML,75.88,53.116,AETNA [1000108],AETNA [100010801],,,76.8,,58.28,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL 4 % EX SOLN,RX-4450,CDM,S5000,HCPCS,259,RC,00054-3505-47,NDC,outpatient,50,ML,107.03,74.921,AETNA [1000108],AETNA [100010801],,,76.8,,82.2,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL 4 % EX SOLN,RX-4450,CDM,S5000,HCPCS,259,RC,60432-0465-51,NDC,outpatient,50,ML,131.72,92.204,AETNA [1000108],AETNA [100010801],,,76.8,,101.16,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL 0.5 % IJ SOLN,RX-4451,CDM,S5000,HCPCS,250,RC,63323-0484-57,NDC,outpatient,50,ML,22.7,15.89,AETNA [1000108],AETNA [100010801],,,76.8,,17.43,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL 1 % IJ SOLN,RX-4452,CDM,S5000,HCPCS,250,RC,00409-4276-17,NDC,outpatient,50,ML,8.23,5.761,AETNA [1000108],AETNA [100010801],,,76.8,,6.32,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL 1 % IJ SOLN,RX-4452,CDM,S5000,HCPCS,250,RC,00409-4276-01,NDC,outpatient,20,ML,4.63,3.241,AETNA [1000108],AETNA [100010801],,,76.8,,3.56,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL 1 % IJ SOLN,RX-4452,CDM,S5000,HCPCS,250,RC,00409-4276-16,NDC,outpatient,20,ML,4.63,3.241,AETNA [1000108],AETNA [100010801],,,76.8,,3.56,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL 1 % IJ SOLN,RX-4452,CDM,S5000,HCPCS,250,RC,00409-4276-02,NDC,outpatient,50,ML,8.23,5.761,AETNA [1000108],AETNA [100010801],,,76.8,,6.32,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,00409-4277-01,NDC,outpatient,20,ML,5.14,3.598,AETNA [1000108],AETNA [100010801],,,76.8,,3.95,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0202-02,NDC,outpatient,2,ML,11.73,8.211,AETNA [1000108],AETNA [100010801],,,76.8,,9.01,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0486-17,NDC,outpatient,10,ML,16.35,11.445,AETNA [1000108],AETNA [100010801],,,76.8,,12.56,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,00409-4277-16,NDC,outpatient,20,ML,5.14,3.598,AETNA [1000108],AETNA [100010801],,,76.8,,3.95,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,55150-0255-20,NDC,outpatient,20,ML,4.22,2.954,AETNA [1000108],AETNA [100010801],,,76.8,,3.24,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0486-02,NDC,outpatient,20,ML,18.2,12.74,AETNA [1000108],AETNA [100010801],,,76.8,,13.98,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,55150-0254-10,NDC,outpatient,10,ML,3.76,2.632,AETNA [1000108],AETNA [100010801],,,76.8,,2.89,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0202-01,NDC,outpatient,2,ML,11.73,8.211,AETNA [1000108],AETNA [100010801],,,76.8,,9.01,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0486-01,NDC,outpatient,10,ML,16.35,11.445,AETNA [1000108],AETNA [100010801],,,76.8,,12.56,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0486-26,NDC,outpatient,20,ML,8.02,5.614,AETNA [1000108],AETNA [100010801],,,76.8,,6.16,0.222255,85118.57664,percent of total billed charges,,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0486-27,NDC,outpatient,20,ML,18.2,12.74,AETNA [1000108],AETNA [100010801],,,76.8,,13.98,0.222255,85118.57664,percent of total billed charges,,,
AMOXICILLIN 250 MG ORAL CAPS,RX-450,CDM,S5000,HCPCS,259,RC,16714-0298-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
AMOXICILLIN 250 MG ORAL CAPS,RX-450,CDM,S5000,HCPCS,259,RC,65862-0016-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LIOTHYRONINE SODIUM 25 MCG ORAL TABS,RX-4504,CDM,S5000,HCPCS,259,RC,00093-2178-01,NDC,outpatient,1,UN,3.21,2.247,AETNA [1000108],AETNA [100010801],,,76.8,,2.47,0.222255,85118.57664,percent of total billed charges,,,
LIOTHYRONINE SODIUM 25 MCG ORAL TABS,RX-4504,CDM,S5000,HCPCS,259,RC,59762-1207-01,NDC,outpatient,1,UN,3.28,2.296,AETNA [1000108],AETNA [100010801],,,76.8,,2.52,0.222255,85118.57664,percent of total billed charges,,,
LIOTHYRONINE SODIUM 25 MCG ORAL TABS,RX-4504,CDM,S5000,HCPCS,259,RC,51862-0321-01,NDC,outpatient,1,UN,3.45,2.415,AETNA [1000108],AETNA [100010801],,,76.8,,2.65,0.222255,85118.57664,percent of total billed charges,,,
AMOXICILLIN 500 MG ORAL CAPS,RX-451,CDM,S5000,HCPCS,259,RC,16714-0299-03,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LITHIUM CARBONATE 150 MG ORAL CAPS,RX-4528,CDM,S5000,HCPCS,259,RC,00054-8526-25,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LITHIUM CARBONATE 300 MG ORAL CAPS,RX-4529,CDM,S5000,HCPCS,259,RC,31722-0545-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LITHIUM CARBONATE 300 MG ORAL CAPS,RX-4529,CDM,S5000,HCPCS,259,RC,00054-8527-25,NDC,outpatient,1,UN,1.04,0.728,AETNA [1000108],AETNA [100010801],,,76.8,,0.8,0.222255,85118.57664,percent of total billed charges,,,
AMOXICILLIN 250 MG/5ML ORAL SUSR,RX-454,CDM,S5000,HCPCS,259,RC,00093-4155-79,NDC,outpatient,80,ML,14.6,10.22,AETNA [1000108],AETNA [100010801],,,76.8,,11.21,0.222255,85118.57664,percent of total billed charges,,,
AMOXICILLIN 250 MG/5ML ORAL SUSR,RX-454,CDM,S5000,HCPCS,259,RC,99999-0002-83,NDC,outpatient,10,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
AMOXICILLIN 250 MG/5ML ORAL SUSR,RX-454,CDM,S5000,HCPCS,259,RC,00143-9889-15,NDC,outpatient,150,ML,20.7,14.49,AETNA [1000108],AETNA [100010801],,,76.8,,15.9,0.222255,85118.57664,percent of total billed charges,,,
LOPERAMIDE HCL 2 MG ORAL CAPS,RX-4560,CDM,S5000,HCPCS,259,RC,60687-0229-01,NDC,outpatient,1,UN,2.63,1.841,AETNA [1000108],AETNA [100010801],,,76.8,,2.02,0.222255,85118.57664,percent of total billed charges,,,
LOPERAMIDE HCL 2 MG ORAL CAPS,RX-4560,CDM,S5000,HCPCS,259,RC,60687-0229-11,NDC,outpatient,1,UN,2.63,1.841,AETNA [1000108],AETNA [100010801],,,76.8,,2.02,0.222255,85118.57664,percent of total billed charges,,,
LOPERAMIDE HCL 2 MG ORAL CAPS,RX-4560,CDM,S5000,HCPCS,259,RC,51079-0690-01,NDC,outpatient,1,UN,3,2.1,AETNA [1000108],AETNA [100010801],,,76.8,,2.3,0.222255,85118.57664,percent of total billed charges,,,
LOPERAMIDE HCL 2 MG ORAL CAPS,RX-4560,CDM,S5000,HCPCS,259,RC,51079-0690-20,NDC,outpatient,1,UN,3,2.1,AETNA [1000108],AETNA [100010801],,,76.8,,2.3,0.222255,85118.57664,percent of total billed charges,,,
LORAZEPAM 2 MG/ML ORAL CONC,RX-4571,CDM,S5000,HCPCS,259,RC,00054-3532-44,NDC,outpatient,30,ML,100.26,70.182,AETNA [1000108],AETNA [100010801],,,76.8,,77,0.222255,85118.57664,percent of total billed charges,,,
LORAZEPAM 2 MG/ML ORAL CONC,RX-4571,CDM,S5000,HCPCS,259,RC,00121-0770-01,NDC,outpatient,30,ML,33.11,23.177,AETNA [1000108],AETNA [100010801],,,76.8,,25.43,0.222255,85118.57664,percent of total billed charges,,,
LORAZEPAM 2 MG/ML ORAL CONC,RX-4571,CDM,S5000,HCPCS,259,RC,99999-0001-38,NDC,outpatient,1,ML,3.55,2.485,AETNA [1000108],AETNA [100010801],,,76.8,,2.73,0.222255,85118.57664,percent of total billed charges,,,
LORAZEPAM 0.5 MG ORAL TABS,RX-4572,CDM,S5000,HCPCS,259,RC,69315-0904-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LORAZEPAM 0.5 MG ORAL TABS,RX-4572,CDM,S5000,HCPCS,259,RC,13107-0083-05,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LORAZEPAM 0.5 MG ORAL TABS,RX-4572,CDM,S5000,HCPCS,259,RC,00093-3425-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LORAZEPAM 0.5 MG ORAL TABS,RX-4572,CDM,S5000,HCPCS,259,RC,00904-6007-60,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LORAZEPAM 0.5 MG ORAL TABS,RX-4572,CDM,S5000,HCPCS,259,RC,00904-6007-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LORAZEPAM 1 MG ORAL TABS,RX-4573,CDM,S5000,HCPCS,259,RC,00093-3426-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LORAZEPAM 1 MG ORAL TABS,RX-4573,CDM,S5000,HCPCS,259,RC,00904-6008-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LORAZEPAM 1 MG ORAL TABS,RX-4573,CDM,S5000,HCPCS,259,RC,69315-0905-05,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LORAZEPAM 1 MG ORAL TABS,RX-4573,CDM,S5000,HCPCS,259,RC,69315-0905-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LOXAPINE SUCCINATE 25 MG ORAL CAPS,RX-4600,CDM,S5000,HCPCS,259,RC,00591-0371-01,NDC,outpatient,1,UN,2.33,1.631,AETNA [1000108],AETNA [100010801],,,76.8,,1.79,0.222255,85118.57664,percent of total billed charges,,,
LOXAPINE SUCCINATE 5 MG ORAL CAPS,RX-4601,CDM,S5000,HCPCS,259,RC,00591-0369-01,NDC,outpatient,1,UN,1.31,0.917,AETNA [1000108],AETNA [100010801],,,76.8,,1.01,0.222255,85118.57664,percent of total billed charges,,,
MAGNESIUM CITRATE 1.745 GM/30ML ORAL SOLN,RX-4711,CDM,S5000,HCPCS,259,RC,70677-1111-01,NDC,outpatient,296,ML,7.91,5.537,AETNA [1000108],AETNA [100010801],,,76.8,,6.07,0.222255,85118.57664,percent of total billed charges,,,
MANNITOL 20 % IV SOLN,RX-4749,CDM,S5000,HCPCS,250,RC,00990-7715-03,NDC,outpatient,500,ML,93.88,65.716,AETNA [1000108],AETNA [100010801],,,76.8,,72.1,0.222255,85118.57664,percent of total billed charges,,,
MANNITOL 20 % IV SOLN,RX-4749,CDM,S5000,HCPCS,250,RC,00338-0357-02,NDC,outpatient,250,ML,79.42,55.594,AETNA [1000108],AETNA [100010801],,,76.8,,60.99,0.222255,85118.57664,percent of total billed charges,,,
MANNITOL 20 % IV SOLN,RX-4749,CDM,S5000,HCPCS,250,RC,00990-7715-13,NDC,outpatient,500,ML,93.88,65.716,AETNA [1000108],AETNA [100010801],,,76.8,,72.1,0.222255,85118.57664,percent of total billed charges,,,
MANNITOL 20 % IV SOLN,RX-4749,CDM,S5000,HCPCS,250,RC,00338-0357-03,NDC,outpatient,500,ML,80.53,56.371,AETNA [1000108],AETNA [100010801],,,76.8,,61.85,0.222255,85118.57664,percent of total billed charges,,,
MEDROXYPROGESTERONE ACETATE 10 MG ORAL TABS,RX-4854,CDM,S5000,HCPCS,259,RC,00555-0779-02,NDC,outpatient,1,UN,1.07,0.749,AETNA [1000108],AETNA [100010801],,,76.8,,0.82,0.222255,85118.57664,percent of total billed charges,,,
MEDROXYPROGESTERONE ACETATE 2.5 MG ORAL TABS,RX-4855,CDM,S5000,HCPCS,259,RC,00555-0872-02,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
METHADONE HCL 10 MG ORAL TABS,RX-4953,CDM,S5000,HCPCS,259,RC,00406-5771-23,NDC,outpatient,1,UN,1.39,0.973,AETNA [1000108],AETNA [100010801],,,76.8,,1.07,0.222255,85118.57664,percent of total billed charges,,,
METHADONE HCL 10 MG ORAL TABS,RX-4953,CDM,S5000,HCPCS,259,RC,00054-0710-20,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
METHADONE HCL 10 MG ORAL TABS,RX-4953,CDM,S5000,HCPCS,259,RC,00406-5771-62,NDC,outpatient,1,UN,1.39,0.973,AETNA [1000108],AETNA [100010801],,,76.8,,1.07,0.222255,85118.57664,percent of total billed charges,,,
METHADONE HCL 5 MG ORAL TABS,RX-4954,CDM,S5000,HCPCS,259,RC,00406-5755-23,NDC,outpatient,1,UN,1.17,0.819,AETNA [1000108],AETNA [100010801],,,76.8,,0.9,0.222255,85118.57664,percent of total billed charges,,,
METHADONE HCL 5 MG ORAL TABS,RX-4954,CDM,S5000,HCPCS,259,RC,00406-5755-62,NDC,outpatient,1,UN,1.17,0.819,AETNA [1000108],AETNA [100010801],,,76.8,,0.9,0.222255,85118.57664,percent of total billed charges,,,
METHAZOLAMIDE 50 MG ORAL TABS,RX-4962,CDM,S5000,HCPCS,259,RC,00574-0791-01,NDC,outpatient,1,UN,6.49,4.543,AETNA [1000108],AETNA [100010801],,,76.8,,4.98,0.222255,85118.57664,percent of total billed charges,,,
METHOCARBAMOL 500 MG ORAL TABS,RX-4971,CDM,S5000,HCPCS,259,RC,76385-0123-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
METHOCARBAMOL 500 MG ORAL TABS,RX-4971,CDM,S5000,HCPCS,259,RC,00904-7057-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
METHOCARBAMOL 500 MG ORAL TABS,RX-4971,CDM,S5000,HCPCS,259,RC,31722-0533-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
METHYLPHENIDATE HCL 10 MG ORAL TABS,RX-4986,CDM,S5000,HCPCS,259,RC,68084-0823-21,NDC,outpatient,1,UN,5.13,3.591,AETNA [1000108],AETNA [100010801],,,76.8,,3.94,0.222255,85118.57664,percent of total billed charges,,,
METHYLPHENIDATE HCL 10 MG ORAL TABS,RX-4986,CDM,S5000,HCPCS,259,RC,00406-1144-01,NDC,outpatient,1,UN,1.43,1.001,AETNA [1000108],AETNA [100010801],,,76.8,,1.1,0.222255,85118.57664,percent of total billed charges,,,
METHYLPHENIDATE HCL 10 MG ORAL TABS,RX-4986,CDM,S5000,HCPCS,259,RC,68084-0823-11,NDC,outpatient,1,UN,5.13,3.591,AETNA [1000108],AETNA [100010801],,,76.8,,3.94,0.222255,85118.57664,percent of total billed charges,,,
METHYLPREDNISOLONE 16 MG ORAL TABS,RX-4992,CDM,S5000,HCPCS,259,RC,59762-0050-01,NDC,outpatient,1,UN,8.54,5.978,AETNA [1000108],AETNA [100010801],,,76.8,,6.56,0.222255,85118.57664,percent of total billed charges,,,
METHYLPREDNISOLONE 4 MG ORAL TABS,RX-4993,CDM,S5000,HCPCS,259,RC,68084-0149-11,NDC,outpatient,1,UN,4.95,3.465,AETNA [1000108],AETNA [100010801],,,76.8,,3.8,0.222255,85118.57664,percent of total billed charges,,,
METHYLPREDNISOLONE 4 MG ORAL TABS,RX-4993,CDM,S5000,HCPCS,259,RC,00904-6914-61,NDC,outpatient,1,UN,4.37,3.059,AETNA [1000108],AETNA [100010801],,,76.8,,3.36,0.222255,85118.57664,percent of total billed charges,,,
METHYLPREDNISOLONE 4 MG ORAL TABS,RX-4993,CDM,S5000,HCPCS,259,RC,68084-0149-01,NDC,outpatient,1,UN,4.95,3.465,AETNA [1000108],AETNA [100010801],,,76.8,,3.8,0.222255,85118.57664,percent of total billed charges,,,
METOCLOPRAMIDE HCL 10 MG ORAL TABS,RX-5005,CDM,S5000,HCPCS,259,RC,60687-0631-11,NDC,outpatient,1,UN,2.56,1.792,AETNA [1000108],AETNA [100010801],,,76.8,,1.97,0.222255,85118.57664,percent of total billed charges,,,
METOCLOPRAMIDE HCL 10 MG ORAL TABS,RX-5005,CDM,S5000,HCPCS,259,RC,60687-0631-01,NDC,outpatient,1,UN,2.56,1.792,AETNA [1000108],AETNA [100010801],,,76.8,,1.97,0.222255,85118.57664,percent of total billed charges,,,
METOPROLOL TARTRATE 50 MG ORAL TABS,RX-5009,CDM,S5000,HCPCS,259,RC,62584-0266-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
METOPROLOL TARTRATE 50 MG ORAL TABS,RX-5009,CDM,S5000,HCPCS,259,RC,51079-0801-20,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
METOPROLOL TARTRATE 50 MG ORAL TABS,RX-5009,CDM,S5000,HCPCS,259,RC,51079-0801-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
METOPROLOL TARTRATE 50 MG ORAL TABS,RX-5009,CDM,S5000,HCPCS,259,RC,62584-0266-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
METRONIDAZOLE 250 MG ORAL TABS,RX-5015,CDM,S5000,HCPCS,259,RC,00904-7156-61,NDC,outpatient,1,UN,1.09,0.763,AETNA [1000108],AETNA [100010801],,,76.8,,0.84,0.222255,85118.57664,percent of total billed charges,,,
METRONIDAZOLE 500 MG ORAL TABS,RX-5016,CDM,S5000,HCPCS,259,RC,60687-0550-01,NDC,outpatient,1,UN,2.17,1.519,AETNA [1000108],AETNA [100010801],,,76.8,,1.67,0.222255,85118.57664,percent of total billed charges,,,
METRONIDAZOLE 500 MG ORAL TABS,RX-5016,CDM,S5000,HCPCS,259,RC,60687-0550-11,NDC,outpatient,1,UN,2.17,1.519,AETNA [1000108],AETNA [100010801],,,76.8,,1.67,0.222255,85118.57664,percent of total billed charges,,,
METRONIDAZOLE 500 MG ORAL TABS,RX-5016,CDM,S5000,HCPCS,259,RC,29300-0227-01,NDC,outpatient,1,UN,1.76,1.232,AETNA [1000108],AETNA [100010801],,,76.8,,1.35,0.222255,85118.57664,percent of total billed charges,,,
MICONAZOLE NITRATE 2 % EX CREA,RX-5039,CDM,S5000,HCPCS,259,RC,61269-0735-14,NDC,outpatient,14,GR,7.54,5.278,AETNA [1000108],AETNA [100010801],,,76.8,,5.79,0.222255,85118.57664,percent of total billed charges,,,
MINERAL OIL ORAL OIL,RX-5086,CDM,S5000,HCPCS,259,RC,48433-0202-30,NDC,outpatient,30,ML,5.08,3.556,AETNA [1000108],AETNA [100010801],,,76.8,,3.9,0.222255,85118.57664,percent of total billed charges,,,
MINERAL OIL ORAL OIL,RX-5086,CDM,S5000,HCPCS,259,RC,99999-0002-15,NDC,outpatient,30,ML,1.39,0.973,AETNA [1000108],AETNA [100010801],,,76.8,,1.07,0.222255,85118.57664,percent of total billed charges,,,
MINOCYCLINE HCL 50 MG ORAL CAPS,RX-5111,CDM,S5000,HCPCS,259,RC,00591-5694-60,NDC,outpatient,1,UN,1.26,0.882,AETNA [1000108],AETNA [100010801],,,76.8,,0.97,0.222255,85118.57664,percent of total billed charges,,,
MINOXIDIL 10 MG ORAL TABS,RX-5114,CDM,S5000,HCPCS,259,RC,68084-0205-01,NDC,outpatient,1,UN,2.48,1.736,AETNA [1000108],AETNA [100010801],,,76.8,,1.9,0.222255,85118.57664,percent of total billed charges,,,
MINOXIDIL 10 MG ORAL TABS,RX-5114,CDM,S5000,HCPCS,259,RC,68084-0205-11,NDC,outpatient,1,UN,2.48,1.736,AETNA [1000108],AETNA [100010801],,,76.8,,1.9,0.222255,85118.57664,percent of total billed charges,,,
MINOXIDIL 2.5 MG ORAL TABS,RX-5115,CDM,S5000,HCPCS,259,RC,00591-5642-01,NDC,outpatient,1,UN,1.01,0.707,AETNA [1000108],AETNA [100010801],,,76.8,,0.78,0.222255,85118.57664,percent of total billed charges,,,
MINOXIDIL 2.5 MG ORAL TABS,RX-5115,CDM,S5000,HCPCS,259,RC,68084-0204-01,NDC,outpatient,1,UN,2.25,1.575,AETNA [1000108],AETNA [100010801],,,76.8,,1.73,0.222255,85118.57664,percent of total billed charges,,,
MINOXIDIL 2.5 MG ORAL TABS,RX-5115,CDM,S5000,HCPCS,259,RC,68084-0204-11,NDC,outpatient,1,UN,2.25,1.575,AETNA [1000108],AETNA [100010801],,,76.8,,1.73,0.222255,85118.57664,percent of total billed charges,,,
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,00121-0904-05,NDC,outpatient,5,ML,4.01,2.807,AETNA [1000108],AETNA [100010801],,,76.8,,3.08,0.222255,85118.57664,percent of total billed charges,,,
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,00121-0904-94,NDC,outpatient,5,ML,4.01,2.807,AETNA [1000108],AETNA [100010801],,,76.8,,3.08,0.222255,85118.57664,percent of total billed charges,,,
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,68094-0001-62,NDC,outpatient,5,ML,4.7,3.29,AETNA [1000108],AETNA [100010801],,,76.8,,3.61,0.222255,85118.57664,percent of total billed charges,,,
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,00054-0237-49,NDC,outpatient,100,ML,37.38,26.166,AETNA [1000108],AETNA [100010801],,,76.8,,28.71,0.222255,85118.57664,percent of total billed charges,,,
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,68094-0001-59,NDC,outpatient,5,ML,4.7,3.29,AETNA [1000108],AETNA [100010801],,,76.8,,3.61,0.222255,85118.57664,percent of total billed charges,,,
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,99999-0002-19,NDC,outpatient,5,ML,2.14,1.498,AETNA [1000108],AETNA [100010801],,,76.8,,1.64,0.222255,85118.57664,percent of total billed charges,,,
MORPHINE SULFATE 15 MG ORAL TABS,RX-5178,CDM,S5000,HCPCS,259,RC,00054-0235-25,NDC,outpatient,1,UN,2.1,1.47,AETNA [1000108],AETNA [100010801],,,76.8,,1.61,0.222255,85118.57664,percent of total billed charges,,,
MORPHINE SULFATE 15 MG ORAL TABS,RX-5178,CDM,S5000,HCPCS,259,RC,00054-0235-24,NDC,outpatient,1,UN,3.2,2.24,AETNA [1000108],AETNA [100010801],,,76.8,,2.46,0.222255,85118.57664,percent of total billed charges,,,
MORPHINE SULFATE 10 MG RE SUPP,RX-5180,CDM,S5000,HCPCS,259,RC,00574-7112-12,NDC,outpatient,1,UN,19.66,13.762,AETNA [1000108],AETNA [100010801],,,76.8,,15.1,0.222255,85118.57664,percent of total billed charges,,,
NADOLOL 20 MG ORAL TABS,RX-5330,CDM,S5000,HCPCS,259,RC,60687-0302-95,NDC,outpatient,1,UN,11.38,7.966,AETNA [1000108],AETNA [100010801],,,76.8,,8.74,0.222255,85118.57664,percent of total billed charges,,,
NADOLOL 20 MG ORAL TABS,RX-5330,CDM,S5000,HCPCS,259,RC,60687-0302-25,NDC,outpatient,1,UN,11.38,7.966,AETNA [1000108],AETNA [100010801],,,76.8,,8.74,0.222255,85118.57664,percent of total billed charges,,,
NADOLOL 40 MG ORAL TABS,RX-5331,CDM,S5000,HCPCS,259,RC,00904-7071-07,NDC,outpatient,1,UN,9.11,6.377,AETNA [1000108],AETNA [100010801],,,76.8,,7,0.222255,85118.57664,percent of total billed charges,,,
NADOLOL 40 MG ORAL TABS,RX-5331,CDM,S5000,HCPCS,259,RC,69097-0868-07,NDC,outpatient,1,UN,1.13,0.791,AETNA [1000108],AETNA [100010801],,,76.8,,0.87,0.222255,85118.57664,percent of total billed charges,,,
NAPROXEN 250 MG ORAL TABS,RX-5391,CDM,S5000,HCPCS,259,RC,50268-0594-15,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
NAPROXEN 250 MG ORAL TABS,RX-5391,CDM,S5000,HCPCS,259,RC,65162-0188-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
NAPROXEN 250 MG ORAL TABS,RX-5391,CDM,S5000,HCPCS,259,RC,50268-0594-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
NAPROXEN 375 MG ORAL TABS,RX-5392,CDM,S5000,HCPCS,259,RC,50268-0595-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
NAPROXEN 375 MG ORAL TABS,RX-5392,CDM,S5000,HCPCS,259,RC,50268-0595-15,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
NAPROXEN 375 MG ORAL TABS,RX-5392,CDM,S5000,HCPCS,259,RC,65162-0189-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
NAPROXEN 500 MG ORAL TABS,RX-5393,CDM,S5000,HCPCS,259,RC,63739-0403-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
NAPROXEN 500 MG ORAL TABS,RX-5393,CDM,S5000,HCPCS,259,RC,65162-0190-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
NAPROXEN 500 MG ORAL TABS,RX-5393,CDM,S5000,HCPCS,259,RC,65862-0522-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
NEOMYCIN SULFATE 500 MG ORAL TABS,RX-5472,CDM,S5000,HCPCS,259,RC,39822-0310-05,NDC,outpatient,1,UN,3.09,2.163,AETNA [1000108],AETNA [100010801],,,76.8,,2.37,0.222255,85118.57664,percent of total billed charges,,,
NEOMYCIN SULFATE 500 MG ORAL TABS,RX-5472,CDM,S5000,HCPCS,259,RC,39822-0310-07,NDC,outpatient,1,UN,3.09,2.163,AETNA [1000108],AETNA [100010801],,,76.8,,2.37,0.222255,85118.57664,percent of total billed charges,,,
NEOMYCIN-POLYMYXIN-GRAMICIDIN 1.75-10000-.025 OP SOLN,RX-5474,CDM,S5000,HCPCS,259,RC,24208-0790-62,NDC,outpatient,10,ML,150.86,105.602,AETNA [1000108],AETNA [100010801],,,76.8,,115.86,0.222255,85118.57664,percent of total billed charges,,,
NIACIN 100 MG ORAL TABS,RX-5539,CDM,S5000,HCPCS,259,RC,80681-0057-00,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
NIFEDIPINE 10 MG ORAL CAPS,RX-5558,CDM,S5000,HCPCS,259,RC,23155-0194-01,NDC,outpatient,1,UN,1.98,1.386,AETNA [1000108],AETNA [100010801],,,76.8,,1.52,0.222255,85118.57664,percent of total billed charges,,,
NITROFURANTOIN MACROCRYSTAL 50 MG ORAL CAPS,RX-5595,CDM,S5000,HCPCS,259,RC,57664-0232-88,NDC,outpatient,1,UN,3.41,2.387,AETNA [1000108],AETNA [100010801],,,76.8,,2.62,0.222255,85118.57664,percent of total billed charges,,,
NITROGLYCERIN 0.3 MG SL SUBL,RX-5603,CDM,S5000,HCPCS,259,RC,68462-0638-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
NITROGLYCERIN 0.3 MG SL SUBL,RX-5603,CDM,S5000,HCPCS,259,RC,00071-0417-24,NDC,outpatient,1,UN,3.05,2.135,AETNA [1000108],AETNA [100010801],,,76.8,,2.34,0.222255,85118.57664,percent of total billed charges,,,
NITROGLYCERIN 0.3 MG SL SUBL,RX-5603,CDM,S5000,HCPCS,259,RC,72888-0138-01,NDC,outpatient,1,UN,1.43,1.001,AETNA [1000108],AETNA [100010801],,,76.8,,1.1,0.222255,85118.57664,percent of total billed charges,,,
NITROGLYCERIN 0.4 MG SL SUBL,RX-5604,CDM,S5000,HCPCS,259,RC,68462-0639-25,NDC,outpatient,0.75,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
NITROGLYCERIN 0.4 MG SL SUBL,RX-5604,CDM,S5000,HCPCS,259,RC,43598-0436-11,NDC,outpatient,0.75,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
NITROGLYCERIN 0.4 MG SL SUBL,RX-5604,CDM,S5000,HCPCS,259,RC,43598-0436-35,NDC,outpatient,0.75,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
NITROGLYCERIN 0.4 MG SL SUBL,RX-5604,CDM,S5000,HCPCS,259,RC,68462-0639-45,NDC,outpatient,0.75,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
NITROGLYCERIN 2 % TD OINT,RX-5606,CDM,S5000,HCPCS,259,RC,00281-0326-08,NDC,outpatient,1,GR,9.96,6.972,AETNA [1000108],AETNA [100010801],,,76.8,,7.65,0.222255,85118.57664,percent of total billed charges,,,
NORTRIPTYLINE HCL 25 MG ORAL CAPS,RX-5675,CDM,S5000,HCPCS,259,RC,60687-0293-01,NDC,outpatient,1,UN,1.89,1.323,AETNA [1000108],AETNA [100010801],,,76.8,,1.45,0.222255,85118.57664,percent of total billed charges,,,
NORTRIPTYLINE HCL 25 MG ORAL CAPS,RX-5675,CDM,S5000,HCPCS,259,RC,60687-0293-11,NDC,outpatient,1,UN,1.89,1.323,AETNA [1000108],AETNA [100010801],,,76.8,,1.45,0.222255,85118.57664,percent of total billed charges,,,
NYSTATIN 100000 UNIT/GM EX CREA,RX-5749,CDM,S5000,HCPCS,259,RC,00713-0678-15,NDC,outpatient,15,GR,53.4,37.38,AETNA [1000108],AETNA [100010801],,,76.8,,41.01,0.222255,85118.57664,percent of total billed charges,,,
NYSTATIN 100000 UNIT/GM EX CREA,RX-5749,CDM,S5000,HCPCS,259,RC,45802-0059-35,NDC,outpatient,15,GR,17.03,11.921,AETNA [1000108],AETNA [100010801],,,76.8,,13.08,0.222255,85118.57664,percent of total billed charges,,,
NYSTATIN 100000 UNIT/GM EX CREA,RX-5749,CDM,S5000,HCPCS,259,RC,51672-1289-01,NDC,outpatient,15,GR,18.83,13.181,AETNA [1000108],AETNA [100010801],,,76.8,,14.46,0.222255,85118.57664,percent of total billed charges,,,
NYSTATIN 100000 UNIT/GM EX OINT,RX-5750,CDM,S5000,HCPCS,259,RC,45802-0048-35,NDC,outpatient,15,GR,13.29,9.303,AETNA [1000108],AETNA [100010801],,,76.8,,10.21,0.222255,85118.57664,percent of total billed charges,,,
NYSTATIN 100000 UNIT/GM EX OINT,RX-5750,CDM,S5000,HCPCS,259,RC,00472-0166-15,NDC,outpatient,15,GR,61.35,42.945,AETNA [1000108],AETNA [100010801],,,76.8,,47.12,0.222255,85118.57664,percent of total billed charges,,,
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,99999-0003-91,NDC,outpatient,5,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,63739-0160-10,NDC,outpatient,5,ML,2.63,1.841,AETNA [1000108],AETNA [100010801],,,76.8,,2.02,0.222255,85118.57664,percent of total billed charges,,,
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,63739-0160-70,NDC,outpatient,5,ML,2.63,1.841,AETNA [1000108],AETNA [100010801],,,76.8,,2.02,0.222255,85118.57664,percent of total billed charges,,,
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,00121-0868-00,NDC,outpatient,5,ML,4.74,3.318,AETNA [1000108],AETNA [100010801],,,76.8,,3.64,0.222255,85118.57664,percent of total billed charges,,,
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,00121-1045-16,NDC,outpatient,5,ML,4.21,2.947,AETNA [1000108],AETNA [100010801],,,76.8,,3.23,0.222255,85118.57664,percent of total billed charges,,,
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,00121-0868-05,NDC,outpatient,5,ML,4.74,3.318,AETNA [1000108],AETNA [100010801],,,76.8,,3.64,0.222255,85118.57664,percent of total billed charges,,,
NYSTATIN-TRIAMCINOLONE 100000-0.1 UNIT/GM-% EX CREA,RX-5754,CDM,S5000,HCPCS,259,RC,51672-1263-01,NDC,outpatient,15,GR,15.02,10.514,AETNA [1000108],AETNA [100010801],,,76.8,,11.54,0.222255,85118.57664,percent of total billed charges,,,
NYSTATIN-TRIAMCINOLONE 100000-0.1 UNIT/GM-% EX OINT,RX-5755,CDM,S5000,HCPCS,259,RC,51672-1272-01,NDC,outpatient,15,GR,22.37,15.659,AETNA [1000108],AETNA [100010801],,,76.8,,17.18,0.222255,85118.57664,percent of total billed charges,,,
ORA-PLUS ORAL LIQD,RX-5851,CDM,S5000,HCPCS,259,RC,00574-0303-16,NDC,outpatient,473,ML,130.96,91.672,AETNA [1000108],AETNA [100010801],,,76.8,,100.58,0.222255,85118.57664,percent of total billed charges,,,
ORA-SWEET SF ORAL SYRP,RX-5853,CDM,S5000,HCPCS,259,RC,00574-0302-16,NDC,outpatient,473,ML,130.96,91.672,AETNA [1000108],AETNA [100010801],,,76.8,,100.58,0.222255,85118.57664,percent of total billed charges,,,
OXAZEPAM 10 MG ORAL CAPS,RX-5930,CDM,S5000,HCPCS,259,RC,00228-2067-10,NDC,outpatient,1,UN,3.24,2.268,AETNA [1000108],AETNA [100010801],,,76.8,,2.49,0.222255,85118.57664,percent of total billed charges,,,
OXAZEPAM 10 MG ORAL CAPS,RX-5930,CDM,S5000,HCPCS,259,RC,62584-0812-01,NDC,outpatient,1,UN,8.63,6.041,AETNA [1000108],AETNA [100010801],,,76.8,,6.63,0.222255,85118.57664,percent of total billed charges,,,
OXAZEPAM 10 MG ORAL CAPS,RX-5930,CDM,S5000,HCPCS,259,RC,62584-0812-11,NDC,outpatient,1,UN,8.63,6.041,AETNA [1000108],AETNA [100010801],,,76.8,,6.63,0.222255,85118.57664,percent of total billed charges,,,
OXAZEPAM 15 MG ORAL CAPS,RX-5931,CDM,S5000,HCPCS,259,RC,62584-0813-11,NDC,outpatient,1,UN,9.09,6.363,AETNA [1000108],AETNA [100010801],,,76.8,,6.98,0.222255,85118.57664,percent of total billed charges,,,
OXAZEPAM 15 MG ORAL CAPS,RX-5931,CDM,S5000,HCPCS,259,RC,62584-0813-01,NDC,outpatient,1,UN,9.09,6.363,AETNA [1000108],AETNA [100010801],,,76.8,,6.98,0.222255,85118.57664,percent of total billed charges,,,
OXYBUTYNIN CHLORIDE 5 MG ORAL TABS,RX-5938,CDM,S5000,HCPCS,259,RC,60687-0670-11,NDC,outpatient,1,UN,1.85,1.295,AETNA [1000108],AETNA [100010801],,,76.8,,1.42,0.222255,85118.57664,percent of total billed charges,,,
OXYBUTYNIN CHLORIDE 5 MG ORAL TABS,RX-5938,CDM,S5000,HCPCS,259,RC,60687-0670-01,NDC,outpatient,1,UN,1.85,1.295,AETNA [1000108],AETNA [100010801],,,76.8,,1.42,0.222255,85118.57664,percent of total billed charges,,,
OXYBUTYNIN CHLORIDE 5 MG ORAL TABS,RX-5938,CDM,S5000,HCPCS,259,RC,00904-7027-61,NDC,outpatient,1,UN,1.69,1.183,AETNA [1000108],AETNA [100010801],,,76.8,,1.3,0.222255,85118.57664,percent of total billed charges,,,
OXYCODONE-ACETAMINOPHEN 5-325 MG ORAL TABS,RX-5940,CDM,S5000,HCPCS,259,RC,00406-0512-62,NDC,outpatient,1,UN,1.65,1.155,AETNA [1000108],AETNA [100010801],,,76.8,,1.27,0.222255,85118.57664,percent of total billed charges,,,
OXYCODONE-ACETAMINOPHEN 5-325 MG ORAL TABS,RX-5940,CDM,S5000,HCPCS,259,RC,00406-0512-23,NDC,outpatient,1,UN,1.65,1.155,AETNA [1000108],AETNA [100010801],,,76.8,,1.27,0.222255,85118.57664,percent of total billed charges,,,
PAPAVERINE HCL 30 MG/ML IJ SOLN,RX-6030,CDM,S5000,HCPCS,250,RC,00517-4002-25,NDC,outpatient,2,ML,103.84,72.688,AETNA [1000108],AETNA [100010801],,,76.8,,79.75,0.222255,85118.57664,percent of total billed charges,,,
PAPAVERINE HCL 30 MG/ML IJ SOLN,RX-6030,CDM,S5000,HCPCS,250,RC,54288-0142-01,NDC,outpatient,2,ML,69.91,48.937,AETNA [1000108],AETNA [100010801],,,76.8,,53.69,0.222255,85118.57664,percent of total billed charges,,,
PAPAVERINE HCL 30 MG/ML IJ SOLN,RX-6030,CDM,S5000,HCPCS,250,RC,14789-0121-05,NDC,outpatient,2,ML,78.96,55.272,AETNA [1000108],AETNA [100010801],,,76.8,,60.64,0.222255,85118.57664,percent of total billed charges,,,
PAPAVERINE HCL 30 MG/ML IJ SOLN,RX-6030,CDM,S5000,HCPCS,250,RC,54288-0142-10,NDC,outpatient,2,ML,69.91,48.937,AETNA [1000108],AETNA [100010801],,,76.8,,53.69,0.222255,85118.57664,percent of total billed charges,,,
PAPAVERINE HCL 30 MG/ML IJ SOLN,RX-6030,CDM,S5000,HCPCS,250,RC,14789-0121-07,NDC,outpatient,2,ML,78.96,55.272,AETNA [1000108],AETNA [100010801],,,76.8,,60.64,0.222255,85118.57664,percent of total billed charges,,,
PENICILLIN G SODIUM 5000000 UNITS IJ SOLR,RX-6087,CDM,S5000,HCPCS,250,RC,00781-6153-95,NDC,outpatient,1,UN,142.02,99.414,AETNA [1000108],AETNA [100010801],,,76.8,,109.07,0.222255,85118.57664,percent of total billed charges,,,
PENICILLIN G SODIUM 5000000 UNITS IJ SOLR,RX-6087,CDM,S5000,HCPCS,250,RC,00781-6153-94,NDC,outpatient,1,UN,142.02,99.414,AETNA [1000108],AETNA [100010801],,,76.8,,109.07,0.222255,85118.57664,percent of total billed charges,,,
PENICILLIN V POTASSIUM 250 MG/5ML ORAL SOLR,RX-6091,CDM,S5000,HCPCS,259,RC,00093-4127-73,NDC,outpatient,100,ML,26.7,18.69,AETNA [1000108],AETNA [100010801],,,76.8,,20.51,0.222255,85118.57664,percent of total billed charges,,,
PENICILLIN V POTASSIUM 250 MG/5ML ORAL SOLR,RX-6091,CDM,S5000,HCPCS,259,RC,99999-0002-88,NDC,outpatient,10,ML,2.67,1.869,AETNA [1000108],AETNA [100010801],,,76.8,,2.05,0.222255,85118.57664,percent of total billed charges,,,
PENICILLIN V POTASSIUM 250 MG ORAL TABS,RX-6092,CDM,S5000,HCPCS,259,RC,57237-0040-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PENICILLIN V POTASSIUM 500 MG ORAL TABS,RX-6093,CDM,S5000,HCPCS,259,RC,00143-9836-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PENICILLIN V POTASSIUM 500 MG ORAL TABS,RX-6093,CDM,S5000,HCPCS,259,RC,00093-1174-01,NDC,outpatient,1,UN,1.67,1.169,AETNA [1000108],AETNA [100010801],,,76.8,,1.28,0.222255,85118.57664,percent of total billed charges,,,
PERPHENAZINE 2 MG ORAL TABS,RX-6157,CDM,S5000,HCPCS,259,RC,00904-6599-61,NDC,outpatient,1,UN,2.75,1.925,AETNA [1000108],AETNA [100010801],,,76.8,,2.11,0.222255,85118.57664,percent of total billed charges,,,
PERPHENAZINE 8 MG ORAL TABS,RX-6159,CDM,S5000,HCPCS,259,RC,00904-6601-61,NDC,outpatient,1,UN,5.02,3.514,AETNA [1000108],AETNA [100010801],,,76.8,,3.86,0.222255,85118.57664,percent of total billed charges,,,
PHENAZOPYRIDINE HCL 100 MG ORAL TABS,RX-6193,CDM,S5000,HCPCS,259,RC,65162-0681-10,NDC,outpatient,1,UN,1.61,1.127,AETNA [1000108],AETNA [100010801],,,76.8,,1.24,0.222255,85118.57664,percent of total billed charges,,,
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,00121-0942-05,NDC,outpatient,5,ML,7.01,4.907,AETNA [1000108],AETNA [100010801],,,76.8,,5.38,0.222255,85118.57664,percent of total billed charges,,,
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,13517-0107-16,NDC,outpatient,473,ML,307.31,215.117,AETNA [1000108],AETNA [100010801],,,76.8,,236.01,0.222255,85118.57664,percent of total billed charges,,,
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,16571-0675-16,NDC,outpatient,473,ML,82.09,57.463,AETNA [1000108],AETNA [100010801],,,76.8,,63.05,0.222255,85118.57664,percent of total billed charges,,,
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,99999-0002-30,NDC,outpatient,5,ML,2.5,1.75,AETNA [1000108],AETNA [100010801],,,76.8,,1.92,0.222255,85118.57664,percent of total billed charges,,,
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,00121-0942-50,NDC,outpatient,5,ML,7.01,4.907,AETNA [1000108],AETNA [100010801],,,76.8,,5.38,0.222255,85118.57664,percent of total billed charges,,,
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,54932-0501-81,NDC,outpatient,473,ML,75.78,53.046,AETNA [1000108],AETNA [100010801],,,76.8,,58.2,0.222255,85118.57664,percent of total billed charges,,,
PHENOBARBITAL 32.4 MG ORAL TABS,RX-6217,CDM,S5000,HCPCS,259,RC,00904-6575-61,NDC,outpatient,1,UN,1.34,0.938,AETNA [1000108],AETNA [100010801],,,76.8,,1.03,0.222255,85118.57664,percent of total billed charges,,,
PHENOBARBITAL 32.4 MG ORAL TABS,RX-6217,CDM,S5000,HCPCS,259,RC,16571-0673-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PHENYLEPHRINE HCL 0.25 % NA SOLN,RX-6243,CDM,S5000,HCPCS,259,RC,00225-0800-47,NDC,outpatient,15,ML,13.42,9.394,AETNA [1000108],AETNA [100010801],,,76.8,,10.31,0.222255,85118.57664,percent of total billed charges,,,
PHENYLEPHRINE HCL 0.5 % NA SOLN,RX-6244,CDM,S5000,HCPCS,259,RC,00225-0805-47,NDC,outpatient,15,ML,13.42,9.394,AETNA [1000108],AETNA [100010801],,,76.8,,10.31,0.222255,85118.57664,percent of total billed charges,,,
PHENYLEPHRINE HCL 1 % NA SOLN,RX-6245,CDM,S5000,HCPCS,259,RC,00225-0810-47,NDC,outpatient,15,ML,15.09,10.563,AETNA [1000108],AETNA [100010801],,,76.8,,11.59,0.222255,85118.57664,percent of total billed charges,,,
PHENYLEPHRINE HCL 2.5 % OP SOLN,RX-6246,CDM,S5000,HCPCS,259,RC,70756-0629-25,NDC,outpatient,2,ML,146.94,102.858,AETNA [1000108],AETNA [100010801],,,76.8,,112.85,0.222255,85118.57664,percent of total billed charges,,,
PHENYTOIN 125 MG/5ML ORAL SUSP,RX-6255,CDM,S5000,HCPCS,259,RC,60687-0275-66,NDC,outpatient,4,ML,13.48,9.436,AETNA [1000108],AETNA [100010801],,,76.8,,10.35,0.222255,85118.57664,percent of total billed charges,,,
PHENYTOIN 125 MG/5ML ORAL SUSP,RX-6255,CDM,S5000,HCPCS,259,RC,60687-0275-62,NDC,outpatient,4,ML,13.48,9.436,AETNA [1000108],AETNA [100010801],,,76.8,,10.35,0.222255,85118.57664,percent of total billed charges,,,
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAPS,RX-6257,CDM,S5000,HCPCS,259,RC,57664-0808-88,NDC,outpatient,1,UN,1.19,0.833,AETNA [1000108],AETNA [100010801],,,76.8,,0.91,0.222255,85118.57664,percent of total billed charges,,,
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAPS,RX-6257,CDM,S5000,HCPCS,259,RC,65862-0692-01,NDC,outpatient,1,UN,1.74,1.218,AETNA [1000108],AETNA [100010801],,,76.8,,1.34,0.222255,85118.57664,percent of total billed charges,,,
PILOCARPINE HCL 1 % OP SOLN,RX-6279,CDM,S5000,HCPCS,259,RC,61314-0203-15,NDC,outpatient,15,ML,342.03,239.421,AETNA [1000108],AETNA [100010801],,,76.8,,262.68,0.222255,85118.57664,percent of total billed charges,,,
PILOCARPINE HCL 2 % OP SOLN,RX-6280,CDM,S5000,HCPCS,259,RC,70069-0191-01,NDC,outpatient,15,ML,140.98,98.686,AETNA [1000108],AETNA [100010801],,,76.8,,108.27,0.222255,85118.57664,percent of total billed charges,,,
PILOCARPINE HCL 2 % OP SOLN,RX-6280,CDM,S5000,HCPCS,259,RC,61314-0204-15,NDC,outpatient,15,ML,351.44,246.008,AETNA [1000108],AETNA [100010801],,,76.8,,269.91,0.222255,85118.57664,percent of total billed charges,,,
PILOCARPINE HCL 4 % OP SOLN,RX-6282,CDM,S5000,HCPCS,259,RC,61314-0206-15,NDC,outpatient,15,ML,326.81,228.767,AETNA [1000108],AETNA [100010801],,,76.8,,250.99,0.222255,85118.57664,percent of total billed charges,,,
PIROXICAM 10 MG ORAL CAPS,RX-6310,CDM,S5000,HCPCS,259,RC,42571-0176-01,NDC,outpatient,1,UN,3.12,2.184,AETNA [1000108],AETNA [100010801],,,76.8,,2.4,0.222255,85118.57664,percent of total billed charges,,,
POLY-VI-SOL ORAL SOLN,RX-6374,CDM,S5000,HCPCS,259,RC,00087-0402-03,NDC,outpatient,1,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
POLY-VI-SOL ORAL SOLN,RX-6374,CDM,S5000,HCPCS,259,RC,99999-0001-68,NDC,outpatient,1,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
POLYMYXIN B SULFATE 500000 UNITS IJ SOLR,RX-6393,CDM,S5000,HCPCS,250,RC,55150-0234-10,NDC,outpatient,1,UN,16.13,11.291,AETNA [1000108],AETNA [100010801],,,76.8,,12.39,0.222255,85118.57664,percent of total billed charges,,,
POTASSIUM ACETATE 2 MEQ/ML IV SOLN,RX-6420,CDM,S5000,HCPCS,250,RC,00409-8183-11,NDC,outpatient,20,ML,16.35,11.445,AETNA [1000108],AETNA [100010801],,,76.8,,12.56,0.222255,85118.57664,percent of total billed charges,,,
POTASSIUM ACETATE 2 MEQ/ML IV SOLN,RX-6420,CDM,S5000,HCPCS,250,RC,00409-8183-01,NDC,outpatient,20,ML,16.35,11.445,AETNA [1000108],AETNA [100010801],,,76.8,,12.56,0.222255,85118.57664,percent of total billed charges,,,
POTASSIUM ACETATE 2 MEQ/ML IV SOLN,RX-6420,CDM,S5000,HCPCS,250,RC,51754-2001-04,NDC,outpatient,20,ML,18.07,12.649,AETNA [1000108],AETNA [100010801],,,76.8,,13.88,0.222255,85118.57664,percent of total billed charges,,,
POVIDONE-IODINE 10 % EX SOLN,RX-6458,CDM,S5000,HCPCS,259,RC,52380-1905-00,NDC,outpatient,59,ML,4.73,3.311,AETNA [1000108],AETNA [100010801],,,76.8,,3.63,0.222255,85118.57664,percent of total billed charges,,,
PRAZOSIN HCL 1 MG ORAL CAPS,RX-6468,CDM,S5000,HCPCS,259,RC,51079-0630-01,NDC,outpatient,1,UN,6.21,4.347,AETNA [1000108],AETNA [100010801],,,76.8,,4.77,0.222255,85118.57664,percent of total billed charges,,,
PRAZOSIN HCL 1 MG ORAL CAPS,RX-6468,CDM,S5000,HCPCS,259,RC,51079-0630-20,NDC,outpatient,1,UN,6.21,4.347,AETNA [1000108],AETNA [100010801],,,76.8,,4.77,0.222255,85118.57664,percent of total billed charges,,,
PRAZOSIN HCL 1 MG ORAL CAPS,RX-6468,CDM,S5000,HCPCS,259,RC,68084-0996-01,NDC,outpatient,1,UN,5.34,3.738,AETNA [1000108],AETNA [100010801],,,76.8,,4.1,0.222255,85118.57664,percent of total billed charges,,,
PRAZOSIN HCL 1 MG ORAL CAPS,RX-6468,CDM,S5000,HCPCS,259,RC,68084-0996-11,NDC,outpatient,1,UN,5.34,3.738,AETNA [1000108],AETNA [100010801],,,76.8,,4.1,0.222255,85118.57664,percent of total billed charges,,,
PRAZOSIN HCL 5 MG ORAL CAPS,RX-6470,CDM,S5000,HCPCS,259,RC,51079-0632-20,NDC,outpatient,1,UN,14.76,10.332,AETNA [1000108],AETNA [100010801],,,76.8,,11.34,0.222255,85118.57664,percent of total billed charges,,,
PRAZOSIN HCL 5 MG ORAL CAPS,RX-6470,CDM,S5000,HCPCS,259,RC,51079-0632-01,NDC,outpatient,1,UN,14.76,10.332,AETNA [1000108],AETNA [100010801],,,76.8,,11.34,0.222255,85118.57664,percent of total billed charges,,,
PREDNISOLONE ACETATE 1 % OP SUSP,RX-6487,CDM,S5000,HCPCS,259,RC,61314-0637-05,NDC,outpatient,5,ML,113.48,79.436,AETNA [1000108],AETNA [100010801],,,76.8,,87.15,0.222255,85118.57664,percent of total billed charges,,,
PREDNISOLONE ACETATE 1 % OP SUSP,RX-6487,CDM,S5000,HCPCS,259,RC,11980-0180-05,NDC,outpatient,5,ML,534.23,373.961,AETNA [1000108],AETNA [100010801],,,76.8,,410.29,0.222255,85118.57664,percent of total billed charges,,,
PREDNISOLONE ACETATE 1 % OP SUSP,RX-6487,CDM,S5000,HCPCS,259,RC,60758-0119-05,NDC,outpatient,5,ML,106.58,74.606,AETNA [1000108],AETNA [100010801],,,76.8,,81.85,0.222255,85118.57664,percent of total billed charges,,,
PREDNISONE 1 MG ORAL TABS,RX-6493,CDM,S5000,HCPCS,259,RC,00054-4741-25,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PREDNISONE 1 MG ORAL TABS,RX-6493,CDM,S5000,HCPCS,259,RC,00054-8739-25,NDC,outpatient,1,UN,1.06,0.742,AETNA [1000108],AETNA [100010801],,,76.8,,0.81,0.222255,85118.57664,percent of total billed charges,,,
PREDNISONE 1 MG ORAL TABS,RX-6493,CDM,S5000,HCPCS,259,RC,59651-0484-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PREDNISONE 10 MG ORAL TABS,RX-6494,CDM,S5000,HCPCS,259,RC,00054-0017-20,NDC,outpatient,1,UN,1.02,0.714,AETNA [1000108],AETNA [100010801],,,76.8,,0.78,0.222255,85118.57664,percent of total billed charges,,,
PREDNISONE 10 MG ORAL TABS,RX-6494,CDM,S5000,HCPCS,259,RC,00603-5338-21,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PREDNISONE 10 MG ORAL TABS,RX-6494,CDM,S5000,HCPCS,259,RC,60687-0134-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PREDNISONE 10 MG ORAL TABS,RX-6494,CDM,S5000,HCPCS,259,RC,60687-0134-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PREDNISONE 10 MG ORAL TABS,RX-6494,CDM,S5000,HCPCS,259,RC,00904-6923-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PREDNISONE 2.5 MG ORAL TABS,RX-6495,CDM,S5000,HCPCS,259,RC,00054-4742-25,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PREDNISONE 2.5 MG ORAL TABS,RX-6495,CDM,S5000,HCPCS,259,RC,00054-8740-25,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,59746-0175-06,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,00054-0018-20,NDC,outpatient,1,UN,1.09,0.763,AETNA [1000108],AETNA [100010801],,,76.8,,0.84,0.222255,85118.57664,percent of total billed charges,,,
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,00904-7127-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,60687-0145-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,60687-0145-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,64380-0785-07,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PREDNISONE 5 MG ORAL TABS,RX-6497,CDM,S5000,HCPCS,259,RC,00054-8724-25,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PREDNISONE 5 MG ORAL TABS,RX-6497,CDM,S5000,HCPCS,259,RC,60687-0122-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PREDNISONE 5 MG ORAL TABS,RX-6497,CDM,S5000,HCPCS,259,RC,60687-0122-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PREDNISONE 50 MG ORAL TABS,RX-6498,CDM,S5000,HCPCS,259,RC,00054-0019-20,NDC,outpatient,1,UN,1.23,0.861,AETNA [1000108],AETNA [100010801],,,76.8,,0.94,0.222255,85118.57664,percent of total billed charges,,,
PREDNISONE 50 MG ORAL TABS,RX-6498,CDM,S5000,HCPCS,259,RC,00054-0019-25,NDC,outpatient,1,UN,1.08,0.756,AETNA [1000108],AETNA [100010801],,,76.8,,0.83,0.222255,85118.57664,percent of total billed charges,,,
PREDNISONE 50 MG ORAL TABS,RX-6498,CDM,S5000,HCPCS,259,RC,10135-0779-01,NDC,outpatient,1,UN,1.24,0.868,AETNA [1000108],AETNA [100010801],,,76.8,,0.95,0.222255,85118.57664,percent of total billed charges,,,
PREDNISONE 50 MG ORAL TABS,RX-6498,CDM,S5000,HCPCS,259,RC,59651-0489-01,NDC,outpatient,1,UN,1.61,1.127,AETNA [1000108],AETNA [100010801],,,76.8,,1.24,0.222255,85118.57664,percent of total billed charges,,,
ASCORBIC ACID 500 MG/ML IJ SOLN,RX-654,CDM,S5000,HCPCS,250,RC,67157-0101-51,NDC,outpatient,50,ML,1099.15,769.405,AETNA [1000108],AETNA [100010801],,,76.8,,844.15,0.222255,85118.57664,percent of total billed charges,,,
PRIMIDONE 250 MG ORAL TABS,RX-6544,CDM,S5000,HCPCS,259,RC,50268-0687-15,NDC,outpatient,1,UN,2.53,1.771,AETNA [1000108],AETNA [100010801],,,76.8,,1.94,0.222255,85118.57664,percent of total billed charges,,,
PRIMIDONE 250 MG ORAL TABS,RX-6544,CDM,S5000,HCPCS,259,RC,50268-0687-11,NDC,outpatient,1,UN,2.53,1.771,AETNA [1000108],AETNA [100010801],,,76.8,,1.94,0.222255,85118.57664,percent of total billed charges,,,
PROBENECID 500 MG ORAL TABS,RX-6561,CDM,S5000,HCPCS,259,RC,00591-5347-01,NDC,outpatient,1,UN,2.65,1.855,AETNA [1000108],AETNA [100010801],,,76.8,,2.04,0.222255,85118.57664,percent of total billed charges,,,
PROMETHAZINE-CODEINE 6.25-10 MG/5ML ORAL SYRP,RX-6627,CDM,S5000,HCPCS,259,RC,27808-0065-02,NDC,outpatient,2.5,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PROMETHAZINE-CODEINE 6.25-10 MG/5ML ORAL SYRP,RX-6627,CDM,S5000,HCPCS,259,RC,99999-0002-39,NDC,outpatient,5,ML,1.21,0.847,AETNA [1000108],AETNA [100010801],,,76.8,,0.93,0.222255,85118.57664,percent of total billed charges,,,
ASCORBIC ACID 500 MG ORAL TABS,RX-664,CDM,S5000,HCPCS,259,RC,00904-0523-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ASCORBIC ACID 500 MG ORAL TABS,RX-664,CDM,S5000,HCPCS,259,RC,00904-0523-60,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PROPARACAINE HCL 0.5 % OP SOLN,RX-6644,CDM,S5000,HCPCS,259,RC,61314-0016-01,NDC,outpatient,15,ML,111.21,77.847,AETNA [1000108],AETNA [100010801],,,76.8,,85.41,0.222255,85118.57664,percent of total billed charges,,,
PROPARACAINE HCL 0.5 % OP SOLN,RX-6644,CDM,S5000,HCPCS,259,RC,24208-0730-06,NDC,outpatient,15,ML,110.61,77.427,AETNA [1000108],AETNA [100010801],,,76.8,,84.95,0.222255,85118.57664,percent of total billed charges,,,
PROPRANOLOL HCL 20 MG/5ML ORAL SOLN,RX-6654,CDM,S5000,HCPCS,259,RC,00054-3727-63,NDC,outpatient,500,ML,209.15,146.405,AETNA [1000108],AETNA [100010801],,,76.8,,160.63,0.222255,85118.57664,percent of total billed charges,,,
PROPRANOLOL HCL 20 MG/5ML ORAL SOLN,RX-6654,CDM,S5000,HCPCS,259,RC,00121-0908-05,NDC,outpatient,5,ML,10.08,7.056,AETNA [1000108],AETNA [100010801],,,76.8,,7.74,0.222255,85118.57664,percent of total billed charges,,,
PROPRANOLOL HCL 20 MG/5ML ORAL SOLN,RX-6654,CDM,S5000,HCPCS,259,RC,00121-0908-40,NDC,outpatient,5,ML,10.08,7.056,AETNA [1000108],AETNA [100010801],,,76.8,,7.74,0.222255,85118.57664,percent of total billed charges,,,
PROPRANOLOL HCL 10 MG ORAL TABS,RX-6656,CDM,S5000,HCPCS,259,RC,60687-0587-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PROPRANOLOL HCL 10 MG ORAL TABS,RX-6656,CDM,S5000,HCPCS,259,RC,69238-2077-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PROPRANOLOL HCL 10 MG ORAL TABS,RX-6656,CDM,S5000,HCPCS,259,RC,00378-0182-01,NDC,outpatient,1,UN,1.22,0.854,AETNA [1000108],AETNA [100010801],,,76.8,,0.94,0.222255,85118.57664,percent of total billed charges,,,
PROPRANOLOL HCL 10 MG ORAL TABS,RX-6656,CDM,S5000,HCPCS,259,RC,60687-0587-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PROPRANOLOL HCL 40 MG ORAL TABS,RX-6658,CDM,S5000,HCPCS,259,RC,60687-0609-11,NDC,outpatient,1,UN,2.26,1.582,AETNA [1000108],AETNA [100010801],,,76.8,,1.74,0.222255,85118.57664,percent of total billed charges,,,
PROPRANOLOL HCL 40 MG ORAL TABS,RX-6658,CDM,S5000,HCPCS,259,RC,60687-0609-01,NDC,outpatient,1,UN,2.26,1.582,AETNA [1000108],AETNA [100010801],,,76.8,,1.74,0.222255,85118.57664,percent of total billed charges,,,
PROPRANOLOL HCL 40 MG ORAL TABS,RX-6658,CDM,S5000,HCPCS,259,RC,00603-5484-21,NDC,outpatient,1,UN,1.21,0.847,AETNA [1000108],AETNA [100010801],,,76.8,,0.93,0.222255,85118.57664,percent of total billed charges,,,
PROPYLTHIOURACIL 50 MG ORAL TABS,RX-6662,CDM,S5000,HCPCS,259,RC,00228-2348-10,NDC,outpatient,1,UN,3.18,2.226,AETNA [1000108],AETNA [100010801],,,76.8,,2.44,0.222255,85118.57664,percent of total billed charges,,,
PROPYLTHIOURACIL 50 MG ORAL TABS,RX-6662,CDM,S5000,HCPCS,259,RC,67253-0651-10,NDC,outpatient,1,UN,2.63,1.841,AETNA [1000108],AETNA [100010801],,,76.8,,2.02,0.222255,85118.57664,percent of total billed charges,,,
PSEUDOEPHEDRINE HCL 30 MG ORAL TABS,RX-6714,CDM,S5000,HCPCS,259,RC,00904-6990-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PSEUDOEPHEDRINE HCL 30 MG ORAL TABS,RX-6714,CDM,S5000,HCPCS,259,RC,00904-5053-59,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PYRAZINAMIDE 500 MG ORAL TABS,RX-6738,CDM,S5000,HCPCS,259,RC,10135-0735-60,NDC,outpatient,1,UN,15.09,10.563,AETNA [1000108],AETNA [100010801],,,76.8,,11.59,0.222255,85118.57664,percent of total billed charges,,,
PYRAZINAMIDE 500 MG ORAL TABS,RX-6738,CDM,S5000,HCPCS,259,RC,33342-0447-11,NDC,outpatient,1,UN,19.28,13.496,AETNA [1000108],AETNA [100010801],,,76.8,,14.81,0.222255,85118.57664,percent of total billed charges,,,
PYRAZINAMIDE 500 MG ORAL TABS,RX-6738,CDM,S5000,HCPCS,259,RC,70954-0484-10,NDC,outpatient,1,UN,17.43,12.201,AETNA [1000108],AETNA [100010801],,,76.8,,13.39,0.222255,85118.57664,percent of total billed charges,,,
PYRIDOXINE HCL 50 MG ORAL TABS,RX-6748,CDM,S5000,HCPCS,259,RC,50268-0858-15,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PYRIDOXINE HCL 50 MG ORAL TABS,RX-6748,CDM,S5000,HCPCS,259,RC,77333-0940-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PYRIDOXINE HCL 50 MG ORAL TABS,RX-6748,CDM,S5000,HCPCS,259,RC,50268-0858-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
PYRIDOXINE HCL 50 MG ORAL TABS,RX-6748,CDM,S5000,HCPCS,259,RC,77333-0940-25,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
QUININE SULFATE 324 MG ORAL CAPS,RX-6781,CDM,S5000,HCPCS,259,RC,50742-0238-30,NDC,outpatient,1,UN,2.82,1.974,AETNA [1000108],AETNA [100010801],,,76.8,,2.17,0.222255,85118.57664,percent of total billed charges,,,
ASPIRIN 81 MG ORAL CHEW,RX-680,CDM,S5000,HCPCS,259,RC,63739-0434-02,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ASPIRIN 81 MG ORAL CHEW,RX-680,CDM,S5000,HCPCS,259,RC,66553-0002-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ASPIRIN 81 MG ORAL CHEW,RX-680,CDM,S5000,HCPCS,259,RC,00904-6794-80,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ASPIRIN 81 MG ORAL CHEW,RX-680,CDM,S5000,HCPCS,259,RC,00904-6794-30,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ASPIRIN 325 MG ORAL TABS,RX-681,CDM,S5000,HCPCS,259,RC,57896-0901-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ASPIRIN 325 MG ORAL TABS,RX-681,CDM,S5000,HCPCS,259,RC,66553-0001-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ASPIRIN 325 MG ORAL TBEC,RX-685,CDM,S5000,HCPCS,259,RC,57896-0921-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ASPIRIN 81 MG ORAL TBEC,RX-688,CDM,S5000,HCPCS,259,RC,00536-1234-41,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ASPIRIN 81 MG ORAL TBEC,RX-688,CDM,S5000,HCPCS,259,RC,63739-0212-02,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ASPIRIN 81 MG ORAL TBEC,RX-688,CDM,S5000,HCPCS,259,RC,00904-6783-70,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ASPIRIN 300 MG RE SUPP,RX-693,CDM,S5000,HCPCS,259,RC,00574-7034-12,NDC,outpatient,1,UN,4.58,3.206,AETNA [1000108],AETNA [100010801],,,76.8,,3.52,0.222255,85118.57664,percent of total billed charges,,,
INSULIN DETEMIR 100 UNIT/ML SC SOLN,RX-70261,CDM,S5000,HCPCS,259,RC,00169-3687-12,NDC,outpatient,10,ML,388.27,271.789,AETNA [1000108],AETNA [100010801],,,76.8,,298.19,0.222255,85118.57664,percent of total billed charges,,,
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PACK,RX-70284,CDM,S5000,HCPCS,259,RC,71351-0010-99,NDC,outpatient,1,UN,1.65,1.155,AETNA [1000108],AETNA [100010801],,,76.8,,1.27,0.222255,85118.57664,percent of total billed charges,,,
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PACK,RX-70284,CDM,S5000,HCPCS,259,RC,60258-0006-15,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PACK,RX-70284,CDM,S5000,HCPCS,259,RC,71351-0010-01,NDC,outpatient,1,UN,1.65,1.155,AETNA [1000108],AETNA [100010801],,,76.8,,1.27,0.222255,85118.57664,percent of total billed charges,,,
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PACK,RX-70284,CDM,S5000,HCPCS,259,RC,60258-0006-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
SALINE NASAL SPRAY 0.65 % NA SOLN,RX-7030,CDM,S5000,HCPCS,259,RC,00904-3865-75,NDC,outpatient,44,ML,3.33,2.331,AETNA [1000108],AETNA [100010801],,,76.8,,2.56,0.222255,85118.57664,percent of total billed charges,,,
SALINE NASAL SPRAY 0.65 % NA SOLN,RX-7030,CDM,S5000,HCPCS,259,RC,49348-0356-25,NDC,outpatient,44,ML,5.88,4.116,AETNA [1000108],AETNA [100010801],,,76.8,,4.52,0.222255,85118.57664,percent of total billed charges,,,
TRAMADOL HCL ER 200 MG ORAL TB24,RX-70353,CDM,S5000,HCPCS,259,RC,68180-0698-06,NDC,outpatient,1,UN,19.84,13.888,AETNA [1000108],AETNA [100010801],,,76.8,,15.24,0.222255,85118.57664,percent of total billed charges,,,
RANOLAZINE ER 500 MG ORAL TB12,RX-70434,CDM,S5000,HCPCS,259,RC,50268-0722-11,NDC,outpatient,1,UN,5.07,3.549,AETNA [1000108],AETNA [100010801],,,76.8,,3.89,0.222255,85118.57664,percent of total billed charges,,,
RANOLAZINE ER 500 MG ORAL TB12,RX-70434,CDM,S5000,HCPCS,259,RC,50268-0722-15,NDC,outpatient,1,UN,5.07,3.549,AETNA [1000108],AETNA [100010801],,,76.8,,3.89,0.222255,85118.57664,percent of total billed charges,,,
RANOLAZINE ER 500 MG ORAL TB12,RX-70434,CDM,S5000,HCPCS,259,RC,60687-0549-11,NDC,outpatient,1,UN,5.08,3.556,AETNA [1000108],AETNA [100010801],,,76.8,,3.9,0.222255,85118.57664,percent of total billed charges,,,
RANOLAZINE ER 500 MG ORAL TB12,RX-70434,CDM,S5000,HCPCS,259,RC,60687-0549-21,NDC,outpatient,1,UN,5.08,3.556,AETNA [1000108],AETNA [100010801],,,76.8,,3.9,0.222255,85118.57664,percent of total billed charges,,,
RANOLAZINE ER 500 MG ORAL TB12,RX-70434,CDM,S5000,HCPCS,259,RC,68462-0319-60,NDC,outpatient,1,UN,1.05,0.735,AETNA [1000108],AETNA [100010801],,,76.8,,0.81,0.222255,85118.57664,percent of total billed charges,,,
LUBIPROSTONE 24 MCG ORAL CAPS,RX-70472,CDM,S5000,HCPCS,259,RC,00254-3029-02,NDC,outpatient,1,UN,4.45,3.115,AETNA [1000108],AETNA [100010801],,,76.8,,3.42,0.222255,85118.57664,percent of total billed charges,,,
FLUTICASONE PROPIONATE 50 MCG/ACT NA SUSP,RX-70536,CDM,S5000,HCPCS,259,RC,00536-1183-99,NDC,outpatient,9.9,ML,45.6,31.92,AETNA [1000108],AETNA [100010801],,,76.8,,35.02,0.222255,85118.57664,percent of total billed charges,,,
FLUTICASONE PROPIONATE 50 MCG/ACT NA SUSP,RX-70536,CDM,S5000,HCPCS,259,RC,00054-3270-99,NDC,outpatient,16,GR,32.12,22.484,AETNA [1000108],AETNA [100010801],,,76.8,,24.67,0.222255,85118.57664,percent of total billed charges,,,
INSULIN LISPRO PROT & LISPRO (75-25) 100 UNIT/ML SC SUSP,RX-70693,CDM,S5000,HCPCS,259,RC,00002-7511-01,NDC,outpatient,10,ML,211.82,148.274,AETNA [1000108],AETNA [100010801],,,76.8,,162.68,0.222255,85118.57664,percent of total billed charges,,,
ATENOLOL 25 MG ORAL TABS,RX-717,CDM,S5000,HCPCS,259,RC,51079-0759-20,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ATENOLOL 25 MG ORAL TABS,RX-717,CDM,S5000,HCPCS,259,RC,51079-0759-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ATENOLOL 50 MG ORAL TABS,RX-718,CDM,S5000,HCPCS,259,RC,51079-0684-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ATENOLOL 50 MG ORAL TABS,RX-718,CDM,S5000,HCPCS,259,RC,51079-0684-20,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
SILVER SULFADIAZINE 1 % EX CREA,RX-7224,CDM,S5000,HCPCS,259,RC,61570-0131-55,NDC,outpatient,50,GR,30.49,21.343,AETNA [1000108],AETNA [100010801],,,76.8,,23.42,0.222255,85118.57664,percent of total billed charges,,,
SILVER SULFADIAZINE 1 % EX CREA,RX-7224,CDM,S5000,HCPCS,259,RC,43598-0210-40,NDC,outpatient,400,GR,153.08,107.156,AETNA [1000108],AETNA [100010801],,,76.8,,117.57,0.222255,85118.57664,percent of total billed charges,,,
SILVER SULFADIAZINE 1 % EX CREA,RX-7224,CDM,S5000,HCPCS,259,RC,43598-0210-50,NDC,outpatient,50,GR,55.18,38.626,AETNA [1000108],AETNA [100010801],,,76.8,,42.38,0.222255,85118.57664,percent of total billed charges,,,
SIMETHICONE 80 MG ORAL CHEW,RX-7227,CDM,S5000,HCPCS,259,RC,69618-0033-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
SIMETHICONE 80 MG ORAL CHEW,RX-7227,CDM,S5000,HCPCS,259,RC,77333-0812-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
SIMETHICONE 80 MG ORAL CHEW,RX-7227,CDM,S5000,HCPCS,259,RC,77333-0812-25,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
SIMETHICONE 80 MG ORAL CHEW,RX-7227,CDM,S5000,HCPCS,259,RC,00904-7206-60,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
SIMETHICONE 80 MG ORAL CHEW,RX-7227,CDM,S5000,HCPCS,259,RC,49348-0188-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
SIMETHICONE 40 MG/0.6ML ORAL SUSP,RX-7228,CDM,S5000,HCPCS,259,RC,00536-1303-75,NDC,outpatient,0.3,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
SIMETHICONE 40 MG/0.6ML ORAL SUSP,RX-7228,CDM,S5000,HCPCS,259,RC,49348-0740-27,NDC,outpatient,0.6,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
SIMETHICONE 40 MG/0.6ML ORAL SUSP,RX-7228,CDM,S5000,HCPCS,259,RC,99999-0003-45,NDC,outpatient,0.6,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
SODIUM ACETATE 2 MEQ/ML IV SOLN,RX-7301,CDM,S5000,HCPCS,250,RC,00409-7299-73,NDC,outpatient,20,ML,14.91,10.437,AETNA [1000108],AETNA [100010801],,,76.8,,11.45,0.222255,85118.57664,percent of total billed charges,,,
SODIUM ACETATE 2 MEQ/ML IV SOLN,RX-7301,CDM,S5000,HCPCS,250,RC,00409-7299-83,NDC,outpatient,20,ML,14.91,10.437,AETNA [1000108],AETNA [100010801],,,76.8,,11.45,0.222255,85118.57664,percent of total billed charges,,,
SODIUM ACETATE 4 MEQ/ML IV SOLN,RX-7302,CDM,S5000,HCPCS,250,RC,63323-0032-04,NDC,outpatient,100,ML,36.05,25.235,AETNA [1000108],AETNA [100010801],,,76.8,,27.69,0.222255,85118.57664,percent of total billed charges,,,
SODIUM ACETATE 4 MEQ/ML IV SOLN,RX-7302,CDM,S5000,HCPCS,250,RC,63323-0032-00,NDC,outpatient,100,ML,36.05,25.235,AETNA [1000108],AETNA [100010801],,,76.8,,27.69,0.222255,85118.57664,percent of total billed charges,,,
SODIUM BICARBONATE 4.2 % IV SOLN,RX-7306,CDM,S5000,HCPCS,250,RC,00409-5555-02,NDC,outpatient,5,ML,19.45,13.615,AETNA [1000108],AETNA [100010801],,,76.8,,14.94,0.222255,85118.57664,percent of total billed charges,,,
SODIUM BICARBONATE 4.2 % IV SOLN,RX-7306,CDM,S5000,HCPCS,250,RC,00409-5534-14,NDC,outpatient,10,ML,57.94,40.558,AETNA [1000108],AETNA [100010801],,,76.8,,44.5,0.222255,85118.57664,percent of total billed charges,,,
SODIUM BICARBONATE 4.2 % IV SOLN,RX-7306,CDM,S5000,HCPCS,250,RC,00409-5534-24,NDC,outpatient,10,ML,57.94,40.558,AETNA [1000108],AETNA [100010801],,,76.8,,44.5,0.222255,85118.57664,percent of total billed charges,,,
SODIUM BICARBONATE 4.2 % IV SOLN,RX-7306,CDM,S5000,HCPCS,250,RC,00409-5555-12,NDC,outpatient,5,ML,19.45,13.615,AETNA [1000108],AETNA [100010801],,,76.8,,14.94,0.222255,85118.57664,percent of total billed charges,,,
SODIUM BICARBONATE 4.2 % IV SOLN,RX-7306,CDM,S5000,HCPCS,250,RC,63323-0083-05,NDC,outpatient,5,ML,33.6,23.52,AETNA [1000108],AETNA [100010801],,,76.8,,25.8,0.222255,85118.57664,percent of total billed charges,,,
SODIUM BICARBONATE 7.5 % IV SOLN,RX-7308,CDM,S5000,HCPCS,250,RC,00409-4916-14,NDC,outpatient,50,ML,85.67,59.969,AETNA [1000108],AETNA [100010801],,,76.8,,65.79,0.222255,85118.57664,percent of total billed charges,,,
SODIUM BICARBONATE 7.5 % IV SOLN,RX-7308,CDM,S5000,HCPCS,250,RC,00409-4916-24,NDC,outpatient,50,ML,85.67,59.969,AETNA [1000108],AETNA [100010801],,,76.8,,65.79,0.222255,85118.57664,percent of total billed charges,,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-4900-24,NDC,outpatient,10,ML,71.78,50.246,AETNA [1000108],AETNA [100010801],,,76.8,,55.13,0.222255,85118.57664,percent of total billed charges,,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-6625-22,NDC,outpatient,50,ML,35.83,25.081,AETNA [1000108],AETNA [100010801],,,76.8,,27.52,0.222255,85118.57664,percent of total billed charges,,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-6637-24,NDC,outpatient,50,ML,54.74,38.318,AETNA [1000108],AETNA [100010801],,,76.8,,42.04,0.222255,85118.57664,percent of total billed charges,,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,69374-0214-50,NDC,outpatient,50,ML,48.95,34.265,AETNA [1000108],AETNA [100010801],,,76.8,,37.59,0.222255,85118.57664,percent of total billed charges,,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-6625-14,NDC,outpatient,50,ML,35.83,25.081,AETNA [1000108],AETNA [100010801],,,76.8,,27.52,0.222255,85118.57664,percent of total billed charges,,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,51754-5001-04,NDC,outpatient,50,ML,22.7,15.89,AETNA [1000108],AETNA [100010801],,,76.8,,17.43,0.222255,85118.57664,percent of total billed charges,,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,76329-3352-01,NDC,outpatient,50,ML,66.31,46.417,AETNA [1000108],AETNA [100010801],,,76.8,,50.93,0.222255,85118.57664,percent of total billed charges,,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-4900-14,NDC,outpatient,10,ML,71.78,50.246,AETNA [1000108],AETNA [100010801],,,76.8,,55.13,0.222255,85118.57664,percent of total billed charges,,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-6637-14,NDC,outpatient,50,ML,54.74,38.318,AETNA [1000108],AETNA [100010801],,,76.8,,42.04,0.222255,85118.57664,percent of total billed charges,,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,51754-5001-01,NDC,outpatient,50,ML,22.7,15.89,AETNA [1000108],AETNA [100010801],,,76.8,,17.43,0.222255,85118.57664,percent of total billed charges,,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,63323-0089-50,NDC,outpatient,50,ML,24.7,17.29,AETNA [1000108],AETNA [100010801],,,76.8,,18.97,0.222255,85118.57664,percent of total billed charges,,,
SODIUM BICARBONATE 650 MG ORAL TABS,RX-7313,CDM,S5000,HCPCS,259,RC,66553-0008-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE 3 % IV SOLN,RX-7321,CDM,S5000,HCPCS,250,RC,99999-0004-11,NDC,outpatient,250,ML,21.14,14.798,AETNA [1000108],AETNA [100010801],,,76.8,,16.24,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE 3 % IV SOLN,RX-7321,CDM,S5000,HCPCS,250,RC,00338-0054-03,NDC,outpatient,500,ML,26.28,18.396,AETNA [1000108],AETNA [100010801],,,76.8,,20.18,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE 4 MEQ/ML IV SOLN,RX-7322,CDM,S5000,HCPCS,250,RC,63323-0095-61,NDC,outpatient,100,ML,55.63,38.941,AETNA [1000108],AETNA [100010801],,,76.8,,42.72,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE 4 MEQ/ML IV SOLN,RX-7322,CDM,S5000,HCPCS,250,RC,63323-0095-02,NDC,outpatient,100,ML,55.63,38.941,AETNA [1000108],AETNA [100010801],,,76.8,,42.72,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % IN NEBU,RX-7325,CDM,S5000,HCPCS,259,RC,00487-9301-03,NDC,outpatient,3,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % IN NEBU,RX-7325,CDM,S5000,HCPCS,259,RC,76204-0300-03,NDC,outpatient,3,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % IN NEBU,RX-7325,CDM,S5000,HCPCS,259,RC,00487-9301-33,NDC,outpatient,3,ML,1.13,0.791,AETNA [1000108],AETNA [100010801],,,76.8,,0.87,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE 3 % IN NEBU,RX-7327,CDM,S5000,HCPCS,259,RC,00487-9003-30,NDC,outpatient,4,ML,2.44,1.708,AETNA [1000108],AETNA [100010801],,,76.8,,1.87,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE 3 % IN NEBU,RX-7327,CDM,S5000,HCPCS,259,RC,50190-0142-63,NDC,outpatient,4,ML,2.6,1.82,AETNA [1000108],AETNA [100010801],,,76.8,,2,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE 1 G ORAL TABS,RX-7328,CDM,S5000,HCPCS,259,RC,77333-0835-25,NDC,outpatient,1,UN,1.03,0.721,AETNA [1000108],AETNA [100010801],,,76.8,,0.79,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE 1 G ORAL TABS,RX-7328,CDM,S5000,HCPCS,259,RC,00223-1760-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE 1 G ORAL TABS,RX-7328,CDM,S5000,HCPCS,259,RC,77333-0835-10,NDC,outpatient,1,UN,1.03,0.721,AETNA [1000108],AETNA [100010801],,,76.8,,0.79,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE (HYPERTONIC) 5 % OP OINT,RX-7331,CDM,S5000,HCPCS,259,RC,24208-0385-55,NDC,outpatient,3.5,GR,68.8,48.16,AETNA [1000108],AETNA [100010801],,,76.8,,52.84,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE (HYPERTONIC) 5 % OP SOLN,RX-7332,CDM,S5000,HCPCS,259,RC,00536-1254-94,NDC,outpatient,15,ML,15.76,11.032,AETNA [1000108],AETNA [100010801],,,76.8,,12.1,0.222255,85118.57664,percent of total billed charges,,,
SODIUM HYPOCHLORITE 5 % SOLN,RX-7343,CDM,S5000,HCPCS,259,RC,SH000-4343-01,NDC,outpatient,4000,ML,17.8,12.46,AETNA [1000108],AETNA [100010801],,,76.8,,13.67,0.222255,85118.57664,percent of total billed charges,,,
SODIUM POLYSTYRENE SULFONATE ORAL POWD,RX-7356,CDM,S5000,HCPCS,259,RC,11534-0166-15,NDC,outpatient,15,GR,55.61,38.927,AETNA [1000108],AETNA [100010801],,,76.8,,42.71,0.222255,85118.57664,percent of total billed charges,,,
SULFACETAMIDE SODIUM 10 % OP SOLN,RX-7359,CDM,S5000,HCPCS,259,RC,24208-0670-04,NDC,outpatient,15,ML,213.67,149.569,AETNA [1000108],AETNA [100010801],,,76.8,,164.1,0.222255,85118.57664,percent of total billed charges,,,
ATROPINE SULFATE 1 % OP SOLN,RX-736,CDM,S5000,HCPCS,259,RC,60219-1749-03,NDC,outpatient,5,ML,103.02,72.114,AETNA [1000108],AETNA [100010801],,,76.8,,79.12,0.222255,85118.57664,percent of total billed charges,,,
SPIRONOLACTONE 25 MG ORAL TABS,RX-7437,CDM,S5000,HCPCS,259,RC,00904-6927-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
SPIRONOLACTONE 25 MG ORAL TABS,RX-7437,CDM,S5000,HCPCS,259,RC,51079-0103-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
SPIRONOLACTONE 25 MG ORAL TABS,RX-7437,CDM,S5000,HCPCS,259,RC,51079-0103-20,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
SPIRONOLACTONE 25 MG ORAL TABS,RX-7437,CDM,S5000,HCPCS,259,RC,63629-1061-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-10,NDC,outpatient,10,ML,3.6,2.52,AETNA [1000108],AETNA [100010801],,,76.8,,2.76,0.222255,85118.57664,percent of total billed charges,,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-24,NDC,outpatient,50,ML,8.74,6.118,AETNA [1000108],AETNA [100010801],,,76.8,,6.71,0.222255,85118.57664,percent of total billed charges,,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00641-6147-10,NDC,outpatient,10,ML,4.22,2.954,AETNA [1000108],AETNA [100010801],,,76.8,,3.24,0.222255,85118.57664,percent of total billed charges,,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-99,NDC,outpatient,100,ML,13.88,9.716,AETNA [1000108],AETNA [100010801],,,76.8,,10.66,0.222255,85118.57664,percent of total billed charges,,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-25,NDC,outpatient,100,ML,13.88,9.716,AETNA [1000108],AETNA [100010801],,,76.8,,10.66,0.222255,85118.57664,percent of total billed charges,,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-17,NDC,outpatient,10,ML,3.6,2.52,AETNA [1000108],AETNA [100010801],,,76.8,,2.76,0.222255,85118.57664,percent of total billed charges,,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-50,NDC,outpatient,50,ML,8.74,6.118,AETNA [1000108],AETNA [100010801],,,76.8,,6.71,0.222255,85118.57664,percent of total billed charges,,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00641-6147-01,NDC,outpatient,10,ML,4.79,3.353,AETNA [1000108],AETNA [100010801],,,76.8,,3.68,0.222255,85118.57664,percent of total billed charges,,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00641-6147-25,NDC,outpatient,10,ML,4.79,3.353,AETNA [1000108],AETNA [100010801],,,76.8,,3.68,0.222255,85118.57664,percent of total billed charges,,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,63323-0185-10,NDC,outpatient,10,ML,4.07,2.849,AETNA [1000108],AETNA [100010801],,,76.8,,3.13,0.222255,85118.57664,percent of total billed charges,,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,63323-0185-20,NDC,outpatient,20,ML,7,4.9,AETNA [1000108],AETNA [100010801],,,76.8,,5.38,0.222255,85118.57664,percent of total billed charges,,,
STERILE WATER FOR IRRIGATION IR SOLN,RX-7485,CDM,S5000,HCPCS,250,RC,00338-0004-04,NDC,outpatient,1000,ML,8.9,6.23,AETNA [1000108],AETNA [100010801],,,76.8,,6.84,0.222255,85118.57664,percent of total billed charges,,,
STERILE WATER FOR IRRIGATION IR SOLN,RX-7485,CDM,S5000,HCPCS,250,RC,00338-0003-47,NDC,outpatient,3000,ML,26.7,18.69,AETNA [1000108],AETNA [100010801],,,76.8,,20.51,0.222255,85118.57664,percent of total billed charges,,,
STOMAHESIVE PASTE PSTE,RX-7493,CDM,S5000,HCPCS,259,RC,68455-0106-90,NDC,outpatient,56.7,GR,38.61,27.027,AETNA [1000108],AETNA [100010801],,,76.8,,29.65,0.222255,85118.57664,percent of total billed charges,,,
SULFADIAZINE 500 MG ORAL TABS,RX-7554,CDM,S5000,HCPCS,259,RC,42806-0757-60,NDC,outpatient,1,UN,65.91,46.137,AETNA [1000108],AETNA [100010801],,,76.8,,50.62,0.222255,85118.57664,percent of total billed charges,,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN,RX-7556,CDM,S5000,HCPCS,250,RC,70069-0362-10,NDC,outpatient,10,ML,27.51,19.257,AETNA [1000108],AETNA [100010801],,,76.8,,21.13,0.222255,85118.57664,percent of total billed charges,,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN,RX-7556,CDM,S5000,HCPCS,250,RC,70069-0362-01,NDC,outpatient,10,ML,27.51,19.257,AETNA [1000108],AETNA [100010801],,,76.8,,21.13,0.222255,85118.57664,percent of total billed charges,,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN,RX-7556,CDM,S5000,HCPCS,250,RC,00703-9514-01,NDC,outpatient,10,ML,28.26,19.782,AETNA [1000108],AETNA [100010801],,,76.8,,21.7,0.222255,85118.57664,percent of total billed charges,,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN,RX-7556,CDM,S5000,HCPCS,250,RC,00703-9514-03,NDC,outpatient,10,ML,28.26,19.782,AETNA [1000108],AETNA [100010801],,,76.8,,21.7,0.222255,85118.57664,percent of total billed charges,,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG ORAL TABS,RX-7557,CDM,S5000,HCPCS,259,RC,50268-0728-11,NDC,outpatient,1,UN,1.12,0.784,AETNA [1000108],AETNA [100010801],,,76.8,,0.86,0.222255,85118.57664,percent of total billed charges,,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG ORAL TABS,RX-7557,CDM,S5000,HCPCS,259,RC,60687-0603-65,NDC,outpatient,1,UN,1.41,0.987,AETNA [1000108],AETNA [100010801],,,76.8,,1.08,0.222255,85118.57664,percent of total billed charges,,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG ORAL TABS,RX-7557,CDM,S5000,HCPCS,259,RC,60687-0603-11,NDC,outpatient,1,UN,1.41,0.987,AETNA [1000108],AETNA [100010801],,,76.8,,1.08,0.222255,85118.57664,percent of total billed charges,,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG ORAL TABS,RX-7557,CDM,S5000,HCPCS,259,RC,50268-0728-15,NDC,outpatient,1,UN,1.12,0.784,AETNA [1000108],AETNA [100010801],,,76.8,,0.86,0.222255,85118.57664,percent of total billed charges,,,
SULFASALAZINE 500 MG ORAL TABS,RX-7562,CDM,S5000,HCPCS,259,RC,59762-5000-05,NDC,outpatient,1,UN,1.02,0.714,AETNA [1000108],AETNA [100010801],,,76.8,,0.78,0.222255,85118.57664,percent of total billed charges,,,
SULFASALAZINE 500 MG ORAL TBEC,RX-7563,CDM,S5000,HCPCS,259,RC,00013-0102-50,NDC,outpatient,1,UN,8.65,6.055,AETNA [1000108],AETNA [100010801],,,76.8,,6.64,0.222255,85118.57664,percent of total billed charges,,,
SULFASALAZINE 500 MG ORAL TBEC,RX-7563,CDM,S5000,HCPCS,259,RC,59762-0104-05,NDC,outpatient,1,UN,1.47,1.029,AETNA [1000108],AETNA [100010801],,,76.8,,1.13,0.222255,85118.57664,percent of total billed charges,,,
VARENICLINE TARTRATE 0.5 MG ORAL TABS,RX-76444,CDM,S5000,HCPCS,259,RC,49884-0155-76,NDC,outpatient,1,UN,6.79,4.753,AETNA [1000108],AETNA [100010801],,,76.8,,5.21,0.222255,85118.57664,percent of total billed charges,,,
VARENICLINE TARTRATE 1 MG ORAL TABS,RX-76445,CDM,S5000,HCPCS,259,RC,60687-0648-11,NDC,outpatient,1,UN,43.68,30.576,AETNA [1000108],AETNA [100010801],,,76.8,,33.55,0.222255,85118.57664,percent of total billed charges,,,
VARENICLINE TARTRATE 1 MG ORAL TABS,RX-76445,CDM,S5000,HCPCS,259,RC,60687-0648-21,NDC,outpatient,1,UN,43.68,30.576,AETNA [1000108],AETNA [100010801],,,76.8,,33.55,0.222255,85118.57664,percent of total billed charges,,,
ACETYLCHOLINE CHLORIDE 20 MG IO SOLR,RX-76641,CDM,S5000,HCPCS,259,RC,24208-0539-20,NDC,outpatient,1,UN,349.11,244.377,AETNA [1000108],AETNA [100010801],,,76.8,,268.12,0.222255,85118.57664,percent of total billed charges,,,
DAKINS (1/4 STRENGTH) 0.125 % EX SOLN,RX-76724,CDM,S5000,HCPCS,259,RC,39328-0064-12,NDC,outpatient,473,ML,44.21,30.947,AETNA [1000108],AETNA [100010801],,,76.8,,33.95,0.222255,85118.57664,percent of total billed charges,,,
DAKINS (1/4 STRENGTH) 0.125 % EX SOLN,RX-76724,CDM,S5000,HCPCS,259,RC,00436-0672-16,NDC,outpatient,473,ML,52.63,36.841,AETNA [1000108],AETNA [100010801],,,76.8,,40.42,0.222255,85118.57664,percent of total billed charges,,,
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,00121-0948-16,NDC,outpatient,7.5,ML,2.05,1.435,AETNA [1000108],AETNA [100010801],,,76.8,,1.57,0.222255,85118.57664,percent of total billed charges,,,
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,00121-0948-15,NDC,outpatient,15,ML,3.54,2.478,AETNA [1000108],AETNA [100010801],,,76.8,,2.72,0.222255,85118.57664,percent of total billed charges,,,
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,00121-4948-15,NDC,outpatient,15,ML,19.43,13.601,AETNA [1000108],AETNA [100010801],,,76.8,,14.92,0.222255,85118.57664,percent of total billed charges,,,
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,00121-4948-40,NDC,outpatient,15,ML,19.43,13.601,AETNA [1000108],AETNA [100010801],,,76.8,,14.92,0.222255,85118.57664,percent of total billed charges,,,
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,63739-0724-50,NDC,outpatient,15,ML,8.75,6.125,AETNA [1000108],AETNA [100010801],,,76.8,,6.72,0.222255,85118.57664,percent of total billed charges,,,
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,63739-0724-01,NDC,outpatient,15,ML,8.75,6.125,AETNA [1000108],AETNA [100010801],,,76.8,,6.72,0.222255,85118.57664,percent of total billed charges,,,
VITAMIN D3 25 MCG (1000 UT) ORAL TABS,RX-76997,CDM,S5000,HCPCS,259,RC,20555-0033-00,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
TANNIC ACID POWD,RX-7715,CDM,S5000,HCPCS,259,RC,,,outpatient,20,GR,9.26,6.482,AETNA [1000108],AETNA [100010801],,,76.8,,7.11,0.222255,85118.57664,percent of total billed charges,,,
SELENIUM 40 MCG/ML IV SOLN,RX-77308,CDM,S5000,HCPCS,250,RC,69784-0840-05,NDC,outpatient,10,ML,230.25,161.175,AETNA [1000108],AETNA [100010801],,,76.8,,176.83,0.222255,85118.57664,percent of total billed charges,,,
SELENIUM 40 MCG/ML IV SOLN,RX-77308,CDM,S5000,HCPCS,250,RC,69784-0840-01,NDC,outpatient,10,ML,230.25,161.175,AETNA [1000108],AETNA [100010801],,,76.8,,176.83,0.222255,85118.57664,percent of total billed charges,,,
SITAGLIPTIN PHOSPHATE 25 MG ORAL TABS,RX-77615,CDM,S5000,HCPCS,259,RC,00006-0221-01,NDC,outpatient,1,UN,78.54,54.978,AETNA [1000108],AETNA [100010801],,,76.8,,60.32,0.222255,85118.57664,percent of total billed charges,,,
SITAGLIPTIN PHOSPHATE 25 MG ORAL TABS,RX-77615,CDM,S5000,HCPCS,259,RC,00006-0221-28,NDC,outpatient,1,UN,78.54,54.978,AETNA [1000108],AETNA [100010801],,,76.8,,60.32,0.222255,85118.57664,percent of total billed charges,,,
SITAGLIPTIN PHOSPHATE 100 MG ORAL TABS,RX-77617,CDM,S5000,HCPCS,259,RC,00006-0277-01,NDC,outpatient,1,UN,78.54,54.978,AETNA [1000108],AETNA [100010801],,,76.8,,60.32,0.222255,85118.57664,percent of total billed charges,,,
SITAGLIPTIN PHOSPHATE 100 MG ORAL TABS,RX-77617,CDM,S5000,HCPCS,259,RC,00006-0277-31,NDC,outpatient,1,UN,78.53,54.971,AETNA [1000108],AETNA [100010801],,,76.8,,60.31,0.222255,85118.57664,percent of total billed charges,,,
SITAGLIPTIN PHOSPHATE 100 MG ORAL TABS,RX-77617,CDM,S5000,HCPCS,259,RC,00006-0277-28,NDC,outpatient,1,UN,78.54,54.978,AETNA [1000108],AETNA [100010801],,,76.8,,60.32,0.222255,85118.57664,percent of total billed charges,,,
METOCLOPRAMIDE HCL 10 MG/10ML ORAL SOLN,RX-77710,CDM,S5000,HCPCS,259,RC,00121-1576-10,NDC,outpatient,10,ML,13.35,9.345,AETNA [1000108],AETNA [100010801],,,76.8,,10.25,0.222255,85118.57664,percent of total billed charges,,,
METOCLOPRAMIDE HCL 10 MG/10ML ORAL SOLN,RX-77710,CDM,S5000,HCPCS,259,RC,99999-0001-27,NDC,outpatient,1,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
TETRACAINE HCL 0.5 % OP SOLN,RX-7795,CDM,S5000,HCPCS,259,RC,68682-0920-64,NDC,outpatient,15,ML,325.88,228.116,AETNA [1000108],AETNA [100010801],,,76.8,,250.28,0.222255,85118.57664,percent of total billed charges,,,
TETRACAINE HCL 0.5 % OP SOLN,RX-7795,CDM,S5000,HCPCS,259,RC,00065-0741-14,NDC,outpatient,4,ML,54.08,37.856,AETNA [1000108],AETNA [100010801],,,76.8,,41.53,0.222255,85118.57664,percent of total billed charges,,,
TETRACYCLINE HCL 250 MG ORAL CAPS,RX-7796,CDM,S5000,HCPCS,259,RC,23155-0766-01,NDC,outpatient,1,UN,2.97,2.079,AETNA [1000108],AETNA [100010801],,,76.8,,2.28,0.222255,85118.57664,percent of total billed charges,,,
THEOPHYLLINE 80 MG/15ML ORAL ELIX,RX-7820,CDM,S5000,HCPCS,259,RC,00121-4820-40,NDC,outpatient,15,ML,35.25,24.675,AETNA [1000108],AETNA [100010801],,,76.8,,27.07,0.222255,85118.57664,percent of total billed charges,,,
THEOPHYLLINE 80 MG/15ML ORAL ELIX,RX-7820,CDM,S5000,HCPCS,259,RC,60687-0258-71,NDC,outpatient,15,ML,40.12,28.084,AETNA [1000108],AETNA [100010801],,,76.8,,30.81,0.222255,85118.57664,percent of total billed charges,,,
THEOPHYLLINE 80 MG/15ML ORAL ELIX,RX-7820,CDM,S5000,HCPCS,259,RC,00121-4820-15,NDC,outpatient,15,ML,35.25,24.675,AETNA [1000108],AETNA [100010801],,,76.8,,27.07,0.222255,85118.57664,percent of total billed charges,,,
THEOPHYLLINE 80 MG/15ML ORAL ELIX,RX-7820,CDM,S5000,HCPCS,259,RC,60687-0258-44,NDC,outpatient,15,ML,40.12,28.084,AETNA [1000108],AETNA [100010801],,,76.8,,30.81,0.222255,85118.57664,percent of total billed charges,,,
THERA ORAL TABS,RX-7825,CDM,S5000,HCPCS,259,RC,00904-0539-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
THERA-DERM EX LOTN,RX-7831,CDM,S5000,HCPCS,259,RC,00904-4299-09,NDC,outpatient,236,ML,8.41,5.887,AETNA [1000108],AETNA [100010801],,,76.8,,6.46,0.222255,85118.57664,percent of total billed charges,,,
MESALAMINE 1.2 G ORAL TBEC,RX-78310,CDM,S5000,HCPCS,259,RC,00527-3012-48,NDC,outpatient,1,UN,7.61,5.327,AETNA [1000108],AETNA [100010801],,,76.8,,5.84,0.222255,85118.57664,percent of total billed charges,,,
CALAMINE 8-8 % EX LOTN,RX-78879,CDM,S5000,HCPCS,259,RC,00395-0413-96,NDC,outpatient,177,ML,11.82,8.274,AETNA [1000108],AETNA [100010801],,,76.8,,9.08,0.222255,85118.57664,percent of total billed charges,,,
CALAMINE 8-8 % EX LOTN,RX-78879,CDM,S5000,HCPCS,259,RC,00904-2533-21,NDC,outpatient,177,ML,5.52,3.864,AETNA [1000108],AETNA [100010801],,,76.8,,4.24,0.222255,85118.57664,percent of total billed charges,,,
CALAMINE 8-8 % EX LOTN,RX-78879,CDM,S5000,HCPCS,259,RC,49348-0011-34,NDC,outpatient,177,ML,6.31,4.417,AETNA [1000108],AETNA [100010801],,,76.8,,4.85,0.222255,85118.57664,percent of total billed charges,,,
GUAIFENESIN-CODEINE 100-10 MG/5ML ORAL SOLN,RX-79088,CDM,S5000,HCPCS,259,RC,00121-1775-40,NDC,outpatient,5,ML,11.06,7.742,AETNA [1000108],AETNA [100010801],,,76.8,,8.49,0.222255,85118.57664,percent of total billed charges,,,
GUAIFENESIN-CODEINE 100-10 MG/5ML ORAL SOLN,RX-79088,CDM,S5000,HCPCS,259,RC,00121-1775-05,NDC,outpatient,5,ML,11.06,7.742,AETNA [1000108],AETNA [100010801],,,76.8,,8.49,0.222255,85118.57664,percent of total billed charges,,,
GUAIFENESIN-CODEINE 100-10 MG/5ML ORAL SOLN,RX-79088,CDM,S5000,HCPCS,259,RC,99999-0002-04,NDC,outpatient,5,ML,1.78,1.246,AETNA [1000108],AETNA [100010801],,,76.8,,1.37,0.222255,85118.57664,percent of total billed charges,,,
THYROID 30 MG ORAL TABS,RX-7944,CDM,S5000,HCPCS,259,RC,62559-0741-01,NDC,outpatient,1,UN,2.88,2.016,AETNA [1000108],AETNA [100010801],,,76.8,,2.21,0.222255,85118.57664,percent of total billed charges,,,
TOLNAFTATE 1 % EX CREA,RX-8020,CDM,S5000,HCPCS,259,RC,00904-0722-36,NDC,outpatient,14.18,GR,4.36,3.052,AETNA [1000108],AETNA [100010801],,,76.8,,3.35,0.222255,85118.57664,percent of total billed charges,,,
TOLNAFTATE 1 % EX CREA,RX-8020,CDM,S5000,HCPCS,259,RC,49348-0155-29,NDC,outpatient,15,GR,8.88,6.216,AETNA [1000108],AETNA [100010801],,,76.8,,6.82,0.222255,85118.57664,percent of total billed charges,,,
TOLNAFTATE 1 % EX POWD,RX-8021,CDM,S5000,HCPCS,259,RC,00536-1329-26,NDC,outpatient,45,GR,7.41,5.187,AETNA [1000108],AETNA [100010801],,,76.8,,5.69,0.222255,85118.57664,percent of total billed charges,,,
TRAZODONE HCL 150 MG ORAL TABS,RX-8084,CDM,S5000,HCPCS,259,RC,68382-0807-01,NDC,outpatient,1,UN,1.31,0.917,AETNA [1000108],AETNA [100010801],,,76.8,,1.01,0.222255,85118.57664,percent of total billed charges,,,
TRAZODONE HCL 150 MG ORAL TABS,RX-8084,CDM,S5000,HCPCS,259,RC,50268-0776-11,NDC,outpatient,1,UN,1.77,1.239,AETNA [1000108],AETNA [100010801],,,76.8,,1.36,0.222255,85118.57664,percent of total billed charges,,,
TRAZODONE HCL 150 MG ORAL TABS,RX-8084,CDM,S5000,HCPCS,259,RC,50268-0776-15,NDC,outpatient,1,UN,1.77,1.239,AETNA [1000108],AETNA [100010801],,,76.8,,1.36,0.222255,85118.57664,percent of total billed charges,,,
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,60505-2653-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,42291-0868-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,00904-6868-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,68382-0805-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,42291-0868-90,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,50111-0560-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
TRIAMCINOLONE ACETONIDE 0.025 % EX CREA,RX-8112,CDM,S5000,HCPCS,259,RC,00168-0003-80,NDC,outpatient,80,GR,21.72,15.204,AETNA [1000108],AETNA [100010801],,,76.8,,16.68,0.222255,85118.57664,percent of total billed charges,,,
TRIAMCINOLONE ACETONIDE 0.1 % EX CREA,RX-8113,CDM,S5000,HCPCS,259,RC,67877-0251-80,NDC,outpatient,80,GR,39.16,27.412,AETNA [1000108],AETNA [100010801],,,76.8,,30.07,0.222255,85118.57664,percent of total billed charges,,,
TRIAMCINOLONE ACETONIDE 0.1 % EX CREA,RX-8113,CDM,S5000,HCPCS,259,RC,45802-0064-36,NDC,outpatient,80,GR,11.04,7.728,AETNA [1000108],AETNA [100010801],,,76.8,,8.48,0.222255,85118.57664,percent of total billed charges,,,
TRIAMCINOLONE ACETONIDE 0.5 % EX CREA,RX-8114,CDM,S5000,HCPCS,259,RC,45802-0065-35,NDC,outpatient,15,GR,20.23,14.161,AETNA [1000108],AETNA [100010801],,,76.8,,15.54,0.222255,85118.57664,percent of total billed charges,,,
TRIAMCINOLONE ACETONIDE 0.025 % EX LOTN,RX-8115,CDM,S5000,HCPCS,259,RC,70752-0129-05,NDC,outpatient,60,ML,126.03,88.221,AETNA [1000108],AETNA [100010801],,,76.8,,96.79,0.222255,85118.57664,percent of total billed charges,,,
TRIAMCINOLONE ACETONIDE 0.1 % EX LOTN,RX-8116,CDM,S5000,HCPCS,259,RC,00713-0676-53,NDC,outpatient,60,ML,73.43,51.401,AETNA [1000108],AETNA [100010801],,,76.8,,56.39,0.222255,85118.57664,percent of total billed charges,,,
TRIAMCINOLONE ACETONIDE 0.1 % EX LOTN,RX-8116,CDM,S5000,HCPCS,259,RC,60432-0561-61,NDC,outpatient,60,ML,66.75,46.725,AETNA [1000108],AETNA [100010801],,,76.8,,51.26,0.222255,85118.57664,percent of total billed charges,,,
TRIAMCINOLONE ACETONIDE 0.025 % EX OINT,RX-8117,CDM,S5000,HCPCS,259,RC,00168-0005-80,NDC,outpatient,80,GR,21.01,14.707,AETNA [1000108],AETNA [100010801],,,76.8,,16.14,0.222255,85118.57664,percent of total billed charges,,,
TRIAMCINOLONE ACETONIDE 0.1 % EX OINT,RX-8118,CDM,S5000,HCPCS,259,RC,45802-0055-36,NDC,outpatient,80,GR,19.58,13.706,AETNA [1000108],AETNA [100010801],,,76.8,,15.04,0.222255,85118.57664,percent of total billed charges,,,
TRIAMCINOLONE ACETONIDE 0.1 % EX OINT,RX-8118,CDM,S5000,HCPCS,259,RC,00168-0006-80,NDC,outpatient,80,GR,22.79,15.953,AETNA [1000108],AETNA [100010801],,,76.8,,17.5,0.222255,85118.57664,percent of total billed charges,,,
TRIAMCINOLONE ACETONIDE 0.1 % EX OINT,RX-8118,CDM,S5000,HCPCS,259,RC,00713-0228-80,NDC,outpatient,80,GR,37.03,25.921,AETNA [1000108],AETNA [100010801],,,76.8,,28.44,0.222255,85118.57664,percent of total billed charges,,,
TRIAMCINOLONE ACETONIDE 0.1 % EX OINT,RX-8118,CDM,S5000,HCPCS,259,RC,51672-1284-08,NDC,outpatient,80,GR,43.44,30.408,AETNA [1000108],AETNA [100010801],,,76.8,,33.36,0.222255,85118.57664,percent of total billed charges,,,
TRIAMCINOLONE ACETONIDE 0.5 % EX OINT,RX-8119,CDM,S5000,HCPCS,259,RC,33342-0332-15,NDC,outpatient,15,GR,28.77,20.139,AETNA [1000108],AETNA [100010801],,,76.8,,22.1,0.222255,85118.57664,percent of total billed charges,,,
TRIAMCINOLONE ACETONIDE 0.1 % MT PSTE,RX-8121,CDM,S5000,HCPCS,259,RC,64980-0320-05,NDC,outpatient,5,GR,139.78,97.846,AETNA [1000108],AETNA [100010801],,,76.8,,107.35,0.222255,85118.57664,percent of total billed charges,,,
DIVALPROEX SODIUM ER 500 MG ORAL TB24,RX-81426,CDM,S5000,HCPCS,259,RC,00904-7182-45,NDC,outpatient,1,UN,11.3,7.91,AETNA [1000108],AETNA [100010801],,,76.8,,8.68,0.222255,85118.57664,percent of total billed charges,,,
BUDESONIDE-FORMOTEROL FUMARATE 80-4.5 MCG/ACT IN AERO,RX-81453,CDM,S5000,HCPCS,259,RC,00310-7372-20,NDC,outpatient,10.2,GR,973.53,681.471,AETNA [1000108],AETNA [100010801],,,76.8,,747.67,0.222255,85118.57664,percent of total billed charges,,,
BUDESONIDE-FORMOTEROL FUMARATE 80-4.5 MCG/ACT IN AERO,RX-81453,CDM,S5000,HCPCS,259,RC,00186-0372-28,NDC,outpatient,6.9,GR,250.86,175.602,AETNA [1000108],AETNA [100010801],,,76.8,,192.66,0.222255,85118.57664,percent of total billed charges,,,
BUDESONIDE-FORMOTEROL FUMARATE 160-4.5 MCG/ACT IN AERO,RX-81454,CDM,S5000,HCPCS,259,RC,00310-7370-20,NDC,outpatient,10.2,GR,1011.48,708.036,AETNA [1000108],AETNA [100010801],,,76.8,,776.82,0.222255,85118.57664,percent of total billed charges,,,
BUDESONIDE-FORMOTEROL FUMARATE 160-4.5 MCG/ACT IN AERO,RX-81454,CDM,S5000,HCPCS,259,RC,00186-0370-28,NDC,outpatient,6,GR,250.85,175.595,AETNA [1000108],AETNA [100010801],,,76.8,,192.65,0.222255,85118.57664,percent of total billed charges,,,
TRIFLUOPERAZINE HCL 1 MG ORAL TABS,RX-8161,CDM,S5000,HCPCS,259,RC,00781-8028-01,NDC,outpatient,1,UN,2.52,1.764,AETNA [1000108],AETNA [100010801],,,76.8,,1.94,0.222255,85118.57664,percent of total billed charges,,,
TRIFLUOPERAZINE HCL 5 MG ORAL TABS,RX-8164,CDM,S5000,HCPCS,259,RC,00781-8034-01,NDC,outpatient,1,UN,4.68,3.276,AETNA [1000108],AETNA [100010801],,,76.8,,3.59,0.222255,85118.57664,percent of total billed charges,,,
TRIHEXYPHENIDYL HCL 2 MG ORAL TABS,RX-8166,CDM,S5000,HCPCS,259,RC,00591-5335-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
TRIHEXYPHENIDYL HCL 2 MG ORAL TABS,RX-8166,CDM,S5000,HCPCS,259,RC,69452-0241-20,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
TRIHEXYPHENIDYL HCL 5 MG ORAL TABS,RX-8167,CDM,S5000,HCPCS,259,RC,70954-0211-10,NDC,outpatient,1,UN,1.15,0.805,AETNA [1000108],AETNA [100010801],,,76.8,,0.88,0.222255,85118.57664,percent of total billed charges,,,
CEFIXIME 200 MG/5ML ORAL SUSR,RX-81816,CDM,S5000,HCPCS,259,RC,68180-0407-03,NDC,outpatient,6.25,ML,50.07,35.049,AETNA [1000108],AETNA [100010801],,,76.8,,38.45,0.222255,85118.57664,percent of total billed charges,,,
CEFIXIME 200 MG/5ML ORAL SUSR,RX-81816,CDM,S5000,HCPCS,259,RC,99999-0002-91,NDC,outpatient,6.25,ML,120.07,84.049,AETNA [1000108],AETNA [100010801],,,76.8,,92.21,0.222255,85118.57664,percent of total billed charges,,,
GLUCOSE 40 % ORAL GEL,RX-81823,CDM,S5000,HCPCS,259,RC,00574-0070-30,NDC,outpatient,37.5,GR,12.35,8.645,AETNA [1000108],AETNA [100010801],,,76.8,,9.48,0.222255,85118.57664,percent of total billed charges,,,
GLUCOSE 40 % ORAL GEL,RX-81823,CDM,S5000,HCPCS,259,RC,19962-0627-63,NDC,outpatient,31,GR,6.68,4.676,AETNA [1000108],AETNA [100010801],,,76.8,,5.13,0.222255,85118.57664,percent of total billed charges,,,
GLUCOSE 40 % ORAL GEL,RX-81823,CDM,S5000,HCPCS,259,RC,00574-0069-15,NDC,outpatient,37.5,GR,12.35,8.645,AETNA [1000108],AETNA [100010801],,,76.8,,9.48,0.222255,85118.57664,percent of total billed charges,,,
GLUCOSE 40 % ORAL GEL,RX-81823,CDM,S5000,HCPCS,259,RC,00574-0069-30,NDC,outpatient,37.5,GR,12.35,8.645,AETNA [1000108],AETNA [100010801],,,76.8,,9.48,0.222255,85118.57664,percent of total billed charges,,,
GLUCOSE 40 % ORAL GEL,RX-81823,CDM,S5000,HCPCS,259,RC,19962-0626-53,NDC,outpatient,31,GR,6.68,4.676,AETNA [1000108],AETNA [100010801],,,76.8,,5.13,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE 7 % IN NEBU,RX-82134,CDM,S5000,HCPCS,259,RC,50190-0141-23,NDC,outpatient,4,ML,2.6,1.82,AETNA [1000108],AETNA [100010801],,,76.8,,2,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE 7 % IN NEBU,RX-82134,CDM,S5000,HCPCS,259,RC,83490-0207-60,NDC,outpatient,4,ML,3.01,2.107,AETNA [1000108],AETNA [100010801],,,76.8,,2.31,0.222255,85118.57664,percent of total billed charges,,,
SODIUM CHLORIDE 7 % IN NEBU,RX-82134,CDM,S5000,HCPCS,259,RC,83490-0307-60,NDC,outpatient,4,ML,1.2,0.84,AETNA [1000108],AETNA [100010801],,,76.8,,0.92,0.222255,85118.57664,percent of total billed charges,,,
THROMBI-GEL 40 EX PADS,RX-82259,CDM,S5000,HCPCS,259,RC,60793-0908-04,NDC,outpatient,1,UN,254.02,177.814,AETNA [1000108],AETNA [100010801],,,76.8,,195.09,0.222255,85118.57664,percent of total billed charges,,,
TROPICAMIDE 1 % OP SOLN,RX-8250,CDM,S5000,HCPCS,259,RC,70069-0121-01,NDC,outpatient,15,ML,25.3,17.71,AETNA [1000108],AETNA [100010801],,,76.8,,19.43,0.222255,85118.57664,percent of total billed charges,,,
RIVASTIGMINE 4.6 MG/24HR TD PT24,RX-82504,CDM,S5000,HCPCS,259,RC,00078-0501-61,NDC,outpatient,1,UN,93.94,65.758,AETNA [1000108],AETNA [100010801],,,76.8,,72.15,0.222255,85118.57664,percent of total billed charges,,,
RIVASTIGMINE 4.6 MG/24HR TD PT24,RX-82504,CDM,S5000,HCPCS,259,RC,00078-0501-15,NDC,outpatient,1,UN,93.94,65.758,AETNA [1000108],AETNA [100010801],,,76.8,,72.15,0.222255,85118.57664,percent of total billed charges,,,
RIVASTIGMINE 9.5 MG/24HR TD PT24,RX-82505,CDM,S5000,HCPCS,259,RC,47781-0305-03,NDC,outpatient,1,UN,24.46,17.122,AETNA [1000108],AETNA [100010801],,,76.8,,18.79,0.222255,85118.57664,percent of total billed charges,,,
RIVASTIGMINE 9.5 MG/24HR TD PT24,RX-82505,CDM,S5000,HCPCS,259,RC,47781-0305-11,NDC,outpatient,1,UN,24.46,17.122,AETNA [1000108],AETNA [100010801],,,76.8,,18.79,0.222255,85118.57664,percent of total billed charges,,,
TUBERCULIN PPD 5 UNIT/0.1ML ID SOLN,RX-8259,CDM,S5000,HCPCS,250,RC,49281-0752-78,NDC,outpatient,0.1,ML,35.98,25.186,AETNA [1000108],AETNA [100010801],,,76.8,,27.63,0.222255,85118.57664,percent of total billed charges,,,
TUBERCULIN PPD 5 UNIT/0.1ML ID SOLN,RX-8259,CDM,S5000,HCPCS,250,RC,49281-0752-21,NDC,outpatient,0.1,ML,35.98,25.186,AETNA [1000108],AETNA [100010801],,,76.8,,27.63,0.222255,85118.57664,percent of total billed charges,,,
UNNA-FLEX ELASTIC UNNA BOOT EX MISC,RX-8371,CDM,S5000,HCPCS,250,RC,68455-0107-63,NDC,outpatient,1,UN,44.16,30.912,AETNA [1000108],AETNA [100010801],,,76.8,,33.91,0.222255,85118.57664,percent of total billed charges,,,
VALPROIC ACID 250 MG ORAL CAPS,RX-8429,CDM,S5000,HCPCS,259,RC,69452-0150-20,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
VALPROIC ACID 250 MG ORAL CAPS,RX-8429,CDM,S5000,HCPCS,259,RC,00591-4012-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
VALPROIC ACID 250 MG ORAL CAPS,RX-8429,CDM,S5000,HCPCS,259,RC,00832-0310-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
BACITRA-NEOMYCIN-POLYMYXIN-HC 1 % OP OINT,RX-849,CDM,S5000,HCPCS,259,RC,24208-0785-55,NDC,outpatient,3.5,GR,70.76,49.532,AETNA [1000108],AETNA [100010801],,,76.8,,54.34,0.222255,85118.57664,percent of total billed charges,,,
VERAPAMIL HCL 2.5 MG/ML IV SOLN,RX-8527,CDM,S5000,HCPCS,250,RC,51754-0203-01,NDC,outpatient,2,ML,15.45,10.815,AETNA [1000108],AETNA [100010801],,,76.8,,11.87,0.222255,85118.57664,percent of total billed charges,,,
VERAPAMIL HCL 2.5 MG/ML IV SOLN,RX-8527,CDM,S5000,HCPCS,250,RC,70710-1643-07,NDC,outpatient,2,ML,44.5,31.15,AETNA [1000108],AETNA [100010801],,,76.8,,34.18,0.222255,85118.57664,percent of total billed charges,,,
VERAPAMIL HCL 2.5 MG/ML IV SOLN,RX-8527,CDM,S5000,HCPCS,250,RC,51754-0203-02,NDC,outpatient,2,ML,15.45,10.815,AETNA [1000108],AETNA [100010801],,,76.8,,11.87,0.222255,85118.57664,percent of total billed charges,,,
VERAPAMIL HCL 2.5 MG/ML IV SOLN,RX-8527,CDM,S5000,HCPCS,250,RC,51754-0203-04,NDC,outpatient,2,ML,15.45,10.815,AETNA [1000108],AETNA [100010801],,,76.8,,11.87,0.222255,85118.57664,percent of total billed charges,,,
VERAPAMIL HCL 120 MG ORAL TABS,RX-8528,CDM,S5000,HCPCS,259,RC,23155-0486-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
VERAPAMIL HCL 40 MG ORAL TABS,RX-8529,CDM,S5000,HCPCS,259,RC,23155-0059-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
VERAPAMIL HCL 80 MG ORAL TABS,RX-8530,CDM,S5000,HCPCS,259,RC,23155-0026-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
BACITRACIN-NEOMYCIN-POLYMYXIN 400-3.5-5000 EX OINT,RX-854,CDM,S5000,HCPCS,259,RC,70677-0013-01,NDC,outpatient,28.4,GR,10.49,7.343,AETNA [1000108],AETNA [100010801],,,76.8,,8.06,0.222255,85118.57664,percent of total billed charges,,,
BACITRACIN-NEOMYCIN-POLYMYXIN 400-3.5-5000 EX OINT,RX-854,CDM,S5000,HCPCS,259,RC,49348-0029-72,NDC,outpatient,30,GR,11.49,8.043,AETNA [1000108],AETNA [100010801],,,76.8,,8.82,0.222255,85118.57664,percent of total billed charges,,,
BACITRACIN-POLYMYXIN B 500-10000 UNIT/GM EX OINT,RX-855,CDM,S5000,HCPCS,259,RC,00501-3798-05,NDC,outpatient,14.2,GR,20.67,14.469,AETNA [1000108],AETNA [100010801],,,76.8,,15.87,0.222255,85118.57664,percent of total billed charges,,,
BACITRACIN-POLYMYXIN B 500-10000 UNIT/GM OP OINT,RX-856,CDM,S5000,HCPCS,259,RC,24208-0555-55,NDC,outpatient,3.5,GR,22.88,16.016,AETNA [1000108],AETNA [100010801],,,76.8,,17.57,0.222255,85118.57664,percent of total billed charges,,,
BACLOFEN 10 MG ORAL TABS,RX-860,CDM,S5000,HCPCS,259,RC,63739-0479-10,NDC,outpatient,1,UN,1.74,1.218,AETNA [1000108],AETNA [100010801],,,76.8,,1.34,0.222255,85118.57664,percent of total billed charges,,,
BACLOFEN 10 MG ORAL TABS,RX-860,CDM,S5000,HCPCS,259,RC,00904-6475-61,NDC,outpatient,1,UN,1.6,1.12,AETNA [1000108],AETNA [100010801],,,76.8,,1.23,0.222255,85118.57664,percent of total billed charges,,,
BACLOFEN 10 MG ORAL TABS,RX-860,CDM,S5000,HCPCS,259,RC,00527-1330-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
VITAMIN C 250 MG ORAL TABS,RX-8679,CDM,S5000,HCPCS,259,RC,50268-0860-15,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
VITAMIN C 250 MG ORAL TABS,RX-8679,CDM,S5000,HCPCS,259,RC,50268-0860-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
VITAMIN E 100 UNITS ORAL CAPS,RX-8698,CDM,S5000,HCPCS,259,RC,80681-0134-00,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
VITAMIN E 400 UNITS ORAL CAPS,RX-8701,CDM,S5000,HCPCS,259,RC,00536-1352-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
VITAMIN E 400 UNITS ORAL CAPS,RX-8701,CDM,S5000,HCPCS,259,RC,77333-0951-25,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
VITAMIN E 400 UNITS ORAL CAPS,RX-8701,CDM,S5000,HCPCS,259,RC,77333-0951-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
VITAMINS A & D EX OINT,RX-8723,CDM,S5000,HCPCS,259,RC,57896-0110-14,NDC,outpatient,5,GR,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
VITAMINS A & D EX OINT,RX-8723,CDM,S5000,HCPCS,259,RC,57896-0110-05,NDC,outpatient,5,GR,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
WARFARIN SODIUM 2 MG ORAL TABS,RX-8749,CDM,S5000,HCPCS,259,RC,62584-0984-01,NDC,outpatient,1,UN,1.22,0.854,AETNA [1000108],AETNA [100010801],,,76.8,,0.94,0.222255,85118.57664,percent of total billed charges,,,
WARFARIN SODIUM 2 MG ORAL TABS,RX-8749,CDM,S5000,HCPCS,259,RC,62584-0984-11,NDC,outpatient,1,UN,1.22,0.854,AETNA [1000108],AETNA [100010801],,,76.8,,0.94,0.222255,85118.57664,percent of total billed charges,,,
WARFARIN SODIUM 2.5 MG ORAL TABS,RX-8750,CDM,S5000,HCPCS,259,RC,00832-1213-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
WARFARIN SODIUM 2.5 MG ORAL TABS,RX-8750,CDM,S5000,HCPCS,259,RC,00832-1213-89,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
WARFARIN SODIUM 2.5 MG ORAL TABS,RX-8750,CDM,S5000,HCPCS,259,RC,68084-0027-11,NDC,outpatient,1,UN,1.29,0.903,AETNA [1000108],AETNA [100010801],,,76.8,,0.99,0.222255,85118.57664,percent of total billed charges,,,
WARFARIN SODIUM 2.5 MG ORAL TABS,RX-8750,CDM,S5000,HCPCS,259,RC,68084-0027-01,NDC,outpatient,1,UN,1.29,0.903,AETNA [1000108],AETNA [100010801],,,76.8,,0.99,0.222255,85118.57664,percent of total billed charges,,,
WARFARIN SODIUM 5 MG ORAL TABS,RX-8751,CDM,S5000,HCPCS,259,RC,00832-1216-89,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
WARFARIN SODIUM 5 MG ORAL TABS,RX-8751,CDM,S5000,HCPCS,259,RC,00832-1216-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
WARFARIN SODIUM 7.5 MG ORAL TABS,RX-8752,CDM,S5000,HCPCS,259,RC,00832-1218-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
WARFARIN SODIUM 7.5 MG ORAL TABS,RX-8752,CDM,S5000,HCPCS,259,RC,00832-1218-89,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
THROMBIN 5000 UNITS EX KIT,RX-87798,CDM,S5000,HCPCS,250,RC,60793-0205-05,NDC,outpatient,1,UN,228.51,159.957,AETNA [1000108],AETNA [100010801],,,76.8,,175.5,0.222255,85118.57664,percent of total billed charges,,,
THROMBIN 5000 UNITS EX KIT,RX-87798,CDM,S5000,HCPCS,250,RC,60793-0705-05,NDC,outpatient,1,UN,217.65,152.355,AETNA [1000108],AETNA [100010801],,,76.8,,167.16,0.222255,85118.57664,percent of total billed charges,,,
CALCIUM GLUCONATE (ANTIDOTE) 2.5 % EX GEL,RX-87801,CDM,S5000,HCPCS,259,RC,35181-7303-32,NDC,outpatient,25,GR,146.52,102.564,AETNA [1000108],AETNA [100010801],,,76.8,,112.53,0.222255,85118.57664,percent of total billed charges,,,
BRIMONIDINE TARTRATE-TIMOLOL 0.2-0.5 % OP SOLN,RX-87834,CDM,S5000,HCPCS,259,RC,00023-9211-05,NDC,outpatient,5,ML,838.92,587.244,AETNA [1000108],AETNA [100010801],,,76.8,,644.29,0.222255,85118.57664,percent of total billed charges,,,
BRIMONIDINE TARTRATE-TIMOLOL 0.2-0.5 % OP SOLN,RX-87834,CDM,S5000,HCPCS,259,RC,82182-0455-05,NDC,outpatient,5,ML,356.54,249.578,AETNA [1000108],AETNA [100010801],,,76.8,,273.82,0.222255,85118.57664,percent of total billed charges,,,
DIAZEPAM 2.5 MG RE GEL,RX-87865,CDM,S5000,HCPCS,259,RC,68682-0650-20,NDC,outpatient,1,UN,430.63,301.441,AETNA [1000108],AETNA [100010801],,,76.8,,330.72,0.222255,85118.57664,percent of total billed charges,,,
DIAZEPAM 10 MG RE GEL,RX-87867,CDM,S5000,HCPCS,259,RC,68682-0652-20,NDC,outpatient,1,UN,622.96,436.072,AETNA [1000108],AETNA [100010801],,,76.8,,478.43,0.222255,85118.57664,percent of total billed charges,,,
DIAZEPAM 20 MG RE GEL,RX-87869,CDM,S5000,HCPCS,259,RC,68682-0655-20,NDC,outpatient,1,UN,601.24,420.868,AETNA [1000108],AETNA [100010801],,,76.8,,461.75,0.222255,85118.57664,percent of total billed charges,,,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,00378-1631-32,NDC,outpatient,2,ML,38.15,26.705,AETNA [1000108],AETNA [100010801],,,76.8,,29.3,0.222255,85118.57664,percent of total billed charges,,,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,62332-0655-01,NDC,outpatient,2,ML,18.21,12.747,AETNA [1000108],AETNA [100010801],,,76.8,,13.99,0.222255,85118.57664,percent of total billed charges,,,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,62332-0655-60,NDC,outpatient,2,ML,18.21,12.747,AETNA [1000108],AETNA [100010801],,,76.8,,13.99,0.222255,85118.57664,percent of total billed charges,,,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,70756-0608-44,NDC,outpatient,2,ML,11.64,8.148,AETNA [1000108],AETNA [100010801],,,76.8,,8.94,0.222255,85118.57664,percent of total billed charges,,,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,70756-0608-60,NDC,outpatient,2,ML,11.64,8.148,AETNA [1000108],AETNA [100010801],,,76.8,,8.94,0.222255,85118.57664,percent of total billed charges,,,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,00093-4061-06,NDC,outpatient,2,ML,64.19,44.933,AETNA [1000108],AETNA [100010801],,,76.8,,49.3,0.222255,85118.57664,percent of total billed charges,,,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,00093-4061-19,NDC,outpatient,2,ML,64.19,44.933,AETNA [1000108],AETNA [100010801],,,76.8,,49.3,0.222255,85118.57664,percent of total billed charges,,,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,00378-1631-93,NDC,outpatient,2,ML,38.15,26.705,AETNA [1000108],AETNA [100010801],,,76.8,,29.3,0.222255,85118.57664,percent of total billed charges,,,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,49502-0605-61,NDC,outpatient,2,ML,20.29,14.203,AETNA [1000108],AETNA [100010801],,,76.8,,15.58,0.222255,85118.57664,percent of total billed charges,,,
RALTEGRAVIR POTASSIUM 400 MG ORAL TABS,RX-88608,CDM,S5000,HCPCS,259,RC,00006-0227-61,NDC,outpatient,1,UN,143.66,100.562,AETNA [1000108],AETNA [100010801],,,76.8,,110.33,0.222255,85118.57664,percent of total billed charges,,,
ZINC CHLORIDE 1 MG/ML IV SOLN,RX-8865,CDM,S5000,HCPCS,250,RC,00409-4090-11,NDC,outpatient,10,ML,63.68,44.576,AETNA [1000108],AETNA [100010801],,,76.8,,48.91,0.222255,85118.57664,percent of total billed charges,,,
ZINC CHLORIDE 1 MG/ML IV SOLN,RX-8865,CDM,S5000,HCPCS,250,RC,00409-4090-01,NDC,outpatient,10,ML,63.68,44.576,AETNA [1000108],AETNA [100010801],,,76.8,,48.91,0.222255,85118.57664,percent of total billed charges,,,
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAPS,RX-88704,CDM,S5000,HCPCS,259,RC,00004-0802-85,NDC,outpatient,1,UN,57.3,40.11,AETNA [1000108],AETNA [100010801],,,76.8,,44.01,0.222255,85118.57664,percent of total billed charges,,,
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAPS,RX-88704,CDM,S5000,HCPCS,259,RC,31722-0630-31,NDC,outpatient,1,UN,3.93,2.751,AETNA [1000108],AETNA [100010801],,,76.8,,3.02,0.222255,85118.57664,percent of total billed charges,,,
OSELTAMIVIR PHOSPHATE 45 MG ORAL CAPS,RX-88705,CDM,S5000,HCPCS,259,RC,00004-0801-85,NDC,outpatient,1,UN,57.3,40.11,AETNA [1000108],AETNA [100010801],,,76.8,,44.01,0.222255,85118.57664,percent of total billed charges,,,
ZINC OXIDE 20 % EX OINT,RX-8874,CDM,S5000,HCPCS,259,RC,00536-1316-98,NDC,outpatient,454,GR,22.23,15.561,AETNA [1000108],AETNA [100010801],,,76.8,,17.07,0.222255,85118.57664,percent of total billed charges,,,
ZINC OXIDE 20 % EX OINT,RX-8874,CDM,S5000,HCPCS,259,RC,75834-0170-01,NDC,outpatient,28.4,GR,13.53,9.471,AETNA [1000108],AETNA [100010801],,,76.8,,10.39,0.222255,85118.57664,percent of total billed charges,,,
ZINC SULFATE 1 MG/ML IV SOLN,RX-8878,CDM,S5000,HCPCS,250,RC,00517-6101-01,NDC,outpatient,10,ML,75.92,53.144,AETNA [1000108],AETNA [100010801],,,76.8,,58.31,0.222255,85118.57664,percent of total billed charges,,,
ZINC SULFATE 1 MG/ML IV SOLN,RX-8878,CDM,S5000,HCPCS,250,RC,00517-6101-25,NDC,outpatient,10,ML,75.92,53.144,AETNA [1000108],AETNA [100010801],,,76.8,,58.31,0.222255,85118.57664,percent of total billed charges,,,
ZINC SULFATE 5 MG/ML IV SOLN,RX-8879,CDM,S5000,HCPCS,250,RC,00517-8005-25,NDC,outpatient,5,ML,189.8,132.86,AETNA [1000108],AETNA [100010801],,,76.8,,145.77,0.222255,85118.57664,percent of total billed charges,,,
ZINC SULFATE 5 MG/ML IV SOLN,RX-8879,CDM,S5000,HCPCS,250,RC,00517-8005-01,NDC,outpatient,5,ML,189.8,132.86,AETNA [1000108],AETNA [100010801],,,76.8,,145.77,0.222255,85118.57664,percent of total billed charges,,,
ZINC SULFATE 220 (50 ZN) MG ORAL CAPS,RX-8880,CDM,S5000,HCPCS,259,RC,77333-0983-25,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ZINC SULFATE 220 (50 ZN) MG ORAL CAPS,RX-8880,CDM,S5000,HCPCS,259,RC,77333-0983-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
SEVELAMER CARBONATE 800 MG ORAL TABS,RX-89201,CDM,S5000,HCPCS,259,RC,68094-0034-59,NDC,outpatient,1,UN,6.38,4.466,AETNA [1000108],AETNA [100010801],,,76.8,,4.9,0.222255,85118.57664,percent of total billed charges,,,
SEVELAMER CARBONATE 800 MG ORAL TABS,RX-89201,CDM,S5000,HCPCS,259,RC,68094-0034-64,NDC,outpatient,1,UN,6.38,4.466,AETNA [1000108],AETNA [100010801],,,76.8,,4.9,0.222255,85118.57664,percent of total billed charges,,,
SEVELAMER CARBONATE 800 MG ORAL TABS,RX-89201,CDM,S5000,HCPCS,259,RC,00904-6707-82,NDC,outpatient,1,UN,11.14,7.798,AETNA [1000108],AETNA [100010801],,,76.8,,8.56,0.222255,85118.57664,percent of total billed charges,,,
NEBIVOLOL HCL 5 MG ORAL TABS,RX-89284,CDM,S5000,HCPCS,259,RC,00904-7189-04,NDC,outpatient,1,UN,7.99,5.593,AETNA [1000108],AETNA [100010801],,,76.8,,6.14,0.222255,85118.57664,percent of total billed charges,,,
CLOPIDOGREL BISULFATE 300 MG ORAL TABS,RX-89346,CDM,S5000,HCPCS,259,RC,00904-6467-10,NDC,outpatient,1,UN,22.14,15.498,AETNA [1000108],AETNA [100010801],,,76.8,,17,0.222255,85118.57664,percent of total billed charges,,,
CLOPIDOGREL BISULFATE 300 MG ORAL TABS,RX-89346,CDM,S5000,HCPCS,259,RC,00904-6467-07,NDC,outpatient,1,UN,32.67,22.869,AETNA [1000108],AETNA [100010801],,,76.8,,25.09,0.222255,85118.57664,percent of total billed charges,,,
ACEBUTOLOL HCL 200 MG ORAL CAPS,RX-8939,CDM,S5000,HCPCS,259,RC,50268-0050-15,NDC,outpatient,1,UN,5.16,3.612,AETNA [1000108],AETNA [100010801],,,76.8,,3.96,0.222255,85118.57664,percent of total billed charges,,,
ACEBUTOLOL HCL 200 MG ORAL CAPS,RX-8939,CDM,S5000,HCPCS,259,RC,50268-0050-11,NDC,outpatient,1,UN,5.16,3.612,AETNA [1000108],AETNA [100010801],,,76.8,,3.96,0.222255,85118.57664,percent of total billed charges,,,
ZINC OXIDE 11.3 % EX CREA,RX-89412,CDM,S5000,HCPCS,259,RC,30103-0040-00,NDC,outpatient,60,GR,12.55,8.785,AETNA [1000108],AETNA [100010801],,,76.8,,9.64,0.222255,85118.57664,percent of total billed charges,,,
ZINC OXIDE 11.3 % EX CREA,RX-89412,CDM,S5000,HCPCS,259,RC,57074-0001-86,NDC,outpatient,60,GR,9.35,6.545,AETNA [1000108],AETNA [100010801],,,76.8,,7.18,0.222255,85118.57664,percent of total billed charges,,,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,00121-1781-05,NDC,outpatient,5,ML,4.72,3.304,AETNA [1000108],AETNA [100010801],,,76.8,,3.62,0.222255,85118.57664,percent of total billed charges,,,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,68094-0231-59,NDC,outpatient,5,ML,2.67,1.869,AETNA [1000108],AETNA [100010801],,,76.8,,2.05,0.222255,85118.57664,percent of total billed charges,,,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,99999-0004-23,NDC,outpatient,5,ML,2.67,1.869,AETNA [1000108],AETNA [100010801],,,76.8,,2.05,0.222255,85118.57664,percent of total billed charges,,,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,00121-1781-00,NDC,outpatient,5,ML,4.72,3.304,AETNA [1000108],AETNA [100010801],,,76.8,,3.62,0.222255,85118.57664,percent of total billed charges,,,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,68094-0231-62,NDC,outpatient,5,ML,2.76,1.932,AETNA [1000108],AETNA [100010801],,,76.8,,2.12,0.222255,85118.57664,percent of total billed charges,,,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,68094-0231-61,NDC,outpatient,5,ML,2.67,1.869,AETNA [1000108],AETNA [100010801],,,76.8,,2.05,0.222255,85118.57664,percent of total billed charges,,,
ETRAVIRINE 100 MG ORAL TABS,RX-89432,CDM,S5000,HCPCS,259,RC,59676-0570-01,NDC,outpatient,1,UN,53.89,37.723,AETNA [1000108],AETNA [100010801],,,76.8,,41.39,0.222255,85118.57664,percent of total billed charges,,,
ETRAVIRINE 100 MG ORAL TABS,RX-89432,CDM,S5000,HCPCS,259,RC,60219-1721-07,NDC,outpatient,1,UN,36.43,25.501,AETNA [1000108],AETNA [100010801],,,76.8,,27.98,0.222255,85118.57664,percent of total billed charges,,,
ACETAMINOPHEN-CODEINE 300-30 MG ORAL TABS,RX-8949,CDM,S5000,HCPCS,259,RC,00406-0484-23,NDC,outpatient,1,UN,1.51,1.057,AETNA [1000108],AETNA [100010801],,,76.8,,1.16,0.222255,85118.57664,percent of total billed charges,,,
ACETAMINOPHEN-CODEINE 300-30 MG ORAL TABS,RX-8949,CDM,S5000,HCPCS,259,RC,00406-0484-62,NDC,outpatient,1,UN,1.51,1.057,AETNA [1000108],AETNA [100010801],,,76.8,,1.16,0.222255,85118.57664,percent of total billed charges,,,
THROMBIN (RECOMBINANT) 5000 UNITS EX SOLR,RX-89570,CDM,S5000,HCPCS,250,RC,00338-0322-01,NDC,outpatient,1,UN,281.38,196.966,AETNA [1000108],AETNA [100010801],,,76.8,,216.1,0.222255,85118.57664,percent of total billed charges,,,
BUTALBITAL-APAP-CAFFEINE 50-325-40 MG ORAL TABS,RX-8958,CDM,S5000,HCPCS,259,RC,60687-0672-11,NDC,outpatient,1,UN,4.66,3.262,AETNA [1000108],AETNA [100010801],,,76.8,,3.58,0.222255,85118.57664,percent of total billed charges,,,
BUTALBITAL-APAP-CAFFEINE 50-325-40 MG ORAL TABS,RX-8958,CDM,S5000,HCPCS,259,RC,10702-0253-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
BUTALBITAL-APAP-CAFFEINE 50-325-40 MG ORAL TABS,RX-8958,CDM,S5000,HCPCS,259,RC,00904-6938-06,NDC,outpatient,1,UN,4.29,3.003,AETNA [1000108],AETNA [100010801],,,76.8,,3.29,0.222255,85118.57664,percent of total billed charges,,,
BUTALBITAL-APAP-CAFFEINE 50-325-40 MG ORAL TABS,RX-8958,CDM,S5000,HCPCS,259,RC,60687-0672-65,NDC,outpatient,1,UN,4.66,3.262,AETNA [1000108],AETNA [100010801],,,76.8,,3.58,0.222255,85118.57664,percent of total billed charges,,,
BUTALBITAL-APAP-CAFFEINE 50-325-40 MG ORAL TABS,RX-8958,CDM,S5000,HCPCS,259,RC,00527-1695-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ACETIC ACID 0.25 % IR SOLN,RX-8963,CDM,S5000,HCPCS,250,RC,00338-0656-04,NDC,outpatient,1000,ML,13.35,9.345,AETNA [1000108],AETNA [100010801],,,76.8,,10.25,0.222255,85118.57664,percent of total billed charges,,,
ACYCLOVIR 5 % EX CREA,RX-8967,CDM,S5000,HCPCS,259,RC,00187-0994-45,NDC,outpatient,5,GR,822.36,575.652,AETNA [1000108],AETNA [100010801],,,76.8,,631.57,0.222255,85118.57664,percent of total billed charges,,,
ACYCLOVIR 5 % EX CREA,RX-8967,CDM,S5000,HCPCS,259,RC,45802-0044-75,NDC,outpatient,5,GR,210.13,147.091,AETNA [1000108],AETNA [100010801],,,76.8,,161.38,0.222255,85118.57664,percent of total billed charges,,,
ACYCLOVIR 200 MG ORAL CAPS,RX-8969,CDM,S5000,HCPCS,259,RC,00904-5789-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ACYCLOVIR 200 MG ORAL CAPS,RX-8969,CDM,S5000,HCPCS,259,RC,60505-0042-06,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ACYCLOVIR 200 MG/5ML ORAL SUSP,RX-8970,CDM,S5000,HCPCS,259,RC,31722-0681-47,NDC,outpatient,473,ML,244.17,170.919,AETNA [1000108],AETNA [100010801],,,76.8,,187.52,0.222255,85118.57664,percent of total billed charges,,,
ACYCLOVIR 200 MG/5ML ORAL SUSP,RX-8970,CDM,S5000,HCPCS,259,RC,00472-0082-16,NDC,outpatient,473,ML,1582.85,1107.995,AETNA [1000108],AETNA [100010801],,,76.8,,1215.63,0.222255,85118.57664,percent of total billed charges,,,
ACYCLOVIR 200 MG/5ML ORAL SUSP,RX-8970,CDM,S5000,HCPCS,259,RC,99999-0004-02,NDC,outpatient,5,ML,4.94,3.458,AETNA [1000108],AETNA [100010801],,,76.8,,3.79,0.222255,85118.57664,percent of total billed charges,,,
ACYCLOVIR 800 MG ORAL TABS,RX-8972,CDM,S5000,HCPCS,259,RC,68084-0109-01,NDC,outpatient,1,UN,3.08,2.156,AETNA [1000108],AETNA [100010801],,,76.8,,2.37,0.222255,85118.57664,percent of total billed charges,,,
ACYCLOVIR 800 MG ORAL TABS,RX-8972,CDM,S5000,HCPCS,259,RC,68084-0109-11,NDC,outpatient,1,UN,3.08,2.156,AETNA [1000108],AETNA [100010801],,,76.8,,2.37,0.222255,85118.57664,percent of total billed charges,,,
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,00904-7325-73,NDC,outpatient,30,ML,11.09,7.763,AETNA [1000108],AETNA [100010801],,,76.8,,8.52,0.222255,85118.57664,percent of total billed charges,,,
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,57896-0629-12,NDC,outpatient,10,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,70677-1063-01,NDC,outpatient,10,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,70677-1063-30,NDC,outpatient,30,ML,1.7,1.19,AETNA [1000108],AETNA [100010801],,,76.8,,1.31,0.222255,85118.57664,percent of total billed charges,,,
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,00904-7325-62,NDC,outpatient,30,ML,11.09,7.763,AETNA [1000108],AETNA [100010801],,,76.8,,8.52,0.222255,85118.57664,percent of total billed charges,,,
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,00121-1761-30,NDC,outpatient,30,ML,7.21,5.047,AETNA [1000108],AETNA [100010801],,,76.8,,5.54,0.222255,85118.57664,percent of total billed charges,,,
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,99999-0002-58,NDC,outpatient,30,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
AMINOCAPROIC ACID 500 MG ORAL TABS,RX-9063,CDM,S5000,HCPCS,259,RC,69680-0115-30,NDC,outpatient,1,UN,26.56,18.592,AETNA [1000108],AETNA [100010801],,,76.8,,20.4,0.222255,85118.57664,percent of total billed charges,,,
AMIODARONE HCL 200 MG ORAL TABS,RX-9066,CDM,S5000,HCPCS,259,RC,00904-6993-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
AMIODARONE HCL 200 MG ORAL TABS,RX-9066,CDM,S5000,HCPCS,259,RC,63739-0051-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
AMIODARONE HCL 200 MG ORAL TABS,RX-9066,CDM,S5000,HCPCS,259,RC,00245-0147-89,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
AMIODARONE HCL 200 MG ORAL TABS,RX-9066,CDM,S5000,HCPCS,259,RC,00245-0147-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
AMLODIPINE BESYLATE 2.5 MG ORAL TABS,RX-9070,CDM,S5000,HCPCS,259,RC,00904-6369-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
AMLODIPINE BESYLATE 5 MG ORAL TABS,RX-9071,CDM,S5000,HCPCS,259,RC,68382-0122-16,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
AMLODIPINE BESYLATE 5 MG ORAL TABS,RX-9071,CDM,S5000,HCPCS,259,RC,00904-6370-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TABS,RX-9081,CDM,S5000,HCPCS,259,RC,64850-0502-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TABS,RX-9081,CDM,S5000,HCPCS,259,RC,42806-0341-01,NDC,outpatient,1,UN,1.52,1.064,AETNA [1000108],AETNA [100010801],,,76.8,,1.17,0.222255,85118.57664,percent of total billed charges,,,
DESVENLAFAXINE SUCCINATE ER 50 MG ORAL TB24,RX-91073,CDM,S5000,HCPCS,259,RC,00591-3659-30,NDC,outpatient,1,UN,2.77,1.939,AETNA [1000108],AETNA [100010801],,,76.8,,2.13,0.222255,85118.57664,percent of total billed charges,,,
DESVENLAFAXINE SUCCINATE ER 50 MG ORAL TB24,RX-91073,CDM,S5000,HCPCS,259,RC,51991-0311-90,NDC,outpatient,1,UN,2.38,1.666,AETNA [1000108],AETNA [100010801],,,76.8,,1.83,0.222255,85118.57664,percent of total billed charges,,,
DESVENLAFAXINE SUCCINATE ER 50 MG ORAL TB24,RX-91073,CDM,S5000,HCPCS,259,RC,00008-1211-14,NDC,outpatient,1,UN,5.76,4.032,AETNA [1000108],AETNA [100010801],,,76.8,,4.42,0.222255,85118.57664,percent of total billed charges,,,
ROPINIROLE HCL ER 2 MG ORAL TB24,RX-92015,CDM,S5000,HCPCS,259,RC,55111-0659-30,NDC,outpatient,1,UN,2.69,1.883,AETNA [1000108],AETNA [100010801],,,76.8,,2.07,0.222255,85118.57664,percent of total billed charges,,,
BENAZEPRIL HCL 10 MG ORAL TABS,RX-9220,CDM,S5000,HCPCS,259,RC,50268-0110-11,NDC,outpatient,1,UN,2.09,1.463,AETNA [1000108],AETNA [100010801],,,76.8,,1.61,0.222255,85118.57664,percent of total billed charges,,,
BENAZEPRIL HCL 10 MG ORAL TABS,RX-9220,CDM,S5000,HCPCS,259,RC,50268-0110-15,NDC,outpatient,1,UN,2.09,1.463,AETNA [1000108],AETNA [100010801],,,76.8,,1.61,0.222255,85118.57664,percent of total billed charges,,,
BETAXOLOL HCL 0.5 % OP SOLN,RX-9268,CDM,S5000,HCPCS,259,RC,61314-0245-01,NDC,outpatient,5,ML,147.74,103.418,AETNA [1000108],AETNA [100010801],,,76.8,,113.46,0.222255,85118.57664,percent of total billed charges,,,
BETAXOLOL HCL 10 MG ORAL TABS,RX-9269,CDM,S5000,HCPCS,259,RC,10702-0013-01,NDC,outpatient,1,UN,1.58,1.106,AETNA [1000108],AETNA [100010801],,,76.8,,1.21,0.222255,85118.57664,percent of total billed charges,,,
BETAXOLOL HCL 10 MG ORAL TABS,RX-9269,CDM,S5000,HCPCS,259,RC,10135-0623-01,NDC,outpatient,1,UN,2.28,1.596,AETNA [1000108],AETNA [100010801],,,76.8,,1.75,0.222255,85118.57664,percent of total billed charges,,,
MOUTH KOTE MT SOLN,RX-92764,CDM,S5000,HCPCS,259,RC,50930-0098-02,NDC,outpatient,59,ML,21.53,15.071,AETNA [1000108],AETNA [100010801],,,76.8,,16.54,0.222255,85118.57664,percent of total billed charges,,,
BROMOCRIPTINE MESYLATE 2.5 MG ORAL TABS,RX-9297,CDM,S5000,HCPCS,259,RC,00574-0106-03,NDC,outpatient,1,UN,3.28,2.296,AETNA [1000108],AETNA [100010801],,,76.8,,2.52,0.222255,85118.57664,percent of total billed charges,,,
BUMETANIDE 0.5 MG ORAL TABS,RX-9309,CDM,S5000,HCPCS,259,RC,42799-0119-01,NDC,outpatient,1,UN,1.43,1.001,AETNA [1000108],AETNA [100010801],,,76.8,,1.1,0.222255,85118.57664,percent of total billed charges,,,
BUMETANIDE 0.5 MG ORAL TABS,RX-9309,CDM,S5000,HCPCS,259,RC,50268-0130-15,NDC,outpatient,1,UN,5.55,3.885,AETNA [1000108],AETNA [100010801],,,76.8,,4.26,0.222255,85118.57664,percent of total billed charges,,,
BUMETANIDE 0.5 MG ORAL TABS,RX-9309,CDM,S5000,HCPCS,259,RC,50268-0130-11,NDC,outpatient,1,UN,5.55,3.885,AETNA [1000108],AETNA [100010801],,,76.8,,4.26,0.222255,85118.57664,percent of total billed charges,,,
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,00185-0129-05,NDC,outpatient,1,UN,1.38,0.966,AETNA [1000108],AETNA [100010801],,,76.8,,1.06,0.222255,85118.57664,percent of total billed charges,,,
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,50268-0131-15,NDC,outpatient,1,UN,3.09,2.163,AETNA [1000108],AETNA [100010801],,,76.8,,2.37,0.222255,85118.57664,percent of total billed charges,,,
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,60687-0384-11,NDC,outpatient,1,UN,3.38,2.366,AETNA [1000108],AETNA [100010801],,,76.8,,2.6,0.222255,85118.57664,percent of total billed charges,,,
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,00185-0129-01,NDC,outpatient,1,UN,1.65,1.155,AETNA [1000108],AETNA [100010801],,,76.8,,1.27,0.222255,85118.57664,percent of total billed charges,,,
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,50268-0131-11,NDC,outpatient,1,UN,3.09,2.163,AETNA [1000108],AETNA [100010801],,,76.8,,2.37,0.222255,85118.57664,percent of total billed charges,,,
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,60687-0384-01,NDC,outpatient,1,UN,3.38,2.366,AETNA [1000108],AETNA [100010801],,,76.8,,2.6,0.222255,85118.57664,percent of total billed charges,,,
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,69238-1490-01,NDC,outpatient,1,UN,1.61,1.127,AETNA [1000108],AETNA [100010801],,,76.8,,1.24,0.222255,85118.57664,percent of total billed charges,,,
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 IJ SOLN,RX-9318,CDM,S5000,HCPCS,250,RC,63323-0463-57,NDC,outpatient,50,ML,49.4,34.58,AETNA [1000108],AETNA [100010801],,,76.8,,37.94,0.222255,85118.57664,percent of total billed charges,,,
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 IJ SOLN,RX-9318,CDM,S5000,HCPCS,250,RC,63323-0463-01,NDC,outpatient,50,ML,49.4,34.58,AETNA [1000108],AETNA [100010801],,,76.8,,37.94,0.222255,85118.57664,percent of total billed charges,,,
BUPROPION HCL 100 MG ORAL TABS,RX-9321,CDM,S5000,HCPCS,259,RC,00904-6636-61,NDC,outpatient,1,UN,4.6,3.22,AETNA [1000108],AETNA [100010801],,,76.8,,3.53,0.222255,85118.57664,percent of total billed charges,,,
BUPROPION HCL 75 MG ORAL TABS,RX-9322,CDM,S5000,HCPCS,259,RC,50268-0142-11,NDC,outpatient,1,UN,2.99,2.093,AETNA [1000108],AETNA [100010801],,,76.8,,2.3,0.222255,85118.57664,percent of total billed charges,,,
BUPROPION HCL 75 MG ORAL TABS,RX-9322,CDM,S5000,HCPCS,259,RC,50268-0142-15,NDC,outpatient,1,UN,2.99,2.093,AETNA [1000108],AETNA [100010801],,,76.8,,2.3,0.222255,85118.57664,percent of total billed charges,,,
BUPROPION HCL 75 MG ORAL TABS,RX-9322,CDM,S5000,HCPCS,259,RC,60687-0340-01,NDC,outpatient,1,UN,3.85,2.695,AETNA [1000108],AETNA [100010801],,,76.8,,2.96,0.222255,85118.57664,percent of total billed charges,,,
BUPROPION HCL 75 MG ORAL TABS,RX-9322,CDM,S5000,HCPCS,259,RC,60687-0340-11,NDC,outpatient,1,UN,3.85,2.695,AETNA [1000108],AETNA [100010801],,,76.8,,2.96,0.222255,85118.57664,percent of total billed charges,,,
BUSPIRONE HCL 5 MG ORAL TABS,RX-9324,CDM,S5000,HCPCS,259,RC,51079-0985-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
BUSPIRONE HCL 5 MG ORAL TABS,RX-9324,CDM,S5000,HCPCS,259,RC,51079-0985-20,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
BUSPIRONE HCL 5 MG ORAL TABS,RX-9324,CDM,S5000,HCPCS,259,RC,00093-0053-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
BUSPIRONE HCL 5 MG ORAL TABS,RX-9324,CDM,S5000,HCPCS,259,RC,00904-7122-61,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
CALCITRIOL 0.25 MCG ORAL CAPS,RX-9350,CDM,S5000,HCPCS,259,RC,23155-0662-01,NDC,outpatient,1,UN,1.4,0.98,AETNA [1000108],AETNA [100010801],,,76.8,,1.08,0.222255,85118.57664,percent of total billed charges,,,
CALCITRIOL 0.25 MCG ORAL CAPS,RX-9350,CDM,S5000,HCPCS,259,RC,69452-0207-20,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
CALCIUM CARBONATE ANTACID 500 MG ORAL CHEW,RX-9385,CDM,S5000,HCPCS,259,RC,68084-0988-33,NDC,outpatient,1,UN,2.86,2.002,AETNA [1000108],AETNA [100010801],,,76.8,,2.2,0.222255,85118.57664,percent of total billed charges,,,
CALCIUM CARBONATE ANTACID 500 MG ORAL CHEW,RX-9385,CDM,S5000,HCPCS,259,RC,66553-0004-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
CALCIUM CARBONATE ANTACID 500 MG ORAL CHEW,RX-9385,CDM,S5000,HCPCS,259,RC,00904-6412-92,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
CALCIUM CARBONATE ANTACID 500 MG ORAL CHEW,RX-9385,CDM,S5000,HCPCS,259,RC,68084-0988-32,NDC,outpatient,1,UN,2.86,2.002,AETNA [1000108],AETNA [100010801],,,76.8,,2.2,0.222255,85118.57664,percent of total billed charges,,,
SORBITOL 70 % SOLN,RX-93927,CDM,S5000,HCPCS,259,RC,46287-0500-30,NDC,outpatient,30,ML,9.48,6.636,AETNA [1000108],AETNA [100010801],,,76.8,,7.28,0.222255,85118.57664,percent of total billed charges,,,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00378-9671-31,NDC,outpatient,3,ML,2.4,1.68,AETNA [1000108],AETNA [100010801],,,76.8,,1.84,0.222255,85118.57664,percent of total billed charges,,,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00487-0201-01,NDC,outpatient,3,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00487-0201-03,NDC,outpatient,3,ML,1.13,0.791,AETNA [1000108],AETNA [100010801],,,76.8,,0.87,0.222255,85118.57664,percent of total billed charges,,,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,76204-0600-01,NDC,outpatient,3,ML,1.22,0.854,AETNA [1000108],AETNA [100010801],,,76.8,,0.94,0.222255,85118.57664,percent of total billed charges,,,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00378-9671-30,NDC,outpatient,3,ML,2.4,1.68,AETNA [1000108],AETNA [100010801],,,76.8,,1.84,0.222255,85118.57664,percent of total billed charges,,,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00378-9671-60,NDC,outpatient,3,ML,2.4,1.68,AETNA [1000108],AETNA [100010801],,,76.8,,1.84,0.222255,85118.57664,percent of total billed charges,,,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00378-9671-93,NDC,outpatient,3,ML,2.4,1.68,AETNA [1000108],AETNA [100010801],,,76.8,,1.84,0.222255,85118.57664,percent of total billed charges,,,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,47335-0756-49,NDC,outpatient,3,ML,1.42,0.994,AETNA [1000108],AETNA [100010801],,,76.8,,1.09,0.222255,85118.57664,percent of total billed charges,,,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,47335-0756-48,NDC,outpatient,3,ML,1.42,0.994,AETNA [1000108],AETNA [100010801],,,76.8,,1.09,0.222255,85118.57664,percent of total billed charges,,,
CAPTOPRIL 12.5 MG ORAL TABS,RX-9401,CDM,S5000,HCPCS,259,RC,00904-7105-61,NDC,outpatient,1,UN,6.29,4.403,AETNA [1000108],AETNA [100010801],,,76.8,,4.83,0.222255,85118.57664,percent of total billed charges,,,
CAPTOPRIL 25 MG ORAL TABS,RX-9402,CDM,S5000,HCPCS,259,RC,00904-7106-61,NDC,outpatient,1,UN,5.2,3.64,AETNA [1000108],AETNA [100010801],,,76.8,,3.99,0.222255,85118.57664,percent of total billed charges,,,
CARBIDOPA-LEVODOPA 10-100 MG ORAL TABS,RX-9406,CDM,S5000,HCPCS,259,RC,00093-9701-01,NDC,outpatient,1,UN,1.15,0.805,AETNA [1000108],AETNA [100010801],,,76.8,,0.88,0.222255,85118.57664,percent of total billed charges,,,
CARBIDOPA-LEVODOPA 25-100 MG ORAL TABS,RX-9407,CDM,S5000,HCPCS,259,RC,60687-0661-11,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
CARBIDOPA-LEVODOPA 25-100 MG ORAL TABS,RX-9407,CDM,S5000,HCPCS,259,RC,60687-0661-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
CARBIDOPA-LEVODOPA 25-100 MG ORAL TABS,RX-9407,CDM,S5000,HCPCS,259,RC,00093-9702-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN,RX-9413,CDM,S5000,HCPCS,250,RC,00009-0856-05,NDC,outpatient,1,ML,319.49,223.643,AETNA [1000108],AETNA [100010801],,,76.8,,245.37,0.222255,85118.57664,percent of total billed charges,,,
CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN,RX-9413,CDM,S5000,HCPCS,250,RC,00009-0856-08,NDC,outpatient,1,ML,319.49,223.643,AETNA [1000108],AETNA [100010801],,,76.8,,245.37,0.222255,85118.57664,percent of total billed charges,,,
BENZOCAINE-MENTHOL 15-3.6 MG MT LOZG,RX-94141,CDM,S5000,HCPCS,259,RC,00904-6255-49,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
RENO CAPS 1 MG ORAL CAPS,RX-94178,CDM,S5000,HCPCS,259,RC,60258-0162-01,NDC,outpatient,1,UN,2.43,1.701,AETNA [1000108],AETNA [100010801],,,76.8,,1.87,0.222255,85118.57664,percent of total billed charges,,,
RENO CAPS 1 MG ORAL CAPS,RX-94178,CDM,S5000,HCPCS,259,RC,63044-0622-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
CEFACLOR 250 MG ORAL CAPS,RX-9430,CDM,S5000,HCPCS,259,RC,61442-0171-30,NDC,outpatient,1,UN,8.1,5.67,AETNA [1000108],AETNA [100010801],,,76.8,,6.22,0.222255,85118.57664,percent of total billed charges,,,
CEFADROXIL 500 MG ORAL CAPS,RX-9436,CDM,S5000,HCPCS,259,RC,16714-0388-01,NDC,outpatient,1,UN,1.08,0.756,AETNA [1000108],AETNA [100010801],,,76.8,,0.83,0.222255,85118.57664,percent of total billed charges,,,
CEFADROXIL 500 MG ORAL CAPS,RX-9436,CDM,S5000,HCPCS,259,RC,65862-0085-50,NDC,outpatient,1,UN,2.45,1.715,AETNA [1000108],AETNA [100010801],,,76.8,,1.88,0.222255,85118.57664,percent of total billed charges,,,
CEFADROXIL 500 MG ORAL CAPS,RX-9436,CDM,S5000,HCPCS,259,RC,68180-0180-01,NDC,outpatient,1,UN,2.36,1.652,AETNA [1000108],AETNA [100010801],,,76.8,,1.81,0.222255,85118.57664,percent of total billed charges,,,
CEFADROXIL 500 MG ORAL CAPS,RX-9436,CDM,S5000,HCPCS,259,RC,68180-0180-08,NDC,outpatient,1,UN,2.65,1.855,AETNA [1000108],AETNA [100010801],,,76.8,,2.04,0.222255,85118.57664,percent of total billed charges,,,
CEFPODOXIME PROXETIL 200 MG ORAL TABS,RX-9469,CDM,S5000,HCPCS,259,RC,65862-0096-20,NDC,outpatient,1,UN,14.53,10.171,AETNA [1000108],AETNA [100010801],,,76.8,,11.16,0.222255,85118.57664,percent of total billed charges,,,
CEFPODOXIME PROXETIL 200 MG ORAL TABS,RX-9469,CDM,S5000,HCPCS,259,RC,00781-5439-20,NDC,outpatient,1,UN,12.33,8.631,AETNA [1000108],AETNA [100010801],,,76.8,,9.47,0.222255,85118.57664,percent of total billed charges,,,
CEFUROXIME AXETIL 250 MG ORAL TABS,RX-9495,CDM,S5000,HCPCS,259,RC,16714-0400-02,NDC,outpatient,1,UN,3.64,2.548,AETNA [1000108],AETNA [100010801],,,76.8,,2.8,0.222255,85118.57664,percent of total billed charges,,,
CEFUROXIME AXETIL 250 MG ORAL TABS,RX-9495,CDM,S5000,HCPCS,259,RC,67877-0215-60,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
CEFUROXIME AXETIL 250 MG ORAL TABS,RX-9495,CDM,S5000,HCPCS,259,RC,65862-0699-60,NDC,outpatient,1,UN,2.34,1.638,AETNA [1000108],AETNA [100010801],,,76.8,,1.8,0.222255,85118.57664,percent of total billed charges,,,
CEPHALEXIN 250 MG ORAL CAPS,RX-9499,CDM,S5000,HCPCS,259,RC,60687-0152-01,NDC,outpatient,1,UN,1.3,0.91,AETNA [1000108],AETNA [100010801],,,76.8,,1,0.222255,85118.57664,percent of total billed charges,,,
CEPHALEXIN 250 MG ORAL CAPS,RX-9499,CDM,S5000,HCPCS,259,RC,67877-0220-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
CEPHALEXIN 250 MG ORAL CAPS,RX-9499,CDM,S5000,HCPCS,259,RC,50268-0151-11,NDC,outpatient,1,UN,1.49,1.043,AETNA [1000108],AETNA [100010801],,,76.8,,1.14,0.222255,85118.57664,percent of total billed charges,,,
CEPHALEXIN 250 MG ORAL CAPS,RX-9499,CDM,S5000,HCPCS,259,RC,50268-0151-15,NDC,outpatient,1,UN,1.49,1.043,AETNA [1000108],AETNA [100010801],,,76.8,,1.14,0.222255,85118.57664,percent of total billed charges,,,
CEPHALEXIN 250 MG ORAL CAPS,RX-9499,CDM,S5000,HCPCS,259,RC,60687-0152-11,NDC,outpatient,1,UN,1.3,0.91,AETNA [1000108],AETNA [100010801],,,76.8,,1,0.222255,85118.57664,percent of total billed charges,,,
CHLORHEXIDINE GLUCONATE 0.12 % MT SOLN,RX-9516,CDM,S5000,HCPCS,259,RC,69339-0138-19,NDC,outpatient,15,ML,6.15,4.305,AETNA [1000108],AETNA [100010801],,,76.8,,4.72,0.222255,85118.57664,percent of total billed charges,,,
CHLORHEXIDINE GLUCONATE 0.12 % MT SOLN,RX-9516,CDM,S5000,HCPCS,259,RC,69339-0138-15,NDC,outpatient,15,ML,6.55,4.585,AETNA [1000108],AETNA [100010801],,,76.8,,5.03,0.222255,85118.57664,percent of total billed charges,,,
CHLOROTHIAZIDE 250 MG/5ML ORAL SUSP,RX-9525,CDM,S5000,HCPCS,259,RC,,,outpatient,5,ML,5.99,4.193,AETNA [1000108],AETNA [100010801],,,76.8,,4.6,0.222255,85118.57664,percent of total billed charges,,,
CHLOROTHIAZIDE 250 MG/5ML ORAL SUSP,RX-9525,CDM,S5000,HCPCS,259,RC,,,outpatient,1,ML,1.39,0.973,AETNA [1000108],AETNA [100010801],,,76.8,,1.07,0.222255,85118.57664,percent of total billed charges,,,
FERROUS SULFATE 75 (15 FE) MG/ML ORAL SOLN,RX-95693,CDM,S5000,HCPCS,259,RC,54838-0011-50,NDC,outpatient,50,ML,14.02,9.814,AETNA [1000108],AETNA [100010801],,,76.8,,10.77,0.222255,85118.57664,percent of total billed charges,,,
FERROUS SULFATE 75 (15 FE) MG/ML ORAL SOLN,RX-95693,CDM,S5000,HCPCS,259,RC,99999-0003-94,NDC,outpatient,1,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
CIPROFLOXACIN HCL 0.3 % OP SOLN,RX-9610,CDM,S5000,HCPCS,259,RC,61314-0656-05,NDC,outpatient,5,ML,15.4,10.78,AETNA [1000108],AETNA [100010801],,,76.8,,11.83,0.222255,85118.57664,percent of total billed charges,,,
CIPROFLOXACIN HCL 0.3 % OP SOLN,RX-9610,CDM,S5000,HCPCS,259,RC,69315-0308-05,NDC,outpatient,5,ML,62.3,43.61,AETNA [1000108],AETNA [100010801],,,76.8,,47.85,0.222255,85118.57664,percent of total billed charges,,,
CLARITHROMYCIN 250 MG ORAL TABS,RX-9616,CDM,S5000,HCPCS,259,RC,00527-1931-06,NDC,outpatient,1,UN,1.14,0.798,AETNA [1000108],AETNA [100010801],,,76.8,,0.88,0.222255,85118.57664,percent of total billed charges,,,
CLARITHROMYCIN 250 MG ORAL TABS,RX-9616,CDM,S5000,HCPCS,259,RC,65862-0225-60,NDC,outpatient,1,UN,1.39,0.973,AETNA [1000108],AETNA [100010801],,,76.8,,1.07,0.222255,85118.57664,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE 1 % EX GEL,RX-9623,CDM,S5000,HCPCS,259,RC,59762-3743-01,NDC,outpatient,30,GR,208.26,145.782,AETNA [1000108],AETNA [100010801],,,76.8,,159.94,0.222255,85118.57664,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE 1 % EX GEL,RX-9623,CDM,S5000,HCPCS,259,RC,00168-0202-30,NDC,outpatient,30,GR,207.33,145.131,AETNA [1000108],AETNA [100010801],,,76.8,,159.23,0.222255,85118.57664,percent of total billed charges,,,
CLOBETASOL PROPIONATE 0.05 % EX CREA,RX-9630,CDM,S5000,HCPCS,259,RC,51672-1258-02,NDC,outpatient,30,GR,31.11,21.777,AETNA [1000108],AETNA [100010801],,,76.8,,23.89,0.222255,85118.57664,percent of total billed charges,,,
CLOBETASOL PROPIONATE 0.05 % EX CREA,RX-9630,CDM,S5000,HCPCS,259,RC,69238-1532-05,NDC,outpatient,15,GR,19.83,13.881,AETNA [1000108],AETNA [100010801],,,76.8,,15.23,0.222255,85118.57664,percent of total billed charges,,,
CLOBETASOL PROPIONATE 0.05 % EX OINT,RX-9631,CDM,S5000,HCPCS,259,RC,51672-1259-02,NDC,outpatient,30,GR,43.53,30.471,AETNA [1000108],AETNA [100010801],,,76.8,,33.43,0.222255,85118.57664,percent of total billed charges,,,
CLOBETASOL PROPIONATE 0.05 % EX OINT,RX-9631,CDM,S5000,HCPCS,259,RC,21922-0017-05,NDC,outpatient,30,GR,42.19,29.533,AETNA [1000108],AETNA [100010801],,,76.8,,32.4,0.222255,85118.57664,percent of total billed charges,,,
CLOMIPRAMINE HCL 25 MG ORAL CAPS,RX-9635,CDM,S5000,HCPCS,259,RC,68084-0790-25,NDC,outpatient,1,UN,36.81,25.767,AETNA [1000108],AETNA [100010801],,,76.8,,28.27,0.222255,85118.57664,percent of total billed charges,,,
CLOMIPRAMINE HCL 25 MG ORAL CAPS,RX-9635,CDM,S5000,HCPCS,259,RC,68084-0790-95,NDC,outpatient,1,UN,36.81,25.767,AETNA [1000108],AETNA [100010801],,,76.8,,28.27,0.222255,85118.57664,percent of total billed charges,,,
CLONAZEPAM 0.5 MG ORAL TABS,RX-9637,CDM,S5000,HCPCS,259,RC,60687-0544-01,NDC,outpatient,1,UN,1.65,1.155,AETNA [1000108],AETNA [100010801],,,76.8,,1.27,0.222255,85118.57664,percent of total billed charges,,,
CLONAZEPAM 0.5 MG ORAL TABS,RX-9637,CDM,S5000,HCPCS,259,RC,60687-0544-11,NDC,outpatient,1,UN,1.65,1.155,AETNA [1000108],AETNA [100010801],,,76.8,,1.27,0.222255,85118.57664,percent of total billed charges,,,
CLONAZEPAM 1 MG ORAL TABS,RX-9638,CDM,S5000,HCPCS,259,RC,43547-0407-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
CLONAZEPAM 1 MG ORAL TABS,RX-9638,CDM,S5000,HCPCS,259,RC,60687-0555-01,NDC,outpatient,1,UN,1.65,1.155,AETNA [1000108],AETNA [100010801],,,76.8,,1.27,0.222255,85118.57664,percent of total billed charges,,,
CLONAZEPAM 1 MG ORAL TABS,RX-9638,CDM,S5000,HCPCS,259,RC,16729-0137-00,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
CLONAZEPAM 1 MG ORAL TABS,RX-9638,CDM,S5000,HCPCS,259,RC,60687-0555-11,NDC,outpatient,1,UN,1.65,1.155,AETNA [1000108],AETNA [100010801],,,76.8,,1.27,0.222255,85118.57664,percent of total billed charges,,,
CLOTRIMAZOLE 10 MG MT TROC,RX-9644,CDM,S5000,HCPCS,259,RC,00054-4146-22,NDC,outpatient,1,UN,1.41,0.987,AETNA [1000108],AETNA [100010801],,,76.8,,1.08,0.222255,85118.57664,percent of total billed charges,,,
CLOTRIMAZOLE 10 MG MT TROC,RX-9644,CDM,S5000,HCPCS,259,RC,00574-0107-70,NDC,outpatient,1,UN,1.34,0.938,AETNA [1000108],AETNA [100010801],,,76.8,,1.03,0.222255,85118.57664,percent of total billed charges,,,
CLOZAPINE 100 MG ORAL TABS,RX-9647,CDM,S5000,HCPCS,259,RC,51079-0922-20,NDC,outpatient,1,UN,4.21,2.947,AETNA [1000108],AETNA [100010801],,,76.8,,3.23,0.222255,85118.57664,percent of total billed charges,,,
CLOZAPINE 100 MG ORAL TABS,RX-9647,CDM,S5000,HCPCS,259,RC,60687-0415-01,NDC,outpatient,1,UN,2.55,1.785,AETNA [1000108],AETNA [100010801],,,76.8,,1.96,0.222255,85118.57664,percent of total billed charges,,,
CLOZAPINE 100 MG ORAL TABS,RX-9647,CDM,S5000,HCPCS,259,RC,60687-0415-11,NDC,outpatient,1,UN,2.55,1.785,AETNA [1000108],AETNA [100010801],,,76.8,,1.96,0.222255,85118.57664,percent of total billed charges,,,
CLOZAPINE 100 MG ORAL TABS,RX-9647,CDM,S5000,HCPCS,259,RC,51079-0922-01,NDC,outpatient,1,UN,4.21,2.947,AETNA [1000108],AETNA [100010801],,,76.8,,3.23,0.222255,85118.57664,percent of total billed charges,,,
CLOZAPINE 25 MG ORAL TABS,RX-9648,CDM,S5000,HCPCS,259,RC,51079-0921-20,NDC,outpatient,1,UN,2.14,1.498,AETNA [1000108],AETNA [100010801],,,76.8,,1.64,0.222255,85118.57664,percent of total billed charges,,,
CLOZAPINE 25 MG ORAL TABS,RX-9648,CDM,S5000,HCPCS,259,RC,51079-0921-01,NDC,outpatient,1,UN,2.14,1.498,AETNA [1000108],AETNA [100010801],,,76.8,,1.64,0.222255,85118.57664,percent of total billed charges,,,
COLLAGENASE 250 UNIT/GM EX OINT,RX-9682,CDM,S5000,HCPCS,259,RC,50484-0010-30,NDC,outpatient,30,GR,1218.46,852.922,AETNA [1000108],AETNA [100010801],,,76.8,,935.78,0.222255,85118.57664,percent of total billed charges,,,
CROMOLYN SODIUM 4 % OP SOLN,RX-9691,CDM,S5000,HCPCS,259,RC,61314-0237-10,NDC,outpatient,10,ML,27.77,19.439,AETNA [1000108],AETNA [100010801],,,76.8,,21.33,0.222255,85118.57664,percent of total billed charges,,,
LACOSAMIDE 50 MG ORAL TABS,RX-96968,CDM,S5000,HCPCS,259,RC,68462-0678-60,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LACOSAMIDE 50 MG ORAL TABS,RX-96968,CDM,S5000,HCPCS,259,RC,00131-2477-35,NDC,outpatient,1,UN,48.43,33.901,AETNA [1000108],AETNA [100010801],,,76.8,,37.19,0.222255,85118.57664,percent of total billed charges,,,
LACOSAMIDE 50 MG ORAL TABS,RX-96968,CDM,S5000,HCPCS,259,RC,00131-2477-60,NDC,outpatient,1,UN,53.28,37.296,AETNA [1000108],AETNA [100010801],,,76.8,,40.92,0.222255,85118.57664,percent of total billed charges,,,
LACOSAMIDE 100 MG ORAL TABS,RX-96969,CDM,S5000,HCPCS,259,RC,00131-2478-60,NDC,outpatient,1,UN,83.29,58.303,AETNA [1000108],AETNA [100010801],,,76.8,,63.97,0.222255,85118.57664,percent of total billed charges,,,
LACOSAMIDE 100 MG ORAL TABS,RX-96969,CDM,S5000,HCPCS,259,RC,31722-0813-60,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LACOSAMIDE 100 MG ORAL TABS,RX-96969,CDM,S5000,HCPCS,259,RC,51991-0349-06,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
LACOSAMIDE 100 MG ORAL TABS,RX-96969,CDM,S5000,HCPCS,259,RC,60687-0687-11,NDC,outpatient,1,UN,5.37,3.759,AETNA [1000108],AETNA [100010801],,,76.8,,4.12,0.222255,85118.57664,percent of total billed charges,,,
LACOSAMIDE 100 MG ORAL TABS,RX-96969,CDM,S5000,HCPCS,259,RC,60687-0687-57,NDC,outpatient,1,UN,5.37,3.759,AETNA [1000108],AETNA [100010801],,,76.8,,4.12,0.222255,85118.57664,percent of total billed charges,,,
CYCLOPENTOLATE HCL 2 % OP SOLN,RX-9700,CDM,S5000,HCPCS,259,RC,00065-0397-02,NDC,outpatient,2,ML,180.67,126.469,AETNA [1000108],AETNA [100010801],,,76.8,,138.75,0.222255,85118.57664,percent of total billed charges,,,
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % OP SOLN,RX-9701,CDM,S5000,HCPCS,259,RC,00065-0359-02,NDC,outpatient,2,ML,144.23,100.961,AETNA [1000108],AETNA [100010801],,,76.8,,110.77,0.222255,85118.57664,percent of total billed charges,,,
CYCLOSPORINE 100 MG ORAL CAPS,RX-9706,CDM,S5000,HCPCS,259,RC,00078-0241-61,NDC,outpatient,1,UN,74.28,51.996,AETNA [1000108],AETNA [100010801],,,76.8,,57.05,0.222255,85118.57664,percent of total billed charges,,,
CYCLOSPORINE 100 MG ORAL CAPS,RX-9706,CDM,S5000,HCPCS,259,RC,60505-0134-00,NDC,outpatient,1,UN,46.97,32.879,AETNA [1000108],AETNA [100010801],,,76.8,,36.07,0.222255,85118.57664,percent of total billed charges,,,
CYCLOSPORINE 100 MG ORAL CAPS,RX-9706,CDM,S5000,HCPCS,259,RC,00078-0241-15,NDC,outpatient,1,UN,74.28,51.996,AETNA [1000108],AETNA [100010801],,,76.8,,57.05,0.222255,85118.57664,percent of total billed charges,,,
CYCLOSPORINE 25 MG ORAL CAPS,RX-9707,CDM,S5000,HCPCS,259,RC,00078-0240-15,NDC,outpatient,1,UN,18.61,13.027,AETNA [1000108],AETNA [100010801],,,76.8,,14.29,0.222255,85118.57664,percent of total billed charges,,,
CYCLOSPORINE 25 MG ORAL CAPS,RX-9707,CDM,S5000,HCPCS,259,RC,00078-0240-61,NDC,outpatient,1,UN,18.61,13.027,AETNA [1000108],AETNA [100010801],,,76.8,,14.29,0.222255,85118.57664,percent of total billed charges,,,
CYCLOSPORINE 25 MG ORAL CAPS,RX-9707,CDM,S5000,HCPCS,259,RC,68084-0879-25,NDC,outpatient,1,UN,18.44,12.908,AETNA [1000108],AETNA [100010801],,,76.8,,14.16,0.222255,85118.57664,percent of total billed charges,,,
CYCLOSPORINE 25 MG ORAL CAPS,RX-9707,CDM,S5000,HCPCS,259,RC,68084-0879-95,NDC,outpatient,1,UN,18.44,12.908,AETNA [1000108],AETNA [100010801],,,76.8,,14.16,0.222255,85118.57664,percent of total billed charges,,,
DANTROLENE SODIUM 20 MG IV SOLR,RX-9716,CDM,S5000,HCPCS,250,RC,42023-0123-06,NDC,outpatient,1,UN,288.51,201.957,AETNA [1000108],AETNA [100010801],,,76.8,,221.58,0.222255,85118.57664,percent of total billed charges,,,
DANTROLENE SODIUM 25 MG ORAL CAPS,RX-9718,CDM,S5000,HCPCS,259,RC,00115-4411-01,NDC,outpatient,1,UN,2.65,1.855,AETNA [1000108],AETNA [100010801],,,76.8,,2.04,0.222255,85118.57664,percent of total billed charges,,,
DANTROLENE SODIUM 25 MG ORAL CAPS,RX-9718,CDM,S5000,HCPCS,259,RC,00904-7211-04,NDC,outpatient,1,UN,4.53,3.171,AETNA [1000108],AETNA [100010801],,,76.8,,3.48,0.222255,85118.57664,percent of total billed charges,,,
SUMATRIPTAN SUCCINATE 6 MG/0.5ML SC SOLN,RX-97343,CDM,S5000,HCPCS,250,RC,55150-0173-01,NDC,outpatient,0.5,ML,17.69,12.383,AETNA [1000108],AETNA [100010801],,,76.8,,13.59,0.222255,85118.57664,percent of total billed charges,,,
SUMATRIPTAN SUCCINATE 6 MG/0.5ML SC SOLN,RX-97343,CDM,S5000,HCPCS,250,RC,63323-0273-01,NDC,outpatient,0.5,ML,24.66,17.262,AETNA [1000108],AETNA [100010801],,,76.8,,18.94,0.222255,85118.57664,percent of total billed charges,,,
PROMETHAZINE HCL 6.25 MG/5ML ORAL SOLN,RX-97609,CDM,S5000,HCPCS,259,RC,99999-0002-38,NDC,outpatient,10,ML,1.5,1.05,AETNA [1000108],AETNA [100010801],,,76.8,,1.15,0.222255,85118.57664,percent of total billed charges,,,
PROMETHAZINE HCL 6.25 MG/5ML ORAL SOLN,RX-97609,CDM,S5000,HCPCS,259,RC,60432-0608-16,NDC,outpatient,10,ML,3.48,2.436,AETNA [1000108],AETNA [100010801],,,76.8,,2.67,0.222255,85118.57664,percent of total billed charges,,,
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,00121-1276-00,NDC,outpatient,10,ML,7.53,5.271,AETNA [1000108],AETNA [100010801],,,76.8,,5.78,0.222255,85118.57664,percent of total billed charges,,,
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,99999-0001-87,NDC,outpatient,10,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,00904-7135-72,NDC,outpatient,10,ML,6.5,4.55,AETNA [1000108],AETNA [100010801],,,76.8,,4.99,0.222255,85118.57664,percent of total billed charges,,,
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,61787-0513-10,NDC,outpatient,10,ML,1.7,1.19,AETNA [1000108],AETNA [100010801],,,76.8,,1.31,0.222255,85118.57664,percent of total billed charges,,,
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,00121-1276-10,NDC,outpatient,10,ML,7.53,5.271,AETNA [1000108],AETNA [100010801],,,76.8,,5.78,0.222255,85118.57664,percent of total billed charges,,,
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,49348-0861-10,NDC,outpatient,10,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,49348-0861-34,NDC,outpatient,118,ML,8.93,6.251,AETNA [1000108],AETNA [100010801],,,76.8,,6.86,0.222255,85118.57664,percent of total billed charges,,,
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,61787-0513-04,NDC,outpatient,118,ML,17.33,12.131,AETNA [1000108],AETNA [100010801],,,76.8,,13.31,0.222255,85118.57664,percent of total billed charges,,,
TOLVAPTAN 15 MG ORAL TABS,RX-97893,CDM,S5000,HCPCS,259,RC,59148-0020-50,NDC,outpatient,1,UN,1428.57,999.999,AETNA [1000108],AETNA [100010801],,,76.8,,1097.14,0.222255,85118.57664,percent of total billed charges,,,
PANCRELIPASE (LIP-PROT-AMYL) 6000-19000 UNITS ORAL CPEP,RX-98034,CDM,S5000,HCPCS,259,RC,00032-0046-70,NDC,outpatient,1,UN,8.55,5.985,AETNA [1000108],AETNA [100010801],,,76.8,,6.57,0.222255,85118.57664,percent of total billed charges,,,
PANCRELIPASE (LIP-PROT-AMYL) 24000-76000 UNITS ORAL CPEP,RX-98036,CDM,S5000,HCPCS,259,RC,00032-1224-01,NDC,outpatient,1,UN,33.86,23.702,AETNA [1000108],AETNA [100010801],,,76.8,,26,0.222255,85118.57664,percent of total billed charges,,,
PANCRELIPASE (LIP-PROT-AMYL) 24000-76000 UNITS ORAL CPEP,RX-98036,CDM,S5000,HCPCS,259,RC,00032-2636-01,NDC,outpatient,1,UN,33.86,23.702,AETNA [1000108],AETNA [100010801],,,76.8,,26,0.222255,85118.57664,percent of total billed charges,,,
DEXTROSE-SODIUM CHLORIDE 10-0.45 % IV SOLN,RX-9809,CDM,S5000,HCPCS,250,RC,00264-7622-00,NDC,outpatient,1000,ML,51.6,36.12,AETNA [1000108],AETNA [100010801],,,76.8,,39.63,0.222255,85118.57664,percent of total billed charges,,,
DEXTROSE-SODIUM CHLORIDE 5-0.2 % IV SOLN,RX-9812,CDM,S5000,HCPCS,250,RC,00338-0077-04,NDC,outpatient,1000,ML,26.28,18.396,AETNA [1000108],AETNA [100010801],,,76.8,,20.18,0.222255,85118.57664,percent of total billed charges,,,
DEXTROSE-SODIUM CHLORIDE 5-0.33 % IV SOLN,RX-9813,CDM,S5000,HCPCS,250,RC,00264-7614-10,NDC,outpatient,500,ML,40.48,28.336,AETNA [1000108],AETNA [100010801],,,76.8,,31.09,0.222255,85118.57664,percent of total billed charges,,,
DEXTROSE-SODIUM CHLORIDE 5-0.45 % IV SOLN,RX-9814,CDM,S5000,HCPCS,250,RC,00338-0085-03,NDC,outpatient,500,ML,23.71,16.597,AETNA [1000108],AETNA [100010801],,,76.8,,18.21,0.222255,85118.57664,percent of total billed charges,,,
DEXTROSE-SODIUM CHLORIDE 5-0.45 % IV SOLN,RX-9814,CDM,S5000,HCPCS,250,RC,00338-0085-04,NDC,outpatient,1000,ML,26.28,18.396,AETNA [1000108],AETNA [100010801],,,76.8,,20.18,0.222255,85118.57664,percent of total billed charges,,,
DRONEDARONE HCL 400 MG ORAL TABS,RX-98329,CDM,S5000,HCPCS,259,RC,00024-4142-60,NDC,outpatient,1,UN,53.6,37.52,AETNA [1000108],AETNA [100010801],,,76.8,,41.16,0.222255,85118.57664,percent of total billed charges,,,
PRASUGREL HCL 5 MG ORAL TABS,RX-98372,CDM,S5000,HCPCS,259,RC,60505-4642-03,NDC,outpatient,1,UN,1.06,0.742,AETNA [1000108],AETNA [100010801],,,76.8,,0.81,0.222255,85118.57664,percent of total billed charges,,,
PRASUGREL HCL 10 MG ORAL TABS,RX-98373,CDM,S5000,HCPCS,259,RC,65162-0002-03,NDC,outpatient,1,UN,2.9,2.03,AETNA [1000108],AETNA [100010801],,,76.8,,2.23,0.222255,85118.57664,percent of total billed charges,,,
PRASUGREL HCL 10 MG ORAL TABS,RX-98373,CDM,S5000,HCPCS,259,RC,00378-5186-93,NDC,outpatient,1,UN,4.12,2.884,AETNA [1000108],AETNA [100010801],,,76.8,,3.16,0.222255,85118.57664,percent of total billed charges,,,
PRASUGREL HCL 10 MG ORAL TABS,RX-98373,CDM,S5000,HCPCS,259,RC,65862-0830-30,NDC,outpatient,1,UN,1,0.7,AETNA [1000108],AETNA [100010801],,,76.8,,0.77,0.222255,85118.57664,percent of total billed charges,,,
BENZOIN COMPOUND EX TINC,RX-987,CDM,S5000,HCPCS,259,RC,00395-0243-92,NDC,outpatient,1,ML,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
DINOPROSTONE 0.5 MG/3GM VA GEL,RX-9874,CDM,S5000,HCPCS,259,RC,00009-3359-01,NDC,outpatient,3,GR,1932.45,1352.715,AETNA [1000108],AETNA [100010801],,,76.8,,1484.12,0.222255,85118.57664,percent of total billed charges,,,
BENZONATATE 100 MG ORAL CAPS,RX-988,CDM,S5000,HCPCS,259,RC,00904-7153-61,NDC,outpatient,1,UN,1.32,0.924,AETNA [1000108],AETNA [100010801],,,76.8,,1.01,0.222255,85118.57664,percent of total billed charges,,,
BENZONATATE 100 MG ORAL CAPS,RX-988,CDM,S5000,HCPCS,259,RC,42806-0714-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
BENZONATATE 100 MG ORAL CAPS,RX-988,CDM,S5000,HCPCS,259,RC,64380-0712-06,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
BENZONATATE 100 MG ORAL CAPS,RX-988,CDM,S5000,HCPCS,259,RC,69452-0143-20,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
DOXAZOSIN MESYLATE 1 MG ORAL TABS,RX-9894,CDM,S5000,HCPCS,259,RC,68084-0836-25,NDC,outpatient,1,UN,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,,,
DOXAZOSIN MESYLATE 1 MG ORAL TABS,RX-9894,CDM,S5000,HCPCS,259,RC,00904-5522-61,NDC,outpatient,1,UN,2.36,1.652,AETNA [1000108],AETNA [100010801],,,76.8,,1.81,0.222255,85118.57664,percent of total billed charges,,,
DOXAZOSIN MESYLATE 1 MG ORAL TABS,RX-9894,CDM,S5000,HCPCS,259,RC,68084-0836-95,NDC,outpatient,1,UN,3.32,2.324,AETNA [1000108],AETNA [100010801],,,76.8,,2.55,0.222255,85118.57664,percent of total billed charges,,,
DOXAZOSIN MESYLATE 4 MG ORAL TABS,RX-9896,CDM,S5000,HCPCS,259,RC,16729-0213-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
DOXAZOSIN MESYLATE 4 MG ORAL TABS,RX-9896,CDM,S5000,HCPCS,259,RC,60505-0095-00,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
DOXAZOSIN MESYLATE 4 MG ORAL TABS,RX-9896,CDM,S5000,HCPCS,259,RC,00904-5524-61,NDC,outpatient,1,UN,2.28,1.596,AETNA [1000108],AETNA [100010801],,,76.8,,1.75,0.222255,85118.57664,percent of total billed charges,,,
DOXYCYCLINE MONOHYDRATE 25 MG/5ML ORAL SUSR,RX-9902,CDM,S5000,HCPCS,259,RC,68180-0657-01,NDC,outpatient,20,ML,27.06,18.942,AETNA [1000108],AETNA [100010801],,,76.8,,20.78,0.222255,85118.57664,percent of total billed charges,,,
DOXYCYCLINE MONOHYDRATE 25 MG/5ML ORAL SUSR,RX-9902,CDM,S5000,HCPCS,259,RC,99999-0002-89,NDC,outpatient,20,ML,27.06,18.942,AETNA [1000108],AETNA [100010801],,,76.8,,20.78,0.222255,85118.57664,percent of total billed charges,,,
ECONAZOLE NITRATE 1 % EX CREA,RX-9915,CDM,S5000,HCPCS,259,RC,51672-1303-01,NDC,outpatient,15,GR,32.65,22.855,AETNA [1000108],AETNA [100010801],,,76.8,,25.08,0.222255,85118.57664,percent of total billed charges,,,
ENALAPRIL MALEATE 10 MG ORAL TABS,RX-9924,CDM,S5000,HCPCS,259,RC,23155-0772-01,NDC,outpatient,1,UN,1.15,0.805,AETNA [1000108],AETNA [100010801],,,76.8,,0.88,0.222255,85118.57664,percent of total billed charges,,,
ENALAPRIL MALEATE 10 MG ORAL TABS,RX-9924,CDM,S5000,HCPCS,259,RC,43547-0547-10,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ENALAPRIL MALEATE 2.5 MG ORAL TABS,RX-9925,CDM,S5000,HCPCS,259,RC,16714-0442-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ENALAPRILAT 1.25 MG/ML IV INJ,RX-9929,CDM,S5000,HCPCS,250,RC,00143-9786-01,NDC,outpatient,2,ML,34.39,24.073,AETNA [1000108],AETNA [100010801],,,76.8,,26.41,0.222255,85118.57664,percent of total billed charges,,,
ENALAPRILAT 1.25 MG/ML IV INJ,RX-9929,CDM,S5000,HCPCS,250,RC,00143-9786-10,NDC,outpatient,2,ML,34.39,24.073,AETNA [1000108],AETNA [100010801],,,76.8,,26.41,0.222255,85118.57664,percent of total billed charges,,,
OPIUM 10 MG/ML (1%) ORAL TINC,RX-99405,CDM,S5000,HCPCS,259,RC,99999-0002-24,NDC,outpatient,0.6,ML,13.98,9.786,AETNA [1000108],AETNA [100010801],,,76.8,,10.74,0.222255,85118.57664,percent of total billed charges,,,
OPIUM 10 MG/ML (1%) ORAL TINC,RX-99405,CDM,S5000,HCPCS,259,RC,42799-0217-01,NDC,outpatient,0.6,ML,13.98,9.786,AETNA [1000108],AETNA [100010801],,,76.8,,10.74,0.222255,85118.57664,percent of total billed charges,,,
GLYCERIN (LAXATIVE) 1 G RE SUPP,RX-99417,CDM,S5000,HCPCS,259,RC,58980-0409-12,NDC,outpatient,1,UN,2.17,1.519,AETNA [1000108],AETNA [100010801],,,76.8,,1.67,0.222255,85118.57664,percent of total billed charges,,,
LEVONORGESTREL 1.5 MG ORAL TABS,RX-99445,CDM,S5000,HCPCS,259,RC,69536-0162-88,NDC,outpatient,1,UN,133.64,93.548,AETNA [1000108],AETNA [100010801],,,76.8,,102.64,0.222255,85118.57664,percent of total billed charges,,,
LEVONORGESTREL 1.5 MG ORAL TABS,RX-99445,CDM,S5000,HCPCS,259,RC,69536-0146-19,NDC,outpatient,1,UN,133.73,93.611,AETNA [1000108],AETNA [100010801],,,76.8,,102.7,0.222255,85118.57664,percent of total billed charges,,,
ESTROGENS CONJUGATED 0.3 MG ORAL TABS,RX-9973,CDM,S5000,HCPCS,259,RC,00046-1100-81,NDC,outpatient,1,UN,28.4,19.88,AETNA [1000108],AETNA [100010801],,,76.8,,21.81,0.222255,85118.57664,percent of total billed charges,,,
ETHACRYNATE SODIUM 50 MG IV SOLR,RX-9979,CDM,S5000,HCPCS,250,RC,42023-0157-01,NDC,outpatient,1,UN,1563.3,1094.31,AETNA [1000108],AETNA [100010801],,,76.8,,1200.61,0.222255,85118.57664,percent of total billed charges,,,
ETHACRYNATE SODIUM 50 MG IV SOLR,RX-9979,CDM,S5000,HCPCS,250,RC,67457-0297-50,NDC,outpatient,1,UN,2098.98,1469.286,AETNA [1000108],AETNA [100010801],,,76.8,,1612.02,0.222255,85118.57664,percent of total billed charges,,,
BENZTROPINE MESYLATE 0.5 MG ORAL TABS,RX-998,CDM,S5000,HCPCS,259,RC,68084-0381-01,NDC,outpatient,1,UN,1.82,1.274,AETNA [1000108],AETNA [100010801],,,76.8,,1.4,0.222255,85118.57664,percent of total billed charges,,,
BENZTROPINE MESYLATE 0.5 MG ORAL TABS,RX-998,CDM,S5000,HCPCS,259,RC,68084-0381-11,NDC,outpatient,1,UN,1.82,1.274,AETNA [1000108],AETNA [100010801],,,76.8,,1.4,0.222255,85118.57664,percent of total billed charges,,,
ETHACRYNIC ACID 25 MG ORAL TABS,RX-9980,CDM,S5000,HCPCS,259,RC,69238-1126-01,NDC,outpatient,1,UN,8.7,6.09,AETNA [1000108],AETNA [100010801],,,76.8,,6.68,0.222255,85118.57664,percent of total billed charges,,,
ETHAMBUTOL HCL 400 MG ORAL TABS,RX-9983,CDM,S5000,HCPCS,259,RC,68850-0012-02,NDC,outpatient,1,UN,3.21,2.247,AETNA [1000108],AETNA [100010801],,,76.8,,2.47,0.222255,85118.57664,percent of total billed charges,,,
GUANFACINE HCL ER 1 MG ORAL TB24,RX-99835,CDM,S5000,HCPCS,259,RC,60505-3927-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
GUANFACINE HCL ER 1 MG ORAL TB24,RX-99835,CDM,S5000,HCPCS,259,RC,24979-0533-01,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
GUANFACINE HCL ER 2 MG ORAL TB24,RX-99836,CDM,S5000,HCPCS,259,RC,62332-0746-31,NDC,outpatient,1,UN,0.99,0.693,AETNA [1000108],AETNA [100010801],,,76.8,,0.76,0.222255,85118.57664,percent of total billed charges,,,
ETHOSUXIMIDE 250 MG ORAL CAPS,RX-9989,CDM,S5000,HCPCS,259,RC,23155-0532-01,NDC,outpatient,1,UN,5.34,3.738,AETNA [1000108],AETNA [100010801],,,76.8,,4.1,0.222255,85118.57664,percent of total billed charges,,,
ETHOSUXIMIDE 250 MG ORAL CAPS,RX-9989,CDM,S5000,HCPCS,259,RC,64380-0878-06,NDC,outpatient,1,UN,1.63,1.141,AETNA [1000108],AETNA [100010801],,,76.8,,1.25,0.222255,85118.57664,percent of total billed charges,,,
BENZTROPINE MESYLATE 1 MG ORAL TABS,RX-999,CDM,S5000,HCPCS,259,RC,68084-0388-01,NDC,outpatient,1,UN,1.62,1.134,AETNA [1000108],AETNA [100010801],,,76.8,,1.24,0.222255,85118.57664,percent of total billed charges,,,
BENZTROPINE MESYLATE 1 MG ORAL TABS,RX-999,CDM,S5000,HCPCS,259,RC,68084-0388-11,NDC,outpatient,1,UN,1.62,1.134,AETNA [1000108],AETNA [100010801],,,76.8,,1.24,0.222255,85118.57664,percent of total billed charges,,,
ETODOLAC 200 MG ORAL CAPS,RX-9997,CDM,S5000,HCPCS,259,RC,62559-0250-01,NDC,outpatient,1,UN,1.72,1.204,AETNA [1000108],AETNA [100010801],,,76.8,,1.32,0.222255,85118.57664,percent of total billed charges,,,
ETODOLAC 200 MG ORAL CAPS,RX-9997,CDM,S5000,HCPCS,259,RC,60505-0039-01,NDC,outpatient,1,UN,1.83,1.281,AETNA [1000108],AETNA [100010801],,,76.8,,1.41,0.222255,85118.57664,percent of total billed charges,,,
ETODOLAC 300 MG ORAL CAPS,RX-9998,CDM,S5000,HCPCS,259,RC,62559-0251-01,NDC,outpatient,1,UN,2.43,1.701,AETNA [1000108],AETNA [100010801],,,76.8,,1.87,0.222255,85118.57664,percent of total billed charges,,,
HC Crisis Intervention Mental Health Services- per Diem,PX-90000001,CDM,S9485,HCPCS,900,RC,,,outpatient,,,1627,1138.9,AETNA [1000108],AETNA [100010801],,,76.8,,1249.54,365.2615,1249.536,percent of total billed charges,,,
HC Full Trauma No Notification,PX-45000633,CDM,TR450,LOCAL,450,RC,,,outpatient,,,10370,7259,AETNA [1000108],AETNA [100010801],,,76.8,,7964.16,399.86,9291.52,percent of total billed charges,,,
HC Partial Trauma No Notification,PX-45000634,CDM,TR450,LOCAL,450,RC,,,outpatient,,,7029,4920.3,AETNA [1000108],AETNA [100010801],,,76.8,,5398.27,399.86,9291.52,percent of total billed charges,,,
IOL 16D 5.5X12.5MM PMMA AC CNVXPLN ACRYSOF MTA3U0 -,SUP-MTA3U0.160,CDM,V2630,HCPCS,276,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,129.686915,921.62304,percent of total billed charges,,,
IOL 9.5D 5.5MMX12.5MM AC CNVXPLN -,SUP-MTA3UO.095,CDM,V2630,HCPCS,276,RC,,,outpatient,,,577.67,404.369,AETNA [1000108],AETNA [100010801],,,76.8,,443.65,129.686915,921.62304,percent of total billed charges,,,
IOL 10.5D 5.5MMX12.5MM AC CNVXPLN -,SUP-MTA3UO.105,CDM,V2630,HCPCS,276,RC,,,outpatient,,,577.67,404.369,AETNA [1000108],AETNA [100010801],,,76.8,,443.65,129.686915,921.62304,percent of total billed charges,,,
IOL 20D 5.5MMX12.5MM AC CNVXPLN -,SUP-MTA3UO.200,CDM,V2630,HCPCS,276,RC,,,outpatient,,,1200.03,840.021,AETNA [1000108],AETNA [100010801],,,76.8,,921.62,129.686915,921.62304,percent of total billed charges,,,
IOL 22D 5.5X13MM AC CNVXPLN -,SUP-MTA4UO.220,CDM,V2630,HCPCS,276,RC,,,outpatient,,,1200.03,840.021,AETNA [1000108],AETNA [100010801],,,76.8,,921.62,129.686915,921.62304,percent of total billed charges,,,
IOL 12.5D 5.5MMX13.5MM AC CNVXPLN -,SUP-MTA5U0.125,CDM,V2630,HCPCS,276,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,129.686915,921.62304,percent of total billed charges,,,
IOL 10.5D X 13.5OP AC CNVXPLN -,SUP-MTA5UO.105,CDM,V2630,HCPCS,276,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,129.686915,921.62304,percent of total billed charges,,,
IOL 8.5D PC -,SUP-AR40MN085,CDM,V2632,HCPCS,276,RC,,,outpatient,,,1021.13,714.791,AETNA [1000108],AETNA [100010801],,,76.8,,784.23,137.54666,3281.45664,percent of total billed charges,,,
IOL 23D 6X13MM CLARIFLEX CLRFLXC 3PC PC BICNVX SIL BLU COR -,SUP-CLRFLXC.230,CDM,V2632,HCPCS,276,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,76.8,,470.54,137.54666,3281.45664,percent of total billed charges,,,
IOL 26.5D CLARIFLEX PC -,SUP-CLRFLXC.265,CDM,V2632,HCPCS,276,RC,,,outpatient,,,612.68,428.876,AETNA [1000108],AETNA [100010801],,,76.8,,470.54,137.54666,3281.45664,percent of total billed charges,,,
IOL 16.5D 6X13MM ACRYSF MA60AC 3PC PC BICNVX BLU ACRYLT -,SUP-MA60AC.165,CDM,V2632,HCPCS,276,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,137.54666,3281.45664,percent of total billed charges,,,
IOL +1D 6X13MM ACRYSF MA60MA MULPC PC MNSCS BLU ACRYLT -,SUP-MA60MA.010,CDM,V2632,HCPCS,276,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,137.54666,3281.45664,percent of total billed charges,,,
IOL 3D 6X13MM ACRYSF MA60MA MULPC PC MNSCS BLU ACRYLT -,SUP-MA60MA.030,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,,,
IOL -4D 6X13MM ACRYSF XPD SRS MULPC PC BICNVX BLU ACRYLT -,SUP-MA60MA-4.0,CDM,V2632,HCPCS,276,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,137.54666,3281.45664,percent of total billed charges,,,
LENS I/O X.010 NEGATIVE D -,SUP-MA60MAN010,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,,,
IOL 4D 6X13MM ACRYSF XPD SRS MULPC PC BICNVX BLU ACRYLT -,SUP-MA60MAN040,CDM,V2632,HCPCS,276,RC,,,outpatient,,,729.38,510.566,AETNA [1000108],AETNA [100010801],,,76.8,,560.16,137.54666,3281.45664,percent of total billed charges,,,
LENS I/O MN60AC X 8.0 -,SUP-MN60AC.080,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,,,
IOL 28D 6X13MM ACRYSF MN60AC MULPC PC BICNVX NAT YEL ACRYLT -,SUP-MN60AC.280,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,,,
IOL 2.0 DIA 6X13MM ACRYSF XPD SRS MULPC PC MNSCS NAT -,SUP-MN60MA.020,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,,,
IOL 3D 6X13MM ACRYSF XPD SRS MULPC PC MNSCS NAT -,SUP-MN60MA.030,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,,,
LENS IOL 5.0D MN60MA 6X13MM ACRYSF MULPC PC MNSCS BLU ACRYLT -,SUP-MN60MA.050,CDM,V2632,HCPCS,276,RC,,,outpatient,,,875.25,612.675,AETNA [1000108],AETNA [100010801],,,76.8,,672.19,137.54666,3281.45664,percent of total billed charges,,,
IOL 9D 6X13MM ACRYSF SA60AT 1-PC PC BICNVX CLR ACRYLT -,SUP-SA60AT.090,CDM,V2632,HCPCS,276,RC,,,outpatient,,,781.89,547.323,AETNA [1000108],AETNA [100010801],,,76.8,,600.49,137.54666,3281.45664,percent of total billed charges,,,
IOL 30D 6X13MM ACRYSF 1-PC PC BICNVX NAT ANT ASYM -,SUP-SN60AT.300,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,,,
IOL 31D 6X13MM 31  ACRYSF SA60AT 1-PC PC BICNVX CLR ACRYLT -,SUP-SN60AT.310,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,,,
IOL 34D 6X13MM ACRYSF SA60AT 1-PC PC BICNVX CLR ACRYLT -,SUP-SN60AT.340,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,,,
IOL 6.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.065,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,,,
IOL 7D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.070,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,,,
IOL 9D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.090,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,,,
IOL 9.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.095,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,,,
IOL 10D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.100,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,,,
IOL 10.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.105,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,,,
IOL 11D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.110,CDM,V2632,HCPCS,276,RC,,,outpatient,,,781.89,547.323,AETNA [1000108],AETNA [100010801],,,76.8,,600.49,137.54666,3281.45664,percent of total billed charges,,,
IOL 11.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.115,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,,,
IOL 12D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.120,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,,,
IOL 13D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.130,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,,,
IOL 13.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.135,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,,,
IOL 14D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.140,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,,,
IOL 14.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.145,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,,,
IOL 16D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.160,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,,,
IOL 16.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.165,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,,,
IOL 17D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.170,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,,,
IOL 17.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.175,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,,,
IOL 18D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.180,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,,,
IOL 19D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.190,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,,,
IOL 20D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.200,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,,,
IOL 21D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.210,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,,,
IOL 21.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.215,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,,,
IOL 22D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.220,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,,,
IOL 22.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.225,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,,,
IOL 23D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.230,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,,,
IOL 24D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.240,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,,,
IOL 24.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.245,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,,,
IOL 25D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.250,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,,,
IOL 26D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.260,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,,,
IOL 26.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.265,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,,,
IOL 19D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.190,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,AETNA [1000108],AETNA [100010801],,,76.8,,3281.46,137.54666,3281.45664,percent of total billed charges,,,
IOL 20D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.200,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,AETNA [1000108],AETNA [100010801],,,76.8,,3281.46,137.54666,3281.45664,percent of total billed charges,,,
IOL 20.5D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.205,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,AETNA [1000108],AETNA [100010801],,,76.8,,3281.46,137.54666,3281.45664,percent of total billed charges,,,
IOL 21D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.210,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,AETNA [1000108],AETNA [100010801],,,76.8,,3281.46,137.54666,3281.45664,percent of total billed charges,,,
IOL 21.5D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.215,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,AETNA [1000108],AETNA [100010801],,,76.8,,3281.46,137.54666,3281.45664,percent of total billed charges,,,
LENS I/O MA60MA x 1.0 -,SUP-UNDEFINED,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA [1000108],AETNA [100010801],,,76.8,,667.71,137.54666,3281.45664,percent of total billed charges,,,
IOL 24.5D 6X13MM TECNIS ZA9003 3PC PC BICNVX HYDRPHB ACRL -,SUP-ZA9003.245,CDM,V2632,HCPCS,276,RC,,,outpatient,,,816.9,571.83,AETNA [1000108],AETNA [100010801],,,76.8,,627.38,137.54666,3281.45664,percent of total billed charges,,,
LENS ACRYSOF TORIC IQ  SN6AT3 X 9.5D -,SUP-SN6AT3.095,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,,,
IOL TORIC LENS  SN6AT3  12.0 -,SUP-SN6AT3.120,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,,,
IOL 15.5D 6X13MM ACRYSF SN6AT3 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT3.155,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,,,
IOL 16.0D  6X13MM ACRYSF  SN6AT3 -,SUP-SN6AT3.160,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,,,
IOL 17.0D  6X13MM ACRYSF  SN6AT3 -,SUP-SN6AT3.170,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,,,
IOL 18.0 D 6X13MM ACRYSF SN6AT3 -,SUP-SN6AT3.180,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,,,
IOL 19.5D 6X13MM ACRYSF SN6AT3 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT3.195,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,,,
IOL 24D 6X13MM ACRYSF  SN6 -,SUP-SN6AT3.240,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,,,
IOL 13.5D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.135,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,,,
IOL 19D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.190,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,,,
IOL 19.5D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.195,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,,,
IOL 21D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.210,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,,,
IOL 16D 6X13MM ACRYSF SN6AT5 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT5.160,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,,,
LENS ACRYSOF IQ  SN6AT5.180 -,SUP-SN6AT5.180,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,,,
IOL 21D 6X13MM ACRYSF SN6AT5 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT5.210,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,,,
IOL 23D 6X13MM ACRYSF SN6AT5 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT5.230,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,,,
IOL 11D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT6.110,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,,,
IOL 13.5D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT -,SUP-SN6AT6.135,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,,,
IOL 14D 6X13MM  ACRYSF  SN6AT6 -,SUP-SN6AT6.140,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,,,
IOL LENS SN6AT6 X 18.0 D -,SUP-SN6AT6.180,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,,,
IOL 20D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT6.200,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,,,
IOL 20.5D 6X13MM ACRYSF SN6AT6 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT6.205,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2093.7,1465.59,AETNA [1000108],AETNA [100010801],,,76.8,,1607.96,399.86,2223.8905,percent of total billed charges,,,
IOL TORIC LENS 23.5 DIOPTER -,SUP-SN6AT6.235,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,,,
IOL 22D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT6U220,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,,,
IOL 20D 6X13MM  ACRYSF -,SUP-SN6AT7.200,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,,,
IOL 23.5D  6X13MM  ACRYSF   SN6AT7 -,SUP-SN6AT7.235,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA [1000108],AETNA [100010801],,,76.8,,2015.04,399.86,2223.8905,percent of total billed charges,,,
AMNIOGRAFT AMNIO MEMBR HUM TIS FRZN 3.5X3.5CM SZ-C -,SUP-AG-3535,CDM,V2790,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,AETNA [1000108],AETNA [100010801],,,76.8,,3281.46,399.86,3992.7552,percent of total billed charges,,,
GRAFT HUM TIS 3.5X3.5CM SZ-C AMNIOGRFT AMNIO MEMBR 50-100U -,SUP-AG-3535F,CDM,V2790,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,AETNA [1000108],AETNA [100010801],,,76.8,,3992.76,399.86,3992.7552,percent of total billed charges,,,
Bilateral procedure,,,,,,,,,,,,,,AETNA [1000108],AETNA [100010801],50,,150,,,,,,150% payment adjustment for the item or service to which the modifier is appended.,,
HC Semi-Private Unit,PX-12100001,CDM,12100001,LOCAL,121,RC,,,inpatient,,,1577,1103.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,525.9295,1261.6,,,,
HC Med/Surg Stepdown,PX-12100003,CDM,12100003,LOCAL,121,RC,,,inpatient,,,2423,1696.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,808.0705,1938.4,,,,
HC Maternity Unit,PX-12200001,CDM,12200001,LOCAL,122,RC,,,inpatient,,,2193,1535.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,731.3655,1754.4,,,,
HC Pediatric Semi-Private Unit,PX-12300001,CDM,12300001,LOCAL,123,RC,,,inpatient,,,3323,2326.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1108.2205,2658.4,,,,
HC S.E. Rehab Semi-Private Unit,PX-12800001,CDM,12800001,LOCAL,128,RC,,,inpatient,,,1783,1248.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,594.6305,2483,,,,
HC Nursery,PX-17000001,CDM,17000001,LOCAL,170,RC,,,inpatient,,,1333,933.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,444.5555,1066.4,,,,
HC Nursery Boarder,PX-17900001,CDM,17900001,LOCAL,179,RC,,,inpatient,,,1195,836.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,398.5325,956,,,,
HC Icu/Ccu Unit,PX-20000001,CDM,20000001,LOCAL,200,RC,,,inpatient,,,4009,2806.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1337.0015,3207.2,,,,
HC Icu Surgical Unit,PX-20100001,CDM,20100001,LOCAL,201,RC,,,inpatient,,,3646,2552.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1215.941,2916.8,,,,
HC Telemetry Unit,PX-20600001,CDM,20600001,LOCAL,206,RC,,,inpatient,,,2015,1410.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,672.0025,1612,,,,
HC Trauma,PX-20800001,CDM,20800001,LOCAL,208,RC,,,inpatient,,,4810,3367,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1604.135,3848,,,,
HC Onc. Vad Kit,PX-27000020,CDM,27000020,LOCAL,270,RC,,,inpatient,,,90,63,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.205,72,,,,
HC Imed Pump for Lvl II,PX-27000021,CDM,27000021,LOCAL,270,RC,,,inpatient,,,118,82.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.491,94.4,,,,
HC Imed Pump,PX-27000022,CDM,27000022,LOCAL,270,RC,,,inpatient,,,113,79.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,25.3685,90.4,,,,
HC Local Anesth Supplies,PX-27000023,CDM,27000023,LOCAL,270,RC,,,inpatient,,,80,56,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,17.96,64,,,,
HC Periop O2,PX-27000044,CDM,27000044,LOCAL,270,RC,,,inpatient,,,79,55.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,17.7355,63.2,,,,
HC Bone Bx Kit,PX-27000050,CDM,27000050,LOCAL,270,RC,,,inpatient,,,267,186.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,59.9415,213.6,,,,
HC Kit Portex Nerve Block,PX-27000051,CDM,27000051,LOCAL,270,RC,,,inpatient,,,90,63,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.205,72,,,,
HC Cannister Vac W/O Gel Ats,PX-27000052,CDM,27000052,LOCAL,270,RC,,,inpatient,,,282,197.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,63.309,225.6,,,,
HC Dressing Kci Small 5/Cs,PX-27000053,CDM,27000053,LOCAL,270,RC,,,inpatient,,,268,187.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.166,214.4,,,,
HC Cannister W/Gel Ats,PX-27000054,CDM,27000054,LOCAL,270,RC,,,inpatient,,,283,198.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,63.5335,226.4,,,,
HC Compression Stocking A6530,PX-27000055,CDM,27000055,LOCAL,270,RC,,,inpatient,,,285,199.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,63.9825,228,,,,
HC Custom Molded Insert,PX-27000056,CDM,27000056,LOCAL,270,RC,,,inpatient,,,287,200.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,64.4315,229.6,,,,
HC Dressing Kci Medium 10/Cs,PX-27000057,CDM,27000057,LOCAL,270,RC,,,inpatient,,,307,214.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,68.9215,245.6,,,,
HC Surgical Boot/Shoe L3260,PX-27000058,CDM,27000058,LOCAL,270,RC,,,inpatient,,,423,296.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,94.9635,338.4,,,,
HC Vaccum Assisted Closure Pump,PX-27000059,CDM,27000059,LOCAL,270,RC,,,inpatient,,,438,306.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,98.331,350.4,,,,
HC Ortho Wedge Shoe,PX-27000060,CDM,27000060,LOCAL,270,RC,,,inpatient,,,529,370.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,118.7605,423.2,,,,
HC Foot Pressure Support A9283,PX-27000061,CDM,27000061,LOCAL,270,RC,,,inpatient,,,529,370.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,118.7605,423.2,,,,
HC Sensor Nicom,PX-27000062,CDM,27000062,LOCAL,270,RC,,,inpatient,,,816,571.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,183.192,652.8,,,,
HC 6 Channel Pneumogram,PX-27000063,CDM,27000063,LOCAL,270,RC,,,inpatient,,,3884,2718.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,871.958,3107.2,,,,
HC Pneumogram 4-Channel,PX-27000064,CDM,27000064,LOCAL,270,RC,,,inpatient,,,4891,3423.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1098.0295,3912.8,,,,
HC Pad Artic Gel Large,PX-27000065,CDM,27000065,LOCAL,270,RC,,,inpatient,,,5242,3669.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1176.829,4193.6,,,,
HC Pneumogram 6- Channel,PX-27000066,CDM,27000066,LOCAL,270,RC,,,inpatient,,,5466,3826.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1227.117,4372.8,,,,
HC Therapy Polar Cooler,PX-27000068,CDM,27000068,LOCAL,270,RC,,,inpatient,,,667,466.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,149.7415,533.6,,,,
HC Liner Foam Permanently Med,PX-27000069,CDM,27000069,LOCAL,270,RC,,,inpatient,,,353,247.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,79.2485,282.4,,,,
HC Dressing Kci Vac Small,PX-27000070,CDM,27000070,LOCAL,270,RC,,,inpatient,,,327,228.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,73.4115,261.6,,,,
HC Dressing Kci Vac Large,PX-27000071,CDM,27000071,LOCAL,270,RC,,,inpatient,,,390,273,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,87.555,312,,,,
HC Developmental Aides,PX-27000072,CDM,27000072,LOCAL,270,RC,,,inpatient,,,707,494.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,158.7215,565.6,,,,
"HC Ez Reacher 30"" Suction",PX-27100004,CDM,27100004,LOCAL,271,RC,,,inpatient,,,144,100.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,32.328,122.0544,,,,
HC Support Bra Ez-on Med 958,PX-27100005,CDM,27100005,LOCAL,271,RC,,,inpatient,,,262,183.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,58.819,222.0712,,,,
HC Support Bra Ez-on Lrg 958,PX-27100006,CDM,27100006,LOCAL,271,RC,,,inpatient,,,272,190.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,61.064,230.5472,,,,
HC Support Bra Ez-on X-Lrg 958,PX-27100007,CDM,27100007,LOCAL,271,RC,,,inpatient,,,306,214.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,68.697,259.3656,,,,
HC Support Bra Ez-on Queen,PX-27100008,CDM,27100008,LOCAL,271,RC,,,inpatient,,,377,263.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,84.6365,319.5452,,,,
HC Bra Ez-on Super Queen,PX-27100009,CDM,27100009,LOCAL,271,RC,,,inpatient,,,471,329.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,105.7395,399.2196,,,,
HC Gradient Com Stocking,PX-27100010,CDM,27100010,LOCAL,271,RC,,,inpatient,,,490,343,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,110.005,415.324,,,,
HC Kit Flexi Seal Fecal,PX-27100011,CDM,27100011,LOCAL,271,RC,,,inpatient,,,939,657.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,210.8055,795.8964,,,,
HC Port Power Loc Access Kit,PX-27200054,CDM,27200054,LOCAL,272,RC,,,inpatient,,,88,61.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.756,74.5888,,,,
HC Dressing Kci Vac White Lg,PX-27200055,CDM,27200055,LOCAL,272,RC,,,inpatient,,,95,66.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,21.3275,80.522,,,,
HC Sheath Brite Tip 11cm,PX-27200056,CDM,27200056,LOCAL,272,RC,,,inpatient,,,108,75.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,24.246,91.5408,,,,
HC Kit Refill Syncromed Sys. Pain,PX-27200057,CDM,27200057,LOCAL,272,RC,,,inpatient,,,128,89.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,28.736,108.4928,,,,
HC Sock Fracture,PX-27200058,CDM,27200058,LOCAL,272,RC,,,inpatient,,,193,135.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,43.3285,163.5868,,,,
HC Tube Gastrostomy Replacement,PX-27200059,CDM,27200059,LOCAL,272,RC,,,inpatient,,,195,136.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,43.7775,165.282,,,,
HC Mod of Depth Shoe,PX-27200060,CDM,27200060,LOCAL,272,RC,,,inpatient,,,225,157.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,50.5125,190.71,,,,
HC Catheter Broncho 39l,PX-27200061,CDM,27200061,LOCAL,272,RC,,,inpatient,,,349,244.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,78.3505,295.8124,,,,
HC Catheter Bronch 35 Left 95892,PX-27200062,CDM,27200062,LOCAL,272,RC,,,inpatient,,,349,244.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,78.3505,295.8124,,,,
HC Endo-Bronch Tube 37fr Left,PX-27200063,CDM,27200063,LOCAL,272,RC,,,inpatient,,,349,244.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,78.3505,295.8124,,,,
HC Tube Endo Bronch #35 Left,PX-27200064,CDM,27200064,LOCAL,272,RC,,,inpatient,,,349,244.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,78.3505,295.8124,,,,
HC Endo Bronch Tube #39,PX-27200065,CDM,27200065,LOCAL,272,RC,,,inpatient,,,349,244.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,78.3505,295.8124,,,,
HC Catheter Broncho 41l,PX-27200066,CDM,27200066,LOCAL,272,RC,,,inpatient,,,349,244.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,78.3505,295.8124,,,,
HC Kit Arterial Line Arrow,PX-27200067,CDM,27200067,LOCAL,272,RC,,,inpatient,,,349,244.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,78.3505,295.8124,,,,
HC Cassette Kci Veralink,PX-27200068,CDM,27200068,LOCAL,272,RC,,,inpatient,,,357,249.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.1465,302.5932,,,,
HC Shiley Trach Tube 6lpc,PX-27200069,CDM,27200069,LOCAL,272,RC,,,inpatient,,,357,249.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.1465,302.5932,,,,
HC Tube Trach Shiley 8lpc,PX-27200070,CDM,27200070,LOCAL,272,RC,,,inpatient,,,357,249.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.1465,302.5932,,,,
HC Catheter Single 4fr Bard,PX-27200071,CDM,27200071,LOCAL,272,RC,,,inpatient,,,374,261.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,83.963,317.0024,,,,
HC Bivona #7 Trach Uncuffed,PX-27200072,CDM,27200072,LOCAL,272,RC,,,inpatient,,,396,277.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,88.902,335.6496,,,,
HC Retractor C Section Large,PX-27200073,CDM,27200073,LOCAL,272,RC,,,inpatient,,,402,281.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,90.249,340.7352,,,,
HC Midline 4fr Bd#384308,PX-27200074,CDM,27200074,LOCAL,272,RC,,,inpatient,,,409,286.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,91.8205,346.6684,,,,
HC Transducer Triple W/Vamp Pls,PX-27200075,CDM,27200075,LOCAL,272,RC,,,inpatient,,,418,292.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,93.841,354.2968,,,,
HC B Pleurx Drainage Kit,PX-27200076,CDM,27200076,LOCAL,272,RC,,,inpatient,,,417,291.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,93.6165,353.4492,,,,
HC Catheter Swan Ganz J Pacing,PX-27200078,CDM,27200078,LOCAL,272,RC,,,inpatient,,,446,312.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,100.127,378.0296,,,,
HC Tube Trach Distal Xlt 5.0,PX-27200079,CDM,27200079,LOCAL,272,RC,,,inpatient,,,451,315.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,101.2495,382.2676,,,,
HC Tube Trach Distal Xlt 6.0,PX-27200080,CDM,27200080,LOCAL,272,RC,,,inpatient,,,466,326.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,104.617,394.9816,,,,
HC Tube Trach 8 Cuff Non X Long,PX-27200081,CDM,27200081,LOCAL,272,RC,,,inpatient,,,466,326.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,104.617,394.9816,,,,
HC Sling Sam Pelvic Medium,PX-27200082,CDM,27200082,LOCAL,272,RC,,,inpatient,,,470,329,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,105.515,398.372,,,,
HC Set Tube Kaci Veratrac Duo,PX-27200083,CDM,27200083,LOCAL,272,RC,,,inpatient,,,488,341.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,109.556,413.6288,,,,
HC Retractor C Section Xlarge,PX-27200084,CDM,27200084,LOCAL,272,RC,,,inpatient,,,516,361.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,115.842,437.3616,,,,
HC Kit Mini 4fr Single Lumen,PX-27200085,CDM,27200085,LOCAL,272,RC,,,inpatient,,,519,363.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,116.5155,439.9044,,,,
HC Trach Bivona Tis 6id,PX-27200086,CDM,27200086,LOCAL,272,RC,,,inpatient,,,523,366.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,117.4135,443.2948,,,,
HC Pack C Section Custom Disp,PX-27200087,CDM,27200087,LOCAL,272,RC,,,inpatient,,,541,378.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,121.4545,458.5516,,,,
HC Trach Bivona Tts 8mm,PX-27200088,CDM,27200088,LOCAL,272,RC,,,inpatient,,,541,378.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,121.4545,458.5516,,,,
HC Trach Bivona 7.5 X 10,PX-27200089,CDM,27200089,LOCAL,272,RC,,,inpatient,,,556,389.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,124.822,471.2656,,,,
HC Tube Feeding Mic Key 14f 1.7,PX-27200091,CDM,27200091,LOCAL,272,RC,,,inpatient,,,674,471.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,151.313,571.2824,,,,
HC Kit Mic-Key G Feeding 16-3.5,PX-27200092,CDM,27200092,LOCAL,272,RC,,,inpatient,,,694,485.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,155.803,588.2344,,,,
HC Kit Mic-Key G Feeding 24-3.5,PX-27200093,CDM,27200093,LOCAL,272,RC,,,inpatient,,,694,485.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,155.803,588.2344,,,,
HC Mic Key G Tube 20fr 3.5cm,PX-27200094,CDM,27200094,LOCAL,272,RC,,,inpatient,,,694,485.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,155.803,588.2344,,,,
HC Device Support Foot,PX-27200095,CDM,27200095,LOCAL,272,RC,,,inpatient,,,703,492.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,157.8235,595.8628,,,,
HC Catheter 4 Fr Mid Line,PX-27200096,CDM,27200096,LOCAL,272,RC,,,inpatient,,,719,503.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,161.4155,609.4244,,,,
HC Tcc Size 3,PX-27200097,CDM,27200097,LOCAL,272,RC,,,inpatient,,,722,505.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,162.089,611.9672,,,,
HC Femostop Gold Compress Sys,PX-27200098,CDM,27200098,LOCAL,272,RC,,,inpatient,,,731,511.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,164.1095,619.5956,,,,
HC Dot Poly Midline 4fr Sl Full,PX-27200099,CDM,27200099,LOCAL,272,RC,,,inpatient,,,765,535.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,171.7425,648.414,,,,
HC Powerwand 5fr 10cm,PX-27200100,CDM,27200100,LOCAL,272,RC,,,inpatient,,,776,543.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.212,657.7376,,,,
HC Powerwand Single Sterile 5fr,PX-27200101,CDM,27200101,LOCAL,272,RC,,,inpatient,,,776,543.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.212,657.7376,,,,
HC Needle Intraosseous Pd 15g,PX-27200102,CDM,27200102,LOCAL,272,RC,,,inpatient,,,845,591.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,189.7025,716.222,,,,
HC Needle Intraosseous Ad 15g,PX-27200103,CDM,27200103,LOCAL,272,RC,,,inpatient,,,845,591.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,189.7025,716.222,,,,
HC Needle Intraosseous,PX-27200104,CDM,27200104,LOCAL,272,RC,,,inpatient,,,845,591.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,189.7025,716.222,,,,
HC Kit Triple Lumen Cath 7 X 6,PX-27200105,CDM,27200105,LOCAL,272,RC,,,inpatient,,,895,626.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,200.9275,758.602,,,,
HC Multi Lumen Cvc Kit Toh Cust,PX-27200106,CDM,27200106,LOCAL,272,RC,,,inpatient,,,895,626.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,200.9275,758.602,,,,
HC Pad Zoll Aed Cprd Access Kit,PX-27200107,CDM,27200107,LOCAL,272,RC,,,inpatient,,,827,578.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,185.6615,700.9652,,,,
HC Kit Flexi Seal Fecal,PX-27200108,CDM,27200108,LOCAL,272,RC,,,inpatient,,,939,657.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,210.8055,795.8964,,,,
HC Powerwand Quick Kit 5fr,PX-27200109,CDM,27200109,LOCAL,272,RC,,,inpatient,,,979,685.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,219.7855,829.8004,,,,
HC Mahurkar Dual Lumen Subclav Ca,PX-27200110,CDM,27200110,LOCAL,272,RC,,,inpatient,,,1581,1106.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,354.9345,1340.0556,,,,
HC Catheter With Curved Extension,PX-27200111,CDM,27200111,LOCAL,272,RC,,,inpatient,,,1581,1106.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,354.9345,1340.0556,,,,
HC Set Cath Cricothyroidotomy,PX-27200112,CDM,27200112,LOCAL,272,RC,,,inpatient,,,1136,795.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,255.032,962.8736,,,,
HC Rusch Quick Trac Small 2.0,PX-27200113,CDM,27200113,LOCAL,272,RC,,,inpatient,,,1269,888.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,284.8905,1075.6044,,,,
HC Set Prism Prewarm M100'2,PX-27200114,CDM,27200114,LOCAL,272,RC,,,inpatient,,,1319,923.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,296.1155,1117.9844,,,,
HC Set Prismaflex M100's,PX-27200115,CDM,27200115,LOCAL,272,RC,,,inpatient,,,1399,979.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,314.0755,1185.7924,,,,
HC Bakri Postpartum Balloon,PX-27200116,CDM,27200116,LOCAL,272,RC,,,inpatient,,,1408,985.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,316.096,1193.4208,,,,
HC Flo Trac Sensor Mhd6,PX-27200117,CDM,27200117,LOCAL,272,RC,,,inpatient,,,2027,1418.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,455.0615,1718.0852,,,,
HC Pad Universal Artic Gel,PX-27200118,CDM,27200118,LOCAL,272,RC,,,inpatient,,,2219,1553.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,498.1655,1880.8244,,,,
HC Cath Presep 8.5 Oximetry,PX-27200119,CDM,27200119,LOCAL,272,RC,,,inpatient,,,2602,1821.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,584.149,2205.4552,,,,
HC Set Cricothyrotomy Cath,PX-27200120,CDM,27200120,LOCAL,272,RC,,,inpatient,,,2943,2060.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,660.7035,2494.4868,,,,
HC Pad Artic Gel Small,PX-27200121,CDM,27200121,LOCAL,272,RC,,,inpatient,,,5565,3895.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1249.3425,4716.894,,,,
HC Pad Gel Artic Medium,PX-27200122,CDM,27200122,LOCAL,272,RC,,,inpatient,,,5512,3858.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1237.444,4671.9712,,,,
HC Rhino G2 Blue,PX-27200123,CDM,27200123,LOCAL,272,RC,,,inpatient,,,4120,2884,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,924.94,3492.112,,,,
HC Pad Artic Gel Lrg,PX-27200124,CDM,27200124,LOCAL,272,RC,,,inpatient,,,5512,3858.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1237.444,4671.9712,,,,
HC Bag External Drainage Collect,PX-27200125,CDM,27200125,LOCAL,272,RC,,,inpatient,,,1349,944.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,302.8505,1143.4124,,,,
HC Catheter Thoracic 28fr,PX-27200126,CDM,27200126,LOCAL,272,RC,,,inpatient,,,39,27.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.7555,33.0564,,,,
HC Tube Endo Bronch Left 37,PX-27200127,CDM,27200127,LOCAL,272,RC,,,inpatient,,,349,244.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,78.3505,295.8124,,,,
HC Electrode Temporary Pacing 6,PX-27200128,CDM,27200128,LOCAL,272,RC,,,inpatient,,,1238,866.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,277.931,1049.3288,,,,
HC Set Pneumothorax,PX-27200129,CDM,27200129,LOCAL,272,RC,,,inpatient,,,1113,779.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,249.8685,943.3788,,,,
HC System External Drainage III,PX-27200130,CDM,27200130,LOCAL,272,RC,,,inpatient,,,1887,1320.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,423.6315,1599.4212,,,,
HC Electrode Temporary Pacing 5,PX-27200131,CDM,27200131,LOCAL,272,RC,,,inpatient,,,1097,767.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,246.2765,929.8172,,,,
HC Tray Tru Close Thoracic Vent,PX-27200132,CDM,27200132,LOCAL,272,RC,,,inpatient,,,1504,1052.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,337.648,1274.7904,,,,
HC Tube Trach Flex Laser 6.0 Mm,PX-27200133,CDM,27200133,LOCAL,272,RC,,,inpatient,,,319,223.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,71.6155,270.3844,,,,
HC Pack Cesarean Custom,PX-27200134,CDM,27200134,LOCAL,272,RC,,,inpatient,,,462,323.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,103.719,391.5912,,,,
HC Hemostat Instat 1gm,PX-27200135,CDM,27200135,LOCAL,272,RC,,,inpatient,,,1077,753.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,241.7865,912.8652,,,,
HC Tube Trach Distal Xlt 7.0,PX-27200136,CDM,27200136,LOCAL,272,RC,,,inpatient,,,486,340.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,109.107,411.9336,,,,
HC Surgicel 2 X 14 #1951,PX-27200137,CDM,27200137,LOCAL,272,RC,,,inpatient,,,447,312.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,100.3515,378.8772,,,,
HC Ligator Saeed Sx Shoot,PX-27200138,CDM,27200138,LOCAL,272,RC,,,inpatient,,,1332,932.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,299.034,1129.0032,,,,
HC Cath Swan Ganz 7.5 Vip Port,PX-27200139,CDM,27200139,LOCAL,272,RC,,,inpatient,,,297,207.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,66.6765,251.7372,,,,
HC Cath Multilumen Access,PX-27200140,CDM,27200140,LOCAL,272,RC,,,inpatient,,,537,375.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,120.5565,455.1612,,,,
HC Trach Bivona Tts 7mm,PX-27200141,CDM,27200141,LOCAL,272,RC,,,inpatient,,,565,395.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,126.8425,478.894,,,,
HC Kit Pleurx Drainage W Bottle,PX-27200142,CDM,27200142,LOCAL,272,RC,,,inpatient,,,417,291.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,93.6165,353.4492,,,,
HC Retractor Wound Alexis Lrg,PX-27200143,CDM,27200143,LOCAL,272,RC,,,inpatient,,,412,288.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,92.494,349.2112,,,,
HC Unit Cold Therapy Deroyal,PX-27200144,CDM,27200144,LOCAL,272,RC,,,inpatient,,,691,483.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,155.1295,585.6916,,,,
HC Dressing Kci Vac Silver Med,PX-27200145,CDM,27200145,LOCAL,272,RC,,,inpatient,,,506,354.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,113.597,428.8856,,,,
HC Kit Midline Cath 20ga X 20cm,PX-27200146,CDM,27200146,LOCAL,272,RC,,,inpatient,,,424,296.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,95.188,359.3824,,,,
HC Cath Mahurkar 3 Lumen 12x20,PX-27200147,CDM,27200147,LOCAL,272,RC,,,inpatient,,,594,415.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,133.353,503.4744,,,,
HC Retractor Alexis Wound Xlg,PX-27200148,CDM,27200148,LOCAL,272,RC,,,inpatient,,,529,370.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,118.7605,448.3804,,,,
HC Surgiflo Hemostatic Matrix,PX-27200149,CDM,27200149,LOCAL,272,RC,,,inpatient,,,906,634.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,203.397,767.9256,,,,
HC Kit Monitoring Press Abviser,PX-27200150,CDM,27200150,LOCAL,272,RC,,,inpatient,,,648,453.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,145.476,549.2448,,,,
HC Tray Fuhrman Pleural Drain,PX-27200151,CDM,27200151,LOCAL,272,RC,,,inpatient,,,990,693,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,222.255,839.124,,,,
HC Kit Cath Triple Lumen 20cm,PX-27200152,CDM,27200152,LOCAL,272,RC,,,inpatient,,,865,605.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,194.1925,733.174,,,,
HC Dressing Kci Simplace Med,PX-27200153,CDM,27200153,LOCAL,272,RC,,,inpatient,,,433,303.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,97.2085,367.0108,,,,
HC Tube Non Balloon Replace Peg,PX-27200154,CDM,27200154,LOCAL,272,RC,,,inpatient,,,394,275.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,88.453,333.9544,,,,
HC Cath 12fr Hp Triple Lumen,PX-27200155,CDM,27200155,LOCAL,272,RC,,,inpatient,,,606,424.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,136.047,513.6456,,,,
HC Cath Pneumothorax Ak01500,PX-27200156,CDM,27200156,LOCAL,272,RC,,,inpatient,,,700,490,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,157.15,593.32,,,,
HC Kit Cranial Access 826614,PX-27200158,CDM,27200158,LOCAL,272,RC,,,inpatient,,,2205,1543.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,495.0225,1868.958,,,,
"HC Sensor Flotrac W Vamp 60""",PX-27200159,CDM,27200159,LOCAL,272,RC,,,inpatient,,,1336,935.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,299.932,1132.3936,,,,
HC Trach Lg 4.0 Quick Rusch,PX-27200160,CDM,27200160,LOCAL,272,RC,,,inpatient,,,1094,765.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,245.603,927.2744,,,,
HC Tray Pericardiocentesis Stra,PX-27200161,CDM,27200161,LOCAL,272,RC,,,inpatient,,,1188,831.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,266.706,1006.9488,,,,
HC Trocar Endo Ethicon 12 512sd,PX-27200162,CDM,27200162,LOCAL,272,RC,,,inpatient,,,1154,807.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,259.073,978.1304,,,,
HC Tube Laryngectomy 12mm Metal,PX-27200163,CDM,27200163,LOCAL,272,RC,,,inpatient,,,1154,807.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,259.073,978.1304,,,,
HC Tray Midline CT 4f 20cm Single,PX-27200164,CDM,27200164,LOCAL,272,RC,,,inpatient,,,785,549.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,176.2325,665.366,,,,
HC Tray Midline CT 5f 20cm Dual,PX-27200165,CDM,27200165,LOCAL,272,RC,,,inpatient,,,779,545.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.8855,660.2804,,,,
HC Mahurkar Triple Lumen Cath Tray #16,PX-27200166,CDM,27200166,LOCAL,272,RC,,,inpatient,,,1191,833.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,267.3795,1009.4916,,,,
HC Mahurkar Triple Lumen Cath Tray #20,PX-27200167,CDM,27200167,LOCAL,272,RC,,,inpatient,,,983,688.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,220.6835,833.1908,,,,
HC Compartment Pressure Monitoring Kit,PX-27200168,CDM,27200168,LOCAL,272,RC,,,inpatient,,,457,319.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,102.5965,387.3532,,,,
HC Kit Perc Sheath Introducer 8.5,PX-27200169,CDM,27200169,LOCAL,272,RC,,,inpatient,,,471,329.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,105.7395,399.2196,,,,
HC Cath Arrow Cvc Kit Latex Free,PX-27200170,CDM,27200170,LOCAL,272,RC,,,inpatient,,,465,325.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,104.3925,394.134,,,,
HC Electrode Temporary Pacing 4,PX-27200171,CDM,27200171,LOCAL,272,RC,,,inpatient,,,823,576.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,184.7635,697.5748,,,,
HC Catheter Bipolar Pacing 5,PX-27200172,CDM,27200172,LOCAL,272,RC,,,inpatient,,,619,433.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,138.9655,524.6644,,,,
HC Set Emergency Pneumothorax,PX-27200173,CDM,27200173,LOCAL,272,RC,,,inpatient,,,795,556.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,178.4775,673.842,,,,
HC Kit Pneumothorax,PX-27200174,CDM,27200174,LOCAL,272,RC,,,inpatient,,,722,505.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,162.089,611.9672,,,,
HC Impella Purge Cassette,PX-27200175,CDM,27200175,LOCAL,272,RC,,,inpatient,,,245,171.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,55.0025,207.662,,,,
HC Tray Midline CT 4f 20cm Singl,PX-27200176,CDM,27200176,LOCAL,272,RC,,,inpatient,,,954,667.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,214.173,808.6104,,,,
HC Tray Midline CT 5f 20cm Dual F,PX-27200177,CDM,27200177,LOCAL,272,RC,,,inpatient,,,1154,807.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,259.073,978.1304,,,,
HC Kit Microez Mst Nitinol 4.5 7c,PX-27200178,CDM,27200178,LOCAL,272,RC,,,inpatient,,,497,347.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,111.5765,421.2572,,,,
HC Kit Microez Mst 5f Nsx,PX-27200179,CDM,27200179,LOCAL,272,RC,,,inpatient,,,251,175.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,56.3495,212.7476,,,,
HC Electrode One Step Cpr Adult,PX-27200180,CDM,27200180,LOCAL,272,RC,,,inpatient,,,408,285.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,91.596,345.8208,,,,
HC Electrode One Step Pediatric,PX-27200181,CDM,27200181,LOCAL,272,RC,,,inpatient,,,447,312.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,100.3515,378.8772,,,,
HC Ambu® Ascopetm 4 Broncho Large (5.8/2.8),PX-27200196,CDM,27200196,LOCAL,272,RC,,,inpatient,,,359,251.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.5955,304.2884,,,,
HC Ambu® Ascopetm 4 Broncho Regular (5.0/2.2),PX-27200197,CDM,27200197,LOCAL,272,RC,,,inpatient,,,312,218.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,70.044,264.4512,,,,
HC Ambu® Ascopetm 4 Broncho Slim (3.8/1.2),PX-27200198,CDM,27200198,LOCAL,272,RC,,,inpatient,,,312,218.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,70.044,264.4512,,,,
HC Tray Pneumothorax Turkel 9 Cm Sys,PX-27200199,CDM,27200199,LOCAL,272,RC,,,inpatient,,,622,435.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,139.639,527.2072,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400003,CDM,27400003,LOCAL,274,RC,,,inpatient,,,552,386.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,123.924,467.8752,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400005,CDM,27400005,LOCAL,274,RC,,,inpatient,,,1221,854.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,274.1145,1034.9196,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400008,CDM,27400008,LOCAL,274,RC,,,inpatient,,,3772,2640.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,846.814,3197.1472,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400012,CDM,27400012,LOCAL,274,RC,,,inpatient,,,1954,1367.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,438.673,1656.2104,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400015,CDM,27400015,LOCAL,274,RC,,,inpatient,,,3806,2664.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,854.447,3225.9656,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400030,CDM,27400030,LOCAL,274,RC,,,inpatient,,,661,462.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,148.3945,560.2636,,,,
HC Brace Knee Enhanced Trom,PX-27400038,CDM,27400038,LOCAL,274,RC,,,inpatient,,,570,399,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,127.965,483.132,,,,
HC Brace Enhanced Trom Donjoy,PX-27400039,CDM,27400039,LOCAL,274,RC,,,inpatient,,,570,399,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,127.965,483.132,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400047,CDM,27400047,LOCAL,274,RC,,,inpatient,,,3385,2369.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,759.9325,2869.126,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400050,CDM,27400050,LOCAL,274,RC,,,inpatient,,,3185,2229.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,715.0325,2699.606,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400107,CDM,27400107,LOCAL,274,RC,,,inpatient,,,380,266,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,85.31,322.088,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400117,CDM,27400117,LOCAL,274,RC,,,inpatient,,,779,545.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.8855,660.2804,,,,
HC Add. to Lower Extremity L2210,PX-27400184,CDM,27400184,LOCAL,274,RC,,,inpatient,,,330,231,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,74.085,279.708,,,,
HC Lift Elevation Heel & Sole,PX-27400185,CDM,27400185,LOCAL,274,RC,,,inpatient,,,382,267.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,85.759,323.7832,,,,
HC Add. Lower Extremity Orthosis,PX-27400186,CDM,27400186,LOCAL,274,RC,,,inpatient,,,448,313.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,100.576,379.7248,,,,
HC Depth Shoe A5500,PX-27400187,CDM,27400187,LOCAL,274,RC,,,inpatient,,,473,331.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,106.1885,400.9148,,,,
HC Compression Stocking A6533,PX-27400188,CDM,27400188,LOCAL,274,RC,,,inpatient,,,502,351.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,112.699,425.4952,,,,
HC Collar L0172,PX-27400189,CDM,27400189,LOCAL,274,RC,,,inpatient,,,658,460.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,147.721,557.7208,,,,
HC Ko Elastic Knee Joint L1820,PX-27400190,CDM,27400190,LOCAL,274,RC,,,inpatient,,,661,462.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,148.3945,560.2636,,,,
HC Procedure Ortho Shoe/L3649,PX-27400191,CDM,27400191,LOCAL,274,RC,,,inpatient,,,703,492.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,157.8235,595.8628,,,,
HC Air Cast Boot L4386,PX-27400192,CDM,27400192,LOCAL,274,RC,,,inpatient,,,745,521.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,167.2525,631.462,,,,
HC Static Afa L4396,PX-27400193,CDM,27400193,LOCAL,274,RC,,,inpatient,,,785,549.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,176.2325,665.366,,,,
HC Brace Tlso,PX-27400194,CDM,27400194,LOCAL,274,RC,,,inpatient,,,901,630.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,202.2745,763.6876,,,,
HC Lumbar Corsette L0450,PX-27400195,CDM,27400195,LOCAL,274,RC,,,inpatient,,,915,640.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,205.4175,775.554,,,,
HC Brace Warm and Form,PX-27400196,CDM,27400196,LOCAL,274,RC,,,inpatient,,,1117,781.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,250.7665,946.7692,,,,
HC Afo L1940,PX-27400197,CDM,27400197,LOCAL,274,RC,,,inpatient,,,2560,1792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,574.72,2169.856,,,,
HC Ankle Foot Orthosis L1940,PX-27400198,CDM,27400198,LOCAL,274,RC,,,inpatient,,,2560,1792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,574.72,2169.856,,,,
HC POS OP Knee Brace L1832,PX-27400199,CDM,27400199,LOCAL,274,RC,,,inpatient,,,2974,2081.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,667.663,2520.7624,,,,
HC Afo Plastic L1960,PX-27400200,CDM,27400200,LOCAL,274,RC,,,inpatient,,,3011,2107.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,675.9695,2552.1236,,,,
HC Ankle/Foot Orthosis Afo,PX-27400201,CDM,27400201,LOCAL,274,RC,,,inpatient,,,3011,2107.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,675.9695,2552.1236,,,,
HC Left Afo Brace/Atlantic Pros,PX-27400202,CDM,27400202,LOCAL,274,RC,,,inpatient,,,3165,2215.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,710.5425,2682.654,,,,
HC Afo L1932,PX-27400203,CDM,27400203,LOCAL,274,RC,,,inpatient,,,3418,2392.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,767.341,2897.0968,,,,
HC Ankle Foot Orthosis L1970,PX-27400204,CDM,27400204,LOCAL,274,RC,,,inpatient,,,3462,2423.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,777.219,2934.3912,,,,
HC Back Brace Tlso Lo486,PX-27400205,CDM,27400205,LOCAL,274,RC,,,inpatient,,,6597,4617.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1481.0265,5591.6172,,,,
HC Cervical Collar L0172,PX-27400206,CDM,27400206,LOCAL,274,RC,,,inpatient,,,658,460.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,147.721,557.7208,,,,
HC Philly Collar No Extension,PX-27400207,CDM,27400207,LOCAL,274,RC,,,inpatient,,,658,460.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,147.721,557.7208,,,,
HC Cervical Collar 2/Piece L0174,PX-27400208,CDM,27400208,LOCAL,274,RC,,,inpatient,,,1232,862.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,276.584,1044.2432,,,,
HC Lumbar Orthosis L0627,PX-27400209,CDM,27400209,LOCAL,274,RC,,,inpatient,,,1750,1225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,392.875,1483.3,,,,
HC Lso Sagoro Rigid Frame L0631,PX-27400210,CDM,27400210,LOCAL,274,RC,,,inpatient,,,3933,2753.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,882.9585,3333.6108,,,,
HC Lso Sagittal Coronal L0637,PX-27400211,CDM,27400211,LOCAL,274,RC,,,inpatient,,,4114,2879.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,923.593,3487.0264,,,,
HC Hip Abduction Orthosis L1686,PX-27400212,CDM,27400212,LOCAL,274,RC,,,inpatient,,,4461,3122.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1001.4945,3781.1436,,,,
HC Knee Orthosis L1830,PX-27400213,CDM,27400213,LOCAL,274,RC,,,inpatient,,,466,326.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,104.617,394.9816,,,,
HC Knee Orthosis L1832,PX-27400214,CDM,27400214,LOCAL,274,RC,,,inpatient,,,2974,2081.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,667.663,2520.7624,,,,
HC Knee Orthosis L1832,PX-27400215,CDM,27400215,LOCAL,274,RC,,,inpatient,,,2974,2081.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,667.663,2520.7624,,,,
HC Knee Osthosis L1832,PX-27400216,CDM,27400216,LOCAL,274,RC,,,inpatient,,,2974,2081.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,667.663,2520.7624,,,,
HC Afo L1930,PX-27400217,CDM,27400217,LOCAL,274,RC,,,inpatient,,,1062,743.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,238.419,900.1512,,,,
HC Adj. Dorsal Splint L1930,PX-27400218,CDM,27400218,LOCAL,274,RC,,,inpatient,,,1062,743.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,238.419,900.1512,,,,
HC L'nard Boot L1930,PX-27400219,CDM,27400219,LOCAL,274,RC,,,inpatient,,,1062,743.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,238.419,900.1512,,,,
HC Hip Adj Ext L2624,PX-27400220,CDM,27400220,LOCAL,274,RC,,,inpatient,,,1445,1011.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,324.4025,1224.782,,,,
HC Bk Soft Interface L2820,PX-27400221,CDM,27400221,LOCAL,274,RC,,,inpatient,,,448,313.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,100.576,379.7248,,,,
HC Lift Elevation L3332,PX-27400222,CDM,27400222,LOCAL,274,RC,,,inpatient,,,347,242.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,77.9015,294.1172,,,,
HC Wrist Hand/Finger Ortho L3807,PX-27400223,CDM,27400223,LOCAL,274,RC,,,inpatient,,,1065,745.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,239.0925,902.694,,,,
HC Wrist Cockup Nonmolded L3908,PX-27400224,CDM,27400224,LOCAL,274,RC,,,inpatient,,,353,247.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,79.2485,299.2028,,,,
HC Orthosis Upper Limb Hum. Frac,PX-27400225,CDM,27400225,LOCAL,274,RC,,,inpatient,,,1413,989.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,317.2185,1197.6588,,,,
HC Walking Boot L4360,PX-27400226,CDM,27400226,LOCAL,274,RC,,,inpatient,,,1290,903,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,289.605,1093.404,,,,
HC Walking Boot Prefab L4360,PX-27400227,CDM,27400227,LOCAL,274,RC,,,inpatient,,,1290,903,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,289.605,1093.404,,,,
HC Walking Boot L4360,PX-27400228,CDM,27400228,LOCAL,274,RC,,,inpatient,,,2135,1494.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,479.3075,1809.626,,,,
HC Cam Walker L4386,PX-27400229,CDM,27400229,LOCAL,274,RC,,,inpatient,,,745,521.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,167.2525,631.462,,,,
HC Bk Stump Shrinker L8440,PX-27400230,CDM,27400230,LOCAL,274,RC,,,inpatient,,,262,183.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,58.819,222.0712,,,,
HC Stump Shrinker L8440,PX-27400231,CDM,27400231,LOCAL,274,RC,,,inpatient,,,262,183.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,58.819,222.0712,,,,
HC Liner Foam Permanently Lg,PX-27400232,CDM,27400232,LOCAL,274,RC,,,inpatient,,,353,247.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,79.2485,299.2028,,,,
HC Kit Electrode Pacing,PX-27500027,CDM,27500027,LOCAL,275,RC,,,inpatient,,,1286,900.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,288.707,1090.0136,,,,
HC Medical/Surgical Supplies: Other Implants,PX-27800095,CDM,27800095,LOCAL,278,RC,,,inpatient,,,649,454.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,145.7005,550.0924,,,,
HC Leg Post Rigid Brace/Sc Ortho,PX-27800096,CDM,27800096,LOCAL,278,RC,,,inpatient,,,758,530.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,170.171,642.4808,,,,
HC Kit Picc 4fr per-Q Poly Cath,PX-27800097,CDM,27800097,LOCAL,278,RC,,,inpatient,,,1063,744.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,238.6435,900.9988,,,,
HC Floseal Matrix Hemostatic,PX-27800098,CDM,27800098,LOCAL,278,RC,,,inpatient,,,1093,765.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,245.3785,926.4268,,,,
HC Kit Picc 5fr per-Q Poly Cath,PX-27800099,CDM,27800099,LOCAL,278,RC,,,inpatient,,,1217,851.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,273.2165,1031.5292,,,,
HC Tray Power Picc Dual 5f,PX-27800100,CDM,27800100,LOCAL,278,RC,,,inpatient,,,1355,948.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,304.1975,1148.498,,,,
HC Tray Power Picc Single 4f,PX-27800101,CDM,27800101,LOCAL,278,RC,,,inpatient,,,1398,978.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,313.851,1184.9448,,,,
HC Tray Power Picc Triple 5fr,PX-27800102,CDM,27800102,LOCAL,278,RC,,,inpatient,,,1474,1031.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,330.913,1249.3624,,,,
HC Tray Power Picc Triple 6f,PX-27800103,CDM,27800103,LOCAL,278,RC,,,inpatient,,,1499,1049.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,336.5255,1270.5524,,,,
HC Sepafilm/5x6,PX-27800104,CDM,27800104,LOCAL,278,RC,,,inpatient,,,1773,1241.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,398.0385,1502.7948,,,,
HC 3cg Power Picc Max 4fr Sl,PX-27800105,CDM,27800105,LOCAL,278,RC,,,inpatient,,,1585,1109.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,355.8325,1343.446,,,,
HC 3cg Power Picc Max 5fr Dl,PX-27800106,CDM,27800106,LOCAL,278,RC,,,inpatient,,,1636,1145.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,367.282,1386.6736,,,,
HC 3cg Power Picc Max 6fr Tl,PX-27800107,CDM,27800107,LOCAL,278,RC,,,inpatient,,,1749,1224.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,392.6505,1482.4524,,,,
HC Valve Passy Muir Aqua,PX-27800108,CDM,27800108,LOCAL,278,RC,,,inpatient,,,474,331.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,106.413,401.7624,,,,
HC Passy Muir Valve - Clear,PX-27800113,CDM,27800113,LOCAL,278,RC,,,inpatient,,,474,331.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,106.413,401.7624,,,,
HC Valve Passy Muir Purple,PX-27800114,CDM,27800114,LOCAL,278,RC,,,inpatient,,,474,331.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,106.413,401.7624,,,,
HC Liner Foam Permanently X-Lg,PX-27800115,CDM,27800115,LOCAL,278,RC,,,inpatient,,,328,229.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,73.636,278.0128,,,,
HC Tube Trach Proximal Xlt 7.0,PX-27800117,CDM,27800117,LOCAL,278,RC,,,inpatient,,,486,340.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,109.107,411.9336,,,,
HC Barrier Seprafilm 3x5in,PX-27800118,CDM,27800118,LOCAL,278,RC,,,inpatient,,,1773,1241.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,398.0385,1502.7948,,,,
HC Tube Feeding Low Profile 20f,PX-27800119,CDM,27800119,LOCAL,278,RC,,,inpatient,,,694,485.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,155.803,588.2344,,,,
HC Valve Speaking White #005,PX-27800121,CDM,27800121,LOCAL,278,RC,,,inpatient,,,474,331.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,106.413,401.7624,,,,
HC Tray Percu Introducer 8.5fr,PX-27800122,CDM,27800122,LOCAL,278,RC,,,inpatient,,,475,332.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,106.6375,402.61,,,,
HC Basket Zerotip Airway Retriv,PX-27800125,CDM,27800125,LOCAL,278,RC,,,inpatient,,,1710,1197,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,383.895,1449.396,,,,
HC Indwelling Prosthesis 20fr 8mm,PX-27800126,CDM,27800126,LOCAL,278,RC,,,inpatient,,,1327,928.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,297.9115,1124.7652,,,,
HC Indwelling Prosthesis 2.0,PX-27800127,CDM,27800127,LOCAL,278,RC,,,inpatient,,,1327,928.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,297.9115,1124.7652,,,,
HC Prosthesis Blom - 8mm,PX-27800128,CDM,27800128,LOCAL,278,RC,,,inpatient,,,1300,910,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,291.85,1101.88,,,,
HC Drug Collection,PX-30000005,CDM,30000005,LOCAL,300,RC,,,inpatient,,,32,22.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,7.184,27.1232,,,,
HC Cardiac Mnr Thoracic Prcd,PX-36000003,CDM,36000003,LOCAL,360,RC,,,inpatient,,,142,99.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,31.879,120.3592,,,,
HC Non-Pump Open Heart Other,PX-36000004,CDM,36000004,LOCAL,360,RC,,,inpatient,,,157,109.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,35.2465,133.0732,,,,
HC Pump Procedure,PX-36000005,CDM,36000005,LOCAL,360,RC,,,inpatient,,,152,106.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,34.124,128.8352,,,,
HC Non Pump Procedure,PX-36000006,CDM,36000006,LOCAL,360,RC,,,inpatient,,,208,145.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,46.696,176.3008,,,,
HC Sub Minor Proc,PX-36000014,CDM,36000014,LOCAL,360,RC,,,inpatient,,,60,42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,13.47,50.856,,,,
HC Pain Mgmt Proc,PX-36000015,CDM,36000015,LOCAL,360,RC,,,inpatient,,,75,52.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,16.8375,63.57,,,,
HC Endoscopy,PX-36000016,CDM,36000016,LOCAL,360,RC,,,inpatient,,,60,42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,13.47,50.856,,,,
HC Minor Proc,PX-36000017,CDM,36000017,LOCAL,360,RC,,,inpatient,,,75,52.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,16.8375,63.57,,,,
HC Major Proc,PX-36000019,CDM,36000019,LOCAL,360,RC,,,inpatient,,,99,69.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2255,83.9124,,,,
HC Intensive Major Procedure,PX-36000020,CDM,36000020,LOCAL,360,RC,,,inpatient,,,140,98,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,31.43,118.664,,,,
HC Ercp,PX-36000021,CDM,36000021,LOCAL,360,RC,,,inpatient,,,138,96.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,30.981,116.9688,,,,
HC Cardiac Maj Thoracic Prcd,PX-36000022,CDM,36000022,LOCAL,360,RC,,,inpatient,,,159,111.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,35.6955,134.7684,,,,
HC Anesthesia Block,PX-37000001,CDM,37000001,LOCAL,370,RC,,,inpatient,,,700,490,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,157.15,593.32,,,,
HC Anesthesia Spinal,PX-37000002,CDM,37000002,LOCAL,370,RC,,,inpatient,,,850,595,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,190.825,720.46,,,,
HC Anesthesia General Minor,PX-37000003,CDM,37000003,LOCAL,370,RC,,,inpatient,,,1662,1163.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,373.119,1408.7112,,,,
HC Anesthesia Epidural,PX-37000004,CDM,37000004,LOCAL,370,RC,,,inpatient,,,950,665,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,213.275,805.22,,,,
HC Anesthesia General Major,PX-37000005,CDM,37000005,LOCAL,370,RC,,,inpatient,,,2924,2046.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,656.438,2478.3824,,,,
HC Anesthesia Gen/Epi,PX-37000006,CDM,37000006,LOCAL,370,RC,,,inpatient,,,1200,840,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,269.4,1017.12,,,,
HC Anesthesia General Intensive,PX-37000007,CDM,37000007,LOCAL,370,RC,,,inpatient,,,4262,2983.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,956.819,3612.4712,,,,
HC Anesthesia General Cvs Bypass Pump,PX-37000008,CDM,37000008,LOCAL,370,RC,,,inpatient,,,9166,6416.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2057.767,7769.1016,,,,
HC Anesthesia Mac,PX-37000009,CDM,37000009,LOCAL,370,RC,,,inpatient,,,1200,840,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,269.4,1017.12,,,,
HC Endo Level I,PX-49000001,CDM,49000001,LOCAL,490,RC,,,inpatient,,,3749,2624.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,841.6505,3177.6524,,,,
HC Endo Level II,PX-49000002,CDM,49000002,LOCAL,490,RC,,,inpatient,,,5356,3749.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1202.422,4539.7456,,,,
HC Endo Level III,PX-49000003,CDM,49000003,LOCAL,490,RC,,,inpatient,,,9641,6748.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2164.4045,8171.7116,,,,
HC Recovery Room,PX-71000001,CDM,71000001,LOCAL,710,RC,,,inpatient,,,25,17.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,5.6125,21.19,,,,
HC Second Stage Recovery per Minute,PX-71000002,CDM,71000002,LOCAL,710,RC,,,inpatient,,,22,15.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.939,18.6472,,,,
HC Recovery - Sub Minor Proc,PX-71000003,CDM,71000003,LOCAL,710,RC,,,inpatient,,,23,16.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,5.1635,19.4948,,,,
HC Recovery Rm - Minor Procedure,PX-71000004,CDM,71000004,LOCAL,710,RC,,,inpatient,,,28,19.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,6.286,23.7328,,,,
HC Recovery Rm,PX-71000005,CDM,71000005,LOCAL,710,RC,,,inpatient,,,29,20.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,6.5105,24.5804,,,,
HC Recovery Rm - Major Procedure,PX-71000006,CDM,71000006,LOCAL,710,RC,,,inpatient,,,33,23.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,7.4085,27.9708,,,,
HC Recovery Rm - Intensive Major,PX-71000007,CDM,71000007,LOCAL,710,RC,,,inpatient,,,38,26.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.531,32.2088,,,,
HC Extended Recovery Overnight,PX-71000009,CDM,71000009,LOCAL,710,RC,,,inpatient,,,1500,1050,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,336.75,1271.4,,,,
HC Observation Nursing Time,PX-76200006,CDM,76200006,LOCAL,762,RC,,,inpatient,,,101,70.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.6745,6652,,,,
HC Tandem Dialysis,PX-80100001,CDM,80100001,LOCAL,801,RC,,,inpatient,,,1142,799.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,256.379,967.9592,,,,
HC Single Dialysis,PX-80100002,CDM,80100002,LOCAL,801,RC,,,inpatient,,,1142,799.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,256.379,967.9592,,,,
HC Unscheduled/Emergent Dialysis,PX-80100003,CDM,80100003,LOCAL,801,RC,,,inpatient,,,1142,799.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,256.379,967.9592,,,,
HC Weekend/Holiday Dialysis,PX-80100004,CDM,80100004,LOCAL,801,RC,,,inpatient,,,1142,799.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,256.379,967.9592,,,,
HC Capd per:Exchange,PX-80300001,CDM,80300001,LOCAL,803,RC,,,inpatient,,,569,398.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,127.7405,482.2844,,,,
HC Ccpd ER,PX-80400001,CDM,80400001,LOCAL,804,RC,,,inpatient,,,569,398.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,127.7405,482.2844,,,,
HC Ccpd,PX-80400002,CDM,80400002,LOCAL,804,RC,,,inpatient,,,1142,799.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,256.379,967.9592,,,,
HC Dietary Services per 15 Mins,PX-99000006,CDM,99000006,LOCAL,990,RC,,,inpatient,,,29,20.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,6.5105,24.5804,,,,
HC Hearing Aid Batteries,PX-99000034,CDM,99000034,LOCAL,479,RC,,,inpatient,,,7,4.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.5715,163,,,,
HC Hearing Aid Tune Up,PX-99000037,CDM,99000037,LOCAL,479,RC,,,inpatient,,,43,30.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.6535,163,,,,
HC Hearing Aid Fit,PX-99000038,CDM,99000038,LOCAL,479,RC,,,inpatient,,,171,119.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,38.3895,163,,,,
HC Full Trauma No Notification,PX-45000633,CDM,TR450,LOCAL,450,RC,,,inpatient,,,10370,7259,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9291.52,,,,
HC Partial Trauma No Notification,PX-45000634,CDM,TR450,LOCAL,450,RC,,,inpatient,,,7029,4920.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6297.984,,,,
Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face- Mouth And Neck With Major O.R. Procedures,3,MS-DRG,,,,,,,inpatient,,,404600.26,283220.182,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,189560.4996,,,189560.4996,7771.48,434261.5728,case rate,,,
Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face- Mouth And Neck Without Major O.R. Procedures,4,MS-DRG,,,,,,,inpatient,,,379341.67,265539.169,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,125063.5024,,,125063.5024,7771.48,303473.336,case rate,,,
Tracheostomy For Face- Mouth And Neck Diagnoses Or Laryngectomy With McC,11,MS-DRG,,,,,,,inpatient,,,57485.95,40240.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,47912.84716,,,47912.84716,7771.48,109336.4384,case rate,,,
Tracheostomy For Face- Mouth And Neck Diagnoses Or Laryngectomy With Cc,12,MS-DRG,,,,,,,inpatient,,,82266.47,57586.529,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,36498.49689,,,36498.49689,7771.48,83151.2976,case rate,,,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With McC Or Chemotherapy Implant Or Epilepsy With Neurostimulator,23,MS-DRG,,,,,,,inpatient,,,82526.76,57768.732,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,50644.09395,,,50644.09395,7771.48,115600.0408,case rate,,,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without McC,24,MS-DRG,,,,,,,inpatient,,,54359.41,38051.587,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,33830.84964,,,33830.84964,7771.48,77031.5696,case rate,,,
Craniotomy And Endovascular Intracranial Procedures With McC,25,MS-DRG,,,,,,,inpatient,,,91861.46,64303.022,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,39754.43987,,,39754.43987,7771.48,90620.608,case rate,,,
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,,,inpatient,,,74058,51840.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,27266.84741,,,27266.84741,7771.48,61975.4176,case rate,,,
Craniotomy And Endovascular Intracranial Procedures Without Cc/McC,27,MS-DRG,,,,,,,inpatient,,,61484.65,43039.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,22048.15206,,,22048.15206,7771.48,50003.4464,case rate,,,
Spinal Procedures With McC,28,MS-DRG,,,,,,,inpatient,,,148126.56,103688.592,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,53951.26988,,,53951.26988,7771.48,123186.8824,case rate,,,
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,inpatient,,,74991.36,52493.952,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,29900.04491,,,29900.04491,7771.48,68016.116,case rate,,,
Spinal Procedures Without Cc/McC,30,MS-DRG,,,,,,,inpatient,,,28580.9,20006.63,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19906.96764,,,19906.96764,7771.48,45091.4528,case rate,,,
Ventricular Shunt Procedures With McC,31,MS-DRG,,,,,,,inpatient,,,61588.79,43112.153,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,37266.10797,,,37266.10797,7771.48,84912.2392,case rate,,,
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,,,inpatient,,,117340.84,82138.588,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19113.74008,,,19113.74008,7771.48,93872.672,case rate,,,
Ventricular Shunt Procedures Without Cc/McC,33,MS-DRG,,,,,,,inpatient,,,50092.67,35064.869,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14342.89147,,,14342.89147,7771.48,40074.136,case rate,,,
Carotid Artery Stent Procedures With McC,34,MS-DRG,,,,,,,inpatient,,,80412.35,56288.645,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,34599.34405,,,34599.34405,7771.48,78796.564,case rate,,,
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,inpatient,,,59060.84,41342.588,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,20343.33113,,,20343.33113,7771.48,47248.672,case rate,,,
Carotid Artery Stent Procedures Without Cc/McC,36,MS-DRG,,,,,,,inpatient,,,55590.26,38913.182,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16441.67619,,,16441.67619,7771.48,44472.208,case rate,,,
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,inpatient,,,47239.38,33067.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14482.45712,,,14482.45712,7771.48,37791.504,case rate,,,
Extracranial Procedures Without Cc/McC,39,MS-DRG,,,,,,,inpatient,,,40302.61,28211.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10303.43753,,,10303.43753,7771.48,32242.088,case rate,,,
Peripheral- Cranial Nerve And Other Nervous System Procedures With McC,40,MS-DRG,,,,,,,inpatient,,,42423.5,29696.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,33569.38488,,,33569.38488,7771.48,76431.7552,case rate,,,
Peripheral- Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator,41,MS-DRG,,,,,,,inpatient,,,29478.8,20635.16,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,20196.69887,,,20196.69887,7771.48,45768.2704,case rate,,,
Peripheral- Cranial Nerve And Other Nervous System Procedures Without Cc/McC,42,MS-DRG,,,,,,,inpatient,,,40958.56,28670.992,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15774.76438,,,15774.76438,7771.48,35613.98,case rate,,,
Spinal Disorders And Injuries With Cc/McC,52,MS-DRG,,,,,,,inpatient,,,14188.67,9932.069,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,18026.36466,,,18026.36466,4731.921445,40779.2736,case rate,,,
Spinal Disorders And Injuries Without Cc/McC,53,MS-DRG,,,,,,,inpatient,,,42918.11,30042.677,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8388.384801,,,8388.384801,7771.48,34334.488,case rate,,,
Nervous System Neoplasms With McC,54,MS-DRG,,,,,,,inpatient,,,16507.92,11555.544,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13491.36433,,,13491.36433,5505.39132,30377.7624,case rate,,,
Nervous System Neoplasms Without McC,55,MS-DRG,,,,,,,inpatient,,,15148.1,10603.67,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9886.507232,,,9886.507232,5051.89135,22105.9976,case rate,,,
Degenerative Nervous System Disorders With McC,56,MS-DRG,,,,,,,inpatient,,,32807.03,22964.921,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,22368.79972,,,22368.79972,7771.48,50741.056,case rate,,,
Degenerative Nervous System Disorders Without McC,57,MS-DRG,,,,,,,inpatient,,,21955.44,15368.808,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12036.52492,,,12036.52492,7322.13924,27046.3608,case rate,,,
Multiple Sclerosis And Cerebellar Ataxia With McC,58,MS-DRG,,,,,,,inpatient,,,18732.22,13112.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16554.74204,,,16554.74204,6247.19537,37401.2648,case rate,,,
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,inpatient,,,30559.84,21391.888,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11057.79871,,,11057.79871,7771.48,24793.004,case rate,,,
Multiple Sclerosis And Cerebellar Ataxia Without Cc/McC,60,MS-DRG,,,,,,,inpatient,,,18686.21,13080.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8132.219999,,,8132.219999,6231.851035,18083.5936,case rate,,,
Ischemic Stroke- Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With McC,61,MS-DRG,,,,,,,inpatient,,,81185.85,56830.095,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,24129.27025,,,24129.27025,7771.48,64948.68,case rate,,,
Ischemic Stroke- Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc,62,MS-DRG,,,,,,,inpatient,,,55465.6,38825.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15980.57955,,,15980.57955,7771.48,44372.48,case rate,,,
Ischemic Stroke- Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/McC,63,MS-DRG,,,,,,,inpatient,,,65826.61,46078.627,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12658.38706,,,12658.38706,7771.48,52661.288,case rate,,,
Intracranial Hemorrhage Or Cerebral Infarction With McC,64,MS-DRG,,,,,,,inpatient,,,31988.78,22392.146,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,17820.54949,,,17820.54949,7771.48,40307.1224,case rate,,,
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,inpatient,,,20095.65,14066.955,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9231.961995,,,9231.961995,6701.899275,20608.488,case rate,,,
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/McC,66,MS-DRG,,,,,,,inpatient,,,17438.35,12206.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6329.349786,,,6329.349786,5143.64,13950.68,case rate,,,
Nonspecific Cva And Precerebral Occlusion Without Infarction With McC,67,MS-DRG,,,,,,,inpatient,,,38053.25,26637.275,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13100.93384,,,13100.93384,7771.48,30442.6,case rate,,,
Nonspecific Cva And Precerebral Occlusion Without Infarction Without McC,68,MS-DRG,,,,,,,inpatient,,,27888.66,19522.062,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8035.937366,,,8035.937366,6429.37,22310.928,case rate,,,
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,inpatient,,,17825.05,12477.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7316.909266,,,7316.909266,5687.74,16215.2528,case rate,,,
Nonspecific Cerebrovascular Disorders With McC,70,MS-DRG,,,,,,,inpatient,,,36237.19,25366.033,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15608.69892,,,15608.69892,7771.48,35233.0168,case rate,,,
Nonspecific Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,inpatient,,,26346.94,18442.858,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9558.79295,,,9558.79295,7313.53,21354.2032,case rate,,,
Cranial And Peripheral Nerve Disorders With McC,73,MS-DRG,,,,,,,inpatient,,,24367.12,17056.984,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13902.11134,,,13902.11134,7771.48,31318.012,case rate,,,
Cranial And Peripheral Nerve Disorders Without McC,74,MS-DRG,,,,,,,inpatient,,,24431.87,17102.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9457.210356,,,9457.210356,7368.52,21123.1936,case rate,,,
Viral Meningitis With Cc/McC,75,MS-DRG,,,,,,,inpatient,,,38318.52,26822.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15463.83331,,,15463.83331,7771.48,34902.7136,case rate,,,
Viral Meningitis Without Cc/McC,76,MS-DRG,,,,,,,inpatient,,,18360.72,12852.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8348.635091,,,8348.635091,6123.30012,18580.0616,case rate,,,
Hypertensive Encephalopathy With McC,77,MS-DRG,,,,,,,inpatient,,,24086.79,16860.753,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13908.29463,,,13908.29463,7771.48,31332.1968,case rate,,,
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,,,inpatient,,,18407.7,12885.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9064.129883,,,9064.129883,6138.96795,20219.4192,case rate,,,
Nontraumatic Stupor And Coma With McC,80,MS-DRG,,,,,,,inpatient,,,17643.44,12350.408,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,17808.18291,,,17808.18291,5884.08724,40280.7792,case rate,,,
Traumatic Stupor And Coma >1 Hour With McC,82,MS-DRG,,,,,,,inpatient,,,45789.39,32052.573,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,20744.36155,,,20744.36155,7771.48,47014.5064,case rate,,,
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,inpatient,,,24521.38,17164.966,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12531.18798,,,12531.18798,7771.48,28173.0392,case rate,,,
Traumatic Stupor And Coma >1 Hour Without Cc/McC,84,MS-DRG,,,,,,,inpatient,,,12382.21,8667.547,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8694.899237,,,8694.899237,4129.467035,19372.384,case rate,,,
Traumatic Stupor And Coma <1 Hour With McC,85,MS-DRG,,,,,,,inpatient,,,44820.5,31374.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,20265.59836,,,20265.59836,7771.48,45916.1976,case rate,,,
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,inpatient,,,22755.94,15929.158,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11835.12638,,,11835.12638,7589.10599,26578.2624,case rate,,,
Traumatic Stupor And Coma <1 Hour Without Cc/McC,87,MS-DRG,,,,,,,inpatient,,,19756.53,13829.571,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8058.020539,,,8058.020539,6241.25,17913.376,case rate,,,
Concussion With McC,88,MS-DRG,,,,,,,inpatient,,,61939.59,43357.713,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12710.50335,,,12710.50335,7771.48,49551.672,case rate,,,
Concussion With Cc,89,MS-DRG,,,,,,,inpatient,,,38694.98,27086.486,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9719.558447,,,9719.558447,7678.2,30955.984,case rate,,,
Other Disorders Of Nervous System With McC,91,MS-DRG,,,,,,,inpatient,,,27946.92,19562.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16351.57685,,,16351.57685,7771.48,36937.2192,case rate,,,
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,inpatient,,,23877.59,16714.313,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9601.192642,,,9601.192642,7134.82,21455.5232,case rate,,,
Other Disorders Of Nervous System Without Cc/McC,93,MS-DRG,,,,,,,inpatient,,,19087.94,13361.558,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7221.50996,,,7221.50996,5653.01,15994.3752,case rate,,,
Bacterial And Tuberculous Infections Of Nervous System With McC,94,MS-DRG,,,,,,,inpatient,,,86655,60658.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,32479.35948,,,32479.35948,7771.48,73931.1776,case rate,,,
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,,,inpatient,,,61521.3,43064.91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,21424.52326,,,21424.52326,7771.48,49217.04,case rate,,,
Bacterial And Tuberculous Infections Of Nervous System Without Cc/McC,96,MS-DRG,,,,,,,inpatient,,,33095.5,23166.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,21424.52326,,,21424.52326,7771.48,48572.808,case rate,,,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With McC,97,MS-DRG,,,,,,,inpatient,,,90065.06,63045.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,31913.14693,,,31913.14693,7771.48,72642.3872,case rate,,,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,inpatient,,,23740.04,16618.028,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19411.42125,,,19411.42125,7771.48,43954.6424,case rate,,,
Seizures With McC,100,MS-DRG,,,,,,,inpatient,,,22104.14,15472.898,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,17786.09974,,,17786.09974,7371.73069,40228.0928,case rate,,,
Seizures Without McC,101,MS-DRG,,,,,,,inpatient,,,15944.38,11161.066,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8391.034782,,,8391.034782,5317.45073,18675.3024,case rate,,,
Headaches With McC,102,MS-DRG,,,,,,,inpatient,,,25624.62,17937.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10491.58616,,,10491.58616,7771.48,23494.0816,case rate,,,
Headaches Without McC,103,MS-DRG,,,,,,,inpatient,,,20277.76,14194.432,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7759.456045,,,7759.456045,5992.35,17228.4528,case rate,,,
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,,,inpatient,,,26970.92,18879.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13773.14561,,,13773.14561,7771.48,31022.1576,case rate,,,
Neurological Eye Disorders,123,MS-DRG,,,,,,,inpatient,,,18842.87,13190.009,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7344.2924,,,7344.2924,5537.24,16276.0448,case rate,,,
Sinus And Mastoid Procedures With Cc/McC,135,MS-DRG,,,,,,,inpatient,,,60852.06,42596.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,21547.3057,,,21547.3057,7771.48,48854.4776,case rate,,,
Mouth Procedures Without Cc/McC,138,MS-DRG,,,,,,,inpatient,,,12689.7,8882.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7435.275071,,,7435.275071,4232.01495,16484.764,case rate,,,
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,inpatient,,,50999.49,35699.643,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19227.68925,,,19227.68925,7771.48,43533.1512,case rate,,,
Major Head And Neck Procedures Without Cc/McC,142,MS-DRG,,,,,,,inpatient,,,31036.34,21725.438,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14138.84295,,,14138.84295,7771.48,31861.0872,case rate,,,
Other Ear- Nose- Mouth And Throat O.R. Procedures With McC,143,MS-DRG,,,,,,,inpatient,,,146130.64,102291.448,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,29415.98177,,,29415.98177,7771.48,116904.512,case rate,,,
Other Ear- Nose- Mouth And Throat O.R. Procedures With Cc,144,MS-DRG,,,,,,,inpatient,,,29177.65,20424.355,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15766.81444,,,15766.81444,7771.48,35595.7424,case rate,,,
Ear- Nose- Mouth And Throat Malignancy With Cc,147,MS-DRG,,,,,,,inpatient,,,20455.22,14318.654,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11245.06401,,,11245.06401,6821.81587,25222.6008,case rate,,,
Ear- Nose- Mouth And Throat Malignancy Without Cc/McC,148,MS-DRG,,,,,,,inpatient,,,18282.89,12798.023,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7322.209227,,,7322.209227,5689.187157,16225.3848,case rate,,,
Dysequilibrium,149,MS-DRG,,,,,,,inpatient,,,21458.09,15020.663,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6852.279314,,,6852.279314,5321.63,17166.472,case rate,,,
Epistaxis With McC,150,MS-DRG,,,,,,,inpatient,,,36459.7,25521.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12458.75518,,,12458.75518,7771.48,29167.76,case rate,,,
Epistaxis Without McC,151,MS-DRG,,,,,,,inpatient,,,17762.28,12433.596,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6945.028639,,,6945.028639,5332.48243,15360.112,case rate,,,
Otitis Media And Uri With McC,152,MS-DRG,,,,,,,inpatient,,,22895.06,16026.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10273.40442,,,10273.40442,7635.50251,22993.5608,case rate,,,
Otitis Media And Uri Without McC,153,MS-DRG,,,,,,,inpatient,,,11257.92,7880.544,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6536.048282,,,6536.048282,3754.51632,14421.8888,case rate,,,
Other Ear- Nose- Mouth And Throat Diagnoses With McC,154,MS-DRG,,,,,,,inpatient,,,33108.79,23176.153,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14614.95615,,,14614.95615,7771.48,32953.3168,case rate,,,
Other Ear- Nose- Mouth And Throat Diagnoses With Cc,155,MS-DRG,,,,,,,inpatient,,,14149.33,9904.531,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8496.150684,,,8496.150684,4718.801555,18918.4704,case rate,,,
Other Ear- Nose- Mouth And Throat Diagnoses Without Cc/McC,156,MS-DRG,,,,,,,inpatient,,,3168.14,2217.698,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6188.900808,,,6188.900808,1056.57469,13625.5136,case rate,,,
Dental And Oral Diseases With McC,157,MS-DRG,,,,,,,inpatient,,,25823.75,18076.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14713.88877,,,14713.88877,7771.48,33180.2736,case rate,,,
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,inpatient,,,17794.61,12456.227,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8557.983567,,,8557.983567,5934.502435,19058.292,case rate,,,
Dental And Oral Diseases Without Cc/McC,159,MS-DRG,,,,,,,inpatient,,,15217,10651.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6075.834964,,,6075.834964,4744.97,13366.1344,case rate,,,
Major Chest Procedures With McC,163,MS-DRG,,,,,,,inpatient,,,128830.68,90181.476,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,40963.7144,,,40963.7144,7771.48,103064.544,case rate,,,
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,inpatient,,,83811.85,58668.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,22482.74889,,,22482.74889,7771.48,67049.48,case rate,,,
Major Chest Procedures Without Cc/McC,165,MS-DRG,,,,,,,inpatient,,,63087.07,44160.949,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16714.62421,,,16714.62421,7771.48,50469.656,case rate,,,
Other Respiratory System O.R. Procedures With McC,166,MS-DRG,,,,,,,inpatient,,,68518.66,47963.062,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,34260.14652,,,34260.14652,7771.48,78036.664,case rate,,,
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,inpatient,,,50504.64,35353.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16389.55991,,,16389.55991,7771.48,40403.712,case rate,,,
Other Respiratory System O.R. Procedures Without Cc/McC,168,MS-DRG,,,,,,,inpatient,,,36816.23,25771.361,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12208.77366,,,12208.77366,7771.48,29452.984,case rate,,,
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,inpatient,,,76600.57,53620.399,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,27355.1801,,,27355.1801,7771.48,62178.0576,case rate,,,
Pulmonary Embolism With McC Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,inpatient,,,27323.68,19126.576,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12696.37012,,,12696.37012,7771.48,28554.0024,case rate,,,
Pulmonary Embolism Without McC,176,MS-DRG,,,,,,,inpatient,,,16280.09,11396.063,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7444.10834,,,7444.10834,5429.410015,16505.028,case rate,,,
Respiratory Infections And Inflammations With McC,177,MS-DRG,,,,,,,inpatient,,,30316.04,21221.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14528.39012,,,14528.39012,7771.48,32756.756,case rate,,,
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,inpatient,,,21346.77,14942.739,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9012.896923,,,9012.896923,7119.147795,20103.9144,case rate,,,
Respiratory Infections And Inflammations Without Cc/McC,179,MS-DRG,,,,,,,inpatient,,,20533.98,14373.786,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7048.377887,,,7048.377887,6302.75,16427.184,case rate,,,
Respiratory Neoplasms With McC,180,MS-DRG,,,,,,,inpatient,,,24678.76,17275.132,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15688.19834,,,15688.19834,7771.48,35415.3928,case rate,,,
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,inpatient,,,15915.05,11140.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10056.98932,,,10056.98932,5307.669175,22497.0928,case rate,,,
Major Chest Trauma With McC,183,MS-DRG,,,,,,,inpatient,,,30366.68,21256.676,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14270.45866,,,14270.45866,7771.48,32163.0208,case rate,,,
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,inpatient,,,23252.15,16276.505,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9684.225371,,,9684.225371,7520.46,21641.952,case rate,,,
Major Chest Trauma Without Cc/McC,185,MS-DRG,,,,,,,inpatient,,,26254.04,18377.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7119.044039,,,7119.044039,5597.297704,21003.232,case rate,,,
Pleural Effusion With McC,186,MS-DRG,,,,,,,inpatient,,,23322.86,16326.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14205.9758,,,14205.9758,7771.48,32017.12,case rate,,,
Pleural Effusion With Cc,187,MS-DRG,,,,,,,inpatient,,,25224.41,17657.087,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9118.012825,,,9118.012825,7468.37,20343.0296,case rate,,,
Pleural Effusion Without Cc/McC,188,MS-DRG,,,,,,,inpatient,,,14227.72,9959.404,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6734.796835,,,6734.796835,4744.94462,14875.8024,case rate,,,
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,inpatient,,,23597.45,16518.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11179.69782,,,11179.69782,7771.48,25076.7,case rate,,,
Chronic Obstructive Pulmonary Disease With McC,190,MS-DRG,,,,,,,inpatient,,,20380.17,14266.119,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10169.17184,,,10169.17184,6796.786695,22762.5512,case rate,,,
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,inpatient,,,18415.04,12890.528,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7838.07214,,,7838.07214,6141.41584,17408.8024,case rate,,,
Chronic Obstructive Pulmonary Disease Without Cc/McC,192,MS-DRG,,,,,,,inpatient,,,15021,10514.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5966.302428,,,5966.302428,5009.5035,13114.8608,case rate,,,
Simple Pneumonia And Pleurisy With McC,193,MS-DRG,,,,,,,inpatient,,,24854.58,17398.206,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11889.00933,,,11889.00933,7771.48,26703.8992,case rate,,,
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,inpatient,,,16852.25,11796.575,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7492.69132,,,7492.69132,5620.225375,16616.48,case rate,,,
Simple Pneumonia And Pleurisy Without Cc/McC,195,MS-DRG,,,,,,,inpatient,,,11327.34,7929.138,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5749.887336,,,5749.887336,3777.66789,12620.4192,case rate,,,
Interstitial Lung Disease With McC,196,MS-DRG,,,,,,,inpatient,,,25824.88,18077.416,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16892.17291,,,16892.17291,7771.48,38181.4288,case rate,,,
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,inpatient,,,14747.43,10323.201,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8994.347058,,,8994.347058,4918.267905,20059.3336,case rate,,,
Interstitial Lung Disease Without Cc/McC,198,MS-DRG,,,,,,,inpatient,,,102750.94,71925.658,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6436.232342,,,6436.232342,5370.829997,82200.752,case rate,,,
Pneumothorax With McC,199,MS-DRG,,,,,,,inpatient,,,30942.21,21659.547,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15842.78055,,,15842.78055,7771.48,35770.0128,case rate,,,
Pneumothorax With Cc,200,MS-DRG,,,,,,,inpatient,,,23899.07,16729.349,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10032.25617,,,10032.25617,7771.48,22440.3536,case rate,,,
Pneumothorax Without Cc/McC,201,MS-DRG,,,,,,,inpatient,,,14142.03,9899.421,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6230.417173,,,6230.417173,4716.367005,13716.7016,case rate,,,
Bronchitis And Asthma With Cc/McC,202,MS-DRG,,,,,,,inpatient,,,14008.78,9806.146,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8788.531889,,,8788.531889,4671.92813,19589.2088,case rate,,,
Bronchitis And Asthma Without Cc/McC,203,MS-DRG,,,,,,,inpatient,,,8434.66,5904.262,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6402.665919,,,6402.665919,2812.95911,14109.8232,case rate,,,
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,inpatient,,,19382.31,13567.617,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7413.191898,,,7413.191898,5734.05,16432.0776,case rate,,,
Other Respiratory System Diagnoses With McC,205,MS-DRG,,,,,,,inpatient,,,29471.66,20630.162,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16924.85601,,,16924.85601,7771.48,38252.3528,case rate,,,
Other Respiratory System Diagnoses Without McC,206,MS-DRG,,,,,,,inpatient,,,18289.13,12802.391,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8250.585804,,,8250.585804,6099.424855,18355.1312,case rate,,,
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,inpatient,,,153413.76,107389.632,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,57375.92829,,,57375.92829,7771.48,131061.4728,case rate,,,
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,inpatient,,,60056.19,42039.333,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,23956.13817,,,23956.13817,7771.48,54390.6024,case rate,,,
Other Heart Assist System Implant,215,MS-DRG,,,,,,,inpatient,,,163000.7,114100.49,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,93836.12961,,,93836.12961,7771.48,214680.8688,case rate,,,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/McC,218,MS-DRG,,,,,,,inpatient,,,144438.6,101107.02,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,52801.17825,,,52801.17825,7771.48,120552.5624,case rate,,,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/McC,221,MS-DRG,,,,,,,inpatient,,,282573.82,197801.674,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,40817.08213,,,40817.08213,7771.48,226059.056,case rate,,,
Other Cardiothoracic Procedures With McC,228,MS-DRG,,,,,,,inpatient,,,215439.26,150807.482,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,44268.24035,,,44268.24035,7771.48,172351.408,case rate,,,
Coronary Bypass With Cardiac Catheterization Or Open Ablation With McC,233,MS-DRG,,,,,,,inpatient,,,335724.2,235006.94,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,69293.77489,,,69293.77489,7771.48,268579.36,case rate,,,
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without McC,234,MS-DRG,,,,,,,inpatient,,,168474.77,117932.339,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,47244.16869,,,47244.16869,7771.48,134779.816,case rate,,,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With McC,239,MS-DRG,,,,,,,inpatient,,,57370.89,40159.623,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,44741.70357,,,44741.70357,7771.48,102059.636,case rate,,,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,inpatient,,,51903.54,36332.478,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,25973.65682,,,25973.65682,7771.48,59008.768,case rate,,,
Permanent Cardiac Pacemaker Implant With McC,242,MS-DRG,,,,,,,inpatient,,,86942.73,60859.911,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,30211.85931,,,30211.85931,7771.48,69554.184,case rate,,,
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,inpatient,,,65531.01,45871.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,20148.99921,,,20148.99921,7771.48,52424.808,case rate,,,
Permanent Cardiac Pacemaker Implant Without Cc/McC,244,MS-DRG,,,,,,,inpatient,,,63411.07,44387.749,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16190.81135,,,16190.81135,7771.48,50728.856,case rate,,,
Aicd Generator Procedures,245,MS-DRG,,,,,,,inpatient,,,15907.12,11134.984,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,43415.82989,,,43415.82989,5305.02452,99020.036,case rate,,,
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without McC,251,MS-DRG,,,,,,,inpatient,,,55424.98,38797.486,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14052.27692,,,14052.27692,7771.48,44339.984,case rate,,,
Other Vascular Procedures With McC,252,MS-DRG,,,,,,,inpatient,,,85181.97,59627.379,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,30551.05684,,,30551.05684,7771.48,69509.5728,case rate,,,
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,inpatient,,,82797.33,57958.131,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,22800.74658,,,22800.74658,7771.48,66237.864,case rate,,,
Other Vascular Procedures Without Cc/McC,254,MS-DRG,,,,,,,inpatient,,,61488.65,43042.055,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15702.33157,,,15702.33157,7771.48,49190.92,case rate,,,
Upper Limb And Toe Amputation For Circulatory System Disorders With McC,255,MS-DRG,,,,,,,inpatient,,,163135.56,114194.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,23361.65917,,,23361.65917,7771.48,130508.448,case rate,,,
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,inpatient,,,13744.76,9621.332,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15210.31849,,,15210.31849,4583.87746,34319.1104,case rate,,,
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/McC,257,MS-DRG,,,,,,,inpatient,,,13802.75,9661.925,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8127.803364,,,8127.803364,4603.217125,18073.4616,case rate,,,
Cardiac Pacemaker Device Replacement Without McC,259,MS-DRG,,,,,,,inpatient,,,51584.98,36109.486,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15775.64771,,,15775.64771,7771.48,41267.984,case rate,,,
Cardiac Pacemaker Revision Except Device Replacement With McC,260,MS-DRG,,,,,,,inpatient,,,218275.68,152792.976,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,30337.29173,,,30337.29173,7771.48,174620.544,case rate,,,
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,inpatient,,,57651.04,40355.728,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,17011.42205,,,17011.42205,7771.48,46120.832,case rate,,,
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,inpatient,,,28475.53,19932.871,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,31122.56935,,,31122.56935,7771.48,70820.6536,case rate,,,
Aortic And Heart Assist Procedures Except Pulsation Balloon With McC,268,MS-DRG,,,,,,,inpatient,,,101907.56,71335.292,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,59146.11541,,,59146.11541,7771.48,135104.1408,case rate,,,
Aortic And Heart Assist Procedures Except Pulsation Balloon Without McC,269,MS-DRG,,,,,,,inpatient,,,145888.49,102121.943,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,37001.99323,,,37001.99323,7771.48,116710.792,case rate,,,
Other Major Cardiovascular Procedures With McC,270,MS-DRG,,,,,,,inpatient,,,185659.89,129961.923,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,45590.58073,,,45590.58073,7771.48,148527.912,case rate,,,
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,inpatient,,,127626.27,89338.389,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,30674.72261,,,30674.72261,7771.48,102101.016,case rate,,,
Other Major Cardiovascular Procedures Without Cc/McC,272,MS-DRG,,,,,,,inpatient,,,104134.1,72893.87,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,22352.01651,,,22352.01651,7771.48,83307.28,case rate,,,
Percutaneous And Other Intracardiac Procedures Without McC,274,MS-DRG,,,,,,,inpatient,,,98959.28,69271.496,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,27818.0434,,,27818.0434,7771.48,79167.424,case rate,,,
Cardiac Defibrillator Implant With Cardiac Catheterization And McC,275,MS-DRG,,,,,,,inpatient,,,167450.04,117215.028,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,62674.12307,,,62674.12307,7771.48,143195.556,case rate,,,
Cardiac Defibrillator Implant Without McC,277,MS-DRG,,,,,,,inpatient,,,278318.05,194822.635,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,41340.89499,,,41340.89499,7771.48,222654.44,case rate,,,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With McC,278,MS-DRG,,,,,,,inpatient,,,130044.83,91031.381,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,44444.90573,,,44444.90573,7771.48,104035.864,case rate,,,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without McC,279,MS-DRG,,,,,,,inpatient,,,135336.66,94735.662,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,28554.73804,,,28554.73804,7771.48,108269.328,case rate,,,
Acute Myocardial Infarction- Discharged Alive With McC,280,MS-DRG,,,,,,,inpatient,,,31571.18,22099.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14748.33852,,,14748.33852,7771.48,33263.356,case rate,,,
Acute Myocardial Infarction- Discharged Alive With Cc,281,MS-DRG,,,,,,,inpatient,,,22298.62,15609.034,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8391.918109,,,8391.918109,6744.11,18679.3552,case rate,,,
Acute Myocardial Infarction- Discharged Alive Without Cc/McC,282,MS-DRG,,,,,,,inpatient,,,15726.17,11008.319,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6654.414087,,,6654.414087,5244.677695,14693.4264,case rate,,,
Acute Myocardial Infarction- Expired With McC,283,MS-DRG,,,,,,,inpatient,,,47695.81,33387.067,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,17521.985,,,17521.985,7771.48,39624.2256,case rate,,,
Acute Myocardial Infarction- Expired With Cc,284,MS-DRG,,,,,,,inpatient,,,30935.67,21654.969,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6794.863065,,,6794.863065,5312.22,24748.536,case rate,,,
Circulatory Disorders Except Ami- With Cardiac Catheterization With McC,286,MS-DRG,,,,,,,inpatient,,,48769.97,34138.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19800.08508,,,19800.08508,7771.48,44850.3112,case rate,,,
Circulatory Disorders Except Ami- With Cardiac Catheterization Without McC,287,MS-DRG,,,,,,,inpatient,,,33854.25,23697.975,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9875.023982,,,9875.023982,7771.48,27083.4,case rate,,,
Acute And Subacute Endocarditis With McC,288,MS-DRG,,,,,,,inpatient,,,36276.49,25393.543,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,24377.48511,,,24377.48511,7771.48,55347.0632,case rate,,,
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,inpatient,,,34648,24253.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14176.82601,,,14176.82601,7771.48,31948.2224,case rate,,,
Heart Failure And Shock With McC,291,MS-DRG,,,,,,,inpatient,,,22051.33,15435.931,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11775.06015,,,11775.06015,7354.118555,26442.4936,case rate,,,
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,inpatient,,,17435.09,12204.563,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7856.622005,,,7856.622005,5814.602515,17453.3832,case rate,,,
Cardiac Arrest- Unexplained With McC,296,MS-DRG,,,,,,,inpatient,,,34260.06,23982.042,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14721.83871,,,14721.83871,7771.48,33198.5112,case rate,,,
Peripheral Vascular Disorders With McC,299,MS-DRG,,,,,,,inpatient,,,30642.24,21449.568,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14538.10671,,,14538.10671,7771.48,32781.0728,case rate,,,
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,inpatient,,,19909.9,13936.93,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9706.308543,,,9706.308543,6639.95165,21692.612,case rate,,,
Peripheral Vascular Disorders Without Cc/McC,301,MS-DRG,,,,,,,inpatient,,,15022.69,10515.883,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6551.064839,,,6551.064839,5010.067115,14454.3112,case rate,,,
Atherosclerosis With McC,302,MS-DRG,,,,,,,inpatient,,,19965.6,13975.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10525.15258,,,10525.15258,6658.5276,23571.0848,case rate,,,
Atherosclerosis Without McC,303,MS-DRG,,,,,,,inpatient,,,16291.73,11404.211,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6188.900808,,,6188.900808,4894.02,13625.5136,case rate,,,
Hypertension With McC,304,MS-DRG,,,,,,,inpatient,,,26689.62,18682.734,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10626.73518,,,10626.73518,7771.48,23806.1472,case rate,,,
Hypertension Without McC,305,MS-DRG,,,,,,,inpatient,,,17122.11,11985.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6880.545775,,,6880.545775,5343.34,15212.1848,case rate,,,
Cardiac Congenital And Valvular Disorders With McC,306,MS-DRG,,,,,,,inpatient,,,18809.29,13166.503,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13476.34777,,,13476.34777,6272.898215,30343.3136,case rate,,,
Cardiac Congenital And Valvular Disorders Without McC,307,MS-DRG,,,,,,,inpatient,,,16249.07,11374.349,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8432.551146,,,8432.551146,5419.064845,18770.5432,case rate,,,
Cardiac Arrhythmia And Conduction Disorders With McC,308,MS-DRG,,,,,,,inpatient,,,21486.31,15040.417,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10901.44985,,,10901.44985,7165.684385,24438.384,case rate,,,
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,inpatient,,,15843.59,11090.513,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6779.846508,,,6779.846508,5283.837265,14981.1752,case rate,,,
Cardiac Arrhythmia And Conduction Disorders Without Cc/McC,310,MS-DRG,,,,,,,inpatient,,,13559.61,9491.727,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5191.624733,,,5191.624733,4040.24,11337.708,case rate,,,
Angina Pectoris,311,MS-DRG,,,,,,,inpatient,,,18298.95,12809.265,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6417.682477,,,6417.682477,5043.07,14639.16,case rate,,,
Syncope And Collapse,312,MS-DRG,,,,,,,inpatient,,,18654.24,13057.968,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7945.838022,,,7945.838022,6057.47,17656.0232,case rate,,,
Chest Pain,313,MS-DRG,,,,,,,inpatient,,,18746.43,13122.501,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6551.064839,,,6551.064839,5215.27,14997.144,case rate,,,
Other Circulatory System Diagnoses With McC,314,MS-DRG,,,,,,,inpatient,,,33351.93,23346.351,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19271.8556,,,19271.8556,7771.48,43636.4976,case rate,,,
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,inpatient,,,17192.63,12034.841,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8749.665505,,,8749.665505,5733.742105,19500.0472,case rate,,,
Other Circulatory System Diagnoses Without Cc/McC,316,MS-DRG,,,,,,,inpatient,,,16812.59,11768.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6279.883479,,,6279.883479,5422.92,13832.2064,case rate,,,
Percutaneous Cardiovascular Procedures With Intraluminal Device With McC Or 4+ Arteries/Intraluminal Devices,321,MS-DRG,,,,,,,inpatient,,,107897.8,75528.46,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,25395.96103,,,25395.96103,7771.48,86318.24,case rate,,,
Percutaneous Cardiovascular Procedures With Intraluminal Device Without McC,322,MS-DRG,,,,,,,inpatient,,,85234.32,59664.024,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16230.56106,,,16230.56106,7771.48,68187.456,case rate,,,
Coronary Intravascular Lithotripsy With Intraluminal Device With McC,323,MS-DRG,,,,,,,inpatient,,,110878.49,77614.943,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,37873.83688,,,37873.83688,7771.48,88702.792,case rate,,,
Coronary Intravascular Lithotripsy With Intraluminal Device Without McC,324,MS-DRG,,,,,,,inpatient,,,99829.51,69880.657,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,28472.58864,,,28472.58864,7771.48,79863.608,case rate,,,
Stomach- Esophageal And Duodenal Procedures With McC,326,MS-DRG,,,,,,,inpatient,,,70344.55,49241.185,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,45113.5842,,,45113.5842,7771.48,102914.7768,case rate,,,
Stomach- Esophageal And Duodenal Procedures With Cc,327,MS-DRG,,,,,,,inpatient,,,76692.68,53684.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,21697.47128,,,21697.47128,7771.48,61354.144,case rate,,,
Stomach- Esophageal And Duodenal Procedures Without Cc/McC,328,MS-DRG,,,,,,,inpatient,,,58306.69,40814.683,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14325.22493,,,14325.22493,7771.48,46645.352,case rate,,,
Major Small And Large Bowel Procedures With McC,329,MS-DRG,,,,,,,inpatient,,,92091.01,64463.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,40810.89884,,,40810.89884,7771.48,93046.2088,case rate,,,
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,inpatient,,,66292.87,46405.009,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,21128.60875,,,21128.60875,7771.48,53034.296,case rate,,,
Major Small And Large Bowel Procedures Without Cc/McC,331,MS-DRG,,,,,,,inpatient,,,44944.36,31461.052,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14833.1379,,,14833.1379,7771.48,35955.488,case rate,,,
Rectal Resection With McC,332,MS-DRG,,,,,,,inpatient,,,65516.56,45861.592,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,30889.37105,,,30889.37105,7771.48,70285.684,case rate,,,
Rectal Resection With Cc,333,MS-DRG,,,,,,,inpatient,,,51060.47,35742.329,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19022.75741,,,19022.75741,7771.48,43063.0264,case rate,,,
Peritoneal Adhesiolysis With McC,335,MS-DRG,,,,,,,inpatient,,,76073.75,53251.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,32255.87777,,,32255.87777,7771.48,73434.7096,case rate,,,
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,inpatient,,,39391.39,27573.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,18907.92491,,,18907.92491,7771.48,42805.6736,case rate,,,
Peritoneal Adhesiolysis Without Cc/McC,337,MS-DRG,,,,,,,inpatient,,,43856.45,30699.515,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13809.36202,,,13809.36202,7771.48,35085.16,case rate,,,
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,inpatient,,,22777.13,15943.991,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13399.49833,,,13399.49833,7596.172855,30177.1488,case rate,,,
Minor Small And Large Bowel Procedures Without Cc/McC,346,MS-DRG,,,,,,,inpatient,,,25360.83,17752.581,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11249.48065,,,11249.48065,7771.48,25232.7328,case rate,,,
Anal And Stomal Procedures With McC,347,MS-DRG,,,,,,,inpatient,,,33046.94,23132.858,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,21155.99188,,,21155.99188,7771.48,47956.7824,case rate,,,
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,inpatient,,,21678.05,15174.635,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11369.61311,,,11369.61311,7229.629675,25508.3232,case rate,,,
Anal And Stomal Procedures Without Cc/McC,349,MS-DRG,,,,,,,inpatient,,,20851.83,14596.281,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8030.637405,,,8030.637405,6954.085305,17850.5576,case rate,,,
Inguinal And Femoral Hernia Procedures With McC,350,MS-DRG,,,,,,,inpatient,,,123839.74,86687.818,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,21614.43855,,,21614.43855,7771.48,99071.792,case rate,,,
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,inpatient,,,41444.06,29010.842,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13539.06398,,,13539.06398,7771.48,33155.248,case rate,,,
Inguinal And Femoral Hernia Procedures Without Cc/McC,352,MS-DRG,,,,,,,inpatient,,,27314.17,19119.919,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9988.973153,,,9988.973153,7771.48,22341.06,case rate,,,
Hernia Procedures Except Inguinal And Femoral With McC,353,MS-DRG,,,,,,,inpatient,,,60356.38,42249.466,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,26157.38882,,,26157.38882,7771.48,59430.2592,case rate,,,
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,inpatient,,,30185.36,21129.752,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15275.68468,,,15275.68468,7771.48,34471.0904,case rate,,,
Hernia Procedures Except Inguinal And Femoral Without Cc/McC,355,MS-DRG,,,,,,,inpatient,,,34745.89,24322.123,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12025.925,,,12025.925,7771.48,27796.712,case rate,,,
Other Digestive System O.R. Procedures With McC,356,MS-DRG,,,,,,,inpatient,,,122041.99,85429.393,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,37929.48648,,,37929.48648,7771.48,97633.592,case rate,,,
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,inpatient,,,40025.14,28017.598,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,20141.9326,,,20141.9326,7771.48,45632.5016,case rate,,,
Other Digestive System O.R. Procedures Without Cc/McC,358,MS-DRG,,,,,,,inpatient,,,22899.78,16029.846,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12219.37359,,,12219.37359,7637.07663,27457.72,case rate,,,
Major Esophageal Disorders With McC,368,MS-DRG,,,,,,,inpatient,,,52357.14,36649.998,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15000.97001,,,15000.97001,7771.48,41885.712,case rate,,,
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,inpatient,,,25013.89,17509.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9238.145284,,,9238.145284,7771.48,20620.6464,case rate,,,
Major Gastrointestinal Disorders And Peritoneal Infections With McC,371,MS-DRG,,,,,,,inpatient,,,31663.98,22164.786,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15689.965,,,15689.965,7771.48,35427.5512,case rate,,,
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,inpatient,,,22657.22,15860.054,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9341.494532,,,9341.494532,7435.09,20857.7352,case rate,,,
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/McC,373,MS-DRG,,,,,,,inpatient,,,16862.96,11804.072,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6657.064068,,,6657.064068,5379.51,14697.4792,case rate,,,
Digestive Malignancy With McC,374,MS-DRG,,,,,,,inpatient,,,35452.33,24816.631,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,18899.97497,,,18899.97497,7771.48,42787.436,case rate,,,
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,inpatient,,,28899.99,20229.993,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11102.84838,,,11102.84838,7771.48,24898.3768,case rate,,,
Digestive Malignancy Without Cc/McC,376,MS-DRG,,,,,,,inpatient,,,13461.5,9423.05,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8049.18727,,,8049.18727,4489.41025,17891.0856,case rate,,,
Gastrointestinal Hemorrhage With McC,377,MS-DRG,,,,,,,inpatient,,,36368.06,25457.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16310.06048,,,16310.06048,7771.48,36841.9784,case rate,,,
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,inpatient,,,26039.38,18227.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8958.130655,,,8958.130655,7186.19,20831.504,case rate,,,
Gastrointestinal Hemorrhage Without Cc/McC,379,MS-DRG,,,,,,,inpatient,,,12685.62,8879.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5873.553103,,,5873.553103,4230.65427,12900.0624,case rate,,,
Complicated Peptic Ulcer With McC,380,MS-DRG,,,,,,,inpatient,,,33309.68,23316.776,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,17247.27033,,,17247.27033,7771.48,38994.0152,case rate,,,
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,inpatient,,,25551.79,17886.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9869.724021,,,9869.724021,7667.34,22069.5224,case rate,,,
Uncomplicated Peptic Ulcer With McC,383,MS-DRG,,,,,,,inpatient,,,17337.01,12135.907,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11416.42943,,,11416.42943,5781.892835,25617.7488,case rate,,,
Uncomplicated Peptic Ulcer Without McC,384,MS-DRG,,,,,,,inpatient,,,17367.77,12157.439,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7930.821465,,,7930.821465,5792.151295,17621.5744,case rate,,,
Inflammatory Bowel Disease With McC,385,MS-DRG,,,,,,,inpatient,,,26393.7,18475.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14601.70625,,,14601.70625,7771.48,32922.9208,case rate,,,
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,inpatient,,,16705.38,11693.766,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9016.430231,,,9016.430231,5571.24423,20109.9936,case rate,,,
Inflammatory Bowel Disease Without Cc/McC,387,MS-DRG,,,,,,,inpatient,,,12511.84,8758.288,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6170.350943,,,6170.350943,4172.69864,13582.9592,case rate,,,
Gastrointestinal Obstruction With McC,388,MS-DRG,,,,,,,inpatient,,,25855.59,18098.913,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13233.43287,,,13233.43287,7771.48,29788.08,case rate,,,
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,inpatient,,,16977.78,11884.446,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7330.159169,,,7330.159169,5662.08963,16245.6488,case rate,,,
Gastrointestinal Obstruction Without Cc/McC,390,MS-DRG,,,,,,,inpatient,,,12959.35,9071.545,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5082.975523,,,5082.975523,4215.34,11086.4344,case rate,,,
Esophagitis- Gastroenteritis And Miscellaneous Digestive Disorders With McC,391,MS-DRG,,,,,,,inpatient,,,20838.16,14586.712,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11595.74479,,,11595.74479,6949.52636,26037.2136,case rate,,,
Esophagitis- Gastroenteritis And Miscellaneous Digestive Disorders Without McC,392,MS-DRG,,,,,,,inpatient,,,16987.8,11891.46,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7142.010538,,,7142.010538,5530.73,15811.9992,case rate,,,
Other Digestive System Diagnoses With McC,393,MS-DRG,,,,,,,inpatient,,,37534.54,26274.178,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14877.30424,,,14877.30424,7771.48,33555.1576,case rate,,,
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,inpatient,,,23011.57,16108.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8564.166855,,,8564.166855,6791.14,19074.5032,case rate,,,
Other Digestive System Diagnoses Without Cc/McC,395,MS-DRG,,,,,,,inpatient,,,17300.89,12110.623,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5870.903122,,,5870.903122,4700.83,13840.712,case rate,,,
Appendix Procedures With McC,397,MS-DRG,,,,,,,inpatient,,,61991.24,43393.868,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,22136.48475,,,22136.48475,7771.48,50206.0864,case rate,,,
Appendix Procedures With Cc,398,MS-DRG,,,,,,,inpatient,,,56760.43,39732.301,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13615.91342,,,13615.91342,7771.48,45408.344,case rate,,,
Appendix Procedures Without Cc/McC,399,MS-DRG,,,,,,,inpatient,,,27586.47,19310.529,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10176.23846,,,10176.23846,7771.48,22778.7624,case rate,,,
Pancreas- Liver And Shunt Procedures With McC,405,MS-DRG,,,,,,,inpatient,,,46019.16,32213.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,48202.57838,,,48202.57838,7771.48,110001.0976,case rate,,,
Pancreas- Liver And Shunt Procedures With Cc,406,MS-DRG,,,,,,,inpatient,,,55926.32,39148.424,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,25056.7635,,,25056.7635,7771.48,56905.3648,case rate,,,
Pancreas- Liver And Shunt Procedures Without Cc/McC,407,MS-DRG,,,,,,,inpatient,,,51764.06,36234.842,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19115.50673,,,19115.50673,7771.48,43275.7984,case rate,,,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,inpatient,,,23884.65,16719.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,18768.35926,,,18768.35926,7771.48,42479.4232,case rate,,,
Laparoscopic Cholecystectomy Without C.D.E. With McC,417,MS-DRG,,,,,,,inpatient,,,63968.01,44777.607,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,21241.67459,,,21241.67459,7771.48,51174.408,case rate,,,
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,inpatient,,,44129.12,30890.384,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14898.50409,,,14898.50409,7771.48,35303.296,case rate,,,
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/McC,419,MS-DRG,,,,,,,inpatient,,,36100.79,25270.553,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11888.126,,,11888.126,7771.48,28880.632,case rate,,,
Hepatobiliary Diagnostic Procedures With McC,420,MS-DRG,,,,,,,inpatient,,,75254.61,52678.227,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,31426.43381,,,31426.43381,7771.48,71515.7088,case rate,,,
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,,,inpatient,,,37061.98,25943.386,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14714.77209,,,14714.77209,7771.48,33182.3,case rate,,,
Hepatobiliary Diagnostic Procedures Without Cc/McC,422,MS-DRG,,,,,,,inpatient,,,34064.62,23845.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13229.01624,,,13229.01624,7771.48,29773.8952,case rate,,,
Other Hepatobiliary Or Pancreas O.R. Procedures With McC,423,MS-DRG,,,,,,,inpatient,,,81747.41,57223.187,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,36177.84923,,,36177.84923,7771.48,82415.7144,case rate,,,
Cirrhosis And Alcoholic Hepatitis With McC,432,MS-DRG,,,,,,,inpatient,,,29574.59,20702.213,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,17554.66809,,,17554.66809,7771.48,39699.2024,case rate,,,
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,inpatient,,,21623.94,15136.758,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9699.241928,,,9699.241928,7211.58399,21676.4008,case rate,,,
Cirrhosis And Alcoholic Hepatitis Without Cc/McC,434,MS-DRG,,,,,,,inpatient,,,14349.7,10044.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6401.782592,,,6401.782592,4483.05,14111.8496,case rate,,,
Malignancy Of Hepatobiliary System Or Pancreas With McC,435,MS-DRG,,,,,,,inpatient,,,41847.14,29292.998,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16366.59341,,,16366.59341,7771.48,36971.668,case rate,,,
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,inpatient,,,20489.14,14342.398,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10210.68821,,,10210.68821,6833.12819,22849.6864,case rate,,,
Disorders Of Pancreas Except Malignancy With McC,438,MS-DRG,,,,,,,inpatient,,,28902.5,20231.75,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14945.32042,,,14945.32042,7771.48,33715.2432,case rate,,,
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,inpatient,,,16481.74,11537.218,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7847.788735,,,7847.788735,5496.66029,17431.0928,case rate,,,
Disorders Of Pancreas Except Malignancy Without Cc/McC,440,MS-DRG,,,,,,,inpatient,,,15295.1,10706.57,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5682.754492,,,5682.754492,4383.92,12464.3864,case rate,,,
Disorders Of Liver Except Malignancy- Cirrhosis Or Alcoholic Hepatitis With McC,441,MS-DRG,,,,,,,inpatient,,,34043.85,23830.695,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16947.82251,,,16947.82251,7771.48,38305.0392,case rate,,,
Disorders Of Liver Except Malignancy- Cirrhosis Or Alcoholic Hepatitis With Cc,442,MS-DRG,,,,,,,inpatient,,,21274.77,14892.339,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8784.115255,,,8784.115255,6740.49,19579.0768,case rate,,,
Disorders Of Liver Except Malignancy- Cirrhosis Or Alcoholic Hepatitis Without Cc/McC,443,MS-DRG,,,,,,,inpatient,,,11297.88,7908.516,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6456.54886,,,6456.54886,3767.84298,14237.4864,case rate,,,
Disorders Of The Biliary Tract With McC,444,MS-DRG,,,,,,,inpatient,,,39694.28,27785.996,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15128.16909,,,15128.16909,7771.48,34134.708,case rate,,,
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,inpatient,,,32558.38,22790.866,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9829.090983,,,9829.090983,7771.48,26046.704,case rate,,,
Disorders Of The Biliary Tract Without Cc/McC,446,MS-DRG,,,,,,,inpatient,,,33146.93,23202.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7292.176112,,,7292.176112,5905.53,26517.544,case rate,,,
Spinal Fusion Except Cervical With Spinal Curvature- Malignancy- Infection Or Extensive Fusions With Cc,457,MS-DRG,,,,,,,inpatient,,,143333.97,100333.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,50947.07508,,,50947.07508,7771.48,116295.096,case rate,,,
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With McC,461,MS-DRG,,,,,,,inpatient,,,327456.17,229219.319,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,54456.53287,,,54456.53287,7771.48,261964.936,case rate,,,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With McC,463,MS-DRG,,,,,,,inpatient,,,128878.42,90214.894,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,47957.89683,,,47957.89683,7771.48,109439.7848,case rate,,,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With Cc,464,MS-DRG,,,,,,,inpatient,,,40970.26,28679.182,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,26295.18782,,,26295.18782,7771.48,59750.4304,case rate,,,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Without Cc/McC,465,MS-DRG,,,,,,,inpatient,,,35885.97,25120.179,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15584.84909,,,15584.84909,7771.48,35176.2776,case rate,,,
Revision Of Hip Or Knee Replacement With McC,466,MS-DRG,,,,,,,inpatient,,,84828.36,59379.852,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,45251.38319,,,45251.38319,7771.48,103230.8952,case rate,,,
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,inpatient,,,72170.88,50519.616,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,30505.12384,,,30505.12384,7771.48,69402.1736,case rate,,,
Revision Of Hip Or Knee Replacement Without Cc/McC,468,MS-DRG,,,,,,,inpatient,,,88973.4,62281.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,23421.72539,,,23421.72539,7771.48,71178.72,case rate,,,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With McC Or Total Ankle Replacement,469,MS-DRG,,,,,,,inpatient,,,112079.98,78455.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,29122.71724,,,29122.71724,7771.48,89663.984,case rate,,,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without McC,470,MS-DRG,,,,,,,inpatient,,,49135.63,34394.941,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16904.53949,,,16904.53949,7771.48,39308.504,case rate,,,
Cervical Spinal Fusion With McC,471,MS-DRG,,,,,,,inpatient,,,68213.66,47749.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,43155.24845,,,43155.24845,7771.48,98422.248,case rate,,,
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,inpatient,,,62194.58,43536.206,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,25841.15779,,,25841.15779,7771.48,58704.808,case rate,,,
Cervical Spinal Fusion Without Cc/McC,473,MS-DRG,,,,,,,inpatient,,,60389.67,42272.769,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,21161.29185,,,21161.29185,7771.48,48311.736,case rate,,,
Amputation For Musculoskeletal System And Connective Tissue Disorders With McC,474,MS-DRG,,,,,,,inpatient,,,118369.6,82858.72,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,39863.9724,,,39863.9724,7771.48,94695.68,case rate,,,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,inpatient,,,42743.34,29920.338,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19305.42202,,,19305.42202,7771.48,43711.4744,case rate,,,
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/McC,476,MS-DRG,,,,,,,inpatient,,,10865.65,7605.955,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10523.38593,,,10523.38593,3623.694275,23567.032,case rate,,,
Biopsies Of Musculoskeletal System And Connective Tissue With McC,477,MS-DRG,,,,,,,inpatient,,,79298.26,55508.782,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,30627.02296,,,30627.02296,7771.48,69683.8432,case rate,,,
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,inpatient,,,43683.25,30578.275,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,20906.8937,,,20906.8937,7771.48,47385.3376,case rate,,,
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/McC,479,MS-DRG,,,,,,,inpatient,,,48180.79,33726.553,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15935.52988,,,15935.52988,7771.48,38544.632,case rate,,,
Hip And Femur Procedures Except Major Joint With McC,480,MS-DRG,,,,,,,inpatient,,,63845.68,44691.976,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,26228.05497,,,26228.05497,7771.48,59596.424,case rate,,,
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,inpatient,,,51147.69,35803.383,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,18577.56065,,,18577.56065,7771.48,42045.7736,case rate,,,
Hip And Femur Procedures Except Major Joint Without Cc/McC,482,MS-DRG,,,,,,,inpatient,,,37492.92,26245.044,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14262.50872,,,14262.50872,7771.48,32146.8096,case rate,,,
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,inpatient,,,82685.37,57879.759,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,22758.34689,,,22758.34689,7771.48,66148.296,case rate,,,
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,inpatient,,,54953.11,38467.177,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,18983.89102,,,18983.89102,7771.48,43962.488,case rate,,,
Knee Procedures With Principal Diagnosis Of Infection Without Cc/McC,487,MS-DRG,,,,,,,inpatient,,,28558.04,19990.628,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14207.74245,,,14207.74245,7771.48,32019.1464,case rate,,,
Knee Procedures Without Principal Diagnosis Of Infection With Cc/McC,488,MS-DRG,,,,,,,inpatient,,,29907.22,20935.054,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,17610.31769,,,17610.31769,7771.48,39824.8392,case rate,,,
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/McC,489,MS-DRG,,,,,,,inpatient,,,28726.07,20108.249,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11188.53109,,,11188.53109,7771.48,25098.9904,case rate,,,
Lower Extremity And Humerus Procedures Except Hip- Foot And Femur With McC,492,MS-DRG,,,,,,,inpatient,,,73476.69,51433.683,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,31618.11574,,,31618.11574,7771.48,71957.464,case rate,,,
Lower Extremity And Humerus Procedures Except Hip- Foot And Femur With Cc,493,MS-DRG,,,,,,,inpatient,,,59232.47,41462.729,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,21458.08969,,,21458.08969,7771.48,48653.864,case rate,,,
Lower Extremity And Humerus Procedures Except Hip- Foot And Femur Without Cc/McC,494,MS-DRG,,,,,,,inpatient,,,55024.26,38516.982,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16903.65616,,,16903.65616,7771.48,44019.408,case rate,,,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/McC,497,MS-DRG,,,,,,,inpatient,,,25582.79,17907.953,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12108.95772,,,12108.95772,7771.48,27214.552,case rate,,,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/McC,498,MS-DRG,,,,,,,inpatient,,,53889.53,37722.671,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,22552.53172,,,22552.53172,7771.48,51160.5208,case rate,,,
Soft Tissue Procedures With McC,500,MS-DRG,,,,,,,inpatient,,,39746.36,27822.452,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,28239.39033,,,28239.39033,7771.48,64206.484,case rate,,,
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,inpatient,,,35413.37,24789.359,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16014.14597,,,16014.14597,7771.48,36169.2136,case rate,,,
Soft Tissue Procedures Without Cc/McC,502,MS-DRG,,,,,,,inpatient,,,46820.44,32774.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12591.25421,,,12591.25421,7771.48,37456.352,case rate,,,
Foot Procedures With McC,503,MS-DRG,,,,,,,inpatient,,,139085.96,97360.172,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,23627.54056,,,23627.54056,7771.48,111268.768,case rate,,,
Foot Procedures With Cc,504,MS-DRG,,,,,,,inpatient,,,58509.52,40956.664,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15751.79788,,,15751.79788,7771.48,46807.616,case rate,,,
Foot Procedures Without Cc/McC,505,MS-DRG,,,,,,,inpatient,,,18215.65,12750.955,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15751.79788,,,15751.79788,6074.919275,35575.4784,case rate,,,
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,inpatient,,,34935.4,24454.78,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13491.36433,,,13491.36433,7771.48,30375.736,case rate,,,
Major Shoulder Or Elbow Joint Procedures With Cc/McC,507,MS-DRG,,,,,,,inpatient,,,46308.19,32415.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,17370.05277,,,17370.05277,7771.48,39273.6584,case rate,,,
Major Shoulder Or Elbow Joint Procedures Without Cc/McC,508,MS-DRG,,,,,,,inpatient,,,21924.51,15347.157,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11649.62773,,,11649.62773,7311.824085,26152.7184,case rate,,,
Arthroscopy,509,MS-DRG,,,,,,,inpatient,,,27294.99,19106.493,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15766.81444,,,15766.81444,7771.48,35593.716,case rate,,,
Shoulder- Elbow Or Forearm Procedures- Except Major Joint Procedures With McC,510,MS-DRG,,,,,,,inpatient,,,62572,43800.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,25495.77697,,,25495.77697,7771.48,57914.512,case rate,,,
Shoulder- Elbow Or Forearm Procedures- Except Major Joint Procedures With Cc,511,MS-DRG,,,,,,,inpatient,,,55415.55,38790.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,17573.21796,,,17573.21796,7771.48,44332.44,case rate,,,
Shoulder- Elbow Or Forearm Procedures- Except Major Joint Procedures Without Cc/McC,512,MS-DRG,,,,,,,inpatient,,,47238.2,33066.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14451.54068,,,14451.54068,7771.48,37790.56,case rate,,,
Hand Or Wrist Procedures- Except Major Thumb Or Joint Procedures With Cc/McC,513,MS-DRG,,,,,,,inpatient,,,43600.38,30520.266,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13548.78058,,,13548.78058,7771.48,34880.304,case rate,,,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With McC,515,MS-DRG,,,,,,,inpatient,,,49277.7,34494.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,27565.41191,,,27565.41191,7771.48,62660.3408,case rate,,,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,inpatient,,,53176.69,37223.683,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,18019.29804,,,18019.29804,7771.48,42541.352,case rate,,,
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/McC,517,MS-DRG,,,,,,,inpatient,,,52111.68,36478.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13434.83141,,,13434.83141,7771.48,41689.344,case rate,,,
Back And Neck Procedures Except Spinal Fusion With McC Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,inpatient,,,37618.21,26332.747,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,31907.84697,,,31907.84697,7771.48,72622.1232,case rate,,,
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,inpatient,,,45454.66,31818.262,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,17667.73394,,,17667.73394,7771.48,39954.5288,case rate,,,
Back And Neck Procedures Except Spinal Fusion Without Cc/McC,520,MS-DRG,,,,,,,inpatient,,,30414.64,21290.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12909.2519,,,12909.2519,7771.48,29040.3384,case rate,,,
Hip Replacement With Principal Diagnosis Of Hip Fracture With McC,521,MS-DRG,,,,,,,inpatient,,,66299.82,46409.874,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,25995.74,,,25995.74,7771.48,59061.4544,case rate,,,
Hip Replacement With Principal Diagnosis Of Hip Fracture Without McC,522,MS-DRG,,,,,,,inpatient,,,59172.56,41420.792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,18870.82518,,,18870.82518,7771.48,47338.048,case rate,,,
Fractures Of Femur With McC,533,MS-DRG,,,,,,,inpatient,,,15534.08,10873.856,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13719.26267,,,13719.26267,5180.61568,30898.5472,case rate,,,
Fractures Of Femur Without McC,534,MS-DRG,,,,,,,inpatient,,,23461.3,16422.91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7439.691705,,,7439.691705,5705.828554,18769.04,case rate,,,
Fractures Of Hip And Pelvis With McC,535,MS-DRG,,,,,,,inpatient,,,19899.42,13929.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11996.77521,,,11996.77521,6636.45657,26949.0936,case rate,,,
Fractures Of Hip And Pelvis Without McC,536,MS-DRG,,,,,,,inpatient,,,17540.07,12278.049,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7412.308571,,,7412.308571,5582.83,16432.0776,case rate,,,
Sprains- Strains- And Dislocations Of Hip- Pelvis And Thigh With Cc/McC,537,MS-DRG,,,,,,,inpatient,,,18243.05,12770.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8367.184956,,,8367.184956,6084.057175,18620.5896,case rate,,,
Sprains- Strains- And Dislocations Of Hip- Pelvis And Thigh Without Cc/McC,538,MS-DRG,,,,,,,inpatient,,,12750.59,8925.413,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6180.950866,,,6180.950866,4252.321765,13607.276,case rate,,,
Osteomyelitis With McC,539,MS-DRG,,,,,,,inpatient,,,15126.14,10588.298,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,18113.81402,,,18113.81402,5044.56769,40987.9928,case rate,,,
Osteomyelitis With Cc,540,MS-DRG,,,,,,,inpatient,,,18734.75,13114.325,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11680.54418,,,11680.54418,6248.039125,26229.7216,case rate,,,
Osteomyelitis Without Cc/McC,541,MS-DRG,,,,,,,inpatient,,,13958.41,9770.887,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7977.63779,,,7977.63779,4655.129735,17726.9472,case rate,,,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With McC,542,MS-DRG,,,,,,,inpatient,,,18971.85,13280.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16724.3408,,,16724.3408,6327.111975,37790.3336,case rate,,,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,inpatient,,,20157.83,14110.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9620.625833,,,9620.625833,6722.636305,21496.0512,case rate,,,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/McC,544,MS-DRG,,,,,,,inpatient,,,15770.25,11039.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6924.71212,,,6924.71212,5259.378375,15313.5048,case rate,,,
Connective Tissue Disorders With McC,545,MS-DRG,,,,,,,inpatient,,,29219.27,20453.489,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,22570.19826,,,22570.19826,7771.48,51201.0488,case rate,,,
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,inpatient,,,19656.15,13759.305,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10475.68628,,,10475.68628,6555.326025,23459.6328,case rate,,,
Connective Tissue Disorders Without Cc/McC,547,MS-DRG,,,,,,,inpatient,,,8610.08,6027.056,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6840.796064,,,6840.796064,2871.46168,15120.9968,case rate,,,
Septic Arthritis With Cc,549,MS-DRG,,,,,,,inpatient,,,46061.25,32242.875,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10894.38323,,,10894.38323,7771.48,36849,case rate,,,
Medical Back Problems With McC,551,MS-DRG,,,,,,,inpatient,,,27883.52,19518.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15322.501,,,15322.501,7771.48,34576.4632,case rate,,,
Medical Back Problems Without McC,552,MS-DRG,,,,,,,inpatient,,,22361.84,15653.288,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8762.915409,,,8762.915409,6815.74,19530.4432,case rate,,,
Bone Diseases And Arthropathies With McC,553,MS-DRG,,,,,,,inpatient,,,13901.34,9730.938,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11785.66008,,,11785.66008,4636.09689,26470.8632,case rate,,,
Bone Diseases And Arthropathies Without McC,554,MS-DRG,,,,,,,inpatient,,,18962.8,13273.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7621.657048,,,7621.657048,5718.85,16912.3344,case rate,,,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without McC,556,MS-DRG,,,,,,,inpatient,,,20178.82,14125.174,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7461.774878,,,7461.774878,5833.89,16545.556,case rate,,,
Tendonitis- Myositis And Bursitis With McC,557,MS-DRG,,,,,,,inpatient,,,32769.21,22938.447,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13938.32774,,,13938.32774,7771.48,31403.1208,case rate,,,
Tendonitis- Myositis And Bursitis Without McC,558,MS-DRG,,,,,,,inpatient,,,15272.59,10690.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7879.588504,,,7879.588504,5093.408765,17504.0432,case rate,,,
Aftercare- Musculoskeletal System And Connective Tissue With McC,559,MS-DRG,,,,,,,inpatient,,,16267.53,11387.271,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16646.60803,,,16646.60803,5425.221255,37612.0104,case rate,,,
Aftercare- Musculoskeletal System And Connective Tissue With Cc,560,MS-DRG,,,,,,,inpatient,,,15449.56,10814.692,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10307.85417,,,10307.85417,5152.42826,23076.6432,case rate,,,
Aftercare- Musculoskeletal System And Connective Tissue Without Cc/McC,561,MS-DRG,,,,,,,inpatient,,,9300.65,6510.455,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7471.491474,,,7471.491474,3101.766775,16567.8464,case rate,,,
Fracture- Sprain- Strain And Dislocation Except Femur- Hip- Pelvis And Thigh With McC,562,MS-DRG,,,,,,,inpatient,,,32385.67,22669.969,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13176.89995,,,13176.89995,7771.48,29660.4168,case rate,,,
Fracture- Sprain- Strain And Dislocation Except Femur- Hip- Pelvis And Thigh Without McC,563,MS-DRG,,,,,,,inpatient,,,24167.6,16917.32,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8144.586575,,,8144.586575,6300.58,19334.08,case rate,,,
Other Musculoskeletal System And Connective Tissue Diagnoses With McC,564,MS-DRG,,,,,,,inpatient,,,25802.93,18062.051,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14110.57649,,,14110.57649,7771.48,31798.2688,case rate,,,
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,inpatient,,,22006.13,15404.291,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9256.695149,,,9256.695149,7280.97,20661.1744,case rate,,,
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/McC,566,MS-DRG,,,,,,,inpatient,,,6764.1,4734.87,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6857.579275,,,6857.579275,2255.82735,15157.472,case rate,,,
Skin Debridement With McC,570,MS-DRG,,,,,,,inpatient,,,33594.41,23516.087,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,26839.31719,,,26839.31719,7771.48,61002.7456,case rate,,,
Skin Debridement With Cc,571,MS-DRG,,,,,,,inpatient,,,26173.08,18321.156,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15038.95307,,,15038.95307,7771.48,33938.1472,case rate,,,
Skin Graft For Skin Ulcer Or Cellulitis With McC,573,MS-DRG,,,,,,,inpatient,,,229287.37,160501.159,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,54646.44815,,,54646.44815,7771.48,183429.896,case rate,,,
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,inpatient,,,76990.64,53893.448,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,30855.80463,,,30855.80463,7771.48,70208.6808,case rate,,,
Other Skin- Subcutaneous Tissue And Breast Procedures With McC,579,MS-DRG,,,,,,,inpatient,,,44370,31059,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,29040.56784,,,29040.56784,7771.48,66042.4024,case rate,,,
Other Skin- Subcutaneous Tissue And Breast Procedures With Cc,580,MS-DRG,,,,,,,inpatient,,,32530.15,22771.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15910.79672,,,15910.79672,7771.48,35926.0456,case rate,,,
Other Skin- Subcutaneous Tissue And Breast Procedures Without Cc/McC,581,MS-DRG,,,,,,,inpatient,,,34001.93,23801.351,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12962.25151,,,12962.25151,7771.48,29161.9224,case rate,,,
Mastectomy For Malignancy Without Cc/McC,583,MS-DRG,,,,,,,inpatient,,,26986.11,18890.277,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14759.82177,,,14759.82177,7771.48,33283.62,case rate,,,
Breast Biopsy- Local Excision And Other Breast Procedures With Cc/McC,584,MS-DRG,,,,,,,inpatient,,,15783.7,11048.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,18334.64575,,,18334.64575,5263.86395,41486.4872,case rate,,,
Skin Ulcers With McC,592,MS-DRG,,,,,,,inpatient,,,11607.65,8125.355,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,18413.26184,,,18413.26184,3871.151275,41666.8368,case rate,,,
Skin Ulcers With Cc,593,MS-DRG,,,,,,,inpatient,,,11196.69,7837.683,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11049.84877,,,11049.84877,3734.096115,24774.7664,case rate,,,
Skin Ulcers Without Cc/McC,594,MS-DRG,,,,,,,inpatient,,,9029.64,6320.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7746.206141,,,7746.206141,3011.38494,17196.0304,case rate,,,
Major Skin Disorders With McC,595,MS-DRG,,,,,,,inpatient,,,27847.46,19493.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,18932.65806,,,18932.65806,7771.48,42858.36,case rate,,,
Major Skin Disorders Without McC,596,MS-DRG,,,,,,,inpatient,,,30386.11,21270.277,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9799.057868,,,9799.057868,7157.25,24308.888,case rate,,,
Malignant Breast Disorders With McC,597,MS-DRG,,,,,,,inpatient,,,49956.04,34969.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15766.81444,,,15766.81444,7771.48,39964.832,case rate,,,
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,inpatient,,,27430.15,19201.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9779.624676,,,9779.624676,7771.48,21944.12,case rate,,,
Non-Malignant Breast Disorders With Cc/McC,600,MS-DRG,,,,,,,inpatient,,,13956.43,9769.501,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8699.315872,,,8699.315872,4654.469405,19396.7008,case rate,,,
Non-Malignant Breast Disorders Without Cc/McC,601,MS-DRG,,,,,,,inpatient,,,9383.02,6568.114,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5544.955495,,,5544.955495,3129.23717,12148.268,case rate,,,
Cellulitis With McC,602,MS-DRG,,,,,,,inpatient,,,27986.19,19590.333,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13227.24959,,,13227.24959,7771.48,29775.9216,case rate,,,
Cellulitis Without McC,603,MS-DRG,,,,,,,inpatient,,,16886.67,11820.669,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8029.754078,,,8029.754078,5631.704445,17850.5576,case rate,,,
Trauma To The Skin- Subcutaneous Tissue And Breast With McC,604,MS-DRG,,,,,,,inpatient,,,38556.84,26989.788,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13372.99853,,,13372.99853,7771.48,30845.472,case rate,,,
Trauma To The Skin- Subcutaneous Tissue And Breast Without McC,605,MS-DRG,,,,,,,inpatient,,,21359.36,14951.552,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8408.70132,,,8408.70132,6578.42,18717.8568,case rate,,,
Minor Skin Disorders With McC,606,MS-DRG,,,,,,,inpatient,,,6185.67,4329.969,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14473.62385,,,14473.62385,2062.920945,32627.0664,case rate,,,
Minor Skin Disorders Without McC,607,MS-DRG,,,,,,,inpatient,,,19860.65,13902.455,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7883.121812,,,7883.121812,5973.54,17514.1752,case rate,,,
Adrenal And Pituitary Procedures With Cc/McC,614,MS-DRG,,,,,,,inpatient,,,37769.13,26438.391,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,20380.43086,,,20380.43086,7771.48,46177.6032,case rate,,,
Adrenal And Pituitary Procedures Without Cc/McC,615,MS-DRG,,,,,,,inpatient,,,58015.91,40611.137,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12907.48525,,,12907.48525,7771.48,46412.728,case rate,,,
Amputation Of Lower Limb For Endocrine- Nutritional And Metabolic Disorders With McC,616,MS-DRG,,,,,,,inpatient,,,66449.27,46514.489,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,34389.99557,,,34389.99557,7771.48,78318.3336,case rate,,,
Amputation Of Lower Limb For Endocrine- Nutritional And Metabolic Disorders With Cc,617,MS-DRG,,,,,,,inpatient,,,29882.58,20917.806,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,17311.75319,,,17311.75319,7771.48,39154.1008,case rate,,,
Amputation Of Lower Limb For Endocrine- Nutritional And Metabolic Disorders Without Cc/McC,618,MS-DRG,,,,,,,inpatient,,,10245.69,7171.983,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11247.71399,,,11247.71399,3416.937615,25228.68,case rate,,,
Skin Grafts And Wound Debridement For Endocrine- Nutritional And Metabolic Disorders With McC,622,MS-DRG,,,,,,,inpatient,,,103303.17,72312.219,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,33303.50348,,,33303.50348,7771.48,82642.536,case rate,,,
Skin Grafts And Wound Debridement For Endocrine- Nutritional And Metabolic Disorders With Cc,623,MS-DRG,,,,,,,inpatient,,,20666.05,14466.235,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,17145.68774,,,17145.68774,6892.127675,38785.296,case rate,,,
Thyroid- Parathyroid And Thyroglossal Procedures With Cc,626,MS-DRG,,,,,,,inpatient,,,27302.86,19112.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13581.46367,,,13581.46367,7771.48,30582.4288,case rate,,,
Thyroid- Parathyroid And Thyroglossal Procedures Without Cc/McC,627,MS-DRG,,,,,,,inpatient,,,31328.53,21929.971,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11440.27926,,,11440.27926,7771.48,25670.4352,case rate,,,
Other Endocrine- Nutritional And Metabolic O.R. Procedures With McC,628,MS-DRG,,,,,,,inpatient,,,48752.32,34126.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,35102.84038,,,35102.84038,7771.48,79967.8232,case rate,,,
Other Endocrine- Nutritional And Metabolic O.R. Procedures With Cc,629,MS-DRG,,,,,,,inpatient,,,41481.26,29036.882,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,20116.31612,,,20116.31612,7771.48,45596.0264,case rate,,,
Diabetes With McC,637,MS-DRG,,,,,,,inpatient,,,33585.6,23509.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13113.30042,,,13113.30042,7771.48,29510.4632,case rate,,,
Diabetes With Cc,638,MS-DRG,,,,,,,inpatient,,,16607.1,11624.97,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8351.285071,,,8351.285071,5538.46785,18586.1408,case rate,,,
Diabetes Without Cc/McC,639,MS-DRG,,,,,,,inpatient,,,15715.82,11001.074,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5784.337086,,,5784.337086,4408.52,12697.4224,case rate,,,
Miscellaneous Disorders Of Nutrition- Metabolism- Fluids And Electrolytes With McC,640,MS-DRG,,,,,,,inpatient,,,19706.61,13794.627,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11979.992,,,11979.992,6572.154435,26912.6184,case rate,,,
Miscellaneous Disorders Of Nutrition- Metabolism- Fluids And Electrolytes Without McC,641,MS-DRG,,,,,,,inpatient,,,15211.2,10647.84,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7151.727134,,,7151.727134,5072.9352,15836.316,case rate,,,
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,inpatient,,,44600.9,31220.63,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11212.38092,,,11212.38092,7771.48,35680.72,case rate,,,
Endocrine Disorders With McC,643,MS-DRG,,,,,,,inpatient,,,24319.36,17023.552,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14888.78749,,,14888.78749,7771.48,33583.5272,case rate,,,
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,inpatient,,,18127.98,12689.586,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9377.710935,,,9377.710935,6045.68133,20942.844,case rate,,,
Endocrine Disorders Without Cc/McC,645,MS-DRG,,,,,,,inpatient,,,13087.48,9161.236,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7127.877308,,,7127.877308,4364.67458,15785.656,case rate,,,
Major Bladder Procedures With McC,653,MS-DRG,,,,,,,inpatient,,,74103.71,51872.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,49491.35234,,,49491.35234,7771.48,112955.5888,case rate,,,
Major Bladder Procedures With Cc,654,MS-DRG,,,,,,,inpatient,,,32847.58,22993.306,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,25177.77928,,,25177.77928,7771.48,57182.9816,case rate,,,
Kidney And Ureter Procedures For Neoplasm With McC,656,MS-DRG,,,,,,,inpatient,,,74882.24,52417.568,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,29028.20126,,,29028.20126,7771.48,66014.0328,case rate,,,
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,inpatient,,,35825.52,25077.864,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16397.50985,,,16397.50985,7771.48,37042.592,case rate,,,
Kidney And Ureter Procedures For Neoplasm Without Cc/McC,658,MS-DRG,,,,,,,inpatient,,,45531.4,31871.98,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13534.64735,,,13534.64735,7771.48,36425.12,case rate,,,
Kidney And Ureter Procedures For Non-Neoplasm With McC,659,MS-DRG,,,,,,,inpatient,,,43577.66,30504.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,23077.2279,,,23077.2279,7771.48,52366.2288,case rate,,,
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,inpatient,,,27744.56,19421.192,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12085.99122,,,12085.99122,7771.48,27151.7336,case rate,,,
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/McC,661,MS-DRG,,,,,,,inpatient,,,23214.29,16250.003,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9317.644705,,,9317.644705,7701.35,20803.0224,case rate,,,
Minor Bladder Procedures With McC,662,MS-DRG,,,,,,,inpatient,,,26200.57,18340.399,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,27805.67682,,,27805.67682,7771.48,63211.5216,case rate,,,
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,inpatient,,,51470.37,36029.259,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13741.34584,,,13741.34584,7771.48,41176.296,case rate,,,
Minor Bladder Procedures Without Cc/McC,664,MS-DRG,,,,,,,inpatient,,,21663.46,15164.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9787.574618,,,9787.574618,7224.76391,21881.0672,case rate,,,
Prostatectomy With McC,665,MS-DRG,,,,,,,inpatient,,,440302,308211.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,30579.3233,,,30579.3233,7771.48,352241.6,case rate,,,
Prostatectomy With Cc,666,MS-DRG,,,,,,,inpatient,,,21861.75,15303.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14800.4548,,,14800.4548,7290.893625,33378.8608,case rate,,,
Prostatectomy Without Cc/McC,667,MS-DRG,,,,,,,inpatient,,,16201.02,11340.714,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9328.244628,,,9328.244628,5403.04017,20825.3128,case rate,,,
Transurethral Procedures With McC,668,MS-DRG,,,,,,,inpatient,,,48931.22,34251.854,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,26009.87323,,,26009.87323,7771.48,59091.8504,case rate,,,
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,inpatient,,,33035.66,23124.962,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13918.89455,,,13918.89455,7771.48,31358.54,case rate,,,
Transurethral Procedures Without Cc/McC,670,MS-DRG,,,,,,,inpatient,,,33732.79,23612.953,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8691.36593,,,8691.36593,7065.36,26986.232,case rate,,,
Other Kidney And Urinary Tract Procedures With McC,673,MS-DRG,,,,,,,inpatient,,,60478,42334.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,37257.27471,,,37257.27471,7771.48,84906.16,case rate,,,
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,inpatient,,,73440.29,51408.203,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,20640.12897,,,20640.12897,7771.48,58752.232,case rate,,,
Renal Failure With McC,682,MS-DRG,,,,,,,inpatient,,,25189.25,17632.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13516.09748,,,13516.09748,7771.48,30436.528,case rate,,,
Renal Failure With Cc,683,MS-DRG,,,,,,,inpatient,,,17753.72,12427.604,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8101.303557,,,8101.303557,5920.86562,18012.6696,case rate,,,
Renal Failure Without Cc/McC,684,MS-DRG,,,,,,,inpatient,,,9135.38,6394.766,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5614.73832,,,5614.73832,3046.64923,12310.38,case rate,,,
Kidney And Urinary Tract Neoplasms With McC,686,MS-DRG,,,,,,,inpatient,,,27497.1,19247.97,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16906.30614,,,16906.30614,7771.48,38209.7984,case rate,,,
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,inpatient,,,25492.34,17844.638,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9548.193027,,,9548.193027,7581.24,21329.8864,case rate,,,
Kidney And Urinary Tract Infections With McC,689,MS-DRG,,,,,,,inpatient,,,20757.97,14530.579,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10586.98547,,,10586.98547,6922.782995,23716.9856,case rate,,,
Kidney And Urinary Tract Infections Without McC,690,MS-DRG,,,,,,,inpatient,,,16632.65,11642.855,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7338.992438,,,7338.992438,5546.988775,16263.8864,case rate,,,
Urinary Stones With McC,693,MS-DRG,,,,,,,inpatient,,,4007.39,2805.173,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13237.84951,,,13237.84951,1336.464565,29794.1592,case rate,,,
Urinary Stones Without McC,694,MS-DRG,,,,,,,inpatient,,,15019.62,10513.734,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7151.727134,,,7151.727134,5009.04327,15834.2896,case rate,,,
Kidney And Urinary Tract Signs And Symptoms With McC,695,MS-DRG,,,,,,,inpatient,,,29850.37,20895.259,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10211.57153,,,10211.57153,7771.48,23880.296,case rate,,,
Kidney And Urinary Tract Signs And Symptoms Without McC,696,MS-DRG,,,,,,,inpatient,,,12055.26,8438.682,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6360.266228,,,6360.266228,4020.42921,14016.6088,case rate,,,
Other Kidney And Urinary Tract Diagnoses With McC,698,MS-DRG,,,,,,,inpatient,,,25421.96,17795.372,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15097.25264,,,15097.25264,7771.48,34061.7576,case rate,,,
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,inpatient,,,18359.1,12851.37,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9258.461802,,,9258.461802,6122.75985,20665.2272,case rate,,,
Other Kidney And Urinary Tract Diagnoses Without Cc/McC,700,MS-DRG,,,,,,,inpatient,,,8380.95,5866.665,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6381.466073,,,6381.466073,2795.046825,14065.2424,case rate,,,
Major Male Pelvic Procedures Without Cc/McC,708,MS-DRG,,,,,,,inpatient,,,55574.17,38901.919,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13344.73206,,,13344.73206,7771.48,44459.336,case rate,,,
Penis Procedures With Cc/McC,709,MS-DRG,,,,,,,inpatient,,,18738.26,13116.782,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,20098.64958,,,20098.64958,6249.20971,45533.208,case rate,,,
Transurethral Prostatectomy With Cc/McC,713,MS-DRG,,,,,,,inpatient,,,28299.1,19809.37,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13022.31774,,,13022.31774,7771.48,29299.7176,case rate,,,
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/McC,717,MS-DRG,,,,,,,inpatient,,,29999.37,20999.559,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16639.54142,,,16639.54142,7771.48,37597.8256,case rate,,,
Malignancy- Male Reproductive System With Cc,723,MS-DRG,,,,,,,inpatient,,,3972.81,2780.967,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10168.28851,,,10168.28851,1324.932135,22754.4456,case rate,,,
Benign Prostatic Hypertrophy Without McC,726,MS-DRG,,,,,,,inpatient,,,40258.34,28180.838,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6824.89618,,,6824.89618,5378.07,32206.672,case rate,,,
Inflammation Of The Male Reproductive System With McC,727,MS-DRG,,,,,,,inpatient,,,22656.48,15859.536,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13229.01624,,,13229.01624,7555.93608,29773.8952,case rate,,,
Inflammation Of The Male Reproductive System Without McC,728,MS-DRG,,,,,,,inpatient,,,13639.47,9547.629,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7467.074839,,,7467.074839,4548.763245,16557.7144,case rate,,,
Other Male Reproductive System Diagnoses With Cc/McC,729,MS-DRG,,,,,,,inpatient,,,16117.99,11282.593,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9973.956595,,,9973.956595,5375.349665,22306.6112,case rate,,,
Other Male Reproductive System Diagnoses Without Cc/McC,730,MS-DRG,,,,,,,inpatient,,,5959.58,4171.706,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5610.321685,,,5610.321685,1987.51993,12298.2216,case rate,,,
Uterine And Adnexa Procedures For Non-Malignancy With Cc/McC,742,MS-DRG,,,,,,,inpatient,,,28503.79,19952.653,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16385.14327,,,16385.14327,7771.48,37014.2224,case rate,,,
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/McC,743,MS-DRG,,,,,,,inpatient,,,26776.68,18743.676,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10837.85031,,,10837.85031,7771.48,24288.4304,case rate,,,
D&C- Conization- Laparoscopy And Tubal Interruption With Cc/McC,744,MS-DRG,,,,,,,inpatient,,,42207.27,29545.089,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,17509.61842,,,17509.61842,7771.48,39593.8296,case rate,,,
D&C- Conization- Laparoscopy And Tubal Interruption Without Cc/McC,745,MS-DRG,,,,,,,inpatient,,,41300.62,28910.434,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9301.744821,,,9301.744821,7771.48,33040.496,case rate,,,
Vagina- Cervix And Vulva Procedures With Cc/McC,746,MS-DRG,,,,,,,inpatient,,,54026.22,37818.354,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15041.60305,,,15041.60305,7771.48,43220.976,case rate,,,
Vagina- Cervix And Vulva Procedures Without Cc/McC,747,MS-DRG,,,,,,,inpatient,,,14150.78,9905.546,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8686.949295,,,8686.949295,4719.28513,19354.1464,case rate,,,
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,,,inpatient,,,71661.69,50163.183,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12282.97312,,,12282.97312,7771.48,57329.352,case rate,,,
Other Female Reproductive System O.R. Procedures With Cc/McC,749,MS-DRG,,,,,,,inpatient,,,40397.2,28278.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,23115.21096,,,23115.21096,7771.48,52451.3376,case rate,,,
Malignancy- Female Reproductive System With McC,754,MS-DRG,,,,,,,inpatient,,,31179.58,21825.706,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16231.44439,,,16231.44439,7771.48,36661.6288,case rate,,,
Malignancy- Female Reproductive System With Cc,755,MS-DRG,,,,,,,inpatient,,,7660.86,5362.602,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10055.22267,,,10055.22267,2554.89681,22495.0664,case rate,,,
Malignancy- Female Reproductive System Without Cc/McC,756,MS-DRG,,,,,,,inpatient,,,11168.92,7818.244,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8685.182641,,,8685.182641,3724.83482,19350.0936,case rate,,,
Infections- Female Reproductive System With Cc,758,MS-DRG,,,,,,,inpatient,,,20130.99,14091.693,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9253.161841,,,9253.161841,6713.685165,20655.0952,case rate,,,
Infections- Female Reproductive System Without Cc/McC,759,MS-DRG,,,,,,,inpatient,,,18187.49,12731.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5902.702891,,,5902.702891,4943.22,14549.992,case rate,,,
Menstrual And Other Female Reproductive System Disorders With Cc/McC,760,MS-DRG,,,,,,,inpatient,,,19375.46,13562.822,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8955.480674,,,8955.480674,6461.71591,19970.172,case rate,,,
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,inpatient,,,14024.34,9817.038,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9933.323558,,,9933.323558,4677.11739,22215.4232,case rate,,,
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,inpatient,,,9265.92,6486.144,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12523.23804,,,12523.23804,3090.18432,28156.828,case rate,,,
Abortion With D&C- Aspiration Curettage Or Hysterotomy,770,MS-DRG,,,,,,,inpatient,,,25214.53,17650.171,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9754.008196,,,9754.008196,6425.75,21802.0376,case rate,,,
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,inpatient,,,8836.34,6185.438,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6551.948166,,,6551.948166,2946.91939,14456.3376,case rate,,,
Cesarean Section With Sterilization With McC,783,MS-DRG,,,,,,,inpatient,,,17734.56,12414.192,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16521.17561,,,16521.17561,5914.47576,37326.288,case rate,,,
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,inpatient,,,18719.59,13103.713,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9815.841079,,,9815.841079,6242.983265,21945.912,case rate,,,
Cesarean Section With Sterilization Without Cc/McC,785,MS-DRG,,,,,,,inpatient,,,17648.18,12353.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7965.271214,,,7965.271214,5885.66803,17728.9736,case rate,,,
Cesarean Section Without Sterilization With McC,786,MS-DRG,,,,,,,inpatient,,,21072.73,14750.911,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14523.09016,,,14523.09016,7027.755455,32742.5712,case rate,,,
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,inpatient,,,18455.52,12918.864,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9628.575776,,,9628.575776,6154.91592,21516.3152,case rate,,,
Cesarean Section Without Sterilization Without Cc/McC,788,MS-DRG,,,,,,,inpatient,,,17822.26,12475.582,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8240.869208,,,8240.869208,5943.72371,18338.92,case rate,,,
Neonates- Died Or Transferred To Another Acute Care Facility,789,MS-DRG,,,,,,,inpatient,,,6500.45,4550.315,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16172.26149,,,16172.26149,2167.900075,36529.9128,case rate,,,
Extreme Immaturity Or Respiratory Distress Syndrome- Neonate,790,MS-DRG,,,,,,,inpatient,,,71335.38,49934.766,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,52761.42854,,,52761.42854,7771.48,120469.48,case rate,,,
Prematurity With Major Problems,791,MS-DRG,,,,,,,inpatient,,,39411.64,27588.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,36111.59971,,,36111.59971,7771.48,82273.8664,case rate,,,
Prematurity Without Major Problems,792,MS-DRG,,,,,,,inpatient,,,10975.85,7683.095,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,21888.26989,,,21888.26989,3660.445975,49642.7472,case rate,,,
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,inpatient,,,8093.71,5665.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,37088.55927,,,37088.55927,2699.252285,84513.0384,case rate,,,
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,inpatient,,,5349.51,3744.657,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13289.08247,,,13289.08247,1784.061585,29913.7168,case rate,,,
Normal Newborn,795,MS-DRG,,,,,,,inpatient,,,4927.51,3449.257,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2014.297856,,,2014.297856,1378.34,7947.23,case rate,,,
Vaginal Delivery With Sterilization And/Or D&C With McC,796,MS-DRG,,,,,,,inpatient,,,17976.19,12583.333,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11525.96197,,,11525.96197,5995.059365,25869.0224,case rate,,,
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,inpatient,,,23001.33,16100.931,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8801.781793,,,8801.781793,6655.835261,19619.6048,case rate,,,
Vaginal Delivery With Sterilization And/Or D&C Without Cc/McC,798,MS-DRG,,,,,,,inpatient,,,14819.75,10373.825,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8801.781793,,,8801.781793,4942.386625,19619.6048,case rate,,,
Splenic Procedures With McC,799,MS-DRG,,,,,,,inpatient,,,81427.43,56999.201,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,42249.83837,,,42249.83837,7771.48,96345.188,case rate,,,
Splenic Procedures Without Cc/McC,801,MS-DRG,,,,,,,inpatient,,,60652.11,42456.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14750.9885,,,14750.9885,7771.48,48521.688,case rate,,,
Other O.R. Procedures Of The Blood And Blood Forming Organs With McC,802,MS-DRG,,,,,,,inpatient,,,94944.09,66460.863,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,31914.91358,,,31914.91358,7771.48,75955.272,case rate,,,
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/McC,804,MS-DRG,,,,,,,inpatient,,,22075,15452.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10015.47296,,,10015.47296,7362.0125,22401.852,case rate,,,
Vaginal Delivery Without Sterilization Or D&C With McC,805,MS-DRG,,,,,,,inpatient,,,13956.78,9769.746,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9065.01321,,,9065.01321,4654.58613,20221.4456,case rate,,,
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,inpatient,,,13483.61,9438.527,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6641.164183,,,6641.164183,4496.783935,14661.004,case rate,,,
Vaginal Delivery Without Sterilization Or D&C Without Cc/McC,807,MS-DRG,,,,,,,inpatient,,,13157.23,9210.061,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5878.853065,,,5878.853065,4387.936205,12912.2208,case rate,,,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With McC,808,MS-DRG,,,,,,,inpatient,,,31882.27,22317.589,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,20480.2468,,,20480.2468,7771.48,46412.6656,case rate,,,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With Cc,809,MS-DRG,,,,,,,inpatient,,,26642.66,18649.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11189.41442,,,11189.41442,7771.48,25096.964,case rate,,,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders Without Cc/McC,810,MS-DRG,,,,,,,inpatient,,,85706.42,59994.494,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8656.91618,,,8656.91618,6951.04,68565.136,case rate,,,
Red Blood Cell Disorders With McC,811,MS-DRG,,,,,,,inpatient,,,33080.94,23156.658,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12676.93692,,,12676.93692,7771.48,28507.3952,case rate,,,
Red Blood Cell Disorders Without McC,812,MS-DRG,,,,,,,inpatient,,,21914.25,15339.975,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8401.634705,,,8401.634705,6364.97,18701.6456,case rate,,,
Coagulation Disorders,813,MS-DRG,,,,,,,inpatient,,,31592.62,22114.834,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13923.31119,,,13923.31119,7771.48,31366.6456,case rate,,,
Reticuloendothelial And Immunity Disorders With McC,814,MS-DRG,,,,,,,inpatient,,,15313.53,10719.471,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,18715.35965,,,18715.35965,5107.062255,42357.8392,case rate,,,
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,inpatient,,,14949.63,10464.741,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9224.89538,,,9224.89538,4985.701605,20590.2504,case rate,,,
Other Antepartum Diagnoses With O.R. Procedures With McC,817,MS-DRG,,,,,,,inpatient,,,35079.77,24555.839,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,22642.63106,,,22642.63106,7771.48,51371.2664,case rate,,,
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,inpatient,,,56068.99,39248.293,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11626.66123,,,11626.66123,7771.48,44855.192,case rate,,,
Other Antepartum Diagnoses With O.R. Procedures Without Cc/McC,819,MS-DRG,,,,,,,inpatient,,,15513.53,10859.471,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7461.774878,,,7461.774878,5173.762255,16545.556,case rate,,,
Lymphoma And Leukemia With Major O.R. Procedures With McC,820,MS-DRG,,,,,,,inpatient,,,86514.51,60560.157,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,51679.35308,,,51679.35308,7771.48,117974.9816,case rate,,,
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,inpatient,,,70253.02,49177.114,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19968.80052,,,19968.80052,7771.48,56202.416,case rate,,,
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/McC,822,MS-DRG,,,,,,,inpatient,,,27823.59,19476.513,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10352.02051,,,10352.02051,7771.48,23173.9104,case rate,,,
Lymphoma And Non-Acute Leukemia With Other Procedures With McC,823,MS-DRG,,,,,,,inpatient,,,49236.57,34465.599,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,41584.69321,,,41584.69321,7771.48,94819.3088,case rate,,,
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/McC,825,MS-DRG,,,,,,,inpatient,,,56788.87,39752.209,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11121.39824,,,11121.39824,7771.48,45431.096,case rate,,,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With McC,826,MS-DRG,,,,,,,inpatient,,,115032.85,80522.995,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,42432.68704,,,42432.68704,7771.48,96764.6528,case rate,,,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without Cc/McC,828,MS-DRG,,,,,,,inpatient,,,37373.35,26161.345,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14408.25766,,,14408.25766,7771.48,32479.1392,case rate,,,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/McC,829,MS-DRG,,,,,,,inpatient,,,26899.5,18829.65,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,27489.44579,,,27489.44579,7771.48,62486.0704,case rate,,,
Other Antepartum Diagnoses Without O.R. Procedures With McC,831,MS-DRG,,,,,,,inpatient,,,8108.51,5675.957,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10416.50337,,,10416.50337,2704.188085,23321.8376,case rate,,,
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,inpatient,,,9811.14,6867.798,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6851.395987,,,6851.395987,3272.01519,15143.2872,case rate,,,
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/McC,833,MS-DRG,,,,,,,inpatient,,,8494.15,5945.905,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4840.943951,,,4840.943951,2832.799025,10533.2272,case rate,,,
Acute Leukemia Without Major O.R. Procedures With McC,834,MS-DRG,,,,,,,inpatient,,,33540.42,23478.294,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,49073.53871,,,49073.53871,7771.48,111997.1016,case rate,,,
Acute Leukemia Without Major O.R. Procedures With Cc,835,MS-DRG,,,,,,,inpatient,,,15922.85,11145.995,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19116.39006,,,19116.39006,5310.270475,43279.8512,case rate,,,
Lymphoma And Non-Acute Leukemia With McC,840,MS-DRG,,,,,,,inpatient,,,35119.86,24583.902,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,28418.7057,,,28418.7057,7771.48,64630.0016,case rate,,,
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,inpatient,,,17465.46,12225.822,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14099.97657,,,14099.97657,5824.73091,31771.9256,case rate,,,
Lymphoma And Non-Acute Leukemia Without Cc/McC,842,MS-DRG,,,,,,,inpatient,,,22518.92,15763.244,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9541.126412,,,9541.126412,7510.05982,21313.6752,case rate,,,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With McC,843,MS-DRG,,,,,,,inpatient,,,21080.37,14756.259,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16973.43899,,,16973.43899,7030.303395,38361.7784,case rate,,,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,inpatient,,,11557.79,8090.453,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10806.93387,,,10806.93387,3854.522965,24217.5064,case rate,,,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/McC,845,MS-DRG,,,,,,,inpatient,,,13919.38,9743.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7641.09024,,,7641.09024,4642.11323,16954.8888,case rate,,,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With McC,846,MS-DRG,,,,,,,inpatient,,,22506.34,15754.438,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,22807.8132,,,22807.8132,7505.86439,51746.1504,case rate,,,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,inpatient,,,14849.65,10394.755,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11473.84568,,,11473.84568,4952.358275,25747.4384,case rate,,,
Infectious And Parasitic Diseases With O.R. Procedures With McC,853,MS-DRG,,,,,,,inpatient,,,91139.43,63797.601,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,44427.23919,,,44427.23919,7771.48,101350.396,case rate,,,
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,inpatient,,,41334.13,28933.891,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,17899.16559,,,17899.16559,7771.48,40491.5248,case rate,,,
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/McC,855,MS-DRG,,,,,,,inpatient,,,41292.75,28904.925,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14608.77287,,,14608.77287,7771.48,33034.2,case rate,,,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With McC,856,MS-DRG,,,,,,,inpatient,,,65177.47,45624.229,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,40101.58734,,,40101.58734,7771.48,91416.9832,case rate,,,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,inpatient,,,33908.27,23735.789,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19496.22063,,,19496.22063,7771.48,44153.2296,case rate,,,
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/McC,858,MS-DRG,,,,,,,inpatient,,,18266.15,12786.305,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11630.19454,,,11630.19454,6091.761025,26108.1376,case rate,,,
Postoperative And Post-Traumatic Infections With McC,862,MS-DRG,,,,,,,inpatient,,,32409.02,22686.314,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16491.1425,,,16491.1425,7771.48,37257.3904,case rate,,,
Postoperative And Post-Traumatic Infections Without McC,863,MS-DRG,,,,,,,inpatient,,,26972.96,18881.072,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9081.796422,,,9081.796422,7071.87,21578.368,case rate,,,
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,inpatient,,,18759.94,13131.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8181.686305,,,8181.686305,6256.43999,18195.0456,case rate,,,
Viral Illness With McC,865,MS-DRG,,,,,,,inpatient,,,22475.35,15732.745,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13286.43249,,,13286.43249,7495.529225,29907.6376,case rate,,,
Viral Illness Without McC,866,MS-DRG,,,,,,,inpatient,,,13589.18,9512.426,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8065.087154,,,8065.087154,4531.99153,17927.5608,case rate,,,
Other Infectious And Parasitic Diseases Diagnoses With McC,867,MS-DRG,,,,,,,inpatient,,,29124.07,20386.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19190.58952,,,19190.58952,7771.48,43450.0688,case rate,,,
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,inpatient,,,22783.92,15948.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9525.226528,,,9525.226528,7598.43732,21277.2,case rate,,,
Other Infectious And Parasitic Diseases Diagnoses Without Cc/McC,869,MS-DRG,,,,,,,inpatient,,,6491.58,4544.106,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6605.831107,,,6605.831107,2164.94193,14579.948,case rate,,,
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,inpatient,,,165811.55,116068.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,61698.04684,,,61698.04684,7771.48,140966.516,case rate,,,
Septicemia Or Severe Sepsis Without Mv >96 Hours With McC,871,MS-DRG,,,,,,,inpatient,,,32860.99,23002.693,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,17581.1679,,,17581.1679,7771.48,39764.0472,case rate,,,
Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC,872,MS-DRG,,,,,,,inpatient,,,22133.41,15493.387,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9356.511089,,,9356.511089,7381.492235,20892.184,case rate,,,
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,,,inpatient,,,167914.64,117540.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,34960.62475,,,34960.62475,7771.48,134331.712,case rate,,,
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,inpatient,,,22889.31,16022.517,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8716.98241,,,8716.98241,6248.48,19425.0704,case rate,,,
Depressive Neuroses,881,MS-DRG,,,,,,,inpatient,,,44762.95,31334.065,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8323.901937,,,8323.901937,5798.441546,35810.36,case rate,,,
Neuroses Except Depressive,882,MS-DRG,,,,,,,inpatient,,,10863.25,7604.275,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8747.015525,,,8747.015525,3622.893875,19491.9416,case rate,,,
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,inpatient,,,35747.4,25023.18,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15002.73666,,,15002.73666,7771.48,33842.9064,case rate,,,
Psychoses,885,MS-DRG,,,,,,,inpatient,,,20082.8,14057.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12700.78675,,,12700.78675,6697.6138,28562.108,case rate,,,
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,inpatient,,,10508,7355.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16118.37855,,,16118.37855,3504.418,36402.2496,case rate,,,
Alcohol- Drug Abuse Or Dependence- Left Ama,894,MS-DRG,,,,,,,inpatient,,,15836.23,11085.361,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5762.253913,,,5762.253913,3961.38,12668.984,case rate,,,
Alcohol- Drug Abuse Or Dependence Without Rehabilitation Therapy With McC,896,MS-DRG,,,,,,,inpatient,,,35553.78,24887.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15979.69622,,,15979.69622,7771.48,36086.1312,case rate,,,
Alcohol- Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC,897,MS-DRG,,,,,,,inpatient,,,18541.81,12979.267,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8042.120655,,,8042.120655,5972.81,17876.9008,case rate,,,
Wound Debridements For Injuries With McC,901,MS-DRG,,,,,,,inpatient,,,46387.19,32471.033,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,39385.20922,,,39385.20922,7771.48,89773.5728,case rate,,,
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,inpatient,,,59864.86,41905.402,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,17011.42205,,,17011.42205,7771.48,47891.888,case rate,,,
Wound Debridements For Injuries Without Cc/McC,903,MS-DRG,,,,,,,inpatient,,,13693.85,9585.695,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11018.049,,,11018.049,4566.898975,24701.816,case rate,,,
Skin Grafts For Injuries With Cc/McC,904,MS-DRG,,,,,,,inpatient,,,114417.1,80091.97,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,34355.54582,,,34355.54582,7771.48,91533.68,case rate,,,
Hand Procedures For Injuries,906,MS-DRG,,,,,,,inpatient,,,51389.12,35972.384,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19528.0204,,,19528.0204,7771.48,44224.1536,case rate,,,
Other O.R. Procedures For Injuries With McC,907,MS-DRG,,,,,,,inpatient,,,48914.02,34239.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,35438.50461,,,35438.50461,7771.48,80721.644,case rate,,,
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,inpatient,,,44494.39,31146.073,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,18066.9977,,,18066.9977,7771.48,40872.488,case rate,,,
Other O.R. Procedures For Injuries Without Cc/McC,909,MS-DRG,,,,,,,inpatient,,,14125.93,9888.151,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11452.64583,,,11452.64583,4710.997655,25698.8048,case rate,,,
Traumatic Injury With McC,913,MS-DRG,,,,,,,inpatient,,,57017.38,39912.166,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14544.29,,,14544.29,7771.48,45613.904,case rate,,,
Traumatic Injury Without McC,914,MS-DRG,,,,,,,inpatient,,,28970.93,20279.651,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8344.218456,,,8344.218456,6429.37,23176.744,case rate,,,
Allergic Reactions With McC,915,MS-DRG,,,,,,,inpatient,,,42664.44,29865.108,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15600.74898,,,15600.74898,7771.48,35214.7792,case rate,,,
Allergic Reactions Without McC,916,MS-DRG,,,,,,,inpatient,,,12818.09,8972.663,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6115.584675,,,6115.584675,4274.833015,13455.296,case rate,,,
Poisoning And Toxic Effects Of Drugs With McC,917,MS-DRG,,,,,,,inpatient,,,41573.69,29101.583,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14733.32196,,,14733.32196,7771.48,33258.952,case rate,,,
Poisoning And Toxic Effects Of Drugs Without McC,918,MS-DRG,,,,,,,inpatient,,,19845.67,13891.969,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8063.3205,,,8063.3205,5723.92,17921.4816,case rate,,,
Complications Of Treatment With McC,919,MS-DRG,,,,,,,inpatient,,,48229.35,33760.545,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16357.76014,,,16357.76014,7771.48,38583.48,case rate,,,
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,inpatient,,,20650.21,14455.147,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9223.128726,,,9223.128726,6886.845035,20584.1712,case rate,,,
Complications Of Treatment Without Cc/McC,921,MS-DRG,,,,,,,inpatient,,,18737.44,13116.208,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6324.049825,,,6324.049825,5002.55,14989.952,case rate,,,
Other Injury- Poisoning And Toxic Effect Diagnoses With McC,922,MS-DRG,,,,,,,inpatient,,,42436.37,29705.459,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15172.33543,,,15172.33543,7771.48,34229.9488,case rate,,,
Other Injury- Poisoning And Toxic Effect Diagnoses Without McC,923,MS-DRG,,,,,,,inpatient,,,18119.88,12683.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9258.461802,,,9258.461802,6042.97998,20665.2272,case rate,,,
Non-Extensive Burns,935,MS-DRG,,,,,,,inpatient,,,6946.99,4862.893,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19650.80284,,,19650.80284,2316.821165,44505.8232,case rate,,,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,inpatient,,,22686.24,15880.368,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,18899.97497,,,18899.97497,7565.86104,42783.3832,case rate,,,
Signs And Symptoms With McC,947,MS-DRG,,,,,,,inpatient,,,29399.47,20579.629,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11610.76135,,,11610.76135,7771.48,26061.5304,case rate,,,
Signs And Symptoms Without McC,948,MS-DRG,,,,,,,inpatient,,,16042.18,11229.526,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7267.442959,,,7267.442959,5350.06703,16099.748,case rate,,,
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,inpatient,,,5109.91,3576.937,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5257.87425,,,5257.87425,1704.154985,11487.6616,case rate,,,
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,,,inpatient,,,149455.54,104618.878,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60565.62174,,,60565.62174,7771.48,138360.5656,case rate,,,
Limb Reattachment- Hip And Femur Procedures For Multiple Significant Trauma,956,MS-DRG,,,,,,,inpatient,,,64530.82,45171.574,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,34013.69831,,,34013.69831,7771.48,77453.0608,case rate,,,
Other O.R. Procedures For Multiple Significant Trauma With McC,957,MS-DRG,,,,,,,inpatient,,,104697.23,73288.061,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66182.69753,,,66182.69753,7771.48,151244.4168,case rate,,,
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,inpatient,,,68495.96,47947.172,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,36552.37984,,,36552.37984,7771.48,83274.908,case rate,,,
Other Multiple Significant Trauma With McC,963,MS-DRG,,,,,,,inpatient,,,43017.73,30112.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,24246.75272,,,24246.75272,7771.48,55049.1824,case rate,,,
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,inpatient,,,32958.94,23071.258,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,13500.1976,,,13500.1976,7771.48,30400.0528,case rate,,,
Hiv With Major Related Condition With McC,974,MS-DRG,,,,,,,inpatient,,,42445.87,29712.109,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,26627.31873,,,26627.31873,7771.48,60508.304,case rate,,,
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,,,inpatient,,,19415.36,13590.752,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12805.01933,,,12805.01933,6475.02256,28801.2232,case rate,,,
Hiv With Major Related Condition Without Cc/McC,976,MS-DRG,,,,,,,inpatient,,,36673.45,25671.415,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9109.179556,,,9109.179556,6867.108649,29338.76,case rate,,,
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,inpatient,,,53209.61,37246.727,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12986.10134,,,12986.10134,7771.48,42567.688,case rate,,,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC,981,MS-DRG,,,,,,,inpatient,,,96543.58,67580.506,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,42241.88843,,,42241.88843,7771.48,96341.1352,case rate,,,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,inpatient,,,54470.12,38129.084,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,21875.90331,,,21875.90331,7771.48,49616.404,case rate,,,
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/McC,983,MS-DRG,,,,,,,inpatient,,,18703.75,13092.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14985.07013,,,14985.07013,6237.700625,33802.3784,case rate,,,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC,987,MS-DRG,,,,,,,inpatient,,,51141.58,35799.106,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,31189.7022,,,31189.7022,7771.48,70984.792,case rate,,,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,inpatient,,,31104,21772.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15407.30039,,,15407.30039,7771.48,34773.024,case rate,,,
HC Fine Needle Aspiration Bx W/O Img Gdn Ea Addl,PX-36900722,CDM,10004,CPT,369,RC,,,outpatient,,,79,55.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,17.7355,1592,other,OPPS APC,,
HC Fine Needle Aspiration Bx W/US Gdn 1st Lesion,PX-36900723,CDM,10005,CPT,369,RC,,,outpatient,,,2116,1481.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,767.89738,,,767.89738,399.86,2141,other,OPPS APC,,
HC Fine Needle Aspiration Bx W/US Gdn Ea Addl,PX-36900724,CDM,10006,CPT,369,RC,,,outpatient,,,258,180.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,57.921,1592,other,OPPS APC,,
HC Fine Needle Aspiration W/O Imaging Guidance,PX-36900674,CDM,10021,CPT,369,RC,,,outpatient,,,871,609.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,195.5395,1592,other,OPPS APC,,
HC Image-Guided Catheter Fluid Collection Drainage,PX-36900043,CDM,10030,CPT,369,RC,,,outpatient,,,692,484.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,767.89738,,,767.89738,155.354,2141,other,OPPS APC,,
HC Plcmt of Soft Tissue Loc Device(S)- Perc- First Lesion,PX-36900637,CDM,10035,CPT,369,RC,,,outpatient,,,1860,1302,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,767.89738,,,767.89738,291.227805,2141,other,OPPS APC,,
HC Plmt Sft Tiss Loclzj Dev Perq Each Addl Lesion,PX-36900889,CDM,10036,CPT,369,RC,,,outpatient,,,130,91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,29.185,1592,other,OPPS APC,,
HC Drain Skin Abscess Simple,PX-36900044,CDM,10060,CPT,369,RC,,,outpatient,,,922,645.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,218.504125,,,218.504125,206.989,1592,other,OPPS APC,,
HC Drain Skin Abscess Complic,PX-36900045,CDM,10061,CPT,369,RC,,,outpatient,,,922,645.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,206.989,1592,other,OPPS APC,,
HC Drainage of Hematoma/Fluid,PX-36900048,CDM,10140,CPT,369,RC,,,outpatient,,,4838,3386.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,3715.584,other,OPPS APC,,
HC Puncture Drainage of Lesion,PX-36100003,CDM,10160,CPT,361,RC,,,outpatient,,,916,641.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,205.642,1592,other,OPPS APC,,
HC Puncture Drainage of Lesion,PX-36900049,CDM,10160,CPT,369,RC,,,outpatient,,,916,641.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,205.642,1592,other,OPPS APC,,
HC Complex Drainage- Wound,PX-36900050,CDM,10180,CPT,369,RC,,,outpatient,,,8640,6048,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3101.269425,,,3101.269425,399.86,6635.52,other,OPPS APC,,
HC Debridement- Infected Skin- Up to 10% Bsa,PX-36900606,CDM,11000,CPT,369,RC,,,outpatient,,,1174,821.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.4672,,,685.4672,263.563,1592,other,OPPS APC,,
HC Debridement- Infected Skin- Ea Add 10% Bsa,PX-36900607,CDM,11001,CPT,369,RC,,,outpatient,,,53,37.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,11.8985,1592,other,OPPS APC,,
HC Debride Necrotic Skin/ Tissue- Genit & Perinm,PX-36900608,CDM,11004,CPT,369,RC,,,outpatient,,,2036,1425.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2998,fee schedule,,,
HC Dbrdmt Skn Subq T/M/F Necro Infctj Abdl Wall,PX-36900876,CDM,11005,CPT,369,RC,,,outpatient,,,2001,1400.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2998,fee schedule,,,
HC Dbrdmt Skn Subq T/M/F Necro Infctj Gent/Abdl,PX-36900877,CDM,11006,CPT,369,RC,,,outpatient,,,1815,1270.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2998,fee schedule,,,
HC Removal Prosthetic Matrl Abdl Wall for Infection,PX-36900878,CDM,11008,CPT,369,RC,,,outpatient,,,706,494.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,158.497,3914,fee schedule,,,
HC Dbrdmt W/Rmvl Fm Fx&/Dislc Skin&Subq Tissus,PX-36900743,CDM,11010,CPT,369,RC,,,outpatient,,,2113,1479.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,767.89738,,,767.89738,399.86,2141,other,OPPS APC,,
HC Dbrdmt W/Rmvl Fm Fx&/Dislc Skn Subq T/M/F Musc,PX-36900773,CDM,11011,CPT,369,RC,,,outpatient,,,2197,1537.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,767.89738,,,767.89738,399.86,2141,other,OPPS APC,,
HC Dbrdmt Fx&/Dislc Subq T/M/F Bone,PX-36900744,CDM,11012,CPT,369,RC,,,outpatient,,,9022,6315.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3101.269425,,,3101.269425,399.86,6928.896,other,OPPS APC,,
HC Debridement- Skin- Sub-Q Tissue-=<20 Sq Cm,PX-36900052,CDM,11042,CPT,369,RC,,,outpatient,,,1018,712.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,228.541,1592,other,OPPS APC,,
HC Debridement- Skin- Sub-Q Tissue-Muscle-=<20 Sq Cm,PX-36900053,CDM,11043,CPT,369,RC,,,outpatient,,,1065,745.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.4672,,,685.4672,239.0925,1592,other,OPPS APC,,
HC Debridement- Skin- Sub-Q Tissue-Muscle-Bone-=<20 Sq Cm,PX-36900054,CDM,11044,CPT,369,RC,,,outpatient,,,2829,1980.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2477.315575,other,OPPS APC,,
HC Debridement- Skin- Sub-Q Tissue-Each Add 20 Sq Cm,PX-36900055,CDM,11045,CPT,369,RC,,,outpatient,,,1203,842.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.0735,1592,other,OPPS APC,,
HC Debridement- Skin- Sub-Q Tissue-Muscle-Each Add 20 Sq Cm,PX-36900056,CDM,11046,CPT,369,RC,,,outpatient,,,1203,842.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.0735,1592,other,OPPS APC,,
HC Debridement- Skin- Sub-Q Tissue-Muscle-Bone-Each Add 20 Sq Cm,PX-36900057,CDM,11047,CPT,369,RC,,,outpatient,,,1910,1337,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,1592,other,OPPS APC,,
HC Trim Nail(S),PX-36900064,CDM,11719,CPT,369,RC,,,outpatient,,,347,242.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,62.19,1592,other,OPPS APC,,
HC Debridement of Nail(S)- 1-5,PX-36900065,CDM,11720,CPT,369,RC,,,outpatient,,,347,242.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,66.75974,1592,other,OPPS APC,,
HC Debridement Nail Any Method 6/>,PX-36900791,CDM,11721,CPT,369,RC,,,outpatient,,,212,148.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,47.594,1592,other,OPPS APC,,
HC Removal of Nail Plate,PX-36900067,CDM,11730,CPT,369,RC,,,outpatient,,,431,301.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,218.504125,,,218.504125,96.7595,1592,other,OPPS APC,,
HC Avulsion Nail Plate Partial/Comp Simple Ea Addl,PX-36900831,CDM,11732,CPT,369,RC,,,outpatient,,,139,97.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,31.2055,1592,other,OPPS APC,,
HC Evacuation Subungual Hematoma,PX-36900832,CDM,11740,CPT,369,RC,,,outpatient,,,159,111.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,35.6955,1592,other,OPPS APC,,
HC Removal of Nail Bed,PX-36900069,CDM,11750,CPT,369,RC,,,outpatient,,,1914,1339.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,399.86,1592,other,OPPS APC,,
HC Biopsy Nail Unit Separate Procedure,PX-36900763,CDM,11755,CPT,369,RC,,,outpatient,,,2197,1537.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,767.89738,,,767.89738,399.86,2141,other,OPPS APC,,
HC Repair Nail Bed,PX-36900833,CDM,11760,CPT,369,RC,,,outpatient,,,909,636.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.4672,,,685.4672,113.876282,1592,other,OPPS APC,,
HC Wedge Excision Skin Nail Fold,PX-36900834,CDM,11765,CPT,369,RC,,,outpatient,,,1377,963.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,156.65,1592,other,OPPS APC,,
HC Resuperf Wnd Body <2.5cm,PX-36900070,CDM,12001,CPT,369,RC,,,outpatient,,,505,353.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,218.504125,,,218.504125,113.3725,1592,other,OPPS APC,,
HC Resup Npterf Wnd Body 2.6-7.5 Cm,PX-36900071,CDM,12002,CPT,369,RC,,,outpatient,,,505,353.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,218.504125,,,218.504125,113.3725,1592,other,OPPS APC,,
HC Resuperf Wnd Body 7.6-12.5 Cm,PX-36900072,CDM,12004,CPT,369,RC,,,outpatient,,,445,311.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,218.504125,,,218.504125,99.9025,1592,other,OPPS APC,,
HC Resuperf Wnd Body 12.6-20 Cm,PX-36900839,CDM,12005,CPT,369,RC,,,outpatient,,,513,359.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,115.1685,1592,other,OPPS APC,,
HC Resuperf Wnd Body 20.1-30 Cm,PX-36900840,CDM,12006,CPT,369,RC,,,outpatient,,,648,453.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,145.476,1592,other,OPPS APC,,
HC Resuperf Wnd Body >30 Cm,PX-36900841,CDM,12007,CPT,369,RC,,,outpatient,,,425,297.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,218.504125,,,218.504125,95.4125,1592,other,OPPS APC,,
HC Simple Repair F/E/E/N/L/M 2.5cm/<,PX-36900758,CDM,12011,CPT,369,RC,,,outpatient,,,329,230.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,218.504125,,,218.504125,73.8605,1592,other,OPPS APC,,
HC Resuperf Wnd Face 2.6-5 Cm,PX-36900842,CDM,12013,CPT,369,RC,,,outpatient,,,400,280,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,218.504125,,,218.504125,89.8,1592,other,OPPS APC,,
HC Resuperf Wnd Face 5.1-7.5 Cm,PX-36900843,CDM,12014,CPT,369,RC,,,outpatient,,,479,335.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,218.504125,,,218.504125,107.5355,1592,other,OPPS APC,,
HC Resuperf Wnd Face 7.6-12.5 Cm,PX-36900844,CDM,12015,CPT,369,RC,,,outpatient,,,633,443.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,218.504125,,,218.504125,142.1085,1592,other,OPPS APC,,
HC Resuperf Wnd Face 12.6-20 Cm,PX-36900845,CDM,12016,CPT,369,RC,,,outpatient,,,779,545.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,174.8855,1592,other,OPPS APC,,
HC Simple Repair Suprfcl Wnds F/E/E/N/L/Mucs Membrnes;20.1-30.0 Cm,PX-36900846,CDM,12017,CPT,369,RC,,,outpatient,,,555,388.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,124.5975,1592,other,OPPS APC,,
HC Simple Repair Suprfcl Wnds F/E/E/N/L/Mucs Membrnes;Over 30.0 Cm,PX-36900847,CDM,12018,CPT,369,RC,,,outpatient,,,448,313.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,218.504125,,,218.504125,100.576,1592,other,OPPS APC,,
HC Closure Superf Wnd Dehis Simple,PX-36900848,CDM,12020,CPT,369,RC,,,outpatient,,,1377,963.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.4672,,,685.4672,309.1365,1592,other,OPPS APC,,
HC Closure Superf Wnd Dehis W Packing,PX-36900849,CDM,12021,CPT,369,RC,,,outpatient,,,809,566.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,181.6205,1592,other,OPPS APC,,
HC Repair Intermediate S/a/T/E 2.5 Cm/<,PX-36900757,CDM,12031,CPT,369,RC,,,outpatient,,,891,623.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,200.0295,1592,other,OPPS APC,,
HC Layr Clos Wnd Trunk-Arm-Leg 2.6-7.5 Cm,PX-36900850,CDM,12032,CPT,369,RC,,,outpatient,,,505,353.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,113.3725,1592,other,OPPS APC,,
HC Layr Clos Wnd Trunk-Arm-Leg 7.6-12.5 Cm,PX-36900851,CDM,12034,CPT,369,RC,,,outpatient,,,685,479.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,153.7825,1592,other,OPPS APC,,
HC Layr Clos Wnd Trunk-Arm-Leg 12.6-20 Cm,PX-36900852,CDM,12035,CPT,369,RC,,,outpatient,,,685,479.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,153.7825,1592,other,OPPS APC,,
HC Layr Clos Wnd Trunk-Arm-Leg 20.1-30 Cm,PX-36900853,CDM,12036,CPT,369,RC,,,outpatient,,,649,454.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.4672,,,685.4672,145.7005,1592,other,OPPS APC,,
HC Layr Clos Wnd Trunk-Arm-Leg >30 Cm,PX-36900854,CDM,12037,CPT,369,RC,,,outpatient,,,4504,3152.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1990.340615,,,1990.340615,399.86,3459.072,other,OPPS APC,,
HC Repair Intermediate N/H/F/Xtrnl Gent 2.5cm/<,PX-36900756,CDM,12041,CPT,369,RC,,,outpatient,,,634,443.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,142.333,1592,other,OPPS APC,,
HC Repair Intermediate Neck/Hand/Feet/Xtrnl Gent 2.6-7.5 Cm,PX-36900806,CDM,12042,CPT,369,RC,,,outpatient,,,633,443.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,142.1085,1592,other,OPPS APC,,
HC Layr Clos Wnd Rest Body 7.6-12.5 Cm,PX-36900855,CDM,12044,CPT,369,RC,,,outpatient,,,623,436.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.4672,,,685.4672,139.8635,1592,other,OPPS APC,,
HC Layr Clos Wnd Rest Body 12.6-20 Cm,PX-36900856,CDM,12045,CPT,369,RC,,,outpatient,,,627,438.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.4672,,,685.4672,140.7615,1592,other,OPPS APC,,
HC Layr Clos Wnd Rest Body 20.1-30 Cm,PX-36900857,CDM,12046,CPT,369,RC,,,outpatient,,,1056,739.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.4672,,,685.4672,237.072,2141,other,OPPS APC,,
HC Repair Intermediate N/H/F/Xtrnl Gent >30.0 Cm,PX-36900858,CDM,12047,CPT,369,RC,,,outpatient,,,5238,3666.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1990.340615,,,1990.340615,399.86,4022.784,other,OPPS APC,,
HC Repair Intermediate F/E/E/N/L&/Muc 2.5 Cm/<,PX-36900755,CDM,12051,CPT,369,RC,,,outpatient,,,891,623.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,200.0295,1592,other,OPPS APC,,
HC Layr Clos Wnd Face-Facial 2.5-5 Cm,PX-36900859,CDM,12052,CPT,369,RC,,,outpatient,,,596,417.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,133.802,1592,other,OPPS APC,,
HC Layr Clos Wnd Face-Facial 5.1-7.5 Cm,PX-36900860,CDM,12053,CPT,369,RC,,,outpatient,,,663,464.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,148.8435,1592,other,OPPS APC,,
HC Layr Clos Wnd Face-Facial 7.6-12.5 Cm,PX-36900861,CDM,12054,CPT,369,RC,,,outpatient,,,652,456.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,146.374,1592,other,OPPS APC,,
HC Layr Clos Wnd Face-Facial 12.6-20 Cm,PX-36900862,CDM,12055,CPT,369,RC,,,outpatient,,,749,524.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,168.1505,1592,other,OPPS APC,,
HC Layr Clos Wnd Face-Facial 20.1-30 Cm,PX-36900863,CDM,12056,CPT,369,RC,,,outpatient,,,1419,993.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,318.5655,1592,other,OPPS APC,,
HC Repair Intermediate F/E/E/N/L&/Muc >30.0 Cm,PX-36900864,CDM,12057,CPT,369,RC,,,outpatient,,,1132,792.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,254.134,1592,other,OPPS APC,,
HC Repair Complex Trunk 1.1-2.5 Cm,PX-36900788,CDM,13100,CPT,369,RC,,,outpatient,,,1831,1281.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.4672,,,685.4672,399.86,1592,other,OPPS APC,,
HC Recmpl Wnd Trunk 2.6-7.5 Cm,PX-36900865,CDM,13101,CPT,369,RC,,,outpatient,,,1090,763,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.4672,,,685.4672,244.705,1592,other,OPPS APC,,
HC Rep-Skin-Trunk-Cmplx-+5 Cm/<,PX-36900866,CDM,13102,CPT,369,RC,,,outpatient,,,250,175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,56.125,1592,other,OPPS APC,,
HC Repair Complex Scalp/Arm/Leg 1.1-2.5 Cm,PX-36900754,CDM,13120,CPT,369,RC,,,outpatient,,,1761,1232.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.4672,,,685.4672,395.3445,1592,other,OPPS APC,,
HC Recmpl Wnd Scalp-Extr 2.6-7.5 Cm,PX-36900867,CDM,13121,CPT,369,RC,,,outpatient,,,735,514.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.4672,,,685.4672,165.0075,1592,other,OPPS APC,,
HC Rep-Skin-Scalp/Extrem+5 Cm/<,PX-36900868,CDM,13122,CPT,369,RC,,,outpatient,,,305,213.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,68.4725,1592,other,OPPS APC,,
HC Repair Complex F/C/C/M/N/Ax/G/H/F 1.1-2.5 Cm,PX-36900753,CDM,13131,CPT,369,RC,,,outpatient,,,1145,801.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,257.0525,1592,other,OPPS APC,,
HC Recmpl Wnd Head-Fac-Hand 2.6-7.5 Cm,PX-36900869,CDM,13132,CPT,369,RC,,,outpatient,,,723,506.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.4672,,,685.4672,162.3135,1592,other,OPPS APC,,
HC Repr-Face-Genital-Hand-Ft+5 Cmcm/<,PX-36900870,CDM,13133,CPT,369,RC,,,outpatient,,,578,404.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,129.761,1592,other,OPPS APC,,
HC Repair Complex Eyelid/Nose/Ear/Lip 1.1-2.5 Cm,PX-36900752,CDM,13151,CPT,369,RC,,,outpatient,,,1761,1232.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.4672,,,685.4672,395.3445,1592,other,OPPS APC,,
HC Recmpl Wnd Lid-Nos-Ear 2.5-7.5 Cm,PX-36900871,CDM,13152,CPT,369,RC,,,outpatient,,,743,520.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.4672,,,685.4672,166.8035,1592,other,OPPS APC,,
HC Repr-Eyelid-Nose-Ear-Lip+5 Cm,PX-36900872,CDM,13153,CPT,369,RC,,,outpatient,,,462,323.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,103.719,1592,other,OPPS APC,,
HC Secd Clos Surg Wnd Exten/Complic,PX-36900873,CDM,13160,CPT,369,RC,,,outpatient,,,4504,3152.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1990.340615,,,1990.340615,399.86,3459.072,other,OPPS APC,,
HC Dressing Change Under Anesthesia,PX-36900774,CDM,15852,CPT,369,RC,,,outpatient,,,1831,1281.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.4672,,,685.4672,108.7,1592,other,OPPS APC,,
HC Exc Coccyx/Ulcer W Suture,PX-36900598,CDM,15920,CPT,369,RC,,,outpatient,,,3425,2397.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3101.269425,,,3101.269425,399.86,4341.777195,other,OPPS APC,,
HC Exc Sacr Press Ulc W Pri Suture,PX-36900599,CDM,15931,CPT,369,RC,,,outpatient,,,7558,5290.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3101.269425,,,3101.269425,399.86,5804.544,other,OPPS APC,,
HC Exc Sacr Press Ulc W Flap Clos,PX-36900600,CDM,15934,CPT,369,RC,,,outpatient,,,9536,6675.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3915.61683,,,3915.61683,399.86,7323.648,other,OPPS APC,,
HC Exc Sacr Press Ulc W Musc Flap Clo,PX-36900601,CDM,15936,CPT,369,RC,,,outpatient,,,5831,4081.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1990.340615,,,1990.340615,399.86,4478.208,other,OPPS APC,,
HC Exc Isch Pres Ulc W Prim Clos,PX-36900602,CDM,15940,CPT,369,RC,,,outpatient,,,7558,5290.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3101.269425,,,3101.269425,399.86,5804.544,other,OPPS APC,,
HC Exc Isch Pres Ulc W Flap Clos,PX-36900603,CDM,15944,CPT,369,RC,,,outpatient,,,5831,4081.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3915.61683,,,3915.61683,399.86,5481.863562,other,OPPS APC,,
HC Exc Isch Pres Ulc Bone Myocut Flap,PX-36900604,CDM,15946,CPT,369,RC,,,outpatient,,,9536,6675.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1990.340615,,,1990.340615,399.86,7323.648,other,OPPS APC,,
HC Exc Troc Pres Ulc W Prim Clos,PX-36900605,CDM,15950,CPT,369,RC,,,outpatient,,,7558,5290.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,5804.544,other,OPPS APC,,
HC Initial Tx 1st Degree Burn Local Tx,PX-36900591,CDM,16000,CPT,369,RC,,,outpatient,,,393,275.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,218.504125,,,218.504125,88.2285,1592,other,OPPS APC,,
HC Dress/Debrid Small Burn No Anes,PX-36900090,CDM,16020,CPT,369,RC,,,outpatient,,,812,568.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,218.504125,,,218.504125,182.294,1592,other,OPPS APC,,
HC Dress/Debrid Med Burn No Anesth,PX-36900091,CDM,16025,CPT,369,RC,,,outpatient,,,812,568.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,218.504125,,,218.504125,182.294,1592,other,OPPS APC,,
HC Dress/Debrid Large Burn No Anesth,PX-36900092,CDM,16030,CPT,369,RC,,,outpatient,,,845,591.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,189.7025,1592,other,OPPS APC,,
HC Escharotomy Each Additional Incision,PX-36900883,CDM,16036,CPT,369,RC,,,outpatient,,,670,469,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.415,2998,fee schedule,,,
HC Destruc Cut/Vasc 10-50 Sqcm,PX-36900094,CDM,17107,CPT,369,RC,,,outpatient,,,1763,1234.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.4672,,,685.4672,395.7935,1592,other,OPPS APC,,
HC Punc/Aspir Breast Cyst,PX-36900096,CDM,19000,CPT,369,RC,,,outpatient,,,1637,1145.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,767.89738,,,767.89738,367.5065,2141,other,OPPS APC,,
HC Puct/Aspir Breast Cyst-Each Addn,PX-36900097,CDM,19001,CPT,369,RC,,,outpatient,,,60,42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,13.47,1592,other,OPPS APC,,
HC Bx Breast W Device 1st Lesion Stereotactic Guide,PX-36900099,CDM,19081,CPT,369,RC,,,outpatient,,,4317,3021.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,3315.456,other,OPPS APC,,
HC Bx Breast W Device Addl Lesion Stereotact Guide,PX-36900100,CDM,19082,CPT,369,RC,,,outpatient,,,3998,2798.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,3070.464,other,OPPS APC,,
HC Bx Breast W Device 1st Lesion Ultrasound Guide,PX-36900101,CDM,19083,CPT,369,RC,,,outpatient,,,3271,2289.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC,,
HC Bx Breast W Device Addl Lesion Ultrasound Guide,PX-36900102,CDM,19084,CPT,369,RC,,,outpatient,,,2336,1635.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,1794.048,other,OPPS APC,,
HC Bx Breast W Device 1st Lesion Magnetic Res Guide,PX-36900103,CDM,19085,CPT,369,RC,,,outpatient,,,5120,3584,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,3932.16,other,OPPS APC,,
HC Bx Breast W Device Addl Lesion Magnet Res Guide,PX-36900104,CDM,19086,CPT,369,RC,,,outpatient,,,2232,1562.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,1714.176,other,OPPS APC,,
HC Perq Device Placemt Breast Loc 1st Les W Guidnce,PX-36900106,CDM,19281,CPT,369,RC,,,outpatient,,,915,640.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,108.7,2998,other,OPPS APC,,
HC Perq Device Placemt Breast Loc Ea Les W Guidnce,PX-36900107,CDM,19282,CPT,369,RC,,,outpatient,,,880,616,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,197.56,1592,other,OPPS APC,,
HC Perq Breast Loc Device Placemt 1st Strtctc Guid,PX-36900108,CDM,19283,CPT,369,RC,,,outpatient,,,2116,1481.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,767.89738,,,767.89738,108.7,2141,other,OPPS APC,,
HC Perq Breast Loc Device Placemt Ea Lesion Strtctc,PX-36900109,CDM,19284,CPT,369,RC,,,outpatient,,,84,58.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,18.858,1592,other,OPPS APC,,
HC Perq Breast Loc Device Placemt 1st Lesio US Imag,PX-36900110,CDM,19285,CPT,369,RC,,,outpatient,,,1175,822.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,767.89738,,,767.89738,108.7,2141,other,OPPS APC,,
HC Perq Breast Loc Device Placemt Each Les US Image,PX-36900111,CDM,19286,CPT,369,RC,,,outpatient,,,274,191.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,61.513,1592,other,OPPS APC,,
HC Perq Breast Loc Device Placemt 1st Lesio MR Guid,PX-36900112,CDM,19287,CPT,369,RC,,,outpatient,,,2116,1481.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,767.89738,,,767.89738,108.7,2141,other,OPPS APC,,
HC Place Postop Breast Cath for Rad,PX-36900114,CDM,19296,CPT,369,RC,,,outpatient,,,14045,9831.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,10288.44571,,,10288.44571,399.86,14403.82399,other,OPPS APC,,
HC Muscle Biopsy,PX-36900115,CDM,20200,CPT,369,RC,,,outpatient,,,3700,2590,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC,,
HC Biopsy Muscle Deep,PX-36900764,CDM,20205,CPT,369,RC,,,outpatient,,,9022,6315.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3101.269425,,,3101.269425,399.86,6928.896,other,OPPS APC,,
HC Needle Biopsy-Muscle,PX-36900116,CDM,20206,CPT,369,RC,,,outpatient,,,3700,2590,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC,,
HC Bone Biopsy-Trocar/Needle Superf,PX-36900117,CDM,20220,CPT,369,RC,,,outpatient,,,3847,2692.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2954.496,other,OPPS APC,,
HC Bone Biopsy-Trocar/Needle Deep,PX-36900118,CDM,20225,CPT,369,RC,,,outpatient,,,3700,2590,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC,,
HC Biopsy Bone Open Superficial,PX-36900770,CDM,20240,CPT,369,RC,,,outpatient,,,9022,6315.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3101.269425,,,3101.269425,399.86,6928.896,other,OPPS APC,,
HC Biopsy Bone Open Deep,PX-36900769,CDM,20245,CPT,369,RC,,,outpatient,,,9022,6315.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3101.269425,,,3101.269425,399.86,6928.896,other,OPPS APC,,
HC Inject Sinus Tract for Dx W Xray,PX-36900120,CDM,20501,CPT,369,RC,,,outpatient,,,1451,1015.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,235.074116,1592,other,OPPS APC,,
HC Removal Foreign Body Muscle/Tendon Sheath Simple,PX-36900749,CDM,20520,CPT,369,RC,,,outpatient,,,5218,3652.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,4007.424,other,OPPS APC,,
HC Rmvl Foreign Body Muscle/Tendon Sheath Deep/Comp,PX-36900748,CDM,20525,CPT,369,RC,,,outpatient,,,5793,4055.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3101.269425,,,3101.269425,399.86,4449.024,other,OPPS APC,,
HC Injection of Tendon Sheath,PX-36900693,CDM,20550,CPT,369,RC,,,outpatient,,,823,576.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,323.2601,,,323.2601,184.7635,1592,other,OPPS APC,,
HC Injection Single Tendon Origin/Insertion,PX-36900793,CDM,20551,CPT,369,RC,,,outpatient,,,903,632.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,323.2601,,,323.2601,202.7235,1592,other,OPPS APC,,
HC Inject Trigger Point- 1 or 2,PX-36900123,CDM,20552,CPT,369,RC,,,outpatient,,,658,460.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,323.2601,,,323.2601,147.721,1592,other,OPPS APC,,
HC Drain/Inject Small Joint/Bursa,PX-36100004,CDM,20600,CPT,361,RC,,,outpatient,,,714,499.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,323.2601,,,323.2601,160.293,1592,other,OPPS APC,,
HC Drain/Inject Small Joint/Bursa,PX-36900125,CDM,20600,CPT,369,RC,,,outpatient,,,714,499.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,323.2601,,,323.2601,160.293,1592,other,OPPS APC,,
HC Arthrocnt Aspir&/Inj Small Jt/Bursaw/US Rec Rprt,PX-36900787,CDM,20604,CPT,369,RC,,,outpatient,,,938,656.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,323.2601,,,323.2601,210.581,1592,other,OPPS APC,,
HC Drain/Inject Intermediate Joint/Bursa,PX-36100005,CDM,20605,CPT,361,RC,,,outpatient,,,753,527.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,323.2601,,,323.2601,169.0485,1592,other,OPPS APC,,
HC Drain/Inject Intermediate Joint/Bursa,PX-36900126,CDM,20605,CPT,369,RC,,,outpatient,,,753,527.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,323.2601,,,323.2601,169.0485,1592,other,OPPS APC,,
HC Arthrocentesis Aspir&/Inj Interm Jt/Burs W/US,PX-36100030,CDM,20606,CPT,361,RC,,,outpatient,,,1844,1290.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,754.76995,,,754.76995,399.86,2141,other,OPPS APC,,
HC Drain/Inject Large Joint/Bursa,PX-36100006,CDM,20610,CPT,361,RC,,,outpatient,,,658,460.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,323.2601,,,323.2601,147.721,1592,other,OPPS APC,,
HC Drain/Inject Large Joint/Bursa,PX-36900127,CDM,20610,CPT,369,RC,,,outpatient,,,658,460.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,323.2601,,,323.2601,147.721,1592,other,OPPS APC,,
HC Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US,PX-36100031,CDM,20611,CPT,361,RC,,,outpatient,,,784,548.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,323.2601,,,323.2601,176.008,1592,other,OPPS APC,,
HC Ablate- Bone Tumor(S) Perq,PX-36900128,CDM,20982,CPT,369,RC,,,outpatient,,,16473,11531.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14364.36381,,,14364.36381,399.86,20110.10933,other,OPPS APC,,
HC Biopsy Soft Tissue Neck/Chest,PX-36900130,CDM,21550,CPT,369,RC,,,outpatient,,,4796,3357.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,3683.328,other,OPPS APC,,
HC Vertebroplasty Each Addl Cervicothor/Lumbosacral,PX-36900134,CDM,22512,CPT,369,RC,,,outpatient,,,1695,1186.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,380.5275,1592,other,OPPS APC,,
HC Biopsy Soft Tissue Shoulder Superficial,PX-36900138,CDM,23065,CPT,369,RC,,,outpatient,,,2502,1751.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2477.315575,other,OPPS APC,,
HC Inj Proc Shoulder Arthrography/CT/MRI,PX-36900139,CDM,23350,CPT,369,RC,,,outpatient,,,1114,779.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,235.074116,1592,other,OPPS APC,,
HC Clsd Tx Shoulder Dislc W/Manipulation W/O Anes,PX-36900581,CDM,23650,CPT,369,RC,,,outpatient,,,735,514.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,257.382395,,,257.382395,165.0075,1592,other,OPPS APC,,
HC Clsd Tx Shoulder Dislc W/Manipulation Req Anes,PX-36900582,CDM,23655,CPT,369,RC,,,outpatient,,,3604,2522.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1754.138515,,,1754.138515,399.86,2998,other,OPPS APC,,
HC I&D Upper Arm/Elbow Deep Abscess/Hematoma,PX-36900784,CDM,23930,CPT,369,RC,,,outpatient,,,5218,3652.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3101.269425,,,3101.269425,399.86,4341.777195,other,OPPS APC,,
HC Incision&Drainage Upper Arm/Elbow Bursa,PX-36900751,CDM,23931,CPT,369,RC,,,outpatient,,,3342,2339.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC,,
HC Biopsy Soft Tissue Upper Arm/Elbow Superficial,PX-36900768,CDM,24065,CPT,369,RC,,,outpatient,,,5218,3652.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,4007.424,other,OPPS APC,,
HC Biopsy Soft Tissue Upper Arm/Elbow Area Deep,PX-36900767,CDM,24066,CPT,369,RC,,,outpatient,,,9022,6315.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3101.269425,,,3101.269425,399.86,6928.896,other,OPPS APC,,
HC Injection for Elbow Arthrogram,PX-36900143,CDM,24220,CPT,369,RC,,,outpatient,,,1224,856.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,274.788,1592,other,OPPS APC,,
HC I&D Forearm&/Wrist Deep Abscess/Hematoma,PX-36900782,CDM,25028,CPT,369,RC,,,outpatient,,,9952,6966.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3532.756365,,,3532.756365,399.86,7643.136,other,OPPS APC,,
HC Incision & Drainage Forearm&/Wrist Bursa,PX-36900783,CDM,25031,CPT,369,RC,,,outpatient,,,4983,3488.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1754.138515,,,1754.138515,399.86,3826.944,other,OPPS APC,,
HC Incision Deep Bone Cortex Forearm&/Wrist,PX-36900785,CDM,25035,CPT,369,RC,,,outpatient,,,21621,15134.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7808.106015,,,7808.106015,399.86,16604.928,other,OPPS APC,,
HC Arthrt Rdcrpl/Midcarpl Jt W/Expl Drg/Rmvl FB,PX-36900778,CDM,25040,CPT,369,RC,,,outpatient,,,9952,6966.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3532.756365,,,3532.756365,399.86,7643.136,other,OPPS APC,,
HC Biopsy Soft Tissue Forearm&/Wrist Superficial,PX-36900766,CDM,25065,CPT,369,RC,,,outpatient,,,5218,3652.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,4007.424,other,OPPS APC,,
HC Biopsy Soft Tissue Forearm&/Wrist Deep,PX-36900765,CDM,25066,CPT,369,RC,,,outpatient,,,9022,6315.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3101.269425,,,3101.269425,399.86,6928.896,other,OPPS APC,,
HC Injection for Wrist Arthrogram,PX-36900149,CDM,25246,CPT,369,RC,,,outpatient,,,1660,1162,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,235.074116,1592,other,OPPS APC,,
HC Cltx Dstl Rdl Fx/Epiphysl Sep W/Manj When Perf,PX-36900792,CDM,25605,CPT,369,RC,,,outpatient,,,2563,1794.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1754.138515,,,1754.138515,399.86,2455.793921,other,OPPS APC,,
HC Drainage Finger Abscess Complicated,PX-36900750,CDM,26011,CPT,369,RC,,,outpatient,,,2563,1794.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC,,
HC Drainage Tendon Sheath Digit&/Palm Each,PX-36900781,CDM,26020,CPT,369,RC,,,outpatient,,,9952,6966.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3532.756365,,,3532.756365,399.86,7643.136,other,OPPS APC,,
HC Drainage of Palmar Bursa Single Bursa,PX-36900780,CDM,26025,CPT,369,RC,,,outpatient,,,9952,6966.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3532.756365,,,3532.756365,399.86,7643.136,other,OPPS APC,,
HC Drainage of Palmar Bursa Multiple Bursa,PX-36900779,CDM,26030,CPT,369,RC,,,outpatient,,,9952,6966.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3532.756365,,,3532.756365,399.86,7643.136,other,OPPS APC,,
HC Incision Bone Cortex Hand/Finger,PX-36900786,CDM,26034,CPT,369,RC,,,outpatient,,,4983,3488.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1754.138515,,,1754.138515,399.86,3826.944,other,OPPS APC,,
HC Arthrt Expl Drg/Rmvl Loose/FB Carp/Mtcrpl Jt,PX-36900775,CDM,26070,CPT,369,RC,,,outpatient,,,4983,3488.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1754.138515,,,1754.138515,399.86,3826.944,other,OPPS APC,,
HC Arthrt Expl Drg/Rmvl Loose/FB Mtcarphlngl Jt Ea,PX-36900777,CDM,26075,CPT,369,RC,,,outpatient,,,9952,6966.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3532.756365,,,3532.756365,399.86,7643.136,other,OPPS APC,,
HC Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea,PX-36900776,CDM,26080,CPT,369,RC,,,outpatient,,,4983,3488.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1754.138515,,,1754.138515,399.86,3826.944,other,OPPS APC,,
HC Bx Soft Tissues-Pelv/Hip-Superficl,PX-36900160,CDM,27040,CPT,369,RC,,,outpatient,,,3700,2590,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2841.6,other,OPPS APC,,
HC Bx Soft Tissues-Pelv/Hip-Deep,PX-36900161,CDM,27041,CPT,369,RC,,,outpatient,,,3700,2590,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2841.6,other,OPPS APC,,
HC Injection Hip Arthrogram,PX-36900162,CDM,27093,CPT,369,RC,,,outpatient,,,1589,1112.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,235.074116,1592,other,OPPS APC,,
HC Closed Rx Prox/Neck Femur Fx-Manip,PX-36900886,CDM,27232,CPT,369,RC,,,outpatient,,,3499,2449.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2998,fee schedule,,,
HC Cltx Hip Dislocation Traumatic W/O Anesthesia,PX-36900583,CDM,27250,CPT,369,RC,,,outpatient,,,902,631.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,257.382395,,,257.382395,202.499,1592,other,OPPS APC,,
HC Cltx Hip Dislocation Traumatic Req Anesthesia,PX-36900584,CDM,27252,CPT,369,RC,,,outpatient,,,2848,1993.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1754.138515,,,1754.138515,399.86,2455.793921,other,OPPS APC,,
HC Cltx Post Hip Arthrp Dislc W/O Anes,PX-36900585,CDM,27265,CPT,369,RC,,,outpatient,,,671,469.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,257.382395,,,257.382395,150.6395,1592,other,OPPS APC,,
HC Cltx Post Hip Arthrp Dislc Req Anes,PX-36900586,CDM,27266,CPT,369,RC,,,outpatient,,,2045,1431.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1754.138515,,,1754.138515,399.86,2998,other,OPPS APC,,
HC Unlisted Procedure Pelvis/Hip Joint,PX-36900700,CDM,27299,CPT,369,RC,,,outpatient,,,715,500.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,257.382395,,,257.382395,160.5175,1592,other,OPPS APC,,
HC I&D Deep Absc Bursa/Hematoma Thigh/Knee Region,PX-36900814,CDM,27301,CPT,369,RC,,,outpatient,,,7663,5364.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3101.269425,,,3101.269425,399.86,5885.184,other,OPPS APC,,
HC Injection Knee Arthrography,PX-36900731,CDM,27369,CPT,369,RC,,,outpatient,,,1446,1012.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,324.627,1592,other,OPPS APC,,
HC Injection for Ankle Arthrogram,PX-36900167,CDM,27648,CPT,369,RC,,,outpatient,,,834,583.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,187.233,1592,other,OPPS APC,,
HC Closed Tx Bimalleolar Ankle Fracture W/Manj,PX-36900880,CDM,27810,CPT,369,RC,,,outpatient,,,3663,2564.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1754.138515,,,1754.138515,292.65,2813.184,other,OPPS APC,,
HC Application Cast Shoulder Hand Long Arm,PX-36900741,CDM,29065,CPT,369,RC,,,outpatient,,,664,464.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,293.11054,,,293.11054,149.068,1592,other,OPPS APC,,
HC Application Cast Elbow Finger Short Arm,PX-36900739,CDM,29075,CPT,369,RC,,,outpatient,,,893,625.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,293.11054,,,293.11054,200.4785,1592,other,OPPS APC,,
HC Application Cast Hand & Lower Forearm Gauntlet,PX-36900740,CDM,29085,CPT,369,RC,,,outpatient,,,491,343.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,171.973915,,,171.973915,110.2295,1592,other,OPPS APC,,
HC Application Cast Finger,PX-36900771,CDM,29086,CPT,369,RC,,,outpatient,,,511,357.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,171.973915,,,171.973915,114.7195,1592,other,OPPS APC,,
HC Application Long Arm Splint Shoulder Hand,PX-36900759,CDM,29105,CPT,369,RC,,,outpatient,,,453,317.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,171.973915,,,171.973915,101.6985,1592,other,OPPS APC,,
HC Application Short Arm Splint Forearm-Hand Static,PX-36900576,CDM,29125,CPT,369,RC,,,outpatient,,,354,247.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,79.473,1592,other,OPPS APC,,
HC Application Short Arm Splint Dynamic,PX-36900577,CDM,29126,CPT,369,RC,,,outpatient,,,354,247.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,79.473,1592,other,OPPS APC,,
HC Application Finger Splint Static,PX-36900579,CDM,29130,CPT,369,RC,,,outpatient,,,221,154.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,49.6145,1592,other,OPPS APC,,
HC Application Finger Splint Dynamic,PX-36900580,CDM,29131,CPT,369,RC,,,outpatient,,,218,152.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,48.941,1592,other,OPPS APC,,
HC Strapping Shoulder,PX-36900761,CDM,29240,CPT,369,RC,,,outpatient,,,405,283.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,90.9225,1592,other,OPPS APC,,
HC Strapping Elbow/Wrist,PX-36900760,CDM,29260,CPT,369,RC,,,outpatient,,,122,85.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,27.389,1592,other,OPPS APC,,
HC Strapping Hand/Finger,PX-36900790,CDM,29280,CPT,369,RC,,,outpatient,,,122,85.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,27.389,1592,other,OPPS APC,,
HC Application Short Leg Cast Below Knee-Toe,PX-36900818,CDM,29405,CPT,369,RC,,,outpatient,,,699,489.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,293.11054,,,293.11054,156.9255,1592,other,OPPS APC,,
HC Application Long Leg Splint Thigh Ankle/Toes,PX-36900737,CDM,29505,CPT,369,RC,,,outpatient,,,554,387.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,171.973915,,,171.973915,124.373,1592,other,OPPS APC,,
HC Application Short Leg Splint Calf Foot,PX-36900578,CDM,29515,CPT,369,RC,,,outpatient,,,354,247.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,171.973915,,,171.973915,79.473,1592,other,OPPS APC,,
HC Ctrl Nosebleed-Anter-Simple,PX-36900181,CDM,30901,CPT,369,RC,,,outpatient,,,347,242.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,77.9015,1592,other,OPPS APC,,
HC PR Control Nasal Hemorrhage Anterior Simple,PX-96000041,CDM,30901,CPT,960,RC,,,outpatient,,,347,242.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,77.9015,1592,other,OPPS APC,,
HC Control Nasal Hemorrhage Anterior Complex,PX-36900745,CDM,30903,CPT,369,RC,,,outpatient,,,289,202.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,64.8805,1592,other,OPPS APC,,
HC PR Control Nasal Hemorrhage Anterior Complex,PX-96000042,CDM,30903,CPT,960,RC,,,outpatient,,,289,202.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,64.8805,1592,other,OPPS APC,,
HC Ctrl Nsl Hemrrg Pst Nasal Packs&/Cautery 1st,PX-36900746,CDM,30905,CPT,369,RC,,,outpatient,,,486,340.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,109.107,1592,other,OPPS APC,,
HC Ctrl Nsl Hemrrg Pst Nasal Packs&/Cautery Subsq,PX-36900747,CDM,30906,CPT,369,RC,,,outpatient,,,510,357,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,266.592215,,,266.592215,114.495,1592,other,OPPS APC,,
HC Insert Emergency Endotrach Airway,PX-36100007,CDM,31500,CPT,361,RC,,,outpatient,,,544,380.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,266.592215,,,266.592215,122.128,1592,other,OPPS APC,,
HC Insert Emergency Endotrach Airway,PX-36900182,CDM,31500,CPT,369,RC,,,outpatient,,,544,380.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,266.592215,,,266.592215,122.128,1592,other,OPPS APC,,
HC PR Intubation Endotracheal Emergency Procedure,PX-96000038,CDM,31500,CPT,960,RC,,,outpatient,,,544,380.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,266.592215,,,266.592215,122.128,1592,other,OPPS APC,,
HC Trach Tube Change,PX-36900183,CDM,31502,CPT,369,RC,,,outpatient,,,615,430.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,266.592215,,,266.592215,138.0675,1592,other,OPPS APC,,
HC Laryngoscopy-Flex Fiber-Diagnostic,PX-36900185,CDM,31575,CPT,369,RC,,,outpatient,,,371,259.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,216.190215,,,216.190215,83.2895,1592,other,OPPS APC,,
HC Bronchoscopy-Diagnostic,PX-36900187,CDM,31622,CPT,369,RC,,,outpatient,,,3151,2205.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1852.43387,,,1852.43387,399.86,2998,other,OPPS APC,,
HC Bronchoscopy-Diagnostic W Brush,PX-36900188,CDM,31623,CPT,369,RC,,,outpatient,,,3150,2205,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1852.43387,,,1852.43387,399.86,2998,other,OPPS APC,,
HC Brnchsc W/Brncl Alveolar Lavage,PX-36900896,CDM,31624,CPT,369,RC,,,outpatient,,,3935,2754.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1852.43387,,,1852.43387,399.86,3022.08,other,OPPS APC,,
HC Bronchoscopy-Biopsy,PX-36900189,CDM,31625,CPT,369,RC,,,outpatient,,,3271,2289.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1852.43387,,,1852.43387,399.86,2998,other,OPPS APC,,
HC Needle Biopsy Pleura,PX-36900190,CDM,32400,CPT,369,RC,,,outpatient,,,3700,2590,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC,,
HC Core Needle Bx Lung/Mediastinum Perq W/Img,PX-36900808,CDM,32408,CPT,369,RC,,,outpatient,,,4594,3215.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,3528.192,other,OPPS APC,,
HC Insertion Indwelling Tunneled Pleural Catheter,PX-36900192,CDM,32550,CPT,369,RC,,,outpatient,,,8367,5856.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3775.95747,,,3775.95747,399.86,6425.856,other,OPPS APC,,
HC Tube Thoracostomy Includes Water Seal,PX-36100008,CDM,32551,CPT,361,RC,,,outpatient,,,1951,1365.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1747.952815,,,1747.952815,399.86,2447.133941,other,OPPS APC,,
HC Tube Thoracostomy Includes Water Seal,PX-36900193,CDM,32551,CPT,369,RC,,,outpatient,,,1951,1365.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1747.952815,,,1747.952815,399.86,2447.133941,other,OPPS APC,,
HC Tube Thoracostomy Includes Water Seal,PX-36900573,CDM,32551,CPT,369,RC,,,outpatient,,,1951,1365.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1747.952815,,,1747.952815,399.86,2447.133941,other,OPPS APC,,
HC PR Tube Thoracostomy Includes Water Seal,PX-96000039,CDM,32551,CPT,960,RC,,,outpatient,,,1951,1365.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1747.952815,,,1747.952815,399.86,2447.133941,other,OPPS APC,,
HC Removal of Indwelling Tunneled Pleural Catheter With Cuff,PX-36900194,CDM,32552,CPT,369,RC,,,outpatient,,,2265,1585.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.639025,,,685.639025,399.86,2141,other,OPPS APC,,
HC Perc Place Intra-Thoracic Interstit Rad Therapy Guide- 1/Mult,PX-36900195,CDM,32553,CPT,369,RC,,,outpatient,,,4198,2938.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1512.300555,,,1512.300555,399.86,3224.064,other,OPPS APC,,
HC Thoracentesis Needle/Cath Pleura W/O Imaging,PX-36900196,CDM,32554,CPT,369,RC,,,outpatient,,,1874,1311.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.639025,,,685.639025,399.86,2141,other,OPPS APC,,
HC Thoracentesis Needle/Cath Pleura W/Imaging,PX-36100001,CDM,32555,CPT,361,RC,,,outpatient,,,1636,1145.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.639025,,,685.639025,367.282,2141,other,OPPS APC,,
HC Thoracentesis Needle/Cath Pleura W/Imaging,PX-36900197,CDM,32555,CPT,369,RC,,,outpatient,,,1636,1145.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.639025,,,685.639025,367.282,2141,other,OPPS APC,,
HC Perq Drainage Pleura Insert Cath W/O Imaging,PX-36900742,CDM,32556,CPT,369,RC,,,outpatient,,,2896,2027.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2076.780045,,,2076.780045,399.86,2998,other,OPPS APC,,
HC Perq Drainage Pleura Insert Cath W/Imaging,PX-36900198,CDM,32557,CPT,369,RC,,,outpatient,,,1882,1317.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1747.952815,,,1747.952815,399.86,2447.133941,other,OPPS APC,,
HC PR Instlj via Chest Tube/Cath Agent for Pleurodesis,PX-96000040,CDM,32560,CPT,960,RC,,,outpatient,,,2265,1585.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.639025,,,685.639025,399.86,1739.52,other,OPPS APC,,
HC Instlj via Ch Tube/Cath Agent Fbrnlysis 1st Day,PX-36900826,CDM,32561,CPT,369,RC,,,outpatient,,,1421,994.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.639025,,,685.639025,319.0145,2141,other,OPPS APC,,
HC Instlj Ch Tube/Cath Agent Fbrnlysis Sbsq Day,PX-36900827,CDM,32562,CPT,369,RC,,,outpatient,,,1421,994.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.639025,,,685.639025,319.0145,2141,other,OPPS APC,,
HC Pericardiocentesis W/Img Guidance When Performed,PX-36100034,CDM,33016,CPT,361,RC,,,outpatient,,,5537,3875.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1747.952815,,,1747.952815,399.86,4252.416,other,OPPS APC,,
HC Pericardiocentesis W/Img Guidance When Performed,PX-36900797,CDM,33016,CPT,369,RC,,,outpatient,,,5537,3875.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1747.952815,,,1747.952815,399.86,4252.416,other,OPPS APC,,
HC Inser Hart Pacer Xvenous Atrial,PX-36900204,CDM,33206,CPT,369,RC,,,outpatient,,,27344,19140.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11654.50028,,,11654.50028,399.86,21000.192,other,OPPS APC,,
HC Inser Hart Pacer Xvenous Ventr,PX-36900205,CDM,33207,CPT,369,RC,,,outpatient,,,36767,25736.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11654.50028,,,11654.50028,399.86,28237.056,other,OPPS APC,,
HC Inser Hart Pacer Xvenous Atr/Ventr,PX-36900206,CDM,33208,CPT,369,RC,,,outpatient,,,27344,19140.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11654.50028,,,11654.50028,399.86,21000.192,other,OPPS APC,,
HC Inser Heart Temp Pacer One Chmbr,PX-36900207,CDM,33210,CPT,369,RC,,,outpatient,,,21456,15019.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9272.375755,,,9272.375755,399.86,16478.208,other,OPPS APC,,
HC Insert Pulse Gener One Chmbr,PX-36900209,CDM,33212,CPT,369,RC,,,outpatient,,,21456,15019.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9272.375755,,,9272.375755,399.86,16478.208,other,OPPS APC,,
HC Insert Pulse Gener Dual Chmbr,PX-36900210,CDM,33213,CPT,369,RC,,,outpatient,,,27344,19140.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11654.50028,,,11654.50028,399.86,21000.192,other,OPPS APC,,
HC Upgrade of Pacemaker System,PX-36900211,CDM,33214,CPT,369,RC,,,outpatient,,,27344,19140.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11654.50028,,,11654.50028,399.86,21000.192,other,OPPS APC,,
HC Reposition Transvenous Electrode,PX-36900212,CDM,33215,CPT,369,RC,,,outpatient,,,4029,2820.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,4870.452937,other,OPPS APC,,
HC Revise Electrode-Pacing-Dual,PX-36900215,CDM,33217,CPT,369,RC,,,outpatient,,,21456,15019.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9272.375755,,,9272.375755,399.86,16478.208,other,OPPS APC,,
HC Reeletrode-Pacing-Single,PX-36900216,CDM,33218,CPT,369,RC,,,outpatient,,,9056,6339.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4286.02571,,,4286.02571,399.86,6955.008,other,OPPS APC,,
HC Reelectrode-Pacing-Dual,PX-36900217,CDM,33220,CPT,369,RC,,,outpatient,,,9056,6339.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4286.02571,,,4286.02571,399.86,6955.008,other,OPPS APC,,
HC Ins Pacemaker Pulse Gen Only W/Exist Mult Leads,PX-36900218,CDM,33221,CPT,369,RC,,,outpatient,,,48979,34285.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,21266.60843,,,21266.60843,399.86,37615.872,other,OPPS APC,,
HC Relocation of Skin Pocket for Pacemaker,PX-36900219,CDM,33222,CPT,369,RC,,,outpatient,,,4504,3152.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1990.340615,,,1990.340615,399.86,3459.072,other,OPPS APC,,
HC Relocate Skin Pocket Cardioverter-Defibrillator,PX-36900220,CDM,33223,CPT,369,RC,,,outpatient,,,2716,1901.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1990.340615,,,1990.340615,399.86,2998,other,OPPS APC,,
HC Insrt Pacing Elect-W/Attach Prev Device,PX-36900221,CDM,33224,CPT,369,RC,,,outpatient,,,27344,19140.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11654.50028,,,11654.50028,399.86,21000.192,other,OPPS APC,,
HC Insj Eltrd Car Ven Sys Tm Insj Cvdfb/Pm Pls Gen,PX-36900222,CDM,33225,CPT,369,RC,,,outpatient,,,7571,5299.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6364,other,OPPS APC,,
HC Reposit Prev Implanted Cardiac Electrode,PX-36900223,CDM,33226,CPT,369,RC,,,outpatient,,,3644,2550.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,4870.452937,other,OPPS APC,,
HC Remvl Perm Pm Plse Gen W/Repl Plse Gen Sngl Lead,PX-36900224,CDM,33227,CPT,369,RC,,,outpatient,,,17786,12450.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9272.375755,,,9272.375755,399.86,13659.648,other,OPPS APC,,
HC Remvl Perm Pm Pls Gen W/Repl Plse Gen 2 Lead Sys,PX-36900225,CDM,33228,CPT,369,RC,,,outpatient,,,19652,13756.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11654.50028,,,11654.50028,399.86,16316.30039,other,OPPS APC,,
HC Remvl Perm Pm Pls Gen W/Repl Plse Gen Mult Lead,PX-36900226,CDM,33229,CPT,369,RC,,,outpatient,,,22582,15807.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,21266.60843,,,21266.60843,399.86,29773.2518,other,OPPS APC,,
HC Ins Pacng Cvdfb Pls Gen Only W/Exist Dual Leads,PX-36900227,CDM,33230,CPT,369,RC,,,outpatient,,,67496,47247.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,25726.38358,,,25726.38358,399.86,51836.928,other,OPPS APC,,
HC Ins Pacng Cvdfb Pls Gen Only W/Exist Multi Leads,PX-36900228,CDM,33231,CPT,369,RC,,,outpatient,,,64998,45498.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,35906.82009,,,35906.82009,399.86,50269.54813,other,OPPS APC,,
HC Remv Perm Pacer Generator,PX-36900229,CDM,33233,CPT,369,RC,,,outpatient,,,21456,15019.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9272.375755,,,9272.375755,399.86,16478.208,other,OPPS APC,,
HC Remv Transven Pacer Electrode-1 Lead,PX-36900230,CDM,33234,CPT,369,RC,,,outpatient,,,9056,6339.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4286.02571,,,4286.02571,399.86,6955.008,other,OPPS APC,,
HC Remv Transven Pacer Electrode-2 Lead,PX-36900231,CDM,33235,CPT,369,RC,,,outpatient,,,9056,6339.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4286.02571,,,4286.02571,399.86,6955.008,other,OPPS APC,,
HC Rmv Pulse Generator-Sngl/Dual,PX-36900233,CDM,33241,CPT,369,RC,,,outpatient,,,9028,6319.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4286.02571,,,4286.02571,399.86,6933.504,other,OPPS APC,,
HC Rmv Pacer/Electrd-Transven Extrct,PX-36900234,CDM,33244,CPT,369,RC,,,outpatient,,,9056,6339.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4286.02571,,,4286.02571,399.86,6955.008,other,OPPS APC,,
HC Insert Electrd Leads/Repostion,PX-36900235,CDM,33249,CPT,369,RC,,,outpatient,,,86384,60468.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,35906.82009,,,35906.82009,399.86,66342.912,other,OPPS APC,,
HC Rem Pac Cvdfb Plse Gen &Repl Plse Gen Sngl Lead,PX-36900236,CDM,33262,CPT,369,RC,,,outpatient,,,63006,44104.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,25726.38358,,,25726.38358,399.86,48388.608,other,OPPS APC,,
HC Rem Pac Cvdfb Plse Gen &Repl Plse Gen Dual Lead,PX-36900237,CDM,33263,CPT,369,RC,,,outpatient,,,65752,46026.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,25726.38358,,,25726.38358,399.86,50497.536,other,OPPS APC,,
HC Rem Pac Cvdfb Pls Gen &Repl Plse Gen Multi Lead,PX-36900238,CDM,33264,CPT,369,RC,,,outpatient,,,65752,46026.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,35906.82009,,,35906.82009,399.86,50497.536,other,OPPS APC,,
HC Replace Aortic Valve Perq Femoral Artry Approach,PX-36900544,CDM,33361,CPT,369,RC,,,outpatient,,,27728,19409.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21295.104,fee schedule,,,
HC Replace Aortic Valve Openfemoral Artery Approach,PX-36900545,CDM,33362,CPT,369,RC,,,outpatient,,,29393,20575.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24913.5068,fee schedule,,,
HC Replace Aortic Valve Open Axillry Artry Approach,PX-36900546,CDM,33363,CPT,369,RC,,,outpatient,,,27728,19409.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21295.104,fee schedule,,,
HC Replace Aortic Valve Open Iliac Artery Approach,PX-36900547,CDM,33364,CPT,369,RC,,,outpatient,,,29393,20575.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,22573.824,fee schedule,,,
HC Replace Aortic Valve Open Transaortic Approach,PX-36900548,CDM,33365,CPT,369,RC,,,outpatient,,,29393,20575.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,22573.824,fee schedule,,,
HC Transcatheter Transapical Replacemt Aortic Valve,PX-36900549,CDM,33366,CPT,369,RC,,,outpatient,,,29393,20575.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24913.5068,fee schedule,,,
HC Replace Aortic Valve W/Byp Prq Art/Venous Apprch,PX-36900550,CDM,33367,CPT,369,RC,,,outpatient,,,27728,19409.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,23502.2528,fee schedule,,,
HC Replace Aortic Valve W/Byp Open Art/Venous Aprch,PX-36900551,CDM,33368,CPT,369,RC,,,outpatient,,,29393,20575.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24913.5068,fee schedule,,,
HC Replace Aorta Valve W/Byp Cntrl Art/Venous Aprch,PX-36900552,CDM,33369,CPT,369,RC,,,outpatient,,,29393,20575.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24913.5068,fee schedule,,,
HC Endovasc Taa Reincl Subcl,PX-36900241,CDM,33880,CPT,369,RC,,,outpatient,,,6951,4865.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,5338.368,fee schedule,,,
HC Endovasc Taa Rew/O Subcl,PX-36900242,CDM,33881,CPT,369,RC,,,outpatient,,,5970,4179,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,4584.96,fee schedule,,,
HC Insert Endovasc Prosth- Taa,PX-36900243,CDM,33883,CPT,369,RC,,,outpatient,,,4420,3094,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,3746.392,fee schedule,,,
HC Endovasc Prosth- Taa- Ea Add,PX-36900244,CDM,33884,CPT,369,RC,,,outpatient,,,1649,1154.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,370.2005,2998,fee schedule,,,
HC Endovasc Dist Extens Taa Prosth- Delayed,PX-36900245,CDM,33886,CPT,369,RC,,,outpatient,,,3820,2674,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,3237.832,fee schedule,,,
HC Car-Car Bypass Grft W/ Endovas Taa Repair,PX-36900247,CDM,33891,CPT,369,RC,,,outpatient,,,4194,2935.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,3220.992,fee schedule,,,
HC Remove Pul Art Emboli No Bypass,PX-36900248,CDM,33915,CPT,369,RC,,,outpatient,,,1800,1260,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2998,fee schedule,,,
HC Insert Intra-Aortic Balloon Asst Device,PX-36900249,CDM,33967,CPT,369,RC,,,outpatient,,,2513,1759.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6913,fee schedule,,,
HC Rmv Aortic Balloon Device,PX-36900250,CDM,33968,CPT,369,RC,,,outpatient,,,139,97.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,31.2055,6913,fee schedule,,,
HC Insj Perq Vad W/Rs&I L Hrt Arterial Access Only,PX-36900251,CDM,33990,CPT,369,RC,,,outpatient,,,4109,2876.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,3155.712,fee schedule,,,
HC Removal Perq Left Hrt Vad Artl/Artl&Ven Sep Insj,PX-36900252,CDM,33992,CPT,369,RC,,,outpatient,,,4188,2931.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,3549.7488,fee schedule,,,
HC Repositioning Perq R/L Vad W/Img Gdn Sep Insj,PX-36900253,CDM,33993,CPT,369,RC,,,outpatient,,,4188,2931.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,3549.7488,fee schedule,,,
HC Insj Perq Vad W/Rs&I R Heart Venous Access Only,PX-36900809,CDM,33995,CPT,369,RC,,,outpatient,,,4109,2876.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,3155.712,fee schedule,,,
HC Removal Perq R Heart Vad Venous Cannula Sep Insj,PX-36900810,CDM,33997,CPT,369,RC,,,outpatient,,,4188,2931.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,293.5896,3216.384,fee schedule,,,
HC Cardiac Surg Procedure Unlist,PX-36900254,CDM,33999,CPT,369,RC,,,outpatient,,,1770,1239,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.639025,,,685.639025,397.365,2141,other,OPPS APC,,
HC Cardiac Surg Procedure Unlist,PX-36900635,CDM,33999,CPT,369,RC,,,outpatient,,,1770,1239,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.639025,,,685.639025,397.365,2141,other,OPPS APC,,
HC Remv Art Clot Axill-Brach-Arm Incis,PX-36900255,CDM,34101,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC,,
HC Remv Art Clot Arm-Arm Incis,PX-36900256,CDM,34111,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC,,
HC Remv Art Clot Iliac-Pop-Leg Incis,PX-36900257,CDM,34201,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC,,
HC Remv Art Clot Low Leg-Leg Incis,PX-36900258,CDM,34203,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC,,
HC Aaa Repair-Iliac Artery Occlsn Device,PX-36900264,CDM,34808,CPT,369,RC,,,outpatient,,,152,106.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,34.124,2998,fee schedule,,,
HC Aaa Repr-Expose Femoral Art-Groin Incis,PX-36900265,CDM,34812,CPT,369,RC,,,outpatient,,,238,166.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,53.431,2998,fee schedule,,,
HC Aaa Repair- Femoral-Femoral Graft,PX-36900266,CDM,34813,CPT,369,RC,,,outpatient,,,167,116.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,37.4915,2998,fee schedule,,,
HC Aaa Repr-Expose Iliac Art-Abd Incis- Unilat,PX-36900267,CDM,34820,CPT,369,RC,,,outpatient,,,337,235.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,75.6565,2998,fee schedule,,,
HC Open Iliac Art Exp W/Conduit-Unilat,PX-36900270,CDM,34833,CPT,369,RC,,,outpatient,,,447,312.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,100.3515,2998,fee schedule,,,
HC Open Brach Art Exp-Endovas Pros-Unilat,PX-36900271,CDM,34834,CPT,369,RC,,,outpatient,,,218,152.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.941,2998,fee schedule,,,
HC Thrombectomy a-V Graft- Exc Hemodialysis,PX-36900278,CDM,35875,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC,,
HC Place Needle in Vein,PX-36900279,CDM,36000,CPT,369,RC,,,outpatient,,,343,240.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,77.0035,1592,other,OPPS APC,,
HC Injection Rx Extremity Pseudoaneurysm,PX-36900280,CDM,36002,CPT,369,RC,,,outpatient,,,775,542.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.639025,,,685.639025,173.9875,2141,other,OPPS APC,,
HC Injection Proc-Extremity-Venography,PX-36900281,CDM,36005,CPT,369,RC,,,outpatient,,,258,180.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,57.921,1592,other,OPPS APC,,
HC Place Cath in Vein-Svc-Ivc,PX-36900282,CDM,36010,CPT,369,RC,,,outpatient,,,541,378.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,121.4545,1592,other,OPPS APC,,
HC Place Cath in Vein-Select,PX-36900283,CDM,36011,CPT,369,RC,,,outpatient,,,773,541.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,173.5385,1592,other,OPPS APC,,
HC Place Cath in Vein-Subselect,PX-36900284,CDM,36012,CPT,369,RC,,,outpatient,,,909,636.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,204.0705,1592,other,OPPS APC,,
HC Place Cath in Rt Hrt-Main Pulm Art,PX-36900285,CDM,36013,CPT,369,RC,,,outpatient,,,8331,5831.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6398.208,other,OPPS APC,,
HC Place Cath in Lt/Rt Pulm Art,PX-36900286,CDM,36014,CPT,369,RC,,,outpatient,,,721,504.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,161.8645,1592,other,OPPS APC,,
HC Place Cath in Subsegmt Pulm Art,PX-36900287,CDM,36015,CPT,369,RC,,,outpatient,,,1662,1163.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,373.119,1592,other,OPPS APC,,
HC Place Cath Carot/Vert Art,PX-36900288,CDM,36100,CPT,369,RC,,,outpatient,,,628,439.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,140.986,1592,other,OPPS APC,,
HC Place Cath Extrem Artery,PX-36900290,CDM,36140,CPT,369,RC,,,outpatient,,,340,238,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,76.33,1592,other,OPPS APC,,
HC Place Cath Aorta via Translumbar,PX-36900293,CDM,36160,CPT,369,RC,,,outpatient,,,2609,1826.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2003.712,other,OPPS APC,,
HC Place Cath Aorta,PX-36900294,CDM,36200,CPT,369,RC,,,outpatient,,,721,504.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,161.8645,1592,other,OPPS APC,,
HC Place Cath Selective Art-Neck,PX-36900295,CDM,36215,CPT,369,RC,,,outpatient,,,1030,721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.235,1592,other,OPPS APC,,
HC Place Cath Subselect Art-Neck,PX-36900296,CDM,36216,CPT,369,RC,,,outpatient,,,568,397.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,127.516,1592,other,OPPS APC,,
HC Place Cath Subsubselect Art-Neck,PX-36900297,CDM,36217,CPT,369,RC,,,outpatient,,,1545,1081.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,346.8525,1592,other,OPPS APC,,
HC Place Cath Addn Subselec Art-Neck,PX-36900298,CDM,36218,CPT,369,RC,,,outpatient,,,109,76.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,24.4705,1592,other,OPPS APC,,
HC Nonslctv Cath Thor Aorta Angio Intr/Xtrcranl Art,PX-36900299,CDM,36221,CPT,369,RC,,,outpatient,,,9691,6783.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,7442.688,other,OPPS APC,,
HC Slctv Cath Carotid/Innom Art Angio Xtrcranl Art,PX-36900300,CDM,36222,CPT,369,RC,,,outpatient,,,9691,6783.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,7442.688,other,OPPS APC,,
HC Slctv Cath Carotid/Innom Art Angio Intrcranl Art,PX-36900301,CDM,36223,CPT,369,RC,,,outpatient,,,9141,6398.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,8396.844904,other,OPPS APC,,
HC Slctv Cath Intrnl Carotid Art Angio Intrcrnl Art,PX-36900302,CDM,36224,CPT,369,RC,,,outpatient,,,15847,11092.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,12170.496,other,OPPS APC,,
HC Slctv Cath Subclavian Art Angio Vertebral Artery,PX-36900303,CDM,36225,CPT,369,RC,,,outpatient,,,9141,6398.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,7020.288,other,OPPS APC,,
HC Slctv Cath Vertebral Art Angio Vertebral Artery,PX-36900304,CDM,36226,CPT,369,RC,,,outpatient,,,15847,11092.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,12170.496,other,OPPS APC,,
HC Slctv Cath Xtrnl Carotid Angio Xtrnl Carotd Circ,PX-36900305,CDM,36227,CPT,369,RC,,,outpatient,,,515,360.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,115.6175,1592,other,OPPS APC,,
HC Slctv Cath Intrcrnl Brnch Angio Intrl Carot/Vert,PX-36900306,CDM,36228,CPT,369,RC,,,outpatient,,,612,428.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.394,1592,other,OPPS APC,,
HC Place Cath Select Art-Abd/Pel,PX-36900307,CDM,36245,CPT,369,RC,,,outpatient,,,1107,774.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,248.5215,1592,other,OPPS APC,,
HC Place Cath Subselect Art-Abd/Pel,PX-36900308,CDM,36246,CPT,369,RC,,,outpatient,,,1236,865.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,277.482,1592,other,OPPS APC,,
HC Place Cath Subsubselect Art-Abd/Pel,PX-36900309,CDM,36247,CPT,369,RC,,,outpatient,,,1442,1009.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,323.729,1592,other,OPPS APC,,
HC Place Cath Addn Subsel Art-Abd/Pel,PX-36900310,CDM,36248,CPT,369,RC,,,outpatient,,,258,180.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,57.921,1592,other,OPPS APC,,
HC Slctv Cath 1stord W/WO Art Punct/Fluoro/S&I Uni,PX-36900311,CDM,36251,CPT,369,RC,,,outpatient,,,9430,6601,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,7242.24,other,OPPS APC,,
HC Slctv Cath 1stord W/WO Art Punct/Fluor/S&I Bilat,PX-36900312,CDM,36252,CPT,369,RC,,,outpatient,,,9430,6601,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,7242.24,other,OPPS APC,,
HC Supslctv Cath 2nd+Ord Renl&Acces Artery/S&I Uni,PX-36900313,CDM,36253,CPT,369,RC,,,outpatient,,,9430,6601,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,8396.844904,other,OPPS APC,,
HC Supslctv Cath 2nd+Ord Renl&Acces Arter/S&I Bilat,PX-36900314,CDM,36254,CPT,369,RC,,,outpatient,,,9430,6601,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,7242.24,other,OPPS APC,,
Vnpnxr <3 Years Phys/Qhp Skill Other Vein,PX-36900875,CDM,36406,CPT,369,RC,,,outpatient,,,24,16.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,5.388,416.02,other,OPPS APC,,
HC Blood Transfusion Service,PX-39100001,CDM,36430,CPT,391,RC,,,outpatient,,,923,646.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,473.790255,,,473.790255,207.2135,1592,other,OPPS APC,,
HC Injection; Spider Veins-Limb/Trunk,PX-36900315,CDM,36468,CPT,369,RC,,,outpatient,,,909,636.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,156.65,1592,other,OPPS APC,,
HC Injection Therapy Vein-One Vein,PX-36900316,CDM,36470,CPT,369,RC,,,outpatient,,,909,636.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,204.0705,1592,other,OPPS APC,,
HC Injection Therapy Vein-Mult Veins,PX-36900317,CDM,36471,CPT,369,RC,,,outpatient,,,383,268.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,435.19836,,,435.19836,85.9835,1592,other,OPPS APC,,
HC Endovenous Rf- 1st Vein,PX-36900318,CDM,36475,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,6623.08,other,OPPS APC,,
HC Endovenous Rf- Vein Add-On,PX-36900319,CDM,36476,CPT,369,RC,,,outpatient,,,1797,1257.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,1592,other,OPPS APC,,
HC Endovenous Laser- 1st Vein,PX-36900320,CDM,36478,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC,,
HC Endovenous Laser Vein Addon,PX-36900321,CDM,36479,CPT,369,RC,,,outpatient,,,1797,1257.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,1592,other,OPPS APC,,
HC Percut Portal Vein Cath,PX-36900322,CDM,36481,CPT,369,RC,,,outpatient,,,915,640.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,205.4175,1592,other,OPPS APC,,
HC Venous Select Sampling W Cath,PX-36900323,CDM,36500,CPT,369,RC,,,outpatient,,,412,288.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,92.494,1592,other,OPPS APC,,
HC Cathj Umbilical Vein Dx/Ther Nb,PX-36900588,CDM,36510,CPT,369,RC,,,outpatient,,,773,541.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,173.5385,1592,other,OPPS APC,,
HC Ther Apheresis-Platelets,PX-36900553,CDM,36513,CPT,369,RC,,,outpatient,,,1337,935.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,473.790255,,,473.790255,300.1565,2081.64,other,OPPS APC,,
HC Ther Apheresis-Plasma Pheresis,PX-36900324,CDM,36514,CPT,369,RC,,,outpatient,,,4919,3443.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1674.594995,,,1674.594995,399.86,3777.792,other,OPPS APC,,
HC Insert Non-Tunnel Cv Cath < 5 Y/O,PX-36100009,CDM,36555,CPT,361,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC,,
HC Insert Non-Tunnel Cv Cath < 5 Y/O,PX-36900325,CDM,36555,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC,,
HC Insert Non-Tunnel Cv Cath,PX-36100010,CDM,36556,CPT,361,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,6012.672,other,OPPS APC,,
HC Insert Non-Tunnel Cv Cath,PX-36900326,CDM,36556,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,6012.672,other,OPPS APC,,
HC PR Insj Non-Tunneled Central Venous Cath Age 5 Yr/>,PX-96000046,CDM,36556,CPT,960,RC,,,outpatient,,,7829,5480.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,6012.672,other,OPPS APC,,
HC Insert Tunneled Cv Cath W/O Port or Pump < 5 Y/O,PX-36100011,CDM,36557,CPT,361,RC,,,outpatient,,,12541,8778.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC,,
HC Insert Tunneled Cv Cath W/O Port or Pump < 5 Y/O,PX-36900327,CDM,36557,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC,,
HC Insert Tunneled Cv Cath W/O Port or Pump,PX-36100012,CDM,36558,CPT,361,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC,,
HC Insert Tunneled Cv Cath W/O Port or Pump,PX-36900328,CDM,36558,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC,,
HC Insert Tunneled Cv Cath With Port <5 Y/O,PX-36100013,CDM,36560,CPT,361,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC,,
HC Insert Tunneled Cv Cath With Port <5 Y/O,PX-36900329,CDM,36560,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC,,
HC Insert Tunneled Cv Cath With Port,PX-36100014,CDM,36561,CPT,361,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC,,
HC Insert Tunneled Cv Cath With Port,PX-36900330,CDM,36561,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC,,
HC Insert Tunneled Cv Cath With Pump,PX-36100015,CDM,36563,CPT,361,RC,,,outpatient,,,12541,8778.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC,,
HC Insert Tunneled Cv Cath With Pump,PX-36900331,CDM,36563,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC,,
HC Insert Tunneled Cv Cath W 2 Access Sites- W/O Pump or Port,PX-36900332,CDM,36565,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC,,
HC Insert Tunneled Cv Cath W 2 Access Sites- W/ Pump or Port,PX-36900333,CDM,36566,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC,,
HC Insert Picc W/O Sub-Q Port <5 Y/O,PX-36900334,CDM,36568,CPT,369,RC,,,outpatient,,,3698,2588.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1747.952815,,,1747.952815,399.86,2840.064,other,OPPS APC,,
HC Insert Picc W/O Sub-Q Port,PX-36900335,CDM,36569,CPT,369,RC,,,outpatient,,,3698,2588.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1747.952815,,,1747.952815,399.86,2953.728,other,OPPS APC,,
HC PR Insj Prph Cvc W/O Subq Port/Pmp Age 5 Yr/>,PX-96000047,CDM,36569,CPT,960,RC,,,outpatient,,,3846,2692.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1747.952815,,,1747.952815,399.86,2953.728,other,OPPS APC,,
HC Insert Picc W/ Sub-Q Port <5 Y/O,PX-36900336,CDM,36570,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC,,
HC Insert Picc W/ Sub-Q Port,PX-36900337,CDM,36571,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC,,
HC Repair Cv Cath W/O Subq Port or Pump,PX-36900338,CDM,36575,CPT,369,RC,,,outpatient,,,1421,994.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.639025,,,685.639025,319.0145,2141,other,OPPS APC,,
HC Repair Cv Cath W Subq Port or Pump,PX-36900339,CDM,36576,CPT,369,RC,,,outpatient,,,3698,2588.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1747.952815,,,1747.952815,399.86,2840.064,other,OPPS APC,,
HC Replace Cv Cath- Catheter Only W Subq Pump or Port,PX-36900340,CDM,36578,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC,,
HC Replace Cv Cath- Complete- Non-Tunneled- W/O Subq Port or Pump,PX-36900341,CDM,36580,CPT,369,RC,,,outpatient,,,3698,2588.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1747.952815,,,1747.952815,399.86,2840.064,other,OPPS APC,,
HC Replace Cv Cath- Complete- Tunneled- W/O Subq Port or Pump,PX-36900342,CDM,36581,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC,,
HC Replace Cv Cath- Complete- Non-Tunneled- W Subq Port or Pump,PX-36900343,CDM,36582,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC,,
HC Replace Cv Cath- Complete- Tunneled- W Subq Port or Pump,PX-36900344,CDM,36583,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC,,
HC Replace Picc W/O Port or Pump,PX-36900345,CDM,36584,CPT,369,RC,,,outpatient,,,3698,2588.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1747.952815,,,1747.952815,399.86,2840.064,other,OPPS APC,,
HC Replace Picc W Port or Pump,PX-36900346,CDM,36585,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC,,
HC Removal Tunneled Cv Cath W/O Subq Port or Pump,PX-36900347,CDM,36589,CPT,369,RC,,,outpatient,,,1421,994.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.639025,,,685.639025,319.0145,2141,other,OPPS APC,,
HC Removal Tunneled Cv Cath W Subq Port or Pump,PX-36900348,CDM,36590,CPT,369,RC,,,outpatient,,,3698,2588.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1747.952815,,,1747.952815,399.86,2998,other,OPPS APC,,
HC Collect Blood From Implant Venous Access Device,PX-76100001,CDM,36591,CPT,761,RC,,,outpatient,,,160,112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,35.92,1592,other,OPPS APC,,
HC Collect Blood From Catheter Venous Nos,PX-36900349,CDM,36592,CPT,369,RC,,,outpatient,,,125,87.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,28.0625,1592,other,OPPS APC,,
HC Declot of Cent Venous Catheter,PX-36900350,CDM,36593,CPT,369,RC,,,outpatient,,,806,564.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,369.62994,,,369.62994,180.947,1592,other,OPPS APC,,
HC Mech Remov Pericath Obstr Cv Dev via Ven Access,PX-36900351,CDM,36595,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC,,
HC Mech Remov Intralum Obstr Cv Dev Thru Lumen,PX-36900352,CDM,36596,CPT,369,RC,,,outpatient,,,3698,2588.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1747.952815,,,1747.952815,399.86,2840.064,other,OPPS APC,,
HC Reposition Venous Catheter,PX-36900353,CDM,36597,CPT,369,RC,,,outpatient,,,3698,2588.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1747.952815,,,1747.952815,399.86,2840.064,other,OPPS APC,,
HC Contrast Inj Cent Ven Cath- Inc Flouro,PX-36900354,CDM,36598,CPT,369,RC,,,outpatient,,,406,284.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,233.93401,,,233.93401,91.147,1592,other,OPPS APC,,
HC Withdrawal of Arterial Blood,PX-36900355,CDM,36600,CPT,369,RC,,,outpatient,,,297,207.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,66.6765,1592,other,OPPS APC,,
HC Insert Cath-Art-Percut-Shortterm,PX-36900356,CDM,36620,CPT,369,RC,,,outpatient,,,309,216.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,69.3705,1592,other,OPPS APC,,
HC Catheterization Umbilical Newborn Art Dx/Therapy,PX-36900836,CDM,36660,CPT,369,RC,,,outpatient,,,10702,7491.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9071.0152,fee schedule,,,
HC Placement Needle Intraosseous Infusion,PX-36900592,CDM,36680,CPT,369,RC,,,outpatient,,,568,397.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,434.866165,,,434.866165,127.516,1592,other,OPPS APC,,
HC PR Placement Needle Intraosseous Infusion,PX-96000050,CDM,36680,CPT,960,RC,,,outpatient,,,568,397.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,434.866165,,,434.866165,127.516,1592,other,OPPS APC,,
HC Insert Cannula-Vein-Vein,PX-36900358,CDM,36800,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC,,
HC Revise Av Fistula-W/O Thrombectomy,PX-36900359,CDM,36832,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC,,
HC Insert Transven Intrahep Portosys Shunt,PX-36900361,CDM,37182,CPT,369,RC,,,outpatient,,,4120,2884,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,5756,fee schedule,,,
HC Revis Transven Intrahep Portosys Shunt,PX-36900362,CDM,37183,CPT,369,RC,,,outpatient,,,13035,9124.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6238.20972,,,6238.20972,399.86,18955.84,other,OPPS APC,,
HC Prim Perc Mech Thrombectomy- Arterial,PX-36900363,CDM,37184,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19138.22361,,,19138.22361,399.86,26793.51305,other,OPPS APC,,
HC Prim Perc Mech Thrombectomy- Arterial Ea Add,PX-36900364,CDM,37185,CPT,369,RC,,,outpatient,,,824,576.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,184.988,4800.911611,other,OPPS APC,,
HC Sec Perc Mech Thrombect- Arterial- W Other Proc,PX-36900365,CDM,37186,CPT,369,RC,,,outpatient,,,1236,865.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,277.482,8164.18419,other,OPPS APC,,
HC Percut Mech Thrombectomy- Venous,PX-36900366,CDM,37187,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12006.91336,,,12006.91336,399.86,20286.72,other,OPPS APC,,
HC Percut Mech Thrombectomy- Venous- Repeat,PX-36900367,CDM,37188,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,6788.57,other,OPPS APC,,
HC Ins Intrvas Vc Filtr W/WO Vas Acs Vsl Selxn Rs&I,PX-36900368,CDM,37191,CPT,369,RC,,,outpatient,,,14030,9821,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,10775.04,other,OPPS APC,,
HC Repsng Intrvas Vc Filtr W/WO Acs Vsl Selxn Rs&I,PX-36900369,CDM,37192,CPT,369,RC,,,outpatient,,,9628,6739.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,7394.304,other,OPPS APC,,
HC Rtrvl Intrvas Vc Filtr W/WO Acs Vsl Selxn Rs&I,PX-36900370,CDM,37193,CPT,369,RC,,,outpatient,,,9998,6998.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,7678.464,other,OPPS APC,,
HC Thrombolysis Cerebral IV Infusion,PX-36900762,CDM,37195,CPT,369,RC,,,outpatient,,,613,429.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,369.62994,,,369.62994,137.6185,1592,other,OPPS APC,,
HC Prq Transcatheter Rtrvl Intrvas FB With Imaging,PX-36900371,CDM,37197,CPT,369,RC,,,outpatient,,,8825,6177.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,6777.6,other,OPPS APC,,
HC Transcatheter Biopsy,PX-36900372,CDM,37200,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC,,
HC Thrombolysis Arterial Infusion W/Imaging Init Tx,PX-36900374,CDM,37211,CPT,369,RC,,,outpatient,,,12541,8778.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC,,
HC Thrombolysis Venous Infusion W/Imaging Init Tx,PX-36900375,CDM,37212,CPT,369,RC,,,outpatient,,,3239,2267.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,4870.452937,other,OPPS APC,,
HC Thrombolysis Art/Venous Infsn W/Image Subsq Tx,PX-36900376,CDM,37213,CPT,369,RC,,,outpatient,,,7224,5056.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5548.032,other,OPPS APC,,
HC Cessation Thrombolytic Thrpy W/Catheter Removal,PX-36900377,CDM,37214,CPT,369,RC,,,outpatient,,,7224,5056.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5548.032,other,OPPS APC,,
HC Transcath Stent- Cca W/Eps,PX-36900378,CDM,37215,CPT,369,RC,,,outpatient,,,553,387.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,124.1485,2998,fee schedule,,,
HC Revascularize Iliac Artery-Angioplasty- Initial Vessel,PX-36900379,CDM,37220,CPT,369,RC,,,outpatient,,,15994,11195.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6238.20972,,,6238.20972,399.86,12283.392,other,OPPS APC,,
HC Revascularize Iliac Artery-Angioplasty/Stent- Initial Vessel,PX-36900380,CDM,37221,CPT,369,RC,,,outpatient,,,16597,11617.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12006.91336,,,12006.91336,399.86,18955.84,other,OPPS APC,,
HC Revascularize Iliac Artery-Angioplasty- Ea Add Vessel,PX-36900381,CDM,37222,CPT,369,RC,,,outpatient,,,15818,11072.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,12148.224,other,OPPS APC,,
HC Revascularize Iliac Artery-Angioplasty/Stent- Ea Add Vessel,PX-36900382,CDM,37223,CPT,369,RC,,,outpatient,,,16216,11351.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,12453.888,other,OPPS APC,,
HC Revascularize Fem/Pop Artery-Angioplasty,PX-36900383,CDM,37224,CPT,369,RC,,,outpatient,,,16599,11619.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6238.20972,,,6238.20972,399.86,12748.032,other,OPPS APC,,
HC Revascularize Fem/Pop Artery-Angioplasty/Atherectomy,PX-36900384,CDM,37225,CPT,369,RC,,,outpatient,,,34070,23849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19138.22361,,,19138.22361,399.86,26793.51305,other,OPPS APC,,
HC Revascularize Fem/Pop Artery-Angioplasty/Stent,PX-36900385,CDM,37226,CPT,369,RC,,,outpatient,,,32579,22805.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12006.91336,,,12006.91336,399.86,25020.672,other,OPPS APC,,
HC Revascularize Fem/Pop Artery-Angioplasty/Stent/Atherectomy,PX-36900386,CDM,37227,CPT,369,RC,,,outpatient,,,59005,41303.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19138.22361,,,19138.22361,399.86,45315.84,other,OPPS APC,,
HC Revascularize Tibial/Peron Artery-Angioplasty Initial,PX-36900387,CDM,37228,CPT,369,RC,,,outpatient,,,15999,11199.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12006.91336,,,12006.91336,399.86,16809.6787,other,OPPS APC,,
HC Revascularize Tibial/Peron Artery-Angioplasty/Atherectomy Initial,PX-36900388,CDM,37229,CPT,369,RC,,,outpatient,,,34866,24406.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19138.22361,,,19138.22361,399.86,26793.51305,other,OPPS APC,,
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent Initial,PX-36900389,CDM,37230,CPT,369,RC,,,outpatient,,,34070,23849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19138.22361,,,19138.22361,399.86,26793.51305,other,OPPS APC,,
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent/Atherectomy Init,PX-36900390,CDM,37231,CPT,369,RC,,,outpatient,,,58146,40702.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19138.22361,,,19138.22361,399.86,44656.128,other,OPPS APC,,
HC Revascularize Tibial/Peron Artery-Angioplasty Ea Add,PX-36900391,CDM,37232,CPT,369,RC,,,outpatient,,,16052,11236.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,12327.936,other,OPPS APC,,
HC Revascularize Tibial/Peron Artery-Angioplasty/Atherectomy Ea Add,PX-36900392,CDM,37233,CPT,369,RC,,,outpatient,,,33576,23503.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,25786.368,other,OPPS APC,,
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent Ea Add,PX-36900393,CDM,37234,CPT,369,RC,,,outpatient,,,16052,11236.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,12327.936,other,OPPS APC,,
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent/Atherectomy Ea Add,PX-36900394,CDM,37235,CPT,369,RC,,,outpatient,,,15818,11072.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,12148.224,other,OPPS APC,,
HC Open/Perq Placement Intravascular Stent Initial,PX-36900395,CDM,37236,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12006.91336,,,12006.91336,399.86,20286.72,other,OPPS APC,,
HC Open/Perq Placement Intravascular Stent Ea Addl,PX-36900396,CDM,37237,CPT,369,RC,,,outpatient,,,3978,2784.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,4532,other,OPPS APC,,
HC Open/Perq Placement Intravascular Stent Same 1st,PX-36900397,CDM,37238,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12006.91336,,,12006.91336,399.86,20286.72,other,OPPS APC,,
HC Open/Perq Placemt Intravasc Stent Same Ea Addl,PX-36900398,CDM,37239,CPT,369,RC,,,outpatient,,,3978,2784.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,4532,other,OPPS APC,,
HC Vascular Embolization or Occlusion Venous Rs&I,PX-36900399,CDM,37241,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12006.91336,,,12006.91336,399.86,20286.72,other,OPPS APC,,
HC Vascular Embolization or Occlusion Arterial Rs&I,PX-36900400,CDM,37242,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19138.22361,,,19138.22361,399.86,26793.51305,other,OPPS APC,,
HC Vascular Embolize/Occlude Organ Tumor Infarct,PX-36900401,CDM,37243,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12006.91336,,,12006.91336,399.86,20286.72,other,OPPS APC,,
HC Vascular Embolization or Occlusion Hemorrhage,PX-36100016,CDM,37244,CPT,361,RC,,,outpatient,,,26415,18490.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12006.91336,,,12006.91336,399.86,20286.72,other,OPPS APC,,
HC Vascular Embolization or Occlusion Hemorrhage,PX-36900402,CDM,37244,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12006.91336,,,12006.91336,399.86,20286.72,other,OPPS APC,,
HC Temporal Artery Ligatn or Bx,PX-36900554,CDM,37609,CPT,369,RC,,,outpatient,,,4643,3250.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,3565.824,other,OPPS APC,,
HC Phleb Veins - Extrem - to 20,PX-36900405,CDM,37765,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC,,
HC Phleb Veins - Extrem 20+,PX-36900406,CDM,37766,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC,,
HC Injection for Spleen X-Ray,PX-36900408,CDM,38200,CPT,369,RC,,,outpatient,,,381,266.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,85.5345,1592,other,OPPS APC,,
HC Bone Marrow; Aspiration Only,PX-36100017,CDM,38220,CPT,361,RC,,,outpatient,,,1973,1381.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2477.315575,other,OPPS APC,,
HC Bone Marrow; Aspiration Only,PX-36900409,CDM,38220,CPT,369,RC,,,outpatient,,,1973,1381.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2477.315575,other,OPPS APC,,
HC Bone Marrow Bx- Needle/Trocar,PX-36100018,CDM,38221,CPT,361,RC,,,outpatient,,,1972,1380.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2477.315575,other,OPPS APC,,
HC Bone Marrow Bx- Needle/Trocar,PX-36900410,CDM,38221,CPT,369,RC,,,outpatient,,,1972,1380.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2477.315575,other,OPPS APC,,
HC Dx Bone Marrow Bx & Aspir,PX-36100032,CDM,38222,CPT,361,RC,,,outpatient,,,4653,3257.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3101.269425,,,3101.269425,399.86,4341.777195,other,OPPS APC,,
HC Dx Bone Marrow Bx & Aspir,PX-36900703,CDM,38222,CPT,369,RC,,,outpatient,,,4653,3257.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3101.269425,,,3101.269425,399.86,4341.777195,other,OPPS APC,,
HC Needle Biopsy- Lymph Node(S),PX-36900411,CDM,38505,CPT,369,RC,,,outpatient,,,1973,1381.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC,,
HC Injection for Lymphatic Xray,PX-36900412,CDM,38790,CPT,369,RC,,,outpatient,,,500,350,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,112.25,1592,other,OPPS APC,,
HC Identify Sentinel Node,PX-36900413,CDM,38792,CPT,369,RC,,,outpatient,,,540,378,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,121.23,1592,other,OPPS APC,,
HC Biopsy of Floor of Mouth,PX-36900555,CDM,41108,CPT,369,RC,,,outpatient,,,2598,1818.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2477.315575,other,OPPS APC,,
HC Biopsy Salivary Gland-Needle,PX-36900414,CDM,42400,CPT,369,RC,,,outpatient,,,1637,1145.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,767.89738,,,767.89738,367.5065,2141,other,OPPS APC,,
HC Injection for Salivary X-Ray,PX-36900415,CDM,42550,CPT,369,RC,,,outpatient,,,424,296.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,95.188,1592,other,OPPS APC,,
HC Dilation/Cath of Salivary Duct,PX-36900416,CDM,42660,CPT,369,RC,,,outpatient,,,533,373.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,600.505465,,,600.505465,119.6585,1592,other,OPPS APC,,
HC Inc/Drain Peritonsil Abscess,PX-36900812,CDM,42700,CPT,369,RC,,,outpatient,,,685,479.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,266.592215,,,266.592215,153.7825,1592,other,OPPS APC,,
HC Placement Ng/Og Tube by Physician,PX-36900423,CDM,43752,CPT,369,RC,,,outpatient,,,325,227.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,434.866165,,,434.866165,72.9625,1592,other,OPPS APC,,
HC PR Naso/Oro-Gastric Tube Plmt Req Phys&Fluor Gdnce,PX-96000043,CDM,43752,CPT,960,RC,,,outpatient,,,325,227.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,434.866165,,,434.866165,72.9625,1592,other,OPPS APC,,
HC Gastric Intubatj & Aspiraj W/Phys Skill/Lavage,PX-36900575,CDM,43753,CPT,369,RC,,,outpatient,,,579,405.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,129.9855,1592,other,OPPS APC,,
HC Reposition Gastric Feeding Tube Thru Duodenum,PX-36900425,CDM,43761,CPT,369,RC,,,outpatient,,,496,347.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,269.74234,,,269.74234,111.352,1592,other,OPPS APC,,
HC Perq Replacement Gtube Not Req Revj Gstrst Trc,PX-36100033,CDM,43762,CPT,361,RC,,,outpatient,,,879,615.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,269.74234,,,269.74234,197.3355,1592,other,OPPS APC,,
HC Perq Replacement Gtube Not Req Revj Gstrst Trc,PX-36900727,CDM,43762,CPT,369,RC,,,outpatient,,,879,615.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,269.74234,,,269.74234,197.3355,1592,other,OPPS APC,,
HC Intro Long GI Tube,PX-36900427,CDM,44500,CPT,369,RC,,,outpatient,,,1673,1171.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,989.356895,,,989.356895,375.5885,2998,other,OPPS APC,,
HC Drainage of Pelvic Abscess,PX-36900428,CDM,45000,CPT,369,RC,,,outpatient,,,2727,1908.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1287.95438,,,1287.95438,399.86,4005.9,other,OPPS APC,,
HC Drainage of Deep Rectal Abscess,PX-36900429,CDM,45020,CPT,369,RC,,,outpatient,,,6425,4497.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3064.48742,,,3064.48742,399.86,4934.4,other,OPPS APC,,
HC I&D Ischiorectal&/Perirectal Abscess Spx,PX-36900738,CDM,46040,CPT,369,RC,,,outpatient,,,3716,2601.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1287.95438,,,1287.95438,399.86,2998,other,OPPS APC,,
HC Needle Biopsy Liver,PX-36900430,CDM,47000,CPT,369,RC,,,outpatient,,,3700,2590,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC,,
HC Needle Biopsy Liver-W Othr Proc,PX-36900431,CDM,47001,CPT,369,RC,,,outpatient,,,972,680.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,218.214,1592,other,OPPS APC,,
HC Ablat-Open-1+ Liver Tumor(S)-Percut Rf,PX-36900433,CDM,47382,CPT,369,RC,,,outpatient,,,13307,9314.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6297.489345,,,6297.489345,399.86,10219.776,other,OPPS APC,,
HC Cholecystostomy-Percutaneous- Complete,PX-36900434,CDM,47490,CPT,369,RC,,,outpatient,,,8367,5856.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3775.95747,,,3775.95747,399.86,6425.856,other,OPPS APC,,
HC Biliary Endoscopy Percut-Dil Strict,PX-36900443,CDM,47555,CPT,369,RC,,,outpatient,,,8367,5856.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3775.95747,,,3775.95747,399.86,6425.856,other,OPPS APC,,
HC Biliary Endoscopy Percut-Dil+Stent,PX-36900444,CDM,47556,CPT,369,RC,,,outpatient,,,13307,9314.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,11234.78908,,,11234.78908,399.86,15728.70471,other,OPPS APC,,
HC Needle Biopsy of Pancreas,PX-36900446,CDM,48102,CPT,369,RC,,,outpatient,,,3700,2590,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC,,
HC Anast Panc Cyst-Bowel-Direct,PX-36900447,CDM,48520,CPT,369,RC,,,outpatient,,,1740,1218,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,390.63,2998,fee schedule,,,
HC Exploratory Laparotomy Celiotomy W/WO Biopsy Spx,PX-36900881,CDM,49000,CPT,369,RC,,,outpatient,,,8564,5994.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6577.152,fee schedule,,,
HC Reopening Recent Laparotomy,PX-36900882,CDM,49002,CPT,369,RC,,,outpatient,,,8564,5994.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6577.152,fee schedule,,,
HC Abdom Paracentesis Dx/Ther W/O Imaging Guidance,PX-36900448,CDM,49082,CPT,369,RC,,,outpatient,,,925,647.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,989.356895,,,989.356895,207.6625,2998,other,OPPS APC,,
HC Abdom Paracentesis Dx/Ther W Imaging Guidance,PX-36100002,CDM,49083,CPT,361,RC,,,outpatient,,,1635,1144.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,989.356895,,,989.356895,367.0575,2998,other,OPPS APC,,
HC Abdom Paracentesis Dx/Ther W Imaging Guidance,PX-36900449,CDM,49083,CPT,369,RC,,,outpatient,,,1635,1144.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,989.356895,,,989.356895,367.0575,2998,other,OPPS APC,,
HC Percut Biopsy- Abdominal Mass,PX-36900450,CDM,49180,CPT,369,RC,,,outpatient,,,3700,2590,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC,,
HC Remove Peritoneal Foreign Body,PX-36900451,CDM,49402,CPT,369,RC,,,outpatient,,,8367,5856.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3775.95747,,,3775.95747,399.86,6425.856,other,OPPS APC,,
HC Image-Guide Fluid Collxn Drainage Cath Visc Perq,PX-36900452,CDM,49405,CPT,369,RC,,,outpatient,,,2870,2009,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC,,
HC Img-Guide Fluid Collxn Drainag Cath Periton Perq,PX-36900453,CDM,49406,CPT,369,RC,,,outpatient,,,2647,1852.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC,,
HC Insertion Tunnel Intraperitoneal Cath W Image Guidance,PX-36900455,CDM,49418,CPT,369,RC,,,outpatient,,,7964,5574.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3775.95747,,,3775.95747,399.86,6116.352,other,OPPS APC,,
HC Removal Tunneled Intraperitoneal Catheter,PX-36900456,CDM,49422,CPT,369,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC,,
HC Drainage Catheter Exchange,PX-36900457,CDM,49423,CPT,369,RC,,,outpatient,,,4271,2989.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2076.780045,,,2076.780045,399.86,3280.128,other,OPPS APC,,
HC Contrast Inj-Abscess/Cyst via Cath Tube,PX-36900458,CDM,49424,CPT,369,RC,,,outpatient,,,491,343.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,110.2295,1592,other,OPPS APC,,
HC Insert Gastrostomy Tube Percutaneous,PX-36900460,CDM,49440,CPT,369,RC,,,outpatient,,,4271,2989.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2076.780045,,,2076.780045,399.86,3280.128,other,OPPS APC,,
HC Convert Gastrostomy-Gastro-Jejunostomy Tube Percutaneous,PX-36900461,CDM,49446,CPT,369,RC,,,outpatient,,,4271,2989.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2076.780045,,,2076.780045,399.86,3280.128,other,OPPS APC,,
HC Replace Gastrostomy/Cecostomy Tube Percutaneous,PX-36100019,CDM,49450,CPT,361,RC,,,outpatient,,,1644,1150.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,989.356895,,,989.356895,369.078,2998,other,OPPS APC,,
HC Replace Gastrostomy/Cecostomy Tube Percutaneous,PX-36900462,CDM,49450,CPT,369,RC,,,outpatient,,,1644,1150.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,989.356895,,,989.356895,369.078,2998,other,OPPS APC,,
HC Replace Duodenostomy/Jejunostomy Tube Percutaneous,PX-36100020,CDM,49451,CPT,361,RC,,,outpatient,,,1692,1184.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,989.356895,,,989.356895,379.854,2998,other,OPPS APC,,
HC Replace Duodenostomy/Jejunostomy Tube Percutaneous,PX-36900463,CDM,49451,CPT,369,RC,,,outpatient,,,1692,1184.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,989.356895,,,989.356895,379.854,2998,other,OPPS APC,,
HC Replacement Gastro-Jejunostomy Tube Percutaneous,PX-36100021,CDM,49452,CPT,361,RC,,,outpatient,,,2617,1831.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,989.356895,,,989.356895,399.86,2998,other,OPPS APC,,
HC Replacement Gastro-Jejunostomy Tube Percutaneous,PX-36900464,CDM,49452,CPT,369,RC,,,outpatient,,,2617,1831.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,989.356895,,,989.356895,399.86,2998,other,OPPS APC,,
HC Obstructive Material Removal From GI Tube,PX-36900465,CDM,49460,CPT,369,RC,,,outpatient,,,2128,1489.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,989.356895,,,989.356895,399.86,2998,other,OPPS APC,,
HC Contrast Injection Percutaneouos Radiologic Eval GI Tube,PX-36900466,CDM,49465,CPT,369,RC,,,outpatient,,,606,424.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,136.047,1592,other,OPPS APC,,
HC Biopsy of Kidney-Percutaneous,PX-36900467,CDM,50200,CPT,369,RC,,,outpatient,,,3700,2590,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC,,
HC Change Ureter Stent- Percut,PX-36900468,CDM,50382,CPT,369,RC,,,outpatient,,,4709,3296.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2223.02603,,,2223.02603,399.86,4179.83,other,OPPS APC,,
HC Remove Ureter Stent- Percut,PX-36900469,CDM,50384,CPT,369,RC,,,outpatient,,,4709,3296.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2223.02603,,,2223.02603,399.86,3616.512,other,OPPS APC,,
HC Change Ext Transneph Ureter Stent W/ Fluoro,PX-36900470,CDM,50387,CPT,369,RC,,,outpatient,,,4709,3296.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2223.02603,,,2223.02603,399.86,3616.512,other,OPPS APC,,
HC Remove Renal Tube W/Fluoro,PX-36900471,CDM,50389,CPT,369,RC,,,outpatient,,,1513,1059.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,745.56013,,,745.56013,339.6685,2141,other,OPPS APC,,
HC Percut Drain/Inject Renal Cyst,PX-36900472,CDM,50390,CPT,369,RC,,,outpatient,,,726,508.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,767.89738,,,767.89738,162.987,2141,other,OPPS APC,,
HC Instll Rx Agnt Into Rnal Tub,PX-36900473,CDM,50391,CPT,369,RC,,,outpatient,,,533,373.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,269.74234,,,269.74234,119.6585,1592,other,OPPS APC,,
HC Measure Kidney Pressure Thru Tube,PX-36900478,CDM,50396,CPT,369,RC,,,outpatient,,,1513,1059.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,745.56013,,,745.56013,334.48,2141,other,OPPS APC,,
HC Plmt Nephrostomy Cath Prq New Access Rs&I,PX-36900659,CDM,50432,CPT,369,RC,,,outpatient,,,5502,3851.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2223.02603,,,2223.02603,399.86,4225.536,other,OPPS APC,,
HC Renal Endoscopy-Remv FB/Stone,PX-36900480,CDM,50561,CPT,369,RC,,,outpatient,,,11603,8122.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5647.40664,,,5647.40664,399.86,8911.104,other,OPPS APC,,
HC Perc Radiofreq Ablate Renal Tumor,PX-36900481,CDM,50592,CPT,369,RC,,,outpatient,,,13307,9314.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6297.489345,,,6297.489345,399.86,10219.776,other,OPPS APC,,
HC Inject Indwell Cath-Ureter X-Ray,PX-36900482,CDM,50684,CPT,369,RC,,,outpatient,,,374,261.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,83.963,1592,other,OPPS APC,,
HC Change of Ureterostomy Tube via Ileal Conduit,PX-36900483,CDM,50688,CPT,369,RC,,,outpatient,,,4709,3296.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2223.02603,,,2223.02603,399.86,3616.512,other,OPPS APC,,
HC Inject Retrograde/Conduit X-Ray,PX-36900484,CDM,50690,CPT,369,RC,,,outpatient,,,533,373.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,119.6585,1592,other,OPPS APC,,
HC Ureter Endoscopy Thru Ureterostomy W Biopsy,PX-36900485,CDM,50955,CPT,369,RC,,,outpatient,,,11603,8122.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5647.40664,,,5647.40664,399.86,8911.104,other,OPPS APC,,
HC Ureter Endoscopy Thru Ureterostomy Remv FB or Calculus,PX-36900486,CDM,50961,CPT,369,RC,,,outpatient,,,11603,8122.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5647.40664,,,5647.40664,399.86,8911.104,other,OPPS APC,,
HC Aspiration Bladder Needle,PX-36100022,CDM,51100,CPT,361,RC,,,outpatient,,,699,489.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,269.74234,,,269.74234,156.9255,1592,other,OPPS APC,,
HC Aspiration Bladder Needle,PX-36900488,CDM,51100,CPT,369,RC,,,outpatient,,,699,489.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,269.74234,,,269.74234,156.9255,1592,other,OPPS APC,,
HC Aspiration Bladder Trocar/Intracatheter,PX-36100023,CDM,51101,CPT,361,RC,,,outpatient,,,2419,1693.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1141.12419,,,1141.12419,179.53,2998,other,OPPS APC,,
HC Aspiration Bladder Trocar/Intracatheter,PX-36900489,CDM,51101,CPT,369,RC,,,outpatient,,,2419,1693.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1141.12419,,,1141.12419,179.53,2998,other,OPPS APC,,
HC Aspiration Bladder Insert Suprapubic Catheter,PX-36100024,CDM,51102,CPT,361,RC,,,outpatient,,,4709,3296.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2223.02603,,,2223.02603,399.86,3616.512,other,OPPS APC,,
HC Aspiration Bladder Insert Suprapubic Catheter,PX-36900490,CDM,51102,CPT,369,RC,,,outpatient,,,4709,3296.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2223.02603,,,2223.02603,399.86,3616.512,other,OPPS APC,,
HC Injection for Bladder X-Ray,PX-36900491,CDM,51600,CPT,369,RC,,,outpatient,,,1455,1018.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,235.074116,1592,other,OPPS APC,,
HC Inject for Retrograde Urethocysto,PX-36900492,CDM,51610,CPT,369,RC,,,outpatient,,,976,683.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,219.112,1592,other,OPPS APC,,
HC Bldr Irrigation Smpl Lavage &/Instlj,PX-36900732,CDM,51700,CPT,369,RC,,,outpatient,,,879,615.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,269.74234,,,269.74234,197.3355,1592,other,OPPS APC,,
HC Insert-Non-Indwelling Bladder Catheter,PX-36900494,CDM,51701,CPT,369,RC,,,outpatient,,,389,272.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,87.3305,1592,other,OPPS APC,,
HC Insert-Temp Indwelling Blad Cath-Simple,PX-36900495,CDM,51702,CPT,369,RC,,,outpatient,,,391,273.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,87.7795,1592,other,OPPS APC,,
HC Insert-Temp Indwelling Blad Cath-Comp,PX-36900496,CDM,51703,CPT,369,RC,,,outpatient,,,354,247.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,170.484765,,,170.484765,79.473,1592,other,OPPS APC,,
HC Change of Bladder Tube-Simple,PX-36900497,CDM,51705,CPT,369,RC,,,outpatient,,,456,319.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,269.74234,,,269.74234,102.372,1592,other,OPPS APC,,
HC Emg Stds Anal/Urtl Sphnctr Oth/Thn Ndl,PX-36900667,CDM,51784,CPT,369,RC,,,outpatient,,,475,332.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,170.484765,,,170.484765,106.6375,1592,other,OPPS APC,,
HC Meas Post-Voiding Residual Urine&/Bladder Cap,PX-36900733,CDM,51798,CPT,369,RC,,,outpatient,,,212,148.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,47.594,1592,other,OPPS APC,,
HC Cysto/Ureteroscopy-Tx Ureter Strict,PX-36900500,CDM,52344,CPT,369,RC,,,outpatient,,,8086,5660.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3804.86989,,,3804.86989,399.86,6210.048,other,OPPS APC,,
HC Circumcision Age >28 Days,PX-36900772,CDM,54161,CPT,369,RC,,,outpatient,,,6599,4619.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2223.02603,,,2223.02603,399.86,5068.032,other,OPPS APC,,
HC Irrigation Corpora Cavernosa Priapism,PX-36900736,CDM,54220,CPT,369,RC,,,outpatient,,,591,413.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,269.74234,,,269.74234,120.28264,1592,other,OPPS APC,,
HC Biopsy of Prostate-Needle/Punch,PX-36900501,CDM,55700,CPT,369,RC,,,outpatient,,,4709,3296.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2223.02603,,,2223.02603,399.86,3616.512,other,OPPS APC,,
HC I&D of Vulva/Perineum Abscess,PX-36900502,CDM,56405,CPT,369,RC,,,outpatient,,,829,580.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,350.13353,,,350.13353,186.1105,1592,other,OPPS APC,,
HC PR Colporrhaphy- Suture Vaginal Injury- Non-OB,PX-36900795,CDM,57200,CPT,369,RC,,,outpatient,,,5013,3509.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3412.181035,,,3412.181035,399.86,4777.053449,other,OPPS APC,,
HC Cath/Inject Hysterosalpingogram,PX-36900505,CDM,58340,CPT,369,RC,,,outpatient,,,1092,764.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,235.074116,1592,other,OPPS APC,,
HC Reopen Fallopian Tube-Transcerv Cath,PX-36900506,CDM,58345,CPT,369,RC,,,outpatient,,,6900,4830,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3412.181035,,,3412.181035,399.86,5299.2,other,OPPS APC,,
HC Fetal Non-Stress Test,PX-92000003,CDM,59025,CPT,920,RC,,,outpatient,,,490,343,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,217.48463,,,217.48463,110.005,416.02,other,OPPS APC,,
HC PR Vaginal Delivery Only,PX-96000044,CDM,59409,CPT,960,RC,,,outpatient,,,3062,2143.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3412.181035,,,3412.181035,399.86,4777.053449,other,OPPS APC,,
HC PR Delivery Placenta Separate Procedure,PX-96000045,CDM,59414,CPT,960,RC,,,outpatient,,,7176,5023.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3412.181035,,,3412.181035,399.86,5511.168,other,OPPS APC,,
HC Biopsy of Thyroid-Percut,PX-36900512,CDM,60100,CPT,369,RC,,,outpatient,,,1514,1059.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,767.89738,,,767.89738,339.893,2141,other,OPPS APC,,
HC Endocrine Surgery Proc Unlisted,PX-36900513,CDM,60699,CPT,369,RC,,,outpatient,,,6035,4224.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6297.489345,,,6297.489345,399.86,11413.04,other,OPPS APC,,
HC Brain Shunt Tube/Reserv Injectn,PX-36900514,CDM,61070,CPT,369,RC,,,outpatient,,,1885,1319.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,754.76995,,,754.76995,399.86,2141,other,OPPS APC,,
HC Endovasc Temp Balloon Occlus-Head/Nck,PX-36900515,CDM,61623,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12006.91336,,,12006.91336,399.86,20286.72,other,OPPS APC,,
HC Perm Occlusion/Embolization-Percut-Cns,PX-36900516,CDM,61624,CPT,369,RC,,,outpatient,,,533,373.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,119.6585,5756,fee schedule,,,
HC Percut Cath Occlusn Non Cns Lesn,PX-36900517,CDM,61626,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12006.91336,,,12006.91336,399.86,20286.72,other,OPPS APC,,
HC Percut Aspiration Vertebral Disc,PX-36900518,CDM,62267,CPT,369,RC,,,outpatient,,,1637,1145.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,767.89738,,,767.89738,367.5065,2141,other,OPPS APC,,
HC Spinal Puncture-Lumbar-Diagnostic,PX-36100025,CDM,62270,CPT,361,RC,,,outpatient,,,915,640.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,754.76995,,,754.76995,205.4175,2141,other,OPPS APC,,
HC Spinal Puncture-Lumbar-Diagnostic,PX-36900519,CDM,62270,CPT,369,RC,,,outpatient,,,915,640.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,754.76995,,,754.76995,205.4175,2141,other,OPPS APC,,
HC PR Spinal Puncture Lumbar Diagnostic,PX-96000051,CDM,62270,CPT,960,RC,,,outpatient,,,915,640.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,754.76995,,,754.76995,205.4175,2141,other,OPPS APC,,
HC Spinal Puncture-Therapeutic Drainage,PX-36100026,CDM,62272,CPT,361,RC,,,outpatient,,,1256,879.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,754.76995,,,754.76995,281.972,2141,other,OPPS APC,,
HC Spinal Puncture-Therapeutic Drainage,PX-36900520,CDM,62272,CPT,369,RC,,,outpatient,,,1256,879.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,754.76995,,,754.76995,281.972,2141,other,OPPS APC,,
HC Inj-Lumb Epidur-Blood/Clot Patch,PX-36900521,CDM,62273,CPT,369,RC,,,outpatient,,,915,640.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,754.76995,,,754.76995,205.4175,2141,other,OPPS APC,,
HC Inject-Myelography &/or CT Scan-Spinal,PX-36900522,CDM,62284,CPT,369,RC,,,outpatient,,,1312,918.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,294.544,1592,other,OPPS APC,,
HC Diskectomy-Percutaneous Lumbar,PX-36900523,CDM,62287,CPT,369,RC,,,outpatient,,,6304,4412.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2107.296165,,,2107.296165,399.86,6224.0876,other,OPPS APC,,
HC Inject Diskogram-Lumbar-Ea Level,PX-36900524,CDM,62290,CPT,369,RC,,,outpatient,,,1256,879.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,281.972,1592,other,OPPS APC,,
HC Inj-Cerv/Thorac-for Diskography,PX-36900525,CDM,62291,CPT,369,RC,,,outpatient,,,1107,774.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,248.5215,1592,other,OPPS APC,,
HC Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/O Img Gdn,PX-36900884,CDM,62322,CPT,369,RC,,,outpatient,,,2586,1810.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,994.809475,,,994.809475,399.86,2141,other,OPPS APC,,
HC Elec Anlys Implt Ithcl/Edrl Pmp W/Repr Phys/Qhp,PX-36900526,CDM,62370,CPT,369,RC,,,outpatient,,,821,574.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,325.997845,,,325.997845,155.844464,1592,other,OPPS APC,,
HC Inject Nerv Blck-Trigeminal,PX-36900609,CDM,64400,CPT,369,RC,,,outpatient,,,891,623.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,323.2601,,,323.2601,200.0295,1592,other,OPPS APC,,
HC Inject Nerv Blck-Great Occiptl,PX-36900611,CDM,64405,CPT,369,RC,,,outpatient,,,1634,1143.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,323.2601,,,323.2601,323.2601,1592,other,OPPS APC,,
HC Inject Nerv Blck-Vagus Nerve,PX-36900612,CDM,64408,CPT,369,RC,,,outpatient,,,877,613.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,323.2601,,,323.2601,196.8865,1592,other,OPPS APC,,
HC Inj-Anes Agent-Brachial Plexus-Single,PX-36900616,CDM,64415,CPT,369,RC,,,outpatient,,,1544,1080.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,994.809475,,,994.809475,346.628,2141,other,OPPS APC,,
HC Inj-Anes Agent-Brachial Plexus-Cont Inf,PX-36900617,CDM,64416,CPT,369,RC,,,outpatient,,,2785,1949.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,994.809475,,,994.809475,399.86,2141,other,OPPS APC,,
HC Inject Nerv Blck-Axillary Nerv,PX-36900618,CDM,64417,CPT,369,RC,,,outpatient,,,1544,1080.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,994.809475,,,994.809475,346.628,2141,other,OPPS APC,,
HC Inject Nerv Blck-Suprascap N.,PX-36900619,CDM,64418,CPT,369,RC,,,outpatient,,,1544,1080.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,754.76995,,,754.76995,346.628,2141,other,OPPS APC,,
HC Inject Nerv Blck-Intercostal-One,PX-36900620,CDM,64420,CPT,369,RC,,,outpatient,,,1382,967.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,754.76995,,,754.76995,310.259,2141,other,OPPS APC,,
HC Inject Nerv Blck-Intercost-Multpl,PX-36900621,CDM,64421,CPT,369,RC,,,outpatient,,,2785,1949.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,994.809475,,,994.809475,399.86,2141,other,OPPS APC,,
HC Inject Nerv Blck-Ilioingu/Iliohyp,PX-36900622,CDM,64425,CPT,369,RC,,,outpatient,,,1544,1080.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,754.76995,,,754.76995,346.628,2141,other,OPPS APC,,
HC Inject Nerv Blck-Pudendal,PX-36100029,CDM,64430,CPT,361,RC,,,outpatient,,,2785,1949.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,994.809475,,,994.809475,399.86,2141,other,OPPS APC,,
HC Inject Nerv Blck-Pudendal,PX-36900623,CDM,64430,CPT,369,RC,,,outpatient,,,2785,1949.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,994.809475,,,994.809475,399.86,2141,other,OPPS APC,,
HC Inject Nerv Blck-Paracervical,PX-36900624,CDM,64435,CPT,369,RC,,,outpatient,,,1544,1080.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,754.76995,,,754.76995,346.628,2141,other,OPPS APC,,
HC Inj-Anes Agent-Sciatic Nerve-Single,PX-36900625,CDM,64445,CPT,369,RC,,,outpatient,,,2785,1949.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,754.76995,,,754.76995,399.86,2141,other,OPPS APC,,
HC Inj-Anes Agent-Sciatic Nerve-Cont Inf,PX-36900626,CDM,64446,CPT,369,RC,,,outpatient,,,2785,1949.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,994.809475,,,994.809475,399.86,2141,other,OPPS APC,,
HC Inj-Anes Agent-Femoral Nerve-Single,PX-36900627,CDM,64447,CPT,369,RC,,,outpatient,,,1544,1080.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,754.76995,,,754.76995,346.628,2141,other,OPPS APC,,
HC Inj-Anes Agent-Femoral Nerve-Cont Inf,PX-36900628,CDM,64448,CPT,369,RC,,,outpatient,,,6090,4263,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,994.809475,,,994.809475,399.86,4677.12,other,OPPS APC,,
HC N Block Inj- Lumbar Plexus,PX-36900629,CDM,64449,CPT,369,RC,,,outpatient,,,2785,1949.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,994.809475,,,994.809475,399.86,2141,other,OPPS APC,,
HC Inject Nerv Blck-Othr Periph Nerv,PX-36900630,CDM,64450,CPT,369,RC,,,outpatient,,,1634,1143.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,754.76995,,,754.76995,366.833,2141,other,OPPS APC,,
HC Njx Aa&/Strd Plantar Common Digital Nerves,PX-36900835,CDM,64455,CPT,369,RC,,,outpatient,,,825,577.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,323.2601,,,323.2601,185.2125,1592,other,OPPS APC,,
HC Inject Anes/Steroid Foramen Cerv/Thoracic W Img Guide -1 Level,PX-36900631,CDM,64479,CPT,369,RC,,,outpatient,,,2785,1949.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,994.809475,,,994.809475,399.86,2141,other,OPPS APC,,
HC Inject Anes/Steroid Foramen Cerv/Thoracic W Img Guide -Ea Add Level,PX-36900632,CDM,64480,CPT,369,RC,,,outpatient,,,230,161,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.635,1592,other,OPPS APC,,
HC Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level,PX-36100027,CDM,64483,CPT,361,RC,,,outpatient,,,1693,1185.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,994.809475,,,994.809475,380.0785,2141,other,OPPS APC,,
HC Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level,PX-36900531,CDM,64483,CPT,369,RC,,,outpatient,,,1693,1185.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,994.809475,,,994.809475,380.0785,2141,other,OPPS APC,,
HC Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl,PX-36900532,CDM,64484,CPT,369,RC,,,outpatient,,,416,291.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,93.392,1592,other,OPPS APC,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- 1st Level,PX-36100028,CDM,64490,CPT,361,RC,,,outpatient,,,1693,1185.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,994.809475,,,994.809475,380.0785,2141,other,OPPS APC,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- 1st Level,PX-36900533,CDM,64490,CPT,369,RC,,,outpatient,,,1693,1185.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,994.809475,,,994.809475,380.0785,2141,other,OPPS APC,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- 2nd Level,PX-36900633,CDM,64491,CPT,369,RC,,,outpatient,,,221,154.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,49.6145,1592,other,OPPS APC,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- Add Level,PX-36900634,CDM,64492,CPT,369,RC,,,outpatient,,,224,156.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,50.288,1592,other,OPPS APC,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Lumbar/Sac- 1st Level,PX-36900536,CDM,64493,CPT,369,RC,,,outpatient,,,1693,1185.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,994.809475,,,994.809475,380.0785,2141,other,OPPS APC,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Lumbar/Sac- 2nd Level,PX-36900537,CDM,64494,CPT,369,RC,,,outpatient,,,1693,1185.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,380.0785,1592,other,OPPS APC,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Lumbar/Sac- Add Level,PX-36900538,CDM,64495,CPT,369,RC,,,outpatient,,,54,37.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.123,1592,other,OPPS APC,,
HC Inject Nerv Blck-Celiac Plexus,PX-36900539,CDM,64530,CPT,369,RC,,,outpatient,,,2165,1515.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,994.809475,,,994.809475,399.86,2141,other,OPPS APC,,
HC Unlisted Procedure Nervous System,PX-36100035,CDM,64999,CPT,361,RC,,,outpatient,,,687,480.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,323.2601,,,323.2601,154.2315,1592,other,OPPS APC,,
HC Unlisted Procedure Nervous System,PX-36900829,CDM,64999,CPT,369,RC,,,outpatient,,,687,480.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,323.2601,,,323.2601,154.2315,1592,other,OPPS APC,,
HC Removal Impacted Cerumen Using Irrigation/Lavage- Unilateral,PX-36900636,CDM,69209,CPT,369,RC,,,outpatient,,,205,143.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,46.0225,1592,other,OPPS APC,,
HC Removal Impacted Cerumen Instrumentation Unilat,PX-36900540,CDM,69210,CPT,369,RC,,,outpatient,,,305,213.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,66.75974,1592,other,OPPS APC,,
HC X-Ray Eye for Foreign Body,PX-32000004,CDM,70030,CPT,320,RC,,,outpatient,,,271,189.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,60.8395,416.02,other,OPPS APC,,
HC X-Ray Jaw <4 Vw,PX-32000005,CDM,70100,CPT,320,RC,,,outpatient,,,595,416.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,71.24,456.96,other,OPPS APC,,
HC X-Ray Jaw 4+ Vw,PX-32000006,CDM,70110,CPT,320,RC,,,outpatient,,,489,342.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,76.026473,416.02,other,OPPS APC,,
HC X-Ray Mastoids <3 Vw,PX-32000007,CDM,70120,CPT,320,RC,,,outpatient,,,384,268.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,86.208,416.02,other,OPPS APC,,
HC X-Ray Mastoids 3+ Vw,PX-32000008,CDM,70130,CPT,320,RC,,,outpatient,,,295,206.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,66.2275,416.02,other,OPPS APC,,
HC X-Ray Facial Bones <3 Vw,PX-32000009,CDM,70140,CPT,320,RC,,,outpatient,,,336,235.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC,,
HC X-Ray Facial Bones 3+ Vw,PX-32000010,CDM,70150,CPT,320,RC,,,outpatient,,,252,176.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,56.574,416.02,other,OPPS APC,,
HC X-Ray Nasal Bones,PX-32000011,CDM,70160,CPT,320,RC,,,outpatient,,,319,223.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC,,
HC X-Ray Orbits,PX-32000012,CDM,70200,CPT,320,RC,,,outpatient,,,328,229.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,73.636,416.02,other,OPPS APC,,
HC X-Ray Sinuses <3 Vw,PX-32000013,CDM,70210,CPT,320,RC,,,outpatient,,,328,229.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC,,
HC X-Ray Sinuses 3+ Vw,PX-32000014,CDM,70220,CPT,320,RC,,,outpatient,,,444,310.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC,,
HC X-Ray Exam Sella,PX-32000015,CDM,70240,CPT,320,RC,,,outpatient,,,262,183.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,58.819,416.02,other,OPPS APC,,
HC X-Ray Skull <4 Vw,PX-32000016,CDM,70250,CPT,320,RC,,,outpatient,,,352,246.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,76.026473,416.02,other,OPPS APC,,
HC X-Ray Skull 4+ Vw,PX-32000017,CDM,70260,CPT,320,RC,,,outpatient,,,419,293.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,76.026473,416.02,other,OPPS APC,,
HC X-Ray Teeth Single,PX-32000018,CDM,70300,CPT,320,RC,,,outpatient,,,241,168.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,54.1045,416.02,other,OPPS APC,,
HC X-Ray Tmj Unilat,PX-32000019,CDM,70328,CPT,320,RC,,,outpatient,,,241,168.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,54.1045,416.02,other,OPPS APC,,
HC X-Ray Tmj Bilat,PX-32000020,CDM,70330,CPT,320,RC,,,outpatient,,,716,501.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,71.24,549.888,other,OPPS APC,,
HC MRI- Tmj,PX-61000008,CDM,70336,CPT,610,RC,,,outpatient,,,2588,1811.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,267.439885,1987.584,other,OPPS APC,,
HC Panoramic X-Ray of Jaws,PX-32000022,CDM,70355,CPT,320,RC,,,outpatient,,,241,168.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,54.1045,416.02,other,OPPS APC,,
HC X-Ray Neck Soft Tissue,PX-32000023,CDM,70360,CPT,320,RC,,,outpatient,,,232,162.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,52.084,416.02,other,OPPS APC,,
HC X-Ray Salivary Gland,PX-32000025,CDM,70380,CPT,320,RC,,,outpatient,,,262,183.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,58.819,416.02,other,OPPS APC,,
HC X-Ray Sialogram,PX-32000026,CDM,70390,CPT,320,RC,,,outpatient,,,537,375.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,120.5565,646.6965,other,OPPS APC,,
HC CT Scan-Head/Brain-W/O Contrast Matl,PX-35000002,CDM,70450,CPT,350,RC,,,outpatient,,,1070,749,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,89.81,821.76,other,OPPS APC,,
HC CT Scan Head Contrast,PX-35000003,CDM,70460,CPT,350,RC,,,outpatient,,,1333,933.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,124.33,1023.744,other,OPPS APC,,
CT Head/Brain W/O & W/Contrast Material,PX-35000004,CDM,70470,CPT,350,RC,,,outpatient,,,1615,1130.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,153.75,1240.32,other,OPPS APC,,
HC CT Scan-Orbit/Sella/Post Fossa/Ear-W/O,PX-35000005,CDM,70480,CPT,350,RC,,,outpatient,,,657,459.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,96.160741,575,other,OPPS APC,,
HC CT Scan Skull Contrast,PX-35000006,CDM,70481,CPT,350,RC,,,outpatient,,,774,541.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,173.763,667.43,other,OPPS APC,,
CT Orbit Sella/Post Fossa/Ear W/O & W/Contr Matr,PX-35000007,CDM,70482,CPT,350,RC,,,outpatient,,,1619,1133.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,1243.392,other,OPPS APC,,
HC CT Scan-Maxillofacial Area-W/O Contrast,PX-35000008,CDM,70486,CPT,350,RC,,,outpatient,,,1200,840,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,96.160741,921.6,other,OPPS APC,,
HC CT Scan- Face/Jaw Contrast,PX-35000009,CDM,70487,CPT,350,RC,,,outpatient,,,1321,924.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,1014.528,other,OPPS APC,,
CT Maxillofacial W/O & W/Contrast Material,PX-35000010,CDM,70488,CPT,350,RC,,,outpatient,,,1158,810.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,889.344,other,OPPS APC,,
HC CT Scan-Soft Tissue Neck-W/O Contrast,PX-35000011,CDM,70490,CPT,350,RC,,,outpatient,,,514,359.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,96.160741,575,other,OPPS APC,,
HC CT Neck Tissue Contrast,PX-35000012,CDM,70491,CPT,350,RC,,,outpatient,,,1482,1037.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,194.55,1138.176,other,OPPS APC,,
CT Soft Tissue Neck W/O & W/Contrast Material,PX-35000014,CDM,70492,CPT,350,RC,,,outpatient,,,1755,1228.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,1347.84,other,OPPS APC,,
CT Angiography Head W/Contrast/Noncontrast,PX-35000013,CDM,70496,CPT,350,RC,,,outpatient,,,1330,931,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,1021.44,other,OPPS APC,,
CT Angiography Neck W/Contrast/Noncontrast,PX-35000015,CDM,70498,CPT,350,RC,,,outpatient,,,1157,809.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,888.576,other,OPPS APC,,
HC MRI- Face- Neck,PX-61000009,CDM,70540,CPT,610,RC,,,outpatient,,,5081,3556.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,237.688956,3902.208,other,OPPS APC,,
HC MRI- Face- Neck W/Contrast,PX-61000010,CDM,70542,CPT,610,RC,,,outpatient,,,2710,1897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,365.99,2081.28,other,OPPS APC,,
MRI Orbit Face & Neck W/O & W/Contrast Matrl,PX-61000011,CDM,70543,CPT,610,RC,,,outpatient,,,1692,1184.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,379.854,1299.456,other,OPPS APC,,
HC MR Angio- Head,PX-61000012,CDM,70544,CPT,610,RC,,,outpatient,,,2279,1595.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,267.439885,1750.272,other,OPPS APC,,
HC MR Angio- Head W/Contrast,PX-61000013,CDM,70545,CPT,610,RC,,,outpatient,,,2279,1595.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,374.62,1750.272,other,OPPS APC,,
Mra Head W/O & W/Contrast Material,PX-61000014,CDM,70546,CPT,610,RC,,,outpatient,,,2279,1595.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,301.425681,1750.272,other,OPPS APC,,
HC MR Angio- Neck,PX-61000015,CDM,70547,CPT,610,RC,,,outpatient,,,2182,1527.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,267.439885,1675.776,other,OPPS APC,,
HC MR Angio- Neck W/Contrast,PX-61000016,CDM,70548,CPT,610,RC,,,outpatient,,,2469,1728.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,399.86,1896.192,other,OPPS APC,,
Mra Neck W/O &W/Contrast Material,PX-61000017,CDM,70549,CPT,610,RC,,,outpatient,,,2534,1773.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,301.425681,1946.112,other,OPPS APC,,
HC MRI Brain,PX-61000018,CDM,70551,CPT,610,RC,,,outpatient,,,2090,1463,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,188.66,1605.12,other,OPPS APC,,
HC MRI Brain Contrast,PX-61000019,CDM,70552,CPT,610,RC,,,outpatient,,,5255,3678.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,268.7,4035.84,other,OPPS APC,,
MRI Brain Brain Stem W/O W/Contrast Material,PX-61000020,CDM,70553,CPT,610,RC,,,outpatient,,,2668,1867.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,307.14,2049.024,other,OPPS APC,,
HC X-Ray Exam Chest 1 View,PX-32000245,CDM,71045,CPT,320,RC,,,outpatient,,,214,149.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,48.043,416.02,other,OPPS APC,,
HC X-Ray Exam Chest 2 Views,PX-32000246,CDM,71046,CPT,320,RC,,,outpatient,,,232,162.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,52.084,416.02,other,OPPS APC,,
HC X-Ray Exam Chest 3 Views,PX-32000247,CDM,71047,CPT,320,RC,,,outpatient,,,245,171.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,55.0025,416.02,other,OPPS APC,,
HC X-Ray Exam Chest 4+ Views,PX-32000248,CDM,71048,CPT,320,RC,,,outpatient,,,410,287,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,76.026473,416.02,other,OPPS APC,,
HC X-Ray Ribs- Chest 3+ Vw,PX-32000036,CDM,71101,CPT,320,RC,,,outpatient,,,484,338.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,76.026473,416.02,other,OPPS APC,,
HC X-Ray Ribs- Chest 4+ Vw,PX-32000038,CDM,71111,CPT,320,RC,,,outpatient,,,562,393.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,76.026473,431.616,other,OPPS APC,,
HC X-Ray Sternum 2+ Vw,PX-32000039,CDM,71120,CPT,320,RC,,,outpatient,,,358,250.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC,,
HC X-Ray Sterno-Clavicluar Jt,PX-32000040,CDM,71130,CPT,320,RC,,,outpatient,,,250,175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,56.125,416.02,other,OPPS APC,,
HC Diagnostic Computed Tomography Thorax W/O Cntrst,PX-35000016,CDM,71250,CPT,350,RC,,,outpatient,,,1388,971.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,96.160741,1065.984,other,OPPS APC,,
HC Diagnostic Computed Tomography Thorax W/Contrast,PX-35000017,CDM,71260,CPT,350,RC,,,outpatient,,,1624,1136.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,195.34,1247.232,other,OPPS APC,,
HC Diagnostic Computed Tomography Thorax C-/C+,PX-35000018,CDM,71270,CPT,350,RC,,,outpatient,,,1982,1387.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,1522.176,other,OPPS APC,,
HC Computed Tomography Thorax Lw Dose Lng Ca Scr C-,PX-35000070,CDM,71271,CPT,350,RC,,,outpatient,,,264,184.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,59.268,575,other,OPPS APC,,
CT Angiography Chest W/Contrast/Noncontrast,PX-35000019,CDM,71275,CPT,350,RC,,,outpatient,,,1592,1114.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,1222.656,other,OPPS APC,,
HC MRI- Chest,PX-61000023,CDM,71550,CPT,610,RC,,,outpatient,,,1979,1385.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,237.688956,1519.872,other,OPPS APC,,
HC MRI- Chest- W/Contrast,PX-61000024,CDM,71551,CPT,610,RC,,,outpatient,,,3128,2189.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,873.87904,,,873.87904,399.86,2402.304,other,OPPS APC,,
MRI Chest W/O & W/Contrast Material,PX-61000025,CDM,71552,CPT,610,RC,,,outpatient,,,1547,1082.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,347.3015,1288.93,other,OPPS APC,,
HC MR Angio Chest (Mra) W/Contrast,PX-61000026,CDM,71555,CPT,610,RC,,,outpatient,,,2367,1656.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,301.425681,1817.856,other,OPPS APC,,
HC MR Angio Chest (Mra) Without Contrast,PX-61000071,CDM,71555,CPT,610,RC,,,outpatient,,,2367,1656.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,301.425681,1817.856,other,OPPS APC,,
HC MR Angio Chest (Mra) W/Without Contrast,PX-61000072,CDM,71555,CPT,610,RC,,,outpatient,,,2367,1656.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,301.425681,1817.856,other,OPPS APC,,
HC X-Ray Spine One View,PX-32000042,CDM,72020,CPT,320,RC,,,outpatient,,,251,175.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,56.3495,416.02,other,OPPS APC,,
HC Radex Spine Cervical 2 or 3 Views,PX-32000043,CDM,72040,CPT,320,RC,,,outpatient,,,296,207.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,66.452,416.02,other,OPPS APC,,
HC Radex Spine Cervical 4 or 5 Views,PX-32000044,CDM,72050,CPT,320,RC,,,outpatient,,,300,210,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,67.35,416.02,other,OPPS APC,,
HC Radex Spine Cervical 6 or More Views,PX-32000045,CDM,72052,CPT,320,RC,,,outpatient,,,300,210,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,67.35,416.02,other,OPPS APC,,
HC X-Ray Thoracic Spine 2 Vw,PX-32000046,CDM,72070,CPT,320,RC,,,outpatient,,,252,176.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,56.574,416.02,other,OPPS APC,,
HC X-Ray Thoracic Spine+Swim 3 Vw,PX-32000047,CDM,72072,CPT,320,RC,,,outpatient,,,283,198.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,63.5335,416.02,other,OPPS APC,,
HC X-Ray Thoracic Spine 4 Vw,PX-32000048,CDM,72074,CPT,320,RC,,,outpatient,,,306,214.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,68.697,416.02,other,OPPS APC,,
HC X-Ray Thor-Lumb Sp 2 Vw,PX-32000049,CDM,72080,CPT,320,RC,,,outpatient,,,357,249.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC,,
HC X-Ray Exam Entire Spi 1 Vw,PX-32000233,CDM,72081,CPT,320,RC,,,outpatient,,,241,168.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,54.1045,416.02,other,OPPS APC,,
HC X-Ray Exam Entire Spi 2/3 Vw,PX-32000234,CDM,72082,CPT,320,RC,,,outpatient,,,385,269.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,86.4325,416.02,other,OPPS APC,,
HC X-Ray Exam Entire Spi 4/5 Vw,PX-32000235,CDM,72083,CPT,320,RC,,,outpatient,,,757,529.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,119.991125,581.376,other,OPPS APC,,
HC X-Ray Exam Entire Spi 6/> Vw,PX-32000236,CDM,72084,CPT,320,RC,,,outpatient,,,757,529.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,76.026473,581.376,other,OPPS APC,,
HC X-Ray Lumbar Spine 2/3 Vw,PX-32000051,CDM,72100,CPT,320,RC,,,outpatient,,,235,164.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,52.7575,416.02,other,OPPS APC,,
HC X-Ray Lumbar Spine 4 Vw,PX-32000052,CDM,72110,CPT,320,RC,,,outpatient,,,323,226.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,72.5135,416.02,other,OPPS APC,,
HC X-Ray Lumbar Spine 6+ Vw,PX-32000053,CDM,72114,CPT,320,RC,,,outpatient,,,602,421.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,76.026473,462.336,other,OPPS APC,,
HC X-Ray Lumbar Spine Flex/Exten,PX-32000232,CDM,72120,CPT,320,RC,,,outpatient,,,411,287.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,92.2695,416.02,other,OPPS APC,,
HC CT Scan-Cervical Spine-W/O Contrast,PX-35000020,CDM,72125,CPT,350,RC,,,outpatient,,,1359,951.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,96.160741,1043.712,other,OPPS APC,,
HC CT Scan Cerv Spine Contrast,PX-35000021,CDM,72126,CPT,350,RC,,,outpatient,,,1556,1089.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,196.52,1195.008,other,OPPS APC,,
CT Cervical Spine W/O &W/Contrast Material,PX-35000022,CDM,72127,CPT,350,RC,,,outpatient,,,2239,1567.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,1719.552,other,OPPS APC,,
HC CT Scan-Thoracic Spine-W/O Contrast,PX-35000023,CDM,72128,CPT,350,RC,,,outpatient,,,909,636.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,96.160741,698.112,other,OPPS APC,,
HC CT Scan Dorsal Sp Contrast,PX-35000024,CDM,72129,CPT,350,RC,,,outpatient,,,1037,725.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,196.52,796.416,other,OPPS APC,,
CT Thoracic Spine W/O & W/Contrast Material,PX-35000025,CDM,72130,CPT,350,RC,,,outpatient,,,2219,1553.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,1704.192,other,OPPS APC,,
HC CT Scan-Lumbar Spine-W/O Contrast,PX-35000026,CDM,72131,CPT,350,RC,,,outpatient,,,688,481.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,96.160741,575,other,OPPS APC,,
HC CT Scan Lumbar Sp Contrast,PX-35000027,CDM,72132,CPT,350,RC,,,outpatient,,,1427,998.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,195.73,1095.936,other,OPPS APC,,
CT Lumbar Spine W/O & W/Contrast Material,PX-35000028,CDM,72133,CPT,350,RC,,,outpatient,,,1377,963.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,1057.536,other,OPPS APC,,
HC MRI- Cerv Spine,PX-61000027,CDM,72141,CPT,610,RC,,,outpatient,,,2115,1480.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,185.92,1624.32,other,OPPS APC,,
HC MRI- Cerv Spine Contrast,PX-61000028,CDM,72142,CPT,610,RC,,,outpatient,,,3043,2130.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,270.27,2337.024,other,OPPS APC,,
HC MRI- Dorsal Spine,PX-61000029,CDM,72146,CPT,610,RC,,,outpatient,,,2222,1555.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,185.92,1706.496,other,OPPS APC,,
HC MRI- Dorsal Spine Contrast,PX-61000030,CDM,72147,CPT,610,RC,,,outpatient,,,2843,1990.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,266.73,2183.424,other,OPPS APC,,
HC MRI- Lumbar Spine,PX-61000031,CDM,72148,CPT,610,RC,,,outpatient,,,2651,1855.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,185.92,2035.968,other,OPPS APC,,
HC MRI- Lumbar Spine Contrast,PX-61000032,CDM,72149,CPT,610,RC,,,outpatient,,,2645,1851.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,265.17,2031.36,other,OPPS APC,,
MRI Spinal Canal Cervical W/O & W/Contr Matrl,PX-61000033,CDM,72156,CPT,610,RC,,,outpatient,,,3124,2186.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,307.53,2399.232,other,OPPS APC,,
MRI Spinal Canal Thoracic W/O & W/Contr Matrl,PX-61000034,CDM,72157,CPT,610,RC,,,outpatient,,,2833,1983.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,307.93,2175.744,other,OPPS APC,,
MRI Spinal Canal Lumbar W/O & W/Contr Matrl,PX-61000035,CDM,72158,CPT,610,RC,,,outpatient,,,3181,2226.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,305.58,2443.008,other,OPPS APC,,
HC X-Ray Pelvis 1/2 Vw,PX-32000054,CDM,72170,CPT,320,RC,,,outpatient,,,287,200.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,64.4315,416.02,other,OPPS APC,,
CT Angiography Pelvis W/Contrast/Noncontrast,PX-35000029,CDM,72191,CPT,350,RC,,,outpatient,,,1269,888.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,974.592,other,OPPS APC,,
HC CT Scan-Pelvis-W/O Contrast,PX-35000030,CDM,72192,CPT,350,RC,,,outpatient,,,1368,957.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,96.160741,1050.624,other,OPPS APC,,
HC CT Scan of Pelvis Contrast,PX-35000031,CDM,72193,CPT,350,RC,,,outpatient,,,1561,1092.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,195.33,1198.848,other,OPPS APC,,
CT Pelvis W/O & W/Contrast Material,PX-35000032,CDM,72194,CPT,350,RC,,,outpatient,,,1902,1331.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,1460.736,other,OPPS APC,,
HC MRI- Pelvis- W/O Contrast,PX-61000036,CDM,72195,CPT,610,RC,,,outpatient,,,2241,1568.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,237.688956,1721.088,other,OPPS APC,,
HC MRI- Pelvis W/Contrast,PX-61000037,CDM,72196,CPT,610,RC,,,outpatient,,,2850,1995,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,372.27,2188.8,other,OPPS APC,,
MRI Pelvis W/O & W/Contrast Material,PX-61000038,CDM,72197,CPT,610,RC,,,outpatient,,,2753,1927.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,399.547552,2114.304,other,OPPS APC,,
HC MR Angio Pelvis(Mra) W/Contrast,PX-61000039,CDM,72198,CPT,610,RC,,,outpatient,,,2908,2035.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2233.344,other,OPPS APC,,
HC MR Angio Pelvis(Mra) Without Contrast,PX-61000073,CDM,72198,CPT,610,RC,,,outpatient,,,2710,1897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2233.344,other,OPPS APC,,
HC MR Angio Pelvis(Mra) W/Without Contrast,PX-61000074,CDM,72198,CPT,610,RC,,,outpatient,,,1826,1278.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2233.344,other,OPPS APC,,
HC X-Ray Sacroiliac Jts 3+ Vw,PX-32000056,CDM,72202,CPT,320,RC,,,outpatient,,,443,310.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,76.026473,416.02,other,OPPS APC,,
HC X-Ray Sacrum/Coccyx 2+ Vw,PX-32000057,CDM,72220,CPT,320,RC,,,outpatient,,,336,235.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC,,
HC Myelography Cerv Spine,PX-32000058,CDM,72240,CPT,320,RC,,,outpatient,,,1478,1034.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,873.87904,,,873.87904,331.811,2051.3855,other,OPPS APC,,
HC Myelography Thorax Spine,PX-32000059,CDM,72255,CPT,320,RC,,,outpatient,,,1823,1276.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,873.87904,,,873.87904,399.86,2051.3855,other,OPPS APC,,
HC Myelography Lumbar Spine,PX-32000060,CDM,72265,CPT,320,RC,,,outpatient,,,1760,1232,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,873.87904,,,873.87904,395.12,2051.3855,other,OPPS APC,,
HC Myelography of Entire Spine,PX-32000061,CDM,72270,CPT,320,RC,,,outpatient,,,1823,1276.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,873.87904,,,873.87904,399.86,2051.3855,other,OPPS APC,,
HC X-Ray-C/T-Disk-Superv/Interpret,PX-32000062,CDM,72285,CPT,320,RC,,,outpatient,,,4306,3014.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2107.296165,,,2107.296165,399.86,4977.9345,other,OPPS APC,,
HC Discography Lumbar Spine,PX-32000064,CDM,72295,CPT,320,RC,,,outpatient,,,4306,3014.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2107.296165,,,2107.296165,399.86,4977.9345,other,OPPS APC,,
HC X-Ray Clavicle,PX-32000065,CDM,73000,CPT,320,RC,,,outpatient,,,170,119,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,38.165,416.02,other,OPPS APC,,
HC X-Ray Scapula,PX-32000066,CDM,73010,CPT,320,RC,,,outpatient,,,306,214.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,68.697,416.02,other,OPPS APC,,
HC X-Ray Shoulder 1 Vw,PX-32000067,CDM,73020,CPT,320,RC,,,outpatient,,,256,179.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,57.472,416.02,other,OPPS APC,,
HC X-Ray Shoulder 2+ Vw,PX-32000068,CDM,73030,CPT,320,RC,,,outpatient,,,139,97.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,31.2055,416.02,other,OPPS APC,,
HC Arthrogram of Shoulder,PX-32000069,CDM,73040,CPT,320,RC,,,outpatient,,,1690,1183,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,379.405,1297.92,other,OPPS APC,,
HC X-Ray Ac Jts,PX-32000070,CDM,73050,CPT,320,RC,,,outpatient,,,323,226.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC,,
HC X-Ray Humerus,PX-32000071,CDM,73060,CPT,320,RC,,,outpatient,,,178,124.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,39.961,416.02,other,OPPS APC,,
HC X-Ray Elbow 2 Vw,PX-32000072,CDM,73070,CPT,320,RC,,,outpatient,,,171,119.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,38.3895,416.02,other,OPPS APC,,
HC X-Ray Elbow 3+ Vw,PX-32000073,CDM,73080,CPT,320,RC,,,outpatient,,,129,90.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,28.9605,416.02,other,OPPS APC,,
HC Arthrogram of Elbow,PX-32000074,CDM,73085,CPT,320,RC,,,outpatient,,,1331,931.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,298.8095,1022.208,other,OPPS APC,,
HC X-Ray Forearm 2 Vw,PX-32000075,CDM,73090,CPT,320,RC,,,outpatient,,,225,157.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,50.5125,416.02,other,OPPS APC,,
HC X-Ray Arm- Infant,PX-32000076,CDM,73092,CPT,320,RC,,,outpatient,,,368,257.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,76.026473,416.02,other,OPPS APC,,
HC X-Ray Wrist 2 Vw,PX-32000077,CDM,73100,CPT,320,RC,,,outpatient,,,190,133,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,42.655,416.02,other,OPPS APC,,
HC X-Ray Wrist 3+ Vw,PX-32000078,CDM,73110,CPT,320,RC,,,outpatient,,,241,168.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,54.1045,416.02,other,OPPS APC,,
HC Arthrogram of Wrist,PX-32000079,CDM,73115,CPT,320,RC,,,outpatient,,,1722,1205.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,237.819698,1322.496,other,OPPS APC,,
HC X-Ray Hand 2 Vw,PX-32000080,CDM,73120,CPT,320,RC,,,outpatient,,,306,214.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,68.697,416.02,other,OPPS APC,,
HC X-Ray Hand 3+ Vw,PX-32000081,CDM,73130,CPT,320,RC,,,outpatient,,,236,165.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,52.982,416.02,other,OPPS APC,,
HC X-Ray Exam of Finger(S),PX-32000082,CDM,73140,CPT,320,RC,,,outpatient,,,129,90.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,28.9605,416.02,other,OPPS APC,,
HC CT Scan-Upper Extremity-W/O Contrast,PX-35000034,CDM,73200,CPT,350,RC,,,outpatient,,,959,671.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,96.160741,736.512,other,OPPS APC,,
HC CT Scan of Arm Contrast,PX-35000035,CDM,73201,CPT,350,RC,,,outpatient,,,1388,971.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,193.37,1065.984,other,OPPS APC,,
CT Upper Extremity W/O & W/Contrast Material,PX-35000036,CDM,73202,CPT,350,RC,,,outpatient,,,1961,1372.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,1506.048,other,OPPS APC,,
CT Angiography Upper Extremity,PX-35000037,CDM,73206,CPT,350,RC,,,outpatient,,,1345,941.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,1032.96,other,OPPS APC,,
HC MRI- Upper Extremity W/O Contrast,PX-61000040,CDM,73218,CPT,610,RC,,,outpatient,,,2888,2021.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,237.688956,2217.984,other,OPPS APC,,
HC MRI- Upper Extremity W/Contrast,PX-61000041,CDM,73219,CPT,610,RC,,,outpatient,,,2936,2055.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,371.09,2254.848,other,OPPS APC,,
HC MRI Ext Upp No Jnt W-W/O,PX-61000042,CDM,73220,CPT,610,RC,,,outpatient,,,3144,2200.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,399.547552,2414.592,other,OPPS APC,,
MRI Any Jt Upper Extremity W/O Contrast Matrl,PX-61000043,CDM,73221,CPT,610,RC,,,outpatient,,,3039,2127.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,204.76,2333.952,other,OPPS APC,,
HC MRI- Joint Upper Extrem W/Contrast,PX-61000044,CDM,73222,CPT,610,RC,,,outpatient,,,3144,2200.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,873.87904,,,873.87904,340.49,2414.592,other,OPPS APC,,
MRI Any Jt Upper Extremity W/O & W/Contr Matrl,PX-61000045,CDM,73223,CPT,610,RC,,,outpatient,,,3060,2142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,399.547552,2350.08,other,OPPS APC,,
HC X-Ray Exam Hip Uni 1 View,PX-32000237,CDM,73501,CPT,320,RC,,,outpatient,,,222,155.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,49.839,416.02,other,OPPS APC,,
HC X-Ray Exam Hip Uni 2-3 Views,PX-32000238,CDM,73502,CPT,320,RC,,,outpatient,,,222,155.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,49.839,416.02,other,OPPS APC,,
HC X-Ray Exam Hip Uni 4/> Views,PX-32000239,CDM,73503,CPT,320,RC,,,outpatient,,,385,269.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,86.4325,416.02,other,OPPS APC,,
HC X-Ray Exam Hips Bi 2 Views,PX-32000240,CDM,73521,CPT,320,RC,,,outpatient,,,385,269.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,86.4325,416.02,other,OPPS APC,,
HC X-Ray Exam Hips Bi 5/> Views,PX-32000242,CDM,73523,CPT,320,RC,,,outpatient,,,757,529.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,76.026473,581.376,other,OPPS APC,,
HC Arthrogram of Hip,PX-32000086,CDM,73525,CPT,320,RC,,,outpatient,,,1616,1131.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,237.819698,1241.088,other,OPPS APC,,
HC X-Ray Exam of Femur 1,PX-32000243,CDM,73551,CPT,320,RC,,,outpatient,,,213,149.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,47.8185,416.02,other,OPPS APC,,
HC X-Ray Exam of Femur 2/>,PX-32000244,CDM,73552,CPT,320,RC,,,outpatient,,,241,168.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,54.1045,416.02,other,OPPS APC,,
HC X-Ray Knee 1 or 2 View,PX-32000090,CDM,73560,CPT,320,RC,,,outpatient,,,213,149.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,47.8185,416.02,other,OPPS APC,,
HC X-Ray Knee 3 View,PX-32000091,CDM,73562,CPT,320,RC,,,outpatient,,,232,162.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,52.084,416.02,other,OPPS APC,,
HC X-Ray Knee 4+ View,PX-32000092,CDM,73564,CPT,320,RC,,,outpatient,,,260,182,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,58.37,416.02,other,OPPS APC,,
HC X-Ray Knee Bilat Standing,PX-32000093,CDM,73565,CPT,320,RC,,,outpatient,,,394,275.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC,,
HC Arthrogram of Knee Joint,PX-32000094,CDM,73580,CPT,320,RC,,,outpatient,,,1704,1192.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,382.548,1308.672,other,OPPS APC,,
HC X-Ray Tib + Fib- 2vw,PX-32000095,CDM,73590,CPT,320,RC,,,outpatient,,,199,139.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,44.6755,416.02,other,OPPS APC,,
HC X-Ray Leg- Infant,PX-32000096,CDM,73592,CPT,320,RC,,,outpatient,,,231,161.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,51.8595,416.02,other,OPPS APC,,
HC X-Ray Ankle 2 Vw,PX-32000097,CDM,73600,CPT,320,RC,,,outpatient,,,137,95.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,30.7565,416.02,other,OPPS APC,,
HC X-Ray Ankle 3+ Vw,PX-32000098,CDM,73610,CPT,320,RC,,,outpatient,,,130,91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,29.185,416.02,other,OPPS APC,,
HC Arthrogram of Ankle,PX-32000099,CDM,73615,CPT,320,RC,,,outpatient,,,1221,854.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,237.819698,1020.2995,other,OPPS APC,,
HC X-Ray Foot 2 Vw,PX-32000100,CDM,73620,CPT,320,RC,,,outpatient,,,158,110.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,35.471,416.02,other,OPPS APC,,
HC X-Ray Foot 3+ Vw,PX-32000101,CDM,73630,CPT,320,RC,,,outpatient,,,164,114.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,36.818,416.02,other,OPPS APC,,
HC X-Ray Heel,PX-32000102,CDM,73650,CPT,320,RC,,,outpatient,,,234,163.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,52.533,416.02,other,OPPS APC,,
HC X-Ray Toe(S),PX-32000103,CDM,73660,CPT,320,RC,,,outpatient,,,192,134.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,43.104,416.02,other,OPPS APC,,
HC CT Scan-Lower Extremity-W/O Contrast,PX-35000038,CDM,73700,CPT,350,RC,,,outpatient,,,968,677.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,96.160741,743.424,other,OPPS APC,,
HC CT Scan of Leg Contrast,PX-35000039,CDM,73701,CPT,350,RC,,,outpatient,,,987,690.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,196.51,758.016,other,OPPS APC,,
CT Lower Extremity W/O & W/Contrast Matrl,PX-35000040,CDM,73702,CPT,350,RC,,,outpatient,,,1903,1332.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,1461.504,other,OPPS APC,,
CT Angiography Lower Extremity,PX-35000041,CDM,73706,CPT,350,RC,,,outpatient,,,1176,823.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,903.168,other,OPPS APC,,
HC MRI- Lower Extrem,PX-61000046,CDM,73718,CPT,610,RC,,,outpatient,,,2836,1985.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,237.688956,2178.048,other,OPPS APC,,
HC MRI- Lower Extrem W/Contrast,PX-61000047,CDM,73719,CPT,610,RC,,,outpatient,,,2396,1677.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,372.66,1840.128,other,OPPS APC,,
HC MRI- Lower Extr- W/O Contrast F/U by Contrast,PX-61000048,CDM,73720,CPT,610,RC,,,outpatient,,,3060,2142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,399.547552,2350.08,other,OPPS APC,,
HC MRI Lower Extrem Jt- W/O Contrast,PX-61000049,CDM,73721,CPT,610,RC,,,outpatient,,,3008,2105.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,205.15,2310.144,other,OPPS APC,,
HC MRI- Joint of Leg W/Contrast,PX-61000050,CDM,73722,CPT,610,RC,,,outpatient,,,3018,2112.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,873.87904,,,873.87904,345.98,2317.824,other,OPPS APC,,
MRI Any Jt Lower Extrem W/O & W/Contrast Matrl,PX-61000051,CDM,73723,CPT,610,RC,,,outpatient,,,3098,2168.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,399.547552,2379.264,other,OPPS APC,,
HC MR Angio Lower Extrem (Mra) W/Contrast,PX-61000052,CDM,73725,CPT,610,RC,,,outpatient,,,2710,1897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2290.176,other,OPPS APC,,
HC MR Angio Lower Extrem (Mra) Without Contrast,PX-61000075,CDM,73725,CPT,610,RC,,,outpatient,,,2710,1897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2290.176,other,OPPS APC,,
HC MR Angio Lower Extrem (Mra) W/Without Contrast,PX-61000076,CDM,73725,CPT,610,RC,,,outpatient,,,2982,2087.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2290.176,other,OPPS APC,,
HC X-Ray Exam Abdomen 1 View,PX-32000249,CDM,74018,CPT,320,RC,,,outpatient,,,232,162.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,52.084,416.02,other,OPPS APC,,
HC X-Ray Exam Abdomen 2 Views,PX-32000250,CDM,74019,CPT,320,RC,,,outpatient,,,443,310.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,76.026473,416.02,other,OPPS APC,,
HC X-Ray Exam Abdomen 3+ Views,PX-32000251,CDM,74021,CPT,320,RC,,,outpatient,,,410,287,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,92.045,416.02,other,OPPS APC,,
HC CT Scan-Abdomen-W/O Contrast,PX-35000042,CDM,74150,CPT,350,RC,,,outpatient,,,1449,1014.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,96.160741,1112.832,other,OPPS APC,,
HC CT Scan of Abdomen Contrast,PX-35000043,CDM,74160,CPT,350,RC,,,outpatient,,,1586,1110.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,194.55,1218.048,other,OPPS APC,,
CT Abdomen W/O & W/Contrast Material,PX-35000044,CDM,74170,CPT,350,RC,,,outpatient,,,2058,1440.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,1580.544,other,OPPS APC,,
HC CT Angio Abd&Plvis Cntrst Mtrl W/WO Cntrst Imges,PX-35000045,CDM,74174,CPT,350,RC,,,outpatient,,,2581,1806.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,329.339098,1982.208,other,OPPS APC,,
CT Angiography Abdomen W/Contrast/Noncontrast,PX-35000046,CDM,74175,CPT,350,RC,,,outpatient,,,1355,948.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,1040.64,other,OPPS APC,,
HC CT Scan-Abdoment and Pelvis-W/O Contrast,PX-35000047,CDM,74176,CPT,350,RC,,,outpatient,,,1368,957.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,142.38,1050.624,other,OPPS APC,,
HC CT Scan-Abdoment and Pelvis-W Contrast,PX-35000048,CDM,74177,CPT,350,RC,,,outpatient,,,1971,1379.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,204.61123,1513.728,other,OPPS APC,,
CT Abdomen & Pelvis W/O Contrst 1/> Body Re,PX-35000049,CDM,74178,CPT,350,RC,,,outpatient,,,2122,1485.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,204.61123,1629.696,other,OPPS APC,,
HC MRI- Abdomen (MRI),PX-61000053,CDM,74181,CPT,610,RC,,,outpatient,,,2357,1649.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,237.688956,1810.176,other,OPPS APC,,
HC MRI- Abdomen W/Contrast,PX-61000054,CDM,74182,CPT,610,RC,,,outpatient,,,5081,3556.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,399.547552,3902.208,other,OPPS APC,,
MRI Abdomen W/O & W/Contrast Material,PX-61000055,CDM,74183,CPT,610,RC,,,outpatient,,,2698,1888.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,399.547552,2072.064,other,OPPS APC,,
HC MR Angio Abdomen (Mra) W/Contrast,PX-61000056,CDM,74185,CPT,610,RC,,,outpatient,,,2446,1712.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,301.425681,1878.528,other,OPPS APC,,
HC MR Angio Abdomen (Mra) Without Contrast,PX-61000077,CDM,74185,CPT,610,RC,,,outpatient,,,2446,1712.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,301.425681,1878.528,other,OPPS APC,,
HC MR Angio Abdomen (Mra) W/Without Contrast,PX-61000078,CDM,74185,CPT,610,RC,,,outpatient,,,2446,1712.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,301.425681,1878.528,other,OPPS APC,,
HC Esophagram,PX-32000107,CDM,74220,CPT,320,RC,,,outpatient,,,981,686.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,76.026473,753.408,other,OPPS APC,,
HC Swallowing Fcn-W/Cine &/or Video,PX-32000108,CDM,74230,CPT,320,RC,,,outpatient,,,874,611.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,128.66,671.232,other,OPPS APC,,
HC Remove Esophagus Obstruction,PX-32000109,CDM,74235,CPT,320,RC,,,outpatient,,,1157,809.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,259.7465,888.576,other,OPPS APC,,
HC Xray Upper GI Tract,PX-32000110,CDM,74240,CPT,320,RC,,,outpatient,,,916,641.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,703.488,other,OPPS APC,,
HC Xray Upper GI Air Contrast,PX-32000113,CDM,74246,CPT,320,RC,,,outpatient,,,865,605.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,194.1925,664.32,other,OPPS APC,,
HC X-Ray-Small Bowel-W/Mult Serial Films,PX-32000116,CDM,74250,CPT,320,RC,,,outpatient,,,2949,2064.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,128.66,2264.832,other,OPPS APC,,
HC X-Ray Small Bowel Enteroclysis,PX-32000117,CDM,74251,CPT,320,RC,,,outpatient,,,1182,827.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,183.14,907.776,other,OPPS APC,,
HC X-Ray Colon Contrast,PX-32000118,CDM,74270,CPT,320,RC,,,outpatient,,,1071,749.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,822.528,other,OPPS APC,,
HC X-Ray Colon Air Contrast,PX-32000119,CDM,74280,CPT,320,RC,,,outpatient,,,1758,1230.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,1350.144,other,OPPS APC,,
HC X-Ray Oper Cholangiogram,PX-32000123,CDM,74300,CPT,320,RC,,,outpatient,,,1336,935.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,145.12362,1026.048,other,OPPS APC,,
HC X-Ray Oper Cholangio Addnl Set,PX-32000124,CDM,74301,CPT,320,RC,,,outpatient,,,289,202.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,64.8805,416.02,other,OPPS APC,,
HC X-Ray Bile/Pancreas Endoscopy,PX-32000129,CDM,74330,CPT,320,RC,,,outpatient,,,1038,726.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,145.12362,797.184,other,OPPS APC,,
HC X-Ray Introductn GI Tube,PX-32000130,CDM,74340,CPT,320,RC,,,outpatient,,,872,610.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,195.08,669.696,other,OPPS APC,,
HC X-Ray Guide Enteroclysis Tube,PX-32000131,CDM,74355,CPT,320,RC,,,outpatient,,,2913,2039.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,260.23,2237.184,other,OPPS APC,,
HC X-Ray Guide- GI Dilation,PX-32000132,CDM,74360,CPT,320,RC,,,outpatient,,,631,441.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,141.6595,484.608,other,OPPS APC,,
HC Percut Transhepat Dilat-Bile Duct Strict,PX-32000133,CDM,74363,CPT,320,RC,,,outpatient,,,2462,1723.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,1890.816,other,OPPS APC,,
HC X-Ray IV Pyelogram (Ivp),PX-32000134,CDM,74400,CPT,320,RC,,,outpatient,,,599,419.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,134.4755,499.422,other,OPPS APC,,
HC X-Ray IV Pyelogram+Tomography,PX-32000136,CDM,74415,CPT,320,RC,,,outpatient,,,2078,1454.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,1595.904,other,OPPS APC,,
HC X-Ray Retrograde Pyelogram,PX-32000137,CDM,74420,CPT,320,RC,,,outpatient,,,1189,832.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,237.819698,1020.2995,other,OPPS APC,,
HC Antegrade Urography Radiological Supvj & Interpj,PX-32000138,CDM,74425,CPT,320,RC,,,outpatient,,,2829,1980.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,399.86,2172.672,other,OPPS APC,,
HC X-Ray Cystogram- Min 3 View,PX-32000139,CDM,74430,CPT,320,RC,,,outpatient,,,1189,832.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,237.819698,1020.2995,other,OPPS APC,,
HC X-Ray Urethrocystogram,PX-32000140,CDM,74450,CPT,320,RC,,,outpatient,,,762,533.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,171.069,646.6965,other,OPPS APC,,
HC X-Ray Urethrocystogram+Voiding,PX-32000141,CDM,74455,CPT,320,RC,,,outpatient,,,762,533.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,171.069,646.6965,other,OPPS APC,,
HC X-Ray Renal Cyst Xlumbar+Contrst,PX-32000142,CDM,74470,CPT,320,RC,,,outpatient,,,542,379.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,602.109165,,,602.109165,121.679,1393.3385,other,OPPS APC,,
HC X-Ray Guide- Gu Dilation,PX-32000145,CDM,74485,CPT,320,RC,,,outpatient,,,3417,2391.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2223.02603,,,2223.02603,399.86,5136.771,other,OPPS APC,,
HC X-Ray Hysterosalpingogram,PX-32000146,CDM,74740,CPT,320,RC,,,outpatient,,,1695,1186.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,237.819698,1301.76,other,OPPS APC,,
HC X-Ray Xcerv Cath Fallopian Tube,PX-32000147,CDM,74742,CPT,320,RC,,,outpatient,,,1270,889,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,285.115,975.36,other,OPPS APC,,
HC Cardiac MRI Morphology & Function W/O Contrast,PX-61000057,CDM,75557,CPT,610,RC,,,outpatient,,,2222,1555.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,88.902,1706.496,other,OPPS APC,,
HC PR Cardiac MRI Morphology & Function W/O Contrast,PX-97200020,CDM,75557,CPT,972,RC,,,outpatient,,,396,277.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,88.902,1706.496,other,OPPS APC,,
HC Cardiac MRI W/W/O Contrast & Further Seq,PX-61000059,CDM,75561,CPT,610,RC,,,outpatient,,,2644,1850.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,102.5965,2030.592,other,OPPS APC,,
HC PR Cardiac MRI W/W/O Contrast & Further Seq,PX-97200021,CDM,75561,CPT,972,RC,,,outpatient,,,457,319.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,102.5965,2030.592,other,OPPS APC,,
HC Cardiac MRI for Velocity Flow Mapping,PX-61000061,CDM,75565,CPT,610,RC,,,outpatient,,,222,155.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.2045,836,other,OPPS APC,,
HC PR Cardiac MRI for Velocity Flow Mapping,PX-97200022,CDM,75565,CPT,972,RC,,,outpatient,,,41,28.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.2045,836,other,OPPS APC,,
HC CT Heart W/O Contrast Quant Eval Coronary Calcium,PX-35000052,CDM,75571,CPT,350,RC,,,outpatient,,,264,184.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,19.0825,575,other,OPPS APC,,
HC PR CT Heart W/O Contrast Quant Eval Coronary Calcium,PX-97200023,CDM,75571,CPT,972,RC,,,outpatient,,,85,59.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,19.0825,575,other,OPPS APC,,
HC CT Heart Contrast Eval Cardiac Struct/Morph,PX-35000053,CDM,75572,CPT,350,RC,,,outpatient,,,872,610.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,58.819,669.696,other,OPPS APC,,
HC PR CT Heart Contrast Eval Cardiac Struct/Morph,PX-97200024,CDM,75572,CPT,972,RC,,,outpatient,,,262,183.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,58.819,669.696,other,OPPS APC,,
HC CT Heart Contrast Eval Cardiac Struct/Morph- Congen Heart Disease,PX-35000054,CDM,75573,CPT,350,RC,,,outpatient,,,1016,711.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,58.819,780.288,other,OPPS APC,,
HC PR CT Heart Contrast Eval Cardiac Struct/Morph- Congen Heart Disease,PX-97200025,CDM,75573,CPT,972,RC,,,outpatient,,,262,183.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,58.819,780.288,other,OPPS APC,,
HC CT Angio Hrt Cornry Art/Bypass Grfts Contrst 3d Post,PX-35000055,CDM,75574,CPT,350,RC,,,outpatient,,,1073,751.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,57.921,824.064,other,OPPS APC,,
HC PR CT Angio Hrt Cornry Art/Bypass Grfts Contrst 3d Post,PX-97200026,CDM,75574,CPT,972,RC,,,outpatient,,,258,180.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,57.921,824.064,other,OPPS APC,,
HC N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp,PX-48000097,CDM,75580,CPT,480,RC,,,outpatient,,,2856,1999.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1141.12419,,,1141.12419,399.86,2536.61118,other,OPPS APC,,
HC Angio Aortogram Thoracic,PX-32000148,CDM,75600,CPT,320,RC,,,outpatient,,,3155,2208.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
HC Angio Aortogram Thor Serial,PX-32000149,CDM,75605,CPT,320,RC,,,outpatient,,,12541,8778.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,14233.715,other,OPPS APC,,
HC Angio Aortogram Abd Serial,PX-32000150,CDM,75625,CPT,320,RC,,,outpatient,,,5654,3957.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
HC Angio Aortobifemoral W Cath,PX-32000151,CDM,75630,CPT,320,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
Cta Abdl Aorta&Bi Iliofem W/Contrast&Postp,PX-35000056,CDM,75635,CPT,350,RC,,,outpatient,,,1721,1204.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,200.53123,,,200.53123,200.53123,1321.728,other,OPPS APC,,
HC Angio Spinal Selectv,PX-32000153,CDM,75705,CPT,320,RC,,,outpatient,,,11403,7982.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,14233.715,other,OPPS APC,,
HC Angio Extremity Unilat,PX-32000154,CDM,75710,CPT,320,RC,,,outpatient,,,6489,4542.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
HC Angio Extermity Bilat,PX-32000155,CDM,75716,CPT,320,RC,,,outpatient,,,7162,5013.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
HC Angio Visceral Selectv/Subselec,PX-32000156,CDM,75726,CPT,320,RC,,,outpatient,,,9831,6881.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,14233.715,other,OPPS APC,,
HC Angio Adrenal Unilat Select,PX-32000157,CDM,75731,CPT,320,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
HC Angio Adrenal Bilat Select,PX-32000158,CDM,75733,CPT,320,RC,,,outpatient,,,6665,4665.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
HC Angio Pelvis,PX-32000159,CDM,75736,CPT,320,RC,,,outpatient,,,11403,7982.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,14233.715,other,OPPS APC,,
HC Angio Pulmon Unilat Select,PX-32000160,CDM,75741,CPT,320,RC,,,outpatient,,,6665,4665.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
HC Angio Pulmon Bilat Select,PX-32000161,CDM,75743,CPT,320,RC,,,outpatient,,,7162,5013.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
HC Angio Pulmon Bilat Nonselec,PX-32000162,CDM,75746,CPT,320,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
HC Angio Intern Mammary,PX-32000163,CDM,75756,CPT,320,RC,,,outpatient,,,6665,4665.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
HC Angio Ea Addnl Selectv Vessel,PX-32000164,CDM,75774,CPT,320,RC,,,outpatient,,,3538,2476.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2717.184,other,OPPS APC,,
HC Nonvascular Shuntogram,PX-32000166,CDM,75809,CPT,320,RC,,,outpatient,,,411,287.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,92.2695,416.02,other,OPPS APC,,
HC Venogram Splenoportogram,PX-32000167,CDM,75810,CPT,320,RC,,,outpatient,,,7698,5388.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
HC Venogram Extrem Unilat,PX-32000168,CDM,75820,CPT,320,RC,,,outpatient,,,3212,2248.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1747.952815,,,1747.952815,399.86,4120.349,other,OPPS APC,,
HC Venogram Extrem Bilat,PX-32000169,CDM,75822,CPT,320,RC,,,outpatient,,,2940,2058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1747.952815,,,1747.952815,399.86,4120.349,other,OPPS APC,,
HC Venogram Infer Vena Cava,PX-32000170,CDM,75825,CPT,320,RC,,,outpatient,,,5987,4190.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
HC Venogram Super Vena Cava,PX-32000171,CDM,75827,CPT,320,RC,,,outpatient,,,2874,2011.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1747.952815,,,1747.952815,399.86,4120.349,other,OPPS APC,,
HC Venogram Renal Unilat,PX-32000172,CDM,75831,CPT,320,RC,,,outpatient,,,6489,4542.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
HC Venogram Renal Bilat,PX-32000173,CDM,75833,CPT,320,RC,,,outpatient,,,6665,4665.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
HC Venogram Adrenal Unilat,PX-32000174,CDM,75840,CPT,320,RC,,,outpatient,,,7698,5388.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
HC Venogram Adrenal Bilat,PX-32000175,CDM,75842,CPT,320,RC,,,outpatient,,,11403,7982.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,14233.715,other,OPPS APC,,
HC Venogram Sinus/Jugular,PX-32000176,CDM,75860,CPT,320,RC,,,outpatient,,,6665,4665.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
HC Venogram Super Sag Sinus,PX-32000177,CDM,75870,CPT,320,RC,,,outpatient,,,4428,3099.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
HC Venogram Epidural,PX-32000178,CDM,75872,CPT,320,RC,,,outpatient,,,4428,3099.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.639025,,,685.639025,399.86,3400.704,other,OPPS APC,,
HC Venogram Orbital,PX-32000179,CDM,75880,CPT,320,RC,,,outpatient,,,1638,1146.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,685.639025,,,685.639025,367.731,1602.0655,other,OPPS APC,,
HC Percut Xhepatic Porto+Dynamic,PX-32000180,CDM,75885,CPT,320,RC,,,outpatient,,,7698,5388.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
HC Percut Xhepatic Portogram,PX-32000181,CDM,75887,CPT,320,RC,,,outpatient,,,7528,5269.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
HC Venogram Hepatic W Hemodynamics,PX-32000182,CDM,75889,CPT,320,RC,,,outpatient,,,5272,3690.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
HC Venogram Hepatic,PX-32000183,CDM,75891,CPT,320,RC,,,outpatient,,,6665,4665.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
HC Venous Sampling by Catheter,PX-32000184,CDM,75893,CPT,320,RC,,,outpatient,,,11403,7982.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5997.74636,,,5997.74636,399.86,14233.715,other,OPPS APC,,
HC Transcatheter Rx Embolizatn,PX-32000185,CDM,75894,CPT,320,RC,,,outpatient,,,2536,1775.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,145.12362,1947.648,other,OPPS APC,,
HC Angrph Cath F-Up Std Tcat Other Than Thrombylsis,PX-32000187,CDM,75898,CPT,320,RC,,,outpatient,,,3747,2622.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3478.894955,,,3478.894955,260.23,8249.769,other,OPPS APC,,
HC Remove-Obst Matl-Cva Dev via Sep Ven Acc,PX-32000188,CDM,75901,CPT,320,RC,,,outpatient,,,4773,3341.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,260.23,3665.664,other,OPPS APC,,
HC Remove-Obst Matl-Cva Device via Lumen,PX-32000189,CDM,75902,CPT,320,RC,,,outpatient,,,471,329.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,105.7395,416.02,other,OPPS APC,,
HC Endovasc Repair Thor Aorta Incl Subclavian,PX-32000195,CDM,75956,CPT,320,RC,,,outpatient,,,1446,1012.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,324.627,1110.528,,,,
HC Endovasc Repair Thor Aorta Excl Subclavian,PX-32000196,CDM,75957,CPT,320,RC,,,outpatient,,,1312,918.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,294.544,1007.616,,,,
HC Proximal Extens Durng Endovasc Rethor Aorta,PX-32000197,CDM,75958,CPT,320,RC,,,outpatient,,,845,591.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,189.7025,648.96,,,,
HC Delayed Prox Extens Endovasc Rethor Aorta,PX-32000198,CDM,75959,CPT,320,RC,,,outpatient,,,744,520.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,167.028,571.392,,,,
HC Vascular Biopsy,PX-32000203,CDM,75970,CPT,320,RC,,,outpatient,,,2918,2042.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,145.12362,2241.024,other,OPPS APC,,
HC Change Percut Tube/Drain Cath W Contrast Monit,PX-32000207,CDM,75984,CPT,320,RC,,,outpatient,,,2885,2019.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,145.12362,2215.68,other,OPPS APC,,
HC Rad Guided-Percut Drainage-W/Cath Place,PX-32000208,CDM,75989,CPT,320,RC,,,outpatient,,,888,621.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,145.12362,681.984,other,OPPS APC,,
HC Rad Guided-Percut Drainage-W/Cath Place,PX-35000057,CDM,75989,CPT,350,RC,,,outpatient,,,888,621.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,145.12362,681.984,other,OPPS APC,,
HC Fluoroscopy Spx Up to 1 Hour Phys/Qhp Time,PX-32000209,CDM,76000,CPT,320,RC,,,outpatient,,,997,697.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,195.08,765.696,other,OPPS APC,,
HC X-Ray Nose-Rectum Child F.B.,PX-32000210,CDM,76010,CPT,320,RC,,,outpatient,,,340,238,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC,,
HC X-Ray Fistula-Abscess-Sinus Tract,PX-32000211,CDM,76080,CPT,320,RC,,,outpatient,,,1950,1365,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,602.109165,,,602.109165,237.819698,1497.6,other,OPPS APC,,
HC X-Ray Exam- Breast Specimen,PX-32000212,CDM,76098,CPT,320,RC,,,outpatient,,,984,688.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,602.109165,,,602.109165,220.908,1393.3385,other,OPPS APC,,
HC Cine/Videoradiology-Exc Where Spec Incl,PX-32000214,CDM,76120,CPT,320,RC,,,outpatient,,,382,267.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,85.759,416.02,other,OPPS APC,,
HC 3d Rendering W/Interp & Postprocess Supervision,PX-35000058,CDM,76376,CPT,350,RC,,,outpatient,,,352,246.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,79.024,836,other,OPPS APC,,
HC 3d Rendering W/Interp & Postprocess Supervision,PX-40200003,CDM,76376,CPT,402,RC,,,outpatient,,,352,246.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,79.024,836,other,OPPS APC,,
HC 3d Rendering W/Interp & Postprocess Supervision,PX-61000062,CDM,76376,CPT,610,RC,,,outpatient,,,352,246.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,79.024,836,other,OPPS APC,,
HC 3d Rendering W/Interp&Postproc Diff Work Station,PX-35000059,CDM,76377,CPT,350,RC,,,outpatient,,,422,295.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,94.739,836,other,OPPS APC,,
HC 3d Rendering W/Interp&Postproc Diff Work Station,PX-40200004,CDM,76377,CPT,402,RC,,,outpatient,,,422,295.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,94.739,836,other,OPPS APC,,
HC 3d Rendering W/Interp&Postproc Diff Work Station,PX-61000063,CDM,76377,CPT,610,RC,,,outpatient,,,422,295.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,94.739,836,other,OPPS APC,,
HC CT Scan-Limited/Localized F/U Study,PX-35000060,CDM,76380,CPT,350,RC,,,outpatient,,,928,649.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,71.24,712.704,other,OPPS APC,,
HC MRI Spectroscopy,PX-61000064,CDM,76390,CPT,610,RC,,,outpatient,,,2218,1552.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,81.08,1703.424,other,OPPS APC,,
HC Magnetic Resonance Elastography,PX-61000090,CDM,76391,CPT,610,RC,,,outpatient,,,842,589.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,189.029,836,other,OPPS APC,,
HC Unlisted CT Procedure,PX-35000061,CDM,76497,CPT,350,RC,,,outpatient,,,229,160.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,51.4105,575,other,OPPS APC,,
HC US- Head- Real Time,PX-40200005,CDM,76506,CPT,402,RC,,,outpatient,,,433,303.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,97.2085,416.02,other,OPPS APC,,
HC US- Head/Neck Tissues-Real Time,PX-40200006,CDM,76536,CPT,402,RC,,,outpatient,,,444,310.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,99.678,416.02,other,OPPS APC,,
HC US- Chest-Real Time,PX-40200007,CDM,76604,CPT,402,RC,,,outpatient,,,417,291.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,93.6165,416.02,other,OPPS APC,,
HC US Breast Uni Real Time With Image Complete,PX-40200056,CDM,76641,CPT,402,RC,,,outpatient,,,385,269.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,86.4325,416.02,other,OPPS APC,,
HC US Breast Uni Real Time With Image Limited,PX-40200055,CDM,76642,CPT,402,RC,,,outpatient,,,353,247.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC,,
HC US- Abdom-B-Scan &/or Real Time-Complete,PX-40200009,CDM,76700,CPT,402,RC,,,outpatient,,,461,322.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,103.4945,416.02,other,OPPS APC,,
HC US- Abdomen Limited,PX-40200010,CDM,76705,CPT,402,RC,,,outpatient,,,341,238.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,76.5545,416.02,other,OPPS APC,,
HC Ultrasound Exam Aaa Screen,PX-40200002,CDM,76706,CPT,402,RC,,,outpatient,,,261,182.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,58.5945,416.02,other,OPPS APC,,
HC US-Retroperit- B-Scan/Real Time-Complete,PX-40200011,CDM,76770,CPT,402,RC,,,outpatient,,,368,257.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,82.616,416.02,other,OPPS APC,,
HC US- Retroperitnl Abd- Ltd,PX-40200012,CDM,76775,CPT,402,RC,,,outpatient,,,345,241.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,77.4525,416.02,other,OPPS APC,,
HC US- Spinal Canal & Contents,PX-40200014,CDM,76800,CPT,402,RC,,,outpatient,,,595,416.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,119.991125,456.96,other,OPPS APC,,
HC US- OB < 14 Wks- Single Fetus,PX-40200015,CDM,76801,CPT,402,RC,,,outpatient,,,289,202.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,64.8805,416.02,other,OPPS APC,,
HC US- OB < 14 Wks- Add'l Fetus,PX-40200016,CDM,76802,CPT,402,RC,,,outpatient,,,224,156.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,50.288,416.02,other,OPPS APC,,
HC US- OB >/= 14 Wks- Sngl Fetus,PX-40200017,CDM,76805,CPT,402,RC,,,outpatient,,,421,294.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,94.5145,416.02,other,OPPS APC,,
HC US- OB >/= 14 Wks- Addl Fetus,PX-40200018,CDM,76810,CPT,402,RC,,,outpatient,,,713,499.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,157.086513,547.584,other,OPPS APC,,
HC US-Preg Uter-Fet & Mat-+ Detl Fet Exm,PX-40200019,CDM,76811,CPT,402,RC,,,outpatient,,,725,507.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,162.7625,646.6965,other,OPPS APC,,
HC US-Preg Uter-Fet & Mat-+ Detl Fet-Addl,PX-40200020,CDM,76812,CPT,402,RC,,,outpatient,,,240,168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,53.88,416.02,other,OPPS APC,,
HC US-Pregnant Uterus-Limited- 1/> Fetuses,PX-40200021,CDM,76815,CPT,402,RC,,,outpatient,,,303,212.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,68.0235,416.02,other,OPPS APC,,
HC US-Pregnant Uterus-F/U-Transabd App,PX-40200022,CDM,76816,CPT,402,RC,,,outpatient,,,600,420,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,119.991125,460.8,other,OPPS APC,,
HC US-Pregnant Uterus-Transvaginal,PX-40200023,CDM,76817,CPT,402,RC,,,outpatient,,,355,248.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,79.6975,416.02,other,OPPS APC,,
HC Fetal Biophysical Profile,PX-40200024,CDM,76818,CPT,402,RC,,,outpatient,,,439,307.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,98.5555,416.02,other,OPPS APC,,
HC Fetal Biophys Prof-W/O Nst,PX-40200025,CDM,76819,CPT,402,RC,,,outpatient,,,358,250.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,80.371,416.02,other,OPPS APC,,
HC Doppler Fetal Umbilical Artery,PX-40200026,CDM,76820,CPT,402,RC,,,outpatient,,,290,203,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,65.105,416.02,other,OPPS APC,,
HC US-Pregnant Uterus-Limited- 1/> Fetuses,PX-40200028,CDM,76827,CPT,402,RC,,,outpatient,,,578,404.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,119.991125,443.904,other,OPPS APC,,
HC Sono Fetal Hrt Doppl F/U,PX-40200029,CDM,76828,CPT,402,RC,,,outpatient,,,146,102.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,32.777,416.02,other,OPPS APC,,
HC Echography-Transvaginal,PX-40200030,CDM,76830,CPT,402,RC,,,outpatient,,,365,255.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,81.9425,416.02,other,OPPS APC,,
HC Sono Exam- Hysterosonography,PX-40200031,CDM,76831,CPT,402,RC,,,outpatient,,,1006,704.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,199.512292,772.608,other,OPPS APC,,
HC Echo-Pelvic (Nonobstetric),PX-40200032,CDM,76856,CPT,402,RC,,,outpatient,,,361,252.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,81.0445,416.02,other,OPPS APC,,
HC Sono Pelvis Limited,PX-40200033,CDM,76857,CPT,402,RC,,,outpatient,,,332,232.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,74.534,416.02,other,OPPS APC,,
HC Echo-Scrotum & Contents,PX-40200034,CDM,76870,CPT,402,RC,,,outpatient,,,457,319.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,102.5965,416.02,other,OPPS APC,,
HC Echo-Transrectal,PX-40200035,CDM,76872,CPT,402,RC,,,outpatient,,,401,280.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,90.0245,416.02,other,OPPS APC,,
HC Echo-Transrectal-Prostate Vol,PX-40200036,CDM,76873,CPT,402,RC,,,outpatient,,,273,191.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,61.2885,416.02,other,OPPS APC,,
HC US-Extremity-Nonvascular-Real-Time Image-Complete,PX-40200037,CDM,76881,CPT,402,RC,,,outpatient,,,400,280,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,89.8,416.02,other,OPPS APC,,
HC US-Extremity-Nonvascular-Real-Time Image-Limited,PX-40200038,CDM,76882,CPT,402,RC,,,outpatient,,,253,177.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,56.7985,416.02,other,OPPS APC,,
HC US Inft Hips R-T Img Dynamic Req Phys/Qhp Manj,PX-40200039,CDM,76885,CPT,402,RC,,,outpatient,,,412,288.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC,,
HC US Inft Hips R-T Img Lmtd Static Phys/Qhp Manj,PX-40200040,CDM,76886,CPT,402,RC,,,outpatient,,,412,288.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC,,
HC US Guid-Comp Repair-Pseudo-Aneur/Av Fist,PX-40200041,CDM,76936,CPT,402,RC,,,outpatient,,,681,476.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,152.8845,775.5705,other,OPPS APC,,
HC US Guide- Vascular Access,PX-40200042,CDM,76937,CPT,402,RC,,,outpatient,,,251,175.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,56.3495,416.02,other,OPPS APC,,
HC US Guide- Tissue Ablation,PX-40200043,CDM,76940,CPT,402,RC,,,outpatient,,,460,322,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,103.27,416.02,other,OPPS APC,,
HC Sono Guide Needle Biopsy,PX-40200044,CDM,76942,CPT,402,RC,,,outpatient,,,868,607.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,166.37,666.624,other,OPPS APC,,
HC Sono Guide Amniocentesis,PX-40200045,CDM,76946,CPT,402,RC,,,outpatient,,,354,247.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,79.473,416.02,other,OPPS APC,,
HC US Guid-Comp Repair-Pseudo-Aneur/Av Fist,PX-40200048,CDM,76998,CPT,402,RC,,,outpatient,,,604,422.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,135.598,463.872,other,OPPS APC,,
HC Fluoroguide Cntrl Ven Access-Place-Replace-Remove,PX-32000217,CDM,77001,CPT,320,RC,,,outpatient,,,521,364.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,116.9645,416.02,other,OPPS APC,,
HC Fluoroscopic Guidance Needle Placement,PX-32000218,CDM,77002,CPT,320,RC,,,outpatient,,,318,222.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,71.391,416.02,other,OPPS APC,,
HC Fluorscopic Guidance Spinal Injection,PX-32000219,CDM,77003,CPT,320,RC,,,outpatient,,,518,362.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,116.291,416.02,other,OPPS APC,,
HC CT Guidance Stereotactic Localization,PX-35000062,CDM,77011,CPT,350,RC,,,outpatient,,,1801,1260.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,1383.168,other,OPPS APC,,
HC CT Guidance Needle Placement,PX-35000063,CDM,77012,CPT,350,RC,,,outpatient,,,1747,1222.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,63.344499,1341.696,other,OPPS APC,,
HC CT Guidance Tissue Ablation,PX-35000064,CDM,77013,CPT,350,RC,,,outpatient,,,1755,1228.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,63.344499,1347.84,other,OPPS APC,,
HC CT Guidance Placement Rad Therapy Fields,PX-35000065,CDM,77014,CPT,350,RC,,,outpatient,,,623,436.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,139.8635,575,other,OPPS APC,,
HC MRI Guidance Needle Placement,PX-61000066,CDM,77021,CPT,610,RC,,,outpatient,,,3092,2164.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2374.656,other,OPPS APC,,
HC MRI Breast Without Contrast Material Unilateral,PX-61000083,CDM,77046,CPT,610,RC,,,outpatient,,,842,589.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,189.029,836,other,OPPS APC,,
HC MRI Breast Without Contrast Material Bilateral,PX-61000086,CDM,77047,CPT,610,RC,,,outpatient,,,842,589.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,189.029,836,other,OPPS APC,,
HC MRI Breast With Contrast W/Cad Unilateral,PX-61000084,CDM,77048,CPT,610,RC,,,outpatient,,,2118,1482.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.547552,1936.896,other,OPPS APC,,
HC MRI Breast W/Out&With Contrast W/Cad Unilateral,PX-61000085,CDM,77048,CPT,610,RC,,,outpatient,,,2522,1765.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.547552,1936.896,other,OPPS APC,,
HC MRI Breast With Contrast W/Cad Bilateral,PX-61000087,CDM,77049,CPT,610,RC,,,outpatient,,,2788,1951.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.547552,2548.224,other,OPPS APC,,
HC MRI Breast W/Out&With Contrast W/Cad Bilateral,PX-61000088,CDM,77049,CPT,610,RC,,,outpatient,,,3318,2322.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.547552,2548.224,other,OPPS APC,,
HC Digital Breast Tomosynthesis Unilateral,PX-40100006,CDM,77061,CPT,401,RC,,,outpatient,,,321,224.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,72.0645,416.02,fee schedule,,,
HC Digital Breast Tomosynthesis Bilateral,PX-40100007,CDM,77062,CPT,401,RC,,,outpatient,,,393,275.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,88.2285,416.02,fee schedule,,,
HC Screening Digital Breast Tomosynthesis Bi,PX-40300004,CDM,77063,CPT,403,RC,,,outpatient,,,202,141.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,25.43,,,25.43,22.99364,416.02,fee schedule,,,
HC Dx Mammo Incl Cad Uni,PX-40100008,CDM,77065,CPT,401,RC,,,outpatient,,,393,275.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,92.45,,,92.45,88.2285,416.02,fee schedule,,,
HC Dx Mammo Incl Cad Bi,PX-40100009,CDM,77066,CPT,401,RC,,,outpatient,,,466,326.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,118.49,,,118.49,90.800319,416.02,fee schedule,,,
HC Scr Mammo Bi Incl Cad,PX-40300005,CDM,77067,CPT,403,RC,,,outpatient,,,466,326.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,97.74,,,97.74,90.800319,416.02,fee schedule,,,
HC Manual Appl Stress Pfrmd Phys/Qhp Joint Films,PX-32000222,CDM,77071,CPT,320,RC,,,outpatient,,,262,183.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,58.819,416.02,other,OPPS APC,,
HC X-Rays for Bone Age,PX-32000223,CDM,77072,CPT,320,RC,,,outpatient,,,218,152.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,48.941,416.02,other,OPPS APC,,
HC X-Rays- Bone Length Studies,PX-32000224,CDM,77073,CPT,320,RC,,,outpatient,,,502,351.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,76.026473,416.02,other,OPPS APC,,
HC X-Rays- Bone Survey- Limited,PX-32000225,CDM,77074,CPT,320,RC,,,outpatient,,,502,351.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,112.699,416.02,other,OPPS APC,,
HC X-Rays- Bone Survey Complete,PX-32000226,CDM,77075,CPT,320,RC,,,outpatient,,,502,351.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,112.699,416.02,other,OPPS APC,,
HC X-Rays- Bone Survey- Infant,PX-32000227,CDM,77076,CPT,320,RC,,,outpatient,,,502,351.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,76.026473,416.02,other,OPPS APC,,
HC Dexa-Bone Density- 1 + Site- Axial Skeleton,PX-32000228,CDM,77080,CPT,320,RC,,,outpatient,,,575,402.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,119.991125,441.6,other,OPPS APC,,
HC Dexa-Bone Density- 1 + Site- Appendiculr Skeltn,PX-32000229,CDM,77081,CPT,320,RC,,,outpatient,,,114,79.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,25.593,416.02,other,OPPS APC,,
HC MRI- Bone Marrow,PX-61000070,CDM,77084,CPT,610,RC,,,outpatient,,,2406,1684.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,267.439885,1847.808,other,OPPS APC,,
HC Tbs Techl Prep&Transmis Data Alys Pfrmd Elsewhr,PX-32000262,CDM,77090,CPT,320,RC,,,outpatient,,,248,173.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,55.676,416.02,other,OPPS APC,,
HC Tbs Technical Calculation Only,PX-32000263,CDM,77091,CPT,320,RC,,,outpatient,,,248,173.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,99.17739,,,99.17739,55.676,416.02,other,OPPS APC,,
HC Thyroid Uptake Single/Multiple Quant Measurement,PX-34100001,CDM,78012,CPT,341,RC,,,outpatient,,,935,654.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,209.9075,1076.394,other,OPPS APC,,
HC Thyroid Imaging With Vascular Flow,PX-34100002,CDM,78013,CPT,341,RC,,,outpatient,,,633,443.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,142.1085,1076.394,other,OPPS APC,,
HC Thyroid Uptake W/Blood Flow Sngle/Mult Quan Meas,PX-34100003,CDM,78014,CPT,341,RC,,,outpatient,,,982,687.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,220.459,1076.394,other,OPPS APC,,
HC Thyroid Met Imaging Body,PX-34100005,CDM,78018,CPT,341,RC,,,outpatient,,,1049,734.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,589.921045,,,589.921045,235.5005,1397.122,other,OPPS APC,,
HC Thyroid Met Uptake,PX-34100006,CDM,78020,CPT,341,RC,,,outpatient,,,171,119.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,38.3895,416.02,other,OPPS APC,,
HC Parathyroid Planar Imaging,PX-34100007,CDM,78070,CPT,341,RC,,,outpatient,,,1575,1102.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,353.5875,1209.6,other,OPPS APC,,
HC Parathyroid Planar Imaging W/WO Subtraction,PX-34100008,CDM,78071,CPT,341,RC,,,outpatient,,,1357,949.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,304.6465,1076.394,other,OPPS APC,,
HC Parathyroid Imaging W/Tomographic Spect & CT,PX-34100009,CDM,78072,CPT,341,RC,,,outpatient,,,1898,1328.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,589.921045,,,589.921045,358.69,1457.664,other,OPPS APC,,
HC Adrenal Nuclear Imaging,PX-34100010,CDM,78075,CPT,341,RC,,,outpatient,,,2974,2081.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC,,
HC Bone Marrow Imaging- Ltd,PX-34100011,CDM,78102,CPT,341,RC,,,outpatient,,,1403,982.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,314.9735,1077.504,other,OPPS APC,,
HC Bone Marrow Imaging- Mult,PX-34100012,CDM,78103,CPT,341,RC,,,outpatient,,,1403,982.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,314.9735,1077.504,other,OPPS APC,,
HC Bone Marrow Imaging- Body,PX-34100013,CDM,78104,CPT,341,RC,,,outpatient,,,659,461.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,147.9455,1076.394,other,OPPS APC,,
HC Spleen Imaging,PX-34100015,CDM,78185,CPT,341,RC,,,outpatient,,,971,679.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,217.9895,1076.394,other,OPPS APC,,
HC Lymphatics & Lymph Glands Imaging,PX-34100016,CDM,78195,CPT,341,RC,,,outpatient,,,1071,749.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,589.921045,,,589.921045,240.4395,1397.122,other,OPPS APC,,
HC Liver Imaging,PX-34100017,CDM,78201,CPT,341,RC,,,outpatient,,,2228,1559.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,589.921045,,,589.921045,399.86,2239.93036,other,OPPS APC,,
HC Liver and Spleen Imaging,PX-34100021,CDM,78215,CPT,341,RC,,,outpatient,,,1205,843.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,270.5225,1076.394,other,OPPS APC,,
HC Hepatobiliary Syst Imaging Including Gallbladder,PX-34100023,CDM,78226,CPT,341,RC,,,outpatient,,,1384,968.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,310.708,1076.394,other,OPPS APC,,
HC Hepatobil Syst Imag Inc Gb W/Pharma Intervenj,PX-34100024,CDM,78227,CPT,341,RC,,,outpatient,,,1384,968.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,589.921045,,,589.921045,310.708,1397.122,other,OPPS APC,,
HC Serial Salivary Imaging,PX-34100025,CDM,78231,CPT,341,RC,,,outpatient,,,788,551.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,176.906,1076.394,other,OPPS APC,,
HC Gastroesophageal Reflux Exam,PX-34100027,CDM,78262,CPT,341,RC,,,outpatient,,,1043,730.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,234.1535,1076.394,other,OPPS APC,,
HC Gastric Emptying Study,PX-34100028,CDM,78264,CPT,341,RC,,,outpatient,,,838,586.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,188.131,1076.394,other,OPPS APC,,
HC Acute GI Blood Loss Imaging,PX-34100031,CDM,78278,CPT,341,RC,,,outpatient,,,2079,1455.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,399.86,1596.672,other,OPPS APC,,
HC Bowel Imaging,PX-34100032,CDM,78290,CPT,341,RC,,,outpatient,,,893,625.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,200.4785,1076.394,other,OPPS APC,,
HC Leveen/Shunt Patency Exam,PX-34100033,CDM,78291,CPT,341,RC,,,outpatient,,,954,667.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,214.173,1076.394,other,OPPS APC,,
HC Bone Imaging- Limited Area,PX-34100034,CDM,78300,CPT,341,RC,,,outpatient,,,962,673.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,215.969,1076.394,other,OPPS APC,,
HC Bone Imaging- Multiple Areas,PX-34100035,CDM,78305,CPT,341,RC,,,outpatient,,,1098,768.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,246.501,1076.394,other,OPPS APC,,
HC Bone Imaging- Whole Body,PX-34100036,CDM,78306,CPT,341,RC,,,outpatient,,,893,625.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,200.4785,1076.394,other,OPPS APC,,
HC Bone Imaging- 3 Phase,PX-34100037,CDM,78315,CPT,341,RC,,,outpatient,,,956,669.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,214.622,1076.394,other,OPPS APC,,
HC Myocardial Spect Single Study at Rest or Stress,PX-34100040,CDM,78451,CPT,341,RC,,,outpatient,,,4510,3157,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC,,
HC Myocardial Spect Multiple Studies,PX-34100041,CDM,78452,CPT,341,RC,,,outpatient,,,4510,3157,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC,,
HC Myocardial Perfusion Planar 1 Study Rest/Stress,PX-34100042,CDM,78453,CPT,341,RC,,,outpatient,,,3900,2730,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC,,
HC Myocardial Perfusion Planar Multiple Studies,PX-34100043,CDM,78454,CPT,341,RC,,,outpatient,,,3900,2730,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC,,
HC Gated Heart- Planar Single,PX-34100048,CDM,78472,CPT,341,RC,,,outpatient,,,1586,1110.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,356.057,1218.048,other,OPPS APC,,
HC Heart Image- Spect,PX-34100050,CDM,78494,CPT,341,RC,,,outpatient,,,1671,1169.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,375.1395,1283.328,other,OPPS APC,,
HC Pulmonary Ventilation Imaging,PX-34100052,CDM,78579,CPT,341,RC,,,outpatient,,,767,536.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,172.1915,1076.394,other,OPPS APC,,
HC Lung Perfusion Imaging,PX-34100053,CDM,78580,CPT,341,RC,,,outpatient,,,640,448,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,143.68,1076.394,other,OPPS APC,,
HC Pulmonary Ventilation & Perfusion Imaging,PX-34100054,CDM,78582,CPT,341,RC,,,outpatient,,,946,662.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,589.921045,,,589.921045,212.377,1397.122,other,OPPS APC,,
HC Quant Differential Pulm Perfusion W/WO Imaging,PX-34100055,CDM,78597,CPT,341,RC,,,outpatient,,,902,631.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,202.499,1076.394,other,OPPS APC,,
HC Quant Diff Pulm Prfusion & Ventlaj W/WO Imaging,PX-34100056,CDM,78598,CPT,341,RC,,,outpatient,,,1499,1049.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,589.921045,,,589.921045,336.5255,1397.122,other,OPPS APC,,
HC Brain Imaging < 4 Static Views W Vascular Flow,PX-34100058,CDM,78601,CPT,341,RC,,,outpatient,,,2704,1892.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,399.86,2076.672,other,OPPS APC,,
HC Brain Imaging Min 4 Static Views W Vascular Flow,PX-34100059,CDM,78606,CPT,341,RC,,,outpatient,,,1589,1112.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,589.921045,,,589.921045,356.7305,1397.122,other,OPPS APC,,
HC Brain Imaging Pet Metabolic,PX-40400003,CDM,78608,CPT,404,RC,,,outpatient,,,4890,3423,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1707.4823,,,1707.4823,399.86,3755.52,other,OPPS APC,,
HC CSF Fluid Scan Cisternography,PX-34100061,CDM,78630,CPT,341,RC,,,outpatient,,,2570,1799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,589.921045,,,589.921045,399.86,1973.76,other,OPPS APC,,
HC CSF Shunt Evaluation,PX-34100062,CDM,78645,CPT,341,RC,,,outpatient,,,916,641.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,589.921045,,,589.921045,205.642,1397.122,other,OPPS APC,,
HC CSF Leakage Detection & Localization,PX-34100063,CDM,78650,CPT,341,RC,,,outpatient,,,3215,2250.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC,,
HC Renal Imaging- Static,PX-34100064,CDM,78700,CPT,341,RC,,,outpatient,,,1292,904.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,290.054,1076.394,other,OPPS APC,,
HC Renal Flow/Funct Imaging,PX-34100065,CDM,78707,CPT,341,RC,,,outpatient,,,1210,847,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,589.921045,,,589.921045,271.645,1397.122,other,OPPS APC,,
HC Renal Flow/Funct Image-Pharm Rx,PX-34100066,CDM,78708,CPT,341,RC,,,outpatient,,,899,629.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,589.921045,,,589.921045,201.8255,1397.122,other,OPPS APC,,
HC Testicular Imaging & Flow,PX-34100069,CDM,78761,CPT,341,RC,,,outpatient,,,845,591.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,189.7025,1076.394,other,OPPS APC,,
HC Tumor Imaging- Limited Area,PX-34100070,CDM,78800,CPT,341,RC,,,outpatient,,,867,606.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,194.6415,1076.394,other,OPPS APC,,
HC Tumor Imaging- Whole Body- Single Day,PX-34100072,CDM,78802,CPT,341,RC,,,outpatient,,,3124,2186.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC,,
HC Tumor Imaging Spect,PX-34100073,CDM,78803,CPT,341,RC,,,outpatient,,,2419,1693.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC,,
HC Tumor Imaging- Whole Body- 2 or More Days,PX-34100074,CDM,78804,CPT,341,RC,,,outpatient,,,2916,2041.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC,,
HC Inject Radiopharm Non-Imaging Localization- IV,PX-34100080,CDM,78808,CPT,341,RC,,,outpatient,,,1227,858.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,450.147135,,,450.147135,275.4615,1076.394,other,OPPS APC,,
HC Pet Imaging CT for Attenuation Limited Area,PX-40400004,CDM,78814,CPT,404,RC,,,outpatient,,,5186,3630.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1707.4823,,,1707.4823,399.86,3982.848,other,OPPS APC,,
HC Pet Imaging CT Attenuation Skull Base Mid-Thigh,PX-40400005,CDM,78815,CPT,404,RC,,,outpatient,,,6904,4832.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1707.4823,,,1707.4823,399.86,5302.272,other,OPPS APC,,
HC Pet Imaging for CT Attenuation Whole Body,PX-40400006,CDM,78816,CPT,404,RC,,,outpatient,,,7705,5393.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1707.4823,,,1707.4823,399.86,5917.44,other,OPPS APC,,
HC Rp Loclzj Tum Spect W/CT 1 Area 1 Day Imaging,PX-34100081,CDM,78830,CPT,341,RC,,,outpatient,,,4318,3022.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC,,
HC Rp Loclzj Tum Spect 2 Area 1d Img/1 Area Img>2+D,PX-34100082,CDM,78831,CPT,341,RC,,,outpatient,,,4318,3022.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC,,
HC Rp Loclzj Tum Spect CT 2area 1d Img/1 AR Img>2+D,PX-34100083,CDM,78832,CPT,341,RC,,,outpatient,,,4899,3429.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1707.4823,,,1707.4823,399.86,4124.5085,other,OPPS APC,,
HC Radiopharmaceutical Quantification Meas 1 Area,PX-34100084,CDM,78835,CPT,341,RC,,,outpatient,,,203,142.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,45.5735,416.02,other,OPPS APC,,
HC Nuclear Therapy- Oral,PX-34200001,CDM,79005,CPT,342,RC,,,outpatient,,,782,547.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,271.52932,,,271.52932,175.559,691.5815,other,OPPS APC,,
HC Urinalysis- Auto- W/O Scope,PX-30000067,CDM,81003,CPT,300,RC,,,outpatient,,,32,22.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.29,24.576,fee schedule,,,
HC Urine Pregnancy Test,PX-30000713,CDM,81025,CPT,300,RC,,,outpatient,,,28,19.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,6.286,21.504,fee schedule,,,
HC Molecular Pathology Procedure Level 4,PX-30000097,CDM,81403,CPT,300,RC,,,outpatient,,,716,501.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,185.2,,,185.2,160.742,549.888,fee schedule,,,
HC Blood Occult-by Peroxid- Feces- 1-3 Simult- Non Ca Screen,PX-30000715,CDM,82272,CPT,300,RC,,,outpatient,,,24,16.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.33,18.432,fee schedule,,,
HC Glucose Blood Test,PX-30000221,CDM,82962,CPT,300,RC,,,outpatient,,,45,31.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.4,34.56,fee schedule,,,
HC Bone Marrow-Smear Interpretation,PX-31000012,CDM,85097,CPT,310,RC,,,outpatient,,,1038,726.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,938.496695,,,938.496695,39.73,1313.895373,other,OPPS APC,,
HC Coagulation Time- Activated,PX-30000417,CDM,85347,CPT,300,RC,,,outpatient,,,80,56,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.35,61.44,fee schedule,,,
HC Hgb/Rbcs Fetal Fetomaternal Hemrrg Rosette,PX-30000732,CDM,85461,CPT,300,RC,,,outpatient,,,32,22.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,6.78,24.576,fee schedule,,,
HC Sickling RBC Reduction,PX-30000730,CDM,85660,CPT,300,RC,,,outpatient,,,25,17.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,5.6125,19.2,fee schedule,,,
HC Platelet Antibodies,PX-30000453,CDM,86022,CPT,300,RC,,,outpatient,,,128,89.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,18.77,98.304,fee schedule,,,
HC Cold Agglutinin Screen,PX-30000465,CDM,86156,CPT,300,RC,,,outpatient,,,158,110.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,6.51,121.344,fee schedule,,,
HC Cold Agglutinin- Titer,PX-30000466,CDM,86157,CPT,300,RC,,,outpatient,,,29,20.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,6.5105,24.43,fee schedule,,,
HC Leukocyte Phagocytosis,PX-30000866,CDM,86344,CPT,300,RC,,,outpatient,,,33,23.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,7.4085,25.344,fee schedule,,,
HC Cmv Antibody,PX-30000526,CDM,86644,CPT,300,RC,,,outpatient,,,155,108.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.71,119.04,fee schedule,,,
HC Hla Typing- a-B-or C /Single,PX-30000582,CDM,86812,CPT,300,RC,,,outpatient,,,252,176.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.37,193.536,fee schedule,,,
HC Hla Typing Dr/Dq Single Antigen,PX-30000731,CDM,86816,CPT,300,RC,,,outpatient,,,124,86.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,27.838,95.232,fee schedule,,,
HC Hla Typing- Dr/Dq-Multi Antgn,PX-30000584,CDM,86817,CPT,300,RC,,,outpatient,,,287,200.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,64.4315,241.472,fee schedule,,,
HC RBC Antibody Screen,PX-30000585,CDM,86850,CPT,300,RC,,,outpatient,,,99,69.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,59.142165,,,59.142165,6.25,92.88556,other,OPPS APC,,
HC RBC Antibody Elution,PX-30000586,CDM,86860,CPT,300,RC,,,outpatient,,,358,250.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,186.41867,,,186.41867,2.072,274.944,other,OPPS APC,,
HC RBC Antibody Identification,PX-30000587,CDM,86870,CPT,300,RC,,,outpatient,,,501,350.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,392.31084,,,392.31084,2.842,549.235176,other,OPPS APC,,
HC Antihuman Globulin Dir Ea Antiserum,PX-30000588,CDM,86880,CPT,300,RC,,,outpatient,,,117,81.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,5.5,93.463636,other,OPPS APC,,
HC Antihuman Globulin Indir Qual Ea Reagent Cell,PX-30000589,CDM,86885,CPT,300,RC,,,outpatient,,,357,249.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,186.41867,,,186.41867,5.85,274.176,other,OPPS APC,,
HC Antihuman Globulin Indirect Ea Antibody Titer,PX-30000590,CDM,86886,CPT,300,RC,,,outpatient,,,357,249.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,186.41867,,,186.41867,5.29,274.176,other,OPPS APC,,
HC Blood Typing- Abo,PX-30000592,CDM,86900,CPT,300,RC,,,outpatient,,,208,145.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,3.05,195.186327,other,OPPS APC,,
HC Blood Typing- Rh (D),PX-30000593,CDM,86901,CPT,300,RC,,,outpatient,,,85,59.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,43.769555,,,43.769555,3.05,65.28,other,OPPS APC,,
HC Blood Type Antigen Donor Reagent Serum- Ea Antigen,PX-30000594,CDM,86902,CPT,300,RC,,,outpatient,,,628,439.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,392.31084,,,392.31084,3.91,549.235176,other,OPPS APC,,
HC Blood Typing Antigen Screen Patient Serum/Unit,PX-30000718,CDM,86904,CPT,300,RC,,,outpatient,,,311,217.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,9.71,238.848,other,OPPS APC,,
HC Blood Typing- RBC Antigens,PX-30000595,CDM,86905,CPT,300,RC,,,outpatient,,,628,439.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,392.31084,,,392.31084,3.91,549.235176,other,OPPS APC,,
HC Blood Typing Serologic Rh Phenotyping Complete,PX-30000719,CDM,86906,CPT,300,RC,,,outpatient,,,284,198.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,43.769555,,,43.769555,7.91,218.112,other,OPPS APC,,
HC Compatibility Test-Spin Tech,PX-30000596,CDM,86920,CPT,300,RC,,,outpatient,,,355,248.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,186.41867,,,186.41867,2.31,272.64,other,OPPS APC,,
HC Compatibility Test-Incub Tech,PX-30000597,CDM,86921,CPT,300,RC,,,outpatient,,,357,249.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,186.41867,,,186.41867,2.072,274.176,other,OPPS APC,,
HC Compatibility Test-Antiglob Tech,PX-30000598,CDM,86922,CPT,300,RC,,,outpatient,,,357,249.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,186.41867,,,186.41867,2.45,274.176,other,OPPS APC,,
HC Compatibility Test- Electronic,PX-30000599,CDM,86923,CPT,300,RC,,,outpatient,,,357,249.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,186.41867,,,186.41867,1.862,274.176,other,OPPS APC,,
HC Plasma- Fresh Frozen,PX-30000600,CDM,86927,CPT,300,RC,,,outpatient,,,312,218.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,186.41867,,,186.41867,1.302,263.69806,other,OPPS APC,,
HC Blood Product/Irradiation,PX-39100002,CDM,86945,CPT,391,RC,,,outpatient,,,116,81.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,43.769555,,,43.769555,1.932,416.02,other,OPPS APC,,
HC Pretx RBC Antibody Incubat W/Chem Agnts/Drugs Ea,PX-30000729,CDM,86970,CPT,300,RC,,,outpatient,,,110,77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,1.932,93.463636,other,OPPS APC,,
HC Pretx RBC Antibody Incubat W/Enzymes Each,PX-30000726,CDM,86971,CPT,300,RC,,,outpatient,,,560,392,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,186.41867,,,186.41867,1.54,499.62884,other,OPPS APC,,
HC Pretx RBC Antibody Incubat W/Density Grad Sep,PX-30000727,CDM,86972,CPT,300,RC,,,outpatient,,,358,250.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,186.41867,,,186.41867,2.702,274.944,other,OPPS APC,,
HC Pretx Serum RBC Antibody Incubation Drugs Each,PX-30000725,CDM,86975,CPT,300,RC,,,outpatient,,,358,250.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,434.866165,,,434.866165,2.072,608.812631,other,OPPS APC,,
HC Pretx Serum RBC Antibody Identification Dilution,PX-30000724,CDM,86976,CPT,300,RC,,,outpatient,,,311,217.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,32.497835,,,32.497835,2.31,238.848,other,OPPS APC,,
HC Pretx Serum RBC Antb ID Incubation Inhibitors Ea,PX-30000734,CDM,86977,CPT,300,RC,,,outpatient,,,509,356.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,186.41867,,,186.41867,2.31,416.02,other,OPPS APC,,
HC RBC Pretreatment-Serum Inhib,PX-39100003,CDM,86977,CPT,391,RC,,,outpatient,,,509,356.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,186.41867,,,186.41867,2.31,416.02,other,OPPS APC,,
HC Pretx Serum RBC Antibody ID Diffial Each Absrpj,PX-30000723,CDM,86978,CPT,300,RC,,,outpatient,,,311,217.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,2.31,238.848,other,OPPS APC,,
HC Unlisted Transfusion Medicine Procedure,PX-30000728,CDM,86999,CPT,300,RC,,,outpatient,,,299,209.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,32.497835,,,32.497835,1.68,229.632,other,OPPS APC,,
HC Strep a Assay W/Optic,PX-30000714,CDM,87880,CPT,300,RC,,,outpatient,,,52,36.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,11.674,39.936,fee schedule,,,
HC Sperm Isolation- Simple,PX-31000079,CDM,89260,CPT,310,RC,,,outpatient,,,210,147,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,59.142165,,,59.142165,47.145,416.02,other,OPPS APC,,
HC Sperm Isolation- Complex,PX-30000709,CDM,89261,CPT,300,RC,,,outpatient,,,152,106.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,59.142165,,,59.142165,34.124,116.736,other,OPPS APC,,
HC Semen Analysis-Volume- Count- Motility- Diff,PX-30000711,CDM,89320,CPT,300,RC,,,outpatient,,,58,40.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.32,44.544,fee schedule,,,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4202-01,NDC,outpatient,1,ML,650.46,455.322,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,160.2909605,,,160.2909605,139.93,1690.176,other,OPPS APC,,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4203-02,NDC,outpatient,5,ML,2200.75,1540.525,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,160.2909605,,,160.2909605,139.93,1690.176,other,OPPS APC,,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4203-01,NDC,outpatient,5,ML,2200.75,1540.525,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,160.2909605,,,160.2909605,139.93,1690.176,other,OPPS APC,,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4202-02,NDC,outpatient,1,ML,650.46,455.322,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,160.2909605,,,160.2909605,139.93,1690.176,other,OPPS APC,,
RABIES IMMUNE GLOBULIN 300 UNIT/ML IJ SOLN,RX-142826,CDM,90375,HCPCS,636,RC,13533-0318-10,NDC,outpatient,1,ML,1554.22,1087.954,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,329.569514,,,329.569514,287.71,7105.5744,other,OPPS APC,,
RABIES IMMUNE GLOBULIN 300 UNIT/ML IJ SOLN,RX-142826,CDM,90375,HCPCS,636,RC,13533-0318-01,NDC,outpatient,1,ML,1554.22,1087.954,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,329.569514,,,329.569514,287.71,7105.5744,other,OPPS APC,,
RABIES IMMUNE GLOBULIN 1500 UNIT/5ML IJ SOLN,RX-142827,CDM,90375,HCPCS,636,RC,13533-0318-50,NDC,outpatient,5,ML,7771.09,5439.763,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,329.569514,,,329.569514,287.71,7105.5744,other,OPPS APC,,
RABIES IMMUNE GLOBULIN 1500 UNIT/5ML IJ SOLN,RX-142827,CDM,90375,HCPCS,636,RC,13533-0318-05,NDC,outpatient,5,ML,7771.09,5439.763,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,329.569514,,,329.569514,287.71,7105.5744,other,OPPS APC,,
RABIES IMMUNE GLOBULIN 900 UNIT/3ML IJ SOLN,RX-150138,CDM,90375,HCPCS,636,RC,13533-0318-03,NDC,outpatient,3,ML,4662.66,3263.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,329.569514,,,329.569514,287.71,7105.5744,other,OPPS APC,,
RABIES IMMUNE GLOBULIN 900 UNIT/3ML IJ SOLN,RX-150138,CDM,90375,HCPCS,636,RC,13533-0318-30,NDC,outpatient,3,ML,4662.66,3263.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,329.569514,,,329.569514,287.71,7105.5744,other,OPPS APC,,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-02,NDC,outpatient,2,ML,1850.42,1295.294,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,329.569514,,,329.569514,287.71,7105.5744,other,OPPS APC,,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-10,NDC,outpatient,10,ML,9252.05,6476.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,329.569514,,,329.569514,287.71,7105.5744,other,OPPS APC,,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-11,NDC,outpatient,10,ML,9252.05,6476.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,329.569514,,,329.569514,287.71,7105.5744,other,OPPS APC,,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-20,NDC,outpatient,2,ML,1850.42,1295.294,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,329.569514,,,329.569514,287.71,7105.5744,other,OPPS APC,,
PALIVIZUMAB 50 MG/0.5ML IM SOLN,RX-108060,CDM,90378,HCPCS,636,RC,66658-0230-01,NDC,outpatient,0.5,ML,5025.03,3517.521,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,389.10344,,,389.10344,389.10344,4791.979,other,OPPS APC,,
HC Immuniz Admin-1 Single/Comb Vac/Toxoid,PX-77100004,CDM,90471,CPT,771,RC,,,outpatient,,,193,135.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,76.88596,,,76.88596,43.3285,416.02,other,OPPS APC,,
HC Immuniz-Admin-Each Addl,PX-77100008,CDM,90472,CPT,771,RC,,,outpatient,,,73,51.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,16.3885,416.02,other,OPPS APC,,
HC Admn Sarscov2 Vacc 1 Dose,PX-77100044,CDM,90480,CPT,771,RC,,,outpatient,,,111,77.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,47.56116,,,47.56116,24.9195,416.02,other,OPPS APC,,
MENINGOCOCCAL B RECOMB OMV ADJ IM SUSY,RX-129389,CDM,90620,HCPCS,636,RC,58160-0976-02,NDC,outpatient,0.5,ML,874.41,612.087,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.5,671.54688,,,,
MENINGOCOCCAL B RECOMB OMV ADJ IM SUSY,RX-129389,CDM,90620,HCPCS,636,RC,58160-0976-20,NDC,outpatient,0.5,ML,874.41,612.087,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.5,671.54688,,,,
HEPATITIS A VACCINE 1440 EL U/ML IM SUSP,RX-91034,CDM,90632,HCPCS,636,RC,58160-0826-43,NDC,outpatient,1,ML,337.61,236.327,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,70.48,416.02,other,OPPS APC,,
HEPATITIS A VACCINE 1440 EL U/ML IM SUSP,RX-91034,CDM,90632,HCPCS,636,RC,58160-0826-52,NDC,outpatient,1,ML,337.61,236.327,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,70.48,416.02,other,OPPS APC,,
HEPATITIS A VACCINE 720 EL U/0.5ML IM SUSP,RX-91033,CDM,90633,HCPCS,636,RC,58160-0825-43,NDC,outpatient,0.5,ML,155.01,108.507,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,34.799745,416.02,other,OPPS APC,,
HEPATITIS A VACCINE 720 EL U/0.5ML IM SUSP,RX-91033,CDM,90633,HCPCS,636,RC,58160-0825-52,NDC,outpatient,0.5,ML,155.01,108.507,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,34.799745,416.02,other,OPPS APC,,
HAEMOPHILUS B POLYSAC CONJ VAC IM SOLR,RX-11931,CDM,90648,HCPCS,636,RC,49281-0545-03,NDC,outpatient,1,UN,49.34,34.538,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,11.07683,416.02,other,OPPS APC,,
HAEMOPHILUS B POLYSAC CONJ VAC IM SOLR,RX-11931,CDM,90648,HCPCS,636,RC,49281-0547-58,NDC,outpatient,1,UN,49.34,34.538,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,11.07683,416.02,other,OPPS APC,,
HPV 9-VALENT RECOMB VACCINE IM SUSY,RX-129114,CDM,90651,HCPCS,636,RC,00006-4121-01,NDC,outpatient,0.5,ML,1147.17,803.019,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.5,881.02656,,,,
HPV 9-VALENT RECOMB VACCINE IM SUSY,RX-129114,CDM,90651,HCPCS,636,RC,00006-4121-02,NDC,outpatient,0.5,ML,1147.17,803.019,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.5,881.02656,,,,
INFLUENZA VAC SUBUNIT QUAD 0.5 ML IM SUSY,RX-135284,CDM,90674,HCPCS,636,RC,70461-0323-04,NDC,outpatient,0.5,ML,94.26,65.982,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.5,416.02,,,,
INFLUENZA VAC SUBUNIT QUAD 0.5 ML IM SUSY,RX-135284,CDM,90674,HCPCS,636,RC,70461-0323-03,NDC,outpatient,0.5,ML,94.26,65.982,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.5,416.02,,,,
RABIES VACCINE WRAPPER,RX-4080220,CDM,90675,HCPCS,636,RC,49281-0252-51,NDC,outpatient,1,UN,1713.57,1199.499,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,401.08537,,,401.08537,91.911626,1316.02176,other,OPPS APC,,
RABIES VACCINE WRAPPER,RX-4080220,CDM,90675,HCPCS,636,RC,50632-0010-01,NDC,outpatient,1,UN,1460.49,1022.343,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,401.08537,,,401.08537,91.911626,1316.02176,other,OPPS APC,,
RABIES VACCINE WRAPPER,RX-4080220,CDM,90675,HCPCS,636,RC,50632-0013-01,NDC,outpatient,1,UN,1460.49,1022.343,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,401.08537,,,401.08537,91.911626,1316.02176,other,OPPS APC,,
PNEUMOCOCCAL 20-VAL CONJ VACC 0.5 ML IM SUSY,RX-156044,CDM,90677,HCPCS,636,RC,00005-2000-02,NDC,outpatient,0.5,ML,1098.4,768.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.5,843.5712,,,,
INFLUENZA VAC A&B SA ADJ QUAD 0.5 ML IM PRSY,RX-150230,CDM,90694,HCPCS,636,RC,70461-0123-04,NDC,outpatient,0.5,ML,241.68,169.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.5,416.02,,,,
INFLUENZA VAC A&B SA ADJ QUAD 0.5 ML IM PRSY,RX-150230,CDM,90694,HCPCS,636,RC,70461-0123-03,NDC,outpatient,0.5,ML,241.68,169.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.5,416.02,,,,
DIPHTH-ACELL PERTUSSIS-TETANUS 15-23-5 LF-MCG/0.5 IM SUSP,RX-140528,CDM,90700,HCPCS,636,RC,49281-0286-10,NDC,outpatient,0.5,ML,107.51,75.257,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,24.135995,416.02,other,OPPS APC,,
DIPHTH-ACELL PERTUSSIS-TETANUS 15-23-5 LF-MCG/0.5 IM SUSP,RX-140528,CDM,90700,HCPCS,636,RC,49281-0286-58,NDC,outpatient,0.5,ML,107.51,75.257,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,24.135995,416.02,other,OPPS APC,,
MEASLES- MUMPS & RUBELLA VAC IJ SOLR,RX-148019,CDM,90707,HCPCS,636,RC,00006-4681-00,NDC,outpatient,1,UN,362.53,253.771,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,54.47,416.02,other,OPPS APC,,
MEASLES- MUMPS & RUBELLA VAC IJ SOLR,RX-148019,CDM,90707,HCPCS,636,RC,00006-4681-01,NDC,outpatient,1,UN,362.53,253.771,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,54.47,416.02,other,OPPS APC,,
POLIOVIRUS VACCINE INACTIVATED IJ INJ,RX-108127,CDM,90713,HCPCS,636,RC,49281-0860-10,NDC,outpatient,0.5,ML,163.66,114.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,25.298577,416.02,other,OPPS APC,,
POLIOVIRUS VACCINE INACTIVATED IJ INJ,RX-108127,CDM,90713,HCPCS,636,RC,49281-0860-78,NDC,outpatient,0.5,ML,163.66,114.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,25.298577,416.02,other,OPPS APC,,
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,58160-0842-11,NDC,outpatient,0.5,ML,193.78,135.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,25.298577,416.02,other,OPPS APC,,
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,49281-0400-10,NDC,outpatient,0.5,ML,187.93,131.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,25.298577,416.02,other,OPPS APC,,
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,58160-0842-01,NDC,outpatient,0.5,ML,193.78,135.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,25.298577,416.02,other,OPPS APC,,
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,49281-0400-58,NDC,outpatient,0.5,ML,187.93,131.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,25.298577,416.02,other,OPPS APC,,
VARICELLA VIRUS VACCINE LIVE 1350 PFU/0.5ML SC INJ,RX-113088,CDM,90716,HCPCS,636,RC,00006-4827-00,NDC,outpatient,1,UN,737.12,515.984,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.5,566.10816,,,,
VARICELLA VIRUS VACCINE LIVE 1350 PFU/0.5ML SC INJ,RX-113088,CDM,90716,HCPCS,636,RC,00006-4827-01,NDC,outpatient,1,UN,737.12,515.984,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.5,566.10816,,,,
DTAP-HEPATITIS B RECOMB-IPV IM SUSY,RX-158218,CDM,90723,HCPCS,636,RC,58160-0811-43,NDC,outpatient,0.5,ML,392.47,274.729,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.5,416.02,,,,
DTAP-HEPATITIS B RECOMB-IPV IM SUSY,RX-158218,CDM,90723,HCPCS,636,RC,58160-0811-52,NDC,outpatient,0.5,ML,392.47,274.729,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.5,416.02,,,,
MENINGOCOCCAL A C Y&W-135 OLIG IM SOLN,RX-161800,CDM,90734,HCPCS,636,RC,58160-0827-03,NDC,outpatient,0.5,ML,640.81,448.567,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.5,492.14208,,,,
MENINGOCOCCAL A C Y&W-135 OLIG IM SOLN,RX-161800,CDM,90734,HCPCS,636,RC,58160-0827-30,NDC,outpatient,0.5,ML,640.81,448.567,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.5,492.14208,,,,
HEPATITIS B VAC RECOMB ADJ 20 MCG/0.5ML IM SOSY,RX-143904,CDM,90739,HCPCS,636,RC,43528-0003-01,NDC,outpatient,0.5,ML,537.53,376.271,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.5,416.02,,,,
HEPATITIS B VAC RECOMB ADJ 20 MCG/0.5ML IM SOSY,RX-143904,CDM,90739,HCPCS,636,RC,43528-0003-05,NDC,outpatient,0.5,ML,537.53,376.271,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.5,416.02,,,,
HC Esophageal Motility Study- Manometry,PX-92000004,CDM,91010,CPT,920,RC,,,outpatient,,,1126,788.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,584.98394,,,584.98394,252.787,1055.807021,other,OPPS APC,,
HC Gerd Tst W/ Mucos Ph Electrod,PX-92000007,CDM,91035,CPT,920,RC,,,outpatient,,,1775,1242.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,584.98394,,,584.98394,398.4875,1363.2,other,OPPS APC,,
HC GI Trc Img Intraluminal Esophagus-Ileum W/I&R,PX-75000005,CDM,91110,CPT,750,RC,,,outpatient,,,3922,2745.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,989.356895,,,989.356895,399.86,3012.096,other,OPPS APC,,
HC GI Imag Intraluminal Esophagus-Ileum W/I&R,PX-92000008,CDM,91110,CPT,920,RC,,,outpatient,,,3922,2745.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,989.356895,,,989.356895,399.86,3012.096,other,OPPS APC,,
HC Rectal Sesation Tone & Compliance Test,PX-36900666,CDM,91120,CPT,369,RC,,,outpatient,,,752,526.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,168.824,1592,other,OPPS APC,,
HC Anal Pressure Record,PX-36900541,CDM,91122,CPT,369,RC,,,outpatient,,,1360,952,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,305.32,1592,other,OPPS APC,,
COVID-19 MRNA VACC (MODERNA) 50 MCG/0.5ML IM SUSY,RX-165852,CDM,91322,HCPCS,636,RC,80777-0102-93,NDC,outpatient,0.5,ML,492.72,344.904,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.5,417.629472,,,,
COVID-19 MRNA VACC (MODERNA) 50 MCG/0.5ML IM SUSY,RX-165852,CDM,91322,HCPCS,636,RC,80777-0102-01,NDC,outpatient,0.5,ML,492.72,344.904,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.5,417.629472,,,,
HC Eye Photography,PX-92000009,CDM,92285,CPT,920,RC,,,outpatient,,,80,56,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,43.769555,,,43.769555,17.96,416.02,other,OPPS APC,,
HC Caloric Vestibular Test Bilateral- Bithermal,PX-47100041,CDM,92537,CPT,471,RC,,,outpatient,,,1270,889,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,170.484765,,,170.484765,163,975.36,other,OPPS APC,,
HC Caloric Vestibular Test Bilateral- Monothermal,PX-47100042,CDM,92538,CPT,471,RC,,,outpatient,,,882,617.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,170.484765,,,170.484765,163,677.376,other,OPPS APC,,
HC Vestibular Eval Nystag Fovl&Perph Stim Oscil Tracking,PX-47000010,CDM,92540,CPT,470,RC,,,outpatient,,,550,385,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,170.484765,,,170.484765,123.475,422.4,other,OPPS APC,,
HC Spontaneous Nystagmus Test,PX-47000011,CDM,92541,CPT,470,RC,,,outpatient,,,155,108.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,34.7975,416.02,other,OPPS APC,,
HC Positional Nystagmus Test,PX-47000012,CDM,92542,CPT,470,RC,,,outpatient,,,155,108.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,34.7975,416.02,other,OPPS APC,,
HC Optokinetic Nystagmus Test- Bidirec- Foveal- Periph- W Record,PX-47000014,CDM,92544,CPT,470,RC,,,outpatient,,,155,108.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,170.484765,,,170.484765,34.7975,416.02,other,OPPS APC,,
HC Oscillating Tracking Test,PX-47000015,CDM,92545,CPT,470,RC,,,outpatient,,,696,487.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,142.97,534.528,other,OPPS APC,,
HC Supplemental Electrical Test,PX-47100012,CDM,92547,CPT,471,RC,,,outpatient,,,225,157.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,50.5125,416.02,other,OPPS APC,,
HC Tympanometry and Reflex Threshold Measurements,PX-47100013,CDM,92550,CPT,471,RC,,,outpatient,,,269,188.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,170.484765,,,170.484765,60.3905,416.02,other,OPPS APC,,
HC Pure Tone Audiometry- Air,PX-47100014,CDM,92552,CPT,471,RC,,,outpatient,,,230,161,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,51.635,416.02,other,OPPS APC,,
HC Audiometry- Air & Bone,PX-47100015,CDM,92553,CPT,471,RC,,,outpatient,,,295,206.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,170.484765,,,170.484765,61.17,416.02,other,OPPS APC,,
HC Speech Threshold Audiometry,PX-47100016,CDM,92555,CPT,471,RC,,,outpatient,,,144,100.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,32.328,416.02,other,OPPS APC,,
HC Speech Audiometry- Complete,PX-47100017,CDM,92556,CPT,471,RC,,,outpatient,,,132,92.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,29.634,416.02,other,OPPS APC,,
HC Comprehensive Hearing Test,PX-47100018,CDM,92557,CPT,471,RC,,,outpatient,,,519,363.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,170.484765,,,170.484765,116.5155,416.02,other,OPPS APC,,
HC Evoked Otoacoustic Emissions Screen Auto Analys,PX-47100047,CDM,92558,CPT,471,RC,,,outpatient,,,35,24.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,7.8575,416.02,,,,
HC Stenger Test- Pure Tone,PX-47100020,CDM,92565,CPT,471,RC,,,outpatient,,,95,66.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,21.3275,416.02,other,OPPS APC,,
HC Tympanometry,PX-47100021,CDM,92567,CPT,471,RC,,,outpatient,,,125,87.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,43.769555,,,43.769555,28.0625,416.02,other,OPPS APC,,
HC Acoustic Immit Test Tympanometry/Acoust Reflex/Decay,PX-47100023,CDM,92570,CPT,471,RC,,,outpatient,,,359,251.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,170.484765,,,170.484765,80.5955,416.02,other,OPPS APC,,
HC Visual Audiometry (Vra),PX-47100027,CDM,92579,CPT,471,RC,,,outpatient,,,500,350,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,170.484765,,,170.484765,112.25,416.02,other,OPPS APC,,
HC Conditioning Play Audiometry,PX-47100028,CDM,92582,CPT,471,RC,,,outpatient,,,511,357.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,170.484765,,,170.484765,114.7195,416.02,other,OPPS APC,,
HC Select Picture Audiometry,PX-47100029,CDM,92583,CPT,471,RC,,,outpatient,,,114,79.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,25.593,416.02,other,OPPS APC,,
HC Evoked Auditory Test-Limited,PX-47100032,CDM,92587,CPT,471,RC,,,outpatient,,,624,436.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,128.12716,479.602522,other,OPPS APC,,
HC Hearing Aid Check- One Ear,PX-47100036,CDM,92592,CPT,471,RC,,,outpatient,,,116,81.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.042,416.02,,,,
HC Hearing Aid Check- Both Ears,PX-47100038,CDM,92593,CPT,471,RC,,,outpatient,,,162,113.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,36.369,416.02,,,,
HC Auditory Function- 60 Min,PX-47100039,CDM,92620,CPT,471,RC,,,outpatient,,,729,510.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,170.484765,,,170.484765,84.99,559.872,other,OPPS APC,,
HC Auditory Function- + 15 Min,PX-47100040,CDM,92621,CPT,471,RC,,,outpatient,,,122,85.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.01,416.02,other,OPPS APC,,
HC Aep Threshold Estimation Mlt Frequencies I&R,PX-47100043,CDM,92652,CPT,471,RC,,,outpatient,,,863,604.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,128.12716,662.784,other,OPPS APC,,
HC Aep Neurodiagnostic Interpretation and Report,PX-47100044,CDM,92653,CPT,471,RC,,,outpatient,,,863,604.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,128.12716,662.784,other,OPPS APC,,
HC Prq Trluml Coronary Angioplasty One Art/Branch,PX-48100012,CDM,92920,CPT,481,RC,,,outpatient,,,17563,12294.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6238.20972,,,6238.20972,399.86,13488.384,other,OPPS APC,,
HC Prq Trluml Coronary Angioplasty Addl Branch,PX-48100013,CDM,92921,CPT,481,RC,,,outpatient,,,17563,12294.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13488.384,other,OPPS APC,,
HC Prq Trluml Coronary Angio/Atherect One Art/Brnch,PX-48100014,CDM,92924,CPT,481,RC,,,outpatient,,,33484,23438.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12006.91336,,,12006.91336,399.86,25715.712,other,OPPS APC,,
HC Prq Trluml Coronary Angio/Atherec Addl Art/Brnch,PX-48100015,CDM,92925,CPT,481,RC,,,outpatient,,,32854,22997.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,25231.872,other,OPPS APC,,
HC Prq Trluml Coronary Stent W/Angio One Art/Brnch,PX-48100016,CDM,92928,CPT,481,RC,,,outpatient,,,32584,22808.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12006.91336,,,12006.91336,399.86,25024.512,other,OPPS APC,,
HC Prq Trluml Coronary Stent W/Angio Addl Art/Brnch,PX-48100017,CDM,92929,CPT,481,RC,,,outpatient,,,26673,18671.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,20484.864,other,OPPS APC,,
HC Prq Trluml Coronry Stent/Ath/Angio One Art/Brnch,PX-48100018,CDM,92933,CPT,481,RC,,,outpatient,,,33887,23720.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19138.22361,,,19138.22361,399.86,26793.51305,other,OPPS APC,,
HC Prq Trluml Coronary Stent/Ath/Angio Addl Branch,PX-48100019,CDM,92934,CPT,481,RC,,,outpatient,,,26169,18318.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,20097.792,other,OPPS APC,,
HC Prq Trluml Coronary Byp Grft Revasc One Vessel,PX-48100020,CDM,92937,CPT,481,RC,,,outpatient,,,26673,18671.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12006.91336,,,12006.91336,399.86,20484.864,other,OPPS APC,,
HC Prq Trluml Coronary Byp Grft Revasc Addl Vessel,PX-48100021,CDM,92938,CPT,481,RC,,,outpatient,,,26169,18318.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,20097.792,other,OPPS APC,,
HC Prq Trluml Coronry Chronic Occlus Revasc One Vsl,PX-48100023,CDM,92943,CPT,481,RC,,,outpatient,,,25667,17966.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12006.91336,,,12006.91336,399.86,19712.256,other,OPPS APC,,
HC Prq Trluml Coronry Chrnic Occlus Revasc Addl Vsl,PX-48100024,CDM,92944,CPT,481,RC,,,outpatient,,,26169,18318.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,20097.792,other,OPPS APC,,
HC Heart/Lung Resuscitation (Cpr),PX-48000001,CDM,92950,CPT,480,RC,,,outpatient,,,1034,723.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,232.133,997.822944,other,OPPS APC,,
HC PR Cardiopulmonary Resuscitation,PX-96000048,CDM,92950,CPT,960,RC,,,outpatient,,,1034,723.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,232.133,997.822944,other,OPPS APC,,
HC Temporary External Pacing,PX-48000002,CDM,92953,CPT,480,RC,,,outpatient,,,1302,911.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,710.32455,,,710.32455,292.299,999.936,other,OPPS APC,,
HC Cardioversion- Elective;Extern,PX-48000003,CDM,92960,CPT,480,RC,,,outpatient,,,2006,1404.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,710.32455,,,710.32455,399.86,1540.608,other,OPPS APC,,
HC PR Cardioversion Elective Arrhythmia External,PX-96000049,CDM,92960,CPT,960,RC,,,outpatient,,,2006,1404.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,710.32455,,,710.32455,399.86,1540.608,other,OPPS APC,,
HC Prq Transluminal Coronary Mechanicl Thrombectomy,PX-48000005,CDM,92973,CPT,480,RC,,,outpatient,,,773,541.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,173.5385,593.664,other,OPPS APC,,
HC Intrav Optcl Chernce Tmgrphy W/S&I Intl Vesl,PX-36900031,CDM,92978,CPT,369,RC,,,outpatient,,,2785,1949.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,145.12362,2138.88,other,OPPS APC,,
HC Intravasc US-Heart-1st Vessel,PX-48100025,CDM,92978,CPT,481,RC,,,outpatient,,,2785,1949.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,145.12362,2138.88,other,OPPS APC,,
HC Intrav Optcal Cohrnce Tmgrphy W/S&I Adl Vesl,PX-36900032,CDM,92979,CPT,369,RC,,,outpatient,,,755,528.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,169.4975,1592,other,OPPS APC,,
HC Intravasc Coronary Sono-Addn Vessel,PX-48100026,CDM,92979,CPT,481,RC,,,outpatient,,,755,528.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,169.4975,1592,other,OPPS APC,,
HC Percut Aortic Valvuloplasty,PX-48100027,CDM,92986,CPT,481,RC,,,outpatient,,,17231,12061.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6238.20972,,,6238.20972,399.86,13233.408,other,OPPS APC,,
HC Percut Mitral Valvuloplasty,PX-48100028,CDM,92987,CPT,481,RC,,,outpatient,,,17231,12061.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12006.91336,,,12006.91336,399.86,16809.6787,other,OPPS APC,,
HC Percut Pulmonary Valvuloplasty,PX-48100029,CDM,92990,CPT,481,RC,,,outpatient,,,17231,12061.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12006.91336,,,12006.91336,399.86,16809.6787,other,OPPS APC,,
HC Electrocardiogram- Tracing,PX-73000001,CDM,93005,CPT,730,RC,,,outpatient,,,157,109.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,25.49469,416.02,other,OPPS APC,,
HC PR Electrocardiogram Report,PX-98500001,CDM,93010,CPT,985,RC,,,outpatient,,,28,19.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,6.286,416.02,fee schedule,,,
HC Cardiac Stress Tst-Tracing Only,PX-48200001,CDM,93017,CPT,482,RC,,,outpatient,,,485,339.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,108.8825,479.602522,other,OPPS APC,,
HC Rhythm Ecg- Tracing,PX-73000003,CDM,93041,CPT,730,RC,,,outpatient,,,120,84,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,25.49469,416.02,other,OPPS APC,,
HC PR Rhythm Ecg 1-3 Leads Interpretation & Reprt On,PX-98500004,CDM,93042,CPT,985,RC,,,outpatient,,,22,15.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.939,416.02,fee schedule,,,
HC Ext Ecg Record Contin 48 Hr- Record,PX-73100001,CDM,93225,CPT,731,RC,,,outpatient,,,433,303.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,84.459332,416.02,other,OPPS APC,,
HC Ext Ecg Record Contin 48 Hr- Scan Analysis W Report,PX-73100002,CDM,93226,CPT,731,RC,,,outpatient,,,318,222.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,66.75974,416.02,other,OPPS APC,,
HC PR Xtrnl Ecg Continuous Rhythm W/I&R Up to 48 Hrs,PX-98500002,CDM,93227,CPT,985,RC,,,outpatient,,,63,44.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.1435,416.02,fee schedule,,,
HC Prgrmg Dev Eval 1 Lead Pm/Ldls Pm 1 Car Chmbr IP,PX-48000087,CDM,93279,CPT,480,RC,,,outpatient,,,118,82.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,41.157815,,,41.157815,26.491,416.02,other,OPPS APC,,
HC Program Eval Implantable in Persn Dual Ld Pacer,PX-92000010,CDM,93280,CPT,920,RC,,,outpatient,,,1217,851.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,41.157815,,,41.157815,41.157815,934.656,other,OPPS APC,,
HC Program Eval Implantable in Prsn Multi Ld Pacer,PX-48000088,CDM,93281,CPT,480,RC,,,outpatient,,,118,82.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,41.157815,,,41.157815,26.491,416.02,other,OPPS APC,,
HC Prgrmng Dev Eval Implantable in Persn 1 Ld Dfb,PX-48000089,CDM,93282,CPT,480,RC,,,outpatient,,,118,82.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,41.157815,,,41.157815,26.491,416.02,other,OPPS APC,,
HC Progrm Eval Implantable in Prsn Dual L Card/Dfb,PX-48000009,CDM,93283,CPT,480,RC,,,outpatient,,,1878,1314.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,41.157815,,,41.157815,41.157815,1442.304,other,OPPS APC,,
HC Prgrmg Eval Implantable in Person Multi Lead Dfb,PX-48000090,CDM,93284,CPT,480,RC,,,outpatient,,,118,82.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,41.157815,,,41.157815,26.491,416.02,other,OPPS APC,,
HC Prgrmg Dev Eval Scrms Phys/Qhp in Person,PX-48000091,CDM,93285,CPT,480,RC,,,outpatient,,,118,82.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,41.157815,,,41.157815,26.491,416.02,other,OPPS APC,,
HC Interrogation Eval in Person 1/Dual/Mlt Lead Pm,PX-48000010,CDM,93288,CPT,480,RC,,,outpatient,,,224,156.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,41.157815,,,41.157815,41.157815,416.02,other,OPPS APC,,
HC Interrog Eval F2f 1/Dual/Mlt Leads Impltbl Dfb,PX-48000086,CDM,93289,CPT,480,RC,,,outpatient,,,118,82.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,41.157815,,,41.157815,26.491,416.02,other,OPPS APC,,
HC Interrogation Evaluation in Person Ilr System,PX-92000011,CDM,93291,CPT,920,RC,,,outpatient,,,248,173.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,32.497835,,,32.497835,23.39896,416.02,other,OPPS APC,,
Rem Interrog Pm/Ldls Pm/Ids <90 D Tech Review,PX-48000085,CDM,93296,CPT,480,RC,,,outpatient,,,118,82.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,41.157815,,,41.157815,26.491,416.02,other,OPPS APC,,
HC Echo Xthoracic-Cong Anom-Complete,PX-48000014,CDM,93303,CPT,480,RC,,,outpatient,,,1337,935.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,602.109165,,,602.109165,54.1045,1223.3,other,OPPS APC,,
HC PR Echo Xthoracic-Cong Anom-Complete,PX-96000009,CDM,93303,CPT,960,RC,,,outpatient,,,241,168.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,602.109165,,,602.109165,54.1045,1223.3,other,OPPS APC,,
HC Echo Xthoracic-Cong Anom-Limited,PX-48000015,CDM,93304,CPT,480,RC,,,outpatient,,,1303,912.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,602.109165,,,602.109165,281.81,1040.64,other,OPPS APC,,
HC PR Echo Xthoracic-Cong Anom-Limited,PX-96000010,CDM,93304,CPT,960,RC,,,outpatient,,,1355,948.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,602.109165,,,602.109165,281.81,1040.64,other,OPPS APC,,
HC Echo Heart Xthoracic-Complete W Doppler W/Contrast,PX-48000016,CDM,93306,CPT,480,RC,,,outpatient,,,1347,942.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,602.109165,,,602.109165,54.1045,1034.496,other,OPPS APC,,
HC Echo Heart Xthoracic-Complete W Doppler W/O Contrast,PX-48000068,CDM,93306,CPT,480,RC,,,outpatient,,,1347,942.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,602.109165,,,602.109165,54.1045,1034.496,other,OPPS APC,,
HC PR Echo Heart Xthoracic-Complete W Doppler,PX-96000036,CDM,93306,CPT,960,RC,,,outpatient,,,241,168.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,602.109165,,,602.109165,54.1045,1034.496,other,OPPS APC,,
HC Echo Heart Xthoracic-Complete- W/O Doppler W/Contrast,PX-48000017,CDM,93307,CPT,480,RC,,,outpatient,,,1228,859.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,267.439885,943.104,other,OPPS APC,,
HC Echo Heart Xthoracic-Complete- W/O Doppler W/O Contrast,PX-48000063,CDM,93307,CPT,480,RC,,,outpatient,,,1228,859.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,267.439885,943.104,other,OPPS APC,,
HC Echo Heart Xthoracic-Limited W/Contrast,PX-48000018,CDM,93308,CPT,480,RC,,,outpatient,,,561,392.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,125.9445,465.66,other,OPPS APC,,
HC Echo Heart Xthoracic-Limited W/O Contrast,PX-48000065,CDM,93308,CPT,480,RC,,,outpatient,,,561,392.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,125.9445,465.66,other,OPPS APC,,
HC PR Echo Heart Xthoracic-Limited,PX-96000037,CDM,93308,CPT,960,RC,,,outpatient,,,561,392.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,125.9445,465.66,other,OPPS APC,,
HC Echo Heart-Transesophageal-Complete W/Contrast,PX-48000019,CDM,93312,CPT,480,RC,,,outpatient,,,1764,1234.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,602.109165,,,602.109165,224.549385,1354.752,other,OPPS APC,,
HC Echo Heart-Transesophageal-Complete W/O Contrast,PX-48000064,CDM,93312,CPT,480,RC,,,outpatient,,,1764,1234.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,602.109165,,,602.109165,224.549385,1354.752,other,OPPS APC,,
HC Echo R-T 2d W/Probe Placement Only,PX-48000083,CDM,93313,CPT,480,RC,,,outpatient,,,1501,1050.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,602.109165,,,602.109165,336.9745,1152.768,other,OPPS APC,,
HC 3d Echo Img&Pst-Pxessing Tee/Tte Cgen Car Anomal,PX-48000084,CDM,93319,CPT,480,RC,,,outpatient,,,352,246.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,79.024,416.02,other,OPPS APC,,
HC Doppler Echo Heart-Complete,PX-48000020,CDM,93320,CPT,480,RC,,,outpatient,,,323,226.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,72.5135,416.02,other,OPPS APC,,
HC Doppler Echo Heart-Limited-F/U,PX-48000021,CDM,93321,CPT,480,RC,,,outpatient,,,384,268.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,86.208,416.02,other,OPPS APC,,
HC Doppler Color Flow Velocity Map,PX-48000022,CDM,93325,CPT,480,RC,,,outpatient,,,744,520.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,135.906309,571.392,other,OPPS APC,,
HC Echo Heart Xthoracic- Stress/Rest W/Contrast,PX-48000023,CDM,93350,CPT,480,RC,,,outpatient,,,1384,968.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,602.109165,,,602.109165,224.549385,1062.912,other,OPPS APC,,
HC Echo Heart Xthoracic- Stress/Rest W/O Contrast,PX-48000066,CDM,93350,CPT,480,RC,,,outpatient,,,1384,968.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,602.109165,,,602.109165,224.549385,1062.912,other,OPPS APC,,
HC Echo Tthrc R-T 2d W/WO M-Mode Rest&Strs Cont Ecg W/Contrast,PX-48000024,CDM,93351,CPT,480,RC,,,outpatient,,,1785,1249.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,602.109165,,,602.109165,224.549385,1370.88,other,OPPS APC,,
HC Echo Tthrc R-T 2d W/WO M-Mode Rest&Strs Cont Ecg W/O Contrast,PX-48000067,CDM,93351,CPT,480,RC,,,outpatient,,,1785,1249.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,602.109165,,,602.109165,224.549385,1370.88,other,OPPS APC,,
HC Echo Tee Guid Tcat Icar/Vessel Structural Intvn,PX-48000052,CDM,93355,CPT,480,RC,,,outpatient,,,778,544.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.661,597.504,other,OPPS APC,,
HC Myocrd Strain Img Speckle Trck Assmt Myocrd Mech,PX-48000480,CDM,93356,CPT,480,RC,,,outpatient,,,1077,753.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,241.7865,827.136,other,OPPS APC,,
HC Right Heart Cath O2 Saturation & Cardiac Output,PX-48100030,CDM,93451,CPT,481,RC,,,outpatient,,,9177,6423.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3556.468215,,,3556.468215,399.86,7870.4,other,OPPS APC,,
HC Cath Place/Coronary Angio- Img Super/Interp,PX-48100031,CDM,93454,CPT,481,RC,,,outpatient,,,10988,7691.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3556.468215,,,3556.468215,399.86,8438.784,other,OPPS APC,,
HC Cath Place/Coronary Angio- Img Super/Interp- Bypass Angio,PX-48100032,CDM,93455,CPT,481,RC,,,outpatient,,,10988,7691.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3556.468215,,,3556.468215,399.86,8438.784,other,OPPS APC,,
HC Cath Place/Coronary Angio- Img Super/Interp-W Right Heart Cath,PX-48100033,CDM,93456,CPT,481,RC,,,outpatient,,,10988,7691.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3556.468215,,,3556.468215,399.86,8438.784,other,OPPS APC,,
HC Cath Place/Coron Angio- Img Super/Interp- Bypass Angio-W R Heart Cath,PX-48100034,CDM,93457,CPT,481,RC,,,outpatient,,,9755,6828.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3556.468215,,,3556.468215,399.86,7870.4,other,OPPS APC,,
HC Cath Place/Coron Angio- Img Super/Interp-W Left Heart Ventriculography,PX-48100035,CDM,93458,CPT,481,RC,,,outpatient,,,9755,6828.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3556.468215,,,3556.468215,399.86,7870.4,other,OPPS APC,,
HC Cath Place/Coron Angio- Img Super/Interp- Bypass Angio-W L Hrt Ventric,PX-48100036,CDM,93459,CPT,481,RC,,,outpatient,,,10988,7691.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3556.468215,,,3556.468215,399.86,8438.784,other,OPPS APC,,
HC Cath Place/Coron Angio- Img Super/Interp-R&L Hrt Cath- L Hrt Ventric,PX-48100037,CDM,93460,CPT,481,RC,,,outpatient,,,10988,7691.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3556.468215,,,3556.468215,399.86,8438.784,other,OPPS APC,,
HC Cath Place/Cor Ang-Img Supr/Intrp-Bypass Ang- R&L Cath- L Hrt Ventric,PX-48100038,CDM,93461,CPT,481,RC,,,outpatient,,,10988,7691.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3556.468215,,,3556.468215,399.86,8438.784,other,OPPS APC,,
HC Left Heart Cath by Transeptal Puncture,PX-48100039,CDM,93462,CPT,481,RC,,,outpatient,,,10365,7255.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7960.32,other,OPPS APC,,
HC Insert/Place Flow Direct Cath,PX-36900885,CDM,93503,CPT,369,RC,,,outpatient,,,2998,2098.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1747.952815,,,1747.952815,399.86,2532.39,other,OPPS APC,,
HC Insert/Place Flow Direct Cath,PX-48000025,CDM,93503,CPT,480,RC,,,outpatient,,,2998,2098.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1747.952815,,,1747.952815,399.86,2532.39,other,OPPS APC,,
HC Inject Select Cor Angio During Congenital Heart Cath,PX-48100044,CDM,93563,CPT,481,RC,,,outpatient,,,2542,1779.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,1952.256,other,OPPS APC,,
HC Inject Select Cor/Graft Angio During Congenital Heart Cath,PX-48100045,CDM,93564,CPT,481,RC,,,outpatient,,,1018,712.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,228.541,1592,other,OPPS APC,,
HC Inject Select Left Vent/Atrial Angio During Heart Cath,PX-48100046,CDM,93565,CPT,481,RC,,,outpatient,,,510,357,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,114.495,1592,other,OPPS APC,,
HC Inject Select Right Vent/Atrial Angio During Heart Cath,PX-48100047,CDM,93566,CPT,481,RC,,,outpatient,,,1018,712.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,228.541,1592,other,OPPS APC,,
HC Inject Supravalvular Aortography During Heart Cath,PX-48100048,CDM,93567,CPT,481,RC,,,outpatient,,,1498,1048.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,235.074116,1592,other,OPPS APC,,
HC Heart Flow Reserv Measure-Init Vessl,PX-48000026,CDM,93571,CPT,480,RC,,,outpatient,,,6936,4855.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,5638.7,other,OPPS APC,,
HC Heart Flow Reserv Measure-Addn Vessl,PX-48000027,CDM,93572,CPT,480,RC,,,outpatient,,,2051,1435.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,1575.168,other,OPPS APC,,
HC Perc Clos-Cong Interatrial Commun W/Impl,PX-48100049,CDM,93580,CPT,481,RC,,,outpatient,,,53254,37277.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19138.22361,,,19138.22361,399.86,40899.072,other,OPPS APC,,
HC Perc Closure-Cong Vsd W/Implant,PX-48100050,CDM,93581,CPT,481,RC,,,outpatient,,,53254,37277.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19138.22361,,,19138.22361,399.86,40899.072,other,OPPS APC,,
HC Percutan Transcath Closure Pat Duct Arteriosus,PX-36900556,CDM,93582,CPT,369,RC,,,outpatient,,,52790,36953,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19138.22361,,,19138.22361,399.86,40542.72,other,OPPS APC,,
HC Percutan Transcath Closure Pat Duct Arteriosus,PX-48100051,CDM,93582,CPT,481,RC,,,outpatient,,,52790,36953,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19138.22361,,,19138.22361,399.86,40542.72,other,OPPS APC,,
HC Percutaneous Transcatheter Septal Reduction Ther,PX-48100055,CDM,93583,CPT,481,RC,,,outpatient,,,16899,11829.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,12978.432,fee schedule,,,
HC Heart Pacing- Mapping,PX-48000042,CDM,93631,CPT,480,RC,,,outpatient,,,8496,5947.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6909.98,other,OPPS APC,,
HC Eval Cardiovert Leads-Initial,PX-48000043,CDM,93640,CPT,480,RC,,,outpatient,,,5892,4124.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,4525.056,other,OPPS APC,,
HC Eval Cardiovert Leads/Puls Gen,PX-48000044,CDM,93641,CPT,480,RC,,,outpatient,,,3075,2152.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2361.6,other,OPPS APC,,
HC Electrophys Eval-Cardioverter,PX-48000045,CDM,93642,CPT,480,RC,,,outpatient,,,3083,2158.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1298.939725,,,1298.939725,399.86,2367.744,other,OPPS APC,,
HC Tilt Table Evaluation,PX-48000049,CDM,93660,CPT,480,RC,,,outpatient,,,3083,2158.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,584.98394,,,584.98394,399.86,2367.744,other,OPPS APC,,
HC Intracard Echo- Ther/Dx Intervent,PX-48000050,CDM,93662,CPT,480,RC,,,outpatient,,,7689,5382.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10671.09667,other,OPPS APC,,
HC Analyze Pacer Sys,PX-48000051,CDM,93724,CPT,480,RC,,,outpatient,,,1217,851.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,325.997845,,,325.997845,73.54,934.656,other,OPPS APC,,
HC Outpatient Cardiac Rehab W/O Cont Ecg Monitor,PX-94300002,CDM,93797,CPT,943,RC,,,outpatient,,,255,178.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,144.21845,,,144.21845,57.2475,416.02,other,OPPS APC,,
HC Outpatient Cardiac Rehab W/Cont Ecg Monitoring,PX-94300003,CDM,93798,CPT,943,RC,,,outpatient,,,271,189.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,144.21845,,,144.21845,60.8395,416.02,other,OPPS APC,,
HC Duplex Scan Extracranial-Bilat,PX-92100008,CDM,93880,CPT,921,RC,,,outpatient,,,915,640.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,199.512292,702.72,other,OPPS APC,,
HC Duplex Scan Extracranial-Limited,PX-92100010,CDM,93882,CPT,921,RC,,,outpatient,,,915,640.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,119.991125,702.72,other,OPPS APC,,
HC Transcran Doppler Intracran Art,PX-92100011,CDM,93886,CPT,921,RC,,,outpatient,,,1137,795.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,255.2565,873.216,other,OPPS APC,,
HC Transcran Doppler Intracran-Limited,PX-92100013,CDM,93888,CPT,921,RC,,,outpatient,,,428,299.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,96.086,686,other,OPPS APC,,
HC Transcran Doppl Intracran- Vasoreact,PX-92100015,CDM,93890,CPT,921,RC,,,outpatient,,,952,666.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,213.724,731.136,other,OPPS APC,,
HC Non-Invas Physiologic Std Extremity Art 1-2 Level,PX-92100017,CDM,93922,CPT,921,RC,,,outpatient,,,915,640.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,135.906309,702.72,other,OPPS APC,,
HC Non-Invasive Physiologic Study Extremity 3 Levels,PX-92100019,CDM,93923,CPT,921,RC,,,outpatient,,,701,490.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,170.484765,,,170.484765,121.132463,686,other,OPPS APC,,
HC Non-Invasive Lower Extrem Art Stress/Rest- Complete-Bilateral,PX-92100020,CDM,93924,CPT,921,RC,,,outpatient,,,915,640.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,170.484765,,,170.484765,135.906309,775.5705,other,OPPS APC,,
HC Duplex Lo Extrem Art Bilat,PX-92100022,CDM,93925,CPT,921,RC,,,outpatient,,,915,640.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,199.512292,702.72,other,OPPS APC,,
HC Duplex Lo Extrem Art Unilat/Ltd,PX-92100024,CDM,93926,CPT,921,RC,,,outpatient,,,441,308.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,99.0045,686,other,OPPS APC,,
HC Duplex Up Extrem Art Bilat,PX-92100025,CDM,93930,CPT,921,RC,,,outpatient,,,842,589.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,135.906309,686,other,OPPS APC,,
HC Duplex Up Extrem Art Bilat,PX-92100026,CDM,93930,CPT,921,RC,,,outpatient,,,842,589.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,135.906309,686,other,OPPS APC,,
HC Duplex Up Extrem Art Unilat/Ltd,PX-92100028,CDM,93931,CPT,921,RC,,,outpatient,,,915,640.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,119.991125,702.72,other,OPPS APC,,
HC Duplex Extrem Venous-Bilat,PX-92100031,CDM,93970,CPT,921,RC,,,outpatient,,,758,530.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,170.171,686,other,OPPS APC,,
HC Duplex Extrem Venous-Bilat,PX-92100032,CDM,93970,CPT,921,RC,,,outpatient,,,758,530.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,170.171,686,other,OPPS APC,,
HC Duplex Extrem Venous-Uni or Ltd,PX-92100034,CDM,93971,CPT,921,RC,,,outpatient,,,915,640.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,119.991125,702.72,other,OPPS APC,,
HC Duplex Abd/Pel Vasc Study-Complete,PX-92100036,CDM,93975,CPT,921,RC,,,outpatient,,,816,571.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,183.192,686,other,OPPS APC,,
HC Duplex Abd/Pel Vasc Study-Limitd,PX-92100037,CDM,93976,CPT,921,RC,,,outpatient,,,418,292.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,93.841,686,other,OPPS APC,,
HC Duplex Large Vessel(S)-Complete,PX-92100039,CDM,93978,CPT,921,RC,,,outpatient,,,915,640.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,199.512292,702.72,other,OPPS APC,,
HC Duplex Large Vessel(S)-Limited,PX-92100041,CDM,93979,CPT,921,RC,,,outpatient,,,387,270.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,86.8815,686,other,OPPS APC,,
HC Duplex Hemodialysis Access,PX-92100042,CDM,93990,CPT,921,RC,,,outpatient,,,614,429.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,119.991125,,,119.991125,119.991125,686,other,OPPS APC,,
HC Breathing Capacity Test,PX-46000002,CDM,94010,CPT,460,RC,,,outpatient,,,295,206.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,170.484765,,,170.484765,66.2275,416.02,other,OPPS APC,,
HC Eval of Bronchospasm,PX-46000003,CDM,94060,CPT,460,RC,,,outpatient,,,446,312.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,100.127,479.602522,other,OPPS APC,,
HC Eval of Bronchospasm-Prolonged,PX-46000004,CDM,94070,CPT,460,RC,,,outpatient,,,925,647.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,163,710.4,other,OPPS APC,,
HC Xers Tst Brncspsm Pre&Post Spmtry&Pls Ox W/Ecg,PX-46000023,CDM,94617,CPT,460,RC,,,outpatient,,,392,274.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,88.004,416.02,other,OPPS APC,,
HC Pulmonary Stress Testing,PX-46000022,CDM,94618,CPT,460,RC,,,outpatient,,,392,274.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,88.004,416.02,other,OPPS APC,,
HC Xers Tst Brncspsm Pre&Post Spmtry&Pls Ox WO /Ecg,PX-46000024,CDM,94619,CPT,460,RC,,,outpatient,,,182,127.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,40.859,416.02,other,OPPS APC,,
HC Inhal Rx- Airway Obst/Dx Sputum Induct,PX-41000006,CDM,94640,CPT,410,RC,,,outpatient,,,494,345.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,232.78851,,,232.78851,59.92,416.02,other,OPPS APC,,
HC Plethysmography Lung Volumes W/WO Airway Resist,PX-46000012,CDM,94726,CPT,460,RC,,,outpatient,,,446,312.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,98.67,479.602522,other,OPPS APC,,
HC Gas Dilut/Washout Lung Vol W/WO Distrib Vent&Vol,PX-46000013,CDM,94727,CPT,460,RC,,,outpatient,,,295,206.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,170.484765,,,170.484765,66.2275,416.02,other,OPPS APC,,
HC Diffusing Capacity,PX-46000014,CDM,94729,CPT,460,RC,,,outpatient,,,265,185.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,59.4925,416.02,other,OPPS APC,,
HC Noninvasv Oxygen Satur;Single,PX-46000015,CDM,94760,CPT,460,RC,,,outpatient,,,54,37.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.123,416.02,other,OPPS APC,,
HC Noninvasv Oxygen Satur-Multiple,PX-46000016,CDM,94761,CPT,460,RC,,,outpatient,,,90,63,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.205,416.02,other,OPPS APC,,
HC Car Seat/Bed Test Initial 60 Mins,PX-46000019,CDM,94780,CPT,460,RC,,,outpatient,,,194,135.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,43.769555,,,43.769555,43.553,416.02,other,OPPS APC,,
HC Car Seat/Bed Test Each Addl 30 Min,PX-46000020,CDM,94781,CPT,460,RC,,,outpatient,,,194,135.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,43.553,416.02,other,OPPS APC,,
HC Pulmonary Service/Procedure,PX-41000002,CDM,94799,CPT,761,RC,,,outpatient,,,367,256.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,170.484765,,,170.484765,22.74,416.02,other,OPPS APC,,
HC Eeg W/O Video by Tech 2-12 Hr Unmonitored,PX-74000012,CDM,95705,CPT,740,RC,,,outpatient,,,827,578.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,185.6615,635.136,other,OPPS APC,,
HC Eeg W/O Video by Tech 2-12 Hr Intermittent Mntr,PX-74000013,CDM,95706,CPT,740,RC,,,outpatient,,,827,578.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,185.6615,635.136,other,OPPS APC,,
HC Eeg W/O Video by Tech 2-12hr Continuous R-T Mntr,PX-74000014,CDM,95707,CPT,740,RC,,,outpatient,,,827,578.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,185.6615,635.136,other,OPPS APC,,
HC Eeg W/O Vid by Tech Ea Incr 12-26hr Unmonitored,PX-74000011,CDM,95708,CPT,740,RC,,,outpatient,,,1649,1154.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,584.98394,,,584.98394,370.2005,1266.432,other,OPPS APC,,
HC Eeg W/O Vid by Tech Ea Incr 12-26 Hr Intmt Mntr,PX-74000015,CDM,95709,CPT,740,RC,,,outpatient,,,1585,1109.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,584.98394,,,584.98394,355.8325,1217.28,other,OPPS APC,,
HC Eeg W/O Vid Tech Ea Incr 12-26 Hr Cont R-T Mntr,PX-74000016,CDM,95710,CPT,740,RC,,,outpatient,,,1585,1109.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,584.98394,,,584.98394,355.8325,1217.28,other,OPPS APC,,
HC Electroencephalogram Extend Monitoring 41-60 Min,PX-74000008,CDM,95812,CPT,740,RC,,,outpatient,,,812,568.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,182.294,623.616,other,OPPS APC,,
HC Eeg >1 Hr,PX-74000002,CDM,95813,CPT,740,RC,,,outpatient,,,958,670.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,215.071,735.744,other,OPPS APC,,
HC Eeg-W/Awake & Drowsy Record,PX-74000003,CDM,95816,CPT,740,RC,,,outpatient,,,701,490.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,157.3745,538.368,other,OPPS APC,,
HC Eeg-W/Awake & Asleep Record,PX-74000004,CDM,95819,CPT,740,RC,,,outpatient,,,786,550.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,176.457,603.648,other,OPPS APC,,
HC Eeg-Coma/Sleep Record Only,PX-74000005,CDM,95822,CPT,740,RC,,,outpatient,,,675,472.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,151.5375,518.4,other,OPPS APC,,
HC Eeg Eval Cerebral Death,PX-74000006,CDM,95824,CPT,740,RC,,,outpatient,,,675,472.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,584.98394,,,584.98394,151.5375,829.50194,other,OPPS APC,,
HC Needle Emg Ea Extremity W/Paraspinl Area Limited,PX-92200011,CDM,95885,CPT,922,RC,,,outpatient,,,332,232.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.817,570,other,OPPS APC,,
HC PR Needle Emg Ea Extremity W/Paraspinl Area Limited,PX-96000021,CDM,95885,CPT,960,RC,,,outpatient,,,66,46.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.817,570,other,OPPS APC,,
HC Needle Emg Ea Extremty W/Paraspinl Area Complete,PX-92200012,CDM,95886,CPT,922,RC,,,outpatient,,,332,232.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,30.083,570,other,OPPS APC,,
HC PR Needle Emg Ea Extremty W/Paraspinl Area Complete,PX-96000022,CDM,95886,CPT,960,RC,,,outpatient,,,134,93.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,30.083,570,other,OPPS APC,,
HC Needle Emg Nonextremty Mscles W/Nerve Conduction,PX-92200013,CDM,95887,CPT,922,RC,,,outpatient,,,180,126,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.4295,570,other,OPPS APC,,
HC PR Needle Emg Nonextremty Mscles W/Nerve Conduction,PX-96000023,CDM,95887,CPT,960,RC,,,outpatient,,,91,63.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.4295,570,other,OPPS APC,,
HC Nerve Conduction Studies 1-2 Studies,PX-92200028,CDM,95907,CPT,922,RC,,,outpatient,,,760,532,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,170.484765,,,170.484765,94.4,583.68,other,OPPS APC,,
HC Motor &/Sens 7-8 Nrv Cndj Preconf Eltrode Limb,PX-92200017,CDM,95910,CPT,922,RC,,,outpatient,,,696,487.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,94.4,570,other,OPPS APC,,
HC PR Motor &/Sens 7-8 Nrv Cndj Preconf Eltrode Limb,PX-96000027,CDM,95910,CPT,960,RC,,,outpatient,,,724,506.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,342.57323,,,342.57323,94.4,570,other,OPPS APC,,
HC Ionm Remote/Nearby/>1 Patient in or per Hour,PX-92000015,CDM,95941,CPT,920,RC,,,outpatient,,,879,615.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,197.3355,675.072,other,OPPS APC,,
HC Eeg Digital Anylysis,PX-74000010,CDM,95957,CPT,740,RC,,,outpatient,,,696,487.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,156.252,534.528,other,OPPS APC,,
HC IV Inf- Hydration- 31 Min to 1 Hr,PX-26000001,CDM,96360,CPT,260,RC,,,outpatient,,,334,233.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,233.93401,,,233.93401,74.983,416.02,other,OPPS APC,,
HC IV Inf- Hydration- Each Add'l Hr,PX-26000002,CDM,96361,CPT,260,RC,,,outpatient,,,89,62.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,51.84533,,,51.84533,19.9805,585.854902,other,OPPS APC,,
HC IV Inf- Therapy - Init to 1 Hr (Spec Drug),PX-26000003,CDM,96365,CPT,260,RC,,,outpatient,,,418,292.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,233.93401,,,233.93401,93.841,416.02,other,OPPS APC,,
HC IV Inf- Therapy- Each Add Hr (Spec Drug),PX-26000004,CDM,96366,CPT,260,RC,,,outpatient,,,132,92.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,51.84533,,,51.84533,29.634,585.854902,other,OPPS APC,,
HC IV Infusion- Therap/Proph/Diagnost-Add Infusion-1st Hour,PX-26000005,CDM,96367,CPT,260,RC,,,outpatient,,,183,128.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,76.88596,,,76.88596,41.0835,416.02,other,OPPS APC,,
HC IV Infusion- Therap/Proph/Diagnost-Concurrent Infusion,PX-26000006,CDM,96368,CPT,260,RC,,,outpatient,,,109,76.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,24.4705,416.02,other,OPPS APC,,
HC Therapeutic Prophylactic/Dx Injection Subq/Im,PX-26000007,CDM,96372,CPT,260,RC,,,outpatient,,,162,113.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,76.88596,,,76.88596,16.16,416.02,other,OPPS APC,,
HC Injection-Therap/Proph/Diagnost- Intra-Arterial,PX-26000008,CDM,96373,CPT,260,RC,,,outpatient,,,334,233.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,233.93401,,,233.93401,74.983,416.02,other,OPPS APC,,
HC IV Push- Initial,PX-26000009,CDM,96374,CPT,260,RC,,,outpatient,,,309,216.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,233.93401,,,233.93401,69.3705,416.02,other,OPPS APC,,
HC IV Push- Ea Add Seq- of New Sub Drug,PX-26000010,CDM,96375,CPT,260,RC,,,outpatient,,,105,73.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,51.84533,,,51.84533,23.5725,416.02,other,OPPS APC,,
HC Injection-Therap/Proph/Diagnost- IV Push- Ea Add- Same Drug,PX-26000011,CDM,96376,CPT,260,RC,,,outpatient,,,303,212.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,68.0235,416.02,other,OPPS APC,,
HC Chemother-Non-Hormone Anti-Neopl- Sub-Q/Im,PX-33100001,CDM,96401,CPT,331,RC,,,outpatient,,,222,155.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,76.88596,,,76.88596,49.839,416.02,other,OPPS APC,,
HC Chemother- IV Push- Sngl Drug,PX-33100003,CDM,96409,CPT,331,RC,,,outpatient,,,691,483.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,369.62994,,,369.62994,155.1295,530.688,other,OPPS APC,,
HC Chemother- IV Infusion- 1 Hr,PX-33500001,CDM,96413,CPT,335,RC,,,outpatient,,,724,506.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,369.62994,,,369.62994,162.538,556.032,other,OPPS APC,,
HC Chemother- IV Infusion- Ea Add Hr,PX-33500002,CDM,96415,CPT,335,RC,,,outpatient,,,187,130.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,76.88596,,,76.88596,41.9815,585.854902,other,OPPS APC,,
HC Chemother-Ia Push Technique,PX-33100006,CDM,96420,CPT,331,RC,,,outpatient,,,668,467.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,369.62994,,,369.62994,70.143083,517.481916,other,OPPS APC,,
HC Chemother-Cns-W/Lumbar Puncture,PX-33100005,CDM,96450,CPT,331,RC,,,outpatient,,,657,459.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,369.62994,,,369.62994,147.4965,585.854902,other,OPPS APC,,
HC Ultraviolet Light Therapy,PX-94000005,CDM,96900,CPT,940,RC,,,outpatient,,,530,371,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,43.769555,,,43.769555,34.385146,416.02,other,OPPS APC,,
HC Mechanical Traction Therapy,PX-42100004,CDM,97012,CPT,421,RC,,,outpatient,,,245,171.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14.38,,,14.38,14.38,416.02,fee schedule,,,
HC Electric Stimulation Therapy,PX-42100005,CDM,97014,CPT,421,RC,,,outpatient,,,123,86.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,27.6135,416.02,fee schedule,,,
HC Electrical Stimulation,PX-42100010,CDM,97032,CPT,421,RC,,,outpatient,,,123,86.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14.73,,,14.73,14.73,416.02,fee schedule,,,
HC Electric Current Therapy,PX-42100011,CDM,97033,CPT,421,RC,,,outpatient,,,185,129.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,20.02,,,20.02,20.02,416.02,fee schedule,,,
HC Ultrasound Therapy,PX-42000005,CDM,97035,CPT,420,RC,,,outpatient,,,115,80.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14.44,,,14.44,14.44,416.02,fee schedule,,,
HC Ultrasound Therapy,PX-42100013,CDM,97035,CPT,421,RC,,,outpatient,,,115,80.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14.44,,,14.44,14.44,416.02,fee schedule,,,
HC Therapeutic Exercises,PX-42000006,CDM,97110,CPT,420,RC,,,outpatient,,,197,137.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,30.33,,,30.33,30.33,416.02,fee schedule,,,
HC Therapeutic Exercises,PX-42100014,CDM,97110,CPT,421,RC,,,outpatient,,,197,137.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,30.33,,,30.33,30.33,416.02,fee schedule,,,
HC Neuromusc Reeducat-1+ Areas- Ea 15 Min,PX-42000007,CDM,97112,CPT,420,RC,,,outpatient,,,115,80.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,34.85,,,34.85,25.8175,416.02,fee schedule,,,
HC Neuromusc Reeducat-1+ Areas- Ea 15 Min,PX-42100015,CDM,97112,CPT,421,RC,,,outpatient,,,115,80.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,34.85,,,34.85,25.8175,416.02,fee schedule,,,
HC Gait Training Therapy,PX-42100017,CDM,97116,CPT,421,RC,,,outpatient,,,115,80.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,30.33,,,30.33,25.8175,416.02,fee schedule,,,
HC Manual Ther Tech-1+Regions-Ea 15 Min,PX-42000008,CDM,97140,CPT,420,RC,,,outpatient,,,140,98,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,27.89,,,27.89,27.89,416.02,fee schedule,,,
HC Manual Ther Tech-1+Regions-Ea 15 Min,PX-42100018,CDM,97140,CPT,421,RC,,,outpatient,,,140,98,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,27.89,,,27.89,27.89,416.02,fee schedule,,,
HC Group Therapeutic Procedures,PX-42000009,CDM,97150,CPT,420,RC,,,outpatient,,,130,91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,18.56,,,18.56,18.56,416.02,fee schedule,,,
HC Group Therapeutic Procedures,PX-42300001,CDM,97150,CPT,423,RC,,,outpatient,,,130,91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,18.56,,,18.56,18.56,416.02,fee schedule,,,
HC Pt Eval Low Complex,PX-42400003,CDM,97161,CPT,424,RC,,,outpatient,,,260,182,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,103.7,,,103.7,58.37,416.02,fee schedule,,,
HC Pt Eval Mod Complex,PX-42400004,CDM,97162,CPT,424,RC,,,outpatient,,,260,182,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,103.7,,,103.7,58.37,416.02,fee schedule,,,
HC Pt Eval High Complex,PX-42400005,CDM,97163,CPT,424,RC,,,outpatient,,,260,182,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,103.7,,,103.7,58.37,416.02,fee schedule,,,
HC Pt Re-Eval Est Plan Care,PX-42400006,CDM,97164,CPT,424,RC,,,outpatient,,,231,161.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,72.14,,,72.14,51.8595,416.02,fee schedule,,,
HC Therapeut Actvity Direct Pt Contact Each 15 Min,PX-42100019,CDM,97530,CPT,421,RC,,,outpatient,,,115,80.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,38.12,,,38.12,25.8175,416.02,fee schedule,,,
HC Self-Care/Home Mgmt Training Each 15 Minutes,PX-42100020,CDM,97535,CPT,421,RC,,,outpatient,,,115,80.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,33.86,,,33.86,25.8175,416.02,fee schedule,,,
HC Orthotic Mgmt and Training- Each 15 Min,PX-42100027,CDM,97760,CPT,421,RC,,,outpatient,,,115,80.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,49.68,,,49.68,25.8175,416.02,fee schedule,,,
HC Prosthetic Training- Each 15 Min,PX-42100028,CDM,97761,CPT,421,RC,,,outpatient,,,104,72.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,43.33,,,43.33,23.348,416.02,fee schedule,,,
HC Med Nutr Ther- 1st- Indiv- Ea 15 Min,PX-94200006,CDM,97802,CPT,942,RC,,,outpatient,,,182,127.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,34.45,,,34.45,34.45,416.02,fee schedule,,,
HC Med Nutr Ther- Subsq- Indiv- Ea 15 Min,PX-94200007,CDM,97803,CPT,942,RC,,,outpatient,,,106,74.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,29.36,,,29.36,23.797,416.02,fee schedule,,,
HC Med Nutr Ther- Group- Ea 30 Min,PX-94200008,CDM,97804,CPT,942,RC,,,outpatient,,,52,36.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16.66,,,16.66,11.674,416.02,fee schedule,,,
HC Mod Sed Same Phys/Qhp <5 Yrs,PX-37000019,CDM,99151,CPT,370,RC,,,outpatient,,,230,161,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.635,416.02,other,OPPS APC,,
HC Mod Sed Same Phys/Qhp 5/>Yrs,PX-37000020,CDM,99152,CPT,370,RC,,,outpatient,,,240,168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,53.88,416.02,other,OPPS APC,,
HC Mod Sed Same Phys/Qhp Ea,PX-37000021,CDM,99153,CPT,370,RC,,,outpatient,,,240,168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,53.88,416.02,other,OPPS APC,,
HC Mod Sed Oth Phys/Qhp <5 Yrs,PX-37000022,CDM,99155,CPT,370,RC,,,outpatient,,,361,252.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,81.0445,416.02,other,OPPS APC,,
HC Mod Sed Oth Phys/Qhp 5/>Yrs,PX-37000023,CDM,99156,CPT,370,RC,,,outpatient,,,240,168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,53.88,416.02,other,OPPS APC,,
HC Mod Sed Other Phys/Qhp Ea,PX-37000024,CDM,99157,CPT,370,RC,,,outpatient,,,330,231,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,74.085,416.02,other,OPPS APC,,
HC Phlebotomy,PX-94000006,CDM,99195,CPT,940,RC,,,outpatient,,,312,218.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.418805,,,139.418805,70.044,416.02,other,OPPS APC,,
HC Office/Outpatient New Sf Mdm 15-29 Minutes,PX-51000025,CDM,99202,CPT,761,RC,,,outpatient,,,387,270.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,82.56,416.02,other,OPPS APC,,
HC Office/Outpatient New Low Mdm 30-44 Minutes,PX-51000026,CDM,99203,CPT,761,RC,,,outpatient,,,573,401.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,126.37,473.871,other,OPPS APC,,
HC Office/Outpatient New Moderate Mdm 45-59 Minutes,PX-51000027,CDM,99204,CPT,761,RC,,,outpatient,,,838,586.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,179.35,693.026,other,OPPS APC,,
HC Office/Outpatient New High Mdm 60-74 Minutes,PX-51000028,CDM,99205,CPT,510,RC,,,outpatient,,,1192,834.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,146.954008,985.784,other,OPPS APC,,
HC Office/Outpatient Est Pt May Not Req Phys/Qhp,PX-51000029,CDM,99211,CPT,761,RC,,,outpatient,,,287,200.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,18.1184,416.02,other,OPPS APC,,
HC Office/Outpatient Est Pt May Not Req Phys/Qhp,PX-76100002,CDM,99211,CPT,761,RC,,,outpatient,,,287,200.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,18.1184,416.02,other,OPPS APC,,
HC Office/Outpatient Est Pt May Not Req Phys/Qhp,PX-94200014,CDM,99211,CPT,761,RC,,,outpatient,,,287,200.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,18.1184,416.02,other,OPPS APC,,
HC Office/Outpatient Established Sf Mdm 10-19 Min,PX-51000030,CDM,99212,CPT,761,RC,,,outpatient,,,394,275.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,50.2428,416.02,other,OPPS APC,,
HC Office/Outpatient Established Sf Mdm 10-19 Min,PX-94200015,CDM,99212,CPT,761,RC,,,outpatient,,,394,275.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,50.2428,416.02,other,OPPS APC,,
HC PR Office/Outpatient Established Sf Mdm 10-19 Min,PX-98800012,CDM,99212,CPT,761,RC,,,outpatient,,,373,261.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,50.2428,416.02,other,OPPS APC,,
HC Office/Outpatient Established Low Mdm 20-29 Min,PX-51000031,CDM,99213,CPT,761,RC,,,outpatient,,,431,301.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,90.68,416.02,other,OPPS APC,,
HC Office/Outpatient Established Low Mdm 20-29 Min,PX-94200016,CDM,99213,CPT,761,RC,,,outpatient,,,431,301.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,90.68,416.02,other,OPPS APC,,
HC Office/Outpatient Established Mod Mdm 30-39 Min,PX-51000032,CDM,99214,CPT,761,RC,,,outpatient,,,467,326.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,104.8415,416.02,other,OPPS APC,,
HC Office/Outpatient Established Mod Mdm 30-39 Min,PX-94200020,CDM,99214,CPT,761,RC,,,outpatient,,,467,326.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,104.8415,416.02,other,OPPS APC,,
HC Office/Outpatient Established High Mdm 40-54 Min,PX-51000033,CDM,99215,CPT,761,RC,,,outpatient,,,829,580.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,169.273,685.583,other,OPPS APC,,
HC Office/Outpatient Established High Mdm 40-54 Min,PX-94200021,CDM,99215,CPT,761,RC,,,outpatient,,,754,527.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,169.273,685.583,other,OPPS APC,,
HC Critical Care Ill/Injured Patient Init 30-74 Min,PX-76000001,CDM,99291,CPT,760,RC,,,outpatient,,,3157,2209.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,968.49734,,,968.49734,318.748996,2424.576,other,OPPS APC,,
HC PR Critical Care Ill/Injured Patient Init 30-74 Min,PX-96000052,CDM,99291,CPT,960,RC,,,outpatient,,,3157,2209.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,968.49734,,,968.49734,318.748996,2424.576,other,OPPS APC,,
HC Critical Care Ill/Injured Patient Addl 30 Min,PX-76000002,CDM,99292,CPT,760,RC,,,outpatient,,,911,637.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,204.5195,699.648,other,OPPS APC,,
HC PR Critical Care Ill/Injured Patient Addl 30 Min,PX-96000053,CDM,99292,CPT,960,RC,,,outpatient,,,911,637.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,204.5195,699.648,other,OPPS APC,,
HC Tobacco Use Cessation Intermediate 3-10 Minutes,PX-94200022,CDM,99406,CPT,942,RC,,,outpatient,,,214,149.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,31.31797,,,31.31797,31.31797,416.02,other,OPPS APC,,
HC Tobacco Use Cessation Intensive >10 Minutes,PX-94200025,CDM,99407,CPT,942,RC,,,outpatient,,,214,149.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,31.31797,,,31.31797,31.31797,416.02,other,OPPS APC,,
HC Arterial Stent- Xcranial Vertebral/ Thoracic Carotid- 1st Vessel,PX-36900026,CDM,0075T,CPT,369,RC,,,outpatient,,,774,541.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,173.763,2998,,,,
HC Arterial Stent- Xcranial Vertebral/ Thoracic Carotid- Ea Add,PX-36900027,CDM,0076T,CPT,369,RC,,,outpatient,,,161,112.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,36.1445,2998,,,,
HC Transluminal Peripheral Atherectomy- Renal Artery,PX-36900028,CDM,0234T,CPT,369,RC,,,outpatient,,,26415,18490.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12006.91336,,,12006.91336,399.86,22389.354,other,OPPS APC,,
HC Transluminal Peripheral Atherectomy- Visceral Artery- Each,PX-36900029,CDM,0235T,CPT,369,RC,,,outpatient,,,735,514.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,165.0075,2998,,,,
BONE BX OSTEO SITE 11G 10CM -,SUP-G36211,CDM,A4215,HCPCS,272,RC,,,outpatient,,,1924.08,1346.856,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,1477.69344,other,OPPS APC,,
CATHETER COUDE 24FR 5CC -,SUP-1524C,CDM,A4340,HCPCS,270,RC,,,outpatient,,,45.92,32.144,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.30904,416.02,other,OPPS APC,,
SILICONE CATHETER FOLEY 24FR 5CC -,SUP-8887605247,CDM,A4344,HCPCS,270,RC,,,outpatient,,,17.15,12.005,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.850175,416.02,other,OPPS APC,,
CATH FOLEY 18FR 5ML BLN 3W DOVER LTX 16IN LUB -,SUP-2718,CDM,A4346,HCPCS,272,RC,,,outpatient,,,39.16,27.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.025285,416.02,other,OPPS APC,,
CATHETER FOLEY 22FR 30CC 3-WAY -,SUP-2822,CDM,A4346,HCPCS,272,RC,,,outpatient,,,41.84,29.288,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.025285,416.02,other,OPPS APC,,
CATHETER FOLEY 24FR 30CC 3-WAY -,SUP-2824,CDM,A4346,HCPCS,272,RC,,,outpatient,,,17.93,12.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.025285,416.02,other,OPPS APC,,
CATH FOLEY SIL 3W 30CC 22FR -,SUP-8887665225,CDM,A4346,HCPCS,272,RC,,,outpatient,,,41.84,29.288,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.025285,416.02,other,OPPS APC,,
SLING ORTHO ARM SM -,SUP-8023-01,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.98585,416.02,other,OPPS APC,,
SLING DEROYAL ARM MEDIUM -,SUP-8023-02,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.98585,416.02,other,OPPS APC,,
SLING DEROYAL ARM LARGE -,SUP-8023-03,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.98585,416.02,other,OPPS APC,,
SLING ORTHO ARM XL -,SUP-8023-04,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.98585,416.02,other,OPPS APC,,
SLING ARM MED STRP -,SUP-TX9901-43,CDM,A4565,HCPCS,270,RC,,,outpatient,,,13.3,9.31,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.98585,416.02,other,OPPS APC,,
HC Tissue Marker,PX-27800092,CDM,A4648,HCPCS,278,RC,,,outpatient,,,418,292.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.325665,1791.14496,other,OPPS APC,,
NEEDLE BRST LOC 20GAX3CM CM MRKNG STD MRKNG CANN ON WIRE -,SUP-253030,CDM,A4648,HCPCS,278,RC,,,outpatient,,,271.33,189.931,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.325665,1791.14496,other,OPPS APC,,
MARKER BRSTBIO 3MM 17GA INCONEL 625 ULTRA CLP -,SUP-862017,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.325665,1791.14496,other,OPPS APC,,
MARKER BRSTBIO 17GA TI ULTRA CLP II US -,SUP-863017,CDM,A4648,HCPCS,278,RC,,,outpatient,,,1097.2,768.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.325665,1791.14496,other,OPPS APC,,
INSTRUMENT BX 18GA/17GA/INTRO ACHIEVE AUTO 11CM SFT TIS -,SUP-CA1811,CDM,A4648,HCPCS,278,RC,,,outpatient,,,497.49,348.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.325665,1791.14496,other,OPPS APC,,
IDENTIFIER BIOPSY SITE FOR CELERO 12 THIRD SHAPE -,SUP-CELEROMARK-2S,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.325665,1791.14496,other,OPPS APC,,
NEEDLE BRST LOC KOPANS 20GAX5CM BVL CUT TIP MOD REINF TIP -,SUP-DKBL-20-5.0-A,CDM,A4648,HCPCS,278,RC,,,outpatient,,,175.17,122.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.325665,1791.14496,other,OPPS APC,,
NEEDLE BRST LOC KOPANS 20GAX7CM BVL CUT TIP MOD REINF TIP -,SUP-DKBL-20-7.0-A,CDM,A4648,HCPCS,278,RC,,,outpatient,,,175.17,122.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.325665,1791.14496,other,OPPS APC,,
NEEDLE BRST LOC KOPANS 20GAX9CM BVL CUT TIP MOD REINF TIP -,SUP-DKBL-20-9.0-A,CDM,A4648,HCPCS,278,RC,,,outpatient,,,175.17,122.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.325665,1791.14496,other,OPPS APC,,
NEEDLE 18GA X 20CM FUSIONCOIL WITH 1 X 5MM FIDUCIAL MARKER -,SUP-MTCTXFC1051820,CDM,A4648,HCPCS,278,RC,,,outpatient,,,752.72,526.904,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.325665,1791.14496,other,OPPS APC,,
MARKERS CIVCO FIDUCIAL 30CM -,SUP-MTNW887835,CDM,A4648,HCPCS,278,RC,,,outpatient,,,1129.01,790.307,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.325665,1791.14496,other,OPPS APC,,
MARKER BRSTBIO TI SCUR MRK MINI CORK -,SUP-SMARK-CELERO,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.325665,1791.14496,other,OPPS APC,,
MARKER BRSTBIO TI SECURMARK TOP HAT SHP -,SUP-SMARK-CELERO-2S,CDM,A4648,HCPCS,278,RC,,,outpatient,,,481.1,336.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.325665,1791.14496,other,OPPS APC,,
MARKER BRSTBIO TI SCUR MRK MINI CORK -,SUP-SMARK-EVIVA-13,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.325665,1791.14496,other,OPPS APC,,
MARKER BRSTBIO TI SECURMARK -,SUP-SMARK-EVIVA-2S-13,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.325665,1791.14496,other,OPPS APC,,
SCOUT 5CM DELIVERY NEEDLE AND REFLECTOR SSR05-01 -,SUP-SSR05-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.325665,1791.14496,other,OPPS APC,,
SCOUT 10CM DELIVERY NEEDLE AND REFLECTOR -,SUP-SSR10-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.325665,1791.14496,other,OPPS APC,,
SCOUT 7.5CM DELIVERY NEEDLE AND REFLECTOR -,SUP-SSR75-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.325665,1791.14496,other,OPPS APC,,
REFLECTOR AND DELIVERY SYSTEM SINGLE HAND 16G 7.5 CM -,SUP-SSR75S-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.325665,1791.14496,other,OPPS APC,,
IDENTIFIER BIOPSY SITE ATEC TRIMARK INTRODUCER SHEATH MARKER -,SUP-TRIMARK TD-2S-13-MR,CDM,A4648,HCPCS,278,RC,,,outpatient,,,371.98,260.386,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.325665,1791.14496,other,OPPS APC,,
EXPANDER BRST 500ML BIOCELL RND NATRLL 13CMX13.5CM 5.7CM -,SUP-133FV-13,CDM,A4649,HCPCS,272,RC,,,outpatient,,,4986.7,3490.69,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC,,
EXPANDER TISSUE SMOOTH 600CC NATRELLE FULL HEIGHT -,SUP-133S-FV-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC,,
EXPANDER TISSUE NATRELLE SMOOTH 650CC -,SUP-133S-FX-14-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC,,
NATRELLE INSPIRA TISSUE EXPANDER 800CC -,SUP-133S-FX-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC,,
TISSUE EXPANDER 400CC NATRELLE SMOOTH MOD HEIGHT EXTRA PROT -,SUP-133S-MX-12-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC,,
TISSUE EXPANDER 500CC NATRELLE SMOOTH MOD HEIGHT EXTRA PROT -,SUP-133S-MX-13-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC,,
TISSUE EXPANDER 600CC NATRELLE -,SUP-133S-MX-14-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC,,
EXPANDER TISSUE NATRELLE SMOOTH 700CC -,SUP-133S-MX-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC,,
EXPANDER TISSUE SMOOTH 400CC SHORT HT EXTRA PROJ NATRELLE -,SUP-133S-SX-13-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5903.4,4132.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC,,
EXPANDER TISSUE SMOOTH 650CC HEIGHT EXTRA PROJ NATRELLE -,SUP-133S-SX-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC,,
EXPANDER TISS 250ML SHRT H -,SUP-133SV-12,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC,,
EXPANDER BRST UNIV NATRLL -,SUP-30-000003,CDM,A4649,HCPCS,272,RC,,,outpatient,,,63.19,44.233,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC,,
EXPANDER BREAST TISSUE CPX4 450CC -,SUP-350-9213,CDM,A4649,HCPCS,272,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC,,
650CC CPX 4 BREAST TISSUE EXPANDER W/SUTURE TABS MED. HEIGHT -,SUP-350-9215,CDM,A4649,HCPCS,272,RC,,,outpatient,,,7745.3,5421.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC,,
EXPANDER TISSUE SMOOTH 800CC CPX 4 W/SUTURE TABS MED HT -,SUP-350-9216,CDM,A4649,HCPCS,272,RC,,,outpatient,,,7745.3,5421.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC,,
EXPANDER BRST 850ML BIOCELL RND NATRLL 16CMX16.5CM 6.8CM -,SUP-37-133800,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5835.5,4084.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC,,
EXPANDER BRST 600ML BIOCELL RND NATRLL 14CMX14.5CM 6.2CM -,SUP-67-133FV14,CDM,A4649,HCPCS,272,RC,,,outpatient,,,4986.7,3490.69,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC,,
SIZER IMPLANT NATRELLE INSPIRA 520CC FULL PROFILE -,SUP-MSZ-F520,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC,,
SIZER IMPLANT NATRELLE INSPIRA 560CC FULL PROFILE -,SUP-MSZ-F560,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC,,
SIZER IMPLANT NATRELLE INSPIRA 605CC FULL PROFILE -,SUP-MSZ-F605,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC,,
SIZER IMPLANT NATRELLE INSPIRA 695CC FULL PROFILE -,SUP-MSZ-F695,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC,,
SIZER IMPLANT NATRELLE INSPIRA 770CC FULL PROFILE -,SUP-MSZ-F770,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC,,
SIZER IMPLANT NATRELLE INSPIRA 275CC MODERATE PROFILE -,SUP-MSZ-M275,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC,,
SIZER IMPLANT NATRELLE INSPIRA 560CC MODERATE PROFILE -,SUP-MSZ-M560,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC,,
SIZER IMPLANT NATRELLE INSPIRA 600CC MODERATE PROFILE -,SUP-MSZ-M600,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC,,
SIZER IMPLANT NATRELLE INSPIRA 525CC EXTRA FULL PROFILE -,SUP-MSZ-X525,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC,,
SIZER IMPLANT NATRELLE INSPIRA 545CC EXTRA FULL PROFILE -,SUP-MSZ-X545,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC,,
SIZER IMPLANT NATRELLE INSPIRA 580CC EXTRA FULL PROFILE -,SUP-MSZ-X580,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC,,
SIZER IMPLANT NATRELLE INSPIRA 750CC XFULL PROFILE -,SUP-MSZ-X750,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC,,
SIZER IMPLANT NATRELLE INSPIRA 800CC EXTRA FULL PROFILE -,SUP-MSZ-X800,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC,,
SIZER IMPLANT NATRELLE INSPIRA 745CC FULL PROFILE -,SUP-SCF-745,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.186155,5948.3904,other,OPPS APC,,
DRESSING WND 2X2IN PURACOL + HI GEL INTGRTY COLL LF -,SUP-MSC8622EP,CDM,A6021,HCPCS,270,RC,,,outpatient,,,32.97,23.079,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,7.401765,416.02,other,OPPS APC,,
DRESSING BURN PURACOL PLUS 2X2 AG SILVER  COLLAGEN -,SUP-MSC8722EP,CDM,A6021,HCPCS,270,RC,,,outpatient,,,43.41,30.387,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,7.401765,416.02,other,OPPS APC,,
SHEETING SILASTIC 4.625X5.625IN SIL GEL HYPAL SLFADH LPRO -,SUP-NC15462,CDM,A6025,HCPCS,272,RC,,,outpatient,,,180.14,126.098,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,11.99,416.02,other,OPPS APC,,
DRESSING KALTOSTAT CA ALGIN 3X4.75IN ABSB -,SUP-168212,CDM,A6196,HCPCS,270,RC,,,outpatient,,,14.44,10.108,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.708445,416.02,other,OPPS APC,,
DRESSING XTRA HYDROFIBER AQUACEL 2X2IN -,SUP-420671,CDM,A6196,HCPCS,270,RC,,,outpatient,,,8.66,6.062,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.708445,416.02,other,OPPS APC,,
DRESSING ALGIN 2X2IN SQ NADH HI ABSB F/MOD TO HVY DRN -,SUP-MSC7022EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,7.61,5.327,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.708445,416.02,other,OPPS APC,,
DRESSING MAXORB 4X4IN EXTRA -,SUP-MSC7044EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,14.23,9.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.708445,416.02,other,OPPS APC,,
DRESSING WND 1X12IN FLT ROPE HI ABSORBENT1 F/WND MAXORB XTR -,SUP-MSC7112EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,20.07,14.049,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.708445,416.02,other,OPPS APC,,
DRESSING MAXORB AG 2X2IN ALGIN SILVER -,SUP-MSC9422EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,18.37,12.859,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.708445,416.02,other,OPPS APC,,
DRESSING AQUACEL 4 X 5 -,SUP-420674,CDM,A6197,HCPCS,270,RC,,,outpatient,,,18.13,12.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.070185,416.02,other,OPPS APC,,
DRESSING GERMC AQUACEL AG EXTRA 4X4IN SLVR STRL -,SUP-420674,CDM,A6197,HCPCS,270,RC,,,outpatient,,,18.13,12.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.070185,416.02,other,OPPS APC,,
DRESSING AQUACEL AG  2X2IN SQ HYDROFIBER SILVER -,SUP-422297,CDM,A6197,HCPCS,270,RC,,,outpatient,,,27.75,19.425,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.070185,416.02,other,OPPS APC,,
DRESSING AQUACEL AG 6X6IN HYDROFIBER -,SUP-422298,CDM,A6197,HCPCS,270,RC,,,outpatient,,,112.45,78.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.070185,416.02,other,OPPS APC,,
DRESSING ALGINATE SILVER 4X4.75IN CA ANTMIC NADH NWVN FLT -,SUP-MSC9445EP,CDM,A6197,HCPCS,270,RC,,,outpatient,,,34.27,23.989,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.070185,416.02,other,OPPS APC,,
DRESSING MAXORB EXTRA AG 4X4 SILVER -,SUP-MSC9445EP,CDM,A6197,HCPCS,270,RC,,,outpatient,,,34.72,24.304,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.070185,416.02,other,OPPS APC,,
DRESSING ALGIN AQUACL HYDROFIBER 0.75X18IN NADH CONFRM NWVN -,SUP-403770,CDM,A6199,HCPCS,270,RC,,,outpatient,,,19.4,13.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.3553,416.02,other,OPPS APC,,
DRESSING ALGIN AQUACL HYDROFIBER 0.75X18IN NADH CONFRM NWVN -,SUP-403770,CDM,A6199,HCPCS,270,RC,,,outpatient,,,22.99,16.093,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.3553,416.02,other,OPPS APC,,
DRESSING AQUACEL AG ROPE .75X18 IN -,SUP-422300,CDM,A6199,HCPCS,270,RC,,,outpatient,,,59.94,41.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.3553,416.02,other,OPPS APC,,
DRESSING SILVERLON 4 X 10 -,SUP-ID-410,CDM,A6206,HCPCS,272,RC,,,outpatient,,,169.8,118.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,5.23,416.02,other,OPPS APC,,
DRESSING ACTICOAT 4X5 -,SUP-66800405,CDM,A6207,HCPCS,272,RC,,,outpatient,,,81.2,56.84,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.98576,416.02,other,OPPS APC,,
DRESSING ACTICOAT 4X4 -,SUP-66800406,CDM,A6207,HCPCS,272,RC,,,outpatient,,,44.48,31.136,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.98576,416.02,other,OPPS APC,,
DRESSING ALLEVYN NONADHESIVE 2X2 NO BORDER -,SUP-66027643,CDM,A6209,HCPCS,272,RC,,,outpatient,,,14.63,10.241,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.94544,416.02,other,OPPS APC,,
DRESSING FOAM 4x4 BORDERLESS -,SUP-66927637,CDM,A6209,HCPCS,272,RC,,,outpatient,,,13.12,9.184,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.94544,416.02,other,OPPS APC,,
"DRESSING HYDROFERA 2.5"" X 2.5"" -",SUP-HLST-HBRT2525,CDM,A6209,HCPCS,272,RC,,,outpatient,,,268.12,187.684,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.94544,416.02,other,OPPS APC,,
HYDROFERA BLUE READY TRANSFER 2.5 X 2.5 -,SUP-HLST-HRBS2214,CDM,A6209,HCPCS,272,RC,,,outpatient,,,26.78,18.746,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.94544,416.02,other,OPPS APC,,
HYDROFERA BLUE READY TRANSFER 4 X 5 -,SUP-HBRS4520,CDM,A6210,HCPCS,272,RC,,,outpatient,,,40.63,28.441,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.121435,416.02,other,OPPS APC,,
HYDROFERA BLUE READY TRANSFER 4 X 5 -,SUP-HLST-HRBT4050,CDM,A6210,HCPCS,272,RC,,,outpatient,,,416.5,291.55,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.121435,416.02,other,OPPS APC,,
HYDROFERA BLUE READY TRANSFER 8 X 8 -,SUP-HLST-HRBS8820,CDM,A6211,HCPCS,272,RC,,,outpatient,,,92.17,64.519,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.692165,416.02,other,OPPS APC,,
DRESSING OPTIFOAM AG 3.5 X 6 -,SUP-412010,CDM,A6212,HCPCS,270,RC,,,outpatient,,,109.06,76.342,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.79151,416.02,other,OPPS APC,,
DRESSING OPTIFOAM AG 3.5 X 10 -,SUP-412011,CDM,A6212,HCPCS,270,RC,,,outpatient,,,139.34,97.538,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.79151,416.02,other,OPPS APC,,
BANDAGE ADH 4X4IN ALLEVYN -,SUP-66800270,CDM,A6212,HCPCS,270,RC,,,outpatient,,,12.57,8.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.79151,416.02,other,OPPS APC,,
BANDAGE ADH 4X4IN ALLEVYN -,SUP-66800270,CDM,A6212,HCPCS,270,RC,,,outpatient,,,18.72,13.104,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.79151,416.02,other,OPPS APC,,
"DRESSING FOAMING ALLEYN GENTLE BORDER LITE 5.5CM X 12CM"" -",SUP-66800836,CDM,A6212,HCPCS,270,RC,,,outpatient,,,8.42,5.894,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.79151,416.02,other,OPPS APC,,
DRESSING FOAM VERSATILE 2 1/8IN X 4 3/4IN SILICONE ADHESIVE -,SUP-66800836,CDM,A6212,HCPCS,270,RC,,,outpatient,,,7.98,5.586,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.79151,416.02,other,OPPS APC,,
DRESSING ALLEVYN LIFE 5 1/16IN x 5 1/16IN -,SUP-66801068,CDM,A6212,HCPCS,270,RC,,,outpatient,,,14.24,9.968,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.79151,416.02,other,OPPS APC,,
DRESSING OPTIFOAM AG 3.5 X 14 -,SUP-412012,CDM,A6213,HCPCS,270,RC,,,outpatient,,,148.97,104.279,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.206745,416.02,other,OPPS APC,,
DRESSING FOAM SACRUM 9.4 X 8.4CM LRG -,SUP-423270,CDM,A6213,HCPCS,270,RC,,,outpatient,,,41.01,28.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.206745,416.02,other,OPPS APC,,
DRESSING MEPORE 2.5 X 3 -,SUP-670800,CDM,A6219,HCPCS,270,RC,,,outpatient,,,0.55,0.385,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.04041,416.02,other,OPPS APC,,
TOWEL ABSORBENT STER 7550 -,SUP-7550,CDM,A6219,HCPCS,270,RC,,,outpatient,,,4,2.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.04041,416.02,other,OPPS APC,,
DRESSING WND 2X2IN ADH ISLND NWVN BRDR WTRPRF BK STRL SQ LF -,SUP-MSC3222,CDM,A6219,HCPCS,270,RC,,,outpatient,,,0.18,0.126,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.04041,416.02,other,OPPS APC,,
DRESSING BORDERED 4X4IN ADH ISLAND NWVN -,SUP-MSC3244,CDM,A6219,HCPCS,270,RC,,,outpatient,,,2.39,1.673,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.04041,416.02,other,OPPS APC,,
DRESSING PETRO ADPTC 3X3IN OIL EMUL NADH GZE CELLU-ACET -,SUP-2012,CDM,A6222,HCPCS,272,RC,,,outpatient,,,14.03,9.821,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.52533,416.02,other,OPPS APC,,
DRESSING ADAPTIC 3INX3IN 7.6CMx7.6CM NON-ADHERING -,SUP-2012,CDM,A6222,HCPCS,272,RC,,,outpatient,,,14.03,9.821,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.52533,416.02,other,OPPS APC,,
DRESSING XEROFORM 1X8 -,SUP-212,CDM,A6222,HCPCS,272,RC,,,outpatient,,,3.03,2.121,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.52533,416.02,other,OPPS APC,,
DRESSING XEROFORM 2 X 2 -,SUP-214,CDM,A6222,HCPCS,272,RC,,,outpatient,,,2.34,1.638,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.52533,416.02,other,OPPS APC,,
DRESSING MESALT RIBBON 3/4x39 IN DEBRIDE 0.75x39 IN ABSB -,SUP-285299,CDM,A6222,HCPCS,272,RC,,,outpatient,,,10.93,7.651,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.52533,416.02,other,OPPS APC,,
DRESSING MESALT 3x3 IN GAUZE -,SUP-285780,CDM,A6222,HCPCS,272,RC,,,outpatient,,,4.67,3.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.52533,416.02,other,OPPS APC,,
DRESSING WND 1.6 X 2.4IN CUTIMED SORBACT SWB PRIM STRL LF -,SUP-7216412,CDM,A6222,HCPCS,272,RC,,,outpatient,,,21.89,15.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.52533,416.02,other,OPPS APC,,
DRESSING ADAPTIC 3X8 -,SUP-2013,CDM,A6223,HCPCS,272,RC,,,outpatient,,,4.43,3.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.698195,416.02,other,OPPS APC,,
DRESSING PETRO VASELINE 1X36IN STRL 1-PLY IMPREG NADH LPRO -,SUP-205-12-A,CDM,A6223,HCPCS,272,RC,,,outpatient,,,3.11,2.177,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.698195,416.02,other,OPPS APC,,
DRESSING XEROFORM 5IN X 9IN -,SUP-213,CDM,A6223,HCPCS,272,RC,,,outpatient,,,4.32,3.024,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.698195,416.02,other,OPPS APC,,
DRESSING XEROFORM 5IN X 9IN -,SUP-213,CDM,A6223,HCPCS,272,RC,,,outpatient,,,4.32,3.024,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.698195,416.02,other,OPPS APC,,
DRESSING PETRO VASELINE 1X36IN OCL NADH STRIP STRL IMPREG -,SUP-8884412600,CDM,A6223,HCPCS,272,RC,,,outpatient,,,3.15,2.205,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.698195,416.02,other,OPPS APC,,
GAUZE VASELINE 1 X 36 -,SUP-8884412600,CDM,A6223,HCPCS,272,RC,,,outpatient,,,3.15,2.205,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.698195,416.02,other,OPPS APC,,
DRESSING ADAPTIC 3X8 -,SUP-JOHN-2013,CDM,A6223,HCPCS,272,RC,,,outpatient,,,26.74,18.718,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.698195,416.02,other,OPPS APC,,
GAUZE VASELINE 3IN X 18IN -,SUP-207-12-A,CDM,A6224,HCPCS,272,RC,,,outpatient,,,5.13,3.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.801465,416.02,other,OPPS APC,,
GAUZE VASELINE 3IN X 18IN -,SUP-207-12-A,CDM,A6224,HCPCS,272,RC,,,outpatient,,,5.13,3.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.801465,416.02,other,OPPS APC,,
"GAUZE VASELINE 3"" X 36"" -",SUP-425600,CDM,A6224,HCPCS,272,RC,,,outpatient,,,7.26,5.082,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.801465,416.02,other,OPPS APC,,
GAUZE PETRO 3X36IN VASELINE -,SUP-8884415600,CDM,A6224,HCPCS,272,RC,,,outpatient,,,3.57,2.499,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.801465,416.02,other,OPPS APC,,
GAUZE VASELINE 1/2 X 72 -,SUP-8884421600,CDM,A6224,HCPCS,272,RC,,,outpatient,,,5.95,4.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.801465,416.02,other,OPPS APC,,
DRESSING HYDROCOLLOID DUODERM 2X4IN XTRA THIN -,SUP-187900,CDM,A6234,HCPCS,272,RC,,,outpatient,,,4.07,2.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.913715,416.02,other,OPPS APC,,
DRESSING HYDROCOLLOID DUODERM 4X4IN XTRA THIN -,SUP-187955,CDM,A6234,HCPCS,272,RC,,,outpatient,,,4.49,3.143,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.913715,416.02,other,OPPS APC,,
DRESSING WND XTHN 4X4IN DDRM STRL CONFRM NADH HYDRCL SQ -,SUP-187955,CDM,A6234,HCPCS,272,RC,,,outpatient,,,6.73,4.711,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.913715,416.02,other,OPPS APC,,
DRESSING DUODERM EXTRA THIN 4X4 -,SUP-187955,CDM,A6234,HCPCS,272,RC,,,outpatient,,,6.71,4.697,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.913715,416.02,other,OPPS APC,,
DRESSING HYDRCL XTHN 4X6IN DDRM CGF STRL XTHN CONFRM NADH -,SUP-187902,CDM,A6235,HCPCS,270,RC,,,outpatient,,,11.92,8.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.67604,416.02,other,OPPS APC,,
DRESSING DUODERM 4 X 4 THICK -,SUP-187660,CDM,A6237,HCPCS,272,RC,,,outpatient,,,9.64,6.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,416.02,other,OPPS APC,,
DRESSING HYDROCOLLOID DUODERM 4X4IN -,SUP-403326,CDM,A6237,HCPCS,272,RC,,,outpatient,,,7.39,5.173,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,416.02,other,OPPS APC,,
DRESSING WND 4X4IN DDRM SGNL STRL CONFRM ADH ABSB WTRPRF -,SUP-403326,CDM,A6237,HCPCS,272,RC,,,outpatient,,,11.11,7.777,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,416.02,other,OPPS APC,,
DRESSING HYDRCL 6X7IN DUADERM CGF STRL -,SUP-187974,CDM,A6238,HCPCS,270,RC,,,outpatient,,,42.72,29.904,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.600005,416.02,other,OPPS APC,,
DRESSING WND 14X14CM DDRM SGNL STRL CONFRM ADH ABSB WTRPRF -,SUP-403327,CDM,A6238,HCPCS,270,RC,,,outpatient,,,20.49,14.343,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.600005,416.02,other,OPPS APC,,
DRESSING WND 15X18CM DDRM SGNL STRL CONFRM ADH ABSB WTRPRF -,SUP-403332,CDM,A6238,HCPCS,270,RC,,,outpatient,,,21.79,15.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.600005,416.02,other,OPPS APC,,
CREAM TRIAD HYDROPHILLIC WOUND DRESSING -,SUP-1964-A,CDM,A6240,HCPCS,270,RC,,,outpatient,,,31.57,22.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,7.087465,416.02,other,OPPS APC,,
DRESSING HYDRCL 1.6IN TENDRWT STRL ACT CVTY LF -,SUP-MSC8401,CDM,A6242,HCPCS,270,RC,,,outpatient,,,16.34,11.438,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.66833,416.02,other,OPPS APC,,
DRESSING DEBRIDE 3X3IN PLYACRL PLYMR GL CVTY PAD TENDRWT ACT -,SUP-MSC8403Z,CDM,A6242,HCPCS,270,RC,,,outpatient,,,22.7,15.89,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.66833,416.02,other,OPPS APC,,
DRESSING GEL 30GM DDRM HYDACTV NADH FIL HYDRCL HYDACTV -,SUP-187987,CDM,A6248,HCPCS,272,RC,,,outpatient,,,13.91,9.737,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.122795,416.02,other,OPPS APC,,
DRESSING SILVASORB GEL 0.25OZ  SILVER ABSB ANTMIC -,SUP-MSC93025EP,CDM,A6248,HCPCS,272,RC,,,outpatient,,,34.03,23.821,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.122795,416.02,other,OPPS APC,,
SURGICAL DRESSING SILK 6 X 8IN -,SUP-NON4313,CDM,A6255,HCPCS,270,RC,,,outpatient,,,8.82,6.174,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.98009,416.02,other,OPPS APC,,
DRESSING TEGADERM 1.75X1.75IN TRANPARENT FILM -,SUP-1622-W,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.17,0.819,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.262665,416.02,other,OPPS APC,,
DRESSING TEGADERM 3 X 3 -,SUP-1624-W,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.17,0.819,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.262665,416.02,other,OPPS APC,,
DRESSING TRANSP 2.375X2.75IN TEGADERM OCL PIC FRM STYL -,SUP-1624-W,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.17,0.819,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.262665,416.02,other,OPPS APC,,
DRESSING TEAGDERM IV 2.75X3.25IN -,SUP-1633,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.63,1.141,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.262665,416.02,other,OPPS APC,,
DRESSING TEGADERM IV 3.5X4.5IN TRANSPARENT -,SUP-1655,CDM,A6257,HCPCS,270,RC,,,outpatient,,,5.37,3.759,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.262665,416.02,other,OPPS APC,,
DRESSING TRANSP 4X4.75IN TEGADERM OCL ORIG FRM STYL PLYSTR -,SUP-1626,CDM,A6258,HCPCS,270,RC,,,outpatient,,,3.38,2.366,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.75881,416.02,other,OPPS APC,,
DRESSING TRANSPARENT 4IN X 4.25IN -,SUP-1626,CDM,A6258,HCPCS,270,RC,,,outpatient,,,3.38,2.366,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.75881,416.02,other,OPPS APC,,
DRESSING TEGADERM 4X5 -,SUP-1626-W,CDM,A6258,HCPCS,270,RC,,,outpatient,,,3.53,2.471,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.75881,416.02,other,OPPS APC,,
DRESSING TEGADERM 15X20CM -,SUP-1628,CDM,A6258,HCPCS,270,RC,,,outpatient,,,6.97,4.879,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.75881,416.02,other,OPPS APC,,
DRESSING TRANSP 4X6.125IN TEGADERM OCL WND FRM STYL ADLT -,SUP-1689,CDM,A6258,HCPCS,270,RC,,,outpatient,,,10.58,7.406,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.75881,416.02,other,OPPS APC,,
DRESSING TEGADERM 20CM X 30CM -,SUP-1629,CDM,A6259,HCPCS,272,RC,,,outpatient,,,9.86,6.902,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.21357,416.02,other,OPPS APC,,
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7015-46,NDC,outpatient,10,ML,100.56,70.392,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.17,416.02,other,OPPS APC,,
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7030-42,NDC,outpatient,10,ML,100.56,70.392,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.17,416.02,other,OPPS APC,,
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7020-38,NDC,outpatient,10,ML,102.5,71.75,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.17,416.02,other,OPPS APC,,
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7025-40,NDC,outpatient,10,ML,100.57,70.399,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.17,416.02,other,OPPS APC,,
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7015-48,NDC,outpatient,10,ML,100.56,70.392,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.17,416.02,other,OPPS APC,,
GADOTERATE MEGLUMINE 1 MMOL/2 ML IV SOLN WRAPPER,RX-4080731,CDM,A9575,HCPCS,636,RC,67684-2000-00,NDC,outpatient,20,ML,136.25,95.375,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.12,416.02,other,OPPS APC,,
7 HOLE SUPERIOR MIDSHAFT CLAVICLE RIGHT PLATE -,SUP-0000000215,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS 4.0 FIXOS X 26MM -,SUP-0000000215,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE ANCHORED APACHE 5MM -,SUP-0000006784,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CABLE ORTHO CBL-RDY COCR 635MM -,SUP-00022320418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2083.36,1458.352,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN IM 4.8X222MM RUSH SS -,SUP-00080200103,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.68,514.976,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN IM 3.2X127MM RUSH SS -,SUP-00080300104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN IM 3.2X140MM RUSH SS -,SUP-00080300105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN IM 3.2X165MM RUSH SS -,SUP-00080300107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN IM 3.2X191MM RUSH SS -,SUP-00080300109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN IM SZ 3L 3.2X241MM RUSH SS -,SUP-00080300113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN IM 3.2X254MM RUSH SS -,SUP-00080300114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X18MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS POR -,SUP-00104223018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X24MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS POR -,SUP-00104223024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X30MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-00104223030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN CANC 4.5X33MM PROTASUL-64 WF TM ANTMC SHLDR STRL -,SUP-00104223033,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN CANC 4.5X36MM PROTASUL-64 WF TM ANTMC SHLDR STRL -,SUP-00104223036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X42MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-00104223042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X48MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-00104223048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FILLER TY I COLL CA PHOS 5ML PST COPIOS DBASC -,SUP-00110302005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3752.36,2626.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FILLER TY I COLL CA PHOS 10ML PST COPIOS DBASC -,SUP-00110302010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6279,4395.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CEMENT BN PLYMTHL MTHCRYLT 40GM PLC R HVISC -,SUP-00111214001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,396.78,277.746,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 40X3MM ANCHR XLPE GLOBAL STRL -,SUP-00113640026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9421.68,6595.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX10MM CANN 7.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX10MM CANN 1/2 5MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX12MM CANN 9.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX12MM CANN 1/3 5MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX16MM CANN 1/2 8MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114701631,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX16MM CANN 13.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX19MM CANN 1/3 6.3MM THRD SD/ST HX REVCT FLUT -,SUP-00114701930,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANN 3.0MM X 20MM 1/3 TH -,SUP-00114702030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX21MM CANN 1/3 7MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX24MM CANN 1/2 12MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702431,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX26MM CANN 1/2 13MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702631,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX28MM CANN 1/2 14MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702831,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX28MM CANN 9.3MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114702835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX28MM CANN 1/3 9.3MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114702840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.27,795.389,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX28MM CANN 1/2 14MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114702841,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.27,795.389,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX30MM CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX30MM CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX30MM CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT. -,SUP-00114703041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX34MM CANN 1/3 11.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX34MM CANN 1/3 11.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX34MM CANN 1/3 17MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703441,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.27,795.389,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX36MM CANN 1/3 12MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX36MM CANN 1/3 12MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX36MM CANN 1/3 18MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703641,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX38MM CANN 1/3 12.7MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX38MM CANN 1/3 19MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703841,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX40MM CANN 1/3 13.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX40MM CANN 1/3 13.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X40MM CANN 1/3 13.3MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX40MM CANN 1/3 20MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX42MM CANN 1/3 39.5MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX44MM CANN 14.7MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX44MM CANN 1/3 14.7MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX44MM CANN 1/2 22MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704441,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5MMX45MM CANN 16MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114704555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5MMX45MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114704556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX46MM CANN 15.3MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX46MM CANN 43.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX46MM CANN 1/3 15.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX46MM CANN 1/2 23MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704641,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX48MM CANN 16MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX48MM CANN 1/3 16MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX50MM CANN 16.7MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114705035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX50MM CANN 1/3 16.7MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114705040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5MMX50MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5MMX50MM CANN 45.3MM FT SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705057,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX50MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114705065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5MMX55MM CANN 16MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5MMX55MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX55MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114705565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5MMX60MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114706056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX60MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX60MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5MMX65MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114706556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX65MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX65MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX70MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX70MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX70MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX70MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX75MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX75MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX75MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX75MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5MMX80MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114708056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX80MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX80MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX80MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX80MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX80MM CANN 74.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114708077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 1.6MMX6IN P/T TROC TIP -,SUP-00114708400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 1.25MMX6IN P/T TROC TIP -,SUP-00114708500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5MMX85MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114708556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX85MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX85MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX85MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX85MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX85MM CANN 79.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114708577,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 2.4MMX9IN P/T TROC TIP -,SUP-00114708700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 3.2MMX9IN P/T TROC TIP -,SUP-00114708800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 1.6MMX9IN SMTH SHFT TROC TIP -,SUP-00114709000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,70.98,49.686,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX90MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX90MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX90MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX90MM CANN 84.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114709077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 2.4MMX9IN SMTH SHFT TROC TIP -,SUP-00114709100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,147.14,102.998,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 3.2MMX9IN SMTH SHFT TROC TIP -,SUP-00114709200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,147.04,102.928,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 1.6MMX6IN SMTH SHFT TROC TIP -,SUP-00114709400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,70.95,49.665,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO 3MM -,SUP-00114709500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX95MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX95MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX95MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX95MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX95MM CANN 89.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114709577,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO F/3.5/4MM CANN SCR NS -,SUP-00114709600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO F/4.5MM CANN SCR SS NS -,SUP-00114709700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO F/5.5MM/7.5MM CANN SCR SS RND NS -,SUP-00114709800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 3.2MMX12IN P/T TROC TIP -,SUP-00114709901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 3.2MM 30CM -,SUP-00114709902,CDM,C1713,HCPCS,278,RC,,,outpatient,,,155.78,109.046,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 3.2MMX12IN SMTH SHFT DRILL TIP -,SUP-00114709903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,155.74,109.018,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX100MM CANN 16MM THRD SD/ST 4.5MM HX REVCT FLUT -,SUP-00114710065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW Z CANN PT 32 6.5 X 100 -,SUP-00114710066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX100MM CANN FT SD/ST 5MM HX REVCT FLUT BIODUR 108 -,SUP-00114710077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX105MM CANN 16MM THRD SD/ST 4.5MM HX REVCT FLUT -,SUP-00114710565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX105MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114710575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1399.33,979.531,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX105MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114710576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX110MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX110MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX115MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX115MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX120MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114712075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.25MM 2.5MM THRD MINI 10MM HRBRT MINI TIV STRL -,SUP-00115001000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2142.36,1499.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.25MM 2.5MM THRD MINI 16MM HRBRT MINI TIV STRL -,SUP-00115001600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2142.36,1499.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5MM 2.1MM THRD 14MM CANN HRBRT/WPL TIV STRL -,SUP-00115201400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2555.05,1788.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X5MM DIA THRD MINI 18MM CANN LAG HRBRT/WPL TIV STRL -,SUP-00115201800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2555.05,1788.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 3.2MMX23CM THRD TROC TIP FRLCK STRL -,SUP-00118102000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.84,81.788,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 12.7MM THRD VFX2 LAG 17MM S/T SS 130MM -,SUP-00119300557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1749.27,1224.489,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 3.2MM TM -,SUP-00119703200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.19,908.033,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD FEM HIP 10MM TM TIV 25MM THRD -,SUP-00119710010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14101.97,9871.379,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN NCB 80MM 4HL CONTR LCK PROTASUL-64 STRL -,SUP-00202262104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5884.73,4119.311,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN NCB 117MM 7HL CONTR LCK PROTASUL-64 STRL -,SUP-00202262107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7175.97,5023.179,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X24MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X30MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X32MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,605.85,424.095,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X36MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,605.85,424.095,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAP LCK NCB NS -,SUP-00203150300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,930.39,651.273,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X24MM NLCKG CORT NCB ST TMX NS -,SUP-00203155024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX26MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX28MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX30MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX32MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX34MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX36MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X38MM NLCKG CORT NCB ST TMX NS -,SUP-00203155038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX40MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX42MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX44MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX46MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX50MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X32MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,778.91,545.237,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X44MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,778.91,545.237,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X46MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,778.91,545.237,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X50MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.68,514.976,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN NCB 93MM 5HL LCK TI -,SUP-00203262005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5979.97,4185.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
STAPLE INTNL 19MMX15.9MM LF -,SUP-00222901300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,294.26,205.982,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DEVICE ORTHO 23MM LNG CBL-RDY GTR TROCH TIV 121MM STRL -,SUP-00223200205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9554.89,6688.423,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CABLE ORTHO 1.8MM CBL-RDY COCR 914MM STRL -,SUP-00223200228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2397.84,1678.488,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 305MM 4.5MM 10HL SS STRL -,SUP-00223200302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4354.7,3048.29,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CABLE PLATE 1.8MM CBL-RDY BN SS 610MM STRL -,SUP-00223200318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1493.73,1045.611,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CABLE SURG 1.8MM X 635MM CBL-RDY CRLGE SS -,SUP-00223200418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2083.36,1458.352,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CABLE FX 1.3MM CBL-RDY SS 889MM STRL -,SUP-00223201113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1788.55,1251.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOPEDIC CBL-RDY GRP 65MM PIN -,SUP-00223205021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2708.43,1895.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX12MM LCK CORT ST FA SS NS -,SUP-00234801235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX18MM LCK CORT ST FA SS NS -,SUP-00234801835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX20MM LCK CORT ST FA SS NS -,SUP-00234802035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX22MM LCK CORT ST FA SS NS -,SUP-00234802235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX26MM LCK CORT ST FA SS NS -,SUP-00234802635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX30MM LCK CORT ST FA SS NS -,SUP-00234803035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX34MM LCK CORT ST FA SS NS -,SUP-00234803435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX40MM LCK CORT ST FA SS NS -,SUP-00234804035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX100MM LCK CORT ST FA SS NS -,SUP-00234810035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 132MM 2.7/3.5MM 8HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235701708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3823.64,2676.548,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 80MM 2.7/3.5MM 4HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235701804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3310.29,2317.203,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 106MM 6HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235701806,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3540.4,2478.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 114MM 3.5MM 6HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235800104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6389.13,4472.391,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 129MM 7HL FX-ANG LCK NS -,SUP-00235800907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.68,2924.376,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 77MM 3HL LCK SS NS -,SUP-00235801203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3788.26,2651.782,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX12MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX14MM LCK NCANN P/T ST CNCL SS NS -,SUP-00235901426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,328.92,230.244,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX14MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX14MM LCK NCANN P/T ST SS NS -,SUP-00235901438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX16MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX16MM LCK NCANN P/T ST CNCL SS NS -,SUP-00235901638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X18MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X30MM LCK NCANN FT ST SS NS -,SUP-00235903035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X32MM LCK NCANN FT ST SS NS -,SUP-00235903235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X36MM LCK NCANN FT ST SS NS -,SUP-00235903635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X38MM LCK NCANN FT ST SS NS -,SUP-00235903835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X40MM LCK NCANN FT ST SS NS -,SUP-00235904035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X42MM LCK NCANN FT ST SS NS -,SUP-00235904235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X44MM LCK NCANN FT ST SS NS -,SUP-00235904435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X46MM LCK NCANN FT ST SS NS -,SUP-00235904635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X48MM LCK NCANN FT ST SS NS -,SUP-00235904835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X50MM LCK NCANN FT ST SS NS -,SUP-00235905035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCRW 14MM CASPAR PIN F/DSTRCT -,SUP-0024-LDR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 3.2X444MM -,SUP-00281001175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
STAPLE INTNL 22MMX9.5MM COCR LF -,SUP-00406000100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.27,530.089,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
STAPLE INTNL 25MMX9.5MM COCR LF -,SUP-00406000200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.27,530.089,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN FX 3.2MM BGLNI/FLTW THRD TIP -,SUP-00430400800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,379.28,265.496,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5MM THRD 7MM CORT FT ST HEX HEAD SS NS -,SUP-00481500701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5MM THRD 8MM CORT FT ST HEX HEAD SS NS -,SUP-00481500801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5MM THRD 9MM CORT FT ST HEX HEAD SS NS -,SUP-00481500901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5MM THRD 14MM CORT FT ST HEX HEAD SS NS -,SUP-00481501401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5MM THRD 16MM CORT FT ST HEX HEAD SS NS -,SUP-00481501601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5MM THRD 20MM CORT FT ST HEX HEAD SS NS -,SUP-00481502001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MM THRD 6MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482000603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MM THRD 8MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482000803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MM THRD 10MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MM THRD 10MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MM THRD 12MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MM THRD 12MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MM THRD 14MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MM THRD 14MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MM THRD 16MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MM THRD 16MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MM THRD 18MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MM THRD 22MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482002201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MM THRD 6MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00482700601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MM THRD 8MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00482700801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MM THRD 10MM LCK CORT FT NON- ST 2.5MM SM HEX RCESS -,SUP-00482701000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,128.9,90.23,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MM THRD 10MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MM THRD 12MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MM THRD 14MM CORT FT ST 2.5MM SM HEX RCESS -,SUP-00482701401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MM THRD 16MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MM THRD 18MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,147.33,103.131,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MM THRD 20MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482702001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MM THRD 26MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482702601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX10MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482801002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX12MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482801202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX12MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482801202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX14MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482801402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX16MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482801602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX18MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482801802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX20MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482802002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX22MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482802202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX26MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482802602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX28MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482802802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX30MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482803002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX16MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483501601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX16MM LCK CORT 6MM P/T NON- ST 2.5MM SM HEX RCESS -,SUP-00483501604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX20MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX20MM LCK CORT 6MM P/T NON- ST 2.5MM SM HEX RCESS -,SUP-00483502004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX22MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX22MM LCK CORT 6MM P/T NON- ST 2.5MM SM HEX RCESS -,SUP-00483502204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX24MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483502404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX26MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX26MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483502604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX28MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX28MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483502804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX30MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483503001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX30MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483503004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN CORT 3.5MM 32MM SS NS FT S/T LOCK 2.5MM SM HEX -,SUP-00483503201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX34MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483503401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX34MM LCK CORT 12MM P/T NON- ST 2.5MM SM HEX -,SUP-00483503404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX45MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483504501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX45MM LCK CORT 12MM P/T NON- ST 2.5MM SM HEX -,SUP-00483504504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX50MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483505001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX55MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483505501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX12MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484001200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX12MM CANC 5MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX14MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484001400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX14MM CANC 5MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX16MM LCK CANC FT 2.5MM SM HEX RCESS SS NS -,SUP-00484001600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX16MM CANC 6MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX18MM LCK CANC FT 2.5MM SM HEX RCESS SS NS -,SUP-00484001800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX18MM CANC 7MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX20MM LCK CANC FT 2.5MM SM HEX RCESS SS NS -,SUP-00484002000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX22MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484002200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX24MM CANC 10MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484002401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX26MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484002600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX28MM CANC 14MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484002801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX30MM CANC 14MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484003001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX34MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484003400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX38MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484003800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX40MM CANC 14MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484004001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX50MM CANC 15MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484005001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MM THRD 36MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484503601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MM THRD 38MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484503801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MM THRD 40MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MM THRD 40MM CORT 20.5MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00484504008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,194.77,136.339,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MM THRD 42MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MM THRD 44MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MM THRD 46MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MM THRD 50MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484505001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MM THRD 50MM CORT 24.5MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00484505008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,194.77,136.339,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MM THRD 55MM CORT 26.5MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00484505508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,194.77,136.339,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MM THRD 58MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484505801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MM THRD 60MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484506001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MM THRD 45MM CANC 32MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486504502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MM THRD 50MM CANC 16MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486505001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MM THRD 50MM CANC 32MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486505002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MM THRD 55MM CANC 32MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486505502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MM THRD 60MM CANC FT 3.5MM LRG HEX RCESS SS NS -,SUP-00486506000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO 4X7MM SM 2.7/3.5/4.0MM SS RND FLT NS -,SUP-00490004051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO 13MM LRG 4.5/6.5MM RND FLT NS -,SUP-00490006551,CDM,C1713,HCPCS,278,RC,,,outpatient,,,207.73,145.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 21MM 2MM SS L-SHP OB R MINI FRAG NS -,SUP-00492000210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,386.57,270.599,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 23MM 4HL 2MM SS STR MINI FRAG NS -,SUP-00492000402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,389.49,272.643,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 32MM 2.7MM SS T-SHP MINI FRAG NS -,SUP-00492700304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.52,254.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 31MM 4HL 1MM SS 1/4 TBLR MINI FRAG NS CLLR -,SUP-00492700403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,432.72,302.904,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 104MM 3.5MM 4HL SS CLVRLF SM FRAG NS -,SUP-00493500416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1493.73,1045.611,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 61MM 5HL SS SM 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500503,CDM,C1713,HCPCS,278,RC,,,outpatient,,,406.82,284.774,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 73MM 3.5MM 6HL COMPR SS SM FRAG NS -,SUP-00493500600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,800.56,560.392,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 73MM 6HL SS SM 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.09,296.863,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 85MM 3.5MM 7HL COMPR SS SM FRAG NS -,SUP-00493500700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,822.21,575.547,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 85MM 7HL SS SM 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.09,296.863,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 97MM 3.5MM 8HL 1.1MM COMPR SS SM FRAG NS -,SUP-00493500800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 97MM 3.5MM 8HL SS 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,454.37,318.059,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 109MM 3.5MM 9HL 1.1MM COMPR SS SM FRAG NS -,SUP-00493500900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,887.1,620.97,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 121MM 3.5MM 10HL 1.1MM COMPR SS SM FRAG NS -,SUP-00493501000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,908.74,636.118,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 74MM 3.5MM HLX3/5 HD/SHFT 1.5MM SS T-SHP OBLQ SM -,SUP-00493503505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1100.65,770.455,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
"PLATE Z ""T"" 4 HOLE 3.5MM -",SUP-00493504404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,714.03,499.821,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 68MM 3.5MM UNIV LCK SYS 5HL LCK SS 1/3 TBLR NS -,SUP-00493600503,CDM,C1713,HCPCS,278,RC,,,outpatient,,,952.04,666.428,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 94MM 3.5MM UNIV LCK SYS 7HL LCK SS 1/3 TBLR NS -,SUP-00493600703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1016.92,711.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 107MM 3.5MM UNIV LCK SYS 8HL LCK SS 1/3 TBLR NS -,SUP-00493600803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.22,742.154,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 105MM 3.5MM UNIV LCK SYS 8HL CONTR LCK DL COMPR SS -,SUP-00493600807,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1867.15,1307.005,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 105MM 3.5MM UNIV LCK SYS 8HL RECON LCK SS NS -,SUP-00493600813,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2566.79,1796.753,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 133MM 3.5MM UNIV LCK SYS 10HL LCK SS 1/3 TBLR LRG -,SUP-00493601003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.81,757.267,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 116MM 4.5MM 6HL SHFT SS T-SHP LRG FRAG NS -,SUP-00494500604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1316.86,921.802,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE Z 4.5 COMP B 12 HOLE -,SUP-00494501201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1356.19,949.333,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
KT MIXER BNCMNT VAC MX 35ML LNG CQ/NOZ FNL CHRCL FLTR SUCT -,SUP-00504903501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,811.07,567.749,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
KT MIXER BNCMNT VAC MX 45ML LNG CQ/NOZ FNL CHRCL FLTR SUCT -,SUP-00504904501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,905.01,633.507,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WIRE PACK .028 SPADE TIP -,SUP-00505004100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,49.89,34.923,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFT HUM TIS 11MM CHONDROFIX OSTCHND LF -,SUP-00560402011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15111.91,10578.337,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFT BN 15MM CHONDROFIX LF -,SUP-00560402015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15891.64,11124.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 48MM HD UNICMPT SS F/HI FLEX SYS -,SUP-00579104100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 48MM HD UNICMPT SS F/HI FLEX SYS -,SUP-00579104100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.77,258.139,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
HOLDER IMPL HDLS 48MM SS GOLD F/UNICMPT HI FLEX KN SPCR BLCK -,SUP-00579104200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEX HEAD 3.5MM -,SUP-00-5901-035-27,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEX HEAD 3.5MM X 48MM -,SUP-00-5901-035-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FLEX LCK -,SUP-00595409000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
EXTENSION STM MG2 PS TIV ALY PLG TAPR KN -,SUP-00596009900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDE SURG NEXGEN F/UNICMPT KN ARTHPL TIB PT SPEC INST HI.. -,SUP-00597000001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDE SURG NEXGEN F/UNICMPT KN ARTHPL TIB PT SPEC INST HI -,SUP-00597000002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO PERSONA CRUCIF RCESS -,SUP-00597000025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BASEPLATE TIB SZ1 58/40MM KN STM NEXGEN TIV ALY PMMA UHMWPE -,SUP-00598002701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP TIBPLT SZ2 62/41MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598002702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP TIBPLT SZ3 66/42MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598003701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP TIBPLT SZ3 66/42MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598003701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8452.1,5916.47,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP TIBPLT SZ4 66/46MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598003702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP TIBPLT SZ5 74/46MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598004701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP TIBPLT SZ6 74/50MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598004702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP TIBPLT SZ7 82/51MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598005701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW AUG 48MM TIV HX HD F/ARTHPL NEXGEN STRL DIST FEM KN -,SUP-00598304048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP TIBTRY SZ3 66/42MM KN CMNT STM WDG NEXGEN TIV PMMA CR -,SUP-00598800300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10515.22,7360.654,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP TIBTRY SZ4 66/46MM KN CMNT STM WDG NEXGEN TIV PMMA CR -,SUP-00598800400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10515.22,7360.654,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP TIBTRY SZ5 74/46MM KN CMNT STM WDG NEXGEN TIV PMMA CR -,SUP-00598800500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10515.22,7360.654,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DEVICE 11X4X11MM TM-S 7DG TM -,SUP-00610101041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10526.36,7368.452,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER 11X14X29MM VBR-11 TM -,SUP-00611100292,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15891.64,11124.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ACTB 6.5X15MM TRILOGY TIV CNTRSNK HEAD ST -,SUP-00625006515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE SELF TAPPED 6.5 X 20 -,SUP-00-6250-065-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE SCREW 6.5X25 SELF-TAP -,SUP-00-6250-065-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE SELF TAP 6.5 X 30 -,SUP-00-6250-065-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ACTB 6.5X35MM TRILOGY TIV CNTRSNK HEAD ST -,SUP-00625006535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 6.5 X 40 SELF TAP -,SUP-00625006540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ACTB 6.5X40MM TRILOGY TIV CNTRSNK HEAD ST -,SUP-00625006540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 6.5X40 SELF-TAP -,SUP-00-6250-065-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE SCREW 6.5 X 50MM SELF TAP -,SUP-00625006550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 6.5 X 50 SELF-TAP -,SUP-00-6250-065-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LINER 56 X 32  TRILOGY LONGEVITY CONSTRAINED -,SUP-00-6334-056-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14191.09,9933.763,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HGP ACETABULAR CUP BONE SLF TP 6.5 X 20 -,SUP-00662406520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HGPAETABULAR CUP BONE SLF TP 6.5 X 30 -,SUP-00662406530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUBSTITUTE BVN SPNG 1ML STRIP FIL COPIOS 10X20MM 5MM -,SUP-00700582001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1934.68,1354.276,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 2MMX45CM TRIMAX NANCY TI ALY E CAP -,SUP-00800620450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1462.94,1024.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLUG ACTB DOME HL HIP CONTIN -,SUP-00875700001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,379.28,265.496,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
HEAD BIOLOX OPT FEM 32MM/+3.5MM DELTA -,SUP-00-8777-032-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8566.51,5996.557,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SIDUS STEM-FREE SHOULDER HUMERAL ANCHOR M -,SUP-01.04555.120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19121.95,13385.365,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
G7 ACETABULAR SCREW 6.5MM / 20L -,SUP-010000997,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
G7 SCREW 6.5MM X 30MM -,SUP-010000999,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
G7 ACETABULAR SCREW 6.5MM / 35L -,SUP-010001000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
G7 SCREW 6.5MM X 40MM -,SUP-010001001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ENDOBUTTON 013186 -,SUP-013186,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.2,778.54,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BASE SLDR GFT F/ACL /PCL GRAFTMS II -,SUP-014950,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3100.9,2170.63,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL FLEXIBLE PRE CURVED 1.50MM X 300MM -,SUP-0194-1500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL FLEXIBLE PRE CURVED 1.75MM X 300MM -,SUP-0194-1750S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.66,795.662,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL FLEXIBLE PRE CURVED 2.25MM X 300MM -,SUP-0194-2250S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1104.62,773.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL FLEXIBLE PRE CURVED 2.5MM X 450MM -,SUP-0194-2500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.59,822.213,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL FLEXIBLE PRE CURVED 3.5MM X 450MM -,SUP-0194-3500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1240.32,868.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL FLEXIBLE PRE CURVED 4.0MM X 450MM -,SUP-0194-4000S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1276.36,893.452,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL FLEXIBLE PRE-CURVED 2.25 X 300MM -,SUP-0195-2250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1104.62,773.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL FLEXIBLE PRE CURVED 2.5 X 450MM -,SUP-0195-2500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.59,822.213,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LCP 158MM 3.5MM 6HL FA LC CONTR LCK COMPR SS TAPR -,SUP-02.104.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5487.49,3841.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN_VA-LCP 45MM 2.4MM HLX6/2 HD/SHFT CLMNX2 VAR ANG LCK -,SUP-02.111.621,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5084.31,3559.017,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.7/3.5 VA ANTEROLAT DSTL TIB PL/10 H/RT -,SUP-02.118.208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10401.04,7280.728,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7 METAPHYSEA SLF-TPNG T8 SD REC/48 -,SUP-02.118.548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7 METAPHYSEA SLF-TPNG T8 SD REC/50 -,SUP-02.118.550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.7 VA LOCKING ANT PATELLA PL SS CORE SILE -,SUP-02.137.003S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11077.74,7754.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7 VA LOCKING SLF-TPNG T8 SD REC 10 -,SUP-02.211.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 12 -,SUP-02.211.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 16 -,SUP-02.211.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 18 -,SUP-02.211.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.7 VA LCKNG SCR SLF-TPNG T8 SD REC 36 -,SUP-02.211.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.7 VA LCKING SCR SLF-TPNG T8 SD REC 38 -,SUP-02.211.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 40 -,SUP-02.211.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7 VA LCKING SLF-TPNG T8 SD REC 42 -,SUP-02.211.042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.7 VA LCKNG SCR SLF-TPING T8 SD REC 46 -,SUP-02.211.046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.7MM VA LCKNG SCREW SLF-TPNG WITH T8 60MM -,SUP-02.211.060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE FUSION CLOVERLEAF SHORT 2.4/2.7 VA-LCP -,SUP-02.211.250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8683.22,6078.254,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAP FEM NCB LCK -,SUP-0203150300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,930.39,651.273,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PRESSURIZER BNCMNT PROX FEM MED -,SUP-0206-545-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.66,71.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FEM PRESSURIZING SEAL - MED -,SUP-0206-546-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.66,71.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN BIOSTEON 7X23MM FT BABSRB WDG SHP HAP PLLA -,SUP-0234-010-161,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN BIOSTEON 8X28MM FT BABSRB WDG SHP HAP PLLA -,SUP-0234-010-167,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR BIOSTEON 10X35MM INTFR HAP PLLA -,SUP-0234-010-178,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CROSS TITANIUM 8MM X 60MM -,SUP-0234500160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,885.69,619.983,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SYNFLATE BALLOON MED -,SUP-03.804.701S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DEVICE TK TI KNOT 5MM -,SUP-030404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1161.17,812.819,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE FUSION 2.4/2.7MM TI VA-LCP TMT -,SUP-04.211.266,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7524.61,5267.227,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN MATRIXRIB 17HL PRCONT TI NS ROSE RD -,SUP-04.501.006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7312.41,5118.687,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN MATRIXRIB 18HL 1.5MM PRCONT LCK TI NS LBLU -,SUP-04.501.007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8297.02,5807.914,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN MATRIXRIB 18HL PRCONT LCK TI NS ROSE RD -,SUP-04.501.008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7312.41,5118.687,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN MATRIXRIB 8HL PRCONT TI UNIV NS GOLD -,SUP-04.501.009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5653.01,3957.107,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.9X10MM LCK MATRIXRIB ST TI NS GOLD.. -,SUP-04.501.020.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1309.22,916.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.9X10MM LCK MATRIXRIB ST TI NS GOLD. -,SUP-04.501.020.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1147.03,802.921,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.9X12MM LCK MATRIXRIB ST TI NS GOLD -,SUP-04.501.022.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1309.22,916.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.9X14MM LCK MATRIXRIB ST TI NS GOLD -,SUP-04.501.024.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1150.21,805.147,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT ZERO-P IMP 8MM LORDOTIC STERILE -,SUP-04.617.128S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11510.3,8057.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT ZERO-P IMP 9MM LORDOTIC STERILE -,SUP-04.617.129S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11510.3,8057.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 3.0MM X 14MM TI CERVICAL SPINE -,SUP-04.617.814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
KT BONE CMNT SPINEPLEX -,SUP-0406-202-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1455.25,1018.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CEMENT BN 20GM VERTAPLEX DMSTC DUEL -,SUP-0406-402-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1853.05,1297.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PCD SYSTEM-LONG 90DEG TUBE W/VERTAPLEX -,SUP-0507-486-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2470.55,1729.385,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PCD PREC SYS LONG TUBE W/VHV -,SUP-0507-586-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2470.55,1729.385,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8X70MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-05080000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
KT BONE CMNT AUTOPLEX STRL -,SUP-0605-687-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3912.53,2738.771,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED TI 6.5X 110MM,SUP-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.94,757.358,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 2MM -,SUP-1007-1200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUSTAIN SPACE SMALL - 11MM -,SUP-101.111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUSTAIN SPACER SMALL NARROW 11MM -,SUP-101.711,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE ROD 5.5 X 250MM -,SUP-10-1025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X14MM CORT/CANC SS NS F/DMD CRPL FUSION PLATE -,SUP-1011602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,651.19,455.833,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X16MM CORT/CANC SS NS F/DMD CRPL FUSION PLATE -,SUP-1011603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,651.19,455.833,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X18MM CORT/CANC SS NS F/DMD CRPL FUSION PLATE -,SUP-1011604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,651.19,455.833,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SET SCREW -,SUP-1020-00-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.0 PLY 3.5 X 24MM SYMPHONY -,SUP-1020-035-124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X100MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.0 PLY 3.5 X 14MM SYMPHONY -,SUP-1020-35-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.0 PLY 3.5 X 16MM SYMPHONY -,SUP-1020-35-116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.0 PLY 3.5 X 18MM SYMPHONY -,SUP-1020-35-118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.0 PLY SCREW 3.5 X 20 -,SUP-102035120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.0 PLY 4.0 X 14MM SYMPHONY -,SUP-102040114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD TI 4.0 X 070 LOR -,SUP-102064070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD TI 4.0 X 075 LOR -,SUP-102064075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TI 4.0 X 090 LOR ROD -,SUP-102064090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X65MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X75MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X85MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER 12X8X27MM LUCENT LRDTC CRV PEEK -,SUP-10227-008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER 12X9X27MM LUCENT LRDTC CRV PEEK -,SUP-10227-009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER 12X11X27MM LUCENT LRDTC CRV PEEK -,SUP-10227-011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11695.95,8187.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN F /FUSSION SS SM NS -,SUP-1024002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7238.14,5066.698,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT ULFX MICROMITE SZ2-0 2.7MM BRD PLYSTR -,SUP-10301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1633.77,1143.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CHIP CANCELLOUS BONE 5CC 1-8 C -,SUP-103015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CREO AMP 5.5 X 50MM -,SUP-1067.1550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CREO AMP 5.5 X 45MM MOD CAN -,SUP-1067.4545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MODULAR CANNULATED 6.5 X 40MM CREO AMP -,SUP-1067.4640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD CURVED TIT ALLOY 4.75MM X 35MM -,SUP-1067.7035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD CURVED TIT ALLOY 4.75MM X 40MM -,SUP-1067.7040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ONLAY LYOPLANT 7.5 X 7.5CM -,SUP-1067040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4108.41,2875.887,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FILLER 10ML OSTEOSPONGE -,SUP-109510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4081.77,2857.239,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FILLER CANC TRBCLR DBM 15ML CHP OSTEOSPONGE ELAS OSTCONDC -,SUP-109515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FILLER DEMIN CANC BN 5ML CHP OSTEOSPONGE ELAS OSTCONDC -,SUP-109550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFT DEMIN CANC BN BLCK 14MM OSTEOSPONGE ELAS OSTCONDC -,SUP-109614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3437.28,2406.096,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUBSTITUTE CORT FBR 10CC 3DEMIN -,SUP-109760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T15 LP CORT 3.5 X 20MM NS -,SUP-110017720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T15 LP CORT 3.5 X 22MM NS -,SUP-110017722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T15 LP CORT 3.5 X 24MM NS -,SUP-110017724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T15 LP CORT 3.5 X 26MM NS -,SUP-110017726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T15 LP CORT 3.5 X 30MM NS -,SUP-110017730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T15 LP CORT 3.5 X 32MM NS -,SUP-110017732,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T15 LP CORT 3.5 X 34MM NS -,SUP-110017734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T15 LOW PROFILE CORT 3.5 X 36MM NS -,SUP-110017736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T15 LOW PROFILE CORT 3.5  X 38MM NS -,SUP-110017738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T15 LOW PROFILE CORT 3.5 X 40MM NS -,SUP-110017740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T15 LP CORT 3.5 X 44 NS -,SUP-110017744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T15 MD 3.5 X 28MM NS -,SUP-110018028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T15 LOCK MULTIDIRECTIONAL 3.5 X 34MM NS -,SUP-110018034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T15 MULTIDDIRECTIONAL 3.5 X 38MM NS SILVER -,SUP-110018038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T15 MULTIDIRECTIONAL 3.5 X 40MM NS SILVER -,SUP-110018040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T15 MULTIDIRECTIONAL 3.5 X 42MM NS SILVER -,SUP-110018042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T15MD 3.5 X 46MM NS -,SUP-110018046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T15 MD 3.5 X 52MM NS -,SUP-110018052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.2MM PEG 20MM -,SUP-110025320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.2MM PEG 24MM -,SUP-110025324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG FIXATION 3.2 X 26MM -,SUP-110025326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG FIXATION 3.2 X 28MM -,SUP-110025328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.2MM PEGS 30MM -,SUP-110025330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG 3.2 X 32 -,SUP-110025332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEGS 3.2MM X 34MM -,SUP-110025334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG 3.2 X 36MM -,SUP-110025336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG 3.2MM X 38MM -,SUP-110025338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG 3.5 X 40MM -,SUP-110025340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG 3.2 X 42 -,SUP-110025342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG 3.2MM X 44MM -,SUP-110025344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG 3.2 X 46MM -,SUP-110025346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG 3.2 X 50MM -,SUP-110025350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG 3.2 X 52MM -,SUP-110025352,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG 3.2MM X 54MM -,SUP-110025354,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG 3.2 X 56 -,SUP-110025356,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG 3.2 X 58MM -,SUP-110025358,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.2MM PEG 60MM -,SUP-110025360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG 3.2 X 65MM -,SUP-110025365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PRX HUM LO LT 3H 73MM -,SUP-110030100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6671.57,4670.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PRX HUM LO PLT LT 7H 133MM -,SUP-110030102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8021.16,5614.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PRX HUM HI PLTLT 3H 80MM -,SUP-110030300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6569.71,4598.797,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PRX HUM HI PLT RT 3H 80MM -,SUP-110030400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6569.71,4598.797,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PRX HUM HI RT 4H 90MM -,SUP-110030401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6824.35,4777.045,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
REFOBACIN BONE CEMENT R 1X14 US -,SUP-110034355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMPR NANO 7IN STEINMANN PIN -,SUP-110045821,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3246.32,2272.424,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFT PLATE CANOPY INLINE 7MM -,SUP-1102.1007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FIXATION VARIABLE ANGLE -,SUP-111655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1457.21,1020.047,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAP SPIN CREO 5.5MM -,SUP-1119.0000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CREO THREADED LOCKING CAP -,SUP-1119.0010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CONNECTOR CROSS 38-50 LONG 5.5 CREO -,SUP-1119.0039,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CREO 5.5 CROSS CONNECTOR 48-60MM LONG -,SUP-1119.0046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TULIP HEAD FOR CORTICAL SCREW -,SUP-1119.0100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CONNECTOR CREO 5.5 LOW PROFILE CROSS  21.5-25MM LONG -,SUP-1119.0221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CREO 5.5 LOW PROFILE CROSS CONN- 24.5-31MM LONG -,SUP-1119.0224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 5.5-4.5X25MM MOD CREO AMP -,SUP-1119.1325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
5.5-4.5 X 30MM CREO MCS SCREW -,SUP-1119.1330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5 4.5 X 35MM CORTICAL MODULAR CREO AMP -,SUP-1119.1335,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 6.0-5.0 X 30ML -,SUP-1119.1430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
6.0-5.0 X 35MM CORTICAL SCREW -,SUP-1119.1435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 6.5-5.5X35MM -,SUP-1119.1535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORITICAL 6.5-5.5X35MM -,SUP-1119.1535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 5.5 X 35 TITANIUM ALLOY -,SUP-1119.5035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD STRAIGHT 5.5MM X 40 -,SUP-1119.5040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD TITANIUM ALLOY 5.5 X 45 STRAIGHT -,SUP-1119.5045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 150MM -,SUP-1119.5150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN CREO 5.5X35MM CRV TI ALY THORLUM -,SUP-1119.7035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
5.5MM CURVED ROD TITANIUM ALLOY 40MM LENGTH -,SUP-1119.7040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD CREO 5.5X40MM -,SUP-1119.7040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD CURVED 5.5MM TITANIUM ALLOY 45MM LENGTH -,SUP-1119.7045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN CREO 5.5X50MM CRV TI ALY THORLUM -,SUP-1119.7050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN CREO 5.5X55MM CRV TI ALY THORLUM -,SUP-1119.7055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD CURVED 5.5MM TITANIUM ALLOY 60MM LENGTH -,SUP-1119.7060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 5.5MM CURVED TIT ALLOY 65MM -,SUP-1119.7065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD CURVED 5.5MM TITANIUM ALLOY 70MM LENGTH -,SUP-1119.7070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD CURVED 5.5MM TITANIUM ALLOY 80MM LENGTH -,SUP-1119.7080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK EXPLOR TI ALY -,SUP-11-210099,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PELVIC ARRAY -,SUP-112230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5393.06,3775.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
STEM TPR DIST SPR 14 X 150MM ARCOS -,SUP-11-300814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
STEM TPR DIST SPR 16 X 150MM ARCOS -,SUP-11-300816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAP LOCKING CREO MIS -,SUP-1134.0010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TULIP MODULAR POLYAXIAL 30MM REDUCTION CREO MIS -,SUP-1134.0100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD CURVED 5.5MM X 50MM TITANIUM ALLOY CREO MIS -,SUP-1134.7050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
HEAD MOD 36MM COCR STD -,SUP-11-363662,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP 44MM GLOBAL AP SHLDR 3MM XLPE PG -,SUP-1136-41-026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8667.95,6067.565,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP 52MM GLOBAL AP SHLDR 3MM XLPE PG -,SUP-1136-43-026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10652.6,7456.82,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
MITRIS RESILIA MITRAL VALVE 25MM -,SUP-11400M25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
MITRIS RESILIA MITRAL VALVE 27MM -,SUP-11400M27,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
MITRIS RESILIA MITRAL VALVE 29MM -,SUP-11400M29,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
MITRIS RESILIA MITRAL VALVE 31MM -,SUP-11400M31,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
THUMBSCREW FOR C501 ROCHE CUVETTE -,SUP-11406701001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,140.74,98.518,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX100MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUTNS.. -,SUP-1147-100-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX100MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT NS. -,SUP-1147-100-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 3.2X353MM THRD -,SUP-115163,CDM,C1713,HCPCS,278,RC,,,outpatient,,,307.85,215.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW COMP RVS CONTROL 6.5 X 20MM ST -,SUP-115380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW COMP RVS CONTROL 6.5 X 30MM ST -,SUP-115382,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X35MM CORT RVRS CNTRL 3.5MM HEX DRV HEX HEAD TI ALY -,SUP-115383,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP RVS CNTRL 6.5 X 20MM ST/RST -,SUP-115394,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP RVS CNTRL 6.5 X 25MM ST/RST -,SUP-115395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X25MM CORT RVRS CNTRL 3.5MM HEX DRV HEX HEAD TI ALY -,SUP-115395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
6.5 X 30MM CENTRAL SCREW -,SUP-115396,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
REVERSE CENTRAL SHOULDER SCREW 3.5MM X 35MM -,SUP-115397,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP RVS CNTRL 6.5 X 40MM ST/RST -,SUP-115398,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP RVS CNTRL 6.5 X 45MM ST/RST -,SUP-115399,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER ANT THORLUM VERT 14MMX15-18MMH XPAND 0DG SM 12MM OPN -,SUP-116.101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14881.7,10417.19,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER ANT THORLUM VERT 21X23MMX37-46MM XPAND 0DG MED OPN TI -,SUP-116.207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16864.45,11805.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER ANT THORLUM VERT 21X23MMX49-70MM XPAND 0DG MED OPN TI -,SUP-116.208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16864.45,11805.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CATH ANGIOPLASTIC MARINER BERENSTEIN 4FR 100CM -,SUP-11714016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SING HEAD OPEN LAT CONN 5.5-6.0 HEAD-5.5-6.35 OPEN 12MM WIDE -,SUP-1175.9214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7265.73,5086.011,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN MOUNTAINEER 3.5-5.5X420MM CRV TI OCT LVL1 NS -,SUP-1183-11-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR LD SWIFT- LOCK SPIN CRD MECH LCK -,SUP-1192,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM-THRD -,SUP-121107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM THRD_ -,SUP-121108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM THRD- -,SUP-121109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM THRD. -,SUP-121110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 19MM COMPR LAG AMBI CLASSIC IMHS 21MM THRD STD 3.5MM -,SUP-121116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,781.07,546.749,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
12MM ROD -,SUP-12-1120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X25MM CANN 19MM THRD SD/ST REVCT FLUT SS -,SUP-121625,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X30MM CANN 16MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X35MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121627,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X40MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X45MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121629,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X50MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X55MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121631,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X60MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X65MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121633,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X70MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X75MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X80MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X85MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121637,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X90MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5 CANNULATED 9.5 -,SUP-121639,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X100MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X105MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121641,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X110MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X115MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121643,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X120MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO 6.5X12.7MM F/7MM CANN BN SCR RND STRL -,SUP-121680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.23,451.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ACTB 6.5X30MM GRIFTON PINNCL LCK TI FOAM DOME ST -,SUP-1217-30-500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,537.46,376.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX10MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX12MM CANN 5MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX14MM CANN 5MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX16MM CANN 6MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX18MM CANN 7MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX22MM CANN 9MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX24MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX26MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX28MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX30MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121830,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX32MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX34MM CANN 14MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121834,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX36MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121836,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX38MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121838,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX40MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX42MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121842,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX44MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121844,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX46MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX48MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121848,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX50MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121850,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX52MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121852,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX54MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121854,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX56MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121856,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX58MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121858,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED 4.0M X 60M -,SUP-121860,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX65MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX70MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121870,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
30MM CROSSLINK -,SUP-12-2052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CATALYST R1 6.5MM CENTER SCREW AND CAP SIZE 30 -,SUP-1230-7508-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CATALYST R1 4.5MM LOCKING SCREW SIZE 20 -,SUP-1230-7511-003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CATALYST R1 4.5MM LOCKING SCREW SIZE 24 -,SUP-1230-7511-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CATALYST R1 GLENOSPHERE LOCKING SCREW IMPLANT -,SUP-1230-7515-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LINER INSERT MDM X3 22.2MM ID X 36MM OD X 36C -,SUP-1236-2-242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ENDCAP SPIN REVERE -,SUP-124.000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
REV LOW PROF ADJ T-CONN 29 X 34 -,SUP-124.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X25MM REVERE DBL LD THRD POLYAX F/5.5MM TI -,SUP-124.051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X30MM REVERE DL HEAD THRD POLYAX F/5.5MM TI -,SUP-124.052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI -,SUP-124.053,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X35MM REVERE DEFRM MONOAX -,SUP-124.263,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X40MM REVERE DEFRM MONOAX -,SUP-124.264,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5X35MM REVERE DEFRM MONOAX -,SUP-124.273,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X30MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.443,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.5MM REVERE PEDICLE SCREW 45MM -,SUP-124.445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X30MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.452,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.453,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X40MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.454,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X45MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X50MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.456,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X55MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.457,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X30MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.462,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.463,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X40MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.464,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X45MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X50MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.466,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X55MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.467,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X60MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.468,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X65MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.469,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5X40MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.474,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN REVERE DEFRM 5.5X100MM STR TI LPRO THORLUM NTHRD -,SUP-124.510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
5.5MM STRAIGHT ROD 125MM -,SUP-124.512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN REVERE DEFRM 5.5X150MM STR TI LPRO THORLUM NTHRD -,SUP-124.515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
5.5MM STRAIGHT ROD 400MM -,SUP-124.520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD STRAIGHT 5.5 X 500 -,SUP-124.521,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN REVERE DEFRM 5.5X45MM STR TI LPRO THORLUM NTHRD LCK -,SUP-124.545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN REVERE DEFRM 5.5X85MM STR TI LPRO THORLUM NTHRD LCK -,SUP-124.585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
5.5MM CURVED ROD 125MM -,SUP-124.612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN REVERE DEFRM 5.5X35MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN REVERE DEFRM 5.5X40MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN REVERE DEFRM 5.5X45MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN REVERE DEFRM 5.5X50MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN REVERE DEFRM 5.5X55MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN REVERE DEFRM 5.5X60MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN REVERE DEFRM 5.5X65MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN REVERE DEFRM 5.5X75MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6MM DL OD 35MM REVERE POLYAX CORT/CANC F/5.5MM TI ALY -,SUP-124.762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6MM DL OD 40MM REVERE POLYAX CORT/CANC F/5.5MM TI ALY -,SUP-124.763,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CONNECTOR ROD REVERE 5.5MM VARIABLE CROSS 38MM-50MM -,SUP-124.984,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3327.48,2329.236,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
5.5MM CLOSED OFFSET CONNECTOR 5.5MM ROD 30MM -,SUP-124.993,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ELIMINATOR ACTB THRD POS STP F/CUP DURALOC -,SUP-1246-03-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
OSTEOAMP GRANULES 1CC -,SUP-12600201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2340.97,1638.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
OSTEOAMP GRANULES 5CC -,SUP-12600401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4725.27,3307.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
OSTEOAMP GRANULES 10CC -,SUP-12600501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7875.46,5512.822,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
OSTEOAMP GRANULES 2-4MM (5CC) -,SUP-12700401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4587.68,3211.376,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 1.3MMX15CM THRD TROC TIP -,SUP-128047,CDM,C1713,HCPCS,278,RC,,,outpatient,,,305.64,213.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
STAPLE BN FX XS COCR -,SUP-128690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2676.59,1873.613,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
STAPLE BN FX SM COCR -,SUP-128692,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2676.59,1873.613,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
RESTRICTOR BNCMNT FMCNL 25MM BUCK -,SUP-129419,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1159.24,811.468,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
UNITED HIP SYSTEM FULL XPE CUP 36MM X 54MM -,SUP-1302-3654,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
STAPLE SPIN RSTRL SM TI -,SUP-131.001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4759.68,3331.776,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
STAPLE SPIN CDL SM TI -,SUP-131.002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4759.68,3331.776,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
STAPLE SPIN ANT VERT SM TI -,SUP-131.011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3413.41,2389.387,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CONNECTOR SPIN REVERE DL CX 15MM TI -,SUP-131.115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CONNECTOR SPIN CX TI -,SUP-131.116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X35MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X40MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X18MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X24MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN TMX 12.9MMX43.7MM COMPR HI STRGTH 2D CONTR LCK Y -,SUP-1312-17-003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2534.99,1774.493,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN F 3 13MMX42.7MM HI FLEX 3D CONTR LCK NS RT -,SUP-131217100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2778.47,1944.929,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN F 3 13MMX42.7MM HI FLEX 3D CONTR LCK NS LT -,SUP-131217101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2778.47,1944.929,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO 3.5MM ALPS F/ELB PLATE SYS NS -,SUP-131218000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X14MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X16MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X28MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X30MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X36MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X40MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X44MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X48MM NLCKG CORT ALPS TRNCT SQ DRV TMX NS -,SUP-131218048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X50MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X60MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X70MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 10.7X85MM 9HL 2.4MM CONTR LCK TMX ANTMC -,SUP-131218203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 17.5X29MM 1.5MM CONTR LCK TMX SM ANTMC NS -,SUP-131218400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3637.79,2546.453,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN SM -,SUP-1312-18-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4024.48,2817.136,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 81X10IN 10HL CONTR LCK COMPR TMX SM ANTMC NS -,SUP-131218600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 10.7X154MM 17HL 2.5MM CONTR LCK COMPR TMX LNG -,SUP-131218607,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4481.66,3137.162,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO 2.5MM ALPS THRD -,SUP-131220025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 2.5MM PRCONT LCK COMPR TMX T-SHP ANTMC NS -,SUP-131220152,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2353.42,1647.394,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 2.5MM PRCONT LCK COMPR TMX SM T-SHP ANTMC NS -,SUP-131220157,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2099,1469.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 2.5MM PRCONT LCK COMPR TMX STR ANTMC NS -,SUP-131220251,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2448.83,1714.181,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 27.6MMX73.8MM 2.5MM 1.65MM PRCONT LCK COMPR -,SUP-131220252,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2448.83,1714.181,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 19.5MMX71.8MM 2.5MM 1.65MM PRCONT LCK COMPR -,SUP-131220253,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2448.83,1714.181,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X11MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X14MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X15MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220415,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X16MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X12MM NLCKG CORT ALPS ST MULDIR MODULAR SQ DRV TMX -,SUP-131220512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X14MM NLCKG CORT ALPS ST MULDIR MODULAR SQ DRV TMX -,SUP-131220514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X15MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X16MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X18MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X20MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.7X18MM LCK SMTH DVR -,SUP-131227118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X20MM LCK CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X22MM LCK CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X14MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X15MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227215,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X16MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X26MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227226,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN DVR 24X85MM F/CROSSLOCK DIST RAD PLATE SYS LNG LCK -,SUP-131812090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4558.06,3190.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN MARS 5.5X45MM CRV CONE TIP TI ANT LMBR -,SUP-132.145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4334.79,3034.353,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN MARS 5.5X50MM CRV CONE TIP TI ANT LMBR -,SUP-132.150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN MARS 5.5X55MM CRV CONE TIP TI ANT LMBR -,SUP-132.155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4334.79,3034.353,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN MARS 5.5X60MM CRV CONE TIP TI ANT LMBR -,SUP-132.160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW REVIEVE 2.2MM X 6MM SELF TAPPING -,SUP-136.506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1235.02,864.514,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FEMORAL HEAD BIOLOX 32MM +5 12 -,SUP-1365-32-720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5432.32,3802.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FEMORAL HEAD BIOLOX DELTA TS CERAMIC  36MM +1.5 12/14 TAPER -,SUP-1365-36-710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5432.32,3802.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CERAMIC FEMORAL HEAD 40MM X 1.5 BIOLOX DELTA TS -,SUP-1365-40-710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FORTIFY I 12MM UPPER ENDPLATE 12 X 14MM 0 DEG -,SUP-137.300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FORTIFY I 12MM UPPER ENDPLATE 12 X 14MM 3.5 DEG -,SUP-137.301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FORTIFY I 12MM LOWER ENDPLATE 12 X 14MM 0 DEG -,SUP-137.350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FORTIFY I 12MM LOWER ENDPLATE 12 X 14MM 3.5 DEG -,SUP-137.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FORTIFY I 12MM LOWER ENDPLAE 12 X 14MM 3.5 DEG -,SUP-137.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
KT BONE CMNT 2.5% GENT40 GM CEMEX GENTA RX STRL -,SUP-1400-AG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 3.2MM STNMN 14IN THRD -,SUP-14012-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,213.27,149.289,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 3.2MMX9IN THRD -,SUP-140129,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X52MM CORT VERSANAIL FT ST NON-DRV END SLD HEX HEAD -,SUP-14022-52,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW AUTOFIX 2.0 X 10MM -,SUP-141-2010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW  AUTOFIX 2.0 X 12MM -,SUP-141-2012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
AUTOFIX HEADLESS SCREW 2.0 X 13 -,SUP-141-2013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW AUTOFIX HEADLESS 2.0 X 13 -,SUP-141-2013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW AUTOFIX HEADLESS 2.0 X 14 -,SUP-141-2014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED 2.0 X 15MM -,SUP-141-2015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW AUTOFIX 2.0 X 16 -,SUP-141-2016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X17MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD MOD -,SUP-1412017,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X18MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD MOD -,SUP-141-2018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED 2.0 X 19MM -,SUP-141-2019,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW AUTOFIX COMPRESSION 2.0 X 20MM -,SUP-141-2020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW AUTOFIX 2.0 X 21MM -,SUP-141-2021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW AUTOFIX 2.5 X 23MM -,SUP-141-2023,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW AUTOFIX 2.5 X 24MM -,SUP-141-2024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
AUTOFIX SCREW 2.0 X 25MM -,SUP-141-2025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW AUTOFIX 2.0 X 26MM -,SUP-141-2026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW AUTOFIX 2.5 X 28MM -,SUP-141-2028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
AUTOFIX 2.0 X 29MM SCREW -,SUP-141-2029,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW AUTOFIX COMPRESSION 2.0 X 30MM -,SUP-141-2030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW AUTOFIX 2.5 X 10 -,SUP-141-2510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW AUTOFIX HEADLESS 2.5 X 14 -,SUP-141-2514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED 25 X 15MM -,SUP-141-2515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
AUTOFIX 2.0/2.5 16MM -,SUP-141-2516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS 2.5 X 17MM -,SUP-141-2517,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW AUTOFIX 2.5 X 18MM -,SUP-141-2518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW AUTOFIX 2.5 X 19 -,SUP-141-2519,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW AUTOFIX 2.5 X 21MM -,SUP-141-2521,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
AUTOFIX 2.0/2.5 23MM -,SUP-141-2523,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X24MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD -,SUP-1412524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS 2.5 X 25MM -,SUP-141-2525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS 2.5 X 26MM -,SUP-141-2526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
AUTOFIX 2.5/2.5 27MM -,SUP-141-2527,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS 2.5 X 28MM -,SUP-141-2528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X30MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD -,SUP-141-2529,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X30MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD -,SUP-1412530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 2.5MM 30MM AUTOFIX STAINLESS STEEL T7 FOOT ANKLE -,SUP-141-2530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO 8MM TI -,SUP-14191,CDM,C1713,HCPCS,278,RC,,,outpatient,,,175.05,122.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8X100MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8X105MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8X110MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8X40MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8X45MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8X50MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8X55MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8X60MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8X65MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8X70MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8X75MM CANN LAG CANC ACE THRD SD/ST CUT FLUTX4 TMX NS -,SUP-14192-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8X85MM CANN LAG CANC ACE 24MM THRD SD/ST CUT FLUTX4 -,SUP-14192-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8X90MM CANN LAG CANC ACE 24MM THRD SD/ST CUT FLUTX4 -,SUP-14192-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8X95MM CANN LAG CANC ACE 24MM THRD SD/ST CUT FLUTX4 -,SUP-14192-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X100MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X105MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X110MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X115MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X120MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X25MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X30MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X35MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X40MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X45MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X50MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X55MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X60MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X65MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X70MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X75MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X80MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X85MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X90MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X95MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X100MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X105MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT -,SUP-14197-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X110MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT -,SUP-14197-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X40MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X45MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X50MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X55MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X60MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X65MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X70MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X75MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X80MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X85MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X90MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X95MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PRECISION PIN TM TAPERED D3.2/3.9X450MM -,SUP-1420-0065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X20MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X22MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X24MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X26MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X28MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X30MM CANNULATEDLAG CORT FT TMX NS -,SUP-14200-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X32MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X34MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X36MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X38MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X40MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X42MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X44MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X46MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X48MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X50MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X55MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X60MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X65MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X70MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X36MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-14223036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X30MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14250-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X32MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X34MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X36MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X38MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X40MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X42MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X44MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X46MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14250-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X48MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14250-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X50MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X55MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X60MM CANN LAG CORT 20MM FT SD/ST BIOCMPT TMX NS -,SUP-14250-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X65MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X70MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO F/4.5-5.0MM CANN SCR SYS FLT -,SUP-14260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,504.67,353.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 10HL 100DG TBLR -,SUP-14355-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,557.3,390.11,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 9.2X49MM 3.5MM 4HL 1.3MM LCK TI 100DG ANG TBLR -,SUP-143554,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 9.2X73MM 3.5MM 6HL LCK COMPR TMX ANTMC THRD HL -,SUP-143556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 9.2X85MM 3.5MM 7HL LCK TI ANTMC NS -,SUP-143557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 9.2X97MM 3.5MM 8HL LCK TI 100DG ANG TBLR ANTMC -,SUP-143558,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X14MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X16MM CANC -,SUP-14376-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,977.89,684.523,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X24MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X34MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-1437634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X40MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X42MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X44MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X46MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X48MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X50MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X55MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X60MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X65MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X70MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE PIN- 4 x 110MM- STERILE (2 Pack) -,SUP-144110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE PIN- 4 x 140MM- STERILE (2 Pack) -,SUP-144140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE PIN- 4 x 170MM- STERILE (2 Pack) -,SUP-144170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER ANT CERV 14X6X12MM SOLITAIRE 12DG LRDTC S/MED -,SUP-14-520506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12505.38,8753.766,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER ANT CERV 14X7X12MM SOLITAIRE 12DG LRDTC S/MED -,SUP-14-520507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12505.38,8753.766,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER ANT CERV 14X9X12MM SOLITAIRE 12DG LRDTC S/MED -,SUP-14-520509,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12505.38,8753.766,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER 10X27X8MM ZYSTON 6DG LRDTC CRV TAPR -,SUP-14-533128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER 10X25X7MM ZYSTON STR CNVX -,SUP-14-534067,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 3.5MM X46MM CANNULATED -,SUP-148.146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.2X13MM PROVIDENCE SD FX-ANG -,SUP-150.013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.2MM X 14MM -,SUP-150.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN PROVIDENCE 12MM 4HL LVL1 TI LCK -,SUP-150.112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN PROVIDENCE 14MM 4HL LVL1 TI LCK -,SUP-150.114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN PROVIDENCE 16MM 4HL LVL1 TI LCK -,SUP-150.116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN PROVIDENCE 18MM 4HL LVL1 TI LCK -,SUP-150.118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANTERIOR CERVICAL PLATE 1-LEVEL -,SUP-150.120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE ANTERIOR CERVICAL 1-LEVEL 22MM PROV -,SUP-150.122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE ANTERIOR CERVICAL 24MM 1 LEVEL PROVIDENCE -,SUP-150.124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANTERIOR CERVICAL PLATE 14MM LORD -,SUP-150.134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN PROVIDENCE 28MM 6HL LVL2 TI LCK -,SUP-150.228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN PROVIDENCE 30MM 6HL LVL2 TI LCK -,SUP-150.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN PROVIDENCE 32MM 6HL LVL2 TI LCK -,SUP-150.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN PROVIDENCE 34MM 6HL LVL2 TI LCK -,SUP-150.234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN PROVIDENCE 36MM 6HL LVL2 TI LCK -,SUP-150.236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CERVICAL ANTERIOR 2-LEVEL 38MM -,SUP-150.238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN PROVIDENCE 45MM 8HL LVL3 TI LCK -,SUP-150.345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN PROVIDENCE 48MM 8HL LVL3 TI LCK -,SUP-150.348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN PROVIDENCE 51MM 8HL LVL3 TI LCK -,SUP-150.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN PROVIDENCE 54MM 8HL LVL3 TI LCK -,SUP-150.354,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN PROVIDENCE 57MM 8HL LVL3 TI LCK -,SUP-150.357,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PROVIDENCE ANTERIOR CERVICAL PLATE 3-LVL 60MM -,SUP-150.360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANTERIOR CERVICAL PLATE 4-LEVEL 69MM -,SUP-150.469,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW PROV 4.6MM FIXED ANGLE SELF DRILL 14MM -,SUP-150.514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.6X16MM PROVIDENCE ST FA TI ALY -,SUP-150.536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.6X18MM PROVIDENCE SD FA TI ALY -,SUP-150.538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.2X12MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.2X13MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.613,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.2X14MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.2X15MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.2X16MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SELF DRILLING 4.6MM X 12MM VAR ANGLE PROV -,SUP-150.712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.6X13MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.713,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.6X14MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.6X16MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SELF DRILLING 4.2MM X 12MM VAR ANGLE PROV -,SUP-150.812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PROVIDENCE 4.2MM VARIABLE ANGLE SCREW SELF-TAP 14MM -,SUP-150.814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW PROVIDENCE 4.6MM VARIABLE ANGLE 16MM SELF TAPPING -,SUP-150.816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW PROVIDENCE 4.2MM VARIABLE ANGLE - 20MM -,SUP-150.820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TRNSCONN 4.6X12MM PROVIDENCE ST VAR ANG TI ANT CERV -,SUP-150.912,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.6X14MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.914,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.6X15MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.915,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.6X16MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.916,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.6X18MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.918,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SELF TAPPING 4.6 X 20 VAR ANGLE PROV -,SUP-150.920,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
OSS POLY LOCK PIN -,SUP-150478,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1865.78,1306.046,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FORTIFY 12MM CORE HEIGHT 21-29MM -,SUP-151.052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FORTIFY 12MM CORE HEIGHT 25-37MM -,SUP-151.053,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CORE FORTIFY 012MM HEIGHT 33-53MM -,SUP-151.054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ENDPLATE UPPER 012MM 12X14 FOOTPRINT 3.5 DEG -,SUP-151.323,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ENDPLATE LOWER 012MM 12 X 14 FOOTPRINT 7 DEG FORTIFY -,SUP-151.374,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SYSTEM CLENCH STAPEL 9MM X 7MM -,SUP-152-30907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SYSTEM CLENCH STAPLE 15MM X 12MM -,SUP-152-31512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SYSTEM CLENCH STAPLE 18MM X 18MM -,SUP-152-31818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
STAPLE CLENCH 15MM X 12MM -,SUP-152-41512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BED F/PROC STRECHER UPR FRM ASMB -,SUP-16042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.68,1.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE OSS RS NON MOD LONG 59 -,SUP-161022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20050.2,14035.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN FX STNMN 2MMX9IN SMTH SGL END PLN DMD PT NS -,SUP-1620-609NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21.41,14.987,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN FX STNMN 2.4MMX9IN SMTH SGL END PLN DMD PT NS -,SUP-1624-609NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21.41,14.987,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN FX STNMN 4.8MMX9IN SMTH SGL END PLN DMD PT NS -,SUP-1648-609X,CDM,C1713,HCPCS,278,RC,,,outpatient,,,29.18,20.426,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIBIAL INSERT PS SZ 6 13MM -,SUP-166-5613,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SHELL ACETABULAR ESCALADE 46MM -,SUP-170-0146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ESCALADE EXL LINER +1 28 X 46MM -,SUP-170-2846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
EXPANSION BOLT RECONSTRUCTION PROSTHESIS -,SUP-172-947/38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
MESH SURG 17X22X50MM OVL TI HARMS -,SUP-1741-48-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17992.27,12594.589,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
MESH SURG 17X22X70MM OVL TI HARMS -,SUP-1741-49,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20248.85,14174.195,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
MESH SURG 22X28X70MM OVL TI HARMS -,SUP-1741-52-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20248.85,14174.195,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
MESH SURG 22X28X90MM OVL TI HARMS -,SUP-1741-53-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,24291.37,17003.959,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
MESH SURG 26X33X50MM OVL TI HARMS -,SUP-1741-54-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17992.27,12594.589,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
MESH SURG 26X33X70MM OVL TI HARMS -,SUP-1741-55-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21889.99,15322.993,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER SPIN TI POLY IEXP -,SUP-1754-91-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NUT SPIN TI BOLT SWVL LCK IEXP -,SUP-1754-91-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,543.24,380.268,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 50MM RND 10MM SGL LVL TI -,SUP-1760-10-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17292.37,12104.659,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 50MM RND 12MM SGL LVL TI -,SUP-1760-12-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17292.37,12104.659,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 90MM RND 12MM SGL LVL TI -,SUP-1760-12-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18873.18,13211.226,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 50MM RND 14MM SGL LVL TI -,SUP-1760-14-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17292.37,12104.659,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 90MM RND 14MM SGL LVL TI -,SUP-1760-14-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19307.6,13515.32,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 50MM RND 16MM SGL LVL TI -,SUP-1760-16-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16483.86,11538.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
MESH ROUND 16MM X 90MM SPN -,SUP-1760-16-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19754.09,13827.863,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
MESH SURG 12X23MM DIA 12X14MM OVL TRPZD TI HARMS -,SUP-1762-02-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10345.35,7241.745,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NUT ORTHO DOME TI SWVL F/MONARCH SPN SYS -,SUP-1770-91-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,481.97,337.379,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKNLC 47MM LVL2 TI LPRO -,SUP-1796-02-047,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6079.53,4255.671,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SET SCREW SPIN EXPEDIUM TI POST PDCL THORLUM SQ THRD -,SUP-1797-02-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SET SCREW SPIN EXPEDIUM TI POST PDCL THORLUM SQ THRD -,SUP-1797-02-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
VIPER TI SAI POLY 8X90MM -,SUP-179704890,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5X45MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5X50MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-179712050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5X65MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.35X20MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.35X25MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.35X30MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.35X35MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.35X40MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5 X 25MM POLYAXIAL SI -,SUP-179712525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X40MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X45MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X50MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X30MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X35MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X55MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7X35MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-735,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7X45MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-745,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7X50MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7X55MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
EXP TI POLY SCREW 8 X 40MM -,SUP-179712840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL 8MM X 65MM -,SUP-179712865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN EXPEDIUM 5.5X480MM HEX END TI POST PDCL THORLUM -,SUP-179762480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN EXPEDIUM 5.5X35MM CRV TI POST PDCL THORLUM PRELRD -,SUP-1797-71-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN EXPEDIUM 5.5X40MM CRV TI POST PDCL THORLUM PRELRD -,SUP-1797-71-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD PRE-LODOSED W/LINE 65MM -,SUP-179771065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD PRE-LORDOSED 75MM W/LINE -,SUP-179771075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD PRE-LORDOSED W/LINE 85MM -,SUP-179771085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CONNECTOR 20MM EXPEDIUM LAT OFST OPN F/10MM TI -,SUP-1797-92-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CONNECTOR 50MM EXPEDIUM LAT OFST OPN F/5.5MM TI -,SUP-1797-92-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CONNECTOR 20MM EXPEDIUM OPN F/5.5MM TI ILC -,SUP-1797-97-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X42MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-49-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X46MM TMX CANN RDC HEAD -,SUP-1802-49-046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X30MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X32MM CANN -,SUP-1802-53-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X34MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X36MM CANN -,SUP-1802-53-036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X38MM CANN -,SUP-1802-53-038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X40MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X42MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X44MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X50MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP SCR 5MM CANN LAG P/T SD/ST TMX 55MM -,SUP-1802-53-055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X60MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X65MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X70MM CANN LAG CANC P/T SD/ST SM HEAD TMX -,SUP-1802-53-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X75MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X80MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMSMX85MM CANN LAG CANC PARTIALY THRD SD/ST RDC HEAD -,SUP-1802-53-085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X90MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMSMX95MM CANNULATEDLAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X100MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.75X15MM LCK CMPRHNSV RVRS FX TI ALY HAP CTD BLU -,SUP-180500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.75X20MM NLCKG CMPRHNSV RVRS FX TI ALY HAP CTD GOLD -,SUP-180508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.75X25MM NLCKG CMPRHNSV RVRS FX TI ALY HAP CTD GOLD -,SUP-180509,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.75X15MM LCK CORT FX 3.5MM HEX HEAD TI ALY HAP CTD -,SUP-180550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.75 X 20MM FIXED LOCKING SCREW 3.5MM HEX -,SUP-180551,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP LK SCR 3.5 HEX 4.75 X 25 ST -,SUP-180552,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW COMP LK 3.5 HEX 4.75 X 30 ST -,SUP-180553,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW COMP LK 3.5 HEX 4.75 X 35 ST -,SUP-180554,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP LK SCR 3.5 HEX 4.75 X 40 ST -,SUP-180555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.75X15MM NLCKG CORT VAR ANG 3.5MM HEX HEAD TI ALY HAP -,SUP-180557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.75X20MM NLCKG CORT VAR ANG 3.5MM HEX HEAD TI ALY HAP -,SUP-180558,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.75X25MM NLCKG CORT VAR ANG 3.5MM HEX HEAD TI ALY HAP -,SUP-180559,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP NLK SCREW 3.5 HEX 4.75 X 30 ST -,SUP-180560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.75X35MM NLCKG CMPRHNSV 3.5MM HX HEX HEAD TMX HAP CTD -,SUP-180561,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
K-WIRE- STERILE 3 x 285MM -,SUP-1806-0050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,459.86,321.902,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
STRYKER PLATE -,SUP-1806-0150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,793.85,555.695,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X320MM VERSANAIL CANN FEM TI ALY -,SUP-1813-10-320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7410.02,5187.014,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X400MM VERSANAIL CANN RT TROCH FEM TI ALY -,SUP-1814-13-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10160.14,7112.098,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 7X220MM VERSANAIL CANN HUM TI ALY -,SUP-1817-07-221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 8X200MM VERSANAIL CANN HUM TI ALY -,SUP-1817-08-201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 9X260MM VERSANAIL CANN HUM TI ALY -,SUP-1817-09-261,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
T2 ANKLE COMPRESSION SCREW -,SUP-1818-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1161.6,813.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X150MM VERSANAIL CANN PROX HUM SS -,SUP-1818-10-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7282.7,5097.89,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL T2 ANKLE ARTHRODESIS LEFT -,SUP-1818-1020S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
T2 ANKLE NAIL 11x200MM LEFT -,SUP-1818-1120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
T2 ANKLE ARTHRODESIS NAIL LEFT 11X300MM -,SUP-1818-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 12X200MM T2 CANN LT ANKL TI ALY BIOMECH -,SUP-1818-1220S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
T2 ANKLE ARTHRODESIS NAIL RIGHT 11 X 150MM -,SUP-1819-1115S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 12X200MM T2 CANN RT ANKL TI ALY BIOMECH -,SUP-1819-1220S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.8MMX20MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-35-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X24MM CORT 3.5MM HX NS F/2.9MM DRLBT -,SUP-1819-35-024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X30MM CORT 3.5MM HX NS F/2.9MM DRLBT -,SUP-1819-35-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.8MMX30MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.8MMX32MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 4.8MMX42MM 3.6MM HX NS -,SUP-1819-48-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.8MMX44MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.8MMX46MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.8MMX50MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X24MM ELLIPSE POLYAX TI -,SUP-182.224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MM X 26MM ELLIPSE POLYAXIAL SHOULDER -,SUP-182.226,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X28MM ELLIPSE POLYAX TI. -,SUP-182.228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X30MM ELLIPSE POLYAX TI. -,SUP-182.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X32MM ELLIPSE POLYAX TI -,SUP-182.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X34MM ELLIPSE POLYAX TI -,SUP-182.234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X10MM ELLIPSE POLYAX TI -,SUP-182.310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X12MM ELLIPSE POLYAX TI -,SUP-182.312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X14MM ELLIPSE POLYAX TI -,SUP-182.314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ELLIPSE POLYAXIAL 3.5MM X 16MM -,SUP-182.316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X18MM ELLIPSE POLYAX TI -,SUP-182.318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X20MM ELLIPSE POLYAX TI -,SUP-182.320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X22MM ELLIPSE POLYAX TI -,SUP-182.322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM ELLIPSE POLYAX TI -,SUP-182.326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X28MM ELLIPSE POLYAX TI -,SUP-182.328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X30MM ELLIPSE POLYAX TI -,SUP-182.330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X10MM ELLIPSE POLYAX TI -,SUP-182.410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X12MM ELLIPSE POLYAX TI -,SUP-182.412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X14MM ELLIPSE POLYAX TI -,SUP-182.414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.0MM ELLIPSE POLYAXIAL SCREW 16MM -,SUP-182.416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X18MM ELLIPSE POLYAX TI -,SUP-182.418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X20MM ELLIPSE POLYAX TI -,SUP-182.420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X22MM ELLIPSE POLYAX TI -,SUP-182.422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X24MM ELLIPSE POLYAX TI -,SUP-182.424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X26MM ELLIPSE POLYAX TI -,SUP-182.426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ELLIPSE POLYAXIAL 4.0 X 28MM -,SUP-182.428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ELLIPSE LOCKING CAP -,SUP-182.500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
HOOK SPIN INLN ELLIPSE -,SUP-182.501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ELLIPSE POLYAXIAL 4.5 X 20 -,SUP-182.520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X22MM ELLIPSE POLYAX TI -,SUP-182.522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X24MM ELLIPSE POLYAX TI -,SUP-182.524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X26MM ELLIPSE POLYAX TI -,SUP-182.526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ELLIPSE POLYAXIAL 4.5 X 28 -,SUP-182.528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ELLIPSE POLYAXIAL 4.5 X 30 -,SUP-182.530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD TO ROD CLAMP CT TO CT 7MM -,SUP-182.741,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD TO ROD CLAMP CT TO CT 9MM -,SUP-182.770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN ELLIPSE 6.35X80MM TI POST OCT -,SUP-182.801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN ELLIPSE 6.35X120MM TI POST OCT -,SUP-182.802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN ELLIPSE 3.5X240MM TI POST OCT -,SUP-182.803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN ELLIPSE 3.5X40MM TI POST OCT -,SUP-182.804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ENDCAP SPIN ELLIPSE T-SHP HD-TO-HD -,SUP-182.900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NUT SPIN ELLIPSE F/HD-TO-HD TRANSV CONN T-SHP -,SUP-182.901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TRNSCONN 27-33MM ELLIPSE HD-TO-HD F/3.5MM T-SHP POST OCT -,SUP-182.912,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TRNSCONN 26-46MM ELLIPSE F/3.5MM CRV POST OCT -,SUP-182.924,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE OCPTL SM ELLIPSE -,SUP-182.950,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 8MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0828S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 8MMSTDX300MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0830S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 8MMSTDX315MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0831S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 8MMSTDX330MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0833S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 8MMSTDX360MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0836S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 8MMSTDX390MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0839S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1028S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIBIAL NAIL 10 X 390MM -,SUP-1822-1039S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1128S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
T2 STD. TIBIAL NAIL 11MM X 300MM -,SUP-1822-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIBIAL NAIL 11 X 375MM -,SUP-1822-1137S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
11 X 390MM TIBIA NAIL -,SUP-1822-1139S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 12MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1228S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 12MMSTDX315MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1231S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 12MMSTDX345MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 12MMSTDX360MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
T2 TIBIAL NAIL SYSTEM  12 X 390MM -,SUP-1822-1239S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8MM COMPR T2 CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1825-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.67,530.369,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8X5MM COMPR T2 CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1825-0005S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.67,530.369,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL SYS T2 FEMUR A/R 010 X 340MM -,SUP-1825-1034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X360MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1038S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11X280MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1128S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11X320MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1132S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11X340MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11X400MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1140S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1144S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 12X280MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1228S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 12X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1230S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 12X360MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 12X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1238S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 12X420MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1242S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 12X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1244S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X180MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1318S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X240MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1324S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1330S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X340MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1334S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1338S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X400MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X420MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1342S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1344S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 14X240MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1424S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 14X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1430S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 14X320MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1432S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 14X340MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1434S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 14X360MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1436S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 14X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1438S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 14X400MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 14X420MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1442S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 14X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1444S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAP ORTHO 8X4MM TI E CAP PROT -,SUP-1826-0003S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,771.97,540.379,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
T2 SUPRACONDYLAR NAIL 9X340MM -,SUP-1826-0934S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
T2 SUPRACONDYLAR NAIL 9X380MM -,SUP-1826-0938S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1020S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUPRACONDYLAR NAIL 10 X 320 -,SUP-1826-1032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10MMLNGX340MM T2 CANN SPRACON TI BIOMECH -,SUP-1826-1034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10MMLNGX360MM T2 CANN SPRACON TI BIOMECH -,SUP-1826-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL SUPRACONDYLAR 10MM X 400MM -,SUP-1826-1040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMLNGX240MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1124S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMLNGX320MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1132S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUPRACONDYLAR NAIL 11 X 360MM -,SUP-1826-1136S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL SUPRACONDYLAR 11 X 380 -,SUP-1826-1138S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL SUPRACONDYLAR 11 X 420 -,SUP-1826-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 12MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1220S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 12MMLNGX280MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1228S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 12MMLNGX300MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1230S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 12MMLNGX320MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1232S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 12MM X 340MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL SUPRACONDYLAR 12 X 360 -,SUP-1826-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
T2 SUPRACONDYLAR NAIL 12X400MM -,SUP-1826-1240S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13MMLNGX300MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1330S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13MMLNGX340MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1334S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL SUPRACONDYLAR 13MM X 360MM -,SUP-1826-1336S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13MMLNGX380MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1338S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13MMLNGX400MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13MMLNGX420MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1342S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL SUPRACONDYLAR 14 X 380 -,SUP-1826-1438S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL FEMORAL 10 X 360 -,SUP-1828-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5072.64,3550.848,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL FEMORAL 11 X 340MM -,SUP-1828-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5072.64,3550.848,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL FEMORAL 11 X 400 -,SUP-1828-1140S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5072.64,3550.848,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X740MM T2 CANN RT KN TI ALY BIOMECH -,SUP-1829-1374S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,28428.72,19900.104,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO 10MM TI ALY SQ STRL -,SUP-1830-0009S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,718.87,503.209,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 7X210MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0721S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 7X220MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0722S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 7X240MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0724S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 8X240MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0824S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 8X250MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0825S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 8X280MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0828S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 9X210MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0921S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 9X220MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0922S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 9X240MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0924S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 9X250MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0925S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ENDCAP ORTHO 6MM STD TI T2 STRL -,SUP-1832-0003S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,725,507.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 8MMLNGX150MM T2 CANN LT PROX HUM TI ALY -,SUP-1832-1035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6798.89,4759.223,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 8MMLNGX240MM T2 CANN LT PROX HUM TI ALY BIOMECH -,SUP-1832-2824S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 8MMLNGX260MM T2 CANN LT PROX HUM TI ALY BIOMECH -,SUP-1832-2826S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 8MMLNGX220MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3822S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMLNGX240MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3824S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 8MMLNGX260MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3826S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMLNGX280MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3828S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 3.6MM VAR SELF-TAPPING 14MM -,SUP-184.114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 3.6MM VAR SELF-TAPPING 16MM -,SUP-184.116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 9MM 1.5M RAD 340MM T2 RECON CANN LT FEM TI ALY RECON -,SUP-1843-0934S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
T2 RECON NAIL R1.5- RIGHT 9 X 360MM X 125DG -,SUP-1845-0936S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
T2 RECON NAIL R1.5- RIGHT 9 X 380MM X 125DG -,SUP-1845-0938S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10MM 1.5M RAD 360MM T2 RECON CANN RT FEM TI ALY -,SUP-1845-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL T2 RECON R1 11MM X 420MM X 125 -,SUP-1845-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ENDCAP SPIN REVERE THORLUM NTHRD REVOLVE -,SUP-185.000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN REVOLVE 5.5X80MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN REVOLVE 5.5X90MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN REVOLVE 5.5X100MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN REVOLVE 5.5X110MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X30MM REVOLVE POLYAX TI -,SUP-185.452,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X35MM REVOLVE POLYAX TI -,SUP-185.453,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X40MM REVOLVE POLYAX TI -,SUP-185.454,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X45MM REVOLVE POLYAX TI -,SUP-185.455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X50MM REVOLVE POLYAX TI -,SUP-185.456,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X55MM REVOLVE POLYAX TI -,SUP-185.457,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X30MM REVOLVE POLYAX TI -,SUP-185.462,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X35MM REVOLVE POLYAX TI -,SUP-185.463,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X40MM REVOLVE POLYAX TI -,SUP-185.464,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X45MM REVOLVE POLYAX TI -,SUP-185.465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X50MM REVOLVE POLYAX TI -,SUP-185.466,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FEMORAL NAIL RIGHT 9 X 360MM -,SUP-1851-0936S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6489.92,4542.944,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X380MM T2 CANN RT GTR TROCH FEM TI ALY RECON -,SUP-1851-1038S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6489.92,4542.944,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CABLE SINGLE LOOP TITANIUM WITH CRIMP -,SUP-186.200S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2978.98,2085.286,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER 28X8MM LPRD 5DG LRDTC BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 28X9MM LPRD 5DG LRDTC BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER 28X7MM LPRD PRLL BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER 28X9MM LPRD PRLL BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER 28X11MM LPRD PRLL BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SET INNER MIS -,SUP-186715000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SET SCREW SPIN VIPER 2 TI PDCL SQ THRD SGL INNIE -,SUP-1867-15-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X35MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X35MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X40MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X40MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6 X 45 POLYAXIAL CANNULA -,SUP-186715645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X45MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X50MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X50MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X55MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7X40MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7X50MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X55MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X40MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X30MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X40MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X45MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TI CORT FIX 6X50MM -,SUP-186731650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TI CORT FIX 6X55MM -,SUP-186731655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X35MM VIPER 2 DBL LD THRD CANN ULTRA TI -,SUP-1867-60-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X40MM VIPER 2 DBL LD THRD CANN ULTRA TI -,SUP-1867-60-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN VIPER 5.5X35MM CRV PREBNT TI F/MN INV SURG NS -,SUP-1867-62-635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN VIPER 5.5X40MM CRV PREBNT TI F/MN INV SURG NS -,SUP-1867-62-640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN VIPER 2  - 5.5 X 35MM LORDOTIC -,SUP-186788035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN VIPER 2 5.5X35MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN VIPER 2 5.5X40MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN VIPER 2 5.5X45MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN VIPER 2 5.5X50MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TRNSCONN REVERE ADDITION RD-TO-RD F/5.5MM PRLL -,SUP-1867-88-055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN VIPER 2 5.5X65MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD VIPER 2 LORDOTIC 75MM -,SUP-186788075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD LORDOTIC 80MM VIPER2 -,SUP-186788080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD LORDOTIC 90MM VIPER2 -,SUP-186788090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 16X12MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 16X14MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 16X16MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 16X18MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 16X20MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 16X22MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 16X24MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 16X26MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SKY 1 LEVEL PLATE 28MM -,SUP-1868-01-028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 16X30MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 28MM SKYLINE 2 LEVEL TI -,SUP-186802028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 16X30MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 16X32MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 16X34MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 16X36MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 16X40MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 16X42MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 16X44MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 16X45MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 16X48MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 16X51MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 16X54MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 16X57MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-057,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X12MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL BLU -,SUP-1868-50-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X14MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL GOLD -,SUP-1868-50-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X16MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL MAG -,SUP-1868-50-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X18MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL -,SUP-1868-50-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X12MM SKYLINE ST VAR ANG HX LOBE HEAD TI STRL BLU -,SUP-1868-52-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X14MM SKYLINE ST VAR ANG HX LOBE HEAD TI STRL GOLD -,SUP-1868-52-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X16MM SKYLINE ST VAR ANG HX LOBE HEAD TI STRL MAG -,SUP-1868-52-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SKY VARIABLE S-T 18MM TI -,SUP-186852018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X12MM SKYLINE ST VAR ANG OVSZ HX LOBE HEAD TI STRL -,SUP-1868-54-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X14MM SKYLINE ST VAR ANG OVSZ HX LOBE HEAD TI STRL -,SUP-1868-54-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X16MM SKYLINE ST VAR ANG OVSZ HX LOBE HEAD TI STRL -,SUP-1868-54-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X14MM SKYLINE ST FA CNSTRN OVSZ HX LOBE HEAD TI -,SUP-1868-64-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT COUGAR SM 12MM 5 DEG -,SUP-187105112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COUGAR IMPLANT MED 14MM 50DEG -,SUP-187105214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER 14MM COUGAR 10DG SM CFRP -,SUP-1871-10-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COUGAR IMPLANT MED 14MM 10DEG -,SUP-187110214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN EXPEDIUM 5.5X70MM STR TI ANT PCUT NS -,SUP-1877-03-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BULLETT CONCORD 9 X 7 X 23 -,SUP-187823107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 9X8X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 9X9X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 9X10X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 9X8X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 9X9X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-187823409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 9X9X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 9X10X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 9X11X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 9X12X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 11X12X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CONCORDE BUL LOR 11X13X23 5DG -,SUP-187823513,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 9X7X27MM CONCORDE -,SUP-187827107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 9X7X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 9X8X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 9X9X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 9X10X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 11X12X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 9X8X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-27-408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 9X9X27MM CONCORDE 5DG LRDTC BLLT NOSE STNT LPRO CFRP -,SUP-1878-27-409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 9X10X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-27-410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CONCORDE BUL LOR 9 X 11 X 27 -,SUP-187827411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 9X11X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-27-411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 11X12X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-187827512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 9X7X23MM CONCORDE PRLL CFRP -,SUP-1879-23-107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14828.79,10380.153,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 11X13X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1879-27-513,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CONNECTOR SPIN MOUNTAINEER LAT OFST TI -,SUP-1883-12-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X10MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X12MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X18MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X12MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X22MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X24MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X26MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X12MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X16MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X20MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X22MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X22MM MOUNTAINEER MINI POLYAX TAPR TI STRL BLU SHNK -,SUP-1883-19-422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X26MM MOUNTAINEER MINI POLYAX TAPR TI STRL BLU SHNK -,SUP-1883-19-426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X50MM MOUNTAINEER MINI POLYAX TAPR TI STRL BLU SHNK -,SUP-1883-19-450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.35X20MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.35X25MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.35X30MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.35X35MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.35X40MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X20MM MOUNTAINEER MINI POLYAX SHNK TAPR TI STRL -,SUP-1883-20-320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X28MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X32MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X34MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X36MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X38MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X40MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
XCONN 21MM MOUNTAINEER HD-TO-HD TI OCT -,SUP-1883-41-021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X12MM MOUNTAINEER MINI POLYAX TI STRL -,SUP-188362012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE OC 37MM -,SUP-188362037,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
MNTR OC PLATE LARGE -,SUP-188362045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.25X8MM MOUNTAINEER MINI POLYAX TI STRL -,SUP-188362108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
MNTR OC PREBENT ROD 3.5X120 -,SUP-188363200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,921.93,645.351,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 34MM LVL2 PRELRD TI VSBL GFT SITE -,SUP-1888-02-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5856.72,4099.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE ANTLAT 33-46MMH X-MESH 0DG MED TI -,SUP-1889-01-033,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20402.94,14282.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 0DG ANTLAT 51-71MM X-MESH MED TI -,SUP-1889-01-051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22445.09,15711.563,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X35MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,820.98,574.686,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X40MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,812.82,568.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X45MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,812.82,568.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X55MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,812.82,568.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X60MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,820.98,574.686,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X65MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,820.98,574.686,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SFX-5.5 TI LAT SIZE F4 -,SUP-189401104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DEPUY SPINE SFX F5 CROSSLINK -,SUP-189401105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CONNECTOR SZ F6 EXPEDIUM SFX FX F/5.5MM TI MDL -,SUP-1894-01-206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CONNECTOR SZ F7 EXPEDIUM SFX FX F/5.5MM TI MDL -,SUP-1894-01-207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CONNECTOR SPIN EXPEDIUM CX TI -,SUP-1894-01-209,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SFX 5.5 TI LAT SIZE A2 -,SUP-189401302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CONNECTOR SZ A4 EXPEDIUM SFX F/5.5MM TI MDL NS -,SUP-1894-01-404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CONNECTOR SZ A5 EXPEDIUM SFX F/5.5MM TI MDL NS -,SUP-1894-01-405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CONNECTOR SZ A6 EXPEDIUM SFX F/5.5MM TI MDL NS -,SUP-1894-01-406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T2 CONDYLE 5MM X 50MM -,SUP-1895-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X60MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X75MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X80MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X85MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X20MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4020S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X22MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4022S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X26MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4028S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X30MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
T2 F/T LOCKING SCREW 4MM X 32MM -,SUP-1896-4032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X36MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X38MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4038S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X45MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X55MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T2 F/T LOCK 5 X 30 -,SUP-1896-5030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX32.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T2 F/T LOCK 5 X 35 -,SUP-1896-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX37.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T2 F/T LOCK 5 X 40 -,SUP-1896-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX42.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T2 F/T LOCK 5 X 45 -,SUP-1896-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX47.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5047S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T2 F/T LOCK 5 X 50 -,SUP-1896-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX52.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5052S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T2 F/T LOCK 5 X 55 -,SUP-1896-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX57.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5057S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T2 F/T LOCK 5 X 60 -,SUP-1896-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T2 F/T LOCK 5 X 65 -,SUP-1896-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T2 F/T LOCK 5 X 70 -,SUP-1896-5070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T2 F/T LOCK 5 X 75 -,SUP-1896-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X80MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X85MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X90MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X100MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN UNIPLATE 2 36MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-02-036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN UNIPLATE 2 38MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-02-038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.6X12MM UNIPLATE ST CANC TI BLU -,SUP-1897-06-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.6X13MM UNIPLATE ST CANC TI BLU -,SUP-1897-06-013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.6X14MM UNIPLATE ST CANC TI GOLD -,SUP-189706014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 14MM UNIPLATE SPINE CERVICAL ANTERIOR SELF -,SUP-1897-06-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1293.32,905.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.6X15MM UNIPLATE ST CANC TI LBLU -,SUP-1897-06-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.6X18MM UNIPLATE ST CANC TI LBLU -,SUP-1897-06-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.2MMX14MM UNIPLATE OVSZ CANC TI GOLD -,SUP-1897-06-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.2MMX18MM UNIPLATE ST CANC TI GOLD -,SUP-1897-06-118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.6X12MM UNIPLATE SD CANC TI BLU -,SUP-1897-07-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.6X13MM UNIPLATE SD CANC TI VIOL -,SUP-1897-07-013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.6X15MM UNIPLATE SD CANC TI LBLU -,SUP-1897-07-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN UNIPLATE 2 14MM LVL1 PRELRD TI NRW MDLN NO- BND -,SUP-189721014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN UNIPLATE 2 16MM LVL1 PRELRD TI NRW MDLN NO- BND -,SUP-189721016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN UNIPLATE 2 28MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-22-028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN UNIPLATE 2 32MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-22-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN UNIPLATE 2 34MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-22-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T2 RECON LAG 6.5MM X 75MM -,SUP-1897-6075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T2 RECON LAG 6.5MM X 80MM -,SUP-1897-6080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LAG T2 RECON SYSTEM 6.5 X 85 -,SUP-1897-6085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LAG BONE T2 RECON SYSTEM 6.5 X 90 -,SUP-1897-6090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LAG T2 RECON 6.5MM X 100MM -,SUP-1897-6100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LEVEL 1 PLATE 20MM -,SUP-19-0120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CALBIBER SPACER 10 X 22MM- 10-15MM -,SUP-194.222,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SEMI CONST DRILL 4.0 X 14 -,SUP-19-6514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MMX6MM LCK COMPR CORT LCP FT STD CRUCIF RCESS SS NS -,SUP-201.006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,93.36,65.352,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.4MMX10MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CLIP ANEUR 2.4MMX12MM SS LCP ST -,SUP-201.762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.4MMX13MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.763,CDM,C1713,HCPCS,278,RC,,,outpatient,,,411.37,287.959,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.4MMX14MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.764,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.4MMX18MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.768,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.4MMX22MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.772,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X10MM LCK COMPR LCP THRD ST FA T6 STRDRV RCESS SS NS -,SUP-201.880,CDM,C1713,HCPCS,278,RC,,,outpatient,,,830.26,581.182,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX10MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,328.22,229.754,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX12MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,328.22,229.754,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX26MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX28MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX30MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX32MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX34MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX36MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX38MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX40MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX45MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX50MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX55MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X10MM LCK COMPR LCP THRD ST T8 STRDRV RCESS SS NS -,SUP-202.210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,886.92,620.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X30MM LCK COMPR LCP THRD ST T8 STRDRV RCESS SS NS -,SUP-202.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.01,516.607,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X40MM LCK COMPR LCP THRD ST T8 STRDRV RCESS SS NS -,SUP-202.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.01,516.607,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X14MM CANN LNG THRD SD/ST CRUCIF RCESS SS NS -,SUP-202.714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1530.52,1071.364,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X16MM LCK COMPR CORT LCP FT ST T8 STRDRV RCESS SS -,SUP-202.876,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X18MM LCK COMPR CORT LCP FT ST T8 STRDRV RCESS SS -,SUP-202.878,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTEX SLF TPNG 2.7 X 20MM T8 SD REC -,SUP-202.880,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X24MM LCK COMPR CORT LCP FT ST T8 STRDRV RCESS SS -,SUP-202.884,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTEX SLF TPNG 2.7 X 26MM T8 SD REC -,SUP-202.886,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTEX SLF TPNG 2.7 X 28MM T8 SD REC -,SUP-202.888,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTEX SLF TPNG 2.7 X 30MM T8 SD REC -,SUP-202.890,CDM,C1713,HCPCS,278,RC,,,outpatient,,,577.67,404.369,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BODY PHOENIX SHRT OPN BD -,SUP-20-2070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BODY STD PHOENIX OPN BD POST PDCL F/MN INV FX SYS -,SUP-20-2090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
6.5 X 40MM CANCELLOUS BONE SCREW -,SUP-2030-6540-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ACTB 6.5X55MM OMNIFIT -,SUP-2030-6555-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ACTB 6.5X60MM OMNIFIT -,SUP-2030-6560-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X10MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X12MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X14MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,192.56,134.792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X16MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX18MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX20MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX22MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX24MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX26MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX28MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX32MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX34MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX36MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX38MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX40MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX45MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X50MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X28MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X30MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X32MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X34MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X36MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X38MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X14MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X20MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X22MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X24MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X28MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X32MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X34MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.834,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X48MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.848,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN PHOENIX 35MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN PHOENIX 40MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN PHOENIX 45MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN PHOENIX 50MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN PHOENIX 55MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN PHOENIX 70MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN PHOENIX 75MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX10MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX12MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX14MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.61,257.327,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX16MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.61,257.327,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX18MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.61,257.327,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX22MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX24MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX26MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX30MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX35MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX40MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX45MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX50MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX55MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX60MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FEM PRESSURIZING SEAL - SMALL -,SUP-206-545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,101.12,70.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X10MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X12MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X14MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X16MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X18MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X20MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X22MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X24MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X26MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X30MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,157.55,110.285,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X40MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X45MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X50MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX34MM LCK CANN LCP LNG THRD SD/ST 2.5MM SM HEX SCKT -,SUP-207.734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7MMX35MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7MMX40MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7MMX45MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7MMX50MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7MMX70MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7MMX75MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X95MM LCK CANN 32MM THRD SD/ST REVCT FLUT 4MM LRG -,SUP-208.441,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1770.37,1239.259,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7MMX45MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7MMX50MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7MMX55MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7MMX80MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7X32MM CANN -,SUP-209.750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.3X75MM LCK CANN THRD SD/ST REVCT FLUT HEX SCKT -,SUP-209.875,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1710.52,1197.364,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT SQA + THRDR TAB TI NTNL -,SUP-210.309,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2065.07,1445.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUBSTITUTE TCP 1.2ML FOAM PK VITOSS RESRB COMPR RSIS -,SUP-2102-1401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1579.18,1105.426,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
VITOSS BIOACTIVE PACK 2.5CC -,SUP-2102-1602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3430.26,2401.182,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
VITOSS BA2X FOAM PK BONE GRAFT 1.2CC -,SUP-2102-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2600.96,1820.672,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
VITOSS BA2X FOAM PACK 1.2CC -,SUP-2102-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2600.96,1820.672,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
VITOSS BA2X BONE GRAFT 2.5CC -,SUP-2102-2102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4015.89,2811.123,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
VITOSS BA2X BONE GRAFT 5CC -,SUP-2102-2105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6693.85,4685.695,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
VITOSS BA2X BONE GRAFT 10CC -,SUP-2102-2110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10931.81,7652.267,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.4MMX12MM CANN 0.5IN LNG THRD SD/ST T8 STRDRV RCESS -,SUP-211.812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1577.85,1104.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CANNULATED SCREW 2.4mm X15mm -,SUP-211.815,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED 2.4MM X17MM L -,SUP-211.817,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1431.14,1001.798,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.4MM CANN SCREW LONG 19MM -,SUP-211.819,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1431.14,1001.798,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX55MM LCK COMPR LCP FT ST SS NS GRN -,SUP-212.123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,813.98,569.786,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE PIN- 3.2 x 110MM- STERILE (2 Pack) -,SUP-213524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE PIN- 3.2 x 140MM- STERILE (2 Pack) -,SUP-213527,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX16MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX28MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX30MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX32MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX36MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX38MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX40MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX46MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX50MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX52MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX56MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX34MM LCK CANN P/T SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1518.59,1063.013,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX42MM LCK CANN P/T SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1518.59,1063.013,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX44MM LCK CANN P/T SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1518.59,1063.013,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX40MM LCK CANN FT SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1562.32,1093.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX44MM LCK CANN FT SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1562.32,1093.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX50MM LCK CANN FT SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1562.32,1093.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX40MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-216.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX55MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX60MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX65MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX70MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX75MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 9MM SHRT FASTFLAP 2HL STR 1.6MM NEURO SYS STRL -,SUP-218-0022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.42,222.194,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRNL 22MM 5HL 0.5MM STR FAST FLAP 1.6MM NEURO SYS TI -,SUP-218-0030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,868.25,607.775,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC MED FST-FLP MSH 5HL TI BUR HL GRV SHNT 1.6MM -,SUP-218-0069,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRNL LNG 2HL 0.25MM STR FAST FLAP 1.6MM NEURO SYS TI -,SUP-218-0093,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.8,316.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRNL 22MM LRG 0.25MM FAST FLAP BUR HL CVR 1.6MM NEURO -,SUP-218-0095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1077.06,753.942,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC 90X90MM FST-FLP OSTFRM MSH TI PREFRM 1.6MM -,SUP-218-2006-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6545.95,4582.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO 10MM F/4.5MM CANN SCR RND NS -,SUP-219.910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,218.81,153.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO 13MM F/6.5MM CANC LRG BN SCR RND NS -,SUP-219.990,CDM,C1713,HCPCS,278,RC,,,outpatient,,,223.19,156.233,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ACCELFIX LUMBAR EXPANDABLE CAGE 8 22 X 11 X 8MM -,SUP-2211-0808S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19669.62,13768.734,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ACCELFIX EXPANDABLE LUMBAR CAGE 15 22 X 11 X 8 -,SUP-2211-0815S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19669.62,13768.734,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE ACCELFIX LUMB EXPAND 8 DEG 22 X 11 X 12 -,SUP-2211-1208S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT HEALIX ADVANCE 4.5MM MUL-THRD BCRL RAPIDE -,SUP-222.295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1643.16,1150.212,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUTURE ORTHOCORD #2 MO-7 36IN BRD BLU VIOL 223114 1/2CIR MPK -,SUP-223.114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.04,210.028,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LC-DCP 11X77MM 3.5MM 6HL LC BSC LCK DCP SS SM NS -,SUP-223.560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2413.05,1689.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LC-DCP 11X90MM 3.5MM 7HL LC BSC LCK DCP SS SM NS -,SUP-223.570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2504.49,1753.143,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LC-DCP 11X103MM 3.5MM 8HL LC BSC DCP SS SM NS -,SUP-223.580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2631.7,1842.19,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LC-DCP 11X116MM 3.5MM 9HL LC BSC LCK DCP SS SM NS -,SUP-223.590,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2466.96,1726.872,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LC-DCP 11X129MM 3.5MM 10HL LC BSC LCK DCP SS SM NS -,SUP-223.600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2542.16,1779.512,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO BRKWY 2.5MM GLOBAL APG + -,SUP-2230-00-019,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1126.16,788.312,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LC-DCP 13.5X155MM 12HL 4.2MM LC COMPR SS 3.5MM BRD -,SUP-225.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2321.62,1625.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUBSTITUTE DEMIN CANC TISS 0.75ML G2 DIVERTED MRSL VOID FIL -,SUP-227005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1139.61,797.727,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUBSTITUTE G2 TISS 0.5ML STRIP PREFL ATF STR TUBE -,SUP-227010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,846.08,592.256,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
KT ORTHO MILAGRO FEM -,SUP-232.300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2199.71,1539.797,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
END CAP LOWER EXTREMITY 8 +0MM -,SUP-2330-0000S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1195.26,836.682,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
T2 ALFPHA COMPRESSION SCREW FEMUR 5.5 -,SUP-2330-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1333.08,933.156,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
END CAP GT/PF T2 ALPHA 013 +10 -,SUP-2330-0010S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1195.26,836.682,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL FEMORAL GT LEFT 11 X 320MM -,SUP-2331-1132S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FEMORAL NAIL GT- LEFT Ã˜11X420MM -,SUP-2331-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9735.49,6814.843,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FEMORAL NAIL GT LEFT 13 X 400MM -,SUP-2331-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10095.65,7066.955,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FEMORAL NAIL GT RT 10 X 360 -,SUP-2333-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12776.73,8943.711,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FEMORAL NAIL GT RIGHT 10 X 420MM -,SUP-2333-1042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL INTRAMEDULLARY T2 ALPHA FEMUR ANTEGRADE SYSTEM 11 X 380 -,SUP-2333-1138S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FEMORAL NAIL GT RIGHT 11 X 420MM -,SUP-2333-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FEMORAL NAIL GT RIGHT 11 X 440MM -,SUP-2333-1144S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FEMORAL NAIL GT RIGHT 13MM X 400MM -,SUP-2333-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10095.65,7066.955,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FEMORAL NAIL RETROGRADE D10X360MM -,SUP-2339-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FEMORAL NAIL RETROGRADE D10X400MM -,SUP-2339-1040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SYS FEMUR RETROGRADE NAIL 11 X 200MM T2 ALPHA SHORT -,SUP-2339-1120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FEMORAL NAIL RETROGRADE 11 X 300MM -,SUP-2339-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL T2 FEMUR ALPHA RETROGRADE 11 X 340MM -,SUP-2339-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FEMORAL NAIL RETROGRADE D11X380MM -,SUP-2339-1138S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FEMORAL NAIL RETROGRADE 12 X 340MM -,SUP-2339-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10561.63,7393.141,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
T2 ALPA FEMUR NAIL RETROGRADE 12 X 360 -,SUP-2339-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10559.77,7391.839,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FEMORAL NAIL RETROGRADE 13X340MM -,SUP-2339-1334S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10561.63,7393.141,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FEMORAL NAIL RETROGRADE D13X360MM -,SUP-2339-1336S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10559.77,7391.839,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN 8X23MM THRD BABSRB PLLA -,SUP-234-010-162,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN BIOSTEON 7X28MM 1MM CANN FLLY BLNT THRD -,SUP-234-010-164,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN BIOSTEON 8X28MM BABSRB WDG SHP HAP PLLA -,SUP-234-010-165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN 9X28MM THRD BABSRB PLLA -,SUP-234-010-166,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN BIOSTEON 11X35MM 1MM CANN FLLY BLNT THRD -,SUP-234-010-179,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN BIOSTEON 12X35MM 1MM CANN FLLY BLNT THRD -,SUP-234-010-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2187.89,1531.523,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMPRESSION SCREW TIBIA 5.5 -,SUP-2341-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1333.08,933.156,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
END CAP TIBIA T2 ALPHA 11.5 X +5MM -,SUP-2341-0005S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
END CAP TIBIA T2 ALPHA 11.5 X 10MM -,SUP-2341-0010S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
END CAP TIBIA T2 ALPHA 11.5 X 15MM -,SUP-2341-0015S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ENDO VERSITOMIC SHP MEM ALY TECH FLXB -,SUP-234-108-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2166.31,1516.417,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ENDO VERSITOMIC FLXB -,SUP-234-108-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2187.89,1531.523,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIBIAL NAIL 9 X 285MM -,SUP-2341-0928S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIBIAL NAIL T2 ALPHA 9 X 300 -,SUP-2341-0930S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIBIAL NAIL T2 09 X 315MM -,SUP-2341-0931S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL TIBIAL 9 X 330 T2 ALPHA -,SUP-2341-0933S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIBIAL NAIL 9 X 345 -,SUP-2341-0934S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIBIAL NAIL 9 X 360 -,SUP-2341-0936S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIBIAL NAIL 9 X 375 -,SUP-2341-0937S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIBIAL NAIL 9 X 390MM -,SUP-2341-0939S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIBIAL NAIL 10X285MM -,SUP-2341-1028S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10764.14,7534.898,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM 10 X 300 -,SUP-2341-1030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM 10 X 315 -,SUP-2341-1031S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM -,SUP-2341-1033S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
T2 ALPHA TIBIA NAIL 10X345MM SYS -,SUP-2341-1034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL TIBIAL 10 X 360 T2 ALPHA -,SUP-2341-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL TIBIAL 10 X 375MM T2 ALPHA -,SUP-2341-1037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL TIBIAL 10 X 390 T2 ALPHA -,SUP-2341-1039S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL TIBIAL T2 ALPHA 11 X 300MM -,SUP-2341-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL TIBIAL T2 11 X 315 -,SUP-2341-1131S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIBIAL NAIL 11 X 330 -,SUP-2341-1133S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL SYSTEM T2 ALPHA TIBIA 11 X 345MM -,SUP-2341-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM -,SUP-2341-1136S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIBIAL NAIL T2 ALPHA 11 X 375 -,SUP-2341-1137S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
T2 ALPHA TIBIA NAIL 11 X 390MM -,SUP-2341-1139S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL TIBIAL T2 ALPHA 12 X 315MM -,SUP-2341-1231S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL TIBIAL T2 ALPHA 12 X 330MM -,SUP-2341-1233S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
T2 ALPHA TIBIA SYSTEM TIBIAL NAIL -,SUP-2341-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
T2 ALPHA TIBIAL NAIL 12 X 380MM -,SUP-2341-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10764.1,7534.87,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIBIAL NAIL 12 X 375MM -,SUP-2341-1237S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 8X50MM -,SUP-234500150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,885.69,619.983,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW 5 X 25MM -,SUP-2360-5025S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW 5 X 27.5MM -,SUP-2360-5027S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 5X32MM -,SUP-2360-5032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW IMN SYSTEM LOCKING SCREW 5 X 35 -,SUP-2360-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMN LOCKING SCREW 5 X 37.5MM -,SUP-2360-5037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMN SCREW SYSTEM LOCKING SCREW 5 X 40 -,SUP-2360-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 5X42MM -,SUP-2360-5042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW 05 X 45MM -,SUP-2360-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMN LOCKING SCREW 5X47.5MM -,SUP-2360-5047S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMN LCK SCREW 5X50 -,SUP-2360-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMN LCK SCREW 5X52 -,SUP-2360-5052S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK STRYKER 5 X 55 -,SUP-2360-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMN LOCKING SCREW 5X57.5MM -,SUP-2360-5057S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMN LOCKING SCREW 0.5 X 60MM -,SUP-2360-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1836.62,1285.634,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING SYS IMN 5 X 60MM -,SUP-2360-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMN LOCKING SCREW 0.5 X 65MM -,SUP-2360-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 5 X 70MM -,SUP-2360-5070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T2 ALPHA IMN LOCKING  0.5 X 75MM -,SUP-2360-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING SYS IMN 5 X 65MM -,SUP-2360-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 5 X 85 -,SUP-2360-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 5 X 90 -,SUP-2360-5090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW IMN T2 ALPHA LOCKING  5MM X 95MM -,SUP-2360-5095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING SYS IMN 5 X 100MM -,SUP-2360-5100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ADVANCED LOCKING SCREW 5X30MM -,SUP-2361-5030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ADVANCED LOCKING 5MM X 32.5MM -,SUP-2361-5032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ADVANCED LOCKING 5 X 35 -,SUP-2361-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING ADVANCED IMN 05 X 37.5MM -,SUP-2361-5037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING ADVANCED IMN 05 X 40MM -,SUP-2361-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ADVANCED LOCKING 5MM X 42.5MM -,SUP-2361-5042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ADVANCED LOCKING SCREW 5MM X 45MM -,SUP-2361-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW IMN LCK 5 X 45 -,SUP-2361-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ADVANCED LOCKING 5MM X 47.5MM -,SUP-2361-5047S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING ADVANCED 5X50MM -,SUP-2361-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ADVANCED LOCKING SCREW 5MM X 52.5MM -,SUP-2361-5052S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ADVANCED LOCKING 5MM X 55MM -,SUP-2361-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ADVANCED LOCKING SCREW 5 X 57.5MM -,SUP-2361-5057S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X60MM IMN ADVANCED LOCKING -,SUP-2361-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ADVANCED LOCKING 5MM X 65MM -,SUP-2361-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ADVANCED LOCKING 5MM X 70MM -,SUP-2361-5070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ADVANCED LOCKING SCREW 5 X 57MM -,SUP-2361-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ADVANCED LOCKING SCREW 5 X 80 -,SUP-2361-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMN ADVANCED LOCKING SCREW 5MM X 85MM -,SUP-2361-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ADVANCED LOCKING SCREW 5 X 90MM -,SUP-2361-5090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1553.05,1087.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW IMN LOCKING 5MM X 95MM -,SUP-2361-5095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LCP 83MM 4/5MM 4HL BSC LCK COMPR SS LRG T-SHP NS -,SUP-240.141,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3467.5,2427.25,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN STERNAL TALON 14MM D FT PLATE LEGX2 SGL TI SM STRL -,SUP-24-009-14-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN STERNAL TALON SGL LEGX2 BIOCMPT TI SM STRL -,SUP-24-009-17-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FOOT PLATE BN STERNAL TALON SGL VRSN TI 17MM MED STRL LEGX2 -,SUP-24-010-17-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN STERNAL TALON 20MM D LEGX2 SGL TI MED STRL -,SUP-24-010-20-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FOOT PLATE XL 12X20MM STERNAL TALON SGL -,SUP-24-012-20-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
STERNAL SCREW 2.3 -,SUP-24-023-09-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X11MM LCK DRL-FR MAXDRIVE THREADLOCK TS SLF RET TI -,SUP-24-023-11-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X13MM LCK DRL-FR MAXDRIVE THREADLOCK TS SLF RET TI -,SUP-24-023-13-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
STERNAL SCREW 2.3 X 15MM -,SUP-24-023-15-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.3MM SELF DRILLING STERNAL SCREWS -,SUP-24-023-17-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE LEVEL 1 THORACIC STERNAL LKG STR 2.3MM SCRW 20 HL -,SUP-24-025-07-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3118.62,2183.034,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
STERNAL PLATE LOCK 6-HOLE 1.8 -,SUP-24-025-42-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2398.48,1678.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 8HL 1.8MM LCK TI X-SHP -,SUP-24-025-44-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2224.88,1557.416,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
4 HOLE STRAIGHT -,SUP-24-025-48-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2155.98,1509.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE LEVEL ONE THORACIC STERNAL LKG STR W/2.3MM SCREW -,SUP-24-025-50-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2580.02,1806.014,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
9 HOLE Y PLATE -,SUP-24-025-52-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2613.77,1829.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 4 HOLE ANGLE -,SUP-24-025-59-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1906.85,1334.795,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LC-DCP 10X50MM 3.5MM 3HL HD/SHFT LC DCP SS T-SHP RT -,SUP-241.130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,781.42,546.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LC-DCP 11X64MM 3.5MM HLX3/5 HD/SHFT LC DCP SS T-SHP -,SUP-241.150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,944.22,660.954,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LC-DCP 10X53MM 3.5MM 3HL HD/SHFT LC LCK DCP SS -,SUP-241.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1176.71,823.697,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LC-DCP 10X63MM 3.5MM 0.75HL HD/SHFT LC LCK DCP SS -,SUP-241.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1296.45,907.515,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LC-DCP 10X75MM 3.5MM HLX3/5 HD/SHFT LC LCK DCP SS -,SUP-241.250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1282.72,897.904,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LC-DCP 9X25MM 3.5MM 2HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LC-DCP 9X49MM 3.5MM 4HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LC-DCP 9X61MM 3.5MM 5HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LCP 9X57MM 2.7/3.5MM 5HL CONTR LCK COMPR SS SM 1/3 -,SUP-241.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1594.13,1115.891,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LC-DCP 9X85MM 3.5MM 7HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1268.14,887.698,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LC-DCP 9X97MM 3.5MM 8HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1315.85,921.095,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LC-DCP 9X121MM 3.5MM 10HL LC DCP SS SM MINI 1/3 -,SUP-241.400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LCP 9X117MM 2.7/3.5MM 10HL CONTR LCK COMPR SS SM -,SUP-241.401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1745.19,1221.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LCP 15MM D 3.5MM 5HL PRCONT LCK COMPR SS HOOK STRL -,SUP-241-085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4546.38,3182.466,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LCP 6.3X49MM 2.4MM 0.75HL HD/SHFT FA CONTR LCK -,SUP-242.507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2479.52,1735.664,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER TNDN 6X24MM SILASTIC PLYSTR COR SWN-HNT STRL -,SUP-24270006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7240.26,5068.182,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 82MM 3.5MM 7HL RECON SS STR NS -,SUP-245.170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3397.89,2378.523,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LC-DCP 94MM 3.5MM 8HL RECON DCP SS STR NS -,SUP-245.181,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3544.7,2481.29,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LC-DCP 106MM 3.5MM 9HL RECON DCP SS STR NS -,SUP-245.190,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3738.04,2616.628,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 53MM 2MM HLX2/8 HD/SHFT 1.2MM RECON SS T-SHP NS -,SUP-247.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1616.65,1131.655,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LCP 54MM 2MM 7HL RECON LCK COMPR SS NS -,SUP-247.349,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4745.36,3321.752,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LCP 44MM 2.4MM 5HL RECON ADPR LCK COMPR SS STR NS -,SUP-247.375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2573.19,1801.233,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LCP 36MM 2.4MM 4HL RECON LCK COMPR SS STR NS -,SUP-249.674,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2496.8,1747.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LCP 59MM 2.4MM 7HL RECON LCK COMPR SS STR NS -,SUP-249.679,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3862.17,2703.519,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LCP 58MM 2.7MM 6HL RECON LCK COMPR SS STR NS -,SUP-249.682,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3247.51,2273.257,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LCP 67MM 2.7MM 7HL RECON LCK COMPR SS STR NS -,SUP-249.683,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2544.54,1781.178,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LCP 32MM 2.7MM 0.66HL HD/SHFT RECON LCK COMPR SS -,SUP-249.685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCK -,SUP-250-1001-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8.5MM SHTH INTRAFIX PEEK PP NS F/ACL FX -,SUP-254.683,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK CRNMXF 2.3X11MM CROSS-DRIVE TI ALY -,SUP-25-773-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 7 MWX8MMX21MM TRAXIS PEEK/ TI -,SUP-2601070921,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE VERT 25MM VUE 7MM/9MM LD /TRAILING DIA SGL LVL PEEK -,SUP-2601070925,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 9X21X9MM TRAXIS VUE 9MM/9MM DIA LD /TRAILING DIA SGL -,SUP-2601090921,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDE DRILL POR F/KN ARTHPL -,SUP-261-0060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
USTAR II KNEE CEMENTED STR STEM RHS 17X125 -,SUP-2715-3117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BLADE IM NAIL 12.5X105MM SS HLCL NS F /LCP DHS -,SUP-282.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2284.52,1599.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BLADE IM NAIL 12.5X120MM SS HLCL NS F /LCP DHS -,SUP-282.243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2277.41,1594.187,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX CAGE 6.5 -,SUP-28-2180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX CAGE 8.5 -,SUP-28-2182,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX CAGE 6.5 X 24 XP -,SUP-28-3140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE XP LORDOTIC 8.5 -,SUP-28-3142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX FORZA XP CAGE 10.5H X 10W X 24L -,SUP-28-3144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX 12H EXPANDABLE CAGE -,SUP-28-3146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
EXPANDABLE CAGE 6.5MMX10MM WIDE X28MM -,SUP-28-3180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE FORZA XP ORTHOFIX 10.5MM -,SUP-28-3184,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX HYPERLORDOTIC CAGE 8.5 -,SUP-28-4142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 10.5HL HYPER XP -,SUP-28-4144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX CAGE 12.5 X 24. HL -,SUP-28-4146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
USTAR II KNEE SEGMENT PART RHS 25MM -,SUP-2915-1025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22014.38,15410.066,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER VERT 22X8MM CAP STN VERTSTCK PEEK -,SUP-2960822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER VERT 26X8MM CAP STN VERTSTCK PEEK -,SUP-2960826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20245.95,14172.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER VERT 22X10MM CAP STN VERTSTCK 8DG PEEK -,SUP-2961022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X12MM LCK ACU-LOC 2 HXLB DRIVE F/VOLAR DIST RAD -,SUP-30-0234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,822.74,575.918,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X14MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X18MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0237,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X20MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X22MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0239,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X24MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0241,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X30MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X32MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X36MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0246,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X45MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0249,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X22MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0262,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X24MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0263,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0264,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X32MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0267,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X40MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0271,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X45MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0272,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X50MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0273,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X55MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0274,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X40MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0294,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW Ti SET 8X17.5MM -,SUP-3003-0822S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,858.1,600.67,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X14MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0327,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X16MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X18MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0329,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X20MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X22MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0331,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAP END +10MM TI GAMMA3 -,SUP-3005-1110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,858.1,600.67,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.7X45MM ACUTRAK 2 NS -,SUP-30-0645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.7X50MM ACUTRAK 2 NS -,SUP-30-0650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.3X26MM LCK POLARUS 3 HXLB DRV TI STRL -,SUP-3011-43026-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.3X46MM HXLB -,SUP-3011-43046-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.6MM/4.5MM DIA TIP/BK END 20MM CANN HDLS BIOTRAK -,SUP-3017-0009-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3465.92,2426.144,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.6MM/4.6MM DIA TIP/BK END 22MM CANN HDLS BIOTRAK -,SUP-3017-0010-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3465.92,2426.144,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM VERT 10X26X8MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM VERT 10X26X9MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM VERT 10X26X10MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM VERT 10X26X11MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM VERT 10X26X12MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM VERT 8X22X8MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.078,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM VERT 8X22X9MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.079,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM VERT 8X22X10MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM VERT 8X22X11MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.081,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM VERT 8X22X12MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM VERT 8X22X13MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.083,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM VERT 10X22X8MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.088,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM VERT 10X22X9MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.089,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM VERT 10X22X10MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM VERT 10X22X11MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.091,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM VERT 10X22X12MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.092,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM VERT 10X22X13MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.093,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM VERT 10X22X15MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM VERT 12X26X10MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.970,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM VERT 12X26X17MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.977,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LAG SCREW TI 10.5 X 75mm -,SUP-3060-0075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW GAMMA3 LAG TI 10.5X80 -,SUP-3060-0080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW GAMMA3 LAG Ti 10.5X85 -,SUP-3060-0085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 90MM -,SUP-3060-0090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW GAMMA3 LAG Ti 10.5X95 -,SUP-3060-0095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GAMMA3 LAG SCREW TI 10.5X100 -,SUP-3060-0100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW GAMMA3 LAG T1 10.5X105 -,SUP-3060-0105S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 110MM -,SUP-3060-0110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 115MM -,SUP-3060-0115S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 120MM -,SUP-3060-0120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 125MM -,SUP-3060-0125S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 130MM -,SUP-3060-0130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
U-BLADE SET TI 10.5 X 95MM -,SUP-3066-0095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2850.17,1995.119,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFT DBM 1ML PTTY OSTEOSELECT VOID FIL OSTCONDC -,SUP-309010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
OSTEOSELECT 2.5CC -,SUP-309025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1749.17,1224.419,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUBSTITUTE DBM 5ML PTTY OSTEOSELECT VOID FIL OSTCONDC -,SUP-309050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUBSTITUTE DBM 10ML PTTY OSTEOSELECT -,SUP-309100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER RADIOLUCENT 7MM CANOPY -,SUP-3102.6007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
5CC BIO4 VIABLE BONE MATRIX -,SUP-3102-2105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8594.1,6015.87,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 15.5/11X180MM GAMMA3 LT TROCH FEM TI BIOMECH STRGTH -,SUP-3120-1180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4598.63,3219.041,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TROCHANTERIC NAIL KIT 10X170MMX125DG -,SUP-3125-0170S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5413.56,3789.492,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL GAMMA3 TROCHANTARIC 180 -,SUP-3125-1180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4598.63,3219.041,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
KIT TROCHANTERIC KIT 11X180 SF -,SUP-3130-1180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4598.63,3219.041,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DRILL BIT RINGLOC + QUICK CONNECT 3.2MM X 20MM -,SUP-31-323220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
EQUINOXE SHLDR -,SUP-320-15-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK COMPR EQUINOXE F/RVRS BALL/SCKT SURG -,SUP-320-15-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SET SCREW INTNL FX EQUINOXE SHLDR RVRS TRQ DEFINING LCK -,SUP-320-20-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X22MM LCK COMPR EQUINOXE BLK F/RVRS BALL/SCKT SURG -,SUP-320-20-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X34MM LCK COMPR EQUINOXE RD F/RVRS BALL/SCKT SURG -,SUP-320-20-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LONG NAIL GAMMA KIT 11X300 RIG -,SUP-3225-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LONG GAMMA NAIL 11X320 RIGHT -,SUP-3225-0320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL KIT LONG R2.0 TI RT. GAMM -,SUP-3225-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LONG GAMMA NAIL 11X380 RIGHT -,SUP-3225-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LONG GAMMA NAIL 11X400 RIGHT -,SUP-3225-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LONG GAMMA NAIL 11X420 RIGHT -,SUP-3225-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL LONG RT GAMMA3 KIT 11MM X -,SUP-3225-0440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 15MM/13MM DIA P/D 2MM RAD LNG 340MM GAMMA3 RT TROCH -,SUP-3225-3340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX16MM CANN ASNIS III 8MM P/T SD/ST REVCT FLUT SS NS -,SUP-325016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX24MM CANN ASNIS III 8MM P/T SD/ST REVCT FLUT SS NS -,SUP-325024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW PT CANN ASNIS 4.0 X 28 -,SUP-325028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX30MM CANN ASNIS III 10MM P/T SD/ST REVCT FLUT SS -,SUP-325030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX32MM CANN ASNIS III 11MM P/T SD/ST REVCT FLUT SS -,SUP-325032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX34MM CANN ASNIS III 11.5MM P/T SD/ST REVCT FLUT SS -,SUP-325034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX34MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-325034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX36MM CANN ASNIS III 12MM P/T SD/ST REVCT FLUT SS -,SUP-325036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX38MM CANN ASNIS III 13MM P/T SD/ST REVCT FLUT SS -,SUP-325038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX40MM CANN ASNIS III 13.5MM P/T SD/ST REVCT FLUT SS -,SUP-325040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX42MM CANN ASNIS III 14MM P/T SD/ST REVCT FLUT SS -,SUP-325042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX44MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325044S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX46MM CANN ASNIS III 15.5MM P/T SD/ST REVCT FLUT SS -,SUP-325046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX46MM CANN ASNIS III 0.33IN P/T SD/ST REVCT FLUT SS -,SUP-325046S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX48MM CANN ASNIS III 16MM P/T SD/ST REVCT FLUT SS -,SUP-325048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX50MM CANN ASNIS III 17MM P/T SD/ST REVCT FLUT SS -,SUP-325050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX55MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-325060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX60MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX70MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED 4.0 X 32 -,SUP-325232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X42MM CANN FT -,SUP-325242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X44MM CANN FT -,SUP-325244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX70MM CANN ASNIS III 23.5MM P/T SD/ST REVCT FLUT SS -,SUP-325470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED 5.0 X 60MM -,SUP-325660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ASNIS III SS CANNULATED SCR 5 X 70MM -,SUP-325670S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SS CANN 6.5 X 70MM ASNIS -,SUP-326070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X75MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X80MM CANN ASNIS III P/T SD/ST REVCT FLUT SS NS -,SUP-326080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X80MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X85MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X85MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X90MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X90MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS 6.5MM 95MM -,SUP-326095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X95MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS 6.5MM 100MM -,SUP-326100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X100MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X105MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326105S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS 6.5 X 110 -,SUP-326110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X110MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X115MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326115S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X120MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW S.S. TL40 6.5 X 55 -,SUP-326255,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
6.5MM PARTIALLY THREADED 40MM SCREW 60MM LENGTH -,SUP-326260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW S.S. TL40 6.5 X 70 -,SUP-326270,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX75MM CANN ASNIS III 40MM THRD SD/ST REVCT FLUT -,SUP-326275,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX80MM CANN ASNIS III 40MM THRD SD/ST REVCT FLUT -,SUP-326280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS CAN 6.5 X 85 -,SUP-326285,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS CAN 6.5 X 90 -,SUP-326290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS CAN 6.5 X 95 -,SUP-326295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.94,757.358,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS CAN 6.5 X 95 -,SUP-326295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS CAN 6.5 X 100 -,SUP-326300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW S.S. TL40 6.5 X 110 -,SUP-326310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW S.S. TL40 6.5 X 115 -,SUP-326315,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW S.S. TL40 6.5 X 120 -,SUP-326320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1196.43,837.501,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 80 -,SUP-326480S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 85 -,SUP-326485S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED FULLY THREADED 6.5 X 90MM -,SUP-326490S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS III SS CANNULATED 6.5X95MM -,SUP-326495S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS III SS CANNULATED 6.5X100MM -,SUP-326500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS III SS CANNULATED 6.5X105MM -,SUP-326505S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS III SS CANNULATED 6.5X110MM -,SUP-326510S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS III SS CANNULATED 6.5X115MM -,SUP-326515S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS III SS CANNULATED 6.5X120MM -,SUP-326520S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS III SS CANNULATED 6.5X125MM -,SUP-326525S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS III SS CANNULATED 6.5X130MM -,SUP-326530S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS III CANN 8.0 X 70MM -,SUP-326670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW S.S. TL25 8.0 X 75 -,SUP-326675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS 8.0 X 80MM -,SUP-326680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS CANNULATED 8.0 X 85MM -,SUP-326685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8MMX90MM CANN ASNIS III 25MM P/T SD/ST REVCT FLUT SS -,SUP-326690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8MMX95MM CANN ASNIS III 25MM P/T SD/ST REVCT FLUT SS -,SUP-326695,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED PARTIALLY THREADED 8MM X 95MM TL25MM -,SUP-326695S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8MMX100MM CANN ASNIS III 25MM P/T SD/ST REVCT FLUT SS -,SUP-326700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
8 x 105MM ASNIS SCREW -,SUP-326705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
8 X 110MM ASNIS SCREW -,SUP-326710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
C/M 16MM & 25MM PLUG WITH NOZZLE -,SUP-32810503800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1313.46,919.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LONG NAIL KIT LEFT 300mm -,SUP-3325-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL LONG KIT 11X320MMX125 GAM -,SUP-3325-0320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL GAMMA LGN LEFT 11X360 -,SUP-3325-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL LONG GAMMA3 11X380 LFT -,SUP-3325-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LONG GAMMA NAIL 11X400 LEFT -,SUP-3325-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LONG GAMMA NAIL 11X420 LEFT -,SUP-3325-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LONG GAMMA NAIL 11X440 LEFT -,SUP-3325-0440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13MMLNGX340MM GAMMA3 LT TROCH FEM TI BIOMECH STRGTH -,SUP-3325-3340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OPLS 2HL STD BRL COMPR SDE 130DG ANG -,SUP-3362-1-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 130DG ANG -,SUP-3362-1-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OPLS 2HL STD BRL COMPR SDE 135DG ANG KYLS -,SUP-3362-1-102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE HIP COMP 135-5-HOLE -,SUP-3362-1-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE HIP OMEGA 135 6 HOLE - OBSOLETE DO NOT USE -,SUP-3362-1-106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OPLS SLOTX2 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OPLS SLOTX5 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OPLS SLOTX6 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OPLS SLOTX8 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OPLS SLOTX3 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-303,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OPLS SLOTX5 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-305,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2896.15,2027.305,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OPLS SLOTX6 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2896.15,2027.305,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OPLS SLOTX8 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OPLS SLOTX10 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 150DG ANG -,SUP-3362-1-404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OPLS SLOTX8 STD BRL COMPR SDE 150DG ANG -,SUP-3362-1-408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OPLS SLOTX10 STD BRL COMPR SDE 150DG ANG -,SUP-3362-1-410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3570.95,2499.665,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OPLS SLOTX12 25.4MM BRL 98DG ANG PRE- KY -,SUP-3362-2-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4883.15,3418.205,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OMG SLOTX4 STD BRL COMPR 130DG ANG KYLS -,SUP-3362-3-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OMG SLOTX2 STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OMG SLOTX3 STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-103,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OPLS 4HL STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OMG SLOTX6 STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OMG SLOTX5 STD BRL COMPR 140DG ANG KYLS -,SUP-3362-3-205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 50MM -,SUP-3362-5-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 55MM -,SUP-3362-5-055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1205.86,844.102,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 60MM -,SUP-3362-5-060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1205.86,844.102,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 65MM -,SUP-3362-5-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 70MM -,SUP-3362-5-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 75MM -,SUP-3362-5-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 80MM -,SUP-3362-5-080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 90MM -,SUP-3362-5-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 95MM -,SUP-3362-5-095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 100MM -,SUP-3362-5-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 105MM -,SUP-3362-5-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X10MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X12MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X14MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X16MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X18MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X20MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X22MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X24MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X28MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X30MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X32MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X34MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X36MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X38MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X40MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X42MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X44MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X45MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X46MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X48MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X50MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X55MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X60MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X65MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X70MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5 X 75 CORTICAL -,SUP-338675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X80MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 3.5MM X 85MM -,SUP-338685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SELF TAP CORTICAL 3.5 X 115MM -,SUP-338715,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SELF TAP CORTICAL 3.5 X 120MM -,SUP-338720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X14MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV CUT -,SUP-340614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX16MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX18MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX20MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX22MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX24MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX26MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX28MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX30MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX34MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX34MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX36MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX36MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX38MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX38MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX40MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX40MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX42MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX42MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX44MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX44MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX46MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX48MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX48MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX50MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 4.5 X 52 -,SUP-340652,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 4.5 X 54 -,SUP-340654,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX55MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX56MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340656,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX58MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340658,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 4.5 X 60MM -,SUP-340660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX65MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX75MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX35MM MATTA CANC OMEGA3 SPS 16MM P/T 3.5MM HEX -,SUP-341035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX40MM MATTA CANC OMEGA3 SPS 16MM P/T 3.5MM HEX -,SUP-341040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER KIKO CORPECTOMY SMALL 12 X 14 0 DEG 21MM -,SUP-342.721,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11547.43,8083.201,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB. -,SUP-3420-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMX320MM RT TI BIOMECH STRGTH STAB 120DG ANG -,SUP-3420-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMX340MM RT TI BIOMECH STRGTH STAB 120DG ANG -,SUP-3420-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX80MM MATTA CANC OMEGA3 SPS 32MM P/T 3.5MM HEX -,SUP-342080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX85MM MATTA CANC OMEGA3 SPS 32MM P/T 3.5MM HEX -,SUP-342085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10MMX300MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10MMX320MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10MMX340MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10MMX360MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB. -,SUP-3425-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10MMX380MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10MMX400MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LONG NAIL 10MM X 420MM X 125 DEGREES -,SUP-3425-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMX300MM GAMMA3 RT HIP TI BIOMECH STRGTH STAB -,SUP-3425-1300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMX320MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMX340MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMX360MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMX380MM GAMMA3 RT TI BIOMECH STRGTH STAB -,SUP-3425-1380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMX400MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANCL FT 6.5 X 20 -,SUP-343020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANCL FT 6.5 X 25 -,SUP-343025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANCL FT 6.5 X 30 -,SUP-343030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANCL FT 6.5 X 40 -,SUP-343040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX85MM MATTA CANC OMEGA3 SPS FT 3.5MM HEX DRV CUT -,SUP-343085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX10MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX12MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX14MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX16MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX18MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX20MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX22MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX24MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX26MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX28MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX30MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX32MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX34MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX36MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX38MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CNCL LCK 4.0 X 40 -,SUP-345440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX45MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX50MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX55MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX60MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX65MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX75MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345475,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX80MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX90MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX10MM LCK CANC AXSOS SPS 5MM P/T ST 2.5MM HEX DRV -,SUP-345510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX14MM LCK CANC AXSOS SPS 6MM P/T ST 2.5MM HEX DRV -,SUP-345514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX18MM LCK CANC AXSOS SPS 6MM P/T ST 2.5MM HEX DRV -,SUP-345518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX34MM LCK CANC AXSOS SPS 14MM P/T ST 2.5MM HEX DRV -,SUP-345534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX36MM LCK CANC AXSOS SPS 14MM P/T ST 2.5MM HEX DRV -,SUP-345536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX38MM LCK CANC AXSOS SPS 14MM P/T ST 2.5MM HEX DRV -,SUP-345538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX40MM LCK CANC AXSOS SPS P/T ST 2.5MM HEX DRV CUT -,SUP-345540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX45MM LCK CANC AXSOS SPS 15MM P/T ST 2.5MM HEX DRV -,SUP-345545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX50MM LCK CANC AXSOS SPS 15MM P/T ST 2.5MM HEX DRV -,SUP-345550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX55MM LCK CANC AXSOS SPS 16MM P/T ST 2.5MM HEX DRV -,SUP-345555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX60MM LCK CANC AXSOS SPS 16MM P/T ST 2.5MM HEX DRV -,SUP-345560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX70MM LCK CANC AXSOS SPS P/T ST 2.5MM HEX DRV CUT -,SUP-345570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX80MM LCK CANC AXSOS SPS P/T ST 2.5MM HEX DRV CUT -,SUP-345580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX8MM CORT AXSOS ISO SPS FT ST 2.5MM HEX DRV CUT -,SUP-349608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 2.7 X 14MM -,SUP-349614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX16MM CORT AXSOS ISO SPS FT ST 2.5MM HEX DRV CUT -,SUP-349616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX18MM CORT AXSOS ISO SPS FT ST 2.5MM HEX DRV CUT -,SUP-349618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CORTEX SCREW SELF TAPPING STEEL 2.7MM X 60MM -,SUP-349660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,127.9,89.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ASSEMBLY CBL CRLGE TI CBL LOCK SPRCBL ISO-ELAS -,SUP-35-100-1010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2597.25,1818.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CABLE ORTHO SUPERCABLE 1.5MM CERVICAL CERCLAGE -,SUP-35-100-1040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2477.71,1734.397,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE KINAMED 2 HOLE SUPERCABLE -,SUP-35-200-1020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8377.66,5864.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN SPRCBL 190MM 4HL TI TROCH GRP -,SUP-35-200-1030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10233.03,7163.121,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMX340MM GAMMA3 LT TI 120DG ANG -,SUP-3520-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMX360MM GAMMA3 LT TI 120DG ANG -,SUP-3520-1360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMX380MM GAMMA3 LT TI 120DG ANG -,SUP-3520-1380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CABLE ORTHO SUPER CBL TI PLATE 6HL -,SUP-35-220-1010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5831.26,4081.882,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CABLE-PLATE 8 HOLE STRAIGHT -,SUP-35-220-2010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7363.34,5154.338,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUPERCABLE GRIP AND PLATE 10 HOLE STRAIGHT -,SUP-35-220-3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9661.23,6762.861,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN SPRCBL 290MM 10HL TI TROCH GRP -,SUP-35-220-3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10530.07,7371.049,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRIP AND PLATE SYSTEM COMPRESSION BONE SCREW 4.5X12MM -,SUP-35-230-4512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,250.91,175.637,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUPERCABLE GRIP AND PLATE SYS COP BONE SCREW 4.5 X 14MM -,SUP-35-230-4514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,250.91,175.637,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRIP AND PLATE COMPRESSION BONE SCREW 4.5 X 16MM -,SUP-35-230-4516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,250.91,175.637,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUPERCABLE BONE SCREW 4.5 X 30 -,SUP-35-230-4530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUPERCABLE BONE SCREW 4.5 X 32 -,SUP-35-230-4532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE SUPERCABLE GRIP AND PLATE COMP  4.5 X 34 -,SUP-35-230-4534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X36MM COMPR SPRCBL F/GRP PLATE SYS -,SUP-35-230-4536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X38MM COMPR SPRCBL F/GRP PLATE SYS -,SUP-35-230-4538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X40MM COMPR SPRCBL F/GRP PLATE SYS -,SUP-35-230-4540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRIP AND PLATE SYS COMP BONE SCREW 4.5MM X 45MM -,SUP-35-230-4545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
KINAMED SUPERCABLE SCREW -,SUP-35-230-4550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X12MM LCK SPRCBL F/GRP PLATE SYS -,SUP-35-234-5012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X16MM LCK SPRCBL F/GRP PLATE SYS -,SUP-35-234-5016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X18MM LCK SPRCBL F/GRP PLATE SYS -,SUP-35-234-5018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE SUPERCABLE GRIP AND PLATE LOCK 5 X 20 -,SUP-35-234-5020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10MMX300MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10MMX340MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10MMX380MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
"NAIL LONG KIT R1.5 TI LEFT 010 X 125"" -",SUP-3525-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMX420MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMX440MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMX300MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMX320MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMX340MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMX380MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMX400MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
"NAIL LONG KIT R15 TI 011 X 400MM X 125"" LEFT GAMMAX3 SYS -",SUP-3525-1400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL LONG KIT R1 5 TI LEFT -,SUP-3525-1420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GAMMA LONG NAIL KIT R1.5 LEFT 11X440MM -,SUP-3525-1440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB. -,SUP-3530-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DBM PUTTY - OSTEOSELECT 2.5CC -,SUP-359025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1749.17,1224.419,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DBM PUTTY - OSTEOSELECT 5CC -,SUP-359050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DBM PUTTY - OSTEOSELECT 10CC -,SUP-359100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN FX STNMN 2.8X230MM SMTH TROC PNT 3-SDE SHNK SS -,SUP-3611-3-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13.5,9.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SET SCREW -,SUP-36-2001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TULIP BODY -,SUP-36-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
REDUCTION HEAD -,SUP-36-2103,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW JANUS ORTHOFIX 4.5 X 30 -,SUP-36-2430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5MM X 35 ORTHOFIX -,SUP-36-2535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW JANUS ORTHOFIX 5.5 X 40 -,SUP-36-2540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SREW ORTHOFIX FIREBIRD 5.5 X 45MM -,SUP-36-2545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MM X 30MM ORTHOFIX -,SUP-36-2630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW JANUS 6.5X35MM ORTHOFIX -,SUP-36-2635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW JANUS ORTHOFIX 6.5 X 40 -,SUP-36-2640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW JANUS CANN 5.5 X 35 -,SUP-36-3535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW JANUS CANN 5.5 X 40 -,SUP-36-3540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW JANUS CANN 5.5 X 45 -,SUP-36-3545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW JANUS CANN 65 X 35 -,SUP-36-3635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW JANUS CANN 65 X 45 -,SUP-36-3645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5 X 25MM ORTHOFIX -,SUP-36-4425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW JANUS 4.5 X 30MM FENESTRATE ORTHOFIX -,SUP-36-4430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW JANUS 4.5 X 35MM FENESTRATE ORTHOFIX -,SUP-36-4435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW JANUS ORTHOFIX 6.5 X 30MM -,SUP-36-4630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW JANUS ORTHOFIX 6.5 X 35MM -,SUP-36-4635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER ACDF COLONIAL 12 X 14 X 6MM 7 DEGREE -,SUP-365.406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER ACDF COLONIAL 12 X 14 X 8MM 7 DEGREE -,SUP-365.408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X10MM LCK AXSOS ST T20 DRV SS NS -,SUP-370110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X12MM LCK AXSOS ST T20 DRV SS NS -,SUP-370112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X14MM LCK AXSOS ST.T20 DRV SS NS -,SUP-370114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X16MM LCK AXSOS ST T20 DRV SS NS -,SUP-370116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X14MM LCK AXSOS ST-T20 DRV SS NS -,SUP-370118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X14MM LCK AXSOS ST..T20 DRV SS NS -,SUP-370120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X14MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.17,457.219,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X26MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X28MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X30MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X32MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X34MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X36MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X40MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X44MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X65MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X70MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X75MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X80MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X85MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370385,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X90MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X95MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CABLE ORTHO 1.6MM DLMLS HIP SS BEAD SM SLV -,SUP-3704-0-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CABLE/SLEEVE FX 0.2MM DLMLS SS BEAD -,SUP-3704-0-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN DLMLS 165MM 4.5MM 5HL RECON SC SS BRD GROOVEX6 -,SUP-3704-3-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN DLMLS F/RECON TRMA 7HL GROOVEX8 RECON COMPR SS -,SUP-3704-3-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN DLMLS 254MM 4.5MM 9HL RECON SC SS BRD GROOVEX10 -,SUP-3704-3-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN DLMLS 305MM 4.5MM 11HL RECON SC SS GROOVEX12 -,SUP-3704-3-130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CABLE ORTHO 2MM HIP SS -,SUP-3704-8-240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS -,SUP-370528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS. -,SUP-370532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS- -,SUP-370538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS_ -,SUP-370540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS.NS -,SUP-370542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS.. -,SUP-370544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS -,SUP-370546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS__ -,SUP-370570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS-- -,SUP-370575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK AXSOS ST T15 DRV-SS NS -,SUP-370585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK ST 3.0 X 10 -,SUP-371010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,301.9,211.33,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X16MM LCK AXSOS -,SUP-371016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,301.9,211.33,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X14MM LCK AXSOS ST.T20 DRV SS NS DIST LAT PERIART -,SUP-371314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCK 5.0 X 16 -,SUP-371316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X14MM LCK AXSOS ST_T20 DRV SS NS DIST LAT PERIART -,SUP-371318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X14MM LCK AXSOS ST T20 DRV SS NS DIST LAT PERIART -,SUP-371320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X22MM LCK AXSOS ST T20 DRV SS NS -,SUP-371322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X26MM LCK AXSOS ST T20 DRV SS NS -,SUP-371326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X28MM LCK AXSOS ST T20 DRV SS NS -,SUP-371328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCK 5.0 X 30 -,SUP-371330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X32MM LCK AXSOS ST T20 DRV SS NS -,SUP-371332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X34MM LCK AXSOS ST T20 DRV SS NS -,SUP-371334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X36MM LCK AXSOS ST T20 DRV SS NS -,SUP-371336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X38MM LCK AXSOS ST T20 DRV SS NS -,SUP-371338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X40MM LCK AXSOS ST T20 DRV SS NS -,SUP-371340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X42MM LCK AXSOS ST T20 DRV SS NS -,SUP-371342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X44MM LCK AXSOS ST T20 DRV SS NS -,SUP-371344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X46MM LCK AXSOS ST T20 DRV SS NS -,SUP-371346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X48MM LCK AXSOS ST T20 DRV SS NS -,SUP-371348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X50MM LCK AXSOS ST T20 DRV SS NS -,SUP-371350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X60MM LCK AXSOS ST T20 DRV SS NS -,SUP-371360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X70MM LCK AXSOS ST T20 DRV SS NS -,SUP-371370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X75MM LCK AXSOS ST T20 DRV SS NS -,SUP-371375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X80MM LCK AXSOS ST T20 DRV SS NS -,SUP-371380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X90MM LCK AXSOS ST T20 DRV SS NS -,SUP-371390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X95MM LCK AXSOS ST T20 DRV SS NS -,SUP-371395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK 4.0 X 14 -,SUP-371514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X16MM LCK AXSOS ST T15 DRV SS NS -,SUP-371516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X20MM LCK AXSOS ST T15 DRV SS NS -,SUP-371520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X22MM LCK AXSOS ST T15 DRV SS NS -,SUP-371522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X24MM LCK AXSOS ST T15 DRV SS NS -,SUP-371524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X26MM LCK AXSOS ST T15 DRV SS NS -,SUP-371526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK AXSOS ST_T15 DRV SS NS PERIART -,SUP-371528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X30MM LCK AXSOS ST T15 DRV SS NS -,SUP-371530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK AXSOS ST.T15 DRV SS NS PERIART -,SUP-371532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X34MM LCK AXSOS ST T15 DRV SS NS -,SUP-371534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X36MM LCK AXSOS ST T15 DRV SS NS -,SUP-371536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK AXSOS ST-T15 DRV SS NS PERIART -,SUP-371538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS.PERIART -,SUP-371542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS_PERIART -,SUP-371544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS-PERIART -,SUP-371546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X48MM LCK AXSOS ST T15 DRV SS NS -,SUP-371548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X50MM LCK AXSOS ST T15 DRV SS NS -,SUP-371550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X55MM LCK AXSOS ST T15 DRV SS NS -,SUP-371555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X60MM LCK AXSOS ST T15 DRV SS NS -,SUP-371560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X65MM LCK AXSOS ST T15 DRV SS NS -,SUP-371565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM-LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM.LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X80MM LCK AXSOS ST T15 DRV SS NS -,SUP-371580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM_LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X95MM LCK AXSOS ST T15 DRV SS NS -,SUP-371595,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 2.4MM -,SUP-373-0224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BIT DRILL 6MM BN -,SUP-3815-1-660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,371.28,259.896,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM 12X14X6MM COALITION 0DG -,SUP-384.006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM 12X14X8MM COALITION 0DG -,SUP-384.008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 2.8MMX23CM THRD TIP -,SUP-3861-0-628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,82.92,58.044,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO 13MM ASNIS III 6.5/8.0MM SS RND NS -,SUP-390016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,182.99,128.093,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO 4MM ASNIS III F/4MM BN SCR SS RND NS -,SUP-390018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,132.57,92.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO 4.1MM ASNIS III F/9MM BN SCR SS RND NS -,SUP-390019,CDM,C1713,HCPCS,278,RC,,,outpatient,,,145.64,101.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
REDUCTION PIN 4.5MM DIA 150MM -,SUP-390082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,624.75,437.325,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT 5.5MM ZIP PEEK #2 SUT FORCE FIB NDL -,SUP-3910-200-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT 5.5MM ZIP PEEK #2 SUTX2 FORCE FIB -,SUP-3910-200-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT 5.5MM ZIP PEEK #2 SUTX2 FORCE FIB -,SUP-3910-200-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT 6.5MM ZIP PEEK #2 SUTX2 FORCE FIB 1/2CIR TAPR NDL -,SUP-3910-200-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT 6.5MM ZIP PEEK #2 SUTX2 FORCE FIB -,SUP-3910-200-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT INTRALINE 4.5MM HA/PLLA COMP BIOSTEON SUTX2 W/O -,SUP-3910-200-080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2648.5,1853.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT TWINLOOP 3.5MM ZIP PEEK #2 SUT FORCE FIB -,SUP-3910-400-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1151.37,805.959,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT TWINLOOP 3.5MM ZIP PEEK #2 SUTX2 FORCE FIB EYLT -,SUP-3910-400-235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2055.64,1438.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT ICONIX 2.3MM PILOT HL 3 STRN #2 FORCE FIB PLYSTR -,SUP-3910-500-532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2376.27,1663.389,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAP PROT STRL F/2.5MM K-WR -,SUP-392.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5.72,4.004,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAP ORTHO -,SUP-393.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11.67,8.169,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAP PROT F/11MM CFBR EXTFIX ROD -,SUP-394.970,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5.02,3.514,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAP PROT F/4.0MM CRBN FIBRE BAR ROD BLK -,SUP-394.990,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5.43,3.801,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAP PROT NS F/4MM FX PIN YEL -,SUP-394.991,CDM,C1713,HCPCS,278,RC,,,outpatient,,,28.24,19.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
HYDROSET HA BONE SUB 3CC -,SUP-397003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4410.87,3087.609,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
HYDROSET BONE SUB 15CC -,SUP-397015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17072.08,11950.456,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 150MM POLARUS 3 PROX HUM LCK -,SUP-4001-1015R-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10270.16,7189.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X90MM COMPR DL -TRAK CUT FLUT TI ALY NS -,SUP-40-0137,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6336.29,4435.403,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUBSTITUTE CANC 30ML CHP FRZDR VOID FIL 1.7-10MM -,SUP-400150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1681.8,1177.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFT HUM TIS WDG FRZDR 10-17 MMX14-20MM TRCORT ILC CRST -,SUP-400405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4361,3052.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTEX TI SLF TPNG 2.4 X 10 T8 SD REC -,SUP-401.760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,656.44,459.508,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTEX TI SLF TPNG 2.4 X 14 T8 SD REC -,SUP-401.764,CDM,C1713,HCPCS,278,RC,,,outpatient,,,656.44,459.508,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTEX TI SLF TPNG 2.4 X 30 T8 SD REC -,SUP-401.780,CDM,C1713,HCPCS,278,RC,,,outpatient,,,656.44,459.508,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SMALL CALCANEOUS FOOT -,SUP-40-10102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2915.48,2040.836,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CALCANEUS SMALL STANDARD -,SUP-40-10112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2915.48,2040.836,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CALCANEUS STANDARD LARGE -,SUP-40-10116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2915.48,2040.836,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 36MM 2.7MM 4HL RECON POLYAX LCK TI NS -,SUP-40-15011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2418.35,1692.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CURVED PLATE 5 HOLES RIGHT -,SUP-40-15012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.07,1837.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 49MM 2.7MM 6HL RECON POLYAX LCK TI NS -,SUP-40-15014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2657.78,1860.446,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
H-PLATE SMALL -,SUP-40-15021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2050.76,1435.532,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE MED-H -,SUP-40-15022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2610.76,1827.532,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE LARGE -,SUP-40-15023,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2451.75,1716.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
RECTANGLE PLATE SZ 1 -,SUP-40-15032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2451.75,1716.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 48MM 2.7/3.5MM 5HL 1MM RECON POLYAX LCK TI -,SUP-40-15041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2439.24,1707.468,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
VARIAX FOOT PLATE -,SUP-40-15042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2547.84,1783.488,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 51MM 2.7/3.5MM 6HL 1MM RECON POLYAX LCK TI -,SUP-40-15062,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2785.68,1949.976,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 35MM 2.7MM 4HL RECON POLYAX LCK TI NS -,SUP-40-15081,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1737.5,1216.25,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MMX8MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MMX9MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MMX10MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MMX11MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MMX12MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MMX13MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MMX14MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MMX15MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MMX16MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MMX18MM CANN ASNIS 5MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MMX20MM CANN ASNIS 5MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MMX22MM CANN ASNIS 5MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MMX24MM CANN ASNIS 6MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MMX26MM CANN ASNIS 6MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MMX28MM CANN ASNIS 6MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 28.5MM 2MM 2HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 60MM 2MM 4HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1910.88,1337.616,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 72MM 2MM 5HL 2MM PRCONT POLYAX TI STR SMRTLC -,SUP-40-20805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 84MM 2MM 6HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20806,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 96MM 2MM 7HL 2MM PRCONT POLYAX TI STR SMRTLC -,SUP-40-20807,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 108MM 2MM 8HL 2MM PRCONT POLYAX TI STR -,SUP-40-20808,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 132MM 2MM 10HL 2MM PRCONT POLYAX TI STR -,SUP-40-20810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1812.72,1268.904,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 156MM 2MM 12HL 2MM PRCONT POLYAX TI STR -,SUP-40-20812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2549.91,1784.937,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO 2MM ASNIS MICRO F/CANN SCR SYS NS -,SUP-40-20900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,304.88,213.416,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 77MM 2MM 3HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.1,1787.87,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 89MM 2MM 4HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.1,1787.87,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 101MM 2MM 5HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.1,1787.87,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 113MM 2MM 6HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2388.81,1672.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 125MM 2MM 7HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2591.95,1814.365,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 137MM 2MM 8HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20908,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2591.95,1814.365,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 149MM 2MM 9HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20909,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2591.95,1814.365,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TOTAL JNT SUBCHONDROPLASTY -,SUP-402201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11788.78,8252.146,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X14MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X16MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X18MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON-LOCKING 2.7 X 20MM -,SUP-40-27020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X22MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X24MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X26MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X28MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T7 2.7 X 38MM -,SUP-40-27038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T7 2.7 X 40 -,SUP-40-27040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T7 2.7 X 45MM -,SUP-40-27045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X12MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-2761,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X10MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X16MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X18MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X20MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X22MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X24MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X26MM LCK -,SUP-4027626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X28MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX8MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX10MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX12MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX13MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX14MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX15MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX16MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX17MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
MICRO ASNIS SCREW 3.0MM X 18MM -,SUP-40-30118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX18MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.48,659.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX19MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30119,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX20MM CANN ASNIS THRD REVCT FLUT TI NS PUR -,SUP-40-30120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX22MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX24MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX26MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX28MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX30MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX32MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX34MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.0 MICRO ASNIS SCREW -,SUP-40-30134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX36MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX40MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO 3MM ASNIS MICRO F/CANN SCR SYS NS -,SUP-40-30900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,339.01,237.307,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X10MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X12MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X14MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X16MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X18MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X20MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X22MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X24MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X28MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X30MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X32MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X34MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X36MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X38MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X40MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X42MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X44MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X46MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X48MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X50MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X55MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X60MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X65MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X70MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X10MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X12MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X14MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X16MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X18MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X20MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X22MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X24MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.5MM LOCKING 28MM SCREW -,SUP-40-35628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.5MM LOCKING 34MM SCREW -,SUP-40-35634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X40MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO F/3.5MM BN SCR -,SUP-40-35900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,376.01,263.207,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX28MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX36MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.836,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX38MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.838,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX55MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.855,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EXHAL SZ 8-32X.375 -,SUP-4-072623-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6.48,4.536,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 2.4MMX23CM -,SUP-410236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,407.52,285.264,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SET SCREWS MARINER SPINE -,SUP-41-1010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
POLYAXIAL HEAD G2 -,SUP-41-3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
HEAD SCREW SEASPINE MARINER POLY EXTEND -,SUP-41-4010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
30MM OFFSET -,SUP-41-4130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLUG CEMENT SMALL DIA 10MM -,SUP-414994,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLUG CEMENT SMALL DIA 12MM -,SUP-414995,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE SCREW 5.5 X 30MM -,SUP-41-5530-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
MARINER SOLD SCREW 5.5 X35MM -,SUP-41-5535-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SEASPINE MARINER SOLID 5.5MM X 35MM -,SUP-41-5535-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE SCREW 5.5 X 40 -,SUP-41-5540-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5 X 45MM -,SUP-41-5545-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SEASPINE MARINER SOLID 6.5MM X 35MM -,SUP-41-6535-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE SCREW 6.5 X 45MM -,SUP-41-6545-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5 X 70MM -,SUP-41-7570-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO TRUMATCH RT -,SUP-420901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6242.92,4370.044,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO TRUMATCH LT -,SUP-420902,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4990.94,3493.658,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN SZ5 ATTUNE TRUMATCH LT KN -,SUP-420945,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC 100X100MM MATRIXNEURO LPRO MSH 0.6MM TI SQ -,SUP-421.534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8428.58,5900.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X26MM LCK CANN SD 3.5MM HEX RCESS CNCL HEAD TI NS -,SUP-422.392,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1537.15,1076.005,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X55MM LCK CANN SD 3.5MM HEX RCESS CNCL HEAD TI NS -,SUP-422.394,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1515.94,1061.158,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X65MM LCK CANN SD 3.5MM HEX RCESS CNCL HEAD TI NS -,SUP-422.395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1515.94,1061.158,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BEARING FIXED ASF UC 14MM PLY R 4-11 EF PERSONA -,SUP-42-5212-005-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SYSTEM KNEE PERSONA ASF UC 35MM PLY R 7-12 GH 9.0 THICKNESS -,SUP-42-5400-000-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CURVED PELVIC R 108MM/L58.5MM/4HOLE -,SUP-425604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CURV PELV R 108MM L74.5MM 5 HOLE -,SUP-425605,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 8 HOLE -,SUP-425608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
10 HOLE PLATE -,SUP-425610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CURV. PELV 108MM/L186.5MM/12H -,SUP-425612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PELV CURV R 108MM L218.5MM 14HOLE -,SUP-425614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PELV CURV R 108MM L250.5MM 16 HOLE -,SUP-425616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5273.81,3691.667,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PELV CURV R 108MM L282.5MM 18H -,SUP-425618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5273.81,3691.667,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PELV CURV R 108MM L314.5MM 20H -,SUP-425620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5273.81,3691.667,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SYMPYSIS -,SUP-425654,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 10.5MMX74.5MM F/3.5MM/4.5MM SCR 4HL MATTA SS 88MM -,SUP-425655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 6 HOLE R88 PELVIS -,SUP-425656,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 8HOLE R88 -,SUP-425658,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PELV CURVED R 88MM/L154.5MM/10H -,SUP-425660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE R88 12 HOLE -,SUP-425662,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE R88 CURVED 218.5 14 HOLE -,SUP-425664,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 16 HOLE R88 PELVIS -,SUP-425666,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PELV CURV R 88MM L282.5 18H -,SUP-425668,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PELV CURV R 88MM L314.5MM 20H -,SUP-425670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PELV STRAIGHT L 26.5MM -,SUP-425702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4046.3,2832.41,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PELVIC PLATE -,SUP-425753,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4676.37,3273.459,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE STRT ACET L 46.5MM 14 HOLE -,SUP-425754,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4676.37,3273.459,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE STRAIGHT ACET L 70.5M 6 HOLE -,SUP-425756,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4571.81,3200.267,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 8HOLE FLEX -,SUP-425758,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4571.81,3200.267,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 10 HOLE FLEX -,SUP-425760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4571.81,3200.267,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE STRT ACET L 142.5MM 12 HOLE -,SUP-425762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5044.63,3531.241,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SYMPHYSIS 4 HOLE -,SUP-425794,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6110.34,4277.238,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PRO SUPRAPECTINEAL QLS LEFT -,SUP-425912S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.77,7018.039,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
INFRAPECTINEAL PLATE SMALL QLS LEFT -,SUP-425932S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8017.17,5612.019,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 45MM 4MM 3HL LCK COMPR SS WAIST SM FRAG NS -,SUP-427003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,557.83,390.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 71MM 4MM 5HL LCK COMPR SS WAIST SM FRAG NS -,SUP-427005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,716.54,501.578,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 97MM 4MM 7HL LCK COMPR SS WAIST RND TAPR END -,SUP-427007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,716.54,501.578,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 110MM 4MM 8HL LCK COMPR SS WAIST RND TAPR END -,SUP-427008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,795.89,557.123,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 123MM 4MM 9HL LCK COMPR SS WAIST SM FRAG STRL -,SUP-427009S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,795.89,557.123,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 136MM 4MM 10HL LCK COMPR SS WAIST RND TAPR -,SUP-427010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,795.89,557.123,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 266MM 4MM 20HL LCK COMPR SS WAIST SM FRAG NS -,SUP-427020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.32,779.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 48MM 4MM 4HL RECON LCK COMPR SS SM FRAG NS -,SUP-427034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1836.09,1285.263,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 60MM 4MM 5HL RECON LCK COMPR SS SM FRAG NS -,SUP-427035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1836.09,1285.263,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 72MM 4MM 6HL RECON LCK COMPR SS ADLT SM FRAG -,SUP-427036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2071.44,1450.008,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 96MM 4MM 8HL RECON LCK COMPR SS ADLT SM FRAG -,SUP-427038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2298.3,1608.81,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 76MM 3MM 6HL LCK SS 1/3 TBLR SM FRAG NS -,SUP-427066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,669.86,468.902,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 89MM 3MM 8HL LCK SS 1/3 TBLR SM FRAG NS -,SUP-427068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,725.87,508.109,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 169MM 5MM 9HL LCK COMPR SS NRW WAIST BSC FRAG -,SUP-427109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,898.59,629.013,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 223MM 5MM 12HL LCK COMPR SS NRW WAIST BSC -,SUP-427112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1075.97,753.179,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 259MM 5MM 14HL LCK COMPR SS NRW WAIST BSC -,SUP-427114S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1075.97,753.179,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE WSTD CMP BRD HL8 -,SUP-427138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 173MM 5MM 9HL LCK COMPR SS BRD WAIST BSC FRAG -,SUP-427139S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 263MM 5MM 14HL LCK COMPR SS BRD WAIST BSC ST -,SUP-427144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1159.75,811.825,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFT HUM TIS HEMI FRZN 10-10.5 MMX8-13CM PTLR TNDN 30-75MM -,SUP-430007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11007.78,7705.446,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 10X60MM F/3.5MM/4MM SCR 5HL SHFT 2.8MM RECON -,SUP-430105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.67,1007.769,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 25MM 3MM 2HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,234.51,164.157,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 38MM 3MM 3HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,234.51,164.157,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 64MM 3MM 5HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,289.01,202.307,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 77MM 3MM 6HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,289.01,202.307,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 90MM 3MM 7HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.42,222.194,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 103MM 3MM 8HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,355.35,248.745,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 129MM 3MM 10HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,355.35,248.745,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
MESH TITANIUM 6X6 - DISCONTINUED DO NOT USE -,SUP-43-1022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 10X49MM F/3.5MM/4.5MM SCR 0.75HL HD/SHFT 1.2MM SS -,SUP-431024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,634.85,444.395,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 10X66MM F/3.5MM/4.5MM SCR HLX3/6 HD/SHFT 1.2MM SS -,SUP-431026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,871.75,610.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
MOLD CMNT SPCR 48MM SIL SS STAGEONE STRL -,SUP-431181,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5199.96,3639.972,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
HIP HEAD CEMENT MOLD 52MM -,SUP-431182,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5199.96,3639.972,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SHOULDER MOLD 12STD 54 X 21 X 64 -,SUP-431412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11946.58,8362.606,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
60MM FEMORAL KNEE CEMENT MOLD -,SUP-432160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8413.73,5889.611,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
MOLD BNCMNT FEM 65MM SIL STAGEONE STRL -,SUP-432165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8413.73,5889.611,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 158MM 4.5MM 10HL RECON SS -,SUP-432210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1420.32,994.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE RECON HL 4.5 X 14 HOLE -,SUP-432214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.92,1168.944,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE T 6 HOLE L=111MM -,SUP-433106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.57,778.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
70MM TIBIAL KNEE CEMENT MOLD -,SUP-433170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4530.53,3171.371,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
MOLD BNCMNT TIB 75MM SIL STAGEONE STRL -,SUP-433175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4530.53,3171.371,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 86MM 4MM 3HL CONTR LCK SS NS 1STRN/PK -,SUP-437123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5167.49,3617.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 112MM 4MM 5HL CONTR LCK SS NS -,SUP-437125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5167.49,3617.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 95MM 4MM HLX2/5 SHFT/METPHYSL CONTR LCK SS NS -,SUP-437302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 121MM 4MM HLX4/5 SHFT/METPHYSL CONTR LT TIB -,SUP-437304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 147MM 4MM HLX6/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 121MM 4MM HLX4/5 SHFT/METPHYSL CONTR RT TIB -,SUP-437324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 173MM 4MM HLX8/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 97MM 4MM HLX4/3 SHFT/METPHYSL CONTR LCK SS -,SUP-437424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4738,3316.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 166MM 5MM HLX6/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5434.02,3803.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 202MM 5MM HLX8/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 238MM 5MM HLX10/5 SHFT/METPHYSL CONTR LCK SS. -,SUP-437510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 310MM 5MM HLX14/5 SHFT/METPHYSL CONTR LCK SS- -,SUP-437514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 238MM 5MM HLX10/5 SHFT/METPHYSL CONTR LCK SS- -,SUP-437530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 310MM 5MM HLX14/5 SHFT/METPHYSL CONTR LCK SS. -,SUP-437534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 343MM 5MM HLX16/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LINER 32X49MM EPSLN STD DRSUL PRIM HOOD -,SUP-4377-32-049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3174.71,2222.297,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SET SCREW SPIN STD FIREBIRD TI -,SUP-44-2001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FIREBIRD TOP LOADING HEAD -,SUP-44-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX 4.5 X 30 SCREW -,SUP-44-5430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX SCREW 4.5 X 35 -,SUP-44-5435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX SCREW 4.5 X 40 -,SUP-44-5440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX SCREW 4.5 X 45 -,SUP-44-5445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX SCREW 5.5 X 30 -,SUP-44-5530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX SCREW 5.5 X 35 -,SUP-44-5535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX SCREW 5.5 X 40 -,SUP-44-5540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX SCREW 5.5 X 45 -,SUP-44-5545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX SCREW 6.5 X 30 -,SUP-44-5630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
6.5 X 35 SHANK -,SUP-44-5635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
6.5 X 40 SHANK -,SUP-44-5640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
6.5 X 45 SHANK -,SUP-44-5645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
7.5 X 40 SHANK -,SUP-44-5740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FIREBIRD ORTHOFIX 7.5 X 45 -,SUP-44-5745,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX SCREW 7.5 X 50 -,SUP-44-5750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX SCREW 6.5 X 35 -,SUP-44-6535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX SCREW 6.5 X 40 -,SUP-44-6540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER 3.5 -,SUP-45-35900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,139.05,97.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
MICROCOIL EMBL 4MMX 5CML AZUR DTCH 18 -,SUP-45-480405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3570.95,2499.665,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT PHALANX 2MM PRO- TOE VO 13MM 10DG ANG -,SUP-45712010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
MINI STICK MAX 5FR X 10CM -,SUP-45-756,CDM,C1713,HCPCS,278,RC,,,outpatient,,,431.21,301.847,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COUNTERSINK FOR SCREWS 02.7/3.5mm AO FITTING -,SUP-45-80040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,516.4,361.48,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X12MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115401200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X16MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115401600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X18MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115401800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X20MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115402000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER SYSTEM CONSTRUX MINI PEEK -,SUP-47-3009SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X10MM CORT SM HX DRV -,SUP-4820-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.04,88.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX24MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-48-3502-41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COUPLING DELTA ROD TO ROD MULTI 05/8/11 5MM PIN -,SUP-4922-1-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4759.25,3331.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CLAMP 5 HOLE PIN -,SUP-4922-2-020-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3516.77,2461.739,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD VECTRAN COATED 11MM X 100MM CARBON CONN -,SUP-4922-8-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1854.96,1298.472,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WIRE BOLT SHORT -,SUP-4933-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,750.96,525.672,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WIRE BOLT MEDIUM -,SUP-4933-1-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,750.96,525.672,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WIRE BOLT ADAPTER SHORT -,SUP-4933-1-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1798.46,1258.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
M8 CONNECTING NUT -,SUP-4933-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,199.56,139.692,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
POST EXTERNAL FIXATION SHORT L44 MM OD8 MM HOFFMANN -,SUP-4933-1-644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,819.23,573.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BOLT FOR RING -,SUP-4933-1-702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,220.56,154.392,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER YELLOW 2MM -,SUP-4933-1-711,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.1,249.97,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CARBON FIBER FULL RING 210MM -,SUP-4933-5-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10863.87,7604.709,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CARBON FIBER OPEN RING 180MM -,SUP-4933-6-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9858.39,6900.873,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CARBON FIBER OPEN RING 210MM -,SUP-4933-6-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9316.66,6521.662,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WIRE WITH OLIVE 1.8 X 450 -,SUP-4933-8-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,850.74,595.518,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
K-WIRE 2.0 OLIVE -,SUP-4933-8-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,887.5,621.25,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
HII COMPACT MRI PERIARTICULAR PIN CLAMP -,SUP-4941-2-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1539.11,1077.377,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SYNMESH 15MM DIA 8MM HEIGHT ROUND CAGE -,SUP-495.361,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9527.78,6669.446,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
END RING 10MM DIAM / 0 DEG -,SUP-495.384,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1024.04,716.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SYNMESH 10MM DIAM 20MM HEIGHT -,SUP-495.603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9664.94,6765.458,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CRNMXF UPR FACE 1.2X5MM UNIVERSAL NEURO II ST TI NS -,SUP-50-12005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,372.97,261.079,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CRNMXF UPR FACE 1.2X10MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-12010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,372.97,261.079,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CRNMXF UPR FACE 1.2X12MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-12012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,372.97,261.079,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CRNMXF UPR FACE 1.2X3MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-12903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,417.55,292.285,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN WND CLSR 200MM -,SUP-5014-5-200S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,680.36,476.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CANC HALF-PIN 5MM SHAFT 6MM X 250 THREAD -,SUP-5015-7-250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CRNMXF MIDFC 1.7X6MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-17006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.31,222.117,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CRNMXF MIDFC 1.7X8MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-17008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.31,222.117,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CRNMXF MIDFC 1.7X10MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-17010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.31,222.117,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ER CRNMXF MIDFC 1.7X4MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-17304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,441.77,309.239,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK CRNMXF MIDFC 1.7X4MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-17504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,416.09,291.263,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK CRNMXF MIDFC 1.7X5MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-17505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,416.09,291.263,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
HALF PIN FX APEX 5MM SS HA CTD SD/TAP180MML 50MM THRD -,SUP-5017-5-180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,642.67,449.869,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CRNMXF MIDFC 1.7X3MM CX PIN HD UNIVERSAL NEURO II SD -,SUP-50-17903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,356.29,249.403,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CRNMXF MIDFC 1.7X4MM CX PIN HD UNIVERSAL NEURO II ST. -,SUP-50-17904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,356.29,249.403,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN EXTFIX 5X150MM SS APEX 40MM THRD SD/ST -,SUP-5018-5-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
HALFPIN EXTFIX 5X150MM SS APEX 50MM THRD SD/ST -,SUP-5018-6-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN EXTFIX 5X50MM HLF SS APEX 180MM THRD SD -,SUP-5018-6-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CRNMXF MIDFC 1.9X3MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-19003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,348.64,244.048,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CRNMXF MAND 2X4MM CX PIN HD UNIVERSAL NEURO II ST TI -,SUP-50-20404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.62,210.434,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CRNMXF MAND 2X6MM CX PIN HD UNIVERSAL NEURO II ST TI -,SUP-50-20406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.62,210.434,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CRNMXF MAND 2X8MM CX PIN HD UNIVERSAL NEURO II ST TI -,SUP-50-20408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.62,210.434,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK CRNMXF MAND 2X12MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-20512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,551.06,385.742,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK CRNMXF MAND 2X14MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-20514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,551.06,385.742,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK CRNMXF MAND 2X16MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-20516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,551.06,385.742,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SELF DRILLING LOCKING 2 X 6MM -,SUP-50-20596,CDM,C1713,HCPCS,278,RC,,,outpatient,,,830.96,581.672,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN EXTFIX 6X200MM HLF SS APEX 70MM THRD SD/ST -,SUP-5021-8-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN EXTFIX 4X120MM SS APEX 30MM THRD SD/ST -,SUP-5023-3-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CRNMXF MAND 2.3X16MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-23416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.43,257.201,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN EXTFIX 4X120MM HLF SS APEX 35MM THRD SD/ST -,SUP-5023-5-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN EXTFIX 4X150MM HLF SS APEX 50MM THRD SD/ST -,SUP-5023-6-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN EXTFIX 4X180MM SS HLF PIN APEX 50MM THRD SD/ST -,SUP-5023-6-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN HYBRID APEX -,SUP-5026-8-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,591.79,414.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAP EXTFIX 5MM HOFFMN XPRESS 40MM THRD F/PIN TIP -,SUP-5027-1-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17.15,12.005,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ER CRNMXF MAND 2.7X12MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-27412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,416.21,291.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK CRNMXF MAND 2.7X10MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-27510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,708.49,495.943,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD CONNECTING VECTRAN COATED CARBON 8MM X 400MM -,SUP-5028-8-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1100.81,770.567,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TRANSFIX PIN 4X300MM -,SUP-5030-4-300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
APEX TRANSFIX 4 X 250 PIN 5 X 50 THR -,SUP-5030-5-250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN EXTFIX 3X100MM TRNSFX SS APEX 25MM THRD SD/ST F/BILAT -,SUP-5038-2-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,329.79,230.853,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN EXTFIX 3X200MM TRNSFX SS APEX -,SUP-5045-5-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD HII COMPACT MRI CONNECTING 5MM X 65MM -,SUP-5048-5-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
HII COMPACT MRI CONNECTING ROD 5MM X 100MM -,SUP-5048-5-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
HII COMPACT MRI CONNECTING ROD 5MM X 150MM -,SUP-5048-5-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD HII COMPACT MRI CONNECTING 5MM X 200MM -,SUP-5048-5-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN TRANSFIXING 300MM 5/6 -,SUP-5050-4-300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN EXTFIX 5MM/4X300MM TRNSFX SS APEX 50MM THRD SD/ST -,SUP-5050-5-250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,623.82,436.674,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BLADE SAW 13X90MM OSCIL/SGTL 0.89MM -,SUP-506123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,460.97,322.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN EXTFIX 2X45MM SS APEX 20MM THRD ST -,SUP-5065-4-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,297.76,208.432,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CARBON CONNECTING ROD 3MMX120MM -,SUP-5079-6-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,290.23,203.161,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
HALFPIN EXTFIX 2X45MM SS U THRD DBL HLCL FLUT APEX 12MM P/T -,SUP-5080-2-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,346.77,242.739,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN 2MM X 45MM HALF HOFFMANN II APEX STAINLESS STEEL MICRO -,SUP-5080-2-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,346.77,242.739,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLY THRD 4.5X25MM CREO -,SUP-5119.1327,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLY THRD 5.5 4.5X30MM CREO -,SUP-5119.1330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CREO 5.5 4.5MM X 40MM POLYAXIAL SCREW -,SUP-5119.1340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CREO 5.5 4.5MM X 45MM POLYAXIAL -,SUP-5119.1345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5 X 40 POLYAXIAL CREO -,SUP-5119.1440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CREO THREADED 5.0 X 45MM POLYAXIAL SCREW -,SUP-5119.1447,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5 X 35 POLYAXIAL CREO -,SUP-5119.1535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5 X 40 POLYAXIAL CREO -,SUP-5119.1540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X45MM CREO THRD PRASMB F/5.5MM TI STRL -,SUP-5119.1545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CREO THREADED 5.5 X 45MM POLYAXIAL SCREW -,SUP-5119.1547,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL 5.5 X 50 -,SUP-5119.1550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL 5.5 6.5 X 30 CREO -,SUP-5119.1630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X35MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.1635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X40MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.1640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X45MM CREO THRD PRASMB F/5.5MM TI STRL -,SUP-5119.1645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL CREO 6.5 X 50 -,SUP-5119.1650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CREO 5.5 6.5 X 60MM POLYAXIAL SCREW -,SUP-5119.1660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5-5.5X30MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5-5.5X35MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3337,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL CREO 5.5- 6.0-5.0X25MM -,SUP-5119.3427,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6-5X30MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.3432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6-5X35MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.3437,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5-6.5X30MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5-6.5X35MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3537,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CREO 5.5 5.5MM X 45MM CORTICAL -,SUP-5119.3547,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER CERV 14X6X12MM MOSAIC PEEK-OPTIMA -,SUP-51412-206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER CERV 14X7X12MM MOSAIC PEEK-OPTIMA -,SUP-51412-207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11436.04,8005.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
UNITED HIP CANCELLOUS LOCKING SCREW 6.5MM X 15MM -,SUP-5208-1015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
UNITED CANCELLOUS LOCKING SCREW 6.5 X 20 -,SUP-5208-1020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
UNITED CANCELLOUS LOCKING SCREW 6.5 X 25 -,SUP-5208-1025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
UNITED CANCELLOUS LOCKING SCREW 6.5 X 30 -,SUP-5208-1030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
UNITED HIP CANCELLOUS LOCKING SCREW 6.5MM X 35MM -,SUP-5208-1035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
UNITED CANCELLOUS LOCKING SCREW 6.5 X 45 -,SUP-5208-1045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD FIREBIRD 40MM ORTHOFIX -,SUP-52-2040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX NXG 70 ROD -,SUP-52-2070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX 80MM ROD -,SUP-52-2080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
90MM TI ROD STRAIGHT -,SUP-52-2090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
100MM TI ROD STRAIGHT -,SUP-52-2100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NXG 110MM ROD -,SUP-52-2110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD FIREBIRD 120MM TI STRAIGHT ORTHOFIX -,SUP-52-2120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD FIREBIRD STRAIGHT 140MM TI ORTHOFIX -,SUP-52-2140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 160MM NXG DIA 5.5MM TI ORTHOFIX -,SUP-52-2160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX ROD 180 -,SUP-52-2180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX ROD 200MM -,SUP-52-2200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD HEX TITANIUM 400MM -,SUP-52-2450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 35MM ORTHOFIX -,SUP-52-6035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
40MM ROD TI CURVED -,SUP-52-6040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 45MM ORTHOFIX -,SUP-52-6045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX ROD 50MM -,SUP-52-6050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ACTB 6.5X12MM OSTLOK -,SUP-5260-5-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ACTB 6.5X14MM OSTLOK -,SUP-5260-5-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ACTB 6.5X18MM OSTLOK -,SUP-5260-5-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ACTB 6.5X30MM OSTLOK -,SUP-5260-5-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ACTB 6.5X35MM OSTLOK -,SUP-5260-5-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ACTB 6.5X40MM OSTLOK -,SUP-5260-5-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ACTB 6.5 X 45MM OSTLOK -,SUP-5260-5-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ACTB 6.5X50MM OSTLOK -,SUP-5260-5-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX ROD 55MM -,SUP-52-6055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX NXG 60MM ROD -,SUP-52-6060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX NXG 65MM ROD -,SUP-52-6065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX 70MM ROD -,SUP-52-6070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX 75MM ROD -,SUP-52-6075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX 80 ROD -,SUP-52-6080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
OPEN CONNCETOR 5.5 - 5.5 -,SUP-52-6805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC 12MM BAR UNIV NEURO III LPRO 2HL TI STR 1.5MM -,SUP-53-05212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,705.92,494.144,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC 2HL 16MM BAR STR UNIV NEURO III 1.5MM TI NS -,SUP-53-05216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,844.97,591.479,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC 4HL 28MM BAR 3D BX UNIV NEURO III 1.5MM TI NS -,SUP-53-05228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.88,735.616,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC LRG 2HL 3D BX LEIBINGER UNIV NEURO 2 1.5MM TI -,SUP-53-05240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1443.7,1010.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC 6MM BAR 4HL STR LEIBINGER UNIV NEURO 2 1.5MM TI -,SUP-53-05406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,702.42,491.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COVER CRANFC 7MM UNIV NEURO III LPRO TI -,SUP-53-05507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1211.85,848.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COVER CRANFC 10MM UNIVERSAL NEURO II LPRO TI NS -,SUP-53-05510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1211.85,848.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COVER CRANFC 14MM UNIVERSAL NEURO II LPRO TI NS -,SUP-53-05514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1211.85,848.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COVER CRANFC 20MM UNIVERSAL NEURO II LPRO TI NS -,SUP-53-05520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1338.06,936.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC 8MM UNIV NEURO III LPRO 6HL TI DBL Y 1.5MM NS -,SUP-53-05608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1331.38,931.966,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE STR LP GAP SMALL -,SUP-53-05612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1587.66,1111.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE STR LP GAP LARGE -,SUP-53-05622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1748.42,1223.894,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC 4HL X-SHP LEIBINGER UNIV NEURO 2 1.5MM TI NS -,SUP-53-05630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1344.26,940.982,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC 8HL STR LEIBINGER UNIV NEURO 2 1.5MM TI NS W/O -,SUP-53-05804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.28,665.896,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC 12MM 2HL UNIV NEURO III XTR RGD TI NS -,SUP-53-06212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,597.33,418.131,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL SFT TIS BIO- ABSB LPRO 1.5X20MM PLYLC ACD PLYMR KN -,SUP-531520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,798.11,558.677,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.7X5MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17005E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK 1.7 X 06 -,SUP-53-17006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,518.32,362.824,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.7X8MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.7X9MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK 1.7 X 10 -,SUP-53-17010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.83,308.581,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.7X12MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK 1.7 X 16 -,SUP-53-17016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.7X16MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX -,SUP-53-20616E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2X18MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX NS -,SUP-53-20618E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2X20MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX NS -,SUP-53-20620E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2X22MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX NS -,SUP-53-20622E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.7X24MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX -,SUP-53-20624E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.7X26MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX. -,SUP-53-20626E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X6MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X8MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X9MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X10MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X11MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23011E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X12MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X13MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23013E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X16MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X18MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23018E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.3MM X 20MM -,SUP-53-23020E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.88,310.016,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.3 X 24 -,SUP-53-23024E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.3 X 26 -,SUP-53-23026E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X10MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23210E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X14MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23214E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X16MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23216E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X18MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23218E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X20MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23220E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X22MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23222E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X24MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23224E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X26MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23226E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X28MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23228E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X30MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23230E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X32MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23232E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X34MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23234E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X36MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23236E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X38MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23238E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X10MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23610E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X12MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23612E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X14MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT. -,SUP-53-23614E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X16MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23616E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X18MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT. -,SUP-53-23618E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X20MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23620E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X22MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23622E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X24MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23624E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X26MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23626E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X28MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23628E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X30MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23630E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X32MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23632E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X34MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23634E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X36MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23636E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X38MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23638E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X16MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27116E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X18MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27118E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X20MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27120E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X22MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27122E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X24MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27124E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X26MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27126E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X10MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27210E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCK 2.7 X 12MM -,SUP-53-27212E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCK 2.7 X 14 -,SUP-53-27214E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X16MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27216E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X18MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27218E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X20MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27220E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X22MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27222E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X24MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27224E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X25MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27226E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X10MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27610E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X12MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27612E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X14MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27614E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X16MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27616E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X18MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27618E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X20MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27620E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7 X 22 -,SUP-53-27622E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X24MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27624E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X26MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27626E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE MSH CRANFC MIDFC MICRO 60X120MM 0.1MM MLBL 1.2MM TI NS -,SUP-54-00261,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3755.99,2629.193,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
MICRO/MESH 120 X 120 X .2MM / GOLD -,SUP-54-00270,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8602.59,6021.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
MICRO/MESH 120 X 60 X .2MM / GOLD -,SUP-54-00271,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6438.15,4506.705,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BLUE DYNAMIC MESH  90X90MM 0.3MM MLBL 1.7MM TI NS -,SUP-54-00346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2066.2,1446.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW 3.5MM T15 L40MM -,SUP-541540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1621.95,1135.365,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 60MMX1.5MM 2.7MM ANTMC POLYAX TI SMRTLC RT -,SUP-54-25290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 60MMX1.5MM 2.7MM ANTMC POLYAX TI SMRTLC LT -,SUP-54-25291,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE WIDE DORSAL RIGHT -,SUP-54-25292,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 60MMX1.5MM 2.7MM ANTMC POLYAX TI W SMRTLC -,SUP-54-25293,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 81MMX1.5MM 2.7MM ANTMC POLYAX TI XLNG SMRTLC -,SUP-54-25295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4270.06,2989.042,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 56MM 2.7MM 9HL 2MM ANTMC POLYAX TI SMRTLC -,SUP-54-25374,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 76MM 2.7MM 2MM ANTMC POLYAX TI LNG NRW LT -,SUP-54-25375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 56MM 2.7MM 11HL ANTMC POLYAX TI STD SMRTLC -,SUP-54-25376,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 76MM 2.7MM 13HL 2MM ANTMC POLYAX TI STD LNG -,SUP-54-25377,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 56MM 2.7MM 9HL ANTMC POLYAX TI STD SMRTLC -,SUP-54-25384,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 76MM 2.7MM 2MM ANTMC POLYAX TI LNG NRW RT -,SUP-54-25385,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 56MM 2.7MM STD ANTMC TI SMRTLC -,SUP-54-25386,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE VOLAR 76MM L 14 HOLE 2MM H STAN LONG RT -,SUP-54-25387,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 53MM 2.7MM 2MM POLYAX TI MED/SHRT UNIV XLN -,SUP-54-25394,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3450.36,2415.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 53MM 2.7MM 2MM POLYAX TI SHRT UNIV STD -,SUP-54-25396,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3450.36,2415.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 53MM 2.7MM 2MM POLYAX TI SHRT UNIV W SMRTLC -,SUP-54-25398,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3450.36,2415.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 44MM 2.7MM 1MM ANTMC POLYAX TI SHRT NRW CLMN -,SUP-54-25400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 57MM 2.7MM ANTMC POLYAX TI LNG CLMN SMRTLC -,SUP-54-25401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 40MMX1MM FRAG SPEC POLYAX TI SHRT SMRTLC -,SUP-54-25402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 40MMX1MM 2.7MM FRAG SPEC POLYAX TI SHRT -,SUP-54-25403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 53MMX1MM FRAG SPEC POLYAX TI LNG SMRTLC -,SUP-54-25405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2.7 X 189 15 HOLE -,SUP-54-25420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7093.08,4965.156,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2.7 145 11 HOLES -,SUP-54-25424S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7093.08,4965.156,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2.7MM XXL VOLAR L100MM 8 HOLE -,SUP-54-25428S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6203.58,4342.506,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE VOLAR XXL 7MM -,SUP-54-25442S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7093.08,4965.156,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2.7MM XXL VOLAR NARROW 8 HOLE -,SUP-54-25444S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6203.58,4342.506,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 8 HOLES / 100MM / 2.7MM XXL -,SUP-54-25446S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6203.58,4342.506,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 3HL XSH NRW -,SUP-54-25573,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 8HL XSH -,SUP-54-25583,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN XSH -,SUP-54-25673,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 2X56MM 11HL INTMD ANTMC SHRT NS -,SUP-54-25674,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE INT LNG LEFT 14 HOLE -,SUP-54-25677,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4468.42,3127.894,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX F/DIST RAD SYS 10HL INTMD XSH -,SUP-54-25683,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 11HL INTMD SHRT -,SUP-54-25684,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 14HL INTMD LNG -,SUP-54-25687,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4468.42,3127.894,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX F/DIST RAD SYS 10HL STD XSH -,SUP-54-25773,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 10HL STD XSH -,SUP-54-25783,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
RESTRICTOR BNCMNT FEM SZ3 13.25MM UHMWPE -,SUP-5460-14-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1026.96,718.872,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
RESTRICTOR BNCMNT FEM SZ3 15.75MM UHMWPE -,SUP-5460-16-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1150.21,805.147,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
RESTRICTOR FMCNL BNCMNT SZ5 18.25MM UHMWPE HIP -,SUP-5460-18-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1070.7,749.49,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE HYBRID MMP -,SUP-55-02950,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1731.83,1212.281,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC UPR FACE 18HL 3D SHP UNIVERSAL NEURO II MLBL -,SUP-55-04218,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2608.27,1825.789,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC UPR FACE HLX2X2 3D UNIVERSAL NEURO II MLBL -,SUP-55-04231,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.51,834.757,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC UPR FACE HLX6X2 0.5MM 3D UNIV 2 MLBL 1.2MM TI -,SUP-55-04233,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2146.54,1502.578,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE UPR FACE 7HL 0.5MM DBL Y UNIVERSAL NEURO II MLBL 1.2MM -,SUP-55-04240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1128.37,789.859,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC UPR FACE 24HL 0.5MM STR UNIV 2 MLBL 1.2MM TI NS -,SUP-55-04424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2500,1750,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC MIDFC 20HL 0.55MM UNIV 2 MLBL 1.7MM TI NS BLU -,SUP-55-04720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2468.01,1727.607,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC MIDFC 24HL 0.55MM STR UNIV 2 MLBL CNDSD 1.7MM -,SUP-55-04724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.85,1788.395,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC MIDFC 7HL 0.6MM UNIVERSAL NEURO II STD 1.7MM TI -,SUP-55-05164,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.58,742.406,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE ORBT MIDFC 6HL CRV LEIBINGER UNIV 2 STD 1.7MM TI NS -,SUP-55-05188,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1255.9,879.13,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE LCK CRANFC MIDFC HL 2X2 0.8MM 3D SHP UNIVERSAL NEURO -,SUP-55-05731,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1390.43,973.301,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC UPR FACE 8HL STR UNIVERSAL NEURO II STD 1.2MM -,SUP-55-06208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1389.47,972.629,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC UPR FACE HLX2X2 3D SHP UNIVERSAL NEURO II STD -,SUP-55-06231,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.43,785.001,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
3D PLATE 6 X 2 HL UPPERFACE -,SUP-55-06233,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2014.51,1410.157,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
3D PLATE 6 X 6 HL UPPERFACE -,SUP-55-06235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4305.34,3013.738,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLT/7 HOLE DOUBLE Y UPPERFACE -,SUP-55-06240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1022.23,715.561,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE MIDFC 4HL STR UNIVERSAL NEURO II STD 1.7MM TI NS BAR -,SUP-55-06704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.58,457.506,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC MIDFC 8HL STR UNIVERSAL NEURO II STD 1.7MM TI -,SUP-55-06708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1319.35,923.545,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE MIDFC 24HL STR UNIVERSAL NEURO II STD 1.7MM TI NS BAR -,SUP-55-06724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2527.07,1768.949,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE STR 2 X 2 3D -,SUP-55-06731,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1207.72,845.404,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE MIDFC 10HL UNIVERSAL NEURO II STD 1.7MM TI NS BAR GOLD -,SUP-55-06750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1390.43,973.301,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE MIDFC 4HL CRV UNIVERSAL NEURO II STD 1.7MM TI NS GOLD -,SUP-55-06754,CDM,C1713,HCPCS,278,RC,,,outpatient,,,804.35,563.045,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE RT CRANFC MIDFC 2MM 5HL 0.6MM LEIBINGER UNIVERSAL -,SUP-55-06761,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1100.48,770.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE RT CRANFC MIDFC 5MM 5HL 0.6MM UNIVERSAL NEURO II STD -,SUP-55-06763,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1133.97,793.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE LCK MAND MINI 4HL 1MM STR UNIVERSAL NEURO II 2MM TI NS -,SUP-55-10504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,513.89,359.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE LCK MAND MINI 6HL 8MM STR UNIVERSAL NEURO II 2MM TI NS -,SUP-55-10507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.51,834.757,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 10MM VUSION TS -,SUP-551-5210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC MAND 4HL STR UNIVERSAL NEURO II RECON FX 2MM TI -,SUP-55-15505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1918.09,1342.663,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLT/FRACTURE 6 HOLES W. BAR -,SUP-55-15507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2440.83,1708.581,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 10 X 9 X 25 -,SUP-551-7410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
INSERT TIB BEARING SZ2 9MM TRIATHLON X3 CR ARTCSURF -,SUP-5530-C-209,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BEARING TIB INSERT CS 9MM SZ1 TRIATHLON X3 -,SUP-5531-G-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BEARING TIB INSERT CS 10MM SZ 1TRIATHLON X3 -,SUP-5531-G-110-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BEARING TIB INSERT CS 11MM SZ 1 TRIATHLON X3 -,SUP-5531-G-111-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
INSERT TIBIAL BEARING  SZ. 5 / 11MM TYPE CS -,SUP-5531-G-511-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIBIAL BEARING INSERT SZ.7 / CS / 11MM -,SUP-5531-G-711-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIBIAL BEARING INSERT SZ.8 CS 9MM TRIATHLON X3 -,SUP-5531-G-809-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
9MM INSERT TRIAL PS#3 -,SUP-5532-T-309,CDM,C1713,HCPCS,278,RC,,,outpatient,,,728.5,509.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMPONENT TIBIAL TRITANIUM SZ 1 TRIATHLON -,SUP-5536-B-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX CROSSLINK 25 -,SUP-55-5325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CONNECTOR ROD FIREBIRD 45MM CROSSLINK ORTHOFIX -,SUP-55-5345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.5MM PERIPHERAL SCREW 16MM -,SUP-5572-4516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.5MM PERIPHERAL SCREW 24MM -,SUP-5572-4524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.5MM PERIPHERAL SCREW 36MM -,SUP-5572-4536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
6.5MM CENTER SCREW 32MM -,SUP-5573-6532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4573.49,3201.443,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX MODULAR TRIATH -,SUP-5575-X-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONESCREW AXS ST 1.2 X 3MM 5P -,SUP-56-12003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONESCREW - AXS ST 1.2 X 4MM 5P -,SUP-56-12004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONESCREW AXS SD 1.2 X 3MM 5P -,SUP-56-12903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,636.37,445.459,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONESCREW AXS SD 1.2 X 4MM 5P -,SUP-56-12904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,636.37,445.459,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE ER AXS ST 1.4 3MM 5P -,SUP-56-14003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,593.3,415.31,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONESCREW AXS SD 1.7 X 4MM 5P -,SUP-56-17904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONESCREW AXS SD 1.7 X 6MM 5P -,SUP-56-17906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFT HUM TIS PTTY 1ML OSTEOSPARX SYR LF -,SUP-562-100-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X30MM CORT FT ST HEX HEAD -,SUP-5645-1-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X32MM CORT FT ST HEX HEAD -,SUP-5645-1-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X44MM CORT FT ST HEX HEAD -,SUP-5645-1-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X48MM CORT FT ST HEX HEAD -,SUP-5645-1-048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X50MM CORT FT ST HEX HEAD -,SUP-5645-1-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X52MM CORT FT ST HEX HEAD -,SUP-5645-1-052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X54MM CORT FT ST HEX HEAD -,SUP-5645-1-054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
STEM EXTENSION CEMENTED 12X30MM -,SUP-565-1203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
MESH HYBRID MEDIUM MALL 90 X 90 X .3 BLUE -,SUP-56-90344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7015.12,4910.584,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PROFYLE 0.55MM 1.2MM 4HL STD PRCONT NLCKG TI XS STR -,SUP-57-05101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PRF 1.7 X 4 HL -,SUP-57-05202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PRF 1.7 X 6 HL LT L -,SUP-57-05221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE HAND -,SUP-57-05240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PRF 1.7 X 7 HL T -,SUP-57-05260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1028.42,719.894,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PROFYLE 0.55MM 1.7MM 1HL PRX2 STD PRCONT NLCKG TI -,SUP-57-05285,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1307.9,915.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PRF 1.7 X 3 X 2 3D -,SUP-57-05291,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1307.9,915.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PRF 1.7 X 4X2 RP 3D -,SUP-57-05295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1307.9,915.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PRF 2.3 6 HL LT L -,SUP-57-10121,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2457.66,1720.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PRF 2.3 X 6 HL NRW T -,SUP-57-10140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2457.66,1720.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PROFYLE 1MM 2.3MM 7HL SHFT PRCONT VAR ANG NLCKG TI -,SUP-57-10170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2457.66,1720.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PRF 2.3 X 5HL ROT -,SUP-57-10185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2395.78,1677.046,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 1.5MM 1.7MM 10HL PRCONT VAR ANG TI SM NRW -,SUP-57-10310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 1.7 X 6 HL LT L -,SUP-57-10321,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 1MM 1.7MM 6HL PRCONT VAR ANG TI SM NRW T-SHP -,SUP-57-10340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 1.7 X 7 HL T -,SUP-57-10360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 1MM 1.7MM 5HL ROT PRCONT VAR ANG TI SM -,SUP-57-10380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 1MM 1.7MM HLX3X2 PRCONT VAR ANG TI SM 3D SHP -,SUP-57-10391,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PROFYLE 1MM 2.3MM 6HL PRCONT NLCKG COMPR TI MED STR -,SUP-57-10407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2921.69,2045.183,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PROFYLE 1MM 2.3MM 7HL PRCONT NLCKG COMPR TI MED Y -,SUP-57-10470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2921.69,2045.183,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PROFYLE 1.3MM 2.3MM 6HL SHFT PRCONT NLCKG COMPR TI -,SUP-57-13150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.06,784.742,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE HAND 2.3 LP 4 HOLE -,SUP-57-13402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PROFYLE 1.3MM 2.3MM 5HL PRCONT NLCKG COMPR TI LRG -,SUP-57-13405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PROFYLE 1.3MM 2.3MM 6HL PRCONT NLCKG COMPR TI LRG -,SUP-57-13408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE T 1O HOLE NARROW COMPRESSION -,SUP-57-13442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 1.5MM 2.3MM 4HL PRCONT VAR ANG TI MED STR -,SUP-57-15301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 1.5MM 2.3MM 4HL_PRCONT VAR ANG TI MED STR -,SUP-57-15302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 1.5MM 2.3MM 16HL PRCONT VAR ANG TI MED -,SUP-57-15316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 1.5MM 2.3MM 4HL PRCONT VAR ANG TI MED SMRTLC -,SUP-57-15340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 1.5MM 2.3MM 7HL PRCONT VAR ANG TI MED SMRTLC -,SUP-57-15370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PROFYLE 2.3 X 13 HL NRWZ -,SUP-57-15379,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 1.5MM 2.3MM 5HL PRCONT VAR ANG TI MED SMRTLC -,SUP-57-15385,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.2X5MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12005E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.2X6MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.2X7MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12007E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.2X8MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.2X14MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX -,SUP-58-12014E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
MIDFOOT FUSION U-PLATE MD LT ORTHOLOC -,SUP-5817002L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5793.06,4055.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.7X8MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.7X9MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.7X10MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.7X11MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17011E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.7X12MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE SCREW 1.7 X 16MM STRYKER -,SUP-58-17016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 2.3 X 6 -,SUP-58-23006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X8MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X9MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X10MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X11MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23011E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X12MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X13MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23013E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X14MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23014E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NL 2.3 X 15MM -,SUP-58-23015E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X16MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X20MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23020E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X24MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23024E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EMERGENCY 2.5 X 6 -,SUP-58-25006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EMERGENCY 2.5 X 8MM CROSSPIN LEFT -,SUP-58-25008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
MTP FUSIOIN MEDIUM 0DG RT ORTHOLOC 3DI PLATING SYSTEM -,SUP-587220RT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5046.12,3532.284,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING LG HD 2.7 X 12MM ORTHOLOC 3DI PLATING SYS -,SUP-58802712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING LG HD 2.7 14MM ORTHOLOCK 3DI PLATING SYS -,SUP-58802714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING LG HD  2.7 X 16MM ORTHOLOCK 3DI PLATING SYS -,SUP-58802716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOW PRO CORT 2.7 X 12MM ORTHOLOC SYS -,SUP-58812712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOW PRO CORT SCREW 2.7 X 14MM ORTHOLOC SYSTEM -,SUP-58812714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOW PRO CORT SCREW 2.7 X 16MM ORTHOLOC SYSTEM -,SUP-58812716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOW PRO CORT 2.7 X 18MM ORTHOLOC SYS -,SUP-58812718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOW PRO CORT SCREW 3.5 X 12MM ORTHOLOC SYSTEM -,SUP-58813512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOW PRO CORT SCREW 3.5 X 14MM ORTHOLOC SYSTEM -,SUP-58813514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOW PRO CORT SCREW 3.5 X 16MM ORTHOLOC SYSTEM -,SUP-58813516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCKING 3.5 X 18 -,SUP-58813518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOW-PRO CORT SCREW 3.5X22MM ORTHOLOC -,SUP-58813522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOW-PRO CORT SCREW 3.5X28MM ORTHOLOC -,SUP-58813528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOW-PRO CORT SCREW 3.5X34MM ORTHOLOC -,SUP-58813534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOW-PRO CORT SCREW 3.5X38MM ORTHOLOC -,SUP-58813538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO F/1.2MM SCR TI RND FLT HEAD NS -,SUP-59-12049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.24,105.868,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO F/1.7MM/1.9MM TI RND BN SCR TITIANIUM FLT EDGE -,SUP-59-17049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.24,105.868,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X10MM CORT PROFYLE ST CX PIN HD TI GOLD -,SUP-59-23010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 16MM -,SUP-59-23016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 18MM -,SUP-59-23018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 20MM -,SUP-59-23020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO F/2.3MM SCR TI RND FLT HEAD NS -,SUP-59-23049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.24,105.868,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 32.3MM COMPR OMEGA3 SS STRL -,SUP-596001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,329.09,230.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
STANDARD BARRELL HIP PLATE- 130DEG- 2 HOLES -,SUP-597002S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2817.14,1971.998,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OMG 3 63MM 3HL STD BRL LCK COMPR SS 135DG ANG KY -,SUP-597023S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE HIP STD BARREL 4 HOLE KEYED 135DEG -,SUP-597024S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
HIP PLATE OMEGA 3 STD BARREL KEYED 135 DEG 6 HOLES -,SUP-597026S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE HIP STD BARREL 3 HOLE KEYED 140DEG -,SUP-597043S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE HIP STD BARREL 4 HOLE KEYED 145DEG -,SUP-597064S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE EXTFIX STD 47MM SS HIP 135DG ANG OMEGA3 KYLS BRL -,SUP-597122S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OMG 3 79MM 4HL STD BRL LCK COMPR SS 135DG ANG KYLS -,SUP-597124S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OMG 3 95MM 5HL STD BRL LCK COMPR SS 150DG ANG KYLS -,SUP-597185S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OMG 3 79MM 4HL SHRT BRL LCK COMPR SS 135DG ANG KYLS -,SUP-597264S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2470.03,1729.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE ANT CERV 12MM BAK HOL CHMFR EDGE 8MM TI -,SUP-6000-0812-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DEVICE ANT CERV 12MM BAK/ C HOL CHMFR EDGE 10MM TI -,SUP-6000-1012-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GW ORTHO 2MM TOEMOTION MRH AXLE -,SUP-6007-1200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN DSTRCT 12MM ASSURE -,SUP-601.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,396.78,277.746,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ASNIS III CANN SCREW 5 X 28MM -,SUP-601628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS TI 5.0 X 30MM -,SUP-601630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ASNIS III CANN SCREW 5 X 32MM -,SUP-601632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS III CANN P/T 5.0MM X 42MM -,SUP-601642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS III CANN 5.0 X 44MM -,SUP-601644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE ASNIS PT 5 X 46 -,SUP-601646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS PT 5.0 X 48 -,SUP-601648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX50MM CANN ASNIS III 17MM P/T SD/ST REVCT FLUT TI -,SUP-601650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX55MM CANN ASNIS III 18.5MM P/T SD/ST REVCT FLUT TI -,SUP-601655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX75MM CANN ASNIS III 27MM P/T SD/ST REVCT FLUT TI -,SUP-601675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX80MM CANN ASNIS III 27MM P/T SD/ST REVCT FLUT TI -,SUP-601680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FULLY THREADED 5MM X 38MM -,SUP-601738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FULLY THREADED 5MM X 40MM -,SUP-601740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FT 5MM X 42MM TITANIUM CANNULATED -,SUP-601742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS FT 5 X 44 -,SUP-601744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED 5 X 50 -,SUP-601750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED 5 X 55 -,SUP-601755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FULLY THREADED 5 X 60 -,SUP-601760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANN HEADED 5.0 X 65MM ASNIS -,SUP-601765,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED 5MM X 70MM -,SUP-601770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANN TI 6.5 X 60MM -,SUP-602660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS TI TL20 6.5 X 65MM -,SUP-602665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANN TI 6.5 X 70MM -,SUP-602670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX75MM CANN ASNIS III 20MM THRD SD/ST HEX DRV -,SUP-602675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANN TI 6.5 X 80MM -,SUP-602680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX80MM CANN ASNIS III 20MM THRD SD/ST HEX DRV -,SUP-602680S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANN ASNIS TI 6.5 X 85MM -,SUP-602685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX90MM CANN ASNIS III 20MM THRD SD/ST HEX DRV NS -,SUP-602690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX90MM CANN ASNIS III 20MM THRD SD/ST HEX DRV STRL -,SUP-602690S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX95MM CANN ASNIS III 20MM THRD SD/ST HEX DRV NS -,SUP-602695,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX95MM CANN ASNIS III 20MM THRD SD/ST HEX DRV STRL -,SUP-602695S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX100MM CANN ASNIS III 20MM THRD SD/ST HEX DRV -,SUP-602700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TI CANNULATED 6.5 X 105MM ASNIS -,SUP-602705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED TI 6.5X 110MM -,SUP-602710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS TI TL20 6.5 X 115 -,SUP-602715,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS TI TL40 6.5 X 60 -,SUP-602860,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS TI TL40 6.5 X 65 -,SUP-602865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS 6.5 X 70MM -,SUP-602870,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS TI TL40 6.5 X 75MM -,SUP-602875,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS TI CANNULATED 6.5 X 80MM -,SUP-602880,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS TI TL40 6.5 X 85 -,SUP-602885,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TI 6.5 X 90MM ASNIS TL40 CANNULATED -,SUP-602890,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS TI TL40 6.5 X 95 -,SUP-602895,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS TI TL40 6.5 X 100 -,SUP-602900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS TI CANNULATED 6.5 X 105MM -,SUP-602905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX28MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE CAN TI 4.0 X 30MM -,SUP-604630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX32MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.0 X 34MM ASNIS CANN SCREW -,SUP-604634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX34MM CANN ASNIS III 11.5MM P/T SD/ST REVCT FLUT TI -,SUP-604634S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE CAN PT 4.0 X 36 -,SUP-604636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX38MM CANN ASNIS III -,SUP-604638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX40MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX40MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY -,SUP-604640S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX42MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX44MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX46MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE CAN PT 4.0 X 48 -,SUP-604648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX50MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX50MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY -,SUP-604650S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX55MM CANN ASNIS III 18.5MM P/T SD/ST REVCT FLUT TI -,SUP-604655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX55MM CANN ASNIS III 18.5MM.P/T SD/ST REVCT FLUT TI -,SUP-604655S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT TI- -,SUP-604660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT TI- -,SUP-604660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT TI_ -,SUP-604660S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX65MM CANN ASNIS III 22MM P/T SD/ST REVCT FLUT TI -,SUP-604665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX65MM CANN ASNIS III 22MM P/T SD/ST REVCT FLUT TI -,SUP-604665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX70MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX70MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY -,SUP-604670S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX40MM CANN ASNIS III FT SD/ST REVCT FLUT TI ALY NS -,SUP-604740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS III TI 4.0 X 42MM -,SUP-604742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANN FT 4.0 X 44MM -,SUP-604744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX50MM CANN ASNIS III FT SD/ST REVCT FLUT TI ALY NS -,SUP-604750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TI SELF TAP CORTICAL 2.7MM X 22MM -,SUP-605022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.06,81.242,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TI SELF TAP CORTICAL 2.7MM X 26MM -,SUP-605026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.06,81.242,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TI SELF TAP CORTICAL 2.7MM X 28MM -,SUP-605028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.06,81.242,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TI ASNIS III CANNULATED 6.5 X 85MM -,SUP-606085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 90 -,SUP-606090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 95 -,SUP-606095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED FULLY THREADED 6.5 X 100 -,SUP-606100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED FULLY THREADED 6.5 X 110 -,SUP-606110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANCELLOUS FT 4 X 14 -,SUP-607314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANCELLOUS FT 4.0 X 16 -,SUP-607316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X18MM CANC FT TI -,SUP-607318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANCELLOUS 4.0 X 20 -,SUP-607320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X22MM CANC FT TI -,SUP-607322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X24MM CANC FT TI -,SUP-607324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANCELLOUS 4.0 X 26MM -,SUP-607326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANCELLOUS 4.0 X 28MM -,SUP-607328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANCELLOUS 4.0 X 32MM -,SUP-607332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X34MM CANC FT TI -,SUP-607334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X36MM CANC FT TI -,SUP-607336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X38MM CANC FT TI -,SUP-607338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X40MM CANC FT TI -,SUP-607340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.0 X 42MM CANC FT TI -,SUP-607342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANN TI 4.0 X 48MM FULL -,SUP-607348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.0 CANCELLOUS SCREW 50MM FULLY THREADED -,SUP-607350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANCELLOUS 4.0 X 50MM -,SUP-607350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.0 X 55MM CANC FT TI -,SUP-607355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X60MM CANC FT TI -,SUP-607360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X65MM CANC FT TI -,SUP-607365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X70MM CANC FT TI -,SUP-607370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANCELLOUS FT 4.0 X 14MM STRYKER -,SUP-607414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANCELLOUS PT 4 X 16 -,SUP-607416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANCELLOUS PT 4 X 20 -,SUP-607420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X36MM CANC 16MM THRD TI -,SUP-607436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X38MM CANC 16MM THRD TI -,SUP-607438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X44MM CANC 16MM THRD TI -,SUP-607444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X46MM CANC 16MM THRD TI -,SUP-607446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X50MM CANC 16MM THRD TI -,SUP-607450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X65MM CANC 16MM THRD TI -,SUP-607465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X70MM CANC 16MM THRD TI -,SUP-607470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANC 6.0MM X 20MM  FULL THREAD -,SUP-608020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANCELLOUS 6 X 25 -,SUP-608025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CAN FT 6.0 X 35 -,SUP-608035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANCELLOUS 6.0 X 40MM -,SUP-608040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X45MM CANC FT TI -,SUP-608045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.0MM X 50MM CANCELLOUS FULL THREAD -,SUP-608050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X60MM CANC FT TI -,SUP-608060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 3.5 X 60 FT -,SUP-608070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X75MM CANC FT TI -,SUP-608075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X80MM CANC FT TI -,SUP-608080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANCELLOUS FT 6.0 X 85 -,SUP-608085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CAN TL 16 6.0 X 35 -,SUP-608235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CAN TL 16 6.0 X 75 -,SUP-608275,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CAN TL 16 6.0 X 80 -,SUP-608280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANCELLOUS 6.0MM 90MM -,SUP-608290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X70MM CANC 32MM THRD TI -,SUP-608470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X80MM CANC 32MM THRD TI -,SUP-608480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X85MM CANC 32MM THRD TI -,SUP-608485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6MM CANCELLOUS TI 6.0MM L90 TL32MM -,SUP-608490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,304.82,213.374,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS TI TL25 8.0 X 70MM -,SUP-611070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CANNULATED SCREW 8.0 X 75MM TI -,SUP-611075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
8.0 X 80MM TI CANNULATED SCREW -,SUP-611080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS TI TL25 8.0 X 85MM -,SUP-611085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ANSIS TI TL25 8.0 X 90MM -,SUP-611090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X8MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X12MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X14MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X16MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X18MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.7 X 20MM LOCKING SCREW -,SUP-614520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X22MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10 2.7 X 24MM -,SUP-614524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X26MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7 LOCKING ST 28 -,SUP-614528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X30MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7 LOCKING ST 34 -,SUP-614534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X36MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X38MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X40MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X55MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X60MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X8MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X10MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X12MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X14MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X16MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X18MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X20MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X22MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X24MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 3.5 X 28MM -,SUP-614628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X30MM LOCKING -,SUP-614630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X32MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
36MM 3.5 LOCKING SCREW -,SUP-614636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5 LCK ST 38 -,SUP-614638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5 X 40MM LOCKING -,SUP-614640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X42MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X44MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5 LCK ST 48 -,SUP-614648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X50MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 3.5 X 55MM T10 -,SUP-614655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE OLECRANON LEFT 8 HOLE -,SUP-614655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X60MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 3.5 X 65MM -,SUP-614665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 3.5 X 70MM -,SUP-614670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X8MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X12MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X14MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X16MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X18MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X20MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X22MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X24MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7 NON LOCKING ST 26 -,SUP-614726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X32MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614732,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X34MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X36MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X38MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X40MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7 NONLCK ST 44 -,SUP-614744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7 NONLOCKING ST 46 -,SUP-614746,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X55MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 2.7 X 60MM -,SUP-614760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X8MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614808,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X10MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X12MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X14MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X16MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X18MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X20MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X22MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X24MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X28MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X30MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614830,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X32MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X34MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614834,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X36MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614836,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5 NONLCK ST 38 -,SUP-614838,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X40MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X42MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614842,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5 X 44 NONLOCK -,SUP-614844,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
46MM 3.5 SCREW -,SUP-614846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5 NONLOCK ST 46 -,SUP-614846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 3.5 X 48MM NON-LOCK -,SUP-614848,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X50MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614850,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X60MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614860,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5 NONLOCK ST 65 -,SUP-614865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X70MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614870,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE CEMENT SIMPLEX -,SUP-6191-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,431.79,302.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CEMENT BONE SIMPLEX P -,SUP-6191-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE CEMENT SPEEDSET SIMPLEX P FULL DOSE -,SUP-6192-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,431.79,302.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CEMENT SIMPLEX SPEED SET -,SUP-6192-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CEMENT BONE SIMPLEX HV -,SUP-6194-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CEMENT BONE SIMPLEX GENTAMICIN -,SUP-6195-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CEMENT BONE SIMPLEX TOBRAMYCIN -,SUP-6197-9-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO ASNIS III F/6.5/8MM BN SCR TI RND -,SUP-619904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,157.55,110.285,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO ASNIS III 4MM TI RND -,SUP-619905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,122.54,85.778,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO 5MM ASNIS III 5MM TI RND -,SUP-619906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.64,107.548,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER FOR 2.3MM BONE SCREWS -,SUP-619915,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.91,88.837,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
Washer T8 & T10 Scrws 2.4/2.7/3.5 -,SUP-619920,CDM,C1713,HCPCS,278,RC,,,outpatient,,,124.4,87.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER 19 FOR SCREWS 6.5/8.0MM -,SUP-619990,CDM,C1713,HCPCS,278,RC,,,outpatient,,,882.25,617.575,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
STIMULAN 5CC -,SUP-620-005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
STIMULAN 10CC -,SUP-620-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN 12MM ASPEN -,SUP-6201-0012-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ASPEN 14MM -,SUP-6211-0014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,26874.69,18812.283,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 10HL TI -,SUP-621410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7788.16,5451.712,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLUG BONE H MED 25 -,SUP-6215-5-011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
MIS CALCANEAL PLATE S7 7 HOLES -,SUP-622102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
MIS CALCANEAL PLATE M8 8 HOLE -,SUP-622104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
INSERT 10 DEG POLYETHYLENE 32MM D TRIDENT X3 -,SUP-623-10-32D,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE SCREW 6.5X30 SELF-TAP -,SUP-6250-65-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ONE-THIRD TUBULAR PLATE 2 HOLE / L23MM -,SUP-626672,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1523.42,1066.394,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TUBULAR PLATE ONE-THIRD 4 HOLE -,SUP-626674,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ONE-THIRD TUBULAR PLATE 5 HOLE / L59MM -,SUP-626675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ONE-THIRD TUBULAR PLATE 6 HOLE / L71MM -,SUP-626676,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TUBULAR PLATE ONE-THIRD 6 HOLE -,SUP-626676S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ONE-THIRD TUBULAR PLATE 7 HOLE L83MM -,SUP-626677,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 8 HOLE -,SUP-626678,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TUBULAR HOLE 9 -,SUP-626679,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2203.63,1542.541,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TUBULAR HOLE 12 -,SUP-626682,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2203.63,1542.541,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TUBULAR 16HL -,SUP-626686,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2746.15,1922.305,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE POLYAXIAL LKG TALO-NAVICULAR LONG T10 -,SUP-626762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4305.48,3013.836,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
VARIAX NAVICULAR PLATE -,SUP-626881,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4186.99,2930.893,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
POLYAXIAL LOCKING PLATE CUBOID (T8) -,SUP-626885,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.24,2762.368,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 3 HOLE SLIM -,SUP-626963,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5843.99,4090.793,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 6 HOLE SLIM -,SUP-626966,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5843.99,4090.793,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SLIM STRAIGHT 7 HOLE T8 -,SUP-626967,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5843.99,4090.793,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2 HOLE FOREFOOT PLATE -,SUP-626972,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BROAD 3 HOLE -,SUP-626973,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BROAD STRAIGHT PLATE 4 HOLE -,SUP-626974,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
5 HOLE FOREFOOT PLATE -,SUP-626975,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
6 HOLE BROAD Y-PLATE -,SUP-626976,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BROAD STRAIGHT T10 7 HOLE -,SUP-626977,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SLIM -,SUP-626982,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
3-HOLE 4-PLATE- SLIM -,SUP-626983,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE-Y 4 HOLE SLIM -,SUP-626984,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 5 HOLE SLIM Y -,SUP-626985,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BROAD Y PLATE 2 SHAFT HOLES -,SUP-626992,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BROAD Y PLATE 3 HOLE -,SUP-626993,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BROAD Y-PLATE- 3 SHAFT -,SUP-626993,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
STRYKER PLATE -,SUP-626994,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
VARIAX 2 FOREFOOT 5 HOLE PLATE -,SUP-626995,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BONE VARIAX BROAD Y 6 SHAFT HOLES T10 -,SUP-626996,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BROAD Y-PLATE- 7 SHAFT HOLES (T10) -,SUP-626997,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BROAD Y PLATE - 7 HOLES -,SUP-626997,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 3HL TI -,SUP-627203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
4 HOLE PLATE HUMERUS -,SUP-627204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 5-HOLE -,SUP-627205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PROX LAT HUMERUS LEFT 6 HOLE L125MM -,SUP-627206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8796.54,6157.578,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PROXIMAL LATERAL HUMERUS 8 HOLE -,SUP-627208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9123.11,6386.177,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 12 HOLE LEFT PROX LAT HUMERAL -,SUP-627212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9529.9,6670.93,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PROXIMAL LATERAL HUMERUS PLATE -,SUP-627216S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10146.77,7102.739,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 3 HOLE PROXIMAL LATERAL HUMERUS -,SUP-627233,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
4 HOLE PLATE RIGHT -,SUP-627234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BONE AXSOS 3 TI 6 HOLE HUMERUS RIGHT PROXIMAL LATERAL -,SUP-627236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8796.54,6157.578,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
8 HOLE PLATE STRYKER -,SUP-627238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9123.11,6386.177,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
10 HOLE PROXIMAL HUMERUS PLATE - RIGHT -,SUP-627240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9123.11,6386.177,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE HUMERUS 12 HOLE RIGHT PR -,SUP-627242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9529.9,6670.93,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PROXIMAL LATERAL HUMERUS PLATE FOR RIGHT HUMERUS 14 HOLE -,SUP-627244S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10146.77,7102.739,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2 HOLE PLATE LEFT TIBIA -,SUP-627302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7207.59,5045.313,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 121MM 4HL -,SUP-627304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7356.55,5149.585,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 147MM 6HL -,SUP-627306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7509.33,5256.531,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 8 HOLE PROX LATERAL FOR LEFT TIBIA L173MM -,SUP-627308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7658.3,5360.81,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PROXIMAL LATERAL TIBIA FOR LEFT TIBIA 10 HOLE -,SUP-627310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8099.46,5669.622,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
AXSOS 3 TI PROX LAT TIBIA LEFT 12 HOLE PLATE -,SUP-627312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8414.58,5890.206,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 95MM 2HL F-SHP RT TIB -,SUP-627332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7207.59,5045.313,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 4HL -,SUP-627334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7356.55,5149.585,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE RIGHT HOLE 6 -,SUP-627336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8887.66,6221.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PROXIMAL MEDIAL TIBIA 8 HOLE RIGHT -,SUP-627338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7658.3,5360.81,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 10 HOLE RIGHT PROX LATERAL TIBIA -,SUP-627340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8099.46,5669.622,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE RIGHT HOLE 12 -,SUP-627342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8252.25,5776.575,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE RIGHT HOLE 14 -,SUP-627344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8414.58,5890.206,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 6HL LT DIST -,SUP-627406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7102.55,4971.785,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DIST RAD TIB 12 HOLE LFT -,SUP-627412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7996.33,5597.431,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 14HL TI -,SUP-627414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8206.41,5744.487,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN MED DST -,SUP-627434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6900.11,4830.077,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 6HL MDL/DIST RIGHT -,SUP-627436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7102.55,4971.785,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DIST MED TIB 8HOLE RIGHT -,SUP-627438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7304.99,5113.493,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DIST MEDIAL 10 HOLE RT -,SUP-627440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7788.16,5451.712,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DIST MED LKD 12 HOLE RT -,SUP-627442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7996.33,5597.431,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 14 HOLE RIGHT DISTAL MEDICAL PLATE -,SUP-627444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8206.41,5744.487,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 4HL TI RT DIST -,SUP-627454,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.44,5926.508,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BONE AXSOS 3 TITANIUM 127 MM TIBIAL LEFT DISTAL -,SUP-627456,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7802.17,5461.519,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 8 HOLE LEFT ANTEROLATERAL -,SUP-627458,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7975.32,5582.724,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW DIST ANTERIORLATERAL TIBIA LFT 10HL 178MM -,SUP-627460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8370.53,5859.371,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TIBIA  14 HOLE LEFT L229MM DISTAL ANTEROLATERAL -,SUP-627464,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8724.98,6107.486,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 4 HOLE -,SUP-627484,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7631.05,5341.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 6 HOLE RIGHT ANT-LAT -,SUP-627486,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7802.17,5461.519,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TIBIA DISTAL ANTEROLATERAL RIGHT 8 HOLE L153MM -,SUP-627488,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7975.32,5582.724,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DISTAL ANTEROLAT TIBIA RIGHT 10 HOLE 178MM -,SUP-627490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8370.53,5859.371,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE LKG COMP 11 HOLD L149MM X 4.0MM -,SUP-627511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5647.28,3953.096,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 12HOLE COMPRESSION -,SUP-627512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5647.28,3953.096,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 14 HOLE AXSOS STRAIGHT -,SUP-627514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5809.61,4066.727,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE LOCKING COMPRESSION 18 HOLE L240MM 4.0MM -,SUP-627518S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6099.9,4269.93,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 7 HOLE NARROW COMPRESSION -,SUP-627537,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6619.37,4633.559,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 8 HOLE NARROW COMPRESSION -,SUP-627538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.27,4961.089,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 9 HOLE NARROW -,SUP-627539,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.27,4961.089,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 10 HOLE STRAIGHT -,SUP-627540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7348.91,5144.237,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE STRAIGHT BROAD 9 HOLE COMPR 173 LENGTH -,SUP-627569,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.27,4961.089,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE STRAIGHT BROAD 10 HOLE COMPRESSION -,SUP-627570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7348.91,5144.237,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE LOCKING COMPRESSION BROAD 12 HOLE -,SUP-627572,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7348.91,5144.237,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 13 HOLE 5.0 COMPRESSION PLATE -,SUP-627573,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7518.88,5263.216,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BROAD 14 HOLE -,SUP-627574,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7518.88,5263.216,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DISTAL LATERAL FEMUR PLATE FOR LEFT FEMUR 4 HOLE -,SUP-627604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7824.24,5476.968,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 166MM 6HL LT DIST LAT FEM -,SUP-627606,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9329.8,6530.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 8HL LT -,SUP-627608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8189.22,5732.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 238MM 10HL LT DIST LAT FEM -,SUP-627610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8683.22,6078.254,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 12HL -,SUP-627612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8871.66,6210.162,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 343MM 16HL LT -,SUP-627616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9250.22,6475.154,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DISTAL FEMUR -,SUP-627618S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9623.69,6736.583,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DISTAL LATERAL FEMUR 4 HOLE -,SUP-627634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7824.24,5476.968,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 166MM 6HL DIST LAT FEM -,SUP-627636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8009.28,5606.496,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DISTAL LATERAL FEMUR -,SUP-627638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8189.22,5732.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 238MM 10HL RT DIST LAT FEM -,SUP-627640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8683.22,6078.254,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 274MM 12HL -,SUP-627642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8871.66,6210.162,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 343MM 16HL 1STRN/PK RT -,SUP-627646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9250.22,6475.154,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE AXSOS 3 TI DISTAL LAT FEMUR RT 18 HOLE L379MM -,SUP-627648S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9623.69,6736.583,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TIBAL 4 HOLE LEFT/L71MM -,SUP-627704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.9,4447.73,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE MEDIAL PROXIMAL TIBIAL 5 HOLES LEFT -,SUP-627705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6560.16,4592.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE MEDIAL 6 HOLES STRYKER -,SUP-627706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6764.51,4735.157,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PROX MED TIBIA FOR LEFT TIBIA 8HOLE L-123MM -,SUP-627708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6966.95,4876.865,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 14 HOLE PROX MEDIAL FOR LEFT TIBIA L201MM -,SUP-627714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7866.47,5506.529,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PROXIMAL MEDIAL TIBIA FOR LEFT TIBIA 16 HOLE -,SUP-627716S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8278.98,5795.286,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKED TIBIAL PLATE -,SUP-627734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.9,4447.73,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TIBIAL LATERAL 5 HOLE -,SUP-627735,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6560.16,4592.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PROX MED TIB RT 6 HL -,SUP-627736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6764.51,4735.157,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PROXIMAL MEDIA TIBIA 97MM LENGTH -,SUP-627736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6764.51,4735.157,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PROXIMAL MEDIAL TIBIA 8 HOLE RIGHT -,SUP-627738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8247.49,5773.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 10HL RT PROX MDL TIB COMPR -,SUP-627740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7438.67,5207.069,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PROXIMAL MEDIAL TIBIA PLATE FOR RT TIBIA 12 HOLE 175MM -,SUP-627742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7654.48,5358.136,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
INTERPROSTHETIC FEMUR PLATE RIGHT 334MM -,SUP-627846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,27813.56,19469.492,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DISTAL FEMUR PLATE RIGHT 280MM -,SUP-627863,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19576.64,13703.648,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
6 HOLE PLATE - LEFT -,SUP-628006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 88MM 7HL STD PRCONT VAR ANG TI ALY DECREASED -,SUP-628007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 99MM 8HL STD PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 122MM 10HL STD PRCONT VAR ANG TI ALY -,SUP-628010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SUPERIOR 7 HOLE RIGHT DECREASED -,SUP-628027,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 99MM 8HL STD PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE VARIAX 99MM CLAVICLE RIGHT SUPERIOR DECREASED 8 HOLE -,SUP-628028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 99MM 6HL BRDG PRCONT VAR ANG TI ALY LT CLVCL -,SUP-628046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 122MM 8HL BRDG PRCONT VAR ANG TI ALY -,SUP-628048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 99MM 6HL BRDG PRCONT VAR ANG TI ALY RT CLCVL -,SUP-628066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BRIDGE 8 HOLE SUPERIOR D -,SUP-628068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 8 HOLE STRYKER -,SUP-628108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 10 HOLE STRYKER -,SUP-628110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CLAVICLE INC CURVED 8 HOLE -,SUP-628128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CLAVICLE IC 10 HOLE -,SUP-628130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 6 HOLE BRIDGE -,SUP-628166,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUPERIOR LATERAL PLATE - 3 HOLE / LEFT -,SUP-628203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 98MM 5HL PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUPERIOR LATERAL PLATES -,SUP-628207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4698.11,3288.677,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 86MM 4HL PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE RIGHT LATERAL 5-HOLE #628225 -,SUP-628225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 7 HOLE LATERAL -,SUP-628227,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4698.11,3288.677,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 86MM 7HL PRCONT VAR ANG TI ALY UNIV SMRTLC -,SUP-628307,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 16MMX68MM PRCONT VAR ANG TI ALY LAT -,SUP-628525S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4480.35,3136.245,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
HOOK PLATE 7 HOLE 16MM RIGHT -,SUP-628537S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4480.35,3136.245,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DISTAL LATERAL HUMERUS PLATE 4 HOLE 109MM -,SUP-629204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 8 HOLE LEFT LATERAL -,SUP-629208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 3HL RT DIST LAT HUM COMPR -,SUP-629223S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DISTAL LATERAL 4 HOLE 109MM -,SUP-629224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 12 HOLE RIGHT HUMERUS L203MM VARIAX DIST LATERAL -,SUP-629232S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE HUMERUS DIST POST LATERAL LEFT 3 HOLE -,SUP-629243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 105MM 4HL PRCONT VAR ANG LCK TI ALY NS LT -,SUP-629244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 128MM 6HL SHFT PRCONT VAR ANG LCK TI ALY NS -,SUP-629246,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 150MM 8HL PRCONT VAR ANG LCK TI ALY NS LT -,SUP-629248,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DIST POST LATERAL HUMERUS 10 HOLE L173MM -,SUP-629250S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 105MM 4HL PRCONT VAR ANG LCK TI ALY NS RT -,SUP-629264,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 150MM 8HL PRCONT VAR ANG LCK TI ALY NS RT -,SUP-629268,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE HUMERUS DISTAL POSTERIOR LATERAL 12 HOLE -,SUP-629272S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE EXTENDED MEDIAL LEFT 3 HOLE -,SUP-629283,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 96MM 4HL PRCONT VAR ANG LCK TI ALY -,SUP-629284,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DISTAL MEDIAL HUMERUS 6 HOLE EXTEND -,SUP-629286,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 104MM 4HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 151MM 8HL SHFT PRCONT VAR ANG LCK TI ALY NS -,SUP-629308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DIST POST MEDIAL HUMERUS 12 HOLE L199MM -,SUP-629312S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DISTAL POSTERIOR MEDIAL HUMERUS PLATE FOR RT HUM 3 HOLE -,SUP-629323,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DIST POST MDL RIGHT 4 -,SUP-629324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DISTAL POSTERIOR MEDIAL 8 HOLE -,SUP-629328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DIST POST MEDIAL HUMERUS 12 HOLE L199MM -,SUP-629332S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE OLECRARON LEFT 3 HOLE -,SUP-629343,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 89MM 4HL PRCONT VAR ANG LCK TI ALY NS LT -,SUP-629344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
3 HOLE RIGHT PLATE -,SUP-629363,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 89MM 4HL PRCONT VAR ANG LCK TI ALY NS RT -,SUP-629364,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 113MM 6HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629366,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 137MM 8HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629368,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE MEDIAL 3 HOLE -,SUP-629383,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 92MM 4HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629384,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 116MM 6HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629386,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 139MM 8HL LCK TI ALY NS -,SUP-629388,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DISTAL MEDIAL HUMERUS LEFT 10HOLE 163MM -,SUP-629390S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DISTAL MEDIAL HUMERUS 12 HOLE -,SUP-629392S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE COMPRESSION NARROW STRAIGHT 4 HOLES -,SUP-629504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1289.93,902.951,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE COMPRESSION NARROW STRAIGHT 5 HOLES -,SUP-629505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 6 HOLE COM PR NRW STR -,SUP-629506S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 7HL COMPR NRW STR -,SUP-629507S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX COMPR TI ALY NRW STR 629508S STRL -,SUP-629508S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE COMP 9 HOLE NARROW STR -,SUP-629509S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 10HL COMPR NRW STR -,SUP-629510S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE COMPRESSION NARROW STRAIGHT 12 HOLES -,SUP-629512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
14 HOLE NARROW COMPRESSION PLATE VARIAX -,SUP-629514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX COMPR TI ALY NRW STR 629527S STRL -,SUP-629527S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 7HL COMPR BRD STR -,SUP-629537S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMPRESSION PLATE BROAD STRAIGHT 6 HOLES -,SUP-629546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 8HL COMPR NRW STR -,SUP-629548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMPRESSION PLATE BROAD STRAIGHT 9 HOLES/L115MM -,SUP-629549S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2509.57,1756.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
VARIAX COMPRESSION PLATE BROAD CURVED 9 HOLES -,SUP-629559,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 8HL COMPR BRD CRV -,SUP-629560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE COMPRESSION BROAD CURVED 11 HOLES -,SUP-629561,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE COMP VARIAX BROAD CURVED 10 HOLES -,SUP-629562,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SHORT BEND -,SUP-629589,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8642.06,6049.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PROFILE 2.0 4HOLE -,SUP-629604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1944.22,1360.954,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PROFILE 2.0 X L33MM 6 HOLE -,SUP-629606,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1944.22,1360.954,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PROFILE PLATE 2.0 54MM -,SUP-629610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1944.22,1360.954,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PROFILE PLATE 2.0 L108MM 20HOLES -,SUP-629620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE NARROW LOCKING 2.0 4 HOLE -,SUP-629624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2488.21,1741.747,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE NARROW LOCK 2.0 L34MM 6 HOLES -,SUP-629626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2488.21,1741.747,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 8 HOLE NARROW -,SUP-629628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2488.21,1741.747,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2.0MM BROAD LOCKING 6 HOLES STRAIGHT -,SUP-629646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BROAD LOCKING 2.0 / 10 HOLE -,SUP-629650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PROFILE 8 HOLE 2.4 -,SUP-629666,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PROFILE 2.4 8HOLE -,SUP-629668,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE VARIAX LOW PROFILE 2.4 X L66MM 10 HOLES -,SUP-629670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE NARROW LOCK 2.4 X L28MM 4 HOLE -,SUP-629684,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
6 HOLE NARROW PLATE -,SUP-629686,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2.4MM 8 HOLE -,SUP-629688,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BONE VARIAX NARROW LOCK 2.4 L69MM 10 HOLE -,SUP-629690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 4 HOLE -,SUP-629704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BROAD LOCKING 2.4 6 HOLE -,SUP-629706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 8 HOLE STRAIGHT 2.4 -,SUP-629708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BONE VARIAX BROAD LOCK 2.4 L80MM 10HOLES -,SUP-629710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BROAD LOCKING 2.4 12 HOLE -,SUP-629712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 4 HOLE NARROW -,SUP-629724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2.7 6 HOLE STRAIGHT -,SUP-629726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 8 HOLE -,SUP-629728,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 10 HOLE -,SUP-629730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE STRAIGHT 10 HOLE -,SUP-629740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BROAD LOCK 2.7 L39MM 4 HOLE -,SUP-629744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2.7 6 HOLE -,SUP-629746,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BROAD LOCK 2.7 X 73MM 8HL -,SUP-629748,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
T-PLATE 2.7MM 3 X 10 -,SUP-629748,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BROAD LOCKING 2.7 10HOLE -,SUP-629750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 12 HOLE BROAD STRAIGHT -,SUP-629752,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3870.76,2709.532,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
T-PLATE NARROW LOCKING 2.0 2 X 5 HOLE -,SUP-629770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NARROW LOCK T-PLATE 2.0 L62MM 2X10HOLES -,SUP-629771,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2716.41,1901.487,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE NARROW LCK T 2.0 3X5 HOLE -,SUP-629772,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
T-PLATE 2.4MM NARROW LOCKING 2 X 5 -,SUP-629776,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
T-PLATE -,SUP-629777,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BONE VARIAX NARROW LOCK T-PLATE 2.4 L41MM 3X5 HOLES -,SUP-629778,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE T 2.4 NARROW -,SUP-629779,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE NARROW T 2.4 X L76MM 5X10 HOLES LKG -,SUP-629781,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE NARROW LOCKING T 5 HOLE -,SUP-629782,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 10 HOLE -,SUP-629783,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE AXSOS TITANIUM 5 HOLE -,SUP-629784,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE NARROW LOCKING T  2.7 X 87MM 10HOLE -,SUP-629785,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE T NARROW LOCK 2.7 L8 7MM X 5 X 10 HOLES -,SUP-629787,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2.7 Y- PLATE -,SUP-629788,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4103.73,2872.611,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2.7MM TRIANGLE -,SUP-629789,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4103.73,2872.611,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE Y 2.4MM -,SUP-629790,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE NARROW LOCK TRIANGLE 2.4 X 81MM 10 HOLE -,SUP-629791,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANTERIOR TT PLATE LEFT -,SUP-630101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10381.67,7267.169,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANTERIOR TT PLATE RIGHT -,SUP-630102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10381.67,7267.169,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT FLEXBLOCK -,SUP-6314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7031.8,4922.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN FX 38MM TRIATH HD F/T/K SYS -,SUP-6541-4-515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ABC IM ROD TRIATHLON INSTRUMENTS -,SUP-6541-4-516E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2213.49,1549.443,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN FX 19MM TRIATH HD F/T/K SYS -,SUP-6541-4-575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,327.34,229.138,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T8 FULL THREAD 2.4 X 6 -,SUP-656006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T8 FULL THREAD 2.4 X 7 -,SUP-656007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK T8 FULL THREAD 2.4X8 -,SUP-656008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T8 FULL THREAD 2.4 X 10 -,SUP-656010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.4 X 11 -,SUP-656011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK T8 FII THRD 2.4 X 12 -,SUP-656012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T8 FULL THREAD 2.4MM L14 -,SUP-656014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.4MM X 16MM LOCKING -,SUP-656016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T8 FULL TRHEAD 2.4MM L 18MM -,SUP-656018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T8 FULL THREAD 2.4 X 22 -,SUP-656022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T8 FULL THREAD 2.4MM X 24MM -,SUP-656024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW T8 FULL THREAD 2.4MM X 26MM -,SUP-656026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T8 FULL THREAD 2.4 X 28 -,SUP-656028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T8 FULL THREAD 2.4 X 30 -,SUP-656030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T8 FULL THREAD 2.4 X 32 -,SUP-656032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T8 FULL THREAD 2.4 X 34 -,SUP-656034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T8 FULL THREAD 2.4 X 36 -,SUP-656036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.4MM X 38MM -,SUP-656038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FULL THREAD 2.4X6 -,SUP-656106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FULL THREAD 2.4X7 -,SUP-656107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FULL THREAD 2.4X8 -,SUP-656108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FULL THREAD 2.4X9 -,SUP-656109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FULL THREAD 2.4X12 -,SUP-656112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FULL THREAD 2.4X14 -,SUP-656114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.4 X 15 NL -,SUP-656115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FULL THREAD 2.4X18 -,SUP-656118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FULL THREAD 2.4X20 -,SUP-656120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FULL THREAD 2.4X24 -,SUP-656124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FULL THREAD 2.4X26 -,SUP-656126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FULL THREAD 2.4X28 -,SUP-656128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FULL THREAD 2.4X30 -,SUP-656130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FULL THREAD 2.4X32 -,SUP-656132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FULL THREAD 2.4X34 -,SUP-656134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FULL THREAD 2.4X36 -,SUP-656136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FULL THREAD 2.4X38 -,SUP-656138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T8  2.4MM X L40MM NL -,SUP-656140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCKING 3.5 X 42 -,SUP-656142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCKING 3.5 X 44 -,SUP-656144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FULL THREAD 2.4X48 -,SUP-656148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FULL THREAD 2.4X50 -,SUP-656150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE VARIAX T8 2.4MM L55MM -,SUP-656155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FULL THREAD 2.4X60 -,SUP-656160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7MM X 6MM -,SUP-656306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T8 FULL THREAD 2.7 X 7 -,SUP-656307,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1150.21,805.147,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T8 FULL THREAD 2.7X8 -,SUP-656308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7MM X 9MM -,SUP-656309,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK T8 FULL THREAD 2.7X10 -,SUP-656310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK T8 2.7 X 11MM -,SUP-656311,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7MM X 12MM -,SUP-656312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7 X 13 LOCKING -,SUP-656313,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7MM X 14MM -,SUP-656314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK T8 2.7 X 15MM -,SUP-656315,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7MM X 16MM -,SUP-656316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7MM X 18MM -,SUP-656318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7MM X 20MM -,SUP-656320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7MM X 22MM -,SUP-656322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7MM X 24MM -,SUP-656324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7MM X 26MM -,SUP-656326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7MM X 22MM -,SUP-656328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7 X 3 LOCKING -,SUP-656330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7MM X 32MM -,SUP-656332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7 X 34 -,SUP-656334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7MM X 36MM -,SUP-656336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7MM X 38MM -,SUP-656338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7MM X 40MM -,SUP-656340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7 X 42 -,SUP-656342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7MM X 44MM -,SUP-656344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7 X 45 -,SUP-656345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7MM X 50MM -,SUP-656350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.7MM X 55MM LOCKING SCREW -,SUP-656355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE VARIAX T8 2.7MM  X  L 60MM LOCKING -,SUP-656360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7 X 70 -,SUP-656370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE VARIAX T8 2.7MM X L 75MM LOCKING SCREW -,SUP-656375S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,694.95,486.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE VARIAX T8 2.7MM X L 80MM LOCKING -,SUP-656380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,694.95,486.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T8 FULL THREAD NON LCK 2.7 X 6 -,SUP-656406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE VARIAX T8  7MM X 2.7MM -,SUP-656407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T8 FULL THREAD 2.7MM X 9 -,SUP-656409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MM X 10MM NON LOCKING -,SUP-656410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T8 2.7 X11MM -,SUP-656411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW N/L 2.7MM X 12MM -,SUP-656412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7 X 13 NL -,SUP-656413,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW N/L 2.7MM X 14MM -,SUP-656414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCKING 2.7 X 15 -,SUP-656415,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW N/L 2.7MM X 16MM -,SUP-656416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW N/L 2.7MM X 18MM -,SUP-656418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7 X 20MM NLCKG FT T8 STRDRV RCESS -,SUP-656420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON-LOCKING 2.7MM X 22MM -,SUP-656422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCKING 2.7 X 26MM -,SUP-656426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.7MM NON LOCKING BONE SCREW 28MM -,SUP-656428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FLL THRD 2.7 X 30 -,SUP-656430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FLL THRD 2.7 X 32 -,SUP-656432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FLL THRD 2.7 X 34 -,SUP-656434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FLL THRD 2.7 X 36 -,SUP-656436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCKING 2.7 X 38 -,SUP-656438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCKING 2.7 X 40 -,SUP-656440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T8 FULL THREAD 2.7 X 40 -,SUP-656440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCKING 2.7MM X 42MM -,SUP-656442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCKING 2.7 X 45 -,SUP-656445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCKING 2.7 X 46 -,SUP-656446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FLL THRD 2.7 X 48MM -,SUP-656448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7 X 50 NL -,SUP-656450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7 X 55 NL -,SUP-656455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCKING 2.7MM X 60MM -,SUP-656460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCKING 2.7MM X 65MM -,SUP-656465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NL 2.7 X 70 -,SUP-656470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 2.7MM X 75MM T8 -,SUP-656475S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE VAIRAX T8 2.7MM X L 80MM -,SUP-656480S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10 FULL THREAD 2.7 X 8 -,SUP-657008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X12MM LCK FT T10 HX DRV -,SUP-657012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X14MM LCK FT T10 HX DRV -,SUP-657014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X16MM LCK FT T10 HX DRV -,SUP-657016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X20MM LCK FT T10 HX DRV -,SUP-657020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10 FULL 2.7 X 22 -,SUP-657022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10 FULL 2.7MM  X 22MM VARIAX -,SUP-657024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7 X 26 LOCKING -,SUP-657026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7 X 28 LOCKING -,SUP-657028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7 X 30 LOCKING -,SUP-657030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10 FULL 2.7 X 32 -,SUP-657032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW T10 FULL THREAD 2.7MM L34MM -,SUP-657034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10 FULL 2.7 X 36 -,SUP-657036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7 X 38 LOCKING -,SUP-657038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MM X 40MM LOCKING -,SUP-657040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10 2.7 X 50 -,SUP-657050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10 2.7 X 55 -,SUP-657055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW T10 FULL THREAD 2.7MM X 60MM -,SUP-657060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10 FULL THREAD 2.7 X 65 -,SUP-657065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10 FULL THREAD 2.7 X 70 -,SUP-657070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 2.7 X 8 -,SUP-657108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X12MM FT T10 HX DRV -,SUP-657112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X14MM FT T10 HX DRV -,SUP-657114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X16MM FT T10 HX DRV -,SUP-657116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X18MM FT T10 HX DRV -,SUP-657118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X20MM FT T10 HX DRV -,SUP-657120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X22MM FT T10 HX DRV -,SUP-657122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 2.7 X 26 -,SUP-657126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 2.7 X 28 -,SUP-657128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
30MM BONE SCREW NONLOCKING 2.7MM -,SUP-657130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NL 2.7 X 32 -,SUP-657132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NL 2.7 X 34 -,SUP-657134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 2.7MM /L36MM -,SUP-657136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NL 2.7 X 38 -,SUP-657138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 2.7MM /L40MM -,SUP-657140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 2.7MM /L42MM -,SUP-657142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 2.7mm / L44mm -,SUP-657144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 2.7MM /L46MM -,SUP-657146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 2.7mm / L48mm -,SUP-657148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 2.7MM /L50MM -,SUP-657150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 2.7MM /L55MM -,SUP-657155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 2.7MM /L60MM -,SUP-657160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 2.7 X 65 -,SUP-657165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 2.7 X 70 -,SUP-657170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10 FULL THREAD 3.5 X 8 -,SUP-657308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X10MM LCK FT T10 HX DRV -,SUP-657310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 3.5MM 12MM VARIAX T10 FULL THREAD LOCK NONSTERILE -,SUP-657312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X14MM LCK FT T10 HX DRV -,SUP-657314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X16MM LCK FT T10 HX DRV -,SUP-657316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X18MM LCK FT T10 HX DRV -,SUP-657318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10 3.5MM / L20MM FULL THREAD -,SUP-657320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 3.5 X 22 -,SUP-657322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10 3.5MM / L22MM FULL THREAD -,SUP-657322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 3.5 X 24 -,SUP-657324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 3.5 X 26 -,SUP-657326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 3.5 X 30 -,SUP-657330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 3.5 X 32 -,SUP-657332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 3.5 X 34 -,SUP-657334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 3.5 X 38 -,SUP-657338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10 FULL THREAD 3.5 X 40 -,SUP-657340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10 FULL THREAD 3.5 X 42 -,SUP-657342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 3.5 X 44 -,SUP-657344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 3.5 X 46 -,SUP-657346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10FULL THREAD 3.5MM X 48MM -,SUP-657348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10 FULL THREAD 3.5MM X 50MM -,SUP-657350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10 FULL THREAD 3.5 X 60 -,SUP-657360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10 FULL THREAD 3.5 X 65 -,SUP-657365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10 FULL THREAD 3.5 X 70 -,SUP-657370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 3.5 X 8 -,SUP-657408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 3.5 X 8 -,SUP-657408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 3.5MM /L10MM -,SUP-657410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5 NON LOCKING 12MM -,SUP-657412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MM X12MM NON LOCKING -,SUP-657412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X14MM FT T10 HX DRV -,SUP-657414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X16MM FT T10 HX DRV -,SUP-657416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X18MM FT T10 HX DRV -,SUP-657418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X20MM FT T10 HX DRV -,SUP-657420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON-LOCKING 3.5 MM X 22 -,SUP-657422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5 NON LOCK FT 24MM -,SUP-657424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5 NON LOCK FT 26MM -,SUP-657426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MM NONLOCKING FT 28MM -,SUP-657428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MM NONLOCKING FT 30MM -,SUP-657430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
VARIAX 305MM NON LOCKING SCREW  32MM -,SUP-657432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.5MM NON-LOCKING SCREW 34MM -,SUP-657434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.5MM NON-LOCKING SCREW 36MM -,SUP-657436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 3.5 X 38 -,SUP-657438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW  BONE T10 FULL THREAD NON LOCKING 3.5 X 40 -,SUP-657440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 3.5MM X 42MM -,SUP-657442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
VARIAX 3.5MM NON LOCKING SCREW 44MM -,SUP-657444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE SCREW T10 FULL THREAD 3.5MM / L46MM -,SUP-657446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10FULL THREAD 3.5 X 48 -,SUP-657448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MM NONLOCKING FT 50MM -,SUP-657450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 3.5 X 55 -,SUP-657455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 3.5 X 60 -,SUP-657460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 3.5 X 65 -,SUP-657465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 3.5 X 70 -,SUP-657470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW VARIAX LOCKING T6 2.0MM L8MM -,SUP-657608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T6 2.0MM L9MM -,SUP-657609,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW VARIAX LOCKING T6 2.0MM L10MM -,SUP-657610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T6 2.0MM L11MM -,SUP-657611,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.0MM  X 12MM LOCKING -,SUP-657612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T6 2 X 14MM -,SUP-657614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK T6 2.0 X 16MM -,SUP-657616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK T6 2.0 X 18MM -,SUP-657618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2-0MM LOCKING 20MM LENGTH -,SUP-657620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK T6 2.0 X 22MM -,SUP-657622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T6 2.0 X 26MM -,SUP-657626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING VARIAX T6 2.0MM X L30MM -,SUP-657630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 2.0M X L6MM T6 -,SUP-657706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NONLCK 2.0 X 10MM -,SUP-657710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2 X 11 -,SUP-657711,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.0MM X 12MM NON LOCKING -,SUP-657712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.0MM X 14MM NON LOCKING -,SUP-657714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2 X 16 -,SUP-657716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW VARIAX 2.0 X 18 -,SUP-657718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.9 NON LOCKING 20MM LENGTH -,SUP-657720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCKING 2 X 22 -,SUP-657722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T6 2.0MM X L 24MM NON-LOCKING -,SUP-657724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T6 2.0MM L26MM -,SUP-657726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.0MM NON LOCKING 28MM LENGTH -,SUP-657728,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T6 2.0MM L30MM -,SUP-657730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE VARIAX T6 2.0MM X L34MM -,SUP-657734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCKING 2 X 36 -,SUP-657736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE VARIAX T6 2.0MM X L38MM -,SUP-657738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FIXOS 4.0 30MM -,SUP-658030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS 4.0 FIXOS 38MM -,SUP-658038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.0 FIXOS 46MM SCREW -,SUP-658046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.0 FIXOS 48MM SCREW -,SUP-658048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS COMP. 7.0MM 50M -,SUP-658050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.0 FIXOS 55MM SCREW -,SUP-658055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS LONG THREAD 7.0 X 70MM -,SUP-658070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS COMP. 7.0MM 75M -,SUP-658075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.0 FIXOS SCREW 80MM -,SUP-658080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS 5 X 32 -,SUP-658132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FIXOS 5.0 X 34MM -,SUP-658134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FIXOS 5.0 X 36MM -,SUP-658136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
HEADLESS COMPRESSION SCREW 5MM X 38MM -,SUP-658138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
5.0 HEADLESS SCREW 44 MM -,SUP-658144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED 5.0 X 46MM FIXOS -,SUP-658146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
5.0 FIXOS 48MM SCREW -,SUP-658148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED 5.0 X 55MM FI -,SUP-658155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
HEADLESS COMPRESSION SCREW 5.0mm / L65mm -,SUP-658165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
HEADLESS COMPRESSION SCREW 5.0mm / L70mm -,SUP-658170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2402.19,1681.533,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FIXOS 5 X 70MM -,SUP-658170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE FIXOS 5 X 75 -,SUP-658175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FIXOS 5 X 80 -,SUP-658180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
HEADLESS COMPRESSION SCREW 7MM / L40MM ST -,SUP-658340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS COMP. 7.0MM 6.5 FIXOS -,SUP-658365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS COMP. 7.0MM 70M -,SUP-658370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS SHORT THREAD 7.0 X 75MM -,SUP-658375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS SHORT THREAD 7.0 X 90MM -,SUP-658390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS COMP. 7.0MM 12.5 FIXOS -,SUP-658425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
HEADLESS COMPRESSION SCREW 7MM / L65MM ST -,SUP-658565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS LONG THREAD 7.0 X 70MM -,SUP-658570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
HEADLESS COMPRESSION SCREW Ã˜7.0MM / L75MM LONG THREAD -,SUP-658575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.0 FIXOS 80MM -,SUP-658580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
HEADLESS COMPRESSION SCREW 7MM X 85MM LONG THREAD -,SUP-658585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
HEADLESS COMPRESSION SCREW 7MM X25MM -,SUP-658625,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 8X20MM -,SUP-660H0820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 9X35MM -,SUP-660H0935,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X14MM LCK -,SUP-661014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X18MM LCK -,SUP-661018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X20MM LCK -,SUP-661020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X22MM LCK -,SUP-661022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X24MM LCK -,SUP-661024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X26MM LCK -,SUP-661026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK -,SUP-661028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X30MM LCK -,SUP-661030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X32MM LCK -,SUP-661032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X34MM LCK -,SUP-661034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X36MM LCK -,SUP-661036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X38MM LCK -,SUP-661038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X40MM LCK -,SUP-661040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1154.51,808.157,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X42MM LCK -,SUP-661042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X44MM LCK -,SUP-661044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X46MM LCK -,SUP-661046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X48MM LCK -,SUP-661048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X50MM LCK -,SUP-661050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCK 4.0 X 55MM -,SUP-661055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X60MM LCK -,SUP-661060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X65MM LCK -,SUP-661065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X70MM LCK -,SUP-661070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X75MM LCK -,SUP-661075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X80MM LCK -,SUP-661080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X85MM LCK -,SUP-661085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X90MM LCK -,SUP-661090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X95MM LCK -,SUP-661095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X14MM LCK -,SUP-661114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X16MM LCK -,SUP-661116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X18MM LCK -,SUP-661118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X20MM LCK -,SUP-661120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X22MM LCK -,SUP-661122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X24MM LCK -,SUP-661124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X26MM LCK -,SUP-661126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X28MM LCK -,SUP-661128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X30MM LCK -,SUP-661130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X32MM LCK -,SUP-661132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X34MM LCK -,SUP-661134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X36MM LCK -,SUP-661136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X38MM LCK -,SUP-661138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X40MM LCK -,SUP-661140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X42MM LCK -,SUP-661142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X44MM LCK -,SUP-661144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X46MM LCK -,SUP-661146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5 X 48MM LCK -,SUP-661148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X55MM LCK -,SUP-661155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X60MM LCK -,SUP-661160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,854.24,597.968,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X65MM LCK -,SUP-661165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X70MM LCK -,SUP-661170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X75MM LCK -,SUP-661175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X80MM LCK -,SUP-661180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X85MM LCK -,SUP-661185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X90MM LCK -,SUP-661190,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X95MM LCK -,SUP-661195,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW FLAT TIP 5.0MM T20 L10MM -,SUP-661210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2630.74,1841.518,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW FLAT TIP 5.0MM /T20 /L20 -,SUP-661220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2630.74,1841.518,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X8MM LCK ST PRPRSTHTC -,SUP-661308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 5.0 X 10MM PERIP -,SUP-661310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 5.0 X 12MM PERIP -,SUP-661312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X14MM LCK ST PRPRSTHTC -,SUP-661314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X16MM PERI- LCK AXSOS -,SUP-661316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X16MM LCK ST PRPRSTHTC -,SUP-661316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X18MM LCK ST PRPRSTHTC -,SUP-661318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X20MM LCK ST PRPRSTHTC -,SUP-661320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCKING 3.5 X 14MM -,SUP-661414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X18MM CORT TI -,SUP-661418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCKING 3.5 X 20MM -,SUP-661420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X22MM CORT TI -,SUP-661422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X24MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X28MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X30MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X32MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X34MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X36MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X38MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X40MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X42MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X44MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X46MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 3.5 X 46 -,SUP-661447,CDM,C1713,HCPCS,278,RC,,,outpatient,,,239.99,167.993,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X48MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X50MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X55MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X65MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X70MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X75MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661475,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X80MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X85MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X90MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTEX 3.5MM X 120MM -,SUP-661520S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTEX TI 4.5 X 14MM -,SUP-661714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTEX SELF TAPPING 4.5 X 16 -,SUP-661716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORT 4.5 X 18 -,SUP-661718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 4.5 X 20MM -,SUP-661720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X22MM CORT TI -,SUP-661722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORT 4.5 X 24 -,SUP-661724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORT 4.5 X 26 -,SUP-661726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORITCAL 4.5MM X 28MM -,SUP-661728,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X30MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X32MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661732,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X34MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X36MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X38MM LCK CORT VARIAX SELF TAPPING -,SUP-661738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X38MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X40MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X42MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X44MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X46MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661746,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X48MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661748,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X50MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X55MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X60MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X65MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661765,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X70MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X75MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661775,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X80MM CORT TI -,SUP-661780,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 4.5 X 85 -,SUP-661785,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX8IN ER CANC CORT VARIAX FT POLYAX ST T7 STRDRV -,SUP-661795,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CABLE PLUG 5.0MM -,SUP-662202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1868.43,1307.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW 5.0MM /T20 / L24MM -,SUP-662324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW 5.0MM /T20 /L30MM -,SUP-662330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW 5.0MM /T20 / L40MM -,SUP-662340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW 5.0MM T20 L46MM -,SUP-662346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW 5.0MM T20 L50MM -,SUP-662350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW 5.0MM T20 L60MM -,SUP-662360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW 5.0MM /T20 / L65MM -,SUP-662365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW 5.0MM T20 L70MM -,SUP-662370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW 5.0MM /T20 / L75MM -,SUP-662375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW 5.0MM /T20 /L80MM -,SUP-662380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK 1.7 X 5 -,SUP-662505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,497.14,347.998,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T5 1.7MM X 9MM -,SUP-662509,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW T5 1.7MM X 22MM -,SUP-662522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,497.14,347.998,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 1.7 X 6 -,SUP-662606,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE SCREW T5 1.7MM X 8MM -,SUP-662608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 1.7 X 9 -,SUP-662609,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.7 X 11 NON LOCKING -,SUP-662611,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.7 X 15 -,SUP-662615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.7 X 16 NL -,SUP-662616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.7 X 18 NL -,SUP-662618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EMERGENCY 1.9 X 5 -,SUP-662705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EMERGENCY T5 1.9MM/L12MM 12 HOLE LEFT -,SUP-662712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED 4.0MM X 38MM COMP -,SUP-663038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER 5MM -,SUP-663101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,202.42,141.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW JFX CANNULATED 5 X 46MM -,SUP-663146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IMPCTR HD XTRCT SHRT 3.2X19MM DURACN -,SUP-6633-7-615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,376.53,263.571,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SOLID COMPRESSION 4.0MM X 36MM L -,SUP-663436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SOLID COMPRESSION 4.0MM X 38MM -,SUP-663438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMPRESSION SCREW SOLID A 4.0MM/ L40MM -,SUP-663440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SOLID COMPRESSION 4 X 22 -,SUP-663442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.0 SOLID COMPRESSION SCREW 48MM -,SUP-663448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SOLID COMPRESSION 4.0MM X L50MM -,SUP-663450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.32,2719.724,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SOLID COMPRESSION 5.0MM X 36MM L -,SUP-663536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SOLID COMP 5MM X 40MM -,SUP-663540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW COMPRESSION 5 X 42 -,SUP-663542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
5.0MM L 44MM COMPRESSION SCREW -,SUP-663544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMPRESSION SCREW 5.0MM -,SUP-663546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5 X 48 MM SOLID -,SUP-663548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SOLID COMPRESSION 5.0MM X L50MM -,SUP-663550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.3MM X 16MM -,SUP-663716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,498.89,349.223,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.3MM X 18MM -,SUP-663718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,498.89,349.223,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 2.3 X 8 -,SUP-663808,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 2.3  X 9 -,SUP-663809,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 2.3 X 10 -,SUP-663810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCKING 2.3MM X 13MM -,SUP-663813,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON-LOCKING 2.3MM 16MM -,SUP-663816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 2.3 X 20 -,SUP-663820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EMERGENCY  2.5 X 6 -,SUP-663906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EMERGENCY 2.5 X 8 -,SUP-663908,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CORTEX SCREW DIA 4.0MM L38MM -,SUP-666138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CANLTD SCRW 16MM THREAD DIA 6.5MM L45MM -,SUP-666445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CANLTD SCREW 16MM THREAD DIA 6.5MM L50MM -,SUP-666450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CANLTD SCREW 16MM THREAD DIA 6.5MM L65MM -,SUP-666465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED 6.5 X 70 -,SUP-666470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED 6.5 X 80 -,SUP-666480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED 6.5 X 85 -,SUP-666485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER MOLD LG FEMORAL 53A/P X 75M/L -,SUP-669-1075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6663.08,4664.156,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRIP CBL 1.6MM DLMLS VITAL -,SUP-6704-0-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3931.1,2751.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CABLE ORTHO 1.6MM DLMLS VITAL MED GRP + 2 -,SUP-6704-0-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3931.1,2751.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRIP LARGE W/2 CABLES DALL MIL -,SUP-6704-0-310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3931.1,2751.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CABLE ORTHO DLMLS 1.6MM VITAL BEAD SM SLV -,SUP-6704-0-420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CABLE ORTHO DLMLS 2MM VITAL MED SLV -,SUP-6704-0-510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DALL-MILES 2.0MM VIT BEADED CABLE/SLEEVE SET -,SUP-6704-0-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SET CABLE SLEEVE BEADED  2.0 D -,SUP-6704-0-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN DLMLS 100MM GRP VITAL MED 2MM CBLX2 -,SUP-6704-3-081,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4408.24,3085.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN DLMLS 150MM GRP VITAL MED 2MM CBLX2 -,SUP-6704-3-082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5744.68,4021.276,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TROC DLMLS 110MM GRP LRG W/2 CBS -,SUP-6704-3-091,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4408.24,3085.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN DLMLS 160MM GRP VITAL LRG 2MM CBLX2 -,SUP-6704-3-092,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5744.68,4021.276,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CENTURION 3.5 X 12 -,SUP-69-3312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CENTURION 3.5 X 18 -,SUP-69-3318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CENTURION 3.5 X 12 -,SUP-69-3412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CENTURION 4.0 X 14 -,SUP-69-3414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CENTURION 4.0 X 30 -,SUP-69-3430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CENTURION 4.5 X 30 -,SUP-69-3530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CENTURION 5.0 X 30 -,SUP-69-3630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
STAPLE INTNL 12X23MM VITAL ELLISON LF -,SUP-6982-1-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1703.05,1192.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
STAPLE INTNL 14X23MM VITAL ELLISON LF -,SUP-6982-2-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1602.87,1122.009,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFT BONE I FACTOR 2.5CC ALLOGRAFT PUTTY SYRINGE -,SUP-700-025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 8HL STR -,SUP-70-0095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 8HL STR -,SUP-70-0096,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 3.5MM 9HL LCK TI NS RT -,SUP-70-0116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.27,4447.289,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 3.5MM 9HL LCK TI NS LT -,SUP-70-0117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.27,4447.289,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 2.3MM 16HL LCK TI NS -,SUP-70-0124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6989.87,4892.909,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 2.3MM 13HL LCK TI NS -,SUP-70-0126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.27,4447.289,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 8HL LT CLAV LPRO TI STR NS -,SUP-70-0286,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 8HL RT CLAV LPRO TI STR NS -,SUP-70-0287,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN F/ELB PLATE SYS 8HL LCK TI LRG NS -,SUP-70-0289,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN F/ELB PLATE SYS 10HL LCK TI NS -,SUP-70-0294,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN F/ELB PLATE SYS 6HL LCK TI NS LT CLVCL -,SUP-70-0296,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN F/ELB PLATE SYS 6HL LCK TI NS RT CLVCL -,SUP-70-0297,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 8HL LT CLAV NRW-PRFL TI STR NS -,SUP-70-0298,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 8HL RT CLAV NRW-PRFL TI STR NS -,SUP-70-0299,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 8HL CONTR LCK TI LRG NS LT -,SUP-70-0300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 8HL CONTR LCK TI LRG NS RT -,SUP-70-0301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 65MM 3HL CONTR LCK TI STD NS -,SUP-70-0302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6535.76,4575.032,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 110MM 7HL CONTR LCK TI STD NS -,SUP-70-0306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7414.27,5189.989,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 90MM 5HL TAP-LCK TI EXTEND NS -,SUP-70-0313,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6535.76,4575.032,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 2MM ASNIS III THRD -,SUP-7007-1300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
K-WIRE ASNIS III 3.2 -,SUP-702463S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,505.08,353.556,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
IRON BENDING -,SUP-702901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.85,795.795,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
AXSOS 5.0 ADAPTOR NUT -,SUP-702977,CDM,C1713,HCPCS,278,RC,,,outpatient,,,559.11,391.377,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOW PROFILE HEX 6.5 X 15 -,SUP-7030-6515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEX LOW PROFILE 6.5MM X 20MM -,SUP-7030-6520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MM LOW PROFILE HEX -,SUP-7030-6525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEX 6.5MM X 30MM LOW PROFILE -,SUP-7030-6530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEX 6.5MM X 35MM LOW PROFILE -,SUP-7030-6535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
6.5x40MM LOW PROFILE HEX SCREW -,SUP-7030-6540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
6.5X45MM LOW PROFILE HEX SCREW -,SUP-7030-6545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
6.5x50MM LOW PROFILE HEX SCREW -,SUP-7030-6550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOW PROFILE HEX 6.5MM x 55MM -,SUP-7030-6555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT HIP 7X35MM POR TI PLASM SPRY SCRILAC IFUSE STRL -,SUP-7035-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDE WIRE WITH CALIBRATION 3.2MM X 230MM QUICK RELEASE -,SUP-705237,CDM,C1713,HCPCS,278,RC,,,outpatient,,,606.84,424.788,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ELEVATOR PERIOSTEAL 6MM ROUND EDGE -,SUP-705294,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1361.01,952.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT HIP 7X65MM POR TI PLASM SPRY SCRILAC IFUSE STRL -,SUP-7065-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN EXTFIX 3X120MM 16MM THRD COVE PNT -,SUP-71022001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN EXTFIX 3X120MM 22MM THRD COVE PNT -,SUP-71022002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN EXTFIX 3X120MM 28MM THRD COVE PNT -,SUP-71022003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X70MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X80MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X85MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X95MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X110MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X130MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 58MM 3.5MM 5HL RECON STR -,SUP-71140105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4158.44,2910.908,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 70MM 3.5MM 6HL RECON STR -,SUP-71140106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4651.85,3256.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 82MM 3.5MM 7HL RECON STR -,SUP-71140107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4446.01,3112.207,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 94MM 3.5MM 8HL RECON STR -,SUP-71140108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5084.1,3558.87,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 75MM 3.5MM 6HL SM T-SHP RT ANG -,SUP-71140406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2349.66,1644.762,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO 3.7X7MM SS -,SUP-71143107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,441.48,309.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 87MM 9HL Y STRL TMPLT -,SUP-71144012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7101.27,4970.889,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TROCAR PIN GEN 1/8 X 3 -,SUP-71210002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.63,108.241,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 3MM GENESIS 12.5CM TROC TIP -,SUP-71210003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.63,108.241,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MM MINI 16MM CORT TC-100 FT HEX HEAD SS -,SUP-71220016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,359.67,251.769,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 15MM REF SPHER HEAD -,SUP-71332515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,811.07,567.749,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 20MM REF SPER HEAD -,SUP-71332520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,811.07,567.749,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CABLE ORTHO 2MM ACCORD COCR -,SUP-71340020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,977.36,684.152,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
INSERT PS LGN XLPE SZ 3-4 11MM -,SUP-71453247,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4520.12,3164.084,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ENDCAP ORTHO 0MM TRIGEN STRL -,SUP-71634000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2293.1,1605.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ENDCAP PROT 5MM TI STRL TRIGEN F/OB GYNAECOLOGICAL PROC TIB -,SUP-71634005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2293.1,1605.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ENDCAP ORTHO 20MM TRIGEN STRL -,SUP-71634020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2293.1,1605.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX25MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2401.07,1680.749,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX30MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX35MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642135,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX40MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX45MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX55MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX65MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX20MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX25MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX35MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX50MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX60MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX65MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642265,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX75MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642275,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X35MM TRIGEN -,SUP-71645035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X45MM TRIGEN -,SUP-71645045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X380MM TRIGEN TAN CANN LT TROCH FEM TI ALY ANTGRD -,SUP-71647238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15450.91,10815.637,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5X380MM TRIGEN TAN CANN LT TROCH FEM TI ALY -,SUP-71647338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15450.91,10815.637,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X320MM TRIGEN META-NAIL CANN DIST FEM TI ALY RTRGD -,SUP-71653032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14208.35,9945.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 8.5X330MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655033,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 8.5X340MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 8.5X350MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X280MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X290MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655129,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10MMX30CM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X310MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655131,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X320MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X340MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X350MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655135,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10MMX37CM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655137,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5X300MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5X360MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5X390MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655239,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5MMX40CM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 3.2MM TRIGEN 343MM THRD BRAD TIP -,SUP-71674130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1491.03,1043.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X180MM TRIGEN INTERTAN 1.5 CANN TROCH FEM TI 125DG -,SUP-71675201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5X180MM TRIGEN INTERTAN 1.5 CANN TROCH FEM TI -,SUP-71675202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X180MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5X200MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X180MM TRIGEN INTERTAN 1.5 CANN TROCH FEM TI 130DG -,SUP-71675207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5MM 180MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP -,SUP-71675208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X180MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71675209,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71675210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X320MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP -,SUP-71675219,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10MMX32CM TRIGEN INTERTAN 1.5 CANN INTST HIP TI -,SUP-71675220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675222,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CAN LT INTS HIP TI LIME -,SUP-71675223,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI125 -,SUP-71675224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X380MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X400MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP -,SUP-71675227,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5X320MM TRIGEN INTERTAN 1.5 CANN RT INTS HIP TI.. -,SUP-71675242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71675244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675245,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71675246,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI_ -,SUP-71675250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5X420MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675251,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI130 -,SUP-71675268,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X280MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X320MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13MMX32CM TRIGEN INTERTAN 1.5 CANN INTST HIP TI -,SUP-71675408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X180MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71675412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X380MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675413,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X400MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675415,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X400MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X440MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X320MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71676507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TIRSE -,SUP-71676510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71676511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676513,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X380MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5X320MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI- -,SUP-71676552,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTS HIP TI.. -,SUP-71676553,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI- -,SUP-71676554,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5MMX36CM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71676555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5X360MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5X380MM TRIGEN INTERTAN 1.5 CANN LT INTST TI -,SUP-71676557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5MMX38CM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71676558,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5X400MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71676598,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X360MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X380MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71676602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 70MM/75MM -,SUP-71677075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 75MM/80MM -,SUP-71677080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 80MM/85MM -,SUP-71677085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 85MM/90MM -,SUP-71677090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 90MM/95MM -,SUP-71677095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI_ -,SUP-71677100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI- -,SUP-71677105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI.. -,SUP-71677110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI. -,SUP-71677115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 11MM TRIGEN INTERTAN LAG 100MM -,SUP-71678010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 11X110MM LAG TRIGEN INTERTAN -,SUP-71678011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11X115MM TRIGEN INTERTAN SBTRCHNTRC TI -,SUP-71678015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 11MM TRIGEN INTERTAN LAG 85MM -,SUP-71678085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 11MM TRIGEN INTERTAN LAG 90MM -,SUP-71678090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 11MM TRIGEN INTERTAN LAG 95MM -,SUP-71678095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 3.2MMX24.8CM THRD DRILL TIP -,SUP-71751147,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X20MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X22MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X24MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X30MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X24MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X26MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X30MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X32MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X34MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X36MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X38MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X40MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X42MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X44MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X46MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 8/ 7MMLNGX260MM TRIGEN CANN PROX HUM TI ALY -,SUP-71770826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 9/ 7.5MMLNGX240MM TRIGEN CANN PROX HUM TI ALY -,SUP-71770924,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10/ 8.5MMLNGX220MM TRIGEN CANN PROX HUM TI ALY -,SUP-71771022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10/ 8.5MMLNGX240MM TRIGEN CANN PROX HUM TI ALY -,SUP-71771024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10/ 8.5MMLNGX280MM TRIGEN CANN PROX HUM TI ALY -,SUP-71771028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 193MM 4.5MM 8HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16207.25,11345.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 286MM 4.5MM 13HL CONTR SCALLP LCK SS BVL LT -,SUP-71800013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17251.71,12076.197,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 342MM 4.5MM 16HL CONTR SCALLP LCK SS BVL LT -,SUP-71800016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17575.86,12303.102,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 193MM 4.5MM 8HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16207.25,11345.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 342MM 4.5MM 16HL CONTR SCALLP LCK SS BVL RT -,SUP-71800116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17575.86,12303.102,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 94MM 4.5MM 4HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17341.75,12139.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 130MM 4.5MM 6HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17575.86,12303.102,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 93MM 4.5MM 3HL CONTR SCALLP LCK BVL TIP -,SUP-71801603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17053.62,11937.534,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X10MM CORT PERILOC ST SS -,SUP-71804010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X12MM CORT PERILOC ST SS -,SUP-71804012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X14MM CORT PERILOC ST SS -,SUP-71804014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X16MM CORT PERILOC ST SS -,SUP-71804016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X18MM CORT PERILOC ST SS -,SUP-71804018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X20MM CORT PERILOC ST SS -,SUP-71804020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X24MM CORT PERILOC ST SS -,SUP-71804024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X32MM CORT PERILOC ST SS -,SUP-71804032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X34MM CORT PERILOC ST SS -,SUP-71804034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X36MM CORT PERILOC ST SS -,SUP-71804036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X38MM CORT PERILOC ST SS -,SUP-71804038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X40MM CORT PERILOC ST SS -,SUP-71804040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X50MM CORT PERILOC ST SS -,SUP-71804050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X55MM CORT PERILOC ST SS -,SUP-71804055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X60MM CORT PERILOC ST SS -,SUP-71804060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X12MM LCK CORT PERILOC ST SS -,SUP-71805012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1866.36,1306.452,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X20MM LCK CORT PERILOC ST SS -,SUP-71805020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1866.36,1306.452,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X14MM CANC PERILOC FT SS -,SUP-71805214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,496.09,347.263,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X36MM CORT PERILOC ST SS -,SUP-71806036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X38MM CORT PERILOC ST SS -,SUP-71806038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X40MM CORT PERILOC ST SS -,SUP-71806040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X42MM NLCKG CORT PERILOC ST SS -,SUP-71806042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X46MM NLCKG CORT PERILOC ST SS -,SUP-71806046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X50MM NLCKG CORT PERILOC ST SS -,SUP-71806050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X70MM NLCKG CORT PERILOC ST SS -,SUP-71806070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X32MM LCK CORT PERILOC ST SS -,SUP-71807032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X34MM LCK CORT PERILOC ST SS PERIART -,SUP-71807034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X36MM LCK CORT PERILOC ST SS PERIART -,SUP-71807036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X38MM LCK CORT PERILOC ST SS -,SUP-71807038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X48MM LCK CORT PERILOC ST SS -,SUP-71807048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X56MM LCK CORT PERILOC ST SS -,SUP-71807056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X58MM LCK CORT PERILOC ST SS -,SUP-71807058,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X60MM LCK CORT PERILOC ST SS PERIART -,SUP-71807060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X74MM LCK CORT PERILOC ST SS -,SUP-71807074,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.7X65MM LCK CANN PERILOC FT SS -,SUP-71808065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 193MM 4.5MM 13HL CONTR SCALLP LCK SS BVL -,SUP-71820008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12497.59,8748.313,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 230MM 4.5MM 10HL CONTR SCALLP LCK SS BVL TIP -,SUP-71820010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12767.71,8937.397,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 98MM 3.5MM 6HL CONTR SCALLP LCK SS BVL TIP -,SUP-71820506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13524.05,9466.835,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 196MM 3.5MM 10HL CONTR SCALLP LCK BVL TIP -,SUP-71821010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15522.94,10866.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X34MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X36MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X40MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X50MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X55MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X60MM LCK PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG -,SUP-71821160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX6MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
RETRACTOR EYELID DSMRS 1.12MMX5.5IN STN FNSH LID V. MUELLER -,SUP-71821208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
RETRACTOR LNG ALLISON 12.25IN 2.125IN BLD SS F/CV V. MUELLER -,SUP-71821210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX12MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX14MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX16MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX18MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821218,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX22MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821222,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX24MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX26MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821226,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX28MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX30MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX34MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX36MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX40MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 89MM 3.5MM 3HL CONTR LCK SS BVL TIP -,SUP-71821303,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14982.7,10487.89,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX6MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM STD -,SUP-71821306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX8MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM STD -,SUP-71821308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX10MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX12MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX14MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX16MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX18MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX20MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX22MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX24MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX26MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX28MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX32MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX34MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX36MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX38MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX40MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX44MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX46MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX50MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 89MM 3.5MM 3HL CONTR LCK SS BVL TIP NS -,SUP-71821403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14982.7,10487.89,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 115MM 3.5MM 5HL CONTR LCK SS BVL TIP -,SUP-71821405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15414.89,10790.423,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 79MM 2.7/3.5MM 5HL CONTR LCK SS BVL TIP -,SUP-71821805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11921.33,8344.931,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX10MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX12MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX14MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX16MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX18MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX20MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX38MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX40MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X10MM LCK CORT PERILOC FT ST SS NS -,SUP-71822310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X12MM LCK CORT PERILOC FT ST SS NS -,SUP-71822312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X14MM LCK CORT PERILOC FT ST SS NS -,SUP-71822314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X16MM LCK CORT PERILOC FT ST SS NS -,SUP-71822316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X18MM LCK CORT PERILOC FT ST SS NS -,SUP-71822318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X20MM LCK CORT PERILOC FT ST SS NS -,SUP-71822320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X24MM LCK CORT PERILOC FT ST SS NS -,SUP-71822324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X28MM LCK CORT PERILOC FT ST SS NS -,SUP-71822328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X30MM LCK CORT PERILOC FT ST SS NS -,SUP-71822330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X36MM LCK CORT PERILOC FT ST SS NS -,SUP-71822336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X40MM LCK CORT PERILOC FT ST SS NS -,SUP-71822340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X45MM LCK CORT PERILOC FT ST SS NS -,SUP-71822345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X50MM LCK CORT PERILOC FT ST SS NS -,SUP-71822350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X60MM LCK CORT PERILOC FT ST SS NS -,SUP-71822360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1413.91,989.737,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X10MM LCK CORT PERILOC FT ST SS -,SUP-71822410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X12MM LCK CORT PERILOC FT ST SS -,SUP-71822412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X14MM LCK CORT PERILOC FT ST SS -,SUP-71822414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X16MM LCK CORT PERILOC FT ST SS -,SUP-71822416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X18MM LCK CORT PERILOC FT ST SS -,SUP-71822418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X20MM LCK CORT PERILOC FT ST SS -,SUP-71822420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X22MM LCK CORT PERILOC FT ST SS -,SUP-71822422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X24MM LCK CORT PERILOC FT ST SS -,SUP-71822424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X26MM LCK CORT PERILOC FT ST SS -,SUP-71822426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 153MM 2.7MM 11HL CONTR SS BVL TIP -,SUP-71822511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14982.7,10487.89,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 80MM 2.7/3.5MM 5HL CONTR LCK SS BVL TIP -,SUP-71822705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12245.47,8571.829,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 81MM 6HL LCK SS CORNL BND -,SUP-71822906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14406.44,10084.508,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 107MM 8HL LCK SS CORNL BND -,SUP-71822908,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15522.94,10866.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX10MM LCK CORT PERILOC VLP ST VAR ANG CP 2.5MM -,SUP-71823010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX12MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX14MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX16MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX18MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DIRECTOR ORAL NO. 2522 7.25IN V. MUELLER SS GZE LIG TUCKER -,SUP-71823020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX22MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX24MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX26MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX30MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX40MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX45MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX50MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX55MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX60MM LCK CORT PERILOC VLP ST FLUTX3 2.5MM STD HX -,SUP-71823060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,611.27,427.889,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 62MM 2.5MM 3HL STD HEAD LCK SS -,SUP-71823110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 86MM 2.5MM 5HL STD HEAD LCK SS LT VOLAR -,SUP-71823112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9562.27,6693.589,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 62MM 2.5MM 3HL HEAD LCK SS STD -,SUP-71823114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 86MM 2.5MM 5HL STD HEAD LCK SS RT VOLAR -,SUP-71823116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9562.27,6693.589,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 62MM 2.5MM 3HL W HEAD LCK SS LT VOLAR RADL -,SUP-71823118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 62MM 2.5MM 3HL W HEAD LCK SS RT VOLAR RADL -,SUP-71823122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 97MM 3.5MM 8HL LCK SS -,SUP-71823401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8830.28,6181.196,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 109MM 3.5MM 6HL LCK SS LT CLVCL -,SUP-71823403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9036.11,6325.277,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 109MM 3.5MM 6HL LCK SS RT CLVCL -,SUP-71823404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9036.11,6325.277,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 81MM 2.7MM LCK SS -,SUP-71823407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9036.11,6325.277,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 81MM 6HL LCK SS -,SUP-71823906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14406.44,10084.508,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X10MM NLCKG CORT PERILOC ST SS -,SUP-71824010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X16MM NLCKG CORT PERILOC ST SS -,SUP-71824016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X22MM NLCKG CORT PERILOC ST SS -,SUP-71824022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X24MM NLCKG CORT PERILOC ST SS -,SUP-71824024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM NLCKG CORT PERILOC ST SS -,SUP-71824026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X28MM NLCKG CORT PERILOC ST SS -,SUP-71824028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X30MM NLCKG CORT PERILOC ST SS -,SUP-71824030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X50MM NLCKG CORT PERILOC ST SS -,SUP-71824050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X18MM LCK CORT PERILOC ST SS -,SUP-71825018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X22MM LCK CORT PERILOC ST SS -,SUP-71825022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X24MM LCK CORT PERILOC ST SS -,SUP-71825024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM LCK CORT PERILOC ST SS -,SUP-71825026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X28MM LCK CORT PERILOC ST SS -,SUP-71825028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X30MM LCK CORT PERILOC ST SS -,SUP-71825030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X32MM LCK CORT PERILOC ST SS -,SUP-71825032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X34MM LCK CORT PERILOC ST SS -,SUP-71825034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X50MM LCK CORT PERILOC ST SS -,SUP-71825050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X55MM LCK CORT PERILOC ST SS -,SUP-71825055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X60MM LCK CORT PERILOC ST SS -,SUP-71825060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X65MM LCK CORT PERILOC ST SS -,SUP-71825065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X80MM LCK CORT PERILOC ST SS -,SUP-71825080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X10MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X12MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X16MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X18MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825218,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X36MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X45MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825245,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X50MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X60MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X65MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825265,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X35MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825335,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X40MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X45MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X55MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X60MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X26MM NLCKG CORT PERILOC ST SS -,SUP-71826026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X30MM NLCKG CORT PERILOC ST SS -,SUP-71826030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X34MM NLCKG CORT PERILOC ST SS -,SUP-71826034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X40MM NLCKG CORT PERILOC ST SS -,SUP-71826040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X44MM NLCKG CORT PERILOC ST SS -,SUP-71826044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X48MM NLCKG CORT PERILOC ST SS -,SUP-71826048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X52MM NLCKG CORT PERILOC ST SS -,SUP-71826052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X60MM NLCKG CORT PERILOC ST SS -,SUP-71826060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X68MM NLCKG CORT PERILOC ST SS -,SUP-71826068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X72MM NLCKG CORT PERILOC ST SS -,SUP-71826072,CDM,C1713,HCPCS,278,RC,,,outpatient,,,594.29,416.003,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X74MM NLCKG CORT PERILOC ST SS -,SUP-71826074,CDM,C1713,HCPCS,278,RC,,,outpatient,,,594.29,416.003,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X10MM LCK CORT PERILOC ST SS -,SUP-71827010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X12MM LCK CORT PERILOC ST BLNT TIP SS -,SUP-71827012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X18MM LCK CORT PERILOC ST SS -,SUP-71827018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X20MM LCK CORT PERILOC ST SS -,SUP-71827020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X24MM LCK CORT PERILOC ST SS -,SUP-71827024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X26MM LCK CORT PERILOC ST SS -,SUP-71827026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X28MM LCK CORT PERILOC ST SS -,SUP-71827028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X30MM LCK CORT PERILOC ST SS -,SUP-71827030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X32MM LCK CORT PERILOC ST SS -,SUP-71827032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X34MM LCK CORT PERILOC ST SS -,SUP-71827034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X36MM LCK CORT PERILOC ST SS PROX FEM -,SUP-71827036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X40MM LCK CORT PERILOC ST SS -,SUP-71827040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X42MM LCK CORT PERILOC ST SS -,SUP-71827042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X46MM LCK CORT PERILOC ST SS -,SUP-71827046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X50MM LCK CORT PERILOC ST SS -,SUP-71827050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X52MM LCK CORT PERILOC ST SS -,SUP-71827052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X60MM LCK CORT PERILOC ST SS PROX FEM -,SUP-71827060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X66MM LCK CORT PERILOC ST SS -,SUP-71827066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X68MM LCK CORT PERILOC ST SS -,SUP-71827068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X70MM LCK CORT PERILOC ST SS -,SUP-71827070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1924.08,1346.856,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X70MM LCK CORT PERILOC ST SS -,SUP-71827070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X72MM LCK CORT PERILOC ST SS -,SUP-71827072,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X76MM LCK CORT PERILOC ST SS -,SUP-71827076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X80MM LCK CORT PERILOC ST SS -,SUP-71827080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X85MM LCK CORT PERILOC ST SS -,SUP-71827085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X90MM LCK CORT PERILOC ST SS -,SUP-71827090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1979.47,1385.629,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.7MMX20MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.7MMX25MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.7MMX35MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.7MMX40MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.7MMX45MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.7MMX50MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.7MMX55MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
RETRACTOR UTR DE LEE UNIV 2INX2.75IN 9.5IN HNDL SS V.MUELLER -,SUP-71828060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.7MMX65MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.7MMX70MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.7MMX80MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.7MMX85MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC CONTR + 57MM 3.5MM 4HL LCK COMPR SS 1/3 -,SUP-71829004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2601.59,1821.113,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC CONTR + 82MM 3.5MM 6HL LCK COMPR SS 1/3 -,SUP-71829006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2601.59,1821.113,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC CONTR + 107MM 3.5MM 8HL LCK COMPR SS 1/3 -,SUP-71829008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2533.04,1773.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 93MM F/3.5MM 6HL NLCKG COMPR SS 1/3 TBLR SM -,SUP-71829406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2395.93,1677.151,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 106MM 3.5MM 7HL NLCKG COMPR 1/3 TBLR SM FRAG -,SUP-71829407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2514.19,1759.933,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 50MM 4.33HL TBLR NS -,SUP-71829434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.31,800.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 62MM 5.33HL TBLR NS -,SUP-71829435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.31,800.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 74MM 6.33HL TBLR NS -,SUP-71829436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1064.29,745.003,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 86MM 7.33HL TBLR NS -,SUP-71829437,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1064.29,745.003,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 98MM 8.33HL TBLR NS -,SUP-71829438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1095.14,766.598,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 122MM 10.33HL TBLR NS -,SUP-71829440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1095.14,766.598,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 70MM 3.5MM 6HL RECON SM FRAG -,SUP-71829516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4693.02,3285.114,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 94MM 3.5MM 8HL RECON -,SUP-71829518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5145.85,3602.095,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 96MM F/3.5MM SM MUL FRAG SYS 6HL LCK COMPR -,SUP-71829706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4528.9,3170.23,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCR- SFTSLK-2.0 PKG.7X20 STER -,SUP-7207256,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SOFTSILK 2.0 7 X 25 -,SUP-7207257,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCR- SFTSLK-2.0 PKG.8X20 STER -,SUP-7207259,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SOFTSILK 2.0 8 X 25 -,SUP-7207260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DEVICE SUT ARSCP ENDBTTN CL 30MM STRL LF -,SUP-7210082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DEVICE SUT ARSCP ENDBTTN CL 35MM STRL LF -,SUP-7210083,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DEVICE SUT ARSCP ENDBTTN CL 40MM STRL LF -,SUP-7210084,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BUTTONENDO CL BTB STER 45MM -,SUP-7210085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BUTTON ENDO 15MM CL -,SUP-7220-0146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.98,1373.386,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ULTRA FAST FIX CURVED -,SUP-7220-1494,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2143.15,1500.205,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT FTPRNT 5.5MM ARSCP NABSB OUTR SHL INR PLG -,SUP-7220-1697,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2143.95,1500.765,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN BIOSURE 9X25MM ABSB TAPR PLLA HAP KN -,SUP-72201781,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1574.57,1102.199,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUT ANCHOR OSTEORAPTOR  2.9 -,SUP-72201995,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2049.44,1434.608,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FAST-FIX 360 STRAIGHT -,SUP-72202467,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2543.73,1780.611,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FAST FIX 360 CVD NEEDLE -,SUP-72202468,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2543.73,1780.611,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FAST-FIX 360 REVERSE CURVED -,SUP-72202469,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2543.73,1780.611,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDE DRILL SZ1.2 ENDBTTN CL ULTRA PAC -,SUP-7220-2799,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2118.19,1482.733,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUTURE 4.5MM HEALICOIL -,SUP-7220-3378,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2261.88,1583.316,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR HEALICOIL 4.75MM REGENE -,SUP-72203697,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3911.82,2738.274,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR HEALICOIL 4.75MM -,SUP-72203704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2249.43,1574.601,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EVOS 2.7MM X 17MM CTX -,SUP-72402717,CDM,C1713,HCPCS,278,RC,,,outpatient,,,400.46,280.322,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EVOS 2.7MM X 24MM CTX -,SUP-72402724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,188.59,132.013,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EVOS 3.5MM X 14MM CTX -,SUP-72403514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.9,95.13,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EVOS 3.5MM X 15MM CTX -,SUP-72403515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EVOS 3.5MM X 16MM CTX -,SUP-72403516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EVOS 3.5MM X 17MM CTX -,SUP-72403517,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EVOS 3.5MM X 18MM CTX -,SUP-72403518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EVOS 2.7MM X 18MM LCK -,SUP-72412718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,598.38,418.866,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EVOS 2.7MM X 19MM LCK -,SUP-72412719,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.55,802.585,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EVOS 2.7MM X 20MM LCK -,SUP-72412720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.55,802.585,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE EVOS VOLAR 10H R STD 138MM -,SUP-72468210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8021.16,5614.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC VLP 64MM 3.5MM 4HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10840.85,7588.595,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC VLP 72MM 3.5MM 5HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8521.53,5965.071,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC VLP 47MM 3.5MM 3HL VAR ANG CONTR LCK SS -,SUP-7282-0303,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7945.19,5561.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC VLP 89MM 3.5MM 3HL VAR ANG CONTR LCK SS -,SUP-7282-0603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10840.85,7588.595,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC VLP 89MM 3.5MM 3HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10840.85,7588.595,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC VLP 62MM 3.5MM 5HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6051.52,4236.064,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC VLP 86MM 3.5MM 7HL 1.5-MM VAR ANG CONTR LCK -,SUP-7282-0807,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7163.02,5014.114,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC VLP 74MM 3.5MM 6HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6607.27,4625.089,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC VLP 86MM 3.5MM 7HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7163.02,5014.114,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC VLP 59MM 3.5MM 3HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-1003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7060.11,4942.077,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC VLP 71MM 3.5MM 4HL VAR ANG CONTR LCK SS LT -,SUP-7282-1004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7492.36,5244.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC VLP 83MM 3.5MM 5HL VAR ANG CONTR LCK SS LT -,SUP-7282-1005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7924.61,5547.227,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC VLP 107MM 3.5MM 7HL 2MM VAR ANG CONTR LCK -,SUP-7282-1007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8336.28,5835.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC VLP 131MM 3.5MM 9HL VAR ANG CONTR LCK SS LT -,SUP-7282-1009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8830.28,6181.196,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC VLP 59MM 3.5MM 3HL VAR ANG CONTR LCK SS -,SUP-7282-2003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6977.77,4884.439,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC VLP 71MM 3.5MM 4HL VAR ANG CONTR LCK SS -,SUP-7282-2004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7451.19,5215.833,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC VLP 83MM 3.5MM 5HL VAR ANG CONTR LCK SS RT -,SUP-7282-2005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7862.86,5504.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC VLP 131MM 3.5MM 9HL VAR ANG CONTR LCK SS RT -,SUP-7282-2009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8768.53,6137.971,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC VLP 62MM 3.5MM 5HL VAR ANG CONTR LCK SS -,SUP-7282-3005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2852.56,1996.792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC VLP 74MM 3.5MM 6HL VAR ANG CONTR LCK SS -,SUP-7282-3006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3223.02,2256.114,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC VLP 86MM 3.5MM 7HL VAR ANG CONTR LCK SS -,SUP-7282-3007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3570.33,2499.231,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK ORLMXLFCL 2.4X14MM STERNALOCK SD TI GOLD -,SUP-73-2414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK ORLMXLFCL 2.4X16MM STERNALOCK SD TI GOLD -,SUP-73-2416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK ORLMXLFCL 2.4X18MM STERNALOCK SD TI GOLD -,SUP-73-2418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,460.97,322.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK ORLMXLFCL 2.4X20MM STERNALOCK SD TI GOLD -,SUP-73-2420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,460.97,322.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE ORLMXLFCL 8HL STERNALOCK 4HL BX TI BLU -,SUP-73-2622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2835.76,1985.032,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE ORLMXLFCL 12HL STERNALOCK LDDR TI BLU -,SUP-73-2632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4401.63,3081.141,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE ORLMXLFCL 12HL STERNALOCK W LDDR TI BLU -,SUP-73-2634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4401.63,3081.141,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE STRNM 8HL JL SHP STERNALOCK BLU TI -,SUP-73-2645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4124.74,2887.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP JRNY II CR FEM OX NP LT SZ 6 -,SUP-74021166,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BASEPLATE TIBIA JOURNEY NP LT SZ 5 -,SUP-74022225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
INSERT JOURNEY II CR XLPE RT SZ 5-6 9MM -,SUP-74025661,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
MESH CAGE 30MM H -,SUP-74-1030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE NGAGE 16MM X 12MM CORPECT -,SUP-74-1216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE N-GAGE TI 16 X 50MM -,SUP-74-1650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TONIER HUMERAL NAIL DISTAL SCREW 4.3MM X 20MM -,SUP-7424520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TONIER HUMERAL NAIL DISTAL SCREW 4.3MM X 22MM -,SUP-7424522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAP END N-GAGE ZERO DEGREE -,SUP-74-5016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ENDCAP 2.5 DEG 10MM -,SUP-74-6010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAP NPLATE 7.5 DEGREE -,SUP-74-6012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NUT LCK F/C IN ADVANCED IMPL SYS -,SUP-7642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.87,143.409,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SET SCREW SPIN 6.35MM CD HORIZN LEGC SS -,SUP-7660000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,869.18,608.426,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X35MM FIREBIRD DBL LD THRD ST CANN TI GRN -,SUP-77-8535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X40MM FIREBIRD DBL LD THRD ST CANN TI GRN -,SUP-77-8540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X45MM FIREBIRD DBL LD THRD ST CANN GRN -,SUP-77-8545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X35MM FIREBIRD DBL LD THRD ST CANN TI GOLD -,SUP-77-8635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X40MM FIREBIRD DBL LD THRD ST CANN GOLD -,SUP-77-8640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X45MM FIREBIRD DBL LD THRD ST CANN TI GOLD -,SUP-77-8645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X50MM FIREBIRD DBL LD THRD ST CANN TI GOLD -,SUP-77-8650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.5MM COCR ROD- 240MM -,SUP-782.803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SET -,SUP-79-2003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CABLE SPIN 1.2MM TI DBL LOP INTGR CRIMPX2 STRL -,SUP-7925011S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1755.53,1228.871,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUBSTITUTE CA PHOS HAP 5ML PTTY CMNT INJ HYDR ST SYNTH -,SUP-79-43905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6318.89,4423.223,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CEMENT BN CA PHOS HAP 10ML HYDR ST -,SUP-79-43910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10521.16,7364.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUBSTITUTE CA PHOS HAP 15ML PTTY CMNT INJ HYDR ST SLF-SET -,SUP-79-43915,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15098.17,10568.719,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 2.5MM HEMICAP -,SUP-8007-1200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT SHT CRANFC 50X76MM 0.85MM MEDPOR EMBD TI MSH F/RECON -,SUP-81020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5562.27,3893.589,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
MESH TITAN SHEET MTB 76 X 50 X 1MM -,SUP-81027,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6586.43,4610.501,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT PE SHT EMBD TI MSH CRANFC 50X76MM -,SUP-81029,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6345.33,4441.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT SHT 76X100MM 1.5MM MEDPOR TITAN MAX F/CRANFC -,SUP-81040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10857.55,7600.285,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X12MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X14MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X16MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X18MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN SPIDER 20MM TMX -,SUP-814100003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERI 70.1MM 5HL COMPR TMX TBLR BLLT -,SUP-814123005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,980.28,686.196,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PE.R.I. 83.1MM 6HL COMP TIMEX 1/3 TBLR -,SUP-814123006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 95.5MM 7HL COMPR COMP TBLR BLLT-SHP -,SUP-814123007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERI 109.2MM 30MM COMPR TMX TBLR BLLT -,SUP-814123008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PE.R.I. 122.2MM 9HL NLCKG PERMTR RDC COMP TBLR -,SUP-814123009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 179.4MM 6HL LCK SHFT STRL -,SUP-814130106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN POLYAX 233.5MM 9HL LCK TMX STRL -,SUP-814131109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 287.6MM 12HL LCK SHFT -,SUP-814131112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN POLYAX 99.6MM 2HL PRCONT LCK TMX STRL -,SUP-814133002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13MMSHRTX180MM AFFIXUS TROCH ANTGRD AN-ROT 125DG ANG -,SUP-814313180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7282.7,5097.89,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 10.5MM AFFIXUS CANN LAG THRD ST TMX 80MM -,SUP-814510080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3265.42,2285.794,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 10.5MM AFFIXUS CANN LAG THRD ST TMX 105MM -,SUP-814510105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3265.42,2285.794,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13MMSHRTX180MM AFFIXUS TROCH ANTGRD AN-ROT 130DG ANG -,SUP-814513180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7282.7,5097.89,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X34MM CORT AFFIXUS VERSANAIL FT ST 3.5MM HX DRV SCKT -,SUP-814550034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X40MM CORT AFFIXUS VERSANAIL FT ST 3.5MM HX DRV SCKT -,SUP-814550040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X20MM CORT ALPS FT ST HX DRV TMX -,SUP-8150-36-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,134.21,93.947,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X10MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X12MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X14MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X20MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X22MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X24MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X28MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X30MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X34MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X38MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X42MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X44MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X46MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X48MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X50MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X55MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X60MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X65MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X26MM LCK SHFT CORT POLYAX FT POLYAX ST FA TMX NS -,SUP-815045526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X28MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X30MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X32MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X34MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X36MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X40MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X45MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X55MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X60MM LCK CANC POLYAX FT POLYAX ST FA BLLT SHP TIP TI -,SUP-815304060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X75MM LCK CANC POLYAX FT POLYAX ST FA BLLT SHP TIP TI -,SUP-815304075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8X70MM LCK DUAL CORE POLYAX FT POLYAX ST FA BLLT SHP -,SUP-815308070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8X75MM LCK DUAL CORE POLYAX FT POLYAX ST FA BLLT SHP -,SUP-815308075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X10MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X14MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X16MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X18MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X20MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X24MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X26MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X34MM CANC FT -,SUP-8153-41-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,278.62,195.034,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X44MM LAG CANC FT -,SUP-8153-41-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,198.39,138.873,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X50MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X55MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X30MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X45MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X60MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X65MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X70MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X75MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X65MM NLCKG CANC POLYAX P/T POLYAX TI NS -,SUP-815455065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X20MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X24MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X30MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X32MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X36MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X42MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X46MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LAG SCREW D10.5X85MM -,SUP-8160-0085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4287.05,3000.935,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X10MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X12MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X14MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X16MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X18MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORT LOCK 3.5 X 20MM NS -,SUP-816135020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X20MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW  CORT LOCK 3.5 X 22MM NS -,SUP-816135022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X22MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X24MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-8161-35-024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.5MM CORT LOCK SCREW 26MM NS -,SUP-816135026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X28MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.5MM CORTLOCK SCREW 30MM NS -,SUP-816135030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X30MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X32MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X34MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X36MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X38MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X40MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X42MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.5MM CORT LOCK SCREW 50MM NS -,SUP-816135050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORT LOCK 3.5 X 52MM NS -,SUP-816135052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 3.5 X 54 CORT NS -,SUP-816135054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X56MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X60MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X65MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X10MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X12MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X14MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X16MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X18MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X26MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X46MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X60MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X65MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X70MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 199MM 12HL PRCONT LCK COMPR TMX W ANTMC FST -,SUP-816200012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6798.89,4759.223,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 77MM 6HL THRD LCK TMX ANTMC NS BLU -,SUP-816204006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 92MM 7HL THRD LCK TMX ANTMC NS BLU -,SUP-816204007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 103MM 8HL THRD LCK TMX ANTMC NS BLU -,SUP-816204008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1526.54,1068.578,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 3.5MM 5HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1208.51,845.957,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 3.5MM 6HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1208.51,845.957,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS HCP 3.5MM 7HL HYBRID LCK COMPR TMX THN ANTMC -,SUP-816235007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 3.5MM 8HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1335.73,935.011,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 3.5MM 9HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1335.73,935.011,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 3.5MM 12HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 3HL PRCONT LCK TMX STD CRV ANTMC LT TIB -,SUP-816235703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5627.54,3939.278,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 5HL PRCONT LCK TMX STD CRV ANTMC -,SUP-816235705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5678.47,3974.929,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 3HL PRCONT LCK TMX STD CRV ANTMC RT TIB -,SUP-816235803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5627.54,3939.278,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X22MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X32MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X50MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X55MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X56MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X65MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER SPNL ANT CERV 13X15X6MM ALTA 5DG PEEK. -,SUP-8401-0506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN FX 1.3MM ABSB -,SUP-84-1052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1153.11,807.177,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER SPNL ANT CERV 13X15X6MM ALTA 5DG PEEK.. -,SUP-8411-0506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER ANT CERV 13X15X7MM ALTA 5DG PEEK -,SUP-8411-0507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COVER LOCKING SHORELINE 8-12 MM STANDALONE GRAY -,SUP-85-2008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TEMP FIX PIN -,SUP-85-2100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LONG NAIL LEFT 13X340MM X 125 DEG -,SUP-8525-3340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13986.87,9790.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5 X 12MM SELF DRILLING -,SUP-85-3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5 X 14MM SELF DRILLING -,SUP-85-3014SD,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAVITY SYNCHFIX SYNDESMOSIS #5 SUTURE -,SUP-86SYN005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4349.11,3044.377,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER TRNSFRMNL POST LMBR 9X23X6MM FORZA 0DG STR BLLT NOSE -,SUP-89-1006SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER TRNSFRMNL POST LMBR 9X23X8MM FORZA 0DG STR BLLT NOSE -,SUP-89-1008SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER TRNSFRMNL POST LMBR 9X27X7MM FORZA 0DG CRV BLLT NOSE -,SUP-89-1707SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER TRNSFRMNL POST LMBR 9X27X8MM FORZA 0DG CRV BLLT NOSE -,SUP-89-1708SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER TRNSFRMNL POST LMBR 9X27X9MM FORZA 0DG CRV BLLT NOSE -,SUP-89-1709SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT HUM TIS 9X27X7MM SZ0 FORZA STR -,SUP-89-3007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER TRNSFRMNL POST LMBR 9X27X10MM FORZA 0DG STR BLLT NOSE -,SUP-89-3010SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE CEMENT HYDROSET XT INJECTABLE HA -,SUP-897003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5310.31,3717.217,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CEMENT BONE HYDROSET XT HA 5CC -,SUP-897005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8517.71,5962.397,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CEMENT BONE HYDROSET XT HA 10CC -,SUP-897010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14367.75,10057.425,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
HYDROSET XT -,SUP-897015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20614.72,14430.304,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFT BONE BIO4 VIABLE BONE MATRIX 2.5CC -,SUP-90174424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS COMPRESSION 2.5MM X 28MM TI -,SUP-90176298,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN FIXATION IJS 2.5MM X 50MM AXIS -,SUP-90176511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1918.78,1343.146,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FREEFIX COMPRESSION 4.5MM X 18MM TI -,SUP-90176560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1009.46,706.622,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FREEFIX LOCKING 4.5MM X 14MM TI -,SUP-90176561,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FREEFIX LOCKING 4.5MM X 16MM TI -,SUP-90176562,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FREEFIX LOCKING 4.5MM X 18MM TI -,SUP-90176563,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FREEFIX LOCKING 4.5MM X 20MM TI -,SUP-90176564,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE MIDSHAFT HUMERUS NARROW 172MM -,SUP-90176565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5334.71,3734.297,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE FREEFIX 173MM ULNA MIDSHAFT -,SUP-90176755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE FREEFIX DISTAL HUMERUS 85MM ASSEMBLED LAT HELICAL LEFT -,SUP-90176827,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FREEFIX COMPRESSION 3.5MM X 12MM TI -,SUP-90176828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FREEFIX LOCKING 3.5MM X 10MM TI -,SUP-90176829,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.51,808.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL LOCKING 3.0MM X 34MM CANNULATED COCR -,SUP-90176830,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL LOCKING 3.0MM X 50MM CANNULATED COCR -,SUP-90176831,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL LOCKING 3.0MM X 60MM CANNULATED COCR -,SUP-90176832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL LOCKING 3.0MM X 65MM CANNULATED COCR -,SUP-90176833,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS COMPRESSION 2.5MM X 20MM TI -,SUP-90176987,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ASSEMBLED FREE FIX DISTAL HUM PLATE LAT DIRECT 85MM RIGHT -,SUP-90178750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ASSEMBLED FREE FIX DISTAL HUM PLATE MED DIRECT 75MM RIGHT -,SUP-90178751,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8504.98,5953.486,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FREEFIX COMPRESSION 3.5MM X 16MM TI -,SUP-90178752,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FREEFIX COMPRESSION 3.5MM X 28MM TI -,SUP-90178753,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FREEFIX LOCKING 3.5MM X 30MM TI -,SUP-90178754,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MULTI-THREAD LOCKING 2.7MM X 16MM TI -,SUP-90178756,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MULTI-THREAD LOCKING 2.7MM X 24MM TI -,SUP-90178757,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ASSEMBLED FREEFIX DIST HUM PLATE LAT DIRECT 85MM LEFT -,SUP-90178787,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DISTAL TROCHLEA COMPRESSION SCREW 3.5MM X 40MM TI -,SUP-90178788,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MULTI-THREAD LOCKING 2.7MM X 26MM TI -,SUP-90178789,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MULTI-THREAD LOCKING 2.7MM X 42MM TI -,SUP-90178790,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
HIGH COMPRESSION LOCKING PEG 2.7MM X 24MM TI -,SUP-90178898,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DRILL CANNULATED 3.7MM X 30MM -,SUP-90178926,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ASSEMBLY DOUBLE IJS -,SUP-90178927,CDM,C1713,HCPCS,278,RC,,,outpatient,,,27394.51,19176.157,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
IJS-E AXIS PIN FEMALE 30MM COCR -,SUP-90178928,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
THREADED HAND NAIL 4.5MM X 45MM TI -,SUP-90178982,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4258.41,2980.887,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
KT SPINAL 4.5MMX30-40MM PEDICAL COMPR TRANSFACET W/SCREWX2 -,SUP-9045-02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9549,6684.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT ELB JNT TOGGLELOC -,SUP-909854,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4344.34,3041.038,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PK VALVE F/INFECT FLD WST MGMT ULTRA QUAD CART -,SUP-91530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CRNL 1.5X4MM STRDRV RCESS SD TI -,SUP-92-15904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,413.82,289.674,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CRNL 1.5X5MM STRDRV RCESS SD TI -,SUP-92-15905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,82.76,57.932,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CRNL 1.5X5MM STRDRV RCESS SD TI -,SUP-92-15905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,413.82,289.674,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE INSERT LOCKING 2.7MM -,SUP-940372,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN FX STNMN 2.8MMX9IN SMTH STRL F /THE VUEPASS PORTAL -,SUP-94152,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2711.63,1898.141,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PFC SIGMA DISTAL AUG COM CEMT SIZE 5 X 4MM RIGHT -,SUP-960901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PFC SIGMA DISTAL AUG COM CEMT SIZE 5 X 8MM RIGHT -,SUP-960903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIBAL INSERT ROTATING PLATFORM (STAB) 5- 10MM -,SUP-962151,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
INSERT TIBIAL ROTATING PLATFORM SZ 2.5MM X 20MM TCS -,SUP-96-2335,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
5.0MM VARIABLE ANGLE EXTENSION ARM -,SUP-991088S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2160.48,1512.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAP TOT JNT SM PLST -,SUP-9911186002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1043.01,730.107,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT HUM TIS CHP ALLOGRAFT CANC 15ML -,SUP-A00035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.87,918.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TEMPORARY TENSION BOLT -,SUP-A-2791.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.07,775.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DRILL BIT AO FIXATION 1.2MM X 25MM X L81MM -,SUP-A-3230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1173.53,821.471,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COUNTERSINK M 1.2/1.5 -,SUP-A-3310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1607.11,1124.977,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.0 CCS COUNTERSINK- AO -,SUP-A-3938,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1978.15,1384.705,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
HOOK PLATE1.5 2 HOLE 2 HOOKS T0.6 -,SUP-A-4200.40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2365.61,1655.927,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
HOOK PLATE 4 HOLE 4 HOOKS T0.6 -,SUP-A-4200.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2632.76,1842.932,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT HUM TIS STRIP 1X20CMX8MM H GRFTN MATRIX -,SUP-A42280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8571.82,6000.274,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M FIX 4 HOLE STRAIGHT -,SUP-A-4300.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2106.42,1474.494,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M FIX 6 HOLE STRAIGHT -,SUP-A-4300.03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.98,1080.086,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M FIX 16 H STRAIGHT -,SUP-A-4300.04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2571.75,1800.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M FIX 16 H CURVED -,SUP-A-4300.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2092.11,1464.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M FIX16 HOLE OFF SET -,SUP-A-4300.06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2700.17,1890.119,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS 10X27MM F/1.2MM/1.5MM FX SCR HLX3X5 TI T-SHP -,SUP-A-4300.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1852.52,1296.764,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M FIX 2/3 H RIGHT L -,SUP-A-4300.21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1852.52,1296.764,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M GD FIX 2X2 RECT LEA -,SUP-A-4300.51,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2632.23,1842.561,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE FIXATION GOLD GRID 2 X 2-HOLE TAPAZOID -,SUP-A-4300.54,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2632.23,1842.561,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS 15MM F/1.2MM/1.5MM SCR HLX3X2 0.6MM GRID FX -,SUP-A-4300.55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2074.62,1452.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN HLX4X2 FA MED L-SHP GRID -,SUP-A-4300.64,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2156.24,1509.368,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRID 5 X 2 HOLE TRAPAZOID -,SUP-A-4300.66,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.52,1855.364,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M CONDYLE 5 H PIN L -,SUP-A-4340.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2542.12,1779.484,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS F/1.2-1.5MM SCR 1HL HOOKX2 COMPR TI TRILOCK -,SUP-A-4340.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3184.74,2229.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE APTUS TRILOCK PI 4 HOLE STRAIGHT IO 8 -,SUP-A-4350.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3757.14,2629.998,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M TRILOCK STR 4 HOLE -,SUP-A-4350.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2752.69,1926.883,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TRILOCK PI 3/5 HOLE T -,SUP-A-4350.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4001.57,2801.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS 11X25MM 0.8MM 8HL HND TRILOCK TI T-SHP -,SUP-A-4350.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4001.57,2801.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS 9X23MM F/1.2MM/1.5MM SCR FX/ROT 6HL 0.8MM VAR -,SUP-A-4350.23,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.67,2999.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TRILOCK ROTATING 3 HOLE 1.2/1.5 -,SUP-A-4350.23,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4080.82,2856.574,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M TRILOCK T 5/4 HL -,SUP-A-4350.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4152.43,2906.701,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING PLATE 1.5 BLUE -,SUP-A-4350.56,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3415.8,2391.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M TRILOCK GRID HL 4 X 2 -,SUP-A-4350.62,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4381.08,3066.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 1.2/1.5 TRILOCK GRID 5X2H TRAPZ T 0.8 -,SUP-A-4350.66,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4471.05,3129.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE LOCKING TRILOCK BLUE 1.5 TRAPEZ 10.8 -,SUP-A-4350.80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3868.85,2708.195,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT HUM TIS GRFTN DBM OTHBLND -,SUP-A44135,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5713.91,3999.737,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS 55MM F/2MM/2.3MM SCR 8HL COMPR TI STR TRILOCK -,SUP-A-4645.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2466.32,1726.424,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS 35MM F/2MM/2.3MM SCR HLX2X4 COMPR TI T-SHP -,SUP-A-4645.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2428.06,1699.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M COMP L 2/8 HOLE RIGHT -,SUP-A-4645.23,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2405.14,1683.598,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE LOCKING 1.0MM THCK 2./2.3 STRAIGHT BLUE -,SUP-A-4650.03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7191.46,5034.022,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING PLATE 2.0/2.3 BLUE T-2/4 HOLE -,SUP-A-4650.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3100.24,2170.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TRILOCK 3/4 HOLE -,SUP-A-4650.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3100.24,2170.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
"PLATE M LK ""Y"" 2/5 H -",SUP-A-4650.13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3199.53,2239.671,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE L 2/4 HOLE RIGHT -,SUP-A-4650.21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3601.51,2521.057,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS 45MM F/2MM/2.3MM SCR 8HL 1MM GRID TI -,SUP-A-4650.67,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3910.86,2737.602,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BLUE LOCKING 2.0 /2.3 4 HOLE STRAIGHT -,SUP-A-4655.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4610.73,3227.511,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE LOCKING T1.3MM 4 HOLE STRAIGHT 2.0/2.3 -,SUP-A-4655.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3973.88,2781.716,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BLUE 2.0 / 2.23 5 HOLE STRAIGHT -,SUP-A-4655.02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4308.93,3016.251,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS 32MM F/2MM/2.3MM SCR 5HL 1.3MM GRID TI STR -,SUP-A-4655.02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4294.08,3005.856,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TRILOCK 8 HOLE STRAIGHT 2 X 3 -,SUP-A-4655.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4971,3479.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TRILOCK STRAIGHT 8 HOLE 2.0/2.3 -,SUP-A-4655.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4969.72,3478.804,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TRILOCK 2.0/2.3 T 2/4 HOLE T1.3 -,SUP-A-4655.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5024.05,3516.835,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M TRILOCK T 2/4 HL -,SUP-A-4655.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5024.05,3516.835,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS 56MM 2.0/2.3MM 10HL 1.3MM GRID TI T-SHP -,SUP-A-4655.16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5311.37,3717.959,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.0/2.3 TRILOCK PLATE 2/4 HOLE LEFT -,SUP-A-4655.20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4600.23,3220.161,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M TRILOCK L RT 2/4 HL -,SUP-A-4655.21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5024.05,3516.835,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M TRILOCK L LT 2/8 HL -,SUP-A-4655.22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4539.38,3177.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE ROTATION 3/3 HOLE T 1.3 -,SUP-A-4655.24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4738.2,3316.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TRILOCK GRIDPI 4 X2H TRAPEZ -,SUP-A-4655.62,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5438.26,3806.782,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TRILOCK GRIDPI 5 X2 H TRAPEZ -,SUP-A-4655.66,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5679.32,3975.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2.0 TRILOCK RADIAL HEAD RIM -,SUP-A-4656.68,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7432.09,5202.463,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.0 TRILOCK RADIAL HEAD BUTTRESS -,SUP-A-4656.69,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7017.88,4912.516,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TRILOCK 4CF 2 X 2.3 -,SUP-A-4660.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7727.9,5409.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M BABYFOOT LONG RT -,SUP-A-4750.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5479,3835.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2.5 ADAPT II TRILOCK DISTRAD L 10 H NARROW -,SUP-A-4750.101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5810.88,4067.616,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M ADAPTIVE II NARROW RT -,SUP-A-4750.102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7626.89,5338.823,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DISTAL RADIUS LOCKING PLATE RIGHT 12 NARROW-LONG -,SUP-A-4750.104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2.5 ADAPTIVE II TRILOCK DISTRAD NARR LONG -,SUP-A-4750.104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8591.98,6014.386,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE ADAPTIVE 2.5 X 12HL NRW LNG -,SUP-A-4750.104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6904.56,4833.192,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M ADAPTIVE II LT -,SUP-A-4750.105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5810.88,4067.616,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M ADAPTIVE II LT -,SUP-A-4750.105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7626.89,5338.823,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE STD WATERSHED RIGHT ADAP -,SUP-A-4750.106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8008.43,5605.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ADAPTIVE II TRILOCK 2.5 DISTRAD. PLATE 13 HOLE -,SUP-A-4750.107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DISTAL RADIUS LOCKING PLATE RIGHT 13 LONG -,SUP-A-4750.108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8591.98,6014.386,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M ADAPTIVE II LONG RIGHT -,SUP-A-4750.108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS 28X52MM 2.5MM 14HL TI TRILOCK TECH -,SUP-A-4750.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2.5 ADAPTIVE II DISTAL RADIUS LEFT WIDE LONG -,SUP-A-4750.111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2.5 ADAPTIVE II TRILOCK DIST RAD 15H WIDE LONG -,SUP-A-4750.112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6234.44,4364.108,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DISTAL RADIUS CORRECTION PLATE WIDE -,SUP-A-4750.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M FPL LT -,SUP-A-4750.123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8106.46,5674.522,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE MEDARTIS 14HL -,SUP-A-4750.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6904.56,4833.192,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE ADAPTIVE 2.5 X 15 HOLE -,SUP-A-4750.15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7057.35,4940.145,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE ADAPTIVE 2.5 X 16 HOLE -,SUP-A-4750.16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7057.35,4940.145,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS 22X62MM 2.5MM 12HL 1.6MM TI LNG NRW TRILOCK -,SUP-A-4750.19,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2.5TRILOCK WR SPANNINGPI DOR. STRAIGHT 11 HOLE TL6-3.4 -,SUP-A-4750.193S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13227.56,9259.292,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS 23X44MM 2.5MM 10HL 1.6MM TI NRW TRILOCK TECH -,SUP-A-4750.31,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS 23X44MM 2.5MM 10HL TI SHRT NRW TRILOCK TECH -,SUP-A-4750.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS 30X64MM F/2.5MM FX 1.6MM LCK TI FRM -,SUP-A-4750.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5815.98,4071.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS 30X64MM F/2.5 TRILOCK SYS 1.6MM LCK TI -,SUP-A-4750.42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5815.98,4071.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS 49MM 2.5MM 6HL TI STR TRILOCK TECH -,SUP-A-4750.54,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4373.94,3061.758,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS 23X54MM 2.5MM 13HL TI TRILOCK TECH RT WRST -,SUP-A-4750.62,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS 23X68MM 2.5MM 15HL TI LNG TRILOCK TECH LT -,SUP-A-4750.64,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6307.43,4415.201,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER BICONCAVE 2.5/2.8 -,SUP-A-4750.70/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,340.18,238.126,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS 46MM 2.5MM 7HL VAR ANG CONTR TI Y -,SUP-A-4750.91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4323.36,3026.352,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS 67MM 2.5MM 10HL 1.6MM VAR ANG CONTR LCK TI Y -,SUP-A-4750.92,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4557.21,3190.047,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.5 TRILOCK ULNA SHORTENING PLATE -,SUP-A-4750.95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9650.43,6755.301,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.5 TRILOCK ULNA SHORTENING PLATE 10HL -,SUP-A-4750.95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9650.43,6755.301,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2.5 TRILOCK WRIST FUSION PI SHORT BEND -,SUP-A-4760.02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11734.57,8214.199,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS 2.5MM 15HL LCK TI STR MULDIR TRILOCK -,SUP-A-4760.03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9292.66,6504.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE STRAIGHT 2.5 TRILOCK TOTAL WRIST FUS -,SUP-A-4760.04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11159.79,7811.853,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.5 TRILOCK TOTAL WRIST FUS PL LONG BEND 16HL T1.8-2.6 DRSL -,SUP-A-4760.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11734.57,8214.199,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.5 TRILOCK TOTAL WRIST FUS PI SHORT BEND 16 HOLE T1.8-2.6 D -,SUP-A-4760.06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11734.57,8214.199,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2.5 TRILOCK WRIST FUSION SHORT BEND 12 HOLE -,SUP-A-4760.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11462.03,8023.421,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TENSION 2.8 TRILOCK 6 HOLE OLECRANON -,SUP-A-4856.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5373.33,3761.331,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TRILOCK T1-6 OLECRANON 7H RIGHT -,SUP-A-4856.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5556.24,3889.368,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2.8 TRILOC OLECRANON 7H LEFT -,SUP-A-4856.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5557.94,3890.558,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TRILOCK OLECRANON 2.8 7H STRAIGHT -,SUP-A-4856.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5306.27,3714.389,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TRILOCK PLATE 2.8 - 10H- RIGHT -,SUP-A-4856.13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5674.23,3971.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TRILOCK PLATE 10H STRAIGHT -,SUP-A-4856.15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5576.62,3903.634,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.8 TRILOCK DIST HUM PL MEDIAL 17H L -,SUP-A-4856.29,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10465.7,7325.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2.8 TRILOCK DIST HUM MEDIAL 12H R -,SUP-A-4856.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9692.45,6784.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TriLock Dist. Hum Pl. Medial- 10h- l -,SUP-A-4856.33,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9291.81,6504.267,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.8 TRILOCK DIST HUM PL LATERAL 18H L -,SUP-A-4856.39,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9432.88,6603.016,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2.8 TRILCK DIST HUM MEDIAL 10H LFT -,SUP-A-4856.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9692.45,6784.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M TRILOCK GRID H 2X2 -,SUP-A-4856.44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9291.81,6504.267,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 10HL 2.8MM TRILOCK TECH RT OLCRN -,SUP-A-4856-13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4323.36,3026.352,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 10HL 2.8MM TRILOCK TECH LT OLCRN -,SUP-A-4856-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5674.23,3971.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
K-WIRES LNCET 150MM 1.8MM -,SUP-A-5042.51/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,247.99,173.593,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
1.1 K-WIRE- TROCAR- 2-END. 100MM -,SUP-A-5043.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,297.59,208.313,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.2X4MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.2X5MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.2X6MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.2X7MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.2X8MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.2X9MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.2X10MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.2X11MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.2X12MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.2X14MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW M CORTEX 1.2 X 16MM -,SUP-A-5100.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X4MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X5MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X6MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW M CORTEX 1.5 X 07 -,SUP-A-5200.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW M CORTEX 1.5 X 07 -,SUP-A-5200.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW M CORTEX 1.5 X 08 -,SUP-A-5200.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X9MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X10MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X11MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X12MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X13MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X14MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X15MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X15MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI. -,SUP-A-5200.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTEX 1.5 X 16 MEDARTIS -,SUP-A-5200.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTEX 1.5 X 17MM CORTICAL HD4 -,SUP-A-5200.17/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X18MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X19MM CORT APTUS DBL THRD ST/RET HEXDRV 4 TI GOLD -,SUP-A-5200.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW M CORTEX 1.5 X 21 -,SUP-A-5200.21/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 1.5 22MM HD4 -,SUP-A-5200.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW M CORTEX 1.5 X 24 -,SUP-A-5200.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE APTUS 1.5 SPEEDTIP 10MM HD4 PK/1 -,SUP-A-5210.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1076.56,753.592,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 1.5MM SPEEDTIP 14MM HD4 PK/1 -,SUP-A-5210.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1076.56,753.592,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X4MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X5MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X6MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5 X 7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X8MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X9MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X10MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X11MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X13MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 1.5 X 16 -,SUP-A-5250.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.8,742.56,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE CANNULATED COMPRESSION 10/4MM -,SUP-A-5281.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.7 CCS LONG THREAD 15/06MM 1/PKG -,SUP-A-5281.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.7 CCS LONG THREAD 16/07MM 1/PKG -,SUP-A-5281.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
1.7 CCS LONG THREAD 18/07MM -,SUP-A-5281.18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.7CCS LONG THREAD 20/08MM -,SUP-A-5281.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.7 CCS FULLY THREADED 10MM 1/PKG -,SUP-A-5282.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.7CCS FULLY THREADED 13MM -,SUP-A-5282.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.7CCS FULLY THREADED 14MM -,SUP-A-5282.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CORTEX BONE SCREWS 1.8MM 06MM LENGTH GOLD -,SUP-A-5300.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,884,618.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW M CORTEX 1.8 X 10 -,SUP-A-5300.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,654.69,458.283,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X4MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X5MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X6MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5400.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X8MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X9MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5400.09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X10MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X11MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X13MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X14MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5400.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X15MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.0 CORTICAL SCREW 16MM -,SUP-A-5400.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.0 X 17MM MEDARTIS -,SUP-A-5400.17/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 2.0 X 18MM HD6 -,SUP-A-5400.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW APTUS TI CORTEX BONE GOLD 2.0 X 19MM -,SUP-A-5400.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X20MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.0 CORTICAL SCREW 24MM -,SUP-A-5400.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X6MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5450.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X8MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5450.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X9MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X10MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X11MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,295.02,206.514,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X12MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X13MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X14MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TRILOCK 2.0 X 14MM HD6 -,SUP-A-5450.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X16MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.0 TRILOCK SCREW 18MM -,SUP-A-5450.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.0 TRILOCK SCREW 20MM -,SUP-A-5450.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.0 TRILOCK 20MM HD6 -,SUP-A-5450.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X5MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X6MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X7MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X8MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X9MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X10MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X11MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X12MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X13MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X14MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X18MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X19MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW M CORTEX 2.3 X 20 -,SUP-A-5500.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW M CORTEX 2.3 X 18 -,SUP-A-5500.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORT MEDARTIS 2.5 8MM -,SUP-A-5700.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X10MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORT MEDARTIS 2.5 11MM -,SUP-A-5700.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X12MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X13MM NLCKG CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5700.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORT MEDARTIS 2.5 14MM -,SUP-A-5700.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW M CORT 2.5 X 15 -,SUP-A-5700.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW 16 MM BLUE 2.5MM -,SUP-A-5700.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NON LOCKING BONE SCREW 16MM -,SUP-A-5700.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORT MEDARTIS 2.5 16MM -,SUP-A-5700.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X18MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW 18MM BLUE 2.5MM -,SUP-A-5700.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW 20MM BLUE 2.5 -,SUP-A-5700.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X20MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X22MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.85,662.095,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X24MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X30MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,623.76,436.632,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CORTEX GOLD NON LCK 2.5 32MM  SCREW -,SUP-A-5700.32/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW M CORT 2.5 X 34MM -,SUP-A-5700.34/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X20MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5720.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X22MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5720.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X10MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TRILOCK SCREW 2.5 12MM -,SUP-A-5750.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X14MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X16MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X18MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCK MEDARTIS 2.5 18MM -,SUP-A-5750.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X24MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X26MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BLUE 2.5 X 28 LOCKING -,SUP-A-5750.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW M LOCKING 2.5 X 30MM -,SUP-A-5750.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X32MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.8,742.56,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.5 TRILOCK SCREW 34MM -,SUP-A-5750.34/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5 TRILOCK EXPRESS 14MM HD7 PK/1 -,SUP-A-5755.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1158.25,810.775,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SILVER LOCKING SCREW 18MM -,SUP-A-5755.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1158.25,810.775,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SILVER LOCKING SCREW 20MM -,SUP-A-5755.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1158.25,810.775,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE APTUS 2.2 CANN COMP 10MM HD7 DISTAL THREAD 4MM -,SUP-A-5780.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE APTUS 2.2 CANN COMP 11MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE APTUS 2.2 CANN COMP 14MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE APTUS 2.2 CANN COMP 15MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE APTUS 2.2 CANN COMP 16MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANULATED COPR 17MM -,SUP-A-5780.17/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE APTUS 2.2 CANN COMP 19MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.2 CANNULATED SCREW COMPRESSION 20MM -,SUP-A-5780.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.2 CANNULATED COMPR 26MM DISTAL THREAD 6MM -,SUP-A-5780.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANULATED COPR 27MM -,SUP-A-5780.27/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.2 CANNULATED COMPR 30MM DISTAL THREAD 6MM -,SUP-A-5780.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MEDART CANN CMPR 2.2 X 22 -,SUP-A-5781.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MEDART CANN CMPR 2.2 X 24MM -,SUP-A-5781.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED 2.2 COMPRESSION LONG THREAD 26MM -,SUP-A-5781.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW COMPR CANNULATED 2.2 X 28MM -,SUP-A-5781.28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW COMPR CANNULATED 2.2 X 30MM -,SUP-A-5781.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MEDART CANN COMPR 2.2 X 32 -,SUP-A-5781.32/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW COMPR CANNULATED 2.2 X 36MM -,SUP-A-5781.36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW COMPR CANNULATED 2.2 X 38MM -,SUP-A-5781.38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.8 CORTICAL SCREW 10MM HD7 -,SUP-A-5800.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.8 CORTICAL SCREW 12MM HD7 -,SUP-A-5800.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.8X16MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.8X18MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.8X20MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.8X22MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.8X24MM CORT -,SUP-A-5800.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,654.69,458.283,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.8 CORTICAL SCREW 26MM HD7 -,SUP-A-5800.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.8 CORTICAL SCREW 28MM -,SUP-A-5800.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.8 CORTICAL SCREW 30MM HD7 -,SUP-A-5800.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.8 CORTICAL SCREW 32MM HD7 -,SUP-A-5800.32/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.8  CORTICAL SCREW 38MM- HD7 -,SUP-A-5800.38/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.8 GOLD CORTEX BONE 40MM HD7 -,SUP-A-5800.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.8X45MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.45/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORITCAL 50MM HD7 2.8 -,SUP-A-5800.50/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.8X55MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.55/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LAG 2.8 X 40 HD7 -,SUP-A-5830.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,654.69,458.283,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.8X14MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TRILOCK BLUE 2.8 LOCKING16MM HD7 -,SUP-A-5850.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.8X18MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.8X20MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.8X22MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TRILOCK 2.8 X 24MM HD7 -,SUP-A-5850.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TRILOCK BLUE 2.8 LOCKING 26MM HD7 -,SUP-A-5850.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.8 TRILOCK  SCREW 28MM HD7 -,SUP-A-5850.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TRILOCK BLUE 2.8 LOCKING 30MM HD7 -,SUP-A-5850.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.8 TRILOCK SCREW 32MM- HD7 -,SUP-A-5850.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.8 TRILOCK SCREW 36MM- HD7 -,SUP-A-5850.36/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.8 TRILOCK SCREW 38MM HD7 -,SUP-A-5850.38/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.8 TRILOCK SCREW 40MM HD7 -,SUP-A-5850.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.8 TRILOCK SCREW 50MM- HD7 -,SUP-A-5850.50/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.8 TRILOCK SCREW 55MM- HD7 -,SUP-A-5850.55/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.8 TRILCK 55MM -,SUP-A-5850.55/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.8,742.56,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.8 TRILOCK SCREW 70MM HD7 -,SUP-A-5850.70/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED SPEED TIP 3MM X 15MM -,SUP-A-5880.15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2326.39,1628.473,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANN SPEED TIP 3MM X 20MM -,SUP-A-5880.20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2326.87,1628.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X24MM CANN SPEEDTIP CCS S/T SD HEXDRIVE 10 TI -,SUP-A-5880.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X26MM CANN SPEEDTIP CCS S/T SD HEXDRIVE 10 TI -,SUP-A-5880.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.0 CANN COMPR 40 -,SUP-A-5880.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X26MM CANN SPEEDTIP CCS LNG THRD SD HEXDRIVE 10 TI -,SUP-A-5881.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.0 CANNULATED COMPRSCREW28MM-HD10- DISTAL THREAD 9MM -,SUP-A-5881.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2326.39,1628.473,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3 X 30 CANN COMPR DISTAL THREAD -,SUP-A-5881.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3 X 36 CANN COMPR DISTAL THREAD -,SUP-A-5881.36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EXTFIX 6/5MM DIA 100/ 40MM CORT TAPR DYNFX THRD -,SUP-A6010040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EXTFIX 6MM/5X150MM CORT TAPR DYNFX VISION 50MM THRD -,SUP-A6015050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EXTFIX 6MM/5X180MM CORT TAPR DYNFX VISION 50MM THRD -,SUP-A6018050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANULATED COMPR 44MM -,SUP-A-8112.44/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1707.29,1195.103,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
"PLATE M LK ""L"" 2/4 H LEFT -",SUP-AÂ€4650.20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3601.51,2521.057,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SYS BONE CMNT BIOCARTILAGE 3ML STRL -,SUP-ABS-1000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BIOCARTILAGE KIT SMALL JOINT -,SUP-ABS-1000-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FUNNEL BNCMNT BIOCARTILAGE -,SUP-ABS-1003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,163.38,114.366,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BIOCARTILAGE 1CC -,SUP-ABS-1010-BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4678.52,3274.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TACKER ABSORBATACK 5MM 30X -,SUP-ABSTACK30X,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2266.08,1586.256,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WAVEFORM C INTERBODY 16 X 14 X 7MM 7 DEG 3D -,SUP-AC4-264077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE WAVEFORM C INTERBODY 16 X 14X 8MM 7 DEGREE 3D -,SUP-AC4-264087,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 24MM COMPR HDLS ACUTRAK ACUTWIST FLLY W THRD PTCH -,SUP-AI-0024-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 26MM COMPR HDLS ACUTRAK ACUTWIST FLLY W THRD PTCH -,SUP-AI-0026-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 28MM COMPR HDLS ACUTRAK ACUTWIST FLLY W THRD PTCH -,SUP-AI-0028-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4-5X25MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0025-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4-5X30MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0030-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4-5X35MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0035-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4-5X40MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0040-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 45MM ACUTRAK 4/5 -,SUP-AM-0045-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5-6.5X50MM CANN HDLS ACUTRAK + 3MM HX DRV TI ALY STRL -,SUP-AP-0050-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2410.87,1687.609,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5-6.5X60MM CANN HDLS ACUTRAK + 3MM HX DRV TI ALY STRL -,SUP-AP-0060-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2410.87,1687.609,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE PLATE 10MM -,SUP-AP1-110010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 12MM -,SUP-AP1-110012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE 13MM PLATE -,SUP-AP1-110013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE ADMIRAL 14MM PLATE -,SUP-AP1-110014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE ANTERIOR CERVICAL PLATE 16MM -,SUP-AP1-110016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 30MM -,SUP-AP1-200030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ADMIRAL PLATE 36MM -,SUP-AP1-200036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE PLATE 28MM -,SUP-AP1-210028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE ADMIRAL 32MM SEASPINE -,SUP-AP1-210032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE ADMIRAL 36MM SPINE CERVICAL 2 LEVEL SEASPINE -,SUP-AP1-210036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE PLATE 54MM -,SUP-AP1-310054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ST 4 X 14 -,SUP-AP1-604014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ADMIRAL SCREW 4X14 -,SUP-AP1-614014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE SCREW 4 X 10 -,SUP-AP1-704010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 12MM -,SUP-AP1-704012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ADMIRA 4 X 14MM SPINE SELF TAP VARIABLE ANGLE SEASPINE -,SUP-AP1-704014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ADMIRAL 4.3 X 12MM SEASPINE -,SUP-AP1-704312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ADMIRAL 4.3 X 14MM SPINE SELF TAP VARIABLE ANGLE -,SUP-AP1-704314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ADMIRAL 4 X 12MM SEASPINE -,SUP-AP1-714012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE SCREW 4MM X 14MM SD -,SUP-AP1-714014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ADMIRAL 4 X 16MM SEASPINE -,SUP-AP1-714016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.0 X 14 FIX SCREW -,SUP-AP1-724014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6-7.5X70MM CANN HDLS ACUTRAK 6/7 4MM HX DRV TI ALY -,SUP-AP-6770-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6-7.5X75MM CANN HDLS ACUTRACK 6/7 4MM HX DRV TI ALY -,SUP-AP-6775-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PROXIMAL ULNA 73MM LEFT -,SUP-APL-PUP-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5428.08,3799.656,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PROXIMAL ULNA 108MM / LEFT -,SUP-APL-PUP-6HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6175.02,4322.514,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PROXIMAL ULNA 108MM / RIGHT -,SUP-APL-PUP-6HR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6175.02,4322.514,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BONE 151MM ULNA LEFT PROXIMAL -,SUP-APL-PUP-9HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6531.52,4572.064,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ARSCP 1.1MM BLNT TIP F/BIOINTF SCR -,SUP-AR-1249,CDM,C1713,HCPCS,278,RC,,,outpatient,,,122.54,85.778,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ARSCP 2.4MM DRILL TIP F/BIOINTF SCR -,SUP-AR-1250L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DRILL SYSTEM FIXATION TIGHTROPE BTBT IB W/FLIPCUTTER III -,SUP-AR-1288BTBIB-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4816.94,3371.858,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DRILL TIGHTROPE RT IB W/FLIPCUTTER III -,SUP-AR-1288RTIB-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4477.42,3134.194,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FIBERTAG TIGHTROPE II IMPLANT W/ FLIPCUTTER III DRILL -,SUP-AR-1288RTT2-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FIBER TAG TIGHTROPE WITH FLIPCUTTER III -,SUP-AR-1288RTT-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ARSCP 2.4MM SUT EYE -,SUP-AR-1297L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,396.78,277.746,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X10MM CORT FT SLD TI STRL F/OSTMY SYS -,SUP-AR-13120T-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X10MM CANN LAG CORT P/T ST SLD TI F/OSTMY SYS -,SUP-AR-13120T-10C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X12MM CANN LAG CORT P/T ST SLD TI F/OSTMY SYS -,SUP-AR-13120T-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X14MM CANN LAG CORT P/T ST SLD TI F/OSTMY SYS -,SUP-AR-13120T-14C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X16MM CANN LAG CORT P/T ST SLD TI STRL F/OSTMY SYS -,SUP-AR-13120T-16C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NANO CORKSCREW FT TI W3-0 FW -,SUP-AR-1317FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUTURE MICRO CORKSCREW FT 2.2 X 4MM -,SUP-AR-1318FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 12.5MM OPN WDG SS -,SUP-AR-13200-12.5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 12.5MM TI SLP STRL -,SUP-AR-13200ST-12.5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUTURE TAK MICRO 2.4 X 6.5 BIOCOMPOSITE -,SUP-AR-1320BCNF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BB-TAK THREADED -,SUP-AR-13226T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUTURETAPE S-TAK ASSY 3.0 SINGLE LOADED -,SUP-AR-1322BCST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUTURETAPE S-TAK ASSY 3.0 SINGLE LOADED -,SUP-AR-1322BCST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X45MM CANC HTO PLATE TI F/OSTMY SYS -,SUP-AR-13280-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X50MM CANC HTO PLATE TI F/OSTMY SYS -,SUP-AR-13280-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ARSCP 2.4MM F/OSTM -,SUP-AR-13303-2.4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,215.9,151.13,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN SURG 3MM -,SUP-AR-13303-3.0,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUBSTITUTE B TCP OPN WDG OSFERION 7MM 30MM -,SUP-AR-13370-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUBSTITUTE B TCP WDG OSFERION 15X35MM -,SUP-AR-13370-4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X40MM CORT HTO PLATE TI F/OSTMY SYS -,SUP-AR-13380-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X46MM CORT HTO PLATE TI F/OSTMY SYS -,SUP-AR-13380-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT IBALANCE 6.5X24MM HI TIB OPN PEEK -,SUP-AR-13401-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT IBALANCE 6.5X28MM HI TIB OPN PEEK -,SUP-AR-13401-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SFT TIS CORT 4.5X38MM IBALANCE HTO -,SUP-AR-13402-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT IBALANCE 4.5X40MM HI TIB OPN PEEK -,SUP-AR-13402-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT IBALANCE HTO 4.5X48MM HI TIB OPN NABSB PEEK -,SUP-AR-13402-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN ARSCP FX 5X40MM PLLA FEM ABSB TRNSFX II F/ACL RECON -,SUP-AR-1351B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN ARSCP FX 5X50MM PLLA FEM ABSB TRNSFX II F/ACL RECON -,SUP-AR-1351LB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN 6X23MM RND HEAD STP TAPR BIOCMPS FEM DBL -,SUP-AR-1360C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SILK 7 X 20 NON SHEATHED -,SUP-AR-1370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.64,822.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN 7X23MM ABSB SHTH RND HEAD STP TAPR BIOCMPS -,SUP-AR-1370B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7X23 BIOCOMPOSITE -,SUP-AR-1370C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN TIGHTROPE RT 7X28MM FT ABSB RND HEAD STP -,SUP-AR-1370TC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN CONTR LOCK HTO 12.5MM A/P SLP WDG -,SUP-AR-13725-12.5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8X23MM BIO -,SUP-AR-1380C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN 8X28MM FT ABSB TAPR PLLA TIB KN STRL -,SUP-AR-1380TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8 X 25 -,SUP-AR-1381,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SILK 9 X 2O NON SHEATHED -,SUP-AR-1390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.64,822.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN TIGHTROPE RT 9X23MM SHTH ABSB HEX HEAD PLLA -,SUP-AR-1390B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 9 X 23 BIOCOMPOSITE -,SUP-AR-1390C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN 9X28MM FT ABSB TAPR BIOCMPS PLLA TIB KN -,SUP-AR-1390TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SILK 9 X 25 NON SHEATHED -,SUP-AR-1391,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.64,822.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN SUTUREPLATE 90MM 3HL POLYAX TI STRL -,SUP-AR-14003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN 10X23MM ABSB SHTH PLLA TIB KN GRD STRL -,SUP-AR-1400B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 10 X 23 BIOCOMPOSITE -,SUP-AR-1400C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN 10X28MM ABSB FT TAPR PLLA TIB KN STRL -,SUP-AR-1400TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X18MM NLCKG CORT SUTUREPLATE TI STRL F/ARTHPL -,SUP-AR-14118NL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,262.58,183.806,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X20MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X22MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM NLCKG CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14126NL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,262.58,183.806,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X28MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X32MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X34MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X36MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X38MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X40MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X50MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X32MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X38MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X48MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14248,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
KIT TENODESIS SCREW 3X8 DISPOSABLE -,SUP-AR-1530DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FOREFOOT IB IMPLANT SYS PEEK -,SUP-AR-1530P-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5920.38,4144.266,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TENODESIS PEEK 3.5 X 8 -,SUP-AR-1530PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2146.7,1502.69,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4 X 10MM BIOTENODESIS -,SUP-AR-1540BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TENODESIS PEEK 4X10 -,SUP-AR-1540PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR BIO-TENODESIS 4.75X15MM BABSRB BIOCMPS ANKL/FT -,SUP-AR-1547BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TENODESIS PEEK 4.75X15MM INTERFERENCE -,SUP-AR-1547PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TENODESIS PEEK  5.5 X 15 -,SUP-AR-1555PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN BIO-TENODESIS 6.25X15MM BABSRB PEEK HND -,SUP-AR-1562BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TENODESIS PEEK 6.25X15 -,SUP-AR-1562PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN BIO-TENODESIS 7X23MM BABSRB PLLA HND WRST -,SUP-AR-1570BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN BIO-TENODESIS 8X23MM BABSRB PLLA HND WRST -,SUP-AR-1580BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 9X20MM CORT RETROSCREW FT RTRGD RND HEAD PLLA STRL -,SUP-AR-1586RB-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1131.99,792.393,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
RETRO BUTTON 15MM -,SUP-AR-1588-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
RETRO BUTTON 20mm -,SUP-AR-1588-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
RETRO BUTTON 12mm/25 -,SUP-AR-1588-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
RETRO BUTTON 12MM/30MM -,SUP-AR-1588-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SYS ARTHROSCOPIC FX BTB TIGHTROPE RT F/ACL RECON -,SUP-AR-1588BTB-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2358.72,1651.104,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIGHTROPE II RT WITH DEPLOYING SUTURE -,SUP-AR-1588RT-2J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2464.73,1725.311,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FIXATION TIGHTROPE RT DBL -,SUP-AR-1588RT-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FIXATION ACL TIGHTROPE RT -,SUP-AR-1588RT-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ACL TIGHTROPE WITH FIBER TAG -,SUP-AR-1588RTT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FIXATION ACL FEM TIGHTROPE -,SUP-AR-1588T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIGHTROPE ABS BUTTON 11MM -,SUP-AR-1588TB-3IB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIGHTROPE ABS BUTTON 14MM -,SUP-AR-1588TB-4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIGHTROPE ABS BUTTON 20MM -,SUP-AR-1588TB-5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIGHTROPE ABS BUTTON ROUND CONCAVE 20MM -,SUP-AR-1588TB-5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT TIGHTROPE ABS -,SUP-AR-1588TN,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
OPEN TIGHTROPE ABS -,SUP-AR-1588TN-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1131.99,792.393,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT FIXATION TIGHTROPE II ABS -,SUP-AR-1588TN-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIGHTROPE II ABS- IMPLANT OPEN -,SUP-AR-1588TN-21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ACL TIGHTROPE WITH FIBER TAG ABS -,SUP-AR-1588TNT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1775.67,1242.969,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIGHTROPE BUTTON EXTENDER -,SUP-AR-1589RT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN BIO-TENODESIS 9X23MM BABSRB PLLA HND WRST -,SUP-AR-1590BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR BIO-TENODESIS 5.5X10MM BABSRB PEEK ANKL/FT HND -,SUP-AR-1655PS-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR BIO-TENODESIS 5.5X12MM PEEK SHOLUDER ELB -,SUP-AR-1655PS-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SWIVELOCK  BIOCOMPOSITE 8MM X 19.5MM -,SUP-AR-1662BC-8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2305.72,1614.004,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SYSTEM LATERAL ANKLE RECON -,SUP-AR-1675BC-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN BIO-TENODESIS 8X12MM BABSRB PLLA SFT TIS -,SUP-AR-1680BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
KIT IB BC W/CC FT AND JUMPSTART -,SUP-AR-1788J-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
KIT IB BC W/CC FT AND JUMPSTART IMPLANT SYSTEM -,SUP-AR-1788J-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SWIVEL LOCK INTERNAL BRACE -,SUP-AR-1788J-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOW PROFILE SCREW 1.0 X 6MM CORTICAL TI -,SUP-AR-18710-06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOW PROFILE SCREW 1.0 X 7MM CORTICAL TI -,SUP-AR-18710-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOW PROFILE 2.4 X 10 CORTICAL -,SUP-AR-18724-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOW PROFILE 2.4 X 26 CORTICAL -,SUP-AR-18724-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
T-PLATE 2.4MM 6 HOLE -,SUP-AR-18724P-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TISSUE TAK TENDON ANCHOR -,SUP-AR-19021TT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUTURE CORKSCREW FT 3.5X10MM -,SUP-AR-1915FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ARTHREX SUTURE ANCHCRKSCRW FT3.5X10MM -,SUP-AR-1915FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT CRKSCR 3.5X12MM THRD TI #2 SUT -,SUP-AR-1915S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT CRKSCR 5X15MM ABSB -,SUP-AR-1920BF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1378.13,964.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUTURE CORKSCREW 5.0 -,SUP-AR-1920S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT PSHLK 4.5X24MM BIOCMPS -,SUP-AR-1922BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT BIO-PSHLK 4.5MMX18.5MM ABSB SLF-PNCH PLLA TI TIP -,SUP-AR-1922BM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2067.2,1447.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR PUSHLOCK 2.9 X 15.5 BIO -,SUP-AR-1923BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR PUSHLOK PEEK 2.9X15.5 -,SUP-AR-1923PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT CRKSCR 6.5MMX15.5MM THRD ST TI SZ2 GRN WHT SUT -,SUP-AR-1925S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR CORKSCREW 6.5 FIBER 2 2 -,SUP-AR-1925SF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BIO-PUSHLOCK COMPOSITE 3.5MM -,SUP-AR-1926BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT PSHLK 3.5MMX19.5MM PEEK HNDL INSRTR DRIVER -,SUP-AR-1926PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT CRKSCR FT 5.5MMX14.7MM ARSCP FT BABSRB BIOCMPS -,SUP-AR-1927BCF-3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1802.17,1261.519,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR 4.5 BIO-COMPOSITE -,SUP-AR-1927BCF-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
6.5 BIOCOMPOSITE ANCHORS -,SUP-AR-1927BCF-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1775.67,1242.969,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR BIO CORKSCREW 5.5 -,SUP-AR-1927BCT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1881.68,1317.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR CORKSCREW 5.5 PEEK (BOX OF 5) -,SUP-AR-1927PSF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT SUTAK 3MMX14.5MM ARSCP BIOCMPS ABSB #2 -,SUP-AR-1934BCF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1616.65,1131.655,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR BIOCOMPOSITE 3MM DBL -,SUP-AR-1934BCF-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT SUTAK 2.4X12MM ARSCP BIOCMPS FIBERWIREX2 -,SUP-AR-1934BCF-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1616.65,1131.655,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT SUTAK 2.4X12MM ARSCP BIOCMPS FIBERWIRE -,SUP-AR-1934BCF-24-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR BIOCOMPOSITE 3MM SING -,SUP-AR-1934BCT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1802.17,1261.519,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BIO SUTURE TAK DISPOSABLE -,SUP-AR-1934DS-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,933.6,653.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
KIT SUTURE TAK 3MM PERCUTANEOUS INSERTION -,SUP-AR-1934PI-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR KNOTLESS SUT TAK 3MM BI -,SUP-AR-1938BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR PEEK SUT TAK 3MM KNOTLESS -,SUP-AR-1938PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT DISTAL BICEP REPAIR 7 X 10MM -,SUP-AR-2260BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BUTTON SUT 2.6MM TI 12MM LF -,SUP-AR-2261,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BUTTON SUT DOG BN LF -,SUP-AR-2270,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SWIVEL LOCK 5.5 -,SUP-AR-2323BCC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT SWIVLK C 5.5MMX19.1MM ABSB CLSD EYLT PLLA -,SUP-AR-2323BSLC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1987.69,1391.383,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SWIVELOCK- SP BC KL 5.5MM -,SUP-AR-2323KBCSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT SWIVLK 5.5MMX24.5MM SLF-PNCH PEEK -,SUP-AR2323PSLM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT SWIVLK C 4.7MMX19.1MM CLSD EYLT BIOCMPS WHT/BLK -,SUP-AR-2324BCCTT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR BIO COMP SWIVELOCK SP 4 (MIN 5 EACH) -,SUP-AR-2324BCM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR BIOCOMPOSITE SWIVEL W\FIBERTAPE -,SUP-AR-2324BCT-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SWIVELOCK  BIOCOMPOSITE 4.75MM X  22MM DOUBLE LOADED -,SUP-AR-2324BCT-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR BIO-SWIVELLOCK 4.75 -,SUP-AR-2324BCT-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SWIVELOCK KNOTLESS 4.75MM BC -,SUP-AR-2324KBCC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
KNOTLESS SWIVELOK 4.75MM BC W/TAPE -,SUP-AR-2324KBCCTT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2530.22,1771.154,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SWIVELOCK- SP BC KL 4.75MM -,SUP-AR-2324KBCSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT BIO- SWIVLK SP 4.75MMX24.5MM SLF-PNCH PEEK TI -,SUP-AR-2324PSLM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BC SWIVELOCK 3.9 X 17.9 MM -,SUP-AR-2326BCC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
KIT SPEEDBRIDGE SHOULDER -,SUP-AR-2600SBS-8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8106.04,5674.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DISTAL CLAVICLE 22 DEG RIGHT -,SUP-AR-2622DR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 8HL PRCONT SS LT CLVCL -,SUP-AR-2651CL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PRCONT SS RT CNTRL CLVCL -,SUP-AR-2653CR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PRCONT SS LT CNTRL CLVCL -,SUP-AR-2654CL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CLAVICLE DISTAL SHOR LEFT SS -,SUP-AR-2656DL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CLAVICLE DISTAL SHORT RIGHT SS -,SUP-AR-2656DR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 8HL PRCONT SS RT CLVCL -,SUP-AR-2657DR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DISTAL CLAVICLE BUTTON -,SUP-AR-2658,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DISTAL CLAVICLE REPAIR ASSEMBLY -,SUP-AR-2658T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUTURE ANCHOR- BIOCOMPOSITE- HIP PUSHLOCK- SHORT 2.9 x 12.5 -,SUP-AR-2923BCH,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
KIT DISPOSABLES FOR FIBERTAK SUTR ANCH -,SUP-AR-3600DC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FIBERTAK WITH SUTURETAPE -,SUP-AR-3602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1881.68,1317.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.6 FIBERTAK ANCHOR DOUBLE  LOADED -,SUP-AR-3632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FIBERTAK ANCHOR TRIPLE LOADED -,SUP-AR-3633,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SELF-PUNCHING TRIPLE LOADED FIBERTAK -,SUP-AR-3633SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR FIBERTAK KNOTLESS -,SUP-AR-3636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FIBERTAK SHOULDER 1.8 SELF BUNCHING -,SUP-AR-3636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FIBERTAK HIP 1.8 SELF BUNCHING -,SUP-AR-3636H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
KNOTLESS 1.8 FIBERTAK W/ #2 SUTURE -,SUP-AR-3638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
KNOTLESS HIP FIBERTAK SUTURE ANCHOR- CURVED -,SUP-AR-3638DHC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
KIT FIBERTAK KNOTLESS STRAIGHT DISPOSABLE -,SUP-AR-3638DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SP FBTAK RC TGRTPE WH/BLK & STTPE WH/BL -,SUP-AR-3652SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SP FBTAC RC RBRTPE BLU & STTPE WH/BLK -,SUP-AR-3652TSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SP FBTAC RC RBRTPE BLK/BLU & STTPE BLU -,SUP-AR-3652TTSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
KL FBTK RC (WH/BLK)TT & (BLU)#2 MTS -,SUP-AR-3653SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2530.22,1771.154,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
KL FBTK RC W/(BLU)FT & (W/BLK) #2 MTS -,SUP-AR-3653TSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2530.22,1771.154,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
KNOTLESS TENSIONABLE FIBERTAK BICEP -,SUP-AR-3687,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ARTHROSCOPIC FX CHNDR -,SUP-AR-4005B-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW VENTED BC IF 7 X 20MM -,SUP-AR-4020C-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW VENTED BC IF 8 X 20MM -,SUP-AR-4020C-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW VENTED BC IF 9 X 20MM -,SUP-AR-4020C-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW VENTED BC IF 10 X 20MM -,SUP-AR-4020C-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ARTHREX PEEK SCREW 7 X 20MM FAST THREAD -,SUP-AR-4020P-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ARTHREX PEEK 8 X 20MM FAST THREAD -,SUP-AR-4020P-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ARTHREX PEEK 9 X 20MM FAST THREAD -,SUP-AR-4020P-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ARTHREX PEEK 10 X 20MM FAST THREAD -,SUP-AR-4020P-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW VENTED BC IF 7 X 30MM -,SUP-AR-4030C-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW VENTED BC IF 8 X 30MM -,SUP-AR-4030C-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW VENTED BC IF 9 X 30MM -,SUP-AR-4030C-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW VENTED BC IF 10 X 30MM -,SUP-AR-4030C-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW VENTED BC IF 11 X 30MM -,SUP-AR-4030C-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ARTHREX PEEK SCREW 7 X 30MM FAST THREAD -,SUP-AR-4030P-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ARTHREX PEEK 8 X 20MM FAST THREAD -,SUP-AR-4030P-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ARTHREX PEEK 9 X 30MM FAST THREAD -,SUP-AR-4030P-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ARTHREX PEEK 10 X 30MM FAST THREAD -,SUP-AR-4030P-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DEVICE SUT 1.5X5MM CRV C IN MNSCL 2-0 FIBERWIRE NDLX2 MINI -,SUP-AR-4500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
KIT BIOCOMPOSITE MENISCAL ROOT REPAIR -,SUP-AR-4550BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FIBER STITCH CURVED -,SUP-AR-4570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUTURE FIBERSTITCH FIBERWIRE POLYESTER 24 D 2-0 CURVE -,SUP-AR-4570-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
KIT ARTHROSCOPIC FIXATION FIBERSTITCH REVERSE CURVE -,SUP-AR-4570R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUTURE FIBERSTITCH STRAIGHT -,SUP-AR-4570S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR BIOCMPRSN 3X18MM BABSRB HDLS PLLA KN TAPR STP -,SUP-AR-5025B-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR BIOCMPRSN 2.7X20MM BABSRB HDLS PLLA KN TAPR STP -,SUP-AR-5025B-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8 X 28 BIOCOMPOSITE -,SUP-AR-5028C-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 9X28 DELTA -,SUP-AR-5028C-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 10 X 28 BIOCOMPOSITE -,SUP-AR-5028C-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 11 X 28 DELTA -,SUP-AR-5028C-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 9 X 35 DELTA -,SUP-AR-5035TC-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 10 X 35 BIOCOMPOSITE -,SUP-AR-5035TC-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 11 X 35 DELTA -,SUP-AR-5035TC-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 12 X 35 BIOCOMPOSITE -,SUP-AR-5035TC-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WIRE GUIDE 1.35MM DUAL TROCAR -,SUP-AR-5050-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,239.24,167.468,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFTBOLT TIBIAL 7MM -,SUP-AR-5100-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFTBOLT TIBIAL 8MM -,SUP-AR-5100-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFTBOLT TIBIAL 9MM -,SUP-AR-5100-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFTBOLT TIBIAL 10MM -,SUP-AR-5100-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUTURE ANCHOR- SWIVELOCK TENODESIS- PEEK -,SUP-AR-7324PSL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2969.43,2078.601,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOW PROFILE SCREW TI 4.5 X 26MM -,SUP-AR-8545-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOW PROFILE SCREW TI 4.5 X 34MM -,SUP-AR-8545-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOW PROFILE SCREW TI 4.5 X 36MM -,SUP-AR-8545-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LO-PRO LOCK SCREW TI 4.5 X 28MM -,SUP-AR-8545L-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X55MM LCK -,SUP-AR-8545L-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X60MM LCK -,SUP-AR-8545L-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT SYSTEM CPR MINI SCORPION DX -,SUP-AR-8690DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
STAPLE BN FX QUICKFIX SM SS -,SUP-AR-8710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NITINOL COMPRESSION STAPLE- 9WX7L -,SUP-AR-8717-0907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NITINOL COMPRESSION STAPLE- 9WX10L -,SUP-AR-8717-0910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DYNANITE NITI STAPLE W/INSTRS 9WX10L -,SUP-AR-8717DS-0910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DYNANITE NITI STAPLE W/INSTRS 10W X 11L -,SUP-AR-8717DS-1110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DYNANITE NITI STAPLE W/INSTRS 11W X 15\12L -,SUP-AR-8717DS-111512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NITINOL COMP STAPLE 15W X 12L -,SUP-AR-8718-1512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
STAPLER DYNAMITE NITI  W/INSTRS 13W X 10L -,SUP-AR-8718DS-1310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8042.38,5629.666,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DYN NITI STAPLE W/INSTRS 15W X 12L -,SUP-AR-8718DS-1512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8042.38,5629.666,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
STAPLE 15W X 15L DYNANITE NITI W/INSTRS -,SUP-AR-8719DS-1515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DYN NITI STAPLE W/INSTRS 18W X 15L -,SUP-AR-8719DS-1815,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
STAPLE DYNANITE NITI W/INSTRS 18W X 18L -,SUP-AR-8719DS-1818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DYNANITE NITI STAPLE WINSTRS 20W X 20L -,SUP-AR-8719DS-2020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
QCKFIX SCRW TI CANN PT 2.0 X 10MM -,SUP-AR-8720-10PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.4X12MM HD CORT QUICKFIX ST SLD STND ALONE TI STRL -,SUP-AR-8724-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOW PROFILE 2.4 X 14 CORTEX -,SUP-AR-8724-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOW PROFILE SCREW 2.4 X 18MM CORTEX -,SUP-AR-8724-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW QUICKFIX 2.4 X 18MM TI CANNULATED -,SUP-AR-8724-18PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,846.08,592.256,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW QUICKFIX 2.4 X 22MM TI CANNULATED -,SUP-AR-8724-22PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,846.08,592.256,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.4X24MM CANN QUICKFIX P/T T8 HXLB DRV TI F/CMPRHNSV -,SUP-AR-8724-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOW PROFILE SCREW 2.4 X 32MM CORTEX -,SUP-AR-8724-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOW PROFILE SCREW 2.4 X 36MM CORTEX -,SUP-AR-8724-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.4 X 8 VAL TI -,SUP-AR-8724V-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.4 X 12 VAL TI -,SUP-AR-8724V-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.4 X 16 VAL TI -,SUP-AR-8724V-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.4MM X 18MM V AL SCREW TI -,SUP-AR-8724V-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW VAL TI 2.4MM X 18MM -,SUP-AR-8724V-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.4MM X 22MMV AL SCREW TI -,SUP-AR-8724V-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW VAL KREULOCK TI 2.4X12 -,SUP-AR-8724VCL-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW VAL KREULOCK TI 2.4X16 -,SUP-AR-8724VCL-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW COMPRESSION FT 2.5MM MICRO X 8MM LGTH -,SUP-AR-8725-08H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5MMX14MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-14H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5MMX16MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-16H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5MMX18MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-18H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5MMX20MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-20H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW COMPR FT 2.5 MICRO 22MM -,SUP-AR-8725-22H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5MMX24MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-24H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5MMX26MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-26H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMPR FT SCREW 2.5 MICRO 28MM LGTH -,SUP-AR-8725-28H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS MICRO 2.5X 30MM -,SUP-AR-8725-30H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMPR FT SCREW 2.5 MICRO 32MM LGTH -,SUP-AR-8725-32H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW QUICKFIX TI CANC PT 3.0 X 12MM -,SUP-AR-8730-12PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX14MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8730-14H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX14MM DUAL CORE QUICKFIX -,SUP-AR-8730-14PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMPR FT SCREW 3.5 MINI 16MM -,SUP-AR-8730-16H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX16MM DUAL CORE QUICKFIX -,SUP-AR-8730-16PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMPR FT SCRW 3.5 MINI 18MM LGTH -,SUP-AR-8730-18H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX18MM DUAL CORE QUICKFIX -,SUP-AR-8730-18PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP SCREW 3.5 MINI 20MM -,SUP-AR-8730-20H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MM X 20MM DUAL CORE QUICKFIX -,SUP-AR-8730-20PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMPR FT SCREW 3.5 MINI 22MM -,SUP-AR-8730-22H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX22MM DUAL CORE QUICKFIX -,SUP-AR-8730-22PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FT COMPR 3.5 X 24MM -,SUP-AR-8730-24H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX24MM DUAL CORE QUICKFIX -,SUP-AR-8730-24PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW COMPR FT 3.5 X 26 MINI -,SUP-AR-8730-26H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX26MM DUAL CORE QUICKFIX P/T SD/ST T10 HXLB DRV TI -,SUP-AR-8730-26PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW COMPR FT 3.5 MINI 28MM -,SUP-AR-8730-28H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FT COMPR 3.5 X 30MM -,SUP-AR-8730-30H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.6MMX32MM COMPR HDLS QUICKFIX P/T SD/ST T10 HXLB DRV -,SUP-AR-8730-32H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMPR FT SCREW 3.5 MINI 34MM LGTH -,SUP-AR-8730-34H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
QCKFIX SCREW TI CANC PT 3.0 X 38MM -,SUP-AR-8730-38PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOW PROFILE SCREW CORTICAL 3.5MM X 14MM DRP -,SUP-AR-8735-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOW PROFILE SCREW CORTICAL 3.5MM X 16MM DRP -,SUP-AR-8735-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOW PROFILE SCREW CORTICAL 3.5MM X 18MM DRP -,SUP-AR-8735-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.5X32MM BEVELED FT SCREW -,SUP-AR-8735BV-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BEVELED FT 3.5MM X40MM -,SUP-AR-8735BV-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5 X 44MM BEVELED FT -,SUP-AR-8735BV-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOW PROFILE SCREW LOCKING 3.5MM X 16MM DRP -,SUP-AR-8735L-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEWIRE 0.86MM W/ LASER LINE SS -,SUP-AR-8737-21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,87.53,61.271,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW COMPR FT 4.0 STD 20MM LGTH -,SUP-AR-8740-20H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW COMPR FT 4.0 STD 22MM LGTH -,SUP-AR-8740-22H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMPRESSION SCREW 4.0 24MM LENGTH -,SUP-AR-8740-24H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMPRESSION SCREW 4.0 26MM LENGTH -,SUP-AR-8740-26H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMPRESSION SCREW 4.0 28MM LENGTH -,SUP-AR-8740-28H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW COMPR FT 4.0 STD 30MM LGTH -,SUP-AR-8740-30H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW QUICKFIX TI CANN ST 4.0 X 38MM CANC -,SUP-AR-8740-38PTS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW QUICKFIX TI CANN 4.0 X 40MM ST CANC -,SUP-AR-8740-40PTS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
4X46MM BEVELED FT SCREW -,SUP-AR-8740BV-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4 X 50MM BEVELED FT -,SUP-AR-8740BV-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4 X 52MM BEVELED FT -,SUP-AR-8740BV-52,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER 7.0MM TI -,SUP-AR-8740W,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEWIRE 1.6MM- 4MM BEVELED FT -,SUP-AR-8741-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEWIRE 1.6X150MM CAPITAL FRAG -,SUP-AR-8741-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW COMPR FT 5.0 X 42MM -,SUP-AR-8750-42H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW COMPR FT 5.0 X 55MM -,SUP-AR-8750-55H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMPR FT SCREW 7.0 XL 65MM LGTH -,SUP-AR-8770-65H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMPR FT SCREW 7.0 XL 70MM LGTH -,SUP-AR-8770-70H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMPR FT SCREW 7.0 XL 75MM LGTH -,SUP-AR-8770-75H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT BIO-PSHLK 2.5X8MM KNTLS PLLA ABSB #2 FIBERWIRE -,SUP-AR-8825B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUTURE PEEK MINI PUSHLOCK -,SUP-AR-8825P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
KREULOCK COMPRESSION SCREW SS 2.7 X 12MM -,SUP-AR-8827CL-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
KREULOCK COMPRESSION SCREW SS 2.7 X 14MM -,SUP-AR-8827CL-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
KREULOCK COMPRESSION SCREW SS 2.7 X 16MM -,SUP-AR-8827CL-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
KREULOCK COMPRESSION SCREW SS 2.7 X 18MM -,SUP-AR-8827CL-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
KREULOCK COMPRESSION SCREW SS 2.7 X 20MM -,SUP-AR-8827CL-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X10MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X12MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X18MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X20MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LO-PRO LOCK SS 2.7 X 22 -,SUP-AR-8827L-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LO-PRO LOCK 2.7 X 24 -,SUP-AR-8827L-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CANCLUS SCREW FULLY THREADED SS 3 X 24MM -,SUP-AR-8830-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LO-PRO SCREW TM SS 3.5 X 12MM CORT -,SUP-AR-8835-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X14MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X16MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X18MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X22MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X28MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X30MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X35MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X45MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X10MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X14MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X16MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X18MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X20MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X14MM NLCKG CANC TIGHTROPE FT SD T15 HXLB DRV SS -,SUP-AR-8840-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X16MM NLCKG CANC TIGHTROPE FT SD T15 HXLB DRV SS -,SUP-AR-8840-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X30MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X40MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X45MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X60MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X30MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X35MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X50MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X60MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PARS Suture Implant Kit w/ SutureTape -,SUP-AR-8862DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIGHTROPE MINI 1.1MM -,SUP-AR-8914DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
VOLAR DISTAL RAD PLT TI NARROW LT 3HOLE -,SUP-AR-8916VNL-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
VOLAR DISTAL RAD PLT TI NARROW RT 3H -,SUP-AR-8916VNR-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT MINI TIGHTROPE 1.1 - 0 -,SUP-AR-8919DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
KT ARTHROSCOPIC FX TIGHTROPE ANKL 6.5MM RND BTN 3.5X10MM -,SUP-AR-8920CDS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
KT ARTHROSCOPIC FX TIGHTROPE ANKL 3.5MM RND/10MM OBLNG BTN -,SUP-AR-8921CDS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIGHTROPE XP KNOTLESS TITANIUM -,SUP-AR-8925T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIGHTROPE KNOTLESS -,SUP-AR-8926SS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4986.7,3490.69,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BIO-COMP ACHILLE SPEEDBRIDGE -,SUP-AR-8928BCJ-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SYSTEM IMPLANT MPFL BIOCOMPOSITE -,SUP-AR-8929BC-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6310.83,4417.581,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X10MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI COLR F -,SUP-AR-8930-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X11MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI MAG F -,SUP-AR-8930-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X12MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI BLU F -,SUP-AR-8930-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X13MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI GRN F -,SUP-AR-8930-13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X14MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI PUR F -,SUP-AR-8930-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X16MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI PUR F -,SUP-AR8930-16PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X20MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI PUR F -,SUP-AR-8930-20PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X12MM CANN CORT P/T TI -,SUP-AR-8933-12PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X14MM CANN CORT P/T TI -,SUP-AR-8933-14PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LP SCREW 3 X 16MM CORTICAL MTP TI -,SUP-AR-8933-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X16MM CANN CORT P/T TI -,SUP-AR-8933-16PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LO-PRO SCREW TI 3.0MM X 18MM CORT -,SUP-AR-8933-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X18MM CANN CORT P/T TI -,SUP-AR-8933-18PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LO-PRO SCREW TI 3.0MM X 20MM CORT -,SUP-AR-8933-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LO-PRO SCREW TI 3.0MM X 22MM CORT -,SUP-AR-8933-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LO-PRO SCREW TI 3.0MM X 36MM CORT -,SUP-AR-8933-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X14MM LCK CORT P/T TI BLU -,SUP-AR-8933L-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X16MM LCK CORT P/T TI BLU -,SUP-AR-8933L-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
VAL KREULOCK SCREW TI 3 X 16 -,SUP-AR-8933VCL-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
VAL KREULOCK SCREW TI 3 X 18 -,SUP-AR-8933VCL-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
VAL KREULOCK SCREW TI 3 X 20 -,SUP-AR-8933VCL-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW VAL KREULOCK 3.0 X 22MM TI -,SUP-AR-8933VCL-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW VAL KREULOCK 3.0 X 26MM TI -,SUP-AR-8933VCL-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUTURETAPE S-TAK ASSY 3.0 DOUBLE LOADED -,SUP-AR-8934BCST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.0 DOUBLE LOADED SUTURETAPE S-TAK ASSY -,SUP-AR-8934BCST-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LO-PRO SCREW TI 3.5MM X 12MM -,SUP-AR-8935-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LO-PRO SCREW TI 3.5MM X 22MM -,SUP-AR-8935-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LO-PRO SCREW TI 3.5MM X 24MM -,SUP-AR-8935-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LO-PRO TI 3.5MM X 26MM -,SUP-AR-8935-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LO-PRO TI 3.5MM X 30MM -,SUP-AR-8935-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LO-PRO SCREW TI 3.5MM X 32MM -,SUP-AR-8935-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LO-PRO TI 3.5MM X 34MM -,SUP-AR-8935-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LO-PRO SCREW TI 3.5MM X 36MM -,SUP-AR-8935-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LO-PRO SCREW TI 3.5MM X 38MM -,SUP-AR-8935-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LO-PRO SCREW TI 3.5MM X 40MM -,SUP-AR-8935-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LO-PRO SCREW TI 3.5MM X 42MM -,SUP-AR-8935-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LO-PRO SCREW TI 3.5MM X 44MM -,SUP-AR-8935-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LO-PRO SCREW TI 3.5MM X 46MM -,SUP-AR-8935-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LO-PRO SCREW TI 3.5MM X 48MM -,SUP-AR-8935-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW KREULOCK TI 3.5 X 24MM -,SUP-AR-8935CL-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW KREULOCK TI 3.5 X 26 -,SUP-AR-8935CL-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
KREULOCK SCREW TI 3.5 X 28 -,SUP-AR-8935CL-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW KREULOCK TI 3.5 X 28MM -,SUP-AR-8935CL-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW KREULOCK TI 3.5 X 30 -,SUP-AR-8935CL-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW KREULOCK TI 3.5 X 32 -,SUP-AR-8935CL-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
KREULOCK SCREW TI 3.5 X 34 -,SUP-AR-8935CL-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
KREULOCK SCREW TI 3.5 X 36 -,SUP-AR-8935CL-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LO-PRO LOCK SCREW TI 3.5MM X 12MM -,SUP-AR-8935L-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW  TI 3.5MM X 14MM -,SUP-AR-8935L-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X24MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW TITANIUM 3.5MM X 28MM -,SUP-AR-8935L-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING TITANIUM 3.5MM X 28MM -,SUP-AR-8935L-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X30MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X32MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW TITANIUM 3.5MM X 34MM -,SUP-AR-8935L-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW TITANIUM 3.5MM X 44MM -,SUP-AR-8935L-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
KIT ENDOSCOPIC BOSTROM REPAIR IMPLANT SYS -,SUP-AR-8936BC-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X30MM CANC FT SD TI STRL F/H-PLATE LPDS SURG -,SUP-AR-8940-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LO-PRO TI 4.0MM X 36MM -,SUP-AR-8940-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X40MM CANC FT SD TI -,SUP-AR-8940-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN TIGHTROPE 79MM F/SYNDSMS RPR 4HL SS BTRSS LT -,SUP-AR-8943BL-04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN TIGHTROPE 79MM F/SYNDSMS RPR 4HL SS BTRSS RT -,SUP-AR-8943BR-04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN TIGHTROPE 91MM F/SYNDSMS RPR 5HL SS BTRSS -,SUP-AR-8943BR-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN TIGHTROPE 104MM F/SYNDSMS RPR 6HL SS BTRSS -,SUP-AR-8943BR-06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN TIGHTROPE 61MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943H-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN TIGHTROPE F/DLTD LGMNT ATTCH AVULSION FX SYNDSMS -,SUP-AR-8943H-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN TIGHTROPE 47MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943T-04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN TIGHTROPE 72MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943T-06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN TIGHTROPE 98MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943T-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1404.63,983.241,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN TIGHTROPE F/SYNDSMS AVULSION FX MGMT 10HL LCK SS -,SUP-AR-8943T-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1484.14,1038.898,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN TIGHTROPE 72MM F/SYNDSMS AVULSION FX MGMT 3HL SS -,SUP-AR-8943TH-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN TIGHTROPE F/SYNDSMS AVULSION FX MGMT 7HL LCK SS 1/3 -,SUP-AR-8943TH-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN TIGHTROPE 43MM TI BTRSS 3.5MM LPS SCR 2.4MM GW -,SUP-AR-8947DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.1,3045.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 7.5MM STP -,SUP-AR-8949-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LISFRANC PLATE MEDIUM LEFT TI -,SUP-AR-8951ML,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE MEDIUM RIGHT TITANIUM LISFRANC -,SUP-AR-8951MR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LISFRANC PLATE SMALL RIGHT TI -,SUP-AR-8951SR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.5MM 2HOLE L-PLATE TI 5H RT -,SUP-AR-8952ML-05R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 3MM 5HL TI STR -,SUP-AR-8952TS-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CALCFX PERCPLT STD ANTERIOR PROCESS L -,SUP-AR-8954ML-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE LONG CALCANEUS RIGHT TUBEROSITY 3.5/4 MM PERCUTANEOUS -,SUP-AR-8954YR-L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE TAP CANNULATED 6.0MM -,SUP-AR-8956C-60T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE LONG METATARSAL RIGHT HOOK -,SUP-AR-8956R-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2 HOLE TITANIUM -,SUP-AR-8958-02S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANTEROLATERAL PILON FUSION PLATE 5 HOLE LT -,SUP-AR-8963ALF-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12624.2,8836.94,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANTEROLATERAL PILON FUSION PLATE 7H RT -,SUP-AR-8963ARF-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.7X65MM CANN 18MM THRD SD/ST TI -,SUP-AR-8967-1865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO 13MM TI -,SUP-AR-8967W,CDM,C1713,HCPCS,278,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
KIT DX SWIVELOCK SL 3.5X8.5MM -,SUP-AR-8978DS-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SWIVELOCK DX SL 3.5 X 8.5 -,SUP-AR-8978P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SYSTEM INTERNAL FIXATION FIBERLOCK SUSPENSION  3.5 X 8.5 -,SUP-AR-8988-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5889.19,4122.433,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUTURE FIBER TAK DX -,SUP-AR-8990ST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2464.73,1725.311,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR FIBERTAK DOUBLE-LOADED DX SUTURE -,SUP-AR-8990ST-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2878.72,2015.104,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DX FIBERTAK SUTURE ANCHOR #2 MTS W/NDL -,SUP-AR-8991,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SWIVELOCK DISP KIT NANO 2.5 X 7 -,SUP-AR-8998DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NANO SWIVELOCK 2.5 X 7 WITH FORK EYELET -,SUP-AR-8998T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X45MM P/T TI F /5TH MTRSL JONES FX SYS -,SUP-AR-9045-45PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X55MM P/T TI GRN -,SUP-AR-9045-55PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LO-PRO SCREW PT THREADED TI 5.5MM X 40MM -,SUP-AR-9055-40PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LO-PRO SCRW PT THD TI 6.0MM X 40MM -,SUP-AR-9060-40PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCK GLENOID PERIPH -,SUP-AR-9145-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CENTRAL NL 6.5 X 25MM -,SUP-AR-9165-25NL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BC ACHILLES SPDBRG W/KL DX CC 3.9MM -,SUP-AR-9928BCK-DX,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10749.14,7524.398,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LP SCREW 3 X 18MM CORTICAL MTP TI -,SUP-AR-9933-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LP SCREW 3 X 20MM CORTICAL MTP TI -,SUP-AR-9933-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LP 3.0 X 22MM CORTICAL MTP TI -,SUP-AR-9933-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LP 3.0 X 24MM CORTICAL MTP TI -,SUP-AR-9933-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LP SCREW 3 X 16MM CORTICAL HYBRID MTP TI -,SUP-AR-9933HY-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCK MED HOOK PLATE TI 3H -,SUP-AR-9943H-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
MAXFORCE MTP PLATE PETITE 0-0 RIGHT -,SUP-AR-9944P-0R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE MAXFORCE STD 5-5 RIGHT MTP -,SUP-AR-9944S-5R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 12.5MM CANN HDLS ACUTRAK STD TI ALY -,SUP-AT-1125-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.3-3.8X15MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI -,SUP-AT-1150-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.3-3.9MM 17.5MM CANN HDLS ACUTRAK FT ST STD 2MM HX -,SUP-AT-1175-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 20MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI ALY -,SUP-AT-1200-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.3-4.2MM 22.5MM CANN HDLS ACUTRAK FT ST STD 2MM HX -,SUP-AT-1225-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.3-4.4X25MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI -,SUP-AT-1250-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.3-4.5MM 27.5MM CANN HDLS ACUTRAK FT ST STD 2MM HX -,SUP-AT-1275-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.3-4.6X30MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI -,SUP-AT-1300-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5-2.8 MMX8MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5-2.8 MMX9MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5-2.8 MMX12MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5-2.8 MMX14MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5-2.8 MMX16MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5-2.8 MMX18MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5-2.8 MMX20MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5-2.8 MMX26MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5-2.8 MMX28MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5-3.6 MMX16MM CANN HDLS ACUTRAK 2 FT SLF CT 2MM HX -,SUP-AT2-M16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5-3.6 MMX22MM CANN HDLS ACUTRAK 2 FT SLF CT 2MM HX -,SUP-AT2-M22-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5-3.6 MMX24MM CANN HDLS ACUTRAK 2 FT SLF CT 2MM HX -,SUP-AT2-M24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4-4.1X16MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT STD -,SUP-AT2-S16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4-4.1X26MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT STD -,SUP-AT2-S26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4-4.1X34MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST CUT STD -,SUP-AT2-S34-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3-2.5X24MM CANN HDLS ACUTRAK FUSION FT ST 1.5MM/2MM -,SUP-ATF-240-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1966.49,1376.543,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3-3.5X32MM CANN HDLS ACUTRAK FUSION FT ST 1.5MM/2MM -,SUP-ATF-320-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1966.49,1376.543,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.8-3.2 MMX10MM CANN HDLS ACUTRAK FT ST 1.5MM HX DRV -,SUP-ATM-100-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
UNIVERSAL CEMENT RESTRICOTR SM 18.5MM -,SUP-B000-0185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
RESTRICTOR CMNT UNIV 24MM OSTEONICS -,SUP-B000-0240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
RESTRICTOR CEMENT UNIVERSAL SMALL INSERTER -,SUP-B000-1185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
RESTRICTOR CMNT MED UNIV STRL -,SUP-B000-1240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
RESTRICTOR BNCMNT 11MM -,SUP-B0010110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
RESTRICTOR BNCMNT 15.5MM -,SUP-B0020125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
RESTRICTOR BNCMNT 14MM -,SUP-B0030140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX110MM CANC DYNFX 50MM THRD TAPR -,SUP-B6011050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EXTFIX 6/5MM DIA 130/ 60MM CORT/CANC TAPR DYNFX THRD -,SUP-B6013060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,485.47,339.829,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TITAN REV SHOULDER LARGE -,SUP-BBS-0960-21LRG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
REVERSE BODY SMALL AND REVERSCE BODY SCREW -,SUP-BBS-0960-21SML,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BALLOON 6FR PTA 200CM X 3MM X 120MM METACROSS -,SUP-BD-P30150ER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
AFX2 BIFURCATED ENDOGRAFT SYSTEM -,SUP-BEA25-80/I13-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
STENT BIFURCATED ENDOGRAFT AFX2  28MM X 80MM -I16-40 -,SUP-BEA28-80/I16-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,37002.53,25901.771,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN TRIMED VOLAR BUTT 20 -,SUP-BP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
RSS BODY SCREW -,SUP-BSC-0960-021-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TI F/TITAN MODLR SHLDR SYS -,SUP-BSW-0920-021-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,758.61,531.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
MIXER CEMENT KYPHON W  CEMENT -,SUP-C01B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,919.01,643.307,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
"K-WIRE PIN COVER .028"" -",SUP-C-028NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X12MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-C03120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X16MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-C03160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
"K-WIRE PIN COVER .035"" -",SUP-C-035NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
"K-WIRE PIN COVER .045"" -",SUP-C-045NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
"K-WIRE PIN COVER .054"" -",SUP-C-054NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
"K-WIRE PIN COVER .062"" -",SUP-C-062NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
EXTERNAL FX 0.375IN BALL COLR F/CAP VRS SZ K-WIRE -,SUP-C50-COL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.5,771.75,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X14MM LCK CANC ACU-LOC 2 HEX HEAD TI NS F/MAYO -,SUP-CA-4140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,542.66,379.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFT CANC 30ML CHP RDIGRF FRZDR CRSH VOID FIL 1-8MM -,SUP-CAN30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1984.24,1388.968,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
EXPERT KNEE CAPITATED REVISION SYSTEM -,SUP-CAP PRICE,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21164.1,14814.87,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CEMENT CARTRIDGE CC02A CDS -,SUP-CC02A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DISC CERVICAL SIZE 6MM LL M6 -,SUP-CDL-637L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CERVICAL DISC SIZE 6MM M6 ORTHOFIX -,SUP-CDM-625,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CERVICAL DISC 6 MEDIUM LONG ARTIFICIAL -,SUP-CDM-635L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CEMENT GUN AND BONE FILLER CDS2A SIZE 2 -,SUP-CDS2A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2361.37,1652.959,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
EXCLUDER ILIAC 23MM X 10MM X 10CM 16FR BRANCH ENDO -,SUP-CEB231010A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31520.86,22064.602,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT VARILIFT- C STND ALONE XPD -,SUP-CIC1-7.5-12-BP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5835.5,4084.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE VARILIFT- C ST -,SUP-CIC1-9.0-12-BP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5835.5,4084.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
KT SUTURE REM SUT PRB KNT PSHR/CTR INTRO CROSSFIX II DISP -,SUP-CM-8000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DEVICE MENISCOTOME UP CRV STRONGER STF NDL HI STRGTH SUT -,SUP-CM-8002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR JK 2.9 SL WT/BL NS BK JUGGERKNOT -,SUP-CM-99329B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2067.2,1447.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR JK 2.9 BDL WT/BL NS BKLU BB JUGGERKNOT -,SUP-CM-99429B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2067.2,1447.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X12MM NLCKG CORT ACU-LOK 2 TI NS F/MAYO -,SUP-CO-2712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X14MM NLCKG CORT ACU-LOK 2 TI NS F/MAYO -,SUP-CO-2714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X16MM NLCKG CORT ACU-LOK 2 TI NS F/MAYO -,SUP-CO-2716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X20MM NLCKG CORT ACU-LOC 2 TI NS F/MAYO -,SUP-CO-2720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X22MM NLCKG CORT ACU-LOC 2 TI NS F/MAYO -,SUP-CO-2722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X6MM NLCKG CORT ACU-LOK 2 TI NS -,SUP-CO-3060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X10MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X12MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X14MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X16MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X24MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X25MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X28MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X30MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X32MM NLCKG CORT ACU-LOC 2 POLARUS TI NS COLR -,SUP-CO-3320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X12MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X14MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X16MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X18MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X8MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X10MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X12MM LCK CORT -,SUP-COL-3120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X14MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X20MM LCK CORT FT TI F/MAYO PLATE/MODULAR/UNIV SYS -,SUP-COL-3200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X22MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORITICAL LOCKING TI 3.5 X 13MM -,SUP-COLS -35130-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW GEMINUS CORTICAL LOCKING 3.5MM X 8MM TI -,SUP-COLS-35080-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL LOCKING 3.5 X 9 -,SUP-COLS-35090-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL LOCKING 3.5 X 10 -,SUP-COLS-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL LOCKING 3.5MM X 11MM -,SUP-COLS-35110-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL LOCKING 3.5MM X 12MM -,SUP-COLS-35120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW- CORTICAL LOCKING 3.5MM X 12MM -,SUP-COLS-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORT LOCKING 3.5MM X 15MM -,SUP-COLS-35150-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL LOCKING 3.5MM X 16MM -,SUP-COLS-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL LOCKING 3.5 X 18 -,SUP-COLS-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL LOCKING 3.5MM X 20MM TI -,SUP-COLS-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL LOCKING 3.5 X 24 -,SUP-COLS-35240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL LOCKING 3.5 X 26 -,SUP-COLS-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X14MM CORT ACU-LOC 2 FT NTOGG TI NS F/UNIV SYS -,SUP-CO-N2314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X22MM CORT ACU-LOC 2 FT NTOGG TI NS F/UNIV SYS -,SUP-CO-N2322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X14MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X16MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X18MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X20MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
RTR CROSS CONNECTOR -,SUP-CPF-CR 26 32-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CROSS CONNECTOR 32-44 -,SUP-CPF-CR 32 44-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 3.5 X 12 -,SUP-CPF-CS 35 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CC PREFERRED ANGLE 3.5 X 14 -,SUP-CPF-CS 35 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CC PREFERRED ANGLE 3.5 X 18 -,SUP-CPF-CS 35 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CC PREFERRED ANGLE 3.5 X 20 -,SUP-CPF-CS 35 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LARGE OFFSET -,SUP-CPF-LC 00 0L-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SPINEART ML PREFERRED ANGLE 4MM X 12MM -,SUP-CPF-MS 04 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ML PREFERRED ANGLE SCRE 4 X 16 -,SUP-CPF-MS 04 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ML PREFERRED ANGLE SCRE 4 X 18 -,SUP-CPF-MS 04 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ML PREFERRED ANGLE 4 X 20 -,SUP-CPF-MS 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ML PREFERRED ANGLE 4 X 24 -,SUP-CPF-MS 04 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPINEART PERLA ML PREFERRED ANGLE SCREW 4 X 28 -,SUP-CPF-MS 04 28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ML PREFERRED 3.5 X 12 -,SUP-CPF-MS 35 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ML 35 X 14 -,SUP-CPF-MS 35 14S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW PERLA ML PREFERRED ANGLE 3.5MM X 16MM -,SUP-CPF-MS 35 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ML PREFERRED 3.5 X 18 -,SUP-CPF-MS 35 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ML 35 X 20 -,SUP-CPF-MS 35 20S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ML 35 X 24 -,SUP-CPF-MS 35 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SPINEART ML PREFERRED ANGLE 4MM X 14MM -,SUP-CPF-MS-04 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CONNECTOR PARALLEL 3-3 -,SUP-CPF-PC 30 3C-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CONNECTOR PARALLEL 3-5 -,SUP-CPF-PC 3C 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD PERLA 90MM TI -,SUP-CPF-PF T0 90-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PREBENT ROD COBALT CHROMIUM 45MM -,SUP-CPF-PR C0 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD PREBENT TITANIUM 3.5 X 40MM -,SUP-CPF-PR T0 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 50MM -,SUP-CPF-PR T0 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 60MM PREBENT TITANIUM -,SUP-CPF-PR T0 60-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PERLA PREBENT ROD TITANIUM 3.5 X 65MM -,SUP-CPF-PR T0 65-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 70MM -,SUP-CPF-PR T0 70-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PERLA PREBENT ROD TITANIUM 3.5 X 75MM -,SUP-CPF-PR T0 75-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD PREBENT TITANIUM 3.5 L80 -,SUP-CPF-PR T0 80-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 85MM -,SUP-CPF-PR T0 85-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 45MM -,SUP-CPF-PR TO 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PREBENT TITANIUM ROD 3.5 X L12 PERLA -,SUP-CPF-PR TO 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD PREBENT TITANIUM 55MM -,SUP-CPF-PR TO 55-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 60MM -,SUP-CPF-PR TO 60-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PRE-BENT ROD 3.5 X 90MM -,SUP-CPF-PR TO 90-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLY PERLA 4 X 10MM -,SUP-CPF-PS 04 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PERLA SCREW 12MM -,SUP-CPF-PS 04 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL PERLA 4MM X 12MM -,SUP-CPF-PS 04 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL 4MM X 14MM -,SUP-CPF-PS 04 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL 4 X 16 -,SUP-CPF-PS 04 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLY 4 X 18MM -,SUP-CPF-PS 04 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL PERLA 4MM X 20MM -,SUP-CPF-PS 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLY PERLA 4.0 X 24MM -,SUP-CPF-PS 04 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE PERLA 4MM X 32MM SPINE POLYAXIAL -,SUP-CPF-PS 04 32-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PERLA POLYAXIAL SCREW 3.5 X 10MM -,SUP-CPF-PS 35 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLY 3.5 X 12MM PERLA -,SUP-CPF-PS 35 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW PERLA 3.5 X 14 -,SUP-CPF-PS 35 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.5 x 16MM POLY SCREW -,SUP-CPF-PS 35 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLY 3.5 X 18MM PERLA -,SUP-CPF-PS 35 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PERLA POLYAXIAL SCREW 3.5 X 20MM -,SUP-CPF-PS 35 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
POLYAXIAL SCREW 3.5 X 24 -,SUP-CPF-PS 35 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLY PERLA 3.5MM X 28MM -,SUP-CPF-PS 35 28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
POLYAXIAL SCREW 3.5 X 12 -,SUP-CPF-PS 3512-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
POLYAXIAL SCREW 4.0 X 28 -,SUP-CPF-PS-0428-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.5 X 28 POLY SCREW -,SUP-CPF-PS-3528-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREWS SET PERLA -,SUP-CPF-SC 00 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPINEART STRAIGHT ROD CHROMIUM 350MM -,SUP-CPF-SR C3 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD TITANIUM 40MM -,SUP-CPF-SR CO 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD TITANIUM 80MM -,SUP-CPF-SR T0 80-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PERLA STRAIGHT ROD TITANIUM 03.5 L100 -,SUP-CPF-SR T1 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD TI 120MM -,SUP-CPF-SR T1 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 240 -,SUP-CPF-SR T2 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SMOOTH SHANK SCREW 4MM Z 20 -,SUP-CPF-SS 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SS 3.5 X 20 -,SUP-CPF-SS 35 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SS 3.5 X 22 -,SUP-CPF-SS 35 22-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SS 3.5 X 24 -,SUP-CPF-SS 35 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREWS SS 3.5 X 26 -,SUP-CPF-SS 35 26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.5 x 28MM SMOOTH SHANK -,SUP-CPF-SS 35 28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SS 3.5 X 34 -,SUP-CPF-SS 35 34-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.5 X 30MM POLY SCREW -,SUP-CPF-SS-35 30-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X12MM CORT DVR FT CRUCIF HEAD MAG -,SUP-CS12000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X16MM CORT DVR FT CRUCIF HEAD MAG -,SUP-CS16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X18MM CORT DVR FT CRUCIF HEAD MAG -,SUP-CS18000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFT STRUT MATRGRF FRZDR 15X100MM -,SUP-CST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3457.04,2419.928,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE CEMENT CX01B XPEDE W MIXER US -,SUP-CX01B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1598.1,1118.67,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
HEADLESS 3.0X40 SCREW -,SUP-D2N30040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.61,678.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TORNIER LONG HUMERAL NAIL LEFT 7MM X 230MM -,SUP-DHN5796,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13273.98,9291.786,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DISTAL HUMERUS MEDIAL DIRECT 105MM -,SUP-DHPF-MDL-5HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN SCREW DISTRACTION 12MM -,SUP-DP-12-TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,145.88,102.116,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN SCREW DISTRACTION 14MM -,SUP-DP-14-TY,CDM,C1713,HCPCS,278,RC,,,outpatient,,,145.88,102.116,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ULNAR STEM 6.0MM 2CM EXT STEM -,SUP-DRUJ-IS260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9932.28,6952.596,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING RADIAL PLATE SZ 20-15MM ASSY -,SUP-DRUJ-LP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19433.84,13603.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
14MM 3.5 LOCKING SCREW -,SUP-DRUJ-LSC14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,799.4,559.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
20MM 3.5 LOCKING SCREW -,SUP-DRUJ-LSC20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,799.4,559.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
22MM 3.5 LOCKING SCREW -,SUP-DRUJ-LSC22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,799.4,559.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
20MM 3.5 CORTICAL SCREW -,SUP-DRUJ-SC20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,636.02,445.214,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW DISTAL TROCHLEA COMP 3.5 X 45 TI -,SUP-DTCS-35045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW DISTAL TROCHLEA COMP 3.5 X 50 -,SUP-DTCS-35050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN DVR 24.4MMX51.3MM 4HL STD SHRT NS LT -,SUP-DVRAL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN DVR ANTMC NRW -,SUP-DVRANR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3828.27,2679.789,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN DVR 21.6MMX48.9MM 4HL SHRT BTRSS NRW NS -,SUP-DVRANSL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN DVR 21.6MMX48.9MM 4HL SHRT NS -,SUP-DVRANSR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN DVR 24.4MMX51.3MM 4HL STD SHRT NS RT -,SUP-DVRAR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN DVR 24.4MMX51.3MM 4HL STD SHRT NS RT RADL -,SUP-DVRASR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN DVR 28.2MMX62.6MM 4HL W NS -,SUP-DVRAWL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN DVR 28.2MMX62.6MM 4HL W BTRSS NS -,SUP-DVRAWR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN DVR 24.4MMX89.5MM 4HL EXTEND XLNG BTRSS NS -,SUP-DVRAXL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN DVR 24.4MMX59.5MM 4HL NS LT -,SUP-DVR-L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TORNIER PERFORM REVERESED CTRSCREW 6.5MM X 25MM NON ST -,SUP-DWJ125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TORNIER PERFORM REVERSED PERIPSCREW 5.0MM X 14MM NON ST -,SUP-DWJ314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1144.91,801.437,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TORNIER PERFORM REVERSED PERIPSCREW 5.0MM X 18MM NON ST -,SUP-DWJ318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1144.91,801.437,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
RESTRICTOR HUM CMNT 24MM F/TOT ELB PROS LTD -,SUP-EB0101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1166.11,816.277,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
RESTRICTOR CMNT TORNIER -,SUP-EBO101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1293.32,905.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ROMEO POLYAXIAL 6 X 40 -,SUP-ELL-PS 06 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X25MM SIGNTR POLYAX FX F /ROMEO PDCL SYS TI ALY -,SUP-ELL-PS0525-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X30MM SIGNTR POLYAX FX F /ROMEO PDCL SYS TI ALY -,SUP-ELL-PS0530-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL 5 X 35 -,SUP-ELL-PS0535-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL 6 X 30 -,SUP-ELL-PS0630-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X35MM SIGNTR POLYAX FX F /ROMEO PDCL SYS TI ALY -,SUP-ELL-PS0635-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 30MM -,SUP-ELL-RD 00 30 S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD ROMEO STRAIGHT HEX TIP 0.54 L240 -,SUP-ELL-RD 22 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN ROMEO 5.4X50MM PREBNT TI LMBR SFT MLBL F/TRNSCONN -,SUP-ELL-RD0050-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SET SCREW SPIN ROMEO2 -,SUP-ELL-SC 00 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFT STENT 49E X 36MM X 36MM ENDURANT II AO EXT -,SUP-ETCF3636C49E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18052.61,12636.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
STENT ENDURANT II GRAFT 16F X 16MM X 146MM LIMB -,SUP-ETLW1616C146E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFT STENT ENDUR II LIMB ELTW1620C146E -,SUP-ETLW1620C146E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
INFRAME IMPLANT 2.0MM X 32MM -,SUP-EXINF922032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
INFRAME EXSOMED IMPLANT 2.0MM X 36MM -,SUP-EXINF922036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6972.89,4881.023,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
INNATE IMPLANT 3.6MM X 35MM -,SUP-EXINN923635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL INTRAMEDULLARY INNATE IMPLANT 3.6MM X 40MM -,SUP-EXINN923640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
INNATE IMPLANT 3.6MM X 50MM -,SUP-EXINN923650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL INTRAMEDULLARY INNATE IMPLANT 3.6MM X 55MM -,SUP-EXINN923655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL INTRAMEDULLARY INNATE IMPLANT 4.5MM X 45MM -,SUP-EXINN924545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL INNATE IMPLANT 4.5MM X 50MM -,SUP-EXINN924550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
INNATE IMPLANT 4.5 X 55 -,SUP-EXINN924555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
STRYKER EASY CLIP STAPLE -,SUP-EZ 20-20-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9747.74,6823.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
EASYCLIP 15 X 15 X 15 -,SUP-EZ15-15-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8823.28,6176.296,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
EASYCLIP FIXATION DEVICE 18 X 19 X 17 -,SUP-EZ18-19-17,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8823.28,6176.296,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
EASYCLIP FIXATION DEVICE 20 X 20 X 20 -,SUP-EZ20-20-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9747.74,6823.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
EASYCLIP 8 X 8 X 8MM -,SUP-EZM08-08-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6512.42,4558.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE FILLER DEVICE SIZE 3 -,SUP-F04B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,577.67,404.369,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DEVICE BN FIL FEM SZ2 KYPHX EXP STRL -,SUP-F06A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,577.67,404.369,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX 8.5 CAGE -,SUP-F28-3182,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SHAFT FROZEN BISECTED FEM -,SUP-FBFS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4383.06,3068.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CLAMP CRANIAL 11MM CRANIOFIX -,SUP-FF490T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,695.9,487.13,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CLAMP CRANIAL 16MM TITANIUM CRANIOFIX 2 -,SUP-FF491T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,862.41,603.687,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CLAMP CRANIAL 20MM TITANIUM CRANIOFIX 2 -,SUP-FF492T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1035.56,724.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FREEFIX  COMPRESSION 3.5MM X 20MM TI -,SUP-FFC-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FREEFIX COMPRESSION 3.5MM X 22MM TI -,SUP-FFC-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FREEFIX COMPRESSION 3.5MM X 24MM TI -,SUP-FFC-35240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FREEFIX COMPRESSION 4.5MM X 20MM TI -,SUP-FFC-45200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1009.46,706.622,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FREEFIX COMPRESSION 4.5MM X 20MM TI -,SUP-FFC-45240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1009.46,706.622,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFT HUMAN TISSUE FEMORAL HEAD 43MM -,SUP-FFH,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4839.09,3387.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFT HUMAN TISSUE FEMORAL HEAD 43MM -,SUP-FFH,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4839.09,3387.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WEDGE FIBULA 18MM FROZEN -,SUP-FFIBW8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2636.84,1845.788,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FREEFIX LOCKING 3.5MM X 20MM TI -,SUP-FFL-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FREEFIX LOCKING 3.5MM X 22MM TI -,SUP-FFL-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FREEFIX LOCKING 3.5MM X 26MM TI -,SUP-FFL-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FREEFIX LOCKING 4.5MM 22MM TI -,SUP-FFL-45220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PRESUTURED ALLOGRAFT -,SUP-FGL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9411.49,6588.043,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFT HUM TIS SPCR FRZN FLEXIGRAFT MNSCS R/M LF -,SUP-FMNRM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14676.34,10273.438,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X8MM LCK FT TI ALPS -,SUP-FP08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X10MM LCK FT TI ALPS NS -,SUP-FP10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X11MM LCK FT TI ALPS NS -,SUP-FP11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X12MM LCK FT TI ALPS NS -,SUP-FP12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X13MM LCK FT TI ALPS NS -,SUP-FP13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X14MM LCK FT TI ALPS -,SUP-FP14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X15MM LCK FT TI ALPS -,SUP-FP15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X16MM LCK FT TI ALPS -,SUP-FP16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2X18MM LCK FT TI DVR NS -,SUP-FP18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X20MM LCK FT TI DVR NS -,SUP-FP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X22MM LCK FT TI F3 NS -,SUP-FP22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X24MM LCK FT TI ALPS -,SUP-FP24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X26MM LCK FT TI ALPS NS -,SUP-FP26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X28MM LCK FT TI ALPS -,SUP-FP28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X30MM LCK FT TI F3 NS -,SUP-FP30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFT HUM TIS FRZN 230CM 7.5MM FLEXIGRAFT PRNS LONGUS TNDN -,SUP-FPLT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.1,4960.97,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 120MM -,SUP-G100-5-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 200MM -,SUP-G100-5-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 400MM -,SUP-G100-5-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 6.0MM STRAIGHT -,SUP-G100-5-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 100MM -,SUP-G150-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIROD 200MM STRAIGHT -,SUP-G150-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 30MM -,SUP-G150-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 35MM -,SUP-G150-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD CURVED 40MM -,SUP-G150-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 40MM CURVED -,SUP-G150-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 45MM -,SUP-G150-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD CURVED 50MM -,SUP-G150-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 55MM -,SUP-G150-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD CURVED 60MM -,SUP-G150-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 65MM GENESYS -,SUP-G15065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 70MM GENESYS -,SUP-G150-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 75MM -,SUP-G150-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 80MM GENESYS -,SUP-G150-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 85MM SPINAL -,SUP-G150-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 90MM -,SUP-G150-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 95MM -,SUP-G150-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 300MM GENESYS -,SUP-G300-5-300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CONNECTOR CROSS LINK LARGE -,SUP-G301-LRG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CROSSLINK MED -,SUP-G301-MED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CROSS LINK -,SUP-G301-SM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
27-35MM CC -,SUP-G301-XSM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
COIL MICRONESTER EMBOLIZATION 0.018 X 7CM X 6MM -,SUP-G52738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,916.1,641.27,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS COMP. 4.0MM 36M -,SUP-G58036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 5.5 X 30MM -,SUP-G700-55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 6.5 X 35MM -,SUP-G700-65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5 X 30MM GENESYS -,SUP-G701-55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW PEDICLE 5.5 X 35MM TI LO -,SUP-G701-55-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW PEDICLE 5.5MM X 40MM -,SUP-G701-55-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TI LOCK 5.5 X 45MM -,SUP-G701-55-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW PEDICLE 6.5 X 30MM -,SUP-G701-65-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW PEDICLE 6.5 X 35MM -,SUP-G701-65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW PEDICLE 6.5 X 40MM -,SUP-G701-65-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TI LOCK 6.5 X 45MM -,SUP-G701-65-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
6.5 X 50MM PEDICLE SCREW -,SUP-G701-65-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TI-LOCK 7.5 X 30MM -,SUP-G701-75-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TI-LOCK 7.5 X 35MM -,SUP-G701-75-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW PEDICLE 7.5 X 40MM -,SUP-G701-75-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TI-LOCK 7.5 X 45MM -,SUP-G701-75-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
7.5 X 50MM PEDICLE SCREW -,SUP-G701-75-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8.5MM X 70MM -,SUP-G701-85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CROSSLINK -,SUP-G701-XSM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MM X 25MM -,SUP-G702-45-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MM X 30MM -,SUP-G702-45-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 5.0 X 25MM -,SUP-G702-50-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 5.0 X 30MM NEW -,SUP-G702-50-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CORTICAL SCREW 25 X 5.5MM -,SUP-G7025525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 5.5 X 25 -,SUP-G702-55-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5 X 45 GENESYS -,SUP-G702-55-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 6.5 X 40MM -,SUP-G702-65-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 7.5 X 45 -,SUP-G702-75-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8.5MM X 45MM -,SUP-G710-85-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ILIAC 8.5 X 60 -,SUP-G710-85-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SPINE 8.5 X 70 -,SUP-G710-85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SPINE 8.5 X 80 -,SUP-G710-85-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HI TOP 6.5 X 35 -,SUP-G711-65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ILIAC 8.5 X 70 -,SUP-G741-85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
OFFSET -,SUP-G780-21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
OFFSET 61 -,SUP-G780-61,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAP CIRCULAR TI LOCKING -,SUP-G826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SET 8.5 -,SUP-G826-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAP LOCKING TI -,SUP-G828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SET CAPS -,SUP-G828-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 5MM SMALL -,SUP-GAC-05-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR APACHE CAGE 7MM -,SUP-GAC-07-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
APACHE CAGE ANCHORED 8MM -,SUP-GAC-08 SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE H8 -,SUP-GAC-08-SC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
APACHE ANCHORED 8MM -,SUP-GAC-08-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 9MM -,SUP-GAC-09-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE APACHE ANCHORED 10MM -,SUP-GAC-10SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
APACHE ANCHORED 6MM -,SUP-GAC3D06-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
APACHE ANCHOR LARGE -,SUP-GAC-LG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR MEDIUM -,SUP-GAC-MD,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SMALL -,SUP-GAC-SM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR GREEN XL -,SUP-GAC-XL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR XXL BROWN -,SUP-GAC-XXL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BUTTRES 22MM -,SUP-GBP1-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9549,6684.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 22MM 5.5 -,SUP-GBP1-2255,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
9mm CERVICAL PECK CAGE APACHE -,SUP-GCL-09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE SMALL APACHE 11MM -,SUP-GCL-11-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 12MM -,SUP-GCP10012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 14MM -,SUP-GCP10014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 14MM RESCU -,SUP-GCP10014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 16MM -,SUP-GCP10016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 35MM -,SUP-GCP20035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BINARY 12MM -,SUP-GCP2-112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 14MM -,SUP-GCP2-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 16MM -,SUP-GCP2-116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CERVICAL 49MM -,SUP-GCP2-349,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.75MM X 16MM BINARY AUGER TIP FIXED -,SUP-GCP2-AF316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREWS 3.75 X 14MM SCREWS -,SUP-GCP2-AV314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.75MM X 18MM BINARY AUGER TIP VAIABLE -,SUP-GCP2-AV318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREWS 4.25 X 12MM -,SUP-GCP2-AV412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FIXED CERV 3.75 X 14MM -,SUP-GCSF37514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 14MM -,SUP-GCSV37514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW VA 16MM -,SUP-GCSV37516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW RESCUE 16MM -,SUP-GCSV42516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
APACHE ANCHOR 6MM -,SUP-GCV-06-SO,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE APACHE 6MM -,SUP-GCV-06-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE APACHE ANCHORED 8MM -,SUP-GCV-08-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE APACHE ANCHORED 9MM -,SUP-GCV-09-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR LARGE -,SUP-GCV-LG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDE PIN 2.0MM X 125MM -,SUP-GDW-890-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.44,297.108,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
6.5 X 40MM PEDICLE SCREW -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CERVICAL APACHE CAGE 8MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CERVICAL 2 LEVEL 32MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BINARY 2 LEVEL CERVICAL 30MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 7.5 X 30MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW REDUCTION 6.5 X 30MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE STANDARD 31MM -,SUP-GLP-131,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 22MM -,SUP-GLPV-55 22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPINE 60MM -,SUP-GM150-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SET SCREW -,SUP-GM520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
MODULAR CORT IMPLANT HEAD -,SUP-GM557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
MODULAR LOCK SCREW -,SUP-GM820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DORSAL SPANNING SHORT -,SUP-GMN-DSP-160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6217.46,4352.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BONE GEMINUS TITANIUM DORSAL SPANNING LONG -,SUP-GMN-DSP-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6416.93,4491.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BONE GEMINUS TITANIUM RADIAL DISTAL DORSAL HOOK -,SUP-GMN-HP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2592.28,1814.596,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW PLATE BONE GEMINUS TITANIUM RADIAL DISTAL DORSAL HOOK -,SUP-GMN-HP-SCRW,CDM,C1713,HCPCS,278,RC,,,outpatient,,,566,396.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ASSEMBLED GEMINUS VOLAR DISTAL RADIUS PLATE NARR 120MM LEFT -,SUP-GMN-LTN-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9969.16,6978.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DIST RAD NARR 3 HOLE LEFT GEMINUS VOLAR -,SUP-GMN-LTN-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE NARROW DIS RAD 4 HOLE LEFT -,SUP-GMN-LTN-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE VOLAR DIST RAD STANDARD 3 HL LEFT -,SUP-GMN-LTS-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE GEMINUS VOLAR DISTAL RADIUS STANDARD 4 HOLE LEFT -,SUP-GMN-LTS-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE ASSEMBLED GEMINUS VOLAR DIST RAD NARROW 120MM RIGHT -,SUP-GMN-RTN-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9969.16,6978.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE VOLAR DISTAL RADIUS NARROW 3 HOLE RIGHT -,SUP-GMN-RTN-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DISTAL RADIUS PLATE- NARROW 4 HOLE RT. -,SUP-GMN-RTN-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE VOLAR DIST RADIUS STD 3 HOLD RIGHTTI GEMINUS -,SUP-GMN-RTS-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DISTAL RADIUS VOLAR GEMINUS WIDE 4HL RIGHT -,SUP-GMN-RTW-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4621.72,3235.204,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5 X 30 -,SUP-GMSD 55 30-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5 X 45 -,SUP-GMSD 55 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 4.5 X 30MM -,SUP-GMSD45-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5 X 35 -,SUP-GMSD-50 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 5.0 X 30MM -,SUP-GMSD50-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 5.0 X 35MM NEW -,SUP-GMSD50-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.0 X 4.0 -,SUP-GMSD50-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 55 X 35 -,SUP-GMSD-55 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 5.5 X 30 -,SUP-GMSD55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CORTICAL MODULAR SCREW 5.5 X 35 -,SUP-GMSD55-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 5.5 X 35 -,SUP-GMSD55-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL SPINE 5.5 X 40 -,SUP-GMSD55-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 5.5 X 45 -,SUP-GMSD55-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 6 X 35 -,SUP-GMSD-60 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 6 X 30 -,SUP-GMSD60-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CORTICAL SCREW 6 X 35 -,SUP-GMSD60-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GENESYS CORTICAL SCREW 6.5MM X 35MM -,SUP-GMSD60-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MODULAR 6.0 x 40 -,SUP-GMSD60-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 65 X 35 -,SUP-GMSD-65 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORITCAL SPINE 6.5 X 35 -,SUP-GMSD65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL SPINE 6.5 X 40 -,SUP-GMSD65-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 6.5 X 45 -,SUP-GMSD65-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW GENESYS MODULAR 6.5 X 50MM -,SUP-GMSD65-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 7.5 X 40 -,SUP-GMSD75-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 75 X 45 -,SUP-GMSD75-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 75 X 50 -,SUP-GMSD75-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 8.5 X 70 -,SUP-GMSD85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5 X 30 -,SUP-GMSP55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.0 X 30 -,SUP-GMSP60-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2-PIECE PIN TIP SECTION-TROCAR TIP -,SUP-GSI209-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,571.83,400.281,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2-PIECE PIN-TAIL SECTION 750MM W/TIP -,SUP-GSI210-02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2P PIN TAIL -,SUP-GSI210-02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
350 TROCAR PIN -,SUP-GSI211-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 9.5 X 35 -,SUP-GSI-SDW09535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 9.5 X 40 -,SUP-GSI-SDW09540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 9.5 X 40 -,SUP-GSI-SDW09545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 9.5 X 60 SI SUAL THREAD WASHER HEAD -,SUP-GSI-SDW09560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
POSTERIOR ALLOGRAFT 20MM -,SUP-GSPA-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
APACHE ANCHOR 8MM -,SUP-GVC-08-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
APACHE ANCHORED 9MM -,SUP-GVC-09-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDE PIN 2.0MM X 150MM -,SUP-GW0920061501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,306.34,214.438,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE CAN PT TI 4.0 X 24MM -,SUP-H00693,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE CAN PT TI 4.0 X 26MM -,SUP-H00693,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X40MM CANC POLARUS FT CNTRSNK TI NS -,SUP-HCA-5140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X45MM CANC POLARUS FT CNTRSNK TI NS -,SUP-HCA-5145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.3X35MM LCK CANC POLARUS FT TI STRL -,SUP-HCA-L5335-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.3X40MM LCK CANC POLARUS FT TI STRL -,SUP-HCA-L5340-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.3X45MM LCK CANC POLARUS FT TI STRL -,SUP-HCA-L5345-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG HIGH COMPRESSION LOCKING 2.7 X 18 -,SUP-HCLP-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG HIGH COMPRESSION LOCKING 2.7MM  X 19MM TI -,SUP-HCLP-27190-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG HIGH COMPRESSION LOCKING 2.7MM  X 20M TI -,SUP-HCLP-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG HIGH COMPRESSION LOCKING 2.7MM  X 21M TI -,SUP-HCLP-27210-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
HIGH COMP PEG LCK 2.7 X 22 -,SUP-HCLP-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
HIGH COMPRESSION LOCKING PEG 2.7MM X 28MM TI -,SUP-HCLP-27280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X20MM NLCKG CORT POLARUS TI STRL -,SUP-HCO3200-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X25MM NLCKG CORT POLARUS TI STRL -,SUP-HCO3250-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX32.5MM NLCKG CORT POLARUS TI STRL -,SUP-HCO3325-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS COMP 2.5 X 14 -,SUP-HCS-25014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS COMP 2.5 X 16 -,SUP-HCS-25016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS COMPRESSION 2.5MM X 18MM -,SUP-HCS-25018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS COMP 2.5MM X 22MM TI -,SUP-HCS-25022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS COMP 2.5MM X 24MM TI -,SUP-HCS-25024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS COMP 2.5MM X 26MM TI -,SUP-HCS-25026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS COMPRESSION 2.5MM X 30MM -,SUP-HCS-25030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD IM 8X240MM POLARUS + CANN TAPR PRFL HUM TI STAB -,SUP-HR-0824-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9312.2,6518.54,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD IM 11X150MM POLARUS PROX HUM -,SUP-HR-L1115-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10452.97,7317.079,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADED 2.5 X 12MM -,SUP-IC2512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.5MM HEADED SCREW LENGTH 14MM -,SUP-IC2514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE MINI HEADED 2.5 X 18MM -,SUP-IC2518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5 HEADED 20MM LENGTH -,SUP-IC2520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADED 2.5 X 22MM -,SUP-IC2522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.5 MM HEADED 26MM LENGTH MINI CANN SCREW -,SUP-IC2526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
MINI SET SCREW 2.5X28MM -,SUP-IC2528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.5 MM HEADED 30MM LENGTH MINI CANN SCREW -,SUP-IC2530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.0 X 10MM CANNULATED SCREW -,SUP-IC3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.0 HEADED 18MM -,SUP-IC3018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.0MM HEADED 22MM LENGTH CANN SCREW -,SUP-IC3022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.0MM HEADED 24MM LENGTH CANN SCREW -,SUP-IC3024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.0MM HEADED 26MM LENGTH MINI CANN SCREW -,SUP-IC3026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MM X 30MM -,SUP-IC3030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.0 HEADED 32MM LENGTH -,SUP-IC3032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.0MM HEADED 34MM LENGTH -,SUP-IC3034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.0MM HEADED 38MM LENGTH -,SUP-IC3038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADED 3.0 X 40MM -,SUP-IC3040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.0MM HEADED 20MM LENGTH MINI CANN SCREW -,SUP-IC4020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.0MM HEADED SCREW LENGTH 32MM -,SUP-IC4032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.0MM HEADED SCREW LENGTH 34MM -,SUP-IC4034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.0MM HEADED 36MM LENGTH MINI CANN SCREW -,SUP-IC4036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.0MM HEADED 38MM LENGTH MINI CANN SCREW -,SUP-IC4038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.0MM HEADED 40MM LENGTH MINI CANN SCREW -,SUP-IC4040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE MINI 46MM X 4MM HEAD NONSTERILE -,SUP-IC4046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.0MM HEADED SCREW LENGTH 48MM -,SUP-IC4048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE MINI 50MM X 4MM HEAD NONSTERILE -,SUP-IC4050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
INFLUX SPARC (IBM) 1CC -,SUP-IFLX-CM-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2597.25,1818.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
INFLUX SPARC (IBM) 5CC -,SUP-IFLX-CM-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8530.44,5971.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
HEADLESS SCREW 2.5X10MM -,SUP-IH2510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.5MM HEADLESS SCREW LENGTH 20MM -,SUP-IH2520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.5MM HEADLESS SCREW LENGTH 24MM -,SUP-IH2524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.5MM HEADLESS SCREW LENGTH 26MM -,SUP-IH2526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.5MM HEADLESS SCREW LENGTH  30MM -,SUP-IH2530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE MINI 2.5 X 36MM HEADLESS -,SUP-IH2536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.0 X 14MM HEADLESS SCREW -,SUP-IH3014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.0 X 22MM HEADLESS -,SUP-IH3022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.0 X 24MM HEADLESS -,SUP-IH3024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.0 X 26MM HEADLESS -,SUP-IH3026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS 3.0MM X 30MM -,SUP-IH3030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.0 X 32MM HEADLESS SCREW -,SUP-IH3032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.0 X 34MM HEADLESS SCREW -,SUP-IH3034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS 3.0MM X 36MM -,SUP-IH3036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS 3.0MM X 38MM -,SUP-IH3038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS 3.0MM X 40MM -,SUP-IH3040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.0MM HEADLESS SCREW LENGTH 32MM -,SUP-IH4032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS 4.0MM X 16MM X 36MM -,SUP-IH4036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS 4.0MM X 38MM -,SUP-IH4038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS 4.0MM X 40MM -,SUP-IH4040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS 4.0MM X 42MM -,SUP-IH4042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS 4.0MM X 46MM -,SUP-IH4046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS 4.0MM X 50MM -,SUP-IH4050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN AXIS 2.5MM X 40MM IJS-E -,SUP-IJS-EAP-25400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1727.96,1209.572,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN IJS-E AXIS 2.5MM X 45MM -,SUP-IJS-EAP-25450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1727.96,1209.572,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BLADE T10 DRIVER 4.0 SCREWS -,SUP-IS1108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,921.23,644.861,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PK SCREW INTNL FX STRL CONTR -,SUP-JG303R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21.15,14.805,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 28MMX10MM JULIET OL LD SHARING ANTMC PEEK -,SUP-JUL-OL 28 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 7X28MM STR -,SUP-JUL-OX2807-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE LUMBAR POSTERIOR TI L24 W8 H7 -,SUP-JUN-P6 24 07-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
8 X 24 PLIF TITANIUM CAGE -,SUP-JUN-P6 24 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE LUMBAR POSTERIOR TI L24 W8 H09 6 DEGREE NARROW JULIET -,SUP-JUN-P6 24 09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE PLIF TI 24 X 8.5 X 10 -,SUP-JUN-P6 24 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LUMBAR POSTERIOR TI CAGE L24 W9 H11 -,SUP-JUN-P6 24 11-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 24 X 9 X 12 PLIF 6 DEGREE -,SUP-JUN-P6 24 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE LUMBAR POSTERIOR TI 14 X 9 X 24 6DEG -,SUP-JUN-P6 24 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LUMBAR POSTERIOR TI CAGE L24 X W8 X H07 6 DEGREE -,SUP-JUN-P62407-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LUMBAR POSTERIOR TI CAGE L24 W8.5 H10 -,SUP-JUN-P62410-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE POSTERIOR LUMBAR TI L24 X W9 X H11 6DEG JULIET -,SUP-JUN-P62411-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TITANIUM PLIF CAGE L24 X W9 X H12 6 DEGREE -,SUP-JUN-P62412-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LUMBAR POSTERIOR TI CAGE L24 W10.5 -,SUP-JUT PX 24 09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE TRANSORAMINLA LUMBAR TI L30 W 10.5 -,SUP-JUT-T6 30 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE LUMBAR TRANSFORAMINAL L30 W 10.5 -,SUP-JUT-T6 30 09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE TRANSFORAMINAL LUMBAR TI CAGE L30 W 10.5 H10 -,SUP-JUT-T6 30 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE TRANSFORAMINAL LUMBAR TI L30 W 10.5 H 11 -,SUP-JUT-T6 30 11-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE TRANSFORAMINAL LUMBAR TI L30 W10.5 H12 6 DEG -,SUP-JUT-T6 30 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE TRANSORAMINAL LUMBAR TI L 30 W 10.5 H 13 -,SUP-JUT-T6 30 13-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SYS BONE CMNT PARALLAX EZFLOW -,SUP-KP-CDS-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
KT DEVICE PARALLAX CONTR -,SUP-KP-CTR-1508C-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7002.6,4901.82,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
STENT ADVANIX BIL 10FR X 3CM DBL PIGTAIL -,SUP-M00532240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.44,231.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DISK SPIN MOBI- C COCR MLYBDNM EPLT UHMWPE INLAY 13X15X5MM -,SUP-MB3355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PROSTHESIS CERV DISC 13 X 17 H -,SUP-MB3375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DISC SPIN MOBI- C COCR MLYBDNM EPLT UHMWPE INLAY 15X15X5MM -,SUP-MB3555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DISC SPIN MOBI- C PROS COCR MLYBDNM EPLT UHMWPE INLAY -,SUP-MB3576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE 40MM ROD -,SUP-MC1-200040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT ROI-C 7MM 12 X 14MM LO -,SUP-MC1343P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE CERV 10MM/7.2MM H A/P ROI- C LRDTC -,SUP-MC1426P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE CERV 5MM/2.3MM H A/P ROI- C LRDTC -,SUP-MC1441P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE CERV 6MM/3.1MM H A/P ROI- C LRDTC -,SUP-MC1442P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE CERV 8MM/5.1MM H A/P ROI- C LRDTC -,SUP-MC1444P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE CERV 9MM/6.1MM H A/P ROI- C LRDTC -,SUP-MC1445P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT ROI-C LORDOSED 12X15.5 -,SUP-MC1454P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.8X22MM S3 MULDIR NS -,SUP-MD22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.8X24MM S3 MULDIR NS -,SUP-MD24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.8X26MM S3 MULDIR NS -,SUP-MD26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.8X28MM S3 MULDIR NS -,SUP-MD-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.8X28MM S3 MULDIR NS -,SUP-MD-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.8X30MM S3 MULDIR NS -,SUP-MD30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.8X32MM S3 MULDIR NS -,SUP-MD32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.8X34MM S3 MULDIR NS -,SUP-MD34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.8X36MM S3 MULDIR NS -,SUP-MD36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.8X38MM S3 MULDIR NS -,SUP-MD38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5MM X 40MM CANNULATED POLYAXIAL -,SUP-MPF-PX  55 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5MM X 35MM CANNULATED POLYAXIAL -,SUP-MPF-PX 55 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
MIDSHAFT RADIUS PLATE 112MM -,SUP-MRP-112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5996.77,4197.739,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE FREEFIX MIDSHAFT RADIUS 127MM -,SUP-MRP-127,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SIZER NATRELLE INSPIRA 325CC FULL -,SUP-MSZ-F325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SIZER NATRELLE INSPIRA 345CC FULL -,SUP-MSZ-F345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SIZER NATRELLE INSPIRA 450CC FULL -,SUP-MSZ-F450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SIZER NATRELLE INSPIRA 485CC FULL -,SUP-MSZ-F485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SIZER NATRELLE INSPIRA 330CC MODERATE -,SUP-MSZ-M330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SIZER NATRELLE INSPIRA 445CC MODERATE -,SUP-MSZ-M445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SIZER NATRELLE INSPIRA 485CC MODERATE -,SUP-MSZ-M485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MULTI-THREAD LOCKING 2.7MM X 18MM TI -,SUP-MTLS-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MULTI-THREAD LOCKING 2.7MM X 20MM -,SUP-MTLS-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MULTI-THREAD LOCKING 2.7 X 22 -,SUP-MTLS-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MULTI THREAD LOCKING 2.7MM X 32MM TI -,SUP-MTLS-27320-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MULTI THREADED LOCKING 3.0MM X 10MM TI -,SUP-MTLS-30100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MULTI THREADED LOCKING 3.0MM X 12MM TI -,SUP-MTLS-30120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MULTI THREADED LOCKING 3.0MM X 14MM TI -,SUP-MTLS-30140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MT LOCKING 3.5MM X 8MM TI -,SUP-MTLS-35080-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MT LOCKING 3.5MM X 10MM TI -,SUP-MTLS-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MT LOCKING 3.5MM X 12MM TI -,SUP-MTLS-35120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MT LOCKING 3.5MM X 14MM TI -,SUP-MTLS-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MT LOCKING 3.5MM X 16MM TI -,SUP-MTLS-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MT LOCKING 3.5MM X 18MM TI -,SUP-MTLS-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MT LOCKING 3.5MM X 20MM TI -,SUP-MTLS-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MT LOCKING 3.5MM X 22MM TI -,SUP-MTLS-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MT LOCKING 3.5MM X 24MM TI -,SUP-MTLS-35240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MT LOCKING 3.5MM X 26MM TI -,SUP-MTLS-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MT LOCKING 3.5MM X 28MM TI -,SUP-MTLS-35280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE LKG 3.5MM X 32MM MULTITHREAD TI -,SUP-MTLS-35320-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE TITANIUM MULTI-THREAD LOCKING 3.5 X 34 -,SUP-MTLS-35340-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MULTI-THREAD LOCKING 3.5MM X 36MM TI -,SUP-MTLS-35360-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MULTI-THREAD LOCKING 3.5MM X 38MM TI -,SUP-MTLS-35380-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE TITANIUM MULTI-THREAD LOCKING 3.5 X 40 -,SUP-MTLS-35400-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MULTI THREAD LOCKING 3.5MM X 42MM TI -,SUP-MTLS-35420-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MULTI-THREAD LOCKING 3.5MM X 55MM TI -,SUP-MTLS-35550-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MULTI-THREAD COMPRESSION 3 X 10 -,SUP-MTNL-30100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MULTI THREAD COMP 3.0MM X 12MM TI -,SUP-MTNL-30120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MULTI-THREAD COMPRESSION 3.0MM X 16MM TI -,SUP-MTNL-30160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE TITANIUM MULTI-THREAD LOCKING 3.5 X 10 -,SUP-MTNL-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MT COMP 3.5MM X 14MM TI -,SUP-MTNL-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MT COMP 3.5MM X 16MM TI -,SUP-MTNL-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MT COMP 3.5MM X 18MM TI -,SUP-MTNL-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MT COMP 3.5MM X 22MM TI -,SUP-MTNL-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MT COMP 3.5MM X 40MM TI -,SUP-MTNL-35400-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MULTI THREAD COMPRESSION 3.5MM X 42MM TI -,SUP-MTNL-35420-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MT COMP 3.5MM X 45MM TI -,SUP-MTNL-35450-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MT COMP 3.5MM X 50MM TI -,SUP-MTNL-35500-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MT COMP 3.5MM X 60MM TI -,SUP-MTNL-35600-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
MIDSHAFT ULNA PLATE 97MM -,SUP-MUP-097,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5937.36,4156.152,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE MIDSHAFT ULNA 112MM -,SUP-MUP-112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5996.77,4197.739,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
MACROFORM NOVABONE 5CC -,SUP-NB1002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
MACROFORM 5CC -,SUP-NB4305,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.8X20MM LCK S3 90DG ANG TI NS -,SUP-NL20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.8X24MM LCK S3 90DG ANG TI NS -,SUP-NL24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.8X26MM LCK S3 90DG ANG TI NS -,SUP-NL-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.8X28MM LCK S3 90DG ANG TI NS -,SUP-NL28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.8X30MM LCK S3 90DG ANG TI NS -,SUP-NL30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.8X32MM LCK S3 90DG ANG TI NS -,SUP-NL32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK 90DG ST BN HND SHLDR -,SUP-NL-SS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,408.45,285.915,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK 90DG ST BN HND SHLDR -,SUP-NL-SS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN FX STNMN 18INX9IN DBL END TROC SMTH SS -,SUP-OM 71-0459,CDM,C1713,HCPCS,278,RC,,,outpatient,,,69.73,48.811,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ARTHROSCOPIC FX MAGNUM2 ACC F/SHLDR FT/ANKL RPR HALLUX -,SUP-OM-1502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1106.83,774.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT MAG PI -,SUP-OM-4500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DEVICE SUT MAG 2 + SMARTSTITCH KNTLS -,SUP-OM-9026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SFT TIS 3.2MM KNTLS FX W/PERFECTPASSER MAGNUMWR SUT -,SUP-OM-9146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3079.23,2155.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SFT TIS 3.2MM PNCH MAG PI + -,SUP-OM-9147,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3079.23,2155.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2X14MM LCK SMTH TI DVR NS -,SUP-P14000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2X16MM LCK SMTH TI DVR NS -,SUP-P16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2X20MM LCK SMTH TI DVR NS -,SUP-P20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2X22MM LCK SMTH TI DVR NS -,SUP-P22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2X26MM LCK SMTH TI DVR NS -,SUP-P26000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL LCK 2.5 X 10 CANNULATED COCR -,SUP-PALS-25100-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL LCK 2.5 X 16 CANNULATED COCR -,SUP-PALS-25160-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL LCK 2.5 X 22MM CANNULATED COCR -,SUP-PALS-25220-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE GEMINUS POLY LOCKING 2.5MM X 24MM CANN COCR -,SUP-PALS-25240-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXL LCK 2.5MM X 26MM CANN -,SUP-PALS-25260-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL LOCKING 3.0MM X 18MM CANNULATED -,SUP-PALS-30180-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL LOCKING 3.0MM X 22MM CANNULATED -,SUP-PALS-30220-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL LOCKING 3.0MM X 24MM CANN -,SUP-PALS-30240-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXAIL LCK 3.0 X 34 -,SUP-PALS-30340-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL LOCKING 3.0MM X 55MM CANNULATED -,SUP-PALS-30550-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
THREADED PEG CORTICAL NON-LOCKING 2.7MM X 10MM TI -,SUP-PANL-27140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL NON LOCKING 2.7 X 16 -,SUP-PANL-27160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW PEG THREADED CORTICAL NON-LOCKING 2.7MM X 18MM TI -,SUP-PANL-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG THREADED CORTICAL NON-LOCKING 2.7MM X 20MM TI -,SUP-PANL-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG THREADED CORTICAL NON-LOCKING 2.7MM X 22MM TI -,SUP-PANL-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG THREADED CORTICAL NL 2.7MM X 26MM TI -,SUP-PANL-27260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL NON LOCKING 3.5 X 9 -,SUP-PANL-35090-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL NON LOCKING 3.5 X 10 -,SUP-PANL-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL NON LOCKING 3.5MM X 11MM -,SUP-PANL-35110-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW- CORTICAL NON-LOCKING 3.5MM X 12MM -,SUP-PANL-35120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON-LOCK 3.5 X 13 POLY TI -,SUP-PANL-35130-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE ASSEMBLED PROTEAN FRAGMENT DOUBLE HOCKEY STICK -,SUP-PANL-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4596.25,3217.375,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON-LOCK 3.5 X 14 POLY TI -,SUP-PANL-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON-LOCK 3.5 X 15 POLY TI -,SUP-PANL-35150-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL NON LOCKING 3.5MM X 16MM TI -,SUP-PANL-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL NON LOCKING 3.5MM X 18MM TI -,SUP-PANL-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON-LOCK 3.5 X 20 POLY TI -,SUP-PANL-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON-LOCK 3.5 X 22 POLY TI -,SUP-PANL-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL NON LCK 3.5MM X 26MM TI -,SUP-PANL-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL NON LOCKING 3.5MM X 28MM TI -,SUP-PANL-35280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MM X 10MM -,SUP-PC1-003510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MM X 12MM -,SUP-PC1-003512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NORTHSTAR 3.5 X 14 SCREW -,SUP-PC1-003514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE 3.5MM X 16MM SCREW -,SUP-PC1-003516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NORTHSTAR SCREW 3.5 X 18 -,SUP-PC1-003518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLY SEASPINE 3.5 MM X 20 MM -,SUP-PC1-003520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE SCREW 3.5MM X 22MM -,SUP-PC1-003522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE SCREW 35 X 24 -,SUP-PC1-003524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE SCREW 3.5 X 26 -,SUP-PC1-003526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE SCREW 4MM X 10MM -,SUP-PC1-004010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE NORTHSTAR 4MM X 12MM SCREW -,SUP-PC1-004012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MM X 14MM SPINE POLYAXIAL -,SUP-PC1-004014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MM X 16MM SPINE POLYAXIAL -,SUP-PC1004016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3007.62,2105.334,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL 4.0 X 16 SEASPINE -,SUP-PC1-004016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SEASPINE 4.0 X 18 POLYAXIAL -,SUP-PC1-004018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NORTHSTAR SCREW 4 X 20 -,SUP-PC1-004020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SEASPINE 4.0 X 22 POLYAXIAL -,SUP-PC1-004022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SEASPINE 4.0 X 24 POLYAXIAL -,SUP-PC1-004024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE SCREW 4MM X 26MM -,SUP-PC1-004026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE SCREW 4MM X 28MM -,SUP-PC1-004028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4 X 30 -,SUP-PC1-004030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE SCREW 4.0 X 34 -,SUP-PC1-004034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CROSS LINK MED 3.5 -,SUP-PC1-013502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CROSSHOLE LARGE 3.5MM -,SUP-PC1-013503,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE MD CROSSLINK -,SUP-PC1-014002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE LARGE CROSSLINK -,SUP-PC1-014003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LATERAL OFFSET -,SUP-PC1-020015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE 0-0CONNECTOR -,SUP-PC1-023540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PARALLELL TOP LOADING 5.5 -,SUP-PC1-023560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE 0-C CONNECTOR -,SUP-PC1-063535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE SCREW 4.5MM X 24MM -,SUP-PC1-104524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE 4.5 X 26 NS#2 -,SUP-PC1-104526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE 5.5 X 26 NS#2 -,SUP-PC1-104526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE SCREW 4.5MM X 28MM -,SUP-PC1-104528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE SCREW 4.5 X 30 NS#2 -,SUP-PC1-104530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE SCREW 4.5 X 34 -,SUP-PC1-104534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE SCREW 3.5 X 24 SS -,SUP-PC1-203524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE SCREW 3.5 X 26 SS -,SUP-PC1-203526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE SCREW 3.5 X 18 -,SUP-PC1-203528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.5 X 30MM SMOOTH SHANK SCREW -,SUP-PC1-203530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE REDUCTION SCREW 3.5 X 14 -,SUP-PC1-303514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SET OCCIPITOCERVICOTHORACIC FIXATION SYSTEM -,SUP-PC1-400000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE ROD OCC 3.5 X 170 -,SUP-PC1-503177,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPINAL100MM TITANIUM CONTOUR -,SUP-PC1-503500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE ROD -,SUP-PC1-503502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE 30MM ROD -,SUP-PC1-503530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPINAL 40MM -,SUP-PC1-503540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 50MM -,SUP-PC1-503550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPINAL 60MM TITANIUM CONTOUR -,SUP-PC1-503560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 70MM -,SUP-PC1-503570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 80MM -,SUP-PC1-503580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE NORTHSTAR 90MM ROD -,SUP-PC1-503590,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE ROD 4 X 120MM -,SUP-PC1-504002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE ROD 4X200MM -,SUP-PC1-504003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE ROD 80MM -,SUP-PC1-504080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE ROD 4 X 120 -,SUP-PC1-514012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE TRAN ROD 3.5 X 5.5 -,SUP-PC1-523555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1166.11,816.277,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE OCC PLATE -,SUP-PC1-700000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE CHIPS CANCELLOUS CRUSHED 1-8 MM 15 CC CHIP -,SUP-PCAN15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.36,804.552,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUBSTITUTE CANC 30ML CUBE RDIGRF PRESERVON CRSH VOID FIL -,SUP-PCANCUBE30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2148.98,1504.286,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
0 PDS PLUS VIOLET 1 X 27 CT-1 -,SUP-PDP340H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18.26,12.782,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAVIO BONE PIN 4.0MM X 89 -,SUP-PFSD-01008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.46,508.522,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUBSTITUTE WDG MATRGRF PRESERVON 18MM -,SUP-PICW8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3831.09,2681.763,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LEG CONTRA EXCLUDER AAA ENDO 16MM X 18MM X 11.5CM 12FR -,SUP-PLC181200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN F/ELB PLATE SYS 16HL LCK TI LNG NS -,SUP-PL-LEM16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6824.35,4777.045,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 11X84MM 7HL LCK TI CONGR NS PNK -,SUP-PL-LEM7,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6017.99,4212.593,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ANCHORAGE 6HL PRCONT LCK TI GRN LT -,SUP-PLP10341,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ANCHORAGE 6HL PRCONT LCK TI GRN RT -,SUP-PLP10342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ANCHORAGE F /HALLUX VALGUS V1 8HL PRCONT LCK TI LNG -,SUP-PLP10462,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE MTP 5-HOLE -,SUP-PLP11341,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ANCHORAGE F /HALLUX VALGUS V2 5HL PRCONT LCK TI GRN -,SUP-PLP11342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ANCHORAGE F/CX PLATE SYS 1.5MM TI THRD HL COLR -,SUP-PLP14341,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHORAGE MTP CP PLATE RIGHT -,SUP-PLP14342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ANCHORAGE F/CX PLATE SYS TI THRD HL GRN -,SUP-PLP14342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ANCHORAGE F/LPDS FUSION 0MM STP PRCONT LCK TI YEL -,SUP-PLP20342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ANCHORAGE F/LPDS FUSION 0MM STP PRCONT LCK TI CP -,SUP-PLP29371,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ANCHORAGE 28MM 4HL PRCONT SYM LCK UTIL TI PNK -,SUP-PLP40280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4564.66,3195.262,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN POLARUS 4HL SLOTX3 TI LRG NS -,SUP-PL-PHGR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5967.06,4176.942,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X10MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X12MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X14MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X16MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X18MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X20MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X16MM LCK ANCHORAGE T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X10MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X12MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X14MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,657.84,460.488,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X16MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,657.84,460.488,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X18MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,657.84,460.488,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X20MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X22MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X24MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X18MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X24MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHORAGE STANDARD SCREW 3.5 X 26MM -,SUP-PLSS3526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TROCAR CLOSURE SUTURE GRASPER -,SUP-PMI-TC-SG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,64.19,44.933,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TEMPORARY FIXATION PIN ADMIRAL -,SUP-PN AP2-100506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN FIXATION -,SUP-PN0920051001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,233.4,163.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE ASSEMBLED PROTEAN CENTRAL COLUMN LEFT -,SUP-PRT-CCP-LT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4681.13,3276.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PROTEAN CORONOID PLATE RIGHT -,SUP-PRT-CRD-RT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5237.1,3665.97,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PROTEAN FRAG DIST ULNA -,SUP-PRT-FSP-DU,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5054.6,3538.22,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE Y PROTEAN FRAGMENT -,SUP-PRT-FSP-YS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4596.25,3217.375,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
DEVICE FIXATION SIZE 18 4FUSION -,SUP-QUA-4F-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11849.67,8294.769,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 12MM X 2.7MM FUCHSIA U PLUS LOCKING -,SUP-RBL1224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1070.7,749.49,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 14MM X 2.7MM GOLD U PLUS LOCKING -,SUP-RBL1225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1070.7,749.49,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 50MM UPLUS RIB -,SUP-RBL1301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6463.61,4524.527,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X50MM -,SUP-RFS-S4500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
TRUNK IPSI EXCLUDER AAA ENDO 26MM X 14.5MM X 12CM 16FR -,SUP-RLT261412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,32100.6,22470.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SIZER SMOOTH ROUND MODERATE GEL XTRA 755 CC -,SUP-RSZSHPX755S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SIZER SMOOTH ROUND MODERATE GEL HP XTRA 790 CC -,SUP-RSZSHPX790S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 1.6MMX12.7MM SBFS SS -,SUP-SBFS062,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE CERVICAL LORDOTIC ANT D12 W15 H08 -,SUP-SCA-AC LS 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CERVICAL 3 X 14MM -,SUP-SCA-CS 3014-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
RSS 4.5MM STAR SCREW AND CAP 15MM L -,SUP-SCW-0961-046-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
RSS 4.5MM STAR SCREW AND CAP 20MM L -,SUP-SCW-0961-046-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
RSS 4.5MM STAR SCREW AND CAP 25MM L -,SUP-SCW-0961-046-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
RSS 4.5MM STAR SCREW AND CAP 30MM -,SUP-SCW-0961-046-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
KIT IMPLANT 10 X 9MM SPEED 1.5 X 1.5MM -,SUP-SE-0910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4623.62,3236.534,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPEED IMPLANT 11 X 08 X 08MM -,SUP-SE-1108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPEED IMPLANT 11X10X10MM -,SUP-SE-1110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPEED IMPLANT 15X15X15MM -,SUP-SE-1515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5690.99,3983.693,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
STAPLE -,SUP-SE-1815,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPEEDTITAM 18X15X15MM -,SUP-SE-1815TI,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7289.07,5102.349,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPEED IMPLANT TI 18X18X18MM -,SUP-SE-1818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5690.99,3983.693,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPEED COMPRESSION IMPLANT KIT 20X20X20 -,SUP-SE-2020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPEED TITAN IMPLANT 20 X 20 X 20MM -,SUP-SE-2020TI,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5644.52,3951.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO -,SUP-SFCW,CDM,C1713,HCPCS,278,RC,,,outpatient,,,379.28,265.496,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCARLET AL-T BONE SCREW 5 X 25MM -,SUP-SJT-LS 50 25-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X20MM CORT/CANC DVR FT HEX HEAD TI -,SUP-SP 20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,545.51,381.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X10MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP10000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG 2.5X11MM NLCKG SCR CANC DVR FT ST HEX HEAD TI NS F/ANTMC -,SUP-SP11000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X12MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP12000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X13MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP13000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X14MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP14000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X15MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP15000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X16MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X16MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X18MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP18000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X20MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X20MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X22MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X22MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X22MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,534.37,374.059,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X24MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP24000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X26MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP26000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X34MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP34000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG SMOTH LOCKING 2 X 14 -,SUP-SPLS-20140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG SMOOTH LOCKING 2 X 16 -,SUP-SPLS-20160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG SMOOTH LOCKING TI GRAY 2.0MM X 17MM -,SUP-SPLS-20170-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG SMOOTH LOCKING 2 X 18 -,SUP-SPLS-20180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SMOOTH PEG LOCKING 2.0MM X 18MM TI -,SUP-SPLS-20180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG SMOOTH LOCKING TI GRAY 2.0MM X 19MM -,SUP-SPLS-20190-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG SMOOTH LOCKING 2 X 20 -,SUP-SPLS-20200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG SMOOTH LOCKING TI GRAY 2.0MM X 21MM -,SUP-SPLS-20210-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG SMOOTH LOCKING TI GRAY 2.0MM X 22MM -,SUP-SPLS-20220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN S3 16X71MM 16MM 3HL CONTR LCK SS SUT HL FST GUIDE -,SUP-SSPL3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5703.94,3992.758,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN S3 16X84MM 4HL CONTR LCK SS SUT HL FST GUIDE TECH -,SUP-SSPL4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5703.94,3992.758,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN S3 16X70MM 16MM 3HL CONTR LCK SS SUT HL FST GUIDE -,SUP-SSPR3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5703.94,3992.758,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN S3 16X150MM 8HL CONTR LCK SS SUT HL FST GUIDE TECH -,SUP-SSPR8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7359.1,5151.37,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SIZER IMPLANT NATR INSPIRA SIL 485CC SINGLE USE FULL PROFILE -,SUP-SSZ-F485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SIZER IMPLANT NATR INSPIRA SIL 605CC SINGLE USE FULL PROFILE -,SUP-SSZ-F605,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SIZER IMPLANT NATR INSPIRA SIL 650CC SINGLE USE FULL PROFILE -,SUP-SSZ-F650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SIZER IMPLANT NATR INSPIRA SIL 695CC SINGLE USE FULL PROFILE -,SUP-SSZ-F695,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SIZER IMPLANT NATR INSPIRA SIL 560CC SINGLE USE MOD PROFILE -,SUP-SSZ-M560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SIZER IMPLANT NATR INSPIRA SIL 600CC SINGLE USE MOD PROFILE -,SUP-SSZ-M600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 4MMSTDX20MM LCK SMTH TI S3 -,SUP-STP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 4MMSTDX25MM LCK SMTH TI S3 NS -,SUP-STP25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 4MMSTDX32.5MM LCK SMTH TI S3 -,SUP-STP325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 4MMSTDX37.5MM LCK SMTH TI S3 NS -,SUP-STP375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 4MMSTDX42.5MM LCK SMTH TI S3 NS -,SUP-STP425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 4MMSTDX45MM LCK SMTH TI S3 -,SUP-STP45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 4MMSTDX47.5MM LCK SMTH TI S3 NS -,SUP-STP475,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 4MMSTDX50MM LCK SMTH TI S3 NS -,SUP-STP50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 4MMSTDX40MM LCK THRD TI S3 NS -,SUP-STPT40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 4MMSTDX50MM LCK THRD TI S3 NS -,SUP-STPT50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ENDOSCOPIC FX SECURESTRAP W/12 ABSB STRP F/HRN RPR -,SUP-STRAP12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1878.06,1314.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SECURESTRAP 5MM ASORB STRAP -,SUP-STRAP25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2542.51,1779.757,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE SCREW T8 FULLY THREADED 2.7 X 24MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ASNIS III SS CANN SCREW 6.5 X 105MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE SCREW T10 NON-LOCKING 2.7 X 70MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE SCREW T8 FULLY THREADED 2.7 X 18MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE SCREW T10 NON-LOCKING 2.7 X 30MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING FULLY THREADED T10 3.5 X 28MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL LONG R2.0 TI LEFT 13 X 320MM GAMMA -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.3 X 15MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.88,310.016,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTEX 3.5 X 22MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING FULLY THREADED T10 3.5 X 20MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING ST 3.5 X 46MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WRIST FUSION PLATE STANDARD BEND 120MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8642.06,6049.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WRIST FUSION PLATE STRAIGHT 120MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8642.06,6049.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5MMX16MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5MMX20MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5MMX26MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5MMX30MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
3-0 20CM STRATAFIX SPIRAL MONOCRYL PLUS UNDYED SH -,SUP-SXMP1B427,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.67,104.769,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
4-0 STRATAFIX SPIRAL MONOCRYL PLUS 45 X 45CM UNDYED PS-2 -,SUP-SXMP2B151,CDM,C1713,HCPCS,278,RC,,,outpatient,,,125.22,87.654,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUTURE STRATAFIX 2-0 CT-1 PDS VIOL 45CM -,SUP-SXPP1A403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,117.01,81.907,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
0 STRATAFIX SYMMETRIC PDS PLUS 23CM CT-1 -,SUP-SXPP1A425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.1,107.87,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUTURE STRATAFIX 0 CT-1 PDS VIOL 45CM -,SUP-SXPP1B407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.07,107.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUTURE STRATAFIX 3-0 SH SPIRAL PDS VIOLET 15CM -,SUP-SXPP1B420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,183.51,128.457,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
"SUTURE STRATAFIX SPIRAL PDS PLUS 2-0 9"" 23CM VIOLET CT-2 -",SUP-SXPP1B432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,155.78,109.046,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUT STRATAFIX 0 30CM SPIRAL PDS PLUS VIOLET CT-1 -,SUP-SXPP1B450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,157.03,109.921,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SET HERNIA KUMAR T ANCHORS -,SUP-TA-008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,46.32,32.424,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE REEF TA INTERBODY 9X28X8MM -,SUP-TA1-928088,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
REEF TA INTERBODY 9 X 28 X 10MM 15DEG -,SUP-TA1-928105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
REEF TA 9X 28 X 11MM INTERBODY -,SUP-TA1-928115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE REEF TA INTERBODY 9X32X8MM -,SUP-TA1-932088,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
INTERBODY 9X32X11 15DEG -,SUP-TA1-932115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN 70MM TENSION BAND -,SUP-TB-1570K,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1219.12,853.384,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TROCHLEAR COMPRESSION FEMALE -,SUP-TCS-F,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1833.97,1283.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TROCHLEAR COMPRESSION LOCKING CAP -,SUP-TCS-LC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1303.92,912.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TROCHLEAR COMPRESSION MALE 60MM -,SUP-TCS-M-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 35MM -,SUP-TLF-5P T0 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 40MM -,SUP-TLF-5P T0 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 45MM -,SUP-TLF-5P T0 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD PREBENT TITANIUM 50MM -,SUP-TLF-5P T0 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PREBENT ROD TITANIUM 55MM -,SUP-TLF-5P T0 55-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 60MM -,SUP-TLF-5P T0 60-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PERLA TL PREBENT ROD TITANIUM 90MM -,SUP-TLF-5P T0 90-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 5.5 X  70 -,SUP-TLF-5P TO 70-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD PREBENT 6MM X 40MM -,SUP-TLF-6P T0 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5 X 35 -,SUP-TLF-CS 55 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5MM X 40MM -,SUP-TLF-CS 55 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CORTICAL BONE SCREW 5.5 X 45 -,SUP-TLF-CS 55 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MM X 30MM -,SUP-TLF-CS 65 30-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5 X 35 -,SUP-TLF-CS 65 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCEW 6.5 X 40 -,SUP-TLF-CS 65 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5 X 45 -,SUP-TLF-CS 65 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEAD -,SUP-TLF-MH PL 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
REDUCTION HEAD -,SUP-TLF-MH RE 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SET -,SUP-TLF-SC 00 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X10MM LCK LAG P/T TI DVR NS -,SUP-TP10000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X14MM TI DVR NS -,SUP-TP14000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X16MM TI DVR NS -,SUP-TP16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X18MM TI DVR NS -,SUP-TP18000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X20MM P/T -,SUP-TP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,534.37,374.059,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X20MM TI DVR NS -,SUP-TP20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X28MM TI DVR NS -,SUP-TP28000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
THREADED PEG FLUTED LCK 2.3 X 20 -,SUP-TPFL-23200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG FIXATION LOCKING 2.3 X 10 TI -,SUP-TPLS-23100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG THREADED LOCKING 2.3MM X 12MM TI -,SUP-TPLS-23120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
THREADED PEG- LOCKING- 2.3MM X 16MM -,SUP-TPLS-23160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK TRH PEG 2.3 X 17MM -,SUP-TPLS-23170-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
THREADED PEG- LOCKING- 2.3MM X 18MM -,SUP-TPLS-23180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG THREADED LOCKING 2.3MM X 19MM -,SUP-TPLS-23190-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK TRH PEG 2.3 X 20MM -,SUP-TPLS-23200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
THREADED PEG- LOCKING 2.3MM X 21MM -,SUP-TPLS-23210-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
THREADED PEG LOCKING 2.3MM X 22MM -,SUP-TPLS-23220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
THREADED PEG- LOCKING 2.3MM X 23MM -,SUP-TPLS-23230-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG THREADED LOCKING TI PINK 2.3MM X 24MM -,SUP-TPLS-23240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
THREADED PEG- LOCKING 2.3MM X 26MM -,SUP-TPLS-23260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG THREADED 2.3 X 28 LOCKING -,SUP-TPLS-23280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG TRHEADED NON-LOCKING 2.7MM X 10MM TI -,SUP-TPNL-27100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG THREADES NON LOCKING 2.7 X 12 -,SUP-TPNL-27120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG THREADED NON LOCKING 2.7MM X 14MM -,SUP-TPNL-27140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG THREADES NON LOCKING 2.7 X 16 -,SUP-TPNL-27160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG THREADED NON LOCKING 2.7 X 18 -,SUP-TPNL-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON-LCK TRH PEG 2.7 X 20MM -,SUP-TPNL-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON-LCK TRH PEG 2.7 X 22MM -,SUP-TPNL-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG THREADED NON-LOCKING 2.7MM X 24MM -,SUP-TPNL-27240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG THREADED NON-LOCKING 2.7MM X 26MM -,SUP-TPNL-27260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG THREADED NON LOCKING 2.7MM X 28MM -,SUP-TPNL-27280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUBSTITUTE DBM 5ML PTTY OPTIUM FRZDR -,SUP-TPUT05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2696.31,1887.417,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE CERVICAL LORDOTIC D12 W14 H07 -,SUP-TRY-CL 12 07-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
CERVICAL CAGE-LORDOTIC D12 W14 H08 -,SUP-TRY-CL 12 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BONE 20MM 1-LEVEL SPINE CERVICAL -,SUP-TRY-CP 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 22MM -,SUP-TRY-CP 04 22-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 24MM 1-LEVEL -,SUP-TRY-CP 04 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 26MM 1-LEVEL -,SUP-TRY-CP 04 26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2 LEVEL 36MM -,SUP-TRY-CP 06 36-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 38MM 2-LEVEL -,SUP-TRY-CP 06 38-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 40MM 2 LEVEL -,SUP-TRY-CP 06 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 43MM 2-LEVEL -,SUP-TRY-CP 06 43-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 46MM 2-LEVEL -,SUP-TRY-CP 06 46-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPINEART TRYPTIK 2- PLATE-52MM-3-LEVEL -,SUP-TRY-CP 08 52-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 55MM 3-LEVEL -,SUP-TRY-CP 08 55-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TRYPTIK 58MM 3-LEVEL -,SUP-TRY-CP 08 58-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 61MM 3-LEVEL -,SUP-TRY-CP 08 61-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TRYPTIK 72MM 3 LEVEL -,SUP-TRY-CP 08 72-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 12MM SELF DRILLING POLYAXIAL -,SUP-TRY-PD 40 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SELF-DRILLING POLYAXIAL 4 X 14 -,SUP-TRY-PD 40 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SELF-DRILLING POLYAXIAL 4 X 16 -,SUP-TRY-PD 40 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SELF DRILLING POLYAXIAL 4.5 X 16 -,SUP-TRY-PD 45 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SELF TAPPING 4 X 14 -,SUP-TRY-PS 40 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TRYPTIK SELF-TAPPING 4 X 16 -,SUP-TRY-PS 40 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
STENT GRAFT 28 X 14 X 140MM OVATION ILIAC LIMB -,SUP-TV-IL1428140-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO THRD DRILL TIP -,SUP-U000-0200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT 2.3MM FIBERWIREX2 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHORAGE LISFRANC PLATING MED -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHORAGE LAPIDUS PLATING LS 0 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
FEMORAL AUGMENT DISTAL SZ3 12M -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL FLEXIBLE 2.0MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL FLEXIBLE 2.5MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.59,822.213,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL LONG R1/5 RT 11 X 440MM X -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M ADAPTIVE II 2.5 TRI DI -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5810.88,4067.616,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SCREW GAP 6.5MM 30MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,663.67,464.569,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE WSTD CMP BRD 16 HOLE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.44,869.708,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL FLEXIBLE 1.5MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL LONG LT TI 11X400 130 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING COMP BROAD 16 HOLE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.44,869.708,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING PLATE 6 HOLE 2.0/2.3 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4600.23,3220.161,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 10 HOLE LOCKING COMPR BR -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CERVICAL 2 LEVEL 30MM GE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DIST POST LAT HUMERAL 6H -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ANCHORAGE 3.5MM X 14MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ANCHORAGE 3.5MM X 16MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ANCHORAGE LOCK 3.5 X 14 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
LO-PRO MTP PLT TM CONTRDSHTLTI -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 2.3 X 18MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 2.7 X 48MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 5.5 X 40MM HIGH -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCK LP 4.5 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCK LP 4.5 X 46MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCKING 2.3 X 21MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,408.04,285.628,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON-LOCK LP 4.5 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.5,297.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL TI LNG RT 15 X 440MM X1 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TRILOCK 2.8 X 12MM HD7 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 6 HOLE STRAIGHT -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.2 X 12MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BROAD 7 HOLE VARIAX COMP -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DIAMOND FUSION LARGE NON -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7238.14,5066.698,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE HUMERUS RT. 14 HOLE L218 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SCREW GAP 6.5MM 20MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,663.67,464.569,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 6 HOLE CURVED -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE GRIP TRICHANTERIC W/2 CA -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7111.03,4977.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE RT ANTERIOR ANKLE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8806.3,6164.41,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SUPERIOR 6H INCREASED -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,158.48,110.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ANCHORAGE 3.5MM X 32MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ANCHORAGE LOCK 3.5 X 18 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS III SS CANN 5 X 46 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS TI 5.0 X 36MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW AUTOFIX 2.5 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 2.3 X 26 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANN ASNIS III 5.0X 70MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 5.5 X 30MM GENE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EMERGENCY 1.4 X 3 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS COMP. 4.0MM 32M -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCK LP 4.5 X 24MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCK LP 4.5 X 32MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10 2.7 X 20MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10 2.7 X 48MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCKING 3.5 X 55MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW S-FIX 2.5LG X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ANCHORAGE 3.0 X 28MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ANCHORAGE LOCK 3.5 X 12 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS 5.0MM 60MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS 6.5MM X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.94,757.358,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ANCHORAGE 3.5MM X 20MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ANSIS 4.0 X 44MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS CANN TI 5.0 X 60MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS III SS CANN 5 X 38 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS TI 5.0 X 40MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 3.5 X 46MM NON-LOCK -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 2.7 X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANN ASNIS III 5.0X 65MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANN FT 4.0 X 40MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORT HI-TOP 5.5 X 35MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTEX T8 2.4MM X 8MM SE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS 2.5 X 12MM MICR -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK ST 2.7 X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCK LP 4.5 X 26MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCK LP 4.5 X 44MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.3 X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.3 X 12MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LP 5.5 X 55MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW M CORTEX 2.3 X 16MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCK LP 4.5 X 30MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCKING 2.3 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LO-PRO PT 5MM X 50MM THR -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING SILVER 2.5 X 16M -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TI LOCK 5.5 X 35MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TRILOCK 2.8 X 34MM HD7 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON-LOCK LP 4.5 X 24MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON-LOCK LP 4.5 X 28MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW PERIPH NL 4.5 X 30MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T2 F/T LOCK 5 X 105MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TRILOCK 2.8 X 10MM HD7 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW VA 4.25 X 14MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WIRE TEMP KIRSCH 1X100MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.71,106.197,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ULTRA PIN -,SUP-UPP3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X23MM COMPR AEQUALIS REVERSED II ST NS F/BSPLT -,SUP-VDV223,CDM,C1713,HCPCS,278,RC,,,outpatient,,,980.28,686.196,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X35MM COMPR AEQUALIS REVERSED II ST NS F/BSPLT -,SUP-VDV235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
"V-LOC 180 ABSORABLE RELOAD 2-0 6"" ES-9 TAPER -",SUP-VLOCA206L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,211.29,147.903,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUTURE V-LOC ABSORBABLE 2-0 8 IN FOR ENDOSTITCH -,SUP-VLOCA208L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,249.42,174.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
"SUT V-LOC 180 2-0 P-12 12""CLEAR -",SUP-VLOCL0015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.68,88.676,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
"V-LOC 0 ABS 12"" GS-21 GREEN -",SUP-VLOCL0316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,125.34,87.738,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
"V-LOC 2-0 ABS 18"" GS-21 GREEN -",SUP-VLOCL0325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,125.34,87.738,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
"V-LOC 0 ABS 18"" GS-21 GREEN -",SUP-VLOCL0326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,130.1,91.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
"SUT V-LOC 180 0 GS-21 9"" GREEN -",SUP-VLOCL0346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,124.81,87.367,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
"V-LOC 3-0 ABS 6"" V-20 GREEN -",SUP-VLOCL0604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.66,927.962,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
"V-LOC 180 GREEN 12"" V-20 TAPER -",SUP-VLOCL0614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
"SUTURE VLOC 9"" 1/2 CIRCLE 26MM -",SUP-VLOCL0644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
"SUT V-LOC 180 3-0 CV-23 6"" GREEN -",SUP-VLOCL0804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
"SUT V-LOC 180 3-0 CV-23 12"" GREEN -",SUP-VLOCL0814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
"V-LOC 2-0 ABS 9"" GS-22 GREEN -",SUP-VLOCL2145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
"V-LOC 3-0 ABS 18"" P-14 UNDYED -",SUP-VLOCM0124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.68,88.676,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
"V-LOC 3-0 ABS  6"" CV-23 VIOLET -",SUP-VLOCM0804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
"V-LOC 3-0 ABS 18"" P-17 UNDYED -",SUP-VLOCM1824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.68,88.676,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUT V-LOC 90 2-0 GS-22 TAPER 12IN VIOLET -,SUP-VLOCM2115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,136.19,95.333,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
"SUTURE V-LOC 0 NON-ABS 6"" GS-21 BLUE -",SUP-VLOCN0306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,90.79,63.553,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
"V-LOC 2-0 PBT NON-ABS 6"" V-20 BLUE -",SUP-VLOCN0605,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1309.01,916.307,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
"V-LOC 2-0 NON-ABS 12"" V-20 BLUE -",SUP-VLOCN0615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
VLOC PBT 1 BLU 12 GS-22 -,SUP-VLOCN2117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,131.58,92.106,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
VLOC PBT 0 BLU 9 GS-22 NON-ABS -,SUP-VLOCN2146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,131.58,92.106,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFT VALLIANT STENT 20F 31 X 90 NACION THORACIC -,SUP-VNMC3131C90TU,CDM,C1713,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN BALL JURGAN .045 YELLOW -,SUP-W045-YL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PK CAP PROT 0.375IN PIN BALL W-SRS F/0.045IN K-WR XTRNFXTR -,SUP-W045-YL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,256.74,179.718,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN BALL JURGAN .062 GREEN -,SUP-W062-GN,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PK CAP PROT 0.375IN PIN HEAD JRGN PIN BALL W-SRS F/.0938IN -,SUP-W332-CR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PK CAP PROT 0.375IN PIN HEAD JRGN PIN BALL W-SRS F/.0781IN -,SUP-W564-BL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PK CAP PROT 0.375IN PIN HEAD JRGN PIN BALL W-SRS F/.0781IN -,SUP-W564-BL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,256.74,179.718,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER INSIDE 2.7MM OUTSIDE 5MM -,SUP-WBTN-2750-T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.27,240.989,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER BUTTON BRONZE -,SUP-WBTN-HCLP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.93,224.651,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MMX12MM NCANN TWST-OFF W- FX FIXOS MICROTHREADED -,SUP-WS12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 13MM NCANN TWST-OFF W- FX FIXOS MICROTHREADED -,SUP-WS13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SNAP OFF SCREW DIAM 2.1 LG.14 -,SUP-WS14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MMX15MM NCANN W- FX FIXOS MICROTHREADED SD/ST/RM -,SUP-WS15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MMX16MM NCANN W- FX FIXOS MICROTHREADED SD/ST/RM -,SUP-WS16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHO 0.35MM -,SUP-WSO906ST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.7,81.69,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
WOUND MATRIX 6 LAYER 10CM X 15CM 150SQCM -,SUP-WSX1015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16411.46,11488.022,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
PK PIN BALL PIN BALL PROT REFL 0.125IN 0.1094X.125IN F/3MM -,SUP-X003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUTURE MONODERM QUILL 3-0 MONO CLR YA-1023Q 30CMX30CM L BARB -,SUP-YA-1023Q,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.56,90.692,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUTURE MONODERM QUILL #0 MONO CLR YA-1029Q 36CMX36CM L BARB -,SUP-YA-1029Q,CDM,C1713,HCPCS,278,RC,,,outpatient,,,136.04,95.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEWIRE HI-TORQUE CONNECT 250FT -,SUP-1012595,CDM,C1714,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC,,
EARLY ACCESSORY DROP OFF FEE -,SUP-10595-10169,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC,,
K-WIRE GAMMA 3.2 X 450MM -,SUP-1210-6451S,CDM,C1714,HCPCS,272,RC,,,outpatient,,,478.7,335.09,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC,,
SCREWDRIVER FLEXIBLE GAMMA -,SUP-1320-0233,CDM,C1714,HCPCS,272,RC,,,outpatient,,,2438.28,1706.796,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC,,
LEE RT ANG BRONCHUS CLAMP 9 39MM JAW -,SUP-320200,CDM,C1714,HCPCS,272,RC,,,outpatient,,,779.26,545.482,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC,,
PROBE BALL TIP 3MM TIP PEDICLE SCREW D344 -,SUP-3603-00-TE,CDM,C1714,HCPCS,272,RC,,,outpatient,,,601.01,420.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC,,
"KWIRE SINGLE POINT STST 150MM X .045"" -",SUP-451-1045,CDM,C1714,HCPCS,272,RC,,,outpatient,,,152.76,106.932,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC,,
10X30CM PICO14 DRESSING KIT -,SUP-66022043,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1562.06,1093.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC,,
HOLDER/POSITIOINER PLATE 1.2/1.55 FOR INSTRUMENT -,SUP-A-2350,CDM,C1714,HCPCS,272,RC,,,outpatient,,,4147.65,2903.355,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC,,
HOLDER/POSITIOINER PLATE 2.0/2.3 FOR INSTRUMENT -,SUP-A-2650,CDM,C1714,HCPCS,272,RC,,,outpatient,,,4147.65,2903.355,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC,,
KIT FIBERTAK KNOTLESS CURVED DISPOSABLE -,SUP-AR-3638DC,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC,,
B CROSSTELLAÂ® RX PTA Balloon Dilatation Cath 6mm x 150mm -,SUP-BD-F60150LR,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC,,
BALLOON R2P CROSTELLA  RX- 200cm- 6mm x 150mm -,SUP-BD-Q60150ER,CDM,C1714,HCPCS,272,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC,,
CATH BLNOCC 1.3MM 5FR SHTH 146CM 20CM LUM C RSSR 14S RX -,SUP-CRU14S,CDM,C1714,HCPCS,272,RC,,,outpatient,,,9315.58,6520.906,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC,,
CATH BLNOCC 1.1MM 5FR SHTH 146CM C RSSR 14P OTW PERIPH -,SUP-CRUO14PA,CDM,C1714,HCPCS,272,RC,,,outpatient,,,9315.58,6520.906,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC,,
CATH PTCA 0.05IN C RSSR S6 156CM RECANALIZATION PERIPH 5FR -,SUP-CRUS6A,CDM,C1714,HCPCS,272,RC,,,outpatient,,,9315.58,6520.906,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC,,
DRILL KIT FOR CONTINUOUS COMPRESSION -,SUP-DK-265C,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1863.92,1304.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC,,
INTERSTIM BELT FIXATION LARGE SCS PH -,SUP-FP9000L,CDM,C1714,HCPCS,272,RC,,,outpatient,,,233.4,163.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC,,
DILATOR COONS -,SUP-G04051,CDM,C1714,HCPCS,272,RC,,,outpatient,,,102.05,71.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC,,
CATH ANG 5FR DAV 100CM ADVANTG BRD VSCR -,SUP-G08581,CDM,C1714,HCPCS,272,RC,,,outpatient,,,151.7,106.19,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC,,
BALLOON EXTRACTOR PRO XL RETREIVAL 9-12 -,SUP-M00547130,CDM,C1714,HCPCS,272,RC,,,outpatient,,,612.32,428.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC,,
SET DELIVERY SIROS -,SUP-SIR-10300,CDM,C1714,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC,,
BLADE HOOK DISSECTING SYNERGY HARMONIC -,SUP-SNGHK,CDM,C1714,HCPCS,272,RC,,,outpatient,,,2781.64,1947.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC,,
SUTURE 3-0 MONO PLUS 16 X 16CM UNDYED -,SUP-SXMP2B402,CDM,C1714,HCPCS,272,RC,,,outpatient,,,166.17,116.319,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC,,
DRESSING KCI VERAFLO CLEANSE CHOICE LARGE -,SUP-ULTVCC05LG,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1428.85,1000.195,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC,,
DRESSING NEG PRSS SM 10X7.5X3.3CM VAC GRANUFOAM -,SUP-XF-DSMF1,CDM,C1714,HCPCS,272,RC,,,outpatient,,,163.38,114.366,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.910225,6679.27086,other,OPPS APC,,
NEEDLE BRCHTX 18GAX20CM ULTRA-SHRP TIP PLSH SURF PRELD BN -,SUP-818205,CDM,C1715,CPT,272,RC,,,outpatient,,,84.61,59.227,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,18.994945,416.02,other,OPPS APC,,
CURRENT DR RF 2207-36 AICD -,SUP-2207-36,CDM,C1721,HCPCS,275,RC,,,outpatient,,,44309.79,31016.853,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR LUMAX 740 DR-T 2CHMBR CARD IMPL W/HOME MNTR -,SUP-365606,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30837.5,21586.25,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR ILESTO DR-T DF-1 2CHMBR HI ENRG CARD IMPL W/TI -,SUP-383562,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25644.47,17951.129,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR ILESTO DR-T DF-4 2CHMBR HI ENRG CARD IMPL W/TI -,SUP-383564,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25644.47,17951.129,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR ITREVIA 7 DR-T DF-4 2CHMBR CARD IMPL W/TI -,SUP-392426,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25644.47,17951.129,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR CRNT + DR DF-4 2CHMBR RR V- PCNG RDC 50X74MM -,SUP-CD2211-36Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR FORTIFY DR DF-1 2CHMBR 40X74MM 14MM 35ML 76GM -,SUP-CD2231-40,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR FORTIFY DR DF-4 2CHMBR RR V- PCNG RDC 40X71MM -,SUP-CD2231-40Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR FORTIFY ASSURA DR DF-1 TELEM 2CHMBR 40X74MM -,SUP-CD2257-40,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR FORTIFY ASSURA DR DF-4 TELEM 2CHMBR 40X71MM -,SUP-CD2257-40Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR ELLIPSE DR DF-1 IS-1 CONN 2CHMBR DEFT RESPONSE -,SUP-CD2311-36,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR ELLIPSE DR DF-4 2CHMBR DEFT RESPONSE RF TELEM -,SUP-CD2311-36Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR FORTIFY ASSURA DR DF-4 2CHMBR CARD IMPL 40C -,SUP-CD2357-40C,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR FORTIFY ASSURA DR DF-4 2CHMBR CARD IMP 40Q -,SUP-CD2357-40Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR ELLIPSE VR IS-1 DF-1 2CHMBR 51X68MM 12MM 31ML -,SUP-CD2411-36C,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR ELLIPSE ASSURA DR DF-4 2CHMBR CARD IMPL -,SUP-CD2411-36Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
ENTRANT ICD CDDRA300Q -,SUP-CDDRA300Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37130,25991,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
ENTRANT DR ICD DF1 CONNECTOR REF: CDDRA300T -,SUP-CDDRA300T,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37130,25991,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
GALLANT ICD CDDRA500Q -,SUP-CDDRA500Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,26150.2,18305.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
GALLANT DR ICD DF1 CONNECTOR REF: CDDRA500T -,SUP-CDDRA500T,CDM,C1721,HCPCS,275,RC,,,outpatient,,,26150.2,18305.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR INOGEN DF-1 SGL-CHMBR 5.23X7.14X0.99 CM D -,SUP-D013,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25975.04,18182.528,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
DYNAGEN MINI ICD DR D022 -,SUP-D022,CDM,C1721,HCPCS,275,RC,,,outpatient,,,36747.56,25723.292,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
ICD MOMENTUM EO DR D121 -,SUP-D121,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25903.5,18132.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR D142 INOGEN MUL PRGM OPTN EXTEND LNGVT DR DF-4 -,SUP-D142,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25091.86,17564.302,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
DYNAGEN D153 EL ICD -DF-1 -,SUP-D153,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25091.86,17564.302,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR CONSULTA DF-4 CARD IMPL -,SUP-D204TRM,CDM,C1721,HCPCS,275,RC,,,outpatient,,,48626.05,34038.235,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR SECURA DR 2CHMBR RR V- PCNG RDC 51X64MM 15MM -,SUP-D224DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,35700.82,24990.574,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR SECURA VR SGL-CHMBR RR V- PCNG RDC 51X64MM -,SUP-D224VRC,CDM,C1721,HCPCS,275,RC,,,outpatient,,,31901.76,22331.232,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
ICD DUAL VIGILANT EL DR DF4 MRI CONDITIONAL -,SUP-D233,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25903.5,18132.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR MAXIMO II DR WRLS TELEM 2CHMBR RR V- PCNG RDC -,SUP-D284DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34217.29,23952.103,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR PROTECTA XT DR DF-1 IS-1 CONN 2CHMBR RR -,SUP-D314DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37579.81,26305.867,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR PROTECTA DR DF-1 IS-1 CONN 2CHMBR RR V- PCNG -,SUP-D334DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32749.43,22924.601,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR PROTECTA DR DF-4 2CHMBR CARD IMPL -,SUP-D334DRM,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32749.43,22924.601,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
ICD PERCIVA DR D401 -,SUP-D401,CDM,C1721,HCPCS,275,RC,,,outpatient,,,27894.37,19526.059,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
ICD PERCIVA DR DF4 D413 MRI CONDITIONAL -,SUP-D413,CDM,C1721,HCPCS,275,RC,,,outpatient,,,27894.37,19526.059,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR EVERA S DR DF-1 2CHMBR CARD IMPL -,SUP-DDBC3D1,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32071,22449.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR EVERA S DR DF-4 2CHMBR CARD IMPL -,SUP-DDBC3D4,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32071,22449.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR EVERA MRI XT DR SURSCN DF-4 CARD IMPL -,SUP-DDMB1D1,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37251.7,26076.19,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
EVERA MRI S DR SURESCAN MODEL DDMC3D1 -,SUP-DDMC3D1,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34784.7,24349.29,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR EVERA 2CHMBR CARD IMPL -,SUP-DDMC3D4,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34784.7,24349.29,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
ICD DUAL COBALT DR MRI REF: DDPB3D4 -,SUP-DDPB3D4,CDM,C1721,HCPCS,275,RC,,,outpatient,,,38485.2,26939.64,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR OVATIO CARD 6550 -,SUP-DR6550,CDM,C1721,HCPCS,275,RC,,,outpatient,,,45639.5,31947.65,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
DYNAGEN CRT-D G151 -,SUP-G151,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32897.45,23028.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR VITALITY II DR IS-1 DF-1 2CHMBR V- PCNG RDC -,SUP-T167,CDM,C1721,HCPCS,275,RC,,,outpatient,,,43197.17,30238.019,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR VITALITY HE IS-1 DF-1 2CHMBR 66MMX82.6MM -,SUP-T180,CDM,C1721,HCPCS,275,RC,,,outpatient,,,41877.33,29314.131,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR PARADYM RF VR IMPL 9250 -,SUP-TDF011U,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25661.73,17963.211,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR SQ-RX DF-1 SGL-CHMBR 65.5MMX78.2MMX15.7MM D -,SUP-1010,CDM,C1722,HCPCS,275,RC,,,outpatient,,,46873,32811.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR CRNT VR RF SGL-CHMBR VNTRC PCNG CARD IMPL -,SUP-1207/36,CDM,C1722,HCPCS,275,RC,,,outpatient,,,37656.29,26359.403,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR LUMAX 540 VR-T IS-1 CONN SGL-CHMBR RR 55X66MM -,SUP-360348,CDM,C1722,HCPCS,275,RC,,,outpatient,,,30895.47,21626.829,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR LUMAX 740 VR-T SGL-CHMBR CARD IMPL W/HOME MNTR -,SUP-365609,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28370.5,19859.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR LUMAX 740 VR-T DX CARD IMPL CELL GSM HOME MNTR -,SUP-372419,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28370.5,19859.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR ILESTO VR-T SGL-CHMBR CARD IMPL -,SUP-383578,CDM,C1722,HCPCS,275,RC,,,outpatient,,,30837.5,21586.25,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR ILESTO VR SGL-CHMBR HI ENRG CARD IMPL W/TI -,SUP-383580,CDM,C1722,HCPCS,275,RC,,,outpatient,,,30837.5,21586.25,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR ILESTO DX HI ENRG CARD IMPL W/TI LANDLINE HOME -,SUP-383594,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35737.63,25016.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR ITREVIA 7 VR-T DX HI ENRG CARD IMPL -,SUP-393037,CDM,C1722,HCPCS,275,RC,,,outpatient,,,24694.67,17286.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
DEVICE HI ENRG CARD IMPL TI -,SUP-393041,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35737.63,25016.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
ICD INTICA NEO 7 VR-T DX REF:429559 -,SUP-429559,CDM,C1722,HCPCS,275,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR EMBLEM S SQ-1 CONN 83.1MMX69.1MMX12.7MM D -,SUP-A209,CDM,C1722,HCPCS,275,RC,,,outpatient,,,46873,32811.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
S-ICD Emblem MRI A219 -,SUP-A219,CDM,C1722,HCPCS,275,RC,,,outpatient,,,44406,31084.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR CRNT + VR SJ-4 CONN SGL-CHMBR 50X74MM 14MM -,SUP-CD1211-36Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR FORTIFY VR DF-1 SGL-CHMBR 40X73MM 14MM 35ML -,SUP-CD1231-40,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR FORTIFY VR DF-4 ATP TERM AUTOMATICITY -,SUP-CD1231-40Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR FORTIFY ASSURA VR DF-1 TELEM SGL-CHMBR 40X73MM -,SUP-CD1257-40,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR FORTIFY ASSURA VR DF-4 SGL-CHMBR RF TELEM -,SUP-CD1257-40Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR ELLIPSE VR DF-1 IS-1 CONN SGL-CHMBR DEFT -,SUP-CD1311-36,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR ELLIPSE VR DF-4 DF-1 IS-1 CONN SGL-CHMBR DEFT -,SUP-CD1311-36Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,25163.4,17614.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR FORTIFY ASSURA VR DF-1 IS-1 CONN SGL-CHMBR -,SUP-CD1357-40C,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR FORTIFY ASSURA VR DF-4 SGL-CHMBR 40X71MM 14MM -,SUP-CD1357-40Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR ELLIPSE VR IS-1 DF-1 SGL-CHMBR 51X68MM 12MM -,SUP-CD1411-36C,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR ELLIPSE VR-ICD MRLN DF-4 SGL-CHMBR -,SUP-CD1411-36Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
ENTRANT ICD CDVRA300Q -,SUP-CDVRA300Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35273.5,24691.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
ENTRANT VR ICD DF1 CONNECTOR REF: CDVRA300T -,SUP-CDVRA300T,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35273.5,24691.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
GALLANT ICD CDVRA500Q -,SUP-CDVRA500Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36201.75,25341.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
GALLANT VR ICD DF1 CONNECTOR REF: CDVRA500T -,SUP-CDVRA500T,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36201.75,25341.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR INOGEN DF-1 SGL-CHMBR 5.23X7.14X0.99 CM D. -,SUP-D011,CDM,C1722,HCPCS,275,RC,,,outpatient,,,26643.6,18650.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
ICD MOMENTUM EL VR D120 -,SUP-D120,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36573.05,25601.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR INOGEN EXTEND LNGVT 5.37X7.36X0.99IN 68.9G -,SUP-D140,CDM,C1722,HCPCS,275,RC,,,outpatient,,,34746.25,24322.375,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
DYNAGEN EL ICD VR MODEL D151 -,SUP-D151,CDM,C1722,HCPCS,275,RC,,,outpatient,,,34746.25,24322.375,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR SECURA DR DF-4 2CHMBR CARD IMPL -,SUP-D204DRM,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35700.82,24990.574,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR SECURA VR DF-4 SGL-CHMBR CARD IMPL -,SUP-D204VRM,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31901.76,22331.232,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
ICD VIGILANT EO VR DF4 D232 MRI CONDITIONAL -,SUP-D232,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36573.05,25601.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR PROTECTA VR DF-1 IS-1 CONN SGL-CHMBR RR -,SUP-D334VRG,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28710.95,20097.665,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR PROTECTA VR DF-4 SGL-CHMBR CARD IMPL -,SUP-D334VRM,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28710.95,20097.665,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
ICD SINGLE PERCIVA VR REF: D400 -,SUP-D400,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36573.05,25601.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
ICD PERCIVA VR DF4 D142 MRI CONDITIONAL -,SUP-D412,CDM,C1722,HCPCS,275,RC,,,outpatient,,,25827.02,18078.914,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
ICD RESONATE EL VR -,SUP-D432,CDM,C1722,HCPCS,275,RC,,,outpatient,,,29019.32,20313.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
COBALT XT DR MRI ICD REF: DDPA2D4 -,SUP-DDPA2D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,41837.85,29286.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR EVERA S VR DF-1 SGL-CHMBR CARD IMPL -,SUP-DVBC3D1,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28617.2,20032.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR EVERA S VR DF-4 SGL-CHMBR CARD IMPL -,SUP-DVBC3D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28617.2,20032.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
VISIA AF MRI VR ICD DVFB1D1 -,SUP-DVFB1D1,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
ICD VISIA AF MRI SURESCAN VR -,SUP-DVFB1D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR CARDIAC VISIA AF MRI SURESCAN DVFC3D1 -,SUP-DVFC3D1,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR EVERA MRI XT DR SURSCN DF-4 CARD IMPL -,SUP-DVMB1D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,35998.464,other,OPPS APC,,
EXPLANT TRUNCATED BLADE 56MM -,SUP-00-7053-056-10,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC,,
C 0.9M .014IN OTW TURBO ELITE -,SUP-410-152,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC,,
C 1.4M .014IN OTW TURBO ELITE -,SUP-414-151,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC,,
"2.0mm .018"" TURBO ELITE LASER -",SUP-420-006,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC,,
C 2.3M .018IN OTW TURBO ELITE -,SUP-423-001,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC,,
C 7FR LASER GUIDE 2.0MM TURBO -,SUP-423-050,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12234.34,8564.038,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC,,
DEVICE ATHRCMY STEALTH 360 1.5MM MICRO CRWN 145CM SHFT DMD -,SUP-DBE-150,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12605.64,8823.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC,,
CATH ATHRCMY DIAMONDBACK 360 1.25MM CROWN 135CM SHAFT -,SUP-DBEC-125,CDM,C1724,HCPCS,272,RC,,,outpatient,,,14833.44,10383.408,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC,,
DEVICE ATHRCMY PREDATOR 360 2MM CRWN DMD CTD SLD ART -,SUP-DBG-SCT30-200,CDM,C1724,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC,,
DEVICE ARTHREC 1.25 SOLID -,SUP-DBP-125MICRO145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC,,
SYSTEM ATHERECTOMY DBP-125MICRO145 -,SUP-DBP-125MICRO145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC,,
DEVICE ARTHREC STEALTH 1.25S -,SUP-DBP-125SOLID145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC,,
DEVICE ARTHREC STEALTH 1.50MM 5F -,SUP-DBP-150SOLID145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC,,
DBP-200SOLID145 -,SUP-DBP-200SOLID145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC,,
CATH ATHRCMY DIAMONDBACK 360 1.50MM X 145CM SOLID -,SUP-DBP-EX-150SOL145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,14462.14,10123.498,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC,,
ROTAPRO ADVANCER 1.25MM -,SUP-H749394671250,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7999.94,5599.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC,,
ROTAPRO ADVANCER 1.5MM -,SUP-H749394671500,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7999.94,5599.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC,,
ROTAPRO ADVANCER 1.75MM -,SUP-H749394671750,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC,,
ROTAPRO ADVANCER 2.0MM -,SUP-H749394672000,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC,,
ROTAPRO ADVANCER 2.25MM -,SUP-H749394672250,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC,,
ROTAPRO ADVANCER 2.38MM -,SUP-H749394672380,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC,,
ROTAPRO ADVANCER 2.5MM -,SUP-H749394672500,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC,,
ROTAPRO ADVANCER 2.15MM -,SUP-H7494672150,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC,,
CATH ATHRCMY ROTLNK + 1.25MM BUR 0.58IN SHTH 135CM TFLN PTFE -,SUP-H802227680020,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4502.88,3152.016,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC,,
BURR ROTALINK 1.50MM 0.58IN SHTH 135CM EXCHGL -,SUP-H802227680030,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4953.17,3467.219,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC,,
CATH ATHRCMY ROTLNK + 1.75MM BUR 0.58IN SHTH 135CM EXCHGL -,SUP-H802227680040,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4953.17,3467.219,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC,,
CATH ATHRCMY ROTLNK + 2MM BUR 0.58IN SHTH 135CM EXCHGL ROT -,SUP-H802227680050,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4502.88,3152.016,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC,,
CATH ATHRCMY ROTLNK 2.15MM BUR 0.58IN SHTH 135CM TFLN PTFE -,SUP-H802227680150,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4502.88,3152.016,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC,,
PHOENIX 1.8MM X130CM -,SUP-P18130,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC,,
1.8MM PHOENIX 149CM -,SUP-P18149K,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC,,
PHOENIX 2.2MM X 130CM -,SUP-P22130K,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC,,
PHOENIX ARTHERECTOMY 2.4MM 7FR -,SUP-P22149K,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC,,
ARTHERECTOMY JTSTRM 1.85MM -,SUP-PV3118F,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12754.16,8927.912,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC,,
ARTHERECTOMY JTSTRM 2.1/3MM -,SUP-PV31300,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12624.2,8836.94,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC,,
CATH ARTHERECTOMY JTSTRM 2.4/3.4MM LT -,SUP-PV41340,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12624.2,8836.94,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10635.57648,other,OPPS APC,,
CATHETER BALLOON VALVULOPLASTY  22MX4.5CMX110CM -,SUP-00224512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER BALLOON VALAVULOPLASTY 20MMX4.5X110CM TRUE DILATION -,SUP-0204511,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER BALLOON VALVULOPLASTY 21MMX4.5CMX110CM TRUE DILATIO -,SUP-0214512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER BALLOON VALVULOPLASTY 23MMX4.5CMX120CM TRUE DILATIO -,SUP-0234512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER BALLOON VALVULOPLASTY 24MMX4.5CMX110CM TRUE DILAT -,SUP-0244512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATHETER TRUE DILATATION 25MM X 4.5CM REF: 0254513 -,SUP-0254513,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATHETER TRUE DILATION 26MM -,SUP-0264513,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER BALLOON VALVULOPLASTY 28MMX4.5CMX110CM TRUE DILAT -,SUP-0284514,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH IABP LINEAR 7.5FR 40CC -,SUP-0684-00-0480-01,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4203.6,2942.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER IABP 7.5FR 40CC SENSATION PLUS -,SUP-0684-00-0568-01U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4524.1,3166.87,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER IABP 8FR 50CC SENSATION PLUS -,SUP-0684-00-0576-01U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4524.1,3166.87,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
GAIA SECOND 190CM MICRO J,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
GAIA THIRD 190CM MICRO J,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
GAIA FIRST 190CM MICRO J,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
RG3 330CM,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X18MM PWRSL 143CM RX F/PTCA COR HYDRCT 0.024IN GW -,SUP-1005527-18,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1086.6,760.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X15MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008189-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
4MM X 20MM X 135CM VIATRAC 14 PLUS BALLOON -,SUP-1008189-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ABBOTT VIATRAC BALLOON 4.5 X 20 X 135 -,SUP-1008191-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X20MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008193-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ABBOTT VIATRAC BALLOON 5.5 X 20 X 135 -,SUP-1008195-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6X20MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008197-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6X40MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008197-40,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH CV 4.5X20MM VIATRAC LF -,SUP-10081991-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ABBOTT VIATRAC BALLOON 6.5 X 20 X 135 -,SUP-1008199-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7X20MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008201-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.2X6MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012268-06U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON MINI TREK RX 1.20MM X 08MM REF: 1012268-08U -,SUP-1012268-08U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.2X12MM MINI TREK II RX UL-LPRO NC COR HYDRCT -,SUP-1012268-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.2X12MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012268-12U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON MINI TREK RX 1.20MM X 15MM REF: 1012268-15U -,SUP-1012268-15U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.2X20MM MINI TREK II RX UL-LPRO NC COR HYDRCT -,SUP-1012268-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.2X20MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012268-20U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X8MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X12MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X15MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X20MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X8MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X12MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X15MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X20MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X25MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X30MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X30MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON TREK RX 2.75MM X 08MM REF: 1012273-08 -,SUP-1012273-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON TREK RX 2.75MM X 12MM REF: 1012273-12 -,SUP-1012273-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON TREK RX 2.75MM X 20MM REF: 1012273-20 -,SUP-1012273-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X30MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON TREK RX 4.0MM X 8MM REF: 1012278-08 -,SUP-1012278-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012278-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON TREK RX 4.0MM X 15MM REF: 1012278-15 -,SUP-1012278-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON TREK RX 4.0MM X 20MM REF: 1012278-20 -,SUP-1012278-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012278-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X30MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012278-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4.5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012279-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON TREK RX 4.5MM X 15MM REF: 1012279-15 -,SUP-1012279-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012280-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON TREK RX 5.0MM X 15MM REF: 1012280-15 -,SUP-1012280-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.2X6MM MINI TREK II OTW UL-LPRO NC COR HYDRCT CTD -,SUP-1012401-06Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.2X8MM MINI TREK II OTW UL-LPRO NC COR HYDRCT CTD -,SUP-1012401-08Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.2X12MM MINI TREK II OTW UL-LPRO NC COR HYDRCT -,SUP-1012401-12Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.2X15MM MINI TREK II OTW UL-LPRO NC COR HYDRCT -,SUP-1012401-15Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.2X20MM MINI TREK II OTW UL-LPRO NC COR HYDRCT -,SUP-1012401-20Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X8MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X12MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X15MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X20MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X8MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012403-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X12MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X15MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X20MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X30MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X30MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012407-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X30MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X12MM NC TREK OTW SM-PRFL NC COR RND TIP HYDRCT -,SUP-1012433-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X15MM NC TREK OTW SM-PRFL NC COR RND TIP -,SUP-1012436-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X25MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X25MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X12 MM NC TREK RX ULLPRO NC COR RND TIP HYDRCT -,SUP-1012450-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X25MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
2.0MM X 60 MM X 150CM ARMADA 18 BALLOON OTW -,SUP-1013463-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA BALLOON 2.5MM X 40MM X 150CM -,SUP-1013464-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 18 2.5 X 200 X 150 -,SUP-1013464-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA BALLOON 2.5MM X 80MM X 150CM -,SUP-1013464-80,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA BALLOON .018 3MM X 60MM X 150CM -,SUP-1013465-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1155.33,808.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA BALLOON .018 3.0MM X 80MM X 150CM -,SUP-1013465-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA BALLOON .018 3.0MM X 100MM X 150CM -,SUP-1013465-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER ARMADA 18 3.0MM X 120MM X 150CM -,SUP-1013465-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER ARMADA 18 PTA -,SUP-1013465-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA BALLOON .018 3 X 200 X 150 -,SUP-1013465-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 18 4 X 20MM -,SUP-1013466-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
4MM X 40MM X 150CM ARMADA 18 BALLOON -,SUP-1013466-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
4MM X 60MM X 150CM ARMADA 18 -,SUP-1013466-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 4MM X 80MM X 150CM 18 -,SUP-1013466-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON ARMADA 4 X 150 X 150MM -,SUP-1013466-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 18 BALLOON 5MM X 20MM -,SUP-1013468-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
5mm x 40mm armada 18 -,SUP-1013468-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
5mm x 60mm Armada 18 Balloon -,SUP-1013468-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 18 BALLOON 5MM X 80MM -,SUP-1013468-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B ARMADA .018 5MM X 100MM -,SUP-1013468-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA BALLOON 5 MM X 150MM -,SUP-1013468-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA BALLOON 5MM X 200MM -,SUP-1013468-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 18 BALLOON 6 X 20MM -,SUP-1013470-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
6MM X 40MM X 150CM ARMADA 18 BALLOON -,SUP-1013470-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 18 B 6MM X 60MM X 150CM -,SUP-1013470-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 018 6MM X 80 MM -,SUP-1013470-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 6MM X 100MM 18 BALLOON -,SUP-1013470-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 6MM X 150MM 0.018 -,SUP-1013470-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 6MM X 200MM 0.018 -,SUP-1013470-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON TREK RX 3.75MM X 8MM REF: 1012277-08 -,SUP-102277-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 1.50MM X 8MM REF: 1400150-08 -,SUP-1400150-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 1.50MM X 12MM REF: 1400150-12 -,SUP-1400150-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 1.50MM X 15MM REF: 1400150-15 -,SUP-1400150-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 1.50MM X 20MM REF: 1400150-20 -,SUP-1400150-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 2.00MM X 8MM REF: 1400200-08 -,SUP-1400200-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 2.00MM X 12MM REF: 1400200-12 -,SUP-1400200-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 2.00MM X 15MM REF: 1400200-15 -,SUP-1400200-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 2.00MM X 20MM REF: 1400200-20 -,SUP-1400200-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 2.25MM X 08MM REF: 1400225-08 -,SUP-1400225-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 2.25MM X 12MM REF: 1400225-12 -,SUP-1400225-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 2.25MM X 15MM REF: 1400225-15 -,SUP-1400225-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 2.25MM X 20MM REF: 1400225-20 -,SUP-1400225-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 2.50MM X 8MM REF: 1400250-08 -,SUP-1400250-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 2.50MM X 12MM REF: 1400250-12 -,SUP-1400250-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 2.50MM X 15MM REF: 1400250-15 -,SUP-1400250-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 2.50MM X 20MM REF: 1400250-20 -,SUP-1400250-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 2.75MM X 8MM REF: 1400275-08 -,SUP-1400275-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 2.75MM X 12MM REF: 1400275-12 -,SUP-1400275-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 2.75MM X 15MM REF: 1400275-15 -,SUP-1400275-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 2.75MM X 20MM REF: 1400275-20 -,SUP-1400275-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 3.00MM X 8MM REF: 1400300-08 -,SUP-1400300-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 3.00MM X 15MM REF: 1400300-15 -,SUP-1400300-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 3.00MM X 20MM REF: 1400300-20 -,SUP-1400300-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 3.25MM X 8MM REF: 1400325-08 -,SUP-1400325-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 3.25MM X 12MM REF: 1400325-12 -,SUP-1400325-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 3.25MM X 15MM REF: 1400325-15 -,SUP-1400325-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 3.25MM X 20MM REF: 1400325-20 -,SUP-1400325-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 3.50MM X 8MM REF: 1400350-08 -,SUP-1400350-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 3.50MM X 12MM REF: 1400350-12 -,SUP-1400350-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 3.50MM X 15MM REF: 1400350-15 -,SUP-1400350-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 3.50MM X 20MM REF: 1400350-20 -,SUP-1400350-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 3.75MM X 12MM REF: 1400375-12 -,SUP-1400375-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 3.75MM X 20MM REF: 1400375-20 -,SUP-1400375-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 4.00MM X 8MM REF: 1400400-08 -,SUP-1400400-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 4.00MM X 12MM REF: 1400400-12 -,SUP-1400400-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 4.00MM X 15MM REF: 1400400-15 -,SUP-1400400-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 4.00MM X 20MM REF: 1400400-20 -,SUP-1400400-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 4.50MM X 8MM REF: 1400450-08 -,SUP-1400450-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 4.50MM X 12MM REF: 1400450-12 -,SUP-1400450-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 4.50MM X 20MM REF: 1400450-20 -,SUP-1400450-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 5.00MM X 12MM REF: 1400500-12 -,SUP-1400500-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 5.00MM X 15MM REF: 1400500-15 -,SUP-1400500-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 5.50MM X 12MM REF: 1400550-12 -,SUP-1400550-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 5.50MM X 15MM REF: 1400550-15 -,SUP-1400550-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 6.00MM X 12MM REF: 1400600-12 -,SUP-1400600-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 6.00MM X 15MM REF: 1400600-15 -,SUP-1400600-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH BLNOCC 15MM LRG 23X71X2.5CM ENDOCATH LPRO PLYISPRN -,SUP-20-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X20MM 2.7CM ANGIOSCULPT XL 137CM OTW F/PTCA -,SUP-2039-2520,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X20MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2076-4020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X40MM ANGIOSCULPT XL 137CM OTW -,SUP-2076-4040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X40MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2076-5040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6X40MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2076-6040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6X20MM ANGIOSCULPT XL 90CM OTW F/PTCA SEM-COM -,SUP-2092-6020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER SAPPHIRE II PRO L5 MM 5F -,SUP-210-053-5UU,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER SAPPHIRE II PRO L15 MM 5F -,SUP-210-153-5UU,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X40MM ANGIOSCULPT XL 155CM OTW F/PTCA SEM-COM -,SUP-2155-2540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR TAPR -,SUP-2200-2006-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X10MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2010-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2015-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.0X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2020-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2506-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X10MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2510-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2515-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2520-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR TAPR -,SUP-2200-3006-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X10MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3010-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3015-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.0X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3020-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3506-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X10MM ANGIOSCULPT 137CM RX F /PTCA SEM-COM COR -,SUP-2200-3510-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3515-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3520-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X100MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2237-50100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6X100MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2237-60100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B ANGIOSCULPT 7MM X 40MM -,SUP-2333-7040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6X100MM STERLNG 135CM OTW COAX SEM-COM PERIPH TAPR -,SUP-39032-60101,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER PCA 4MM X 30MM x 145CM COYOTE ES M -,SUP-39135-40301,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 14MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-1440L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER DILATION16MM X 4MM -,SUP-417-1640L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 18MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-1840L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 20MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-2040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 22MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-2240L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 25MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-2540L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 12MMX4CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-2040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3MMX4CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-3040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3MMX8CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-3080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX10CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-4000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX2CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-4020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
MIRROR SURG 16.4MMX7.625IN LRYNG HEX HNDL V. MUELLER -,SUP-419-4040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX6CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-4060L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX10CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-5000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 8MMX8CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-8080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-5040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MM 5FR SHFT 6CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-5060L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MM 5FR SHFT 8CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-5080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MM 5FR SHFT 6FR SHTH 10CM POWERFLX P3 110CM OTW -,SUP-420-6000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MM 5FR SHFT 5FR SHTH 2CM POWERFLX P3 110CM OTW -,SUP-420-6020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-6040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MM 5FR SHFT 6CM POWERFLX P3 80CM OTW F/PTA PERIPH -,SUP-420-6060S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MM 5FR SHFT 8CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-6080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MM 5FR SHFT 10CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-7000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MM 5FR SHFT 2CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-7020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-7040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 8MM 5FR SHFT 6FR SHTH 2CM POWERFLX P3 110CM OTW -,SUP-420-8020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 8MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-8040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX2CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-4020W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX3CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-4030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
RETRACTOR RGNL 6IN DBL END STN FNSH SS DLCT V. MUELLER NS -,SUP-424-5030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX3CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-6030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MMX3CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-7030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH DIL 3MM 4FR SHTH 4CM BLN 150CM F/PTA -,SUP-425-3004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3MMX4CM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-3004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X120MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X40MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-4004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X40MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-5004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X100MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-5010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX28CM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-5028X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1696.16,1187.312,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX6CM SAVVY 120CM OTW COAX MOD PRSS PERIPH TAPR -,SUP-435-506L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1155.51,808.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX22CM SAVVY LONG 120CM OTW COAX MOD PRSS PERIPH -,SUP-436-4022L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1420.53,994.371,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX22CM SAVVY LONG 150CM OTW COAX MOD PRSS PERIPH -,SUP-436-4022X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1420.53,994.371,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0302S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0402S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX4CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0404S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X220MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0422X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX2CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0502S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0504S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X60MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X100MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X220MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0522X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX2CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0602S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX4CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0604S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6X100MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0610X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6X150MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0615X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,840.24,588.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0702S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0704S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7X40MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0704X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 8X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0802S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 8X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0804S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 9X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0902S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 10X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-1004S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
TURNPIKE 150 CM MICRO CATH -,SUP-5643,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2859.63,2001.741,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 22MMX4CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-610462,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 25MMX4CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-610463,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 28MMX4CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-610465,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA BALLOON DILATAION 22X4X100 Z-MED II -,SUP-611761,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 30MMX2CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-611801,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 28MMX2CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-611803,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 25MMX3CM Z-MED 100CM LPRO COAX F/PTA HPRS PERIPH -,SUP-611816,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER PTV 16MMX4CM TYSHAK II REF:611920 -,SUP-611920,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER PTV 18MMX4CM TYSHAK II REF:611928 -,SUP-611928,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER PTV 20MMX4CM TYSHAK II REF:611932 -,SUP-611932,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER PTV 22MMX4CM TYSHAK II REF:611936 -,SUP-611936,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER PTV 25MMX4CM TYSHAK II REF:611944 -,SUP-611944,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH GUID 0.07IN 6FR MPA-1 90CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-270-90,CDM,C1725,HCPCS,272,RC,,,outpatient,,,309.26,216.482,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X6MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R06350N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R10200N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10225N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10250N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10325N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10350N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R10400N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R12250N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R12300N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R12325N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R12350N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R12400N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R15250N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R15300N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R15325N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R15340N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R15400N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
C PIG 5FR 20/1CM MARKS -,SUP-7602-20M65SH,CDM,C1725,HCPCS,272,RC,,,outpatient,,,528.13,369.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X12MM EMPIRA 139CM RX F/PTCA SEM-COM -,SUP-85R12250S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X12MM EMPIRA 139CM RX F/PTCA SEM-COM DURALYN -,SUP-85R12300S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X12MM EMPIRA 139CM RX F/PTCA SEM-COM -,SUP-85R12325S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X15MM EMPIRA 139CM RX F/PTCA SEM-COM -,SUP-85R15250S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X15MM EMPIRA 139CM RX F/PTCA SEM-COM DURALYN -,SUP-85R15300S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 3.00MM X 12MM REF: 1400300-12 -,SUP-90176431,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 4.50MM X 15MM REF: 1400450-15 -,SUP-90176448,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON TREK RX 2.75MM X 15MM REF: 1012273-15 -,SUP-90176463,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON TREK RX 3.75MM X 12MM REF: 1012277-12 -,SUP-90176465,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON TREK RX 3.75MM X 15MM REF: 1012277-15 -,SUP-90176466,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 3.75MM X 15MM REF: 1400375-15 -,SUP-90176697,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH ANG 6FR 18MM 70CM 3.5CM BLN AMPLATZER SZ LUMX3 FLXB -,SUP-9-SB-018,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH ANG 24MM 7FR 70CM 4.5CM BLN AMPLATZER SZ LUMX3 FLXB -,SUP-9-SB-024,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X20MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2015-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 14 1.5MM X 40MM X 150CM -,SUP-A2015-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X20MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X60MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X80MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X200MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2025-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND -,SUP-A2025-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X200MM ARMADA 14 150CM LPRO F/PTA PERIPH RND -,SUP-A2025-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X20MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X60MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X80MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B ARMADA 14 PTA C 3.0 X 200M -,SUP-A2030-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X60MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X80MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X200MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X40MM NANOCROSS ELITE 150CM OTW ULTRA LO XING -,SUP-AB14W030040150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2093.7,1465.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X80MM NANOCROSS ELITE 150CM OTW ULTRA LO XING -,SUP-AB14W030080150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2093.7,1465.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
4MM X 40MM STELLAREX DCB -,SUP-AB35SX040040135,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON ATLAS PTA CATHETER 16MMX 40MM X 120CM REF: AT120164 -,SUP-AT120164,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1966.49,1376.543,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B ATLAS 12MM X 4CM X 75CM -,SUP-AT-75124,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B ATLAS 14MM X 4CM X 75CM -,SUP-AT-75144,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B ATLAS 16MM X 4CM X 75CM -,SUP-AT-75164,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1966.49,1376.543,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B ATLAS 18MM X 4CM X 75CM -,SUP-AT75184,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1966.49,1376.543,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ATLAS BALLOON 20 X 40 -,SUP-AT75204,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2276.62,1593.634,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ATLAS BALLOON 24 X 40 -,SUP-AT75244,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2910.99,2037.693,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 26MMX4CM ATLAS 75CM OTW COAX ULTRA NC PERIPH 12FR -,SUP-AT-75264,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2826.21,1978.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ATLAS GOLD PTA DILATATION CATHETER 120CM -,SUP-ATG120164,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1913.48,1339.436,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH ATLAS GOLD PTA DILATATION 16 X 6 X 80MM - 8 FR -,SUP-ATG80166,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1913.48,1339.436,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35  4.0MM X 20MM X 80CM -,SUP-B1040-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 4.0MM X 40MM X 80CM -,SUP-B1040-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
4MM X 80MM X 80CM ARMADA 35 BALLOON -,SUP-B1040-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON ARMADA 4MM X 80MM X 80CM -,SUP-B1040-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 5MM X 20MM X 80CM -,SUP-B1050-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B ARMADA 35 5MM X 40MM X 80CM -,SUP-B1050-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X40MM ARMADA  .035 -,SUP-B1050-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 5MM X 60MM X 80CM -,SUP-B1050-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B ARMADA 35 5.0 X 80 X 80 PTA CATH -,SUP-B1050-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON ARMADA 5MM X 100MM X 80CM -,SUP-B1050-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 5MM X 120MM X 80CM -,SUP-B1050-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 6MMx40MMx80CM -,SUP-B1060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 6MM X 40MM X 80CM -,SUP-B1060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
6MM X 60MM X 80CM ARMADA 35 BALLOON -,SUP-B1060-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 6.0MM X 60MM X80CM -,SUP-B1060-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
6MM X 80MM X 80CM ARMADA 35 BALLOON -,SUP-B1060-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON ARMADA 6MM X 100MM X 80CM -,SUP-B1060-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 6 X 150 X 80 -,SUP-B1060-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON 35 ARMADA 7 X 20 X 80 PTA -,SUP-B1070-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA PTA 7MM X 40MM X 80CM -,SUP-B1070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA B  35  7.0X60X80 PTA -,SUP-B1070-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 7MM X 60MM X 80CM -,SUP-B1070-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 7 X 80MM X 80CM -,SUP-B1070-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B ARMADA 35 7MM X 80MM X 80CM -,SUP-B1070-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B ARMADA 35 7.0 X 100 X 80 PTA CATH -,SUP-B1070-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON ARMADA 7MM X 150MM X 80CM -,SUP-B1070-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 8MM X 20MM X 80CM -,SUP-B1080-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
8mm x 40mm x 80cm Armada 35 -,SUP-B1080-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
XARMADA 35 8.0MM X 40MM X 80C -,SUP-B1080-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 8mmx60mmX80cm -,SUP-B1080-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B ARMADA 35 8MM X 60MM ON 80MM -,SUP-B1080-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
8MM X 80MM X 80CM ARMADA 35 BALLOON -,SUP-B1080-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 8.0MM X 80MM X 80CM -,SUP-B1080-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
9MM X 20MM X 80CM ARMADA 35 BALLOON -,SUP-B1090-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 BALLOON 9 X 40MM X 80CM -,SUP-B1090-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
10MM X 20MM X 80CM ARMADA 35 BALLOON -,SUP-B1100-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
10.0MM X 40MM X 80 ARMADA 35 BALLOON -,SUP-B1100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 10.0MM X 40MM X 80CM -,SUP-B1100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
10MM X 60MM X 80CM ARMADA 35 BALLOON -,SUP-B1100-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 10MM 60MM X 80CM -,SUP-B1100-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
12MM X 20MM X 80CM ARMADA 35 BALLOON -,SUP-B1120-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 12.0MM X 40MM X 80CM -,SUP-B1120-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 12.0MM X 60MM X 80CM -,SUP-B1120-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 12 X 60MM X 80CM -,SUP-B1120-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 14.0MM X 20MM X 80CM -,SUP-B1140-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
14MM X 40MM X 80CM ARMADA 35 BALLOON -,SUP-B1140-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 14MM X 60MM X 80CM -,SUP-B1140-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
4MM X 20MM X 135CM ARMADA 35 BALLOON -,SUP-B2040-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
Armada 4 x 40 x 135 Balloon -,SUP-B2040-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 4MM X 60MM X 135CM -,SUP-B2040-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 4X100X135 -,SUP-B2040-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
5MM X 20MM X 135CM ARMADA 35 -,SUP-B2050-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
5MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2050-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
5MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2050-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA PTA 0.035MM X 5MM X 60MM X 135CM -,SUP-B2050-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA PTA .035  5MM X 80MM X 135CM -,SUP-B2050-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
5MMX100MMX135CM ARMADA 35 -,SUP-B2050-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
5MM X 200MM X 135CM ARMADA 35 BALLOON -,SUP-B2050-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
6MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA PTA 0.035 6MM X 40MM X 135CM -,SUP-B2060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
6MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2060-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 6MM 80MM 135CM -,SUP-B2060-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 6MM 100MM 135CM -,SUP-B2060-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
6mm x 150mm x 135cm ARMADA 35 -,SUP-B2060-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
6MM X 200MM X 135CM ARMADA 35 BALLOON -,SUP-B2060-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
7MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35  BALLOON  7.0MM X 40MM X 135CM -,SUP-B2070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B ARMADA 35  7MM X 40MM X 135CM -,SUP-B2070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
7MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2070-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 7MM X 100MM BALLOON -,SUP-B2070-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
7MM X 200MM X 135CM ARMADA 35 BALLOON -,SUP-B2070-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 8MM X 20MM X 135CM -,SUP-B2080-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 8MM X 40MM X 135CM -,SUP-B2080-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35  8MM X 60MM X 135CM -,SUP-B2080-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 8MM X 80MM 35 BALLOON -,SUP-B2080-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON 9MM X 20MM X 135CM CATH ARMADA 35 -,SUP-B2090-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
9MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2090-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA PTA CATHETER 9MM X 60MM X 135CM -,SUP-B2090-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA PTA 10MM X 20MM X 135CM -,SUP-B2100-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
10MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA PTA 10MM X 40MM X 135CM -,SUP-B2100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA PTA 10MM X 60MM X 135MM -,SUP-B2100-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 12MM X 40MM X 135CM -,SUP-B2120-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
12MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2120-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 BALLOON DIAL CATH 14X20X135 -,SUP-B2140-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
14MM X 40MM X 135CM ARMADA 35 BALOON -,SUP-B2140-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH BALLOON DIL CROSPERIO RX 0.014 X 4.0MM X 150CM 4FR -,SUP-BD-B40150LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1229.72,860.804,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH BALLOON DILATION R2P PTA 4.0MM X 150MM CROSPERIO RX -,SUP-BD-B40150LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1229.72,860.804,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CROSTELLA RX PTA DIL CATH 3MM X 8MM X 150CM -,SUP-BD-F30080LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CROSSTELLA OTW 3MM X 200MM 150CM -,SUP-BD-F30200LW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH CROSTELLA BALLOON RX PTA 4.0MM X 40MM 150CM 4FR -,SUP-BD-F40040LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH CROSTELLA BALLOON RX PTA 5.0MM X 80MM 150CM 4FR -,SUP-BD-F50080LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CROSSTELLAÂ® RX PTA Balloon Dil Cath 5mm x 150mm -,SUP-BD-F50150LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON METACROS 5MM X 150 X .030 PTCA -,SUP-BD-P50150ER,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON R2P CROSTELLA RX 2MM X 40MM X 200CM -,SUP-BD-Q20040ER,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X120MM CHOC 120CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CB1812050120OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X40MM CHOC 150CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CF1415025040OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X120MM CHOC 150CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CF1415025120OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X120MM CHOC 150CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CF1415030120OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 10MMX4CM CONQUST 75CM OTW COAX ULTRA NC PERIPH -,SUP-CQ-75104,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 12MMX4CM CONQUST 75CM OTW COAX ULTRA NC PERIPH -,SUP-CQ-75124,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1490.45,1043.315,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX2CM CONQUST 75CM OTW COAX ULTRA NC PERIPH -,SUP-CQ-7562,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CONQUEST 6 X 4 X 75 -,SUP-CQ-7564,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CONQUEST 7 X 4 X 75 -,SUP-CQ-7574,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CONQUEST 8 X 4 X 75 -,SUP-CQ-7584,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH BALLOON CHOLANGIOGRAPHY -,SUP-CS-01701,CDM,C1725,HCPCS,272,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON DILATATION CATH OTW TAKERU 1.5X6MM REF:DC-PY1506UA1 -,SUP-DC-PY1506UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 1.5X12MM REF: DC-PY1512UA1 -,SUP-DC-PY1512UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON DILATATION CATH OTW TAKERU 1.5X15MM REF:DC-PY1515UA1 -,SUP-DC-PY1515UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 1.5X20MM REF: DC-PY1520UA1 -,SUP-DC-PY1520UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 2.0X8MM REF: DC-PY2008UA2 -,SUP-DC-PY2008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 2.0X12MM REF: DC-PY2012UA2 -,SUP-DC-PY2012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON DILATATION CATH OTW TAKERU 2.0X15MM REF:DC-PY2015UA2 -,SUP-DC-PY2015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON DILATATION CATH OTW TAKERU 2.0X20MM REF:DC-PY2020UA2 -,SUP-DC-PY2020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 2.25X12MM REF: DC-PY2212UA2 -,SUP-DC-PY2212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 2.25X15MM REF: DC-PY2215UA2 -,SUP-DC-PY2215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 2.25X20MM REF: DC-PY2220UA2 -,SUP-DC-PY2220UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 2.5X8MM REF: DC-PY2508UA2 -,SUP-DC-PY2508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 2.5X15MM REF: DC-PY2515UA2 -,SUP-DC-PY2515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 2.5X20MM REF: DC-PY2520UA2 -,SUP-DC-PY2520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 3.0X8MM REF: DC-PY3008UA2 -,SUP-DC-PY3008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 3.0X12MM REF: DC-PY3012UA2 -,SUP-DC-PY3012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 3.0X15MM REF: DC-PY3015UA2 -,SUP-DC-PY3015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 3.0X20MM REF: DC-PY3020UA2 -,SUP-DC-PY3020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 3.5X8MM REF: DC-PY3508UA2 -,SUP-DC-PY3508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 3.5X12MM REF: DC-PY3512UA2 -,SUP-DC-PY3512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 3.5X15MM REF: DC-PY3515UA2 -,SUP-DC-PY3515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 3.5X20MM REF: DC-PY3520UA2 -,SUP-DC-PY3520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 4.0X8MM REF: DC-PY4008UA2 -,SUP-DC-PY4008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 4.0X12MM REF: DC-PY4012UA2 -,SUP-DC-PY4012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 4.0X20MM REF: DC-PY4020UA2 -,SUP-DC-PY4020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON DILATATION CATH RX TAKERU 1.5X6MM REF:DC-RY1506UA1 -,SUP-DC-RY1506UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX 1.5X12MM REF: DC-RY1512UA1 -,SUP-DC-RY1512UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON DILATATION CATH RX TAKERU 1.5X15MM REF:DC-RY1515UA1 -,SUP-DC-RY1515UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON DILATATION CATH RX TAKERU 1.5X20MM REF:DC-RY1520UA1 -,SUP-DC-RY1520UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX 2.0X8MM REF: DC-RY2008UA2 -,SUP-DC-RY2008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX 2.0X12MM REF: DC-RY2012UA2 -,SUP-DC-RY2012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON DILATATION CATH RX TAKERU 2.0X15MM REF:DC-RY2015UA2 -,SUP-DC-RY2015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON DILATATION CATH RX TAKERU 2.0X20MM REF:DC-RY2020UA2 -,SUP-DC-RY2020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX 2.25X12MM REF: DC-RY2212UA2 -,SUP-DC-RY2212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX 2.25X15MM REF: DC-RY2215UA2 -,SUP-DC-RY2215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX 2.5X8MM REF: DC-RY2508UA2 -,SUP-DC-RY2508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX 2.5X12MM REF: DC-RY2512UA2 -,SUP-DC-RY2512UA,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX 2.5X15MM REF: DC-RY2515UA2 -,SUP-DC-RY2515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX 2.5X20MM REF: DC-RY2520UA2 -,SUP-DC-RY2520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX 3.0X8MM REF: DC-RY3008UA2 -,SUP-DC-RY3008UA,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX 3.0X12MM REF: DC-RY3012UA2 -,SUP-DC-RY3012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX 3.0X15MM REF: DC-RY3015UA2 -,SUP-DC-RY3015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX 3.0X20MM REF: DC-RY3020UA2 -,SUP-DC-RY3020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX 3.5X8MM REF: DC-RY3508UA2 -,SUP-DC-RY3508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX 3.5X12MM REF: DC-RY3512UA2 -,SUP-DC-RY3512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX 3.5X15MM REF: DC-RY3515UA2 -,SUP-DC-RY3515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX 3.5X20MM REF: DC-RY3520UA2 -,SUP-DC-RY3520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX 4.0X8MM REF: DC-RY4008UA2 -,SUP-DC-RY4008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX 4.0X12MM REF: DC-RY4012UA2 -,SUP-DC-RY4012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX 4.0X15MM REF: DC-RY4015UA2 -,SUP-DC-RY4015UA,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX 4.0X20MM REF: DC-RY4020UA2 -,SUP-DC-RY4020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 2.0X8MM REF: DC-RZ2008UA2 -,SUP-DC-RZ2008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 2.0X12MM REF: DC-RZ2012UA2 -,SUP-DC-RZ2012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 2.0X15MM REF: DC-RZ2015UA2 -,SUP-DC-RZ2015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 2.0X21MM REF: DC-RZ2021UA2 -,SUP-DC-RZ2021UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 2.25X8MM REF: DC-RZ2208UA2 -,SUP-DC-RZ2208UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 2.25X12MM REF: DC-RZ2212UA2 -,SUP-DC-RZ2212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 2.25X15MM REF: DC-RZ2215UA2 -,SUP-DC-RZ2215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 2.25X21MM REF: DC-RZ2221UA2 -,SUP-DC-RZ2221UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 2.5X8MM REF: DC-RZ2508UA2 -,SUP-DC-RZ2508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 2.5X12MM REF: DC-RZ2512UA2 -,SUP-DC-RZ2512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 2.5X15MM REF: DC-RZ2515UA2 -,SUP-DC-RZ2515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 2.5X21MM REF: DC-RZ2521UA2 -,SUP-DC-RZ2521UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 2.75X8MM REF: DC-RZ2708UA2 -,SUP-DC-RZ2708UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 2.75X12MM REF: DC-RZ2712UA2 -,SUP-DC-RZ2712UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 2.75X15MM REF: DC-RZ2715UA2 -,SUP-DC-RZ2715UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 2.75X21MM REF: DC-RZ2721UA2 -,SUP-DC-RZ2721UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 3.0X8MM REF: DC-RZ3008UA2 -,SUP-DC-RZ3008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 3.0X12MM REF: DC-RZ3012UA2 -,SUP-DC-RZ3012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 3.0X15MM REF: DC-RZ3015UA2 -,SUP-DC-RZ3015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 3.0X21MM REF: DC-RZ3021UA2 -,SUP-DC-RZ3021UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 3.25X8MM REF: DC-RZ3208UA2 -,SUP-DC-RZ3208UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 3.25X12MM REF: DC-RZ3212UA2 -,SUP-DC-RZ3212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 3.25X15MM REF: DC-RZ3215UA2 -,SUP-DC-RZ3215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 3.25X21MM REF: DC-RZ3221UA2 -,SUP-DC-RZ3221UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 3.5X08MM REF: DC-RZ3508UA2 -,SUP-DC-RZ3508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 3.5X12MM REF: DC-RZ3512UA2 -,SUP-DC-RZ3512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 3.5X15MM REF: DC-RZ3515UA2 -,SUP-DC-RZ3515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 3.5X21MM REF: DC-RZ3521UA2 -,SUP-DC-RZ3521UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 4.0X8MM REF: DC-RZ4008UA2 -,SUP-DC-RZ4008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 4.0X12MM REF: DC-RZ4012UA2 -,SUP-DC-RZ4012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 4.0X15MM REF: DC-RZ4015UA2 -,SUP-DC-RZ4015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 4.0X21MM REF: DC-RZ4021UA2 -,SUP-DC-RZ4021UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 2.5X12MM REF: DC-PY2512UA2 -,SUP-D-PY2512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX2CM DORADO 40CM OTW F/PTA ULTRA NC PERIPH 5FR -,SUP-DR4042,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1335.73,935.011,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MMX6CM DORADO 80CM OTW F/PTA ULTRA NC PERIPH 6FR -,SUP-DR8076,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1335.73,935.011,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP1506X EUPHORA RX -,SUP-EUP1506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP1512X EUPHORA RX -,SUP-EUP1512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP1515X EUPHORA RX -,SUP-EUP1515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP1520X EUPHORA RX -,SUP-EUP1520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP2006X EUPHORA RX -,SUP-EUP2006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP2010X EUPHORA RX -,SUP-EUP2010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP2012X EUPHORA RX -,SUP-EUP2012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP2015X EUPHORA RX -,SUP-EUP2015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP2020X EUPHORA RX -,SUP-EUP2020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP2025X EUPHORA RX -,SUP-EUP2025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP2030X EUPHORA RX -,SUP-EUP2030X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP22506X EUPHORA RX -,SUP-EUP22506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP22510X EUPHORA RX -,SUP-EUP22510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP22512X EUPHORA RX -,SUP-EUP22512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP22515X EUPHORA RX -,SUP-EUP22515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP22520X EUPHORA RX -,SUP-EUP22520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP22525X EUPHORA RX -,SUP-EUP22525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP2506X EUPHORA RX -,SUP-EUP2506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP2510X EUPHORA RX -,SUP-EUP2510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP2512X EUPHORA RX -,SUP-EUP2512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP2515X EUPHORA RX -,SUP-EUP2515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP2520X EUPHORA RX -,SUP-EUP2520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP2525X EUPHORA RX -,SUP-EUP2525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP2530X EUPHORA RX -,SUP-EUP2530X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP27506X EUPHORA RX -,SUP-EUP27506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP27510X EUPHORA RX -,SUP-EUP27510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP27512X EUPHORA RX -,SUP-EUP27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP27515X EUPHORA RX -,SUP-EUP27515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP27520X EUPHORA RX -,SUP-EUP27520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP27525X EUPHORA RX -,SUP-EUP27525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP3006X EUPHORA RX -,SUP-EUP3006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP3010X EUPHORA RX -,SUP-EUP3010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP3012X EUPHORA RX -,SUP-EUP3012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP3015X EUPHORA RX -,SUP-EUP3015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP3020X EUPHORA RX -,SUP-EUP3020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP3025X EUPHORA RX -,SUP-EUP3025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP3030X EUPHORA RX -,SUP-EUP3030X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP32506X EUPHORA RX -,SUP-EUP32506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP32510X EUPHORA RX -,SUP-EUP32510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP32512X EUPHORA RX -,SUP-EUP32512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP32515X EUPHORA RX -,SUP-EUP32515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP32520X EUPHORA RX -,SUP-EUP32520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP32525X EUPHORA RX -,SUP-EUP32525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP3506X EUPHORA RX -,SUP-EUP3506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP3510X EUPHORA RX -,SUP-EUP3510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP3512X EUPHORA RX -,SUP-EUP3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP3515X EUPHORA RX -,SUP-EUP3515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP3520X EUPHORA RX -,SUP-EUP3520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP3525X EUPHORA RX -,SUP-EUP3525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP3530X EUPHORA RX -,SUP-EUP3530X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP37506X EUPHORA RX -,SUP-EUP37506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP37510X EUPHORA RX -,SUP-EUP37510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP37512X EUPHORA RX -,SUP-EUP37512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP37515X EUPHORA RX -,SUP-EUP37515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP37520X EUPHORA RX -,SUP-EUP37520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP37525X EUPHORA RX -,SUP-EUP37525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP4006X EUPHORA RX -,SUP-EUP4006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP4010X EUPHORA RX -,SUP-EUP4010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP4012X EUPHORA RX -,SUP-EUP4012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP4015X EUPHORA RX -,SUP-EUP4015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP4020X EUPHORA RX -,SUP-EUP4020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP4025X EUPHORA RX -,SUP-EUP4025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP4030X EUPHORA RX -,SUP-EUP4030X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH BLNOCC 9FRX120CM CODA -,SUP-G03831,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2702.08,1891.456,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5MMX4CM ADVANCE MICRO 14 150CM OTW UL-LPRO F/PTA -,SUP-G26614,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2289.76,1602.832,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2MMX12CM ADVANCE MICRO 14 150CM OTW UL-LPRO F/PTA -,SUP-G26641,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2289.76,1602.832,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX2CM ADVANCE ATB 80CM OTW F/PTA MIN-CMPLNT -,SUP-G26895,CDM,C1725,HCPCS,272,RC,,,outpatient,,,705.98,494.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH DIL 4MMX12CM ADVANCE 18 LP 150CM LPRO F/PTA 4FR SHTH -,SUP-G30949,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30952,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX15CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30955,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ANGIOPLASTY 5 - 15 PTA -,SUP-G30956,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B 18LP ADVANCE 5MM X 15CM -,SUP-G30956,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ANGIOPLASTY / PTA4-18-150-5-20 -,SUP-G30958,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30958,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH DIL 6MMX12CM ADVANCE 18 LP 150CM LPRO F/PTA 5FR SHTH -,SUP-G30961,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ANGIOPLASTY 6 - 15 PTA -,SUP-G30962,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30964,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MMX12CM ADVANCE 18 LP 150CM LPRO F/PTA 5FR SHTH -,SUP-G30967,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30970,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3MMX4CM ADVANCE 18LP 150CM LPRO F/PTA -,SUP-G34319,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
3X6X150 PTA ADVANCE CATH -,SUP-G34320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3MMX8CM ADVANCE 18LP -,SUP-G34321,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON ADVANCE .018 3MM X 10CM X 150CM -,SUP-G34322,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G34331,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G34336,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX6CM ADVANCE 35LP 135CM LPRO PERIPH D-SHP -,SUP-G35532,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER ADVANCED LOW PROFILE BALLOON 6MM X 20MM X 135CM -,SUP-G35536,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MMX20CM ADVANCE 35LP 135CM LPRO F/PTA -,SUP-G35540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 10MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G35546,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH ANG 5FRX80CM ADVANCE LPRO -,SUP-G35547,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
GW ENDO 0.035INX260CM ACROBAT CLBRT TIP -,SUP-G47614,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1038.63,727.041,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G49479,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50216,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50218,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50222,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50224,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX10CM ADVANCE 18LP 135CM LUMX2 -,SUP-G50226,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX4CM ADVANCE 18LP - USE 0141543 DISC. -,SUP-G50228,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50230,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50235,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50237,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50239,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50241,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 -,SUP-G50243,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50245,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50247,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50249,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50251,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50253,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50257,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50262,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50264,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2MMX2CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50313,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50314,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2MMX6CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50315,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50316,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50317,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50318,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50319,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50321,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1836.57,1285.599,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5MMX6CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50322,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50323,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50324,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50325,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ADVANCE 14 LP BALLOON CATHETER -,SUP-G50327,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50328,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3MMX4CM ADVANCE 14LP 60MM LPRO LUMX2 F/PTA SEM-COM -,SUP-G50329,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50330,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50332,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50333,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX2CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50334,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50335,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX6CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50336,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50337,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50338,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50339,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50340,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52251,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52253,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52254,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52257,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52258,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX6CM ADVANCE 35LP 135CM LPRO PERIPH -,SUP-G52259,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52260,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52261,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX14CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52263,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52265,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52266,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52267,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52268,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX14CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52271,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52272,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52273,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52274,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52275,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MMX14CM ADVANCE 35LP 135CM LPRO F/PTA -,SUP-G52277,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 8MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52278,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 8MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52279,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 8MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52280,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 8MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52282,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 9MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52286,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 9MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52287,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 10MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52293,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 10MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52294,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 12MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52299,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 12MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
US PRE PP-CA-422 DIR BALLOON CATHER T3 20-23 -,SUP-G57885,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER US PRE PP-CA-422 DIR BALLOON T3 20-23 -,SUP-G57887,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ADVANCE SERENITY 14 150-20-220 -,SUP-G57889,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER BALLOON DILATATION ADVANCE SERENITY 14 2.5MM X10CM -,SUP-G57894,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATHETER T3 20-23 -,SUP-G57896,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
DIRECT BALLOON CATHETERS T2 23-26 -,SUP-G57897,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER US PRE PP-CA-422 DIR BALLOON  T3 20-23 -,SUP-G57900,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ADVANCE SERENITY 14 HYDROPHILIC PTA BALLOON DILA CATH 3 X 10 -,SUP-G57901,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ADVANCE SERENITY 14 HYDROPHILIC PTA BALLOON DILA CATH 3 X 22 -,SUP-G57903,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
US PRE PP-CA-422 DIR BALLOON CATHETER T3 20-23 150-40-20 -,SUP-G57911,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ADVANCE SERENITY 14 4MM x 100MM x 150CM -,SUP-G57915,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER BALLOON DIR SERENITY 14 4MM X 15CM 150CM -,SUP-G57916,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER US PRE PP-CA-422 DIR BALLOON  T3 20-23 -,SUP-G57917,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PIG 0.045IN 5FR PIG 125CM EXPO -,SUP-H749085262151,CDM,C1725,HCPCS,272,RC,,,outpatient,,,87.53,61.271,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP 0.014IN -,SUP-H7493895808200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP 0.014IN -,SUP-H7493895808300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP 0.014IN -,SUP-H7493895808400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X12MM APEX FLX UL-LPRO NC -,SUP-H7493895812150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X30MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895830250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,991.95,694.365,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X8MM APEX FLEX MONORAIL RX UL-LPRO NC -,SUP-H7493895908150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X12MM APEX FLEX MONORAIL RX UL-LPRO -,SUP-H7493895912150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X15MM APEX FLEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X20MM APEX FLEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B APEX MR  30MM X 2.50 MONORAIL RX -,SUP-H7493895930250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.0X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X8MM APEX OTW UL-LPRO F/PTCA OPTILEAP -,SUP-H7493896008150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X12MM APEX MONORAIL OTW UL-LPRO PSH -,SUP-H7493896012150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493896015150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X20MM APEX OTW UL-LPRO F/PTCA OPTILEAP -,SUP-H7493896020150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493896108150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X12MM APEX MONORAIL RX UL-LPRO PSH -,SUP-H7493896112150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X15MM APEX MONORAIL RX UL-LPRO -,SUP-H7493896115150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493896120150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
STERLING MONORAIL RAPID EXCHANGE 3 X 60 -,SUP-H74939031306010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON FG STERLING MR 4.5MM X 20MM X 135CM 4FR -,SUP-H74939031452010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2014.19,1409.933,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
STERLING MONORAIL .018 5X20X80CM 4F -,SUP-H74939031502080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6X20MM STERLNG MONORAIL 135CM RX LPRO COAX SEM-COM -,SUP-H74939031602010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH BALLOON STERLING 7.0MM X 40MM X 80CM 4FR FG MONORL -,SUP-H74939031704080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 10.0 X 60 135 -,SUP-H74939032106010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 10.0 X 80 135 -,SUP-H74939032108010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 4 X 10 X 135 39 -,SUP-H74939032401010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X220MM STERLNG 150CM OTW COAX SEM-COM PERIPH TAPR -,SUP-H74939032402210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 4.0 X 30 135 -,SUP-H74939032403010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 4 X 40 X 135 MA -,SUP-H74939032404010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 4.0 X 60 135 -,SUP-H74939032406010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1669.29,1168.503,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 4.0 X 80 135 -,SUP-H74939032408010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1669.29,1168.503,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 5 X 10 X 135 39 -,SUP-H74939032501010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 5.0 X 120 150 -,SUP-H74939032501210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 5.0 X 150 150 -,SUP-H74939032501510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 5.0 X 200 150 -,SUP-H74939032502110,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 5.0 X 220 150 -,SUP-H74939032502210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 5.0 X 30 135 -,SUP-H74939032503010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 5 X 4 X 135 390 -,SUP-H74939032504010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 5.0 X 60 135 -,SUP-H74939032506010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 5.0 X 80 135 -,SUP-H74939032508010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 6 X 10 X 135 39 -,SUP-H74939032601010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6X120MM 150CM -,SUP-H74939032601210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 6.0 X 150 150 -,SUP-H74939032601510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 6.0 X 200 150 -,SUP-H74939032602110,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 6.0 X 220 150 -,SUP-H7493903260221,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 6.0X30X135 -,SUP-H74939032603010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 6 X 4 X 135 390 -,SUP-H74939032604010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 6.0 X 80 135 -,SUP-H74939032608010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 7.0 X 100 135 -,SUP-H74939032701010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 7.0 X 120 150 -,SUP-H74939032701210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 7.0 X 150 150 -,SUP-H74939032701510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 7.0 X 200 150 -,SUP-H74939032702110,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 7.0 X 220 150 -,SUP-H74939032702210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 7.0 X 30 135 -,SUP-H74939032703010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 7.0 X 40 135 -,SUP-H74939032704010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 7.0 X 60 135 -,SUP-H74939032706010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 7.0 X 80 135 -,SUP-H74939032708010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 8.0 X 30 135 -,SUP-H74939032803010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 8.0 X 40 135 -,SUP-H74939032804010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 8.0 X 60 135 -,SUP-H74939032806010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 8.0 X 80 135 -,SUP-H74939032808010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 9.0 X 60 135 -,SUP-H74939032906010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 9.0 X 80 135 -,SUP-H74939032908010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4.5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912412200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X12MM NC QUANTM APEX MONORAIL UL-LPRO NC -,SUP-H7493912412270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X12MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912412320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X12MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912412370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X12MM NC QUANTM APEX MONORAIL RX UL -LPRO NC -,SUP-H7493912412400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4.5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912412450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912412500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X15MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912415270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X15MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912415320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X15MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912415370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4.5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912420200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X20MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912420270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X20MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912420320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X20MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912420370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4.5X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912420450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5 X 20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912430200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4732.06,3312.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4732.06,3312.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4.5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4.5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4.5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4.5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X40MM COYOTE ES MONORAIL 145CM RX SEM-COM PERIPH -,SUP-H74939134204010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON COYOTE 2.5MM X 40MM X 145CM  .014 -,SUP-H74939134254010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X20MM COYOTE ES 143CM OTW UL-LPRO SEM-COM PERIPH -,SUP-H74939134302010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X30MM COYOTE ES 144MM OTW UL-LPRO SEM-COM PERIPH -,SUP-H74939134303010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X40MM COYOTE ES 145CM OTW UL-LPRO SEM-COM PERIPH -,SUP-H74939134404010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X20MM COYOTE ES MONORAIL 143CM RX SEM-COM -,SUP-H74939135152010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X20MM COYOTE ES MONORAIL 143CM RX SEM-COM PERIPH -,SUP-H74939135202010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X20MM COYOTE ES MONORAIL 144CM RX SEM-COM PERIPH -,SUP-H74939135302010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X30MM COYOTE ES MONORAIL 145CM RX SEM-COM PERIPH -,SUP-H74939135303010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X40MM COYOTE ES MONORAIL 146CM RX SEM-COM PERIPH -,SUP-H74939135304010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X20MM COYOTE ES MONORAIL 144CM RX SEM-COM -,SUP-H74939135352010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X30MM COYOTE ES MONORAIL 145CM RX SEM-COM -,SUP-H74939135353010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X20MM COYOTE ES MONORAIL 144CM RX SEM-COM PERIPH -,SUP-H74939135402010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X30MM COYOTE ES MONORAIL 145CM RX SEM-COM PERIPH -,SUP-H74939135403010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X40MM COYOTE ES MONORAIL 146CM RX SEM-COM PERIPH -,SUP-H74939135404010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X100MM STERLNG SL 150CM OTW COAX SEM-COM PERIPH -,SUP-H74939148401510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 3.0 X 20 135CM -,SUP-H74939171030210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171030270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 3.0 X 40 135CM -,SUP-H74939171030410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
3MM X 40MM X 40CM MUSTANG -,SUP-H74939171030440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171030470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 3.0 X 60 135CM -,SUP-H74939171030610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
MUSTANG 3 X 60 X 75 -,SUP-H74939171030670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 3.0 X 80 135CM -,SUP-H74939171030810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 3.0 X 100 135C -,SUP-H74939171031010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 3.0 X 120 135C -,SUP-H74939171031210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 3.0 X 150 135C -,SUP-H74939171031510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 3.0 X 180 135C -,SUP-H74939171031810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 3.0 200 135CM -,SUP-H74939171032010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 4.0 X 20 135CM -,SUP-H74939171040210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171040270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 4.0 X 40 135CM -,SUP-H74939171040410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
MUSTANG 4MM X 40MM X 40CM -,SUP-H74939171040440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171040470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 4.0 X 60 135CM -,SUP-H74939171040610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171040670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 4.0 X 80 135CM -,SUP-H74939171040810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
MUSTANG 4MM X 80MM X 40CM -,SUP-H74939171040840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 4.0 X 100 135C -,SUP-H74939171041010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171041070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 4.0 X 120 135C -,SUP-H74939171041210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 4.0 X 150 135C -,SUP-H74939171041510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 4.0 X 180 135C -,SUP-H74939171041810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 4.0X200 135CM -,SUP-H74939171042010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 5.0 X 20 135CM -,SUP-H74939171050210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X30MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 5.0 X 40 135CM -,SUP-H74939171050410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
MUSTANG 5MM X 40MM X 40 CM -,SUP-H74939171050440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 5.0 X 60 135CM -,SUP-H74939171050610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 5.0 X 80 135CM -,SUP-H74939171050810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
MUSTANG 5MM X 80MM X 40CM -,SUP-H74939171050840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 5.0 X 100 135C -,SUP-H74939171051010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171051070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 5.0 X 120 135C -,SUP-H74939171051210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 5.0 X 150 135C -,SUP-H74939171051510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 5.0 180 135CM -,SUP-H74939171051810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 5.0 200 135CM -,SUP-H74939171052010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 6.0 X 20 135CM -,SUP-H74939171060210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 6.0 X 40 135CM -,SUP-H74939171060410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6X40MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1079.48,755.636,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
MUSTANG 6MM X 40MM X 40CM -,SUP-H74939171060440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 6.0 X 60 135CM -,SUP-H74939171060610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 6.0 X 80 135CM -,SUP-H74939171060810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
6MM X 80MM X 40CM MUSTANG PTA -,SUP-H74939171060840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
MUSTANG 6MM X 80MM X 40CM -,SUP-H74939171060840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 6.0 X 100 135C -,SUP-H74939171061010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 6.0 X 120 135C -,SUP-H74939171061210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6X150MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171061510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6X150MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171061570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 6.0 180 135CM -,SUP-H74939171061810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6X200MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171062010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 7.0 X 20 135CM -,SUP-H74939171070210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 7.0 X 40 135cm -,SUP-H74939171070410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
7MM X 40MM X 40CM MUSTANG -,SUP-H74939171070440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 7.0 X 60 135CM -,SUP-H74939171070610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7X80MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 7.0 X 100 135C -,SUP-H74939171071010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171071070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 7.0 X 120 135C -,SUP-H74939171071210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7X150MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171071510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7X150MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171071570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 7.0 180 135CM -,SUP-H74939171071810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7X200MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171072010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7X200MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171072070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 8.0 X 20 135CM -,SUP-H74939171080210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 8X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171080270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 8.0 X 40 135CM -,SUP-H74939171080410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
8MM X 40MM X 40CM MUSTANG -,SUP-H74939171080440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON MUSTANG 8MM X 40MM X 40CM -,SUP-H74939171080440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON MUSTANG 7.0MM X 80MM X 40CM -,SUP-H74939171080440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 8X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171080470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 8.0 X 60 135CM -,SUP-H74939171080610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 8.0 X 80 135CM -,SUP-H74939171080810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
8MM X 80MM X 40CM MUSTANG PTA -,SUP-H74939171080840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 8X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171080870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 8.0 X 100 135C -,SUP-H74939171081010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 8X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171081070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 8.0 X 120 135C -,SUP-H74939171081210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 8X150MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171081570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 8.0 180 135CM -,SUP-H74939171081810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 8X200MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171082010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 8X200MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171082070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 9.0 X 20 135CM -,SUP-H74939171090210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 9X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 9.0 X 40 135CM -,SUP-H74939171090410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 9X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 9X60MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 9X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 9.0 X 80 135CM -,SUP-H74939171090810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 9X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 10.0 X 20 135C -,SUP-H74939171100210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 10X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 10.0X40 135CM -,SUP-H74939171100410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
MUSTANG BALLOON 10MM X 40MM X 40CM -,SUP-H74939171100440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 10X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 10.0 X 60 135C -,SUP-H74939171100610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 10X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 10.0 X 80 135C -,SUP-H74939171100810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
MUSTANG 10MM X 80MM X 40CM -,SUP-H74939171100840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 10X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 12.0X20 135CM -,SUP-H74939171120210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 12X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171120270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 12.0X40 135CM -,SUP-H74939171120410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 12X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171120470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 12X60MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171120610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 12X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171120670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 12.0 X 80 135C -,SUP-H74939171120810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 12MM X 80MM 40CM -,SUP-H74939171120840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 1.5X40X150 -,SUP-H74939186150410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 2X60X150 -,SUP-H74939186200610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 2X80X150 -,SUP-H74939186200810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 2X100X150 -,SUP-H74939186201010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 2X120X150 -,SUP-H74939186201210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 2X220X150 -,SUP-H74939186202210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
COYOTE 2 X 220 -,SUP-H74939186202290,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 2.5X60X150 -,SUP-H74939186250610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 2.5X80X150 -,SUP-H74939186250810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OW 2.5X100X150 -,SUP-H74939186251010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OW 2.5X120X150 -,SUP-H74939186251210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OW 2.5X220X150 -,SUP-H74939186252210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 3X60X150 -,SUP-H74939186300610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 3X80X150 -,SUP-H74939186300810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 3X100X150 -,SUP-H74939186301010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 3X120X150 -,SUP-H74939186301210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 3X150X150 -,SUP-H74939186301510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 3X220X150 -,SUP-H74939186302210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 3.5X60X150 -,SUP-H74939186350610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 3.5X80X150 -,SUP-H7493918635081,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1637.85,1146.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OW 3.5X100X150 -,SUP-H74939186351010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OW 3.5X120X150 -,SUP-H74939186351210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OW 3.5X150X150 -,SUP-H74939186351510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OW 3.5X220X150 -,SUP-H74939186352210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 4X60X150 -,SUP-H74939186400610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 4X80X150 -,SUP-H74939186400810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 4X100X150 -,SUP-H74939186401010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1637.85,1146.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 4X120X150 -,SUP-H74939186401210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1637.85,1146.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 4X150X150 -,SUP-H74939186401510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 4X220X150 -,SUP-H74939186402210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 1.20MM X 8MM -,SUP-H7493918908120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 1.50MM X 8MM -,SUP-H7493918908150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 2.00 MM X 8MM -,SUP-H7493918908200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 2.50 MM X 8MM -,SUP-H7493918908250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 2.75 MM X 8MM -,SUP-H7493918908270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 3.00 MM X 8MM -,SUP-H7493918908300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 3.25 MM X 8MM -,SUP-H7493918908320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 3.50 MM X 8MM -,SUP-H7493918908350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 3.75 MM X 8MM -,SUP-H7493918908370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 4.00MM X 8MM -,SUP-H7493918908400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 1.20MM X 12MM -,SUP-H7493918912120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 1.50MM X 12MM -,SUP-H7493918912150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 2.00 MM X 12 MM -,SUP-H7493918912200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 2.25 MM X 12MM -,SUP-H7493918912220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 2.50 MM X 12 MM -,SUP-H7493918912250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 2.75 MM X 12MM -,SUP-H7493918912270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 3.00 MM X 12MM -,SUP-H7493918912300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 3.25 MM X 12MM -,SUP-H7493918912320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 3.50 MM X 12MM -,SUP-H7493918912350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 3.75 MM X 12MM -,SUP-H7493918912370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 4.00MM X 12MM -,SUP-H7493918912400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 1.20MM X 15MM -,SUP-H7493918915120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 1.50MM X 15MM -,SUP-H7493918915150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 2.00 MM X 15 MM -,SUP-H7493918915200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 2.25 MM X 15MM -,SUP-H7493918915220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 2.50 MM X 15MM -,SUP-H7493918915250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 2.75 MM X 15MM -,SUP-H7493918915270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 3.00 MM X 15MM -,SUP-H7493918915300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 3.25 MM X 15MM -,SUP-H7493918915320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 3.50 MM X 15MM -,SUP-H7493918915350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 3.75 MM X 15MM -,SUP-H7493918915370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 4.00MM X 15MM -,SUP-H7493918915400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 1.20MM X 20MM -,SUP-H7493918920120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 1.50MM X 20MM -,SUP-H7493918920150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 2.00 MM X 20 MM -,SUP-H7493918920200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 2.25 MM X 20MM -,SUP-H7493918920220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 2.50 MM X 20 MM -,SUP-H7493918920250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 2.75 MM X 20MM -,SUP-H7493918920270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 3.00 MM X 20 MM -,SUP-H7493918920300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 3.25 MM X 20MM -,SUP-H7493918920320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 3.50 MM X 20MM -,SUP-H7493918920350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 3.75 MM X 20MM -,SUP-H7493918920370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 4.00MM X 20MM -,SUP-H7493918920400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 2.00 MM X 30MM -,SUP-H7493918930200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 2.25 MM X 30MM -,SUP-H7493918930220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 2.50 MM X 30MM -,SUP-H7493918930250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 2.75 MM X 30MM -,SUP-H7493918930270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 3.00 MM X 30MM -,SUP-H7493918930300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 3.25 MM X 30MM -,SUP-H7493918930320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 3.50 MM X 30MM -,SUP-H7493918930350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 3.75 MM X 30MM -,SUP-H7493918930370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 4.00MM X 30MM -,SUP-H7493918930400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE PUSH MR 1.20MM X 8MM -,SUP-H7493919008120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE PUSH MR 1.50MM X 8MM -,SUP-H7493919008150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE PUSH MR 1.20MM X 12MM -,SUP-H7493919012120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE PUSH MR 1.50MM X 12MM -,SUP-H7493919012150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE PUSH MR 1.20MM X 15MM -,SUP-H7493919015120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE PUSH MR 1.50MM X 15MM -,SUP-H7493919015150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE PUSH MR 1.20MM X 20MM -,SUP-H7493919020120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE PUSH MR 1.50MM X 20MM -,SUP-H7493919020150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 1.20MM X 8MM -,SUP-H7493919108120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 1.50MM X 8MM -,SUP-H7493919108150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 2.00MM X 8MM -,SUP-H7493919108200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 2.25MM X 8MM -,SUP-H7493919108220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 2.50MM X 8MM -,SUP-H7493919108250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 2.75MM X 8MM -,SUP-H7493919108270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 3.00MM X 8MM -,SUP-H7493919108300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 3.25MM X 8MM -,SUP-H7493919108320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 3.50MM X 8MM -,SUP-H7493919108350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 3.75MM X 8MM -,SUP-H7493919108370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 4.00MM X 8MM -,SUP-H7493919108400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 1.20MM X 12MM -,SUP-H7493919112120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 1.50MM X 12MM -,SUP-H7493919112150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 2.00MM X 12MM -,SUP-H7493919112200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 2.25MM X 12MM -,SUP-H7493919112220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 2.50MM X 12MM -,SUP-H7493919112250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 2.75MM X 12MM -,SUP-H7493919112270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 3.00MM X 12MM -,SUP-H7493919112300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 3.25MM X 12MM -,SUP-H7493919112320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 3.50MM X 12MM -,SUP-H7493919112350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 3.75MM X 12MM -,SUP-H7493919112370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 4.00MM X 12MM -,SUP-H7493919112400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 1.20MM X 15MM -,SUP-H7493919115120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 1.50MM X 15MM -,SUP-H7493919115150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 2.00MM X 15MM -,SUP-H7493919115200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 2.25MM X 15MM -,SUP-H7493919115220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 2.50MM X 15MM -,SUP-H7493919115250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 2.75MM X 15MM -,SUP-H7493919115270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 3.00MM X 15MM -,SUP-H7493919115300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 3.25MM X 15MM -,SUP-H7493919115320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 3.50MM X 15MM -,SUP-H7493919115350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 3.75MM X 15MM -,SUP-H7493919115370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 4.00MM X 15MM -,SUP-H7493919115400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 1.20MM X 20MM -,SUP-H7493919120120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 1.50MM X 20MM -,SUP-H7493919120150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 2.25MM X 20MM -,SUP-H7493919120220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 2.50MM X 20MM -,SUP-H7493919120250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 2.75MM X 20MM -,SUP-H7493919120270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 3.00MM X 20MM -,SUP-H7493919120300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 3.25MM X 20MM -,SUP-H7493919120320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 3.50MM X 20MM -,SUP-H7493919120350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 3.75MM X 20MM -,SUP-H7493919120370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 4.00MM X 20MM -,SUP-H7493919120400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 2.00MM X 30MM -,SUP-H7493919130200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 2.00MM X 20MM -,SUP-H7493919130200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 2.25MM X 30MM -,SUP-H7493919130220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 2.50MM X 30MM -,SUP-H7493919130250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 2.75MM X 30MM -,SUP-H7493919130270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 3.00MM X 30MM -,SUP-H7493919130300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 3.25MM X 30MM -,SUP-H7493919130320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 3.50MM X 30MM -,SUP-H7493919130350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 3.75MM X 30MM -,SUP-H7493919130370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 4.00MM X 30MM -,SUP-H7493919130400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE PUSH OTW 1.20MM X 8MM -,SUP-H7493919208120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE PUSH OTW 1.50MM X 8MM -,SUP-H7493919208150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE PUSH OTW 1.20MM X 12MM -,SUP-H7493919212120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE PUSH OTW 1.50MM X 12MM -,SUP-H7493919212150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE PUSH OTW 1.20MM X 15MM -,SUP-H7493919215120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE PUSH OTW 1.50MM X 15MM -,SUP-H7493919215150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE PUSH OTW 1.20MM X 20MM -,SUP-H7493919220120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE PUSH OTW 1.50MM X 20MM -,SUP-H7493919220150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER BALLOON 3 X 20 X 135 -,SUP-H74939206030210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER BALLOON 3 X 20 X 75 -,SUP-H74939206030270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER BALLOON 3MM X 40MM X 130CM -,SUP-H74939206030410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER BALLOON 3MM X 80MM X 135CM -,SUP-H74939206030810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
3MM X 100MM X 135CM CHARGER -,SUP-H74939206031010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CHARGER 3MM X 120MM -,SUP-H74939206031210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
3.0MM X 150MM X 135CM CHARGER BALLOON -,SUP-H74939206031510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER 3MM X 200MM X 135CM -,SUP-H74939206032010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER OTW 4 X 20MM X135CM BALLOON -,SUP-H74939206040210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
4MM X 20MM X 75CM CHARGER BALLOON -,SUP-H74939206040270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
PTA BALLOON 5F -,SUP-H74939206040670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER BALLOON 4MM X 80MM X 75CM -,SUP-H74939206040870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER 4MM X 100MM X 135CM -,SUP-H74939206041010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
4MM X 100MM X 75CM CHARGER BALLOON -,SUP-H74939206041070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER BALLOON 4MM X 150MM X 135CM -,SUP-H74939206041510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
5MM X 20MM X 75CM .035 CHARGER SHORT SHAFT -,SUP-H74939206050270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER 5MM X 40MM X 135CM -,SUP-H74939206050410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER BALLOON 5MM X 60MM X 135CM -,SUP-H74939206050610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER BALLOON 5MM X 80MM X 135CM -,SUP-H74939206050810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
5MM X 80MM X 75CM CHARGER BALLOON -,SUP-H74939206050870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER 5MM X 100MM X 135CM -,SUP-H74939206051010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER 5MM X 120MM X 135CM -,SUP-H74939206051210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER BALLOON 5 X 150MM -,SUP-H74939206051510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
5MM X 200MM X 135CM CHARGER -,SUP-H74939206052010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
6MM X 20MM X 135CM CHARGER -,SUP-H74939206060210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
6MM X 20MM X 75CM .035 CHARGER SHORT SHAFT -,SUP-H74939206060270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER BALLOON 6MM X 40MM X 135CM -,SUP-H74939206060410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER 6MM X 40MM X 75CM BALLOON -,SUP-H74939206060470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
6.0MM X 60MM X 75CM CHARGER -,SUP-H74939206060670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
6MM X 8MM X 135CM CHARGER -,SUP-H74939206060810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER 6.0MM X 80MM X 75CM -,SUP-H74939206060870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER BALLOON 6MM X 100MM X 135CM -,SUP-H74939206061010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER 6MM X 100MM X 75CM -,SUP-H74939206061070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER BALLOON 6MM X 150MM X 135CM -,SUP-H74939206061510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
7MM X 20MM X 135CM CHARGER -,SUP-H74939206070210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
7MM X 40MM X 135CM CHARGER BALLOON -,SUP-H74939206070410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
7MM X 40MM X 75CM CHARGER BALLOON -,SUP-H74939206070470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER 7MM X 80MM X 135CM -,SUP-H74939206070610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER BALLOON .035 7MM X 60MM X 75CM -,SUP-H74939206070670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
7MM X 80MM X 75CM CHARGER BALLOON -,SUP-H74939206070870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
7MM X 100MM X 135CM CHARGER BALLOON -,SUP-H74939206071010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
7MM X 100MM X 75CM CHARGER PTA -,SUP-H74939206071070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER BALLOON 8MM X 40MM X 135CM -,SUP-H74939206080410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER 8MM X 40MM X 75CM -,SUP-H74939206080470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
8MM X 60MM X 75CM CHARGER PTA -,SUP-H74939206080670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
8MM X 80MM X 135CM CHARGER BALLOON -,SUP-H74939206080810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
8.0MM X 80MM X 75CM CHARGER -,SUP-H74939206080870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER PTA 8MM X 100MM X 135CM -,SUP-H74939206081010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
8MM X 100MM X 75CM CHARGER PTA -,SUP-H74939206081070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER 8MM X 180MM X 135CM -,SUP-H74939206081810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
8.0MM X 200MM X 135XM CHARGER BALLOON -,SUP-H74939206082010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
9MM X 40MM X 135CM CHARGER BALLOON -,SUP-H74939206090410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
9MM X 40MM X 75CM CHARGER BALLOON -,SUP-H74939206090470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CHARGER 9MM X 60MM X 75CM -,SUP-H74939206090670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER OTW 10 X 20 BALLOON 135CM -,SUP-H74939206100210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CHARGER .035 10MM X 40MM X 135CM -,SUP-H74939206100410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
10MM X 40MM X 75CM CHARGER PTA -,SUP-H74939206100470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
10.0MM X 80MM X 75CM CHARGER BALLOON -,SUP-H74939206100870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
12MM X 20MM X 75CM CHARGER -,SUP-H74939206120270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
12MM X 40MM X 135CM CHARGER -,SUP-H74939206120410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
12MM X 40MM X 75CM CHARGER -,SUP-H74939206120470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CHARGER 12MM X 60MM X 75CM -,SUP-H74939206120670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER 12MM X 80MM X 75CM -,SUP-H74939206120870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.00MM x 6MM -,SUP-H7493926706200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.25MM x 6MM -,SUP-H7493926706220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.50MM x 6MM -,SUP-H7493926706250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.75MM x 6MM -,SUP-H7493926706270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.00MM x 6MM -,SUP-H7493926706300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.25MM x 6MM -,SUP-H7493926706320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.50MM x 6MM -,SUP-H7493926706350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.75MM x 6MM -,SUP-H7493926706370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 4.00MM X 6MM -,SUP-H7493926706400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 4.50MM x 6MM -,SUP-H7493926706450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 5.00MM x 6MM -,SUP-H7493926706500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.00MM x 8MM -,SUP-H7493926708200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.25MM x 8MM -,SUP-H7493926708220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.50MM x 8MM -,SUP-H7493926708250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.75MM x 8MM -,SUP-H7493926708270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.00MM x 8MM -,SUP-H7493926708300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.25MM x 8MM -,SUP-H7493926708320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.50MM x 8MM -,SUP-H7493926708350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.75MM x 8MM -,SUP-H7493926708370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 4.0 MM X 8 MM -,SUP-H7493926708400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 4.50MM x 8MM -,SUP-H7493926708450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 5.00MM x 8MM -,SUP-H7493926708500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 5.50MM x 8MM -,SUP-H7493926708550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 6.00MM x 8MM -,SUP-H7493926708600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.00MM X 12MM -,SUP-H7493926712200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.25MM x 12MM -,SUP-H7493926712220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.50 MM X 12 MM -,SUP-H7493926712250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.75MM x 12MM -,SUP-H7493926712270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.00MM x 12MM -,SUP-H7493926712300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.25MM x 12MM -,SUP-H7493926712320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.50MM x 12MM -,SUP-H7493926712350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.75MM x 12MM -,SUP-H7493926712370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 4.00MM x 12MM -,SUP-H7493926712400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 4.50MM x 12MM -,SUP-H7493926712450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 5.0 MM X 12 MM -,SUP-H7493926712500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 5.50MM x 12MM -,SUP-H7493926712550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 6.00MM x 12MM -,SUP-H7493926712600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.00MM x 15MM -,SUP-H7493926715200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.25MM x 15MM -,SUP-H7493926715220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.50 MM X 15 MM -,SUP-H7493926715250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.75MM x 15MM -,SUP-H7493926715270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.0 MM X 15 MM -,SUP-H7493926715300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.25MM x 15MM -,SUP-H7493926715320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.50MM x 15MM -,SUP-H7493926715350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.75MM x 15MM -,SUP-H7493926715370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 4.00MM X 15MM -,SUP-H7493926715400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 4.50MM x 15MM -,SUP-H7493926715450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 5.00MM x 15MM -,SUP-H7493926715500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 5.50MM x 15MM -,SUP-H7493926715550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 6.00MM x 15MM -,SUP-H7493926715600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.00MM x 20MM -,SUP-H7493926720200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.25MM x 20MM -,SUP-H7493926720220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.50 MM X 20 MM -,SUP-H7493926720250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.75MM x 20MM -,SUP-H7493926720270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.0 MM X 20 MM -,SUP-H7493926720300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.25MM x 20MM -,SUP-H7493926720320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.50MM x 20MM -,SUP-H7493926720350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.75MM x 20MM -,SUP-H7493926720370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 4.00MM x 20MM -,SUP-H7493926720400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 4.50MM x 20MM -,SUP-H7493926720450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 5.00MM x 20MM -,SUP-H7493926720500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 5.50MM x 20MM -,SUP-H7493926720550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 6.00MM x 20MM -,SUP-H7493926720600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.00MM x 30MM -,SUP-H7493926730200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.25MM x 30MM -,SUP-H7493926730220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.50MM x 30MM -,SUP-H7493926730250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.75MM x 30MM -,SUP-H7493926730270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.00MM x 30MM -,SUP-H7493926730300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.25MM x 30MM -,SUP-H7493926730320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.50MM x 30MM -,SUP-H7493926730350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.75MM x 30MM -,SUP-H7493926730370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 4.00MM x 30MM -,SUP-H7493926730400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.00MM x 6MM -,SUP-H7493926806200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.25MM x 6MM -,SUP-H7493926806220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.50MM x 6MM -,SUP-H7493926806250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.75MM x 6MM -,SUP-H7493926806270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.00MM x 6MM -,SUP-H7493926806300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.25MM x 6MM -,SUP-H7493926806320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.50MM x 6MM -,SUP-H7493926806350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.75MM x 6MM -,SUP-H7493926806370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 4.00MM x 6MM -,SUP-H7493926806400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 4.50MM x 6MM -,SUP-H7493926806450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 5.00MM x 6MM -,SUP-H7493926806500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.00MM x 8MM -,SUP-H7493926808200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.25MM x 8MM -,SUP-H7493926808220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.50MM x 8MM -,SUP-H7493926808250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.75MM x 8MM -,SUP-H7493926808270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.00MM x 8MM -,SUP-H7493926808300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.25MM x 8MM -,SUP-H7493926808320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.50MM x 8MM -,SUP-H7493926808350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.75MM x 8MM -,SUP-H7493926808370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 4.00MM x 8MM -,SUP-H7493926808400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 4.50MM x 8MM -,SUP-H7493926808450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 5.00MM x 8MM -,SUP-H7493926808500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 5.50MM x 8MM -,SUP-H7493926808550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 6.00MM x 8MM -,SUP-H7493926808600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.00MM x 12MM -,SUP-H7493926812200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.25MM x 12MM -,SUP-H7493926812220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.50MM x 12MM -,SUP-H7493926812250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.75MM X 12MM -,SUP-H7493926812270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.00MM x 12MM -,SUP-H7493926812300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.25MM x 12MM -,SUP-H7493926812320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.50MM x 12MM -,SUP-H7493926812350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.75MM x 12MM -,SUP-H7493926812370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 4.00MM x 12MM -,SUP-H7493926812400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 4.50MM x 12MM -,SUP-H7493926812450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 5.00MM x 12MM -,SUP-H7493926812500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 5.50MM x 12MM -,SUP-H7493926812550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 6.00MM x 12MM -,SUP-H7493926812600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.00MM x 15MM -,SUP-H7493926815200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.25MM x 15MM -,SUP-H7493926815220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.50MM x 15MM -,SUP-H7493926815250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.75MM x 15MM -,SUP-H7493926815270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.00MM x 15MM -,SUP-H7493926815300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.25MM x 15MM -,SUP-H7493926815320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.50MM x 15MM -,SUP-H7493926815350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.75MM x 15MM -,SUP-H7493926815370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 4.00MM x 15MM -,SUP-H7493926815400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 4.50MM x 15MM -,SUP-H7493926815450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 5.00MM x 15MM -,SUP-H7493926815500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 5.50MM x 15MM -,SUP-H7493926815550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 6.00MM x 15MM -,SUP-H7493926815600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.00MM x 20MM -,SUP-H7493926820200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.25MM x 20MM -,SUP-H7493926820220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.50MM x 20MM -,SUP-H7493926820250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.75MM x 20MM -,SUP-H7493926820270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.00MM x 20MM -,SUP-H7493926820300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.25MM x 20MM -,SUP-H7493926820320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.50MM x 20MM -,SUP-H7493926820350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.75MM x 20MM -,SUP-H7493926820370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 4.00MM x 20MM -,SUP-H7493926820400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 4.50MM x 20MM -,SUP-H7493926820450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 5.00MM x 20MM -,SUP-H7493926820500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 5.50MM x 20MM -,SUP-H7493926820550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 6.00MM x 20MM -,SUP-H7493926820600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.00MM x 30MM -,SUP-H7493926830200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.25MM x 30MM -,SUP-H7493926830220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.50MM x 20MM -,SUP-H7493926830250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.75MM x 30MM -,SUP-H7493926830270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.00MM x 30MM -,SUP-H7493926830300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.25MM x 30MM -,SUP-H7493926830320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.50MM x 30MM -,SUP-H7493926830350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.75MM x 30MM -,SUP-H7493926830370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 4.00MM x 30MM -,SUP-H7493926830400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CUTTING 6MMX2.0MM WOLVERINE -,SUP-H74939401062000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CUTTING 6MMX2.5MM WOLVERINE -,SUP-H74939401062500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CUTTING 6MMX3.0MM WOLVERINE -,SUP-H74939401063000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CUTTING 6MMX3.5MM WOLVERINE -,SUP-H74939401063500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CUTTING 6MMX4.0MM WOLVERINE -,SUP-H74939401064000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CUTTING 10MMX2.0MM WOLVERINE -,SUP-H74939401102000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CUTTING 10MMX2.5MM WOLVERINE -,SUP-H74939401102500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CUTTING 10MMX3.0MM WOLVERINE -,SUP-H74939401103000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CUTTING 10MMX3.5MM WOLVERINE -,SUP-H74939401103500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CUTTING 10MMX4.0MM WOLVERINE -,SUP-H74939401104000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CUTTING 15MX2.00MM WOLVERINE -,SUP-H74939401152000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CUTTING 15MX2.50MM WOLVERINE -,SUP-H74939401152500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CUTTING 15MMX3.0MM WOLVERINE -,SUP-H74939401153000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
RANGER GLOBAL DCB OTW 6.0 X 150MM 150CM -,SUP-H74939419601510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
RANGER DCB OTW  7.0MM x 40MM x 80CM -,SUP-H74939419700480,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT BLN -,SUP-H749CBM3200100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X6MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3225060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3225100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X6MM FLEXTOME CUT BLN MONORAIL 142CM RX -,SUP-H749CBM3250060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3250100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3250150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3275100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3275150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT BLN -,SUP-H749CBM3300100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT BLN -,SUP-H749CBM3300150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3325100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X15MM FLEXTOME CUT BLN MONORAIL 142CM RX -,SUP-H749CBM3325150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3350100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3350150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3375100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3200060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3200100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3225060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3225100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X15MM FLEXTOME BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3225150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3250060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3250100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X15MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3250150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3275100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X15MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3275150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3300060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X15MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3300150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3325100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X15MM FLEXTOME CUT BLN 142CM CUT BLN NC -,SUP-H749CBO3325150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN -,SUP-H749CBO3350100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH DX 2.4FR ID 3.4FR RND TIP 135CM CROSSBOSS XING MUL-WIRE -,SUP-H749M2000A0,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4648.07,3253.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH ANG 0.045IN 5FR FR4 125CM EXPO FUL-R WIRE BRD ROBST -,SUP-H759085262251,CDM,C1725,HCPCS,272,RC,,,outpatient,,,87.53,61.271,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER IABP 7.5FR 40CC ULTRA FLEX REF: IAB-06840-U -,SUP-IAB-06840-U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER IABP 8FR 40CC REDIGUARD REF: IAB-S840C -,SUP-IAB-S840C,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4010.16,2807.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
INFLATION KIT 30/30 BASIX -,SUP-IN4530,CDM,C1725,HCPCS,272,RC,,,outpatient,,,364.57,255.199,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X220MM LUTONIX -,SUP-LX3513052205F,CDM,C1725,HCPCS,272,RC,,,outpatient,,,8063.6,5644.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
LUTONIX BALLOON 7MM X 80MM -,SUP-LX351307805F,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5305,3713.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
LUTONIX PTA 5MM X 60MM X 75CM -,SUP-LX3575560V,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
LUTONIX BALLOON 7 X 80 -,SUP-LX3575780V,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
LUTONIX 8 X 80 -,SUP-LX3575880V,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B XXL 14MM 4CM 75 14-514 -,SUP-M001145140,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH XXL VASC 12 X 6 X 75CM -,SUP-M001145300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 14X60MM 2XL 75CM LPRO F/PTA PERIPH NYBAX LUB -,SUP-M001145320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON XXL 16 X 4 X 75 -,SUP-M001145530,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON XXL 16 X 4  5.8/120 -,SUP-M001145530,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 16X60MM 2XL 75CM LPRO PERIPH NYBAX LUB BIOSLD CTD -,SUP-M001145540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH XXL 18MM X 4CM 120CM -,SUP-M001145580,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH DIL 18MM 8FR SHEA 0.037IN TIP 5.8FRX75CM 6CM BLN GALWAY -,SUP-M001145590,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X40MM ULTR-THN DMD 75CM F/PTA PERIPH 5FR SHTH -,SUP-M001164230,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6X20MM ULTR-THN DMD 75CM F/PTA PERIPH 5FR SHTH -,SUP-M001164570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7X20MM ULTR-THN DMD 75CM F/PTA PERIPH 5FR SHTH -,SUP-M001164770,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B DUT 8MM 4CM 75CM  16-505 -,SUP-M001165050,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
AST-GN45 -,SUP-M001NC20000001,CDM,C1725,HCPCS,272,RC,,,outpatient,,,358.85,251.195,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7X40MM POLAR 120CM COAX F/PTA CLD THRP PERIPH -,SUP-M001P740120010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2807.11,1964.977,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7X60MM POLAR 120CM COAX F/PTA CLD THRP PERIPH -,SUP-M001P760120010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2807.11,1964.977,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 8X20MM POLAR 120CM COAX F/PTA CLD THRP PERIPH -,SUP-M001P820120010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
DEVICE INFL POLAR N2O -,SUP-M001PCIU400000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4927.28,3449.096,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X40MM POLAR 150CM COAX F/PTA CLD THRP PERIPH -,SUP-M001T3040150010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X40MM POLAR 150CM COAX F/PTA CLD THRP PERIPH -,SUP-M001T4040150010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
RETRACTOR ORTHO HHMN 18MMX9.25IN STN FNSH SS V. MUELLER -,SUP-M001T5040135010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6X40MM POLAR 135CM COAX F/PTA CLD THRP PERIPH -,SUP-M001T6040135010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER  SHOCKWAVE M5+ IVL CATHETER 5.0X60MM -,SUP-M5PIVL5060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER SHOCKWAVE 5.5 X 60 MM M5+ -,SUP-M5PIVL5560,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER- SHOCKWAVE M5+ IVL CATHETER- 6.0X60MM -,SUP-M5PIVL6060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER- SHOCKWAVE M5+ IVL CATHETER- 7.0X60MM -,SUP-M5PIVL7060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER- SHOCKWAVE M5+ IVL CATHETER- 8.0X60MM -,SUP-M5PIVL8060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP2006X NCEUPHORA RX -,SUP-NCEUP2006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP2008X NCEUPHORA RX -,SUP-NCEUP2008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP2012X NCEUPHORA RX -,SUP-NCEUP2012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP2015X NCEUPHORA RX -,SUP-NCEUP2015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP2020X NCEUPHORA RX -,SUP-NCEUP2020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP22506X NCEUPHORA RX -,SUP-NCEUP22506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP22508X NCEUPHORA RX -,SUP-NCEUP22508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP22512X NCEUPHORA RX -,SUP-NCEUP22512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP22515X NCEUPHORA RX -,SUP-NCEUP22515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP22520X NCEUPHORA RX -,SUP-NCEUP22520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP2506X NCEUPHORA RX -,SUP-NCEUP2506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP2508X NCEUPHORA RX -,SUP-NCEUP2508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP2512X NCEUPHORA RX -,SUP-NCEUP2512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP2515X NCEUPHORA RX -,SUP-NCEUP2515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP2520X NCEUPHORA RX -,SUP-NCEUP2520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP2527X NCEUPHORA RX -,SUP-NCEUP2527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP27506X NCEUPHORA RX -,SUP-NCEUP27506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP27508X NCEUPHORA RX -,SUP-NCEUP27508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP27512X NCEUPHORA RX -,SUP-NCEUP27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP27515X NCEUPHORA RX -,SUP-NCEUP27515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP27520X NCEUPHORA RX -,SUP-NCEUP27520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP27527X NCEUPHORA RX -,SUP-NCEUP27527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP3006X NCEUPHORA RX -,SUP-NCEUP3006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP3008X NCEUPHORA RX -,SUP-NCEUP3008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP3012X NCEUPHORA RX -,SUP-NCEUP3012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP3015X NCEUPHORA RX -,SUP-NCEUP3015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP3020X NCEUPHORA RX -,SUP-NCEUP3020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP3027X NCEUPHORA RX -,SUP-NCEUP3027X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP32506X NCEUPHORA RX -,SUP-NCEUP32506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP32508X NCEUPHORA RX -,SUP-NCEUP32508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP32512X NCEUPHORA RX -,SUP-NCEUP32512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP32515X NCEUPHORA RX -,SUP-NCEUP32515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP32520X NCEUPHORA RX -,SUP-NCEUP32520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP32527X NCEUPHORA RX -,SUP-NCEUP32527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP3506X NCEUPHORA RX -,SUP-NCEUP3506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP3508X NCEUPHORA RX -,SUP-NCEUP3508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP3512X NCEUPHORA RX -,SUP-NCEUP3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP3515X NCEUPHORA RX -,SUP-NCEUP3515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP3520X NCEUPHORA RX -,SUP-NCEUP3520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP3527X NCEUPHORA RX -,SUP-NCEUP3527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP37506X NCEUPHORA RX -,SUP-NCEUP37506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP37508X NCEUPHORA RX -,SUP-NCEUP37508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP37512X NCEUPHORA RX -,SUP-NCEUP37512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP37515X NCEUPHORA RX -,SUP-NCEUP37515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP37520X NCEUPHORA RX -,SUP-NCEUP37520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP37527X NCEUPHORA RX -,SUP-NCEUP37527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP4006X NCEUPHORA RX -,SUP-NCEUP4006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP4008X NCEUPHORA RX -,SUP-NCEUP4008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP4012X NCEUPHORA RX -,SUP-NCEUP4012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP4015X NCEUPHORA RX -,SUP-NCEUP4015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP4020X NCEUPHORA RX -,SUP-NCEUP4020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP4027X NCEUPHORA RX -,SUP-NCEUP4027X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP4508X NCEUPHORA RX -,SUP-NCEUP4508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP4512X NCEUPHORA RX -,SUP-NCEUP4512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP4515X NCEUPHORA RX -,SUP-NCEUP4515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP4520X NCEUPHORA RX -,SUP-NCEUP4520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP5008X NCEUPHORA RX -,SUP-NCEUP5008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP5012X NCEUPHORA RX -,SUP-NCEUP5012,CDM,C1725,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP5015X NCEUPHORA RX -,SUP-NCEUP5015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X6MM NC STRMR 138CM OTW NC COR 3- FOLD FLCRM + -,SUP-NCS2506W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X11MM NC STRMR 138CM OTW NC COR 3- FOLD FLCRM + -,SUP-NCS2511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS2514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X6MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS27506W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X11MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM -,SUP-NCS27511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS27514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X16MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS27516W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X6MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS3006W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X11MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS3011W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS3014W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X16MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS3016W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X11MM NC STRMR 138CM OTW NC COR 5- FOLD FLCRM -,SUP-NCS32511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS32514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X11MM NC STRMR 138CM OTW NC COR 5- FOLD FLCRM + -,SUP-NCS3511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X16MM NC STRMR 138CM OTW NC COR 5- FOLD FLCRM + -,SUP-NCS3516W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X11MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS37511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS37514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X11MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS4011W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X16MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS4016W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X21MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS4021W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X6MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP2506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP2512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP2515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X6MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP27506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X21MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP27521X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X6MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT FLCRM -,SUP-NCSP3006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X21MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3021X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X12MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP32512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X15MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP32515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X27MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X12MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP37512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP37515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X21MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4021X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4.5X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X15MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP5015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
PALADIN CAROTID PTA CATHETER WITH INTEGRATED EMB PRO -,SUP-PD-5520-140-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER ADVANCE MICRO 14 ULTRA LOW PROFILE BALLOON -,SUP-PTA3-14-90-2.5-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2289.76,1602.832,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER PTA BALLOON DILATION 18LP ADVANCE LP 2MM X 20CM -,SUP-PTA4-18-150-2-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX10CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX6CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-8,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH ADVANCE 18LP 5X10 150 -,SUP-PTA4-18-150-510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-5-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-5-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX6CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-5-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX10CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-6-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-6-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH ANG 4FR 0.018/ 150CM/6MM DIA 6CM ADVANCE RNL POPLT PTA -,SUP-PTA4-18-150-6-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MMX10CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-710,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MMX6CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-8,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 10MMX3CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-PTA5-35-135-103,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-PTA5-35-135-44,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-PTA5-35-13562.0,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 8MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-PTA5-35-135-8-8,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-PTAX4141702.520,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-PTAX414170312,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 26MM 12FRX2.5CM INOUE 70CM PVC 0.025IN GW COMP -,SUP-PTMC-26,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10025.1,7017.57,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 28MM 12FRX2.5CM INOUE 70CM PVC 0.025IN GW COMP -,SUP-PTMC-28,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10025.1,7017.57,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 30MM 12FRX2.5CM INOUE 70CM PVC 0.025IN GW COMP -,SUP-PTMC-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10025.1,7017.57,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
SHOCKWAVE 3.0 X 40MM IVL KIT -,SUP-S4IVLK3040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ADV SERENITY 14 HYDROPHILIC PTA BALL DIL CATH 2.5X60X150CM -,SUP-SER14-150-25-60,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ADVANCE SERENITY 14 HYDROPHILIC PTA BALLOON DIL CATH -,SUP-SER14-150-30-60,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.25X6MM SPRINTER LEGEND 152CM OTW SEM-COM COR -,SUP-SPL12506WL,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.25X6MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.25X10MM SPRINTER LEGEND 152CM OTW SEM-COM COR -,SUP-SPL12510WL,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.25X10MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.25X12MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.25X15MM SPRINTER LEGEND 152CM OTW SEM-COM COR -,SUP-SPL12515WL,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.25X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X6MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL15006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL15012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL15015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL20012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL20015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X20MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL20020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X6MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL22506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL22515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL25012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL25015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X20MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL25020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X25MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL25025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X12MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL27515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X20MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL27520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL30012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL30015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X20MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL30020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X12MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL40012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL40015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR1512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR1515W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2012W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2015W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X20MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2020W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X25MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2025W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X12MM SPRINTER 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR22512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X6MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2506W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2515W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X20MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2520W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR27512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR27515W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3012W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3015W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X20MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3020W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR32512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR4015W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ENROUTE ENFLATE TRANSCAROTID RX BALLOON -,SUP-SR-4525-BC,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2008.89,1406.223,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
ENROUTE ENFLATE TRANSCAROTID RX BALLOON -,SUP-SR-5035-BC,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2008.89,1406.223,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH ANG 4FR STR 125CM TEMPO AQ SLCT BRD SHFT NO SH NYL -,SUP-SRD6667,CDM,C1725,HCPCS,272,RC,,,outpatient,,,269.58,188.706,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER BALLOON TRUE FLOW 24 MM x 3.5CM REF: TF0243514 -,SUP-TF0243514,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6153.8,4307.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CABLE ADPTR IABP -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,344.79,241.353,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X15MM 140CM OTW PERIPH -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4134.28,2893.996,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X15MM 140CM OTW PERIPH -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4134.28,2893.996,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH SHEATH RITESITE C315H1802 -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2MMX2CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V142020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V142040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V142540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3MMX2CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V143020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3319.12,2323.384,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V143040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3MMX6CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V143060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX12CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V1840120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX8CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V184080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V185040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX6CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V185060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX12CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V1860120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER PTV DILATATION 26MX4CM VIDA REF:VDA100264 -,SUP-VDA100264,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2802.82,1961.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.650485,9184.66245,other,OPPS APC,,
DILATOR 6-30FR DIA TIP 30CM PE/PTFE -,SUP-118768,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1395.36,976.752,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
LEAD DEFIB IMPL BIPLR PERMNT PCNG ETAK RELIANCE G_59CM -,SUP-5843,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
KT MNMTRY BLN ADLT RCTL BLN -,SUP-A86-1070,CDM,C1726,HCPCS,272,RC,,,outpatient,,,52.52,36.764,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH DIL 6MMX16MM RELIEVA ULTIRRA SIN 2LUM SHFT ENDO F/IRR -,SUP-BC0616RU,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3728.49,2609.943,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH DIL 6MMX16MM RELIEVA SOLO PRO SIN 2LUM SHFT ENDO F/IRR -,SUP-BC0616SP,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3265.42,2285.794,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
KIT CATHETER SURGILUBE VINYL PEDIATRIC FEMALE OD8 FR SOFT LF -,SUP-CKF105L,CDM,C1726,HCPCS,272,RC,,,outpatient,,,18.99,13.293,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
KIT CATHETER SURGILUBE VINYL PEDIATRIC FEMALE OD8 FR SOFT LF -,SUP-CKF105L,CDM,C1726,HCPCS,272,RC,,,outpatient,,,18.96,13.272,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
TRAY URETHRAL 8FR FEMALE VINYL PVP URINE COLLECTION DEVICE -,SUP-CKF105L,CDM,C1726,HCPCS,272,RC,,,outpatient,,,18.15,12.705,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
BALLOON CERVICAL RIPENING W/STYLET -,SUP-G19891,CDM,C1726,HCPCS,272,RC,,,outpatient,,,243.61,170.527,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
IMPLANT PIP MCP SZ5 SWNSN SIL -,SUP-G470-0005,CDM,C1726,HCPCS,272,RC,,,outpatient,,,4413.76,3089.632,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
HURRICANE RX 4 X 4 -,SUP-G49219,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
HURRICANE RX 6 X 4 -,SUP-G49220,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
HURRICANE RX 8 X 4 -,SUP-G49221,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
HURRICANE RX 10 X 4 -,SUP-G49222,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH DIL 7FR CATH 7-5FR TIP 200CM 2CM BLN FUSION BIL TAPR -,SUP-G49571,CDM,C1726,HCPCS,272,RC,,,outpatient,,,676.86,473.802,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH DIL 8.5FR CATH 8.5-6FR TAPR 200CM 2CM BLN FUSION BIL -,SUP-G49572,CDM,C1726,HCPCS,272,RC,,,outpatient,,,676.86,473.802,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH DIL 7FR TAPR 200CM 2CM BLN FUSION BIL DOME TIP ENDO -,SUP-G49573,CDM,C1726,HCPCS,272,RC,,,outpatient,,,676.86,473.802,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH PTCA 6X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171061070,CDM,C1726,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
B CUTTING 5 X 2 X 135 -,SUP-M001PCB50201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
BALLOON 2CM PERIPHERAL CUTTING -,SUP-M001PCB50201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH PTCA 5MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-M001PCB50201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
PERIPHERAL CUTTING BALLOON  5MM X 2CM  50CM -,SUP-M001PCB5020500,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
B 6 X 2 X 135 CUTTING BAL -,SUP-M001PCB60201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
B CUTTING 7 X 2 X 135 -,SUP-M001PCB70201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH PTCA 7MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-M001PCB70201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH PTCA 7X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-M001PCB7020900,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
B CUTTING 8 X 2 X 135 -,SUP-M001PCB80201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH PTCA 8MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-M001PCB80201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH PTCA 8X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-M001PCB8020900,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH PTCA 1.5X3MM CUT BLN 140CM OTW PERIPH 0.018IN GW COMP -,SUP-M001PCBO3015140,CDM,C1726,HCPCS,272,RC,,,outpatient,,,4134.28,2893.996,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
B PERIPHERAL 6F 3.0X15X140 M00 -,SUP-M001PCBO3015140F0,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
B PER CUT OTW FLEX 4X15X140 M0 -,SUP-M001PCBO4015140F0,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CUTTING BALLOON 4MM X 1.5CM  X 135CM -,SUP-M001PCBO4015140F0,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH DIL 5.8FR 6MM BLN 180CM 4CM BLN HURRCN SS BIL RX ENDO -,SUP-M00545920,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH DIL 5.8FR 8MM BLN 180CM 4CM BLN HURRCN SS BIL RX ENDO -,SUP-M00545940,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATHETER CHOLANGIOGRAM SPYGLASS 65CM CHOLANGIOSCOPY -,SUP-M00546780,CDM,C1726,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
DILATOR BLN 36-40.5-45FR OD BLN 75CM 5.5CM CRE ESPH WG ENDO -,SUP-M00550300,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1649.04,1154.328,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
DILATOR BLN 24-27-30FR OD BLN 75CM 3CM CRE ESPH WG ENDO -,SUP-M00550330,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1649.04,1154.328,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
DILATOR BLN 30-33-36FR OD BLN 75CM 3CM CRE ESPH WG ENDO -,SUP-M00550340,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1649.04,1154.328,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
DILATOR BALLOON 35MM RIGIFLEX -,SUP-M00554510,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3112.17,2178.519,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
DILATOR BLN 7.5FR 6-7-8 MMX180CM 5.5CM BLN CRE PEBAX ESPH FX -,SUP-M00556860,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CRE 8-10MM 8CM F/G -,SUP-M00558340,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CRE 10-12MM 8CM F/G -,SUP-M00558350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CRE 12-15MM 8CM F/G -,SUP-M00558360,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
DILATOR BLN 6FR 12-13.5-15 MMX180CM 8CM BLN CRE PEBAX ESPH -,SUP-M00558360,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CRE 15-18MM 8CM F/G -,SUP-M00558370,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CRE 18-20MM 8CM F/G -,SUP-M00558380,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
DILATOR BLN 6FR 18-19-20 MMX180CM 8CM BLN CRE PEBAX ESPH FX -,SUP-M00558380,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
DILATOR WIREGUIDED CRE 15-18 180CM -,SUP-M00558430,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
DILATOR BLN 7.5FR 10-11-12 MMX240CM 5.5CM BLN CRE PEBAX ESPH -,SUP-M00558470,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
DILATOR BLN 7.5FR 12-13.5-15 MMX240CM 5.5CM BLN CRE PEBAX -,SUP-M00558480,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
DILATOR WIREGUIDED CRE 8-10 180CM -,SUP-M00558610,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
DILATOR WIREGUIDED CRE 10-12 180CM -,SUP-M00558620,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
DILATOR WIREGUIDED CRE 12-15 180CM -,SUP-M00558630,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CRE PRO WIREGUIDED 6-7-8MM 240CM -,SUP-M00558660,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CRE PRO WIREGUIDE 8-9-10MM 240 -,SUP-M00558670,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CRE PRO WIREGUIDE 10-11-12MM 240 -,SUP-M00558680,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CRE PRO WIREGUIDE 12-13.5-15MM 240 -,SUP-M00558690,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CRE PRO WIREGUIDE 15-16.5-18MM 240 -,SUP-M00558700,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
DILATOR BLN 7.5FR 15-16.5-18 MMX240CM 5.5CM BLN CRE PEBAX -,SUP-M00558700,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CRE PRO WIREGUIDE 18-19-20MM 240 -,SUP-M00558710,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH BILIARY BALLOON DILATATION CRE 8-10 3CM -,SUP-M00558920,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1517,1061.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH BILIARY BALLOON DILATATION CRE 10-12 3CM -,SUP-M00558930,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1517,1061.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH BILIARY BALLOON DILATATION CRE 12-15 3CM -,SUP-M00558940,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1517,1061.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH NEPH DIL 7FR 30FR BLN LPRO NPHRMX LF MRKR STPCK 17CM -,SUP-M0062101170,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1232.21,862.547,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH NEPH 7FR 10MM NPHRMX LF MRKR PTFE SHTH STPCK INFL DVC -,SUP-M0062101180,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1347.23,943.061,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH NEPH DIL 7FR 30FR BLN LPRO NPHRMX LF MRKR STPCK 20CM -,SUP-M0062101440,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1303.92,912.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH URET 4MM BLN 12FR INFL 3FR SHFT 150CM HYDRPLS CTD SS -,SUP-M0062181100,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1434.32,1004.024,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
PASSPORT BALLOON CATH 2CM -,SUP-M0062181200,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1540.27,1078.189,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH URET 5.8FRX4MM OD BLN 12FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251000,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1208.3,845.81,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
URO-MAX 2Q 4CM BALLOON KIT -,SUP-M0062251010,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1252.72,876.904,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH URET 5.8FRX10MM OD BLN 30FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251050,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1170.62,819.434,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
UROMAX 2/Q CATH 6CM 15FR SINGLE -,SUP-M0062251070,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1170.62,819.434,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH UROMAX U2Q\8-8 SINGLE -,SUP-M0062251100,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1170.62,819.434,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
UROMAX 2/Q CATH 10CM 15FR -,SUP-M0062251160,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1252.72,876.904,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH URET 5.8FRX6MM OD BLN 15FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251360,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1464.74,1025.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH URET 5.8FRX6MM OD BLN 18FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251370,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1384.17,968.919,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
APPLICATOR ENDO BLN US F /BF-UC16F-OL8 LTX STRL -,SUP-MAJ-1351,CDM,C1726,HCPCS,272,RC,,,outpatient,,,191.19,133.833,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CUFF BLN ADLT ENDO US F -,SUP-MAJ-249,CDM,C1726,HCPCS,272,RC,,,outpatient,,,157.36,110.152,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH ESPH 4.2MMX1CM SPC HI-RESOLTN CHNLX36 MANOSCAN -,SUP-MSC-1286,CDM,C1726,HCPCS,272,RC,,,outpatient,,,25903.5,18132.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATHETER HEMOSTATIC BALLOON NEXPOWDER -,SUP-NHS03,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH ATHRCMY PERIPH CUT BLN 4MMX140MM OTW PERIPH -,SUP-PCB04015140F,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH PTCA 6MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-PCB6020135,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH PTCA 7X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-PCB702090,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH PTCA 8X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-PCB802090,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.074675,18572.8095,other,OPPS APC,,
HERNIA BALLOON #OMS-PDBS2 -,SUP-OMS-PDBS2,CDM,C1727,HCPCS,272,RC,,,outpatient,,,1296.65,907.655,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,291.097925,929.69805,other,OPPS APC,,
CATH BRCHTX MULTLUM 4-5CM CONTURA STRL -,SUP-B01245,CDM,C1728,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,195.18479,8389.93965,other,OPPS APC,,
APPLICATOR BRCHTX MULTLUM 5-6CM BLN CONTURA STRL SUD -,SUP-B01256,CDM,C1728,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,195.18479,8389.93965,other,OPPS APC,,
CATH BRCHTX 5-6CM CONTURAFLEX LF -,SUP-B13256,CDM,C1728,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,195.18479,8389.93965,other,OPPS APC,,
CATH BRCHTX F/CVTY MNTN CONTURA -,SUP-B90012,CDM,C1728,HCPCS,272,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,195.18479,8389.93965,other,OPPS APC,,
TRY APPLICATOR BRCHTX SAVI 6-1 -,SUP-SAVI-06,CDM,C1728,HCPCS,272,RC,,,outpatient,,,9468.15,6627.705,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,195.18479,8389.93965,other,OPPS APC,,
APPLICATOR BRCHTX SGL-ENTRY MUL-CATH SAVI PREP -,SUP-SPC-01,CDM,C1728,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,195.18479,8389.93965,other,OPPS APC,,
CT/MR APPLICATOR W/BASE PLATE -,SUP-UNDEFINED,CDM,C1728,HCPCS,272,RC,,,outpatient,,,11701.45,8191.015,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,195.18479,8389.93965,other,OPPS APC,,
DRAIN PENROSE19MM 30CM 32MM FLAT -,SUP-00000,CDM,C1729,HCPCS,272,RC,,,outpatient,,,4.14,2.898,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH NEPH PEZ 28FR EYEX2 PRPRTN HEAD LTX MSHRM SHP -,SUP-064028,CDM,C1729,HCPCS,272,RC,,,outpatient,,,44.17,30.919,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH NEPH MLCT 14FR WNGX4 LTX -,SUP-086014,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.82,46.074,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH MALECOT 18FR BARD -,SUP-086018,CDM,C1729,HCPCS,272,RC,,,outpatient,,,49.29,34.503,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH MALECOT 20FR BARD -,SUP-086020,CDM,C1729,HCPCS,272,RC,,,outpatient,,,49.29,34.503,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH MALECOT 22FR BARD -,SUP-086022,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.06,45.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH MALECOT 24FR BARD -,SUP-086024,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.07,45.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH MALECOT 34FR PROPORTIONATE HEAD LATEX -,SUP-086034,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.07,45.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH NEPH MLCT 38FR WNGX4 LTX -,SUP-086038,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.06,45.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH NEPH MLCT 40FR WNGX4 LTX -,SUP-086040,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.89,45.423,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
24FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14024,CDM,C1729,HCPCS,272,RC,,,outpatient,,,123.9,86.73,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
28FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14028,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
32 FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14032,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
36FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14036,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH DRN 10.2FRX25CM SDPRTX6 COOK-COPE TY LCK LOOP -,SUP-192550,CDM,C1729,HCPCS,272,RC,,,outpatient,,,429.81,300.867,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH DRN 16FRX25CM SDPRTX6 COOK-COPE TY LCK LOOP -,SUP-193581,CDM,C1729,HCPCS,272,RC,,,outpatient,,,609.7,426.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH BIL DRN 12FRX40CM SDPRTX32 MA C -LOC LCK LOOP -,SUP-228702,CDM,C1729,HCPCS,272,RC,,,outpatient,,,545.51,381.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH DRN 12 FR X 25CM J-CRV THAL-QUICK PVC SDPRTX3 -,SUP-228707,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH DRN 14FRX25CM SDPRTX6 MA C -LOC LCK LOOP -,SUP-228709,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
TUBE VACUTNR 4ML GRN CAP NAHEP SAFTY PLST PPR LBL STRL HG-FR -,SUP-367871,CDM,C1729,HCPCS,272,RC,,,outpatient,,,0.94,0.658,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
THORACENTESIS TRAY/P4340A -,SUP-4340A,CDM,C1729,HCPCS,272,RC,,,outpatient,,,176.04,123.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
TRY THORCNTS 14GAX2IN L INTRO NDLX4 3WAY STP C LOCK BTRFLY -,SUP-4341B,CDM,C1729,HCPCS,272,RC,,,outpatient,,,228.45,159.915,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH VNTRC DRN 80CM TUOHY NDL FX TAB BLNT NDL STRN RLF OPN -,SUP-464-20,CDM,C1729,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
THORACENTESIS 30IN TUBING 4653 -,SUP-4653-48,CDM,C1729,HCPCS,272,RC,,,outpatient,,,23.96,16.772,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
SYS VNTRC DRN 35CM DUET W/ICP LN NDL-FR PRTX3 DRP CHMBR TBG -,SUP-469-13,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1120.58,784.406,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
SYS BAG VNTRC DRN REPL 35CM INTLNK NDL-FR INJ SITE -,SUP-469-14,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1120.58,784.406,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
KIT CSF DRAINAGE W CATH -,SUP-46916,CDM,C1729,HCPCS,272,RC,,,outpatient,,,2091.05,1463.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATHETER PLEURAL PLEURX KIT -,SUP-50-7000B,CDM,C1729,HCPCS,272,RC,,,outpatient,,,3841.3,2688.91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH WORD BARTHOLIN GLAND 10FR 5CM -,SUP-564000,CDM,C1729,HCPCS,272,RC,,,outpatient,,,104.15,72.905,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATHETER THORACIC 28F STRAIGHT -,SUP-8028,CDM,C1729,HCPCS,272,RC,,,outpatient,,,35.56,24.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATHETER THORACIC 32FR STERILE -,SUP-8032,CDM,C1729,HCPCS,272,RC,,,outpatient,,,35.05,24.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATHETER THORACIC 36F STRAIGHT -,SUP-8036,CDM,C1729,HCPCS,272,RC,,,outpatient,,,35.88,25.116,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATHETER THORACIC 24FR RT ANGL -,SUP-8124,CDM,C1729,HCPCS,272,RC,,,outpatient,,,57.26,40.082,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATHETER THORACIC  32F RT ANGLE -,SUP-8132,CDM,C1729,HCPCS,272,RC,,,outpatient,,,54.52,38.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
DRAIN CATH LUMBAR KTXTRN DRN 0.76MM 1.65MMX46CM -,SUP-82-1706,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1526.54,1068.578,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH VNTRC DRN 1.5MM BCTSL EVD SIL 0.15% CLNDMCN -,SUP-82-1745,CDM,C1729,HCPCS,272,RC,,,outpatient,,,2522.1,1765.47,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
DRAIN PENROSE 5/8 WND 0.625X12IN GRVTY  FLT LTX -,SUP-8888515007,CDM,C1729,HCPCS,272,RC,,,outpatient,,,223.25,156.275,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH TROCAR 12FR ARGYLE -,SUP-8888561027,CDM,C1729,HCPCS,272,RC,,,outpatient,,,106.84,74.788,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH TROCAR 20FR X 16 ARGYLE -,SUP-8888561043,CDM,C1729,HCPCS,272,RC,,,outpatient,,,78.42,54.894,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH TROCAR 28FR X 16 ARGYLE -,SUP-8888561068,CDM,C1729,HCPCS,272,RC,,,outpatient,,,110.81,77.567,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
KT DRN 20FRX10IN ARGYLE PVC GLVX2 PREP SWB /CUPX2 FEN DRAPE -,SUP-8888565036,CDM,C1729,HCPCS,272,RC,,,outpatient,,,192.93,135.051,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATHETER TROCAR KIT 28 FR NSQ -,SUP-8888565044,CDM,C1729,HCPCS,272,RC,,,outpatient,,,199.28,139.496,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH THORACIC 12FR MAR -,SUP-8888570507,CDM,C1729,HCPCS,272,RC,,,outpatient,,,55.61,38.927,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH THORACIC 16FR MAR -,SUP-8888570515,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.3,26.81,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATHETER THORACIC 16FR -,SUP-8888570515,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.3,26.81,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH THORACIC 20FR MAR -,SUP-8888570523,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.68,27.076,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
"CATHETER THORACIC 20FR X 20"" RADIOPAQUE 5 EYELETS -",SUP-8888570523,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.69,27.083,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH THORACIC 24FR MAR -,SUP-8888570531,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.18,27.426,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATHETER THORACIC 24FR -,SUP-8888570531,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.15,27.405,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATHETER THORACIC 28FR -,SUP-8888570549,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.44,27.608,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH THORACIC 28FR MAR -,SUP-8888570549,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.44,27.608,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH THORACIC 32FR MAR -,SUP-8888570556,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.85,27.895,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATHETER THORACIC 32FR -,SUP-8888570556,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.85,27.895,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATHETER THORACIC 36FR -,SUP-8888570564,CDM,C1729,HCPCS,272,RC,,,outpatient,,,40.26,28.182,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH THORACIC 36FR MAR -,SUP-8888570564,CDM,C1729,HCPCS,272,RC,,,outpatient,,,40.24,28.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH THORACIC 40FR MAR -,SUP-8888570572,CDM,C1729,HCPCS,272,RC,,,outpatient,,,40.63,28.441,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
TUBE CHEST RIGHT ANGLE 28 -,SUP-8888571042,CDM,C1729,HCPCS,272,RC,,,outpatient,,,77.11,53.977,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH THORCNTS 18FRX20IN LT VNTRC -,SUP-8888590216,CDM,C1729,HCPCS,272,RC,,,outpatient,,,193.84,135.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
KIT LUMBAR DRAINAGE CATH -,SUP-910121,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1076.58,753.606,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH DISTAL ATRIAL PERITONEAL SOPHYSA -,SUP-B905S,CDM,C1729,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATHETER VENTRICULAR STR 1.3 X 2.5 MM (INCL IN ITEM 0154508) -,SUP-BO19-10,CDM,C1729,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
TRAY CHEST TUBE 10FR THAL QUICK LUMX1 SDPRTX3 18GA ECHOTIP -,SUP-C-TQTSY-1000,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1096.98,767.886,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH PERFUS 12FR STR PVC -,SUP-EM012,CDM,C1729,HCPCS,272,RC,,,outpatient,,,263.92,184.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
EVACUATOR TBG UNIV ELLIK -,SUP-ET,CDM,C1729,HCPCS,272,RC,,,outpatient,,,74.71,52.297,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
BILIARY DRAINAGE CATH 8.5FR. -,SUP-G09497,CDM,C1729,HCPCS,272,RC,,,outpatient,,,545.51,381.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH BIL DRN 10.2FRX40CM MAC-LOC SDPRTX32 MA C -LOC LCK LOOP -,SUP-G09498,CDM,C1729,HCPCS,272,RC,,,outpatient,,,545.51,381.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH DRN 8.5FRX25CM LCK LOOP -,SUP-G09501,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH DRN 10FR NEPHROSTOMY TUBE -,SUP-G09502,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH MP DRAINAGE 10.2F 45CM UL -,SUP-G09766,CDM,C1729,HCPCS,272,RC,,,outpatient,,,554.27,387.989,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH DRN 12FRX45CM BND SDPRTX6 MA C -LOC LCK LOOP -,SUP-G09767,CDM,C1729,HCPCS,272,RC,,,outpatient,,,554.27,387.989,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH DRN 6FR UNIV 25CM CRV SDPRTX3 -,SUP-G10956,CDM,C1729,HCPCS,272,RC,,,outpatient,,,539.68,377.776,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
SET COLON DECOMPRESION 14FR -,SUP-G22181,CDM,C1729,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
Set Fuhrman Pleural Pneumopericardial Drainage -,SUP-G55723,CDM,C1729,HCPCS,272,RC,,,outpatient,,,711.87,498.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
Tray Fuhrman Pleural Pneumopericardial Drainage -,SUP-G55724,CDM,C1729,HCPCS,272,RC,,,outpatient,,,968.61,678.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
UNIV. LOOP DRAINAGE SET 10FR -,SUP-G55802,CDM,C1729,HCPCS,272,RC,,,outpatient,,,887.5,621.25,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
UNIV.  LOOP DRAINAGE SET 14FR X 30 -,SUP-G55804,CDM,C1729,HCPCS,272,RC,,,outpatient,,,887.5,621.25,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
ST UNIVERSA MALEOCOT16FRX22CM BLN SS NDL OBTR CON TUBE 3ML -,SUP-G55825,CDM,C1729,HCPCS,272,RC,,,outpatient,,,307.21,215.047,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
TRAY WAYNE PNEUMOTHORAX CATHETER 14.0 FR 29 CM -,SUP-G56537,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1250.92,875.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH PERC DRN 8FRX25CM STD LOOP TIP EXODUS LF -,SUP-H965101431,CDM,C1729,HCPCS,272,RC,,,outpatient,,,511.85,358.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH DRN 10FRX20CM EXODUS LF -,SUP-H965101511,CDM,C1729,HCPCS,272,RC,,,outpatient,,,511.85,358.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATHETER DRN 8FRX25CM EXODUS TIGHT TIP LOOP -,SUP-H965104031,CDM,C1729,HCPCS,272,RC,,,outpatient,,,537.4,376.18,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH DRN 10FRX25CM EXODUS TIGHT TIP LOOP -,SUP-H965104111,CDM,C1729,HCPCS,272,RC,,,outpatient,,,537.4,376.18,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH MULTIPURPOSE 14FR  25CM STD ;OOP W/MARKER BAND -,SUP-H965105621,CDM,C1729,HCPCS,272,RC,,,outpatient,,,2440.88,1708.616,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
SYSTEM EXTERNAL DRAINAGE WITHOUT VENTRICULAR CATH ACCUDRAIN -,SUP-INS8401,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1401.56,981.092,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH NEPH 14FR VTC -,SUP-M001245290,CDM,C1729,HCPCS,272,RC,,,outpatient,,,570.95,399.665,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH DRN 6FRX25CM PIGTL FOGARTY LOOP -,SUP-M001271380,CDM,C1729,HCPCS,272,RC,,,outpatient,,,468.26,327.782,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH DRN MP 10FR UNIV 30CM LCK PIGTL HUB LOCK CANN NTNL NAVR -,SUP-NNU10LPT,CDM,C1729,HCPCS,272,RC,,,outpatient,,,661.69,463.183,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
DRAIN SURG 30CM 12FR UNIV NTNL PIGTL MP -,SUP-NNU12LPT,CDM,C1729,HCPCS,272,RC,,,outpatient,,,661.69,463.183,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH DRN MP 8FR UNIV 30CM NTNL LCK PIGTL HUB LOCK CANN NAVR -,SUP-NNU8LPT,CDM,C1729,HCPCS,272,RC,,,outpatient,,,661.69,463.183,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
KIT PERICARDIOCENTESIS 6F PIGTAIL CATH -,SUP-PC101,CDM,C1729,HCPCS,272,RC,,,outpatient,,,542.95,380.065,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
KT PERICRDCTS PIGTL 8.3FRX40CM ACC LF -,SUP-PC801,CDM,C1729,HCPCS,272,RC,,,outpatient,,,676.86,473.802,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
VALVE POLARIS ADJ 30-200 SHUNT WITH ITEM BO19-10 INCL -,SUP-SPVA-2010,CDM,C1729,HCPCS,272,RC,,,outpatient,,,14425.01,10097.507,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATHETER FIXATION SYSTEM 8F -,SUP-TFK-08,CDM,C1729,HCPCS,272,RC,,,outpatient,,,379.28,265.496,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
TRAY THORACENTESIS PARACENTESIS -,SUP-TPT1000SP,CDM,C1729,HCPCS,272,RC,,,outpatient,,,195.82,137.074,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21103,10342.73217,other,OPPS APC,,
ELECTRODE PCNG 5FRX110CM BIPLR NON- HEP BND -,SUP-006173P,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1018.79,713.153,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH QUAD  MARINR-MDT -,SUP-072322M,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1378.13,964.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH EP P- TY CRV 5FR 2-8-2MM SPC 110CM DECAPL MP POLEX10 -,SUP-1085122RT,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1505.34,1053.738,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH ACHIEVE ADVANCE 2ACH20 REPROCESS MAPPING -,SUP-2ACH20,CDM,C1730,HCPCS,272,RC,,,outpatient,,,2983.75,2088.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH ACHIEVE ADVANCE 2ACH20 MAPPING -,SUP-2ACH20,CDM,C1730,HCPCS,272,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH EP RESPONSE CRD-SJM QUAD 6FR -,SUP-401226,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH RESPONSE CRD -REPROC QUAD 6FR -,SUP-401226,CDM,C1730,HCPCS,272,RC,,,outpatient,,,185.14,129.598,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH EP RESPONSE JSN -SJM QUAD  6FR -,SUP-401227,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH RESPONSE JSN-REPROC 6FR -,SUP-401227,CDM,C1730,HCPCS,272,RC,,,outpatient,,,185.14,129.598,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH EP RESPONSE CRD-SJM  DECAPOLAR -,SUP-401305,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1081.3,756.91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH EP RESPONSE CSL-SJM 6FR  DECAPOLAR  STEER -,SUP-401381,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH RESPONSE DEC CSL-REPROC -,SUP-401381,CDM,C1730,HCPCS,272,RC,,,outpatient,,,349.87,244.909,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH EP SPRM JSPHSN CRV 6FR 2-5-2MM ELCTRD SPC 120CM FX QDPL -,SUP-401451,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH EP LIVEWIRE MED SWEEP-REPROC DECAPOLAR -,SUP-401575,CDM,C1730,HCPCS,272,RC,,,outpatient,,,588.34,411.838,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH EP LIVEWIRE MED SWEEP-SJM DECAPOLAR -,SUP-401575,CDM,C1730,HCPCS,272,RC,,,outpatient,,,2056.59,1439.613,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH LIVEWIRE QUAD STEERABLE REPROC -,SUP-401606,CDM,C1730,HCPCS,272,RC,,,outpatient,,,593.19,415.233,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH EP LIVEWIRE LRG SWP-SJM  QUAD STEERABLE  2-5-2 -,SUP-401606,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1876.38,1313.466,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC,,
BIPOLAR PACING CATH BALLOON TIP 5 FR 110CM- PACEL REF:401763 -,SUP-401763,CDM,C1730,HCPCS,272,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH  LIVEWIRE 7F DUO SUPER LRG CURL-REPROC 2/10 -,SUP-401904,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1154.02,807.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH EP LIVEWIRE SUPER LRG CURL- SJM DECA 2-10-2 -,SUP-401904,CDM,C1730,HCPCS,272,RC,,,outpatient,,,4392.08,3074.456,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH LIVEWIRE MED CRL-REPROC 2-2-2 NO SPACE -,SUP-401908,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1591.63,1114.141,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH EP LIVEWIRE EXTRA LGE CURL-REPROC  DECAPL 2-5-2 -,SUP-401915,CDM,C1730,HCPCS,272,RC,,,outpatient,,,612.91,429.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH EP  LIVEWIRE EXTRA LGE CURL-SJM  DECAPL 2-5-2 -,SUP-401915,CDM,C1730,HCPCS,272,RC,,,outpatient,,,2258.01,1580.607,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH  LIVEWIRE DUO DEC SUPER LGE CURL-REPROC 2-8-2-60-2-8-2 -,SUP-401932,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1208.14,845.698,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH EP LIVEWIRE LRG SWP -REPROC  QUAD STEER 5-5-5 NO SPACE -,SUP-401934,CDM,C1730,HCPCS,272,RC,,,outpatient,,,593.19,415.233,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH EP LIVEWIRE LRG SWP -SJM  QUAD STEER 5-5-5 NO SPACE -,SUP-401934,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1876.38,1313.466,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH EP SUPREME CRD-2 -SJM QUAD -,SUP-402004,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH RESPONSE CRD-2 REPROC 6FR -,SUP-402004,CDM,C1730,HCPCS,272,RC,,,outpatient,,,193.84,135.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC,,
INQUIRY STEERABLE  SJM EP CATH 6FR -,SUP-81102,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH 20MM ACHIEVE MAPPING EP CRV 3.3FRX6MM SPC 165CM BIPLR -,SUP-990063020,CDM,C1730,HCPCS,272,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC,,
MEDIGUIDE LV CATH MED SWEEP MODEL D402058 -,SUP-D402058,CDM,C1730,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC,,
ADVISOR HD GRID MAPPING CATHETER D-AVHD-DF16 -,SUP-D-AVHD-DF-16,CDM,C1730,HCPCS,272,RC,,,outpatient,,,9090.65,6363.455,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC,,
ADVISOR HD GRID MAPPING CATHETER D-AVHD-DF 16 REPRO -,SUP-D-AVHD-DF-16,CDM,C1730,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC,,
EPSTAR CATHETER DCF-2-8-55-130 -,SUP-DCF-2-8-55-130,CDM,C1730,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATHETER INQUIRY STEER 4 FR DEC 1110-4-2-M IBI-81530 -,SUP-IBI-81530,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH EP POLARISX270DG ANG 6FR 2.5-5-2.5MM SPC 105CM QDPL -,SUP-M0047003D0,CDM,C1730,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.56393,6517.99605,other,OPPS APC,,
BLAZER DX -20 CATHETER SUPERLARGE CURVE -,SUP-20SL2860,CDM,C1731,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,4619.19363,other,OPPS APC,,
CATH EP LIVEWIRE MED CURL-SJM  2-2-2 -,SUP-401908,CDM,C1731,HCPCS,272,RC,,,outpatient,,,4392.08,3074.456,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,4619.19363,other,OPPS APC,,
CATH EP LIVEWIRE SUPER LGE CURL-SJM 2-8-2-60-2-8-2 -,SUP-401932,CDM,C1731,HCPCS,272,RC,,,outpatient,,,4596.25,3217.375,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,4619.19363,other,OPPS APC,,
CATH EP REFLEXION SPIRAL SJM -,SUP-D402893,CDM,C1731,HCPCS,272,RC,,,outpatient,,,6442.39,4509.673,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,4619.19363,other,OPPS APC,,
CATH ABLT BLAZER D X-20 SUPER LRG 7FR SHFT 2-10-2MM SPC -,SUP-M00420SL21020,CDM,C1731,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,4619.19363,other,OPPS APC,,
CATH ACHIEVE ADVANCE 2ACH15 MAPPING -,SUP-2ACH15,CDM,C1732,HCPCS,272,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC,,
CATH ACHIEVE ADVANCE 2ACH15 REPROCESS MAPPING -,SUP-2ACH15,CDM,C1732,HCPCS,272,RC,,,outpatient,,,2983.75,2088.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC,,
CATH ACHIEVE ADVANCE 2ACH25  MAPPING -,SUP-2ACH25,CDM,C1732,HCPCS,272,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC,,
SOFTWARE MED ENSITE FUSION REGST MOD XPD F/SEG CT -,SUP-75-05772-001,CDM,C1732,HCPCS,272,RC,,,outpatient,,,27847.5,19493.25,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC,,
CATHETER PVAC GOLD - REF:990078 -,SUP-990078,CDM,C1732,HCPCS,272,RC,,,outpatient,,,25991,18193.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC,,
CATH ABLT THERMOCOOL SF CARTO XP D-F CRV 8FR 2-5-2MM SPC -,SUP-BNI35DFH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,11324.65,7927.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC,,
CATH ABLT THERMOCOOL SF NAV F-J CRV 8FR 2-5-2MM SPC 115CM -,SUP-BNI35FJH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,11324.65,7927.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC,,
CATH EP LASSO NAV ECO D-TYP CRV 7FR 4FR LOOP 25-15MM 2-6-2MM -,SUP-D134301,CDM,C1732,HCPCS,272,RC,,,outpatient,,,7257.24,5080.068,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC,,
CATH EP WEBSTER CS CS-D CRV 6FR 2-8-2MM SPC 115CM SGL-BRD -,SUP-D135303,CDM,C1732,HCPCS,272,RC,,,outpatient,,,2644.95,1851.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC,,
CATH EP WEBSTER CS CS-F CRV 6FR2MM TIP 2-8-2MM SPC 115CM FX -,SUP-D135304,CDM,C1732,HCPCS,272,RC,,,outpatient,,,2014.19,1409.933,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC,,
CATH ABLT NAVISTAR C F-TY CRV 7FR EP -,SUP-D17TCFLRT,CDM,C1732,HCPCS,272,RC,,,outpatient,,,7057.77,4940.439,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC,,
POLARX FIT BALLOON CATHETER ST REF:M004CRBS2060 -,SUP-M004CRBS2060,CDM,C1732,HCPCS,272,RC,,,outpatient,,,14852,10396.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC,,
POLARX FIT BALLOON CATHETER LT REF:M004CRBS2160 -,SUP-M004CRBS2160,CDM,C1732,HCPCS,272,RC,,,outpatient,,,14852,10396.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC,,
CATH POLARMAP CIRCULAR DX MAPPING CATHETER REF:M004CRBS7210 -,SUP-M004CRBS7210,CDM,C1732,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC,,
CATHETER INTELLANAV ST 7/110/2.5/7-4 QUAD STD -,SUP-M004R5031TH0,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC,,
CATHETER INTELLANAV ST K2 7/110/2.5/7-4 QUAD -,SUP-M004R5031THK20,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC,,
INTELLAMAP ORION CATHETER M004RC64S0 -,SUP-M004RC64S0,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC,,
CATH ABLT NAVISTAR THERMOCOOL D-CRV 8FR 2-5-2MM SPC 115CM -,SUP-NI75TCDH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC,,
CATH ABLT THERMOCOOL F-TY CRV 7.5FR 2-5-2MM SPC 115CM COOL -,SUP-NI75TCFH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC,,
CATH ABLT NAVISTAR C D-TYP CRV 7FR 1-7-4MM SPC 4MM TIP 115CM -,SUP-NS7TCDL174HS,CDM,C1732,HCPCS,272,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC,,
CATH ABLT NAVISTAR DS F-TY CRV 7FR 1-7-4MM SPC 8MM TIP 115CM -,SUP-NS7TCF8L174HS,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC,,
CATH ABLT NAVISTAR F-TY CRV 7FR 1-7-4MM SPC 4MM TIP 115CM -,SUP-NS7TCFL174HS,CDM,C1732,HCPCS,272,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19966.6575,other,OPPS APC,,
CATH ABLT FREEZOR 4MM TIP MDT -,SUP-207F3,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH CRYABL FREEZOR MAX CRV 9FR 3-5-2MM SPC 90CM STEER BIDIR -,SUP-209F3,CDM,C1733,HCPCS,272,RC,,,outpatient,,,9124.6,6387.22,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABLT FREEZOR XTRA 6MM 7FR 2-5-2MM SPC 108CM -,SUP-217F3,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABLT FREEZOR XTRA LG CURVE 6MM 7FR REF:217F5 -,SUP-217F5,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH CRYABL ARCTIC FRN 23MM STEER BIDIR EP -,SUP-2AF234,CDM,C1733,HCPCS,272,RC,,,outpatient,,,16337.2,11436.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH CRYABL ARCTIC FRN 28MM STEER BIDIR EP -,SUP-2AF284,CDM,C1733,HCPCS,272,RC,,,outpatient,,,16337.2,11436.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ESPH ABLT 18MM 360DG ELCTRD ARRAY 85CM BARRX RF -,SUP-32041-18,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8339.46,5837.622,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH PCNG 5FRX2.5CM SPC 110CM PACEL TEMP BIPLR 60DG CRV RT -,SUP-401775,CDM,C1733,HCPCS,272,RC,,,outpatient,,,513.48,359.436,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABLT SAFIRE MED SWP 7FR 2-5-2MM SPC 115CM QDPL BIDIR -,SUP-402807,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3010.01,2107.007,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABL SAFIRE LRG SWP 7FR -,SUP-402808,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3208.13,2245.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH SAFIRE 7F 4MM SM CRL US -,SUP-402809,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3010.01,2107.007,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABLT SAFIRE MED CURL 7FR 2-5-2MM SPC 115CM 7MM BIDIR -,SUP-402810,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3208.13,2245.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABLT SAFIRE LRG CRV 7FR 2-5-2MM SPC 115CM QDPL BIDIR -,SUP-402811,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3208.13,2245.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABLT SAFIRE LRG CRV 7FR 2-5-2MM 115CM 5MM QDPL BIDIR -,SUP-402817,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3232,2262.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH SAFIRE TX  MED 7F 8 MM BI-DIR -,SUP-402839,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4501.88,3151.316,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH SAFIRE TX  LRG  BI-DIR  7F 8MM -,SUP-402840,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4501.88,3151.316,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
FARAWAVE PFA CATHETER REF:41C601 -,SUP-41C601,CDM,C1733,HCPCS,272,RC,,,outpatient,,,25062.75,17543.925,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
FARAWAVE PFA CATHETER 35MM REF:41C602 -,SUP-41C602,CDM,C1733,HCPCS,272,RC,,,outpatient,,,25062.75,17543.925,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATHETER BARRX RFA EXPRESS RFA BALLOON -,SUP-64082,CDM,C1733,HCPCS,272,RC,,,outpatient,,,10218.18,7152.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABLT THRP 7FR 2-5-2 MMMEDX110CM 4MM -,SUP-83365,CDM,C1733,HCPCS,272,RC,,,outpatient,,,2491.24,1743.868,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABLT THRP 7FR 2-5-2 MMX110CM 4MM -,SUP-83366,CDM,C1733,HCPCS,272,RC,,,outpatient,,,2634.35,1844.045,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABLT THRP 2-5-2 MMMEDX110CM DL -8 -,SUP-83371,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABLT THRP 7FR MED 8MM DL -,SUP-83372,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3542.31,2479.617,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABLT THRP DL -8 EXTEND REACH CRV 7FR 2-5-2MM SPC 110CM -,SUP-83374,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATHETER BARRX FOCAL 90 RFA 20MMX 13MM -,SUP-90-9100,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8492.24,5944.568,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATHETER BARRX FOCAL 90 RFA 40MM X 13MM -,SUP-90-9500,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7469.44,5228.608,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABLT SAFIRE BLU LRG CURL DIST REACH CRV 7FR 2-5-2MM SPC -,SUP-A088109,CDM,C1733,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH CRYABL ARCTIC FRN ADVANCED PRO 28MM STEER BIDIR EP -,SUP-AFAPRO28,CDM,C1733,HCPCS,272,RC,,,outpatient,,,16337.2,11436.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
FLEXABILITY SENSOR ENABLED BI DIR IRR CATH FJ CURVE -,SUP-A-FASE-FJ,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8190.92,5733.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH 7F D/F BI-DIRECT CS REPROC -,SUP-BD710DF282RTS,CDM,C1733,HCPCS,272,RC,,,outpatient,,,1132.05,792.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABLT WEBSTER EZ STEER D-F ASYM CRV 7FR 2-8-2MM SPC -,SUP-BD710DF282RTS,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3547.08,2482.956,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH CV 7FRX3CM SIL CLSR FST LF ACC -,SUP-CF7-3-60,CDM,C1733,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ELCSURG 7FRX60CM RF FLXB CLSR FST -,SUP-CF7-7-60,CDM,C1733,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
AGILLIS NXT STEERABLE INTRO DUAL-REACH REF: I-V2-MED -,SUP-I-V2-MED,CDM,C1733,HCPCS,624,RC,,,outpatient,,,5.89,4.123,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABLT BLAZER II STD CRV 7FRX2.5MM SPC 4MM TIP QDPL DIST -,SUP-M0045031TH0,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABLT BLAZER II STD CRV 7FRX2.5MM SPC QDPL EXTEND DIST -,SUP-M0045086TL0,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABLT BLAZER PRIM XP LRG CRV 8MM TIP QDPL EP -,SUP-M004P4500THK20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7427,5198.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABLT BLAZER PRIM XP STD CRV STR 7FR 8FR TIP 2.5MM SPC -,SUP-M004P4790TH0,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7639.2,5347.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABLT BLAZER PRIM XP LRG CRV 10mm  8FRX2.5MM SPC 110CM -,SUP-M004P4790THK20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7639.2,5347.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABLT BLAZER PRIM HTD ASYM CRV 7FRX2.5MM SPC 110CM QDPL -,SUP-M004P5031THN40,CDM,C1733,HCPCS,272,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABLT INTELLATIP MIFI XP STD CRV STR 7FR 8FR TIP 2.5MM -,SUP-M004PM45000,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABLT INTELLATIP MIFI XP LRG CRV STR 7FR 8FR TIP 2.5MM -,SUP-M004PM4500K20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATHETER INTELLANAV MIFI OI 7.5/110/2.5.4.5 STD -,SUP-M004PMR96200,CDM,C1733,HCPCS,272,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATHETER INTELLANAV MIFI K2 OI 7.5/110/2.5/4.5 -,SUP-M004PMR9620K20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
PULSESELECT PFA LOOP CATHETER REF: PSCC100 -,SUP-PSCC100,CDM,C1733,HCPCS,272,RC,,,outpatient,,,23763.2,16634.24,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
VOLT PFA CATHETER REF: P-SPI-DF8 -,SUP-VOLT PFA CATHETER REF: P-SPI-DF8,CDM,C1733,HCPCS,624,RC,,,outpatient,,,5.89,4.123,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATHETER 27CM GLIDEPATH LONG TERM HEMO -,SUP-5393270,CDM,C1750,HCPCS,278,RC,,,outpatient,,,2210.31,1547.217,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC,,
CATH HMDLYS HEMOSPLIT 14.5FRX31CM -,SUP-5733310,CDM,C1750,HCPCS,278,RC,,,outpatient,,,2390.53,1673.371,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC,,
CATH SHNT 1.2X2.5MM HLTR 65CM SIL RBR T-SHP 1PC -,SUP-82-1699,CDM,C1750,HCPCS,278,RC,,,outpatient,,,2533.64,1773.548,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC,,
CATH PERITONEALTENCKHOFF42CM -,SUP-8810888003,CDM,C1750,HCPCS,278,RC,,,outpatient,,,255.92,179.144,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC,,
CATH TENCKHOFF 15FRX62CM -,SUP-8811313010,CDM,C1750,HCPCS,278,RC,,,outpatient,,,366.38,256.466,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC,,
KIT CATHETER PERITONEAL DIALYSIS ARGYLE 62CM SILICONE CURLED -,SUP-8817278006,CDM,C1750,HCPCS,278,RC,,,outpatient,,,450.39,315.273,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC,,
KT DLYS 60CM CURL STYL 60CM PREPERITONEIAL CUF CLMP ADPTR -,SUP-8817278010,CDM,C1750,HCPCS,278,RC,,,outpatient,,,537.58,376.306,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC,,
KT HMDLYS PRMCTH 36CM SIL RBR LUMX2 -,SUP-8817748001,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1012.58,708.806,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC,,
CATH HMDLYS MHRKR 11.5FRX16CM PU ACUTE LUMX2 ACC -,SUP-8817749001,CDM,C1750,HCPCS,278,RC,,,outpatient,,,923.47,646.429,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC,,
CATH HMDLYS PALINDROME 14.5FRX19CM -,SUP-8888119360P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1259.4,881.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC,,
KIT CATHETER PALINDROME 14.5FR X 19CM -,SUP-8888145014P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC,,
KIT CATHETER PALINDROME 14.5FR X 23CM -,SUP-8888145015P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC,,
KIT CATHETER PALINDROME 14.5FR X 28CM -,SUP-8888145016P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC,,
KIT CATHETER PALINDROME 14.5FR X 33CM -,SUP-8888145042P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC,,
STENCIL PERITONEAL DIALYSIS RITUS PRE-OPERATIVE -,SUP-8888412305,CDM,C1750,HCPCS,278,RC,,,outpatient,,,55.72,39.004,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC,,
KIT CATHETER PERITONEAL DIALYSIS ARGYLE 62.5CM SILICONE -,SUP-8888413823,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1150.95,805.665,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC,,
KT HMDLYS PALINDROME 15FRX43CM CRBTHN ACC -,SUP-8888541023P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1612.03,1128.421,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC,,
KT HMDLYS PALINDROME 15FRX48CM CRBTHN ACC -,SUP-8888541028P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1612.03,1128.421,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC,,
CATH TESIO LEFT BFL-6 -,SUP-BFL-6,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1595.45,1116.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC,,
CATH HMDLYS BFL TSO 10FR 22CM/25CM CUF -,SUP-BFR-6,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1690.86,1183.602,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC,,
ST HMDLYS TESIO 10FRX52CM PU LUMX2 INTRO NDL GW TUNNLER -,SUP-BFR-6E,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1881.68,1317.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC,,
CATH ARROW NEXT STEP 23CM HEMODIALYSIS -,SUP-CS-15232-X,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1436.44,1005.508,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC,,
CATH ARROW NEXT STEP 27CM HEMODIALSIS -,SUP-CS-15272-X,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1436.44,1005.508,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC,,
CATHETER KIT DIALYSIS 15FR ARROW -,SUP-CS-15282-SPM,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.50914,1945.83552,other,OPPS APC,,
HC Try Cv Lumx3 5fr Triple Powerpicc Acc,PX-27200312,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1544,1080.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
HC Needle Provena 4fr Dl Picc 4fr Dl Max Barrier,PX-27200313,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1417,991.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
HC Needle Provena 4fr Dl Provena Midline Max Barrier,PX-27200314,CDM,C1751,HCPCS,272,RC,,,outpatient,,,967,676.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
HC Cath Cv Lumx2 4frx20 Cm Dual Mdln,PX-27200315,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1012,708.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
HC Needle Provena 3fr Sl Provena Midline Max Barrier,PX-27200316,CDM,C1751,CPT,272,RC,,,outpatient,,,831,581.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
KIT URETERAL IRIS INFRARED -,SUP-0220180518,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1863.01,1304.107,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
TRY CV LUMX2 9FRX90CM SIL PED HKMN LF ACC -,SUP-0600604,CDM,C1751,HCPCS,272,RC,,,outpatient,,,2291.14,1603.798,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH SWAN GANZ TD 6FR X 110 - 096F6P -,SUP-096F6P,CDM,C1751,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH GUIDE ECHELON 14 MICRO STR AIGHT REF:105-5092-150 -,SUP-105-5092-150,CDM,C1751,HCPCS,272,RC,,,outpatient,,,4838.16,3386.712,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
TRY CV LUMX1 4FR PU POWERPICC LF ACC SINGLE -,SUP-1174108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1252.61,876.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
5FR POWERPICC TRAY CV LUMX2 DBL PU  LF ACC -,SUP-1275108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1232.53,862.771,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH SWAN GANZ TD 7FR 131F7P -,SUP-131F7P,CDM,C1751,HCPCS,272,RC,,,outpatient,,,501.81,351.267,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATHETER IV JELCO PROTECTIV 24G X 3/4IN YELLOW -,SUP-305306,CDM,C1751,HCPCS,272,RC,,,outpatient,,,12.2,8.54,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATHETER IV WINGED HUB PEDI 24G X 5/8â€ PERIPHERAL RADIOPAQUE -,SUP-307300,CDM,C1751,HCPCS,272,RC,,,outpatient,,,11.94,8.358,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
TRY CV LUMX1 5FRX55CM PU POWERPICC LF ACC -,SUP-3175155,CDM,C1751,HCPCS,272,RC,,,outpatient,,,456.94,319.858,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV PROT 22GAX1IN FEP PLYMR SAFTY STR HUB WNG INDWL VPNT -,SUP-326010,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.66,7.462,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV PROTECTIVE 22 X 1 -,SUP-326010,CDM,C1751,HCPCS,272,RC,,,outpatient,,,12.05,8.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV PROT 24GAX.75IN FEP PLYMR SAFTY STR HUB WNG INDWL -,SUP-326310,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.68,7.476,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV PROTECTIVE 24 X 3/4 RA -,SUP-326310,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.68,7.476,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV PROTECTIVE 20 X 1 -,SUP-326710,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.28,6.496,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV PROT 20GAX1IN FEP PLYMR SAFTY STR HUB WNG INDWL VPNT -,SUP-326710,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.28,6.496,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV 14GA X 1.25 IN VIAVALVE -,SUP-3268,CDM,C1751,HCPCS,272,RC,,,outpatient,,,12.05,8.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
TRY CV LUMX2 5FRX55CM PU POWERPICC LF ACC -,SUP-3275335,CDM,C1751,HCPCS,272,RC,,,outpatient,,,602.11,421.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV ANGIOCATH 14 X 1.88 -,SUP-381167,CDM,C1751,HCPCS,272,RC,,,outpatient,,,22.71,15.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV 24G X .56 IN INSYTE BD -,SUP-381411,CDM,C1751,HCPCS,272,RC,,,outpatient,,,14.41,10.087,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV 20G X 1.88 IN INSYTE BD -,SUP-381437,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.86,6.902,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV INSYT AUTOGRD 20GAX48MM VIALON SAFTY WNG INDWL BLD -,SUP-381437,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.86,6.902,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV 14G X 1.75 IN INSYTE BD -,SUP-381467,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.87,6.909,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV 24G X .56 IN INSYTE BD -,SUP-381511,CDM,C1751,HCPCS,272,RC,,,outpatient,,,14.42,10.094,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV 22G x 1 IN INSYTE AUTOGUARD BC -,SUP-382523,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.12,7.084,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV 16G X 1.16 IN INSYTE BD -,SUP-382554,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.86,6.902,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV SAF-T-INTIMA 23GAX0.75IN VIALON SAFTY WNG INDWL -,SUP-383323,CDM,C1751,HCPCS,272,RC,,,outpatient,,,20.11,14.077,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV SAF-T-INTIMA 20GAX1IN VIALON SAFTY WNG INDWL SLFBNT -,SUP-383336,CDM,C1751,HCPCS,272,RC,,,outpatient,,,19.62,13.734,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV 24G X .75 IN NEXIVA BD -,SUP-383511,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV 22GA X 1 IN NEXIVA BD -,SUP-383512,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV 20GA X 1 IN NEXIVA BD -,SUP-383516,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV 18GA X 1.25 IN NEXIVA BD -,SUP-383519-A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
ST NEEDLE INFS 24GAX0.75IN NEXIVA SAFTY LRG BORE WNG DL PRT -,SUP-383531,CDM,C1751,HCPCS,272,RC,,,outpatient,,,31.28,21.896,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
KT ARTERIAL LN 20GAX20CM 1ST MI D CATH MDLN SFN -,SUP-384304,CDM,C1751,HCPCS,272,RC,,,outpatient,,,468.67,328.069,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATHETER IV 16 X 2 SFR -,SUP-4082,CDM,C1751,HCPCS,272,RC,,,outpatient,,,11.6,8.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV 14 X 2.25in JELCO -,SUP-4088,CDM,C1751,HCPCS,272,RC,,,outpatient,,,20.36,14.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
TRY MIDLINE CATH 4FR 18GA LUM LUMX1 LF -,SUP-4154108,CDM,C1751,HCPCS,272,RC,,,outpatient,,,526.32,368.424,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
TRY CV LUMX1 4FR PU LF ACC -,SUP-4154108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1151.36,805.952,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV INTROCAN SAFTY 20GAX1.75IN FEP POYMER SAFTY STR HUB -,SUP-4252527-02,CDM,C1751,HCPCS,272,RC,,,outpatient,,,7.39,5.173,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV INTROCAN SAFTY 18GAX2.5IN TFLN FEP PLYMR SAFTY STR -,SUP-4252561-02,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.22,6.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH CV 5FRX8CM POWERWAND PWR-INJ MDLN QCK CHRNFLX C -,SUP-72135,CDM,C1751,HCPCS,272,RC,,,outpatient,,,811.07,567.749,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
PICC LINE CHANGE KIT IVAD ACCE -,SUP-73240B,CDM,C1751,HCPCS,272,RC,,,outpatient,,,17.27,12.089,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
PORT INFS 8FR 1LUM -,SUP-7711802,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1505.34,1053.738,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH PA 8FRX110CM SWAN-GNZ C CMB VOL LUMX7 INJ PRT ANTMIC -,SUP-777HF8,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1446.77,1012.739,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
SWAN-GANZ VIP/ OXIMETRY THERMOD CATHETER -,SUP-782F75M,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1519.92,1063.944,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
KT IT F/LEGEND SYNCHROMED INFS PMP RPR -,SUP-8590-9,CDM,C1751,HCPCS,272,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
TRY CV LUMX1 4FRX60CM PU POLY P-Q-CTH LF ACC -,SUP-9154108,CDM,C1751,HCPCS,272,RC,,,outpatient,,,908.45,635.915,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
TRY CV LUMX1 4FR STD 55CM PU POWERPICC LF ACC -,SUP-9174108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1953.71,1367.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH CV 5FRX10CM POWERWAND PWR-INJ MDLN CHRNFLX C -,SUP-92006,CDM,C1751,HCPCS,272,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
TRY CV LUMX2 5FRX60CM PU POLY P-Q-CTH LF ACC -,SUP-9255108,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1040.96,728.672,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH PA 7.5FRX110CM SWAN-GNZ PCNG LUMX5 AMC THRMBSHLD HPCT -,SUP-931HF75,CDM,C1751,HCPCS,272,RC,,,outpatient,,,303.24,212.268,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
TRY CV LUMX3 6FR STD 55CM PU POWERPICC LF ACC -,SUP-9386108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,2085.78,1460.046,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH PA 8FRX110CM SWAN-GNZ A-V PCNG LUMX6 INJ PRT ANTMIC AMC -,SUP-991HF8,CDM,C1751,HCPCS,272,RC,,,outpatient,,,787.2,551.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
"ACCUCATH 22G 1.25"" BASIC KIT -",SUP-AC0221250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,133.27,93.289,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
KIT CATHETER ACCUCATH ACE 18G 2.25 BASIC -,SUP-AC1182250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,254.41,178.087,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
"ACCUCATH 20G 1.25"" BASIC KIT -",SUP-AC1201250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,133.27,93.289,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
ACCUCATH ACE 20G X 2.25IN BASIC KIT -,SUP-AC1202250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,254.41,178.087,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH PRSS MONTR BLN WDG 5FR -,SUP-AI-07124,CDM,C1751,HCPCS,272,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH A-LN BLN WDG LUMX2 6FRX110CM PA INDWL 1ML CTRL STRK SYR -,SUP-AI-07126,CDM,C1751,HCPCS,272,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH PA 6FRX110CM BLN -,SUP-AI-07365-NHL,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
ST ARTERIAL CATH 20GAX1.75IN SHRP SAFTY LF -,SUP-AK-04020-SPC,CDM,C1751,HCPCS,272,RC,,,outpatient,,,145.29,101.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
KT A-LN 20GAX5IN PA INDWL 0.25IN SPR STR SFT TIP JTP GW -,SUP-AK-04510-S,CDM,C1751,HCPCS,272,RC,,,outpatient,,,164.55,115.185,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
KIT CENTRAL VENOUS TWO LUMEN -,SUP-AK-11142-D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,568.91,398.237,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
KT CV LUMX2 4FRX8CM PU ARROW G+ARD LF ACC -,SUP-AK-25402,CDM,C1751,HCPCS,272,RC,,,outpatient,,,431.79,302.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
FEMORAL ARTERY CATH KIT  5FR REF: G58398 -,SUP-APM-5.0-35J-1-15-NY,CDM,C1751,HCPCS,272,RC,,,outpatient,,,259.07,181.349,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
KIT CATH TRIPLE LUMEN 20CM CEN -,SUP-ASK-45703-PSCH,CDM,C1751,HCPCS,272,RC,,,outpatient,,,847.94,593.558,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
KT CV MULTLUM 20CM ARROW G+ARD LF ACC -,SUP-ASK-45703-PSCH,CDM,C1751,HCPCS,272,RC,,,outpatient,,,847.94,593.558,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
KT CV LUMX3 7FRX16CM PU ARW HWS LF ACC -,SUP-CDC-12703-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,352.9,247.03,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
KT CV LUMX3 7FRX20CM PU ARW HWS LF ACC -,SUP-CDC-15703-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,408.63,286.041,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
KT CV LUMX1 16GAX20CM PU ARROW G+ARD LF ACC -,SUP-CDC-24301-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,395.61,276.927,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
KT CV LUMX1 16GAX20CM PU ARROW G+ARD LF ACC -,SUP-CDC-24301-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,395.61,276.927,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
ARROW PEDI CENTRAL LINE KIT 13CM -,SUP-CDC-24402-X1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,754.66,528.262,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
SWAN -GANZ TEMP PACR STR EDWARDS -,SUP-D97120F5,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1130.07,791.049,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
SWAN-GANZ BIPOLAR PACING CATH J-TIP 5 FR 90CM -,SUP-D97130F5,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1130.07,791.049,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH PERFUS 20FRX.25IN ACPT 6CM PRFX STR PVC -,SUP-E063,CDM,C1751,HCPCS,272,RC,,,outpatient,,,239.59,167.713,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
ST ARTERIAL CATH 18GAX4.25IN LF -,SUP-FA-04018,CDM,C1751,HCPCS,272,RC,,,outpatient,,,81.46,57.022,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CENTRAL VENOUS CATHETER TRAY 4.0FR -,SUP-G02138,CDM,C1751,HCPCS,272,RC,,,outpatient,,,245.65,171.955,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH INFS 3FR STR 135CM SLIP-CATH NYL SS HYDRCT 0.025IN GW -,SUP-G12044,CDM,C1751,HCPCS,272,RC,,,outpatient,,,283,198.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH INFS 3FR STR 150CM SLIP-CATH NYL SS HYDRCT 0.025IN GW -,SUP-G12045,CDM,C1751,HCPCS,272,RC,,,outpatient,,,283,198.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
KT BLOOD GS ART 182CM CHMBR IV SPK 3W STPCKX2 122IN PRESSMNT -,SUP-H965700361481,CDM,C1751,HCPCS,272,RC,,,outpatient,,,164.55,115.185,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH INFS 4FRX135CM 10CM INFS ACCESSPLUS VLV PEBAX OCL WIRE -,SUP-IS4-135-10,CDM,C1751,HCPCS,272,RC,,,outpatient,,,793.56,555.492,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH INFS 4FRX135CM 20CM INFS ACCESSPLUS VLV PEBAX OCL WIRE -,SUP-IS4-135-20,CDM,C1751,HCPCS,272,RC,,,outpatient,,,793.56,555.492,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
KT INTRAVENOUS CATH 20GAX8CM POWERGLIDE LF -,SUP-M020081,CDM,C1751,HCPCS,272,RC,,,outpatient,,,493.06,345.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
KT INTRAVENOUS CATH 20GAX10CM POWERGLIDE -,SUP-M020101,CDM,C1751,HCPCS,272,RC,,,outpatient,,,493.06,345.142,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH VASC ACCESS 3FR LUMX1 MDLN PU PRELD STYL INTRO GW SYR -,SUP-ML3S20FN,CDM,C1751,HCPCS,272,RC,,,outpatient,,,595.17,416.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH CV LUMX1 4FRX200CM SINGLE MDLN -,SUP-MLCT4S20FN,CDM,C1751,HCPCS,272,RC,,,outpatient,,,805.52,563.864,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH PICC LUMX1 6FR PWR PICC -,SUP-MR17036306MB,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1081.3,756.91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
ARTERIAL CATHETERIZATION KIT 20G -,SUP-NA-04550-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,303.42,212.394,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH CV LUMX2 4FRX20 CM DUAL MDLN -,SUP-P4254108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,982.38,687.666,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH RADIAL ARTERY 20G -,SUP-RA-04020,CDM,C1751,HCPCS,272,RC,,,outpatient,,,55.96,39.172,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH SET RADIAL ARTERY 20GX1.5 -,SUP-RA-04220,CDM,C1751,HCPCS,272,RC,,,outpatient,,,70.49,49.343,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
SET RAPID INFUSION 7FR CATHETER EXCHANGE -,SUP-RC-09700,CDM,C1751,HCPCS,272,RC,,,outpatient,,,61.73,43.211,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
SET RAPID INFUSION 8.5FR CATHETER EXCHANGE -,SUP-RC-09850,CDM,C1751,HCPCS,272,RC,,,outpatient,,,59.52,41.664,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
STYLET ELCSURG 6FRX12CM RF D MRKNG CLOSURERFS -,SUP-RFS2612,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1908.18,1335.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
TRY CV LUMX3 5FR TRIPLE  POWERPICC ACC -,SUP-S1385108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1499.41,1049.587,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
MULTI-LUMEN VENOUS CATH 8FR -,SUP-SS-14703,CDM,C1751,HCPCS,272,RC,,,outpatient,,,187.89,131.523,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
C 6FR TRIPLE LUMEN PICC -,SUP-UNDEFINED,CDM,C1751,HCPCS,272,RC,,,outpatient,,,669.86,468.902,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.659055,3468.96072,other,OPPS APC,,
KT HMDLYS PWR TRIALYSIS 13FRX20CM LUMX3 SHRT TERM -,SUP-5603200,CDM,C1752,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.92327,4457.91882,other,OPPS APC,,
TRY HMDLYS PWR TRIALYSIS 13FRX15CM PU ACUTE SHRT TERM LUMX3 -,SUP-5605150,CDM,C1752,HCPCS,272,RC,,,outpatient,,,6217.46,4352.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.92327,4457.91882,other,OPPS APC,,
KT HMDLYS PWR -TRIALYSIS 13FRX20CM SHRT TERM LUMX3 ACC -,SUP-5605200,CDM,C1752,HCPCS,272,RC,,,outpatient,,,6217.46,4352.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.92327,4457.91882,other,OPPS APC,,
KT HMDLYS PWR -TRIALYSIS 13FRX20CM SHRT TERM LUMX3 ACC -,SUP-5605200,CDM,C1752,HCPCS,272,RC,,,outpatient,,,1553.05,1087.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.92327,4457.91882,other,OPPS APC,,
KT HMDLYS PWR -TRIALYSIS 13FRX15CM SHRT TERM LUMX3 ACC -,SUP-5613150,CDM,C1752,HCPCS,272,RC,,,outpatient,,,1372.83,960.981,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.92327,4457.91882,other,OPPS APC,,
MAHUKAR CATH DUAL 19FR. -,SUP-8813793009,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.92327,4457.91882,other,OPPS APC,,
MAHUKUR CATH DUAL 10 FR. -,SUP-8817146007,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.92327,4457.91882,other,OPPS APC,,
KT HMDLYS MHRKR 11.5FR LNG EXTEND 16CM LUMX2 ACUTE ACC -,SUP-8830415001,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.92327,4457.91882,other,OPPS APC,,
TRY HMDLYS MHRKR 11.5FRX24CM PU 1% 5ML LIDOCN LUMX2 ACC -,SUP-8831663001,CDM,C1752,HCPCS,272,RC,,,outpatient,,,443.65,310.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.92327,4457.91882,other,OPPS APC,,
CATH MAHURKAR CURVED 12FR 16CM -,SUP-8888101002HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,553.17,387.219,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.92327,4457.91882,other,OPPS APC,,
MAHURKER CATH DUAL 13.5 FR. -,SUP-8888135192,CDM,C1752,HCPCS,272,RC,,,outpatient,,,415.92,291.144,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.92327,4457.91882,other,OPPS APC,,
MAHURKAR STRAIGHT CATH KIT 12FR -,SUP-8888221220,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.92327,4457.91882,other,OPPS APC,,
TRY MHRKR ELITE ACUTE 12FRX20CM -,SUP-8888233420,CDM,C1752,HCPCS,272,RC,,,outpatient,,,859.55,601.685,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.92327,4457.91882,other,OPPS APC,,
KT HMDLYS MHRKR 12FRX20CM PU LUMX3 ACUTE ACC -,SUP-8888340629HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,471.37,329.959,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.92327,4457.91882,other,OPPS APC,,
KIT HEMODIALYSIS MAHURKAR 12FRX24CM PU LUMX3 ACUTE ACC -,SUP-8888340637HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,489.29,342.503,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.92327,4457.91882,other,OPPS APC,,
KT HMDLYS MHRKR 12FRX16CM PU LUMX3 ACUTE ACC -,SUP-8888345611HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,471.37,329.959,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.92327,4457.91882,other,OPPS APC,,
KT HEMODIALYSIS MHRKR TLC- C E 12FRX20CM LF -,SUP-8888345637,CDM,C1752,HCPCS,272,RC,,,outpatient,,,499.18,349.426,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.92327,4457.91882,other,OPPS APC,,
KT HMDLYS 12FR PU LUMX3 ACUTE ACC CVD -,SUP-8888345637HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,471.37,329.959,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,80.92327,4457.91882,other,OPPS APC,,
IVUS 0.014P RX CATHETER -,SUP-014R,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7720.4409,other,OPPS APC,,
CATH US 8FRX90CM ACUNAV 4W STEER -,SUP-10135936,CDM,C1753,HCPCS,272,RC,,,outpatient,,,10767.7,7537.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7720.4409,other,OPPS APC,,
CATH DRAGONFLY OPSTAR REF: 1014651 -,SUP-1014651,CDM,C1753,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7720.4409,other,OPPS APC,,
CATH US 5FR20MM IMG TAPR 150CM EAGLE EYE GOLD OTW COR PERIPH -,SUP-85900,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7720.4409,other,OPPS APC,,
CATH US 5FR ID 20MM STR 150CM EAGLE EYE RX COR GLYDX PLTNM -,SUP-85900P,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7720.4409,other,OPPS APC,,
CATH US EAGLE EYE PLATINUM REF: 85900P -,SUP-85900P,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7720.4409,other,OPPS APC,,
CATH US EAGLE EYE PLTNM SHORT TIP -,SUP-85900PST,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7720.4409,other,OPPS APC,,
CATH VISIONS PV 0.018 -,SUP-86700,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7720.4409,other,OPPS APC,,
C VOLCANO IVUS PV035 -,SUP-88901,CDM,C1753,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7720.4409,other,OPPS APC,,
CATH DX VIEWFLEXX ICE 4W -,SUP-D087031,CDM,C1753,HCPCS,272,RC,,,outpatient,,,8496.49,5947.543,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7720.4409,other,OPPS APC,,
CATH DX VIEWFLEX ECO ICE CATHERTER REPROC REF: D087031-R -,SUP-D087031-R,CDM,C1753,HCPCS,272,RC,,,outpatient,,,5544.79,3881.353,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7720.4409,other,OPPS APC,,
ECHO ATLANTIS ICE -,SUP-H749389790,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7720.4409,other,OPPS APC,,
CATHETER OPTICROSS HD IVUS 5FR -,SUP-H74939352040,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3843.07,2690.149,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7720.4409,other,OPPS APC,,
CATHETER OPTICROSS HD IVUS 6FR -,SUP-H74939354080,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3843.07,2690.149,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7720.4409,other,OPPS APC,,
CATH US 9FR 9 MHZ 110CM ULTRA ICE IMG COR -,SUP-M00499000,CDM,C1753,HCPCS,272,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7720.4409,other,OPPS APC,,
CATH US 6FR CRV NDL 120CM PIONEER + TRPL BRD SHFT PERC -,SUP-PPLUS120,CDM,C1753,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7720.4409,other,OPPS APC,,
KIT EPIDURAL MINI BREVI-XL -,SUP-181-2340,CDM,C1755,HCPCS,278,RC,,,outpatient,,,481.1,336.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC,,
ST NEEDLE NRV BLCK CONTIPLEX -,SUP-331686,CDM,C1755,HCPCS,278,RC,,,outpatient,,,209.88,146.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC,,
TRAY EPIDURAL PERIFIX 17GA -,SUP-332079,CDM,C1755,HCPCS,278,RC,,,outpatient,,,140.22,98.154,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC,,
TRAY EPIDURAL WITH DURAPREP -,SUP-332215,CDM,C1755,HCPCS,278,RC,,,outpatient,,,192.5,134.75,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC,,
EPIDURAL CATHETER SET 20GA -,SUP-333540,CDM,C1755,HCPCS,278,RC,,,outpatient,,,46,32.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC,,
TRY EPDRL/SPIN CONT TUOHY WHITACRE 18GA PERISAFE 1% LIDOCN -,SUP-406048,CDM,C1755,HCPCS,278,RC,,,outpatient,,,114.89,80.423,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC,,
TRAY SPINAL LIDOCAINE 25GA X 3.5IN WHITACRE 0.75% HCL D8.25W -,SUP-406704,CDM,C1755,HCPCS,278,RC,,,outpatient,,,159.23,111.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC,,
LUMBAR PUNCTURE TRAY PEDI 22GA 1.5IN -,SUP-646,CDM,C1755,HCPCS,278,RC,,,outpatient,,,75.04,52.528,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC,,
TRAY LUMBAR PUNCTURE 20G -,SUP-648,CDM,C1755,HCPCS,278,RC,,,outpatient,,,92.06,64.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC,,
PASSER SURG SS HOL OBTR STRL -,SUP-8591-38,CDM,C1755,HCPCS,278,RC,,,outpatient,,,571.83,400.281,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC,,
KT IT 4FR CLSD TIP SIL MRKNG GW SPIN NDL ANCHR RLR -,SUP-8598A,CDM,C1755,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC,,
KT IT SIL RBR CLSD TIP SIL MRKNG GW SPIN NDL ANCHR RLR -,SUP-8709SC,CDM,C1755,HCPCS,278,RC,,,outpatient,,,3150.84,2205.588,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC,,
CATH IT 0.53MM 1.4MM/2.2MM SPIN/PMP SEG SIL RBR TRMBL CLSD -,SUP-8731SC,CDM,C1755,HCPCS,278,RC,,,outpatient,,,3150.84,2205.588,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC,,
CATHETER INTRA MEDTRONIC -,SUP-8780,CDM,C1755,HCPCS,278,RC,,,outpatient,,,4430.74,3101.518,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC,,
CATHETER INTRATHECAL  MEDTRONIC -,SUP-8781,CDM,C1755,HCPCS,278,RC,,,outpatient,,,4430.74,3101.518,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC,,
PROCEDURE 20GA 3.5IN NDL SF-T + F/LP -,SUP-974,CDM,C1755,HCPCS,278,RC,,,outpatient,,,130.65,91.455,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC,,
PROCEDURE 20GA 3.5IN NDL SF-T + F/LP -,SUP-974,CDM,C1755,HCPCS,278,RC,,,outpatient,,,130.65,91.455,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC,,
KIT SINGLE SHOT EPIDURAL -,SUP-A4082-20,CDM,C1755,HCPCS,278,RC,,,outpatient,,,85.52,59.864,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC,,
KT NEEDLE NRV BLCK 20GA STIMUCATH CONT INSL 4CM -,SUP-AB-20604-KS,CDM,C1755,HCPCS,278,RC,,,outpatient,,,518.08,362.656,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC,,
ST NEEDLE NRV BLCK 20GA STIMUCATH CONT INSL -,SUP-AB-20604-S,CDM,C1755,HCPCS,278,RC,,,outpatient,,,369.64,258.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC,,
KT NEEDLE NRV BLCK 20GA STIMUCATH CONT INSL 8CM -,SUP-AB-20608-KS,CDM,C1755,HCPCS,278,RC,,,outpatient,,,256.13,179.291,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC,,
SPACEOAR KITS -,SUP-SO-2101,CDM,C1755,HCPCS,278,RC,,,outpatient,,,11779.68,8245.776,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC,,
SPINAL -,SUP-UNDEFINED,CDM,C1755,HCPCS,278,RC,,,outpatient,,,80.87,56.609,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.327,9046.79424,other,OPPS APC,,
POWER PULSE KIT ANGIO JET Y SE -,SUP-104834-0020,CDM,C1757,HCPCS,272,RC,,,outpatient,,,214.56,150.192,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
SET POWER PULSE Y SPIKE ANGIO -,SUP-104834-0021,CDM,C1757,HCPCS,272,RC,,,outpatient,,,214.56,150.192,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
C ANGIOJET AVX -,SUP-105039-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,3746.49,2622.543,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
DISC INJ F/THRMB -,SUP-105040001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,5326.22,3728.354,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH THRMB 5FRX140CM ANGIOJET XVG HYDRCT -,SUP-105042-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,6917.72,4842.404,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
THROMBECTOMY 16.5INX54INX25IN D ANGIOJET -,SUP-105650-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,85111.5,59578.05,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH THRMB 4.2FR FETCH -,SUP-106127-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH THRMB 4FRX135CM ANGIOJET SPIROFLEX RX CX-STRM TECH -,SUP-106553-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10062.52,7043.764,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH THRMB 5FRX135CM ANGIOJET SPIROFLEXVG RX CX-STRM TECH -,SUP-106608-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10062.52,7043.764,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH THRMB 6FRX90CM ANGIOJET SOLENT PROXI OTW SPRL CUT PROX -,SUP-109676-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10503.9,7352.73,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
6FR 120CM ANGIOJET SOLENT OMNI -,SUP-109681-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9202.73,6441.911,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
4FRX145CM ANGIOJET  SOLENT DISTA THROMBECTOMY SE -,SUP-111303-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11183.56,7828.492,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
ANGIOIJET ZELANTEDVT 8X105CM -,SUP-114610-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10452.1,7316.47,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH FOGARTY 3FR EMB 3 / SHORT -,SUP-120403FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH FOGARTY 4FR EMB 4 SHORT -,SUP-120404FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH FOGARTY 2FR / EMB 2 SHORT -,SUP-120602FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,493.23,345.261,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH FOGARTY 3FR / EMB 3 -,SUP-120803FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH FOGARTY 4FR 9MM  EMB 4 -,SUP-120804F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,214.44,150.108,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH EMBCMT 4FR 9MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120804FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH EMBCMT 5FR 11MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120805FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH EMBCMT 6FR 13MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120806FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH EMBCMT 7FR 14MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120807FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
C FOGARTY 3FR 12TLW403F -,SUP-12TLW403F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
C FOGARTY 4FR 12TLW404F -,SUP-12TLW404F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
C FOGARTY 5F 40 CM -,SUP-12TLW405F35,CDM,C1757,HCPCS,272,RC,,,outpatient,,,567.98,397.586,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
C FOGARTY 6FR 40CM -,SUP-12TLW406F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH FOGARTY THRU LUMEN 3 -,SUP-12TLW803F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
C FOGARTY 4 80CM -,SUP-12TLW804F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
C FOGARTY 5.5 80CM OTW -,SUP-12TLW805F35,CDM,C1757,HCPCS,272,RC,,,outpatient,,,567.98,397.586,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
C FOGARTY 6 80CM -,SUP-12TLW806F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,567.98,397.586,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH EMBCMT 7FRX14MM/8FR INFL/DFLT BLN 80CM FOGARTY OTW -,SUP-12TLW807F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH FOGARTY 6FR. ACC 6/10 -,SUP-1408010,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1347.12,942.984,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH FOGARTY 6FR. / EMB 6 -,SUP-160246F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1992.72,1394.904,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH THRMB 5.5FR 138CM PRONTO V4 LRG LUM LNGTDNL WIRE HYDRCT -,SUP-4005,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1765.07,1235.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH PTCA 4MMX4CM SAVVY 120CM OTW COAX MOD PRSS PERIPH TAPR -,SUP-435-404L,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1155.51,808.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH US 5.2FRX106CM 12CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-55112,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH US 5.2FRX106CM 18CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-55118,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH US 5.2FRX106CM 24CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-55124,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH US 5.2FRX135CM 12CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56112,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH US 5.2FRX135CM 30CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56130,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH US 5.2FRX135CM 40CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56140,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH US 5.2FRX135CM 50CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56150,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH THRMB 0.066IN 6FRX140CM WKG PRONTO LP LPRO XTRCT HYDRCT -,SUP-5010,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1929.38,1350.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CLOT TRIEVER SHEATH -,SUP-50-101,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CLOTTRIEVER SHEATH 16FR X 15CM -,SUP-51-101,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
INDIGO CATHETER 5 + LARGE LUMEN ASPIRATION TUBING -,SUP-90178584,CDM,C1757,HCPCS,272,RC,,,outpatient,,,6599.42,4619.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
INDIGO CATHETER 6 + LARGE LUMEN ASPIRATION TUBING -,SUP-90178585,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9782.42,6847.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH INFS 6FR 3-10 MMX80CM 10CM BLN TRELLIS OTW MULTLUM INFS -,SUP-BVT608010,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8891.18,6223.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH THRMB 8FRX80CM 15CM TRELLIS INFS PTRN -,SUP-BVT808015,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8891.18,6223.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH THRMB 8FRX80CM 30CM TRELLIS INFS PTRN -,SUP-BVT808030,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9145.82,6402.074,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH INFS 8FR 5-16 MMX120CM 30CM BLN TRELLIS OTW MULTLUM -,SUP-BVT812030,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8891.18,6223.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH THRMB 0.041IN/0.032IN ID 4.1FR/3.4FR P/D 150CM INDIGO -,SUP-CAT3,CDM,C1757,HCPCS,272,RC,,,outpatient,,,5114.02,3579.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH THRMB 0.064IN/0.054IN ID 6FR/5FR P/D 132CM INDIGO -,SUP-CAT5,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4753.28,3327.296,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH THRMB 6FRX135CM INDIGO -,SUP-CAT6,CDM,C1757,HCPCS,272,RC,,,outpatient,,,7936.28,5555.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
INDIGO CATHETER 7D PLUS DYNAMIC ASPIRATION TUBING -,SUP-CAT7DKIT,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9913.71,6939.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH THRMB 8FRX115CM INDIGO -,SUP-CAT8XTORQ115,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10804.83,7563.381,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATHETER D + INDIGO LARGE LUMEN ASPIRATING TUBING -,SUP-CATD,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9913.71,6939.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
INDIGO CATHETER RX 140 CM + LG LUMEN ASPIRATION TUBING -,SUP-CATRXKIT,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8063.6,5644.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATHETER SILICONE EMBOLECTOMY 4FR 80CM -,SUP-E1801-48,CDM,C1757,HCPCS,272,RC,,,outpatient,,,811.07,567.749,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATHETER SILICONE EMBOLECTOMY 5FR 80CM -,SUP-E1801-58,CDM,C1757,HCPCS,272,RC,,,outpatient,,,811.07,567.749,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
EXCIPIO SV THROMBECTOMY DEVICE 8MM -,SUP-EXC-0940-165,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11101.87,7771.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH EXPORT AP ASPIRATION 6F 0 -,SUP-EXPORTAP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH PTCA 4MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50233,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH EMBCMT 7FRX145CM EXPORT AP BRD ASPIR SFT TIP FLXB -,SUP-GEZ6200US7B,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
EKOS+ KIT 106CM 8 CM -,SUP-H74939605106080,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
DEVICE THROMBECTOMY EKOS+ 106CM X 2.62CM TREATMENT ZONE 12CM -,SUP-H74939605106120,CDM,C1757,HCPCS,272,RC,,,outpatient,,,13181.15,9226.805,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
EKOS+ KIT 106CM 16 CM -,SUP-H74939605106160,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
EKOS+ KIT 106CM 20 CM -,SUP-H74939605106200,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
EKOS+ KIT 135CM 20 CM -,SUP-H74939605135200,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
INDIGO CATHETER 12 115CM HTORQ -,SUP-LITNG12HTORQ115,CDM,C1757,HCPCS,272,RC,,,outpatient,,,25137.01,17595.907,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
INDIGO CATHETER 7 130CM XTORQ -,SUP-LITNG7XTORQ130,CDM,C1757,HCPCS,272,RC,,,outpatient,,,20681.41,14476.987,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
INDIGO CATHETER 8 115CM XTORQ -,SUP-LITNG8XTORQ115,CDM,C1757,HCPCS,272,RC,,,outpatient,,,21424.01,14996.807,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-5080-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-5120-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-6080-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-6120-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-6200-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
ACCESSORY KIT JETI NON STERILE DISPOSABLE -,SUP-WV1500,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
JETI CATHETER KIT 6FR -,SUP-WV6203A,CDM,C1757,HCPCS,272,RC,,,outpatient,,,12141.51,8499.057,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
JETI CATHETER KIT 8FR -,SUP-WV8803A,CDM,C1757,HCPCS,272,RC,,,outpatient,,,17109.5,11976.65,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH URETH 5FR TIGTL PU LF 70CM NPRT EYE FLXB OPN TIP -,SUP-0139005,CDM,C1758,HCPCS,272,RC,,,outpatient,,,549.07,384.349,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,11.97932,751.60242,other,OPPS APC,,
CATH URETERAL POLLACK 5 70 -,SUP-021305,CDM,C1758,HCPCS,272,RC,,,outpatient,,,94.44,66.108,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,11.97932,751.60242,other,OPPS APC,,
CATH FOLEY 6FR 2W LUBRI-SIL SIL LF PED -,SUP-175806N,CDM,C1758,HCPCS,272,RC,,,outpatient,,,146.07,102.249,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,11.97932,751.60242,other,OPPS APC,,
CATH URET 6FRX70CM PVC OP-EN TIP LF PVC SOF-FLEX -,SUP-G15942,CDM,C1758,HCPCS,272,RC,,,outpatient,,,65.41,45.787,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,11.97932,751.60242,other,OPPS APC,,
CATH URET 5FRX80CM VNYL LUMX1 LF BUSH SL CATHX2 CMN L/S -,SUP-G16746,CDM,C1758,HCPCS,272,RC,,,outpatient,,,1048.26,733.782,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,11.97932,751.60242,other,OPPS APC,,
CATH ANG 5FR KMP 100CM SLIP-CATH BRD HYDRCT -,SUP-G28535,CDM,C1758,HCPCS,272,RC,,,outpatient,,,379.26,265.482,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,11.97932,751.60242,other,OPPS APC,,
CATHETER ACCESS 6FR AXXCESS -,SUP-M0064001161,CDM,C1758,HCPCS,272,RC,,,outpatient,,,61.04,42.728,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,11.97932,751.60242,other,OPPS APC,,
CATH 5FR X 70 CONE TIP BX/20 -,SUP-M0064002111,CDM,C1758,HCPCS,272,RC,,,outpatient,,,53.36,37.352,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,11.97932,751.60242,other,OPPS APC,,
CATH DUAL LUMEN URETERAL -,SUP-M0064051000,CDM,C1758,HCPCS,272,RC,,,outpatient,,,384.35,269.045,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,11.97932,751.60242,other,OPPS APC,,
CATHETER 5.5 S2 -,SUP-1000100,CDM,C1759,HCPCS,272,RC,,,outpatient,,,101147,70802.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,72522.399,other,OPPS APC,,
CATH US 10FRX90CM 5.5-10 MHZ SOUNDSTAR NAV COR -,SUP-SNDSTR10,CDM,C1759,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,72522.399,other,OPPS APC,,
DEVICE SUT -,SUP-123250101,CDM,C1760,HCPCS,278,RC,,,outpatient,,,116.7,81.69,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC,,
CLOSURE PERCLOSE PROGLIDE 6F -,SUP-12673-03,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC,,
PERCLOSE PROSTYLE -,SUP-12773-03,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC,,
DEVICE VASC CLSR 56FR STARCLOSE SE -,SUP-14679-01,CDM,C1760,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC,,
STAR CLOSE SELF -,SUP-14679-01,CDM,C1760,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC,,
ANGIO SEAL STS VIP/PLUS 6FR -,SUP-610119,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC,,
ANGIO SEAL STS VIP/PLUS 8FR -,SUP-610121,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC,,
DEVICE VASC CLSR 6FR ANGIO-SEAL VIP -,SUP-610130,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC,,
DEVICE VASC CLSR 8FR ANGIO-SE  70CM -,SUP-610131,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC,,
VASCADE MVP - VENOUS VASCULAR CLOSURE SYSTEM 6-12F -,SUP-800-612C-10U,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC,,
SYS ATRICLIP STD 40 -,SUP-ACH140,CDM,C1760,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC,,
SYS ATRICLIP STD 45 -,SUP-ACH145,CDM,C1760,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC,,
DEVICE VASC CLSR 5FR EXOSEAL -,SUP-EX500,CDM,C1760,HCPCS,278,RC,,,outpatient,,,933.6,653.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC,,
DEVICE VASC CLSR 6FR EXOSEAL -,SUP-EX600,CDM,C1760,HCPCS,278,RC,,,outpatient,,,933.6,653.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC,,
PAS-PORT PROXIMAL ANASTOMOSIS -,SUP-FG-000001-13,CDM,C1760,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC,,
CELT ACD 5FR CLOSURE DEVICE -,SUP-KCLT-05,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC,,
CELT ACD 6FR CLOSURE DEVICE -,SUP-KCLT-06,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC,,
CELT ACD 7FR CLOSURE DEVICE -,SUP-KCLT-07,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC,,
MYNX GRIP 5FR CLOSURE DEVICE M - MULTIPLES OF 10 ONLY -,SUP-M465MX50210C,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC,,
DEVICE 6F/7F MYNX GRIP CLOSURE -,SUP-MX6721,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC,,
DEVICE VASC CLSR 6FR MYNXGRIP -,SUP-MX6721,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC,,
VENASEAL SYSTEM CLOSURE -,SUP-VS-404,CDM,C1760,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3585.3312,other,OPPS APC,,
BALLOON SHOCKWAVE C2 + IVL CATHETER 2.5X12 REF: C2PIVL2512 -,SUP-C2PIVL2512,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,14791.55236,other,OPPS APC,,
BALLOON SHOCKWAVE C2 + IVL CATHETER 3.0X12 REF: C2PIVL3012 -,SUP-C2PIVL3012,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,14791.55236,other,OPPS APC,,
BALLOON SHOCKWAVE C2 + IVL CATHETER 3.5X12 REF: C2PIVL3512 -,SUP-C2PIVL3512,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,14791.55236,other,OPPS APC,,
BALLOON SHOCKWAVE C2 + IVL CATHETER 4.0X12 REF: C2PIVL4012 -,SUP-C2PIVL4012,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,14791.55236,other,OPPS APC,,
CATHETER  SHOCKWAVE L6 1VL- 8.0 X 30 MM -,SUP-L6IVL080030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,14791.55236,other,OPPS APC,,
CATHETER  SHOCKWAVE L6 1VL- 9.0 X 30 MM -,SUP-L6IVL090030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,14791.55236,other,OPPS APC,,
CATHETER  SHOCKWAVE L6 1VL- 10.0 X 30 MM -,SUP-L6IVL100030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,14791.55236,other,OPPS APC,,
CATHETER  SHOCKWAVE L6 1VL- 12.0 X 30 MM -,SUP-L6IVL120030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,14791.55236,other,OPPS APC,,
CATHETER SHOCKWAVE 6.5 X 60 MM M5+ -,SUP-M5PIVL6560,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,14791.55236,other,OPPS APC,,
TENDON SEMITENINOSIS -,SUP-004023,CDM,C1762,HCPCS,278,RC,,,outpatient,,,5817.25,4072.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC,,
GRAFT HUM TIS NAT DENOVO LF -,SUP-00560600010,CDM,C1762,HCPCS,278,RC,,,outpatient,,,17339.71,12137.797,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC,,
ADVANCE NERVE GRAFT D 1-2MM X 15MM -,SUP-111215,CDM,C1762,HCPCS,278,RC,,,outpatient,,,8649.27,6054.489,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC,,
ADVANCE NERVE ALLOGRAFT -,SUP-111230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC,,
STRATTICE RECONSTRUCTIVE TISSUE MATRIX 16 X 20CM -,SUP-1620002,CDM,C1762,HCPCS,278,RC,,,outpatient,,,30012.18,21008.526,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC,,
STRATTICE RECONSTRUCTIVE TISSUE MATRIX 20 X 20CM -,SUP-2020002,CDM,C1762,HCPCS,278,RC,,,outpatient,,,24926.57,17448.599,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC,,
GRAFT HUM TIS SPORTSMED TIB IRRAD LF -,SUP-208002,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC,,
GRAFT HUM TIS SPORTSMED TIB TNDN POST TIB IRRAD LF -,SUP-208003,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC,,
AVANCE NERVE GRAFT 2MM DIAM / 30MM LENGTH -,SUP-211230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC,,
ADVANCE NERVE GRAFT 3-4MM X 30MM -,SUP-311230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC,,
AXOGEN ADVANCE NERVE GRAFT 3.4MM X 70MM -,SUP-311270,CDM,C1762,HCPCS,278,RC,,,outpatient,,,25322.66,17725.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC,,
NERVE GRAFT ADVANCED 4-5MM X 30MM -,SUP-411230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC,,
AXOGEN ADVANCE NERVE GRAFT 4.5MM X 70MM -,SUP-411270,CDM,C1762,HCPCS,278,RC,,,outpatient,,,25322.66,17725.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC,,
GRAFT HUM TIS FRZN 6-12 MMX20-38CM ANT TIB TNDN LF -,SUP-430335,CDM,C1762,HCPCS,278,RC,,,outpatient,,,8376.38,5863.466,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC,,
TENDON TIBIALIS POSTERIOR -,SUP-430343,CDM,C1762,HCPCS,278,RC,,,outpatient,,,8168.81,5718.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC,,
GRAFT HUM TIS FRZN 3-10 MMX26-38CM SEMITNDS TNDN LF -,SUP-430350,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC,,
GRAFT HUM TIS FRZN 3-10 MMX20-25.9CM ANT TIB TNDN LF -,SUP-430355,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC,,
IMPLANT HUM TIS PS 10MM TNDN ACH -,SUP-450200,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10971.92,7680.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC,,
GRAFT HUM TIS FRZDR 2X14CM IOPATCH TUTOPLAST FSCA LATA -,SUP-68021,CDM,C1762,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC,,
GRAFT HUM TIS DHYDR 1.5X1.5CM IOPATCH TUTOPLAST PROC -,SUP-68250,CDM,C1762,HCPCS,278,RC,,,outpatient,,,1404.63,983.241,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC,,
GRAFT HUM TIS PTCH DHYDR 1X3CM IOPATCH TUTOPLAST SCLR IRRAD -,SUP-68334,CDM,C1762,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC,,
GRAFT HTM NMSH SFT REGEN 5X5CM STD GRAFTJACKET ACLR DERM 1MM -,SUP-8600-5X05,CDM,C1762,HCPCS,278,RC,,,outpatient,,,9761.2,6832.84,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC,,
GRAFT HTM FRZDR SFT REGEN 2X4CM GRAFTJACKET COLL 1.5MM UND -,SUP-86MX-2X04,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10752.85,7526.995,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC,,
PATELLA TENDON W/ EXTENSION MECHANISM -,SUP-92-3300,CDM,C1762,HCPCS,278,RC,,,outpatient,,,26622.21,18635.547,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC,,
GRAFT HUM TIS SPLT THK VSNGRFT CRNA NON-IMMUNOGENIC XLNK -,SUP-C0301AL-90,CDM,C1762,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC,,
CORNEA HUMAN -,SUP-CORNEA,CDM,C1762,HCPCS,278,RC,,,outpatient,,,16467.16,11527.012,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC,,
IMPLANT HUM TIS BLCK AT -,SUP-FATB,CDM,C1762,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC,,
IMPLANT HUM TIS ALLOGRAFT BIOCLEANSE GRCLS TNDN FRZN -,SUP-FGRACILIS,CDM,C1762,HCPCS,278,RC,,,outpatient,,,5267.78,3687.446,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC,,
GRAFT HUM TIS FRZDR 30X150MM MED RDIGRF FSCA LATA LF -,SUP-FLM,CDM,C1762,HCPCS,278,RC,,,outpatient,,,4565.66,3195.962,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC,,
GRAFT HUM TIS SFT 230MM 7.5MM FLEXIGRAFT POST TIB TNDN FRZN -,SUP-FPOST.TIBIAL,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7087.1,4960.97,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC,,
FLEXIGRAFT QUADLINK-ZORC -,SUP-FQL,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10482.68,7337.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC,,
GRAFT HUM TIS HAMSTRING FRZN >150MM4MM-5.5MM DIA FLEXIGRAFT -,SUP-FROPE,CDM,C1762,HCPCS,278,RC,,,outpatient,,,3719.57,2603.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC,,
GRAFT HUM TIS HAMSTRING FRZN 160-250MM 4-6MM FLEXIGRAFT -,SUP-FSTP,CDM,C1762,HCPCS,278,RC,,,outpatient,,,3657.31,2560.117,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC,,
SLING TRNVAG RPLFRM COLL 5X10CM NABSB FEM FRZDR SLF-ANCHR -,SUP-M0068202450,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7456.11,5219.277,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC,,
SLING TRNVAG RPLFRM COLL 6X12CM NABSB FEM FRZDR SLF-ANCHR -,SUP-M0068202460,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7882.17,5517.519,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC,,
MACROFORM COMPOSITE NOVABONE 10CC -,SUP-NB1003,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC,,
NOVABONE BIOACTIVE BONE GRAFT 10CC LONG STRIP -,SUP-NB2310L,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC,,
NOVABONE 10CC STRIP -,SUP-NB2310S,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC,,
NOVABONE 2.5CC PUTTY -,SUP-NB2602,CDM,C1762,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC,,
NOVABONE 5CC PUTTY -,SUP-NB2605,CDM,C1762,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC,,
NOVABONE 10CC PUTTY SYRINGE -,SUP-NB2610,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC,,
GRAFT HUM TIS FRZN >=150MM TIB POST TNDN LF -,SUP-X30820,CDM,C1762,HCPCS,278,RC,,,outpatient,,,6302.34,4411.638,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,315.339435,23049.35424,other,OPPS APC,,
IMPLANT BIO TISS 15X20CM RECT PRCN COLL MATRIX NXLNK XENMTRX -,SUP-1161520,CDM,C1763,HCPCS,278,RC,,,outpatient,,,31189.2,21832.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC,,
EPIDISK -,SUP-1417100,CDM,C1763,HCPCS,278,RC,,,outpatient,,,1203.21,842.247,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC,,
IMPLANT COLL MEMBR 50X40MM GEISTLICH BIO-GIDE BILAYER RESRB -,SUP-20153,CDM,C1763,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC,,
SHEET MEDPOR 38 X 50 X 0.85 ORBITAL IMPLANT -,SUP-7210,CDM,C1763,HCPCS,278,RC,,,outpatient,,,2390.53,1673.371,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC,,
SUBSTITUTE CA SLPHT 5ML GRNL MIIGX3 RESRB SYNTH PREFL -,SUP-84XS-0405,CDM,C1763,HCPCS,278,RC,,,outpatient,,,7940.52,5558.364,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC,,
SUBSTITUTE CA SLPHT 5ML GRNL MIIGX3 RESRB SYNTH PREFL -,SUP-84XS-0405,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9145.82,6402.074,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC,,
GRID CRNL 106X97MM 6MM MEDPOR FLEXBLOCK -,SUP-9524,CDM,C1763,HCPCS,278,RC,,,outpatient,,,15136.27,10595.389,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC,,
NERVE PROTECTOR WRAP 2MM X 20MM -,SUP-AG0220,CDM,C1763,HCPCS,278,RC,,,outpatient,,,8118.77,5683.139,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC,,
NERVE PROTECTOR WRAP 3.5MM X 20MM -,SUP-AG0320,CDM,C1763,HCPCS,278,RC,,,outpatient,,,8118.77,5683.139,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC,,
NERVE WRAP AVANCE 3.5MM X 40MM -,SUP-AG0340,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9921.14,6944.798,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC,,
NERVE WRAP AVANCE 3.5MM X 40MM -,SUP-AG0340,CDM,C1763,HCPCS,278,RC,,,outpatient,,,10525.12,7367.584,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC,,
NERVE PROTECTOR 7MM X 40MM -,SUP-AG0740,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9442.16,6609.512,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC,,
NERVE PROTECTOR 7MM X 40MM - USE 0169678 -,SUP-AG0740,CDM,C1763,HCPCS,278,RC,,,outpatient,,,10121.64,7085.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC,,
AXOGUARD NERVE PROTECTOR 40MM 10MM -,SUP-AG1040,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9442.16,6609.512,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC,,
AXOGAURD NERVE CONNECTOR 2 X 15 -,SUP-AGX215,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC,,
AXOGAURD NERVE CONNECTOR D 3MM L 15MM -,SUP-AGX315,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC,,
AXOGAURD NERVE CONNECTOR D 4MM L 15MM -,SUP-AGX415,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC,,
CONNECTOR AXOGUARD NERVE D 5MM L 15MM -,SUP-AGX515,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC,,
PLUG ANAL FISTULA -,SUP-G53614,CDM,C1763,HCPCS,278,RC,,,outpatient,,,5071.58,3550.106,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC,,
IMPLANT GYN 17X70CM SYNTH UPHOLD LT -,SUP-M0068317170,CDM,C1763,HCPCS,278,RC,,,outpatient,,,8668.37,6067.859,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC,,
SURGICAL MATRIX THICK 10 X 20CM -,SUP-PSMT1020,CDM,C1763,HCPCS,278,RC,,,outpatient,,,20941.32,14658.924,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC,,
5 X 5CM 6 LAYER GENTRIX SURGICAL MATRIX DRESSING -,SUP-PSMX0505,CDM,C1763,HCPCS,278,RC,,,outpatient,,,3471.65,2430.155,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC,,
ROD TNDN 3X250MM PLYSTR COR SIL PSS KNOB END HNTR STRL STR -,SUP-PT300000,CDM,C1763,HCPCS,278,RC,,,outpatient,,,5254.07,3677.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC,,
ROD TNDN 5X250MM PLYSTR COR SIL PSS KNOB END HNTR STRL STR -,SUP-PT500000,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6315.07,4420.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC,,
ROD TNDN STD 4X245MM PLYSTR COR SIL PSS HNTR STRL STR -,SUP-TR400000,CDM,C1763,HCPCS,278,RC,,,outpatient,,,5254.07,3677.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC,,
WOUND MATRIX 6 LAYER 10 X 15 -,SUP-WSX1015,CDM,C1763,HCPCS,278,RC,,,outpatient,,,16411.46,11488.022,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,270.120645,23953.3056,other,OPPS APC,,
RECORDER LOOP 2-AF BIOMONITOR -,SUP-398493,CDM,C1764,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,14243.66592,other,OPPS APC,,
MONITOR CARD IMPL REVEAL XT 19X62MM TI 9ML 15GM -,SUP-9529,CDM,C1764,HCPCS,278,RC,,,outpatient,,,13348.24,9343.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,14243.66592,other,OPPS APC,,
MONITOR CARD IMPL CNFRM 18.5MMX56.3MM 6.5ML 12GM FRZDR LRDTC -,SUP-DM2100,CDM,C1764,HCPCS,278,RC,,,outpatient,,,11346.93,7942.851,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,14243.66592,other,OPPS APC,,
LOOP RECORDER NEXT GEN JOT DX REF: DM4500 -,SUP-DM4500,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,14243.66592,other,OPPS APC,,
LOOP RECORDER ASSERT IQ3+ ICM REF: DM5300 -,SUP-DM5300,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,14243.66592,other,OPPS APC,,
LOOP RECORDER ASSERT IQ EL+ ICM REF: DM5500 -,SUP-DM5500,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17636.75,12345.725,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,14243.66592,other,OPPS APC,,
REVEAL LINQ ICM SYSTEM LOOP RECORDER MDT -,SUP-LINQSYS,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17246.89,12072.823,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,14243.66592,other,OPPS APC,,
LOOP RECORDER REVEAL LINQ II SYSTEM REF: LNQ22SYS -,SUP-LNQ22SYS,CDM,C1764,HCPCS,278,RC,,,outpatient,,,18546.44,12982.508,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,14243.66592,other,OPPS APC,,
LUX DX INSERTABLE CARDIAC MONITOR M301 -,SUP-M301,CDM,C1764,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,14243.66592,other,OPPS APC,,
LUX -DX II+ INSERTABLE CARDIAC MONITOR REF: M312 -,SUP-M312,CDM,C1764,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,14243.66592,other,OPPS APC,,
GELFILM OPTH -,SUP-0009-0297-03,CDM,C1765,HCPCS,278,RC,,,outpatient,,,1102.46,771.722,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,247.50227,1378.95936,other,OPPS APC,,
"BARRIER ADHESION SEPRAFILM 5 X 6"" -",SUP-430102,CDM,C1765,HCPCS,278,RC,,,outpatient,,,1691.39,1183.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,247.50227,1378.95936,other,OPPS APC,,
BARRIER INTERCEED 3X4 -,SUP-4350,CDM,C1765,HCPCS,278,RC,,,outpatient,,,1795.52,1256.864,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,247.50227,1378.95936,other,OPPS APC,,
FLEXCATH CONTOUR STERERABLE SHEATH REF:10FCC13 -,SUP-10FCC13,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,109.158635,4260.1272,other,OPPS APC,,
FLEXCATH CONTOUR STERRABLE SHEATH 10FRX20MM REF:10FCC20 -,SUP-10FCC20,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,109.158635,4260.1272,other,OPPS APC,,
FLEXCATH CONTOUR STEERABLE SHEATH 12FRx13MM REF:12FCC13 -,SUP-12FCC13,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,109.158635,4260.1272,other,OPPS APC,,
FLEXCATH CONTOUR STEERABLE SHEATH 12FRx20MM REF:12FCC20 -,SUP-12FCC20,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,109.158635,4260.1272,other,OPPS APC,,
FARADRIVE STEERABLE SHEATH REF: 21C602 -,SUP-21C602,CDM,C1766,HCPCS,272,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,109.158635,4260.1272,other,OPPS APC,,
AGILIS SHEATH SMALL -SJM  8.5FRX91CM -,SUP-408309,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4139.92,2897.944,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,109.158635,4260.1272,other,OPPS APC,,
SHEATH AGILIS SM- REPROC 8.5FR -,SUP-408309,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2639.83,1847.881,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,109.158635,4260.1272,other,OPPS APC,,
AGILIS SHEATH  MED - SJM 8.5FR X 91CM -,SUP-408310,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4267.96,2987.572,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,109.158635,4260.1272,other,OPPS APC,,
INTRO SHTH FLEXCATH ADVANCE 12FR -,SUP-4FC12,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,109.158635,4260.1272,other,OPPS APC,,
CATH ABLT CARTO 3 XTRN REF -,SUP-CREFP6,CDM,C1766,HCPCS,272,RC,,,outpatient,,,486.23,340.361,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,109.158635,4260.1272,other,OPPS APC,,
SHEATH AGILIS LGE- REPROC  8.5FR -,SUP-G408234,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2473.84,1731.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,109.158635,4260.1272,other,OPPS APC,,
AGILIS SHEATH LRG CURL SFT 3MM J FNGR SJM -,SUP-G408324,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4172.48,2920.736,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,109.158635,4260.1272,other,OPPS APC,,
SHEATH POLARSHEATH STEERABLE SHEATH REF:M004CRBS3150 -,SUP-M004CRBS3150,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,109.158635,4260.1272,other,OPPS APC,,
AMULET STEERABLE DELIVERY SHEATH REF: STRBL-14F-075 -,SUP-STRBL-14F-075,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,109.158635,4260.1272,other,OPPS APC,,
TOURGUIDE 7FR X 55CM -,SUP-TG0705509,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,109.158635,4260.1272,other,OPPS APC,,
SHEATH 6.5 FR. 55CM -,SUP-UNDEFINED,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,109.158635,4260.1272,other,OPPS APC,,
SHEATH GRAFT 7FR. 9MM 45CM -,SUP-UNDEFINED,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,109.158635,4260.1272,other,OPPS APC,,
GENERATOR NEURSTM INTSTM TI 60MMX55MM SCRL NRV MRI-COND -,SUP-3023,CDM,C1767,HCPCS,278,RC,,,outpatient,,,36758.7,25731.09,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,39874.22976,other,OPPS APC,,
INTERSTIM STIMULATOR EXTERNAL NEURO -,SUP-353101,CDM,C1767,HCPCS,278,RC,,,outpatient,,,1987.69,1391.383,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,39874.22976,other,OPPS APC,,
PROCLAIM 5 ELITE -,SUP-3660ANS,CDM,C1767,HCPCS,278,RC,,,outpatient,,,40409.46,28286.622,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,39874.22976,other,OPPS APC,,
NEUROSTIMULATOR PROCLAIM 5 -,SUP-3661,CDM,C1767,HCPCS,278,RC,,,outpatient,,,45984.88,32189.416,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,39874.22976,other,OPPS APC,,
PROCLAIM 7 PULSE GENERATOR -,SUP-3663,CDM,C1767,HCPCS,278,RC,,,outpatient,,,44998.08,31498.656,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,39874.22976,other,OPPS APC,,
PROCLAIM DRG IPG 5.3AHG MRI EIFU RED -,SUP-3664,CDM,C1767,HCPCS,278,RC,,,outpatient,,,51919.57,36343.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,39874.22976,other,OPPS APC,,
DEVICE NEURSTM PRIM ADVANCED 2.6INX1.9IN PERC MRI-COND -,SUP-377-02,CDM,C1767,HCPCS,278,RC,,,outpatient,,,29604,20722.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,39874.22976,other,OPPS APC,,
NEURSTM PRGM ITREL 60MMX55MM SPIN CRD PRIM CELL -,SUP-377-03,CDM,C1767,HCPCS,278,RC,,,outpatient,,,27012.08,18908.456,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,39874.22976,other,OPPS APC,,
INS 977006 PAIN PC M -,SUP-977006,CDM,C1767,HCPCS,278,RC,,,outpatient,,,50457.55,35320.285,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,39874.22976,other,OPPS APC,,
NEURSTM IMPL PRIM ADVANCED 65X49X15MM SPIN CRD MRI-COND -,SUP-9770-2,CDM,C1767,HCPCS,278,RC,,,outpatient,,,32564.4,22795.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,39874.22976,other,OPPS APC,,
INTELLIS BATTERY #97715 -,SUP-97715,CDM,C1767,HCPCS,278,RC,,,outpatient,,,44376.4,31063.48,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,39874.22976,other,OPPS APC,,
INTERSTIM X NEUROSTIMULATOR IMPLANT -,SUP-97800,CDM,C1767,HCPCS,278,RC,,,outpatient,,,26510.38,18557.266,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,39874.22976,other,OPPS APC,,
PLEDGET FELT PTFE BARD 6 X 6IN -,SUP-007837,CDM,C1768,HCPCS,278,RC,,,outpatient,,,589.34,412.538,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT HEMA MDV BIF 20 10 40 -,SUP-0085201,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 20MM 15CM HEMASHLD GOLD STR KNTD DBL VELR AOR BVN -,SUP-095120,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1996.38,1397.466,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT HEMA 16MM 30CM MDV -,SUP-095216,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2628.78,1840.146,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT HEMA 18MM 30CM MDV -,SUP-095218,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2628.78,1840.146,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 22MM 30CM HEMASHLD GOLD STR KNTD DBL VELR AOR BVN -,SUP-095222,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2628.78,1840.146,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 1X6CM GORE-TEX 0.6MM PTCH -,SUP-1702515006,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2581.34,1806.938,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT HEMASHIELD D:28MM L:30CM -,SUP-175428P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 32MM 32X30CM HEMASHLD PLTNM STR WVN AOR COLL -,SUP-175432P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 38MMX30CM HEMASHLD PLTNM FINESSE STR WVN AOR BVN -,SUP-175438P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 20MM THOR 10MM BRNCH 50CM HEMASHLD PLTNM STR 20CM -,SUP-175820P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5377.66,3764.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 26MM THOR 10MM/10MM/8MM/8MM ID BRNCH 50CM -,SUP-175926P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6299.92,4409.944,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 7X10CM GORE-HYBRID PRECLUDE 0.1MM MEMBR PERICARD -,SUP-1PCM001,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1812.77,1268.939,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT ATRIUM VXT 4 7 45CM  - DISCONTINUED DO NOT USE -,SUP-22115,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2091.84,1464.288,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
KT INFL 20/20 PRIORITY PACK -,SUP-22297,CDM,C1768,HCPCS,278,RC,,,outpatient,,,227.57,159.299,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 6MM 50CM FLIXENE STR GRAD WL REINF SFT WRP TNLR -,SUP-25058,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5114.4,3580.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 6MM 40CM FLIXENE STR GRAD WL REINF SFT WRP TNLR -,SUP-25061,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4720.98,3304.686,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 4-7MM 30CM FLIXENE STR REINF SFT-WRP TNLR ATTCH -,SUP-25098,CDM,C1768,HCPCS,278,RC,,,outpatient,,,9358.02,6550.614,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT FLIXENE GTW GW 4 7 35 -,SUP-25129,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6294.62,4406.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 8MM 80CM STR HEP FUSION BIOLINE CTD RNG SUPP -,SUP-503088B,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10403.74,7282.618,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
VALVE AOR 6-30MM CRYOVALVE CONDT -,SUP-AV00,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39965.4,27975.78,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT STENT BIFURCATED -,SUP-BEA22-70/I16-30,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
AFX2 BIFURCATED ENDOGRAFT SYSTEM -,SUP-BEA25-80/113-40,CDM,C1768,HCPCS,278,RC,,,outpatient,,,14944.83,10461.381,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT STENT BIFURCATED -,SUP-BEA25-80/I20-40,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT STENT 90MM 28MM 16MM AFX2 2 BRANCH MAIN BODY ILIAC LIM -,SUP-BEA28-90/I16-30,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 7X15CM CORMATRIX PERICARD COLL GRW FACT PRTN -,SUP-CMCV-003-402,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT DISTAFLO VASCULAR 6X70 -,SUP-DFM7006SC,CDM,C1768,HCPCS,278,RC,,,outpatient,,,30067.87,21047.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
PATCH BOVINE 0.8 X 8CM DURAVESS PERICARDIAL -,SUP-DP08X8,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1126.45,788.515,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
PATCH BOVINE 2 X 9 DURAVESS PERICARDIUM -,SUP-DP2X9,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1655.24,1158.668,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 4-7MM 45CM ACUSEAL -,SUP-ECH470045A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6675.81,4673.067,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT ZENITH FLEX LEG 20X56 -,SUP-G55241,CDM,C1768,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT GORE PROPATEN 6 X 40 -,SUP-H060040A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4766.01,3336.207,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT GORE H470045A -,SUP-H470045A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5661.5,3963.05,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
PROPATEN AXILLO BIFEMORAL VASC GRAFT -,SUP-HAX02A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,17306.29,12114.403,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 26X34MM SKRT 15CM CARDIOROOT 26MM SKRT 10MM CLLR -,SUP-HEWROOT0026,CDM,C1768,HCPCS,278,RC,,,outpatient,,,8640.74,6048.518,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 6MM 70CM HEMAGARD STR 0.49MM KNTD RVRS LOCKNIT -,SUP-HGK000670,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2112.2,1478.54,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC PROPATEN 6 X 80 -,SUP-HT066080A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10957.06,7669.942,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
PROPATEN VASCULAR GRAFT 7MM X 80CM -,SUP-HT076080A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10957.06,7669.942,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT PROPATEN 8 X 70 -,SUP-HT087080A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,11287.52,7901.264,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT FUSION BIOLINE 6 X 80 RING SUPPORTED -,SUP-M00201503086B0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10403.74,7282.618,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT CARDIOVASCULAR HEMASHIELD GOLD MDV BIF 14X7 40CM -,SUP-M002020851470,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT 16X8 40CM HEMA BIF MDV -,SUP-M002020851680,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT HEMA MDV BIF 18X9 40CM -,SUP-M002020851890,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT HEMA MDV BIF 22X11X40 -,SUP-M002020852210,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT HEMASHIELD D:6MM L:15CM GOLD -,SUP-M002020951060,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1879.03,1315.321,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT HEMASHIELD D:8MM L:15CM GOLD -,SUP-M002020951080,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1879.03,1315.321,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT HEMASHIELD GOLD 10MM X 30CM -,SUP-M002020954100,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2538.41,1776.887,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT HEMASHIELD D:10MM L:30CM GOLD -,SUP-M002020954100,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2538.41,1776.887,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 8MM 30CM HEMASHLD PLTNM STR WVN DBL VELR AOR BVN -,SUP-M00202175208P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2473.41,1731.387,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT HEMASHIELD 22MM X 30CM -,SUP-M00202175422P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2644.27,1850.989,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT HEMASHIELD D:24MM L:30CM -,SUP-M00202175424P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2644.27,1850.989,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT HEMASHIELD D:26MM L:30CM -,SUP-M00202175426P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT HEMASHIELD D:30MM L:30CM -,SUP-M00202175430P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT HEMASHIELD D:32MM L:30CM -,SUP-M00202175432P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
PERICARDIUM PERIGUARD 6X8 -,SUP-PC0608SNBIO,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2602.81,1821.967,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
PERICARDIUM PEROGIARD 8X14 -,SUP-PC0814SNBIO,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3079.33,2155.531,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 6MM 40CM GORE-TEX STR 30CM RNG SECT THNWL STRCH -,SUP-RRT06030040L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3933.78,2753.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 6MM 70CM GORE-TEX STR 60CM RNG SECT THNWL STRCH -,SUP-RRT06060070L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5648.76,3954.132,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 8MM 40CM GORE-TEX STR 30CM RNG SECT THNWL STRCH -,SUP-RRT08030040L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3933.78,2753.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 6MM 50CM GORE-TEX STR STD WL STRCH EPTFE -,SUP-S0605,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3403.86,2382.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 14X7MM 40CM GORE-TEX BIFUR THNWL STRCH EPTFE -,SUP-SBT1401D,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4303.42,3012.394,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 16X8MM 40CM GORE-TEX BIFUR THNWL STRCH -,SUP-SBT1601,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4000.61,2800.427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
STRETCH THIN WALL BIFURCATED GRAFT 16-8MM X 50CM -,SUP-SBT1602D,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5377.15,3764.005,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 8MM 40CM GORE-TEX STR THNWL STRCH LN REM RNG AOR -,SUP-SRRT08030040L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4387.31,3071.117,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 8MM 80CM GORE-TEX STR 70CM RNG SECT THNWL -,SUP-SRRT08070080L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,7032.31,4922.617,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 6MM 40CM GORE-TEX STR THNWL STRCH AOR EPTFE -,SUP-ST0604,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3232,2262.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 6MM 80CM GORE-TEX -,SUP-ST0608,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5330.46,3731.322,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
AORTIC BODY ALTO TM ABDOMINAL STENT GRAFT -,SUP-TV-AB2080-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
ALTO ABDOMINAL STENT GRAFT SYSTEM 23MM -,SUP-TV-AB2380-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
ALTO ABDOMINAL STENT GRAFT SYSTEM 26MM -,SUP-TV-AB2680-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
OVATION IX ABDOMINAL STENT GRAFT SYSTEM 29MM ALTO -,SUP-TV-AB2980-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
ALTO ABDOMINAL STENT GRAFT SYSTEM 34MM -,SUP-TV-AB3480-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
ILIAC GRAFT OVATION IX 10 X 160MM -,SUP-TV-IL1410160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT STENT TRIVASCULAR OVATION IX 12 X 140 ILIAC LIMB -,SUP-TV-IL1412140-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
ILIAC GRAFT 14 X 100MM -,SUP-TV-IL1414100-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
OVATION IX ILAC STENT GRAFT 14 X 160MM -,SUP-TV-IL1414160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
OVATION IX ILIAC STENT GRAFT 18MM X 140MM -,SUP-TV-IL1418140-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT STENT OVATION IX ILIAC LIMB 18 X 160MM -,SUP-TV-IL1418160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
OVATION IX 22 X 100MM -,SUP-TV-IL1422100-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT STENT TRIVASCULAR OVATION IX 28 X 120 ILIAC LIMB -,SUP-TV-IL1428120-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT STENT TRIVASCULAR OVATION IX 28 X 160 ILIAC LIMB -,SUP-TV-IL1428160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT HUM TIS VEIN CRYPRSR CRYOVEIN SAPHENOUS -,SUP-V010,CDM,C1768,HCPCS,278,RC,,,outpatient,,,30011.06,21007.742,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 6MM 50CM VENAFLO II STR CRBN IMPREG EPTFE CUF -,SUP-VL5006C,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6999.2,4899.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 6MM 80CM GORE-TEX THNWL LN EPTFE -,SUP-VT06080L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4621.23,3234.861,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,51.089465,30693.4272,other,OPPS APC,,
GUIDEWIRE SPRING TIP REUSABLE MARKED -,SUP-000150,CDM,C1769,HCPCS,272,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.038INX260CM 3MM JTP TAPR FXCR STD PTFE-CTD 6CM -,SUP-00-8634,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.43,38.801,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW CATH 0.025IN GW LNR SS PTFE-CTD -,SUP-0684-00-0254-09,CDM,C1769,HCPCS,272,RC,,,outpatient,,,123.7,86.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM HTORQ ALL STAR STR XTR SUPP INTMD -,SUP-1001741,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
HI-TORQUE SUPRACORE 35 (300cm) -,SUP-1002703-02,CDM,C1769,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.018INX190CM HTORQ STLCOR 18 STR FLXB SFT SS MICGLD -,SUP-1003281,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.018INX300CM HTORQ STLCOR 18 STR FLXB SFT SS MICGLD -,SUP-1003282,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX190CM HTORQ XIT 100XT STR SS/CTD 3CM 1.7GM -,SUP-1003309H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
SPARTA CORE 190CM ST -,SUP-1005202,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
SPARTACORE 14 WIRE (0.014IN- 300CM) -,SUP-1005203,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX190CM HTORQ SPARTACORE STR SFT SS SHFT -,SUP-1005205,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM HTORQ SPARTACORE STR SFT SS SHFT -,SUP-1005206,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX190CM HTORQ  WHISPER MS STR SFT DURASTEEL -,SUP-1005357H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM HTORQ WHISPER MS STR SFT DURASTEEL/ -,SUP-1005359H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX190CM HTORQ BAL MDWT UNIV STR RBN INTMD -,SUP-1009660,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE HI-TORQUE BALANCE MIDDLEWEIGHT UNIVERSAL II 190CM -,SUP-1009664,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX190CM HTORQ PILOT 50 STR SFT DURASTEEL/ -,SUP-1010480-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX190CM HTORQ PILOT 150 STR STF DURASTEEL/ -,SUP-1010481-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX190CM HTORQ PILOT 200 STR DURASTEEL/ SS/CTD -,SUP-1010482-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM HTORQ PILOT 50 STR SFT DURASTEEL/ -,SUP-1010483-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM HTORQ PILOT 150 STR DURASTEEL/ SS/CTD -,SUP-1010484-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM HTORQ PILOT 200 STR SFT DURASTEEL -,SUP-1010485-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
HI-TORQUE WHISPER GUIDE WIRE -,SUP-1011835H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX180CM ASAHI FIELDER F C STR XTR SUPP CTD 3CM -,SUP-1011895-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE HI-TORQUE COMMAND 18 ST WORKHORSE 0.018IN x 210CM -,SUP-1013730,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.018INX300CM HTORQ COMMAND ES SS/NTNL/CTD 30CM -,SUP-1013731,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE VERRATA 185 CM STRAIGHT TIP -,SUP-10185,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE VERRATA 185 CM J-TIP -,SUP-10185J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE VERRATA PLUS 185 CM J-TIP -,SUP-10185JP,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE VERRATA 300 CM STRAIGHT TIP -,SUP-10300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE VERRATA 300 CM J-TIP -,SUP-10300J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE VERRATA PLUS 300 CM J-TIP -,SUP-10300JP,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE VERRATA PLUS 300 CM STRAIGHT TIP -,SUP-10300P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
ST INTUB 11FRX110CM RTRGD 0.38IN STR/3MM J WG INTRO NDL SYR -,SUP-110-70-38J-110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1022.29,715.603,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INSHRTX182CM CHC STR SPR COIL HYDRCT SS -,SUP-12132-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,480.8,336.56,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE ASAHI PROWATER 180 L -,SUP-12776-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM ASAHI MIRACLEBROS 3 STR STEER FLXB SS -,SUP-14937-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW URO 0.38IN NTNL -,SUP-150NSA38,CDM,C1769,HCPCS,272,RC,,,outpatient,,,221.73,155.211,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW URO 0.038INX150CM NICORE NTNL HYDRCT STR STF COR -,SUP-150NSS38,CDM,C1769,HCPCS,272,RC,,,outpatient,,,221.73,155.211,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.009INX180CM ASAHI CONFIANZA PRO PTCA STR STEER -,SUP-20629-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE VASCULAR HI-TORQUE COMMAND 0.014IN X 190CM -,SUP-2078174,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM HTORQ COMMAND ES SS/NTNL/CTD 30CM -,SUP-2078175,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014IN/0.018IN DIA 145CM -,SUP-22260,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX190CM HTORQ FLPY II JTP RBN LGT SUPP SFT SS -,SUP-22339MJ,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM HTORQ FLPY II STR RBN LGT SUPP SFT SS -,SUP-22359M,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM HTORQ FLPY II JTP RBN LGT SUPP SFT SS -,SUP-22359MJ,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM HTORQ WIGGLE STR RBN SS HYDRPHB -,SUP-22359M-W2,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM HTORQ TRAV STR STD SHFT SS/CTD 3CM -,SUP-22379H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE FLTR DLV BAREWIRE 0.014INX315CM SS COR PTFE-CTD -,SUP-22440-31,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX180CM RUNTHROUGH NS STR STEER EXTEND WIRE SS -,SUP-25-1011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM RUNTHROUGH NS STR WIRE SS -,SUP-25-1013,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDE WIRE PTCA RUNTHROUGH NS HYPERCOAT 0.014X180CM -,SUP-25-3011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX150CM RUNTHROUGH NS STEER EXTEND WIRE SS -,SUP-25-9092,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX260CM STR FXCR PTFE-CTD -,SUP-395369,CDM,C1769,HCPCS,272,RC,,,outpatient,,,218.81,153.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX200CM STR FXCR PTFE-CTD -,SUP-395703,CDM,C1769,HCPCS,272,RC,,,outpatient,,,218.81,153.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC GUIDERIGHT 0.035INX150CM  3MM J REF:404570 -,SUP-404570,CDM,C1769,HCPCS,272,RC,,,outpatient,,,40.85,28.595,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE GUIDERIGHT 3 MM J CURVE  L180 CM L5 CM OD.035 -,SUP-404571,CDM,C1769,HCPCS,272,RC,,,outpatient,,,43.76,30.632,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE VASCULAR GUIDERIGHT J CURVE L260 CM L5 CM OD.35 -,SUP-404577,CDM,C1769,HCPCS,272,RC,,,outpatient,,,93.36,65.352,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE VASCULAR GUIDERIGHT BENTSON L150 CM L15 CM OD.035 -,SUP-404843,CDM,C1769,HCPCS,272,RC,,,outpatient,,,54.27,37.989,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 190CM WHISPER VW HTORQ -,SUP-4483,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC WHISPER VW HTORQ -,SUP-4639,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE EMERALD 0.35INx260CM J TIP  FLEX FIXED CORE PTFE -,SUP-502455,CDM,C1769,HCPCS,272,RC,,,outpatient,,,52.52,36.764,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.038INX150CM EMERLD 3MM JTP FXCR FLXB STD PTFE-CTD -,SUP-502-520,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.14,38.598,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.032INX150CM EMERLD 3MM JTP FXCR FLXB STD PTFE-CTD -,SUP-502-526,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.14,38.598,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX150CM EMERLD STR FXCR FLXB STD PTFE-CTD 7CM -,SUP-502-542,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.14,38.598,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX300CM STORQ ANG STEER 1PC COR SFT SGL OUTR -,SUP-503-356Y,CDM,C1769,HCPCS,272,RC,,,outpatient,,,404.37,283.059,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM STBR + STR STEER S-SFT 3CM -,SUP-507-114X,CDM,C1769,HCPCS,272,RC,,,outpatient,,,349.22,244.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM STBR XS STR STEER XTR SUPP SFT -,SUP-527-300E,CDM,C1769,HCPCS,272,RC,,,outpatient,,,560.16,392.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
PLATE LEFT ANTER LATERAL -,SUP-630111,CDM,C1769,HCPCS,272,RC,,,outpatient,,,10381.67,7267.169,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE WARRIOR 200CM REF: 7388 -,SUP-7388,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1131.99,792.393,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE R350 350CM REF: 7390 -,SUP-7390,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1367.53,957.271,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE BANDIT 200CM REF: 7444 -,SUP-7444,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1131.99,792.393,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE GUIDE .035X260 STIFF SUPER -,SUP-80129-406,CDM,C1769,HCPCS,272,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM ASAHI PROWATER FLEX STR FLXB SPR COIL -,SUP-82358-02,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
"GUIDEWIRE 0.014"" X300CM PTCA STRAIGHT -",SUP-82902-02,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
PRESSURE GUIDEWIRE OMNIWIRE 185CM STRAIGHT TIP REF:89185 -,SUP-89185,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
PRESSURE GUIDEWIRE OMNIWIRE 185CM J-TIP REF:89185J -,SUP-89185J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX260CM AMPLATZER MOD 1.5MM JTP NOODLEWIRE -,SUP-9-GW-002,CDM,C1769,HCPCS,272,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
EXTENSION GW ASAHI -,SUP-AG14900-0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,408.45,285.915,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE VASCULAR MIRACLEBROS 6 L180 CM OD.014 IN STERILE L -,SUP-AG14M060,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE ASAHI MIRACLEBROS 6 300CM DUPLICATE -,SUP-AG14M360,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
W VASC 0.014INX300CM ASAHI MIRACLEBROS 12 STR STEER FLXB SS -,SUP-AG14M370,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM ASAHI CONFIANZA 9 STR XTR SUPP SPR -,SUP-AGH143390,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE ASAHI PROWATER 300 CM .014 -,SUP-AGH146300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.009INX180CM ASAHI FIELDER F C PTCA JTP 1.2GM LD -,SUP-AGP1400-01J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.009INX190CM ASAHI FIELDER XT STR SPR COIL -,SUP-AGP140002,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.009INX300CM ASAHI FIELDER XT STR SPR COIL -,SUP-AGP140302,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDE WIRE ASAHI SION BLUE 180/190CM -,SUP-AHW14R004S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,495.98,347.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GAIA FIRST 190CM MICRO J -,SUP-AHW14R007P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GAIA SECOND 190CM MICRO J -,SUP-AHW14R008P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GAIA THIRD 190CM MICRO J -,SUP-AHW14R011P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM ASAHI SOFT STR STEER COR-TO-TIP SS -,SUP-AHW14R304S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,490.14,343.098,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW GLADIUS MONGO190CM REF: AP14R023S -,SUP-AP14R023S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW FIELDER XT-A 190CM REF: APW14R009S -,SUP-APW14R009S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDE WIRE ASAHI SION BLACK 190CM STRAIGHT REF:APW14R010S -,SUP-APW14R010S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,566,396.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDE WIRE DOUBLE ENDED TROCAR .86MM -,SUP-AR-8737-39KD,CDM,C1769,HCPCS,272,RC,,,outpatient,,,175.05,122.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.018INX25CM 2FLX STR DBL END SPR WIRE SS -,SUP-AW-04018,CDM,C1769,HCPCS,272,RC,,,outpatient,,,53.92,37.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDE SPRING WIRE .018D 25CM -,SUP-AW-04018,CDM,C1769,HCPCS,272,RC,,,outpatient,,,53.92,37.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
"GUIDE SPRING WIRE .032"" -",SUP-AW-04432,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.08,38.556,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 175CM PRESSUREWIRE CERTUS SS NTNL PTFE-CTD -,SUP-C12008,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
PRESSUREWIRE X GUIDEWIRE 0.014INX175CM -,SUP-C12059,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 300CM PRESSUREWIRE CERTUS STEER CTD -,SUP-C12308,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
PRESSUREWIRE X GUIDEWIRE .014MMX300CM -,SUP-C12358,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX260CM TIGRWRE ANG TAPR STEER FLXB FLPY SFT -,SUP-C405085,CDM,C1769,HCPCS,272,RC,,,outpatient,,,390.95,273.665,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX180CM TIGRWRE ANG TAPR STEER FLXB FLPY SFT -,SUP-C405086,CDM,C1769,HCPCS,272,RC,,,outpatient,,,390.95,273.665,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
INTRO LAP 6MM SHTH 18GA 50CM -,SUP-C-LASS-6-10,CDM,C1769,HCPCS,272,RC,,,outpatient,,,431.79,302.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
ST CRICO MLKR 5MM PTFE XSTIF WG ENTRY NDLHLDR CUP GZE -,SUP-C-TCCSB-500-UNI,CDM,C1769,HCPCS,272,RC,,,outpatient,,,2450.49,1715.343,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
CPS EXCEL MEDIGUIDE MEDIUM GUIDEWIRE -,SUP-DS2M028,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
CPS EXCEL MEDIGUIDE STIFF GUIDEWIRE -,SUP-DS2M029,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
MEDIGUIDE GUIDEWIRE TORQUE CLIP -,SUP-DS2M030,CDM,C1769,HCPCS,272,RC,,,outpatient,,,408.45,285.915,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX145CM STR 3MM JTP DBL END FLPY SS HEP -,SUP-G00362,CDM,C1769,HCPCS,272,RC,,,outpatient,,,93.3,65.31,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
W 15J .035 145CM x 15MM CURVE -,SUP-G00509,CDM,C1769,HCPCS,272,RC,,,outpatient,,,67.04,46.928,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX145CM 3MM JTP CRV FXCR STD FLXB SS NO HEP -,SUP-G00511,CDM,C1769,HCPCS,272,RC,,,outpatient,,,67.04,46.928,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE GUIDE .035 260 SAFE-T-J T -,SUP-G00517,CDM,C1769,HCPCS,272,RC,,,outpatient,,,104.97,73.479,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX50CM 3MM NWTN JTP FNGR STR FXCR FLXB FLPY -,SUP-G00524,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.63,57.141,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE GUIDE FIXED CORE 3MM J CURVED -,SUP-G00524,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.63,57.141,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.038INX145CM 3MM JTP FXCR FLXB SS HEP PTFE-CTD 6CM -,SUP-G00541,CDM,C1769,HCPCS,272,RC,,,outpatient,,,67.04,46.928,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE GUIDE FIXED CORE STRAIGHT -,SUP-G00650,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.37,38.759,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
W BENTSON .035 145CM -,SUP-G00691,CDM,C1769,HCPCS,272,RC,,,outpatient,,,87.47,61.229,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX180CM SAFE-T-J-TIP FXCR FLPY SS PTFE-CTD -,SUP-G00902,CDM,C1769,HCPCS,272,RC,,,outpatient,,,72.88,51.016,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
W .035 260 BENTSON TSFB-35-260 -,SUP-G01063,CDM,C1769,HCPCS,272,RC,,,outpatient,,,116.64,81.648,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX260CM CRV RSN TIP FXCR FLPY W/OUT HEP -,SUP-G01253,CDM,C1769,HCPCS,272,RC,,,outpatient,,,104.97,73.479,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
THSCF 35 260 1.5 ROSEN 43700 -,SUP-G01253,CDM,C1769,HCPCS,272,RC,,,outpatient,,,104.97,73.479,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
W THSCF-35-180-1.5 ROSEN WIRE -,SUP-G01264,CDM,C1769,HCPCS,272,RC,,,outpatient,,,78.71,55.097,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WTSFB-35-180 BENTSON -,SUP-G01290,CDM,C1769,HCPCS,272,RC,,,outpatient,,,96.22,67.354,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.025INX180CM 3MM JTP FXCR STD FLXB SS HEP PTFE-CTD -,SUP-G01602,CDM,C1769,HCPCS,272,RC,,,outpatient,,,84.55,59.185,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE GUIDE 0.032 IN X180CM SAFE T JTP PTFE-C  - G02335 -,SUP-G02335,CDM,C1769,HCPCS,272,RC,,,outpatient,,,84.55,59.185,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE GUIDE 0.032 IN X260CM SAFE T J HEAVY DUTY - G03133 -,SUP-G03133,CDM,C1769,HCPCS,272,RC,,,outpatient,,,294.61,206.227,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE AMPLATZ  0.035 INX145CM J CRV TIP XSTIF FLPY SS -,SUP-G03203,CDM,C1769,HCPCS,272,RC,,,outpatient,,,169.16,118.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE AMPLATZ  0.025 IN X 145 OR 180 CM SAFE-T-J XTR-STF -,SUP-G03304,CDM,C1769,HCPCS,272,RC,,,outpatient,,,457.99,320.593,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX180CM AMP STR XSTIF SS PTFE-CTD 7CM TAPR 3CM -,SUP-G03330,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.31,89.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE AMPLATZ 0.032 IN X180CM JTP XSTIF FLPY SS PTFE-CTD -,SUP-G03584,CDM,C1769,HCPCS,272,RC,,,outpatient,,,125.39,87.773,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.038INX80CM AMP STR XSTIF FLPY SS PTFE-CTD 9.5CM -,SUP-G04003,CDM,C1769,HCPCS,272,RC,,,outpatient,,,148.73,104.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
SET CRIC MELKER 3.5MM 3.8CM -,SUP-G06245,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1139.28,797.496,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE ROADRUNNER EXTRA SUP -,SUP-G07640,CDM,C1769,HCPCS,272,RC,,,outpatient,,,676.8,473.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 60CM NTNL -,SUP-G08427,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.18,167.426,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
W PMG-18SP-60-COPE-NT -,SUP-G08427,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.18,167.426,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
W PMG-18SP-COPE-NT -,SUP-G08733,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.18,167.426,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
COPE WIRE 60CM ST -,SUP-G09395,CDM,C1769,HCPCS,272,RC,,,outpatient,,,262.52,183.764,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX180CM AMP STR ULTRA STF FLPY SS PTFE-CTD -,SUP-G09956,CDM,C1769,HCPCS,272,RC,,,outpatient,,,119.56,83.692,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
SHORT TAPER AMPLATZ WIRE 1CM -,SUP-G23639,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.31,89.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIREGLIDE AMPLATZ EXTRA STIFF 0.035 X 180CM -,SUP-G23639,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.31,89.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE UNIGLIDE ANG .018 260CM -,SUP-G30489,CDM,C1769,HCPCS,272,RC,,,outpatient,,,251.48,176.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE UNIGLIDE ANG. .035 260CM -,SUP-G30492,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE UNIGLIDE SIFF STR .035 260CM -,SUP-G30496,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.018INX260CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-G30500,CDM,C1769,HCPCS,272,RC,,,outpatient,,,269.57,188.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE UNIGLIDE STR .018 260CM -,SUP-G30500,CDM,C1769,HCPCS,272,RC,,,outpatient,,,269.57,188.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE UNIGLIDE STR .035 260CM -,SUP-G30502,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE UNIGLIDE STIFF ANG .035 260CM -,SUP-G30506,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX260CM LNDRQST STR XSTIF FLXB SS PTFE-CTD 4CM -,SUP-G31453,CDM,C1769,HCPCS,272,RC,,,outpatient,,,919.6,643.72,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW ENDO 0.035INX260CM TRACER METRO DRCT -,SUP-G31914,CDM,C1769,HCPCS,272,RC,,,outpatient,,,770.22,539.154,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
ACROBAT STR WIRE GUIDE 260 .03 -,SUP-G34265,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1042.19,729.533,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
SET GASTRONOMY ENTUIT START INIT PLCMT SM FOR 12/14FR -,SUP-G34442,CDM,C1769,HCPCS,272,RC,,,outpatient,,,551.35,385.945,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE GUIDE HIWIRE HYDROPHILIC ANGLED 35 -,SUP-G36284,CDM,C1769,HCPCS,272,RC,,,outpatient,,,215.3,150.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE HI .035 X 150CM STIFF ANGLED -,SUP-G36290,CDM,C1769,HCPCS,272,RC,,,outpatient,,,215.3,150.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE HI .035 X 260CM STIFF STRAIGHT -,SUP-G36327,CDM,C1769,HCPCS,272,RC,,,outpatient,,,308.08,215.656,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE GUIDE EX-STIFF 35-300 LUN -,SUP-G45408,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1025.79,718.053,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX450CM ACROBAT 2 CTD -,SUP-G47616,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1038.63,727.041,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX190CM PRO-LT NTNL/PTFE-CTD/SS/PD 8CM TAPR -,SUP-G47736,CDM,C1769,HCPCS,272,RC,,,outpatient,,,339.6,237.72,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
LUNDERQUIST WIRE 0.035 x 180CM -,SUP-G49228,CDM,C1769,HCPCS,272,RC,,,outpatient,,,593.41,415.387,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE METRO TRACER .035 X 600 -,SUP-G50660,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX190CM CTO MICROWIRE FLPY SS/PTFE-CTD/PLTNM -,SUP-G50788,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
CATH CTO 25 GRAM X 014 X 190CM -,SUP-G50789,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
W CTO 6G CMW-14-300-6G -,SUP-G50790,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
W CTO 12G CMW-14-300-12G -,SUP-G50791,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
W CTO 18G GUIDE WIRE -,SUP-G50792,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
W CTO 25G -,SUP-G50793,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX190CM HYDR ST MICRO FLPY SS/PTFE-CTD/PLTNM -,SUP-G52938,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1038.57,726.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM HYDR ST MICRO FLPY SS/PTFE-CTD/PLTNM -,SUP-G52939,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1038.57,726.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.018INX180CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-G56141,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE UNIGLIDE STR .018 180CM -,SUP-G56141,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE UNIGLIDE STR .035 180CM -,SUP-G56150,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE UNIGLIDE STIFF STR .035 180CM -,SUP-G56153,CDM,C1769,HCPCS,272,RC,,,outpatient,,,260.81,182.567,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
W GLIDE STIFF .035 180 STR -,SUP-G56153,CDM,C1769,HCPCS,272,RC,,,outpatient,,,308.15,215.705,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE UNIGLIDE ANG .018 180CM -,SUP-G56160,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE UNIGLIDE STR .035 260CM -,SUP-G56174,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE UNIGLIDE STIFF ANG .035 180CM -,SUP-G56177,CDM,C1769,HCPCS,272,RC,,,outpatient,,,260.81,182.567,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GLIDEWIRE ADV .014 300CM ANG -,SUP-GA1430,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
W GLIDE ADVANTAGE 300 .018 -,SUP-GA1830,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1431.14,1001.798,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX150CM GLIDEWIR ADVANTG ANG STF SHFT FLXB STD -,SUP-GA3501,CDM,C1769,HCPCS,272,RC,,,outpatient,,,933.6,653.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
W GLIDE ADVANTAGE 260 .035 -,SUP-GA3502,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.018INX300CM GLIDEWIR GOLD 45DG ANG FLXB -,SUP-GM1831,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1115.94,781.158,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.018INX300CM GLIDEWIR 70DG ANG GOLDBAND FLXB TIP -,SUP-GM1832,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1115.94,781.158,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE .018/180 STRAIGHT -,SUP-GR1803,CDM,C1769,HCPCS,272,RC,,,outpatient,,,354.24,247.968,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GLIDEWIRE .018 150 ANGLED -,SUP-GR1805,CDM,C1769,HCPCS,272,RC,,,outpatient,,,354.24,247.968,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE GLIDEWIRE 0.018INX180CM ANG STD FLXB -,SUP-GR1806,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.018INX260CM GLIDEWIR ANG STF SHFT STD FLXB -,SUP-GR1807,CDM,C1769,HCPCS,272,RC,,,outpatient,,,251.48,176.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
W GLIDE .035 180 STR -,SUP-GR3503,CDM,C1769,HCPCS,272,RC,,,outpatient,,,261.7,183.19,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE GLIDE .035 260 STR -,SUP-GR3504,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX150CM GLIDEWIR ANG STF SHFT STD FLXB -,SUP-GR3506,CDM,C1769,HCPCS,272,RC,,,outpatient,,,194.95,136.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE GLIDE .035 180 ANG  GR3508 -,SUP-GR3508,CDM,C1769,HCPCS,272,RC,,,outpatient,,,261.7,183.19,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE GLIDE .035 260 ANGLED -,SUP-GR3509,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.038INX180CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-GR3803,CDM,C1769,HCPCS,272,RC,,,outpatient,,,261.7,183.19,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.038INX260CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-GR3804,CDM,C1769,HCPCS,272,RC,,,outpatient,,,292.57,204.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE VASCULAR GLIDEWIRE NITINOL STRAIGHT 260CM -,SUP-GS3504,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE GLIDE 0.035 IN X 80 CM ANG STIFF -,SUP-GS3505,CDM,C1769,HCPCS,272,RC,,,outpatient,,,297.59,208.313,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE GLIDE STIFF .035 180CM -,SUP-GS3508,CDM,C1769,HCPCS,272,RC,,,outpatient,,,260.81,182.567,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE VASCULAR GLIDEWIRE NITINOL HYDROPHILIC ANGLE 260CM -,SUP-GS3509,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX270CM LINEARGUIDEV ANG PTFE-CTD -,SUP-G-V210-3527A,CDM,C1769,HCPCS,272,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC VIPERWIRE .014IN TIP X 325CM -,SUP-GWC-12325LG-FLP,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC VIPERWIRE W/FLEX TIP .014IN TIP X 325CM -,SUP-GWC-12325LG-FT,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM MLMN STR SUPER RAIL SUPP FLXB SPR COIL -,SUP-H74912120012,CDM,C1769,HCPCS,272,RC,,,outpatient,,,480.8,336.56,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE MAILMAN 182CM STRAIGHT TIP 0.014 -,SUP-H74912136011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,480.8,336.56,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.14X190CM PLTNM + STR SUPER RAIL SUPP INTMD SPR -,SUP-H74917511,CDM,C1769,HCPCS,272,RC,,,outpatient,,,485.59,339.913,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX300CM PLTNM + STR SUPER RAIL SUPP INTMD SPR -,SUP-H74917521,CDM,C1769,HCPCS,272,RC,,,outpatient,,,485.61,339.927,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.018INX300CM PLTNM + STR SUPER RAIL SUPP INTMD SPR -,SUP-H74917541,CDM,C1769,HCPCS,272,RC,,,outpatient,,,485.61,339.927,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM VCT 14 CTRL WIRE STR SHRT TAPR ICE CTD -,SUP-H74939216730010,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
PRESSURE WIRE COMET II -,SUP-H74939359110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3926.81,2748.767,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE SAFARI2  0.035 x 0275 CM XSMALL CURVE -,SUP-H74939406XS1,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3007.62,2105.334,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX330CM RTBLTR RTWR FLXB FLPY SS/CTD 2.2CM -,SUP-H74939462005,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1518.31,1062.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.009INX330CM RTWR 1.5MM RSN JTP CRV STF XTR SUPP -,SUP-H74939463005,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1518.31,1062.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM VCT 14 12GM CTRL WIRE STR LNG TAPR -,SUP-H74939470300120,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1219.12,853.384,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM VCT 14 18GM CTRL WIRE STR LNG TAPR -,SUP-H74939470300180,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1219.12,853.384,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM VCT 14 25GM CTRL WIRE STR LNG TAPR -,SUP-H74939471300250,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM VCT 14 30GM CTRL WIRE STR LNG TAPR -,SUP-H74939471300300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
COMET FFR WIRE 555111 -,SUP-H7495551110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3414.6,2390.22,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM STINGRAY CTD CONN -,SUP-H749M3004A0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1625.29,1137.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX145CM STINGRAY CTD CONN -,SUP-H749M3010A0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,521.24,364.868,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX185CM STINGRAY CTD CONN -,SUP-H749M3012A0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1789.24,1252.468,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX180CM INTUITION STR SS SIL CTD -,SUP-INTU180SS,CDM,C1769,HCPCS,272,RC,,,outpatient,,,169.22,118.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE GUIDE .035 260 INQWIRE REF: IQ35F260J3 -,SUP-IQ35F260J3,CDM,C1769,HCPCS,272,RC,,,outpatient,,,59.63,41.741,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE AMPLATZ INQWIRE 0.035 X 71IN STRAIGHT SHORT TIP -,SUP-IQA511,CDM,C1769,HCPCS,272,RC,,,outpatient,,,255.63,178.941,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX150CM ZIPWIRE STR STEER STF SHFT FLXB -,SUP-M00146306B1,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.24,167.468,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW AMPLATZ 0.035INX180CM J-TIP SUPER STIFF -,SUP-M001465011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
AMPLATZ WIRE SUPER STIFF  0.035 X 260 J -,SUP-M001465021,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035IN X 260CM SUPER STIFF AMP STR SHRT TAPR FLXB -,SUP-M001465091,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
W AMPLATZ SS ST 35 145 BX/5 GU -,SUP-M001465231,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX145CM SUPER STIFF AMP STR SHRT TAPR STD -,SUP-M001465241,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX180CM SUPER STIFF AMP STR STD STEER SHFT -,SUP-M001465251,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
W AMPL SS EXCHANGE 260 STR -,SUP-M001465261,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
MAGIC TORQUE DLVR GW .035/315CM -,SUP-M001465301,CDM,C1769,HCPCS,272,RC,,,outpatient,,,805.23,563.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
W TORQUE 35 180 MAGIC 46-591 -,SUP-M001465911,CDM,C1769,HCPCS,272,RC,,,outpatient,,,443.46,310.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE MAGIC TORQUE STRAIGHT 35-260 -,SUP-M001465921,CDM,C1769,HCPCS,272,RC,,,outpatient,,,443.46,310.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.018INX260CM PLTNM + SHRT TAPR STEER STF SHFT FLXB -,SUP-M001466050,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE PLATINUM PLUS PTFE .014 X -,SUP-M001467120,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
W CON V18 8 200 46-852 -,SUP-M001468520,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE V18 18 300    46-854 -,SUP-M001468540,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.018INX200CM 12CM V-18 CTRL WIRE STR STEER SFT SCTN -,SUP-M001468580,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX150CM STRTR 3MM J FNGR STR FXCR STD SPR COIL -,SUP-M001491181,CDM,C1769,HCPCS,272,RC,,,outpatient,,,70.02,49.014,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
J WIRE 0.035 X 180CM -,SUP-M001491201,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.69,57.183,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX260CM STRTR 3MM J FNGR STR FXCR STD SPR COIL -,SUP-M001491211,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.69,57.183,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.018INX190CM THRUWAY STR SHRT TAPR STEER SFT FLXB -,SUP-M001492791,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.018INX300CM THRUWAY STR SHRT TAPR STEER SFT FLXB -,SUP-M001492831,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
BSX THRUWAY 190CM 0.014 WIRE -,SUP-M001492921,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE THRUWAY .014 X 300 STR -,SUP-M001492971,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.016INX180CM FATHOM 16 STR STEER NTNL ALY/PLTNM -,SUP-M001509100,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1563.65,1094.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW ENDO 0.035INX180CM JGWR -,SUP-M00515171,CDM,C1769,HCPCS,272,RC,,,outpatient,,,735.47,514.829,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
NOVAGOLD .018/260 -,SUP-M00552000,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1082.39,757.673,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW ENDO 0.035INX260CM HYD JGWR STF SHFT -,SUP-M00556061,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
DREAMWIRE .035/260 -,SUP-M00556100,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
DREAMWIRE .035/260 ANGLED -,SUP-M00556110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
DREAMWIRE .035/260 STIFF -,SUP-M00556120,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
DREAMWIRE .035/450 -,SUP-M00556140,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW ENDO 0.035IN STD 450CM DREAMWIRE HI-PRFRM DIST TIP -,SUP-M00556141,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
DREAMWIRE ANGLED 0.035 X 450CM -,SUP-M00556150,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW ENDO 0.035INX450CM DREAMWIRE HIPERF STF -,SUP-M00556161,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
JAGWIRE .038 / 260CM STRIAGHT -,SUP-M00556620,CDM,C1769,HCPCS,272,RC,,,outpatient,,,594.64,416.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
JAG-REVOLUTION WIRE .025/260 -,SUP-M00557000,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE JAG REVOLUTION .025/450 -,SUP-M00557021,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
TUBE PEG 24FR ENDOVIVE LPRO PUL LF -,SUP-M00566480,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
"SPHINTEROTOME JAGTOME RX 44 0.35"" X 260CM -",SUP-M00573040,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1685.56,1179.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE .038 -,SUP-M0066201010,CDM,C1769,HCPCS,272,RC,,,outpatient,,,65.06,45.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW URO 0.035INX150CM ZIPWIRE NTNL COR HYDRCT STR STD SHFT -,SUP-M006630205B1,CDM,C1769,HCPCS,272,RC,,,outpatient,,,219.51,153.657,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE SENSOR .038 ANGLED -,SUP-M0066703021,CDM,C1769,HCPCS,272,RC,,,outpatient,,,241.45,169.015,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE SENSOR -,SUP-M0066703091,CDM,C1769,HCPCS,272,RC,,,outpatient,,,230.6,161.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW URO 0.018IN X 150CM STD ZIPWIRE STRAIGHT -,SUP-M0066802001,CDM,C1769,HCPCS,272,RC,,,outpatient,,,298.43,208.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GLIDEWIRE STRAIGHT STIFF .035 SS -,SUP-M0066802221,CDM,C1769,HCPCS,272,RC,,,outpatient,,,302.94,212.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GLIDEWIRE STRAIGHT .038 SS -,SUP-M0066802251,CDM,C1769,HCPCS,272,RC,,,outpatient,,,302.94,212.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GLIDEWIRE ANGLED .038 SS STIFF -,SUP-M0066802261,CDM,C1769,HCPCS,272,RC,,,outpatient,,,302.94,212.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.018INX40CM SS -,SUP-MAK001,CDM,C1769,HCPCS,272,RC,,,outpatient,,,114.37,80.059,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.018INX40CM NTNL PLTNM -,SUP-MAK001N,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.37,89.859,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW METRO TRACER .035 X 480 -,SUP-METII-35-480,CDM,C1769,HCPCS,272,RC,,,outpatient,,,770.22,539.154,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE W/NITREX .018 80CM STRAIGHT -,SUP-N180801,CDM,C1769,HCPCS,272,RC,,,outpatient,,,348.82,244.174,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014/ 0.008INX300CM ASTATO XS 20 STR TAPR PTFE-CTD -,SUP-PAGH143392,CDM,C1769,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.0180.0 13INX300CM ASTATO 30 STR PTFE-CTD 15CM 30GM -,SUP-PAGH18M371,CDM,C1769,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM REGALIA XS 1 STR STF SHFT FLXB SPR -,SUP-PAGP140300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
TUBE JEJUNAL 12FR X 60CM PEG24 -,SUP-PEGJ-12-24,CDM,C1769,HCPCS,272,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
PHOENIX .014 FLOPPY TIP WIRE EXTRA SUPPORT -,SUP-PG14300XF,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
PIGTAIL WIRE PRO TRACK 175CM -,SUP-PTW-25-175,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1120.32,784.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE DX 0.025IN BD PIGTL 230CM PROTRACK -,SUP-PTW-25-230,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1120.32,784.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
ILLUMINATION RELIEVA LUMA SENTRY -,SUP-SIS-100B,CDM,C1769,HCPCS,272,RC,,,outpatient,,,2273.91,1591.737,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE 0.014 TCAR ENROUTE -,SUP-SR-014-GW,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE SAFESEPT TRASEPTAL  0.014INX135CM -,SUP-SS-135,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1102.82,771.974,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
PK PROC CUST CARD CATHETERISATION LAB SLHSFR -,SUP-STLM004-13,CDM,C1769,HCPCS,272,RC,,,outpatient,,,288.66,202.062,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
DEVICE TRQ SGL HND F/0.010-0.038IN GW MUL-TRQ VISE STRL -,SUP-TD01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,38.34,26.838,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE AMPLATZ 0.035 IN X 260CM CRV TIP XSTIF FLXB SS PTFE-CTD -,SUP-THSCF-025-260-3,CDM,C1769,HCPCS,272,RC,,,outpatient,,,166.24,116.368,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.032INX260CM AMP CRV JTP XSTIF FLPY SS PTFE-CTD 8CM -,SUP-THSCF322603AES,CDM,C1769,HCPCS,272,RC,,,outpatient,,,166.24,116.368,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX145CM CRV RSN TIP FXCR FLXB FLPY SS PTFE-CTD -,SUP-THSCF351451.5R,CDM,C1769,HCPCS,272,RC,,,outpatient,,,78.71,55.097,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDE WIRE TORAY TRG-25230 -,SUP-TRG-25230,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.021INX180CM 3MM JTP FXCR FLXB SS PTFE-CTD 7CM TAPR -,SUP-TSCF-21-180-3BH,CDM,C1769,HCPCS,272,RC,,,outpatient,,,96.04,67.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX180CM 3MM JTP FXCR FLXB SS HEP PTFE-CTD 6CM -,SUP-TSCF-35-180-3,CDM,C1769,HCPCS,272,RC,,,outpatient,,,72.88,51.016,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX260CM LNDRQST FLXB LO SURF FRCTN EXTEND CRV -,SUP-TSCMG35260ELESD,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1025.79,718.053,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE GUIDE LUNDERQUIST .035 -,SUP-TSCMG35260LESDC,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1025.79,718.053,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC HTORQ WHISPER VW EDS -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
LOOP TIP WIRE GUIDE .035 X 480 -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1085.31,759.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
W MOVEABLE CORE 1.5J 035 145CM -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,151.71,106.197,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
W MOVEABLE CORE 3J 035 145CM -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,151.71,106.197,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDE WIRE VIPER .014 TIP -,SUP-VPR-GW-14,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDE WIRE VIPER .017 335CM -,SUP-VPR-GW-FLEX18,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX180CM ZINGER LS RSN JTP CRV LGT SUPP FRMG -,SUP-ZNGRLS180J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,169.22,118.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.60733,7443.65739,other,OPPS APC,,
COIL MRI ENDORECTAL DISP BPX15 -,SUP-BPX 15,CDM,C1770,HCPCS,272,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,144.095325,460.20645,other,OPPS APC,,
SYS SLING MALE VIRTUE -,SUP-50020,CDM,C1771,HCPCS,278,RC,,,outpatient,,,20164.56,14115.192,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,248.891925,15486.38208,other,OPPS APC,,
SLING SINGLE INCISION ALTIS -,SUP-519650,CDM,C1771,HCPCS,278,RC,,,outpatient,,,6206.85,4344.795,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,248.891925,15486.38208,other,OPPS APC,,
SYS SLING URETH ADVANCE MALE 3.55X36CM NABSB MSH NDLHLDRX2 -,SUP-720088-01,CDM,C1771,HCPCS,278,RC,,,outpatient,,,18026.62,12618.634,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,248.891925,15486.38208,other,OPPS APC,,
MESH SURG MINI ARC SLNG -,SUP-720095-01,CDM,C1771,HCPCS,278,RC,,,outpatient,,,5623.3,3936.31,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,248.891925,15486.38208,other,OPPS APC,,
MESH MINI ARC SLING PRECISE - DISCONTINUED -,SUP-720191-01,CDM,C1771,HCPCS,278,RC,,,outpatient,,,6578.45,4604.915,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,248.891925,15486.38208,other,OPPS APC,,
PROSTHESIS PENL MONARCH + 1.1CMX35CM SAL FIL CYL NABSB -,SUP-724041-93,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4807.35,3365.145,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,248.891925,15486.38208,other,OPPS APC,,
SLING GYN TVT PP 1.1X45CM URETH FEM MECH CUT -,SUP-810041B,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4965.48,3475.836,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,248.891925,15486.38208,other,OPPS APC,,
KIT TRANS OBTURATOR W TAPE INC -,SUP-93-4001,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4720.05,3304.035,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,248.891925,15486.38208,other,OPPS APC,,
ANCHORSURE SACROSPINOUS LIGAMENT FIXATION -,SUP-A-SURE,CDM,C1771,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,248.891925,15486.38208,other,OPPS APC,,
NEOMEDIC ANCHORSURE ANCHOR SYSTEM 2 ANCHORS -,SUP-A-SURE02,CDM,C1771,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,248.891925,15486.38208,other,OPPS APC,,
SLING URETH PP NABSB FEM -,SUP-M006850200051,CDM,C1771,HCPCS,278,RC,,,outpatient,,,3571.91,2500.337,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,248.891925,15486.38208,other,OPPS APC,,
SLING ADVANTAGE TRAN VAGINAL -,SUP-M0068502110,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4616.84,3231.788,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,248.891925,15486.38208,other,OPPS APC,,
SLING GYN ADVANTG FIT PP TRNVAG MI D URETH FEM -,SUP-M0068502110,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4616.84,3231.788,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,248.891925,15486.38208,other,OPPS APC,,
SLING LYNX MID URETHRAL SUPRAPUBIC BLUE SYSTEM -,SUP-M0068503010,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4439.29,3107.503,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,248.891925,15486.38208,other,OPPS APC,,
SLING GYN OBTRYX II -,SUP-M0068505110,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4420,3094,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,248.891925,15486.38208,other,OPPS APC,,
SLING GYN SOLYX SGL-INCS -,SUP-ML00001621,CDM,C1771,HCPCS,278,RC,,,outpatient,,,5030.63,3521.441,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,248.891925,15486.38208,other,OPPS APC,,
PUMP IT 87.5MM 19.5MM 20ML 165/185 GM EMTY/FUL 0.22UM FLTR -,SUP-8637-20,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29090.86,20363.602,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,23012.49024,other,OPPS APC,,
PUMP IT 87.5X26MM THK 40ML 175/215 GM EMTY/FUL 0.22UM FLTR -,SUP-8637-40,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29090.86,20363.602,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,23012.49024,other,OPPS APC,,
PUMP 8667-20 SYNCHROMEDIII INFUSION 20ML -,SUP-8667-20,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29964.18,20974.926,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,23012.49024,other,OPPS APC,,
PUMP 8667-40 SYNCHROMEDIII INFUSION 40ML -,SUP-8667-40,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29964.18,20974.926,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,23012.49024,other,OPPS APC,,
TIGHTRAIL SUB-C  9FR 560-009 -,SUP-560-009,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7193.58,5035.506,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC,,
TIGHTRAIL SUB-C 11FR 560-011 -,SUP-560-011,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7830.18,5481.126,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC,,
TIGHTRAIL SUB-C 13FR 560-013 -,SUP-560-013,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7830.18,5481.126,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC,,
SHEATH CATH DLV 10FRX80CM AMPLATZER TORQVUE VASC 45DG ANG -,SUP-9-ATV10F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC,,
SHEATH CATH DLV 9FRX80CM AMPLATZER TORQVUE VASC 45DG ANG SFT -,SUP-9-EITV09F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC,,
SHEATH CATH DLV 12FRX80CM AMPLATZER TORQVUE VASC 45DG ANG -,SUP-9-EITV12F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC,,
SYSTEM AMPLATZER DELIVERY TORQVUE 9-ITV06F 180/80 -,SUP-9-ITV06F 180/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,3909.91,2736.937,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC,,
SHEATH CATH DLV 6FRX60CM AMPLATZER TORQVUE VASC 45DG ANG SFT -,SUP-9-ITV06F45/60,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC,,
SHEATH CATH DLV 7FRX80CM AMPLATZER TORQVUE VASC 180DG ANG -,SUP-9-ITV07F180/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC,,
SHEATH CATH DLV 7FRX80CM AMPLATZER TORQVUE VASC 45DG ANG SFT -,SUP-9-ITV07F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC,,
SHEATH CATH DLV AMPLATZER TORQVUE/TREVISIO VASC 45DG ANG SFT -,SUP-9-ITV08F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC,,
SHEATH CATH DLV 9FRX80CM AMPLATZER TORQVUE VASC 45DG ANG -,SUP-9-ITV09F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC,,
SHEATH CATH DLV 12FRX80CM AMPLATZER TORQVUE VASC 45DG ANG- -,SUP-9-ITV12F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC,,
AMPLATZER TALISMAN DELIVERY SHEATH 8F 80 -,SUP-9-TDS-08F45-80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC,,
AMPLATZER TALISMAN DELIVERY SHEATH 9FR 80 -,SUP-9-TDS-09F45-80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC,,
COMP LOADING SYS CLS-3000- 18F -,SUP-CLS-3000-18F-US,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2067.2,1447.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC,,
VALVE DEL SYS COMM 26/29/31 -,SUP-DCS-C4-18F-US,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC,,
CATH DELIVERY EVOLUT FX 23-29 REF: D-EVOLUTFX-2329 -,SUP-D-EVOLUTFX-2329,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC,,
CATH DELIVERY EVOLUT FX 34 REF: D-EVOLUTFX-34 -,SUP-D-EVOLUTFX-34,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC,,
CATH DELIVERY EVPROP2329US -,SUP-D-EVPROP2329US,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC,,
SNARE ENSNARE SYSTEM 9-15 120 -,SUP-EN2006015,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1779.27,1245.489,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC,,
SNARE ENSNARE 18 30 CM -,SUP-EN2007030,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC,,
SNARE VASC EN SNR 27-45MM 7FR CATH 120CM 3 PREFRM LOOP NTNL -,SUP-EN2007045,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2644.95,1851.465,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC,,
GTRS-200-RB RETREIVAL SET TULI -,SUP-G13287,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1590.1,1113.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC,,
EXTRACTION TOOL 13FR MANUAL CONTROL ROTATION DILATOR SHEATH -,SUP-G23747,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7285.21,5099.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC,,
SHEATH DILATOR 11FR EVOLUTION SHORTIE RL PERC -,SUP-G23749,CDM,C1773,HCPCS,272,RC,,,outpatient,,,5843.14,4090.198,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC,,
SNARE VASC EYE SNR 13MMX94CM FLSH PRT NTNL 16FR WRKSTN -,SUP-G26517,CDM,C1773,HCPCS,272,RC,,,outpatient,,,5674.23,3971.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC,,
SNARE VASC AMP GOOSENECK 15MM/6FR LOOP/CATH 120CM GOLD TUNG -,SUP-GN1500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC,,
SNARE EV AMP GOOSENECK 20X120MM GOLD TUNG NTNL 6FRX102CM -,SUP-GN2000,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC,,
SNARE VASC AMP GOOSENECK 25MM/6FR LOOP/CATH 120CM GOLD TUNG -,SUP-GN2500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC,,
KIT GOOSE NECK SNARE 25MM LOOP -,SUP-GN3000,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC,,
SNARE GOOSENECK GN3500 -,SUP-GN3500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC,,
SNARE AMPLATZ GN 5MM -,SUP-GN500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC,,
STYLET LD LIBERATOR 140CM -,SUP-LR-OFA01,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2639.4,1847.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC,,
CATHETER INTRODUCER AVEIR 50CM REF:LSN25501 -,SUP-LSN25501,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC,,
BASKET STONE SEGURA -,SUP-M0063801120,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1030.93,721.651,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC,,
SNARE ONE700 175CM 7MM LOOP -,SUP-ONE700,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2851.99,1996.393,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC,,
SNARE ONE701 200CM 7MM LOOP -,SUP-ONE701,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2959.88,2071.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC,,
SNARE VASC AMP GOOSENECK 7X175MM GOLD TUNG NTNL -,SUP-SK700,CDM,C1773,HCPCS,272,RC,,,outpatient,,,3126.44,2188.508,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,231.443785,6420.62028,other,OPPS APC,,
HEAD FEM 12/ 1440MMX3.5MM NK TAPR -,SUP-00080184001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 40MM -,SUP-00080184002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 15X190MM WAGNER SL REVISN PROTASUL-100 POR CTD -,SUP-00100101915,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 18X225MM WAGNER SL REVISN PROTASUL-100 POR CTD -,SUP-00100102218,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 9MM PRFT ANTMC 110MM PROTASUL-100 UNCEM TAPR SHLDR -,SUP-00104201092,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 40X14MM -,SUP-00104212400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 44X16MM PROTASUL-21 WF ANTMCREM -,SUP-00104212440,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 46X16MM PROTASUL-21 WF ANTMC REM -,SUP-00104212460,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 48X17MM ANTMC SHLDR PROTASUL-21 REM -,SUP-00104212480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 50X18MM PROTASUL-21 WF ANTMC REM -,SUP-00104212500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP 24MM SM ANTMC SHLDR 16MM PE PG CMNT -,SUP-00104214340,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP 28MM MED ANTMC SHLDR 19MM PE PG CMNT -,SUP-00104214370,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ3 39.68MM OFST 141MM AVENIR MULLER STD 56.11MM NK -,SUP-00106010003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ4 40.22MM OFST 147MM AVENIR MULLER STD 56.88MM NK -,SUP-00106010004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM LAT AVENIR MUELLER SZ 4 -,SUP-00106010104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 12/14 TAPR M/L HIP -,SUP-00106010107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
WEDGE ANKL JNT OSSEOTI 15X15MM POR MTL -,SUP-00110003821,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8785.08,6149.556,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CEMENT BN PLYMTHL MTHCRYLT 40GM PLC R HVISC -,SUP-00111214001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,396.78,277.746,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INTEGRAL SHORT GTR W/2 CABLES 23 X 53 -,SUP-00223200204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6861.23,4802.861,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 46X18MM BGLNI/FLTW STD ZML MODULAR OFST -,SUP-00430004618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP 40MM BGLNI/FLTW SHLDR UHMWPE SS PG -,SUP-00430008500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP 46MM BGLNI/FLTW SHLDR UHMWPE SS PG -,SUP-00430008600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 40X18MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 40X21MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP 40MM 46MM ARTC SURF BGLNI/FLTW SHLDR UHMWPE SS PG -,SUP-00430204046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 46X15MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204615,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 46X17MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 46MM OFST MODULAR -,SUP-00430204618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 46X19MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 46X27MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204627,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP 46MM BGLNI/FLTW SHLDR W/52MM SS PG -,SUP-00430204652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BF OFFSET HUM HEAD 18MM X 52MM -,SUP-00430205218,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 52X19MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430205219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 52X21MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430205221,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 10MM INTOP FLXB 130MM TM 42DG ANG NK SHLDR -,SUP-00434211013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 11MM INTOP FLXB 130MM TM 42DG ANG NK SHLDR -,SUP-00434211113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 6MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434810613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 8MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434810813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 9MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434810913,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 10MM TM 130MM 48DG ANG SHLDR -,SUP-00434811013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 11MM TM 130MM 48DG ANG SHLDR -,SUP-00434811113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 12MM TM 130MM 48DG ANG SHLDR -,SUP-00434811213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 13MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434811313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 12MM RVRS 130MM TM LPRO SHLDR -,SUP-00434901213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18477.37,12934.159,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 32X53MM EPSLN STD DRSL UHMWPE PRIM HD -,SUP-00437732053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 42MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500104200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 43MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500104300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 28X47-49MM VERSYS BIPLR UHMWPE -,SUP-00500104728,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 49MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500104900,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 28X50-52MM VERSYS BIPLR UHMWPE -,SUP-00500105028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 51MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 52MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 28X53-55MM VERSYS BIPLR UHMWPE -,SUP-00500105328,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 54MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 55MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 60MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500106000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT LMRL KN SZ2 27MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800227,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HALF BLOCK TRABECULAR TIBIAL AUGMENT RT LATERAL/LT MEDIAL -,SUP-00-5448-002-28,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10465.7,7325.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT RM/LL KN SZ2 37MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800237,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HALF BLOCK TRABECULAR TIBIAL AUGMENT LT LATERAL/RT MEDIAL -,SUP-00-5448-002-38,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10465.7,7325.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT LMRL KN SZ3 27MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800327,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT LMRL KN SZ3 26MM NEXGEN 5MM WDG FUL BLCK TM TIV PMMA -,SUP-00544800337,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT LMRL KN SZ5 27MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800527,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT RM/LL KN SZ5 37MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT KN 31MMMEDX31MM TM -,SUP-00545001331,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15863.61,11104.527,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT KN 36MM MED 25MMX36MM TM -,SUP-00545001336,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CONE TIBIAL TM LARGE 51 X 34 RIGHT -,SUP-00-5450-013-52,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CONE FEMORAL LT SM 30MM -,SUP-00545001730,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT RT DPHSL KN SZ30 SM TM -,SUP-00545001731,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT RT DPHSL KN SZ30 MED TM -,SUP-00545001831,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TM FEM DIAPHYSEAL CONE- 30 LARGE- RIGHT -,SUP-00-5450-019-31,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT KN SZ48 XS NEXGEN 15MM TM -,SUP-00545004801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19404.14,13582.898,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT TRAB METALTIB SZ 52-51MM FULL SMALL -,SUP-00-5450-052-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19404.14,13582.898,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT DIST KN SZ-D NEXGEN 5MM BLCK REVISN TM TIV -,SUP-00549003401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT KN SZ-D NEXGEN 5MM DIST BLCK REVISN TM TIV -,SUP-00549003410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT KN SZ-D NEXGEN 10MM BLCK REVISN TM TIV -,SUP-00549003420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT POST 5MM BLCK SZ-E NEXGEN BLCK REVISN TM TIV -,SUP-00549003501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT DIST KN SZ-E NEXGEN 5MM BLCK REVISN TM TIV -,SUP-00549003510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT KN SZ-E NEXGEN 10MM DIST BLCK REVISN TM TIV -,SUP-00549003520,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT POST KN SZ-F NEXGEN 5MM DIST BLCK REVISN TM TIV -,SUP-00549003601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT KN SZ-F NEXGEN 10MM POST BLCK REVISN TM TIV -,SUP-00549003602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT DIST KN SZ-F NEXGEN 5MM DIST BLCK REVISN TM TIV -,SUP-00549003610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-E MINUS NEXGEN GENDR SOL LT KN CR CMNT ZML PMMA -,SUP-00575001505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-E MINUS NEXGEN GENDR SOL LT KN CR CMNT COCR FLEX -,SUP-00575201505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-E MINUS NEXGEN GENDR SOL RT KN CR CMNT COCR FLEX -,SUP-00575201506,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-D NEXGEN LEGC GENDR SOL LT KN PS CMNT ZML FLEX -,SUP-00576401451,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-E NEXGEN LEGC GENDR SOL LT KN PS CMNT ZML FLEX -,SUP-00576401551,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-E NEXGEN LEGC GENDR SOL RT KN PS CMNT ZML FLEX -,SUP-00576401552,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-F NEXGEN LEGC GENDR SOL LT KN PS CMNT ZML FLEX -,SUP-00576401651,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBPLT SZ2 44/25MM LMRL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBPLT SZ3 47/27MM LMRL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBPLT SZ4 50/29MM LL/RM KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBPLT SZ5 53/31MM LMRL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBPLT SZ5 53/31MM RM/LL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-D 23/48MM NEXGEN LMRL CONDL UNICMPT ZML HI FLEX -,SUP-00584201401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-E 24/51.5MM NEXGEN LMRL CONDL UNICMPT ZML HI -,SUP-00584201501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-F 25/55.5MM NEXGEN LMRL CONDL UNICMPT ZML HI -,SUP-00584201601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-F 25/55.5MM NEXGEN LL/RM KN UNICMPT ZML HI FLEX -,SUP-00584201602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL SIZE G RM/LL -,SUP-00584201702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
ARTICULAR SURFACE SIZE 2 11MM -,SUP-00584202211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 8MM UNICMPT ARTCSURF NET SHP KN-HI FLEX MLD -,SUP-00584202308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
ARTICULAR SURFACE SIZE 5 8MM -,SUP-00584202508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ2 9MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3229.61,2260.727,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 8MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ4 8MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ4 10MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4521.46,3165.022,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5 8MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 32MM MED 19.5MM TM PMMA NEXGEN -,SUP-00587601019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16244.38,11371.066,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 29MM MICRO 10MM PEGX3 POR -,SUP-00587806129,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 32X10MM THK TM PMMA NEXGEN PRIM POR -,SUP-00587806532,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
NEXGEN POROUS TM PATELLA 10MM X 32MM -,SUP-00-5878-065-32,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 38X10MM THK TM PMMA NEXGEN PRIM POR -,SUP-00-5878-065-41,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIB SZ C-H FEM 3 TIB 10X67/43MM NEXGEN PRFT CR MBLK -,SUP-00588604310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12109.95,8476.965,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIB SZ C-H FEM 5 TIB 10X75/47.5MM NEXGEN PRFT CR MBLK -,SUP-00588604510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10860.53,7602.371,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SCREW HEADED HEX 3.5MM X -,SUP-00-5901-035-33,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ1 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ2 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT. -,SUP-00592601201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ2 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ3 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ3 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ4 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ4 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
NEXTGEN CR FLEX PROLONG ART SURF C-H/1-2 SPUR- 14MM -,SUP-00-5952.021-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
NEXGEN CR FLEX PROLONG  ART SURF -,SUP-00-5952-021-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ A-B/1-2 10MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596202010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ C-D/1-2 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596202212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ C-D SZ1-2 FEM 14MM NEXGEN PS ARTCSURF KN FLEX -,SUP-00596202214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ C-D/1-2 17MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596202217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ-E SZ1-2 FEM 10MM NEXGEN PS ARTCSURF KN FLEX FX -,SUP-00596202410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ E-F/3-4 10MM NEXGEN LEGACY ARTCSURF KN PS FLEX -,SUP-00596203210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ E-F/3-4 14MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596203214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ E-F/3-4 17MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596203217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
NEXTGEN LPS-FLEX FIXED PROLONG ART SUR EF 3-4- 20MM -,SUP-00-5962-032-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ E-F/5-6 10MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ E-F/5-6 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ E-F/5-6 17MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ G-H/5-6 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ G-H/5-6 14MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ E-F/7-10 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596205112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-E 68/62.5MM NEXGEN LEGC RT KN PS CMNT ZML FLEX -,SUP-00596401552,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-F 72/65.5MM NEXGEN LEGC R/L KN PS CMNT ZML FLEX -,SUP-00596401652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-G 76.5/71.5MM NEXGEN LEGC L/L KN PS CMNT ZML -,SUP-00596401751,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-G 76.5/71.5MM NEXGEN LEGC R/L KN PS CMNT ZML -,SUP-00596401752,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ C-D/3-4 14MM NEXGEN LPS ARTCSURF NET SHP KN -,SUP-00596403012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-D NEXGEN LEGC LT KN PS CMNT TIV NPOR FLEX FX -,SUP-00596801451,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-F NEXGEN LEGC LT KN PS CMNT TIV NPOR FLEX FX -,SUP-00596801651,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-G NEXGEN LEGC RT KN PS CMNT TIV NPOR FLEX FX -,SUP-00596801752,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 29MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206529,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 32MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206532,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 35MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 38MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206538,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 29MM PRLNG NEXGEN ON ST -,SUP-00597206629,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 32MM PRLNG NEXGEN ON ST -,SUP-00597206632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PATELLA NEXGEN PROLONG ALLPOLY 35MM -,SUP-00597206635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 38MM PRLNG NEXGEN ON ST -,SUP-00597206638,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
NEXGEN AC ART SURF 5-6 GREEN 12MM -,SUP-00597604012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT KN SZ3 NEXGEN 5MM CR PRCTD TIV PMMA -,SUP-00-5988-003-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5398.37,3778.859,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT L/R KN SZ4 NEXGEN 10MM HLF BLCK CR TIV PMMA -,SUP-00598800427,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5398.37,3778.859,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 11MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 12MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SCISSORS OPTH KNAPP 4IN SS CRV V. MUELLER MIRR FNSH S/S IRIS -,SUP-00-5988-010-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 16MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 18MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 20MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 16MM NEXGEN 155MM TIV ALY STR FEM/TBL KN -,SUP-00598801116,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 12.7MM NEXGEN 30MM TIV ALY STR FEM/TBL KN -,SUP-00598801212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 15MM NEXGEN 30MM TIV ALY STR FEM/TBL KN -,SUP-00598801215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SCISSORS OPTH STVNS 4IN SS STR V. MUELLER MIRR FNSH -,SUP-00598802011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SCOOP SURG SM 11IN SLVR PLT CMN DCT MLBL V. MUELLER -,SUP-00598802012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 13MM NEXGEN OFST 100MM TIV ALY FEM/TBL KN -,SUP-00598802013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 14MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 15MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 16MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 17MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 12MM NEXGEN OFST 155MM TIV ALY FEM/TBL KN -,SUP-00598802112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 11MM NEXGEN OFST 155MM TIV ALY FEM/TBL KN -,SUP-00598802115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT ANT KN SZ-D NEXGEN 5MM WDG BLCK TIV PMMA -,SUP-00599003431,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5398.37,3778.859,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-C 60/53.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401392,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-D 64/57.5MM NEXGEN LEGC LT CONDL KN CNSTRN -,SUP-00599401491,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-D 64/57.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401492,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-E 68/61.5MM NEXGEN LEGC LT CONDL KN CNSTRN -,SUP-00599401591,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-E 68/61.5MM NEXGEN LEGC RT KN REVISN CNSTRN -,SUP-00599401592,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-F 72/65.5MM NEXGEN LEGC LT KN REVISN CNSTRN -,SUP-00599401691,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-F 72/65.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401692,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-G 76.5/70.5MM NEXGEN LEGC LT KN REVISN CNSTRN -,SUP-00599401791,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-G 76.5/70.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401792,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ C-D/1-2 MICRO 10X58/40MM NEXGEN LEGC CNSTRN -,SUP-00599402210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ C-D/1-2 MICRO 12X58/40MM NEXGEN LEGC CNSTRN -,SUP-00599402212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ C-D/1-2 MICRO 14X58/40MM NEXGEN LEGC CNSTRN -,SUP-00599402214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB 0.5X20MM THK 58MM/40MM M/L A/P NEXGEN LEGC CNSTRN -,SUP-00599402220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ C-D/3-4 17X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ C-D/3-4 20X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ E-F/3-4 10X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ E-F/3-4 12X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ E-F/3-4 14X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ E-F SZ3-4 FEM 17MM 66MM/42MM M/L/A/P NEXGEN -,SUP-00599403217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
NEXGEN LCCK ART SURF EF 3-4/STR YELLOW 20MM -,SUP-00599403220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9695.93,6787.151,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ E-F/5-6 10X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ E-F/5-6 14X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ E-F/5-6 17X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ E-F/5-6 20X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ-G 5-6 17X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ G-H/7-10 14X82/50MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599405014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIA ALL POLY NEXGEN LPS SZ 8 BLUE 14MM FEM G H -,SUP-00599600814,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4638.69,3247.083,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 32X50MM TRILOGY 10DG TIV ALY UHMWPE 6.3MM PRIM -,SUP-00615405032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8097.55,5668.285,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 32X68MM TRILOGY 10DG TIV ALY UHMWPE 12.4MM PRIM -,SUP-00615406832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8097.55,5668.285,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 54MM TRILOGY PRIM MUL-HL TIV POR CTD SLD HMSPHR -,SUP-00620005420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6960.16,4872.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 44MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620204420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 48MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620204820,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 50MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620205020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 54MM PRIM MODULAR REVISN CLUS-HL TM TNTLM TIV SLD -,SUP-00620205422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 56MM PRIM MODULAR REVISN NO-HL TM TNTLM TIV SLD -,SUP-00620205620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 22X62MM TRILOGY PRIM MODULAR REVISN CLUS-HL TM -,SUP-00620206220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 68MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620206820,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 32X48MM XL TRILOGY 0DG STD LNGVT XLPE 5.3MM PRIM -,SUP-00630504832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 36X50MM TRILOGY 0DG STD LNGVT XLPE 6.8MM PRIM -,SUP-00630505036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 28X44MM TRILOGY 10DG ELEV RM LNGVT XLPE 5.2MM -,SUP-00631004428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 28X46MM TRILOGY 10DG ELEV RM LNGVT XLPE 6.3MM -,SUP-00631004628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 36X58MM XL TRILOGY 10DG STD LNGVT XLPE 8.9MM PRIM -,SUP-00631005836,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 32X62MM TRILOGY 10DG LNGVT XLPE 9.3MM PRIM -,SUP-00631006236,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 28X44MM TRILOGY 20DG ELEV RM LNGVT XLPE 5.2MM -,SUP-00632004428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 28X46MM TRILOGY 20DG ELEV RM LNGVT XLPE 6.3MM -,SUP-00632004628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 32X48MM TRILOGY 20DG ELEV RM LNGVT XLPE 5.3MM -,SUP-00632004832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 32X56MM TRILOGY 20DG ELEV RM LNGVT XLPE 6.4MM -,SUP-00632005632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 28X50MM TRILOGY LNGVT XLPE 7.2MM CNSTRN MODULAR -,SUP-00633405028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14191.09,9933.763,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 32X56MM TRILOGY LNGVT XLPE 6.4MM CNSTRN MODULAR -,SUP-00633405632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14191.09,9933.763,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRABECULAR METAL REVISION SHELL 56MM -,SUP-00700005620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16582.26,11607.582,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BLADE EXPLANT TRUNCATED 60MM -,SUP-00705306010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BLADE FULL EXPLANT 60MM -,SUP-00705306020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 6X111MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 TAPR -,SUP-00771100600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 10X119MM PRFT EXTEND OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 11X121MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 12.5X124MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 15X129MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM VERSYS 41MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM VERSYS 43MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM VERSYS 44MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM VERSYS 47MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM VERSYS 50MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781805000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM VERSYS 51MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781805100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM VERSYS 52MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781805200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
ADAPTER HIP VERSYS ENPROS TIV TAPR. -,SUP-00781809901,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ11 120MM VERSYS LD/FX PRFT ZML CMNT HIP -,SUP-00783301100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ12 125MM VERSYS LD/FX PRFT ZML CMNT HIP -,SUP-00783301200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ14 135MM VERSYS LD/FX PRFT ZML CMNT HIP -,SUP-00783301400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
NECK FEM SZ K2 KINECTIV M/L HIP MODULAR COCR -,SUP-00784802001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
NECK FEM SZ S2 KINECTIV M/L HIP MODULAR COCR -,SUP-00784803001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
NECK FEM SZ P2 KINECTIV M/L HIP MODULAR COCR STR 12/14 TAPR -,SUP-00784803101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
KINECTIV MODULAR NECK G2 -,SUP-00784803201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4916.67,3441.669,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
NECK FEM SZ R2 KINECTIV M/L HIP MODULAR COCR STR 12/14 TAPR -,SUP-00784804201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ13 130MM VERSYS ADVCT PRIM STD OFST NON V-LIGN -,SUP-00785001300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM VERSYS CMTD STD 14X135 -,SUP-00785001400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CENTRALIZER DIST FEM HIP 11MM VERSYS PMMA CMNT -,SUP-00785901100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CENTRALIZER DIST FEM HIP 13MM VERSYS PMMA CMNT -,SUP-00785901300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 14X135MM VERSYS PRIM EXTEND OFST TIV POR CTD FM -,SUP-00786201420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 16X145MM VERSYS PRIM STD OFST TIV POR CTD FM TAPR -,SUP-00786201600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 16X145MM VERSYS PRIM EXTEND OFST TIV POR CTD FM -,SUP-00786201620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 18X155MM VERSYS PRIM STD LRG OFST TIV POR CTD FM -,SUP-00786201830,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 20X155MM VERSYS PRIM EXTEND LRG OFST TIV POR CTD FM -,SUP-00786202050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 13X170MM VERSYS REVISN ZML CMNT CLCR HIP -,SUP-00787101360,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21520.55,15064.385,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 13X210MM VERSYS REVISN ZML CMNT CLCR HIP -,SUP-00-7871-013-61,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21520.55,15064.385,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ15 220MM VERSYS REVISN ZML CMNT CLCR HIP -,SUP-00787101561,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21520.55,15064.385,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM VERSYS 28X0MM NK ZML 12/14 TAPR STRL -,SUP-00801802802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM VERSYS 28MM +3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801802803,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM VERSYS 28MM +7MM NK ZML 12/14 TAPR STRL -,SUP-00801802814,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM VERSYS 32MM-3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM VERSYS 32MM +3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM VERSYS 32MM +7MM NK ZML 12/14 TAPR STRL -,SUP-00801803214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM VERSYS 36MM-3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM VERSYS 36X0MM NK ZML 12/14 TAPR STRL -,SUP-00801803602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM VERSYS 36MM +3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803603,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ELEV RIM 32MM I.D. LONGE -,SUP-00875200832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 36X52MM II SHL CONTIN ELEV LNGVT XLPE 4.7MM F -,SUP-00875201036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
RIM LINER 36MM SIZE JJ LONGEVITY HIGHLY CROSSLINKED POLY -,SUP-00-8752-011-36,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ EE 44MM CONTIN CLUS-HL TM TIV SNP FIT LCK GRV -,SUP-00875704401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ FF 46MM CONTIN MUL-HL TM TIV SNP FIT LCK GRV -,SUP-00875704602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ GG 48MM CONTIN CLUS-HL TM TIV SNP FIT LCK GRV -,SUP-00875704801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ HH 50MM CONTIN CLUS-HL TM TIV SNP FIT LCK GRV -,SUP-00875705001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ II LINER 52MM CONTIN CLUS-HL TM TIV SNP FIT -,SUP-00875705201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ II 52MM CONTIN MUL-HL TM TIV SNP FIT LCK GRV -,SUP-00875705202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ JJ LINER 54MM CONTIN MUL-HL TM TIV SNP FIT LCK -,SUP-00875705401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 28MMX-3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877502801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BIOLOX DELTA FEM HEAD 28MM +0MM -,SUP-00877502802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 32MM-3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 32MM +0MML NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 36MM-3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEMORAL 36MM CERAMIC -,SUP-00-8775-036-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 36MM +3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503603,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 36MM +7MM BIOLOX DELTA CER -,SUP-00-8775-036-04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BIOLOX DELTA OPTION FEM HEAD 28MM +0MM -,SUP-00-8777-028-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3150.84,2205.588,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BIOLOX OPTION HEAD 36/+3.5 TAPER 12/14 -,SUP-00-8777-036-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9780.3,6846.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BIOLOX OPTION HEAD XL 36/+7 TAPER 12/14 -,SUP-00-8777-036-04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9780.3,6846.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 28X44MM EE SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 28X46MM FF SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200728,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 32X48MM GG SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 32X50MM HH SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200932,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 36NN ID 52MM II SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885201036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 36X54MM JJ SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885201136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 22MMLNGX5.5MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902602300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 28MM SHRT +0MML NK ZML 6DG TAPR ANTMC STRL -,SUP-00902602800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 28MMMEDX+7MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902602900,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 28MMLNGX+14MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902603000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 32MMSHRTX3.5MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902603235,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD 6DEGREE COCR FEM 36MM +3.5 S+ -,SUP-00-9026-036-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD 6 DEGREE COCR FEM 36MM +7 M -,SUP-00-9026-036-07,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 15X185MM ZMR REVISN MODULAR TIV PLASM SPRY POR CTD -,SUP-00998201518,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14636.65,10245.655,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BODY HIP SZ A 17.7MM BD 40MM OFST ZMR REVISN MODULAR 45MM NK -,SUP-00999601745,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21253.21,14877.247,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM WAGNER REVISION 135 NK ANGLE 18MM X 265MM -,SUP-01.00102.618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB DURAM -,SUP-01.00214.152,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16626.81,11638.767,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CONE WAGNER 135 DEG X 21MM -,SUP-01.00561.321,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13856.92,9699.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SIDUS STEM-FREE SHOULDER HUMERAL HEAD 48-17 -,SUP-01.04555.480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM AVENIR STANDARD CEM 4 -,SUP-01.06010.204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM STD CEMENTED 7 TAPER 12/14 AVENIR -,SUP-01.06010.207,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AVENIR LATERAL STEM CEM 4 -,SUP-01.06010.304,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM AVENIR LATERAL CEM 8 -,SUP-01.06010.308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP RVRS 25MM BSPLT HA+ADPTR -,SUP-010000589,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL G7 ACETABULAR PPS LTD 46B -,SUP-010000660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 PPS LTD ACET SHELL 48C -,SUP-010000661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 PPS LTD ACET SHELL 50D -,SUP-010000662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL G7 ACETABULAR PPS LTD 52E -,SUP-010000663,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL G7 ACET PPS LTD SHELL 54F -,SUP-010000664,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 PPS LTD ACET SHELL 56F -,SUP-010000665,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 PPS LTD ACET SHELL 60G -,SUP-010000667,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL G7 PPS LTD ACET 46 B -,SUP-010000719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER G7 NEUTRAL ARCOMXL 32MM B -,SUP-010000729,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 NEUTRAL ARCOMXL LNR 36MM D -,SUP-010000739,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 NEUTRAL ARCOMXL LNR 36MM E -,SUP-010000740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ARCOMXL G7 NEUTRAL 36MM F -,SUP-010000741,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 ACETABULAR LINER 36MM / G -,SUP-010000742,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 NEUTRAL ARCOMXL LNR 40MM G -,SUP-010000748,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 NEUTRAL E1 LINER 28MM C -,SUP-010000837,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 NEUTRAL E1 LINER 32MM -,SUP-010000846,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 NEUTRAL E1 LINER 32MM C -,SUP-010000847,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 NEUTRAL E1 LINER 36MM D -,SUP-010000856,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 NEUTRAL E1 LINER 36MM F -,SUP-010000858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 FREEDOM CONST E1 LNR 36MM -,SUP-010000982,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 FREEDOM COSTR E1 LNR 36MM G -,SUP-010000985,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD COCR FEM 40MM TYPE 1 +9MM -,SUP-010001032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COCR FEM HD 40MM TYPE 1 +6MM -,SUP-010001033,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEMORAL COCR 40MM TYPE 1 STD -,SUP-010001035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COCR FEM HD 40MM TYPE 1-3MM -,SUP-010001036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
WAGNER SL REVISION STEM 135 NK ANGLE 15MM X 225MM -,SUP-0100102215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
WAGNER SL REV STEM 135 NK ANGLE 14 X 265 -,SUP-0100102614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CONE WAGNER 125 DEG X 19MM -,SUP-0100561219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13856.92,9699.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
ADAPTER ANTMC BGLNI 42 -,SUP-0104250042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AS B/F ADAPTOR 48 DEG -,SUP-0104250048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AC-CONNECTOR -,SUP-0104440000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM AVENIR 5 TAPER 12/14 MULL -,SUP-0106010005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM AVENIR 6 TAPER 12/14 MULL -,SUP-0106010006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
MORSE TAPER HEAD +5 OFFSET WITH LFIT 32MM -,SUP-01-3205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PLATE 2.7/3.5 VA ANTLAT DSTL TIB PL/10 H/LFT -,SUP-02.118.209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10401.04,7280.728,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BONE PREP KIT 21-1000 SFN -,SUP-0206-710-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,740.32,518.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LOW FRICTION ION TREATMENT -,SUP-06-2200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
C-TAPER LFIT HEAD LOW FRI ION TREATMENT -,SUP-06-2205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 26X0MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-06-2600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEMORAL LFIT COCR +5 MM OFFSET C TAPER 26MM HIP -,SUP-06-2605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
C-TAPER LFIT HEAD LOW FRICTION SZ. 26MM / +10 -,SUP-06-2610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 28X0MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-062800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
C-TAPER LFIT HEAD LOW FRICTION SZ. 28MM / +10 -,SUP-06-2810,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 32X0MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-063200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 32MM-5MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-063299,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 36MM +0MML NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-063600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 40MM-2.5MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-064097,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM PLASMA SPRAY STD SIZE 2 TI6AI4V -,SUP-101-0002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HIP STEM PLASAM STD SZ 3 -,SUP-101-0003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ4 37MM OFST 110MM OVATN STD OFST 29MM 7MM M/L/A/P -,SUP-101-0004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ5 OVATN STD OFST TI PLASM SPRY CTD 12/14 TAPR -,SUP-101-0005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ6 38MM OFST 118MM OVATN STD OFST 31MM 9MM M/L/A/P -,SUP-101-0006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ7 32MM OFST 122MM OVATN STD OFST 32MM 10MM -,SUP-101-0007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ8 43MM OFST 126MM OVATN STD OFST 34MM 11MM -,SUP-101-0008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ9 44MM OFST 130MM OVATN STD OFST 36MM 13MM -,SUP-101-0009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ10 47MM OFST 134MM OVATN STD OFST 38MM 16MM -,SUP-101-0010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ5 44MM OFST 114MM OVATN EXTEND OFST 30MM 8MM -,SUP-101-1005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8233.36,5763.352,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ6 9/31X118MM OVATN EXTEND OFST 33MM LEG 44MM HZNT -,SUP-101-1006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ7 49MM OFST 122MM OVATN EXTEND OFST 32MM 10MM -,SUP-101-1007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ8 50MM OFST 126MM OVATN EXTEND OFST 34MM 11MM -,SUP-101-1008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ9 STD OVATN EXTEND OFST TI PLASM SPRY CTD 12/14 -,SUP-101-1009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ10 55MM OFST 134MM TI PLASM SPRY CTD HIP OVATN -,SUP-101-1010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SELF CENT HIP 41X28 RUST -,SUP-1035-41-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
WIRE EXTFIX 1.8MM BAYNT PNT -,SUP-104.690,CDM,C1776,HCPCS,278,RC,,,outpatient,,,367.02,256.914,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
RING ACTB SZ23 TI HIP LCK LINER YEL RINGLOC STRL SUD -,SUP-1054-23,CDM,C1776,HCPCS,278,RC,,,outpatient,,,770.22,539.154,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SPACER DIST HIP 10MM ACCOLADE C SZ SMALL -,SUP-1059-2310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SPACER FEM CMNT RNG STYL MED 12MM DIST F/STM 4/5 ACCOLADE -,SUP-1059-4512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
RINGLOC + HIP SYSTEM SZ 21 -,SUP-106021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,945.27,661.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SPACER DIST FEM HIP UNIV 8MM ACCOLADE CMNT -,SUP-1067-0008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SPACER DIST FEM HIP 9MM UNIV CMNT -,SUP-1067-0009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SPACER DIST FEM HIP 10MM UNIV CMNT -,SUP-1067-0010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SPACER DIST FEM HIP 11MM UNIV RECON CMNT -,SUP-1067-0011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SPACER DIST FEM HIP 12MM UNIV CMNT -,SUP-1067-0012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SPACER DIST FEM HIP 13MM UNIV CMNT -,SUP-1067-0013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SPACER DIST FEM HIP 14MM UNIV CMNT -,SUP-1067-0014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SPACER DIST FEM HIP 15MM UNIV CMNT -,SUP-1067-0015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
OMNIFIT UNIVERSAL DISTAL CEMENT SPACER 16MM -,SUP-1067-0016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CEMENT SPACER UNIVERSAL DISTAL -,SUP-1067-0017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
VARIO CUP 28MM X 47MM -,SUP-107-220/47,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5160.7,3612.49,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
VARIO CUP 28MM X 48MM -,SUP-107-220/48,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5160.7,3612.49,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
VARIO-CUP SYSTEM OUTER 50MM HEAD 28MM -,SUP-107-220/50,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5160.7,3612.49,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 OSSEOTI 3 HOLE SHELL 50MM D -,SUP-110010243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 OSSEOTI MULTIHOLE 50MM D -,SUP-110010263,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 MULTIHOLE 52MM -,SUP-110010264,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 OSSEOTI MULTIHOLE 54MM F -,SUP-110010265,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 OSSEOTI MULTIHOLE 56MM F -,SUP-110010266,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 OSSEO TI ACETABULAR SHELL 58MM / G -,SUP-110010267,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 OSSEO TI MULTIHOLE 60MM G -,SUP-110010268,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL G7 OSSEO TI MULTIHOLE 62MM H -,SUP-110010269,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 OSSEO TI MULTIHOLE 64MM H -,SUP-110010270,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER G7 DUAL MOBILITY 38MM C -,SUP-110024461,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 DUAL MOBILITY LINER 42MM E -,SUP-110024463,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 DUAL MOBILITY LINER 44MM F -,SUP-110024464,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 DUAL MOBILITY LINER 50MM H -,SUP-110024466,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPR VRS GLEN PPS MIN TPR ADR -,SUP-110027734,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26395.72,18477.004,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PRX HUM LO PLT LT 4H 83MM -,SUP-110030101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6875.28,4812.696,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
40MM VERSA-DIAL GLEN STD -,SUP-110030776,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
40MM VERSA-DIAL GLEN +3 -,SUP-110030777,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BEARING VIVACIT-E DM 28 X 44MM -,SUP-110031012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BEARING VIVACIT-E DM 28 X 50MM -,SUP-110031015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
VERSA-DIAL TAPER ADAPTOR 25MM -,SUP-110031378,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HMRL TRAY STD STD -,SUP-110031399,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRAY HMRL STD SHOULDER REVERSE TI -,SUP-110031408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HMRLBEARING 36MM +3 PRLNG -,SUP-110031419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HMRL BEARING 40MM STD PRLNG -,SUP-110031421,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HMRL BEARING 36 MM STD VITE -,SUP-110031424,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HMRL BEARING 36 MM +3 VITE -,SUP-110031425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BEARING HUMERAL 40MM STD VITE -,SUP-110031427,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPR AUG BSPLT W ADP SM -,SUP-110032410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPR AUG BSPLT W ADP MD -,SUP-110032420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPR AUG BSPLT W ADP LG -,SUP-110032430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HMRL BEARING 36MM STD PRLNG -,SUP-11031418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FREEDOM CONSTR HD 36MM T1 -,SUP-11-107016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7259.36,5081.552,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FREEDOM CONSTR 36MM T1 +9MM -,SUP-11-107021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7259.36,5081.552,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 6MM MAC PRIM RVRS CMPRHNSV 140MM COCR PLASM CTD -,SUP-11-113556,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PROXIMAL FEMORAL OMPONENT RHS LEFT -,SUP-1115-9110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22682.72,15877.904,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL CHECKPOINT STERILE -,SUP-111651,CDM,C1776,HCPCS,278,RC,,,outpatient,,,260.65,182.455,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
RINGLOC BIPOLAR 28X49MM -,SUP-11-165222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD RADL SZ12 22MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6332.05,4432.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD RADL SZ14 24MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM RADL SZ7 26MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7295.44,5106.808,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM RADL SZ8 28MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210063,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7507.64,5255.348,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM STR DIST ARCOS 23MM X 150MM TAPER -,SUP-11-300823,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STS DISTAL STEM 15 X 190MM -,SUP-11-300915,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
DIST ARCOS 19 X 190MM SPL TPR -,SUP-11-300919,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CON ARCOS SZ A STD 60MM -,SUP-11-301301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CON ARCOS SZ A STD HI 50MM -,SUP-11-301310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
ARCOS CON SIZE E HI 70MM -,SUP-11-301335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STANDARD CONE PROX BODY 80MM -,SUP-11-301342,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
ARCOS CON SIZE B HI 80MM -,SUP-11-301352,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
VERSA-DIAL 38 X 19 X 39 HUM HEAD -,SUP-113022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
VERSA-DIAL 38X21X38 HUM HEAD -,SUP-113024,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 42MM 46X18MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
VERSA DIAL 42 X 21 X 43 HUM HEAD -,SUP-113034,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 46X53MM 18MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 46X50MM 24MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 46X46MM 27MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 50MM 57X21MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 50X50MM 27MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113057,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
MODULAR HEAD 54MM 21MM 64MM -,SUP-113063,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TAPER ADAPTER 54MM X 24MM -,SUP-113065,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM VERSA-DIAL 54X27X55 -,SUP-113067,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HUM HEAD VERSA-DIAL 58 X 24 X 64 -,SUP-113075,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE COMP FX HUM POS 8MM -,SUP-113576,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE COMP FX HUM POS 9MM -,SUP-113577,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
POSTIONING SLEEVE COMP FX HUM 10MM -,SUP-113578,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE COMP FX HUM POS 11MM -,SUP-113579,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FX HUM POS SLEEVE 12MM -,SUP-113580,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FX HUM POS SLEEVE 13MM -,SUP-113581,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PRIMARY STEM 9MM MICRO -,SUP-113609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PRIMARY STEM 10MM MICRO -,SUP-113610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PRIMARY STEM 11MM MICRO -,SUP-113611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PRIMARY STEM 12MM MICRO -,SUP-113612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM COMP PRIMARY MICRO 13MM -,SUP-113613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM COMP PRIMARY MICRO 14MM -,SUP-113614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PRIMARY STEM 15MM MICRO -,SUP-113615,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PRIMARY STEM 17MM MICRO -,SUP-113617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PRIMARY STEM 19MM MICRO -,SUP-113619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM COMP PRIMARY 5MM MINI -,SUP-113625,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM COMP PRIMARY 6MM MINI -,SUP-113626,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PRIMARY STEM 7MM MINI -,SUP-113627,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM COMP PRIMARY 8MM MINI -,SUP-113628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPREHENSIVE HUMERAL STEM 9MM MINI -,SUP-113629,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
POROUS PLASMA 10MM 83MM LONG -,SUP-113630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PRIMARY STEM 11MM MINI -,SUP-113631,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPREHENSIVE HUMERAL STEM 12MM MINI -,SUP-113632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM COMP PRIMARY 13MM MINI -,SUP-113633,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM COMP PRIMARY 14MM MINI -,SUP-113634,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM COMP PRIMARY 15MM MINI -,SUP-113635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM COMP PRIMARY 16MM MINI -,SUP-113636,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD MOD 36MM COCR 3MM -,SUP-11-363661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD COCR MOD HD STD 36MM -,SUP-11-363662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD 36MM COCR MOD +36MM -,SUP-11-363663,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM COMP PRIMARY 17MM MINI -,SUP-113637,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 7MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113647,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 8MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113648,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 12MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 15MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113655,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 16MM STD PRIM PRFT RVRS CMPRHNSV 122MM COCR PLASM -,SUP-113656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP MODULAR HYBRID SHLDR POST 4MM UHMWPE PG -,SUP-113951,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP SM MODULAR HYBRID SHLDR BS 4MM UHMWPE PG -,SUP-113952,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP MED MODULAR HYBRID SHLDR BS 4MM UHMWPE PG -,SUP-113954,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SPHERE GLND 36MM STD CMPRHNSV VERSA-DIAL RVRS HAP POR CTD -,SUP-115310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SPHERE GLND +3MM 36MM CMPRHNSV VERSA-DIAL RVRS HAP POR CTD -,SUP-115313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE 28MM CMPRHNSV SHLDR RVRS -,SUP-115330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRY HUMERAL STD 44MM COCR SHLDR RVRS CMPRHNSV STRL SUD -,SUP-115370,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PIN INSRTR 24.5CM FRLCK F/VFX2 FEM FX SYS -,SUP-118001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
KT BONE CMNT PREP-IM -,SUP-121010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3685.53,2579.871,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM COMPR 6MM HUM FRACT PPS -,SUP-12-113556,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPR 8MM HUM FRACT STEM PPS -,SUP-12-113558,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPR 10MM HUM FRACT STEM PPS -,SUP-12-113560,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPR 12NN HUM FRACT STEM PPS -,SUP-12-113562,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD MODULAR CER BIOLOXD 28MM -3 NK -,SUP-12-115109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CER BIOLOXD MOD HD 28MM STD NK -,SUP-12-115110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CER BIOLOXD MOD HD 28MM +3 NK -,SUP-12-115111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CER BIOLOXD MOD HD 32MM-3NK -,SUP-12-115114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD CERAMIC BIOLOX STANDARD NECK -,SUP-12-115115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CER BIOLOXD MOD HD 36MM STD NK -,SUP-12-115121,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CER BIOLOXD MOD HD 36MM +3 NK -,SUP-12-115122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CER BIOLOXD MOD HD 36MM +6 NK -,SUP-12-115123,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD ENDO II MOD SIZE 49 -,SUP-12-139022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 54MM PINNCL NO-HL POR CTD LCK RNG SLD -,SUP-1217-01-054,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4847.45,3393.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 58MM PINNCL NO-HL POR CTD LCK RNG SLD -,SUP-1217-01-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4992.9,3495.03,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 60MM PINNCL NO-HL POR CTD LCK RNG SLD -,SUP-1217-01-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4992.9,3495.03,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 46MM PINNCL MUL-HL BANTAM POR CTD PLASM SPRY LCK -,SUP-1217-20-046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6137.89,4296.523,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 48MM PINNCL MUL-HL BANTAM PE POR CTD LCK RNG SLD -,SUP-1217-22-048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6215.13,4350.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 52MM PINNCL MUL-HL BANTAM SECT PE POR CTD LCK RNG -,SUP-1217-22-052,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4847.45,3393.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 54MM PINNCL MUL-HL BANTAM SECT PE POR CTD LCK RNG -,SUP-1217-22-054,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4706.3,3294.41,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 62MM PINNCL PRFT NO-HL GRIPTN -,SUP-1217-31-062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16040.16,11228.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 48MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CUP ACETABULAR 50MM -,SUP-1217-32-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 52MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-052,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10299.17,7209.419,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 54MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-054,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 56MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10299.17,7209.419,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 58MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10509.65,7356.755,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 60MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10299.17,7209.419,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 62MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACETABULAR PINNACLE 54 47 -,SUP-121854047,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13117.66,9182.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PINNACLE DM LINER 56 49 -,SUP-121856049,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13117.66,9182.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER DUR MAR +4 10D 36 X 54 -,SUP-122036554,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 32X50MM PINNCL NEUT ALTRX BLU -,SUP-1221-32-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 32X48MM PINNCL +4 10DG ALTRX BLU -,SUP-1221-32-148,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 32X50MM PINNCL +4 10DG ALTRX BLU -,SUP-1221-32-150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 36X58MM PINNCL NEUT ALTRX ORNG -,SUP-1221-36-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 36X52MM PINNCL +4 10DG ALTRX ORNG -,SUP-1221-36-152,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 36X54MM PINNCL +4 10DG ALTRX ORNG -,SUP-1221-36-154,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 36X56MM PINNCL +4 10DG ALTRX ORNG -,SUP-1221-36-156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 40X56MM PINNCL NEUT ALTRX -,SUP-1221-40-056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 40X58MM PINNCL NEUT ALTRX WHT -,SUP-1221-40-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 40X62MM PINNCL NEUT ALTRX -,SUP-1221-40-062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 40X56MM PINNCL LD +4 10DG ALTRX PNK -,SUP-1221-40-156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 40X58MM PINNCL LD +4 10DG ALTRX PNK -,SUP-1221-40-158,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
ALTRX +4 10D 40IDX620D -,SUP-1221-40-162,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CATALYST R1 SHORT STEM HUMERAL SIZE 36S -,SUP-1230-7501-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CATALYST R1 POLY INSERT IMPLANT36 +0 -,SUP-1230-7504-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CATALYST R1 POLY INSERT SIZE 36 +4 -,SUP-1230-7504-002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CATALYST R1 STANDARD BASEPLATE IMPLANT -,SUP-1230-7506-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10674.88,7472.416,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CATALYST R1 GLENOSHERE SIZE 36 STD -,SUP-1230-7513-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9761.2,6832.84,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 52MM RESTOR ADM X3 PRFT MBL BRNG CMNTLS SLF-LCK -,SUP-1235-2-521,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 54MM RESTOR ADM X3 PRFT MBL BRNG CMNTLS SLF-LCK -,SUP-1235-2-541,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 60MM RESTOR ADM PRIM -,SUP-1235-2-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 28X48MM RESTOR ADM 0DG DURATION PE 6.9MM -,SUP-1235-2-848,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 28X54MM RESTOR ADM 0DG DURATION PE 9.9MM -,SUP-1235-2-854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 28X60MM RESTOR ADM 0DG DURATION PE 12.9MM -,SUP-1235-2-860,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 36X22.2MM RECON ADM MDM X3 UHMWPE PRIM ASYM -,SUP-1236-2-242,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 38X22.2MM RECON ADM MDM X3 UHMWPE PRIM ASYM -,SUP-1236-2-244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 28X48MM RESTOR ADM X3 PE 6.9MM REVISN -,SUP-1236-2-848,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT RESTORATION ADM/MD/ 29MM X 28/48 SIZE 42E X3 -,SUP-1236-2-848,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT RESTORATION ADM/MD/ 28MM X 28/52 SIZE 46F X3 -,SUP-1236-2-852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 28X52MM RESTOR ADM X3 PE 8.9MM REVISN -,SUP-1236-2-852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 28X54MM RESTOR ADM X3 PE 9.9MM REVISN -,SUP-1236-2-854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT RESTORATION ADM/MDM 28MM X 52H X3 SZ 28/58MM -,SUP-1236-2-858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
RES INSERT ADM/MDM 28MM SZ54I -,SUP-1236-2-860,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PROSTHESIS HEAD A 28MM NECK L S +3.5 TAPER 12/14 -,SUP-128-791/03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PROSTHESIS HEAD A 32MM MED 12/14 -,SUP-128-792/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PROSTHESIS HEAD A 36MM NECK L S -4 TAPER 12/14 -,SUP-128-793/01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PROSTHESIS HEAD A 36MM NECK M NECK LEN 0 TAPER 12/14 -,SUP-128-793/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PROSTHESIS HEAD A 36MM NECK LARGE +4 TAPER 12/14 -,SUP-128-793/03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINK PROSTHESIS HEAD A CERAMIC 8MM -,SUP-128-793/04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PROSTHESIS HEAD A 40MM NECK M TAPER 12/14 -,SUP-128-794/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD PROSTESIS B 24MM 12/14 M -,SUP-128-824/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PROSTHESIS HEAD B 28MM M NEC L 0 12/14 -,SUP-128-828/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PROSTHESIS HEAD B NECK XL +10.5 -,SUP-128-828/04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINK PROSTHESIS HEAD B 36MM +4 -,SUP-128-836/03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ2.5 69.6/45.8MM KN CMNT STM SIGMA COCR PS -,SUP-1294-33-125,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ3 KN CMNT STM SIGMA COCR PS TCMPRTMNTL MBL -,SUP-1294-33-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ5 KN CMNT STM SIGMA COCR PS TCMPRTMNTL MBL -,SUP-1294-33-150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ6 KN CMNT STM SIGMA COCR PS TCMPRTMNTL MBL -,SUP-1294-33-160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ2.5 67/44MM KN CMNT SIGMA COCR PS REVISN MBL -,SUP-1294-35-125,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ3 70MM M/L 46MM A/P KN CMNT SIGMA COCR PS -,SUP-1294-35-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIB TRAY ROT PLAT MBT REV SZ 4 -,SUP-129435140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
REV MBT TIBIAL ROT PLAT TRAY SZ. 3 -,SUP-1294-35-315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
REVISION MBT TIBIAL TRAY SZ. 4 / 15MM -,SUP-1294-35-415,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRAY TIBIAL ROTATING PLAT MBT REV SZ 4 25MM THICK CEMENTED -,SUP-1294-35-425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE FEMORAL UNIV DISTAL PORUS 34MM -,SUP-1294-53-225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE UNIV FEMORAL 48MM FULL POROUS -,SUP-1294-53-246,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE TIB 29X29/26MM LCS COMPL MODULAR REVISN BEAR KN RP -,SUP-1294-54-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE TIB 37X37/27MM LCS COMPL MODULAR REVISN BEAR KN RP -,SUP-1294-54-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE TIB 45X45/27MM LCS COMPL MODULAR REVISN BEAR KN RP -,SUP-1294-54-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE METAPHYSEAL 53MM POUROUS MBT REV -,SUP-1294-54-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
METAPHYSEAL SLEEVE POROUS -,SUP-1294-54-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
METAPHYSEAL SLEEVE 29MM CEMENTED REV -,SUP-1294-54-140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
UNITED HIP FULL XPE CUP I.D. 32MM O.D. 48MM -,SUP-1302-3248,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
UNITED HIP FULL XPE CUP I.D. 32MM O.D. 50MM -,SUP-1302-3250,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
UNITED HIP FULL XPE CUP I.D. 28MM O.D. 46MM -,SUP-1302-3846,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
UNITED HIP LOCKING CAGE OD58MM LEFT -,SUP-1308-1158,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
UNITED HIP LOCKING CAGE OD54MM RIGHT -,SUP-1308-1254,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
UNITED HIP LOCKING CAGE OD 58MM RIGHT -,SUP-1308-1258,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
UNITED HIP SYS LOCKING CAGE 62MM RIGHT -,SUP-1308-1262,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
UNIPOLAR 42MM OD -,SUP-132-0042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD SOLITUDE UNIPOLAR 43MM -,SUP-132-0043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
UNIPOLAR 47MM -,SUP-132-0047,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
UNIPOLAR 53MM SOLITUDE -,SUP-132-0053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
UNIPOLAR SOLITUDE 55MM -,SUP-132-0055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
UNIPOLAR 57MM -,SUP-132-0057,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
ADAPTER SOLITUDE UNIPOLAR +0MM -,SUP-132-1200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
ADAPTER +6MM 12/14 -,SUP-132-1206,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
ADAPTER OFFSET 9MM 12/14 -,SUP-132-1209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP 3MM SOLITUDE OFST ADPTR UNIPL COCR 12/14 TAPR -,SUP-132-1230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL BIPOLAR PIVOT 22 X 40 ACETABULAR -,SUP-133-2240,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PIVOT BIPOLAR 22 X 43MM BIPOLAR -,SUP-133-2243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM 22X44MM SHL OFST L CUP BIPLR TI COCR UHMWPE -,SUP-133-2244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM 28X46MM SHL OFST L CUP BIPLR TI COCR UHMWPE -,SUP-133-2846,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CUP BIPOLAR MOD COCR 28X47MM -,SUP-133-2847,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PIVOT BIPOLAR 28 X 49 -,SUP-133-2849,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PIVOT BIPOLAR 28 X 50MM -,SUP-133-2850,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BIPOLAR 28MM ID 51MM OD -,SUP-133-2851,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PIVOT BIPOLAR 28 X 52 BIPOLAR -,SUP-133-2852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL BIPOLAR PIVOT 28MM X 53MM -,SUP-133-2853,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL BIPOLAR PIVOT 28X54MM -,SUP-133-2854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PIVOT BIPOLAR 28 X 55 -,SUP-133-2855,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PIVOT BIPOLAR 28X56MM BIPOLAR -,SUP-133-2856,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PIVOT BIPOLAR 28MM X 57MM -,SUP-133-2857,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEMORAL CERAMIC 28MM -,SUP-136-2800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEMORAL CERAMIC DELTA 28MM 3 BIOLOX -,SUP-136-2830,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TAPERED SPACER ARTICUL/EZE -3 -,SUP-136308000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SPACER HIP ARTICL/EZ MODULAR CATHCART UNIPL +0MML NK 12/14 -,SUP-1363-10-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1144.83,801.381,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SPACER HIP ARTICL/EZ MODULAR CATHCART UNIPL +5MM NK 12/14 -,SUP-1363-12-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1144.83,801.381,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL HEAD 32MM -3 CERAMIC 12/14 TAPER -,SUP-136-3230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 51MM UNIPL MODLR CATHCART BALL ORTHCNTRC DSGN -,SUP-1363-51-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1933.62,1353.534,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
MODULAR CATHCART BALL 53MM OD -,SUP-136353000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD 36MM +0 BIOLOX DELTA CERAMIC FEMORAL -,SUP-136-3600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM BIOLOX DELTA 36MM XL MODULAR -,SUP-136-3604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEMORAL 36MM +3 BIOLOX DELTA CERAMIC -,SUP-136-3613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEMORAL 36MM +6 CERAMIC 12/14 TAPER -,SUP-136-3616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEMORAL BIOLOX DELTA CERAMIC 36MM -3 -,SUP-136-3630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FERMORAL HEAD BIOLOX DELTA CERAMIC 36MM -6 -,SUP-136-3660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD CERAMIC FEMORAL DELTA -,SUP-136-4000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 40MMMEDX-1MM NK BIOLOX DELTA 12/14 TAPR -,SUP-136-4002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2570.74,1799.518,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL HEAD CERAMIC 40MM +3 BIOLOX -,SUP-136-4013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL CERAMIC HEAD 40MM +9 -,SUP-136-4019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL HEAD CERAMIC 40MM -3 BIOLOX -,SUP-136-4030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
ARTICUL/EZE BALL 28 +1.5 GR -,SUP-136511000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM ARTICL/EZ 28MMSTDX+8.5MM NK BIOLOX DELTA TS CERM -,SUP-1365-13-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
ARTIUL/EZE BALL 28 +12 BLK -,SUP-136514000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4405.7,3083.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEMORAL BIOLOX DELTA 28MM +5 12/14 TAPER CERAMIC REV -,SUP-1365-28-720,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8563.54,5994.478,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
ARTICUL/EZE BALL 22.225+4 NK -,SUP-136529000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4405.7,3083.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD S-ROM M 36MM +0 -,SUP-136531000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL HEAD M-SPEC METAL 36MM +3 11/13 -,SUP-1365-32-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CERAMIC FEMORAL HEAD 32MM +0 11/13 TAPER -,SUP-1365-32-210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12117,8481.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD BIOLOX DELTA CERAMIC FEMORAL 36MM -,SUP-1365-36-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4487.56,3141.292,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CERAMIC FEMORAL HEAD 40MM X +8.5 BIOLOX DELTA TS 12/14 TAPER -,SUP-1365-40-730,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CERAMIC FEMORAL HEAD 40MM +12 BIOLOX DELTA TS -,SUP-1365-40-740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM ARTICL/EZ 44MM +1.5MM NK COCR 12/14 TAPR CONTR -,SUP-1365-61-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CEMENTRALIZER 11.0 -,SUP-137620000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 22MM BIPLR COCR MODLR -,SUP-138-2200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL HEAD 22MM +3 COCR -,SUP-138-2203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL HEAD COCR 22MM -3 -,SUP-138-2230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM OVATN 28MM +0MML NK COCR 12/14 TAPR STRL -,SUP-138-2800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL HEAD 28MM +9 12/14 TAPER -,SUP-138-2809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEMORAL COCR 28MM -,SUP-138-2830,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM OVATN 36MM +0MML NK COCR 12/14 TAPR -,SUP-138-3600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL HEAD COCR 36MM +6 -,SUP-138-3606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL HEAD COCR 36MM +9 -,SUP-138-3609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM OVATN 36MM-3MM NK COCR 12/14 TAPR -,SUP-138-3630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL HEAD 40MM +3 -,SUP-138-4003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COCR FEMORAL HEAD -,SUP-138-4009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ENDO II TAPER STD 0MM T -,SUP-139247,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FRDM CNSTR 36MM T12/14 -6MM -,SUP-14-107016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7206.31,5044.417,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FRDM CNSTR HD 36MM T 12/14 - 14-107018 -,SUP-14-107018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7206.31,5044.417,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BAR ORTHO INTLOK TI ASCENT MAXIM L/R KN CR PRIM STRL -,SUP-141205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1136.02,795.214,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRAY TIBIAL ILOK PRI 79MM BIOMET -,SUP-141215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL PLATE 67MM -,SUP-141232,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRAY COCR CRUCIATE 71MM CC BIOMET -,SUP-141233,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HIP FINNED PRI 80 X 10MM BIOMET -,SUP-141316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PIN FX STNMN 2MMX6IN SMTH PLN BAYNT PNT FA KN -,SUP-141796,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7206.31,5044.417,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM BMT SPLINED KNEE V2 12 X 40 -,SUP-148287,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM BMT SPLINED KNEE V2 14 X 40 -,SUP-148289,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SPLINED KNEE STEM V2 -,SUP-148291,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM BMT SPLINED KNEE V2 10 X 80 -,SUP-148300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 7MM PRSRVN RM/LL KN -,SUP-1498-11-306,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5824.89,4077.423,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 9.5MM PRSRVN RM/LL KN -,SUP-1498-11-308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5824.89,4077.423,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM OSS CEMENTED IM 9MM X 90MM -,SUP-150358,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9594.39,6716.073,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM OSS CEMENTED IM 12MM X 90MM -,SUP-150361,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9594.39,6716.073,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
OSS CEMENTED IM STEM 13MM X 90MM -,SUP-150362,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9594.39,6716.073,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
OSS CEMENTED IM STEM 13X150 -,SUP-150367,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10426.1,7298.27,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM OSS POUROUS IM 11.5MM X 90MM -,SUP-150382,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ3 ATTUNE LT KN CR CMNT -,SUP-1504-00-103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ9 ATTUNE LT KN CR CMNT -,SUP-1504-00-109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
OSS POROUS IM STEM 12.5 X 225 -,SUP-150402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
OSS POROUS IM STEM 14.5 X 225 -,SUP-150403,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
OSS POROUS IM STEM 18.5 X 225 -,SUP-150405,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
OSS TIBAL POLY BEARING 14MM -,SUP-150411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7469.44,5228.608,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
OSS TIBAL POLY BEARING 18MM -,SUP-150413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7469.44,5228.608,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PLATE OSS NON-MOD TIBAL SHORT 67MM -,SUP-150417,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19307.6,13515.32,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
OSS MOD TIBAL BASEPLATE 71MM -,SUP-150422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20436.35,14305.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BLOCK OSS TIB 20 X 63/67 MR/LL -,SUP-150429,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BLOCK OSS TIB 20 X 63/67 MR/LR -,SUP-150430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
REVISION CRS FEMORAL SZ 7 LEFT CEMENTED -,SUP-1504-40-107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24255.17,16978.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
OSS FINN MOD PROX FMRL RT 7CM -,SUP-150457,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26939.64,18857.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT OSS LETSON MOD PROX FMRL R 7CM -,SUP-150459,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26939.64,18857.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
OSS 3CM ELLIP DIAPHYSEAL SEG -,SUP-150461,CDM,C1776,HCPCS,278,RC,,,outpatient,,,35466.58,24826.606,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
OSS POLY TIBIAL BUSHING -,SUP-150476,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2501.84,1751.288,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
OSS POLY FEMORAL BUSHINGS 2PK -,SUP-150477,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1738.56,1216.992,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
OSS AXLE -,SUP-150480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3399.09,2379.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
OSS REINFORCED YOKE -,SUP-150493,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6994.11,4895.877,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL BASE FIXED BEARING -,SUP-1506-40-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12048.69,8434.083,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASE TIBIAL REV RP SIZE 4 CEM -,SUP-1506-60-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18338.51,12836.957,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIA SLV M/L ATUNE 29MM FULL POR -,SUP-1511-11-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13490.44,9443.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
REVISED CEMENTED SYSTEM -,SUP-1512-14-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4423.31,3096.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM PRESSFIT STR ATUNE 16 X 60MM -,SUP-1513-16-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.93,4893.651,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 6MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-306,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5 10MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ6 6MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ9 7MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-907,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT FIXED BEARING POSTERIOR STABILIZED -,SUP-1516-40-412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBAL INSERT FIXED BEARING POST STAB 7X10MM -,SUP-1516-40-710,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT PS RP SZ 5 ATTUNE 16MM -,SUP-1516-50-516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 41MM ATTUNE MDL DOME -,SUP-1518-20-041,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2364.02,1654.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUG TIBIL UNIV ATUE SZ 3/4 X 5MM -,SUP-1523-03-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5835.5,4084.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ1 41MM OFST 120MM PROSTALAC HI OFST 26MM LEG COCR -,SUP-1541-06-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19493.25,13645.275,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CUP ACTB PROSTALAC CMNT PE 32X42MM -,SUP-1541-42-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3762.63,2633.841,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
OXFORD PARTIAL KNEE SYM FIXED LATERAL TIBIAL LEFT -,SUP-154335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FIXED LATERAL TIBIAL COSTRUCT LEFT  (E3) -,SUP-154340,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
OXF FIX LAT BRG E4 LEFT -,SUP-154341,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
OXF FIX LAT BRG B3 RIGHT -,SUP-154355,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
OXFORD FIX LAT BRG E5 RIGHT -,SUP-154372,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
OXFORD FIX LAT BRG F3 RIGHT -,SUP-154375,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SM OXFORD KN UNICMPT COCR -,SUP-154600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM MED OXFORD KN UNICMPT COCR -,SUP-154601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9586.97,6710.879,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
REVISION DISTAL FEMORAL AUGMENT SZ 7X4MM CEMENTED -,SUP-1547-07-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5135.24,3594.668,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ A LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154718,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ A R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ B LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154720,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ B R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154721,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ-C LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154722,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ-C L/M PMA ARTC OXFORD TI NIOBM NTRD CTD UHMWP -,SUP-154722,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ-C R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154723,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ-D LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154724,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ-D R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154725,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ-E R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154727,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
REVISION POSTERIOR FEMORAL AUGMENT SZ 7X4MM -,SUP-1549-07-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5135.24,3594.668,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SUMMIT BASIC CEMENTED SZ 6 -,SUP-157006120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ4 OFST 12/14 TAPR W/ POROCOAT -,SUP-1570-11-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL STEM 12/14 TAPER / SZ 5 / 145MM -,SUP-1570-11-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ6 12/14 TAPER W/ PORCOAT -,SUP-1570-11-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL STEM 12/14 TAPER SZ7X155MM -,SUP-1570-11-135,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB XS OXFORD UNICMPT ANTMC BEAR LT FEM MNSCL KN -,SUP-159530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
OXFORD KNEED RIGHT MEDIAL TIBIAL TRAY SZAA -,SUP-159532,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SM SZ4 PMA OXFORD UNICMPT ANTMC BRG LT MNSCL -,SUP-159541,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SM 5MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159542,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SM 6MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159543,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SM 9MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159546,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB MED 3MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159547,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB MED 4MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159548,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB MED 6MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159550,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB LRG 3MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159554,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB LRG 6MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159557,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB XL 4MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159562,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB XL 5MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159563,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SM 3MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159568,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SM 6MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159571,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SM 7MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159572,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SM 8MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159573,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SM 9MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159574,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB MED 3MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159575,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB MED 4MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159576,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
OXF ANAT BRG RT MD SZ 5 PMA -,SUP-159577,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB MED 6MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159578,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB MED 7MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159579,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB MED 8MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159580,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB LRG 3MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159582,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB LRG 4MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159583,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB LRG 5MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159584,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB LRG 6MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159585,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB XL 3MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL KN -,SUP-159589,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB XL 4MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL KN -,SUP-159590,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB XS 4MM OXFORD UNICMPT ANTMC ARTC BEAR LT MNSCL KN -,SUP-159791,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ5 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-05132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ6 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD. -,SUP-1601-06127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ6 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-06132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ7 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD. -,SUP-1601-07127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ7 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-07132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ8 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD. -,SUP-1601-08127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ8 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-08132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8806.3,6164.41,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ9 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-09127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HIP STEM SZ.9 34MM 142MM V40 -,SUP-1601-09132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HIP STEM SZ.10 34MM / 148MM -,SUP-1601-10132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ11 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-11132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB XS 4MM OXFORD UNIV ANTMC ARTC BEAR RT KN -,SUP-160791,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
OSS 3CM PROXIMAL TIBIAL SLEEVE -,SUP-161000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13099.46,9169.622,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
OSS RS 3 CM RESURF FMRL-LT -,SUP-161006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26742.28,18719.596,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
OSS RS 7 CM MOD SEG FMRL-RT -,SUP-161011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28518.52,19962.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE OSS RS 3 CM PROX TIBIAL -,SUP-161023,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13663.84,9564.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BUSHING OSS RS POLY FEM SET/2 -,SUP-161034,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3131.74,2192.218,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AXLE OSS RS -,SUP-161035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3399.09,2379.363,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SEGMENT OSS 3CM LG ELLIPT DIAPH -,SUP-161079,CDM,C1776,HCPCS,278,RC,,,outpatient,,,35466.58,24826.606,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
MOD BEARING TIBIAL OSS RS 63MM -,SUP-161088,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21683.92,15178.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BEARING TIBIAL OSS RS 12MM LS -,SUP-161094,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BEARING TIBIAL OSS RS 16MM LS -,SUP-161096,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BEARING TIBIAL OSS RS 18MM LS -,SUP-161097,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT LT SZ 2 FEMORAL PS NONPOROUS -,SUP-161-1201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL PS RIGHT SZ 2 NON-POROUS -,SUP-161-1202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SEG OSS RS 8.5CM FMRL LEFT -,SUP-161124,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29722.42,20805.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ3 BAL KN LT PS NPOR -,SUP-161-1301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ3 BAL KN RT KN PS NPOR -,SUP-161-1302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ4 BAL KN LT KN PS NPOR -,SUP-161-1401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ4 BAL KN RT KN PS NPOR -,SUP-161-1402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT FEMORAL BALANCED KNEE COCR NONPOROUS 4N KNEE LEFT -,SUP-161-1405,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL PS NARROW RIGHT SZ 4 NON-POROUS -,SUP-161-1406,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 BAL KN LT KN PS NPOR -,SUP-161-1501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 BAL KN RT KN PS NPOR -,SUP-161-1502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL PS NARROW LEFT SZ 5 NON-POROUS -,SUP-161-1505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL PS NARROW RIGHT SZ 5 NON-POROUS -,SUP-161-1506,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ6 BAL KN LT KN PS NPOR -,SUP-161-1601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ6 BAL KN RT KN PS NPOR -,SUP-161-1602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ7 BAL KN LT KN PS NPOR -,SUP-161-1701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ7 BAL KN RT KN PS NPOR -,SUP-161-1702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
RT SIZE 2 FEMORAL CR NONPOROUS -,SUP-161-3202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ4 BAL KN LT KN CR NPOR -,SUP-161-3401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 BAL KN LT KN CR NPOR -,SUP-161-3501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 BAL KN RT KN CR NPOR -,SUP-161-3502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ6 BAL KN LT KN CR NPOR -,SUP-161-3601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ6 BAL KN RT KN CR NPOR -,SUP-161-3602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM XS OXFORD KN TWN PG PRT CMNT COCR MLYBDNM ALY -,SUP-161467,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SM OXFORD KN TWN PG PRT CMNT COCR MLYBDNM ALY -,SUP-161468,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM MED OXFORD KN TWN PG PRT CMNT COCR MLYBDNM ALY -,SUP-161469,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TWIN PEGGED FEMORAL LRG KNEE -,SUP-161470,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ2 BAL KN NPOR -,SUP-162-1200A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ3 BAL KN NPOR -,SUP-162-1300A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ4 BAL KN NPOR -,SUP-162-1400A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ5 BAL KN NPOR -,SUP-162-1500A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ6 BAL KN NPOR -,SUP-162-1600A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL TRAY NONPOROUS SIZE 7 -,SUP-162-1700A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 11MM PS KN -,SUP-163-1311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5 8MM PS KN -,SUP-163-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5 13MM PS KN -,SUP-163-1513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ6 12MM PS KN -,SUP-163-1612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ2 13MM UL CONG KN -,SUP-163-3213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 11MM UL CONG KN -,SUP-163-3311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 16MM UL CONG KN -,SUP-163-3316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ4 9MM UL CONG KN PE -,SUP-163-3409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5 14MM UL CONG KN -,SUP-163-3514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2726.14,1908.298,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ6 10MM UL CONG KN -,SUP-163-3610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ6 11MM UL CONG KN -,SUP-163-3611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ6 14MM UL CONG KN -,SUP-163-3614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
MODULAR HEAD COMPONENT 32MM DIA HD 3MM NK -,SUP-163661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
28MM DIA COCR MOD HD -,SUP-163665,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
MODULAR HEAD COMPONENT 32MM -,SUP-163674,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PATELLA  29MM VITAMIN 3 -,SUP-164-5029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PATELLA 32MM VITAMIN E -,SUP-164-5032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PATELLA 35MM VITAMIN E -,SUP-164-5035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PATELLA 38MM VITAMIN E -,SUP-164-5038,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
41MM PATELLA VITAMIN E -,SUP-164-5041,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL PS RIGHT SZ 4 NON-POROUS -,SUP-165-1402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL CR LEFT SZ 6 NON-POROUS -,SUP-165-3601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT PS SIZE 2 7MM VITAMIN E -,SUP-166-5207,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT BKS E-VITALIZE 9MM SZ 2 -,SUP-166-5209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT PS TIBIAL 10MM SIZE 2 V -,SUP-166-5210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT PS TIBIAL SIZE 2 11MM VITAMIN E -,SUP-166-5211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT PS VITAMIN E SIZE 2 12MM -,SUP-166-5212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT PS TIBIAL SIZE 3 7MM VITAMIN E -,SUP-166-5307,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL PS SIZE 3 8MM VITAMIN E -,SUP-166-5308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SIZE 3 9MM TIBIAL INSERT PS VITAMIN E -,SUP-166-5309,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT PS TIBIAL 10MM SIZE 3 V -,SUP-166-5310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL PS SIZE 3 10MM VITAMIN E -,SUP-166-5310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL PS 11MM SIZE 3 V -,SUP-166-5311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL PS 12MM SIZE 3 V -,SUP-166-5312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL PS 13MM SIZE 3 V -,SUP-166-5313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT PS TIBIAL 14MM SIZE 3 V -,SUP-166-5314,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL PS 16MM SIZE 3 V -,SUP-166-5316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SIZE 3 18MM VIT E -,SUP-166-5318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SIZE 3 20MM -,SUP-166-5320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT PS VITAMIN E SZ4 7MM -,SUP-166-5407,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL PS 8MM SIZE 4 VITAMIN E -,SUP-166-5408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT PS TIBIAL 9MM SIZE 4 HI -,SUP-166-5409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT PS TIBIAL 10MM SIZE 4 V -,SUP-166-5410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL PS SIZE 4 10MM VITAMIN E -,SUP-166-5410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT PS VITAMIN E SZ 4 10MM -,SUP-166-5410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL PS 11MM SIZE 4 V -,SUP-166-5411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL PS 11MM SIZE 4 VITAMIN E -,SUP-166-5411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT PS TIBIAL 12MM SIZE 4 H -,SUP-166-5412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL PS SIZE 4 12MM VITAMIN E -,SUP-166-5412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT PS TIBIAL 13MM SIZE 4 H -,SUP-166-5413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL 14MM SIZE 4 HIGH -,SUP-166-5414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SIZE 4 16MM VIT E -,SUP-166-5416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT PS SIZE 4 18MM -,SUP-166-5418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT PS VIT 3 SIZE 4 20MM -,SUP-166-5420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT PS SIZE 5 7 MM VIT E -,SUP-166-5507,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIIAL PS SIZE 5 8MM VITAMIN E -,SUP-166-5508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT PS SIZE 5 9MM TIBIAL VITAMIN E -,SUP-166-5509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL PS SIZE 5 10MM VITAMIN E -,SUP-166-5510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL PS 10MM SIZE 5 V -,SUP-166-5510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL 11MM PS SIZE 5 HIGH FLEX VITAMIN E -,SUP-166-5511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL NONPOROUS SIZE 5 -,SUP-166-5511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL PS 12MM SIZE 5 V -,SUP-166-5512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL PS SIZE 5 12MM VITAMIN E -,SUP-166-5512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL PS 14MM SIZE 5 H -,SUP-166-5514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SIZE 5 16MM VIT E -,SUP-166-5516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SIZE 5 20MM -,SUP-166-5520,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SIZE 6 7MM -,SUP-166-5607,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SIZE 6 8MM VIT E -,SUP-166-5608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SZ 6 9MM PS -,SUP-166-5609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL PS 10MM SIZE 6 H -,SUP-166-5610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SIZE 6 10MM TIBIAL INSERT PS VITAMIN E -,SUP-166-5610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL PS 11MM SIZE 6 VITAMIN E -,SUP-166-5611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SIZE 6 12MM VIT E -,SUP-166-5612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SIZE6 14MM VITAMIN E -,SUP-166-5614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT PS SZ 6 16MM VITAMN-E -,SUP-166-5616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT INSERT PS SIZE 7 10MM VIT E XLPE -,SUP-166-5710,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT CR SZ 5 10MM VITAMIN E -,SUP-166-6510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SZ 2 12MM VIT E -,SUP-166-7212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT UC SZ 3 9MM VIT-E -,SUP-166-7309,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SIZE 3 11MM VIT E XLPE -,SUP-166-7311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT UC SZ 4 8MM VIT E -,SUP-166-7408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SZ 4 9MM VIT E -,SUP-166-7409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT UC SIZE 4 10MM VIT E -,SUP-166-7410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SIZE 4 11MM VIT E -,SUP-166-7411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SIZE 4 12MM VIT E -,SUP-166-7412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SIZE 4 13MM -,SUP-166-7413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT UC SZ 4 14MM VIT E -,SUP-166-7414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SZ 5 7MM VIT E -,SUP-166-7507,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT UC SZ 5 8MM VITAMIN-E -,SUP-166-7508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL UC SZ 5 9MM E-VITALIZE KNEE -,SUP-166-7509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SIZE 5 10MM VIT E -,SUP-166-7510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT BKS E-VITALIZE 11MM SZ 5 -,SUP-166-7511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT UC SZ 5 12MM VIT-E -,SUP-166-7512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SIZE 5 13MM VITAMIN E -,SUP-166-7513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SIZE 5 14MM VIT E -,SUP-166-7514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT UC SIZE 5 16MM VIT-E -,SUP-166-7516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SIZE 6 10MM VIT E -,SUP-166-7610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SIZE 6 11MM VITAMIN E -,SUP-166-7611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SIZE 6 12MM VIT E -,SUP-166-7612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT UC SIZE 6 13MM VIT E -,SUP-166-7613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SIZE 6 14MM VIT E -,SUP-166-7614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SIZE 7 11MM VIT E -,SUP-166-7711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE HIP UNITRAX V40 UNIPL TI -,SUP-170000E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL THREE HOLE 44MM -,SUP-170-0144,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 48MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0148,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4630.78,3241.546,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 50MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 52MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0152,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 56MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 58MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0158,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 60MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 62MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0162,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ESCALADE 68MM THREE HOLE -,SUP-170-0168,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACETABULAR LEGEND OD50 MM 3 HOLE -,SUP-170-0550,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
POROUS ACET SHELL THREE HOLE 52MM OD -,SUP-170-0552,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
POROUS ACETABULAR SHELL THREE-HOLE 54MM OD -,SUP-170-0554,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
POROUS ACETABULAR SHELL THREE HOLE 56MM OD -,SUP-170-0556,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4630.78,3241.546,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 32MM X 52MM NEUTRAL HXLPE -,SUP-170-3252,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 36MM 52MM SHL ESCALADE +3 NEUT -,SUP-170-3652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 36MM 54MM SHL ESCALADE +1 NEUT -,SUP-170-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 36MM 56MM SHL ESCALADE +0 NEUT -,SUP-170-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 36MM 58MM SHL ESCALADE +0 NEUT -,SUP-170-3658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 36MM 60MM SHL ESCALADE +0 NEUT -,SUP-170-3660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 36X62MM ESCALDE +ODEG NEUT F/T/H ARTHPL -,SUP-170-3662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER +3 NEUTRAL 40 X 56MM HXL -,SUP-170-4056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER NEUTRAL +1 ESCALADE -,SUP-170-4058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 40X60MM ESCALDE +ODEG NEUT F/T/H ARTHPL -,SUP-170-4060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 40X62MM ESCALDE +ODEG NEUT F/T/H ARTHPL -,SUP-170-4062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
ACETABULAR LINER 36 X 52 +3 HOODED HXLPE -,SUP-171-3652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACETABULAR 36 X 54 HOODED -,SUP-171-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 36X56MM ESCALDE +ODEG HD F/T/H ARTHPL -,SUP-171-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER 28MM ID 44MM OD NEUTRAL HXLPE -,SUP-172-2844,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER 32MM ID 46MM OD NEUTRAL HXLPE -,SUP-172-3246,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER 36MM ID 50MM OD NEUTRAL HXLPE -,SUP-172-3650,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER 36MM ID 52MM OD NEUTRAL HXLPE -,SUP-172-3652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER 36MM ID 54MM OD NEUTRAL HXLPE -,SUP-172-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER 36MM ID 56MM OD NEUTRAL HXLPE -,SUP-172-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER 36MM ID 58MM OD NEUTRAL HXLPE -,SUP-172-3658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER 36MM ID 60MM OD NEUTRAL HXLPE -,SUP-172-3660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER 36MM 64-70MM OD NEUTRAL -,SUP-172-3664,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER 40MM ID 56MM OD NEUTRAL HXLPE -,SUP-172-4056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER 40MM ID 58MM OD NEUTRAL HXLPE -,SUP-172-4058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER 40MM ID 60MM OD NEUTRAL HXLPE -,SUP-172-4060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM WITH MICROPOUROUS SUR 14MM X 12MM X 180CM -,SUP-172-918/14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM WITH MICROPOROUS SURGACE 14MM X 16MM L 180MM -,SUP-172-918/16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM WITH MICROPOROUS SURFACE 18MM X 16MM L180MM -,SUP-172-918/18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEMORAL LINK W/MICROPOROUS CEMTLESS 20MM X 18MM X 180MM -,SUP-172-918/20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINK STEM WITH MICROP SUR 14MM X 16MM -,SUP-172-921/16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM WITH MICROPOROUS SURFACE 16 X 18 X 210 -,SUP-172-921/18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINK STEM WITH MICROP SUR 14MM X 11MM X 120MM -,SUP-172-925/14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM WITH MICROPOROUS SURFACE 12.5MM X 16MM L 250MM -,SUP-172-925/16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM MICROPOROUS SURF 14.5MM X 18MM L 250MM CEMENTLESS -,SUP-172-925/18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SPACER PROXIMAL 20MM X 14MM COCRMO -,SUP-172-950/20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1484.14,1038.898,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINK NECK SEGMENT WITHOUT COLLAR CEMLESS 65MM 126CCD -,SUP-172-964/26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
NECK FEMORAL W/O COLLAR CEMENTLESS TILASTAN TI6AI-4V LINK -,SUP-172-964/35,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
NECK SEGMENT WITHOUT COLLAR CEMENTLESS -,SUP-172-965/26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
NECK SEGMENT XXL W/O COLLAR 65MM 12/14MM CEMENTLESS -,SUP-172-984/26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINK NECK SEG XXL WITHOUT COLLAR CEMENLESS 65MM -,SUP-172-984/35,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER 36MM ID 50MM OD HOODED HXLPE -,SUP-173-3650,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER 36MM ID 54MM OD HOODED HXLPE -,SUP-173-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER 36MM ID 56MM OD HOODED -,SUP-173-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER 36MM ID 58MM OD HOODED HXLPE -,SUP-173-3658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM ABC 36X0MM NK ALMN C-TAPR PRIM -,SUP-173600E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
ASCENT ANT STBLZD TIBIAL BEARING 14 X 67 -,SUP-179822,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5551.15,3885.805,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP RESTORIS SZ 3 LEFT MAKO PATELLOFEMORAL COCRMO -,SUP-180403,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT RESTORIS MCK SIZE 4 LEFT PATELLOFEMORAL COCRMO -,SUP-180404,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP RESTORIS MCK PAT/FEM SZ 5 RIGHT COCRMO -,SUP-180415,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT FEMORAL RESTORIS MCK SIZE 1 LM/RL -,SUP-180501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT FEMORAL SZ 3 LM/RL RESTORIS MAKO COCRMO -,SUP-180503,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT FEMORAL SIZE 4 LM/RL RESTORIS MCK COCRMO -,SUP-180504,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT FEMORAL SZ 5 LM/RL RESTORIS MAKO COCRMO -,SUP-180505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT FEMORAL SZ 6 LM/RL RESTORIS MAKO COCRMO -,SUP-180506,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT FEMORAL SZ 1 RM/LL RESTORIS MAKO COCRMO -,SUP-180511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT FEM ONLAY SZ 3 RM/LL RESTORIS MAKO COCRMO -,SUP-180513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT FEMORAL SZ 4 RM/LL RESTORIS MAKO COCRMO -,SUP-180514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT FEMORAL RESTORIS MCK SZ 5 RM/LL COCRMO MAKO -,SUP-180515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT FEMORAL RESTORIS MCK SZ 6 RM/LL COCRMO MAKO -,SUP-180516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT FEM RESTORIS MCK SZ 7 RM/LL COCRMO -,SUP-180517,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIBIAL RESTORIS MCK ONLAY SIZE 2 LM/RL -,SUP-180602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIBIAL RESTORIS SZ 3 LM/RL T/6A/4V ONLAY MAKO -,SUP-180603,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE ONLAY TIBIAL SZ 4 LM/RL T/6A/4V RESTORIS MAKO -,SUP-180604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE ONLAY TIBIAL 5 LM/RL RESTORIS MCK -,SUP-180605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE ONLAY TIBIAL 6 LM/RL RESTORIS MCK -,SUP-180606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE ONLAY TIBIAL SZ 2 RM/LL Ti6AI4V RESTORIS MAKO -,SUP-180612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE ONLAY TIBIAL SIZE 3 RM/LL RESTORIS MCK TI6AI4V -,SUP-180613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE ONLAY TIBIAL SZ 4 RM/LL Ti6AI4V RESTORIS MAKO -,SUP-180614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIBIAL RESTORIS MCK SZ 5 RM/LL ONLAY MAKO TI6AI4V -,SUP-180615,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE ONLAY TIBIAL 6 RM/LL RESTORIS MCK -,SUP-180616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE ONLAY TIBIAL 7 RM/LL RESTORIS MCK TI6A14V -,SUP-180617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIBIAL RESTORIS MCK SZ 8 RM/LL TI6I4V -,SUP-180618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL SIZE 2 UNI X 8MM MAKO X3 ONLAY -,SUP-180732-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL MAKO X3 UNI ONLAY SIZE 2 X 8MM -,SUP-180732-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL MAKO X3 3 X 8 MM KNEE ONLAY -,SUP-180733-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ONLAY TIBIAL SZ 4 X 8MM MAKO X3 UNI -,SUP-180734-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL SIZE 4 X 8MM UNI ONLAY MAKO X3 -,SUP-180734-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL UNI ONLAY SIZE 4 X 9MM THKNS MAKO X3 -,SUP-180734-2,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL ONLAY SZ 5 X 8MM MAKO X3 UNI -,SUP-180735-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL ONLAY SZ 5 X 9MM MAKO X3 UNI -,SUP-180735-2,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ONLAY TIBIAL SZ 6 X 8MM MAKO X3 UNI -,SUP-180736-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL ONLAY SZ 6 X 8MM MAKO X3 UNI -,SUP-180736-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ONLAY TIBIAL SZ 7 X 8MM MAKO X3 UNI -,SUP-180737-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ONLAY TIBIAL MAKO X3 UNI SZ 8 X 8MM THKNS -,SUP-180738-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 28MM +0MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-18-2800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM 55MM VANGRD RT KN CR ANTMC CMNT COCR NPOR INTLOK -,SUP-183000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM 62.5MM VANGRD RT KN CR ANTMC CMNT COCR NPOR INTLOK -,SUP-183006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMUR CR INTERLOCK RIGHT 65MM VANGUARD -,SUP-183008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
VANGUARD CR ILOK FEM-LT 62.5 -,SUP-183026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM 57.5MM VANGRD LT KN CR ANTMC CMNTLS TI POR -,SUP-183062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM 62.5MM VANGRD LT KN CR ANTMC CMNTLS TI POR -,SUP-183066,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM 70MM VANGRD LT KN CR ANTMC CMNTLS TI POR -,SUP-183072,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM 57.5MM VANGRD RT FEM OPN BX CMNT COCR -,SUP-183102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM 60MM VANGRD RT KN PS OPN BX CMNT COCR NPOR INTLOK -,SUP-183104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PS OPEN BOX FEMORAL - LEFT 62.5MM -,SUP-183126,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PLATE VN PS OPEN INTL FEM-LT 70 -,SUP-183132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 32MM +0MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 32MM +5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB 10X63/67MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-183520,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB 16X63/67MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-183526,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 36MM +0MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 36MM +5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB 12X63/67MM VANGRD PS MODULAR ARTC BEAR 0DG SLP KN -,SUP-183622,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 36MM -5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-18365,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 36MM +7.5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183675,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL BEARING 14MM X 63/67 MM -,SUP-183724,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BRIDGE VANGUARD PS+TIB 20 X63/67MM -,SUP-183730,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL BEARING 14MM X 71/75MM -,SUP-183744,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BRIDGE VNGD PS+TIB 24 X79/83MM -,SUP-183774,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
VNGD SSK PSC TIB BRG 20 X 71/75 -,SUP-183890,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9735.49,6814.843,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 31MM STD 8MM TI SS UNMWPE PEGX3 VANGRD -,SUP-184764,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SERIES A ASYMMETRIC PAT 31X8 -,SUP-184792,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SERIES-A ASYMMETRICAL PATELLA 31MM / 8MM -,SUP-184792,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SERIES A ASYMMETRIC PAT 34X8.5 -,SUP-184793,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
DRILL HEADLESS TROCAR PIN 75MM -,SUP-185086,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9557.26,6690.082,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL TRAY WITH TI LCK BAR AND SCREW -,SUP-185203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11606.84,8124.788,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
OFFSET ADAPTER WITH SCREWS -,SUP-185210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4611.68,3228.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
ADAPTER OFFSET BMT 360 TIB 6.0 -,SUP-185211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4611.68,3228.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT BMT 360 TIBIAL 7 X 5MM -,SUP-185223,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5321.98,3725.386,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT BMT 360 TIBIAL 71 X 15MM RL/LM -,SUP-185243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5321.98,3725.386,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT BMT 360 TIBIAL 71 X 15MM LL/RM -,SUP-185253,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5321.98,3725.386,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
VNGD SSK 360 L FEMORAL R 67.5 -,SUP-185265,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29741.13,20818.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
VNGD SSK 360 L FEMORAL 65MM -,SUP-185284,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29741.13,20818.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT VG 360 DIST FM 67.5 X 5 RL/LM -,SUP-185305,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT VG 360 DIST FM 67.5 X 5 LL/RM -,SUP-185325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT VG 360 UNIV PST FM 65 X 10 -,SUP-185424,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT VG 360 UNIV PST FM 67.5 X 10 -,SUP-185425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
WING BMT 360 TIBIAL SM CRUCIATE -,SUP-185650,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
VANGUARD ANT STBLZD BRG 12X67 -,SUP-189042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BRIDGE VANGUARD ANT STBLZD 14 X 67 -,SUP-189044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BRIDGE ANT TIBIAL STABILIZED10 X 71MM VANGD -,SUP-189060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE HIP UNIV TRIDENT PRIM ADPTR +0MML NK OFST BIOLOX -,SUP-19-0000T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
ADAPTER UNIV C-TAPER +5MM SLEE -,SUP-19-0005T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
UNIVERSAL C-TAPER +2.5MM ADAPTER SLEEVE -,SUP-19-0025T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
UNITED HIP SYSTEM ISCHIAL FLANGE -,SUP-1908-5401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6459.37,4521.559,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM ECHO POR FEMORAL LAT NC 28 X 44MM -,SUP-192114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BOLT LOCKING CONICAL PROX BODY CEMENTLESS 24 X 95 -,SUP-1975-24-095,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17895.36,12526.752,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM DISTAL TAPERED 15 X 190 STRAIGHT -,SUP-1976-15-190,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15238.52,10666.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ7 FNDTN LT KN CR TI NPOR -,SUP-201-01-107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 LONGEVITY NEUTRIAL 32MM C -,SUP-20103203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 LONGEVITY NEUTRIAL 32MM D -,SUP-20103204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3174.71,2222.297,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL G7 LONGEVITY NEUTRIAL 32MM D -,SUP-20103204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 LONGEVITY NEUTRIAL 32MM E -,SUP-20103205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 LONGEVITY NEUTRAL 36MM D -,SUP-20103604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 LONGEVITY NEUTRAL 36MM E -,SUP-20103605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 LONGEVITY NEUTRAL 36MM F -,SUP-20103606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 LONGEVITY NEUTRAL 36MM G -,SUP-20103607,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 LONGEVITY NEUTRAL 40MM F -,SUP-20104006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 LONGEVITY NEUTRAL 40MM G -,SUP-20104007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 FNDTN RT KN CR TI NPOR -,SUP-202-01-105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ7 FNDTN RT KN CR TI NPOR -,SUP-202-01-107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 28X58-60MM SHL OMNIFIT 10DG CROSSFIRE 13.1MM -,SUP-2041C-2858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4587.76,3211.432,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT OMNIFIT SERIES II 20 DEGREE 32MM -,SUP-2042-3250,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3800.96,2660.672,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
JIG TOT JNT RT TIB KN PERSONA ROT -,SUP-20-8070-002-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
JIG TOT JNT LT KN PERSONA PREF -,SUP-20-8070-010-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
GW ORTHO TM PT SPEC INST -,SUP-20-8075-001-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 28X58MM OSTEONICS 0DG BIPLR PE 5.8-10.4MM THK -,SUP-2099-2858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9662.67,6763.869,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR KNEE SYS FEMORAL COMPONENT HINGED #3 LEFT -,SUP-2115-1330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR II KNEE SYSTEM FEMORAL COMPONENT HINGED #4 LEFT -,SUP-2115-1340,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR KNEE FEMORAL COMPONENT HINGED #5 LEFT -,SUP-2115-1350,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
UNITED II KNEE FEMORAL COMPONENT HINGED #6 HINGED -,SUP-2115-1360,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
URSTAR II KNEE SYSTEM FEMORAL COMPONENT HINGED #3 RIGHT -,SUP-2115-1430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR II KNEE FEMORAL COMPONENT HINGED #5 RIGHT -,SUP-2115-1450,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR II KNEE DISTAL FEMORAL COMPONENT RHS S LEFT -,SUP-2115-3310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30242.39,21169.673,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR II KNEE DISTAL FEMORAL COMP RHS S RIGHT -,SUP-2115-3410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30242.39,21169.673,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ4 FNDTN LT KN PS TI NPOR -,SUP-213-01-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ8 FNDTN LT KN PS TI NPOR -,SUP-213-01-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ8 FNDTN RT KN PS TI NPOR -,SUP-214-01-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ12 FNDTN RT KN PS TI NPOR -,SUP-214-01-012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
IMPLANT  CUSTOM PFR KINEMATCH -,SUP-22-100-1001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19864.55,13905.185,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR II TIBIAL BASEPLATE HINGED #1 -,SUP-2215-1410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIBIAL USTAR II HINGED 2 KNEE -,SUP-2215-1420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIBIAL SYSTEM USTAR II HINGED 3 -,SUP-2215-1430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIBIAL USTAR II HINGED 4 KNEE -,SUP-2215-1440,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT TIBIAL USTAR II KNEE PROXIMAL RHS S -,SUP-2215-3410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,34950.47,24465.329,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL KNEE USTAR II XPE SMALL 12MM -,SUP-2315-3211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL USTAR II KNEE XPE S 14MM -,SUP-2315-3212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL USTAR II KNEE XPE S 17MM -,SUP-2315-3213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL USTAR II XPE H20 SMALL 20MM -,SUP-2315-3214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR II KNEE XPE TIBIAL INSERT M 17MM -,SUP-2315-3243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR II KNEE XPE TIBIAL INSERT M 20MM -,SUP-2315-3244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL USTAR II KNEW XPE M 23MM -,SUP-2315-3245,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT FEMORAL U2 PSA COCR 5 4MM POSTERIOR SET -,SUP-2603-5051,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5852.48,4096.736,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AGUMENT FEMORAL U2 TOTAL KNEE SET DISTAL #5 12MM -,SUP-2603-5353,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5852.48,4096.736,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEADED PIN 17-4 PH S.S. -,SUP-262-0520A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PS Insert Trial Size 2  14mm -,SUP-263-1214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 40X17MM COCR -,SUP-265 108,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9253.24,6477.268,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
U2 TOTAL KNEE STRAIGHT STEM PSA 14MM X 75MM -,SUP-2703-5013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TIBIAL U2 PSA TI STRAIGHT 16MM X 75MM KNEE -,SUP-2703-5014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
U2 TOTAL KNEE SYSTEM STRAIGHT STEM PSA 22MM DIA 75MM STEM -,SUP-2703-5017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
U2 TOTAL  KNEE STRAIGHT STEM PSA 24MM DIA 75MM STEM LENGTH -,SUP-2703-5018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
U2 TOTAL KNEE STRAIGHT STEM PSA 12MM DIA 100MM STEM LENGTH -,SUP-2703-5022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TIBIAL U2 PSA STRAIGHT 20MM X 150MM TOTAL KNEE -,SUP-2703-5056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR II KNEE CEMENTED STRT STEM RHS NON COAT 9 X 100 -,SUP-2715-3009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR II KNEE SYS CEMENTED STR STEM RHS NON-COAT 11X100 -,SUP-2715-3011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR II KNEE CEMENTED STRAIGHT STEM RHS NON COATED 13 X 100 -,SUP-2715-3013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR II KNEE CEMENTED STRT STEM RHS NON COATED 15 X 100 -,SUP-2715-3015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR II KNEE CEMENTED STRAIGHT STEM RHS NON COAT 17X100 -,SUP-2715-3017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CEMENTED STRAIGHT STEM RHS COLLARLESS 9 X 125MM -,SUP-2715-3109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR II KNEE CEMENTED STRAIGHT STEM RHS NON COATED 11X125 -,SUP-2715-3111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR CEMENTED STRAIGHT STEM RHS NON COATED 13 X 125MM -,SUP-2715-3113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
KNEE SYSTEM CEMENTED STRAIGHT STEM RHS NON COATED 15 X 125MM -,SUP-2715-3115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR II KEE CEMENTED TIBIAL STEM 9MM X 20MM STEM LENG -,SUP-2715-5109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR II KNEE CEMENTED TIBIAL STEM 9MM X 45MM STEM -,SUP-2715-5209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TIBIAL USTAR II 9MM X 95MM KNEE CEMENT -,SUP-2715-5409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR II KNEE TIBIAL STEM 12.5MM X 70MM -,SUP-2715-7312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR II KNEE TIBIAL AUGMENT #2 10MM THICK -,SUP-2815-1022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5215.88,3651.116,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR SEGMENT PART RHS 50MM LENGTH -,SUP-2915-1050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22014.38,15410.066,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR II KNEE SEGMENT PART RHS 70MM LENGTH -,SUP-2915-1070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22014.38,15410.066,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 11MM 8.5MM MDL OFST PRIM PRFT EQUINOXE 110MM TI ALY -,SUP-300-01-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 15MM 9.5MM MDL OFST PRIM PRFT EQUINOXE 120MM TI ALY -,SUP-300-01-15,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PLATE BN EQUINOXE F/RVRS SYS ANTMC REPLICATOR TI ALY 4.5MM -,SUP-300-10-45,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4686.87,3280.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER G7 VIT E NEUTRAL 36MM E -,SUP-30103605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER G7 VIT E NEUTRAL 36MM F -,SUP-30103606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 VIT E HIGH WALL LNR 36MM D -,SUP-30123604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER G7 VIT E HIGH WALL 36MM F -,SUP-30123606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER G7 VIT E HIGH WALL 40MM H -,SUP-30124008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER G7 VIT E +5MM 40MM H -,SUP-30154008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8963.33,6274.331,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 47MM SHRT 18MM EQUINOXE 1.5MM OFST COCR -,SUP-310-01-47,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7808.96,5466.272,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 53MM SHRT EQUINOXE -,SUP-310-21-53,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6472.1,4530.47,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP B MED EQUINOXE SHLDR PG -,SUP-314-02-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4010.16,2807.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SPHERE GLND 38MM EQUINOXE RVRS -,SUP-320-01-38,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRY ADAPTER HUM WDG +0MM RVRS BALL SCKT EQUINOXE -,SUP-320-10-00,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 10MM FNDTN MODULAR REVISN 100MM TIB KN -,SUP-320-10-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER HUM 38MM STD EQUINOXE -,SUP-320-38-00,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4559.17,3191.419,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER HUM 38MM STD RVRS EQUINOXE -,SUP-320-38-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4559.17,3191.419,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BLOCK CUT SZ4 10MM RM/LL FNDTN KN REVISN F/SPCR -,SUP-321-101-04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ4 RT KN STM FNDTN REVISN MODULAR NPOR -,SUP-322-01-104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BLOCK CUT SZ4 5MM RL/LM FNDTN KN REVISN F/SPCR -,SUP-322-05-104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BLOCK CUT SZ4 10MM RL/LM FNDTN KN REVISN F/SPCR -,SUP-322-10-104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ2 10.9MM FNDTN PS ARTC CONGR KN COMPR MLD -,SUP-360-09-510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ2 11MM FNDTN PS ARTC CONGR KN COMPR MLD UHMWPE -,SUP-360-11-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ2 13MM FNDTN PS ARTC CONGR KN COMPR MLD UHMWPE -,SUP-360-13-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB 4MM AXSOS LCK -,SUP-370002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,240.4,168.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ORTHO 14X8.5MM DIA FEM LCK 5MM HL AXSOS NS -,SUP-370003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,274.83,192.381,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ2 13MM FNDTN CR PRIM CNSTRN ARTC CONGR L/R KN -,SUP-385-13-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CENTRALIZER DIST HIP TI ALY -,SUP-400-03-002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 36MM +4MM NK BIOLOX DELTA CERM -,SUP-400-03-363,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4487.56,3141.292,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM BIOLOX DELTA 40MM NEUT CERM -,SUP-400-03-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP REV SHLDER 9 IN STEINMANN -,SUP-405800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SEASPINE TULIP HEADS -,SUP-41-1000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE HIP NEUT OFST UNIPL ANG -,SUP-411-00-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 46MM UNIPL -,SUP-411-00-146,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PLUG SMALL DIA CEMENT 8MM -,SUP-414993,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
KT THR SZ3 FEM 3 TIB RT HIP TRUMATCH -,SUP-420859,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
KT TKR LT HIPERF 3T/3F -,SUP-420878,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
KT TKR RT HIPERF -,SUP-420890,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMUR PERSONA CEMENTED CCR NARROW SIZE 5 R -,SUP-42500005802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMUR PERSONA CEMENTED NARROW PS LT SZ 6 -,SUP-42500006001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMUR PERSONA CEMENTED CCR NARROW SIZE 8 R -,SUP-42-5000-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT PSN FEM PS CMT CCR SZ 7 R STD -,SUP-42-5006-062-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT PSN FEM PS CCR STD SIZE 10 L -,SUP-42500606801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ3 PERSONA RT KN CR CMNT COCR NRW -,SUP-42-5020-054-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ6 PERSONA LT KN CR CMNT COCR NRW -,SUP-42-5020-060-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ7 PERSONA LT KN CR CMNT COCR NRW -,SUP-42-5020-062-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ7 PERSONA RT KN CR CMNT COCR NRW -,SUP-42-5020-062-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMUR PERSONA CEMENTED CR NARROW RT SZ 9 -,SUP-42502006602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMUR PERSONA CEMENTED KNEE CR   RT SZ10 -,SUP-42-5020-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 PERSONA LT KN CR CMNT COCR POR NRW -,SUP-42-5022-058-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ6 PERSONA LT KN CR CMNT COCR POR NRW -,SUP-42-5022-060-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMUR FEMORAL CR POR CCR NRW SIZE 6 RIGHT PERSONA -,SUP-42-5022-060-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ7 PERSONA RT KN CR CMNT COCR POR NRW -,SUP-42-5022-062-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PSN FEM SZ 10 R CR CCR POR NRW -,SUP-42-5022-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ6 LEFT PERSONA KN CR STD CMNT CCR -,SUP-42-5026-060-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PERSONA FEMUR CMNT STD CCR SIZE 7 RIGHT -,SUP-42502606202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ8 PERSONA LT KN CR STD CMNT COCR NRW -,SUP-42-5026-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ8 RIGHT PERSONA KN CR STD CMNT COCR -,SUP-42-5026-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ10 PERSONA RT KN CR STD CMNT COCR NRW -,SUP-42-5026-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PSN FEM CR POR CCR STD SZ7 L -,SUP-42-5028-062-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ8 PERSONA LT KN CR STD COCR POR -,SUP-42-5028-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ8 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ9 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-066-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PERSONA KNEE SYSTEM FEMUR -,SUP-42-5028-068-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ10 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ11 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-070-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ12 R PERSONA RT KN CCR STD COCR POR -,SUP-42-5028-074-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PSN REV FEM CMT CCR STD SZ 5 R -,SUP-42-5046-058-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,33973.95,23781.765,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PSN REV FEM CMT CCR STD SZ 9 L -,SUP-42-5046-066-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,31746.15,22222.305,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PSN ASF CR 12MM PLY L 3-11 EF -,SUP-42-5110-005-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ8 139MM LNR PRFT LAT OFST CLLRLS 47.4MM NK TI POR -,SUP-425-11-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ13 148.5MM LNR PRFT LAT OFST CLLRLS 49.8MM NK TI -,SUP-425-11-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SYS PERSONA KNEE ASF UC 18MM PLY L-4-11 EF -,SUP-42-5112-005-18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PERSONA KNEE SYSTEM ARTICULAR SURFACE -,SUP-42-5112-006-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ C-D/3-9 10MM PERSONA CR ARTCSURF LT KN PE -,SUP-42-5120-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ C-D/3-9 11MM PERSONA CR ARTCSURF LT KN PE -,SUP-42-5120-004-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ C-D/3-9 12MM PERSONA CR ARTCSURF LT KN PE -,SUP-42-5120-004-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ E-F SZ3-11 FEM 10MM PERSONA ARTCSURF LT KN PE -,SUP-42-5120-005-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PSN ASF CR 12MM VE L 3-11EF -,SUP-42-5120-005-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PERSONA ARTICULAR SURFACE LEFT 11MM -,SUP-42-5121-007-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PSN MC VE ASF L 12MM 12/GH -,SUP-42-5121-010-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ C-D SZ3-7 FEM 12MM PERSONA CR ARTCSURF LT KN -,SUP-42-5122-004-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SURFACE ARTICULAR PERSONA VIVACIT-E 3-7 UC C-D 10MM KNEE LFT -,SUP-42512200410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PERSONA ARTICULAR FIXED BEARING LEFT 16MM -,SUP-42512200516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PERSONA ARTICULAR SURFACE 10MM -,SUP-42-5122-006-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
ARTICULAR SURFACE PERSONA LT 16MM -,SUP-42512600516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PSN ASF CPS 14MM VE L 6-9 GH -,SUP-42-5126-009-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PSN PK VE PLY- LM- SZ E- 8MM -,SUP-42-5182-005-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ7 PERSONA LT KN CR STD COCR POR -,SUP-42-5208-062-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PSN FEMORALASF UC 10MM POLY R 4-11 EF -,SUP-42-5212-00-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BEARING FIXED ASF UC 12MM PLY 3-7CD PERSONA -,SUP-42-5212-004-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BEARING FIXED ASF UC 12MM PLY R 4-11 EF PERSONA -,SUP-42-5212-005-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BEARING PSN ASF UC 10MM PLY R 7-12 GH -,SUP-42521200610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PSN ASF UC 12MM PLY R 7-12 GH -,SUP-42-5212-006-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ C-D SZ3-9 FEM 10MM PERSONA CR ARTCSURF RT KN -,SUP-42-5220-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ C-D/3-9 11MM PERSONA CR ARTCSURF RT KN PE -,SUP-42-5220-004-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ E-F/3-11 11MM PERSONA CR ARTCSURF RT KN PE -,SUP-42-5220-005-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SURFACE ARTICULAR 10MM HEIGHT RIGHT -,SUP-42-5221-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
ARTICULAR SURFACE PERSONA MC VE RT 13MM -,SUP-42522100513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
ARTICULAR SURFACE PERSONA MC RT 10MM -,SUP-42522100810,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
ARTICULAR SURFACE RIGHT 10MM /SIZES E-F/CR 8-11 -,SUP-42-5221-008-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
ARTICULAR SURFACE PERSONA MC RT 11MM -,SUP-42-5221-008-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SURFACE ARTICULAR PERSONA RIGHT 10MM X 12/GH MC VE ASF -,SUP-42-5221-010-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ C-D/3-7 10MM PERSONA ARTCSURF UL CONG RT KN PE -,SUP-42-5222-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ E-F 10MM PERSONA UL CONG ARTCSURF RT KN PE -,SUP-42-5222-005-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HIGHLY CROSSLINKED POLY ARTICULAR FIXED BEARING -,SUP-42-5222-005-18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
VIVICIT-E PERSONA ASF UC 11MM 7 - 12GH -,SUP-42-5222-006-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CD PERSONA ASF PS 16MM VE R 3-5 -,SUP-42522400416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL PSN ASF PS 13MM VE R 6-9 CD -,SUP-42-5224-005-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PSN ASF CPS 14MM VE R 3-5CD -,SUP-42-5226-004-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PERSONA HIGHLY CROSSLINKED POLY 6-9EF VE R -,SUP-42-5226-007-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PERSONA HIGHLY CROSSLINKED POLYETHLENE 6-9EF -,SUP-42-5226-007-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PSN REV CCK ART SURF VE 12MM R 7-9+ CD -,SUP-42522800512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIB SZ-C PERSONA PEGX2 LT KN POR TM -,SUP-42-5300-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIB SZ-D PERSONA PEGX2 RT KN POR TM -,SUP-42-5300-067-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PSN TIB POR 2 PEG SZ E L -,SUP-42-5300-071-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIB SZ-F PERSONA PEGX2 RT KN POR TM -,SUP-42-5300-075-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PSN TIB POR 2 PEG SZ G L -,SUP-42-5300-079-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PSN TIB POR 2 PEG SZ G R -,SUP-42530007902,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PSN TIB POR 2 PEG SZ H R -,SUP-42-5300-083-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TIB SZ-C 5DG PERSONA LT KN -,SUP-42-5320-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM PERSONA ASF 16MM VE 3-5 R CD -,SUP-42532006402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TIB SZ-C 5DG PERSONA RT KN -,SUP-42-5320-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TIB 5DG SZ-D PERSONA LT KN -,SUP-42-5320-067-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TIB SZ-D 5DG PERSONA RT KN -,SUP-42-5320-067-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TIB 5DG SZ-E PERSONA LT KN -,SUP-42-5320-071-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIA PERSONA CEMENTED STEMMED RT SZ E -,SUP-42532007102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
NAT TIBIA CEME 5 DG SIZE F -,SUP-42-5320-075-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TIB SZ-F 5DG PERSONA RT KN -,SUP-42-5320-075-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PSN PK CMT TIB- LM- SZ E -,SUP-42-5380-005-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT PATELLAR PERSONA ALL POLY PAT PLY 41MM -,SUP-42540000041,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
DIA ALL POLY PAT PERSONA  29MM -,SUP-42540200029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 29MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-29,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 32MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-32,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 35MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-35,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 41MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-41,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ8 SHRT TAPR FIL TI POR CTD P-SQUARED HIP -,SUP-425-41-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ15 SHRT TAPR FIL TI POR CTD P-SQUARED HIP -,SUP-425-41-015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
KEEL PSN REV TIB FIXED CMT SIZE C R -,SUP-42-5420-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11361.78,7953.246,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PSN REV TIB FIXED KEEL CMT SZ G L -,SUP-42-5420-079-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11361.78,7953.246,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUG PSN REV FEM DISTAL SZ 5 5MM -,SUP-42-5566-058-05,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5602.08,3921.456,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTENSION PERSONA CEMETED TPRD 14MM X +30MM -,SUP-42557000114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PSN PK CMT FEM- LM- SZ 3 -,SUP-42-5580-003-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PSN PK CMT FEM- RM SZ.4 -,SUP-42558000402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PSN REV TAPERED SMOOTH STEM EXT 14 X 75MM -,SUP-42-5600-075-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8199.41,5739.587,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM PSN REV 6MM OFFSET EXT 10MM X 135MM -,SUP-42-5606-135-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11584.56,8109.192,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMUR PSN CR CMT TIN NRW SIZE 6R -,SUP-42-5720-060-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT FEMORAL PERSONA 7 KNEE -,SUP-42572606201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT PSN FEMORAL TIN STD SIZE 9L -,SUP-42-5726-066-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ8 109MM TAPR FIL PRFT LAT OFST 37MM NK TI POR CTD -,SUP-425-96-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ8 109MM TAPR FIL PRFT LAT OFST 42.5MM NK TI POR -,SUP-425-97-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ9 111MM TAPR FIL PRFT LAT OFST 42.5MM NK TI POR -,SUP-425-97-009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ12 LRG TAPR FIL PRFT LAT OFST TI POR COAT -,SUP-425-97-012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ13 117MM TAPR FIL PRFT LAT OFST 42.5MM NK TI POR -,SUP-425-97-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 13MM STD BGLNI/FLTW 130MM -,SUP-4300-13-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5470.69,3829.483,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 46X21MM BGLNI/FLTW ZML MODULAR OFST -,SUP-4302-46-21,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 48MM POR STRUCTURED TECH HMSPHR -,SUP-430-98-048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM STAGEONE SLCT 56MM SIL MODULAR SPCR STRL -,SUP-431183,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5199.96,3639.972,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
ADAPTER STD STAGEONE CMNT MLD SPCR -,SUP-431186,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1636.53,1145.571,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HIP ADAPTER STD STAGEONE 6MM -,SUP-431188,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1428.48,999.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 15X155MM STG 1 HIP -,SUP-431193,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6510.3,4557.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HIP MOLD STEM W/REINF 13 X 200 -,SUP-431197,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6510.3,4557.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 12MM FNDTN CLLR FRG COCR CMNT 132DG ANG TAPR HIP -,SUP-450-01-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD RADL 26MM 10.5MM EVOLVE PROLINE COCR MODULAR -,SUP-496H026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7999.94,5599.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 28MM SHRT -3.5MM NK COCR MODULAR -,SUP-497-28-035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ-G 62MM RIM TRIDENT PRIM MODULAR HAP CTD -,SUP-500-01-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ-C 48MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-48C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ-D 50MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ-D 52MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-52D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ-E 54MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ-E 56MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-56E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ-F 58MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL SOLID BACK 60MM F -,SUP-500-03-60F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 48MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-5001-48,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ-C 46MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-01-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ-C 48MM RIM TRIDENT PRIM MODULAR CLUS-HL. -,SUP-502-03-48C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 50MM TRIDENT PRIM MODULAR CLUS-HL X3 TRTNM LCK -,SUP-502-03-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ-D 52MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-03-52D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL HEMISPHERICAL 54MM SZ-E RIM CLUSTER HOLE -,SUP-502-03-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ-E 56MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-03-56E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ-D 50MM RIM TRIDENT PRIM.MODULAR CLUS-HL -,SUP-502-03-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ-F 60MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-03-60F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ-D 50MM RIM TRIDENT PRIM MODULAR.CLUS-HL -,SUP-502-11-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
ANATOMIC HEMISPHERICAL SHELL  56MM D RT -,SUP-504-02-56D-R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12514.18,8759.926,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEMISPHERICAL SHELL ANATOMIC RESTORATION -,SUP-504-02-58D-L,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12514.18,8759.926,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEMISPHERICAL SHELL 64MM -,SUP-504-02-64E-R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12514.18,8759.926,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT HUM 4MM 32MM STD PE RVRS SCKT F/RSP STRL -,SUP-508-00-432,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4559.17,3191.419,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL TRIDENT HEMISPHERICAL ACETABULAR 46MM C -,SUP-508-11-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL HEMI ACETABULAR 48MM -,SUP-508-11-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ-D 50MM RIM TRIDENT PRIM MODULAR MUL-HL -,SUP-508-11-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
ACETABULAR SHELL 52MM -,SUP-508-11-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ-E 54MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL HEMISPHERICAL 56MM E TRI -,SUP-509-02-56E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ-F 58MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ-F 60MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-60F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ-G 62MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ-G 64MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-64G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ H LINER 66MM RIM TRIDENT REVISN MUL-HL -,SUP-509-02-66H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ H LINER 68MM RIM TRIDENT REVISN MUL-HL -,SUP-509-02-68H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIDENT TRITANIUM HEMI SHELL SZ 70MM -,SUP-509-02-70I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT ACTB 50MM RESTOR REVISN RECON HIP 15MM -,SUP-5096-5015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT ACTB 50MM RESTOR REVISN RECON HIP 20MM -,SUP-5096-5020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
WEDGE AUGMENT RESTORATION ACET 54MM X 56MM X 15MM -,SUP-5096-5415,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT ACTB 58MM RESTOR REVISN RECON HIP -,SUP-5096-5815,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 6MM PRIM MBLK RVRS RSP 101MM CMNT 150DG ANG NK CYL -,SUP-510-00-006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19030.28,13321.196,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TPRLC 133 FP TYPE 1 PPS SO 5.0 -,SUP-51-100050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TPRLC 133 FP TYPE 1 PPS SO 6.0 -,SUP-51-100060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TPRLC 133 FP TYPE1 PPS SO 7.0 -,SUP-51-100070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TPRLC 133 FP TYPE1 PPS SO 8.0 -,SUP-51-100080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEMORAL TPRLC 133 FP PPS TYPE 1  6.0 H -,SUP-51-101060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TPRLC 133 FP PPS TYPE 1 HO 7.0 -,SUP-51-101070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TPRLC 133 FP PPS TYPE 1 HO 8.0 -,SUP-51-101080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TPRLC XR FP TYPE 1 PPS 5 X 130MM -,SUP-51-102050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TPRLC XR FP TYPE 1 PPS 6 X 132MM -,SUP-51-102060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TPRLC XR FP TYPE 1 PPS 8 X 136MM -,SUP-51-102080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TPRLC 133 TYPE 1 PPS SO 9 X 137MM -,SUP-51-103090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TPRLC 133 TYPE 1 PPS SO 10 X 140MM -,SUP-51-103100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TPRLC 133 TYPE 1 PPS SO 11 X 142MM -,SUP-51-103110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TPRLC 133 T1 PPS SO 12 X 144MM -,SUP-51-103120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TPRLC 133 T1 PPS SO 13 X 146MM -,SUP-51-103130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TPRLC 133 T1 PPS SO 14 X 148MM -,SUP-51-103140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TPRLC 133 TYPE 1 PPS SO 15 X 150MM -,SUP-51-103150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TAPERLOC 133 T1 9 X 137MM -,SUP-51-104090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TPRLC 133 T1 PPS 11 X 142MM -,SUP-51-104110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TPRLC 133 T1 PPS HO 13 X 146MM -,SUP-51-104130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TPRLC TYPE 1 PPS HO 14 X 148MM FEM POR -,SUP-51-104140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TPRLC TYPE 1 PPS HO 15 X 150MM FEM POR -,SUP-51-104150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TPRLC 133 TYPE 1 PPS HO 16 X 152MM -,SUP-51-104160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TAPERLOC 133 T1 PPS HO 20 X 160MM -,SUP-51-104200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TAPERLOC 10 X 140MM COMP XR FEM POR T1 TAPER -,SUP-51-105100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TAPERLOC 11 X 142MM COMP XR 123 FEM POR T1 TAPER -,SUP-51-105110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TPRLC 133 MP TYPE 1 PPS SO 11.0 -,SUP-51-106110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TPRLC 133 MP TYPE1 PPS HO 9.0 -,SUP-51-107090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TPRLC 133 MP TYPE1 PPS HO 14.0 -,SUP-51-107140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TPRLC 133 MP TYPE1 PPS HO 16.0 -,SUP-51-107160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TPRLC 133 MP TYPE1 PPS HO 17.0 -,SUP-51-107170,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TPRL 133 MP TYPE1 PPS SO 4.0 -,SUP-51-108040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TPRLC 133 MP T1 PPS SO 5X95MM -,SUP-51-108050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TPRLC133 MP 6X97.5MM -,SUP-51-108060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TPRLC 133 MP T1 PPS SO 8X101MM -,SUP-51-108080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TLOC 133 MP SP T1 PPSHO 6X97.5 -,SUP-51-109060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TLOC 133 MP SP T1 PPS HO 8X101 -,SUP-51-109080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM S-ROM 28MMSTDX+6MM NK COCR 11/13 TAPR MODULAR -,SUP-52-2029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4824.58,3377.206,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SCREW 2.3X12MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23212E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,342.57,239.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 45X15MM -,SUP-5350-4515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6472.1,4530.47,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 12MM SOLAR 130MM TI SHLDR -,SUP-5351-4108,CDM,C1776,HCPCS,278,RC,,,outpatient,,,33064.27,23144.989,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 40X15MM OFST -,SUP-5352-4015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6472.1,4530.47,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ-D 46MM 47.8MM RIM TRIDENT PSL PRIM MODULAR HAP -,SUP-540-11-46D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ1 TRIATH LT KN CR CMNT -,SUP-5510-F-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ1 TRIATH RT KN CR CMNT -,SUP-5510-F-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ2 TRIATH LT KN CR CMNT -,SUP-5510-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ2 TRIATH RT KN CR CMNT -,SUP-5510-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ3 TRIATH LT KN CR CMNT -,SUP-5510-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ3 TRIATH RT KN CR CMNT -,SUP-5510-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ4 TRIATH LT KN CR CMNT -,SUP-5510-F-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ4 TRIATH RT KN CR CMNT -,SUP-5510-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 TRIATH LT KN CR CMNT -,SUP-5510-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 TRIATH RT KN CR CMNT -,SUP-5510-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ6 TRIATH LT KN CR CMNT -,SUP-5510-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ6 TRIATH RT KN CR CMNT -,SUP-5510-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ7 TRIATH LT KN CR CMNT -,SUP-5510-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ7 TRIATH RT KN CR CMNT -,SUP-5510-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ8 TRIATH LT KN CR CMNT -,SUP-5510-F-801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ1 59/53MM TRIATH RT KN TOTAL STABILIZED REVISN -,SUP-5512-F-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ2 62/56MM TRIATH LT KN TOTAL STABILIZED REVISN -,SUP-5512-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT FEMORAL TOTAL STABILIZER #2 RT TS -,SUP-5512-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ3 65/59MM TRIATH LT KN CRCTE STAB REVISN COCR -,SUP-5512-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ3 65/59MM TRIATH RT KN CRCTE STAB REVISN COCR -,SUP-5512-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ4 68/62MM TRIATH LT KN CRCTE STAB REVISN COCR -,SUP-5512-F-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ4 68/62MM TRIATH RT KN CRCTE STAB REVISN COCR -,SUP-5512-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 71/65MM TRIATH LT KN CRCTE STAB REVISN COCR -,SUP-5512-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 71/65MM TRIATH RT KN CRCTE STAB REVISN COCR -,SUP-5512-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ6 74/68MM TRIATH LT KN TOTAL STABILIZED REVISN -,SUP-5512-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TOTAL STABILIZER COMPONET FEMORAL -,SUP-5512-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ7 77/71MM TRIATH LT KN TOTAL STABILIZED REVISN -,SUP-5512-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STABILIZER TOTAL FEM COMP SZ 7 RIGHT TS TRIATHLON -,SUP-5512-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ8 80/75MM TRIATH RT KN TOTAL STABILIZED REVISN -,SUP-5512-F-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ1 TRIATH LT KN PS CMNT -,SUP-5515-F-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ2 TRIATH LT KN PS CMNT -,SUP-5515-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ2 TRIATH RT KN PS CMNT -,SUP-5515-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ3 TRIATH LT KN PS CMNT -,SUP-5515-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ3 TRIATH RT KN PS CMNT -,SUP-5515-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ4 TRIATH RT KN PS CMNT -,SUP-5515-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 TRIATH LT KN PS CMNT -,SUP-5515-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 TRIATH RT KN PS CMNT -,SUP-5515-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ6 TRIATH LT KN PS CMNT -,SUP-5515-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ6 TRIATH RT KN PS CMNT -,SUP-5515-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ7 TRIATH LT KN PS CMNT -,SUP-5515-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ7 TRIATH RT KN PS CMNT -,SUP-5515-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIATHLON PS FEM COMP SZ 8 CEMENTED -,SUP-5515-F-801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ8 TRIATH RT KN PS CMNT -,SUP-5515-F-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
POSTERIOR STABILIZED FEMORAL -,SUP-5516-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIATHLON CRUCLATE RETAINING FEMORAL SZ #1 LEFT CR -,SUP-5517-F-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIATHLON CRUCLATE RETAINING FEMORAL SZ #1 RIGHT CR -,SUP-5517-F-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIATHLON CR FEM COMPONENT - BEADED W/PA -,SUP-5517-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ2 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ3 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ3 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ4 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ4 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ6 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ6 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ7 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ7 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ8 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIATHLON CRUCIATE RETAINING FEMORAL -,SUP-5517-F-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ1 KN CMNT TRIATH PRIM -,SUP-5520-B-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ2 KN CMNT TRIATH PRIM -,SUP-5520-B-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ3 KN CMNT TRIATH PRIM -,SUP-5520-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ4 KN CMNT TRIATH PRIM -,SUP-5520-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ5 KN CMNT TRIATH PRIM -,SUP-5520-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ6 KN CMNT TRIATH PRIM -,SUP-5520-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ7 KN CMNT TRIATH PRIM -,SUP-5520-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ8 KN CMNT TRIATH PRIM -,SUP-5520-B-800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ1 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ2 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ3 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL BASEPLATE TRIATHLON UNIV SIZE 4 -,SUP-5521-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ5 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ6 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ7 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ8 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ3 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ4 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ5 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ6 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ7 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ1 9MM TRIATH CR ARTC KN X3 -,SUP-5530-G-109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ1 11MM TRIATH CR ARTC KN X3 -,SUP-5530-G-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ1 13MM TRIATH CR ARTC KN X3 -,SUP-5530-G-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ1 16MM TRIATH CR ARTC KN X3 -,SUP-5530-G-116,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ1 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-119,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL BEARING INSERT CR SZ2 9MM -,SUP-5530-G-209-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ2 13MM TRIATH CR ARTC KN X3 -,SUP-5530-G-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ2 16MM TRIATH CR ARTC KN X3 -,SUP-5530-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ2 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL BEARING SZ 3 X 10MM CR X3 TRIATHLON -,SUP-5530-G-310-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL BEARING CR SZ4 9MM -,SUP-5530-G-409-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL BEARING CR SZ4 10MM TRIATHLON X3 -,SUP-5530-G-410-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL BEARING INSERT CR SZ4 11MM -,SUP-5530-G-411-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ4 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5 10MM TRIATH CR ARTCSURF KN X3 UHMWPE -,SUP-5530-G-510-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-519,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL BEARING SZ6 10MM TRIATH X3 CR -,SUP-5530-G-610-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ6 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBAL BEARING CR SZ 7 X 9MM TRIATHLON X3 -,SUP-5530-G-709-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBAL BEARING CR SZ 7 X 10MM TRIATHLON X3 -,SUP-5530-G-710-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ7 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ8 13MM TRIATH CR ARTC KN X3 -,SUP-5530-G-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ8 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-819,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIATHALON INSERT CS #1 12MM X3 -,SUP-5531-G-112-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ2 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-209-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL BEARING CS SZ 2 X 10MM TRIATHLON X3 -,SUP-5531-G-210-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ2 11MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT BEARING TIBIAL CS SIZE 2 X 11MM TRIATHLON X3 -,SUP-5531-G-211-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL BEARING CS SZ 2 X 12MM TRIATHLON X3 -,SUP-5531-G-212-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ2 13MM TRIATH CS BEAR KN X3 -,SUP-5531-G-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TRIATHLON X3 TIBIAL BEARING SIZE 2 X 13MM CS -,SUP-5531-G-213-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ2 16MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-309-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 11MM TRIATH CS BEAR KN X3 -,SUP-5531-G-311-A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL BEARING INSERT  SZ.3 / CS / 12MM -,SUP-5531-G-312-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 13MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL BEARING CS SIZE 3 X 13MM TRIATHLON X3 -,SUP-5531-G-313-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 16MM TRIATH CS ARTCSURF KN X3 UHMWPE -,SUP-5531-G-316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 19MM TRIATH ARTCSURF KN X3 UHMWPE -,SUP-5531-G-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ4 9MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-409-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ4 11MM TRIATH CS BEAR X3 -,SUP-5531-G-411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ4 11MM TRIATH CS BEAR KN X3 -,SUP-5531-G-411-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ4 13MM TRIATH CS BEAR KN X3 -,SUP-5531-G-413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT BEARING TIBIAL CS SIZE 4 X 13MM TRIATHLON X3 -,SUP-5531-G-413-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ4 16MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ4 19MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL BEARING SZ 5 CS 9MM TRIATHLON X3 -,SUP-5531-G-509-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL BEARING INSERT  SZ. 5 / 10MM -,SUP-5531-G-510-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5 11MM TRIATH CS BEAR KN X3 -,SUP-5531-G-511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TRIATHLON X3 TIBIAL BEARING CS -,SUP-5531-G-512-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5 13MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
X3 TRIATHILON CS INS SIZE 5 13MM -,SUP-5531-G-513-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5 16MM TRIATH CS BEAR KN X3 -,SUP-5531-G-516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL BEARING CS SIZE 5 X 19MM TRIATHLON X3 -,SUP-5531-G-519-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ6 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-609-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ6 11MM TRIATH CONDL STAB BEAR KN -,SUP-5531-G-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ6 11MM TRIATH CONDL STAB BEAR CS X3 -,SUP-5531-G-611-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ6 13MM TRIATH CS BEAR KN X3 -,SUP-5531-G-613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ6 13MM TRIATH X3 CS BEAR X3 -,SUP-5531-G-613-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ6 16MM TRIATH ARTCSURF KN X3 UHMWPE -,SUP-5531-G-616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ6 19MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ7 9MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-709-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ7 11MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ7 13MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-713,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ7 16MM TRIATH CS BEAR KN X3 -,SUP-5531-G-716,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL TRIATHLON X3 SZ 7 16MM BEARING INSERT-CS -,SUP-5531-G-716-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ8 9MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIATHLON TIBIAL BEARING INSERT - CS SZ8 11MM -,SUP-5531-G-811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ1 13MM TRIATH PS ARTC KN X3 -,SUP-5532-G-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ2 9MM TRIATH PS ARTC KN X3 -,SUP-5532-G-209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIATHLON PS X3 TIBIAL INSERT -,SUP-5532-G-209-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ2 11MM TRIATH PS ARTCSURF KN X3 UHMWPE -,SUP-5532-G-211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB H TRTHLN PS 2-13MM -,SUP-5532-G-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ2 16MM TRIATH PS ARTC KN X3 -,SUP-5532-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ2 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL BEARING PS SZ 3 X 16MM TRIATHLON X3 -,SUP-5532-G-316-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL BEARING PS SZ 4 X 11MM TRIATHLON X3 -,SUP-5532-G-411-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ4 16MM TRIATH PS ARTCSURF KN X3 UHMWPE -,SUP-5532-G-416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ4 19MM TRIATH PS ARTC KN X3 -,SUP-5532-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ4 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5 22MM TRIATH PS ARTC KN X3 -,SUP-5532-G-522,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-525,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL BEARING INSERT TRI - PS SZ.6 / 9MM -,SUP-5532-G-609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ6 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-625,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ7 9MM TRIATH PS ARTC KN X3 -,SUP-5532-G-709,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ7 16MM TRIATH PS ARTC KN X3 -,SUP-5532-G-716,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL BEARING / SZ. 7  / 19MM -,SUP-5532-G-719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ7 22MM TRIATH PS ARTC KN X3 -,SUP-5532-G-722,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ7 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-725,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ8 9MM TRIATH PS ARTC KN X3 -,SUP-5532-G-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIATHLON PS X3 TIBIAL INSERT SZ 8 -,SUP-5532-G-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT TIBIAL SIZE 2 X 16MM PS TRIATHLON ALL POLY -,SUP-5535-A-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT TIBIAL SIZE 5 X 9MM PS TRIATHLON ALL POLY -,SUP-5535-A-509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT TRIATHLON ALL POLY TIBIAL PS SIZE 5 13MM -,SUP-5535-A-513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT TRIATHLON ALL POLY TIBIAL PS SIZE 6 16MM -,SUP-5535-A-616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL COMPONENT TRITANIUM #2 -,SUP-5536-B-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ3 KN TRIATH TRTNM -,SUP-5536-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ4 KN TRIATH TRTNM -,SUP-5536-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ5 KN TRIATH TRTNM -,SUP-5536-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ6 KN TRIATH TRTNM -,SUP-5536-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ7 KN TRIATH TRTNM -,SUP-5536-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIATHLON TIBIAL COMPONENT -,SUP-5536-B-800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ1 19MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-119,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ2 11MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ2 10MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT TOTAL STABILIZER #2 19MM TS -,SUP-5537-G-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ2 22MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
NO 3 TRIATHLON TS PLUS TIBIAL INSERT X3 POLY -,SUP-5537-G-309-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 19MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 22MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 25MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TOTAL STABILIZER+ TIBIAL INSERT -,SUP-5537-G-409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL TOTAL STABILIZER + SIZE 4 X 9MM TS TRIATH X3 -,SUP-5537-G-409-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT TRIATHLON X3 TOTAL STABILIZER SIZE F 11MM TS -,SUP-5537-G-411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ4 13MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ4 16MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
NO 4 TRIATHLON TS PLUS TIBIAL INSERT X3 POLY 16MM -,SUP-5537-G-416-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ4 19MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ4 22MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ4 25MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ4 28MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL TOTAL STAB SIZE 5 X 16MM TS TRIATHLON X3 -,SUP-5537-G-516-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL TOTAL STABILIZER+ SIZE 5 X 19MM TRIATHLON X3 -,SUP-5537-G-519-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5 22MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-522,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5 28MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-528,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5 31MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-531,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ6 9MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ6 11MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ6 16MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ6 19MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ6 25MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-625,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TOTAL STABILIZER TIBIAL INSERT SZ7 -,SUP-5537-G-711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ7 16MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-716,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ8 22MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-822,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT RT DIST KN SZ1 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT LT DIST KN SZ2 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL DISTAL AUGMENT - RIGHT -,SUP-5540-A-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT LT DIST KN SZ4 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT RT DIST KN SZ4 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL DISTAL AUGMENT - RIGHT -,SUP-5540-A-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT RT DIST KN SZ8 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL DISTAL AUGMENT RIGHT #2 10MM -,SUP-5541-A-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT FEMORAL DISTAL LEFT TRIATHLON SIZE 3 10MM -,SUP-5541-A-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT LT DIST KN SZ4 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5541-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT LT DIST KN SZ5 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5541-A-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT FEMORAL DISTAL RIGHT SZ 7 X 5MM TRIATHLON -,SUP-5541-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT FEMORAL DISTAL RIGHT SZ 7 X 10MM TRIATHLON -,SUP-5541-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIATHLON FEMORAL DISTAL SUGMENT 15MM SIZE 4 LEFT -,SUP-5542-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4581.78,3207.246,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT FEMORAL DISTAL RIGHT SZ 7 X 15MM TRIATHLON -,SUP-5542-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4581.78,3207.246,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP SZ48 7MM REUNION ALLOGRAFT SHOLUDER PG -,SUP-5542-P-0048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP SZ56 7MM REUNION ALLOGRAFT SHOLUDER PG -,SUP-5542-P-0056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT POST KN SZ1 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT POST KN SZ2 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT POST KN SZ3 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT POST KN SZ4 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT POST KN SZ5 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT POST KN SZ6 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT POST KN SZ7 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT POST KN SZ2 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT POST KN SZ3 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT POST KN SZ4 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT POST KN SZ5 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT POST KN SZ6 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HALF BLOCK TIBIAL AUGMENT SIZE 3 X 5MM TRIATHLON -,SUP-5545-A-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT RM/LL KN SZ3 TRIATH 5MM BLCK TOTAL STABILIZED AUG -,SUP-5545-A-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT LMRL KN SZ7 TRIATH 5MM BLCK TOTAL STABILIZED AUG -,SUP-5545-A-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT RM/LL KN SZ7 TRIATH 5MM BLCK TOTAL STABILIZED AUG -,SUP-5545-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT LMRL KN SZ1 TRIATH 10MM BLCK TOTAL STABILIZED AUG -,SUP-5546-A-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT RM/LL KN SZ1 TRIATH 10MM BLCK TOTAL STABILIZED AUG -,SUP-5546-A-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL AUGMENT HALF BLOCK -,SUP-5546-A-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL AUGMENT HALF BLOCK - 10MM -,SUP-5546-A-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT LMRL KN SZ3 TRIATH 10MM HLF BLCK TOTAL STABILIZED -,SUP-5546-A-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL AUGMENT HALF BLOCK / SZ.3 -,SUP-5546-A-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT LMRL KN SZ4 TRIATH 10MM HLF BLCK TOTAL STABILIZED -,SUP-5546-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT RM/LL KN SZ4 TRIATH 10MM HLF BLCK TOTAL STABILIZED -,SUP-5546-A-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL SYMMETRIC CONE AUGMENT SIZE A -,SUP-5549-A-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13500.17,9450.119,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL SYMMETRIC CONE AUGMENT -,SUP-5549-A-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13500.17,9450.119,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL SYMMETRIC CONE AUGMENT SIZE C -,SUP-5549-A-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13500.17,9450.119,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL CONE AUGMENT SZ 1&2 RT -,SUP-5549-A-322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15374.42,10762.094,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIATH TRITNUM CNTRLFEMCONE AUG SZ 3&4 LEFT -,SUP-5549-A-641,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15375.53,10762.871,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIATH TRITNUM CNTRLFEMCONE AUG SZ 3 & 4 RIGHT -,SUP-5549-A-642,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15375.53,10762.871,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT CENTRAL FEM CONE SZ 7&8 RIGHT TRIATHLON -,SUP-5549-A-672,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15375.53,10762.871,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PATELLA SYMMETRIC SZ S27MM X 8MM TRIATHLON X3 -,SUP-5550-G-278-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIATHLON SYMMETRIC X3 PATELLA -,SUP-5550-G-298-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIATHLON X3 SYMMETRIC PATELLA 31MM 9MM -,SUP-5550-G-319-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 33X9MM THK X3 TRIATH PRIM SYM -,SUP-5550-G-339,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 39X11MM THK X3 TRIATH PRIM SYM -,SUP-5550-G-391,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 29X9MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-299-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 32X10MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-320-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 35X10MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-350-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 38X11MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-381-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SINGLE RADIUS HUMERAL HEAD SIZE 44 19MM -,SUP-5552-E-4419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13563.59,9494.513,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 4MM OFST 52X17 REUNION -,SUP-5552-E-5217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 29X9MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-299,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 32X10MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 35X10MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-350,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 38X11MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-381,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PATELLA ASYMMETRIC A40/11MM -,SUP-5552-L-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 56MM STD REUNION SGL RAD -,SUP-5552-S-5622,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 32X10MM THK X3 PERIAPATITE TRIATH ASYM MTL BK -,SUP-5554-L-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 35X10MM THK X3 PERIAPATITE TRIATH ASYM MTL BK -,SUP-5554-L-350,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 38X11MM THK X3 PERIAPATITE ASYM BEADX3 MTL BK -,SUP-5554L381,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 40X11MM THK X3 PERIAPATITE ASYM BEADX3 MTL BK -,SUP-5554L401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND SZ1 12MM TRIATH TOTAL STABILIZED 50MM COCR FEM -,SUP-5560-S-112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TOTAL KNEE 9MM X 100MM -,SUP-5560-S-209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND SZ2 12MM TRIATH TOTAL STABILIZED 100MM COCR FEM -,SUP-5560-S-212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND SZ2 15MM TRIATH TOTAL STABILIZED 50MM COCR FEM -,SUP-5560-S-215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND SZ3 12MM TRIATH TOTAL STABILIZED 50MM COCR FEM -,SUP-5560-S-312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 10MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 11MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 12MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 13MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 14MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 15MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 16MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 17MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FLUTED STEM 18MM / 100MM / TS -,SUP-5565-S-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 18MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 19MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 20MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 21MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 22MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 13MM TRIATH PRFT REVISN TOTAL STABILIZED 150MM -,SUP-5566-S-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4789.23,3352.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FLUTED STEM 14MM / 150MM / TS -,SUP-5566-S-014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4789.23,3352.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HUMERAL FRATURE STEM 7 X 113 -,SUP-5568-0007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,32158.29,22510.803,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
REUNION RFX-HUMERAL FRACTURE STEM 9MM -,SUP-5568-0009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,31160.68,21812.476,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUMERAL FRACTURE 11MM X 123MM REUNION RFX -,SUP-5568-0011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,33766.02,23636.214,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HUMERAL CUP 36MM DIA X 4MM THK -,SUP-5570-3604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16968.41,11877.887,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
ADAPTER FEM 2MM OFST TRIATH RECON KN REVISN TOTAL STABILIZED -,SUP-5570-S-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4348.4,3043.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
ADAPTER FEM 4MM OFST TRIATH RECON KN REVISN TOTAL STABILIZED -,SUP-5570-S-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4348.4,3043.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
ADAPTER FEM 6MM OFST TRIATH RECON KN REVISN TOTAL STABILIZED -,SUP-5570-S-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4348.4,3043.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
EXTENDER STEM TRIATHLON 25MM LENGTH -,SUP-5571-S-025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4512.24,3158.568,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
X3 HUMERAL INSERT 36MM X 4MM STANDARD -,SUP-5571-S-3604-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13571.02,9499.714,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE 28MM X 10.05MM -,SUP-5572-2802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18676.39,13073.473,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
GLENOSPHERE 36MM DIA X 2MM THK CONCENTRIC -,SUP-5573-C-3602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16968.41,11877.887,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ2 TRIATH LMRL KN UNICMPT PRIM PRT RSRFC COCR -,SUP-5610-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ2 TRIATH RM/LL KN UNICMPT PRIM PRT RSRFC COCR -,SUP-5610-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL REVISION LEFT SZ 2 NON-POROUS -,SUP-561-1201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ3 BAL KN MODULAR REVISN RT KN -,SUP-561-1302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ4 BAL KN MODULAR REVISN LT KN -,SUP-561-1401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ4 BAL KN RT KN MODULAR REVISN SYS -,SUP-561-1402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 BAL KN LT KN MODULAR REVISN SYS -,SUP-561-1501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 BAL KN RT KN MODULAR REVISN SYS -,SUP-561-1502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ6 BAL KN LT KN MODULAR REVISN SYS -,SUP-561-1601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
MODULAR FEMORAL LEFT SIZE 7 -,SUP-561-1701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
MODULAR FEMORAL SIZE 7 -,SUP-561-1702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ3 27/47MM LMRL KN TRIATH COCR PRIM REVISN -,SUP-5620-B-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ3 27/47MM RM/LL KN TRIATH COCR PRIM REVISN -,SUP-5620-B-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ2 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRAY TIBIAL REVISION SZ 2 NEUTRAL NON-POROUS -,SUP-562-1200A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ3 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL TRAY REVISION SZ 3 NEUTRAL NON-POROUS -,SUP-562-1300A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ4 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL TRAY REVISION SZ 4 NEUTRAL NON-POROUS -,SUP-562-1400A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ5 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL TRAY REVISION SZ 5 NEUTRAL NON-POROUS -,SUP-562-1500A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ6 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL TRAY SLOPED SIZE 5 MODULAR -,SUP-562-2500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9431.02,6601.714,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CONE TIBIAL CENTRAL 31MM -,SUP-562-7031,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12705.89,8894.123,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CONE TIBIAL CENTRAL 34MM -,SUP-562-7034,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12705.89,8894.123,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CONE TIBIAL CENTRAL 36MM -,SUP-562-7036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12705.89,8894.123,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CONE TIBIAL 25MM M-L 35MM A-P -,SUP-562-7135,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12223.2,8556.24,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CONE TIBIAL LARGE 47MM M/L 31MM A/P -,SUP-562-7247,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15108.2,10575.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 8MM TRIATH BEAR LMRL KN X3 UHMWPE -,SUP-5630-G-308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 8MM TRIATH BEAR RM/LL KN X3 UHMWPE -,SUP-5630-G-328,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 8MM CNSTRN -,SUP-563-1308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 10MM CNSTRN -,SUP-563-1310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 12MM CNSTRN -,SUP-563-1312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 14MM CNSTRN -,SUP-563-1314,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 16MM CNSTRN -,SUP-563-1316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 18MM CNSTRN -,SUP-563-1318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 20MM CNSTRN -,SUP-563-1320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SROM*ST XL 36+8LINK 18 X 13 X 255L -,SUP-563138L,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27357.55,19150.285,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL CK SZ 4 8MM -,SUP-563-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT CK SIZE 4 18MM -,SUP-563-1418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT CK SIZE 4 24MM -,SUP-563-1424,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5 8MM CNSTRN -,SUP-563-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5 10MM CNSTRN -,SUP-563-1510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5 12MM CNSTRN -,SUP-563-1512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT CK SIZE 6 8MM -,SUP-563-1608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ6 10MM CNSTRN -,SUP-563-1610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT CK SIZE 6 14MM -,SUP-563-1614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SZ 2 10MM -,SUP-563-2210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SZ 2 12MM -,SUP-563-2212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL REVISION CK SZ 2 14MM -,SUP-563-2214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SZ 2 18MM -,SUP-563-2218,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SZ 2 20MM -,SUP-563-2220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SZ 2 22MM -,SUP-563-2222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SZ 3 8MM -,SUP-563-2308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SZ 3 12MM -,SUP-563-2312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SZ 3 14MM -,SUP-563-2314,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SZ 3 18MM -,SUP-563-2318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL REV CK SZ 3 20MM -,SUP-563-2320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SZ 3 24MM -,SUP-563-2324,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SZ 4 8MM -,SUP-563-2408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SZ 4 10MM -,SUP-563-2410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SZ 4 12MM -,SUP-563-2412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SZ 4 14MM -,SUP-563-2414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SZ 4 16MM -,SUP-563-2416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SZ 4 18MM -,SUP-563-2418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SZ 4 22MM -,SUP-563-2422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SZ 5 10MM -,SUP-563-2510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SZ 5 12MM -,SUP-563-2512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SZ5 14MM -,SUP-563-2514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SZ 5 16MM -,SUP-563-2516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL REVISION CK SZ 6.8MM -,SUP-563-2608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SIZE 6 14MM -,SUP-563-2614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM 12MM X 50MM CEMENTED -,SUP-565-1205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM 12 X 80 CEMENTED -,SUP-565-1208,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXT CEMENTED 12MM X 110MM -,SUP-565-1211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTENSION CEMENTED 14MM X 30MM -,SUP-565-1403,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4481.66,3137.162,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM 14MM X 50MM CEMENTED -,SUP-565-1405,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 14MM BAL KN 80MM CMNT -,SUP-565-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4481.66,3137.162,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 10MM BAL KN 80MM FEM/TBL -,SUP-566-1008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM 10 X 150MM EXT FLUTED -,SUP-566-1015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 12MM BAL KN 80MM FEM/TBL -,SUP-566-1208,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 13MM BAL KN 80MM FEM/TBL -,SUP-566-1308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 13MM BAL KN 150MM FEM/TBL -,SUP-566-1315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 14MM BAL KN 80MM FEM/TBL -,SUP-566-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTENSION FLUTED 14 X 110 -,SUP-566-1411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 15MM BAL KN 80MM FEM/TBL -,SUP-566-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 16MM BAL KN 80MM FEM/TBL -,SUP-566-1608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 17MM BAL KN 80MM FEM/TBL -,SUP-566-1708,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTENSION FLUTED 17MM X 110MM -,SUP-566-1711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 18MM BAL KN 80MM FEM/TBL -,SUP-566-1808,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM 18MM X 110MM FLUTED -,SUP-566-1811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 20MM BAL KN 80MM FEM/TBL -,SUP-566-2008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTENSION FLUTED 20 X 110 -,SUP-566-2011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTENSION FLUTED 24 X 80MM -,SUP-566-2408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTENSION FLUTED 24 X 110MM -,SUP-566-2411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT RM/LL KN SZ3 BAL KN 5MM BLCK REVISN -,SUP-567-5103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL AUGMENT BLOCK 5MM RT LAT LT MED SIZE 4 -,SUP-567-5104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT RM/LL KN SZ3 BAL KN BLCK REVISN -,SUP-567-5203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL AUGMENT SZ 3 15MM BLOCK LT LATERAL RT MEDIAL -,SUP-567-7203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT DIST KN SZ3 BAL KN 4MM REVISN -,SUP-568-1304,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL AUGMENT DISTAL SIZE 3 8MM -,SUP-568-1308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT DIST KN SZ4 BAL KN 4MM REVISN -,SUP-568-1404,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT FEMORAL SZ 4 4MM DISTAL -,SUP-568-1404A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT DIST KN SZ4 BAL KN 8MM REVISN -,SUP-568-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL AUGMENT SZ 4 8MM DISTAL -,SUP-568-1408A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT DIST KN SZ5 BAL KN 4MM REVISN -,SUP-568-1504,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL AUGMENT SZ 5 4MM DISTAL -,SUP-568-1504A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL AUGMENT DISTA SIZE 5 8MM -,SUP-568-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL AUGMENT DISTAL 12MM -,SUP-568-1512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT DISTAL 4MM SIZE 6 -,SUP-568-1604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL AUGMENT SZ 6 8MM DISTAL -,SUP-568-1608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT POST KN SZ4 BAL KN 4MM REVISN -,SUP-568-2404,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FERMORAL AUGMENT POSTERIOR 4MM SIZE 6 -,SUP-568-2604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 14MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-5988-10-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4394.75,3076.325,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 14MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-5988-10-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
EXTENSION STM 15X30MM -,SUP-5988-12-15,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4394.75,3076.325,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ0 33MM OFST 86MM ACCOLADE PRFT STD OFST 30MM NK -,SUP-6020-0030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ1 34MM OFST 110MM RECON ACCOLADE PRFT PRIM STD -,SUP-6020-0130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ2 35MM OFST 115MM ACCOLADE PRFT STD OFST 30MM NK -,SUP-6020-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ3 39MM OFST 120MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-0335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ4 40MM OFST 125MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ5 44MM OFST 130MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-0537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ2.5 36MM OFST 118MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-2530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ3.5 39MM OFST 124MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-3535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ4.5 41MM OFST 129MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-4535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ5.5 45MM OFST 133MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-5537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ0 +0MM 37MM OFST 86MM ACCOLADE PRFT EXTEND OFST -,SUP-6021-0030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ1 +0MM 38MM OFST 110MM ACCOLADE PRFT EXTEND OFST -,SUP-6021-0130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ2 39MM OFST 115MM ACCOLADE PRFT PRIM EXTEND OFST -,SUP-6021-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ3 43MM OFST 120MM ACCOLADE RECON PRFT PRIM HI -,SUP-6021-0335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ4 44MM OFST 125MM ACCOLADE RECON PRFT PRIM HI -,SUP-6021-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ5 48MM OFST 130MM ACCOLADE RECON PRFT PRIM EXTEND -,SUP-6021-0537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ2.5 40MM OFST 118MM ACCOLADE RECON PRFT PRIM -,SUP-6021-2530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ3.5 124MM RECON ACCOLADE PRFT PRIM EXTEND OFST -,SUP-6021-3535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ4.5 45MM OFST 130MM ACCOLADE RECON PRFT PRIM -,SUP-6021-4535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ5.5 49MM OFST 133MM ACCOLADE PRFT EXTEND OFST -,SUP-6021-5537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ4 OMNIFIT PRIM CLLR CMNT MDL CLCR HIP -,SUP-6034-0425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ6 30MM OFST 132MM SECUR-FIT PRFT PRIM 25MM -,SUP-6051-0625S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ7 35.1MM OFST 132MM SECUR-FIT MAX PRFT PRIM 30MM -,SUP-6051-0730S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ8 132MM RECON SECUR-FIT MAX PRFT PRIM TI HAP CTD -,SUP-6051-0830S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ9 40.8MM OFST 132MM SECUR-FIT MAX PRFT PRIM 35MM -,SUP-6051-0935S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ10 132MM RECON SECUR-FIT MAX PRFT PRIM TI HAP CTD -,SUP-6051-1035S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ11 132MM RECON SECUR-FIT MAX PRFT PRIM TI HAP CTD -,SUP-6051-1140S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ12 47.3MM OFST 132MM SECUR-FIT MAX PRFT PRIM 40MM -,SUP-6051-1240S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HIP STEM SIZE 6 25MM C-TPR -,SUP-6052-0625S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ7 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-0730S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ8 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-0830S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ9 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-0935S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ10 127 DEG SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-1035S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ13 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-1340S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HIP SECUR-FIT PLUS MAX SZ 11 C-TPR 40MM X 170MM -,SUP-6054-1115S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HIP 127 DEG NECK ANGLE SZ 12 C-TPR 40MM X 170MM -,SUP-6054-1216S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HIP STEM 127 DEG CEMENTED SZ 2 V40 TPR 30MM X 124MM ACCOLADE -,SUP-6057-0230D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HIP ACCOLADE 127 DEG CEM NK 35MM SZ 3 V40 131MM LGTH -,SUP-6057-0335D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HIP CEM SZ4 V40 TPR 35MM X 137MM 127 DEG -,SUP-6057-0435D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HIP ACCOLADE 127 DEC CEM NK 37MM SZ 5 V40 145MM LGTH -,SUP-6057-0537D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HIP ACCOLADE 127 DEG CEM NK 37MM SZ 6 V40 158MM LGTH -,SUP-6057-0637D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HIP 127 DEG CEMENTED SZ 7 V40 TPR 40MM X 158MM ACCOLADE -,SUP-6057-0740D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HIP 132 DEG SIZE 3 V40 X 35MM X 131MM CEM ACCOLADE C -,SUP-6058-0335D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HIP 132 DEG CEMENTED SZ 4 V40 35MM X 137MM ACCOLADE -,SUP-6058-0435D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HIP STEM 132 DEG CEMENTED SZ 5 V40 TPR 37MM X 145MM -,SUP-6058-0537D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ10 42MM OFST 160MM OMNIFIT HFX RECON PRIM 35MM NK -,SUP-6070-1035A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ11 132MM OMNIFIT HFX PRIM COCR CMNT HIP -,SUP-6070-1140A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ5 35MM OFST 110MM RECON OMNIFIT HFX PRIM 25MM NK -,SUP-6076-0525A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ6 36MM OFST 120MM OMNIFIT HFX PRIM 25MM NK COCR -,SUP-6076-0625A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ7 41MM OFST 130MM OMNIFIT HFX PRIM 30MM NK COCR -,SUP-6076-0730A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ8 42MM OFST 140MM RECON OMNIFIT HFX PRIM 30MM NK -,SUP-6076-0830A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ2 +0MM 43MM OFST 120MM ACCOLADE HFX PRFT PRIM -,SUP-6077-0335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ4 +0MM 44MM OFST 125MM ACCOLADE HFX PRFT PRIM -,SUP-6077-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ5 +0MM 48MM OFST 130MM ACCOLADE HFX PRFT PRIM -,SUP-6077-0537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
OMNIFIT CEMENTED LONG STEM RIGHT -,SUP-6088-0730-200R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17512.18,12258.526,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ4 33MM OFST 100MM OMNIFIT EON PRIM EXTEND OFST -,SUP-6097-0425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ5 8.9MM DIST TIP 39MM OFST 110MM OMNIFIT EON PRIM -,SUP-6097-0530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ6 9.6MM DIST TIP 40MM OFST 120MM OMNIFIT EON PRIM -,SUP-6097-0630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ7 10.4MM DIST TIP 45MM OFST 130MM OMNIFIT EON -,SUP-6097-0735,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ8 46MM OFST 135MM OMNIFIT EON PRIM EXTEND OFST -,SUP-6097-0835,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HIP OMNIFIT EON PLUS SIZE 11 C-TPR 40MM X 150MM -,SUP-6097-1140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ5 8.9MM DIST TIP 35MM OFST 110MM OMNIFIT EON STD -,SUP-6098-0530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ6 9.6MM DIST TIP 36MM OFST 120MM OMNIFIT EON PRIM -,SUP-6098-0630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ7 9.6MM DIST TIP 41MM OFST 130MM OMNIFIT EON PRIM -,SUP-6098-0735,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ8 11.3MM DIST TIP 42MM OFST 135MM OMNIFIT EON STD -,SUP-6098-0835,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ9 46MM OFST 140MM OMNIFIT EON STD OFST 40MM NK -,SUP-6098-0940,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
MODULAR CUP REPLACEMTN LOCK RING 54MM -,SUP-6201-54,CDM,C1776,HCPCS,278,RC,,,outpatient,,,816.9,571.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRABECULAR METAL LOCKING RING -,SUP-6201-56,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL MULTI HOLE TRABECULAR METAL 54MM -,SUP-6202-54-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9990.38,6993.266,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 36X58-60MM G SHL TRIDENT 0DG CROSSFIRE PRIM -,SUP-621-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 28X46-48MM D SHL TRIDENT 0DG NEUT X3 7.9MM PRIM -,SUP-623-00-28D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT 00 DEG X3 32MM ID TRIDENT -,SUP-623-00-32C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 32X44MM C SHL TRIDENT 0DG NEUT X3 4.9MM PRIM -,SUP-623-00-32C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT POLYETHLENE 0 DEG 32MM CODE D TRIDENT X3 -,SUP-623-00-32D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 32X54-56MM F SHL TRIDENT 0DG NEUT X3 9.9MM PRIM -,SUP-623-00-32F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT POLYETHLENE 0 DEG 36MM CODE D TRIDENT X3 -,SUP-623-00-36D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT POLYETHLENE 0 DEG 36MM CODE E TRIDENT X3 -,SUP-623-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 36X54-56MM F SHL TRIDENT 0DG NEUT X3 7.9MM PRIM -,SUP-623-00-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT POLYETHLENE 0 DEG 36MM CODE F TRIDENT X3 -,SUP-623-00-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT POLY ZERO DEGREE 36MM X ALPHA G TRIDENT X3 -,SUP-623-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 36X58-60MM G SHL TRIDENT 0DG NEUT X3 9.4MM PRIM -,SUP-623-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACET TRIDENT X3 0 DEG POLY 36MM H -,SUP-623-00-36H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIDENT X3 0 DG  POLY INSERT 40MM SZ E -,SUP-623-00-40E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIDENT X3 0 DG POLYETTHYLENE INSERT 40MM SZ E RIM -,SUP-623-00-40E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT 0 DEG POLYETHYLENE 40MM ALPHA CODE F TRIDENT X3 -,SUP-623-00-40F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 40X58-60MM G SHL TRIDENT 0DG X3 7.4MM PRIM -,SUP-623-00-40G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT POLY ZERO DEGREE 40MM X ALPHA G TRIDENT X3 -,SUP-623-00-40G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT POLY ZERO DEGREE 40MM X ALPHA H TRIDENT X3 -,SUP-623-00-40H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 40X62-64MM H SHL TRIDENT 0DG X3 9.1MM PRIM -,SUP-623-00-40H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TRIDENT X3 0 D POLY 40MM ALPHA I -,SUP-623-00-40I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 44X54-56MM F SHL TRIDENT 0DG X3 3.8MM PRIM -,SUP-623-00-44F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 44X58-60MM G SHL TRIDENT 0DG X3 5.4MM PRIM -,SUP-623-00-44G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 44X62-64MM H SHL TRIDENT 0DG X3 7.1MM PRIM -,SUP-623-00-44H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TRIDENT X3 0 DEGREE POLY 44MM ALPHA I -,SUP-623-00-44I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 22X42MM B SHL TRIDENT 10DG X3 8.8MM PRIM -,SUP-623-10-22B,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 32X54-56MM F SHL TRIDENT 10DG X3 9.9MM PRIM -,SUP-623-10-32F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT 10 DEG POLYETHYLENE 36MM E TRIDENT X3 -,SUP-623-10-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 36X50-52MM E SHL TRIDENT 10DG X3 5.9MM PRIM -,SUP-623-10-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT 10 DEG X3 36MM ID TRIDENT -,SUP-623-10-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 36X54-56MM F SHL TRIDENT 10DG X3 7.9MM PRIM -,SUP-623-10-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT 10 DEGREE POLY 36MM G TRIDENT X3 -,SUP-623-10-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 36X58-60MM G SHL TRIDENT 10DG X3 9.4MM PRIM -,SUP-623-10-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 36X66-68MM I SHL TRIDENT 10DG X3 12.7MM PRIM -,SUP-623-10-36I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM DISTAL 19MM DIA CENTRALIZER-CEMENTED -,SUP-6259-8-180,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 32X50-52MM E SHL TRIDENT 0DG ALMN CERM PRIM -,SUP-625-OT-32E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 36MM D SHL RECON MDM CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-36C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 38MM D SHL MDM RECON CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-38D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 42MM E SHL RECON MDM CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-42E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 46MM F SHL RECON MDM CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-46F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 48MM G SHL MDM RECON CMNTLS COCR REVISN MODULAR -,SUP-626-00-48G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER MDM 52MM H CEMENTLESS -,SUP-626-00-52H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 22.2MMSTDX0MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-4-122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 26MM-3MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 26MM +4MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-226,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 26MM +8MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-326,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 26MM +12MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-426,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 26MM -3MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 40MM -4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 44MM -4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 22MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 26MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-126,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V40 28MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-128,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 36MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 40MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL HEAD LFIT V40 22.2MM +3MM -,SUP-6260-9-222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 26MM +4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-226,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 28MM +4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-228,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 40MM +4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-240,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 26MM +8MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-326,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 28MM +8MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-328,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 32MM +8MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-332,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 36MM +10MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-336,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 26MM +12MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-426,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V40 28MM +12MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL HEAD LFIT ANATOMIC V40 6.5MM X 16MM -,SUP-6260-9-440,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ15 47MM OFST 140MM PARTNERSHIP RELIANCE PF PRFT -,SUP-6265-2-005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ6 50MM OFST 150MM PARTNERSHIP RELIANCE PF PRFT -,SUP-6265-2-006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CENTRALIZER DIST HIP 13MM TY A -,SUP-6265-4-413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,601.24,420.868,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CENTRALIZER DIST HIP 14MM TY A -,SUP-6265-4-414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,601.24,420.868,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CENTRALIZER DIST HIP 15MM TY B -,SUP-6265-4-515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,601.24,420.868,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ1 10X34MM OFST 115MM PARTNERSHIP CITNN PRFT PRIM -,SUP-6265-5101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ2 36MM OFST 120MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ4 44MM OFST 130MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ5 47MM OFST 135MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ0 9X34MM OFST 110MM PARTNERSHIP CITNN PRFT PRIM -,SUP-6265-5110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ1 34MM OFST 118MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ2 36MM OFST 120MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ3 40MM OFST 133MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ4 44MM OFST 130MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ5 47MM OFST 135MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BODY PROX HIP 21MM STD RESTOR MODULAR REVISN BOLT CNCL -,SUP-6276-1-021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SYS HIP RESTORATION MODULAR SZ 21MM +0 HT V40 TPR -,SUP-6276-1-021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BODY PROX HIP 25MM STD RESTOR MODULAR REVISN BOLT CNCL -,SUP-6276-1-025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BODY PROX HIP 19MM RESTOR MODULAR REVISN BOLT +10MM NK CNCL -,SUP-6276-1-119,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BODY PROX HIP 21MM RESTOR MODULAR REVISN BOLT +11MM NK CNCL -,SUP-6276-1-121,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIP SUCT ACORN STD V. MUELLER 1.0625IN SIL RBR -,SUP-6276-1-123,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
MODULAR HIP SYSTEM RESTORATION 25MM X +10 X V40 TPR -,SUP-6276-1-125,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SYSTEM HIP MODULAR 27MM X +10 X V40 TPR RESTORAITON -,SUP-6276-1-127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BODY PROX HIP 19MM RESTOR MODULAR REVISN BOLT +20MM NK CNCL -,SUP-6276-1-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BODY PROX HIP 21MM RESTOR MODULAR REVISN BOLT +20MM NK CNCL -,SUP-6276-1-221,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BODY PROX HIP 25MM RESTOR MODULAR REVISN BOLT +10MM NK CNCL -,SUP-6276-1-225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BODY PROX HIP 19MM RESTOR MODULAR REVISN BOLT +30MM NK CNCL -,SUP-6276-1-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BODY PROX HIP 21MM RESTOR MODULAR REVISN BOLT +30MM NK CNCL -,SUP-6276-1-321,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BODY PROX HIP 23MM RESTOR MODULAR REVISN BOLT +30MM NK CNCL -,SUP-6276-1-323,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
RESTORATION MODULAR HIP SYSTEM 25MM X 30 V40 -,SUP-6276-1-325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 14X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 15X155MM RESTOR REVISN MODULAR STR CNCL DIST HIP -,SUP-6276-7-015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 16X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 17X155MM RESTOR REVISN MODULAR STR CNCL DIST HIP -,SUP-6276-7-017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 18X155MM RESTOR REVISN MODULAR STR CNCL DIST HIP -,SUP-6276-7-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 19X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HIP RESTORATION MODULAR 20MM X 155MM -,SUP-6276-7-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
RESTORATION MODULAR HIP SYS 22MM X 155MM -,SUP-6276-7-022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 23X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-023,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 14X195MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10547.44,7383.208,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 14X195MM RESTOR REVISN MODULAR HIP -,SUP-6276-7-214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 15X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 16X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 19X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 21X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
RESTORATION MODULAR HIP SYSTEM 21MM X 195MM -,SUP-6276-7-221,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 24X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-224,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 15X235MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11716.67,8201.669,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
RESTORATION HIP STEM 235MM X 19MM -,SUP-6276-7-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11716.67,8201.669,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 22X235MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11716.67,8201.669,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SYS RESTORATION MOD HIP 18MM X 115MM -,SUP-6276-7-418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24628.33,17239.831,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM PCA 28X0MM NK COCR REVISN -,SUP-6280-0-136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM PCA 32MM +5MM NK COCR REVISN -,SUP-6280-0-232,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM PCA 36MM +5MM NK COCR REVISN -,SUP-6280-0-236,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM PCA 32MM +10MM NK COCR REVISN -,SUP-6280-0-332,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM PCA 36MM +10MM NK COCR REVISN -,SUP-6280-0-336,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 32X52-55MM DURATION 10DG UHMWPE PCA -,SUP-6299-7-525,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4020.85,2814.595,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINEAR STANDARD TRILOGY ACETABULAR SYSTEM -,SUP-6305-50-36,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5260.44,3682.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB SZ P6 28X62-64MM SHL S12 +4 10DG CROSSFIRE CONGR -,SUP-6352-5-076,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4458.11,3120.677,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CROSSFIRE SYSTEM 12 POLYETHYLENE INSERT 10 -,SUP-6352-5-105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4458.11,3120.677,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR SM 9MM PE PEGX3 AVON RND DOME REVISN OFST -,SUP-6430-0-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4079.19,2855.433,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR MED 9.5MM PE PEGX3 AVON RND DOME REVISN OFST -,SUP-6430-0-030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4079.19,2855.433,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR LRG 10MM PE PEGX3 AVON RND DOME REVISN OFST -,SUP-6430-0-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4079.19,2855.433,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM XS 43.5MMX42.5MM AVON KN CMNT PEGX4 COCR -,SUP-6430-0-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14140.63,9898.441,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM MED 50.3MMX47.5MM AVON KN CMNT PEGX4 COCR -,SUP-6430-0-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14140.63,9898.441,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 36MM E SHL TRIDENT 0DG ELEV RM ECCT X3 PRIM -,SUP-643-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIDENT ELEVATED RIM INSERT 36MM G -,SUP-643-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND XS KINEMAX PLUS PRFT REVISN MODULAR 80MM COCR -,SUP-6476-8-260,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3594.54,2516.178,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 14MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 16MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 19MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-645,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 23MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-665,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TITANIUM FLUTED 16MM X 155MM -,SUP-6478-6-715,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 17MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-720,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 21MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 SM M LT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 SM M RT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 MED M LT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 LRG M RT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-131,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
MRH KNEE FEMORAL DISTAL BLOCK MED 10MM -,SUP-6481-1-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3438.71,2407.097,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIB STD XS XL KN GMRS COCR MRH -,SUP-6481-2-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11254.62,7878.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL BEARING COMPONENT MRH -,SUP-6481-2-103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11254.62,7878.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ7 STD GMRS KN MODULAR REVISN BUSHNG COCR ROT HNG -,SUP-6481-2-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1628.47,1139.929,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ7 STD GMRS KN MODULAR REVISN AXLE COCR ROT HNG -,SUP-6481-2-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4454.42,3118.094,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB BEAR KN PE -,SUP-6481-2-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3005.95,2104.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
MRH KNEE BUMPER INSERT 3 DEGREES -,SUP-6481-2-133,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3005.95,2104.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE TIB SZ4 MODULAR BMPR DIST KN ROT HNG DURATION -,SUP-6481-2-140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2514.7,1760.29,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ1 KN GMRS COCR MODULAR KLD ROT HNG -,SUP-6481-3-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12573.67,8801.569,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ2 SM KN GMRS COCR MODULAR KLD ROT HNG -,SUP-6481-3-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12573.67,8801.569,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ2 LRG KN GMRS COCR MODULAR KLD ROT HNG -,SUP-6481-3-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12573.67,8801.569,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ1-2 XS/SM 10MM PS ARTCSURF KN PE -,SUP-6481-3-210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ1-2 XS/SM 13MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ1-2 XS/SM 16MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ1-2 XS/SM 20MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB MED 2/ L2 13MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5011.74,3508.218,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB MED 2/ L2 24MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-324,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5011.74,3508.218,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
KINEMATIC ROTATING HINGE KNEE XSM 8MM -,SUP-6485-2-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HINGE KNEE ROTATING SIZE XSM 11MM THKNS KINEMATIC -,SUP-6485-2-011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
KINEMATIC ROTATING HINGE KNEE -,SUP-6485-2-016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
KINEMATIC ROTATING  HINGE KNEE SM 8MM -,SUP-6485-2-108,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
KINEMATIC ROTATING HINGE KNEE -,SUP-6485-2-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
KINEMATIC ROTATING HINGE KNEE 16MM MEDIUM -,SUP-6485-2-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
KINEMATIC ROTATING HINGE KNEE LARGE 21MM -,SUP-6485-2-321,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM STRAIGHT CEMENTED 10MM X 102MM -,SUP-6485-3-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM REPLACEMENT STRAIGHT CEMENTED 8MM X 102MM -,SUP-6485-3-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM REPLACEMENT STRAIGHT 9MM X 102MM -,SUP-6485-3-019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM CEMENTED STRAIGHT 11 X 127 -,SUP-6485-3-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM MRS STRAIGHT CEMENTED 13 X 127 -,SUP-6485-3-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM-REPLACEMENT CURVED CEMENTED 10MM X 102MM -,SUP-6485-3-310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM REPLACEMENT CURVED CEMENTED 8MM X 102MM -,SUP-6485-3-318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM REPLACEMENT CURVED CEMENTED -,SUP-6485-3-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 11MM LNG GMRS MODULAR 203MM TI HAP PLASM SPRY CTD -,SUP-6485-3-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14897,10427.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 17X203MM MRS MODULAR COCR POR CTD CMNT CRV DIST HIP -,SUP-6485-3-617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14897,10427.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
MRS CURVED CEMENTED STEM 11MM X 127MM -,SUP-6485-3-811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
MRS CURVED CEMENTED STEM 13MM X 127MM -,SUP-6485-3-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM CEMENTED STEM 15 X 127 -,SUP-6485-3-815,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM CEMENTED 17MM X 127MM CURVED -,SUP-6485-3-817,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
GMRS PROXIMAL FEMORAL COMPONENT V40 -,SUP-6495-1-002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19014.24,13309.968,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT DISTAL FEMORAL SMALL LEFT 65MM -,SUP-6495-2-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27396.07,19177.249,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
DISTAL FEMORAL COMPONENT SMALL RT 65MM -,SUP-6495-2-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27396.07,19177.249,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM STD 65MM GMRS LT DIST KN MODULAR COCR ROT HNG -,SUP-6495-2-030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27152.28,19006.596,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM STD 65MM GMRS RT DIST KN MODULAR COCR ROT HNG -,SUP-6495-2-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27152.28,19006.596,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BUSHING FOR SMALL DISTAL FEMUR -,SUP-6495-2-105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1672.63,1170.841,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AXLE GMRS -,SUP-6495-2-115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4462.74,3123.918,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT FOR SMALL PROXIMAL TIBIAL COMPONENT 13MM -,SUP-6495-3-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT FOR SMALL PROXIMAL TIBIAL COMPONENT 24MM -,SUP-6495-3-024,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PROXIMAL TIBIA GMRS SM 80MM -,SUP-6495-3-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27343.31,19140.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIA PROXIMAL STD 80MM -,SUP-6495-3-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27343.31,19140.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL ROTATING COMPONENT SM -,SUP-6495-3-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11240.07,7868.049,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND GMRS REVISN MODULAR 30MM FEM KN -,SUP-6495-6-030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PIECE EXTENSION GMRS 40MM LENGTH -,SUP-6495-6-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
GMRS EXTENSION PIECE 50MM -,SUP-6495-6-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
EXTENSION PIECE GMRS -,SUP-6495-6-070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
GMRS EXTENSION PIECE 120MM -,SUP-6495-6-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
GRAFT HUM TIS 6X10CM TISSUEMEND COLL -,SUP-6495-9-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10181.42,7126.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD DELTA CERAMIC FEMORAL 36/-3MM -,SUP-650-0660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD DELTA CERAMIC FEMORAL 36/0MM -,SUP-650-0661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD DELTA CERAMIC FEMORAL 36/+3MM -,SUP-650-0662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CERAMIC HEAD BIOLOX DELTA  OP HIP SYSTEM 28MM -,SUP-650-1055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD CER BIOLOX D OPTION 28MM -,SUP-650-1055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD CER BIOLOXD OPTION 36MM -,SUP-650-1057,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CER OPTION TYPE 1 TPR SLEEVE +3 -,SUP-650-1067,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
+6MM NECK BIOLOCK OPTION HIP SYSTEM -,SUP-650-1068,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEMORAL G7 BIOLOX DELTA -3 MM OFFSET OD28 MM HIP -,SUP-650-1159,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL HEAD UNIVERSAL TAPER 28MM OD BIOLOX DELTA -,SUP-6519-1-028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL HEAD UNIVERSAL TAPER BIOLOX DELTA -,SUP-6519-1-032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 36MM UNIV +0MML NK BIOLOX DELTA CERM TAPR PRIM -,SUP-6519-1-036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEMORAL 40MM BIOLOX DELTA -,SUP-6519-1-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
UNIVERSAL V40  -2.5MM ADAPTER SLEEVE (TI) -,SUP-6519-T-025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE HIP UNIV V-40 RECON PRIM ADPTR +0MML NK OFST TI TAPR -,SUP-6519-T-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE HIP +4MM OFST UNIV V-40 RECON PRIM ADPTR TI TAPR -,SUP-6519-T-204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
IMPACTOR SURG F/TIB INS TRIATH -,SUP-6541-4-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2125.24,1487.668,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 36MM-5MM NK ALMN PRIM -,SUP-6565-0-036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 32X0MM NK ALMN PRIM -,SUP-6565-0-132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 28MM -2.7MM OFST BIOLOX DELTA CERAMIC -,SUP-6570-0-028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 32MM -4MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 36MM -5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 28MM +0MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-128,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 32MM +0MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 36MM +0MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 28MM +4MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-228,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 32MM +4MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-232,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 36MM +5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-236,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 36MM -2.5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-436,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 36MM +2.5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-536,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 36MM +7.5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-736,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 36X54-56MM F SHL TRIDENT 0DG ECCT X3 PRIM -,SUP-663-00-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT KN SZ1 SM DURACN 10MM WDG BLCK REVISN VITAL -,SUP-6630-6-510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5255.98,3679.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
DURACON TOTAL KNEE FULL FLAT TIBIAL WEDGE SM-2 10MM -,SUP-6630-6-515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5255.98,3679.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 32X46-48MM D SHL TRIDENT 10DG ECCT X3 16.8MM -,SUP-663-10-32D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 36X58-60MM G SHL TRIDENT 10DG ECCT X3 18.8MM -,SUP-663-10-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 36X62-64MM H SHL TRIDENT 10DG ECCT X3 20.4MM -,SUP-663-10-36H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CK Insert Trial Sz 4 8mm -,SUP-663-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CK Insert Trial Sz 5 16mm -,SUP-663-1516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB LRG 9X77/53MM DURACN CR A/P LIP ARTC L/R KN -,SUP-6642-1-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3601.27,2520.889,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT A-P LIPPED DURACON XLGE 9MM -,SUP-6642-1-909,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3601.27,2520.889,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR XS PE DURACON DURATION ASYM -,SUP-6642-2-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR MED PE DURACON DURATION ASYM -,SUP-6642-2-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SM 11MMX45MM A/P DURACN CNSTRN ARTC L/R KN -,SUP-6642-9-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB LRG 9MMX55MM ARTCSURF L/R KN PE -,SUP-6642-9-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB LRG 11MMX55MM A/P DURACN CNSTRN ARTC L/R KN -,SUP-6642-9-811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB LRG 13MMX55MM A/P DURACN CNSTRN ARTC L/R KN -,SUP-6642-9-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TibAugSz1Trial20Â°WedgeLtLat/RtMed -,SUP-667-2201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,945.27,661.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TibAugSz2Trial20Â°WedgeLtLat/RtMed -,SUP-667-2202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,945.27,661.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ2 33MM OFST 99MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ3 35MM OFST 102MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ4 38MM OFST 105MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ5 35MM OFST 108MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ6 41MM OFST 111MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ7 46MM OFST 114MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0737,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HIP ACCOLADE 132 SZ 8 -,SUP-6720-0837,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HIP 132 DEG SZ #9 37MM X 120MM V40 ANGLE ACCOLADE II -,SUP-6720-0937,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
NECK ANGLE HIP STEM SZ# 0 / 27MM / 93MM / V40 -,SUP-6721-0027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ1 34MM OFST 96MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ2 37MM OFST 99MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ3 30MM OFST 102MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ4 42MM OFST 105MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
ACCOLADE II SZ5 35MM NECK ANGLE HIP STEM 108MM V40 -,SUP-6721-0535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ6 35MM OFST 111MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ7 50MM OFST 114MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0737,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ8 51MM OFST 117MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0837,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ9 53MM OFST 120MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0937,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ10 57MM OFST 123MM ACCOLADE II V40 PRFT PRIM -,SUP-6721-1040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SM 9MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4186.89,2930.823,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SM 11MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4186.89,2930.823,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SM 16MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-116,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4186.89,2930.823,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ2 16MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB LRG 9MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-309,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 11MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB LRG 16MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 22X50-52MM D SHL TRIDENT 0DG ECCT UHMWPE CNSTRN -,SUP-690-00-22D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 22X50-52MM E SHL TRIDENT 0DG ECCT UHMWPE CNSTRN -,SUP-690-00-22E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 22X54-56MM F SHL TRIDENT 0DG ECCT UHMWPE CNSTRN -,SUP-690-00-28F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIDENT 0 DG ACETABULAR INSERT SZ H -,SUP-690-00-32H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIDENT ALL POLY CONSTRAINED ACETABULAR INSERT -,SUP-69-2244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10027.4,7019.18,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
ALL POLY CONSTRAINED INSERT 46MM -,SUP-69-2246,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10027.4,7019.18,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM UNITRAX 40MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM UNITRAX 42MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM UNITRAX 43MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM UNITRAX 46MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM UNITRAX 47MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-047,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE HIP UNITRAX V40 PRIM MODULAR UNIPL -4MM NK TAPR -,SUP-6942-6-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE HIP UNITRAX V40 PRIM MODULAR UNIPL +0MML NK TAPR -,SUP-6942-6-065,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE HIP UNITRAX V40 PRIM MODULAR UNIPL +8MM NK TAPR -,SUP-6942-6-075,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE HIP UNITRAX C UNIPL -3MM NK C-TAPR -,SUP-6942-7-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE HIP UNITRAX C UNIPL +0MML NK C-TAPR -,SUP-6942-7-065,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE HIP UNITRAX C UNIPL +5MM NK C-TAPR -,SUP-6942-7-075,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE HIP UNITRAX C UNIPL +10MM NK C-TAPR -,SUP-6942-7-085,CDM,C1776,HCPCS,278,RC,,,outpatient,,,810.6,567.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HIP HIGH OFFSET INSIGNIA SZ 4 X 36MM X 103MM -,SUP-7000-6604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL CLUSTERHOLE ACET 46MM C TRIDENT TRITANIUM -,SUP-702-04-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIDENT IITRITANIUM CLUSTERHOLE 48MM D -,SUP-702-04-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL TRIDENT II TRITANIUM CLUSTERHOLE ACETABULAR 50MM D -,SUP-702-04-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIDENT II TRITANIUM CLUSTERHOLE ACETABULAR SHELL -,SUP-702-04-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIDENT II TRITANIUM CLUSTERHOLE ACET SHELL 54MM -,SUP-702-04-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIDENT II TRITANIUM CLUSTERHOLE ACE SHELL 56MM F -,SUP-702-04-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIDENT II TRITANIUM CLUSTERHOLE ACE SHELL 58MM F -,SUP-702-04-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIDENT II TRITANIUM CLUST ACE SHELL SZ 60MM G -,SUP-702-04-60G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL CLUSTERHOLE ACET SIZE 62MM G TRIDENT II TRITANIUM -,SUP-702-04-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACET 64MM H TRIDENT II TRIT CLUSTERHOLE -,SUP-702-04-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
44MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-44B,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
46MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
48MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
52MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
54MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
56MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
58MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
60MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-60G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
62MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
64MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
66MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-66H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIDENT II TRITANIUM MULTIHOLE ACE SHELL 48MM D -,SUP-709-04-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL TRIDENT II TITAN MLTHLE ACE SIZE 52MM E -,SUP-709-04-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL TRIDENT II TRITANIUM MLTHOLE ACE 54MM E -,SUP-709-04-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIDENT II TRITANIUM MULTHL SHELL 56MM F -,SUP-709-04-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL MULTIHOLE ACETABULAR 62MM X G TRIDENT II TRITANIUM -,SUP-709-04-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL TRIDENT II TITANIUM 64MM H MULTIHOLE -,SUP-709-04-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL MULTIHOLE ACET SZ 66MM H TRIDENT II TRITANIUM -,SUP-709-04-66H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACETABULAR 68MM ALPHA I MULTIHOLE TRIDENT II TRITANIUM -,SUP-709-04-68I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP ACTB 22X42MM SHL TANDEM AN-ROT BIPLR COCR UHMWPE MAX -,SUP-71322042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2755.51,1928.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
REF XLPE 36 20 DEG 54-56F -,SUP-7133-3345,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9094.89,6366.423,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
ACET LINER 36 X 58 R3 20 DEG XLPE -,SUP-71335758,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6230.19,4361.133,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COVER SCR HL HIP THRD R3 REFLC STRL -,SUP-71336500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,407.81,285.467,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACETABULAR 58MM R3 MULTI HOLE -,SUP-71338668,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8734.15,6113.905,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
OXINIUM HD 12/14 22MM +4 -,SUP-71342204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7011.09,4907.763,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 36MM +0MML NK OXNM 12/14 TAPR STRL -,SUP-71343600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8339.46,5837.622,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
GNS II CMT TIB SIZE 2 LEFT -,SUP-71420162,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
GNS II CMT TIBIAL SIZE 3 LEFT -,SUP-71420164,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
GNS II CMT TIB SIZE 5 LEFT -,SUP-71420168,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ3 64/48MM RT KN CMNT GENESIS II NPOR -,SUP-71420182,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4286.44,3000.508,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
GNS II CMT TIB SIZE 4 RIGHT -,SUP-71420184,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
GNS II CMT TIB SIZE 6 RIGHT -,SUP-71420188,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
GNSII CON INS SZ3-4 11MM -,SUP-71420524,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT GENESIS II SZ 3-4 13MM -,SUP-71420526,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3-4 15MM 68-71MM M/L 48-50MM A/P GENESIS II -,SUP-71420528,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
GNS II CON INS SZ 3-4 18MM -,SUP-71420530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
GNS II CON INS SZ5-6 15MM -,SUP-71420542,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
GNS II RESUR PAT 29MM -,SUP-71420574,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
RESURF PAT GEN II 32MM -,SUP-71420576,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 35X9MM THK UHMWPE PEGX3 RSRFC GENESIS II -,SUP-71420578,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
GNS II RESURF PAT 26MM -,SUP-71420580,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5-6 13MM 74-77MM M/L 52-54MM A/P GENESIS II PS -,SUP-71420834,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2502.77,1751.939,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEGION CON ART INS 9MM SZ 1-2 -,SUP-71420959,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT G2 CONST SZ1-2 11MM -,SUP-71420960,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ARTICULAR G2 CONST SIZE 1-2 13MM -,SUP-71420962,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEMORAL SIZE 4 RIGHT LEGI -,SUP-71420964,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ1-2 18MM 60-64MM M/L 42-45MM A/P GENESIS II -,SUP-71420966,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LGN HM ST 3-4 5MM LTMD-RTLA -,SUP-71421142,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6854.06,4797.842,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ3 LEGION LT KN CNSTRN REVISN OXNM -,SUP-71421163,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LGN OX CONSTRAINED FEM 4 LT -,SUP-71421164,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LGN OX CONSTRAINED FEM 6 LT -,SUP-71421166,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT FEMORAL SIZE 4 RIGHT -,SUP-71421174,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29666.87,20766.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEGION OX CONSTRAINED FEM 5 RT -,SUP-71421175,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEGION PS OIN FEM SZ3 RT -,SUP-71421203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ4 LEGION RT KN PS OXNM POR -,SUP-71421204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10489.23,7342.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 LEGION RT KN PS OXNM POR -,SUP-71421205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ6 LEGION PS OXIN RIGHT -,SUP-71421206,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEGION PS OXIN FEM SZ4 LT -,SUP-71421214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEGION PS OXIN FEM SZ6 LT -,SUP-71421216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 LEGION RT KN CR REVISN OXNM POR -,SUP-71421225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9893.85,6925.695,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEGION CR OXIN FEM SZ6 RT -,SUP-71421226,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEGION NARROW PS OXIN SZ 4N LT -,SUP-71421264,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEGION NARROW PS OXIN SZ 6N LT -,SUP-71421266,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEGION NARROW PS OXIN SZ 5N RT -,SUP-71421275,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEGION NARROW PS OXIN SZ 6N RT -,SUP-71421276,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9574.46,6702.122,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3-4 13MM GENESIS II PS ARTC L/R KN-HI FLEX OXNM -,SUP-71421510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3539.59,2477.713,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
GEN II PS HIGH FLEXION ARTICULAR INSERT SZ 5-6 13 -,SUP-71421517,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5975.55,4182.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT DIST KN SZ3 LEGION 10MM WDG BLCK -,SUP-71421658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
WEDGE FEM LGN SCRW DIS SZ4 5MM -,SUP-71421661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEGION SCREW DIS FEM WDG SZ5 5MM -,SUP-71421664,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6068.92,4248.244,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEGION SCW LWDG S5 5D X 5P -,SUP-71421741,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8891.18,6223.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
JUNI OX FB FEM SZ 3 LM RL -,SUP-71422343,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
JUNI OX FB FEM SZ 5 LM RL -,SUP-71422345,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
JUNI OX FB FEM SZ 7 LM RL -,SUP-71422347,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT FEMORAL JOURNEY OXINIUM SZ 5 RM LL -,SUP-71422355,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LGN RK/HK HEMI SZ 3-4 LL/RM 5MM -,SUP-71423420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8496.49,5947.543,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LGN RK/HK HEMI SZ 3-4 LM/RL 5MM -,SUP-71423432,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8496.49,5947.543,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEGION REVISION TIBIAL BASEPLATE -,SUP-71424001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE REVISION LONG TIBIA SIZE 2 LT -,SUP-71424002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIA BASE LGN REV SIZE 4 LT -,SUP-71424004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LGN REV TIBIA BASE SZ 5 LT -,SUP-71424005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIBIAL SIZE 2 RIGHT -,SUP-71424012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11863.04,8304.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ3 RT KN LEGION TI REVISN -,SUP-71424013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEGION REV TIBIA BASE SZ 5 RT -,SUP-71424015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM PRESSFIT LONG 10MM X 120MM -,SUP-71424023,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LGN PRESSFIT STEM 12MM X 120MM -,SUP-71424025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 13MM LEGION PRFT REVISN 120MM TI FEM KN -,SUP-71424026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM STRAIGHT 14MM X 120MM LEG -,SUP-71424027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM LGN PRESSFIT 15MM X 120MM -,SUP-71424028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LGN PRESSFIT STEM 16MM X 120MM -,SUP-71424029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTENSION LEGION TI PRESSFIT 18MM X 120MM -,SUP-71424031,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LGN PRESSFIT STEM 11MM X 160MM -,SUP-71424044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM LGN PRESSFIT 12MM X 160MM -,SUP-71424045,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM LGN PRESSFIT 13MM X 160MM -,SUP-71424046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LGN PRESSFIT STEM 15MM X 160MM -,SUP-71424048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 16MM LEGION PRFT REVISN 160MM TI FEM KN -,SUP-71424049,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM LGN CEMENT 14MM X 160MM STRT -,SUP-71424206,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6527.27,4569.089,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LGN OFFSET COUPLER 2MM -,SUP-71424223,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6132.58,4292.806,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LGN OFFSET COUPLER 4MM -,SUP-71424225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6132.58,4292.806,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LGN CR HIGH FLEX XLPE SZ 3-4 9MM -,SUP-71453111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT LEGION CR HIGH FLEX XLPE SZ 3-4 -,SUP-71453112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3-4 9MM LEGION CR KN XLPE -,SUP-71453146,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LGN PS HIGH FLEX XLPE SZ 1-2 10MM -,SUP-71453171,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LGN PS HIGH FLEX XLPE SZ 3-4 12MM -,SUP-71453174,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LGN PS HIGH FLEX XLPE SZ 1-2 15MM -,SUP-71453204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LGN PS HIGH FLEX XLPE SZ 3-4 9MM -,SUP-71453211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEGION PS HIGH FLEX XLPE SZ 3-4 11MM -,SUP-71453212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LGN PS HIGH FLEX SLPE SZ 3-4 13MM -,SUP-71453213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEGION PS HIGH FLEX XLPE SZ 3-4 15MM -,SUP-71453214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4308.51,3015.957,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LGN PS HIGH FLEX XLPE SZ 5-6 15MM -,SUP-71453224,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3-4 13MM PS KN LEGION XLPE -,SUP-71453248,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LGN XLPE DISHED ISRT SZ 5-6 15MM -,SUP-71453287,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
JOURNEY PFJ IMPLANT X-SM LT -,SUP-71461010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
JOURNEY PFJ IMPLANT X-SMALL RIGHT -,SUP-71461011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12604.89,8823.423,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
JOURNEY PFJ IMPLANT SM LT -,SUP-71461012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
JOURNEY PF IMPLANT SM RT -,SUP-71461013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SCREW 5MMX55MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642255,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
UNIPL -,SUP-71701035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14184.25,9928.975,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 38X9MM THK GENESIS II REVISN PS -,SUP-71926225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
GEN II 7.5MM RESUR PAT 26MM -,SUP-71932634,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
GEN II 7.5MM RESUR PAT 29MM -,SUP-71932635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3366.62,2356.634,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEGION REV TIB BASE W/JRNY LOCK SZ 5 -,SUP-71933571,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11863.04,8304.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CONE TIB LGN ID 18 SHORT -,SUP-71935386,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22278,15594.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
WEDGE TIB LEGION CONE ID 20 SHORT -,SUP-71935387,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21210.51,14847.357,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEGION TIB CONE ID 22 SHORT -,SUP-71935388,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21210.51,14847.357,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL CONE LEGION 18 LONG -,SUP-71935393,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22927.78,16049.446,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEGION TIB CONE ID 22 LONG -,SUP-71935395,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21210.51,14847.357,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEM CONE LGN ID 18MM LEFT -,SUP-71935400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22324.41,15627.087,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEGION FEM CONE ID 20MM LEFT -,SUP-71935401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22324.41,15627.087,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEGION FEM CONE ID 22MM LEFT -,SUP-71935402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22324.41,15627.087,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
WEDGE FEMORAL LEGION CONE ID 18MM KNEE RIGHT -,SUP-71935407,CDM,C1776,HCPCS,278,RC,,,outpatient,,,23447.6,16413.32,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEMORAL ANTHOLOGY AFIT SO POR PL HA SZ7 -,SUP-71935567,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6009.5,4206.65,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SCROPIO-FLEX X3 TIBIAL BEARING INSERT CR SZ11 -,SUP-72-26-1110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 36X46-48MM D SHL TRIDENT 0DG NEUT X3 3.9MM PRIM -,SUP-723-00-36D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 36X50-52MM E SHL TRIDENT 0DG NEUT X3 5.9MM PRIM -,SUP-723-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 40X54-56MM G SHL TRIDENT 0DG X3 5.8MM PRIM -,SUP-723-00-40F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 28MM X 54MM RESTOR ADM/MDM X3 48G -,SUP-7236-2-854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ7 24X71/47MM 18X27MM SCORP CNSTRN TOTAL -,SUP-72-4-0724,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5828.45,4079.915,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PIN NONRIM SPEED 65 STERILE -,SUP-74013480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,128.37,89.859,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PIN NONRIM SPEED 80 STERILE -,SUP-74013490,CDM,C1776,HCPCS,278,RC,,,outpatient,,,122.54,85.778,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
JOURNEY II CR FEM OX NP RT SZ. 4 -,SUP-74021154,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP JRNY II CR FEM OX NP LT SZ 4 -,SUP-74021164,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
JRNY II BCS FEMORAL OXIN RT SZ 3 -,SUP-74022113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
JOURNEY TIBIA BASE NP RT SZ 2 -,SUP-74022212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
JOURNEY TIBIA BASE NP RT SZ 3 -,SUP-74022213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
JOURNEY TIBA BASE NP RT SZ. 4 -,SUP-74022214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4218.31,2952.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
JOURNEY TIBIA BASE NP LT SZ3 -,SUP-74022223,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
JOURNEY BCS PAT RESRF RD 32 MM STD -,SUP-74024832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2017.9,1412.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
JOURNEY II CR ISRT XLPE RT SZ 3-4 9MM -,SUP-74025631,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
JRNY II ISRT XLPE DD LT SZ 3-4 9MM -,SUP-74025741,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
JRNY II BCS XLPE ART ISRT SZ 1-2 RT 12MM -,SUP-74027214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
JRNY II BCS XLPE ART ISRT SZ 5-6 LT 12MM -,SUP-74027264,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
44MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-44B,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
48MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
50MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
52MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
54MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
56MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
58MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
64MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
POLARCUP XLPE INSERT 43/22 NON-CEM -,SUP-75018942,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4478.01,3134.607,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
POLARCUP SHELL 43 CEMENTED -,SUP-75100451,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT DIST KN SZ7 SCORP 5MM WDG BLCK CMNT SPCR TOTAL -,SUP-75-1-0705,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4305.81,3014.067,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT POST KN SZ7 SCORP 5MM WDG BLCK SPCR TOTAL STABILIZED -,SUP-75-2-0705,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4305.81,3014.067,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL LEFT MEDIAL SZ 4 NON-POROUS -,SUP-761-1401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL LEFT MEDIAL SIZE 6 NON-POROUS -,SUP-761-1601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL TRAY LEFT MEDIAL SIZE 3 NON-POROUS -,SUP-762-3100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL TRAY LEFT MEDIAL SZ 4 NON-POROUS -,SUP-762-4100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TRIDENT X3 ECCENTRIC 0DEG 36MM -,SUP-763-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT LEFT MEDIAL SZ 4 7MM -,SUP-763-4071,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ7 66MM M/L 60-62MM A/P SCORP LT KN TOTAL -,SUP-76-4107L,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17711.12,12397.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL HEAD 12/14 COCR 36MM +3.5 -,SUP-8018-36-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD 12/14 COCR FRDM 36MM X +6 -,SUP-802403605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7259.36,5081.552,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
3.5MM CORT LOCK SCR 48MM NS -,SUP-816135048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,882.25,617.575,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SPACER NO PROFILE 16 X 14 X 8MM 7IN STERILE SHORELINE -,SUP-85-0208-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9039.72,6327.804,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ4 76/51MM L/R KN PFC TI CR MODULAR + NPOR -,SUP-86-0124,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11851.9,8296.33,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ2 64/43MM L/R KN PFC SIG KLD NPOR -,SUP-86-4180,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TAPER SIDMA 13 X 120 CEMENTED -,SUP-86-6498,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TAPER 13 X 150 -,SUP-86-6499,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 12MM UNIV PFC PRFT MODULAR 75MM CMNT TIB KN -,SUP-86-7412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 14MM UNIV PFC PRFT MODULAR 75MM CMNT TIB KN -,SUP-86-7414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM UNIVERSAL FLUTED 75MM X 18MM -,SUP-86-7418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM UNIVERSAL FLUTED 75MM X 24MM -,SUP-86-7421,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FLUTED 115 X 16MM -,SUP-86-7430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM UNIVERSAL FLUTED 115MM X 18MM -,SUP-86-7432,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM UNIVERSAL FLUTED 115MM X 20MM -,SUP-86-7433,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM RADIAL ALIGN TITANIUM 11MM X 0MM -,SUP-90176510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10481.8,7337.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 28X48-50MM X-ALT 0DG NEUT STD HXLPE 6MM NON- HD F -,SUP-931-28-248,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 36X52-54MM X-ALT 0DG NEUT STD HXLPE 6MM HD F /FMP -,SUP-932-36-252,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ2.5 63/59MM SIGMA FB RT KN CR CMNT COCR NPOR -,SUP-96-0018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7199.14,5039.398,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SIGMA TC3 FEM RT SZ2 -,SUP-96-0087,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL TC3 CEMENTED SIGMA SIZE 5 RIGHT -,SUP-96-0090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL TC3 CEMENTED SIGMA SIZE 2.5 RIGHT -,SUP-96-0092,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 32MM XS UHMWPE PEGX3 PFC SIG OVL DOME -,SUP-96-0100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 38MM STD UHMWPE PEGX3 PFC SIG OVL DOME -,SUP-96-0102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 41MM LRG UHMWPE PEGX3 PFC SIG OVL DOME -,SUP-96-0103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
ADAPTER FEM 5DG PFC SIGMA TC3 KN REVISN CMNT TI -,SUP-96-0781,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8615.53,6030.871,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BOLT FEMORAL ADAPTER +2/-2 OFF -,SUP-96-0784,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1623.81,1136.667,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
DISTAL AUGMENT SIZE 2 4MM RIGHT -,SUP-96-0821,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
DISTAL AUGMENT SIZE 2 8MM RIGHT -,SUP-96-0823,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
DISTAL AUGMENT SIZE 2.5 8MM RIGHT -,SUP-96-0843,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
DISTAL  AUGMENT  COMBO  SIZE 2.5 16MM RIGHT -,SUP-96-0852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT FEM SZ4 PFC SIG POST KN WDG/BLCK 4MM COCR -,SUP-96-0886,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMBO PFC SIGMA POST AUG CEMENTED SIZE 5 X 8MM -,SUP-960908,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMBO PFC SIGMA DIST AUG CEMENTED SIZE 6 X 12MM LEFT -,SUP-96-0909,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMBO PFC SIGMA DIST AUG CEMENTED SIZE 6 X 16MM LEFT -,SUP-96-0911,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5 10MM 74MM/47MM M/L/A/P PFC SIG PS ARTCSURF -,SUP-96-2051,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT ROTATING PLTFRM SIZE 3 X 12.5MM -,SUP-96-2132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBAL INSERT ROT PLAT STAB SZ4 12.5MM -,SUP-96-2142,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBAL INSERT ROTATING PLATFORM (STAB) 4- 20MM -,SUP-96-2145,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT ROT PLTFRM TC3 SZ 2 12.5MM -,SUP-96-2322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT ROTATING PLATFORM SIZE 2 20MM -,SUP-96-2325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT ROTATING PLATFORM TC3 SZ 12.5 -,SUP-96-2332,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT ROTATING PLTFRM SZ3 30MM -,SUP-96-2348,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT TC3 RP S4 12.5 -,SUP-96-2352,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL PLATFORM TCS SZ 5 GVF 22.5MM -,SUP-96-2366,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ3 8MM KN PFC SIG UHMWPE CR POST LIP -,SUP-96-2540,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6645.51,4651.857,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5 15X89/55MM PFC SIG PS TCMPRTMNTL BEAR ARTC -,SUP-97-0473,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM UNIPL COCR POR -,SUP-98000100400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12559.22,8791.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
KT THR PRFT SUMMIT -,SUP-98-0001-006-00,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12559.22,8791.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB LRG VIVACIT VIT-E XLNK PE CNSTRN F/T/H ARTHPL -,SUP-98000125053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21605.69,15123.983,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
KT THR PRIM KINECTIV -,SUP-98000132001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21605.69,15123.983,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
KT THR PERSONA -,SUP-98-0002-415-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21605.69,15123.983,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SYS TKR PRIM CONSTRUT -,SUP-98000600000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20654.23,14457.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 10MM PFC SIG MODULAR CS STAB ANTMC KN POR CTD -,SUP-98-6061,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINK NECK SEGMENT WITHOUTH COLLAR 12/14MM 126 DEG 65MM -,SUP-99-0984/30,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19311.31,13517.917,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE HIP +5MM 12/14 TAPR ASR UNIPL -,SUP-9998-00-315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1022.29,715.603,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE HIP +8MM 12/14 TAPR ASR ADPR UNIPL -,SUP-9998-00-318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
RADIAL HEAD 22MM -,SUP-ALN-RH1-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9803.64,6862.548,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD RADIAL 20MM -,SUP-ALN-RHI-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9803.64,6862.548,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
RADIAL HEAD 24MM -,SUP-ALN-RHI-240,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9803.64,6862.548,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM 8MM X 0MM -,SUP-ALN-RST-0800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM 8MM X 2MM -,SUP-ALN-RST-0802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
RADAIL STEM ALIGN 9MM X 0MM -,SUP-ALN-RST-0900,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM 10MM X 0MM -,SUP-ALN-RST-1000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PACKAGED RADIAL STEM 11MM X 2MM -,SUP-ALN-RST-1102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT KN 7DG 8DG XL LRG 9.83 MDL OPN 78-88MM 88-96 MM -,SUP-AR-13400L-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT KN 11DG 12DG XL LRG 14.13 MDL OPN 78-88MM 88-96 MM -,SUP-AR-13400L-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PIP DART PEEK 10 DEGREE 2.5X30MM -,SUP-AR-4154PS-3010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
IMPLANT PIP 3MM PEEK 30MM 10DG ANG -,SUP-AR-4155PS-3010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SCREW 7X12 PROSTOP ARTHROEREISIS -,SUP-AR-4207-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SCREW 8 X 14 MM PROSTOP SFT THRD -,SUP-AR-4208-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6154.44,4308.108,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SCREW 9X14 PROSTOP ARTHROEREISIS -,SUP-AR-4209-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SCREW 10X14MM PROSTOP SFT THRD CNCL TI F /ARTHROEREISIS -,SUP-AR-4210-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SCREW 11X16MM PROSTOP SFT THRD CNCL TI F /ARTHROEREISIS -,SUP-AR-4211-16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SCREW 12X16 PROSTOP ARTHROEREISI S -,SUP-AR-4212-16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
"GUIDE WIRE .045"" X 5.91"" -",SUP-AR-8933K,CDM,C1776,HCPCS,278,RC,,,outpatient,,,40.85,28.595,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUMERAL UNIVERS  SZ 6 -,SUP-AR-9100-06P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13645.28,9551.696,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 10MM UNIVERS II 148MM SHLDR -,SUP-AR-9100-10P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13645.28,9551.696,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
GLENOID UNIV BASEPLATE SMALL -,SUP-AR-9120-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7278.46,5094.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 54X23MM UNIVERS II ECCT -,SUP-AR-9154-23P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
ANATOEMIC PROSTHESIS 17MM -,SUP-AR-9500-170,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
ANATOEMIC PROSTHESIS 18.5MM -,SUP-AR-9500-185,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
ANATOEMIC PROSTHESIS 20MM -,SUP-AR-9500-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
ANATOEMIC PROSTHESIS 21.5 MM -,SUP-AR-9500-215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
RESTRICTOR CEMENT REV 30MM -,SUP-B000-0300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
REVERSE BODY STANDARD AND REVERSE BODY SCREW -,SUP-BBS-0960-21STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS PRIMARY PROXIMAL BODY 2.5 08STD -,SUP-BOD-0923-020-08STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BODY TSS PRIMARY PROXIMAL 10 LRG -,SUP-BOD-0923-020-10LRG,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BODY TSS PRIMARY PROXIMAL 10 STD -,SUP-BOD-0923-020-10STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BODY TSS PRIMARY PROXIMAL 2.5 X 12 STD -,SUP-BOD-0923-020-12STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BODY HUM LRG 40MM TI PROX GFT TITAN F/MODULAR SHLDR SYS -,SUP-BOD-0923-020-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6836.57,4785.599,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BODY TSS PRIMARY PROX 2.5 14 LRG -,SUP-BOD-0923-020-14LRG,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS PRIMARY PROXIMAL BODY 2.5 14STD -,SUP-BOD-0923-020-14STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS FRACTURE BODY 2.5 08LRG -,SUP-BOD-0923-021-08LRG,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS FRACTURE BODY 2.5 08STD -,SUP-BOD-0923-021-08STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
ULNAR STEM 5.0MM 2CM EXT STEM -,SUP-DRUJ-IS250,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9932.28,6952.596,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AEQREVSD FX/ADAPTER LATRLZD HMRL INSRT 36MM 9MM -,SUP-DWD861,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8929.38,6250.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AEQUALIS REVERSED FX STEM 11MM X 130MM -,SUP-DWD903,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24223.61,16956.527,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TORNIER PERFORM REVERSED STANDARD GLENOSPHERE DIA 36MM -,SUP-DWJ012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15178.74,10625.118,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB SZ23 36MM MAX-ROM RINGLOC +3 HW E1 -,SUP-EP108323,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BEARING E1 44-36 STD HMRL -,SUP-EP-115393,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB 10X71/75MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-EP-183540,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB 12X71/75MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-EP-183542,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB 18MMX67MM M/L VANGRD ANT STAB MODULAR ARTC BEAR -,SUP-EP-189048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
ACT ARTIC E1 HIP BRG 28X42MM -,SUP-EP-200148,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
ACT ARTIC E1 HIP BRG 28X44MM -,SUP-EP-200150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
ACT ARTIC E1 HIP BRG 28 X 50MM -,SUP-EP-200156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
IMPLANT TOE JOINT PRIMUS SIZE 40 -,SUP-FGT-40T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6915.85,4841.095,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
RSS GLENOID BASEPLATE-S -,SUP-GBP-0961-094-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS PEGGED GLENOID XS -,SUP-GLN-0920-030-00P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9802.32,6861.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
GLENOID TSS PEGGED S -,SUP-GLN-0920-030-01P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4010.16,2807.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS PEGGED GLENOID S -,SUP-GLN-0920-030-01P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9802.32,6861.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS PEGGED GLENOID -,SUP-GLN-0920-030-02P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9802.32,6861.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS PEGGED GLENOID L -,SUP-GLN-0920-030-03P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4010.16,2807.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
GLENDOID S FIN-LOCK -,SUP-GLN-0926-030-01A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5882.18,4117.526,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
RSS GLENOSPHERE CONCENTRIC -S 2MM -,SUP-GLS-0961-02C-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
RSS GLENOSPHERE CONCENTRIC -S 5MM -,SUP-GLS-0961-05C-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS PEGGED GLENOID XS -,SUP-GN092003000P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10292.44,7204.708,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
KEY SURG 26MM F /UHR ACTB HEAD REM -,SUP-HIUHRK26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1195.26,836.682,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASE PLATE ASSEMBLY IJS-E -,SUP-IJS-ELB-BPA,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21316.33,14921.431,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STANDARD POLY LINER +0 -,SUP-LNR-0960-00S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
RSS HXL LINER STANDARD +35 -,SUP-LNR-0960-191-3S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
RSS HXL LINER STANDARD +65 -,SUP-LNR-0960-191-6S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
RSS HXL LINER STANDARD +9S -,SUP-LNR-0960-191-9S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
RSS HXL LINER STANDARD +OS -,SUP-LNR-0960-191-OS,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
RSS HXL LINER RETENTIVE +6R -,SUP-LNR-0960-192-6R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SYSTEM GREAT TOE MOVEMENT PROX PHALANX HEMI -,SUP-MGT-890-20PPH,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10627.83,7439.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SYS MOVEMENT GREAT TOE SIZE 40 HEMI PROX PHALANX -,SUP-MGT89040PPH,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10627.83,7439.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 44X19MM TITAN 2.5 ECCT COCR -,SUP-MHH-0920-010-4419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6991.01,4893.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS COCR ECCENTRIC HEAD 2.5 40 X 15MM -,SUP-MHH-0923-010-4015E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS COCR CONCENTRIC HEAD 2.5 44 X 19MM -,SUP-MHH-0923-010-4419C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD TSS COCR ECCENTRIC 2.5 44 X 19MM -,SUP-MHH-0923-010-4419E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CONCENTRIC HEAD TSS COCR 2.5 46 X 14MM -,SUP-MHH-0923-010-4614C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS COCR ECCENTRIC HEAD 2.5 46 X 14MM -,SUP-MHH-0923-010-4614E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD CONCENTRIC TSS COCR 2.5 46MM X 17MM -,SUP-MHH-0923-010-4617C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD TSS COCR ECCENTRIC 2.5 46 X 17MM -,SUP-MHH-0923-010-4617E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS COCR CONCENTRIC HEAD 2.5 46 X 20MM -,SUP-MHH-0923-010-4620C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS COCR CONCENTRIC HEAD 2.5 48 X 18MM -,SUP-MHH-0923-010-4818C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM COCR CONC 2.5 X 48 X 21MM TSS -,SUP-MHH-0923-010-4821C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD TSS COCR ECCENTRIC 2.5 48 X 21MM -,SUP-MHH-0923-010-4821E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS COCR CONCENTRIC HEAD 2.5 50 X 19MM -,SUP-MHH-0923-010-5019C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS COCR CONCENTRIC HEAD 2.5 50 X 22MM -,SUP-MHH-0923-010-5022C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD TSS COCR CONCENTRIC 2.5 52 X 20MM -,SUP-MHH-0923-010-5220C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
IMPLANT SZ30 -,SUP-MHT-30,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6017.99,4212.593,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT LT SIZE 7 FEMORAL CR NONPOROUS COCR -,SUP-ORTHO DEV,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEMORAL 36MM +3 BIOLOX DELTA -,SUP-ORTHO DEV,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL PS 8MM SIZE 5 VITAMIN E -,SUP-ORTHO DEV,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM PLASMA SPRAY STD SIZE 11 -,SUP-ORTHO DEVELOPMENT,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIB SZ1 STRIDE LL/RM -,SUP-PFSI-00001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIB SZ2 STRIDE LL/RM -,SUP-PFSI-00003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIB SZ2 STRIDE RL/LM -,SUP-PFSI-00004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STRIDE TIBIA BASEPLATE SIZE 3 RM/LL -,SUP-PFSI00005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIB SZ3 STRIDE LL/RM -,SUP-PFSI-00005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIB SZ3 STRIDE RL/LM -,SUP-PFSI-00006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBIAL STRIDE SZ 4 RMLL -,SUP-PFSI00007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STRIDE TIBIA BASEPLATE SZ. 4 LM/RL -,SUP-PFSI00008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIB SZ4 STRIDE RL/LM -,SUP-PFSI-00008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIB SZ5 STRIDE LL/RM -,SUP-PFSI-00009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5156.46,3609.522,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL 8MM SIZE A -,SUP-PFSI00021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ A 9MM -,SUP-PFSI-00022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ B 8MM -,SUP-PFSI00027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STRIDE POLY INSERT SZ. B 8MM -,SUP-PFSI00027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STRIDE POLY INSERT TIB SZ-C 8MM -,SUP-PFSI00033,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ1 STRIDE LL/RM -,SUP-PFSI-00052,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STRIDE FEMUR SZ. 3 LM/RL -,SUP-PFSI00055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10492.44,7344.708,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ3 STRIDE LL/RM -,SUP-PFSI00056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10492.44,7344.708,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STRIDE FEMUR SIZE 4 RM/LL -,SUP-PFSI00058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10492.44,7344.708,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 STRIDE LL/RM -,SUP-PFSI-00060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP COMPREHESIVE MODULAR HYBRID REGNREX SHLDR POST -,SUP-PT-113950,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 9MM LNG REUNION COCR HAP CTD SHLDR -,SUP-R53514509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SPACER KN 46MM FEM MODHD ANTBTC REMEDY -,SUP-RHHDSM,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8093.31,5665.317,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM MED MODULAR -,SUP-RHSTMD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM REFLEX HYBRID 32MM +2.5MM NK COCR C-TAPR PRIM LFRIC -,SUP-S1400HH32,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
C-TAPER LFIT INTER HEAD 28MM +2.5 -,SUP-S-1400-HH82,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
C-TAPER HEAD +7.5 OFFSET LFIT SZ. 28MM / +7.5 -,SUP-S-1400-HH84,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PEG 4 MOD GLEN SZ 2 -,SUP-SAGL2042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
4 PEG MOD GLEN SZ 3 -,SUP-SAGL2043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PEG 4 MOD GLEN SZ 4 -,SUP-SAGL2044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PEG 4 MOD GLEN SZ5 -,SUP-SAGL2045,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT 4 PEG MOD GLEN LT AUG SZ 2 -,SUP-SAGL2142,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
4 PEG MOD GLEN LT AUG SZ 3 -,SUP-SAGL2143,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PEG 4 MOD GLEN LT AUG SZ 5 -,SUP-SAGL2145,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
4 PEG MOD GLEN RT AUG SZ 2 -,SUP-SAGL2242,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
4 PEG MOD GLEN RT AUG SZ 3 -,SUP-SAGL2243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
4 PEG MOD GLEN RT AUG SZ 4 -,SUP-SAGL2244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PEG 4 MOD GLEN RT AUG SZ 5 -,SUP-SAGL2245,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
MODULAR POST PPS -,SUP-SAGP0001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
MODULAR POST TM -,SUP-SAGP0002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 10MM SHLDR -,SUP-SEM092002510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
OXINIUM LEGION PS-SPC FEMUR LEFT SIZE 5 -,SUP-SMITH & NE,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9155.58,6408.906,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 16.7MM PROX 10MM DIST SM 150MM INTSPC HI RELS 25MM -,SUP-SPC0022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12735.59,8914.913,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 10.5MM/21.9MM DIA P/D MED/SHRT 156MM INTSPC HI RELS -,SUP-SPC0122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12364.29,8655.003,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SPACER THR CMNT XL 54MM HIP REVISN INTSPC -,SUP-SPC0421,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11101.87,7771.309,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 10.5MM/21.9MM DIA P/D MED LNG 271MM INTSPC HI RELS -,SUP-SPC0422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SPACER THR CMNT LNG STM 60MM HIP REVISN INTSPC -,SUP-SPC0522,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
SMART TOE INTRAMEDULLARY ARTHRODEAL 11MM -,SUP-ST0XS-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6409.29,4486.503,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS PRESS FIT STEM SZ. O7 -,SUP-STEM-0920-025-07,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS PRESS FIT STEM SIZE 08 -,SUP-STEM-0920-025-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS PRESS FIT HUM STEM SIZE 09 -,SUP-STEM-0920-025-09,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 12MM PRFT TITAN -,SUP-STEM-0920-025-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS PRESS FIT STEM SZ 10 -,SUP-STEM-0920-025-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 11MM PRFT TITAN -,SUP-STEM-0920-025-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM PRESS FIT TSS SZ 12 -,SUP-STEM-0920-025-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 13MM PRFT TITAN -,SUP-STEM-0920-025-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS PRESS FIT STEM SZ 14 -,SUP-STEM-0920-025-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM PRESS FIT TSS SZ 15 -,SUP-STEM-0920-025-15,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS PRESS FIT STEM SIZE 16 -,SUP-STEM-0920-025-16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS CEMENTED STEM SZ 08 -,SUP-STEM-0950-025-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ECCENTRIC CUP 10' X 36MM X3 CODE E TRIDENT -,SUP-STRYKER,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
WEDGE ACETABULAR AUGMENT 54MM X 56MM X 15MM -,SUP-STRYKER,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP VRSDL GLNSPR 36MM TI -,SUP-TI-115310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP ACTB 26X42MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-42-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP ACTB 26X43MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-43-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP ACTB 26X44MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-44-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP ACTB 26X45MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-45-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP ACTB 26X46MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-46-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP ACTB 26X47MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-47-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP ACTB 26X48MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-48-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP ACTB 26X50MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-50-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP ACTB 26X51MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-51-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP ACTB 26X52MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-52-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP ACTB 26X53MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-53-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP ACTB 26X54MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-54-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP ACTB 26X55MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-55-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP ACTB 26X56MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-56-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP ACTB 26X58MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-58-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT TIBIAL HALF BLOCK #6 T -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT FEM DIST 12MM SIZE 4 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE MED GLENOID UNIVER -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7278.46,5094.922,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE 3LT REV TIBIA LNG -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT LT MOD FEM SIZE 3 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CONE FEMORAL MEDIUM LEFT 30MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CONE TIBIAL 31 X 31 X 25MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CONE PROX BODY SIZE 0 60MM TYP -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT LGN OX FEMORAL 5LT C -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CUP PIVOT BIPOLAR 22 X 45MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
CUP UNIVERS REVERS 39 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7575.54,5302.878,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
GLENOID REVERS 39 +4 LAT -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT HUMERAL M/39 +3 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
GLENOID POLY WITH PEG LG -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
GLENOID POLY WITH PEG SMALL -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD 40 CER 16/18 TAPER BIOLOXD -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
HUMERAL HEAD UNIVERS 44/17 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL #5 13MM TS -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HIP MODULAR 12MM X 127MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10941.84,7659.288,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
POSTERIOR FEM AUGMENT 8MM SZ 4 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIB TRAY ROTATING REV  SZ 2 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM DIST CONICAL 21MM X 155MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM STR DIST 21MM X 150MM TAP -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HIP MODULAR 13MM X 127MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10941.84,7659.288,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM STR DIST 21MM X 90MM TAPE -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM UNIVERS SZ10 CAP COATED -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10546.34,7382.438,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBAL INSERT TOTAL STAB SZ.3 9 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIAL CONE MED 31 X 31 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2768.92,1938.244,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIAL KNEE INSERT 3X12 PS ORTH -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
WEDGE ACET AUGMENT 46MM X 15MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL HALF BLOCK #6 5MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPR NANO HMRL PPS 36MM -,SUP-US-115736,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24134.5,16894.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPR NANO HMRL PPS 38MM -,SUP-US-115738,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24134.5,16894.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPR NANO HMRL PPS 40MM -,SUP-US-115740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24134.5,16894.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
BEARING HUM 44-36MM XL STD RVRS CMPRHNSV ARCM -,SUP-XL115363,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
ARCOM XL 44-36 STD HMRL BRNG -,SUP-XL-115363,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
44MM X 36MM CURV HUMERAL BEARING -,SUP-XL-115364,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
PERSONA FEMUR CEMENTED STD CCR SIZE 7 LEFT -,SUP-ZIMMER,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEAD DEFIB IMPL BIPLR PERMNT PCNG ETAK RELIANCE 59CM 9FR -,SUP-0137,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC,,
ENDOTAK RELIANCE S 64CM REF: 0138 -,SUP-0138,CDM,C1777,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC,,
LEAD PCNG 64CM ETAK RELIANCE SG -,SUP-0181,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC,,
ENDOTAK RELIANCE S 0272 59CM -,SUP-0272-59,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC,,
ENDOTAK RELIANCE S 0273 64CM -,SUP-0273-64,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC,,
LEAD ENDOTAK RELIANCE SINGLE C -,SUP-0292,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC,,
LEAD DEFIB PCNG ETAK RELIANCE 59CM GORE-HYBRID ETFE CTD STRD -,SUP-0292-59,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC,,
LEAD ICD RELIANCE 4-FRONT DEFIB -,SUP-0672-59,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC,,
LEAD DEFIB IMPL LINOX SMRT S 65CM ECRD SIL INSL SGL COIL -,SUP-369818,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC,,
LEAD DEFIB IMPL LINOX SMRT S 60CM ECRD SIL INSL SGL COIL -,SUP-375012,CDM,C1777,HCPCS,278,RC,,,outpatient,,,12976.94,9083.858,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC,,
LEAD PCNG PROTEGO T FX -,SUP-379967,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC,,
DEFIBRILLATOR PROTEGO S SGL COIL 75CM LD CARD IMPL -,SUP-379968,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC,,
DEFIBRILLATOR PROTEGO S SGL COIL 60CM LD CARD IMPL -,SUP-379970,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC,,
PLEXA PROMRI DF-1 S DS 65/15 -,SUP-414005,CDM,C1777,HCPCS,278,RC,,,outpatient,,,10734.28,7513.996,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC,,
LEAD DEFIB TRIPLR SPRNT QUATTRO 58CM 8.6FRX12MM SPC RT ECRD -,SUP-6935-58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC,,
LEAD DEFIB TRIPLR SPRNT QUATTRO 75CM 8.6FRX12MM SPC SIL -,SUP-6935M,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC,,
LEAD DEFIB TRIPLR SPRNT QUATTRO 72CM 8.6FRX12MM SPC SIL -,SUP-6935M72,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC,,
LEAD DEFIB UNIPL 58CM 7.5FR SUBQ SIL INSL SUT ON ANCHR SLV -,SUP-6996SQ58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC,,
LEAD DEFIB TRUE BIPLR DURATA 60CM 7FR VNTRC OPTIM INSL STRD -,SUP-7122/60,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC,,
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FR VNTRC OPTIM INSL STRD -,SUP-7122/65,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC,,
LEAD DEFIB TRUE BIPLR DURATA 52CM 7FR VNTRC OPTIM INSL SGL. -,SUP-7122Q/52,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC,,
LEAD DEFIB 7FRX58CM DURATA TRUE BIPLR HLCL TIP AV SGL SHOCK. -,SUP-7122Q/58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC,,
LEAD DEFIB 7FRX65CM DURATA TRUE BIPLR HLCL TIP AV SGL SHOCK -,SUP-7122Q/65,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC,,
LEAD DEFIB 8FR INTRO 58CM OPTISURE TRUE BIPLR SGL COIL -,SUP-LDA210Q/58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC,,
LEAD DEFIB 8FR INTRO 65CM OPTISURE TRUE BIPLR SGL COIL -,SUP-LDA210Q-65,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9966.28992,other,OPPS APC,,
PK LEAD NEURSTM ACC -,SUP-30571SC,CDM,C1778,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC,,
KT LEAD NEURSTM OCTRODE 60CM ACC -,SUP-3186,CDM,C1778,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC,,
OCTRODE -,SUP-3189,CDM,C1778,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC,,
LEAD NEURSTM PENTA 60CM PDL -,SUP-3228,CDM,C1778,HCPCS,278,RC,,,outpatient,,,14480.7,10136.49,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC,,
KT LEAD NEURSTM LMTRD S-8 60CM ACC -,SUP-3286,CDM,C1778,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC,,
KT 8MMX60CM LDX1 REVISN F/MDTRNC DEEP BRN STIM DBS -,SUP-3550-27,CDM,C1778,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC,,
KT EXTENSION NEURSTM 40CM ACC -,SUP-3708140,CDM,C1778,HCPCS,278,RC,,,outpatient,,,3007.62,2105.334,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC,,
KT LEAD NEURSTM PLTNM-IRDM ELCTRD 60CM STD ACC -,SUP-3777-60,CDM,C1778,HCPCS,278,RC,,,outpatient,,,7193.58,5035.506,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC,,
KT LEAD NEURSTM 60CM PERC CMPCT ACC -,SUP-3778-60,CDM,C1778,HCPCS,278,RC,,,outpatient,,,7193.58,5035.506,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC,,
KT LEAD NEURSTM PLTNM-IRDM ELCTRD PU SLVR COR 75CM PERC -,SUP-3778-75,CDM,C1778,HCPCS,278,RC,,,outpatient,,,7193.58,5035.506,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC,,
LEAD PCNG 56CM TIP PISCES QUAD -,SUP-3887-56,CDM,C1778,HCPCS,278,RC,,,outpatient,,,4498.64,3149.048,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC,,
KT LEAD NEURSTM SPEC FLRPLYMR PLTNM-IRDM SIL RBR PLYSTR PU -,SUP-3956530,CDM,C1778,HCPCS,278,RC,,,outpatient,,,17822.4,12475.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC,,
KT LEAD NEURSTM SPEC 65CM SPIN CRD 5-6-5 LD ACC -,SUP-3956565,CDM,C1778,HCPCS,278,RC,,,outpatient,,,17822.4,12475.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC,,
REACTIV8 IMPLANTABLE LEAD 45CM -,SUP-8145,CDM,C1778,HCPCS,278,RC,,,outpatient,,,11127.86,7789.502,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC,,
STIMULATOR NERVE SPRINT ENDURA PNS SYSTEM -,SUP-9244-6001,CDM,C1778,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC,,
STIMULATOR NERVE SPRINT EXTENSA PNS SYSTEM -,SUP-9288-6002,CDM,C1778,HCPCS,278,RC,,,outpatient,,,30075.3,21052.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC,,
LEAD NEURSTM VECTRIS SURECAN 60CM PERC IMPL -,SUP-977A260,CDM,C1778,HCPCS,278,RC,,,outpatient,,,8347.95,5843.565,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC,,
SYS PROGRAMMER NEURSTM VECTRIS SURSCN 75CM SPIN CRD CMPCT -,SUP-977A275,CDM,C1778,HCPCS,278,RC,,,outpatient,,,8347.95,5843.565,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC,,
SURESCAN MRI -,SUP-977C165,CDM,C1778,HCPCS,278,RC,,,outpatient,,,20681.41,14476.987,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC,,
LEAD SPECIFY SURESCAN MRI LEAD -,SUP-977C265,CDM,C1778,HCPCS,278,RC,,,outpatient,,,20681.41,14476.987,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC,,
SURESCAN 2 X 8 PADDLE LEAD -,SUP-977C290,CDM,C1778,HCPCS,278,RC,,,outpatient,,,20681.41,14476.987,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC,,
LEAD INTERSTIM MICRO 28CM SSMRI TINED -,SUP-978A128,CDM,C1778,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC,,
INTERSTIM MRI LEAD KIT 2.16MM X 28CM -,SUP-978B128,CDM,C1778,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC,,
LEAD NEUROSTIMULATOR INTERSTIM L41 CM TINE SSMRI -,SUP-978B133,CDM,C1778,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC,,
FREEDOM 4A NEUROSTIMULATOR FR4A-TRL-A0 -,SUP-FR4A-TRL-A0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC,,
FREEDOM 4A NEUROSTIMULATOR FR4A-TRL-B0 -,SUP-FR4A-TRL-B0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC,,
FREEDOM-8A TRIAL KIT CH A US -,SUP-FR8A-TRL-A0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC,,
FREEDOM 8A NEUROSTIMULATOR FR8A-TRL-B0 -,SUP-FR8A-TRL-B0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC,,
KIT INTELLIS TRIAL LEAD 2 -,SUP-INTELTRIAL2,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC,,
BLUE PERC LEAD KIT -,SUP-LEAD1058-70B,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC,,
NEVRO 70CM SURGICAL LEAD KIT -,SUP-LEAD3005-70B,CDM,C1778,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC,,
KT NEURSTM PRGMR PRECISN ACC -,SUP-M365SC550040,CDM,C1778,HCPCS,278,RC,,,outpatient,,,6196.24,4337.368,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC,,
VECTRIS SURESCAN MRI COMPACT LEAD KIT 1 X 8 SC -,SUP-MEDTRONIC INC,CDM,C1778,HCPCS,278,RC,,,outpatient,,,8347.95,5843.565,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC,,
SLIM TIP DRG -,SUP-MN10450-50A,CDM,C1778,HCPCS,278,RC,,,outpatient,,,9331.07,6531.749,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC,,
SLIMTIP DRG 90A -,SUP-MN10450-90A,CDM,C1778,HCPCS,278,RC,,,outpatient,,,9509.36,6656.552,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC,,
KIT NEUROSTIMULATOR TUNNEL TOOL -,SUP-MN15000,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2572.47,1800.729,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC,,
FREEDOM -4A PNS SYSTEM -,SUP-Q4SP-1-US DW,CDM,C1778,HCPCS,278,RC,,,outpatient,,,40705.5,28493.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC,,
FREEDOM -4A PNS SYSTEM -,SUP-Q4SP-2-US,CDM,C1778,HCPCS,278,RC,,,outpatient,,,44406,31084.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC,,
COVEREDGE 32 MRI PADDLE LEAD 50CM -,SUP-SC-8436-50,CDM,C1778,HCPCS,278,RC,,,outpatient,,,29704,20792.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC,,
TRIAL LEAD KIT -,SUP-TLEAD1058-70B,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,34103.808,other,OPPS APC,,
LEAD PCNG 9FRX12MM SPC AV + DX PERMNT BIPLR STRD ELUT TND FX -,SUP-1368,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2035.392,other,OPPS APC,,
LEAD PCNG 9FRX12MM SPC 52CM AV + DX PERMNT BIPLR STRD ELUT -,SUP-1368/52,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2035.392,other,OPPS APC,,
LEAD PCNG 9FRX12MM SPC 58CM AV + DX PERMNT BIPLR STRD ELUT -,SUP-1368/58,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2035.392,other,OPPS APC,,
PACING  LEAD TENDRIL STS 2088TC-65 -,SUP-2088TC-65,CDM,C1779,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2035.392,other,OPPS APC,,
LEAD PCNG 58CM SOLOX IMPL BIPLR ECRD SGL -PASS PSS FX -,SUP-333900,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2035.392,other,OPPS APC,,
MESH SURG LRG 5.4X7IN OVL PP EPTFE CMPSX KL NABSB PTCH -,SUP-0010202,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5029.22,3520.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG SM 3.1X4.7IN OVL MONO PP PDS EPTFE VENTRIO PRT -,SUP-0010211,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3818.72,2673.104,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG LRG 5.4X7IN OVL MONO PP PDS EPTFE VENTRIO PRT ABSB -,SUP-0010212,CDM,C1781,HCPCS,278,RC,,,outpatient,,,7123.55,4986.485,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG 4.5IN LRG CIR MONO PP PDS EPTFE VENTRIO PRT ABSB -,SUP-0010214,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4340.04,3038.028,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG MED 4.3X5.5IN OVL MONO PP PDS EPTFE VENTRIO PRT -,SUP-0010215,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5013.01,3509.107,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG 8CM LRG 3.2X3.2IN CIR PP EPTFE VENTRALEX NABSB -,SUP-0010303,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4167.7,2917.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PERFIX PLUG MED -,SUP-0112760,CDM,C1781,HCPCS,278,RC,,,outpatient,,,984.1,688.87,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PERFIX PLUG LRG -,SUP-0112770,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1660.12,1162.084,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PLUG PERFIX X-LRG -,SUP-0112780,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1159.39,811.573,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH 3DMAX DAVOL LRG LEFT -,SUP-0115311,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH 3DMAX DAVOL X-LRG LEFT -,SUP-0115312,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1187.9,831.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH 3DMAX DAVOL LRG RIGHT -,SUP-0115321,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH 3DMAX DAVOL X-LRG RIGHT -,SUP-0115322,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1187.9,831.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH MOD KUGEL 3.5 X 5 -,SUP-0115816,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG 4X6IN ELLIP MONO PP EPTFE COMPOSIX E /X NABSB -,SUP-0123460,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2954.63,2068.241,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH ATRIUM 1 X 4 - DISC DO NOT USE -,SUP-1000104-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,116.7,81.69,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH ATRIUM 2 X 4 -  DISC DO NOT USE -,SUP-1000204-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,128.37,89.859,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH ATRIUM 6 X 6 - DO NOT USE DISCONTINUED -,SUP-1000606-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,163.38,114.366,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH ATRIUM 6X6 - DISCONTINUED DO NOT USE -,SUP-1000606-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,163.38,114.366,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG 10X14IN PP KNTD PROLITE NABSB SHT -,SUP-1001014-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,478.47,334.929,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH ATRIUM PRE SHAPED -,SUP-1010306-02,CDM,C1781,HCPCS,278,RC,,,outpatient,,,192.56,134.792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG 20X30CM RECT EPTFE GORE-TEX PTCH -,SUP-1320030020,CDM,C1781,HCPCS,278,RC,,,outpatient,,,18928.87,13250.209,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG 5X10CM EPTFE GORE-TEX PTCH -,SUP-1405010010,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1754.47,1228.129,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG 10X15CM OVL EPTFE GORE-TEX PLG -,SUP-1410015010,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4014.93,2810.451,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
IMPLANT ARTELON 0.3X16CM -,SUP-31052,CDM,C1781,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
IMPLANT ARTELON 0.7X16CM -,SUP-31056,CDM,C1781,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PROLENE 3D PATCH LRG -,SUP-3DPL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3399.12,2379.384,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PROLENE 3D PATCH MED -,SUP-3DPM,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3399.12,2379.384,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH RESTORELLE 24CM X 4CM -,SUP-501420,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4419.28,3093.496,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH VENTRALEX ST SM 4.3CM -,SUP-5950007,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2292.25,1604.575,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH VENTRALEX ST MD 6.4CM -,SUP-5950008,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2488.78,1742.146,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH VENTRALEX ST LRG 8.0CM -,SUP-5950009,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3167.55,2217.285,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG 3IN SM CIR MONO PP CO-KNTD VENTRALEX ST ECHO PS -,SUP-5950010,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3765.73,2636.011,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG SM 3.1X4.7IN OVL MONO PP CO-KNTD VENTRALEX ST ECHO -,SUP-5950030,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4634.12,3243.884,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG MED 4.3.X5.5IN OVL MONO PP CO-KNTD VENTRALEX ST -,SUP-5950040,CDM,C1781,HCPCS,278,RC,,,outpatient,,,6128.34,4289.838,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG XL 8.7X10.7IN OVL MONO PP PTFE HYDRGL CO-KNTD -,SUP-5950080,CDM,C1781,HCPCS,278,RC,,,outpatient,,,12018.24,8412.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG 4X6IN ELLIP MONO PP PTFE HYDRGL CO-KNTD -,SUP-5954460,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3720.86,2604.602,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG 15CM MED RND ACCUMESH PSTN -,SUP-AMPPCO15X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3904.18,2732.926,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG 20CM MED RND ACCUMESH PSTN -,SUP-AMPPCO20X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4655.67,3258.969,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PARIETEX 15CM X 10CM RT -,SUP-AUTO-VTX1510,CDM,C1781,HCPCS,278,RC,,,outpatient,,,465.28,325.696,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH DEXTILE MEDIUM LEFT 13 X 9CM ANATOMICAL -,SUP-DXT1309AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH DEXTILE MEDIUM RIGHT 13 X 9CM ANATOMICAL -,SUP-DXT1309AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,787.73,551.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH DEXTILE LARGE LEFT 15 X 10CM ANATOMICAL -,SUP-DXT1510AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,846.08,592.256,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH DEXTILE LARGE RIGHT 15 X 10CM ANATOMICAL -,SUP-DXT1510AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,846.08,592.256,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH DEXTILE XL LEFT 16 X 12CM ANATOMICAL -,SUP-DXT1612AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH DEXTILE XL RIGHT 16 X 12CM ANATOMICAL -,SUP-DXT1612AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
PATCH BOVINE 0.8 X 8CM -,SUP-E0.8P8,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1160.81,812.567,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
PATCH BOVINE 2.0 X 9CM -,SUP-E2P9,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2008.89,1406.223,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
GORE BIOABSORBABLE SYNTHETIC MESH 7CM X 10CM -,SUP-HH0710,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH LAP PROGRIP 15 X 10 -,SUP-LPG1510,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1664.57,1165.199,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PROGRIP ANATOM 15x10 L -,SUP-LPG1510AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1878.87,1315.209,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PROGRIP ANATOM 15x10 R -,SUP-LPG1510AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1878.87,1315.209,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PROGRIP LAPAROSCOPIC SELF-FIX 16 X 12 -,SUP-LPG1612,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1888.04,1321.628,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PROGRIP ANATOM 16X12 L -,SUP-LPG1612AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2098.94,1469.258,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PROGRIP ANATOMICAL RIGHT 16CM X 12CM -,SUP-LPG1612AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2098.94,1469.258,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
UPSYLON TRADITIONAL Y MESH -,SUP-M0068318200,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4180.97,2926.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PROCEED 6IN X 8IN -,SUP-PCDG1,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4886.8,3420.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PROCEED 4IN X 6IN -,SUP-PCDN1,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2936.68,2055.676,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
IMPLANT BIO TISS 10X15CM 3D RND PLYSTR PRCN COLL OPN SKRT -,SUP-PCO1510OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2440.67,1708.469,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
IMPLANT PLYSTR PRCN COLL 10X15CM PRTX 1.7MM ABSB 3D RND KNTD -,SUP-PCO1510X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1920.48,1344.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
IMPLANT BIO TISS 15CM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCO15X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2513.71,1759.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
IMPLANT BIO TISS 15X20CM 3D RECT PLYSTR PRCN COLL KNTD PRTX -,SUP-PCO2015OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3387.39,2371.173,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
IMPLANT BIO TISS 15X20CM 3D RND PLYSTR PRCN COLL KNTD PRTX -,SUP-PCO2015X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3237.25,2266.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PARIETEX HEART SHAPED -,SUP-PCO2H1,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1862.49,1303.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PARIETEX HORSE SHOE -,SUP-PCO2H3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1999.72,1399.804,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
IMPLANT BIO TISS 20X30CM 3D RECT PLYSTR PRCN COLL KNTD PRTX -,SUP-PCO3020X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5125.65,3587.955,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
PATCH VENTRAL PARITEX 4.6CM -,SUP-PCO4VP,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1712.49,1198.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
PATCH VENTRAL PARITEX 6.6CM -,SUP-PCO6VP,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2052.19,1436.533,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
IMPLANT BIO TISS 8CM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCO8OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2128.52,1489.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
IMPLANT BIO TISS 8CM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCO8OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2365.35,1655.745,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
PATCH VENTRAL PARITEX 8.6CM -,SUP-PCO8VP,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2635.99,1845.193,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
IMPLANT BIO TISS 50MM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCOPM15H50,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2579.06,1805.342,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PROLENE HERNIA SYSTEM LARGE -,SUP-PHSL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2038.93,1427.251,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PROLENE HERNIA SYSTEM MEDIUM -,SUP-PHSM,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2038.93,1427.251,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PARIENTENE PROGRIP 15CM X 9CM -,SUP-PP1509G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1083.58,758.506,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PARITENE MACROPOROUS 15 X 10 -,SUP-PPM1510X3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,223.71,156.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PARITENE MACROPOROUS 15 X 15 -,SUP-PPM1515X3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,259.54,181.678,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PARIETENE 20 X 20 -,SUP-PPM2020,CDM,C1781,HCPCS,278,RC,,,outpatient,,,301.09,210.763,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PARIETENE 30 X 30 -,SUP-PPM3030,CDM,C1781,HCPCS,278,RC,,,outpatient,,,563.14,394.198,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PARIETENE 45 X 30 -,SUP-PPM4530,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1191.23,833.861,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
DURASORB PTM 0616 6 X 16 -,SUP-PTM 0616,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
DURASORB PTM1 025 10 X 25 -,SUP-PTM1025,CDM,C1781,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
DURASORB PTM 2025 -,SUP-PTM2025,CDM,C1781,HCPCS,278,RC,,,outpatient,,,20050.2,14035.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG 6X11CM RECT PLYSTR KNTD MERSILN NABSB SHT -,SUP-RMS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,992.11,694.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SYMBOTEX 25 X 20 0118362 -,SUP-SMY2520OS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,6454.57,4518.199,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SYMBOTEX VENTRAL 12CM -,SUP-SYM12,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1989.6,1392.72,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SYMBOTEX VENTRAL 15CM -,SUP-SYM15,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2490.4,1743.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SYMBOTEX VENTRAL 15CM -,SUP-SYM15,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2571.48,1800.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SYMBOTEX VENTRAL 15 X 10 NON SKIRTED -,SUP-SYM1510,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1808.74,1266.118,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SYMBOTEX 15 X 10 -,SUP-SYM1510OS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2418.08,1692.656,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SYMBOTEX 2012E -,SUP-SYM2012E,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2774.79,1942.353,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SYMBOTEX 20 X 15 CM -,SUP-SYM2015,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2613.29,1829.303,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SYMBOTEX 20 X 15 SKIRTED -,SUP-SYM2015OS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3726.15,2608.305,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG 25X15CM ELLIP MONO PLYSTR COLL SYMBOTEX NABSB -,SUP-SYM2515E,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4592.69,3214.883,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PARIETENE DS COMPOSITE 25CM X 20CM -,SUP-SYM2520,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4274.74,2992.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SYMBOTEX 25 X 20 -,SUP-SYM2520,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4118.24,2882.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SYMBOTEX 30 X 20 -,SUP-SYM3020,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5381.94,3767.358,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SYMBOTEX COMPOSITE -,SUP-SYM3728,CDM,C1781,HCPCS,278,RC,,,outpatient,,,6391.04,4473.728,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
Symbotexâ„¢ Composite Mesh- 42 x 32 cm -,SUP-SYM4232,CDM,C1781,HCPCS,278,RC,,,outpatient,,,7515.87,5261.109,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SYMBOTEX VENTRAL 9CM -,SUP-SYM9,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1450.75,1015.525,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG 10X15CM PLYSTR KNTD PRTX SHT -,SUP-TECT1510ADPL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,734.63,514.241,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
"MESH PARIETEX ANATOMICAL LEFT 6X4"" -",SUP-TECT1510AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,648.04,453.628,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
"MESH PARIETEX ANATOMICAL RIGHT 6X4"" -",SUP-TECT1510AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,648.04,453.628,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG 8X12CM MONO PLYSTR KNTD PRTX PROGRIP PRT -,SUP-TEM1208GL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1175.76,823.032,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG 8X12CM MONO PLYSTR KNTD PRTX PROGRIP PRT ABSB -,SUP-TEM1208GR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1175.76,823.032,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PARIETEX PROGRIP 15cm x 9cm -,SUP-TEM1509G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1083.58,758.506,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PARIETEX PROGRIP 15 X 15CM -,SUP-TEM1515G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1131.55,792.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PARIETEX PROGRIP 20X15 -,SUP-TEM2015G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1382.48,967.736,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PARIETEX PROGRIP 30X15 -,SUP-TEM3015G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1925.62,1347.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG 30X30CM 3D PLYSTR KNTD PRTX EASEGRIP SHT -,SUP-TET3030,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1054.85,738.395,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG 3X6IN RECT MONO PLGCPRN-25 PP KNTD ULTRAPRO PRT -,SUP-UMR3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,908.96,636.272,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
GRAFT HEMASHIELD 10MM X100CM G -,SUP-UNDEFINED,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2550.8,1785.56,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH VENTRIO XL 10 X 13 -,SUP-UNDEFINED,CDM,C1781,HCPCS,278,RC,,,outpatient,,,8233.36,5763.352,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH VICRYL WOVEN FLAT12IN x 12IN ABSORBABLE HERNIA REPAIR -,SUP-VWML,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4702.1,3291.47,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,15398.5536,other,OPPS APC,,
STENT DES 2.25X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332220,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,200.09685,4563.1488,other,OPPS APC,,
STENT DES 2.5X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332250,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,200.09685,4563.1488,other,OPPS APC,,
STENT DES 3X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332300,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,200.09685,4563.1488,other,OPPS APC,,
STENT DES 3.5X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332350,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,200.09685,4563.1488,other,OPPS APC,,
STENT DES 4X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332400,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,200.09685,4563.1488,other,OPPS APC,,
STENT DES 2.75X38MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902338270,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,200.09685,4563.1488,other,OPPS APC,,
STENT DES 3.5X38MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902338350,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,200.09685,4563.1488,other,OPPS APC,,
STENT DES 4X38MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902338400,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,200.09685,4563.1488,other,OPPS APC,,
IMPLANT BIO TISS 6.5CM 3D RND PLYSTR PRCN COLL KNTD PRTX -,SUP-PNP6X3,CDM,C1784,HCPCS,278,RC,,,outpatient,,,891.3,623.91,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,200.09685,4563.1488,other,OPPS APC,,
PACEMAKER UNIPL BIPLR INSGA I ULTRA 2CHMBR RR 10.8ML 25.4GM -,SUP-1290,CDM,C1785,HCPCS,275,RC,,,outpatient,,,21052.71,14736.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER UNIPL BIPLR EVIA 2CHMBR 44.5X53MM 6.5MM 12ML 25GM -,SUP-359529,CDM,C1785,HCPCS,275,RC,,,outpatient,,,11220.69,7854.483,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER UNIPL BIPLR EVIA 2CHMBR RR 44.5X53MM 6.5MM 12ML -,SUP-377848,CDM,C1785,HCPCS,275,RC,,,outpatient,,,14573.53,10201.471,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER IMPL ENTOVIS PROMRI 2CHMBR IS-1 CONN SR-T ACC -,SUP-404722,CDM,C1785,HCPCS,275,RC,,,outpatient,,,18565,12995.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER IMPL UNIPL VERITY ADX MS DR 2CHMBR RR 45X52MM 6MM -,SUP-5357M/S,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9332.85,6532.995,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC,,
GENERATOR TEMP PLS 2CHMBR 5392 ACC -,SUP-5392KIT,CDM,C1785,HCPCS,275,RC,,,outpatient,,,27828.94,19480.258,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER IMPL UNIPL BIPLR VCT DR 2CHMBR RR V- PCNG RDC -,SUP-5810,CDM,C1785,HCPCS,275,RC,,,outpatient,,,13842.06,9689.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER IMPL UNIPL BIPLR VCT XL DR 2CHMBR RR V- PCNG RDC -,SUP-5816,CDM,C1785,HCPCS,275,RC,,,outpatient,,,13842.06,9689.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER IMPL UNIPL BIPLR ZPHR 2CHMBR RR 43X44MM 6MM 8.5ML -,SUP-5820,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9332.85,6532.995,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER IMPL UNIPL BIPLR ZPHR 2CHMBR RR 43X44MM 6MM 8.5ML -,SUP-5820,CDM,C1785,HCPCS,275,RC,,,outpatient,,,22278,15594.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER IMPL UNIPL BIPLR ZPHR DR 2CHMBR RR 44X52MM 6MM -,SUP-5826,CDM,C1785,HCPCS,275,RC,,,outpatient,,,18565,12995.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER IMPL SURSCN ADVISA 2CHMBR RR MUL-PRGM IS-1 CONN SR -,SUP-A2DR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16337.2,11436.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER IMPL UNIPL ADAPTA DR 2CHMBR RR 12ML 21GM IS-1 -,SUP-ADAPTADRK2,CDM,C1785,HCPCS,275,RC,,,outpatient,,,27828.94,19480.258,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER IMPL BIPLR ADAPT 2CHMBR RR 13.1ML 31.3GM IS-1 CONN -,SUP-ADDRL1,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16567.96,11597.572,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER IMPL UNIPL BIPLR ADAPTA 2CHMBR RR 42.9MMX44.7MM -,SUP-ADDRS1,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16567.96,11597.572,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC,,
GENERATOR 2CHMBR -,SUP-DR2550,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16708.5,11695.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER ESSENTIO DR DYNMC ADJ TI ACC -,SUP-L101,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9341.91,6539.337,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER ESSENTIO DR MRI L111 -,SUP-L111,CDM,C1785,HCPCS,275,RC,,,outpatient,,,12460.83,8722.581,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER IMPL ESSENTIO EL DR 2CHMBR 4.45X5.88X0.75IN 29.1GM -,SUP-L121,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9341.91,6539.337,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER ACCOLADE DR -REF: L301 -,SUP-L301,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9442.9,6610.03,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER ACCOLADE MRI DR L311 -,SUP-L311,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10582.05,7407.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER IMPL UNIPL BIPLR ACCENT DR 2CHMBR RR WRLS TELEM -,SUP-PM2110,CDM,C1785,HCPCS,275,RC,,,outpatient,,,12438.55,8706.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER ENDURITY 2CHMBR 50X46MM 6MM 10.4ML 19GM IS-1 CONN -,SUP-PM2160,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10470.66,7329.462,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER IMPL ACCENT DR 2CHMBR RR 52X52MM 6MM 12.8ML 23GM -,SUP-PM2210,CDM,C1785,HCPCS,275,RC,,,outpatient,,,12438.55,8706.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER IMPL ASSURITY 2CHMBR RR 50X47MM 6MM 10.4ML 20GM -,SUP-PM2240,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10732.43,7512.701,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC,,
ASSURITY MRI PACEMAKER DR-RF PM2272 -,SUP-PM2272,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10582.05,7407.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER IMPL BIPLR REVO 2CHMBR RR SURSCN PCNG -,SUP-REVOMRIPEEM,CDM,C1785,HCPCS,275,RC,,,outpatient,,,23622.66,16535.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER IMPL BIPLR REVO SURSCN 2CHMBR RR 45X51X8MM 12.7ML -,SUP-RVDR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,17439.96,12207.972,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER ALTRUA 20 DDDR MUL-PRGM 43X49X8MM 29.6GM 12.6ML -,SUP-S202,CDM,C1785,HCPCS,275,RC,,,outpatient,,,17451.1,12215.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER ALTRUA 20 MUL-PRGM 42X44X8MM 25.4GM 10.8ML IS-1 -,SUP-S203,CDM,C1785,HCPCS,275,RC,,,outpatient,,,14373.02,10061.114,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER BIPLR ALTRUA 60 2CHMBR RR 42X44MM 8MM 10.8ML -,SUP-S603,CDM,C1785,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER IMPL UNIPL BIPLR SENSIA 2CHMBR RR -,SUP-SEDR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10396.4,7277.48,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC,,
GENERATOR VERSA DUAL CHAMBER -,SUP-UNDEFINED,CDM,C1785,HCPCS,275,RC,,,outpatient,,,20402.94,14282.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER ALTRUA 20 DR 2 LD -,SUP-UNDEFINED,CDM,C1785,HCPCS,275,RC,,,outpatient,,,19827.42,13879.194,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC,,
VERSA DR VEDR01 -,SUP-VEDR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10396.4,7277.48,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER MRI AZURE XT DR SURESCAN -,SUP-W1DR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,18565,12995.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC,,
Azure S DR MRI Surescan W3DR01 -,SUP-W3DR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16708.5,11695.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER BIPLR INSGA ULTRA SR SGL-CHMBR RR 10ML 23.4GM IS-1 -,SUP-1190,CDM,C1786,HCPCS,275,RC,,,outpatient,,,17451.1,12215.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC,,
PACEMAKER RELAY INTMD UNIPL CARD 5MM -,SUP-293-03,CDM,C1786,HCPCS,275,RC,,,outpatient,,,16151.55,11306.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC,,
PACEMAKER UNIPL BIPLR EVIA SR-T SGL-CHMBR RR 39X53MM 6.5MM -,SUP-359 533,CDM,C1786,HCPCS,275,RC,,,outpatient,,,10983.05,7688.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC,,
PACEMAKER IMPL ENTOVIS SR-T PROMRI SGL-CHMBR ACC -,SUP-404723,CDM,C1786,HCPCS,275,RC,,,outpatient,,,10457.22,7320.054,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC,,
GENERATOR IMPL VERF SGL-CHMBR -,SUP-5156,CDM,C1786,HCPCS,275,RC,,,outpatient,,,11792.49,8254.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC,,
PACEMAKER IMPL UNIPL VERITY ADX MS DR SGL-CHMBR RR 42X52MM -,SUP-5157M/S,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8533.24,5973.268,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC,,
PACEMAKER IMPL UNIPL BIPLR ZPHR SGL-CHMBR RR 41X44MM 6MM 8ML -,SUP-5620,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8533.24,5973.268,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC,,
PACEMAKER IMPL UNIPL BIPLR ZPHR XL SR SGL-CHMBR RR 52X42MM -,SUP-5626,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8533.24,5973.268,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC,,
PACEMAKER IMPL SURSCN ADVISA 1CHMBR IS-1 CONN SR -,SUP-A3SR01,CDM,C1786,HCPCS,275,RC,,,outpatient,,,14852,10396.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC,,
PACEMAKER IMPL UNIPL ADAPTA SR SGL-CHMBR RR 7.5MM 11ML -,SUP-ADSR06,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9952.18,6966.526,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC,,
GENERATOR PCMKR  SR SSIR -,SUP-ICV1122,CDM,C1786,HCPCS,275,RC,,,outpatient,,,12497.96,8748.572,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC,,
ESSENTIO 4.45X4.81X0.75 CM D 13.2ML TI -,SUP-L100,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8899.67,6229.769,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC,,
PACEMAKER ESSENTIO SR MRI -,SUP-L110,CDM,C1786,HCPCS,275,RC,,,outpatient,,,10901.37,7630.959,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC,,
PACEMAKER ACCOLADE SR -REF: L300 -,SUP-L300,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC,,
ACCOLADE MRI SR PACEMAKER L310 -,SUP-L310,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC,,
PACEMAKER LEADLESS SINGLE AVEIR RV REF: LSP112V -,SUP-LSP112V,CDM,C1786,HCPCS,275,RC,,,outpatient,,,37130,25991,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC,,
MICRA MDT TRANSCATHER PACING MICRA SYSTEM -,SUP-MC1VR01,CDM,C1786,HCPCS,275,RC,,,outpatient,,,26520.25,18564.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC,,
MICRA AV TRANSCATHETER  MC1AVR1 -,SUP-MICRAAVTCPSYSTEM,CDM,C1786,HCPCS,275,RC,,,outpatient,,,38855.25,27198.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC,,
TRANSCATHETER PACING SYSTEM INC:CAPSULEDELIV CATHINTROD -,SUP-MICRATCPSYSTEM,CDM,C1786,HCPCS,275,RC,,,outpatient,,,26520.25,18564.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC,,
PACEMAKER IMPL UNIPL BIPLR ACCENT SR SGL-CHMBR RR WRLS TELEM -,SUP-PM1110,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9375.33,6562.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC,,
PACEMAKER ENDURITY SGL-CHMBR 50X41X6MM 6MM 19GM 9.7ML IS-1 -,SUP-PM1160,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC,,
PACEMAKER IMPL UNIPL BIPLR ACCENT SR SGL-CHMBR RR WRLS TELEM -,SUP-PM1210,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9375.33,6562.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC,,
PACEMAKER IMPL ASSURITY SGL-CHMBR RR 50X47MM 6MM 10.4ML 20GM -,SUP-PM1240,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC,,
ASSURITY MRI PACEMAKER SR-RF -,SUP-PM1272,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC,,
PACEMAKER ALTRUA 40 SR SGL-CHMBR RR 42X42X8MM 10ML 23.4GM -,SUP-S401,CDM,C1786,HCPCS,275,RC,,,outpatient,,,12887.82,9021.474,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC,,
SYS ADAPTER PCMKR F/SR -,SUP-UNDEFINED,CDM,C1786,HCPCS,275,RC,,,outpatient,,,23744.64,16621.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC,,
DEFIBRILLATOR VIVA QUAD S CRTN -,SUP-VIVA QUAD S CRT-D,CDM,C1786,HCPCS,275,RC,,,outpatient,,,60532.78,42372.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC,,
Azure S SR NRI SureScan W3SR01 -,SUP-W3SR01,CDM,C1786,HCPCS,275,RC,,,outpatient,,,16708.5,11695.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46489.17504,other,OPPS APC,,
GENERATOR PROCLAIM 7 ELITE -,SUP-3662,CDM,C1787,HCPCS,272,RC,,,outpatient,,,40409.46,28286.622,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,28973.58282,other,OPPS APC,,
PROGRAMMER NEURSTM MYSTIM HNDHLD DVC -,SUP-377-44,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4606.91,3224.837,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,28973.58282,other,OPPS APC,,
PROGRAMMER NEURSTM MYSTIM 2.2X3.7X1.1IN -,SUP-377-46,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4606.91,3224.837,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,28973.58282,other,OPPS APC,,
PROGRAMMER NEURSTM IMMG-LN -,SUP-3852,CDM,C1787,HCPCS,272,RC,,,outpatient,,,2517.74,1762.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,28973.58282,other,OPPS APC,,
PRODIGY 3856 -,SUP-3856,CDM,C1787,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,28973.58282,other,OPPS APC,,
PROCLAIM DRG CONTROLLER LEAD -,SUP-7883,CDM,C1787,HCPCS,272,RC,,,outpatient,,,6212.96,4349.072,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,28973.58282,other,OPPS APC,,
PROGRAMMER PATIENT 97740 -,SUP-97740,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4507.13,3154.991,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,28973.58282,other,OPPS APC,,
CONTROLLER 97745NT INTELLIS PTM NONTRIAL -,SUP-97745NT,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4507.13,3154.991,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,28973.58282,other,OPPS APC,,
INTERSTIM KIT COMM W/HANDSET GU US -,SUP-TH90Q01,CDM,C1787,HCPCS,272,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,28973.58282,other,OPPS APC,,
PORT IMPLINFN NPWR 8FRX1.6MM ID 12.7MM X- PRT ISP PU LF -,SUP-0607540,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1620.15,1134.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC,,
PORT IMPLINFN NPWR 9.5FR CATH X- PRT PLST PRT LF MRI-COND -,SUP-0607675,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2417.77,1692.439,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC,,
PORT POWER LOW PROFILE 8F -,SUP-1708060,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2318.07,1622.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC,,
PORT IMPLINFN PWR INJ 6FR CATH PWR PRT TI LF 1LUM -,SUP-1716000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2242.11,1569.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC,,
PORT IMPLINFN PWR INJ 8FR CATH PWR PRT M R I ISP PU LF 1LUM -,SUP-1808000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2243.33,1570.331,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC,,
PORT POWER 8F #1808000 -,SUP-1808000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2243.33,1570.331,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC,,
PORT INFS 9FR CATH PWR PRT DUO M R I PLST LF LUMX2 -,SUP-1829500,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2559.29,1791.503,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC,,
KT NEEDLE INFS 20GAX1IN POWERLOC PRT ACCESS SAFTY YST NACL -,SUP-2672010,CDM,C1788,HCPCS,278,RC,,,outpatient,,,99.2,69.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC,,
PORT INFS PWR INJ 8FR CATH PWR PRT VUE ISP PU CATH LF -,SUP-5608062,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1261.52,883.064,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC,,
PORT INFS 8FR MRI-SF PWR SLIM -,SUP-5618000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1261.52,883.064,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC,,
TRY CV LUMX2 9.5FRX60CM GRSHNG LF ACC -,SUP-7726952,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1902.88,1332.016,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC,,
CATH INFS PRT 6.6FR SMRT PRT CT TI /CARBOTHAN/ PU LPRO INJ -,SUP-CT66LTPD,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC,,
CATH INFS PRT 8FR SMRT PRT CT TI/SIL INJ -,SUP-CT75STSD,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC,,
CATH INFS PRT 8FR SMRT PRT CT FLUOROMAX TI/PU INJ -,SUP-CT80STPD,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC,,
CATH INFS PRT 6.6FR MINI SMRT PRT CT TI /CARBOTHAN/ PU INJ -,SUP-H787CT66PTPD0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC,,
SMARTPORT PLASTIC W/VORTEX TECH IF FILLED DETATCHED -,SUP-H787CT80LPPDVI0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC,,
CATH INFS PRT 9.6FR SMRT PRT CT FLUOROMAX TI/SIL INJ -,SUP-H787CT96STSD0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC,,
CATH INFS PRT 12/11.4 FR DIA INTRO/CATH VORT LP TI SIL DL -,SUP-H787LVTX52130,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC,,
PORT IMPLINFN 8FR INTRO 7.2FR CATH VORT VX TI SIL LF -,SUP-H787P12355K0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC,,
PORT VORTEX VASC 9.6 -,SUP-H787P5455K0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC,,
PORT XCELA PLUS POWER INDECTABLE 8F FILLED DETATCHED -,SUP-H965440320,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC,,
PORT INFS 8FR MED DIGNITY -,SUP-MRDP80AMS,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1404.63,983.241,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.2704,1965.53472,other,OPPS APC,,
EXPANDER TISSUE SMOOTH 600CC NATRELLE FULL HT VAR -,SUP-133S-FV-14-T,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BRST 397ML 13.1CM NATRLL 4.2CM PRJCT -,SUP-15-397,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BRST 125ML SIL GEL MOD+ RND 8.9CM MEMORYGEL 2.8CM -,SUP-350-1251BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BRST SIL GEL MOD+ RND 150CC -,SUP-350-1501BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BRST 175ML SIL GEL MOD+ RND 10CM MEMORYGEL 3.1CM -,SUP-350-1751BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BRST 200ML SIL GEL MOD+ RND 10.5CM MEMORYGEL 3.2CM -,SUP-350-2001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BRST 350-420ML SAL MOD+ RND 12.1-11.7CM MENTOR -,SUP-350-2350,CDM,C1789,HCPCS,278,RC,,,outpatient,,,2597.25,1818.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BRST 250ML SIL GEL HPRO RND 10.5CM MEMORYGEL 4.3CM -,SUP-350-2504BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BRST 600ML SIL GEL MOD+ RND 15CM MEMORYGEL 4.6CM -,SUP-350-6001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4320.47,3024.329,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BRST 650ML SIL GEL MOD+ RND 15.4CM MEMORYGEL 4.7CM -,SUP-350-6501BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4320.47,3024.329,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BRST 650ML SIL GEL HPRO RND 14.4CM MEMORYGEL 5.7CM -,SUP-350-6504BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BRST 700ML SIL GEL MOD+ RND 15.8CM MEMORYGEL 4.9CM -,SUP-350-7001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4320.47,3024.329,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BRST 130ML SIL GEL MOD CLASS RND 9.6CM MEMORYGEL -,SUP-350-7130MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BRST 150ML SIL GEL MOD CLASS RND 10.3CM MEMORYGEL -,SUP-350-7150MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BRST SIL GEL MOD+ RND CLSSC 190CC -,SUP-350-7190MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BRST SIL GEL MOD+ RND CLSSC 215CC -,SUP-350-7215MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BRST 750ML SIL GEL MOD CLASS RND 16.1CM MEMORYGEL -,SUP-350-7501BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
BREAST IMPLANT SMOOTH ROUND MODERATE 750CC -,SUP-350-7750MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
BREAST IMPLANT SMOOTH ROUND MODERATE 800CC -,SUP-350-7800MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BRST 800ML SIL GEL HPRO RND 16.5CM MEMORYGEL 5.1CM -,SUP-350-8001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BRST 800ML SIL GEL HPRO RND 15.5CM MEMORYGEL 6CM -,SUP-350-8004BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BRST 330-350ML SIL SAL BIOCELL PTOTIC SHP NATRLL -,SUP-363LF-330,CDM,C1789,HCPCS,278,RC,,,outpatient,,,3628.24,2539.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
NATRELLE SALINE FILLED SMOOTH ROUND IMLANTS 640CC -,SUP-68HP-600,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1637.85,1146.495,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
NATRELLE SMOOTH ROUND SALINE IMPLANTS 68LP-225 -,SUP-68LP-225,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
NATRELLE SMOOTH ROUND SALINE IMPLANTS 250CC -,SUP-68LP-250,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
NATRELLE SMOOTH ROUND SALINE IMPLANTS 275CC -,SUP-68LP-275,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
SIZER IMPLANT NATRELLE INSPIRA 295CC FULL PROFILE -,SUP-MSZ-F295,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
SIZER NATRELLE INSPIRA 335CC FULL -,SUP-MSZ-F335,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
SIZER IMPLANT NATRELLE INSPIRA 650CC FULL PROFILE -,SUP-MSZ-F650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 200CC NATRELLE INSPIRA FULL -,SUP-SCF-200,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 240CC NATRELLE INSPIRA FULL -,SUP-SCF-240,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 265CC NATRELLE INSPIRA FULL -,SUP-SCF-265,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 295CC NATRELLE INSPIRA FULL -,SUP-SCF-295,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 335CC NATRELLE INSPIRA FULL -,SUP-SCF-335,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 345CC NATRELLE INSPIRA FULL -,SUP-SCF-345,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 365CC NATRELLE INSPIRA FULL -,SUP-SCF-365,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 385CC NATRELLE INSPIRA FULL -,SUP-SCF-385,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 415CC NATRELLE INSPIRA FULL -,SUP-SCF-415,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 450CC NATRELLE INSPIRA FULL -,SUP-SCF-450,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 485CC NATRELLE INSPIRA FULL -,SUP-SCF-485,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4787.23,3351.061,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 520CC NATRELLE INSPIRA FULL -,SUP-SCF-520,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 560CC NATRELLE INSPIRA FULL -,SUP-SCF-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 605CC NATRELLE INSPIRA FULL -,SUP-SCF-605,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5623.3,3936.31,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 650CC NATRELLE INSPIRA FULL -,SUP-SCF-650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHES GEL 695CC NATRELLE INSPIRA FULL -,SUP-SCF-695,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
NATRELLE INSPIRA COHESIVE IMPLANT 745 -,SUP-SCF-745,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
NATRELLE INSPIRA COHESIVE IMPLANT 770 -,SUP-SCF-770,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST 460CC NATRELLE SMOOTH ROUND -,SUP-SCL-460,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST 490CC SMOOTH COHESIVE LOW PLUS PROFILE -,SUP-SCLP-490,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST 540CC SMOOTH COHESIVE LOW PLUS PROFILE -,SUP-SCLP-540,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST 330CC NATRELLE SMOOTH ROUND -,SUP-SCM-330,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST 360CC NATRELLE SMOOTH ROUND -,SUP-SCM-360,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST 375CC NATRELLE SMOOTH ROUND -,SUP-SCM-375,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SILICONE 375CC NATRELLE INSPIRA STYLE MODERAT -,SUP-SCM-375,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST 405CC NATRELLE SMOOTH ROUND -,SUP-SCM-405,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHES 485CC NATRELLE INSPIRA MODERATE -,SUP-SCM-485,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 560CC NATRELLE INSPIRA MOD -,SUP-SCM-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 600CC NATRELLE INSPIRA MOD -,SUP-SCM-600,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 640CC NAT INSPIRA MOD -,SUP-SCM-640,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHES GEL 685CC NATRELLE INSPIRA MOD -,SUP-SCM-685,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHES GEL 755CC NATRELLE INSPIRA MOD -,SUP-SCM-755,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 340CC NATRELLE INSPIRA FULL -,SUP-SCX-340,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 375CC NATRELLE INSP EXTRA FUL -,SUP-SCX-375,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 525CC NATRELLE INSPIRA FULL -,SUP-SCX-525,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 545CC NATRELLE INSPIRA FULL -,SUP-SCX-545,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST 560CC SMOOTH COHESIVE NATRELLE INSPIRA FULL -,SUP-SCX-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST 580CC SMOOTH COHESIVE NATRELLE INSPIRA FULL -,SUP-SCX-580,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST 615CC SMOOTH COHESIVE NATRELLE INSPIRA FULL -,SUP-SCX-615,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 650CC NATRELLE INSP EX-FULL -,SUP-SCX-650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
NATRELLE INSPIRA COHESIVE IMPLANT 700 -,SUP-SCX-700,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
NATRELLE INSPIRA COHESIVE IMPLANT 750 -,SUP-SCX-750,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
NATRELLE INSPIRA COHESIVE IMPLANT 800CC -,SUP-SCX-800,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT SMOOTH HIGH PROFILE XTRA 755 CC -,SUP-SHPX755,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5211.63,3648.141,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT SMOOTH HIGH PROFILE XTRA 790 CC -,SUP-SHPX790,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5211.63,3648.141,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH FULL 450CC NATRELLE INSPIRA FULL -,SUP-SSF-450,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH FULL 520CC NATRELLE INSPIRA FULL -,SUP-SSF-520,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH FULL 560CC NATRELLE INSPIRA FULL -,SUP-SSF-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH FULL 650CC NATRELLE INSPIRA FULL -,SUP-SSF-650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH FULL 695CC NATRELLE INSPIRA FULL -,SUP-SSF-695,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH FULL 745CC NATRELLE INSPIRA FULL -,SUP-SSF-745,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH SOFT TOUCH 330CC NATRELLE INSPIRA MOD -,SUP-SSM-330,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH SOFT TOUCH 445CC NATRELLE INSPIRA MOD -,SUP-SSM-445,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH SOFT TOUCH 485CC NATRELLE INSPIRA MOD -,SUP-SSM-485,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH SOFT TOUCH 520CC NATRELLE INSPIRA MOD -,SUP-SSM-520,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST EXTRA FULL SOFT TOUCH 750CC -,SUP-SSX-750,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST EXTRA FULL SOFT TOUCH 800CC -,SUP-SSX-800,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,261.9915,4400.1792,other,OPPS APC,,
PROSTHESIS PENL CL SPCTR MALE 9.5MMX12CM CNCLBL SNP FIT TIP -,SUP-720054-01,CDM,C1813,HCPCS,278,RC,,,outpatient,,,20421.5,14295.05,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC,,
PROSTHESIS PENL CL SPCTR MALE 9.5MMX16CM SIL PE TI SEG -,SUP-720054-02,CDM,C1813,HCPCS,278,RC,,,outpatient,,,21238.36,14866.852,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC,,
PROSTHESIS PENL AMS SPCTR MALE 12MMX20CM SIL PE TI SEG CYL -,SUP-720074-03,CDM,C1813,HCPCS,278,RC,,,outpatient,,,28358.17,19850.719,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC,,
PROSTHESIS PENL AMS 700 LGX 100CM SAL FIL INFL MOMNTRY SQZ -,SUP-720185-01,CDM,C1813,HCPCS,278,RC,,,outpatient,,,12122.95,8486.065,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC,,
AMS 800 PRESSURE REGULATION BALLOON -,SUP-72400024,CDM,C1813,HCPCS,278,RC,,,outpatient,,,12791.29,8953.903,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC,,
KT PROSTHESIS PENL URIN ARTF SPHNCR IMPL SAL FIL SCRT CYL -,SUP-724000-95,CDM,C1813,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC,,
PUMP URIN SPHNCR AMS 800 MALE SIL CNCLD FLD-FIL W/O INHBZN -,SUP-724000-98,CDM,C1813,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC,,
PROSTHESIS PENL AMBICOR 11MM/12.5MM DIA FIL PMP 16CM SAL FIL -,SUP-72401451,CDM,C1813,HCPCS,278,RC,,,outpatient,,,31752.76,22226.932,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC,,
AMS AMBICOR PENILE PROTHESIS -,SUP-72401452,CDM,C1813,HCPCS,278,RC,,,outpatient,,,34352.98,24047.086,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC,,
AMS AMBICOR PENILE PROTHESIS 18CM X 14 MM -,SUP-72401454,CDM,C1813,HCPCS,278,RC,,,outpatient,,,31752.76,22226.932,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC,,
RESERVOIR PROS -,SUP-724014-77,CDM,C1813,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC,,
PROSTHESIS PENL AMS 700 LGX 65CM SAL FIL INFL MOMNTRY SQZ -,SUP-724041-55,CDM,C1813,HCPCS,278,RC,,,outpatient,,,12122.95,8486.065,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC,,
PROSTHESIS PENL AMS 700 CX MALE 100ML SAL FIL INFL CYL TIP -,SUP-72404156,CDM,C1813,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC,,
PROSTHESIS PENL PMP AMS 700 CX MALE SAL FIL INFL STRL -,SUP-724042-09,CDM,C1813,HCPCS,278,RC,,,outpatient,,,15498.06,10848.642,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC,,
18CM 700CX -,SUP-72404232,CDM,C1813,HCPCS,278,RC,,,outpatient,,,25200.41,17640.287,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC,,
PUMP AMS 700 12MM X 18CM CX MS PENILE -,SUP-72404232-10,CDM,C1813,HCPCS,278,RC,,,outpatient,,,31466.59,22026.613,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC,,
AMS 700 CX MS PUMP IZ 21CM -,SUP-72404233-12,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26705.28,18693.696,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC,,
PROSTHESIS PENL AMS 700 LGX 15MM CL INFL PRECNCT W/MS PMP -,SUP-724042-51,CDM,C1813,HCPCS,278,RC,,,outpatient,,,28543.19,19980.233,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC,,
PROSTHESIS PENL AMS 700 LGX 18CM SAL FIL INFL MOMNTRY SQZ -,SUP-72404252,CDM,C1813,HCPCS,278,RC,,,outpatient,,,36034.67,25224.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC,,
AMS 700 LGX MS PUMP IZ 21CM X 12MM -,SUP-72404253-12,CDM,C1813,HCPCS,278,RC,,,outpatient,,,32354.71,22648.297,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC,,
PROSTHESIS PENL AMS 700 CXR 14CM X 9.5MM -,SUP-72404262,CDM,C1813,HCPCS,278,RC,,,outpatient,,,25200.41,17640.287,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC,,
AMS CXR MS PUMP IZ -,SUP-72404264,CDM,C1813,HCPCS,278,RC,,,outpatient,,,32749.43,22924.601,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC,,
EXTENDER PENL AMS SPCTR 12MM/14MM DIA CL 3CM REAR TIP -,SUP-724043-23,CDM,C1813,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC,,
IMPLANT PENL RSVR CLPLST 75ML HYDRPHL CTD LKOUT VLV STRL -,SUP-90-9075K-LOC,CDM,C1813,HCPCS,278,RC,,,outpatient,,,5602.08,3921.456,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC,,
PROSTHESIS PENL TITAN 16CM HYDRPHL RST CTD CYL 3 PRT REFL -,SUP-90-9916SC,CDM,C1813,HCPCS,278,RC,,,outpatient,,,24505.8,17154.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC,,
PROSTHESIS PENL STD 18CM BIOFLEX/SIL MALE SCRT CL/PMP ST -,SUP-90-9918SNCOTR,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26752.17,18726.519,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC,,
PROSTHESIS PENL STD 20CM BIOFLEX/SIL MALE SCRT CL/PMP ST -,SUP-90-9920SCOTR,CDM,C1813,HCPCS,278,RC,,,outpatient,,,24505.8,17154.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC,,
KT PROSTHESIS PENL TITAN MALE NRW BS EXTEND ESSAY NDLX1 -,SUP-91-9480SNC,CDM,C1813,HCPCS,278,RC,,,outpatient,,,2507.14,1754.998,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC,,
PROSTHESIS PENL RSVR TITAN 75ML BIOFLEX SIL INFL SLF-CNTN -,SUP-ER8075,CDM,C1813,HCPCS,278,RC,,,outpatient,,,6938.94,4857.258,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC,,
ST PROSTHESIS PENL TITAN 18CM BIOFLEX SIL CYL INFL SLF-CNTN -,SUP-ES2918,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26956.38,18869.466,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC,,
ST PROSTHESIS TITAN 22CM BIOFLEX SIL TCH ZERO DG CL PMP -,SUP-ES2922,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26956.38,18869.466,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC,,
PROSTHESIS PENL TITAN 18CM 0DG ANG CYL INFL 1-TCH RELS -,SUP-ESR918,CDM,C1813,HCPCS,278,RC,,,outpatient,,,27550.46,19285.322,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC,,
ST UROLOGICAL PMP/CL TITAN 20CM BIOFLEX SIL 0DG ANG PENL -,SUP-ESR920,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26752.17,18726.519,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC,,
AMS AMBICOR 16CM X 14MM -,SUP-UNDEFINED,CDM,C1813,HCPCS,278,RC,,,outpatient,,,30531.59,21372.113,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,150.646235,27674.62656,other,OPPS APC,,
PROSTHESIS PENL 3.5CM INFL SCRT INHBZN CONTINENCE -,SUP-720157-01,CDM,C1815,HCPCS,278,RC,,,outpatient,,,16337.2,11436.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21443.91168,other,OPPS APC,,
PUMP CORTIAL 700 PROSTHESIS -,SUP-72404127,CDM,C1815,HCPCS,278,RC,,,outpatient,,,26900.69,18830.483,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21443.91168,other,OPPS APC,,
SYS UROLOGICAL AMS 800 4CM CUF BLT W/IZ -,SUP-724041-30,CDM,C1815,HCPCS,278,RC,,,outpatient,,,27921.76,19545.232,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21443.91168,other,OPPS APC,,
PROSTHESIS PENL AMS 800 4.5CM SAL FIL CNCLD CYL SCRT INHBZN -,SUP-72404131,CDM,C1815,HCPCS,278,RC,,,outpatient,,,27921.76,19545.232,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21443.91168,other,OPPS APC,,
PROSTHESIS PENL AMS 800 5.0CM SAL FIL CNCLD CYL SCRT INHBZN -,SUP-72404132,CDM,C1815,HCPCS,278,RC,,,outpatient,,,26585.08,18609.556,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21443.91168,other,OPPS APC,,
PROSTHESIS PENL AMS 800 6.0CM SAL FIL ARTIF URINARY SPHINCTR -,SUP-72404134,CDM,C1815,HCPCS,278,RC,,,outpatient,,,25935.31,18154.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,21443.91168,other,OPPS APC,,
OCCLUDERS FLO RESTER 1.5 -,SUP-50150,CDM,C1817,HCPCS,278,RC,,,outpatient,,,470.8,329.56,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDERS FLO RESTER 2.5 -,SUP-50250,CDM,C1817,HCPCS,278,RC,,,outpatient,,,470.8,329.56,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER VASC 2MM BLB 30MM INTNL VES FLO-RST DISP -,SUP-60200,CDM,C1817,HCPCS,278,RC,,,outpatient,,,443.78,310.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
AMPLATZER AMULET 16MM WW REF: 9-ACP2-007-016 -,SUP-9-ACP2-007-016,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
AMPLATZER AMULET 18MM WW REF: 9-ACP2-007-018 -,SUP-9-ACP2-007-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
AMPLATZER AMULET 20 MM WW REF: 9-ACP2-007-020 -,SUP-9-ACP2-007-020,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
AMPLATZER AMULET 22 MM WW REF: 9-ACP2-007-022 -,SUP-9-ACP2-007-022,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
AMPLATZER AMULET 25 MM WW REF: 9-ACP2-010-025 -,SUP-9-ACP2-010-025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
AMPLATZER AMULET 28 MM WW REF: 9-ACP2-010-028 -,SUP-9-ACP2-010-028,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
AMPLATZER AMULET 31 MM WW REF: 9-ACP2-010-031 -,SUP-9-ACP2-010-031,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
AMPLATZER AMULET 34 MM WW REF: 9-ACP2-010-034 -,SUP-9-ACP2-010-034,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER AMPLATZER SEPTAL 5MM  REF: 9-ASD-005 -,SUP-9-ASD-005,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER AMPLATZER SEPTAL 6MM  REF: 9-ASD-006 -,SUP-9-ASD-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 08MM WST 16MM/20MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-008,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 10MM WST 18MM/22MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-010,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 11MM WST 21MM/25MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-011,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 12MM WST 22MM/26MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-012,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 13MM WST 23MM/27MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-013,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 14MM WST 24MM/28MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-014,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 15MM WST 25MM/29MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-015,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 16MM WST 26MM/30MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-016,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 18MM WST 28MM/32MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 19MM WST 28MM/32MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-019,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 20MM WST 30MM/34MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-020,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 22MM WST 32MM/36MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-022,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 24MM WST 34MM/38MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-024,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 26MM WST 36MM/40MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-026,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 28MM WST 38MM/42MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-028,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 30MM WST 40MM/44MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-030,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 32MM WST 42MM/46MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-032,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 34MM WST 44MM/50MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-034,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 36MM WST 46MM/52MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-036,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 18MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 25MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 30MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-030,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 35MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-035,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
GRAFT VASC 5MMX12.5MM AMPLATZER OCLR SE FUL CX-SECT CVRGLS -,SUP-9-AVP038-005,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
GRAFT VASC 6X11MM AMPLATZER PLG SE FUL CX-SECT CVRGLS LT ATR -,SUP-9-AVP038-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
GRAFT VASC 7MMX12.5MM AMPLATZER PLG OCLR SE FUL CX-SECT -,SUP-9-AVP038-007,CDM,C1817,HCPCS,278,RC,,,outpatient,,,5177.68,3624.376,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
PLUG VASCULAR AMPLATZER 6MM REF:09-AVP2-006 -,SUP-9-AVP2-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
PLUG VASCULAR AMPLATZER 8 -,SUP-9-AVP2-008,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
PLUG VASCULAR AMPLATZER 10 011 -,SUP-9-AVP2-010,CDM,C1817,HCPCS,278,RC,,,outpatient,,,3971.97,2780.379,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
PLUG VASCULAR AMPLATZER 12 -,SUP-9-AVP2-012,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
PLUG VASCULAR AMPLATZER 16 -,SUP-9-AVP2-016,CDM,C1817,HCPCS,278,RC,,,outpatient,,,3971.97,2780.379,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
PLUG VASCULAR AMPLATZER 18 -,SUP-9-AVP2-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
GRAFT VASC 22X6MM AMPLATZER PLG SE MUL-LOBE LT ATR NTNL -,SUP-9-AVP2-022,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER DCT 5MM/4MM DIA DSCND AOR/PA AMPLATZER NTNL INTRWVN -,SUP-9-PDA-003,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER DCT 6MM/4MM DIA DSCND AOR/PA AMPLATZER NTNL INTRWVN -,SUP-9-PDA-004,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER DCT 8MM/6MM DIA DSCND AOR/PA AMPLATZER NTNL INTRWVN -,SUP-9-PDA-005,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
10/8 AMPLATZER DUCT OCCLUDER -,SUP-9-PDA-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER VASC DCT 12MM/10MM DIA/DSCND/PULM AOR 7FRX8MM NTNL -,SUP-9-PDA-007,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER DUCT II AMPLATZER 3MMX4MM -,SUP-9-PDA2-03-04,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER DCT 5MM/4MM DIA WST/DISC AMPLATZER NTNL DBL DISC -,SUP-9-PDA2-05-04,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER DCT 5MM/6MM DIA WST/DISC AMPLATZER NTNL DBL DISC. -,SUP-9-PDA2-05-06,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER DUCT II AMPLATZER 6MMX4MM -,SUP-9-PDA2-06-04,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER DCT 5MM/11MM DIA WST/DISC AMPLATZER NTNL DBL DISC.. -,SUP-9-PDA2-06-06,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER DUCT II AMPLATZER 6MMX6MM -,SUP-9-PDA2-06-06,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCULUDER AMPLATZER PFO 18MM -,SUP-9-PFO-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER AMPLATZER PFO 25MM -,SUP-9-PFO-025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER AMPLATZER PFO 35MM -,SUP-9-PFO-035,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
AMPLATZER TALISMAN PFO OCCLUDER 8FR 18MM REF:9-PFO-1818 -,SUP-9-PFO-1818,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
AMPLATZER TALISMAN PFO OCCLUDER 25-18MM -,SUP-9-PFO-2518,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
AMPLATZER TALISMAN PFO OCCLUDER 30-25MM -,SUP-9-PFO-3025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
TORQVUE SHEATH 12F 80CM 45X45 REF: 9-TV45X45-12F-080 -,SUP-9-TV45X45-12F-080,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4676.89,3273.823,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
CLOSURE DEVICE WATCHMAN FLEX 27MM -,SUP-M635WU0270,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
SHEATH WATCHMAN 21MM 12FR CLSR 75CM TRNSEPT -,SUP-M635WU21060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
SHEATH WATCHMAN 24MM 12FR CLSR 75CM  TRNSEPT -,SUP-M635WU24060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
SHEATH WATCHMAN 27MM 12FR CLSR 75CM  TRNSEPT -,SUP-M635WU27060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
SHEATH WATCHMAN 30MM 12FR CLSR 75CM TRNSEPT -,SUP-M635WU30060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
SHEATH WATCHMAN 33MM 12FR CLSR 75CM TRANSEPT -,SUP-M635WU33060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
CLOSURE DEVICE WATCHMAN FLEX 20MM -,SUP-M635WU50200,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
CLOSURE DEVICE WATCHMAN FLEX 31MM -,SUP-M635WU50310,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
CLOSURE DEVICE WATCHMAN FLEX 35MM -,SUP-M635WU50350,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
CLOSURE DEVICE WATCHMAN FLEX PRO 20MM REF:M635WU60200 -,SUP-M635WU60200,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
CLOSURE DEVICE WATCHMAN FLEX PRO 24MM REF:M635WU60240 -,SUP-M635WU60240,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
CLOSURE DEVICE WATCHMAN FLEX PRO 27MM REF:M635WU60270 -,SUP-M635WU60270,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
CLOSURE DEVICE WATCHMAN FLEX PRO 31MM REF:M635WU60310 -,SUP-M635WU60310,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
CLOSURE DEVICE WATCHMAN FLEX PRO 35MM REF:M635WU60350 -,SUP-M635WU60350,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
CLOSURE DEVICE WATCHMAN FLEX PRO 40MM REF:M635WU60400 -,SUP-M635WU60400,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
CLOSURE DEVICE WATCHMAN FLEX 24MM -,SUP-M63WU50240,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,99.62861,33156.48,other,OPPS APC,,
TULOC LOCALIZATION WIRE 20G X 5CM -,SUP-271660,CDM,C1819,HCPCS,278,RC,,,outpatient,,,200.72,140.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,45.06164,416.02,other,OPPS APC,,
TULOC LOCALIZATION WIRE 20G X 9CM -,SUP-271661,CDM,C1819,HCPCS,278,RC,,,outpatient,,,200.72,140.504,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,45.06164,416.02,other,OPPS APC,,
TULOC PREMIUM LOCALIZATION WIRE 20G X 5CM -,SUP-271880,CDM,C1819,HCPCS,278,RC,,,outpatient,,,256.74,179.718,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,45.06164,416.02,other,OPPS APC,,
TULOC PREMIUM LOCALIZATION WIRE 20G X 9CM -,SUP-271881,CDM,C1819,HCPCS,278,RC,,,outpatient,,,256.74,179.718,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,45.06164,416.02,other,OPPS APC,,
ETERNA IMPLANTABLE PULSE GENERATOR -,SUP-32400,CDM,C1820,HCPCS,278,RC,,,outpatient,,,45639.5,31947.65,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,41625.59232,other,OPPS APC,,
PRODIGY 3730 -,SUP-3730,CDM,C1820,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,41625.59232,other,OPPS APC,,
SYS GENERATOR NEURSTM RSTOR ADVANCED PERC MUL-PRGM RCHG ACC -,SUP-377-13,CDM,C1820,HCPCS,278,RC,,,outpatient,,,31108.87,21776.209,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,41625.59232,other,OPPS APC,,
NEURSTM IMPL RESTORESENSOR 2.1INX2.1IN PERC SMALLEST -,SUP-377-14,CDM,C1820,HCPCS,278,RC,,,outpatient,,,38238.5,26766.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,41625.59232,other,OPPS APC,,
PRODIGY MRI -,SUP-3772,CDM,C1820,HCPCS,278,RC,,,outpatient,,,38929.26,27250.482,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,41625.59232,other,OPPS APC,,
NEURSTM IMPL RESTORESENSOR SURSCN 9X54X54MM SPIN CRD RCHG -,SUP-97714,CDM,C1820,HCPCS,278,RC,,,outpatient,,,38238.5,26766.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,41625.59232,other,OPPS APC,,
INTERSTIM MICRO MRI RECHARGEABLE NEUROSTIMULATOR -,SUP-97810,CDM,C1820,HCPCS,278,RC,,,outpatient,,,25644.47,17951.129,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,41625.59232,other,OPPS APC,,
MICROSTIMULATOR INS 97810 RECHARGEABLE -,SUP-97810,CDM,C1820,HCPCS,278,RC,,,outpatient,,,25644.47,17951.129,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,41625.59232,other,OPPS APC,,
KT GENERATOR NEURSTM PRECISN SPCTR -,SUP-M365SC1110020,CDM,C1820,HCPCS,278,RC,,,outpatient,,,54199.99,37939.993,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,41625.59232,other,OPPS APC,,
VERTIFLEX SUPERION IDS-10MM -,SUP-101-9810,CDM,C1821,HCPCS,278,RC,,,outpatient,,,25619.7,17933.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
VERTIFLEX SUPERION IDS-12MM -,SUP-101-9812,CDM,C1821,HCPCS,278,RC,,,outpatient,,,25619.7,17933.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
VERTIFLEX SUPERION IDS -14MM -,SUP-101-9814,CDM,C1821,HCPCS,278,RC,,,outpatient,,,25619.7,17933.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
SPACER CERV 8X27MMX0.016IN ZYSTON -,SUP-14-533108,CDM,C1821,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
SPACER ANT CERV 19-25MMH FORTIFY OPTMZ FIT TI -,SUP-151.051,CDM,C1821,HCPCS,278,RC,,,outpatient,,,18565,12995.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
SPACER ANT CERV 15X18MM FTPRNT FORTIFY 7DG OPTMZ FIT TI -,SUP-151.334,CDM,C1821,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
SPACER ANT CERV 15X18MM FTPRNT FORTIFY 7DG OPTMZ FIT TI. -,SUP-151.384,CDM,C1821,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
MESH 14MM ROUND 30MM HGT -,SUP-176014030,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11221.61,7855.127,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
MESH SURG 23X27MM DIA 12X14MM OBLNG TRPZD TI HARMS -,SUP-1763-02-012,CDM,C1821,HCPCS,278,RC,,,outpatient,,,14854.78,10398.346,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
RISE SPACER 8 X 22MM- 7-13MM -,SUP-193.001,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
SPACER RISE 8 X 22MM 8-14MM 10 DEG -,SUP-193.021,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
SPACER RISE 10 X 22 7-13 -,SUP-193.101,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
SPACER RISE 10 X 26MM 7-14MM -,SUP-193.102,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
SPACER RISE 10 X 26MM 10-17MM -,SUP-193.112,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
RISE SPACER 10X22MM 8-14MM 10 DEGREES -,SUP-193.121,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
RISE SPACER 10MM X 26MM 8-15MM 10 DEGREES -,SUP-193.122,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
SPACER SPINAL RISE 10MM X 30MM 8-15MM 10 DEG -,SUP-193.123,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
RISE SPACER 10 X 26MM 10-17MM -,SUP-193.142,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
RISER SPACER 10X22MM- 9-15MM -,SUP-193.151,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
NORMANDY 12X14 30MM 10DEGREES -,SUP-250-1214-30-10,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19597.21,13718.047,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
CAGE 12X14 44-76 10 DEGREE -,SUP-250-1214-4410,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19597.21,13718.047,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
SPACER THORLUM VERT 12X26X12MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.972,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
SPACER SMALL 12 X 14 ZERO DEG 19MM NIKO CORPECTOMY -,SUP-342.719,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11547.43,8083.201,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
SPACER SPINAL NIKO PEEK 7 D D12 MM SMALL 14X15MM CORPECTOMY -,SUP-342.815,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11547.43,8083.201,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
SEASPINE 7H CAGE -,SUP-AC4-143077,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9901.25,6930.875,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
SEASPINE CAGE 16X14X6MM 7 DEGREE 3D INTERBODY -,SUP-AC4-264067,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
GENESYS 6H CAGE -,SUP-ACC804-06S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
CAGE 9 X 26 X 12 6-20 DEGREES -,SUP-ET1-102612,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19678.9,13775.23,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
SEASPINE 9 X 26 0-14 DEGREE LORDOTIC CAGE -,SUP-ET1-142608,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
SEASPINE 10H 17 DEGREE CAGE -,SUP-ET1-172610,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
CAGE EXPANDABLE SEASPINE 10H 9W 30L -,SUP-ET1-173010,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
SEASPINE 10-14MM 8 DEGREE CAGE -,SUP-ET1-382810,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
APACHE SPACER 8MM -,SUP-GAC-08SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
TITANIUM APACHE CAGE 5MM -,SUP-GAC3D-05SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
TITANIUM APACHE CAGE 6MM -,SUP-GAC3D-06SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
7MM CAGE APACHE -,SUP-GAC3D-07SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
CAGE TLIF 7MM X 30MM -,SUP-GP-07-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
CAGE APACHE PEEK SPACER 8 X 30 -,SUP-GP-08-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
CAGE 25 STRAIGHT 9MM -,SUP-GP-09,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
CAGE 9 X 30 -,SUP-GP-09-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
CAGE 10MM STANDARD PLIF -,SUP-GP-10,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
CAGE PEEK 30 X 10MM -,SUP-GP-10-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
CAGE APACHE 11MM -,SUP-GP-11,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
CAGE 8MM BI-CONVEX PLIF -,SUP-GPC2-08,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
CAGE 9MM CONVEX PLIF -,SUP-GPC2-09,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
SPACER PEEK 10 X 24 CONVEX -,SUP-GPC2-10,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
CAGE PEEK APACHE 11MM -,SUP-GPC2-11,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
SPINEART LUMBAR POSTERIOR TI CAGE L24 W10.5 H08 12 DEG -,SUP-JUT-PX 24 08-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
JULIET TI PO LUMBAR POSTERIOR TI CAGE L24 W10.5 H10 12DEG -,SUP-JUT-PX 24 10-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
CAGE LUMBAR POSTERIOR TI L24 W10.5 H11 12 DEG -,SUP-JUT-PX 24 11-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
CAGE LUMBAR POSTERIOR TI L24 W10.5 H12 -,SUP-JUT-PX 24 12-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
CAGE TRANSORAMINAL LUMBAR TI L 30 W 10.5 H 14 -,SUP-JUT-T6 30 14-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
TRANSFORMATIONAL LUMBAR TI CAGE L34 W10.5 H12 06 DEG -,SUP-JUT-T6 34 12-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
CAGE CERV 7MM/4.1MM H A/P ROI- C LRDTC -,SUP-MC1443P,CDM,C1821,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
CAGE CERV 10MM/7.1MM H A/P ROI- C LRDTC -,SUP-MC1446P,CDM,C1821,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
PATHLOC LUMBAR INTERBODY FUSION CAGE 12MM 15 DEGREES -,SUP-PT2211-0815S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19678.9,13775.23,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
SCARLET AL-T SECURED ANTERIOR CAGE SMALL H12 15' -,SUP-SCA-LS 15 12-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
CAGE 11MM LUCENT STR -,SUP-UNDEFINED,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11695.95,8187.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,19675.9296,other,OPPS APC,,
NPG IMPLANT AND CHARGER -,SUP-HFX-D,CDM,C1822,HCPCS,278,RC,,,outpatient,,,60441.5,42309.05,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46419.072,other,OPPS APC,,
KIT BLUE LEAD 90CM WITH 5MM SPACING -,SUP-LEAD1058-90B,CDM,C1822,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46419.072,other,OPPS APC,,
IPG KIT -,SUP-NIPG2500,CDM,C1822,HCPCS,278,RC,,,outpatient,,,60441.5,42309.05,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46419.072,other,OPPS APC,,
NEVRO IPG KIT WITH NEW BATTERY -,SUP-NIPG3000,CDM,C1822,HCPCS,278,RC,,,outpatient,,,60441.5,42309.05,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,46419.072,other,OPPS APC,,
STENT DES 4X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-10074400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X15MM XIENCE V RX BE PRMNT 143CM EVEROL CMPLNT -,SUP-1009541-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT 2.8X16MM GRAFTMS RX 143CM SEM-COM HYDRCT -,SUP-1012580-16,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT 4X16MM GRAFTMS RX 143CM SEM-COM HYDRCT -,SUP-1012582-16,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT 4X26MM GRAFTMS RX 143CM SEM-COM HYDRCT -,SUP-1012582-26,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.25X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.25X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.25X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.25X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.25X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.25X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.25X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.25X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125225-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125275-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.25X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.25X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.25X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35644.8,24951.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.25X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.25X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT 3X19MM JOST GRAFTMS OTW BE 143CM SEM-COM HYDREX CTD -,SUP-12744-19,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT 4X19MM JOST GRAFTMS OTW BE 143CM SEM-COM HYDREX CTD -,SUP-12746-19,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X8MM XIENCE SKYPOINT -,SUP-1804225-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X12MM XIENCE SKYPOINT -,SUP-1804225-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X15MM XIENCE SKYPOINT -,SUP-1804225-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X18MM XIENCE SKYPOINT -,SUP-1804225-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X23MM XIENCE SKYPOINT -,SUP-1804225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X28MM XIENCE SKYPOINT -,SUP-1804225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X33MM XIENCE SKYPOINT -,SUP-1804225-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X38MM XIENCE SKYPOINT -,SUP-1804225-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X8MM XIENCE SKYPOINT -,SUP-1804250-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X12MM XIENCE SKYPOINT -,SUP-1804250-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X15MM XIENCE SKYPOINT -,SUP-1804250-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X18MM XIENCE SKYPOINT -,SUP-1804250-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X23MM XIENCE SKYPOINT -,SUP-1804250-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X28MM XIENCE SKYPOINT -,SUP-1804250-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X33MM XIENCE SKYPOINT -,SUP-1804250-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X38MM XIENCE SKYPOINT -,SUP-1804250-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X8MM XIENCE SKYPOINT -,SUP-1804275-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X12MM XIENCE SKYPOINT -,SUP-1804275-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X15MM XIENCE SKYPOINT -,SUP-1804275-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X18MM XIENCE SKYPOINT -,SUP-1804275-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X23MM XIENCE SKYPOINT -,SUP-1804275-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X28MM XIENCE SKYPOINT -,SUP-1804275-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X33MM XIENCE SKYPOINT -,SUP-1804275-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X38MM XIENCE SKYPOINT -,SUP-1804275-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.0X8MM XIENCE SKYPOINT -,SUP-1804300-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.0X12MM XIENCE SKYPOINT -,SUP-1804300-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.0X15MM XIENCE SKYPOINT -,SUP-1804300-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.0X18MM XIENCE SKYPOINT -,SUP-1804300-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.0X23MM XIENCE SKYPOINT -,SUP-1804300-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.0X28MM XIENCE SKYPOINT -,SUP-1804300-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.0X33MM XIENCE SKYPOINT -,SUP-1804300-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.0X38MM XIENCE SKYPOINT -,SUP-1804300-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.25X8MM XIENCE SKYPOINT -,SUP-1804325-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.25X12MM XIENCE SKYPOINT -,SUP-1804325-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.25X15MM XIENCE SKYPOINT -,SUP-1804325-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.25X18MM XIENCE SKYPOINT -,SUP-1804325-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.25X23MM XIENCE SKYPOINT -,SUP-1804325-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.25X28MM XIENCE SKYPOINT -,SUP-1804325-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.25X33MM XIENCE SKYPOINT -,SUP-1804325-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.25X38MM XIENCE SKYPOINT -,SUP-1804325-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X8MM XIENCE SKYPOINT -,SUP-1804350-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X12MM XIENCE SKYPOINT -,SUP-1804350-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X15MM XIENCE SKYPOINT -,SUP-1804350-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X18MM XIENCE SKYPOINT -,SUP-1804350-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X23MM XIENCE SKYPOINT -,SUP-1804350-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X28MM XIENCE SKYPOINT -,SUP-1804350-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X33MM XIENCE SKYPOINT -,SUP-1804350-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X38MM XIENCE SKYPOINT -,SUP-1804350-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4.0X8MM XIENCE SKYPOINT -,SUP-1804400-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4.0X12MM XIENCE SKYPOINT -,SUP-1804400-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4.0X15MM XIENCE SKYPOINT -,SUP-1804400-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4.0X18MM XIENCE SKYPOINT -,SUP-1804400-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4.0X23MM XIENCE SKYPOINT -,SUP-1804400-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4.0X28MM XIENCE SKYPOINT -,SUP-1804400-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4.0X33MM XIENCE SKYPOINT -,SUP-1804400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4.0X38MM XIENCE SKYPOINT -,SUP-1804400-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4.5 X12MM XIENCE SKYPOINT -,SUP-1804450-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4.5 X15MM XIENCE SKYPOINT -,SUP-1804450-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4.5 X18MM XIENCE SKYPOINT -,SUP-1804450-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4.5 X23MM XIENCE SKYPOINT -,SUP-1804450-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4.5 X28MM XIENCE SKYPOINT -,SUP-1804450-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4.5 X33MM XIENCE SKYPOINT -,SUP-1804450-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 5.0 X12MM XIENCE SKYPOINT -,SUP-1804500-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 5.0 X15MM XIENCE SKYPOINT -,SUP-1804500-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 5.0 X18MM XIENCE SKYPOINT -,SUP-1804500-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 5.0 X23MM XIENCE SKYPOINT -,SUP-1804500-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 5.0 X28MM XIENCE SKYPOINT -,SUP-1804500-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 5.0 X33MM XIENCE SKYPOINT -,SUP-1804500-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 30MM PROX 30MM DIST 25-27MM OD AOR 140MM ZENITH TX2 -,SUP-2TEG-2P-30-140-,CDM,C1874,HCPCS,278,RC,,,outpatient,,,29835.9,20885.13,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
DETACHABLE COIL 4MM X 8MM -,SUP-36-152,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PK PAPYRUS 2.5/15 -,SUP-434887,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PK PAPYRUS 3.0/15 -,SUP-434888,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PK PAPYRUS 3.5/15 -,SUP-434889,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PK PAPYRUS 4.0/15 -,SUP-434890,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PK PAPYRUS 4.5/15 -,SUP-434891,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PK PAPYRUS 5.0/15 -,SUP-434892,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PK PAPYRUS 2.5/20 -,SUP-434893,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PK PAPYRUS 3.0/20 -,SUP-434894,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PK PAPYRUS 3.5/20 -,SUP-434895,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PK PAPYRUS 4.0/20 -,SUP-434896,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PK PAPYRUS 4.5/20 -,SUP-434897,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PK PAPYRUS 5.0/20 -,SUP-434898,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PK PAPYRUS 3.0/26 -,SUP-434899,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PK PAPYRUS 3.5/26 -,SUP-434900,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PK PAPYRUS 4.0/26 -,SUP-434901,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PK PAPYRUS 4.5/26 -,SUP-434902,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PK PAPYRUS 5.0/26 -,SUP-434903,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
COVERA VASCULAR COVERED STENT 6 x 60 Ref: AVFM06060 -,SUP-AVFM06060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
COVERA VASCULAR COVERED STENT 7 X 80 8F -,SUP-AVFM07080,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
COVERA 8MM X 40MM FLARED -,SUP-AVFM08040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
COVERA 8MM X 60MM FLARED -,SUP-AVFM08060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT VASCULAR COVERA FLARE 8MM X 80MM -,SUP-AVFM08080,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
COVERA STENT GRAFT 10 X 40 -,SUP-AVFM10040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
COVERA VASCULAR COVERED STENT 6 x 40 Ref: AVSM06040 -,SUP-AVSM06040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
COVERA AV STENT GRAFT 8MM X 60MM X 80MM -,SUP-AVSM08060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT COVERA AV GRAFT 8MM X 80MM X 80MM -,SUP-AVSM08080,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT COVERA AV GRAFT 10MM X 60MM 80CM STRAIGHT -,SUP-AVSM10060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
VIABAHN BALLOON EXPANDABLE 7MM X 29MM STENT -,SUP-BXA072902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12468.25,8727.775,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
BALLOON EXPANDABLE ENDOPROSTHESIS VIABAHN 8-11 7FR 29LGTH -,SUP-BXA082902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13199.72,9239.804,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
BALLOON EXPANDABLE ENDOPROSTHESIS VIABAHN 8-11 7FR 39LGTH -,SUP-BXA083902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
BALLOON EXPANDABLE ENDOPROSTHESIS VIABAHN 8-11 7FR 59 LGTH -,SUP-BXA085902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12468.25,8727.775,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT VIABAHN 11MM X 39CM GORE -,SUP-BXA113902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11844.47,8291.129,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
VIABAHN BALLOON EXPANDABLE 1MM X 59MM STENT -,SUP-BXA115902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT VIABAHN VBX BALLOON EXPANDABLE ENDOPROSTHESIS 2 -,SUP-BXAL082901A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
VIABAHN VBX BALLOON EXPANDABLE ENDOPROSTHESIS -,SUP-BXAL082902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT VIABAHN VBX 8MM X 39MM BALLOON EXPANDABLE -,SUP-BXAL083901A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
VIABAHN VBX 8MM X 59MM BALLOON AXPANDABLE STENT -,SUP-BXAL085901A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
VIABAHN VBX BALLOON EXPANDABLE ENDOPROSTHESIS -,SUP-BXAL085902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
EXCLUDER CONFORM AAA EXT ENDO 26MM X 4.5CM 15FR -,SUP-CXA260005,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19511.82,13658.274,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT 3.5X15MM DRIVER OTW BE  143CM 0.014IN GW COMP -,SUP-DRV35015W,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 22X39MM ZENITH FLEX BIFUR MAIN BD EXTEND Z-TRAK -,SUP-ESBE-22-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 24X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-24-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 26X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-26-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 28MM DI 39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK -,SUP-ESBE-28-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 30X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-30-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 32X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-32-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 36X50MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-36-50-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT STENT ENDURANT 23MM -,SUP-ESBF2314C103E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 28/14X103MM ENDURANT IIS BIFUR STNT PRELD PROX -,SUP-ESBF2814C103E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,36592.73,25614.911,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 32/14X103MM ENDURANT IIS BIFUR STNT PRELD PROX -,SUP-ESBF3214C103E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
CONVERTER EV 12MM DIST 24MM PROX 80MM ZENITH FLEX Z-TRAK -,SUP-ESC-24-12-80-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
CONVERTER EV 28MMX12MMX80MM ZENITH FLEX Z-TRAK INTRO SYS -,SUP-ESC-28-12-80ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
CONVERTER EV 32MMX12MMX80MM ZENITH FLEX Z-TRAK INTRO SYS -,SUP-ESC-32-12-80-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
CONVERTER EV 36MMX12MMX82MM ZENITH FLEX Z-TRAK INTRO SYS -,SUP-ESC-36-12-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 18X55MM ZENITH AOR -,SUP-ESLE-18-55-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8246.09,5772.263,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
SYS STENT ENDURANT II GRAFT BI -,SUP-ETBF2316C145E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT GRAFT ENDURANT II AORTIC EXTENSION 49E -,SUP-ETCF2323C49E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14726.69,10308.683,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT GRAFT ENDURANT II AO EXT -,SUP-ETCF2828C49E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15079.42,10555.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STEN GRAFT ENDURANT II AORTIC EXT 49E -,SUP-ETCF3232C49E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16783.13,11748.191,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT GRAFT ENDURANTII ILEXT -,SUP-ETEW1313C82E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16402.18,11481.526,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT GRAFT ENDUR II LIMB -,SUP-ETLW1610C156E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT STENT ENDUR II LIMB -,SUP-ETLW1610C199E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,22910.14,16037.098,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT STENT ENDUR IIS LIMB -,SUP-ETLW1610C93E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17372.2,12160.54,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 16/13X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1613C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17548.57,12283.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 16/13X156MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1613C156E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,24713.73,17299.611,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 16/16X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1616C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,18067.09,12646.963,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 16/16X82MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1616C82E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17280.3,12096.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 16/20X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1620C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17548.57,12283.999,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 16/20X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1620C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,18250.51,12775.357,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT GRAFT ENDUR II LIMB -,SUP-ETLW1624C156E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT GRAFT CONTRAL ENDURANT -,SUP-ETLW1624C93E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17372.2,12160.54,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT GRAFT ENDURANT II AUI -,SUP-ETUF2314C102E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 28/14X102MM ENDURANT II BIFUR STNT AOR ILC PRELD -,SUP-ETUF2814C102E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT STENT ENDURANT II 14MM X 36 X102MM -,SUP-ETUF3614C102E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 7MM 9FR CATH 50MM 120CM TOT 80CM DLV SYS FLAIR FLR -,SUP-FAF07050,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 8MM 9FR CATH 40MM 800CM TOT 80CM DLV SYS FLAIR FLR -,SUP-FAF08040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 7MM 9FR CATH 40MM 120CM TOT 80CM DLV SYS FLAIR STR -,SUP-FAS07040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9995.4,6996.78,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 10MM 9FR CATH 40MM FLUENCY+ 117CM TRACHBR SE -,SUP-FTL10040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9825.92,6878.144,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 7MM 8FR CATH 60MM FLUENCY+ 80CM TRACHBR SE -,SUP-FTM07060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10077.08,7053.956,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 8MM 9FR CATH 40MM FLUENCY+ 80CM TRACHBR SE -,SUP-FTM08040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10077.08,7053.956,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 12X54MM ZENITH AAA CNTRLAT ILC LEG WVN PLYSTR -,SUP-G12446,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 12MM IPSI LEG DIA 106MM DIST LEG 28MM DIST BD -,SUP-G32500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 30MM PROX 24-26MM OD AOR 94MM PROX BD ZENITH FEN -,SUP-G32533,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
ZENITH FENESTRATED PROXIMAL BODY -,SUP-G32537,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7045.04,4931.528,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT CUST ZFEN-P 2-24-124-R -,SUP-G32540,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 28MM PROX 23-24MM OD AOR 124MM PROX BD ZENITH FEN -,SUP-G32542,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 30MM PROX 24-26MM OD AOR 124MM PROX BD ZENITH FEN -,SUP-G32543,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT ZENITH FEN PROXIMAL BODY - ZFEN-P-2-32-124-R -,SUP-G32544,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 36MM PROX 29-31MM OD AOR 122MM PROX BD ZENITH FEN -,SUP-G32548,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT ZENITH DISTAL BODY - ZFEN-12-28-91 -,SUP-G32554,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 24/12X113MM ZENITH RENU ANCLRY CNVTR H&L-B 1-SHOT -,SUP-G36155,CDM,C1874,HCPCS,278,RC,,,outpatient,,,24186.48,16930.536,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
DRUG ELUTING STENT 80 PTX -,SUP-G38480,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
S ZILVER PTX 6 X 120 X 125 DRU -,SUP-G38482,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9315.54,6520.878,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PTX 7MM X 40MM -,SUP-G38486,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5487.45,3841.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
DRUG ELUTING STENT 7 - 60 PTX -,SUP-G38487,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6981.34,4886.938,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
DRUG ELUTING STENT 7 - 100 PTX -,SUP-G38489,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ZILVER PTX 7MM X 120MM P -,SUP-G38490,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9315.54,6520.878,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT 8mm x 40mm PTX ZILVER -,SUP-G38495,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5487.45,3841.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ZILVER 8MM X 80MM PTX DRUG ELUTING PERIP -,SUP-G38518,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ZIV6-35-125-8-120-PTX -,SUP-G38532,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9315.54,6520.878,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 20X30MM ZENITH FLEX BIFUR ILC PLG H&L-B 1-SHOT -,SUP-G43055,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7775.01,5442.507,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 36MMX11.3CM ZENITH FLEX AAA BIFUR STNT 20FR DLV SYS -,SUP-G43357,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30491.16,21343.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 36MMX12MMX127MM ZENITH RENU ANCLRY CNVTR H&L-B -,SUP-G43366,CDM,C1874,HCPCS,278,RC,,,outpatient,,,23484.73,16439.311,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
ZENITH TX2 DISSECTION ENDOVASCULAR GRAFT STRAIGHT COMPONENT -,SUP-G47454,CDM,C1874,HCPCS,278,RC,,,outpatient,,,49547.23,34683.061,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
COMPONENT STRAIGHT ENDO GRAFT ZENITH TX2 DISSECTION -,SUP-G47457,CDM,C1874,HCPCS,278,RC,,,outpatient,,,43823.79,30676.653,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
ZENITH FLEX AAA ENDOVASC GRAFT MAIN BODY -,SUP-G48403,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 24MM BD 20-21MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-G48408,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT ZENITH FLEX AAA ENDOVASCULAR BIFURC MAIN BODY -,SUP-G48409,CDM,C1874,HCPCS,278,RC,,,outpatient,,,34530.9,24171.63,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
ENDOGRAFT 32-82 ZENITH FLEX -,SUP-G48427,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 36MM BD 29-32MM OD AOR 95MM ZENITH FLEX BIFUR MAIN -,SUP-G48428,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
ZENITH FLEX AAA ENDOVASCULAR GRAFT 20FR -,SUP-G48429,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT ZEINTH 36X95MM ENDOVAS A -,SUP-G48432,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 36MM BD 29-32MM OD AOR 113MM ZENITH FLEX BIFUR MAIN -,SUP-G48433,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 14MM MAIN BD 37MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-G48454,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 22MM MAIN BD 39MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-G48472,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11454.61,8018.227,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 24MM MAIN BD 39MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-G48476,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11454.61,8018.227,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT COLONIC 18MM X 23MM X 12 -,SUP-G51183,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ESOPHAGEAL EVOLUTION FULLY COVERED 20-25-8 -,SUP-G52225,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 38MM PROX 38MM DIST 33-34MM OD AOR 202MM ZENITH TX2 -,SUP-G53435,CDM,C1874,HCPCS,278,RC,,,outpatient,,,29835.9,20885.13,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT ZENITH FLES Z-TRAK AAA ENDOVASC MAIN BODY EXT -,SUP-G55213,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9273.14,6491.198,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
ZENITH FLEX WITH SPIRAL Z ENDOVASCULAR GRAFT -,SUP-G55221,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT ZENITH FLEX LEG 13X56 -,SUP-G55231,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 16MM DIST 56MM ZENITH SPRL-Z CNTRLAT IPSI ILC LEG -,SUP-G55237,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT ZENITH FLEX LEG 16X74 14FR -,SUP-G55238,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT ZENITH FLEX LEG 20MM X 39MM -,SUP-G55240,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 24MM DIST 90MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-G55247,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT ZENITH 22 X 113 -,SUP-G55357,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30944.14,21660.898,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
ZENITH RENU AAA ANCILLARY GRAFT CON 12MM X 28MM X 113MM -,SUP-G55376,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30944.14,21660.898,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
ICAST COVERED STENT- 9MMX38MMX120CM -,SUP-G60511,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9841.79,6889.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
SYNERGY II US MR 2.5X8 -,SUP-H493926008250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
SYNERGY II US MR 2.75X8 -,SUP-H493926008270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
SYNERGY II US MR 3.5X8 -,SUP-H7433926008350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X24MM TAXUS EXPR2 OTW BE PRMNT 135CM PACLIT -,SUP-H7493896824250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X16MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902316250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X16MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902316400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X20MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902320270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X20MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902320300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X20MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902320400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X16MM ION MONORAIL RX BE PRMNT 144CM PACLIT -,SUP-H7493902416220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X16MM ION MONORAIL RX BE PRMNT 144CM PACLIT -,SUP-H7493902416270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X20MM ION MONORAIL RX BE PRMNT 144CM PACLIT THN -,SUP-H7493902420300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X28MM ION MONORAIL RX BE PRMNT 144CM PACLIT THN -,SUP-H7493902428300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X32MM ION MONORAIL RX BE PRMNT 144CM PACLIT THN -,SUP-H7493902432250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X32MM ION MONORAIL RX BE PRMNT 144CM PACLIT -,SUP-H7493902432270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X32MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911432220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X32MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911432250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X32MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911432350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SV -,SUP-H7493911608220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911608250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911608270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL WKHRS -,SUP-H7493911608300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911608400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911612250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911612400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911616400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911620400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911624400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911628250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911628400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911632250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911632400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911638250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911638270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911638300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911638350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911638400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.25 X 8 -,SUP-H7493926008220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
SYNERGY II US MR 2.25X8 -,SUP-H7493926008220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.50 X 8 -,SUP-H7493926008250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.75 X 8 -,SUP-H7493926008270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 3.00 X 8 -,SUP-H7493926008300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
SYNERGY II US MR 3.00X8 -,SUP-H7493926008300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 3.50 X 8 -,SUP-H7493926008350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 4.00 X 8 -,SUP-H7493926008400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
SYNERGY II US MR 4.0X8 -,SUP-H7493926008400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.25 X 12 -,SUP-H7493926012220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.50 X 12 -,SUP-H7493926012250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.75 X 12 -,SUP-H7493926012270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 3.00 X 12 -,SUP-H7493926012300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 3.50 X 12 -,SUP-H7493926012350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 4.00 X 12 -,SUP-H7493926012400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.25 X 16 -,SUP-H7493926016220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.50 X 16 -,SUP-H7493926016250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.75 X 16 -,SUP-H7493926016270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 3.00 X 16 -,SUP-H7493926016300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 3.50 X 16 -,SUP-H7493926016350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 4.00 X 16 -,SUP-H7493926016400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.25 X 20 -,SUP-H7493926020220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.50 X 24 -,SUP-H7493926020250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.50 X 28 -,SUP-H7493926020250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.50 X 20 -,SUP-H7493926020250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.75 X 20 -,SUP-H7493926020270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 3.00 X 20 -,SUP-H749392602030,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 3.50 X 20 -,SUP-H7493926020350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 4.00 X 20 -,SUP-H7493926020400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.25 X 24 -,SUP-H7493926024220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.75 X 24 -,SUP-H7493926024270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 3.00 X 24 -,SUP-H7493926024300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 3.50 X 24 -,SUP-H7493926024350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 4.00 X 24 -,SUP-H7493926024400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.25 X 28 -,SUP-H7493926028220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.75 X 28 -,SUP-H7493926028270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 3.00 X 28 -,SUP-H7493926028300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 3.50 X 28 -,SUP-H7493926028350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 4.00 X 28 -,SUP-H7493926028400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.50 X 32 -,SUP-H7493926032250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.75 X 32 -,SUP-H7493926032270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 3.00 X 32 -,SUP-H7493926032300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 3.50 X 32 -,SUP-H7493926032350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 4.00 X 32 -,SUP-H7493926032400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.25 X 38 -,SUP-H7493926038220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.50 X 38 -,SUP-H7493926038250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.75 X 38 -,SUP-H7493926038270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 3.00 X 38 -,SUP-H7493926038300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 3.50 X 38 -,SUP-H7493926038350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 4.00 X 38 -,SUP-H7493926038400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.25 X 8 -,SUP-H7493926108220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.50 X 8 -,SUP-H7493926108250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.75 X 8 -,SUP-H7493926108270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 3.00 X 8 -,SUP-H7493926108300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 3.50 X 8 -,SUP-H7493926108350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 4.00 X 8 -,SUP-H7493926108400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.25 X 12 -,SUP-H7493926112220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.50 X 12 -,SUP-H7493926112250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.75 X 12 -,SUP-H7493926112270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 3.00 X 12 -,SUP-H7493926112300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 3.50 X 12 -,SUP-H7493926112350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 4.00 X 12 -,SUP-H7493926112400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.25 X 16 -,SUP-H7493926116220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.50 X 16 -,SUP-H7493926116250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.75 X 16 -,SUP-H7493926116270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 3.00 X 16 -,SUP-H7493926116300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 3.50 X 16 -,SUP-H7493926116350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 4.00 X 16 -,SUP-H7493926116400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.25 X 20 -,SUP-H7493926120220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.50 X 20 -,SUP-H7493926120250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.75 X 20 -,SUP-H7493926120270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 3.00 X 20 -,SUP-H7493926120300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 3.50 X 20 -,SUP-H7493926120350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 4.00 X 20 -,SUP-H7493926120400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.25 X 24 -,SUP-H7493926124220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.50 X 24 -,SUP-H7493926124250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.75 X 24 -,SUP-H7493926124270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 3.00 X 24 -,SUP-H7493926124300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 3.50 X 24 -,SUP-H7493926124350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 4.00 X 24 -,SUP-H7493926124400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.25 X 28 -,SUP-H7493926128220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.50 X 28 -,SUP-H7493926128250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.75 X 28 -,SUP-H7493926128270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 3.00 X 28 -,SUP-H7493926128300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 3.50 X 28 -,SUP-H7493926128350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 4.00 X 28 -,SUP-H7493926128400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.25 X 32 -,SUP-H7493926132220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.50 X 32 -,SUP-H7493926132250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.75 X 32 -,SUP-H7493926132270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 3.00 X 32 -,SUP-H7493926132300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 3.50 X 32 -,SUP-H7493926132350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 4.00 X 32 -,SUP-H7493926132400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.25 X 38 -,SUP-H7493926138220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.50 X 38 -,SUP-H7493926138250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.75 X 38 -,SUP-H7493926138270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 3.00 X 38 -,SUP-H7493926138300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 3.50 X 38 -,SUP-H7493926138350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 4.00 X 38 -,SUP-H7493926138400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
ELUVIA US 6MM X 40MM X 130CM -,SUP-H74939294600410,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
ELUVIA US 6MM X 60MM X 130CM -,SUP-H74939294600610,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
ELUVIA US 6MM X 80MM X 130CM -,SUP-H74939294600810,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
ELUVIA US 6MM X 100MM X 130CM -,SUP-H74939294601010,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
ELUVIA US 6MM X 120MM X 130CM -,SUP-H74939294601210,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10749.14,7524.398,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
ELUVIA US 6X150 130 cm -,SUP-H74939294601510,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13719.54,9603.678,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
ELUVIA 7MM x 40MM x 130CM -,SUP-H74939294700410,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
ELUVIA 7MM x 60MM x 130CM -,SUP-H74939294700610,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
ELUVIA DRUG-ELUTING VASCULAR STENT SYSTEM 7MM X 80MM X 130CM -,SUP-H74939294700810,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
ELUVIA 7MM x 100MM x 130CM -,SUP-H74939294701010,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
ELUVIA 7MM x 120MM x 130CM -,SUP-H74939294701210,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10749.14,7524.398,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
ELUVIA US 7X150 130 cm -,SUP-H74939294701510,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13719.54,9603.678,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PROMUS ELITE US MR 4.0 X 8MM -,SUP-H7493941208400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PROMUS ELITE US MR 4.0 X 12MM -,SUP-H7493941212400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PROMUS ELITE US MR 2.50 X 32MM -,SUP-H7493941232250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PROMUS ELITE US MR 3.50 X 32MM -,SUP-H7493941232350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PROMUS ELITE US MR 3.50 X 38MM -,SUP-H7493941238350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.25 X 8 -,SUP-H7493941808220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.50 X 8 -,SUP-H7493941808250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.75 X 8 -,SUP-H7493941808270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 3.0 X 8 -,SUP-H7493941808300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 3.5 X 8 -,SUP-H7493941808350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 4.0 X 8 -,SUP-H7493941808400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.25 X 12 -,SUP-H7493941812220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.50 X 12 -,SUP-H7493941812250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.75 X 12 -,SUP-H7493941812270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 3.0 X 12 -,SUP-H7493941812300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 3.5 X 12 -,SUP-H7493941812350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 4.0 X 12 -,SUP-H7493941812400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 4.5 X 12 -,SUP-H7493941812450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 5.0 X 12 -,SUP-H7493941812500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.25 X 16 -,SUP-H7493941816220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.50 X 16 -,SUP-H7493941816250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.75 X 16 -,SUP-H7493941816270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 3.0 X 16 -,SUP-H7493941816300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 3.5 X 16 -,SUP-H7493941816350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 4.0 X 16 -,SUP-H7493941816400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 4.5 X 16 -,SUP-H7493941816450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 5.0 X 16 -,SUP-H7493941816500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.25 X 20 -,SUP-H7493941820220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.50 X 20 -,SUP-H7493941820250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.75 X 20 -,SUP-H7493941820270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 3.0 X 20 -,SUP-H7493941820300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 3.5 X 20 -,SUP-H7493941820350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 4.0 X 20 -,SUP-H7493941820400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 4.5 X 20 -,SUP-H7493941820450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 5.0 X 20 -,SUP-H7493941820500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.25 X 24 -,SUP-H7493941824220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.50 X 24 -,SUP-H7493941824250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.75 X 24 -,SUP-H7493941824270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 3.0 X 24 -,SUP-H7493941824300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 3.5 X 24 -,SUP-H7493941824350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 4.0 X 24 -,SUP-H7493941824400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 4.5 X 24 -,SUP-H7493941824450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 5.0 X 24 -,SUP-H7493941824500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.25 X 28 -,SUP-H7493941828220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.50 X 28 -,SUP-H7493941828250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.75 X 28 -,SUP-H7493941828270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 3.0 X 28 -,SUP-H7493941828300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 3.5 X 28 -,SUP-H7493941828350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 4.0 X 28 -,SUP-H7493941828400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 4.5 X 28 -,SUP-H7493941828450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 5.0 X 28 -,SUP-H7493941828500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.25 X 32 -,SUP-H7493941832220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.50 X 32 -,SUP-H7493941832250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.75 X 32 -,SUP-H7493941832270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 3.0 X 32 -,SUP-H7493941832300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 3.5 X 32 -,SUP-H7493941832350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 4.0 X 32 -,SUP-H7493941832400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 4.5 X 32 -,SUP-H7493941832450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 5.0 X 32 -,SUP-H7493941832500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.25 X 38 -,SUP-H7493941838220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.50 X 38 -,SUP-H7493941838250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.75 X 38 -,SUP-H7493941838270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 3.0 X 38 -,SUP-H7493941838300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 3.5 X 38 -,SUP-H7493941838350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 4.0 X 38 -,SUP-H7493941838400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR US 2.5 X 48MM REF:H7493941848250 -,SUP-H7493941848250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR US 2.75 X 48MM REF:H7493941848270 -,SUP-H7493941848270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR US 3 X 48MM REF:H7493941848300 -,SUP-H7493941848300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR US 3.5 X 48MM REF:H7493941848350 -,SUP-H7493941848350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR US 4 X 48MM REF:H7493941848400 -,SUP-H7493941848400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT S MEGATRON DES US MR 3.5 X 16MM REF:H7493942816350 -,SUP-H7493942816350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT S MEGATRON DES US MR 3.5 X 20MM REF:H7493942820350 -,SUP-H7493942820350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT S MEGATRON DES US MR 4 X 20MM REF:H7493942820400 -,SUP-H7493942820400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT S MEGATRON DES US MR 4.5 X 20MM REF:H7493942820450 -,SUP-H7493942820450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT S MEGATRON DES US MR 5 X 20MM REF:H7493942820500 -,SUP-H7493942820500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT S MEGATRON DES US MR 3.5 X 24MM REF:H7493942824350 -,SUP-H7493942824350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT S MEGATRON DES US MR 4 X 24MM REF:H7493942824400 -,SUP-H7493942824400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT S MEGATRON DES US MR 4.5 X 24MM REF:H7493942824450 -,SUP-H7493942824450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT S MEGATRON DES US MR 5 X 24MM REF:H7493942824500 -,SUP-H7493942824500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT S MEGATRON DES US MR 3.5 X 28MM REF:H7493942828350 -,SUP-H7493942828350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT S MEGATRON DES US MR 4.0 X 28MM REF:H7493942828400 -,SUP-H7493942828400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT S MEGATRON DES US MR 4.5 X 28MM REF:H7493942828450 -,SUP-H7493942828450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT S MEGATRON DES US MR 5.0 X 28MM REF:H7493942828500 -,SUP-H7493942828500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT S MEGATRON DES US MR 3.5 X 32MM REF:H7493942832350 -,SUP-H7493942832350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT S MEGATRON DES US MR 4.0 X 32MM REF:H7493942832400 -,SUP-H7493942832400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT S MEGATRON DES US MR 4.5 X 32MM REF:H7493942832450 -,SUP-H7493942832450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT S MEGATRON DES US MR 5.0 X 32MM REF:H7493942832500 -,SUP-H7493942832500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
SYNERGY II US MR 2.25X12 -,SUP-H749396012220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT BIL 10X60MM 194CM CATH WALLSTNT SE UNCNTSTR CVR ENPROS -,SUP-H965431100,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7116.04,4981.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT BALLOON EXPANDABLE VASC COVERED -,SUP-LSMU0800737,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT LIFESTREAM 7MM X 58MM BALLOON EXP -,SUP-LSMU0800758,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
LIFESTREAM BALLOON EP VASC COVERED STENT 80CM X 26MM -,SUP-LSMU0800826,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
12MM X 38MM LIFE STREAM -,SUP-LSMU0801238,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT LIFESTREAM 5MM X 26MM -,SUP-LSMU1350526,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
LIFESTREAM 12MM X 38MM X 80CM -,SUP-LSMU1350626,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
FIBERED PLATINUM COIL 2 X 5MM -,SUP-M0013120211,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2243.7,1570.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
FIBERED PLATNUM COIL 4 X 4MM -,SUP-M0013120221,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2243.7,1570.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
DETACHABLE COIL 3MM X 6MM -,SUP-M001361500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2622.16,1835.512,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
DETACHABLE COIL 6MM X 10MM -,SUP-M001361560,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
PUSHER SURG ARSCP 0.016INX177CM VASC COIL 16 -,SUP-M0014012160,CDM,C1874,HCPCS,278,RC,,,outpatient,,,1036.3,725.41,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ESPH 18MM BD 13MM BD 23MM FLR 15CM POLYFLEX SE SIL LF -,SUP-M00514320,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8623.21,6036.247,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ESPH 18MM 25/23MM OD P/D FLR 18.5FR CATH 10CM WALLFLX -,SUP-M00516700,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ESPH 18MM 25/23MM OD P/D FLR 12CM WALLFLX SE BRD FLLY -,SUP-M00516710,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
WALLFLEX ESOPHAGEAL FULLY COVERED 18 X 15 -,SUP-M00516720,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
WALLFLEX ESOPHAGEAL FULLY COVERED 23 X 10 -,SUP-M00516730,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ESPH 23MM 28/28MM OD P/D FLR 10CM WALLFLX SE BRD FLLY -,SUP-M00516730,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ESPH 23MM 28/28MM OD P/D FLR 12CM WALLFLX SE BRD FLLY -,SUP-M00516740,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
WALLFLEX ESOPHAGEAL FULLY COVERED 23 X 12 -,SUP-M00516740,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
WALLFLEX ESOPHAGEAL FULLY COVERED 18 X 15 -,SUP-M00516750,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ESPH 18MM 23/23MM OD P/D FLR 10CM WALLFLX SE BRD FLLY -,SUP-M00516900,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9314.91,6520.437,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
WALLFLEX ESOPHAGEAL PARTIALLY COVERED 18 X 10 -,SUP-M00516900,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ESPH 18MM 23/23MM OD P/D FLR 123MM WALLFLX SE BRD FLLY -,SUP-M00516910,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
WALLFLEX ESOPHAGEAL PARTIALLY COVERED 18 X 12 -,SUP-M00516910,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
WALLFLEX PC ESOPH STENT 23/28MM X 105MM -,SUP-M00516930,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
WALLFLEX ESOPHAGEAL PARTIALLY COVERED 23 X 12 -,SUP-M00516940,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT AXIOS ELECTROCAUTERY-ENHANCED 15mm X 10mm -,SUP-M00553650,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17317.43,12122.201,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT CYST GASTROSTOMY AXIOS -,SUP-M00553650,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19659.22,13761.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT AXIOS 10 X 20 EE LO -,SUP-M00553660,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19659.22,13761.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT BIL 10X60MM WALLSTNT RX SE PRT CVR MTL 0.035IN GW COMP -,SUP-M00569710,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7266.24,5086.368,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT WALLFLEX BILIARY FULLY COVERED -,SUP-M00570350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
S WALLFLEX BILI 10X40 RX COV -,SUP-M00570360,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT BIL 10X60MM WALLFLX RX SE FLLY CVR PLATINOL 0.035IN GW -,SUP-M00570370,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT BIL 10X80MM WALLFLX RX SE FLLY CVR PLATINOL 0.035IN GW -,SUP-M00570380,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PARTIALLY COVERED 8 X 100 -,SUP-M00570730,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9639.76,6747.832,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ULTRAFLEX 8 X 40 25MM TR -,SUP-M00576520,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT TRACHBR 10MM XPND 18FR COMPRESS 30MM ULFLX PRT CVR -,SUP-M00576530,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT RX COVRD 15 X 30 -,SUP-M00576550,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT RX COVRD 25 X 40 -,SUP-M00576560,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT CVRD ULTRAFLEX 14 X 40 -,SUP-M00576580,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT CVRD ULTRAFLEX 14 X 60 -,SUP-M00576590,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT TRACHBR 16MMX40MM ULFLX CVR DIST RELS SIL DIST RELS -,SUP-M00576610,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ULTRAFLEX 16X45 -,SUP-M00576620,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT CVRD ULTRAFLEX 18 X 40 -,SUP-M00576640,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT CVRD ULTRAFLEX 20 X 40 -,SUP-M00576670,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11747.93,8223.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT CVRD ULTRAFLEX 20 X 80 -,SUP-M00576690,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ESOPHAGEAL 23 X 150 ENDO -,SUP-MAXX-2315,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9175.53,6422.871,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.00 x 08MM -,SUP-ONYXNG20008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.00 x 12MM -,SUP-ONYXNG20012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.00 x 15MM -,SUP-ONYXNG20015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.00 x 18MM -,SUP-ONYXNG20018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.00 x 30MM -,SUP-ONYXNG20030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.25 x 08MM -,SUP-ONYXNG22508UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.25 x 12MM -,SUP-ONYXNG22512UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.25 x 15MM -,SUP-ONYXNG22515UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.25 x 18MM -,SUP-ONYXNG22518UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.25 x 22MM -,SUP-ONYXNG22522UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.25 x 26MM -,SUP-ONYXNG22526UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.25 x 30MM -,SUP-ONYXNG22530UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.25 x 34MM -,SUP-ONYXNG22534UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.25 x 38MM -,SUP-ONYXNG22538UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.50 x 08MM -,SUP-ONYXNG25008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.50 x 12MM -,SUP-ONYXNG25012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.50 x 15MM -,SUP-ONYXNG25015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.50 x 18MM -,SUP-ONYXNG25018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.50 x 22MM -,SUP-ONYXNG25022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.50 x 26MM -,SUP-ONYXNG25026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.50 x 30MM -,SUP-ONYXNG25030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.50 x 34MM -,SUP-ONYXNG25034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.50 x 38MM -,SUP-ONYXNG25038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.75 x 08MM -,SUP-ONYXNG27508UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.75 x 12MM -,SUP-ONYXNG27512UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.75 x 15MM -,SUP-ONYXNG27515UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.75 x 18MM -,SUP-ONYXNG27518UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.75 x 22MM -,SUP-ONYXNG27522UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.75 x 26MM -,SUP-ONYXNG27526UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.75 x 30MM -,SUP-ONYXNG27530UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.75 x 34MM -,SUP-ONYXNG27534UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.75 x 38MM -,SUP-ONYXNG27538UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  3.0 x 08MM -,SUP-ONYXNG30008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  3.0 x 12MM -,SUP-ONYXNG30012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  3.0 x 15MM -,SUP-ONYXNG30015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  3.0 x 18MM -,SUP-ONYXNG30018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  3.0 x 22MM -,SUP-ONYXNG30022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  3.0 x 26MM -,SUP-ONYXNG30026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  3.0 x 30MM -,SUP-ONYXNG30030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  3.0 x 34MM -,SUP-ONYXNG30034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  3.0 x 38MM -,SUP-ONYXNG30038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  3.5 x 08MM -,SUP-ONYXNG35008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  3.5 x 12MM -,SUP-ONYXNG35012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  3.5 x 15MM -,SUP-ONYXNG35015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  3.5 x 18MM -,SUP-ONYXNG35018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  3.5 x 22MM -,SUP-ONYXNG35022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  3.5 x 26MM -,SUP-ONYXNG35026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  3.5 x 30MM -,SUP-ONYXNG35030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  3.5 x 34MM -,SUP-ONYXNG35034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  3.5 x 38MM -,SUP-ONYXNG35038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  4.0 x 12MM -,SUP-ONYXNG40012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  4.0 x 15MM -,SUP-ONYXNG40015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  4.0 x 18MM -,SUP-ONYXNG40018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  4.0 x 22MM -,SUP-ONYXNG40022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  4.0 x 26MM -,SUP-ONYXNG40026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  4.0 x 30MM -,SUP-ONYXNG40030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  4.0 x 34MM -,SUP-ONYXNG40034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  4.0 x 38MM -,SUP-ONYXNG40038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  4.5 x 12MM -,SUP-ONYXNG45012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  4.5 x 15MM -,SUP-ONYXNG45015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  4.5 x 18MM -,SUP-ONYXNG45018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  4.5 x 22MM -,SUP-ONYXNG45022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  4.5 x 26MM -,SUP-ONYXNG45026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  4.5 x 30MM -,SUP-ONYXNG45030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  5.0 x 18MM -,SUP-ONYXNG50018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  5.0 x 22MM -,SUP-ONYXNG50022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  5.0 x 30MM -,SUP-ONYXNG50030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT BIL 5X18MM 135CM PALMZ GENESIS RX BE TRNSHEP SS -,SUP-PG1850BAX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4882.72,3417.904,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
EXCLUDER AAA ENDO EXTENDER 26MMX3.3CM 16FR -,SUP-PLA260300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13934.89,9754.423,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 32MM 27-29MM AOR 4.5CM EXCLDR AOR EXTEND LPRO SULS -,SUP-PLA320400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13934.89,9754.423,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
EXCLUDER AAA ENDO EXTENDER 36MM X 4.5CM 18FR -,SUP-PLA360400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13934.89,9754.423,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
EXCLUDER AAA ENDOPROSTHESIS L 16MM X 12MM X 14CM 12F -,SUP-PLC121400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
EXCLUDER CONTRALATERAL LEG 16MM X 14.5MM X 10CM 12F -,SUP-PLC141000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GORE EXCLUDER AAA ENDOPROSTHESIS -,SUP-PLC141200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 13.5-14.5MM 16MM ILC 9.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PLC161000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 13.5-14.5MM 16MM ILC 11.5CM EXCLDR CNTRLAT LEG ILC -,SUP-PLC161200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 13.5-14.5MM 16MM ILC 13.5CM EXCLDR CNTRLAT LEG ILC -,SUP-PLC161400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EXCLUDER AAA ENDO CONTRA LEG 16 X 18 X 9.5CM 12FR -,SUP-PLC181000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
EXCLUDER AAA ENDO CONTRA LEG 16MM X 20MM X 11.5CM 12FR -,SUP-PLC201200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
EXCLUDER AAA ENDO CONTRA LEG 16 X 23 X 12 14FR -,SUP-PLC231200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
EXCLUDER AAA ENDO CONTRA LEG 16MM X 23MM X 14CM 14FR -,SUP-PLC231400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GORE EXCLUDER AAA CONTRALATERAL LEG 16 X 27 X 100MM -,SUP-PLK271000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GORE VIATORR 10MM X 6CM -,SUP-PTB8106275,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17651.6,12356.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GORE VIATORR 10MM X 7CM -,SUP-PTB8107275,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17651.6,12356.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 10-11MM 12MM ILC 10CM EXCLDR CNTRLAT LEG LPRO SULS -,SUP-PXC121000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 12-13.5MM 14.5MM ILC 12CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC141200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 13.5-14.5 MM 6MMX11.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC161200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 16.5-18.5 MM 20MMX11.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC201200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 16.5-18.5 MM 20MMX13.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC201400-L,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 10MMX7CM EXCLDR ILC EXTEND LPRO SULS CNSTRCT SEAL -,SUP-PXL161007,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11510.3,8057.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 12MMX7CM EXCLDR ILC EXTEND LPRO SULS CNSTRCT SEAL -,SUP-PXL161207,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10953.35,7667.345,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 27-29/12-13.5MM 31/14.5MM DIA AOR/ILC 18CM EXCLDR -,SUP-RLT311413,CDM,C1874,HCPCS,278,RC,,,outpatient,,,32100.6,22470.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X18MM RESOLUT IN RX BE PRMNT 140CM ZOTARO -,SUP-RSINT27518UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30022W,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30026W,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X38MM RESOLUT IN RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT30038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X38MM RESOLUT IN RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT40038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 22MM 18FR SHTH 8.2CM BIFUR -,SUP-TFFB-22-82,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30491.16,21343.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT 22X82 ZENITH ENDOVASC AA -,SUP-TFFB-22-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 22MM BD 18-19MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-22-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT ZENITH 24X82 ENDOVASC -,SUP-TFFB-24-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 26MM BD 22MM AOR 111MM ZENITH FLEX BIFUR MAIN BD -,SUP-TFFB-26-111-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT 26X82 ZEINTH ENDOV AAA -,SUP-TFFB-26-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 26MM BD 22MM AOR 96MM ZENITH FLEX BIFUR MAIN BD -,SUP-TFFB-26-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 28MM BD 23-24MM OD AOR 111MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-28-111-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 28MM BD 23-24MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-28-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 30MM BD 25-26MM OD AOR 11.1CM ZENITH FLEX BIFUR -,SUP-TFFB-30-111,CDM,C1874,HCPCS,278,RC,,,outpatient,,,31404.55,21983.185,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 30MM BD 25-26MM OD AOR 111MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-30-111-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT 30X82 ZEINTH ENDOVASC AB -,SUP-TFFB-30-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV ZENITH FLEX 30MM 20FRX9.6MM BIFUR MAIN BD EXTEND -,SUP-TFFB-30-96,CDM,C1874,HCPCS,278,RC,,,outpatient,,,29150.76,20405.532,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 30MM BD 25-26MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-30-96-2T,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
COOK GRAFT TFFB-30-96-ZT -,SUP-TFFB-30-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 12X71MM ZENITH AAA CNTRLAT ILC LEG WVN PLYSTR -,SUP-TFLE-12-71,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 14X54MM ZENITH AAA CNTRLAT ILC LEG WVN PLYSTR -,SUP-TFLE-14-54,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 14MM MAIN 56MM LEG ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-TFLE-14-56-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11454.61,8018.227,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 14MM MAIN BD 73MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-TFLE-14-73,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 14X56MM ZENITH FLEX AAA Z-TRAK BIFUR ILC CNTRLAT -,SUP-TFLE-15-56,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 18MM 16FR SHTH 54MM ZENITH AAA CNTRLAT ILC LEG -,SUP-TFLE-18-54,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT ZENITH FLEX AAA 28X82M -,SUP-TTFB-28-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GORE VIATORR 10MM X 8CM -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16385.47,11469.829,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT STENT ENDUR IIS BIF BODY -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
S VIABAHN 7MM X 7CM VIA VAS -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ESOPHAGEAL 21X150 -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9175.53,6422.871,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT POLYFLEX AIRWAY 16X40 -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8267.48,5787.236,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
VALIANT THORACIC CAPTIVA STENT GRAFT 26MM X 112MM 22FR -,SUP-VAMF2626C100TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,40668.87,28468.209,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT GRAFT VALIANT CAPTIVA WITH DELIVERY SYSTEM -,SUP-VAMF2828C100TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,40668.5,28467.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 5MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART. -,SUP-VBH051002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12063.54,8444.478,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 6MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART. -,SUP-VBH061002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12152.65,8506.855,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 6MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC_ART. -,SUP-VBH061502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13968.31,9777.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 7MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBH071002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12152.65,8506.855,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 8MMX10CM 120CM VIABAHN SE LPRO TIP TO HUB DPLY -,SUP-VBH081002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12152.65,8506.855,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 9MMX15CM 120CM VIABAHN SE LPRO TIP TO HUB DPLY -,SUP-VBH091502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13968.31,9777.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
S 10MMX 5.0CM VIA VASC 120CM -,SUP-VBH100502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11785.06,8249.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 10MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBH101502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14495.55,10146.885,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GORE VIABAHN ENDOPROSTHESIS- 7MMX5CM 8FR 120CMCATH -,SUP-VBHR070502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12910.1,9037.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 8MM 8FR DVC 5CM GORE-HYBRID VIABAHN 120CM NTNL -,SUP-VBHR080502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12910.1,9037.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 6MMX5CM 120CM VIABAHN FEM ILC ART TIP TO HUB -,SUP-VBJ060502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11268.96,7888.272,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 6MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART. -,SUP-VBJ061502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14347.03,10042.921,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 6MMX25CM 120CM GORE-HYBRID VIABAHN SUPRFC FEM -,SUP-VBJ062502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,23555.27,16488.689,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 7MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJ071502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14347.03,10042.921,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 8MMX5CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJ080502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10923.65,7646.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 8MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJ081002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12445.98,8712.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 5MM 6FRX5CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR050502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11669.96,8168.972,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 5MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR051002A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12761.58,8933.106,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 5MMX15CM VIABAHN 120MM CATH -,SUP-VBJR051502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14885.42,10419.794,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 5MM 6FRX25CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR052502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,24297.87,17008.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 6MMX5CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR060502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13403.93,9382.751,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 6MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR061002A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 6MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR061502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14224.5,9957.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 6MM 6FRX25CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR062502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,23351.06,16345.742,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 7MM 7FRX5CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR070502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12226.91,8558.837,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 7MM 7FRX10CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR071002A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 7MMX25CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR072502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26414.28,18489.996,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
VALIANT NAVION THORACIC STENT GRAFT SYSTEM -,SUP-VNMC2020C94TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
THORACIC STENT GRAFT 94MM 25MM -,SUP-VNMC2525C94TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT GRAFT VALION NAVION THORACIC -,SUP-VNMC4040C55TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT GORE VIABIL 10MM X 6CM BILIARY -,SUP-VSWVN1006,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT GORE VIABIL 10MM X 8CM BILIARY -,SUP-VSWVN1008,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 28MM PROX BD DIA 94MM PROX BD ZENITH FEN INTNL -,SUP-ZFEN-9-2-28-94R,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 12MM IPSI LEG DIA 121MM DIST LEG 28MM DIST BD -,SUP-ZFEN-D-1228121C,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
FENESTRATED DISTAL BODY -,SUP-ZFEN-D-12-2876C,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT HUM TIS FEN 26MM ZENITH EV PROX BD LF -,SUP-ZFEN-P-226124-R,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 36MM PROX 29-31MM OD AOR 107MM PROX BD ZENITH FEN -,SUP-ZFEN-P-2-36107R,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT VASC DES ZILVER PTX 6X100MM 125CM OTW SE PRELD -,SUP-ZISV6351256100,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT VASC DES ZILVER PTX 6X60MM 125CM OTW SE PRELD -,SUP-ZIV6-35-125660,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6981.34,4886.938,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT VASC DES ZILVER PTX 7X100MM 125CM OTW SE PRELD -,SUP-ZIV6351257100PT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7617.98,5332.586,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT VASC DES ZILVER PTX 7X80MM 125CM OTW SE PRELD -,SUP-ZIV635125780PTX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7617.98,5332.586,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 11MM DIST 56MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-ZSLE-11-56-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14387.88,10071.516,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 11MM DIST 74MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-ZSLE-11-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT ZENITH FLEX LEG 13X74 -,SUP-ZSLE-13-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT ZENITH AAA LEG 13X90MM -,SUP-ZSLE-13-90-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 16MMX90MM ZENITH SPRL -Z BIFUR CNTRLAT IPSI -,SUP-ZSLE-16-16-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 16MM DIST 39MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-ZSLE-16-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT ZENITH AAA LEG 20X74MM -,SUP-ZSLE-20-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT ZENITH AAA 24 X 56MM LEG -,SUP-ZSLE-24-56-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 24MM 16FR ID 6MM INTRO SHTH 74MM ZENITH SPRL -Z -,SUP-ZSLE-24-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT 4.5X13MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003381-13,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4.5X18MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003381-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4.5X28MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003381-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 5X13MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003382-13,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2X8MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2X12MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2X15MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2X18MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2X23MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2X28MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X8MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X12MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X15MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X18MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X23MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X28MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X8MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X12MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X15MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X18MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X23MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X28MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.75X8MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007847-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.75X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007847-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.75X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007847-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3X8MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3X23MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X8MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X23MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007850-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4X23MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007850-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007850-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.75X15MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010142-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.75X23MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010142-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3X8MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010143-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3X15MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010143-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VISION OTW 3.5 X 15 -,SUP-1010144-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VISION OTW 3.5 X 23 -,SUP-1010144-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X28MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010144-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4X18MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010145-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4X23MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010145-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2X8MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X12MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2X15MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X18MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2X23MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2X28MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X8MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X12MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X15MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X18MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X23MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X28MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X8MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X12MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X15MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X18MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X23MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ACCULINK 5X20MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011337-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ACCULINK 5X30MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011337-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ACCULINK 5X40MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011337-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S RX ACCULINK 7.0MM X 30MM X 132CM -,SUP-1011339-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ACCULINK 7X40MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011339-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
6-8 mm X 30mm RX ACCULINK STENT -,SUP-1011343-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ACCULINK 6-8X40MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011343-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
ACCULINK STENT 7-10 X 40MM -,SUP-1011344-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 4X12MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011487-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 4X18MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011487-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 4.5X15MM 135CM DLV CATH HERCULINK ELITE RX BE -,SUP-1011490-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 5X15MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011493-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 5X18MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011493-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 6.0MM X 100MM X 80CM -,SUP-1012528-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 6.0MM X 20MM X 80CM -,SUP-1012528-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 6.0MM X 30MM X 80CM -,SUP-1012528-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 6.0MM X 40MM X 80CM -,SUP-1012528-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SEL-EXPANDING 6.0MM X 60MM X 80CM -,SUP-1012528-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAT SELF-EXPANDING 6.0MM X 80MM X 80CM -,SUP-1012528-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 100MM X 80CM -,SUP-1012529-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 20MM X 80CM -,SUP-1012529-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 30MM X 80CM -,SUP-1012529-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 40MM X 80CM -,SUP-1012529-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 60MM X 80CM -,SUP-1012529-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 80MM X 80CM -,SUP-1012529-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
ABSOLUTE PRO 8 X 100MM X 80CM -,SUP-1012530-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCUALR SELF-EXPANDING 8.0MM X 20MM X 80CM -,SUP-1012530-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 8.0MM X 30MM X 80CM -,SUP-1012530-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
ABSOLUTE PRO VASCULAR SELF-EXPANDING STENT SYS 8 X 40 -,SUP-1012530-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
ABSOLUTE PRO 8 X 60MM X 80CM -,SUP-1012530-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
ABSOLUTE PRO 8 X 80MM X 80CM -,SUP-1012530-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 9.0MM X 100MM X 80CM -,SUP-1012531-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 9.0MM 20MM X 80CM -,SUP-1012531-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 9.0MM X 30MM X 80CM -,SUP-1012531-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 9.0MM X 40MM X 80CM -,SUP-1012531-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 9.0MM X 60MM X 80CM -,SUP-1012531-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 9.0MM X 80MM X 80CM -,SUP-1012531-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 100MM X 80CM -,SUP-1012532-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 20MM X 80CM -,SUP-1012532-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 30MM X 80CM -,SUP-1012532-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT ABSOLUTE PRO 10 X 40MM X 80CM -,SUP-1012532-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ABSOLUTE PRO 10X60CM -,SUP-1012532-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
ABSOLUTE PRO SELF EXPANDING STENT 10MM X 80MM C 80CM -,SUP-1012532-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ABSOLUTE PRO 6X100MM 135CM OTW SE PRMNT -,SUP-1012534-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ABSOLUTE PRO 6X40MM 135CM OTW SE PRMNT -,SUP-1012534-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ABSOLUTE PRO 7.0X100MM 135CM -,SUP-1012535-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 20MM X 135CM -,SUP-1012535-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 30MM X 135CM -,SUP-1012535-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ABSOLUTE PRO 7X40MM 135CM OTW SE PRMNT -,SUP-1012535-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ABSOLUTE PRO 7X60MM 135CM OTW SE PRMNT -,SUP-1012535-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 80MM X 135CM -,SUP-1012535-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 8.0MM X 100MM X 135CM -,SUP-1012536-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 8.0MM X 20MM X 135CM -,SUP-1012536-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 8.0MM X 30MM X 135CM -,SUP-1012536-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 8.0MM X 40MM X 135CM -,SUP-1012536-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ABSOLUTE PRO 8.0 X 60MM X 135CM -,SUP-1012536-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 9.0MM X 100MM X 135CM -,SUP-1012537-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDED 9.0MM X 40MM X 135CM -,SUP-1012537-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 9.0MM X 80MM X 135CM -,SUP-1012537-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 100MM X 135CM -,SUP-1012538-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 20MM X 135CM -,SUP-1012538-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 30MM X 135CM -,SUP-1012538-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 40MM X 135CM -,SUP-1012538-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 60MM X 135CM -,SUP-1012538-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 80MM X 135CM -,SUP-1012538-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR BALLOON-EXPANDABLE 6.0MM X 16MM X 80CM -,SUP-1012622-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 6X19MM 80CM OTW BE PRMNT -,SUP-1012622-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 6X29MM 80CM OTW BE PRMNT -,SUP-1012622-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 6X39MM 80CM OTW BE PRMNT -,SUP-1012622-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 6X59MM 80CM OTW BE PRMNT -,SUP-1012622-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 12MM X 80CM -,SUP-1012623-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 16MM X 80CM -,SUP-1012623-16,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 7X19MM 80CM OTW BE PRMNT -,SUP-1012623-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 7X29MM 80CM OTW BE PRMNT -,SUP-1012623-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 7X39MM 80CM OTW BE PRMNT -,SUP-1012623-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 7X59MM 80CM OTW BE PRMNT -,SUP-1012623-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 8X19MM 80CM OTW BE PRMNT -,SUP-1012624-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 8X29MM 80CM OTW BE PRMNT -,SUP-1012624-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 8X39MM 80CM OTW BE PRMNT -,SUP-1012624-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 8X59MM 80CM OTW BE PRMNT -,SUP-1012624-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 9X19MM 80CM OTW BE PRMNT -,SUP-1012625-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 9X29MM 80CM OTW BE PRMNT -,SUP-1012625-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 9X39MM 80CM OTW BE PRMNT -,SUP-1012625-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 9X59MM 80CM OTW BE PRMNT -,SUP-1012625-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 10X19MM 80CM OTW BE PRMNT -,SUP-1012626-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 10X29MM 80CM OTW BE PRMNT -,SUP-1012626-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 10X39MM 80CM OTW BE PRMNT -,SUP-1012626-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 10X59MM 80CM OTW BE PRMNT -,SUP-1012626-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR BALLOON-EXPANDABLE 6.0MM X 16MM X 135 -,SUP-1012629-16,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 6X19MM 135CM OTW BE PRMNT -,SUP-1012629-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 6X29MM 135CM OTW BE PRMNT -,SUP-1012629-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 6X39MM 135CM OTW BE PRMNT -,SUP-1012629-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 6X59MM 135CM OTW BE PRMNT -,SUP-1012629-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 12MM X 135CM -,SUP-1012630-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 16MM X 135CM -,SUP-1012630-16,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 7X19MM 135CM OTW BE PRMNT -,SUP-1012630-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 7X29MM 135CM OTW BE PRMNT -,SUP-1012630-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 7X39MM 135CM OTW BE PRMNT -,SUP-1012630-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 7X59MM 135CM OTW BE PRMNT -,SUP-1012630-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 8X19MM 135CM OTW BE PRMNT -,SUP-1012631-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 8X29MM 135CM OTW BE PRMNT -,SUP-1012631-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 8X39MM 135CM OTW BE PRMNT -,SUP-1012631-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 8X59MM 135CM OTW BE PRMNT -,SUP-1012631-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 9X19MM 135CM OTW BE PRMNT -,SUP-1012632-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 9X29MM 135CM OTW BE PRMNT -,SUP-1012632-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 9X39MM 135CM OTW BE PRMNT -,SUP-1012632-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 9X59MM 135CM OTW BE PRMNT -,SUP-1012632-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 10X19MM 135CM OTW BE PRMNT -,SUP-1012633-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 10X29MM 135CM OTW BE PRMNT -,SUP-1012633-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 10X39MM 135CM OTW BE PRMNT -,SUP-1012633-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 10X59MM 135CM OTW BE PRMNT -,SUP-1012633-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4X12MM JOST GRAFTMS OTW BE 143CM SEM-COM HYDREX CTD -,SUP-12746-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
BIOMIMICS 3-D STENT 5MM X 60MM -,SUP-142122-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
BIOMIMICS 3-D STENT 6MM X 60MM -,SUP-142122-02,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
BIOMIMICS 3-D STENT 7MM X 60MM -,SUP-142122-03,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
BIOMIMICS 3-D STENT 5MM X 80MM -,SUP-142122-05,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
BIOMIMICS 3-D STENT 6MM X 80MM -,SUP-142122-06,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
BIOMIMICS 3-D STENT 7MM X 80MM -,SUP-142122-07,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
BIOMIMICS 3-D STENT 5MM X 100MM -,SUP-142122-09,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
BIOMIMICS 3-D STENT 6MM X 100MM -,SUP-142122-10,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
BIOMIMICS 3-D STENT 7MM X 100MM -,SUP-142122-11,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5305,3713.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
BIOMIMICS 3-D STENT 5MM X 125MM -,SUP-142122-13,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
BIOMIMICS 3-D STENT 6MM X 125MM -,SUP-142122-14,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
BIOMIMICS 3-D STENT 7MM X 125MM -,SUP-142122-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
BIOMIMICS 3-D STENT 5MM X 150MM -,SUP-144700-05,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
BIOMIMICS 3-D STENT 6MM X 150MM -,SUP-144700-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
BIOMIMICS 3-D STENT 7MM X 150MM -,SUP-144700-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S BILIARY LD PMTD 8 X 37 X75 6 -,SUP-38046-84075,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X37MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38046-84075,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 9 X 25MM 75CM EXP LD -,SUP-38046-92075,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 10X25MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-12013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 10X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-16013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-63013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-76013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S BILIARY EXPRESS 8X37X135CM L -,SUP-38047-84013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-38047-84013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
PULSAR 18 - 6 X 40 X 135 -,SUP-390724,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
PULSAR 18 - 6 X 120 X 135 -,SUP-390728,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
PULSAR 18 - 6 X 150 X 135 -,SUP-390729,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
PULSAR 18  7X40X135  .018 -,SUP-390734,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC OTW 6 X 120 X 120 -,SUP-39200-06122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC EPIC 6X120MM 120CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-39200-06122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 7X118X120 -,SUP-39200-07122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC EPIC 7X120MM 163CM/120CM WKG CATH SE MTLC ILC -,SUP-39200-07122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 7X79X120 -,SUP-39200-07802,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC EPIC 7X80MM 120CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-39200-07802,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 9X40X120 -,SUP-39200-09402,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
EPIC STENT 10MM X 40MM X 120CM -,SUP-39200-10402,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
EPIC STENT 10MM X 60MM X 120CM -,SUP-39200-10602,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
EPIC STENT 12MM X 60MM X 120CM -,SUP-39200-12602,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT ENPROS 24MM 11FR CATH 70MM WALLSTNT RP 100CM TOT 75CM -,SUP-40512,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PULSAR - 18 T3 4/20/135 -,SUP-430477,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PULSAR - 18 T3 4/40/135 -,SUP-430479,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PULSAR - 18 T3 4/80/135 -,SUP-430481,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PULSAR - 18 T3  5/80/135 -,SUP-430491,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PULSAR - 18 T3 5/120/135 -,SUP-430493,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PULSAR - 18 T3 5/200/135 -,SUP-430496,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PULSAR - 18 T3 6/40/135 -,SUP-430499,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PULSAR - 18 T3 6/80/135 -,SUP-430501,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PULSAR - 18 T3 6/120/135 -,SUP-430503,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PULSAR - 18 T3 6/150/135 -,SUP-430504,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PULSAR - 18 T3 6/200/135 -,SUP-430506,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PULSAR - 18 T3 7/120/135 -,SUP-430513,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PULSAR - 18 T3 7/150/135 -,SUP-430514,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
WRENCH SPLTY HX F /CPI -,SUP-6563,CDM,C1876,HCPCS,278,RC,,,outpatient,,,175.05,122.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT URET 6FR 22-32CM INLAY OPTM PLYMR BLND DBL PIGTL TAPR -,SUP-788600,CDM,C1876,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC XACT 7-9X40MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82086-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC XACT 7-9X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82087-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC XACT 9X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82088-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC XACT 9X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82089-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC XACT 6-8X40MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82090-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC XACT 6-8X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82091-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC XACT 8X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82092-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC XACT 8X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82093-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC XACT 7X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82094-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC XACT 7X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82095-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC XACT 10.8MM X 40MM X 136CM -,SUP-82096-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC XACT 10X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82098-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC XACT 10X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82099-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
ABRE STENTS 16MM X 80MM -,SUP-AB9U16080090,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6896.5,4827.55,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
ABRE STENTS 18MM X 100MM -,SUP-AB9U18100090,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6896.5,4827.55,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
ABRE STENTS 18MM X 120MM -,SUP-AB9U18120090,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6896.5,4827.55,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
COVERA AV STENT GRAFT 7MM X 60MM X 80MM -,SUP-AVSM07060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 6X30MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06030ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 6X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 6X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 6X80MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06080ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 6X100MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06100ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 6X120MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06120ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 6X150MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06150ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 7X30MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07030ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 7X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 7X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 7X80MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07080ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 7X100MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07100ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 7X120MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07120ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 7X150MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07150ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 8X30MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08030ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 8X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 8X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 8X80MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08080ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 8X100MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08100ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 8X120MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08120ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 8X150MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08150ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 10X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C10040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 10X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C10060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 12X40MM 120CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-C12040MB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 12X60MM 120CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-C12060MB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 12X60MM 80CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-C12060SB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X100MM 130CM LIFESTENT SE HLCL NTNL 0.035IN GW -,SUP-EX061003CD,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9230.7,6461.49,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC LIFESTENT 6X150MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX061503CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC LIFESTENT 6X170MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX061703CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC LIFESTENT 6X200MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX062003CL,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC LIFESTENT 7X60MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX070603CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
GRAFT EV 8MM 9FR CATH 40MM 120CM TOT 80CM DLV SYS FLAIR STR -,SUP-FAS08040,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11020.18,7714.126,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
COIL MICRONESTER EMBOLIZATION 0.018 X 5CM X 3MM -,SUP-G23520,CDM,C1876,HCPCS,278,RC,,,outpatient,,,851.91,596.337,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 5MM 7FR GUID CATH 30MM 125CM ZILVER 518 OTW SE -,SUP-G31351,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S ZILVER 518 5X40 125CM S-E ZI -,SUP-G31352,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 4X40MM 125CM ZILVER 518 OTW SE PRELD FLXB SLT TUBE -,SUP-G31439,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8MM 6FRX40MM 80CM SE PRELD MTL NTNL 5FR SHTH MUL -,SUP-G32020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S ZILVER .035 125CM 5 X 60 -,SUP-G32033,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X80MM MTL SE 6FRX125CM PRELD DLV SYS NTNL 6FR -,SUP-G36025,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S ZILVER 518 5X80 125CM S-E -,SUP-G36048,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 14X30MM 80CM ZILVER 635 OTW SE PRELD FLXB SLT TUBE -,SUP-G36233,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 12MM 8FR GUID CATH 40MM 125CM ZILVER 635 OTW SE -,SUP-G36239,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
12MM X 8CM ZILVER 635 STENT -,SUP-G36241,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 14MM 8FR GUID CATH 40MM 125CM ZILVER 635 OTW SE -,SUP-G36244,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 14X60MM 125CM ZILVER 635 OTW SE PRELD 0.035IN GW -,SUP-G36245,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 5X20MM 135CM FRMLA 418 BLN-XPD GUID CATH 5/6 FR -,SUP-G42956,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4034.03,2823.821,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X24MM 135CM FRMLA 418 OTW BE U STRUT TAPR 0.018IN -,SUP-G42962,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S ZILVER 518 VASC 6X40 125CM S -,SUP-G43771,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S ZILVER518 VASC 6X60 125CM -,SUP-G43772,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S ZILVER 518 VASC 6X80 125CM S -,SUP-G43773,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
7x40x125 ZILVER STENT 0.018 -,SUP-G43776,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ZILVER 518 7X80MM 125CM OTW SE 0.018IN/5FR -,SUP-G43778,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ZILVER 518 8X60MM 125CM OTW SE 0.018IN/5FR -,SUP-G43782,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S ZILVER .035 125CM 6 X 60 012 -,SUP-G43822,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S ZILVER .035 125CM 6 X 80 012 -,SUP-G43823,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ZILVER 635 7X30MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43825,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ZILVER 635 7X40MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43826,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ZILVER 635 7X60MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43827,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ZILVER 635 7X80MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43828,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ZILVER 635 8X30MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ZILVER 635 8X40MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43831,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ZILVER 635 8X60MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43832,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ZILVER 635 8X80MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43833,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ZILVER 635 10X40MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43841,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ZILVER 635 10X60MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43842,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ZILVER 635 10X80MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43843,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
COIL NESTOR 3 X 5 -,SUP-G47334,CDM,C1876,HCPCS,278,RC,,,outpatient,,,577.61,404.327,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
COIL MICRONESTOR EMBOLIZATION .018 X 7CM X 4MM PLAT -,SUP-G47339,CDM,C1876,HCPCS,278,RC,,,outpatient,,,638.87,447.209,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
ZENITH DISSECTION ENDOVASCULAR STENT -,SUP-G47492,CDM,C1876,HCPCS,278,RC,,,outpatient,,,41924.2,29346.94,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
ZENITH DISSECTION ENDOVASCULAR STENT -,SUP-G47493,CDM,C1876,HCPCS,278,RC,,,outpatient,,,41924.2,29346.94,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT ENDOVASCULAR DISSECTION ZENITH -,SUP-G47496,CDM,C1876,HCPCS,278,RC,,,outpatient,,,37318.31,26122.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DUODENAL EVOLUTION CONTROL RELEASE 22-27-9 -,SUP-G48026,CDM,C1876,HCPCS,278,RC,,,outpatient,,,8886.94,6220.858,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S ZILVER .035 125CM 5 X 100 -,SUP-G50162,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7MM 8FR GUID CATH LNG 100MM 125CM ZILVER FLEX 35 -,SUP-G50168,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7MM 8FR GUID CATH LNG 120MM 125CM ZILVER FLEX 35 -,SUP-G50169,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7X140MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-G50170,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X100MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-G50171,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8MM 8FR GUID CATH LNG 140MM 125CM ZILVER FLEX 35 -,SUP-G50173,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 10X100MM 80CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-G50177,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
Z STENT BILIARY 8 X 8 -,SUP-G50623,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC FRMLA 418 5X16MM 80CM OTW BE PRMNT -,SUP-G56609,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC FRMLA 418 5X20MM 80CM OTW BE PRMNT -,SUP-G56610,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC FRMLA 418 6X12MM 80CM OTW BE PRMNT -,SUP-G56611,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC FRMLA 418 6X16MM 80CM OTW BE PRMNT -,SUP-G56613,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC FRMLA 418 6X20MM 80CM OTW BE PRMNT -,SUP-G56614,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC FRMLA 418 7X16MM 80CM -,SUP-G56617,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC FRMLA 418 5X12MM 80CM OTW BE PRMNT -,SUP-G56631,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC FRMLA 414 5X20MM 80CM RX BE PRMNT 0.014IN/5FR/6FR -,SUP-G56950,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC FRMLA 414 5X16MM 135CM RX BE PRMNT -,SUP-G56958,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
0.14 ZILVER 5MM X 120MM X 135CM -,SUP-G56966,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC FRMLA 414 5X20MM 135CM RX BE PRMNT -,SUP-G56969,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC FRMLA 414 6X12MM 135CM RX BE PRMNT -,SUP-G56970,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC FRMLA 414 6X16MM 135CM RX BE PRMNT -,SUP-G56971,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC FRMLA 414 6X20MM 135CM RX BE PRMNT -,SUP-G56972,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
0.14 ZILVER 7MM X 160MM X 135CM -,SUP-G56974,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC FRMLA 414 7X20MM 135CM RX BE PRMNT -,SUP-G56975,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
US PRE PP-CA-397 P&B BARE METAL STENT ZVT7-35-120-16-60 -,SUP-G57453,CDM,C1876,HCPCS,278,RC,,,outpatient,,,8016.87,5611.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
SYS STENT VASCULAR ZILVER VENA 16MM 100MM 120CM VEIN OTW -,SUP-G57454,CDM,C1876,HCPCS,278,RC,,,outpatient,,,8016.87,5611.809,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
VENOUS WALLSTENT 10X94X75CM -,SUP-H74912044109470,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
VENOUS WALLSTENT 12X60X75CM -,SUP-H74912044126070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
VENOUS WALLSTENT 12X90X75CM -,SUP-H74912044129070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
VENOUS WALLSTENT 14X60X75CM -,SUP-H74912044146070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
VENOUS WALLSTENT 14X90X75CM -,SUP-H74912044149070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
VENOUS WALLSTENT 16X40X75CM -,SUP-H74912044164070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
VENOUS WALLSTENT 16X60X75CM -,SUP-H74912044166070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
VENOUS WALLSTENT 16X90X75CM -,SUP-H74912044169070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
VENOUS WALLSTENT 18X40X75CM -,SUP-H74912044184070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
VENOUS WALLSTENT 18X60X75CM -,SUP-H74912044186070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
VENOUS WALLSTENT 18X90X75CM -,SUP-H74912044189070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
VENOUS WALLSTENT 20X40X75CM -,SUP-H74912044204070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
VENOUS WALLSTENT 20X55X75CM -,SUP-H74912044205570,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
VENOUS WALLSTENT 20X80X75CM -,SUP-H74912044208070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
VICI VENOUS STENT 12MM X60MM X 100CM -,SUP-H74912060100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
VICI VENOUS STENT 14MM X 60MM X 100CM -,SUP-H74914060100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
VICI VENOUS STENT 14MM X 90MM X 100CM -,SUP-H74914090100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
VICI VENOUS STENT 16MM X 60MM X 100CM -,SUP-H74916060100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
VICI VENOUS STENT 16MM X90MM X 100CM -,SUP-H74916090100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X14MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937911614150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
FG EXP SD RENAL-BILIARY 7.0mmX15mmX150cm -,SUP-H74937911715150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 4X19MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912419150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 5X19MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912519150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X18MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912618150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7X19MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912719150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 10X37MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046104070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 10X57MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046106070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S BIL EXPRESS PMTD  6X27X75 -,SUP-H74938046630750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X27MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046630750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S BILIARY LD PMTD 6X37X75 6FR -,SUP-H74938046640750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X37MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046640750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S BILI LD PMTD 6 X 57 X 75 EXP -,SUP-H74938046660750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X57MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046660750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7X27MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046730750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S BILIARY LD PMTD 7X37X75 40CM -,SUP-H74938046740750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S  BILI LD PMTD 7 X 57 X 75 EX -,SUP-H74938046760750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EXPRESS B-I LD 8 X 27 X 75 P -,SUP-H74938046830750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X27MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046830750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
BEACON 8MM X 37MM X 75CM  ILIAC STENT -,SUP-H74938046840750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
8 X 57 X 75CM EXPRESS STENT -,SUP-H74938046860750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S BILI LD PMTD 8 X 57 X 75 EXP -,SUP-H74938046860750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 9X57MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046960750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 10X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047140130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 5X17MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047520130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 5X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047530130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 5X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047540130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 5X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047560130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X17MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047620130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047640130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047660130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7X17MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047720130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047730130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047740130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
7 X 57MM EXPRESS ILIAC / BILIARY STENT 135CM -,SUP-H74938047760130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047830130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047860130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 9X25MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047920130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 9X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047940130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 9X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047960130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3X16MM VERIFLEX OTW BE PRMNT LO XING THN STRUT HYDRCT -,SUP-H7493893516300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3294.06,2305.842,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 6X100X120 -,SUP-H74939200061020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 6X19X120 -,SUP-H74939200062020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 6X29X120 -,SUP-H74939200063020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 6X40X120 -,SUP-H74939200064020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 6X51X120 -,SUP-H74939200065020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 6X61X120 -,SUP-H74939200066020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 6X71X120 -,SUP-H74939200067020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 6X80X120 -,SUP-H74939200068020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 7X99X120 -,SUP-H74939200071020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 7X19X120 -,SUP-H74939200072020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 7X29X120 -,SUP-H74939200073020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 7X41X120 -,SUP-H74939200074020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 7X50X120 -,SUP-H74939200075020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 7X60X120 -,SUP-H74939200076020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 7X70X120 -,SUP-H74939200077020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 8X100X120 -,SUP-H74939200081020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 8X120X120 -,SUP-H74939200081220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 8X20X120 -,SUP-H74939200082020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 8X31X120 -,SUP-H74939200083020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 8X41X120 -,SUP-H74939200084020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 8X51X120 -,SUP-H74939200085020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 8X61X120 -,SUP-H74939200086020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 8X72X120 -,SUP-H74939200087020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 8X82X120 -,SUP-H74939200088020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 9X99X120 -,SUP-H74939200091020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 9X21X120 -,SUP-H74939200092020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 9X30X120 -,SUP-H74939200093020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 9X51X120 -,SUP-H74939200095020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 9X61X120 -,SUP-H74939200096020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 9X81X120 -,SUP-H74939200098020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 10X98X120 -,SUP-H74939200101020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-EXP 10X20X120 -,SUP-H74939200102020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-EXP 10X30X120 -,SUP-H74939200103020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 10X40X120 -,SUP-H74939200104020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 10X50X120 -,SUP-H74939200105020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC EPIC 10X60MM 120CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939200106020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 10X71X120 -,SUP-H74939200107020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 10X80X120 -,SUP-H74939200108020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-EXP 12X32X120 -,SUP-H74939200123020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 12X42X120 -,SUP-H74939200124020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 12X52X120 -,SUP-H74939200125020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 12X61X120 -,SUP-H74939200126020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.2X8MM REBEL MR RX BE -,SUP-H7493927408220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X8MM REBEL MR RX BE -,SUP-H7493927408250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.75X8MM REBEL MR RX BE -,SUP-H7493927408270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3X8MM REBEL MR RX BE -,SUP-H7493927408300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X8MM REBEL MR RX BE -,SUP-H7493927408350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4X8MM REBEL MR RX BE -,SUP-H7493927408400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X12MM REBEL MR RX BE -,SUP-H7493927412220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X12MM REBEL MR RX BE -,SUP-H7493927412250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.75X12MM REBEL MR RX BE -,SUP-H7493927412270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3X12MM REBEL MR RX BE -,SUP-H7493927412300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X12MM REBEL MR RX BE -,SUP-H7493927412350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4X12MM REBEL MR RX BE -,SUP-H7493927412400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4.5X12MM REBEL MR RX BE -,SUP-H7493927412450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X16MM REBEL MR RX BE -,SUP-H7493927416220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X16MM REBEL MR RX BE -,SUP-H7493927416250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.75X16MM REBEL MR RX BE -,SUP-H7493927416270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3X16MM REBEL MR RX BE -,SUP-H7493927416300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X16MM REBEL MR RX BE -,SUP-H7493927416350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4X16MM REBEL MR RX BE -,SUP-H7493927416400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4.5X16MM REBEL MR RX BE -,SUP-H7493927416450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X20MM REBEL MR RX BE -,SUP-H7493927420220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X20MM REBEL MR RX BE -,SUP-H7493927420250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.75X20MM REBEL MR RX BE -,SUP-H7493927420270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3X20MM REBEL MR RX BE -,SUP-H7493927420300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X20MM REBEL MR RX BE -,SUP-H7493927420350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4X20MM REBEL MR RX BE -,SUP-H7493927420400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4.5X20MM REBEL MR RX BE -,SUP-H7493927420450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X24MM REBEL MR RX BE -,SUP-H7493927424220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X24MM REBEL MR RX BE -,SUP-H7493927424250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.75X24MM REBEL MR RX BE -,SUP-H7493927424270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3X24MM REBEL MR RX BE -,SUP-H7493927424300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X24MM REBEL MR RX BE -,SUP-H7493927424350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4X24MM REBEL MR RX BE -,SUP-H7493927424400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4.5X24MM REBEL MR RX BE -,SUP-H7493927424450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X28MM REBEL MR RX BE -,SUP-H7493927428220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X28MM REBEL MR RX BE -,SUP-H7493927428250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.75X28MM REBEL MR RX BE -,SUP-H7493927428270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3X28MM REBEL MR RX BE -,SUP-H7493927428300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X28MM REBEL MR RX BE -,SUP-H7493927428350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4X28MM REBEL MR RX BE -,SUP-H7493927428400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4.5X28MM REBEL MR RX BE -,SUP-H7493927428450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.75X32MM REBEL MR RX BE -,SUP-H7493927432270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3X32MM REBEL MR RX BE -,SUP-H7493927432300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X32MM REBEL MR RX BE -,SUP-H7493927432350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4X32MM REBEL MR RX BE -,SUP-H7493927432400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4.5X32MM REBEL MR RX BE -,SUP-H7493927432450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X8MM REBEL OTW BE -,SUP-H7493927508220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X8MM REBEL OTW BE -,SUP-H7493927508250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.75X8MM REBEL OTW BE -,SUP-H7493927508270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3X8MM REBEL OTW BE -,SUP-H7493927508300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X8MM REBEL OTW BE -,SUP-H7493927508350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4X8MM REBEL OTW BE -,SUP-H7493927508400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X12MM REBEL OTW BE -,SUP-H7493927512220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X12MM REBEL OTW BE -,SUP-H7493927512250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.75X12MM REBEL OTW BE -,SUP-H7493927512270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3X12MM REBEL OTW BE -,SUP-H7493927512300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X12MM REBEL OTW BE -,SUP-H7493927512350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4X12MM REBEL OTW BE -,SUP-H7493927512400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4.5X12MM REBEL OTW BE -,SUP-H7493927512450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X16MM REBEL OTW BE -,SUP-H7493927516220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X16MM REBEL OTW BE -,SUP-H7493927516250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.75X16MM REBEL OTW BE -,SUP-H7493927516270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3X16MM REBEL OTW BE -,SUP-H7493927516300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X16MM REBEL OTW BE -,SUP-H7493927516350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4X16MM REBEL OTW BE -,SUP-H7493927516400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4.5X16MM REBEL OTW BE -,SUP-H7493927516450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X20MM REBEL OTW BE -,SUP-H7493927520220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X20MM REBEL OTW BE -,SUP-H7493927520250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.75X20MM REBEL OTW BE -,SUP-H7493927520270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3X20MM REBEL OTW BE -,SUP-H7493927520300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X20MM REBEL OTW BE -,SUP-H7493927520350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4X20MM REBEL OTW BE -,SUP-H7493927520400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4.5X20MM REBEL OTW BE -,SUP-H7493927520450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X24MM REBEL OTW BE -,SUP-H7493927524220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X24MM REBEL OTW BE -,SUP-H7493927524250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.75X24MM REBEL OTW BE -,SUP-H7493927524270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3X24MM REBEL OTW BE -,SUP-H7493927524300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X24MM REBEL OTW BE -,SUP-H7493927524350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4X24MM REBEL OTW BE -,SUP-H7493927524400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4.5X24MM REBEL OTW BE -,SUP-H7493927524450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X28MM REBEL OTW BE -,SUP-H7493927528220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X28MM REBEL OTW BE -,SUP-H7493927528250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.75X28MM REBEL OTW BE -,SUP-H7493927528270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3X28MM REBEL OTW BE -,SUP-H7493927528300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X28MM REBEL OTW BE -,SUP-H7493927528350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4X28MM REBEL OTW BE -,SUP-H7493927528400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4.5X28MM REBEL OTW BE -,SUP-H7493927528450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.75X32MM REBEL OTW BE -,SUP-H7493927532270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3X32MM REBEL OTW BE -,SUP-H7493927532300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X32MM REBEL OTW BE -,SUP-H7493927532350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4X32MM REBEL OTW BE -,SUP-H7493927532400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4.5X32MM REBEL OTW BE -,SUP-H7493927532450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 5X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293050230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 5X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 5X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 5X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 5X180MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 5X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293052030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9018.5,6312.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 5X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293054030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 5X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293056030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 5X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293058030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 6X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293060230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 6X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 6X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 6X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 6X180MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 6X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293062030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 6X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293064030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 6X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293066030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 6X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293068030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 7X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293070230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 7X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293071030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 7X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293071230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 7X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293071530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 7X180X130 SE ILC -,SUP-H74939293071830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 7X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293072030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 7X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293074030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 7X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293076030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 7X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293078030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 8X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293080230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 8X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293081030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 8X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293081230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 8X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293081530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 8X180X130 SE ILC -,SUP-H74939293081830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 8X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293082030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 8X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293084030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 8X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293086030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 8X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293088030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT ENPROS 22MM 10FR CATH 45MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965404510,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT ENPROS 22MM 10FR CATH 70MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965404520,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT ENPROS 24MM 11FR CATH 35MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965405100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT ENPROS 24MM 11FR CATH 45MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965405110,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
WALLSTENT 24X70 X 75CM/11F UNI PLUS 1 -,SUP-H965405120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.25X8MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22508UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.25X8MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.25X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22512UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.25X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.25X14MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22514UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.25X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22518UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.25X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.25X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22522UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.25X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.25X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22526UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.25X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.5X8MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25008UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.5X8MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25008W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.5X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.5X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.5X14MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25014UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS #1 27IN INTGRTY MO-4 DTCH 140CM MONO GUT TAPR PNT -,SUP-INT25014W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.5X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.5X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.5X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.5X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.5X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.5X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.75X8MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27508UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.75X8MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.75X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27512UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.75X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.75X14MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27514UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.75X14MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27514W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.75X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27518UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.75X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.75X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27522UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.75X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.75X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27526UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.75X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3X9MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30009UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3X9MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3X15MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30015UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3X15MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3X30MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30030UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3.5X9MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35009UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3.5X9MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3.5X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3.5X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3.5X15MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35015UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3.5X15MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3.5X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3.5X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3.5X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3.5X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3.5X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3.5X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3.5X30MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35030UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3.5X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 4X9MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40009UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 4X9MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 4X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 4X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 4X15MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40015UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 4X15MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 4X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 4X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 4X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 4X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 4X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 4X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 4X30MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40030UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 4X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT LIFESTREAM 7MM X 26MM X 80MM -,SUP-LSMU0800726,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT ENPROS 8MM 6FR CATH 80MM WALLSTNT RP 100CM TOT 75CM -,SUP-M001711300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7320.9,5124.63,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT ESPH 18MM BD 23MMX7CM ULFLX NON- CVR FLR END MTL LF -,SUP-M00514070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DUOD 22MMX6CM WALLFLX 230CM DLV SYS TTS/ OTW NTNL FLR -,SUP-M00565010,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT WALLFLEX DUODENAL 22 X 60 -,SUP-M00565010,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DUOD 22MMX9CM WALLFLX 230CM NON- CVR NTNL LF -,SUP-M00565020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT WALLFLEX DUODENAL 22 X 90 -,SUP-M00565020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT WALLFLEX DUODENAL 22 X 120 -,SUP-M00565030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT WALLFLEX COLONIC 25 X 60 -,SUP-M00565040,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT WALLFLEX COLONIC 25 X 90 -,SUP-M00565050,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT WALLFLEX COLONIC 25 X 120 -,SUP-M00565060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT WALLFLEX COLONIC 22 X 60 -,SUP-M00565100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT WALLFLEX COLONIC 22 X 90 -,SUP-M00565110,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT WALLFLEX COLONIC 22 X 120 -,SUP-M00565120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT ENPROS 10FR 20X60MM WALLSTNT 135CM HRP -,SUP-M00565620,CDM,C1876,HCPCS,278,RC,,,outpatient,,,116.7,81.69,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT COLN 22MM BD 10FR CATH 6CM WALLSTNT 135CM CATH 160CM -,SUP-M00565640,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7434.26,5203.982,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 10X80MM WALLSTNT RX SE UNCVR MTL 0.035IN GW COMP -,SUP-M00569660,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6340.15,4438.105,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X80MM WALLFLX RX SE UNCVR PLATINOL 0.035IN GW -,SUP-M00570620,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X100MM WALLFLX RX SE NON- CVR PLATINOL 0.035IN GW -,SUP-M00570630,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 10X60MM WALLFLX RX SE NON- CVR PLATINOL 0.035IN GW -,SUP-M00570640,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
CATH GUID 6FRX68CM ACUITY BREAK-AWAY COR CS-IC 130 -,SUP-M00570650,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
WALLFLEX BILIARY RX UNCOVERED 10 X 80 -,SUP-M00570650,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
WALLFLEX RX UNCOVERED BILIARY STENT 10MM X 100MM -,SUP-M00570660,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
WALLFLEX BILIARY RX UNCOVERED 10 X 40 -,SUP-M00570890,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 14X60MM 120CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-N1460BB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PULSAR - 18 T3 5/40/135 -,SUP-NO MANUFACTURE IN DICTIONARY,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 10X30MM PALMZ XL BE UNMT TRNSHEP CLSD CELLFLEX SEG -,SUP-P3110,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 5X15MM 135CM PALMZ BLU RX BE TRNSHEP COCR 0.014IN -,SUP-PB1550BAX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4882.72,3417.904,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 5X15MM 135CM PALMZ BLU OTW BE TRNSHEP COCR 0.018IN -,SUP-PB1550BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X18MM 80CM PALMZ BLU OTW BE TRNSHEP COCR 0.014IN -,SUP-PB1860BSS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X18MM 135CM PALMZ BLU OTW BE TRNSHEP COCR 0.018IN -,SUP-PB1860BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X24MM 135CM PALMZ BLU OTW BE TRNSHEP COCR 0.018IN -,SUP-PB2460BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X18MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG1860BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X18MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG1860BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 9X19MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG1990BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X24MM 135CM PALMZ GENESIS RX BE TRNSHEP SS -,SUP-PG2460BAX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4948.93,3464.251,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X24MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2460BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X24MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG2480BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 10X29MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2910BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 5X29MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG2950BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 5X30MM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW COMP -,SUP-PG2950BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2960BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2970BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN. -,SUP-PG2970BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN. -,SUP-PG2980BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN- -,SUP-PG2980BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 10X39MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3910BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3960BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3970BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X29MM 135CM PALMZ_GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3980BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3980BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7X59MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG5970BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7X59MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG5970BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X59MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG5980BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X79MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG7960BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X20MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506020120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X40MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X60MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X80MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506080120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X100MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506100120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X120MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506120120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X150MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506150120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X200MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506200120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,12141.51,8499.057,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7X20MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507020120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7X40MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7X60MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7X80MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507080120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7X120MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507120120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7X150MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507150120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X40MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3508040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X60MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3508060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X80MM 120CM EVERFLX SE SUPRFC FEM/PROX POPLT ART -,SUP-PRB3508080120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC EVERFLX 10X120MM 120CM SE 3-WV PEAK DSGN PRECISN -,SUP-PRB3508100120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 12X120MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT -,SUP-PRB3508120120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X150MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3508150120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7X37MM 135CM VISI-PRO BE MNT SS 0.035IN/6FR -,SUP-PXB350737135,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X27MM 135CM VISI-PRO BE MNT SS 0.035IN/6FR -,SUP-PXB350827135,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X37MM 135CM VISI-PRO BE MNT SS 0.035IN/6FR -,SUP-PXB350837135,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 2.25X8MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 2.25X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 2.25X14MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22514W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 2.25X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 2.25X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 2.25X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.25X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22530W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 2.5X8MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25008W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 2.5X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 2.5X14MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25014W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 2.5X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 2.5X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 2.5X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 2.5X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 2.75X8MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 2.75X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 2.75X14MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27514W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 2.75X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 2.75X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 2.75X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 2.75X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27530W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 3X9MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT30009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 3X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 3X15MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 3X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 3X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 3.5X9MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 3.5X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 3.5X15MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 3.5X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 3.5X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 3.5X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 3.5X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 4X9MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT40009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 4X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 4X15MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 4X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 4X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 4X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 4X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 4MM 6FR CATH 60MM 120CM SUPERA TRNSHEP -,SUP-S-04-060-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 5MM 6FR CATH 40MM 120CM SUPERA TRNSHEP -,SUP-S-05-040-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 5MM 6FR CATH 80MM 120CM SUPERA TRNSHEP -,SUP-S-05-080-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6599.42,4619.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 5MM 6FR CATH 100MM 120CM SUPERA TRNSHEP -,SUP-S-05-100-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6599.42,4619.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6MM 6FR CATH 40MM 120CM SUPERA TRNSHEP -,SUP-S-06-040-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7617.98,5332.586,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7MM 6FR CATH 60MM 120CM SUPERA TRNSHEP -,SUP-S-07-060-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X100MM 120CM SUPERA TRNSHEP -,SUP-S-08-100-120-G3,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6599.42,4619.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PERIPHERAL 4.5MM X 20MM X 120CM  6F -,SUP-S-45-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PERIPHERAL 4.5MM X 30MM X 120CM  6F -,SUP-S-45-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SUPERA 4.5X40MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-45-040-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SUPERA 4.5X60MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-45-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PERIPHERAL 4.5MM X 80MM X 120CM  6F -,SUP-S-45-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PERIPHERAL 4.5MM X 100MM X 120CM  6F -,SUP-S-45-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SUPERA 4.5X120MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-45-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PERIPHERAL 5MM X 20MM X 120CM  6F -,SUP-S-50-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PERIPHERAL 5MM X 30MM X 120CM  6F -,SUP-S-50-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SUPERA 5 X 60MM 120 -,SUP-S-50-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT  VASC SUPERA 5 X 80MM x 120 -,SUP-S-50-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
5MM X 100MM X 120CM SUPERA STENT -,SUP-S-50-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
5MM x 120MM x 120CM SUPERA STENT -,SUP-S-50-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SUPERA 5.5X40MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-040-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SUPERA 5.5X60MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SUPERA 5.5X80MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
SUPERA PERIPHERAL STENT SYSTEM 5.5MM X 100MM X 120CM -,SUP-S-55-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5495.98,3847.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SUPERA 5.5X120MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SUPERA 5.5X150MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-150-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PERIPHERAL 6MM X 30MM X 120CM  6F -,SUP-S-60-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT SUPERA 6.0MM X 80 X 120CM -,SUP-S-60-080-120-P,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5920.38,4144.266,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT SUPERA 6MM X 80 X 120CM -,SUP-S-60-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S SUPERA 6.0MM X 100 X 120CM -,SUP-S-60-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S SUPERA 6.0MM X 120 X 120CM -,SUP-S-60-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S SUPERA 6.0MM X 150 X 120CM -,SUP-S-60-150-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PERIPHERAL  6.5MM X 20MM X 120CM 6F -,SUP-S-65-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PERIPHERAL 6.5MM X 30MM X 120CM  6F -,SUP-S-65-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SUPERA 6.5X40MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-040-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SUPERA 6.5X60MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SUPERA 6.5X80MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SUPERA 6.5X100MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SUPERA 6.5X120MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SUPERA 6.5X150MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-150-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PERIPHERAL 7.0MM X 020MM X 120CM  6F -,SUP-S-70-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PERIPHERAL 7.0MM X 030MM X 120CM  6F -,SUP-S-70-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 10X40MM 120CM PROTEGE GPS OTW SE PRMNT OPN LATTICE -,SUP-SERB651040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 10X60MM 120CM PROTEGE GPS OTW SE PRMNT OPN LATTICE -,SUP-SERB651060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 12X20MM 120CM PROTEGE GPS OTW SE PRMNT OPN LATTICE -,SUP-SERB651220120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
7MM X 30MM TCAR STENT ENROUTE -,SUP-SR-0730-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
7MM X 40MM STENT TCAR ENROUTE -,SUP-SR-0740-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
8MM X 30MM STENT TCAR ENROUTE -,SUP-SR-0830-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
8MM X 40MM STENT TCAR ENROUTE -,SUP-SR-0840-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
9MM X 30MM STENT TCAR ENROUTE -,SUP-SR-0930-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
9MM X 40MM STENT TCAR ENROUTE -,SUP-SR-0940-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
ENROUTE TANSCAROTID STENT SYSTEM SR-1030-CS -,SUP-SR-1030-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
ENROUTE TANSCAROTID STENT -,SUP-SR-1040-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC MISAGO 6MM X120MM X 200CM RX R -,SUP-SXR06120R,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC MISAGO 6X150MM 135CM SELF EXPANDING -,SUP-SXR06150R,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
GRAFT EV 14X40 ILC -,SUP-UNDEFINED,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S BILI EXPRESS 5X15X150 -,SUP-UNDEFINED,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 5X18 GENESIS AVIATOR -,SUP-UNDEFINED,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
VENOUS 8F 10mm x 80 mm 120cm CATHETER LENGTH -,SUP-VENUM10080,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
VENOVO VENOUS STENT 12MM X 60MM -,SUP-VENUM12060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
16MM x 60MM x 80CM VENOVO STENT -,SUP-VENUM16060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
VENOUS STENT 14MM x 100MM 120CM CATHETER LENGTH -,SUP-VENUM16080,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
VENOVO VENOUS STENT 18MM X 100MM X 80CM -,SUP-VENUM18100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
VENOUS STENT SYSTEM 18X 120MM 80CM CATH LENGTH -,SUP-VENUM18120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
VENOVO 10FR 20MM X 60MM- 80CM CATHETER LENGTH -,SUP-VENUM20060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 4MMX6CM 125CM ZILVER 518 OTW SE PRELD SLT TUBE -,SUP-ZIB5-125-4.0-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 4MMX8CM 125CM ZILVER 518 OTW SE PRELD SLT TUBE -,SUP-ZIB5-125-4.0-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S ZILVER 518 5X60 125CM S-E -,SUP-ZIB5-125-5.0-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 12MM 8FR GUID CATH 60MM 125CM ZILVER 635 OTW SE -,SUP-ZIB6-125-12.060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S ZILVER .035 120CM 5 X 40 -,SUP-ZIB6-125-5.0-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S ZILVER .035 125CM 5 X 80 -,SUP-ZIB6-125-5.0-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X100MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-ZIB6-35-1256100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X140MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-ZIB6-35-1256140,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT ZILVER 6MM X 60MM X 125MM -,SUP-ZIV5-18-125-6-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ZILVER 518 8X40MM 125CM OTW SE 0.018IN/5FR -,SUP-ZIV5-18-125-840,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ZILVER 518 8X80MM 125CM OTW SE 0.018IN/5FR -,SUP-ZIV5-18-125-880,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
S ZILVER 6 X 30 -,SUP-ZIV6-35-125-630,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT ZILVER 6 X 40 -,SUP-ZIV6-35-125-640,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC DES ZILVER PTX 6X40MM 125CM OTW SE PRELD -,SUP-ZIV635125640PTX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5487.45,3841.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X18MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010144-18,CDM,C1877,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,198.065125,7007.6928,other,OPPS APC,,
CATH GUID 7FR AL 0.75 SH 100CM -,SUP-G782AL75,CDM,C1877,HCPCS,278,RC,,,outpatient,,,882.25,617.575,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,198.065125,7007.6928,other,OPPS APC,,
STENT ESPH 18MM 23/23MM OD P/D FLR 153MM WALLFLX SE BRD FLLY -,SUP-M00516920,CDM,C1877,HCPCS,278,RC,,,outpatient,,,9124.6,6387.22,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,198.065125,7007.6928,other,OPPS APC,,
PALMAZ UNMOUNTED STENT DIA 1 -,SUP-P4010,CDM,C1877,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,198.065125,7007.6928,other,OPPS APC,,
STENT BIL 10X59MM PALMZ GENESIS BE UNMT TRNSHEP SS 0.035IN -,SUP-PG5910B,CDM,C1877,HCPCS,278,RC,,,outpatient,,,3986.29,2790.403,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,198.065125,7007.6928,other,OPPS APC,,
IMPLANT VOCAL CRD PST PROLARYN PLUS 1ML SYR -,SUP-8044M0K5,CDM,C1878,HCPCS,278,RC,,,outpatient,,,3246.32,2272.424,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2621.49888,other,OPPS APC,,
IMPLANT VOCAL CORD PROLARYN GEL 1CC NEEDLE -,SUP-8602M0K5,CDM,C1878,HCPCS,278,RC,,,outpatient,,,3413.41,2389.387,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2621.49888,other,OPPS APC,,
IMPLANT THYRPL MONT SZ9 SIL EAR FEM STRL -,SUP-MTF.09,CDM,C1878,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2621.49888,other,OPPS APC,,
KIT THYROPLASTY MALE -,SUP-MT-SPM,CDM,C1878,HCPCS,278,RC,,,outpatient,,,3308.38,2315.866,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2621.49888,other,OPPS APC,,
FILTER VASC BIRDS NEST 40MMX40CM SS VC MRKR -,SUP-178242,CDM,C1880,HCPCS,278,RC,,,outpatient,,,9467.05,6626.935,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.22547,6153.5825,other,OPPS APC,,
FILTER EMBL PROT OPTEASE 6FR ID 8FR INTRO SHTH 55CM SLF CNTR -,SUP-466-F220A,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3189.03,2232.321,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.22547,6153.5825,other,OPPS APC,,
FILTER OPTEASE FEMORAL 55CM -,SUP-466-F230AF,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3189.03,2232.321,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.22547,6153.5825,other,OPPS APC,,
FILTER VASC BIRD S NEST 40MM 11FR CATH 12FR INTRO 75CM SS VC -,SUP-BNF-75-PB,CDM,C1880,HCPCS,278,RC,,,outpatient,,,9467.05,6626.935,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.22547,6153.5825,other,OPPS APC,,
FILTER EMBL NAVALIGN CELECT 30X48MM FEM VC -,SUP-G03767,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.22547,6153.5825,other,OPPS APC,,
FILTER CELECT VENA CAVA UNI -,SUP-G34505,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4773.95,3341.765,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.22547,6153.5825,other,OPPS APC,,
VENA CAVA FILTER FEMORAL & JUG -,SUP-G34505,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4773.95,3341.765,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.22547,6153.5825,other,OPPS APC,,
FILTER EMBL CELECT 30MM 7FR INTRO SHTH 48MM UNISET VC -,SUP-G52915,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.22547,6153.5825,other,OPPS APC,,
FILTER EMBL GUNTHER TULIP 30X50MM FEM VC -,SUP-G52917,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3819.15,2673.405,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.22547,6153.5825,other,OPPS APC,,
FILTER VASC NAVALIGN CELECT 30MM 7FR CATH UNIV 49MM UNISET -,SUP-IGTCFS651UNICEL,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4773.95,3341.765,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.22547,6153.5825,other,OPPS APC,,
FILTER VASC GUNTHER TULIP 30MM 8.5FR INTRO SHTH 50MM PRELD -,SUP-IGTCFS-65-FEM,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.22547,6153.5825,other,OPPS APC,,
FILTER VENA CAVA TULIP UNI GUNTHER -,SUP-IGTCFS-65-UNI,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3819.15,2673.405,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.22547,6153.5825,other,OPPS APC,,
FILTER VASC GUNTHER TULIP 30MM 8.5FR INTRO SHTH 50MM- -,SUP-IGTCFS-65-UNI,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.22547,6153.5825,other,OPPS APC,,
FILTER GREENFIELD JUG -,SUP-M001503000,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4249.67,2974.769,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.22547,6153.5825,other,OPPS APC,,
FILTER GREENFIELD FEM -,SUP-M001503010,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4249.67,2974.769,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.22547,6153.5825,other,OPPS APC,,
DILATOR VASC 18GA GW 0.038IN DILATOR 8/10/12 FR DIA SYR -,SUP-M001503500,CDM,C1880,HCPCS,278,RC,,,outpatient,,,776.06,543.242,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.22547,6153.5825,other,OPPS APC,,
FILTER VASC MERIDIAN NTNL VC -,SUP-MD800F,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.22547,6153.5825,other,OPPS APC,,
FILTER VASC MERIDIAN NTNL SBCLVN VC -,SUP-MD800J,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.22547,6153.5825,other,OPPS APC,,
FILTER OPTEASE JUGULAR 55CM -,SUP-UNDEFINED,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3189.03,2232.321,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.22547,6153.5825,other,OPPS APC,,
FILTER OPTEASE JUGULAR 90CM -,SUP-UNDEFINED,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,174.22547,6153.5825,other,OPPS APC,,
DEFIBRILLATOR PRMT RF DF-1 2CHMBR 50X81MM 14MM 43ML 82GM -,SUP-3207-36,CDM,C1882,HCPCS,275,RC,,,outpatient,,,59022.98,41316.086,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR LUMAX 540 HF-T DF-1 IS-1 CONN 3 CHMBR RR. -,SUP-360347,CDM,C1882,HCPCS,275,RC,,,outpatient,,,38238.5,26766.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR LUMAX 740 HF-T BIVEN PCNG CARD IMPL W/HOME -,SUP-365608,CDM,C1882,HCPCS,275,RC,,,outpatient,,,40705.5,28493.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR ILESTO HF-T DF-1 BIVEN PCNG RDC HI ENRG CARD -,SUP-383547,CDM,C1882,HCPCS,275,RC,,,outpatient,,,40705.5,28493.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR ILESTO HF-T DF-4 BIVEN PCNG HI ENRG CARD IMPL -,SUP-383549,CDM,C1882,HCPCS,275,RC,,,outpatient,,,32036.46,22425.522,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR LUMAX 740 HF-T CARD IMPL W/HOME MNTR MBL -,SUP-393803,CDM,C1882,HCPCS,275,RC,,,outpatient,,,39472,27630.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIB HI ENRG BIVEN CARD IMPL TI -,SUP-401662,CDM,C1882,HCPCS,275,RC,,,outpatient,,,34503.46,24152.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR PRMT + DF-4 RR V- PCNG RDC 50X75MM 14MM 42ML -,SUP-CD3211-36Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR UNIFY IS-1 CONN 40X79MM 14MM 36ML 78GM CARD -,SUP-CD3231-40,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR UNIFY QUADRA DF-4 IS-4 IS-1 CONN 41X75MM 14MM -,SUP-CD3249-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43251.44,30276.008,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR UNIFY ASSURA DF-1 IS-1 DF-4 BIVEN PCNG 40X79MM -,SUP-CD3257-40,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR UNIFY ASSURA DF-4 TELEM 2CHMBR 40X73MM 14MM -,SUP-CD3257-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR QUADRA ASSURA DF-1 BIVEN PCNG 41X83MM 14MM -,SUP-CD3265-40,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43251.44,30276.008,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR QUADRA ASSURA DF-4 IS-4 IS-1 CONN BIVEN PCNG -,SUP-CD3265-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43251.44,30276.008,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR UNIFY ASSURA CARD IMPL PARYLENE CTD -,SUP-CD3357-40C,CDM,C1882,HCPCS,275,RC,,,outpatient,,,29974.05,20981.835,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
UNIFY ASSURA NXGEN CRT-D 40 MEDIGUIDE -,SUP-CD3357-40C,CDM,C1882,HCPCS,275,RC,,,outpatient,,,47726.58,33408.606,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR UNIFY ASSURA DF-4 CARD IMPL PARYLENE CTD CD -,SUP-CD3357-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,29974.05,20981.835,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
CRT-D 40 QUADRA ASSURA -,SUP-CD3365-40C CELL,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35225.31,24657.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR QUADRA ASSURA DF-4 SGL/2CHMBR 41X75MM 14MM -,SUP-CD3365-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35225.31,24657.717,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
CRT-D QUADRA ASSURA MP CD3369-40C -,SUP-CD3369-40C,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
CRT-D QUADRA ASSURA MP DFR CON -,SUP-CD3369-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
ENTRANT CRT-D CDHFA300Q -,SUP-CDHFA300Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35771.5,25040.05,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
ENTRANT HF CRT-D DF1 CONNECTOR REF: CDHFA300T -,SUP-CDHFA300T,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35771.5,25040.05,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
GALLANT CRT-D CDHFA500Q -,SUP-CDHFA500Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,38238.5,26766.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
GALLANT HF CRT-D DF1 CONNECTOR REF: CDHFA500T -,SUP-CDHFA500T,CDM,C1882,HCPCS,275,RC,,,outpatient,,,38238.5,26766.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR INOGEN MUL PRGM OPTN EXTEND LNGVT VR -,SUP-D141,CDM,C1882,HCPCS,275,RC,,,outpatient,,,28370.5,19859.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR CONSULTA DF-1 IS-1 CONN WRLS TELEM 2CHMBR RR -,SUP-D224TRK,CDM,C1882,HCPCS,275,RC,,,outpatient,,,48626.05,34038.235,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR PROTECTA DF-4 CARD IMPL -,SUP-D334TRM,CDM,C1882,HCPCS,275,RC,,,outpatient,,,39911.13,27937.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
EVERA MRI MRT XT DR DDMB1D4 -,SUP-DDMB1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,37251.7,26076.19,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
VIVA CARD IMPL -,SUP-DTBA1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50599.65,35419.755,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR VIVA XT IS-1 DF-1 ADPTVCRT PHYCRV SMRTSHCK -,SUP-DTBA1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50599.65,35419.755,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR VIVA S DF-4 IS-1 CONN SGL-CHMBR CARD IMPL -,SUP-DTBB1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,42839.46,29987.622,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR VIVA S DF-4 IS-1 CONN SGL-CHMBR CARD IMPL. -,SUP-DTBB1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,42839.46,29987.622,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIB  VIVA QUAD S CRT-D DF-1 IS-4 CONN CARD IMPL -,SUP-DTBB1Q1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43172.5,30220.75,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR VIVA QUAD S DF-4 IS-4 CONN CARD IMPL -,SUP-DTBB1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,42839.46,29987.622,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
CLARIA MRI CRT-D DTMA1D1 -,SUP-DTMA1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49006.96,34304.872,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
CLARIA MRI CRT-D MODEL DTMA1D1 -,SUP-DTMA1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49006.96,34304.872,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
CLARIA MRI CRT-D DTMA1D4 -,SUP-DTMA1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49006.96,34304.872,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
CLARIA MRI QUAD CRT-D DTMA1QQ -,SUP-DTMA1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50326.8,35228.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
CLARIA MRI QUAD CRT-D Model DTMA1QQ -,SUP-DTMA1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50326.8,35228.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
AMPLIA MRI CRT-D DTMB1D1 -,SUP-DTMB1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,47773.46,33441.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
CRTD DTMB1D1 AMPLIA MRI US DF1 -,SUP-DTMB1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,47773.46,33441.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
AMPLIA CRT-D MRI DEVICE -,SUP-DTMB1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,54249.33,37974.531,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
AMPLIA MRI QUAD CRT-D -,SUP-DTMB1Q1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
AMPLIA MRI QUAD CRT-D SURESCAN DTMB1Q1 -,SUP-DTMB1Q1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
AMPLIA CRT-D DTMB 1 QQ -,SUP-DTMB1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
ICD COBALT HF CRT-D MRI SURESCAN REF: DTPB2D1 -,SUP-DTPB2D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,48237.25,33766.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
COBALT HF QUAD CRTD REF: DTPB2QQ -,SUP-DTPB2QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,52793.8,36955.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
CROME MRI CRTD REF: DTPC2D4 -,SUP-DTPC2D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50240.46,35168.322,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
CRT-D MOMENTUM IS1 DF4 G124 -,SUP-G124,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
CRT-D MOMENTUM IS1 DF1 G125 -,SUP-G125,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
CRT-D MOMENTUM LV-1 G126 -,SUP-G126,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
CRT-D MOMENTUM X4 IS4-DF1 G138 -,SUP-G138,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
PACEMAKER INOGEN CARD -,SUP-G140,CDM,C1882,HCPCS,275,RC,,,outpatient,,,39225.3,27457.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR INOGEN CARD -,SUP-G141,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR INOGEN DF-1 SGL-CHMBR 5.37CMX8.08CMX0.99CM D -,SUP-G146,CDM,C1882,HCPCS,275,RC,,,outpatient,,,41692.3,29184.61,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR INOGEN DF-4 5.37CMX8.08CMX0.99CM D 32ML CARD -,SUP-G148,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
DYNAGEN CRT-D MODEL G150 -,SUP-G150,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
DYNAGEN CRT-D G-154 DEFIBRILLATOR -,SUP-G154,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
CRT-D DYNAGEN X4 G156 -,SUP-G156,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33218.16,23252.712,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
CRT-D VIGILANT X4 IS4 DF4 MRI CONDITIONAL -,SUP-G247,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
COMPIA CRT-D MRI QUAD -,SUP-UNDEFINED,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,45329.64864,other,OPPS APC,,
ANCHOR LD C IN 94IN LF ACC -,SUP-1194,CDM,C1883,HCPCS,278,RC,,,outpatient,,,437.63,306.341,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3519.77472,other,OPPS APC,,
KIT EXTENSION INTERSTIM 10CM S  - DISCONTINUED DO NOT USE -,SUP-3095-10,CDM,C1883,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3519.77472,other,OPPS APC,,
KIT REVISION INTERSTIM -,SUP-3550-05,CDM,C1883,HCPCS,278,RC,,,outpatient,,,1079.48,755.636,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3519.77472,other,OPPS APC,,
KT EXTENSION NEURSTM INTSTM 60CM PERC MRI-COND INSL MULI- -,SUP-3708160,CDM,C1883,HCPCS,278,RC,,,outpatient,,,3007.62,2105.334,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3519.77472,other,OPPS APC,,
LEAD ADPTR -,SUP-5866,CDM,C1883,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3519.77472,other,OPPS APC,,
CABLE PCNG -,SUP-5867AS,CDM,C1883,HCPCS,278,RC,,,outpatient,,,116.7,81.69,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3519.77472,other,OPPS APC,,
EXTENDER LD UNIPL -,SUP-6981M,CDM,C1883,HCPCS,278,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3519.77472,other,OPPS APC,,
EXTENDER LD BIPLR MRI-COND -,SUP-6984M,CDM,C1883,HCPCS,278,RC,,,outpatient,,,1079.48,755.636,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3519.77472,other,OPPS APC,,
ADAPTER NEURSTM 27.4CM SPIN CRD 2X4 PCKT -,SUP-740-02,CDM,C1883,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,26.19915,3519.77472,other,OPPS APC,,
FILTER EMBL PROT EMBOSHIELD NAV6 5MMX190CM WIRE UNCNTSTR -,SUP-22437-19,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,5331.24633,other,OPPS APC,,
FILTER EMBL PROT EMBOSHIELD NAV6 7.2MMSMX190CM WIRE UNCNTSTR -,SUP-22438-19,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,5331.24633,other,OPPS APC,,
FILTER EMBL PROT FLTWR EZ 3.2FRX190CM WIRE NTNL LOOP CRTD -,SUP-H749201001900,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6875.28,4812.696,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,5331.24633,other,OPPS APC,,
FILTER EMBL PROT FLTWR EZ 3.2FRX300CM WIRE NTNL LOOP CRTD -,SUP-H749201003000,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7078.99,4955.293,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,5331.24633,other,OPPS APC,,
EMBOLIC PROT FLTWR EZ 0.042IN 0.014 DIA GW 110U FLTR 190CM -,SUP-H749390711900,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7435.49,5204.843,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,5331.24633,other,OPPS APC,,
FILTERWIRE EMBL EZ 2.25MM 3.5MMX300CM FEM VC -,SUP-H74939071300,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6457.03,4519.921,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,5331.24633,other,OPPS APC,,
DEVICE EMBL PROT SPIDERFX 3MM FLTR BSKT 0.014IN GW 0.066IN -,SUP-SPD2US030320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,5331.24633,other,OPPS APC,,
DEVICE EMBL PROT SPIDERFX 4MM FLTR BSKT 0.014IN GW 0.066IN -,SUP-SPD2US040320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,5331.24633,other,OPPS APC,,
SPIDER FX 5MM 320 .014 EMBOLIC -,SUP-SPD2US050320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,5331.24633,other,OPPS APC,,
SPIDER FX 6MM 320 .014 EMBOLIC -,SUP-SPD2US060320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,5331.24633,other,OPPS APC,,
DEVICE EMBL PROT SPIDERFX 7MM FLTR BSKT 0.014IN GW 0.066IN -,SUP-SPD2US070320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,5331.24633,other,OPPS APC,,
CATHETER LASER CORONARY ATHETECTOMY 0.9X80 ELACX-80 -,SUP-110-004,CDM,C1885,HCPCS,272,RC,,,outpatient,,,10588.78,7412.146,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7592.15526,other,OPPS APC,,
CATHETER 1.4MM ELCA CORONARY LASER ATHE -,SUP-114-009,CDM,C1885,HCPCS,272,RC,,,outpatient,,,10588.78,7412.146,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7592.15526,other,OPPS APC,,
C 1.7M .018IN OTW TURBO ELITE -,SUP-417-152,CDM,C1885,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7592.15526,other,OPPS APC,,
CATH ABLT 4MM 90DG 160CM BARRX ULTRA LNG LF -,SUP-90-9200,CDM,C1886,HCPCS,272,RC,,,outpatient,,,9419.88,6593.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7607.37,other,OPPS APC,,
CATHETER BRONCHIAL THERMOPLAST -,SUP-M005ATS25010,CDM,C1886,HCPCS,272,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7607.37,other,OPPS APC,,
CATH SHEATH RITESITE C315H40,SUP-,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
GUIDE 8F MARK 1 AL 2 -,SUP-34358-20,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
GUIDE 8F MARK 1 IM -,SUP-34358-26,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
LEAD PCNG 6.6FR 7FR INTRO 53CM TILDA HELIX ELECTRICALLY -,SUP-382889,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
LEAD PCNG 6.6FR 7FR INTRO 60CM TILDA HELIX ELECTRICALLY -,SUP-382895,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER GUIDE 6FR X 85CM INTERNAL MAMMARY -,SUP-38969-122/H749389691220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 5FR IL-3.5 HEARTRAIL III NO SH COR SS FLTWR PTFE -,SUP-40-5370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 5FR IKARI RT 2 HEARTRAIL III NO SH COR SS FLTWR -,SUP-40-5382,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 6FR ID 0.081IN IL-3.5 100CM HEARTRAIL III LRG LUM -,SUP-40-6370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 6FR ID 0.081IN IL-4.5 100CM HEARTRAIL III LRG LUM -,SUP-40-6375,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
MICRO GUIDE CATH NHANCER RX REF: 451669 -,SUP-451669,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER GUIDE -,SUP-490107,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX 0.039/0.026IN DIA P/D 45DG ANG TAPR 135CM QCK-CX -,SUP-518-032,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX 0.044/0.030IN DIA P/D 15MM SPC 45DG ANG TAPR 90CM -,SUP-518-033,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
C QUICKCROSS .018 150CM -,SUP-518-035,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX 0.063/0.050IN DIA P/D 15MM SPC 45DG ANG TAPR 90CM -,SUP-518-036,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
C QUICKCROSS .035 135CM -,SUP-518-037,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
C QUICKCROSS .035 150CM -,SUP-518-038,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
C 0.014-150CM QUICK CROSS -,SUP-518-065,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX 0.052/0.059IN DIA P/D 15MM SPC 45DG ANG TAPR 135CM -,SUP-518-081,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
C QUICK CROSS SEL .035 150CM -,SUP-518-083,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
C QUICK CROSS SEL .014 150 -,SUP-518-087,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
C QUICK CROSS SEL .018 150 -,SUP-518-093,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX 3FR ID 1.9FRX140CM TWN PASS RX LPRO LUMX2 COR PERIPH -,SUP-5200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2003.59,1402.513,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER SUPERCROSS 45 ANGLED 0.014 X 130CM -,SUP-5302,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
SUPERCROSS 90 ANGLED TIP CATH -,SUP-5305,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2279.22,1595.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
MICRO GUIDE CATH SUPERCROSS 120 ANGLED TIP REF: 5306 -,SUP-5306,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2472.93,1731.051,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ANG INFINITI 5FR JR4 REF: 534521T -,SUP-534521T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ANG 5FR 145 PIGTL 110CM INFINITI REF: 534-552S -,SUP-534552S,CDM,C1887,HCPCS,272,RC,,,outpatient,,,43.47,30.429,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ANG 5FR IMA CRV 100CM INFIN SLCT 3 STG BRD NBRD PROX -,SUP-534-560T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ANG INFINITI 6FR JL4 REF: 534620T -,SUP-534620T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ANG INFINITI 6FR JR4 REF: 534-621T -,SUP-534-621T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ANG INFINITI 6FR AR MOD REF: 534648T -,SUP-534648T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ANG INFINITI 6FR RCB REF: 534670T -,SUP-534670T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ANG INFINITI 6FR LCB REF: 534672T -,SUP-534672T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
SHEATH GUID 5FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-54-54501,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX 6FR 145DG PIGTL 110CM LANGSTON BRD LUMX2 LO XING -,SUP-5540,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1088.81,762.167,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.056IN 5FRX100CM 2.5MM VISTA BRITE TIP SS PTFE -,SUP-556-002-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.056IN 5FR JL3.5 100CM VISTA BRITE TIP BRD -,SUP-556-002-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.056IN 5FR LT COR EBU 3.5 100CM 2.5MM VISTA BRITE -,SUP-556-054-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.056IN 5FR  XBLAD 3.5 LBT 100CM 2.5MM VISTA -,SUP-556-060-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.056IN 5FR BARB 100CM VISTA BRITE TIP BRD MUL-SEG -,SUP-556-174-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER 6FRX150CM TRAPLINER REF:5566 -,SUP-5566,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3652.11,2556.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER 7FRX150CM TRAPLINER REF:5567 -,SUP-5567,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3652.11,2556.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX 6FRX150CM GUIDELINER V2 RX COAX PERIPH -,SUP-5571,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2183.81,1528.667,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX 7FRX150CM GUIDELINER V2 RX COAX PERIPH -,SUP-5572,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2183.81,1528.667,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX 8FRX150CM GUIDELINER V2 RX COAX PERIPH -,SUP-5573,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2173.21,1521.247,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
TURNPIKE GOLD 135CM MICRO CATH -,SUP-5621,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3294.06,2305.842,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
TURNPIKE LP 135 ON MICRO CATHETER -,SUP-5638,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3771.46,2640.022,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
TURNPIKE LP 150CM MICRO CATH -,SUP-5639,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2931.24,2051.868,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER TURNPIKE SPIRAL 135CM -,SUP-5640,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3771.46,2640.022,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.018IN 3.5FR SHFT 70CM 8MM VENTURE OTW CS PED -,SUP-5822,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3146.07,2202.249,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.088IN 8FR JL4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-588-823,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.088IN 8FR LT COR EBU3 100CM 2.5MM VISTA BRITE -,SUP-588-829,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.088IN 8FR JR4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-588-830,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.088IN 8FR JL3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-588-851,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID VISTA 8FR XB 3.5 -,SUP-588-882,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.088IN 8FR LT COR EBU 4 100CM 2.5MM VISTA BRIT -,SUP-588-894,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX 0.054IN 6FRX100CM 2CM PERFORM ULTMT 2 -,SUP-610038ULT2,CDM,C1887,HCPCS,272,RC,,,outpatient,,,140.74,98.518,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 130DG CRV ATTAIN SELECT COR STR 5.5FR INR CATH -,SUP-6248DEL,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER ATTAIN SELECT REF: 6248V-130 -,SUP-6248V-130,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1284.84,899.388,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH 6248V-90 ATTAIN SELECT II -,SUP-6248V-90,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1284.84,899.388,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER  CRDM Adaptor 6250V-EH -,SUP-6250V-EH,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER ATTAIN COMMAND REF: 6250V-MPR -,SUP-6250V-MPR,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.96MM/MIN 2.4MM/MAX MPX COR 50CM ATTAIN COMMAND -,SUP-6250VMPX,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR JL3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-002-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR JL4 100CM VISTA BRITE TIP BRD -,SUP-670-004-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR JL4 SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-005-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR JL4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-014-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR AL1 100CM .75MM SH VISTA BRITE TIP -,SUP-67003500,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR ALC1 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-036-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR ALC2 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-040-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR  XB3 100CM 1.8MM VISTA BRITE TIP -,SUP-670-052-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR XB 3 SH 100CM VISTA BRITE TIP -,SUP-670-053-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUIDING 6FR XB 3.5 VISTA -,SUP-670-054-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUIDING 6FR XB 3.5 VISTA LBT -,SUP-670-054-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,253.82,177.674,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR LT COR EBU3.5 SH 100CM 2.5MM VISTA -,SUP-670-055-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR XB4 100CM 2.5MM VISTA BRITE TIP -,SUP-670-056-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR XB4.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-67005800,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR XBLAD 3.5 100CM  VISTA BRITE -,SUP-670-060-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR XBLAD 4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-062-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 6FR XBLAD 4.5 100CM VISTA BRITE TIP -,SUP-67006400,CDM,C1887,HCPCS,272,RC,,,outpatient,,,198.39,138.873,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR XBLAD 3 100CM VISTA BRITE TIP -,SUP-670-066-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR JR3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-080-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR JR4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-67008200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR JR4 55CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-082-55,CDM,C1887,HCPCS,272,RC,,,outpatient,,,355.35,248.745,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR JR4 SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-083-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR ARC1 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-67011000,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR XBRCA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-126-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 6FR JFL LT REF: 670-166-00 -,SUP-670-166-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR JEAN- FJL 100CM 2.5MM VISTA BRITE TIP -,SUP-670-166-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR BARB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-174-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR LCB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-180-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR LCB 90CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-180-90,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR RCB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-182-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR RCB 90CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-182-90,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR IMA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-190-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR VERT 55CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-190-55,CDM,C1887,HCPCS,272,RC,,,outpatient,,,355.35,248.745,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR IM SH REF: 670-191-00 -,SUP-670-191-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 6FR IM VB-1 100CM VISTA BRITE TIP -,SUP-67019200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,198.39,138.873,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR RNL CRV 55CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-212-55,CDM,C1887,HCPCS,272,RC,,,outpatient,,,355.35,248.745,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR HS 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-278-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR HS SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-279-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.078IN 7FR JL4 100CM 2.5MM VISTA BRITE TIP BD -,SUP-778-004-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER GUIDING 7FR JL 5 SH JUDKINS -,SUP-77800900,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUIDE 7FR AL2 REF: 778704000 -,SUP-77804000,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.078IN 7FR LT EBU LAD 3 100CM 2.5MM VISTA BRITE -,SUP-778-052-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.078IN 7FR XB 3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-054-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUIDING  7FR XB3.5 SH VIS -,SUP-778-055-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.078IN 7FR XB4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-056-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.078IN 7FR LT EBU LAD 4.5 100CM 2.5MM VISTA BRITE -,SUP-778-058-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUIDING 7FR XBLAD 3.5 100CM 2.5MM VISTA -,SUP-778-060-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.078IN 7FR LT COR EBU LAD 4 100CM 2.5MM VISTA -,SUP-778-062-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.078IN 7FR JR4 100CM 2.5MM VISTA BRITE BRD -,SUP-778-082-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.078IN 7FR JR4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-083-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.078IN 7FR ARC1 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-110-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.078IN 7FR ARC2 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-112-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.078IN 7FR RCB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-182-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.078IN 7FR IMA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-190-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.078IN 7FR MPA-1 COR 100CM 2.5MM VISTA BRITE TIP -,SUP-778-270-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.078IN 7FR HS 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-278-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.078IN 7FR HS SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-279-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH BLN OCCULSION 2.1FRX135CM ASAHI TORNUS SUPP CHRNC OTW -,SUP-82380-01,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX 2.6FRX135CM ASAHI TORNUS SUPP OTW THRD COR SS -,SUP-82381-01,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3795.33,2656.731,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER CENTER POINT REF:9181 -,SUP-9181,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER CENTER POINT REF:9182 -,SUP-9182,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER CENTER POINT REF:9183 -,SUP-9183,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER CENTER POINT REF:9184 -,SUP-9184,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH SHEATH RITESITE C315H2002 -,SUP-C315H2002,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH SHEATH RITESITE C315H4002 -,SUP-C315H4002,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH SHEATH C315HIS02 -,SUP-C315HIS02,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
HIS SHEATH DELIVERY SYSTEM C315HIS02 -,SUP-C315HIS02,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH SHEATH RITESITE C315J02 -,SUP-C315J02,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH SHEATH RITESITE C315S1002 -,SUP-C315S1002,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH SHEATH RITESITE C315S402 -,SUP-C315S402,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH SHEATH RITESITE C315S502 -,SUP-C315S502,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ELCSURG 7FRX100CM RF FLXB CLSR FST -,SUP-CF7-7-100,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
GLIDECATH MG1 4F 125CM  LONG -,SUP-CG440,CDM,C1887,HCPCS,272,RC,,,outpatient,,,295.54,206.878,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
GLIDECATH MG2 4F 135CM  LONG -,SUP-CG441,CDM,C1887,HCPCS,272,RC,,,outpatient,,,295.54,206.878,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ABLT CLSR FST 65CM PROC KT MIS-7F11 INTRO -,SUP-CPK6511,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1908.18,1335.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ABLT CLSR FST 73CM PROC KT MIS-7F11 INTRO -,SUP-CPK8511,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1908.18,1335.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
ASAHI CARAVEL MICROCATHETER 150 CM -,SUP-CRV150-19P,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER CORSAIR PRO XS 150CM REF: CSR150-21S -,SUP-CSR150-21S,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER CORSAIR PRO 150CM CSR150-26P ASAHI -,SUP-CSR150-26P,CDM,C1887,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
"CATHETER CXI SUPPORT 4.OFR X 135CM STR TIP .035"" MAX GUIDEWR -",SUP-CXI-4.0-35-135-P-NS-O,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER CPS LOCATOR 3D- SMALL REF:DS2C100-42 -,SUP-DS2C100-42,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER CPS LOCATOR 3D- MEDIUM REF:DS2C200-42 -,SUP-DS2C200-42,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER CPS LOCATOR 3D- LAGE REF:DS2C300-42 -,SUP-DS2C300-42,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER AGILIS HISPRO DS3H010-38  BUNDLE -,SUP-DS3H010-38,CDM,C1887,HCPCS,272,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER AGILIS HISPRO DS3H010-38 -,SUP-DS3H010-38,CDM,C1887,HCPCS,272,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ANG 0.056IN 6FR AR1 100CM DXTERITY REF: DXT6AR10 -,SUP-DXT6AR10,CDM,C1887,HCPCS,272,RC,,,outpatient,,,9.92,6.944,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
RING TRANS-JUG ACCESS SET WITH 10fr -,SUP-G06541,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2542.11,1779.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
TRANSJUGLAR LIVER ACCESS SET R -,SUP-G06929,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2558.82,1791.174,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
BEACON TIP 5.0 FR ANGIOGRAPHIC CATHETER - C2 -,SUP-G08442,CDM,C1887,HCPCS,272,RC,,,outpatient,,,151.7,106.19,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER RIM 5FR X 100CM -,SUP-G12870,CDM,C1887,HCPCS,272,RC,,,outpatient,,,758.49,530.943,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX 2.6FR STR 65CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G18367,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1051.93,736.351,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER CXI SUPPORT -,SUP-G18368,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1051.93,736.351,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CXI-2.3-14-65-0 -,SUP-G18369,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH CXI 2.3FR X 65CM X 014 SU -,SUP-G18370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH CXI 2.3FR X 90CM X 014 SU -,SUP-G18371,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CXI-2.3-14-90-ANG -,SUP-G18372,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CXI-2.3-14-150-ANG -,SUP-G18376,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX 2.6FR ANG 150CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G50003,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX 2.6FR STR 90CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G50004,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX 3FR/1.9FR P/D STR 135CM CROSSCATH SUPP LUMX1 PERIPH -,SUP-G51573,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX 4.8FR/3.7FR P/D STR 90CM CROSSCATH SUPP LUMX1 PERIPH -,SUP-G51580,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX 4.8FR/3.7FR P/D STR 135CM CROSSCATH SUPP LUMX1 -,SUP-G51581,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX 3.4FR/2.2FR P/D STR 135CM CROSSCATH SUPP LUMX1 -,SUP-G51583,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX 4FR DAV 135CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G52543,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX 4FR DAV 150CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G52545,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
C NAVICROSS ANG 150CM .035 -,SUP-G52545,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER CXI SUPPORT 4FR X 90CM STR TIP .035 MAX GUIDEWRE -,SUP-G52546,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ANG 90CM NAVICROSS -,SUP-G52547,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX 4FR DAV 90CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G52547,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 7FR XBRCA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-G778126,CDM,C1887,HCPCS,272,RC,,,outpatient,,,882.25,617.575,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID RELIEVA FLEX SIN S-0 SFT DIST TIP ENDO -,SUP-GC000RF,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1961.19,1372.833,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID RELIEVA FLEX SIN F-70 C SFT DIST TIP ENDO -,SUP-GC070CRF,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1961.19,1372.833,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID RELIEVA FLEX SIN M-110 SFT DIST TIP ENDO -,SUP-GC110RF,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1961.19,1372.833,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ANGIO IMPULSE 5FR FL3.5 REF:H74916391212 -,SUP-H74916391212,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER 5FR FL4 IMPULSE REF:H74916391222 -,SUP-H74916391222,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ANGIO IMPULSE 5FR AR1 REF:H74916391842 -,SUP-H74916391842,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ANG 0.045IN 5FR AL1 100CM IMPULSE REF:H74916391962 -,SUP-H74916391962,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER 5FR AL2 IMPULSE REF:H74916391982 -,SUP-H74916391982,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
ANGIO CATH PIG 6F IMPULSE -,SUP-H74916599412,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR AL3 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934356210,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER GUIDING 6FR Mach 1 AL .75 -,SUP-H74934356220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 6FR MACH 1 ML 3.5 REF: H749343565370 -,SUP-H749343565370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.081IN 7FR FL3 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934357050,CDM,C1887,HCPCS,272,RC,,,outpatient,,,306.51,214.557,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.081IN 7FR FL3.5 100CM MACH1 4X2 RND BRD LRG LUM -,SUP-H74934357060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 7FR IM 85CM MACH1 -,SUP-H749343571220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 7FR AL.75 100CM MACH1 REF:H74934357220 -,SUP-H74934357220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.081IN 7FR RCB 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934357240,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.081IN 7FR Q- TY CRV 4 100CM MACH1 4X2 RND BRD -,SUP-H749343572940,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 7FR Q4.5 MACH 1 -,SUP-H749343572950,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.081IN 7FR MP1 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934357380,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUIDE 7FR MP2 REF: H74934357390 -,SUP-H74934357390,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.081IN 7FR FR3.5 SH 100CM MACH1 2X2 RND BRD -,SUP-H74934357470,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.081IN 7FR FL4.5 100CM MACH1 2X2 RND BRD LRG LUM -,SUP-H74934357540,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.081IN 7FR CNTRLAT 3 100CM MACH1 2X2 RND BRD LRG -,SUP-H749343575730,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.081IN 7FR CLS 3.5 100CM MACH1 4X2 RND BRD LRG -,SUP-H749343575740,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.081IN 7FR VL3 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934357710,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.081IN 7FR VL3.5 100CM MACH1 4X2 RND BRD LRG LUM -,SUP-H74934357720,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.081IN 7FR FR4 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934357920,CDM,C1887,HCPCS,272,RC,,,outpatient,,,306.51,214.557,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.091IN 8FR FR3.5 100CM MACH1 2X2 RND BRD SD HOL -,SUP-H74934358010,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.091IN 8FR FR4 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934358020,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.091IN 8FR FL3.5 100CM MACH1 4X2 RND BRD LRG LUM -,SUP-H74934358060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.091IN 8FR FL4.5 100CM MACH1 2X2 RND BRD LRG LUM -,SUP-H74934358080,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID MACH1 8FR AL.75 SH  90CM - H749343581920 -,SUP-H749343581920,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.091IN 8FR LCB 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934358250,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.091IN 8FR FR4 100CM MACH1 4X2 RND BRD LRG LUM SH -,SUP-H74934358480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR FR3.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969010,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR FR4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969020,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR FL3 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969050,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR FL3.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR FL4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969070,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR FL4.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969080,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR FEM HS 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H749389691410,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR AR2 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969180,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR AL1 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969190,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR AL2 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR FRC BYPS 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H74938969240,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR LCB RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969250,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR IMA RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969260,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR FL4 ST RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H74938969290,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR Q3.5 -,SUP-H749389692930,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR Q4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389692940,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR Q4.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389692950,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR MP1 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969380,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR FEM MP 2 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H74938969390,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR HS RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969410,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR IMA 90CM RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389694460,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR RC 4 SC RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389694480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR RC 3.5 SC RUNWAY 2X2 RND BRD LRG LUM -,SUP-H74938969460,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR FR3.5 RUNWAY 2X2 RND BRD LRG LUM SH -,SUP-H74938969470,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR FR4 RUNWAY 2X2 RND BRD LRG LUM SH FEM -,SUP-H74938969480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR ART3 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389694960,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR ART3.5 RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389694980,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR ART3.5 RUNWAY 2X2 RND BRD LRG LUM SH -,SUP-H749389694990,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR ART4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389695000,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR FL 3.5 SH RUNWAY 2X2 RND BRD LRG -,SUP-H74938969520,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR MUTA LT 3 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695360,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR MUTA LT 3.5 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR MUTA LT 4 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695380,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR MUTA LT 4.5 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695390,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR FEM CLS 3 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H749389695730,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR CLS 3.5 RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389695740,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR CLS 4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389695750,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR CLS 3.5 RUNWAY 2X2 RND BRD LRG LUM SH -,SUP-H749389695780,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUIDE RUNWAY 6F CLS4 SH -,SUP-H749389695790,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR KRT HZNT 3H RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389696480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.081IN 7FR VL3.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389696620,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR FEM JL5 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H749389696640,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR FEM AL1 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H74938969680,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR VL3 RUNWAY -,SUP-H74938969710,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR FL BK -UP 4 100CM RUNWAY 2X2 RND BRD -,SUP-H749389697160,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR FR4 ST RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H74938969920,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR MP1 125CM RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389699530,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
MICRO GUIDE CATH MAMBA FLEX 135 REF: H7493928713540 -,SUP-H7493928713540,CDM,C1887,HCPCS,272,RC,,,outpatient,,,5071.58,3550.106,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
STINGRAY LP BALLOON 3.2FR -,SUP-H749393120SR0,CDM,C1887,HCPCS,272,RC,,,outpatient,,,6490.48,4543.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
GUIDE EXTENSION CATHETER GUIDEZILLA II 6F -,SUP-H7493933515060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
GUIDE EXTENSION CATHETER GUIDEZILLA II 6F LONG -,SUP-H74939335150610,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
GUIDE EXTENSION CATHETER GUIDEZILLA II 7F -,SUP-H7493933515070,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
GUIDE EXTENSION CATHETER GUIDEZILLA II 8F -,SUP-H7493933515080,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH PTCA 135CM CROSSBOSS STINGRAY F/COR CTO -,SUP-H749M1000A0,CDM,C1887,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ANG 4FR STR 65CM RADIFOCUS GLIDECATH DBL BRD SM-PRFL -,SUP-H787117140155,CDM,C1887,HCPCS,272,RC,,,outpatient,,,388.61,272.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
4FR GLIDECATH LONG 100CM STRAIGHT -,SUP-H787117140225,CDM,C1887,HCPCS,272,RC,,,outpatient,,,295.54,206.878,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ANG 5FR ANG TAPR 65CM RADIFOCUS GLIDECATH SGL-BRD LRG -,SUP-H787117221045,CDM,C1887,HCPCS,272,RC,,,outpatient,,,388.61,272.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ANG 5FR STR TAPR 65CM RADIFOCUS GLIDECATH SGL-BRD LRG -,SUP-H787117315025,CDM,C1887,HCPCS,272,RC,,,outpatient,,,388.61,272.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ANG 4FR JB3 TIP 100CM TORCONNB ADVANTG BEACN BRD PERIPH -,SUP-HNBR4.0-35-100-P-NS-JB3,CDM,C1887,HCPCS,272,RC,,,outpatient,,,227.57,159.299,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.071IN 5FR EBU3.5 100CM LAUNCHR BRD LRG LUM DIST -,SUP-LA5EBU35,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 6FR 3D RIGHT LAUNCHR REF: LA63DRIGHT -,SUP-LA63DRIGHT,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.071IN 6FR AL1 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6AL10,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 6FR AL75 100CM LAUNCHR REF: LA6AL75 -,SUP-LA6AL75,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.071IN 6FR AR1 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6AR10,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.071IN 6FR BU LT EBU 3 100CM LAUNCHR BRD LRG LUM -,SUP-LA6EBU30,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.071IN 6FR BU LT EBU 3.5 100CM LAUNCHR BRD LRG -,SUP-LA6EBU35,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.071IN 6FR BU LT EBU 3.75 100CM LAUNCHR BRD LRG -,SUP-LA6EBU375,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.071IN 6FR BU LT EBU 4 100CM LAUNCHR BRD LRG LUM -,SUP-LA6EBU40,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.071IN 6FR EBU 4.5 100CM LAUNCHR -,SUP-LA6EBU45,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.071IN 6FR BYPS IMA 90CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6IMAD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.071IN 6FR STD JR4 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6JR40,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 7FR 3D RIGHT LAUNCHR REF: LA73DRIGHT -,SUP-LA73DRIGHT,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUIDE 7 FR AL.75 SH D REF: LA7AL75SHD -,SUP-LA7AL75SHD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.081IN 7FR COR EBU3.5 100CM LAUNCHR BRD LRG LUM -,SUP-LA7EBU35,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.081IN 7FR COR EBU4 100CM LAUNCHR BRD LRG LUM -,SUP-LA7EBU40,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.081IN 7FR EBU4.5 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA7EBU45,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 7FR JR4 90CM LAUNCHR -,SUP-LA7JR40D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,256.74,179.718,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
GUIDE 8F AL 1.0 SH 90CM -,SUP-LA8AL10D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
GUIDE 8F AL 2.0 90CM MICR CATH -,SUP-LA8AL20D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
GUIDE 8F AL .75 90CM CATH -,SUP-LA8AL75D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
GUIDE 8F EBU 3.5 90CM -,SUP-LA8EBU35D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
GUIDE 8F EBU 3.5 SH 90CM -,SUP-LA8EBU35D SHD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
GUIDE 8F EBU 4.0 90CM -,SUP-LA8EBU40D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
GUIDE 8F JL 4.0 90CM -,SUP-LA8JL40D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
GUIDE 8F JL 4.0 SH 90CM -,SUP-LA8JL40D SHD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 105CM 20CM -,SUP-M001181250,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2497.81,1748.467,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D C 1 130CM 20CM -,SUP-M001181310,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2497.81,1748.467,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 150CM 20CM STC-18 -,SUP-M001181370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2497.81,1748.467,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 130CM 20CM -,SUP-M001182520,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1981.8,1387.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 150CM 20CM -,SUP-M001182530,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2297.77,1608.439,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
C RENEGADE HI-FLO MICROCATH -,SUP-M001183030,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2589.9,1812.93,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
MICROCATH INTVN 0.021IN SWAN 130CM DIREXION HI-FLO -,SUP-M001195300,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3221.16,2254.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH MICRO DREXION HI FLO J TO -,SUP-M001195470,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2566.03,1796.221,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.081IN 7FR LIMA 55CM MACH1 4X2 RND BRD LRG LUM -,SUP-M001197620,CDM,C1887,HCPCS,272,RC,,,outpatient,,,560.22,392.154,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.091IN 8FR LIMA 55CM MACH1 RND BRD LRG LUM PERIPH -,SUP-M001198620,CDM,C1887,HCPCS,272,RC,,,outpatient,,,560.22,392.154,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ANG 4FR PIGTL 65CM IMAGER II SLCT FLSH BRD TRQ TUNG -,SUP-M001315091,CDM,C1887,HCPCS,272,RC,,,outpatient,,,58.24,40.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ANG 4FR PIGTL 90CM IMAGER II FLSH BRD TRQ MED-GLD CTD -,SUP-M001315111,CDM,C1887,HCPCS,272,RC,,,outpatient,,,58.24,40.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ANG 4FR CNTRLAT 2 CRV 65CM IMAGER II SLCT BRD TRQ SDE -,SUP-M001316581,CDM,C1887,HCPCS,272,RC,,,outpatient,,,58.24,40.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
MICRO GUIDE CATH FINECROSS M3 2.5 Fr 130 CM REF: M3-1430 -,SUP-M3-1430,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
MICRO GUIDE CATH FINECROSS M3 2.5 Fr 150 CM REF: M3-1450 -,SUP-M3-1450,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
PROGREAT 2.0 70 DEGREE ANGLE  150CM -,SUP-MC*PC2015ZRA,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3652.11,2556.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
PROGREAT COAXIAL MICROCATHETER2.4 FR  150CM   DEGREE ANGLE -,SUP-MC*PE24151YV,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2673.44,1871.408,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
PROGREAT COAXIAL 2.8 FR  150CM   RO MARKER BAND -,SUP-MC*PE28151YV,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2673.44,1871.408,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
PROGREAT 2.4  70 DEGREE ANGLE  150CM -,SUP-MC*PV2415ZRA,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2061.89,1443.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
PROGREAT MICROCATHETER 2.4x150CM -,SUP-MCPV2415Y,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1749.17,1224.419,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER NAVICROSS 018 65CM ANGLED STAINLESS STEEL -,SUP-NC18651,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER NAVICROSS 018 90CM ANGLED STAINLESS STEEL -,SUP-NC18901,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
C NAVICROSS 135CM .035 STR T -,SUP-NC35130,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
C NAVICROSS 135CM .035 ANGLE -,SUP-NC35131,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH INTVN 12MM TIP STR TAPR 150CM NAVICROSS SUPP DBL BRD -,SUP-NC35150,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER SUPPORT NAVICROSS 0.035 150CM ANGLED -,SUP-NC35151,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
SHEATH GUID 6FRX90CM PINNACLE -,SUP-RSC03,CDM,C1887,HCPCS,272,RC,,,outpatient,,,743.96,520.772,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
SHEATH GUID 6FRX90CM PINNCL DSTNTN VASC STR CRV GOLD COIL. -,SUP-RSC05,CDM,C1887,HCPCS,272,RC,,,outpatient,,,743.96,520.772,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
SHEATH GUID 6FRX90CM PINNCL DSTNTN VASC MP CRV GOLD COIL -,SUP-RSC07,CDM,C1887,HCPCS,272,RC,,,outpatient,,,743.96,520.772,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
SHEATH GUID 6FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL- -,SUP-RSR01,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
SHEATH GUID 7FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-RSR04,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
SHEATH GUID 7FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-RSR04,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
TIP GUIDE CATH RELIEVA SPIN SPND SIN S-0 SHP TIP BLN WND ORT -,SUP-RSS0,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1696.16,1187.312,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX TAPR 65CM TRAILBLAZER SUPP HYDRCT -,SUP-SC035065,CDM,C1887,HCPCS,272,RC,,,outpatient,,,816.9,571.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER GUIDING 6FR X 125 JL 5 JUDKINS -,SUP-SM7361,CDM,C1887,HCPCS,272,RC,,,outpatient,,,882.25,617.575,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
SHEATH 6.5 FR X 55CM X 17MM -,SUP-TG0655517,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH SHEATH RITESITE C315H20 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH SHEATH RITESITE C315H4001 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH SHEATH RITESITE C315J -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH SHEATH RITESITE C315S1001 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH SHEATH RITESITE C315S4 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH SHEATH RITESITE C315S401 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH SHEATH RITESITE C315S501 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH SHEATH RITESITE C315G -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH SHEATH RITESITE C315H40 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH SHEATH RITESITE C315J01 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH SHEATH RITESITE C315S10 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH SHEATH RITESITE C315S5 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH SHEATH RITESITE C315H2001 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
COIL MICRO RENEGADE STR FIBER -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2297.77,1608.439,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH OCL 0.97MM 6FR SHTH 110CM WILDCAT FLSH OTW 2MM XING -,SUP-W400,CDM,C1887,HCPCS,272,RC,,,outpatient,,,6769.18,4738.426,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH OCL 0.43MM 5FR SHTH 150CM KITTYCAT 2 OTW 1.7MM XING -,SUP-W550,CDM,C1887,HCPCS,272,RC,,,outpatient,,,6769.18,4738.426,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.22704,7607.37,other,OPPS APC,,
TUBE PEG 20FR PONSKY NBR NON BALLOON REPLACEMENT -,SUP-000700,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1250.92,875.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
TUBE JJUNO 16FRX108IN PVC/PLST 15ML BLN LUMX2 -,SUP-0042510,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1602.34,1121.638,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
TUBE GASTROSTOMY 14 FR -,SUP-0100-14LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
TUBE GASTROSTOMY FEEDING 16 FR -,SUP-010016LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,220.33,154.231,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
TUBE GASTROSTOMY 16FR -,SUP-0100-16LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
TUBE GASTROSTOMY FEEDING 18FR -,SUP-0100-18,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
MIC GASTROSTOMY TUBE 20 FR -,SUP-0100-20,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
TUBE GASTROSTOMY FEEDING 20 FR -,SUP-0100-20,CDM,C1889,HCPCS,278,RC,,,outpatient,,,45.16,31.612,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
TUBE GASTROSTOMY FEEDING 22 FR -,SUP-0100-22,CDM,C1889,HCPCS,278,RC,,,outpatient,,,225.87,158.109,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
MIC GASTROSTOMY TUBE 24 FR -,SUP-0100-24,CDM,C1889,HCPCS,278,RC,,,outpatient,,,43.52,30.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
TUBE GASTROSTOMY 26 FR -,SUP-0100-26,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
TUBE JJUNO 12FR SIL MI C SECUR-LOK XTRN RETEN RNG -,SUP-0200-12LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
TUBE JJUNO 14FR SIL 7-10ML BLN MI C SECUR-LOK XTRN RETEN RNG -,SUP-0200-14,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
TUBE FEEDING JEJUNAL 16F -,SUP-0200-16,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
TUBE JJUNO 18FR SIL 7-10ML BLN MIC-KEY SECUR-LOK XTRN RETEN -,SUP-0200-18,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
TUBE JEJUNOSTOMY 22FR MIC SECUR-LOK SILICONE -,SUP-0200-22,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
TUBE JJUNO 22FRX45CM SIL 7-10ML BLN MIC-KEY LPRO -,SUP-0250-22,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1221.18,854.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
TUBE MIC JEJUNOSTOMY 14FR / DR. GLEESON -,SUP-0301-14,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1113.49,779.443,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
TUBE NG 6FR SALEM SMP 60CM VYGON -,SUP-1340.06,CDM,C1889,HCPCS,278,RC,,,outpatient,,,79.12,55.384,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
CONNECTOR CATHETER NYLON STRAIGHT 1.5 X 1.0 X 1.9 -,SUP-45103,CDM,C1889,HCPCS,278,RC,,,outpatient,,,481.1,336.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
CONNECTOR CSF CATH STRAIGHT 3 WAY IMP 2 X 1.5 X 1.8 X 1.0 -,SUP-45105,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1359.53,951.671,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
AZUR 18D SYSTEM 4MM X 5CM -,SUP-45-480405,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3570.95,2499.665,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
AZUR CX 35D 4MM X 7C3 DETACHABLE -,SUP-45-750407,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
AZUR CX .035 5MM X 11CM DETACH -,SUP-45-750511,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
AZUR CX DETACH 035 6MMX17CM -,SUP-45-750617,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
AZUR CK DETACHABLE 035 8MM X 12CM -,SUP-45-750812,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
AZUR CX DETACH 035 8MMX24CM -,SUP-45-750824,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
AZUR CX DETACH 035 10MMX19CM -,SUP-45-751019,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
AZUR CX 35 DETACH 13MMX24CM CX COIL -,SUP-45-751324,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
AZUR CX 35D 16MM X 32 CM -,SUP-45-751632,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
AZUR CX 35D 20MM X 39 CM -,SUP-45-752039,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
AZUR CX DETACHABLE 018 6MM X 20CM -,SUP-45-780620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
AZUR CX DETACHABLE 018 7MM X 24CM -,SUP-45-780724,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
AZUR CX DETACHABLE 018 8MM X 28CM -,SUP-45-780828,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBOLIZATION POD 0.020IN 4MM 30CM FULLY DETACHABLE RESH -,SUP-90178538,CDM,C1889,HCPCS,278,RC,,,outpatient,,,8190.92,5733.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
KIT INTRO GASTROSTOMY FEED -,SUP-98432,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1149.84,804.888,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
SENTINEL CEREBRAL PROTECTION SYSTEM REF: CMS15-10C-US -,SUP-CMS15-10C-US,CDM,C1889,HCPCS,278,RC,,,outpatient,,,14852,10396.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBOLIZATION NESTER MICROCOIL PLATINUM L3 CM OD2 MM . -,SUP-G47331,CDM,C1889,HCPCS,278,RC,,,outpatient,,,577.61,404.327,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
14X14 NESTER COIL 0.035 -,SUP-G47347,CDM,C1889,HCPCS,278,RC,,,outpatient,,,705.98,494.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
CATH COOK AIRWAY EXCHANGE 14FR 83CM. -,SUP-G57622,CDM,C1889,HCPCS,278,RC,,,outpatient,,,374.02,261.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
SPACER BONE CERVICAL LOR 6MM -,SUP-LGAL906,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
SPACER BONE CERVICAL LOR 7MM -,SUP-LGAL907,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
SPACER BONE CERVICAL LOR 8MM -,SUP-LGAL908,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
SPACER BONE CERVICAL PAR 6MM -,SUP-LGAP906-P,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
SPACER BONE CERVICAL PAR 7MM -,SUP-LGAP907-P,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
SPACER BONE CERVICAL PAR 8MM -,SUP-LGAP908-P,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
CATHETER DELIVERY AVEIR REF:LSCD111 -,SUP-LSCD111,CDM,C1889,HCPCS,278,RC,,,outpatient,,,7427,5198.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
BASKET SPECIMEN RETRIEVAL ZERO TIP 0.8MM 12MM ENDOSCOPIC -,SUP-M00513200,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1398.8,979.16,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
PROBE BILIARY EHL -,SUP-M00546620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2273.91,1591.737,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
TUBE PEG 16FR ENDOVIVE LPRO PUL LF -,SUP-M00582060,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
TUBE PEG 18FR ENDOVIVE LPRO PUL LF -,SUP-M00582070,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
KIT BALLOON REPLACEMENT STRAIGHT BOLSTER 20FR -,SUP-M00582080,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
KT TUBE PEG 24FR ENDOVIVE LPRO PUL LF -,SUP-M00582090,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
KIT BALLOON REPLACEMENT RIGHT ANGLE BOLSTER 20FR -,SUP-M00582150,CDM,C1889,HCPCS,278,RC,,,outpatient,,,192.44,134.708,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
TUBE PEG 24FR 3ML BLN SIL ENDOVIVE RT ANG LF -,SUP-M00582160,CDM,C1889,HCPCS,278,RC,,,outpatient,,,192.44,134.708,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
WATCHMAN FXD CURVE ACCESS SYSTEM SGL US REF: M635TU80010 -,SUP-M635TU80010,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
WATCHMAN FXD CURVE ACCESS SYSTEM DBL US REF: M635TU80020 -,SUP-M635TU80020,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
TUBE PEG 14FR 5ML BALLON TRITON LTX -,SUP-PEG-14-BRT-TR1,CDM,C1889,HCPCS,278,RC,,,outpatient,,,233.4,163.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 3MMX5CM RUBY MICRO CMPLX STD FRM FLLY DTCH RSHEATH -,SUP-RBY2C0305,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 3MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0320,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4769.23,3338.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 4MMX10CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0410,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 4MMX15CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0415,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 4MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0420,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 4MMX35CM RUBY CMPLX STD FRM FLLY DTCH RSHEATH -,SUP-RBY2C0435,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 5MMX12CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0512,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 5MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0520,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 5MMX30CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0530,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 6MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4769.23,3338.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 6MMX30CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0630,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 7MMX25CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0725,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 8MMX25CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0825,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 8MMX40CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0840,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 9MMX30CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0930,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 10MMX35CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1035,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 12MMX40CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1240,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 12MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1260,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 14MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1460,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 16MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1660,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 18MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1857,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 20MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C2060,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 24MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C2457,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 28MMX60CM RUBY MICRO CMPLX STD FRM FLLY -,SUP-RBY2C2860,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 32MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C3260,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
RUBYCOIL 36MM X 60MM STANDARD -,SUP-RBY2C3660,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
RUBYCOIL 40MM X 60MM STANDARD -,SUP-RBY2C4060,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 2MMX4CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH PLTNM -,SUP-RBY4C0204,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3814.43,2670.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 3MMX5CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH PLTNM -,SUP-RBY4C0305,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 3MMX15CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0315,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 4MMX6CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH PLTNM -,SUP-RBY4C0406,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 4MMX15CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0415,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 6MMX20CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 6MMX30CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0630,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 8MMX35CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0835,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 8MMX60CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0860,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 16MMX50CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C1650,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
RUBY COIL LP- 1 MM x 5 CM PERIPHERAL EMBOLIZATION COILS -,SUP-RBYLP0105,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
RUBY COIL LP- 2 MM x 10 CM PERIPHERAL EMBOLIZATION COILS -,SUP-RBYLP0210,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
RUBY COIL LP- 3 MM x 4 CM PERIPHERAL EMBOLIZATION COILS -,SUP-RBYLP0304,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
PENUMBRA RUBY POD 6MM X 50CM -,SUP-RBYPOD6,CDM,C1889,HCPCS,278,RC,,,outpatient,,,8190.92,5733.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
SPACE OAR VUE HYDROGEL -,SUP-SV-2101,CDM,C1889,HCPCS,278,RC,,,outpatient,,,12791.29,8953.903,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.77024,11406.336,other,OPPS APC,,
INTRO SHTH 6FRX14CM J SHP TIP 12ML SYR DI-LOK DILATOR 18GA -,SUP-405104,CDM,C1892,HCPCS,272,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.121935,3080.6622,other,OPPS APC,,
INTRO SHTH 7FRX14CM 0.038INX50CM JTP GW 18GA XTW NDL 12ML -,SUP-405108,CDM,C1892,HCPCS,272,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.121935,3080.6622,other,OPPS APC,,
KT 12FR 18GAX14CM 0.38INX50CM GW CV 3MM JTP PEEL-AWAY -,SUP-405120,CDM,C1892,HCPCS,272,RC,,,outpatient,,,186.72,130.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.121935,3080.6622,other,OPPS APC,,
INTRO SHTH 10.5FRX14CM 0.038INX50CM JTP GW 18GA XTW NDL 12ML -,SUP-405122,CDM,C1892,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.121935,3080.6622,other,OPPS APC,,
INTRO SHTH 8T-TW FR DIA 14CM 0.038INX50CM JTP GW 18GA XTW -,SUP-405129,CDM,C1892,HCPCS,272,RC,,,outpatient,,,245.07,171.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.121935,3080.6622,other,OPPS APC,,
INTRO SHTH 8FRX14CM J SHP TIP 12ML SYR DI-LOK DILATOR 18GA -,SUP-405145,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.121935,3080.6622,other,OPPS APC,,
INTRO LD 9FR PEEL-AWAY SHTH SGL-CHMBR -,SUP-405147,CDM,C1892,HCPCS,272,RC,,,outpatient,,,320.93,224.651,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.121935,3080.6622,other,OPPS APC,,
INTRO SHTH 8FRX14CM 0.038IN GW DI- LOCK DILATOR -,SUP-405412,CDM,C1892,HCPCS,272,RC,,,outpatient,,,90.56,63.392,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.121935,3080.6622,other,OPPS APC,,
INTRO SHTH 9FRX14CM 0.038IN GW DI- LOCK DILATOR -,SUP-405416,CDM,C1892,HCPCS,272,RC,,,outpatient,,,89.63,62.741,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.121935,3080.6622,other,OPPS APC,,
TRANSDC TRANSTHORACIC BTRY PK VIEWMATE -,SUP-405422,CDM,C1892,HCPCS,272,RC,,,outpatient,,,175.05,122.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.121935,3080.6622,other,OPPS APC,,
INTRO SHTH 11FRX14CM 0.038INX50CM JTP GW 18GA XTW NDL 12ML -,SUP-405424,CDM,C1892,HCPCS,272,RC,,,outpatient,,,175.05,122.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.121935,3080.6622,other,OPPS APC,,
INTRO VASC 8FR SUPER SHTH INFS SDPRT -,SUP-CLS-1008,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.121935,3080.6622,other,OPPS APC,,
INTRO VASC 8.5FR SUPER SHTH INFS SDPRT -,SUP-CLS-1008.5,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.121935,3080.6622,other,OPPS APC,,
INTRO VASC 10.5FR SUPER SHTH INFS SDPRT -,SUP-CLS-1010.5,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.121935,3080.6622,other,OPPS APC,,
INTRO VASC 8FR LNG SUPER SHTH INFS SDPRT -,SUP-CLS-2508,CDM,C1892,HCPCS,272,RC,,,outpatient,,,301.67,211.169,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.121935,3080.6622,other,OPPS APC,,
CPS DIRECT MEDI GUIDE ENABLED OUT CATH  RIGHT -,SUP-DS2M044,CDM,C1892,HCPCS,272,RC,,,outpatient,,,4296.6,3007.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.121935,3080.6622,other,OPPS APC,,
SET INTRODUCER PEEL-AWAY SAFE-T-J -,SUP-G04496,CDM,C1892,HCPCS,272,RC,,,outpatient,,,397.66,278.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.121935,3080.6622,other,OPPS APC,,
SHEATH SAFE PRELUDE 6F 13CM LN -,SUP-PLS-1006,CDM,C1892,HCPCS,272,RC,,,outpatient,,,274.25,191.975,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.121935,3080.6622,other,OPPS APC,,
INTRODUCER MERIT PRELUDE 9F 25CM -,SUP-PLS-2509,CDM,C1892,HCPCS,272,RC,,,outpatient,,,301.67,211.169,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.121935,3080.6622,other,OPPS APC,,
INTRODUCER 9FR OPTISEAL -,SUP-UNDEFINED,CDM,C1892,HCPCS,272,RC,,,outpatient,,,379.28,265.496,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,20.121935,3080.6622,other,OPPS APC,,
CATH GUID 7FR COR -,SUP-358735,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2448.83,1714.181,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,165.054645,2224.9227,other,OPPS APC,,
INTRO  SL1  CURVE - SJM 8.5FRX 63CM -,SUP-406849,CDM,C1893,HCPCS,272,RC,,,outpatient,,,892.76,624.932,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,165.054645,2224.9227,other,OPPS APC,,
INTRO GUID 8.5FRX60CM FAST-CATH SWARTZ TRNSEPT SAFL CRV -,SUP-406868,CDM,C1893,HCPCS,272,RC,,,outpatient,,,898.59,629.013,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,165.054645,2224.9227,other,OPPS APC,,
INTRO GUID 8FRX60CM FAST-CATH SWARTZ TRNSEPT SAFL CRV -,SUP-406871,CDM,C1893,HCPCS,272,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,165.054645,2224.9227,other,OPPS APC,,
INTRO GUID 8FRX60CM FAST-CATH SWARTZ TRNSEPT SEPT CRV -,SUP-406885,CDM,C1893,HCPCS,272,RC,,,outpatient,,,904.43,633.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,165.054645,2224.9227,other,OPPS APC,,
INTRO SEPT CURVE-SJM  8.5FRX60CM -,SUP-406894,CDM,C1893,HCPCS,272,RC,,,outpatient,,,898.59,629.013,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,165.054645,2224.9227,other,OPPS APC,,
INTRO  RAMP  CURVE - SJM 8.5FRX 63CM -,SUP-406965,CDM,C1893,HCPCS,272,RC,,,outpatient,,,735.21,514.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,165.054645,2224.9227,other,OPPS APC,,
SHEATH GUIDE LAMP 45 407363 -,SUP-407363,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1015.29,710.703,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,165.054645,2224.9227,other,OPPS APC,,
INTRODUCER CATHETER BRITE TIP RADIANZ GUIDING 6FR 110CM -,SUP-687280110,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1363.55,954.485,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,165.054645,2224.9227,other,OPPS APC,,
INTRODUCER CATHETER BRITE TIP RADIANZ GUIDING 6FR 135CM -,SUP-687280135,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1363.55,954.485,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,165.054645,2224.9227,other,OPPS APC,,
TRANSSEPTAL ACCESS STYSTEM ACQCROSS QX AG 71 CM REF: 900301 -,SUP-900301,CDM,C1893,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,165.054645,2224.9227,other,OPPS APC,,
TRANSSEPTAL ACCESS STYSTEM ACQCROSS QX - FC 65CM REF: 900304 -,SUP-900304,CDM,C1893,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,165.054645,2224.9227,other,OPPS APC,,
TRANSSEPTAL ACCESS STYSTEM ACQCROSS  WT 75CM REF: 900308 -,SUP-900308,CDM,C1893,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,165.054645,2224.9227,other,OPPS APC,,
FLEXCATH CROSS FCC 65CM 10FR REF:900310 -,SUP-900310,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,165.054645,2224.9227,other,OPPS APC,,
FLEXCATH CROSS FCC 65CM 12FR REF:900311 -,SUP-900311,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,165.054645,2224.9227,other,OPPS APC,,
CATHETER CPS LOCATOR 3D- LAGE EXTRA LONG REF:DS2C300-45 -,SUP-DS2C300-45,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,165.054645,2224.9227,other,OPPS APC,,
SHEATH GUID WORLEY RNL TLSCP GUIDE -,SUP-LVI7556207RE,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2464.73,1725.311,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,165.054645,2224.9227,other,OPPS APC,,
TORFLEX TRANSSEPTAL GUIDING SH -,SUP-TF85-32-63-45,CDM,C1893,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,165.054645,2224.9227,other,OPPS APC,,
DILATOR VESSEL 5 FR 35 -,SUP-040037A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,23.34,16.338,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
MICINTRO VASC 4.5FRX50CM MICRO EZ FNL DSGN SMTH DILATOR PTFE -,SUP-0928945,CDM,C1894,HCPCS,272,RC,,,outpatient,,,205.74,144.018,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
MICINTRO VASC 5FRX50CM MICRO EZ FNL DSGN SMTH DILATOR PTFE -,SUP-0928950,CDM,C1894,HCPCS,272,RC,,,outpatient,,,213.56,149.492,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
MICINTRO VASC 6FRX50CM MICRO EZ SMTH DILATOR PTFE 7CM A BVL -,SUP-0928960,CDM,C1894,HCPCS,272,RC,,,outpatient,,,189.64,132.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH INTRO 6FRX10CM PINNCL TIF TIP PERIPH 0.038INX45CM SS -,SUP-10-2032,CDM,C1894,HCPCS,272,RC,,,outpatient,,,72.94,51.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO INFS 7FR PEEL-AWAY -,SUP-120089,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.83,253.281,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH INTRO 5FRX10CM GLIDESHEATH RADL STR GOLD COIL MRKR -,SUP-20 -1050,CDM,C1894,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH INTRO 6FRX10CM GLIDESHEATH RADL STR GOLD COIL MRKR -,SUP-20 -1060,CDM,C1894,HCPCS,272,RC,,,outpatient,,,338.43,236.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
S COOK 7FR X 6CM -,SUP-242381,CDM,C1894,HCPCS,272,RC,,,outpatient,,,170.73,119.511,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH INTRO 5FRX10CM GLIDESHEATH RADL STR CRV GOLD COIL -,SUP-30-1050,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.48,364.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH INTRO 6FRX10CM GLIDESHEATH RADL STR CRV GOLD COIL -,SUP-30-1060,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.48,364.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH INTRO 6FRX10CM GLIDESHEATH RADL  STR CRV GOLD COIL -,SUP-30-1065,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.48,364.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 0.110IN 8FRX62CM PREFACE MP ST TAPR PRFL -,SUP-301803MS,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO CATH 4FRX3.2CM INTRSYT-N PERC SHLD -,SUP-384011,CDM,C1894,HCPCS,272,RC,,,outpatient,,,234.57,164.199,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO CATH 1.9FRX1.9CM INTRSYT-N PERC SHLD -,SUP-384021,CDM,C1894,HCPCS,272,RC,,,outpatient,,,280.08,196.056,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
FORTRESS SHEALTH 5FRx45CM -,SUP-386591,CDM,C1894,HCPCS,272,RC,,,outpatient,,,102.7,71.89,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
FORTRESS SHEATH 5FR x 45CM -,SUP-386591,CDM,C1894,HCPCS,272,RC,,,outpatient,,,102.7,71.89,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 10FRX11CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-011M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
S BRITE TIP 10FR 11CM  RB -,SUP-401-011M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH BRITE TIP 4F 11CM -,SUP-401411M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 5FR 11CM BRITE TIP -,SUP-401511M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 5FR BRITE TIP 23CM -,SUP-401-523M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 5FRX55CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-555M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 6FRX5.5CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401605M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 6FRX5.5CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-605M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 6FR 11CM BRITE TIP -,SUP-401-611M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 6FRX5.5CM X 23CM CANN BRT TIP PERC TAPR SMTH -,SUP-401-623M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 6F 23CM BRITE TIP -,SUP-401-623M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 6FRX55CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-655M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 7 FR 11CM BRITE TIP -,SUP-401-711M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 7FR X 23CM BRITE TIP -,SUP-401-723M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 7FRX45CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-745M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 8FR 11CM BRITE TIP -,SUP-401-811M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
S BRITE TIP 8FR 23CM RB -,SUP-401-823M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 8FRX45CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-845M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
S BRITE TIP 9FR X 11CM RB -,SUP-401-911M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHTH INTRO 11FR X 11CM CANN BRT -,SUP-402611X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,43.18,30.226,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 6FR STD L 11CM REF: 402656X -,SUP-402656X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,43.18,30.226,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 2MM ANCURE -,SUP-40320,CDM,C1894,HCPCS,272,RC,,,outpatient,,,962.78,673.946,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
HEMOSTASIS INTRODUCER FAST CATH 10FRX30CM REF: 406180 -,SUP-406180,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.77,253.239,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
HEMOSTASIS INTRODUCER FAST CATH 14FRX30CM REF: 406188 -,SUP-406188,CDM,C1894,HCPCS,272,RC,,,outpatient,,,385.11,269.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
FAST CATH DUO SHEATH 12F  12CM -,SUP-406301,CDM,C1894,HCPCS,272,RC,,,outpatient,,,140.04,98.028,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 7FRX12CM FAST-CATH CATH-LOCK PERC JTP STR SNP -,SUP-406702,CDM,C1894,HCPCS,272,RC,,,outpatient,,,62.26,43.582,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 8FRX12CM FAST-CATH CATH-LOCK PERC JTP STR SNP -,SUP-406706,CDM,C1894,HCPCS,272,RC,,,outpatient,,,105.03,73.521,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 4FRX12CM FAST-CATH CATH-LOCK PERC JTP STR SNP -,SUP-406709,CDM,C1894,HCPCS,272,RC,,,outpatient,,,105.03,73.521,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 8FRX60CM FAST-CATH TRNSEPT MLNS CRV SNP LOCK -,SUP-406805,CDM,C1894,HCPCS,272,RC,,,outpatient,,,501.81,351.267,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SR0 CURVE-SJM -,SUP-406853,CDM,C1894,HCPCS,272,RC,,,outpatient,,,898.59,629.013,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH AGILIS MED-REPROC  8.5X 71CM -,SUP-408310,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2473.84,1731.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 4FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-604X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 6FR MI D L 23CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-606D,CDM,C1894,HCPCS,272,RC,,,outpatient,,,93.36,65.352,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 7FR MI D L 23CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-607T,CDM,C1894,HCPCS,272,RC,,,outpatient,,,93.36,65.352,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH INTRODUCER AVANTI 7FR X 11 CM -,SUP-504-607X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 8FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-608X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 9FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-609X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 10FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504610X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 11FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-611X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 5MS FR DIA MI D L 23CM CANN AVANTI + PERC TAPR SS -,SUP-504-655T,CDM,C1894,HCPCS,272,RC,,,outpatient,,,103.57,72.499,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 5MS DIA STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-655X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 5MS DIA STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-655X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 6MS FR DIA MI D L 23CM CANN AVANTI + PERC TAPR SS -,SUP-504-656T,CDM,C1894,HCPCS,272,RC,,,outpatient,,,93.36,65.352,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 6FR STD L 11CM CANN AVANTI  PERC TAPR SS W/O -,SUP-504-656X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 6FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-656X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
MONITORING SHEATH 7 FR INTRO -,SUP-504-657X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 8MS DIA STD L 11CM CANN AVANTI PERC TAPR SS W/O -,SUP-504-658X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
TIGHTRAIL MINI 11FR 545-011 -,SUP-540-011,CDM,C1894,HCPCS,272,RC,,,outpatient,,,7193.58,5035.506,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
TIGHTRAIL MINI  9FR 545-009 -,SUP-545-009,CDM,C1894,HCPCS,272,RC,,,outpatient,,,7193.58,5035.506,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
TIGHTRAIL LONG  9FR 545-509 -,SUP-545-509,CDM,C1894,HCPCS,272,RC,,,outpatient,,,10121.94,7085.358,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
TIGHTRAIL LONG 11FR 545-511 -,SUP-545-511,CDM,C1894,HCPCS,272,RC,,,outpatient,,,10121.94,7085.358,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
TIGHTRAIL LONG 13FR 545-513 -,SUP-545-513,CDM,C1894,HCPCS,272,RC,,,outpatient,,,10121.94,7085.358,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 8FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-54-84501,CDM,C1894,HCPCS,272,RC,,,outpatient,,,609.76,426.832,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
GLIDESHEATH SLENDER 6FR X 10CM X .021CM SS GLIDEWIRE -,SUP-60-1060,CDM,C1894,HCPCS,272,RC,,,outpatient,,,353.02,247.114,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
GLIDESHEATH SLENDER A KIT 0.025 GW 6FR 10CM -,SUP-60-1065,CDM,C1894,HCPCS,272,RC,,,outpatient,,,619.97,433.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
GLIDESHEATH SLENDER A KIT 0.025 GW 7FR 10CM -,SUP-60-1075,CDM,C1894,HCPCS,272,RC,,,outpatient,,,619.97,433.979,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 7FRX11CM INPUT PS PERC 0.038IN GW COMP VES -,SUP-700-11,CDM,C1894,HCPCS,272,RC,,,outpatient,,,56.02,39.214,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRODUCER SET 11 FR - DISCONTINUED DO NOT USE -,SUP-7097,CDM,C1894,HCPCS,272,RC,,,outpatient,,,320.93,224.651,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
GLIDESHEATH SLENDER SS KIT 0.025 GW 6FR 10CM -,SUP-80-1065,CDM,C1894,HCPCS,272,RC,,,outpatient,,,353.02,247.114,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
GLIDESHEATH SLENDER SS KIT 0.025 GW 7FR 10CM -,SUP-80-1075,CDM,C1894,HCPCS,272,RC,,,outpatient,,,353.02,247.114,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
AMPLATZER DELIVERY SHEATH TORQVUE 2 5FR REF: 9-TV2-05F120 -,SUP-90176109,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
AMPLATZER DELIVERY SHEATH TORQVUE 2 6FR REF: 9-TV2-06F120 -,SUP-9-TV2-06F120,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
TORQVUE SHEATH 14F 80CM 45X45 REF: 9-TV45X45-14F-080 -,SUP-9-TV45X45-14F-080,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4676.89,3273.823,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
OBTURATOR VASC 8FR SHRT -,SUP-AO-09000,CDM,C1894,HCPCS,272,RC,,,outpatient,,,13.65,9.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
CATH PA 7FR X 110CM SWAN-GNZ LUMX4 PLYMR BLND -,SUP-C146F7,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2531.31,1771.917,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRODUCER SHEATH 8.5FR CATH-GARD PERC ARROW KIT -,SUP-CDC-09803-1A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,430.62,301.434,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
9FR. PERC SHEATH INTRO KIT -,SUP-CDC-09903-1A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,418.37,292.859,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 10FRX35CM SUPER ARROW-FLEX PERC SNP-LOCK MIN -,SUP-CL-07035,CDM,C1894,HCPCS,272,RC,,,outpatient,,,547.82,383.474,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 5FR SHTH 4.375IN SHTH 0.035-0.038IN GW HEMSTS VLV -,SUP-CL-07511,CDM,C1894,HCPCS,272,RC,,,outpatient,,,182.55,127.785,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 6FRX24CM SUPER ARROW-FLEX PERC 0.038IN GW COMP -,SUP-CL-07624,CDM,C1894,HCPCS,272,RC,,,outpatient,,,431.79,302.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 6FRX45CM SUPER ARROW-FLEX PERC ANTMIC SURF PU -,SUP-CL-07645,CDM,C1894,HCPCS,272,RC,,,outpatient,,,553.38,387.366,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 7FRX24CM SUPER ARROW-FLEX PERC INTGR HEMSTS -,SUP-CL-07724,CDM,C1894,HCPCS,272,RC,,,outpatient,,,379.08,265.356,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 7FRX45CM SUPER ARROW-FLEX PERC ANTMIC SURF PU -,SUP-CL-07745,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.82,364.574,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH CLASSICSHEATH 6FR STD 13CM CRV GRN CAP -,SUP-CLS-1006,CDM,C1894,HCPCS,272,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO VASC 7FR SAFESHEATH INFS SDPRT -,SUP-CLS-1007,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.77,253.239,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO VASC 10FR SUPER SHTH INFS SDPRT -,SUP-CLS-1010,CDM,C1894,HCPCS,272,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 5FRX11CM SUPER ARROW-FLEX PERC 0.035IN GW COMP -,SUP-CP-07511,CDM,C1894,HCPCS,272,RC,,,outpatient,,,148.79,104.153,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
DRYSEAL FLEX INTRODUCER SHEATH - 1233 -,SUP-DSF1233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3695.08,2586.556,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH INTRO 12FRX28CM DRYSEAL HYDRCT -,SUP-DSF1233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3695.08,2586.556,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH DRYSEAL INTRODUCER -,SUP-DSF1245,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4821.18,3374.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
DRYSEAL FLEX INTRODUCER SHEATH 14FR REF: DSF1433 -,SUP-DSF1433,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
GORE INTRODUCER SHEATH 16 -,SUP-DSF1633,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3695.08,2586.556,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
DRYSEAL SHEATH--16 FR X 65CM -,SUP-DSF1665,CDM,C1894,HCPCS,272,RC,,,outpatient,,,5780.33,4046.231,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
GORE INTRODUCER SHEATH 18 -,SUP-DSF1833,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
22FR X 33CM DRYSEAL SHEATH -,SUP-DSF2233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
GORE DRY SEAL SHEATH 22F X 33CM -,SUP-DSF2233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
22FR X 65CM DRYSEAL SHEATH -,SUP-DSF2265,CDM,C1894,HCPCS,272,RC,,,outpatient,,,5780.33,4046.231,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
GORE DRY SEAL SHEATH 26F X 33CM -,SUP-DSF2633,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH INTRO 18FRX28CM DRYSEAL HYDRCT -,SUP-DSL1828,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
URETHRAL ACCESS SHTH 9.5FR ID AQ HYDRCT TAPR LUMX1 DILATOR -,SUP-FUS-095045,CDM,C1894,HCPCS,272,RC,,,outpatient,,,774.6,542.22,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
URETHRAL ACCESS SHTH 14FRX28CM AQ HYDRCT FLEXOR TAPR LUMX1 -,SUP-FUS-120028,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
URETHRAL ACCESS SHTH 12FR ID HYDRCT LUMX1 DILATOR -,SUP-FUS-120035,CDM,C1894,HCPCS,272,RC,,,outpatient,,,762.34,533.638,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
URETHRAL ACCESS SHTH 12FRX45CM HYDRCT TAPR LUMX1 DILATOR -,SUP-FUS-120045,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
DILATOR VASCULAR 16FR 20CM REF G01212 -,SUP-G01212,CDM,C1894,HCPCS,272,RC,,,outpatient,,,49.54,34.678,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH MICROPUN TRANSTLS TIP 0.018INX40CM GW PEDAL -,SUP-G02972,CDM,C1894,HCPCS,272,RC,,,outpatient,,,349.52,244.664,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 16FRX30CM PEEL-AWAY 0.038IN GW COMP -,SUP-G02997,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO CATH 22FRX13CM PEEL-AWAY LNG COONS TAPR STR 0.038IN GW -,SUP-G04096,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.57,194.299,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 18FRX15.5CM PEEL-AWAY LNG COONS TAPR STR 20CM VES -,SUP-G06444,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 20FRX13CM PEEL-AWAY PERC STR 20CM VES DILATOR W/O -,SUP-G06445,CDM,C1894,HCPCS,272,RC,,,outpatient,,,273.6,191.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 24FRX13CM PEEL-AWAY PERC STR 20CM VES DILATOR W/O -,SUP-G06446,CDM,C1894,HCPCS,272,RC,,,outpatient,,,273.6,191.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 12FRX15.5CM PEEL-AWAY PERC STR 0.038IN GW COMP -,SUP-G06492,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 14FRX15.5CM PEEL-AWAY PERC STR 0.038IN GW COMP -,SUP-G06496,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SET INTRODUCER PEEL-AWAY .038IN 15.5CM 15FR -,SUP-G06497,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
RING TRANS-JUG ACCESS SET WITH 9Fr -,SUP-G06541,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2759.32,1931.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 4MM 12FRX13CM PERFORM JTP 0.038IN GW COMP -,SUP-G07369,CDM,C1894,HCPCS,272,RC,,,outpatient,,,293.56,205.492,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 2.9MM 8FRX13CM FLEXOR 0.038IN GW SM CHECK-FLO VLV -,SUP-G07856,CDM,C1894,HCPCS,272,RC,,,outpatient,,,243.44,170.408,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH CHECKFLO PERFORMA 10FRX30CM -,SUP-G08686,CDM,C1894,HCPCS,272,RC,,,outpatient,,,419.77,293.839,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRODUCER CHECK-FLO PERFORMER 12FR 30CM -,SUP-G08956,CDM,C1894,HCPCS,272,RC,,,outpatient,,,419.77,293.839,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRODUCER CHECK-FLO PERFORMER 14FR 30CM -,SUP-G08957,CDM,C1894,HCPCS,272,RC,,,outpatient,,,419.77,293.839,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
CHECK FLOW PERFORMER INTRODUCER 16FR 70CM REF:G09582 -,SUP-G09582,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRODUCER CHECK-FLO PERFORMER 16FR 30CM -,SUP-G09691,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SET INTRODUCER CHECK-FLO EXTRA LARGE 18FR 40CM -,SUP-G10626,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 2.2MM 6FRX45CM FLEXOR CHECK-FLO BLKN UP/ OVR -,SUP-G10634,CDM,C1894,HCPCS,272,RC,,,outpatient,,,313.51,219.457,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
S COOK 6FR X 6CM -,SUP-G10675,CDM,C1894,HCPCS,272,RC,,,outpatient,,,170.73,119.511,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SET INTRODUCER CATHETER NEFF 4/6FR -,SUP-G10797,CDM,C1894,HCPCS,272,RC,,,outpatient,,,513.42,359.394,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 5FRX9CM PEEL-AWAY MICROPUNCTURE DENNY MOD LCK -,SUP-G11566,CDM,C1894,HCPCS,272,RC,,,outpatient,,,465.11,325.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 6FRX9CM PEEL-AWAY PERC DENNY MOD 0.018IN GW COMP -,SUP-G11568,CDM,C1894,HCPCS,272,RC,,,outpatient,,,465.11,325.577,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 8FRX9CM PEEL-AWAY PERC DENNY MOD 0.038IN GW COMP -,SUP-G11570,CDM,C1894,HCPCS,272,RC,,,outpatient,,,375.77,263.039,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
VALVE CHECK-FLO 7F 55C RAABE K -,SUP-G11633,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH RAABE FLEXOR 7FR X 90CM -,SUP-G11634,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 7FRX70CM FLEXOR CHECK-FLO RAABE MOD STR 0.038IN -,SUP-G11635,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 6FRX70CM FLEXOR CHECK-FLO RAABE MOD STR 0.038IN -,SUP-G11636,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 2.9MM 8FRX70CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G11637,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 2.2MM 6FRX55CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G11638,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 6FR STRAIGHT FLEXOR -,SUP-G11638,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
CHECK FLOW PERFORMER INTRODUCER 18FR X 30CM -,SUP-G11672,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
VALVE CHECK-FLO 8F 55C RAABE K -,SUP-G12242,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 6FR 90CM RAABE KCFW-6.0 -,SUP-G12266,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 3.2MM 9FRX70CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G12606,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRODUCER CHECK-FLO PERFORMER 22FR 25CM -,SUP-G12831,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2364.02,1654.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 2.5MM 7FRX90CM FLEXOR SHTL SFT TIP HYDRCT -,SUP-G12835,CDM,C1894,HCPCS,272,RC,,,outpatient,,,611.39,427.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 1.9MM 5FRX55CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G13009,CDM,C1894,HCPCS,272,RC,,,outpatient,,,268.41,187.887,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 1.9MM 5FRX90CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G13069,CDM,C1894,HCPCS,272,RC,,,outpatient,,,348.58,244.006,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 5FRX70CM FLEXOR CHECK-FLO RAABE MOD STR 0.038IN -,SUP-G13091,CDM,C1894,HCPCS,272,RC,,,outpatient,,,268.41,187.887,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 6FR. 80CM -,SUP-G13539,CDM,C1894,HCPCS,272,RC,,,outpatient,,,611.39,427.973,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
URETHRAL ACCESS SHTH 9.5FR ID HYDRCT TAPR LUMX1 DILATOR -,SUP-G19174,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
URETHRAL ACCESS SHTH 9.5FRX28CM AQ HYDRCT FLEXOR TAPR LUMX1 -,SUP-G19176,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 20F X 25CM COOK -,SUP-G28999,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2364.02,1654.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 12FRX24CM PEEL-AWAY PERC CRV 0.038IN GW COMP 34CM -,SUP-G29839,CDM,C1894,HCPCS,272,RC,,,outpatient,,,689.99,482.993,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 14FRX24CM PEEL-AWAY CRV 0.038IN GW COMP 18GA 12ML -,SUP-G29840,CDM,C1894,HCPCS,272,RC,,,outpatient,,,689.99,482.993,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 2.5MM 7FRX45CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29885,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
5Fr. 45cm ANSEL SHEATH WITH ANGLE KCFW-5.0-18/38/45-RB-ANL1- -,SUP-G29981,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 1.9MM 5FRX45CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29981,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 1.9MM 5FRX90MM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29988,CDM,C1894,HCPCS,272,RC,,,outpatient,,,586.83,410.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 6F ANSEL 90CM FLEXOR KC -,SUP-G29989,CDM,C1894,HCPCS,272,RC,,,outpatient,,,586.83,410.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 2.2MM 6FRX55MM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29996,CDM,C1894,HCPCS,272,RC,,,outpatient,,,420.18,294.126,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 2.2MM 6FRX55MM FLEXOR CHECK-FLO ANSEL MOD RNL -,SUP-G29997,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHUTTLE SELECT GUIDE SHEATH KS -,SUP-G31138,CDM,C1894,HCPCS,272,RC,,,outpatient,,,617.11,431.977,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH CHECKFLOW 3.4MM 10FRX40CM FLEXOR -,SUP-G32233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,385.81,270.067,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 4.1MM 12FRX40CM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-G32373,CDM,C1894,HCPCS,272,RC,,,outpatient,,,444.22,310.954,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SET MICROPUNCTURE 5.0F 10CM -,SUP-G36333,CDM,C1894,HCPCS,272,RC,,,outpatient,,,159.7,111.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 3.2MM 9FRX55CM FLEXOR CHECK-FLO RAABE MOD -,SUP-G36393,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
MICRO PUNCTURE  5FR X 10CM  0.018INX40CM -,SUP-G43870,CDM,C1894,HCPCS,272,RC,,,outpatient,,,191.21,133.847,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 5F ANSEL 45CM ANLO -,SUP-G44153,CDM,C1894,HCPCS,272,RC,,,outpatient,,,300.62,210.434,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 6F ANSEL 45CM -,SUP-G44154,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH MICROPUNCTURE TRANSTLS TIP 0.018INX40CM PLTNM TIP -,SUP-G47942,CDM,C1894,HCPCS,272,RC,,,outpatient,,,190.1,133.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
MICROPUNCTURE STIFF 4F NIT -,SUP-G48003,CDM,C1894,HCPCS,272,RC,,,outpatient,,,281.36,196.952,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
MICROPUNCTURE TRANSITIONLESS STIFFENED CANNULA ACCESS SET -,SUP-G48005,CDM,C1894,HCPCS,272,RC,,,outpatient,,,281.36,196.952,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
WIRE FOR  MICROPUNCTURE 0.018 IN X 40 CM PLTNM TIP -,SUP-G48007,CDM,C1894,HCPCS,272,RC,,,outpatient,,,281.36,196.952,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 1.5MM 4FRX45MM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-G48186,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 4F ANSEL 90CM -,SUP-G48188,CDM,C1894,HCPCS,272,RC,,,outpatient,,,620.26,434.182,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 5F 90 RB ANSEL KCF-5.0- -,SUP-G48189,CDM,C1894,HCPCS,272,RC,,,outpatient,,,620.26,434.182,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 7F X 55CM ANSEL 1 -,SUP-G49043,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 2.9MM 8FRX45CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G49100,CDM,C1894,HCPCS,272,RC,,,outpatient,,,356.11,249.277,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 3.2MM 9FRX45MM FLEXOR CHECK-FLO ANSEL MOD ANL1 -,SUP-G49102,CDM,C1894,HCPCS,272,RC,,,outpatient,,,356.11,249.277,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 6FRX70CM FLEXOR 0.038IN GW COMP HYDRCT -,SUP-G56221,CDM,C1894,HCPCS,272,RC,,,outpatient,,,452.45,316.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUIDING 7FR x 70CM STRAIGHT -,SUP-G56222,CDM,C1894,HCPCS,272,RC,,,outpatient,,,452.45,316.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 2.2MM 6FRX70CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G56226,CDM,C1894,HCPCS,272,RC,,,outpatient,,,452.45,316.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 1.9MM 5FRX55CM FLEXOR CHECK-FLO ANSEL MOD STR. -,SUP-G56230,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 1.9MM 5FRX55CM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-G56235,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 6F X 55 ANSEL 1 -,SUP-G56236,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH FLEXOR PARALLEL 9.5CM x 28CM - URETERAL -,SUP-G56429,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1012.66,708.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH FLEXOR PARALLEL 9.5FR x 45CM URETERAL -,SUP-G56431,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1012.66,708.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SET MICROPUNCTURE INTRODUCER 21G -,SUP-G84006,CDM,C1894,HCPCS,272,RC,,,outpatient,,,252.07,176.449,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUIDING DESTINATION SLENDER 105CM 6FR STRAIGHT -,SUP-GS-R6ST1C10W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1599.43,1119.601,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SYS SHEATH RTRVL 4FR BNTP EMBL PROT FLTWR EZ -,SUP-H749501001500,CDM,C1894,HCPCS,272,RC,,,outpatient,,,595.17,416.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
COAXIAL MICROINTRODUCER KIT 4FR -,SUP-H965457531,CDM,C1894,HCPCS,272,RC,,,outpatient,,,175.05,122.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO PERC 6FR SHTH INTROFLEX -,SUP-I500-F6,CDM,C1894,HCPCS,272,RC,,,outpatient,,,288.25,201.775,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 9FR STD INTROFLEX PERC W/O LIDOCN -,SUP-I505BF9C,CDM,C1894,HCPCS,272,RC,,,outpatient,,,243.32,170.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 5FRX10CM MICROPUNCTURE STF CANN COAX CATH PR -,SUP-JCD5.01810.0MPI,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.06,81.242,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
10fr 0.035 Flexer Guiding Sheath -,SUP-KCFW-10.0-35-RB-RTPS-100,CDM,C1894,HCPCS,272,RC,,,outpatient,,,641.79,449.253,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 2.2MM 6FRX30CM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-KCFW6.0-38-30RB,CDM,C1894,HCPCS,272,RC,,,outpatient,,,268.35,187.845,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO CATH 6FRX13CM SHTH FLEXOR NTPR 0.038IN GW VES DILATOR -,SUP-KCFW-6.0-38-RB,CDM,C1894,HCPCS,272,RC,,,outpatient,,,243.44,170.408,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO 4.5FRX5CM MICRO-ACCESS TEARAWAY 0.018INX4.CM MRK NTNL -,SUP-KIT-010-03,CDM,C1894,HCPCS,272,RC,,,outpatient,,,204.23,142.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
CATHETER RETRIEVAL AVEIR REF:LSCR111 -,SUP-LSCR111,CDM,C1894,HCPCS,272,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
LOADING SYSTEM ENVEO R  LS-MDT2-2629-US -,SUP-LS-MDT2-2629-US,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2067.2,1447.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
CATHETER INTRODUCER AVEIR 30CM REF:LSN25301 -,SUP-LSN25301,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 21GA ACCUSTICK II STF CANN -,SUP-M001207020,CDM,C1894,HCPCS,272,RC,,,outpatient,,,416.39,291.473,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH INTRO 8.5FRX60CM HEARTSPAN TRNSEPT 55DG CRV TAPR -,SUP-M0045660550,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1108.65,776.055,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH URET 11/13FRX36CM NAVIGATOR -,SUP-M0062502021,CDM,C1894,HCPCS,272,RC,,,outpatient,,,567.91,397.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH NAVIGATOR HD 11/13 X 28 -,SUP-M0062502210,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH NAVIGATOR HD 11 13 36 -,SUP-M0062502220,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH NAVIGATOR HD 11 13 46 -,SUP-M0062502230,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH NAVIGATOR HD 12 14 36 -,SUP-M0062502250,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH NAVIGATOR 12F/14F X 46CM -,SUP-M0062502260,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
ST DILATOR URETH 8-30FR OD 35CM 30CM SHTH TFLN-CT TAPR GRAD -,SUP-M0062601000,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1208.3,845.81,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
ST DILATOR URETH SHTH 8FR/10FR 70CM/35CM L PTFE TAPR LF -,SUP-M0062601200,CDM,C1894,HCPCS,272,RC,,,outpatient,,,280.31,196.217,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
URETHRAL ACCESS SHTH 34FR TAPR -,SUP-M0062601600,CDM,C1894,HCPCS,272,RC,,,outpatient,,,344.5,241.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
MICRO PUNCTURE 4FR X 10 CM NTNL 0.018X 40 -,SUP-MAK401NPD,CDM,C1894,HCPCS,272,RC,,,outpatient,,,91.84,64.288,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
MICRO PUNCTURE  5FR X 10CM  0.018INX40CM - MAK501N -,SUP-MAK501N,CDM,C1894,HCPCS,272,RC,,,outpatient,,,151.42,105.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
MICRA INTRO SHEATH HYDRO COAT -,SUP-MI2355A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
MICINTRO SHTH 7FRX7CM VENEFIT ECHGNC TIP 21GA -,SUP-MIS7F07,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
MICRO INTRO SHEATH 7F 11CM -,SUP-MIS-7F11,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH MICROPUNCTURE TRANSTLS TIP 0.018INX40CM PLTNM TIP -,SUP-MPIS-401-NT,CDM,C1894,HCPCS,272,RC,,,outpatient,,,190.1,133.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 4FR MICROPUNCTURE TRANSTLS TIP 0.018INX40CM PLTNM -,SUP-MPIS401PEDNTSST,CDM,C1894,HCPCS,272,RC,,,outpatient,,,197.05,137.935,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 5FRX10CM MICROPUNCTURE TRANSTLS TIP 0.018INX40CM -,SUP-MPIS-501-NT,CDM,C1894,HCPCS,272,RC,,,outpatient,,,191.21,133.847,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO ORTHO 4FR MICRO-STK NTNL WIRE -,SUP-MR190421,CDM,C1894,HCPCS,272,RC,,,outpatient,,,105.03,73.521,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 18FRX85CM PERFORM 0.038IN GW 97CM VES DILATOR -,SUP-RCFW18.0P3885RB,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 2.6MM 8FRX63CM PERFORM MLNS CRV 0.038IN GW COMP -,SUP-RCFW8.0-38-63,CDM,C1894,HCPCS,272,RC,,,outpatient,,,433.42,303.394,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH INTRO 6FRX10CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB602,CDM,C1894,HCPCS,272,RC,,,outpatient,,,152.29,106.603,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH INTRO 7FR X 10CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB702,CDM,C1894,HCPCS,272,RC,,,outpatient,,,152.29,106.603,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH INTRO 8FRX25CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB803,CDM,C1894,HCPCS,272,RC,,,outpatient,,,193.72,135.604,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH INTRO 9FRX10CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB902,CDM,C1894,HCPCS,272,RC,,,outpatient,,,152.29,106.603,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH INTRO 9FRX25CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB903,CDM,C1894,HCPCS,272,RC,,,outpatient,,,193.72,135.604,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH INTRO 5FRX10CM PINNCL PERIPH STR CRV 0.035IN GW COMP -,SUP-RSS501,CDM,C1894,HCPCS,272,RC,,,outpatient,,,63.43,44.401,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 8FR 10CM PINNACLE -,SUP-RSS802,CDM,C1894,HCPCS,272,RC,,,outpatient,,,60.68,42.476,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 9FR 10CM PINNACLE -,SUP-RSS901,CDM,C1894,HCPCS,272,RC,,,outpatient,,,63.43,44.401,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 14FRX28CM SENTRANT 0.035IN GW HYDRCT -,SUP-SENSH1428W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1108.65,776.055,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 16FRX28CM SENTRANT 0.035IN GW COMP HYDRCT -,SUP-SENSH1628W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1123.71,786.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 18FR MEDTRONIC -,SUP-SENSH1828W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1123.71,786.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 20FR X 28CM MEDTRONIC -,SUP-SENSH2028W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1258.87,881.209,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
MICRO PUNCTURE  5FR X 10CM  0.018INX40CM STIFF- S-MAK501N -,SUP-S-MAK501N,CDM,C1894,HCPCS,272,RC,,,outpatient,,,210.06,147.042,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH NAVIGATOR 12F/14F X 28CM -,SUP-STRYKER INSTRUMENTS,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
9.5F SAFESHEATH PEEL AWAY HEMO -,SUP-UNDEFINED,CDM,C1894,HCPCS,272,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH INTRO 6FR BRT TIP -,SUP-UNDEFINED,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
CATAPULT US 5F 15CM STRAIGHT 5PK -,SUP-US-35015-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,519.32,363.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
CATAPULT US 5F 45CM STRAIGHT 5PK -,SUP-US-35045-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,636.02,445.214,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
CATAPULT US 5F 60CM STRAIGHT 5PK -,SUP-US-35060-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,694.37,486.059,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
CATAPULT US 5F 90CM STRAIGHT 5PK -,SUP-US-35090-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
TRANSEPTAL ACCESS SET VERSACROSS REF: VXSK0032 -,SUP-VXSK0032,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4630.78,3241.546,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
SET INTRODUCER CHECK-FLO EXTRA LARGE 20FR 40CM -,SUP-XVCFW-20.0-35-40,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2364.02,1654.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.064425,7986.663,other,OPPS APC,,
LEAD DEFIB IMPL BIPLR PERMNT PCNG ETAK RELIANCE 59CM 8FR -,SUP-0157,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB ETAK RELIANCE 59CM -,SUP-0275-59,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB ETAK RELIANCE 64CM -,SUP-0276-64,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB ENDOTAK RELIANCE G 64CM -,SUP-0286,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB PCNG ETAK RELIANCE 64CM GORE-HYBRID ETFE CTD STRD -,SUP-0293-64,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10470.66,7329.462,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB IMPL BIPLR ETAK RELIANCE 4- SITE 59CM RT ECRD -,SUP-0295,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB IMPL BIPLR ETAK RELIANCE 4- SITE 64CM RT ECRD -,SUP-0296,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD RELIANCE 4-FRONT 0673 64 CM -,SUP-0673-64,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB BIPLR PERMNT PCNG KENTROX SL 65CM 7.8FRX180MM SPC -,SUP-350054,CDM,C1895,HCPCS,278,RC,,,outpatient,,,14265.35,9985.745,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB IMPL LINOX SMRT SD 65CM 18CM ECRD SIL INSL DL -,SUP-359067,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD PCNG 60MM LINOX SD IMPL BIPLR RV STRD ELUT ACT -,SUP-363303,CDM,C1895,HCPCS,278,RC,,,outpatient,,,14265.35,9985.745,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB TRIPLR SPRNT QUATTRO 65CM 8.6FRX12MM SPC RT ECRD -,SUP-6935-65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB 8.6FRX12MM SPC 55CM SPRNT QUATTRO TRIPLR STRD -,SUP-6935M55,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB TRIPLR SPRNT QUATTRO 62CM 8.6FRX12MM SPC SIL -,SUP-6935M62,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD PCNG 8.6FRX12MM SPC 58CM SPRNT QUATTRO PERMNT QDPL -,SUP-6947-58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD PCNG 8.6FRX12MM SPC 65CM SPRNT QUATTRO PERMNT QDPL -,SUP-6947-65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB QDPL SPRNT QUATTRO 55CM 8.6FRX12MM SPC RT ECRD -,SUP-6947M55,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB QDPL SPRNT QUATTRO 62CM 8.6FRX12MM SPC RT ECRD -,SUP-6947M62,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB QDPL SPRNT QUATTRO 72CM 8.6FRX12MM SPC RT ECRD -,SUP-6947M72,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FRX170MM SPC VNTRC OPTIM -,SUP-7120/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB TRUE BIPLR DURATA 52CM 7FRX170MM SPC VNTRC OPTIM -,SUP-7120Q/52,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB TRUE BIPLR DURATA 58CM 7FR VNTRC OPTIM INSL SGL -,SUP-7120Q/58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FR VNTRC OPTIM INSL SGL -,SUP-7120Q/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIBRILLATOR DURATA OPTIM L21 CM OD7 FR 2 COIL -,SUP-7121,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11031.32,7721.924,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FRX210MM SPC VNTRC OPTIM -,SUP-7121/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB TRUE BIPLR DURATA 52CM 7FR VNTRC OPTIM INSL SGL -,SUP-7121Q/52,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB DURATA IMPL -,SUP-7131,CDM,C1895,HCPCS,278,RC,,,outpatient,,,17543.93,12280.751,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB TRUE BIPLR DURATA 58CM 17CM-TO-PROX COIL 7FR -,SUP-7170Q/58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB TRUE BIPLR DURATA 58CM 21CM-TO-PROX COIL 7FR -,SUP-7171Q/58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB 8FR INTRO 65CM OPTISURE TRUE BIPLR XTD-RETRAC -,SUP-LDA230Q/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,13473.73824,other,OPPS APC,,
ELECTRODE DEFIB 12FR DIST TIP 9FR COIL 45CM Q-TRAK TRIPLR -,SUP-3400,CDM,C1896,HCPCS,278,RC,,,outpatient,,,14852,10396.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,11406.336,other,OPPS APC,,
ELECTRODE DEFIB 12FR DIST TIP 45CM EMBLEM TRIPLR SUBQ DIST -,SUP-3401,CDM,C1896,HCPCS,278,RC,,,outpatient,,,14852,10396.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,11406.336,other,OPPS APC,,
EMBLEM S-ICD LEAD 3501-45CM -,SUP-3501-45,CDM,C1896,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,11406.336,other,OPPS APC,,
LEAD EPICARDIAC 5071 -,SUP-5071,CDM,C1896,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,11406.336,other,OPPS APC,,
LEAD PCNG 58CM TRANSVENE IMPL UNIPL ECRD CS SVC -,SUP-6937A58,CDM,C1896,HCPCS,278,RC,,,outpatient,,,4774,3341.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,11406.336,other,OPPS APC,,
OPTISURE DEFIBRILLATION LEAD DF1 SINGLE COIL LDA210-65 -,SUP-LDA210-65,CDM,C1896,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,11406.336,other,OPPS APC,,
KT LEAD NEURSTM OCTRODE 60CM PERC ACC -,SUP-3086ANS,CDM,C1897,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,196.493625,28414.1568,other,OPPS APC,,
KT LEAD NEURSTM 60CM PERC ACC 6MM -,SUP-3873-60,CDM,C1897,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,196.493625,28414.1568,other,OPPS APC,,
KT LEAD NEURSTM 60CM PERC SUBCOMPACT ACC -,SUP-3875-60,CDM,C1897,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,196.493625,28414.1568,other,OPPS APC,,
REACTIV8 IMPLANTABLE PULSE GENERATOR -,SUP-5100,CDM,C1897,HCPCS,278,RC,,,outpatient,,,36997.6,25898.32,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,196.493625,28414.1568,other,OPPS APC,,
KT IT REVISN INTFC TRANSP STRN RLF SLVX2 NS RLR F/SULS PMP -,SUP-8578,CDM,C1897,HCPCS,278,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,196.493625,28414.1568,other,OPPS APC,,
LEAD NEURSTM VECTRIS SURSCN 60CM PERC SPIN CRD MRI-COND -,SUP-977D260,CDM,C1897,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,196.493625,28414.1568,other,OPPS APC,,
SLIM TIP DRG TRIAL LEAD KIT -,SUP-MN10350-50A,CDM,C1897,HCPCS,278,RC,,,outpatient,,,4874.15,3411.905,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,196.493625,28414.1568,other,OPPS APC,,
SLIP TIP DRG -,SUP-MN10350-90A,CDM,C1897,HCPCS,278,RC,,,outpatient,,,4909.5,3436.65,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,196.493625,28414.1568,other,OPPS APC,,
STIMWAVE NEUROSTIMULATOR RECEIVER KIT -,SUP-STQ4-RCV-A0,CDM,C1897,HCPCS,278,RC,,,outpatient,,,32936.92,23055.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,196.493625,28414.1568,other,OPPS APC,,
PNS PERMANENT TINED RECEIVER KIT CHANNEL B -,SUP-STQ4-RCV-B0,CDM,C1897,HCPCS,278,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,196.493625,28414.1568,other,OPPS APC,,
LEAD NRV STIM 50CM F/TRL -,SUP-UNDEFINED,CDM,C1897,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,196.493625,28414.1568,other,OPPS APC,,
LEAD PCNG 8FR INTRO 58CM TENDRIL DX PERMNT BIPLR AV -,SUP-1388TC/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 1642T X 46 -,SUP-1642T/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 7FR INTRO 10MM SPC 52CM ISFLX PERMNT BIPLR STR AV -,SUP-1646T/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 1646T-58 ISFLX PERMNT BIPLR_STR AV -,SUP-1646T/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 46CM TENDRIL -,SUP-1688TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
TENDRIL SDX 1688TC/46 -,SUP-1688TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD TENDRIL 1688 TC/58 -,SUP-1688TC-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 6FR INTRO 10MM SPC 52CM TENDRILL SDX PERMNT BIPLR -,SUP-1788TC/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 6FR INTRO 10MM SPC 58CM TENDRILL SDX PERMNT BIPLR -,SUP-1788TC/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 7FR INTRO 10MM SPC 46CM TENDRILL ST PERMNT BIPLR -,SUP-1882TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 7FR INTRO 10MM SPC 52CM TENDRILL ST PERMNT BIPLR -,SUP-1882TC/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 6FR INTRO 10MM SPC 46CM TENDRILL ST PERMNT BIPLR -,SUP-1888TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 6FR INTRO 10MM SPC 52CM TENDRILL ST PERMNT BIPLR -,SUP-1888TC/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 6FR INTRO 10MM SPC 58CM TENDRILL ST PERMNT BIPLR -,SUP-1888TC/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD ISOFLEX OPTIM J 1944-46CM -,SUP-1944/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 7FR INTRO 10MM SPC 52CM ISFLX PERMNT BIPLR J-SHP -,SUP-1944/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG ISOFLEX 1948-52 ISFLX PERMNT BIPLR STR AV. -,SUP-1948/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 7FR INTRO 10MM SPC 58CM ISFLX PERMNT BIPLR STR AV -,SUP-1948/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD OPINSENSE  MODEL 1999-52 -,SUP-1999/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD CATH DELIVERED 3830 69CM,SUP-2,CDM,C1898,HCPCS,275,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 6FRX46CM TENDRIL STS IMPL BIPLR RAV ACT SCR IN FX -,SUP-2088TC-46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 6FRX52CM TENDRIL STS IMPL BIPLR RAV ACT SCR IN FX -,SUP-2088TC-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 6FRX58CM TENDRIL STS IMPL BIPLR RAV ACT SCR IN FX -,SUP-2088TC-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 6.6FRX15MM SPC 60CM SELOX ST 60 PERMNT IMPL BIPLR -,SUP-346367,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 6.6FRX15MM SPC 53CM SELOX JT 53 PERMNT IMPL BIPLR -,SUP-346368,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 6.6FRX10MM SPC 45CM SETROX DX PERMNT IMPL BIPLR -,SUP-350973,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 7FRX10MM SPC 53CM SETROX DX PERMNT IMPL BIPLR HLCL -,SUP-350974,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 6.6FRX10MM SPC 60CM SETROX DX PERMNT IMPL BIPLR -,SUP-350975,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 6.6FR 7FR INTRO 53CM TILDA STR PSS FX -,SUP-382872,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD CATH DELIVERED 3830 69 CM -,SUP-383069,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 52CM SELUTE PICOTIP COMPLIANCE PRACTITIONERS -,SUP-4064,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 5.7FRX10MM SPC 35CM CAP NOV PERMNT BIPLR AV STRD -,SUP-4076-35,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2570.74,1799.518,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PPM 45CM CAPSURE FIX NOVUS 4076-45 -,SUP-4076-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 5.7FRX10MM SPC 45CM CAP NOV IMPL BIPLR AV STRD -,SUP-4076-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 5.3FRX9MM SPC 52CM CPSR SP NOVUS PERMNT BIPLR AV -,SUP-4092-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 5.3FRX9MM SPC 58CM CPSR SP NOVUS PERMNT BIPLR AV -,SUP-4092-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 6.7FRX10MM SPC 53CM DEXTRUS PERMNT BIPLR HLCL TIP -,SUP-4136-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 6.7FRX10MM SPC 60CM DEXTRUS PERMNT BIPLR HLCL TIP -,SUP-4137,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 5.7FRX16MM SPC 58CM FNLN STRX PERMNT BIPLR STR -,SUP-4457,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 1.7X16MM SPC_45CM FINELINE II EZ STEROX PERMNT -,SUP-4469,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 1.7X16MM SPC 45CM FINELINE II EZ STEROX PERMNT -,SUP-4469-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 1.7X16MM SPC 52CM FINELINE II EZ STEROX PERMNT -,SUP-4470-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 1.7X16MM SPC 58CM FINELINE II EZ STEROX PERMNT -,SUP-4471,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 5.7FRX45CM FNLN STRX AJ PERMNT BIPLR JTP RA ECRD -,SUP-4479,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 5.7FRX52CM FNLN STRX AJ PERMNT BIPLR JTP RA ECRD -,SUP-4480-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 5.3FRX9MM SPC 45CM CPSR SP NOVUS PERMNT BIPLR JTP -,SUP-4592-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 5.3FR CPSR SP NOVUS J-SHP ATR BIPLR -,SUP-4592-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD MEDTRONIC CAPSURE VDD-2 5038S-52 -,SUP-5038S-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD MEDTRONIC CAPSURE VDD-2 5038S-58 -,SUP-5038S-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG EPCRD -,SUP-5071-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PPM 45CM CAPSUREFIX SURSCN NOVUS 5076-45 -,SUP-5076-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 6.2FRX10MM SPC 52CM CAPSUREFIX SURSCN NOVUS IMPL -,SUP-5076-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 6.2FR X10MM SPC 58CM CAPSUREFIX SURSCN NOVUS IMPL -,SUP-5076-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 6.2FRX10MM SPC 65CM CAPSUREFIX SURSCN NOVUS IMPL -,SUP-5076-65,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 7FRX45CM CPSR FX MRI BIPLR STR AV ACT SCR IN FX -,SUP-5086MRI-45CM,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 7FRX52CM CPSR FX MRI BIPLR STR AV ACT SCR IN FX -,SUP-5086MRI-52CM,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 7FRX58CM CAPSUREFIX BIPLR STR AV ACT SCR IN FX -,SUP-5086MRI-58CM,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD MYOPORE BIPOLAR 511211 -,SUP-511211,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 35MM MYOPORE IMPL BIPLR EPCRD AV STRD ELUT ACT SCR -,SUP-511211,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 54CM MYOPORE IMPL BIPLR EPCRD AV STRD ELUT ACT SCR -,SUP-511212,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 7.2FRX53CM CAPSUREFIX PERMNT BIPLR J-SHP TIP ATR -,SUP-5568-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
BIPOLAR TEMPORARY MYOCARDIAL PACING LEAD -,SUP-6495F,CDM,C1898,HCPCS,278,RC,,,outpatient,,,408.45,285.915,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
OIL MNRL F/EZ INS STYL -,SUP-6529,CDM,C1898,HCPCS,278,RC,,,outpatient,,,175.05,122.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD INGEVITY MRI 7731 52 CM P -,SUP-7731,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD INGEVITY MRI 7732-59 ( PASSIVE ) -,SUP-7732,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD INGEVITY MRI 7732 59 -,SUP-7732-59,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
INGEVITY MRI  MODEL 7735-45 -,SUP-7735,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD INGEVITY MRI 7736-52 ( PASSIVE J ) -,SUP-7736,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD INGEVITY MRI 7740 -,SUP-7740,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD INGEVITY MRI 7741 52CM -,SUP-7741,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD INGEVITY MRI 7742 59CM -,SUP-7742,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
INGEVITY + 7840-45cm -,SUP-7840,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
INGEVITY + 7841/52 -,SUP-7841/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
INGEVITY + 7842/59 LEAD -,SUP-7842/59,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG ELAFIX ATR -,SUP-ELAFIX P2 752,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2549.32,1784.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 7FRX52CM BIPLR ECRD THN TND -,SUP-ELAPASSP752,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 7FRX58CM BIPLR ECRD THN TND -,SUP-ELAPASSP758,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2549.32,1784.524,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 7FRX52CM BIPLR J-SHP ECRD THN TND -,SUP-ELAPASSPJ752,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
TENDRIL MRI LEAD 46CM -,SUP-LPA1200M/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
TENDRIL MRI LEAD- 52CM -,SUP-LPA1200M/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
TENDRIL MRI LEAD- 58CM -,SUP-LPA1200M/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD CATH DELIVERED 3830 59CM -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD CATH DELIVERED 3830 49CM -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD CATH DELIVERED 3830 74CM -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD GENTR -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 7FR INTRO 20MM SPC 86CM QUICKFLEX PERMNT BIPLR -,SUP-1156T/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD PCNG 5FRX20MM SPC 75CM QUICKFLEX U BIPLR STYP CRV LH -,SUP-1258T/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD PCNG 5FRX20MM SPC 86CM QUICKFLEX U BIPLR STYP CRV LH -,SUP-1258T/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD PCNG 5FRX20MM SPC 92CM QUICKFLEX U BIPLR STYP CRV LH -,SUP-1258T/92,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC,,
Lead Quartet 1456/75Q LV Lead -,SUP-1456/75Q,CDM,C1900,HCPCS,278,RC,,,outpatient,,,8445.56,5911.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD QUARTET 1456Q/86 LV LEAD -,SUP-1456/86Q,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC,,
QUARTET LEAD DOUBLE BEND- 75 CM MODEL 1457Q/75 -,SUP-1457Q/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC,,
QUARTET LEAD DOUBLE BEND-86CM MODEL 1457Q/86 -,SUP-1457Q/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD PCNG 7FR INTRO 75CMX16MM QRTT CRT STYP CRV LH LPRO -,SUP-1458Q/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD PCNG 7FR INTRO 86CMX16MM QRTT CRT STYP CRV LH LPRO -,SUP-1458Q/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD QUARTET 75 WIDE SPACING -,SUP-1458QL/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD QUARTET 1458QL 86 WIDE SPACING -,SUP-1458QL/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD PCNG 5.4FRX18MM SPC 77CM COROX PERMNT IMPL BIPLR HMSPHR -,SUP-355148,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5228.61,3660.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD SENTUS OTW QP L-75 -,SUP-386835,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD SENTUS OTW QP S-75 -,SUP-400719,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC,,
LV LEAD SENTUS OTW QP L 75/49 -,SUP-408718,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC,,
LV LEAD SENTUS OTW QP L 85/49 -,SUP-408719,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD PCNG 5FRX88CM ATTAIN PERMNT UNIPL CANTED LT VNTRC OTW -,SUP-4195-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD PCNG 4FRX21MM SPC 88CM ATTAIN PERMNT BIPLR ANG LT VNTRC -,SUP-4196-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD PCNG 5.3FRX21MM SPC 88CM ATTAIN ABILITY + IMPL BIPLR -,SUP-4296-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD ATTAIN PERFORMA LV REF:429878 -,SUP-429878,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD PCNG 5.3FRX21MM SPC 78CM ATTAIN PERFORM QDPL DBL CRV LT -,SUP-4298-78,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD ATTAIN PERFORM 4298-88 CM QDPL DBL CRV LT -,SUP-4298-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD ATTAIN PERFORMA QUAD LV  88 -,SUP-439888,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD PCNG 6FRX11MM SPC 80CM EASYTRAK 2 IMPL UNIPL BIPLR LT -,SUP-4542,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5585.1,3909.57,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD PCNG 6FRX11MM SPC 90CM EASYTRAK 2 IMPL UNIPL BIPLR LT -,SUP-4543,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5585.1,3909.57,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD PCNG 6FRX11MM SPC 90CM EASYTRAK 3 IMPL UNIPL BIPLR LT -,SUP-4549,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5585.1,3909.57,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD PCNG 4.5FRX90CM ACUITY IMPL UNIPL LT ECRD VNTRC SPRL FX -,SUP-4592,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD ATTAIN PERFORMA LV 4598-78 -,SUP-4598-78,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD ATTAIN PERFORMA LV 4598-88 -,SUP-4598-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD ACUITY X4 86CM STRAIGHT -,SUP-4671,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD ACUITY X4 95CM STRAIGHT -,SUP-4672-95,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC,,
LV LEAD ACUTIY SPIRAL S MODEL 4674-86 -,SUP-4674,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD ACUITY X4 95CM SPIRAL S -,SUP-4675-95,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD ACUITY X4 86CM SPIRAL L -,SUP-4677,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD ACUITY X4 95CM SPIRAL L -,SUP-4678-95,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD ATTAIN STABILITY QUAD MRI SURESCAN LV LEAD REF:4798-88 -,SUP-4798-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10247.88,7173.516,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC,,
LV LEAD SENTUS OTW QP S 75/49 MODEL 406081 -,SUP-706081,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD COROX OTW-L 85-BP -,SUP-UNDEFINED,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5228.61,3660.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD COROX OTW-L 75-BP -,SUP-UNDEFINED,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5228.61,3660.027,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,9410.2272,other,OPPS APC,,
PROBE PERC SPIN 17GAX6IN -,SUP-0407-250-000,CDM,C2614,HCPCS,270,RC,,,outpatient,,,8309.75,5816.825,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6381.888,other,OPPS APC,,
SIR-SPHERES Y-90 RESIN MICROSPHERES -,SUP-SIR-Y001,CDM,C2616,HCPCS,278,RC,,,outpatient,,,44393.67,31075.569,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19676.26496,,,19676.26496,399.86,42246.08608,other,OPPS APC,,
STENT BLDR 14F/7FRX24CM RETROMAX + PERCUFLEX HYDRPLS CTD -,SUP-145-148,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1085.19,759.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT 6FR OPEN END -,SUP-160205,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 8FRX80CM PERCUFLEX STR OPEN TIP -,SUP-160215,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
URINARY STENT 7FR CLOSED TIP -,SUP-160230,CDM,C2617,HCPCS,278,RC,,,outpatient,,,535.8,375.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PANC 7FR PSHR CATH 5CM FREEMN -ALIPERT FLEX-STNT -,SUP-6521,CDM,C2617,HCPCS,278,RC,,,outpatient,,,320.93,224.651,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PANC 7FRX9CM FREEMN FLX-STNT SGL PIGTL DBL XTRN FLNG -,SUP-6575,CDM,C2617,HCPCS,278,RC,,,outpatient,,,268.41,187.887,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 4.7FRX26CM INLAY DBL PIGTL TAPR -,SUP-778426,CDM,C2617,HCPCS,278,RC,,,outpatient,,,396.78,277.746,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT BIL 10FRX5CM COTTON-LEUNG CRV TAPR PE -,SUP-CLSO 10-5,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT BIL 7FRX7CM COTTON-LEUNG CRV TAPR PE P/D FLP -,SUP-CLSO 7-7,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT BILIARY ZIMMON 8FR 12CM 0.035IN GW 3.2MM -,SUP-G21404,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT BIL 10FRX7CM COTTON-LEUNG CRV TAPR PE -,SUP-G21469,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT BIL 10FRX8CM COTTON-LEUNG CRV TAPR PE P/D FLP -,SUP-G21472,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT BIL 10FRX10CM COTTON-LEUNG CRV TAPR PE P/D FLP -,SUP-G21807,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT BILIARY ZIMMON 10-5 -,SUP-G21975,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PANC 5FRX5CM ZIMMON SPRL SH PE PIGTL TAPR FLP LF MRI -,SUP-G22980,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PANC 3FRX4CM ZIMMON SPRL SH PE PIGTL TAPR OPTN DCT FLP -,SUP-G24566,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PANC 5FRX9CM GEENEN SPRL SH SOF-FLEX OFST PROX FLP LF -,SUP-G49666,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PANC 5FR 7CM GEENEN SOF-FLEX NO INTERNAL FLAP -,SUP-G49670,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PANC 5FR 9CM GEENEN SOF-FLEX NO INTERNAL FLAP -,SUP-G49671,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT BIL 7FRX5CM COMPASS BDS DBL PIGTL TAPR PLST 0.035IN GW -,SUP-G55519,CDM,C2617,HCPCS,278,RC,,,outpatient,,,414.29,290.003,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PANC 5FR 3CM GEENEN SOF-FLEX NO INTERNAL FLAP -,SUP-GPSOS-SF-5-3,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PANC 5FR 5CM GEENEN SOF-FLEX NO INTERNAL PLAP -,SUP-GPSOS-SF-5-5,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 8FRX22CM PERCUFLEX DBL PIGTL FLXB STF -,SUP-M001245500,CDM,C2617,HCPCS,278,RC,,,outpatient,,,826.41,578.487,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 6FRX22CM PERCUFLEX DBL PIGTL -,SUP-M001245730,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 6FRX24CM PERCUFLEX DBL PIGTL -,SUP-M001245740,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 6FRX26CM PERCUFLEX DBL PIGTL -,SUP-M001245750,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 6FRX28CM PERCUFLEX DBL PIGTL -,SUP-M001245760,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 8FRX26CM FLEXIMA DBL PIGTL -,SUP-M001274030,CDM,C2617,HCPCS,278,RC,,,outpatient,,,697.87,488.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT ADVANIX 7FR X 3CM DOUBLE PIGTAIL -,SUP-M00532160,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
ADVANIX DOUBLE PIGTAIL 7FR X 5CM -,SUP-M00532180,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
ADVANIX DOUBLE PIGTAIL 7FR X 7CM -,SUP-M00532190,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
ADVANIX DOUBLE PIGTAIL 7FR X 10CM -,SUP-M00532210,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
ADVANIX DOUBLE PIGTAIL 10FR X 5CM -,SUP-M00532260,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT BIL 10FRX5CM ADVANIX RX SGL DBL PIGTL PLST 4.2MM WKG -,SUP-M00532260,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
ADVANIX DOUBLE PIGTAIL 10FR X 7CM -,SUP-M00532270,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT BIL 10FRX15CM WALLSTNT DUOD BND PERCUFLEX -,SUP-M00533700,CDM,C2617,HCPCS,278,RC,,,outpatient,,,290.87,203.609,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 8FRX22CM PERCUFLEX DBL PIGTL PSTNR -,SUP-M0061453800,CDM,C2617,HCPCS,278,RC,,,outpatient,,,441.13,308.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
SCISSORS SURG KAYE CRV 7.5IN SERR DSCT V. MUELLER LF -,SUP-M0061552310,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 6FRX24CM POLARIS LOOP PERCUFLEX -,SUP-M0061552320,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 6FRX26CM POLARIS LOOP PERCUFLEX -,SUP-M0061552330,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 6FRX28CM POLARIS LOOP PERCUFLEX -,SUP-M0061552340,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 8FRX26CM POLARIS LOOP PERCUFLEX -,SUP-M0061552530,CDM,C2617,HCPCS,278,RC,,,outpatient,,,836.51,585.557,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 7FRX80CM PERCUFLEX STR LF -,SUP-M006160210,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PERC PLUS 4.8 X 24 -,SUP-M0061752520,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PERC PLUS 4.8 X 26 -,SUP-M0061752530,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PERC PLUS 4.8 X 28 -,SUP-M0061752540,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PERCUFLEX PLUS 6 X 22 -,SUP-M0061752610,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PERCUFLEX PLUS 6 X 24 -,SUP-M0061752620,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PERCUFLEX PLUS 6 X 26 -,SUP-M0061752630,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PERCUFLEX PLUS 6 X 28 -,SUP-M0061752640,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PERCUFLEX PLUS 6 X 30 -,SUP-M0061752650,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PERCUFLEX PLUS 7FR X 24CM -,SUP-M0061752720,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PERCUFLEX PLUS 7FR X 26CM -,SUP-M0061752730,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PERCUFLEX PLUS 8 X 26 -,SUP-M0061752830,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PERCUFLEX PLUS 8 X 28 NO -,SUP-M0061752840,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 8FRX30CM PERCUFLEX DBL PIGTL TAPR -,SUP-M0061752850,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 4.8FR 22-30CM CONTR VL PERCUFLEX DBL PIGTL TAPR -,SUP-M0061801550,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 6FR 22-30CM CONTR VL PERCUFLEX DBL PIGTL TAPR -,SUP-M0061801560,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET CONTOUR 6 X 22 -,SUP-M0061802210,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET CONTOUR 6 X 28 -,SUP-M0061802240,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 8FRX28CM PERCUFLEX TAPR LF -,SUP-M00618022440,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET CONTOUR 8 X 24 -,SUP-M0061802420,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 6FRX22CM NTNL/PTFE DBL PIGTL -,SUP-M006190131090,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1073.17,751.219,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 6FRX24CM NTNL/PTFE DBL PIGTL -,SUP-M006190132090,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1073.17,751.219,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 6FRX22CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921310,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 6FRX24CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921320,CDM,C2617,HCPCS,278,RC,,,outpatient,,,791.28,553.896,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 6FRX26CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921330,CDM,C2617,HCPCS,278,RC,,,outpatient,,,791.28,553.896,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 6FRX28CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921340,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 8FRX22CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921510,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 8FRX26CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921530,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PANC 5FRX5CM ZIMMON SPRL SH PE PIGTL TAPR OPTN DCT FLP -,SUP-SPSOF-5-5,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT BIL 7FRX10CM ZIMMON DBL PIGTL TAPR PE -,SUP-ZSO-7-10,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT BIL 7FRX7CM ZIMMON DBL PIGTL TAPR PE -,SUP-ZSO-7-7,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,734.3115,other,OPPS APC,,
PROBE CRYOSPHERE 11IN -,SUP-CRYOS,CDM,C2618,HCPCS,272,RC,,,outpatient,,,10397.8,7278.46,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7607.37,other,OPPS APC,,
PROBE CRYOSPHERE 18IN -,SUP-CRYOS-L,CDM,C2618,HCPCS,272,RC,,,outpatient,,,9468.15,6627.705,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7607.37,other,OPPS APC,,
ICEROD 1.5C X 90 NEEDLE -,SUP-FPRPR3533,CDM,C2618,HCPCS,272,RC,,,outpatient,,,8042.38,5629.666,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7607.37,other,OPPS APC,,
NEEDLE ICEROD CX 90 VL -,SUP-FPRPR3533,CDM,C2618,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7607.37,other,OPPS APC,,
NEEDLE ICEPEARL  2.1C X 90 -,SUP-FPRPR3601,CDM,C2618,HCPCS,272,RC,,,outpatient,,,8042.38,5629.666,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7607.37,other,OPPS APC,,
NEEDLE ICEFORCE 2.1 X 90 -,SUP-FPRPR3602,CDM,C2618,HCPCS,272,RC,,,outpatient,,,10610,7427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,7607.37,other,OPPS APC,,
PACEMAKER IMPL BIPLR ADAPTA VDD SGL-CHMBR RR 11.1ML 23.6GM -,SUP-ADVDD01,CDM,C2619,HCPCS,275,RC,,,outpatient,,,16567.96,11597.572,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,12724.19328,other,OPPS APC,,
PACEMAKER IMPL EVIA HF-T TRI CHMBR 14ML 27GM IS-1 CONN -,SUP-377208,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25991,18193.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24381.0432,other,OPPS APC,,
PACEMAKER IMPL SYNCRA 15ML 26GM DR -,SUP-C2TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24381.0432,other,OPPS APC,,
PACEMAKER IMPL CONSULTA CRT-P SGL-CHMBR 15ML 26GM IS-1 CONN -,SUP-C4TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24381.0432,other,OPPS APC,,
PACEMAKER IMPL ANTHEM 2CHMBR RR 52X58MM 6MM 13.7ML 25GM IS-1 -,SUP-PM3210,CDM,C2621,HCPCS,275,RC,,,outpatient,,,19897.97,13928.579,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24381.0432,other,OPPS APC,,
PACEMAKER IMPL ALLURE RF 59X55MM 6MM 14ML 24GM IS-1 CONN -,SUP-PM3222,CDM,C2621,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24381.0432,other,OPPS APC,,
PACEMAKER IMPL QDPL ALLURE QUADRA RF 2CHMBR RR 59X56MM 6MM -,SUP-PM3242,CDM,C2621,HCPCS,275,RC,,,outpatient,,,20792.8,14554.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24381.0432,other,OPPS APC,,
CRT-PACER QUADRA ALLURE MP  RF -,SUP-PM3262,CDM,C2621,HCPCS,275,RC,,,outpatient,,,21813.88,15269.716,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24381.0432,other,OPPS APC,,
QUADRA ALLURE MP MRI PM3562 -,SUP-PM3562,CDM,C2621,HCPCS,275,RC,,,outpatient,,,20792.8,14554.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24381.0432,other,OPPS APC,,
PACEMAKER ALTRUA 60 49MMX43X8MM 12.1ML TI -,SUP-S606 DR EL,CDM,C2621,HCPCS,275,RC,,,outpatient,,,18193.7,12735.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24381.0432,other,OPPS APC,,
VALITUDE CRT-P U125 -,SUP-U125,CDM,C2621,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24381.0432,other,OPPS APC,,
CRT-P VALITUDE MODEL - U128 -,SUP-U128,CDM,C2621,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24381.0432,other,OPPS APC,,
VISIONIST CRT-P MODEL U226 BI-V PACEMAKER -,SUP-U226,CDM,C2621,HCPCS,275,RC,,,outpatient,,,27736.11,19415.277,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24381.0432,other,OPPS APC,,
CRT-P VISIONIST X4 - U228 -,SUP-U228,CDM,C2621,HCPCS,275,RC,,,outpatient,,,20313.82,14219.674,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24381.0432,other,OPPS APC,,
PACEMAKER IMPL INVIVE CRT-PS SMARTDELAY ALGORITHM RPM -,SUP-V172,CDM,C2621,HCPCS,275,RC,,,outpatient,,,31746.15,22222.305,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24381.0432,other,OPPS APC,,
PACEMAKER INTUA CARD -,SUP-V272,CDM,C2621,HCPCS,275,RC,,,outpatient,,,28590.1,20013.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24381.0432,other,OPPS APC,,
PACEMAKER PERCEPTA CRT-P MRI W1TR01 -,SUP-W1TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25991,18193.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24381.0432,other,OPPS APC,,
SOLARA CRT-P MRI W1TR03 -,SUP-W1TR03,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24381.0432,other,OPPS APC,,
PACEMAKER PERCEPTA QUAD CRT-P MRI W4TR01 -,SUP-W4TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25991,18193.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24381.0432,other,OPPS APC,,
PACEMAKER SERENA QUAD CRT-P MRI W4TR02 -,SUP-W4TR02,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25248.4,17673.88,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24381.0432,other,OPPS APC,,
SOLARA QUAD CRT-P MRI W4TR03 -,SUP-W4TR03,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24381.0432,other,OPPS APC,,
PROSTHESIS PENL CNCLBL 14MMX16CM ANG RGD CONN MIN SPR BK -,SUP-720056-02,CDM,C2622,HCPCS,278,RC,,,outpatient,,,24383.27,17068.289,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,23086.3872,other,OPPS APC,,
IMPLANT PENL CL 12MMX12CM SIL PE TI SEG MALE CNCLBL SNP FIT -,SUP-720074-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,20421.5,14295.05,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,23086.3872,other,OPPS APC,,
PROSTHESIS TACTRA 9.5MM X 14CM-23CM MALLEABLE -,SUP-720080-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,30060.4,21042.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,23086.3872,other,OPPS APC,,
TACTRA 11CM MALLEABLE PROSTHESIS -,SUP-720081-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,30060.4,21042.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,23086.3872,other,OPPS APC,,
TACTRA 13MM X 18CM-27CM MALLEABLE PROSTHESIS -,SUP-720082-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,28358.17,19850.719,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,23086.3872,other,OPPS APC,,
IMPLANT PENL DURA 11 10MMX14CM CL HX WRNCH STRL -,SUP-720093-10,CDM,C2622,HCPCS,278,RC,,,outpatient,,,15579.75,10905.825,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,23086.3872,other,OPPS APC,,
TIP PROS DURA II 10MMX1CM UNIV PENL STRL -,SUP-720093-12,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,23086.3872,other,OPPS APC,,
TIP PROS DURA II 10MMX5CM PROX PENL STRL -,SUP-720093-16,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,23086.3872,other,OPPS APC,,
TIP PROS DURA II 10MMX4CM DIST PENL STRL -,SUP-720093-23,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,23086.3872,other,OPPS APC,,
TIP PROS DURA II 10MMX2CM UNIV PENL STRL -,SUP-720093-60,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,23086.3872,other,OPPS APC,,
KT PROSTHESIS PENL 11MMX25CM MALE CYL MLBL TRMBL ADPR W/TAIL -,SUP-91-9511SC,CDM,C2622,HCPCS,278,RC,,,outpatient,,,20291.55,14204.085,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,23086.3872,other,OPPS APC,,
BARD BALLOON LUTONIX .035 4.0 X 150MM -,SUP-BSLX3513041505F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8912.4,6238.68,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
CATH PTCA 6MMX130CM LUTONIX 60MM DRG CTD 0.035IN GW COMP -,SUP-BSLX351306605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
LUTONIX BALLOON 6MM X 80MM -,SUP-BSLX351306805F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,7214.8,5050.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER DCB OTW  4.0MM x 40MM x 135CM -,SUP-H74939419400410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER GLOBAL DCB OTW 4.0 X 80MM 135CM -,SUP-H74939419400810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER GLOBAL DCB OTW 4.0 X 100MM 135CM -,SUP-H74939419401010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER GLOBAL DCB OTW 4.0 X 150MM 150CM -,SUP-H74939419401510,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER GLOBAL DCB OTW 4.0 X 200MM 150CM -,SUP-H74939419402010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER GLOBAL DCB OTW 4.0 X 200MM 150CM -,SUP-H74939419500410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER GLOBAL DCB OTW 5.0 X 60MM 135CM -,SUP-H74939419500610,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
CATH BALLOON RANGER GLOBAL 5.0 X 80MM X 135CM GLOBAL DCB OTW -,SUP-H74939419500810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER GLOBAL DCB OTW 5.0 X 100MM 135CM -,SUP-H74939419501010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER GLOBAL DCB OTW 5.0 X 120MM 150CM -,SUP-H74939419501210,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5708.18,3995.726,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER GLOBAL DCB OTW 5.0 X 150MM 150CM -,SUP-H74939419501510,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER DCB OTW 5.0MM x 200MM x 150CM -,SUP-H74939419502010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER GLOBAL DCB OTW 5.0 X 200MM 90CM -,SUP-H74939419502090,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER GLOBAL DCB OTW 6.0 X 40MM 135CM -,SUP-H74939419600410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER GLOBAL DCB OTW 6.0 X 60MM 135CM -,SUP-H74939419600610,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
CATH BALLOON RANGER GLOBAL 6.0 X 80MM X 135CM GLOBAL DCB OTW -,SUP-H74939419600810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER GLOBAL DCB OTW 6.0 X 100MM 135CM -,SUP-H74939419601010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER GLOBAL DCB OTW 6.0 X 200MM 150CM -,SUP-H74939419602010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER GLOBAL DCB OTW 7.0 X 40MM 135CM -,SUP-H74939419700410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER GLOBAL DCB OTW 7.0 X 60MM 135CM -,SUP-H74939419700610,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER GLOBAL DCB OTW 7.0 X 80MM 135CM -,SUP-H74939419700810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER GLOBAL DCB OTW 7.0 X 100MM 135CM -,SUP-H74939419701010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER GLOBAL DCB OTW 7.0 X 150MM 150CM -,SUP-H74939419701510,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER GLOBAL DCB OTW 7.0 X 200MM 150CM -,SUP-H74939419702010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
LUTONIX 018 6 X 80MM -,SUP-LX181306805F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
CATH PTCA 4MMX130CM LUTONIX 40MM DRG CTD 0.035IN GW COMP -,SUP-LX351304405F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
CATH PTCA 4MMX130CM LUTONIX 60MM DRG CTD 0.035IN GW COMP -,SUP-LX351304605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
CATH PTCA 5MMX130CM LUTONIX 100MM DRG CTD 0.035IN GW COMP -,SUP-LX3513051005F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
CATH PTCA 5X150MM LUTONIX 130CM -,SUP-LX3513051505F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
CATH PTCA 5MMX130CM LUTONIX 60MM DRG CTD 0.035IN GW COMP -,SUP-LX351305605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
B LUTONIX 6MM X 100MM X 130 -,SUP-LX3513061005F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
CATH PTCA 6X150MM LUTONIX 130CM -,SUP-LX3513061505F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
LUTONIX BALLOON -,SUP-LX3513062205F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8700.2,6090.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
CATH PTCA LUTONIX 0.035 X 6.0MM X 130CM 6FR DRG CTD GW GROUP -,SUP-LX351306605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
CATH PTCA 6MMX130CM LUTONIX 80MM DRG CTD 0.035IN GW COMP -,SUP-LX351306805F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
LUTONIX BALLOON 7MM X 100MM X 130M -,SUP-LX3513071005F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
S LUTONIX 7 X 40 X 130 -,SUP-LX351307405F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
S LUTONIX 7 X 60 X 130 -,SUP-LX351307605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
BALLOON LUTONIX .035 X 10MM X 40MM -,SUP-LX35751040V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
BALLOON LUTONIX .035 X 10MM X 60MM -,SUP-LX35751060V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
LUTONIX 12MM X 40MMX 75CM -,SUP-LX35751240V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6896.5,4827.55,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
BALLOON LUTONIX .035  4.0MM X 40MM -,SUP-LX3575440V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
CATH LUTONIX BALLOON DILATATION 6MM 75CM 40MM PACLITAXEL LF -,SUP-LX3575640V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
CATH LUTONIX BALLOON DILATATION 6MM 75CM 60MM PACLITAXEL LF -,SUP-LX3575660V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
LUTONIX DCB BALLOON 6 X 80 X 75 -,SUP-LX3575680V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
BALLOON LUTONIX .035  7.0MM X 40MM -,SUP-LX3575740V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
BALLOON LUTONIX .035  4 X 60 X 75 -,SUP-LX3575760V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
BALLOON LUTONIX .035 X 8MM X 40MM X 75CM -,SUP-LX3575840V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
BALLOON LUTONIX  .035 8 X 60 X 75 -,SUP-LX3575860V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
BALLOON LUTONIX .035 9.0MM X 40MM X 75CM -,SUP-LX3575940V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,6390.1908,other,OPPS APC,,
STENT NEPHURET 8.5FRX22CM ULTRATHANE COPE DBL PIGTL BND -,SUP-240735,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT NEPHURET 8.5FRX24CM ULTRATHANE COPE DBL PIGTL BND -,SUP-240736,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT NEPHURET 8.5FRX28 CM ULTRATHANE COPE DBL PIGTL BND -,SUP-244806,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT URET 4.7FRX24CM INLAY DBL PIGTL TAPR -,SUP-778424,CDM,C2625,HCPCS,278,RC,,,outpatient,,,396.78,277.746,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
8FR X 22 BARD OPTIMA INLAY URETERAL STENT -,SUP-778822,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
8FR X 24 BARD OPTIMA INLAY URETERAL STENT -,SUP-778824,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
8FR X 26 BARD OPTIMA INLAY URETERAL STENT -,SUP-778826,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
8FR X 28 BARD OPTIMA INLAY URETERAL STENT -,SUP-778828,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT URETERAL INLAY 6F 20 OPT -,SUP-788620,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT URETERAL INLAY 6F 22 OPT -,SUP-788622,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT URETERAL INLAY 6F 24 -,SUP-788624,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT URETERAL INLAY 6F 26 -,SUP-788626,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT URETERAL INLAY 6F 28 -,SUP-788628,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT URETERAL INLAY 6F 30 -,SUP-788630,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
BARD OPTIMA INLAY STENT 7 X 24 -,SUP-788724,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
BARD OPTIMA INLAY STENT 7 X 26 -,SUP-788726,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
BARD OPTIMA INLAY STENT 7 X 28 -,SUP-788728,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT BIL 7FRX5CM COTTON-LEUNG CRV TAPR PE P/D FLP PSH CATH -,SUP-CLBS-7-5,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT FANELLI BILIARY -,SUP-G13699,CDM,C2625,HCPCS,278,RC,,,outpatient,,,2999.5,2099.65,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT URET 7FRX75CM BNDR RT SOF-FLEX -,SUP-G14779,CDM,C2625,HCPCS,278,RC,,,outpatient,,,446.79,312.753,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT URET 7FRX75CM BNDR PTFE -,SUP-G14780,CDM,C2625,HCPCS,278,RC,,,outpatient,,,451.1,315.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT BILIARY DOUBLE PIGTAIL 7 X 7 -,SUP-G21396,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT BILIARY DOUBLE PIGTAIL 7 X 9 -,SUP-G21398,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT GEENAN PANCREATIC 7X7 -,SUP-G21479,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT GEENAN PANCREATIC 7X9 -,SUP-G21480,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT SET ZIMMON BILIARY 7-12 -,SUP-G21526,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT ZIMON BILIARY 7 X 15 -,SUP-G21529,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT ZIMMON DBL PIGTAIL 10X4 -,SUP-G21781,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT BIL 10MMX5CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN -,SUP-G25379,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT BIL 10MMX7CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN -,SUP-G25380,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT BIL 7MMX5CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN GW -,SUP-G25656,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT BIL 7MMX7CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN GW -,SUP-G25657,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT SOLUS DOUBLE PIGTAIL 10FR 3CM -,SUP-G25670,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT SOLUS DBL PIGTAIL 10 X 4 -,SUP-G25671,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT SOLUS DBL PIGTAIL 10 X 5 -,SUP-G25672,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT DBLE PIGTAIL 10F 1CM -,SUP-G26829,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT SOLUS DOUBLE PIGTAIL 10FR 1CM -,SUP-G26829,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT NEPHURET 10.2FRX22CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48162,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT NEPHURET 8.5FRX24CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48176,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT NEPHURET 8.5FRX26CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48180,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT NEPHURET 8.5FRX26CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48180,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
COMPASS BDS BILIARY STENT 7FR 15CM -,SUP-G58990,CDM,C2625,HCPCS,278,RC,,,outpatient,,,408.45,285.915,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT PANC 3FRX4CM GEENEN 170CM/320CM PSH/GUID CATH SPRL SH -,SUP-GEPD3-4,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
TUBE LRNCMY JCKSN SZ8 12MMX7CM OSDE V. MUELLER CRV MIRR FNSH -,SUP-GEPD3-5,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
CATH DRN 10FR NAVIFLEX RX -,SUP-M00533580,CDM,C2625,HCPCS,278,RC,,,outpatient,,,512.08,358.456,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT ADVANIX RX 7FR X 5CM PRELOADED -,SUP-M00534200,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT ADVANIX RX 7FR X 7CM PRELOADED -,SUP-M00534210,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT ADVANIX RX 7FR X 9CM PRELOADED -,SUP-M00534220,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT BIL 2.3MMX9CM ADVANIX RX PRELD DUOD BND PLST 3.2MM WKG -,SUP-M00534220,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT ADVANIX RX 7FR X 12CM PRELOADED -,SUP-M00534230,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT ADVANIX RX 10FR X 5CM PRELOADED -,SUP-M00534320,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT ADVANIX RX 10FR X 5CM PRELOADED -,SUP-M00534330,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT BIL 10FRX9CM ADVANIX RX PRELD DUOD BND PLST 4.2MM WKG -,SUP-M00534340,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT ADVANIX RX 10FR X 9CM PRELOADED -,SUP-M00534340,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT ADVANIX RX 10FR X 12CM PRELOADED -,SUP-M00534350,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT BIL 10FRX12CM ADVANIX RX PRELD DUOD BND PLST 4.2MM WKG -,SUP-M00534350,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT ADVANIX RX 10FR X 15CM -,SUP-M00534360,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT BIL 10FRX15CM ADVANIX RX PRELD DUOD BND PLST 4.2MM WKG -,SUP-M00534360,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT BIL 8.5FRX7CM ADVANIX RX PRELD CTR BND PLST 3.2MM WKG -,SUP-M00534630,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT BIL 8.5FRX9CM ADVANIX RX PRELD CTR BND PLST 3.2MM WKG -,SUP-M00534640,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT BIL 10FRX7CM ADVANIX RX PRELD CTR BND PLST 4.2MM WKG -,SUP-M00534690,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT BIL 10FRX12CM ADVANIX RX PRELD CTR BND PLST 4.2MM WKG -,SUP-M00534710,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT ADVANTIX 5X3 PANCREATIC NO LEADING BARB SINGLE PIGTAIL -,SUP-M00537390,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT ADVANTIX 5 X 4 PANCREATIC - NO LEADING BARB -,SUP-M00537400,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT ADVANTIX 5X5 PANCREATIC NO LEADING BARB SINGLE PIGTAIL -,SUP-M00537410,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT ADVANTIX 5 X 3 PANCREATIC -LEADING BARB -,SUP-M00537430,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT ADVANTIX 5 X 4 PANCREATIC -LEADING BARB -,SUP-M00537440,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT ADVANTIX 5X3 PANCREATIC NO LEADING BARB STRAIGHT -,SUP-M00537500,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT ADVANTIX 5X5 PANCREATIC NO LEADING BARB STRAIGHT -,SUP-M00537520,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT KIT PANCREATIC 5FR X 3CM -,SUP-M00537540,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT BIL 7FRX4CM ZIMMON DBL PIGTL TAPR PE 170CM PSH CATH -,SUP-ZEBD-7-4,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,89.07711,1949.675,other,OPPS APC,,
PAIN CONTROL DEVICE BEELINE -,SUP-UNDEFINED,CDM,C2626,HCPCS,278,RC,,,outpatient,,,758.55,530.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,170.294475,582.5664,other,OPPS APC,,
HC Cath Stamey Suprapubic 14,PX-27200045,CDM,C2627,HCPCS,272,RC,,,outpatient,,,306,214.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,24.890315,416.02,other,OPPS APC,,
ST SUPRAPUBIC 12FRX25CM CONN TUBEX1/NDL OBTURATORX1/ 1W -,SUP-G14313,CDM,C2627,HCPCS,272,RC,,,outpatient,,,357.1,249.97,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,24.890315,416.02,other,OPPS APC,,
CATHETER MALECOT DRAINAGE 14FR 30CM -,SUP-G55824,CDM,C2627,HCPCS,272,RC,,,outpatient,,,307.21,215.047,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,24.890315,416.02,other,OPPS APC,,
LAWRENCE SUPRA-FOLEY 16F -,SUP-SF-S16-851,CDM,C2627,HCPCS,272,RC,,,outpatient,,,110.87,77.609,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,24.890315,416.02,other,OPPS APC,,
OCCULSION BALLOON CATH 90CM BR -,SUP-590-001,CDM,C2628,HCPCS,272,RC,,,outpatient,,,4415.95,3091.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,23.64434,10635.57648,other,OPPS APC,,
CATH OCL 6FRX10MM BLN ATTAIN COR -,SUP-6215,CDM,C2628,HCPCS,272,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,23.64434,10635.57648,other,OPPS APC,,
CATHETER PRUITT OCCLUSION 3F 7MM 27CM -,SUP-E2103-36,CDM,C2628,HCPCS,272,RC,,,outpatient,,,1743.86,1220.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,23.64434,10635.57648,other,OPPS APC,,
CATH ANG 5FR SHTH 135CM 3.75X20X1.5MM BLN ENTEER PERIPH -,SUP-ENB37520135,CDM,C2628,HCPCS,272,RC,,,outpatient,,,10273.24,7191.268,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,23.64434,10635.57648,other,OPPS APC,,
CATHETER OCCLUSION ER-REBOA PLUS -,SUP-ER7232PLUS,CDM,C2628,HCPCS,272,RC,,,outpatient,,,14833.44,10383.408,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,23.64434,10635.57648,other,OPPS APC,,
CATH HSG 5FRX30CM SIL 1ML BLN/SYR OPN TIP MRI-COND STRL SUD -,SUP-G17147,CDM,C2628,HCPCS,272,RC,,,outpatient,,,171.9,120.33,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,23.64434,10635.57648,other,OPPS APC,,
B CODA-2-10.0-35-140-46 -,SUP-G23773,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2702.08,1891.456,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,23.64434,10635.57648,other,OPPS APC,,
CODA BALLOON 46MM -,SUP-G23773,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2702.08,1891.456,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,23.64434,10635.57648,other,OPPS APC,,
CATH URET 6.2FRX26CM LF W/HSG/SHG MLBL STYL -,SUP-J-UHSG-062026,CDM,C2628,HCPCS,272,RC,,,outpatient,,,105.32,73.724,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,23.64434,10635.57648,other,OPPS APC,,
KIT CATHETER REBOA CONVENIENCE -,SUP-KT1835C,CDM,C2628,HCPCS,272,RC,,,outpatient,,,1192.61,834.827,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,23.64434,10635.57648,other,OPPS APC,,
CATHETER BALLOON MOLDING OCCLUSION 10MM X 37MM 10FR -,SUP-MOB37,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2740.28,1918.196,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,23.64434,10635.57648,other,OPPS APC,,
CATH OUTBACK RE-ENTRY 120CM -,SUP-OTB59120A,CDM,C2628,HCPCS,272,RC,,,outpatient,,,8021.16,5614.812,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,23.64434,10635.57648,other,OPPS APC,,
Q50X STENT GRAFT BALLOON CATHETER -,SUP-Q50-100-X,CDM,C2628,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,23.64434,10635.57648,other,OPPS APC,,
CATH GUID 8FR 10-46MM INFL 100CM RELIANT PU 12FR SHTH -,SUP-REL46,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2500.25,1750.175,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,23.64434,10635.57648,other,OPPS APC,,
MICRO INTRO KIT 21G 4FR 7CM TCAR - MULT'S OF 10EA -,SUP-SR-4F21G7D-MP,CDM,C2628,HCPCS,272,RC,,,outpatient,,,1167,816.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,23.64434,10635.57648,other,OPPS APC,,
HSG CATHETER -,SUP-UNDEFINED,CDM,C2628,HCPCS,272,RC,,,outpatient,,,207.35,145.145,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,23.64434,10635.57648,other,OPPS APC,,
CATH ABLT THRP COOL PATH MED CURL 7FR 2-5-2MM SPC 110CM QDPL -,SUP-A088047,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT THRP COOL PATH LRG CURL 7FR 2-5-2MM SPC 110CM QDPL -,SUP-A088049,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT SAFIRE BLU MED SWP DIST REACH CRV 7FR 2-5-2MM SPC -,SUP-A088106,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT SAFIRE BLU MED CURL DIST REACH CRV 7FR 2-5-2MM SPC -,SUP-A088107,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT SAFIRE BLU LRG SWP 7FR 2-5-2MM SPC LRG SWP 110CM -,SUP-A088108,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT SAFIRE BLU MED CURL DIST REACH CRV 7FR HGH TRQ -,SUP-A402871,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT SAFIRE BLU LRG CURL DIST REACH CRV HGH TRQ SHFT -,SUP-A402872,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT SAFIRE BLU MED CURL CRV EP DUO -,SUP-A700455,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT TACTICATH SE BI-D DF -,SUP-A-TCSE-DF,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10440.96,7308.672,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT TACTI SE BI-D FJ -,SUP-A-TCSE-FJ,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10440.96,7308.672,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT TACTIFLEX SE BID DF REF: A-TFSE-DF -,SUP-A-TFSE-DF,CDM,C2630,HCPCS,272,RC,,,outpatient,,,14387.88,10071.516,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT TACTIFLEX SE BID FJ REF: A-TFSE-FJ -,SUP-A-TFSE-FJ,CDM,C2630,HCPCS,272,RC,,,outpatient,,,14387.88,10071.516,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT THERMOCOOL SF F-J CRV 8FR 2-5-2MM SPC 115CM BIDIR -,SUP-BDI35FJRT,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7957.5,5570.25,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT THERMOCOOL SF B- CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131601,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT THERMOCOOL SF D-CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131602,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT THERMOCOOL SF F-CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131603,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT THERMOCOOL SF J-CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131604,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT THERMOCOOL SF CARTO XP F-TY CRV STEER UNI- DRCT -,SUP-D131803,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT THERMOCOOL SF CARTO XP J CRV STEER UNI- DRCT HTORQ -,SUP-D131804,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT CHILLI II STD CRV 7.5FRX2.5MM SPC 4MM TIP 110CM -,SUP-M00490310,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7151.14,5005.798,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT THRMCPL CRV 7.5FR LRG 110CM 2.5/2.5MM SPC -,SUP-M0049031K20,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7151.14,5005.798,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT TACTICATH 65 MM -,SUP-PN-004 065,CDM,C2630,HCPCS,272,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT TACTICATH 75MM -,SUP-PN-004075,CDM,C2630,HCPCS,272,RC,,,outpatient,,,11139,7797.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10316.10996,other,OPPS APC,,
DEVICE SUTCAP 12MM OPN ACCESS -,SUP-M0068311251,CDM,C2631,HCPCS,272,RC,,,outpatient,,,2073.95,1451.765,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,1487.02215,other,OPPS APC,,
HC Mra- W/Dye- Upper Extremity,PX-61000005,CDM,C8934,CPT,610,RC,,,outpatient,,,2034,1423.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,399.86,1724.0184,other,OPPS APC,,
HC Mra- W/O Dye- Upper Extr,PX-61000006,CDM,C8935,CPT,610,RC,,,outpatient,,,1745,1221.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,267.439885,,,267.439885,267.439885,1479.062,other,OPPS APC,,
HC Mra- W/O&W/Dye- Upper Extr,PX-61000007,CDM,C8936,CPT,610,RC,,,outpatient,,,3036,2125.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,419.73411,,,419.73411,399.86,2573.3136,other,OPPS APC,,
HC Cad Breast MRI,PX-61000089,CDM,C8937,HCPCS,610,RC,,,outpatient,,,344,240.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,77.228,836,other,OPPS APC,,
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML IJ SOLN,RX-155306,CDM,C9088,HCPCS,636,RC,47426-0301-02,NDC,outpatient,14,ML,1200.46,840.322,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.8808895,,,0.8808895,0.71,921.95328,other,OPPS APC,,
COCAINE HCL 4 % EX SOLN,RX-1792,CDM,C9143,HCPCS,636,RC,70839-0362-04,NDC,outpatient,4,ML,1089.63,762.741,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.4,836.83584,other,OPPS APC,,
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-01,NDC,outpatient,50,ML,360.88,252.616,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.39,416.02,other,OPPS APC,,
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-10,NDC,outpatient,50,ML,344.88,241.416,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,,,,,3.39,416.02,other,OPPS APC,,
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-01,NDC,outpatient,50,ML,344.88,241.416,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,,,,,3.39,416.02,other,OPPS APC,,
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-10,NDC,outpatient,50,ML,360.88,252.616,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.39,416.02,other,OPPS APC,,
LACOSAMIDE 200 MG/20ML IV SOLN,RX-96972,CDM,C9254,HCPCS,636,RC,72603-0140-02,NDC,outpatient,20,ML,100.4,70.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.31,416.02,other,OPPS APC,,
LACOSAMIDE 200 MG/20ML IV SOLN,RX-96972,CDM,C9254,HCPCS,636,RC,00131-1810-67,NDC,outpatient,20,ML,278.22,194.754,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.31,416.02,other,OPPS APC,,
LACOSAMIDE 200 MG/20ML IV SOLN,RX-96972,CDM,C9254,HCPCS,636,RC,72603-0140-01,NDC,outpatient,20,ML,100.4,70.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.31,416.02,other,OPPS APC,,
BUPIVACAINE LIPOSOME 1.3 % IJ SUSP,RX-112781,CDM,C9290,HCPCS,636,RC,65250-0266-09,NDC,outpatient,20,ML,1495.03,1046.521,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.36,1148.18304,other,OPPS APC,,
BUPIVACAINE LIPOSOME 1.3 % IJ SUSP,RX-112781,CDM,C9290,HCPCS,636,RC,65250-0266-20,NDC,outpatient,20,ML,1495.03,1046.521,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.36,1148.18304,other,OPPS APC,,
CAP NERVE AXOGEN 2MM X 15MM -,SUP-AGT215,CDM,C9353,HCPCS,278,RC,,,outpatient,,,6688.54,4681.978,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,5136.79872,other,OPPS APC,,
CAP NERVE AXOGEN 3MM X 15MM -,SUP-AGT315,CDM,C9353,HCPCS,278,RC,,,outpatient,,,6688.54,4681.978,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,5136.79872,other,OPPS APC,,
CAP NERVE AXOGEN 4 X 15 -,SUP-AGT415,CDM,C9353,HCPCS,278,RC,,,outpatient,,,6688.54,4681.978,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,5136.79872,other,OPPS APC,,
NEUROMATRIX 6.0MM DIAMETER 2.5CM LENGTH -,SUP-CNC6025,CDM,C9355,HCPCS,278,RC,,,outpatient,,,5756.22,4029.354,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,182.24,5164.04736,other,OPPS APC,,
NEUROFLEX NERVE 4MM X 2.5CM -,SUP-CNCF4025,CDM,C9355,HCPCS,278,RC,,,outpatient,,,6724.02,4706.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,182.24,5164.04736,other,OPPS APC,,
NEUROFLEX NERVE 6MM X 2.5CM -,SUP-CNCF6025,CDM,C9355,HCPCS,278,RC,,,outpatient,,,6724.02,4706.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,182.24,5164.04736,other,OPPS APC,,
MESH SURGIMEND 5X6CM 1.0MM -,SUP-606-001-002,CDM,C9358,HCPCS,636,RC,,,outpatient,,,2525.06,1767.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24858.15552,other,OPPS APC,,
MESH SURGIMEND 5X6CM 1.0MM - C -,SUP-606-001-002,CDM,C9358,HCPCS,636,RC,,,outpatient,,,2525.06,1767.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24858.15552,other,OPPS APC,,
MESH SURGIMEND BOVINE 10 X 15CM -,SUP-606-001-006,CDM,C9358,HCPCS,636,RC,,,outpatient,,,9819.33,6873.531,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24858.15552,other,OPPS APC,,
IMPLANT NDNTR COLL 4X7CM SRGMND RECT -,SUP-606-001-013,CDM,C9358,HCPCS,636,RC,,,outpatient,,,2616.64,1831.648,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24858.15552,other,OPPS APC,,
SURGIMEND PRS 10CM X 20CM RECT -,SUP-606-004-102,CDM,C9358,HCPCS,636,RC,,,outpatient,,,16238.36,11366.852,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24858.15552,other,OPPS APC,,
MESH SURGIMEND 8CM X 16CM SEMI OVAL FENESTRAED -,SUP-606-004-103,CDM,C9358,HCPCS,636,RC,,,outpatient,,,10392.54,7274.778,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24858.15552,other,OPPS APC,,
GRAFT FTL BVN NDNTR COLL MATRIX 20X30CM SRGMND 2MM SHT RECT -,SUP-606-200-017,CDM,C9358,HCPCS,636,RC,,,outpatient,,,27546.57,19282.599,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24858.15552,other,OPPS APC,,
MESH SURGIMEND 3.0 13 X 25CM -,SUP-606-300-009,CDM,C9358,HCPCS,636,RC,,,outpatient,,,26387.33,18471.131,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24858.15552,other,OPPS APC,,
MESH SURGIMEND 20 X 30 X 3MM -,SUP-606-300-017,CDM,C9358,HCPCS,636,RC,,,outpatient,,,32367.39,22657.173,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24858.15552,other,OPPS APC,,
GENTRIX SURGICAL MATRIX HIATAL 7.5 X 6CM -,SUP-HIAT0706,CDM,C9358,HCPCS,636,RC,,,outpatient,,,4704.78,3293.346,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,24858.15552,other,OPPS APC,,
MESH SURGIMEND 3.0 10 X 15CM -,SUP-603-300-006,CDM,C9360,HCPCS,636,RC,,,outpatient,,,12178.79,8525.153,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,41430.25152,other,OPPS APC,,
MESH SURGIMEND 10 X 15CM 2.0 -,SUP-606-200-006,CDM,C9360,HCPCS,636,RC,,,outpatient,,,10364.84,7255.388,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,41430.25152,other,OPPS APC,,
IMPLANT NDNTR COLL 13X20CM SRGMND RECT -,SUP-606-200-009,CDM,C9360,HCPCS,636,RC,,,outpatient,,,22457.19,15720.033,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,41430.25152,other,OPPS APC,,
MESH SURGIMEND 25X40 X 3.0MM -,SUP-606-300-016,CDM,C9360,HCPCS,636,RC,,,outpatient,,,53945.64,37761.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,41430.25152,other,OPPS APC,,
NEUROMEND12MM X 2.5CM -,SUP-CNW12025,CDM,C9361,HCPCS,636,RC,,,outpatient,,,6724.07,4706.849,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,177.26,5164.08576,other,OPPS APC,,
NEUROMEND 4MM X 2.25CM -,SUP-CNW4025,CDM,C9361,HCPCS,636,RC,,,outpatient,,,6464.93,4525.451,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,177.26,5164.08576,other,OPPS APC,,
IMPLANT BIO TISS 3X8CM 3D HYDR PRCN COLL MATRIX PERMACOL SHT -,SUP-P100308,CDM,C9364,HCPCS,636,RC,,,outpatient,,,2987.95,2091.565,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,18.39,18739.8144,other,OPPS APC,,
MESH PERMACOL 5X10CM 1.0MM -,SUP-P100510,CDM,C9364,HCPCS,636,RC,,,outpatient,,,4648.41,3253.887,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,18.39,18739.8144,other,OPPS APC,,
IMPLANT BIO TISS 10X10CM 3D HYDR PRCN DERM COLL PERMACOL SHT -,SUP-P101010,CDM,C9364,HCPCS,636,RC,,,outpatient,,,9294.36,6506.052,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,18.39,18739.8144,other,OPPS APC,,
IMPLANT BIO TISS 15X20CM 3D HYDR PRCN COLL MATRIX PERMACOL -,SUP-P151520,CDM,C9364,HCPCS,636,RC,,,outpatient,,,24400.8,17080.56,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,18.39,18739.8144,other,OPPS APC,,
CANGRELOR TETRASODIUM 50 MG IV SOLR,RX-131579,CDM,C9460,HCPCS,636,RC,10122-0620-01,NDC,outpatient,1,UN,2428.93,1700.251,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,21.562892,,,21.562892,18.2,1865.41824,other,OPPS APC,,
CANGRELOR TETRASODIUM 50 MG IV SOLR,RX-131579,CDM,C9460,HCPCS,636,RC,10122-0620-10,NDC,outpatient,1,UN,2428.93,1700.251,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,21.562892,,,21.562892,18.2,1865.41824,other,OPPS APC,,
HC Perc Drug-El Cor Stent Sing,PX-48100003,CDM,C9600,CPT,481,RC,,,outpatient,,,32584,22808.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12006.91336,,,12006.91336,399.86,25024.512,other,OPPS APC,,
HC Perc Drug-El Cor Stent Bran,PX-48100004,CDM,C9601,CPT,481,RC,,,outpatient,,,33887,23720.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,26025.216,other,OPPS APC,,
HC Perc D-E Cor Stent Ather S,PX-48100005,CDM,C9602,CPT,481,RC,,,outpatient,,,33887,23720.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19138.22361,,,19138.22361,399.86,26793.51305,other,OPPS APC,,
HC Perc D-E Cor Revasc T Cabg S,PX-48100007,CDM,C9604,CPT,481,RC,,,outpatient,,,33887,23720.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12006.91336,,,12006.91336,399.86,26025.216,other,OPPS APC,,
HC Perc D-E Cor Revasc T Cabg B,PX-48100008,CDM,C9605,CPT,481,RC,,,outpatient,,,33887,23720.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,26025.216,other,OPPS APC,,
HC Perc D-E Cor Revasc Chro Sin,PX-48100010,CDM,C9607,CPT,481,RC,,,outpatient,,,33887,23720.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,19138.22361,,,19138.22361,399.86,26793.51305,other,OPPS APC,,
HC Perc D-E Cor Revasc Chro Add,PX-48100011,CDM,C9608,CPT,481,RC,,,outpatient,,,33887,23720.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,26025.216,other,OPPS APC,,
HC Admin Influenza Virus Vac,PX-77100001,CDM,G0008,CPT,771,RC,,,outpatient,,,193,135.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,51.84533,,,51.84533,19.95,416.02,other,OPPS APC,,
HC Immuniz-Admin-Each Addl,PX-77100005,CDM,G0008,CPT,771,RC,,,outpatient,,,215,150.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,51.84533,,,51.84533,19.95,416.02,other,OPPS APC,,
HC Admin Pneumococcal Vaccine,PX-77100002,CDM,G0009,CPT,771,RC,,,outpatient,,,193,135.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,51.84533,,,51.84533,19.95,416.02,other,OPPS APC,,
HC Immuniz-Admin-Each Addl,PX-77100006,CDM,G0009,CPT,771,RC,,,outpatient,,,215,150.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,51.84533,,,51.84533,19.95,416.02,other,OPPS APC,,
HC Admin Hepatitis B Vaccine,PX-77100003,CDM,G0010,CPT,771,RC,,,outpatient,,,193,135.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,51.84533,,,51.84533,19.95,416.02,other,OPPS APC,,
HC Immuniz-Admin-Each Addl,PX-77100007,CDM,G0010,CPT,771,RC,,,outpatient,,,215,150.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,51.84533,,,51.84533,19.95,416.02,other,OPPS APC,,
HC Inject for Sacroiliac Joint,PX-36900022,CDM,G0259,CPT,369,RC,,,outpatient,,,827,578.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,185.6615,1592,other,OPPS APC,,
HC Inj for Sacroiliac Jt Anesth,PX-36900023,CDM,G0260,CPT,369,RC,,,outpatient,,,1722,1205.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,754.76995,,,754.76995,386.589,2141,other,OPPS APC,,
HC Occlusive Device in Vein Art,PX-48100001,CDM,G0269,CPT,481,RC,,,outpatient,,,202,141.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,45.349,1592,other,OPPS APC,,
HC Iliac Art Angio-Cardiac Cath,PX-32000003,CDM,G0278,CPT,320,RC,,,outpatient,,,113,79.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,25.3685,416.02,other,OPPS APC,,
HC Elec Stim Other Than Wound,PX-42000003,CDM,G0283,CPT,420,RC,,,outpatient,,,123,86.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12.01,,,12.01,12.01,416.02,fee schedule,,,
HC Observation Time,PX-76200003,CDM,G0378,CPT,762,RC,,,outpatient,,,101,70.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.6745,6652,other,OPPS APC,,
HC Observation Carve-Out,PX-76200004,CDM,G0378,CPT,762,RC,,,outpatient,,,101,70.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,22.6745,6652,other,OPPS APC,,
HC Direct Refer Hospital Observ,PX-76200001,CDM,G0379,CPT,762,RC,,,outpatient,,,1442,1009.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,701.034545,,,701.034545,104.83,6652,other,OPPS APC,,
HC PR Trauma Respons W/Hosp Criti,PX-68200001,CDM,G0390,HCPCS,682,RC,,,outpatient,,,10370,7259,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1494.270385,,,1494.270385,399.86,7964.16,other,OPPS APC,,
HC Full Trauma,PX-68200002,CDM,G0390,HCPCS,682,RC,,,outpatient,,,10370,7259,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1494.270385,,,1494.270385,399.86,7964.16,other,OPPS APC,,
HC Partial Trauma,PX-68200003,CDM,G0390,HCPCS,682,RC,,,outpatient,,,7029,4920.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1494.270385,,,1494.270385,399.86,7964.16,other,OPPS APC,,
HC Mod Sedat Endo Service >5yrs,PX-37000025,CDM,G0500,HCPCS,370,RC,,,outpatient,,,240,168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,53.88,416.02,other,OPPS APC,,
ABATACEPT 250 MG IV SOLR,RX-70287,CDM,J0129,HCPCS,636,RC,00003-2187-13,NDC,outpatient,1,UN,3823.57,2676.499,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,49.7570835,,,49.7570835,43.27,2936.50176,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0131,HCPCS,636,RC,36000-0306-60,NDC,outpatient,100,ML,53.83,37.681,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.04,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0131,HCPCS,636,RC,67457-0940-10,NDC,outpatient,100,ML,44.93,31.451,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.04,416.02,other,OPPS APC,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0131,HCPCS,636,RC,67457-0940-10,NDC,outpatient,100,ML,44.93,31.451,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.04,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0131,HCPCS,636,RC,36000-0306-60,NDC,outpatient,100,ML,53.83,37.681,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.04,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0131,HCPCS,636,RC,67457-0940-10,NDC,outpatient,100,ML,44.93,31.451,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.04,416.02,other,OPPS APC,,
ACETYLCYSTEINE 200 MG/ML IV SOLN,RX-38303,CDM,J0132,HCPCS,636,RC,00574-0805-00,NDC,outpatient,30,ML,278.49,194.943,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.57,416.02,other,OPPS APC,,
ACETYLCYSTEINE 200 MG/ML IV SOLN,RX-38303,CDM,J0132,HCPCS,636,RC,00574-0805-30,NDC,outpatient,30,ML,278.49,194.943,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.57,416.02,other,OPPS APC,,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,55150-0154-10,NDC,outpatient,10,ML,11.47,8.029,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.02,416.02,other,OPPS APC,,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-10,NDC,outpatient,10,ML,8.9,6.23,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.02,416.02,other,OPPS APC,,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-03,NDC,outpatient,10,ML,8.9,6.23,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.02,416.02,other,OPPS APC,,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,55150-0155-20,NDC,outpatient,20,ML,19.14,13.398,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.02,416.02,other,OPPS APC,,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-09,NDC,outpatient,20,ML,18.52,12.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.02,416.02,other,OPPS APC,,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-20,NDC,outpatient,20,ML,18.52,12.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.02,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,24.48,17.136,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,40.48,28.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,40.48,28.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,24.48,17.136,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,24.48,17.136,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,40.48,28.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,24.48,17.136,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,40.48,28.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,24.48,17.136,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,40.48,28.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,40.48,28.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,24.48,17.136,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC,,
ADALIMUMAB 40 MG/0.8ML SC PSKT,RX-129739,CDM,J0135,HCPCS,636,RC,00074-3799-02,NDC,outpatient,1,UN,9266.62,6486.634,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2101.412877,,,2101.412877,336.23,7116.76416,other,OPPS APC,,
ADALIMUMAB 40 MG/0.8ML SC PNKT,RX-129742,CDM,J0135,HCPCS,636,RC,00074-4339-02,NDC,outpatient,1,UN,9266.62,6486.634,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2101.412877,,,2101.412877,336.23,7116.76416,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,39.59,27.713,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.054984,,,0.054984,0.05,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0136,HCPCS,636,RC,00264-4100-95,NDC,outpatient,100,ML,39.59,27.713,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.054984,,,0.054984,0.05,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,23.59,16.513,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.054984,,,0.054984,0.05,416.02,other,OPPS APC,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,39.59,27.713,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.054984,,,0.054984,0.05,416.02,other,OPPS APC,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,23.59,16.513,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.054984,,,0.054984,0.05,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,39.59,27.713,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.054984,,,0.054984,0.05,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0136,HCPCS,636,RC,00264-4100-95,NDC,outpatient,100,ML,39.59,27.713,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.054984,,,0.054984,0.05,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,23.59,16.513,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.054984,,,0.054984,0.05,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,34.69,24.283,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,18.69,13.083,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,34.69,24.283,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,18.69,13.083,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,34.69,24.283,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,18.69,13.083,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,34.69,24.283,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,18.69,13.083,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,18.69,13.083,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,34.69,24.283,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,34.69,24.283,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,18.69,13.083,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC,,
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,RX-15330,CDM,J0153,HCPCS,636,RC,67457-0857-30,NDC,outpatient,30,ML,821.94,575.358,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,631.24992,other,OPPS APC,,
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,RX-15330,CDM,J0153,HCPCS,636,RC,16714-0997-01,NDC,outpatient,30,ML,109.72,76.804,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,631.24992,other,OPPS APC,,
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,RX-15330,CDM,J0153,HCPCS,636,RC,55150-0193-01,NDC,outpatient,30,ML,91.83,64.281,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,631.24992,other,OPPS APC,,
ADENOSINE 6 MG/2ML IV SOLN,RX-38703,CDM,J0153,HCPCS,636,RC,67457-0855-02,NDC,outpatient,2,ML,24.68,17.276,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,631.24992,other,OPPS APC,,
ADENOSINE 6 MG/2ML IV SOLN,RX-38703,CDM,J0153,HCPCS,636,RC,67457-0855-00,NDC,outpatient,2,ML,24.68,17.276,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,631.24992,other,OPPS APC,,
EPINEPHRINE 0.15 MG/0.3ML IJ SOAJ,RX-124855,CDM,J0171,HCPCS,636,RC,49502-0101-02,NDC,outpatient,1,UN,616.75,431.725,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.73,960.94464,other,OPPS APC,,
EPINEPHRINE 0.15 MG/0.3ML IJ SOAJ,RX-124855,CDM,J0171,HCPCS,636,RC,49502-0501-02,NDC,outpatient,1,UN,1251.23,875.861,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.73,960.94464,other,OPPS APC,,
EPINEPHRINE 0.15 MG/0.3ML IJ SOAJ,RX-124855,CDM,J0171,HCPCS,636,RC,49502-0101-01,NDC,outpatient,1,UN,616.75,431.725,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.73,960.94464,other,OPPS APC,,
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,00115-1694-30,NDC,outpatient,1,UN,506.88,354.816,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.73,960.94464,other,OPPS APC,,
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,00115-1694-49,NDC,outpatient,1,UN,506.88,354.816,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.73,960.94464,other,OPPS APC,,
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,49502-0500-02,NDC,outpatient,1,UN,1251.23,875.861,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.73,960.94464,other,OPPS APC,,
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,49502-0102-01,NDC,outpatient,1,UN,616.75,431.725,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.73,960.94464,other,OPPS APC,,
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,49502-0102-02,NDC,outpatient,1,UN,616.75,431.725,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.73,960.94464,other,OPPS APC,,
EPINEPHRINE INFUSION PREMIX 1 MG IN 250 ML,RX-4080061,CDM,J0171,HCPCS,636,RC,99999-0001-65,NDC,outpatient,250,ML,83.79,58.653,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.73,960.94464,other,OPPS APC,,
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER,RX-4080099,CDM,J0171,HCPCS,636,RC,42023-0159-01,NDC,outpatient,1,ML,57.57,40.299,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.73,960.94464,other,OPPS APC,,
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER,RX-4080099,CDM,J0171,HCPCS,636,RC,42023-0159-25,NDC,outpatient,1,ML,57.57,40.299,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.73,960.94464,other,OPPS APC,,
EPINEPHRINE HCL 0.1 MG/ML IJ WRAPPER,RX-4080103,CDM,J0171,HCPCS,636,RC,76329-3318-01,NDC,outpatient,10,ML,42.5,29.75,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.73,960.94464,other,OPPS APC,,
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER FOR CODE NARRATOR,RX-4081384,CDM,J0171,HCPCS,636,RC,42023-0159-25,NDC,outpatient,1,ML,57.57,40.299,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.73,960.94464,other,OPPS APC,,
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER FOR CODE NARRATOR,RX-4081384,CDM,J0171,HCPCS,636,RC,42023-0159-01,NDC,outpatient,1,ML,57.57,40.299,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.73,960.94464,other,OPPS APC,,
EPINEPHRINE PF 1 MG/ML IJ SOLN,RX-140555,CDM,J0173,HCPCS,636,RC,54288-0103-10,NDC,outpatient,1,ML,35.98,25.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.3013095,,,2.3013095,1.61,416.02,other,OPPS APC,,
EPINEPHRINE PF 1 MG/ML IJ SOLN,RX-140555,CDM,J0173,HCPCS,636,RC,54288-0103-01,NDC,outpatient,1,ML,35.98,25.186,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.3013095,,,2.3013095,1.61,416.02,other,OPPS APC,,
AGALSIDASE BETA 35 MG IV SOLR,RX-35775,CDM,J0180,HCPCS,636,RC,58468-0040-01,NDC,outpatient,1,UN,20575.06,14402.542,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,256.044451,,,256.044451,215.38,15801.64608,other,OPPS APC,,
AGALSIDASE BETA 5 MG IV SOLR,RX-38494,CDM,J0180,HCPCS,636,RC,58468-0041-01,NDC,outpatient,1,UN,2938.8,2057.16,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,256.044451,,,256.044451,215.38,15801.64608,other,OPPS APC,,
ALGLUCOSIDASE ALFA 50 MG IV SOLR,RX-76353,CDM,J0221,HCPCS,636,RC,58468-0160-01,NDC,outpatient,1,UN,2661.83,1863.281,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,231.3509075,,,231.3509075,194.92,2044.28544,other,OPPS APC,,
REMDESIVIR 100 MG IV SOLR,RX-150611,CDM,J0248,HCPCS,636,RC,61958-2901-02,NDC,outpatient,1,UN,1654.57,1158.199,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7.278507,,,7.278507,5.51,1270.70976,other,OPPS APC,,
ALPHA1-PROTEINASE INHIBITOR 1000 MG/20ML IV SOLN,RX-141646,CDM,J0256,HCPCS,636,RC,13533-0705-01,NDC,outpatient,1,UN,1462.8,1023.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5.6530425,,,5.6530425,4.88,1606.272,other,OPPS APC,,
ALPHA1-PROTEINASE INHIBITOR 1000 MG/20ML IV SOLN,RX-141646,CDM,J0256,HCPCS,636,RC,13533-0705-11,NDC,outpatient,1,UN,1462.8,1023.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5.6530425,,,5.6530425,4.88,1606.272,other,OPPS APC,,
ZEMAIRA 1000 MG IV SOLR,RX-36564,CDM,J0256,HCPCS,636,RC,00053-7201-02,NDC,outpatient,1,UN,2091.5,1464.05,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5.6530425,,,5.6530425,4.88,1606.272,other,OPPS APC,,
ALPROSTADIL 500 MCG/ML IJ SOLN,RX-9001,CDM,J0270,HCPCS,636,RC,00009-3169-01,NDC,outpatient,1,ML,564.52,395.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.98,4260,,,,
ALPROSTADIL 500 MCG/ML IJ SOLN,RX-9001,CDM,J0270,HCPCS,636,RC,00009-3169-06,NDC,outpatient,1,ML,564.52,395.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.98,4260,,,,
AMIKACIN SULFATE 500 MG/2ML IJ SOLN,RX-108131,CDM,J0278,HCPCS,636,RC,23155-0290-31,NDC,outpatient,2,ML,17.6,12.32,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.77,416.02,other,OPPS APC,,
AMIKACIN SULFATE 500 MG/2ML IJ SOLN,RX-108131,CDM,J0278,HCPCS,636,RC,23155-0290-41,NDC,outpatient,2,ML,17.6,12.32,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.77,416.02,other,OPPS APC,,
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5921-01,NDC,outpatient,10,ML,61.06,42.742,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.51,416.02,other,OPPS APC,,
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5922-16,NDC,outpatient,20,ML,38.54,26.978,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.51,416.02,other,OPPS APC,,
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5921-16,NDC,outpatient,10,ML,61.06,42.742,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.51,416.02,other,OPPS APC,,
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5922-01,NDC,outpatient,20,ML,38.54,26.978,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.51,416.02,other,OPPS APC,,
AMIODARONE HCL IN DEXTROSE 900-5 MG/500ML-% IV SOLN,RX-135815,CDM,J0282,HCPCS,636,RC,70092-1005-38,NDC,outpatient,500,ML,218.97,153.279,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.46,416.02,other,OPPS APC,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,00143-9875-01,NDC,outpatient,3,ML,3.58,2.506,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.46,416.02,other,OPPS APC,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,67457-0153-18,NDC,outpatient,18,ML,55.43,38.801,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.46,416.02,other,OPPS APC,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,00143-9875-25,NDC,outpatient,3,ML,3.58,2.506,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.46,416.02,other,OPPS APC,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-03,NDC,outpatient,3,ML,9.41,6.587,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.46,416.02,other,OPPS APC,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-09,NDC,outpatient,9,ML,22.43,15.701,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.46,416.02,other,OPPS APC,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,67457-0153-00,NDC,outpatient,3,ML,16.55,11.585,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.46,416.02,other,OPPS APC,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,67457-0153-03,NDC,outpatient,3,ML,16.55,11.585,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.46,416.02,other,OPPS APC,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-01,NDC,outpatient,3,ML,9.41,6.587,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.46,416.02,other,OPPS APC,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-02,NDC,outpatient,9,ML,22.43,15.701,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.46,416.02,other,OPPS APC,,
AMPHOTERICIN B 50 MG IV SOLR,RX-464,CDM,J0285,HCPCS,636,RC,39822-1055-05,NDC,outpatient,1,UN,155.22,108.654,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,34.84689,416.02,other,OPPS APC,,
AMPHOTERICIN B LIPID 5 MG/ML IV SUSP,RX-22981,CDM,J0287,HCPCS,636,RC,57665-0101-41,NDC,outpatient,20,ML,431.74,302.218,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12.749415,,,12.749415,11.13,416.02,other,OPPS APC,,
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,RX-21900,CDM,J0289,HCPCS,636,RC,00469-3051-30,NDC,outpatient,1,UN,1268.66,888.062,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,26.7187875,,,26.7187875,23.33,974.33088,other,OPPS APC,,
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,RX-21900,CDM,J0289,HCPCS,636,RC,62756-0233-01,NDC,outpatient,1,UN,328.95,230.265,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,26.7187875,,,26.7187875,23.33,974.33088,other,OPPS APC,,
AMPICILLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080940,CDM,J0290,HCPCS,636,RC,25021-0136-10,NDC,outpatient,1,UN,10.62,7.434,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC,,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,00781-3407-78,NDC,outpatient,1,UN,4.29,3.003,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC,,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,00781-3407-95,NDC,outpatient,1,UN,4.29,3.003,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC,,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,65219-0016-01,NDC,outpatient,1,UN,5.52,3.864,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC,,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,67850-0024-00,NDC,outpatient,1,UN,8.62,6.034,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC,,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,65219-0016-10,NDC,outpatient,1,UN,5.52,3.864,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC,,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,67850-0024-10,NDC,outpatient,1,UN,8.62,6.034,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC,,
AMPICILLIN SODIUM 1 G IJ SOLR,RX-469,CDM,J0290,HCPCS,636,RC,25021-0136-10,NDC,outpatient,1,UN,10.62,7.434,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,72485-0422-10,NDC,outpatient,1,UN,18.51,12.957,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,25021-0137-20,NDC,outpatient,1,UN,16.54,11.578,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,65219-0020-23,NDC,outpatient,1,UN,32.57,22.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,72485-0422-01,NDC,outpatient,1,UN,18.51,12.957,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,44567-0103-10,NDC,outpatient,1,UN,45.23,31.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,65219-0020-03,NDC,outpatient,1,UN,32.57,22.799,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,55150-0114-20,NDC,outpatient,1,UN,13.5,9.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC,,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,67850-0024-00,NDC,outpatient,1,UN,8.62,6.034,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC,,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,67850-0024-10,NDC,outpatient,1,UN,8.62,6.034,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC,,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,00781-3407-78,NDC,outpatient,1,UN,4.29,3.003,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC,,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,00781-3407-95,NDC,outpatient,1,UN,4.29,3.003,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC,,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,65219-0016-01,NDC,outpatient,1,UN,5.52,3.864,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC,,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,65219-0016-10,NDC,outpatient,1,UN,5.52,3.864,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC,,
AMPICILLIN-SULBACTAM SODIUM 15 (10-5) G IV SOLR,RX-105616,CDM,J0295,HCPCS,636,RC,00049-0024-28,NDC,outpatient,1,UN,84.11,58.877,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.600685,416.02,other,OPPS APC,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IV SOLR,RX-27283,CDM,J0295,HCPCS,636,RC,00409-2987-03,NDC,outpatient,1,UN,24.87,17.409,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.600685,416.02,other,OPPS APC,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IV SOLR,RX-27283,CDM,J0295,HCPCS,636,RC,00409-2987-23,NDC,outpatient,1,UN,24.87,17.409,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.600685,416.02,other,OPPS APC,,
AMPICILLIN-SULBACTAM 3 G 100 ML ADD-VANTAGE BAG,RX-400006,CDM,J0295,HCPCS,636,RC,99999-0003-15,NDC,outpatient,100,ML,43.51,30.457,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.600685,416.02,other,OPPS APC,,
AMPICILLIN-SULBACTAM 3 G 100 ML IVPB BATCHED,RX-4081206,CDM,J0295,HCPCS,636,RC,99999-0003-29,NDC,outpatient,100,ML,29.73,20.811,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.600685,416.02,other,OPPS APC,,
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR,RX-9083,CDM,J0295,HCPCS,636,RC,71288-0031-21,NDC,outpatient,1,UN,21.1,14.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.600685,416.02,other,OPPS APC,,
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR,RX-9083,CDM,J0295,HCPCS,636,RC,71288-0031-20,NDC,outpatient,1,UN,21.1,14.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.600685,416.02,other,OPPS APC,,
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR,RX-9083,CDM,J0295,HCPCS,636,RC,55150-0116-20,NDC,outpatient,1,UN,7.13,4.991,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.600685,416.02,other,OPPS APC,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,00641-6117-01,NDC,outpatient,1,UN,28.2,19.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.600685,416.02,other,OPPS APC,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,00641-6117-10,NDC,outpatient,1,UN,28.2,19.74,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.600685,416.02,other,OPPS APC,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,25021-0143-30,NDC,outpatient,1,UN,36.19,25.333,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.600685,416.02,other,OPPS APC,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,70594-0082-02,NDC,outpatient,1,UN,37.01,25.907,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.600685,416.02,other,OPPS APC,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,71288-0032-20,NDC,outpatient,1,UN,33.6,23.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.600685,416.02,other,OPPS APC,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,72485-0417-01,NDC,outpatient,1,UN,18.05,12.635,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.600685,416.02,other,OPPS APC,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,55150-0117-01,NDC,outpatient,1,UN,13.78,9.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.600685,416.02,other,OPPS APC,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,55150-0117-10,NDC,outpatient,1,UN,13.78,9.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.600685,416.02,other,OPPS APC,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,55150-0117-20,NDC,outpatient,1,UN,13.78,9.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.600685,416.02,other,OPPS APC,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,70594-0082-01,NDC,outpatient,1,UN,37.01,25.907,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.600685,416.02,other,OPPS APC,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,71288-0032-21,NDC,outpatient,1,UN,33.6,23.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.600685,416.02,other,OPPS APC,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,72485-0417-10,NDC,outpatient,1,UN,18.05,12.635,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.600685,416.02,other,OPPS APC,,
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,70004-0910-09,NDC,outpatient,5,ML,31.6,22.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.82,416.02,other,OPPS APC,,
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,70092-1086-44,NDC,outpatient,5,ML,84.42,59.094,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.82,416.02,other,OPPS APC,,
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,69374-0920-05,NDC,outpatient,5,ML,14.14,9.898,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.82,416.02,other,OPPS APC,,
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,70004-0908-09,NDC,outpatient,5,ML,95.5,66.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.82,416.02,other,OPPS APC,,
ANIDULAFUNGIN 100 MG IV SOLR,RX-88093,CDM,J0348,HCPCS,636,RC,00049-0116-28,NDC,outpatient,1,UN,139.38,97.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.46,416.02,other,OPPS APC,,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,00641-6231-25,NDC,outpatient,1,ML,12.17,8.519,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.732165,416.02,other,OPPS APC,,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,55150-0400-01,NDC,outpatient,1,ML,14.72,10.304,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.732165,416.02,other,OPPS APC,,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,00641-6231-01,NDC,outpatient,1,ML,12.17,8.519,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.732165,416.02,other,OPPS APC,,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,63323-0614-01,NDC,outpatient,1,ML,14.49,10.143,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.732165,416.02,other,OPPS APC,,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,55150-0400-25,NDC,outpatient,1,ML,14.72,10.304,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.732165,416.02,other,OPPS APC,,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,63323-0614-00,NDC,outpatient,1,ML,14.49,10.143,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.732165,416.02,other,OPPS APC,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70095-0025-02,NDC,outpatient,1,UN,8.79,6.153,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.834165,416.02,other,OPPS APC,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,00069-3150-83,NDC,outpatient,1,UN,24.39,17.073,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.834165,416.02,other,OPPS APC,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,55150-0174-10,NDC,outpatient,1,UN,9.22,6.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.834165,416.02,other,OPPS APC,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70095-0025-01,NDC,outpatient,1,UN,8.79,6.153,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.834165,416.02,other,OPPS APC,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,63323-0398-01,NDC,outpatient,1,UN,8.17,5.719,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.834165,416.02,other,OPPS APC,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70860-0100-41,NDC,outpatient,1,UN,13.9,9.73,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.834165,416.02,other,OPPS APC,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,00069-3150-84,NDC,outpatient,1,UN,24.39,17.073,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.834165,416.02,other,OPPS APC,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,63323-0398-10,NDC,outpatient,1,UN,8.17,5.719,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.834165,416.02,other,OPPS APC,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70436-0019-82,NDC,outpatient,1,UN,12.13,8.491,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.834165,416.02,other,OPPS APC,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70860-0100-10,NDC,outpatient,1,UN,13.9,9.73,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.834165,416.02,other,OPPS APC,,
AZITHROMYCIN 500 MG IN 250 ML NS PREMIX,RX-4080917,CDM,J0456,HCPCS,636,RC,99999-0001-37,NDC,outpatient,255,ML,46.12,32.284,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.834165,416.02,other,OPPS APC,,
AZTREONAM 1 G IJ SOLR 100 MG/ML,RX-4081004,CDM,J0457,HCPCS,636,RC,00409-0829-11,NDC,outpatient,1,UN,98.69,69.083,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC,,
AZTREONAM 1 G IJ SOLR 100 MG/ML,RX-4081004,CDM,J0457,HCPCS,636,RC,00003-2560-16,NDC,outpatient,1,UN,122.23,85.561,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC,,
AZTREONAM 1 G IJ SOLR 100 MG/ML,RX-4081004,CDM,J0457,HCPCS,636,RC,00409-0829-01,NDC,outpatient,1,UN,98.69,69.083,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC,,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,00409-0830-11,NDC,outpatient,1,UN,201.48,141.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC,,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,00409-0830-01,NDC,outpatient,1,UN,201.48,141.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC,,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,00003-2570-16,NDC,outpatient,1,UN,244.45,171.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC,,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,63323-0402-01,NDC,outpatient,1,UN,201.48,141.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC,,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,63323-0402-20,NDC,outpatient,1,UN,201.48,141.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC,,
AZTREONAM 1 G IJ SOLR,RX-9185,CDM,J0457,HCPCS,636,RC,00003-2560-16,NDC,outpatient,1,UN,122.23,85.561,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC,,
AZTREONAM 1 G IJ SOLR,RX-9185,CDM,J0457,HCPCS,636,RC,00409-0829-01,NDC,outpatient,1,UN,98.69,69.083,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC,,
AZTREONAM 1 G IJ SOLR,RX-9185,CDM,J0457,HCPCS,636,RC,00409-0829-11,NDC,outpatient,1,UN,98.69,69.083,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC,,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,00003-2570-16,NDC,outpatient,1,UN,244.45,171.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC,,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,00409-0830-11,NDC,outpatient,1,UN,201.48,141.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC,,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,63323-0402-01,NDC,outpatient,1,UN,201.48,141.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC,,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,63323-0402-20,NDC,outpatient,1,UN,201.48,141.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC,,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,00409-0830-01,NDC,outpatient,1,UN,201.48,141.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC,,
ATROPINE SULFATE 0.1 MG/ML IJ SOLN WRAPPER,RX-4080930,CDM,J0461,HCPCS,636,RC,76329-3340-01,NDC,outpatient,10,ML,42.72,29.904,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
ATROPINE SULFATE 0.4 MG/ML IJ SOLN WRAPPER,RX-4080931,CDM,J0461,HCPCS,636,RC,00517-1004-01,NDC,outpatient,1,ML,19.31,13.517,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
ATROPINE SULFATE 0.4 MG/ML IJ SOLN WRAPPER,RX-4080931,CDM,J0461,HCPCS,636,RC,00517-1004-25,NDC,outpatient,1,ML,19.31,13.517,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
ATROPINE SULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4081335,CDM,J0461,HCPCS,636,RC,00517-1001-01,NDC,outpatient,1,ML,30.76,21.532,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
ATROPINE SULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4081335,CDM,J0461,HCPCS,636,RC,00517-1001-25,NDC,outpatient,1,ML,30.76,21.532,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
ATROPINE SULFATE 0.25 MG/5ML IJ SOSY,RX-729,CDM,J0461,HCPCS,636,RC,00409-9630-05,NDC,outpatient,5,ML,87.58,61.306,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
ATROPINE SULFATE 0.25 MG/5ML IJ SOSY,RX-729,CDM,J0461,HCPCS,636,RC,00409-9630-15,NDC,outpatient,5,ML,87.58,61.306,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
BACLOFEN 10000 MCG/20ML IT WRAPPER,RX-4081072,CDM,J0475,HCPCS,636,RC,66794-0155-01,NDC,outpatient,20,ML,794.33,556.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,199.9825355,,,199.9825355,174.58,1359.95136,other,OPPS APC,,
BACLOFEN 20000 MCG/20ML IT WRAPPER,RX-4081073,CDM,J0475,HCPCS,636,RC,66794-0156-02,NDC,outpatient,20,ML,1497.87,1048.509,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,199.9825355,,,199.9825355,174.58,1359.95136,other,OPPS APC,,
BACLOFEN 40000 MCG/20ML IT WRAPPER,RX-4081074,CDM,J0475,HCPCS,636,RC,66794-0157-02,NDC,outpatient,20,ML,1770.77,1239.539,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,199.9825355,,,199.9825355,174.58,1359.95136,other,OPPS APC,,
BACLOFEN 50 MCG/ML IT SOSY,RX-107798,CDM,J0476,HCPCS,636,RC,66794-0151-01,NDC,outpatient,1,ML,326.81,228.767,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,40.38,416.02,other,OPPS APC,,
BELIMUMAB 120 MG IV SOLR,RX-108842,CDM,J0490,HCPCS,636,RC,49401-0101-01,NDC,outpatient,1,UN,1753.47,1227.429,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,62.0276795,,,62.0276795,50.93,4488.66816,other,OPPS APC,,
BELIMUMAB 400 MG IV SOLR,RX-108843,CDM,J0490,HCPCS,636,RC,49401-0102-01,NDC,outpatient,1,UN,5844.62,4091.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,62.0276795,,,62.0276795,50.93,4488.66816,other,OPPS APC,,
DICYCLOMINE HCL 10 MG/ML IM SOLN,RX-2417,CDM,J0500,HCPCS,636,RC,14789-0010-02,NDC,outpatient,2,ML,41.12,28.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.23144,416.02,other,OPPS APC,,
DICYCLOMINE HCL 10 MG/ML IM SOLN,RX-2417,CDM,J0500,HCPCS,636,RC,58914-0080-52,NDC,outpatient,2,ML,345.64,241.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.23144,416.02,other,OPPS APC,,
DICYCLOMINE HCL 10 MG/ML IM SOLN,RX-2417,CDM,J0500,HCPCS,636,RC,14789-0010-07,NDC,outpatient,2,ML,41.12,28.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.23144,416.02,other,OPPS APC,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9233-05,NDC,outpatient,2,ML,97.73,68.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,16.21,416.02,other,OPPS APC,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9233-01,NDC,outpatient,2,ML,97.73,68.411,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,16.21,416.02,other,OPPS APC,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,68382-0860-10,NDC,outpatient,2,ML,102.98,72.086,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,16.21,416.02,other,OPPS APC,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9729-01,NDC,outpatient,2,ML,114.01,79.807,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,16.21,416.02,other,OPPS APC,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9729-05,NDC,outpatient,2,ML,114.01,79.807,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,16.21,416.02,other,OPPS APC,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,68382-0860-02,NDC,outpatient,2,ML,102.98,72.086,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,16.21,416.02,other,OPPS APC,,
PENICILLIN G BENZATHINE & PROC 1200000 UNIT/2ML IM SUSP,RX-108051,CDM,J0558,HCPCS,636,RC,60793-0600-02,NDC,outpatient,2,ML,908.68,636.076,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,22.3635965,,,22.3635965,15.67,697.86624,other,OPPS APC,,
PENICILLIN G BENZATHINE & PROC 1200000 UNIT/2ML IM SUSP,RX-108051,CDM,J0558,HCPCS,636,RC,60793-0600-10,NDC,outpatient,2,ML,908.68,636.076,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,22.3635965,,,22.3635965,15.67,697.86624,other,OPPS APC,,
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SUSY,RX-158171,CDM,J0561,HCPCS,636,RC,60793-0700-10,NDC,outpatient,1,ML,595.58,416.906,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,27.913544,,,27.913544,20.17,1623.552,other,OPPS APC,,
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SUSY,RX-158171,CDM,J0561,HCPCS,636,RC,60793-0700-01,NDC,outpatient,1,ML,595.58,416.906,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,27.913544,,,27.913544,20.17,1623.552,other,OPPS APC,,
PENICILLIN G BENZATHINE 1200000 UNIT/2ML IM SUSY,RX-158172,CDM,J0561,HCPCS,636,RC,60793-0701-10,NDC,outpatient,2,ML,1139.95,797.965,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,27.913544,,,27.913544,20.17,1623.552,other,OPPS APC,,
PENICILLIN G BENZATHINE 1200000 UNIT/2ML IM SUSY,RX-158172,CDM,J0561,HCPCS,636,RC,60793-0701-02,NDC,outpatient,2,ML,1139.95,797.965,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,27.913544,,,27.913544,20.17,1623.552,other,OPPS APC,,
PENICILLIN G BENZATHINE 2400000 UNIT/4ML IM SUSY,RX-162947,CDM,J0561,HCPCS,636,RC,60793-0702-04,NDC,outpatient,4,ML,2114,1479.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,27.913544,,,27.913544,20.17,1623.552,other,OPPS APC,,
PENICILLIN G BENZATHINE 2400000 UNIT/4ML IM SUSY,RX-162947,CDM,J0561,HCPCS,636,RC,60793-0702-10,NDC,outpatient,4,ML,2114,1479.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,27.913544,,,27.913544,20.17,1623.552,other,OPPS APC,,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,00781-3158-95,NDC,outpatient,1,UN,308.39,215.873,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.17,416.02,other,OPPS APC,,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,00781-3158-94,NDC,outpatient,1,UN,308.39,215.873,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.17,416.02,other,OPPS APC,,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,16729-0275-03,NDC,outpatient,1,UN,294.51,206.157,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.17,416.02,other,OPPS APC,,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,16729-0275-67,NDC,outpatient,1,UN,294.51,206.157,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.17,416.02,other,OPPS APC,,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,55150-0210-10,NDC,outpatient,1,UN,189.45,132.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.17,416.02,other,OPPS APC,,
ONABOTULINUMTOXINA 100 UNITS IJ SOLR,RX-100610,CDM,J0585,HCPCS,636,RC,00023-1145-01,NDC,outpatient,1,UN,1749.84,1224.888,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7.338073,,,7.338073,6.15,1343.87712,other,OPPS APC,,
BUPRENORPHINE HCL 0.3 MG/ML IJ SOLN,RX-9320,CDM,J0592,HCPCS,636,RC,42023-0179-05,NDC,outpatient,1,ML,53.16,37.212,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.03,416.02,other,OPPS APC,,
BUPRENORPHINE HCL 0.3 MG/ML IJ SOLN,RX-9320,CDM,J0592,HCPCS,636,RC,42023-0179-01,NDC,outpatient,1,ML,53.16,37.212,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.03,416.02,other,OPPS APC,,
BUTORPHANOL TARTRATE 2 MG/ML IJ SOLN,RX-9334,CDM,J0595,HCPCS,636,RC,00409-1626-01,NDC,outpatient,1,ML,29.94,20.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.06,416.02,other,OPPS APC,,
BUTORPHANOL TARTRATE 2 MG/ML IJ SOLN,RX-9334,CDM,J0595,HCPCS,636,RC,00409-1626-21,NDC,outpatient,1,ML,29.94,20.958,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.06,416.02,other,OPPS APC,,
EDETATE CALCIUM DISODIUM 1 GM/5ML IJ SOLN,RX-108094,CDM,J0600,HCPCS,250,RC,64980-0588-51,NDC,outpatient,5,ML,16465.83,11526.081,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6971.878415,,,6971.878415,60.43,12645.75744,other,OPPS APC,,
EDETATE CALCIUM DISODIUM 1 GM/5ML IJ SOLN,RX-108094,CDM,J0600,HCPCS,250,RC,64980-0588-05,NDC,outpatient,5,ML,16465.83,11526.081,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6971.878415,,,6971.878415,60.43,12645.75744,other,OPPS APC,,
CALCIUM GLUCONATE 10 % IV SOLN,RX-1312,CDM,J0612,HCPCS,636,RC,63323-0360-19,NDC,outpatient,10,ML,36.54,25.578,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0446745,,,0.0446745,0.04,416.02,other,OPPS APC,,
CALCIUM GLUCONATE 10 % IV SOLN,RX-1312,CDM,J0612,HCPCS,636,RC,63323-0360-01,NDC,outpatient,10,ML,36.54,25.578,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0446745,,,0.0446745,0.04,416.02,other,OPPS APC,,
CALCIUM GLUCONATE-NACL 1-0.8 GM/100ML-% IV SOLN,RX-156703,CDM,J0613,HCPCS,636,RC,44567-0622-01,NDC,outpatient,100,ML,37.38,26.166,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.100804,,,0.100804,0.08,416.02,other,OPPS APC,,
CALCIUM GLUCONATE-NACL 1-0.8 GM/100ML-% IV SOLN,RX-156703,CDM,J0613,HCPCS,636,RC,44567-0622-24,NDC,outpatient,100,ML,37.38,26.166,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.100804,,,0.100804,0.08,416.02,other,OPPS APC,,
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-01,NDC,outpatient,100,ML,37.38,26.166,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.100804,,,0.100804,0.08,416.02,other,OPPS APC,,
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-01,NDC,outpatient,100,ML,53.38,37.366,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.100804,,,0.100804,0.08,416.02,other,OPPS APC,,
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-24,NDC,outpatient,100,ML,37.38,26.166,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.100804,,,0.100804,0.08,416.02,other,OPPS APC,,
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-24,NDC,outpatient,100,ML,53.38,37.366,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.100804,,,0.100804,0.08,416.02,other,OPPS APC,,
CALCITONIN (SALMON) 200 UNIT/ML IJ SOLN,RX-9347,CDM,J0630,HCPCS,636,RC,42023-0205-01,NDC,outpatient,2,ML,2193.21,1535.247,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1343.739085,,,1343.739085,399.86,2155.44576,other,OPPS APC,,
CALCITONIN (SALMON) 200 UNIT/ML IJ SOLN,RX-9347,CDM,J0630,HCPCS,636,RC,67457-0675-02,NDC,outpatient,2,ML,2806.57,1964.599,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1343.739085,,,1343.739085,399.86,2155.44576,other,OPPS APC,,
LEUCOVORIN CALCIUM IM INJECTION,RX-4080923,CDM,J0640,HCPCS,636,RC,25021-0813-10,NDC,outpatient,50,ME,16.97,11.879,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.68951,416.02,other,OPPS APC,,
LEUCOVORIN CALCIUM 350 MG IJ SOLR,RX-4393,CDM,J0640,HCPCS,636,RC,00143-9552-01,NDC,outpatient,1,UN,106.72,74.704,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.68951,416.02,other,OPPS APC,,
LEUCOVORIN CALCIUM 50 MG IJ SOLR,RX-4394,CDM,J0640,HCPCS,636,RC,25021-0813-10,NDC,outpatient,50,ME,11.98,8.386,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.68951,416.02,other,OPPS APC,,
LEVOTHYROXINE SODIUM 100 MCG IV SOLR,RX-113060,CDM,J0651,HCPCS,250,RC,63323-0885-12,NDC,outpatient,5,ML,293.44,205.408,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4.2921885,,,4.2921885,4.2921885,416.02,other,OPPS APC,,
LEVOTHYROXINE SODIUM 100 MCG IV SOLR,RX-113060,CDM,J0651,HCPCS,250,RC,63323-0649-07,NDC,outpatient,1,UN,279.46,195.622,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4.2921885,,,4.2921885,4.2921885,416.02,other,OPPS APC,,
LEVOTHYROXINE SODIUM 100 MCG IV SOLR,RX-113060,CDM,J0651,HCPCS,250,RC,63323-0885-10,NDC,outpatient,5,ML,293.44,205.408,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4.2921885,,,4.2921885,4.2921885,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00143-9330-01,NDC,outpatient,10,ML,7.82,5.474,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,55150-0168-30,NDC,outpatient,30,ML,11.11,7.777,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,63323-0464-17,NDC,outpatient,10,ML,6.48,4.536,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00143-9330-10,NDC,outpatient,10,ML,7.82,5.474,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-01,NDC,outpatient,10,ML,8.79,6.153,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,55150-0167-10,NDC,outpatient,10,ML,10.85,7.595,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,63323-0464-01,NDC,outpatient,10,ML,6.48,4.536,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-02,NDC,outpatient,30,ML,8.79,6.153,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-18,NDC,outpatient,10,ML,8.79,6.153,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-19,NDC,outpatient,30,ML,8.79,6.153,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1559-19,NDC,outpatient,30,ML,19.59,13.713,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1559-30,NDC,outpatient,30,ML,19.59,13.713,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1162-01,NDC,outpatient,10,ML,10.08,7.056,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1560-18,NDC,outpatient,10,ML,19.43,13.601,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1560-19,NDC,outpatient,30,ML,17.89,12.523,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,63323-0466-37,NDC,outpatient,30,ML,9.57,6.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,55150-0170-30,NDC,outpatient,30,ML,12.34,8.638,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1162-02,NDC,outpatient,30,ML,9.72,6.804,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,63323-0466-01,NDC,outpatient,30,ML,9.57,6.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,63323-0472-01,NDC,outpatient,30,ML,12.8,8.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,00409-1165-02,NDC,outpatient,30,ML,16.97,11.879,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,00409-1165-19,NDC,outpatient,30,ML,16.97,11.879,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,63323-0472-37,NDC,outpatient,30,ML,12.8,8.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL 0.25 % IJ SOLN,RX-1222,CDM,J0665,HCPCS,636,RC,63323-0465-57,NDC,outpatient,5,ML,5.5,3.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL 0.25 % IJ SOLN,RX-1222,CDM,J0665,HCPCS,636,RC,63323-0465-01,NDC,outpatient,5,ML,5.5,3.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL 0.5 % IJ SOLN,RX-1223,CDM,J0665,HCPCS,636,RC,00409-1163-01,NDC,outpatient,5,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL 0.5 % IJ SOLN,RX-1223,CDM,J0665,HCPCS,636,RC,00409-1163-18,NDC,outpatient,5,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE IN DEXTROSE 0.75-8.25 % IT SOLN,RX-9316,CDM,J0665,HCPCS,636,RC,00409-1761-18,NDC,outpatient,2,ML,20.36,14.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE IN DEXTROSE 0.75-8.25 % IT SOLN,RX-9316,CDM,J0665,HCPCS,636,RC,00409-1761-10,NDC,outpatient,2,ML,20.36,14.252,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
MEPIVACAINE HCL (PF) 2 % IJ SOLN,RX-105638,CDM,J0670,HCPCS,636,RC,63323-0294-01,NDC,outpatient,20,ML,27.95,19.565,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.08,416.02,other,OPPS APC,,
MEPIVACAINE HCL (PF) 2 % IJ SOLN,RX-105638,CDM,J0670,HCPCS,636,RC,63323-0294-27,NDC,outpatient,20,ML,27.95,19.565,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.08,416.02,other,OPPS APC,,
CEFAZOLIN IVPB 2 G IN 100 ML D4W PREMIX|DISCARDED DRUG NOT ADMINISTERED,RX-4080727,CDM,J0689,HCPCS,636,RC,00338-3508-41,NDC,outpatient,100,ML,26.74,18.718,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,1.44333,,,1.44333,1.22,416.02,other,OPPS APC,,
CEFAZOLIN IVPB 2 G IN 100 ML D4W PREMIX,RX-4080727,CDM,J0689,HCPCS,636,RC,00338-3508-41,NDC,outpatient,100,ML,42.74,29.918,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.44333,,,1.44333,1.22,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,44567-0707-25,NDC,outpatient,1,UN,7.84,5.488,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,00143-9924-90,NDC,outpatient,1,UN,5.85,4.095,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,25021-0101-10,NDC,outpatient,1,UN,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,60505-6142-00,NDC,outpatient,1,UN,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,60505-6142-05,NDC,outpatient,1,UN,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 10 G IJ SOLR,RX-1446,CDM,J0690,HCPCS,636,RC,00143-9983-03,NDC,outpatient,1,UN,40.9,28.63,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 10 G IJ SOLR,RX-1446,CDM,J0690,HCPCS,636,RC,00143-9983-91,NDC,outpatient,1,UN,40.9,28.63,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 500 MG IJ SOLR,RX-1448,CDM,J0690,HCPCS,636,RC,44567-0706-25,NDC,outpatient,1,UN,4.28,2.996,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 2 G IJ SOLR,RX-158156,CDM,J0690,HCPCS,636,RC,60505-6231-00,NDC,outpatient,1,UN,18.74,13.118,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 2 G IJ SOLR,RX-158156,CDM,J0690,HCPCS,636,RC,60505-6231-05,NDC,outpatient,1,UN,18.74,13.118,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 1 G IV SOLR ADD-VANTAGE,RX-27297,CDM,J0690,HCPCS,636,RC,00409-2585-01,NDC,outpatient,1,UN,12.17,8.519,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 1 G IV SOLR ADD-VANTAGE,RX-27297,CDM,J0690,HCPCS,636,RC,00409-2585-11,NDC,outpatient,1,UN,12.17,8.519,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,00143-9924-90,NDC,outpatient,1,UN,5.85,4.095,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,44567-0707-25,NDC,outpatient,1,UN,7.84,5.488,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,25021-0101-10,NDC,outpatient,1,UN,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,60505-6142-00,NDC,outpatient,1,UN,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,60505-6142-05,NDC,outpatient,1,UN,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,25021-0101-10,NDC,outpatient,1,UN,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,60505-6142-00,NDC,outpatient,1,UN,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,44567-0707-25,NDC,outpatient,1,UN,7.84,5.488,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,60505-6142-05,NDC,outpatient,1,UN,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,00143-9924-90,NDC,outpatient,1,UN,5.85,4.095,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 1 G 100 ML ADD-VANTAGE BAG,RX-4081138,CDM,J0690,HCPCS,636,RC,99999-0003-01,NDC,outpatient,100,ML,32.9,23.03,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC,,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,00409-9566-10,NDC,outpatient,1,UN,16.63,11.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,25021-0121-20,NDC,outpatient,1,UN,17.97,12.579,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,44567-0240-10,NDC,outpatient,1,UN,23.44,16.408,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,60505-6146-00,NDC,outpatient,1,UN,12,8.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,00409-9566-01,NDC,outpatient,1,UN,16.63,11.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,60505-6146-04,NDC,outpatient,1,UN,12,8.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,44567-0241-10,NDC,outpatient,1,UN,40.3,28.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,70594-0090-01,NDC,outpatient,1,UN,40.3,28.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,00409-9735-01,NDC,outpatient,1,UN,25.5,17.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,25021-0122-50,NDC,outpatient,1,UN,32.22,22.554,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,60505-6246-00,NDC,outpatient,1,UN,19.47,13.629,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,00409-9735-10,NDC,outpatient,1,UN,25.5,17.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,60505-6246-04,NDC,outpatient,1,UN,19.47,13.629,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,70594-0090-02,NDC,outpatient,1,UN,40.3,28.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME IVPB 1 G IN 100 ML NS COMPOUNDED,RX-4080828,CDM,J0692,HCPCS,636,RC,99999-0001-09,NDC,outpatient,100,ML,48.93,34.251,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,00409-9735-01,NDC,outpatient,1,UN,25.5,17.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,70594-0090-02,NDC,outpatient,1,UN,40.3,28.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,60505-6147-00,NDC,outpatient,1,UN,34.31,24.017,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,44567-0241-10,NDC,outpatient,1,UN,40.3,28.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,60505-6147-04,NDC,outpatient,1,UN,19.47,13.629,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,70594-0090-01,NDC,outpatient,1,UN,40.3,28.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,00409-9735-10,NDC,outpatient,1,UN,25.5,17.85,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,60505-6146-04,NDC,outpatient,1,UN,12,8.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,44567-0240-10,NDC,outpatient,1,UN,23.44,16.408,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,00409-9566-01,NDC,outpatient,1,UN,16.63,11.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,00409-9566-10,NDC,outpatient,1,UN,16.63,11.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,25021-0121-20,NDC,outpatient,1,UN,17.97,12.579,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,60505-6146-00,NDC,outpatient,1,UN,12,8.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.22,416.02,other,OPPS APC,,
CEFOXITIN SODIUM-DEXTROSE 2-2.2 GM-%(50ML) IV SOLR,RX-144407,CDM,J0694,HCPCS,636,RC,00264-3125-11,NDC,outpatient,1,UN,147.33,103.131,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.679555,416.02,other,OPPS APC,,
CEFOXITIN IVPB 2 G IN 100 ML NS COMPOUNDED,RX-4080864,CDM,J0694,HCPCS,636,RC,99999-0001-16,NDC,outpatient,100,ML,46.14,32.298,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.679555,416.02,other,OPPS APC,,
CEFOXITIN SODIUM 1 G IV SOLR 1000 MG/10.5 ML,RX-4080998,CDM,J0694,HCPCS,636,RC,44567-0245-25,NDC,outpatient,1,UN,40.92,28.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.679555,416.02,other,OPPS APC,,
CEFOXITIN SODIUM 1 G IV SOLR 1000 MG/10.5 ML,RX-4080998,CDM,J0694,HCPCS,636,RC,25021-0109-10,NDC,outpatient,1,UN,16.39,11.473,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.679555,416.02,other,OPPS APC,,
CEFOXITIN SODIUM 2 G IV SOLR 2000 MG/11.1 ML,RX-4081009,CDM,J0694,HCPCS,636,RC,25021-0110-20,NDC,outpatient,1,UN,30.34,21.238,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.679555,416.02,other,OPPS APC,,
CEFOXITIN SODIUM 2 G IV SOLR 2000 MG/11.1 ML,RX-4081009,CDM,J0694,HCPCS,636,RC,44567-0246-25,NDC,outpatient,1,UN,82.04,57.428,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.679555,416.02,other,OPPS APC,,
CEFOXITIN SODIUM 1 G IV SOLR,RX-9461,CDM,J0694,HCPCS,636,RC,44567-0245-25,NDC,outpatient,1,UN,40.92,28.644,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.679555,416.02,other,OPPS APC,,
CEFOXITIN SODIUM 1 G IV SOLR,RX-9461,CDM,J0694,HCPCS,636,RC,25021-0109-10,NDC,outpatient,1,UN,16.39,11.473,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.679555,416.02,other,OPPS APC,,
CEFOXITIN SODIUM 2 G IV SOLR,RX-9463,CDM,J0694,HCPCS,636,RC,25021-0110-20,NDC,outpatient,1,UN,30.34,21.238,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.679555,416.02,other,OPPS APC,,
CEFOXITIN SODIUM 2 G IV SOLR,RX-9463,CDM,J0694,HCPCS,636,RC,44567-0246-25,NDC,outpatient,1,UN,82.04,57.428,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.679555,416.02,other,OPPS APC,,
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G IV SOLR,RX-129169,CDM,J0695,HCPCS,636,RC,67919-0030-01,NDC,outpatient,1,UN,652.32,456.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9.427465,,,9.427465,7.54,500.98176,other,OPPS APC,,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00781-3208-95,NDC,outpatient,1,UN,17.99,12.593,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,25021-0106-10,NDC,outpatient,1,UN,9.22,6.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,44567-0701-25,NDC,outpatient,1,UN,4.75,3.325,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00143-9857-01,NDC,outpatient,1,UN,5.23,3.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00143-9857-25,NDC,outpatient,1,UN,5.23,3.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00781-3208-85,NDC,outpatient,1,UN,17.99,12.593,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00143-9856-01,NDC,outpatient,1,UN,9.12,6.384,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00781-3209-90,NDC,outpatient,1,UN,11.14,7.798,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00143-9856-25,NDC,outpatient,1,UN,9.12,6.384,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00781-3209-95,NDC,outpatient,1,UN,11.14,7.798,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,25021-0107-20,NDC,outpatient,1,UN,18.72,13.104,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,44567-0702-25,NDC,outpatient,1,UN,9.03,6.321,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00409-7332-01,NDC,outpatient,1,UN,6.94,4.858,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,25021-0106-10,NDC,outpatient,1,UN,9.22,6.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00143-9857-01,NDC,outpatient,1,UN,5.23,3.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00143-9857-25,NDC,outpatient,1,UN,5.23,3.661,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00781-3208-95,NDC,outpatient,1,UN,17.99,12.593,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00409-7332-11,NDC,outpatient,1,UN,6.94,4.858,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00781-3208-85,NDC,outpatient,1,UN,17.99,12.593,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,44567-0701-25,NDC,outpatient,1,UN,4.75,3.325,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00143-9856-25,NDC,outpatient,1,UN,9.12,6.384,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00781-3209-90,NDC,outpatient,1,UN,11.14,7.798,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00781-3209-95,NDC,outpatient,1,UN,11.14,7.798,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,25021-0107-20,NDC,outpatient,1,UN,18.72,13.104,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00143-9856-01,NDC,outpatient,1,UN,9.12,6.384,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,44567-0702-25,NDC,outpatient,1,UN,9.03,6.321,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00143-9859-01,NDC,outpatient,1,UN,4.32,3.024,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00409-7337-01,NDC,outpatient,1,UN,3.47,2.429,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00781-3206-85,NDC,outpatient,1,UN,6.33,4.431,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00409-7337-11,NDC,outpatient,1,UN,3.47,2.429,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00781-3206-95,NDC,outpatient,1,UN,6.33,4.431,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00143-9859-25,NDC,outpatient,1,UN,4.32,3.024,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC,,
CEFUROXIME SODIUM 750 MG IJ SOLR,RX-1465,CDM,J0697,HCPCS,636,RC,00143-9979-22,NDC,outpatient,1,UN,12.5,8.75,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.88,416.02,other,OPPS APC,,
CEFUROXIME SODIUM 750 MG IJ SOLR,RX-1465,CDM,J0697,HCPCS,636,RC,00143-9979-90,NDC,outpatient,1,UN,12.5,8.75,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.88,416.02,other,OPPS APC,,
CEFUROXIME SODIUM 750 MG IJ SOLR,RX-1465,CDM,J0697,HCPCS,636,RC,25021-0118-10,NDC,outpatient,1,UN,9.6,6.72,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.88,416.02,other,OPPS APC,,
CEFUROXIME SODIUM 1.5 G IV SOLR,RX-27299,CDM,J0697,HCPCS,636,RC,00143-9977-22,NDC,outpatient,1,UN,21.64,15.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.88,416.02,other,OPPS APC,,
CEFUROXIME SODIUM 1.5 G IV SOLR,RX-27299,CDM,J0697,HCPCS,636,RC,00143-9977-90,NDC,outpatient,1,UN,21.64,15.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.88,416.02,other,OPPS APC,,
CEFUROXIME SODIUM 750 MG IJ SOLR 750 MG/8.3 ML,RX-4080994,CDM,J0697,HCPCS,636,RC,00143-9979-22,NDC,outpatient,1,UN,12.5,8.75,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.88,416.02,other,OPPS APC,,
CEFUROXIME SODIUM 750 MG IJ SOLR 750 MG/8.3 ML,RX-4080994,CDM,J0697,HCPCS,636,RC,00143-9979-90,NDC,outpatient,1,UN,12.5,8.75,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.88,416.02,other,OPPS APC,,
CEFUROXIME SODIUM 750 MG IJ SOLR 750 MG/8.3 ML,RX-4080994,CDM,J0697,HCPCS,636,RC,25021-0118-10,NDC,outpatient,1,UN,9.6,6.72,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.88,416.02,other,OPPS APC,,
CEFUROXIME SODIUM 1.5 G IJ SOLR IN 16 ML,RX-4081008,CDM,J0697,HCPCS,636,RC,00143-9977-22,NDC,outpatient,1,UN,21.64,15.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.88,416.02,other,OPPS APC,,
CEFUROXIME SODIUM 1.5 G IJ SOLR IN 16 ML,RX-4081008,CDM,J0697,HCPCS,636,RC,00143-9977-90,NDC,outpatient,1,UN,21.64,15.148,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.88,416.02,other,OPPS APC,,
BETAMETHASONE SOD PHOS & ACET 6 (3-3) MG/ML IJ SUSP,RX-9266,CDM,J0702,HCPCS,636,RC,78206-0118-01,NDC,outpatient,5,ML,170.75,119.525,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,6.96,416.02,other,OPPS APC,,
BETAMETHASONE SOD PHOS & ACET 6 (3-3) MG/ML IJ SUSP,RX-9266,CDM,J0702,HCPCS,636,RC,00517-0720-01,NDC,outpatient,5,ML,143.92,100.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,6.96,416.02,other,OPPS APC,,
CAFFEINE CITRATE 60 MG/3ML IV SOLN,RX-109034,CDM,J0706,HCPCS,636,RC,51754-0500-01,NDC,outpatient,3,ML,26.75,18.725,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.65,416.02,other,OPPS APC,,
CEFTAROLINE FOSAMIL 400 MG IV SOLR,RX-107670,CDM,J0712,HCPCS,636,RC,00456-0400-01,NDC,outpatient,1,UN,806.58,564.606,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4.5075425,,,4.5075425,3.89,619.45344,other,OPPS APC,,
CEFTAROLINE FOSAMIL 400 MG IV SOLR,RX-107670,CDM,J0712,HCPCS,636,RC,00456-0400-10,NDC,outpatient,1,UN,806.58,564.606,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4.5075425,,,4.5075425,3.89,619.45344,other,OPPS APC,,
CEFTAROLINE FOSAMIL 600 MG IV SOLR,RX-107671,CDM,J0712,HCPCS,636,RC,00456-0600-01,NDC,outpatient,1,UN,806.58,564.606,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4.5075425,,,4.5075425,3.89,619.45344,other,OPPS APC,,
CEFTAROLINE FOSAMIL 600 MG IV SOLR,RX-107671,CDM,J0712,HCPCS,636,RC,00456-0600-10,NDC,outpatient,1,UN,806.58,564.606,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4.5075425,,,4.5075425,3.89,619.45344,other,OPPS APC,,
CEFTAZIDIME 2 G IV SOLR,RX-27291,CDM,J0713,HCPCS,636,RC,25021-0128-50,NDC,outpatient,1,UN,37.01,25.907,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.66,416.02,other,OPPS APC,,
CEFTAZIDIME 2 G IV SOLR,RX-27291,CDM,J0713,HCPCS,636,RC,44567-0236-10,NDC,outpatient,1,UN,23.52,16.464,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.66,416.02,other,OPPS APC,,
CEFTAZIDIME 1 MG/ML IJ SOLR,RX-4080666,CDM,J0713,HCPCS,636,RC,00409-5082-16,NDC,outpatient,1,UN,14.25,9.975,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.66,416.02,other,OPPS APC,,
CEFTAZIDIME 1 G IJ SOLR 1000 MG/10.8 ML,RX-4081001,CDM,J0713,HCPCS,636,RC,00409-5082-16,NDC,outpatient,1,UN,14.25,9.975,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.66,416.02,other,OPPS APC,,
CEFTAZIDIME 2 G IJ SOLR 2000 MG/11.5 ML,RX-4081002,CDM,J0713,HCPCS,636,RC,25021-0128-50,NDC,outpatient,1,UN,37.01,25.907,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.66,416.02,other,OPPS APC,,
CEFTAZIDIME 1 G IJ SOLR,RX-9474,CDM,J0713,HCPCS,636,RC,44567-0235-25,NDC,outpatient,1,UN,13.87,9.709,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.66,416.02,other,OPPS APC,,
CEFTAZIDIME 1 G IJ SOLR,RX-9474,CDM,J0713,HCPCS,636,RC,00409-5082-11,NDC,outpatient,1,UN,14.25,9.975,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.66,416.02,other,OPPS APC,,
CEFTAZIDIME 1 G IJ SOLR,RX-9474,CDM,J0713,HCPCS,636,RC,00409-5082-16,NDC,outpatient,1,UN,14.25,9.975,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.66,416.02,other,OPPS APC,,
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G IV SOLR,RX-130403,CDM,J0714,HCPCS,636,RC,00456-2700-10,NDC,outpatient,1,UN,1625.76,1138.032,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,115.216681,,,115.216681,92.48,1248.58368,other,OPPS APC,,
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G IV SOLR,RX-130403,CDM,J0714,HCPCS,636,RC,00456-2700-01,NDC,outpatient,1,UN,1625.76,1138.032,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,115.216681,,,115.216681,92.48,1248.58368,other,OPPS APC,,
CLONIDINE HCL (ANALGESIA) 100 MCG/ML EP SOLN,RX-19333,CDM,J0735,HCPCS,636,RC,67457-0218-10,NDC,outpatient,10,ML,45.22,31.654,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.15189,416.02,other,OPPS APC,,
CLONIDINE HCL (ANALGESIA) 500 MCG/ML EP SOLN,RX-27113,CDM,J0735,HCPCS,636,RC,39822-2010-01,NDC,outpatient,10,ML,402.95,282.065,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.15189,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE 150 MG/ML IJ WRAPPER,RX-4080195,CDM,J0736,HCPCS,636,RC,00009-0775-20,NDC,outpatient,4,ML,13.99,9.793,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.8236575,,,2.8236575,1.61,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE 150 MG/ML IJ WRAPPER,RX-4080195,CDM,J0736,HCPCS,636,RC,00009-0775-26,NDC,outpatient,4,ML,13.99,9.793,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.8236575,,,2.8236575,1.61,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0736,HCPCS,636,RC,00781-3288-09,NDC,outpatient,50,ML,48.27,33.789,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.8236575,,,2.8236575,1.61,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0736,HCPCS,636,RC,00781-3288-91,NDC,outpatient,50,ML,48.27,33.789,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.8236575,,,2.8236575,1.61,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-09,NDC,outpatient,50,ML,64.73,45.311,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.8236575,,,2.8236575,1.61,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-09,NDC,outpatient,50,ML,48.73,34.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,2.8236575,,,2.8236575,1.61,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-91,NDC,outpatient,50,ML,48.73,34.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,2.8236575,,,2.8236575,1.61,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-91,NDC,outpatient,50,ML,64.73,45.311,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.8236575,,,2.8236575,1.61,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0737,HCPCS,636,RC,00338-3410-50,NDC,outpatient,50,ML,30.91,21.637,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0737,HCPCS,636,RC,00338-3410-24,NDC,outpatient,50,ML,30.91,21.637,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-50,NDC,outpatient,50,ML,34.25,23.975,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-24,NDC,outpatient,50,ML,34.25,23.975,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-50,NDC,outpatient,50,ML,34.25,23.975,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-24,NDC,outpatient,50,ML,18.25,12.775,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-24,NDC,outpatient,50,ML,34.25,23.975,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-24,NDC,outpatient,50,ML,18.25,12.775,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-50,NDC,outpatient,50,ML,18.25,12.775,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-50,NDC,outpatient,50,ML,18.25,12.775,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-24,NDC,outpatient,50,ML,38.7,27.09,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-50,NDC,outpatient,50,ML,38.7,27.09,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-24,NDC,outpatient,50,ML,22.7,15.89,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-50,NDC,outpatient,50,ML,22.7,15.89,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC,,
IMIPENEM-CILASTATIN 250 MG IV SOLR,RX-9602,CDM,J0743,HCPCS,636,RC,63323-0349-25,NDC,outpatient,1,UN,25.58,17.906,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,5.74271,416.02,other,OPPS APC,,
IMIPENEM-CILASTATIN 500 MG IV SOLR,RX-9603,CDM,J0743,HCPCS,636,RC,63323-0322-25,NDC,outpatient,1,UN,43.92,30.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,5.74271,416.02,other,OPPS APC,,
IMIPENEM-CILASTATIN 500 MG IV SOLR,RX-9603,CDM,J0743,HCPCS,636,RC,63323-0322-01,NDC,outpatient,1,UN,43.92,30.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,5.74271,416.02,other,OPPS APC,,
CIPROFLOXACIN IN D5W 200 MG/100ML IV SOLN,RX-108130,CDM,J0744,HCPCS,636,RC,00409-2300-24,NDC,outpatient,100,ML,26.8,18.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.86,416.02,other,OPPS APC,,
CIPROFLOXACIN IN D5W 200 MG/100ML IV SOLN,RX-108130,CDM,J0744,HCPCS,636,RC,00409-2300-01,NDC,outpatient,100,ML,26.8,18.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.86,416.02,other,OPPS APC,,
CIPROFLOXACIN IN D5W 400 MG/200ML IV SOLN,RX-108132,CDM,J0744,HCPCS,636,RC,25021-0114-87,NDC,outpatient,200,ML,42.7,29.89,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.86,416.02,other,OPPS APC,,
COLISTIMETHATE SODIUM (CBA) 150 MG IJ SOLR,RX-142413,CDM,J0770,HCPCS,636,RC,70594-0023-04,NDC,outpatient,1,UN,46.34,32.438,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.40333,416.02,other,OPPS APC,,
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,00713-0351-09,NDC,outpatient,2,ML,15.66,10.962,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.01,416.02,other,OPPS APC,,
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,00713-0351-25,NDC,outpatient,2,ML,13.73,9.611,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.01,416.02,other,OPPS APC,,
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,14789-0700-02,NDC,outpatient,2,ML,14.97,10.479,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.01,416.02,other,OPPS APC,,
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,14789-0700-07,NDC,outpatient,2,ML,14.97,10.479,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.01,416.02,other,OPPS APC,,
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,00713-0351-02,NDC,outpatient,2,ML,13.73,9.611,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.01,416.02,other,OPPS APC,,
COSYNTROPIN 0.25 MG IJ SOLR,RX-9686,CDM,J0834,HCPCS,636,RC,00548-5900-00,NDC,outpatient,1,UN,74.02,51.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,16.61749,416.02,other,OPPS APC,,
COSYNTROPIN 0.25 MG IJ SOLR,RX-9686,CDM,J0834,HCPCS,636,RC,00781-3440-95,NDC,outpatient,1,UN,356.89,249.823,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,16.61749,416.02,other,OPPS APC,,
COSYNTROPIN 0.25 MG IJ SOLR,RX-9686,CDM,J0834,HCPCS,636,RC,00781-3440-71,NDC,outpatient,1,UN,356.89,249.823,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,16.61749,416.02,other,OPPS APC,,
DAPTOMYCIN 500 MG IV SOLR,RX-36989,CDM,J0873,HCPCS,636,RC,70594-0034-01,NDC,outpatient,1,UN,65.78,46.046,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.04,416.02,other,OPPS APC,,
DALBAVANCIN HCL 500 MG IV SOLR,RX-125774,CDM,J0875,HCPCS,636,RC,57970-0100-01,NDC,outpatient,1,UN,2550.24,1785.168,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,17.883546,,,17.883546,14.7,4668.927562,other,OPPS APC,,
DAPTOMYCIN 350 MG IV SOLR,RX-143414,CDM,J0878,HCPCS,636,RC,16729-0434-45,NDC,outpatient,1,UN,201.59,141.113,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.03,416.02,other,OPPS APC,,
DAPTOMYCIN 350 MG IV SOLR,RX-143414,CDM,J0878,HCPCS,636,RC,16729-0434-05,NDC,outpatient,1,UN,201.5,141.05,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.03,416.02,other,OPPS APC,,
DAPTOMYCIN 500 MG IV SOLR,RX-36989,CDM,J0878,HCPCS,636,RC,00143-9378-01,NDC,outpatient,1,UN,57.59,40.313,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.03,416.02,other,OPPS APC,,
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0883,HCPCS,636,RC,16729-0430-43,NDC,outpatient,50,ML,358.65,251.055,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.4398935,,,1.4398935,1.35,1059.84,other,OPPS APC,,
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0883,HCPCS,636,RC,00143-9559-01,NDC,outpatient,50,ML,422.53,295.771,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,1.4398935,,,1.4398935,1.35,1059.84,other,OPPS APC,,
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0883,HCPCS,636,RC,25021-0414-50,NDC,outpatient,50,ML,317.29,222.103,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,1.4398935,,,1.4398935,1.35,1059.84,other,OPPS APC,,
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0883,HCPCS,636,RC,00143-9559-01,NDC,outpatient,50,ML,438.53,306.971,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.4398935,,,1.4398935,1.35,1059.84,other,OPPS APC,,
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0883,HCPCS,636,RC,25021-0414-50,NDC,outpatient,50,ML,333.29,233.303,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.4398935,,,1.4398935,1.35,1059.84,other,OPPS APC,,
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0883,HCPCS,636,RC,16729-0430-43,NDC,outpatient,50,ML,342.65,239.855,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,1.4398935,,,1.4398935,1.35,1059.84,other,OPPS APC,,
ARGATROBAN 250 MG/2.5ML IV SOLN,RX-28947,CDM,J0883,HCPCS,636,RC,63323-0526-03,NDC,outpatient,2.5,ML,1328.82,930.174,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.4398935,,,1.4398935,1.35,1059.84,other,OPPS APC,,
ARGATROBAN 250 MG/2.5ML IV SOLN,RX-28947,CDM,J0883,HCPCS,636,RC,00143-9674-01,NDC,outpatient,2.5,ML,1380,966,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.4398935,,,1.4398935,1.35,1059.84,other,OPPS APC,,
ARGATROBAN 250 MG/2.5ML IV SOLN,RX-28947,CDM,J0883,HCPCS,636,RC,00409-1140-01,NDC,outpatient,2.5,ML,226.15,158.305,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.4398935,,,1.4398935,1.35,1059.84,other,OPPS APC,,
EPOETIN ALFA 10000 UNIT/ML IJ SOLN,RX-9938,CDM,J0885,HCPCS,636,RC,59676-0310-00,NDC,outpatient,1,ML,622.94,436.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8.623324,,,8.623324,6.88,478.41792,other,OPPS APC,,
EPOETIN ALFA 10000 UNIT/ML IJ SOLN,RX-9938,CDM,J0885,HCPCS,636,RC,59676-0310-01,NDC,outpatient,1,ML,622.94,436.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8.623324,,,8.623324,6.88,478.41792,other,OPPS APC,,
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,55513-0148-10,NDC,outpatient,1,ML,283.41,198.387,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8.623324,,,8.623324,6.88,478.41792,other,OPPS APC,,
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,59676-0304-00,NDC,outpatient,1,ML,456.83,319.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8.623324,,,8.623324,6.88,478.41792,other,OPPS APC,,
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,55513-0148-01,NDC,outpatient,1,ML,283.41,198.387,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8.623324,,,8.623324,6.88,478.41792,other,OPPS APC,,
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,59676-0304-01,NDC,outpatient,1,ML,456.83,319.781,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8.623324,,,8.623324,6.88,478.41792,other,OPPS APC,,
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0891,HCPCS,636,RC,16729-0430-11,NDC,outpatient,50,ML,358.65,251.055,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4.808809,,,4.808809,0.46,416.02,other,OPPS APC,,
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0891,HCPCS,636,RC,16729-0430-11,NDC,outpatient,50,ML,342.65,239.855,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,4.808809,,,4.808809,0.46,416.02,other,OPPS APC,,
DECITABINE 50 MG IV SOLR,RX-76364,CDM,J0894,HCPCS,636,RC,16729-0224-05,NDC,outpatient,1,UN,335.38,234.766,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.63,416.02,other,OPPS APC,,
DEFEROXAMINE MESYLATE 500 MG IJ SOLR,RX-9723,CDM,J0895,HCPCS,636,RC,60505-6236-00,NDC,outpatient,1,UN,46.34,32.438,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,6.78,416.02,other,OPPS APC,,
DEFEROXAMINE MESYLATE 500 MG IJ SOLR,RX-9723,CDM,J0895,HCPCS,636,RC,60505-6236-06,NDC,outpatient,1,UN,46.34,32.438,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,6.78,416.02,other,OPPS APC,,
DENOSUMAB 120 MG/1.7ML SC SOLN,RX-106804,CDM,J0897,HCPCS,636,RC,55513-0730-01,NDC,outpatient,1.7,ML,8861.12,6202.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,30.88268,,,30.88268,24.19,6805.34016,other,OPPS APC,,
DENOSUMAB 60 MG/ML SC SOSY,RX-146195,CDM,J0897,HCPCS,636,RC,55513-0710-01,NDC,outpatient,1,ML,4649.31,3254.517,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,30.88268,,,30.88268,24.19,6805.34016,other,OPPS APC,,
TESTOSTERONE CYPIONATE 200 MG/ML IM SOLN,RX-7784,CDM,J1071,HCPCS,636,RC,00009-0417-01,NDC,outpatient,1,ML,41.92,29.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.03,416.02,other,OPPS APC,,
DEXAMETHASONE SOD PHOSPHATE PF 10 MG/ML IJ SOLN,RX-116345,CDM,J1100,HCPCS,636,RC,99999-0003-18,NDC,outpatient,1,ML,8.17,5.719,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.11,416.02,other,OPPS APC,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,63323-0165-01,NDC,outpatient,1,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.11,416.02,other,OPPS APC,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,67457-0423-12,NDC,outpatient,1,ML,3.69,2.583,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.11,416.02,other,OPPS APC,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,67457-0423-00,NDC,outpatient,1,ML,3.69,2.583,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.11,416.02,other,OPPS APC,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,63323-0165-02,NDC,outpatient,1,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.11,416.02,other,OPPS APC,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,00641-6145-01,NDC,outpatient,1,ML,4.14,2.898,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.11,416.02,other,OPPS APC,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,00641-6145-25,NDC,outpatient,1,ML,4.14,2.898,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.11,416.02,other,OPPS APC,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,55150-0237-01,NDC,outpatient,1,ML,4.01,2.807,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.11,416.02,other,OPPS APC,,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,00641-0367-21,NDC,outpatient,1,ML,6.11,4.277,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.11,416.02,other,OPPS APC,,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,70069-0021-25,NDC,outpatient,1,ML,8.17,5.719,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.11,416.02,other,OPPS APC,,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,63323-0506-01,NDC,outpatient,1,ML,6.99,4.893,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.11,416.02,other,OPPS APC,,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,00641-0367-25,NDC,outpatient,1,ML,6.11,4.277,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.11,416.02,other,OPPS APC,,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,70069-0021-01,NDC,outpatient,1,ML,8.17,5.719,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.11,416.02,other,OPPS APC,,
DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN,RX-9859,CDM,J1110,HCPCS,636,RC,81284-0411-00,NDC,outpatient,1,ML,179.49,125.643,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,40.295505,416.02,other,OPPS APC,,
DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN,RX-9859,CDM,J1110,HCPCS,636,RC,81284-0411-10,NDC,outpatient,1,ML,179.49,125.643,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,40.295505,416.02,other,OPPS APC,,
DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN,RX-9859,CDM,J1110,HCPCS,636,RC,81284-0411-05,NDC,outpatient,1,ML,220.97,154.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,40.295505,416.02,other,OPPS APC,,
ACETAZOLAMIDE SODIUM 500 MG IJ SOLR,RX-114,CDM,J1120,HCPCS,636,RC,00143-9503-01,NDC,outpatient,1,UN,178.94,125.258,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.29108,416.02,other,OPPS APC,,
ACETAZOLAMIDE SODIUM 500 MG IJ SOLR,RX-114,CDM,J1120,HCPCS,636,RC,23155-0313-31,NDC,outpatient,1,UN,45.84,32.088,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.29108,416.02,other,OPPS APC,,
ACETAZOLAMIDE SODIUM 500 MG IJ SOLR,RX-114,CDM,J1120,HCPCS,636,RC,67457-0853-50,NDC,outpatient,1,UN,164.43,115.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.29108,416.02,other,OPPS APC,,
DIGOXIN 0.25 MG/ML IJ SOLN,RX-2442,CDM,J1160,HCPCS,636,RC,00641-1410-35,NDC,outpatient,2,ML,14.62,10.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.28219,416.02,other,OPPS APC,,
DIGOXIN 0.25 MG/ML IJ SOLN,RX-2442,CDM,J1160,HCPCS,636,RC,00641-1410-31,NDC,outpatient,2,ML,14.62,10.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.28219,416.02,other,OPPS APC,,
DIGOXIN 0.1 MG/ML IJ SOLN,RX-9853,CDM,J1160,HCPCS,636,RC,70515-0263-10,NDC,outpatient,1,ML,449.39,314.573,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.28219,416.02,other,OPPS APC,,
DIGOXIN IMMUNE FAB 40 MG IV SOLR,RX-31432,CDM,J1162,HCPCS,636,RC,50633-0120-11,NDC,outpatient,1,UN,12197.8,8538.46,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5599.323132,,,5599.323132,399.86,9367.9104,other,OPPS APC,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,00641-0493-25,NDC,outpatient,2,ML,5.82,4.074,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-30,NDC,outpatient,5,ML,10.7,7.49,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-02,NDC,outpatient,2,ML,10.45,7.315,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,00641-0493-21,NDC,outpatient,2,ML,5.82,4.074,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-05,NDC,outpatient,5,ML,10.7,7.49,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-10,NDC,outpatient,2,ML,10.45,7.315,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.44,416.02,other,OPPS APC,,
DEXRAZOXANE HCL 500 MG IV SOLR,RX-146172,CDM,J1190,HCPCS,636,RC,51991-0942-98,NDC,outpatient,1,UN,575.66,402.962,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,100.224377,,,100.224377,87.49,442.10688,other,OPPS APC,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,00641-0376-25,NDC,outpatient,1,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,72485-0101-01,NDC,outpatient,1,ML,4.75,3.325,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,72485-0101-25,NDC,outpatient,1,ML,4.75,3.325,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-00,NDC,outpatient,1,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-16,NDC,outpatient,1,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-41,NDC,outpatient,1,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-01,NDC,outpatient,1,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,00641-0376-21,NDC,outpatient,1,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC,,
CHLOROTHIAZIDE SODIUM 500 MG IV SOLR,RX-9526,CDM,J1205,HCPCS,636,RC,25021-0305-20,NDC,outpatient,1,UN,139.6,97.72,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,31.3402,416.02,other,OPPS APC,,
DIMETHYL SULFOXIDE 50 % IS SOLN,RX-9873,CDM,J1212,HCPCS,636,RC,67457-0177-50,NDC,outpatient,50,ML,1852.55,1296.785,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,820.0645955,,,820.0645955,399.86,1422.7584,other,OPPS APC,,
METHADONE HCL 10 MG/ML IJ SOLN,RX-10546,CDM,J1230,HCPCS,636,RC,67457-0217-20,NDC,outpatient,20,ML,869.71,608.797,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.763505,945.2928,other,OPPS APC,,
METHADONE HCL 10 MG/ML IJ SOLN,RX-10546,CDM,J1230,HCPCS,636,RC,99999-0000-89,NDC,outpatient,1,ML,43.49,30.443,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.763505,945.2928,other,OPPS APC,,
METHADONE 10 MG/ML PCA,RX-4080162,CDM,J1230,HCPCS,636,RC,99999-0000-13,NDC,outpatient,50,ML,1230.85,861.595,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.763505,945.2928,other,OPPS APC,,
METHADONE 1 MG/ML IV INFUSION PREMIX,RX-4080178,CDM,J1230,HCPCS,636,RC,99999-0000-27,NDC,outpatient,200,ML,874.19,611.933,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.763505,945.2928,other,OPPS APC,,
DIPYRIDAMOLE 5 MG/ML IV SOLN,RX-9891,CDM,J1245,HCPCS,636,RC,00641-2569-41,NDC,outpatient,10,ML,75.79,53.053,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.78,416.02,other,OPPS APC,,
DIPYRIDAMOLE 5 MG/ML IV SOLN,RX-9891,CDM,J1245,HCPCS,636,RC,00641-2569-44,NDC,outpatient,10,ML,75.79,53.053,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.78,416.02,other,OPPS APC,,
DOBUTAMINE-DEXTROSE 1-5 MG/ML-% IV SOLN,RX-18314,CDM,J1250,HCPCS,636,RC,00338-1073-02,NDC,outpatient,250,ML,38.25,26.775,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.15774,416.02,other,OPPS APC,,
DOBUTAMINE-DEXTROSE 1-5 MG/ML-% IV SOLN,RX-18314,CDM,J1250,HCPCS,636,RC,00409-2346-32,NDC,outpatient,250,ML,52.72,36.904,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.15774,416.02,other,OPPS APC,,
DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN,RX-18315,CDM,J1250,HCPCS,636,RC,00338-1075-02,NDC,outpatient,250,ML,52.72,36.904,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.15774,416.02,other,OPPS APC,,
DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN,RX-18315,CDM,J1250,HCPCS,636,RC,00409-2347-31,NDC,outpatient,250,ML,72.74,50.918,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.15774,416.02,other,OPPS APC,,
DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN,RX-18315,CDM,J1250,HCPCS,636,RC,00409-2347-32,NDC,outpatient,250,ML,72.74,50.918,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.15774,416.02,other,OPPS APC,,
DOBUTAMINE 50 MG IN D5W 50 ML SYRINGE FROM PREMIX BAG (NEO/PED),RX-4081532,CDM,J1250,HCPCS,636,RC,99999-0004-34,NDC,outpatient,50,ML,24.49,17.143,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.15774,416.02,other,OPPS APC,,
DOBUTAMINE HCL 250 MG/20ML IV SOLN,RX-77318,CDM,J1250,HCPCS,636,RC,00143-9141-01,NDC,outpatient,20,ML,18.52,12.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.15774,416.02,other,OPPS APC,,
DOBUTAMINE HCL 250 MG/20ML IV SOLN,RX-77318,CDM,J1250,HCPCS,636,RC,00409-2344-01,NDC,outpatient,20,ML,27.59,19.313,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.15774,416.02,other,OPPS APC,,
DOBUTAMINE HCL 250 MG/20ML IV SOLN,RX-77318,CDM,J1250,HCPCS,636,RC,00143-9141-10,NDC,outpatient,20,ML,18.52,12.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.15774,416.02,other,OPPS APC,,
DOPAMINE-DEXTROSE 0.8-5 MG/ML-% IV SOLN,RX-14844,CDM,J1265,HCPCS,636,RC,00338-1005-02,NDC,outpatient,250,ML,41.59,29.113,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.7,416.02,other,OPPS APC,,
DOPAMINE-DEXTROSE 1.6-5 MG/ML-% IV SOLN,RX-14845,CDM,J1265,HCPCS,636,RC,00409-7809-22,NDC,outpatient,250,ML,50.49,35.343,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.7,416.02,other,OPPS APC,,
DOPAMINE-DEXTROSE 1.6-5 MG/ML-% IV SOLN,RX-14845,CDM,J1265,HCPCS,636,RC,00338-1007-02,NDC,outpatient,250,ML,48.27,33.789,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.7,416.02,other,OPPS APC,,
DOPAMINE-DEXTROSE 1.6-5 MG/ML-% IV SOLN,RX-14845,CDM,J1265,HCPCS,636,RC,00409-7809-11,NDC,outpatient,250,ML,50.49,35.343,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.7,416.02,other,OPPS APC,,
DOPAMINE HCL 40 MG/ML IV SOLN,RX-2595,CDM,J1265,HCPCS,636,RC,00409-9104-20,NDC,outpatient,10,ML,13.16,9.212,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.7,416.02,other,OPPS APC,,
DOPAMINE HCL 40 MG/ML IV SOLN,RX-2595,CDM,J1265,HCPCS,636,RC,00409-9104-21,NDC,outpatient,10,ML,13.16,9.212,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.7,416.02,other,OPPS APC,,
DOPAMINE 40 MG IN D5W 50 ML SYRINGE FROM PREMIX BAG (NEO/PED),RX-4081531,CDM,J1265,HCPCS,636,RC,99999-0004-33,NDC,outpatient,50,ML,21.92,15.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.7,416.02,other,OPPS APC,,
ECULIZUMAB 300 MG/30ML IV SOLN,RX-81696,CDM,J1300,HCPCS,636,RC,25682-0001-01,NDC,outpatient,30,ML,18003.46,12602.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,257.3171015,,,257.3171015,224.63,13826.65728,other,OPPS APC,,
VELETRI 1.5 MG IV SOLR,RX-106514,CDM,J1325,HCPCS,636,RC,66215-0402-01,NDC,outpatient,1,UN,260.55,182.385,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,15.86,416.02,other,OPPS APC,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00143-9398-10,NDC,outpatient,1,UN,100.74,70.518,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00409-3510-22,NDC,outpatient,1,UN,135.69,94.983,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,60505-6196-04,NDC,outpatient,1,UN,127.17,89.019,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00143-9398-01,NDC,outpatient,1,UN,100.74,70.518,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,42023-0221-01,NDC,outpatient,1,UN,95.49,66.843,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00409-3510-21,NDC,outpatient,1,UN,135.69,94.983,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,16714-0889-10,NDC,outpatient,1,UN,129.15,90.405,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,42023-0221-10,NDC,outpatient,1,UN,95.49,66.843,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,55150-0282-20,NDC,outpatient,1,UN,111.68,78.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,60505-6196-00,NDC,outpatient,1,UN,127.17,89.019,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,16714-0889-01,NDC,outpatient,1,UN,129.15,90.405,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,16714-0889-10,NDC,outpatient,1,UN,129.15,90.405,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,42023-0221-10,NDC,outpatient,1,UN,95.49,66.843,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,60505-6196-00,NDC,outpatient,1,UN,127.17,89.019,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00409-3510-21,NDC,outpatient,1,UN,135.69,94.983,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,16714-0889-01,NDC,outpatient,1,UN,129.15,90.405,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,55150-0282-20,NDC,outpatient,1,UN,111.68,78.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00143-9398-10,NDC,outpatient,1,UN,100.74,70.518,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00409-3510-22,NDC,outpatient,1,UN,135.69,94.983,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,42023-0221-01,NDC,outpatient,1,UN,95.49,66.843,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00143-9398-01,NDC,outpatient,1,UN,100.74,70.518,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,60505-6196-04,NDC,outpatient,1,UN,127.17,89.019,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.42,416.02,other,OPPS APC,,
ERYTHROMYCIN LACTOBIONATE 500 MG IV SOLR,RX-2903,CDM,J1364,HCPCS,636,RC,00409-6482-11,NDC,outpatient,1,UN,236.03,165.221,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,74.8916445,,,74.8916445,52.988735,416.02,other,OPPS APC,,
ERYTHROMYCIN LACTOBIONATE 500 MG IV SOLR,RX-2903,CDM,J1364,HCPCS,636,RC,00409-6482-01,NDC,outpatient,1,UN,236.03,165.221,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,74.8916445,,,74.8916445,52.988735,416.02,other,OPPS APC,,
ESTROGENS CONJUGATED 25 MG IJ SOLR,RX-9972,CDM,J1410,HCPCS,636,RC,00046-0749-05,NDC,outpatient,1,UN,1513.36,1059.352,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,438.481363,,,438.481363,339.74932,1162.26048,other,OPPS APC,,
FERRIC CARBOXYMALTOSE 750 MG/15ML IV SOLN,RX-122648,CDM,J1439,HCPCS,636,RC,00517-0650-01,NDC,outpatient,15,ML,2478.29,1734.803,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.2611955,,,1.2611955,1.1,1903.32672,other,OPPS APC,,
FLUCONAZOLE IN SODIUM CHLORIDE 200-0.9 MG/100ML-% IV SOLN,RX-10049,CDM,J1450,HCPCS,636,RC,25021-0184-82,NDC,outpatient,100,ML,36.03,25.221,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.61,416.02,other,OPPS APC,,
FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN,RX-10050,CDM,J1450,HCPCS,636,RC,00409-4688-16,NDC,outpatient,200,ML,35.54,24.878,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.61,416.02,other,OPPS APC,,
FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN,RX-10050,CDM,J1450,HCPCS,636,RC,00409-4688-12,NDC,outpatient,200,ML,35.54,24.878,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.61,416.02,other,OPPS APC,,
FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN,RX-10050,CDM,J1450,HCPCS,636,RC,69784-0003-06,NDC,outpatient,200,ML,35.58,24.906,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.61,416.02,other,OPPS APC,,
FLUCONAZOLE IVPB,RX-4080630,CDM,J1450,HCPCS,636,RC,99999-0001-23,NDC,outpatient,50,ML,23.46,16.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.61,416.02,other,OPPS APC,,
FOMEPIZOLE 1 GM/ML IV SOLN,RX-22185,CDM,J1451,HCPCS,636,RC,70710-1478-01,NDC,outpatient,1.5,ML,2014.79,1410.353,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7.3781655,,,7.3781655,7.3781655,1590,other,OPPS APC,,
FOMEPIZOLE 1 GM/ML IV SOLN,RX-22185,CDM,J1451,HCPCS,636,RC,67457-0211-02,NDC,outpatient,1.5,ML,1680.9,1176.63,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7.3781655,,,7.3781655,7.3781655,1590,other,OPPS APC,,
FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR,RX-106783,CDM,J1453,HCPCS,636,RC,00006-3061-01,NDC,outpatient,1,UN,1375.94,963.158,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.14,1056.72192,other,OPPS APC,,
FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR,RX-106783,CDM,J1453,HCPCS,636,RC,00006-3061-00,NDC,outpatient,1,UN,1375.94,963.158,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.14,1056.72192,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0436-05,NDC,outpatient,100,ML,2692.38,1884.666,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,55.6472445,,,55.6472445,47.99,8270.99136,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0437-10,NDC,outpatient,100,ML,2692.38,1884.666,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,55.6472445,,,55.6472445,47.99,8270.99136,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0437-91,NDC,outpatient,100,ML,2692.38,1884.666,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,55.6472445,,,55.6472445,47.99,8270.99136,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0438-20,NDC,outpatient,200,ML,5384.76,3769.332,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,55.6472445,,,55.6472445,47.99,8270.99136,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0439-93,NDC,outpatient,400,ML,10769.52,7538.664,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,55.6472445,,,55.6472445,47.99,8270.99136,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0436-90,NDC,outpatient,100,ML,2692.38,1884.666,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,55.6472445,,,55.6472445,47.99,8270.99136,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0439-40,NDC,outpatient,400,ML,10769.52,7538.664,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,55.6472445,,,55.6472445,47.99,8270.99136,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) IM INJ,RX-15342,CDM,J1460,HCPCS,636,RC,13533-0335-04,NDC,outpatient,2,ML,422.8,295.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,57.105466,,,57.105466,48.47,416.02,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) IM INJ,RX-15342,CDM,J1460,HCPCS,636,RC,13533-0335-40,NDC,outpatient,2,ML,422.8,295.96,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,57.105466,,,57.105466,48.47,416.02,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-24,NDC,outpatient,200,ML,4199.62,2939.734,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,55.9061275,,,55.9061275,48.81,6450.61632,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-72,NDC,outpatient,100,ML,2099.81,1469.867,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,55.9061275,,,55.9061275,48.81,6450.61632,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-20,NDC,outpatient,100,ML,2099.81,1469.867,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,55.9061275,,,55.9061275,48.81,6450.61632,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-41,NDC,outpatient,400,ML,8399.24,5879.468,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,55.9061275,,,55.9061275,48.81,6450.61632,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-25,NDC,outpatient,200,ML,4199.62,2939.734,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,55.9061275,,,55.9061275,48.81,6450.61632,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-71,NDC,outpatient,100,ML,2099.81,1469.867,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,55.9061275,,,55.9061275,48.81,6450.61632,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-21,NDC,outpatient,100,ML,2099.81,1469.867,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,55.9061275,,,55.9061275,48.81,6450.61632,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-40,NDC,outpatient,400,ML,8399.24,5879.468,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,55.9061275,,,55.9061275,48.81,6450.61632,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD S/D  5 % IGA <=2.2,RX-4080223,CDM,J1566,HCPCS,636,RC,00944-2620-03,NDC,outpatient,5,GR,934.5,654.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,94.150936,,,94.150936,77.77,1531.4,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD S/D  5 % IGA <= 1,RX-4080224,CDM,J1566,HCPCS,636,RC,00944-2656-03,NDC,outpatient,5,GR,577.48,404.236,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,94.150936,,,94.150936,77.77,1531.4,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD S/D  5 % IGA <= 1,RX-4080224,CDM,J1566,HCPCS,636,RC,00944-2658-04,NDC,outpatient,10,GR,1154.96,808.472,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,94.150936,,,94.150936,77.77,1531.4,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) OCTAGAM 5 % IV SOLN,RX-4080225,CDM,J1568,HCPCS,636,RC,68209-0843-03,NDC,outpatient,200,ML,1884.53,1319.171,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,56.1237725,,,56.1237725,44.12,1447.31904,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) OCTAGAM 5 % IV SOLN,RX-4080225,CDM,J1568,HCPCS,636,RC,68209-0843-04,NDC,outpatient,200,ML,1884.53,1319.171,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,56.1237725,,,56.1237725,44.12,1447.31904,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-03,NDC,outpatient,100,ML,2726.33,1908.431,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-06,NDC,outpatient,200,ML,5452.66,3816.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-07,NDC,outpatient,300,ML,8178.99,5725.293,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-09,NDC,outpatient,100,ML,2726.33,1908.431,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-11,NDC,outpatient,100,ML,2726.33,1908.431,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-08,NDC,outpatient,100,ML,2726.33,1908.431,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-12,NDC,outpatient,200,ML,5452.66,3816.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-02,NDC,outpatient,100,ML,2726.33,1908.431,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-05,NDC,outpatient,100,ML,2726.33,1908.431,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-04,NDC,outpatient,100,ML,2726.33,1908.431,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-10,NDC,outpatient,100,ML,2726.33,1908.431,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-13,NDC,outpatient,300,ML,8178.99,5725.293,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC,,
GANCICLOVIR SODIUM 500 MG IV SOLR,RX-10101,CDM,J1570,HCPCS,636,RC,70436-0089-55,NDC,outpatient,1,UN,165.87,116.109,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,36.41,416.02,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-03,NDC,outpatient,200,ML,2125.2,1487.64,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,64.280878,,,64.280878,48.52,3264.3072,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-04,NDC,outpatient,200,ML,2125.2,1487.64,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,64.280878,,,64.280878,48.52,3264.3072,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-05,NDC,outpatient,400,ML,4250.4,2975.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,64.280878,,,64.280878,48.52,3264.3072,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-08,NDC,outpatient,200,ML,2125.2,1487.64,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,64.280878,,,64.280878,48.52,3264.3072,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-00,NDC,outpatient,400,ML,4250.4,2975.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,64.280878,,,64.280878,48.52,3264.3072,other,OPPS APC,,
GENTAMICIN 80 MG IN NS 50 ML IV SOLN PREMIX,RX-15911,CDM,J1580,HCPCS,636,RC,00338-0509-41,NDC,outpatient,50,ML,25,17.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.23924,416.02,other,OPPS APC,,
GENTAMICIN 80 MG IN NS 50 ML IV SOLN PREMIX,RX-15911,CDM,J1580,HCPCS,636,RC,99999-0002-93,NDC,outpatient,50,ML,25.25,17.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.23924,416.02,other,OPPS APC,,
GENTAMICIN SULFATE 10 MG/ML IJ SOLN,RX-3425,CDM,J1580,HCPCS,636,RC,63323-0173-02,NDC,outpatient,2,ML,9.88,6.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.23924,416.02,other,OPPS APC,,
GENTAMICIN SULFATE 10 MG/ML IJ SOLN,RX-3425,CDM,J1580,HCPCS,636,RC,63323-0173-01,NDC,outpatient,2,ML,9.88,6.916,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.23924,416.02,other,OPPS APC,,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,00409-1207-03,NDC,outpatient,2,ML,12.55,8.785,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.23924,416.02,other,OPPS APC,,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,00409-1207-13,NDC,outpatient,2,ML,12.55,8.785,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.23924,416.02,other,OPPS APC,,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-01,NDC,outpatient,2,ML,5.52,3.864,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.23924,416.02,other,OPPS APC,,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-02,NDC,outpatient,2,ML,5.52,3.864,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.23924,416.02,other,OPPS APC,,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-03,NDC,outpatient,20,ML,102.62,71.834,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.23924,416.02,other,OPPS APC,,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-20,NDC,outpatient,20,ML,102.62,71.834,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.23924,416.02,other,OPPS APC,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,00143-9682-25,NDC,outpatient,1,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.51,416.02,other,OPPS APC,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,70121-1394-05,NDC,outpatient,1,ML,17.13,11.991,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.51,416.02,other,OPPS APC,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,71288-0414-03,NDC,outpatient,1,ML,4.37,3.059,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.51,416.02,other,OPPS APC,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,70121-1394-01,NDC,outpatient,1,ML,17.13,11.991,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.51,416.02,other,OPPS APC,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,00143-9682-01,NDC,outpatient,1,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.51,416.02,other,OPPS APC,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,00517-4601-25,NDC,outpatient,1,ML,7.56,5.292,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.51,416.02,other,OPPS APC,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,16714-0536-01,NDC,outpatient,1,ML,5.69,3.983,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.51,416.02,other,OPPS APC,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,16714-0536-25,NDC,outpatient,1,ML,5.69,3.983,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.51,416.02,other,OPPS APC,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,71288-0414-01,NDC,outpatient,1,ML,4.37,3.059,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.51,416.02,other,OPPS APC,,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00548-5850-00,NDC,outpatient,1,UN,754.5,528.15,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,220.2830865,,,220.2830865,90.641875,579.456,other,OPPS APC,,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00597-0053-01,NDC,outpatient,1,UN,403.75,282.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,220.2830865,,,220.2830865,90.641875,579.456,other,OPPS APC,,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00597-0053-45,NDC,outpatient,1,UN,403.75,282.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,220.2830865,,,220.2830865,90.641875,579.456,other,OPPS APC,,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00597-0260-10,NDC,outpatient,1,UN,403.75,282.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,220.2830865,,,220.2830865,90.641875,579.456,other,OPPS APC,,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1611,HCPCS,636,RC,63323-0596-11,NDC,outpatient,1,UN,610.61,427.427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,124.7735875,,,124.7735875,101.41,468.94848,other,OPPS APC,,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1611,HCPCS,636,RC,63323-0596-13,NDC,outpatient,1,UN,610.61,427.427,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,124.7735875,,,124.7735875,101.41,468.94848,other,OPPS APC,,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1611,HCPCS,636,RC,63323-0593-03,NDC,outpatient,1,UN,610.59,427.413,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,124.7735875,,,124.7735875,101.41,468.94848,other,OPPS APC,,
GRANISETRON HCL 1 MG/ML IV SOLN,RX-12552,CDM,J1626,HCPCS,636,RC,00143-9744-01,NDC,outpatient,1,ML,11.46,8.022,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.28,416.02,other,OPPS APC,,
GRANISETRON HCL 1 MG/ML IV SOLN,RX-12552,CDM,J1626,HCPCS,636,RC,00143-9744-10,NDC,outpatient,1,ML,11.46,8.022,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.28,416.02,other,OPPS APC,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,63323-0474-01,NDC,outpatient,1,ML,3.76,2.632,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,76045-0737-10,NDC,outpatient,1,ML,15.64,10.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,63323-0474-00,NDC,outpatient,1,ML,3.76,2.632,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,76045-0737-01,NDC,outpatient,1,ML,15.64,10.948,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,67457-0426-12,NDC,outpatient,1,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,00143-9501-01,NDC,outpatient,1,ML,7.22,5.054,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,00143-9501-25,NDC,outpatient,1,ML,7.22,5.054,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,67457-0426-00,NDC,outpatient,1,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC,,
HEPARIN LOCK FLUSH 100 UNIT/ML IV SOLN WRAPPER,RX-4080200,CDM,J1642,HCPCS,636,RC,64253-0333-35,NDC,outpatient,5,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.02,416.02,other,OPPS APC,,
HEPARIN LOCK FLUSH 100 UNIT/ML IV SOLN WRAPPER,RX-4080200,CDM,J1642,HCPCS,636,RC,08290-3064-24,NDC,outpatient,5,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.02,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-05,NDC,outpatient,10,ML,18.71,13.097,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0931-28,NDC,outpatient,10,ML,10.28,7.196,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,00409-2720-02,NDC,outpatient,10,ML,15.99,11.193,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,25021-0400-01,NDC,outpatient,1,ML,5.04,3.528,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0276-01,NDC,outpatient,2,ML,21.8,15.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-15,NDC,outpatient,10,ML,18.71,13.097,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0920-11,NDC,outpatient,1,ML,3.83,2.681,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0920-25,NDC,outpatient,1,ML,3.83,2.681,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0385-10,NDC,outpatient,10,ML,19.64,13.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0385-99,NDC,outpatient,10,ML,19.64,13.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,71288-0400-02,NDC,outpatient,2,ML,19.86,13.902,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,00409-2720-31,NDC,outpatient,10,ML,15.99,11.193,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0276-02,NDC,outpatient,2,ML,21.8,15.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0931-14,NDC,outpatient,10,ML,10.28,7.196,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0372-99,NDC,outpatient,1,ML,13.11,9.177,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,71288-0400-03,NDC,outpatient,2,ML,19.86,13.902,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,25021-0400-10,NDC,outpatient,10,ML,16.81,11.767,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-33,NDC,outpatient,30,ML,21.77,15.239,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-36,NDC,outpatient,30,ML,21.77,15.239,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0372-12,NDC,outpatient,1,ML,13.11,9.177,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 20000 UNIT/ML IJ SOLN,RX-10178,CDM,J1644,HCPCS,636,RC,63739-0986-11,NDC,outpatient,1,ML,33.86,23.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 20000 UNIT/ML IJ SOLN,RX-10178,CDM,J1644,HCPCS,636,RC,63739-0986-25,NDC,outpatient,1,ML,33.86,23.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,00409-2723-02,NDC,outpatient,1,ML,3.99,2.793,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,71288-0403-01,NDC,outpatient,1,ML,3.33,2.331,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,71288-0403-02,NDC,outpatient,1,ML,3.33,2.331,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,63739-0953-11,NDC,outpatient,1,ML,6.36,4.452,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,63739-0953-25,NDC,outpatient,1,ML,6.36,4.452,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,00409-2723-31,NDC,outpatient,1,ML,3.99,2.793,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN (PORCINE) IN NACL 25000-0.45 UT/250ML-% IV SOLN,RX-135728,CDM,J1644,HCPCS,636,RC,00409-7650-52,NDC,outpatient,250,ML,63.84,44.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN (PORCINE) IN NACL 25000-0.45 UT/250ML-% IV SOLN,RX-135728,CDM,J1644,HCPCS,636,RC,00409-7650-62,NDC,outpatient,250,ML,63.84,44.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SOD (PORCINE) IN D5W 100 UNIT/ML IV SOLN,RX-24329,CDM,J1644,HCPCS,636,RC,00264-9587-20,NDC,outpatient,250,ML,77.19,54.033,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SOD (PORCINE) IN D5W 100 UNIT/ML IV SOLN,RX-24329,CDM,J1644,HCPCS,636,RC,63323-0523-01,NDC,outpatient,250,ML,44.93,31.451,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SOD (PORCINE) IN D5W 100 UNIT/ML IV SOLN,RX-24329,CDM,J1644,HCPCS,636,RC,63323-0523-74,NDC,outpatient,250,ML,44.93,31.451,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SOD (PORCINE) PREMIX 30000 UNITS IN 1L NS,RX-4080227,CDM,J1644,HCPCS,636,RC,99999-0921-33,NDC,outpatient,1000,ML,91.43,64.001,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SOD (PORCINE) PREMIX 30000 UNITS IN 1L NS,RX-4080227,CDM,J1644,HCPCS,636,RC,70092-1281-08,NDC,outpatient,1000,ML,120.09,84.063,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00338-0424-18,NDC,outpatient,500,ML,28.85,20.195,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,99999-0001-71,NDC,outpatient,500,ML,22,15.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,99999-0002-94,NDC,outpatient,5,ML,16.13,11.291,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-7620-13,NDC,outpatient,500,ML,33.99,23.793,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-1005-20,NDC,outpatient,500,ML,33.99,23.793,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,63323-0519-77,NDC,outpatient,500,ML,31.42,21.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00264-9872-10,NDC,outpatient,500,ML,33.8,23.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-1005-01,NDC,outpatient,500,ML,33.99,23.793,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-7620-03,NDC,outpatient,500,ML,33.99,23.793,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,63323-0519-02,NDC,outpatient,500,ML,31.42,21.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,99999-0001-81,NDC,outpatient,1000,ML,22.86,16.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN (PORCINE) IN NACL 25000-0.9 UT/250ML-% IV SOLN,RX-4081544,CDM,J1644,HCPCS,636,RC,99999-0003-32,NDC,outpatient,250,ML,30.4,21.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN (PORCINE) IN NACL 25000-0.9 UT/250ML-% IV SOLN,RX-4081544,CDM,J1644,HCPCS,636,RC,99999-0003-31,NDC,outpatient,250,ML,42.73,29.911,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
ENOXAPARIN SODIUM 30 MG/0.3ML IJ SOSY,RX-158184,CDM,J1650,HCPCS,636,RC,00548-5601-00,NDC,outpatient,0.3,ML,20.03,14.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.57,416.02,other,OPPS APC,,
ENOXAPARIN SODIUM 40 MG/0.4ML IJ SOSY,RX-158185,CDM,J1650,HCPCS,636,RC,00548-5602-00,NDC,outpatient,0.4,ML,26.7,18.69,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.57,416.02,other,OPPS APC,,
ENOXAPARIN SODIUM 60 MG/0.6ML IJ SOSY,RX-158186,CDM,J1650,HCPCS,636,RC,00548-5603-00,NDC,outpatient,0.6,ML,40.05,28.035,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.57,416.02,other,OPPS APC,,
ENOXAPARIN SODIUM 80 MG/0.8ML IJ SOSY,RX-158187,CDM,J1650,HCPCS,636,RC,00548-5604-00,NDC,outpatient,0.8,ML,53.4,37.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.57,416.02,other,OPPS APC,,
ENOXAPARIN SODIUM 100 MG/ML IJ SOSY,RX-158188,CDM,J1650,HCPCS,636,RC,00548-5605-00,NDC,outpatient,1,ML,66.75,46.725,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.57,416.02,other,OPPS APC,,
ENOXAPARIN SODIUM 120 MG/0.8ML IJ SOSY,RX-158189,CDM,J1650,HCPCS,636,RC,00548-5606-00,NDC,outpatient,0.8,ML,80.1,56.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.57,416.02,other,OPPS APC,,
ENOXAPARIN SODIUM 150 MG/ML IJ SOSY,RX-158190,CDM,J1650,HCPCS,636,RC,00548-5607-00,NDC,outpatient,1,ML,100.13,70.091,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.57,416.02,other,OPPS APC,,
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,67457-0583-04,NDC,outpatient,0.4,ML,146.14,102.298,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC,,
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,55150-0231-00,NDC,outpatient,0.4,ML,58.52,40.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC,,
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,55150-0231-10,NDC,outpatient,0.4,ML,58.52,40.964,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC,,
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,67457-0583-00,NDC,outpatient,0.4,ML,146.14,102.298,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC,,
FONDAPARINUX SODIUM 7.5 MG/0.6ML SC SOLN,RX-108028,CDM,J1652,HCPCS,636,RC,55111-0680-10,NDC,outpatient,0.6,ML,45.65,31.955,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC,,
FONDAPARINUX SODIUM 7.5 MG/0.6ML SC SOLN,RX-108028,CDM,J1652,HCPCS,636,RC,55111-0680-11,NDC,outpatient,0.6,ML,45.65,31.955,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC,,
FONDAPARINUX SODIUM 10 MG/0.8ML SC SOLN,RX-108029,CDM,J1652,HCPCS,636,RC,67457-0585-00,NDC,outpatient,0.8,ML,146.14,102.298,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC,,
FONDAPARINUX SODIUM 10 MG/0.8ML SC SOLN,RX-108029,CDM,J1652,HCPCS,636,RC,67457-0585-08,NDC,outpatient,0.8,ML,146.14,102.298,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC,,
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55111-0678-11,NDC,outpatient,0.5,ML,21,14.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC,,
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55150-0230-10,NDC,outpatient,0.5,ML,20.75,14.525,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC,,
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55150-0230-00,NDC,outpatient,0.5,ML,20.75,14.525,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC,,
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55111-0678-10,NDC,outpatient,0.5,ML,21,14.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC,,
TETANUS IMMUNE GLOBULIN 250 UNIT/ML IM SOSY,RX-156399,CDM,J1670,HCPCS,636,RC,13533-0634-02,NDC,outpatient,1,ML,1484.53,1039.171,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,666.4255535,,,666.4255535,333.276985,1140.11904,other,OPPS APC,,
TETANUS IMMUNE GLOBULIN 250 UNIT/ML IM SOSY,RX-156399,CDM,J1670,HCPCS,636,RC,13533-0634-20,NDC,outpatient,1,ML,1484.53,1039.171,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,666.4255535,,,666.4255535,333.276985,1140.11904,other,OPPS APC,,
HYDROCORTISONE SOD SUC (PF) 250 MG IJ SOLR,RX-160127,CDM,J1720,HCPCS,636,RC,00009-0013-05,NDC,outpatient,1,UN,153.4,107.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,13.56878,416.02,other,OPPS APC,,
HYDROCORTISONE SOD SUC (PF) 500 MG IJ SOLR,RX-160129,CDM,J1720,HCPCS,636,RC,00009-0016-12,NDC,outpatient,1,UN,308.7,216.09,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,13.56878,416.02,other,OPPS APC,,
HYDROCORTISONE NA SUCCINATE PF 100 MG IJ WRAPPER,RX-4080176,CDM,J1720,HCPCS,636,RC,00009-0011-04,NDC,outpatient,1,UN,83.69,58.583,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,13.56878,416.02,other,OPPS APC,,
HYDROCORTISONE NA SUCCINATE PF 100 MG IJ WRAPPER,RX-4080176,CDM,J1720,HCPCS,636,RC,00009-0825-01,NDC,outpatient,1,UN,60.44,42.308,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,13.56878,416.02,other,OPPS APC,,
IBANDRONATE SODIUM 3 MG/3ML IV SOLN,RX-110306,CDM,J1740,HCPCS,636,RC,60505-6097-00,NDC,outpatient,3,ML,291.8,204.26,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,27.14,416.02,other,OPPS APC,,
IBUTILIDE FUMARATE 1 MG/10ML IV SOLN,RX-100740,CDM,J1742,HCPCS,636,RC,00009-3794-01,NDC,outpatient,10,ML,380.26,266.182,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,276.5271365,,,276.5271365,85.36837,416.02,other,OPPS APC,,
INFLIXIMAB 100 MG IV SOLR,RX-23796,CDM,J1745,HCPCS,636,RC,57894-0030-01,NDC,outpatient,1,UN,3124.93,2187.451,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,36.9114465,,,36.9114465,32.22,2399.94624,other,OPPS APC,,
IRON DEXTRAN 50 MG/ML IJ SOLN,RX-3990,CDM,J1750,HCPCS,636,RC,00023-6082-10,NDC,outpatient,2,ML,145.94,102.158,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,20.2398395,,,20.2398395,17.18,416.02,other,OPPS APC,,
IRON DEXTRAN 50 MG/ML IJ SOLN,RX-3990,CDM,J1750,HCPCS,636,RC,00023-6082-01,NDC,outpatient,2,ML,145.94,102.158,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,20.2398395,,,20.2398395,17.18,416.02,other,OPPS APC,,
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2310-05,NDC,outpatient,10,ML,278.93,195.251,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21,416.02,other,OPPS APC,,
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2340-10,NDC,outpatient,5,ML,131.72,92.204,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21,416.02,other,OPPS APC,,
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2340-01,NDC,outpatient,5,ML,137.29,96.103,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21,416.02,other,OPPS APC,,
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2310-01,NDC,outpatient,10,ML,278.93,195.251,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.21,416.02,other,OPPS APC,,
DROPERIDOL 2.5 MG/ML IJ SOLN,RX-2654,CDM,J1790,HCPCS,636,RC,00517-9702-25,NDC,outpatient,2,ML,31.33,21.931,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.83,416.02,other,OPPS APC,,
DROPERIDOL 2.5 MG/ML IJ SOLN,RX-2654,CDM,J1790,HCPCS,636,RC,00517-9702-01,NDC,outpatient,2,ML,31.33,21.931,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.83,416.02,other,OPPS APC,,
PROPRANOLOL HCL 1 MG/ML IV SOLN,RX-29335,CDM,J1800,HCPCS,636,RC,63323-0604-00,NDC,outpatient,1,ML,8.17,5.719,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.834165,416.02,other,OPPS APC,,
PROPRANOLOL HCL 1 MG/ML IV SOLN,RX-29335,CDM,J1800,HCPCS,636,RC,63323-0604-01,NDC,outpatient,1,ML,8.17,5.719,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.834165,416.02,other,OPPS APC,,
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN,RX-29805,CDM,J1805,HCPCS,636,RC,67457-0657-25,NDC,outpatient,250,ML,426.52,298.564,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.222227,,,0.222227,0.19,416.02,other,OPPS APC,,
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-29805,CDM,J1805,HCPCS,636,RC,25021-0308-84,NDC,outpatient,250,ML,320.4,224.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.222227,,,0.222227,0.19,416.02,other,OPPS APC,,
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN,RX-29805,CDM,J1805,HCPCS,636,RC,25021-0308-84,NDC,outpatient,250,ML,336.4,235.48,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.222227,,,0.222227,0.19,416.02,other,OPPS APC,,
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-29805,CDM,J1805,HCPCS,636,RC,67457-0657-25,NDC,outpatient,250,ML,410.52,287.364,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.222227,,,0.222227,0.19,416.02,other,OPPS APC,,
ESMOLOL HCL 100 MG/10ML IV SOLN,RX-82085,CDM,J1805,HCPCS,636,RC,67457-0182-00,NDC,outpatient,10,ML,17.12,11.984,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.222227,,,0.222227,0.19,416.02,other,OPPS APC,,
ESMOLOL HCL 100 MG/10ML IV SOLN,RX-82085,CDM,J1805,HCPCS,636,RC,67457-0182-10,NDC,outpatient,10,ML,17.12,11.984,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.222227,,,0.222227,0.19,416.02,other,OPPS APC,,
ESMOLOL HCL 100 MG/10ML IV SOLN,RX-82085,CDM,J1805,HCPCS,636,RC,55150-0194-10,NDC,outpatient,10,ML,10.39,7.273,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.222227,,,0.222227,0.19,416.02,other,OPPS APC,,
ESMOLOL HCL 2500 MG/250ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-142051,CDM,J1806,HCPCS,636,RC,44567-0811-10,NDC,outpatient,250,ML,414.97,290.479,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.410089,,,0.410089,0.36,416.02,other,OPPS APC,,
ESMOLOL HCL 2500 MG/250ML IV SOLN,RX-142051,CDM,J1806,HCPCS,636,RC,44567-0811-10,NDC,outpatient,250,ML,430.97,301.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.410089,,,0.410089,0.36,416.02,other,OPPS APC,,
INTERFERON BETA-1B 0.3 MG SC KIT,RX-124318,CDM,J1830,HCPCS,636,RC,50419-0524-35,NDC,outpatient,1,UN,1865.02,1305.514,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,114.43,1432.33536,,,,
INTERFERON BETA-1B 0.3 MG SC KIT,RX-124318,CDM,J1830,HCPCS,636,RC,50419-0524-01,NDC,outpatient,1,UN,1865.02,1305.514,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,114.43,1432.33536,,,,
ISAVUCONAZONIUM SULFATE 372 MG IV SOLR,RX-130407,CDM,J1833,HCPCS,636,RC,00469-0420-01,NDC,outpatient,1,UN,1572.32,1100.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.12259,,,1.12259,1,1207.54176,other,OPPS APC,,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-24,NDC,outpatient,100,ML,24.23,16.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.029783,,,0.029783,0.02,416.02,other,OPPS APC,,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,47335-0993-01,NDC,outpatient,100,ML,23.2,16.24,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.029783,,,0.029783,0.02,416.02,other,OPPS APC,,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-01,NDC,outpatient,100,ML,8.23,5.761,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.029783,,,0.029783,0.02,416.02,other,OPPS APC,,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,47335-0993-01,NDC,outpatient,100,ML,7.2,5.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.029783,,,0.029783,0.02,416.02,other,OPPS APC,,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,00338-1055-48,NDC,outpatient,100,ML,21.14,14.798,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.029783,,,0.029783,0.02,416.02,other,OPPS APC,,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-24,NDC,outpatient,100,ML,8.23,5.761,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.029783,,,0.029783,0.02,416.02,other,OPPS APC,,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-01,NDC,outpatient,100,ML,24.23,16.961,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.029783,,,0.029783,0.02,416.02,other,OPPS APC,,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,00338-1055-48,NDC,outpatient,100,ML,5.14,3.598,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.029783,,,0.029783,0.02,416.02,other,OPPS APC,,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,25021-0131-82,NDC,outpatient,100,ML,9.77,6.839,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,0.029783,,,0.029783,0.02,416.02,other,OPPS APC,,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,25021-0131-82,NDC,outpatient,100,ML,25.77,18.039,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.029783,,,0.029783,0.02,416.02,other,OPPS APC,,
METRONIDAZOLE IN NACL IVPB,RX-4080369,CDM,J1836,HCPCS,636,RC,99999-0001-74,NDC,outpatient,50,ML,20.37,14.259,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.029783,,,0.029783,0.02,416.02,other,OPPS APC,,
METRONIDAZOLE IV SYRINGE (PEDIATRIC),RX-40840043,CDM,J1836,HCPCS,636,RC,99999-0001-74,NDC,outpatient,50,ML,20.37,14.259,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.029783,,,0.029783,0.02,416.02,other,OPPS APC,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,00409-3795-01,NDC,outpatient,1,ML,18.43,12.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.55,416.02,other,OPPS APC,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,63323-0162-00,NDC,outpatient,1,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.55,416.02,other,OPPS APC,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,72266-0118-25,NDC,outpatient,1,ML,4.8,3.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.55,416.02,other,OPPS APC,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,00338-0072-25,NDC,outpatient,1,ML,3.57,2.499,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.55,416.02,other,OPPS APC,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,63323-0162-01,NDC,outpatient,1,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.55,416.02,other,OPPS APC,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,62332-0600-01,NDC,outpatient,1,ML,9.77,6.839,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.55,416.02,other,OPPS APC,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,62332-0600-25,NDC,outpatient,1,ML,9.77,6.839,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.55,416.02,other,OPPS APC,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,00409-3795-19,NDC,outpatient,1,ML,18.43,12.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.55,416.02,other,OPPS APC,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,72266-0118-01,NDC,outpatient,1,ML,4.8,3.36,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.55,416.02,other,OPPS APC,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,72266-0102-01,NDC,outpatient,20,ML,12.14,8.498,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.3058485,,,0.3058485,0.24,416.02,other,OPPS APC,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,00409-2339-24,NDC,outpatient,4,ML,35.3,24.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.3058485,,,0.3058485,0.24,416.02,other,OPPS APC,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,00409-2339-34,NDC,outpatient,4,ML,35.3,24.71,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.3058485,,,0.3058485,0.24,416.02,other,OPPS APC,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,25021-0317-20,NDC,outpatient,20,ML,9.98,6.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.3058485,,,0.3058485,0.24,416.02,other,OPPS APC,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,36000-0320-01,NDC,outpatient,4,ML,16.17,11.319,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.3058485,,,0.3058485,0.24,416.02,other,OPPS APC,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,36000-0320-10,NDC,outpatient,4,ML,16.17,11.319,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.3058485,,,0.3058485,0.24,416.02,other,OPPS APC,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,00409-2267-54,NDC,outpatient,40,ML,40.77,28.539,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.3058485,,,0.3058485,0.24,416.02,other,OPPS APC,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1921,HCPCS,636,RC,00143-9622-01,NDC,outpatient,20,ML,8.85,6.195,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.8683105,,,1.8683105,1.24,416.02,other,OPPS APC,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1921,HCPCS,636,RC,00143-9623-01,NDC,outpatient,40,ML,18.87,13.209,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.8683105,,,1.8683105,1.24,416.02,other,OPPS APC,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0570-04,NDC,outpatient,4,ML,8.04,5.628,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.62,416.02,other,OPPS APC,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,72205-0101-01,NDC,outpatient,4,ML,12.36,8.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.62,416.02,other,OPPS APC,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6007-10,NDC,outpatient,10,ML,15.42,10.794,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.62,416.02,other,OPPS APC,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6008-01,NDC,outpatient,4,ML,14.21,9.947,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.62,416.02,other,OPPS APC,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,72205-0101-07,NDC,outpatient,4,ML,12.36,8.652,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.62,416.02,other,OPPS APC,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6008-10,NDC,outpatient,4,ML,14.21,9.947,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.62,416.02,other,OPPS APC,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0572-10,NDC,outpatient,10,ML,8.64,6.048,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.62,416.02,other,OPPS APC,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6007-01,NDC,outpatient,10,ML,15.42,10.794,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.62,416.02,other,OPPS APC,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0570-01,NDC,outpatient,4,ML,8.04,5.628,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.62,416.02,other,OPPS APC,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0572-01,NDC,outpatient,10,ML,8.64,6.048,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.62,416.02,other,OPPS APC,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,00409-6102-04,NDC,outpatient,4,ML,9.24,6.468,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,416.02,other,OPPS APC,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-33,NDC,outpatient,10,ML,7.2,5.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,416.02,other,OPPS APC,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,63323-0280-04,NDC,outpatient,4,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,416.02,other,OPPS APC,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,70860-0302-42,NDC,outpatient,4,ML,4.94,3.458,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,416.02,other,OPPS APC,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,71288-0203-05,NDC,outpatient,4,ML,3.66,2.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,416.02,other,OPPS APC,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,72603-0251-01,NDC,outpatient,4,ML,3.79,2.653,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,416.02,other,OPPS APC,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,72603-0251-25,NDC,outpatient,4,ML,3.79,2.653,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,416.02,other,OPPS APC,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,25021-0311-10,NDC,outpatient,10,ML,7.25,5.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,416.02,other,OPPS APC,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,63323-0280-26,NDC,outpatient,4,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,416.02,other,OPPS APC,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,00409-6102-18,NDC,outpatient,4,ML,9.24,6.468,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,416.02,other,OPPS APC,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-42,NDC,outpatient,4,ML,4.75,3.325,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,416.02,other,OPPS APC,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,36000-0283-25,NDC,outpatient,4,ML,5.41,3.787,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,416.02,other,OPPS APC,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,36000-0284-25,NDC,outpatient,10,ML,8.33,5.831,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,416.02,other,OPPS APC,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,63323-0280-03,NDC,outpatient,4,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,416.02,other,OPPS APC,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-32,NDC,outpatient,4,ML,4.75,3.325,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,416.02,other,OPPS APC,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-44,NDC,outpatient,10,ML,7.2,5.04,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,416.02,other,OPPS APC,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,70860-0302-04,NDC,outpatient,4,ML,4.94,3.458,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,416.02,other,OPPS APC,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,71288-0203-04,NDC,outpatient,4,ML,3.66,2.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.4,416.02,other,OPPS APC,,
LEUPROLIDE ACETATE 3.75 MG IM KIT,RX-13691,CDM,J1950,HCPCS,636,RC,00074-3641-03,NDC,outpatient,1,UN,4758.7,3331.09,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1853.014639,,,1853.014639,399.86,10964.15232,other,OPPS APC,,
LEUPROLIDE ACETATE (3 MONTH) 11.25 MG IM KIT,RX-21044,CDM,J1950,HCPCS,636,RC,00074-3663-03,NDC,outpatient,1,UN,14276.24,9993.368,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1853.014639,,,1853.014639,399.86,10964.15232,other,OPPS APC,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,00264-1009-90,NDC,outpatient,100,ML,43.15,30.205,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,14789-0220-08,NDC,outpatient,100,ML,48.49,33.943,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,44567-0502-01,NDC,outpatient,100,ML,49.38,34.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,43598-0636-10,NDC,outpatient,100,ML,87.65,61.355,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,43598-0636-52,NDC,outpatient,100,ML,87.65,61.355,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,67457-0265-00,NDC,outpatient,100,ML,64.06,44.842,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,70860-0603-41,NDC,outpatient,100,ML,63.62,44.534,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,14789-0220-10,NDC,outpatient,100,ML,48.49,33.943,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,44567-0502-10,NDC,outpatient,100,ML,49.38,34.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,67457-0265-10,NDC,outpatient,100,ML,64.06,44.842,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,70860-0603-82,NDC,outpatient,100,ML,63.62,44.534,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC,,
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,44567-0503-01,NDC,outpatient,100,ML,60.06,42.042,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC,,
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,44567-0503-10,NDC,outpatient,100,ML,60.06,42.042,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC,,
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,70860-0604-82,NDC,outpatient,100,ML,79.64,55.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC,,
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,70860-0604-41,NDC,outpatient,100,ML,79.64,55.748,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC,,
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,00409-1886-02,NDC,outpatient,5,ML,6.38,4.466,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC,,
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,00409-1886-22,NDC,outpatient,5,ML,6.38,4.466,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC,,
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,55150-0177-05,NDC,outpatient,5,ML,5.07,3.549,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC,,
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,67457-0790-00,NDC,outpatient,5,ML,10.7,7.49,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC,,
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,67457-0790-05,NDC,outpatient,5,ML,10.7,7.49,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC,,
LEVOFLOXACIN IN D5W 250 MG/50ML IV SOLN,RX-108118,CDM,J1956,HCPCS,636,RC,25021-0132-81,NDC,outpatient,50,ML,25.26,17.682,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC,,
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00143-9721-01,NDC,outpatient,100,ML,25.77,18.039,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC,,
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00143-9721-24,NDC,outpatient,100,ML,25.77,18.039,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC,,
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00409-0528-23,NDC,outpatient,100,ML,28.85,20.195,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC,,
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,25021-0132-82,NDC,outpatient,100,ML,26.28,18.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC,,
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00409-0528-25,NDC,outpatient,100,ML,28.85,20.195,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC,,
LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN,RX-108120,CDM,J1956,HCPCS,636,RC,00409-0528-31,NDC,outpatient,150,ML,32.2,22.54,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC,,
LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN,RX-108120,CDM,J1956,HCPCS,636,RC,00409-0528-35,NDC,outpatient,150,ML,32.2,22.54,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC,,
LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN,RX-108120,CDM,J1956,HCPCS,636,RC,25021-0132-83,NDC,outpatient,150,ML,33.74,23.618,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC,,
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,00143-9722-24,NDC,outpatient,50,ML,23.97,16.779,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC,,
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,25021-0132-81,NDC,outpatient,50,ML,25.26,17.682,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC,,
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,63323-0355-50,NDC,outpatient,50,ML,45.6,31.92,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC,,
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,36000-0046-24,NDC,outpatient,50,ML,26.54,18.578,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92,416.02,other,OPPS APC,,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,00781-3433-46,NDC,outpatient,300,ML,100.11,70.077,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.08,416.02,other,OPPS APC,,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,57664-0683-31,NDC,outpatient,300,ML,46.71,32.697,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.08,416.02,other,OPPS APC,,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,57664-0683-57,NDC,outpatient,300,ML,46.71,32.697,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.08,416.02,other,OPPS APC,,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,00781-3433-95,NDC,outpatient,300,ML,100.11,70.077,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.08,416.02,other,OPPS APC,,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,55150-0242-51,NDC,outpatient,300,ML,53.38,37.366,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.08,416.02,other,OPPS APC,,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,63323-0713-13,NDC,outpatient,300,ML,49.38,34.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.08,416.02,other,OPPS APC,,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,63323-0713-03,NDC,outpatient,300,ML,49.38,34.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.08,416.02,other,OPPS APC,,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,55150-0242-51,NDC,outpatient,300,ML,53.38,37.366,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.08,416.02,other,OPPS APC,,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,57664-0683-31,NDC,outpatient,300,ML,46.71,32.697,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.08,416.02,other,OPPS APC,,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,57664-0683-57,NDC,outpatient,300,ML,46.71,32.697,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.08,416.02,other,OPPS APC,,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,00781-3433-46,NDC,outpatient,300,ML,100.11,70.077,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.08,416.02,other,OPPS APC,,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,63323-0713-13,NDC,outpatient,300,ML,49.38,34.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.08,416.02,other,OPPS APC,,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,00781-3433-95,NDC,outpatient,300,ML,100.11,70.077,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.08,416.02,other,OPPS APC,,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,63323-0713-03,NDC,outpatient,300,ML,49.38,34.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.08,416.02,other,OPPS APC,,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6207-25,NDC,outpatient,1,ML,5.04,3.528,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.85,416.02,other,OPPS APC,,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6044-01,NDC,outpatient,1,ML,4.94,3.458,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.85,416.02,other,OPPS APC,,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00409-1985-03,NDC,outpatient,1,ML,16.06,11.242,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.85,416.02,other,OPPS APC,,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00409-1985-30,NDC,outpatient,1,ML,16.06,11.242,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.85,416.02,other,OPPS APC,,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6044-25,NDC,outpatient,1,ML,4.94,3.458,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.85,416.02,other,OPPS APC,,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6207-01,NDC,outpatient,1,ML,5.04,3.528,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.85,416.02,other,OPPS APC,,
LORAZEPAM INFUSION PREMIX,RX-4080084,CDM,J2060,HCPCS,636,RC,SH408-0084-01,NDC,outpatient,100,ML,126.59,88.613,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.85,416.02,other,OPPS APC,,
MANNITOL 25 % IV SOLN,RX-4750,CDM,J2150,HCPCS,636,RC,00409-4031-01,NDC,outpatient,50,ML,10.28,7.196,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.30786,416.02,other,OPPS APC,,
MANNITOL 25 % IV SOLN,RX-4750,CDM,J2150,HCPCS,636,RC,00409-4031-16,NDC,outpatient,50,ML,10.28,7.196,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.30786,416.02,other,OPPS APC,,
MEPERIDINE 10 MG/ML PCA,RX-400415,CDM,J2175,HCPCS,636,RC,99999-0000-09,NDC,outpatient,50,ML,59.93,41.951,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.386435,416.02,other,OPPS APC,,
MEPERIDINE HCL 25 MG/ML IJ SOLN,RX-4903,CDM,J2175,HCPCS,636,RC,00641-6052-25,NDC,outpatient,1,ML,10.63,7.441,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.386435,416.02,other,OPPS APC,,
MEPERIDINE HCL 25 MG/ML IJ SOLN,RX-4903,CDM,J2175,HCPCS,636,RC,00641-6052-01,NDC,outpatient,1,ML,10.63,7.441,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.386435,416.02,other,OPPS APC,,
MEPERIDINE HCL 50 MG/ML IJ SOLN,RX-4904,CDM,J2175,HCPCS,636,RC,00641-6053-01,NDC,outpatient,1,ML,11.08,7.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.386435,416.02,other,OPPS APC,,
MEPERIDINE HCL 50 MG/ML IJ SOLN,RX-4904,CDM,J2175,HCPCS,636,RC,00641-6053-25,NDC,outpatient,1,ML,11.08,7.756,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.386435,416.02,other,OPPS APC,,
MEPOLIZUMAB 100 MG SC SOLR,RX-131231,CDM,J2182,HCPCS,636,RC,00173-0881-01,NDC,outpatient,1,UN,8145.21,5701.647,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,34.8632925,,,34.8632925,29.75,6255.52128,other,OPPS APC,,
MEROPENEM 500 MG IV SOLR,RX-17379,CDM,J2185,HCPCS,636,RC,55150-0207-20,NDC,outpatient,1,UN,7.45,5.215,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.35,416.02,other,OPPS APC,,
MEROPENEM 500 MG IV SOLR,RX-17379,CDM,J2185,HCPCS,636,RC,63323-0507-01,NDC,outpatient,1,UN,14.25,9.975,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.35,416.02,other,OPPS APC,,
MEROPENEM 500 MG IV SOLR,RX-17379,CDM,J2185,HCPCS,636,RC,63323-0507-20,NDC,outpatient,1,UN,14.25,9.975,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.35,416.02,other,OPPS APC,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00781-3098-94,NDC,outpatient,1,UN,48.95,34.265,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.35,416.02,other,OPPS APC,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,70121-1453-07,NDC,outpatient,1,UN,45.95,32.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.35,416.02,other,OPPS APC,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00409-1391-22,NDC,outpatient,1,UN,20.02,14.014,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.35,416.02,other,OPPS APC,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00781-3098-95,NDC,outpatient,1,UN,48.95,34.265,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.35,416.02,other,OPPS APC,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,55150-0208-30,NDC,outpatient,1,UN,17.23,12.061,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.35,416.02,other,OPPS APC,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00409-1391-21,NDC,outpatient,1,UN,20.02,14.014,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.35,416.02,other,OPPS APC,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,70121-1453-01,NDC,outpatient,1,UN,45.95,32.165,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.35,416.02,other,OPPS APC,,
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,00517-0740-01,NDC,outpatient,1,ML,89.19,62.433,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,15.18518,416.02,other,OPPS APC,,
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,00517-0740-20,NDC,outpatient,1,ML,89.19,62.433,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,15.18518,416.02,other,OPPS APC,,
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,51991-0144-99,NDC,outpatient,1,ML,67.64,47.348,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,15.18518,416.02,other,OPPS APC,,
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,51991-0144-17,NDC,outpatient,1,ML,67.64,47.348,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,15.18518,416.02,other,OPPS APC,,
METHYLNALTREXONE BROMIDE 12 MG/0.6ML SC SOLN,RX-91651,CDM,J2212,HCPCS,636,RC,65649-0551-02,NDC,outpatient,0.6,ML,659.14,461.398,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.07677,,,1.07677,1.07677,506.21952,other,OPPS APC,,
MICAFUNGIN SODIUM 50 MG IV SOLR,RX-41144,CDM,J2248,HCPCS,636,RC,00469-3250-10,NDC,outpatient,1,UN,384.44,269.108,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.29,590.53056,other,OPPS APC,,
MICAFUNGIN SODIUM 50 MG IV SOLR,RX-41144,CDM,J2248,HCPCS,636,RC,70710-1724-01,NDC,outpatient,1,UN,160.37,112.259,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.29,590.53056,other,OPPS APC,,
MICAFUNGIN SODIUM 50 MG IV SOLR,RX-41144,CDM,J2248,HCPCS,636,RC,70710-1724-06,NDC,outpatient,1,UN,160.37,112.259,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.29,590.53056,other,OPPS APC,,
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,25021-0191-10,NDC,outpatient,1,UN,136.09,95.263,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.29,590.53056,other,OPPS APC,,
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,70710-1725-06,NDC,outpatient,1,UN,320.73,224.511,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.29,590.53056,other,OPPS APC,,
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,00469-3211-10,NDC,outpatient,1,UN,768.92,538.244,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.29,590.53056,other,OPPS APC,,
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,70710-1725-01,NDC,outpatient,1,UN,320.73,224.511,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.29,590.53056,other,OPPS APC,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,23155-0600-31,NDC,outpatient,2,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.13,416.02,other,OPPS APC,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,23155-0600-41,NDC,outpatient,2,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.13,416.02,other,OPPS APC,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,00409-2305-17,NDC,outpatient,2,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.13,416.02,other,OPPS APC,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-15,NDC,outpatient,2,ML,6.08,4.256,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.13,416.02,other,OPPS APC,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-18,NDC,outpatient,5,ML,13.45,9.415,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.13,416.02,other,OPPS APC,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-25,NDC,outpatient,5,ML,13.45,9.415,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.13,416.02,other,OPPS APC,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,00409-2305-16,NDC,outpatient,2,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.13,416.02,other,OPPS APC,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-12,NDC,outpatient,2,ML,6.08,4.256,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.13,416.02,other,OPPS APC,,
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2250,HCPCS,636,RC,99999-0001-46,NDC,outpatient,100,ML,75.72,53.004,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.13,416.02,other,OPPS APC,,
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2250,HCPCS,636,RC,70004-0411-59,NDC,outpatient,100,ML,159.16,111.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.13,416.02,other,OPPS APC,,
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00641-6060-01,NDC,outpatient,10,ML,8.07,5.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.13,416.02,other,OPPS APC,,
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00409-2308-01,NDC,outpatient,1,ML,3.95,2.765,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.13,416.02,other,OPPS APC,,
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00409-2308-21,NDC,outpatient,1,ML,3.95,2.765,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.13,416.02,other,OPPS APC,,
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00641-6060-10,NDC,outpatient,10,ML,8.07,5.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.13,416.02,other,OPPS APC,,
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2251,HCPCS,636,RC,44567-0611-10,NDC,outpatient,100,ML,77.41,54.187,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.18,416.02,other,OPPS APC,,
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2251,HCPCS,636,RC,44567-0611-01,NDC,outpatient,100,ML,77.41,54.187,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.18,416.02,other,OPPS APC,,
MILRINONE IN DEXTROSE 20 MG/100ML IV SOLN,RX-122186,CDM,J2260,HCPCS,636,RC,00143-9719-10,NDC,outpatient,100,ML,44.93,31.451,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.41,416.02,other,OPPS APC,,
MILRINONE IN DEXTROSE 20 MG/100ML IV SOLN,RX-122186,CDM,J2260,HCPCS,636,RC,00143-9719-01,NDC,outpatient,100,ML,44.93,31.451,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.41,416.02,other,OPPS APC,,
MILRINONE IN DEXTROSE 20 MG/100ML IV SOLN,RX-122186,CDM,J2260,HCPCS,636,RC,25021-0313-82,NDC,outpatient,100,ML,50.27,35.189,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.41,416.02,other,OPPS APC,,
MILRINONE LACTATE 10 MG/10ML IV SOLN,RX-122188,CDM,J2260,HCPCS,636,RC,00143-9710-10,NDC,outpatient,10,ML,16.45,11.515,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.41,416.02,other,OPPS APC,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00409-1891-01,NDC,outpatient,1,ML,9.04,6.328,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.02948,416.02,other,OPPS APC,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00409-1891-03,NDC,outpatient,1,ML,9.04,6.328,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.02948,416.02,other,OPPS APC,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00641-6125-25,NDC,outpatient,1,ML,10.46,7.322,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.02948,416.02,other,OPPS APC,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00641-6125-01,NDC,outpatient,1,ML,10.46,7.322,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.02948,416.02,other,OPPS APC,,
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2270,HCPCS,636,RC,00641-6127-25,NDC,outpatient,1,ML,10.68,7.476,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.02948,416.02,other,OPPS APC,,
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2270,HCPCS,636,RC,00641-6127-01,NDC,outpatient,1,ML,10.68,7.476,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.02948,416.02,other,OPPS APC,,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2270,HCPCS,636,RC,00409-1890-03,NDC,outpatient,1,ML,9.93,6.951,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.02948,416.02,other,OPPS APC,,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2270,HCPCS,636,RC,00409-1890-01,NDC,outpatient,1,ML,9.93,6.951,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.02948,416.02,other,OPPS APC,,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2270,HCPCS,636,RC,52533-0161-45,NDC,outpatient,1,ML,33.38,23.366,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.02948,416.02,other,OPPS APC,,
MORPHINE SULFATE 50 MG/ML IV SOLN,RX-27393,CDM,J2270,HCPCS,636,RC,00409-1134-05,NDC,outpatient,50,ML,115.7,80.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.02948,416.02,other,OPPS APC,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2272,HCPCS,636,RC,63323-0454-00,NDC,outpatient,1,ML,8.51,5.957,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.816205,416.02,other,OPPS APC,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2272,HCPCS,636,RC,76045-0005-10,NDC,outpatient,1,ML,8.79,6.153,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.816205,416.02,other,OPPS APC,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2272,HCPCS,636,RC,63323-0454-01,NDC,outpatient,1,ML,8.51,5.957,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.816205,416.02,other,OPPS APC,,
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2272,HCPCS,636,RC,63323-0451-01,NDC,outpatient,1,ML,9.36,6.552,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.816205,416.02,other,OPPS APC,,
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2272,HCPCS,636,RC,63323-0451-00,NDC,outpatient,1,ML,9.36,6.552,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.816205,416.02,other,OPPS APC,,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2272,HCPCS,636,RC,63323-0452-00,NDC,outpatient,1,ML,8.27,5.789,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.816205,416.02,other,OPPS APC,,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2272,HCPCS,636,RC,63323-0452-01,NDC,outpatient,1,ML,8.27,5.789,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.816205,416.02,other,OPPS APC,,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2272,HCPCS,636,RC,76045-0004-10,NDC,outpatient,1,ML,8.09,5.663,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.816205,416.02,other,OPPS APC,,
MORPHINE SULFATE (PF) 1 MG/ML IJ SOLN,RX-15852,CDM,J2274,HCPCS,636,RC,00641-6019-01,NDC,outpatient,10,ML,82.11,57.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.46,1022.48448,other,OPPS APC,,
MORPHINE SULFATE (PF) 1 MG/ML IJ SOLN,RX-15852,CDM,J2274,HCPCS,636,RC,00641-6019-10,NDC,outpatient,10,ML,82.11,57.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.46,1022.48448,other,OPPS APC,,
MORPHINE SULF MICROINFUSION PF 200 MG/20ML (10 MG/ML) IJ SOLN,RX-77009,CDM,J2274,HCPCS,636,RC,00641-6039-01,NDC,outpatient,20,ML,695.45,486.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.46,1022.48448,other,OPPS APC,,
MORPHINE SULF MICROINFUSION PF 500 MG/20ML (25 MG/ML) IJ SOLN,RX-77010,CDM,J2274,HCPCS,636,RC,00641-6040-01,NDC,outpatient,20,ML,1331.36,931.952,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,10.46,1022.48448,other,OPPS APC,,
NALBUPHINE HCL 10 MG/ML IJ SOLN,RX-5339,CDM,J2300,HCPCS,636,RC,00409-1463-01,NDC,outpatient,1,ML,17.79,12.453,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.72,416.02,other,OPPS APC,,
NALBUPHINE HCL 10 MG/ML IJ SOLN,RX-5339,CDM,J2300,HCPCS,636,RC,00409-1463-71,NDC,outpatient,1,ML,17.79,12.453,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.72,416.02,other,OPPS APC,,
NITROGLYCERIN IN D5W 400-5 MCG/ML-% IV SOLN,RX-14895,CDM,J2305,HCPCS,636,RC,00338-1051-02,NDC,outpatient,250,ML,62.73,43.911,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.612864,,,1.612864,1.3,416.02,other,OPPS APC,,
NITROGLYCERIN IN D5W 400-5 MCG/ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-14895,CDM,J2305,HCPCS,636,RC,00338-1051-02,NDC,outpatient,250,ML,46.73,32.711,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,1.612864,,,1.612864,1.3,416.02,other,OPPS APC,,
NITROGLYCERIN IN D5W 100-5 MCG/ML-% IV SOLN,RX-15858,CDM,J2305,HCPCS,636,RC,00338-1047-02,NDC,outpatient,250,ML,56.05,39.235,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.612864,,,1.612864,1.3,416.02,other,OPPS APC,,
NITROGLYCERIN IN D5W 100-5 MCG/ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-15858,CDM,J2305,HCPCS,636,RC,00338-1047-02,NDC,outpatient,250,ML,40.05,28.035,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,1.612864,,,1.612864,1.3,416.02,other,OPPS APC,,
NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-15859,CDM,J2305,HCPCS,636,RC,00338-1049-02,NDC,outpatient,250,ML,42.28,29.596,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,1.612864,,,1.612864,1.3,416.02,other,OPPS APC,,
NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN,RX-15859,CDM,J2305,HCPCS,636,RC,00338-1049-02,NDC,outpatient,250,ML,58.28,40.796,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.612864,,,1.612864,1.3,416.02,other,OPPS APC,,
NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN,RX-15859,CDM,J2305,HCPCS,636,RC,99999-0004-40,NDC,outpatient,250,ML,45.49,31.843,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.612864,,,1.612864,1.3,416.02,other,OPPS APC,,
NITROGLYCERIN 5 MG/ML IV SOLN,RX-5599,CDM,J2305,HCPCS,636,RC,00517-4810-01,NDC,outpatient,10,ML,51.4,35.98,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.612864,,,1.612864,1.3,416.02,other,OPPS APC,,
NITROGLYCERIN 5 MG/ML IV SOLN,RX-5599,CDM,J2305,HCPCS,636,RC,00517-4810-25,NDC,outpatient,10,ML,51.4,35.98,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.612864,,,1.612864,1.3,416.02,other,OPPS APC,,
NALOXONE HCL 2 MG/2ML IJ SOSY,RX-136113,CDM,J2310,HCPCS,636,RC,76329-3369-01,NDC,outpatient,2,ML,42.08,29.456,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.03075,416.02,other,OPPS APC,,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,00409-1215-01,NDC,outpatient,1,ML,63.16,44.212,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.03075,416.02,other,OPPS APC,,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,00409-1215-21,NDC,outpatient,1,ML,63.16,44.212,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.03075,416.02,other,OPPS APC,,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,36000-0308-10,NDC,outpatient,1,ML,13.5,9.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.03075,416.02,other,OPPS APC,,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,67457-0292-00,NDC,outpatient,1,ML,15.44,10.808,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.03075,416.02,other,OPPS APC,,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,67457-0292-02,NDC,outpatient,1,ML,15.44,10.808,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.03075,416.02,other,OPPS APC,,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,36000-0308-01,NDC,outpatient,1,ML,13.5,9.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.03075,416.02,other,OPPS APC,,
OCTREOTIDE ACETATE 50 MCG/ML IJ SOLN,RX-91278,CDM,J2354,HCPCS,636,RC,67457-0239-00,NDC,outpatient,1,ML,17.58,12.306,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.86,416.02,other,OPPS APC,,
OCTREOTIDE ACETATE 50 MCG/ML IJ SOLN,RX-91278,CDM,J2354,HCPCS,636,RC,67457-0239-01,NDC,outpatient,1,ML,17.58,12.306,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.86,416.02,other,OPPS APC,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,23155-0688-31,NDC,outpatient,1,ML,11.88,8.316,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.86,416.02,other,OPPS APC,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,63323-0376-00,NDC,outpatient,1,ML,11.92,8.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.86,416.02,other,OPPS APC,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,00641-6175-10,NDC,outpatient,1,ML,7.84,5.488,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.86,416.02,other,OPPS APC,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,00641-6175-01,NDC,outpatient,1,ML,7.84,5.488,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.86,416.02,other,OPPS APC,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,23155-0688-41,NDC,outpatient,1,ML,11.88,8.316,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.86,416.02,other,OPPS APC,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,63323-0376-01,NDC,outpatient,1,ML,11.92,8.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.86,416.02,other,OPPS APC,,
OCTREOTIDE ACETATE 200 MCG/ML IJ SOLN,RX-91280,CDM,J2354,HCPCS,636,RC,00641-6177-01,NDC,outpatient,0.5,ML,25.17,17.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.86,416.02,other,OPPS APC,,
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,63323-0377-00,NDC,outpatient,1,ML,41.91,29.337,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.86,416.02,other,OPPS APC,,
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,63323-0377-01,NDC,outpatient,1,ML,41.91,29.337,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.86,416.02,other,OPPS APC,,
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,00641-6176-01,NDC,outpatient,1,ML,46.52,32.564,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.86,416.02,other,OPPS APC,,
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,00641-6176-10,NDC,outpatient,1,ML,46.52,32.564,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.86,416.02,other,OPPS APC,,
OMALIZUMAB 150 MG/ML SC SOSY,RX-144954,CDM,J2357,HCPCS,636,RC,50242-0215-01,NDC,outpatient,1,ML,3822.49,2675.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,43.8646315,,,43.8646315,38.29,2935.67232,other,OPPS APC,,
OMALIZUMAB 75 MG/0.5ML SC SOSY,RX-144955,CDM,J2357,HCPCS,636,RC,50242-0214-01,NDC,outpatient,0.5,ML,1911.25,1337.875,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,43.8646315,,,43.8646315,38.29,2935.67232,other,OPPS APC,,
OMALIZUMAB 150 MG SC SOLR,RX-36151,CDM,J2357,HCPCS,636,RC,50242-0040-62,NDC,outpatient,1,UN,3822.49,2675.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,43.8646315,,,43.8646315,38.29,2935.67232,other,OPPS APC,,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00002-7597-01,NDC,outpatient,1,UN,206.8,144.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.049278,,,1.049278,0.92,416.02,other,OPPS APC,,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00781-9105-72,NDC,outpatient,1,UN,62.44,43.708,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.049278,,,1.049278,0.92,416.02,other,OPPS APC,,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,55150-0308-01,NDC,outpatient,1,UN,77.39,54.173,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.049278,,,1.049278,0.92,416.02,other,OPPS APC,,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00517-0955-01,NDC,outpatient,1,UN,115.66,80.962,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.049278,,,1.049278,0.92,416.02,other,OPPS APC,,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00781-3159-72,NDC,outpatient,1,UN,62.44,43.708,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.049278,,,1.049278,0.92,416.02,other,OPPS APC,,
ORPHENADRINE CITRATE 30 MG/ML IJ SOLN,RX-5886,CDM,J2360,HCPCS,636,RC,00641-6182-10,NDC,outpatient,2,ML,19.23,13.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.317135,416.02,other,OPPS APC,,
ORPHENADRINE CITRATE 30 MG/ML IJ SOLN,RX-5886,CDM,J2360,HCPCS,636,RC,00641-6182-01,NDC,outpatient,2,ML,19.23,13.461,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.317135,416.02,other,OPPS APC,,
PHENYLEPHRINE HCL 100 MCG/ML SYRINGE,RX-4080501,CDM,J2371,HCPCS,636,RC,70004-0810-12,NDC,outpatient,10,ML,25.28,17.696,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.01,416.02,other,OPPS APC,,
PHENYLEPHRINE HCL 100 MCG/ML SYRINGE,RX-4080501,CDM,J2371,HCPCS,636,RC,70004-0810-11,NDC,outpatient,5,ML,23.81,16.667,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.01,416.02,other,OPPS APC,,
PHENYLEPHRINE HCL 100 MCG/ML SYRINGE,RX-4080501,CDM,J2371,HCPCS,636,RC,70092-1046-46,NDC,outpatient,10,ML,24.79,17.353,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.01,416.02,other,OPPS APC,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1577-01,NDC,outpatient,1,ML,9.89,6.923,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.01,416.02,other,OPPS APC,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,00781-3422-71,NDC,outpatient,1,ML,12.34,8.638,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.01,416.02,other,OPPS APC,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,00781-3422-92,NDC,outpatient,1,ML,12.34,8.638,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.01,416.02,other,OPPS APC,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70069-0801-25,NDC,outpatient,1,ML,6.49,4.543,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.01,416.02,other,OPPS APC,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,25021-0315-01,NDC,outpatient,1,ML,3.42,2.394,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.01,416.02,other,OPPS APC,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70069-0801-01,NDC,outpatient,1,ML,6.49,4.543,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.01,416.02,other,OPPS APC,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1577-05,NDC,outpatient,1,ML,9.89,6.923,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.01,416.02,other,OPPS APC,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1578-01,NDC,outpatient,5,ML,19.7,13.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.01,416.02,other,OPPS APC,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1578-07,NDC,outpatient,5,ML,19.7,13.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.01,416.02,other,OPPS APC,,
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,00143-9209-01,NDC,outpatient,20,ML,51.18,35.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.032074,,,0.032074,0.03,416.02,other,OPPS APC,,
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,63323-0477-27,NDC,outpatient,20,ML,78.86,55.202,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.032074,,,0.032074,0.03,416.02,other,OPPS APC,,
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,00143-9209-10,NDC,outpatient,20,ML,51.18,35.826,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.032074,,,0.032074,0.03,416.02,other,OPPS APC,,
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,63323-0477-01,NDC,outpatient,20,ML,78.86,55.202,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.032074,,,0.032074,0.03,416.02,other,OPPS APC,,
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,63323-0478-27,NDC,outpatient,20,ML,82.77,57.939,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.032074,,,0.032074,0.03,416.02,other,OPPS APC,,
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,00143-9210-10,NDC,outpatient,20,ML,54.03,37.821,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.032074,,,0.032074,0.03,416.02,other,OPPS APC,,
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,63323-0478-01,NDC,outpatient,20,ML,82.77,57.939,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.032074,,,0.032074,0.03,416.02,other,OPPS APC,,
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,00143-9210-01,NDC,outpatient,20,ML,54.03,37.821,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.032074,,,0.032074,0.03,416.02,other,OPPS APC,,
NICARDIPINE HCL 2.5 MG/ML IV SOLN,RX-12370,CDM,J2404,HCPCS,636,RC,00143-9689-01,NDC,outpatient,10,ML,41.12,28.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.54,416.02,other,OPPS APC,,
NICARDIPINE HCL 2.5 MG/ML IV SOLN,RX-12370,CDM,J2404,HCPCS,636,RC,00143-9689-10,NDC,outpatient,10,ML,41.12,28.784,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.54,416.02,other,OPPS APC,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,23155-0547-42,NDC,outpatient,2,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,23155-0549-31,NDC,outpatient,20,ML,18.1,12.67,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,60505-6130-00,NDC,outpatient,2,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00409-4755-03,NDC,outpatient,2,ML,6.09,4.263,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00641-6078-01,NDC,outpatient,2,ML,3.61,2.527,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00641-6078-25,NDC,outpatient,2,ML,3.61,2.527,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,36000-0012-25,NDC,outpatient,2,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00409-4755-18,NDC,outpatient,2,ML,6.09,4.263,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,23155-0547-31,NDC,outpatient,2,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,60505-6130-05,NDC,outpatient,2,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
PAMIDRONATE DISODIUM 30 MG/10ML IV SOLN,RX-32589,CDM,J2430,HCPCS,636,RC,61703-0324-18,NDC,outpatient,10,ML,46.42,32.494,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.263845,416.02,other,OPPS APC,,
PAMIDRONATE DISODIUM 30 MG/10ML IV SOLN,RX-32589,CDM,J2430,HCPCS,636,RC,67457-0430-10,NDC,outpatient,10,ML,36.81,25.767,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,8.263845,416.02,other,OPPS APC,,
PALONOSETRON HCL 0.25 MG/5ML IV SOLN,RX-36591,CDM,J2469,HCPCS,636,RC,55111-0694-07,NDC,outpatient,5,ML,25.1,17.57,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.62,416.02,other,OPPS APC,,
PALONOSETRON HCL 0.25 MG/5ML IV SOLN,RX-36591,CDM,J2469,HCPCS,636,RC,60505-6193-01,NDC,outpatient,5,ML,13.32,9.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.62,416.02,other,OPPS APC,,
PARICALCITOL 5 MCG/ML IV SOLN,RX-22960,CDM,J2501,HCPCS,636,RC,00074-1658-01,NDC,outpatient,1,ML,40.71,28.497,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.5,416.02,other,OPPS APC,,
PEGLOTICASE 8 MG/ML IV SOLN,RX-107664,CDM,J2507,HCPCS,636,RC,75987-0080-10,NDC,outpatient,1,ML,59467.57,41627.299,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3988.807407,,,3988.807407,399.86,45671.09376,other,OPPS APC,,
PENICILLIN G POT IN DEXTROSE 60000 UNIT/ML IV WRAPPER,RX-4080111,CDM,J2540,HCPCS,636,RC,00338-1025-41,NDC,outpatient,50,ML,55.67,38.969,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.01,416.02,other,OPPS APC,,
PENICILLIN G POTASSIUM 5000000 UNITS IJ SOLR,RX-6086,CDM,J2540,HCPCS,636,RC,44567-0311-10,NDC,outpatient,1,UN,17.93,12.551,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.01,416.02,other,OPPS APC,,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,00781-3114-95,NDC,outpatient,1,UN,30.55,21.385,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.1,416.02,other,OPPS APC,,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,00781-3114-91,NDC,outpatient,1,UN,30.55,21.385,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.1,416.02,other,OPPS APC,,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,72485-0404-10,NDC,outpatient,1,UN,18.51,12.957,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.1,416.02,other,OPPS APC,,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,44567-0803-10,NDC,outpatient,1,UN,27.96,19.572,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.1,416.02,other,OPPS APC,,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,55150-0121-50,NDC,outpatient,1,UN,18.43,12.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.1,416.02,other,OPPS APC,,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,72485-0404-01,NDC,outpatient,1,UN,18.51,12.957,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.1,416.02,other,OPPS APC,,
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,55150-0120-30,NDC,outpatient,1,UN,12.91,9.037,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.1,416.02,other,OPPS APC,,
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,64679-0056-01,NDC,outpatient,1,UN,13.78,9.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.1,416.02,other,OPPS APC,,
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,60505-6157-00,NDC,outpatient,1,UN,9.79,6.853,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.1,416.02,other,OPPS APC,,
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,64679-0056-02,NDC,outpatient,1,UN,13.78,9.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.1,416.02,other,OPPS APC,,
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,60505-6157-04,NDC,outpatient,1,UN,9.79,6.853,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.1,416.02,other,OPPS APC,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00781-3110-90,NDC,outpatient,1,UN,17.66,12.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.1,416.02,other,OPPS APC,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00781-3110-95,NDC,outpatient,1,UN,17.66,12.362,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.1,416.02,other,OPPS APC,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,60505-6156-00,NDC,outpatient,1,UN,7.94,5.558,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.1,416.02,other,OPPS APC,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00409-3383-02,NDC,outpatient,1,UN,25.13,17.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.1,416.02,other,OPPS APC,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00409-3383-11,NDC,outpatient,1,UN,25.13,17.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.1,416.02,other,OPPS APC,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,44567-0801-10,NDC,outpatient,1,UN,14.21,9.947,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.1,416.02,other,OPPS APC,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,55150-0119-30,NDC,outpatient,1,UN,8.76,6.132,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.1,416.02,other,OPPS APC,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,60505-6156-04,NDC,outpatient,1,UN,7.94,5.558,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.1,416.02,other,OPPS APC,,
PROMETHAZINE HCL 25 MG/ML IJ SOLN,RX-6618,CDM,J2550,HCPCS,636,RC,00641-1495-31,NDC,outpatient,1,ML,7.75,5.425,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.739875,416.02,other,OPPS APC,,
PROMETHAZINE HCL 25 MG/ML IJ SOLN,RX-6618,CDM,J2550,HCPCS,636,RC,00641-1495-35,NDC,outpatient,1,ML,7.75,5.425,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.739875,416.02,other,OPPS APC,,
PHENOBARBITAL SODIUM 130 MG/ML IJ SOLN,RX-6221,CDM,J2560,HCPCS,636,RC,00641-0477-21,NDC,outpatient,1,ML,155.87,109.109,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,13.89655,416.02,other,OPPS APC,,
PHENOBARBITAL SODIUM 130 MG/ML IJ SOLN,RX-6221,CDM,J2560,HCPCS,636,RC,00641-0477-25,NDC,outpatient,1,ML,155.87,109.109,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,13.89655,416.02,other,OPPS APC,,
PHENOBARBITAL SODIUM 65 MG/ML IJ SOLN,RX-6224,CDM,J2560,HCPCS,636,RC,00641-0476-21,NDC,outpatient,1,ML,61.9,43.33,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,13.89655,416.02,other,OPPS APC,,
PHENOBARBITAL SODIUM 65 MG/ML IJ SOLN,RX-6224,CDM,J2560,HCPCS,636,RC,00641-0476-25,NDC,outpatient,1,ML,61.9,43.33,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,13.89655,416.02,other,OPPS APC,,
OXYTOCIN 10 UNIT/ML IJ SOLN,RX-5944,CDM,J2590,HCPCS,636,RC,63323-0012-10,NDC,outpatient,0.3,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC,,
OXYTOCIN 10 UNIT/ML IJ SOLN,RX-5944,CDM,J2590,HCPCS,636,RC,63323-0012-06,NDC,outpatient,0.3,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC,,
OXYTOCIN 10 UNIT/ML IJ SOLN,RX-5944,CDM,J2590,HCPCS,636,RC,42023-0116-25,NDC,outpatient,1,ML,7.42,5.194,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.74534,416.02,other,OPPS APC,,
DESMOPRESSIN ACETATE 4 MCG/ML IJ SOLN WRAPPER,RX-4081353,CDM,J2597,HCPCS,636,RC,69918-0899-01,NDC,outpatient,1,ML,91.9,64.33,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6.20861,,,6.20861,5.42,416.02,other,OPPS APC,,
DESMOPRESSIN ACETATE 4 MCG/ML IJ SOLN WRAPPER,RX-4081353,CDM,J2597,HCPCS,636,RC,69918-0899-10,NDC,outpatient,1,ML,91.9,64.33,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6.20861,,,6.20861,5.42,416.02,other,OPPS APC,,
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-10,NDC,outpatient,100,ML,534.45,374.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,1.8545645,,,1.8545645,1.62,422.7456,other,OPPS APC,,
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-01,NDC,outpatient,100,ML,534.45,374.115,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,1.8545645,,,1.8545645,1.62,422.7456,other,OPPS APC,,
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-10,NDC,outpatient,100,ML,550.45,385.315,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.8545645,,,1.8545645,1.62,422.7456,other,OPPS APC,,
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-01,NDC,outpatient,100,ML,550.45,385.315,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.8545645,,,1.8545645,1.62,422.7456,other,OPPS APC,,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42367-0570-22,NDC,outpatient,0.25,ML,175.83,123.081,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.8545645,,,1.8545645,1.62,422.7456,other,OPPS APC,,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,55150-0370-25,NDC,outpatient,0.25,ML,21.94,15.358,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.8545645,,,1.8545645,1.62,422.7456,other,OPPS APC,,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42023-0164-25,NDC,outpatient,1,ML,50.82,35.574,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.8545645,,,1.8545645,1.62,422.7456,other,OPPS APC,,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42367-0570-87,NDC,outpatient,0.25,ML,175.83,123.081,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.8545645,,,1.8545645,1.62,422.7456,other,OPPS APC,,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42023-0164-01,NDC,outpatient,1,ML,50.82,35.574,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.8545645,,,1.8545645,1.62,422.7456,other,OPPS APC,,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,55150-0370-01,NDC,outpatient,0.25,ML,21.94,15.358,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.8545645,,,1.8545645,1.62,422.7456,other,OPPS APC,,
FLUPHENAZINE HCL 2.5 MG/ML IJ SOLN,RX-3216,CDM,J2679,HCPCS,636,RC,63323-0281-10,NDC,outpatient,0.5,ML,19.62,13.734,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.40469,416.02,other,OPPS APC,,
FLUPHENAZINE DECANOATE 25 MG/ML IJ SOLN,RX-3215,CDM,J2680,HCPCS,636,RC,42023-0129-01,NDC,outpatient,0.5,ML,20.43,14.301,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.586535,416.02,other,OPPS APC,,
FLUPHENAZINE DECANOATE 25 MG/ML IJ SOLN,RX-3215,CDM,J2680,HCPCS,636,RC,63323-0272-05,NDC,outpatient,0.5,ML,32.89,23.023,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.586535,416.02,other,OPPS APC,,
PROCAINAMIDE HCL 100 MG/ML IJ SOLN,RX-6562,CDM,J2690,HCPCS,636,RC,00409-1902-01,NDC,outpatient,1,ML,24.43,17.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,625.518603,,,625.518603,5.484535,1082.90304,other,OPPS APC,,
PROCAINAMIDE HCL 100 MG/ML IJ SOLN,RX-6562,CDM,J2690,HCPCS,636,RC,00409-1902-11,NDC,outpatient,1,ML,24.43,17.101,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,625.518603,,,625.518603,5.484535,1082.90304,other,OPPS APC,,
PROCAINAMIDE HCL 500 MG/ML IJ SOLN,RX-6563,CDM,J2690,HCPCS,636,RC,14789-0900-02,NDC,outpatient,2,ML,1410.03,987.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,625.518603,,,625.518603,5.484535,1082.90304,other,OPPS APC,,
PROCAINAMIDE HCL 500 MG/ML IJ SOLN,RX-6563,CDM,J2690,HCPCS,636,RC,14789-0900-07,NDC,outpatient,2,ML,1410.03,987.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,625.518603,,,625.518603,5.484535,1082.90304,other,OPPS APC,,
OXACILLIN SODIUM 10 G IV SOLR,RX-150085,CDM,J2700,HCPCS,636,RC,25021-0163-99,NDC,outpatient,1,UN,489.5,342.65,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.87,416.02,other,OPPS APC,,
OXACILLIN SODIUM 10 G IV SOLR,RX-150085,CDM,J2700,HCPCS,636,RC,55150-0129-99,NDC,outpatient,1,UN,150.46,105.322,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.87,416.02,other,OPPS APC,,
OXACILLIN SODIUM 10 G IV SOLR,RX-150085,CDM,J2700,HCPCS,636,RC,63323-0811-00,NDC,outpatient,1,UN,137.38,96.166,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.87,416.02,other,OPPS APC,,
OXACILLIN SODIUM 1 G IJ SOLR,RX-5924,CDM,J2700,HCPCS,636,RC,55150-0127-15,NDC,outpatient,1,UN,19.11,13.377,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.87,416.02,other,OPPS APC,,
OXACILLIN SODIUM 1 G IJ SOLR,RX-5924,CDM,J2700,HCPCS,636,RC,64679-0698-02,NDC,outpatient,1,UN,20.97,14.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.87,416.02,other,OPPS APC,,
OXACILLIN SODIUM 1 G IJ SOLR,RX-5924,CDM,J2700,HCPCS,636,RC,64679-0698-01,NDC,outpatient,1,UN,20.97,14.679,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.87,416.02,other,OPPS APC,,
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,63323-0812-20,NDC,outpatient,1,UN,25.17,17.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.87,416.02,other,OPPS APC,,
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,64679-0699-01,NDC,outpatient,1,UN,38.24,26.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.87,416.02,other,OPPS APC,,
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,64679-0699-02,NDC,outpatient,1,UN,38.24,26.768,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.87,416.02,other,OPPS APC,,
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,63323-0812-01,NDC,outpatient,1,UN,25.17,17.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.87,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0209-10,NDC,outpatient,20,ML,9.98,6.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0248-01,NDC,outpatient,100,ML,43.17,30.219,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-33,NDC,outpatient,50,ML,18.47,12.929,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0528-10,NDC,outpatient,20,ML,9.98,6.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0977-20,NDC,outpatient,50,ML,18.69,13.083,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,25021-0608-50,NDC,outpatient,50,ML,28.71,20.097,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,63323-0269-22,NDC,outpatient,20,ML,9.57,6.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,63323-0269-29,NDC,outpatient,20,ML,9.57,6.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0209-01,NDC,outpatient,20,ML,9.98,6.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0234-20,NDC,outpatient,50,ML,21.59,15.113,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-53,NDC,outpatient,50,ML,18.47,12.929,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0528-01,NDC,outpatient,20,ML,8.95,6.265,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0690-10,NDC,outpatient,100,ML,32.93,23.051,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,25021-0608-20,NDC,outpatient,20,ML,10.49,7.343,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,43598-0548-21,NDC,outpatient,50,ML,20.47,14.329,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0234-01,NDC,outpatient,50,ML,21.59,15.113,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0248-10,NDC,outpatient,100,ML,43.17,30.219,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-24,NDC,outpatient,100,ML,36.94,25.858,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-54,NDC,outpatient,100,ML,36.94,25.858,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0690-01,NDC,outpatient,100,ML,32.93,23.051,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0977-01,NDC,outpatient,50,ML,18.69,13.083,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,25021-0608-51,NDC,outpatient,100,ML,57.41,40.187,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,43598-0548-50,NDC,outpatient,50,ML,20.47,14.329,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-24,NDC,outpatient,100,ML,52.94,37.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-53,NDC,outpatient,50,ML,34.47,24.129,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,43598-0548-21,NDC,outpatient,50,ML,36.47,25.529,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0977-20,NDC,outpatient,50,ML,34.69,24.283,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,25021-0608-50,NDC,outpatient,50,ML,44.71,31.297,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,25021-0608-51,NDC,outpatient,100,ML,73.41,51.387,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,43598-0548-50,NDC,outpatient,50,ML,36.47,25.529,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0234-01,NDC,outpatient,50,ML,37.59,26.313,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0234-20,NDC,outpatient,50,ML,37.59,26.313,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0248-01,NDC,outpatient,100,ML,59.17,41.419,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0248-10,NDC,outpatient,100,ML,59.17,41.419,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-33,NDC,outpatient,50,ML,34.47,24.129,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0690-10,NDC,outpatient,100,ML,48.93,34.251,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0977-01,NDC,outpatient,50,ML,34.69,24.283,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-54,NDC,outpatient,100,ML,52.94,37.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0690-01,NDC,outpatient,100,ML,48.93,34.251,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
NEOSTIGMINE METHYLSULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4080613,CDM,J2710,HCPCS,636,RC,70121-1479-07,NDC,outpatient,10,ML,34.98,24.486,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.43,416.02,other,OPPS APC,,
NEOSTIGMINE METHYLSULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4080613,CDM,J2710,HCPCS,636,RC,70121-1479-01,NDC,outpatient,10,ML,34.98,24.486,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.43,416.02,other,OPPS APC,,
PROTAMINE SULFATE 10 MG/ML IV SOLN,RX-6677,CDM,J2720,HCPCS,636,RC,63323-0229-30,NDC,outpatient,25,ML,134.62,94.234,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.95,416.02,other,OPPS APC,,
PROTAMINE SULFATE 10 MG/ML IV SOLN,RX-6677,CDM,J2720,HCPCS,636,RC,63323-0229-05,NDC,outpatient,5,ML,44.82,31.374,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.95,416.02,other,OPPS APC,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-3414-18,NDC,outpatient,2,ML,4.14,2.898,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92943,416.02,other,OPPS APC,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-5255-25,NDC,outpatient,2,ML,4.14,2.898,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92943,416.02,other,OPPS APC,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-3414-01,NDC,outpatient,2,ML,4.14,2.898,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92943,416.02,other,OPPS APC,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00703-4502-04,NDC,outpatient,2,ML,17.23,12.061,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92943,416.02,other,OPPS APC,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,76045-0101-20,NDC,outpatient,2,ML,9.08,6.356,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92943,416.02,other,OPPS APC,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-5255-02,NDC,outpatient,2,ML,4.14,2.898,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92943,416.02,other,OPPS APC,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00703-4502-01,NDC,outpatient,2,ML,17.23,12.061,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.92943,416.02,other,OPPS APC,,
QUINUPRISTIN-DALFOPRISTIN 500 MG IV SOLR,RX-26335,CDM,J2770,HCPCS,636,RC,61570-0260-01,NDC,outpatient,1,UN,1916.14,1341.298,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7.136465,,,7.136465,7.136465,1471.59552,other,OPPS APC,,
QUINUPRISTIN-DALFOPRISTIN 500 MG IV SOLR,RX-26335,CDM,J2770,HCPCS,636,RC,61570-0260-10,NDC,outpatient,1,UN,1916.14,1341.298,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,7.136465,,,7.136465,7.136465,1471.59552,other,OPPS APC,,
RASBURICASE 1.5 MG IV SOLR,RX-33591,CDM,J2783,HCPCS,636,RC,00024-5150-10,NDC,outpatient,1,UN,3073.12,2151.184,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,425.3161315,,,425.3161315,357.36,11800.75008,other,OPPS APC,,
RASBURICASE 7.5 MG IV SOLR,RX-76868,CDM,J2783,HCPCS,636,RC,00024-5151-75,NDC,outpatient,1,UN,15365.56,10755.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,425.3161315,,,425.3161315,357.36,11800.75008,other,OPPS APC,,
REGADENOSON 0.4 MG/5ML IV SOLN,RX-91408,CDM,J2785,HCPCS,636,RC,67457-0994-05,NDC,outpatient,5,ML,26.97,18.879,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.88,455.8464,other,OPPS APC,,
REGADENOSON 0.4 MG/5ML IV SOLN,RX-91408,CDM,J2785,HCPCS,636,RC,71288-0201-85,NDC,outpatient,5,ML,30.71,21.497,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.88,455.8464,other,OPPS APC,,
REGADENOSON 0.4 MG/5ML IV SOLN,RX-91408,CDM,J2785,HCPCS,636,RC,00469-6501-89,NDC,outpatient,5,ML,593.55,415.485,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.88,455.8464,other,OPPS APC,,
RHO D IMMUNE GLOBULIN 1500 UNIT/2ML IJ SOSY,RX-129748,CDM,J2791,HCPCS,636,RC,44206-0300-10,NDC,outpatient,2,ML,207.1,144.97,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,,,other,OPPS APC,,
RHO D IMMUNE GLOBULIN 1500 UNIT/2ML IJ SOSY,RX-129748,CDM,J2791,HCPCS,636,RC,44206-0300-90,NDC,outpatient,2,ML,78.48,54.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,,,other,OPPS APC,,
RHO D IMMUNE GLOBULIN 1500 UNIT/2ML IJ SOSY,RX-129748,CDM,J2791,HCPCS,636,RC,44206-0300-01,NDC,outpatient,2,ML,207.1,144.97,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,,,other,OPPS APC,,
RHO D IMMUNE GLOBULIN 5000 UNIT/4.4ML IJ SOLN,RX-70574,CDM,J2792,HCPCS,636,RC,70257-0310-51,NDC,outpatient,4.4,ML,3912.94,2739.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,39.331888,,,39.331888,33.71,3005.13792,other,OPPS APC,,
RHO D IMMUNE GLOBULIN 5000 UNIT/4.4ML IJ SOLN,RX-70574,CDM,J2792,HCPCS,636,RC,70257-0310-04,NDC,outpatient,4.4,ML,3912.94,2739.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,39.331888,,,39.331888,33.71,3005.13792,other,OPPS APC,,
RISPERIDONE MICROSPHERES ER 37.5 MG IM SRER,RX-148032,CDM,J2794,HCPCS,636,RC,50458-0307-11,NDC,outpatient,1,UN,2304,1612.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12.9430045,,,12.9430045,10.7,2359.38048,other,OPPS APC,,
RISPERIDONE MICROSPHERES ER 50 MG IM SRER,RX-148033,CDM,J2794,HCPCS,636,RC,50458-0308-11,NDC,outpatient,1,UN,3072.11,2150.477,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,12.9430045,,,12.9430045,10.7,2359.38048,other,OPPS APC,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,70069-0064-01,NDC,outpatient,30,ML,20.21,14.147,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-01,NDC,outpatient,20,ML,59.55,41.685,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,43066-0023-10,NDC,outpatient,30,ML,15.73,11.011,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,55150-0198-30,NDC,outpatient,30,ML,20.21,14.147,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-11,NDC,outpatient,30,ML,20.56,14.392,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,43066-0023-01,NDC,outpatient,30,ML,15.73,11.011,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-20,NDC,outpatient,20,ML,59.55,41.685,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-35,NDC,outpatient,30,ML,20.56,14.392,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC,,
ROMIPLOSTIM 125 MCG SC SOLR|DISCARDED DRUG NOT ADMINISTERED,RX-148858,CDM,J2796,HCPCS,636,RC,55513-0223-01,NDC,outpatient,1,UN,3455.52,2418.864,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,115.755066,,,115.755066,95.47,5307.61728,other,OPPS APC,,
ROMIPLOSTIM 125 MCG SC SOLR,RX-148858,CDM,J2796,HCPCS,636,RC,55513-0223-01,NDC,outpatient,1,UN,3455.52,2418.864,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,115.755066,,,115.755066,95.47,5307.61728,other,OPPS APC,,
ROMIPLOSTIM 250 MCG SC SOLR,RX-93566,CDM,J2796,HCPCS,636,RC,55513-0221-01,NDC,outpatient,1,UN,6910.96,4837.672,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,115.755066,,,115.755066,95.47,5307.61728,other,OPPS APC,,
SILTUXIMAB 100 MG IV SOLR,RX-125552,CDM,J2860,HCPCS,636,RC,73090-0420-01,NDC,outpatient,1,UN,4143.92,2900.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,179.925976,,,179.925976,139.22,12730.14528,other,OPPS APC,,
SILTUXIMAB 400 MG IV SOLR,RX-125553,CDM,J2860,HCPCS,636,RC,73090-0421-01,NDC,outpatient,1,UN,16575.71,11602.997,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,179.925976,,,179.925976,139.22,12730.14528,other,OPPS APC,,
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00024-2792-01,NDC,outpatient,5,ML,35.83,25.081,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.12,416.02,other,OPPS APC,,
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00143-9570-01,NDC,outpatient,5,ML,61.68,43.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.12,416.02,other,OPPS APC,,
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00143-9570-10,NDC,outpatient,5,ML,61.68,43.176,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.12,416.02,other,OPPS APC,,
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00024-2792-10,NDC,outpatient,5,ML,35.83,25.081,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.12,416.02,other,OPPS APC,,
ALTEPLASE 2 MG IJ SOLR,RX-31310,CDM,J2997,HCPCS,636,RC,50242-0041-64,NDC,outpatient,1,UN,725.13,507.591,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,104.778885,,,104.778885,89.15,17236.24704,other,OPPS APC,,
ALTEPLASE 2 MG IJ SOLR,RX-31310,CDM,J2997,HCPCS,636,RC,99999-0000-50,NDC,outpatient,2,ML,723.71,506.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,104.778885,,,104.778885,89.15,17236.24704,other,OPPS APC,,
ALTEPLASE 100 MG IV SOLR,RX-9002,CDM,J2997,HCPCS,636,RC,50242-0085-27,NDC,outpatient,1,UN,22443.03,15710.121,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,104.778885,,,104.778885,89.15,17236.24704,other,OPPS APC,,
ALTEPLASE 50 MG IV SOLR,RX-9003,CDM,J2997,HCPCS,636,RC,50242-0044-13,NDC,outpatient,1,UN,11221.53,7855.071,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,104.778885,,,104.778885,89.15,17236.24704,other,OPPS APC,,
STREPTOMYCIN SULFATE 1 G IM SOLR,RX-7508,CDM,J3000,HCPCS,636,RC,39822-0706-02,NDC,outpatient,1,UN,186.61,130.627,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,31.57,416.02,other,OPPS APC,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-12,NDC,outpatient,2,ML,7.31,5.117,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.84,416.02,other,OPPS APC,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-05,NDC,outpatient,5,ML,9.41,6.587,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.84,416.02,other,OPPS APC,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-22,NDC,outpatient,2,ML,7.31,5.117,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.84,416.02,other,OPPS APC,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00641-6027-01,NDC,outpatient,2,ML,6.08,4.256,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.84,416.02,other,OPPS APC,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-12,NDC,outpatient,2,ML,7.42,5.194,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.84,416.02,other,OPPS APC,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-13,NDC,outpatient,5,ML,9.41,6.587,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.84,416.02,other,OPPS APC,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-61,NDC,outpatient,50,ML,40.05,28.035,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.84,416.02,other,OPPS APC,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00641-6027-25,NDC,outpatient,2,ML,6.08,4.256,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.84,416.02,other,OPPS APC,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-02,NDC,outpatient,2,ML,7.42,5.194,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.84,416.02,other,OPPS APC,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-41,NDC,outpatient,50,ML,40.05,28.035,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.84,416.02,other,OPPS APC,,
TENECTEPLASE 50 MG IV KIT,RX-28530,CDM,J3101,HCPCS,636,RC,50242-0120-47,NDC,outpatient,1,UN,19380.84,13566.588,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,180.672842,,,180.672842,152.7,14884.48512,other,OPPS APC,,
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,00143-9746-01,NDC,outpatient,1,ML,6.05,4.235,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.358225,416.02,other,OPPS APC,,
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,63323-0665-01,NDC,outpatient,1,ML,6.42,4.494,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.358225,416.02,other,OPPS APC,,
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,00143-9746-10,NDC,outpatient,1,ML,6.05,4.235,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.358225,416.02,other,OPPS APC,,
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,63323-0665-00,NDC,outpatient,1,ML,6.42,4.494,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.358225,416.02,other,OPPS APC,,
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,55150-0318-25,NDC,outpatient,1,ML,65.18,45.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.63291,416.02,other,OPPS APC,,
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,00641-1398-31,NDC,outpatient,2,ML,108.05,75.635,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.63291,416.02,other,OPPS APC,,
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,55150-0318-01,NDC,outpatient,1,ML,65.18,45.626,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.63291,416.02,other,OPPS APC,,
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,00641-1398-35,NDC,outpatient,2,ML,108.05,75.635,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.63291,416.02,other,OPPS APC,,
THYROTROPIN ALFA 0.9 MG IM SOLR,RX-156409,CDM,J3240,HCPCS,636,RC,58468-0030-02,NDC,outpatient,1,UN,5457.19,3820.033,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2375.012116,,,2375.012116,399.86,4191.12192,other,OPPS APC,,
TIGECYCLINE 50 MG IV SOLR,RX-41652,CDM,J3243,HCPCS,636,RC,55150-0228-10,NDC,outpatient,1,UN,119.66,83.762,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.52,416.02,other,OPPS APC,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-01,NDC,outpatient,100,ML,285.69,199.983,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,4.382683,,,4.382683,3.83,567.65184,other,OPPS APC,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-03,NDC,outpatient,100,ML,198.47,138.929,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,4.382683,,,4.382683,3.83,567.65184,other,OPPS APC,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-01,NDC,outpatient,100,ML,301.69,211.183,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4.382683,,,4.382683,3.83,567.65184,other,OPPS APC,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0430-01,NDC,outpatient,250,ML,529.98,370.986,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4.382683,,,4.382683,3.83,567.65184,other,OPPS APC,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0429-01,NDC,outpatient,100,ML,219.39,153.573,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,4.382683,,,4.382683,3.83,567.65184,other,OPPS APC,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-02,NDC,outpatient,250,ML,739.13,517.391,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4.382683,,,4.382683,3.83,567.65184,other,OPPS APC,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-03,NDC,outpatient,100,ML,214.47,150.129,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4.382683,,,4.382683,3.83,567.65184,other,OPPS APC,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-02,NDC,outpatient,250,ML,723.13,506.191,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,4.382683,,,4.382683,3.83,567.65184,other,OPPS APC,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0430-01,NDC,outpatient,250,ML,513.98,359.786,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,4.382683,,,4.382683,3.83,567.65184,other,OPPS APC,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0429-01,NDC,outpatient,100,ML,235.39,164.773,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4.382683,,,4.382683,3.83,567.65184,other,OPPS APC,,
TRIMETHOBENZAMIDE HCL 100 MG/ML IM SOLN,RX-8178,CDM,J3250,HCPCS,636,RC,42023-0119-25,NDC,outpatient,2,ML,199.22,139.454,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,44.72489,416.02,other,OPPS APC,,
TOBRAMYCIN SULFATE 1.2 G IJ SOLR,RX-11565,CDM,J3260,HCPCS,636,RC,39822-0412-01,NDC,outpatient,1,UN,217.92,152.544,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.882285,416.02,other,OPPS APC,,
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,00409-3578-01,NDC,outpatient,2,ML,13.74,9.618,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.882285,416.02,other,OPPS APC,,
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,67457-0473-00,NDC,outpatient,2,ML,3.93,2.751,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.882285,416.02,other,OPPS APC,,
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,00409-3578-11,NDC,outpatient,2,ML,13.74,9.618,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.882285,416.02,other,OPPS APC,,
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,67457-0473-22,NDC,outpatient,2,ML,3.93,2.751,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.882285,416.02,other,OPPS APC,,
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,63323-0306-02,NDC,outpatient,2,ML,16.01,11.207,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.882285,416.02,other,OPPS APC,,
TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN,RX-97790,CDM,J3260,HCPCS,636,RC,67457-0428-30,NDC,outpatient,30,ML,45.26,31.682,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.882285,416.02,other,OPPS APC,,
TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN,RX-97790,CDM,J3260,HCPCS,636,RC,63323-0306-30,NDC,outpatient,30,ML,60.48,42.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.882285,416.02,other,OPPS APC,,
TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN,RX-97790,CDM,J3260,HCPCS,636,RC,67457-0428-00,NDC,outpatient,30,ML,45.26,31.682,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.882285,416.02,other,OPPS APC,,
TOCILIZUMAB 20 MG/ML IV WRAPPER,RX-4080174,CDM,J3262,HCPCS,636,RC,50242-0136-01,NDC,outpatient,10,ML,3555.08,2488.556,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6.829471,,,6.829471,5.91,5460.64128,other,OPPS APC,,
TOCILIZUMAB 20 MG/ML IV WRAPPER,RX-4080174,CDM,J3262,HCPCS,636,RC,50242-0135-01,NDC,outpatient,4,ML,1422.05,995.435,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6.829471,,,6.829471,5.91,5460.64128,other,OPPS APC,,
TOCILIZUMAB 20 MG/ML IV WRAPPER,RX-4080174,CDM,J3262,HCPCS,636,RC,50242-0137-01,NDC,outpatient,20,ML,7110.21,4977.147,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6.829471,,,6.829471,5.91,5460.64128,other,OPPS APC,,
TRIAMCINOLONE ACETONIDE 10 MG/ML IJ SUSP,RX-11584,CDM,J3301,HCPCS,636,RC,00003-0494-20,NDC,outpatient,5,ML,49.71,34.797,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.9,416.02,other,OPPS APC,,
TRIAMCINOLONE ACETONIDE 40 MG/ML IJ SUSP,RX-8120,CDM,J3301,HCPCS,636,RC,00003-0293-05,NDC,outpatient,1,ML,38.5,26.95,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.9,416.02,other,OPPS APC,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00409-1273-03,NDC,outpatient,2,ML,106.04,74.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,5.25,416.02,other,OPPS APC,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,69339-0136-34,NDC,outpatient,2,ML,63.74,44.618,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,5.25,416.02,other,OPPS APC,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00409-1273-32,NDC,outpatient,2,ML,106.04,74.228,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,5.25,416.02,other,OPPS APC,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,69339-0136-03,NDC,outpatient,2,ML,63.74,44.618,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,5.25,416.02,other,OPPS APC,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00641-6244-01,NDC,outpatient,2,ML,60.45,42.315,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,5.25,416.02,other,OPPS APC,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00641-6244-10,NDC,outpatient,2,ML,60.45,42.315,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,5.25,416.02,other,OPPS APC,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,76045-0204-20,NDC,outpatient,2,ML,59.63,41.741,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,5.25,416.02,other,OPPS APC,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,76045-0204-00,NDC,outpatient,2,ML,59.63,41.741,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,5.25,416.02,other,OPPS APC,,
VANCOMYCIN HCL IN DEXTROSE 750 MG/150ML IV SOLN,RX-108740,CDM,J3370,HCPCS,636,RC,00338-3580-48,NDC,outpatient,150,ML,49.93,34.951,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC,,
VANCOMYCIN HCL IN DEXTROSE 750 MG/150ML IV SOLN,RX-108740,CDM,J3370,HCPCS,636,RC,99999-0000-88,NDC,outpatient,150,ML,35.17,24.619,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC,,
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,67457-0342-10,NDC,outpatient,10,GR,875.85,613.095,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC,,
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,25021-0158-99,NDC,outpatient,10,GR,205.59,143.913,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC,,
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,63323-0314-61,NDC,outpatient,10,GR,107.34,75.138,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC,,
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,70594-0048-01,NDC,outpatient,10,GR,267,186.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC,,
VANCOMYCIN HCL IN DEXTROSE 500 MG/100ML IV SOLN,RX-11632,CDM,J3370,HCPCS,636,RC,00338-3551-48,NDC,outpatient,100,ML,52.94,37.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC,,
VANCOMYCIN HCL IN NACL 750-0.9 MG/150ML-% IV SOLN,RX-134904,CDM,J3370,HCPCS,636,RC,00338-3582-01,NDC,outpatient,150,ML,73.41,51.387,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC,,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,00143-9357-01,NDC,outpatient,1,UN,12.35,8.645,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC,,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,67457-0340-01,NDC,outpatient,1,UN,16.63,11.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC,,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,16714-0309-01,NDC,outpatient,1,UN,11.19,7.833,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC,,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,16714-0309-10,NDC,outpatient,1,UN,11.19,7.833,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC,,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,67457-0340-00,NDC,outpatient,1,UN,16.63,11.641,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC,,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,00143-9357-10,NDC,outpatient,1,UN,12.35,8.645,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC,,
VANCOMYCIN HCL 5 G IV SOLR,RX-144290,CDM,J3370,HCPCS,636,RC,00409-6509-01,NDC,outpatient,5,GR,364.64,255.248,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC,,
VANCOMYCIN HCL 5 G IV SOLR,RX-144290,CDM,J3370,HCPCS,636,RC,67457-0341-05,NDC,outpatient,5,GR,361.57,253.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC,,
VANCOMYCIN HCL 5 G IV SOLR,RX-144290,CDM,J3370,HCPCS,636,RC,25021-0157-99,NDC,outpatient,5,GR,81.22,56.854,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC,,
VANCOMYCIN HCL 1.5 G IV SOLR,RX-145320,CDM,J3370,HCPCS,636,RC,00409-3515-01,NDC,outpatient,1,UN,51.81,36.267,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC,,
VANCOMYCIN HCL 1.5 G IV SOLR,RX-145320,CDM,J3370,HCPCS,636,RC,00409-3515-11,NDC,outpatient,1,UN,51.81,36.267,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC,,
VANCOMYCIN HCL 500 MG IV SOLR,RX-8443,CDM,J3370,HCPCS,636,RC,72611-0761-01,NDC,outpatient,1,UN,15.42,10.794,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC,,
VANCOMYCIN HCL 500 MG IV SOLR,RX-8443,CDM,J3370,HCPCS,636,RC,72611-0761-10,NDC,outpatient,1,UN,15.42,10.794,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC,,
VANCOMYCIN HCL IN DEXTROSE 1 GM/200ML IV SOLN,RX-92895,CDM,J3370,HCPCS,636,RC,00338-3552-48,NDC,outpatient,200,ML,52.27,36.589,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.16,672.6528,other,OPPS APC,,
VEDOLIZUMAB 300 MG IV SOLR,RX-125757,CDM,J3380,HCPCS,636,RC,64764-0300-20,NDC,outpatient,1,UN,23919.77,16743.839,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,25.49883,,,25.49883,22.26,18370.38336,other,OPPS APC,,
HYDROXYZINE HCL 50 MG/ML IM SOLN,RX-3770,CDM,J3410,HCPCS,636,RC,00517-5601-25,NDC,outpatient,1,ML,82.29,57.603,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.41,416.02,other,OPPS APC,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,55150-0273-01,NDC,outpatient,0.5,ML,4.61,3.227,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.88453,416.02,other,OPPS APC,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,25021-0500-02,NDC,outpatient,0.5,ML,4.68,3.276,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.88453,416.02,other,OPPS APC,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,67457-0196-02,NDC,outpatient,0.5,ML,3.94,2.758,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.88453,416.02,other,OPPS APC,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,00641-6228-01,NDC,outpatient,0.5,ML,4.75,3.325,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.88453,416.02,other,OPPS APC,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,00641-6228-25,NDC,outpatient,0.5,ML,4.75,3.325,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.88453,416.02,other,OPPS APC,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,55150-0273-25,NDC,outpatient,0.5,ML,4.61,3.227,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.88453,416.02,other,OPPS APC,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,67457-0196-00,NDC,outpatient,0.5,ML,3.94,2.758,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.88453,416.02,other,OPPS APC,,
PYRIDOXINE HCL 100 MG/ML IJ SOLN,RX-6744,CDM,J3415,HCPCS,636,RC,63323-0180-00,NDC,outpatient,0.5,ML,20.17,14.119,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.528165,416.02,other,OPPS APC,,
PYRIDOXINE HCL 100 MG/ML IJ SOLN,RX-6744,CDM,J3415,HCPCS,636,RC,63323-0180-01,NDC,outpatient,0.5,ML,20.17,14.119,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.528165,416.02,other,OPPS APC,,
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,63323-0044-01,NDC,outpatient,1,ML,6.18,4.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.15,416.02,other,OPPS APC,,
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,00143-9621-01,NDC,outpatient,1,ML,10.83,7.581,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.15,416.02,other,OPPS APC,,
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,63323-0044-00,NDC,outpatient,1,ML,6.18,4.326,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.15,416.02,other,OPPS APC,,
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,00143-9621-25,NDC,outpatient,1,ML,10.83,7.581,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.15,416.02,other,OPPS APC,,
HYDROXOCOBALAMIN 5 G IV SOLR,RX-111437,CDM,J3424,HCPCS,250,RC,50633-0310-11,NDC,outpatient,1,UN,2471.2,1729.84,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,5.7653015,,,5.7653015,5.69,1897.8816,other,OPPS APC,,
PHYTONADIONE 1 MG/0.5ML IJ SOLN WRAPPER,RX-4080206,CDM,J3430,HCPCS,636,RC,76329-1240-01,NDC,outpatient,0.5,ML,98.15,68.705,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.51,416.02,other,OPPS APC,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,43598-0405-11,NDC,outpatient,1,ML,78.97,55.279,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.51,416.02,other,OPPS APC,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,43598-0405-16,NDC,outpatient,1,ML,78.97,55.279,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.51,416.02,other,OPPS APC,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,69097-0708-96,NDC,outpatient,1,ML,82.7,57.89,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.51,416.02,other,OPPS APC,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,69097-0708-31,NDC,outpatient,1,ML,82.7,57.89,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.51,416.02,other,OPPS APC,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,00409-9158-31,NDC,outpatient,1,ML,85.53,59.871,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.51,416.02,other,OPPS APC,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,00409-9158-01,NDC,outpatient,1,ML,85.53,59.871,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.51,416.02,other,OPPS APC,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,00409-9158-50,NDC,outpatient,1,ML,85.53,59.871,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.51,416.02,other,OPPS APC,,
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,00049-3190-28,NDC,outpatient,1,UN,59.15,41.405,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC,,
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,00781-3416-94,NDC,outpatient,1,UN,325.92,228.144,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC,,
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,70436-0029-80,NDC,outpatient,1,UN,78.41,54.887,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC,,
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,39822-1077-01,NDC,outpatient,1,UN,89.45,62.615,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.78,416.02,other,OPPS APC,,
HYALURONIDASE HUMAN 15 UNIT/ML INJECTION SYRINGE,RX-4081350,CDM,J3473,HCPCS,636,RC,99999-0004-00,NDC,outpatient,1,ML,164.85,115.395,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.36,416.02,other,OPPS APC,,
HYALURONIDASE HUMAN 150 UNIT/ML IJ SOLN,RX-76338,CDM,J3473,HCPCS,636,RC,18657-0117-01,NDC,outpatient,1,ML,164.85,115.395,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.36,416.02,other,OPPS APC,,
HYALURONIDASE HUMAN 150 UNIT/ML IJ SOLN,RX-76338,CDM,J3473,HCPCS,636,RC,18657-0117-04,NDC,outpatient,1,ML,164.85,115.395,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.36,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,63323-0108-01,NDC,outpatient,100,ML,26.28,18.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00409-6727-11,NDC,outpatient,100,ML,46.71,32.697,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00409-6727-23,NDC,outpatient,100,ML,46.71,32.697,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00264-4400-54,NDC,outpatient,100,ML,30.4,21.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00338-1709-40,NDC,outpatient,100,ML,22.17,15.519,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,63323-0108-00,NDC,outpatient,100,ML,26.28,18.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,67457-0567-00,NDC,outpatient,100,ML,30.4,21.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,00338-1708-40,NDC,outpatient,50,ML,28.6,20.02,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,63323-0106-05,NDC,outpatient,50,ML,32.45,22.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,00409-6729-24,NDC,outpatient,50,ML,36.31,25.417,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,67457-0553-00,NDC,outpatient,50,ML,33.74,23.618,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,00409-6729-11,NDC,outpatient,50,ML,36.31,25.417,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,25021-0612-81,NDC,outpatient,50,ML,24.74,17.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,44567-0420-00,NDC,outpatient,50,ML,43.82,30.674,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,44567-0420-24,NDC,outpatient,50,ML,43.82,30.674,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,47335-0992-01,NDC,outpatient,50,ML,28.85,20.195,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,63323-0106-02,NDC,outpatient,50,ML,32.45,22.715,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 40 MG/ML SOLN WRAPPER,RX-4080721,CDM,J3475,HCPCS,636,RC,63323-0106-15,NDC,outpatient,500,ML,33.99,23.793,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 40 MG/ML SOLN WRAPPER,RX-4080721,CDM,J3475,HCPCS,636,RC,00409-2050-01,NDC,outpatient,500,ML,38.25,26.775,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 40 MG/ML SOLN WRAPPER,RX-4080721,CDM,J3475,HCPCS,636,RC,00409-2050-20,NDC,outpatient,500,ML,38.25,26.775,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-11,NDC,outpatient,10,ML,6.53,4.571,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0642-50,NDC,outpatient,2,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-01,NDC,outpatient,2,ML,5.46,3.822,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,99999-0002-95,NDC,outpatient,2,ML,3.32,2.324,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-03,NDC,outpatient,2,ML,5.46,3.822,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-04,NDC,outpatient,10,ML,6.53,4.571,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0642-02,NDC,outpatient,50,ML,55.41,38.787,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.47,416.02,other,OPPS APC,,
POTASSIUM CHLORIDE 10 MEQ/100ML IV SOLN,RX-11074,CDM,J3480,HCPCS,636,RC,00338-0709-48,NDC,outpatient,100,ML,26.8,18.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC,,
POTASSIUM CHLORIDE 10 MEQ/100ML IV SOLN,RX-11074,CDM,J3480,HCPCS,636,RC,00990-7074-26,NDC,outpatient,100,ML,36.92,25.844,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC,,
POTASSIUM CHLORIDE 20 MEQ/100ML IV SOLN,RX-11076,CDM,J3480,HCPCS,636,RC,00338-0705-48,NDC,outpatient,100,ML,26.8,18.76,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC,,
POTASSIUM CHLORIDE 20 MEQ/100ML IV SOLN,RX-11076,CDM,J3480,HCPCS,636,RC,00990-7075-26,NDC,outpatient,100,ML,37.81,26.467,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC,,
POTASSIUM CHLORIDE 20 MEQ/50ML IV SOLN,RX-11077,CDM,J3480,HCPCS,636,RC,00338-0703-41,NDC,outpatient,50,ML,26.28,18.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC,,
POTASSIUM CHLORIDE 20 MEQ/50ML IV SOLN,RX-11077,CDM,J3480,HCPCS,636,RC,00990-7077-14,NDC,outpatient,50,ML,37.59,26.313,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC,,
POTASSIUM CHLORIDE IN NACL 20-0.9 MEQ/L-% IV SOLN,RX-11081,CDM,J3480,HCPCS,636,RC,00338-0691-04,NDC,outpatient,1000,ML,26.28,18.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC,,
POTASSIUM CHLORIDE IN NACL 40-0.9 MEQ/L-% IV SOLN,RX-11082,CDM,J3480,HCPCS,636,RC,00338-0695-04,NDC,outpatient,1000,ML,31.42,21.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC,,
KCL IN NACL 0.9% 10 MEQ/100ML IV SOLN,RX-166975,CDM,J3480,HCPCS,636,RC,99999-0001-77,NDC,outpatient,100,ML,26.28,18.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC,,
POTASSIUM CHLORIDE IN NACL 20-0.45 MEQ/L-% IV SOLN,RX-36046,CDM,J3480,HCPCS,636,RC,00338-0704-34,NDC,outpatient,1000,ML,26.28,18.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC,,
POTASSIUM CHLORIDE IN NACL 20 MEQ/50ML IV SOLN,RX-4081006,CDM,J3480,HCPCS,636,RC,99999-0001-79,NDC,outpatient,50,ML,31.17,21.819,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC,,
POTASSIUM CHLORIDE IN NACL 20 MEQ/100ML IV SOLN,RX-4081007,CDM,J3480,HCPCS,636,RC,99999-0001-78,NDC,outpatient,100,ML,30.91,21.637,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC,,
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN,RX-6429,CDM,J3480,HCPCS,636,RC,63323-0965-20,NDC,outpatient,20,ML,6.48,4.536,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC,,
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN,RX-6429,CDM,J3480,HCPCS,636,RC,63323-0965-02,NDC,outpatient,20,ML,6.48,4.536,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC,,
POTASSIUM CL IN DEXTROSE 5% 20 MEQ/L IV SOLN,RX-9791,CDM,J3480,HCPCS,636,RC,00338-0683-04,NDC,outpatient,1000,ML,31.42,21.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC,,
KCL IN DEXTROSE-NACL 20-5-0.9 MEQ/L-%-% IV SOLN,RX-9795,CDM,J3480,HCPCS,636,RC,00264-7652-00,NDC,outpatient,1000,ML,38.25,26.775,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC,,
KCL IN DEXTROSE-NACL 20-5-0.9 MEQ/L-%-% IV SOLN,RX-9795,CDM,J3480,HCPCS,636,RC,00338-0803-04,NDC,outpatient,1000,ML,26.28,18.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC,,
KCL IN DEXTROSE-NACL 10-5-0.45 MEQ/L-%-% IV SOLN,RX-9799,CDM,J3480,HCPCS,636,RC,00338-0669-04,NDC,outpatient,1000,ML,31.42,21.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC,,
KCL IN DEXTROSE-NACL 10-5-0.45 MEQ/L-%-% IV SOLN,RX-9799,CDM,J3480,HCPCS,636,RC,00990-7993-09,NDC,outpatient,1000,ML,47.15,33.005,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC,,
KCL IN DEXTROSE-NACL 20-5-0.2 MEQ/L-%-% IV SOLN,RX-9800,CDM,J3480,HCPCS,636,RC,00338-0663-04,NDC,outpatient,1000,ML,31.42,21.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC,,
KCL IN DEXTROSE-NACL 20-5-0.2 MEQ/L-%-% IV SOLN,RX-9800,CDM,J3480,HCPCS,636,RC,00264-7645-00,NDC,outpatient,1000,ML,47.15,33.005,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC,,
KCL IN DEXTROSE-NACL 20-5-0.45 MEQ/L-%-% IV SOLN,RX-9801,CDM,J3480,HCPCS,636,RC,00338-0671-04,NDC,outpatient,1000,ML,26.28,18.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC,,
KCL IN DEXTROSE-NACL 40-5-0.45 MEQ/L-%-% IV SOLN,RX-9807,CDM,J3480,HCPCS,636,RC,00338-0675-04,NDC,outpatient,1000,ML,31.42,21.994,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC,,
ZIDOVUDINE 10 MG/ML IV SOLN,RX-11691,CDM,J3485,HCPCS,636,RC,49702-0213-01,NDC,outpatient,20,ML,126.03,88.221,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.51,416.02,other,OPPS APC,,
ZIDOVUDINE 10 MG/ML IV SOLN,RX-11691,CDM,J3485,HCPCS,636,RC,49702-0213-26,NDC,outpatient,20,ML,126.03,88.221,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.51,416.02,other,OPPS APC,,
ZIPRASIDONE MESYLATE 20 MG IM SOLR,RX-33175,CDM,J3486,HCPCS,636,RC,00049-3920-20,NDC,outpatient,1,UN,264.92,185.444,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,7.43,416.02,other,OPPS APC,,
ZIPRASIDONE MESYLATE 20 MG IM SOLR,RX-33175,CDM,J3486,HCPCS,636,RC,00049-3920-83,NDC,outpatient,1,UN,264.92,185.444,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,7.43,416.02,other,OPPS APC,,
ZOLEDRONIC ACID 4 MG/5ML IV CONC,RX-35640,CDM,J3489,HCPCS,636,RC,67457-0390-54,NDC,outpatient,5,ML,30.53,21.371,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,6.47,416.02,other,OPPS APC,,
ZOLEDRONIC ACID 5 MG/100ML IV SOLN,RX-81434,CDM,J3489,HCPCS,636,RC,67457-0619-10,NDC,outpatient,100,ML,182.43,127.701,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,6.47,416.02,other,OPPS APC,,
ZOLEDRONIC ACID 5 MG/100ML IV SOLN,RX-81434,CDM,J3489,HCPCS,636,RC,55111-0688-52,NDC,outpatient,100,ML,126.81,88.767,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,6.47,416.02,other,OPPS APC,,
IDARUCIZUMAB 2.5 GM/50ML IV SOLN,RX-132721,CDM,J3590,HCPCS,636,RC,00597-0197-05,NDC,outpatient,100,ML,13473.22,9431.254,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,10347.43296,other,OPPS APC,,
SODIUM CHLORIDE 0.45 % IV SOLN,RX-7318,CDM,J7030,HCPCS,250,RC,00338-0043-04,NDC,outpatient,1000,ML,26.28,18.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.54,416.02,other,OPPS APC,,
SODIUM CHLORIDE 0.45 % IV SOLN,RX-7318,CDM,J7030,HCPCS,250,RC,00338-0043-03,NDC,outpatient,500,ML,23.71,16.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.54,416.02,other,OPPS APC,,
DEXTROSE-SODIUM CHLORIDE 5-0.9 % IV SOLN,RX-9815,CDM,J7042,HCPCS,636,RC,00338-0089-04,NDC,outpatient,1000,ML,26.28,18.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.14,416.02,other,OPPS APC,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-11,NDC,outpatient,50,ML,22.43,15.701,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.81,416.02,other,OPPS APC,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-38,NDC,outpatient,100,ML,22.17,15.519,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.81,416.02,other,OPPS APC,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-48,NDC,outpatient,100,ML,22.69,15.883,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.81,416.02,other,OPPS APC,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00409-7100-02,NDC,outpatient,250,ML,30.14,21.098,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.81,416.02,other,OPPS APC,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-03,NDC,outpatient,500,ML,23.71,16.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.81,416.02,other,OPPS APC,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-02,NDC,outpatient,250,ML,22.43,15.701,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.81,416.02,other,OPPS APC,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00409-7100-04,NDC,outpatient,250,ML,30.14,21.098,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.81,416.02,other,OPPS APC,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,63323-0624-74,NDC,outpatient,250,ML,25,17.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.81,416.02,other,OPPS APC,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-31,NDC,outpatient,50,ML,22.43,15.701,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.81,416.02,other,OPPS APC,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-41,NDC,outpatient,50,ML,22.94,16.058,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.81,416.02,other,OPPS APC,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,63323-0624-04,NDC,outpatient,250,ML,25,17.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.81,416.02,other,OPPS APC,,
DEXTROSE 5 % IV PVC FREE SOLN,RX-4080550,CDM,J7060,HCPCS,636,RC,00338-6346-03,NDC,outpatient,500,ML,42.7,29.89,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.81,416.02,other,OPPS APC,,
DEXTROSE 5 % IV PVC FREE SOLN,RX-4080550,CDM,J7060,HCPCS,636,RC,00264-7510-10,NDC,outpatient,500,ML,33.99,23.793,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.81,416.02,other,OPPS APC,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7070,HCPCS,636,RC,00338-0017-04,NDC,outpatient,1000,ML,21.14,14.798,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.62,416.02,other,OPPS APC,,
DEXTRAN 40 IN D5W 10 % IV SOLN,RX-9759,CDM,J7100,HCPCS,636,RC,00409-7418-13,NDC,outpatient,500,ML,116.13,81.291,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.23,416.02,other,OPPS APC,,
DEXTRAN 40 IN D5W 10 % IV SOLN,RX-9759,CDM,J7100,HCPCS,636,RC,00409-7418-03,NDC,outpatient,500,ML,116.13,81.291,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,19.23,416.02,other,OPPS APC,,
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00338-0117-02,NDC,outpatient,250,ML,22.43,15.701,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.39,416.02,other,OPPS APC,,
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00338-0117-03,NDC,outpatient,500,ML,23.71,16.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.39,416.02,other,OPPS APC,,
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00338-0117-04,NDC,outpatient,1000,ML,26.28,18.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.39,416.02,other,OPPS APC,,
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00264-7750-20,NDC,outpatient,250,ML,33.8,23.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.39,416.02,other,OPPS APC,,
DEXTROSE IN LACTATED RINGERS 5 % IV SOLN,RX-9788,CDM,J7121,HCPCS,636,RC,00338-0125-04,NDC,outpatient,1000,ML,26.28,18.396,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,5.89986,416.02,other,OPPS APC,,
PROTHROMBIN COMPLEX CONC HUMAN 500 UNITS IV KIT,RX-122122,CDM,J7168,HCPCS,636,RC,63833-0386-02,NDC,outpatient,1,UN,3022.2,2115.54,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.568211,,,2.568211,2.568211,4642.0992,other,OPPS APC,,
PROTHROMBIN COMPLEX CONC HUMAN 1000 UNITS IV KIT,RX-125272,CDM,J7168,HCPCS,636,RC,63833-0387-02,NDC,outpatient,1,UN,6044.4,4231.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.568211,,,2.568211,2.568211,4642.0992,other,OPPS APC,,
ANTIHEMOPHILIC FACTOR-VWF 500-500 UNITS IV KIT,RX-134441,CDM,J7183,HCPCS,636,RC,68982-0182-01,NDC,outpatient,1,UN,1449,1014.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.46624,,,1.46624,1.26,2225.664,other,OPPS APC,,
ANTIHEMOPHILIC FACTOR-VWF 1000-1000 UNITS IV KIT,RX-134442,CDM,J7183,HCPCS,636,RC,68982-0182-02,NDC,outpatient,1,UN,2898,2028.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.46624,,,1.46624,1.26,2225.664,other,OPPS APC,,
ANTIHEMOPHILIC FACTOR-VWF 250-600 UNITS IV SOLR,RX-70404,CDM,J7187,HCPCS,636,RC,63833-0615-02,NDC,outpatient,1,UN,1821.6,1275.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.5979725,,,1.5979725,1.23,3240,other,OPPS APC,,
ANTIHEMOPHILIC FACTOR-VWF 250-600 UNITS IV SOLR,RX-70404,CDM,J7187,HCPCS,636,RC,63833-0625-01,NDC,outpatient,1,UN,1821.6,1275.12,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.5979725,,,1.5979725,1.23,3240,other,OPPS APC,,
ANTIHEMOPHILIC FACTOR-VWF 500-1200 UNITS IV SOLR,RX-70405,CDM,J7187,HCPCS,636,RC,63833-0626-01,NDC,outpatient,1,UN,3643.2,2550.24,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.5979725,,,1.5979725,1.23,3240,other,OPPS APC,,
ANTIHEMOPHILIC FACTOR-VWF 500-1200 UNITS IV SOLR,RX-70405,CDM,J7187,HCPCS,636,RC,63833-0616-02,NDC,outpatient,1,UN,3643.2,2550.24,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.5979725,,,1.5979725,1.23,3240,other,OPPS APC,,
ANTIHEMOPHILIC FACTOR-VWF 1000-2400 UNITS IV SOLR,RX-70406,CDM,J7187,HCPCS,636,RC,63833-0627-01,NDC,outpatient,1,UN,3036,2125.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.5979725,,,1.5979725,1.23,3240,other,OPPS APC,,
ANTIHEMOPHILIC FACTOR-VWF 1000-2400 UNITS IV SOLR,RX-70406,CDM,J7187,HCPCS,636,RC,63833-0617-02,NDC,outpatient,1,UN,3036,2125.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.5979725,,,1.5979725,1.23,3240,other,OPPS APC,,
COAGULATION FACTOR VIIA RECOMB 1 MG IV SOLR,RX-92853,CDM,J7189,HCPCS,636,RC,00169-7211-11,NDC,outpatient,1,UN,6342.76,4439.932,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.8832235,,,2.8832235,2.13,24356.18304,other,OPPS APC,,
COAGULATION FACTOR VIIA RECOMB 1 MG IV SOLR,RX-92853,CDM,J7189,HCPCS,636,RC,00169-7201-01,NDC,outpatient,1,UN,6342.76,4439.932,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.8832235,,,2.8832235,2.13,24356.18304,other,OPPS APC,,
COAGULATION FACTOR VIIA RECOMB 2 MG IV SOLR,RX-92854,CDM,J7189,HCPCS,636,RC,00169-7202-01,NDC,outpatient,1,UN,12685.52,8879.864,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.8832235,,,2.8832235,2.13,24356.18304,other,OPPS APC,,
COAGULATION FACTOR VIIA RECOMB 2 MG IV SOLR,RX-92854,CDM,J7189,HCPCS,636,RC,00169-7212-11,NDC,outpatient,1,UN,12685.52,8879.864,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.8832235,,,2.8832235,2.13,24356.18304,other,OPPS APC,,
COAGULATION FACTOR VIIA RECOMB 5 MG IV SOLR,RX-92855,CDM,J7189,HCPCS,636,RC,00169-7205-01,NDC,outpatient,1,UN,31713.78,22199.646,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.8832235,,,2.8832235,2.13,24356.18304,other,OPPS APC,,
ANTIHEMOPHILIC FACTOR VIII RAHF-PFM 500 UNITS IV SOLR,RX-76366,CDM,J7192,HCPCS,636,RC,00944-3052-02,NDC,outpatient,1,UN,1863,1304.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.773234,,,1.773234,1.25,2861.568,other,OPPS APC,,
ANTIHEMOPHILIC FACTOR VIII RAHF-PFM 1000 UNITS IV SOLR,RX-76367,CDM,J7192,HCPCS,636,RC,00944-3053-02,NDC,outpatient,1,UN,3726,2608.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.773234,,,1.773234,1.25,2861.568,other,OPPS APC,,
ANTITHROMBIN III (HUMAN) 500 UNITS IV SOLR,RX-9116,CDM,J7197,HCPCS,636,RC,13533-0606-12,NDC,outpatient,1,UN,4954.2,3467.94,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4.4136115,,,4.4136115,3.35,3804.8256,other,OPPS APC,,
ANTITHROMBIN III (HUMAN) 500 UNITS IV SOLR,RX-9116,CDM,J7197,HCPCS,636,RC,13533-0602-50,NDC,outpatient,1,UN,4954.2,3467.94,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4.4136115,,,4.4136115,3.35,3804.8256,other,OPPS APC,,
ANTIINHIBITOR COAGULANT CMPLX 2500 UNITS IV SOLR,RX-146201,CDM,J7198,HCPCS,636,RC,64193-0425-02,NDC,outpatient,1,UN,13869,9708.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2.685052,,,2.685052,1.94,10651.392,other,OPPS APC,,
SODIUM HYALURONATE (VISCOSUP) 25 MG/2.5ML IX SOSY,RX-127543,CDM,J7321,HCPCS,636,RC,89130-4444-01,NDC,outpatient,2.5,ML,1023.91,716.737,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,73.22,786.36288,other,OPPS APC,,
AZATHIOPRINE 50 MG ORAL TABS,RX-9183,CDM,J7500,HCPCS,259,RC,68084-0229-11,NDC,outpatient,1,UN,2.39,1.673,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.536555,416.02,other,OPPS APC,,
AZATHIOPRINE 50 MG ORAL TABS,RX-9183,CDM,J7500,HCPCS,259,RC,68084-0229-01,NDC,outpatient,1,UN,2.39,1.673,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.536555,416.02,other,OPPS APC,,
CYCLOSPORINE 50 MG/ML IV SOLN,RX-9705,CDM,J7516,HCPCS,636,RC,00574-0866-10,NDC,outpatient,5,ML,142.85,99.995,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,15.32,416.02,other,OPPS APC,,
MYCOPHENOLATE MOFETIL HCL 500 MG IV SOLR,RX-23968,CDM,J7519,HCPCS,636,RC,00004-0298-09,NDC,outpatient,1,UN,298.3,208.81,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.5922235,,,0.5922235,0.52,416.02,other,OPPS APC,,
MYCOPHENOLATE MOFETIL HCL 500 MG IV SOLR,RX-23968,CDM,J7519,HCPCS,636,RC,71288-0803-20,NDC,outpatient,1,UN,89.27,62.489,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.5922235,,,0.5922235,0.52,416.02,other,OPPS APC,,
METHACHOLINE CHLORIDE 100 MG IN SOLR,RX-27032,CDM,J7674,HCPCS,636,RC,64281-0100-06,NDC,outpatient,1,UN,341.28,238.896,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.86,416.02,other,OPPS APC,,
METHACHOLINE CHLORIDE 100 MG IN SOLR,RX-27032,CDM,J7674,HCPCS,636,RC,64281-0100-00,NDC,outpatient,1,UN,341.28,238.896,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.86,416.02,other,OPPS APC,,
ETOPOSIDE 50 MG ORAL CAPS,RX-10001,CDM,J8560,HCPCS,636,RC,00378-3266-32,NDC,outpatient,1,UN,309.74,216.818,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,87.818612,,,87.818612,69.53663,416.02,other,OPPS APC,,
ETOPOSIDE 50 MG ORAL CAPS,RX-10001,CDM,J8560,HCPCS,636,RC,00378-3266-94,NDC,outpatient,1,UN,309.74,216.818,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,87.818612,,,87.818612,69.53663,416.02,other,OPPS APC,,
MERCAPTOPURINE 50 MG ORAL TABS,RX-10531,CDM,J8999,HCPCS,259,RC,00054-4581-11,NDC,outpatient,1,UN,14.11,9.877,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.370425,416.02,,,,
MERCAPTOPURINE 50 MG ORAL TABS,RX-10531,CDM,J8999,HCPCS,259,RC,00378-3547-52,NDC,outpatient,1,UN,4.39,3.073,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.370425,416.02,,,,
BICALUTAMIDE 50 MG ORAL TABS,RX-15746,CDM,J8999,HCPCS,259,RC,16729-0023-10,NDC,outpatient,1,UN,2.86,2.002,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.370425,416.02,,,,
ANASTROZOLE 1 MG ORAL TABS,RX-16205,CDM,J8999,HCPCS,259,RC,60687-0112-11,NDC,outpatient,1,UN,3.22,2.254,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.370425,416.02,,,,
ANASTROZOLE 1 MG ORAL TABS,RX-16205,CDM,J8999,HCPCS,259,RC,60687-0112-21,NDC,outpatient,1,UN,3.22,2.254,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.370425,416.02,,,,
MEGESTROL ACETATE 40 MG ORAL TABS,RX-4871,CDM,J8999,HCPCS,259,RC,64380-0159-01,NDC,outpatient,1,UN,1.65,1.155,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.370425,416.02,,,,
MEGESTROL ACETATE 400 MG/10ML ORAL SUSP,RX-76824,CDM,J8999,HCPCS,259,RC,00121-0945-40,NDC,outpatient,10,ML,15.58,10.906,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.370425,416.02,,,,
MEGESTROL ACETATE 400 MG/10ML ORAL SUSP,RX-76824,CDM,J8999,HCPCS,259,RC,00121-0945-10,NDC,outpatient,10,ML,15.58,10.906,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.370425,416.02,,,,
MEGESTROL ACETATE 400 MG/10ML ORAL SUSP,RX-76824,CDM,J8999,HCPCS,259,RC,99999-0003-95,NDC,outpatient,10,ML,8.73,6.111,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.370425,416.02,,,,
TAMOXIFEN CITRATE 10 MG ORAL TABS,RX-7711,CDM,J8999,HCPCS,259,RC,63739-0143-10,NDC,outpatient,1,UN,1.98,1.386,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.370425,416.02,,,,
DOXORUBICIN HCL 2 MG/ML IV PUSH SOLN,RX-2616,CDM,J9000,HCPCS,636,RC,00069-3030-20,NDC,outpatient,5,ML,19.68,13.776,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.5,525.12,other,OPPS APC,,
DOXORUBICIN HCL 2 MG/ML IV PUSH SOLN,RX-2616,CDM,J9000,HCPCS,636,RC,00069-3032-20,NDC,outpatient,25,ML,44.02,30.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.5,525.12,other,OPPS APC,,
DOXORUBICIN HCL 2 MG/ML IV PUSH SOLN,RX-2616,CDM,J9000,HCPCS,636,RC,00069-3031-20,NDC,outpatient,10,ML,34.71,24.297,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.5,525.12,other,OPPS APC,,
DOXORUBICIN HCL 10 MG IV SOLR,RX-2617,CDM,J9000,HCPCS,636,RC,00143-9092-01,NDC,outpatient,1,UN,143.64,100.548,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.5,525.12,other,OPPS APC,,
DOXORUBICIN HCL 50 MG IV SOLR,RX-2619,CDM,J9000,HCPCS,636,RC,00143-9277-01,NDC,outpatient,1,UN,683.75,478.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.5,525.12,other,OPPS APC,,
ARSENIC TRIOXIDE 12 MG/6ML IV SOLN,RX-141420,CDM,J9017,HCPCS,636,RC,63459-0601-06,NDC,outpatient,6,ML,3082.97,2158.079,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8.2464545,,,8.2464545,7.2,2367.72096,other,OPPS APC,,
ARSENIC TRIOXIDE 12 MG/6ML IV SOLN,RX-141420,CDM,J9017,HCPCS,636,RC,63459-0601-11,NDC,outpatient,6,ML,3082.97,2158.079,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8.2464545,,,8.2464545,7.2,2367.72096,other,OPPS APC,,
AZACITIDINE 100 MG IJ SUSR,RX-78420,CDM,J9025,HCPCS,636,RC,43598-0305-62,NDC,outpatient,1,UN,83.86,58.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.32,416.02,other,OPPS APC,,
AZACITIDINE 100 MG IJ SUSR,RX-78420,CDM,J9025,HCPCS,636,RC,63323-0771-39,NDC,outpatient,1,UN,117.36,82.152,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.32,416.02,other,OPPS APC,,
BENDAMUSTINE HCL 5 MG/ML IV SOLR WRAPPER,RX-4080211,CDM,J9033,HCPCS,636,RC,63459-0391-20,NDC,outpatient,20,ML,2803.09,1962.163,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6.2212105,,,6.2212105,5.43,2152.77312,other,OPPS APC,,
BENDAMUSTINE HCL 5 MG/ML IV SOLR WRAPPER,RX-4080211,CDM,J9033,HCPCS,636,RC,63459-0390-08,NDC,outpatient,5,ML,889.43,622.601,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,6.2212105,,,6.2212105,5.43,2152.77312,other,OPPS APC,,
BENDAMUSTINE HCL 100 MG/4ML IV SOLN,RX-133070,CDM,J9034,HCPCS,636,RC,63459-0348-04,NDC,outpatient,4,ML,5078.48,3554.936,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,14.829643,,,14.829643,12.95,3900.27264,other,OPPS APC,,
BEVACIZUMAB 25 MG/ML IV WRAPPER,RX-4080193,CDM,J9035,HCPCS,636,RC,50242-0060-01,NDC,outpatient,4,ML,2279.25,1595.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,83.282432,,,83.282432,72.7,7001.856,other,OPPS APC,,
BEVACIZUMAB 25 MG/ML IV WRAPPER,RX-4080193,CDM,J9035,HCPCS,636,RC,50242-0061-01,NDC,outpatient,16,ML,9117,6381.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,83.282432,,,83.282432,72.7,7001.856,other,OPPS APC,,
BLEOMYCIN SULFATE 30 UNITS IJ SOLR,RX-17012,CDM,J9040,HCPCS,636,RC,63323-0137-20,NDC,outpatient,1,UN,120.16,84.112,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.931495,416.02,other,OPPS APC,,
BLEOMYCIN SULFATE 15 UNITS IJ SOLR *TEST DOSE*,RX-9289,CDM,J9040,HCPCS,636,RC,16714-0886-01,NDC,outpatient,1,UN,66.51,46.557,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,14.931495,416.02,other,OPPS APC,,
BORTEZOMIB 3.5 MG IJ SOLR,RX-123070,CDM,J9041,HCPCS,636,RC,00143-9098-01,NDC,outpatient,1,UN,58.7,41.09,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.800726,,,1.800726,1.57,905.322979,other,OPPS APC,,
BORTEZOMIB 3.5 MG IJ SOLR,RX-123070,CDM,J9041,HCPCS,636,RC,10019-0991-01,NDC,outpatient,1,UN,147.6,103.32,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,1.800726,,,1.800726,1.57,905.322979,other,OPPS APC,,
BRENTUXIMAB VEDOTIN 50 MG IV SOLR,RX-111348,CDM,J9042,HCPCS,636,RC,51144-0050-01,NDC,outpatient,1,UN,32323.72,22626.604,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,274.755048,,,274.755048,221.96,24824.61696,other,OPPS APC,,
CABAZITAXEL 60 MG/1.5ML IV SOLN,RX-105644,CDM,J9043,HCPCS,636,RC,00024-5824-11,NDC,outpatient,6,ML,39665.77,27766.039,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,247.9492025,,,247.9492025,206.03,30463.31136,other,OPPS APC,,
CARBOPLATIN 10 MG/ML IV SOLN WRAPPER,RX-4080212,CDM,J9045,HCPCS,636,RC,00703-4248-01,NDC,outpatient,45,ML,63.71,44.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.41,416.02,other,OPPS APC,,
CARBOPLATIN 10 MG/ML IV SOLN WRAPPER,RX-4080212,CDM,J9045,HCPCS,636,RC,61703-0339-50,NDC,outpatient,45,ML,157.96,110.572,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.41,416.02,other,OPPS APC,,
CARFILZOMIB 60 MG IV SOLR,RX-117047,CDM,J9047,HCPCS,636,RC,76075-0101-01,NDC,outpatient,1,UN,8945.66,6261.962,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,56.7904535,,,56.7904535,47.04,6870.26688,other,OPPS APC,,
CETUXIMAB 200 MG/100ML IV SOLN,RX-108072,CDM,J9055,HCPCS,636,RC,66733-0958-23,NDC,outpatient,100,ML,4373.8,3061.66,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,86.4611945,,,86.4611945,72.08,3359.0784,other,OPPS APC,,
CETUXIMAB 100 MG/50ML IV SOLN,RX-37989,CDM,J9055,HCPCS,636,RC,66733-0948-23,NDC,outpatient,50,ML,2186.9,1530.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,86.4611945,,,86.4611945,72.08,3359.0784,other,OPPS APC,,
CISPLATIN 1 MG/ML IV WRAPPER,RX-4080194,CDM,J9060,HCPCS,636,RC,00703-5748-11,NDC,outpatient,100,ML,67.89,47.523,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.37,416.02,other,OPPS APC,,
CLADRIBINE 1 MG/ML IV SOLN WRAPPER,RX-4080791,CDM,J9065,HCPCS,636,RC,63323-0140-10,NDC,outpatient,10,ML,347.72,243.404,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,16.3176475,,,16.3176475,14.25,416.02,other,OPPS APC,,
CYTARABINE (PF) 100 MG/ML IJ SOLN,RX-20156,CDM,J9100,HCPCS,636,RC,61703-0319-22,NDC,outpatient,20,ML,53.29,37.303,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.77,416.02,other,OPPS APC,,
CYTARABINE (PF) 100 MG/ML IJ SOLN,RX-20156,CDM,J9100,HCPCS,636,RC,63323-0120-20,NDC,outpatient,20,ML,40.95,28.665,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.77,416.02,other,OPPS APC,,
CYTARABINE (PF) 20 MG/ML IJ SOLN,RX-96982,CDM,J9100,HCPCS,636,RC,61703-0303-46,NDC,outpatient,50,ML,62.44,43.708,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.77,416.02,other,OPPS APC,,
CYTARABINE (PF) 20 MG/ML IJ SOLN,RX-96982,CDM,J9100,HCPCS,636,RC,61703-0305-38,NDC,outpatient,5,ML,16.81,11.767,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.77,416.02,other,OPPS APC,,
CYTARABINE (PF) 20 MG/ML IJ SOLN,RX-96982,CDM,J9100,HCPCS,636,RC,61703-0305-58,NDC,outpatient,5,ML,16.81,11.767,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.77,416.02,other,OPPS APC,,
CYTARABINE 20 MG/ML IJ SOLN,RX-9709,CDM,J9100,HCPCS,636,RC,61703-0304-36,NDC,outpatient,25,ML,34.67,24.269,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.77,416.02,other,OPPS APC,,
DACARBAZINE 200 MG IV SOLR,RX-2091,CDM,J9130,HCPCS,636,RC,00143-9245-01,NDC,outpatient,1,UN,16.44,11.508,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.69078,416.02,other,OPPS APC,,
DACARBAZINE 200 MG IV SOLR,RX-2091,CDM,J9130,HCPCS,636,RC,00143-9245-10,NDC,outpatient,1,UN,16.44,11.508,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.69078,416.02,other,OPPS APC,,
DEGARELIX ACETATE(240 MG DOSE) 120 MG/VIAL SC SOLR,RX-150086,CDM,J9155,HCPCS,636,RC,55566-8403-01,NDC,outpatient,1,UN,1744.22,1220.954,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4.783608,,,4.783608,4.18,1339.56096,other,OPPS APC,,
DEGARELIX ACETATE 80 MG SC SOLR,RX-96986,CDM,J9155,HCPCS,636,RC,55566-8303-01,NDC,outpatient,1,UN,1117.94,782.558,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4.783608,,,4.783608,4.18,1339.56096,other,OPPS APC,,
DOCETAXEL 20 MG/ML IV CONC WRAPPER,RX-4080197,CDM,J9171,HCPCS,636,RC,16729-0267-65,NDC,outpatient,8,ML,615.8,431.06,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.79,1115.136,other,OPPS APC,,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,00409-0201-02,NDC,outpatient,2,ML,45.67,31.969,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.79,1115.136,other,OPPS APC,,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,43066-0006-01,NDC,outpatient,8,ML,120.55,84.385,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.79,1115.136,other,OPPS APC,,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,00409-0201-20,NDC,outpatient,16,ML,345.35,241.745,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.79,1115.136,other,OPPS APC,,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,66758-0050-01,NDC,outpatient,2,ML,181.5,127.05,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.79,1115.136,other,OPPS APC,,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,66758-0050-02,NDC,outpatient,8,ML,726,508.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.79,1115.136,other,OPPS APC,,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,66758-0050-03,NDC,outpatient,16,ML,1452,1016.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.79,1115.136,other,OPPS APC,,
EPIRUBICIN HCL 2 MG/ML IV SOLN WRAPPER,RX-4080365,CDM,J9178,HCPCS,636,RC,00009-5091-01,NDC,outpatient,25,ML,112.35,78.645,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.34,416.02,other,OPPS APC,,
ERIBULIN MESYLATE 1 MG/2ML IV PUSH SOLN,RX-106773,CDM,J9179,HCPCS,636,RC,62856-0389-01,NDC,outpatient,2,ML,4032.6,2822.82,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,155.5417175,,,155.5417175,128.78,3097.0368,other,OPPS APC,,
ETOPOSIDE 100 MG/5ML IV SOLN,RX-124543,CDM,J9181,HCPCS,636,RC,16729-0114-31,NDC,outpatient,5,ML,33.84,23.688,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.7,416.02,other,OPPS APC,,
ETOPOSIDE 100 MG/5ML IV SOLN,RX-124543,CDM,J9181,HCPCS,636,RC,16729-0114-08,NDC,outpatient,25,ML,169.25,118.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.7,416.02,other,OPPS APC,,
FLUDARABINE PHOSPHATE 25 MG/ML IV WRAPPER,RX-4080526,CDM,J9185,HCPCS,636,RC,25021-0242-02,NDC,outpatient,2,ML,278.39,194.873,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,153.673407,,,153.673407,62.498555,604.75,other,OPPS APC,,
FLUOROURACIL 50 MG/ML IV SOLN WRAPPER,RX-4080199,CDM,J9190,HCPCS,636,RC,16729-0276-11,NDC,outpatient,50,ML,99.65,69.755,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.83,416.02,other,OPPS APC,,
FLUOROURACIL 500 MG/10ML IV PUSH SOLN,RX-82200,CDM,J9190,HCPCS,636,RC,63323-0117-00,NDC,outpatient,10,ML,8.43,5.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.83,416.02,other,OPPS APC,,
FLUOROURACIL 500 MG/10ML IV PUSH SOLN,RX-82200,CDM,J9190,HCPCS,636,RC,63323-0117-10,NDC,outpatient,10,ML,8.43,5.901,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.83,416.02,other,OPPS APC,,
GEMCITABINE HCL 200 MG/5.26ML IV SOLN,RX-112786,CDM,J9201,HCPCS,636,RC,00409-0183-01,NDC,outpatient,5.26,ML,31.43,22.001,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.79,416.02,other,OPPS APC,,
GEMCITABINE HCL 1 GM/26.3ML IV SOLN,RX-112787,CDM,J9201,HCPCS,636,RC,00409-0181-01,NDC,outpatient,26.3,ML,133.66,93.562,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.79,416.02,other,OPPS APC,,
GEMCITABINE HCL 200 MG IV SOLR,RX-17121,CDM,J9201,HCPCS,636,RC,25021-0234-10,NDC,outpatient,1,UN,27.81,19.467,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.79,416.02,other,OPPS APC,,
GEMCITABINE HCL 1 G IV SOLR,RX-17122,CDM,J9201,HCPCS,636,RC,16714-0930-01,NDC,outpatient,1,UN,63.54,44.478,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.79,416.02,other,OPPS APC,,
GOSERELIN ACETATE 3.6 MG SC IMPL,RX-10137,CDM,J9202,HCPCS,636,RC,70720-0950-36,NDC,outpatient,1,UN,2706.82,1894.774,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,772.951326,,,772.951326,399.86,5828.5824,other,OPPS APC,,
GOSERELIN ACETATE 10.8 MG SC IMPL,RX-16254,CDM,J9202,HCPCS,636,RC,70720-0951-30,NDC,outpatient,1,UN,7589.3,5312.51,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,772.951326,,,772.951326,399.86,5828.5824,other,OPPS APC,,
IRINOTECAN HCL 20 MG/ML IV SOLN WRAPPER,RX-4080202,CDM,J9206,HCPCS,636,RC,61703-0349-09,NDC,outpatient,5,ML,56.89,39.823,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.5,416.02,other,OPPS APC,,
IRINOTECAN HCL 20 MG/ML IV SOLN WRAPPER,RX-4080202,CDM,J9206,HCPCS,636,RC,60505-6128-01,NDC,outpatient,5,ML,26.29,18.403,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.5,416.02,other,OPPS APC,,
IRINOTECAN HCL 20 MG/ML IV SOLN WRAPPER,RX-4080202,CDM,J9206,HCPCS,636,RC,61703-0349-16,NDC,outpatient,2,ML,43.49,30.443,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.5,416.02,other,OPPS APC,,
IXABEPILONE 15 MG IV SOLR,RX-88652,CDM,J9207,HCPCS,636,RC,70020-1910-01,NDC,outpatient,1,UN,5537.91,3876.537,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,153.5622935,,,153.5622935,122.55,12759.31392,other,OPPS APC,,
IXABEPILONE 45 MG IV SOLR,RX-88653,CDM,J9207,HCPCS,636,RC,70020-1911-01,NDC,outpatient,1,UN,16613.69,11629.583,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,153.5622935,,,153.5622935,122.55,12759.31392,other,OPPS APC,,
IFOSFAMIDE 1 G IV SOLR,RX-10248,CDM,J9208,HCPCS,636,RC,10019-0925-01,NDC,outpatient,1,UN,94.35,66.045,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,21.181575,416.02,other,OPPS APC,,
IFOSFAMIDE 1 G IV SOLR,RX-10248,CDM,J9208,HCPCS,636,RC,10019-0925-82,NDC,outpatient,1,UN,94.35,66.045,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,21.181575,416.02,other,OPPS APC,,
IFOSFAMIDE 3 G IV SOLR,RX-10249,CDM,J9208,HCPCS,636,RC,00338-3993-01,NDC,outpatient,1,UN,350.95,245.665,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,21.181575,416.02,other,OPPS APC,,
IFOSFAMIDE 3 G IV SOLR,RX-10249,CDM,J9208,HCPCS,636,RC,10019-0926-16,NDC,outpatient,1,UN,288.44,201.908,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,21.181575,416.02,other,OPPS APC,,
IFOSFAMIDE 3 G IV SOLR,RX-10249,CDM,J9208,HCPCS,636,RC,10019-0926-02,NDC,outpatient,1,UN,288.44,201.908,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,21.181575,416.02,other,OPPS APC,,
MESNA 100 MG/ML IV SOLN,RX-10537,CDM,J9209,HCPCS,636,RC,00338-1305-01,NDC,outpatient,10,ML,28.36,19.852,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.67,416.02,other,OPPS APC,,
MESNA 100 MG/ML IV SOLN,RX-10537,CDM,J9209,HCPCS,636,RC,63323-0733-11,NDC,outpatient,10,ML,222.31,155.617,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.67,416.02,other,OPPS APC,,
IDARUBICIN HCL 1 MG/ML IV SOLN WRAPPER,RX-4080583,CDM,J9211,HCPCS,636,RC,00013-2576-91,NDC,outpatient,5,ML,121.76,85.232,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,27.33512,416.02,other,OPPS APC,,
LEUPROLIDE ACETATE 7.5 MG IM KIT,RX-10392,CDM,J9217,HCPCS,636,RC,00074-3642-03,NDC,outpatient,1,UN,5670.76,3969.532,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,202.192205,,,202.192205,165.86,17420.48256,other,OPPS APC,,
LEUPROLIDE ACETATE (3 MONTH) 22.5 MG IM KIT,RX-21045,CDM,J9217,HCPCS,636,RC,00074-3346-03,NDC,outpatient,1,UN,17012.14,11908.498,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,202.192205,,,202.192205,165.86,17420.48256,other,OPPS APC,,
LEUPROLIDE ACETATE (4 MONTH) 30 MG IM KIT,RX-21108,CDM,J9217,HCPCS,636,RC,00074-3683-03,NDC,outpatient,1,UN,22682.92,15878.044,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,202.192205,,,202.192205,165.86,17420.48256,other,OPPS APC,,
LEUPROLIDE ACETATE (4 MONTH) 30 MG SC KIT,RX-35236,CDM,J9217,HCPCS,636,RC,62935-0303-30,NDC,outpatient,1,UN,1549.29,1084.503,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,202.192205,,,202.192205,165.86,17420.48256,other,OPPS APC,,
IPILIMUMAB 5 MG/ML IV SOLN WRAPPER,RX-4080201,CDM,J9228,HCPCS,636,RC,00003-2327-11,NDC,outpatient,10,ML,24402.93,17082.051,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,202.620622,,,202.620622,167.93,74965.60128,other,OPPS APC,,
IPILIMUMAB 5 MG/ML IV SOLN WRAPPER,RX-4080201,CDM,J9228,HCPCS,636,RC,00003-2328-22,NDC,outpatient,40,ML,97611.46,68328.022,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,202.620622,,,202.620622,167.93,74965.60128,other,OPPS APC,,
METHOTREXATE SODIUM (PF) 25 MG/ML IJ SOLN WRAPPER,RX-4080789,CDM,J9260,HCPCS,636,RC,00143-9519-10,NDC,outpatient,2,ML,6.58,4.606,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.47721,416.02,other,OPPS APC,,
METHOTREXATE SODIUM (PF) 25 MG/ML IJ SOLN WRAPPER,RX-4080789,CDM,J9260,HCPCS,636,RC,00143-9519-01,NDC,outpatient,2,ML,6.58,4.606,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.47721,416.02,other,OPPS APC,,
NELARABINE 5 MG/ML IV SOLN,RX-70267,CDM,J9261,HCPCS,636,RC,00078-0683-61,NDC,outpatient,50,ML,2241.96,1569.372,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,83.0796785,,,83.0796785,72.53,1721.82528,other,OPPS APC,,
OXALIPLATIN 5 MG/ML IV SOLR WRAPPER,RX-4080205,CDM,J9263,HCPCS,636,RC,00703-3986-01,NDC,outpatient,20,ML,216.64,151.648,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC,,
OXALIPLATIN 5 MG/ML IV SOLR WRAPPER,RX-4080205,CDM,J9263,HCPCS,636,RC,67457-0469-10,NDC,outpatient,10,ML,50.32,35.224,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.06,416.02,other,OPPS APC,,
PACLITAXEL PROTEIN-BOUND PART 100 MG IV SUSR,RX-40475,CDM,J9264,HCPCS,636,RC,68817-0134-50,NDC,outpatient,1,UN,4383.41,3068.387,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15.285552,,,15.285552,12.06,3366.45888,other,OPPS APC,,
PACLITAXEL 6 MG/ML IV CONC WRAPPER,RX-4080637,CDM,J9267,HCPCS,636,RC,63323-0763-50,NDC,outpatient,50,ML,433.61,303.527,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC,,
PACLITAXEL 6 MG/ML IV CONC WRAPPER,RX-4080637,CDM,J9267,HCPCS,636,RC,61703-0342-50,NDC,outpatient,50,ML,238.31,166.817,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.1,416.02,other,OPPS APC,,
PENTOSTATIN 10 MG IV SOLR,RX-10910,CDM,J9268,HCPCS,636,RC,00409-0801-01,NDC,outpatient,1,UN,6377.89,4464.523,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,2911.602117,,,2911.602117,399.86,4898.21952,other,OPPS APC,,
PEMBROLIZUMAB 25 MG/ML IV SOLN WRAPPER,RX-4080564,CDM,J9271,HCPCS,636,RC,00006-3026-02,NDC,outpatient,4,ML,16212.43,11348.701,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.686428,,,66.686428,54.81,12451.14624,other,OPPS APC,,
MITOMYCIN 20 MG IV SOLR,RX-10630,CDM,J9280,HCPCS,636,RC,16729-0108-11,NDC,outpatient,1,UN,505.56,353.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,48.6894775,,,48.6894775,42.51,2565.35808,other,OPPS APC,,
MITOMYCIN 40 MG IV SOLR,RX-10631,CDM,J9280,HCPCS,636,RC,00143-9280-01,NDC,outpatient,1,UN,3340.31,2338.217,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,48.6894775,,,48.6894775,42.51,2565.35808,other,OPPS APC,,
MITOMYCIN 40 MG IV SOLR,RX-10631,CDM,J9280,HCPCS,636,RC,16729-0116-38,NDC,outpatient,1,UN,3340.2,2338.14,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,48.6894775,,,48.6894775,42.51,2565.35808,other,OPPS APC,,
MITOMYCIN 5 MG IV SOLR,RX-10632,CDM,J9280,HCPCS,636,RC,16729-0115-05,NDC,outpatient,1,UN,734.35,514.045,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,48.6894775,,,48.6894775,42.51,2565.35808,other,OPPS APC,,
MITOXANTRONE HCL 20 MG/10ML IV CONC,RX-93748,CDM,J9293,HCPCS,636,RC,61703-0343-18,NDC,outpatient,10,ML,279.99,195.993,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,62.6027205,,,62.6027205,29.06,416.02,other,OPPS APC,,
NIVOLUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080562,CDM,J9299,HCPCS,636,RC,00003-3734-13,NDC,outpatient,24,ML,21406.97,14984.879,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,36.369625,,,36.369625,30.46,16440.55296,other,OPPS APC,,
NIVOLUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080562,CDM,J9299,HCPCS,636,RC,00003-3772-11,NDC,outpatient,4,ML,3567.83,2497.481,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,36.369625,,,36.369625,30.46,16440.55296,other,OPPS APC,,
NIVOLUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080562,CDM,J9299,HCPCS,636,RC,00003-3774-12,NDC,outpatient,10,ML,8919.54,6243.678,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,36.369625,,,36.369625,30.46,16440.55296,other,OPPS APC,,
OBINUTUZUMAB 1000 MG/40ML IV SOLN,RX-124650,CDM,J9301,HCPCS,636,RC,50242-0070-01,NDC,outpatient,40,ML,23571.67,16500.169,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,85.440554,,,85.440554,70.55,18103.04256,other,OPPS APC,,
PANITUMUMAB 20 MG/ML IV SOLN WRAPPER,RX-4080216,CDM,J9303,HCPCS,636,RC,55513-0954-01,NDC,outpatient,5,ML,4571.26,3199.882,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,182.507933,,,182.507933,149.71,14042.8032,other,OPPS APC,,
PANITUMUMAB 20 MG/ML IV SOLN WRAPPER,RX-4080216,CDM,J9303,HCPCS,636,RC,55513-0956-01,NDC,outpatient,20,ML,18284.9,12799.43,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,182.507933,,,182.507933,149.71,14042.8032,other,OPPS APC,,
PEMETREXED DISODIUM 500 MG IV SOLR,RX-37894,CDM,J9305,HCPCS,636,RC,00002-7623-01,NDC,outpatient,1,UN,11216.1,7851.27,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4.792772,,,4.792772,4.18,8613.9648,other,OPPS APC,,
PEMETREXED DISODIUM 100 MG IV SOLR,RX-89350,CDM,J9305,HCPCS,636,RC,00002-7640-01,NDC,outpatient,1,UN,2243.22,1570.254,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,4.792772,,,4.792772,4.18,8613.9648,other,OPPS APC,,
PERTUZUMAB 420 MG/14ML IV SOLN,RX-116596,CDM,J9306,HCPCS,636,RC,50242-0145-01,NDC,outpatient,14,ML,18666.61,13066.627,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,18.463169,,,18.463169,15.37,14335.95648,other,OPPS APC,,
PRALATREXATE 20 MG/ML IV SOLN WRAPPER,RX-4080207,CDM,J9307,HCPCS,636,RC,72893-0003-01,NDC,outpatient,1,ML,20371.07,14259.749,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,428.151244,,,428.151244,356.51,15644.98176,other,OPPS APC,,
RAMUCIRUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080567,CDM,J9308,HCPCS,636,RC,00002-7678-01,NDC,outpatient,50,ML,20423.69,14296.583,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,81.4118305,,,81.4118305,68.87,15685.39392,other,OPPS APC,,
RAMUCIRUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080567,CDM,J9308,HCPCS,636,RC,00002-7669-01,NDC,outpatient,10,ML,4084.74,2859.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,81.4118305,,,81.4118305,68.87,15685.39392,other,OPPS APC,,
RITUXIMAB 10 MG/ML IV SOLN WRAPPER,RX-4080719,CDM,J9312,HCPCS,636,RC,50242-0051-21,NDC,outpatient,10,ML,2687.03,1880.921,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,88.563187,,,88.563187,77.31,10318.18752,other,OPPS APC,,
RITUXIMAB 10 MG/ML IV SOLN WRAPPER,RX-4080719,CDM,J9312,HCPCS,636,RC,50242-0053-06,NDC,outpatient,50,ML,13435.14,9404.598,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,88.563187,,,88.563187,77.31,10318.18752,other,OPPS APC,,
STREPTOZOCIN 1 G IV SOLR,RX-11436,CDM,J9320,HCPCS,636,RC,00703-4636-01,NDC,outpatient,1,UN,1171.99,820.393,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,424.045772,,,424.045772,223.44,900.08832,other,OPPS APC,,
TEMSIROLIMUS 25 MG/ML IV SOLN,RX-82228,CDM,J9330,HCPCS,636,RC,00008-1179-01,NDC,outpatient,2.5,ML,5549.29,3884.503,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,36.896555,,,36.896555,32.21,4261.85472,other,OPPS APC,,
TOPOTECAN HCL 1 MG/ML IV SOLN WRAPPER,RX-4080561,CDM,J9351,HCPCS,636,RC,16729-0151-31,NDC,outpatient,1,UN,263.29,184.303,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.5,416.02,other,OPPS APC,,
ADO-TRASTUZUMAB EMTANSINE 100 MG IV SOLR,RX-120086,CDM,J9354,HCPCS,636,RC,50242-0088-01,NDC,outpatient,1,UN,11130.41,7791.287,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,46.3297475,,,46.3297475,38.33,13677.02016,other,OPPS APC,,
ADO-TRASTUZUMAB EMTANSINE 160 MG IV SOLR,RX-120087,CDM,J9354,HCPCS,636,RC,50242-0087-01,NDC,outpatient,1,UN,17808.62,12466.034,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,46.3297475,,,46.3297475,38.33,13677.02016,other,OPPS APC,,
TRASTUZUMAB 21 MG/ML IV SOLR WRAPPER,RX-4080954,CDM,J9355,HCPCS,636,RC,50242-0132-01,NDC,outpatient,150,ME,4754.01,3327.807,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,89.28027,,,89.28027,77.94,3651.07968,other,OPPS APC,,
TRASTUZUMAB 21 MG/ML IV SOLR WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080954,CDM,J9355,HCPCS,636,RC,50242-0132-01,NDC,outpatient,150,ME,4456.89,3119.823,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,89.28027,,,89.28027,77.94,3651.07968,other,OPPS APC,,
VINBLASTINE SULFATE 1 MG/ML IV SOLN IV PUSH,RX-8594,CDM,J9360,HCPCS,636,RC,63323-0278-10,NDC,outpatient,10,ML,173.56,121.492,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.95,416.02,other,OPPS APC,,
VINCRISTINE SULFATE 1 MG/ML IV SOLN,RX-8597,CDM,J9370,HCPCS,636,RC,61703-0309-16,NDC,outpatient,2,ML,46.03,32.221,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,7.49,416.02,other,OPPS APC,,
VINCRISTINE SULFATE 1 MG/ML IV SOLN,RX-8597,CDM,J9370,HCPCS,636,RC,61703-0309-06,NDC,outpatient,2,ML,92.35,64.645,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,7.49,416.02,other,OPPS APC,,
VINORELBINE TARTRATE 10 MG/ML IV SOLN WRAPPER,RX-4080209,CDM,J9390,HCPCS,636,RC,25021-0204-05,NDC,outpatient,5,ML,163.03,114.121,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,7.59,416.02,other,OPPS APC,,
FULVESTRANT 250 MG/5ML IM SOSY,RX-160451,CDM,J9394,HCPCS,636,RC,63323-0715-01,NDC,outpatient,10,ML,518.07,362.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7115,,,60.7115,1.65,1060,other,OPPS APC,,
FULVESTRANT 250 MG/5ML IM SOSY,RX-160451,CDM,J9394,HCPCS,636,RC,63323-0715-05,NDC,outpatient,10,ML,518.07,362.649,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7115,,,60.7115,1.65,1060,other,OPPS APC,,
COLLAR CERV FOAM LARGE -,SUP-00273900400,CDM,L0120,HCPCS,274,RC,,,outpatient,,,175.05,122.535,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,29.2,,,29.2,4.41367,416.02,fee schedule,,,
COLLAR SM 20.5INX3.5IN SFT DENS BRTHBL STCKNT CVR FOAM/CTTN -,SUP-1018-02,CDM,L0120,HCPCS,274,RC,,,outpatient,,,22.99,16.093,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,29.2,,,29.2,4.41367,416.02,fee schedule,,,
COLLAR CERVICAL STAT MEDIUM -,SUP-1018-03,CDM,L0120,HCPCS,274,RC,,,outpatient,,,19.66,13.762,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,29.2,,,29.2,4.41367,416.02,fee schedule,,,
CERVICAL COLLAR XL SOFT 22x3.5 -,SUP-1050-24,CDM,L0120,HCPCS,274,RC,,,outpatient,,,23.75,16.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,29.2,,,29.2,4.41367,416.02,fee schedule,,,
COLLAR PHILADELPHIA CERVICAL SM TRACH 2PC 4.25IN X 10-13IN -,SUP-1044-11,CDM,L0172,HCPCS,274,RC,,,outpatient,,,126.85,88.795,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.68,,,139.68,12.10504,416.02,fee schedule,,,
COLLAR PHILADELPHIA CERVICAL MD TRACH 2PC 4.25IN X 13-16IN -,SUP-1044-12,CDM,L0172,HCPCS,274,RC,,,outpatient,,,126.85,88.795,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.68,,,139.68,12.10504,416.02,fee schedule,,,
COLLAR PHILADELPHIA CERVICAL LRG TRACH 2PC 4.25IN X 16-19IN -,SUP-1044-13,CDM,L0172,HCPCS,274,RC,,,outpatient,,,126.85,88.795,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.68,,,139.68,12.10504,416.02,fee schedule,,,
COLLAR CERVICAL RIGID MED TRACH 2PC 3.25IN X 13-16IN -,SUP-1113MPP,CDM,L0172,HCPCS,274,RC,,,outpatient,,,53.92,37.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.68,,,139.68,12.10504,416.02,fee schedule,,,
COLLAR CERVICAL RIGID SM TRACH 2PC 3.25IN X 10-13IN -,SUP-1113SPP,CDM,L0172,HCPCS,274,RC,,,outpatient,,,53.92,37.744,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.68,,,139.68,12.10504,416.02,fee schedule,,,
COLLAR PHILADELPHIA SM 3.25IN 10-13 IN -,SUP-79-83133,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.23,46.361,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.68,,,139.68,12.10504,416.02,fee schedule,,,
COLLAR PHILADELPHIA MD 3.25IN x 13-16 IN -,SUP-79-83135,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.23,46.361,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.68,,,139.68,12.10504,416.02,fee schedule,,,
COLLAR PHILADELPHIA LG 3.25IN x 16-19IN -,SUP-79-83137,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.23,46.361,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.68,,,139.68,12.10504,416.02,fee schedule,,,
COLLAR PHILADELPHIA SM 4.25IN x 10-13IN -,SUP-79-83143,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.46,46.522,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.68,,,139.68,12.10504,416.02,fee schedule,,,
COLLAR PHILADELPHIA LG 4.25IN x 16-19IN -,SUP-79-83147,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.46,46.522,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,139.68,,,139.68,12.10504,416.02,fee schedule,,,
KNEE SUPPORT- HINGED PULL UP- MEDIUM -,SUP-NE7711-73,CDM,L1820,HCPCS,274,RC,,,outpatient,,,136.07,95.249,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,167.47,,,167.47,29.06826,416.02,fee schedule,,,
KNEE SUPPORT HINGED PULL UP- LRG -,SUP-NE7711-74,CDM,L1820,HCPCS,274,RC,,,outpatient,,,129.48,90.636,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,167.47,,,167.47,29.06826,416.02,fee schedule,,,
SUPPORT KNEE HINGED PULL UP LARGE -,SUP-NE7711-74,CDM,L1820,HCPCS,274,RC,,,outpatient,,,136.13,95.291,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,167.47,,,167.47,29.06826,416.02,fee schedule,,,
KNEE SUPPORT HINGED PULL UP X-LRG -,SUP-NE7711-75,CDM,L1820,HCPCS,274,RC,,,outpatient,,,136.07,95.249,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,167.47,,,167.47,29.06826,416.02,fee schedule,,,
SUPPORT KNEE HINGED PULL UP X-LARGE -,SUP-NE7711-75,CDM,L1820,HCPCS,274,RC,,,outpatient,,,129.48,90.636,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,167.47,,,167.47,29.06826,416.02,fee schedule,,,
BRACE KNEE ENHANCED TROM - DONJOY -,SUP-11-9114-9,CDM,L1832,HCPCS,274,RC,,,outpatient,,,544.99,381.493,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,873.34,,,873.34,110.03643,1222.676,fee schedule,,,
KNEE BRACE HINGED TROM DONJOY -,SUP-11-9114-9,CDM,L1832,HCPCS,274,RC,,,outpatient,,,544.99,381.493,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,873.34,,,873.34,110.03643,1222.676,fee schedule,,,
BRACE KN POSTOP 18-26IN FIT UPTO 34IN THG 6IN ABV MI D PTLR -,SUP-75-7500-000,CDM,L1832,HCPCS,274,RC,,,outpatient,,,490.14,343.098,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,873.34,,,873.34,110.03643,1222.676,fee schedule,,,
ANKLE BRACE SPORTS ORTHOSIS LACE UP BOA SMALL -,SUP-AB3000-12,CDM,L1902,HCPCS,274,RC,,,outpatient,,,105.56,73.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,101.16,,,101.16,23.579235,416.02,fee schedule,,,
ANKLE BRACE SPORTS ORTHOSIS LACE UP BOA MEDIUM -,SUP-AB3000-14,CDM,L1902,HCPCS,274,RC,,,outpatient,,,105.03,73.521,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,101.16,,,101.16,23.579235,416.02,fee schedule,,,
BRACE ANKLE SPORTS ORTHOSIS LACE UP BOA LARGE -,SUP-AB3000-16,CDM,L1902,HCPCS,274,RC,,,outpatient,,,105.56,73.892,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,101.16,,,101.16,23.579235,416.02,fee schedule,,,
BRACE ANKLE- SPORTS ORTHOSIS LACE UP BOA- XL -,SUP-AB3000-18,CDM,L1902,HCPCS,274,RC,,,outpatient,,,111.45,78.015,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,101.16,,,101.16,23.579235,416.02,fee schedule,,,
SPLINT ORTHO LT ANKL/FT LRG SZ8-10 PLST CLSD HL MLD HK/LOP -,SUP-A508LL,CDM,L1930,HCPCS,274,RC,,,outpatient,,,180.48,126.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,300.36,,,300.36,34.77954,420.504,fee schedule,,,
SPLINT ORTHO LT ANKL/FT MED SZ8-10 PLST CLSD HL MLD HK/LOP -,SUP-A508LM,CDM,L1930,HCPCS,274,RC,,,outpatient,,,179.78,125.846,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,300.36,,,300.36,34.77954,420.504,fee schedule,,,
SPLINT ORTHO RT ANKL/FT LRG SZ8-10 MALE PLST CLSD HL MLD -,SUP-A508RL,CDM,L1930,HCPCS,274,RC,,,outpatient,,,180.48,126.336,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,300.36,,,300.36,34.77954,420.504,fee schedule,,,
SPLINT ORTHO RT ANKL/FT LRG SZ8-10 PLST CLSD HL MLD HK/LOP -,SUP-A508RM,CDM,L1930,HCPCS,274,RC,,,outpatient,,,175.28,122.696,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,300.36,,,300.36,34.77954,420.504,fee schedule,,,
SPLINT ORTHO RT ANKL/FT SM SZ3-6 FEM PLST CLSD HL MLD HK/LOP -,SUP-A508RS,CDM,L1930,HCPCS,274,RC,,,outpatient,,,226.22,158.354,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,300.36,,,300.36,34.77954,420.504,fee schedule,,,
AFO FOR FOOT AND ANKLE -,SUP-XEE64330,CDM,L1930,HCPCS,274,RC,,,outpatient,,,154.92,108.444,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,300.36,,,300.36,34.77954,420.504,fee schedule,,,
AFO FOR FOOT AND ANKLE -,SUP-XEE64331,CDM,L1930,HCPCS,274,RC,,,outpatient,,,154.92,108.444,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,300.36,,,300.36,34.77954,420.504,fee schedule,,,
SYS FOOT OTHTC SM PEGASSIST DARCO -,SUP-PW1,CDM,L3002,HCPCS,274,RC,,,outpatient,,,73.46,51.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,185.48,,,185.48,16.49177,416.02,fee schedule,,,
SYS FOOT OTHTC MED PEGASSIST DARCO -,SUP-PW2,CDM,L3002,HCPCS,274,RC,,,outpatient,,,73.46,51.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,185.48,,,185.48,16.49177,416.02,fee schedule,,,
SYS FOOT OTHTC XL PEGASSIST DARCO -,SUP-PW4,CDM,L3002,HCPCS,274,RC,,,outpatient,,,73.46,51.422,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,185.48,,,185.48,16.49177,416.02,fee schedule,,,
SHOE POSTOP SZ5-6.5 SM MALE RT/LT LACE-UP CLSR -,SUP-2020-01,CDM,L3260,HCPCS,274,RC,,,outpatient,,,31.86,22.302,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,,,
SHOE POSTOP SZ7-8.5 MED MALE RT/LT LACE-UP CLSR -,SUP-2020-02,CDM,L3260,HCPCS,274,RC,,,outpatient,,,31.86,22.302,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,,,
SHOE POSTOP SZ9-11 LRG MALE RT/LT LACE-UP CLSR -,SUP-2020-03,CDM,L3260,HCPCS,274,RC,,,outpatient,,,31.86,22.302,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,,,
SHOE POSTOP SZ4-6 SM FEM RT/LT LACE-UP CLSR -,SUP-2021-01,CDM,L3260,HCPCS,274,RC,,,outpatient,,,30.87,21.609,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,,,
SHOE POSTOP SZ6.5-8 MED FEM RT/LT LACE-UP CLSR -,SUP-2021-02,CDM,L3260,HCPCS,274,RC,,,outpatient,,,30.87,21.609,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,,,
SHOE POSTOP SZ8.5-10 LRG L/R ANKL OPN TOE CLSD HL CNVS RBR -,SUP-2021-03,CDM,L3260,HCPCS,274,RC,,,outpatient,,,30.87,21.609,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,,,
BOOT CAST SM 4.5X8.5IN CNVS FT RCKR SOLE NSLIP HK/LOP CLSR -,SUP-2035-02,CDM,L3260,HCPCS,274,RC,,,outpatient,,,27.25,19.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,,,
CAST SHOE MED CANVAS ROCKER -,SUP-2035-03,CDM,L3260,HCPCS,274,RC,,,outpatient,,,27.6,19.32,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,,,
SHOE CAST LRG 5.25X11.5IN CNVS FT RCKR SOLE NSLIP HK/LOP -,SUP-2035-04,CDM,L3260,HCPCS,274,RC,,,outpatient,,,27.25,19.075,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,,,
SURGICAL SHOE MENS XL -,SUP-5701024,CDM,L3260,HCPCS,274,RC,,,outpatient,,,39.56,27.692,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,,,
SHOE ORTHO ANKL SM SZ7.5-10 MSH CLSD HL CLSD TOE HK/LOP STRP -,SUP-92732502,CDM,L3260,HCPCS,274,RC,,,outpatient,,,221.73,155.211,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,,,
SHOE ORTHO ANKL MED SZ8.5-10 MALE MSH CLSD HL CLSD TOE -,SUP-92732503,CDM,L3260,HCPCS,274,RC,,,outpatient,,,214.44,150.108,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,,,
SHOE ORTHO ANKL LRG SZ10.5-12 MSH CLSD HL CLSD TOE HK/LOP -,SUP-92732504,CDM,L3260,HCPCS,274,RC,,,outpatient,,,214.44,150.108,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,,,
SHOE CAST SZ6-8 MALE SZ7.5-10 FEM SM FT DARCO HEELWEDGE -,SUP-92732602,CDM,L3260,HCPCS,274,RC,,,outpatient,,,116.41,81.487,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,,,
SHOE CAST SZ8.5-10 MALE 10.5-13 FEM MED FT DARCO HEELWEDGE -,SUP-92732603,CDM,L3260,HCPCS,274,RC,,,outpatient,,,124.52,87.164,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,,,
SHOE POST-OP NYLON RUBBER HOOK/LOOP MALE SMALL -,SUP-A152305,CDM,L3260,HCPCS,274,RC,,,outpatient,,,20.66,14.462,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,,,
POST OP SHOE NYLON RUBBER HOOK/LOOP MALE LRG -,SUP-A152307,CDM,L3260,HCPCS,274,RC,,,outpatient,,,22.29,15.603,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,,,
SHOE POSTOP MENS SM SIZES 6-8 MEDSURG -,SUP-MQM1B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,,,
SHOE POSTOP MENS MED SIZES 8.5-10 MEDSURG -,SUP-MQM2B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,,,
SHOE POSTOP MENS LG SIZES 10.5-12 MEDSURG -,SUP-MQM3B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,,,
SHOE POSTOP MENS XL SIZES 12.5-14 MEDSURG -,SUP-MQM4B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,,,
SHOE POSTOP WOMENS SM SIZES 4-6 MEDSURG -,SUP-MQW1B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,,,
SHOE POSTOP WOMENS MED SIZES 6.5- 8 MEDSURG -,SUP-MQW2B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,,,
SHOE POSTOP SZ6.5-8 FEM MED MEDSURG OPN TOE CLSD HL RCKR BTM -,SUP-MQW2B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,110.4,77.28,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,,,
SHOE POSTOP WOMENS LG SIZES  8.5 -10 MEDSURG -,SUP-MQW3B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,,,
SHOE DARCO SURGICAL MENS SMALL -,SUP-MSM1N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,28.47,19.929,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,,,
SHOES DARCO MENS MEDIUM -,SUP-MSM2N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,47.21,33.047,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,,,
SHOES DARCO MENS LARGE -,SUP-MSM3N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,48.55,33.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,,,
SHOES DARCO WOMENS SMALL -,SUP-MSW1N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,48.55,33.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,,,
SHOES DARCO WOMENS MEDIUM -,SUP-MSW2N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,28.47,19.929,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,,,
SHOES DARCO WOMENS LARGE -,SUP-MSW3N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,45.63,31.941,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,,,
BOOT CAST REG FT PD WVN TCC-EZ -,SUP-TCC21100,CDM,L3260,HCPCS,274,RC,,,outpatient,,,393.57,275.499,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,,,
BOOT CAST LRG FT PD WVN TCC-EZ -,SUP-TCC21114,CDM,L3260,HCPCS,274,RC,,,outpatient,,,444.34,311.038,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,,,
BOOT CAST LRG FT CHARCOT PD WVN TCC-EZ -,SUP-TCC21116,CDM,L3260,HCPCS,274,RC,,,outpatient,,,538.28,376.796,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,,,
SYS CAST 3IN FT CHARCOT PD WVN W/REGULARX2 BT TCC-EZ -,SUP-TCC23000,CDM,L3260,HCPCS,274,RC,,,outpatient,,,627.97,439.579,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,,,
SYS CAST SZ4 IN FT PD WVN W/2 REG BT TCC-EZ -,SUP-TCC24000,CDM,L3260,HCPCS,274,RC,,,outpatient,,,627.97,439.579,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,4.63817,482.28096,,,,
IMMOBILIZER SHLDR LRG ELAS HUM CUF RB WRP -,SUP-00078300300,CDM,L3670,HCPCS,274,RC,,,outpatient,,,291.75,204.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,121.74,,,121.74,3.81201,416.02,fee schedule,,,
IMMOBILIZER SHLDR LRG ELAS HUM CUF CONTR RB WRP -,SUP-00078400300,CDM,L3670,HCPCS,274,RC,,,outpatient,,,233.4,163.38,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,121.74,,,121.74,3.81201,416.02,fee schedule,,,
IMMOBILIZER SHLDR SMALL ULTRASLING III BLACK -,SUP-11-0449-2,CDM,L3670,HCPCS,274,RC,,,outpatient,,,305.46,213.822,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,121.74,,,121.74,3.81201,416.02,fee schedule,,,
IMMOBILIZER SHLDR MED ULTRASLING III BLACK -,SUP-11-0449-3,CDM,L3670,HCPCS,274,RC,,,outpatient,,,305.46,213.822,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,121.74,,,121.74,3.81201,416.02,fee schedule,,,
SUPPORT RT SHLDR SM 11IN MSH FBRC ULSNG ER HUM CUF 15DEG -,SUP-11-1343-2-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,121.74,,,121.74,3.81201,416.02,fee schedule,,,
SUPPORT LT SHLDR ARM SM UPTO 11IN MSH FBRC ULSNG ER BRTHBL -,SUP-11-1344-2-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,121.74,,,121.74,3.81201,416.02,fee schedule,,,
SUPPORT LT SHLDR ARM LRG ABV 13IN MSH FBRC ULSNG ER BRTHBL -,SUP-11-1344-4-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,121.74,,,121.74,3.81201,416.02,fee schedule,,,
SUPPORT RT SHLDR SM 11IN MSH FBRC ULSNG ER HUM CUF 30DEG -,SUP-11-1345-2,CDM,L3670,HCPCS,274,RC,,,outpatient,,,371.22,259.854,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,121.74,,,121.74,3.81201,416.02,fee schedule,,,
SUPPORT RT SHLDR LRG 13-15IN MSH FBRC ULSNG ER HUM 30DEG -,SUP-11-1345-4-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,121.74,,,121.74,3.81201,416.02,fee schedule,,,
SUPPORT LT SHLDR LRG 13-15IN MSH FBRC ULSNG ER BRTHBL HUM -,SUP-11-1346-4-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,121.74,,,121.74,3.81201,416.02,fee schedule,,,
IMMOBILIZER SHLDR SLING MED 7IN X 17IN -,SUP-11630006,CDM,L3670,HCPCS,274,RC,,,outpatient,,,243.14,170.198,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,121.74,,,121.74,3.81201,416.02,fee schedule,,,
IMMOBILIZER SHLDR SLING LRG 7IN X 18IN -,SUP-11630007,CDM,L3670,HCPCS,274,RC,,,outpatient,,,243.14,170.198,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,121.74,,,121.74,3.81201,416.02,fee schedule,,,
IIMMOBILIZER SHOULDER VELPEAU M -,SUP-23-1872,CDM,L3670,HCPCS,274,RC,,,outpatient,,,29.7,20.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,121.74,,,121.74,3.81201,416.02,fee schedule,,,
IMMOBILIZER SHOULDER VELPEAU L -,SUP-23-1873-000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,29.7,20.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,121.74,,,121.74,3.81201,416.02,fee schedule,,,
IMMOBILIZER SHLDR SM PD WRST/HUM CUF SHLDR/WST STRP -,SUP-667110,CDM,L3670,HCPCS,274,RC,,,outpatient,,,343.1,240.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,121.74,,,121.74,3.81201,416.02,fee schedule,,,
IMMOBILIZER RT/LT SHLDR XS CTTN CLTH 6X12.5IN PCH CLSD/OPN -,SUP-9002-01,CDM,L3670,HCPCS,274,RC,,,outpatient,,,29.12,20.384,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,121.74,,,121.74,3.81201,416.02,fee schedule,,,
IMMOBILIZER SHOULDER UNIVERSAL -,SUP-9013-00,CDM,L3670,HCPCS,274,RC,,,outpatient,,,56.25,39.375,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,121.74,,,121.74,3.81201,416.02,fee schedule,,,
SHOULDER IMMOBILIZER W/FOAM SMALL -,SUP-A111015,CDM,L3670,HCPCS,274,RC,,,outpatient,,,19.02,13.314,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,121.74,,,121.74,3.81201,416.02,fee schedule,,,
SHOULDER IMMOBILIZER W/FOAM WAIST STRAP M -,SUP-A111016,CDM,L3670,HCPCS,274,RC,,,outpatient,,,19.02,13.314,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,121.74,,,121.74,3.81201,416.02,fee schedule,,,
IMMOBILIZER SHLDR X-LRG 9IN X 22.5IN -,SUP-A111018,CDM,L3670,HCPCS,274,RC,,,outpatient,,,16.98,11.886,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,121.74,,,121.74,3.81201,416.02,fee schedule,,,
IMMOBILIZER SHOULDER VELP XLG -,SUP-TX9023-04,CDM,L3670,HCPCS,274,RC,,,outpatient,,,31.1,21.77,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,121.74,,,121.74,3.81201,416.02,fee schedule,,,
SPLINT RT HND SM 6.5-7.25IN ALIFLEECE LINER THRMPLST DLX FIG -,SUP-5183,CDM,L3807,HCPCS,274,RC,,,outpatient,,,286.27,200.389,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,261.35,,,261.35,31.76675,416.02,fee schedule,,,
SPLINT RT HND LRG 8.25-9.25IN ALIFLEECE LINER THRMPLST DLX -,SUP-5187,CDM,L3807,HCPCS,274,RC,,,outpatient,,,284.4,199.08,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,261.35,,,261.35,31.76675,416.02,fee schedule,,,
SPLINT LT SM RST -,SUP-5812,CDM,L3807,HCPCS,274,RC,,,outpatient,,,273.08,191.156,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,261.35,,,261.35,31.76675,416.02,fee schedule,,,
SPLINT WRST MED POLY FOAM CCKUP -,SUP-A1601P,CDM,L3807,HCPCS,274,RC,,,outpatient,,,141.5,99.05,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,261.35,,,261.35,31.76675,416.02,fee schedule,,,
EXTERNAL FIX DIGIT WIDGET -,SUP-DWD-232,CDM,L3921,HCPCS,274,RC,,,outpatient,,,7002.6,4901.82,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,335.72,,,335.72,335.72,5377.9968,fee schedule,,,
SPLINT THUMB SPICA RIGHT MED/LRG 3.5IN - 4.25IN -,SUP-340M/LR,CDM,L3924,HCPCS,274,RC,,,outpatient,,,68.27,47.789,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,124.86,,,124.86,15.326615,416.02,fee schedule,,,
THUMB SPLINT COMFORT COOL CMC LT MEDIUM -,SUP-348ML,CDM,L3924,HCPCS,274,RC,,,outpatient,,,92.66,64.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,124.86,,,124.86,15.326615,416.02,fee schedule,,,
THUMB SPLINT COMFORT COOL CMC RT MEDIUM -,SUP-348MR,CDM,L3924,HCPCS,274,RC,,,outpatient,,,92.66,64.862,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,124.86,,,124.86,15.326615,416.02,fee schedule,,,
LMB SPRING PIP EXTENSION ASSIST -,SUP-704103,CDM,L3925,HCPCS,274,RC,,,outpatient,,,89.16,62.412,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,56.18,,,56.18,17.225885,416.02,fee schedule,,,
SPLINT FINGER EXTENSION LMB SPRING SIZE A -,SUP-704200,CDM,L3925,HCPCS,274,RC,,,outpatient,,,76.73,53.711,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,56.18,,,56.18,17.225885,416.02,fee schedule,,,
SPLINT FINGER EXTENSION SPRING LMB SIZE C -,SUP-704202,CDM,L3925,HCPCS,274,RC,,,outpatient,,,76.79,53.753,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,56.18,,,56.18,17.225885,416.02,fee schedule,,,
BOOT WALKER LRG AIRCAST SZ10-13 MALE SZ11-15 FEM PED -,SUP-01EF-L,CDM,L4361,HCPCS,274,RC,,,outpatient,,,269.52,188.664,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,406.17,,,406.17,50.613525,568.638,fee schedule,,,
BOOT WALKER MED AIRCAST SZ7-10 MALE SZ8-11 FEM -,SUP-01EF-M,CDM,L4361,HCPCS,274,RC,,,outpatient,,,269.52,188.664,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,406.17,,,406.17,50.613525,568.638,fee schedule,,,
BOOT WALKER SM AIRCAST SZ4-7 MALE SZ5-8 FEM -,SUP-01F-S,CDM,L4361,HCPCS,274,RC,,,outpatient,,,263.86,184.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,406.17,,,406.17,50.613525,568.638,fee schedule,,,
BOOT WALKER XL AIRCAST SZ 13+ MALE SZ 15+ FEM -,SUP-01F-XL,CDM,L4361,HCPCS,274,RC,,,outpatient,,,263.86,184.702,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,406.17,,,406.17,50.613525,568.638,fee schedule,,,
BOOT WALKER LRG SHELL 10-13M/11-15F -,SUP-1175LPP,CDM,L4361,HCPCS,274,RC,,,outpatient,,,225.45,157.815,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,406.17,,,406.17,50.613525,568.638,fee schedule,,,
WALKER FULL SHELL 2 SHORT- SMALL -,SUP-15500047,CDM,L4361,HCPCS,274,RC,,,outpatient,,,274.6,192.22,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,406.17,,,406.17,50.613525,568.638,fee schedule,,,
WALKER- FULL SHELL 2 SHORT- MEDIUM -,SUP-15500048,CDM,L4361,HCPCS,274,RC,,,outpatient,,,249.74,174.818,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,406.17,,,406.17,50.613525,568.638,fee schedule,,,
WALKER FULL SHELL 2 SHORT LARGE -,SUP-1550049,CDM,L4361,HCPCS,274,RC,,,outpatient,,,234.33,164.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,406.17,,,406.17,50.613525,568.638,fee schedule,,,
BOOT ORTHO FT MED/L FLEECE LINER OPN TOE SEMI- FLXB SHL -,SUP-6963,CDM,L4394,HCPCS,274,RC,,,outpatient,,,127.09,88.963,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,20.61,,,20.61,20.61,416.02,fee schedule,,,
VALVE SPK 15X23MM PASSY-MUIR WHITE -,SUP-PMV 005,CDM,L8501,HCPCS,274,RC,,,outpatient,,,429.46,300.622,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,188.78,,,188.78,52.37136,418.655068,fee schedule,,,
VALVE SPK PASSY-MUIR PMV 15X22MM LPRO REUS FLEX AQUA -,SUP-PMV 007,CDM,L8501,HCPCS,274,RC,,,outpatient,,,493.93,345.751,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,188.78,,,188.78,52.37136,418.655068,fee schedule,,,
VALVE SPK/SWALW IN G 15X23MM PASSY-MUIR PMV 1W  CLEAR -,SUP-PMV 2000,CDM,L8501,HCPCS,274,RC,,,outpatient,,,429.46,300.622,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,188.78,,,188.78,52.37136,418.655068,fee schedule,,,
VALVE PASSY MUIR PURPLE SPEAK SWALLOW IN G 15X23MM PMV -,SUP-PMV 2001,CDM,L8501,HCPCS,274,RC,,,outpatient,,,429.46,300.622,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,188.78,,,188.78,52.37136,418.655068,fee schedule,,,
VALVE SPK SHILEY 0.66MM MINI STRL MONOKA PHONATE W/O O2 PRT -,SUP-SSV,CDM,L8501,HCPCS,274,RC,,,outpatient,,,233.28,163.296,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,188.78,,,188.78,52.37136,418.655068,fee schedule,,,
PROSTHESIS VOCAL CRD BLOM-SINGER CLASSIC 20FRX8MM INDWL STRL -,SUP-IN 2008-SO,CDM,L8509,HCPCS,274,RC,,,outpatient,,,1378.13,964.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,125.65,,,125.65,125.65,1058.40384,fee schedule,,,
PROSTHESIS VOCAL CRD BLOM-SINGER 20FRX14MM INDWL STRL -,SUP-IN2014-SO,CDM,L8509,HCPCS,274,RC,,,outpatient,,,1378.13,964.691,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,125.65,,,125.65,125.65,1058.40384,fee schedule,,,
IMPLANT BRST 600ML SIL GEL HPRO RND 14CM MEMORYGEL 5.6CM -,SUP-350-6004BC,CDM,L8600,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,3409.78176,other,OPPS APC,,
BULKAMID URETHRAL BULKING SYSTEM -,SUP-50050,CDM,L8606,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,252.25,3748.3008,other,OPPS APC,,
COAPTITE SYRINGE 1ML -,SUP-M0068903000,CDM,L8606,HCPCS,278,RC,,,outpatient,,,1975.44,1382.808,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,252.25,3748.3008,other,OPPS APC,,
SPHERE EYE 18MM -,SUP-14254,CDM,L8610,HCPCS,278,RC,,,outpatient,,,315.09,220.563,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,70.737705,686.06,other,OPPS APC,,
IMPLANT OSS PRT WIET 1.14MM SHFT 3.25MMX5MM OFF-CTR HAP FLEX -,SUP-0516,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC,,
PROSTHESIS OSS PRT 4X5MM CTR HAP FLEX TI MLBL -,SUP-0550,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2565.44,1795.808,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC,,
MNP TOTAL TITANIUM .2 X 3.00MM -,SUP-1004434,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC,,
MNP TOTAL TITANIUM .2 X 3.5MM -,SUP-1004436,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC,,
OMEGA CONNECTOR 1.5MM X 8MMX0.5 -,SUP-1004930,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1219.12,853.384,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC,,
PROSTHESIS OSS ASTN PLAS-PR MOD PORP 3MM FLNG DIA 1MM SHFT -,SUP-14-0063,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1300.05,910.035,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC,,
PISTON OTO SCHKNT 0.8MMX4.25MM WIRE LOOP FLPLS SS -,SUP-14-0105,CDM,L8613,HCPCS,278,RC,,,outpatient,,,628.66,440.062,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC,,
LOOP WIRE HOUSE TYPE .12 X 4.0 -,SUP-140184,CDM,L8613,HCPCS,278,RC,,,outpatient,,,268.41,187.887,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC,,
LOOP WIRE HOUSE TYPE .12 X 4.25 -,SUP-140184,CDM,L8613,HCPCS,278,RC,,,outpatient,,,346.6,242.62,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC,,
PISTON OTO RCHRD 0.6MMX3.50MM RBN LOOP FLPLS PLTNM -,SUP-14-0781,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC,,
PISTON OTO RCHRD 0.6X4MM RBN LOOP FLPLS PLTNM -,SUP-14-0783,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC,,
PISTON OTO RCHRD 0.6MMX4.25MM RBN LOOP FLPLS PLTNM -,SUP-14-0784,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC,,
PISTON OTO RCHRD 0.8X4MM RBN LOOP FLPLS PLTNM -,SUP-14-0792,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1024.74,717.318,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC,,
PISTON OTO RCHRD 0.8MMX4.5MM RBN LOOP FLPLS PLTNM -,SUP-14-0794,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC,,
PLATE OSS MED 10MM POR HAP ATTIC DFCT -,SUP-14-0863,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1063.14,744.198,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC,,
PLATE OSS 14MM LRG POR HAP ATTIC DFCT -,SUP-14-0864,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1072.41,750.687,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC,,
PROSTHESIS OSS APLBM SM 2X2MM 1MM CANN HAP INCSTP -,SUP-14-0956,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2182.32,1527.624,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC,,
PROSTHESIS OSS PRT GLDNBRG 1.5MM 1.14MM FLLY CANN HAP EAR -,SUP-14-0963,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2038.36,1426.852,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC,,
PROSTHESIS OSS APLBM 2.5X3MM HAP INCUS -,SUP-14-0973,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2205.54,1543.878,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC,,
PROSTHESIS OSS RCHRD 0.4MM PSTN 1MM WELL 4.50MM CUP PED -,SUP-142152,CDM,L8613,HCPCS,278,RC,,,outpatient,,,761.58,533.106,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC,,
Eclipse Flat Ribbon Piston .6MM X 4.50MM -,SUP-472-450,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1863.34,1304.338,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC,,
Eclipse Flat Ribbon Piston .6MM X 4.75MM -,SUP-472-475,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1863.34,1304.338,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC,,
Eclipse Flat Ribbon Piston .6MM X 5.00MM -,SUP-472-500,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1863.34,1304.338,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC,,
PROSTHESIS OSS UM TORP 2X10MM CTR TI ADJ -,SUP-7014-1044,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1852.68,1296.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC,,
PROSTHESIS OSS UM TORP 2X5MM CTR TI ADJ -,SUP-7014-1046,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1852.68,1296.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC,,
PISTON OSS SMRT 0.6X4MM WIRE LOOP FLPLS NTNL STPS ADLT -,SUP-70145926,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1601.92,1121.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC,,
PISTON OSS SMRT 0.6MMX4.25MM WIRE LOOP FLPLS NTNL STPS ADLT -,SUP-70145927,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1601.92,1121.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC,,
PISTON OSS SMRT 0.6MMX4.50MM WIRE LOOP FLPLS NTNL STPS ADLT -,SUP-70145928,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1601.92,1121.344,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC,,
DISTANCE PLATES REPLACEMENT 0.1 /0.2 /0.3 -,SUP-8000140,CDM,L8613,HCPCS,278,RC,,,outpatient,,,723.54,506.478,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,60.258045,2016.5376,other,OPPS APC,,
JOINT FINGER SWANSON 1 MCP FLEXIBLE STERILE W/O GROMMETS SIL -,SUP-4700001,CDM,L8630,HCPCS,278,RC,,,outpatient,,,4602.62,3221.834,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,3534.81216,other,OPPS APC,,
IMPLANT PIP MCP SZ4 SWNSN SIL -,SUP-G470-0004,CDM,L8630,HCPCS,278,RC,,,outpatient,,,4413.76,3089.632,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,3534.81216,other,OPPS APC,,
PROSTHESIS PENL TOROSA LRG SAL FIL CYL INFL PRECNCT SCRT -,SUP-450-1329,CDM,L8699,HCPCS,278,RC,,,outpatient,,,8471.02,5929.714,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,163.74581,6505.74336,other,OPPS APC,,
PROSTHESIS TSTCLR 2.9CMX4.5IN -,SUP-96-450-1329,CDM,L8699,HCPCS,278,RC,,,outpatient,,,7002.6,4901.82,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,163.74581,6505.74336,other,OPPS APC,,
LEAD ANCHOR KIT -,SUP-ACCK5300,CDM,L8699,HCPCS,278,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,163.74581,6505.74336,other,OPPS APC,,
WEIGHT EYELID THN 0.6MM PLTNM 0.6GM SPHRCL CRV TAPR EDGE RND -,SUP-LL 6006,CDM,L8699,HCPCS,278,RC,,,outpatient,,,1749.17,1224.419,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,163.74581,6505.74336,other,OPPS APC,,
UROLIFT ATC IMPLANT CARTRIDGE -,SUP-UL2ATC-C,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4986.7,3490.69,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,163.74581,6505.74336,other,OPPS APC,,
IMPLANT CARTRIDGE UROLIFT -,SUP-UL2-C,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4350.1,3045.07,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,163.74581,6505.74336,other,OPPS APC,,
IMPLANT UROLOGICAL UROLIFT 2 CARTRIDGE -,SUP-UL2-C,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,163.74581,6505.74336,other,OPPS APC,,
IMPLANT HANDLE CARTRIDGE UROLIFT -,SUP-UL2-CHK,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,163.74581,6505.74336,other,OPPS APC,,
KIT HANDLE UROLIFT DELIVERY HANDLE IMPLANT CARTRIDGE -,SUP-UL2-CHK,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,163.74581,6505.74336,other,OPPS APC,,
HC Bebtelovimab Injection,PX-26000018,CDM,M0222,HCPCS,260,RC,,,outpatient,,,1455,1018.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,401.49775,,,401.49775,326.6475,1117.44,other,OPPS APC,,
HC Cryoprecipitate Each Unit,PX-39000006,CDM,P9012,CPT,390,RC,,,outpatient,,,1227,858.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,68.581085,,,68.581085,49.4,942.336,other,OPPS APC,,
HC RBC Leukocytes Reduced,PX-39000007,CDM,P9016,CPT,390,RC,,,outpatient,,,551,385.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,207.12931,,,207.12931,123.6995,423.168,other,OPPS APC,,
HC Plasma 1 Donor Frz W/in 8 Hr,PX-39000008,CDM,P9017,CPT,390,RC,,,outpatient,,,379,265.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,91.59418,,,91.59418,71.53,416.02,other,OPPS APC,,
HC Red Blood Cells Unit,PX-39000009,CDM,P9021,CPT,390,RC,,,outpatient,,,471,329.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,156.372205,,,156.372205,105.7395,416.02,other,OPPS APC,,
HC Washed Red Blood Cells Unit,PX-39000010,CDM,P9022,CPT,390,RC,,,outpatient,,,1028,719.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,454.90096,,,454.90096,163,871.3328,other,OPPS APC,,
HC Platelets Leukocytes Reduced,PX-39000011,CDM,P9031,CPT,390,RC,,,outpatient,,,1397,977.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,149.92304,,,149.92304,136.61,1072.896,other,OPPS APC,,
HC Platelets Leukoreduced Irrad,PX-39000012,CDM,P9033,CPT,390,RC,,,outpatient,,,1633,1143.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,264.186665,,,264.186665,163,1384.1308,other,OPPS APC,,
HC Platelet Pheres Leukoreduced,PX-39000013,CDM,P9035,CPT,390,RC,,,outpatient,,,1233,863.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,541.054015,,,541.054015,163,1119.53,other,OPPS APC,,
HC Plate Pheres Leukoredu Irrad,PX-39000014,CDM,P9037,CPT,390,RC,,,outpatient,,,1624,1136.8,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,770.32584,,,770.32584,163,1476.21,other,OPPS APC,,
HC RBC Deglycerolized,PX-39000015,CDM,P9039,CPT,390,RC,,,outpatient,,,2586,1810.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,356.376505,,,356.376505,163,2191.8936,other,OPPS APC,,
HC RBC Leukoreduced Irradiated,PX-39000016,CDM,P9040,CPT,390,RC,,,outpatient,,,636,445.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,289.21584,,,289.21584,142.782,598.2,other,OPPS APC,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,68516-5214-01,NDC,outpatient,250,ML,168.42,117.894,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7997035,,,60.7997035,25.321355,416.02,other,OPPS APC,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,76125-0790-25,NDC,outpatient,250,ML,171.75,120.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7997035,,,60.7997035,25.321355,416.02,other,OPPS APC,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,44206-0310-25,NDC,outpatient,250,ML,199.57,139.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7997035,,,60.7997035,25.321355,416.02,other,OPPS APC,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,44206-0310-90,NDC,outpatient,250,ML,199.57,139.699,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7997035,,,60.7997035,25.321355,416.02,other,OPPS APC,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,68516-5214-03,NDC,outpatient,250,ML,168.42,117.894,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7997035,,,60.7997035,25.321355,416.02,other,OPPS APC,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,76125-0790-26,NDC,outpatient,250,ML,171.75,120.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7997035,,,60.7997035,25.321355,416.02,other,OPPS APC,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,00944-0495-05,NDC,outpatient,250,ML,112.79,78.953,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7997035,,,60.7997035,25.321355,416.02,other,OPPS APC,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,00944-0495-06,NDC,outpatient,250,ML,112.79,78.953,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7997035,,,60.7997035,25.321355,416.02,other,OPPS APC,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,68982-0623-03,NDC,outpatient,500,ML,363.1,254.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7997035,,,60.7997035,25.321355,416.02,other,OPPS APC,,
ALBUMIN HUMAN 5 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8982,CDM,P9045,HCPCS,636,RC,68982-0623-03,NDC,outpatient,500,ML,347.1,242.97,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,60.7997035,,,60.7997035,25.321355,416.02,other,OPPS APC,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-04,NDC,outpatient,100,ML,48.49,33.943,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,64208-2512-07,NDC,outpatient,100,ML,309.7,216.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-00,NDC,outpatient,100,ML,309.7,216.79,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-02,NDC,outpatient,100,ML,320.83,224.581,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC,,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-02,NDC,outpatient,100,ML,32.49,22.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC,,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-04,NDC,outpatient,100,ML,304.83,213.381,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-01,NDC,outpatient,50,ML,209.58,146.706,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-04,NDC,outpatient,100,ML,320.83,224.581,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-08,NDC,outpatient,100,ML,430.3,301.21,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC,,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,64208-2512-07,NDC,outpatient,100,ML,293.7,205.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-03,NDC,outpatient,50,ML,209.58,146.706,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-01,NDC,outpatient,50,ML,168.42,117.894,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-03,NDC,outpatient,50,ML,168.42,117.894,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC,,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-00,NDC,outpatient,100,ML,293.7,205.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC,,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-02,NDC,outpatient,100,ML,304.83,213.381,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-02,NDC,outpatient,100,ML,48.49,33.943,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC,,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-04,NDC,outpatient,100,ML,32.49,22.743,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC,,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-08,NDC,outpatient,100,ML,414.3,290.01,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],JW,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC,,
HC Platelets- Hla-M- L/R- Unit,PX-39000026,CDM,P9052,HCPCS,390,RC,,,outpatient,,,1807,1264.9,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,825.527485,,,825.527485,163,1698,other,OPPS APC,,
HC RBC- Frz/Deg/Wsh- L/R- Irrad,PX-39000023,CDM,P9057,CPT,390,RC,,,outpatient,,,2062,1443.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,564.38785,,,564.38785,163,1747.7512,other,OPPS APC,,
HC RBC- L/R- Cmv-Neg- Irrad,PX-39000024,CDM,P9058,CPT,390,RC,,,outpatient,,,1235,864.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,277.05063,,,277.05063,163,1046.786,other,OPPS APC,,
HC Plasma- Frz Between 8-24hour,PX-39000025,CDM,P9059,CPT,390,RC,,,outpatient,,,222,155.4,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,83.128935,,,83.128935,49.839,416.02,other,OPPS APC,,
HC Platelets- Pheresis- Pathogen-Reduced- Each Unit,PX-39000028,CDM,P9073,HCPCS,390,RC,,,outpatient,,,1626,1138.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,631.49124,,,631.49124,163,1265.41,other,OPPS APC,,
HC Pathogen Test for Platelets,PX-30000897,CDM,P9100,HCPCS,300,RC,,,outpatient,,,89,62.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,66.75974,,,66.75974,19.9805,416.02,other,OPPS APC,,
FERUMOXYTOL 510 MG/17ML IV SOLN,RX-98312,CDM,Q0138,HCPCS,636,RC,59338-0775-01,NDC,outpatient,17,ML,945.71,661.997,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.387179,,,0.387179,0.34,726.30528,other,OPPS APC,,
ONDANSETRON HCL 4 MG ORAL TABS,RX-10778,CDM,Q0162,HCPCS,259,RC,00904-6551-61,NDC,outpatient,1,UN,1.57,1.099,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.01,416.02,other,OPPS APC,,
ONDANSETRON 4 MG ORAL TBDP,RX-27697,CDM,Q0162,HCPCS,259,RC,68462-0157-13,NDC,outpatient,1,UN,0.99,0.693,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.01,416.02,other,OPPS APC,,
ONDANSETRON 4 MG ORAL TBDP,RX-27697,CDM,Q0162,HCPCS,259,RC,68462-0157-40,NDC,outpatient,1,UN,0.99,0.693,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.01,416.02,other,OPPS APC,,
ONDANSETRON 4 MG ORAL TBDP,RX-27697,CDM,Q0162,HCPCS,259,RC,65862-0390-10,NDC,outpatient,1,UN,0.99,0.693,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.01,416.02,other,OPPS APC,,
PROCHLORPERAZINE MALEATE 5 MG ORAL TABS,RX-6583,CDM,Q0164,HCPCS,259,RC,50268-0684-15,NDC,outpatient,1,UN,3.56,2.492,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.35,416.02,other,OPPS APC,,
PROCHLORPERAZINE MALEATE 5 MG ORAL TABS,RX-6583,CDM,Q0164,HCPCS,259,RC,50268-0684-11,NDC,outpatient,1,UN,3.56,2.492,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.35,416.02,other,OPPS APC,,
DRONABINOL 2.5 MG ORAL CAPS,RX-9904,CDM,Q0167,HCPCS,259,RC,60687-0375-11,NDC,outpatient,1,UN,18.82,13.174,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.73,416.02,other,OPPS APC,,
DRONABINOL 2.5 MG ORAL CAPS,RX-9904,CDM,Q0167,HCPCS,259,RC,60687-0375-21,NDC,outpatient,1,UN,18.82,13.174,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.73,416.02,other,OPPS APC,,
PROMETHAZINE HCL 25 MG ORAL TABS,RX-6622,CDM,Q0169,HCPCS,259,RC,68382-0041-01,NDC,outpatient,1,UN,0.99,0.693,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
PROMETHAZINE HCL 25 MG ORAL TABS,RX-6622,CDM,Q0169,HCPCS,259,RC,00904-7304-61,NDC,outpatient,1,UN,0.99,0.693,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.09,416.02,other,OPPS APC,,
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,00069-6001-21,NDC,outpatient,10,ML,77.92,54.544,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3.6656,,,3.6656,2.55,416.02,other,OPPS APC,,
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,63323-0403-02,NDC,outpatient,2,ML,19.75,13.825,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3.6656,,,3.6656,2.55,416.02,other,OPPS APC,,
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,00069-6001-10,NDC,outpatient,10,ML,77.92,54.544,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3.6656,,,3.6656,2.55,416.02,other,OPPS APC,,
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,63323-0403-01,NDC,outpatient,2,ML,19.75,13.825,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,3.6656,,,3.6656,2.55,416.02,other,OPPS APC,,
DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ,RX-27431,CDM,Q2050,HCPCS,636,RC,00338-0067-01,NDC,outpatient,25,ML,1408.44,985.908,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,152.44314,,,152.44314,87.98,1653.428703,other,OPPS APC,,
DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ,RX-27431,CDM,Q2050,HCPCS,636,RC,47335-0050-40,NDC,outpatient,25,ML,1589.76,1112.832,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,152.44314,,,152.44314,87.98,1653.428703,other,OPPS APC,,
IMPLANT TY I COLL 1X1IN DURAMATRIX-ONLAY -,SUP-CDSLM11,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,1553.95,1087.765,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,348.861775,3862.93248,other,OPPS APC,,
DURAMATRIX SUTURABLE 2 X 2 -,SUP-DMS22,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,2490.5,1743.35,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,348.861775,3862.93248,other,OPPS APC,,
DURAMATRIX SUTURABLE  3x3 -,SUP-DMS33,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,4042.29,2829.603,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,348.861775,3862.93248,other,OPPS APC,,
DURAMATRIX SUTURABLE 4 X 5 -,SUP-DMS45,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,5029.86,3520.902,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,348.861775,3862.93248,other,OPPS APC,,
HC Skin Apligraf,PX-63600004,CDM,Q4101,HCPCS,636,RC,,,outpatient,,,8745,6121.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,30.42,6716.16,other,OPPS APC,,
HC Matrix Wound Oasis by Sq Cm,PX-63600006,CDM,Q4102,HCPCS,636,RC,,,outpatient,,,65,45.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.25,659.42016,other,OPPS APC,,
DRESSING WND 3 X 3.5CM OASIS WND MATRIX -,SUP-8213-1000-33,CDM,Q4102,CPT,278,RC,,,outpatient,,,858.62,601.034,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,12.25,659.42016,other,OPPS APC,,
INTEGRA BILAYER MATRIX WOUND DRESSING 4 x 5 -,SUP-BMW4051,CDM,Q4104,HCPCS,278,RC,,,outpatient,,,24698.88,17289.216,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.96,24594.91584,other,OPPS APC,,
MATRIX MESHED BILAYER 2X2 INTE -,SUP-MWM2021,CDM,Q4104,HCPCS,278,RC,,,outpatient,,,20440.07,14308.049,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.96,24594.91584,other,OPPS APC,,
MATRIX MESH BILAYER 4 X 5 -,SUP-MWM4051,CDM,Q4104,HCPCS,278,RC,,,outpatient,,,32024.63,22417.241,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,48.96,24594.91584,other,OPPS APC,,
HC Primatrix Mesh by Sq Cm,PX-63600008,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,186,130.2,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.757,4074.24,other,OPPS APC,,
PRIMATRIX 0.2 x 26.5 ROPE 3 UNITS/BOX -,SUP-607-001-009,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,2157.3,1510.11,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.757,4074.24,other,OPPS APC,,
PRIMATRIX 2X2 MESHED -,SUP-607-005-220,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,2364.02,1654.814,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.757,4074.24,other,OPPS APC,,
PRIMATRIX 3X3 MESHED -,SUP-607-005-330,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,2506.35,1754.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.757,4074.24,other,OPPS APC,,
PRIMATRIX 4 X 4CM  MESH -,SUP-607-005-440,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,3074.46,2152.122,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.757,4074.24,other,OPPS APC,,
PRIMATRIX 6 X 6 MESH -,SUP-607-005-660,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,5305,3713.5,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.757,4074.24,other,OPPS APC,,
PRIMATRIX 4X4 AG -,SUP-UNDEFINED,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,41.757,4074.24,other,OPPS APC,,
ALLODERM LARGE THK1.04-2.28 MM THICK L12 CM X W4 CM 48CM2 -,SUP-102050,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,5700.37,3990.259,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,31.11,14996.48256,other,OPPS APC,,
ALLODERM LARGE THK2-2.8 MM THICK L12CM X W6CM 72CM2 -,SUP-151972,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,4655.67,3258.969,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,31.11,14996.48256,other,OPPS APC,,
GRAFT SOFT TISSUE AXIS TUTOPLAST DERMIS 12CM X 8CM ALLODERM -,SUP-939812,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,10961.89,7673.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,31.11,14996.48256,other,OPPS APC,,
ALLODERM CONTOUR LARGE PERF L21.5 CM X W10 230.05CM2 -,SUP-CL1519P,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,19526.67,13668.669,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,31.11,14996.48256,other,OPPS APC,,
ALLODERM CONTOUR MED PERF THICK 19.3 CM X 9.6 CM 185.28CM2 -,SUP-CM1519P,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,15267.86,10687.502,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,31.11,14996.48256,other,OPPS APC,,
ACELL MICROMATRIX POWDER 200MG -,SUP-MM0200,CDM,Q4118,HCPCS,278,RC,,,outpatient,,,2929.8,2050.86,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.5,8051.0208,other,OPPS APC,,
ACELL MICRO MATRIX 500 MG -,SUP-MM0500,CDM,Q4118,HCPCS,278,RC,,,outpatient,,,5728.55,4009.985,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.5,8051.0208,other,OPPS APC,,
ACELL MICRO MATRIX 1000 MG -,SUP-MM1000,CDM,Q4118,HCPCS,278,RC,,,outpatient,,,10483.1,7338.17,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,2.5,8051.0208,other,OPPS APC,,
SURGICLOSE MICRO 38CM2 -,SUP-50205P04D0D,CDM,Q4121,HCPCS,636,RC,,,outpatient,,,8488,5941.6,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,46.98,6518.784,other,OPPS APC,,
HC Matrix Wound Oasis Ultra by Sq Cm,PX-63600010,CDM,Q4124,HCPCS,636,RC,,,outpatient,,,61,42.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.16,4034.304,other,OPPS APC,,
HC Matrix Oasis Ultra 7 X 10,PX-63600014,CDM,Q4124,HCPCS,636,RC,,,outpatient,,,5253,3677.1,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,9.16,4034.304,other,OPPS APC,,
GRAFT ARTHROFLEX DERMIS THK1.5MM 35MM X 35MM 12.25CM2 -,SUP-AFLEX100,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,7779.25,5445.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,209.5932,10851.38688,other,OPPS APC,,
DERMIS DECELLULARIZED 35MM X 35MM X 2.0MM 12.25SQCM -,SUP-AFLEX200,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,11781.35,8246.945,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,209.5932,10851.38688,other,OPPS APC,,
ARTHROFLEX 40MM X 70MM X 3.0 DERMIS DECELLULARIZED 28SQCM -,SUP-AFLEX301,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,14129.41,9890.587,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,209.5932,10851.38688,other,OPPS APC,,
ARTHROFLEX 25 X 30 X 1MM 7.5SQCM -,SUP-AFLEX403,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,933.6,653.52,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,209.5932,10851.38688,other,OPPS APC,,
CONNECT PRE-SUTURED TENDON-ZORC 4.5 x 160MM -,SUP-FCON,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,5187.44,3631.208,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,209.5932,10851.38688,other,OPPS APC,,
SURGICLOSE 7 X 10CM- 70SQCM -,SUP-50205N03D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,16121.85,11285.295,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.06,20434.45248,other,OPPS APC,,
SURGICLOSE 6 X 8 MESHED 2:1 UP TO 86CM2 -,SUP-50205N18D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,10804.83,7563.381,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.06,20434.45248,other,OPPS APC,,
SURGICLOSE MESHED 2:1 4X6 CM- 24SQCM -,SUP-50205N20D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,6934.7,4854.29,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.06,20434.45248,other,OPPS APC,,
SURGICLOSE MESHED 7 X 20 -,SUP-50205N21D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,26607.36,18625.152,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.06,20434.45248,other,OPPS APC,,
SURGICLOSE MICRO 95 CM2 -,SUP-50205P31D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,15965.9,11176.13,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,3.06,20434.45248,other,OPPS APC,,
ACELL WOUND/BURN MATRIX 2 LAYER -,SUP-BMM0710,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,4509.25,3156.475,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,18.9,9453.0048,other,OPPS APC,,
CYTAL BURN MATRIX -,SUP-BMM1015,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,8116.65,5681.655,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,18.9,9453.0048,other,OPPS APC,,
CYTAL WOUND MATRIX 1 LAYER 3 X 7CM -,SUP-WS0307,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,853.08,597.156,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,18.9,9453.0048,other,OPPS APC,,
MATRIX WOUND ACELL GENTRIX 5M X 5CM 25CM2 3 LAYERS -,SUP-WSR0505,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,4118.77,2883.139,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,18.9,9453.0048,other,OPPS APC,,
WOUND MATRIX CYTEL 3 LAYER 7 X 10CM -,SUP-WSR0710,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,8206.84,5744.788,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,18.9,9453.0048,other,OPPS APC,,
WOUND MATRIX 3 LAYER 10 X 15CM -,SUP-WSR1015,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,12308.6,8616.02,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,18.9,9453.0048,other,OPPS APC,,
ACELL WOUND MATRIX 6-LAYER MESH -,SUP-WSX0505,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,4869.99,3408.993,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,18.9,9453.0048,other,OPPS APC,,
CYTAL WOUND MATRIX 6 LAYER 7 X 10CM -,SUP-WSX0710,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,9562.83,6693.981,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,18.9,9453.0048,other,OPPS APC,,
HC Epifix- per Square Centimeter,PX-63600024,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,501,350.7,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,112.4745,3643.99872,other,OPPS APC,,
EPIFIX DISK 14MM -,SUP-GS-5140,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,1746.51,1222.557,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,112.4745,3643.99872,other,OPPS APC,,
EPIFIX DISK 18MM -,SUP-GS-5180,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,3733.27,2613.289,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,112.4745,3643.99872,other,OPPS APC,,
EPIFIX 2 X 2 CM -,SUP-GS-5220,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,4744.79,3321.353,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,112.4745,3643.99872,other,OPPS APC,,
PURAPLY AM 2CMX2CM -,SUP-00000000000000000000000000000,CDM,Q4196,HCPCS,636,RC,,,outpatient,,,4057.9,2840.53,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,102.28,3422.3616,other,OPPS APC,,
PURAPLY AM 2CMX4CM -,SUP-PURAPLYAM-COM 2X4,CDM,Q4196,HCPCS,636,RC,,,outpatient,,,4456.2,3119.34,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,102.28,3422.3616,other,OPPS APC,,
FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY,RX-132201,CDM,Q5101,HCPCS,636,RC,61314-0318-01,NDC,outpatient,0.5,ML,603.11,422.177,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.414671,,,0.414671,0.18,741.12768,other,OPPS APC,,
FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY,RX-132201,CDM,Q5101,HCPCS,636,RC,61314-0318-05,NDC,outpatient,0.5,ML,603.14,422.198,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.414671,,,0.414671,0.18,741.12768,other,OPPS APC,,
FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY,RX-132201,CDM,Q5101,HCPCS,636,RC,61314-0318-10,NDC,outpatient,0.5,ML,603.14,422.198,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.414671,,,0.414671,0.18,741.12768,other,OPPS APC,,
FILGRASTIM-SNDZ 480 MCG/0.8ML IJ SOSY,RX-132202,CDM,Q5101,HCPCS,636,RC,61314-0326-10,NDC,outpatient,0.8,ML,965.01,675.507,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.414671,,,0.414671,0.18,741.12768,other,OPPS APC,,
FILGRASTIM-SNDZ 480 MCG/0.8ML IJ SOSY,RX-132202,CDM,Q5101,HCPCS,636,RC,61314-0326-05,NDC,outpatient,0.8,ML,965.01,675.507,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,0.414671,,,0.414671,0.18,741.12768,other,OPPS APC,,
INFLIXIMAB-DYYB 100 MG IV SOLR,RX-136637,CDM,Q5103,HCPCS,636,RC,00069-0809-01,NDC,outpatient,1,UN,1389.66,972.762,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,15.599419,,,15.599419,13.62,1653.428703,other,OPPS APC,,
INFLIXIMAB-ABDA 100 MG IV SOLR,RX-139995,CDM,Q5104,HCPCS,636,RC,00006-4305-01,NDC,outpatient,1,UN,1902.38,1331.666,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,31.136981,,,31.136981,27.18,1653.428703,other,OPPS APC,,
INFLIXIMAB-ABDA 100 MG IV SOLR,RX-139995,CDM,Q5104,HCPCS,636,RC,00006-4305-02,NDC,outpatient,1,UN,1902.38,1331.666,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,31.136981,,,31.136981,27.18,1653.428703,other,OPPS APC,,
EPOETIN ALFA-EPBX 2000 UNIT/ML IJ SOLN,RX-143174,CDM,Q5106,HCPCS,636,RC,00069-1305-10,NDC,outpatient,1,ML,79.46,55.622,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8.726419,,,8.726419,7.5,416.02,other,OPPS APC,,
EPOETIN ALFA-EPBX 2000 UNIT/ML IJ SOLN,RX-143174,CDM,Q5106,HCPCS,636,RC,00069-1305-01,NDC,outpatient,1,ML,79.46,55.622,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8.726419,,,8.726419,7.5,416.02,other,OPPS APC,,
EPOETIN ALFA-EPBX 3000 UNIT/ML IJ SOLN,RX-143175,CDM,Q5106,HCPCS,636,RC,00069-1306-10,NDC,outpatient,1,ML,119.19,83.433,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8.726419,,,8.726419,7.5,416.02,other,OPPS APC,,
EPOETIN ALFA-EPBX 3000 UNIT/ML IJ SOLN,RX-143175,CDM,Q5106,HCPCS,636,RC,00069-1306-01,NDC,outpatient,1,ML,119.19,83.433,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8.726419,,,8.726419,7.5,416.02,other,OPPS APC,,
EPOETIN ALFA-EPBX 4000 UNIT/ML IJ SOLN,RX-143176,CDM,Q5106,HCPCS,636,RC,00069-1307-01,NDC,outpatient,1,ML,158.92,111.244,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8.726419,,,8.726419,7.5,416.02,other,OPPS APC,,
EPOETIN ALFA-EPBX 4000 UNIT/ML IJ SOLN,RX-143176,CDM,Q5106,HCPCS,636,RC,00069-1307-10,NDC,outpatient,1,ML,158.92,111.244,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8.726419,,,8.726419,7.5,416.02,other,OPPS APC,,
EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN,RX-143177,CDM,Q5106,HCPCS,636,RC,00069-1308-10,NDC,outpatient,1,ML,377.7,264.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8.726419,,,8.726419,7.5,416.02,other,OPPS APC,,
EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN,RX-143177,CDM,Q5106,HCPCS,636,RC,00069-1308-01,NDC,outpatient,1,ML,377.7,264.39,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8.726419,,,8.726419,7.5,416.02,other,OPPS APC,,
EPOETIN ALFA-EPBX 40000 UNIT/ML IJ SOLN,RX-143178,CDM,Q5106,HCPCS,636,RC,00069-1309-01,NDC,outpatient,0.05,ML,75.54,52.878,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8.726419,,,8.726419,7.5,416.02,other,OPPS APC,,
EPOETIN ALFA-EPBX 40000 UNIT/ML IJ SOLN,RX-143178,CDM,Q5106,HCPCS,636,RC,00069-1309-04,NDC,outpatient,0.05,ML,75.54,52.878,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,8.726419,,,8.726419,7.5,416.02,other,OPPS APC,,
RITUXIMAB-ABBS 10 MG/ML IV SOLN WRAPPER,RX-4081244,CDM,Q5115,HCPCS,636,RC,63459-0103-10,NDC,outpatient,10,ML,1691.22,1183.854,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,38.481927,,,38.481927,33.59,7269.974281,other,OPPS APC,,
RITUXIMAB-ABBS 10 MG/ML IV SOLN WRAPPER,RX-4081244,CDM,Q5115,HCPCS,636,RC,63459-0104-50,NDC,outpatient,50,ML,6662.37,4663.659,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,38.481927,,,38.481927,33.59,7269.974281,other,OPPS APC,,
INFLIXIMAB-AXXQ 100 MG IV SOLR,RX-150921,CDM,Q5121,HCPCS,636,RC,55513-0670-01,NDC,outpatient,1,UN,2071.48,1450.036,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,24.387695,,,24.387695,21.29,1590.89664,other,OPPS APC,,
MEDIA CONTR PRFLTRN LPD MICSPHR INJ SUSP VL DEFINITY -,SUP-DE16,CDM,Q9957,CPT,636,RC,,,outpatient,,,554.33,388.031,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,40.92,438.4896,other,OPPS APC,,
DEFINITY DE-4 -,SUP-DE4,CDM,Q9957,CPT,636,RC,,,outpatient,,,570.95,399.665,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,40.92,438.4896,other,OPPS APC,,
DIATRIZOATE MEGLUMINE & SODIUM 66-10 % ORAL SOLN,RX-9828,CDM,Q9963,HCPCS,636,RC,00270-0445-40,NDC,outpatient,7.5,ML,3.71,2.597,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.22,416.02,other,OPPS APC,,
IOHEXOL 180 MG/ML IJ SOLN,RX-10319,CDM,Q9965,HCPCS,636,RC,00407-1411-10,NDC,outpatient,3,ML,16.35,11.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.56,416.02,other,OPPS APC,,
IOHEXOL 180 MG/ML IJ SOLN,RX-10319,CDM,Q9965,HCPCS,636,RC,99999-0004-10,NDC,outpatient,3,ML,16.35,11.445,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,1.56,416.02,other,OPPS APC,,
IOPAMIDOL 41 % IJ SOLN,RX-10325,CDM,Q9966,HCPCS,636,RC,00270-1411-11,NDC,outpatient,10,ML,98.1,68.67,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.38,416.02,other,OPPS APC,,
IOHEXOL 240 MG/ML IJ SOLN,RX-119843,CDM,Q9966,HCPCS,636,RC,00407-1412-30,NDC,outpatient,10,ML,32.7,22.89,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.38,416.02,other,OPPS APC,,
IOHEXOL 240 MG/ML IJ SOLN,RX-119843,CDM,Q9966,HCPCS,636,RC,00407-1412-33,NDC,outpatient,10,ML,32.7,22.89,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.38,416.02,other,OPPS APC,,
IOHEXOL 240 MG/ML IJ SOLN,RX-119843,CDM,Q9966,HCPCS,636,RC,99999-0004-07,NDC,outpatient,10,ML,32.7,22.89,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.38,416.02,other,OPPS APC,,
IOPAMIDOL 61 % IJ SOLN,RX-10327,CDM,Q9967,HCPCS,636,RC,00270-1412-15,NDC,outpatient,15,ML,81.75,57.225,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.14,416.02,other,OPPS APC,,
IOPAMIDOL 76 % IV SOLN,RX-10328,CDM,Q9967,HCPCS,636,RC,00270-1316-35,NDC,outpatient,50,ML,272.5,190.75,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.14,416.02,other,OPPS APC,,
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,99999-0004-09,NDC,outpatient,5,ML,10.9,7.63,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.14,416.02,other,OPPS APC,,
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-10,NDC,outpatient,5,ML,10.9,7.63,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.14,416.02,other,OPPS APC,,
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-58,NDC,outpatient,5,ML,10.9,7.63,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.14,416.02,other,OPPS APC,,
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-59,NDC,outpatient,5,ML,10.9,7.63,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.14,416.02,other,OPPS APC,,
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-61,NDC,outpatient,5,ML,10.9,7.63,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.14,416.02,other,OPPS APC,,
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-63,NDC,outpatient,5,ML,10.9,7.63,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.14,416.02,other,OPPS APC,,
IOPAMIDOL 61 % IV SOLN,RX-27737,CDM,Q9967,HCPCS,636,RC,00270-1315-25,NDC,outpatient,30,ML,163.5,114.45,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.14,416.02,other,OPPS APC,,
IOVERSOL 68 % IJ SOLN,RX-39700,CDM,Q9967,HCPCS,636,RC,00019-1323-02,NDC,outpatient,20,ML,109,76.3,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,0.14,416.02,other,OPPS APC,,
ISOSULFAN BLUE 1 % SC SOLN,RX-10358,CDM,Q9968,HCPCS,636,RC,67457-0220-00,NDC,outpatient,5,ML,2840.8,1988.56,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9.775697,,,9.775697,9.53,2181.7344,other,OPPS APC,,
ISOSULFAN BLUE 1 % SC SOLN,RX-10358,CDM,Q9968,HCPCS,636,RC,67457-0220-05,NDC,outpatient,5,ML,2840.8,1988.56,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,9.775697,,,9.775697,9.53,2181.7344,other,OPPS APC,,
IOL 16D 5.5X12.5MM PMMA AC CNVXPLN ACRYSOF MTA3U0 -,SUP-MTA3U0.160,CDM,V2630,HCPCS,276,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,129.686915,921.62304,other,OPPS APC,,
IOL 9.5D 5.5MMX12.5MM AC CNVXPLN -,SUP-MTA3UO.095,CDM,V2630,HCPCS,276,RC,,,outpatient,,,577.67,404.369,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,129.686915,921.62304,other,OPPS APC,,
IOL 10.5D 5.5MMX12.5MM AC CNVXPLN -,SUP-MTA3UO.105,CDM,V2630,HCPCS,276,RC,,,outpatient,,,577.67,404.369,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,129.686915,921.62304,other,OPPS APC,,
IOL 20D 5.5MMX12.5MM AC CNVXPLN -,SUP-MTA3UO.200,CDM,V2630,HCPCS,276,RC,,,outpatient,,,1200.03,840.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,129.686915,921.62304,other,OPPS APC,,
IOL 22D 5.5X13MM AC CNVXPLN -,SUP-MTA4UO.220,CDM,V2630,HCPCS,276,RC,,,outpatient,,,1200.03,840.021,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,129.686915,921.62304,other,OPPS APC,,
IOL 12.5D 5.5MMX13.5MM AC CNVXPLN -,SUP-MTA5U0.125,CDM,V2630,HCPCS,276,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,129.686915,921.62304,other,OPPS APC,,
IOL 10.5D X 13.5OP AC CNVXPLN -,SUP-MTA5UO.105,CDM,V2630,HCPCS,276,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,129.686915,921.62304,other,OPPS APC,,
IOL 8.5D PC -,SUP-AR40MN085,CDM,V2632,HCPCS,276,RC,,,outpatient,,,1021.13,714.791,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 23D 6X13MM CLARIFLEX CLRFLXC 3PC PC BICNVX SIL BLU COR -,SUP-CLRFLXC.230,CDM,V2632,HCPCS,276,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 26.5D CLARIFLEX PC -,SUP-CLRFLXC.265,CDM,V2632,HCPCS,276,RC,,,outpatient,,,612.68,428.876,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 16.5D 6X13MM ACRYSF MA60AC 3PC PC BICNVX BLU ACRYLT -,SUP-MA60AC.165,CDM,V2632,HCPCS,276,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL +1D 6X13MM ACRYSF MA60MA MULPC PC MNSCS BLU ACRYLT -,SUP-MA60MA.010,CDM,V2632,HCPCS,276,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 3D 6X13MM ACRYSF MA60MA MULPC PC MNSCS BLU ACRYLT -,SUP-MA60MA.030,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL -4D 6X13MM ACRYSF XPD SRS MULPC PC BICNVX BLU ACRYLT -,SUP-MA60MA-4.0,CDM,V2632,HCPCS,276,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
LENS I/O X.010 NEGATIVE D -,SUP-MA60MAN010,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 4D 6X13MM ACRYSF XPD SRS MULPC PC BICNVX BLU ACRYLT -,SUP-MA60MAN040,CDM,V2632,HCPCS,276,RC,,,outpatient,,,729.38,510.566,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
LENS I/O MN60AC X 8.0 -,SUP-MN60AC.080,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 28D 6X13MM ACRYSF MN60AC MULPC PC BICNVX NAT YEL ACRYLT -,SUP-MN60AC.280,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 2.0 DIA 6X13MM ACRYSF XPD SRS MULPC PC MNSCS NAT -,SUP-MN60MA.020,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 3D 6X13MM ACRYSF XPD SRS MULPC PC MNSCS NAT -,SUP-MN60MA.030,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
LENS IOL 5.0D MN60MA 6X13MM ACRYSF MULPC PC MNSCS BLU ACRYLT -,SUP-MN60MA.050,CDM,V2632,HCPCS,276,RC,,,outpatient,,,875.25,612.675,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 9D 6X13MM ACRYSF SA60AT 1-PC PC BICNVX CLR ACRYLT -,SUP-SA60AT.090,CDM,V2632,HCPCS,276,RC,,,outpatient,,,781.89,547.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 30D 6X13MM ACRYSF 1-PC PC BICNVX NAT ANT ASYM -,SUP-SN60AT.300,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 31D 6X13MM 31  ACRYSF SA60AT 1-PC PC BICNVX CLR ACRYLT -,SUP-SN60AT.310,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 34D 6X13MM ACRYSF SA60AT 1-PC PC BICNVX CLR ACRYLT -,SUP-SN60AT.340,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 6.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.065,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 7D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.070,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 9D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.090,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 9.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.095,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 10D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.100,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 10.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.105,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 11D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.110,CDM,V2632,HCPCS,276,RC,,,outpatient,,,781.89,547.323,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 11.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.115,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 12D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.120,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 13D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.130,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 13.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.135,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 14D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.140,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 14.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.145,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 16D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.160,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 16.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.165,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 17D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.170,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 17.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.175,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 18D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.180,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 19D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.190,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 20D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.200,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 21D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.210,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 21.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.215,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 22D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.220,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 22.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.225,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 23D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.230,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 24D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.240,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 24.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.245,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 25D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.250,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 26D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.260,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 26.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.265,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 19D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.190,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 20D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.200,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 20.5D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.205,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 21D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.210,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 21.5D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.215,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
LENS I/O MA60MA x 1.0 -,SUP-UNDEFINED,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 24.5D 6X13MM TECNIS ZA9003 3PC PC BICNVX HYDRPHB ACRL -,SUP-ZA9003.245,CDM,V2632,HCPCS,276,RC,,,outpatient,,,816.9,571.83,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,137.54666,3281.45664,other,OPPS APC,,
LENS ACRYSOF TORIC IQ  SN6AT3 X 9.5D -,SUP-SN6AT3.095,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,,,
IOL TORIC LENS  SN6AT3  12.0 -,SUP-SN6AT3.120,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,,,
IOL 15.5D 6X13MM ACRYSF SN6AT3 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT3.155,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,,,
IOL 16.0D  6X13MM ACRYSF  SN6AT3 -,SUP-SN6AT3.160,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,,,
IOL 17.0D  6X13MM ACRYSF  SN6AT3 -,SUP-SN6AT3.170,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,,,
IOL 18.0 D 6X13MM ACRYSF SN6AT3 -,SUP-SN6AT3.180,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,,,
IOL 19.5D 6X13MM ACRYSF SN6AT3 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT3.195,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,,,
IOL 24D 6X13MM ACRYSF  SN6 -,SUP-SN6AT3.240,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,,,
IOL 13.5D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.135,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,,,
IOL 19D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.190,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,,,
IOL 19.5D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.195,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,,,
IOL 21D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.210,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,,,
IOL 16D 6X13MM ACRYSF SN6AT5 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT5.160,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,,,
LENS ACRYSOF IQ  SN6AT5.180 -,SUP-SN6AT5.180,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,,,
IOL 21D 6X13MM ACRYSF SN6AT5 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT5.210,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,,,
IOL 23D 6X13MM ACRYSF SN6AT5 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT5.230,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,,,
IOL 11D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT6.110,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,,,
IOL 13.5D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT -,SUP-SN6AT6.135,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,,,
IOL 14D 6X13MM  ACRYSF  SN6AT6 -,SUP-SN6AT6.140,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,,,
IOL LENS SN6AT6 X 18.0 D -,SUP-SN6AT6.180,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,,,
IOL 20D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT6.200,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,,,
IOL 20.5D 6X13MM ACRYSF SN6AT6 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT6.205,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2093.7,1465.59,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,,,
IOL TORIC LENS 23.5 DIOPTER -,SUP-SN6AT6.235,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,,,
IOL 22D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT6U220,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,,,
IOL 20D 6X13MM  ACRYSF -,SUP-SN6AT7.200,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,,,
IOL 23.5D  6X13MM  ACRYSF   SN6AT7 -,SUP-SN6AT7.235,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,2223.8905,,,,
AMNIOGRAFT AMNIO MEMBR HUM TIS FRZN 3.5X3.5CM SZ-C -,SUP-AG-3535,CDM,V2790,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,3992.7552,other,OPPS APC,,
GRAFT HUM TIS 3.5X3.5CM SZ-C AMNIOGRFT AMNIO MEMBR 50-100U -,SUP-AG-3535F,CDM,V2790,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],,,,,,399.86,3992.7552,other,OPPS APC,,
Bilateral procedure,,,,,,,,,,,,,,AETNA MEDICARE MANAGED CARE [1010301],AETNA MEDICARE MANAGED CARE [101030101],50,,150,,,,,,150% payment adjustment for the item or service to which the modifier is appended.,,
HC Semi-Private Unit,PX-12100001,CDM,12100001,LOCAL,121,RC,,,inpatient,,,1577,1103.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,525.9295,1261.6,,,,
HC Med/Surg Stepdown,PX-12100003,CDM,12100003,LOCAL,121,RC,,,inpatient,,,2423,1696.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,808.0705,1938.4,,,,
HC Maternity Unit,PX-12200001,CDM,12200001,LOCAL,122,RC,,,inpatient,,,2193,1535.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,731.3655,1754.4,,,,
HC Pediatric Semi-Private Unit,PX-12300001,CDM,12300001,LOCAL,123,RC,,,inpatient,,,3323,2326.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1108.2205,2658.4,,,,
HC S.E. Rehab Semi-Private Unit,PX-12800001,CDM,12800001,LOCAL,128,RC,,,inpatient,,,1783,1248.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,594.6305,2483,,,,
HC Nursery,PX-17000001,CDM,17000001,LOCAL,170,RC,,,inpatient,,,1333,933.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,444.5555,1066.4,,,,
HC Nursery Boarder,PX-17900001,CDM,17900001,LOCAL,179,RC,,,inpatient,,,1195,836.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,398.5325,956,,,,
HC Icu/Ccu Unit,PX-20000001,CDM,20000001,LOCAL,200,RC,,,inpatient,,,4009,2806.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1337.0015,3207.2,,,,
HC Icu Surgical Unit,PX-20100001,CDM,20100001,LOCAL,201,RC,,,inpatient,,,3646,2552.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1215.941,2916.8,,,,
HC Telemetry Unit,PX-20600001,CDM,20600001,LOCAL,206,RC,,,inpatient,,,2015,1410.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,672.0025,1612,,,,
HC Trauma,PX-20800001,CDM,20800001,LOCAL,208,RC,,,inpatient,,,4810,3367,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1604.135,3848,,,,
HC Onc. Vad Kit,PX-27000020,CDM,27000020,LOCAL,270,RC,,,inpatient,,,90,63,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.205,72,,,,
HC Imed Pump for Lvl II,PX-27000021,CDM,27000021,LOCAL,270,RC,,,inpatient,,,118,82.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.491,94.4,,,,
HC Imed Pump,PX-27000022,CDM,27000022,LOCAL,270,RC,,,inpatient,,,113,79.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,25.3685,90.4,,,,
HC Local Anesth Supplies,PX-27000023,CDM,27000023,LOCAL,270,RC,,,inpatient,,,80,56,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,17.96,64,,,,
HC Periop O2,PX-27000044,CDM,27000044,LOCAL,270,RC,,,inpatient,,,79,55.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,17.7355,63.2,,,,
HC Bone Bx Kit,PX-27000050,CDM,27000050,LOCAL,270,RC,,,inpatient,,,267,186.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,59.9415,213.6,,,,
HC Kit Portex Nerve Block,PX-27000051,CDM,27000051,LOCAL,270,RC,,,inpatient,,,90,63,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.205,72,,,,
HC Cannister Vac W/O Gel Ats,PX-27000052,CDM,27000052,LOCAL,270,RC,,,inpatient,,,282,197.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,63.309,225.6,,,,
HC Dressing Kci Small 5/Cs,PX-27000053,CDM,27000053,LOCAL,270,RC,,,inpatient,,,268,187.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.166,214.4,,,,
HC Cannister W/Gel Ats,PX-27000054,CDM,27000054,LOCAL,270,RC,,,inpatient,,,283,198.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,63.5335,226.4,,,,
HC Compression Stocking A6530,PX-27000055,CDM,27000055,LOCAL,270,RC,,,inpatient,,,285,199.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,63.9825,228,,,,
HC Custom Molded Insert,PX-27000056,CDM,27000056,LOCAL,270,RC,,,inpatient,,,287,200.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,64.4315,229.6,,,,
HC Dressing Kci Medium 10/Cs,PX-27000057,CDM,27000057,LOCAL,270,RC,,,inpatient,,,307,214.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,68.9215,245.6,,,,
HC Surgical Boot/Shoe L3260,PX-27000058,CDM,27000058,LOCAL,270,RC,,,inpatient,,,423,296.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,94.9635,338.4,,,,
HC Vaccum Assisted Closure Pump,PX-27000059,CDM,27000059,LOCAL,270,RC,,,inpatient,,,438,306.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,98.331,350.4,,,,
HC Ortho Wedge Shoe,PX-27000060,CDM,27000060,LOCAL,270,RC,,,inpatient,,,529,370.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,118.7605,423.2,,,,
HC Foot Pressure Support A9283,PX-27000061,CDM,27000061,LOCAL,270,RC,,,inpatient,,,529,370.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,118.7605,423.2,,,,
HC Sensor Nicom,PX-27000062,CDM,27000062,LOCAL,270,RC,,,inpatient,,,816,571.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,183.192,652.8,,,,
HC 6 Channel Pneumogram,PX-27000063,CDM,27000063,LOCAL,270,RC,,,inpatient,,,3884,2718.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,871.958,3107.2,,,,
HC Pneumogram 4-Channel,PX-27000064,CDM,27000064,LOCAL,270,RC,,,inpatient,,,4891,3423.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1098.0295,3912.8,,,,
HC Pad Artic Gel Large,PX-27000065,CDM,27000065,LOCAL,270,RC,,,inpatient,,,5242,3669.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1176.829,4193.6,,,,
HC Pneumogram 6- Channel,PX-27000066,CDM,27000066,LOCAL,270,RC,,,inpatient,,,5466,3826.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1227.117,4372.8,,,,
HC Therapy Polar Cooler,PX-27000068,CDM,27000068,LOCAL,270,RC,,,inpatient,,,667,466.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,149.7415,533.6,,,,
HC Liner Foam Permanently Med,PX-27000069,CDM,27000069,LOCAL,270,RC,,,inpatient,,,353,247.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,79.2485,282.4,,,,
HC Dressing Kci Vac Small,PX-27000070,CDM,27000070,LOCAL,270,RC,,,inpatient,,,327,228.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,73.4115,261.6,,,,
HC Dressing Kci Vac Large,PX-27000071,CDM,27000071,LOCAL,270,RC,,,inpatient,,,390,273,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,87.555,312,,,,
HC Developmental Aides,PX-27000072,CDM,27000072,LOCAL,270,RC,,,inpatient,,,707,494.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,158.7215,565.6,,,,
"HC Ez Reacher 30"" Suction",PX-27100004,CDM,27100004,LOCAL,271,RC,,,inpatient,,,144,100.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,32.328,122.0544,,,,
HC Support Bra Ez-on Med 958,PX-27100005,CDM,27100005,LOCAL,271,RC,,,inpatient,,,262,183.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,58.819,222.0712,,,,
HC Support Bra Ez-on Lrg 958,PX-27100006,CDM,27100006,LOCAL,271,RC,,,inpatient,,,272,190.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,61.064,230.5472,,,,
HC Support Bra Ez-on X-Lrg 958,PX-27100007,CDM,27100007,LOCAL,271,RC,,,inpatient,,,306,214.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,68.697,259.3656,,,,
HC Support Bra Ez-on Queen,PX-27100008,CDM,27100008,LOCAL,271,RC,,,inpatient,,,377,263.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,84.6365,319.5452,,,,
HC Bra Ez-on Super Queen,PX-27100009,CDM,27100009,LOCAL,271,RC,,,inpatient,,,471,329.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,105.7395,399.2196,,,,
HC Gradient Com Stocking,PX-27100010,CDM,27100010,LOCAL,271,RC,,,inpatient,,,490,343,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,110.005,415.324,,,,
HC Kit Flexi Seal Fecal,PX-27100011,CDM,27100011,LOCAL,271,RC,,,inpatient,,,939,657.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,210.8055,795.8964,,,,
HC Port Power Loc Access Kit,PX-27200054,CDM,27200054,LOCAL,272,RC,,,inpatient,,,88,61.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.756,74.5888,,,,
HC Dressing Kci Vac White Lg,PX-27200055,CDM,27200055,LOCAL,272,RC,,,inpatient,,,95,66.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,21.3275,80.522,,,,
HC Sheath Brite Tip 11cm,PX-27200056,CDM,27200056,LOCAL,272,RC,,,inpatient,,,108,75.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,24.246,91.5408,,,,
HC Kit Refill Syncromed Sys. Pain,PX-27200057,CDM,27200057,LOCAL,272,RC,,,inpatient,,,128,89.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,28.736,108.4928,,,,
HC Sock Fracture,PX-27200058,CDM,27200058,LOCAL,272,RC,,,inpatient,,,193,135.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,43.3285,163.5868,,,,
HC Tube Gastrostomy Replacement,PX-27200059,CDM,27200059,LOCAL,272,RC,,,inpatient,,,195,136.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,43.7775,165.282,,,,
HC Mod of Depth Shoe,PX-27200060,CDM,27200060,LOCAL,272,RC,,,inpatient,,,225,157.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,50.5125,190.71,,,,
HC Catheter Broncho 39l,PX-27200061,CDM,27200061,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,78.3505,295.8124,,,,
HC Catheter Bronch 35 Left 95892,PX-27200062,CDM,27200062,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,78.3505,295.8124,,,,
HC Endo-Bronch Tube 37fr Left,PX-27200063,CDM,27200063,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,78.3505,295.8124,,,,
HC Tube Endo Bronch #35 Left,PX-27200064,CDM,27200064,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,78.3505,295.8124,,,,
HC Endo Bronch Tube #39,PX-27200065,CDM,27200065,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,78.3505,295.8124,,,,
HC Catheter Broncho 41l,PX-27200066,CDM,27200066,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,78.3505,295.8124,,,,
HC Kit Arterial Line Arrow,PX-27200067,CDM,27200067,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,78.3505,295.8124,,,,
HC Cassette Kci Veralink,PX-27200068,CDM,27200068,LOCAL,272,RC,,,inpatient,,,357,249.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.1465,302.5932,,,,
HC Shiley Trach Tube 6lpc,PX-27200069,CDM,27200069,LOCAL,272,RC,,,inpatient,,,357,249.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.1465,302.5932,,,,
HC Tube Trach Shiley 8lpc,PX-27200070,CDM,27200070,LOCAL,272,RC,,,inpatient,,,357,249.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.1465,302.5932,,,,
HC Catheter Single 4fr Bard,PX-27200071,CDM,27200071,LOCAL,272,RC,,,inpatient,,,374,261.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,83.963,317.0024,,,,
HC Bivona #7 Trach Uncuffed,PX-27200072,CDM,27200072,LOCAL,272,RC,,,inpatient,,,396,277.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,88.902,335.6496,,,,
HC Retractor C Section Large,PX-27200073,CDM,27200073,LOCAL,272,RC,,,inpatient,,,402,281.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,90.249,340.7352,,,,
HC Midline 4fr Bd#384308,PX-27200074,CDM,27200074,LOCAL,272,RC,,,inpatient,,,409,286.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,91.8205,346.6684,,,,
HC Transducer Triple W/Vamp Pls,PX-27200075,CDM,27200075,LOCAL,272,RC,,,inpatient,,,418,292.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,93.841,354.2968,,,,
HC B Pleurx Drainage Kit,PX-27200076,CDM,27200076,LOCAL,272,RC,,,inpatient,,,417,291.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,93.6165,353.4492,,,,
HC Catheter Swan Ganz J Pacing,PX-27200078,CDM,27200078,LOCAL,272,RC,,,inpatient,,,446,312.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,100.127,378.0296,,,,
HC Tube Trach Distal Xlt 5.0,PX-27200079,CDM,27200079,LOCAL,272,RC,,,inpatient,,,451,315.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,101.2495,382.2676,,,,
HC Tube Trach Distal Xlt 6.0,PX-27200080,CDM,27200080,LOCAL,272,RC,,,inpatient,,,466,326.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,104.617,394.9816,,,,
HC Tube Trach 8 Cuff Non X Long,PX-27200081,CDM,27200081,LOCAL,272,RC,,,inpatient,,,466,326.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,104.617,394.9816,,,,
HC Sling Sam Pelvic Medium,PX-27200082,CDM,27200082,LOCAL,272,RC,,,inpatient,,,470,329,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,105.515,398.372,,,,
HC Set Tube Kaci Veratrac Duo,PX-27200083,CDM,27200083,LOCAL,272,RC,,,inpatient,,,488,341.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,109.556,413.6288,,,,
HC Retractor C Section Xlarge,PX-27200084,CDM,27200084,LOCAL,272,RC,,,inpatient,,,516,361.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,115.842,437.3616,,,,
HC Kit Mini 4fr Single Lumen,PX-27200085,CDM,27200085,LOCAL,272,RC,,,inpatient,,,519,363.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,116.5155,439.9044,,,,
HC Trach Bivona Tis 6id,PX-27200086,CDM,27200086,LOCAL,272,RC,,,inpatient,,,523,366.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,117.4135,443.2948,,,,
HC Pack C Section Custom Disp,PX-27200087,CDM,27200087,LOCAL,272,RC,,,inpatient,,,541,378.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,121.4545,458.5516,,,,
HC Trach Bivona Tts 8mm,PX-27200088,CDM,27200088,LOCAL,272,RC,,,inpatient,,,541,378.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,121.4545,458.5516,,,,
HC Trach Bivona 7.5 X 10,PX-27200089,CDM,27200089,LOCAL,272,RC,,,inpatient,,,556,389.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,124.822,471.2656,,,,
HC Tube Feeding Mic Key 14f 1.7,PX-27200091,CDM,27200091,LOCAL,272,RC,,,inpatient,,,674,471.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,151.313,571.2824,,,,
HC Kit Mic-Key G Feeding 16-3.5,PX-27200092,CDM,27200092,LOCAL,272,RC,,,inpatient,,,694,485.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,155.803,588.2344,,,,
HC Kit Mic-Key G Feeding 24-3.5,PX-27200093,CDM,27200093,LOCAL,272,RC,,,inpatient,,,694,485.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,155.803,588.2344,,,,
HC Mic Key G Tube 20fr 3.5cm,PX-27200094,CDM,27200094,LOCAL,272,RC,,,inpatient,,,694,485.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,155.803,588.2344,,,,
HC Device Support Foot,PX-27200095,CDM,27200095,LOCAL,272,RC,,,inpatient,,,703,492.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,157.8235,595.8628,,,,
HC Catheter 4 Fr Mid Line,PX-27200096,CDM,27200096,LOCAL,272,RC,,,inpatient,,,719,503.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,161.4155,609.4244,,,,
HC Tcc Size 3,PX-27200097,CDM,27200097,LOCAL,272,RC,,,inpatient,,,722,505.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,162.089,611.9672,,,,
HC Femostop Gold Compress Sys,PX-27200098,CDM,27200098,LOCAL,272,RC,,,inpatient,,,731,511.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,164.1095,619.5956,,,,
HC Dot Poly Midline 4fr Sl Full,PX-27200099,CDM,27200099,LOCAL,272,RC,,,inpatient,,,765,535.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,171.7425,648.414,,,,
HC Powerwand 5fr 10cm,PX-27200100,CDM,27200100,LOCAL,272,RC,,,inpatient,,,776,543.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.212,657.7376,,,,
HC Powerwand Single Sterile 5fr,PX-27200101,CDM,27200101,LOCAL,272,RC,,,inpatient,,,776,543.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.212,657.7376,,,,
HC Needle Intraosseous Pd 15g,PX-27200102,CDM,27200102,LOCAL,272,RC,,,inpatient,,,845,591.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,189.7025,716.222,,,,
HC Needle Intraosseous Ad 15g,PX-27200103,CDM,27200103,LOCAL,272,RC,,,inpatient,,,845,591.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,189.7025,716.222,,,,
HC Needle Intraosseous,PX-27200104,CDM,27200104,LOCAL,272,RC,,,inpatient,,,845,591.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,189.7025,716.222,,,,
HC Kit Triple Lumen Cath 7 X 6,PX-27200105,CDM,27200105,LOCAL,272,RC,,,inpatient,,,895,626.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,200.9275,758.602,,,,
HC Multi Lumen Cvc Kit Toh Cust,PX-27200106,CDM,27200106,LOCAL,272,RC,,,inpatient,,,895,626.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,200.9275,758.602,,,,
HC Pad Zoll Aed Cprd Access Kit,PX-27200107,CDM,27200107,LOCAL,272,RC,,,inpatient,,,827,578.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,185.6615,700.9652,,,,
HC Kit Flexi Seal Fecal,PX-27200108,CDM,27200108,LOCAL,272,RC,,,inpatient,,,939,657.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,210.8055,795.8964,,,,
HC Powerwand Quick Kit 5fr,PX-27200109,CDM,27200109,LOCAL,272,RC,,,inpatient,,,979,685.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,219.7855,829.8004,,,,
HC Mahurkar Dual Lumen Subclav Ca,PX-27200110,CDM,27200110,LOCAL,272,RC,,,inpatient,,,1581,1106.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,354.9345,1340.0556,,,,
HC Catheter With Curved Extension,PX-27200111,CDM,27200111,LOCAL,272,RC,,,inpatient,,,1581,1106.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,354.9345,1340.0556,,,,
HC Set Cath Cricothyroidotomy,PX-27200112,CDM,27200112,LOCAL,272,RC,,,inpatient,,,1136,795.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,255.032,962.8736,,,,
HC Rusch Quick Trac Small 2.0,PX-27200113,CDM,27200113,LOCAL,272,RC,,,inpatient,,,1269,888.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,284.8905,1075.6044,,,,
HC Set Prism Prewarm M100'2,PX-27200114,CDM,27200114,LOCAL,272,RC,,,inpatient,,,1319,923.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,296.1155,1117.9844,,,,
HC Set Prismaflex M100's,PX-27200115,CDM,27200115,LOCAL,272,RC,,,inpatient,,,1399,979.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,314.0755,1185.7924,,,,
HC Bakri Postpartum Balloon,PX-27200116,CDM,27200116,LOCAL,272,RC,,,inpatient,,,1408,985.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,316.096,1193.4208,,,,
HC Flo Trac Sensor Mhd6,PX-27200117,CDM,27200117,LOCAL,272,RC,,,inpatient,,,2027,1418.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,455.0615,1718.0852,,,,
HC Pad Universal Artic Gel,PX-27200118,CDM,27200118,LOCAL,272,RC,,,inpatient,,,2219,1553.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,498.1655,1880.8244,,,,
HC Cath Presep 8.5 Oximetry,PX-27200119,CDM,27200119,LOCAL,272,RC,,,inpatient,,,2602,1821.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,584.149,2205.4552,,,,
HC Set Cricothyrotomy Cath,PX-27200120,CDM,27200120,LOCAL,272,RC,,,inpatient,,,2943,2060.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,660.7035,2494.4868,,,,
HC Pad Artic Gel Small,PX-27200121,CDM,27200121,LOCAL,272,RC,,,inpatient,,,5565,3895.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1249.3425,4716.894,,,,
HC Pad Gel Artic Medium,PX-27200122,CDM,27200122,LOCAL,272,RC,,,inpatient,,,5512,3858.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1237.444,4671.9712,,,,
HC Rhino G2 Blue,PX-27200123,CDM,27200123,LOCAL,272,RC,,,inpatient,,,4120,2884,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,924.94,3492.112,,,,
HC Pad Artic Gel Lrg,PX-27200124,CDM,27200124,LOCAL,272,RC,,,inpatient,,,5512,3858.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1237.444,4671.9712,,,,
HC Bag External Drainage Collect,PX-27200125,CDM,27200125,LOCAL,272,RC,,,inpatient,,,1349,944.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,302.8505,1143.4124,,,,
HC Catheter Thoracic 28fr,PX-27200126,CDM,27200126,LOCAL,272,RC,,,inpatient,,,39,27.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.7555,33.0564,,,,
HC Tube Endo Bronch Left 37,PX-27200127,CDM,27200127,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,78.3505,295.8124,,,,
HC Electrode Temporary Pacing 6,PX-27200128,CDM,27200128,LOCAL,272,RC,,,inpatient,,,1238,866.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,277.931,1049.3288,,,,
HC Set Pneumothorax,PX-27200129,CDM,27200129,LOCAL,272,RC,,,inpatient,,,1113,779.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,249.8685,943.3788,,,,
HC System External Drainage III,PX-27200130,CDM,27200130,LOCAL,272,RC,,,inpatient,,,1887,1320.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,423.6315,1599.4212,,,,
HC Electrode Temporary Pacing 5,PX-27200131,CDM,27200131,LOCAL,272,RC,,,inpatient,,,1097,767.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,246.2765,929.8172,,,,
HC Tray Tru Close Thoracic Vent,PX-27200132,CDM,27200132,LOCAL,272,RC,,,inpatient,,,1504,1052.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,337.648,1274.7904,,,,
HC Tube Trach Flex Laser 6.0 Mm,PX-27200133,CDM,27200133,LOCAL,272,RC,,,inpatient,,,319,223.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,71.6155,270.3844,,,,
HC Pack Cesarean Custom,PX-27200134,CDM,27200134,LOCAL,272,RC,,,inpatient,,,462,323.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,103.719,391.5912,,,,
HC Hemostat Instat 1gm,PX-27200135,CDM,27200135,LOCAL,272,RC,,,inpatient,,,1077,753.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,241.7865,912.8652,,,,
HC Tube Trach Distal Xlt 7.0,PX-27200136,CDM,27200136,LOCAL,272,RC,,,inpatient,,,486,340.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,109.107,411.9336,,,,
HC Surgicel 2 X 14 #1951,PX-27200137,CDM,27200137,LOCAL,272,RC,,,inpatient,,,447,312.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,100.3515,378.8772,,,,
HC Ligator Saeed Sx Shoot,PX-27200138,CDM,27200138,LOCAL,272,RC,,,inpatient,,,1332,932.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,299.034,1129.0032,,,,
HC Cath Swan Ganz 7.5 Vip Port,PX-27200139,CDM,27200139,LOCAL,272,RC,,,inpatient,,,297,207.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,66.6765,251.7372,,,,
HC Cath Multilumen Access,PX-27200140,CDM,27200140,LOCAL,272,RC,,,inpatient,,,537,375.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,120.5565,455.1612,,,,
HC Trach Bivona Tts 7mm,PX-27200141,CDM,27200141,LOCAL,272,RC,,,inpatient,,,565,395.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,126.8425,478.894,,,,
HC Kit Pleurx Drainage W Bottle,PX-27200142,CDM,27200142,LOCAL,272,RC,,,inpatient,,,417,291.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,93.6165,353.4492,,,,
HC Retractor Wound Alexis Lrg,PX-27200143,CDM,27200143,LOCAL,272,RC,,,inpatient,,,412,288.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,92.494,349.2112,,,,
HC Unit Cold Therapy Deroyal,PX-27200144,CDM,27200144,LOCAL,272,RC,,,inpatient,,,691,483.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,155.1295,585.6916,,,,
HC Dressing Kci Vac Silver Med,PX-27200145,CDM,27200145,LOCAL,272,RC,,,inpatient,,,506,354.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,113.597,428.8856,,,,
HC Kit Midline Cath 20ga X 20cm,PX-27200146,CDM,27200146,LOCAL,272,RC,,,inpatient,,,424,296.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,95.188,359.3824,,,,
HC Cath Mahurkar 3 Lumen 12x20,PX-27200147,CDM,27200147,LOCAL,272,RC,,,inpatient,,,594,415.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,133.353,503.4744,,,,
HC Retractor Alexis Wound Xlg,PX-27200148,CDM,27200148,LOCAL,272,RC,,,inpatient,,,529,370.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,118.7605,448.3804,,,,
HC Surgiflo Hemostatic Matrix,PX-27200149,CDM,27200149,LOCAL,272,RC,,,inpatient,,,906,634.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,203.397,767.9256,,,,
HC Kit Monitoring Press Abviser,PX-27200150,CDM,27200150,LOCAL,272,RC,,,inpatient,,,648,453.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,145.476,549.2448,,,,
HC Tray Fuhrman Pleural Drain,PX-27200151,CDM,27200151,LOCAL,272,RC,,,inpatient,,,990,693,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,222.255,839.124,,,,
HC Kit Cath Triple Lumen 20cm,PX-27200152,CDM,27200152,LOCAL,272,RC,,,inpatient,,,865,605.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,194.1925,733.174,,,,
HC Dressing Kci Simplace Med,PX-27200153,CDM,27200153,LOCAL,272,RC,,,inpatient,,,433,303.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,97.2085,367.0108,,,,
HC Tube Non Balloon Replace Peg,PX-27200154,CDM,27200154,LOCAL,272,RC,,,inpatient,,,394,275.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,88.453,333.9544,,,,
HC Cath 12fr Hp Triple Lumen,PX-27200155,CDM,27200155,LOCAL,272,RC,,,inpatient,,,606,424.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,136.047,513.6456,,,,
HC Cath Pneumothorax Ak01500,PX-27200156,CDM,27200156,LOCAL,272,RC,,,inpatient,,,700,490,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,157.15,593.32,,,,
HC Kit Cranial Access 826614,PX-27200158,CDM,27200158,LOCAL,272,RC,,,inpatient,,,2205,1543.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,495.0225,1868.958,,,,
"HC Sensor Flotrac W Vamp 60""",PX-27200159,CDM,27200159,LOCAL,272,RC,,,inpatient,,,1336,935.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,299.932,1132.3936,,,,
HC Trach Lg 4.0 Quick Rusch,PX-27200160,CDM,27200160,LOCAL,272,RC,,,inpatient,,,1094,765.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,245.603,927.2744,,,,
HC Tray Pericardiocentesis Stra,PX-27200161,CDM,27200161,LOCAL,272,RC,,,inpatient,,,1188,831.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,266.706,1006.9488,,,,
HC Trocar Endo Ethicon 12 512sd,PX-27200162,CDM,27200162,LOCAL,272,RC,,,inpatient,,,1154,807.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,259.073,978.1304,,,,
HC Tube Laryngectomy 12mm Metal,PX-27200163,CDM,27200163,LOCAL,272,RC,,,inpatient,,,1154,807.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,259.073,978.1304,,,,
HC Tray Midline CT 4f 20cm Single,PX-27200164,CDM,27200164,LOCAL,272,RC,,,inpatient,,,785,549.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,176.2325,665.366,,,,
HC Tray Midline CT 5f 20cm Dual,PX-27200165,CDM,27200165,LOCAL,272,RC,,,inpatient,,,779,545.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.8855,660.2804,,,,
HC Mahurkar Triple Lumen Cath Tray #16,PX-27200166,CDM,27200166,LOCAL,272,RC,,,inpatient,,,1191,833.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,267.3795,1009.4916,,,,
HC Mahurkar Triple Lumen Cath Tray #20,PX-27200167,CDM,27200167,LOCAL,272,RC,,,inpatient,,,983,688.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,220.6835,833.1908,,,,
HC Compartment Pressure Monitoring Kit,PX-27200168,CDM,27200168,LOCAL,272,RC,,,inpatient,,,457,319.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,102.5965,387.3532,,,,
HC Kit Perc Sheath Introducer 8.5,PX-27200169,CDM,27200169,LOCAL,272,RC,,,inpatient,,,471,329.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,105.7395,399.2196,,,,
HC Cath Arrow Cvc Kit Latex Free,PX-27200170,CDM,27200170,LOCAL,272,RC,,,inpatient,,,465,325.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,104.3925,394.134,,,,
HC Electrode Temporary Pacing 4,PX-27200171,CDM,27200171,LOCAL,272,RC,,,inpatient,,,823,576.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,184.7635,697.5748,,,,
HC Catheter Bipolar Pacing 5,PX-27200172,CDM,27200172,LOCAL,272,RC,,,inpatient,,,619,433.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,138.9655,524.6644,,,,
HC Set Emergency Pneumothorax,PX-27200173,CDM,27200173,LOCAL,272,RC,,,inpatient,,,795,556.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,178.4775,673.842,,,,
HC Kit Pneumothorax,PX-27200174,CDM,27200174,LOCAL,272,RC,,,inpatient,,,722,505.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,162.089,611.9672,,,,
HC Impella Purge Cassette,PX-27200175,CDM,27200175,LOCAL,272,RC,,,inpatient,,,245,171.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,55.0025,207.662,,,,
HC Tray Midline CT 4f 20cm Singl,PX-27200176,CDM,27200176,LOCAL,272,RC,,,inpatient,,,954,667.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,214.173,808.6104,,,,
HC Tray Midline CT 5f 20cm Dual F,PX-27200177,CDM,27200177,LOCAL,272,RC,,,inpatient,,,1154,807.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,259.073,978.1304,,,,
HC Kit Microez Mst Nitinol 4.5 7c,PX-27200178,CDM,27200178,LOCAL,272,RC,,,inpatient,,,497,347.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,111.5765,421.2572,,,,
HC Kit Microez Mst 5f Nsx,PX-27200179,CDM,27200179,LOCAL,272,RC,,,inpatient,,,251,175.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,56.3495,212.7476,,,,
HC Electrode One Step Cpr Adult,PX-27200180,CDM,27200180,LOCAL,272,RC,,,inpatient,,,408,285.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,91.596,345.8208,,,,
HC Electrode One Step Pediatric,PX-27200181,CDM,27200181,LOCAL,272,RC,,,inpatient,,,447,312.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,100.3515,378.8772,,,,
HC Ambu® Ascopetm 4 Broncho Large (5.8/2.8),PX-27200196,CDM,27200196,LOCAL,272,RC,,,inpatient,,,359,251.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.5955,304.2884,,,,
HC Ambu® Ascopetm 4 Broncho Regular (5.0/2.2),PX-27200197,CDM,27200197,LOCAL,272,RC,,,inpatient,,,312,218.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,70.044,264.4512,,,,
HC Ambu® Ascopetm 4 Broncho Slim (3.8/1.2),PX-27200198,CDM,27200198,LOCAL,272,RC,,,inpatient,,,312,218.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,70.044,264.4512,,,,
HC Tray Pneumothorax Turkel 9 Cm Sys,PX-27200199,CDM,27200199,LOCAL,272,RC,,,inpatient,,,622,435.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,139.639,527.2072,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400003,CDM,27400003,LOCAL,274,RC,,,inpatient,,,552,386.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,123.924,467.8752,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400005,CDM,27400005,LOCAL,274,RC,,,inpatient,,,1221,854.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,274.1145,1034.9196,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400008,CDM,27400008,LOCAL,274,RC,,,inpatient,,,3772,2640.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,846.814,3197.1472,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400012,CDM,27400012,LOCAL,274,RC,,,inpatient,,,1954,1367.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,438.673,1656.2104,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400015,CDM,27400015,LOCAL,274,RC,,,inpatient,,,3806,2664.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,854.447,3225.9656,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400030,CDM,27400030,LOCAL,274,RC,,,inpatient,,,661,462.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,148.3945,560.2636,,,,
HC Brace Knee Enhanced Trom,PX-27400038,CDM,27400038,LOCAL,274,RC,,,inpatient,,,570,399,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,127.965,483.132,,,,
HC Brace Enhanced Trom Donjoy,PX-27400039,CDM,27400039,LOCAL,274,RC,,,inpatient,,,570,399,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,127.965,483.132,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400047,CDM,27400047,LOCAL,274,RC,,,inpatient,,,3385,2369.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,759.9325,2869.126,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400050,CDM,27400050,LOCAL,274,RC,,,inpatient,,,3185,2229.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,715.0325,2699.606,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400107,CDM,27400107,LOCAL,274,RC,,,inpatient,,,380,266,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,85.31,322.088,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400117,CDM,27400117,LOCAL,274,RC,,,inpatient,,,779,545.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.8855,660.2804,,,,
HC Add. to Lower Extremity L2210,PX-27400184,CDM,27400184,LOCAL,274,RC,,,inpatient,,,330,231,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,74.085,279.708,,,,
HC Lift Elevation Heel & Sole,PX-27400185,CDM,27400185,LOCAL,274,RC,,,inpatient,,,382,267.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,85.759,323.7832,,,,
HC Add. Lower Extremity Orthosis,PX-27400186,CDM,27400186,LOCAL,274,RC,,,inpatient,,,448,313.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,100.576,379.7248,,,,
HC Depth Shoe A5500,PX-27400187,CDM,27400187,LOCAL,274,RC,,,inpatient,,,473,331.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,106.1885,400.9148,,,,
HC Compression Stocking A6533,PX-27400188,CDM,27400188,LOCAL,274,RC,,,inpatient,,,502,351.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,112.699,425.4952,,,,
HC Collar L0172,PX-27400189,CDM,27400189,LOCAL,274,RC,,,inpatient,,,658,460.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,147.721,557.7208,,,,
HC Ko Elastic Knee Joint L1820,PX-27400190,CDM,27400190,LOCAL,274,RC,,,inpatient,,,661,462.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,148.3945,560.2636,,,,
HC Procedure Ortho Shoe/L3649,PX-27400191,CDM,27400191,LOCAL,274,RC,,,inpatient,,,703,492.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,157.8235,595.8628,,,,
HC Air Cast Boot L4386,PX-27400192,CDM,27400192,LOCAL,274,RC,,,inpatient,,,745,521.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,167.2525,631.462,,,,
HC Static Afa L4396,PX-27400193,CDM,27400193,LOCAL,274,RC,,,inpatient,,,785,549.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,176.2325,665.366,,,,
HC Brace Tlso,PX-27400194,CDM,27400194,LOCAL,274,RC,,,inpatient,,,901,630.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,202.2745,763.6876,,,,
HC Lumbar Corsette L0450,PX-27400195,CDM,27400195,LOCAL,274,RC,,,inpatient,,,915,640.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,205.4175,775.554,,,,
HC Brace Warm and Form,PX-27400196,CDM,27400196,LOCAL,274,RC,,,inpatient,,,1117,781.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,250.7665,946.7692,,,,
HC Afo L1940,PX-27400197,CDM,27400197,LOCAL,274,RC,,,inpatient,,,2560,1792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,574.72,2169.856,,,,
HC Ankle Foot Orthosis L1940,PX-27400198,CDM,27400198,LOCAL,274,RC,,,inpatient,,,2560,1792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,574.72,2169.856,,,,
HC POS OP Knee Brace L1832,PX-27400199,CDM,27400199,LOCAL,274,RC,,,inpatient,,,2974,2081.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,667.663,2520.7624,,,,
HC Afo Plastic L1960,PX-27400200,CDM,27400200,LOCAL,274,RC,,,inpatient,,,3011,2107.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,675.9695,2552.1236,,,,
HC Ankle/Foot Orthosis Afo,PX-27400201,CDM,27400201,LOCAL,274,RC,,,inpatient,,,3011,2107.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,675.9695,2552.1236,,,,
HC Left Afo Brace/Atlantic Pros,PX-27400202,CDM,27400202,LOCAL,274,RC,,,inpatient,,,3165,2215.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,710.5425,2682.654,,,,
HC Afo L1932,PX-27400203,CDM,27400203,LOCAL,274,RC,,,inpatient,,,3418,2392.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,767.341,2897.0968,,,,
HC Ankle Foot Orthosis L1970,PX-27400204,CDM,27400204,LOCAL,274,RC,,,inpatient,,,3462,2423.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,777.219,2934.3912,,,,
HC Back Brace Tlso Lo486,PX-27400205,CDM,27400205,LOCAL,274,RC,,,inpatient,,,6597,4617.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1481.0265,5591.6172,,,,
HC Cervical Collar L0172,PX-27400206,CDM,27400206,LOCAL,274,RC,,,inpatient,,,658,460.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,147.721,557.7208,,,,
HC Philly Collar No Extension,PX-27400207,CDM,27400207,LOCAL,274,RC,,,inpatient,,,658,460.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,147.721,557.7208,,,,
HC Cervical Collar 2/Piece L0174,PX-27400208,CDM,27400208,LOCAL,274,RC,,,inpatient,,,1232,862.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,276.584,1044.2432,,,,
HC Lumbar Orthosis L0627,PX-27400209,CDM,27400209,LOCAL,274,RC,,,inpatient,,,1750,1225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,392.875,1483.3,,,,
HC Lso Sagoro Rigid Frame L0631,PX-27400210,CDM,27400210,LOCAL,274,RC,,,inpatient,,,3933,2753.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,882.9585,3333.6108,,,,
HC Lso Sagittal Coronal L0637,PX-27400211,CDM,27400211,LOCAL,274,RC,,,inpatient,,,4114,2879.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,923.593,3487.0264,,,,
HC Hip Abduction Orthosis L1686,PX-27400212,CDM,27400212,LOCAL,274,RC,,,inpatient,,,4461,3122.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1001.4945,3781.1436,,,,
HC Knee Orthosis L1830,PX-27400213,CDM,27400213,LOCAL,274,RC,,,inpatient,,,466,326.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,104.617,394.9816,,,,
HC Knee Orthosis L1832,PX-27400214,CDM,27400214,LOCAL,274,RC,,,inpatient,,,2974,2081.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,667.663,2520.7624,,,,
HC Knee Orthosis L1832,PX-27400215,CDM,27400215,LOCAL,274,RC,,,inpatient,,,2974,2081.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,667.663,2520.7624,,,,
HC Knee Osthosis L1832,PX-27400216,CDM,27400216,LOCAL,274,RC,,,inpatient,,,2974,2081.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,667.663,2520.7624,,,,
HC Afo L1930,PX-27400217,CDM,27400217,LOCAL,274,RC,,,inpatient,,,1062,743.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,238.419,900.1512,,,,
HC Adj. Dorsal Splint L1930,PX-27400218,CDM,27400218,LOCAL,274,RC,,,inpatient,,,1062,743.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,238.419,900.1512,,,,
HC L'nard Boot L1930,PX-27400219,CDM,27400219,LOCAL,274,RC,,,inpatient,,,1062,743.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,238.419,900.1512,,,,
HC Hip Adj Ext L2624,PX-27400220,CDM,27400220,LOCAL,274,RC,,,inpatient,,,1445,1011.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,324.4025,1224.782,,,,
HC Bk Soft Interface L2820,PX-27400221,CDM,27400221,LOCAL,274,RC,,,inpatient,,,448,313.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,100.576,379.7248,,,,
HC Lift Elevation L3332,PX-27400222,CDM,27400222,LOCAL,274,RC,,,inpatient,,,347,242.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,77.9015,294.1172,,,,
HC Wrist Hand/Finger Ortho L3807,PX-27400223,CDM,27400223,LOCAL,274,RC,,,inpatient,,,1065,745.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,239.0925,902.694,,,,
HC Wrist Cockup Nonmolded L3908,PX-27400224,CDM,27400224,LOCAL,274,RC,,,inpatient,,,353,247.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,79.2485,299.2028,,,,
HC Orthosis Upper Limb Hum. Frac,PX-27400225,CDM,27400225,LOCAL,274,RC,,,inpatient,,,1413,989.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,317.2185,1197.6588,,,,
HC Walking Boot L4360,PX-27400226,CDM,27400226,LOCAL,274,RC,,,inpatient,,,1290,903,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,289.605,1093.404,,,,
HC Walking Boot Prefab L4360,PX-27400227,CDM,27400227,LOCAL,274,RC,,,inpatient,,,1290,903,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,289.605,1093.404,,,,
HC Walking Boot L4360,PX-27400228,CDM,27400228,LOCAL,274,RC,,,inpatient,,,2135,1494.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,479.3075,1809.626,,,,
HC Cam Walker L4386,PX-27400229,CDM,27400229,LOCAL,274,RC,,,inpatient,,,745,521.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,167.2525,631.462,,,,
HC Bk Stump Shrinker L8440,PX-27400230,CDM,27400230,LOCAL,274,RC,,,inpatient,,,262,183.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,58.819,222.0712,,,,
HC Stump Shrinker L8440,PX-27400231,CDM,27400231,LOCAL,274,RC,,,inpatient,,,262,183.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,58.819,222.0712,,,,
HC Liner Foam Permanently Lg,PX-27400232,CDM,27400232,LOCAL,274,RC,,,inpatient,,,353,247.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,79.2485,299.2028,,,,
HC Kit Electrode Pacing,PX-27500027,CDM,27500027,LOCAL,275,RC,,,inpatient,,,1286,900.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,288.707,1090.0136,,,,
HC Medical/Surgical Supplies: Other Implants,PX-27800095,CDM,27800095,LOCAL,278,RC,,,inpatient,,,649,454.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,145.7005,550.0924,,,,
HC Leg Post Rigid Brace/Sc Ortho,PX-27800096,CDM,27800096,LOCAL,278,RC,,,inpatient,,,758,530.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,170.171,642.4808,,,,
HC Kit Picc 4fr per-Q Poly Cath,PX-27800097,CDM,27800097,LOCAL,278,RC,,,inpatient,,,1063,744.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,238.6435,900.9988,,,,
HC Floseal Matrix Hemostatic,PX-27800098,CDM,27800098,LOCAL,278,RC,,,inpatient,,,1093,765.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,245.3785,926.4268,,,,
HC Kit Picc 5fr per-Q Poly Cath,PX-27800099,CDM,27800099,LOCAL,278,RC,,,inpatient,,,1217,851.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,273.2165,1031.5292,,,,
HC Tray Power Picc Dual 5f,PX-27800100,CDM,27800100,LOCAL,278,RC,,,inpatient,,,1355,948.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,304.1975,1148.498,,,,
HC Tray Power Picc Single 4f,PX-27800101,CDM,27800101,LOCAL,278,RC,,,inpatient,,,1398,978.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,313.851,1184.9448,,,,
HC Tray Power Picc Triple 5fr,PX-27800102,CDM,27800102,LOCAL,278,RC,,,inpatient,,,1474,1031.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,330.913,1249.3624,,,,
HC Tray Power Picc Triple 6f,PX-27800103,CDM,27800103,LOCAL,278,RC,,,inpatient,,,1499,1049.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,336.5255,1270.5524,,,,
HC Sepafilm/5x6,PX-27800104,CDM,27800104,LOCAL,278,RC,,,inpatient,,,1773,1241.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,398.0385,1502.7948,,,,
HC 3cg Power Picc Max 4fr Sl,PX-27800105,CDM,27800105,LOCAL,278,RC,,,inpatient,,,1585,1109.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,355.8325,1343.446,,,,
HC 3cg Power Picc Max 5fr Dl,PX-27800106,CDM,27800106,LOCAL,278,RC,,,inpatient,,,1636,1145.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,367.282,1386.6736,,,,
HC 3cg Power Picc Max 6fr Tl,PX-27800107,CDM,27800107,LOCAL,278,RC,,,inpatient,,,1749,1224.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,392.6505,1482.4524,,,,
HC Valve Passy Muir Aqua,PX-27800108,CDM,27800108,LOCAL,278,RC,,,inpatient,,,474,331.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,106.413,401.7624,,,,
HC Passy Muir Valve - Clear,PX-27800113,CDM,27800113,LOCAL,278,RC,,,inpatient,,,474,331.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,106.413,401.7624,,,,
HC Valve Passy Muir Purple,PX-27800114,CDM,27800114,LOCAL,278,RC,,,inpatient,,,474,331.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,106.413,401.7624,,,,
HC Liner Foam Permanently X-Lg,PX-27800115,CDM,27800115,LOCAL,278,RC,,,inpatient,,,328,229.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,73.636,278.0128,,,,
HC Tube Trach Proximal Xlt 7.0,PX-27800117,CDM,27800117,LOCAL,278,RC,,,inpatient,,,486,340.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,109.107,411.9336,,,,
HC Barrier Seprafilm 3x5in,PX-27800118,CDM,27800118,LOCAL,278,RC,,,inpatient,,,1773,1241.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,398.0385,1502.7948,,,,
HC Tube Feeding Low Profile 20f,PX-27800119,CDM,27800119,LOCAL,278,RC,,,inpatient,,,694,485.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,155.803,588.2344,,,,
HC Valve Speaking White #005,PX-27800121,CDM,27800121,LOCAL,278,RC,,,inpatient,,,474,331.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,106.413,401.7624,,,,
HC Tray Percu Introducer 8.5fr,PX-27800122,CDM,27800122,LOCAL,278,RC,,,inpatient,,,475,332.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,106.6375,402.61,,,,
HC Basket Zerotip Airway Retriv,PX-27800125,CDM,27800125,LOCAL,278,RC,,,inpatient,,,1710,1197,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,383.895,1449.396,,,,
HC Indwelling Prosthesis 20fr 8mm,PX-27800126,CDM,27800126,LOCAL,278,RC,,,inpatient,,,1327,928.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,297.9115,1124.7652,,,,
HC Indwelling Prosthesis 2.0,PX-27800127,CDM,27800127,LOCAL,278,RC,,,inpatient,,,1327,928.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,297.9115,1124.7652,,,,
HC Prosthesis Blom - 8mm,PX-27800128,CDM,27800128,LOCAL,278,RC,,,inpatient,,,1300,910,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,291.85,1101.88,,,,
HC Drug Collection,PX-30000005,CDM,30000005,LOCAL,300,RC,,,inpatient,,,32,22.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,7.184,27.1232,,,,
HC Cardiac Mnr Thoracic Prcd,PX-36000003,CDM,36000003,LOCAL,360,RC,,,inpatient,,,142,99.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,31.879,120.3592,,,,
HC Non-Pump Open Heart Other,PX-36000004,CDM,36000004,LOCAL,360,RC,,,inpatient,,,157,109.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,35.2465,133.0732,,,,
HC Pump Procedure,PX-36000005,CDM,36000005,LOCAL,360,RC,,,inpatient,,,152,106.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,34.124,128.8352,,,,
HC Non Pump Procedure,PX-36000006,CDM,36000006,LOCAL,360,RC,,,inpatient,,,208,145.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,46.696,176.3008,,,,
HC Sub Minor Proc,PX-36000014,CDM,36000014,LOCAL,360,RC,,,inpatient,,,60,42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,13.47,50.856,,,,
HC Pain Mgmt Proc,PX-36000015,CDM,36000015,LOCAL,360,RC,,,inpatient,,,75,52.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,16.8375,63.57,,,,
HC Endoscopy,PX-36000016,CDM,36000016,LOCAL,360,RC,,,inpatient,,,60,42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,13.47,50.856,,,,
HC Minor Proc,PX-36000017,CDM,36000017,LOCAL,360,RC,,,inpatient,,,75,52.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,16.8375,63.57,,,,
HC Major Proc,PX-36000019,CDM,36000019,LOCAL,360,RC,,,inpatient,,,99,69.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2255,83.9124,,,,
HC Intensive Major Procedure,PX-36000020,CDM,36000020,LOCAL,360,RC,,,inpatient,,,140,98,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,31.43,118.664,,,,
HC Ercp,PX-36000021,CDM,36000021,LOCAL,360,RC,,,inpatient,,,138,96.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,30.981,116.9688,,,,
HC Cardiac Maj Thoracic Prcd,PX-36000022,CDM,36000022,LOCAL,360,RC,,,inpatient,,,159,111.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,35.6955,134.7684,,,,
HC Anesthesia Block,PX-37000001,CDM,37000001,LOCAL,370,RC,,,inpatient,,,700,490,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,157.15,593.32,,,,
HC Anesthesia Spinal,PX-37000002,CDM,37000002,LOCAL,370,RC,,,inpatient,,,850,595,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,190.825,720.46,,,,
HC Anesthesia General Minor,PX-37000003,CDM,37000003,LOCAL,370,RC,,,inpatient,,,1662,1163.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,373.119,1408.7112,,,,
HC Anesthesia Epidural,PX-37000004,CDM,37000004,LOCAL,370,RC,,,inpatient,,,950,665,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,213.275,805.22,,,,
HC Anesthesia General Major,PX-37000005,CDM,37000005,LOCAL,370,RC,,,inpatient,,,2924,2046.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,656.438,2478.3824,,,,
HC Anesthesia Gen/Epi,PX-37000006,CDM,37000006,LOCAL,370,RC,,,inpatient,,,1200,840,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,269.4,1017.12,,,,
HC Anesthesia General Intensive,PX-37000007,CDM,37000007,LOCAL,370,RC,,,inpatient,,,4262,2983.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,956.819,3612.4712,,,,
HC Anesthesia General Cvs Bypass Pump,PX-37000008,CDM,37000008,LOCAL,370,RC,,,inpatient,,,9166,6416.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2057.767,7769.1016,,,,
HC Anesthesia Mac,PX-37000009,CDM,37000009,LOCAL,370,RC,,,inpatient,,,1200,840,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,269.4,1017.12,,,,
HC Endo Level I,PX-49000001,CDM,49000001,LOCAL,490,RC,,,inpatient,,,3749,2624.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,841.6505,3177.6524,,,,
HC Endo Level II,PX-49000002,CDM,49000002,LOCAL,490,RC,,,inpatient,,,5356,3749.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1202.422,4539.7456,,,,
HC Endo Level III,PX-49000003,CDM,49000003,LOCAL,490,RC,,,inpatient,,,9641,6748.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2164.4045,8171.7116,,,,
HC Recovery Room,PX-71000001,CDM,71000001,LOCAL,710,RC,,,inpatient,,,25,17.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,5.6125,21.19,,,,
HC Second Stage Recovery per Minute,PX-71000002,CDM,71000002,LOCAL,710,RC,,,inpatient,,,22,15.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.939,18.6472,,,,
HC Recovery - Sub Minor Proc,PX-71000003,CDM,71000003,LOCAL,710,RC,,,inpatient,,,23,16.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,5.1635,19.4948,,,,
HC Recovery Rm - Minor Procedure,PX-71000004,CDM,71000004,LOCAL,710,RC,,,inpatient,,,28,19.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,6.286,23.7328,,,,
HC Recovery Rm,PX-71000005,CDM,71000005,LOCAL,710,RC,,,inpatient,,,29,20.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,6.5105,24.5804,,,,
HC Recovery Rm - Major Procedure,PX-71000006,CDM,71000006,LOCAL,710,RC,,,inpatient,,,33,23.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,7.4085,27.9708,,,,
HC Recovery Rm - Intensive Major,PX-71000007,CDM,71000007,LOCAL,710,RC,,,inpatient,,,38,26.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.531,32.2088,,,,
HC Extended Recovery Overnight,PX-71000009,CDM,71000009,LOCAL,710,RC,,,inpatient,,,1500,1050,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,336.75,1271.4,,,,
HC Observation Nursing Time,PX-76200006,CDM,76200006,LOCAL,762,RC,,,inpatient,,,101,70.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.6745,6652,,,,
HC Tandem Dialysis,PX-80100001,CDM,80100001,LOCAL,801,RC,,,inpatient,,,1142,799.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,256.379,967.9592,,,,
HC Single Dialysis,PX-80100002,CDM,80100002,LOCAL,801,RC,,,inpatient,,,1142,799.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,256.379,967.9592,,,,
HC Unscheduled/Emergent Dialysis,PX-80100003,CDM,80100003,LOCAL,801,RC,,,inpatient,,,1142,799.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,256.379,967.9592,,,,
HC Weekend/Holiday Dialysis,PX-80100004,CDM,80100004,LOCAL,801,RC,,,inpatient,,,1142,799.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,256.379,967.9592,,,,
HC Capd per:Exchange,PX-80300001,CDM,80300001,LOCAL,803,RC,,,inpatient,,,569,398.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,127.7405,482.2844,,,,
HC Ccpd ER,PX-80400001,CDM,80400001,LOCAL,804,RC,,,inpatient,,,569,398.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,127.7405,482.2844,,,,
HC Ccpd,PX-80400002,CDM,80400002,LOCAL,804,RC,,,inpatient,,,1142,799.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,256.379,967.9592,,,,
HC Dietary Services per 15 Mins,PX-99000006,CDM,99000006,LOCAL,990,RC,,,inpatient,,,29,20.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,6.5105,24.5804,,,,
HC Hearing Aid Batteries,PX-99000034,CDM,99000034,LOCAL,479,RC,,,inpatient,,,7,4.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.5715,163,,,,
HC Hearing Aid Tune Up,PX-99000037,CDM,99000037,LOCAL,479,RC,,,inpatient,,,43,30.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.6535,163,,,,
HC Hearing Aid Fit,PX-99000038,CDM,99000038,LOCAL,479,RC,,,inpatient,,,171,119.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,38.3895,163,,,,
HC Full Trauma No Notification,PX-45000633,CDM,TR450,LOCAL,450,RC,,,inpatient,,,10370,7259,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9291.52,,,,
HC Partial Trauma No Notification,PX-45000634,CDM,TR450,LOCAL,450,RC,,,inpatient,,,7029,4920.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6297.984,,,,
Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face- Mouth And Neck With Major O.R. Procedures,3,MS-DRG,,,,,,,inpatient,,,404600.26,283220.182,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,189560.4996,,,189560.4996,7771.48,434261.5728,case rate,,,
Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face- Mouth And Neck Without Major O.R. Procedures,4,MS-DRG,,,,,,,inpatient,,,379341.67,265539.169,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,125063.5024,,,125063.5024,7771.48,303473.336,case rate,,,
Tracheostomy For Face- Mouth And Neck Diagnoses Or Laryngectomy With McC,11,MS-DRG,,,,,,,inpatient,,,57485.95,40240.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,47912.84716,,,47912.84716,7771.48,109336.4384,case rate,,,
Tracheostomy For Face- Mouth And Neck Diagnoses Or Laryngectomy With Cc,12,MS-DRG,,,,,,,inpatient,,,82266.47,57586.529,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,36498.49689,,,36498.49689,7771.48,83151.2976,case rate,,,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With McC Or Chemotherapy Implant Or Epilepsy With Neurostimulator,23,MS-DRG,,,,,,,inpatient,,,82526.76,57768.732,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,50644.09395,,,50644.09395,7771.48,115600.0408,case rate,,,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without McC,24,MS-DRG,,,,,,,inpatient,,,54359.41,38051.587,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,33830.84964,,,33830.84964,7771.48,77031.5696,case rate,,,
Craniotomy And Endovascular Intracranial Procedures With McC,25,MS-DRG,,,,,,,inpatient,,,91861.46,64303.022,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,39754.43987,,,39754.43987,7771.48,90620.608,case rate,,,
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,,,inpatient,,,74058,51840.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,27266.84741,,,27266.84741,7771.48,61975.4176,case rate,,,
Craniotomy And Endovascular Intracranial Procedures Without Cc/McC,27,MS-DRG,,,,,,,inpatient,,,61484.65,43039.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,22048.15206,,,22048.15206,7771.48,50003.4464,case rate,,,
Spinal Procedures With McC,28,MS-DRG,,,,,,,inpatient,,,148126.56,103688.592,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,53951.26988,,,53951.26988,7771.48,123186.8824,case rate,,,
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,inpatient,,,74991.36,52493.952,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,29900.04491,,,29900.04491,7771.48,68016.116,case rate,,,
Spinal Procedures Without Cc/McC,30,MS-DRG,,,,,,,inpatient,,,28580.9,20006.63,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19906.96764,,,19906.96764,7771.48,45091.4528,case rate,,,
Ventricular Shunt Procedures With McC,31,MS-DRG,,,,,,,inpatient,,,61588.79,43112.153,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,37266.10797,,,37266.10797,7771.48,84912.2392,case rate,,,
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,,,inpatient,,,117340.84,82138.588,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19113.74008,,,19113.74008,7771.48,93872.672,case rate,,,
Ventricular Shunt Procedures Without Cc/McC,33,MS-DRG,,,,,,,inpatient,,,50092.67,35064.869,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14342.89147,,,14342.89147,7771.48,40074.136,case rate,,,
Carotid Artery Stent Procedures With McC,34,MS-DRG,,,,,,,inpatient,,,80412.35,56288.645,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,34599.34405,,,34599.34405,7771.48,78796.564,case rate,,,
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,inpatient,,,59060.84,41342.588,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,20343.33113,,,20343.33113,7771.48,47248.672,case rate,,,
Carotid Artery Stent Procedures Without Cc/McC,36,MS-DRG,,,,,,,inpatient,,,55590.26,38913.182,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16441.67619,,,16441.67619,7771.48,44472.208,case rate,,,
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,inpatient,,,47239.38,33067.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14482.45712,,,14482.45712,7771.48,37791.504,case rate,,,
Extracranial Procedures Without Cc/McC,39,MS-DRG,,,,,,,inpatient,,,40302.61,28211.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10303.43753,,,10303.43753,7771.48,32242.088,case rate,,,
Peripheral- Cranial Nerve And Other Nervous System Procedures With McC,40,MS-DRG,,,,,,,inpatient,,,42423.5,29696.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,33569.38488,,,33569.38488,7771.48,76431.7552,case rate,,,
Peripheral- Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator,41,MS-DRG,,,,,,,inpatient,,,29478.8,20635.16,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,20196.69887,,,20196.69887,7771.48,45768.2704,case rate,,,
Peripheral- Cranial Nerve And Other Nervous System Procedures Without Cc/McC,42,MS-DRG,,,,,,,inpatient,,,40958.56,28670.992,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15774.76438,,,15774.76438,7771.48,35613.98,case rate,,,
Spinal Disorders And Injuries With Cc/McC,52,MS-DRG,,,,,,,inpatient,,,14188.67,9932.069,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,18026.36466,,,18026.36466,4731.921445,40779.2736,case rate,,,
Spinal Disorders And Injuries Without Cc/McC,53,MS-DRG,,,,,,,inpatient,,,42918.11,30042.677,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8388.384801,,,8388.384801,7771.48,34334.488,case rate,,,
Nervous System Neoplasms With McC,54,MS-DRG,,,,,,,inpatient,,,16507.92,11555.544,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13491.36433,,,13491.36433,5505.39132,30377.7624,case rate,,,
Nervous System Neoplasms Without McC,55,MS-DRG,,,,,,,inpatient,,,15148.1,10603.67,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9886.507232,,,9886.507232,5051.89135,22105.9976,case rate,,,
Degenerative Nervous System Disorders With McC,56,MS-DRG,,,,,,,inpatient,,,32807.03,22964.921,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,22368.79972,,,22368.79972,7771.48,50741.056,case rate,,,
Degenerative Nervous System Disorders Without McC,57,MS-DRG,,,,,,,inpatient,,,21955.44,15368.808,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12036.52492,,,12036.52492,7322.13924,27046.3608,case rate,,,
Multiple Sclerosis And Cerebellar Ataxia With McC,58,MS-DRG,,,,,,,inpatient,,,18732.22,13112.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16554.74204,,,16554.74204,6247.19537,37401.2648,case rate,,,
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,inpatient,,,30559.84,21391.888,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11057.79871,,,11057.79871,7771.48,24793.004,case rate,,,
Multiple Sclerosis And Cerebellar Ataxia Without Cc/McC,60,MS-DRG,,,,,,,inpatient,,,18686.21,13080.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8132.219999,,,8132.219999,6231.851035,18083.5936,case rate,,,
Ischemic Stroke- Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With McC,61,MS-DRG,,,,,,,inpatient,,,81185.85,56830.095,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,24129.27025,,,24129.27025,7771.48,64948.68,case rate,,,
Ischemic Stroke- Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc,62,MS-DRG,,,,,,,inpatient,,,55465.6,38825.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15980.57955,,,15980.57955,7771.48,44372.48,case rate,,,
Ischemic Stroke- Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/McC,63,MS-DRG,,,,,,,inpatient,,,65826.61,46078.627,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12658.38706,,,12658.38706,7771.48,52661.288,case rate,,,
Intracranial Hemorrhage Or Cerebral Infarction With McC,64,MS-DRG,,,,,,,inpatient,,,31988.78,22392.146,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,17820.54949,,,17820.54949,7771.48,40307.1224,case rate,,,
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,inpatient,,,20095.65,14066.955,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9231.961995,,,9231.961995,6701.899275,20608.488,case rate,,,
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/McC,66,MS-DRG,,,,,,,inpatient,,,17438.35,12206.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6329.349786,,,6329.349786,5143.64,13950.68,case rate,,,
Nonspecific Cva And Precerebral Occlusion Without Infarction With McC,67,MS-DRG,,,,,,,inpatient,,,38053.25,26637.275,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13100.93384,,,13100.93384,7771.48,30442.6,case rate,,,
Nonspecific Cva And Precerebral Occlusion Without Infarction Without McC,68,MS-DRG,,,,,,,inpatient,,,27888.66,19522.062,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8035.937366,,,8035.937366,6429.37,22310.928,case rate,,,
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,inpatient,,,17825.05,12477.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7316.909266,,,7316.909266,5687.74,16215.2528,case rate,,,
Nonspecific Cerebrovascular Disorders With McC,70,MS-DRG,,,,,,,inpatient,,,36237.19,25366.033,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15608.69892,,,15608.69892,7771.48,35233.0168,case rate,,,
Nonspecific Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,inpatient,,,26346.94,18442.858,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9558.79295,,,9558.79295,7313.53,21354.2032,case rate,,,
Cranial And Peripheral Nerve Disorders With McC,73,MS-DRG,,,,,,,inpatient,,,24367.12,17056.984,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13902.11134,,,13902.11134,7771.48,31318.012,case rate,,,
Cranial And Peripheral Nerve Disorders Without McC,74,MS-DRG,,,,,,,inpatient,,,24431.87,17102.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9457.210356,,,9457.210356,7368.52,21123.1936,case rate,,,
Viral Meningitis With Cc/McC,75,MS-DRG,,,,,,,inpatient,,,38318.52,26822.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15463.83331,,,15463.83331,7771.48,34902.7136,case rate,,,
Viral Meningitis Without Cc/McC,76,MS-DRG,,,,,,,inpatient,,,18360.72,12852.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8348.635091,,,8348.635091,6123.30012,18580.0616,case rate,,,
Hypertensive Encephalopathy With McC,77,MS-DRG,,,,,,,inpatient,,,24086.79,16860.753,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13908.29463,,,13908.29463,7771.48,31332.1968,case rate,,,
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,,,inpatient,,,18407.7,12885.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9064.129883,,,9064.129883,6138.96795,20219.4192,case rate,,,
Nontraumatic Stupor And Coma With McC,80,MS-DRG,,,,,,,inpatient,,,17643.44,12350.408,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,17808.18291,,,17808.18291,5884.08724,40280.7792,case rate,,,
Traumatic Stupor And Coma >1 Hour With McC,82,MS-DRG,,,,,,,inpatient,,,45789.39,32052.573,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,20744.36155,,,20744.36155,7771.48,47014.5064,case rate,,,
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,inpatient,,,24521.38,17164.966,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12531.18798,,,12531.18798,7771.48,28173.0392,case rate,,,
Traumatic Stupor And Coma >1 Hour Without Cc/McC,84,MS-DRG,,,,,,,inpatient,,,12382.21,8667.547,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8694.899237,,,8694.899237,4129.467035,19372.384,case rate,,,
Traumatic Stupor And Coma <1 Hour With McC,85,MS-DRG,,,,,,,inpatient,,,44820.5,31374.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,20265.59836,,,20265.59836,7771.48,45916.1976,case rate,,,
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,inpatient,,,22755.94,15929.158,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11835.12638,,,11835.12638,7589.10599,26578.2624,case rate,,,
Traumatic Stupor And Coma <1 Hour Without Cc/McC,87,MS-DRG,,,,,,,inpatient,,,19756.53,13829.571,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8058.020539,,,8058.020539,6241.25,17913.376,case rate,,,
Concussion With McC,88,MS-DRG,,,,,,,inpatient,,,61939.59,43357.713,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12710.50335,,,12710.50335,7771.48,49551.672,case rate,,,
Concussion With Cc,89,MS-DRG,,,,,,,inpatient,,,38694.98,27086.486,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9719.558447,,,9719.558447,7678.2,30955.984,case rate,,,
Other Disorders Of Nervous System With McC,91,MS-DRG,,,,,,,inpatient,,,27946.92,19562.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16351.57685,,,16351.57685,7771.48,36937.2192,case rate,,,
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,inpatient,,,23877.59,16714.313,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9601.192642,,,9601.192642,7134.82,21455.5232,case rate,,,
Other Disorders Of Nervous System Without Cc/McC,93,MS-DRG,,,,,,,inpatient,,,19087.94,13361.558,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7221.50996,,,7221.50996,5653.01,15994.3752,case rate,,,
Bacterial And Tuberculous Infections Of Nervous System With McC,94,MS-DRG,,,,,,,inpatient,,,86655,60658.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,32479.35948,,,32479.35948,7771.48,73931.1776,case rate,,,
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,,,inpatient,,,61521.3,43064.91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,21424.52326,,,21424.52326,7771.48,49217.04,case rate,,,
Bacterial And Tuberculous Infections Of Nervous System Without Cc/McC,96,MS-DRG,,,,,,,inpatient,,,33095.5,23166.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,21424.52326,,,21424.52326,7771.48,48572.808,case rate,,,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With McC,97,MS-DRG,,,,,,,inpatient,,,90065.06,63045.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,31913.14693,,,31913.14693,7771.48,72642.3872,case rate,,,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,inpatient,,,23740.04,16618.028,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19411.42125,,,19411.42125,7771.48,43954.6424,case rate,,,
Seizures With McC,100,MS-DRG,,,,,,,inpatient,,,22104.14,15472.898,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,17786.09974,,,17786.09974,7371.73069,40228.0928,case rate,,,
Seizures Without McC,101,MS-DRG,,,,,,,inpatient,,,15944.38,11161.066,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8391.034782,,,8391.034782,5317.45073,18675.3024,case rate,,,
Headaches With McC,102,MS-DRG,,,,,,,inpatient,,,25624.62,17937.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10491.58616,,,10491.58616,7771.48,23494.0816,case rate,,,
Headaches Without McC,103,MS-DRG,,,,,,,inpatient,,,20277.76,14194.432,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7759.456045,,,7759.456045,5992.35,17228.4528,case rate,,,
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,,,inpatient,,,26970.92,18879.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13773.14561,,,13773.14561,7771.48,31022.1576,case rate,,,
Neurological Eye Disorders,123,MS-DRG,,,,,,,inpatient,,,18842.87,13190.009,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7344.2924,,,7344.2924,5537.24,16276.0448,case rate,,,
Sinus And Mastoid Procedures With Cc/McC,135,MS-DRG,,,,,,,inpatient,,,60852.06,42596.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,21547.3057,,,21547.3057,7771.48,48854.4776,case rate,,,
Mouth Procedures Without Cc/McC,138,MS-DRG,,,,,,,inpatient,,,12689.7,8882.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7435.275071,,,7435.275071,4232.01495,16484.764,case rate,,,
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,inpatient,,,50999.49,35699.643,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19227.68925,,,19227.68925,7771.48,43533.1512,case rate,,,
Major Head And Neck Procedures Without Cc/McC,142,MS-DRG,,,,,,,inpatient,,,31036.34,21725.438,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14138.84295,,,14138.84295,7771.48,31861.0872,case rate,,,
Other Ear- Nose- Mouth And Throat O.R. Procedures With McC,143,MS-DRG,,,,,,,inpatient,,,146130.64,102291.448,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,29415.98177,,,29415.98177,7771.48,116904.512,case rate,,,
Other Ear- Nose- Mouth And Throat O.R. Procedures With Cc,144,MS-DRG,,,,,,,inpatient,,,29177.65,20424.355,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15766.81444,,,15766.81444,7771.48,35595.7424,case rate,,,
Ear- Nose- Mouth And Throat Malignancy With Cc,147,MS-DRG,,,,,,,inpatient,,,20455.22,14318.654,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11245.06401,,,11245.06401,6821.81587,25222.6008,case rate,,,
Ear- Nose- Mouth And Throat Malignancy Without Cc/McC,148,MS-DRG,,,,,,,inpatient,,,18282.89,12798.023,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7322.209227,,,7322.209227,5689.187157,16225.3848,case rate,,,
Dysequilibrium,149,MS-DRG,,,,,,,inpatient,,,21458.09,15020.663,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6852.279314,,,6852.279314,5321.63,17166.472,case rate,,,
Epistaxis With McC,150,MS-DRG,,,,,,,inpatient,,,36459.7,25521.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12458.75518,,,12458.75518,7771.48,29167.76,case rate,,,
Epistaxis Without McC,151,MS-DRG,,,,,,,inpatient,,,17762.28,12433.596,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6945.028639,,,6945.028639,5332.48243,15360.112,case rate,,,
Otitis Media And Uri With McC,152,MS-DRG,,,,,,,inpatient,,,22895.06,16026.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10273.40442,,,10273.40442,7635.50251,22993.5608,case rate,,,
Otitis Media And Uri Without McC,153,MS-DRG,,,,,,,inpatient,,,11257.92,7880.544,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6536.048282,,,6536.048282,3754.51632,14421.8888,case rate,,,
Other Ear- Nose- Mouth And Throat Diagnoses With McC,154,MS-DRG,,,,,,,inpatient,,,33108.79,23176.153,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14614.95615,,,14614.95615,7771.48,32953.3168,case rate,,,
Other Ear- Nose- Mouth And Throat Diagnoses With Cc,155,MS-DRG,,,,,,,inpatient,,,14149.33,9904.531,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8496.150684,,,8496.150684,4718.801555,18918.4704,case rate,,,
Other Ear- Nose- Mouth And Throat Diagnoses Without Cc/McC,156,MS-DRG,,,,,,,inpatient,,,3168.14,2217.698,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6188.900808,,,6188.900808,1056.57469,13625.5136,case rate,,,
Dental And Oral Diseases With McC,157,MS-DRG,,,,,,,inpatient,,,25823.75,18076.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14713.88877,,,14713.88877,7771.48,33180.2736,case rate,,,
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,inpatient,,,17794.61,12456.227,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8557.983567,,,8557.983567,5934.502435,19058.292,case rate,,,
Dental And Oral Diseases Without Cc/McC,159,MS-DRG,,,,,,,inpatient,,,15217,10651.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6075.834964,,,6075.834964,4744.97,13366.1344,case rate,,,
Major Chest Procedures With McC,163,MS-DRG,,,,,,,inpatient,,,128830.68,90181.476,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,40963.7144,,,40963.7144,7771.48,103064.544,case rate,,,
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,inpatient,,,83811.85,58668.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,22482.74889,,,22482.74889,7771.48,67049.48,case rate,,,
Major Chest Procedures Without Cc/McC,165,MS-DRG,,,,,,,inpatient,,,63087.07,44160.949,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16714.62421,,,16714.62421,7771.48,50469.656,case rate,,,
Other Respiratory System O.R. Procedures With McC,166,MS-DRG,,,,,,,inpatient,,,68518.66,47963.062,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,34260.14652,,,34260.14652,7771.48,78036.664,case rate,,,
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,inpatient,,,50504.64,35353.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16389.55991,,,16389.55991,7771.48,40403.712,case rate,,,
Other Respiratory System O.R. Procedures Without Cc/McC,168,MS-DRG,,,,,,,inpatient,,,36816.23,25771.361,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12208.77366,,,12208.77366,7771.48,29452.984,case rate,,,
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,inpatient,,,76600.57,53620.399,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,27355.1801,,,27355.1801,7771.48,62178.0576,case rate,,,
Pulmonary Embolism With McC Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,inpatient,,,27323.68,19126.576,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12696.37012,,,12696.37012,7771.48,28554.0024,case rate,,,
Pulmonary Embolism Without McC,176,MS-DRG,,,,,,,inpatient,,,16280.09,11396.063,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7444.10834,,,7444.10834,5429.410015,16505.028,case rate,,,
Respiratory Infections And Inflammations With McC,177,MS-DRG,,,,,,,inpatient,,,30316.04,21221.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14528.39012,,,14528.39012,7771.48,32756.756,case rate,,,
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,inpatient,,,21346.77,14942.739,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9012.896923,,,9012.896923,7119.147795,20103.9144,case rate,,,
Respiratory Infections And Inflammations Without Cc/McC,179,MS-DRG,,,,,,,inpatient,,,20533.98,14373.786,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7048.377887,,,7048.377887,6302.75,16427.184,case rate,,,
Respiratory Neoplasms With McC,180,MS-DRG,,,,,,,inpatient,,,24678.76,17275.132,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15688.19834,,,15688.19834,7771.48,35415.3928,case rate,,,
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,inpatient,,,15915.05,11140.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10056.98932,,,10056.98932,5307.669175,22497.0928,case rate,,,
Major Chest Trauma With McC,183,MS-DRG,,,,,,,inpatient,,,30366.68,21256.676,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14270.45866,,,14270.45866,7771.48,32163.0208,case rate,,,
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,inpatient,,,23252.15,16276.505,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9684.225371,,,9684.225371,7520.46,21641.952,case rate,,,
Major Chest Trauma Without Cc/McC,185,MS-DRG,,,,,,,inpatient,,,26254.04,18377.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7119.044039,,,7119.044039,5597.297704,21003.232,case rate,,,
Pleural Effusion With McC,186,MS-DRG,,,,,,,inpatient,,,23322.86,16326.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14205.9758,,,14205.9758,7771.48,32017.12,case rate,,,
Pleural Effusion With Cc,187,MS-DRG,,,,,,,inpatient,,,25224.41,17657.087,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9118.012825,,,9118.012825,7468.37,20343.0296,case rate,,,
Pleural Effusion Without Cc/McC,188,MS-DRG,,,,,,,inpatient,,,14227.72,9959.404,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6734.796835,,,6734.796835,4744.94462,14875.8024,case rate,,,
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,inpatient,,,23597.45,16518.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11179.69782,,,11179.69782,7771.48,25076.7,case rate,,,
Chronic Obstructive Pulmonary Disease With McC,190,MS-DRG,,,,,,,inpatient,,,20380.17,14266.119,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10169.17184,,,10169.17184,6796.786695,22762.5512,case rate,,,
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,inpatient,,,18415.04,12890.528,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7838.07214,,,7838.07214,6141.41584,17408.8024,case rate,,,
Chronic Obstructive Pulmonary Disease Without Cc/McC,192,MS-DRG,,,,,,,inpatient,,,15021,10514.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5966.302428,,,5966.302428,5009.5035,13114.8608,case rate,,,
Simple Pneumonia And Pleurisy With McC,193,MS-DRG,,,,,,,inpatient,,,24854.58,17398.206,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11889.00933,,,11889.00933,7771.48,26703.8992,case rate,,,
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,inpatient,,,16852.25,11796.575,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7492.69132,,,7492.69132,5620.225375,16616.48,case rate,,,
Simple Pneumonia And Pleurisy Without Cc/McC,195,MS-DRG,,,,,,,inpatient,,,11327.34,7929.138,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5749.887336,,,5749.887336,3777.66789,12620.4192,case rate,,,
Interstitial Lung Disease With McC,196,MS-DRG,,,,,,,inpatient,,,25824.88,18077.416,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16892.17291,,,16892.17291,7771.48,38181.4288,case rate,,,
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,inpatient,,,14747.43,10323.201,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8994.347058,,,8994.347058,4918.267905,20059.3336,case rate,,,
Interstitial Lung Disease Without Cc/McC,198,MS-DRG,,,,,,,inpatient,,,102750.94,71925.658,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6436.232342,,,6436.232342,5370.829997,82200.752,case rate,,,
Pneumothorax With McC,199,MS-DRG,,,,,,,inpatient,,,30942.21,21659.547,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15842.78055,,,15842.78055,7771.48,35770.0128,case rate,,,
Pneumothorax With Cc,200,MS-DRG,,,,,,,inpatient,,,23899.07,16729.349,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10032.25617,,,10032.25617,7771.48,22440.3536,case rate,,,
Pneumothorax Without Cc/McC,201,MS-DRG,,,,,,,inpatient,,,14142.03,9899.421,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6230.417173,,,6230.417173,4716.367005,13716.7016,case rate,,,
Bronchitis And Asthma With Cc/McC,202,MS-DRG,,,,,,,inpatient,,,14008.78,9806.146,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8788.531889,,,8788.531889,4671.92813,19589.2088,case rate,,,
Bronchitis And Asthma Without Cc/McC,203,MS-DRG,,,,,,,inpatient,,,8434.66,5904.262,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6402.665919,,,6402.665919,2812.95911,14109.8232,case rate,,,
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,inpatient,,,19382.31,13567.617,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7413.191898,,,7413.191898,5734.05,16432.0776,case rate,,,
Other Respiratory System Diagnoses With McC,205,MS-DRG,,,,,,,inpatient,,,29471.66,20630.162,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16924.85601,,,16924.85601,7771.48,38252.3528,case rate,,,
Other Respiratory System Diagnoses Without McC,206,MS-DRG,,,,,,,inpatient,,,18289.13,12802.391,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8250.585804,,,8250.585804,6099.424855,18355.1312,case rate,,,
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,inpatient,,,153413.76,107389.632,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,57375.92829,,,57375.92829,7771.48,131061.4728,case rate,,,
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,inpatient,,,60056.19,42039.333,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,23956.13817,,,23956.13817,7771.48,54390.6024,case rate,,,
Other Heart Assist System Implant,215,MS-DRG,,,,,,,inpatient,,,163000.7,114100.49,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,93836.12961,,,93836.12961,7771.48,214680.8688,case rate,,,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/McC,218,MS-DRG,,,,,,,inpatient,,,144438.6,101107.02,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,52801.17825,,,52801.17825,7771.48,120552.5624,case rate,,,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/McC,221,MS-DRG,,,,,,,inpatient,,,282573.82,197801.674,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,40817.08213,,,40817.08213,7771.48,226059.056,case rate,,,
Other Cardiothoracic Procedures With McC,228,MS-DRG,,,,,,,inpatient,,,215439.26,150807.482,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,44268.24035,,,44268.24035,7771.48,172351.408,case rate,,,
Coronary Bypass With Cardiac Catheterization Or Open Ablation With McC,233,MS-DRG,,,,,,,inpatient,,,335724.2,235006.94,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,69293.77489,,,69293.77489,7771.48,268579.36,case rate,,,
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without McC,234,MS-DRG,,,,,,,inpatient,,,168474.77,117932.339,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,47244.16869,,,47244.16869,7771.48,134779.816,case rate,,,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With McC,239,MS-DRG,,,,,,,inpatient,,,57370.89,40159.623,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,44741.70357,,,44741.70357,7771.48,102059.636,case rate,,,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,inpatient,,,51903.54,36332.478,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,25973.65682,,,25973.65682,7771.48,59008.768,case rate,,,
Permanent Cardiac Pacemaker Implant With McC,242,MS-DRG,,,,,,,inpatient,,,86942.73,60859.911,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,30211.85931,,,30211.85931,7771.48,69554.184,case rate,,,
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,inpatient,,,65531.01,45871.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,20148.99921,,,20148.99921,7771.48,52424.808,case rate,,,
Permanent Cardiac Pacemaker Implant Without Cc/McC,244,MS-DRG,,,,,,,inpatient,,,63411.07,44387.749,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16190.81135,,,16190.81135,7771.48,50728.856,case rate,,,
Aicd Generator Procedures,245,MS-DRG,,,,,,,inpatient,,,15907.12,11134.984,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,43415.82989,,,43415.82989,5305.02452,99020.036,case rate,,,
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without McC,251,MS-DRG,,,,,,,inpatient,,,55424.98,38797.486,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14052.27692,,,14052.27692,7771.48,44339.984,case rate,,,
Other Vascular Procedures With McC,252,MS-DRG,,,,,,,inpatient,,,85181.97,59627.379,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,30551.05684,,,30551.05684,7771.48,69509.5728,case rate,,,
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,inpatient,,,82797.33,57958.131,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,22800.74658,,,22800.74658,7771.48,66237.864,case rate,,,
Other Vascular Procedures Without Cc/McC,254,MS-DRG,,,,,,,inpatient,,,61488.65,43042.055,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15702.33157,,,15702.33157,7771.48,49190.92,case rate,,,
Upper Limb And Toe Amputation For Circulatory System Disorders With McC,255,MS-DRG,,,,,,,inpatient,,,163135.56,114194.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,23361.65917,,,23361.65917,7771.48,130508.448,case rate,,,
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,inpatient,,,13744.76,9621.332,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15210.31849,,,15210.31849,4583.87746,34319.1104,case rate,,,
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/McC,257,MS-DRG,,,,,,,inpatient,,,13802.75,9661.925,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8127.803364,,,8127.803364,4603.217125,18073.4616,case rate,,,
Cardiac Pacemaker Device Replacement Without McC,259,MS-DRG,,,,,,,inpatient,,,51584.98,36109.486,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15775.64771,,,15775.64771,7771.48,41267.984,case rate,,,
Cardiac Pacemaker Revision Except Device Replacement With McC,260,MS-DRG,,,,,,,inpatient,,,218275.68,152792.976,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,30337.29173,,,30337.29173,7771.48,174620.544,case rate,,,
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,inpatient,,,57651.04,40355.728,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,17011.42205,,,17011.42205,7771.48,46120.832,case rate,,,
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,inpatient,,,28475.53,19932.871,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,31122.56935,,,31122.56935,7771.48,70820.6536,case rate,,,
Aortic And Heart Assist Procedures Except Pulsation Balloon With McC,268,MS-DRG,,,,,,,inpatient,,,101907.56,71335.292,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,59146.11541,,,59146.11541,7771.48,135104.1408,case rate,,,
Aortic And Heart Assist Procedures Except Pulsation Balloon Without McC,269,MS-DRG,,,,,,,inpatient,,,145888.49,102121.943,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,37001.99323,,,37001.99323,7771.48,116710.792,case rate,,,
Other Major Cardiovascular Procedures With McC,270,MS-DRG,,,,,,,inpatient,,,185659.89,129961.923,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,45590.58073,,,45590.58073,7771.48,148527.912,case rate,,,
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,inpatient,,,127626.27,89338.389,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,30674.72261,,,30674.72261,7771.48,102101.016,case rate,,,
Other Major Cardiovascular Procedures Without Cc/McC,272,MS-DRG,,,,,,,inpatient,,,104134.1,72893.87,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,22352.01651,,,22352.01651,7771.48,83307.28,case rate,,,
Percutaneous And Other Intracardiac Procedures Without McC,274,MS-DRG,,,,,,,inpatient,,,98959.28,69271.496,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,27818.0434,,,27818.0434,7771.48,79167.424,case rate,,,
Cardiac Defibrillator Implant With Cardiac Catheterization And McC,275,MS-DRG,,,,,,,inpatient,,,167450.04,117215.028,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,62674.12307,,,62674.12307,7771.48,143195.556,case rate,,,
Cardiac Defibrillator Implant Without McC,277,MS-DRG,,,,,,,inpatient,,,278318.05,194822.635,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,41340.89499,,,41340.89499,7771.48,222654.44,case rate,,,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With McC,278,MS-DRG,,,,,,,inpatient,,,130044.83,91031.381,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,44444.90573,,,44444.90573,7771.48,104035.864,case rate,,,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without McC,279,MS-DRG,,,,,,,inpatient,,,135336.66,94735.662,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,28554.73804,,,28554.73804,7771.48,108269.328,case rate,,,
Acute Myocardial Infarction- Discharged Alive With McC,280,MS-DRG,,,,,,,inpatient,,,31571.18,22099.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14748.33852,,,14748.33852,7771.48,33263.356,case rate,,,
Acute Myocardial Infarction- Discharged Alive With Cc,281,MS-DRG,,,,,,,inpatient,,,22298.62,15609.034,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8391.918109,,,8391.918109,6744.11,18679.3552,case rate,,,
Acute Myocardial Infarction- Discharged Alive Without Cc/McC,282,MS-DRG,,,,,,,inpatient,,,15726.17,11008.319,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6654.414087,,,6654.414087,5244.677695,14693.4264,case rate,,,
Acute Myocardial Infarction- Expired With McC,283,MS-DRG,,,,,,,inpatient,,,47695.81,33387.067,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,17521.985,,,17521.985,7771.48,39624.2256,case rate,,,
Acute Myocardial Infarction- Expired With Cc,284,MS-DRG,,,,,,,inpatient,,,30935.67,21654.969,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6794.863065,,,6794.863065,5312.22,24748.536,case rate,,,
Circulatory Disorders Except Ami- With Cardiac Catheterization With McC,286,MS-DRG,,,,,,,inpatient,,,48769.97,34138.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19800.08508,,,19800.08508,7771.48,44850.3112,case rate,,,
Circulatory Disorders Except Ami- With Cardiac Catheterization Without McC,287,MS-DRG,,,,,,,inpatient,,,33854.25,23697.975,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9875.023982,,,9875.023982,7771.48,27083.4,case rate,,,
Acute And Subacute Endocarditis With McC,288,MS-DRG,,,,,,,inpatient,,,36276.49,25393.543,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,24377.48511,,,24377.48511,7771.48,55347.0632,case rate,,,
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,inpatient,,,34648,24253.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14176.82601,,,14176.82601,7771.48,31948.2224,case rate,,,
Heart Failure And Shock With McC,291,MS-DRG,,,,,,,inpatient,,,22051.33,15435.931,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11775.06015,,,11775.06015,7354.118555,26442.4936,case rate,,,
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,inpatient,,,17435.09,12204.563,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7856.622005,,,7856.622005,5814.602515,17453.3832,case rate,,,
Cardiac Arrest- Unexplained With McC,296,MS-DRG,,,,,,,inpatient,,,34260.06,23982.042,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14721.83871,,,14721.83871,7771.48,33198.5112,case rate,,,
Peripheral Vascular Disorders With McC,299,MS-DRG,,,,,,,inpatient,,,30642.24,21449.568,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14538.10671,,,14538.10671,7771.48,32781.0728,case rate,,,
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,inpatient,,,19909.9,13936.93,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9706.308543,,,9706.308543,6639.95165,21692.612,case rate,,,
Peripheral Vascular Disorders Without Cc/McC,301,MS-DRG,,,,,,,inpatient,,,15022.69,10515.883,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6551.064839,,,6551.064839,5010.067115,14454.3112,case rate,,,
Atherosclerosis With McC,302,MS-DRG,,,,,,,inpatient,,,19965.6,13975.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10525.15258,,,10525.15258,6658.5276,23571.0848,case rate,,,
Atherosclerosis Without McC,303,MS-DRG,,,,,,,inpatient,,,16291.73,11404.211,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6188.900808,,,6188.900808,4894.02,13625.5136,case rate,,,
Hypertension With McC,304,MS-DRG,,,,,,,inpatient,,,26689.62,18682.734,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10626.73518,,,10626.73518,7771.48,23806.1472,case rate,,,
Hypertension Without McC,305,MS-DRG,,,,,,,inpatient,,,17122.11,11985.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6880.545775,,,6880.545775,5343.34,15212.1848,case rate,,,
Cardiac Congenital And Valvular Disorders With McC,306,MS-DRG,,,,,,,inpatient,,,18809.29,13166.503,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13476.34777,,,13476.34777,6272.898215,30343.3136,case rate,,,
Cardiac Congenital And Valvular Disorders Without McC,307,MS-DRG,,,,,,,inpatient,,,16249.07,11374.349,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8432.551146,,,8432.551146,5419.064845,18770.5432,case rate,,,
Cardiac Arrhythmia And Conduction Disorders With McC,308,MS-DRG,,,,,,,inpatient,,,21486.31,15040.417,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10901.44985,,,10901.44985,7165.684385,24438.384,case rate,,,
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,inpatient,,,15843.59,11090.513,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6779.846508,,,6779.846508,5283.837265,14981.1752,case rate,,,
Cardiac Arrhythmia And Conduction Disorders Without Cc/McC,310,MS-DRG,,,,,,,inpatient,,,13559.61,9491.727,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5191.624733,,,5191.624733,4040.24,11337.708,case rate,,,
Angina Pectoris,311,MS-DRG,,,,,,,inpatient,,,18298.95,12809.265,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6417.682477,,,6417.682477,5043.07,14639.16,case rate,,,
Syncope And Collapse,312,MS-DRG,,,,,,,inpatient,,,18654.24,13057.968,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7945.838022,,,7945.838022,6057.47,17656.0232,case rate,,,
Chest Pain,313,MS-DRG,,,,,,,inpatient,,,18746.43,13122.501,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6551.064839,,,6551.064839,5215.27,14997.144,case rate,,,
Other Circulatory System Diagnoses With McC,314,MS-DRG,,,,,,,inpatient,,,33351.93,23346.351,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19271.8556,,,19271.8556,7771.48,43636.4976,case rate,,,
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,inpatient,,,17192.63,12034.841,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8749.665505,,,8749.665505,5733.742105,19500.0472,case rate,,,
Other Circulatory System Diagnoses Without Cc/McC,316,MS-DRG,,,,,,,inpatient,,,16812.59,11768.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6279.883479,,,6279.883479,5422.92,13832.2064,case rate,,,
Percutaneous Cardiovascular Procedures With Intraluminal Device With McC Or 4+ Arteries/Intraluminal Devices,321,MS-DRG,,,,,,,inpatient,,,107897.8,75528.46,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,25395.96103,,,25395.96103,7771.48,86318.24,case rate,,,
Percutaneous Cardiovascular Procedures With Intraluminal Device Without McC,322,MS-DRG,,,,,,,inpatient,,,85234.32,59664.024,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16230.56106,,,16230.56106,7771.48,68187.456,case rate,,,
Coronary Intravascular Lithotripsy With Intraluminal Device With McC,323,MS-DRG,,,,,,,inpatient,,,110878.49,77614.943,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,37873.83688,,,37873.83688,7771.48,88702.792,case rate,,,
Coronary Intravascular Lithotripsy With Intraluminal Device Without McC,324,MS-DRG,,,,,,,inpatient,,,99829.51,69880.657,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,28472.58864,,,28472.58864,7771.48,79863.608,case rate,,,
Stomach- Esophageal And Duodenal Procedures With McC,326,MS-DRG,,,,,,,inpatient,,,70344.55,49241.185,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,45113.5842,,,45113.5842,7771.48,102914.7768,case rate,,,
Stomach- Esophageal And Duodenal Procedures With Cc,327,MS-DRG,,,,,,,inpatient,,,76692.68,53684.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,21697.47128,,,21697.47128,7771.48,61354.144,case rate,,,
Stomach- Esophageal And Duodenal Procedures Without Cc/McC,328,MS-DRG,,,,,,,inpatient,,,58306.69,40814.683,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14325.22493,,,14325.22493,7771.48,46645.352,case rate,,,
Major Small And Large Bowel Procedures With McC,329,MS-DRG,,,,,,,inpatient,,,92091.01,64463.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,40810.89884,,,40810.89884,7771.48,93046.2088,case rate,,,
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,inpatient,,,66292.87,46405.009,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,21128.60875,,,21128.60875,7771.48,53034.296,case rate,,,
Major Small And Large Bowel Procedures Without Cc/McC,331,MS-DRG,,,,,,,inpatient,,,44944.36,31461.052,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14833.1379,,,14833.1379,7771.48,35955.488,case rate,,,
Rectal Resection With McC,332,MS-DRG,,,,,,,inpatient,,,65516.56,45861.592,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,30889.37105,,,30889.37105,7771.48,70285.684,case rate,,,
Rectal Resection With Cc,333,MS-DRG,,,,,,,inpatient,,,51060.47,35742.329,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19022.75741,,,19022.75741,7771.48,43063.0264,case rate,,,
Peritoneal Adhesiolysis With McC,335,MS-DRG,,,,,,,inpatient,,,76073.75,53251.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,32255.87777,,,32255.87777,7771.48,73434.7096,case rate,,,
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,inpatient,,,39391.39,27573.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,18907.92491,,,18907.92491,7771.48,42805.6736,case rate,,,
Peritoneal Adhesiolysis Without Cc/McC,337,MS-DRG,,,,,,,inpatient,,,43856.45,30699.515,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13809.36202,,,13809.36202,7771.48,35085.16,case rate,,,
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,inpatient,,,22777.13,15943.991,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13399.49833,,,13399.49833,7596.172855,30177.1488,case rate,,,
Minor Small And Large Bowel Procedures Without Cc/McC,346,MS-DRG,,,,,,,inpatient,,,25360.83,17752.581,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11249.48065,,,11249.48065,7771.48,25232.7328,case rate,,,
Anal And Stomal Procedures With McC,347,MS-DRG,,,,,,,inpatient,,,33046.94,23132.858,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,21155.99188,,,21155.99188,7771.48,47956.7824,case rate,,,
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,inpatient,,,21678.05,15174.635,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11369.61311,,,11369.61311,7229.629675,25508.3232,case rate,,,
Anal And Stomal Procedures Without Cc/McC,349,MS-DRG,,,,,,,inpatient,,,20851.83,14596.281,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8030.637405,,,8030.637405,6954.085305,17850.5576,case rate,,,
Inguinal And Femoral Hernia Procedures With McC,350,MS-DRG,,,,,,,inpatient,,,123839.74,86687.818,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,21614.43855,,,21614.43855,7771.48,99071.792,case rate,,,
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,inpatient,,,41444.06,29010.842,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13539.06398,,,13539.06398,7771.48,33155.248,case rate,,,
Inguinal And Femoral Hernia Procedures Without Cc/McC,352,MS-DRG,,,,,,,inpatient,,,27314.17,19119.919,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9988.973153,,,9988.973153,7771.48,22341.06,case rate,,,
Hernia Procedures Except Inguinal And Femoral With McC,353,MS-DRG,,,,,,,inpatient,,,60356.38,42249.466,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,26157.38882,,,26157.38882,7771.48,59430.2592,case rate,,,
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,inpatient,,,30185.36,21129.752,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15275.68468,,,15275.68468,7771.48,34471.0904,case rate,,,
Hernia Procedures Except Inguinal And Femoral Without Cc/McC,355,MS-DRG,,,,,,,inpatient,,,34745.89,24322.123,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12025.925,,,12025.925,7771.48,27796.712,case rate,,,
Other Digestive System O.R. Procedures With McC,356,MS-DRG,,,,,,,inpatient,,,122041.99,85429.393,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,37929.48648,,,37929.48648,7771.48,97633.592,case rate,,,
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,inpatient,,,40025.14,28017.598,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,20141.9326,,,20141.9326,7771.48,45632.5016,case rate,,,
Other Digestive System O.R. Procedures Without Cc/McC,358,MS-DRG,,,,,,,inpatient,,,22899.78,16029.846,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12219.37359,,,12219.37359,7637.07663,27457.72,case rate,,,
Major Esophageal Disorders With McC,368,MS-DRG,,,,,,,inpatient,,,52357.14,36649.998,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15000.97001,,,15000.97001,7771.48,41885.712,case rate,,,
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,inpatient,,,25013.89,17509.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9238.145284,,,9238.145284,7771.48,20620.6464,case rate,,,
Major Gastrointestinal Disorders And Peritoneal Infections With McC,371,MS-DRG,,,,,,,inpatient,,,31663.98,22164.786,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15689.965,,,15689.965,7771.48,35427.5512,case rate,,,
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,inpatient,,,22657.22,15860.054,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9341.494532,,,9341.494532,7435.09,20857.7352,case rate,,,
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/McC,373,MS-DRG,,,,,,,inpatient,,,16862.96,11804.072,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6657.064068,,,6657.064068,5379.51,14697.4792,case rate,,,
Digestive Malignancy With McC,374,MS-DRG,,,,,,,inpatient,,,35452.33,24816.631,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,18899.97497,,,18899.97497,7771.48,42787.436,case rate,,,
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,inpatient,,,28899.99,20229.993,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11102.84838,,,11102.84838,7771.48,24898.3768,case rate,,,
Digestive Malignancy Without Cc/McC,376,MS-DRG,,,,,,,inpatient,,,13461.5,9423.05,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8049.18727,,,8049.18727,4489.41025,17891.0856,case rate,,,
Gastrointestinal Hemorrhage With McC,377,MS-DRG,,,,,,,inpatient,,,36368.06,25457.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16310.06048,,,16310.06048,7771.48,36841.9784,case rate,,,
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,inpatient,,,26039.38,18227.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8958.130655,,,8958.130655,7186.19,20831.504,case rate,,,
Gastrointestinal Hemorrhage Without Cc/McC,379,MS-DRG,,,,,,,inpatient,,,12685.62,8879.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5873.553103,,,5873.553103,4230.65427,12900.0624,case rate,,,
Complicated Peptic Ulcer With McC,380,MS-DRG,,,,,,,inpatient,,,33309.68,23316.776,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,17247.27033,,,17247.27033,7771.48,38994.0152,case rate,,,
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,inpatient,,,25551.79,17886.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9869.724021,,,9869.724021,7667.34,22069.5224,case rate,,,
Uncomplicated Peptic Ulcer With McC,383,MS-DRG,,,,,,,inpatient,,,17337.01,12135.907,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11416.42943,,,11416.42943,5781.892835,25617.7488,case rate,,,
Uncomplicated Peptic Ulcer Without McC,384,MS-DRG,,,,,,,inpatient,,,17367.77,12157.439,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7930.821465,,,7930.821465,5792.151295,17621.5744,case rate,,,
Inflammatory Bowel Disease With McC,385,MS-DRG,,,,,,,inpatient,,,26393.7,18475.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14601.70625,,,14601.70625,7771.48,32922.9208,case rate,,,
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,inpatient,,,16705.38,11693.766,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9016.430231,,,9016.430231,5571.24423,20109.9936,case rate,,,
Inflammatory Bowel Disease Without Cc/McC,387,MS-DRG,,,,,,,inpatient,,,12511.84,8758.288,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6170.350943,,,6170.350943,4172.69864,13582.9592,case rate,,,
Gastrointestinal Obstruction With McC,388,MS-DRG,,,,,,,inpatient,,,25855.59,18098.913,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13233.43287,,,13233.43287,7771.48,29788.08,case rate,,,
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,inpatient,,,16977.78,11884.446,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7330.159169,,,7330.159169,5662.08963,16245.6488,case rate,,,
Gastrointestinal Obstruction Without Cc/McC,390,MS-DRG,,,,,,,inpatient,,,12959.35,9071.545,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5082.975523,,,5082.975523,4215.34,11086.4344,case rate,,,
Esophagitis- Gastroenteritis And Miscellaneous Digestive Disorders With McC,391,MS-DRG,,,,,,,inpatient,,,20838.16,14586.712,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11595.74479,,,11595.74479,6949.52636,26037.2136,case rate,,,
Esophagitis- Gastroenteritis And Miscellaneous Digestive Disorders Without McC,392,MS-DRG,,,,,,,inpatient,,,16987.8,11891.46,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7142.010538,,,7142.010538,5530.73,15811.9992,case rate,,,
Other Digestive System Diagnoses With McC,393,MS-DRG,,,,,,,inpatient,,,37534.54,26274.178,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14877.30424,,,14877.30424,7771.48,33555.1576,case rate,,,
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,inpatient,,,23011.57,16108.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8564.166855,,,8564.166855,6791.14,19074.5032,case rate,,,
Other Digestive System Diagnoses Without Cc/McC,395,MS-DRG,,,,,,,inpatient,,,17300.89,12110.623,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5870.903122,,,5870.903122,4700.83,13840.712,case rate,,,
Appendix Procedures With McC,397,MS-DRG,,,,,,,inpatient,,,61991.24,43393.868,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,22136.48475,,,22136.48475,7771.48,50206.0864,case rate,,,
Appendix Procedures With Cc,398,MS-DRG,,,,,,,inpatient,,,56760.43,39732.301,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13615.91342,,,13615.91342,7771.48,45408.344,case rate,,,
Appendix Procedures Without Cc/McC,399,MS-DRG,,,,,,,inpatient,,,27586.47,19310.529,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10176.23846,,,10176.23846,7771.48,22778.7624,case rate,,,
Pancreas- Liver And Shunt Procedures With McC,405,MS-DRG,,,,,,,inpatient,,,46019.16,32213.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,48202.57838,,,48202.57838,7771.48,110001.0976,case rate,,,
Pancreas- Liver And Shunt Procedures With Cc,406,MS-DRG,,,,,,,inpatient,,,55926.32,39148.424,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,25056.7635,,,25056.7635,7771.48,56905.3648,case rate,,,
Pancreas- Liver And Shunt Procedures Without Cc/McC,407,MS-DRG,,,,,,,inpatient,,,51764.06,36234.842,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19115.50673,,,19115.50673,7771.48,43275.7984,case rate,,,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,inpatient,,,23884.65,16719.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,18768.35926,,,18768.35926,7771.48,42479.4232,case rate,,,
Laparoscopic Cholecystectomy Without C.D.E. With McC,417,MS-DRG,,,,,,,inpatient,,,63968.01,44777.607,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,21241.67459,,,21241.67459,7771.48,51174.408,case rate,,,
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,inpatient,,,44129.12,30890.384,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14898.50409,,,14898.50409,7771.48,35303.296,case rate,,,
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/McC,419,MS-DRG,,,,,,,inpatient,,,36100.79,25270.553,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11888.126,,,11888.126,7771.48,28880.632,case rate,,,
Hepatobiliary Diagnostic Procedures With McC,420,MS-DRG,,,,,,,inpatient,,,75254.61,52678.227,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,31426.43381,,,31426.43381,7771.48,71515.7088,case rate,,,
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,,,inpatient,,,37061.98,25943.386,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14714.77209,,,14714.77209,7771.48,33182.3,case rate,,,
Hepatobiliary Diagnostic Procedures Without Cc/McC,422,MS-DRG,,,,,,,inpatient,,,34064.62,23845.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13229.01624,,,13229.01624,7771.48,29773.8952,case rate,,,
Other Hepatobiliary Or Pancreas O.R. Procedures With McC,423,MS-DRG,,,,,,,inpatient,,,81747.41,57223.187,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,36177.84923,,,36177.84923,7771.48,82415.7144,case rate,,,
Cirrhosis And Alcoholic Hepatitis With McC,432,MS-DRG,,,,,,,inpatient,,,29574.59,20702.213,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,17554.66809,,,17554.66809,7771.48,39699.2024,case rate,,,
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,inpatient,,,21623.94,15136.758,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9699.241928,,,9699.241928,7211.58399,21676.4008,case rate,,,
Cirrhosis And Alcoholic Hepatitis Without Cc/McC,434,MS-DRG,,,,,,,inpatient,,,14349.7,10044.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6401.782592,,,6401.782592,4483.05,14111.8496,case rate,,,
Malignancy Of Hepatobiliary System Or Pancreas With McC,435,MS-DRG,,,,,,,inpatient,,,41847.14,29292.998,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16366.59341,,,16366.59341,7771.48,36971.668,case rate,,,
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,inpatient,,,20489.14,14342.398,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10210.68821,,,10210.68821,6833.12819,22849.6864,case rate,,,
Disorders Of Pancreas Except Malignancy With McC,438,MS-DRG,,,,,,,inpatient,,,28902.5,20231.75,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14945.32042,,,14945.32042,7771.48,33715.2432,case rate,,,
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,inpatient,,,16481.74,11537.218,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7847.788735,,,7847.788735,5496.66029,17431.0928,case rate,,,
Disorders Of Pancreas Except Malignancy Without Cc/McC,440,MS-DRG,,,,,,,inpatient,,,15295.1,10706.57,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5682.754492,,,5682.754492,4383.92,12464.3864,case rate,,,
Disorders Of Liver Except Malignancy- Cirrhosis Or Alcoholic Hepatitis With McC,441,MS-DRG,,,,,,,inpatient,,,34043.85,23830.695,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16947.82251,,,16947.82251,7771.48,38305.0392,case rate,,,
Disorders Of Liver Except Malignancy- Cirrhosis Or Alcoholic Hepatitis With Cc,442,MS-DRG,,,,,,,inpatient,,,21274.77,14892.339,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8784.115255,,,8784.115255,6740.49,19579.0768,case rate,,,
Disorders Of Liver Except Malignancy- Cirrhosis Or Alcoholic Hepatitis Without Cc/McC,443,MS-DRG,,,,,,,inpatient,,,11297.88,7908.516,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6456.54886,,,6456.54886,3767.84298,14237.4864,case rate,,,
Disorders Of The Biliary Tract With McC,444,MS-DRG,,,,,,,inpatient,,,39694.28,27785.996,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15128.16909,,,15128.16909,7771.48,34134.708,case rate,,,
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,inpatient,,,32558.38,22790.866,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9829.090983,,,9829.090983,7771.48,26046.704,case rate,,,
Disorders Of The Biliary Tract Without Cc/McC,446,MS-DRG,,,,,,,inpatient,,,33146.93,23202.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7292.176112,,,7292.176112,5905.53,26517.544,case rate,,,
Spinal Fusion Except Cervical With Spinal Curvature- Malignancy- Infection Or Extensive Fusions With Cc,457,MS-DRG,,,,,,,inpatient,,,143333.97,100333.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,50947.07508,,,50947.07508,7771.48,116295.096,case rate,,,
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With McC,461,MS-DRG,,,,,,,inpatient,,,327456.17,229219.319,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,54456.53287,,,54456.53287,7771.48,261964.936,case rate,,,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With McC,463,MS-DRG,,,,,,,inpatient,,,128878.42,90214.894,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,47957.89683,,,47957.89683,7771.48,109439.7848,case rate,,,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With Cc,464,MS-DRG,,,,,,,inpatient,,,40970.26,28679.182,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,26295.18782,,,26295.18782,7771.48,59750.4304,case rate,,,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Without Cc/McC,465,MS-DRG,,,,,,,inpatient,,,35885.97,25120.179,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15584.84909,,,15584.84909,7771.48,35176.2776,case rate,,,
Revision Of Hip Or Knee Replacement With McC,466,MS-DRG,,,,,,,inpatient,,,84828.36,59379.852,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,45251.38319,,,45251.38319,7771.48,103230.8952,case rate,,,
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,inpatient,,,72170.88,50519.616,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,30505.12384,,,30505.12384,7771.48,69402.1736,case rate,,,
Revision Of Hip Or Knee Replacement Without Cc/McC,468,MS-DRG,,,,,,,inpatient,,,88973.4,62281.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,23421.72539,,,23421.72539,7771.48,71178.72,case rate,,,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With McC Or Total Ankle Replacement,469,MS-DRG,,,,,,,inpatient,,,112079.98,78455.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,29122.71724,,,29122.71724,7771.48,89663.984,case rate,,,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without McC,470,MS-DRG,,,,,,,inpatient,,,49135.63,34394.941,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16904.53949,,,16904.53949,7771.48,39308.504,case rate,,,
Cervical Spinal Fusion With McC,471,MS-DRG,,,,,,,inpatient,,,68213.66,47749.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,43155.24845,,,43155.24845,7771.48,98422.248,case rate,,,
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,inpatient,,,62194.58,43536.206,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,25841.15779,,,25841.15779,7771.48,58704.808,case rate,,,
Cervical Spinal Fusion Without Cc/McC,473,MS-DRG,,,,,,,inpatient,,,60389.67,42272.769,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,21161.29185,,,21161.29185,7771.48,48311.736,case rate,,,
Amputation For Musculoskeletal System And Connective Tissue Disorders With McC,474,MS-DRG,,,,,,,inpatient,,,118369.6,82858.72,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,39863.9724,,,39863.9724,7771.48,94695.68,case rate,,,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,inpatient,,,42743.34,29920.338,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19305.42202,,,19305.42202,7771.48,43711.4744,case rate,,,
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/McC,476,MS-DRG,,,,,,,inpatient,,,10865.65,7605.955,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10523.38593,,,10523.38593,3623.694275,23567.032,case rate,,,
Biopsies Of Musculoskeletal System And Connective Tissue With McC,477,MS-DRG,,,,,,,inpatient,,,79298.26,55508.782,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,30627.02296,,,30627.02296,7771.48,69683.8432,case rate,,,
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,inpatient,,,43683.25,30578.275,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,20906.8937,,,20906.8937,7771.48,47385.3376,case rate,,,
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/McC,479,MS-DRG,,,,,,,inpatient,,,48180.79,33726.553,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15935.52988,,,15935.52988,7771.48,38544.632,case rate,,,
Hip And Femur Procedures Except Major Joint With McC,480,MS-DRG,,,,,,,inpatient,,,63845.68,44691.976,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,26228.05497,,,26228.05497,7771.48,59596.424,case rate,,,
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,inpatient,,,51147.69,35803.383,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,18577.56065,,,18577.56065,7771.48,42045.7736,case rate,,,
Hip And Femur Procedures Except Major Joint Without Cc/McC,482,MS-DRG,,,,,,,inpatient,,,37492.92,26245.044,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14262.50872,,,14262.50872,7771.48,32146.8096,case rate,,,
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,inpatient,,,82685.37,57879.759,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,22758.34689,,,22758.34689,7771.48,66148.296,case rate,,,
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,inpatient,,,54953.11,38467.177,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,18983.89102,,,18983.89102,7771.48,43962.488,case rate,,,
Knee Procedures With Principal Diagnosis Of Infection Without Cc/McC,487,MS-DRG,,,,,,,inpatient,,,28558.04,19990.628,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14207.74245,,,14207.74245,7771.48,32019.1464,case rate,,,
Knee Procedures Without Principal Diagnosis Of Infection With Cc/McC,488,MS-DRG,,,,,,,inpatient,,,29907.22,20935.054,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,17610.31769,,,17610.31769,7771.48,39824.8392,case rate,,,
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/McC,489,MS-DRG,,,,,,,inpatient,,,28726.07,20108.249,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11188.53109,,,11188.53109,7771.48,25098.9904,case rate,,,
Lower Extremity And Humerus Procedures Except Hip- Foot And Femur With McC,492,MS-DRG,,,,,,,inpatient,,,73476.69,51433.683,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,31618.11574,,,31618.11574,7771.48,71957.464,case rate,,,
Lower Extremity And Humerus Procedures Except Hip- Foot And Femur With Cc,493,MS-DRG,,,,,,,inpatient,,,59232.47,41462.729,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,21458.08969,,,21458.08969,7771.48,48653.864,case rate,,,
Lower Extremity And Humerus Procedures Except Hip- Foot And Femur Without Cc/McC,494,MS-DRG,,,,,,,inpatient,,,55024.26,38516.982,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16903.65616,,,16903.65616,7771.48,44019.408,case rate,,,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/McC,497,MS-DRG,,,,,,,inpatient,,,25582.79,17907.953,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12108.95772,,,12108.95772,7771.48,27214.552,case rate,,,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/McC,498,MS-DRG,,,,,,,inpatient,,,53889.53,37722.671,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,22552.53172,,,22552.53172,7771.48,51160.5208,case rate,,,
Soft Tissue Procedures With McC,500,MS-DRG,,,,,,,inpatient,,,39746.36,27822.452,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,28239.39033,,,28239.39033,7771.48,64206.484,case rate,,,
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,inpatient,,,35413.37,24789.359,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16014.14597,,,16014.14597,7771.48,36169.2136,case rate,,,
Soft Tissue Procedures Without Cc/McC,502,MS-DRG,,,,,,,inpatient,,,46820.44,32774.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12591.25421,,,12591.25421,7771.48,37456.352,case rate,,,
Foot Procedures With McC,503,MS-DRG,,,,,,,inpatient,,,139085.96,97360.172,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,23627.54056,,,23627.54056,7771.48,111268.768,case rate,,,
Foot Procedures With Cc,504,MS-DRG,,,,,,,inpatient,,,58509.52,40956.664,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15751.79788,,,15751.79788,7771.48,46807.616,case rate,,,
Foot Procedures Without Cc/McC,505,MS-DRG,,,,,,,inpatient,,,18215.65,12750.955,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15751.79788,,,15751.79788,6074.919275,35575.4784,case rate,,,
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,inpatient,,,34935.4,24454.78,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13491.36433,,,13491.36433,7771.48,30375.736,case rate,,,
Major Shoulder Or Elbow Joint Procedures With Cc/McC,507,MS-DRG,,,,,,,inpatient,,,46308.19,32415.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,17370.05277,,,17370.05277,7771.48,39273.6584,case rate,,,
Major Shoulder Or Elbow Joint Procedures Without Cc/McC,508,MS-DRG,,,,,,,inpatient,,,21924.51,15347.157,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11649.62773,,,11649.62773,7311.824085,26152.7184,case rate,,,
Arthroscopy,509,MS-DRG,,,,,,,inpatient,,,27294.99,19106.493,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15766.81444,,,15766.81444,7771.48,35593.716,case rate,,,
Shoulder- Elbow Or Forearm Procedures- Except Major Joint Procedures With McC,510,MS-DRG,,,,,,,inpatient,,,62572,43800.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,25495.77697,,,25495.77697,7771.48,57914.512,case rate,,,
Shoulder- Elbow Or Forearm Procedures- Except Major Joint Procedures With Cc,511,MS-DRG,,,,,,,inpatient,,,55415.55,38790.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,17573.21796,,,17573.21796,7771.48,44332.44,case rate,,,
Shoulder- Elbow Or Forearm Procedures- Except Major Joint Procedures Without Cc/McC,512,MS-DRG,,,,,,,inpatient,,,47238.2,33066.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14451.54068,,,14451.54068,7771.48,37790.56,case rate,,,
Hand Or Wrist Procedures- Except Major Thumb Or Joint Procedures With Cc/McC,513,MS-DRG,,,,,,,inpatient,,,43600.38,30520.266,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13548.78058,,,13548.78058,7771.48,34880.304,case rate,,,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With McC,515,MS-DRG,,,,,,,inpatient,,,49277.7,34494.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,27565.41191,,,27565.41191,7771.48,62660.3408,case rate,,,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,inpatient,,,53176.69,37223.683,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,18019.29804,,,18019.29804,7771.48,42541.352,case rate,,,
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/McC,517,MS-DRG,,,,,,,inpatient,,,52111.68,36478.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13434.83141,,,13434.83141,7771.48,41689.344,case rate,,,
Back And Neck Procedures Except Spinal Fusion With McC Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,inpatient,,,37618.21,26332.747,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,31907.84697,,,31907.84697,7771.48,72622.1232,case rate,,,
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,inpatient,,,45454.66,31818.262,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,17667.73394,,,17667.73394,7771.48,39954.5288,case rate,,,
Back And Neck Procedures Except Spinal Fusion Without Cc/McC,520,MS-DRG,,,,,,,inpatient,,,30414.64,21290.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12909.2519,,,12909.2519,7771.48,29040.3384,case rate,,,
Hip Replacement With Principal Diagnosis Of Hip Fracture With McC,521,MS-DRG,,,,,,,inpatient,,,66299.82,46409.874,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,25995.74,,,25995.74,7771.48,59061.4544,case rate,,,
Hip Replacement With Principal Diagnosis Of Hip Fracture Without McC,522,MS-DRG,,,,,,,inpatient,,,59172.56,41420.792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,18870.82518,,,18870.82518,7771.48,47338.048,case rate,,,
Fractures Of Femur With McC,533,MS-DRG,,,,,,,inpatient,,,15534.08,10873.856,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13719.26267,,,13719.26267,5180.61568,30898.5472,case rate,,,
Fractures Of Femur Without McC,534,MS-DRG,,,,,,,inpatient,,,23461.3,16422.91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7439.691705,,,7439.691705,5705.828554,18769.04,case rate,,,
Fractures Of Hip And Pelvis With McC,535,MS-DRG,,,,,,,inpatient,,,19899.42,13929.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11996.77521,,,11996.77521,6636.45657,26949.0936,case rate,,,
Fractures Of Hip And Pelvis Without McC,536,MS-DRG,,,,,,,inpatient,,,17540.07,12278.049,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7412.308571,,,7412.308571,5582.83,16432.0776,case rate,,,
Sprains- Strains- And Dislocations Of Hip- Pelvis And Thigh With Cc/McC,537,MS-DRG,,,,,,,inpatient,,,18243.05,12770.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8367.184956,,,8367.184956,6084.057175,18620.5896,case rate,,,
Sprains- Strains- And Dislocations Of Hip- Pelvis And Thigh Without Cc/McC,538,MS-DRG,,,,,,,inpatient,,,12750.59,8925.413,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6180.950866,,,6180.950866,4252.321765,13607.276,case rate,,,
Osteomyelitis With McC,539,MS-DRG,,,,,,,inpatient,,,15126.14,10588.298,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,18113.81402,,,18113.81402,5044.56769,40987.9928,case rate,,,
Osteomyelitis With Cc,540,MS-DRG,,,,,,,inpatient,,,18734.75,13114.325,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11680.54418,,,11680.54418,6248.039125,26229.7216,case rate,,,
Osteomyelitis Without Cc/McC,541,MS-DRG,,,,,,,inpatient,,,13958.41,9770.887,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7977.63779,,,7977.63779,4655.129735,17726.9472,case rate,,,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With McC,542,MS-DRG,,,,,,,inpatient,,,18971.85,13280.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16724.3408,,,16724.3408,6327.111975,37790.3336,case rate,,,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,inpatient,,,20157.83,14110.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9620.625833,,,9620.625833,6722.636305,21496.0512,case rate,,,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/McC,544,MS-DRG,,,,,,,inpatient,,,15770.25,11039.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6924.71212,,,6924.71212,5259.378375,15313.5048,case rate,,,
Connective Tissue Disorders With McC,545,MS-DRG,,,,,,,inpatient,,,29219.27,20453.489,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,22570.19826,,,22570.19826,7771.48,51201.0488,case rate,,,
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,inpatient,,,19656.15,13759.305,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10475.68628,,,10475.68628,6555.326025,23459.6328,case rate,,,
Connective Tissue Disorders Without Cc/McC,547,MS-DRG,,,,,,,inpatient,,,8610.08,6027.056,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6840.796064,,,6840.796064,2871.46168,15120.9968,case rate,,,
Septic Arthritis With Cc,549,MS-DRG,,,,,,,inpatient,,,46061.25,32242.875,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10894.38323,,,10894.38323,7771.48,36849,case rate,,,
Medical Back Problems With McC,551,MS-DRG,,,,,,,inpatient,,,27883.52,19518.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15322.501,,,15322.501,7771.48,34576.4632,case rate,,,
Medical Back Problems Without McC,552,MS-DRG,,,,,,,inpatient,,,22361.84,15653.288,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8762.915409,,,8762.915409,6815.74,19530.4432,case rate,,,
Bone Diseases And Arthropathies With McC,553,MS-DRG,,,,,,,inpatient,,,13901.34,9730.938,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11785.66008,,,11785.66008,4636.09689,26470.8632,case rate,,,
Bone Diseases And Arthropathies Without McC,554,MS-DRG,,,,,,,inpatient,,,18962.8,13273.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7621.657048,,,7621.657048,5718.85,16912.3344,case rate,,,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without McC,556,MS-DRG,,,,,,,inpatient,,,20178.82,14125.174,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7461.774878,,,7461.774878,5833.89,16545.556,case rate,,,
Tendonitis- Myositis And Bursitis With McC,557,MS-DRG,,,,,,,inpatient,,,32769.21,22938.447,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13938.32774,,,13938.32774,7771.48,31403.1208,case rate,,,
Tendonitis- Myositis And Bursitis Without McC,558,MS-DRG,,,,,,,inpatient,,,15272.59,10690.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7879.588504,,,7879.588504,5093.408765,17504.0432,case rate,,,
Aftercare- Musculoskeletal System And Connective Tissue With McC,559,MS-DRG,,,,,,,inpatient,,,16267.53,11387.271,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16646.60803,,,16646.60803,5425.221255,37612.0104,case rate,,,
Aftercare- Musculoskeletal System And Connective Tissue With Cc,560,MS-DRG,,,,,,,inpatient,,,15449.56,10814.692,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10307.85417,,,10307.85417,5152.42826,23076.6432,case rate,,,
Aftercare- Musculoskeletal System And Connective Tissue Without Cc/McC,561,MS-DRG,,,,,,,inpatient,,,9300.65,6510.455,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7471.491474,,,7471.491474,3101.766775,16567.8464,case rate,,,
Fracture- Sprain- Strain And Dislocation Except Femur- Hip- Pelvis And Thigh With McC,562,MS-DRG,,,,,,,inpatient,,,32385.67,22669.969,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13176.89995,,,13176.89995,7771.48,29660.4168,case rate,,,
Fracture- Sprain- Strain And Dislocation Except Femur- Hip- Pelvis And Thigh Without McC,563,MS-DRG,,,,,,,inpatient,,,24167.6,16917.32,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8144.586575,,,8144.586575,6300.58,19334.08,case rate,,,
Other Musculoskeletal System And Connective Tissue Diagnoses With McC,564,MS-DRG,,,,,,,inpatient,,,25802.93,18062.051,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14110.57649,,,14110.57649,7771.48,31798.2688,case rate,,,
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,inpatient,,,22006.13,15404.291,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9256.695149,,,9256.695149,7280.97,20661.1744,case rate,,,
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/McC,566,MS-DRG,,,,,,,inpatient,,,6764.1,4734.87,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6857.579275,,,6857.579275,2255.82735,15157.472,case rate,,,
Skin Debridement With McC,570,MS-DRG,,,,,,,inpatient,,,33594.41,23516.087,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,26839.31719,,,26839.31719,7771.48,61002.7456,case rate,,,
Skin Debridement With Cc,571,MS-DRG,,,,,,,inpatient,,,26173.08,18321.156,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15038.95307,,,15038.95307,7771.48,33938.1472,case rate,,,
Skin Graft For Skin Ulcer Or Cellulitis With McC,573,MS-DRG,,,,,,,inpatient,,,229287.37,160501.159,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,54646.44815,,,54646.44815,7771.48,183429.896,case rate,,,
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,inpatient,,,76990.64,53893.448,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,30855.80463,,,30855.80463,7771.48,70208.6808,case rate,,,
Other Skin- Subcutaneous Tissue And Breast Procedures With McC,579,MS-DRG,,,,,,,inpatient,,,44370,31059,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,29040.56784,,,29040.56784,7771.48,66042.4024,case rate,,,
Other Skin- Subcutaneous Tissue And Breast Procedures With Cc,580,MS-DRG,,,,,,,inpatient,,,32530.15,22771.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15910.79672,,,15910.79672,7771.48,35926.0456,case rate,,,
Other Skin- Subcutaneous Tissue And Breast Procedures Without Cc/McC,581,MS-DRG,,,,,,,inpatient,,,34001.93,23801.351,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12962.25151,,,12962.25151,7771.48,29161.9224,case rate,,,
Mastectomy For Malignancy Without Cc/McC,583,MS-DRG,,,,,,,inpatient,,,26986.11,18890.277,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14759.82177,,,14759.82177,7771.48,33283.62,case rate,,,
Breast Biopsy- Local Excision And Other Breast Procedures With Cc/McC,584,MS-DRG,,,,,,,inpatient,,,15783.7,11048.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,18334.64575,,,18334.64575,5263.86395,41486.4872,case rate,,,
Skin Ulcers With McC,592,MS-DRG,,,,,,,inpatient,,,11607.65,8125.355,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,18413.26184,,,18413.26184,3871.151275,41666.8368,case rate,,,
Skin Ulcers With Cc,593,MS-DRG,,,,,,,inpatient,,,11196.69,7837.683,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11049.84877,,,11049.84877,3734.096115,24774.7664,case rate,,,
Skin Ulcers Without Cc/McC,594,MS-DRG,,,,,,,inpatient,,,9029.64,6320.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7746.206141,,,7746.206141,3011.38494,17196.0304,case rate,,,
Major Skin Disorders With McC,595,MS-DRG,,,,,,,inpatient,,,27847.46,19493.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,18932.65806,,,18932.65806,7771.48,42858.36,case rate,,,
Major Skin Disorders Without McC,596,MS-DRG,,,,,,,inpatient,,,30386.11,21270.277,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9799.057868,,,9799.057868,7157.25,24308.888,case rate,,,
Malignant Breast Disorders With McC,597,MS-DRG,,,,,,,inpatient,,,49956.04,34969.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15766.81444,,,15766.81444,7771.48,39964.832,case rate,,,
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,inpatient,,,27430.15,19201.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9779.624676,,,9779.624676,7771.48,21944.12,case rate,,,
Non-Malignant Breast Disorders With Cc/McC,600,MS-DRG,,,,,,,inpatient,,,13956.43,9769.501,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8699.315872,,,8699.315872,4654.469405,19396.7008,case rate,,,
Non-Malignant Breast Disorders Without Cc/McC,601,MS-DRG,,,,,,,inpatient,,,9383.02,6568.114,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5544.955495,,,5544.955495,3129.23717,12148.268,case rate,,,
Cellulitis With McC,602,MS-DRG,,,,,,,inpatient,,,27986.19,19590.333,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13227.24959,,,13227.24959,7771.48,29775.9216,case rate,,,
Cellulitis Without McC,603,MS-DRG,,,,,,,inpatient,,,16886.67,11820.669,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8029.754078,,,8029.754078,5631.704445,17850.5576,case rate,,,
Trauma To The Skin- Subcutaneous Tissue And Breast With McC,604,MS-DRG,,,,,,,inpatient,,,38556.84,26989.788,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13372.99853,,,13372.99853,7771.48,30845.472,case rate,,,
Trauma To The Skin- Subcutaneous Tissue And Breast Without McC,605,MS-DRG,,,,,,,inpatient,,,21359.36,14951.552,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8408.70132,,,8408.70132,6578.42,18717.8568,case rate,,,
Minor Skin Disorders With McC,606,MS-DRG,,,,,,,inpatient,,,6185.67,4329.969,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14473.62385,,,14473.62385,2062.920945,32627.0664,case rate,,,
Minor Skin Disorders Without McC,607,MS-DRG,,,,,,,inpatient,,,19860.65,13902.455,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7883.121812,,,7883.121812,5973.54,17514.1752,case rate,,,
Adrenal And Pituitary Procedures With Cc/McC,614,MS-DRG,,,,,,,inpatient,,,37769.13,26438.391,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,20380.43086,,,20380.43086,7771.48,46177.6032,case rate,,,
Adrenal And Pituitary Procedures Without Cc/McC,615,MS-DRG,,,,,,,inpatient,,,58015.91,40611.137,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12907.48525,,,12907.48525,7771.48,46412.728,case rate,,,
Amputation Of Lower Limb For Endocrine- Nutritional And Metabolic Disorders With McC,616,MS-DRG,,,,,,,inpatient,,,66449.27,46514.489,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,34389.99557,,,34389.99557,7771.48,78318.3336,case rate,,,
Amputation Of Lower Limb For Endocrine- Nutritional And Metabolic Disorders With Cc,617,MS-DRG,,,,,,,inpatient,,,29882.58,20917.806,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,17311.75319,,,17311.75319,7771.48,39154.1008,case rate,,,
Amputation Of Lower Limb For Endocrine- Nutritional And Metabolic Disorders Without Cc/McC,618,MS-DRG,,,,,,,inpatient,,,10245.69,7171.983,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11247.71399,,,11247.71399,3416.937615,25228.68,case rate,,,
Skin Grafts And Wound Debridement For Endocrine- Nutritional And Metabolic Disorders With McC,622,MS-DRG,,,,,,,inpatient,,,103303.17,72312.219,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,33303.50348,,,33303.50348,7771.48,82642.536,case rate,,,
Skin Grafts And Wound Debridement For Endocrine- Nutritional And Metabolic Disorders With Cc,623,MS-DRG,,,,,,,inpatient,,,20666.05,14466.235,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,17145.68774,,,17145.68774,6892.127675,38785.296,case rate,,,
Thyroid- Parathyroid And Thyroglossal Procedures With Cc,626,MS-DRG,,,,,,,inpatient,,,27302.86,19112.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13581.46367,,,13581.46367,7771.48,30582.4288,case rate,,,
Thyroid- Parathyroid And Thyroglossal Procedures Without Cc/McC,627,MS-DRG,,,,,,,inpatient,,,31328.53,21929.971,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11440.27926,,,11440.27926,7771.48,25670.4352,case rate,,,
Other Endocrine- Nutritional And Metabolic O.R. Procedures With McC,628,MS-DRG,,,,,,,inpatient,,,48752.32,34126.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,35102.84038,,,35102.84038,7771.48,79967.8232,case rate,,,
Other Endocrine- Nutritional And Metabolic O.R. Procedures With Cc,629,MS-DRG,,,,,,,inpatient,,,41481.26,29036.882,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,20116.31612,,,20116.31612,7771.48,45596.0264,case rate,,,
Diabetes With McC,637,MS-DRG,,,,,,,inpatient,,,33585.6,23509.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13113.30042,,,13113.30042,7771.48,29510.4632,case rate,,,
Diabetes With Cc,638,MS-DRG,,,,,,,inpatient,,,16607.1,11624.97,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8351.285071,,,8351.285071,5538.46785,18586.1408,case rate,,,
Diabetes Without Cc/McC,639,MS-DRG,,,,,,,inpatient,,,15715.82,11001.074,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5784.337086,,,5784.337086,4408.52,12697.4224,case rate,,,
Miscellaneous Disorders Of Nutrition- Metabolism- Fluids And Electrolytes With McC,640,MS-DRG,,,,,,,inpatient,,,19706.61,13794.627,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11979.992,,,11979.992,6572.154435,26912.6184,case rate,,,
Miscellaneous Disorders Of Nutrition- Metabolism- Fluids And Electrolytes Without McC,641,MS-DRG,,,,,,,inpatient,,,15211.2,10647.84,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7151.727134,,,7151.727134,5072.9352,15836.316,case rate,,,
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,inpatient,,,44600.9,31220.63,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11212.38092,,,11212.38092,7771.48,35680.72,case rate,,,
Endocrine Disorders With McC,643,MS-DRG,,,,,,,inpatient,,,24319.36,17023.552,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14888.78749,,,14888.78749,7771.48,33583.5272,case rate,,,
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,inpatient,,,18127.98,12689.586,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9377.710935,,,9377.710935,6045.68133,20942.844,case rate,,,
Endocrine Disorders Without Cc/McC,645,MS-DRG,,,,,,,inpatient,,,13087.48,9161.236,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7127.877308,,,7127.877308,4364.67458,15785.656,case rate,,,
Major Bladder Procedures With McC,653,MS-DRG,,,,,,,inpatient,,,74103.71,51872.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,49491.35234,,,49491.35234,7771.48,112955.5888,case rate,,,
Major Bladder Procedures With Cc,654,MS-DRG,,,,,,,inpatient,,,32847.58,22993.306,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,25177.77928,,,25177.77928,7771.48,57182.9816,case rate,,,
Kidney And Ureter Procedures For Neoplasm With McC,656,MS-DRG,,,,,,,inpatient,,,74882.24,52417.568,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,29028.20126,,,29028.20126,7771.48,66014.0328,case rate,,,
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,inpatient,,,35825.52,25077.864,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16397.50985,,,16397.50985,7771.48,37042.592,case rate,,,
Kidney And Ureter Procedures For Neoplasm Without Cc/McC,658,MS-DRG,,,,,,,inpatient,,,45531.4,31871.98,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13534.64735,,,13534.64735,7771.48,36425.12,case rate,,,
Kidney And Ureter Procedures For Non-Neoplasm With McC,659,MS-DRG,,,,,,,inpatient,,,43577.66,30504.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,23077.2279,,,23077.2279,7771.48,52366.2288,case rate,,,
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,inpatient,,,27744.56,19421.192,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12085.99122,,,12085.99122,7771.48,27151.7336,case rate,,,
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/McC,661,MS-DRG,,,,,,,inpatient,,,23214.29,16250.003,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9317.644705,,,9317.644705,7701.35,20803.0224,case rate,,,
Minor Bladder Procedures With McC,662,MS-DRG,,,,,,,inpatient,,,26200.57,18340.399,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,27805.67682,,,27805.67682,7771.48,63211.5216,case rate,,,
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,inpatient,,,51470.37,36029.259,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13741.34584,,,13741.34584,7771.48,41176.296,case rate,,,
Minor Bladder Procedures Without Cc/McC,664,MS-DRG,,,,,,,inpatient,,,21663.46,15164.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9787.574618,,,9787.574618,7224.76391,21881.0672,case rate,,,
Prostatectomy With McC,665,MS-DRG,,,,,,,inpatient,,,440302,308211.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,30579.3233,,,30579.3233,7771.48,352241.6,case rate,,,
Prostatectomy With Cc,666,MS-DRG,,,,,,,inpatient,,,21861.75,15303.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14800.4548,,,14800.4548,7290.893625,33378.8608,case rate,,,
Prostatectomy Without Cc/McC,667,MS-DRG,,,,,,,inpatient,,,16201.02,11340.714,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9328.244628,,,9328.244628,5403.04017,20825.3128,case rate,,,
Transurethral Procedures With McC,668,MS-DRG,,,,,,,inpatient,,,48931.22,34251.854,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,26009.87323,,,26009.87323,7771.48,59091.8504,case rate,,,
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,inpatient,,,33035.66,23124.962,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13918.89455,,,13918.89455,7771.48,31358.54,case rate,,,
Transurethral Procedures Without Cc/McC,670,MS-DRG,,,,,,,inpatient,,,33732.79,23612.953,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8691.36593,,,8691.36593,7065.36,26986.232,case rate,,,
Other Kidney And Urinary Tract Procedures With McC,673,MS-DRG,,,,,,,inpatient,,,60478,42334.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,37257.27471,,,37257.27471,7771.48,84906.16,case rate,,,
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,inpatient,,,73440.29,51408.203,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,20640.12897,,,20640.12897,7771.48,58752.232,case rate,,,
Renal Failure With McC,682,MS-DRG,,,,,,,inpatient,,,25189.25,17632.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13516.09748,,,13516.09748,7771.48,30436.528,case rate,,,
Renal Failure With Cc,683,MS-DRG,,,,,,,inpatient,,,17753.72,12427.604,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8101.303557,,,8101.303557,5920.86562,18012.6696,case rate,,,
Renal Failure Without Cc/McC,684,MS-DRG,,,,,,,inpatient,,,9135.38,6394.766,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5614.73832,,,5614.73832,3046.64923,12310.38,case rate,,,
Kidney And Urinary Tract Neoplasms With McC,686,MS-DRG,,,,,,,inpatient,,,27497.1,19247.97,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16906.30614,,,16906.30614,7771.48,38209.7984,case rate,,,
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,inpatient,,,25492.34,17844.638,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9548.193027,,,9548.193027,7581.24,21329.8864,case rate,,,
Kidney And Urinary Tract Infections With McC,689,MS-DRG,,,,,,,inpatient,,,20757.97,14530.579,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10586.98547,,,10586.98547,6922.782995,23716.9856,case rate,,,
Kidney And Urinary Tract Infections Without McC,690,MS-DRG,,,,,,,inpatient,,,16632.65,11642.855,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7338.992438,,,7338.992438,5546.988775,16263.8864,case rate,,,
Urinary Stones With McC,693,MS-DRG,,,,,,,inpatient,,,4007.39,2805.173,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13237.84951,,,13237.84951,1336.464565,29794.1592,case rate,,,
Urinary Stones Without McC,694,MS-DRG,,,,,,,inpatient,,,15019.62,10513.734,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7151.727134,,,7151.727134,5009.04327,15834.2896,case rate,,,
Kidney And Urinary Tract Signs And Symptoms With McC,695,MS-DRG,,,,,,,inpatient,,,29850.37,20895.259,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10211.57153,,,10211.57153,7771.48,23880.296,case rate,,,
Kidney And Urinary Tract Signs And Symptoms Without McC,696,MS-DRG,,,,,,,inpatient,,,12055.26,8438.682,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6360.266228,,,6360.266228,4020.42921,14016.6088,case rate,,,
Other Kidney And Urinary Tract Diagnoses With McC,698,MS-DRG,,,,,,,inpatient,,,25421.96,17795.372,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15097.25264,,,15097.25264,7771.48,34061.7576,case rate,,,
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,inpatient,,,18359.1,12851.37,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9258.461802,,,9258.461802,6122.75985,20665.2272,case rate,,,
Other Kidney And Urinary Tract Diagnoses Without Cc/McC,700,MS-DRG,,,,,,,inpatient,,,8380.95,5866.665,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6381.466073,,,6381.466073,2795.046825,14065.2424,case rate,,,
Major Male Pelvic Procedures Without Cc/McC,708,MS-DRG,,,,,,,inpatient,,,55574.17,38901.919,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13344.73206,,,13344.73206,7771.48,44459.336,case rate,,,
Penis Procedures With Cc/McC,709,MS-DRG,,,,,,,inpatient,,,18738.26,13116.782,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,20098.64958,,,20098.64958,6249.20971,45533.208,case rate,,,
Transurethral Prostatectomy With Cc/McC,713,MS-DRG,,,,,,,inpatient,,,28299.1,19809.37,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13022.31774,,,13022.31774,7771.48,29299.7176,case rate,,,
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/McC,717,MS-DRG,,,,,,,inpatient,,,29999.37,20999.559,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16639.54142,,,16639.54142,7771.48,37597.8256,case rate,,,
Malignancy- Male Reproductive System With Cc,723,MS-DRG,,,,,,,inpatient,,,3972.81,2780.967,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10168.28851,,,10168.28851,1324.932135,22754.4456,case rate,,,
Benign Prostatic Hypertrophy Without McC,726,MS-DRG,,,,,,,inpatient,,,40258.34,28180.838,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6824.89618,,,6824.89618,5378.07,32206.672,case rate,,,
Inflammation Of The Male Reproductive System With McC,727,MS-DRG,,,,,,,inpatient,,,22656.48,15859.536,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13229.01624,,,13229.01624,7555.93608,29773.8952,case rate,,,
Inflammation Of The Male Reproductive System Without McC,728,MS-DRG,,,,,,,inpatient,,,13639.47,9547.629,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7467.074839,,,7467.074839,4548.763245,16557.7144,case rate,,,
Other Male Reproductive System Diagnoses With Cc/McC,729,MS-DRG,,,,,,,inpatient,,,16117.99,11282.593,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9973.956595,,,9973.956595,5375.349665,22306.6112,case rate,,,
Other Male Reproductive System Diagnoses Without Cc/McC,730,MS-DRG,,,,,,,inpatient,,,5959.58,4171.706,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5610.321685,,,5610.321685,1987.51993,12298.2216,case rate,,,
Uterine And Adnexa Procedures For Non-Malignancy With Cc/McC,742,MS-DRG,,,,,,,inpatient,,,28503.79,19952.653,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16385.14327,,,16385.14327,7771.48,37014.2224,case rate,,,
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/McC,743,MS-DRG,,,,,,,inpatient,,,26776.68,18743.676,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10837.85031,,,10837.85031,7771.48,24288.4304,case rate,,,
D&C- Conization- Laparoscopy And Tubal Interruption With Cc/McC,744,MS-DRG,,,,,,,inpatient,,,42207.27,29545.089,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,17509.61842,,,17509.61842,7771.48,39593.8296,case rate,,,
D&C- Conization- Laparoscopy And Tubal Interruption Without Cc/McC,745,MS-DRG,,,,,,,inpatient,,,41300.62,28910.434,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9301.744821,,,9301.744821,7771.48,33040.496,case rate,,,
Vagina- Cervix And Vulva Procedures With Cc/McC,746,MS-DRG,,,,,,,inpatient,,,54026.22,37818.354,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15041.60305,,,15041.60305,7771.48,43220.976,case rate,,,
Vagina- Cervix And Vulva Procedures Without Cc/McC,747,MS-DRG,,,,,,,inpatient,,,14150.78,9905.546,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8686.949295,,,8686.949295,4719.28513,19354.1464,case rate,,,
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,,,inpatient,,,71661.69,50163.183,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12282.97312,,,12282.97312,7771.48,57329.352,case rate,,,
Other Female Reproductive System O.R. Procedures With Cc/McC,749,MS-DRG,,,,,,,inpatient,,,40397.2,28278.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,23115.21096,,,23115.21096,7771.48,52451.3376,case rate,,,
Malignancy- Female Reproductive System With McC,754,MS-DRG,,,,,,,inpatient,,,31179.58,21825.706,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16231.44439,,,16231.44439,7771.48,36661.6288,case rate,,,
Malignancy- Female Reproductive System With Cc,755,MS-DRG,,,,,,,inpatient,,,7660.86,5362.602,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10055.22267,,,10055.22267,2554.89681,22495.0664,case rate,,,
Malignancy- Female Reproductive System Without Cc/McC,756,MS-DRG,,,,,,,inpatient,,,11168.92,7818.244,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8685.182641,,,8685.182641,3724.83482,19350.0936,case rate,,,
Infections- Female Reproductive System With Cc,758,MS-DRG,,,,,,,inpatient,,,20130.99,14091.693,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9253.161841,,,9253.161841,6713.685165,20655.0952,case rate,,,
Infections- Female Reproductive System Without Cc/McC,759,MS-DRG,,,,,,,inpatient,,,18187.49,12731.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5902.702891,,,5902.702891,4943.22,14549.992,case rate,,,
Menstrual And Other Female Reproductive System Disorders With Cc/McC,760,MS-DRG,,,,,,,inpatient,,,19375.46,13562.822,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8955.480674,,,8955.480674,6461.71591,19970.172,case rate,,,
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,inpatient,,,14024.34,9817.038,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9933.323558,,,9933.323558,4677.11739,22215.4232,case rate,,,
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,inpatient,,,9265.92,6486.144,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12523.23804,,,12523.23804,3090.18432,28156.828,case rate,,,
Abortion With D&C- Aspiration Curettage Or Hysterotomy,770,MS-DRG,,,,,,,inpatient,,,25214.53,17650.171,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9754.008196,,,9754.008196,6425.75,21802.0376,case rate,,,
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,inpatient,,,8836.34,6185.438,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6551.948166,,,6551.948166,2946.91939,14456.3376,case rate,,,
Cesarean Section With Sterilization With McC,783,MS-DRG,,,,,,,inpatient,,,17734.56,12414.192,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16521.17561,,,16521.17561,5914.47576,37326.288,case rate,,,
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,inpatient,,,18719.59,13103.713,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9815.841079,,,9815.841079,6242.983265,21945.912,case rate,,,
Cesarean Section With Sterilization Without Cc/McC,785,MS-DRG,,,,,,,inpatient,,,17648.18,12353.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7965.271214,,,7965.271214,5885.66803,17728.9736,case rate,,,
Cesarean Section Without Sterilization With McC,786,MS-DRG,,,,,,,inpatient,,,21072.73,14750.911,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14523.09016,,,14523.09016,7027.755455,32742.5712,case rate,,,
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,inpatient,,,18455.52,12918.864,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9628.575776,,,9628.575776,6154.91592,21516.3152,case rate,,,
Cesarean Section Without Sterilization Without Cc/McC,788,MS-DRG,,,,,,,inpatient,,,17822.26,12475.582,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8240.869208,,,8240.869208,5943.72371,18338.92,case rate,,,
Neonates- Died Or Transferred To Another Acute Care Facility,789,MS-DRG,,,,,,,inpatient,,,6500.45,4550.315,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16172.26149,,,16172.26149,2167.900075,36529.9128,case rate,,,
Extreme Immaturity Or Respiratory Distress Syndrome- Neonate,790,MS-DRG,,,,,,,inpatient,,,71335.38,49934.766,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,52761.42854,,,52761.42854,7771.48,120469.48,case rate,,,
Prematurity With Major Problems,791,MS-DRG,,,,,,,inpatient,,,39411.64,27588.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,36111.59971,,,36111.59971,7771.48,82273.8664,case rate,,,
Prematurity Without Major Problems,792,MS-DRG,,,,,,,inpatient,,,10975.85,7683.095,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,21888.26989,,,21888.26989,3660.445975,49642.7472,case rate,,,
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,inpatient,,,8093.71,5665.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,37088.55927,,,37088.55927,2699.252285,84513.0384,case rate,,,
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,inpatient,,,5349.51,3744.657,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13289.08247,,,13289.08247,1784.061585,29913.7168,case rate,,,
Normal Newborn,795,MS-DRG,,,,,,,inpatient,,,4927.51,3449.257,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2014.297856,,,2014.297856,1378.34,7947.23,case rate,,,
Vaginal Delivery With Sterilization And/Or D&C With McC,796,MS-DRG,,,,,,,inpatient,,,17976.19,12583.333,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11525.96197,,,11525.96197,5995.059365,25869.0224,case rate,,,
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,inpatient,,,23001.33,16100.931,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8801.781793,,,8801.781793,6655.835261,19619.6048,case rate,,,
Vaginal Delivery With Sterilization And/Or D&C Without Cc/McC,798,MS-DRG,,,,,,,inpatient,,,14819.75,10373.825,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8801.781793,,,8801.781793,4942.386625,19619.6048,case rate,,,
Splenic Procedures With McC,799,MS-DRG,,,,,,,inpatient,,,81427.43,56999.201,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,42249.83837,,,42249.83837,7771.48,96345.188,case rate,,,
Splenic Procedures Without Cc/McC,801,MS-DRG,,,,,,,inpatient,,,60652.11,42456.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14750.9885,,,14750.9885,7771.48,48521.688,case rate,,,
Other O.R. Procedures Of The Blood And Blood Forming Organs With McC,802,MS-DRG,,,,,,,inpatient,,,94944.09,66460.863,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,31914.91358,,,31914.91358,7771.48,75955.272,case rate,,,
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/McC,804,MS-DRG,,,,,,,inpatient,,,22075,15452.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10015.47296,,,10015.47296,7362.0125,22401.852,case rate,,,
Vaginal Delivery Without Sterilization Or D&C With McC,805,MS-DRG,,,,,,,inpatient,,,13956.78,9769.746,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9065.01321,,,9065.01321,4654.58613,20221.4456,case rate,,,
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,inpatient,,,13483.61,9438.527,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6641.164183,,,6641.164183,4496.783935,14661.004,case rate,,,
Vaginal Delivery Without Sterilization Or D&C Without Cc/McC,807,MS-DRG,,,,,,,inpatient,,,13157.23,9210.061,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5878.853065,,,5878.853065,4387.936205,12912.2208,case rate,,,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With McC,808,MS-DRG,,,,,,,inpatient,,,31882.27,22317.589,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,20480.2468,,,20480.2468,7771.48,46412.6656,case rate,,,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With Cc,809,MS-DRG,,,,,,,inpatient,,,26642.66,18649.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11189.41442,,,11189.41442,7771.48,25096.964,case rate,,,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders Without Cc/McC,810,MS-DRG,,,,,,,inpatient,,,85706.42,59994.494,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8656.91618,,,8656.91618,6951.04,68565.136,case rate,,,
Red Blood Cell Disorders With McC,811,MS-DRG,,,,,,,inpatient,,,33080.94,23156.658,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12676.93692,,,12676.93692,7771.48,28507.3952,case rate,,,
Red Blood Cell Disorders Without McC,812,MS-DRG,,,,,,,inpatient,,,21914.25,15339.975,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8401.634705,,,8401.634705,6364.97,18701.6456,case rate,,,
Coagulation Disorders,813,MS-DRG,,,,,,,inpatient,,,31592.62,22114.834,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13923.31119,,,13923.31119,7771.48,31366.6456,case rate,,,
Reticuloendothelial And Immunity Disorders With McC,814,MS-DRG,,,,,,,inpatient,,,15313.53,10719.471,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,18715.35965,,,18715.35965,5107.062255,42357.8392,case rate,,,
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,inpatient,,,14949.63,10464.741,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9224.89538,,,9224.89538,4985.701605,20590.2504,case rate,,,
Other Antepartum Diagnoses With O.R. Procedures With McC,817,MS-DRG,,,,,,,inpatient,,,35079.77,24555.839,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,22642.63106,,,22642.63106,7771.48,51371.2664,case rate,,,
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,inpatient,,,56068.99,39248.293,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11626.66123,,,11626.66123,7771.48,44855.192,case rate,,,
Other Antepartum Diagnoses With O.R. Procedures Without Cc/McC,819,MS-DRG,,,,,,,inpatient,,,15513.53,10859.471,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7461.774878,,,7461.774878,5173.762255,16545.556,case rate,,,
Lymphoma And Leukemia With Major O.R. Procedures With McC,820,MS-DRG,,,,,,,inpatient,,,86514.51,60560.157,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,51679.35308,,,51679.35308,7771.48,117974.9816,case rate,,,
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,inpatient,,,70253.02,49177.114,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19968.80052,,,19968.80052,7771.48,56202.416,case rate,,,
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/McC,822,MS-DRG,,,,,,,inpatient,,,27823.59,19476.513,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10352.02051,,,10352.02051,7771.48,23173.9104,case rate,,,
Lymphoma And Non-Acute Leukemia With Other Procedures With McC,823,MS-DRG,,,,,,,inpatient,,,49236.57,34465.599,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,41584.69321,,,41584.69321,7771.48,94819.3088,case rate,,,
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/McC,825,MS-DRG,,,,,,,inpatient,,,56788.87,39752.209,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11121.39824,,,11121.39824,7771.48,45431.096,case rate,,,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With McC,826,MS-DRG,,,,,,,inpatient,,,115032.85,80522.995,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,42432.68704,,,42432.68704,7771.48,96764.6528,case rate,,,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without Cc/McC,828,MS-DRG,,,,,,,inpatient,,,37373.35,26161.345,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14408.25766,,,14408.25766,7771.48,32479.1392,case rate,,,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/McC,829,MS-DRG,,,,,,,inpatient,,,26899.5,18829.65,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,27489.44579,,,27489.44579,7771.48,62486.0704,case rate,,,
Other Antepartum Diagnoses Without O.R. Procedures With McC,831,MS-DRG,,,,,,,inpatient,,,8108.51,5675.957,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10416.50337,,,10416.50337,2704.188085,23321.8376,case rate,,,
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,inpatient,,,9811.14,6867.798,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6851.395987,,,6851.395987,3272.01519,15143.2872,case rate,,,
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/McC,833,MS-DRG,,,,,,,inpatient,,,8494.15,5945.905,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4840.943951,,,4840.943951,2832.799025,10533.2272,case rate,,,
Acute Leukemia Without Major O.R. Procedures With McC,834,MS-DRG,,,,,,,inpatient,,,33540.42,23478.294,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,49073.53871,,,49073.53871,7771.48,111997.1016,case rate,,,
Acute Leukemia Without Major O.R. Procedures With Cc,835,MS-DRG,,,,,,,inpatient,,,15922.85,11145.995,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19116.39006,,,19116.39006,5310.270475,43279.8512,case rate,,,
Lymphoma And Non-Acute Leukemia With McC,840,MS-DRG,,,,,,,inpatient,,,35119.86,24583.902,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,28418.7057,,,28418.7057,7771.48,64630.0016,case rate,,,
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,inpatient,,,17465.46,12225.822,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14099.97657,,,14099.97657,5824.73091,31771.9256,case rate,,,
Lymphoma And Non-Acute Leukemia Without Cc/McC,842,MS-DRG,,,,,,,inpatient,,,22518.92,15763.244,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9541.126412,,,9541.126412,7510.05982,21313.6752,case rate,,,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With McC,843,MS-DRG,,,,,,,inpatient,,,21080.37,14756.259,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16973.43899,,,16973.43899,7030.303395,38361.7784,case rate,,,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,inpatient,,,11557.79,8090.453,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10806.93387,,,10806.93387,3854.522965,24217.5064,case rate,,,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/McC,845,MS-DRG,,,,,,,inpatient,,,13919.38,9743.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7641.09024,,,7641.09024,4642.11323,16954.8888,case rate,,,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With McC,846,MS-DRG,,,,,,,inpatient,,,22506.34,15754.438,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,22807.8132,,,22807.8132,7505.86439,51746.1504,case rate,,,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,inpatient,,,14849.65,10394.755,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11473.84568,,,11473.84568,4952.358275,25747.4384,case rate,,,
Infectious And Parasitic Diseases With O.R. Procedures With McC,853,MS-DRG,,,,,,,inpatient,,,91139.43,63797.601,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,44427.23919,,,44427.23919,7771.48,101350.396,case rate,,,
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,inpatient,,,41334.13,28933.891,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,17899.16559,,,17899.16559,7771.48,40491.5248,case rate,,,
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/McC,855,MS-DRG,,,,,,,inpatient,,,41292.75,28904.925,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14608.77287,,,14608.77287,7771.48,33034.2,case rate,,,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With McC,856,MS-DRG,,,,,,,inpatient,,,65177.47,45624.229,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,40101.58734,,,40101.58734,7771.48,91416.9832,case rate,,,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,inpatient,,,33908.27,23735.789,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19496.22063,,,19496.22063,7771.48,44153.2296,case rate,,,
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/McC,858,MS-DRG,,,,,,,inpatient,,,18266.15,12786.305,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11630.19454,,,11630.19454,6091.761025,26108.1376,case rate,,,
Postoperative And Post-Traumatic Infections With McC,862,MS-DRG,,,,,,,inpatient,,,32409.02,22686.314,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16491.1425,,,16491.1425,7771.48,37257.3904,case rate,,,
Postoperative And Post-Traumatic Infections Without McC,863,MS-DRG,,,,,,,inpatient,,,26972.96,18881.072,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9081.796422,,,9081.796422,7071.87,21578.368,case rate,,,
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,inpatient,,,18759.94,13131.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8181.686305,,,8181.686305,6256.43999,18195.0456,case rate,,,
Viral Illness With McC,865,MS-DRG,,,,,,,inpatient,,,22475.35,15732.745,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13286.43249,,,13286.43249,7495.529225,29907.6376,case rate,,,
Viral Illness Without McC,866,MS-DRG,,,,,,,inpatient,,,13589.18,9512.426,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8065.087154,,,8065.087154,4531.99153,17927.5608,case rate,,,
Other Infectious And Parasitic Diseases Diagnoses With McC,867,MS-DRG,,,,,,,inpatient,,,29124.07,20386.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19190.58952,,,19190.58952,7771.48,43450.0688,case rate,,,
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,inpatient,,,22783.92,15948.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9525.226528,,,9525.226528,7598.43732,21277.2,case rate,,,
Other Infectious And Parasitic Diseases Diagnoses Without Cc/McC,869,MS-DRG,,,,,,,inpatient,,,6491.58,4544.106,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6605.831107,,,6605.831107,2164.94193,14579.948,case rate,,,
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,inpatient,,,165811.55,116068.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,61698.04684,,,61698.04684,7771.48,140966.516,case rate,,,
Septicemia Or Severe Sepsis Without Mv >96 Hours With McC,871,MS-DRG,,,,,,,inpatient,,,32860.99,23002.693,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,17581.1679,,,17581.1679,7771.48,39764.0472,case rate,,,
Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC,872,MS-DRG,,,,,,,inpatient,,,22133.41,15493.387,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9356.511089,,,9356.511089,7381.492235,20892.184,case rate,,,
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,,,inpatient,,,167914.64,117540.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,34960.62475,,,34960.62475,7771.48,134331.712,case rate,,,
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,inpatient,,,22889.31,16022.517,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8716.98241,,,8716.98241,6248.48,19425.0704,case rate,,,
Depressive Neuroses,881,MS-DRG,,,,,,,inpatient,,,44762.95,31334.065,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8323.901937,,,8323.901937,5798.441546,35810.36,case rate,,,
Neuroses Except Depressive,882,MS-DRG,,,,,,,inpatient,,,10863.25,7604.275,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8747.015525,,,8747.015525,3622.893875,19491.9416,case rate,,,
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,inpatient,,,35747.4,25023.18,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15002.73666,,,15002.73666,7771.48,33842.9064,case rate,,,
Psychoses,885,MS-DRG,,,,,,,inpatient,,,20082.8,14057.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12700.78675,,,12700.78675,6697.6138,28562.108,case rate,,,
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,inpatient,,,10508,7355.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16118.37855,,,16118.37855,3504.418,36402.2496,case rate,,,
Alcohol- Drug Abuse Or Dependence- Left Ama,894,MS-DRG,,,,,,,inpatient,,,15836.23,11085.361,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5762.253913,,,5762.253913,3961.38,12668.984,case rate,,,
Alcohol- Drug Abuse Or Dependence Without Rehabilitation Therapy With McC,896,MS-DRG,,,,,,,inpatient,,,35553.78,24887.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15979.69622,,,15979.69622,7771.48,36086.1312,case rate,,,
Alcohol- Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC,897,MS-DRG,,,,,,,inpatient,,,18541.81,12979.267,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8042.120655,,,8042.120655,5972.81,17876.9008,case rate,,,
Wound Debridements For Injuries With McC,901,MS-DRG,,,,,,,inpatient,,,46387.19,32471.033,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,39385.20922,,,39385.20922,7771.48,89773.5728,case rate,,,
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,inpatient,,,59864.86,41905.402,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,17011.42205,,,17011.42205,7771.48,47891.888,case rate,,,
Wound Debridements For Injuries Without Cc/McC,903,MS-DRG,,,,,,,inpatient,,,13693.85,9585.695,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11018.049,,,11018.049,4566.898975,24701.816,case rate,,,
Skin Grafts For Injuries With Cc/McC,904,MS-DRG,,,,,,,inpatient,,,114417.1,80091.97,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,34355.54582,,,34355.54582,7771.48,91533.68,case rate,,,
Hand Procedures For Injuries,906,MS-DRG,,,,,,,inpatient,,,51389.12,35972.384,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19528.0204,,,19528.0204,7771.48,44224.1536,case rate,,,
Other O.R. Procedures For Injuries With McC,907,MS-DRG,,,,,,,inpatient,,,48914.02,34239.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,35438.50461,,,35438.50461,7771.48,80721.644,case rate,,,
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,inpatient,,,44494.39,31146.073,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,18066.9977,,,18066.9977,7771.48,40872.488,case rate,,,
Other O.R. Procedures For Injuries Without Cc/McC,909,MS-DRG,,,,,,,inpatient,,,14125.93,9888.151,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11452.64583,,,11452.64583,4710.997655,25698.8048,case rate,,,
Traumatic Injury With McC,913,MS-DRG,,,,,,,inpatient,,,57017.38,39912.166,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14544.29,,,14544.29,7771.48,45613.904,case rate,,,
Traumatic Injury Without McC,914,MS-DRG,,,,,,,inpatient,,,28970.93,20279.651,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8344.218456,,,8344.218456,6429.37,23176.744,case rate,,,
Allergic Reactions With McC,915,MS-DRG,,,,,,,inpatient,,,42664.44,29865.108,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15600.74898,,,15600.74898,7771.48,35214.7792,case rate,,,
Allergic Reactions Without McC,916,MS-DRG,,,,,,,inpatient,,,12818.09,8972.663,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6115.584675,,,6115.584675,4274.833015,13455.296,case rate,,,
Poisoning And Toxic Effects Of Drugs With McC,917,MS-DRG,,,,,,,inpatient,,,41573.69,29101.583,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14733.32196,,,14733.32196,7771.48,33258.952,case rate,,,
Poisoning And Toxic Effects Of Drugs Without McC,918,MS-DRG,,,,,,,inpatient,,,19845.67,13891.969,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8063.3205,,,8063.3205,5723.92,17921.4816,case rate,,,
Complications Of Treatment With McC,919,MS-DRG,,,,,,,inpatient,,,48229.35,33760.545,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16357.76014,,,16357.76014,7771.48,38583.48,case rate,,,
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,inpatient,,,20650.21,14455.147,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9223.128726,,,9223.128726,6886.845035,20584.1712,case rate,,,
Complications Of Treatment Without Cc/McC,921,MS-DRG,,,,,,,inpatient,,,18737.44,13116.208,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6324.049825,,,6324.049825,5002.55,14989.952,case rate,,,
Other Injury- Poisoning And Toxic Effect Diagnoses With McC,922,MS-DRG,,,,,,,inpatient,,,42436.37,29705.459,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15172.33543,,,15172.33543,7771.48,34229.9488,case rate,,,
Other Injury- Poisoning And Toxic Effect Diagnoses Without McC,923,MS-DRG,,,,,,,inpatient,,,18119.88,12683.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9258.461802,,,9258.461802,6042.97998,20665.2272,case rate,,,
Non-Extensive Burns,935,MS-DRG,,,,,,,inpatient,,,6946.99,4862.893,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19650.80284,,,19650.80284,2316.821165,44505.8232,case rate,,,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,inpatient,,,22686.24,15880.368,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,18899.97497,,,18899.97497,7565.86104,42783.3832,case rate,,,
Signs And Symptoms With McC,947,MS-DRG,,,,,,,inpatient,,,29399.47,20579.629,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11610.76135,,,11610.76135,7771.48,26061.5304,case rate,,,
Signs And Symptoms Without McC,948,MS-DRG,,,,,,,inpatient,,,16042.18,11229.526,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7267.442959,,,7267.442959,5350.06703,16099.748,case rate,,,
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,inpatient,,,5109.91,3576.937,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5257.87425,,,5257.87425,1704.154985,11487.6616,case rate,,,
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,,,inpatient,,,149455.54,104618.878,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60565.62174,,,60565.62174,7771.48,138360.5656,case rate,,,
Limb Reattachment- Hip And Femur Procedures For Multiple Significant Trauma,956,MS-DRG,,,,,,,inpatient,,,64530.82,45171.574,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,34013.69831,,,34013.69831,7771.48,77453.0608,case rate,,,
Other O.R. Procedures For Multiple Significant Trauma With McC,957,MS-DRG,,,,,,,inpatient,,,104697.23,73288.061,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66182.69753,,,66182.69753,7771.48,151244.4168,case rate,,,
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,inpatient,,,68495.96,47947.172,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,36552.37984,,,36552.37984,7771.48,83274.908,case rate,,,
Other Multiple Significant Trauma With McC,963,MS-DRG,,,,,,,inpatient,,,43017.73,30112.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,24246.75272,,,24246.75272,7771.48,55049.1824,case rate,,,
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,inpatient,,,32958.94,23071.258,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,13500.1976,,,13500.1976,7771.48,30400.0528,case rate,,,
Hiv With Major Related Condition With McC,974,MS-DRG,,,,,,,inpatient,,,42445.87,29712.109,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,26627.31873,,,26627.31873,7771.48,60508.304,case rate,,,
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,,,inpatient,,,19415.36,13590.752,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12805.01933,,,12805.01933,6475.02256,28801.2232,case rate,,,
Hiv With Major Related Condition Without Cc/McC,976,MS-DRG,,,,,,,inpatient,,,36673.45,25671.415,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9109.179556,,,9109.179556,6867.108649,29338.76,case rate,,,
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,inpatient,,,53209.61,37246.727,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12986.10134,,,12986.10134,7771.48,42567.688,case rate,,,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC,981,MS-DRG,,,,,,,inpatient,,,96543.58,67580.506,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,42241.88843,,,42241.88843,7771.48,96341.1352,case rate,,,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,inpatient,,,54470.12,38129.084,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,21875.90331,,,21875.90331,7771.48,49616.404,case rate,,,
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/McC,983,MS-DRG,,,,,,,inpatient,,,18703.75,13092.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14985.07013,,,14985.07013,6237.700625,33802.3784,case rate,,,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC,987,MS-DRG,,,,,,,inpatient,,,51141.58,35799.106,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,31189.7022,,,31189.7022,7771.48,70984.792,case rate,,,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,inpatient,,,31104,21772.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15407.30039,,,15407.30039,7771.48,34773.024,case rate,,,
HC Fine Needle Aspiration Bx W/O Img Gdn Ea Addl,PX-36900722,CDM,10004,CPT,369,RC,,,outpatient,,,79,55.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,17.7355,1592,,,,
HC Fine Needle Aspiration Bx W/US Gdn 1st Lesion,PX-36900723,CDM,10005,CPT,369,RC,,,outpatient,,,2116,1481.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,767.89738,,,767.89738,399.86,2141,other,OPPS APC,,
HC Fine Needle Aspiration Bx W/US Gdn Ea Addl,PX-36900724,CDM,10006,CPT,369,RC,,,outpatient,,,258,180.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,57.921,1592,other,OPPS APC,,
HC Fine Needle Aspiration W/O Imaging Guidance,PX-36900674,CDM,10021,CPT,369,RC,,,outpatient,,,871,609.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,195.5395,1592,other,OPPS APC,,
HC Image-Guided Catheter Fluid Collection Drainage,PX-36900043,CDM,10030,CPT,369,RC,,,outpatient,,,692,484.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,767.89738,,,767.89738,155.354,2141,other,OPPS APC,,
HC Plcmt of Soft Tissue Loc Device(S)- Perc- First Lesion,PX-36900637,CDM,10035,CPT,369,RC,,,outpatient,,,1860,1302,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,767.89738,,,767.89738,291.227805,2141,other,OPPS APC,,
HC Plmt Sft Tiss Loclzj Dev Perq Each Addl Lesion,PX-36900889,CDM,10036,CPT,369,RC,,,outpatient,,,130,91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,29.185,1592,,,,
HC Drain Skin Abscess Simple,PX-36900044,CDM,10060,CPT,369,RC,,,outpatient,,,922,645.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,218.504125,,,218.504125,206.989,1592,other,OPPS APC,,
HC Drain Skin Abscess Complic,PX-36900045,CDM,10061,CPT,369,RC,,,outpatient,,,922,645.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,206.989,1592,other,OPPS APC,,
HC Drainage of Hematoma/Fluid,PX-36900048,CDM,10140,CPT,369,RC,,,outpatient,,,4838,3386.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,3715.584,other,OPPS APC,,
HC Puncture Drainage of Lesion,PX-36100003,CDM,10160,CPT,361,RC,,,outpatient,,,916,641.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,205.642,1592,other,OPPS APC,,
HC Puncture Drainage of Lesion,PX-36900049,CDM,10160,CPT,369,RC,,,outpatient,,,916,641.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,205.642,1592,other,OPPS APC,,
HC Complex Drainage- Wound,PX-36900050,CDM,10180,CPT,369,RC,,,outpatient,,,8640,6048,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3101.269425,,,3101.269425,399.86,6635.52,other,OPPS APC,,
HC Debridement- Infected Skin- Up to 10% Bsa,PX-36900606,CDM,11000,CPT,369,RC,,,outpatient,,,1174,821.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.4672,,,685.4672,263.563,1592,other,OPPS APC,,
HC Debridement- Infected Skin- Ea Add 10% Bsa,PX-36900607,CDM,11001,CPT,369,RC,,,outpatient,,,53,37.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,11.8985,1592,,,,
HC Debride Necrotic Skin/ Tissue- Genit & Perinm,PX-36900608,CDM,11004,CPT,369,RC,,,outpatient,,,2036,1425.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2998,,,,
HC Dbrdmt Skn Subq T/M/F Necro Infctj Abdl Wall,PX-36900876,CDM,11005,CPT,369,RC,,,outpatient,,,2001,1400.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2998,,,,
HC Dbrdmt Skn Subq T/M/F Necro Infctj Gent/Abdl,PX-36900877,CDM,11006,CPT,369,RC,,,outpatient,,,1815,1270.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2998,,,,
HC Removal Prosthetic Matrl Abdl Wall for Infection,PX-36900878,CDM,11008,CPT,369,RC,,,outpatient,,,706,494.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,158.497,3914,,,,
HC Dbrdmt W/Rmvl Fm Fx&/Dislc Skin&Subq Tissus,PX-36900743,CDM,11010,CPT,369,RC,,,outpatient,,,2113,1479.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,767.89738,,,767.89738,399.86,2141,other,OPPS APC,,
HC Dbrdmt W/Rmvl Fm Fx&/Dislc Skn Subq T/M/F Musc,PX-36900773,CDM,11011,CPT,369,RC,,,outpatient,,,2197,1537.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,767.89738,,,767.89738,399.86,2141,other,OPPS APC,,
HC Dbrdmt Fx&/Dislc Subq T/M/F Bone,PX-36900744,CDM,11012,CPT,369,RC,,,outpatient,,,9022,6315.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3101.269425,,,3101.269425,399.86,6928.896,other,OPPS APC,,
HC Debridement- Skin- Sub-Q Tissue-=<20 Sq Cm,PX-36900052,CDM,11042,CPT,369,RC,,,outpatient,,,1018,712.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,228.541,1592,other,OPPS APC,,
HC Debridement- Skin- Sub-Q Tissue-Muscle-=<20 Sq Cm,PX-36900053,CDM,11043,CPT,369,RC,,,outpatient,,,1065,745.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.4672,,,685.4672,239.0925,1592,other,OPPS APC,,
HC Debridement- Skin- Sub-Q Tissue-Muscle-Bone-=<20 Sq Cm,PX-36900054,CDM,11044,CPT,369,RC,,,outpatient,,,2829,1980.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2477.315575,other,OPPS APC,,
HC Debridement- Skin- Sub-Q Tissue-Each Add 20 Sq Cm,PX-36900055,CDM,11045,CPT,369,RC,,,outpatient,,,1203,842.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.0735,1592,other,OPPS APC,,
HC Debridement- Skin- Sub-Q Tissue-Muscle-Each Add 20 Sq Cm,PX-36900056,CDM,11046,CPT,369,RC,,,outpatient,,,1203,842.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.0735,1592,other,OPPS APC,,
HC Debridement- Skin- Sub-Q Tissue-Muscle-Bone-Each Add 20 Sq Cm,PX-36900057,CDM,11047,CPT,369,RC,,,outpatient,,,1910,1337,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,1592,other,OPPS APC,,
HC Trim Nail(S),PX-36900064,CDM,11719,CPT,369,RC,,,outpatient,,,347,242.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,62.19,1592,other,OPPS APC,,
HC Debridement of Nail(S)- 1-5,PX-36900065,CDM,11720,CPT,369,RC,,,outpatient,,,347,242.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,66.75974,1592,other,OPPS APC,,
HC Debridement Nail Any Method 6/>,PX-36900791,CDM,11721,CPT,369,RC,,,outpatient,,,212,148.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,47.594,1592,other,OPPS APC,,
HC Removal of Nail Plate,PX-36900067,CDM,11730,CPT,369,RC,,,outpatient,,,431,301.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,218.504125,,,218.504125,96.7595,1592,other,OPPS APC,,
HC Avulsion Nail Plate Partial/Comp Simple Ea Addl,PX-36900831,CDM,11732,CPT,369,RC,,,outpatient,,,139,97.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,31.2055,1592,,,,
HC Evacuation Subungual Hematoma,PX-36900832,CDM,11740,CPT,369,RC,,,outpatient,,,159,111.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,35.6955,1592,other,OPPS APC,,
HC Removal of Nail Bed,PX-36900069,CDM,11750,CPT,369,RC,,,outpatient,,,1914,1339.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,399.86,1592,other,OPPS APC,,
HC Biopsy Nail Unit Separate Procedure,PX-36900763,CDM,11755,CPT,369,RC,,,outpatient,,,2197,1537.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,767.89738,,,767.89738,399.86,2141,other,OPPS APC,,
HC Repair Nail Bed,PX-36900833,CDM,11760,CPT,369,RC,,,outpatient,,,909,636.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.4672,,,685.4672,113.876282,1592,other,OPPS APC,,
HC Wedge Excision Skin Nail Fold,PX-36900834,CDM,11765,CPT,369,RC,,,outpatient,,,1377,963.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,156.65,1592,other,OPPS APC,,
HC Resuperf Wnd Body <2.5cm,PX-36900070,CDM,12001,CPT,369,RC,,,outpatient,,,505,353.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,218.504125,,,218.504125,113.3725,1592,other,OPPS APC,,
HC Resup Npterf Wnd Body 2.6-7.5 Cm,PX-36900071,CDM,12002,CPT,369,RC,,,outpatient,,,505,353.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,218.504125,,,218.504125,113.3725,1592,other,OPPS APC,,
HC Resuperf Wnd Body 7.6-12.5 Cm,PX-36900072,CDM,12004,CPT,369,RC,,,outpatient,,,445,311.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,218.504125,,,218.504125,99.9025,1592,other,OPPS APC,,
HC Resuperf Wnd Body 12.6-20 Cm,PX-36900839,CDM,12005,CPT,369,RC,,,outpatient,,,513,359.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,115.1685,1592,other,OPPS APC,,
HC Resuperf Wnd Body 20.1-30 Cm,PX-36900840,CDM,12006,CPT,369,RC,,,outpatient,,,648,453.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,145.476,1592,other,OPPS APC,,
HC Resuperf Wnd Body >30 Cm,PX-36900841,CDM,12007,CPT,369,RC,,,outpatient,,,425,297.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,218.504125,,,218.504125,95.4125,1592,other,OPPS APC,,
HC Simple Repair F/E/E/N/L/M 2.5cm/<,PX-36900758,CDM,12011,CPT,369,RC,,,outpatient,,,329,230.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,218.504125,,,218.504125,73.8605,1592,other,OPPS APC,,
HC Resuperf Wnd Face 2.6-5 Cm,PX-36900842,CDM,12013,CPT,369,RC,,,outpatient,,,400,280,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,218.504125,,,218.504125,89.8,1592,other,OPPS APC,,
HC Resuperf Wnd Face 5.1-7.5 Cm,PX-36900843,CDM,12014,CPT,369,RC,,,outpatient,,,479,335.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,218.504125,,,218.504125,107.5355,1592,other,OPPS APC,,
HC Resuperf Wnd Face 7.6-12.5 Cm,PX-36900844,CDM,12015,CPT,369,RC,,,outpatient,,,633,443.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,218.504125,,,218.504125,142.1085,1592,other,OPPS APC,,
HC Resuperf Wnd Face 12.6-20 Cm,PX-36900845,CDM,12016,CPT,369,RC,,,outpatient,,,779,545.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,174.8855,1592,other,OPPS APC,,
HC Simple Repair Suprfcl Wnds F/E/E/N/L/Mucs Membrnes;20.1-30.0 Cm,PX-36900846,CDM,12017,CPT,369,RC,,,outpatient,,,555,388.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,124.5975,1592,other,OPPS APC,,
HC Simple Repair Suprfcl Wnds F/E/E/N/L/Mucs Membrnes;Over 30.0 Cm,PX-36900847,CDM,12018,CPT,369,RC,,,outpatient,,,448,313.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,218.504125,,,218.504125,100.576,1592,other,OPPS APC,,
HC Closure Superf Wnd Dehis Simple,PX-36900848,CDM,12020,CPT,369,RC,,,outpatient,,,1377,963.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.4672,,,685.4672,309.1365,1592,other,OPPS APC,,
HC Closure Superf Wnd Dehis W Packing,PX-36900849,CDM,12021,CPT,369,RC,,,outpatient,,,809,566.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,181.6205,1592,other,OPPS APC,,
HC Repair Intermediate S/a/T/E 2.5 Cm/<,PX-36900757,CDM,12031,CPT,369,RC,,,outpatient,,,891,623.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,200.0295,1592,other,OPPS APC,,
HC Layr Clos Wnd Trunk-Arm-Leg 2.6-7.5 Cm,PX-36900850,CDM,12032,CPT,369,RC,,,outpatient,,,505,353.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,113.3725,1592,other,OPPS APC,,
HC Layr Clos Wnd Trunk-Arm-Leg 7.6-12.5 Cm,PX-36900851,CDM,12034,CPT,369,RC,,,outpatient,,,685,479.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,153.7825,1592,other,OPPS APC,,
HC Layr Clos Wnd Trunk-Arm-Leg 12.6-20 Cm,PX-36900852,CDM,12035,CPT,369,RC,,,outpatient,,,685,479.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,153.7825,1592,other,OPPS APC,,
HC Layr Clos Wnd Trunk-Arm-Leg 20.1-30 Cm,PX-36900853,CDM,12036,CPT,369,RC,,,outpatient,,,649,454.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.4672,,,685.4672,145.7005,1592,other,OPPS APC,,
HC Layr Clos Wnd Trunk-Arm-Leg >30 Cm,PX-36900854,CDM,12037,CPT,369,RC,,,outpatient,,,4504,3152.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1990.340615,,,1990.340615,399.86,3459.072,other,OPPS APC,,
HC Repair Intermediate N/H/F/Xtrnl Gent 2.5cm/<,PX-36900756,CDM,12041,CPT,369,RC,,,outpatient,,,634,443.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,142.333,1592,other,OPPS APC,,
HC Repair Intermediate Neck/Hand/Feet/Xtrnl Gent 2.6-7.5 Cm,PX-36900806,CDM,12042,CPT,369,RC,,,outpatient,,,633,443.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,142.1085,1592,other,OPPS APC,,
HC Layr Clos Wnd Rest Body 7.6-12.5 Cm,PX-36900855,CDM,12044,CPT,369,RC,,,outpatient,,,623,436.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.4672,,,685.4672,139.8635,1592,other,OPPS APC,,
HC Layr Clos Wnd Rest Body 12.6-20 Cm,PX-36900856,CDM,12045,CPT,369,RC,,,outpatient,,,627,438.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.4672,,,685.4672,140.7615,1592,other,OPPS APC,,
HC Layr Clos Wnd Rest Body 20.1-30 Cm,PX-36900857,CDM,12046,CPT,369,RC,,,outpatient,,,1056,739.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.4672,,,685.4672,237.072,2141,other,OPPS APC,,
HC Repair Intermediate N/H/F/Xtrnl Gent >30.0 Cm,PX-36900858,CDM,12047,CPT,369,RC,,,outpatient,,,5238,3666.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1990.340615,,,1990.340615,399.86,4022.784,other,OPPS APC,,
HC Repair Intermediate F/E/E/N/L&/Muc 2.5 Cm/<,PX-36900755,CDM,12051,CPT,369,RC,,,outpatient,,,891,623.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,200.0295,1592,other,OPPS APC,,
HC Layr Clos Wnd Face-Facial 2.5-5 Cm,PX-36900859,CDM,12052,CPT,369,RC,,,outpatient,,,596,417.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,133.802,1592,other,OPPS APC,,
HC Layr Clos Wnd Face-Facial 5.1-7.5 Cm,PX-36900860,CDM,12053,CPT,369,RC,,,outpatient,,,663,464.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,148.8435,1592,other,OPPS APC,,
HC Layr Clos Wnd Face-Facial 7.6-12.5 Cm,PX-36900861,CDM,12054,CPT,369,RC,,,outpatient,,,652,456.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,146.374,1592,other,OPPS APC,,
HC Layr Clos Wnd Face-Facial 12.6-20 Cm,PX-36900862,CDM,12055,CPT,369,RC,,,outpatient,,,749,524.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,168.1505,1592,other,OPPS APC,,
HC Layr Clos Wnd Face-Facial 20.1-30 Cm,PX-36900863,CDM,12056,CPT,369,RC,,,outpatient,,,1419,993.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,318.5655,1592,other,OPPS APC,,
HC Repair Intermediate F/E/E/N/L&/Muc >30.0 Cm,PX-36900864,CDM,12057,CPT,369,RC,,,outpatient,,,1132,792.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,254.134,1592,other,OPPS APC,,
HC Repair Complex Trunk 1.1-2.5 Cm,PX-36900788,CDM,13100,CPT,369,RC,,,outpatient,,,1831,1281.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.4672,,,685.4672,399.86,1592,other,OPPS APC,,
HC Recmpl Wnd Trunk 2.6-7.5 Cm,PX-36900865,CDM,13101,CPT,369,RC,,,outpatient,,,1090,763,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.4672,,,685.4672,244.705,1592,other,OPPS APC,,
HC Rep-Skin-Trunk-Cmplx-+5 Cm/<,PX-36900866,CDM,13102,CPT,369,RC,,,outpatient,,,250,175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,56.125,1592,,,,
HC Repair Complex Scalp/Arm/Leg 1.1-2.5 Cm,PX-36900754,CDM,13120,CPT,369,RC,,,outpatient,,,1761,1232.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.4672,,,685.4672,395.3445,1592,other,OPPS APC,,
HC Recmpl Wnd Scalp-Extr 2.6-7.5 Cm,PX-36900867,CDM,13121,CPT,369,RC,,,outpatient,,,735,514.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.4672,,,685.4672,165.0075,1592,other,OPPS APC,,
HC Rep-Skin-Scalp/Extrem+5 Cm/<,PX-36900868,CDM,13122,CPT,369,RC,,,outpatient,,,305,213.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,68.4725,1592,,,,
HC Repair Complex F/C/C/M/N/Ax/G/H/F 1.1-2.5 Cm,PX-36900753,CDM,13131,CPT,369,RC,,,outpatient,,,1145,801.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,257.0525,1592,other,OPPS APC,,
HC Recmpl Wnd Head-Fac-Hand 2.6-7.5 Cm,PX-36900869,CDM,13132,CPT,369,RC,,,outpatient,,,723,506.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.4672,,,685.4672,162.3135,1592,other,OPPS APC,,
HC Repr-Face-Genital-Hand-Ft+5 Cmcm/<,PX-36900870,CDM,13133,CPT,369,RC,,,outpatient,,,578,404.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,129.761,1592,,,,
HC Repair Complex Eyelid/Nose/Ear/Lip 1.1-2.5 Cm,PX-36900752,CDM,13151,CPT,369,RC,,,outpatient,,,1761,1232.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.4672,,,685.4672,395.3445,1592,other,OPPS APC,,
HC Recmpl Wnd Lid-Nos-Ear 2.5-7.5 Cm,PX-36900871,CDM,13152,CPT,369,RC,,,outpatient,,,743,520.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.4672,,,685.4672,166.8035,1592,other,OPPS APC,,
HC Repr-Eyelid-Nose-Ear-Lip+5 Cm,PX-36900872,CDM,13153,CPT,369,RC,,,outpatient,,,462,323.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,103.719,1592,,,,
HC Secd Clos Surg Wnd Exten/Complic,PX-36900873,CDM,13160,CPT,369,RC,,,outpatient,,,4504,3152.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1990.340615,,,1990.340615,399.86,3459.072,other,OPPS APC,,
HC Dressing Change Under Anesthesia,PX-36900774,CDM,15852,CPT,369,RC,,,outpatient,,,1831,1281.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.4672,,,685.4672,108.7,1592,other,OPPS APC,,
HC Exc Coccyx/Ulcer W Suture,PX-36900598,CDM,15920,CPT,369,RC,,,outpatient,,,3425,2397.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3101.269425,,,3101.269425,399.86,4341.777195,other,OPPS APC,,
HC Exc Sacr Press Ulc W Pri Suture,PX-36900599,CDM,15931,CPT,369,RC,,,outpatient,,,7558,5290.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3101.269425,,,3101.269425,399.86,5804.544,other,OPPS APC,,
HC Exc Sacr Press Ulc W Flap Clos,PX-36900600,CDM,15934,CPT,369,RC,,,outpatient,,,9536,6675.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3915.61683,,,3915.61683,399.86,7323.648,other,OPPS APC,,
HC Exc Sacr Press Ulc W Musc Flap Clo,PX-36900601,CDM,15936,CPT,369,RC,,,outpatient,,,5831,4081.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1990.340615,,,1990.340615,399.86,4478.208,other,OPPS APC,,
HC Exc Isch Pres Ulc W Prim Clos,PX-36900602,CDM,15940,CPT,369,RC,,,outpatient,,,7558,5290.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3101.269425,,,3101.269425,399.86,5804.544,other,OPPS APC,,
HC Exc Isch Pres Ulc W Flap Clos,PX-36900603,CDM,15944,CPT,369,RC,,,outpatient,,,5831,4081.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3915.61683,,,3915.61683,399.86,5481.863562,other,OPPS APC,,
HC Exc Isch Pres Ulc Bone Myocut Flap,PX-36900604,CDM,15946,CPT,369,RC,,,outpatient,,,9536,6675.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1990.340615,,,1990.340615,399.86,7323.648,other,OPPS APC,,
HC Exc Troc Pres Ulc W Prim Clos,PX-36900605,CDM,15950,CPT,369,RC,,,outpatient,,,7558,5290.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,5804.544,other,OPPS APC,,
HC Initial Tx 1st Degree Burn Local Tx,PX-36900591,CDM,16000,CPT,369,RC,,,outpatient,,,393,275.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,218.504125,,,218.504125,88.2285,1592,other,OPPS APC,,
HC Dress/Debrid Small Burn No Anes,PX-36900090,CDM,16020,CPT,369,RC,,,outpatient,,,812,568.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,218.504125,,,218.504125,182.294,1592,other,OPPS APC,,
HC Dress/Debrid Med Burn No Anesth,PX-36900091,CDM,16025,CPT,369,RC,,,outpatient,,,812,568.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,218.504125,,,218.504125,182.294,1592,other,OPPS APC,,
HC Dress/Debrid Large Burn No Anesth,PX-36900092,CDM,16030,CPT,369,RC,,,outpatient,,,845,591.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,189.7025,1592,other,OPPS APC,,
HC Escharotomy Each Additional Incision,PX-36900883,CDM,16036,CPT,369,RC,,,outpatient,,,670,469,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.415,2998,,,,
HC Destruc Cut/Vasc 10-50 Sqcm,PX-36900094,CDM,17107,CPT,369,RC,,,outpatient,,,1763,1234.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.4672,,,685.4672,395.7935,1592,other,OPPS APC,,
HC Punc/Aspir Breast Cyst,PX-36900096,CDM,19000,CPT,369,RC,,,outpatient,,,1637,1145.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,767.89738,,,767.89738,367.5065,2141,other,OPPS APC,,
HC Puct/Aspir Breast Cyst-Each Addn,PX-36900097,CDM,19001,CPT,369,RC,,,outpatient,,,60,42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,13.47,1592,other,OPPS APC,,
HC Bx Breast W Device 1st Lesion Stereotactic Guide,PX-36900099,CDM,19081,CPT,369,RC,,,outpatient,,,4317,3021.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,3315.456,other,OPPS APC,,
HC Bx Breast W Device Addl Lesion Stereotact Guide,PX-36900100,CDM,19082,CPT,369,RC,,,outpatient,,,3998,2798.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,3070.464,other,OPPS APC,,
HC Bx Breast W Device 1st Lesion Ultrasound Guide,PX-36900101,CDM,19083,CPT,369,RC,,,outpatient,,,3271,2289.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC,,
HC Bx Breast W Device Addl Lesion Ultrasound Guide,PX-36900102,CDM,19084,CPT,369,RC,,,outpatient,,,2336,1635.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,1794.048,other,OPPS APC,,
HC Bx Breast W Device 1st Lesion Magnetic Res Guide,PX-36900103,CDM,19085,CPT,369,RC,,,outpatient,,,5120,3584,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,3932.16,other,OPPS APC,,
HC Bx Breast W Device Addl Lesion Magnet Res Guide,PX-36900104,CDM,19086,CPT,369,RC,,,outpatient,,,2232,1562.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,1714.176,other,OPPS APC,,
HC Perq Device Placemt Breast Loc 1st Les W Guidnce,PX-36900106,CDM,19281,CPT,369,RC,,,outpatient,,,915,640.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,108.7,2998,other,OPPS APC,,
HC Perq Device Placemt Breast Loc Ea Les W Guidnce,PX-36900107,CDM,19282,CPT,369,RC,,,outpatient,,,880,616,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,197.56,1592,other,OPPS APC,,
HC Perq Breast Loc Device Placemt 1st Strtctc Guid,PX-36900108,CDM,19283,CPT,369,RC,,,outpatient,,,2116,1481.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,767.89738,,,767.89738,108.7,2141,other,OPPS APC,,
HC Perq Breast Loc Device Placemt Ea Lesion Strtctc,PX-36900109,CDM,19284,CPT,369,RC,,,outpatient,,,84,58.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,18.858,1592,,,,
HC Perq Breast Loc Device Placemt 1st Lesio US Imag,PX-36900110,CDM,19285,CPT,369,RC,,,outpatient,,,1175,822.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,767.89738,,,767.89738,108.7,2141,other,OPPS APC,,
HC Perq Breast Loc Device Placemt Each Les US Image,PX-36900111,CDM,19286,CPT,369,RC,,,outpatient,,,274,191.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,61.513,1592,other,OPPS APC,,
HC Perq Breast Loc Device Placemt 1st Lesio MR Guid,PX-36900112,CDM,19287,CPT,369,RC,,,outpatient,,,2116,1481.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,767.89738,,,767.89738,108.7,2141,other,OPPS APC,,
HC Place Postop Breast Cath for Rad,PX-36900114,CDM,19296,CPT,369,RC,,,outpatient,,,14045,9831.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,10288.44571,,,10288.44571,399.86,14403.82399,other,OPPS APC,,
HC Muscle Biopsy,PX-36900115,CDM,20200,CPT,369,RC,,,outpatient,,,3700,2590,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC,,
HC Biopsy Muscle Deep,PX-36900764,CDM,20205,CPT,369,RC,,,outpatient,,,9022,6315.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3101.269425,,,3101.269425,399.86,6928.896,other,OPPS APC,,
HC Needle Biopsy-Muscle,PX-36900116,CDM,20206,CPT,369,RC,,,outpatient,,,3700,2590,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC,,
HC Bone Biopsy-Trocar/Needle Superf,PX-36900117,CDM,20220,CPT,369,RC,,,outpatient,,,3847,2692.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2954.496,other,OPPS APC,,
HC Bone Biopsy-Trocar/Needle Deep,PX-36900118,CDM,20225,CPT,369,RC,,,outpatient,,,3700,2590,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC,,
HC Biopsy Bone Open Superficial,PX-36900770,CDM,20240,CPT,369,RC,,,outpatient,,,9022,6315.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3101.269425,,,3101.269425,399.86,6928.896,other,OPPS APC,,
HC Biopsy Bone Open Deep,PX-36900769,CDM,20245,CPT,369,RC,,,outpatient,,,9022,6315.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3101.269425,,,3101.269425,399.86,6928.896,other,OPPS APC,,
HC Inject Sinus Tract for Dx W Xray,PX-36900120,CDM,20501,CPT,369,RC,,,outpatient,,,1451,1015.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,235.074116,1592,other,OPPS APC,,
HC Removal Foreign Body Muscle/Tendon Sheath Simple,PX-36900749,CDM,20520,CPT,369,RC,,,outpatient,,,5218,3652.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,4007.424,other,OPPS APC,,
HC Rmvl Foreign Body Muscle/Tendon Sheath Deep/Comp,PX-36900748,CDM,20525,CPT,369,RC,,,outpatient,,,5793,4055.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3101.269425,,,3101.269425,399.86,4449.024,other,OPPS APC,,
HC Injection of Tendon Sheath,PX-36900693,CDM,20550,CPT,369,RC,,,outpatient,,,823,576.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,323.2601,,,323.2601,184.7635,1592,other,OPPS APC,,
HC Injection Single Tendon Origin/Insertion,PX-36900793,CDM,20551,CPT,369,RC,,,outpatient,,,903,632.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,323.2601,,,323.2601,202.7235,1592,other,OPPS APC,,
HC Inject Trigger Point- 1 or 2,PX-36900123,CDM,20552,CPT,369,RC,,,outpatient,,,658,460.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,323.2601,,,323.2601,147.721,1592,other,OPPS APC,,
HC Drain/Inject Small Joint/Bursa,PX-36100004,CDM,20600,CPT,361,RC,,,outpatient,,,714,499.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,323.2601,,,323.2601,160.293,1592,other,OPPS APC,,
HC Drain/Inject Small Joint/Bursa,PX-36900125,CDM,20600,CPT,369,RC,,,outpatient,,,714,499.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,323.2601,,,323.2601,160.293,1592,other,OPPS APC,,
HC Arthrocnt Aspir&/Inj Small Jt/Bursaw/US Rec Rprt,PX-36900787,CDM,20604,CPT,369,RC,,,outpatient,,,938,656.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,323.2601,,,323.2601,210.581,1592,other,OPPS APC,,
HC Drain/Inject Intermediate Joint/Bursa,PX-36100005,CDM,20605,CPT,361,RC,,,outpatient,,,753,527.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,323.2601,,,323.2601,169.0485,1592,other,OPPS APC,,
HC Drain/Inject Intermediate Joint/Bursa,PX-36900126,CDM,20605,CPT,369,RC,,,outpatient,,,753,527.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,323.2601,,,323.2601,169.0485,1592,other,OPPS APC,,
HC Arthrocentesis Aspir&/Inj Interm Jt/Burs W/US,PX-36100030,CDM,20606,CPT,361,RC,,,outpatient,,,1844,1290.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,754.76995,,,754.76995,399.86,2141,other,OPPS APC,,
HC Drain/Inject Large Joint/Bursa,PX-36100006,CDM,20610,CPT,361,RC,,,outpatient,,,658,460.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,323.2601,,,323.2601,147.721,1592,other,OPPS APC,,
HC Drain/Inject Large Joint/Bursa,PX-36900127,CDM,20610,CPT,369,RC,,,outpatient,,,658,460.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,323.2601,,,323.2601,147.721,1592,other,OPPS APC,,
HC Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US,PX-36100031,CDM,20611,CPT,361,RC,,,outpatient,,,784,548.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,323.2601,,,323.2601,176.008,1592,other,OPPS APC,,
HC Ablate- Bone Tumor(S) Perq,PX-36900128,CDM,20982,CPT,369,RC,,,outpatient,,,16473,11531.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14364.36381,,,14364.36381,399.86,20110.10933,other,OPPS APC,,
HC Biopsy Soft Tissue Neck/Chest,PX-36900130,CDM,21550,CPT,369,RC,,,outpatient,,,4796,3357.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,3683.328,other,OPPS APC,,
HC Vertebroplasty Each Addl Cervicothor/Lumbosacral,PX-36900134,CDM,22512,CPT,369,RC,,,outpatient,,,1695,1186.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,380.5275,1592,,,,
HC Biopsy Soft Tissue Shoulder Superficial,PX-36900138,CDM,23065,CPT,369,RC,,,outpatient,,,2502,1751.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2477.315575,other,OPPS APC,,
HC Inj Proc Shoulder Arthrography/CT/MRI,PX-36900139,CDM,23350,CPT,369,RC,,,outpatient,,,1114,779.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,235.074116,1592,other,OPPS APC,,
HC Clsd Tx Shoulder Dislc W/Manipulation W/O Anes,PX-36900581,CDM,23650,CPT,369,RC,,,outpatient,,,735,514.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,257.382395,,,257.382395,165.0075,1592,other,OPPS APC,,
HC Clsd Tx Shoulder Dislc W/Manipulation Req Anes,PX-36900582,CDM,23655,CPT,369,RC,,,outpatient,,,3604,2522.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1754.138515,,,1754.138515,399.86,2998,other,OPPS APC,,
HC I&D Upper Arm/Elbow Deep Abscess/Hematoma,PX-36900784,CDM,23930,CPT,369,RC,,,outpatient,,,5218,3652.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3101.269425,,,3101.269425,399.86,4341.777195,other,OPPS APC,,
HC Incision&Drainage Upper Arm/Elbow Bursa,PX-36900751,CDM,23931,CPT,369,RC,,,outpatient,,,3342,2339.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC,,
HC Biopsy Soft Tissue Upper Arm/Elbow Superficial,PX-36900768,CDM,24065,CPT,369,RC,,,outpatient,,,5218,3652.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,4007.424,other,OPPS APC,,
HC Biopsy Soft Tissue Upper Arm/Elbow Area Deep,PX-36900767,CDM,24066,CPT,369,RC,,,outpatient,,,9022,6315.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3101.269425,,,3101.269425,399.86,6928.896,other,OPPS APC,,
HC Injection for Elbow Arthrogram,PX-36900143,CDM,24220,CPT,369,RC,,,outpatient,,,1224,856.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,274.788,1592,,,,
HC I&D Forearm&/Wrist Deep Abscess/Hematoma,PX-36900782,CDM,25028,CPT,369,RC,,,outpatient,,,9952,6966.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3532.756365,,,3532.756365,399.86,7643.136,other,OPPS APC,,
HC Incision & Drainage Forearm&/Wrist Bursa,PX-36900783,CDM,25031,CPT,369,RC,,,outpatient,,,4983,3488.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1754.138515,,,1754.138515,399.86,3826.944,other,OPPS APC,,
HC Incision Deep Bone Cortex Forearm&/Wrist,PX-36900785,CDM,25035,CPT,369,RC,,,outpatient,,,21621,15134.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7808.106015,,,7808.106015,399.86,16604.928,other,OPPS APC,,
HC Arthrt Rdcrpl/Midcarpl Jt W/Expl Drg/Rmvl FB,PX-36900778,CDM,25040,CPT,369,RC,,,outpatient,,,9952,6966.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3532.756365,,,3532.756365,399.86,7643.136,other,OPPS APC,,
HC Biopsy Soft Tissue Forearm&/Wrist Superficial,PX-36900766,CDM,25065,CPT,369,RC,,,outpatient,,,5218,3652.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,4007.424,other,OPPS APC,,
HC Biopsy Soft Tissue Forearm&/Wrist Deep,PX-36900765,CDM,25066,CPT,369,RC,,,outpatient,,,9022,6315.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3101.269425,,,3101.269425,399.86,6928.896,other,OPPS APC,,
HC Injection for Wrist Arthrogram,PX-36900149,CDM,25246,CPT,369,RC,,,outpatient,,,1660,1162,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,235.074116,1592,other,OPPS APC,,
HC Cltx Dstl Rdl Fx/Epiphysl Sep W/Manj When Perf,PX-36900792,CDM,25605,CPT,369,RC,,,outpatient,,,2563,1794.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1754.138515,,,1754.138515,399.86,2455.793921,other,OPPS APC,,
HC Drainage Finger Abscess Complicated,PX-36900750,CDM,26011,CPT,369,RC,,,outpatient,,,2563,1794.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC,,
HC Drainage Tendon Sheath Digit&/Palm Each,PX-36900781,CDM,26020,CPT,369,RC,,,outpatient,,,9952,6966.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3532.756365,,,3532.756365,399.86,7643.136,other,OPPS APC,,
HC Drainage of Palmar Bursa Single Bursa,PX-36900780,CDM,26025,CPT,369,RC,,,outpatient,,,9952,6966.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3532.756365,,,3532.756365,399.86,7643.136,other,OPPS APC,,
HC Drainage of Palmar Bursa Multiple Bursa,PX-36900779,CDM,26030,CPT,369,RC,,,outpatient,,,9952,6966.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3532.756365,,,3532.756365,399.86,7643.136,other,OPPS APC,,
HC Incision Bone Cortex Hand/Finger,PX-36900786,CDM,26034,CPT,369,RC,,,outpatient,,,4983,3488.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1754.138515,,,1754.138515,399.86,3826.944,other,OPPS APC,,
HC Arthrt Expl Drg/Rmvl Loose/FB Carp/Mtcrpl Jt,PX-36900775,CDM,26070,CPT,369,RC,,,outpatient,,,4983,3488.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1754.138515,,,1754.138515,399.86,3826.944,other,OPPS APC,,
HC Arthrt Expl Drg/Rmvl Loose/FB Mtcarphlngl Jt Ea,PX-36900777,CDM,26075,CPT,369,RC,,,outpatient,,,9952,6966.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3532.756365,,,3532.756365,399.86,7643.136,other,OPPS APC,,
HC Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea,PX-36900776,CDM,26080,CPT,369,RC,,,outpatient,,,4983,3488.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1754.138515,,,1754.138515,399.86,3826.944,other,OPPS APC,,
HC Bx Soft Tissues-Pelv/Hip-Superficl,PX-36900160,CDM,27040,CPT,369,RC,,,outpatient,,,3700,2590,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2841.6,other,OPPS APC,,
HC Bx Soft Tissues-Pelv/Hip-Deep,PX-36900161,CDM,27041,CPT,369,RC,,,outpatient,,,3700,2590,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2841.6,other,OPPS APC,,
HC Injection Hip Arthrogram,PX-36900162,CDM,27093,CPT,369,RC,,,outpatient,,,1589,1112.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,235.074116,1592,other,OPPS APC,,
HC Closed Rx Prox/Neck Femur Fx-Manip,PX-36900886,CDM,27232,CPT,369,RC,,,outpatient,,,3499,2449.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2998,,,,
HC Cltx Hip Dislocation Traumatic W/O Anesthesia,PX-36900583,CDM,27250,CPT,369,RC,,,outpatient,,,902,631.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,257.382395,,,257.382395,202.499,1592,other,OPPS APC,,
HC Cltx Hip Dislocation Traumatic Req Anesthesia,PX-36900584,CDM,27252,CPT,369,RC,,,outpatient,,,2848,1993.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1754.138515,,,1754.138515,399.86,2455.793921,other,OPPS APC,,
HC Cltx Post Hip Arthrp Dislc W/O Anes,PX-36900585,CDM,27265,CPT,369,RC,,,outpatient,,,671,469.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,257.382395,,,257.382395,150.6395,1592,other,OPPS APC,,
HC Cltx Post Hip Arthrp Dislc Req Anes,PX-36900586,CDM,27266,CPT,369,RC,,,outpatient,,,2045,1431.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1754.138515,,,1754.138515,399.86,2998,other,OPPS APC,,
HC Unlisted Procedure Pelvis/Hip Joint,PX-36900700,CDM,27299,CPT,369,RC,,,outpatient,,,715,500.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,257.382395,,,257.382395,160.5175,1592,other,OPPS APC,,
HC I&D Deep Absc Bursa/Hematoma Thigh/Knee Region,PX-36900814,CDM,27301,CPT,369,RC,,,outpatient,,,7663,5364.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3101.269425,,,3101.269425,399.86,5885.184,other,OPPS APC,,
HC Injection Knee Arthrography,PX-36900731,CDM,27369,CPT,369,RC,,,outpatient,,,1446,1012.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,324.627,1592,other,OPPS APC,,
HC Injection for Ankle Arthrogram,PX-36900167,CDM,27648,CPT,369,RC,,,outpatient,,,834,583.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,187.233,1592,other,OPPS APC,,
HC Closed Tx Bimalleolar Ankle Fracture W/Manj,PX-36900880,CDM,27810,CPT,369,RC,,,outpatient,,,3663,2564.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1754.138515,,,1754.138515,292.65,2813.184,other,OPPS APC,,
HC Application Cast Shoulder Hand Long Arm,PX-36900741,CDM,29065,CPT,369,RC,,,outpatient,,,664,464.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,293.11054,,,293.11054,149.068,1592,other,OPPS APC,,
HC Application Cast Elbow Finger Short Arm,PX-36900739,CDM,29075,CPT,369,RC,,,outpatient,,,893,625.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,293.11054,,,293.11054,200.4785,1592,other,OPPS APC,,
HC Application Cast Hand & Lower Forearm Gauntlet,PX-36900740,CDM,29085,CPT,369,RC,,,outpatient,,,491,343.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,171.973915,,,171.973915,110.2295,1592,other,OPPS APC,,
HC Application Cast Finger,PX-36900771,CDM,29086,CPT,369,RC,,,outpatient,,,511,357.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,171.973915,,,171.973915,114.7195,1592,other,OPPS APC,,
HC Application Long Arm Splint Shoulder Hand,PX-36900759,CDM,29105,CPT,369,RC,,,outpatient,,,453,317.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,171.973915,,,171.973915,101.6985,1592,other,OPPS APC,,
HC Application Short Arm Splint Forearm-Hand Static,PX-36900576,CDM,29125,CPT,369,RC,,,outpatient,,,354,247.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,79.473,1592,other,OPPS APC,,
HC Application Short Arm Splint Dynamic,PX-36900577,CDM,29126,CPT,369,RC,,,outpatient,,,354,247.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,79.473,1592,other,OPPS APC,,
HC Application Finger Splint Static,PX-36900579,CDM,29130,CPT,369,RC,,,outpatient,,,221,154.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,49.6145,1592,other,OPPS APC,,
HC Application Finger Splint Dynamic,PX-36900580,CDM,29131,CPT,369,RC,,,outpatient,,,218,152.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,48.941,1592,other,OPPS APC,,
HC Strapping Shoulder,PX-36900761,CDM,29240,CPT,369,RC,,,outpatient,,,405,283.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,90.9225,1592,other,OPPS APC,,
HC Strapping Elbow/Wrist,PX-36900760,CDM,29260,CPT,369,RC,,,outpatient,,,122,85.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,27.389,1592,other,OPPS APC,,
HC Strapping Hand/Finger,PX-36900790,CDM,29280,CPT,369,RC,,,outpatient,,,122,85.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,27.389,1592,other,OPPS APC,,
HC Application Short Leg Cast Below Knee-Toe,PX-36900818,CDM,29405,CPT,369,RC,,,outpatient,,,699,489.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,293.11054,,,293.11054,156.9255,1592,other,OPPS APC,,
HC Application Long Leg Splint Thigh Ankle/Toes,PX-36900737,CDM,29505,CPT,369,RC,,,outpatient,,,554,387.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,171.973915,,,171.973915,124.373,1592,other,OPPS APC,,
HC Application Short Leg Splint Calf Foot,PX-36900578,CDM,29515,CPT,369,RC,,,outpatient,,,354,247.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,171.973915,,,171.973915,79.473,1592,other,OPPS APC,,
HC Ctrl Nosebleed-Anter-Simple,PX-36900181,CDM,30901,CPT,369,RC,,,outpatient,,,347,242.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,77.9015,1592,other,OPPS APC,,
HC PR Control Nasal Hemorrhage Anterior Simple,PX-96000041,CDM,30901,CPT,960,RC,,,outpatient,,,347,242.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,77.9015,1592,other,OPPS APC,,
HC Control Nasal Hemorrhage Anterior Complex,PX-36900745,CDM,30903,CPT,369,RC,,,outpatient,,,289,202.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,64.8805,1592,other,OPPS APC,,
HC PR Control Nasal Hemorrhage Anterior Complex,PX-96000042,CDM,30903,CPT,960,RC,,,outpatient,,,289,202.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,64.8805,1592,other,OPPS APC,,
HC Ctrl Nsl Hemrrg Pst Nasal Packs&/Cautery 1st,PX-36900746,CDM,30905,CPT,369,RC,,,outpatient,,,486,340.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,109.107,1592,other,OPPS APC,,
HC Ctrl Nsl Hemrrg Pst Nasal Packs&/Cautery Subsq,PX-36900747,CDM,30906,CPT,369,RC,,,outpatient,,,510,357,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,266.592215,,,266.592215,114.495,1592,other,OPPS APC,,
HC Insert Emergency Endotrach Airway,PX-36100007,CDM,31500,CPT,361,RC,,,outpatient,,,544,380.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,266.592215,,,266.592215,122.128,1592,other,OPPS APC,,
HC Insert Emergency Endotrach Airway,PX-36900182,CDM,31500,CPT,369,RC,,,outpatient,,,544,380.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,266.592215,,,266.592215,122.128,1592,other,OPPS APC,,
HC PR Intubation Endotracheal Emergency Procedure,PX-96000038,CDM,31500,CPT,960,RC,,,outpatient,,,544,380.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,266.592215,,,266.592215,122.128,1592,other,OPPS APC,,
HC Trach Tube Change,PX-36900183,CDM,31502,CPT,369,RC,,,outpatient,,,615,430.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,266.592215,,,266.592215,138.0675,1592,other,OPPS APC,,
HC Laryngoscopy-Flex Fiber-Diagnostic,PX-36900185,CDM,31575,CPT,369,RC,,,outpatient,,,371,259.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,216.190215,,,216.190215,83.2895,1592,other,OPPS APC,,
HC Bronchoscopy-Diagnostic,PX-36900187,CDM,31622,CPT,369,RC,,,outpatient,,,3151,2205.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1852.43387,,,1852.43387,399.86,2998,other,OPPS APC,,
HC Bronchoscopy-Diagnostic W Brush,PX-36900188,CDM,31623,CPT,369,RC,,,outpatient,,,3150,2205,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1852.43387,,,1852.43387,399.86,2998,other,OPPS APC,,
HC Brnchsc W/Brncl Alveolar Lavage,PX-36900896,CDM,31624,CPT,369,RC,,,outpatient,,,3935,2754.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1852.43387,,,1852.43387,399.86,3022.08,other,OPPS APC,,
HC Bronchoscopy-Biopsy,PX-36900189,CDM,31625,CPT,369,RC,,,outpatient,,,3271,2289.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1852.43387,,,1852.43387,399.86,2998,other,OPPS APC,,
HC Needle Biopsy Pleura,PX-36900190,CDM,32400,CPT,369,RC,,,outpatient,,,3700,2590,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC,,
HC Core Needle Bx Lung/Mediastinum Perq W/Img,PX-36900808,CDM,32408,CPT,369,RC,,,outpatient,,,4594,3215.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,3528.192,other,OPPS APC,,
HC Insertion Indwelling Tunneled Pleural Catheter,PX-36900192,CDM,32550,CPT,369,RC,,,outpatient,,,8367,5856.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3775.95747,,,3775.95747,399.86,6425.856,other,OPPS APC,,
HC Tube Thoracostomy Includes Water Seal,PX-36100008,CDM,32551,CPT,361,RC,,,outpatient,,,1951,1365.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1747.952815,,,1747.952815,399.86,2447.133941,other,OPPS APC,,
HC Tube Thoracostomy Includes Water Seal,PX-36900193,CDM,32551,CPT,369,RC,,,outpatient,,,1951,1365.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1747.952815,,,1747.952815,399.86,2447.133941,other,OPPS APC,,
HC Tube Thoracostomy Includes Water Seal,PX-36900573,CDM,32551,CPT,369,RC,,,outpatient,,,1951,1365.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1747.952815,,,1747.952815,399.86,2447.133941,other,OPPS APC,,
HC PR Tube Thoracostomy Includes Water Seal,PX-96000039,CDM,32551,CPT,960,RC,,,outpatient,,,1951,1365.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1747.952815,,,1747.952815,399.86,2447.133941,other,OPPS APC,,
HC Removal of Indwelling Tunneled Pleural Catheter With Cuff,PX-36900194,CDM,32552,CPT,369,RC,,,outpatient,,,2265,1585.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.639025,,,685.639025,399.86,2141,other,OPPS APC,,
HC Perc Place Intra-Thoracic Interstit Rad Therapy Guide- 1/Mult,PX-36900195,CDM,32553,CPT,369,RC,,,outpatient,,,4198,2938.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1512.300555,,,1512.300555,399.86,3224.064,other,OPPS APC,,
HC Thoracentesis Needle/Cath Pleura W/O Imaging,PX-36900196,CDM,32554,CPT,369,RC,,,outpatient,,,1874,1311.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.639025,,,685.639025,399.86,2141,other,OPPS APC,,
HC Thoracentesis Needle/Cath Pleura W/Imaging,PX-36100001,CDM,32555,CPT,361,RC,,,outpatient,,,1636,1145.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.639025,,,685.639025,367.282,2141,other,OPPS APC,,
HC Thoracentesis Needle/Cath Pleura W/Imaging,PX-36900197,CDM,32555,CPT,369,RC,,,outpatient,,,1636,1145.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.639025,,,685.639025,367.282,2141,other,OPPS APC,,
HC Perq Drainage Pleura Insert Cath W/O Imaging,PX-36900742,CDM,32556,CPT,369,RC,,,outpatient,,,2896,2027.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2076.780045,,,2076.780045,399.86,2998,other,OPPS APC,,
HC Perq Drainage Pleura Insert Cath W/Imaging,PX-36900198,CDM,32557,CPT,369,RC,,,outpatient,,,1882,1317.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1747.952815,,,1747.952815,399.86,2447.133941,other,OPPS APC,,
HC PR Instlj via Chest Tube/Cath Agent for Pleurodesis,PX-96000040,CDM,32560,CPT,960,RC,,,outpatient,,,2265,1585.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.639025,,,685.639025,399.86,1739.52,other,OPPS APC,,
HC Instlj via Ch Tube/Cath Agent Fbrnlysis 1st Day,PX-36900826,CDM,32561,CPT,369,RC,,,outpatient,,,1421,994.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.639025,,,685.639025,319.0145,2141,other,OPPS APC,,
HC Instlj Ch Tube/Cath Agent Fbrnlysis Sbsq Day,PX-36900827,CDM,32562,CPT,369,RC,,,outpatient,,,1421,994.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.639025,,,685.639025,319.0145,2141,other,OPPS APC,,
HC Pericardiocentesis W/Img Guidance When Performed,PX-36100034,CDM,33016,CPT,361,RC,,,outpatient,,,5537,3875.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1747.952815,,,1747.952815,399.86,4252.416,other,OPPS APC,,
HC Pericardiocentesis W/Img Guidance When Performed,PX-36900797,CDM,33016,CPT,369,RC,,,outpatient,,,5537,3875.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1747.952815,,,1747.952815,399.86,4252.416,other,OPPS APC,,
HC Inser Hart Pacer Xvenous Atrial,PX-36900204,CDM,33206,CPT,369,RC,,,outpatient,,,27344,19140.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11654.50028,,,11654.50028,399.86,21000.192,other,OPPS APC,,
HC Inser Hart Pacer Xvenous Ventr,PX-36900205,CDM,33207,CPT,369,RC,,,outpatient,,,36767,25736.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11654.50028,,,11654.50028,399.86,28237.056,other,OPPS APC,,
HC Inser Hart Pacer Xvenous Atr/Ventr,PX-36900206,CDM,33208,CPT,369,RC,,,outpatient,,,27344,19140.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11654.50028,,,11654.50028,399.86,21000.192,other,OPPS APC,,
HC Inser Heart Temp Pacer One Chmbr,PX-36900207,CDM,33210,CPT,369,RC,,,outpatient,,,21456,15019.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9272.375755,,,9272.375755,399.86,16478.208,other,OPPS APC,,
HC Insert Pulse Gener One Chmbr,PX-36900209,CDM,33212,CPT,369,RC,,,outpatient,,,21456,15019.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9272.375755,,,9272.375755,399.86,16478.208,other,OPPS APC,,
HC Insert Pulse Gener Dual Chmbr,PX-36900210,CDM,33213,CPT,369,RC,,,outpatient,,,27344,19140.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11654.50028,,,11654.50028,399.86,21000.192,other,OPPS APC,,
HC Upgrade of Pacemaker System,PX-36900211,CDM,33214,CPT,369,RC,,,outpatient,,,27344,19140.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11654.50028,,,11654.50028,399.86,21000.192,other,OPPS APC,,
HC Reposition Transvenous Electrode,PX-36900212,CDM,33215,CPT,369,RC,,,outpatient,,,4029,2820.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,4870.452937,other,OPPS APC,,
HC Revise Electrode-Pacing-Dual,PX-36900215,CDM,33217,CPT,369,RC,,,outpatient,,,21456,15019.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9272.375755,,,9272.375755,399.86,16478.208,other,OPPS APC,,
HC Reeletrode-Pacing-Single,PX-36900216,CDM,33218,CPT,369,RC,,,outpatient,,,9056,6339.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4286.02571,,,4286.02571,399.86,6955.008,other,OPPS APC,,
HC Reelectrode-Pacing-Dual,PX-36900217,CDM,33220,CPT,369,RC,,,outpatient,,,9056,6339.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4286.02571,,,4286.02571,399.86,6955.008,other,OPPS APC,,
HC Ins Pacemaker Pulse Gen Only W/Exist Mult Leads,PX-36900218,CDM,33221,CPT,369,RC,,,outpatient,,,48979,34285.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,21266.60843,,,21266.60843,399.86,37615.872,other,OPPS APC,,
HC Relocation of Skin Pocket for Pacemaker,PX-36900219,CDM,33222,CPT,369,RC,,,outpatient,,,4504,3152.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1990.340615,,,1990.340615,399.86,3459.072,other,OPPS APC,,
HC Relocate Skin Pocket Cardioverter-Defibrillator,PX-36900220,CDM,33223,CPT,369,RC,,,outpatient,,,2716,1901.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1990.340615,,,1990.340615,399.86,2998,other,OPPS APC,,
HC Insrt Pacing Elect-W/Attach Prev Device,PX-36900221,CDM,33224,CPT,369,RC,,,outpatient,,,27344,19140.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11654.50028,,,11654.50028,399.86,21000.192,other,OPPS APC,,
HC Insj Eltrd Car Ven Sys Tm Insj Cvdfb/Pm Pls Gen,PX-36900222,CDM,33225,CPT,369,RC,,,outpatient,,,7571,5299.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6364,other,OPPS APC,,
HC Reposit Prev Implanted Cardiac Electrode,PX-36900223,CDM,33226,CPT,369,RC,,,outpatient,,,3644,2550.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,4870.452937,other,OPPS APC,,
HC Remvl Perm Pm Plse Gen W/Repl Plse Gen Sngl Lead,PX-36900224,CDM,33227,CPT,369,RC,,,outpatient,,,17786,12450.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9272.375755,,,9272.375755,399.86,13659.648,other,OPPS APC,,
HC Remvl Perm Pm Pls Gen W/Repl Plse Gen 2 Lead Sys,PX-36900225,CDM,33228,CPT,369,RC,,,outpatient,,,19652,13756.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11654.50028,,,11654.50028,399.86,16316.30039,other,OPPS APC,,
HC Remvl Perm Pm Pls Gen W/Repl Plse Gen Mult Lead,PX-36900226,CDM,33229,CPT,369,RC,,,outpatient,,,22582,15807.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,21266.60843,,,21266.60843,399.86,29773.2518,other,OPPS APC,,
HC Ins Pacng Cvdfb Pls Gen Only W/Exist Dual Leads,PX-36900227,CDM,33230,CPT,369,RC,,,outpatient,,,67496,47247.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,25726.38358,,,25726.38358,399.86,51836.928,other,OPPS APC,,
HC Ins Pacng Cvdfb Pls Gen Only W/Exist Multi Leads,PX-36900228,CDM,33231,CPT,369,RC,,,outpatient,,,64998,45498.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,35906.82009,,,35906.82009,399.86,50269.54813,other,OPPS APC,,
HC Remv Perm Pacer Generator,PX-36900229,CDM,33233,CPT,369,RC,,,outpatient,,,21456,15019.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9272.375755,,,9272.375755,399.86,16478.208,other,OPPS APC,,
HC Remv Transven Pacer Electrode-1 Lead,PX-36900230,CDM,33234,CPT,369,RC,,,outpatient,,,9056,6339.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4286.02571,,,4286.02571,399.86,6955.008,other,OPPS APC,,
HC Remv Transven Pacer Electrode-2 Lead,PX-36900231,CDM,33235,CPT,369,RC,,,outpatient,,,9056,6339.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4286.02571,,,4286.02571,399.86,6955.008,other,OPPS APC,,
HC Rmv Pulse Generator-Sngl/Dual,PX-36900233,CDM,33241,CPT,369,RC,,,outpatient,,,9028,6319.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4286.02571,,,4286.02571,399.86,6933.504,other,OPPS APC,,
HC Rmv Pacer/Electrd-Transven Extrct,PX-36900234,CDM,33244,CPT,369,RC,,,outpatient,,,9056,6339.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4286.02571,,,4286.02571,399.86,6955.008,other,OPPS APC,,
HC Insert Electrd Leads/Repostion,PX-36900235,CDM,33249,CPT,369,RC,,,outpatient,,,86384,60468.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,35906.82009,,,35906.82009,399.86,66342.912,other,OPPS APC,,
HC Rem Pac Cvdfb Plse Gen &Repl Plse Gen Sngl Lead,PX-36900236,CDM,33262,CPT,369,RC,,,outpatient,,,63006,44104.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,25726.38358,,,25726.38358,399.86,48388.608,other,OPPS APC,,
HC Rem Pac Cvdfb Plse Gen &Repl Plse Gen Dual Lead,PX-36900237,CDM,33263,CPT,369,RC,,,outpatient,,,65752,46026.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,25726.38358,,,25726.38358,399.86,50497.536,other,OPPS APC,,
HC Rem Pac Cvdfb Pls Gen &Repl Plse Gen Multi Lead,PX-36900238,CDM,33264,CPT,369,RC,,,outpatient,,,65752,46026.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,35906.82009,,,35906.82009,399.86,50497.536,other,OPPS APC,,
HC Replace Aortic Valve Perq Femoral Artry Approach,PX-36900544,CDM,33361,CPT,369,RC,,,outpatient,,,27728,19409.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21295.104,other,Status Indicator C,,
HC Replace Aortic Valve Openfemoral Artery Approach,PX-36900545,CDM,33362,CPT,369,RC,,,outpatient,,,29393,20575.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24913.5068,,,,
HC Replace Aortic Valve Open Axillry Artry Approach,PX-36900546,CDM,33363,CPT,369,RC,,,outpatient,,,27728,19409.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21295.104,,,,
HC Replace Aortic Valve Open Iliac Artery Approach,PX-36900547,CDM,33364,CPT,369,RC,,,outpatient,,,29393,20575.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,22573.824,,,,
HC Replace Aortic Valve Open Transaortic Approach,PX-36900548,CDM,33365,CPT,369,RC,,,outpatient,,,29393,20575.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,22573.824,,,,
HC Transcatheter Transapical Replacemt Aortic Valve,PX-36900549,CDM,33366,CPT,369,RC,,,outpatient,,,29393,20575.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24913.5068,,,,
HC Replace Aortic Valve W/Byp Prq Art/Venous Apprch,PX-36900550,CDM,33367,CPT,369,RC,,,outpatient,,,27728,19409.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,23502.2528,,,,
HC Replace Aortic Valve W/Byp Open Art/Venous Aprch,PX-36900551,CDM,33368,CPT,369,RC,,,outpatient,,,29393,20575.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24913.5068,,,,
HC Replace Aorta Valve W/Byp Cntrl Art/Venous Aprch,PX-36900552,CDM,33369,CPT,369,RC,,,outpatient,,,29393,20575.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24913.5068,,,,
HC Endovasc Taa Reincl Subcl,PX-36900241,CDM,33880,CPT,369,RC,,,outpatient,,,6951,4865.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,5338.368,,,,
HC Endovasc Taa Rew/O Subcl,PX-36900242,CDM,33881,CPT,369,RC,,,outpatient,,,5970,4179,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,4584.96,,,,
HC Insert Endovasc Prosth- Taa,PX-36900243,CDM,33883,CPT,369,RC,,,outpatient,,,4420,3094,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,3746.392,,,,
HC Endovasc Prosth- Taa- Ea Add,PX-36900244,CDM,33884,CPT,369,RC,,,outpatient,,,1649,1154.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,370.2005,2998,,,,
HC Endovasc Dist Extens Taa Prosth- Delayed,PX-36900245,CDM,33886,CPT,369,RC,,,outpatient,,,3820,2674,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,3237.832,,,,
HC Car-Car Bypass Grft W/ Endovas Taa Repair,PX-36900247,CDM,33891,CPT,369,RC,,,outpatient,,,4194,2935.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,3220.992,,,,
HC Remove Pul Art Emboli No Bypass,PX-36900248,CDM,33915,CPT,369,RC,,,outpatient,,,1800,1260,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2998,,,,
HC Insert Intra-Aortic Balloon Asst Device,PX-36900249,CDM,33967,CPT,369,RC,,,outpatient,,,2513,1759.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6913,,,,
HC Rmv Aortic Balloon Device,PX-36900250,CDM,33968,CPT,369,RC,,,outpatient,,,139,97.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,31.2055,6913,,,,
HC Insj Perq Vad W/Rs&I L Hrt Arterial Access Only,PX-36900251,CDM,33990,CPT,369,RC,,,outpatient,,,4109,2876.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,3155.712,,,,
HC Removal Perq Left Hrt Vad Artl/Artl&Ven Sep Insj,PX-36900252,CDM,33992,CPT,369,RC,,,outpatient,,,4188,2931.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,3549.7488,,,,
HC Repositioning Perq R/L Vad W/Img Gdn Sep Insj,PX-36900253,CDM,33993,CPT,369,RC,,,outpatient,,,4188,2931.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,3549.7488,,,,
HC Insj Perq Vad W/Rs&I R Heart Venous Access Only,PX-36900809,CDM,33995,CPT,369,RC,,,outpatient,,,4109,2876.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,3155.712,,,,
HC Removal Perq R Heart Vad Venous Cannula Sep Insj,PX-36900810,CDM,33997,CPT,369,RC,,,outpatient,,,4188,2931.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,293.5896,3216.384,,,,
HC Cardiac Surg Procedure Unlist,PX-36900254,CDM,33999,CPT,369,RC,,,outpatient,,,1770,1239,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.639025,,,685.639025,397.365,2141,other,OPPS APC,,
HC Cardiac Surg Procedure Unlist,PX-36900635,CDM,33999,CPT,369,RC,,,outpatient,,,1770,1239,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.639025,,,685.639025,397.365,2141,other,OPPS APC,,
HC Remv Art Clot Axill-Brach-Arm Incis,PX-36900255,CDM,34101,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC,,
HC Remv Art Clot Arm-Arm Incis,PX-36900256,CDM,34111,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC,,
HC Remv Art Clot Iliac-Pop-Leg Incis,PX-36900257,CDM,34201,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC,,
HC Remv Art Clot Low Leg-Leg Incis,PX-36900258,CDM,34203,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC,,
HC Aaa Repair-Iliac Artery Occlsn Device,PX-36900264,CDM,34808,CPT,369,RC,,,outpatient,,,152,106.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,34.124,2998,,,,
HC Aaa Repr-Expose Femoral Art-Groin Incis,PX-36900265,CDM,34812,CPT,369,RC,,,outpatient,,,238,166.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,53.431,2998,,,,
HC Aaa Repair- Femoral-Femoral Graft,PX-36900266,CDM,34813,CPT,369,RC,,,outpatient,,,167,116.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,37.4915,2998,,,,
HC Aaa Repr-Expose Iliac Art-Abd Incis- Unilat,PX-36900267,CDM,34820,CPT,369,RC,,,outpatient,,,337,235.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,75.6565,2998,,,,
HC Open Iliac Art Exp W/Conduit-Unilat,PX-36900270,CDM,34833,CPT,369,RC,,,outpatient,,,447,312.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,100.3515,2998,,,,
HC Open Brach Art Exp-Endovas Pros-Unilat,PX-36900271,CDM,34834,CPT,369,RC,,,outpatient,,,218,152.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.941,2998,,,,
HC Thrombectomy a-V Graft- Exc Hemodialysis,PX-36900278,CDM,35875,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC,,
HC Place Needle in Vein,PX-36900279,CDM,36000,CPT,369,RC,,,outpatient,,,343,240.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,77.0035,1592,other,OPPS APC,,
HC Injection Rx Extremity Pseudoaneurysm,PX-36900280,CDM,36002,CPT,369,RC,,,outpatient,,,775,542.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.639025,,,685.639025,173.9875,2141,other,OPPS APC,,
HC Injection Proc-Extremity-Venography,PX-36900281,CDM,36005,CPT,369,RC,,,outpatient,,,258,180.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,57.921,1592,other,OPPS APC,,
HC Place Cath in Vein-Svc-Ivc,PX-36900282,CDM,36010,CPT,369,RC,,,outpatient,,,541,378.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,121.4545,1592,other,OPPS APC,,
HC Place Cath in Vein-Select,PX-36900283,CDM,36011,CPT,369,RC,,,outpatient,,,773,541.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,173.5385,1592,other,OPPS APC,,
HC Place Cath in Vein-Subselect,PX-36900284,CDM,36012,CPT,369,RC,,,outpatient,,,909,636.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,204.0705,1592,other,OPPS APC,,
HC Place Cath in Rt Hrt-Main Pulm Art,PX-36900285,CDM,36013,CPT,369,RC,,,outpatient,,,8331,5831.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6398.208,,,,
HC Place Cath in Lt/Rt Pulm Art,PX-36900286,CDM,36014,CPT,369,RC,,,outpatient,,,721,504.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,161.8645,1592,,,,
HC Place Cath in Subsegmt Pulm Art,PX-36900287,CDM,36015,CPT,369,RC,,,outpatient,,,1662,1163.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,373.119,1592,other,OPPS APC,,
HC Place Cath Carot/Vert Art,PX-36900288,CDM,36100,CPT,369,RC,,,outpatient,,,628,439.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,140.986,1592,,,,
HC Place Cath Extrem Artery,PX-36900290,CDM,36140,CPT,369,RC,,,outpatient,,,340,238,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,76.33,1592,other,OPPS APC,,
HC Place Cath Aorta via Translumbar,PX-36900293,CDM,36160,CPT,369,RC,,,outpatient,,,2609,1826.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2003.712,,,,
HC Place Cath Aorta,PX-36900294,CDM,36200,CPT,369,RC,,,outpatient,,,721,504.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,161.8645,1592,other,OPPS APC,,
HC Place Cath Selective Art-Neck,PX-36900295,CDM,36215,CPT,369,RC,,,outpatient,,,1030,721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.235,1592,other,OPPS APC,,
HC Place Cath Subselect Art-Neck,PX-36900296,CDM,36216,CPT,369,RC,,,outpatient,,,568,397.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,127.516,1592,other,OPPS APC,,
HC Place Cath Subsubselect Art-Neck,PX-36900297,CDM,36217,CPT,369,RC,,,outpatient,,,1545,1081.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,346.8525,1592,other,OPPS APC,,
HC Place Cath Addn Subselec Art-Neck,PX-36900298,CDM,36218,CPT,369,RC,,,outpatient,,,109,76.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,24.4705,1592,other,OPPS APC,,
HC Nonslctv Cath Thor Aorta Angio Intr/Xtrcranl Art,PX-36900299,CDM,36221,CPT,369,RC,,,outpatient,,,9691,6783.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,7442.688,other,OPPS APC,,
HC Slctv Cath Carotid/Innom Art Angio Xtrcranl Art,PX-36900300,CDM,36222,CPT,369,RC,,,outpatient,,,9691,6783.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,7442.688,other,OPPS APC,,
HC Slctv Cath Carotid/Innom Art Angio Intrcranl Art,PX-36900301,CDM,36223,CPT,369,RC,,,outpatient,,,9141,6398.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,8396.844904,other,OPPS APC,,
HC Slctv Cath Intrnl Carotid Art Angio Intrcrnl Art,PX-36900302,CDM,36224,CPT,369,RC,,,outpatient,,,15847,11092.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,12170.496,other,OPPS APC,,
HC Slctv Cath Subclavian Art Angio Vertebral Artery,PX-36900303,CDM,36225,CPT,369,RC,,,outpatient,,,9141,6398.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,7020.288,other,OPPS APC,,
HC Slctv Cath Vertebral Art Angio Vertebral Artery,PX-36900304,CDM,36226,CPT,369,RC,,,outpatient,,,15847,11092.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,12170.496,other,OPPS APC,,
HC Slctv Cath Xtrnl Carotid Angio Xtrnl Carotd Circ,PX-36900305,CDM,36227,CPT,369,RC,,,outpatient,,,515,360.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,115.6175,1592,,,,
HC Slctv Cath Intrcrnl Brnch Angio Intrl Carot/Vert,PX-36900306,CDM,36228,CPT,369,RC,,,outpatient,,,612,428.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.394,1592,,,,
HC Place Cath Select Art-Abd/Pel,PX-36900307,CDM,36245,CPT,369,RC,,,outpatient,,,1107,774.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,248.5215,1592,other,OPPS APC,,
HC Place Cath Subselect Art-Abd/Pel,PX-36900308,CDM,36246,CPT,369,RC,,,outpatient,,,1236,865.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,277.482,1592,other,OPPS APC,,
HC Place Cath Subsubselect Art-Abd/Pel,PX-36900309,CDM,36247,CPT,369,RC,,,outpatient,,,1442,1009.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,323.729,1592,other,OPPS APC,,
HC Place Cath Addn Subsel Art-Abd/Pel,PX-36900310,CDM,36248,CPT,369,RC,,,outpatient,,,258,180.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,57.921,1592,other,OPPS APC,,
HC Slctv Cath 1stord W/WO Art Punct/Fluoro/S&I Uni,PX-36900311,CDM,36251,CPT,369,RC,,,outpatient,,,9430,6601,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,7242.24,other,OPPS APC,,
HC Slctv Cath 1stord W/WO Art Punct/Fluor/S&I Bilat,PX-36900312,CDM,36252,CPT,369,RC,,,outpatient,,,9430,6601,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,7242.24,other,OPPS APC,,
HC Supslctv Cath 2nd+Ord Renl&Acces Artery/S&I Uni,PX-36900313,CDM,36253,CPT,369,RC,,,outpatient,,,9430,6601,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,8396.844904,other,OPPS APC,,
HC Supslctv Cath 2nd+Ord Renl&Acces Arter/S&I Bilat,PX-36900314,CDM,36254,CPT,369,RC,,,outpatient,,,9430,6601,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,7242.24,other,OPPS APC,,
Vnpnxr <3 Years Phys/Qhp Skill Other Vein,PX-36900875,CDM,36406,CPT,369,RC,,,outpatient,,,24,16.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,5.388,416.02,,,,
HC Blood Transfusion Service,PX-39100001,CDM,36430,CPT,391,RC,,,outpatient,,,923,646.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,473.790255,,,473.790255,207.2135,1592,other,OPPS APC,,
HC Injection; Spider Veins-Limb/Trunk,PX-36900315,CDM,36468,CPT,369,RC,,,outpatient,,,909,636.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,156.65,1592,other,OPPS APC,,
HC Injection Therapy Vein-One Vein,PX-36900316,CDM,36470,CPT,369,RC,,,outpatient,,,909,636.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,204.0705,1592,other,OPPS APC,,
HC Injection Therapy Vein-Mult Veins,PX-36900317,CDM,36471,CPT,369,RC,,,outpatient,,,383,268.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,435.19836,,,435.19836,85.9835,1592,other,OPPS APC,,
HC Endovenous Rf- 1st Vein,PX-36900318,CDM,36475,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,6623.08,other,OPPS APC,,
HC Endovenous Rf- Vein Add-On,PX-36900319,CDM,36476,CPT,369,RC,,,outpatient,,,1797,1257.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,1592,,,,
HC Endovenous Laser- 1st Vein,PX-36900320,CDM,36478,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC,,
HC Endovenous Laser Vein Addon,PX-36900321,CDM,36479,CPT,369,RC,,,outpatient,,,1797,1257.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,1592,,,,
HC Percut Portal Vein Cath,PX-36900322,CDM,36481,CPT,369,RC,,,outpatient,,,915,640.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,205.4175,1592,,,,
HC Venous Select Sampling W Cath,PX-36900323,CDM,36500,CPT,369,RC,,,outpatient,,,412,288.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,92.494,1592,,,,
HC Cathj Umbilical Vein Dx/Ther Nb,PX-36900588,CDM,36510,CPT,369,RC,,,outpatient,,,773,541.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,173.5385,1592,,,,
HC Ther Apheresis-Platelets,PX-36900553,CDM,36513,CPT,369,RC,,,outpatient,,,1337,935.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,473.790255,,,473.790255,300.1565,2081.64,other,OPPS APC,,
HC Ther Apheresis-Plasma Pheresis,PX-36900324,CDM,36514,CPT,369,RC,,,outpatient,,,4919,3443.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1674.594995,,,1674.594995,399.86,3777.792,other,OPPS APC,,
HC Insert Non-Tunnel Cv Cath < 5 Y/O,PX-36100009,CDM,36555,CPT,361,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC,,
HC Insert Non-Tunnel Cv Cath < 5 Y/O,PX-36900325,CDM,36555,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC,,
HC Insert Non-Tunnel Cv Cath,PX-36100010,CDM,36556,CPT,361,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,6012.672,other,OPPS APC,,
HC Insert Non-Tunnel Cv Cath,PX-36900326,CDM,36556,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,6012.672,other,OPPS APC,,
HC PR Insj Non-Tunneled Central Venous Cath Age 5 Yr/>,PX-96000046,CDM,36556,CPT,960,RC,,,outpatient,,,7829,5480.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,6012.672,other,OPPS APC,,
HC Insert Tunneled Cv Cath W/O Port or Pump < 5 Y/O,PX-36100011,CDM,36557,CPT,361,RC,,,outpatient,,,12541,8778.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC,,
HC Insert Tunneled Cv Cath W/O Port or Pump < 5 Y/O,PX-36900327,CDM,36557,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC,,
HC Insert Tunneled Cv Cath W/O Port or Pump,PX-36100012,CDM,36558,CPT,361,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC,,
HC Insert Tunneled Cv Cath W/O Port or Pump,PX-36900328,CDM,36558,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC,,
HC Insert Tunneled Cv Cath With Port <5 Y/O,PX-36100013,CDM,36560,CPT,361,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC,,
HC Insert Tunneled Cv Cath With Port <5 Y/O,PX-36900329,CDM,36560,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC,,
HC Insert Tunneled Cv Cath With Port,PX-36100014,CDM,36561,CPT,361,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC,,
HC Insert Tunneled Cv Cath With Port,PX-36900330,CDM,36561,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC,,
HC Insert Tunneled Cv Cath With Pump,PX-36100015,CDM,36563,CPT,361,RC,,,outpatient,,,12541,8778.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC,,
HC Insert Tunneled Cv Cath With Pump,PX-36900331,CDM,36563,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC,,
HC Insert Tunneled Cv Cath W 2 Access Sites- W/O Pump or Port,PX-36900332,CDM,36565,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC,,
HC Insert Tunneled Cv Cath W 2 Access Sites- W/ Pump or Port,PX-36900333,CDM,36566,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC,,
HC Insert Picc W/O Sub-Q Port <5 Y/O,PX-36900334,CDM,36568,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1747.952815,,,1747.952815,399.86,2840.064,other,OPPS APC,,
HC Insert Picc W/O Sub-Q Port,PX-36900335,CDM,36569,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1747.952815,,,1747.952815,399.86,2953.728,other,OPPS APC,,
HC PR Insj Prph Cvc W/O Subq Port/Pmp Age 5 Yr/>,PX-96000047,CDM,36569,CPT,960,RC,,,outpatient,,,3846,2692.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1747.952815,,,1747.952815,399.86,2953.728,other,OPPS APC,,
HC Insert Picc W/ Sub-Q Port <5 Y/O,PX-36900336,CDM,36570,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC,,
HC Insert Picc W/ Sub-Q Port,PX-36900337,CDM,36571,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC,,
HC Repair Cv Cath W/O Subq Port or Pump,PX-36900338,CDM,36575,CPT,369,RC,,,outpatient,,,1421,994.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.639025,,,685.639025,319.0145,2141,other,OPPS APC,,
HC Repair Cv Cath W Subq Port or Pump,PX-36900339,CDM,36576,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1747.952815,,,1747.952815,399.86,2840.064,other,OPPS APC,,
HC Replace Cv Cath- Catheter Only W Subq Pump or Port,PX-36900340,CDM,36578,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC,,
HC Replace Cv Cath- Complete- Non-Tunneled- W/O Subq Port or Pump,PX-36900341,CDM,36580,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1747.952815,,,1747.952815,399.86,2840.064,other,OPPS APC,,
HC Replace Cv Cath- Complete- Tunneled- W/O Subq Port or Pump,PX-36900342,CDM,36581,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC,,
HC Replace Cv Cath- Complete- Non-Tunneled- W Subq Port or Pump,PX-36900343,CDM,36582,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC,,
HC Replace Cv Cath- Complete- Tunneled- W Subq Port or Pump,PX-36900344,CDM,36583,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC,,
HC Replace Picc W/O Port or Pump,PX-36900345,CDM,36584,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1747.952815,,,1747.952815,399.86,2840.064,other,OPPS APC,,
HC Replace Picc W Port or Pump,PX-36900346,CDM,36585,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC,,
HC Removal Tunneled Cv Cath W/O Subq Port or Pump,PX-36900347,CDM,36589,CPT,369,RC,,,outpatient,,,1421,994.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.639025,,,685.639025,319.0145,2141,other,OPPS APC,,
HC Removal Tunneled Cv Cath W Subq Port or Pump,PX-36900348,CDM,36590,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1747.952815,,,1747.952815,399.86,2998,other,OPPS APC,,
HC Collect Blood From Implant Venous Access Device,PX-76100001,CDM,36591,CPT,761,RC,,,outpatient,,,160,112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,35.92,1592,other,OPPS APC,,
HC Collect Blood From Catheter Venous Nos,PX-36900349,CDM,36592,CPT,369,RC,,,outpatient,,,125,87.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,28.0625,1592,other,OPPS APC,,
HC Declot of Cent Venous Catheter,PX-36900350,CDM,36593,CPT,369,RC,,,outpatient,,,806,564.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,369.62994,,,369.62994,180.947,1592,other,OPPS APC,,
HC Mech Remov Pericath Obstr Cv Dev via Ven Access,PX-36900351,CDM,36595,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC,,
HC Mech Remov Intralum Obstr Cv Dev Thru Lumen,PX-36900352,CDM,36596,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1747.952815,,,1747.952815,399.86,2840.064,other,OPPS APC,,
HC Reposition Venous Catheter,PX-36900353,CDM,36597,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1747.952815,,,1747.952815,399.86,2840.064,other,OPPS APC,,
HC Contrast Inj Cent Ven Cath- Inc Flouro,PX-36900354,CDM,36598,CPT,369,RC,,,outpatient,,,406,284.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,233.93401,,,233.93401,91.147,1592,other,OPPS APC,,
HC Withdrawal of Arterial Blood,PX-36900355,CDM,36600,CPT,369,RC,,,outpatient,,,297,207.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,66.6765,1592,other,OPPS APC,,
HC Insert Cath-Art-Percut-Shortterm,PX-36900356,CDM,36620,CPT,369,RC,,,outpatient,,,309,216.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,69.3705,1592,other,OPPS APC,,
HC Catheterization Umbilical Newborn Art Dx/Therapy,PX-36900836,CDM,36660,CPT,369,RC,,,outpatient,,,10702,7491.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9071.0152,,,,
HC Placement Needle Intraosseous Infusion,PX-36900592,CDM,36680,CPT,369,RC,,,outpatient,,,568,397.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,434.866165,,,434.866165,127.516,1592,other,OPPS APC,,
HC PR Placement Needle Intraosseous Infusion,PX-96000050,CDM,36680,CPT,960,RC,,,outpatient,,,568,397.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,434.866165,,,434.866165,127.516,1592,other,OPPS APC,,
HC Insert Cannula-Vein-Vein,PX-36900358,CDM,36800,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC,,
HC Revise Av Fistula-W/O Thrombectomy,PX-36900359,CDM,36832,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC,,
HC Insert Transven Intrahep Portosys Shunt,PX-36900361,CDM,37182,CPT,369,RC,,,outpatient,,,4120,2884,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,5756,,,,
HC Revis Transven Intrahep Portosys Shunt,PX-36900362,CDM,37183,CPT,369,RC,,,outpatient,,,13035,9124.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6238.20972,,,6238.20972,399.86,18955.84,other,OPPS APC,,
HC Prim Perc Mech Thrombectomy- Arterial,PX-36900363,CDM,37184,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19138.22361,,,19138.22361,399.86,26793.51305,other,OPPS APC,,
HC Prim Perc Mech Thrombectomy- Arterial Ea Add,PX-36900364,CDM,37185,CPT,369,RC,,,outpatient,,,824,576.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,184.988,4800.911611,other,OPPS APC,,
HC Sec Perc Mech Thrombect- Arterial- W Other Proc,PX-36900365,CDM,37186,CPT,369,RC,,,outpatient,,,1236,865.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,277.482,8164.18419,other,OPPS APC,,
HC Percut Mech Thrombectomy- Venous,PX-36900366,CDM,37187,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12006.91336,,,12006.91336,399.86,20286.72,other,OPPS APC,,
HC Percut Mech Thrombectomy- Venous- Repeat,PX-36900367,CDM,37188,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,6788.57,other,OPPS APC,,
HC Ins Intrvas Vc Filtr W/WO Vas Acs Vsl Selxn Rs&I,PX-36900368,CDM,37191,CPT,369,RC,,,outpatient,,,14030,9821,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,10775.04,other,OPPS APC,,
HC Repsng Intrvas Vc Filtr W/WO Acs Vsl Selxn Rs&I,PX-36900369,CDM,37192,CPT,369,RC,,,outpatient,,,9628,6739.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,7394.304,other,OPPS APC,,
HC Rtrvl Intrvas Vc Filtr W/WO Acs Vsl Selxn Rs&I,PX-36900370,CDM,37193,CPT,369,RC,,,outpatient,,,9998,6998.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,7678.464,other,OPPS APC,,
HC Thrombolysis Cerebral IV Infusion,PX-36900762,CDM,37195,CPT,369,RC,,,outpatient,,,613,429.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,369.62994,,,369.62994,137.6185,1592,other,OPPS APC,,
HC Prq Transcatheter Rtrvl Intrvas FB With Imaging,PX-36900371,CDM,37197,CPT,369,RC,,,outpatient,,,8825,6177.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,6777.6,other,OPPS APC,,
HC Transcatheter Biopsy,PX-36900372,CDM,37200,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC,,
HC Thrombolysis Arterial Infusion W/Imaging Init Tx,PX-36900374,CDM,37211,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,9631.488,other,OPPS APC,,
HC Thrombolysis Venous Infusion W/Imaging Init Tx,PX-36900375,CDM,37212,CPT,369,RC,,,outpatient,,,3239,2267.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,4870.452937,other,OPPS APC,,
HC Thrombolysis Art/Venous Infsn W/Image Subsq Tx,PX-36900376,CDM,37213,CPT,369,RC,,,outpatient,,,7224,5056.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5548.032,other,OPPS APC,,
HC Cessation Thrombolytic Thrpy W/Catheter Removal,PX-36900377,CDM,37214,CPT,369,RC,,,outpatient,,,7224,5056.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5548.032,other,OPPS APC,,
HC Transcath Stent- Cca W/Eps,PX-36900378,CDM,37215,CPT,369,RC,,,outpatient,,,553,387.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,124.1485,2998,,,,
HC Revascularize Iliac Artery-Angioplasty- Initial Vessel,PX-36900379,CDM,37220,CPT,369,RC,,,outpatient,,,15994,11195.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6238.20972,,,6238.20972,399.86,12283.392,other,OPPS APC,,
HC Revascularize Iliac Artery-Angioplasty/Stent- Initial Vessel,PX-36900380,CDM,37221,CPT,369,RC,,,outpatient,,,16597,11617.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12006.91336,,,12006.91336,399.86,18955.84,other,OPPS APC,,
HC Revascularize Iliac Artery-Angioplasty- Ea Add Vessel,PX-36900381,CDM,37222,CPT,369,RC,,,outpatient,,,15818,11072.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,12148.224,other,OPPS APC,,
HC Revascularize Iliac Artery-Angioplasty/Stent- Ea Add Vessel,PX-36900382,CDM,37223,CPT,369,RC,,,outpatient,,,16216,11351.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,12453.888,other,OPPS APC,,
HC Revascularize Fem/Pop Artery-Angioplasty,PX-36900383,CDM,37224,CPT,369,RC,,,outpatient,,,16599,11619.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6238.20972,,,6238.20972,399.86,12748.032,other,OPPS APC,,
HC Revascularize Fem/Pop Artery-Angioplasty/Atherectomy,PX-36900384,CDM,37225,CPT,369,RC,,,outpatient,,,34070,23849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19138.22361,,,19138.22361,399.86,26793.51305,other,OPPS APC,,
HC Revascularize Fem/Pop Artery-Angioplasty/Stent,PX-36900385,CDM,37226,CPT,369,RC,,,outpatient,,,32579,22805.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12006.91336,,,12006.91336,399.86,25020.672,other,OPPS APC,,
HC Revascularize Fem/Pop Artery-Angioplasty/Stent/Atherectomy,PX-36900386,CDM,37227,CPT,369,RC,,,outpatient,,,59005,41303.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19138.22361,,,19138.22361,399.86,45315.84,other,OPPS APC,,
HC Revascularize Tibial/Peron Artery-Angioplasty Initial,PX-36900387,CDM,37228,CPT,369,RC,,,outpatient,,,15999,11199.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12006.91336,,,12006.91336,399.86,16809.6787,other,OPPS APC,,
HC Revascularize Tibial/Peron Artery-Angioplasty/Atherectomy Initial,PX-36900388,CDM,37229,CPT,369,RC,,,outpatient,,,34866,24406.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19138.22361,,,19138.22361,399.86,26793.51305,other,OPPS APC,,
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent Initial,PX-36900389,CDM,37230,CPT,369,RC,,,outpatient,,,34070,23849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19138.22361,,,19138.22361,399.86,26793.51305,other,OPPS APC,,
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent/Atherectomy Init,PX-36900390,CDM,37231,CPT,369,RC,,,outpatient,,,58146,40702.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19138.22361,,,19138.22361,399.86,44656.128,other,OPPS APC,,
HC Revascularize Tibial/Peron Artery-Angioplasty Ea Add,PX-36900391,CDM,37232,CPT,369,RC,,,outpatient,,,16052,11236.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,12327.936,other,OPPS APC,,
HC Revascularize Tibial/Peron Artery-Angioplasty/Atherectomy Ea Add,PX-36900392,CDM,37233,CPT,369,RC,,,outpatient,,,33576,23503.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,25786.368,other,OPPS APC,,
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent Ea Add,PX-36900393,CDM,37234,CPT,369,RC,,,outpatient,,,16052,11236.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,12327.936,other,OPPS APC,,
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent/Atherectomy Ea Add,PX-36900394,CDM,37235,CPT,369,RC,,,outpatient,,,15818,11072.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,12148.224,,,,
HC Open/Perq Placement Intravascular Stent Initial,PX-36900395,CDM,37236,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12006.91336,,,12006.91336,399.86,20286.72,other,OPPS APC,,
HC Open/Perq Placement Intravascular Stent Ea Addl,PX-36900396,CDM,37237,CPT,369,RC,,,outpatient,,,3978,2784.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,4532,other,OPPS APC,,
HC Open/Perq Placement Intravascular Stent Same 1st,PX-36900397,CDM,37238,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12006.91336,,,12006.91336,399.86,20286.72,other,OPPS APC,,
HC Open/Perq Placemt Intravasc Stent Same Ea Addl,PX-36900398,CDM,37239,CPT,369,RC,,,outpatient,,,3978,2784.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,4532,other,OPPS APC,,
HC Vascular Embolization or Occlusion Venous Rs&I,PX-36900399,CDM,37241,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12006.91336,,,12006.91336,399.86,20286.72,other,OPPS APC,,
HC Vascular Embolization or Occlusion Arterial Rs&I,PX-36900400,CDM,37242,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19138.22361,,,19138.22361,399.86,26793.51305,other,OPPS APC,,
HC Vascular Embolize/Occlude Organ Tumor Infarct,PX-36900401,CDM,37243,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12006.91336,,,12006.91336,399.86,20286.72,other,OPPS APC,,
HC Vascular Embolization or Occlusion Hemorrhage,PX-36100016,CDM,37244,CPT,361,RC,,,outpatient,,,26415,18490.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12006.91336,,,12006.91336,399.86,20286.72,other,OPPS APC,,
HC Vascular Embolization or Occlusion Hemorrhage,PX-36900402,CDM,37244,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12006.91336,,,12006.91336,399.86,20286.72,other,OPPS APC,,
HC Temporal Artery Ligatn or Bx,PX-36900554,CDM,37609,CPT,369,RC,,,outpatient,,,4643,3250.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,3565.824,other,OPPS APC,,
HC Phleb Veins - Extrem - to 20,PX-36900405,CDM,37765,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC,,
HC Phleb Veins - Extrem 20+,PX-36900406,CDM,37766,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC,,
HC Injection for Spleen X-Ray,PX-36900408,CDM,38200,CPT,369,RC,,,outpatient,,,381,266.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,85.5345,1592,,,,
HC Bone Marrow; Aspiration Only,PX-36100017,CDM,38220,CPT,361,RC,,,outpatient,,,1973,1381.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2477.315575,other,OPPS APC,,
HC Bone Marrow; Aspiration Only,PX-36900409,CDM,38220,CPT,369,RC,,,outpatient,,,1973,1381.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2477.315575,other,OPPS APC,,
HC Bone Marrow Bx- Needle/Trocar,PX-36100018,CDM,38221,CPT,361,RC,,,outpatient,,,1972,1380.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2477.315575,other,OPPS APC,,
HC Bone Marrow Bx- Needle/Trocar,PX-36900410,CDM,38221,CPT,369,RC,,,outpatient,,,1972,1380.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2477.315575,other,OPPS APC,,
HC Dx Bone Marrow Bx & Aspir,PX-36100032,CDM,38222,CPT,361,RC,,,outpatient,,,4653,3257.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3101.269425,,,3101.269425,399.86,4341.777195,other,OPPS APC,,
HC Dx Bone Marrow Bx & Aspir,PX-36900703,CDM,38222,CPT,369,RC,,,outpatient,,,4653,3257.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3101.269425,,,3101.269425,399.86,4341.777195,other,OPPS APC,,
HC Needle Biopsy- Lymph Node(S),PX-36900411,CDM,38505,CPT,369,RC,,,outpatient,,,1973,1381.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC,,
HC Injection for Lymphatic Xray,PX-36900412,CDM,38790,CPT,369,RC,,,outpatient,,,500,350,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,112.25,1592,,,,
HC Identify Sentinel Node,PX-36900413,CDM,38792,CPT,369,RC,,,outpatient,,,540,378,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,121.23,1592,other,OPPS APC,,
HC Biopsy of Floor of Mouth,PX-36900555,CDM,41108,CPT,369,RC,,,outpatient,,,2598,1818.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2477.315575,other,OPPS APC,,
HC Biopsy Salivary Gland-Needle,PX-36900414,CDM,42400,CPT,369,RC,,,outpatient,,,1637,1145.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,767.89738,,,767.89738,367.5065,2141,other,OPPS APC,,
HC Injection for Salivary X-Ray,PX-36900415,CDM,42550,CPT,369,RC,,,outpatient,,,424,296.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,95.188,1592,,,,
HC Dilation/Cath of Salivary Duct,PX-36900416,CDM,42660,CPT,369,RC,,,outpatient,,,533,373.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,600.505465,,,600.505465,119.6585,1592,other,OPPS APC,,
HC Inc/Drain Peritonsil Abscess,PX-36900812,CDM,42700,CPT,369,RC,,,outpatient,,,685,479.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,266.592215,,,266.592215,153.7825,1592,other,OPPS APC,,
HC Placement Ng/Og Tube by Physician,PX-36900423,CDM,43752,CPT,369,RC,,,outpatient,,,325,227.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,434.866165,,,434.866165,72.9625,1592,other,OPPS APC,,
HC PR Naso/Oro-Gastric Tube Plmt Req Phys&Fluor Gdnce,PX-96000043,CDM,43752,CPT,960,RC,,,outpatient,,,325,227.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,434.866165,,,434.866165,72.9625,1592,other,OPPS APC,,
HC Gastric Intubatj & Aspiraj W/Phys Skill/Lavage,PX-36900575,CDM,43753,CPT,369,RC,,,outpatient,,,579,405.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,129.9855,1592,other,OPPS APC,,
HC Reposition Gastric Feeding Tube Thru Duodenum,PX-36900425,CDM,43761,CPT,369,RC,,,outpatient,,,496,347.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,269.74234,,,269.74234,111.352,1592,other,OPPS APC,,
HC Perq Replacement Gtube Not Req Revj Gstrst Trc,PX-36100033,CDM,43762,CPT,361,RC,,,outpatient,,,879,615.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,269.74234,,,269.74234,197.3355,1592,other,OPPS APC,,
HC Perq Replacement Gtube Not Req Revj Gstrst Trc,PX-36900727,CDM,43762,CPT,369,RC,,,outpatient,,,879,615.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,269.74234,,,269.74234,197.3355,1592,other,OPPS APC,,
HC Intro Long GI Tube,PX-36900427,CDM,44500,CPT,369,RC,,,outpatient,,,1673,1171.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,989.356895,,,989.356895,375.5885,2998,other,OPPS APC,,
HC Drainage of Pelvic Abscess,PX-36900428,CDM,45000,CPT,369,RC,,,outpatient,,,2727,1908.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1287.95438,,,1287.95438,399.86,4005.9,other,OPPS APC,,
HC Drainage of Deep Rectal Abscess,PX-36900429,CDM,45020,CPT,369,RC,,,outpatient,,,6425,4497.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3064.48742,,,3064.48742,399.86,4934.4,other,OPPS APC,,
HC I&D Ischiorectal&/Perirectal Abscess Spx,PX-36900738,CDM,46040,CPT,369,RC,,,outpatient,,,3716,2601.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1287.95438,,,1287.95438,399.86,2998,other,OPPS APC,,
HC Needle Biopsy Liver,PX-36900430,CDM,47000,CPT,369,RC,,,outpatient,,,3700,2590,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC,,
HC Needle Biopsy Liver-W Othr Proc,PX-36900431,CDM,47001,CPT,369,RC,,,outpatient,,,972,680.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,218.214,1592,,,,
HC Ablat-Open-1+ Liver Tumor(S)-Percut Rf,PX-36900433,CDM,47382,CPT,369,RC,,,outpatient,,,13307,9314.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6297.489345,,,6297.489345,399.86,10219.776,other,OPPS APC,,
HC Cholecystostomy-Percutaneous- Complete,PX-36900434,CDM,47490,CPT,369,RC,,,outpatient,,,8367,5856.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3775.95747,,,3775.95747,399.86,6425.856,other,OPPS APC,,
HC Biliary Endoscopy Percut-Dil Strict,PX-36900443,CDM,47555,CPT,369,RC,,,outpatient,,,8367,5856.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3775.95747,,,3775.95747,399.86,6425.856,other,OPPS APC,,
HC Biliary Endoscopy Percut-Dil+Stent,PX-36900444,CDM,47556,CPT,369,RC,,,outpatient,,,13307,9314.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,11234.78908,,,11234.78908,399.86,15728.70471,other,OPPS APC,,
HC Needle Biopsy of Pancreas,PX-36900446,CDM,48102,CPT,369,RC,,,outpatient,,,3700,2590,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC,,
HC Anast Panc Cyst-Bowel-Direct,PX-36900447,CDM,48520,CPT,369,RC,,,outpatient,,,1740,1218,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,390.63,2998,other,Status Indicator C,,
HC Exploratory Laparotomy Celiotomy W/WO Biopsy Spx,PX-36900881,CDM,49000,CPT,369,RC,,,outpatient,,,8564,5994.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6577.152,,,,
HC Reopening Recent Laparotomy,PX-36900882,CDM,49002,CPT,369,RC,,,outpatient,,,8564,5994.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6577.152,,,,
HC Abdom Paracentesis Dx/Ther W/O Imaging Guidance,PX-36900448,CDM,49082,CPT,369,RC,,,outpatient,,,925,647.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,989.356895,,,989.356895,207.6625,2998,other,OPPS APC,,
HC Abdom Paracentesis Dx/Ther W Imaging Guidance,PX-36100002,CDM,49083,CPT,361,RC,,,outpatient,,,1635,1144.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,989.356895,,,989.356895,367.0575,2998,other,OPPS APC,,
HC Abdom Paracentesis Dx/Ther W Imaging Guidance,PX-36900449,CDM,49083,CPT,369,RC,,,outpatient,,,1635,1144.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,989.356895,,,989.356895,367.0575,2998,other,OPPS APC,,
HC Percut Biopsy- Abdominal Mass,PX-36900450,CDM,49180,CPT,369,RC,,,outpatient,,,3700,2590,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC,,
HC Remove Peritoneal Foreign Body,PX-36900451,CDM,49402,CPT,369,RC,,,outpatient,,,8367,5856.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3775.95747,,,3775.95747,399.86,6425.856,other,OPPS APC,,
HC Image-Guide Fluid Collxn Drainage Cath Visc Perq,PX-36900452,CDM,49405,CPT,369,RC,,,outpatient,,,2870,2009,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC,,
HC Img-Guide Fluid Collxn Drainag Cath Periton Perq,PX-36900453,CDM,49406,CPT,369,RC,,,outpatient,,,2647,1852.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC,,
HC Insertion Tunnel Intraperitoneal Cath W Image Guidance,PX-36900455,CDM,49418,CPT,369,RC,,,outpatient,,,7964,5574.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3775.95747,,,3775.95747,399.86,6116.352,other,OPPS APC,,
HC Removal Tunneled Intraperitoneal Catheter,PX-36900456,CDM,49422,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,5781.504,other,OPPS APC,,
HC Drainage Catheter Exchange,PX-36900457,CDM,49423,CPT,369,RC,,,outpatient,,,4271,2989.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2076.780045,,,2076.780045,399.86,3280.128,other,OPPS APC,,
HC Contrast Inj-Abscess/Cyst via Cath Tube,PX-36900458,CDM,49424,CPT,369,RC,,,outpatient,,,491,343.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,110.2295,1592,other,OPPS APC,,
HC Insert Gastrostomy Tube Percutaneous,PX-36900460,CDM,49440,CPT,369,RC,,,outpatient,,,4271,2989.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2076.780045,,,2076.780045,399.86,3280.128,other,OPPS APC,,
HC Convert Gastrostomy-Gastro-Jejunostomy Tube Percutaneous,PX-36900461,CDM,49446,CPT,369,RC,,,outpatient,,,4271,2989.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2076.780045,,,2076.780045,399.86,3280.128,other,OPPS APC,,
HC Replace Gastrostomy/Cecostomy Tube Percutaneous,PX-36100019,CDM,49450,CPT,361,RC,,,outpatient,,,1644,1150.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,989.356895,,,989.356895,369.078,2998,other,OPPS APC,,
HC Replace Gastrostomy/Cecostomy Tube Percutaneous,PX-36900462,CDM,49450,CPT,369,RC,,,outpatient,,,1644,1150.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,989.356895,,,989.356895,369.078,2998,other,OPPS APC,,
HC Replace Duodenostomy/Jejunostomy Tube Percutaneous,PX-36100020,CDM,49451,CPT,361,RC,,,outpatient,,,1692,1184.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,989.356895,,,989.356895,379.854,2998,other,OPPS APC,,
HC Replace Duodenostomy/Jejunostomy Tube Percutaneous,PX-36900463,CDM,49451,CPT,369,RC,,,outpatient,,,1692,1184.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,989.356895,,,989.356895,379.854,2998,other,OPPS APC,,
HC Replacement Gastro-Jejunostomy Tube Percutaneous,PX-36100021,CDM,49452,CPT,361,RC,,,outpatient,,,2617,1831.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,989.356895,,,989.356895,399.86,2998,other,OPPS APC,,
HC Replacement Gastro-Jejunostomy Tube Percutaneous,PX-36900464,CDM,49452,CPT,369,RC,,,outpatient,,,2617,1831.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,989.356895,,,989.356895,399.86,2998,other,OPPS APC,,
HC Obstructive Material Removal From GI Tube,PX-36900465,CDM,49460,CPT,369,RC,,,outpatient,,,2128,1489.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,989.356895,,,989.356895,399.86,2998,other,OPPS APC,,
HC Contrast Injection Percutaneouos Radiologic Eval GI Tube,PX-36900466,CDM,49465,CPT,369,RC,,,outpatient,,,606,424.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,136.047,1592,other,OPPS APC,,
HC Biopsy of Kidney-Percutaneous,PX-36900467,CDM,50200,CPT,369,RC,,,outpatient,,,3700,2590,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1769.511125,,,1769.511125,399.86,2998,other,OPPS APC,,
HC Change Ureter Stent- Percut,PX-36900468,CDM,50382,CPT,369,RC,,,outpatient,,,4709,3296.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2223.02603,,,2223.02603,399.86,4179.83,other,OPPS APC,,
HC Remove Ureter Stent- Percut,PX-36900469,CDM,50384,CPT,369,RC,,,outpatient,,,4709,3296.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2223.02603,,,2223.02603,399.86,3616.512,other,OPPS APC,,
HC Change Ext Transneph Ureter Stent W/ Fluoro,PX-36900470,CDM,50387,CPT,369,RC,,,outpatient,,,4709,3296.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2223.02603,,,2223.02603,399.86,3616.512,other,OPPS APC,,
HC Remove Renal Tube W/Fluoro,PX-36900471,CDM,50389,CPT,369,RC,,,outpatient,,,1513,1059.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,745.56013,,,745.56013,339.6685,2141,other,OPPS APC,,
HC Percut Drain/Inject Renal Cyst,PX-36900472,CDM,50390,CPT,369,RC,,,outpatient,,,726,508.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,767.89738,,,767.89738,162.987,2141,other,OPPS APC,,
HC Instll Rx Agnt Into Rnal Tub,PX-36900473,CDM,50391,CPT,369,RC,,,outpatient,,,533,373.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,269.74234,,,269.74234,119.6585,1592,other,OPPS APC,,
HC Measure Kidney Pressure Thru Tube,PX-36900478,CDM,50396,CPT,369,RC,,,outpatient,,,1513,1059.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,745.56013,,,745.56013,334.48,2141,other,OPPS APC,,
HC Plmt Nephrostomy Cath Prq New Access Rs&I,PX-36900659,CDM,50432,CPT,369,RC,,,outpatient,,,5502,3851.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2223.02603,,,2223.02603,399.86,4225.536,other,OPPS APC,,
HC Renal Endoscopy-Remv FB/Stone,PX-36900480,CDM,50561,CPT,369,RC,,,outpatient,,,11603,8122.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5647.40664,,,5647.40664,399.86,8911.104,other,OPPS APC,,
HC Perc Radiofreq Ablate Renal Tumor,PX-36900481,CDM,50592,CPT,369,RC,,,outpatient,,,13307,9314.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6297.489345,,,6297.489345,399.86,10219.776,other,OPPS APC,,
HC Inject Indwell Cath-Ureter X-Ray,PX-36900482,CDM,50684,CPT,369,RC,,,outpatient,,,374,261.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,83.963,1592,other,OPPS APC,,
HC Change of Ureterostomy Tube via Ileal Conduit,PX-36900483,CDM,50688,CPT,369,RC,,,outpatient,,,4709,3296.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2223.02603,,,2223.02603,399.86,3616.512,other,OPPS APC,,
HC Inject Retrograde/Conduit X-Ray,PX-36900484,CDM,50690,CPT,369,RC,,,outpatient,,,533,373.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,119.6585,1592,other,OPPS APC,,
HC Ureter Endoscopy Thru Ureterostomy W Biopsy,PX-36900485,CDM,50955,CPT,369,RC,,,outpatient,,,11603,8122.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5647.40664,,,5647.40664,399.86,8911.104,other,OPPS APC,,
HC Ureter Endoscopy Thru Ureterostomy Remv FB or Calculus,PX-36900486,CDM,50961,CPT,369,RC,,,outpatient,,,11603,8122.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5647.40664,,,5647.40664,399.86,8911.104,other,OPPS APC,,
HC Aspiration Bladder Needle,PX-36100022,CDM,51100,CPT,361,RC,,,outpatient,,,699,489.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,269.74234,,,269.74234,156.9255,1592,other,OPPS APC,,
HC Aspiration Bladder Needle,PX-36900488,CDM,51100,CPT,369,RC,,,outpatient,,,699,489.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,269.74234,,,269.74234,156.9255,1592,other,OPPS APC,,
HC Aspiration Bladder Trocar/Intracatheter,PX-36100023,CDM,51101,CPT,361,RC,,,outpatient,,,2419,1693.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1141.12419,,,1141.12419,179.53,2998,other,OPPS APC,,
HC Aspiration Bladder Trocar/Intracatheter,PX-36900489,CDM,51101,CPT,369,RC,,,outpatient,,,2419,1693.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1141.12419,,,1141.12419,179.53,2998,other,OPPS APC,,
HC Aspiration Bladder Insert Suprapubic Catheter,PX-36100024,CDM,51102,CPT,361,RC,,,outpatient,,,4709,3296.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2223.02603,,,2223.02603,399.86,3616.512,other,OPPS APC,,
HC Aspiration Bladder Insert Suprapubic Catheter,PX-36900490,CDM,51102,CPT,369,RC,,,outpatient,,,4709,3296.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2223.02603,,,2223.02603,399.86,3616.512,other,OPPS APC,,
HC Injection for Bladder X-Ray,PX-36900491,CDM,51600,CPT,369,RC,,,outpatient,,,1455,1018.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,235.074116,1592,other,OPPS APC,,
HC Inject for Retrograde Urethocysto,PX-36900492,CDM,51610,CPT,369,RC,,,outpatient,,,976,683.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,219.112,1592,other,OPPS APC,,
HC Bldr Irrigation Smpl Lavage &/Instlj,PX-36900732,CDM,51700,CPT,369,RC,,,outpatient,,,879,615.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,269.74234,,,269.74234,197.3355,1592,other,OPPS APC,,
HC Insert-Non-Indwelling Bladder Catheter,PX-36900494,CDM,51701,CPT,369,RC,,,outpatient,,,389,272.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,87.3305,1592,other,OPPS APC,,
HC Insert-Temp Indwelling Blad Cath-Simple,PX-36900495,CDM,51702,CPT,369,RC,,,outpatient,,,391,273.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,87.7795,1592,other,OPPS APC,,
HC Insert-Temp Indwelling Blad Cath-Comp,PX-36900496,CDM,51703,CPT,369,RC,,,outpatient,,,354,247.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,170.484765,,,170.484765,79.473,1592,other,OPPS APC,,
HC Change of Bladder Tube-Simple,PX-36900497,CDM,51705,CPT,369,RC,,,outpatient,,,456,319.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,269.74234,,,269.74234,102.372,1592,other,OPPS APC,,
HC Emg Stds Anal/Urtl Sphnctr Oth/Thn Ndl,PX-36900667,CDM,51784,CPT,369,RC,,,outpatient,,,475,332.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,170.484765,,,170.484765,106.6375,1592,other,OPPS APC,,
HC Meas Post-Voiding Residual Urine&/Bladder Cap,PX-36900733,CDM,51798,CPT,369,RC,,,outpatient,,,212,148.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,47.594,1592,other,OPPS APC,,
HC Cysto/Ureteroscopy-Tx Ureter Strict,PX-36900500,CDM,52344,CPT,369,RC,,,outpatient,,,8086,5660.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3804.86989,,,3804.86989,399.86,6210.048,other,OPPS APC,,
HC Circumcision Age >28 Days,PX-36900772,CDM,54161,CPT,369,RC,,,outpatient,,,6599,4619.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2223.02603,,,2223.02603,399.86,5068.032,other,OPPS APC,,
HC Irrigation Corpora Cavernosa Priapism,PX-36900736,CDM,54220,CPT,369,RC,,,outpatient,,,591,413.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,269.74234,,,269.74234,120.28264,1592,other,OPPS APC,,
HC Biopsy of Prostate-Needle/Punch,PX-36900501,CDM,55700,CPT,369,RC,,,outpatient,,,4709,3296.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2223.02603,,,2223.02603,399.86,3616.512,other,OPPS APC,,
HC I&D of Vulva/Perineum Abscess,PX-36900502,CDM,56405,CPT,369,RC,,,outpatient,,,829,580.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,350.13353,,,350.13353,186.1105,1592,other,OPPS APC,,
HC PR Colporrhaphy- Suture Vaginal Injury- Non-OB,PX-36900795,CDM,57200,CPT,369,RC,,,outpatient,,,5013,3509.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3412.181035,,,3412.181035,399.86,4777.053449,other,OPPS APC,,
HC Cath/Inject Hysterosalpingogram,PX-36900505,CDM,58340,CPT,369,RC,,,outpatient,,,1092,764.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,235.074116,1592,other,OPPS APC,,
HC Reopen Fallopian Tube-Transcerv Cath,PX-36900506,CDM,58345,CPT,369,RC,,,outpatient,,,6900,4830,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3412.181035,,,3412.181035,399.86,5299.2,other,OPPS APC,,
HC Fetal Non-Stress Test,PX-92000003,CDM,59025,CPT,920,RC,,,outpatient,,,490,343,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,217.48463,,,217.48463,110.005,416.02,other,OPPS APC,,
HC PR Vaginal Delivery Only,PX-96000044,CDM,59409,CPT,960,RC,,,outpatient,,,3062,2143.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3412.181035,,,3412.181035,399.86,4777.053449,other,OPPS APC,,
HC PR Delivery Placenta Separate Procedure,PX-96000045,CDM,59414,CPT,960,RC,,,outpatient,,,7176,5023.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3412.181035,,,3412.181035,399.86,5511.168,other,OPPS APC,,
HC Biopsy of Thyroid-Percut,PX-36900512,CDM,60100,CPT,369,RC,,,outpatient,,,1514,1059.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,767.89738,,,767.89738,339.893,2141,other,OPPS APC,,
HC Endocrine Surgery Proc Unlisted,PX-36900513,CDM,60699,CPT,369,RC,,,outpatient,,,6035,4224.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6297.489345,,,6297.489345,399.86,11413.04,other,OPPS APC,,
HC Brain Shunt Tube/Reserv Injectn,PX-36900514,CDM,61070,CPT,369,RC,,,outpatient,,,1885,1319.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,754.76995,,,754.76995,399.86,2141,other,OPPS APC,,
HC Endovasc Temp Balloon Occlus-Head/Nck,PX-36900515,CDM,61623,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12006.91336,,,12006.91336,399.86,20286.72,other,OPPS APC,,
HC Perm Occlusion/Embolization-Percut-Cns,PX-36900516,CDM,61624,CPT,369,RC,,,outpatient,,,533,373.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,119.6585,5756,,,,
HC Percut Cath Occlusn Non Cns Lesn,PX-36900517,CDM,61626,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12006.91336,,,12006.91336,399.86,20286.72,other,OPPS APC,,
HC Percut Aspiration Vertebral Disc,PX-36900518,CDM,62267,CPT,369,RC,,,outpatient,,,1637,1145.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,767.89738,,,767.89738,367.5065,2141,other,OPPS APC,,
HC Spinal Puncture-Lumbar-Diagnostic,PX-36100025,CDM,62270,CPT,361,RC,,,outpatient,,,915,640.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,754.76995,,,754.76995,205.4175,2141,other,OPPS APC,,
HC Spinal Puncture-Lumbar-Diagnostic,PX-36900519,CDM,62270,CPT,369,RC,,,outpatient,,,915,640.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,754.76995,,,754.76995,205.4175,2141,other,OPPS APC,,
HC PR Spinal Puncture Lumbar Diagnostic,PX-96000051,CDM,62270,CPT,960,RC,,,outpatient,,,915,640.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,754.76995,,,754.76995,205.4175,2141,other,OPPS APC,,
HC Spinal Puncture-Therapeutic Drainage,PX-36100026,CDM,62272,CPT,361,RC,,,outpatient,,,1256,879.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,754.76995,,,754.76995,281.972,2141,other,OPPS APC,,
HC Spinal Puncture-Therapeutic Drainage,PX-36900520,CDM,62272,CPT,369,RC,,,outpatient,,,1256,879.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,754.76995,,,754.76995,281.972,2141,other,OPPS APC,,
HC Inj-Lumb Epidur-Blood/Clot Patch,PX-36900521,CDM,62273,CPT,369,RC,,,outpatient,,,915,640.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,754.76995,,,754.76995,205.4175,2141,other,OPPS APC,,
HC Inject-Myelography &/or CT Scan-Spinal,PX-36900522,CDM,62284,CPT,369,RC,,,outpatient,,,1312,918.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,294.544,1592,,,,
HC Diskectomy-Percutaneous Lumbar,PX-36900523,CDM,62287,CPT,369,RC,,,outpatient,,,6304,4412.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2107.296165,,,2107.296165,399.86,6224.0876,other,OPPS APC,,
HC Inject Diskogram-Lumbar-Ea Level,PX-36900524,CDM,62290,CPT,369,RC,,,outpatient,,,1256,879.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,281.972,1592,,,,
HC Inj-Cerv/Thorac-for Diskography,PX-36900525,CDM,62291,CPT,369,RC,,,outpatient,,,1107,774.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,248.5215,1592,,,,
HC Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/O Img Gdn,PX-36900884,CDM,62322,CPT,369,RC,,,outpatient,,,2586,1810.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,994.809475,,,994.809475,399.86,2141,other,OPPS APC,,
HC Elec Anlys Implt Ithcl/Edrl Pmp W/Repr Phys/Qhp,PX-36900526,CDM,62370,CPT,369,RC,,,outpatient,,,821,574.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,325.997845,,,325.997845,155.844464,1592,other,OPPS APC,,
HC Inject Nerv Blck-Trigeminal,PX-36900609,CDM,64400,CPT,369,RC,,,outpatient,,,891,623.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,323.2601,,,323.2601,200.0295,1592,other,OPPS APC,,
HC Inject Nerv Blck-Great Occiptl,PX-36900611,CDM,64405,CPT,369,RC,,,outpatient,,,1634,1143.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,323.2601,,,323.2601,323.2601,1592,other,OPPS APC,,
HC Inject Nerv Blck-Vagus Nerve,PX-36900612,CDM,64408,CPT,369,RC,,,outpatient,,,877,613.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,323.2601,,,323.2601,196.8865,1592,other,OPPS APC,,
HC Inj-Anes Agent-Brachial Plexus-Single,PX-36900616,CDM,64415,CPT,369,RC,,,outpatient,,,1544,1080.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,994.809475,,,994.809475,346.628,2141,other,OPPS APC,,
HC Inj-Anes Agent-Brachial Plexus-Cont Inf,PX-36900617,CDM,64416,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,994.809475,,,994.809475,399.86,2141,other,OPPS APC,,
HC Inject Nerv Blck-Axillary Nerv,PX-36900618,CDM,64417,CPT,369,RC,,,outpatient,,,1544,1080.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,994.809475,,,994.809475,346.628,2141,other,OPPS APC,,
HC Inject Nerv Blck-Suprascap N.,PX-36900619,CDM,64418,CPT,369,RC,,,outpatient,,,1544,1080.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,754.76995,,,754.76995,346.628,2141,other,OPPS APC,,
HC Inject Nerv Blck-Intercostal-One,PX-36900620,CDM,64420,CPT,369,RC,,,outpatient,,,1382,967.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,754.76995,,,754.76995,310.259,2141,other,OPPS APC,,
HC Inject Nerv Blck-Intercost-Multpl,PX-36900621,CDM,64421,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,994.809475,,,994.809475,399.86,2141,other,OPPS APC,,
HC Inject Nerv Blck-Ilioingu/Iliohyp,PX-36900622,CDM,64425,CPT,369,RC,,,outpatient,,,1544,1080.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,754.76995,,,754.76995,346.628,2141,other,OPPS APC,,
HC Inject Nerv Blck-Pudendal,PX-36100029,CDM,64430,CPT,361,RC,,,outpatient,,,2785,1949.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,994.809475,,,994.809475,399.86,2141,other,OPPS APC,,
HC Inject Nerv Blck-Pudendal,PX-36900623,CDM,64430,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,994.809475,,,994.809475,399.86,2141,other,OPPS APC,,
HC Inject Nerv Blck-Paracervical,PX-36900624,CDM,64435,CPT,369,RC,,,outpatient,,,1544,1080.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,754.76995,,,754.76995,346.628,2141,other,OPPS APC,,
HC Inj-Anes Agent-Sciatic Nerve-Single,PX-36900625,CDM,64445,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,754.76995,,,754.76995,399.86,2141,other,OPPS APC,,
HC Inj-Anes Agent-Sciatic Nerve-Cont Inf,PX-36900626,CDM,64446,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,994.809475,,,994.809475,399.86,2141,other,OPPS APC,,
HC Inj-Anes Agent-Femoral Nerve-Single,PX-36900627,CDM,64447,CPT,369,RC,,,outpatient,,,1544,1080.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,754.76995,,,754.76995,346.628,2141,other,OPPS APC,,
HC Inj-Anes Agent-Femoral Nerve-Cont Inf,PX-36900628,CDM,64448,CPT,369,RC,,,outpatient,,,6090,4263,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,994.809475,,,994.809475,399.86,4677.12,other,OPPS APC,,
HC N Block Inj- Lumbar Plexus,PX-36900629,CDM,64449,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,994.809475,,,994.809475,399.86,2141,other,OPPS APC,,
HC Inject Nerv Blck-Othr Periph Nerv,PX-36900630,CDM,64450,CPT,369,RC,,,outpatient,,,1634,1143.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,754.76995,,,754.76995,366.833,2141,other,OPPS APC,,
HC Njx Aa&/Strd Plantar Common Digital Nerves,PX-36900835,CDM,64455,CPT,369,RC,,,outpatient,,,825,577.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,323.2601,,,323.2601,185.2125,1592,other,OPPS APC,,
HC Inject Anes/Steroid Foramen Cerv/Thoracic W Img Guide -1 Level,PX-36900631,CDM,64479,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,994.809475,,,994.809475,399.86,2141,other,OPPS APC,,
HC Inject Anes/Steroid Foramen Cerv/Thoracic W Img Guide -Ea Add Level,PX-36900632,CDM,64480,CPT,369,RC,,,outpatient,,,230,161,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.635,1592,,,,
HC Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level,PX-36100027,CDM,64483,CPT,361,RC,,,outpatient,,,1693,1185.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,994.809475,,,994.809475,380.0785,2141,other,OPPS APC,,
HC Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level,PX-36900531,CDM,64483,CPT,369,RC,,,outpatient,,,1693,1185.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,994.809475,,,994.809475,380.0785,2141,other,OPPS APC,,
HC Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl,PX-36900532,CDM,64484,CPT,369,RC,,,outpatient,,,416,291.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,93.392,1592,,,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- 1st Level,PX-36100028,CDM,64490,CPT,361,RC,,,outpatient,,,1693,1185.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,994.809475,,,994.809475,380.0785,2141,other,OPPS APC,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- 1st Level,PX-36900533,CDM,64490,CPT,369,RC,,,outpatient,,,1693,1185.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,994.809475,,,994.809475,380.0785,2141,other,OPPS APC,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- 2nd Level,PX-36900633,CDM,64491,CPT,369,RC,,,outpatient,,,221,154.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,49.6145,1592,,,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- Add Level,PX-36900634,CDM,64492,CPT,369,RC,,,outpatient,,,224,156.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,50.288,1592,,,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Lumbar/Sac- 1st Level,PX-36900536,CDM,64493,CPT,369,RC,,,outpatient,,,1693,1185.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,994.809475,,,994.809475,380.0785,2141,other,OPPS APC,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Lumbar/Sac- 2nd Level,PX-36900537,CDM,64494,CPT,369,RC,,,outpatient,,,1693,1185.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,380.0785,1592,,,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Lumbar/Sac- Add Level,PX-36900538,CDM,64495,CPT,369,RC,,,outpatient,,,54,37.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.123,1592,,,,
HC Inject Nerv Blck-Celiac Plexus,PX-36900539,CDM,64530,CPT,369,RC,,,outpatient,,,2165,1515.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,994.809475,,,994.809475,399.86,2141,other,OPPS APC,,
HC Unlisted Procedure Nervous System,PX-36100035,CDM,64999,CPT,361,RC,,,outpatient,,,687,480.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,323.2601,,,323.2601,154.2315,1592,other,OPPS APC,,
HC Unlisted Procedure Nervous System,PX-36900829,CDM,64999,CPT,369,RC,,,outpatient,,,687,480.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,323.2601,,,323.2601,154.2315,1592,other,OPPS APC,,
HC Removal Impacted Cerumen Using Irrigation/Lavage- Unilateral,PX-36900636,CDM,69209,CPT,369,RC,,,outpatient,,,205,143.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,46.0225,1592,other,OPPS APC,,
HC Removal Impacted Cerumen Instrumentation Unilat,PX-36900540,CDM,69210,CPT,369,RC,,,outpatient,,,305,213.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,66.75974,1592,other,OPPS APC,,
HC X-Ray Eye for Foreign Body,PX-32000004,CDM,70030,CPT,320,RC,,,outpatient,,,271,189.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,60.8395,416.02,other,OPPS APC,,
HC X-Ray Jaw <4 Vw,PX-32000005,CDM,70100,CPT,320,RC,,,outpatient,,,595,416.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,71.24,456.96,other,OPPS APC,,
HC X-Ray Jaw 4+ Vw,PX-32000006,CDM,70110,CPT,320,RC,,,outpatient,,,489,342.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,76.026473,416.02,other,OPPS APC,,
HC X-Ray Mastoids <3 Vw,PX-32000007,CDM,70120,CPT,320,RC,,,outpatient,,,384,268.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,86.208,416.02,other,OPPS APC,,
HC X-Ray Mastoids 3+ Vw,PX-32000008,CDM,70130,CPT,320,RC,,,outpatient,,,295,206.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,66.2275,416.02,other,OPPS APC,,
HC X-Ray Facial Bones <3 Vw,PX-32000009,CDM,70140,CPT,320,RC,,,outpatient,,,336,235.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC,,
HC X-Ray Facial Bones 3+ Vw,PX-32000010,CDM,70150,CPT,320,RC,,,outpatient,,,252,176.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,56.574,416.02,other,OPPS APC,,
HC X-Ray Nasal Bones,PX-32000011,CDM,70160,CPT,320,RC,,,outpatient,,,319,223.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC,,
HC X-Ray Orbits,PX-32000012,CDM,70200,CPT,320,RC,,,outpatient,,,328,229.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,73.636,416.02,other,OPPS APC,,
HC X-Ray Sinuses <3 Vw,PX-32000013,CDM,70210,CPT,320,RC,,,outpatient,,,328,229.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC,,
HC X-Ray Sinuses 3+ Vw,PX-32000014,CDM,70220,CPT,320,RC,,,outpatient,,,444,310.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC,,
HC X-Ray Exam Sella,PX-32000015,CDM,70240,CPT,320,RC,,,outpatient,,,262,183.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,58.819,416.02,other,OPPS APC,,
HC X-Ray Skull <4 Vw,PX-32000016,CDM,70250,CPT,320,RC,,,outpatient,,,352,246.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,76.026473,416.02,other,OPPS APC,,
HC X-Ray Skull 4+ Vw,PX-32000017,CDM,70260,CPT,320,RC,,,outpatient,,,419,293.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,76.026473,416.02,other,OPPS APC,,
HC X-Ray Teeth Single,PX-32000018,CDM,70300,CPT,320,RC,,,outpatient,,,241,168.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,54.1045,416.02,other,OPPS APC,,
HC X-Ray Tmj Unilat,PX-32000019,CDM,70328,CPT,320,RC,,,outpatient,,,241,168.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,54.1045,416.02,other,OPPS APC,,
HC X-Ray Tmj Bilat,PX-32000020,CDM,70330,CPT,320,RC,,,outpatient,,,716,501.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,71.24,549.888,other,OPPS APC,,
HC MRI- Tmj,PX-61000008,CDM,70336,CPT,610,RC,,,outpatient,,,2588,1811.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,267.439885,1987.584,other,OPPS APC,,
HC Panoramic X-Ray of Jaws,PX-32000022,CDM,70355,CPT,320,RC,,,outpatient,,,241,168.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,54.1045,416.02,other,OPPS APC,,
HC X-Ray Neck Soft Tissue,PX-32000023,CDM,70360,CPT,320,RC,,,outpatient,,,232,162.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,52.084,416.02,other,OPPS APC,,
HC X-Ray Salivary Gland,PX-32000025,CDM,70380,CPT,320,RC,,,outpatient,,,262,183.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,58.819,416.02,other,OPPS APC,,
HC X-Ray Sialogram,PX-32000026,CDM,70390,CPT,320,RC,,,outpatient,,,537,375.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,120.5565,646.6965,other,OPPS APC,,
HC CT Scan-Head/Brain-W/O Contrast Matl,PX-35000002,CDM,70450,CPT,350,RC,,,outpatient,,,1070,749,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,89.81,821.76,other,OPPS APC,,
HC CT Scan Head Contrast,PX-35000003,CDM,70460,CPT,350,RC,,,outpatient,,,1333,933.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,124.33,1023.744,other,OPPS APC,,
CT Head/Brain W/O & W/Contrast Material,PX-35000004,CDM,70470,CPT,350,RC,,,outpatient,,,1615,1130.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,153.75,1240.32,other,OPPS APC,,
HC CT Scan-Orbit/Sella/Post Fossa/Ear-W/O,PX-35000005,CDM,70480,CPT,350,RC,,,outpatient,,,657,459.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,96.160741,575,other,OPPS APC,,
HC CT Scan Skull Contrast,PX-35000006,CDM,70481,CPT,350,RC,,,outpatient,,,774,541.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,173.763,667.43,other,OPPS APC,,
CT Orbit Sella/Post Fossa/Ear W/O & W/Contr Matr,PX-35000007,CDM,70482,CPT,350,RC,,,outpatient,,,1619,1133.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,1243.392,other,OPPS APC,,
HC CT Scan-Maxillofacial Area-W/O Contrast,PX-35000008,CDM,70486,CPT,350,RC,,,outpatient,,,1200,840,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,96.160741,921.6,other,OPPS APC,,
HC CT Scan- Face/Jaw Contrast,PX-35000009,CDM,70487,CPT,350,RC,,,outpatient,,,1321,924.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,1014.528,other,OPPS APC,,
CT Maxillofacial W/O & W/Contrast Material,PX-35000010,CDM,70488,CPT,350,RC,,,outpatient,,,1158,810.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,889.344,other,OPPS APC,,
HC CT Scan-Soft Tissue Neck-W/O Contrast,PX-35000011,CDM,70490,CPT,350,RC,,,outpatient,,,514,359.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,96.160741,575,other,OPPS APC,,
HC CT Neck Tissue Contrast,PX-35000012,CDM,70491,CPT,350,RC,,,outpatient,,,1482,1037.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,194.55,1138.176,other,OPPS APC,,
CT Soft Tissue Neck W/O & W/Contrast Material,PX-35000014,CDM,70492,CPT,350,RC,,,outpatient,,,1755,1228.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,1347.84,other,OPPS APC,,
CT Angiography Head W/Contrast/Noncontrast,PX-35000013,CDM,70496,CPT,350,RC,,,outpatient,,,1330,931,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,1021.44,other,OPPS APC,,
CT Angiography Neck W/Contrast/Noncontrast,PX-35000015,CDM,70498,CPT,350,RC,,,outpatient,,,1157,809.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,888.576,other,OPPS APC,,
HC MRI- Face- Neck,PX-61000009,CDM,70540,CPT,610,RC,,,outpatient,,,5081,3556.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,237.688956,3902.208,other,OPPS APC,,
HC MRI- Face- Neck W/Contrast,PX-61000010,CDM,70542,CPT,610,RC,,,outpatient,,,2710,1897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,365.99,2081.28,other,OPPS APC,,
MRI Orbit Face & Neck W/O & W/Contrast Matrl,PX-61000011,CDM,70543,CPT,610,RC,,,outpatient,,,1692,1184.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,379.854,1299.456,other,OPPS APC,,
HC MR Angio- Head,PX-61000012,CDM,70544,CPT,610,RC,,,outpatient,,,2279,1595.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,267.439885,1750.272,other,OPPS APC,,
HC MR Angio- Head W/Contrast,PX-61000013,CDM,70545,CPT,610,RC,,,outpatient,,,2279,1595.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,374.62,1750.272,other,OPPS APC,,
Mra Head W/O & W/Contrast Material,PX-61000014,CDM,70546,CPT,610,RC,,,outpatient,,,2279,1595.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,301.425681,1750.272,other,OPPS APC,,
HC MR Angio- Neck,PX-61000015,CDM,70547,CPT,610,RC,,,outpatient,,,2182,1527.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,267.439885,1675.776,other,OPPS APC,,
HC MR Angio- Neck W/Contrast,PX-61000016,CDM,70548,CPT,610,RC,,,outpatient,,,2469,1728.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,399.86,1896.192,other,OPPS APC,,
Mra Neck W/O &W/Contrast Material,PX-61000017,CDM,70549,CPT,610,RC,,,outpatient,,,2534,1773.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,301.425681,1946.112,other,OPPS APC,,
HC MRI Brain,PX-61000018,CDM,70551,CPT,610,RC,,,outpatient,,,2090,1463,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,188.66,1605.12,other,OPPS APC,,
HC MRI Brain Contrast,PX-61000019,CDM,70552,CPT,610,RC,,,outpatient,,,5255,3678.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,268.7,4035.84,other,OPPS APC,,
MRI Brain Brain Stem W/O W/Contrast Material,PX-61000020,CDM,70553,CPT,610,RC,,,outpatient,,,2668,1867.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,307.14,2049.024,other,OPPS APC,,
HC X-Ray Exam Chest 1 View,PX-32000245,CDM,71045,CPT,320,RC,,,outpatient,,,214,149.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,48.043,416.02,other,OPPS APC,,
HC X-Ray Exam Chest 2 Views,PX-32000246,CDM,71046,CPT,320,RC,,,outpatient,,,232,162.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,52.084,416.02,other,OPPS APC,,
HC X-Ray Exam Chest 3 Views,PX-32000247,CDM,71047,CPT,320,RC,,,outpatient,,,245,171.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,55.0025,416.02,other,OPPS APC,,
HC X-Ray Exam Chest 4+ Views,PX-32000248,CDM,71048,CPT,320,RC,,,outpatient,,,410,287,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,76.026473,416.02,other,OPPS APC,,
HC X-Ray Ribs- Chest 3+ Vw,PX-32000036,CDM,71101,CPT,320,RC,,,outpatient,,,484,338.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,76.026473,416.02,other,OPPS APC,,
HC X-Ray Ribs- Chest 4+ Vw,PX-32000038,CDM,71111,CPT,320,RC,,,outpatient,,,562,393.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,76.026473,431.616,other,OPPS APC,,
HC X-Ray Sternum 2+ Vw,PX-32000039,CDM,71120,CPT,320,RC,,,outpatient,,,358,250.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC,,
HC X-Ray Sterno-Clavicluar Jt,PX-32000040,CDM,71130,CPT,320,RC,,,outpatient,,,250,175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,56.125,416.02,other,OPPS APC,,
HC Diagnostic Computed Tomography Thorax W/O Cntrst,PX-35000016,CDM,71250,CPT,350,RC,,,outpatient,,,1388,971.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,96.160741,1065.984,other,OPPS APC,,
HC Diagnostic Computed Tomography Thorax W/Contrast,PX-35000017,CDM,71260,CPT,350,RC,,,outpatient,,,1624,1136.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,195.34,1247.232,other,OPPS APC,,
HC Diagnostic Computed Tomography Thorax C-/C+,PX-35000018,CDM,71270,CPT,350,RC,,,outpatient,,,1982,1387.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,1522.176,other,OPPS APC,,
HC Computed Tomography Thorax Lw Dose Lng Ca Scr C-,PX-35000070,CDM,71271,CPT,350,RC,,,outpatient,,,264,184.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,59.268,575,other,OPPS APC,,
CT Angiography Chest W/Contrast/Noncontrast,PX-35000019,CDM,71275,CPT,350,RC,,,outpatient,,,1592,1114.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,1222.656,other,OPPS APC,,
HC MRI- Chest,PX-61000023,CDM,71550,CPT,610,RC,,,outpatient,,,1979,1385.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,237.688956,1519.872,other,OPPS APC,,
HC MRI- Chest- W/Contrast,PX-61000024,CDM,71551,CPT,610,RC,,,outpatient,,,3128,2189.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,873.87904,,,873.87904,399.86,2402.304,other,OPPS APC,,
MRI Chest W/O & W/Contrast Material,PX-61000025,CDM,71552,CPT,610,RC,,,outpatient,,,1547,1082.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,347.3015,1288.93,other,OPPS APC,,
HC MR Angio Chest (Mra) W/Contrast,PX-61000026,CDM,71555,CPT,610,RC,,,outpatient,,,2367,1656.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,301.425681,1817.856,other,OPPS APC,,
HC MR Angio Chest (Mra) Without Contrast,PX-61000071,CDM,71555,CPT,610,RC,,,outpatient,,,2367,1656.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,301.425681,1817.856,other,OPPS APC,,
HC MR Angio Chest (Mra) W/Without Contrast,PX-61000072,CDM,71555,CPT,610,RC,,,outpatient,,,2367,1656.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,301.425681,1817.856,other,OPPS APC,,
HC X-Ray Spine One View,PX-32000042,CDM,72020,CPT,320,RC,,,outpatient,,,251,175.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,56.3495,416.02,other,OPPS APC,,
HC Radex Spine Cervical 2 or 3 Views,PX-32000043,CDM,72040,CPT,320,RC,,,outpatient,,,296,207.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,66.452,416.02,other,OPPS APC,,
HC Radex Spine Cervical 4 or 5 Views,PX-32000044,CDM,72050,CPT,320,RC,,,outpatient,,,300,210,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,67.35,416.02,other,OPPS APC,,
HC Radex Spine Cervical 6 or More Views,PX-32000045,CDM,72052,CPT,320,RC,,,outpatient,,,300,210,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,67.35,416.02,other,OPPS APC,,
HC X-Ray Thoracic Spine 2 Vw,PX-32000046,CDM,72070,CPT,320,RC,,,outpatient,,,252,176.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,56.574,416.02,other,OPPS APC,,
HC X-Ray Thoracic Spine+Swim 3 Vw,PX-32000047,CDM,72072,CPT,320,RC,,,outpatient,,,283,198.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,63.5335,416.02,other,OPPS APC,,
HC X-Ray Thoracic Spine 4 Vw,PX-32000048,CDM,72074,CPT,320,RC,,,outpatient,,,306,214.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,68.697,416.02,other,OPPS APC,,
HC X-Ray Thor-Lumb Sp 2 Vw,PX-32000049,CDM,72080,CPT,320,RC,,,outpatient,,,357,249.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC,,
HC X-Ray Exam Entire Spi 1 Vw,PX-32000233,CDM,72081,CPT,320,RC,,,outpatient,,,241,168.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,54.1045,416.02,other,OPPS APC,,
HC X-Ray Exam Entire Spi 2/3 Vw,PX-32000234,CDM,72082,CPT,320,RC,,,outpatient,,,385,269.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,86.4325,416.02,other,OPPS APC,,
HC X-Ray Exam Entire Spi 4/5 Vw,PX-32000235,CDM,72083,CPT,320,RC,,,outpatient,,,757,529.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,119.991125,581.376,other,OPPS APC,,
HC X-Ray Exam Entire Spi 6/> Vw,PX-32000236,CDM,72084,CPT,320,RC,,,outpatient,,,757,529.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,76.026473,581.376,other,OPPS APC,,
HC X-Ray Lumbar Spine 2/3 Vw,PX-32000051,CDM,72100,CPT,320,RC,,,outpatient,,,235,164.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,52.7575,416.02,other,OPPS APC,,
HC X-Ray Lumbar Spine 4 Vw,PX-32000052,CDM,72110,CPT,320,RC,,,outpatient,,,323,226.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,72.5135,416.02,other,OPPS APC,,
HC X-Ray Lumbar Spine 6+ Vw,PX-32000053,CDM,72114,CPT,320,RC,,,outpatient,,,602,421.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,76.026473,462.336,other,OPPS APC,,
HC X-Ray Lumbar Spine Flex/Exten,PX-32000232,CDM,72120,CPT,320,RC,,,outpatient,,,411,287.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,92.2695,416.02,other,OPPS APC,,
HC CT Scan-Cervical Spine-W/O Contrast,PX-35000020,CDM,72125,CPT,350,RC,,,outpatient,,,1359,951.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,96.160741,1043.712,other,OPPS APC,,
HC CT Scan Cerv Spine Contrast,PX-35000021,CDM,72126,CPT,350,RC,,,outpatient,,,1556,1089.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,196.52,1195.008,other,OPPS APC,,
CT Cervical Spine W/O &W/Contrast Material,PX-35000022,CDM,72127,CPT,350,RC,,,outpatient,,,2239,1567.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,1719.552,other,OPPS APC,,
HC CT Scan-Thoracic Spine-W/O Contrast,PX-35000023,CDM,72128,CPT,350,RC,,,outpatient,,,909,636.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,96.160741,698.112,other,OPPS APC,,
HC CT Scan Dorsal Sp Contrast,PX-35000024,CDM,72129,CPT,350,RC,,,outpatient,,,1037,725.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,196.52,796.416,other,OPPS APC,,
CT Thoracic Spine W/O & W/Contrast Material,PX-35000025,CDM,72130,CPT,350,RC,,,outpatient,,,2219,1553.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,1704.192,other,OPPS APC,,
HC CT Scan-Lumbar Spine-W/O Contrast,PX-35000026,CDM,72131,CPT,350,RC,,,outpatient,,,688,481.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,96.160741,575,other,OPPS APC,,
HC CT Scan Lumbar Sp Contrast,PX-35000027,CDM,72132,CPT,350,RC,,,outpatient,,,1427,998.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,195.73,1095.936,other,OPPS APC,,
CT Lumbar Spine W/O & W/Contrast Material,PX-35000028,CDM,72133,CPT,350,RC,,,outpatient,,,1377,963.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,1057.536,other,OPPS APC,,
HC MRI- Cerv Spine,PX-61000027,CDM,72141,CPT,610,RC,,,outpatient,,,2115,1480.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,185.92,1624.32,other,OPPS APC,,
HC MRI- Cerv Spine Contrast,PX-61000028,CDM,72142,CPT,610,RC,,,outpatient,,,3043,2130.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,270.27,2337.024,other,OPPS APC,,
HC MRI- Dorsal Spine,PX-61000029,CDM,72146,CPT,610,RC,,,outpatient,,,2222,1555.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,185.92,1706.496,other,OPPS APC,,
HC MRI- Dorsal Spine Contrast,PX-61000030,CDM,72147,CPT,610,RC,,,outpatient,,,2843,1990.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,266.73,2183.424,other,OPPS APC,,
HC MRI- Lumbar Spine,PX-61000031,CDM,72148,CPT,610,RC,,,outpatient,,,2651,1855.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,185.92,2035.968,other,OPPS APC,,
HC MRI- Lumbar Spine Contrast,PX-61000032,CDM,72149,CPT,610,RC,,,outpatient,,,2645,1851.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,265.17,2031.36,other,OPPS APC,,
MRI Spinal Canal Cervical W/O & W/Contr Matrl,PX-61000033,CDM,72156,CPT,610,RC,,,outpatient,,,3124,2186.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,307.53,2399.232,other,OPPS APC,,
MRI Spinal Canal Thoracic W/O & W/Contr Matrl,PX-61000034,CDM,72157,CPT,610,RC,,,outpatient,,,2833,1983.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,307.93,2175.744,other,OPPS APC,,
MRI Spinal Canal Lumbar W/O & W/Contr Matrl,PX-61000035,CDM,72158,CPT,610,RC,,,outpatient,,,3181,2226.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,305.58,2443.008,other,OPPS APC,,
HC X-Ray Pelvis 1/2 Vw,PX-32000054,CDM,72170,CPT,320,RC,,,outpatient,,,287,200.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,64.4315,416.02,other,OPPS APC,,
CT Angiography Pelvis W/Contrast/Noncontrast,PX-35000029,CDM,72191,CPT,350,RC,,,outpatient,,,1269,888.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,974.592,other,OPPS APC,,
HC CT Scan-Pelvis-W/O Contrast,PX-35000030,CDM,72192,CPT,350,RC,,,outpatient,,,1368,957.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,96.160741,1050.624,other,OPPS APC,,
HC CT Scan of Pelvis Contrast,PX-35000031,CDM,72193,CPT,350,RC,,,outpatient,,,1561,1092.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,195.33,1198.848,other,OPPS APC,,
CT Pelvis W/O & W/Contrast Material,PX-35000032,CDM,72194,CPT,350,RC,,,outpatient,,,1902,1331.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,1460.736,other,OPPS APC,,
HC MRI- Pelvis- W/O Contrast,PX-61000036,CDM,72195,CPT,610,RC,,,outpatient,,,2241,1568.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,237.688956,1721.088,other,OPPS APC,,
HC MRI- Pelvis W/Contrast,PX-61000037,CDM,72196,CPT,610,RC,,,outpatient,,,2850,1995,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,372.27,2188.8,other,OPPS APC,,
MRI Pelvis W/O & W/Contrast Material,PX-61000038,CDM,72197,CPT,610,RC,,,outpatient,,,2753,1927.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,399.547552,2114.304,other,OPPS APC,,
HC MR Angio Pelvis(Mra) W/Contrast,PX-61000039,CDM,72198,CPT,610,RC,,,outpatient,,,2908,2035.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2233.344,,,,
HC MR Angio Pelvis(Mra) Without Contrast,PX-61000073,CDM,72198,CPT,610,RC,,,outpatient,,,2710,1897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2233.344,,,,
HC MR Angio Pelvis(Mra) W/Without Contrast,PX-61000074,CDM,72198,CPT,610,RC,,,outpatient,,,1826,1278.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2233.344,,,,
HC X-Ray Sacroiliac Jts 3+ Vw,PX-32000056,CDM,72202,CPT,320,RC,,,outpatient,,,443,310.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,76.026473,416.02,other,OPPS APC,,
HC X-Ray Sacrum/Coccyx 2+ Vw,PX-32000057,CDM,72220,CPT,320,RC,,,outpatient,,,336,235.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC,,
HC Myelography Cerv Spine,PX-32000058,CDM,72240,CPT,320,RC,,,outpatient,,,1478,1034.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,873.87904,,,873.87904,331.811,2051.3855,other,OPPS APC,,
HC Myelography Thorax Spine,PX-32000059,CDM,72255,CPT,320,RC,,,outpatient,,,1823,1276.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,873.87904,,,873.87904,399.86,2051.3855,other,OPPS APC,,
HC Myelography Lumbar Spine,PX-32000060,CDM,72265,CPT,320,RC,,,outpatient,,,1760,1232,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,873.87904,,,873.87904,395.12,2051.3855,other,OPPS APC,,
HC Myelography of Entire Spine,PX-32000061,CDM,72270,CPT,320,RC,,,outpatient,,,1823,1276.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,873.87904,,,873.87904,399.86,2051.3855,other,OPPS APC,,
HC X-Ray-C/T-Disk-Superv/Interpret,PX-32000062,CDM,72285,CPT,320,RC,,,outpatient,,,4306,3014.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2107.296165,,,2107.296165,399.86,4977.9345,other,OPPS APC,,
HC Discography Lumbar Spine,PX-32000064,CDM,72295,CPT,320,RC,,,outpatient,,,4306,3014.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2107.296165,,,2107.296165,399.86,4977.9345,other,OPPS APC,,
HC X-Ray Clavicle,PX-32000065,CDM,73000,CPT,320,RC,,,outpatient,,,170,119,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,38.165,416.02,other,OPPS APC,,
HC X-Ray Scapula,PX-32000066,CDM,73010,CPT,320,RC,,,outpatient,,,306,214.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,68.697,416.02,other,OPPS APC,,
HC X-Ray Shoulder 1 Vw,PX-32000067,CDM,73020,CPT,320,RC,,,outpatient,,,256,179.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,57.472,416.02,other,OPPS APC,,
HC X-Ray Shoulder 2+ Vw,PX-32000068,CDM,73030,CPT,320,RC,,,outpatient,,,139,97.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,31.2055,416.02,other,OPPS APC,,
HC Arthrogram of Shoulder,PX-32000069,CDM,73040,CPT,320,RC,,,outpatient,,,1690,1183,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,379.405,1297.92,other,OPPS APC,,
HC X-Ray Ac Jts,PX-32000070,CDM,73050,CPT,320,RC,,,outpatient,,,323,226.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC,,
HC X-Ray Humerus,PX-32000071,CDM,73060,CPT,320,RC,,,outpatient,,,178,124.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,39.961,416.02,other,OPPS APC,,
HC X-Ray Elbow 2 Vw,PX-32000072,CDM,73070,CPT,320,RC,,,outpatient,,,171,119.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,38.3895,416.02,other,OPPS APC,,
HC X-Ray Elbow 3+ Vw,PX-32000073,CDM,73080,CPT,320,RC,,,outpatient,,,129,90.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,28.9605,416.02,other,OPPS APC,,
HC Arthrogram of Elbow,PX-32000074,CDM,73085,CPT,320,RC,,,outpatient,,,1331,931.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,298.8095,1022.208,other,OPPS APC,,
HC X-Ray Forearm 2 Vw,PX-32000075,CDM,73090,CPT,320,RC,,,outpatient,,,225,157.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,50.5125,416.02,other,OPPS APC,,
HC X-Ray Arm- Infant,PX-32000076,CDM,73092,CPT,320,RC,,,outpatient,,,368,257.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,76.026473,416.02,other,OPPS APC,,
HC X-Ray Wrist 2 Vw,PX-32000077,CDM,73100,CPT,320,RC,,,outpatient,,,190,133,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,42.655,416.02,other,OPPS APC,,
HC X-Ray Wrist 3+ Vw,PX-32000078,CDM,73110,CPT,320,RC,,,outpatient,,,241,168.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,54.1045,416.02,other,OPPS APC,,
HC Arthrogram of Wrist,PX-32000079,CDM,73115,CPT,320,RC,,,outpatient,,,1722,1205.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,237.819698,1322.496,other,OPPS APC,,
HC X-Ray Hand 2 Vw,PX-32000080,CDM,73120,CPT,320,RC,,,outpatient,,,306,214.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,68.697,416.02,other,OPPS APC,,
HC X-Ray Hand 3+ Vw,PX-32000081,CDM,73130,CPT,320,RC,,,outpatient,,,236,165.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,52.982,416.02,other,OPPS APC,,
HC X-Ray Exam of Finger(S),PX-32000082,CDM,73140,CPT,320,RC,,,outpatient,,,129,90.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,28.9605,416.02,other,OPPS APC,,
HC CT Scan-Upper Extremity-W/O Contrast,PX-35000034,CDM,73200,CPT,350,RC,,,outpatient,,,959,671.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,96.160741,736.512,other,OPPS APC,,
HC CT Scan of Arm Contrast,PX-35000035,CDM,73201,CPT,350,RC,,,outpatient,,,1388,971.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,193.37,1065.984,other,OPPS APC,,
CT Upper Extremity W/O & W/Contrast Material,PX-35000036,CDM,73202,CPT,350,RC,,,outpatient,,,1961,1372.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,1506.048,other,OPPS APC,,
CT Angiography Upper Extremity,PX-35000037,CDM,73206,CPT,350,RC,,,outpatient,,,1345,941.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,1032.96,other,OPPS APC,,
HC MRI- Upper Extremity W/O Contrast,PX-61000040,CDM,73218,CPT,610,RC,,,outpatient,,,2888,2021.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,237.688956,2217.984,other,OPPS APC,,
HC MRI- Upper Extremity W/Contrast,PX-61000041,CDM,73219,CPT,610,RC,,,outpatient,,,2936,2055.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,371.09,2254.848,other,OPPS APC,,
HC MRI Ext Upp No Jnt W-W/O,PX-61000042,CDM,73220,CPT,610,RC,,,outpatient,,,3144,2200.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,399.547552,2414.592,other,OPPS APC,,
MRI Any Jt Upper Extremity W/O Contrast Matrl,PX-61000043,CDM,73221,CPT,610,RC,,,outpatient,,,3039,2127.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,204.76,2333.952,other,OPPS APC,,
HC MRI- Joint Upper Extrem W/Contrast,PX-61000044,CDM,73222,CPT,610,RC,,,outpatient,,,3144,2200.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,873.87904,,,873.87904,340.49,2414.592,other,OPPS APC,,
MRI Any Jt Upper Extremity W/O & W/Contr Matrl,PX-61000045,CDM,73223,CPT,610,RC,,,outpatient,,,3060,2142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,399.547552,2350.08,other,OPPS APC,,
HC X-Ray Exam Hip Uni 1 View,PX-32000237,CDM,73501,CPT,320,RC,,,outpatient,,,222,155.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,49.839,416.02,other,OPPS APC,,
HC X-Ray Exam Hip Uni 2-3 Views,PX-32000238,CDM,73502,CPT,320,RC,,,outpatient,,,222,155.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,49.839,416.02,other,OPPS APC,,
HC X-Ray Exam Hip Uni 4/> Views,PX-32000239,CDM,73503,CPT,320,RC,,,outpatient,,,385,269.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,86.4325,416.02,other,OPPS APC,,
HC X-Ray Exam Hips Bi 2 Views,PX-32000240,CDM,73521,CPT,320,RC,,,outpatient,,,385,269.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,86.4325,416.02,other,OPPS APC,,
HC X-Ray Exam Hips Bi 5/> Views,PX-32000242,CDM,73523,CPT,320,RC,,,outpatient,,,757,529.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,76.026473,581.376,other,OPPS APC,,
HC Arthrogram of Hip,PX-32000086,CDM,73525,CPT,320,RC,,,outpatient,,,1616,1131.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,237.819698,1241.088,other,OPPS APC,,
HC X-Ray Exam of Femur 1,PX-32000243,CDM,73551,CPT,320,RC,,,outpatient,,,213,149.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,47.8185,416.02,other,OPPS APC,,
HC X-Ray Exam of Femur 2/>,PX-32000244,CDM,73552,CPT,320,RC,,,outpatient,,,241,168.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,54.1045,416.02,other,OPPS APC,,
HC X-Ray Knee 1 or 2 View,PX-32000090,CDM,73560,CPT,320,RC,,,outpatient,,,213,149.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,47.8185,416.02,other,OPPS APC,,
HC X-Ray Knee 3 View,PX-32000091,CDM,73562,CPT,320,RC,,,outpatient,,,232,162.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,52.084,416.02,other,OPPS APC,,
HC X-Ray Knee 4+ View,PX-32000092,CDM,73564,CPT,320,RC,,,outpatient,,,260,182,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,58.37,416.02,other,OPPS APC,,
HC X-Ray Knee Bilat Standing,PX-32000093,CDM,73565,CPT,320,RC,,,outpatient,,,394,275.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC,,
HC Arthrogram of Knee Joint,PX-32000094,CDM,73580,CPT,320,RC,,,outpatient,,,1704,1192.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,382.548,1308.672,other,OPPS APC,,
HC X-Ray Tib + Fib- 2vw,PX-32000095,CDM,73590,CPT,320,RC,,,outpatient,,,199,139.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,44.6755,416.02,other,OPPS APC,,
HC X-Ray Leg- Infant,PX-32000096,CDM,73592,CPT,320,RC,,,outpatient,,,231,161.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,51.8595,416.02,other,OPPS APC,,
HC X-Ray Ankle 2 Vw,PX-32000097,CDM,73600,CPT,320,RC,,,outpatient,,,137,95.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,30.7565,416.02,other,OPPS APC,,
HC X-Ray Ankle 3+ Vw,PX-32000098,CDM,73610,CPT,320,RC,,,outpatient,,,130,91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,29.185,416.02,other,OPPS APC,,
HC Arthrogram of Ankle,PX-32000099,CDM,73615,CPT,320,RC,,,outpatient,,,1221,854.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,237.819698,1020.2995,other,OPPS APC,,
HC X-Ray Foot 2 Vw,PX-32000100,CDM,73620,CPT,320,RC,,,outpatient,,,158,110.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,35.471,416.02,other,OPPS APC,,
HC X-Ray Foot 3+ Vw,PX-32000101,CDM,73630,CPT,320,RC,,,outpatient,,,164,114.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,36.818,416.02,other,OPPS APC,,
HC X-Ray Heel,PX-32000102,CDM,73650,CPT,320,RC,,,outpatient,,,234,163.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,52.533,416.02,other,OPPS APC,,
HC X-Ray Toe(S),PX-32000103,CDM,73660,CPT,320,RC,,,outpatient,,,192,134.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,43.104,416.02,other,OPPS APC,,
HC CT Scan-Lower Extremity-W/O Contrast,PX-35000038,CDM,73700,CPT,350,RC,,,outpatient,,,968,677.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,96.160741,743.424,other,OPPS APC,,
HC CT Scan of Leg Contrast,PX-35000039,CDM,73701,CPT,350,RC,,,outpatient,,,987,690.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,196.51,758.016,other,OPPS APC,,
CT Lower Extremity W/O & W/Contrast Matrl,PX-35000040,CDM,73702,CPT,350,RC,,,outpatient,,,1903,1332.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,1461.504,other,OPPS APC,,
CT Angiography Lower Extremity,PX-35000041,CDM,73706,CPT,350,RC,,,outpatient,,,1176,823.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,903.168,other,OPPS APC,,
HC MRI- Lower Extrem,PX-61000046,CDM,73718,CPT,610,RC,,,outpatient,,,2836,1985.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,237.688956,2178.048,other,OPPS APC,,
HC MRI- Lower Extrem W/Contrast,PX-61000047,CDM,73719,CPT,610,RC,,,outpatient,,,2396,1677.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,372.66,1840.128,other,OPPS APC,,
HC MRI- Lower Extr- W/O Contrast F/U by Contrast,PX-61000048,CDM,73720,CPT,610,RC,,,outpatient,,,3060,2142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,399.547552,2350.08,other,OPPS APC,,
HC MRI Lower Extrem Jt- W/O Contrast,PX-61000049,CDM,73721,CPT,610,RC,,,outpatient,,,3008,2105.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,205.15,2310.144,other,OPPS APC,,
HC MRI- Joint of Leg W/Contrast,PX-61000050,CDM,73722,CPT,610,RC,,,outpatient,,,3018,2112.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,873.87904,,,873.87904,345.98,2317.824,other,OPPS APC,,
MRI Any Jt Lower Extrem W/O & W/Contrast Matrl,PX-61000051,CDM,73723,CPT,610,RC,,,outpatient,,,3098,2168.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,399.547552,2379.264,other,OPPS APC,,
HC MR Angio Lower Extrem (Mra) W/Contrast,PX-61000052,CDM,73725,CPT,610,RC,,,outpatient,,,2710,1897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2290.176,other,OPPS APC,,
HC MR Angio Lower Extrem (Mra) Without Contrast,PX-61000075,CDM,73725,CPT,610,RC,,,outpatient,,,2710,1897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2290.176,other,OPPS APC,,
HC MR Angio Lower Extrem (Mra) W/Without Contrast,PX-61000076,CDM,73725,CPT,610,RC,,,outpatient,,,2982,2087.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2290.176,other,OPPS APC,,
HC X-Ray Exam Abdomen 1 View,PX-32000249,CDM,74018,CPT,320,RC,,,outpatient,,,232,162.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,52.084,416.02,other,OPPS APC,,
HC X-Ray Exam Abdomen 2 Views,PX-32000250,CDM,74019,CPT,320,RC,,,outpatient,,,443,310.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,76.026473,416.02,other,OPPS APC,,
HC X-Ray Exam Abdomen 3+ Views,PX-32000251,CDM,74021,CPT,320,RC,,,outpatient,,,410,287,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,92.045,416.02,other,OPPS APC,,
HC CT Scan-Abdomen-W/O Contrast,PX-35000042,CDM,74150,CPT,350,RC,,,outpatient,,,1449,1014.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,96.160741,1112.832,other,OPPS APC,,
HC CT Scan of Abdomen Contrast,PX-35000043,CDM,74160,CPT,350,RC,,,outpatient,,,1586,1110.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,194.55,1218.048,other,OPPS APC,,
CT Abdomen W/O & W/Contrast Material,PX-35000044,CDM,74170,CPT,350,RC,,,outpatient,,,2058,1440.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,1580.544,other,OPPS APC,,
HC CT Angio Abd&Plvis Cntrst Mtrl W/WO Cntrst Imges,PX-35000045,CDM,74174,CPT,350,RC,,,outpatient,,,2581,1806.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,329.339098,1982.208,other,OPPS APC,,
CT Angiography Abdomen W/Contrast/Noncontrast,PX-35000046,CDM,74175,CPT,350,RC,,,outpatient,,,1355,948.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,1040.64,other,OPPS APC,,
HC CT Scan-Abdoment and Pelvis-W/O Contrast,PX-35000047,CDM,74176,CPT,350,RC,,,outpatient,,,1368,957.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,142.38,1050.624,other,OPPS APC,,
HC CT Scan-Abdoment and Pelvis-W Contrast,PX-35000048,CDM,74177,CPT,350,RC,,,outpatient,,,1971,1379.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,204.61123,1513.728,other,OPPS APC,,
CT Abdomen & Pelvis W/O Contrst 1/> Body Re,PX-35000049,CDM,74178,CPT,350,RC,,,outpatient,,,2122,1485.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,204.61123,1629.696,other,OPPS APC,,
HC MRI- Abdomen (MRI),PX-61000053,CDM,74181,CPT,610,RC,,,outpatient,,,2357,1649.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,237.688956,1810.176,other,OPPS APC,,
HC MRI- Abdomen W/Contrast,PX-61000054,CDM,74182,CPT,610,RC,,,outpatient,,,5081,3556.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,399.547552,3902.208,other,OPPS APC,,
MRI Abdomen W/O & W/Contrast Material,PX-61000055,CDM,74183,CPT,610,RC,,,outpatient,,,2698,1888.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,399.547552,2072.064,other,OPPS APC,,
HC MR Angio Abdomen (Mra) W/Contrast,PX-61000056,CDM,74185,CPT,610,RC,,,outpatient,,,2446,1712.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,301.425681,1878.528,other,OPPS APC,,
HC MR Angio Abdomen (Mra) Without Contrast,PX-61000077,CDM,74185,CPT,610,RC,,,outpatient,,,2446,1712.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,301.425681,1878.528,other,OPPS APC,,
HC MR Angio Abdomen (Mra) W/Without Contrast,PX-61000078,CDM,74185,CPT,610,RC,,,outpatient,,,2446,1712.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,301.425681,1878.528,other,OPPS APC,,
HC Esophagram,PX-32000107,CDM,74220,CPT,320,RC,,,outpatient,,,981,686.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,76.026473,753.408,other,OPPS APC,,
HC Swallowing Fcn-W/Cine &/or Video,PX-32000108,CDM,74230,CPT,320,RC,,,outpatient,,,874,611.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,128.66,671.232,other,OPPS APC,,
HC Remove Esophagus Obstruction,PX-32000109,CDM,74235,CPT,320,RC,,,outpatient,,,1157,809.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,259.7465,888.576,,,,
HC Xray Upper GI Tract,PX-32000110,CDM,74240,CPT,320,RC,,,outpatient,,,916,641.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,703.488,other,OPPS APC,,
HC Xray Upper GI Air Contrast,PX-32000113,CDM,74246,CPT,320,RC,,,outpatient,,,865,605.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,194.1925,664.32,other,OPPS APC,,
HC X-Ray-Small Bowel-W/Mult Serial Films,PX-32000116,CDM,74250,CPT,320,RC,,,outpatient,,,2949,2064.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,128.66,2264.832,other,OPPS APC,,
HC X-Ray Small Bowel Enteroclysis,PX-32000117,CDM,74251,CPT,320,RC,,,outpatient,,,1182,827.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,183.14,907.776,other,OPPS APC,,
HC X-Ray Colon Contrast,PX-32000118,CDM,74270,CPT,320,RC,,,outpatient,,,1071,749.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,822.528,other,OPPS APC,,
HC X-Ray Colon Air Contrast,PX-32000119,CDM,74280,CPT,320,RC,,,outpatient,,,1758,1230.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,1350.144,other,OPPS APC,,
HC X-Ray Oper Cholangiogram,PX-32000123,CDM,74300,CPT,320,RC,,,outpatient,,,1336,935.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,145.12362,1026.048,other,OPPS APC,,
HC X-Ray Oper Cholangio Addnl Set,PX-32000124,CDM,74301,CPT,320,RC,,,outpatient,,,289,202.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,64.8805,416.02,,,,
HC X-Ray Bile/Pancreas Endoscopy,PX-32000129,CDM,74330,CPT,320,RC,,,outpatient,,,1038,726.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,145.12362,797.184,other,OPPS APC,,
HC X-Ray Introductn GI Tube,PX-32000130,CDM,74340,CPT,320,RC,,,outpatient,,,872,610.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,195.08,669.696,,,,
HC X-Ray Guide Enteroclysis Tube,PX-32000131,CDM,74355,CPT,320,RC,,,outpatient,,,2913,2039.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,260.23,2237.184,,,,
HC X-Ray Guide- GI Dilation,PX-32000132,CDM,74360,CPT,320,RC,,,outpatient,,,631,441.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,141.6595,484.608,other,OPPS APC,,
HC Percut Transhepat Dilat-Bile Duct Strict,PX-32000133,CDM,74363,CPT,320,RC,,,outpatient,,,2462,1723.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,1890.816,,,,
HC X-Ray IV Pyelogram (Ivp),PX-32000134,CDM,74400,CPT,320,RC,,,outpatient,,,599,419.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,134.4755,499.422,other,OPPS APC,,
HC X-Ray IV Pyelogram+Tomography,PX-32000136,CDM,74415,CPT,320,RC,,,outpatient,,,2078,1454.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,1595.904,other,OPPS APC,,
HC X-Ray Retrograde Pyelogram,PX-32000137,CDM,74420,CPT,320,RC,,,outpatient,,,1189,832.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,237.819698,1020.2995,other,OPPS APC,,
HC Antegrade Urography Radiological Supvj & Interpj,PX-32000138,CDM,74425,CPT,320,RC,,,outpatient,,,2829,1980.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,399.86,2172.672,other,OPPS APC,,
HC X-Ray Cystogram- Min 3 View,PX-32000139,CDM,74430,CPT,320,RC,,,outpatient,,,1189,832.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,237.819698,1020.2995,other,OPPS APC,,
HC X-Ray Urethrocystogram,PX-32000140,CDM,74450,CPT,320,RC,,,outpatient,,,762,533.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,171.069,646.6965,other,OPPS APC,,
HC X-Ray Urethrocystogram+Voiding,PX-32000141,CDM,74455,CPT,320,RC,,,outpatient,,,762,533.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,171.069,646.6965,other,OPPS APC,,
HC X-Ray Renal Cyst Xlumbar+Contrst,PX-32000142,CDM,74470,CPT,320,RC,,,outpatient,,,542,379.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,602.109165,,,602.109165,121.679,1393.3385,other,OPPS APC,,
HC X-Ray Guide- Gu Dilation,PX-32000145,CDM,74485,CPT,320,RC,,,outpatient,,,3417,2391.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2223.02603,,,2223.02603,399.86,5136.771,other,OPPS APC,,
HC X-Ray Hysterosalpingogram,PX-32000146,CDM,74740,CPT,320,RC,,,outpatient,,,1695,1186.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,237.819698,1301.76,other,OPPS APC,,
HC X-Ray Xcerv Cath Fallopian Tube,PX-32000147,CDM,74742,CPT,320,RC,,,outpatient,,,1270,889,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,285.115,975.36,,,,
HC Cardiac MRI Morphology & Function W/O Contrast,PX-61000057,CDM,75557,CPT,610,RC,,,outpatient,,,2222,1555.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,88.902,1706.496,other,OPPS APC,,
HC PR Cardiac MRI Morphology & Function W/O Contrast,PX-97200020,CDM,75557,CPT,972,RC,,,outpatient,,,396,277.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,88.902,1706.496,other,OPPS APC,,
HC Cardiac MRI W/W/O Contrast & Further Seq,PX-61000059,CDM,75561,CPT,610,RC,,,outpatient,,,2644,1850.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,102.5965,2030.592,other,OPPS APC,,
HC PR Cardiac MRI W/W/O Contrast & Further Seq,PX-97200021,CDM,75561,CPT,972,RC,,,outpatient,,,457,319.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,102.5965,2030.592,other,OPPS APC,,
HC Cardiac MRI for Velocity Flow Mapping,PX-61000061,CDM,75565,CPT,610,RC,,,outpatient,,,222,155.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.2045,836,,,,
HC PR Cardiac MRI for Velocity Flow Mapping,PX-97200022,CDM,75565,CPT,972,RC,,,outpatient,,,41,28.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.2045,836,,,,
HC CT Heart W/O Contrast Quant Eval Coronary Calcium,PX-35000052,CDM,75571,CPT,350,RC,,,outpatient,,,264,184.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,19.0825,575,other,OPPS APC,,
HC PR CT Heart W/O Contrast Quant Eval Coronary Calcium,PX-97200023,CDM,75571,CPT,972,RC,,,outpatient,,,85,59.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,19.0825,575,other,OPPS APC,,
HC CT Heart Contrast Eval Cardiac Struct/Morph,PX-35000053,CDM,75572,CPT,350,RC,,,outpatient,,,872,610.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,58.819,669.696,other,OPPS APC,,
HC PR CT Heart Contrast Eval Cardiac Struct/Morph,PX-97200024,CDM,75572,CPT,972,RC,,,outpatient,,,262,183.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,58.819,669.696,other,OPPS APC,,
HC CT Heart Contrast Eval Cardiac Struct/Morph- Congen Heart Disease,PX-35000054,CDM,75573,CPT,350,RC,,,outpatient,,,1016,711.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,58.819,780.288,other,OPPS APC,,
HC PR CT Heart Contrast Eval Cardiac Struct/Morph- Congen Heart Disease,PX-97200025,CDM,75573,CPT,972,RC,,,outpatient,,,262,183.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,58.819,780.288,other,OPPS APC,,
HC CT Angio Hrt Cornry Art/Bypass Grfts Contrst 3d Post,PX-35000055,CDM,75574,CPT,350,RC,,,outpatient,,,1073,751.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,57.921,824.064,other,OPPS APC,,
HC PR CT Angio Hrt Cornry Art/Bypass Grfts Contrst 3d Post,PX-97200026,CDM,75574,CPT,972,RC,,,outpatient,,,258,180.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,57.921,824.064,other,OPPS APC,,
HC N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp,PX-48000097,CDM,75580,CPT,480,RC,,,outpatient,,,2856,1999.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1141.12419,,,1141.12419,399.86,2536.61118,other,OPPS APC,,
HC Angio Aortogram Thoracic,PX-32000148,CDM,75600,CPT,320,RC,,,outpatient,,,3155,2208.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
HC Angio Aortogram Thor Serial,PX-32000149,CDM,75605,CPT,320,RC,,,outpatient,,,12541,8778.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,14233.715,other,OPPS APC,,
HC Angio Aortogram Abd Serial,PX-32000150,CDM,75625,CPT,320,RC,,,outpatient,,,5654,3957.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
HC Angio Aortobifemoral W Cath,PX-32000151,CDM,75630,CPT,320,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
Cta Abdl Aorta&Bi Iliofem W/Contrast&Postp,PX-35000056,CDM,75635,CPT,350,RC,,,outpatient,,,1721,1204.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,200.53123,,,200.53123,200.53123,1321.728,other,OPPS APC,,
HC Angio Spinal Selectv,PX-32000153,CDM,75705,CPT,320,RC,,,outpatient,,,11403,7982.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,14233.715,other,OPPS APC,,
HC Angio Extremity Unilat,PX-32000154,CDM,75710,CPT,320,RC,,,outpatient,,,6489,4542.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
HC Angio Extermity Bilat,PX-32000155,CDM,75716,CPT,320,RC,,,outpatient,,,7162,5013.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
HC Angio Visceral Selectv/Subselec,PX-32000156,CDM,75726,CPT,320,RC,,,outpatient,,,9831,6881.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,14233.715,other,OPPS APC,,
HC Angio Adrenal Unilat Select,PX-32000157,CDM,75731,CPT,320,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
HC Angio Adrenal Bilat Select,PX-32000158,CDM,75733,CPT,320,RC,,,outpatient,,,6665,4665.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
HC Angio Pelvis,PX-32000159,CDM,75736,CPT,320,RC,,,outpatient,,,11403,7982.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,14233.715,other,OPPS APC,,
HC Angio Pulmon Unilat Select,PX-32000160,CDM,75741,CPT,320,RC,,,outpatient,,,6665,4665.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
HC Angio Pulmon Bilat Select,PX-32000161,CDM,75743,CPT,320,RC,,,outpatient,,,7162,5013.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
HC Angio Pulmon Bilat Nonselec,PX-32000162,CDM,75746,CPT,320,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
HC Angio Intern Mammary,PX-32000163,CDM,75756,CPT,320,RC,,,outpatient,,,6665,4665.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
HC Angio Ea Addnl Selectv Vessel,PX-32000164,CDM,75774,CPT,320,RC,,,outpatient,,,3538,2476.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2717.184,other,OPPS APC,,
HC Nonvascular Shuntogram,PX-32000166,CDM,75809,CPT,320,RC,,,outpatient,,,411,287.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,92.2695,416.02,other,OPPS APC,,
HC Venogram Splenoportogram,PX-32000167,CDM,75810,CPT,320,RC,,,outpatient,,,7698,5388.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
HC Venogram Extrem Unilat,PX-32000168,CDM,75820,CPT,320,RC,,,outpatient,,,3212,2248.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1747.952815,,,1747.952815,399.86,4120.349,other,OPPS APC,,
HC Venogram Extrem Bilat,PX-32000169,CDM,75822,CPT,320,RC,,,outpatient,,,2940,2058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1747.952815,,,1747.952815,399.86,4120.349,other,OPPS APC,,
HC Venogram Infer Vena Cava,PX-32000170,CDM,75825,CPT,320,RC,,,outpatient,,,5987,4190.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
HC Venogram Super Vena Cava,PX-32000171,CDM,75827,CPT,320,RC,,,outpatient,,,2874,2011.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1747.952815,,,1747.952815,399.86,4120.349,other,OPPS APC,,
HC Venogram Renal Unilat,PX-32000172,CDM,75831,CPT,320,RC,,,outpatient,,,6489,4542.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
HC Venogram Renal Bilat,PX-32000173,CDM,75833,CPT,320,RC,,,outpatient,,,6665,4665.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
HC Venogram Adrenal Unilat,PX-32000174,CDM,75840,CPT,320,RC,,,outpatient,,,7698,5388.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
HC Venogram Adrenal Bilat,PX-32000175,CDM,75842,CPT,320,RC,,,outpatient,,,11403,7982.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,14233.715,other,OPPS APC,,
HC Venogram Sinus/Jugular,PX-32000176,CDM,75860,CPT,320,RC,,,outpatient,,,6665,4665.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
HC Venogram Super Sag Sinus,PX-32000177,CDM,75870,CPT,320,RC,,,outpatient,,,4428,3099.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
HC Venogram Epidural,PX-32000178,CDM,75872,CPT,320,RC,,,outpatient,,,4428,3099.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.639025,,,685.639025,399.86,3400.704,other,OPPS APC,,
HC Venogram Orbital,PX-32000179,CDM,75880,CPT,320,RC,,,outpatient,,,1638,1146.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,685.639025,,,685.639025,367.731,1602.0655,other,OPPS APC,,
HC Percut Xhepatic Porto+Dynamic,PX-32000180,CDM,75885,CPT,320,RC,,,outpatient,,,7698,5388.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
HC Percut Xhepatic Portogram,PX-32000181,CDM,75887,CPT,320,RC,,,outpatient,,,7528,5269.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
HC Venogram Hepatic W Hemodynamics,PX-32000182,CDM,75889,CPT,320,RC,,,outpatient,,,5272,3690.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
HC Venogram Hepatic,PX-32000183,CDM,75891,CPT,320,RC,,,outpatient,,,6665,4665.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,399.86,8249.769,other,OPPS APC,,
HC Venous Sampling by Catheter,PX-32000184,CDM,75893,CPT,320,RC,,,outpatient,,,11403,7982.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5997.74636,,,5997.74636,399.86,14233.715,other,OPPS APC,,
HC Transcatheter Rx Embolizatn,PX-32000185,CDM,75894,CPT,320,RC,,,outpatient,,,2536,1775.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,145.12362,1947.648,other,OPPS APC,,
HC Angrph Cath F-Up Std Tcat Other Than Thrombylsis,PX-32000187,CDM,75898,CPT,320,RC,,,outpatient,,,3747,2622.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3478.894955,,,3478.894955,260.23,8249.769,other,OPPS APC,,
HC Remove-Obst Matl-Cva Dev via Sep Ven Acc,PX-32000188,CDM,75901,CPT,320,RC,,,outpatient,,,4773,3341.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,260.23,3665.664,,,,
HC Remove-Obst Matl-Cva Device via Lumen,PX-32000189,CDM,75902,CPT,320,RC,,,outpatient,,,471,329.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,105.7395,416.02,,,,
HC Endovasc Repair Thor Aorta Incl Subclavian,PX-32000195,CDM,75956,CPT,320,RC,,,outpatient,,,1446,1012.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,324.627,1110.528,,,,
HC Endovasc Repair Thor Aorta Excl Subclavian,PX-32000196,CDM,75957,CPT,320,RC,,,outpatient,,,1312,918.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,294.544,1007.616,,,,
HC Proximal Extens Durng Endovasc Rethor Aorta,PX-32000197,CDM,75958,CPT,320,RC,,,outpatient,,,845,591.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,189.7025,648.96,,,,
HC Delayed Prox Extens Endovasc Rethor Aorta,PX-32000198,CDM,75959,CPT,320,RC,,,outpatient,,,744,520.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,167.028,571.392,,,,
HC Vascular Biopsy,PX-32000203,CDM,75970,CPT,320,RC,,,outpatient,,,2918,2042.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,145.12362,2241.024,other,OPPS APC,,
HC Change Percut Tube/Drain Cath W Contrast Monit,PX-32000207,CDM,75984,CPT,320,RC,,,outpatient,,,2885,2019.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,145.12362,2215.68,other,OPPS APC,,
HC Rad Guided-Percut Drainage-W/Cath Place,PX-32000208,CDM,75989,CPT,320,RC,,,outpatient,,,888,621.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,145.12362,681.984,other,OPPS APC,,
HC Rad Guided-Percut Drainage-W/Cath Place,PX-35000057,CDM,75989,CPT,350,RC,,,outpatient,,,888,621.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,145.12362,681.984,other,OPPS APC,,
HC Fluoroscopy Spx Up to 1 Hour Phys/Qhp Time,PX-32000209,CDM,76000,CPT,320,RC,,,outpatient,,,997,697.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,195.08,765.696,other,OPPS APC,,
HC X-Ray Nose-Rectum Child F.B.,PX-32000210,CDM,76010,CPT,320,RC,,,outpatient,,,340,238,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC,,
HC X-Ray Fistula-Abscess-Sinus Tract,PX-32000211,CDM,76080,CPT,320,RC,,,outpatient,,,1950,1365,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,602.109165,,,602.109165,237.819698,1497.6,other,OPPS APC,,
HC X-Ray Exam- Breast Specimen,PX-32000212,CDM,76098,CPT,320,RC,,,outpatient,,,984,688.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,602.109165,,,602.109165,220.908,1393.3385,other,OPPS APC,,
HC Cine/Videoradiology-Exc Where Spec Incl,PX-32000214,CDM,76120,CPT,320,RC,,,outpatient,,,382,267.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,85.759,416.02,other,OPPS APC,,
HC 3d Rendering W/Interp & Postprocess Supervision,PX-35000058,CDM,76376,CPT,350,RC,,,outpatient,,,352,246.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,79.024,836,other,OPPS APC,,
HC 3d Rendering W/Interp & Postprocess Supervision,PX-40200003,CDM,76376,CPT,402,RC,,,outpatient,,,352,246.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,79.024,836,other,OPPS APC,,
HC 3d Rendering W/Interp & Postprocess Supervision,PX-61000062,CDM,76376,CPT,610,RC,,,outpatient,,,352,246.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,79.024,836,other,OPPS APC,,
HC 3d Rendering W/Interp&Postproc Diff Work Station,PX-35000059,CDM,76377,CPT,350,RC,,,outpatient,,,422,295.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,94.739,836,other,OPPS APC,,
HC 3d Rendering W/Interp&Postproc Diff Work Station,PX-40200004,CDM,76377,CPT,402,RC,,,outpatient,,,422,295.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,94.739,836,other,OPPS APC,,
HC 3d Rendering W/Interp&Postproc Diff Work Station,PX-61000063,CDM,76377,CPT,610,RC,,,outpatient,,,422,295.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,94.739,836,other,OPPS APC,,
HC CT Scan-Limited/Localized F/U Study,PX-35000060,CDM,76380,CPT,350,RC,,,outpatient,,,928,649.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,71.24,712.704,other,OPPS APC,,
HC MRI Spectroscopy,PX-61000064,CDM,76390,CPT,610,RC,,,outpatient,,,2218,1552.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,81.08,1703.424,other,OPPS APC,,
HC Magnetic Resonance Elastography,PX-61000090,CDM,76391,CPT,610,RC,,,outpatient,,,842,589.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,189.029,836,other,OPPS APC,,
HC Unlisted CT Procedure,PX-35000061,CDM,76497,CPT,350,RC,,,outpatient,,,229,160.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,51.4105,575,other,OPPS APC,,
HC US- Head- Real Time,PX-40200005,CDM,76506,CPT,402,RC,,,outpatient,,,433,303.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,97.2085,416.02,other,OPPS APC,,
HC US- Head/Neck Tissues-Real Time,PX-40200006,CDM,76536,CPT,402,RC,,,outpatient,,,444,310.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,99.678,416.02,other,OPPS APC,,
HC US- Chest-Real Time,PX-40200007,CDM,76604,CPT,402,RC,,,outpatient,,,417,291.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,93.6165,416.02,other,OPPS APC,,
HC US Breast Uni Real Time With Image Complete,PX-40200056,CDM,76641,CPT,402,RC,,,outpatient,,,385,269.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,86.4325,416.02,other,OPPS APC,,
HC US Breast Uni Real Time With Image Limited,PX-40200055,CDM,76642,CPT,402,RC,,,outpatient,,,353,247.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC,,
HC US- Abdom-B-Scan &/or Real Time-Complete,PX-40200009,CDM,76700,CPT,402,RC,,,outpatient,,,461,322.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,103.4945,416.02,other,OPPS APC,,
HC US- Abdomen Limited,PX-40200010,CDM,76705,CPT,402,RC,,,outpatient,,,341,238.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,76.5545,416.02,other,OPPS APC,,
HC Ultrasound Exam Aaa Screen,PX-40200002,CDM,76706,CPT,402,RC,,,outpatient,,,261,182.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,58.5945,416.02,other,OPPS APC,,
HC US-Retroperit- B-Scan/Real Time-Complete,PX-40200011,CDM,76770,CPT,402,RC,,,outpatient,,,368,257.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,82.616,416.02,other,OPPS APC,,
HC US- Retroperitnl Abd- Ltd,PX-40200012,CDM,76775,CPT,402,RC,,,outpatient,,,345,241.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,77.4525,416.02,other,OPPS APC,,
HC US- Spinal Canal & Contents,PX-40200014,CDM,76800,CPT,402,RC,,,outpatient,,,595,416.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,119.991125,456.96,other,OPPS APC,,
HC US- OB < 14 Wks- Single Fetus,PX-40200015,CDM,76801,CPT,402,RC,,,outpatient,,,289,202.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,64.8805,416.02,other,OPPS APC,,
HC US- OB < 14 Wks- Add'l Fetus,PX-40200016,CDM,76802,CPT,402,RC,,,outpatient,,,224,156.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,50.288,416.02,other,OPPS APC,,
HC US- OB >/= 14 Wks- Sngl Fetus,PX-40200017,CDM,76805,CPT,402,RC,,,outpatient,,,421,294.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,94.5145,416.02,other,OPPS APC,,
HC US- OB >/= 14 Wks- Addl Fetus,PX-40200018,CDM,76810,CPT,402,RC,,,outpatient,,,713,499.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,157.086513,547.584,other,OPPS APC,,
HC US-Preg Uter-Fet & Mat-+ Detl Fet Exm,PX-40200019,CDM,76811,CPT,402,RC,,,outpatient,,,725,507.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,162.7625,646.6965,other,OPPS APC,,
HC US-Preg Uter-Fet & Mat-+ Detl Fet-Addl,PX-40200020,CDM,76812,CPT,402,RC,,,outpatient,,,240,168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,53.88,416.02,,,,
HC US-Pregnant Uterus-Limited- 1/> Fetuses,PX-40200021,CDM,76815,CPT,402,RC,,,outpatient,,,303,212.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,68.0235,416.02,other,OPPS APC,,
HC US-Pregnant Uterus-F/U-Transabd App,PX-40200022,CDM,76816,CPT,402,RC,,,outpatient,,,600,420,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,119.991125,460.8,other,OPPS APC,,
HC US-Pregnant Uterus-Transvaginal,PX-40200023,CDM,76817,CPT,402,RC,,,outpatient,,,355,248.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,79.6975,416.02,other,OPPS APC,,
HC Fetal Biophysical Profile,PX-40200024,CDM,76818,CPT,402,RC,,,outpatient,,,439,307.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,98.5555,416.02,other,OPPS APC,,
HC Fetal Biophys Prof-W/O Nst,PX-40200025,CDM,76819,CPT,402,RC,,,outpatient,,,358,250.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,80.371,416.02,other,OPPS APC,,
HC Doppler Fetal Umbilical Artery,PX-40200026,CDM,76820,CPT,402,RC,,,outpatient,,,290,203,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,65.105,416.02,other,OPPS APC,,
HC US-Pregnant Uterus-Limited- 1/> Fetuses,PX-40200028,CDM,76827,CPT,402,RC,,,outpatient,,,578,404.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,119.991125,443.904,other,OPPS APC,,
HC Sono Fetal Hrt Doppl F/U,PX-40200029,CDM,76828,CPT,402,RC,,,outpatient,,,146,102.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,32.777,416.02,other,OPPS APC,,
HC Echography-Transvaginal,PX-40200030,CDM,76830,CPT,402,RC,,,outpatient,,,365,255.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,81.9425,416.02,other,OPPS APC,,
HC Sono Exam- Hysterosonography,PX-40200031,CDM,76831,CPT,402,RC,,,outpatient,,,1006,704.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,199.512292,772.608,other,OPPS APC,,
HC Echo-Pelvic (Nonobstetric),PX-40200032,CDM,76856,CPT,402,RC,,,outpatient,,,361,252.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,81.0445,416.02,other,OPPS APC,,
HC Sono Pelvis Limited,PX-40200033,CDM,76857,CPT,402,RC,,,outpatient,,,332,232.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,74.534,416.02,other,OPPS APC,,
HC Echo-Scrotum & Contents,PX-40200034,CDM,76870,CPT,402,RC,,,outpatient,,,457,319.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,102.5965,416.02,other,OPPS APC,,
HC Echo-Transrectal,PX-40200035,CDM,76872,CPT,402,RC,,,outpatient,,,401,280.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,90.0245,416.02,other,OPPS APC,,
HC Echo-Transrectal-Prostate Vol,PX-40200036,CDM,76873,CPT,402,RC,,,outpatient,,,273,191.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,61.2885,416.02,other,OPPS APC,,
HC US-Extremity-Nonvascular-Real-Time Image-Complete,PX-40200037,CDM,76881,CPT,402,RC,,,outpatient,,,400,280,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,89.8,416.02,other,OPPS APC,,
HC US-Extremity-Nonvascular-Real-Time Image-Limited,PX-40200038,CDM,76882,CPT,402,RC,,,outpatient,,,253,177.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,56.7985,416.02,other,OPPS APC,,
HC US Inft Hips R-T Img Dynamic Req Phys/Qhp Manj,PX-40200039,CDM,76885,CPT,402,RC,,,outpatient,,,412,288.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC,,
HC US Inft Hips R-T Img Lmtd Static Phys/Qhp Manj,PX-40200040,CDM,76886,CPT,402,RC,,,outpatient,,,412,288.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,71.24,416.02,other,OPPS APC,,
HC US Guid-Comp Repair-Pseudo-Aneur/Av Fist,PX-40200041,CDM,76936,CPT,402,RC,,,outpatient,,,681,476.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,152.8845,775.5705,other,OPPS APC,,
HC US Guide- Vascular Access,PX-40200042,CDM,76937,CPT,402,RC,,,outpatient,,,251,175.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,56.3495,416.02,other,OPPS APC,,
HC US Guide- Tissue Ablation,PX-40200043,CDM,76940,CPT,402,RC,,,outpatient,,,460,322,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,103.27,416.02,other,OPPS APC,,
HC Sono Guide Needle Biopsy,PX-40200044,CDM,76942,CPT,402,RC,,,outpatient,,,868,607.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,166.37,666.624,other,OPPS APC,,
HC Sono Guide Amniocentesis,PX-40200045,CDM,76946,CPT,402,RC,,,outpatient,,,354,247.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,79.473,416.02,,,,
HC US Guid-Comp Repair-Pseudo-Aneur/Av Fist,PX-40200048,CDM,76998,CPT,402,RC,,,outpatient,,,604,422.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,135.598,463.872,other,OPPS APC,,
HC Fluoroguide Cntrl Ven Access-Place-Replace-Remove,PX-32000217,CDM,77001,CPT,320,RC,,,outpatient,,,521,364.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,116.9645,416.02,other,OPPS APC,,
HC Fluoroscopic Guidance Needle Placement,PX-32000218,CDM,77002,CPT,320,RC,,,outpatient,,,318,222.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,71.391,416.02,other,OPPS APC,,
HC Fluorscopic Guidance Spinal Injection,PX-32000219,CDM,77003,CPT,320,RC,,,outpatient,,,518,362.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,116.291,416.02,other,OPPS APC,,
HC CT Guidance Stereotactic Localization,PX-35000062,CDM,77011,CPT,350,RC,,,outpatient,,,1801,1260.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,1383.168,other,OPPS APC,,
HC CT Guidance Needle Placement,PX-35000063,CDM,77012,CPT,350,RC,,,outpatient,,,1747,1222.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,63.344499,1341.696,other,OPPS APC,,
HC CT Guidance Tissue Ablation,PX-35000064,CDM,77013,CPT,350,RC,,,outpatient,,,1755,1228.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,63.344499,1347.84,other,OPPS APC,,
HC CT Guidance Placement Rad Therapy Fields,PX-35000065,CDM,77014,CPT,350,RC,,,outpatient,,,623,436.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,139.8635,575,other,OPPS APC,,
HC MRI Guidance Needle Placement,PX-61000066,CDM,77021,CPT,610,RC,,,outpatient,,,3092,2164.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2374.656,,,,
HC MRI Breast Without Contrast Material Unilateral,PX-61000083,CDM,77046,CPT,610,RC,,,outpatient,,,842,589.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,189.029,836,other,OPPS APC,,
HC MRI Breast Without Contrast Material Bilateral,PX-61000086,CDM,77047,CPT,610,RC,,,outpatient,,,842,589.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,189.029,836,other,OPPS APC,,
HC MRI Breast With Contrast W/Cad Unilateral,PX-61000084,CDM,77048,CPT,610,RC,,,outpatient,,,2118,1482.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.547552,1936.896,other,OPPS APC,,
HC MRI Breast W/Out&With Contrast W/Cad Unilateral,PX-61000085,CDM,77048,CPT,610,RC,,,outpatient,,,2522,1765.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.547552,1936.896,other,OPPS APC,,
HC MRI Breast With Contrast W/Cad Bilateral,PX-61000087,CDM,77049,CPT,610,RC,,,outpatient,,,2788,1951.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.547552,2548.224,other,OPPS APC,,
HC MRI Breast W/Out&With Contrast W/Cad Bilateral,PX-61000088,CDM,77049,CPT,610,RC,,,outpatient,,,3318,2322.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.547552,2548.224,other,OPPS APC,,
HC Digital Breast Tomosynthesis Unilateral,PX-40100006,CDM,77061,CPT,401,RC,,,outpatient,,,321,224.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,72.0645,416.02,fee schedule,,,
HC Digital Breast Tomosynthesis Bilateral,PX-40100007,CDM,77062,CPT,401,RC,,,outpatient,,,393,275.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,88.2285,416.02,fee schedule,,,
HC Screening Digital Breast Tomosynthesis Bi,PX-40300004,CDM,77063,CPT,403,RC,,,outpatient,,,202,141.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,25.43,,,25.43,22.99364,416.02,fee schedule,,,
HC Dx Mammo Incl Cad Uni,PX-40100008,CDM,77065,CPT,401,RC,,,outpatient,,,393,275.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,92.45,,,92.45,88.2285,416.02,fee schedule,,,
HC Dx Mammo Incl Cad Bi,PX-40100009,CDM,77066,CPT,401,RC,,,outpatient,,,466,326.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,118.49,,,118.49,90.800319,416.02,fee schedule,,,
HC Scr Mammo Bi Incl Cad,PX-40300005,CDM,77067,CPT,403,RC,,,outpatient,,,466,326.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,97.74,,,97.74,90.800319,416.02,fee schedule,,,
HC Manual Appl Stress Pfrmd Phys/Qhp Joint Films,PX-32000222,CDM,77071,CPT,320,RC,,,outpatient,,,262,183.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,58.819,416.02,other,OPPS APC,,
HC X-Rays for Bone Age,PX-32000223,CDM,77072,CPT,320,RC,,,outpatient,,,218,152.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,48.941,416.02,other,OPPS APC,,
HC X-Rays- Bone Length Studies,PX-32000224,CDM,77073,CPT,320,RC,,,outpatient,,,502,351.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,76.026473,416.02,other,OPPS APC,,
HC X-Rays- Bone Survey- Limited,PX-32000225,CDM,77074,CPT,320,RC,,,outpatient,,,502,351.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,112.699,416.02,other,OPPS APC,,
HC X-Rays- Bone Survey Complete,PX-32000226,CDM,77075,CPT,320,RC,,,outpatient,,,502,351.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,112.699,416.02,other,OPPS APC,,
HC X-Rays- Bone Survey- Infant,PX-32000227,CDM,77076,CPT,320,RC,,,outpatient,,,502,351.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,76.026473,416.02,other,OPPS APC,,
HC Dexa-Bone Density- 1 + Site- Axial Skeleton,PX-32000228,CDM,77080,CPT,320,RC,,,outpatient,,,575,402.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,119.991125,441.6,other,OPPS APC,,
HC Dexa-Bone Density- 1 + Site- Appendiculr Skeltn,PX-32000229,CDM,77081,CPT,320,RC,,,outpatient,,,114,79.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,25.593,416.02,other,OPPS APC,,
HC MRI- Bone Marrow,PX-61000070,CDM,77084,CPT,610,RC,,,outpatient,,,2406,1684.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,267.439885,1847.808,other,OPPS APC,,
HC Tbs Techl Prep&Transmis Data Alys Pfrmd Elsewhr,PX-32000262,CDM,77090,CPT,320,RC,,,outpatient,,,248,173.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,55.676,416.02,other,OPPS APC,,
HC Tbs Technical Calculation Only,PX-32000263,CDM,77091,CPT,320,RC,,,outpatient,,,248,173.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,99.17739,,,99.17739,55.676,416.02,other,OPPS APC,,
HC Thyroid Uptake Single/Multiple Quant Measurement,PX-34100001,CDM,78012,CPT,341,RC,,,outpatient,,,935,654.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,209.9075,1076.394,other,OPPS APC,,
HC Thyroid Imaging With Vascular Flow,PX-34100002,CDM,78013,CPT,341,RC,,,outpatient,,,633,443.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,142.1085,1076.394,other,OPPS APC,,
HC Thyroid Uptake W/Blood Flow Sngle/Mult Quan Meas,PX-34100003,CDM,78014,CPT,341,RC,,,outpatient,,,982,687.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,220.459,1076.394,other,OPPS APC,,
HC Thyroid Met Imaging Body,PX-34100005,CDM,78018,CPT,341,RC,,,outpatient,,,1049,734.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,589.921045,,,589.921045,235.5005,1397.122,other,OPPS APC,,
HC Thyroid Met Uptake,PX-34100006,CDM,78020,CPT,341,RC,,,outpatient,,,171,119.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,38.3895,416.02,,,,
HC Parathyroid Planar Imaging,PX-34100007,CDM,78070,CPT,341,RC,,,outpatient,,,1575,1102.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,353.5875,1209.6,other,OPPS APC,,
HC Parathyroid Planar Imaging W/WO Subtraction,PX-34100008,CDM,78071,CPT,341,RC,,,outpatient,,,1357,949.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,304.6465,1076.394,other,OPPS APC,,
HC Parathyroid Imaging W/Tomographic Spect & CT,PX-34100009,CDM,78072,CPT,341,RC,,,outpatient,,,1898,1328.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,589.921045,,,589.921045,358.69,1457.664,other,OPPS APC,,
HC Adrenal Nuclear Imaging,PX-34100010,CDM,78075,CPT,341,RC,,,outpatient,,,2974,2081.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC,,
HC Bone Marrow Imaging- Ltd,PX-34100011,CDM,78102,CPT,341,RC,,,outpatient,,,1403,982.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,314.9735,1077.504,other,OPPS APC,,
HC Bone Marrow Imaging- Mult,PX-34100012,CDM,78103,CPT,341,RC,,,outpatient,,,1403,982.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,314.9735,1077.504,other,OPPS APC,,
HC Bone Marrow Imaging- Body,PX-34100013,CDM,78104,CPT,341,RC,,,outpatient,,,659,461.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,147.9455,1076.394,other,OPPS APC,,
HC Spleen Imaging,PX-34100015,CDM,78185,CPT,341,RC,,,outpatient,,,971,679.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,217.9895,1076.394,other,OPPS APC,,
HC Lymphatics & Lymph Glands Imaging,PX-34100016,CDM,78195,CPT,341,RC,,,outpatient,,,1071,749.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,589.921045,,,589.921045,240.4395,1397.122,other,OPPS APC,,
HC Liver Imaging,PX-34100017,CDM,78201,CPT,341,RC,,,outpatient,,,2228,1559.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,589.921045,,,589.921045,399.86,2239.93036,other,OPPS APC,,
HC Liver and Spleen Imaging,PX-34100021,CDM,78215,CPT,341,RC,,,outpatient,,,1205,843.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,270.5225,1076.394,other,OPPS APC,,
HC Hepatobiliary Syst Imaging Including Gallbladder,PX-34100023,CDM,78226,CPT,341,RC,,,outpatient,,,1384,968.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,310.708,1076.394,other,OPPS APC,,
HC Hepatobil Syst Imag Inc Gb W/Pharma Intervenj,PX-34100024,CDM,78227,CPT,341,RC,,,outpatient,,,1384,968.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,589.921045,,,589.921045,310.708,1397.122,other,OPPS APC,,
HC Serial Salivary Imaging,PX-34100025,CDM,78231,CPT,341,RC,,,outpatient,,,788,551.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,176.906,1076.394,other,OPPS APC,,
HC Gastroesophageal Reflux Exam,PX-34100027,CDM,78262,CPT,341,RC,,,outpatient,,,1043,730.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,234.1535,1076.394,other,OPPS APC,,
HC Gastric Emptying Study,PX-34100028,CDM,78264,CPT,341,RC,,,outpatient,,,838,586.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,188.131,1076.394,other,OPPS APC,,
HC Acute GI Blood Loss Imaging,PX-34100031,CDM,78278,CPT,341,RC,,,outpatient,,,2079,1455.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,399.86,1596.672,other,OPPS APC,,
HC Bowel Imaging,PX-34100032,CDM,78290,CPT,341,RC,,,outpatient,,,893,625.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,200.4785,1076.394,other,OPPS APC,,
HC Leveen/Shunt Patency Exam,PX-34100033,CDM,78291,CPT,341,RC,,,outpatient,,,954,667.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,214.173,1076.394,other,OPPS APC,,
HC Bone Imaging- Limited Area,PX-34100034,CDM,78300,CPT,341,RC,,,outpatient,,,962,673.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,215.969,1076.394,other,OPPS APC,,
HC Bone Imaging- Multiple Areas,PX-34100035,CDM,78305,CPT,341,RC,,,outpatient,,,1098,768.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,246.501,1076.394,other,OPPS APC,,
HC Bone Imaging- Whole Body,PX-34100036,CDM,78306,CPT,341,RC,,,outpatient,,,893,625.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,200.4785,1076.394,other,OPPS APC,,
HC Bone Imaging- 3 Phase,PX-34100037,CDM,78315,CPT,341,RC,,,outpatient,,,956,669.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,214.622,1076.394,other,OPPS APC,,
HC Myocardial Spect Single Study at Rest or Stress,PX-34100040,CDM,78451,CPT,341,RC,,,outpatient,,,4510,3157,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC,,
HC Myocardial Spect Multiple Studies,PX-34100041,CDM,78452,CPT,341,RC,,,outpatient,,,4510,3157,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC,,
HC Myocardial Perfusion Planar 1 Study Rest/Stress,PX-34100042,CDM,78453,CPT,341,RC,,,outpatient,,,3900,2730,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC,,
HC Myocardial Perfusion Planar Multiple Studies,PX-34100043,CDM,78454,CPT,341,RC,,,outpatient,,,3900,2730,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC,,
HC Gated Heart- Planar Single,PX-34100048,CDM,78472,CPT,341,RC,,,outpatient,,,1586,1110.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,356.057,1218.048,other,OPPS APC,,
HC Heart Image- Spect,PX-34100050,CDM,78494,CPT,341,RC,,,outpatient,,,1671,1169.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,375.1395,1283.328,other,OPPS APC,,
HC Pulmonary Ventilation Imaging,PX-34100052,CDM,78579,CPT,341,RC,,,outpatient,,,767,536.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,172.1915,1076.394,other,OPPS APC,,
HC Lung Perfusion Imaging,PX-34100053,CDM,78580,CPT,341,RC,,,outpatient,,,640,448,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,143.68,1076.394,other,OPPS APC,,
HC Pulmonary Ventilation & Perfusion Imaging,PX-34100054,CDM,78582,CPT,341,RC,,,outpatient,,,946,662.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,589.921045,,,589.921045,212.377,1397.122,other,OPPS APC,,
HC Quant Differential Pulm Perfusion W/WO Imaging,PX-34100055,CDM,78597,CPT,341,RC,,,outpatient,,,902,631.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,202.499,1076.394,other,OPPS APC,,
HC Quant Diff Pulm Prfusion & Ventlaj W/WO Imaging,PX-34100056,CDM,78598,CPT,341,RC,,,outpatient,,,1499,1049.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,589.921045,,,589.921045,336.5255,1397.122,other,OPPS APC,,
HC Brain Imaging < 4 Static Views W Vascular Flow,PX-34100058,CDM,78601,CPT,341,RC,,,outpatient,,,2704,1892.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,399.86,2076.672,other,OPPS APC,,
HC Brain Imaging Min 4 Static Views W Vascular Flow,PX-34100059,CDM,78606,CPT,341,RC,,,outpatient,,,1589,1112.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,589.921045,,,589.921045,356.7305,1397.122,other,OPPS APC,,
HC Brain Imaging Pet Metabolic,PX-40400003,CDM,78608,CPT,404,RC,,,outpatient,,,4890,3423,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1707.4823,,,1707.4823,399.86,3755.52,other,OPPS APC,,
HC CSF Fluid Scan Cisternography,PX-34100061,CDM,78630,CPT,341,RC,,,outpatient,,,2570,1799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,589.921045,,,589.921045,399.86,1973.76,other,OPPS APC,,
HC CSF Shunt Evaluation,PX-34100062,CDM,78645,CPT,341,RC,,,outpatient,,,916,641.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,589.921045,,,589.921045,205.642,1397.122,other,OPPS APC,,
HC CSF Leakage Detection & Localization,PX-34100063,CDM,78650,CPT,341,RC,,,outpatient,,,3215,2250.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC,,
HC Renal Imaging- Static,PX-34100064,CDM,78700,CPT,341,RC,,,outpatient,,,1292,904.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,290.054,1076.394,other,OPPS APC,,
HC Renal Flow/Funct Imaging,PX-34100065,CDM,78707,CPT,341,RC,,,outpatient,,,1210,847,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,589.921045,,,589.921045,271.645,1397.122,other,OPPS APC,,
HC Renal Flow/Funct Image-Pharm Rx,PX-34100066,CDM,78708,CPT,341,RC,,,outpatient,,,899,629.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,589.921045,,,589.921045,201.8255,1397.122,other,OPPS APC,,
HC Testicular Imaging & Flow,PX-34100069,CDM,78761,CPT,341,RC,,,outpatient,,,845,591.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,189.7025,1076.394,other,OPPS APC,,
HC Tumor Imaging- Limited Area,PX-34100070,CDM,78800,CPT,341,RC,,,outpatient,,,867,606.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,194.6415,1076.394,other,OPPS APC,,
HC Tumor Imaging- Whole Body- Single Day,PX-34100072,CDM,78802,CPT,341,RC,,,outpatient,,,3124,2186.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC,,
HC Tumor Imaging Spect,PX-34100073,CDM,78803,CPT,341,RC,,,outpatient,,,2419,1693.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC,,
HC Tumor Imaging- Whole Body- 2 or More Days,PX-34100074,CDM,78804,CPT,341,RC,,,outpatient,,,2916,2041.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC,,
HC Inject Radiopharm Non-Imaging Localization- IV,PX-34100080,CDM,78808,CPT,341,RC,,,outpatient,,,1227,858.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,450.147135,,,450.147135,275.4615,1076.394,other,OPPS APC,,
HC Pet Imaging CT for Attenuation Limited Area,PX-40400004,CDM,78814,CPT,404,RC,,,outpatient,,,5186,3630.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1707.4823,,,1707.4823,399.86,3982.848,other,OPPS APC,,
HC Pet Imaging CT Attenuation Skull Base Mid-Thigh,PX-40400005,CDM,78815,CPT,404,RC,,,outpatient,,,6904,4832.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1707.4823,,,1707.4823,399.86,5302.272,other,OPPS APC,,
HC Pet Imaging for CT Attenuation Whole Body,PX-40400006,CDM,78816,CPT,404,RC,,,outpatient,,,7705,5393.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1707.4823,,,1707.4823,399.86,5917.44,other,OPPS APC,,
HC Rp Loclzj Tum Spect W/CT 1 Area 1 Day Imaging,PX-34100081,CDM,78830,CPT,341,RC,,,outpatient,,,4318,3022.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC,,
HC Rp Loclzj Tum Spect 2 Area 1d Img/1 Area Img>2+D,PX-34100082,CDM,78831,CPT,341,RC,,,outpatient,,,4318,3022.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1549.781315,,,1549.781315,399.86,3675.6585,other,OPPS APC,,
HC Rp Loclzj Tum Spect CT 2area 1d Img/1 AR Img>2+D,PX-34100083,CDM,78832,CPT,341,RC,,,outpatient,,,4899,3429.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1707.4823,,,1707.4823,399.86,4124.5085,other,OPPS APC,,
HC Radiopharmaceutical Quantification Meas 1 Area,PX-34100084,CDM,78835,CPT,341,RC,,,outpatient,,,203,142.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,45.5735,416.02,,,,
HC Nuclear Therapy- Oral,PX-34200001,CDM,79005,CPT,342,RC,,,outpatient,,,782,547.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,271.52932,,,271.52932,175.559,691.5815,other,OPPS APC,,
HC Urinalysis- Auto- W/O Scope,PX-30000067,CDM,81003,CPT,300,RC,,,outpatient,,,32,22.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.29,24.576,fee schedule,,,
HC Urine Pregnancy Test,PX-30000713,CDM,81025,CPT,300,RC,,,outpatient,,,28,19.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,6.286,21.504,fee schedule,,,
HC Molecular Pathology Procedure Level 4,PX-30000097,CDM,81403,CPT,300,RC,,,outpatient,,,716,501.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,185.2,,,185.2,160.742,549.888,fee schedule,,,
HC Blood Occult-by Peroxid- Feces- 1-3 Simult- Non Ca Screen,PX-30000715,CDM,82272,CPT,300,RC,,,outpatient,,,24,16.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.33,18.432,,,,
HC Glucose Blood Test,PX-30000221,CDM,82962,CPT,300,RC,,,outpatient,,,45,31.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.4,34.56,fee schedule,,,
HC Bone Marrow-Smear Interpretation,PX-31000012,CDM,85097,CPT,310,RC,,,outpatient,,,1038,726.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,938.496695,,,938.496695,39.73,1313.895373,other,OPPS APC,,
HC Coagulation Time- Activated,PX-30000417,CDM,85347,CPT,300,RC,,,outpatient,,,80,56,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.35,61.44,fee schedule,,,
HC Hgb/Rbcs Fetal Fetomaternal Hemrrg Rosette,PX-30000732,CDM,85461,CPT,300,RC,,,outpatient,,,32,22.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,6.78,24.576,,,,
HC Sickling RBC Reduction,PX-30000730,CDM,85660,CPT,300,RC,,,outpatient,,,25,17.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,5.6125,19.2,fee schedule,,,
HC Platelet Antibodies,PX-30000453,CDM,86022,CPT,300,RC,,,outpatient,,,128,89.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,18.77,98.304,fee schedule,,,
HC Cold Agglutinin Screen,PX-30000465,CDM,86156,CPT,300,RC,,,outpatient,,,158,110.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,6.51,121.344,,,,
HC Cold Agglutinin- Titer,PX-30000466,CDM,86157,CPT,300,RC,,,outpatient,,,29,20.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,6.5105,24.43,fee schedule,,,
HC Leukocyte Phagocytosis,PX-30000866,CDM,86344,CPT,300,RC,,,outpatient,,,33,23.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,7.4085,25.344,,,,
HC Cmv Antibody,PX-30000526,CDM,86644,CPT,300,RC,,,outpatient,,,155,108.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.71,119.04,fee schedule,,,
HC Hla Typing- a-B-or C /Single,PX-30000582,CDM,86812,CPT,300,RC,,,outpatient,,,252,176.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.37,193.536,fee schedule,,,
HC Hla Typing Dr/Dq Single Antigen,PX-30000731,CDM,86816,CPT,300,RC,,,outpatient,,,124,86.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,27.838,95.232,,,,
HC Hla Typing- Dr/Dq-Multi Antgn,PX-30000584,CDM,86817,CPT,300,RC,,,outpatient,,,287,200.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,64.4315,241.472,,,,
HC RBC Antibody Screen,PX-30000585,CDM,86850,CPT,300,RC,,,outpatient,,,99,69.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,59.142165,,,59.142165,6.25,92.88556,other,OPPS APC,,
HC RBC Antibody Elution,PX-30000586,CDM,86860,CPT,300,RC,,,outpatient,,,358,250.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,186.41867,,,186.41867,2.072,274.944,other,OPPS APC,,
HC RBC Antibody Identification,PX-30000587,CDM,86870,CPT,300,RC,,,outpatient,,,501,350.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,392.31084,,,392.31084,2.842,549.235176,other,OPPS APC,,
HC Antihuman Globulin Dir Ea Antiserum,PX-30000588,CDM,86880,CPT,300,RC,,,outpatient,,,117,81.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,5.5,93.463636,other,OPPS APC,,
HC Antihuman Globulin Indir Qual Ea Reagent Cell,PX-30000589,CDM,86885,CPT,300,RC,,,outpatient,,,357,249.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,186.41867,,,186.41867,5.85,274.176,other,OPPS APC,,
HC Antihuman Globulin Indirect Ea Antibody Titer,PX-30000590,CDM,86886,CPT,300,RC,,,outpatient,,,357,249.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,186.41867,,,186.41867,5.29,274.176,other,OPPS APC,,
HC Blood Typing- Abo,PX-30000592,CDM,86900,CPT,300,RC,,,outpatient,,,208,145.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,3.05,195.186327,other,OPPS APC,,
HC Blood Typing- Rh (D),PX-30000593,CDM,86901,CPT,300,RC,,,outpatient,,,85,59.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,43.769555,,,43.769555,3.05,65.28,other,OPPS APC,,
HC Blood Type Antigen Donor Reagent Serum- Ea Antigen,PX-30000594,CDM,86902,CPT,300,RC,,,outpatient,,,628,439.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,392.31084,,,392.31084,3.91,549.235176,other,OPPS APC,,
HC Blood Typing Antigen Screen Patient Serum/Unit,PX-30000718,CDM,86904,CPT,300,RC,,,outpatient,,,311,217.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,9.71,238.848,other,OPPS APC,,
HC Blood Typing- RBC Antigens,PX-30000595,CDM,86905,CPT,300,RC,,,outpatient,,,628,439.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,392.31084,,,392.31084,3.91,549.235176,other,OPPS APC,,
HC Blood Typing Serologic Rh Phenotyping Complete,PX-30000719,CDM,86906,CPT,300,RC,,,outpatient,,,284,198.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,43.769555,,,43.769555,7.91,218.112,other,OPPS APC,,
HC Compatibility Test-Spin Tech,PX-30000596,CDM,86920,CPT,300,RC,,,outpatient,,,355,248.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,186.41867,,,186.41867,2.31,272.64,other,OPPS APC,,
HC Compatibility Test-Incub Tech,PX-30000597,CDM,86921,CPT,300,RC,,,outpatient,,,357,249.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,186.41867,,,186.41867,2.072,274.176,other,OPPS APC,,
HC Compatibility Test-Antiglob Tech,PX-30000598,CDM,86922,CPT,300,RC,,,outpatient,,,357,249.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,186.41867,,,186.41867,2.45,274.176,other,OPPS APC,,
HC Compatibility Test- Electronic,PX-30000599,CDM,86923,CPT,300,RC,,,outpatient,,,357,249.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,186.41867,,,186.41867,1.862,274.176,other,OPPS APC,,
HC Plasma- Fresh Frozen,PX-30000600,CDM,86927,CPT,300,RC,,,outpatient,,,312,218.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,186.41867,,,186.41867,1.302,263.69806,other,OPPS APC,,
HC Blood Product/Irradiation,PX-39100002,CDM,86945,CPT,391,RC,,,outpatient,,,116,81.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,43.769555,,,43.769555,1.932,416.02,other,OPPS APC,,
HC Pretx RBC Antibody Incubat W/Chem Agnts/Drugs Ea,PX-30000729,CDM,86970,CPT,300,RC,,,outpatient,,,110,77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,1.932,93.463636,other,OPPS APC,,
HC Pretx RBC Antibody Incubat W/Enzymes Each,PX-30000726,CDM,86971,CPT,300,RC,,,outpatient,,,560,392,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,186.41867,,,186.41867,1.54,499.62884,other,OPPS APC,,
HC Pretx RBC Antibody Incubat W/Density Grad Sep,PX-30000727,CDM,86972,CPT,300,RC,,,outpatient,,,358,250.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,186.41867,,,186.41867,2.702,274.944,other,OPPS APC,,
HC Pretx Serum RBC Antibody Incubation Drugs Each,PX-30000725,CDM,86975,CPT,300,RC,,,outpatient,,,358,250.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,434.866165,,,434.866165,2.072,608.812631,other,OPPS APC,,
HC Pretx Serum RBC Antibody Identification Dilution,PX-30000724,CDM,86976,CPT,300,RC,,,outpatient,,,311,217.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,32.497835,,,32.497835,2.31,238.848,other,OPPS APC,,
HC Pretx Serum RBC Antb ID Incubation Inhibitors Ea,PX-30000734,CDM,86977,CPT,300,RC,,,outpatient,,,509,356.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,186.41867,,,186.41867,2.31,416.02,other,OPPS APC,,
HC RBC Pretreatment-Serum Inhib,PX-39100003,CDM,86977,CPT,391,RC,,,outpatient,,,509,356.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,186.41867,,,186.41867,2.31,416.02,other,OPPS APC,,
HC Pretx Serum RBC Antibody ID Diffial Each Absrpj,PX-30000723,CDM,86978,CPT,300,RC,,,outpatient,,,311,217.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,2.31,238.848,other,OPPS APC,,
HC Unlisted Transfusion Medicine Procedure,PX-30000728,CDM,86999,CPT,300,RC,,,outpatient,,,299,209.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,32.497835,,,32.497835,1.68,229.632,other,OPPS APC,,
HC Strep a Assay W/Optic,PX-30000714,CDM,87880,CPT,300,RC,,,outpatient,,,52,36.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,11.674,39.936,,,,
HC Sperm Isolation- Simple,PX-31000079,CDM,89260,CPT,310,RC,,,outpatient,,,210,147,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,59.142165,,,59.142165,47.145,416.02,other,OPPS APC,,
HC Sperm Isolation- Complex,PX-30000709,CDM,89261,CPT,300,RC,,,outpatient,,,152,106.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,59.142165,,,59.142165,34.124,116.736,other,OPPS APC,,
HC Semen Analysis-Volume- Count- Motility- Diff,PX-30000711,CDM,89320,CPT,300,RC,,,outpatient,,,58,40.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.32,44.544,,,,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4202-01,NDC,outpatient,1,ML,650.46,455.322,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,160.2909605,,,160.2909605,139.93,1690.176,other,OPPS APC,,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4203-02,NDC,outpatient,5,ML,2200.75,1540.525,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,160.2909605,,,160.2909605,139.93,1690.176,other,OPPS APC,,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4202-02,NDC,outpatient,1,ML,650.46,455.322,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,160.2909605,,,160.2909605,139.93,1690.176,other,OPPS APC,,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4203-01,NDC,outpatient,5,ML,2200.75,1540.525,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,160.2909605,,,160.2909605,139.93,1690.176,other,OPPS APC,,
RABIES IMMUNE GLOBULIN 300 UNIT/ML IJ SOLN,RX-142826,CDM,90375,HCPCS,636,RC,13533-0318-10,NDC,outpatient,1,ML,1554.22,1087.954,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,329.569514,,,329.569514,287.71,7105.5744,other,OPPS APC,,
RABIES IMMUNE GLOBULIN 300 UNIT/ML IJ SOLN,RX-142826,CDM,90375,HCPCS,636,RC,13533-0318-01,NDC,outpatient,1,ML,1554.22,1087.954,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,329.569514,,,329.569514,287.71,7105.5744,other,OPPS APC,,
RABIES IMMUNE GLOBULIN 1500 UNIT/5ML IJ SOLN,RX-142827,CDM,90375,HCPCS,636,RC,13533-0318-05,NDC,outpatient,5,ML,7771.09,5439.763,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,329.569514,,,329.569514,287.71,7105.5744,other,OPPS APC,,
RABIES IMMUNE GLOBULIN 1500 UNIT/5ML IJ SOLN,RX-142827,CDM,90375,HCPCS,636,RC,13533-0318-50,NDC,outpatient,5,ML,7771.09,5439.763,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,329.569514,,,329.569514,287.71,7105.5744,other,OPPS APC,,
RABIES IMMUNE GLOBULIN 900 UNIT/3ML IJ SOLN,RX-150138,CDM,90375,HCPCS,636,RC,13533-0318-03,NDC,outpatient,3,ML,4662.66,3263.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,329.569514,,,329.569514,287.71,7105.5744,other,OPPS APC,,
RABIES IMMUNE GLOBULIN 900 UNIT/3ML IJ SOLN,RX-150138,CDM,90375,HCPCS,636,RC,13533-0318-30,NDC,outpatient,3,ML,4662.66,3263.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,329.569514,,,329.569514,287.71,7105.5744,other,OPPS APC,,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-10,NDC,outpatient,10,ML,9252.05,6476.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,329.569514,,,329.569514,287.71,7105.5744,other,OPPS APC,,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-20,NDC,outpatient,2,ML,1850.42,1295.294,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,329.569514,,,329.569514,287.71,7105.5744,other,OPPS APC,,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-02,NDC,outpatient,2,ML,1850.42,1295.294,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,329.569514,,,329.569514,287.71,7105.5744,other,OPPS APC,,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-11,NDC,outpatient,10,ML,9252.05,6476.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,329.569514,,,329.569514,287.71,7105.5744,other,OPPS APC,,
PALIVIZUMAB 50 MG/0.5ML IM SOLN,RX-108060,CDM,90378,HCPCS,636,RC,66658-0230-01,NDC,outpatient,0.5,ML,5025.03,3517.521,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,389.10344,,,389.10344,389.10344,4791.979,other,OPPS APC,,
HC Immuniz Admin-1 Single/Comb Vac/Toxoid,PX-77100004,CDM,90471,CPT,771,RC,,,outpatient,,,193,135.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,76.88596,,,76.88596,43.3285,416.02,other,OPPS APC,,
HC Immuniz-Admin-Each Addl,PX-77100008,CDM,90472,CPT,771,RC,,,outpatient,,,73,51.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,16.3885,416.02,other,OPPS APC,,
HC Admn Sarscov2 Vacc 1 Dose,PX-77100044,CDM,90480,CPT,771,RC,,,outpatient,,,111,77.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,47.56116,,,47.56116,24.9195,416.02,other,OPPS APC,,
MENINGOCOCCAL B RECOMB OMV ADJ IM SUSY,RX-129389,CDM,90620,HCPCS,636,RC,58160-0976-20,NDC,outpatient,0.5,ML,874.41,612.087,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.5,671.54688,,,,
MENINGOCOCCAL B RECOMB OMV ADJ IM SUSY,RX-129389,CDM,90620,HCPCS,636,RC,58160-0976-02,NDC,outpatient,0.5,ML,874.41,612.087,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.5,671.54688,,,,
HEPATITIS A VACCINE 1440 EL U/ML IM SUSP,RX-91034,CDM,90632,HCPCS,636,RC,58160-0826-43,NDC,outpatient,1,ML,337.61,236.327,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,70.48,416.02,other,OPPS APC,,
HEPATITIS A VACCINE 1440 EL U/ML IM SUSP,RX-91034,CDM,90632,HCPCS,636,RC,58160-0826-52,NDC,outpatient,1,ML,337.61,236.327,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,70.48,416.02,other,OPPS APC,,
HEPATITIS A VACCINE 720 EL U/0.5ML IM SUSP,RX-91033,CDM,90633,HCPCS,636,RC,58160-0825-43,NDC,outpatient,0.5,ML,155.01,108.507,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,34.799745,416.02,,,,
HEPATITIS A VACCINE 720 EL U/0.5ML IM SUSP,RX-91033,CDM,90633,HCPCS,636,RC,58160-0825-52,NDC,outpatient,0.5,ML,155.01,108.507,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,34.799745,416.02,,,,
HAEMOPHILUS B POLYSAC CONJ VAC IM SOLR,RX-11931,CDM,90648,HCPCS,636,RC,49281-0547-58,NDC,outpatient,1,UN,49.34,34.538,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,11.07683,416.02,other,OPPS APC,,
HAEMOPHILUS B POLYSAC CONJ VAC IM SOLR,RX-11931,CDM,90648,HCPCS,636,RC,49281-0545-03,NDC,outpatient,1,UN,49.34,34.538,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,11.07683,416.02,other,OPPS APC,,
HPV 9-VALENT RECOMB VACCINE IM SUSY,RX-129114,CDM,90651,HCPCS,636,RC,00006-4121-01,NDC,outpatient,0.5,ML,1147.17,803.019,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.5,881.02656,,,,
HPV 9-VALENT RECOMB VACCINE IM SUSY,RX-129114,CDM,90651,HCPCS,636,RC,00006-4121-02,NDC,outpatient,0.5,ML,1147.17,803.019,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.5,881.02656,,,,
INFLUENZA VAC SUBUNIT QUAD 0.5 ML IM SUSY,RX-135284,CDM,90674,HCPCS,636,RC,70461-0323-04,NDC,outpatient,0.5,ML,94.26,65.982,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.5,416.02,,,,
INFLUENZA VAC SUBUNIT QUAD 0.5 ML IM SUSY,RX-135284,CDM,90674,HCPCS,636,RC,70461-0323-03,NDC,outpatient,0.5,ML,94.26,65.982,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.5,416.02,,,,
RABIES VACCINE WRAPPER,RX-4080220,CDM,90675,HCPCS,636,RC,50632-0010-01,NDC,outpatient,1,UN,1460.49,1022.343,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,401.08537,,,401.08537,91.911626,1316.02176,other,OPPS APC,,
RABIES VACCINE WRAPPER,RX-4080220,CDM,90675,HCPCS,636,RC,49281-0252-51,NDC,outpatient,1,UN,1713.57,1199.499,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,401.08537,,,401.08537,91.911626,1316.02176,other,OPPS APC,,
RABIES VACCINE WRAPPER,RX-4080220,CDM,90675,HCPCS,636,RC,50632-0013-01,NDC,outpatient,1,UN,1460.49,1022.343,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,401.08537,,,401.08537,91.911626,1316.02176,other,OPPS APC,,
PNEUMOCOCCAL 20-VAL CONJ VACC 0.5 ML IM SUSY,RX-156044,CDM,90677,HCPCS,636,RC,00005-2000-02,NDC,outpatient,0.5,ML,1098.4,768.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.5,843.5712,,,,
INFLUENZA VAC A&B SA ADJ QUAD 0.5 ML IM PRSY,RX-150230,CDM,90694,HCPCS,636,RC,70461-0123-03,NDC,outpatient,0.5,ML,241.68,169.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.5,416.02,,,,
INFLUENZA VAC A&B SA ADJ QUAD 0.5 ML IM PRSY,RX-150230,CDM,90694,HCPCS,636,RC,70461-0123-04,NDC,outpatient,0.5,ML,241.68,169.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.5,416.02,,,,
DIPHTH-ACELL PERTUSSIS-TETANUS 15-23-5 LF-MCG/0.5 IM SUSP,RX-140528,CDM,90700,HCPCS,636,RC,49281-0286-10,NDC,outpatient,0.5,ML,107.51,75.257,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,24.135995,416.02,other,OPPS APC,,
DIPHTH-ACELL PERTUSSIS-TETANUS 15-23-5 LF-MCG/0.5 IM SUSP,RX-140528,CDM,90700,HCPCS,636,RC,49281-0286-58,NDC,outpatient,0.5,ML,107.51,75.257,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,24.135995,416.02,other,OPPS APC,,
MEASLES- MUMPS & RUBELLA VAC IJ SOLR,RX-148019,CDM,90707,HCPCS,636,RC,00006-4681-00,NDC,outpatient,1,UN,362.53,253.771,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,54.47,416.02,,,,
MEASLES- MUMPS & RUBELLA VAC IJ SOLR,RX-148019,CDM,90707,HCPCS,636,RC,00006-4681-01,NDC,outpatient,1,UN,362.53,253.771,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,54.47,416.02,,,,
POLIOVIRUS VACCINE INACTIVATED IJ INJ,RX-108127,CDM,90713,HCPCS,636,RC,49281-0860-78,NDC,outpatient,0.5,ML,163.66,114.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,25.298577,416.02,other,OPPS APC,,
POLIOVIRUS VACCINE INACTIVATED IJ INJ,RX-108127,CDM,90713,HCPCS,636,RC,49281-0860-10,NDC,outpatient,0.5,ML,163.66,114.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,25.298577,416.02,other,OPPS APC,,
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,58160-0842-01,NDC,outpatient,0.5,ML,193.78,135.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,25.298577,416.02,other,OPPS APC,,
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,49281-0400-58,NDC,outpatient,0.5,ML,187.93,131.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,25.298577,416.02,other,OPPS APC,,
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,58160-0842-11,NDC,outpatient,0.5,ML,193.78,135.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,25.298577,416.02,other,OPPS APC,,
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,49281-0400-10,NDC,outpatient,0.5,ML,187.93,131.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,25.298577,416.02,other,OPPS APC,,
VARICELLA VIRUS VACCINE LIVE 1350 PFU/0.5ML SC INJ,RX-113088,CDM,90716,HCPCS,636,RC,00006-4827-01,NDC,outpatient,1,UN,737.12,515.984,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.5,566.10816,,,,
VARICELLA VIRUS VACCINE LIVE 1350 PFU/0.5ML SC INJ,RX-113088,CDM,90716,HCPCS,636,RC,00006-4827-00,NDC,outpatient,1,UN,737.12,515.984,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.5,566.10816,,,,
DTAP-HEPATITIS B RECOMB-IPV IM SUSY,RX-158218,CDM,90723,HCPCS,636,RC,58160-0811-52,NDC,outpatient,0.5,ML,392.47,274.729,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.5,416.02,,,,
DTAP-HEPATITIS B RECOMB-IPV IM SUSY,RX-158218,CDM,90723,HCPCS,636,RC,58160-0811-43,NDC,outpatient,0.5,ML,392.47,274.729,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.5,416.02,,,,
MENINGOCOCCAL A C Y&W-135 OLIG IM SOLN,RX-161800,CDM,90734,HCPCS,636,RC,58160-0827-30,NDC,outpatient,0.5,ML,640.81,448.567,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.5,492.14208,,,,
MENINGOCOCCAL A C Y&W-135 OLIG IM SOLN,RX-161800,CDM,90734,HCPCS,636,RC,58160-0827-03,NDC,outpatient,0.5,ML,640.81,448.567,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.5,492.14208,,,,
HEPATITIS B VAC RECOMB ADJ 20 MCG/0.5ML IM SOSY,RX-143904,CDM,90739,HCPCS,636,RC,43528-0003-01,NDC,outpatient,0.5,ML,537.53,376.271,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.5,416.02,,,,
HEPATITIS B VAC RECOMB ADJ 20 MCG/0.5ML IM SOSY,RX-143904,CDM,90739,HCPCS,636,RC,43528-0003-05,NDC,outpatient,0.5,ML,537.53,376.271,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.5,416.02,,,,
HC Esophageal Motility Study- Manometry,PX-92000004,CDM,91010,CPT,920,RC,,,outpatient,,,1126,788.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,584.98394,,,584.98394,252.787,1055.807021,other,OPPS APC,,
HC Gerd Tst W/ Mucos Ph Electrod,PX-92000007,CDM,91035,CPT,920,RC,,,outpatient,,,1775,1242.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,584.98394,,,584.98394,398.4875,1363.2,other,OPPS APC,,
HC GI Trc Img Intraluminal Esophagus-Ileum W/I&R,PX-75000005,CDM,91110,CPT,750,RC,,,outpatient,,,3922,2745.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,989.356895,,,989.356895,399.86,3012.096,other,OPPS APC,,
HC GI Imag Intraluminal Esophagus-Ileum W/I&R,PX-92000008,CDM,91110,CPT,920,RC,,,outpatient,,,3922,2745.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,989.356895,,,989.356895,399.86,3012.096,other,OPPS APC,,
HC Rectal Sesation Tone & Compliance Test,PX-36900666,CDM,91120,CPT,369,RC,,,outpatient,,,752,526.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,168.824,1592,other,OPPS APC,,
HC Anal Pressure Record,PX-36900541,CDM,91122,CPT,369,RC,,,outpatient,,,1360,952,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,305.32,1592,other,OPPS APC,,
COVID-19 MRNA VACC (MODERNA) 50 MCG/0.5ML IM SUSY,RX-165852,CDM,91322,HCPCS,636,RC,80777-0102-01,NDC,outpatient,0.5,ML,492.72,344.904,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.5,417.629472,,,,
COVID-19 MRNA VACC (MODERNA) 50 MCG/0.5ML IM SUSY,RX-165852,CDM,91322,HCPCS,636,RC,80777-0102-93,NDC,outpatient,0.5,ML,492.72,344.904,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.5,417.629472,,,,
HC Eye Photography,PX-92000009,CDM,92285,CPT,920,RC,,,outpatient,,,80,56,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,43.769555,,,43.769555,17.96,416.02,other,OPPS APC,,
HC Caloric Vestibular Test Bilateral- Bithermal,PX-47100041,CDM,92537,CPT,471,RC,,,outpatient,,,1270,889,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,170.484765,,,170.484765,163,975.36,other,OPPS APC,,
HC Caloric Vestibular Test Bilateral- Monothermal,PX-47100042,CDM,92538,CPT,471,RC,,,outpatient,,,882,617.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,170.484765,,,170.484765,163,677.376,other,OPPS APC,,
HC Vestibular Eval Nystag Fovl&Perph Stim Oscil Tracking,PX-47000010,CDM,92540,CPT,470,RC,,,outpatient,,,550,385,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,170.484765,,,170.484765,123.475,422.4,other,OPPS APC,,
HC Spontaneous Nystagmus Test,PX-47000011,CDM,92541,CPT,470,RC,,,outpatient,,,155,108.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,34.7975,416.02,other,OPPS APC,,
HC Positional Nystagmus Test,PX-47000012,CDM,92542,CPT,470,RC,,,outpatient,,,155,108.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,34.7975,416.02,other,OPPS APC,,
HC Optokinetic Nystagmus Test- Bidirec- Foveal- Periph- W Record,PX-47000014,CDM,92544,CPT,470,RC,,,outpatient,,,155,108.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,170.484765,,,170.484765,34.7975,416.02,other,OPPS APC,,
HC Oscillating Tracking Test,PX-47000015,CDM,92545,CPT,470,RC,,,outpatient,,,696,487.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,142.97,534.528,other,OPPS APC,,
HC Supplemental Electrical Test,PX-47100012,CDM,92547,CPT,471,RC,,,outpatient,,,225,157.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,50.5125,416.02,,,,
HC Tympanometry and Reflex Threshold Measurements,PX-47100013,CDM,92550,CPT,471,RC,,,outpatient,,,269,188.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,170.484765,,,170.484765,60.3905,416.02,other,OPPS APC,,
HC Pure Tone Audiometry- Air,PX-47100014,CDM,92552,CPT,471,RC,,,outpatient,,,230,161,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,51.635,416.02,other,OPPS APC,,
HC Audiometry- Air & Bone,PX-47100015,CDM,92553,CPT,471,RC,,,outpatient,,,295,206.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,170.484765,,,170.484765,61.17,416.02,other,OPPS APC,,
HC Speech Threshold Audiometry,PX-47100016,CDM,92555,CPT,471,RC,,,outpatient,,,144,100.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,32.328,416.02,other,OPPS APC,,
HC Speech Audiometry- Complete,PX-47100017,CDM,92556,CPT,471,RC,,,outpatient,,,132,92.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,29.634,416.02,other,OPPS APC,,
HC Comprehensive Hearing Test,PX-47100018,CDM,92557,CPT,471,RC,,,outpatient,,,519,363.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,170.484765,,,170.484765,116.5155,416.02,other,OPPS APC,,
HC Evoked Otoacoustic Emissions Screen Auto Analys,PX-47100047,CDM,92558,CPT,471,RC,,,outpatient,,,35,24.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,7.8575,416.02,,,,
HC Stenger Test- Pure Tone,PX-47100020,CDM,92565,CPT,471,RC,,,outpatient,,,95,66.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,21.3275,416.02,other,OPPS APC,,
HC Tympanometry,PX-47100021,CDM,92567,CPT,471,RC,,,outpatient,,,125,87.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,43.769555,,,43.769555,28.0625,416.02,other,OPPS APC,,
HC Acoustic Immit Test Tympanometry/Acoust Reflex/Decay,PX-47100023,CDM,92570,CPT,471,RC,,,outpatient,,,359,251.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,170.484765,,,170.484765,80.5955,416.02,other,OPPS APC,,
HC Visual Audiometry (Vra),PX-47100027,CDM,92579,CPT,471,RC,,,outpatient,,,500,350,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,170.484765,,,170.484765,112.25,416.02,other,OPPS APC,,
HC Conditioning Play Audiometry,PX-47100028,CDM,92582,CPT,471,RC,,,outpatient,,,511,357.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,170.484765,,,170.484765,114.7195,416.02,other,OPPS APC,,
HC Select Picture Audiometry,PX-47100029,CDM,92583,CPT,471,RC,,,outpatient,,,114,79.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,25.593,416.02,other,OPPS APC,,
HC Evoked Auditory Test-Limited,PX-47100032,CDM,92587,CPT,471,RC,,,outpatient,,,624,436.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,128.12716,479.602522,other,OPPS APC,,
HC Hearing Aid Check- One Ear,PX-47100036,CDM,92592,CPT,471,RC,,,outpatient,,,116,81.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.042,416.02,,,,
HC Hearing Aid Check- Both Ears,PX-47100038,CDM,92593,CPT,471,RC,,,outpatient,,,162,113.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,36.369,416.02,,,,
HC Auditory Function- 60 Min,PX-47100039,CDM,92620,CPT,471,RC,,,outpatient,,,729,510.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,170.484765,,,170.484765,84.99,559.872,other,OPPS APC,,
HC Auditory Function- + 15 Min,PX-47100040,CDM,92621,CPT,471,RC,,,outpatient,,,122,85.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.01,416.02,other,OPPS APC,,
HC Aep Threshold Estimation Mlt Frequencies I&R,PX-47100043,CDM,92652,CPT,471,RC,,,outpatient,,,863,604.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,128.12716,662.784,other,OPPS APC,,
HC Aep Neurodiagnostic Interpretation and Report,PX-47100044,CDM,92653,CPT,471,RC,,,outpatient,,,863,604.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,128.12716,662.784,other,OPPS APC,,
HC Prq Trluml Coronary Angioplasty One Art/Branch,PX-48100012,CDM,92920,CPT,481,RC,,,outpatient,,,17563,12294.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6238.20972,,,6238.20972,399.86,13488.384,other,OPPS APC,,
HC Prq Trluml Coronary Angioplasty Addl Branch,PX-48100013,CDM,92921,CPT,481,RC,,,outpatient,,,17563,12294.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13488.384,other,OPPS APC,,
HC Prq Trluml Coronary Angio/Atherect One Art/Brnch,PX-48100014,CDM,92924,CPT,481,RC,,,outpatient,,,33484,23438.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12006.91336,,,12006.91336,399.86,25715.712,other,OPPS APC,,
HC Prq Trluml Coronary Angio/Atherec Addl Art/Brnch,PX-48100015,CDM,92925,CPT,481,RC,,,outpatient,,,32854,22997.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,25231.872,,,,
HC Prq Trluml Coronary Stent W/Angio One Art/Brnch,PX-48100016,CDM,92928,CPT,481,RC,,,outpatient,,,32584,22808.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12006.91336,,,12006.91336,399.86,25024.512,other,OPPS APC,,
HC Prq Trluml Coronary Stent W/Angio Addl Art/Brnch,PX-48100017,CDM,92929,CPT,481,RC,,,outpatient,,,26673,18671.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,20484.864,,,,
HC Prq Trluml Coronry Stent/Ath/Angio One Art/Brnch,PX-48100018,CDM,92933,CPT,481,RC,,,outpatient,,,33887,23720.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19138.22361,,,19138.22361,399.86,26793.51305,other,OPPS APC,,
HC Prq Trluml Coronary Stent/Ath/Angio Addl Branch,PX-48100019,CDM,92934,CPT,481,RC,,,outpatient,,,26169,18318.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,20097.792,,,,
HC Prq Trluml Coronary Byp Grft Revasc One Vessel,PX-48100020,CDM,92937,CPT,481,RC,,,outpatient,,,26673,18671.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12006.91336,,,12006.91336,399.86,20484.864,other,OPPS APC,,
HC Prq Trluml Coronary Byp Grft Revasc Addl Vessel,PX-48100021,CDM,92938,CPT,481,RC,,,outpatient,,,26169,18318.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,20097.792,,,,
HC Prq Trluml Coronry Chronic Occlus Revasc One Vsl,PX-48100023,CDM,92943,CPT,481,RC,,,outpatient,,,25667,17966.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12006.91336,,,12006.91336,399.86,19712.256,other,OPPS APC,,
HC Prq Trluml Coronry Chrnic Occlus Revasc Addl Vsl,PX-48100024,CDM,92944,CPT,481,RC,,,outpatient,,,26169,18318.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,20097.792,other,OPPS APC,,
HC Heart/Lung Resuscitation (Cpr),PX-48000001,CDM,92950,CPT,480,RC,,,outpatient,,,1034,723.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,232.133,997.822944,other,OPPS APC,,
HC PR Cardiopulmonary Resuscitation,PX-96000048,CDM,92950,CPT,960,RC,,,outpatient,,,1034,723.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,232.133,997.822944,other,OPPS APC,,
HC Temporary External Pacing,PX-48000002,CDM,92953,CPT,480,RC,,,outpatient,,,1302,911.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,710.32455,,,710.32455,292.299,999.936,other,OPPS APC,,
HC Cardioversion- Elective;Extern,PX-48000003,CDM,92960,CPT,480,RC,,,outpatient,,,2006,1404.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,710.32455,,,710.32455,399.86,1540.608,other,OPPS APC,,
HC PR Cardioversion Elective Arrhythmia External,PX-96000049,CDM,92960,CPT,960,RC,,,outpatient,,,2006,1404.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,710.32455,,,710.32455,399.86,1540.608,other,OPPS APC,,
HC Prq Transluminal Coronary Mechanicl Thrombectomy,PX-48000005,CDM,92973,CPT,480,RC,,,outpatient,,,773,541.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,173.5385,593.664,,,,
HC Intrav Optcl Chernce Tmgrphy W/S&I Intl Vesl,PX-36900031,CDM,92978,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,145.12362,2138.88,other,OPPS APC,,
HC Intravasc US-Heart-1st Vessel,PX-48100025,CDM,92978,CPT,481,RC,,,outpatient,,,2785,1949.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,145.12362,2138.88,other,OPPS APC,,
HC Intrav Optcal Cohrnce Tmgrphy W/S&I Adl Vesl,PX-36900032,CDM,92979,CPT,369,RC,,,outpatient,,,755,528.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,169.4975,1592,other,OPPS APC,,
HC Intravasc Coronary Sono-Addn Vessel,PX-48100026,CDM,92979,CPT,481,RC,,,outpatient,,,755,528.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,169.4975,1592,other,OPPS APC,,
HC Percut Aortic Valvuloplasty,PX-48100027,CDM,92986,CPT,481,RC,,,outpatient,,,17231,12061.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6238.20972,,,6238.20972,399.86,13233.408,other,OPPS APC,,
HC Percut Mitral Valvuloplasty,PX-48100028,CDM,92987,CPT,481,RC,,,outpatient,,,17231,12061.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12006.91336,,,12006.91336,399.86,16809.6787,other,OPPS APC,,
HC Percut Pulmonary Valvuloplasty,PX-48100029,CDM,92990,CPT,481,RC,,,outpatient,,,17231,12061.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12006.91336,,,12006.91336,399.86,16809.6787,other,OPPS APC,,
HC Electrocardiogram- Tracing,PX-73000001,CDM,93005,CPT,730,RC,,,outpatient,,,157,109.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,25.49469,416.02,other,OPPS APC,,
HC PR Electrocardiogram Report,PX-98500001,CDM,93010,CPT,985,RC,,,outpatient,,,28,19.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,6.286,416.02,other,Status Indicator B on TOB 12x or 13x: Research Alt,,
HC Cardiac Stress Tst-Tracing Only,PX-48200001,CDM,93017,CPT,482,RC,,,outpatient,,,485,339.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,108.8825,479.602522,other,OPPS APC,,
HC Rhythm Ecg- Tracing,PX-73000003,CDM,93041,CPT,730,RC,,,outpatient,,,120,84,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,25.49469,416.02,other,OPPS APC,,
HC PR Rhythm Ecg 1-3 Leads Interpretation & Reprt On,PX-98500004,CDM,93042,CPT,985,RC,,,outpatient,,,22,15.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.939,416.02,other,Status Indicator B on TOB 12x or 13x: Research Alt,,
HC Ext Ecg Record Contin 48 Hr- Record,PX-73100001,CDM,93225,CPT,731,RC,,,outpatient,,,433,303.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,84.459332,416.02,other,OPPS APC,,
HC Ext Ecg Record Contin 48 Hr- Scan Analysis W Report,PX-73100002,CDM,93226,CPT,731,RC,,,outpatient,,,318,222.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,66.75974,416.02,other,OPPS APC,,
HC PR Xtrnl Ecg Continuous Rhythm W/I&R Up to 48 Hrs,PX-98500002,CDM,93227,CPT,985,RC,,,outpatient,,,63,44.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.1435,416.02,fee schedule,,,
HC Prgrmg Dev Eval 1 Lead Pm/Ldls Pm 1 Car Chmbr IP,PX-48000087,CDM,93279,CPT,480,RC,,,outpatient,,,118,82.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,41.157815,,,41.157815,26.491,416.02,other,OPPS APC,,
HC Program Eval Implantable in Persn Dual Ld Pacer,PX-92000010,CDM,93280,CPT,920,RC,,,outpatient,,,1217,851.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,41.157815,,,41.157815,41.157815,934.656,other,OPPS APC,,
HC Program Eval Implantable in Prsn Multi Ld Pacer,PX-48000088,CDM,93281,CPT,480,RC,,,outpatient,,,118,82.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,41.157815,,,41.157815,26.491,416.02,other,OPPS APC,,
HC Prgrmng Dev Eval Implantable in Persn 1 Ld Dfb,PX-48000089,CDM,93282,CPT,480,RC,,,outpatient,,,118,82.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,41.157815,,,41.157815,26.491,416.02,other,OPPS APC,,
HC Progrm Eval Implantable in Prsn Dual L Card/Dfb,PX-48000009,CDM,93283,CPT,480,RC,,,outpatient,,,1878,1314.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,41.157815,,,41.157815,41.157815,1442.304,other,OPPS APC,,
HC Prgrmg Eval Implantable in Person Multi Lead Dfb,PX-48000090,CDM,93284,CPT,480,RC,,,outpatient,,,118,82.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,41.157815,,,41.157815,26.491,416.02,other,OPPS APC,,
HC Prgrmg Dev Eval Scrms Phys/Qhp in Person,PX-48000091,CDM,93285,CPT,480,RC,,,outpatient,,,118,82.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,41.157815,,,41.157815,26.491,416.02,other,OPPS APC,,
HC Interrogation Eval in Person 1/Dual/Mlt Lead Pm,PX-48000010,CDM,93288,CPT,480,RC,,,outpatient,,,224,156.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,41.157815,,,41.157815,41.157815,416.02,other,OPPS APC,,
HC Interrog Eval F2f 1/Dual/Mlt Leads Impltbl Dfb,PX-48000086,CDM,93289,CPT,480,RC,,,outpatient,,,118,82.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,41.157815,,,41.157815,26.491,416.02,other,OPPS APC,,
HC Interrogation Evaluation in Person Ilr System,PX-92000011,CDM,93291,CPT,920,RC,,,outpatient,,,248,173.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,32.497835,,,32.497835,23.39896,416.02,other,OPPS APC,,
Rem Interrog Pm/Ldls Pm/Ids <90 D Tech Review,PX-48000085,CDM,93296,CPT,480,RC,,,outpatient,,,118,82.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,41.157815,,,41.157815,26.491,416.02,other,OPPS APC,,
HC Echo Xthoracic-Cong Anom-Complete,PX-48000014,CDM,93303,CPT,480,RC,,,outpatient,,,1337,935.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,602.109165,,,602.109165,54.1045,1223.3,other,OPPS APC,,
HC PR Echo Xthoracic-Cong Anom-Complete,PX-96000009,CDM,93303,CPT,960,RC,,,outpatient,,,241,168.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,602.109165,,,602.109165,54.1045,1223.3,other,OPPS APC,,
HC Echo Xthoracic-Cong Anom-Limited,PX-48000015,CDM,93304,CPT,480,RC,,,outpatient,,,1303,912.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,602.109165,,,602.109165,281.81,1040.64,other,OPPS APC,,
HC PR Echo Xthoracic-Cong Anom-Limited,PX-96000010,CDM,93304,CPT,960,RC,,,outpatient,,,1355,948.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,602.109165,,,602.109165,281.81,1040.64,other,OPPS APC,,
HC Echo Heart Xthoracic-Complete W Doppler W/Contrast,PX-48000016,CDM,93306,CPT,480,RC,,,outpatient,,,1347,942.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,602.109165,,,602.109165,54.1045,1034.496,other,OPPS APC,,
HC Echo Heart Xthoracic-Complete W Doppler W/O Contrast,PX-48000068,CDM,93306,CPT,480,RC,,,outpatient,,,1347,942.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,602.109165,,,602.109165,54.1045,1034.496,other,OPPS APC,,
HC PR Echo Heart Xthoracic-Complete W Doppler,PX-96000036,CDM,93306,CPT,960,RC,,,outpatient,,,241,168.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,602.109165,,,602.109165,54.1045,1034.496,other,OPPS APC,,
HC Echo Heart Xthoracic-Complete- W/O Doppler W/Contrast,PX-48000017,CDM,93307,CPT,480,RC,,,outpatient,,,1228,859.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,267.439885,943.104,other,OPPS APC,,
HC Echo Heart Xthoracic-Complete- W/O Doppler W/O Contrast,PX-48000063,CDM,93307,CPT,480,RC,,,outpatient,,,1228,859.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,267.439885,943.104,other,OPPS APC,,
HC Echo Heart Xthoracic-Limited W/Contrast,PX-48000018,CDM,93308,CPT,480,RC,,,outpatient,,,561,392.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,125.9445,465.66,other,OPPS APC,,
HC Echo Heart Xthoracic-Limited W/O Contrast,PX-48000065,CDM,93308,CPT,480,RC,,,outpatient,,,561,392.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,125.9445,465.66,other,OPPS APC,,
HC PR Echo Heart Xthoracic-Limited,PX-96000037,CDM,93308,CPT,960,RC,,,outpatient,,,561,392.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,125.9445,465.66,other,OPPS APC,,
HC Echo Heart-Transesophageal-Complete W/Contrast,PX-48000019,CDM,93312,CPT,480,RC,,,outpatient,,,1764,1234.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,602.109165,,,602.109165,224.549385,1354.752,other,OPPS APC,,
HC Echo Heart-Transesophageal-Complete W/O Contrast,PX-48000064,CDM,93312,CPT,480,RC,,,outpatient,,,1764,1234.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,602.109165,,,602.109165,224.549385,1354.752,other,OPPS APC,,
HC Echo R-T 2d W/Probe Placement Only,PX-48000083,CDM,93313,CPT,480,RC,,,outpatient,,,1501,1050.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,602.109165,,,602.109165,336.9745,1152.768,other,OPPS APC,,
HC 3d Echo Img&Pst-Pxessing Tee/Tte Cgen Car Anomal,PX-48000084,CDM,93319,CPT,480,RC,,,outpatient,,,352,246.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,79.024,416.02,,,,
HC Doppler Echo Heart-Complete,PX-48000020,CDM,93320,CPT,480,RC,,,outpatient,,,323,226.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,72.5135,416.02,other,OPPS APC,,
HC Doppler Echo Heart-Limited-F/U,PX-48000021,CDM,93321,CPT,480,RC,,,outpatient,,,384,268.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,86.208,416.02,other,OPPS APC,,
HC Doppler Color Flow Velocity Map,PX-48000022,CDM,93325,CPT,480,RC,,,outpatient,,,744,520.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,135.906309,571.392,other,OPPS APC,,
HC Echo Heart Xthoracic- Stress/Rest W/Contrast,PX-48000023,CDM,93350,CPT,480,RC,,,outpatient,,,1384,968.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,602.109165,,,602.109165,224.549385,1062.912,other,OPPS APC,,
HC Echo Heart Xthoracic- Stress/Rest W/O Contrast,PX-48000066,CDM,93350,CPT,480,RC,,,outpatient,,,1384,968.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,602.109165,,,602.109165,224.549385,1062.912,other,OPPS APC,,
HC Echo Tthrc R-T 2d W/WO M-Mode Rest&Strs Cont Ecg W/Contrast,PX-48000024,CDM,93351,CPT,480,RC,,,outpatient,,,1785,1249.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,602.109165,,,602.109165,224.549385,1370.88,other,OPPS APC,,
HC Echo Tthrc R-T 2d W/WO M-Mode Rest&Strs Cont Ecg W/O Contrast,PX-48000067,CDM,93351,CPT,480,RC,,,outpatient,,,1785,1249.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,602.109165,,,602.109165,224.549385,1370.88,other,OPPS APC,,
HC Echo Tee Guid Tcat Icar/Vessel Structural Intvn,PX-48000052,CDM,93355,CPT,480,RC,,,outpatient,,,778,544.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.661,597.504,,,,
HC Myocrd Strain Img Speckle Trck Assmt Myocrd Mech,PX-48000480,CDM,93356,CPT,480,RC,,,outpatient,,,1077,753.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,241.7865,827.136,other,OPPS APC,,
HC Right Heart Cath O2 Saturation & Cardiac Output,PX-48100030,CDM,93451,CPT,481,RC,,,outpatient,,,9177,6423.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3556.468215,,,3556.468215,399.86,7870.4,other,OPPS APC,,
HC Cath Place/Coronary Angio- Img Super/Interp,PX-48100031,CDM,93454,CPT,481,RC,,,outpatient,,,10988,7691.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3556.468215,,,3556.468215,399.86,8438.784,other,OPPS APC,,
HC Cath Place/Coronary Angio- Img Super/Interp- Bypass Angio,PX-48100032,CDM,93455,CPT,481,RC,,,outpatient,,,10988,7691.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3556.468215,,,3556.468215,399.86,8438.784,other,OPPS APC,,
HC Cath Place/Coronary Angio- Img Super/Interp-W Right Heart Cath,PX-48100033,CDM,93456,CPT,481,RC,,,outpatient,,,10988,7691.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3556.468215,,,3556.468215,399.86,8438.784,other,OPPS APC,,
HC Cath Place/Coron Angio- Img Super/Interp- Bypass Angio-W R Heart Cath,PX-48100034,CDM,93457,CPT,481,RC,,,outpatient,,,9755,6828.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3556.468215,,,3556.468215,399.86,7870.4,other,OPPS APC,,
HC Cath Place/Coron Angio- Img Super/Interp-W Left Heart Ventriculography,PX-48100035,CDM,93458,CPT,481,RC,,,outpatient,,,9755,6828.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3556.468215,,,3556.468215,399.86,7870.4,other,OPPS APC,,
HC Cath Place/Coron Angio- Img Super/Interp- Bypass Angio-W L Hrt Ventric,PX-48100036,CDM,93459,CPT,481,RC,,,outpatient,,,10988,7691.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3556.468215,,,3556.468215,399.86,8438.784,other,OPPS APC,,
HC Cath Place/Coron Angio- Img Super/Interp-R&L Hrt Cath- L Hrt Ventric,PX-48100037,CDM,93460,CPT,481,RC,,,outpatient,,,10988,7691.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3556.468215,,,3556.468215,399.86,8438.784,other,OPPS APC,,
HC Cath Place/Cor Ang-Img Supr/Intrp-Bypass Ang- R&L Cath- L Hrt Ventric,PX-48100038,CDM,93461,CPT,481,RC,,,outpatient,,,10988,7691.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3556.468215,,,3556.468215,399.86,8438.784,other,OPPS APC,,
HC Left Heart Cath by Transeptal Puncture,PX-48100039,CDM,93462,CPT,481,RC,,,outpatient,,,10365,7255.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7960.32,other,OPPS APC,,
HC Insert/Place Flow Direct Cath,PX-36900885,CDM,93503,CPT,369,RC,,,outpatient,,,2998,2098.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1747.952815,,,1747.952815,399.86,2532.39,other,OPPS APC,,
HC Insert/Place Flow Direct Cath,PX-48000025,CDM,93503,CPT,480,RC,,,outpatient,,,2998,2098.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1747.952815,,,1747.952815,399.86,2532.39,other,OPPS APC,,
HC Inject Select Cor Angio During Congenital Heart Cath,PX-48100044,CDM,93563,CPT,481,RC,,,outpatient,,,2542,1779.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,1952.256,,,,
HC Inject Select Cor/Graft Angio During Congenital Heart Cath,PX-48100045,CDM,93564,CPT,481,RC,,,outpatient,,,1018,712.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,228.541,1592,,,,
HC Inject Select Left Vent/Atrial Angio During Heart Cath,PX-48100046,CDM,93565,CPT,481,RC,,,outpatient,,,510,357,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,114.495,1592,,,,
HC Inject Select Right Vent/Atrial Angio During Heart Cath,PX-48100047,CDM,93566,CPT,481,RC,,,outpatient,,,1018,712.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,228.541,1592,other,OPPS APC,,
HC Inject Supravalvular Aortography During Heart Cath,PX-48100048,CDM,93567,CPT,481,RC,,,outpatient,,,1498,1048.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,235.074116,1592,other,OPPS APC,,
HC Heart Flow Reserv Measure-Init Vessl,PX-48000026,CDM,93571,CPT,480,RC,,,outpatient,,,6936,4855.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,5638.7,other,OPPS APC,,
HC Heart Flow Reserv Measure-Addn Vessl,PX-48000027,CDM,93572,CPT,480,RC,,,outpatient,,,2051,1435.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,1575.168,other,OPPS APC,,
HC Perc Clos-Cong Interatrial Commun W/Impl,PX-48100049,CDM,93580,CPT,481,RC,,,outpatient,,,53254,37277.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19138.22361,,,19138.22361,399.86,40899.072,other,OPPS APC,,
HC Perc Closure-Cong Vsd W/Implant,PX-48100050,CDM,93581,CPT,481,RC,,,outpatient,,,53254,37277.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19138.22361,,,19138.22361,399.86,40899.072,other,OPPS APC,,
HC Percutan Transcath Closure Pat Duct Arteriosus,PX-36900556,CDM,93582,CPT,369,RC,,,outpatient,,,52790,36953,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19138.22361,,,19138.22361,399.86,40542.72,other,OPPS APC,,
HC Percutan Transcath Closure Pat Duct Arteriosus,PX-48100051,CDM,93582,CPT,481,RC,,,outpatient,,,52790,36953,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19138.22361,,,19138.22361,399.86,40542.72,other,OPPS APC,,
HC Percutaneous Transcatheter Septal Reduction Ther,PX-48100055,CDM,93583,CPT,481,RC,,,outpatient,,,16899,11829.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,12978.432,,,,
HC Heart Pacing- Mapping,PX-48000042,CDM,93631,CPT,480,RC,,,outpatient,,,8496,5947.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6909.98,,,,
HC Eval Cardiovert Leads-Initial,PX-48000043,CDM,93640,CPT,480,RC,,,outpatient,,,5892,4124.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,4525.056,,,,
HC Eval Cardiovert Leads/Puls Gen,PX-48000044,CDM,93641,CPT,480,RC,,,outpatient,,,3075,2152.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2361.6,other,OPPS APC,,
HC Electrophys Eval-Cardioverter,PX-48000045,CDM,93642,CPT,480,RC,,,outpatient,,,3083,2158.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1298.939725,,,1298.939725,399.86,2367.744,other,OPPS APC,,
HC Tilt Table Evaluation,PX-48000049,CDM,93660,CPT,480,RC,,,outpatient,,,3083,2158.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,584.98394,,,584.98394,399.86,2367.744,other,OPPS APC,,
HC Intracard Echo- Ther/Dx Intervent,PX-48000050,CDM,93662,CPT,480,RC,,,outpatient,,,7689,5382.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10671.09667,other,OPPS APC,,
HC Analyze Pacer Sys,PX-48000051,CDM,93724,CPT,480,RC,,,outpatient,,,1217,851.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,325.997845,,,325.997845,73.54,934.656,other,OPPS APC,,
HC Outpatient Cardiac Rehab W/O Cont Ecg Monitor,PX-94300002,CDM,93797,CPT,943,RC,,,outpatient,,,255,178.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,144.21845,,,144.21845,57.2475,416.02,other,OPPS APC,,
HC Outpatient Cardiac Rehab W/Cont Ecg Monitoring,PX-94300003,CDM,93798,CPT,943,RC,,,outpatient,,,271,189.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,144.21845,,,144.21845,60.8395,416.02,other,OPPS APC,,
HC Duplex Scan Extracranial-Bilat,PX-92100008,CDM,93880,CPT,921,RC,,,outpatient,,,915,640.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,199.512292,702.72,other,OPPS APC,,
HC Duplex Scan Extracranial-Limited,PX-92100010,CDM,93882,CPT,921,RC,,,outpatient,,,915,640.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,119.991125,702.72,other,OPPS APC,,
HC Transcran Doppler Intracran Art,PX-92100011,CDM,93886,CPT,921,RC,,,outpatient,,,1137,795.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,255.2565,873.216,other,OPPS APC,,
HC Transcran Doppler Intracran-Limited,PX-92100013,CDM,93888,CPT,921,RC,,,outpatient,,,428,299.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,96.086,686,other,OPPS APC,,
HC Transcran Doppl Intracran- Vasoreact,PX-92100015,CDM,93890,CPT,921,RC,,,outpatient,,,952,666.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,213.724,731.136,other,OPPS APC,,
HC Non-Invas Physiologic Std Extremity Art 1-2 Level,PX-92100017,CDM,93922,CPT,921,RC,,,outpatient,,,915,640.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,135.906309,702.72,other,OPPS APC,,
HC Non-Invasive Physiologic Study Extremity 3 Levels,PX-92100019,CDM,93923,CPT,921,RC,,,outpatient,,,701,490.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,170.484765,,,170.484765,121.132463,686,other,OPPS APC,,
HC Non-Invasive Lower Extrem Art Stress/Rest- Complete-Bilateral,PX-92100020,CDM,93924,CPT,921,RC,,,outpatient,,,915,640.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,170.484765,,,170.484765,135.906309,775.5705,other,OPPS APC,,
HC Duplex Lo Extrem Art Bilat,PX-92100022,CDM,93925,CPT,921,RC,,,outpatient,,,915,640.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,199.512292,702.72,other,OPPS APC,,
HC Duplex Lo Extrem Art Unilat/Ltd,PX-92100024,CDM,93926,CPT,921,RC,,,outpatient,,,441,308.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,99.0045,686,other,OPPS APC,,
HC Duplex Up Extrem Art Bilat,PX-92100025,CDM,93930,CPT,921,RC,,,outpatient,,,842,589.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,135.906309,686,other,OPPS APC,,
HC Duplex Up Extrem Art Bilat,PX-92100026,CDM,93930,CPT,921,RC,,,outpatient,,,842,589.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,135.906309,686,other,OPPS APC,,
HC Duplex Up Extrem Art Unilat/Ltd,PX-92100028,CDM,93931,CPT,921,RC,,,outpatient,,,915,640.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,119.991125,702.72,other,OPPS APC,,
HC Duplex Extrem Venous-Bilat,PX-92100031,CDM,93970,CPT,921,RC,,,outpatient,,,758,530.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,170.171,686,other,OPPS APC,,
HC Duplex Extrem Venous-Bilat,PX-92100032,CDM,93970,CPT,921,RC,,,outpatient,,,758,530.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,170.171,686,other,OPPS APC,,
HC Duplex Extrem Venous-Uni or Ltd,PX-92100034,CDM,93971,CPT,921,RC,,,outpatient,,,915,640.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,119.991125,702.72,other,OPPS APC,,
HC Duplex Abd/Pel Vasc Study-Complete,PX-92100036,CDM,93975,CPT,921,RC,,,outpatient,,,816,571.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,183.192,686,other,OPPS APC,,
HC Duplex Abd/Pel Vasc Study-Limitd,PX-92100037,CDM,93976,CPT,921,RC,,,outpatient,,,418,292.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,93.841,686,other,OPPS APC,,
HC Duplex Large Vessel(S)-Complete,PX-92100039,CDM,93978,CPT,921,RC,,,outpatient,,,915,640.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,199.512292,702.72,other,OPPS APC,,
HC Duplex Large Vessel(S)-Limited,PX-92100041,CDM,93979,CPT,921,RC,,,outpatient,,,387,270.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,86.8815,686,other,OPPS APC,,
HC Duplex Hemodialysis Access,PX-92100042,CDM,93990,CPT,921,RC,,,outpatient,,,614,429.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,119.991125,,,119.991125,119.991125,686,other,OPPS APC,,
HC Breathing Capacity Test,PX-46000002,CDM,94010,CPT,460,RC,,,outpatient,,,295,206.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,170.484765,,,170.484765,66.2275,416.02,other,OPPS APC,,
HC Eval of Bronchospasm,PX-46000003,CDM,94060,CPT,460,RC,,,outpatient,,,446,312.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,100.127,479.602522,other,OPPS APC,,
HC Eval of Bronchospasm-Prolonged,PX-46000004,CDM,94070,CPT,460,RC,,,outpatient,,,925,647.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,163,710.4,other,OPPS APC,,
HC Xers Tst Brncspsm Pre&Post Spmtry&Pls Ox W/Ecg,PX-46000023,CDM,94617,CPT,460,RC,,,outpatient,,,392,274.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,88.004,416.02,other,OPPS APC,,
HC Pulmonary Stress Testing,PX-46000022,CDM,94618,CPT,460,RC,,,outpatient,,,392,274.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,88.004,416.02,other,OPPS APC,,
HC Xers Tst Brncspsm Pre&Post Spmtry&Pls Ox WO /Ecg,PX-46000024,CDM,94619,CPT,460,RC,,,outpatient,,,182,127.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,40.859,416.02,other,OPPS APC,,
HC Inhal Rx- Airway Obst/Dx Sputum Induct,PX-41000006,CDM,94640,CPT,410,RC,,,outpatient,,,494,345.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,232.78851,,,232.78851,59.92,416.02,other,OPPS APC,,
HC Plethysmography Lung Volumes W/WO Airway Resist,PX-46000012,CDM,94726,CPT,460,RC,,,outpatient,,,446,312.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,98.67,479.602522,other,OPPS APC,,
HC Gas Dilut/Washout Lung Vol W/WO Distrib Vent&Vol,PX-46000013,CDM,94727,CPT,460,RC,,,outpatient,,,295,206.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,170.484765,,,170.484765,66.2275,416.02,other,OPPS APC,,
HC Diffusing Capacity,PX-46000014,CDM,94729,CPT,460,RC,,,outpatient,,,265,185.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,59.4925,416.02,other,OPPS APC,,
HC Noninvasv Oxygen Satur;Single,PX-46000015,CDM,94760,CPT,460,RC,,,outpatient,,,54,37.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.123,416.02,other,OPPS APC,,
HC Noninvasv Oxygen Satur-Multiple,PX-46000016,CDM,94761,CPT,460,RC,,,outpatient,,,90,63,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.205,416.02,,,,
HC Car Seat/Bed Test Initial 60 Mins,PX-46000019,CDM,94780,CPT,460,RC,,,outpatient,,,194,135.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,43.769555,,,43.769555,43.553,416.02,other,OPPS APC,,
HC Car Seat/Bed Test Each Addl 30 Min,PX-46000020,CDM,94781,CPT,460,RC,,,outpatient,,,194,135.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,43.553,416.02,,,,
HC Pulmonary Service/Procedure,PX-41000002,CDM,94799,CPT,410,RC,,,outpatient,,,367,256.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,170.484765,,,170.484765,22.74,416.02,other,OPPS APC,,
HC Eeg W/O Video by Tech 2-12 Hr Unmonitored,PX-74000012,CDM,95705,CPT,740,RC,,,outpatient,,,827,578.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,185.6615,635.136,other,OPPS APC,,
HC Eeg W/O Video by Tech 2-12 Hr Intermittent Mntr,PX-74000013,CDM,95706,CPT,740,RC,,,outpatient,,,827,578.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,185.6615,635.136,other,OPPS APC,,
HC Eeg W/O Video by Tech 2-12hr Continuous R-T Mntr,PX-74000014,CDM,95707,CPT,740,RC,,,outpatient,,,827,578.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,185.6615,635.136,other,OPPS APC,,
HC Eeg W/O Vid by Tech Ea Incr 12-26hr Unmonitored,PX-74000011,CDM,95708,CPT,740,RC,,,outpatient,,,1649,1154.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,584.98394,,,584.98394,370.2005,1266.432,other,OPPS APC,,
HC Eeg W/O Vid by Tech Ea Incr 12-26 Hr Intmt Mntr,PX-74000015,CDM,95709,CPT,740,RC,,,outpatient,,,1585,1109.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,584.98394,,,584.98394,355.8325,1217.28,other,OPPS APC,,
HC Eeg W/O Vid Tech Ea Incr 12-26 Hr Cont R-T Mntr,PX-74000016,CDM,95710,CPT,740,RC,,,outpatient,,,1585,1109.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,584.98394,,,584.98394,355.8325,1217.28,other,OPPS APC,,
HC Electroencephalogram Extend Monitoring 41-60 Min,PX-74000008,CDM,95812,CPT,740,RC,,,outpatient,,,812,568.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,182.294,623.616,other,OPPS APC,,
HC Eeg >1 Hr,PX-74000002,CDM,95813,CPT,740,RC,,,outpatient,,,958,670.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,215.071,735.744,other,OPPS APC,,
HC Eeg-W/Awake & Drowsy Record,PX-74000003,CDM,95816,CPT,740,RC,,,outpatient,,,701,490.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,157.3745,538.368,other,OPPS APC,,
HC Eeg-W/Awake & Asleep Record,PX-74000004,CDM,95819,CPT,740,RC,,,outpatient,,,786,550.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,176.457,603.648,other,OPPS APC,,
HC Eeg-Coma/Sleep Record Only,PX-74000005,CDM,95822,CPT,740,RC,,,outpatient,,,675,472.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,151.5375,518.4,other,OPPS APC,,
HC Eeg Eval Cerebral Death,PX-74000006,CDM,95824,CPT,740,RC,,,outpatient,,,675,472.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,584.98394,,,584.98394,151.5375,829.50194,other,OPPS APC,,
HC Needle Emg Ea Extremity W/Paraspinl Area Limited,PX-92200011,CDM,95885,CPT,922,RC,,,outpatient,,,332,232.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.817,570,,,,
HC PR Needle Emg Ea Extremity W/Paraspinl Area Limited,PX-96000021,CDM,95885,CPT,960,RC,,,outpatient,,,66,46.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.817,570,,,,
HC Needle Emg Ea Extremty W/Paraspinl Area Complete,PX-92200012,CDM,95886,CPT,922,RC,,,outpatient,,,332,232.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,30.083,570,,,,
HC PR Needle Emg Ea Extremty W/Paraspinl Area Complete,PX-96000022,CDM,95886,CPT,960,RC,,,outpatient,,,134,93.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,30.083,570,,,,
HC Needle Emg Nonextremty Mscles W/Nerve Conduction,PX-92200013,CDM,95887,CPT,922,RC,,,outpatient,,,180,126,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.4295,570,,,,
HC PR Needle Emg Nonextremty Mscles W/Nerve Conduction,PX-96000023,CDM,95887,CPT,960,RC,,,outpatient,,,91,63.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.4295,570,,,,
HC Nerve Conduction Studies 1-2 Studies,PX-92200028,CDM,95907,CPT,922,RC,,,outpatient,,,760,532,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,170.484765,,,170.484765,94.4,583.68,other,OPPS APC,,
HC Motor &/Sens 7-8 Nrv Cndj Preconf Eltrode Limb,PX-92200017,CDM,95910,CPT,922,RC,,,outpatient,,,696,487.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,94.4,570,other,OPPS APC,,
HC PR Motor &/Sens 7-8 Nrv Cndj Preconf Eltrode Limb,PX-96000027,CDM,95910,CPT,960,RC,,,outpatient,,,724,506.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,342.57323,,,342.57323,94.4,570,other,OPPS APC,,
HC Ionm Remote/Nearby/>1 Patient in or per Hour,PX-92000015,CDM,95941,CPT,920,RC,,,outpatient,,,879,615.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,197.3355,675.072,,,,
HC Eeg Digital Anylysis,PX-74000010,CDM,95957,CPT,740,RC,,,outpatient,,,696,487.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,156.252,534.528,,,,
HC IV Inf- Hydration- 31 Min to 1 Hr,PX-26000001,CDM,96360,CPT,260,RC,,,outpatient,,,334,233.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,233.93401,,,233.93401,74.983,416.02,other,OPPS APC,,
HC IV Inf- Hydration- Each Add'l Hr,PX-26000002,CDM,96361,CPT,260,RC,,,outpatient,,,89,62.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,51.84533,,,51.84533,19.9805,585.854902,other,OPPS APC,,
HC IV Inf- Therapy - Init to 1 Hr (Spec Drug),PX-26000003,CDM,96365,CPT,260,RC,,,outpatient,,,418,292.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,233.93401,,,233.93401,93.841,416.02,other,OPPS APC,,
HC IV Inf- Therapy- Each Add Hr (Spec Drug),PX-26000004,CDM,96366,CPT,260,RC,,,outpatient,,,132,92.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,51.84533,,,51.84533,29.634,585.854902,other,OPPS APC,,
HC IV Infusion- Therap/Proph/Diagnost-Add Infusion-1st Hour,PX-26000005,CDM,96367,CPT,260,RC,,,outpatient,,,183,128.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,76.88596,,,76.88596,41.0835,416.02,other,OPPS APC,,
HC IV Infusion- Therap/Proph/Diagnost-Concurrent Infusion,PX-26000006,CDM,96368,CPT,260,RC,,,outpatient,,,109,76.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,24.4705,416.02,other,OPPS APC,,
HC Therapeutic Prophylactic/Dx Injection Subq/Im,PX-26000007,CDM,96372,CPT,260,RC,,,outpatient,,,162,113.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,76.88596,,,76.88596,16.16,416.02,other,OPPS APC,,
HC Injection-Therap/Proph/Diagnost- Intra-Arterial,PX-26000008,CDM,96373,CPT,260,RC,,,outpatient,,,334,233.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,233.93401,,,233.93401,74.983,416.02,other,OPPS APC,,
HC IV Push- Initial,PX-26000009,CDM,96374,CPT,260,RC,,,outpatient,,,309,216.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,233.93401,,,233.93401,69.3705,416.02,other,OPPS APC,,
HC IV Push- Ea Add Seq- of New Sub Drug,PX-26000010,CDM,96375,CPT,260,RC,,,outpatient,,,105,73.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,51.84533,,,51.84533,23.5725,416.02,other,OPPS APC,,
HC Injection-Therap/Proph/Diagnost- IV Push- Ea Add- Same Drug,PX-26000011,CDM,96376,CPT,260,RC,,,outpatient,,,303,212.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,68.0235,416.02,other,OPPS APC,,
HC Chemother-Non-Hormone Anti-Neopl- Sub-Q/Im,PX-33100001,CDM,96401,CPT,331,RC,,,outpatient,,,222,155.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,76.88596,,,76.88596,49.839,416.02,other,OPPS APC,,
HC Chemother- IV Push- Sngl Drug,PX-33100003,CDM,96409,CPT,331,RC,,,outpatient,,,691,483.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,369.62994,,,369.62994,155.1295,530.688,other,OPPS APC,,
HC Chemother- IV Infusion- 1 Hr,PX-33500001,CDM,96413,CPT,335,RC,,,outpatient,,,724,506.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,369.62994,,,369.62994,162.538,556.032,other,OPPS APC,,
HC Chemother- IV Infusion- Ea Add Hr,PX-33500002,CDM,96415,CPT,335,RC,,,outpatient,,,187,130.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,76.88596,,,76.88596,41.9815,585.854902,other,OPPS APC,,
HC Chemother-Ia Push Technique,PX-33100006,CDM,96420,CPT,331,RC,,,outpatient,,,668,467.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,369.62994,,,369.62994,70.143083,517.481916,other,OPPS APC,,
HC Chemother-Cns-W/Lumbar Puncture,PX-33100005,CDM,96450,CPT,331,RC,,,outpatient,,,657,459.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,369.62994,,,369.62994,147.4965,585.854902,other,OPPS APC,,
HC Ultraviolet Light Therapy,PX-94000005,CDM,96900,CPT,940,RC,,,outpatient,,,530,371,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,43.769555,,,43.769555,34.385146,416.02,other,OPPS APC,,
HC Mechanical Traction Therapy,PX-42100004,CDM,97012,CPT,421,RC,,,outpatient,,,245,171.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14.38,,,14.38,14.38,416.02,fee schedule,,,
HC Electric Stimulation Therapy,PX-42100005,CDM,97014,CPT,421,RC,,,outpatient,,,123,86.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,27.6135,416.02,fee schedule,,,
HC Electrical Stimulation,PX-42100010,CDM,97032,CPT,421,RC,,,outpatient,,,123,86.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14.73,,,14.73,14.73,416.02,fee schedule,,,
HC Electric Current Therapy,PX-42100011,CDM,97033,CPT,421,RC,,,outpatient,,,185,129.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,20.02,,,20.02,20.02,416.02,fee schedule,,,
HC Ultrasound Therapy,PX-42000005,CDM,97035,CPT,420,RC,,,outpatient,,,115,80.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14.44,,,14.44,14.44,416.02,fee schedule,,,
HC Ultrasound Therapy,PX-42100013,CDM,97035,CPT,421,RC,,,outpatient,,,115,80.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14.44,,,14.44,14.44,416.02,fee schedule,,,
HC Therapeutic Exercises,PX-42000006,CDM,97110,CPT,420,RC,,,outpatient,,,197,137.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,30.33,,,30.33,30.33,416.02,fee schedule,,,
HC Therapeutic Exercises,PX-42100014,CDM,97110,CPT,421,RC,,,outpatient,,,197,137.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,30.33,,,30.33,30.33,416.02,fee schedule,,,
HC Neuromusc Reeducat-1+ Areas- Ea 15 Min,PX-42000007,CDM,97112,CPT,420,RC,,,outpatient,,,115,80.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,34.85,,,34.85,25.8175,416.02,fee schedule,,,
HC Neuromusc Reeducat-1+ Areas- Ea 15 Min,PX-42100015,CDM,97112,CPT,421,RC,,,outpatient,,,115,80.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,34.85,,,34.85,25.8175,416.02,fee schedule,,,
HC Gait Training Therapy,PX-42100017,CDM,97116,CPT,421,RC,,,outpatient,,,115,80.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,30.33,,,30.33,25.8175,416.02,fee schedule,,,
HC Manual Ther Tech-1+Regions-Ea 15 Min,PX-42000008,CDM,97140,CPT,420,RC,,,outpatient,,,140,98,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,27.89,,,27.89,27.89,416.02,fee schedule,,,
HC Manual Ther Tech-1+Regions-Ea 15 Min,PX-42100018,CDM,97140,CPT,421,RC,,,outpatient,,,140,98,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,27.89,,,27.89,27.89,416.02,fee schedule,,,
HC Group Therapeutic Procedures,PX-42000009,CDM,97150,CPT,420,RC,,,outpatient,,,130,91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,18.56,,,18.56,18.56,416.02,other,OPPS APC,,
HC Group Therapeutic Procedures,PX-42300001,CDM,97150,CPT,423,RC,,,outpatient,,,130,91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,18.56,,,18.56,18.56,416.02,other,OPPS APC,,
HC Pt Eval Low Complex,PX-42400003,CDM,97161,CPT,424,RC,,,outpatient,,,260,182,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,103.7,,,103.7,58.37,416.02,fee schedule,,,
HC Pt Eval Mod Complex,PX-42400004,CDM,97162,CPT,424,RC,,,outpatient,,,260,182,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,103.7,,,103.7,58.37,416.02,fee schedule,,,
HC Pt Eval High Complex,PX-42400005,CDM,97163,CPT,424,RC,,,outpatient,,,260,182,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,103.7,,,103.7,58.37,416.02,fee schedule,,,
HC Pt Re-Eval Est Plan Care,PX-42400006,CDM,97164,CPT,424,RC,,,outpatient,,,231,161.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,72.14,,,72.14,51.8595,416.02,fee schedule,,,
HC Therapeut Actvity Direct Pt Contact Each 15 Min,PX-42100019,CDM,97530,CPT,421,RC,,,outpatient,,,115,80.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,38.12,,,38.12,25.8175,416.02,fee schedule,,,
HC Self-Care/Home Mgmt Training Each 15 Minutes,PX-42100020,CDM,97535,CPT,421,RC,,,outpatient,,,115,80.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,33.86,,,33.86,25.8175,416.02,fee schedule,,,
HC Orthotic Mgmt and Training- Each 15 Min,PX-42100027,CDM,97760,CPT,421,RC,,,outpatient,,,115,80.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,49.68,,,49.68,25.8175,416.02,fee schedule,,,
HC Prosthetic Training- Each 15 Min,PX-42100028,CDM,97761,CPT,421,RC,,,outpatient,,,104,72.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,43.33,,,43.33,23.348,416.02,fee schedule,,,
HC Med Nutr Ther- 1st- Indiv- Ea 15 Min,PX-94200006,CDM,97802,CPT,942,RC,,,outpatient,,,182,127.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,34.45,,,34.45,34.45,416.02,fee schedule,,,
HC Med Nutr Ther- Subsq- Indiv- Ea 15 Min,PX-94200007,CDM,97803,CPT,942,RC,,,outpatient,,,106,74.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,29.36,,,29.36,23.797,416.02,fee schedule,,,
HC Med Nutr Ther- Group- Ea 30 Min,PX-94200008,CDM,97804,CPT,942,RC,,,outpatient,,,52,36.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16.66,,,16.66,11.674,416.02,other,OPPS APC,,
HC Mod Sed Same Phys/Qhp <5 Yrs,PX-37000019,CDM,99151,CPT,370,RC,,,outpatient,,,230,161,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.635,416.02,,,,
HC Mod Sed Same Phys/Qhp 5/>Yrs,PX-37000020,CDM,99152,CPT,370,RC,,,outpatient,,,240,168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,53.88,416.02,other,OPPS APC,,
HC Mod Sed Same Phys/Qhp Ea,PX-37000021,CDM,99153,CPT,370,RC,,,outpatient,,,240,168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,53.88,416.02,other,OPPS APC,,
HC Mod Sed Oth Phys/Qhp <5 Yrs,PX-37000022,CDM,99155,CPT,370,RC,,,outpatient,,,361,252.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,81.0445,416.02,,,,
HC Mod Sed Oth Phys/Qhp 5/>Yrs,PX-37000023,CDM,99156,CPT,370,RC,,,outpatient,,,240,168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,53.88,416.02,,,,
HC Mod Sed Other Phys/Qhp Ea,PX-37000024,CDM,99157,CPT,370,RC,,,outpatient,,,330,231,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,74.085,416.02,,,,
HC Phlebotomy,PX-94000006,CDM,99195,CPT,940,RC,,,outpatient,,,312,218.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.418805,,,139.418805,70.044,416.02,other,OPPS APC,,
HC Office/Outpatient New Sf Mdm 15-29 Minutes,PX-51000025,CDM,99202,CPT,510,RC,,,outpatient,,,387,270.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,82.56,416.02,other,OPPS APC,,
HC Office/Outpatient New Low Mdm 30-44 Minutes,PX-51000026,CDM,99203,CPT,510,RC,,,outpatient,,,573,401.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,126.37,473.871,other,OPPS APC,,
HC Office/Outpatient New Moderate Mdm 45-59 Minutes,PX-51000027,CDM,99204,CPT,510,RC,,,outpatient,,,838,586.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,179.35,693.026,other,OPPS APC,,
HC Office/Outpatient New High Mdm 60-74 Minutes,PX-51000028,CDM,99205,CPT,510,RC,,,outpatient,,,1192,834.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,146.954008,985.784,other,OPPS APC,,
HC Office/Outpatient Est Pt May Not Req Phys/Qhp,PX-51000029,CDM,99211,CPT,510,RC,,,outpatient,,,287,200.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,18.1184,416.02,other,OPPS APC,,
HC Office/Outpatient Est Pt May Not Req Phys/Qhp,PX-76100002,CDM,99211,CPT,761,RC,,,outpatient,,,287,200.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,18.1184,416.02,other,OPPS APC,,
HC Office/Outpatient Est Pt May Not Req Phys/Qhp,PX-94200014,CDM,99211,CPT,942,RC,,,outpatient,,,287,200.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,18.1184,416.02,other,OPPS APC,,
HC Office/Outpatient Established Sf Mdm 10-19 Min,PX-51000030,CDM,99212,CPT,510,RC,,,outpatient,,,394,275.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,50.2428,416.02,other,OPPS APC,,
HC Office/Outpatient Established Sf Mdm 10-19 Min,PX-94200015,CDM,99212,CPT,942,RC,,,outpatient,,,394,275.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,50.2428,416.02,other,OPPS APC,,
HC PR Office/Outpatient Established Sf Mdm 10-19 Min,PX-98800012,CDM,99212,CPT,988,RC,,,outpatient,,,373,261.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,50.2428,416.02,other,Status Indicator B on TOB 12x or 13x: Research Alt,,
HC Office/Outpatient Established Low Mdm 20-29 Min,PX-51000031,CDM,99213,CPT,510,RC,,,outpatient,,,431,301.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,90.68,416.02,other,OPPS APC,,
HC Office/Outpatient Established Low Mdm 20-29 Min,PX-94200016,CDM,99213,CPT,942,RC,,,outpatient,,,431,301.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,90.68,416.02,other,OPPS APC,,
HC Office/Outpatient Established Mod Mdm 30-39 Min,PX-51000032,CDM,99214,CPT,510,RC,,,outpatient,,,467,326.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,104.8415,416.02,other,OPPS APC,,
HC Office/Outpatient Established Mod Mdm 30-39 Min,PX-94200020,CDM,99214,CPT,942,RC,,,outpatient,,,467,326.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,104.8415,416.02,other,OPPS APC,,
HC Office/Outpatient Established High Mdm 40-54 Min,PX-51000033,CDM,99215,CPT,510,RC,,,outpatient,,,829,580.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,169.273,685.583,other,OPPS APC,,
HC Office/Outpatient Established High Mdm 40-54 Min,PX-94200021,CDM,99215,CPT,942,RC,,,outpatient,,,754,527.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,169.273,685.583,other,OPPS APC,,
HC Critical Care Ill/Injured Patient Init 30-74 Min,PX-76000001,CDM,99291,CPT,760,RC,,,outpatient,,,3157,2209.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,968.49734,,,968.49734,318.748996,2424.576,other,OPPS APC,,
HC PR Critical Care Ill/Injured Patient Init 30-74 Min,PX-96000052,CDM,99291,CPT,960,RC,,,outpatient,,,3157,2209.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,968.49734,,,968.49734,318.748996,2424.576,other,OPPS APC,,
HC Critical Care Ill/Injured Patient Addl 30 Min,PX-76000002,CDM,99292,CPT,760,RC,,,outpatient,,,911,637.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,204.5195,699.648,,,,
HC PR Critical Care Ill/Injured Patient Addl 30 Min,PX-96000053,CDM,99292,CPT,960,RC,,,outpatient,,,911,637.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,204.5195,699.648,,,,
HC Tobacco Use Cessation Intermediate 3-10 Minutes,PX-94200022,CDM,99406,CPT,942,RC,,,outpatient,,,214,149.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,31.31797,,,31.31797,31.31797,416.02,other,OPPS APC,,
HC Tobacco Use Cessation Intensive >10 Minutes,PX-94200025,CDM,99407,CPT,942,RC,,,outpatient,,,214,149.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,31.31797,,,31.31797,31.31797,416.02,other,OPPS APC,,
HC Arterial Stent- Xcranial Vertebral/ Thoracic Carotid- 1st Vessel,PX-36900026,CDM,0075T,CPT,369,RC,,,outpatient,,,774,541.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,173.763,2998,,,,
HC Arterial Stent- Xcranial Vertebral/ Thoracic Carotid- Ea Add,PX-36900027,CDM,0076T,CPT,369,RC,,,outpatient,,,161,112.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,36.1445,2998,,,,
HC Transluminal Peripheral Atherectomy- Renal Artery,PX-36900028,CDM,0234T,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12006.91336,,,12006.91336,399.86,22389.354,other,OPPS APC,,
HC Transluminal Peripheral Atherectomy- Visceral Artery- Each,PX-36900029,CDM,0235T,CPT,369,RC,,,outpatient,,,735,514.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,165.0075,2998,,,,
BONE BX OSTEO SITE 11G 10CM -,SUP-G36211,CDM,A4215,HCPCS,272,RC,,,outpatient,,,1924.08,1346.856,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,1477.69344,other,OPPS APC,,
CATHETER COUDE 24FR 5CC -,SUP-1524C,CDM,A4340,HCPCS,270,RC,,,outpatient,,,45.92,32.144,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.30904,416.02,,,,
SILICONE CATHETER FOLEY 24FR 5CC -,SUP-8887605247,CDM,A4344,HCPCS,270,RC,,,outpatient,,,17.15,12.005,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.850175,416.02,,,,
CATH FOLEY 18FR 5ML BLN 3W DOVER LTX 16IN LUB -,SUP-2718,CDM,A4346,HCPCS,272,RC,,,outpatient,,,39.16,27.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.025285,416.02,other,OPPS APC,,
CATHETER FOLEY 22FR 30CC 3-WAY -,SUP-2822,CDM,A4346,HCPCS,272,RC,,,outpatient,,,41.84,29.288,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.025285,416.02,other,OPPS APC,,
CATHETER FOLEY 24FR 30CC 3-WAY -,SUP-2824,CDM,A4346,HCPCS,272,RC,,,outpatient,,,17.93,12.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.025285,416.02,other,OPPS APC,,
CATH FOLEY SIL 3W 30CC 22FR -,SUP-8887665225,CDM,A4346,HCPCS,272,RC,,,outpatient,,,41.84,29.288,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.025285,416.02,other,OPPS APC,,
SLING ORTHO ARM SM -,SUP-8023-01,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.98585,416.02,other,OPPS APC,,
SLING DEROYAL ARM MEDIUM -,SUP-8023-02,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.98585,416.02,other,OPPS APC,,
SLING DEROYAL ARM LARGE -,SUP-8023-03,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.98585,416.02,other,OPPS APC,,
SLING ORTHO ARM XL -,SUP-8023-04,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.98585,416.02,other,OPPS APC,,
SLING ARM MED STRP -,SUP-TX9901-43,CDM,A4565,HCPCS,270,RC,,,outpatient,,,13.3,9.31,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.98585,416.02,other,OPPS APC,,
HC Tissue Marker,PX-27800092,CDM,A4648,HCPCS,278,RC,,,outpatient,,,418,292.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.325665,1791.14496,other,OPPS APC,,
NEEDLE BRST LOC 20GAX3CM CM MRKNG STD MRKNG CANN ON WIRE -,SUP-253030,CDM,A4648,HCPCS,278,RC,,,outpatient,,,271.33,189.931,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.325665,1791.14496,other,OPPS APC,,
MARKER BRSTBIO 3MM 17GA INCONEL 625 ULTRA CLP -,SUP-862017,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.325665,1791.14496,other,OPPS APC,,
MARKER BRSTBIO 17GA TI ULTRA CLP II US -,SUP-863017,CDM,A4648,HCPCS,278,RC,,,outpatient,,,1097.2,768.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.325665,1791.14496,other,OPPS APC,,
INSTRUMENT BX 18GA/17GA/INTRO ACHIEVE AUTO 11CM SFT TIS -,SUP-CA1811,CDM,A4648,HCPCS,278,RC,,,outpatient,,,497.49,348.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.325665,1791.14496,other,OPPS APC,,
IDENTIFIER BIOPSY SITE FOR CELERO 12 THIRD SHAPE -,SUP-CELEROMARK-2S,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.325665,1791.14496,other,OPPS APC,,
NEEDLE BRST LOC KOPANS 20GAX5CM BVL CUT TIP MOD REINF TIP -,SUP-DKBL-20-5.0-A,CDM,A4648,HCPCS,278,RC,,,outpatient,,,175.17,122.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.325665,1791.14496,other,OPPS APC,,
NEEDLE BRST LOC KOPANS 20GAX7CM BVL CUT TIP MOD REINF TIP -,SUP-DKBL-20-7.0-A,CDM,A4648,HCPCS,278,RC,,,outpatient,,,175.17,122.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.325665,1791.14496,other,OPPS APC,,
NEEDLE BRST LOC KOPANS 20GAX9CM BVL CUT TIP MOD REINF TIP -,SUP-DKBL-20-9.0-A,CDM,A4648,HCPCS,278,RC,,,outpatient,,,175.17,122.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.325665,1791.14496,other,OPPS APC,,
NEEDLE 18GA X 20CM FUSIONCOIL WITH 1 X 5MM FIDUCIAL MARKER -,SUP-MTCTXFC1051820,CDM,A4648,HCPCS,278,RC,,,outpatient,,,752.72,526.904,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.325665,1791.14496,other,OPPS APC,,
MARKERS CIVCO FIDUCIAL 30CM -,SUP-MTNW887835,CDM,A4648,HCPCS,278,RC,,,outpatient,,,1129.01,790.307,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.325665,1791.14496,other,OPPS APC,,
MARKER BRSTBIO TI SCUR MRK MINI CORK -,SUP-SMARK-CELERO,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.325665,1791.14496,other,OPPS APC,,
MARKER BRSTBIO TI SECURMARK TOP HAT SHP -,SUP-SMARK-CELERO-2S,CDM,A4648,HCPCS,278,RC,,,outpatient,,,481.1,336.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.325665,1791.14496,other,OPPS APC,,
MARKER BRSTBIO TI SCUR MRK MINI CORK -,SUP-SMARK-EVIVA-13,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.325665,1791.14496,other,OPPS APC,,
MARKER BRSTBIO TI SECURMARK -,SUP-SMARK-EVIVA-2S-13,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.325665,1791.14496,other,OPPS APC,,
SCOUT 5CM DELIVERY NEEDLE AND REFLECTOR SSR05-01 -,SUP-SSR05-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.325665,1791.14496,other,OPPS APC,,
SCOUT 10CM DELIVERY NEEDLE AND REFLECTOR -,SUP-SSR10-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.325665,1791.14496,other,OPPS APC,,
SCOUT 7.5CM DELIVERY NEEDLE AND REFLECTOR -,SUP-SSR75-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.325665,1791.14496,other,OPPS APC,,
REFLECTOR AND DELIVERY SYSTEM SINGLE HAND 16G 7.5 CM -,SUP-SSR75S-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.325665,1791.14496,other,OPPS APC,,
IDENTIFIER BIOPSY SITE ATEC TRIMARK INTRODUCER SHEATH MARKER -,SUP-TRIMARK TD-2S-13-MR,CDM,A4648,HCPCS,278,RC,,,outpatient,,,371.98,260.386,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.325665,1791.14496,other,OPPS APC,,
EXPANDER BRST 500ML BIOCELL RND NATRLL 13CMX13.5CM 5.7CM -,SUP-133FV-13,CDM,A4649,HCPCS,272,RC,,,outpatient,,,4986.7,3490.69,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC,,
EXPANDER TISSUE SMOOTH 600CC NATRELLE FULL HEIGHT -,SUP-133S-FV-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC,,
EXPANDER TISSUE NATRELLE SMOOTH 650CC -,SUP-133S-FX-14-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC,,
NATRELLE INSPIRA TISSUE EXPANDER 800CC -,SUP-133S-FX-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC,,
TISSUE EXPANDER 400CC NATRELLE SMOOTH MOD HEIGHT EXTRA PROT -,SUP-133S-MX-12-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC,,
TISSUE EXPANDER 500CC NATRELLE SMOOTH MOD HEIGHT EXTRA PROT -,SUP-133S-MX-13-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC,,
TISSUE EXPANDER 600CC NATRELLE -,SUP-133S-MX-14-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC,,
EXPANDER TISSUE NATRELLE SMOOTH 700CC -,SUP-133S-MX-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC,,
EXPANDER TISSUE SMOOTH 400CC SHORT HT EXTRA PROJ NATRELLE -,SUP-133S-SX-13-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5903.4,4132.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC,,
EXPANDER TISSUE SMOOTH 650CC HEIGHT EXTRA PROJ NATRELLE -,SUP-133S-SX-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC,,
EXPANDER TISS 250ML SHRT H -,SUP-133SV-12,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC,,
EXPANDER BRST UNIV NATRLL -,SUP-30-000003,CDM,A4649,HCPCS,272,RC,,,outpatient,,,63.19,44.233,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC,,
EXPANDER BREAST TISSUE CPX4 450CC -,SUP-350-9213,CDM,A4649,HCPCS,272,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC,,
650CC CPX 4 BREAST TISSUE EXPANDER W/SUTURE TABS MED. HEIGHT -,SUP-350-9215,CDM,A4649,HCPCS,272,RC,,,outpatient,,,7745.3,5421.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC,,
EXPANDER TISSUE SMOOTH 800CC CPX 4 W/SUTURE TABS MED HT -,SUP-350-9216,CDM,A4649,HCPCS,272,RC,,,outpatient,,,7745.3,5421.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC,,
EXPANDER BRST 850ML BIOCELL RND NATRLL 16CMX16.5CM 6.8CM -,SUP-37-133800,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5835.5,4084.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC,,
EXPANDER BRST 600ML BIOCELL RND NATRLL 14CMX14.5CM 6.2CM -,SUP-67-133FV14,CDM,A4649,HCPCS,272,RC,,,outpatient,,,4986.7,3490.69,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC,,
SIZER IMPLANT NATRELLE INSPIRA 520CC FULL PROFILE -,SUP-MSZ-F520,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC,,
SIZER IMPLANT NATRELLE INSPIRA 560CC FULL PROFILE -,SUP-MSZ-F560,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC,,
SIZER IMPLANT NATRELLE INSPIRA 605CC FULL PROFILE -,SUP-MSZ-F605,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC,,
SIZER IMPLANT NATRELLE INSPIRA 695CC FULL PROFILE -,SUP-MSZ-F695,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC,,
SIZER IMPLANT NATRELLE INSPIRA 770CC FULL PROFILE -,SUP-MSZ-F770,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC,,
SIZER IMPLANT NATRELLE INSPIRA 275CC MODERATE PROFILE -,SUP-MSZ-M275,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC,,
SIZER IMPLANT NATRELLE INSPIRA 560CC MODERATE PROFILE -,SUP-MSZ-M560,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC,,
SIZER IMPLANT NATRELLE INSPIRA 600CC MODERATE PROFILE -,SUP-MSZ-M600,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC,,
SIZER IMPLANT NATRELLE INSPIRA 525CC EXTRA FULL PROFILE -,SUP-MSZ-X525,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC,,
SIZER IMPLANT NATRELLE INSPIRA 545CC EXTRA FULL PROFILE -,SUP-MSZ-X545,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC,,
SIZER IMPLANT NATRELLE INSPIRA 580CC EXTRA FULL PROFILE -,SUP-MSZ-X580,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC,,
SIZER IMPLANT NATRELLE INSPIRA 750CC XFULL PROFILE -,SUP-MSZ-X750,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC,,
SIZER IMPLANT NATRELLE INSPIRA 800CC EXTRA FULL PROFILE -,SUP-MSZ-X800,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC,,
SIZER IMPLANT NATRELLE INSPIRA 745CC FULL PROFILE -,SUP-SCF-745,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.186155,5948.3904,other,OPPS APC,,
DRESSING WND 2X2IN PURACOL + HI GEL INTGRTY COLL LF -,SUP-MSC8622EP,CDM,A6021,HCPCS,270,RC,,,outpatient,,,32.97,23.079,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,7.401765,416.02,,,,
DRESSING BURN PURACOL PLUS 2X2 AG SILVER  COLLAGEN -,SUP-MSC8722EP,CDM,A6021,HCPCS,270,RC,,,outpatient,,,43.41,30.387,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,7.401765,416.02,,,,
SHEETING SILASTIC 4.625X5.625IN SIL GEL HYPAL SLFADH LPRO -,SUP-NC15462,CDM,A6025,HCPCS,272,RC,,,outpatient,,,180.14,126.098,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,11.99,416.02,,,,
DRESSING KALTOSTAT CA ALGIN 3X4.75IN ABSB -,SUP-168212,CDM,A6196,HCPCS,270,RC,,,outpatient,,,14.44,10.108,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.708445,416.02,,,,
DRESSING XTRA HYDROFIBER AQUACEL 2X2IN -,SUP-420671,CDM,A6196,HCPCS,270,RC,,,outpatient,,,8.66,6.062,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.708445,416.02,,,,
DRESSING ALGIN 2X2IN SQ NADH HI ABSB F/MOD TO HVY DRN -,SUP-MSC7022EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,7.61,5.327,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.708445,416.02,,,,
DRESSING MAXORB 4X4IN EXTRA -,SUP-MSC7044EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,14.23,9.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.708445,416.02,,,,
DRESSING WND 1X12IN FLT ROPE HI ABSORBENT1 F/WND MAXORB XTR -,SUP-MSC7112EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,20.07,14.049,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.708445,416.02,,,,
DRESSING MAXORB AG 2X2IN ALGIN SILVER -,SUP-MSC9422EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,18.37,12.859,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.708445,416.02,,,,
DRESSING AQUACEL 4 X 5 -,SUP-420674,CDM,A6197,HCPCS,270,RC,,,outpatient,,,18.13,12.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.070185,416.02,other,OPPS APC,,
DRESSING GERMC AQUACEL AG EXTRA 4X4IN SLVR STRL -,SUP-420674,CDM,A6197,HCPCS,270,RC,,,outpatient,,,18.13,12.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.070185,416.02,other,OPPS APC,,
DRESSING AQUACEL AG  2X2IN SQ HYDROFIBER SILVER -,SUP-422297,CDM,A6197,HCPCS,270,RC,,,outpatient,,,27.75,19.425,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.070185,416.02,other,OPPS APC,,
DRESSING AQUACEL AG 6X6IN HYDROFIBER -,SUP-422298,CDM,A6197,HCPCS,270,RC,,,outpatient,,,112.45,78.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.070185,416.02,other,OPPS APC,,
DRESSING ALGINATE SILVER 4X4.75IN CA ANTMIC NADH NWVN FLT -,SUP-MSC9445EP,CDM,A6197,HCPCS,270,RC,,,outpatient,,,34.27,23.989,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.070185,416.02,other,OPPS APC,,
DRESSING MAXORB EXTRA AG 4X4 SILVER -,SUP-MSC9445EP,CDM,A6197,HCPCS,270,RC,,,outpatient,,,34.72,24.304,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.070185,416.02,other,OPPS APC,,
DRESSING ALGIN AQUACL HYDROFIBER 0.75X18IN NADH CONFRM NWVN -,SUP-403770,CDM,A6199,HCPCS,270,RC,,,outpatient,,,19.4,13.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.3553,416.02,,,,
DRESSING ALGIN AQUACL HYDROFIBER 0.75X18IN NADH CONFRM NWVN -,SUP-403770,CDM,A6199,HCPCS,270,RC,,,outpatient,,,22.99,16.093,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.3553,416.02,,,,
DRESSING AQUACEL AG ROPE .75X18 IN -,SUP-422300,CDM,A6199,HCPCS,270,RC,,,outpatient,,,59.94,41.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.3553,416.02,,,,
DRESSING SILVERLON 4 X 10 -,SUP-ID-410,CDM,A6206,HCPCS,272,RC,,,outpatient,,,169.8,118.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,5.23,416.02,,,,
DRESSING ACTICOAT 4X5 -,SUP-66800405,CDM,A6207,HCPCS,272,RC,,,outpatient,,,81.2,56.84,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.98576,416.02,,,,
DRESSING ACTICOAT 4X4 -,SUP-66800406,CDM,A6207,HCPCS,272,RC,,,outpatient,,,44.48,31.136,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.98576,416.02,,,,
DRESSING ALLEVYN NONADHESIVE 2X2 NO BORDER -,SUP-66027643,CDM,A6209,HCPCS,272,RC,,,outpatient,,,14.63,10.241,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.94544,416.02,,,,
DRESSING FOAM 4x4 BORDERLESS -,SUP-66927637,CDM,A6209,HCPCS,272,RC,,,outpatient,,,13.12,9.184,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.94544,416.02,,,,
"DRESSING HYDROFERA 2.5"" X 2.5"" -",SUP-HLST-HBRT2525,CDM,A6209,HCPCS,272,RC,,,outpatient,,,268.12,187.684,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.94544,416.02,,,,
HYDROFERA BLUE READY TRANSFER 2.5 X 2.5 -,SUP-HLST-HRBS2214,CDM,A6209,HCPCS,272,RC,,,outpatient,,,26.78,18.746,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.94544,416.02,,,,
HYDROFERA BLUE READY TRANSFER 4 X 5 -,SUP-HBRS4520,CDM,A6210,HCPCS,272,RC,,,outpatient,,,40.63,28.441,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.121435,416.02,,,,
HYDROFERA BLUE READY TRANSFER 4 X 5 -,SUP-HLST-HRBT4050,CDM,A6210,HCPCS,272,RC,,,outpatient,,,416.5,291.55,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.121435,416.02,,,,
HYDROFERA BLUE READY TRANSFER 8 X 8 -,SUP-HLST-HRBS8820,CDM,A6211,HCPCS,272,RC,,,outpatient,,,92.17,64.519,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.692165,416.02,,,,
DRESSING OPTIFOAM AG 3.5 X 6 -,SUP-412010,CDM,A6212,HCPCS,270,RC,,,outpatient,,,109.06,76.342,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.79151,416.02,other,OPPS APC,,
DRESSING OPTIFOAM AG 3.5 X 10 -,SUP-412011,CDM,A6212,HCPCS,270,RC,,,outpatient,,,139.34,97.538,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.79151,416.02,other,OPPS APC,,
BANDAGE ADH 4X4IN ALLEVYN -,SUP-66800270,CDM,A6212,HCPCS,270,RC,,,outpatient,,,12.57,8.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.79151,416.02,other,OPPS APC,,
BANDAGE ADH 4X4IN ALLEVYN -,SUP-66800270,CDM,A6212,HCPCS,270,RC,,,outpatient,,,18.72,13.104,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.79151,416.02,other,OPPS APC,,
DRESSING FOAM VERSATILE 2 1/8IN X 4 3/4IN SILICONE ADHESIVE -,SUP-66800836,CDM,A6212,HCPCS,270,RC,,,outpatient,,,7.98,5.586,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.79151,416.02,other,OPPS APC,,
"DRESSING FOAMING ALLEYN GENTLE BORDER LITE 5.5CM X 12CM"" -",SUP-66800836,CDM,A6212,HCPCS,270,RC,,,outpatient,,,8.42,5.894,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.79151,416.02,other,OPPS APC,,
DRESSING ALLEVYN LIFE 5 1/16IN x 5 1/16IN -,SUP-66801068,CDM,A6212,HCPCS,270,RC,,,outpatient,,,14.24,9.968,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.79151,416.02,other,OPPS APC,,
DRESSING OPTIFOAM AG 3.5 X 14 -,SUP-412012,CDM,A6213,HCPCS,270,RC,,,outpatient,,,148.97,104.279,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.206745,416.02,other,OPPS APC,,
DRESSING FOAM SACRUM 9.4 X 8.4CM LRG -,SUP-423270,CDM,A6213,HCPCS,270,RC,,,outpatient,,,41.01,28.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.206745,416.02,other,OPPS APC,,
DRESSING MEPORE 2.5 X 3 -,SUP-670800,CDM,A6219,HCPCS,270,RC,,,outpatient,,,0.55,0.385,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.04041,416.02,other,OPPS APC,,
TOWEL ABSORBENT STER 7550 -,SUP-7550,CDM,A6219,HCPCS,270,RC,,,outpatient,,,4,2.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.04041,416.02,other,OPPS APC,,
DRESSING WND 2X2IN ADH ISLND NWVN BRDR WTRPRF BK STRL SQ LF -,SUP-MSC3222,CDM,A6219,HCPCS,270,RC,,,outpatient,,,0.18,0.126,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.04041,416.02,other,OPPS APC,,
DRESSING BORDERED 4X4IN ADH ISLAND NWVN -,SUP-MSC3244,CDM,A6219,HCPCS,270,RC,,,outpatient,,,2.39,1.673,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.04041,416.02,other,OPPS APC,,
DRESSING ADAPTIC 3INX3IN 7.6CMx7.6CM NON-ADHERING -,SUP-2012,CDM,A6222,HCPCS,272,RC,,,outpatient,,,14.03,9.821,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.52533,416.02,other,OPPS APC,,
DRESSING PETRO ADPTC 3X3IN OIL EMUL NADH GZE CELLU-ACET -,SUP-2012,CDM,A6222,HCPCS,272,RC,,,outpatient,,,14.03,9.821,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.52533,416.02,other,OPPS APC,,
DRESSING XEROFORM 1X8 -,SUP-212,CDM,A6222,HCPCS,272,RC,,,outpatient,,,3.03,2.121,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.52533,416.02,other,OPPS APC,,
DRESSING XEROFORM 2 X 2 -,SUP-214,CDM,A6222,HCPCS,272,RC,,,outpatient,,,2.34,1.638,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.52533,416.02,other,OPPS APC,,
DRESSING MESALT RIBBON 3/4x39 IN DEBRIDE 0.75x39 IN ABSB -,SUP-285299,CDM,A6222,HCPCS,272,RC,,,outpatient,,,10.93,7.651,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.52533,416.02,other,OPPS APC,,
DRESSING MESALT 3x3 IN GAUZE -,SUP-285780,CDM,A6222,HCPCS,272,RC,,,outpatient,,,4.67,3.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.52533,416.02,other,OPPS APC,,
DRESSING WND 1.6 X 2.4IN CUTIMED SORBACT SWB PRIM STRL LF -,SUP-7216412,CDM,A6222,HCPCS,272,RC,,,outpatient,,,21.89,15.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.52533,416.02,other,OPPS APC,,
DRESSING ADAPTIC 3X8 -,SUP-2013,CDM,A6223,HCPCS,272,RC,,,outpatient,,,4.43,3.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.698195,416.02,other,OPPS APC,,
DRESSING PETRO VASELINE 1X36IN STRL 1-PLY IMPREG NADH LPRO -,SUP-205-12-A,CDM,A6223,HCPCS,272,RC,,,outpatient,,,3.11,2.177,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.698195,416.02,other,OPPS APC,,
DRESSING XEROFORM 5IN X 9IN -,SUP-213,CDM,A6223,HCPCS,272,RC,,,outpatient,,,4.32,3.024,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.698195,416.02,other,OPPS APC,,
DRESSING XEROFORM 5IN X 9IN -,SUP-213,CDM,A6223,HCPCS,272,RC,,,outpatient,,,4.32,3.024,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.698195,416.02,other,OPPS APC,,
DRESSING PETRO VASELINE 1X36IN OCL NADH STRIP STRL IMPREG -,SUP-8884412600,CDM,A6223,HCPCS,272,RC,,,outpatient,,,3.15,2.205,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.698195,416.02,other,OPPS APC,,
GAUZE VASELINE 1 X 36 -,SUP-8884412600,CDM,A6223,HCPCS,272,RC,,,outpatient,,,3.15,2.205,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.698195,416.02,other,OPPS APC,,
DRESSING ADAPTIC 3X8 -,SUP-JOHN-2013,CDM,A6223,HCPCS,272,RC,,,outpatient,,,26.74,18.718,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.698195,416.02,other,OPPS APC,,
GAUZE VASELINE 3IN X 18IN -,SUP-207-12-A,CDM,A6224,HCPCS,272,RC,,,outpatient,,,5.13,3.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.801465,416.02,,,,
GAUZE VASELINE 3IN X 18IN -,SUP-207-12-A,CDM,A6224,HCPCS,272,RC,,,outpatient,,,5.13,3.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.801465,416.02,,,,
"GAUZE VASELINE 3"" X 36"" -",SUP-425600,CDM,A6224,HCPCS,272,RC,,,outpatient,,,7.26,5.082,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.801465,416.02,,,,
GAUZE PETRO 3X36IN VASELINE -,SUP-8884415600,CDM,A6224,HCPCS,272,RC,,,outpatient,,,3.57,2.499,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.801465,416.02,,,,
GAUZE VASELINE 1/2 X 72 -,SUP-8884421600,CDM,A6224,HCPCS,272,RC,,,outpatient,,,5.95,4.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.801465,416.02,,,,
DRESSING HYDROCOLLOID DUODERM 2X4IN XTRA THIN -,SUP-187900,CDM,A6234,HCPCS,272,RC,,,outpatient,,,4.07,2.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.913715,416.02,other,OPPS APC,,
DRESSING HYDROCOLLOID DUODERM 4X4IN XTRA THIN -,SUP-187955,CDM,A6234,HCPCS,272,RC,,,outpatient,,,4.49,3.143,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.913715,416.02,other,OPPS APC,,
DRESSING WND XTHN 4X4IN DDRM STRL CONFRM NADH HYDRCL SQ -,SUP-187955,CDM,A6234,HCPCS,272,RC,,,outpatient,,,6.73,4.711,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.913715,416.02,other,OPPS APC,,
DRESSING DUODERM EXTRA THIN 4X4 -,SUP-187955,CDM,A6234,HCPCS,272,RC,,,outpatient,,,6.71,4.697,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.913715,416.02,other,OPPS APC,,
DRESSING HYDRCL XTHN 4X6IN DDRM CGF STRL XTHN CONFRM NADH -,SUP-187902,CDM,A6235,HCPCS,270,RC,,,outpatient,,,11.92,8.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.67604,416.02,,,,
DRESSING DUODERM 4 X 4 THICK -,SUP-187660,CDM,A6237,HCPCS,272,RC,,,outpatient,,,9.64,6.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,416.02,other,OPPS APC,,
DRESSING HYDROCOLLOID DUODERM 4X4IN -,SUP-403326,CDM,A6237,HCPCS,272,RC,,,outpatient,,,7.39,5.173,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,416.02,other,OPPS APC,,
DRESSING WND 4X4IN DDRM SGNL STRL CONFRM ADH ABSB WTRPRF -,SUP-403326,CDM,A6237,HCPCS,272,RC,,,outpatient,,,11.11,7.777,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,416.02,other,OPPS APC,,
DRESSING HYDRCL 6X7IN DUADERM CGF STRL -,SUP-187974,CDM,A6238,HCPCS,270,RC,,,outpatient,,,42.72,29.904,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.600005,416.02,,,,
DRESSING WND 14X14CM DDRM SGNL STRL CONFRM ADH ABSB WTRPRF -,SUP-403327,CDM,A6238,HCPCS,270,RC,,,outpatient,,,20.49,14.343,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.600005,416.02,,,,
DRESSING WND 15X18CM DDRM SGNL STRL CONFRM ADH ABSB WTRPRF -,SUP-403332,CDM,A6238,HCPCS,270,RC,,,outpatient,,,21.79,15.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.600005,416.02,,,,
CREAM TRIAD HYDROPHILLIC WOUND DRESSING -,SUP-1964-A,CDM,A6240,HCPCS,270,RC,,,outpatient,,,31.57,22.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,7.087465,416.02,,,,
DRESSING HYDRCL 1.6IN TENDRWT STRL ACT CVTY LF -,SUP-MSC8401,CDM,A6242,HCPCS,270,RC,,,outpatient,,,16.34,11.438,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.66833,416.02,,,,
DRESSING DEBRIDE 3X3IN PLYACRL PLYMR GL CVTY PAD TENDRWT ACT -,SUP-MSC8403Z,CDM,A6242,HCPCS,270,RC,,,outpatient,,,22.7,15.89,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.66833,416.02,,,,
DRESSING GEL 30GM DDRM HYDACTV NADH FIL HYDRCL HYDACTV -,SUP-187987,CDM,A6248,HCPCS,272,RC,,,outpatient,,,13.91,9.737,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.122795,416.02,,,,
DRESSING SILVASORB GEL 0.25OZ  SILVER ABSB ANTMIC -,SUP-MSC93025EP,CDM,A6248,HCPCS,272,RC,,,outpatient,,,34.03,23.821,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.122795,416.02,,,,
SURGICAL DRESSING SILK 6 X 8IN -,SUP-NON4313,CDM,A6255,HCPCS,270,RC,,,outpatient,,,8.82,6.174,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.98009,416.02,,,,
DRESSING TEGADERM 1.75X1.75IN TRANPARENT FILM -,SUP-1622-W,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.17,0.819,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.262665,416.02,other,OPPS APC,,
DRESSING TRANSP 2.375X2.75IN TEGADERM OCL PIC FRM STYL -,SUP-1624-W,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.17,0.819,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.262665,416.02,other,OPPS APC,,
DRESSING TEGADERM 3 X 3 -,SUP-1624-W,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.17,0.819,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.262665,416.02,other,OPPS APC,,
DRESSING TEAGDERM IV 2.75X3.25IN -,SUP-1633,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.63,1.141,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.262665,416.02,other,OPPS APC,,
DRESSING TEGADERM IV 3.5X4.5IN TRANSPARENT -,SUP-1655,CDM,A6257,HCPCS,270,RC,,,outpatient,,,5.37,3.759,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.262665,416.02,other,OPPS APC,,
DRESSING TRANSP 4X4.75IN TEGADERM OCL ORIG FRM STYL PLYSTR -,SUP-1626,CDM,A6258,HCPCS,270,RC,,,outpatient,,,3.38,2.366,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.75881,416.02,other,OPPS APC,,
DRESSING TRANSPARENT 4IN X 4.25IN -,SUP-1626,CDM,A6258,HCPCS,270,RC,,,outpatient,,,3.38,2.366,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.75881,416.02,other,OPPS APC,,
DRESSING TEGADERM 4X5 -,SUP-1626-W,CDM,A6258,HCPCS,270,RC,,,outpatient,,,3.53,2.471,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.75881,416.02,other,OPPS APC,,
DRESSING TEGADERM 15X20CM -,SUP-1628,CDM,A6258,HCPCS,270,RC,,,outpatient,,,6.97,4.879,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.75881,416.02,other,OPPS APC,,
DRESSING TRANSP 4X6.125IN TEGADERM OCL WND FRM STYL ADLT -,SUP-1689,CDM,A6258,HCPCS,270,RC,,,outpatient,,,10.58,7.406,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.75881,416.02,other,OPPS APC,,
DRESSING TEGADERM 20CM X 30CM -,SUP-1629,CDM,A6259,HCPCS,272,RC,,,outpatient,,,9.86,6.902,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.21357,416.02,other,OPPS APC,,
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7015-46,NDC,outpatient,10,ML,100.56,70.392,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.17,416.02,other,OPPS APC,,
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7020-38,NDC,outpatient,10,ML,102.5,71.75,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.17,416.02,other,OPPS APC,,
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7025-40,NDC,outpatient,10,ML,100.57,70.399,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.17,416.02,other,OPPS APC,,
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7015-48,NDC,outpatient,10,ML,100.56,70.392,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.17,416.02,other,OPPS APC,,
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7030-42,NDC,outpatient,10,ML,100.56,70.392,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.17,416.02,other,OPPS APC,,
GADOTERATE MEGLUMINE 1 MMOL/2 ML IV SOLN WRAPPER,RX-4080731,CDM,A9575,HCPCS,636,RC,67684-2000-00,NDC,outpatient,20,ML,136.25,95.375,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.12,416.02,other,OPPS APC,,
7 HOLE SUPERIOR MIDSHAFT CLAVICLE RIGHT PLATE -,SUP-0000000215,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS 4.0 FIXOS X 26MM -,SUP-0000000215,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE ANCHORED APACHE 5MM -,SUP-0000006784,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CABLE ORTHO CBL-RDY COCR 635MM -,SUP-00022320418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2083.36,1458.352,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN IM 4.8X222MM RUSH SS -,SUP-00080200103,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.68,514.976,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN IM 3.2X127MM RUSH SS -,SUP-00080300104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN IM 3.2X140MM RUSH SS -,SUP-00080300105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN IM 3.2X165MM RUSH SS -,SUP-00080300107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN IM 3.2X191MM RUSH SS -,SUP-00080300109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN IM SZ 3L 3.2X241MM RUSH SS -,SUP-00080300113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN IM 3.2X254MM RUSH SS -,SUP-00080300114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X18MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS POR -,SUP-00104223018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X24MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS POR -,SUP-00104223024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X30MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-00104223030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN CANC 4.5X33MM PROTASUL-64 WF TM ANTMC SHLDR STRL -,SUP-00104223033,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN CANC 4.5X36MM PROTASUL-64 WF TM ANTMC SHLDR STRL -,SUP-00104223036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X42MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-00104223042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X48MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-00104223048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FILLER TY I COLL CA PHOS 5ML PST COPIOS DBASC -,SUP-00110302005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3752.36,2626.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FILLER TY I COLL CA PHOS 10ML PST COPIOS DBASC -,SUP-00110302010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6279,4395.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CEMENT BN PLYMTHL MTHCRYLT 40GM PLC R HVISC -,SUP-00111214001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 40X3MM ANCHR XLPE GLOBAL STRL -,SUP-00113640026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9421.68,6595.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX10MM CANN 7.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX10MM CANN 1/2 5MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX12MM CANN 9.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX12MM CANN 1/3 5MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX16MM CANN 1/2 8MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114701631,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX16MM CANN 13.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX19MM CANN 1/3 6.3MM THRD SD/ST HX REVCT FLUT -,SUP-00114701930,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANN 3.0MM X 20MM 1/3 TH -,SUP-00114702030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX21MM CANN 1/3 7MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX24MM CANN 1/2 12MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702431,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX26MM CANN 1/2 13MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702631,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX28MM CANN 1/2 14MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702831,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX28MM CANN 9.3MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114702835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX28MM CANN 1/3 9.3MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114702840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.27,795.389,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX28MM CANN 1/2 14MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114702841,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.27,795.389,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX30MM CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX30MM CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX30MM CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT. -,SUP-00114703041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX34MM CANN 1/3 11.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX34MM CANN 1/3 11.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX34MM CANN 1/3 17MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703441,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.27,795.389,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX36MM CANN 1/3 12MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX36MM CANN 1/3 12MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX36MM CANN 1/3 18MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703641,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX38MM CANN 1/3 12.7MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX38MM CANN 1/3 19MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703841,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX40MM CANN 1/3 13.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX40MM CANN 1/3 13.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X40MM CANN 1/3 13.3MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX40MM CANN 1/3 20MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX42MM CANN 1/3 39.5MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX44MM CANN 14.7MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX44MM CANN 1/3 14.7MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX44MM CANN 1/2 22MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704441,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5MMX45MM CANN 16MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114704555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5MMX45MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114704556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX46MM CANN 15.3MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX46MM CANN 43.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX46MM CANN 1/3 15.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX46MM CANN 1/2 23MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704641,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX48MM CANN 16MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX48MM CANN 1/3 16MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX50MM CANN 16.7MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114705035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX50MM CANN 1/3 16.7MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114705040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5MMX50MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5MMX50MM CANN 45.3MM FT SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705057,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX50MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114705065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5MMX55MM CANN 16MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5MMX55MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX55MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114705565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5MMX60MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114706056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX60MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX60MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5MMX65MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114706556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX65MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX65MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX70MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX70MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX70MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX70MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX75MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX75MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX75MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX75MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5MMX80MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114708056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX80MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX80MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX80MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX80MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX80MM CANN 74.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114708077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 1.6MMX6IN P/T TROC TIP -,SUP-00114708400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 1.25MMX6IN P/T TROC TIP -,SUP-00114708500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5MMX85MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114708556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX85MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX85MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX85MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX85MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX85MM CANN 79.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114708577,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 2.4MMX9IN P/T TROC TIP -,SUP-00114708700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 3.2MMX9IN P/T TROC TIP -,SUP-00114708800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 1.6MMX9IN SMTH SHFT TROC TIP -,SUP-00114709000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,70.98,49.686,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX90MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX90MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX90MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX90MM CANN 84.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114709077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 2.4MMX9IN SMTH SHFT TROC TIP -,SUP-00114709100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,147.14,102.998,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 3.2MMX9IN SMTH SHFT TROC TIP -,SUP-00114709200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,147.04,102.928,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 1.6MMX6IN SMTH SHFT TROC TIP -,SUP-00114709400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,70.95,49.665,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO 3MM -,SUP-00114709500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX95MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX95MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX95MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX95MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX95MM CANN 89.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114709577,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO F/3.5/4MM CANN SCR NS -,SUP-00114709600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO F/4.5MM CANN SCR SS NS -,SUP-00114709700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO F/5.5MM/7.5MM CANN SCR SS RND NS -,SUP-00114709800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 3.2MMX12IN P/T TROC TIP -,SUP-00114709901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 3.2MM 30CM -,SUP-00114709902,CDM,C1713,HCPCS,278,RC,,,outpatient,,,155.78,109.046,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 3.2MMX12IN SMTH SHFT DRILL TIP -,SUP-00114709903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,155.74,109.018,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX100MM CANN 16MM THRD SD/ST 4.5MM HX REVCT FLUT -,SUP-00114710065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW Z CANN PT 32 6.5 X 100 -,SUP-00114710066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX100MM CANN FT SD/ST 5MM HX REVCT FLUT BIODUR 108 -,SUP-00114710077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX105MM CANN 16MM THRD SD/ST 4.5MM HX REVCT FLUT -,SUP-00114710565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX105MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114710575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1399.33,979.531,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX105MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114710576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX110MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX110MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX115MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX115MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX120MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114712075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.25MM 2.5MM THRD MINI 10MM HRBRT MINI TIV STRL -,SUP-00115001000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2142.36,1499.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.25MM 2.5MM THRD MINI 16MM HRBRT MINI TIV STRL -,SUP-00115001600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2142.36,1499.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5MM 2.1MM THRD 14MM CANN HRBRT/WPL TIV STRL -,SUP-00115201400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2555.05,1788.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X5MM DIA THRD MINI 18MM CANN LAG HRBRT/WPL TIV STRL -,SUP-00115201800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2555.05,1788.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 3.2MMX23CM THRD TROC TIP FRLCK STRL -,SUP-00118102000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.84,81.788,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 12.7MM THRD VFX2 LAG 17MM S/T SS 130MM -,SUP-00119300557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1749.27,1224.489,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 3.2MM TM -,SUP-00119703200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.19,908.033,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD FEM HIP 10MM TM TIV 25MM THRD -,SUP-00119710010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14101.97,9871.379,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN NCB 80MM 4HL CONTR LCK PROTASUL-64 STRL -,SUP-00202262104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5884.73,4119.311,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN NCB 117MM 7HL CONTR LCK PROTASUL-64 STRL -,SUP-00202262107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7175.97,5023.179,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X24MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X30MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X32MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,605.85,424.095,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X36MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,605.85,424.095,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAP LCK NCB NS -,SUP-00203150300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,930.39,651.273,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X24MM NLCKG CORT NCB ST TMX NS -,SUP-00203155024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX26MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX28MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX30MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX32MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX34MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX36MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X38MM NLCKG CORT NCB ST TMX NS -,SUP-00203155038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX40MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX42MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX44MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX46MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX50MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X32MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,778.91,545.237,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X44MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,778.91,545.237,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X46MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,778.91,545.237,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X50MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.68,514.976,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN NCB 93MM 5HL LCK TI -,SUP-00203262005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5979.97,4185.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
STAPLE INTNL 19MMX15.9MM LF -,SUP-00222901300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,294.26,205.982,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DEVICE ORTHO 23MM LNG CBL-RDY GTR TROCH TIV 121MM STRL -,SUP-00223200205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9554.89,6688.423,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CABLE ORTHO 1.8MM CBL-RDY COCR 914MM STRL -,SUP-00223200228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2397.84,1678.488,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 305MM 4.5MM 10HL SS STRL -,SUP-00223200302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4354.7,3048.29,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CABLE PLATE 1.8MM CBL-RDY BN SS 610MM STRL -,SUP-00223200318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1493.73,1045.611,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CABLE SURG 1.8MM X 635MM CBL-RDY CRLGE SS -,SUP-00223200418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2083.36,1458.352,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CABLE FX 1.3MM CBL-RDY SS 889MM STRL -,SUP-00223201113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1788.55,1251.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOPEDIC CBL-RDY GRP 65MM PIN -,SUP-00223205021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2708.43,1895.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX12MM LCK CORT ST FA SS NS -,SUP-00234801235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX18MM LCK CORT ST FA SS NS -,SUP-00234801835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX20MM LCK CORT ST FA SS NS -,SUP-00234802035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX22MM LCK CORT ST FA SS NS -,SUP-00234802235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX26MM LCK CORT ST FA SS NS -,SUP-00234802635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX30MM LCK CORT ST FA SS NS -,SUP-00234803035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX34MM LCK CORT ST FA SS NS -,SUP-00234803435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX40MM LCK CORT ST FA SS NS -,SUP-00234804035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX100MM LCK CORT ST FA SS NS -,SUP-00234810035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 132MM 2.7/3.5MM 8HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235701708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3823.64,2676.548,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 80MM 2.7/3.5MM 4HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235701804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3310.29,2317.203,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 106MM 6HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235701806,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3540.4,2478.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 114MM 3.5MM 6HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235800104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6389.13,4472.391,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 129MM 7HL FX-ANG LCK NS -,SUP-00235800907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.68,2924.376,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 77MM 3HL LCK SS NS -,SUP-00235801203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3788.26,2651.782,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX12MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX14MM LCK NCANN P/T ST CNCL SS NS -,SUP-00235901426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,328.92,230.244,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX14MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX14MM LCK NCANN P/T ST SS NS -,SUP-00235901438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX16MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX16MM LCK NCANN P/T ST CNCL SS NS -,SUP-00235901638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X18MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X30MM LCK NCANN FT ST SS NS -,SUP-00235903035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X32MM LCK NCANN FT ST SS NS -,SUP-00235903235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X36MM LCK NCANN FT ST SS NS -,SUP-00235903635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X38MM LCK NCANN FT ST SS NS -,SUP-00235903835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X40MM LCK NCANN FT ST SS NS -,SUP-00235904035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X42MM LCK NCANN FT ST SS NS -,SUP-00235904235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X44MM LCK NCANN FT ST SS NS -,SUP-00235904435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X46MM LCK NCANN FT ST SS NS -,SUP-00235904635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X48MM LCK NCANN FT ST SS NS -,SUP-00235904835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X50MM LCK NCANN FT ST SS NS -,SUP-00235905035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCRW 14MM CASPAR PIN F/DSTRCT -,SUP-0024-LDR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 3.2X444MM -,SUP-00281001175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
STAPLE INTNL 22MMX9.5MM COCR LF -,SUP-00406000100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.27,530.089,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
STAPLE INTNL 25MMX9.5MM COCR LF -,SUP-00406000200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.27,530.089,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN FX 3.2MM BGLNI/FLTW THRD TIP -,SUP-00430400800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,379.28,265.496,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5MM THRD 7MM CORT FT ST HEX HEAD SS NS -,SUP-00481500701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5MM THRD 8MM CORT FT ST HEX HEAD SS NS -,SUP-00481500801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5MM THRD 9MM CORT FT ST HEX HEAD SS NS -,SUP-00481500901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5MM THRD 14MM CORT FT ST HEX HEAD SS NS -,SUP-00481501401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5MM THRD 16MM CORT FT ST HEX HEAD SS NS -,SUP-00481501601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5MM THRD 20MM CORT FT ST HEX HEAD SS NS -,SUP-00481502001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MM THRD 6MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482000603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MM THRD 8MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482000803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MM THRD 10MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MM THRD 10MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MM THRD 12MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MM THRD 12MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MM THRD 14MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MM THRD 14MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MM THRD 16MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MM THRD 16MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MM THRD 18MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MM THRD 22MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482002201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MM THRD 6MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00482700601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MM THRD 8MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00482700801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MM THRD 10MM LCK CORT FT NON- ST 2.5MM SM HEX RCESS -,SUP-00482701000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,128.9,90.23,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MM THRD 10MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MM THRD 12MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MM THRD 14MM CORT FT ST 2.5MM SM HEX RCESS -,SUP-00482701401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MM THRD 16MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MM THRD 18MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,147.33,103.131,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MM THRD 20MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482702001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MM THRD 26MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482702601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX10MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482801002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX12MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482801202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX12MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482801202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX14MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482801402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX16MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482801602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX18MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482801802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX20MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482802002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX22MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482802202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX26MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482802602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX28MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482802802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX30MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482803002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX16MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483501601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX16MM LCK CORT 6MM P/T NON- ST 2.5MM SM HEX RCESS -,SUP-00483501604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX20MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX20MM LCK CORT 6MM P/T NON- ST 2.5MM SM HEX RCESS -,SUP-00483502004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX22MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX22MM LCK CORT 6MM P/T NON- ST 2.5MM SM HEX RCESS -,SUP-00483502204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX24MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483502404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX26MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX26MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483502604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX28MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX28MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483502804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX30MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483503001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX30MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483503004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN CORT 3.5MM 32MM SS NS FT S/T LOCK 2.5MM SM HEX -,SUP-00483503201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX34MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483503401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX34MM LCK CORT 12MM P/T NON- ST 2.5MM SM HEX -,SUP-00483503404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX45MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483504501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX45MM LCK CORT 12MM P/T NON- ST 2.5MM SM HEX -,SUP-00483504504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX50MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483505001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX55MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483505501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX12MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484001200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX12MM CANC 5MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX14MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484001400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX14MM CANC 5MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX16MM LCK CANC FT 2.5MM SM HEX RCESS SS NS -,SUP-00484001600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX16MM CANC 6MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX18MM LCK CANC FT 2.5MM SM HEX RCESS SS NS -,SUP-00484001800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX18MM CANC 7MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX20MM LCK CANC FT 2.5MM SM HEX RCESS SS NS -,SUP-00484002000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX22MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484002200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX24MM CANC 10MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484002401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX26MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484002600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX28MM CANC 14MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484002801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX30MM CANC 14MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484003001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX34MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484003400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX38MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484003800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX40MM CANC 14MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484004001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX50MM CANC 15MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484005001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MM THRD 36MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484503601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MM THRD 38MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484503801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MM THRD 40MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MM THRD 40MM CORT 20.5MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00484504008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,194.77,136.339,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MM THRD 42MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MM THRD 44MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MM THRD 46MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MM THRD 50MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484505001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MM THRD 50MM CORT 24.5MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00484505008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,194.77,136.339,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MM THRD 55MM CORT 26.5MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00484505508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,194.77,136.339,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MM THRD 58MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484505801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MM THRD 60MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484506001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MM THRD 45MM CANC 32MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486504502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MM THRD 50MM CANC 16MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486505001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MM THRD 50MM CANC 32MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486505002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MM THRD 55MM CANC 32MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486505502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MM THRD 60MM CANC FT 3.5MM LRG HEX RCESS SS NS -,SUP-00486506000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO 4X7MM SM 2.7/3.5/4.0MM SS RND FLT NS -,SUP-00490004051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO 13MM LRG 4.5/6.5MM RND FLT NS -,SUP-00490006551,CDM,C1713,HCPCS,278,RC,,,outpatient,,,207.73,145.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 21MM 2MM SS L-SHP OB R MINI FRAG NS -,SUP-00492000210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,386.57,270.599,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 23MM 4HL 2MM SS STR MINI FRAG NS -,SUP-00492000402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,389.49,272.643,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 32MM 2.7MM SS T-SHP MINI FRAG NS -,SUP-00492700304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.52,254.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 31MM 4HL 1MM SS 1/4 TBLR MINI FRAG NS CLLR -,SUP-00492700403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,432.72,302.904,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 104MM 3.5MM 4HL SS CLVRLF SM FRAG NS -,SUP-00493500416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1493.73,1045.611,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 61MM 5HL SS SM 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500503,CDM,C1713,HCPCS,278,RC,,,outpatient,,,406.82,284.774,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 73MM 3.5MM 6HL COMPR SS SM FRAG NS -,SUP-00493500600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,800.56,560.392,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 73MM 6HL SS SM 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.09,296.863,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 85MM 3.5MM 7HL COMPR SS SM FRAG NS -,SUP-00493500700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,822.21,575.547,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 85MM 7HL SS SM 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.09,296.863,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 97MM 3.5MM 8HL 1.1MM COMPR SS SM FRAG NS -,SUP-00493500800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 97MM 3.5MM 8HL SS 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,454.37,318.059,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 109MM 3.5MM 9HL 1.1MM COMPR SS SM FRAG NS -,SUP-00493500900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,887.1,620.97,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 121MM 3.5MM 10HL 1.1MM COMPR SS SM FRAG NS -,SUP-00493501000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,908.74,636.118,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 74MM 3.5MM HLX3/5 HD/SHFT 1.5MM SS T-SHP OBLQ SM -,SUP-00493503505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1100.65,770.455,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
"PLATE Z ""T"" 4 HOLE 3.5MM -",SUP-00493504404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,714.03,499.821,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 68MM 3.5MM UNIV LCK SYS 5HL LCK SS 1/3 TBLR NS -,SUP-00493600503,CDM,C1713,HCPCS,278,RC,,,outpatient,,,952.04,666.428,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 94MM 3.5MM UNIV LCK SYS 7HL LCK SS 1/3 TBLR NS -,SUP-00493600703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1016.92,711.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 107MM 3.5MM UNIV LCK SYS 8HL LCK SS 1/3 TBLR NS -,SUP-00493600803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.22,742.154,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 105MM 3.5MM UNIV LCK SYS 8HL CONTR LCK DL COMPR SS -,SUP-00493600807,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1867.15,1307.005,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 105MM 3.5MM UNIV LCK SYS 8HL RECON LCK SS NS -,SUP-00493600813,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2566.79,1796.753,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 133MM 3.5MM UNIV LCK SYS 10HL LCK SS 1/3 TBLR LRG -,SUP-00493601003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.81,757.267,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 116MM 4.5MM 6HL SHFT SS T-SHP LRG FRAG NS -,SUP-00494500604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1316.86,921.802,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE Z 4.5 COMP B 12 HOLE -,SUP-00494501201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1356.19,949.333,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
KT MIXER BNCMNT VAC MX 35ML LNG CQ/NOZ FNL CHRCL FLTR SUCT -,SUP-00504903501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,811.07,567.749,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
KT MIXER BNCMNT VAC MX 45ML LNG CQ/NOZ FNL CHRCL FLTR SUCT -,SUP-00504904501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,905.01,633.507,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WIRE PACK .028 SPADE TIP -,SUP-00505004100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,49.89,34.923,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFT HUM TIS 11MM CHONDROFIX OSTCHND LF -,SUP-00560402011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15111.91,10578.337,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFT BN 15MM CHONDROFIX LF -,SUP-00560402015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15891.64,11124.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 48MM HD UNICMPT SS F/HI FLEX SYS -,SUP-00579104100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.77,258.139,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 48MM HD UNICMPT SS F/HI FLEX SYS -,SUP-00579104100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
HOLDER IMPL HDLS 48MM SS GOLD F/UNICMPT HI FLEX KN SPCR BLCK -,SUP-00579104200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEX HEAD 3.5MM -,SUP-00-5901-035-27,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEX HEAD 3.5MM X 48MM -,SUP-00-5901-035-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FLEX LCK -,SUP-00595409000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
EXTENSION STM MG2 PS TIV ALY PLG TAPR KN -,SUP-00596009900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDE SURG NEXGEN F/UNICMPT KN ARTHPL TIB PT SPEC INST HI.. -,SUP-00597000001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDE SURG NEXGEN F/UNICMPT KN ARTHPL TIB PT SPEC INST HI -,SUP-00597000002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO PERSONA CRUCIF RCESS -,SUP-00597000025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BASEPLATE TIB SZ1 58/40MM KN STM NEXGEN TIV ALY PMMA UHMWPE -,SUP-00598002701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP TIBPLT SZ2 62/41MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598002702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP TIBPLT SZ3 66/42MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598003701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP TIBPLT SZ3 66/42MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598003701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8452.1,5916.47,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP TIBPLT SZ4 66/46MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598003702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP TIBPLT SZ5 74/46MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598004701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP TIBPLT SZ6 74/50MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598004702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP TIBPLT SZ7 82/51MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598005701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW AUG 48MM TIV HX HD F/ARTHPL NEXGEN STRL DIST FEM KN -,SUP-00598304048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP TIBTRY SZ3 66/42MM KN CMNT STM WDG NEXGEN TIV PMMA CR -,SUP-00598800300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10515.22,7360.654,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP TIBTRY SZ4 66/46MM KN CMNT STM WDG NEXGEN TIV PMMA CR -,SUP-00598800400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10515.22,7360.654,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP TIBTRY SZ5 74/46MM KN CMNT STM WDG NEXGEN TIV PMMA CR -,SUP-00598800500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10515.22,7360.654,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DEVICE 11X4X11MM TM-S 7DG TM -,SUP-00610101041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10526.36,7368.452,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER 11X14X29MM VBR-11 TM -,SUP-00611100292,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15891.64,11124.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ACTB 6.5X15MM TRILOGY TIV CNTRSNK HEAD ST -,SUP-00625006515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE SELF TAPPED 6.5 X 20 -,SUP-00-6250-065-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE SCREW 6.5X25 SELF-TAP -,SUP-00-6250-065-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE SELF TAP 6.5 X 30 -,SUP-00-6250-065-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ACTB 6.5X35MM TRILOGY TIV CNTRSNK HEAD ST -,SUP-00625006535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 6.5 X 40 SELF TAP -,SUP-00625006540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ACTB 6.5X40MM TRILOGY TIV CNTRSNK HEAD ST -,SUP-00625006540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 6.5X40 SELF-TAP -,SUP-00-6250-065-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE SCREW 6.5 X 50MM SELF TAP -,SUP-00625006550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 6.5 X 50 SELF-TAP -,SUP-00-6250-065-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LINER 56 X 32  TRILOGY LONGEVITY CONSTRAINED -,SUP-00-6334-056-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14191.09,9933.763,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HGP ACETABULAR CUP BONE SLF TP 6.5 X 20 -,SUP-00662406520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HGPAETABULAR CUP BONE SLF TP 6.5 X 30 -,SUP-00662406530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUBSTITUTE BVN SPNG 1ML STRIP FIL COPIOS 10X20MM 5MM -,SUP-00700582001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1934.68,1354.276,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 2MMX45CM TRIMAX NANCY TI ALY E CAP -,SUP-00800620450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1462.94,1024.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLUG ACTB DOME HL HIP CONTIN -,SUP-00875700001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,379.28,265.496,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
HEAD BIOLOX OPT FEM 32MM/+3.5MM DELTA -,SUP-00-8777-032-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8566.51,5996.557,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SIDUS STEM-FREE SHOULDER HUMERAL ANCHOR M -,SUP-01.04555.120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19121.95,13385.365,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
G7 ACETABULAR SCREW 6.5MM / 20L -,SUP-010000997,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
G7 SCREW 6.5MM X 30MM -,SUP-010000999,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
G7 ACETABULAR SCREW 6.5MM / 35L -,SUP-010001000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
G7 SCREW 6.5MM X 40MM -,SUP-010001001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ENDOBUTTON 013186 -,SUP-013186,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.2,778.54,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BASE SLDR GFT F/ACL /PCL GRAFTMS II -,SUP-014950,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3100.9,2170.63,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL FLEXIBLE PRE CURVED 1.50MM X 300MM -,SUP-0194-1500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL FLEXIBLE PRE CURVED 1.75MM X 300MM -,SUP-0194-1750S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.66,795.662,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL FLEXIBLE PRE CURVED 2.25MM X 300MM -,SUP-0194-2250S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1104.62,773.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL FLEXIBLE PRE CURVED 2.5MM X 450MM -,SUP-0194-2500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.59,822.213,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL FLEXIBLE PRE CURVED 3.5MM X 450MM -,SUP-0194-3500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1240.32,868.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL FLEXIBLE PRE CURVED 4.0MM X 450MM -,SUP-0194-4000S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1276.36,893.452,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL FLEXIBLE PRE-CURVED 2.25 X 300MM -,SUP-0195-2250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1104.62,773.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL FLEXIBLE PRE CURVED 2.5 X 450MM -,SUP-0195-2500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.59,822.213,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LCP 158MM 3.5MM 6HL FA LC CONTR LCK COMPR SS TAPR -,SUP-02.104.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5487.49,3841.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN_VA-LCP 45MM 2.4MM HLX6/2 HD/SHFT CLMNX2 VAR ANG LCK -,SUP-02.111.621,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5084.31,3559.017,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.7/3.5 VA ANTEROLAT DSTL TIB PL/10 H/RT -,SUP-02.118.208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10401.04,7280.728,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7 METAPHYSEA SLF-TPNG T8 SD REC/48 -,SUP-02.118.548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7 METAPHYSEA SLF-TPNG T8 SD REC/50 -,SUP-02.118.550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.7 VA LOCKING ANT PATELLA PL SS CORE SILE -,SUP-02.137.003S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11077.74,7754.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7 VA LOCKING SLF-TPNG T8 SD REC 10 -,SUP-02.211.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 12 -,SUP-02.211.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 16 -,SUP-02.211.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 18 -,SUP-02.211.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.7 VA LCKNG SCR SLF-TPNG T8 SD REC 36 -,SUP-02.211.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.7 VA LCKING SCR SLF-TPNG T8 SD REC 38 -,SUP-02.211.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 40 -,SUP-02.211.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7 VA LCKING SLF-TPNG T8 SD REC 42 -,SUP-02.211.042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.7 VA LCKNG SCR SLF-TPING T8 SD REC 46 -,SUP-02.211.046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.7MM VA LCKNG SCREW SLF-TPNG WITH T8 60MM -,SUP-02.211.060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE FUSION CLOVERLEAF SHORT 2.4/2.7 VA-LCP -,SUP-02.211.250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8683.22,6078.254,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAP FEM NCB LCK -,SUP-0203150300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,930.39,651.273,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PRESSURIZER BNCMNT PROX FEM MED -,SUP-0206-545-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.66,71.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FEM PRESSURIZING SEAL - MED -,SUP-0206-546-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.66,71.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN BIOSTEON 7X23MM FT BABSRB WDG SHP HAP PLLA -,SUP-0234-010-161,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN BIOSTEON 8X28MM FT BABSRB WDG SHP HAP PLLA -,SUP-0234-010-167,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR BIOSTEON 10X35MM INTFR HAP PLLA -,SUP-0234-010-178,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CROSS TITANIUM 8MM X 60MM -,SUP-0234500160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,885.69,619.983,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SYNFLATE BALLOON MED -,SUP-03.804.701S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DEVICE TK TI KNOT 5MM -,SUP-030404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1161.17,812.819,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE FUSION 2.4/2.7MM TI VA-LCP TMT -,SUP-04.211.266,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7524.61,5267.227,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN MATRIXRIB 17HL PRCONT TI NS ROSE RD -,SUP-04.501.006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7312.41,5118.687,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN MATRIXRIB 18HL 1.5MM PRCONT LCK TI NS LBLU -,SUP-04.501.007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8297.02,5807.914,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN MATRIXRIB 18HL PRCONT LCK TI NS ROSE RD -,SUP-04.501.008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7312.41,5118.687,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN MATRIXRIB 8HL PRCONT TI UNIV NS GOLD -,SUP-04.501.009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5653.01,3957.107,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.9X10MM LCK MATRIXRIB ST TI NS GOLD.. -,SUP-04.501.020.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1309.22,916.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.9X10MM LCK MATRIXRIB ST TI NS GOLD. -,SUP-04.501.020.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1147.03,802.921,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.9X12MM LCK MATRIXRIB ST TI NS GOLD -,SUP-04.501.022.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1309.22,916.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.9X14MM LCK MATRIXRIB ST TI NS GOLD -,SUP-04.501.024.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1150.21,805.147,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT ZERO-P IMP 8MM LORDOTIC STERILE -,SUP-04.617.128S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11510.3,8057.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT ZERO-P IMP 9MM LORDOTIC STERILE -,SUP-04.617.129S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11510.3,8057.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 3.0MM X 14MM TI CERVICAL SPINE -,SUP-04.617.814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
KT BONE CMNT SPINEPLEX -,SUP-0406-202-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1455.25,1018.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CEMENT BN 20GM VERTAPLEX DMSTC DUEL -,SUP-0406-402-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1853.05,1297.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PCD SYSTEM-LONG 90DEG TUBE W/VERTAPLEX -,SUP-0507-486-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2470.55,1729.385,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PCD PREC SYS LONG TUBE W/VHV -,SUP-0507-586-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2470.55,1729.385,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8X70MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-05080000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
KT BONE CMNT AUTOPLEX STRL -,SUP-0605-687-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3912.53,2738.771,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED TI 6.5X 110MM,SUP-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.94,757.358,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 2MM -,SUP-1007-1200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUSTAIN SPACE SMALL - 11MM -,SUP-101.111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUSTAIN SPACER SMALL NARROW 11MM -,SUP-101.711,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE ROD 5.5 X 250MM -,SUP-10-1025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X14MM CORT/CANC SS NS F/DMD CRPL FUSION PLATE -,SUP-1011602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,651.19,455.833,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X16MM CORT/CANC SS NS F/DMD CRPL FUSION PLATE -,SUP-1011603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,651.19,455.833,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X18MM CORT/CANC SS NS F/DMD CRPL FUSION PLATE -,SUP-1011604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,651.19,455.833,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SET SCREW -,SUP-1020-00-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.0 PLY 3.5 X 24MM SYMPHONY -,SUP-1020-035-124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X100MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.0 PLY 3.5 X 14MM SYMPHONY -,SUP-1020-35-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.0 PLY 3.5 X 16MM SYMPHONY -,SUP-1020-35-116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.0 PLY 3.5 X 18MM SYMPHONY -,SUP-1020-35-118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.0 PLY SCREW 3.5 X 20 -,SUP-102035120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.0 PLY 4.0 X 14MM SYMPHONY -,SUP-102040114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD TI 4.0 X 070 LOR -,SUP-102064070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD TI 4.0 X 075 LOR -,SUP-102064075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TI 4.0 X 090 LOR ROD -,SUP-102064090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X65MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X75MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X85MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER 12X8X27MM LUCENT LRDTC CRV PEEK -,SUP-10227-008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER 12X9X27MM LUCENT LRDTC CRV PEEK -,SUP-10227-009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER 12X11X27MM LUCENT LRDTC CRV PEEK -,SUP-10227-011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11695.95,8187.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN F /FUSSION SS SM NS -,SUP-1024002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7238.14,5066.698,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT ULFX MICROMITE SZ2-0 2.7MM BRD PLYSTR -,SUP-10301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1633.77,1143.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CHIP CANCELLOUS BONE 5CC 1-8 C -,SUP-103015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CREO AMP 5.5 X 50MM -,SUP-1067.1550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CREO AMP 5.5 X 45MM MOD CAN -,SUP-1067.4545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MODULAR CANNULATED 6.5 X 40MM CREO AMP -,SUP-1067.4640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD CURVED TIT ALLOY 4.75MM X 35MM -,SUP-1067.7035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD CURVED TIT ALLOY 4.75MM X 40MM -,SUP-1067.7040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ONLAY LYOPLANT 7.5 X 7.5CM -,SUP-1067040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4108.41,2875.887,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FILLER 10ML OSTEOSPONGE -,SUP-109510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4081.77,2857.239,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FILLER CANC TRBCLR DBM 15ML CHP OSTEOSPONGE ELAS OSTCONDC -,SUP-109515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FILLER DEMIN CANC BN 5ML CHP OSTEOSPONGE ELAS OSTCONDC -,SUP-109550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFT DEMIN CANC BN BLCK 14MM OSTEOSPONGE ELAS OSTCONDC -,SUP-109614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3437.28,2406.096,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUBSTITUTE CORT FBR 10CC 3DEMIN -,SUP-109760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T15 LP CORT 3.5 X 20MM NS -,SUP-110017720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T15 LP CORT 3.5 X 22MM NS -,SUP-110017722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T15 LP CORT 3.5 X 24MM NS -,SUP-110017724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T15 LP CORT 3.5 X 26MM NS -,SUP-110017726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T15 LP CORT 3.5 X 30MM NS -,SUP-110017730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T15 LP CORT 3.5 X 32MM NS -,SUP-110017732,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T15 LP CORT 3.5 X 34MM NS -,SUP-110017734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T15 LOW PROFILE CORT 3.5 X 36MM NS -,SUP-110017736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T15 LOW PROFILE CORT 3.5  X 38MM NS -,SUP-110017738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T15 LOW PROFILE CORT 3.5 X 40MM NS -,SUP-110017740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T15 LP CORT 3.5 X 44 NS -,SUP-110017744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T15 MD 3.5 X 28MM NS -,SUP-110018028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T15 LOCK MULTIDIRECTIONAL 3.5 X 34MM NS -,SUP-110018034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T15 MULTIDDIRECTIONAL 3.5 X 38MM NS SILVER -,SUP-110018038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T15 MULTIDIRECTIONAL 3.5 X 40MM NS SILVER -,SUP-110018040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T15 MULTIDIRECTIONAL 3.5 X 42MM NS SILVER -,SUP-110018042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T15MD 3.5 X 46MM NS -,SUP-110018046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T15 MD 3.5 X 52MM NS -,SUP-110018052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.2MM PEG 20MM -,SUP-110025320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.2MM PEG 24MM -,SUP-110025324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG FIXATION 3.2 X 26MM -,SUP-110025326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG FIXATION 3.2 X 28MM -,SUP-110025328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.2MM PEGS 30MM -,SUP-110025330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG 3.2 X 32 -,SUP-110025332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEGS 3.2MM X 34MM -,SUP-110025334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG 3.2 X 36MM -,SUP-110025336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG 3.2MM X 38MM -,SUP-110025338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG 3.5 X 40MM -,SUP-110025340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG 3.2 X 42 -,SUP-110025342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG 3.2MM X 44MM -,SUP-110025344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG 3.2 X 46MM -,SUP-110025346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG 3.2 X 50MM -,SUP-110025350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG 3.2 X 52MM -,SUP-110025352,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG 3.2MM X 54MM -,SUP-110025354,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG 3.2 X 56 -,SUP-110025356,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG 3.2 X 58MM -,SUP-110025358,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.2MM PEG 60MM -,SUP-110025360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG 3.2 X 65MM -,SUP-110025365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PRX HUM LO LT 3H 73MM -,SUP-110030100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6671.57,4670.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PRX HUM LO PLT LT 7H 133MM -,SUP-110030102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8021.16,5614.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PRX HUM HI PLTLT 3H 80MM -,SUP-110030300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6569.71,4598.797,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PRX HUM HI PLT RT 3H 80MM -,SUP-110030400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6569.71,4598.797,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PRX HUM HI RT 4H 90MM -,SUP-110030401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6824.35,4777.045,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
REFOBACIN BONE CEMENT R 1X14 US -,SUP-110034355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMPR NANO 7IN STEINMANN PIN -,SUP-110045821,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3246.32,2272.424,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFT PLATE CANOPY INLINE 7MM -,SUP-1102.1007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FIXATION VARIABLE ANGLE -,SUP-111655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1457.21,1020.047,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAP SPIN CREO 5.5MM -,SUP-1119.0000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CREO THREADED LOCKING CAP -,SUP-1119.0010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CONNECTOR CROSS 38-50 LONG 5.5 CREO -,SUP-1119.0039,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CREO 5.5 CROSS CONNECTOR 48-60MM LONG -,SUP-1119.0046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TULIP HEAD FOR CORTICAL SCREW -,SUP-1119.0100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CONNECTOR CREO 5.5 LOW PROFILE CROSS  21.5-25MM LONG -,SUP-1119.0221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CREO 5.5 LOW PROFILE CROSS CONN- 24.5-31MM LONG -,SUP-1119.0224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 5.5-4.5X25MM MOD CREO AMP -,SUP-1119.1325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
5.5-4.5 X 30MM CREO MCS SCREW -,SUP-1119.1330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5 4.5 X 35MM CORTICAL MODULAR CREO AMP -,SUP-1119.1335,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 6.0-5.0 X 30ML -,SUP-1119.1430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
6.0-5.0 X 35MM CORTICAL SCREW -,SUP-1119.1435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORITICAL 6.5-5.5X35MM -,SUP-1119.1535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 6.5-5.5X35MM -,SUP-1119.1535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 5.5 X 35 TITANIUM ALLOY -,SUP-1119.5035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD STRAIGHT 5.5MM X 40 -,SUP-1119.5040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD TITANIUM ALLOY 5.5 X 45 STRAIGHT -,SUP-1119.5045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 150MM -,SUP-1119.5150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN CREO 5.5X35MM CRV TI ALY THORLUM -,SUP-1119.7035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
5.5MM CURVED ROD TITANIUM ALLOY 40MM LENGTH -,SUP-1119.7040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD CREO 5.5X40MM -,SUP-1119.7040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD CURVED 5.5MM TITANIUM ALLOY 45MM LENGTH -,SUP-1119.7045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN CREO 5.5X50MM CRV TI ALY THORLUM -,SUP-1119.7050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN CREO 5.5X55MM CRV TI ALY THORLUM -,SUP-1119.7055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD CURVED 5.5MM TITANIUM ALLOY 60MM LENGTH -,SUP-1119.7060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 5.5MM CURVED TIT ALLOY 65MM -,SUP-1119.7065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD CURVED 5.5MM TITANIUM ALLOY 70MM LENGTH -,SUP-1119.7070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD CURVED 5.5MM TITANIUM ALLOY 80MM LENGTH -,SUP-1119.7080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK EXPLOR TI ALY -,SUP-11-210099,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PELVIC ARRAY -,SUP-112230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5393.06,3775.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
STEM TPR DIST SPR 14 X 150MM ARCOS -,SUP-11-300814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
STEM TPR DIST SPR 16 X 150MM ARCOS -,SUP-11-300816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAP LOCKING CREO MIS -,SUP-1134.0010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TULIP MODULAR POLYAXIAL 30MM REDUCTION CREO MIS -,SUP-1134.0100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD CURVED 5.5MM X 50MM TITANIUM ALLOY CREO MIS -,SUP-1134.7050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
HEAD MOD 36MM COCR STD -,SUP-11-363662,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP 44MM GLOBAL AP SHLDR 3MM XLPE PG -,SUP-1136-41-026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8667.95,6067.565,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP 52MM GLOBAL AP SHLDR 3MM XLPE PG -,SUP-1136-43-026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10652.6,7456.82,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
MITRIS RESILIA MITRAL VALVE 25MM -,SUP-11400M25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
MITRIS RESILIA MITRAL VALVE 27MM -,SUP-11400M27,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
MITRIS RESILIA MITRAL VALVE 29MM -,SUP-11400M29,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
MITRIS RESILIA MITRAL VALVE 31MM -,SUP-11400M31,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
THUMBSCREW FOR C501 ROCHE CUVETTE -,SUP-11406701001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,140.74,98.518,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX100MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT NS. -,SUP-1147-100-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5MMX100MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUTNS.. -,SUP-1147-100-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 3.2X353MM THRD -,SUP-115163,CDM,C1713,HCPCS,278,RC,,,outpatient,,,307.85,215.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW COMP RVS CONTROL 6.5 X 20MM ST -,SUP-115380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW COMP RVS CONTROL 6.5 X 30MM ST -,SUP-115382,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X35MM CORT RVRS CNTRL 3.5MM HEX DRV HEX HEAD TI ALY -,SUP-115383,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP RVS CNTRL 6.5 X 20MM ST/RST -,SUP-115394,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP RVS CNTRL 6.5 X 25MM ST/RST -,SUP-115395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X25MM CORT RVRS CNTRL 3.5MM HEX DRV HEX HEAD TI ALY -,SUP-115395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
6.5 X 30MM CENTRAL SCREW -,SUP-115396,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
REVERSE CENTRAL SHOULDER SCREW 3.5MM X 35MM -,SUP-115397,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP RVS CNTRL 6.5 X 40MM ST/RST -,SUP-115398,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP RVS CNTRL 6.5 X 45MM ST/RST -,SUP-115399,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER ANT THORLUM VERT 14MMX15-18MMH XPAND 0DG SM 12MM OPN -,SUP-116.101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14881.7,10417.19,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER ANT THORLUM VERT 21X23MMX37-46MM XPAND 0DG MED OPN TI -,SUP-116.207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16864.45,11805.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER ANT THORLUM VERT 21X23MMX49-70MM XPAND 0DG MED OPN TI -,SUP-116.208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16864.45,11805.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CATH ANGIOPLASTIC MARINER BERENSTEIN 4FR 100CM -,SUP-11714016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SING HEAD OPEN LAT CONN 5.5-6.0 HEAD-5.5-6.35 OPEN 12MM WIDE -,SUP-1175.9214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7265.73,5086.011,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN MOUNTAINEER 3.5-5.5X420MM CRV TI OCT LVL1 NS -,SUP-1183-11-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR LD SWIFT- LOCK SPIN CRD MECH LCK -,SUP-1192,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM-THRD -,SUP-121107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM THRD_ -,SUP-121108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM THRD- -,SUP-121109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM THRD. -,SUP-121110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 19MM COMPR LAG AMBI CLASSIC IMHS 21MM THRD STD 3.5MM -,SUP-121116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,781.07,546.749,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
12MM ROD -,SUP-12-1120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X25MM CANN 19MM THRD SD/ST REVCT FLUT SS -,SUP-121625,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X30MM CANN 16MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X35MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121627,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X40MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X45MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121629,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X50MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X55MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121631,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X60MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X65MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121633,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X70MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X75MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X80MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X85MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121637,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X90MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5 CANNULATED 9.5 -,SUP-121639,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X100MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X105MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121641,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X110MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X115MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121643,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X120MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO 6.5X12.7MM F/7MM CANN BN SCR RND STRL -,SUP-121680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.23,451.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ACTB 6.5X30MM GRIFTON PINNCL LCK TI FOAM DOME ST -,SUP-1217-30-500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,537.46,376.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX10MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX12MM CANN 5MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX14MM CANN 5MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX16MM CANN 6MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX18MM CANN 7MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX22MM CANN 9MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX24MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX26MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX28MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX30MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121830,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX32MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX34MM CANN 14MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121834,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX36MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121836,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX38MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121838,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX40MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX42MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121842,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX44MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121844,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX46MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX48MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121848,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX50MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121850,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX52MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121852,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX54MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121854,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX56MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121856,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX58MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121858,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED 4.0M X 60M -,SUP-121860,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX65MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX70MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121870,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
30MM CROSSLINK -,SUP-12-2052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CATALYST R1 6.5MM CENTER SCREW AND CAP SIZE 30 -,SUP-1230-7508-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CATALYST R1 4.5MM LOCKING SCREW SIZE 20 -,SUP-1230-7511-003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CATALYST R1 4.5MM LOCKING SCREW SIZE 24 -,SUP-1230-7511-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CATALYST R1 GLENOSPHERE LOCKING SCREW IMPLANT -,SUP-1230-7515-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LINER INSERT MDM X3 22.2MM ID X 36MM OD X 36C -,SUP-1236-2-242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ENDCAP SPIN REVERE -,SUP-124.000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
REV LOW PROF ADJ T-CONN 29 X 34 -,SUP-124.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X25MM REVERE DBL LD THRD POLYAX F/5.5MM TI -,SUP-124.051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X30MM REVERE DL HEAD THRD POLYAX F/5.5MM TI -,SUP-124.052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI -,SUP-124.053,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X35MM REVERE DEFRM MONOAX -,SUP-124.263,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X40MM REVERE DEFRM MONOAX -,SUP-124.264,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5X35MM REVERE DEFRM MONOAX -,SUP-124.273,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X30MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.443,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.5MM REVERE PEDICLE SCREW 45MM -,SUP-124.445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X30MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.452,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.453,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X40MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.454,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X45MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X50MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.456,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X55MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.457,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X30MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.462,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.463,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X40MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.464,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X45MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X50MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.466,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X55MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.467,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X60MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.468,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X65MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.469,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5X40MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.474,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN REVERE DEFRM 5.5X100MM STR TI LPRO THORLUM NTHRD -,SUP-124.510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
5.5MM STRAIGHT ROD 125MM -,SUP-124.512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN REVERE DEFRM 5.5X150MM STR TI LPRO THORLUM NTHRD -,SUP-124.515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
5.5MM STRAIGHT ROD 400MM -,SUP-124.520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD STRAIGHT 5.5 X 500 -,SUP-124.521,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN REVERE DEFRM 5.5X45MM STR TI LPRO THORLUM NTHRD LCK -,SUP-124.545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN REVERE DEFRM 5.5X85MM STR TI LPRO THORLUM NTHRD LCK -,SUP-124.585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
5.5MM CURVED ROD 125MM -,SUP-124.612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN REVERE DEFRM 5.5X35MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN REVERE DEFRM 5.5X40MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN REVERE DEFRM 5.5X45MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN REVERE DEFRM 5.5X50MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN REVERE DEFRM 5.5X55MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN REVERE DEFRM 5.5X60MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN REVERE DEFRM 5.5X65MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN REVERE DEFRM 5.5X75MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6MM DL OD 35MM REVERE POLYAX CORT/CANC F/5.5MM TI ALY -,SUP-124.762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6MM DL OD 40MM REVERE POLYAX CORT/CANC F/5.5MM TI ALY -,SUP-124.763,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CONNECTOR ROD REVERE 5.5MM VARIABLE CROSS 38MM-50MM -,SUP-124.984,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3327.48,2329.236,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
5.5MM CLOSED OFFSET CONNECTOR 5.5MM ROD 30MM -,SUP-124.993,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ELIMINATOR ACTB THRD POS STP F/CUP DURALOC -,SUP-1246-03-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
OSTEOAMP GRANULES 1CC -,SUP-12600201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2340.97,1638.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
OSTEOAMP GRANULES 5CC -,SUP-12600401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4725.27,3307.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
OSTEOAMP GRANULES 10CC -,SUP-12600501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7875.46,5512.822,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
OSTEOAMP GRANULES 2-4MM (5CC) -,SUP-12700401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4587.68,3211.376,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 1.3MMX15CM THRD TROC TIP -,SUP-128047,CDM,C1713,HCPCS,278,RC,,,outpatient,,,305.64,213.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
STAPLE BN FX XS COCR -,SUP-128690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2676.59,1873.613,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
STAPLE BN FX SM COCR -,SUP-128692,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2676.59,1873.613,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
RESTRICTOR BNCMNT FMCNL 25MM BUCK -,SUP-129419,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1159.24,811.468,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
UNITED HIP SYSTEM FULL XPE CUP 36MM X 54MM -,SUP-1302-3654,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
STAPLE SPIN RSTRL SM TI -,SUP-131.001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4759.68,3331.776,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
STAPLE SPIN CDL SM TI -,SUP-131.002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4759.68,3331.776,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
STAPLE SPIN ANT VERT SM TI -,SUP-131.011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3413.41,2389.387,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CONNECTOR SPIN REVERE DL CX 15MM TI -,SUP-131.115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CONNECTOR SPIN CX TI -,SUP-131.116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X35MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X40MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X18MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X24MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN TMX 12.9MMX43.7MM COMPR HI STRGTH 2D CONTR LCK Y -,SUP-1312-17-003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2534.99,1774.493,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN F 3 13MMX42.7MM HI FLEX 3D CONTR LCK NS RT -,SUP-131217100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2778.47,1944.929,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN F 3 13MMX42.7MM HI FLEX 3D CONTR LCK NS LT -,SUP-131217101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2778.47,1944.929,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO 3.5MM ALPS F/ELB PLATE SYS NS -,SUP-131218000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X14MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X16MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X28MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X30MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X36MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X40MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X44MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X48MM NLCKG CORT ALPS TRNCT SQ DRV TMX NS -,SUP-131218048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X50MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X60MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X70MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 10.7X85MM 9HL 2.4MM CONTR LCK TMX ANTMC -,SUP-131218203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 17.5X29MM 1.5MM CONTR LCK TMX SM ANTMC NS -,SUP-131218400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3637.79,2546.453,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN SM -,SUP-1312-18-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4024.48,2817.136,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 81X10IN 10HL CONTR LCK COMPR TMX SM ANTMC NS -,SUP-131218600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 10.7X154MM 17HL 2.5MM CONTR LCK COMPR TMX LNG -,SUP-131218607,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4481.66,3137.162,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO 2.5MM ALPS THRD -,SUP-131220025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 2.5MM PRCONT LCK COMPR TMX T-SHP ANTMC NS -,SUP-131220152,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2353.42,1647.394,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 2.5MM PRCONT LCK COMPR TMX SM T-SHP ANTMC NS -,SUP-131220157,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2099,1469.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 2.5MM PRCONT LCK COMPR TMX STR ANTMC NS -,SUP-131220251,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2448.83,1714.181,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 27.6MMX73.8MM 2.5MM 1.65MM PRCONT LCK COMPR -,SUP-131220252,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2448.83,1714.181,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 19.5MMX71.8MM 2.5MM 1.65MM PRCONT LCK COMPR -,SUP-131220253,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2448.83,1714.181,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X11MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X14MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X15MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220415,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X16MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X12MM NLCKG CORT ALPS ST MULDIR MODULAR SQ DRV TMX -,SUP-131220512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X14MM NLCKG CORT ALPS ST MULDIR MODULAR SQ DRV TMX -,SUP-131220514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X15MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X16MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X18MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X20MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.7X18MM LCK SMTH DVR -,SUP-131227118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X20MM LCK CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X22MM LCK CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X14MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X15MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227215,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X16MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X26MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227226,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN DVR 24X85MM F/CROSSLOCK DIST RAD PLATE SYS LNG LCK -,SUP-131812090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4558.06,3190.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN MARS 5.5X45MM CRV CONE TIP TI ANT LMBR -,SUP-132.145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4334.79,3034.353,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN MARS 5.5X50MM CRV CONE TIP TI ANT LMBR -,SUP-132.150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN MARS 5.5X55MM CRV CONE TIP TI ANT LMBR -,SUP-132.155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4334.79,3034.353,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN MARS 5.5X60MM CRV CONE TIP TI ANT LMBR -,SUP-132.160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW REVIEVE 2.2MM X 6MM SELF TAPPING -,SUP-136.506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1235.02,864.514,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FEMORAL HEAD BIOLOX 32MM +5 12 -,SUP-1365-32-720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5432.32,3802.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FEMORAL HEAD BIOLOX DELTA TS CERAMIC  36MM +1.5 12/14 TAPER -,SUP-1365-36-710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5432.32,3802.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CERAMIC FEMORAL HEAD 40MM X 1.5 BIOLOX DELTA TS -,SUP-1365-40-710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FORTIFY I 12MM UPPER ENDPLATE 12 X 14MM 0 DEG -,SUP-137.300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FORTIFY I 12MM UPPER ENDPLATE 12 X 14MM 3.5 DEG -,SUP-137.301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FORTIFY I 12MM LOWER ENDPLATE 12 X 14MM 0 DEG -,SUP-137.350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FORTIFY I 12MM LOWER ENDPLATE 12 X 14MM 3.5 DEG -,SUP-137.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FORTIFY I 12MM LOWER ENDPLAE 12 X 14MM 3.5 DEG -,SUP-137.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
KT BONE CMNT 2.5% GENT40 GM CEMEX GENTA RX STRL -,SUP-1400-AG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 3.2MM STNMN 14IN THRD -,SUP-14012-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,213.27,149.289,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 3.2MMX9IN THRD -,SUP-140129,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X52MM CORT VERSANAIL FT ST NON-DRV END SLD HEX HEAD -,SUP-14022-52,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW AUTOFIX 2.0 X 10MM -,SUP-141-2010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW  AUTOFIX 2.0 X 12MM -,SUP-141-2012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
AUTOFIX HEADLESS SCREW 2.0 X 13 -,SUP-141-2013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW AUTOFIX HEADLESS 2.0 X 13 -,SUP-141-2013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW AUTOFIX HEADLESS 2.0 X 14 -,SUP-141-2014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED 2.0 X 15MM -,SUP-141-2015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW AUTOFIX 2.0 X 16 -,SUP-141-2016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X17MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD MOD -,SUP-1412017,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X18MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD MOD -,SUP-141-2018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED 2.0 X 19MM -,SUP-141-2019,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW AUTOFIX COMPRESSION 2.0 X 20MM -,SUP-141-2020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW AUTOFIX 2.0 X 21MM -,SUP-141-2021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW AUTOFIX 2.5 X 23MM -,SUP-141-2023,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW AUTOFIX 2.5 X 24MM -,SUP-141-2024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
AUTOFIX SCREW 2.0 X 25MM -,SUP-141-2025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW AUTOFIX 2.0 X 26MM -,SUP-141-2026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW AUTOFIX 2.5 X 28MM -,SUP-141-2028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
AUTOFIX 2.0 X 29MM SCREW -,SUP-141-2029,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW AUTOFIX COMPRESSION 2.0 X 30MM -,SUP-141-2030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW AUTOFIX 2.5 X 10 -,SUP-141-2510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW AUTOFIX HEADLESS 2.5 X 14 -,SUP-141-2514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED 25 X 15MM -,SUP-141-2515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
AUTOFIX 2.0/2.5 16MM -,SUP-141-2516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS 2.5 X 17MM -,SUP-141-2517,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW AUTOFIX 2.5 X 18MM -,SUP-141-2518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW AUTOFIX 2.5 X 19 -,SUP-141-2519,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW AUTOFIX 2.5 X 21MM -,SUP-141-2521,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
AUTOFIX 2.0/2.5 23MM -,SUP-141-2523,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X24MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD -,SUP-1412524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS 2.5 X 25MM -,SUP-141-2525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS 2.5 X 26MM -,SUP-141-2526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
AUTOFIX 2.5/2.5 27MM -,SUP-141-2527,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS 2.5 X 28MM -,SUP-141-2528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X30MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD -,SUP-141-2529,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X30MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD -,SUP-1412530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 2.5MM 30MM AUTOFIX STAINLESS STEEL T7 FOOT ANKLE -,SUP-141-2530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO 8MM TI -,SUP-14191,CDM,C1713,HCPCS,278,RC,,,outpatient,,,175.05,122.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8X100MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8X105MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8X110MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8X40MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8X45MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8X50MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8X55MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8X60MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8X65MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8X70MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8X75MM CANN LAG CANC ACE THRD SD/ST CUT FLUTX4 TMX NS -,SUP-14192-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8X85MM CANN LAG CANC ACE 24MM THRD SD/ST CUT FLUTX4 -,SUP-14192-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8X90MM CANN LAG CANC ACE 24MM THRD SD/ST CUT FLUTX4 -,SUP-14192-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8X95MM CANN LAG CANC ACE 24MM THRD SD/ST CUT FLUTX4 -,SUP-14192-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X100MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X105MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X110MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X115MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X120MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X25MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X30MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X35MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X40MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X45MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X50MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X55MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X60MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X65MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X70MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X75MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X80MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X85MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X90MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X95MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X100MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X105MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT -,SUP-14197-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X110MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT -,SUP-14197-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X40MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X45MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X50MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X55MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X60MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X65MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X70MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X75MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X80MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X85MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X90MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X95MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PRECISION PIN TM TAPERED D3.2/3.9X450MM -,SUP-1420-0065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X20MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X22MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X24MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X26MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X28MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X30MM CANNULATEDLAG CORT FT TMX NS -,SUP-14200-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X32MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X34MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X36MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X38MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X40MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X42MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X44MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X46MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X48MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X50MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X55MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X60MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X65MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X70MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X36MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-14223036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X30MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14250-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X32MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X34MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X36MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X38MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X40MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X42MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X44MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X46MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14250-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X48MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14250-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X50MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X55MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X60MM CANN LAG CORT 20MM FT SD/ST BIOCMPT TMX NS -,SUP-14250-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X65MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X70MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO F/4.5-5.0MM CANN SCR SYS FLT -,SUP-14260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,504.67,353.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 10HL 100DG TBLR -,SUP-14355-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,557.3,390.11,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 9.2X49MM 3.5MM 4HL 1.3MM LCK TI 100DG ANG TBLR -,SUP-143554,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 9.2X73MM 3.5MM 6HL LCK COMPR TMX ANTMC THRD HL -,SUP-143556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 9.2X85MM 3.5MM 7HL LCK TI ANTMC NS -,SUP-143557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 9.2X97MM 3.5MM 8HL LCK TI 100DG ANG TBLR ANTMC -,SUP-143558,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X14MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X16MM CANC -,SUP-14376-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,977.89,684.523,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X24MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X34MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-1437634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X40MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X42MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X44MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X46MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X48MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X50MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X55MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X60MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X65MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X70MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE PIN- 4 x 110MM- STERILE (2 Pack) -,SUP-144110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE PIN- 4 x 140MM- STERILE (2 Pack) -,SUP-144140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE PIN- 4 x 170MM- STERILE (2 Pack) -,SUP-144170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER ANT CERV 14X6X12MM SOLITAIRE 12DG LRDTC S/MED -,SUP-14-520506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12505.38,8753.766,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER ANT CERV 14X7X12MM SOLITAIRE 12DG LRDTC S/MED -,SUP-14-520507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12505.38,8753.766,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER ANT CERV 14X9X12MM SOLITAIRE 12DG LRDTC S/MED -,SUP-14-520509,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12505.38,8753.766,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER 10X27X8MM ZYSTON 6DG LRDTC CRV TAPR -,SUP-14-533128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER 10X25X7MM ZYSTON STR CNVX -,SUP-14-534067,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 3.5MM X46MM CANNULATED -,SUP-148.146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.2X13MM PROVIDENCE SD FX-ANG -,SUP-150.013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.2MM X 14MM -,SUP-150.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN PROVIDENCE 12MM 4HL LVL1 TI LCK -,SUP-150.112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN PROVIDENCE 14MM 4HL LVL1 TI LCK -,SUP-150.114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN PROVIDENCE 16MM 4HL LVL1 TI LCK -,SUP-150.116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN PROVIDENCE 18MM 4HL LVL1 TI LCK -,SUP-150.118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANTERIOR CERVICAL PLATE 1-LEVEL -,SUP-150.120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE ANTERIOR CERVICAL 1-LEVEL 22MM PROV -,SUP-150.122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE ANTERIOR CERVICAL 24MM 1 LEVEL PROVIDENCE -,SUP-150.124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANTERIOR CERVICAL PLATE 14MM LORD -,SUP-150.134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN PROVIDENCE 28MM 6HL LVL2 TI LCK -,SUP-150.228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN PROVIDENCE 30MM 6HL LVL2 TI LCK -,SUP-150.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN PROVIDENCE 32MM 6HL LVL2 TI LCK -,SUP-150.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN PROVIDENCE 34MM 6HL LVL2 TI LCK -,SUP-150.234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN PROVIDENCE 36MM 6HL LVL2 TI LCK -,SUP-150.236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CERVICAL ANTERIOR 2-LEVEL 38MM -,SUP-150.238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN PROVIDENCE 45MM 8HL LVL3 TI LCK -,SUP-150.345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN PROVIDENCE 48MM 8HL LVL3 TI LCK -,SUP-150.348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN PROVIDENCE 51MM 8HL LVL3 TI LCK -,SUP-150.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN PROVIDENCE 54MM 8HL LVL3 TI LCK -,SUP-150.354,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN PROVIDENCE 57MM 8HL LVL3 TI LCK -,SUP-150.357,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PROVIDENCE ANTERIOR CERVICAL PLATE 3-LVL 60MM -,SUP-150.360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANTERIOR CERVICAL PLATE 4-LEVEL 69MM -,SUP-150.469,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW PROV 4.6MM FIXED ANGLE SELF DRILL 14MM -,SUP-150.514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.6X16MM PROVIDENCE ST FA TI ALY -,SUP-150.536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.6X18MM PROVIDENCE SD FA TI ALY -,SUP-150.538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.2X12MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.2X13MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.613,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.2X14MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.2X15MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.2X16MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SELF DRILLING 4.6MM X 12MM VAR ANGLE PROV -,SUP-150.712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.6X13MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.713,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.6X14MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.6X16MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SELF DRILLING 4.2MM X 12MM VAR ANGLE PROV -,SUP-150.812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PROVIDENCE 4.2MM VARIABLE ANGLE SCREW SELF-TAP 14MM -,SUP-150.814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW PROVIDENCE 4.6MM VARIABLE ANGLE 16MM SELF TAPPING -,SUP-150.816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW PROVIDENCE 4.2MM VARIABLE ANGLE - 20MM -,SUP-150.820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TRNSCONN 4.6X12MM PROVIDENCE ST VAR ANG TI ANT CERV -,SUP-150.912,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.6X14MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.914,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.6X15MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.915,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.6X16MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.916,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.6X18MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.918,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SELF TAPPING 4.6 X 20 VAR ANGLE PROV -,SUP-150.920,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
OSS POLY LOCK PIN -,SUP-150478,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1865.78,1306.046,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FORTIFY 12MM CORE HEIGHT 21-29MM -,SUP-151.052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FORTIFY 12MM CORE HEIGHT 25-37MM -,SUP-151.053,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CORE FORTIFY 012MM HEIGHT 33-53MM -,SUP-151.054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ENDPLATE UPPER 012MM 12X14 FOOTPRINT 3.5 DEG -,SUP-151.323,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ENDPLATE LOWER 012MM 12 X 14 FOOTPRINT 7 DEG FORTIFY -,SUP-151.374,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SYSTEM CLENCH STAPEL 9MM X 7MM -,SUP-152-30907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SYSTEM CLENCH STAPLE 15MM X 12MM -,SUP-152-31512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SYSTEM CLENCH STAPLE 18MM X 18MM -,SUP-152-31818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
STAPLE CLENCH 15MM X 12MM -,SUP-152-41512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BED F/PROC STRECHER UPR FRM ASMB -,SUP-16042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.68,1.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE OSS RS NON MOD LONG 59 -,SUP-161022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20050.2,14035.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN FX STNMN 2MMX9IN SMTH SGL END PLN DMD PT NS -,SUP-1620-609NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21.41,14.987,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN FX STNMN 2.4MMX9IN SMTH SGL END PLN DMD PT NS -,SUP-1624-609NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21.41,14.987,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN FX STNMN 4.8MMX9IN SMTH SGL END PLN DMD PT NS -,SUP-1648-609X,CDM,C1713,HCPCS,278,RC,,,outpatient,,,29.18,20.426,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIBIAL INSERT PS SZ 6 13MM -,SUP-166-5613,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SHELL ACETABULAR ESCALADE 46MM -,SUP-170-0146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ESCALADE EXL LINER +1 28 X 46MM -,SUP-170-2846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
EXPANSION BOLT RECONSTRUCTION PROSTHESIS -,SUP-172-947/38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
MESH SURG 17X22X50MM OVL TI HARMS -,SUP-1741-48-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17992.27,12594.589,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
MESH SURG 17X22X70MM OVL TI HARMS -,SUP-1741-49,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20248.85,14174.195,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
MESH SURG 22X28X70MM OVL TI HARMS -,SUP-1741-52-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20248.85,14174.195,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
MESH SURG 22X28X90MM OVL TI HARMS -,SUP-1741-53-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,24291.37,17003.959,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
MESH SURG 26X33X50MM OVL TI HARMS -,SUP-1741-54-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17992.27,12594.589,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
MESH SURG 26X33X70MM OVL TI HARMS -,SUP-1741-55-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21889.99,15322.993,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER SPIN TI POLY IEXP -,SUP-1754-91-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NUT SPIN TI BOLT SWVL LCK IEXP -,SUP-1754-91-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,543.24,380.268,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 50MM RND 10MM SGL LVL TI -,SUP-1760-10-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17292.37,12104.659,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 50MM RND 12MM SGL LVL TI -,SUP-1760-12-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17292.37,12104.659,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 90MM RND 12MM SGL LVL TI -,SUP-1760-12-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18873.18,13211.226,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 50MM RND 14MM SGL LVL TI -,SUP-1760-14-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17292.37,12104.659,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 90MM RND 14MM SGL LVL TI -,SUP-1760-14-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19307.6,13515.32,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 50MM RND 16MM SGL LVL TI -,SUP-1760-16-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16483.86,11538.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
MESH ROUND 16MM X 90MM SPN -,SUP-1760-16-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19754.09,13827.863,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
MESH SURG 12X23MM DIA 12X14MM OVL TRPZD TI HARMS -,SUP-1762-02-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10345.35,7241.745,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NUT ORTHO DOME TI SWVL F/MONARCH SPN SYS -,SUP-1770-91-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,481.97,337.379,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKNLC 47MM LVL2 TI LPRO -,SUP-1796-02-047,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6079.53,4255.671,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SET SCREW SPIN EXPEDIUM TI POST PDCL THORLUM SQ THRD -,SUP-1797-02-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SET SCREW SPIN EXPEDIUM TI POST PDCL THORLUM SQ THRD -,SUP-1797-02-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
VIPER TI SAI POLY 8X90MM -,SUP-179704890,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5X45MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5X50MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-179712050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5X65MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.35X20MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.35X25MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.35X30MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.35X35MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.35X40MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5 X 25MM POLYAXIAL SI -,SUP-179712525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X40MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X45MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X50MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X30MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X35MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X55MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7X35MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-735,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7X45MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-745,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7X50MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7X55MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
EXP TI POLY SCREW 8 X 40MM -,SUP-179712840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL 8MM X 65MM -,SUP-179712865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN EXPEDIUM 5.5X480MM HEX END TI POST PDCL THORLUM -,SUP-179762480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN EXPEDIUM 5.5X35MM CRV TI POST PDCL THORLUM PRELRD -,SUP-1797-71-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN EXPEDIUM 5.5X40MM CRV TI POST PDCL THORLUM PRELRD -,SUP-1797-71-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD PRE-LODOSED W/LINE 65MM -,SUP-179771065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD PRE-LORDOSED 75MM W/LINE -,SUP-179771075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD PRE-LORDOSED W/LINE 85MM -,SUP-179771085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CONNECTOR 20MM EXPEDIUM LAT OFST OPN F/10MM TI -,SUP-1797-92-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CONNECTOR 50MM EXPEDIUM LAT OFST OPN F/5.5MM TI -,SUP-1797-92-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CONNECTOR 20MM EXPEDIUM OPN F/5.5MM TI ILC -,SUP-1797-97-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X42MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-49-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X46MM TMX CANN RDC HEAD -,SUP-1802-49-046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X30MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X32MM CANN -,SUP-1802-53-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X34MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X36MM CANN -,SUP-1802-53-036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X38MM CANN -,SUP-1802-53-038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X40MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X42MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X44MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X50MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP SCR 5MM CANN LAG P/T SD/ST TMX 55MM -,SUP-1802-53-055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X60MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X65MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X70MM CANN LAG CANC P/T SD/ST SM HEAD TMX -,SUP-1802-53-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X75MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X80MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMSMX85MM CANN LAG CANC PARTIALY THRD SD/ST RDC HEAD -,SUP-1802-53-085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X90MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMSMX95MM CANNULATEDLAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X100MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.75X15MM LCK CMPRHNSV RVRS FX TI ALY HAP CTD BLU -,SUP-180500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.75X20MM NLCKG CMPRHNSV RVRS FX TI ALY HAP CTD GOLD -,SUP-180508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.75X25MM NLCKG CMPRHNSV RVRS FX TI ALY HAP CTD GOLD -,SUP-180509,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.75X15MM LCK CORT FX 3.5MM HEX HEAD TI ALY HAP CTD -,SUP-180550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.75 X 20MM FIXED LOCKING SCREW 3.5MM HEX -,SUP-180551,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP LK SCR 3.5 HEX 4.75 X 25 ST -,SUP-180552,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW COMP LK 3.5 HEX 4.75 X 30 ST -,SUP-180553,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW COMP LK 3.5 HEX 4.75 X 35 ST -,SUP-180554,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP LK SCR 3.5 HEX 4.75 X 40 ST -,SUP-180555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.75X15MM NLCKG CORT VAR ANG 3.5MM HEX HEAD TI ALY HAP -,SUP-180557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.75X20MM NLCKG CORT VAR ANG 3.5MM HEX HEAD TI ALY HAP -,SUP-180558,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.75X25MM NLCKG CORT VAR ANG 3.5MM HEX HEAD TI ALY HAP -,SUP-180559,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP NLK SCREW 3.5 HEX 4.75 X 30 ST -,SUP-180560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.75X35MM NLCKG CMPRHNSV 3.5MM HX HEX HEAD TMX HAP CTD -,SUP-180561,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
K-WIRE- STERILE 3 x 285MM -,SUP-1806-0050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,459.86,321.902,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
STRYKER PLATE -,SUP-1806-0150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,793.85,555.695,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X320MM VERSANAIL CANN FEM TI ALY -,SUP-1813-10-320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7410.02,5187.014,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X400MM VERSANAIL CANN RT TROCH FEM TI ALY -,SUP-1814-13-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10160.14,7112.098,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 7X220MM VERSANAIL CANN HUM TI ALY -,SUP-1817-07-221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 8X200MM VERSANAIL CANN HUM TI ALY -,SUP-1817-08-201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 9X260MM VERSANAIL CANN HUM TI ALY -,SUP-1817-09-261,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
T2 ANKLE COMPRESSION SCREW -,SUP-1818-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1161.6,813.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X150MM VERSANAIL CANN PROX HUM SS -,SUP-1818-10-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7282.7,5097.89,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL T2 ANKLE ARTHRODESIS LEFT -,SUP-1818-1020S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
T2 ANKLE NAIL 11x200MM LEFT -,SUP-1818-1120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
T2 ANKLE ARTHRODESIS NAIL LEFT 11X300MM -,SUP-1818-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 12X200MM T2 CANN LT ANKL TI ALY BIOMECH -,SUP-1818-1220S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
T2 ANKLE ARTHRODESIS NAIL RIGHT 11 X 150MM -,SUP-1819-1115S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 12X200MM T2 CANN RT ANKL TI ALY BIOMECH -,SUP-1819-1220S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.8MMX20MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-35-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X24MM CORT 3.5MM HX NS F/2.9MM DRLBT -,SUP-1819-35-024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X30MM CORT 3.5MM HX NS F/2.9MM DRLBT -,SUP-1819-35-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.8MMX30MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.8MMX32MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 4.8MMX42MM 3.6MM HX NS -,SUP-1819-48-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.8MMX44MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.8MMX46MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.8MMX50MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X24MM ELLIPSE POLYAX TI -,SUP-182.224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MM X 26MM ELLIPSE POLYAXIAL SHOULDER -,SUP-182.226,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X28MM ELLIPSE POLYAX TI. -,SUP-182.228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X30MM ELLIPSE POLYAX TI. -,SUP-182.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X32MM ELLIPSE POLYAX TI -,SUP-182.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X34MM ELLIPSE POLYAX TI -,SUP-182.234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X10MM ELLIPSE POLYAX TI -,SUP-182.310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X12MM ELLIPSE POLYAX TI -,SUP-182.312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X14MM ELLIPSE POLYAX TI -,SUP-182.314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ELLIPSE POLYAXIAL 3.5MM X 16MM -,SUP-182.316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X18MM ELLIPSE POLYAX TI -,SUP-182.318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X20MM ELLIPSE POLYAX TI -,SUP-182.320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X22MM ELLIPSE POLYAX TI -,SUP-182.322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM ELLIPSE POLYAX TI -,SUP-182.326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X28MM ELLIPSE POLYAX TI -,SUP-182.328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X30MM ELLIPSE POLYAX TI -,SUP-182.330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X10MM ELLIPSE POLYAX TI -,SUP-182.410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X12MM ELLIPSE POLYAX TI -,SUP-182.412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X14MM ELLIPSE POLYAX TI -,SUP-182.414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.0MM ELLIPSE POLYAXIAL SCREW 16MM -,SUP-182.416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X18MM ELLIPSE POLYAX TI -,SUP-182.418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X20MM ELLIPSE POLYAX TI -,SUP-182.420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X22MM ELLIPSE POLYAX TI -,SUP-182.422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X24MM ELLIPSE POLYAX TI -,SUP-182.424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X26MM ELLIPSE POLYAX TI -,SUP-182.426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ELLIPSE POLYAXIAL 4.0 X 28MM -,SUP-182.428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ELLIPSE LOCKING CAP -,SUP-182.500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
HOOK SPIN INLN ELLIPSE -,SUP-182.501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ELLIPSE POLYAXIAL 4.5 X 20 -,SUP-182.520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X22MM ELLIPSE POLYAX TI -,SUP-182.522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X24MM ELLIPSE POLYAX TI -,SUP-182.524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X26MM ELLIPSE POLYAX TI -,SUP-182.526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ELLIPSE POLYAXIAL 4.5 X 28 -,SUP-182.528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ELLIPSE POLYAXIAL 4.5 X 30 -,SUP-182.530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD TO ROD CLAMP CT TO CT 7MM -,SUP-182.741,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD TO ROD CLAMP CT TO CT 9MM -,SUP-182.770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN ELLIPSE 6.35X80MM TI POST OCT -,SUP-182.801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN ELLIPSE 6.35X120MM TI POST OCT -,SUP-182.802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN ELLIPSE 3.5X240MM TI POST OCT -,SUP-182.803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN ELLIPSE 3.5X40MM TI POST OCT -,SUP-182.804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ENDCAP SPIN ELLIPSE T-SHP HD-TO-HD -,SUP-182.900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NUT SPIN ELLIPSE F/HD-TO-HD TRANSV CONN T-SHP -,SUP-182.901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TRNSCONN 27-33MM ELLIPSE HD-TO-HD F/3.5MM T-SHP POST OCT -,SUP-182.912,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TRNSCONN 26-46MM ELLIPSE F/3.5MM CRV POST OCT -,SUP-182.924,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE OCPTL SM ELLIPSE -,SUP-182.950,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 8MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0828S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 8MMSTDX300MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0830S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 8MMSTDX315MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0831S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 8MMSTDX330MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0833S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 8MMSTDX360MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0836S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 8MMSTDX390MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0839S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1028S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIBIAL NAIL 10 X 390MM -,SUP-1822-1039S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1128S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
T2 STD. TIBIAL NAIL 11MM X 300MM -,SUP-1822-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIBIAL NAIL 11 X 375MM -,SUP-1822-1137S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
11 X 390MM TIBIA NAIL -,SUP-1822-1139S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 12MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1228S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 12MMSTDX315MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1231S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 12MMSTDX345MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 12MMSTDX360MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
T2 TIBIAL NAIL SYSTEM  12 X 390MM -,SUP-1822-1239S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8MM COMPR T2 CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1825-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.67,530.369,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8X5MM COMPR T2 CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1825-0005S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.67,530.369,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL SYS T2 FEMUR A/R 010 X 340MM -,SUP-1825-1034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X360MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1038S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11X280MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1128S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11X320MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1132S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11X340MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11X400MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1140S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1144S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 12X280MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1228S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 12X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1230S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 12X360MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 12X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1238S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 12X420MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1242S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 12X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1244S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X180MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1318S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X240MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1324S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1330S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X340MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1334S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1338S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X400MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X420MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1342S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1344S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 14X240MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1424S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 14X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1430S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 14X320MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1432S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 14X340MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1434S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 14X360MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1436S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 14X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1438S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 14X400MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 14X420MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1442S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 14X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1444S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAP ORTHO 8X4MM TI E CAP PROT -,SUP-1826-0003S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,771.97,540.379,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
T2 SUPRACONDYLAR NAIL 9X340MM -,SUP-1826-0934S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
T2 SUPRACONDYLAR NAIL 9X380MM -,SUP-1826-0938S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1020S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUPRACONDYLAR NAIL 10 X 320 -,SUP-1826-1032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10MMLNGX340MM T2 CANN SPRACON TI BIOMECH -,SUP-1826-1034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10MMLNGX360MM T2 CANN SPRACON TI BIOMECH -,SUP-1826-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL SUPRACONDYLAR 10MM X 400MM -,SUP-1826-1040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMLNGX240MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1124S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMLNGX320MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1132S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUPRACONDYLAR NAIL 11 X 360MM -,SUP-1826-1136S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL SUPRACONDYLAR 11 X 380 -,SUP-1826-1138S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL SUPRACONDYLAR 11 X 420 -,SUP-1826-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 12MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1220S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 12MMLNGX280MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1228S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 12MMLNGX300MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1230S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 12MMLNGX320MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1232S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 12MM X 340MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL SUPRACONDYLAR 12 X 360 -,SUP-1826-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
T2 SUPRACONDYLAR NAIL 12X400MM -,SUP-1826-1240S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13MMLNGX300MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1330S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13MMLNGX340MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1334S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL SUPRACONDYLAR 13MM X 360MM -,SUP-1826-1336S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13MMLNGX380MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1338S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13MMLNGX400MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13MMLNGX420MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1342S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL SUPRACONDYLAR 14 X 380 -,SUP-1826-1438S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL FEMORAL 10 X 360 -,SUP-1828-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5072.64,3550.848,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL FEMORAL 11 X 340MM -,SUP-1828-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5072.64,3550.848,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL FEMORAL 11 X 400 -,SUP-1828-1140S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5072.64,3550.848,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X740MM T2 CANN RT KN TI ALY BIOMECH -,SUP-1829-1374S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,28428.72,19900.104,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO 10MM TI ALY SQ STRL -,SUP-1830-0009S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,718.87,503.209,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 7X210MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0721S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 7X220MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0722S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 7X240MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0724S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 8X240MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0824S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 8X250MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0825S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 8X280MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0828S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 9X210MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0921S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 9X220MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0922S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 9X240MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0924S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 9X250MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0925S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ENDCAP ORTHO 6MM STD TI T2 STRL -,SUP-1832-0003S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,725,507.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 8MMLNGX150MM T2 CANN LT PROX HUM TI ALY -,SUP-1832-1035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6798.89,4759.223,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 8MMLNGX240MM T2 CANN LT PROX HUM TI ALY BIOMECH -,SUP-1832-2824S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 8MMLNGX260MM T2 CANN LT PROX HUM TI ALY BIOMECH -,SUP-1832-2826S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 8MMLNGX220MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3822S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMLNGX240MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3824S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 8MMLNGX260MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3826S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMLNGX280MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3828S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 3.6MM VAR SELF-TAPPING 14MM -,SUP-184.114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 3.6MM VAR SELF-TAPPING 16MM -,SUP-184.116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 9MM 1.5M RAD 340MM T2 RECON CANN LT FEM TI ALY RECON -,SUP-1843-0934S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
T2 RECON NAIL R1.5- RIGHT 9 X 360MM X 125DG -,SUP-1845-0936S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
T2 RECON NAIL R1.5- RIGHT 9 X 380MM X 125DG -,SUP-1845-0938S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10MM 1.5M RAD 360MM T2 RECON CANN RT FEM TI ALY -,SUP-1845-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL T2 RECON R1 11MM X 420MM X 125 -,SUP-1845-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ENDCAP SPIN REVERE THORLUM NTHRD REVOLVE -,SUP-185.000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN REVOLVE 5.5X80MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN REVOLVE 5.5X90MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN REVOLVE 5.5X100MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN REVOLVE 5.5X110MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X30MM REVOLVE POLYAX TI -,SUP-185.452,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X35MM REVOLVE POLYAX TI -,SUP-185.453,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X40MM REVOLVE POLYAX TI -,SUP-185.454,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X45MM REVOLVE POLYAX TI -,SUP-185.455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X50MM REVOLVE POLYAX TI -,SUP-185.456,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X55MM REVOLVE POLYAX TI -,SUP-185.457,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X30MM REVOLVE POLYAX TI -,SUP-185.462,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X35MM REVOLVE POLYAX TI -,SUP-185.463,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X40MM REVOLVE POLYAX TI -,SUP-185.464,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X45MM REVOLVE POLYAX TI -,SUP-185.465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X50MM REVOLVE POLYAX TI -,SUP-185.466,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FEMORAL NAIL RIGHT 9 X 360MM -,SUP-1851-0936S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6489.92,4542.944,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X380MM T2 CANN RT GTR TROCH FEM TI ALY RECON -,SUP-1851-1038S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6489.92,4542.944,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CABLE SINGLE LOOP TITANIUM WITH CRIMP -,SUP-186.200S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2978.98,2085.286,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER 28X8MM LPRD 5DG LRDTC BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 28X9MM LPRD 5DG LRDTC BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER 28X7MM LPRD PRLL BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER 28X9MM LPRD PRLL BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER 28X11MM LPRD PRLL BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SET INNER MIS -,SUP-186715000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SET SCREW SPIN VIPER 2 TI PDCL SQ THRD SGL INNIE -,SUP-1867-15-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X35MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X35MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X40MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X40MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6 X 45 POLYAXIAL CANNULA -,SUP-186715645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X45MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X50MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X50MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X55MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7X40MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7X50MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X55MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X40MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X30MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X40MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X45MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TI CORT FIX 6X50MM -,SUP-186731650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TI CORT FIX 6X55MM -,SUP-186731655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X35MM VIPER 2 DBL LD THRD CANN ULTRA TI -,SUP-1867-60-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X40MM VIPER 2 DBL LD THRD CANN ULTRA TI -,SUP-1867-60-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN VIPER 5.5X35MM CRV PREBNT TI F/MN INV SURG NS -,SUP-1867-62-635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN VIPER 5.5X40MM CRV PREBNT TI F/MN INV SURG NS -,SUP-1867-62-640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN VIPER 2  - 5.5 X 35MM LORDOTIC -,SUP-186788035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN VIPER 2 5.5X35MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN VIPER 2 5.5X40MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN VIPER 2 5.5X45MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN VIPER 2 5.5X50MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TRNSCONN REVERE ADDITION RD-TO-RD F/5.5MM PRLL -,SUP-1867-88-055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN VIPER 2 5.5X65MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD VIPER 2 LORDOTIC 75MM -,SUP-186788075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD LORDOTIC 80MM VIPER2 -,SUP-186788080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD LORDOTIC 90MM VIPER2 -,SUP-186788090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 16X12MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 16X14MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 16X16MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 16X18MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 16X20MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 16X22MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 16X24MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 16X26MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SKY 1 LEVEL PLATE 28MM -,SUP-1868-01-028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 16X30MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 28MM SKYLINE 2 LEVEL TI -,SUP-186802028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 16X30MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 16X32MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 16X34MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 16X36MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 16X40MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 16X42MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 16X44MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 16X45MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 16X48MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 16X51MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 16X54MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 16X57MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-057,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X12MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL BLU -,SUP-1868-50-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X14MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL GOLD -,SUP-1868-50-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X16MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL MAG -,SUP-1868-50-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X18MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL -,SUP-1868-50-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X12MM SKYLINE ST VAR ANG HX LOBE HEAD TI STRL BLU -,SUP-1868-52-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X14MM SKYLINE ST VAR ANG HX LOBE HEAD TI STRL GOLD -,SUP-1868-52-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X16MM SKYLINE ST VAR ANG HX LOBE HEAD TI STRL MAG -,SUP-1868-52-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SKY VARIABLE S-T 18MM TI -,SUP-186852018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X12MM SKYLINE ST VAR ANG OVSZ HX LOBE HEAD TI STRL -,SUP-1868-54-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X14MM SKYLINE ST VAR ANG OVSZ HX LOBE HEAD TI STRL -,SUP-1868-54-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X16MM SKYLINE ST VAR ANG OVSZ HX LOBE HEAD TI STRL -,SUP-1868-54-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X14MM SKYLINE ST FA CNSTRN OVSZ HX LOBE HEAD TI -,SUP-1868-64-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT COUGAR SM 12MM 5 DEG -,SUP-187105112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COUGAR IMPLANT MED 14MM 50DEG -,SUP-187105214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER 14MM COUGAR 10DG SM CFRP -,SUP-1871-10-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COUGAR IMPLANT MED 14MM 10DEG -,SUP-187110214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN EXPEDIUM 5.5X70MM STR TI ANT PCUT NS -,SUP-1877-03-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BULLETT CONCORD 9 X 7 X 23 -,SUP-187823107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 9X8X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 9X9X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 9X10X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 9X8X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 9X9X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-187823409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 9X9X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 9X10X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 9X11X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 9X12X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 11X12X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CONCORDE BUL LOR 11X13X23 5DG -,SUP-187823513,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 9X7X27MM CONCORDE -,SUP-187827107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 9X7X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 9X8X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 9X9X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 9X10X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 11X12X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 9X8X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-27-408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 9X9X27MM CONCORDE 5DG LRDTC BLLT NOSE STNT LPRO CFRP -,SUP-1878-27-409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 9X10X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-27-410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CONCORDE BUL LOR 9 X 11 X 27 -,SUP-187827411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 9X11X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-27-411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 11X12X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-187827512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 9X7X23MM CONCORDE PRLL CFRP -,SUP-1879-23-107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14828.79,10380.153,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 11X13X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1879-27-513,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CONNECTOR SPIN MOUNTAINEER LAT OFST TI -,SUP-1883-12-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X10MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X12MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X18MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X12MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X22MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X24MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X26MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X12MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X16MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X20MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X22MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X22MM MOUNTAINEER MINI POLYAX TAPR TI STRL BLU SHNK -,SUP-1883-19-422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X26MM MOUNTAINEER MINI POLYAX TAPR TI STRL BLU SHNK -,SUP-1883-19-426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X50MM MOUNTAINEER MINI POLYAX TAPR TI STRL BLU SHNK -,SUP-1883-19-450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.35X20MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.35X25MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.35X30MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.35X35MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.35X40MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X20MM MOUNTAINEER MINI POLYAX SHNK TAPR TI STRL -,SUP-1883-20-320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X28MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X32MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X34MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X36MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X38MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X40MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
XCONN 21MM MOUNTAINEER HD-TO-HD TI OCT -,SUP-1883-41-021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X12MM MOUNTAINEER MINI POLYAX TI STRL -,SUP-188362012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE OC 37MM -,SUP-188362037,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
MNTR OC PLATE LARGE -,SUP-188362045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.25X8MM MOUNTAINEER MINI POLYAX TI STRL -,SUP-188362108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
MNTR OC PREBENT ROD 3.5X120 -,SUP-188363200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,921.93,645.351,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN SKYLINE 34MM LVL2 PRELRD TI VSBL GFT SITE -,SUP-1888-02-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5856.72,4099.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE ANTLAT 33-46MMH X-MESH 0DG MED TI -,SUP-1889-01-033,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20402.94,14282.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 0DG ANTLAT 51-71MM X-MESH MED TI -,SUP-1889-01-051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22445.09,15711.563,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X35MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,820.98,574.686,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X40MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,812.82,568.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X45MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,812.82,568.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X55MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,812.82,568.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X60MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,820.98,574.686,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X65MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,820.98,574.686,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SFX-5.5 TI LAT SIZE F4 -,SUP-189401104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DEPUY SPINE SFX F5 CROSSLINK -,SUP-189401105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CONNECTOR SZ F6 EXPEDIUM SFX FX F/5.5MM TI MDL -,SUP-1894-01-206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CONNECTOR SZ F7 EXPEDIUM SFX FX F/5.5MM TI MDL -,SUP-1894-01-207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CONNECTOR SPIN EXPEDIUM CX TI -,SUP-1894-01-209,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SFX 5.5 TI LAT SIZE A2 -,SUP-189401302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CONNECTOR SZ A4 EXPEDIUM SFX F/5.5MM TI MDL NS -,SUP-1894-01-404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CONNECTOR SZ A5 EXPEDIUM SFX F/5.5MM TI MDL NS -,SUP-1894-01-405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CONNECTOR SZ A6 EXPEDIUM SFX F/5.5MM TI MDL NS -,SUP-1894-01-406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T2 CONDYLE 5MM X 50MM -,SUP-1895-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X60MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X75MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X80MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X85MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X20MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4020S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X22MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4022S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X26MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4028S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X30MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
T2 F/T LOCKING SCREW 4MM X 32MM -,SUP-1896-4032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X36MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X38MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4038S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X45MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X55MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T2 F/T LOCK 5 X 30 -,SUP-1896-5030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX32.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T2 F/T LOCK 5 X 35 -,SUP-1896-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX37.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T2 F/T LOCK 5 X 40 -,SUP-1896-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX42.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T2 F/T LOCK 5 X 45 -,SUP-1896-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX47.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5047S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T2 F/T LOCK 5 X 50 -,SUP-1896-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX52.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5052S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T2 F/T LOCK 5 X 55 -,SUP-1896-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX57.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5057S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T2 F/T LOCK 5 X 60 -,SUP-1896-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T2 F/T LOCK 5 X 65 -,SUP-1896-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T2 F/T LOCK 5 X 70 -,SUP-1896-5070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T2 F/T LOCK 5 X 75 -,SUP-1896-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X80MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X85MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X90MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X100MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN UNIPLATE 2 36MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-02-036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN UNIPLATE 2 38MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-02-038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.6X12MM UNIPLATE ST CANC TI BLU -,SUP-1897-06-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.6X13MM UNIPLATE ST CANC TI BLU -,SUP-1897-06-013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.6X14MM UNIPLATE ST CANC TI GOLD -,SUP-189706014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 14MM UNIPLATE SPINE CERVICAL ANTERIOR SELF -,SUP-1897-06-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1293.32,905.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.6X15MM UNIPLATE ST CANC TI LBLU -,SUP-1897-06-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.6X18MM UNIPLATE ST CANC TI LBLU -,SUP-1897-06-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.2MMX14MM UNIPLATE OVSZ CANC TI GOLD -,SUP-1897-06-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.2MMX18MM UNIPLATE ST CANC TI GOLD -,SUP-1897-06-118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.6X12MM UNIPLATE SD CANC TI BLU -,SUP-1897-07-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.6X13MM UNIPLATE SD CANC TI VIOL -,SUP-1897-07-013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.6X15MM UNIPLATE SD CANC TI LBLU -,SUP-1897-07-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN UNIPLATE 2 14MM LVL1 PRELRD TI NRW MDLN NO- BND -,SUP-189721014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN UNIPLATE 2 16MM LVL1 PRELRD TI NRW MDLN NO- BND -,SUP-189721016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN UNIPLATE 2 28MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-22-028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN UNIPLATE 2 32MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-22-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN UNIPLATE 2 34MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-22-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T2 RECON LAG 6.5MM X 75MM -,SUP-1897-6075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T2 RECON LAG 6.5MM X 80MM -,SUP-1897-6080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LAG T2 RECON SYSTEM 6.5 X 85 -,SUP-1897-6085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LAG BONE T2 RECON SYSTEM 6.5 X 90 -,SUP-1897-6090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LAG T2 RECON 6.5MM X 100MM -,SUP-1897-6100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LEVEL 1 PLATE 20MM -,SUP-19-0120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CALBIBER SPACER 10 X 22MM- 10-15MM -,SUP-194.222,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SEMI CONST DRILL 4.0 X 14 -,SUP-19-6514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MMX6MM LCK COMPR CORT LCP FT STD CRUCIF RCESS SS NS -,SUP-201.006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,93.36,65.352,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.4MMX10MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CLIP ANEUR 2.4MMX12MM SS LCP ST -,SUP-201.762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.4MMX13MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.763,CDM,C1713,HCPCS,278,RC,,,outpatient,,,411.37,287.959,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.4MMX14MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.764,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.4MMX18MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.768,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.4MMX22MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.772,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X10MM LCK COMPR LCP THRD ST FA T6 STRDRV RCESS SS NS -,SUP-201.880,CDM,C1713,HCPCS,278,RC,,,outpatient,,,830.26,581.182,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX10MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,328.22,229.754,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX12MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,328.22,229.754,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX26MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX28MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX30MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX32MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX34MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX36MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX38MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX40MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX45MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX50MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX55MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X10MM LCK COMPR LCP THRD ST T8 STRDRV RCESS SS NS -,SUP-202.210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,886.92,620.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X30MM LCK COMPR LCP THRD ST T8 STRDRV RCESS SS NS -,SUP-202.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.01,516.607,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X40MM LCK COMPR LCP THRD ST T8 STRDRV RCESS SS NS -,SUP-202.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.01,516.607,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X14MM CANN LNG THRD SD/ST CRUCIF RCESS SS NS -,SUP-202.714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1530.52,1071.364,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X16MM LCK COMPR CORT LCP FT ST T8 STRDRV RCESS SS -,SUP-202.876,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X18MM LCK COMPR CORT LCP FT ST T8 STRDRV RCESS SS -,SUP-202.878,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTEX SLF TPNG 2.7 X 20MM T8 SD REC -,SUP-202.880,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X24MM LCK COMPR CORT LCP FT ST T8 STRDRV RCESS SS -,SUP-202.884,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTEX SLF TPNG 2.7 X 26MM T8 SD REC -,SUP-202.886,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTEX SLF TPNG 2.7 X 28MM T8 SD REC -,SUP-202.888,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTEX SLF TPNG 2.7 X 30MM T8 SD REC -,SUP-202.890,CDM,C1713,HCPCS,278,RC,,,outpatient,,,577.67,404.369,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BODY PHOENIX SHRT OPN BD -,SUP-20-2070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BODY STD PHOENIX OPN BD POST PDCL F/MN INV FX SYS -,SUP-20-2090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
6.5 X 40MM CANCELLOUS BONE SCREW -,SUP-2030-6540-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ACTB 6.5X55MM OMNIFIT -,SUP-2030-6555-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ACTB 6.5X60MM OMNIFIT -,SUP-2030-6560-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X10MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X12MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X14MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,192.56,134.792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X16MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX18MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX20MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX22MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX24MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX26MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX28MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX32MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX34MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX36MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX38MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX40MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX45MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X50MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X28MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X30MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X32MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X34MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X36MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X38MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X14MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X20MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X22MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X24MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X28MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X32MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X34MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.834,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X48MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.848,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN PHOENIX 35MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN PHOENIX 40MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN PHOENIX 45MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN PHOENIX 50MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN PHOENIX 55MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN PHOENIX 70MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN PHOENIX 75MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX10MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX12MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX14MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.61,257.327,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX16MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.61,257.327,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX18MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.61,257.327,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX22MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX24MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX26MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX30MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX35MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX40MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX45MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX50MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX55MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX60MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FEM PRESSURIZING SEAL - SMALL -,SUP-206-545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,101.12,70.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X10MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X12MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X14MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X16MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X18MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X20MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X22MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X24MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X26MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X30MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,157.55,110.285,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X40MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X45MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X50MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX34MM LCK CANN LCP LNG THRD SD/ST 2.5MM SM HEX SCKT -,SUP-207.734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7MMX35MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7MMX40MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7MMX45MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7MMX50MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7MMX70MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7MMX75MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X95MM LCK CANN 32MM THRD SD/ST REVCT FLUT 4MM LRG -,SUP-208.441,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1770.37,1239.259,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7MMX45MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7MMX50MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7MMX55MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7MMX80MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7X32MM CANN -,SUP-209.750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.3X75MM LCK CANN THRD SD/ST REVCT FLUT HEX SCKT -,SUP-209.875,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1710.52,1197.364,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT SQA + THRDR TAB TI NTNL -,SUP-210.309,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2065.07,1445.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUBSTITUTE TCP 1.2ML FOAM PK VITOSS RESRB COMPR RSIS -,SUP-2102-1401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1579.18,1105.426,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
VITOSS BIOACTIVE PACK 2.5CC -,SUP-2102-1602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3430.26,2401.182,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
VITOSS BA2X FOAM PACK 1.2CC -,SUP-2102-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2600.96,1820.672,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
VITOSS BA2X FOAM PK BONE GRAFT 1.2CC -,SUP-2102-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2600.96,1820.672,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
VITOSS BA2X BONE GRAFT 2.5CC -,SUP-2102-2102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4015.89,2811.123,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
VITOSS BA2X BONE GRAFT 5CC -,SUP-2102-2105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6693.85,4685.695,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
VITOSS BA2X BONE GRAFT 10CC -,SUP-2102-2110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10931.81,7652.267,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.4MMX12MM CANN 0.5IN LNG THRD SD/ST T8 STRDRV RCESS -,SUP-211.812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1577.85,1104.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CANNULATED SCREW 2.4mm X15mm -,SUP-211.815,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED 2.4MM X17MM L -,SUP-211.817,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1431.14,1001.798,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.4MM CANN SCREW LONG 19MM -,SUP-211.819,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1431.14,1001.798,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX55MM LCK COMPR LCP FT ST SS NS GRN -,SUP-212.123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,813.98,569.786,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE PIN- 3.2 x 110MM- STERILE (2 Pack) -,SUP-213524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE PIN- 3.2 x 140MM- STERILE (2 Pack) -,SUP-213527,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX16MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX28MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX30MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX32MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX36MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX38MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX40MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX46MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX50MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX52MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX56MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX34MM LCK CANN P/T SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1518.59,1063.013,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX42MM LCK CANN P/T SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1518.59,1063.013,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX44MM LCK CANN P/T SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1518.59,1063.013,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX40MM LCK CANN FT SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1562.32,1093.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX44MM LCK CANN FT SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1562.32,1093.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX50MM LCK CANN FT SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1562.32,1093.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX40MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-216.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX55MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX60MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX65MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX70MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX75MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 9MM SHRT FASTFLAP 2HL STR 1.6MM NEURO SYS STRL -,SUP-218-0022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.42,222.194,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRNL 22MM 5HL 0.5MM STR FAST FLAP 1.6MM NEURO SYS TI -,SUP-218-0030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,868.25,607.775,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC MED FST-FLP MSH 5HL TI BUR HL GRV SHNT 1.6MM -,SUP-218-0069,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRNL LNG 2HL 0.25MM STR FAST FLAP 1.6MM NEURO SYS TI -,SUP-218-0093,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.8,316.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRNL 22MM LRG 0.25MM FAST FLAP BUR HL CVR 1.6MM NEURO -,SUP-218-0095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1077.06,753.942,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC 90X90MM FST-FLP OSTFRM MSH TI PREFRM 1.6MM -,SUP-218-2006-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6545.95,4582.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO 10MM F/4.5MM CANN SCR RND NS -,SUP-219.910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,218.81,153.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO 13MM F/6.5MM CANC LRG BN SCR RND NS -,SUP-219.990,CDM,C1713,HCPCS,278,RC,,,outpatient,,,223.19,156.233,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ACCELFIX LUMBAR EXPANDABLE CAGE 8 22 X 11 X 8MM -,SUP-2211-0808S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19669.62,13768.734,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ACCELFIX EXPANDABLE LUMBAR CAGE 15 22 X 11 X 8 -,SUP-2211-0815S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19669.62,13768.734,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE ACCELFIX LUMB EXPAND 8 DEG 22 X 11 X 12 -,SUP-2211-1208S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT HEALIX ADVANCE 4.5MM MUL-THRD BCRL RAPIDE -,SUP-222.295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1643.16,1150.212,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUTURE ORTHOCORD #2 MO-7 36IN BRD BLU VIOL 223114 1/2CIR MPK -,SUP-223.114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.04,210.028,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LC-DCP 11X77MM 3.5MM 6HL LC BSC LCK DCP SS SM NS -,SUP-223.560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2413.05,1689.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LC-DCP 11X90MM 3.5MM 7HL LC BSC LCK DCP SS SM NS -,SUP-223.570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2504.49,1753.143,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LC-DCP 11X103MM 3.5MM 8HL LC BSC DCP SS SM NS -,SUP-223.580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2631.7,1842.19,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LC-DCP 11X116MM 3.5MM 9HL LC BSC LCK DCP SS SM NS -,SUP-223.590,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2466.96,1726.872,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LC-DCP 11X129MM 3.5MM 10HL LC BSC LCK DCP SS SM NS -,SUP-223.600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2542.16,1779.512,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO BRKWY 2.5MM GLOBAL APG + -,SUP-2230-00-019,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1126.16,788.312,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LC-DCP 13.5X155MM 12HL 4.2MM LC COMPR SS 3.5MM BRD -,SUP-225.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2321.62,1625.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUBSTITUTE DEMIN CANC TISS 0.75ML G2 DIVERTED MRSL VOID FIL -,SUP-227005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1139.61,797.727,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUBSTITUTE G2 TISS 0.5ML STRIP PREFL ATF STR TUBE -,SUP-227010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,846.08,592.256,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
KT ORTHO MILAGRO FEM -,SUP-232.300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2199.71,1539.797,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
END CAP LOWER EXTREMITY 8 +0MM -,SUP-2330-0000S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1195.26,836.682,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
T2 ALFPHA COMPRESSION SCREW FEMUR 5.5 -,SUP-2330-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1333.08,933.156,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
END CAP GT/PF T2 ALPHA 013 +10 -,SUP-2330-0010S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1195.26,836.682,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL FEMORAL GT LEFT 11 X 320MM -,SUP-2331-1132S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FEMORAL NAIL GT- LEFT Ã˜11X420MM -,SUP-2331-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9735.49,6814.843,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FEMORAL NAIL GT LEFT 13 X 400MM -,SUP-2331-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10095.65,7066.955,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FEMORAL NAIL GT RT 10 X 360 -,SUP-2333-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12776.73,8943.711,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FEMORAL NAIL GT RIGHT 10 X 420MM -,SUP-2333-1042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL INTRAMEDULLARY T2 ALPHA FEMUR ANTEGRADE SYSTEM 11 X 380 -,SUP-2333-1138S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FEMORAL NAIL GT RIGHT 11 X 420MM -,SUP-2333-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FEMORAL NAIL GT RIGHT 11 X 440MM -,SUP-2333-1144S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FEMORAL NAIL GT RIGHT 13MM X 400MM -,SUP-2333-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10095.65,7066.955,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FEMORAL NAIL RETROGRADE D10X360MM -,SUP-2339-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FEMORAL NAIL RETROGRADE D10X400MM -,SUP-2339-1040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SYS FEMUR RETROGRADE NAIL 11 X 200MM T2 ALPHA SHORT -,SUP-2339-1120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FEMORAL NAIL RETROGRADE 11 X 300MM -,SUP-2339-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL T2 FEMUR ALPHA RETROGRADE 11 X 340MM -,SUP-2339-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FEMORAL NAIL RETROGRADE D11X380MM -,SUP-2339-1138S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FEMORAL NAIL RETROGRADE 12 X 340MM -,SUP-2339-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10561.63,7393.141,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
T2 ALPA FEMUR NAIL RETROGRADE 12 X 360 -,SUP-2339-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10559.77,7391.839,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FEMORAL NAIL RETROGRADE 13X340MM -,SUP-2339-1334S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10561.63,7393.141,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FEMORAL NAIL RETROGRADE D13X360MM -,SUP-2339-1336S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10559.77,7391.839,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN 8X23MM THRD BABSRB PLLA -,SUP-234-010-162,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN BIOSTEON 7X28MM 1MM CANN FLLY BLNT THRD -,SUP-234-010-164,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN BIOSTEON 8X28MM BABSRB WDG SHP HAP PLLA -,SUP-234-010-165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN 9X28MM THRD BABSRB PLLA -,SUP-234-010-166,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN BIOSTEON 11X35MM 1MM CANN FLLY BLNT THRD -,SUP-234-010-179,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN BIOSTEON 12X35MM 1MM CANN FLLY BLNT THRD -,SUP-234-010-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2187.89,1531.523,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMPRESSION SCREW TIBIA 5.5 -,SUP-2341-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1333.08,933.156,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
END CAP TIBIA T2 ALPHA 11.5 X +5MM -,SUP-2341-0005S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
END CAP TIBIA T2 ALPHA 11.5 X 10MM -,SUP-2341-0010S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
END CAP TIBIA T2 ALPHA 11.5 X 15MM -,SUP-2341-0015S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ENDO VERSITOMIC SHP MEM ALY TECH FLXB -,SUP-234-108-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2166.31,1516.417,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ENDO VERSITOMIC FLXB -,SUP-234-108-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2187.89,1531.523,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIBIAL NAIL 9 X 285MM -,SUP-2341-0928S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIBIAL NAIL T2 ALPHA 9 X 300 -,SUP-2341-0930S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIBIAL NAIL T2 09 X 315MM -,SUP-2341-0931S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL TIBIAL 9 X 330 T2 ALPHA -,SUP-2341-0933S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIBIAL NAIL 9 X 345 -,SUP-2341-0934S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIBIAL NAIL 9 X 360 -,SUP-2341-0936S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIBIAL NAIL 9 X 375 -,SUP-2341-0937S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIBIAL NAIL 9 X 390MM -,SUP-2341-0939S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIBIAL NAIL 10X285MM -,SUP-2341-1028S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10764.14,7534.898,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM 10 X 300 -,SUP-2341-1030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM 10 X 315 -,SUP-2341-1031S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM -,SUP-2341-1033S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
T2 ALPHA TIBIA NAIL 10X345MM SYS -,SUP-2341-1034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL TIBIAL 10 X 360 T2 ALPHA -,SUP-2341-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL TIBIAL 10 X 375MM T2 ALPHA -,SUP-2341-1037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL TIBIAL 10 X 390 T2 ALPHA -,SUP-2341-1039S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL TIBIAL T2 ALPHA 11 X 300MM -,SUP-2341-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL TIBIAL T2 11 X 315 -,SUP-2341-1131S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIBIAL NAIL 11 X 330 -,SUP-2341-1133S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL SYSTEM T2 ALPHA TIBIA 11 X 345MM -,SUP-2341-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM -,SUP-2341-1136S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIBIAL NAIL T2 ALPHA 11 X 375 -,SUP-2341-1137S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
T2 ALPHA TIBIA NAIL 11 X 390MM -,SUP-2341-1139S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL TIBIAL T2 ALPHA 12 X 315MM -,SUP-2341-1231S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL TIBIAL T2 ALPHA 12 X 330MM -,SUP-2341-1233S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
T2 ALPHA TIBIA SYSTEM TIBIAL NAIL -,SUP-2341-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
T2 ALPHA TIBIAL NAIL 12 X 380MM -,SUP-2341-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10764.1,7534.87,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIBIAL NAIL 12 X 375MM -,SUP-2341-1237S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 8X50MM -,SUP-234500150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,885.69,619.983,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW 5 X 25MM -,SUP-2360-5025S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW 5 X 27.5MM -,SUP-2360-5027S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 5X32MM -,SUP-2360-5032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW IMN SYSTEM LOCKING SCREW 5 X 35 -,SUP-2360-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMN LOCKING SCREW 5 X 37.5MM -,SUP-2360-5037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMN SCREW SYSTEM LOCKING SCREW 5 X 40 -,SUP-2360-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 5X42MM -,SUP-2360-5042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW 05 X 45MM -,SUP-2360-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMN LOCKING SCREW 5X47.5MM -,SUP-2360-5047S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMN LCK SCREW 5X50 -,SUP-2360-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMN LCK SCREW 5X52 -,SUP-2360-5052S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK STRYKER 5 X 55 -,SUP-2360-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMN LOCKING SCREW 5X57.5MM -,SUP-2360-5057S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMN LOCKING SCREW 0.5 X 60MM -,SUP-2360-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1836.62,1285.634,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING SYS IMN 5 X 60MM -,SUP-2360-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMN LOCKING SCREW 0.5 X 65MM -,SUP-2360-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 5 X 70MM -,SUP-2360-5070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T2 ALPHA IMN LOCKING  0.5 X 75MM -,SUP-2360-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING SYS IMN 5 X 65MM -,SUP-2360-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 5 X 85 -,SUP-2360-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 5 X 90 -,SUP-2360-5090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW IMN T2 ALPHA LOCKING  5MM X 95MM -,SUP-2360-5095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING SYS IMN 5 X 100MM -,SUP-2360-5100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ADVANCED LOCKING SCREW 5X30MM -,SUP-2361-5030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ADVANCED LOCKING 5MM X 32.5MM -,SUP-2361-5032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ADVANCED LOCKING 5 X 35 -,SUP-2361-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING ADVANCED IMN 05 X 37.5MM -,SUP-2361-5037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING ADVANCED IMN 05 X 40MM -,SUP-2361-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ADVANCED LOCKING 5MM X 42.5MM -,SUP-2361-5042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ADVANCED LOCKING SCREW 5MM X 45MM -,SUP-2361-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW IMN LCK 5 X 45 -,SUP-2361-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ADVANCED LOCKING 5MM X 47.5MM -,SUP-2361-5047S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING ADVANCED 5X50MM -,SUP-2361-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ADVANCED LOCKING SCREW 5MM X 52.5MM -,SUP-2361-5052S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ADVANCED LOCKING 5MM X 55MM -,SUP-2361-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ADVANCED LOCKING SCREW 5 X 57.5MM -,SUP-2361-5057S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X60MM IMN ADVANCED LOCKING -,SUP-2361-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ADVANCED LOCKING 5MM X 65MM -,SUP-2361-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ADVANCED LOCKING 5MM X 70MM -,SUP-2361-5070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ADVANCED LOCKING SCREW 5 X 57MM -,SUP-2361-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ADVANCED LOCKING SCREW 5 X 80 -,SUP-2361-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMN ADVANCED LOCKING SCREW 5MM X 85MM -,SUP-2361-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ADVANCED LOCKING SCREW 5 X 90MM -,SUP-2361-5090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1553.05,1087.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW IMN LOCKING 5MM X 95MM -,SUP-2361-5095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LCP 83MM 4/5MM 4HL BSC LCK COMPR SS LRG T-SHP NS -,SUP-240.141,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3467.5,2427.25,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN STERNAL TALON 14MM D FT PLATE LEGX2 SGL TI SM STRL -,SUP-24-009-14-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN STERNAL TALON SGL LEGX2 BIOCMPT TI SM STRL -,SUP-24-009-17-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FOOT PLATE BN STERNAL TALON SGL VRSN TI 17MM MED STRL LEGX2 -,SUP-24-010-17-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN STERNAL TALON 20MM D LEGX2 SGL TI MED STRL -,SUP-24-010-20-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FOOT PLATE XL 12X20MM STERNAL TALON SGL -,SUP-24-012-20-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
STERNAL SCREW 2.3 -,SUP-24-023-09-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X11MM LCK DRL-FR MAXDRIVE THREADLOCK TS SLF RET TI -,SUP-24-023-11-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X13MM LCK DRL-FR MAXDRIVE THREADLOCK TS SLF RET TI -,SUP-24-023-13-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
STERNAL SCREW 2.3 X 15MM -,SUP-24-023-15-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.3MM SELF DRILLING STERNAL SCREWS -,SUP-24-023-17-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE LEVEL 1 THORACIC STERNAL LKG STR 2.3MM SCRW 20 HL -,SUP-24-025-07-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3118.62,2183.034,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
STERNAL PLATE LOCK 6-HOLE 1.8 -,SUP-24-025-42-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2398.48,1678.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 8HL 1.8MM LCK TI X-SHP -,SUP-24-025-44-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2224.88,1557.416,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
4 HOLE STRAIGHT -,SUP-24-025-48-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2155.98,1509.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE LEVEL ONE THORACIC STERNAL LKG STR W/2.3MM SCREW -,SUP-24-025-50-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2580.02,1806.014,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
9 HOLE Y PLATE -,SUP-24-025-52-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2613.77,1829.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 4 HOLE ANGLE -,SUP-24-025-59-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1906.85,1334.795,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LC-DCP 10X50MM 3.5MM 3HL HD/SHFT LC DCP SS T-SHP RT -,SUP-241.130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,781.42,546.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LC-DCP 11X64MM 3.5MM HLX3/5 HD/SHFT LC DCP SS T-SHP -,SUP-241.150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,944.22,660.954,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LC-DCP 10X53MM 3.5MM 3HL HD/SHFT LC LCK DCP SS -,SUP-241.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1176.71,823.697,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LC-DCP 10X63MM 3.5MM 0.75HL HD/SHFT LC LCK DCP SS -,SUP-241.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1296.45,907.515,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LC-DCP 10X75MM 3.5MM HLX3/5 HD/SHFT LC LCK DCP SS -,SUP-241.250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1282.72,897.904,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LC-DCP 9X25MM 3.5MM 2HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LC-DCP 9X49MM 3.5MM 4HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LC-DCP 9X61MM 3.5MM 5HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LCP 9X57MM 2.7/3.5MM 5HL CONTR LCK COMPR SS SM 1/3 -,SUP-241.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1594.13,1115.891,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LC-DCP 9X85MM 3.5MM 7HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1268.14,887.698,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LC-DCP 9X97MM 3.5MM 8HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1315.85,921.095,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LC-DCP 9X121MM 3.5MM 10HL LC DCP SS SM MINI 1/3 -,SUP-241.400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LCP 9X117MM 2.7/3.5MM 10HL CONTR LCK COMPR SS SM -,SUP-241.401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1745.19,1221.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LCP 15MM D 3.5MM 5HL PRCONT LCK COMPR SS HOOK STRL -,SUP-241-085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4546.38,3182.466,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LCP 6.3X49MM 2.4MM 0.75HL HD/SHFT FA CONTR LCK -,SUP-242.507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2479.52,1735.664,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER TNDN 6X24MM SILASTIC PLYSTR COR SWN-HNT STRL -,SUP-24270006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7240.26,5068.182,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 82MM 3.5MM 7HL RECON SS STR NS -,SUP-245.170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3397.89,2378.523,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LC-DCP 94MM 3.5MM 8HL RECON DCP SS STR NS -,SUP-245.181,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3544.7,2481.29,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LC-DCP 106MM 3.5MM 9HL RECON DCP SS STR NS -,SUP-245.190,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3738.04,2616.628,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 53MM 2MM HLX2/8 HD/SHFT 1.2MM RECON SS T-SHP NS -,SUP-247.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1616.65,1131.655,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LCP 54MM 2MM 7HL RECON LCK COMPR SS NS -,SUP-247.349,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4745.36,3321.752,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LCP 44MM 2.4MM 5HL RECON ADPR LCK COMPR SS STR NS -,SUP-247.375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2573.19,1801.233,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LCP 36MM 2.4MM 4HL RECON LCK COMPR SS STR NS -,SUP-249.674,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2496.8,1747.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LCP 59MM 2.4MM 7HL RECON LCK COMPR SS STR NS -,SUP-249.679,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3862.17,2703.519,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LCP 58MM 2.7MM 6HL RECON LCK COMPR SS STR NS -,SUP-249.682,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3247.51,2273.257,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LCP 67MM 2.7MM 7HL RECON LCK COMPR SS STR NS -,SUP-249.683,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2544.54,1781.178,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN LCP 32MM 2.7MM 0.66HL HD/SHFT RECON LCK COMPR SS -,SUP-249.685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCK -,SUP-250-1001-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8.5MM SHTH INTRAFIX PEEK PP NS F/ACL FX -,SUP-254.683,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK CRNMXF 2.3X11MM CROSS-DRIVE TI ALY -,SUP-25-773-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 7 MWX8MMX21MM TRAXIS PEEK/ TI -,SUP-2601070921,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE VERT 25MM VUE 7MM/9MM LD /TRAILING DIA SGL LVL PEEK -,SUP-2601070925,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 9X21X9MM TRAXIS VUE 9MM/9MM DIA LD /TRAILING DIA SGL -,SUP-2601090921,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDE DRILL POR F/KN ARTHPL -,SUP-261-0060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
USTAR II KNEE CEMENTED STR STEM RHS 17X125 -,SUP-2715-3117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BLADE IM NAIL 12.5X105MM SS HLCL NS F /LCP DHS -,SUP-282.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2284.52,1599.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BLADE IM NAIL 12.5X120MM SS HLCL NS F /LCP DHS -,SUP-282.243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2277.41,1594.187,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX CAGE 6.5 -,SUP-28-2180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX CAGE 8.5 -,SUP-28-2182,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX CAGE 6.5 X 24 XP -,SUP-28-3140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE XP LORDOTIC 8.5 -,SUP-28-3142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX FORZA XP CAGE 10.5H X 10W X 24L -,SUP-28-3144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX 12H EXPANDABLE CAGE -,SUP-28-3146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
EXPANDABLE CAGE 6.5MMX10MM WIDE X28MM -,SUP-28-3180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE FORZA XP ORTHOFIX 10.5MM -,SUP-28-3184,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX HYPERLORDOTIC CAGE 8.5 -,SUP-28-4142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 10.5HL HYPER XP -,SUP-28-4144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX CAGE 12.5 X 24. HL -,SUP-28-4146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
USTAR II KNEE SEGMENT PART RHS 25MM -,SUP-2915-1025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22014.38,15410.066,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER VERT 22X8MM CAP STN VERTSTCK PEEK -,SUP-2960822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER VERT 26X8MM CAP STN VERTSTCK PEEK -,SUP-2960826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20245.95,14172.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER VERT 22X10MM CAP STN VERTSTCK 8DG PEEK -,SUP-2961022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X12MM LCK ACU-LOC 2 HXLB DRIVE F/VOLAR DIST RAD -,SUP-30-0234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,822.74,575.918,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X14MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X18MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0237,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X20MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X22MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0239,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X24MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0241,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X30MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X32MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X36MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0246,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X45MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0249,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X22MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0262,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X24MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0263,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0264,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X32MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0267,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X40MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0271,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X45MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0272,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X50MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0273,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X55MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0274,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X40MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0294,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW Ti SET 8X17.5MM -,SUP-3003-0822S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,858.1,600.67,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X14MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0327,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X16MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X18MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0329,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X20MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X22MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0331,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAP END +10MM TI GAMMA3 -,SUP-3005-1110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,858.1,600.67,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.7X45MM ACUTRAK 2 NS -,SUP-30-0645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.7X50MM ACUTRAK 2 NS -,SUP-30-0650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.3X26MM LCK POLARUS 3 HXLB DRV TI STRL -,SUP-3011-43026-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.3X46MM HXLB -,SUP-3011-43046-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.6MM/4.5MM DIA TIP/BK END 20MM CANN HDLS BIOTRAK -,SUP-3017-0009-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3465.92,2426.144,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.6MM/4.6MM DIA TIP/BK END 22MM CANN HDLS BIOTRAK -,SUP-3017-0010-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3465.92,2426.144,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM VERT 10X26X8MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM VERT 10X26X9MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM VERT 10X26X10MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM VERT 10X26X11MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM VERT 10X26X12MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM VERT 8X22X8MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.078,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM VERT 8X22X9MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.079,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM VERT 8X22X10MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM VERT 8X22X11MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.081,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM VERT 8X22X12MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM VERT 8X22X13MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.083,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM VERT 10X22X8MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.088,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM VERT 10X22X9MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.089,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM VERT 10X22X10MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM VERT 10X22X11MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.091,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM VERT 10X22X12MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.092,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM VERT 10X22X13MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.093,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM VERT 10X22X15MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM VERT 12X26X10MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.970,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM VERT 12X26X17MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.977,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LAG SCREW TI 10.5 X 75mm -,SUP-3060-0075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW GAMMA3 LAG TI 10.5X80 -,SUP-3060-0080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW GAMMA3 LAG Ti 10.5X85 -,SUP-3060-0085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 90MM -,SUP-3060-0090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW GAMMA3 LAG Ti 10.5X95 -,SUP-3060-0095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GAMMA3 LAG SCREW TI 10.5X100 -,SUP-3060-0100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW GAMMA3 LAG T1 10.5X105 -,SUP-3060-0105S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 110MM -,SUP-3060-0110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 115MM -,SUP-3060-0115S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 120MM -,SUP-3060-0120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 125MM -,SUP-3060-0125S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 130MM -,SUP-3060-0130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
U-BLADE SET TI 10.5 X 95MM -,SUP-3066-0095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2850.17,1995.119,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFT DBM 1ML PTTY OSTEOSELECT VOID FIL OSTCONDC -,SUP-309010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
OSTEOSELECT 2.5CC -,SUP-309025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1749.17,1224.419,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUBSTITUTE DBM 5ML PTTY OSTEOSELECT VOID FIL OSTCONDC -,SUP-309050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUBSTITUTE DBM 10ML PTTY OSTEOSELECT -,SUP-309100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER RADIOLUCENT 7MM CANOPY -,SUP-3102.6007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
5CC BIO4 VIABLE BONE MATRIX -,SUP-3102-2105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8594.1,6015.87,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 15.5/11X180MM GAMMA3 LT TROCH FEM TI BIOMECH STRGTH -,SUP-3120-1180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4598.63,3219.041,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TROCHANTERIC NAIL KIT 10X170MMX125DG -,SUP-3125-0170S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5413.56,3789.492,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL GAMMA3 TROCHANTARIC 180 -,SUP-3125-1180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4598.63,3219.041,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
KIT TROCHANTERIC KIT 11X180 SF -,SUP-3130-1180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4598.63,3219.041,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DRILL BIT RINGLOC + QUICK CONNECT 3.2MM X 20MM -,SUP-31-323220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
EQUINOXE SHLDR -,SUP-320-15-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK COMPR EQUINOXE F/RVRS BALL/SCKT SURG -,SUP-320-15-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SET SCREW INTNL FX EQUINOXE SHLDR RVRS TRQ DEFINING LCK -,SUP-320-20-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X22MM LCK COMPR EQUINOXE BLK F/RVRS BALL/SCKT SURG -,SUP-320-20-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X34MM LCK COMPR EQUINOXE RD F/RVRS BALL/SCKT SURG -,SUP-320-20-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LONG NAIL GAMMA KIT 11X300 RIG -,SUP-3225-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LONG GAMMA NAIL 11X320 RIGHT -,SUP-3225-0320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL KIT LONG R2.0 TI RT. GAMM -,SUP-3225-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LONG GAMMA NAIL 11X380 RIGHT -,SUP-3225-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LONG GAMMA NAIL 11X400 RIGHT -,SUP-3225-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LONG GAMMA NAIL 11X420 RIGHT -,SUP-3225-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL LONG RT GAMMA3 KIT 11MM X -,SUP-3225-0440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 15MM/13MM DIA P/D 2MM RAD LNG 340MM GAMMA3 RT TROCH -,SUP-3225-3340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX16MM CANN ASNIS III 8MM P/T SD/ST REVCT FLUT SS NS -,SUP-325016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX24MM CANN ASNIS III 8MM P/T SD/ST REVCT FLUT SS NS -,SUP-325024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW PT CANN ASNIS 4.0 X 28 -,SUP-325028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX30MM CANN ASNIS III 10MM P/T SD/ST REVCT FLUT SS -,SUP-325030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX32MM CANN ASNIS III 11MM P/T SD/ST REVCT FLUT SS -,SUP-325032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX34MM CANN ASNIS III 11.5MM P/T SD/ST REVCT FLUT SS -,SUP-325034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX34MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-325034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX36MM CANN ASNIS III 12MM P/T SD/ST REVCT FLUT SS -,SUP-325036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX38MM CANN ASNIS III 13MM P/T SD/ST REVCT FLUT SS -,SUP-325038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX40MM CANN ASNIS III 13.5MM P/T SD/ST REVCT FLUT SS -,SUP-325040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX42MM CANN ASNIS III 14MM P/T SD/ST REVCT FLUT SS -,SUP-325042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX44MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325044S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX46MM CANN ASNIS III 15.5MM P/T SD/ST REVCT FLUT SS -,SUP-325046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX46MM CANN ASNIS III 0.33IN P/T SD/ST REVCT FLUT SS -,SUP-325046S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX48MM CANN ASNIS III 16MM P/T SD/ST REVCT FLUT SS -,SUP-325048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX50MM CANN ASNIS III 17MM P/T SD/ST REVCT FLUT SS -,SUP-325050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX55MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-325060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX60MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX70MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED 4.0 X 32 -,SUP-325232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X42MM CANN FT -,SUP-325242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X44MM CANN FT -,SUP-325244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX70MM CANN ASNIS III 23.5MM P/T SD/ST REVCT FLUT SS -,SUP-325470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED 5.0 X 60MM -,SUP-325660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ASNIS III SS CANNULATED SCR 5 X 70MM -,SUP-325670S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SS CANN 6.5 X 70MM ASNIS -,SUP-326070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X75MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X80MM CANN ASNIS III P/T SD/ST REVCT FLUT SS NS -,SUP-326080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X80MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X85MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X85MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X90MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X90MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS 6.5MM 95MM -,SUP-326095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X95MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS 6.5MM 100MM -,SUP-326100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X100MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X105MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326105S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS 6.5 X 110 -,SUP-326110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X110MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X115MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326115S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X120MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW S.S. TL40 6.5 X 55 -,SUP-326255,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
6.5MM PARTIALLY THREADED 40MM SCREW 60MM LENGTH -,SUP-326260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW S.S. TL40 6.5 X 70 -,SUP-326270,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX75MM CANN ASNIS III 40MM THRD SD/ST REVCT FLUT -,SUP-326275,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX80MM CANN ASNIS III 40MM THRD SD/ST REVCT FLUT -,SUP-326280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS CAN 6.5 X 85 -,SUP-326285,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS CAN 6.5 X 90 -,SUP-326290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS CAN 6.5 X 95 -,SUP-326295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS CAN 6.5 X 95 -,SUP-326295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.94,757.358,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS CAN 6.5 X 100 -,SUP-326300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW S.S. TL40 6.5 X 110 -,SUP-326310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW S.S. TL40 6.5 X 115 -,SUP-326315,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW S.S. TL40 6.5 X 120 -,SUP-326320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1196.43,837.501,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 80 -,SUP-326480S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 85 -,SUP-326485S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED FULLY THREADED 6.5 X 90MM -,SUP-326490S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS III SS CANNULATED 6.5X95MM -,SUP-326495S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS III SS CANNULATED 6.5X100MM -,SUP-326500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS III SS CANNULATED 6.5X105MM -,SUP-326505S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS III SS CANNULATED 6.5X110MM -,SUP-326510S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS III SS CANNULATED 6.5X115MM -,SUP-326515S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS III SS CANNULATED 6.5X120MM -,SUP-326520S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS III SS CANNULATED 6.5X125MM -,SUP-326525S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS III SS CANNULATED 6.5X130MM -,SUP-326530S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS III CANN 8.0 X 70MM -,SUP-326670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW S.S. TL25 8.0 X 75 -,SUP-326675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS 8.0 X 80MM -,SUP-326680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS CANNULATED 8.0 X 85MM -,SUP-326685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8MMX90MM CANN ASNIS III 25MM P/T SD/ST REVCT FLUT SS -,SUP-326690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8MMX95MM CANN ASNIS III 25MM P/T SD/ST REVCT FLUT SS -,SUP-326695,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED PARTIALLY THREADED 8MM X 95MM TL25MM -,SUP-326695S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8MMX100MM CANN ASNIS III 25MM P/T SD/ST REVCT FLUT SS -,SUP-326700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
8 x 105MM ASNIS SCREW -,SUP-326705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
8 X 110MM ASNIS SCREW -,SUP-326710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
C/M 16MM & 25MM PLUG WITH NOZZLE -,SUP-32810503800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1313.46,919.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LONG NAIL KIT LEFT 300mm -,SUP-3325-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL LONG KIT 11X320MMX125 GAM -,SUP-3325-0320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL GAMMA LGN LEFT 11X360 -,SUP-3325-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL LONG GAMMA3 11X380 LFT -,SUP-3325-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LONG GAMMA NAIL 11X400 LEFT -,SUP-3325-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LONG GAMMA NAIL 11X420 LEFT -,SUP-3325-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LONG GAMMA NAIL 11X440 LEFT -,SUP-3325-0440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13MMLNGX340MM GAMMA3 LT TROCH FEM TI BIOMECH STRGTH -,SUP-3325-3340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OPLS 2HL STD BRL COMPR SDE 130DG ANG -,SUP-3362-1-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 130DG ANG -,SUP-3362-1-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OPLS 2HL STD BRL COMPR SDE 135DG ANG KYLS -,SUP-3362-1-102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE HIP COMP 135-5-HOLE -,SUP-3362-1-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE HIP OMEGA 135 6 HOLE - OBSOLETE DO NOT USE -,SUP-3362-1-106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OPLS SLOTX2 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OPLS SLOTX5 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OPLS SLOTX6 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OPLS SLOTX8 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OPLS SLOTX3 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-303,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OPLS SLOTX5 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-305,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2896.15,2027.305,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OPLS SLOTX6 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2896.15,2027.305,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OPLS SLOTX8 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OPLS SLOTX10 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 150DG ANG -,SUP-3362-1-404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OPLS SLOTX8 STD BRL COMPR SDE 150DG ANG -,SUP-3362-1-408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OPLS SLOTX10 STD BRL COMPR SDE 150DG ANG -,SUP-3362-1-410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3570.95,2499.665,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OPLS SLOTX12 25.4MM BRL 98DG ANG PRE- KY -,SUP-3362-2-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4883.15,3418.205,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OMG SLOTX4 STD BRL COMPR 130DG ANG KYLS -,SUP-3362-3-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OMG SLOTX2 STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OMG SLOTX3 STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-103,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OPLS 4HL STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OMG SLOTX6 STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OMG SLOTX5 STD BRL COMPR 140DG ANG KYLS -,SUP-3362-3-205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 50MM -,SUP-3362-5-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 55MM -,SUP-3362-5-055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1205.86,844.102,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 60MM -,SUP-3362-5-060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1205.86,844.102,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 65MM -,SUP-3362-5-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 70MM -,SUP-3362-5-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 75MM -,SUP-3362-5-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 80MM -,SUP-3362-5-080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 90MM -,SUP-3362-5-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 95MM -,SUP-3362-5-095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 100MM -,SUP-3362-5-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 105MM -,SUP-3362-5-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X10MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X12MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X14MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X16MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X18MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X20MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X22MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X24MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X28MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X30MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X32MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X34MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X36MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X38MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X40MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X42MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X44MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X45MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X46MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X48MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X50MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X55MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X60MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X65MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X70MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5 X 75 CORTICAL -,SUP-338675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X80MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 3.5MM X 85MM -,SUP-338685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SELF TAP CORTICAL 3.5 X 115MM -,SUP-338715,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SELF TAP CORTICAL 3.5 X 120MM -,SUP-338720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X14MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV CUT -,SUP-340614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX16MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX18MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX20MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX22MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX24MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX26MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX28MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX30MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX34MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX34MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX36MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX36MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX38MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX38MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX40MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX40MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX42MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX42MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX44MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX44MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX46MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX48MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX48MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX50MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 4.5 X 52 -,SUP-340652,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 4.5 X 54 -,SUP-340654,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX55MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX56MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340656,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX58MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340658,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 4.5 X 60MM -,SUP-340660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX65MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX75MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX35MM MATTA CANC OMEGA3 SPS 16MM P/T 3.5MM HEX -,SUP-341035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX40MM MATTA CANC OMEGA3 SPS 16MM P/T 3.5MM HEX -,SUP-341040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER KIKO CORPECTOMY SMALL 12 X 14 0 DEG 21MM -,SUP-342.721,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11547.43,8083.201,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB. -,SUP-3420-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMX320MM RT TI BIOMECH STRGTH STAB 120DG ANG -,SUP-3420-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMX340MM RT TI BIOMECH STRGTH STAB 120DG ANG -,SUP-3420-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX80MM MATTA CANC OMEGA3 SPS 32MM P/T 3.5MM HEX -,SUP-342080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX85MM MATTA CANC OMEGA3 SPS 32MM P/T 3.5MM HEX -,SUP-342085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10MMX300MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10MMX320MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10MMX340MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10MMX360MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB. -,SUP-3425-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10MMX380MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10MMX400MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LONG NAIL 10MM X 420MM X 125 DEGREES -,SUP-3425-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMX300MM GAMMA3 RT HIP TI BIOMECH STRGTH STAB -,SUP-3425-1300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMX320MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMX340MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMX360MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMX380MM GAMMA3 RT TI BIOMECH STRGTH STAB -,SUP-3425-1380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMX400MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANCL FT 6.5 X 20 -,SUP-343020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANCL FT 6.5 X 25 -,SUP-343025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANCL FT 6.5 X 30 -,SUP-343030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANCL FT 6.5 X 40 -,SUP-343040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX85MM MATTA CANC OMEGA3 SPS FT 3.5MM HEX DRV CUT -,SUP-343085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX10MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX12MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX14MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX16MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX18MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX20MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX22MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX24MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX26MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX28MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX30MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX32MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX34MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX36MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX38MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CNCL LCK 4.0 X 40 -,SUP-345440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX45MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX50MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX55MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX60MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX65MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX75MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345475,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX80MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX90MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX10MM LCK CANC AXSOS SPS 5MM P/T ST 2.5MM HEX DRV -,SUP-345510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX14MM LCK CANC AXSOS SPS 6MM P/T ST 2.5MM HEX DRV -,SUP-345514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX18MM LCK CANC AXSOS SPS 6MM P/T ST 2.5MM HEX DRV -,SUP-345518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX34MM LCK CANC AXSOS SPS 14MM P/T ST 2.5MM HEX DRV -,SUP-345534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX36MM LCK CANC AXSOS SPS 14MM P/T ST 2.5MM HEX DRV -,SUP-345536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX38MM LCK CANC AXSOS SPS 14MM P/T ST 2.5MM HEX DRV -,SUP-345538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX40MM LCK CANC AXSOS SPS P/T ST 2.5MM HEX DRV CUT -,SUP-345540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX45MM LCK CANC AXSOS SPS 15MM P/T ST 2.5MM HEX DRV -,SUP-345545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX50MM LCK CANC AXSOS SPS 15MM P/T ST 2.5MM HEX DRV -,SUP-345550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX55MM LCK CANC AXSOS SPS 16MM P/T ST 2.5MM HEX DRV -,SUP-345555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX60MM LCK CANC AXSOS SPS 16MM P/T ST 2.5MM HEX DRV -,SUP-345560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX70MM LCK CANC AXSOS SPS P/T ST 2.5MM HEX DRV CUT -,SUP-345570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX80MM LCK CANC AXSOS SPS P/T ST 2.5MM HEX DRV CUT -,SUP-345580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX8MM CORT AXSOS ISO SPS FT ST 2.5MM HEX DRV CUT -,SUP-349608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 2.7 X 14MM -,SUP-349614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX16MM CORT AXSOS ISO SPS FT ST 2.5MM HEX DRV CUT -,SUP-349616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX18MM CORT AXSOS ISO SPS FT ST 2.5MM HEX DRV CUT -,SUP-349618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CORTEX SCREW SELF TAPPING STEEL 2.7MM X 60MM -,SUP-349660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,127.9,89.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ASSEMBLY CBL CRLGE TI CBL LOCK SPRCBL ISO-ELAS -,SUP-35-100-1010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2597.25,1818.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CABLE ORTHO SUPERCABLE 1.5MM CERVICAL CERCLAGE -,SUP-35-100-1040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2477.71,1734.397,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE KINAMED 2 HOLE SUPERCABLE -,SUP-35-200-1020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8377.66,5864.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN SPRCBL 190MM 4HL TI TROCH GRP -,SUP-35-200-1030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10233.03,7163.121,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMX340MM GAMMA3 LT TI 120DG ANG -,SUP-3520-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMX360MM GAMMA3 LT TI 120DG ANG -,SUP-3520-1360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMX380MM GAMMA3 LT TI 120DG ANG -,SUP-3520-1380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CABLE ORTHO SUPER CBL TI PLATE 6HL -,SUP-35-220-1010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5831.26,4081.882,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CABLE-PLATE 8 HOLE STRAIGHT -,SUP-35-220-2010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7363.34,5154.338,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUPERCABLE GRIP AND PLATE 10 HOLE STRAIGHT -,SUP-35-220-3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9661.23,6762.861,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN SPRCBL 290MM 10HL TI TROCH GRP -,SUP-35-220-3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10530.07,7371.049,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRIP AND PLATE SYSTEM COMPRESSION BONE SCREW 4.5X12MM -,SUP-35-230-4512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,250.91,175.637,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUPERCABLE GRIP AND PLATE SYS COP BONE SCREW 4.5 X 14MM -,SUP-35-230-4514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,250.91,175.637,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRIP AND PLATE COMPRESSION BONE SCREW 4.5 X 16MM -,SUP-35-230-4516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,250.91,175.637,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUPERCABLE BONE SCREW 4.5 X 30 -,SUP-35-230-4530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUPERCABLE BONE SCREW 4.5 X 32 -,SUP-35-230-4532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE SUPERCABLE GRIP AND PLATE COMP  4.5 X 34 -,SUP-35-230-4534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X36MM COMPR SPRCBL F/GRP PLATE SYS -,SUP-35-230-4536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X38MM COMPR SPRCBL F/GRP PLATE SYS -,SUP-35-230-4538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X40MM COMPR SPRCBL F/GRP PLATE SYS -,SUP-35-230-4540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRIP AND PLATE SYS COMP BONE SCREW 4.5MM X 45MM -,SUP-35-230-4545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
KINAMED SUPERCABLE SCREW -,SUP-35-230-4550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X12MM LCK SPRCBL F/GRP PLATE SYS -,SUP-35-234-5012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X16MM LCK SPRCBL F/GRP PLATE SYS -,SUP-35-234-5016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X18MM LCK SPRCBL F/GRP PLATE SYS -,SUP-35-234-5018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE SUPERCABLE GRIP AND PLATE LOCK 5 X 20 -,SUP-35-234-5020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10MMX300MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10MMX340MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10MMX380MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
"NAIL LONG KIT R1.5 TI LEFT 010 X 125"" -",SUP-3525-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMX420MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMX440MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMX300MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMX320MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMX340MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMX380MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11MMX400MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
"NAIL LONG KIT R15 TI 011 X 400MM X 125"" LEFT GAMMAX3 SYS -",SUP-3525-1400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL LONG KIT R1 5 TI LEFT -,SUP-3525-1420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GAMMA LONG NAIL KIT R1.5 LEFT 11X440MM -,SUP-3525-1440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB. -,SUP-3530-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DBM PUTTY - OSTEOSELECT 2.5CC -,SUP-359025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1749.17,1224.419,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DBM PUTTY - OSTEOSELECT 5CC -,SUP-359050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DBM PUTTY - OSTEOSELECT 10CC -,SUP-359100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN FX STNMN 2.8X230MM SMTH TROC PNT 3-SDE SHNK SS -,SUP-3611-3-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13.5,9.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SET SCREW -,SUP-36-2001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TULIP BODY -,SUP-36-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
REDUCTION HEAD -,SUP-36-2103,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW JANUS ORTHOFIX 4.5 X 30 -,SUP-36-2430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5MM X 35 ORTHOFIX -,SUP-36-2535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW JANUS ORTHOFIX 5.5 X 40 -,SUP-36-2540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SREW ORTHOFIX FIREBIRD 5.5 X 45MM -,SUP-36-2545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MM X 30MM ORTHOFIX -,SUP-36-2630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW JANUS 6.5X35MM ORTHOFIX -,SUP-36-2635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW JANUS ORTHOFIX 6.5 X 40 -,SUP-36-2640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW JANUS CANN 5.5 X 35 -,SUP-36-3535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW JANUS CANN 5.5 X 40 -,SUP-36-3540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW JANUS CANN 5.5 X 45 -,SUP-36-3545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW JANUS CANN 65 X 35 -,SUP-36-3635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW JANUS CANN 65 X 45 -,SUP-36-3645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5 X 25MM ORTHOFIX -,SUP-36-4425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW JANUS 4.5 X 30MM FENESTRATE ORTHOFIX -,SUP-36-4430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW JANUS 4.5 X 35MM FENESTRATE ORTHOFIX -,SUP-36-4435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW JANUS ORTHOFIX 6.5 X 30MM -,SUP-36-4630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW JANUS ORTHOFIX 6.5 X 35MM -,SUP-36-4635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER ACDF COLONIAL 12 X 14 X 6MM 7 DEGREE -,SUP-365.406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER ACDF COLONIAL 12 X 14 X 8MM 7 DEGREE -,SUP-365.408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X10MM LCK AXSOS ST T20 DRV SS NS -,SUP-370110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X12MM LCK AXSOS ST T20 DRV SS NS -,SUP-370112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X14MM LCK AXSOS ST.T20 DRV SS NS -,SUP-370114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X16MM LCK AXSOS ST T20 DRV SS NS -,SUP-370116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X14MM LCK AXSOS ST-T20 DRV SS NS -,SUP-370118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X14MM LCK AXSOS ST..T20 DRV SS NS -,SUP-370120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X14MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.17,457.219,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X26MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X28MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X30MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X32MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X34MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X36MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X40MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X44MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X65MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X70MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X75MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X80MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X85MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370385,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X90MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X95MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CABLE ORTHO 1.6MM DLMLS HIP SS BEAD SM SLV -,SUP-3704-0-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CABLE/SLEEVE FX 0.2MM DLMLS SS BEAD -,SUP-3704-0-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN DLMLS 165MM 4.5MM 5HL RECON SC SS BRD GROOVEX6 -,SUP-3704-3-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN DLMLS F/RECON TRMA 7HL GROOVEX8 RECON COMPR SS -,SUP-3704-3-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN DLMLS 254MM 4.5MM 9HL RECON SC SS BRD GROOVEX10 -,SUP-3704-3-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN DLMLS 305MM 4.5MM 11HL RECON SC SS GROOVEX12 -,SUP-3704-3-130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CABLE ORTHO 2MM HIP SS -,SUP-3704-8-240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS -,SUP-370528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS. -,SUP-370532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS- -,SUP-370538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS_ -,SUP-370540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS.NS -,SUP-370542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS.. -,SUP-370544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS -,SUP-370546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS__ -,SUP-370570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS-- -,SUP-370575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK AXSOS ST T15 DRV-SS NS -,SUP-370585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK ST 3.0 X 10 -,SUP-371010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,301.9,211.33,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X16MM LCK AXSOS -,SUP-371016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,301.9,211.33,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X14MM LCK AXSOS ST.T20 DRV SS NS DIST LAT PERIART -,SUP-371314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCK 5.0 X 16 -,SUP-371316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X14MM LCK AXSOS ST_T20 DRV SS NS DIST LAT PERIART -,SUP-371318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X14MM LCK AXSOS ST T20 DRV SS NS DIST LAT PERIART -,SUP-371320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X22MM LCK AXSOS ST T20 DRV SS NS -,SUP-371322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X26MM LCK AXSOS ST T20 DRV SS NS -,SUP-371326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X28MM LCK AXSOS ST T20 DRV SS NS -,SUP-371328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCK 5.0 X 30 -,SUP-371330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X32MM LCK AXSOS ST T20 DRV SS NS -,SUP-371332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X34MM LCK AXSOS ST T20 DRV SS NS -,SUP-371334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X36MM LCK AXSOS ST T20 DRV SS NS -,SUP-371336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X38MM LCK AXSOS ST T20 DRV SS NS -,SUP-371338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X40MM LCK AXSOS ST T20 DRV SS NS -,SUP-371340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X42MM LCK AXSOS ST T20 DRV SS NS -,SUP-371342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X44MM LCK AXSOS ST T20 DRV SS NS -,SUP-371344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X46MM LCK AXSOS ST T20 DRV SS NS -,SUP-371346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X48MM LCK AXSOS ST T20 DRV SS NS -,SUP-371348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X50MM LCK AXSOS ST T20 DRV SS NS -,SUP-371350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X60MM LCK AXSOS ST T20 DRV SS NS -,SUP-371360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X70MM LCK AXSOS ST T20 DRV SS NS -,SUP-371370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X75MM LCK AXSOS ST T20 DRV SS NS -,SUP-371375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X80MM LCK AXSOS ST T20 DRV SS NS -,SUP-371380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X90MM LCK AXSOS ST T20 DRV SS NS -,SUP-371390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X95MM LCK AXSOS ST T20 DRV SS NS -,SUP-371395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK 4.0 X 14 -,SUP-371514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X16MM LCK AXSOS ST T15 DRV SS NS -,SUP-371516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X20MM LCK AXSOS ST T15 DRV SS NS -,SUP-371520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X22MM LCK AXSOS ST T15 DRV SS NS -,SUP-371522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X24MM LCK AXSOS ST T15 DRV SS NS -,SUP-371524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X26MM LCK AXSOS ST T15 DRV SS NS -,SUP-371526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK AXSOS ST_T15 DRV SS NS PERIART -,SUP-371528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X30MM LCK AXSOS ST T15 DRV SS NS -,SUP-371530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK AXSOS ST.T15 DRV SS NS PERIART -,SUP-371532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X34MM LCK AXSOS ST T15 DRV SS NS -,SUP-371534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X36MM LCK AXSOS ST T15 DRV SS NS -,SUP-371536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK AXSOS ST-T15 DRV SS NS PERIART -,SUP-371538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS.PERIART -,SUP-371542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS_PERIART -,SUP-371544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS-PERIART -,SUP-371546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X48MM LCK AXSOS ST T15 DRV SS NS -,SUP-371548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X50MM LCK AXSOS ST T15 DRV SS NS -,SUP-371550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X55MM LCK AXSOS ST T15 DRV SS NS -,SUP-371555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X60MM LCK AXSOS ST T15 DRV SS NS -,SUP-371560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X65MM LCK AXSOS ST T15 DRV SS NS -,SUP-371565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM-LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM.LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X80MM LCK AXSOS ST T15 DRV SS NS -,SUP-371580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM_LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X95MM LCK AXSOS ST T15 DRV SS NS -,SUP-371595,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 2.4MM -,SUP-373-0224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BIT DRILL 6MM BN -,SUP-3815-1-660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,371.28,259.896,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM 12X14X6MM COALITION 0DG -,SUP-384.006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER THORLUM 12X14X8MM COALITION 0DG -,SUP-384.008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 2.8MMX23CM THRD TIP -,SUP-3861-0-628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,82.92,58.044,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO 13MM ASNIS III 6.5/8.0MM SS RND NS -,SUP-390016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,182.99,128.093,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO 4MM ASNIS III F/4MM BN SCR SS RND NS -,SUP-390018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,132.57,92.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO 4.1MM ASNIS III F/9MM BN SCR SS RND NS -,SUP-390019,CDM,C1713,HCPCS,278,RC,,,outpatient,,,145.64,101.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
REDUCTION PIN 4.5MM DIA 150MM -,SUP-390082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,624.75,437.325,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT 5.5MM ZIP PEEK #2 SUT FORCE FIB NDL -,SUP-3910-200-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT 5.5MM ZIP PEEK #2 SUTX2 FORCE FIB -,SUP-3910-200-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT 5.5MM ZIP PEEK #2 SUTX2 FORCE FIB -,SUP-3910-200-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT 6.5MM ZIP PEEK #2 SUTX2 FORCE FIB 1/2CIR TAPR NDL -,SUP-3910-200-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT 6.5MM ZIP PEEK #2 SUTX2 FORCE FIB -,SUP-3910-200-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT INTRALINE 4.5MM HA/PLLA COMP BIOSTEON SUTX2 W/O -,SUP-3910-200-080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2648.5,1853.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT TWINLOOP 3.5MM ZIP PEEK #2 SUT FORCE FIB -,SUP-3910-400-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1151.37,805.959,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT TWINLOOP 3.5MM ZIP PEEK #2 SUTX2 FORCE FIB EYLT -,SUP-3910-400-235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2055.64,1438.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT ICONIX 2.3MM PILOT HL 3 STRN #2 FORCE FIB PLYSTR -,SUP-3910-500-532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2376.27,1663.389,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAP PROT STRL F/2.5MM K-WR -,SUP-392.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5.72,4.004,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAP ORTHO -,SUP-393.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11.67,8.169,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAP PROT F/11MM CFBR EXTFIX ROD -,SUP-394.970,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5.02,3.514,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAP PROT F/4.0MM CRBN FIBRE BAR ROD BLK -,SUP-394.990,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5.43,3.801,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAP PROT NS F/4MM FX PIN YEL -,SUP-394.991,CDM,C1713,HCPCS,278,RC,,,outpatient,,,28.24,19.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
HYDROSET HA BONE SUB 3CC -,SUP-397003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4410.87,3087.609,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
HYDROSET BONE SUB 15CC -,SUP-397015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17072.08,11950.456,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 150MM POLARUS 3 PROX HUM LCK -,SUP-4001-1015R-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10270.16,7189.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X90MM COMPR DL -TRAK CUT FLUT TI ALY NS -,SUP-40-0137,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6336.29,4435.403,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUBSTITUTE CANC 30ML CHP FRZDR VOID FIL 1.7-10MM -,SUP-400150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1681.8,1177.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFT HUM TIS WDG FRZDR 10-17 MMX14-20MM TRCORT ILC CRST -,SUP-400405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4361,3052.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTEX TI SLF TPNG 2.4 X 10 T8 SD REC -,SUP-401.760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,656.44,459.508,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTEX TI SLF TPNG 2.4 X 14 T8 SD REC -,SUP-401.764,CDM,C1713,HCPCS,278,RC,,,outpatient,,,656.44,459.508,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTEX TI SLF TPNG 2.4 X 30 T8 SD REC -,SUP-401.780,CDM,C1713,HCPCS,278,RC,,,outpatient,,,656.44,459.508,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SMALL CALCANEOUS FOOT -,SUP-40-10102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2915.48,2040.836,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CALCANEUS SMALL STANDARD -,SUP-40-10112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2915.48,2040.836,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CALCANEUS STANDARD LARGE -,SUP-40-10116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2915.48,2040.836,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 36MM 2.7MM 4HL RECON POLYAX LCK TI NS -,SUP-40-15011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2418.35,1692.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CURVED PLATE 5 HOLES RIGHT -,SUP-40-15012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.07,1837.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 49MM 2.7MM 6HL RECON POLYAX LCK TI NS -,SUP-40-15014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2657.78,1860.446,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
H-PLATE SMALL -,SUP-40-15021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2050.76,1435.532,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE MED-H -,SUP-40-15022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2610.76,1827.532,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE LARGE -,SUP-40-15023,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2451.75,1716.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
RECTANGLE PLATE SZ 1 -,SUP-40-15032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2451.75,1716.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 48MM 2.7/3.5MM 5HL 1MM RECON POLYAX LCK TI -,SUP-40-15041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2439.24,1707.468,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
VARIAX FOOT PLATE -,SUP-40-15042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2547.84,1783.488,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 51MM 2.7/3.5MM 6HL 1MM RECON POLYAX LCK TI -,SUP-40-15062,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2785.68,1949.976,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 35MM 2.7MM 4HL RECON POLYAX LCK TI NS -,SUP-40-15081,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1737.5,1216.25,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MMX8MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MMX9MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MMX10MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MMX11MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MMX12MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MMX13MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MMX14MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MMX15MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MMX16MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MMX18MM CANN ASNIS 5MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MMX20MM CANN ASNIS 5MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MMX22MM CANN ASNIS 5MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MMX24MM CANN ASNIS 6MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MMX26MM CANN ASNIS 6MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MMX28MM CANN ASNIS 6MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 28.5MM 2MM 2HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 60MM 2MM 4HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1910.88,1337.616,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 72MM 2MM 5HL 2MM PRCONT POLYAX TI STR SMRTLC -,SUP-40-20805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 84MM 2MM 6HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20806,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 96MM 2MM 7HL 2MM PRCONT POLYAX TI STR SMRTLC -,SUP-40-20807,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 108MM 2MM 8HL 2MM PRCONT POLYAX TI STR -,SUP-40-20808,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 132MM 2MM 10HL 2MM PRCONT POLYAX TI STR -,SUP-40-20810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1812.72,1268.904,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 156MM 2MM 12HL 2MM PRCONT POLYAX TI STR -,SUP-40-20812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2549.91,1784.937,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO 2MM ASNIS MICRO F/CANN SCR SYS NS -,SUP-40-20900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,304.88,213.416,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 77MM 2MM 3HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.1,1787.87,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 89MM 2MM 4HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.1,1787.87,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 101MM 2MM 5HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.1,1787.87,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 113MM 2MM 6HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2388.81,1672.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 125MM 2MM 7HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2591.95,1814.365,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 137MM 2MM 8HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20908,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2591.95,1814.365,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 149MM 2MM 9HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20909,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2591.95,1814.365,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TOTAL JNT SUBCHONDROPLASTY -,SUP-402201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11788.78,8252.146,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X14MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X16MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X18MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON-LOCKING 2.7 X 20MM -,SUP-40-27020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X22MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X24MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X26MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X28MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T7 2.7 X 38MM -,SUP-40-27038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T7 2.7 X 40 -,SUP-40-27040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T7 2.7 X 45MM -,SUP-40-27045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X12MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-2761,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X10MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X16MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X18MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X20MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X22MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X24MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X26MM LCK -,SUP-4027626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X28MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX8MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX10MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX12MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX13MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX14MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX15MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX16MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX17MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX18MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.48,659.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
MICRO ASNIS SCREW 3.0MM X 18MM -,SUP-40-30118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX19MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30119,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX20MM CANN ASNIS THRD REVCT FLUT TI NS PUR -,SUP-40-30120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX22MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX24MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX26MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX28MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX30MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX32MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX34MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.0 MICRO ASNIS SCREW -,SUP-40-30134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX36MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX40MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO 3MM ASNIS MICRO F/CANN SCR SYS NS -,SUP-40-30900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,339.01,237.307,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X10MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X12MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X14MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X16MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X18MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X20MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X22MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X24MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X28MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X30MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X32MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X34MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X36MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X38MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X40MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X42MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X44MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X46MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X48MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X50MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X55MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X60MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X65MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X70MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X10MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X12MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X14MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X16MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X18MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X20MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X22MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X24MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.5MM LOCKING 28MM SCREW -,SUP-40-35628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.5MM LOCKING 34MM SCREW -,SUP-40-35634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X40MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO F/3.5MM BN SCR -,SUP-40-35900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,376.01,263.207,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX28MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX36MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.836,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX38MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.838,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX55MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.855,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EXHAL SZ 8-32X.375 -,SUP-4-072623-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6.48,4.536,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 2.4MMX23CM -,SUP-410236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,407.52,285.264,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SET SCREWS MARINER SPINE -,SUP-41-1010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
POLYAXIAL HEAD G2 -,SUP-41-3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
HEAD SCREW SEASPINE MARINER POLY EXTEND -,SUP-41-4010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
30MM OFFSET -,SUP-41-4130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLUG CEMENT SMALL DIA 10MM -,SUP-414994,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLUG CEMENT SMALL DIA 12MM -,SUP-414995,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE SCREW 5.5 X 30MM -,SUP-41-5530-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
MARINER SOLD SCREW 5.5 X35MM -,SUP-41-5535-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SEASPINE MARINER SOLID 5.5MM X 35MM -,SUP-41-5535-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE SCREW 5.5 X 40 -,SUP-41-5540-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5 X 45MM -,SUP-41-5545-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SEASPINE MARINER SOLID 6.5MM X 35MM -,SUP-41-6535-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE SCREW 6.5 X 45MM -,SUP-41-6545-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.5 X 70MM -,SUP-41-7570-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO TRUMATCH RT -,SUP-420901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6242.92,4370.044,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO TRUMATCH LT -,SUP-420902,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4990.94,3493.658,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN SZ5 ATTUNE TRUMATCH LT KN -,SUP-420945,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC 100X100MM MATRIXNEURO LPRO MSH 0.6MM TI SQ -,SUP-421.534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8428.58,5900.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X26MM LCK CANN SD 3.5MM HEX RCESS CNCL HEAD TI NS -,SUP-422.392,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1537.15,1076.005,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X55MM LCK CANN SD 3.5MM HEX RCESS CNCL HEAD TI NS -,SUP-422.394,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1515.94,1061.158,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X65MM LCK CANN SD 3.5MM HEX RCESS CNCL HEAD TI NS -,SUP-422.395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1515.94,1061.158,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BEARING FIXED ASF UC 14MM PLY R 4-11 EF PERSONA -,SUP-42-5212-005-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SYSTEM KNEE PERSONA ASF UC 35MM PLY R 7-12 GH 9.0 THICKNESS -,SUP-42-5400-000-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CURVED PELVIC R 108MM/L58.5MM/4HOLE -,SUP-425604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CURV PELV R 108MM L74.5MM 5 HOLE -,SUP-425605,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 8 HOLE -,SUP-425608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
10 HOLE PLATE -,SUP-425610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CURV. PELV 108MM/L186.5MM/12H -,SUP-425612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PELV CURV R 108MM L218.5MM 14HOLE -,SUP-425614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PELV CURV R 108MM L250.5MM 16 HOLE -,SUP-425616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5273.81,3691.667,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PELV CURV R 108MM L282.5MM 18H -,SUP-425618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5273.81,3691.667,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PELV CURV R 108MM L314.5MM 20H -,SUP-425620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5273.81,3691.667,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SYMPYSIS -,SUP-425654,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 10.5MMX74.5MM F/3.5MM/4.5MM SCR 4HL MATTA SS 88MM -,SUP-425655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 6 HOLE R88 PELVIS -,SUP-425656,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 8HOLE R88 -,SUP-425658,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PELV CURVED R 88MM/L154.5MM/10H -,SUP-425660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE R88 12 HOLE -,SUP-425662,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE R88 CURVED 218.5 14 HOLE -,SUP-425664,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 16 HOLE R88 PELVIS -,SUP-425666,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PELV CURV R 88MM L282.5 18H -,SUP-425668,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PELV CURV R 88MM L314.5MM 20H -,SUP-425670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PELV STRAIGHT L 26.5MM -,SUP-425702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4046.3,2832.41,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PELVIC PLATE -,SUP-425753,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4676.37,3273.459,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE STRT ACET L 46.5MM 14 HOLE -,SUP-425754,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4676.37,3273.459,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE STRAIGHT ACET L 70.5M 6 HOLE -,SUP-425756,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4571.81,3200.267,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 8HOLE FLEX -,SUP-425758,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4571.81,3200.267,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 10 HOLE FLEX -,SUP-425760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4571.81,3200.267,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE STRT ACET L 142.5MM 12 HOLE -,SUP-425762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5044.63,3531.241,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SYMPHYSIS 4 HOLE -,SUP-425794,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6110.34,4277.238,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PRO SUPRAPECTINEAL QLS LEFT -,SUP-425912S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.77,7018.039,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
INFRAPECTINEAL PLATE SMALL QLS LEFT -,SUP-425932S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8017.17,5612.019,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 45MM 4MM 3HL LCK COMPR SS WAIST SM FRAG NS -,SUP-427003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,557.83,390.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 71MM 4MM 5HL LCK COMPR SS WAIST SM FRAG NS -,SUP-427005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,716.54,501.578,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 97MM 4MM 7HL LCK COMPR SS WAIST RND TAPR END -,SUP-427007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,716.54,501.578,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 110MM 4MM 8HL LCK COMPR SS WAIST RND TAPR END -,SUP-427008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,795.89,557.123,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 123MM 4MM 9HL LCK COMPR SS WAIST SM FRAG STRL -,SUP-427009S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,795.89,557.123,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 136MM 4MM 10HL LCK COMPR SS WAIST RND TAPR -,SUP-427010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,795.89,557.123,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 266MM 4MM 20HL LCK COMPR SS WAIST SM FRAG NS -,SUP-427020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.32,779.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 48MM 4MM 4HL RECON LCK COMPR SS SM FRAG NS -,SUP-427034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1836.09,1285.263,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 60MM 4MM 5HL RECON LCK COMPR SS SM FRAG NS -,SUP-427035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1836.09,1285.263,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 72MM 4MM 6HL RECON LCK COMPR SS ADLT SM FRAG -,SUP-427036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2071.44,1450.008,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 96MM 4MM 8HL RECON LCK COMPR SS ADLT SM FRAG -,SUP-427038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2298.3,1608.81,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 76MM 3MM 6HL LCK SS 1/3 TBLR SM FRAG NS -,SUP-427066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,669.86,468.902,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 89MM 3MM 8HL LCK SS 1/3 TBLR SM FRAG NS -,SUP-427068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,725.87,508.109,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 169MM 5MM 9HL LCK COMPR SS NRW WAIST BSC FRAG -,SUP-427109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,898.59,629.013,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 223MM 5MM 12HL LCK COMPR SS NRW WAIST BSC -,SUP-427112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1075.97,753.179,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 259MM 5MM 14HL LCK COMPR SS NRW WAIST BSC -,SUP-427114S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1075.97,753.179,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE WSTD CMP BRD HL8 -,SUP-427138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 173MM 5MM 9HL LCK COMPR SS BRD WAIST BSC FRAG -,SUP-427139S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 263MM 5MM 14HL LCK COMPR SS BRD WAIST BSC ST -,SUP-427144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1159.75,811.825,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFT HUM TIS HEMI FRZN 10-10.5 MMX8-13CM PTLR TNDN 30-75MM -,SUP-430007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11007.78,7705.446,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 10X60MM F/3.5MM/4MM SCR 5HL SHFT 2.8MM RECON -,SUP-430105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.67,1007.769,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 25MM 3MM 2HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,234.51,164.157,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 38MM 3MM 3HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,234.51,164.157,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 64MM 3MM 5HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,289.01,202.307,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 77MM 3MM 6HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,289.01,202.307,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 90MM 3MM 7HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.42,222.194,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 103MM 3MM 8HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,355.35,248.745,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 129MM 3MM 10HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,355.35,248.745,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
MESH TITANIUM 6X6 - DISCONTINUED DO NOT USE -,SUP-43-1022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 10X49MM F/3.5MM/4.5MM SCR 0.75HL HD/SHFT 1.2MM SS -,SUP-431024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,634.85,444.395,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 10X66MM F/3.5MM/4.5MM SCR HLX3/6 HD/SHFT 1.2MM SS -,SUP-431026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,871.75,610.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
MOLD CMNT SPCR 48MM SIL SS STAGEONE STRL -,SUP-431181,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5199.96,3639.972,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
HIP HEAD CEMENT MOLD 52MM -,SUP-431182,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5199.96,3639.972,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SHOULDER MOLD 12STD 54 X 21 X 64 -,SUP-431412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11946.58,8362.606,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
60MM FEMORAL KNEE CEMENT MOLD -,SUP-432160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8413.73,5889.611,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
MOLD BNCMNT FEM 65MM SIL STAGEONE STRL -,SUP-432165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8413.73,5889.611,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 158MM 4.5MM 10HL RECON SS -,SUP-432210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1420.32,994.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE RECON HL 4.5 X 14 HOLE -,SUP-432214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.92,1168.944,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE T 6 HOLE L=111MM -,SUP-433106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.57,778.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
70MM TIBIAL KNEE CEMENT MOLD -,SUP-433170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4530.53,3171.371,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
MOLD BNCMNT TIB 75MM SIL STAGEONE STRL -,SUP-433175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4530.53,3171.371,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 86MM 4MM 3HL CONTR LCK SS NS 1STRN/PK -,SUP-437123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5167.49,3617.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 112MM 4MM 5HL CONTR LCK SS NS -,SUP-437125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5167.49,3617.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 95MM 4MM HLX2/5 SHFT/METPHYSL CONTR LCK SS NS -,SUP-437302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 121MM 4MM HLX4/5 SHFT/METPHYSL CONTR LT TIB -,SUP-437304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 147MM 4MM HLX6/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 121MM 4MM HLX4/5 SHFT/METPHYSL CONTR RT TIB -,SUP-437324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 173MM 4MM HLX8/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 97MM 4MM HLX4/3 SHFT/METPHYSL CONTR LCK SS -,SUP-437424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4738,3316.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 166MM 5MM HLX6/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5434.02,3803.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 202MM 5MM HLX8/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 238MM 5MM HLX10/5 SHFT/METPHYSL CONTR LCK SS. -,SUP-437510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 310MM 5MM HLX14/5 SHFT/METPHYSL CONTR LCK SS- -,SUP-437514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 238MM 5MM HLX10/5 SHFT/METPHYSL CONTR LCK SS- -,SUP-437530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 310MM 5MM HLX14/5 SHFT/METPHYSL CONTR LCK SS. -,SUP-437534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 343MM 5MM HLX16/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LINER 32X49MM EPSLN STD DRSUL PRIM HOOD -,SUP-4377-32-049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3174.71,2222.297,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SET SCREW SPIN STD FIREBIRD TI -,SUP-44-2001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FIREBIRD TOP LOADING HEAD -,SUP-44-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX 4.5 X 30 SCREW -,SUP-44-5430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX SCREW 4.5 X 35 -,SUP-44-5435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX SCREW 4.5 X 40 -,SUP-44-5440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX SCREW 4.5 X 45 -,SUP-44-5445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX SCREW 5.5 X 30 -,SUP-44-5530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX SCREW 5.5 X 35 -,SUP-44-5535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX SCREW 5.5 X 40 -,SUP-44-5540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX SCREW 5.5 X 45 -,SUP-44-5545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX SCREW 6.5 X 30 -,SUP-44-5630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
6.5 X 35 SHANK -,SUP-44-5635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
6.5 X 40 SHANK -,SUP-44-5640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
6.5 X 45 SHANK -,SUP-44-5645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
7.5 X 40 SHANK -,SUP-44-5740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FIREBIRD ORTHOFIX 7.5 X 45 -,SUP-44-5745,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX SCREW 7.5 X 50 -,SUP-44-5750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX SCREW 6.5 X 35 -,SUP-44-6535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX SCREW 6.5 X 40 -,SUP-44-6540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER 3.5 -,SUP-45-35900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,139.05,97.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
MICROCOIL EMBL 4MMX 5CML AZUR DTCH 18 -,SUP-45-480405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3570.95,2499.665,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT PHALANX 2MM PRO- TOE VO 13MM 10DG ANG -,SUP-45712010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
MINI STICK MAX 5FR X 10CM -,SUP-45-756,CDM,C1713,HCPCS,278,RC,,,outpatient,,,431.21,301.847,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COUNTERSINK FOR SCREWS 02.7/3.5mm AO FITTING -,SUP-45-80040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,516.4,361.48,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X12MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115401200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X16MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115401600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X18MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115401800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X20MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115402000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER SYSTEM CONSTRUX MINI PEEK -,SUP-47-3009SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X10MM CORT SM HX DRV -,SUP-4820-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.04,88.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX24MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-48-3502-41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COUPLING DELTA ROD TO ROD MULTI 05/8/11 5MM PIN -,SUP-4922-1-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4759.25,3331.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CLAMP 5 HOLE PIN -,SUP-4922-2-020-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3516.77,2461.739,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD VECTRAN COATED 11MM X 100MM CARBON CONN -,SUP-4922-8-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1854.96,1298.472,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WIRE BOLT SHORT -,SUP-4933-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,750.96,525.672,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WIRE BOLT MEDIUM -,SUP-4933-1-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,750.96,525.672,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WIRE BOLT ADAPTER SHORT -,SUP-4933-1-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1798.46,1258.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
M8 CONNECTING NUT -,SUP-4933-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,199.56,139.692,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
POST EXTERNAL FIXATION SHORT L44 MM OD8 MM HOFFMANN -,SUP-4933-1-644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,819.23,573.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BOLT FOR RING -,SUP-4933-1-702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,220.56,154.392,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER YELLOW 2MM -,SUP-4933-1-711,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.1,249.97,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CARBON FIBER FULL RING 210MM -,SUP-4933-5-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10863.87,7604.709,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CARBON FIBER OPEN RING 180MM -,SUP-4933-6-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9858.39,6900.873,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CARBON FIBER OPEN RING 210MM -,SUP-4933-6-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9316.66,6521.662,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WIRE WITH OLIVE 1.8 X 450 -,SUP-4933-8-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,850.74,595.518,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
K-WIRE 2.0 OLIVE -,SUP-4933-8-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,887.5,621.25,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
HII COMPACT MRI PERIARTICULAR PIN CLAMP -,SUP-4941-2-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1539.11,1077.377,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SYNMESH 15MM DIA 8MM HEIGHT ROUND CAGE -,SUP-495.361,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9527.78,6669.446,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
END RING 10MM DIAM / 0 DEG -,SUP-495.384,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1024.04,716.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SYNMESH 10MM DIAM 20MM HEIGHT -,SUP-495.603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9664.94,6765.458,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CRNMXF UPR FACE 1.2X5MM UNIVERSAL NEURO II ST TI NS -,SUP-50-12005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,372.97,261.079,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CRNMXF UPR FACE 1.2X10MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-12010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,372.97,261.079,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CRNMXF UPR FACE 1.2X12MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-12012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,372.97,261.079,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CRNMXF UPR FACE 1.2X3MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-12903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,417.55,292.285,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN WND CLSR 200MM -,SUP-5014-5-200S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,680.36,476.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CANC HALF-PIN 5MM SHAFT 6MM X 250 THREAD -,SUP-5015-7-250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CRNMXF MIDFC 1.7X6MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-17006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.31,222.117,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CRNMXF MIDFC 1.7X8MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-17008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.31,222.117,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CRNMXF MIDFC 1.7X10MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-17010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.31,222.117,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ER CRNMXF MIDFC 1.7X4MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-17304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,441.77,309.239,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK CRNMXF MIDFC 1.7X4MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-17504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,416.09,291.263,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK CRNMXF MIDFC 1.7X5MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-17505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,416.09,291.263,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
HALF PIN FX APEX 5MM SS HA CTD SD/TAP180MML 50MM THRD -,SUP-5017-5-180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,642.67,449.869,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CRNMXF MIDFC 1.7X3MM CX PIN HD UNIVERSAL NEURO II SD -,SUP-50-17903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,356.29,249.403,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CRNMXF MIDFC 1.7X4MM CX PIN HD UNIVERSAL NEURO II ST. -,SUP-50-17904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,356.29,249.403,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN EXTFIX 5X150MM SS APEX 40MM THRD SD/ST -,SUP-5018-5-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
HALFPIN EXTFIX 5X150MM SS APEX 50MM THRD SD/ST -,SUP-5018-6-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN EXTFIX 5X50MM HLF SS APEX 180MM THRD SD -,SUP-5018-6-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CRNMXF MIDFC 1.9X3MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-19003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,348.64,244.048,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CRNMXF MAND 2X4MM CX PIN HD UNIVERSAL NEURO II ST TI -,SUP-50-20404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.62,210.434,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CRNMXF MAND 2X6MM CX PIN HD UNIVERSAL NEURO II ST TI -,SUP-50-20406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.62,210.434,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CRNMXF MAND 2X8MM CX PIN HD UNIVERSAL NEURO II ST TI -,SUP-50-20408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.62,210.434,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK CRNMXF MAND 2X12MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-20512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,551.06,385.742,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK CRNMXF MAND 2X14MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-20514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,551.06,385.742,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK CRNMXF MAND 2X16MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-20516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,551.06,385.742,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SELF DRILLING LOCKING 2 X 6MM -,SUP-50-20596,CDM,C1713,HCPCS,278,RC,,,outpatient,,,830.96,581.672,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN EXTFIX 6X200MM HLF SS APEX 70MM THRD SD/ST -,SUP-5021-8-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN EXTFIX 4X120MM SS APEX 30MM THRD SD/ST -,SUP-5023-3-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CRNMXF MAND 2.3X16MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-23416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.43,257.201,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN EXTFIX 4X120MM HLF SS APEX 35MM THRD SD/ST -,SUP-5023-5-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN EXTFIX 4X150MM HLF SS APEX 50MM THRD SD/ST -,SUP-5023-6-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN EXTFIX 4X180MM SS HLF PIN APEX 50MM THRD SD/ST -,SUP-5023-6-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN HYBRID APEX -,SUP-5026-8-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,591.79,414.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAP EXTFIX 5MM HOFFMN XPRESS 40MM THRD F/PIN TIP -,SUP-5027-1-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17.15,12.005,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ER CRNMXF MAND 2.7X12MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-27412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,416.21,291.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK CRNMXF MAND 2.7X10MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-27510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,708.49,495.943,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD CONNECTING VECTRAN COATED CARBON 8MM X 400MM -,SUP-5028-8-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1100.81,770.567,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TRANSFIX PIN 4X300MM -,SUP-5030-4-300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
APEX TRANSFIX 4 X 250 PIN 5 X 50 THR -,SUP-5030-5-250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN EXTFIX 3X100MM TRNSFX SS APEX 25MM THRD SD/ST F/BILAT -,SUP-5038-2-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,329.79,230.853,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN EXTFIX 3X200MM TRNSFX SS APEX -,SUP-5045-5-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD HII COMPACT MRI CONNECTING 5MM X 65MM -,SUP-5048-5-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
HII COMPACT MRI CONNECTING ROD 5MM X 100MM -,SUP-5048-5-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
HII COMPACT MRI CONNECTING ROD 5MM X 150MM -,SUP-5048-5-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD HII COMPACT MRI CONNECTING 5MM X 200MM -,SUP-5048-5-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN TRANSFIXING 300MM 5/6 -,SUP-5050-4-300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN EXTFIX 5MM/4X300MM TRNSFX SS APEX 50MM THRD SD/ST -,SUP-5050-5-250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,623.82,436.674,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BLADE SAW 13X90MM OSCIL/SGTL 0.89MM -,SUP-506123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,460.97,322.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN EXTFIX 2X45MM SS APEX 20MM THRD ST -,SUP-5065-4-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,297.76,208.432,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CARBON CONNECTING ROD 3MMX120MM -,SUP-5079-6-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,290.23,203.161,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
HALFPIN EXTFIX 2X45MM SS U THRD DBL HLCL FLUT APEX 12MM P/T -,SUP-5080-2-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,346.77,242.739,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN 2MM X 45MM HALF HOFFMANN II APEX STAINLESS STEEL MICRO -,SUP-5080-2-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,346.77,242.739,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLY THRD 4.5X25MM CREO -,SUP-5119.1327,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLY THRD 5.5 4.5X30MM CREO -,SUP-5119.1330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CREO 5.5 4.5MM X 40MM POLYAXIAL SCREW -,SUP-5119.1340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CREO 5.5 4.5MM X 45MM POLYAXIAL -,SUP-5119.1345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5 X 40 POLYAXIAL CREO -,SUP-5119.1440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CREO THREADED 5.0 X 45MM POLYAXIAL SCREW -,SUP-5119.1447,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5 X 35 POLYAXIAL CREO -,SUP-5119.1535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5 X 40 POLYAXIAL CREO -,SUP-5119.1540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X45MM CREO THRD PRASMB F/5.5MM TI STRL -,SUP-5119.1545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CREO THREADED 5.5 X 45MM POLYAXIAL SCREW -,SUP-5119.1547,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL 5.5 X 50 -,SUP-5119.1550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL 5.5 6.5 X 30 CREO -,SUP-5119.1630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X35MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.1635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X40MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.1640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X45MM CREO THRD PRASMB F/5.5MM TI STRL -,SUP-5119.1645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL CREO 6.5 X 50 -,SUP-5119.1650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CREO 5.5 6.5 X 60MM POLYAXIAL SCREW -,SUP-5119.1660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5-5.5X30MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5-5.5X35MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3337,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL CREO 5.5- 6.0-5.0X25MM -,SUP-5119.3427,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6-5X30MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.3432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6-5X35MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.3437,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5-6.5X30MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5-6.5X35MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3537,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CREO 5.5 5.5MM X 45MM CORTICAL -,SUP-5119.3547,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER CERV 14X6X12MM MOSAIC PEEK-OPTIMA -,SUP-51412-206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER CERV 14X7X12MM MOSAIC PEEK-OPTIMA -,SUP-51412-207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11436.04,8005.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
UNITED HIP CANCELLOUS LOCKING SCREW 6.5MM X 15MM -,SUP-5208-1015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
UNITED CANCELLOUS LOCKING SCREW 6.5 X 20 -,SUP-5208-1020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
UNITED CANCELLOUS LOCKING SCREW 6.5 X 25 -,SUP-5208-1025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
UNITED CANCELLOUS LOCKING SCREW 6.5 X 30 -,SUP-5208-1030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
UNITED HIP CANCELLOUS LOCKING SCREW 6.5MM X 35MM -,SUP-5208-1035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
UNITED CANCELLOUS LOCKING SCREW 6.5 X 45 -,SUP-5208-1045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD FIREBIRD 40MM ORTHOFIX -,SUP-52-2040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX NXG 70 ROD -,SUP-52-2070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX 80MM ROD -,SUP-52-2080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
90MM TI ROD STRAIGHT -,SUP-52-2090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
100MM TI ROD STRAIGHT -,SUP-52-2100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NXG 110MM ROD -,SUP-52-2110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD FIREBIRD 120MM TI STRAIGHT ORTHOFIX -,SUP-52-2120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD FIREBIRD STRAIGHT 140MM TI ORTHOFIX -,SUP-52-2140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 160MM NXG DIA 5.5MM TI ORTHOFIX -,SUP-52-2160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX ROD 180 -,SUP-52-2180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX ROD 200MM -,SUP-52-2200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD HEX TITANIUM 400MM -,SUP-52-2450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 35MM ORTHOFIX -,SUP-52-6035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
40MM ROD TI CURVED -,SUP-52-6040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 45MM ORTHOFIX -,SUP-52-6045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX ROD 50MM -,SUP-52-6050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ACTB 6.5X12MM OSTLOK -,SUP-5260-5-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ACTB 6.5X14MM OSTLOK -,SUP-5260-5-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ACTB 6.5X18MM OSTLOK -,SUP-5260-5-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ACTB 6.5X30MM OSTLOK -,SUP-5260-5-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ACTB 6.5X35MM OSTLOK -,SUP-5260-5-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ACTB 6.5X40MM OSTLOK -,SUP-5260-5-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ACTB 6.5 X 45MM OSTLOK -,SUP-5260-5-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ACTB 6.5X50MM OSTLOK -,SUP-5260-5-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX ROD 55MM -,SUP-52-6055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX NXG 60MM ROD -,SUP-52-6060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX NXG 65MM ROD -,SUP-52-6065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX 70MM ROD -,SUP-52-6070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX 75MM ROD -,SUP-52-6075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX 80 ROD -,SUP-52-6080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
OPEN CONNCETOR 5.5 - 5.5 -,SUP-52-6805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC 12MM BAR UNIV NEURO III LPRO 2HL TI STR 1.5MM -,SUP-53-05212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,705.92,494.144,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC 2HL 16MM BAR STR UNIV NEURO III 1.5MM TI NS -,SUP-53-05216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,844.97,591.479,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC 4HL 28MM BAR 3D BX UNIV NEURO III 1.5MM TI NS -,SUP-53-05228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.88,735.616,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC LRG 2HL 3D BX LEIBINGER UNIV NEURO 2 1.5MM TI -,SUP-53-05240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1443.7,1010.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC 6MM BAR 4HL STR LEIBINGER UNIV NEURO 2 1.5MM TI -,SUP-53-05406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,702.42,491.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COVER CRANFC 7MM UNIV NEURO III LPRO TI -,SUP-53-05507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1211.85,848.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COVER CRANFC 10MM UNIVERSAL NEURO II LPRO TI NS -,SUP-53-05510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1211.85,848.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COVER CRANFC 14MM UNIVERSAL NEURO II LPRO TI NS -,SUP-53-05514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1211.85,848.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COVER CRANFC 20MM UNIVERSAL NEURO II LPRO TI NS -,SUP-53-05520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1338.06,936.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC 8MM UNIV NEURO III LPRO 6HL TI DBL Y 1.5MM NS -,SUP-53-05608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1331.38,931.966,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE STR LP GAP SMALL -,SUP-53-05612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1587.66,1111.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE STR LP GAP LARGE -,SUP-53-05622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1748.42,1223.894,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC 4HL X-SHP LEIBINGER UNIV NEURO 2 1.5MM TI NS -,SUP-53-05630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1344.26,940.982,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC 8HL STR LEIBINGER UNIV NEURO 2 1.5MM TI NS W/O -,SUP-53-05804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.28,665.896,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC 12MM 2HL UNIV NEURO III XTR RGD TI NS -,SUP-53-06212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,597.33,418.131,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL SFT TIS BIO- ABSB LPRO 1.5X20MM PLYLC ACD PLYMR KN -,SUP-531520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,798.11,558.677,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.7X5MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17005E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK 1.7 X 06 -,SUP-53-17006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,518.32,362.824,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.7X8MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.7X9MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK 1.7 X 10 -,SUP-53-17010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.83,308.581,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.7X12MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK 1.7 X 16 -,SUP-53-17016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.7X16MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX -,SUP-53-20616E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2X18MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX NS -,SUP-53-20618E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2X20MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX NS -,SUP-53-20620E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2X22MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX NS -,SUP-53-20622E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.7X24MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX -,SUP-53-20624E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.7X26MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX. -,SUP-53-20626E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X6MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X8MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X9MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X10MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X11MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23011E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X12MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X13MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23013E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X16MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X18MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23018E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.3MM X 20MM -,SUP-53-23020E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.88,310.016,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.3 X 24 -,SUP-53-23024E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.3 X 26 -,SUP-53-23026E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X10MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23210E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X14MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23214E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X16MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23216E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X18MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23218E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X20MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23220E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X22MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23222E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X24MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23224E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X26MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23226E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X28MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23228E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X30MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23230E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X32MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23232E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X34MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23234E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X36MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23236E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X38MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23238E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X10MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23610E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X12MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23612E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X14MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT. -,SUP-53-23614E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X16MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23616E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X18MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT. -,SUP-53-23618E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X20MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23620E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X22MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23622E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X24MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23624E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X26MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23626E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X28MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23628E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X30MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23630E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X32MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23632E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X34MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23634E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X36MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23636E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X38MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23638E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X16MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27116E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X18MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27118E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X20MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27120E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X22MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27122E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X24MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27124E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X26MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27126E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X10MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27210E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCK 2.7 X 12MM -,SUP-53-27212E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCK 2.7 X 14 -,SUP-53-27214E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X16MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27216E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X18MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27218E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X20MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27220E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X22MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27222E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X24MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27224E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X25MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27226E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X10MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27610E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X12MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27612E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X14MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27614E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X16MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27616E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X18MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27618E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X20MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27620E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7 X 22 -,SUP-53-27622E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X24MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27624E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X26MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27626E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE MSH CRANFC MIDFC MICRO 60X120MM 0.1MM MLBL 1.2MM TI NS -,SUP-54-00261,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3755.99,2629.193,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
MICRO/MESH 120 X 120 X .2MM / GOLD -,SUP-54-00270,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8602.59,6021.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
MICRO/MESH 120 X 60 X .2MM / GOLD -,SUP-54-00271,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6438.15,4506.705,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BLUE DYNAMIC MESH  90X90MM 0.3MM MLBL 1.7MM TI NS -,SUP-54-00346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2066.2,1446.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW 3.5MM T15 L40MM -,SUP-541540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1621.95,1135.365,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 60MMX1.5MM 2.7MM ANTMC POLYAX TI SMRTLC RT -,SUP-54-25290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 60MMX1.5MM 2.7MM ANTMC POLYAX TI SMRTLC LT -,SUP-54-25291,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE WIDE DORSAL RIGHT -,SUP-54-25292,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 60MMX1.5MM 2.7MM ANTMC POLYAX TI W SMRTLC -,SUP-54-25293,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 81MMX1.5MM 2.7MM ANTMC POLYAX TI XLNG SMRTLC -,SUP-54-25295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4270.06,2989.042,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 56MM 2.7MM 9HL 2MM ANTMC POLYAX TI SMRTLC -,SUP-54-25374,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 76MM 2.7MM 2MM ANTMC POLYAX TI LNG NRW LT -,SUP-54-25375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 56MM 2.7MM 11HL ANTMC POLYAX TI STD SMRTLC -,SUP-54-25376,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 76MM 2.7MM 13HL 2MM ANTMC POLYAX TI STD LNG -,SUP-54-25377,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 56MM 2.7MM 9HL ANTMC POLYAX TI STD SMRTLC -,SUP-54-25384,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 76MM 2.7MM 2MM ANTMC POLYAX TI LNG NRW RT -,SUP-54-25385,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 56MM 2.7MM STD ANTMC TI SMRTLC -,SUP-54-25386,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE VOLAR 76MM L 14 HOLE 2MM H STAN LONG RT -,SUP-54-25387,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 53MM 2.7MM 2MM POLYAX TI MED/SHRT UNIV XLN -,SUP-54-25394,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3450.36,2415.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 53MM 2.7MM 2MM POLYAX TI SHRT UNIV STD -,SUP-54-25396,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3450.36,2415.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 53MM 2.7MM 2MM POLYAX TI SHRT UNIV W SMRTLC -,SUP-54-25398,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3450.36,2415.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 44MM 2.7MM 1MM ANTMC POLYAX TI SHRT NRW CLMN -,SUP-54-25400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 57MM 2.7MM ANTMC POLYAX TI LNG CLMN SMRTLC -,SUP-54-25401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 40MMX1MM FRAG SPEC POLYAX TI SHRT SMRTLC -,SUP-54-25402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 40MMX1MM 2.7MM FRAG SPEC POLYAX TI SHRT -,SUP-54-25403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 53MMX1MM FRAG SPEC POLYAX TI LNG SMRTLC -,SUP-54-25405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2.7 X 189 15 HOLE -,SUP-54-25420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7093.08,4965.156,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2.7 145 11 HOLES -,SUP-54-25424S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7093.08,4965.156,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2.7MM XXL VOLAR L100MM 8 HOLE -,SUP-54-25428S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6203.58,4342.506,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE VOLAR XXL 7MM -,SUP-54-25442S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7093.08,4965.156,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2.7MM XXL VOLAR NARROW 8 HOLE -,SUP-54-25444S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6203.58,4342.506,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 8 HOLES / 100MM / 2.7MM XXL -,SUP-54-25446S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6203.58,4342.506,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 3HL XSH NRW -,SUP-54-25573,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 8HL XSH -,SUP-54-25583,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN XSH -,SUP-54-25673,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 2X56MM 11HL INTMD ANTMC SHRT NS -,SUP-54-25674,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE INT LNG LEFT 14 HOLE -,SUP-54-25677,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4468.42,3127.894,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX F/DIST RAD SYS 10HL INTMD XSH -,SUP-54-25683,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 11HL INTMD SHRT -,SUP-54-25684,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 14HL INTMD LNG -,SUP-54-25687,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4468.42,3127.894,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX F/DIST RAD SYS 10HL STD XSH -,SUP-54-25773,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 10HL STD XSH -,SUP-54-25783,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
RESTRICTOR BNCMNT FEM SZ3 13.25MM UHMWPE -,SUP-5460-14-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1026.96,718.872,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
RESTRICTOR BNCMNT FEM SZ3 15.75MM UHMWPE -,SUP-5460-16-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1150.21,805.147,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
RESTRICTOR FMCNL BNCMNT SZ5 18.25MM UHMWPE HIP -,SUP-5460-18-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1070.7,749.49,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE HYBRID MMP -,SUP-55-02950,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1731.83,1212.281,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC UPR FACE 18HL 3D SHP UNIVERSAL NEURO II MLBL -,SUP-55-04218,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2608.27,1825.789,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC UPR FACE HLX2X2 3D UNIVERSAL NEURO II MLBL -,SUP-55-04231,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.51,834.757,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC UPR FACE HLX6X2 0.5MM 3D UNIV 2 MLBL 1.2MM TI -,SUP-55-04233,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2146.54,1502.578,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE UPR FACE 7HL 0.5MM DBL Y UNIVERSAL NEURO II MLBL 1.2MM -,SUP-55-04240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1128.37,789.859,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC UPR FACE 24HL 0.5MM STR UNIV 2 MLBL 1.2MM TI NS -,SUP-55-04424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2500,1750,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC MIDFC 20HL 0.55MM UNIV 2 MLBL 1.7MM TI NS BLU -,SUP-55-04720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2468.01,1727.607,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC MIDFC 24HL 0.55MM STR UNIV 2 MLBL CNDSD 1.7MM -,SUP-55-04724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.85,1788.395,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC MIDFC 7HL 0.6MM UNIVERSAL NEURO II STD 1.7MM TI -,SUP-55-05164,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.58,742.406,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE ORBT MIDFC 6HL CRV LEIBINGER UNIV 2 STD 1.7MM TI NS -,SUP-55-05188,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1255.9,879.13,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE LCK CRANFC MIDFC HL 2X2 0.8MM 3D SHP UNIVERSAL NEURO -,SUP-55-05731,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1390.43,973.301,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC UPR FACE 8HL STR UNIVERSAL NEURO II STD 1.2MM -,SUP-55-06208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1389.47,972.629,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC UPR FACE HLX2X2 3D SHP UNIVERSAL NEURO II STD -,SUP-55-06231,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.43,785.001,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
3D PLATE 6 X 2 HL UPPERFACE -,SUP-55-06233,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2014.51,1410.157,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
3D PLATE 6 X 6 HL UPPERFACE -,SUP-55-06235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4305.34,3013.738,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLT/7 HOLE DOUBLE Y UPPERFACE -,SUP-55-06240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1022.23,715.561,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE MIDFC 4HL STR UNIVERSAL NEURO II STD 1.7MM TI NS BAR -,SUP-55-06704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.58,457.506,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC MIDFC 8HL STR UNIVERSAL NEURO II STD 1.7MM TI -,SUP-55-06708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1319.35,923.545,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE MIDFC 24HL STR UNIVERSAL NEURO II STD 1.7MM TI NS BAR -,SUP-55-06724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2527.07,1768.949,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE STR 2 X 2 3D -,SUP-55-06731,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1207.72,845.404,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE MIDFC 10HL UNIVERSAL NEURO II STD 1.7MM TI NS BAR GOLD -,SUP-55-06750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1390.43,973.301,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE MIDFC 4HL CRV UNIVERSAL NEURO II STD 1.7MM TI NS GOLD -,SUP-55-06754,CDM,C1713,HCPCS,278,RC,,,outpatient,,,804.35,563.045,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE RT CRANFC MIDFC 2MM 5HL 0.6MM LEIBINGER UNIVERSAL -,SUP-55-06761,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1100.48,770.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE RT CRANFC MIDFC 5MM 5HL 0.6MM UNIVERSAL NEURO II STD -,SUP-55-06763,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1133.97,793.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE LCK MAND MINI 4HL 1MM STR UNIVERSAL NEURO II 2MM TI NS -,SUP-55-10504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,513.89,359.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE LCK MAND MINI 6HL 8MM STR UNIVERSAL NEURO II 2MM TI NS -,SUP-55-10507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.51,834.757,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 10MM VUSION TS -,SUP-551-5210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CRANFC MAND 4HL STR UNIVERSAL NEURO II RECON FX 2MM TI -,SUP-55-15505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1918.09,1342.663,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLT/FRACTURE 6 HOLES W. BAR -,SUP-55-15507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2440.83,1708.581,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 10 X 9 X 25 -,SUP-551-7410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
INSERT TIB BEARING SZ2 9MM TRIATHLON X3 CR ARTCSURF -,SUP-5530-C-209,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BEARING TIB INSERT CS 9MM SZ1 TRIATHLON X3 -,SUP-5531-G-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BEARING TIB INSERT CS 10MM SZ 1TRIATHLON X3 -,SUP-5531-G-110-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BEARING TIB INSERT CS 11MM SZ 1 TRIATHLON X3 -,SUP-5531-G-111-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
INSERT TIBIAL BEARING  SZ. 5 / 11MM TYPE CS -,SUP-5531-G-511-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIBIAL BEARING INSERT SZ.7 / CS / 11MM -,SUP-5531-G-711-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIBIAL BEARING INSERT SZ.8 CS 9MM TRIATHLON X3 -,SUP-5531-G-809-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
9MM INSERT TRIAL PS#3 -,SUP-5532-T-309,CDM,C1713,HCPCS,278,RC,,,outpatient,,,728.5,509.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMPONENT TIBIAL TRITANIUM SZ 1 TRIATHLON -,SUP-5536-B-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX CROSSLINK 25 -,SUP-55-5325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CONNECTOR ROD FIREBIRD 45MM CROSSLINK ORTHOFIX -,SUP-55-5345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.5MM PERIPHERAL SCREW 16MM -,SUP-5572-4516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.5MM PERIPHERAL SCREW 24MM -,SUP-5572-4524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.5MM PERIPHERAL SCREW 36MM -,SUP-5572-4536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
6.5MM CENTER SCREW 32MM -,SUP-5573-6532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4573.49,3201.443,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX MODULAR TRIATH -,SUP-5575-X-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONESCREW AXS ST 1.2 X 3MM 5P -,SUP-56-12003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONESCREW - AXS ST 1.2 X 4MM 5P -,SUP-56-12004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONESCREW AXS SD 1.2 X 3MM 5P -,SUP-56-12903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,636.37,445.459,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONESCREW AXS SD 1.2 X 4MM 5P -,SUP-56-12904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,636.37,445.459,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE ER AXS ST 1.4 3MM 5P -,SUP-56-14003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,593.3,415.31,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONESCREW AXS SD 1.7 X 4MM 5P -,SUP-56-17904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONESCREW AXS SD 1.7 X 6MM 5P -,SUP-56-17906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFT HUM TIS PTTY 1ML OSTEOSPARX SYR LF -,SUP-562-100-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X30MM CORT FT ST HEX HEAD -,SUP-5645-1-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X32MM CORT FT ST HEX HEAD -,SUP-5645-1-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X44MM CORT FT ST HEX HEAD -,SUP-5645-1-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X48MM CORT FT ST HEX HEAD -,SUP-5645-1-048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X50MM CORT FT ST HEX HEAD -,SUP-5645-1-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X52MM CORT FT ST HEX HEAD -,SUP-5645-1-052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X54MM CORT FT ST HEX HEAD -,SUP-5645-1-054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
STEM EXTENSION CEMENTED 12X30MM -,SUP-565-1203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
MESH HYBRID MEDIUM MALL 90 X 90 X .3 BLUE -,SUP-56-90344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7015.12,4910.584,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PROFYLE 0.55MM 1.2MM 4HL STD PRCONT NLCKG TI XS STR -,SUP-57-05101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PRF 1.7 X 4 HL -,SUP-57-05202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PRF 1.7 X 6 HL LT L -,SUP-57-05221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE HAND -,SUP-57-05240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PRF 1.7 X 7 HL T -,SUP-57-05260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1028.42,719.894,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PROFYLE 0.55MM 1.7MM 1HL PRX2 STD PRCONT NLCKG TI -,SUP-57-05285,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1307.9,915.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PRF 1.7 X 3 X 2 3D -,SUP-57-05291,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1307.9,915.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PRF 1.7 X 4X2 RP 3D -,SUP-57-05295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1307.9,915.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PRF 2.3 6 HL LT L -,SUP-57-10121,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2457.66,1720.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PRF 2.3 X 6 HL NRW T -,SUP-57-10140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2457.66,1720.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PROFYLE 1MM 2.3MM 7HL SHFT PRCONT VAR ANG NLCKG TI -,SUP-57-10170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2457.66,1720.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PRF 2.3 X 5HL ROT -,SUP-57-10185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2395.78,1677.046,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 1.5MM 1.7MM 10HL PRCONT VAR ANG TI SM NRW -,SUP-57-10310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 1.7 X 6 HL LT L -,SUP-57-10321,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 1MM 1.7MM 6HL PRCONT VAR ANG TI SM NRW T-SHP -,SUP-57-10340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 1.7 X 7 HL T -,SUP-57-10360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 1MM 1.7MM 5HL ROT PRCONT VAR ANG TI SM -,SUP-57-10380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 1MM 1.7MM HLX3X2 PRCONT VAR ANG TI SM 3D SHP -,SUP-57-10391,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PROFYLE 1MM 2.3MM 6HL PRCONT NLCKG COMPR TI MED STR -,SUP-57-10407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2921.69,2045.183,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PROFYLE 1MM 2.3MM 7HL PRCONT NLCKG COMPR TI MED Y -,SUP-57-10470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2921.69,2045.183,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PROFYLE 1.3MM 2.3MM 6HL SHFT PRCONT NLCKG COMPR TI -,SUP-57-13150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.06,784.742,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE HAND 2.3 LP 4 HOLE -,SUP-57-13402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PROFYLE 1.3MM 2.3MM 5HL PRCONT NLCKG COMPR TI LRG -,SUP-57-13405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PROFYLE 1.3MM 2.3MM 6HL PRCONT NLCKG COMPR TI LRG -,SUP-57-13408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE T 1O HOLE NARROW COMPRESSION -,SUP-57-13442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 1.5MM 2.3MM 4HL PRCONT VAR ANG TI MED STR -,SUP-57-15301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 1.5MM 2.3MM 4HL_PRCONT VAR ANG TI MED STR -,SUP-57-15302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 1.5MM 2.3MM 16HL PRCONT VAR ANG TI MED -,SUP-57-15316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 1.5MM 2.3MM 4HL PRCONT VAR ANG TI MED SMRTLC -,SUP-57-15340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 1.5MM 2.3MM 7HL PRCONT VAR ANG TI MED SMRTLC -,SUP-57-15370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PROFYLE 2.3 X 13 HL NRWZ -,SUP-57-15379,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 1.5MM 2.3MM 5HL PRCONT VAR ANG TI MED SMRTLC -,SUP-57-15385,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.2X5MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12005E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.2X6MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.2X7MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12007E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.2X8MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.2X14MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX -,SUP-58-12014E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
MIDFOOT FUSION U-PLATE MD LT ORTHOLOC -,SUP-5817002L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5793.06,4055.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.7X8MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.7X9MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.7X10MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.7X11MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17011E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.7X12MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE SCREW 1.7 X 16MM STRYKER -,SUP-58-17016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 2.3 X 6 -,SUP-58-23006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X8MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X9MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X10MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X11MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23011E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X12MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X13MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23013E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X14MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23014E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NL 2.3 X 15MM -,SUP-58-23015E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X16MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X20MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23020E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X24MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23024E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EMERGENCY 2.5 X 6 -,SUP-58-25006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EMERGENCY 2.5 X 8MM CROSSPIN LEFT -,SUP-58-25008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
MTP FUSIOIN MEDIUM 0DG RT ORTHOLOC 3DI PLATING SYSTEM -,SUP-587220RT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5046.12,3532.284,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING LG HD 2.7 X 12MM ORTHOLOC 3DI PLATING SYS -,SUP-58802712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING LG HD 2.7 14MM ORTHOLOCK 3DI PLATING SYS -,SUP-58802714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING LG HD  2.7 X 16MM ORTHOLOCK 3DI PLATING SYS -,SUP-58802716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOW PRO CORT 2.7 X 12MM ORTHOLOC SYS -,SUP-58812712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOW PRO CORT SCREW 2.7 X 14MM ORTHOLOC SYSTEM -,SUP-58812714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOW PRO CORT SCREW 2.7 X 16MM ORTHOLOC SYSTEM -,SUP-58812716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOW PRO CORT 2.7 X 18MM ORTHOLOC SYS -,SUP-58812718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOW PRO CORT SCREW 3.5 X 12MM ORTHOLOC SYSTEM -,SUP-58813512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOW PRO CORT SCREW 3.5 X 14MM ORTHOLOC SYSTEM -,SUP-58813514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOW PRO CORT SCREW 3.5 X 16MM ORTHOLOC SYSTEM -,SUP-58813516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCKING 3.5 X 18 -,SUP-58813518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOW-PRO CORT SCREW 3.5X22MM ORTHOLOC -,SUP-58813522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOW-PRO CORT SCREW 3.5X28MM ORTHOLOC -,SUP-58813528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOW-PRO CORT SCREW 3.5X34MM ORTHOLOC -,SUP-58813534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOW-PRO CORT SCREW 3.5X38MM ORTHOLOC -,SUP-58813538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO F/1.2MM SCR TI RND FLT HEAD NS -,SUP-59-12049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.24,105.868,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO F/1.7MM/1.9MM TI RND BN SCR TITIANIUM FLT EDGE -,SUP-59-17049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.24,105.868,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X10MM CORT PROFYLE ST CX PIN HD TI GOLD -,SUP-59-23010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 16MM -,SUP-59-23016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 18MM -,SUP-59-23018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 20MM -,SUP-59-23020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO F/2.3MM SCR TI RND FLT HEAD NS -,SUP-59-23049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.24,105.868,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 32.3MM COMPR OMEGA3 SS STRL -,SUP-596001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,329.09,230.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
STANDARD BARRELL HIP PLATE- 130DEG- 2 HOLES -,SUP-597002S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2817.14,1971.998,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OMG 3 63MM 3HL STD BRL LCK COMPR SS 135DG ANG KY -,SUP-597023S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE HIP STD BARREL 4 HOLE KEYED 135DEG -,SUP-597024S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
HIP PLATE OMEGA 3 STD BARREL KEYED 135 DEG 6 HOLES -,SUP-597026S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE HIP STD BARREL 3 HOLE KEYED 140DEG -,SUP-597043S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE HIP STD BARREL 4 HOLE KEYED 145DEG -,SUP-597064S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE EXTFIX STD 47MM SS HIP 135DG ANG OMEGA3 KYLS BRL -,SUP-597122S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OMG 3 79MM 4HL STD BRL LCK COMPR SS 135DG ANG KYLS -,SUP-597124S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OMG 3 95MM 5HL STD BRL LCK COMPR SS 150DG ANG KYLS -,SUP-597185S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN OMG 3 79MM 4HL SHRT BRL LCK COMPR SS 135DG ANG KYLS -,SUP-597264S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2470.03,1729.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE ANT CERV 12MM BAK HOL CHMFR EDGE 8MM TI -,SUP-6000-0812-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DEVICE ANT CERV 12MM BAK/ C HOL CHMFR EDGE 10MM TI -,SUP-6000-1012-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GW ORTHO 2MM TOEMOTION MRH AXLE -,SUP-6007-1200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN DSTRCT 12MM ASSURE -,SUP-601.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ASNIS III CANN SCREW 5 X 28MM -,SUP-601628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS TI 5.0 X 30MM -,SUP-601630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ASNIS III CANN SCREW 5 X 32MM -,SUP-601632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS III CANN P/T 5.0MM X 42MM -,SUP-601642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS III CANN 5.0 X 44MM -,SUP-601644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE ASNIS PT 5 X 46 -,SUP-601646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS PT 5.0 X 48 -,SUP-601648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX50MM CANN ASNIS III 17MM P/T SD/ST REVCT FLUT TI -,SUP-601650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX55MM CANN ASNIS III 18.5MM P/T SD/ST REVCT FLUT TI -,SUP-601655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX75MM CANN ASNIS III 27MM P/T SD/ST REVCT FLUT TI -,SUP-601675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX80MM CANN ASNIS III 27MM P/T SD/ST REVCT FLUT TI -,SUP-601680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FULLY THREADED 5MM X 38MM -,SUP-601738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FULLY THREADED 5MM X 40MM -,SUP-601740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FT 5MM X 42MM TITANIUM CANNULATED -,SUP-601742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS FT 5 X 44 -,SUP-601744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED 5 X 50 -,SUP-601750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED 5 X 55 -,SUP-601755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FULLY THREADED 5 X 60 -,SUP-601760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANN HEADED 5.0 X 65MM ASNIS -,SUP-601765,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED 5MM X 70MM -,SUP-601770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANN TI 6.5 X 60MM -,SUP-602660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS TI TL20 6.5 X 65MM -,SUP-602665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANN TI 6.5 X 70MM -,SUP-602670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX75MM CANN ASNIS III 20MM THRD SD/ST HEX DRV -,SUP-602675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANN TI 6.5 X 80MM -,SUP-602680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX80MM CANN ASNIS III 20MM THRD SD/ST HEX DRV -,SUP-602680S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANN ASNIS TI 6.5 X 85MM -,SUP-602685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX90MM CANN ASNIS III 20MM THRD SD/ST HEX DRV NS -,SUP-602690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX90MM CANN ASNIS III 20MM THRD SD/ST HEX DRV STRL -,SUP-602690S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX95MM CANN ASNIS III 20MM THRD SD/ST HEX DRV NS -,SUP-602695,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX95MM CANN ASNIS III 20MM THRD SD/ST HEX DRV STRL -,SUP-602695S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MMX100MM CANN ASNIS III 20MM THRD SD/ST HEX DRV -,SUP-602700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TI CANNULATED 6.5 X 105MM ASNIS -,SUP-602705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED TI 6.5X 110MM -,SUP-602710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS TI TL20 6.5 X 115 -,SUP-602715,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS TI TL40 6.5 X 60 -,SUP-602860,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS TI TL40 6.5 X 65 -,SUP-602865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS 6.5 X 70MM -,SUP-602870,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS TI TL40 6.5 X 75MM -,SUP-602875,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS TI CANNULATED 6.5 X 80MM -,SUP-602880,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS TI TL40 6.5 X 85 -,SUP-602885,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TI 6.5 X 90MM ASNIS TL40 CANNULATED -,SUP-602890,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS TI TL40 6.5 X 95 -,SUP-602895,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS TI TL40 6.5 X 100 -,SUP-602900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS TI CANNULATED 6.5 X 105MM -,SUP-602905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX28MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE CAN TI 4.0 X 30MM -,SUP-604630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX32MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.0 X 34MM ASNIS CANN SCREW -,SUP-604634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX34MM CANN ASNIS III 11.5MM P/T SD/ST REVCT FLUT TI -,SUP-604634S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE CAN PT 4.0 X 36 -,SUP-604636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX38MM CANN ASNIS III -,SUP-604638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX40MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX40MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY -,SUP-604640S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX42MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX44MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX46MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE CAN PT 4.0 X 48 -,SUP-604648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX50MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX50MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY -,SUP-604650S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX55MM CANN ASNIS III 18.5MM P/T SD/ST REVCT FLUT TI -,SUP-604655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX55MM CANN ASNIS III 18.5MM.P/T SD/ST REVCT FLUT TI -,SUP-604655S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT TI- -,SUP-604660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT TI- -,SUP-604660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT TI_ -,SUP-604660S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX65MM CANN ASNIS III 22MM P/T SD/ST REVCT FLUT TI -,SUP-604665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX65MM CANN ASNIS III 22MM P/T SD/ST REVCT FLUT TI -,SUP-604665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX70MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX70MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY -,SUP-604670S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX40MM CANN ASNIS III FT SD/ST REVCT FLUT TI ALY NS -,SUP-604740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS III TI 4.0 X 42MM -,SUP-604742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANN FT 4.0 X 44MM -,SUP-604744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MMX50MM CANN ASNIS III FT SD/ST REVCT FLUT TI ALY NS -,SUP-604750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TI SELF TAP CORTICAL 2.7MM X 22MM -,SUP-605022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.06,81.242,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TI SELF TAP CORTICAL 2.7MM X 26MM -,SUP-605026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.06,81.242,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TI SELF TAP CORTICAL 2.7MM X 28MM -,SUP-605028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.06,81.242,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TI ASNIS III CANNULATED 6.5 X 85MM -,SUP-606085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 90 -,SUP-606090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 95 -,SUP-606095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED FULLY THREADED 6.5 X 100 -,SUP-606100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED FULLY THREADED 6.5 X 110 -,SUP-606110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANCELLOUS FT 4 X 14 -,SUP-607314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANCELLOUS FT 4.0 X 16 -,SUP-607316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X18MM CANC FT TI -,SUP-607318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANCELLOUS 4.0 X 20 -,SUP-607320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X22MM CANC FT TI -,SUP-607322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X24MM CANC FT TI -,SUP-607324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANCELLOUS 4.0 X 26MM -,SUP-607326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANCELLOUS 4.0 X 28MM -,SUP-607328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANCELLOUS 4.0 X 32MM -,SUP-607332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X34MM CANC FT TI -,SUP-607334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X36MM CANC FT TI -,SUP-607336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X38MM CANC FT TI -,SUP-607338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X40MM CANC FT TI -,SUP-607340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.0 X 42MM CANC FT TI -,SUP-607342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANN TI 4.0 X 48MM FULL -,SUP-607348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.0 CANCELLOUS SCREW 50MM FULLY THREADED -,SUP-607350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANCELLOUS 4.0 X 50MM -,SUP-607350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.0 X 55MM CANC FT TI -,SUP-607355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X60MM CANC FT TI -,SUP-607360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X65MM CANC FT TI -,SUP-607365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X70MM CANC FT TI -,SUP-607370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANCELLOUS FT 4.0 X 14MM STRYKER -,SUP-607414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANCELLOUS PT 4 X 16 -,SUP-607416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANCELLOUS PT 4 X 20 -,SUP-607420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X36MM CANC 16MM THRD TI -,SUP-607436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X38MM CANC 16MM THRD TI -,SUP-607438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X44MM CANC 16MM THRD TI -,SUP-607444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X46MM CANC 16MM THRD TI -,SUP-607446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X50MM CANC 16MM THRD TI -,SUP-607450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X65MM CANC 16MM THRD TI -,SUP-607465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X70MM CANC 16MM THRD TI -,SUP-607470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANC 6.0MM X 20MM  FULL THREAD -,SUP-608020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANCELLOUS 6 X 25 -,SUP-608025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CAN FT 6.0 X 35 -,SUP-608035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANCELLOUS 6.0 X 40MM -,SUP-608040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X45MM CANC FT TI -,SUP-608045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.0MM X 50MM CANCELLOUS FULL THREAD -,SUP-608050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X60MM CANC FT TI -,SUP-608060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 3.5 X 60 FT -,SUP-608070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X75MM CANC FT TI -,SUP-608075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X80MM CANC FT TI -,SUP-608080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANCELLOUS FT 6.0 X 85 -,SUP-608085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CAN TL 16 6.0 X 35 -,SUP-608235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CAN TL 16 6.0 X 75 -,SUP-608275,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CAN TL 16 6.0 X 80 -,SUP-608280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANCELLOUS 6.0MM 90MM -,SUP-608290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X70MM CANC 32MM THRD TI -,SUP-608470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X80MM CANC 32MM THRD TI -,SUP-608480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X85MM CANC 32MM THRD TI -,SUP-608485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6MM CANCELLOUS TI 6.0MM L90 TL32MM -,SUP-608490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,304.82,213.374,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS TI TL25 8.0 X 70MM -,SUP-611070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CANNULATED SCREW 8.0 X 75MM TI -,SUP-611075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
8.0 X 80MM TI CANNULATED SCREW -,SUP-611080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS TI TL25 8.0 X 85MM -,SUP-611085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ANSIS TI TL25 8.0 X 90MM -,SUP-611090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X8MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X12MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X14MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X16MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X18MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.7 X 20MM LOCKING SCREW -,SUP-614520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X22MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10 2.7 X 24MM -,SUP-614524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X26MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7 LOCKING ST 28 -,SUP-614528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X30MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7 LOCKING ST 34 -,SUP-614534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X36MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X38MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X40MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X55MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X60MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X8MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X10MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X12MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X14MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X16MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X18MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X20MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X22MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X24MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 3.5 X 28MM -,SUP-614628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X30MM LOCKING -,SUP-614630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X32MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
36MM 3.5 LOCKING SCREW -,SUP-614636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5 LCK ST 38 -,SUP-614638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5 X 40MM LOCKING -,SUP-614640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X42MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X44MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5 LCK ST 48 -,SUP-614648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X50MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE OLECRANON LEFT 8 HOLE -,SUP-614655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 3.5 X 55MM T10 -,SUP-614655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X60MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 3.5 X 65MM -,SUP-614665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 3.5 X 70MM -,SUP-614670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X8MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X12MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X14MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X16MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X18MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X20MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X22MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X24MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7 NON LOCKING ST 26 -,SUP-614726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X32MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614732,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X34MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X36MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X38MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X40MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7 NONLCK ST 44 -,SUP-614744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7 NONLOCKING ST 46 -,SUP-614746,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X55MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 2.7 X 60MM -,SUP-614760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X8MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614808,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X10MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X12MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X14MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X16MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X18MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X20MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X22MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X24MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X28MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X30MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614830,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X32MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X34MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614834,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X36MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614836,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5 NONLCK ST 38 -,SUP-614838,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X40MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X42MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614842,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5 X 44 NONLOCK -,SUP-614844,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
46MM 3.5 SCREW -,SUP-614846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5 NONLOCK ST 46 -,SUP-614846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 3.5 X 48MM NON-LOCK -,SUP-614848,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X50MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614850,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X60MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614860,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5 NONLOCK ST 65 -,SUP-614865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X70MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614870,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE CEMENT SIMPLEX -,SUP-6191-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,431.79,302.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CEMENT BONE SIMPLEX P -,SUP-6191-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE CEMENT SPEEDSET SIMPLEX P FULL DOSE -,SUP-6192-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,431.79,302.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CEMENT SIMPLEX SPEED SET -,SUP-6192-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CEMENT BONE SIMPLEX HV -,SUP-6194-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CEMENT BONE SIMPLEX GENTAMICIN -,SUP-6195-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CEMENT BONE SIMPLEX TOBRAMYCIN -,SUP-6197-9-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO ASNIS III F/6.5/8MM BN SCR TI RND -,SUP-619904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,157.55,110.285,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO ASNIS III 4MM TI RND -,SUP-619905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,122.54,85.778,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO 5MM ASNIS III 5MM TI RND -,SUP-619906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.64,107.548,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER FOR 2.3MM BONE SCREWS -,SUP-619915,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.91,88.837,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
Washer T8 & T10 Scrws 2.4/2.7/3.5 -,SUP-619920,CDM,C1713,HCPCS,278,RC,,,outpatient,,,124.4,87.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER 19 FOR SCREWS 6.5/8.0MM -,SUP-619990,CDM,C1713,HCPCS,278,RC,,,outpatient,,,882.25,617.575,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
STIMULAN 5CC -,SUP-620-005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
STIMULAN 10CC -,SUP-620-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SPIN 12MM ASPEN -,SUP-6201-0012-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ASPEN 14MM -,SUP-6211-0014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,26874.69,18812.283,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 10HL TI -,SUP-621410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7788.16,5451.712,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLUG BONE H MED 25 -,SUP-6215-5-011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
MIS CALCANEAL PLATE S7 7 HOLES -,SUP-622102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
MIS CALCANEAL PLATE M8 8 HOLE -,SUP-622104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
INSERT 10 DEG POLYETHYLENE 32MM D TRIDENT X3 -,SUP-623-10-32D,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE SCREW 6.5X30 SELF-TAP -,SUP-6250-65-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ONE-THIRD TUBULAR PLATE 2 HOLE / L23MM -,SUP-626672,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1523.42,1066.394,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TUBULAR PLATE ONE-THIRD 4 HOLE -,SUP-626674,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ONE-THIRD TUBULAR PLATE 5 HOLE / L59MM -,SUP-626675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ONE-THIRD TUBULAR PLATE 6 HOLE / L71MM -,SUP-626676,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TUBULAR PLATE ONE-THIRD 6 HOLE -,SUP-626676S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ONE-THIRD TUBULAR PLATE 7 HOLE L83MM -,SUP-626677,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 8 HOLE -,SUP-626678,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TUBULAR HOLE 9 -,SUP-626679,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2203.63,1542.541,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TUBULAR HOLE 12 -,SUP-626682,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2203.63,1542.541,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TUBULAR 16HL -,SUP-626686,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2746.15,1922.305,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE POLYAXIAL LKG TALO-NAVICULAR LONG T10 -,SUP-626762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4305.48,3013.836,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
VARIAX NAVICULAR PLATE -,SUP-626881,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4186.99,2930.893,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
POLYAXIAL LOCKING PLATE CUBOID (T8) -,SUP-626885,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.24,2762.368,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 3 HOLE SLIM -,SUP-626963,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5843.99,4090.793,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 6 HOLE SLIM -,SUP-626966,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5843.99,4090.793,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SLIM STRAIGHT 7 HOLE T8 -,SUP-626967,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5843.99,4090.793,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2 HOLE FOREFOOT PLATE -,SUP-626972,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BROAD 3 HOLE -,SUP-626973,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BROAD STRAIGHT PLATE 4 HOLE -,SUP-626974,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
5 HOLE FOREFOOT PLATE -,SUP-626975,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
6 HOLE BROAD Y-PLATE -,SUP-626976,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BROAD STRAIGHT T10 7 HOLE -,SUP-626977,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SLIM -,SUP-626982,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
3-HOLE 4-PLATE- SLIM -,SUP-626983,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE-Y 4 HOLE SLIM -,SUP-626984,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 5 HOLE SLIM Y -,SUP-626985,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BROAD Y PLATE 2 SHAFT HOLES -,SUP-626992,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BROAD Y PLATE 3 HOLE -,SUP-626993,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BROAD Y-PLATE- 3 SHAFT -,SUP-626993,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
STRYKER PLATE -,SUP-626994,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
VARIAX 2 FOREFOOT 5 HOLE PLATE -,SUP-626995,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BONE VARIAX BROAD Y 6 SHAFT HOLES T10 -,SUP-626996,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BROAD Y PLATE - 7 HOLES -,SUP-626997,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BROAD Y-PLATE- 7 SHAFT HOLES (T10) -,SUP-626997,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 3HL TI -,SUP-627203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
4 HOLE PLATE HUMERUS -,SUP-627204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 5-HOLE -,SUP-627205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PROX LAT HUMERUS LEFT 6 HOLE L125MM -,SUP-627206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8796.54,6157.578,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PROXIMAL LATERAL HUMERUS 8 HOLE -,SUP-627208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9123.11,6386.177,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 12 HOLE LEFT PROX LAT HUMERAL -,SUP-627212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9529.9,6670.93,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PROXIMAL LATERAL HUMERUS PLATE -,SUP-627216S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10146.77,7102.739,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 3 HOLE PROXIMAL LATERAL HUMERUS -,SUP-627233,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
4 HOLE PLATE RIGHT -,SUP-627234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BONE AXSOS 3 TI 6 HOLE HUMERUS RIGHT PROXIMAL LATERAL -,SUP-627236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8796.54,6157.578,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
8 HOLE PLATE STRYKER -,SUP-627238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9123.11,6386.177,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
10 HOLE PROXIMAL HUMERUS PLATE - RIGHT -,SUP-627240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9123.11,6386.177,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE HUMERUS 12 HOLE RIGHT PR -,SUP-627242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9529.9,6670.93,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PROXIMAL LATERAL HUMERUS PLATE FOR RIGHT HUMERUS 14 HOLE -,SUP-627244S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10146.77,7102.739,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2 HOLE PLATE LEFT TIBIA -,SUP-627302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7207.59,5045.313,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 121MM 4HL -,SUP-627304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7356.55,5149.585,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 147MM 6HL -,SUP-627306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7509.33,5256.531,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 8 HOLE PROX LATERAL FOR LEFT TIBIA L173MM -,SUP-627308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7658.3,5360.81,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PROXIMAL LATERAL TIBIA FOR LEFT TIBIA 10 HOLE -,SUP-627310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8099.46,5669.622,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
AXSOS 3 TI PROX LAT TIBIA LEFT 12 HOLE PLATE -,SUP-627312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8414.58,5890.206,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 95MM 2HL F-SHP RT TIB -,SUP-627332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7207.59,5045.313,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 4HL -,SUP-627334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7356.55,5149.585,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE RIGHT HOLE 6 -,SUP-627336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8887.66,6221.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PROXIMAL MEDIAL TIBIA 8 HOLE RIGHT -,SUP-627338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7658.3,5360.81,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 10 HOLE RIGHT PROX LATERAL TIBIA -,SUP-627340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8099.46,5669.622,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE RIGHT HOLE 12 -,SUP-627342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8252.25,5776.575,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE RIGHT HOLE 14 -,SUP-627344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8414.58,5890.206,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 6HL LT DIST -,SUP-627406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7102.55,4971.785,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DIST RAD TIB 12 HOLE LFT -,SUP-627412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7996.33,5597.431,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 14HL TI -,SUP-627414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8206.41,5744.487,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN MED DST -,SUP-627434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6900.11,4830.077,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 6HL MDL/DIST RIGHT -,SUP-627436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7102.55,4971.785,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DIST MED TIB 8HOLE RIGHT -,SUP-627438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7304.99,5113.493,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DIST MEDIAL 10 HOLE RT -,SUP-627440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7788.16,5451.712,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DIST MED LKD 12 HOLE RT -,SUP-627442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7996.33,5597.431,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 14 HOLE RIGHT DISTAL MEDICAL PLATE -,SUP-627444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8206.41,5744.487,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 4HL TI RT DIST -,SUP-627454,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.44,5926.508,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BONE AXSOS 3 TITANIUM 127 MM TIBIAL LEFT DISTAL -,SUP-627456,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7802.17,5461.519,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 8 HOLE LEFT ANTEROLATERAL -,SUP-627458,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7975.32,5582.724,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW DIST ANTERIORLATERAL TIBIA LFT 10HL 178MM -,SUP-627460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8370.53,5859.371,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TIBIA  14 HOLE LEFT L229MM DISTAL ANTEROLATERAL -,SUP-627464,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8724.98,6107.486,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 4 HOLE -,SUP-627484,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7631.05,5341.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 6 HOLE RIGHT ANT-LAT -,SUP-627486,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7802.17,5461.519,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TIBIA DISTAL ANTEROLATERAL RIGHT 8 HOLE L153MM -,SUP-627488,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7975.32,5582.724,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DISTAL ANTEROLAT TIBIA RIGHT 10 HOLE 178MM -,SUP-627490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8370.53,5859.371,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE LKG COMP 11 HOLD L149MM X 4.0MM -,SUP-627511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5647.28,3953.096,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 12HOLE COMPRESSION -,SUP-627512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5647.28,3953.096,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 14 HOLE AXSOS STRAIGHT -,SUP-627514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5809.61,4066.727,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE LOCKING COMPRESSION 18 HOLE L240MM 4.0MM -,SUP-627518S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6099.9,4269.93,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 7 HOLE NARROW COMPRESSION -,SUP-627537,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6619.37,4633.559,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 8 HOLE NARROW COMPRESSION -,SUP-627538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.27,4961.089,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 9 HOLE NARROW -,SUP-627539,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.27,4961.089,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 10 HOLE STRAIGHT -,SUP-627540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7348.91,5144.237,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE STRAIGHT BROAD 9 HOLE COMPR 173 LENGTH -,SUP-627569,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.27,4961.089,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE STRAIGHT BROAD 10 HOLE COMPRESSION -,SUP-627570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7348.91,5144.237,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE LOCKING COMPRESSION BROAD 12 HOLE -,SUP-627572,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7348.91,5144.237,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 13 HOLE 5.0 COMPRESSION PLATE -,SUP-627573,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7518.88,5263.216,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BROAD 14 HOLE -,SUP-627574,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7518.88,5263.216,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DISTAL LATERAL FEMUR PLATE FOR LEFT FEMUR 4 HOLE -,SUP-627604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7824.24,5476.968,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 166MM 6HL LT DIST LAT FEM -,SUP-627606,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9329.8,6530.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 8HL LT -,SUP-627608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8189.22,5732.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 238MM 10HL LT DIST LAT FEM -,SUP-627610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8683.22,6078.254,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 12HL -,SUP-627612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8871.66,6210.162,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 343MM 16HL LT -,SUP-627616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9250.22,6475.154,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DISTAL FEMUR -,SUP-627618S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9623.69,6736.583,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DISTAL LATERAL FEMUR 4 HOLE -,SUP-627634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7824.24,5476.968,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 166MM 6HL DIST LAT FEM -,SUP-627636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8009.28,5606.496,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DISTAL LATERAL FEMUR -,SUP-627638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8189.22,5732.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 238MM 10HL RT DIST LAT FEM -,SUP-627640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8683.22,6078.254,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 274MM 12HL -,SUP-627642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8871.66,6210.162,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 343MM 16HL 1STRN/PK RT -,SUP-627646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9250.22,6475.154,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE AXSOS 3 TI DISTAL LAT FEMUR RT 18 HOLE L379MM -,SUP-627648S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9623.69,6736.583,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TIBAL 4 HOLE LEFT/L71MM -,SUP-627704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.9,4447.73,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE MEDIAL PROXIMAL TIBIAL 5 HOLES LEFT -,SUP-627705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6560.16,4592.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE MEDIAL 6 HOLES STRYKER -,SUP-627706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6764.51,4735.157,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PROX MED TIBIA FOR LEFT TIBIA 8HOLE L-123MM -,SUP-627708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6966.95,4876.865,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 14 HOLE PROX MEDIAL FOR LEFT TIBIA L201MM -,SUP-627714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7866.47,5506.529,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PROXIMAL MEDIAL TIBIA FOR LEFT TIBIA 16 HOLE -,SUP-627716S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8278.98,5795.286,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKED TIBIAL PLATE -,SUP-627734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.9,4447.73,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TIBIAL LATERAL 5 HOLE -,SUP-627735,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6560.16,4592.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PROX MED TIB RT 6 HL -,SUP-627736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6764.51,4735.157,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PROXIMAL MEDIA TIBIA 97MM LENGTH -,SUP-627736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6764.51,4735.157,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PROXIMAL MEDIAL TIBIA 8 HOLE RIGHT -,SUP-627738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8247.49,5773.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN AXSOS 10HL RT PROX MDL TIB COMPR -,SUP-627740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7438.67,5207.069,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PROXIMAL MEDIAL TIBIA PLATE FOR RT TIBIA 12 HOLE 175MM -,SUP-627742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7654.48,5358.136,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
INTERPROSTHETIC FEMUR PLATE RIGHT 334MM -,SUP-627846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,27813.56,19469.492,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DISTAL FEMUR PLATE RIGHT 280MM -,SUP-627863,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19576.64,13703.648,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
6 HOLE PLATE - LEFT -,SUP-628006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 88MM 7HL STD PRCONT VAR ANG TI ALY DECREASED -,SUP-628007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 99MM 8HL STD PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 122MM 10HL STD PRCONT VAR ANG TI ALY -,SUP-628010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SUPERIOR 7 HOLE RIGHT DECREASED -,SUP-628027,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 99MM 8HL STD PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE VARIAX 99MM CLAVICLE RIGHT SUPERIOR DECREASED 8 HOLE -,SUP-628028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 99MM 6HL BRDG PRCONT VAR ANG TI ALY LT CLVCL -,SUP-628046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 122MM 8HL BRDG PRCONT VAR ANG TI ALY -,SUP-628048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 99MM 6HL BRDG PRCONT VAR ANG TI ALY RT CLCVL -,SUP-628066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BRIDGE 8 HOLE SUPERIOR D -,SUP-628068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 8 HOLE STRYKER -,SUP-628108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 10 HOLE STRYKER -,SUP-628110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CLAVICLE INC CURVED 8 HOLE -,SUP-628128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CLAVICLE IC 10 HOLE -,SUP-628130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 6 HOLE BRIDGE -,SUP-628166,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUPERIOR LATERAL PLATE - 3 HOLE / LEFT -,SUP-628203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 98MM 5HL PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUPERIOR LATERAL PLATES -,SUP-628207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4698.11,3288.677,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 86MM 4HL PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE RIGHT LATERAL 5-HOLE #628225 -,SUP-628225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 7 HOLE LATERAL -,SUP-628227,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4698.11,3288.677,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 86MM 7HL PRCONT VAR ANG TI ALY UNIV SMRTLC -,SUP-628307,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 16MMX68MM PRCONT VAR ANG TI ALY LAT -,SUP-628525S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4480.35,3136.245,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
HOOK PLATE 7 HOLE 16MM RIGHT -,SUP-628537S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4480.35,3136.245,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DISTAL LATERAL HUMERUS PLATE 4 HOLE 109MM -,SUP-629204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 8 HOLE LEFT LATERAL -,SUP-629208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 3HL RT DIST LAT HUM COMPR -,SUP-629223S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DISTAL LATERAL 4 HOLE 109MM -,SUP-629224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 12 HOLE RIGHT HUMERUS L203MM VARIAX DIST LATERAL -,SUP-629232S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE HUMERUS DIST POST LATERAL LEFT 3 HOLE -,SUP-629243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 105MM 4HL PRCONT VAR ANG LCK TI ALY NS LT -,SUP-629244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 128MM 6HL SHFT PRCONT VAR ANG LCK TI ALY NS -,SUP-629246,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 150MM 8HL PRCONT VAR ANG LCK TI ALY NS LT -,SUP-629248,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DIST POST LATERAL HUMERUS 10 HOLE L173MM -,SUP-629250S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 105MM 4HL PRCONT VAR ANG LCK TI ALY NS RT -,SUP-629264,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 150MM 8HL PRCONT VAR ANG LCK TI ALY NS RT -,SUP-629268,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE HUMERUS DISTAL POSTERIOR LATERAL 12 HOLE -,SUP-629272S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE EXTENDED MEDIAL LEFT 3 HOLE -,SUP-629283,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 96MM 4HL PRCONT VAR ANG LCK TI ALY -,SUP-629284,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DISTAL MEDIAL HUMERUS 6 HOLE EXTEND -,SUP-629286,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 104MM 4HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 151MM 8HL SHFT PRCONT VAR ANG LCK TI ALY NS -,SUP-629308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DIST POST MEDIAL HUMERUS 12 HOLE L199MM -,SUP-629312S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DISTAL POSTERIOR MEDIAL HUMERUS PLATE FOR RT HUM 3 HOLE -,SUP-629323,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DIST POST MDL RIGHT 4 -,SUP-629324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DISTAL POSTERIOR MEDIAL 8 HOLE -,SUP-629328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DIST POST MEDIAL HUMERUS 12 HOLE L199MM -,SUP-629332S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE OLECRARON LEFT 3 HOLE -,SUP-629343,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 89MM 4HL PRCONT VAR ANG LCK TI ALY NS LT -,SUP-629344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
3 HOLE RIGHT PLATE -,SUP-629363,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 89MM 4HL PRCONT VAR ANG LCK TI ALY NS RT -,SUP-629364,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 113MM 6HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629366,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 137MM 8HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629368,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE MEDIAL 3 HOLE -,SUP-629383,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 92MM 4HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629384,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 116MM 6HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629386,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 139MM 8HL LCK TI ALY NS -,SUP-629388,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DISTAL MEDIAL HUMERUS LEFT 10HOLE 163MM -,SUP-629390S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DISTAL MEDIAL HUMERUS 12 HOLE -,SUP-629392S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE COMPRESSION NARROW STRAIGHT 4 HOLES -,SUP-629504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1289.93,902.951,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE COMPRESSION NARROW STRAIGHT 5 HOLES -,SUP-629505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 6 HOLE COM PR NRW STR -,SUP-629506S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 7HL COMPR NRW STR -,SUP-629507S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX COMPR TI ALY NRW STR 629508S STRL -,SUP-629508S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE COMP 9 HOLE NARROW STR -,SUP-629509S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 10HL COMPR NRW STR -,SUP-629510S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE COMPRESSION NARROW STRAIGHT 12 HOLES -,SUP-629512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
14 HOLE NARROW COMPRESSION PLATE VARIAX -,SUP-629514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX COMPR TI ALY NRW STR 629527S STRL -,SUP-629527S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 7HL COMPR BRD STR -,SUP-629537S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMPRESSION PLATE BROAD STRAIGHT 6 HOLES -,SUP-629546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 8HL COMPR NRW STR -,SUP-629548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMPRESSION PLATE BROAD STRAIGHT 9 HOLES/L115MM -,SUP-629549S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2509.57,1756.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
VARIAX COMPRESSION PLATE BROAD CURVED 9 HOLES -,SUP-629559,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN VARIAX 8HL COMPR BRD CRV -,SUP-629560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE COMPRESSION BROAD CURVED 11 HOLES -,SUP-629561,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE COMP VARIAX BROAD CURVED 10 HOLES -,SUP-629562,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SHORT BEND -,SUP-629589,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8642.06,6049.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PROFILE 2.0 4HOLE -,SUP-629604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1944.22,1360.954,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PROFILE 2.0 X L33MM 6 HOLE -,SUP-629606,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1944.22,1360.954,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PROFILE PLATE 2.0 54MM -,SUP-629610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1944.22,1360.954,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PROFILE PLATE 2.0 L108MM 20HOLES -,SUP-629620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE NARROW LOCKING 2.0 4 HOLE -,SUP-629624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2488.21,1741.747,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE NARROW LOCK 2.0 L34MM 6 HOLES -,SUP-629626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2488.21,1741.747,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 8 HOLE NARROW -,SUP-629628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2488.21,1741.747,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2.0MM BROAD LOCKING 6 HOLES STRAIGHT -,SUP-629646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BROAD LOCKING 2.0 / 10 HOLE -,SUP-629650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PROFILE 8 HOLE 2.4 -,SUP-629666,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PROFILE 2.4 8HOLE -,SUP-629668,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE VARIAX LOW PROFILE 2.4 X L66MM 10 HOLES -,SUP-629670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE NARROW LOCK 2.4 X L28MM 4 HOLE -,SUP-629684,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
6 HOLE NARROW PLATE -,SUP-629686,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2.4MM 8 HOLE -,SUP-629688,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BONE VARIAX NARROW LOCK 2.4 L69MM 10 HOLE -,SUP-629690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 4 HOLE -,SUP-629704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BROAD LOCKING 2.4 6 HOLE -,SUP-629706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 8 HOLE STRAIGHT 2.4 -,SUP-629708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BONE VARIAX BROAD LOCK 2.4 L80MM 10HOLES -,SUP-629710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BROAD LOCKING 2.4 12 HOLE -,SUP-629712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 4 HOLE NARROW -,SUP-629724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2.7 6 HOLE STRAIGHT -,SUP-629726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 8 HOLE -,SUP-629728,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 10 HOLE -,SUP-629730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE STRAIGHT 10 HOLE -,SUP-629740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BROAD LOCK 2.7 L39MM 4 HOLE -,SUP-629744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2.7 6 HOLE -,SUP-629746,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BROAD LOCK 2.7 X 73MM 8HL -,SUP-629748,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
T-PLATE 2.7MM 3 X 10 -,SUP-629748,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BROAD LOCKING 2.7 10HOLE -,SUP-629750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 12 HOLE BROAD STRAIGHT -,SUP-629752,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3870.76,2709.532,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
T-PLATE NARROW LOCKING 2.0 2 X 5 HOLE -,SUP-629770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NARROW LOCK T-PLATE 2.0 L62MM 2X10HOLES -,SUP-629771,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2716.41,1901.487,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE NARROW LCK T 2.0 3X5 HOLE -,SUP-629772,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
T-PLATE 2.4MM NARROW LOCKING 2 X 5 -,SUP-629776,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
T-PLATE -,SUP-629777,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BONE VARIAX NARROW LOCK T-PLATE 2.4 L41MM 3X5 HOLES -,SUP-629778,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE T 2.4 NARROW -,SUP-629779,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE NARROW T 2.4 X L76MM 5X10 HOLES LKG -,SUP-629781,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE NARROW LOCKING T 5 HOLE -,SUP-629782,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 10 HOLE -,SUP-629783,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE AXSOS TITANIUM 5 HOLE -,SUP-629784,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE NARROW LOCKING T  2.7 X 87MM 10HOLE -,SUP-629785,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE T NARROW LOCK 2.7 L8 7MM X 5 X 10 HOLES -,SUP-629787,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2.7 Y- PLATE -,SUP-629788,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4103.73,2872.611,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2.7MM TRIANGLE -,SUP-629789,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4103.73,2872.611,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE Y 2.4MM -,SUP-629790,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE NARROW LOCK TRIANGLE 2.4 X 81MM 10 HOLE -,SUP-629791,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANTERIOR TT PLATE LEFT -,SUP-630101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10381.67,7267.169,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANTERIOR TT PLATE RIGHT -,SUP-630102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10381.67,7267.169,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT FLEXBLOCK -,SUP-6314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7031.8,4922.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN FX 38MM TRIATH HD F/T/K SYS -,SUP-6541-4-515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ABC IM ROD TRIATHLON INSTRUMENTS -,SUP-6541-4-516E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2213.49,1549.443,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN FX 19MM TRIATH HD F/T/K SYS -,SUP-6541-4-575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,327.34,229.138,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T8 FULL THREAD 2.4 X 6 -,SUP-656006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T8 FULL THREAD 2.4 X 7 -,SUP-656007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK T8 FULL THREAD 2.4X8 -,SUP-656008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T8 FULL THREAD 2.4 X 10 -,SUP-656010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.4 X 11 -,SUP-656011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK T8 FII THRD 2.4 X 12 -,SUP-656012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T8 FULL THREAD 2.4MM L14 -,SUP-656014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.4MM X 16MM LOCKING -,SUP-656016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T8 FULL TRHEAD 2.4MM L 18MM -,SUP-656018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T8 FULL THREAD 2.4 X 22 -,SUP-656022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T8 FULL THREAD 2.4MM X 24MM -,SUP-656024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW T8 FULL THREAD 2.4MM X 26MM -,SUP-656026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T8 FULL THREAD 2.4 X 28 -,SUP-656028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T8 FULL THREAD 2.4 X 30 -,SUP-656030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T8 FULL THREAD 2.4 X 32 -,SUP-656032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T8 FULL THREAD 2.4 X 34 -,SUP-656034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T8 FULL THREAD 2.4 X 36 -,SUP-656036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.4MM X 38MM -,SUP-656038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FULL THREAD 2.4X6 -,SUP-656106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FULL THREAD 2.4X7 -,SUP-656107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FULL THREAD 2.4X8 -,SUP-656108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FULL THREAD 2.4X9 -,SUP-656109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FULL THREAD 2.4X12 -,SUP-656112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FULL THREAD 2.4X14 -,SUP-656114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.4 X 15 NL -,SUP-656115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FULL THREAD 2.4X18 -,SUP-656118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FULL THREAD 2.4X20 -,SUP-656120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FULL THREAD 2.4X24 -,SUP-656124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FULL THREAD 2.4X26 -,SUP-656126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FULL THREAD 2.4X28 -,SUP-656128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FULL THREAD 2.4X30 -,SUP-656130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FULL THREAD 2.4X32 -,SUP-656132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FULL THREAD 2.4X34 -,SUP-656134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FULL THREAD 2.4X36 -,SUP-656136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FULL THREAD 2.4X38 -,SUP-656138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T8  2.4MM X L40MM NL -,SUP-656140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCKING 3.5 X 42 -,SUP-656142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCKING 3.5 X 44 -,SUP-656144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FULL THREAD 2.4X48 -,SUP-656148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FULL THREAD 2.4X50 -,SUP-656150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE VARIAX T8 2.4MM L55MM -,SUP-656155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FULL THREAD 2.4X60 -,SUP-656160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7MM X 6MM -,SUP-656306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T8 FULL THREAD 2.7 X 7 -,SUP-656307,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1150.21,805.147,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T8 FULL THREAD 2.7X8 -,SUP-656308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7MM X 9MM -,SUP-656309,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK T8 FULL THREAD 2.7X10 -,SUP-656310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK T8 2.7 X 11MM -,SUP-656311,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7MM X 12MM -,SUP-656312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7 X 13 LOCKING -,SUP-656313,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7MM X 14MM -,SUP-656314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK T8 2.7 X 15MM -,SUP-656315,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7MM X 16MM -,SUP-656316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7MM X 18MM -,SUP-656318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7MM X 20MM -,SUP-656320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7MM X 22MM -,SUP-656322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7MM X 24MM -,SUP-656324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7MM X 26MM -,SUP-656326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7MM X 22MM -,SUP-656328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7 X 3 LOCKING -,SUP-656330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7MM X 32MM -,SUP-656332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7 X 34 -,SUP-656334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7MM X 36MM -,SUP-656336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7MM X 38MM -,SUP-656338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7MM X 40MM -,SUP-656340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7 X 42 -,SUP-656342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7MM X 44MM -,SUP-656344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7 X 45 -,SUP-656345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7MM X 50MM -,SUP-656350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.7MM X 55MM LOCKING SCREW -,SUP-656355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE VARIAX T8 2.7MM  X  L 60MM LOCKING -,SUP-656360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.7 X 70 -,SUP-656370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE VARIAX T8 2.7MM X L 75MM LOCKING SCREW -,SUP-656375S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,694.95,486.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE VARIAX T8 2.7MM X L 80MM LOCKING -,SUP-656380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,694.95,486.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T8 FULL THREAD NON LCK 2.7 X 6 -,SUP-656406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE VARIAX T8  7MM X 2.7MM -,SUP-656407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T8 FULL THREAD 2.7MM X 9 -,SUP-656409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MM X 10MM NON LOCKING -,SUP-656410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T8 2.7 X11MM -,SUP-656411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW N/L 2.7MM X 12MM -,SUP-656412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7 X 13 NL -,SUP-656413,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW N/L 2.7MM X 14MM -,SUP-656414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCKING 2.7 X 15 -,SUP-656415,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW N/L 2.7MM X 16MM -,SUP-656416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW N/L 2.7MM X 18MM -,SUP-656418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7 X 20MM NLCKG FT T8 STRDRV RCESS -,SUP-656420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON-LOCKING 2.7MM X 22MM -,SUP-656422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCKING 2.7 X 26MM -,SUP-656426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.7MM NON LOCKING BONE SCREW 28MM -,SUP-656428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FLL THRD 2.7 X 30 -,SUP-656430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FLL THRD 2.7 X 32 -,SUP-656432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FLL THRD 2.7 X 34 -,SUP-656434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FLL THRD 2.7 X 36 -,SUP-656436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCKING 2.7 X 38 -,SUP-656438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCKING 2.7 X 40 -,SUP-656440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T8 FULL THREAD 2.7 X 40 -,SUP-656440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCKING 2.7MM X 42MM -,SUP-656442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCKING 2.7 X 45 -,SUP-656445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCKING 2.7 X 46 -,SUP-656446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN T8 FLL THRD 2.7 X 48MM -,SUP-656448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7 X 50 NL -,SUP-656450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7 X 55 NL -,SUP-656455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCKING 2.7MM X 60MM -,SUP-656460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCKING 2.7MM X 65MM -,SUP-656465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NL 2.7 X 70 -,SUP-656470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 2.7MM X 75MM T8 -,SUP-656475S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE VAIRAX T8 2.7MM X L 80MM -,SUP-656480S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10 FULL THREAD 2.7 X 8 -,SUP-657008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X12MM LCK FT T10 HX DRV -,SUP-657012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X14MM LCK FT T10 HX DRV -,SUP-657014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X16MM LCK FT T10 HX DRV -,SUP-657016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X20MM LCK FT T10 HX DRV -,SUP-657020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10 FULL 2.7 X 22 -,SUP-657022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10 FULL 2.7MM  X 22MM VARIAX -,SUP-657024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7 X 26 LOCKING -,SUP-657026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7 X 28 LOCKING -,SUP-657028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7 X 30 LOCKING -,SUP-657030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10 FULL 2.7 X 32 -,SUP-657032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW T10 FULL THREAD 2.7MM L34MM -,SUP-657034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10 FULL 2.7 X 36 -,SUP-657036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7 X 38 LOCKING -,SUP-657038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MM X 40MM LOCKING -,SUP-657040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10 2.7 X 50 -,SUP-657050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10 2.7 X 55 -,SUP-657055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW T10 FULL THREAD 2.7MM X 60MM -,SUP-657060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10 FULL THREAD 2.7 X 65 -,SUP-657065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10 FULL THREAD 2.7 X 70 -,SUP-657070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 2.7 X 8 -,SUP-657108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X12MM FT T10 HX DRV -,SUP-657112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X14MM FT T10 HX DRV -,SUP-657114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X16MM FT T10 HX DRV -,SUP-657116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X18MM FT T10 HX DRV -,SUP-657118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X20MM FT T10 HX DRV -,SUP-657120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X22MM FT T10 HX DRV -,SUP-657122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 2.7 X 26 -,SUP-657126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 2.7 X 28 -,SUP-657128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
30MM BONE SCREW NONLOCKING 2.7MM -,SUP-657130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NL 2.7 X 32 -,SUP-657132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NL 2.7 X 34 -,SUP-657134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 2.7MM /L36MM -,SUP-657136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NL 2.7 X 38 -,SUP-657138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 2.7MM /L40MM -,SUP-657140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 2.7MM /L42MM -,SUP-657142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 2.7mm / L44mm -,SUP-657144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 2.7MM /L46MM -,SUP-657146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 2.7mm / L48mm -,SUP-657148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 2.7MM /L50MM -,SUP-657150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 2.7MM /L55MM -,SUP-657155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 2.7MM /L60MM -,SUP-657160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 2.7 X 65 -,SUP-657165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 2.7 X 70 -,SUP-657170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10 FULL THREAD 3.5 X 8 -,SUP-657308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X10MM LCK FT T10 HX DRV -,SUP-657310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 3.5MM 12MM VARIAX T10 FULL THREAD LOCK NONSTERILE -,SUP-657312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X14MM LCK FT T10 HX DRV -,SUP-657314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X16MM LCK FT T10 HX DRV -,SUP-657316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X18MM LCK FT T10 HX DRV -,SUP-657318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10 3.5MM / L20MM FULL THREAD -,SUP-657320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 3.5 X 22 -,SUP-657322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10 3.5MM / L22MM FULL THREAD -,SUP-657322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 3.5 X 24 -,SUP-657324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 3.5 X 26 -,SUP-657326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 3.5 X 30 -,SUP-657330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 3.5 X 32 -,SUP-657332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 3.5 X 34 -,SUP-657334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 3.5 X 38 -,SUP-657338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10 FULL THREAD 3.5 X 40 -,SUP-657340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10 FULL THREAD 3.5 X 42 -,SUP-657342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 3.5 X 44 -,SUP-657344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 3.5 X 46 -,SUP-657346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10FULL THREAD 3.5MM X 48MM -,SUP-657348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10 FULL THREAD 3.5MM X 50MM -,SUP-657350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10 FULL THREAD 3.5 X 60 -,SUP-657360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10 FULL THREAD 3.5 X 65 -,SUP-657365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10 FULL THREAD 3.5 X 70 -,SUP-657370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 3.5 X 8 -,SUP-657408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 3.5 X 8 -,SUP-657408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 3.5MM /L10MM -,SUP-657410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5 NON LOCKING 12MM -,SUP-657412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MM X12MM NON LOCKING -,SUP-657412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X14MM FT T10 HX DRV -,SUP-657414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X16MM FT T10 HX DRV -,SUP-657416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X18MM FT T10 HX DRV -,SUP-657418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X20MM FT T10 HX DRV -,SUP-657420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON-LOCKING 3.5 MM X 22 -,SUP-657422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5 NON LOCK FT 24MM -,SUP-657424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5 NON LOCK FT 26MM -,SUP-657426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MM NONLOCKING FT 28MM -,SUP-657428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MM NONLOCKING FT 30MM -,SUP-657430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
VARIAX 305MM NON LOCKING SCREW  32MM -,SUP-657432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.5MM NON-LOCKING SCREW 34MM -,SUP-657434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.5MM NON-LOCKING SCREW 36MM -,SUP-657436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 3.5 X 38 -,SUP-657438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW  BONE T10 FULL THREAD NON LOCKING 3.5 X 40 -,SUP-657440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 3.5MM X 42MM -,SUP-657442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
VARIAX 3.5MM NON LOCKING SCREW 44MM -,SUP-657444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE SCREW T10 FULL THREAD 3.5MM / L46MM -,SUP-657446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10FULL THREAD 3.5 X 48 -,SUP-657448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MM NONLOCKING FT 50MM -,SUP-657450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 3.5 X 55 -,SUP-657455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 3.5 X 60 -,SUP-657460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 3.5 X 65 -,SUP-657465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 FULL THREAD 3.5 X 70 -,SUP-657470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW VARIAX LOCKING T6 2.0MM L8MM -,SUP-657608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T6 2.0MM L9MM -,SUP-657609,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW VARIAX LOCKING T6 2.0MM L10MM -,SUP-657610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T6 2.0MM L11MM -,SUP-657611,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.0MM  X 12MM LOCKING -,SUP-657612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T6 2 X 14MM -,SUP-657614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK T6 2.0 X 16MM -,SUP-657616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK T6 2.0 X 18MM -,SUP-657618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2-0MM LOCKING 20MM LENGTH -,SUP-657620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK T6 2.0 X 22MM -,SUP-657622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T6 2.0 X 26MM -,SUP-657626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING VARIAX T6 2.0MM X L30MM -,SUP-657630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 2.0M X L6MM T6 -,SUP-657706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NONLCK 2.0 X 10MM -,SUP-657710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2 X 11 -,SUP-657711,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.0MM X 12MM NON LOCKING -,SUP-657712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.0MM X 14MM NON LOCKING -,SUP-657714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2 X 16 -,SUP-657716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW VARIAX 2.0 X 18 -,SUP-657718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.9 NON LOCKING 20MM LENGTH -,SUP-657720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCKING 2 X 22 -,SUP-657722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T6 2.0MM X L 24MM NON-LOCKING -,SUP-657724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T6 2.0MM L26MM -,SUP-657726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.0MM NON LOCKING 28MM LENGTH -,SUP-657728,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T6 2.0MM L30MM -,SUP-657730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE VARIAX T6 2.0MM X L34MM -,SUP-657734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCKING 2 X 36 -,SUP-657736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE VARIAX T6 2.0MM X L38MM -,SUP-657738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FIXOS 4.0 30MM -,SUP-658030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS 4.0 FIXOS 38MM -,SUP-658038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.0 FIXOS 46MM SCREW -,SUP-658046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.0 FIXOS 48MM SCREW -,SUP-658048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS COMP. 7.0MM 50M -,SUP-658050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.0 FIXOS 55MM SCREW -,SUP-658055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS LONG THREAD 7.0 X 70MM -,SUP-658070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS COMP. 7.0MM 75M -,SUP-658075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.0 FIXOS SCREW 80MM -,SUP-658080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS 5 X 32 -,SUP-658132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FIXOS 5.0 X 34MM -,SUP-658134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FIXOS 5.0 X 36MM -,SUP-658136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
HEADLESS COMPRESSION SCREW 5MM X 38MM -,SUP-658138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
5.0 HEADLESS SCREW 44 MM -,SUP-658144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED 5.0 X 46MM FIXOS -,SUP-658146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
5.0 FIXOS 48MM SCREW -,SUP-658148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED 5.0 X 55MM FI -,SUP-658155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
HEADLESS COMPRESSION SCREW 5.0mm / L65mm -,SUP-658165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
HEADLESS COMPRESSION SCREW 5.0mm / L70mm -,SUP-658170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2402.19,1681.533,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FIXOS 5 X 70MM -,SUP-658170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE FIXOS 5 X 75 -,SUP-658175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FIXOS 5 X 80 -,SUP-658180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
HEADLESS COMPRESSION SCREW 7MM / L40MM ST -,SUP-658340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS COMP. 7.0MM 6.5 FIXOS -,SUP-658365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS COMP. 7.0MM 70M -,SUP-658370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS SHORT THREAD 7.0 X 75MM -,SUP-658375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS SHORT THREAD 7.0 X 90MM -,SUP-658390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS COMP. 7.0MM 12.5 FIXOS -,SUP-658425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
HEADLESS COMPRESSION SCREW 7MM / L65MM ST -,SUP-658565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS LONG THREAD 7.0 X 70MM -,SUP-658570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
HEADLESS COMPRESSION SCREW Ã˜7.0MM / L75MM LONG THREAD -,SUP-658575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7.0 FIXOS 80MM -,SUP-658580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
HEADLESS COMPRESSION SCREW 7MM X 85MM LONG THREAD -,SUP-658585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
HEADLESS COMPRESSION SCREW 7MM X25MM -,SUP-658625,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 8X20MM -,SUP-660H0820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 9X35MM -,SUP-660H0935,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X14MM LCK -,SUP-661014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X18MM LCK -,SUP-661018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X20MM LCK -,SUP-661020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X22MM LCK -,SUP-661022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X24MM LCK -,SUP-661024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X26MM LCK -,SUP-661026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK -,SUP-661028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X30MM LCK -,SUP-661030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X32MM LCK -,SUP-661032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X34MM LCK -,SUP-661034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X36MM LCK -,SUP-661036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X38MM LCK -,SUP-661038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X40MM LCK -,SUP-661040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1154.51,808.157,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X42MM LCK -,SUP-661042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X44MM LCK -,SUP-661044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X46MM LCK -,SUP-661046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X48MM LCK -,SUP-661048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X50MM LCK -,SUP-661050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCK 4.0 X 55MM -,SUP-661055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X60MM LCK -,SUP-661060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X65MM LCK -,SUP-661065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X70MM LCK -,SUP-661070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X75MM LCK -,SUP-661075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X80MM LCK -,SUP-661080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X85MM LCK -,SUP-661085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X90MM LCK -,SUP-661090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X95MM LCK -,SUP-661095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X14MM LCK -,SUP-661114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X16MM LCK -,SUP-661116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X18MM LCK -,SUP-661118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X20MM LCK -,SUP-661120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X22MM LCK -,SUP-661122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X24MM LCK -,SUP-661124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X26MM LCK -,SUP-661126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X28MM LCK -,SUP-661128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X30MM LCK -,SUP-661130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X32MM LCK -,SUP-661132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X34MM LCK -,SUP-661134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X36MM LCK -,SUP-661136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X38MM LCK -,SUP-661138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X40MM LCK -,SUP-661140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X42MM LCK -,SUP-661142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X44MM LCK -,SUP-661144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X46MM LCK -,SUP-661146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5 X 48MM LCK -,SUP-661148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X55MM LCK -,SUP-661155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X60MM LCK -,SUP-661160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,854.24,597.968,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X65MM LCK -,SUP-661165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X70MM LCK -,SUP-661170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X75MM LCK -,SUP-661175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X80MM LCK -,SUP-661180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X85MM LCK -,SUP-661185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X90MM LCK -,SUP-661190,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X95MM LCK -,SUP-661195,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW FLAT TIP 5.0MM T20 L10MM -,SUP-661210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2630.74,1841.518,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW FLAT TIP 5.0MM /T20 /L20 -,SUP-661220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2630.74,1841.518,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X8MM LCK ST PRPRSTHTC -,SUP-661308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 5.0 X 10MM PERIP -,SUP-661310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 5.0 X 12MM PERIP -,SUP-661312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X14MM LCK ST PRPRSTHTC -,SUP-661314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X16MM LCK ST PRPRSTHTC -,SUP-661316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X16MM PERI- LCK AXSOS -,SUP-661316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X18MM LCK ST PRPRSTHTC -,SUP-661318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X20MM LCK ST PRPRSTHTC -,SUP-661320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCKING 3.5 X 14MM -,SUP-661414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X18MM CORT TI -,SUP-661418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCKING 3.5 X 20MM -,SUP-661420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X22MM CORT TI -,SUP-661422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X24MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X28MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X30MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X32MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X34MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X36MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X38MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X40MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X42MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X44MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X46MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 3.5 X 46 -,SUP-661447,CDM,C1713,HCPCS,278,RC,,,outpatient,,,239.99,167.993,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X48MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X50MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X55MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X65MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X70MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X75MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661475,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X80MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X85MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X90MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTEX 3.5MM X 120MM -,SUP-661520S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTEX TI 4.5 X 14MM -,SUP-661714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTEX SELF TAPPING 4.5 X 16 -,SUP-661716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORT 4.5 X 18 -,SUP-661718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 4.5 X 20MM -,SUP-661720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X22MM CORT TI -,SUP-661722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORT 4.5 X 24 -,SUP-661724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORT 4.5 X 26 -,SUP-661726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORITCAL 4.5MM X 28MM -,SUP-661728,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X30MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X32MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661732,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X34MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X36MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X38MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X38MM LCK CORT VARIAX SELF TAPPING -,SUP-661738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X40MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X42MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X44MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X46MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661746,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X48MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661748,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X50MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X55MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X60MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X65MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661765,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X70MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X75MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661775,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X80MM CORT TI -,SUP-661780,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 4.5 X 85 -,SUP-661785,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX8IN ER CANC CORT VARIAX FT POLYAX ST T7 STRDRV -,SUP-661795,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CABLE PLUG 5.0MM -,SUP-662202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1868.43,1307.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW 5.0MM /T20 / L24MM -,SUP-662324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW 5.0MM /T20 /L30MM -,SUP-662330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW 5.0MM /T20 / L40MM -,SUP-662340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW 5.0MM T20 L46MM -,SUP-662346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW 5.0MM T20 L50MM -,SUP-662350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW 5.0MM T20 L60MM -,SUP-662360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW 5.0MM /T20 / L65MM -,SUP-662365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW 5.0MM T20 L70MM -,SUP-662370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW 5.0MM /T20 / L75MM -,SUP-662375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW 5.0MM /T20 /L80MM -,SUP-662380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK 1.7 X 5 -,SUP-662505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,497.14,347.998,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T5 1.7MM X 9MM -,SUP-662509,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW T5 1.7MM X 22MM -,SUP-662522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,497.14,347.998,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 1.7 X 6 -,SUP-662606,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE SCREW T5 1.7MM X 8MM -,SUP-662608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 1.7 X 9 -,SUP-662609,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.7 X 11 NON LOCKING -,SUP-662611,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.7 X 15 -,SUP-662615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.7 X 16 NL -,SUP-662616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.7 X 18 NL -,SUP-662618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EMERGENCY 1.9 X 5 -,SUP-662705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EMERGENCY T5 1.9MM/L12MM 12 HOLE LEFT -,SUP-662712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED 4.0MM X 38MM COMP -,SUP-663038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER 5MM -,SUP-663101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,202.42,141.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW JFX CANNULATED 5 X 46MM -,SUP-663146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IMPCTR HD XTRCT SHRT 3.2X19MM DURACN -,SUP-6633-7-615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,376.53,263.571,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SOLID COMPRESSION 4.0MM X 36MM L -,SUP-663436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SOLID COMPRESSION 4.0MM X 38MM -,SUP-663438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMPRESSION SCREW SOLID A 4.0MM/ L40MM -,SUP-663440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SOLID COMPRESSION 4 X 22 -,SUP-663442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.0 SOLID COMPRESSION SCREW 48MM -,SUP-663448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SOLID COMPRESSION 4.0MM X L50MM -,SUP-663450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.32,2719.724,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SOLID COMPRESSION 5.0MM X 36MM L -,SUP-663536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SOLID COMP 5MM X 40MM -,SUP-663540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW COMPRESSION 5 X 42 -,SUP-663542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
5.0MM L 44MM COMPRESSION SCREW -,SUP-663544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMPRESSION SCREW 5.0MM -,SUP-663546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5 X 48 MM SOLID -,SUP-663548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SOLID COMPRESSION 5.0MM X L50MM -,SUP-663550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.3MM X 16MM -,SUP-663716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,498.89,349.223,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.3MM X 18MM -,SUP-663718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,498.89,349.223,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 2.3 X 8 -,SUP-663808,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 2.3  X 9 -,SUP-663809,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 2.3 X 10 -,SUP-663810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCKING 2.3MM X 13MM -,SUP-663813,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON-LOCKING 2.3MM 16MM -,SUP-663816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 2.3 X 20 -,SUP-663820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EMERGENCY  2.5 X 6 -,SUP-663906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EMERGENCY 2.5 X 8 -,SUP-663908,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CORTEX SCREW DIA 4.0MM L38MM -,SUP-666138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CANLTD SCRW 16MM THREAD DIA 6.5MM L45MM -,SUP-666445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CANLTD SCREW 16MM THREAD DIA 6.5MM L50MM -,SUP-666450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CANLTD SCREW 16MM THREAD DIA 6.5MM L65MM -,SUP-666465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED 6.5 X 70 -,SUP-666470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED 6.5 X 80 -,SUP-666480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED 6.5 X 85 -,SUP-666485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER MOLD LG FEMORAL 53A/P X 75M/L -,SUP-669-1075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6663.08,4664.156,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRIP CBL 1.6MM DLMLS VITAL -,SUP-6704-0-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3931.1,2751.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CABLE ORTHO 1.6MM DLMLS VITAL MED GRP + 2 -,SUP-6704-0-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3931.1,2751.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRIP LARGE W/2 CABLES DALL MIL -,SUP-6704-0-310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3931.1,2751.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CABLE ORTHO DLMLS 1.6MM VITAL BEAD SM SLV -,SUP-6704-0-420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CABLE ORTHO DLMLS 2MM VITAL MED SLV -,SUP-6704-0-510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DALL-MILES 2.0MM VIT BEADED CABLE/SLEEVE SET -,SUP-6704-0-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SET CABLE SLEEVE BEADED  2.0 D -,SUP-6704-0-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN DLMLS 100MM GRP VITAL MED 2MM CBLX2 -,SUP-6704-3-081,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4408.24,3085.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN DLMLS 150MM GRP VITAL MED 2MM CBLX2 -,SUP-6704-3-082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5744.68,4021.276,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TROC DLMLS 110MM GRP LRG W/2 CBS -,SUP-6704-3-091,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4408.24,3085.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN DLMLS 160MM GRP VITAL LRG 2MM CBLX2 -,SUP-6704-3-092,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5744.68,4021.276,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CENTURION 3.5 X 12 -,SUP-69-3312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CENTURION 3.5 X 18 -,SUP-69-3318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CENTURION 3.5 X 12 -,SUP-69-3412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CENTURION 4.0 X 14 -,SUP-69-3414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CENTURION 4.0 X 30 -,SUP-69-3430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CENTURION 4.5 X 30 -,SUP-69-3530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CENTURION 5.0 X 30 -,SUP-69-3630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
STAPLE INTNL 12X23MM VITAL ELLISON LF -,SUP-6982-1-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1703.05,1192.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
STAPLE INTNL 14X23MM VITAL ELLISON LF -,SUP-6982-2-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1602.87,1122.009,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFT BONE I FACTOR 2.5CC ALLOGRAFT PUTTY SYRINGE -,SUP-700-025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 8HL STR -,SUP-70-0095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 8HL STR -,SUP-70-0096,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 3.5MM 9HL LCK TI NS RT -,SUP-70-0116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.27,4447.289,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 3.5MM 9HL LCK TI NS LT -,SUP-70-0117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.27,4447.289,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 2.3MM 16HL LCK TI NS -,SUP-70-0124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6989.87,4892.909,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 2.3MM 13HL LCK TI NS -,SUP-70-0126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.27,4447.289,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 8HL LT CLAV LPRO TI STR NS -,SUP-70-0286,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 8HL RT CLAV LPRO TI STR NS -,SUP-70-0287,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN F/ELB PLATE SYS 8HL LCK TI LRG NS -,SUP-70-0289,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN F/ELB PLATE SYS 10HL LCK TI NS -,SUP-70-0294,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN F/ELB PLATE SYS 6HL LCK TI NS LT CLVCL -,SUP-70-0296,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN F/ELB PLATE SYS 6HL LCK TI NS RT CLVCL -,SUP-70-0297,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 8HL LT CLAV NRW-PRFL TI STR NS -,SUP-70-0298,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 8HL RT CLAV NRW-PRFL TI STR NS -,SUP-70-0299,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 8HL CONTR LCK TI LRG NS LT -,SUP-70-0300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 8HL CONTR LCK TI LRG NS RT -,SUP-70-0301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 65MM 3HL CONTR LCK TI STD NS -,SUP-70-0302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6535.76,4575.032,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 110MM 7HL CONTR LCK TI STD NS -,SUP-70-0306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7414.27,5189.989,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 90MM 5HL TAP-LCK TI EXTEND NS -,SUP-70-0313,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6535.76,4575.032,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 2MM ASNIS III THRD -,SUP-7007-1300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
K-WIRE ASNIS III 3.2 -,SUP-702463S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,505.08,353.556,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
IRON BENDING -,SUP-702901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.85,795.795,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
AXSOS 5.0 ADAPTOR NUT -,SUP-702977,CDM,C1713,HCPCS,278,RC,,,outpatient,,,559.11,391.377,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOW PROFILE HEX 6.5 X 15 -,SUP-7030-6515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEX LOW PROFILE 6.5MM X 20MM -,SUP-7030-6520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MM LOW PROFILE HEX -,SUP-7030-6525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEX 6.5MM X 30MM LOW PROFILE -,SUP-7030-6530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEX 6.5MM X 35MM LOW PROFILE -,SUP-7030-6535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
6.5x40MM LOW PROFILE HEX SCREW -,SUP-7030-6540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
6.5X45MM LOW PROFILE HEX SCREW -,SUP-7030-6545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
6.5x50MM LOW PROFILE HEX SCREW -,SUP-7030-6550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOW PROFILE HEX 6.5MM x 55MM -,SUP-7030-6555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT HIP 7X35MM POR TI PLASM SPRY SCRILAC IFUSE STRL -,SUP-7035-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDE WIRE WITH CALIBRATION 3.2MM X 230MM QUICK RELEASE -,SUP-705237,CDM,C1713,HCPCS,278,RC,,,outpatient,,,606.84,424.788,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ELEVATOR PERIOSTEAL 6MM ROUND EDGE -,SUP-705294,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1361.01,952.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT HIP 7X65MM POR TI PLASM SPRY SCRILAC IFUSE STRL -,SUP-7065-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN EXTFIX 3X120MM 16MM THRD COVE PNT -,SUP-71022001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN EXTFIX 3X120MM 22MM THRD COVE PNT -,SUP-71022002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN EXTFIX 3X120MM 28MM THRD COVE PNT -,SUP-71022003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X70MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X80MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X85MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X95MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X110MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X130MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 58MM 3.5MM 5HL RECON STR -,SUP-71140105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4158.44,2910.908,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 70MM 3.5MM 6HL RECON STR -,SUP-71140106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4651.85,3256.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 82MM 3.5MM 7HL RECON STR -,SUP-71140107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4446.01,3112.207,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 94MM 3.5MM 8HL RECON STR -,SUP-71140108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5084.1,3558.87,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 75MM 3.5MM 6HL SM T-SHP RT ANG -,SUP-71140406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2349.66,1644.762,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO 3.7X7MM SS -,SUP-71143107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,441.48,309.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 87MM 9HL Y STRL TMPLT -,SUP-71144012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7101.27,4970.889,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TROCAR PIN GEN 1/8 X 3 -,SUP-71210002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.63,108.241,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 3MM GENESIS 12.5CM TROC TIP -,SUP-71210003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.63,108.241,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MM MINI 16MM CORT TC-100 FT HEX HEAD SS -,SUP-71220016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,359.67,251.769,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 15MM REF SPHER HEAD -,SUP-71332515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,811.07,567.749,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 20MM REF SPER HEAD -,SUP-71332520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,811.07,567.749,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CABLE ORTHO 2MM ACCORD COCR -,SUP-71340020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,977.36,684.152,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
INSERT PS LGN XLPE SZ 3-4 11MM -,SUP-71453247,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4520.12,3164.084,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ENDCAP ORTHO 0MM TRIGEN STRL -,SUP-71634000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2293.1,1605.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ENDCAP PROT 5MM TI STRL TRIGEN F/OB GYNAECOLOGICAL PROC TIB -,SUP-71634005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2293.1,1605.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ENDCAP ORTHO 20MM TRIGEN STRL -,SUP-71634020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2293.1,1605.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX25MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2401.07,1680.749,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX30MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX35MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642135,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX40MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX45MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX55MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MMX65MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX20MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX25MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX35MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX50MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX60MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX65MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642265,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX75MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642275,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X35MM TRIGEN -,SUP-71645035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X45MM TRIGEN -,SUP-71645045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X380MM TRIGEN TAN CANN LT TROCH FEM TI ALY ANTGRD -,SUP-71647238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15450.91,10815.637,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5X380MM TRIGEN TAN CANN LT TROCH FEM TI ALY -,SUP-71647338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15450.91,10815.637,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X320MM TRIGEN META-NAIL CANN DIST FEM TI ALY RTRGD -,SUP-71653032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14208.35,9945.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 8.5X330MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655033,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 8.5X340MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 8.5X350MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X280MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X290MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655129,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10MMX30CM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X310MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655131,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X320MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X340MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X350MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655135,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10MMX37CM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655137,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5X300MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5X360MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5X390MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655239,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5MMX40CM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 3.2MM TRIGEN 343MM THRD BRAD TIP -,SUP-71674130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1491.03,1043.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X180MM TRIGEN INTERTAN 1.5 CANN TROCH FEM TI 125DG -,SUP-71675201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5X180MM TRIGEN INTERTAN 1.5 CANN TROCH FEM TI -,SUP-71675202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X180MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5X200MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X180MM TRIGEN INTERTAN 1.5 CANN TROCH FEM TI 130DG -,SUP-71675207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5MM 180MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP -,SUP-71675208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X180MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71675209,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71675210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X320MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP -,SUP-71675219,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10MMX32CM TRIGEN INTERTAN 1.5 CANN INTST HIP TI -,SUP-71675220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675222,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CAN LT INTS HIP TI LIME -,SUP-71675223,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI125 -,SUP-71675224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X380MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X400MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP -,SUP-71675227,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5X320MM TRIGEN INTERTAN 1.5 CANN RT INTS HIP TI.. -,SUP-71675242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71675244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675245,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71675246,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI_ -,SUP-71675250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5X420MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675251,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI130 -,SUP-71675268,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X280MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X320MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13MMX32CM TRIGEN INTERTAN 1.5 CANN INTST HIP TI -,SUP-71675408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X180MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71675412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X380MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675413,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X400MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675415,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X400MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X440MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X320MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71676507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TIRSE -,SUP-71676510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71676511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676513,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10X380MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5X320MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI- -,SUP-71676552,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTS HIP TI.. -,SUP-71676553,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI- -,SUP-71676554,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5MMX36CM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71676555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5X360MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5X380MM TRIGEN INTERTAN 1.5 CANN LT INTST TI -,SUP-71676557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5MMX38CM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71676558,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11.5X400MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71676598,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X360MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13X380MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71676602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 70MM/75MM -,SUP-71677075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 75MM/80MM -,SUP-71677080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 80MM/85MM -,SUP-71677085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 85MM/90MM -,SUP-71677090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 90MM/95MM -,SUP-71677095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI_ -,SUP-71677100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI- -,SUP-71677105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI.. -,SUP-71677110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI. -,SUP-71677115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 11MM TRIGEN INTERTAN LAG 100MM -,SUP-71678010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 11X110MM LAG TRIGEN INTERTAN -,SUP-71678011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 11X115MM TRIGEN INTERTAN SBTRCHNTRC TI -,SUP-71678015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 11MM TRIGEN INTERTAN LAG 85MM -,SUP-71678085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 11MM TRIGEN INTERTAN LAG 90MM -,SUP-71678090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 11MM TRIGEN INTERTAN LAG 95MM -,SUP-71678095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 3.2MMX24.8CM THRD DRILL TIP -,SUP-71751147,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X20MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X22MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X24MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X30MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X24MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X26MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X30MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X32MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X34MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X36MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X38MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X40MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X42MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X44MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X46MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 8/ 7MMLNGX260MM TRIGEN CANN PROX HUM TI ALY -,SUP-71770826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 9/ 7.5MMLNGX240MM TRIGEN CANN PROX HUM TI ALY -,SUP-71770924,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10/ 8.5MMLNGX220MM TRIGEN CANN PROX HUM TI ALY -,SUP-71771022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10/ 8.5MMLNGX240MM TRIGEN CANN PROX HUM TI ALY -,SUP-71771024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 10/ 8.5MMLNGX280MM TRIGEN CANN PROX HUM TI ALY -,SUP-71771028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 193MM 4.5MM 8HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16207.25,11345.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 286MM 4.5MM 13HL CONTR SCALLP LCK SS BVL LT -,SUP-71800013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17251.71,12076.197,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 342MM 4.5MM 16HL CONTR SCALLP LCK SS BVL LT -,SUP-71800016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17575.86,12303.102,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 193MM 4.5MM 8HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16207.25,11345.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 342MM 4.5MM 16HL CONTR SCALLP LCK SS BVL RT -,SUP-71800116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17575.86,12303.102,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 94MM 4.5MM 4HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17341.75,12139.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 130MM 4.5MM 6HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17575.86,12303.102,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 93MM 4.5MM 3HL CONTR SCALLP LCK BVL TIP -,SUP-71801603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17053.62,11937.534,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X10MM CORT PERILOC ST SS -,SUP-71804010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X12MM CORT PERILOC ST SS -,SUP-71804012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X14MM CORT PERILOC ST SS -,SUP-71804014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X16MM CORT PERILOC ST SS -,SUP-71804016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X18MM CORT PERILOC ST SS -,SUP-71804018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X20MM CORT PERILOC ST SS -,SUP-71804020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X24MM CORT PERILOC ST SS -,SUP-71804024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X32MM CORT PERILOC ST SS -,SUP-71804032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X34MM CORT PERILOC ST SS -,SUP-71804034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X36MM CORT PERILOC ST SS -,SUP-71804036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X38MM CORT PERILOC ST SS -,SUP-71804038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X40MM CORT PERILOC ST SS -,SUP-71804040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X50MM CORT PERILOC ST SS -,SUP-71804050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X55MM CORT PERILOC ST SS -,SUP-71804055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X60MM CORT PERILOC ST SS -,SUP-71804060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X12MM LCK CORT PERILOC ST SS -,SUP-71805012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1866.36,1306.452,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X20MM LCK CORT PERILOC ST SS -,SUP-71805020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1866.36,1306.452,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X14MM CANC PERILOC FT SS -,SUP-71805214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,496.09,347.263,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X36MM CORT PERILOC ST SS -,SUP-71806036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X38MM CORT PERILOC ST SS -,SUP-71806038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X40MM CORT PERILOC ST SS -,SUP-71806040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X42MM NLCKG CORT PERILOC ST SS -,SUP-71806042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X46MM NLCKG CORT PERILOC ST SS -,SUP-71806046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X50MM NLCKG CORT PERILOC ST SS -,SUP-71806050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X70MM NLCKG CORT PERILOC ST SS -,SUP-71806070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X32MM LCK CORT PERILOC ST SS -,SUP-71807032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X34MM LCK CORT PERILOC ST SS PERIART -,SUP-71807034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X36MM LCK CORT PERILOC ST SS PERIART -,SUP-71807036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X38MM LCK CORT PERILOC ST SS -,SUP-71807038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X48MM LCK CORT PERILOC ST SS -,SUP-71807048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X56MM LCK CORT PERILOC ST SS -,SUP-71807056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X58MM LCK CORT PERILOC ST SS -,SUP-71807058,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X60MM LCK CORT PERILOC ST SS PERIART -,SUP-71807060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X74MM LCK CORT PERILOC ST SS -,SUP-71807074,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.7X65MM LCK CANN PERILOC FT SS -,SUP-71808065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 193MM 4.5MM 13HL CONTR SCALLP LCK SS BVL -,SUP-71820008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12497.59,8748.313,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 230MM 4.5MM 10HL CONTR SCALLP LCK SS BVL TIP -,SUP-71820010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12767.71,8937.397,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 98MM 3.5MM 6HL CONTR SCALLP LCK SS BVL TIP -,SUP-71820506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13524.05,9466.835,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 196MM 3.5MM 10HL CONTR SCALLP LCK BVL TIP -,SUP-71821010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15522.94,10866.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X34MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X36MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X40MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X50MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X55MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X60MM LCK PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG -,SUP-71821160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX6MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
RETRACTOR EYELID DSMRS 1.12MMX5.5IN STN FNSH LID V. MUELLER -,SUP-71821208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
RETRACTOR LNG ALLISON 12.25IN 2.125IN BLD SS F/CV V. MUELLER -,SUP-71821210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX12MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX14MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX16MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX18MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821218,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX22MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821222,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX24MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX26MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821226,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX28MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX30MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX34MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX36MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX40MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 89MM 3.5MM 3HL CONTR LCK SS BVL TIP -,SUP-71821303,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14982.7,10487.89,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX6MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM STD -,SUP-71821306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX8MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM STD -,SUP-71821308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX10MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX12MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX14MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX16MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX18MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX20MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX22MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX24MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX26MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX28MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX32MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX34MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX36MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX38MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX40MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX44MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX46MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX50MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 89MM 3.5MM 3HL CONTR LCK SS BVL TIP NS -,SUP-71821403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14982.7,10487.89,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 115MM 3.5MM 5HL CONTR LCK SS BVL TIP -,SUP-71821405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15414.89,10790.423,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 79MM 2.7/3.5MM 5HL CONTR LCK SS BVL TIP -,SUP-71821805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11921.33,8344.931,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX10MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX12MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX14MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX16MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX18MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX20MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX38MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX40MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X10MM LCK CORT PERILOC FT ST SS NS -,SUP-71822310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X12MM LCK CORT PERILOC FT ST SS NS -,SUP-71822312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X14MM LCK CORT PERILOC FT ST SS NS -,SUP-71822314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X16MM LCK CORT PERILOC FT ST SS NS -,SUP-71822316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X18MM LCK CORT PERILOC FT ST SS NS -,SUP-71822318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X20MM LCK CORT PERILOC FT ST SS NS -,SUP-71822320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X24MM LCK CORT PERILOC FT ST SS NS -,SUP-71822324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X28MM LCK CORT PERILOC FT ST SS NS -,SUP-71822328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X30MM LCK CORT PERILOC FT ST SS NS -,SUP-71822330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X36MM LCK CORT PERILOC FT ST SS NS -,SUP-71822336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X40MM LCK CORT PERILOC FT ST SS NS -,SUP-71822340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X45MM LCK CORT PERILOC FT ST SS NS -,SUP-71822345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X50MM LCK CORT PERILOC FT ST SS NS -,SUP-71822350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X60MM LCK CORT PERILOC FT ST SS NS -,SUP-71822360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1413.91,989.737,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X10MM LCK CORT PERILOC FT ST SS -,SUP-71822410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X12MM LCK CORT PERILOC FT ST SS -,SUP-71822412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X14MM LCK CORT PERILOC FT ST SS -,SUP-71822414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X16MM LCK CORT PERILOC FT ST SS -,SUP-71822416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X18MM LCK CORT PERILOC FT ST SS -,SUP-71822418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X20MM LCK CORT PERILOC FT ST SS -,SUP-71822420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X22MM LCK CORT PERILOC FT ST SS -,SUP-71822422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X24MM LCK CORT PERILOC FT ST SS -,SUP-71822424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X26MM LCK CORT PERILOC FT ST SS -,SUP-71822426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 153MM 2.7MM 11HL CONTR SS BVL TIP -,SUP-71822511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14982.7,10487.89,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 80MM 2.7/3.5MM 5HL CONTR LCK SS BVL TIP -,SUP-71822705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12245.47,8571.829,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 81MM 6HL LCK SS CORNL BND -,SUP-71822906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14406.44,10084.508,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 107MM 8HL LCK SS CORNL BND -,SUP-71822908,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15522.94,10866.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX10MM LCK CORT PERILOC VLP ST VAR ANG CP 2.5MM -,SUP-71823010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX12MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX14MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX16MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX18MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DIRECTOR ORAL NO. 2522 7.25IN V. MUELLER SS GZE LIG TUCKER -,SUP-71823020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX22MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX24MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX26MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX30MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX40MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX45MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX50MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX55MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7MMX60MM LCK CORT PERILOC VLP ST FLUTX3 2.5MM STD HX -,SUP-71823060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,611.27,427.889,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 62MM 2.5MM 3HL STD HEAD LCK SS -,SUP-71823110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 86MM 2.5MM 5HL STD HEAD LCK SS LT VOLAR -,SUP-71823112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9562.27,6693.589,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 62MM 2.5MM 3HL HEAD LCK SS STD -,SUP-71823114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 86MM 2.5MM 5HL STD HEAD LCK SS RT VOLAR -,SUP-71823116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9562.27,6693.589,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 62MM 2.5MM 3HL W HEAD LCK SS LT VOLAR RADL -,SUP-71823118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 62MM 2.5MM 3HL W HEAD LCK SS RT VOLAR RADL -,SUP-71823122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 97MM 3.5MM 8HL LCK SS -,SUP-71823401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8830.28,6181.196,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 109MM 3.5MM 6HL LCK SS LT CLVCL -,SUP-71823403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9036.11,6325.277,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 109MM 3.5MM 6HL LCK SS RT CLVCL -,SUP-71823404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9036.11,6325.277,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 81MM 2.7MM LCK SS -,SUP-71823407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9036.11,6325.277,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 81MM 6HL LCK SS -,SUP-71823906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14406.44,10084.508,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X10MM NLCKG CORT PERILOC ST SS -,SUP-71824010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X16MM NLCKG CORT PERILOC ST SS -,SUP-71824016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X22MM NLCKG CORT PERILOC ST SS -,SUP-71824022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X24MM NLCKG CORT PERILOC ST SS -,SUP-71824024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM NLCKG CORT PERILOC ST SS -,SUP-71824026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X28MM NLCKG CORT PERILOC ST SS -,SUP-71824028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X30MM NLCKG CORT PERILOC ST SS -,SUP-71824030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X50MM NLCKG CORT PERILOC ST SS -,SUP-71824050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X18MM LCK CORT PERILOC ST SS -,SUP-71825018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X22MM LCK CORT PERILOC ST SS -,SUP-71825022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X24MM LCK CORT PERILOC ST SS -,SUP-71825024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM LCK CORT PERILOC ST SS -,SUP-71825026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X28MM LCK CORT PERILOC ST SS -,SUP-71825028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X30MM LCK CORT PERILOC ST SS -,SUP-71825030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X32MM LCK CORT PERILOC ST SS -,SUP-71825032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X34MM LCK CORT PERILOC ST SS -,SUP-71825034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X50MM LCK CORT PERILOC ST SS -,SUP-71825050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X55MM LCK CORT PERILOC ST SS -,SUP-71825055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X60MM LCK CORT PERILOC ST SS -,SUP-71825060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X65MM LCK CORT PERILOC ST SS -,SUP-71825065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X80MM LCK CORT PERILOC ST SS -,SUP-71825080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X10MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X12MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X16MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X18MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825218,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X36MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X45MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825245,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X50MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X60MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X65MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825265,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X35MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825335,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X40MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X45MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X55MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X60MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X26MM NLCKG CORT PERILOC ST SS -,SUP-71826026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X30MM NLCKG CORT PERILOC ST SS -,SUP-71826030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X34MM NLCKG CORT PERILOC ST SS -,SUP-71826034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X40MM NLCKG CORT PERILOC ST SS -,SUP-71826040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X44MM NLCKG CORT PERILOC ST SS -,SUP-71826044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X48MM NLCKG CORT PERILOC ST SS -,SUP-71826048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X52MM NLCKG CORT PERILOC ST SS -,SUP-71826052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X60MM NLCKG CORT PERILOC ST SS -,SUP-71826060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X68MM NLCKG CORT PERILOC ST SS -,SUP-71826068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X72MM NLCKG CORT PERILOC ST SS -,SUP-71826072,CDM,C1713,HCPCS,278,RC,,,outpatient,,,594.29,416.003,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X74MM NLCKG CORT PERILOC ST SS -,SUP-71826074,CDM,C1713,HCPCS,278,RC,,,outpatient,,,594.29,416.003,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X10MM LCK CORT PERILOC ST SS -,SUP-71827010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X12MM LCK CORT PERILOC ST BLNT TIP SS -,SUP-71827012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X18MM LCK CORT PERILOC ST SS -,SUP-71827018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X20MM LCK CORT PERILOC ST SS -,SUP-71827020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X24MM LCK CORT PERILOC ST SS -,SUP-71827024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X26MM LCK CORT PERILOC ST SS -,SUP-71827026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X28MM LCK CORT PERILOC ST SS -,SUP-71827028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X30MM LCK CORT PERILOC ST SS -,SUP-71827030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X32MM LCK CORT PERILOC ST SS -,SUP-71827032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X34MM LCK CORT PERILOC ST SS -,SUP-71827034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X36MM LCK CORT PERILOC ST SS PROX FEM -,SUP-71827036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X40MM LCK CORT PERILOC ST SS -,SUP-71827040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X42MM LCK CORT PERILOC ST SS -,SUP-71827042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X46MM LCK CORT PERILOC ST SS -,SUP-71827046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X50MM LCK CORT PERILOC ST SS -,SUP-71827050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X52MM LCK CORT PERILOC ST SS -,SUP-71827052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X60MM LCK CORT PERILOC ST SS PROX FEM -,SUP-71827060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X66MM LCK CORT PERILOC ST SS -,SUP-71827066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X68MM LCK CORT PERILOC ST SS -,SUP-71827068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X70MM LCK CORT PERILOC ST SS -,SUP-71827070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1924.08,1346.856,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X70MM LCK CORT PERILOC ST SS -,SUP-71827070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X72MM LCK CORT PERILOC ST SS -,SUP-71827072,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X76MM LCK CORT PERILOC ST SS -,SUP-71827076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X80MM LCK CORT PERILOC ST SS -,SUP-71827080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X85MM LCK CORT PERILOC ST SS -,SUP-71827085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X90MM LCK CORT PERILOC ST SS -,SUP-71827090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1979.47,1385.629,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.7MMX20MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.7MMX25MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.7MMX35MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.7MMX40MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.7MMX45MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.7MMX50MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.7MMX55MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
RETRACTOR UTR DE LEE UNIV 2INX2.75IN 9.5IN HNDL SS V.MUELLER -,SUP-71828060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.7MMX65MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.7MMX70MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.7MMX80MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.7MMX85MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC CONTR + 57MM 3.5MM 4HL LCK COMPR SS 1/3 -,SUP-71829004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2601.59,1821.113,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC CONTR + 82MM 3.5MM 6HL LCK COMPR SS 1/3 -,SUP-71829006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2601.59,1821.113,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC CONTR + 107MM 3.5MM 8HL LCK COMPR SS 1/3 -,SUP-71829008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2533.04,1773.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 93MM F/3.5MM 6HL NLCKG COMPR SS 1/3 TBLR SM -,SUP-71829406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2395.93,1677.151,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 106MM 3.5MM 7HL NLCKG COMPR 1/3 TBLR SM FRAG -,SUP-71829407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2514.19,1759.933,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 50MM 4.33HL TBLR NS -,SUP-71829434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.31,800.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 62MM 5.33HL TBLR NS -,SUP-71829435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.31,800.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 74MM 6.33HL TBLR NS -,SUP-71829436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1064.29,745.003,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 86MM 7.33HL TBLR NS -,SUP-71829437,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1064.29,745.003,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 98MM 8.33HL TBLR NS -,SUP-71829438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1095.14,766.598,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 122MM 10.33HL TBLR NS -,SUP-71829440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1095.14,766.598,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 70MM 3.5MM 6HL RECON SM FRAG -,SUP-71829516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4693.02,3285.114,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 94MM 3.5MM 8HL RECON -,SUP-71829518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5145.85,3602.095,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC 96MM F/3.5MM SM MUL FRAG SYS 6HL LCK COMPR -,SUP-71829706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4528.9,3170.23,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCR- SFTSLK-2.0 PKG.7X20 STER -,SUP-7207256,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SOFTSILK 2.0 7 X 25 -,SUP-7207257,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCR- SFTSLK-2.0 PKG.8X20 STER -,SUP-7207259,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SOFTSILK 2.0 8 X 25 -,SUP-7207260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DEVICE SUT ARSCP ENDBTTN CL 30MM STRL LF -,SUP-7210082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DEVICE SUT ARSCP ENDBTTN CL 35MM STRL LF -,SUP-7210083,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DEVICE SUT ARSCP ENDBTTN CL 40MM STRL LF -,SUP-7210084,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BUTTONENDO CL BTB STER 45MM -,SUP-7210085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BUTTON ENDO 15MM CL -,SUP-7220-0146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.98,1373.386,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ULTRA FAST FIX CURVED -,SUP-7220-1494,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2143.15,1500.205,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT FTPRNT 5.5MM ARSCP NABSB OUTR SHL INR PLG -,SUP-7220-1697,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2143.95,1500.765,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN BIOSURE 9X25MM ABSB TAPR PLLA HAP KN -,SUP-72201781,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1574.57,1102.199,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUT ANCHOR OSTEORAPTOR  2.9 -,SUP-72201995,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2049.44,1434.608,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FAST-FIX 360 STRAIGHT -,SUP-72202467,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2543.73,1780.611,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FAST FIX 360 CVD NEEDLE -,SUP-72202468,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2543.73,1780.611,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FAST-FIX 360 REVERSE CURVED -,SUP-72202469,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2543.73,1780.611,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDE DRILL SZ1.2 ENDBTTN CL ULTRA PAC -,SUP-7220-2799,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2118.19,1482.733,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUTURE 4.5MM HEALICOIL -,SUP-7220-3378,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2261.88,1583.316,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR HEALICOIL 4.75MM REGENE -,SUP-72203697,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3911.82,2738.274,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR HEALICOIL 4.75MM -,SUP-72203704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2249.43,1574.601,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EVOS 2.7MM X 17MM CTX -,SUP-72402717,CDM,C1713,HCPCS,278,RC,,,outpatient,,,400.46,280.322,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EVOS 2.7MM X 24MM CTX -,SUP-72402724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,188.59,132.013,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EVOS 3.5MM X 14MM CTX -,SUP-72403514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.9,95.13,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EVOS 3.5MM X 15MM CTX -,SUP-72403515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EVOS 3.5MM X 16MM CTX -,SUP-72403516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EVOS 3.5MM X 17MM CTX -,SUP-72403517,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EVOS 3.5MM X 18MM CTX -,SUP-72403518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EVOS 2.7MM X 18MM LCK -,SUP-72412718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,598.38,418.866,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EVOS 2.7MM X 19MM LCK -,SUP-72412719,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.55,802.585,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EVOS 2.7MM X 20MM LCK -,SUP-72412720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.55,802.585,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE EVOS VOLAR 10H R STD 138MM -,SUP-72468210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8021.16,5614.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC VLP 64MM 3.5MM 4HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10840.85,7588.595,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC VLP 72MM 3.5MM 5HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8521.53,5965.071,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC VLP 47MM 3.5MM 3HL VAR ANG CONTR LCK SS -,SUP-7282-0303,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7945.19,5561.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC VLP 89MM 3.5MM 3HL VAR ANG CONTR LCK SS -,SUP-7282-0603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10840.85,7588.595,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC VLP 89MM 3.5MM 3HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10840.85,7588.595,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC VLP 62MM 3.5MM 5HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6051.52,4236.064,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC VLP 86MM 3.5MM 7HL 1.5-MM VAR ANG CONTR LCK -,SUP-7282-0807,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7163.02,5014.114,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC VLP 74MM 3.5MM 6HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6607.27,4625.089,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC VLP 86MM 3.5MM 7HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7163.02,5014.114,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC VLP 59MM 3.5MM 3HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-1003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7060.11,4942.077,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC VLP 71MM 3.5MM 4HL VAR ANG CONTR LCK SS LT -,SUP-7282-1004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7492.36,5244.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC VLP 83MM 3.5MM 5HL VAR ANG CONTR LCK SS LT -,SUP-7282-1005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7924.61,5547.227,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC VLP 107MM 3.5MM 7HL 2MM VAR ANG CONTR LCK -,SUP-7282-1007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8336.28,5835.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC VLP 131MM 3.5MM 9HL VAR ANG CONTR LCK SS LT -,SUP-7282-1009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8830.28,6181.196,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC VLP 59MM 3.5MM 3HL VAR ANG CONTR LCK SS -,SUP-7282-2003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6977.77,4884.439,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC VLP 71MM 3.5MM 4HL VAR ANG CONTR LCK SS -,SUP-7282-2004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7451.19,5215.833,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC VLP 83MM 3.5MM 5HL VAR ANG CONTR LCK SS RT -,SUP-7282-2005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7862.86,5504.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC VLP 131MM 3.5MM 9HL VAR ANG CONTR LCK SS RT -,SUP-7282-2009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8768.53,6137.971,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC VLP 62MM 3.5MM 5HL VAR ANG CONTR LCK SS -,SUP-7282-3005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2852.56,1996.792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC VLP 74MM 3.5MM 6HL VAR ANG CONTR LCK SS -,SUP-7282-3006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3223.02,2256.114,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERILOC VLP 86MM 3.5MM 7HL VAR ANG CONTR LCK SS -,SUP-7282-3007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3570.33,2499.231,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK ORLMXLFCL 2.4X14MM STERNALOCK SD TI GOLD -,SUP-73-2414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK ORLMXLFCL 2.4X16MM STERNALOCK SD TI GOLD -,SUP-73-2416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK ORLMXLFCL 2.4X18MM STERNALOCK SD TI GOLD -,SUP-73-2418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,460.97,322.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK ORLMXLFCL 2.4X20MM STERNALOCK SD TI GOLD -,SUP-73-2420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,460.97,322.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE ORLMXLFCL 8HL STERNALOCK 4HL BX TI BLU -,SUP-73-2622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2835.76,1985.032,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE ORLMXLFCL 12HL STERNALOCK LDDR TI BLU -,SUP-73-2632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4401.63,3081.141,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE ORLMXLFCL 12HL STERNALOCK W LDDR TI BLU -,SUP-73-2634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4401.63,3081.141,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE STRNM 8HL JL SHP STERNALOCK BLU TI -,SUP-73-2645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4124.74,2887.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP JRNY II CR FEM OX NP LT SZ 6 -,SUP-74021166,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BASEPLATE TIBIA JOURNEY NP LT SZ 5 -,SUP-74022225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
INSERT JOURNEY II CR XLPE RT SZ 5-6 9MM -,SUP-74025661,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
MESH CAGE 30MM H -,SUP-74-1030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE NGAGE 16MM X 12MM CORPECT -,SUP-74-1216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE N-GAGE TI 16 X 50MM -,SUP-74-1650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TONIER HUMERAL NAIL DISTAL SCREW 4.3MM X 20MM -,SUP-7424520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TONIER HUMERAL NAIL DISTAL SCREW 4.3MM X 22MM -,SUP-7424522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAP END N-GAGE ZERO DEGREE -,SUP-74-5016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ENDCAP 2.5 DEG 10MM -,SUP-74-6010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAP NPLATE 7.5 DEGREE -,SUP-74-6012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NUT LCK F/C IN ADVANCED IMPL SYS -,SUP-7642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.87,143.409,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SET SCREW SPIN 6.35MM CD HORIZN LEGC SS -,SUP-7660000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,869.18,608.426,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X35MM FIREBIRD DBL LD THRD ST CANN TI GRN -,SUP-77-8535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X40MM FIREBIRD DBL LD THRD ST CANN TI GRN -,SUP-77-8540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X45MM FIREBIRD DBL LD THRD ST CANN GRN -,SUP-77-8545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X35MM FIREBIRD DBL LD THRD ST CANN TI GOLD -,SUP-77-8635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X40MM FIREBIRD DBL LD THRD ST CANN GOLD -,SUP-77-8640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X45MM FIREBIRD DBL LD THRD ST CANN TI GOLD -,SUP-77-8645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X50MM FIREBIRD DBL LD THRD ST CANN TI GOLD -,SUP-77-8650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.5MM COCR ROD- 240MM -,SUP-782.803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SET -,SUP-79-2003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CABLE SPIN 1.2MM TI DBL LOP INTGR CRIMPX2 STRL -,SUP-7925011S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1755.53,1228.871,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUBSTITUTE CA PHOS HAP 5ML PTTY CMNT INJ HYDR ST SYNTH -,SUP-79-43905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6318.89,4423.223,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CEMENT BN CA PHOS HAP 10ML HYDR ST -,SUP-79-43910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10521.16,7364.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUBSTITUTE CA PHOS HAP 15ML PTTY CMNT INJ HYDR ST SLF-SET -,SUP-79-43915,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15098.17,10568.719,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO 2.5MM HEMICAP -,SUP-8007-1200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT SHT CRANFC 50X76MM 0.85MM MEDPOR EMBD TI MSH F/RECON -,SUP-81020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5562.27,3893.589,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
MESH TITAN SHEET MTB 76 X 50 X 1MM -,SUP-81027,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6586.43,4610.501,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT PE SHT EMBD TI MSH CRANFC 50X76MM -,SUP-81029,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6345.33,4441.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT SHT 76X100MM 1.5MM MEDPOR TITAN MAX F/CRANFC -,SUP-81040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10857.55,7600.285,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X12MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X14MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X16MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X18MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN SPIDER 20MM TMX -,SUP-814100003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERI 70.1MM 5HL COMPR TMX TBLR BLLT -,SUP-814123005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,980.28,686.196,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PE.R.I. 83.1MM 6HL COMP TIMEX 1/3 TBLR -,SUP-814123006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 95.5MM 7HL COMPR COMP TBLR BLLT-SHP -,SUP-814123007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PERI 109.2MM 30MM COMPR TMX TBLR BLLT -,SUP-814123008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PE.R.I. 122.2MM 9HL NLCKG PERMTR RDC COMP TBLR -,SUP-814123009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 179.4MM 6HL LCK SHFT STRL -,SUP-814130106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN POLYAX 233.5MM 9HL LCK TMX STRL -,SUP-814131109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 287.6MM 12HL LCK SHFT -,SUP-814131112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN POLYAX 99.6MM 2HL PRCONT LCK TMX STRL -,SUP-814133002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13MMSHRTX180MM AFFIXUS TROCH ANTGRD AN-ROT 125DG ANG -,SUP-814313180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7282.7,5097.89,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 10.5MM AFFIXUS CANN LAG THRD ST TMX 80MM -,SUP-814510080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3265.42,2285.794,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 10.5MM AFFIXUS CANN LAG THRD ST TMX 105MM -,SUP-814510105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3265.42,2285.794,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 13MMSHRTX180MM AFFIXUS TROCH ANTGRD AN-ROT 130DG ANG -,SUP-814513180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7282.7,5097.89,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X34MM CORT AFFIXUS VERSANAIL FT ST 3.5MM HX DRV SCKT -,SUP-814550034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X40MM CORT AFFIXUS VERSANAIL FT ST 3.5MM HX DRV SCKT -,SUP-814550040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X20MM CORT ALPS FT ST HX DRV TMX -,SUP-8150-36-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,134.21,93.947,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X10MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X12MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X14MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X20MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X22MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X24MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X28MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X30MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X34MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X38MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X42MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X44MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X46MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X48MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X50MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X55MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X60MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X65MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X26MM LCK SHFT CORT POLYAX FT POLYAX ST FA TMX NS -,SUP-815045526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X28MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X30MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X32MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X34MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X36MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X40MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X45MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X55MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X60MM LCK CANC POLYAX FT POLYAX ST FA BLLT SHP TIP TI -,SUP-815304060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X75MM LCK CANC POLYAX FT POLYAX ST FA BLLT SHP TIP TI -,SUP-815304075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8X70MM LCK DUAL CORE POLYAX FT POLYAX ST FA BLLT SHP -,SUP-815308070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8X75MM LCK DUAL CORE POLYAX FT POLYAX ST FA BLLT SHP -,SUP-815308075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X10MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X14MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X16MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X18MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X20MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X24MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X26MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X34MM CANC FT -,SUP-8153-41-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,278.62,195.034,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X44MM LAG CANC FT -,SUP-8153-41-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,198.39,138.873,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X50MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X55MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X30MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X45MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X60MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X65MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X70MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X75MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5X65MM NLCKG CANC POLYAX P/T POLYAX TI NS -,SUP-815455065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X20MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X24MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X30MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X32MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X36MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X42MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X46MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LAG SCREW D10.5X85MM -,SUP-8160-0085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4287.05,3000.935,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X10MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X12MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X14MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X16MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X18MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X20MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORT LOCK 3.5 X 20MM NS -,SUP-816135020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X22MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW  CORT LOCK 3.5 X 22MM NS -,SUP-816135022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X24MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-8161-35-024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.5MM CORT LOCK SCREW 26MM NS -,SUP-816135026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X28MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.5MM CORTLOCK SCREW 30MM NS -,SUP-816135030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X30MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X32MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X34MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X36MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X38MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X40MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X42MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.5MM CORT LOCK SCREW 50MM NS -,SUP-816135050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORT LOCK 3.5 X 52MM NS -,SUP-816135052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 3.5 X 54 CORT NS -,SUP-816135054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X56MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X60MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X65MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X10MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X12MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X14MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X16MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X18MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X26MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X46MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X60MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X65MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X70MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 199MM 12HL PRCONT LCK COMPR TMX W ANTMC FST -,SUP-816200012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6798.89,4759.223,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 77MM 6HL THRD LCK TMX ANTMC NS BLU -,SUP-816204006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 92MM 7HL THRD LCK TMX ANTMC NS BLU -,SUP-816204007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 103MM 8HL THRD LCK TMX ANTMC NS BLU -,SUP-816204008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1526.54,1068.578,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 3.5MM 5HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1208.51,845.957,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 3.5MM 6HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1208.51,845.957,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS HCP 3.5MM 7HL HYBRID LCK COMPR TMX THN ANTMC -,SUP-816235007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 3.5MM 8HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1335.73,935.011,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 3.5MM 9HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1335.73,935.011,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 3.5MM 12HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 3HL PRCONT LCK TMX STD CRV ANTMC LT TIB -,SUP-816235703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5627.54,3939.278,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 5HL PRCONT LCK TMX STD CRV ANTMC -,SUP-816235705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5678.47,3974.929,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ALPS 3HL PRCONT LCK TMX STD CRV ANTMC RT TIB -,SUP-816235803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5627.54,3939.278,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X22MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X32MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X50MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X55MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X56MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X65MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER SPNL ANT CERV 13X15X6MM ALTA 5DG PEEK. -,SUP-8401-0506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN FX 1.3MM ABSB -,SUP-84-1052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1153.11,807.177,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER SPNL ANT CERV 13X15X6MM ALTA 5DG PEEK.. -,SUP-8411-0506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER ANT CERV 13X15X7MM ALTA 5DG PEEK -,SUP-8411-0507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COVER LOCKING SHORELINE 8-12 MM STANDALONE GRAY -,SUP-85-2008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TEMP FIX PIN -,SUP-85-2100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LONG NAIL LEFT 13X340MM X 125 DEG -,SUP-8525-3340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13986.87,9790.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5 X 12MM SELF DRILLING -,SUP-85-3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5 X 14MM SELF DRILLING -,SUP-85-3014SD,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAVITY SYNCHFIX SYNDESMOSIS #5 SUTURE -,SUP-86SYN005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4349.11,3044.377,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER TRNSFRMNL POST LMBR 9X23X6MM FORZA 0DG STR BLLT NOSE -,SUP-89-1006SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER TRNSFRMNL POST LMBR 9X23X8MM FORZA 0DG STR BLLT NOSE -,SUP-89-1008SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER TRNSFRMNL POST LMBR 9X27X7MM FORZA 0DG CRV BLLT NOSE -,SUP-89-1707SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER TRNSFRMNL POST LMBR 9X27X8MM FORZA 0DG CRV BLLT NOSE -,SUP-89-1708SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER TRNSFRMNL POST LMBR 9X27X9MM FORZA 0DG CRV BLLT NOSE -,SUP-89-1709SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT HUM TIS 9X27X7MM SZ0 FORZA STR -,SUP-89-3007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPACER TRNSFRMNL POST LMBR 9X27X10MM FORZA 0DG STR BLLT NOSE -,SUP-89-3010SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE CEMENT HYDROSET XT INJECTABLE HA -,SUP-897003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5310.31,3717.217,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CEMENT BONE HYDROSET XT HA 5CC -,SUP-897005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8517.71,5962.397,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CEMENT BONE HYDROSET XT HA 10CC -,SUP-897010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14367.75,10057.425,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
HYDROSET XT -,SUP-897015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20614.72,14430.304,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFT BONE BIO4 VIABLE BONE MATRIX 2.5CC -,SUP-90174424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS COMPRESSION 2.5MM X 28MM TI -,SUP-90176298,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN FIXATION IJS 2.5MM X 50MM AXIS -,SUP-90176511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1918.78,1343.146,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FREEFIX COMPRESSION 4.5MM X 18MM TI -,SUP-90176560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1009.46,706.622,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FREEFIX LOCKING 4.5MM X 14MM TI -,SUP-90176561,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FREEFIX LOCKING 4.5MM X 16MM TI -,SUP-90176562,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FREEFIX LOCKING 4.5MM X 18MM TI -,SUP-90176563,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FREEFIX LOCKING 4.5MM X 20MM TI -,SUP-90176564,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE MIDSHAFT HUMERUS NARROW 172MM -,SUP-90176565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5334.71,3734.297,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE FREEFIX 173MM ULNA MIDSHAFT -,SUP-90176755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE FREEFIX DISTAL HUMERUS 85MM ASSEMBLED LAT HELICAL LEFT -,SUP-90176827,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FREEFIX COMPRESSION 3.5MM X 12MM TI -,SUP-90176828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FREEFIX LOCKING 3.5MM X 10MM TI -,SUP-90176829,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.51,808.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL LOCKING 3.0MM X 34MM CANNULATED COCR -,SUP-90176830,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL LOCKING 3.0MM X 50MM CANNULATED COCR -,SUP-90176831,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL LOCKING 3.0MM X 60MM CANNULATED COCR -,SUP-90176832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL LOCKING 3.0MM X 65MM CANNULATED COCR -,SUP-90176833,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS COMPRESSION 2.5MM X 20MM TI -,SUP-90176987,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ASSEMBLED FREE FIX DISTAL HUM PLATE LAT DIRECT 85MM RIGHT -,SUP-90178750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ASSEMBLED FREE FIX DISTAL HUM PLATE MED DIRECT 75MM RIGHT -,SUP-90178751,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8504.98,5953.486,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FREEFIX COMPRESSION 3.5MM X 16MM TI -,SUP-90178752,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FREEFIX COMPRESSION 3.5MM X 28MM TI -,SUP-90178753,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FREEFIX LOCKING 3.5MM X 30MM TI -,SUP-90178754,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MULTI-THREAD LOCKING 2.7MM X 16MM TI -,SUP-90178756,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MULTI-THREAD LOCKING 2.7MM X 24MM TI -,SUP-90178757,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ASSEMBLED FREEFIX DIST HUM PLATE LAT DIRECT 85MM LEFT -,SUP-90178787,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DISTAL TROCHLEA COMPRESSION SCREW 3.5MM X 40MM TI -,SUP-90178788,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MULTI-THREAD LOCKING 2.7MM X 26MM TI -,SUP-90178789,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MULTI-THREAD LOCKING 2.7MM X 42MM TI -,SUP-90178790,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
HIGH COMPRESSION LOCKING PEG 2.7MM X 24MM TI -,SUP-90178898,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DRILL CANNULATED 3.7MM X 30MM -,SUP-90178926,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ASSEMBLY DOUBLE IJS -,SUP-90178927,CDM,C1713,HCPCS,278,RC,,,outpatient,,,27394.51,19176.157,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
IJS-E AXIS PIN FEMALE 30MM COCR -,SUP-90178928,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
THREADED HAND NAIL 4.5MM X 45MM TI -,SUP-90178982,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4258.41,2980.887,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
KT SPINAL 4.5MMX30-40MM PEDICAL COMPR TRANSFACET W/SCREWX2 -,SUP-9045-02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT ELB JNT TOGGLELOC -,SUP-909854,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4344.34,3041.038,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PK VALVE F/INFECT FLD WST MGMT ULTRA QUAD CART -,SUP-91530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CRNL 1.5X4MM STRDRV RCESS SD TI -,SUP-92-15904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,413.82,289.674,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CRNL 1.5X5MM STRDRV RCESS SD TI -,SUP-92-15905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,413.82,289.674,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CRNL 1.5X5MM STRDRV RCESS SD TI -,SUP-92-15905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,82.76,57.932,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE INSERT LOCKING 2.7MM -,SUP-940372,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN FX STNMN 2.8MMX9IN SMTH STRL F /THE VUEPASS PORTAL -,SUP-94152,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2711.63,1898.141,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PFC SIGMA DISTAL AUG COM CEMT SIZE 5 X 4MM RIGHT -,SUP-960901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PFC SIGMA DISTAL AUG COM CEMT SIZE 5 X 8MM RIGHT -,SUP-960903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIBAL INSERT ROTATING PLATFORM (STAB) 5- 10MM -,SUP-962151,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
INSERT TIBIAL ROTATING PLATFORM SZ 2.5MM X 20MM TCS -,SUP-96-2335,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
5.0MM VARIABLE ANGLE EXTENSION ARM -,SUP-991088S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2160.48,1512.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAP TOT JNT SM PLST -,SUP-9911186002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1043.01,730.107,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT HUM TIS CHP ALLOGRAFT CANC 15ML -,SUP-A00035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.87,918.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TEMPORARY TENSION BOLT -,SUP-A-2791.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.07,775.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DRILL BIT AO FIXATION 1.2MM X 25MM X L81MM -,SUP-A-3230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1173.53,821.471,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COUNTERSINK M 1.2/1.5 -,SUP-A-3310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1607.11,1124.977,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.0 CCS COUNTERSINK- AO -,SUP-A-3938,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1978.15,1384.705,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
HOOK PLATE1.5 2 HOLE 2 HOOKS T0.6 -,SUP-A-4200.40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2365.61,1655.927,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
HOOK PLATE 4 HOLE 4 HOOKS T0.6 -,SUP-A-4200.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2632.76,1842.932,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT HUM TIS STRIP 1X20CMX8MM H GRFTN MATRIX -,SUP-A42280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8571.82,6000.274,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M FIX 4 HOLE STRAIGHT -,SUP-A-4300.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2106.42,1474.494,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M FIX 6 HOLE STRAIGHT -,SUP-A-4300.03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.98,1080.086,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M FIX 16 H STRAIGHT -,SUP-A-4300.04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2571.75,1800.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M FIX 16 H CURVED -,SUP-A-4300.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2092.11,1464.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M FIX16 HOLE OFF SET -,SUP-A-4300.06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2700.17,1890.119,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS 10X27MM F/1.2MM/1.5MM FX SCR HLX3X5 TI T-SHP -,SUP-A-4300.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1852.52,1296.764,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M FIX 2/3 H RIGHT L -,SUP-A-4300.21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1852.52,1296.764,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M GD FIX 2X2 RECT LEA -,SUP-A-4300.51,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2632.23,1842.561,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE FIXATION GOLD GRID 2 X 2-HOLE TAPAZOID -,SUP-A-4300.54,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2632.23,1842.561,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS 15MM F/1.2MM/1.5MM SCR HLX3X2 0.6MM GRID FX -,SUP-A-4300.55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2074.62,1452.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN HLX4X2 FA MED L-SHP GRID -,SUP-A-4300.64,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2156.24,1509.368,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRID 5 X 2 HOLE TRAPAZOID -,SUP-A-4300.66,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.52,1855.364,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M CONDYLE 5 H PIN L -,SUP-A-4340.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2542.12,1779.484,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS F/1.2-1.5MM SCR 1HL HOOKX2 COMPR TI TRILOCK -,SUP-A-4340.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3184.74,2229.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE APTUS TRILOCK PI 4 HOLE STRAIGHT IO 8 -,SUP-A-4350.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3757.14,2629.998,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M TRILOCK STR 4 HOLE -,SUP-A-4350.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2752.69,1926.883,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TRILOCK PI 3/5 HOLE T -,SUP-A-4350.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4001.57,2801.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS 11X25MM 0.8MM 8HL HND TRILOCK TI T-SHP -,SUP-A-4350.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4001.57,2801.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS 9X23MM F/1.2MM/1.5MM SCR FX/ROT 6HL 0.8MM VAR -,SUP-A-4350.23,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.67,2999.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TRILOCK ROTATING 3 HOLE 1.2/1.5 -,SUP-A-4350.23,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4080.82,2856.574,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M TRILOCK T 5/4 HL -,SUP-A-4350.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4152.43,2906.701,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING PLATE 1.5 BLUE -,SUP-A-4350.56,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3415.8,2391.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M TRILOCK GRID HL 4 X 2 -,SUP-A-4350.62,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4381.08,3066.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 1.2/1.5 TRILOCK GRID 5X2H TRAPZ T 0.8 -,SUP-A-4350.66,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4471.05,3129.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE LOCKING TRILOCK BLUE 1.5 TRAPEZ 10.8 -,SUP-A-4350.80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3868.85,2708.195,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT HUM TIS GRFTN DBM OTHBLND -,SUP-A44135,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5713.91,3999.737,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS 55MM F/2MM/2.3MM SCR 8HL COMPR TI STR TRILOCK -,SUP-A-4645.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2466.32,1726.424,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS 35MM F/2MM/2.3MM SCR HLX2X4 COMPR TI T-SHP -,SUP-A-4645.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2428.06,1699.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M COMP L 2/8 HOLE RIGHT -,SUP-A-4645.23,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2405.14,1683.598,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE LOCKING 1.0MM THCK 2./2.3 STRAIGHT BLUE -,SUP-A-4650.03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7191.46,5034.022,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING PLATE 2.0/2.3 BLUE T-2/4 HOLE -,SUP-A-4650.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3100.24,2170.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TRILOCK 3/4 HOLE -,SUP-A-4650.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3100.24,2170.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
"PLATE M LK ""Y"" 2/5 H -",SUP-A-4650.13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3199.53,2239.671,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE L 2/4 HOLE RIGHT -,SUP-A-4650.21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3601.51,2521.057,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS 45MM F/2MM/2.3MM SCR 8HL 1MM GRID TI -,SUP-A-4650.67,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3910.86,2737.602,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE LOCKING T1.3MM 4 HOLE STRAIGHT 2.0/2.3 -,SUP-A-4655.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3973.88,2781.716,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BLUE LOCKING 2.0 /2.3 4 HOLE STRAIGHT -,SUP-A-4655.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4610.73,3227.511,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BLUE 2.0 / 2.23 5 HOLE STRAIGHT -,SUP-A-4655.02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4308.93,3016.251,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS 32MM F/2MM/2.3MM SCR 5HL 1.3MM GRID TI STR -,SUP-A-4655.02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4294.08,3005.856,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TRILOCK 8 HOLE STRAIGHT 2 X 3 -,SUP-A-4655.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4971,3479.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TRILOCK STRAIGHT 8 HOLE 2.0/2.3 -,SUP-A-4655.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4969.72,3478.804,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TRILOCK 2.0/2.3 T 2/4 HOLE T1.3 -,SUP-A-4655.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5024.05,3516.835,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M TRILOCK T 2/4 HL -,SUP-A-4655.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5024.05,3516.835,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS 56MM 2.0/2.3MM 10HL 1.3MM GRID TI T-SHP -,SUP-A-4655.16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5311.37,3717.959,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.0/2.3 TRILOCK PLATE 2/4 HOLE LEFT -,SUP-A-4655.20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4600.23,3220.161,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M TRILOCK L RT 2/4 HL -,SUP-A-4655.21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5024.05,3516.835,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M TRILOCK L LT 2/8 HL -,SUP-A-4655.22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4539.38,3177.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE ROTATION 3/3 HOLE T 1.3 -,SUP-A-4655.24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4738.2,3316.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TRILOCK GRIDPI 4 X2H TRAPEZ -,SUP-A-4655.62,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5438.26,3806.782,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TRILOCK GRIDPI 5 X2 H TRAPEZ -,SUP-A-4655.66,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5679.32,3975.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2.0 TRILOCK RADIAL HEAD RIM -,SUP-A-4656.68,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7432.09,5202.463,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.0 TRILOCK RADIAL HEAD BUTTRESS -,SUP-A-4656.69,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7017.88,4912.516,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TRILOCK 4CF 2 X 2.3 -,SUP-A-4660.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7727.9,5409.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M BABYFOOT LONG RT -,SUP-A-4750.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5479,3835.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2.5 ADAPT II TRILOCK DISTRAD L 10 H NARROW -,SUP-A-4750.101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5810.88,4067.616,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M ADAPTIVE II NARROW RT -,SUP-A-4750.102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7626.89,5338.823,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DISTAL RADIUS LOCKING PLATE RIGHT 12 NARROW-LONG -,SUP-A-4750.104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE ADAPTIVE 2.5 X 12HL NRW LNG -,SUP-A-4750.104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6904.56,4833.192,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2.5 ADAPTIVE II TRILOCK DISTRAD NARR LONG -,SUP-A-4750.104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8591.98,6014.386,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M ADAPTIVE II LT -,SUP-A-4750.105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7626.89,5338.823,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M ADAPTIVE II LT -,SUP-A-4750.105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5810.88,4067.616,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE STD WATERSHED RIGHT ADAP -,SUP-A-4750.106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8008.43,5605.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ADAPTIVE II TRILOCK 2.5 DISTRAD. PLATE 13 HOLE -,SUP-A-4750.107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DISTAL RADIUS LOCKING PLATE RIGHT 13 LONG -,SUP-A-4750.108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8591.98,6014.386,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M ADAPTIVE II LONG RIGHT -,SUP-A-4750.108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS 28X52MM 2.5MM 14HL TI TRILOCK TECH -,SUP-A-4750.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2.5 ADAPTIVE II DISTAL RADIUS LEFT WIDE LONG -,SUP-A-4750.111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2.5 ADAPTIVE II TRILOCK DIST RAD 15H WIDE LONG -,SUP-A-4750.112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6234.44,4364.108,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DISTAL RADIUS CORRECTION PLATE WIDE -,SUP-A-4750.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M FPL LT -,SUP-A-4750.123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8106.46,5674.522,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE MEDARTIS 14HL -,SUP-A-4750.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6904.56,4833.192,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE ADAPTIVE 2.5 X 15 HOLE -,SUP-A-4750.15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7057.35,4940.145,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE ADAPTIVE 2.5 X 16 HOLE -,SUP-A-4750.16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7057.35,4940.145,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS 22X62MM 2.5MM 12HL 1.6MM TI LNG NRW TRILOCK -,SUP-A-4750.19,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2.5TRILOCK WR SPANNINGPI DOR. STRAIGHT 11 HOLE TL6-3.4 -,SUP-A-4750.193S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13227.56,9259.292,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS 23X44MM 2.5MM 10HL 1.6MM TI NRW TRILOCK TECH -,SUP-A-4750.31,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS 23X44MM 2.5MM 10HL TI SHRT NRW TRILOCK TECH -,SUP-A-4750.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS 30X64MM F/2.5MM FX 1.6MM LCK TI FRM -,SUP-A-4750.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5815.98,4071.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS 30X64MM F/2.5 TRILOCK SYS 1.6MM LCK TI -,SUP-A-4750.42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5815.98,4071.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS 49MM 2.5MM 6HL TI STR TRILOCK TECH -,SUP-A-4750.54,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4373.94,3061.758,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS 23X54MM 2.5MM 13HL TI TRILOCK TECH RT WRST -,SUP-A-4750.62,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS 23X68MM 2.5MM 15HL TI LNG TRILOCK TECH LT -,SUP-A-4750.64,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6307.43,4415.201,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER BICONCAVE 2.5/2.8 -,SUP-A-4750.70/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,340.18,238.126,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS 46MM 2.5MM 7HL VAR ANG CONTR TI Y -,SUP-A-4750.91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4323.36,3026.352,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS 67MM 2.5MM 10HL 1.6MM VAR ANG CONTR LCK TI Y -,SUP-A-4750.92,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4557.21,3190.047,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.5 TRILOCK ULNA SHORTENING PLATE 10HL -,SUP-A-4750.95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9650.43,6755.301,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.5 TRILOCK ULNA SHORTENING PLATE -,SUP-A-4750.95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9650.43,6755.301,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2.5 TRILOCK WRIST FUSION PI SHORT BEND -,SUP-A-4760.02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11734.57,8214.199,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN APTUS 2.5MM 15HL LCK TI STR MULDIR TRILOCK -,SUP-A-4760.03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9292.66,6504.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE STRAIGHT 2.5 TRILOCK TOTAL WRIST FUS -,SUP-A-4760.04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11159.79,7811.853,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.5 TRILOCK TOTAL WRIST FUS PL LONG BEND 16HL T1.8-2.6 DRSL -,SUP-A-4760.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11734.57,8214.199,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.5 TRILOCK TOTAL WRIST FUS PI SHORT BEND 16 HOLE T1.8-2.6 D -,SUP-A-4760.06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11734.57,8214.199,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2.5 TRILOCK WRIST FUSION SHORT BEND 12 HOLE -,SUP-A-4760.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11462.03,8023.421,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TENSION 2.8 TRILOCK 6 HOLE OLECRANON -,SUP-A-4856.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5373.33,3761.331,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TRILOCK T1-6 OLECRANON 7H RIGHT -,SUP-A-4856.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5556.24,3889.368,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2.8 TRILOC OLECRANON 7H LEFT -,SUP-A-4856.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5557.94,3890.558,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TRILOCK OLECRANON 2.8 7H STRAIGHT -,SUP-A-4856.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5306.27,3714.389,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TRILOCK PLATE 2.8 - 10H- RIGHT -,SUP-A-4856.13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5674.23,3971.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TRILOCK PLATE 10H STRAIGHT -,SUP-A-4856.15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5576.62,3903.634,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.8 TRILOCK DIST HUM PL MEDIAL 17H L -,SUP-A-4856.29,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10465.7,7325.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2.8 TRILOCK DIST HUM MEDIAL 12H R -,SUP-A-4856.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9692.45,6784.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TriLock Dist. Hum Pl. Medial- 10h- l -,SUP-A-4856.33,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9291.81,6504.267,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.8 TRILOCK DIST HUM PL LATERAL 18H L -,SUP-A-4856.39,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9432.88,6603.016,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2.8 TRILCK DIST HUM MEDIAL 10H LFT -,SUP-A-4856.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9692.45,6784.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M TRILOCK GRID H 2X2 -,SUP-A-4856.44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9291.81,6504.267,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 10HL 2.8MM TRILOCK TECH RT OLCRN -,SUP-A-4856-13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4323.36,3026.352,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 10HL 2.8MM TRILOCK TECH LT OLCRN -,SUP-A-4856-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5674.23,3971.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
K-WIRES LNCET 150MM 1.8MM -,SUP-A-5042.51/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,247.99,173.593,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
1.1 K-WIRE- TROCAR- 2-END. 100MM -,SUP-A-5043.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,297.59,208.313,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.2X4MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.2X5MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.2X6MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.2X7MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.2X8MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.2X9MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.2X10MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.2X11MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.2X12MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.2X14MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW M CORTEX 1.2 X 16MM -,SUP-A-5100.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X4MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X5MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X6MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW M CORTEX 1.5 X 07 -,SUP-A-5200.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW M CORTEX 1.5 X 07 -,SUP-A-5200.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW M CORTEX 1.5 X 08 -,SUP-A-5200.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X9MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X10MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X11MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X12MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X13MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X14MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X15MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI. -,SUP-A-5200.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X15MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTEX 1.5 X 16 MEDARTIS -,SUP-A-5200.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTEX 1.5 X 17MM CORTICAL HD4 -,SUP-A-5200.17/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X18MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X19MM CORT APTUS DBL THRD ST/RET HEXDRV 4 TI GOLD -,SUP-A-5200.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW M CORTEX 1.5 X 21 -,SUP-A-5200.21/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 1.5 22MM HD4 -,SUP-A-5200.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW M CORTEX 1.5 X 24 -,SUP-A-5200.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE APTUS 1.5 SPEEDTIP 10MM HD4 PK/1 -,SUP-A-5210.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1076.56,753.592,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 1.5MM SPEEDTIP 14MM HD4 PK/1 -,SUP-A-5210.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1076.56,753.592,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X4MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X5MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X6MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5 X 7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X8MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X9MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X10MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X11MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.5X13MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 1.5 X 16 -,SUP-A-5250.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.8,742.56,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE CANNULATED COMPRESSION 10/4MM -,SUP-A-5281.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.7 CCS LONG THREAD 15/06MM 1/PKG -,SUP-A-5281.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.7 CCS LONG THREAD 16/07MM 1/PKG -,SUP-A-5281.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
1.7 CCS LONG THREAD 18/07MM -,SUP-A-5281.18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.7CCS LONG THREAD 20/08MM -,SUP-A-5281.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.7 CCS FULLY THREADED 10MM 1/PKG -,SUP-A-5282.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.7CCS FULLY THREADED 13MM -,SUP-A-5282.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.7CCS FULLY THREADED 14MM -,SUP-A-5282.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CORTEX BONE SCREWS 1.8MM 06MM LENGTH GOLD -,SUP-A-5300.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,884,618.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW M CORTEX 1.8 X 10 -,SUP-A-5300.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,654.69,458.283,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X4MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X5MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X6MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5400.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X8MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X9MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5400.09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X10MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X11MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X13MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X14MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5400.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X15MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.0 CORTICAL SCREW 16MM -,SUP-A-5400.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.0 X 17MM MEDARTIS -,SUP-A-5400.17/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 2.0 X 18MM HD6 -,SUP-A-5400.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW APTUS TI CORTEX BONE GOLD 2.0 X 19MM -,SUP-A-5400.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X20MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.0 CORTICAL SCREW 24MM -,SUP-A-5400.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X6MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5450.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X8MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5450.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X9MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X10MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X11MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,295.02,206.514,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X12MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X13MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X14MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TRILOCK 2.0 X 14MM HD6 -,SUP-A-5450.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X16MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.0 TRILOCK SCREW 18MM -,SUP-A-5450.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.0 TRILOCK SCREW 20MM -,SUP-A-5450.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.0 TRILOCK 20MM HD6 -,SUP-A-5450.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X5MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X6MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X7MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X8MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X9MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X10MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X11MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X12MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X13MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X14MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X18MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X19MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW M CORTEX 2.3 X 20 -,SUP-A-5500.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW M CORTEX 2.3 X 18 -,SUP-A-5500.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORT MEDARTIS 2.5 8MM -,SUP-A-5700.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X10MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORT MEDARTIS 2.5 11MM -,SUP-A-5700.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X12MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X13MM NLCKG CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5700.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORT MEDARTIS 2.5 14MM -,SUP-A-5700.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW M CORT 2.5 X 15 -,SUP-A-5700.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW 16 MM BLUE 2.5MM -,SUP-A-5700.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NON LOCKING BONE SCREW 16MM -,SUP-A-5700.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORT MEDARTIS 2.5 16MM -,SUP-A-5700.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X18MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW 18MM BLUE 2.5MM -,SUP-A-5700.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW 20MM BLUE 2.5 -,SUP-A-5700.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X20MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X22MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.85,662.095,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X24MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X30MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,623.76,436.632,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CORTEX GOLD NON LCK 2.5 32MM  SCREW -,SUP-A-5700.32/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW M CORT 2.5 X 34MM -,SUP-A-5700.34/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X20MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5720.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X22MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5720.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X10MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TRILOCK SCREW 2.5 12MM -,SUP-A-5750.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X14MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X16MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X18MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCK MEDARTIS 2.5 18MM -,SUP-A-5750.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X24MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X26MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BLUE 2.5 X 28 LOCKING -,SUP-A-5750.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW M LOCKING 2.5 X 30MM -,SUP-A-5750.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X32MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.8,742.56,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.5 TRILOCK SCREW 34MM -,SUP-A-5750.34/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5 TRILOCK EXPRESS 14MM HD7 PK/1 -,SUP-A-5755.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1158.25,810.775,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SILVER LOCKING SCREW 18MM -,SUP-A-5755.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1158.25,810.775,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SILVER LOCKING SCREW 20MM -,SUP-A-5755.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1158.25,810.775,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE APTUS 2.2 CANN COMP 10MM HD7 DISTAL THREAD 4MM -,SUP-A-5780.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE APTUS 2.2 CANN COMP 11MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE APTUS 2.2 CANN COMP 14MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE APTUS 2.2 CANN COMP 15MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE APTUS 2.2 CANN COMP 16MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANULATED COPR 17MM -,SUP-A-5780.17/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE APTUS 2.2 CANN COMP 19MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.2 CANNULATED SCREW COMPRESSION 20MM -,SUP-A-5780.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.2 CANNULATED COMPR 26MM DISTAL THREAD 6MM -,SUP-A-5780.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANULATED COPR 27MM -,SUP-A-5780.27/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.2 CANNULATED COMPR 30MM DISTAL THREAD 6MM -,SUP-A-5780.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MEDART CANN CMPR 2.2 X 22 -,SUP-A-5781.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MEDART CANN CMPR 2.2 X 24MM -,SUP-A-5781.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED 2.2 COMPRESSION LONG THREAD 26MM -,SUP-A-5781.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW COMPR CANNULATED 2.2 X 28MM -,SUP-A-5781.28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW COMPR CANNULATED 2.2 X 30MM -,SUP-A-5781.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MEDART CANN COMPR 2.2 X 32 -,SUP-A-5781.32/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW COMPR CANNULATED 2.2 X 36MM -,SUP-A-5781.36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW COMPR CANNULATED 2.2 X 38MM -,SUP-A-5781.38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.8 CORTICAL SCREW 10MM HD7 -,SUP-A-5800.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.8 CORTICAL SCREW 12MM HD7 -,SUP-A-5800.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.8X16MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.8X18MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.8X20MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.8X22MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.8X24MM CORT -,SUP-A-5800.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,654.69,458.283,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.8 CORTICAL SCREW 26MM HD7 -,SUP-A-5800.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.8 CORTICAL SCREW 28MM -,SUP-A-5800.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.8 CORTICAL SCREW 30MM HD7 -,SUP-A-5800.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.8 CORTICAL SCREW 32MM HD7 -,SUP-A-5800.32/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.8  CORTICAL SCREW 38MM- HD7 -,SUP-A-5800.38/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.8 GOLD CORTEX BONE 40MM HD7 -,SUP-A-5800.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.8X45MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.45/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORITCAL 50MM HD7 2.8 -,SUP-A-5800.50/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.8X55MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.55/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LAG 2.8 X 40 HD7 -,SUP-A-5830.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,654.69,458.283,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.8X14MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TRILOCK BLUE 2.8 LOCKING16MM HD7 -,SUP-A-5850.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.8X18MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.8X20MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.8X22MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TRILOCK 2.8 X 24MM HD7 -,SUP-A-5850.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TRILOCK BLUE 2.8 LOCKING 26MM HD7 -,SUP-A-5850.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.8 TRILOCK  SCREW 28MM HD7 -,SUP-A-5850.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TRILOCK BLUE 2.8 LOCKING 30MM HD7 -,SUP-A-5850.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.8 TRILOCK SCREW 32MM- HD7 -,SUP-A-5850.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.8 TRILOCK SCREW 36MM- HD7 -,SUP-A-5850.36/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.8 TRILOCK SCREW 38MM HD7 -,SUP-A-5850.38/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.8 TRILOCK SCREW 40MM HD7 -,SUP-A-5850.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.8 TRILOCK SCREW 50MM- HD7 -,SUP-A-5850.50/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.8 TRILOCK SCREW 55MM- HD7 -,SUP-A-5850.55/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.8 TRILCK 55MM -,SUP-A-5850.55/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.8,742.56,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.8 TRILOCK SCREW 70MM HD7 -,SUP-A-5850.70/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANNULATED SPEED TIP 3MM X 15MM -,SUP-A-5880.15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2326.39,1628.473,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANN SPEED TIP 3MM X 20MM -,SUP-A-5880.20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2326.87,1628.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X24MM CANN SPEEDTIP CCS S/T SD HEXDRIVE 10 TI -,SUP-A-5880.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X26MM CANN SPEEDTIP CCS S/T SD HEXDRIVE 10 TI -,SUP-A-5880.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.0 CANN COMPR 40 -,SUP-A-5880.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X26MM CANN SPEEDTIP CCS LNG THRD SD HEXDRIVE 10 TI -,SUP-A-5881.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.0 CANNULATED COMPRSCREW28MM-HD10- DISTAL THREAD 9MM -,SUP-A-5881.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2326.39,1628.473,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3 X 30 CANN COMPR DISTAL THREAD -,SUP-A-5881.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3 X 36 CANN COMPR DISTAL THREAD -,SUP-A-5881.36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EXTFIX 6/5MM DIA 100/ 40MM CORT TAPR DYNFX THRD -,SUP-A6010040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EXTFIX 6MM/5X150MM CORT TAPR DYNFX VISION 50MM THRD -,SUP-A6015050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EXTFIX 6MM/5X180MM CORT TAPR DYNFX VISION 50MM THRD -,SUP-A6018050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANULATED COMPR 44MM -,SUP-A-8112.44/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1707.29,1195.103,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
"PLATE M LK ""L"" 2/4 H LEFT -",SUP-AÂ€4650.20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3601.51,2521.057,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SYS BONE CMNT BIOCARTILAGE 3ML STRL -,SUP-ABS-1000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BIOCARTILAGE KIT SMALL JOINT -,SUP-ABS-1000-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FUNNEL BNCMNT BIOCARTILAGE -,SUP-ABS-1003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,163.38,114.366,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BIOCARTILAGE 1CC -,SUP-ABS-1010-BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4678.52,3274.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TACKER ABSORBATACK 5MM 30X -,SUP-ABSTACK30X,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2266.08,1586.256,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WAVEFORM C INTERBODY 16 X 14 X 7MM 7 DEG 3D -,SUP-AC4-264077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE WAVEFORM C INTERBODY 16 X 14X 8MM 7 DEGREE 3D -,SUP-AC4-264087,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 24MM COMPR HDLS ACUTRAK ACUTWIST FLLY W THRD PTCH -,SUP-AI-0024-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 26MM COMPR HDLS ACUTRAK ACUTWIST FLLY W THRD PTCH -,SUP-AI-0026-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 28MM COMPR HDLS ACUTRAK ACUTWIST FLLY W THRD PTCH -,SUP-AI-0028-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4-5X25MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0025-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4-5X30MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0030-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4-5X35MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0035-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4-5X40MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0040-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 45MM ACUTRAK 4/5 -,SUP-AM-0045-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5-6.5X50MM CANN HDLS ACUTRAK + 3MM HX DRV TI ALY STRL -,SUP-AP-0050-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2410.87,1687.609,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5-6.5X60MM CANN HDLS ACUTRAK + 3MM HX DRV TI ALY STRL -,SUP-AP-0060-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2410.87,1687.609,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE PLATE 10MM -,SUP-AP1-110010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 12MM -,SUP-AP1-110012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE 13MM PLATE -,SUP-AP1-110013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE ADMIRAL 14MM PLATE -,SUP-AP1-110014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE ANTERIOR CERVICAL PLATE 16MM -,SUP-AP1-110016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 30MM -,SUP-AP1-200030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ADMIRAL PLATE 36MM -,SUP-AP1-200036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE PLATE 28MM -,SUP-AP1-210028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE ADMIRAL 32MM SEASPINE -,SUP-AP1-210032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE ADMIRAL 36MM SPINE CERVICAL 2 LEVEL SEASPINE -,SUP-AP1-210036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE PLATE 54MM -,SUP-AP1-310054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ST 4 X 14 -,SUP-AP1-604014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ADMIRAL SCREW 4X14 -,SUP-AP1-614014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE SCREW 4 X 10 -,SUP-AP1-704010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 12MM -,SUP-AP1-704012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ADMIRA 4 X 14MM SPINE SELF TAP VARIABLE ANGLE SEASPINE -,SUP-AP1-704014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ADMIRAL 4.3 X 12MM SEASPINE -,SUP-AP1-704312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ADMIRAL 4.3 X 14MM SPINE SELF TAP VARIABLE ANGLE -,SUP-AP1-704314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ADMIRAL 4 X 12MM SEASPINE -,SUP-AP1-714012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE SCREW 4MM X 14MM SD -,SUP-AP1-714014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ADMIRAL 4 X 16MM SEASPINE -,SUP-AP1-714016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.0 X 14 FIX SCREW -,SUP-AP1-724014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6-7.5X70MM CANN HDLS ACUTRAK 6/7 4MM HX DRV TI ALY -,SUP-AP-6770-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6-7.5X75MM CANN HDLS ACUTRACK 6/7 4MM HX DRV TI ALY -,SUP-AP-6775-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PROXIMAL ULNA 73MM LEFT -,SUP-APL-PUP-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5428.08,3799.656,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PROXIMAL ULNA 108MM / LEFT -,SUP-APL-PUP-6HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6175.02,4322.514,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PROXIMAL ULNA 108MM / RIGHT -,SUP-APL-PUP-6HR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6175.02,4322.514,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BONE 151MM ULNA LEFT PROXIMAL -,SUP-APL-PUP-9HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6531.52,4572.064,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ARSCP 1.1MM BLNT TIP F/BIOINTF SCR -,SUP-AR-1249,CDM,C1713,HCPCS,278,RC,,,outpatient,,,122.54,85.778,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ARSCP 2.4MM DRILL TIP F/BIOINTF SCR -,SUP-AR-1250L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DRILL SYSTEM FIXATION TIGHTROPE BTBT IB W/FLIPCUTTER III -,SUP-AR-1288BTBIB-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4816.94,3371.858,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DRILL TIGHTROPE RT IB W/FLIPCUTTER III -,SUP-AR-1288RTIB-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4477.42,3134.194,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FIBERTAG TIGHTROPE II IMPLANT W/ FLIPCUTTER III DRILL -,SUP-AR-1288RTT2-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FIBER TAG TIGHTROPE WITH FLIPCUTTER III -,SUP-AR-1288RTT-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ARSCP 2.4MM SUT EYE -,SUP-AR-1297L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X10MM CORT FT SLD TI STRL F/OSTMY SYS -,SUP-AR-13120T-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X10MM CANN LAG CORT P/T ST SLD TI F/OSTMY SYS -,SUP-AR-13120T-10C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X12MM CANN LAG CORT P/T ST SLD TI F/OSTMY SYS -,SUP-AR-13120T-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X14MM CANN LAG CORT P/T ST SLD TI F/OSTMY SYS -,SUP-AR-13120T-14C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X16MM CANN LAG CORT P/T ST SLD TI STRL F/OSTMY SYS -,SUP-AR-13120T-16C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NANO CORKSCREW FT TI W3-0 FW -,SUP-AR-1317FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUTURE MICRO CORKSCREW FT 2.2 X 4MM -,SUP-AR-1318FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 12.5MM OPN WDG SS -,SUP-AR-13200-12.5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 12.5MM TI SLP STRL -,SUP-AR-13200ST-12.5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUTURE TAK MICRO 2.4 X 6.5 BIOCOMPOSITE -,SUP-AR-1320BCNF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BB-TAK THREADED -,SUP-AR-13226T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUTURETAPE S-TAK ASSY 3.0 SINGLE LOADED -,SUP-AR-1322BCST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUTURETAPE S-TAK ASSY 3.0 SINGLE LOADED -,SUP-AR-1322BCST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X45MM CANC HTO PLATE TI F/OSTMY SYS -,SUP-AR-13280-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5X50MM CANC HTO PLATE TI F/OSTMY SYS -,SUP-AR-13280-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ARSCP 2.4MM F/OSTM -,SUP-AR-13303-2.4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,215.9,151.13,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN SURG 3MM -,SUP-AR-13303-3.0,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUBSTITUTE B TCP OPN WDG OSFERION 7MM 30MM -,SUP-AR-13370-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUBSTITUTE B TCP WDG OSFERION 15X35MM -,SUP-AR-13370-4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X40MM CORT HTO PLATE TI F/OSTMY SYS -,SUP-AR-13380-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X46MM CORT HTO PLATE TI F/OSTMY SYS -,SUP-AR-13380-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT IBALANCE 6.5X24MM HI TIB OPN PEEK -,SUP-AR-13401-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT IBALANCE 6.5X28MM HI TIB OPN PEEK -,SUP-AR-13401-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SFT TIS CORT 4.5X38MM IBALANCE HTO -,SUP-AR-13402-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT IBALANCE 4.5X40MM HI TIB OPN PEEK -,SUP-AR-13402-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT IBALANCE HTO 4.5X48MM HI TIB OPN NABSB PEEK -,SUP-AR-13402-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN ARSCP FX 5X40MM PLLA FEM ABSB TRNSFX II F/ACL RECON -,SUP-AR-1351B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN ARSCP FX 5X50MM PLLA FEM ABSB TRNSFX II F/ACL RECON -,SUP-AR-1351LB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN 6X23MM RND HEAD STP TAPR BIOCMPS FEM DBL -,SUP-AR-1360C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SILK 7 X 20 NON SHEATHED -,SUP-AR-1370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.64,822.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN 7X23MM ABSB SHTH RND HEAD STP TAPR BIOCMPS -,SUP-AR-1370B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 7X23 BIOCOMPOSITE -,SUP-AR-1370C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN TIGHTROPE RT 7X28MM FT ABSB RND HEAD STP -,SUP-AR-1370TC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN CONTR LOCK HTO 12.5MM A/P SLP WDG -,SUP-AR-13725-12.5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8X23MM BIO -,SUP-AR-1380C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN 8X28MM FT ABSB TAPR PLLA TIB KN STRL -,SUP-AR-1380TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8 X 25 -,SUP-AR-1381,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SILK 9 X 2O NON SHEATHED -,SUP-AR-1390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.64,822.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN TIGHTROPE RT 9X23MM SHTH ABSB HEX HEAD PLLA -,SUP-AR-1390B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 9 X 23 BIOCOMPOSITE -,SUP-AR-1390C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN 9X28MM FT ABSB TAPR BIOCMPS PLLA TIB KN -,SUP-AR-1390TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SILK 9 X 25 NON SHEATHED -,SUP-AR-1391,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.64,822.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN SUTUREPLATE 90MM 3HL POLYAX TI STRL -,SUP-AR-14003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN 10X23MM ABSB SHTH PLLA TIB KN GRD STRL -,SUP-AR-1400B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 10 X 23 BIOCOMPOSITE -,SUP-AR-1400C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN 10X28MM ABSB FT TAPR PLLA TIB KN STRL -,SUP-AR-1400TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X18MM NLCKG CORT SUTUREPLATE TI STRL F/ARTHPL -,SUP-AR-14118NL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,262.58,183.806,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X20MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X22MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM NLCKG CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14126NL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,262.58,183.806,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X28MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X32MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X34MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X36MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X38MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X40MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X50MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X28MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X32MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X38MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X48MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14248,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
KIT TENODESIS SCREW 3X8 DISPOSABLE -,SUP-AR-1530DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FOREFOOT IB IMPLANT SYS PEEK -,SUP-AR-1530P-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5920.38,4144.266,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TENODESIS PEEK 3.5 X 8 -,SUP-AR-1530PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2146.7,1502.69,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4 X 10MM BIOTENODESIS -,SUP-AR-1540BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TENODESIS PEEK 4X10 -,SUP-AR-1540PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR BIO-TENODESIS 4.75X15MM BABSRB BIOCMPS ANKL/FT -,SUP-AR-1547BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TENODESIS PEEK 4.75X15MM INTERFERENCE -,SUP-AR-1547PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TENODESIS PEEK  5.5 X 15 -,SUP-AR-1555PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN BIO-TENODESIS 6.25X15MM BABSRB PEEK HND -,SUP-AR-1562BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TENODESIS PEEK 6.25X15 -,SUP-AR-1562PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN BIO-TENODESIS 7X23MM BABSRB PLLA HND WRST -,SUP-AR-1570BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN BIO-TENODESIS 8X23MM BABSRB PLLA HND WRST -,SUP-AR-1580BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 9X20MM CORT RETROSCREW FT RTRGD RND HEAD PLLA STRL -,SUP-AR-1586RB-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1131.99,792.393,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
RETRO BUTTON 15MM -,SUP-AR-1588-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
RETRO BUTTON 20mm -,SUP-AR-1588-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
RETRO BUTTON 12mm/25 -,SUP-AR-1588-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
RETRO BUTTON 12MM/30MM -,SUP-AR-1588-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SYS ARTHROSCOPIC FX BTB TIGHTROPE RT F/ACL RECON -,SUP-AR-1588BTB-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2358.72,1651.104,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIGHTROPE II RT WITH DEPLOYING SUTURE -,SUP-AR-1588RT-2J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2464.73,1725.311,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FIXATION ACL TIGHTROPE RT -,SUP-AR-1588RT-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FIXATION TIGHTROPE RT DBL -,SUP-AR-1588RT-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ACL TIGHTROPE WITH FIBER TAG -,SUP-AR-1588RTT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FIXATION ACL FEM TIGHTROPE -,SUP-AR-1588T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIGHTROPE ABS BUTTON 11MM -,SUP-AR-1588TB-3IB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIGHTROPE ABS BUTTON 14MM -,SUP-AR-1588TB-4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIGHTROPE ABS BUTTON 20MM -,SUP-AR-1588TB-5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIGHTROPE ABS BUTTON ROUND CONCAVE 20MM -,SUP-AR-1588TB-5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT TIGHTROPE ABS -,SUP-AR-1588TN,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
OPEN TIGHTROPE ABS -,SUP-AR-1588TN-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1131.99,792.393,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT FIXATION TIGHTROPE II ABS -,SUP-AR-1588TN-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIGHTROPE II ABS- IMPLANT OPEN -,SUP-AR-1588TN-21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ACL TIGHTROPE WITH FIBER TAG ABS -,SUP-AR-1588TNT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1775.67,1242.969,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIGHTROPE BUTTON EXTENDER -,SUP-AR-1589RT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN BIO-TENODESIS 9X23MM BABSRB PLLA HND WRST -,SUP-AR-1590BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR BIO-TENODESIS 5.5X10MM BABSRB PEEK ANKL/FT HND -,SUP-AR-1655PS-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR BIO-TENODESIS 5.5X12MM PEEK SHOLUDER ELB -,SUP-AR-1655PS-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SWIVELOCK  BIOCOMPOSITE 8MM X 19.5MM -,SUP-AR-1662BC-8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2305.72,1614.004,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SYSTEM LATERAL ANKLE RECON -,SUP-AR-1675BC-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR CANN BIO-TENODESIS 8X12MM BABSRB PLLA SFT TIS -,SUP-AR-1680BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
KIT IB BC W/CC FT AND JUMPSTART -,SUP-AR-1788J-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
KIT IB BC W/CC FT AND JUMPSTART IMPLANT SYSTEM -,SUP-AR-1788J-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SWIVEL LOCK INTERNAL BRACE -,SUP-AR-1788J-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOW PROFILE SCREW 1.0 X 6MM CORTICAL TI -,SUP-AR-18710-06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOW PROFILE SCREW 1.0 X 7MM CORTICAL TI -,SUP-AR-18710-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOW PROFILE 2.4 X 10 CORTICAL -,SUP-AR-18724-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOW PROFILE 2.4 X 26 CORTICAL -,SUP-AR-18724-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
T-PLATE 2.4MM 6 HOLE -,SUP-AR-18724P-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TISSUE TAK TENDON ANCHOR -,SUP-AR-19021TT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUTURE CORKSCREW FT 3.5X10MM -,SUP-AR-1915FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ARTHREX SUTURE ANCHCRKSCRW FT3.5X10MM -,SUP-AR-1915FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT CRKSCR 3.5X12MM THRD TI #2 SUT -,SUP-AR-1915S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT CRKSCR 5X15MM ABSB -,SUP-AR-1920BF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1378.13,964.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUTURE CORKSCREW 5.0 -,SUP-AR-1920S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT PSHLK 4.5X24MM BIOCMPS -,SUP-AR-1922BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT BIO-PSHLK 4.5MMX18.5MM ABSB SLF-PNCH PLLA TI TIP -,SUP-AR-1922BM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2067.2,1447.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR PUSHLOCK 2.9 X 15.5 BIO -,SUP-AR-1923BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR PUSHLOK PEEK 2.9X15.5 -,SUP-AR-1923PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT CRKSCR 6.5MMX15.5MM THRD ST TI SZ2 GRN WHT SUT -,SUP-AR-1925S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR CORKSCREW 6.5 FIBER 2 2 -,SUP-AR-1925SF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BIO-PUSHLOCK COMPOSITE 3.5MM -,SUP-AR-1926BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT PSHLK 3.5MMX19.5MM PEEK HNDL INSRTR DRIVER -,SUP-AR-1926PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT CRKSCR FT 5.5MMX14.7MM ARSCP FT BABSRB BIOCMPS -,SUP-AR-1927BCF-3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1802.17,1261.519,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR 4.5 BIO-COMPOSITE -,SUP-AR-1927BCF-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
6.5 BIOCOMPOSITE ANCHORS -,SUP-AR-1927BCF-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1775.67,1242.969,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR BIO CORKSCREW 5.5 -,SUP-AR-1927BCT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1881.68,1317.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR CORKSCREW 5.5 PEEK (BOX OF 5) -,SUP-AR-1927PSF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT SUTAK 3MMX14.5MM ARSCP BIOCMPS ABSB #2 -,SUP-AR-1934BCF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1616.65,1131.655,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR BIOCOMPOSITE 3MM DBL -,SUP-AR-1934BCF-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT SUTAK 2.4X12MM ARSCP BIOCMPS FIBERWIREX2 -,SUP-AR-1934BCF-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1616.65,1131.655,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT SUTAK 2.4X12MM ARSCP BIOCMPS FIBERWIRE -,SUP-AR-1934BCF-24-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR BIOCOMPOSITE 3MM SING -,SUP-AR-1934BCT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1802.17,1261.519,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BIO SUTURE TAK DISPOSABLE -,SUP-AR-1934DS-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
KIT SUTURE TAK 3MM PERCUTANEOUS INSERTION -,SUP-AR-1934PI-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR KNOTLESS SUT TAK 3MM BI -,SUP-AR-1938BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR PEEK SUT TAK 3MM KNOTLESS -,SUP-AR-1938PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT DISTAL BICEP REPAIR 7 X 10MM -,SUP-AR-2260BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BUTTON SUT 2.6MM TI 12MM LF -,SUP-AR-2261,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BUTTON SUT DOG BN LF -,SUP-AR-2270,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SWIVEL LOCK 5.5 -,SUP-AR-2323BCC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT SWIVLK C 5.5MMX19.1MM ABSB CLSD EYLT PLLA -,SUP-AR-2323BSLC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1987.69,1391.383,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SWIVELOCK- SP BC KL 5.5MM -,SUP-AR-2323KBCSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT SWIVLK 5.5MMX24.5MM SLF-PNCH PEEK -,SUP-AR2323PSLM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT SWIVLK C 4.7MMX19.1MM CLSD EYLT BIOCMPS WHT/BLK -,SUP-AR-2324BCCTT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR BIO COMP SWIVELOCK SP 4 (MIN 5 EACH) -,SUP-AR-2324BCM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR BIOCOMPOSITE SWIVEL W\FIBERTAPE -,SUP-AR-2324BCT-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SWIVELOCK  BIOCOMPOSITE 4.75MM X  22MM DOUBLE LOADED -,SUP-AR-2324BCT-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR BIO-SWIVELLOCK 4.75 -,SUP-AR-2324BCT-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SWIVELOCK KNOTLESS 4.75MM BC -,SUP-AR-2324KBCC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
KNOTLESS SWIVELOK 4.75MM BC W/TAPE -,SUP-AR-2324KBCCTT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2530.22,1771.154,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SWIVELOCK- SP BC KL 4.75MM -,SUP-AR-2324KBCSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT BIO- SWIVLK SP 4.75MMX24.5MM SLF-PNCH PEEK TI -,SUP-AR-2324PSLM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BC SWIVELOCK 3.9 X 17.9 MM -,SUP-AR-2326BCC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
KIT SPEEDBRIDGE SHOULDER -,SUP-AR-2600SBS-8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8106.04,5674.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DISTAL CLAVICLE 22 DEG RIGHT -,SUP-AR-2622DR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 8HL PRCONT SS LT CLVCL -,SUP-AR-2651CL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PRCONT SS RT CNTRL CLVCL -,SUP-AR-2653CR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN PRCONT SS LT CNTRL CLVCL -,SUP-AR-2654CL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CLAVICLE DISTAL SHOR LEFT SS -,SUP-AR-2656DL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CLAVICLE DISTAL SHORT RIGHT SS -,SUP-AR-2656DR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 8HL PRCONT SS RT CLVCL -,SUP-AR-2657DR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DISTAL CLAVICLE BUTTON -,SUP-AR-2658,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DISTAL CLAVICLE REPAIR ASSEMBLY -,SUP-AR-2658T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUTURE ANCHOR- BIOCOMPOSITE- HIP PUSHLOCK- SHORT 2.9 x 12.5 -,SUP-AR-2923BCH,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
KIT DISPOSABLES FOR FIBERTAK SUTR ANCH -,SUP-AR-3600DC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FIBERTAK WITH SUTURETAPE -,SUP-AR-3602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1881.68,1317.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.6 FIBERTAK ANCHOR DOUBLE  LOADED -,SUP-AR-3632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FIBERTAK ANCHOR TRIPLE LOADED -,SUP-AR-3633,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SELF-PUNCHING TRIPLE LOADED FIBERTAK -,SUP-AR-3633SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR FIBERTAK KNOTLESS -,SUP-AR-3636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FIBERTAK SHOULDER 1.8 SELF BUNCHING -,SUP-AR-3636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FIBERTAK HIP 1.8 SELF BUNCHING -,SUP-AR-3636H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
KNOTLESS 1.8 FIBERTAK W/ #2 SUTURE -,SUP-AR-3638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
KNOTLESS HIP FIBERTAK SUTURE ANCHOR- CURVED -,SUP-AR-3638DHC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
KIT FIBERTAK KNOTLESS STRAIGHT DISPOSABLE -,SUP-AR-3638DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SP FBTAK RC TGRTPE WH/BLK & STTPE WH/BL -,SUP-AR-3652SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SP FBTAC RC RBRTPE BLU & STTPE WH/BLK -,SUP-AR-3652TSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SP FBTAC RC RBRTPE BLK/BLU & STTPE BLU -,SUP-AR-3652TTSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
KL FBTK RC (WH/BLK)TT & (BLU)#2 MTS -,SUP-AR-3653SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2530.22,1771.154,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
KL FBTK RC W/(BLU)FT & (W/BLK) #2 MTS -,SUP-AR-3653TSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2530.22,1771.154,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
KNOTLESS TENSIONABLE FIBERTAK BICEP -,SUP-AR-3687,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ARTHROSCOPIC FX CHNDR -,SUP-AR-4005B-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW VENTED BC IF 7 X 20MM -,SUP-AR-4020C-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW VENTED BC IF 8 X 20MM -,SUP-AR-4020C-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW VENTED BC IF 9 X 20MM -,SUP-AR-4020C-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW VENTED BC IF 10 X 20MM -,SUP-AR-4020C-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ARTHREX PEEK SCREW 7 X 20MM FAST THREAD -,SUP-AR-4020P-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ARTHREX PEEK 8 X 20MM FAST THREAD -,SUP-AR-4020P-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ARTHREX PEEK 9 X 20MM FAST THREAD -,SUP-AR-4020P-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ARTHREX PEEK 10 X 20MM FAST THREAD -,SUP-AR-4020P-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW VENTED BC IF 7 X 30MM -,SUP-AR-4030C-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW VENTED BC IF 8 X 30MM -,SUP-AR-4030C-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW VENTED BC IF 9 X 30MM -,SUP-AR-4030C-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW VENTED BC IF 10 X 30MM -,SUP-AR-4030C-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW VENTED BC IF 11 X 30MM -,SUP-AR-4030C-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ARTHREX PEEK SCREW 7 X 30MM FAST THREAD -,SUP-AR-4030P-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ARTHREX PEEK 8 X 20MM FAST THREAD -,SUP-AR-4030P-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ARTHREX PEEK 9 X 30MM FAST THREAD -,SUP-AR-4030P-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ARTHREX PEEK 10 X 30MM FAST THREAD -,SUP-AR-4030P-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DEVICE SUT 1.5X5MM CRV C IN MNSCL 2-0 FIBERWIRE NDLX2 MINI -,SUP-AR-4500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
KIT BIOCOMPOSITE MENISCAL ROOT REPAIR -,SUP-AR-4550BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FIBER STITCH CURVED -,SUP-AR-4570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUTURE FIBERSTITCH FIBERWIRE POLYESTER 24 D 2-0 CURVE -,SUP-AR-4570-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
KIT ARTHROSCOPIC FIXATION FIBERSTITCH REVERSE CURVE -,SUP-AR-4570R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUTURE FIBERSTITCH STRAIGHT -,SUP-AR-4570S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR BIOCMPRSN 3X18MM BABSRB HDLS PLLA KN TAPR STP -,SUP-AR-5025B-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW INTFR BIOCMPRSN 2.7X20MM BABSRB HDLS PLLA KN TAPR STP -,SUP-AR-5025B-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8 X 28 BIOCOMPOSITE -,SUP-AR-5028C-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 9X28 DELTA -,SUP-AR-5028C-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 10 X 28 BIOCOMPOSITE -,SUP-AR-5028C-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 11 X 28 DELTA -,SUP-AR-5028C-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 9 X 35 DELTA -,SUP-AR-5035TC-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 10 X 35 BIOCOMPOSITE -,SUP-AR-5035TC-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 11 X 35 DELTA -,SUP-AR-5035TC-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 12 X 35 BIOCOMPOSITE -,SUP-AR-5035TC-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WIRE GUIDE 1.35MM DUAL TROCAR -,SUP-AR-5050-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,239.24,167.468,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFTBOLT TIBIAL 7MM -,SUP-AR-5100-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFTBOLT TIBIAL 8MM -,SUP-AR-5100-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFTBOLT TIBIAL 9MM -,SUP-AR-5100-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFTBOLT TIBIAL 10MM -,SUP-AR-5100-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUTURE ANCHOR- SWIVELOCK TENODESIS- PEEK -,SUP-AR-7324PSL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2969.43,2078.601,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOW PROFILE SCREW TI 4.5 X 26MM -,SUP-AR-8545-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOW PROFILE SCREW TI 4.5 X 34MM -,SUP-AR-8545-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOW PROFILE SCREW TI 4.5 X 36MM -,SUP-AR-8545-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LO-PRO LOCK SCREW TI 4.5 X 28MM -,SUP-AR-8545L-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X55MM LCK -,SUP-AR-8545L-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X60MM LCK -,SUP-AR-8545L-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT SYSTEM CPR MINI SCORPION DX -,SUP-AR-8690DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
STAPLE BN FX QUICKFIX SM SS -,SUP-AR-8710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NITINOL COMPRESSION STAPLE- 9WX7L -,SUP-AR-8717-0907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NITINOL COMPRESSION STAPLE- 9WX10L -,SUP-AR-8717-0910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DYNANITE NITI STAPLE W/INSTRS 9WX10L -,SUP-AR-8717DS-0910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DYNANITE NITI STAPLE W/INSTRS 10W X 11L -,SUP-AR-8717DS-1110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DYNANITE NITI STAPLE W/INSTRS 11W X 15\12L -,SUP-AR-8717DS-111512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NITINOL COMP STAPLE 15W X 12L -,SUP-AR-8718-1512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
STAPLER DYNAMITE NITI  W/INSTRS 13W X 10L -,SUP-AR-8718DS-1310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8042.38,5629.666,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DYN NITI STAPLE W/INSTRS 15W X 12L -,SUP-AR-8718DS-1512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8042.38,5629.666,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
STAPLE 15W X 15L DYNANITE NITI W/INSTRS -,SUP-AR-8719DS-1515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DYN NITI STAPLE W/INSTRS 18W X 15L -,SUP-AR-8719DS-1815,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
STAPLE DYNANITE NITI W/INSTRS 18W X 18L -,SUP-AR-8719DS-1818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DYNANITE NITI STAPLE WINSTRS 20W X 20L -,SUP-AR-8719DS-2020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
QCKFIX SCRW TI CANN PT 2.0 X 10MM -,SUP-AR-8720-10PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.4X12MM HD CORT QUICKFIX ST SLD STND ALONE TI STRL -,SUP-AR-8724-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOW PROFILE 2.4 X 14 CORTEX -,SUP-AR-8724-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOW PROFILE SCREW 2.4 X 18MM CORTEX -,SUP-AR-8724-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW QUICKFIX 2.4 X 18MM TI CANNULATED -,SUP-AR-8724-18PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,846.08,592.256,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW QUICKFIX 2.4 X 22MM TI CANNULATED -,SUP-AR-8724-22PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,846.08,592.256,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.4X24MM CANN QUICKFIX P/T T8 HXLB DRV TI F/CMPRHNSV -,SUP-AR-8724-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOW PROFILE SCREW 2.4 X 32MM CORTEX -,SUP-AR-8724-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOW PROFILE SCREW 2.4 X 36MM CORTEX -,SUP-AR-8724-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.4 X 8 VAL TI -,SUP-AR-8724V-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.4 X 12 VAL TI -,SUP-AR-8724V-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.4 X 16 VAL TI -,SUP-AR-8724V-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.4MM X 18MM V AL SCREW TI -,SUP-AR-8724V-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW VAL TI 2.4MM X 18MM -,SUP-AR-8724V-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.4MM X 22MMV AL SCREW TI -,SUP-AR-8724V-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW VAL KREULOCK TI 2.4X12 -,SUP-AR-8724VCL-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW VAL KREULOCK TI 2.4X16 -,SUP-AR-8724VCL-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW COMPRESSION FT 2.5MM MICRO X 8MM LGTH -,SUP-AR-8725-08H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5MMX14MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-14H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5MMX16MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-16H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5MMX18MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-18H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5MMX20MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-20H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW COMPR FT 2.5 MICRO 22MM -,SUP-AR-8725-22H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5MMX24MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-24H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5MMX26MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-26H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMPR FT SCREW 2.5 MICRO 28MM LGTH -,SUP-AR-8725-28H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS MICRO 2.5X 30MM -,SUP-AR-8725-30H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMPR FT SCREW 2.5 MICRO 32MM LGTH -,SUP-AR-8725-32H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW QUICKFIX TI CANC PT 3.0 X 12MM -,SUP-AR-8730-12PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX14MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8730-14H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX14MM DUAL CORE QUICKFIX -,SUP-AR-8730-14PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMPR FT SCREW 3.5 MINI 16MM -,SUP-AR-8730-16H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX16MM DUAL CORE QUICKFIX -,SUP-AR-8730-16PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMPR FT SCRW 3.5 MINI 18MM LGTH -,SUP-AR-8730-18H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX18MM DUAL CORE QUICKFIX -,SUP-AR-8730-18PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMP SCREW 3.5 MINI 20MM -,SUP-AR-8730-20H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MM X 20MM DUAL CORE QUICKFIX -,SUP-AR-8730-20PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMPR FT SCREW 3.5 MINI 22MM -,SUP-AR-8730-22H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX22MM DUAL CORE QUICKFIX -,SUP-AR-8730-22PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FT COMPR 3.5 X 24MM -,SUP-AR-8730-24H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX24MM DUAL CORE QUICKFIX -,SUP-AR-8730-24PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW COMPR FT 3.5 X 26 MINI -,SUP-AR-8730-26H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MMX26MM DUAL CORE QUICKFIX P/T SD/ST T10 HXLB DRV TI -,SUP-AR-8730-26PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW COMPR FT 3.5 MINI 28MM -,SUP-AR-8730-28H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FT COMPR 3.5 X 30MM -,SUP-AR-8730-30H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.6MMX32MM COMPR HDLS QUICKFIX P/T SD/ST T10 HXLB DRV -,SUP-AR-8730-32H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMPR FT SCREW 3.5 MINI 34MM LGTH -,SUP-AR-8730-34H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
QCKFIX SCREW TI CANC PT 3.0 X 38MM -,SUP-AR-8730-38PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOW PROFILE SCREW CORTICAL 3.5MM X 14MM DRP -,SUP-AR-8735-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOW PROFILE SCREW CORTICAL 3.5MM X 16MM DRP -,SUP-AR-8735-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOW PROFILE SCREW CORTICAL 3.5MM X 18MM DRP -,SUP-AR-8735-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.5X32MM BEVELED FT SCREW -,SUP-AR-8735BV-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BEVELED FT 3.5MM X40MM -,SUP-AR-8735BV-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5 X 44MM BEVELED FT -,SUP-AR-8735BV-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOW PROFILE SCREW LOCKING 3.5MM X 16MM DRP -,SUP-AR-8735L-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEWIRE 0.86MM W/ LASER LINE SS -,SUP-AR-8737-21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,87.53,61.271,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW COMPR FT 4.0 STD 20MM LGTH -,SUP-AR-8740-20H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW COMPR FT 4.0 STD 22MM LGTH -,SUP-AR-8740-22H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMPRESSION SCREW 4.0 24MM LENGTH -,SUP-AR-8740-24H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMPRESSION SCREW 4.0 26MM LENGTH -,SUP-AR-8740-26H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMPRESSION SCREW 4.0 28MM LENGTH -,SUP-AR-8740-28H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW COMPR FT 4.0 STD 30MM LGTH -,SUP-AR-8740-30H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW QUICKFIX TI CANN ST 4.0 X 38MM CANC -,SUP-AR-8740-38PTS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW QUICKFIX TI CANN 4.0 X 40MM ST CANC -,SUP-AR-8740-40PTS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
4X46MM BEVELED FT SCREW -,SUP-AR-8740BV-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4 X 50MM BEVELED FT -,SUP-AR-8740BV-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4 X 52MM BEVELED FT -,SUP-AR-8740BV-52,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER 7.0MM TI -,SUP-AR-8740W,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEWIRE 1.6MM- 4MM BEVELED FT -,SUP-AR-8741-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEWIRE 1.6X150MM CAPITAL FRAG -,SUP-AR-8741-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW COMPR FT 5.0 X 42MM -,SUP-AR-8750-42H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW COMPR FT 5.0 X 55MM -,SUP-AR-8750-55H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMPR FT SCREW 7.0 XL 65MM LGTH -,SUP-AR-8770-65H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMPR FT SCREW 7.0 XL 70MM LGTH -,SUP-AR-8770-70H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COMPR FT SCREW 7.0 XL 75MM LGTH -,SUP-AR-8770-75H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT BIO-PSHLK 2.5X8MM KNTLS PLLA ABSB #2 FIBERWIRE -,SUP-AR-8825B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUTURE PEEK MINI PUSHLOCK -,SUP-AR-8825P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
KREULOCK COMPRESSION SCREW SS 2.7 X 12MM -,SUP-AR-8827CL-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
KREULOCK COMPRESSION SCREW SS 2.7 X 14MM -,SUP-AR-8827CL-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
KREULOCK COMPRESSION SCREW SS 2.7 X 16MM -,SUP-AR-8827CL-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
KREULOCK COMPRESSION SCREW SS 2.7 X 18MM -,SUP-AR-8827CL-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
KREULOCK COMPRESSION SCREW SS 2.7 X 20MM -,SUP-AR-8827CL-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X10MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X12MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X18MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X20MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LO-PRO LOCK SS 2.7 X 22 -,SUP-AR-8827L-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LO-PRO LOCK 2.7 X 24 -,SUP-AR-8827L-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CANCLUS SCREW FULLY THREADED SS 3 X 24MM -,SUP-AR-8830-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LO-PRO SCREW TM SS 3.5 X 12MM CORT -,SUP-AR-8835-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X14MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X16MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X18MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X22MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X28MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X30MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X35MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X45MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X10MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X14MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X16MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X18MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X20MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X14MM NLCKG CANC TIGHTROPE FT SD T15 HXLB DRV SS -,SUP-AR-8840-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X16MM NLCKG CANC TIGHTROPE FT SD T15 HXLB DRV SS -,SUP-AR-8840-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X30MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X40MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X45MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X60MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X30MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X35MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X50MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X60MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PARS Suture Implant Kit w/ SutureTape -,SUP-AR-8862DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIGHTROPE MINI 1.1MM -,SUP-AR-8914DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
VOLAR DISTAL RAD PLT TI NARROW LT 3HOLE -,SUP-AR-8916VNL-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
VOLAR DISTAL RAD PLT TI NARROW RT 3H -,SUP-AR-8916VNR-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT MINI TIGHTROPE 1.1 - 0 -,SUP-AR-8919DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
KT ARTHROSCOPIC FX TIGHTROPE ANKL 6.5MM RND BTN 3.5X10MM -,SUP-AR-8920CDS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
KT ARTHROSCOPIC FX TIGHTROPE ANKL 3.5MM RND/10MM OBLNG BTN -,SUP-AR-8921CDS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIGHTROPE XP KNOTLESS TITANIUM -,SUP-AR-8925T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIGHTROPE KNOTLESS -,SUP-AR-8926SS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4986.7,3490.69,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BIO-COMP ACHILLE SPEEDBRIDGE -,SUP-AR-8928BCJ-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SYSTEM IMPLANT MPFL BIOCOMPOSITE -,SUP-AR-8929BC-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6310.83,4417.581,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X10MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI COLR F -,SUP-AR-8930-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X11MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI MAG F -,SUP-AR-8930-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X12MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI BLU F -,SUP-AR-8930-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X13MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI GRN F -,SUP-AR-8930-13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X14MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI PUR F -,SUP-AR-8930-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X16MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI PUR F -,SUP-AR8930-16PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2X20MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI PUR F -,SUP-AR-8930-20PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X12MM CANN CORT P/T TI -,SUP-AR-8933-12PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X14MM CANN CORT P/T TI -,SUP-AR-8933-14PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LP SCREW 3 X 16MM CORTICAL MTP TI -,SUP-AR-8933-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X16MM CANN CORT P/T TI -,SUP-AR-8933-16PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LO-PRO SCREW TI 3.0MM X 18MM CORT -,SUP-AR-8933-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X18MM CANN CORT P/T TI -,SUP-AR-8933-18PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LO-PRO SCREW TI 3.0MM X 20MM CORT -,SUP-AR-8933-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LO-PRO SCREW TI 3.0MM X 22MM CORT -,SUP-AR-8933-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LO-PRO SCREW TI 3.0MM X 36MM CORT -,SUP-AR-8933-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X14MM LCK CORT P/T TI BLU -,SUP-AR-8933L-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X16MM LCK CORT P/T TI BLU -,SUP-AR-8933L-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
VAL KREULOCK SCREW TI 3 X 16 -,SUP-AR-8933VCL-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
VAL KREULOCK SCREW TI 3 X 18 -,SUP-AR-8933VCL-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
VAL KREULOCK SCREW TI 3 X 20 -,SUP-AR-8933VCL-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW VAL KREULOCK 3.0 X 22MM TI -,SUP-AR-8933VCL-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW VAL KREULOCK 3.0 X 26MM TI -,SUP-AR-8933VCL-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUTURETAPE S-TAK ASSY 3.0 DOUBLE LOADED -,SUP-AR-8934BCST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.0 DOUBLE LOADED SUTURETAPE S-TAK ASSY -,SUP-AR-8934BCST-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LO-PRO SCREW TI 3.5MM X 12MM -,SUP-AR-8935-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LO-PRO SCREW TI 3.5MM X 22MM -,SUP-AR-8935-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LO-PRO SCREW TI 3.5MM X 24MM -,SUP-AR-8935-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LO-PRO TI 3.5MM X 26MM -,SUP-AR-8935-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LO-PRO TI 3.5MM X 30MM -,SUP-AR-8935-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LO-PRO SCREW TI 3.5MM X 32MM -,SUP-AR-8935-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LO-PRO TI 3.5MM X 34MM -,SUP-AR-8935-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LO-PRO SCREW TI 3.5MM X 36MM -,SUP-AR-8935-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LO-PRO SCREW TI 3.5MM X 38MM -,SUP-AR-8935-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LO-PRO SCREW TI 3.5MM X 40MM -,SUP-AR-8935-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LO-PRO SCREW TI 3.5MM X 42MM -,SUP-AR-8935-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LO-PRO SCREW TI 3.5MM X 44MM -,SUP-AR-8935-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LO-PRO SCREW TI 3.5MM X 46MM -,SUP-AR-8935-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LO-PRO SCREW TI 3.5MM X 48MM -,SUP-AR-8935-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW KREULOCK TI 3.5 X 24MM -,SUP-AR-8935CL-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW KREULOCK TI 3.5 X 26 -,SUP-AR-8935CL-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
KREULOCK SCREW TI 3.5 X 28 -,SUP-AR-8935CL-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW KREULOCK TI 3.5 X 28MM -,SUP-AR-8935CL-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW KREULOCK TI 3.5 X 30 -,SUP-AR-8935CL-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW KREULOCK TI 3.5 X 32 -,SUP-AR-8935CL-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
KREULOCK SCREW TI 3.5 X 34 -,SUP-AR-8935CL-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
KREULOCK SCREW TI 3.5 X 36 -,SUP-AR-8935CL-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LO-PRO LOCK SCREW TI 3.5MM X 12MM -,SUP-AR-8935L-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW  TI 3.5MM X 14MM -,SUP-AR-8935L-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X24MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW TITANIUM 3.5MM X 28MM -,SUP-AR-8935L-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING TITANIUM 3.5MM X 28MM -,SUP-AR-8935L-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X30MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X32MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW TITANIUM 3.5MM X 34MM -,SUP-AR-8935L-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING SCREW TITANIUM 3.5MM X 44MM -,SUP-AR-8935L-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
KIT ENDOSCOPIC BOSTROM REPAIR IMPLANT SYS -,SUP-AR-8936BC-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X30MM CANC FT SD TI STRL F/H-PLATE LPDS SURG -,SUP-AR-8940-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LO-PRO TI 4.0MM X 36MM -,SUP-AR-8940-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X40MM CANC FT SD TI -,SUP-AR-8940-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN TIGHTROPE 79MM F/SYNDSMS RPR 4HL SS BTRSS LT -,SUP-AR-8943BL-04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN TIGHTROPE 79MM F/SYNDSMS RPR 4HL SS BTRSS RT -,SUP-AR-8943BR-04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN TIGHTROPE 91MM F/SYNDSMS RPR 5HL SS BTRSS -,SUP-AR-8943BR-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN TIGHTROPE 104MM F/SYNDSMS RPR 6HL SS BTRSS -,SUP-AR-8943BR-06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN TIGHTROPE 61MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943H-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN TIGHTROPE F/DLTD LGMNT ATTCH AVULSION FX SYNDSMS -,SUP-AR-8943H-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN TIGHTROPE 47MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943T-04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN TIGHTROPE 72MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943T-06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN TIGHTROPE 98MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943T-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1404.63,983.241,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN TIGHTROPE F/SYNDSMS AVULSION FX MGMT 10HL LCK SS -,SUP-AR-8943T-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1484.14,1038.898,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN TIGHTROPE 72MM F/SYNDSMS AVULSION FX MGMT 3HL SS -,SUP-AR-8943TH-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN TIGHTROPE F/SYNDSMS AVULSION FX MGMT 7HL LCK SS 1/3 -,SUP-AR-8943TH-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN TIGHTROPE 43MM TI BTRSS 3.5MM LPS SCR 2.4MM GW -,SUP-AR-8947DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.1,3045.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 7.5MM STP -,SUP-AR-8949-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LISFRANC PLATE MEDIUM LEFT TI -,SUP-AR-8951ML,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE MEDIUM RIGHT TITANIUM LISFRANC -,SUP-AR-8951MR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LISFRANC PLATE SMALL RIGHT TI -,SUP-AR-8951SR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.5MM 2HOLE L-PLATE TI 5H RT -,SUP-AR-8952ML-05R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 3MM 5HL TI STR -,SUP-AR-8952TS-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CALCFX PERCPLT STD ANTERIOR PROCESS L -,SUP-AR-8954ML-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE LONG CALCANEUS RIGHT TUBEROSITY 3.5/4 MM PERCUTANEOUS -,SUP-AR-8954YR-L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE TAP CANNULATED 6.0MM -,SUP-AR-8956C-60T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE LONG METATARSAL RIGHT HOOK -,SUP-AR-8956R-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2 HOLE TITANIUM -,SUP-AR-8958-02S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANTEROLATERAL PILON FUSION PLATE 5 HOLE LT -,SUP-AR-8963ALF-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12624.2,8836.94,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANTEROLATERAL PILON FUSION PLATE 7H RT -,SUP-AR-8963ARF-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.7X65MM CANN 18MM THRD SD/ST TI -,SUP-AR-8967-1865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO 13MM TI -,SUP-AR-8967W,CDM,C1713,HCPCS,278,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
KIT DX SWIVELOCK SL 3.5X8.5MM -,SUP-AR-8978DS-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SWIVELOCK DX SL 3.5 X 8.5 -,SUP-AR-8978P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SYSTEM INTERNAL FIXATION FIBERLOCK SUSPENSION  3.5 X 8.5 -,SUP-AR-8988-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5889.19,4122.433,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUTURE FIBER TAK DX -,SUP-AR-8990ST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2464.73,1725.311,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR FIBERTAK DOUBLE-LOADED DX SUTURE -,SUP-AR-8990ST-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2878.72,2015.104,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DX FIBERTAK SUTURE ANCHOR #2 MTS W/NDL -,SUP-AR-8991,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SWIVELOCK DISP KIT NANO 2.5 X 7 -,SUP-AR-8998DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NANO SWIVELOCK 2.5 X 7 WITH FORK EYELET -,SUP-AR-8998T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X45MM P/T TI F /5TH MTRSL JONES FX SYS -,SUP-AR-9045-45PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X55MM P/T TI GRN -,SUP-AR-9045-55PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LO-PRO SCREW PT THREADED TI 5.5MM X 40MM -,SUP-AR-9055-40PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LO-PRO SCRW PT THD TI 6.0MM X 40MM -,SUP-AR-9060-40PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCK GLENOID PERIPH -,SUP-AR-9145-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CENTRAL NL 6.5 X 25MM -,SUP-AR-9165-25NL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BC ACHILLES SPDBRG W/KL DX CC 3.9MM -,SUP-AR-9928BCK-DX,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10749.14,7524.398,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LP SCREW 3 X 18MM CORTICAL MTP TI -,SUP-AR-9933-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LP SCREW 3 X 20MM CORTICAL MTP TI -,SUP-AR-9933-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LP 3.0 X 22MM CORTICAL MTP TI -,SUP-AR-9933-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LP 3.0 X 24MM CORTICAL MTP TI -,SUP-AR-9933-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LP SCREW 3 X 16MM CORTICAL HYBRID MTP TI -,SUP-AR-9933HY-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCK MED HOOK PLATE TI 3H -,SUP-AR-9943H-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
MAXFORCE MTP PLATE PETITE 0-0 RIGHT -,SUP-AR-9944P-0R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE MAXFORCE STD 5-5 RIGHT MTP -,SUP-AR-9944S-5R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 12.5MM CANN HDLS ACUTRAK STD TI ALY -,SUP-AT-1125-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.3-3.8X15MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI -,SUP-AT-1150-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.3-3.9MM 17.5MM CANN HDLS ACUTRAK FT ST STD 2MM HX -,SUP-AT-1175-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 20MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI ALY -,SUP-AT-1200-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.3-4.2MM 22.5MM CANN HDLS ACUTRAK FT ST STD 2MM HX -,SUP-AT-1225-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.3-4.4X25MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI -,SUP-AT-1250-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.3-4.5MM 27.5MM CANN HDLS ACUTRAK FT ST STD 2MM HX -,SUP-AT-1275-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.3-4.6X30MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI -,SUP-AT-1300-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5-2.8 MMX8MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5-2.8 MMX9MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5-2.8 MMX12MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5-2.8 MMX14MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5-2.8 MMX16MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5-2.8 MMX18MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5-2.8 MMX20MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5-2.8 MMX26MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5-2.8 MMX28MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5-3.6 MMX16MM CANN HDLS ACUTRAK 2 FT SLF CT 2MM HX -,SUP-AT2-M16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5-3.6 MMX22MM CANN HDLS ACUTRAK 2 FT SLF CT 2MM HX -,SUP-AT2-M22-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5-3.6 MMX24MM CANN HDLS ACUTRAK 2 FT SLF CT 2MM HX -,SUP-AT2-M24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4-4.1X16MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT STD -,SUP-AT2-S16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4-4.1X26MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT STD -,SUP-AT2-S26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4-4.1X34MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST CUT STD -,SUP-AT2-S34-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3-2.5X24MM CANN HDLS ACUTRAK FUSION FT ST 1.5MM/2MM -,SUP-ATF-240-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1966.49,1376.543,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3-3.5X32MM CANN HDLS ACUTRAK FUSION FT ST 1.5MM/2MM -,SUP-ATF-320-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1966.49,1376.543,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.8-3.2 MMX10MM CANN HDLS ACUTRAK FT ST 1.5MM HX DRV -,SUP-ATM-100-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
UNIVERSAL CEMENT RESTRICOTR SM 18.5MM -,SUP-B000-0185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
RESTRICTOR CMNT UNIV 24MM OSTEONICS -,SUP-B000-0240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
RESTRICTOR CEMENT UNIVERSAL SMALL INSERTER -,SUP-B000-1185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
RESTRICTOR CMNT MED UNIV STRL -,SUP-B000-1240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
RESTRICTOR BNCMNT 11MM -,SUP-B0010110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
RESTRICTOR BNCMNT 15.5MM -,SUP-B0020125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
RESTRICTOR BNCMNT 14MM -,SUP-B0030140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5MMX110MM CANC DYNFX 50MM THRD TAPR -,SUP-B6011050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EXTFIX 6/5MM DIA 130/ 60MM CORT/CANC TAPR DYNFX THRD -,SUP-B6013060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,485.47,339.829,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TITAN REV SHOULDER LARGE -,SUP-BBS-0960-21LRG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
REVERSE BODY SMALL AND REVERSCE BODY SCREW -,SUP-BBS-0960-21SML,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BALLOON 6FR PTA 200CM X 3MM X 120MM METACROSS -,SUP-BD-P30150ER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
AFX2 BIFURCATED ENDOGRAFT SYSTEM -,SUP-BEA25-80/I13-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
STENT BIFURCATED ENDOGRAFT AFX2  28MM X 80MM -I16-40 -,SUP-BEA28-80/I16-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,37002.53,25901.771,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN TRIMED VOLAR BUTT 20 -,SUP-BP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
RSS BODY SCREW -,SUP-BSC-0960-021-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TI F/TITAN MODLR SHLDR SYS -,SUP-BSW-0920-021-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,758.61,531.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
MIXER CEMENT KYPHON W  CEMENT -,SUP-C01B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,919.01,643.307,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
"K-WIRE PIN COVER .028"" -",SUP-C-028NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X12MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-C03120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X16MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-C03160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
"K-WIRE PIN COVER .035"" -",SUP-C-035NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
"K-WIRE PIN COVER .045"" -",SUP-C-045NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
"K-WIRE PIN COVER .054"" -",SUP-C-054NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
"K-WIRE PIN COVER .062"" -",SUP-C-062NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
EXTERNAL FX 0.375IN BALL COLR F/CAP VRS SZ K-WIRE -,SUP-C50-COL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.5,771.75,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4X14MM LCK CANC ACU-LOC 2 HEX HEAD TI NS F/MAYO -,SUP-CA-4140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,542.66,379.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFT CANC 30ML CHP RDIGRF FRZDR CRSH VOID FIL 1-8MM -,SUP-CAN30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1984.24,1388.968,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
EXPERT KNEE CAPITATED REVISION SYSTEM -,SUP-CAP PRICE,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21164.1,14814.87,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CEMENT CARTRIDGE CC02A CDS -,SUP-CC02A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DISC CERVICAL SIZE 6MM LL M6 -,SUP-CDL-637L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CERVICAL DISC SIZE 6MM M6 ORTHOFIX -,SUP-CDM-625,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CERVICAL DISC 6 MEDIUM LONG ARTIFICIAL -,SUP-CDM-635L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CEMENT GUN AND BONE FILLER CDS2A SIZE 2 -,SUP-CDS2A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2361.37,1652.959,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
EXCLUDER ILIAC 23MM X 10MM X 10CM 16FR BRANCH ENDO -,SUP-CEB231010A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31520.86,22064.602,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT VARILIFT- C STND ALONE XPD -,SUP-CIC1-7.5-12-BP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5835.5,4084.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE VARILIFT- C ST -,SUP-CIC1-9.0-12-BP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5835.5,4084.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
KT SUTURE REM SUT PRB KNT PSHR/CTR INTRO CROSSFIX II DISP -,SUP-CM-8000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DEVICE MENISCOTOME UP CRV STRONGER STF NDL HI STRGTH SUT -,SUP-CM-8002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR JK 2.9 SL WT/BL NS BK JUGGERKNOT -,SUP-CM-99329B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2067.2,1447.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR JK 2.9 BDL WT/BL NS BKLU BB JUGGERKNOT -,SUP-CM-99429B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2067.2,1447.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X12MM NLCKG CORT ACU-LOK 2 TI NS F/MAYO -,SUP-CO-2712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X14MM NLCKG CORT ACU-LOK 2 TI NS F/MAYO -,SUP-CO-2714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X16MM NLCKG CORT ACU-LOK 2 TI NS F/MAYO -,SUP-CO-2716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X20MM NLCKG CORT ACU-LOC 2 TI NS F/MAYO -,SUP-CO-2720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X22MM NLCKG CORT ACU-LOC 2 TI NS F/MAYO -,SUP-CO-2722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X6MM NLCKG CORT ACU-LOK 2 TI NS -,SUP-CO-3060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X10MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X12MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X14MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X16MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X24MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X25MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X26MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X28MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X30MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X32MM NLCKG CORT ACU-LOC 2 POLARUS TI NS COLR -,SUP-CO-3320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X12MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X14MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X16MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.7X18MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X8MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X10MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X12MM LCK CORT -,SUP-COL-3120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X14MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X20MM LCK CORT FT TI F/MAYO PLATE/MODULAR/UNIV SYS -,SUP-COL-3200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X22MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORITICAL LOCKING TI 3.5 X 13MM -,SUP-COLS -35130-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW GEMINUS CORTICAL LOCKING 3.5MM X 8MM TI -,SUP-COLS-35080-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL LOCKING 3.5 X 9 -,SUP-COLS-35090-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL LOCKING 3.5 X 10 -,SUP-COLS-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL LOCKING 3.5MM X 11MM -,SUP-COLS-35110-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL LOCKING 3.5MM X 12MM -,SUP-COLS-35120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW- CORTICAL LOCKING 3.5MM X 12MM -,SUP-COLS-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORT LOCKING 3.5MM X 15MM -,SUP-COLS-35150-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL LOCKING 3.5MM X 16MM -,SUP-COLS-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL LOCKING 3.5 X 18 -,SUP-COLS-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL LOCKING 3.5MM X 20MM TI -,SUP-COLS-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL LOCKING 3.5 X 24 -,SUP-COLS-35240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL LOCKING 3.5 X 26 -,SUP-COLS-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X14MM CORT ACU-LOC 2 FT NTOGG TI NS F/UNIV SYS -,SUP-CO-N2314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X22MM CORT ACU-LOC 2 FT NTOGG TI NS F/UNIV SYS -,SUP-CO-N2322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X14MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X16MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X18MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.3X20MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
RTR CROSS CONNECTOR -,SUP-CPF-CR 26 32-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CROSS CONNECTOR 32-44 -,SUP-CPF-CR 32 44-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 3.5 X 12 -,SUP-CPF-CS 35 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CC PREFERRED ANGLE 3.5 X 14 -,SUP-CPF-CS 35 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CC PREFERRED ANGLE 3.5 X 18 -,SUP-CPF-CS 35 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CC PREFERRED ANGLE 3.5 X 20 -,SUP-CPF-CS 35 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LARGE OFFSET -,SUP-CPF-LC 00 0L-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SPINEART ML PREFERRED ANGLE 4MM X 12MM -,SUP-CPF-MS 04 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ML PREFERRED ANGLE SCRE 4 X 16 -,SUP-CPF-MS 04 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ML PREFERRED ANGLE SCRE 4 X 18 -,SUP-CPF-MS 04 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ML PREFERRED ANGLE 4 X 20 -,SUP-CPF-MS 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ML PREFERRED ANGLE 4 X 24 -,SUP-CPF-MS 04 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPINEART PERLA ML PREFERRED ANGLE SCREW 4 X 28 -,SUP-CPF-MS 04 28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ML PREFERRED 3.5 X 12 -,SUP-CPF-MS 35 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ML 35 X 14 -,SUP-CPF-MS 35 14S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW PERLA ML PREFERRED ANGLE 3.5MM X 16MM -,SUP-CPF-MS 35 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ML PREFERRED 3.5 X 18 -,SUP-CPF-MS 35 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ML 35 X 20 -,SUP-CPF-MS 35 20S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ML 35 X 24 -,SUP-CPF-MS 35 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SPINEART ML PREFERRED ANGLE 4MM X 14MM -,SUP-CPF-MS-04 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CONNECTOR PARALLEL 3-3 -,SUP-CPF-PC 30 3C-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CONNECTOR PARALLEL 3-5 -,SUP-CPF-PC 3C 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD PERLA 90MM TI -,SUP-CPF-PF T0 90-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PREBENT ROD COBALT CHROMIUM 45MM -,SUP-CPF-PR C0 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD PREBENT TITANIUM 3.5 X 40MM -,SUP-CPF-PR T0 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 50MM -,SUP-CPF-PR T0 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 60MM PREBENT TITANIUM -,SUP-CPF-PR T0 60-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PERLA PREBENT ROD TITANIUM 3.5 X 65MM -,SUP-CPF-PR T0 65-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 70MM -,SUP-CPF-PR T0 70-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PERLA PREBENT ROD TITANIUM 3.5 X 75MM -,SUP-CPF-PR T0 75-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD PREBENT TITANIUM 3.5 L80 -,SUP-CPF-PR T0 80-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 85MM -,SUP-CPF-PR T0 85-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 45MM -,SUP-CPF-PR TO 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PREBENT TITANIUM ROD 3.5 X L12 PERLA -,SUP-CPF-PR TO 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD PREBENT TITANIUM 55MM -,SUP-CPF-PR TO 55-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 60MM -,SUP-CPF-PR TO 60-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PRE-BENT ROD 3.5 X 90MM -,SUP-CPF-PR TO 90-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLY PERLA 4 X 10MM -,SUP-CPF-PS 04 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PERLA SCREW 12MM -,SUP-CPF-PS 04 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL PERLA 4MM X 12MM -,SUP-CPF-PS 04 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL 4MM X 14MM -,SUP-CPF-PS 04 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL 4 X 16 -,SUP-CPF-PS 04 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLY 4 X 18MM -,SUP-CPF-PS 04 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL PERLA 4MM X 20MM -,SUP-CPF-PS 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLY PERLA 4.0 X 24MM -,SUP-CPF-PS 04 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE PERLA 4MM X 32MM SPINE POLYAXIAL -,SUP-CPF-PS 04 32-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PERLA POLYAXIAL SCREW 3.5 X 10MM -,SUP-CPF-PS 35 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLY 3.5 X 12MM PERLA -,SUP-CPF-PS 35 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW PERLA 3.5 X 14 -,SUP-CPF-PS 35 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.5 x 16MM POLY SCREW -,SUP-CPF-PS 35 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLY 3.5 X 18MM PERLA -,SUP-CPF-PS 35 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PERLA POLYAXIAL SCREW 3.5 X 20MM -,SUP-CPF-PS 35 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
POLYAXIAL SCREW 3.5 X 24 -,SUP-CPF-PS 35 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLY PERLA 3.5MM X 28MM -,SUP-CPF-PS 35 28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
POLYAXIAL SCREW 3.5 X 12 -,SUP-CPF-PS 3512-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
POLYAXIAL SCREW 4.0 X 28 -,SUP-CPF-PS-0428-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.5 X 28 POLY SCREW -,SUP-CPF-PS-3528-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREWS SET PERLA -,SUP-CPF-SC 00 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPINEART STRAIGHT ROD CHROMIUM 350MM -,SUP-CPF-SR C3 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD TITANIUM 40MM -,SUP-CPF-SR CO 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD TITANIUM 80MM -,SUP-CPF-SR T0 80-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PERLA STRAIGHT ROD TITANIUM 03.5 L100 -,SUP-CPF-SR T1 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD TI 120MM -,SUP-CPF-SR T1 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 240 -,SUP-CPF-SR T2 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SMOOTH SHANK SCREW 4MM Z 20 -,SUP-CPF-SS 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SS 3.5 X 20 -,SUP-CPF-SS 35 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SS 3.5 X 22 -,SUP-CPF-SS 35 22-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SS 3.5 X 24 -,SUP-CPF-SS 35 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREWS SS 3.5 X 26 -,SUP-CPF-SS 35 26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.5 x 28MM SMOOTH SHANK -,SUP-CPF-SS 35 28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SS 3.5 X 34 -,SUP-CPF-SS 35 34-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.5 X 30MM POLY SCREW -,SUP-CPF-SS-35 30-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X12MM CORT DVR FT CRUCIF HEAD MAG -,SUP-CS12000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X16MM CORT DVR FT CRUCIF HEAD MAG -,SUP-CS16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X18MM CORT DVR FT CRUCIF HEAD MAG -,SUP-CS18000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFT STRUT MATRGRF FRZDR 15X100MM -,SUP-CST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3457.04,2419.928,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE CEMENT CX01B XPEDE W MIXER US -,SUP-CX01B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1598.1,1118.67,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
HEADLESS 3.0X40 SCREW -,SUP-D2N30040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.61,678.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TORNIER LONG HUMERAL NAIL LEFT 7MM X 230MM -,SUP-DHN5796,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13273.98,9291.786,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DISTAL HUMERUS MEDIAL DIRECT 105MM -,SUP-DHPF-MDL-5HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN SCREW DISTRACTION 12MM -,SUP-DP-12-TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,145.88,102.116,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN SCREW DISTRACTION 14MM -,SUP-DP-14-TY,CDM,C1713,HCPCS,278,RC,,,outpatient,,,145.88,102.116,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ULNAR STEM 6.0MM 2CM EXT STEM -,SUP-DRUJ-IS260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9932.28,6952.596,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING RADIAL PLATE SZ 20-15MM ASSY -,SUP-DRUJ-LP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19433.84,13603.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
14MM 3.5 LOCKING SCREW -,SUP-DRUJ-LSC14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,799.4,559.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
20MM 3.5 LOCKING SCREW -,SUP-DRUJ-LSC20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,799.4,559.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
22MM 3.5 LOCKING SCREW -,SUP-DRUJ-LSC22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,799.4,559.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
20MM 3.5 CORTICAL SCREW -,SUP-DRUJ-SC20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,636.02,445.214,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW DISTAL TROCHLEA COMP 3.5 X 45 TI -,SUP-DTCS-35045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW DISTAL TROCHLEA COMP 3.5 X 50 -,SUP-DTCS-35050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN DVR 24.4MMX51.3MM 4HL STD SHRT NS LT -,SUP-DVRAL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN DVR ANTMC NRW -,SUP-DVRANR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3828.27,2679.789,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN DVR 21.6MMX48.9MM 4HL SHRT BTRSS NRW NS -,SUP-DVRANSL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN DVR 21.6MMX48.9MM 4HL SHRT NS -,SUP-DVRANSR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN DVR 24.4MMX51.3MM 4HL STD SHRT NS RT -,SUP-DVRAR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN DVR 24.4MMX51.3MM 4HL STD SHRT NS RT RADL -,SUP-DVRASR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN DVR 28.2MMX62.6MM 4HL W NS -,SUP-DVRAWL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN DVR 28.2MMX62.6MM 4HL W BTRSS NS -,SUP-DVRAWR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN DVR 24.4MMX89.5MM 4HL EXTEND XLNG BTRSS NS -,SUP-DVRAXL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN DVR 24.4MMX59.5MM 4HL NS LT -,SUP-DVR-L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TORNIER PERFORM REVERESED CTRSCREW 6.5MM X 25MM NON ST -,SUP-DWJ125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TORNIER PERFORM REVERSED PERIPSCREW 5.0MM X 14MM NON ST -,SUP-DWJ314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1144.91,801.437,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TORNIER PERFORM REVERSED PERIPSCREW 5.0MM X 18MM NON ST -,SUP-DWJ318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1144.91,801.437,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
RESTRICTOR HUM CMNT 24MM F/TOT ELB PROS LTD -,SUP-EB0101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1166.11,816.277,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
RESTRICTOR CMNT TORNIER -,SUP-EBO101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1293.32,905.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ROMEO POLYAXIAL 6 X 40 -,SUP-ELL-PS 06 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X25MM SIGNTR POLYAX FX F /ROMEO PDCL SYS TI ALY -,SUP-ELL-PS0525-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X30MM SIGNTR POLYAX FX F /ROMEO PDCL SYS TI ALY -,SUP-ELL-PS0530-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL 5 X 35 -,SUP-ELL-PS0535-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL 6 X 30 -,SUP-ELL-PS0630-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6X35MM SIGNTR POLYAX FX F /ROMEO PDCL SYS TI ALY -,SUP-ELL-PS0635-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 30MM -,SUP-ELL-RD 00 30 S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD ROMEO STRAIGHT HEX TIP 0.54 L240 -,SUP-ELL-RD 22 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPIN ROMEO 5.4X50MM PREBNT TI LMBR SFT MLBL F/TRNSCONN -,SUP-ELL-RD0050-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SET SCREW SPIN ROMEO2 -,SUP-ELL-SC 00 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFT STENT 49E X 36MM X 36MM ENDURANT II AO EXT -,SUP-ETCF3636C49E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18052.61,12636.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
STENT ENDURANT II GRAFT 16F X 16MM X 146MM LIMB -,SUP-ETLW1616C146E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFT STENT ENDUR II LIMB ELTW1620C146E -,SUP-ETLW1620C146E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
INFRAME IMPLANT 2.0MM X 32MM -,SUP-EXINF922032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
INFRAME EXSOMED IMPLANT 2.0MM X 36MM -,SUP-EXINF922036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6972.89,4881.023,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
INNATE IMPLANT 3.6MM X 35MM -,SUP-EXINN923635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL INTRAMEDULLARY INNATE IMPLANT 3.6MM X 40MM -,SUP-EXINN923640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
INNATE IMPLANT 3.6MM X 50MM -,SUP-EXINN923650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL INTRAMEDULLARY INNATE IMPLANT 3.6MM X 55MM -,SUP-EXINN923655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL INTRAMEDULLARY INNATE IMPLANT 4.5MM X 45MM -,SUP-EXINN924545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL INNATE IMPLANT 4.5MM X 50MM -,SUP-EXINN924550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
INNATE IMPLANT 4.5 X 55 -,SUP-EXINN924555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
STRYKER EASY CLIP STAPLE -,SUP-EZ 20-20-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9747.74,6823.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
EASYCLIP 15 X 15 X 15 -,SUP-EZ15-15-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8823.28,6176.296,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
EASYCLIP FIXATION DEVICE 18 X 19 X 17 -,SUP-EZ18-19-17,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8823.28,6176.296,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
EASYCLIP FIXATION DEVICE 20 X 20 X 20 -,SUP-EZ20-20-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9747.74,6823.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
EASYCLIP 8 X 8 X 8MM -,SUP-EZM08-08-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6512.42,4558.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE FILLER DEVICE SIZE 3 -,SUP-F04B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,577.67,404.369,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DEVICE BN FIL FEM SZ2 KYPHX EXP STRL -,SUP-F06A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,577.67,404.369,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHOFIX 8.5 CAGE -,SUP-F28-3182,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SHAFT FROZEN BISECTED FEM -,SUP-FBFS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4383.06,3068.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CLAMP CRANIAL 11MM CRANIOFIX -,SUP-FF490T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,695.9,487.13,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CLAMP CRANIAL 16MM TITANIUM CRANIOFIX 2 -,SUP-FF491T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,862.41,603.687,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CLAMP CRANIAL 20MM TITANIUM CRANIOFIX 2 -,SUP-FF492T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1035.56,724.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FREEFIX  COMPRESSION 3.5MM X 20MM TI -,SUP-FFC-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FREEFIX COMPRESSION 3.5MM X 22MM TI -,SUP-FFC-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FREEFIX COMPRESSION 3.5MM X 24MM TI -,SUP-FFC-35240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FREEFIX COMPRESSION 4.5MM X 20MM TI -,SUP-FFC-45200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1009.46,706.622,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FREEFIX COMPRESSION 4.5MM X 20MM TI -,SUP-FFC-45240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1009.46,706.622,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFT HUMAN TISSUE FEMORAL HEAD 43MM -,SUP-FFH,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4839.09,3387.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFT HUMAN TISSUE FEMORAL HEAD 43MM -,SUP-FFH,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4839.09,3387.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WEDGE FIBULA 18MM FROZEN -,SUP-FFIBW8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2636.84,1845.788,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FREEFIX LOCKING 3.5MM X 20MM TI -,SUP-FFL-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FREEFIX LOCKING 3.5MM X 22MM TI -,SUP-FFL-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FREEFIX LOCKING 3.5MM X 26MM TI -,SUP-FFL-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FREEFIX LOCKING 4.5MM 22MM TI -,SUP-FFL-45220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PRESUTURED ALLOGRAFT -,SUP-FGL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9411.49,6588.043,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFT HUM TIS SPCR FRZN FLEXIGRAFT MNSCS R/M LF -,SUP-FMNRM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14676.34,10273.438,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X8MM LCK FT TI ALPS -,SUP-FP08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X10MM LCK FT TI ALPS NS -,SUP-FP10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X11MM LCK FT TI ALPS NS -,SUP-FP11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X12MM LCK FT TI ALPS NS -,SUP-FP12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X13MM LCK FT TI ALPS NS -,SUP-FP13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X14MM LCK FT TI ALPS -,SUP-FP14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X15MM LCK FT TI ALPS -,SUP-FP15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X16MM LCK FT TI ALPS -,SUP-FP16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2X18MM LCK FT TI DVR NS -,SUP-FP18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X20MM LCK FT TI DVR NS -,SUP-FP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X22MM LCK FT TI F3 NS -,SUP-FP22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X24MM LCK FT TI ALPS -,SUP-FP24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X26MM LCK FT TI ALPS NS -,SUP-FP26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X28MM LCK FT TI ALPS -,SUP-FP28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X30MM LCK FT TI F3 NS -,SUP-FP30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFT HUM TIS FRZN 230CM 7.5MM FLEXIGRAFT PRNS LONGUS TNDN -,SUP-FPLT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.1,4960.97,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 120MM -,SUP-G100-5-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 200MM -,SUP-G100-5-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 400MM -,SUP-G100-5-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 6.0MM STRAIGHT -,SUP-G100-5-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 100MM -,SUP-G150-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TIROD 200MM STRAIGHT -,SUP-G150-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 30MM -,SUP-G150-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 35MM -,SUP-G150-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 40MM CURVED -,SUP-G150-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD CURVED 40MM -,SUP-G150-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 45MM -,SUP-G150-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD CURVED 50MM -,SUP-G150-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 55MM -,SUP-G150-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD CURVED 60MM -,SUP-G150-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 65MM GENESYS -,SUP-G15065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 70MM GENESYS -,SUP-G150-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 75MM -,SUP-G150-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 80MM GENESYS -,SUP-G150-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 85MM SPINAL -,SUP-G150-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 90MM -,SUP-G150-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 95MM -,SUP-G150-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 300MM GENESYS -,SUP-G300-5-300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CONNECTOR CROSS LINK LARGE -,SUP-G301-LRG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CROSSLINK MED -,SUP-G301-MED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CROSS LINK -,SUP-G301-SM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
27-35MM CC -,SUP-G301-XSM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
COIL MICRONESTER EMBOLIZATION 0.018 X 7CM X 6MM -,SUP-G52738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,916.1,641.27,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS COMP. 4.0MM 36M -,SUP-G58036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 5.5 X 30MM -,SUP-G700-55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 6.5 X 35MM -,SUP-G700-65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5 X 30MM GENESYS -,SUP-G701-55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW PEDICLE 5.5 X 35MM TI LO -,SUP-G701-55-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW PEDICLE 5.5MM X 40MM -,SUP-G701-55-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TI LOCK 5.5 X 45MM -,SUP-G701-55-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW PEDICLE 6.5 X 30MM -,SUP-G701-65-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW PEDICLE 6.5 X 35MM -,SUP-G701-65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW PEDICLE 6.5 X 40MM -,SUP-G701-65-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TI LOCK 6.5 X 45MM -,SUP-G701-65-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
6.5 X 50MM PEDICLE SCREW -,SUP-G701-65-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TI-LOCK 7.5 X 30MM -,SUP-G701-75-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TI-LOCK 7.5 X 35MM -,SUP-G701-75-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW PEDICLE 7.5 X 40MM -,SUP-G701-75-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TI-LOCK 7.5 X 45MM -,SUP-G701-75-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
7.5 X 50MM PEDICLE SCREW -,SUP-G701-75-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8.5MM X 70MM -,SUP-G701-85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CROSSLINK -,SUP-G701-XSM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MM X 25MM -,SUP-G702-45-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5MM X 30MM -,SUP-G702-45-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 5.0 X 25MM -,SUP-G702-50-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 5.0 X 30MM NEW -,SUP-G702-50-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CORTICAL SCREW 25 X 5.5MM -,SUP-G7025525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 5.5 X 25 -,SUP-G702-55-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5 X 45 GENESYS -,SUP-G702-55-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 6.5 X 40MM -,SUP-G702-65-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 7.5 X 45 -,SUP-G702-75-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 8.5MM X 45MM -,SUP-G710-85-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ILIAC 8.5 X 60 -,SUP-G710-85-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SPINE 8.5 X 70 -,SUP-G710-85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SPINE 8.5 X 80 -,SUP-G710-85-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HI TOP 6.5 X 35 -,SUP-G711-65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ILIAC 8.5 X 70 -,SUP-G741-85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
OFFSET -,SUP-G780-21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
OFFSET 61 -,SUP-G780-61,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAP CIRCULAR TI LOCKING -,SUP-G826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SET 8.5 -,SUP-G826-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAP LOCKING TI -,SUP-G828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SET CAPS -,SUP-G828-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 5MM SMALL -,SUP-GAC-05-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR APACHE CAGE 7MM -,SUP-GAC-07-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
APACHE CAGE ANCHORED 8MM -,SUP-GAC-08 SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE H8 -,SUP-GAC-08-SC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
APACHE ANCHORED 8MM -,SUP-GAC-08-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 9MM -,SUP-GAC-09-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE APACHE ANCHORED 10MM -,SUP-GAC-10SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
APACHE ANCHORED 6MM -,SUP-GAC3D06-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
APACHE ANCHOR LARGE -,SUP-GAC-LG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR MEDIUM -,SUP-GAC-MD,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SMALL -,SUP-GAC-SM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR GREEN XL -,SUP-GAC-XL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR XXL BROWN -,SUP-GAC-XXL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BUTTRES 22MM -,SUP-GBP1-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 22MM 5.5 -,SUP-GBP1-2255,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
9mm CERVICAL PECK CAGE APACHE -,SUP-GCL-09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE SMALL APACHE 11MM -,SUP-GCL-11-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 12MM -,SUP-GCP10012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 14MM RESCU -,SUP-GCP10014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 14MM -,SUP-GCP10014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 16MM -,SUP-GCP10016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 35MM -,SUP-GCP20035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BINARY 12MM -,SUP-GCP2-112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 14MM -,SUP-GCP2-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 16MM -,SUP-GCP2-116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CERVICAL 49MM -,SUP-GCP2-349,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.75MM X 16MM BINARY AUGER TIP FIXED -,SUP-GCP2-AF316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREWS 3.75 X 14MM SCREWS -,SUP-GCP2-AV314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.75MM X 18MM BINARY AUGER TIP VAIABLE -,SUP-GCP2-AV318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREWS 4.25 X 12MM -,SUP-GCP2-AV412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW FIXED CERV 3.75 X 14MM -,SUP-GCSF37514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BN 14MM -,SUP-GCSV37514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW VA 16MM -,SUP-GCSV37516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW RESCUE 16MM -,SUP-GCSV42516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
APACHE ANCHOR 6MM -,SUP-GCV-06-SO,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE APACHE 6MM -,SUP-GCV-06-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE APACHE ANCHORED 8MM -,SUP-GCV-08-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE APACHE ANCHORED 9MM -,SUP-GCV-09-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR LARGE -,SUP-GCV-LG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDE PIN 2.0MM X 125MM -,SUP-GDW-890-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.44,297.108,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
6.5 X 40MM PEDICLE SCREW -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CERVICAL APACHE CAGE 8MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 7.5 X 30MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BINARY 2 LEVEL CERVICAL 30MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CERVICAL 2 LEVEL 32MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW REDUCTION 6.5 X 30MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE STANDARD 31MM -,SUP-GLP-131,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 22MM -,SUP-GLPV-55 22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPINE 60MM -,SUP-GM150-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SET SCREW -,SUP-GM520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
MODULAR CORT IMPLANT HEAD -,SUP-GM557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
MODULAR LOCK SCREW -,SUP-GM820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DORSAL SPANNING SHORT -,SUP-GMN-DSP-160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6217.46,4352.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BONE GEMINUS TITANIUM DORSAL SPANNING LONG -,SUP-GMN-DSP-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6416.93,4491.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BONE GEMINUS TITANIUM RADIAL DISTAL DORSAL HOOK -,SUP-GMN-HP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2592.28,1814.596,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW PLATE BONE GEMINUS TITANIUM RADIAL DISTAL DORSAL HOOK -,SUP-GMN-HP-SCRW,CDM,C1713,HCPCS,278,RC,,,outpatient,,,566,396.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ASSEMBLED GEMINUS VOLAR DISTAL RADIUS PLATE NARR 120MM LEFT -,SUP-GMN-LTN-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9969.16,6978.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DIST RAD NARR 3 HOLE LEFT GEMINUS VOLAR -,SUP-GMN-LTN-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE NARROW DIS RAD 4 HOLE LEFT -,SUP-GMN-LTN-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE VOLAR DIST RAD STANDARD 3 HL LEFT -,SUP-GMN-LTS-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE GEMINUS VOLAR DISTAL RADIUS STANDARD 4 HOLE LEFT -,SUP-GMN-LTS-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE ASSEMBLED GEMINUS VOLAR DIST RAD NARROW 120MM RIGHT -,SUP-GMN-RTN-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9969.16,6978.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE VOLAR DISTAL RADIUS NARROW 3 HOLE RIGHT -,SUP-GMN-RTN-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DISTAL RADIUS PLATE- NARROW 4 HOLE RT. -,SUP-GMN-RTN-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE VOLAR DIST RADIUS STD 3 HOLD RIGHTTI GEMINUS -,SUP-GMN-RTS-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DISTAL RADIUS VOLAR GEMINUS WIDE 4HL RIGHT -,SUP-GMN-RTW-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4621.72,3235.204,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5 X 30 -,SUP-GMSD 55 30-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5 X 45 -,SUP-GMSD 55 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 4.5 X 30MM -,SUP-GMSD45-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5 X 35 -,SUP-GMSD-50 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 5.0 X 30MM -,SUP-GMSD50-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 5.0 X 35MM NEW -,SUP-GMSD50-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.0 X 4.0 -,SUP-GMSD50-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 55 X 35 -,SUP-GMSD-55 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 5.5 X 30 -,SUP-GMSD55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CORTICAL MODULAR SCREW 5.5 X 35 -,SUP-GMSD55-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 5.5 X 35 -,SUP-GMSD55-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL SPINE 5.5 X 40 -,SUP-GMSD55-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 5.5 X 45 -,SUP-GMSD55-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 6 X 35 -,SUP-GMSD-60 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 6 X 30 -,SUP-GMSD60-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GENESYS CORTICAL SCREW 6.5MM X 35MM -,SUP-GMSD60-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CORTICAL SCREW 6 X 35 -,SUP-GMSD60-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MODULAR 6.0 x 40 -,SUP-GMSD60-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 65 X 35 -,SUP-GMSD-65 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORITCAL SPINE 6.5 X 35 -,SUP-GMSD65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL SPINE 6.5 X 40 -,SUP-GMSD65-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 6.5 X 45 -,SUP-GMSD65-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW GENESYS MODULAR 6.5 X 50MM -,SUP-GMSD65-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 7.5 X 40 -,SUP-GMSD75-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 75 X 45 -,SUP-GMSD75-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 75 X 50 -,SUP-GMSD75-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 8.5 X 70 -,SUP-GMSD85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5 X 30 -,SUP-GMSP55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.0 X 30 -,SUP-GMSP60-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2-PIECE PIN TIP SECTION-TROCAR TIP -,SUP-GSI209-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,571.83,400.281,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2-PIECE PIN-TAIL SECTION 750MM W/TIP -,SUP-GSI210-02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2P PIN TAIL -,SUP-GSI210-02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
350 TROCAR PIN -,SUP-GSI211-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 9.5 X 35 -,SUP-GSI-SDW09535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 9.5 X 40 -,SUP-GSI-SDW09540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 9.5 X 40 -,SUP-GSI-SDW09545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 9.5 X 60 SI SUAL THREAD WASHER HEAD -,SUP-GSI-SDW09560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
POSTERIOR ALLOGRAFT 20MM -,SUP-GSPA-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
APACHE ANCHOR 8MM -,SUP-GVC-08-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
APACHE ANCHORED 9MM -,SUP-GVC-09-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDE PIN 2.0MM X 150MM -,SUP-GW0920061501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,306.34,214.438,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE CAN PT TI 4.0 X 26MM -,SUP-H00693,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE CAN PT TI 4.0 X 24MM -,SUP-H00693,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X40MM CANC POLARUS FT CNTRSNK TI NS -,SUP-HCA-5140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5X45MM CANC POLARUS FT CNTRSNK TI NS -,SUP-HCA-5145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.3X35MM LCK CANC POLARUS FT TI STRL -,SUP-HCA-L5335-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.3X40MM LCK CANC POLARUS FT TI STRL -,SUP-HCA-L5340-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.3X45MM LCK CANC POLARUS FT TI STRL -,SUP-HCA-L5345-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG HIGH COMPRESSION LOCKING 2.7 X 18 -,SUP-HCLP-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG HIGH COMPRESSION LOCKING 2.7MM  X 19MM TI -,SUP-HCLP-27190-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG HIGH COMPRESSION LOCKING 2.7MM  X 20M TI -,SUP-HCLP-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG HIGH COMPRESSION LOCKING 2.7MM  X 21M TI -,SUP-HCLP-27210-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
HIGH COMP PEG LCK 2.7 X 22 -,SUP-HCLP-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
HIGH COMPRESSION LOCKING PEG 2.7MM X 28MM TI -,SUP-HCLP-27280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X20MM NLCKG CORT POLARUS TI STRL -,SUP-HCO3200-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X25MM NLCKG CORT POLARUS TI STRL -,SUP-HCO3250-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MMX32.5MM NLCKG CORT POLARUS TI STRL -,SUP-HCO3325-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS COMP 2.5 X 14 -,SUP-HCS-25014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS COMP 2.5 X 16 -,SUP-HCS-25016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS COMPRESSION 2.5MM X 18MM -,SUP-HCS-25018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS COMP 2.5MM X 22MM TI -,SUP-HCS-25022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS COMP 2.5MM X 24MM TI -,SUP-HCS-25024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS COMP 2.5MM X 26MM TI -,SUP-HCS-25026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS COMPRESSION 2.5MM X 30MM -,SUP-HCS-25030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD IM 8X240MM POLARUS + CANN TAPR PRFL HUM TI STAB -,SUP-HR-0824-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9312.2,6518.54,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD IM 11X150MM POLARUS PROX HUM -,SUP-HR-L1115-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10452.97,7317.079,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADED 2.5 X 12MM -,SUP-IC2512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.5MM HEADED SCREW LENGTH 14MM -,SUP-IC2514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE MINI HEADED 2.5 X 18MM -,SUP-IC2518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5 HEADED 20MM LENGTH -,SUP-IC2520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADED 2.5 X 22MM -,SUP-IC2522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.5 MM HEADED 26MM LENGTH MINI CANN SCREW -,SUP-IC2526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
MINI SET SCREW 2.5X28MM -,SUP-IC2528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.5 MM HEADED 30MM LENGTH MINI CANN SCREW -,SUP-IC2530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.0 X 10MM CANNULATED SCREW -,SUP-IC3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.0 HEADED 18MM -,SUP-IC3018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.0MM HEADED 22MM LENGTH CANN SCREW -,SUP-IC3022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.0MM HEADED 24MM LENGTH CANN SCREW -,SUP-IC3024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.0MM HEADED 26MM LENGTH MINI CANN SCREW -,SUP-IC3026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3MM X 30MM -,SUP-IC3030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.0 HEADED 32MM LENGTH -,SUP-IC3032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.0MM HEADED 34MM LENGTH -,SUP-IC3034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.0MM HEADED 38MM LENGTH -,SUP-IC3038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADED 3.0 X 40MM -,SUP-IC3040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.0MM HEADED 20MM LENGTH MINI CANN SCREW -,SUP-IC4020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.0MM HEADED SCREW LENGTH 32MM -,SUP-IC4032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.0MM HEADED SCREW LENGTH 34MM -,SUP-IC4034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.0MM HEADED 36MM LENGTH MINI CANN SCREW -,SUP-IC4036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.0MM HEADED 38MM LENGTH MINI CANN SCREW -,SUP-IC4038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.0MM HEADED 40MM LENGTH MINI CANN SCREW -,SUP-IC4040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE MINI 46MM X 4MM HEAD NONSTERILE -,SUP-IC4046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.0MM HEADED SCREW LENGTH 48MM -,SUP-IC4048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE MINI 50MM X 4MM HEAD NONSTERILE -,SUP-IC4050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
INFLUX SPARC (IBM) 1CC -,SUP-IFLX-CM-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2597.25,1818.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
INFLUX SPARC (IBM) 5CC -,SUP-IFLX-CM-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8530.44,5971.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
HEADLESS SCREW 2.5X10MM -,SUP-IH2510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.5MM HEADLESS SCREW LENGTH 20MM -,SUP-IH2520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.5MM HEADLESS SCREW LENGTH 24MM -,SUP-IH2524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.5MM HEADLESS SCREW LENGTH 26MM -,SUP-IH2526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
2.5MM HEADLESS SCREW LENGTH  30MM -,SUP-IH2530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE MINI 2.5 X 36MM HEADLESS -,SUP-IH2536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.0 X 14MM HEADLESS SCREW -,SUP-IH3014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.0 X 22MM HEADLESS -,SUP-IH3022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.0 X 24MM HEADLESS -,SUP-IH3024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.0 X 26MM HEADLESS -,SUP-IH3026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS 3.0MM X 30MM -,SUP-IH3030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.0 X 32MM HEADLESS SCREW -,SUP-IH3032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.0 X 34MM HEADLESS SCREW -,SUP-IH3034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS 3.0MM X 36MM -,SUP-IH3036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS 3.0MM X 38MM -,SUP-IH3038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS 3.0MM X 40MM -,SUP-IH3040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
4.0MM HEADLESS SCREW LENGTH 32MM -,SUP-IH4032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS 4.0MM X 16MM X 36MM -,SUP-IH4036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS 4.0MM X 38MM -,SUP-IH4038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS 4.0MM X 40MM -,SUP-IH4040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS 4.0MM X 42MM -,SUP-IH4042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS 4.0MM X 46MM -,SUP-IH4046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS 4.0MM X 50MM -,SUP-IH4050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN AXIS 2.5MM X 40MM IJS-E -,SUP-IJS-EAP-25400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1727.96,1209.572,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN IJS-E AXIS 2.5MM X 45MM -,SUP-IJS-EAP-25450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1727.96,1209.572,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BLADE T10 DRIVER 4.0 SCREWS -,SUP-IS1108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,921.23,644.861,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PK SCREW INTNL FX STRL CONTR -,SUP-JG303R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21.15,14.805,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 28MMX10MM JULIET OL LD SHARING ANTMC PEEK -,SUP-JUL-OL 28 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 7X28MM STR -,SUP-JUL-OX2807-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE LUMBAR POSTERIOR TI L24 W8 H7 -,SUP-JUN-P6 24 07-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
8 X 24 PLIF TITANIUM CAGE -,SUP-JUN-P6 24 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE LUMBAR POSTERIOR TI L24 W8 H09 6 DEGREE NARROW JULIET -,SUP-JUN-P6 24 09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE PLIF TI 24 X 8.5 X 10 -,SUP-JUN-P6 24 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LUMBAR POSTERIOR TI CAGE L24 W9 H11 -,SUP-JUN-P6 24 11-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE 24 X 9 X 12 PLIF 6 DEGREE -,SUP-JUN-P6 24 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE LUMBAR POSTERIOR TI 14 X 9 X 24 6DEG -,SUP-JUN-P6 24 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LUMBAR POSTERIOR TI CAGE L24 X W8 X H07 6 DEGREE -,SUP-JUN-P62407-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LUMBAR POSTERIOR TI CAGE L24 W8.5 H10 -,SUP-JUN-P62410-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE POSTERIOR LUMBAR TI L24 X W9 X H11 6DEG JULIET -,SUP-JUN-P62411-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TITANIUM PLIF CAGE L24 X W9 X H12 6 DEGREE -,SUP-JUN-P62412-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LUMBAR POSTERIOR TI CAGE L24 W10.5 -,SUP-JUT PX 24 09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE TRANSORAMINLA LUMBAR TI L30 W 10.5 -,SUP-JUT-T6 30 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE LUMBAR TRANSFORAMINAL L30 W 10.5 -,SUP-JUT-T6 30 09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE TRANSFORAMINAL LUMBAR TI CAGE L30 W 10.5 H10 -,SUP-JUT-T6 30 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE TRANSFORAMINAL LUMBAR TI L30 W 10.5 H 11 -,SUP-JUT-T6 30 11-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE TRANSFORAMINAL LUMBAR TI L30 W10.5 H12 6 DEG -,SUP-JUT-T6 30 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE TRANSORAMINAL LUMBAR TI L 30 W 10.5 H 13 -,SUP-JUT-T6 30 13-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SYS BONE CMNT PARALLAX EZFLOW -,SUP-KP-CDS-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
KT DEVICE PARALLAX CONTR -,SUP-KP-CTR-1508C-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7002.6,4901.82,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
STENT ADVANIX BIL 10FR X 3CM DBL PIGTAIL -,SUP-M00532240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DISK SPIN MOBI- C COCR MLYBDNM EPLT UHMWPE INLAY 13X15X5MM -,SUP-MB3355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PROSTHESIS CERV DISC 13 X 17 H -,SUP-MB3375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DISC SPIN MOBI- C COCR MLYBDNM EPLT UHMWPE INLAY 15X15X5MM -,SUP-MB3555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DISC SPIN MOBI- C PROS COCR MLYBDNM EPLT UHMWPE INLAY -,SUP-MB3576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE 40MM ROD -,SUP-MC1-200040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT ROI-C 7MM 12 X 14MM LO -,SUP-MC1343P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE CERV 10MM/7.2MM H A/P ROI- C LRDTC -,SUP-MC1426P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE CERV 5MM/2.3MM H A/P ROI- C LRDTC -,SUP-MC1441P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE CERV 6MM/3.1MM H A/P ROI- C LRDTC -,SUP-MC1442P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE CERV 8MM/5.1MM H A/P ROI- C LRDTC -,SUP-MC1444P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE CERV 9MM/6.1MM H A/P ROI- C LRDTC -,SUP-MC1445P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
IMPLANT ROI-C LORDOSED 12X15.5 -,SUP-MC1454P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.8X22MM S3 MULDIR NS -,SUP-MD22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.8X24MM S3 MULDIR NS -,SUP-MD24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.8X26MM S3 MULDIR NS -,SUP-MD26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.8X28MM S3 MULDIR NS -,SUP-MD-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.8X28MM S3 MULDIR NS -,SUP-MD-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.8X30MM S3 MULDIR NS -,SUP-MD30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.8X32MM S3 MULDIR NS -,SUP-MD32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.8X34MM S3 MULDIR NS -,SUP-MD34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.8X36MM S3 MULDIR NS -,SUP-MD36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.8X38MM S3 MULDIR NS -,SUP-MD38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5MM X 40MM CANNULATED POLYAXIAL -,SUP-MPF-PX  55 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5MM X 35MM CANNULATED POLYAXIAL -,SUP-MPF-PX 55 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
MIDSHAFT RADIUS PLATE 112MM -,SUP-MRP-112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5996.77,4197.739,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE FREEFIX MIDSHAFT RADIUS 127MM -,SUP-MRP-127,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SIZER NATRELLE INSPIRA 325CC FULL -,SUP-MSZ-F325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SIZER NATRELLE INSPIRA 345CC FULL -,SUP-MSZ-F345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SIZER NATRELLE INSPIRA 450CC FULL -,SUP-MSZ-F450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SIZER NATRELLE INSPIRA 485CC FULL -,SUP-MSZ-F485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SIZER NATRELLE INSPIRA 330CC MODERATE -,SUP-MSZ-M330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SIZER NATRELLE INSPIRA 445CC MODERATE -,SUP-MSZ-M445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SIZER NATRELLE INSPIRA 485CC MODERATE -,SUP-MSZ-M485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MULTI-THREAD LOCKING 2.7MM X 18MM TI -,SUP-MTLS-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MULTI-THREAD LOCKING 2.7MM X 20MM -,SUP-MTLS-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MULTI-THREAD LOCKING 2.7 X 22 -,SUP-MTLS-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MULTI THREAD LOCKING 2.7MM X 32MM TI -,SUP-MTLS-27320-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MULTI THREADED LOCKING 3.0MM X 10MM TI -,SUP-MTLS-30100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MULTI THREADED LOCKING 3.0MM X 12MM TI -,SUP-MTLS-30120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MULTI THREADED LOCKING 3.0MM X 14MM TI -,SUP-MTLS-30140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MT LOCKING 3.5MM X 8MM TI -,SUP-MTLS-35080-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MT LOCKING 3.5MM X 10MM TI -,SUP-MTLS-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MT LOCKING 3.5MM X 12MM TI -,SUP-MTLS-35120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MT LOCKING 3.5MM X 14MM TI -,SUP-MTLS-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MT LOCKING 3.5MM X 16MM TI -,SUP-MTLS-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MT LOCKING 3.5MM X 18MM TI -,SUP-MTLS-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MT LOCKING 3.5MM X 20MM TI -,SUP-MTLS-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MT LOCKING 3.5MM X 22MM TI -,SUP-MTLS-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MT LOCKING 3.5MM X 24MM TI -,SUP-MTLS-35240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MT LOCKING 3.5MM X 26MM TI -,SUP-MTLS-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MT LOCKING 3.5MM X 28MM TI -,SUP-MTLS-35280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE LKG 3.5MM X 32MM MULTITHREAD TI -,SUP-MTLS-35320-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE TITANIUM MULTI-THREAD LOCKING 3.5 X 34 -,SUP-MTLS-35340-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MULTI-THREAD LOCKING 3.5MM X 36MM TI -,SUP-MTLS-35360-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MULTI-THREAD LOCKING 3.5MM X 38MM TI -,SUP-MTLS-35380-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE TITANIUM MULTI-THREAD LOCKING 3.5 X 40 -,SUP-MTLS-35400-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MULTI THREAD LOCKING 3.5MM X 42MM TI -,SUP-MTLS-35420-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MULTI-THREAD LOCKING 3.5MM X 55MM TI -,SUP-MTLS-35550-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MULTI-THREAD COMPRESSION 3 X 10 -,SUP-MTNL-30100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MULTI THREAD COMP 3.0MM X 12MM TI -,SUP-MTNL-30120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MULTI-THREAD COMPRESSION 3.0MM X 16MM TI -,SUP-MTNL-30160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE TITANIUM MULTI-THREAD LOCKING 3.5 X 10 -,SUP-MTNL-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MT COMP 3.5MM X 14MM TI -,SUP-MTNL-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MT COMP 3.5MM X 16MM TI -,SUP-MTNL-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MT COMP 3.5MM X 18MM TI -,SUP-MTNL-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MT COMP 3.5MM X 22MM TI -,SUP-MTNL-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MT COMP 3.5MM X 40MM TI -,SUP-MTNL-35400-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MULTI THREAD COMPRESSION 3.5MM X 42MM TI -,SUP-MTNL-35420-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MT COMP 3.5MM X 45MM TI -,SUP-MTNL-35450-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MT COMP 3.5MM X 50MM TI -,SUP-MTNL-35500-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW MT COMP 3.5MM X 60MM TI -,SUP-MTNL-35600-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
MIDSHAFT ULNA PLATE 97MM -,SUP-MUP-097,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5937.36,4156.152,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE MIDSHAFT ULNA 112MM -,SUP-MUP-112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5996.77,4197.739,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
MACROFORM NOVABONE 5CC -,SUP-NB1002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
MACROFORM 5CC -,SUP-NB4305,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.8X20MM LCK S3 90DG ANG TI NS -,SUP-NL20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.8X24MM LCK S3 90DG ANG TI NS -,SUP-NL24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.8X26MM LCK S3 90DG ANG TI NS -,SUP-NL-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.8X28MM LCK S3 90DG ANG TI NS -,SUP-NL28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.8X30MM LCK S3 90DG ANG TI NS -,SUP-NL30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.8X32MM LCK S3 90DG ANG TI NS -,SUP-NL32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK 90DG ST BN HND SHLDR -,SUP-NL-SS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,408.45,285.915,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK 90DG ST BN HND SHLDR -,SUP-NL-SS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN FX STNMN 18INX9IN DBL END TROC SMTH SS -,SUP-OM 71-0459,CDM,C1713,HCPCS,278,RC,,,outpatient,,,69.73,48.811,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ARTHROSCOPIC FX MAGNUM2 ACC F/SHLDR FT/ANKL RPR HALLUX -,SUP-OM-1502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1106.83,774.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT MAG PI -,SUP-OM-4500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DEVICE SUT MAG 2 + SMARTSTITCH KNTLS -,SUP-OM-9026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SFT TIS 3.2MM KNTLS FX W/PERFECTPASSER MAGNUMWR SUT -,SUP-OM-9146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3079.23,2155.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SFT TIS 3.2MM PNCH MAG PI + -,SUP-OM-9147,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3079.23,2155.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2X14MM LCK SMTH TI DVR NS -,SUP-P14000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2X16MM LCK SMTH TI DVR NS -,SUP-P16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2X20MM LCK SMTH TI DVR NS -,SUP-P20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2X22MM LCK SMTH TI DVR NS -,SUP-P22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2X26MM LCK SMTH TI DVR NS -,SUP-P26000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL LCK 2.5 X 10 CANNULATED COCR -,SUP-PALS-25100-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL LCK 2.5 X 16 CANNULATED COCR -,SUP-PALS-25160-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL LCK 2.5 X 22MM CANNULATED COCR -,SUP-PALS-25220-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE GEMINUS POLY LOCKING 2.5MM X 24MM CANN COCR -,SUP-PALS-25240-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXL LCK 2.5MM X 26MM CANN -,SUP-PALS-25260-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL LOCKING 3.0MM X 18MM CANNULATED -,SUP-PALS-30180-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL LOCKING 3.0MM X 22MM CANNULATED -,SUP-PALS-30220-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL LOCKING 3.0MM X 24MM CANN -,SUP-PALS-30240-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXAIL LCK 3.0 X 34 -,SUP-PALS-30340-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL LOCKING 3.0MM X 55MM CANNULATED -,SUP-PALS-30550-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
THREADED PEG CORTICAL NON-LOCKING 2.7MM X 10MM TI -,SUP-PANL-27140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL NON LOCKING 2.7 X 16 -,SUP-PANL-27160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW PEG THREADED CORTICAL NON-LOCKING 2.7MM X 18MM TI -,SUP-PANL-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG THREADED CORTICAL NON-LOCKING 2.7MM X 20MM TI -,SUP-PANL-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG THREADED CORTICAL NON-LOCKING 2.7MM X 22MM TI -,SUP-PANL-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG THREADED CORTICAL NL 2.7MM X 26MM TI -,SUP-PANL-27260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL NON LOCKING 3.5 X 9 -,SUP-PANL-35090-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL NON LOCKING 3.5 X 10 -,SUP-PANL-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL NON LOCKING 3.5MM X 11MM -,SUP-PANL-35110-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW- CORTICAL NON-LOCKING 3.5MM X 12MM -,SUP-PANL-35120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON-LOCK 3.5 X 13 POLY TI -,SUP-PANL-35130-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE ASSEMBLED PROTEAN FRAGMENT DOUBLE HOCKEY STICK -,SUP-PANL-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4596.25,3217.375,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON-LOCK 3.5 X 14 POLY TI -,SUP-PANL-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON-LOCK 3.5 X 15 POLY TI -,SUP-PANL-35150-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL NON LOCKING 3.5MM X 16MM TI -,SUP-PANL-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL NON LOCKING 3.5MM X 18MM TI -,SUP-PANL-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON-LOCK 3.5 X 20 POLY TI -,SUP-PANL-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON-LOCK 3.5 X 22 POLY TI -,SUP-PANL-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL NON LCK 3.5MM X 26MM TI -,SUP-PANL-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL NON LOCKING 3.5MM X 28MM TI -,SUP-PANL-35280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MM X 10MM -,SUP-PC1-003510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5MM X 12MM -,SUP-PC1-003512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NORTHSTAR 3.5 X 14 SCREW -,SUP-PC1-003514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE 3.5MM X 16MM SCREW -,SUP-PC1-003516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NORTHSTAR SCREW 3.5 X 18 -,SUP-PC1-003518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLY SEASPINE 3.5 MM X 20 MM -,SUP-PC1-003520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE SCREW 3.5MM X 22MM -,SUP-PC1-003522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE SCREW 35 X 24 -,SUP-PC1-003524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE SCREW 3.5 X 26 -,SUP-PC1-003526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE SCREW 4MM X 10MM -,SUP-PC1-004010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE NORTHSTAR 4MM X 12MM SCREW -,SUP-PC1-004012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MM X 14MM SPINE POLYAXIAL -,SUP-PC1-004014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4MM X 16MM SPINE POLYAXIAL -,SUP-PC1004016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3007.62,2105.334,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW POLYAXIAL 4.0 X 16 SEASPINE -,SUP-PC1-004016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SEASPINE 4.0 X 18 POLYAXIAL -,SUP-PC1-004018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NORTHSTAR SCREW 4 X 20 -,SUP-PC1-004020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SEASPINE 4.0 X 22 POLYAXIAL -,SUP-PC1-004022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SEASPINE 4.0 X 24 POLYAXIAL -,SUP-PC1-004024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE SCREW 4MM X 26MM -,SUP-PC1-004026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE SCREW 4MM X 28MM -,SUP-PC1-004028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4 X 30 -,SUP-PC1-004030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE SCREW 4.0 X 34 -,SUP-PC1-004034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CROSS LINK MED 3.5 -,SUP-PC1-013502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CROSSHOLE LARGE 3.5MM -,SUP-PC1-013503,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE MD CROSSLINK -,SUP-PC1-014002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE LARGE CROSSLINK -,SUP-PC1-014003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LATERAL OFFSET -,SUP-PC1-020015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE 0-0CONNECTOR -,SUP-PC1-023540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PARALLELL TOP LOADING 5.5 -,SUP-PC1-023560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE 0-C CONNECTOR -,SUP-PC1-063535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE SCREW 4.5MM X 24MM -,SUP-PC1-104524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE 4.5 X 26 NS#2 -,SUP-PC1-104526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE 5.5 X 26 NS#2 -,SUP-PC1-104526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE SCREW 4.5MM X 28MM -,SUP-PC1-104528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE SCREW 4.5 X 30 NS#2 -,SUP-PC1-104530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE SCREW 4.5 X 34 -,SUP-PC1-104534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE SCREW 3.5 X 24 SS -,SUP-PC1-203524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE SCREW 3.5 X 26 SS -,SUP-PC1-203526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE SCREW 3.5 X 18 -,SUP-PC1-203528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
3.5 X 30MM SMOOTH SHANK SCREW -,SUP-PC1-203530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE REDUCTION SCREW 3.5 X 14 -,SUP-PC1-303514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SET OCCIPITOCERVICOTHORACIC FIXATION SYSTEM -,SUP-PC1-400000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE ROD OCC 3.5 X 170 -,SUP-PC1-503177,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPINAL100MM TITANIUM CONTOUR -,SUP-PC1-503500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE ROD -,SUP-PC1-503502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE 30MM ROD -,SUP-PC1-503530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPINAL 40MM -,SUP-PC1-503540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 50MM -,SUP-PC1-503550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD SPINAL 60MM TITANIUM CONTOUR -,SUP-PC1-503560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 70MM -,SUP-PC1-503570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 80MM -,SUP-PC1-503580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE NORTHSTAR 90MM ROD -,SUP-PC1-503590,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE ROD 4 X 120MM -,SUP-PC1-504002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE ROD 4X200MM -,SUP-PC1-504003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE ROD 80MM -,SUP-PC1-504080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE ROD 4 X 120 -,SUP-PC1-514012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE TRAN ROD 3.5 X 5.5 -,SUP-PC1-523555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1166.11,816.277,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE OCC PLATE -,SUP-PC1-700000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE CHIPS CANCELLOUS CRUSHED 1-8 MM 15 CC CHIP -,SUP-PCAN15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.36,804.552,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUBSTITUTE CANC 30ML CUBE RDIGRF PRESERVON CRSH VOID FIL -,SUP-PCANCUBE30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2148.98,1504.286,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
0 PDS PLUS VIOLET 1 X 27 CT-1 -,SUP-PDP340H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18.26,12.782,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAVIO BONE PIN 4.0MM X 89 -,SUP-PFSD-01008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.46,508.522,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUBSTITUTE WDG MATRGRF PRESERVON 18MM -,SUP-PICW8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3831.09,2681.763,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LEG CONTRA EXCLUDER AAA ENDO 16MM X 18MM X 11.5CM 12FR -,SUP-PLC181200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN F/ELB PLATE SYS 16HL LCK TI LNG NS -,SUP-PL-LEM16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6824.35,4777.045,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN 11X84MM 7HL LCK TI CONGR NS PNK -,SUP-PL-LEM7,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6017.99,4212.593,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ANCHORAGE 6HL PRCONT LCK TI GRN LT -,SUP-PLP10341,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ANCHORAGE 6HL PRCONT LCK TI GRN RT -,SUP-PLP10342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ANCHORAGE F /HALLUX VALGUS V1 8HL PRCONT LCK TI LNG -,SUP-PLP10462,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE MTP 5-HOLE -,SUP-PLP11341,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ANCHORAGE F /HALLUX VALGUS V2 5HL PRCONT LCK TI GRN -,SUP-PLP11342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ANCHORAGE F/CX PLATE SYS 1.5MM TI THRD HL COLR -,SUP-PLP14341,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHORAGE MTP CP PLATE RIGHT -,SUP-PLP14342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ANCHORAGE F/CX PLATE SYS TI THRD HL GRN -,SUP-PLP14342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ANCHORAGE F/LPDS FUSION 0MM STP PRCONT LCK TI YEL -,SUP-PLP20342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ANCHORAGE F/LPDS FUSION 0MM STP PRCONT LCK TI CP -,SUP-PLP29371,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ANCHORAGE 28MM 4HL PRCONT SYM LCK UTIL TI PNK -,SUP-PLP40280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4564.66,3195.262,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN POLARUS 4HL SLOTX3 TI LRG NS -,SUP-PL-PHGR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5967.06,4176.942,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X10MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X12MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X14MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X16MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X18MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X20MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X16MM LCK ANCHORAGE T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X10MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X12MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X14MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,657.84,460.488,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X16MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,657.84,460.488,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X18MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,657.84,460.488,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X20MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X22MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3X24MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X18MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 3.5X24MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHORAGE STANDARD SCREW 3.5 X 26MM -,SUP-PLSS3526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TROCAR CLOSURE SUTURE GRASPER -,SUP-PMI-TC-SG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,64.19,44.933,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TEMPORARY FIXATION PIN ADMIRAL -,SUP-PN AP2-100506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN FIXATION -,SUP-PN0920051001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,233.4,163.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE ASSEMBLED PROTEAN CENTRAL COLUMN LEFT -,SUP-PRT-CCP-LT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4681.13,3276.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PROTEAN CORONOID PLATE RIGHT -,SUP-PRT-CRD-RT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5237.1,3665.97,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE PROTEAN FRAG DIST ULNA -,SUP-PRT-FSP-DU,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5054.6,3538.22,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE Y PROTEAN FRAGMENT -,SUP-PRT-FSP-YS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4596.25,3217.375,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
DEVICE FIXATION SIZE 18 4FUSION -,SUP-QUA-4F-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11849.67,8294.769,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 12MM X 2.7MM FUCHSIA U PLUS LOCKING -,SUP-RBL1224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1070.7,749.49,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 14MM X 2.7MM GOLD U PLUS LOCKING -,SUP-RBL1225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1070.7,749.49,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 50MM UPLUS RIB -,SUP-RBL1301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6463.61,4524.527,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X50MM -,SUP-RFS-S4500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
TRUNK IPSI EXCLUDER AAA ENDO 26MM X 14.5MM X 12CM 16FR -,SUP-RLT261412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,32100.6,22470.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SIZER SMOOTH ROUND MODERATE GEL XTRA 755 CC -,SUP-RSZSHPX755S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SIZER SMOOTH ROUND MODERATE GEL HP XTRA 790 CC -,SUP-RSZSHPX790S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL IM 1.6MMX12.7MM SBFS SS -,SUP-SBFS062,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE CERVICAL LORDOTIC ANT D12 W15 H08 -,SUP-SCA-AC LS 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CERVICAL 3 X 14MM -,SUP-SCA-CS 3014-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
RSS 4.5MM STAR SCREW AND CAP 15MM L -,SUP-SCW-0961-046-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
RSS 4.5MM STAR SCREW AND CAP 20MM L -,SUP-SCW-0961-046-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
RSS 4.5MM STAR SCREW AND CAP 25MM L -,SUP-SCW-0961-046-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
RSS 4.5MM STAR SCREW AND CAP 30MM -,SUP-SCW-0961-046-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
KIT IMPLANT 10 X 9MM SPEED 1.5 X 1.5MM -,SUP-SE-0910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4623.62,3236.534,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPEED IMPLANT 11 X 08 X 08MM -,SUP-SE-1108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPEED IMPLANT 11X10X10MM -,SUP-SE-1110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPEED IMPLANT 15X15X15MM -,SUP-SE-1515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5690.99,3983.693,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
STAPLE -,SUP-SE-1815,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPEEDTITAM 18X15X15MM -,SUP-SE-1815TI,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7289.07,5102.349,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPEED IMPLANT TI 18X18X18MM -,SUP-SE-1818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5690.99,3983.693,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPEED COMPRESSION IMPLANT KIT 20X20X20 -,SUP-SE-2020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPEED TITAN IMPLANT 20 X 20 X 20MM -,SUP-SE-2020TI,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5644.52,3951.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO -,SUP-SFCW,CDM,C1713,HCPCS,278,RC,,,outpatient,,,379.28,265.496,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCARLET AL-T BONE SCREW 5 X 25MM -,SUP-SJT-LS 50 25-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5X20MM CORT/CANC DVR FT HEX HEAD TI -,SUP-SP 20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,545.51,381.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X10MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP10000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG 2.5X11MM NLCKG SCR CANC DVR FT ST HEX HEAD TI NS F/ANTMC -,SUP-SP11000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X12MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP12000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X13MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP13000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X14MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP14000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X15MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP15000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X16MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X16MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X18MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP18000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X20MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X20MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X22MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,534.37,374.059,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X22MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X22MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X24MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP24000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X26MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP26000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X34MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP34000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG SMOTH LOCKING 2 X 14 -,SUP-SPLS-20140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG SMOOTH LOCKING 2 X 16 -,SUP-SPLS-20160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG SMOOTH LOCKING TI GRAY 2.0MM X 17MM -,SUP-SPLS-20170-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG SMOOTH LOCKING 2 X 18 -,SUP-SPLS-20180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SMOOTH PEG LOCKING 2.0MM X 18MM TI -,SUP-SPLS-20180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG SMOOTH LOCKING TI GRAY 2.0MM X 19MM -,SUP-SPLS-20190-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG SMOOTH LOCKING 2 X 20 -,SUP-SPLS-20200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG SMOOTH LOCKING TI GRAY 2.0MM X 21MM -,SUP-SPLS-20210-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG SMOOTH LOCKING TI GRAY 2.0MM X 22MM -,SUP-SPLS-20220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN S3 16X71MM 16MM 3HL CONTR LCK SS SUT HL FST GUIDE -,SUP-SSPL3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5703.94,3992.758,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN S3 16X84MM 4HL CONTR LCK SS SUT HL FST GUIDE TECH -,SUP-SSPL4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5703.94,3992.758,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN S3 16X70MM 16MM 3HL CONTR LCK SS SUT HL FST GUIDE -,SUP-SSPR3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5703.94,3992.758,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN S3 16X150MM 8HL CONTR LCK SS SUT HL FST GUIDE TECH -,SUP-SSPR8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7359.1,5151.37,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SIZER IMPLANT NATR INSPIRA SIL 485CC SINGLE USE FULL PROFILE -,SUP-SSZ-F485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SIZER IMPLANT NATR INSPIRA SIL 605CC SINGLE USE FULL PROFILE -,SUP-SSZ-F605,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SIZER IMPLANT NATR INSPIRA SIL 650CC SINGLE USE FULL PROFILE -,SUP-SSZ-F650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SIZER IMPLANT NATR INSPIRA SIL 695CC SINGLE USE FULL PROFILE -,SUP-SSZ-F695,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SIZER IMPLANT NATR INSPIRA SIL 560CC SINGLE USE MOD PROFILE -,SUP-SSZ-M560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SIZER IMPLANT NATR INSPIRA SIL 600CC SINGLE USE MOD PROFILE -,SUP-SSZ-M600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 4MMSTDX20MM LCK SMTH TI S3 -,SUP-STP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 4MMSTDX25MM LCK SMTH TI S3 NS -,SUP-STP25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 4MMSTDX32.5MM LCK SMTH TI S3 -,SUP-STP325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 4MMSTDX37.5MM LCK SMTH TI S3 NS -,SUP-STP375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 4MMSTDX42.5MM LCK SMTH TI S3 NS -,SUP-STP425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 4MMSTDX45MM LCK SMTH TI S3 -,SUP-STP45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 4MMSTDX47.5MM LCK SMTH TI S3 NS -,SUP-STP475,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 4MMSTDX50MM LCK SMTH TI S3 NS -,SUP-STP50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 4MMSTDX40MM LCK THRD TI S3 NS -,SUP-STPT40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 4MMSTDX50MM LCK THRD TI S3 NS -,SUP-STPT50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ENDOSCOPIC FX SECURESTRAP W/12 ABSB STRP F/HRN RPR -,SUP-STRAP12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1878.06,1314.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SECURESTRAP 5MM ASORB STRAP -,SUP-STRAP25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2542.51,1779.757,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE SCREW T10 NON-LOCKING 2.7 X 30MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE SCREW T10 NON-LOCKING 2.7 X 70MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE SCREW T8 FULLY THREADED 2.7 X 18MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ASNIS III SS CANN SCREW 6.5 X 105MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
BONE SCREW T8 FULLY THREADED 2.7 X 24MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.3 X 15MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.88,310.016,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL LONG R2.0 TI LEFT 13 X 320MM GAMMA -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING FULLY THREADED T10 3.5 X 20MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING FULLY THREADED T10 3.5 X 28MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTEX 3.5 X 22MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING ST 3.5 X 46MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WRIST FUSION PLATE STANDARD BEND 120MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8642.06,6049.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WRIST FUSION PLATE STRAIGHT 120MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8642.06,6049.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5MMX16MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5MMX20MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5MMX26MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2.5MMX30MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
3-0 20CM STRATAFIX SPIRAL MONOCRYL PLUS UNDYED SH -,SUP-SXMP1B427,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.67,104.769,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
4-0 STRATAFIX SPIRAL MONOCRYL PLUS 45 X 45CM UNDYED PS-2 -,SUP-SXMP2B151,CDM,C1713,HCPCS,278,RC,,,outpatient,,,125.22,87.654,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUTURE STRATAFIX 2-0 CT-1 PDS VIOL 45CM -,SUP-SXPP1A403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,117.01,81.907,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
0 STRATAFIX SYMMETRIC PDS PLUS 23CM CT-1 -,SUP-SXPP1A425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.1,107.87,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUTURE STRATAFIX 0 CT-1 PDS VIOL 45CM -,SUP-SXPP1B407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.07,107.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUTURE STRATAFIX 3-0 SH SPIRAL PDS VIOLET 15CM -,SUP-SXPP1B420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,183.51,128.457,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
"SUTURE STRATAFIX SPIRAL PDS PLUS 2-0 9"" 23CM VIOLET CT-2 -",SUP-SXPP1B432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,155.78,109.046,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUT STRATAFIX 0 30CM SPIRAL PDS PLUS VIOLET CT-1 -,SUP-SXPP1B450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,157.03,109.921,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SET HERNIA KUMAR T ANCHORS -,SUP-TA-008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,46.32,32.424,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE REEF TA INTERBODY 9X28X8MM -,SUP-TA1-928088,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
REEF TA INTERBODY 9 X 28 X 10MM 15DEG -,SUP-TA1-928105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
REEF TA 9X 28 X 11MM INTERBODY -,SUP-TA1-928115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SEASPINE REEF TA INTERBODY 9X32X8MM -,SUP-TA1-932088,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
INTERBODY 9X32X11 15DEG -,SUP-TA1-932115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN 70MM TENSION BAND -,SUP-TB-1570K,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1219.12,853.384,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TROCHLEAR COMPRESSION FEMALE -,SUP-TCS-F,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1833.97,1283.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TROCHLEAR COMPRESSION LOCKING CAP -,SUP-TCS-LC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1303.92,912.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TROCHLEAR COMPRESSION MALE 60MM -,SUP-TCS-M-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 35MM -,SUP-TLF-5P T0 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 40MM -,SUP-TLF-5P T0 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 45MM -,SUP-TLF-5P T0 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD PREBENT TITANIUM 50MM -,SUP-TLF-5P T0 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PREBENT ROD TITANIUM 55MM -,SUP-TLF-5P T0 55-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 60MM -,SUP-TLF-5P T0 60-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PERLA TL PREBENT ROD TITANIUM 90MM -,SUP-TLF-5P T0 90-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD 5.5 X  70 -,SUP-TLF-5P TO 70-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ROD PREBENT 6MM X 40MM -,SUP-TLF-6P T0 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5 X 35 -,SUP-TLF-CS 55 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 5.5MM X 40MM -,SUP-TLF-CS 55 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CORTICAL BONE SCREW 5.5 X 45 -,SUP-TLF-CS 55 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5MM X 30MM -,SUP-TLF-CS 65 30-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5 X 35 -,SUP-TLF-CS 65 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCEW 6.5 X 40 -,SUP-TLF-CS 65 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 6.5 X 45 -,SUP-TLF-CS 65 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEAD -,SUP-TLF-MH PL 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
REDUCTION HEAD -,SUP-TLF-MH RE 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SET -,SUP-TLF-SC 00 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X10MM LCK LAG P/T TI DVR NS -,SUP-TP10000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X14MM TI DVR NS -,SUP-TP14000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X16MM TI DVR NS -,SUP-TP16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X18MM TI DVR NS -,SUP-TP18000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X20MM P/T -,SUP-TP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,534.37,374.059,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X20MM TI DVR NS -,SUP-TP20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG BN FX 2.5X28MM TI DVR NS -,SUP-TP28000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
THREADED PEG FLUTED LCK 2.3 X 20 -,SUP-TPFL-23200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG FIXATION LOCKING 2.3 X 10 TI -,SUP-TPLS-23100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG THREADED LOCKING 2.3MM X 12MM TI -,SUP-TPLS-23120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
THREADED PEG- LOCKING- 2.3MM X 16MM -,SUP-TPLS-23160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK TRH PEG 2.3 X 17MM -,SUP-TPLS-23170-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
THREADED PEG- LOCKING- 2.3MM X 18MM -,SUP-TPLS-23180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG THREADED LOCKING 2.3MM X 19MM -,SUP-TPLS-23190-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK TRH PEG 2.3 X 20MM -,SUP-TPLS-23200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
THREADED PEG- LOCKING 2.3MM X 21MM -,SUP-TPLS-23210-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
THREADED PEG LOCKING 2.3MM X 22MM -,SUP-TPLS-23220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
THREADED PEG- LOCKING 2.3MM X 23MM -,SUP-TPLS-23230-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG THREADED LOCKING TI PINK 2.3MM X 24MM -,SUP-TPLS-23240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
THREADED PEG- LOCKING 2.3MM X 26MM -,SUP-TPLS-23260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG THREADED 2.3 X 28 LOCKING -,SUP-TPLS-23280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG TRHEADED NON-LOCKING 2.7MM X 10MM TI -,SUP-TPNL-27100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG THREADES NON LOCKING 2.7 X 12 -,SUP-TPNL-27120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG THREADED NON LOCKING 2.7MM X 14MM -,SUP-TPNL-27140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG THREADES NON LOCKING 2.7 X 16 -,SUP-TPNL-27160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG THREADED NON LOCKING 2.7 X 18 -,SUP-TPNL-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON-LCK TRH PEG 2.7 X 20MM -,SUP-TPNL-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON-LCK TRH PEG 2.7 X 22MM -,SUP-TPNL-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG THREADED NON-LOCKING 2.7MM X 24MM -,SUP-TPNL-27240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG THREADED NON-LOCKING 2.7MM X 26MM -,SUP-TPNL-27260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PEG THREADED NON LOCKING 2.7MM X 28MM -,SUP-TPNL-27280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUBSTITUTE DBM 5ML PTTY OPTIUM FRZDR -,SUP-TPUT05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2696.31,1887.417,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CAGE CERVICAL LORDOTIC D12 W14 H07 -,SUP-TRY-CL 12 07-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
CERVICAL CAGE-LORDOTIC D12 W14 H08 -,SUP-TRY-CL 12 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BONE 20MM 1-LEVEL SPINE CERVICAL -,SUP-TRY-CP 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 22MM -,SUP-TRY-CP 04 22-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 24MM 1-LEVEL -,SUP-TRY-CP 04 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 26MM 1-LEVEL -,SUP-TRY-CP 04 26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 2 LEVEL 36MM -,SUP-TRY-CP 06 36-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 38MM 2-LEVEL -,SUP-TRY-CP 06 38-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 40MM 2 LEVEL -,SUP-TRY-CP 06 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 43MM 2-LEVEL -,SUP-TRY-CP 06 43-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 46MM 2-LEVEL -,SUP-TRY-CP 06 46-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SPINEART TRYPTIK 2- PLATE-52MM-3-LEVEL -,SUP-TRY-CP 08 52-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 55MM 3-LEVEL -,SUP-TRY-CP 08 55-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TRYPTIK 58MM 3-LEVEL -,SUP-TRY-CP 08 58-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 61MM 3-LEVEL -,SUP-TRY-CP 08 61-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE TRYPTIK 72MM 3 LEVEL -,SUP-TRY-CP 08 72-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 12MM SELF DRILLING POLYAXIAL -,SUP-TRY-PD 40 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SELF-DRILLING POLYAXIAL 4 X 14 -,SUP-TRY-PD 40 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SELF-DRILLING POLYAXIAL 4 X 16 -,SUP-TRY-PD 40 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SELF DRILLING POLYAXIAL 4.5 X 16 -,SUP-TRY-PD 45 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW SELF TAPPING 4 X 14 -,SUP-TRY-PS 40 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TRYPTIK SELF-TAPPING 4 X 16 -,SUP-TRY-PS 40 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
STENT GRAFT 28 X 14 X 140MM OVATION ILIAC LIMB -,SUP-TV-IL1428140-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEPIN ORTHO THRD DRILL TIP -,SUP-U000-0200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHORAGE LISFRANC PLATING MED -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHOR SUT 2.3MM FIBERWIREX2 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ANCHORAGE LAPIDUS PLATING LS 0 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
FEMORAL AUGMENT DISTAL SZ3 12M -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 10 HOLE LOCKING COMPR BR -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 6 HOLE CURVED -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE CERVICAL 2 LEVEL 30MM GE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DIST POST LAT HUMERAL 6H -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING PLATE 6 HOLE 2.0/2.3 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4600.23,3220.161,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 1.2 X 12MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL FLEXIBLE 2.0MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL FLEXIBLE 2.5MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.59,822.213,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL LONG R1/5 RT 11 X 440MM X -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LOCKING COMP BROAD 16 HOLE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.44,869.708,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE M ADAPTIVE II 2.5 TRI DI -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5810.88,4067.616,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SCREW GAP 6.5MM 30MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,663.67,464.569,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ANCHORAGE 3.5MM X 32MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ANCHORAGE LOCK 3.5 X 12 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
LO-PRO MTP PLT TM CONTRDSHTLTI -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS III SS CANN 5 X 46 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SUPERIOR 6H INCREASED -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE WSTD CMP BRD 16 HOLE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.44,869.708,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANN FT 4.0 X 40MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 5.5 X 30MM GENE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL FLEXIBLE 1.5MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW EMERGENCY 1.4 X 3 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS COMP. 4.0MM 32M -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LCK ST 2.7 X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LO-PRO PT 5MM X 50MM THR -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10 2.7 X 20MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW M CORTEX 2.3 X 16MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCKING 3.5 X 55MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON-LOCK LP 4.5 X 28MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL LONG LT TI 11X400 130 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
NAIL TI LNG RT 15 X 440MM X1 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TRILOCK 2.8 X 34MM HD7 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE 6 HOLE STRAIGHT -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BROAD 7 HOLE VARIAX COMP -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE DIAMOND FUSION LARGE NON -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7238.14,5066.698,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE HUMERUS RT. 14 HOLE L218 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE SCREW GAP 6.5MM 20MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,663.67,464.569,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE GRIP TRICHANTERIC W/2 CA -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7111.03,4977.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE RT ANTERIOR ANKLE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8806.3,6164.41,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ANCHORAGE 3.5MM X 14MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ANCHORAGE LOCK 3.5 X 14 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 2.7 X 48MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW HEADLESS 2.5 X 12MM MICR -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING SILVER 2.5 X 16M -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCKING 2.3 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON-LOCK LP 4.5 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.5,297.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TI LOCK 5.5 X 35MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TRILOCK 2.8 X 10MM HD7 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ANCHORAGE 3.0 X 28MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS 5.0MM 60MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS 6.5MM X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.94,757.358,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ANCHORAGE 3.5MM X 16MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ANCHORAGE 3.5MM X 20MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ANCHORAGE LOCK 3.5 X 18 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ANSIS 4.0 X 44MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS CANN TI 5.0 X 60MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS III SS CANN 5 X 38 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS TI 5.0 X 36MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW ASNIS TI 5.0 X 40MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW AUTOFIX 2.5 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 2.3 X 26 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 3.5 X 46MM NON-LOCK -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE 2.3 X 18MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW BONE T10 2.7 X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANN ASNIS III 5.0X 65MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORT HI-TOP 5.5 X 35MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTICAL 5.5 X 40MM HIGH -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CANN ASNIS III 5.0X 70MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW CORTEX T8 2.4MM X 8MM SE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCK LP 4.5 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCK LP 4.5 X 26MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCK LP 4.5 X 32MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCK LP 4.5 X 44MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.3 X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING 2.3 X 12MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LP 5.5 X 55MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCK LP 4.5 X 30MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCK LP 4.5 X 24MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCK LP 4.5 X 46MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW LOCKING T10 2.7 X 48MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON LOCKING 2.3 X 21MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,408.04,285.628,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW NON-LOCK LP 4.5 X 24MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW PERIPH NL 4.5 X 30MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW S-FIX 2.5LG X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW T2 F/T LOCK 5 X 105MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW TRILOCK 2.8 X 12MM HD7 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW VA 4.25 X 14MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WIRE TEMP KIRSCH 1X100MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.71,106.197,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER ORTHO -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,158.48,110.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PLATE BN ULTRA PIN -,SUP-UPP3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X23MM COMPR AEQUALIS REVERSED II ST NS F/BSPLT -,SUP-VDV223,CDM,C1713,HCPCS,278,RC,,,outpatient,,,980.28,686.196,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 4.5X35MM COMPR AEQUALIS REVERSED II ST NS F/BSPLT -,SUP-VDV235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
"V-LOC 180 ABSORABLE RELOAD 2-0 6"" ES-9 TAPER -",SUP-VLOCA206L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,211.29,147.903,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUTURE V-LOC ABSORBABLE 2-0 8 IN FOR ENDOSTITCH -,SUP-VLOCA208L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,249.42,174.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
"SUT V-LOC 180 2-0 P-12 12""CLEAR -",SUP-VLOCL0015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.68,88.676,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
"V-LOC 0 ABS 12"" GS-21 GREEN -",SUP-VLOCL0316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,125.34,87.738,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
"V-LOC 2-0 ABS 18"" GS-21 GREEN -",SUP-VLOCL0325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,125.34,87.738,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
"V-LOC 0 ABS 18"" GS-21 GREEN -",SUP-VLOCL0326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,130.1,91.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
"SUT V-LOC 180 0 GS-21 9"" GREEN -",SUP-VLOCL0346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,124.81,87.367,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
"V-LOC 3-0 ABS 6"" V-20 GREEN -",SUP-VLOCL0604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.66,927.962,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
"V-LOC 180 GREEN 12"" V-20 TAPER -",SUP-VLOCL0614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
"SUTURE VLOC 9"" 1/2 CIRCLE 26MM -",SUP-VLOCL0644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
"SUT V-LOC 180 3-0 CV-23 6"" GREEN -",SUP-VLOCL0804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
"SUT V-LOC 180 3-0 CV-23 12"" GREEN -",SUP-VLOCL0814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
"V-LOC 2-0 ABS 9"" GS-22 GREEN -",SUP-VLOCL2145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
"V-LOC 3-0 ABS 18"" P-14 UNDYED -",SUP-VLOCM0124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.68,88.676,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
"V-LOC 3-0 ABS  6"" CV-23 VIOLET -",SUP-VLOCM0804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
"V-LOC 3-0 ABS 18"" P-17 UNDYED -",SUP-VLOCM1824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.68,88.676,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUT V-LOC 90 2-0 GS-22 TAPER 12IN VIOLET -,SUP-VLOCM2115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,136.19,95.333,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
"SUTURE V-LOC 0 NON-ABS 6"" GS-21 BLUE -",SUP-VLOCN0306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,90.79,63.553,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
"V-LOC 2-0 PBT NON-ABS 6"" V-20 BLUE -",SUP-VLOCN0605,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1309.01,916.307,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
"V-LOC 2-0 NON-ABS 12"" V-20 BLUE -",SUP-VLOCN0615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
VLOC PBT 1 BLU 12 GS-22 -,SUP-VLOCN2117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,131.58,92.106,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
VLOC PBT 0 BLU 9 GS-22 NON-ABS -,SUP-VLOCN2146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,131.58,92.106,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GRAFT VALLIANT STENT 20F 31 X 90 NACION THORACIC -,SUP-VNMC3131C90TU,CDM,C1713,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PK CAP PROT 0.375IN PIN BALL W-SRS F/0.045IN K-WR XTRNFXTR -,SUP-W045-YL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,256.74,179.718,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN BALL JURGAN .045 YELLOW -,SUP-W045-YL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PIN BALL JURGAN .062 GREEN -,SUP-W062-GN,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PK CAP PROT 0.375IN PIN HEAD JRGN PIN BALL W-SRS F/.0938IN -,SUP-W332-CR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PK CAP PROT 0.375IN PIN HEAD JRGN PIN BALL W-SRS F/.0781IN -,SUP-W564-BL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PK CAP PROT 0.375IN PIN HEAD JRGN PIN BALL W-SRS F/.0781IN -,SUP-W564-BL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,256.74,179.718,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER INSIDE 2.7MM OUTSIDE 5MM -,SUP-WBTN-2750-T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.27,240.989,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WASHER BUTTON BRONZE -,SUP-WBTN-HCLP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.93,224.651,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MMX12MM NCANN TWST-OFF W- FX FIXOS MICROTHREADED -,SUP-WS12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 13MM NCANN TWST-OFF W- FX FIXOS MICROTHREADED -,SUP-WS13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SNAP OFF SCREW DIAM 2.1 LG.14 -,SUP-WS14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MMX15MM NCANN W- FX FIXOS MICROTHREADED SD/ST/RM -,SUP-WS15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SCREW 2MMX16MM NCANN W- FX FIXOS MICROTHREADED SD/ST/RM -,SUP-WS16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
ORTHO 0.35MM -,SUP-WSO906ST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.7,81.69,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
WOUND MATRIX 6 LAYER 10CM X 15CM 150SQCM -,SUP-WSX1015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16411.46,11488.022,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
PK PIN BALL PIN BALL PROT REFL 0.125IN 0.1094X.125IN F/3MM -,SUP-X003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUTURE MONODERM QUILL 3-0 MONO CLR YA-1023Q 30CMX30CM L BARB -,SUP-YA-1023Q,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.56,90.692,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
SUTURE MONODERM QUILL #0 MONO CLR YA-1029Q 36CMX36CM L BARB -,SUP-YA-1029Q,CDM,C1713,HCPCS,278,RC,,,outpatient,,,136.04,95.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.518595,35041.66656,other,OPPS APC,,
GUIDEWIRE HI-TORQUE CONNECT 250FT -,SUP-1012595,CDM,C1714,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC,,
EARLY ACCESSORY DROP OFF FEE -,SUP-10595-10169,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC,,
K-WIRE GAMMA 3.2 X 450MM -,SUP-1210-6451S,CDM,C1714,HCPCS,272,RC,,,outpatient,,,478.7,335.09,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC,,
SCREWDRIVER FLEXIBLE GAMMA -,SUP-1320-0233,CDM,C1714,HCPCS,272,RC,,,outpatient,,,2438.28,1706.796,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC,,
LEE RT ANG BRONCHUS CLAMP 9 39MM JAW -,SUP-320200,CDM,C1714,HCPCS,272,RC,,,outpatient,,,779.26,545.482,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC,,
PROBE BALL TIP 3MM TIP PEDICLE SCREW D344 -,SUP-3603-00-TE,CDM,C1714,HCPCS,272,RC,,,outpatient,,,601.01,420.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC,,
"KWIRE SINGLE POINT STST 150MM X .045"" -",SUP-451-1045,CDM,C1714,HCPCS,272,RC,,,outpatient,,,152.76,106.932,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC,,
10X30CM PICO14 DRESSING KIT -,SUP-66022043,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1562.06,1093.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC,,
HOLDER/POSITIOINER PLATE 1.2/1.55 FOR INSTRUMENT -,SUP-A-2350,CDM,C1714,HCPCS,272,RC,,,outpatient,,,4147.65,2903.355,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC,,
HOLDER/POSITIOINER PLATE 2.0/2.3 FOR INSTRUMENT -,SUP-A-2650,CDM,C1714,HCPCS,272,RC,,,outpatient,,,4147.65,2903.355,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC,,
KIT FIBERTAK KNOTLESS CURVED DISPOSABLE -,SUP-AR-3638DC,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC,,
B CROSSTELLAÂ® RX PTA Balloon Dilatation Cath 6mm x 150mm -,SUP-BD-F60150LR,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC,,
BALLOON R2P CROSTELLA  RX- 200cm- 6mm x 150mm -,SUP-BD-Q60150ER,CDM,C1714,HCPCS,272,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC,,
CATH BLNOCC 1.3MM 5FR SHTH 146CM 20CM LUM C RSSR 14S RX -,SUP-CRU14S,CDM,C1714,HCPCS,272,RC,,,outpatient,,,9315.58,6520.906,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC,,
CATH BLNOCC 1.1MM 5FR SHTH 146CM C RSSR 14P OTW PERIPH -,SUP-CRUO14PA,CDM,C1714,HCPCS,272,RC,,,outpatient,,,9315.58,6520.906,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC,,
CATH PTCA 0.05IN C RSSR S6 156CM RECANALIZATION PERIPH 5FR -,SUP-CRUS6A,CDM,C1714,HCPCS,272,RC,,,outpatient,,,9315.58,6520.906,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC,,
DRILL KIT FOR CONTINUOUS COMPRESSION -,SUP-DK-265C,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1863.92,1304.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC,,
INTERSTIM BELT FIXATION LARGE SCS PH -,SUP-FP9000L,CDM,C1714,HCPCS,272,RC,,,outpatient,,,233.4,163.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC,,
DILATOR COONS -,SUP-G04051,CDM,C1714,HCPCS,272,RC,,,outpatient,,,102.05,71.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC,,
CATH ANG 5FR DAV 100CM ADVANTG BRD VSCR -,SUP-G08581,CDM,C1714,HCPCS,272,RC,,,outpatient,,,151.7,106.19,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC,,
BALLOON EXTRACTOR PRO XL RETREIVAL 9-12 -,SUP-M00547130,CDM,C1714,HCPCS,272,RC,,,outpatient,,,612.32,428.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC,,
SET DELIVERY SIROS -,SUP-SIR-10300,CDM,C1714,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC,,
BLADE HOOK DISSECTING SYNERGY HARMONIC -,SUP-SNGHK,CDM,C1714,HCPCS,272,RC,,,outpatient,,,2781.64,1947.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC,,
SUTURE 3-0 MONO PLUS 16 X 16CM UNDYED -,SUP-SXMP2B402,CDM,C1714,HCPCS,272,RC,,,outpatient,,,166.17,116.319,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC,,
DRESSING KCI VERAFLO CLEANSE CHOICE LARGE -,SUP-ULTVCC05LG,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1428.85,1000.195,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC,,
DRESSING NEG PRSS SM 10X7.5X3.3CM VAC GRANUFOAM -,SUP-XF-DSMF1,CDM,C1714,HCPCS,272,RC,,,outpatient,,,163.38,114.366,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.910225,6679.27086,other,OPPS APC,,
NEEDLE BRCHTX 18GAX20CM ULTRA-SHRP TIP PLSH SURF PRELD BN -,SUP-818205,CDM,C1715,CPT,272,RC,,,outpatient,,,84.61,59.227,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,18.994945,416.02,,,,
CURRENT DR RF 2207-36 AICD -,SUP-2207-36,CDM,C1721,HCPCS,275,RC,,,outpatient,,,44309.79,31016.853,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR LUMAX 740 DR-T 2CHMBR CARD IMPL W/HOME MNTR -,SUP-365606,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30837.5,21586.25,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR ILESTO DR-T DF-1 2CHMBR HI ENRG CARD IMPL W/TI -,SUP-383562,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25644.47,17951.129,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR ILESTO DR-T DF-4 2CHMBR HI ENRG CARD IMPL W/TI -,SUP-383564,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25644.47,17951.129,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR ITREVIA 7 DR-T DF-4 2CHMBR CARD IMPL W/TI -,SUP-392426,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25644.47,17951.129,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR CRNT + DR DF-4 2CHMBR RR V- PCNG RDC 50X74MM -,SUP-CD2211-36Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR FORTIFY DR DF-1 2CHMBR 40X74MM 14MM 35ML 76GM -,SUP-CD2231-40,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR FORTIFY DR DF-4 2CHMBR RR V- PCNG RDC 40X71MM -,SUP-CD2231-40Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR FORTIFY ASSURA DR DF-1 TELEM 2CHMBR 40X74MM -,SUP-CD2257-40,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR FORTIFY ASSURA DR DF-4 TELEM 2CHMBR 40X71MM -,SUP-CD2257-40Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR ELLIPSE DR DF-1 IS-1 CONN 2CHMBR DEFT RESPONSE -,SUP-CD2311-36,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR ELLIPSE DR DF-4 2CHMBR DEFT RESPONSE RF TELEM -,SUP-CD2311-36Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR FORTIFY ASSURA DR DF-4 2CHMBR CARD IMPL 40C -,SUP-CD2357-40C,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR FORTIFY ASSURA DR DF-4 2CHMBR CARD IMP 40Q -,SUP-CD2357-40Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR ELLIPSE VR IS-1 DF-1 2CHMBR 51X68MM 12MM 31ML -,SUP-CD2411-36C,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR ELLIPSE ASSURA DR DF-4 2CHMBR CARD IMPL -,SUP-CD2411-36Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
ENTRANT ICD CDDRA300Q -,SUP-CDDRA300Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37130,25991,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
ENTRANT DR ICD DF1 CONNECTOR REF: CDDRA300T -,SUP-CDDRA300T,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37130,25991,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
GALLANT ICD CDDRA500Q -,SUP-CDDRA500Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,26150.2,18305.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
GALLANT DR ICD DF1 CONNECTOR REF: CDDRA500T -,SUP-CDDRA500T,CDM,C1721,HCPCS,275,RC,,,outpatient,,,26150.2,18305.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR INOGEN DF-1 SGL-CHMBR 5.23X7.14X0.99 CM D -,SUP-D013,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25975.04,18182.528,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
DYNAGEN MINI ICD DR D022 -,SUP-D022,CDM,C1721,HCPCS,275,RC,,,outpatient,,,36747.56,25723.292,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
ICD MOMENTUM EO DR D121 -,SUP-D121,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25903.5,18132.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR D142 INOGEN MUL PRGM OPTN EXTEND LNGVT DR DF-4 -,SUP-D142,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25091.86,17564.302,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
DYNAGEN D153 EL ICD -DF-1 -,SUP-D153,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25091.86,17564.302,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR CONSULTA DF-4 CARD IMPL -,SUP-D204TRM,CDM,C1721,HCPCS,275,RC,,,outpatient,,,48626.05,34038.235,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR SECURA DR 2CHMBR RR V- PCNG RDC 51X64MM 15MM -,SUP-D224DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,35700.82,24990.574,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR SECURA VR SGL-CHMBR RR V- PCNG RDC 51X64MM -,SUP-D224VRC,CDM,C1721,HCPCS,275,RC,,,outpatient,,,31901.76,22331.232,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
ICD DUAL VIGILANT EL DR DF4 MRI CONDITIONAL -,SUP-D233,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25903.5,18132.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR MAXIMO II DR WRLS TELEM 2CHMBR RR V- PCNG RDC -,SUP-D284DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34217.29,23952.103,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR PROTECTA XT DR DF-1 IS-1 CONN 2CHMBR RR -,SUP-D314DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37579.81,26305.867,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR PROTECTA DR DF-1 IS-1 CONN 2CHMBR RR V- PCNG -,SUP-D334DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32749.43,22924.601,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR PROTECTA DR DF-4 2CHMBR CARD IMPL -,SUP-D334DRM,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32749.43,22924.601,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
ICD PERCIVA DR D401 -,SUP-D401,CDM,C1721,HCPCS,275,RC,,,outpatient,,,27894.37,19526.059,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
ICD PERCIVA DR DF4 D413 MRI CONDITIONAL -,SUP-D413,CDM,C1721,HCPCS,275,RC,,,outpatient,,,27894.37,19526.059,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR EVERA S DR DF-1 2CHMBR CARD IMPL -,SUP-DDBC3D1,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32071,22449.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR EVERA S DR DF-4 2CHMBR CARD IMPL -,SUP-DDBC3D4,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32071,22449.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR EVERA MRI XT DR SURSCN DF-4 CARD IMPL -,SUP-DDMB1D1,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37251.7,26076.19,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
EVERA MRI S DR SURESCAN MODEL DDMC3D1 -,SUP-DDMC3D1,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34784.7,24349.29,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR EVERA 2CHMBR CARD IMPL -,SUP-DDMC3D4,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34784.7,24349.29,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
ICD DUAL COBALT DR MRI REF: DDPB3D4 -,SUP-DDPB3D4,CDM,C1721,HCPCS,275,RC,,,outpatient,,,38485.2,26939.64,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR OVATIO CARD 6550 -,SUP-DR6550,CDM,C1721,HCPCS,275,RC,,,outpatient,,,45639.5,31947.65,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
DYNAGEN CRT-D G151 -,SUP-G151,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32897.45,23028.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR VITALITY II DR IS-1 DF-1 2CHMBR V- PCNG RDC -,SUP-T167,CDM,C1721,HCPCS,275,RC,,,outpatient,,,43197.17,30238.019,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR VITALITY HE IS-1 DF-1 2CHMBR 66MMX82.6MM -,SUP-T180,CDM,C1721,HCPCS,275,RC,,,outpatient,,,41877.33,29314.131,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR PARADYM RF VR IMPL 9250 -,SUP-TDF011U,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25661.73,17963.211,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,37344.8064,other,OPPS APC,,
DEFIBRILLATOR SQ-RX DF-1 SGL-CHMBR 65.5MMX78.2MMX15.7MM D -,SUP-1010,CDM,C1722,HCPCS,275,RC,,,outpatient,,,46873,32811.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR CRNT VR RF SGL-CHMBR VNTRC PCNG CARD IMPL -,SUP-1207/36,CDM,C1722,HCPCS,275,RC,,,outpatient,,,37656.29,26359.403,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR LUMAX 540 VR-T IS-1 CONN SGL-CHMBR RR 55X66MM -,SUP-360348,CDM,C1722,HCPCS,275,RC,,,outpatient,,,30895.47,21626.829,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR LUMAX 740 VR-T SGL-CHMBR CARD IMPL W/HOME MNTR -,SUP-365609,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28370.5,19859.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR LUMAX 740 VR-T DX CARD IMPL CELL GSM HOME MNTR -,SUP-372419,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28370.5,19859.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR ILESTO VR-T SGL-CHMBR CARD IMPL -,SUP-383578,CDM,C1722,HCPCS,275,RC,,,outpatient,,,30837.5,21586.25,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR ILESTO VR SGL-CHMBR HI ENRG CARD IMPL W/TI -,SUP-383580,CDM,C1722,HCPCS,275,RC,,,outpatient,,,30837.5,21586.25,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR ILESTO DX HI ENRG CARD IMPL W/TI LANDLINE HOME -,SUP-383594,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35737.63,25016.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR ITREVIA 7 VR-T DX HI ENRG CARD IMPL -,SUP-393037,CDM,C1722,HCPCS,275,RC,,,outpatient,,,24694.67,17286.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
DEVICE HI ENRG CARD IMPL TI -,SUP-393041,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35737.63,25016.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
ICD INTICA NEO 7 VR-T DX REF:429559 -,SUP-429559,CDM,C1722,HCPCS,275,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR EMBLEM S SQ-1 CONN 83.1MMX69.1MMX12.7MM D -,SUP-A209,CDM,C1722,HCPCS,275,RC,,,outpatient,,,46873,32811.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
S-ICD Emblem MRI A219 -,SUP-A219,CDM,C1722,HCPCS,275,RC,,,outpatient,,,44406,31084.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR CRNT + VR SJ-4 CONN SGL-CHMBR 50X74MM 14MM -,SUP-CD1211-36Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR FORTIFY VR DF-1 SGL-CHMBR 40X73MM 14MM 35ML -,SUP-CD1231-40,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR FORTIFY VR DF-4 ATP TERM AUTOMATICITY -,SUP-CD1231-40Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR FORTIFY ASSURA VR DF-1 TELEM SGL-CHMBR 40X73MM -,SUP-CD1257-40,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR FORTIFY ASSURA VR DF-4 SGL-CHMBR RF TELEM -,SUP-CD1257-40Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR ELLIPSE VR DF-1 IS-1 CONN SGL-CHMBR DEFT -,SUP-CD1311-36,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR ELLIPSE VR DF-4 DF-1 IS-1 CONN SGL-CHMBR DEFT -,SUP-CD1311-36Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,25163.4,17614.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR FORTIFY ASSURA VR DF-1 IS-1 CONN SGL-CHMBR -,SUP-CD1357-40C,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR FORTIFY ASSURA VR DF-4 SGL-CHMBR 40X71MM 14MM -,SUP-CD1357-40Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR ELLIPSE VR IS-1 DF-1 SGL-CHMBR 51X68MM 12MM -,SUP-CD1411-36C,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR ELLIPSE VR-ICD MRLN DF-4 SGL-CHMBR -,SUP-CD1411-36Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
ENTRANT ICD CDVRA300Q -,SUP-CDVRA300Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35273.5,24691.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
ENTRANT VR ICD DF1 CONNECTOR REF: CDVRA300T -,SUP-CDVRA300T,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35273.5,24691.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
GALLANT ICD CDVRA500Q -,SUP-CDVRA500Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36201.75,25341.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
GALLANT VR ICD DF1 CONNECTOR REF: CDVRA500T -,SUP-CDVRA500T,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36201.75,25341.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR INOGEN DF-1 SGL-CHMBR 5.23X7.14X0.99 CM D. -,SUP-D011,CDM,C1722,HCPCS,275,RC,,,outpatient,,,26643.6,18650.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
ICD MOMENTUM EL VR D120 -,SUP-D120,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36573.05,25601.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR INOGEN EXTEND LNGVT 5.37X7.36X0.99IN 68.9G -,SUP-D140,CDM,C1722,HCPCS,275,RC,,,outpatient,,,34746.25,24322.375,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
DYNAGEN EL ICD VR MODEL D151 -,SUP-D151,CDM,C1722,HCPCS,275,RC,,,outpatient,,,34746.25,24322.375,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR SECURA DR DF-4 2CHMBR CARD IMPL -,SUP-D204DRM,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35700.82,24990.574,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR SECURA VR DF-4 SGL-CHMBR CARD IMPL -,SUP-D204VRM,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31901.76,22331.232,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
ICD VIGILANT EO VR DF4 D232 MRI CONDITIONAL -,SUP-D232,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36573.05,25601.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR PROTECTA VR DF-1 IS-1 CONN SGL-CHMBR RR -,SUP-D334VRG,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28710.95,20097.665,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR PROTECTA VR DF-4 SGL-CHMBR CARD IMPL -,SUP-D334VRM,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28710.95,20097.665,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
ICD SINGLE PERCIVA VR REF: D400 -,SUP-D400,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36573.05,25601.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
ICD PERCIVA VR DF4 D142 MRI CONDITIONAL -,SUP-D412,CDM,C1722,HCPCS,275,RC,,,outpatient,,,25827.02,18078.914,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
ICD RESONATE EL VR -,SUP-D432,CDM,C1722,HCPCS,275,RC,,,outpatient,,,29019.32,20313.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
COBALT XT DR MRI ICD REF: DDPA2D4 -,SUP-DDPA2D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,41837.85,29286.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR EVERA S VR DF-1 SGL-CHMBR CARD IMPL -,SUP-DVBC3D1,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28617.2,20032.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR EVERA S VR DF-4 SGL-CHMBR CARD IMPL -,SUP-DVBC3D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28617.2,20032.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
VISIA AF MRI VR ICD DVFB1D1 -,SUP-DVFB1D1,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
ICD VISIA AF MRI SURESCAN VR -,SUP-DVFB1D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR CARDIAC VISIA AF MRI SURESCAN DVFC3D1 -,SUP-DVFC3D1,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
DEFIBRILLATOR EVERA MRI XT DR SURSCN DF-4 CARD IMPL -,SUP-DVMB1D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,35998.464,other,OPPS APC,,
EXPLANT TRUNCATED BLADE 56MM -,SUP-00-7053-056-10,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC,,
C 0.9M .014IN OTW TURBO ELITE -,SUP-410-152,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC,,
C 1.4M .014IN OTW TURBO ELITE -,SUP-414-151,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC,,
"2.0mm .018"" TURBO ELITE LASER -",SUP-420-006,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC,,
C 2.3M .018IN OTW TURBO ELITE -,SUP-423-001,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC,,
C 7FR LASER GUIDE 2.0MM TURBO -,SUP-423-050,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12234.34,8564.038,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC,,
DEVICE ATHRCMY STEALTH 360 1.5MM MICRO CRWN 145CM SHFT DMD -,SUP-DBE-150,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12605.64,8823.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC,,
CATH ATHRCMY DIAMONDBACK 360 1.25MM CROWN 135CM SHAFT -,SUP-DBEC-125,CDM,C1724,HCPCS,272,RC,,,outpatient,,,14833.44,10383.408,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC,,
DEVICE ATHRCMY PREDATOR 360 2MM CRWN DMD CTD SLD ART -,SUP-DBG-SCT30-200,CDM,C1724,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC,,
DEVICE ARTHREC 1.25 SOLID -,SUP-DBP-125MICRO145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC,,
SYSTEM ATHERECTOMY DBP-125MICRO145 -,SUP-DBP-125MICRO145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC,,
DEVICE ARTHREC STEALTH 1.25S -,SUP-DBP-125SOLID145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC,,
DEVICE ARTHREC STEALTH 1.50MM 5F -,SUP-DBP-150SOLID145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC,,
DBP-200SOLID145 -,SUP-DBP-200SOLID145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC,,
CATH ATHRCMY DIAMONDBACK 360 1.50MM X 145CM SOLID -,SUP-DBP-EX-150SOL145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,14462.14,10123.498,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC,,
ROTAPRO ADVANCER 1.25MM -,SUP-H749394671250,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7999.94,5599.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC,,
ROTAPRO ADVANCER 1.5MM -,SUP-H749394671500,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7999.94,5599.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC,,
ROTAPRO ADVANCER 1.75MM -,SUP-H749394671750,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC,,
ROTAPRO ADVANCER 2.0MM -,SUP-H749394672000,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC,,
ROTAPRO ADVANCER 2.25MM -,SUP-H749394672250,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC,,
ROTAPRO ADVANCER 2.38MM -,SUP-H749394672380,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC,,
ROTAPRO ADVANCER 2.5MM -,SUP-H749394672500,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC,,
ROTAPRO ADVANCER 2.15MM -,SUP-H7494672150,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC,,
CATH ATHRCMY ROTLNK + 1.25MM BUR 0.58IN SHTH 135CM TFLN PTFE -,SUP-H802227680020,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4502.88,3152.016,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC,,
BURR ROTALINK 1.50MM 0.58IN SHTH 135CM EXCHGL -,SUP-H802227680030,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4953.17,3467.219,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC,,
CATH ATHRCMY ROTLNK + 1.75MM BUR 0.58IN SHTH 135CM EXCHGL -,SUP-H802227680040,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4953.17,3467.219,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC,,
CATH ATHRCMY ROTLNK + 2MM BUR 0.58IN SHTH 135CM EXCHGL ROT -,SUP-H802227680050,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4502.88,3152.016,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC,,
CATH ATHRCMY ROTLNK 2.15MM BUR 0.58IN SHTH 135CM TFLN PTFE -,SUP-H802227680150,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4502.88,3152.016,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC,,
PHOENIX 1.8MM X130CM -,SUP-P18130,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC,,
1.8MM PHOENIX 149CM -,SUP-P18149K,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC,,
PHOENIX 2.2MM X 130CM -,SUP-P22130K,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC,,
PHOENIX ARTHERECTOMY 2.4MM 7FR -,SUP-P22149K,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC,,
ARTHERECTOMY JTSTRM 1.85MM -,SUP-PV3118F,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12754.16,8927.912,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC,,
ARTHERECTOMY JTSTRM 2.1/3MM -,SUP-PV31300,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12624.2,8836.94,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC,,
CATH ARTHERECTOMY JTSTRM 2.4/3.4MM LT -,SUP-PV41340,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12624.2,8836.94,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10635.57648,other,OPPS APC,,
CATHETER BALLOON VALVULOPLASTY  22MX4.5CMX110CM -,SUP-00224512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER BALLOON VALAVULOPLASTY 20MMX4.5X110CM TRUE DILATION -,SUP-0204511,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER BALLOON VALVULOPLASTY 21MMX4.5CMX110CM TRUE DILATIO -,SUP-0214512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER BALLOON VALVULOPLASTY 23MMX4.5CMX120CM TRUE DILATIO -,SUP-0234512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER BALLOON VALVULOPLASTY 24MMX4.5CMX110CM TRUE DILAT -,SUP-0244512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATHETER TRUE DILATATION 25MM X 4.5CM REF: 0254513 -,SUP-0254513,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATHETER TRUE DILATION 26MM -,SUP-0264513,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER BALLOON VALVULOPLASTY 28MMX4.5CMX110CM TRUE DILAT -,SUP-0284514,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH IABP LINEAR 7.5FR 40CC -,SUP-0684-00-0480-01,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4203.6,2942.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER IABP 7.5FR 40CC SENSATION PLUS -,SUP-0684-00-0568-01U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4524.1,3166.87,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER IABP 8FR 50CC SENSATION PLUS -,SUP-0684-00-0576-01U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4524.1,3166.87,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
GAIA FIRST 190CM MICRO J,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
GAIA THIRD 190CM MICRO J,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
GAIA SECOND 190CM MICRO J,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
RG3 330CM,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X18MM PWRSL 143CM RX F/PTCA COR HYDRCT 0.024IN GW -,SUP-1005527-18,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1086.6,760.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X15MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008189-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
4MM X 20MM X 135CM VIATRAC 14 PLUS BALLOON -,SUP-1008189-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ABBOTT VIATRAC BALLOON 4.5 X 20 X 135 -,SUP-1008191-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X20MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008193-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ABBOTT VIATRAC BALLOON 5.5 X 20 X 135 -,SUP-1008195-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6X20MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008197-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6X40MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008197-40,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH CV 4.5X20MM VIATRAC LF -,SUP-10081991-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ABBOTT VIATRAC BALLOON 6.5 X 20 X 135 -,SUP-1008199-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7X20MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008201-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.2X6MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012268-06U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON MINI TREK RX 1.20MM X 08MM REF: 1012268-08U -,SUP-1012268-08U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.2X12MM MINI TREK II RX UL-LPRO NC COR HYDRCT -,SUP-1012268-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.2X12MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012268-12U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON MINI TREK RX 1.20MM X 15MM REF: 1012268-15U -,SUP-1012268-15U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.2X20MM MINI TREK II RX UL-LPRO NC COR HYDRCT -,SUP-1012268-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.2X20MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012268-20U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X8MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X12MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X15MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X20MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X8MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X12MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X15MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X20MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X25MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X30MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X30MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON TREK RX 2.75MM X 08MM REF: 1012273-08 -,SUP-1012273-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON TREK RX 2.75MM X 12MM REF: 1012273-12 -,SUP-1012273-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON TREK RX 2.75MM X 20MM REF: 1012273-20 -,SUP-1012273-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X30MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON TREK RX 4.0MM X 8MM REF: 1012278-08 -,SUP-1012278-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012278-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON TREK RX 4.0MM X 15MM REF: 1012278-15 -,SUP-1012278-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON TREK RX 4.0MM X 20MM REF: 1012278-20 -,SUP-1012278-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012278-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X30MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012278-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4.5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012279-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON TREK RX 4.5MM X 15MM REF: 1012279-15 -,SUP-1012279-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012280-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON TREK RX 5.0MM X 15MM REF: 1012280-15 -,SUP-1012280-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.2X6MM MINI TREK II OTW UL-LPRO NC COR HYDRCT CTD -,SUP-1012401-06Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.2X8MM MINI TREK II OTW UL-LPRO NC COR HYDRCT CTD -,SUP-1012401-08Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.2X12MM MINI TREK II OTW UL-LPRO NC COR HYDRCT -,SUP-1012401-12Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.2X15MM MINI TREK II OTW UL-LPRO NC COR HYDRCT -,SUP-1012401-15Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.2X20MM MINI TREK II OTW UL-LPRO NC COR HYDRCT -,SUP-1012401-20Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X8MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X12MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X15MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X20MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X8MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012403-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X12MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X15MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X20MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X30MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X30MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012407-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X30MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X12MM NC TREK OTW SM-PRFL NC COR RND TIP HYDRCT -,SUP-1012433-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X15MM NC TREK OTW SM-PRFL NC COR RND TIP -,SUP-1012436-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X25MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X25MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X12 MM NC TREK RX ULLPRO NC COR RND TIP HYDRCT -,SUP-1012450-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X25MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
2.0MM X 60 MM X 150CM ARMADA 18 BALLOON OTW -,SUP-1013463-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA BALLOON 2.5MM X 40MM X 150CM -,SUP-1013464-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 18 2.5 X 200 X 150 -,SUP-1013464-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA BALLOON 2.5MM X 80MM X 150CM -,SUP-1013464-80,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA BALLOON .018 3MM X 60MM X 150CM -,SUP-1013465-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1155.33,808.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA BALLOON .018 3.0MM X 80MM X 150CM -,SUP-1013465-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA BALLOON .018 3.0MM X 100MM X 150CM -,SUP-1013465-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER ARMADA 18 3.0MM X 120MM X 150CM -,SUP-1013465-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER ARMADA 18 PTA -,SUP-1013465-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA BALLOON .018 3 X 200 X 150 -,SUP-1013465-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 18 4 X 20MM -,SUP-1013466-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
4MM X 40MM X 150CM ARMADA 18 BALLOON -,SUP-1013466-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
4MM X 60MM X 150CM ARMADA 18 -,SUP-1013466-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 4MM X 80MM X 150CM 18 -,SUP-1013466-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON ARMADA 4 X 150 X 150MM -,SUP-1013466-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 18 BALLOON 5MM X 20MM -,SUP-1013468-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
5mm x 40mm armada 18 -,SUP-1013468-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
5mm x 60mm Armada 18 Balloon -,SUP-1013468-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 18 BALLOON 5MM X 80MM -,SUP-1013468-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B ARMADA .018 5MM X 100MM -,SUP-1013468-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA BALLOON 5 MM X 150MM -,SUP-1013468-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA BALLOON 5MM X 200MM -,SUP-1013468-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 18 BALLOON 6 X 20MM -,SUP-1013470-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
6MM X 40MM X 150CM ARMADA 18 BALLOON -,SUP-1013470-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 18 B 6MM X 60MM X 150CM -,SUP-1013470-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 018 6MM X 80 MM -,SUP-1013470-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 6MM X 100MM 18 BALLOON -,SUP-1013470-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 6MM X 150MM 0.018 -,SUP-1013470-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 6MM X 200MM 0.018 -,SUP-1013470-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON TREK RX 3.75MM X 8MM REF: 1012277-08 -,SUP-102277-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 1.50MM X 8MM REF: 1400150-08 -,SUP-1400150-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 1.50MM X 12MM REF: 1400150-12 -,SUP-1400150-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 1.50MM X 15MM REF: 1400150-15 -,SUP-1400150-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 1.50MM X 20MM REF: 1400150-20 -,SUP-1400150-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 2.00MM X 8MM REF: 1400200-08 -,SUP-1400200-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 2.00MM X 12MM REF: 1400200-12 -,SUP-1400200-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 2.00MM X 15MM REF: 1400200-15 -,SUP-1400200-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 2.00MM X 20MM REF: 1400200-20 -,SUP-1400200-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 2.25MM X 08MM REF: 1400225-08 -,SUP-1400225-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 2.25MM X 12MM REF: 1400225-12 -,SUP-1400225-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 2.25MM X 15MM REF: 1400225-15 -,SUP-1400225-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 2.25MM X 20MM REF: 1400225-20 -,SUP-1400225-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 2.50MM X 8MM REF: 1400250-08 -,SUP-1400250-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 2.50MM X 12MM REF: 1400250-12 -,SUP-1400250-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 2.50MM X 15MM REF: 1400250-15 -,SUP-1400250-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 2.50MM X 20MM REF: 1400250-20 -,SUP-1400250-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 2.75MM X 8MM REF: 1400275-08 -,SUP-1400275-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 2.75MM X 12MM REF: 1400275-12 -,SUP-1400275-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 2.75MM X 15MM REF: 1400275-15 -,SUP-1400275-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 2.75MM X 20MM REF: 1400275-20 -,SUP-1400275-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 3.00MM X 8MM REF: 1400300-08 -,SUP-1400300-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 3.00MM X 15MM REF: 1400300-15 -,SUP-1400300-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 3.00MM X 20MM REF: 1400300-20 -,SUP-1400300-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 3.25MM X 8MM REF: 1400325-08 -,SUP-1400325-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 3.25MM X 12MM REF: 1400325-12 -,SUP-1400325-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 3.25MM X 15MM REF: 1400325-15 -,SUP-1400325-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 3.25MM X 20MM REF: 1400325-20 -,SUP-1400325-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 3.50MM X 8MM REF: 1400350-08 -,SUP-1400350-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 3.50MM X 12MM REF: 1400350-12 -,SUP-1400350-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 3.50MM X 15MM REF: 1400350-15 -,SUP-1400350-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 3.50MM X 20MM REF: 1400350-20 -,SUP-1400350-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 3.75MM X 12MM REF: 1400375-12 -,SUP-1400375-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 3.75MM X 20MM REF: 1400375-20 -,SUP-1400375-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 4.00MM X 8MM REF: 1400400-08 -,SUP-1400400-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 4.00MM X 12MM REF: 1400400-12 -,SUP-1400400-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 4.00MM X 15MM REF: 1400400-15 -,SUP-1400400-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 4.00MM X 20MM REF: 1400400-20 -,SUP-1400400-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 4.50MM X 8MM REF: 1400450-08 -,SUP-1400450-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 4.50MM X 12MM REF: 1400450-12 -,SUP-1400450-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 4.50MM X 20MM REF: 1400450-20 -,SUP-1400450-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 5.00MM X 12MM REF: 1400500-12 -,SUP-1400500-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 5.00MM X 15MM REF: 1400500-15 -,SUP-1400500-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 5.50MM X 12MM REF: 1400550-12 -,SUP-1400550-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 5.50MM X 15MM REF: 1400550-15 -,SUP-1400550-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 6.00MM X 12MM REF: 1400600-12 -,SUP-1400600-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 6.00MM X 15MM REF: 1400600-15 -,SUP-1400600-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH BLNOCC 15MM LRG 23X71X2.5CM ENDOCATH LPRO PLYISPRN -,SUP-20-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X20MM 2.7CM ANGIOSCULPT XL 137CM OTW F/PTCA -,SUP-2039-2520,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X20MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2076-4020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X40MM ANGIOSCULPT XL 137CM OTW -,SUP-2076-4040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X40MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2076-5040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6X40MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2076-6040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6X20MM ANGIOSCULPT XL 90CM OTW F/PTCA SEM-COM -,SUP-2092-6020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER SAPPHIRE II PRO L5 MM 5F -,SUP-210-053-5UU,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER SAPPHIRE II PRO L15 MM 5F -,SUP-210-153-5UU,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X40MM ANGIOSCULPT XL 155CM OTW F/PTCA SEM-COM -,SUP-2155-2540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR TAPR -,SUP-2200-2006-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X10MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2010-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2015-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.0X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2020-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2506-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X10MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2510-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2515-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2520-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR TAPR -,SUP-2200-3006-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X10MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3010-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3015-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.0X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3020-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3506-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X10MM ANGIOSCULPT 137CM RX F /PTCA SEM-COM COR -,SUP-2200-3510-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3515-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3520-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X100MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2237-50100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6X100MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2237-60100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B ANGIOSCULPT 7MM X 40MM -,SUP-2333-7040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6X100MM STERLNG 135CM OTW COAX SEM-COM PERIPH TAPR -,SUP-39032-60101,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER PCA 4MM X 30MM x 145CM COYOTE ES M -,SUP-39135-40301,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 14MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-1440L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER DILATION16MM X 4MM -,SUP-417-1640L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 18MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-1840L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 20MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-2040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 22MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-2240L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 25MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-2540L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 12MMX4CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-2040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3MMX4CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-3040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3MMX8CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-3080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX10CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-4000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX2CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-4020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
MIRROR SURG 16.4MMX7.625IN LRYNG HEX HNDL V. MUELLER -,SUP-419-4040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX6CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-4060L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX10CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-5000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 8MMX8CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-8080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-5040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MM 5FR SHFT 6CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-5060L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MM 5FR SHFT 8CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-5080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MM 5FR SHFT 6FR SHTH 10CM POWERFLX P3 110CM OTW -,SUP-420-6000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MM 5FR SHFT 5FR SHTH 2CM POWERFLX P3 110CM OTW -,SUP-420-6020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-6040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MM 5FR SHFT 6CM POWERFLX P3 80CM OTW F/PTA PERIPH -,SUP-420-6060S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MM 5FR SHFT 8CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-6080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MM 5FR SHFT 10CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-7000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MM 5FR SHFT 2CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-7020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-7040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 8MM 5FR SHFT 6FR SHTH 2CM POWERFLX P3 110CM OTW -,SUP-420-8020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 8MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-8040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX2CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-4020W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX3CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-4030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
RETRACTOR RGNL 6IN DBL END STN FNSH SS DLCT V. MUELLER NS -,SUP-424-5030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX3CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-6030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MMX3CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-7030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH DIL 3MM 4FR SHTH 4CM BLN 150CM F/PTA -,SUP-425-3004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3MMX4CM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-3004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X120MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X40MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-4004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X40MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-5004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X100MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-5010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX28CM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-5028X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1696.16,1187.312,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX6CM SAVVY 120CM OTW COAX MOD PRSS PERIPH TAPR -,SUP-435-506L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1155.51,808.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX22CM SAVVY LONG 120CM OTW COAX MOD PRSS PERIPH -,SUP-436-4022L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1420.53,994.371,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX22CM SAVVY LONG 150CM OTW COAX MOD PRSS PERIPH -,SUP-436-4022X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1420.53,994.371,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0302S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0402S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX4CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0404S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X220MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0422X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX2CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0502S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0504S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X60MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X100MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X220MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0522X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX2CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0602S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX4CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0604S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6X100MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0610X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6X150MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0615X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,840.24,588.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0702S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0704S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7X40MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0704X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 8X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0802S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 8X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0804S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 9X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0902S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 10X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-1004S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
TURNPIKE 150 CM MICRO CATH -,SUP-5643,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2859.63,2001.741,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 22MMX4CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-610462,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 25MMX4CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-610463,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 28MMX4CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-610465,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA BALLOON DILATAION 22X4X100 Z-MED II -,SUP-611761,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 30MMX2CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-611801,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 28MMX2CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-611803,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 25MMX3CM Z-MED 100CM LPRO COAX F/PTA HPRS PERIPH -,SUP-611816,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER PTV 16MMX4CM TYSHAK II REF:611920 -,SUP-611920,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER PTV 18MMX4CM TYSHAK II REF:611928 -,SUP-611928,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER PTV 20MMX4CM TYSHAK II REF:611932 -,SUP-611932,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER PTV 22MMX4CM TYSHAK II REF:611936 -,SUP-611936,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER PTV 25MMX4CM TYSHAK II REF:611944 -,SUP-611944,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH GUID 0.07IN 6FR MPA-1 90CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-270-90,CDM,C1725,HCPCS,272,RC,,,outpatient,,,309.26,216.482,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X6MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R06350N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R10200N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10225N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10250N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10325N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10350N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R10400N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R12250N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R12300N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R12325N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R12350N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R12400N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R15250N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R15300N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R15325N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R15340N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R15400N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
C PIG 5FR 20/1CM MARKS -,SUP-7602-20M65SH,CDM,C1725,HCPCS,272,RC,,,outpatient,,,528.13,369.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X12MM EMPIRA 139CM RX F/PTCA SEM-COM -,SUP-85R12250S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X12MM EMPIRA 139CM RX F/PTCA SEM-COM DURALYN -,SUP-85R12300S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X12MM EMPIRA 139CM RX F/PTCA SEM-COM -,SUP-85R12325S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X15MM EMPIRA 139CM RX F/PTCA SEM-COM -,SUP-85R15250S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X15MM EMPIRA 139CM RX F/PTCA SEM-COM DURALYN -,SUP-85R15300S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 3.00MM X 12MM REF: 1400300-12 -,SUP-90176431,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 4.50MM X 15MM REF: 1400450-15 -,SUP-90176448,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON TREK RX 2.75MM X 15MM REF: 1012273-15 -,SUP-90176463,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON TREK RX 3.75MM X 12MM REF: 1012277-12 -,SUP-90176465,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON TREK RX 3.75MM X 15MM REF: 1012277-15 -,SUP-90176466,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC TREK NEO 3.75MM X 15MM REF: 1400375-15 -,SUP-90176697,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH ANG 6FR 18MM 70CM 3.5CM BLN AMPLATZER SZ LUMX3 FLXB -,SUP-9-SB-018,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH ANG 24MM 7FR 70CM 4.5CM BLN AMPLATZER SZ LUMX3 FLXB -,SUP-9-SB-024,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X20MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2015-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 14 1.5MM X 40MM X 150CM -,SUP-A2015-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X20MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X60MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X80MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X200MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2025-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND -,SUP-A2025-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X200MM ARMADA 14 150CM LPRO F/PTA PERIPH RND -,SUP-A2025-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X20MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X60MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X80MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B ARMADA 14 PTA C 3.0 X 200M -,SUP-A2030-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X60MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X80MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X200MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X40MM NANOCROSS ELITE 150CM OTW ULTRA LO XING -,SUP-AB14W030040150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2093.7,1465.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X80MM NANOCROSS ELITE 150CM OTW ULTRA LO XING -,SUP-AB14W030080150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2093.7,1465.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
4MM X 40MM STELLAREX DCB -,SUP-AB35SX040040135,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON ATLAS PTA CATHETER 16MMX 40MM X 120CM REF: AT120164 -,SUP-AT120164,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1966.49,1376.543,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B ATLAS 12MM X 4CM X 75CM -,SUP-AT-75124,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B ATLAS 14MM X 4CM X 75CM -,SUP-AT-75144,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B ATLAS 16MM X 4CM X 75CM -,SUP-AT-75164,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1966.49,1376.543,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B ATLAS 18MM X 4CM X 75CM -,SUP-AT75184,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1966.49,1376.543,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ATLAS BALLOON 20 X 40 -,SUP-AT75204,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2276.62,1593.634,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ATLAS BALLOON 24 X 40 -,SUP-AT75244,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2910.99,2037.693,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 26MMX4CM ATLAS 75CM OTW COAX ULTRA NC PERIPH 12FR -,SUP-AT-75264,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2826.21,1978.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ATLAS GOLD PTA DILATATION CATHETER 120CM -,SUP-ATG120164,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1913.48,1339.436,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH ATLAS GOLD PTA DILATATION 16 X 6 X 80MM - 8 FR -,SUP-ATG80166,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1913.48,1339.436,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35  4.0MM X 20MM X 80CM -,SUP-B1040-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 4.0MM X 40MM X 80CM -,SUP-B1040-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
4MM X 80MM X 80CM ARMADA 35 BALLOON -,SUP-B1040-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON ARMADA 4MM X 80MM X 80CM -,SUP-B1040-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 5MM X 20MM X 80CM -,SUP-B1050-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B ARMADA 35 5MM X 40MM X 80CM -,SUP-B1050-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X40MM ARMADA  .035 -,SUP-B1050-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 5MM X 60MM X 80CM -,SUP-B1050-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B ARMADA 35 5.0 X 80 X 80 PTA CATH -,SUP-B1050-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON ARMADA 5MM X 100MM X 80CM -,SUP-B1050-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 5MM X 120MM X 80CM -,SUP-B1050-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 6MM X 40MM X 80CM -,SUP-B1060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 6MMx40MMx80CM -,SUP-B1060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
6MM X 60MM X 80CM ARMADA 35 BALLOON -,SUP-B1060-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 6.0MM X 60MM X80CM -,SUP-B1060-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
6MM X 80MM X 80CM ARMADA 35 BALLOON -,SUP-B1060-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON ARMADA 6MM X 100MM X 80CM -,SUP-B1060-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 6 X 150 X 80 -,SUP-B1060-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON 35 ARMADA 7 X 20 X 80 PTA -,SUP-B1070-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA PTA 7MM X 40MM X 80CM -,SUP-B1070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA B  35  7.0X60X80 PTA -,SUP-B1070-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 7MM X 60MM X 80CM -,SUP-B1070-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B ARMADA 35 7MM X 80MM X 80CM -,SUP-B1070-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 7 X 80MM X 80CM -,SUP-B1070-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B ARMADA 35 7.0 X 100 X 80 PTA CATH -,SUP-B1070-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON ARMADA 7MM X 150MM X 80CM -,SUP-B1070-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 8MM X 20MM X 80CM -,SUP-B1080-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
8mm x 40mm x 80cm Armada 35 -,SUP-B1080-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
XARMADA 35 8.0MM X 40MM X 80C -,SUP-B1080-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 8mmx60mmX80cm -,SUP-B1080-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B ARMADA 35 8MM X 60MM ON 80MM -,SUP-B1080-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
8MM X 80MM X 80CM ARMADA 35 BALLOON -,SUP-B1080-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 8.0MM X 80MM X 80CM -,SUP-B1080-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
9MM X 20MM X 80CM ARMADA 35 BALLOON -,SUP-B1090-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 BALLOON 9 X 40MM X 80CM -,SUP-B1090-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
10MM X 20MM X 80CM ARMADA 35 BALLOON -,SUP-B1100-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
10.0MM X 40MM X 80 ARMADA 35 BALLOON -,SUP-B1100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 10.0MM X 40MM X 80CM -,SUP-B1100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
10MM X 60MM X 80CM ARMADA 35 BALLOON -,SUP-B1100-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 10MM 60MM X 80CM -,SUP-B1100-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
12MM X 20MM X 80CM ARMADA 35 BALLOON -,SUP-B1120-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 12.0MM X 40MM X 80CM -,SUP-B1120-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 12 X 60MM X 80CM -,SUP-B1120-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 12.0MM X 60MM X 80CM -,SUP-B1120-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 14.0MM X 20MM X 80CM -,SUP-B1140-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
14MM X 40MM X 80CM ARMADA 35 BALLOON -,SUP-B1140-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 14MM X 60MM X 80CM -,SUP-B1140-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
4MM X 20MM X 135CM ARMADA 35 BALLOON -,SUP-B2040-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
Armada 4 x 40 x 135 Balloon -,SUP-B2040-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 4MM X 60MM X 135CM -,SUP-B2040-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 4X100X135 -,SUP-B2040-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
5MM X 20MM X 135CM ARMADA 35 -,SUP-B2050-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
5MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2050-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
5MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2050-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA PTA 0.035MM X 5MM X 60MM X 135CM -,SUP-B2050-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA PTA .035  5MM X 80MM X 135CM -,SUP-B2050-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
5MMX100MMX135CM ARMADA 35 -,SUP-B2050-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
5MM X 200MM X 135CM ARMADA 35 BALLOON -,SUP-B2050-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
6MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA PTA 0.035 6MM X 40MM X 135CM -,SUP-B2060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
6MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2060-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 6MM 80MM 135CM -,SUP-B2060-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 6MM 100MM 135CM -,SUP-B2060-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
6mm x 150mm x 135cm ARMADA 35 -,SUP-B2060-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
6MM X 200MM X 135CM ARMADA 35 BALLOON -,SUP-B2060-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
7MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35  BALLOON  7.0MM X 40MM X 135CM -,SUP-B2070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B ARMADA 35  7MM X 40MM X 135CM -,SUP-B2070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
7MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2070-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 7MM X 100MM BALLOON -,SUP-B2070-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
7MM X 200MM X 135CM ARMADA 35 BALLOON -,SUP-B2070-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 8MM X 20MM X 135CM -,SUP-B2080-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 8MM X 40MM X 135CM -,SUP-B2080-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35  8MM X 60MM X 135CM -,SUP-B2080-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 8MM X 80MM 35 BALLOON -,SUP-B2080-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON 9MM X 20MM X 135CM CATH ARMADA 35 -,SUP-B2090-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
9MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2090-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA PTA CATHETER 9MM X 60MM X 135CM -,SUP-B2090-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA PTA 10MM X 20MM X 135CM -,SUP-B2100-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
10MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA PTA 10MM X 40MM X 135CM -,SUP-B2100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA PTA 10MM X 60MM X 135MM -,SUP-B2100-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 12MM X 40MM X 135CM -,SUP-B2120-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
12MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2120-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ARMADA 35 BALLOON DIAL CATH 14X20X135 -,SUP-B2140-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
14MM X 40MM X 135CM ARMADA 35 BALOON -,SUP-B2140-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH BALLOON DIL CROSPERIO RX 0.014 X 4.0MM X 150CM 4FR -,SUP-BD-B40150LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1229.72,860.804,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH BALLOON DILATION R2P PTA 4.0MM X 150MM CROSPERIO RX -,SUP-BD-B40150LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1229.72,860.804,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CROSTELLA RX PTA DIL CATH 3MM X 8MM X 150CM -,SUP-BD-F30080LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CROSSTELLA OTW 3MM X 200MM 150CM -,SUP-BD-F30200LW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH CROSTELLA BALLOON RX PTA 4.0MM X 40MM 150CM 4FR -,SUP-BD-F40040LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH CROSTELLA BALLOON RX PTA 5.0MM X 80MM 150CM 4FR -,SUP-BD-F50080LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CROSSTELLAÂ® RX PTA Balloon Dil Cath 5mm x 150mm -,SUP-BD-F50150LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON METACROS 5MM X 150 X .030 PTCA -,SUP-BD-P50150ER,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON R2P CROSTELLA RX 2MM X 40MM X 200CM -,SUP-BD-Q20040ER,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X120MM CHOC 120CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CB1812050120OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X40MM CHOC 150CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CF1415025040OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X120MM CHOC 150CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CF1415025120OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X120MM CHOC 150CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CF1415030120OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 10MMX4CM CONQUST 75CM OTW COAX ULTRA NC PERIPH -,SUP-CQ-75104,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 12MMX4CM CONQUST 75CM OTW COAX ULTRA NC PERIPH -,SUP-CQ-75124,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1490.45,1043.315,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX2CM CONQUST 75CM OTW COAX ULTRA NC PERIPH -,SUP-CQ-7562,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CONQUEST 6 X 4 X 75 -,SUP-CQ-7564,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CONQUEST 7 X 4 X 75 -,SUP-CQ-7574,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CONQUEST 8 X 4 X 75 -,SUP-CQ-7584,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH BALLOON CHOLANGIOGRAPHY -,SUP-CS-01701,CDM,C1725,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON DILATATION CATH OTW TAKERU 1.5X6MM REF:DC-PY1506UA1 -,SUP-DC-PY1506UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 1.5X12MM REF: DC-PY1512UA1 -,SUP-DC-PY1512UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON DILATATION CATH OTW TAKERU 1.5X15MM REF:DC-PY1515UA1 -,SUP-DC-PY1515UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 1.5X20MM REF: DC-PY1520UA1 -,SUP-DC-PY1520UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 2.0X8MM REF: DC-PY2008UA2 -,SUP-DC-PY2008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 2.0X12MM REF: DC-PY2012UA2 -,SUP-DC-PY2012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON DILATATION CATH OTW TAKERU 2.0X15MM REF:DC-PY2015UA2 -,SUP-DC-PY2015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON DILATATION CATH OTW TAKERU 2.0X20MM REF:DC-PY2020UA2 -,SUP-DC-PY2020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 2.25X12MM REF: DC-PY2212UA2 -,SUP-DC-PY2212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 2.25X15MM REF: DC-PY2215UA2 -,SUP-DC-PY2215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 2.25X20MM REF: DC-PY2220UA2 -,SUP-DC-PY2220UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 2.5X8MM REF: DC-PY2508UA2 -,SUP-DC-PY2508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 2.5X15MM REF: DC-PY2515UA2 -,SUP-DC-PY2515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 2.5X20MM REF: DC-PY2520UA2 -,SUP-DC-PY2520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 3.0X8MM REF: DC-PY3008UA2 -,SUP-DC-PY3008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 3.0X12MM REF: DC-PY3012UA2 -,SUP-DC-PY3012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 3.0X15MM REF: DC-PY3015UA2 -,SUP-DC-PY3015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 3.0X20MM REF: DC-PY3020UA2 -,SUP-DC-PY3020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 3.5X8MM REF: DC-PY3508UA2 -,SUP-DC-PY3508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 3.5X12MM REF: DC-PY3512UA2 -,SUP-DC-PY3512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 3.5X15MM REF: DC-PY3515UA2 -,SUP-DC-PY3515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 3.5X20MM REF: DC-PY3520UA2 -,SUP-DC-PY3520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 4.0X8MM REF: DC-PY4008UA2 -,SUP-DC-PY4008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 4.0X12MM REF: DC-PY4012UA2 -,SUP-DC-PY4012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 4.0X20MM REF: DC-PY4020UA2 -,SUP-DC-PY4020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON DILATATION CATH RX TAKERU 1.5X6MM REF:DC-RY1506UA1 -,SUP-DC-RY1506UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX 1.5X12MM REF: DC-RY1512UA1 -,SUP-DC-RY1512UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON DILATATION CATH RX TAKERU 1.5X15MM REF:DC-RY1515UA1 -,SUP-DC-RY1515UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON DILATATION CATH RX TAKERU 1.5X20MM REF:DC-RY1520UA1 -,SUP-DC-RY1520UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX 2.0X8MM REF: DC-RY2008UA2 -,SUP-DC-RY2008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX 2.0X12MM REF: DC-RY2012UA2 -,SUP-DC-RY2012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON DILATATION CATH RX TAKERU 2.0X15MM REF:DC-RY2015UA2 -,SUP-DC-RY2015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON DILATATION CATH RX TAKERU 2.0X20MM REF:DC-RY2020UA2 -,SUP-DC-RY2020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX 2.25X12MM REF: DC-RY2212UA2 -,SUP-DC-RY2212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX 2.25X15MM REF: DC-RY2215UA2 -,SUP-DC-RY2215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX 2.5X8MM REF: DC-RY2508UA2 -,SUP-DC-RY2508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX 2.5X12MM REF: DC-RY2512UA2 -,SUP-DC-RY2512UA,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX 2.5X15MM REF: DC-RY2515UA2 -,SUP-DC-RY2515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX 2.5X20MM REF: DC-RY2520UA2 -,SUP-DC-RY2520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX 3.0X8MM REF: DC-RY3008UA2 -,SUP-DC-RY3008UA,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX 3.0X12MM REF: DC-RY3012UA2 -,SUP-DC-RY3012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX 3.0X15MM REF: DC-RY3015UA2 -,SUP-DC-RY3015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX 3.0X20MM REF: DC-RY3020UA2 -,SUP-DC-RY3020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX 3.5X8MM REF: DC-RY3508UA2 -,SUP-DC-RY3508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX 3.5X12MM REF: DC-RY3512UA2 -,SUP-DC-RY3512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX 3.5X15MM REF: DC-RY3515UA2 -,SUP-DC-RY3515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX 3.5X20MM REF: DC-RY3520UA2 -,SUP-DC-RY3520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX 4.0X8MM REF: DC-RY4008UA2 -,SUP-DC-RY4008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX 4.0X12MM REF: DC-RY4012UA2 -,SUP-DC-RY4012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX 4.0X15MM REF: DC-RY4015UA2 -,SUP-DC-RY4015UA,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX 4.0X20MM REF: DC-RY4020UA2 -,SUP-DC-RY4020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 2.0X8MM REF: DC-RZ2008UA2 -,SUP-DC-RZ2008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 2.0X12MM REF: DC-RZ2012UA2 -,SUP-DC-RZ2012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 2.0X15MM REF: DC-RZ2015UA2 -,SUP-DC-RZ2015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 2.0X21MM REF: DC-RZ2021UA2 -,SUP-DC-RZ2021UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 2.25X8MM REF: DC-RZ2208UA2 -,SUP-DC-RZ2208UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 2.25X12MM REF: DC-RZ2212UA2 -,SUP-DC-RZ2212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 2.25X15MM REF: DC-RZ2215UA2 -,SUP-DC-RZ2215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 2.25X21MM REF: DC-RZ2221UA2 -,SUP-DC-RZ2221UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 2.5X8MM REF: DC-RZ2508UA2 -,SUP-DC-RZ2508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 2.5X12MM REF: DC-RZ2512UA2 -,SUP-DC-RZ2512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 2.5X15MM REF: DC-RZ2515UA2 -,SUP-DC-RZ2515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 2.5X21MM REF: DC-RZ2521UA2 -,SUP-DC-RZ2521UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 2.75X8MM REF: DC-RZ2708UA2 -,SUP-DC-RZ2708UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 2.75X12MM REF: DC-RZ2712UA2 -,SUP-DC-RZ2712UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 2.75X15MM REF: DC-RZ2715UA2 -,SUP-DC-RZ2715UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 2.75X21MM REF: DC-RZ2721UA2 -,SUP-DC-RZ2721UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 3.0X8MM REF: DC-RZ3008UA2 -,SUP-DC-RZ3008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 3.0X12MM REF: DC-RZ3012UA2 -,SUP-DC-RZ3012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 3.0X15MM REF: DC-RZ3015UA2 -,SUP-DC-RZ3015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 3.0X21MM REF: DC-RZ3021UA2 -,SUP-DC-RZ3021UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 3.25X8MM REF: DC-RZ3208UA2 -,SUP-DC-RZ3208UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 3.25X12MM REF: DC-RZ3212UA2 -,SUP-DC-RZ3212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 3.25X15MM REF: DC-RZ3215UA2 -,SUP-DC-RZ3215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 3.25X21MM REF: DC-RZ3221UA2 -,SUP-DC-RZ3221UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 3.5X08MM REF: DC-RZ3508UA2 -,SUP-DC-RZ3508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 3.5X12MM REF: DC-RZ3512UA2 -,SUP-DC-RZ3512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 3.5X15MM REF: DC-RZ3515UA2 -,SUP-DC-RZ3515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 3.5X21MM REF: DC-RZ3521UA2 -,SUP-DC-RZ3521UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 4.0X8MM REF: DC-RZ4008UA2 -,SUP-DC-RZ4008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 4.0X12MM REF: DC-RZ4012UA2 -,SUP-DC-RZ4012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 4.0X15MM REF: DC-RZ4015UA2 -,SUP-DC-RZ4015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU RX NC 4.0X21MM REF: DC-RZ4021UA2 -,SUP-DC-RZ4021UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATH TAKERU OTW 2.5X12MM REF: DC-PY2512UA2 -,SUP-D-PY2512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX2CM DORADO 40CM OTW F/PTA ULTRA NC PERIPH 5FR -,SUP-DR4042,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1335.73,935.011,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MMX6CM DORADO 80CM OTW F/PTA ULTRA NC PERIPH 6FR -,SUP-DR8076,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1335.73,935.011,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP1506X EUPHORA RX -,SUP-EUP1506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP1512X EUPHORA RX -,SUP-EUP1512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP1515X EUPHORA RX -,SUP-EUP1515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP1520X EUPHORA RX -,SUP-EUP1520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP2006X EUPHORA RX -,SUP-EUP2006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP2010X EUPHORA RX -,SUP-EUP2010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP2012X EUPHORA RX -,SUP-EUP2012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP2015X EUPHORA RX -,SUP-EUP2015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP2020X EUPHORA RX -,SUP-EUP2020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP2025X EUPHORA RX -,SUP-EUP2025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP2030X EUPHORA RX -,SUP-EUP2030X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP22506X EUPHORA RX -,SUP-EUP22506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP22510X EUPHORA RX -,SUP-EUP22510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP22512X EUPHORA RX -,SUP-EUP22512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP22515X EUPHORA RX -,SUP-EUP22515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP22520X EUPHORA RX -,SUP-EUP22520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP22525X EUPHORA RX -,SUP-EUP22525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP2506X EUPHORA RX -,SUP-EUP2506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP2510X EUPHORA RX -,SUP-EUP2510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP2512X EUPHORA RX -,SUP-EUP2512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP2515X EUPHORA RX -,SUP-EUP2515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP2520X EUPHORA RX -,SUP-EUP2520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP2525X EUPHORA RX -,SUP-EUP2525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP2530X EUPHORA RX -,SUP-EUP2530X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP27506X EUPHORA RX -,SUP-EUP27506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP27510X EUPHORA RX -,SUP-EUP27510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP27512X EUPHORA RX -,SUP-EUP27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP27515X EUPHORA RX -,SUP-EUP27515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP27520X EUPHORA RX -,SUP-EUP27520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP27525X EUPHORA RX -,SUP-EUP27525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP3006X EUPHORA RX -,SUP-EUP3006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP3010X EUPHORA RX -,SUP-EUP3010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP3012X EUPHORA RX -,SUP-EUP3012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP3015X EUPHORA RX -,SUP-EUP3015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP3020X EUPHORA RX -,SUP-EUP3020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP3025X EUPHORA RX -,SUP-EUP3025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP3030X EUPHORA RX -,SUP-EUP3030X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP32506X EUPHORA RX -,SUP-EUP32506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP32510X EUPHORA RX -,SUP-EUP32510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP32512X EUPHORA RX -,SUP-EUP32512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP32515X EUPHORA RX -,SUP-EUP32515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP32520X EUPHORA RX -,SUP-EUP32520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP32525X EUPHORA RX -,SUP-EUP32525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP3506X EUPHORA RX -,SUP-EUP3506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP3510X EUPHORA RX -,SUP-EUP3510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP3512X EUPHORA RX -,SUP-EUP3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP3515X EUPHORA RX -,SUP-EUP3515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP3520X EUPHORA RX -,SUP-EUP3520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP3525X EUPHORA RX -,SUP-EUP3525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP3530X EUPHORA RX -,SUP-EUP3530X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP37506X EUPHORA RX -,SUP-EUP37506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP37510X EUPHORA RX -,SUP-EUP37510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP37512X EUPHORA RX -,SUP-EUP37512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP37515X EUPHORA RX -,SUP-EUP37515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP37520X EUPHORA RX -,SUP-EUP37520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP37525X EUPHORA RX -,SUP-EUP37525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP4006X EUPHORA RX -,SUP-EUP4006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP4010X EUPHORA RX -,SUP-EUP4010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP4012X EUPHORA RX -,SUP-EUP4012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP4015X EUPHORA RX -,SUP-EUP4015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP4020X EUPHORA RX -,SUP-EUP4020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP4025X EUPHORA RX -,SUP-EUP4025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EUP4030X EUPHORA RX -,SUP-EUP4030X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH BLNOCC 9FRX120CM CODA -,SUP-G03831,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2702.08,1891.456,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5MMX4CM ADVANCE MICRO 14 150CM OTW UL-LPRO F/PTA -,SUP-G26614,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2289.76,1602.832,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2MMX12CM ADVANCE MICRO 14 150CM OTW UL-LPRO F/PTA -,SUP-G26641,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2289.76,1602.832,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX2CM ADVANCE ATB 80CM OTW F/PTA MIN-CMPLNT -,SUP-G26895,CDM,C1725,HCPCS,272,RC,,,outpatient,,,705.98,494.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH DIL 4MMX12CM ADVANCE 18 LP 150CM LPRO F/PTA 4FR SHTH -,SUP-G30949,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30952,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX15CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30955,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ANGIOPLASTY 5 - 15 PTA -,SUP-G30956,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B 18LP ADVANCE 5MM X 15CM -,SUP-G30956,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ANGIOPLASTY / PTA4-18-150-5-20 -,SUP-G30958,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30958,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH DIL 6MMX12CM ADVANCE 18 LP 150CM LPRO F/PTA 5FR SHTH -,SUP-G30961,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ANGIOPLASTY 6 - 15 PTA -,SUP-G30962,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30964,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MMX12CM ADVANCE 18 LP 150CM LPRO F/PTA 5FR SHTH -,SUP-G30967,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30970,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3MMX4CM ADVANCE 18LP 150CM LPRO F/PTA -,SUP-G34319,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
3X6X150 PTA ADVANCE CATH -,SUP-G34320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3MMX8CM ADVANCE 18LP -,SUP-G34321,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON ADVANCE .018 3MM X 10CM X 150CM -,SUP-G34322,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G34331,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G34336,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX6CM ADVANCE 35LP 135CM LPRO PERIPH D-SHP -,SUP-G35532,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER ADVANCED LOW PROFILE BALLOON 6MM X 20MM X 135CM -,SUP-G35536,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MMX20CM ADVANCE 35LP 135CM LPRO F/PTA -,SUP-G35540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 10MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G35546,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH ANG 5FRX80CM ADVANCE LPRO -,SUP-G35547,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
GW ENDO 0.035INX260CM ACROBAT CLBRT TIP -,SUP-G47614,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1038.63,727.041,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G49479,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50216,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50218,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50222,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50224,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX10CM ADVANCE 18LP 135CM LUMX2 -,SUP-G50226,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX4CM ADVANCE 18LP - USE 0141543 DISC. -,SUP-G50228,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50230,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50235,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50237,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50239,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50241,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 -,SUP-G50243,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50245,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50247,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50249,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50251,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50253,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50257,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50262,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50264,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2MMX2CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50313,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50314,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2MMX6CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50315,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50316,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50317,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50318,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50319,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50321,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1836.57,1285.599,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5MMX6CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50322,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50323,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50324,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50325,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ADVANCE 14 LP BALLOON CATHETER -,SUP-G50327,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50328,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3MMX4CM ADVANCE 14LP 60MM LPRO LUMX2 F/PTA SEM-COM -,SUP-G50329,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50330,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50332,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50333,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX2CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50334,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50335,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX6CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50336,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50337,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50338,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50339,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50340,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52251,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52253,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52254,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52257,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52258,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX6CM ADVANCE 35LP 135CM LPRO PERIPH -,SUP-G52259,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52260,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52261,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX14CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52263,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52265,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52266,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52267,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52268,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX14CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52271,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52272,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52273,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52274,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52275,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MMX14CM ADVANCE 35LP 135CM LPRO F/PTA -,SUP-G52277,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 8MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52278,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 8MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52279,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 8MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52280,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 8MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52282,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 9MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52286,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 9MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52287,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 10MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52293,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 10MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52294,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 12MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52299,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 12MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
US PRE PP-CA-422 DIR BALLOON CATHER T3 20-23 -,SUP-G57885,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER US PRE PP-CA-422 DIR BALLOON T3 20-23 -,SUP-G57887,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ADVANCE SERENITY 14 150-20-220 -,SUP-G57889,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER BALLOON DILATATION ADVANCE SERENITY 14 2.5MM X10CM -,SUP-G57894,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CATHETER T3 20-23 -,SUP-G57896,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
DIRECT BALLOON CATHETERS T2 23-26 -,SUP-G57897,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER US PRE PP-CA-422 DIR BALLOON  T3 20-23 -,SUP-G57900,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ADVANCE SERENITY 14 HYDROPHILIC PTA BALLOON DILA CATH 3 X 10 -,SUP-G57901,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ADVANCE SERENITY 14 HYDROPHILIC PTA BALLOON DILA CATH 3 X 22 -,SUP-G57903,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
US PRE PP-CA-422 DIR BALLOON CATHETER T3 20-23 150-40-20 -,SUP-G57911,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ADVANCE SERENITY 14 4MM x 100MM x 150CM -,SUP-G57915,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER BALLOON DIR SERENITY 14 4MM X 15CM 150CM -,SUP-G57916,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER US PRE PP-CA-422 DIR BALLOON  T3 20-23 -,SUP-G57917,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PIG 0.045IN 5FR PIG 125CM EXPO -,SUP-H749085262151,CDM,C1725,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP 0.014IN -,SUP-H7493895808200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP 0.014IN -,SUP-H7493895808300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP 0.014IN -,SUP-H7493895808400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X12MM APEX FLX UL-LPRO NC -,SUP-H7493895812150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X30MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895830250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,991.95,694.365,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X8MM APEX FLEX MONORAIL RX UL-LPRO NC -,SUP-H7493895908150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X12MM APEX FLEX MONORAIL RX UL-LPRO -,SUP-H7493895912150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X15MM APEX FLEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X20MM APEX FLEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B APEX MR  30MM X 2.50 MONORAIL RX -,SUP-H7493895930250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.0X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X8MM APEX OTW UL-LPRO F/PTCA OPTILEAP -,SUP-H7493896008150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X12MM APEX MONORAIL OTW UL-LPRO PSH -,SUP-H7493896012150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493896015150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X20MM APEX OTW UL-LPRO F/PTCA OPTILEAP -,SUP-H7493896020150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493896108150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X12MM APEX MONORAIL RX UL-LPRO PSH -,SUP-H7493896112150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X15MM APEX MONORAIL RX UL-LPRO -,SUP-H7493896115150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493896120150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
STERLING MONORAIL RAPID EXCHANGE 3 X 60 -,SUP-H74939031306010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON FG STERLING MR 4.5MM X 20MM X 135CM 4FR -,SUP-H74939031452010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2014.19,1409.933,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
STERLING MONORAIL .018 5X20X80CM 4F -,SUP-H74939031502080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6X20MM STERLNG MONORAIL 135CM RX LPRO COAX SEM-COM -,SUP-H74939031602010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH BALLOON STERLING 7.0MM X 40MM X 80CM 4FR FG MONORL -,SUP-H74939031704080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 10.0 X 60 135 -,SUP-H74939032106010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 10.0 X 80 135 -,SUP-H74939032108010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 4 X 10 X 135 39 -,SUP-H74939032401010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X220MM STERLNG 150CM OTW COAX SEM-COM PERIPH TAPR -,SUP-H74939032402210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 4.0 X 30 135 -,SUP-H74939032403010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 4 X 40 X 135 MA -,SUP-H74939032404010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 4.0 X 60 135 -,SUP-H74939032406010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1669.29,1168.503,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 4.0 X 80 135 -,SUP-H74939032408010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1669.29,1168.503,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 5 X 10 X 135 39 -,SUP-H74939032501010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 5.0 X 120 150 -,SUP-H74939032501210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 5.0 X 150 150 -,SUP-H74939032501510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 5.0 X 200 150 -,SUP-H74939032502110,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 5.0 X 220 150 -,SUP-H74939032502210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 5.0 X 30 135 -,SUP-H74939032503010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 5 X 4 X 135 390 -,SUP-H74939032504010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 5.0 X 60 135 -,SUP-H74939032506010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 5.0 X 80 135 -,SUP-H74939032508010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 6 X 10 X 135 39 -,SUP-H74939032601010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6X120MM 150CM -,SUP-H74939032601210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 6.0 X 150 150 -,SUP-H74939032601510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 6.0 X 200 150 -,SUP-H74939032602110,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 6.0 X 220 150 -,SUP-H7493903260221,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 6.0X30X135 -,SUP-H74939032603010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 6 X 4 X 135 390 -,SUP-H74939032604010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 6.0 X 80 135 -,SUP-H74939032608010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 7.0 X 100 135 -,SUP-H74939032701010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 7.0 X 120 150 -,SUP-H74939032701210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 7.0 X 150 150 -,SUP-H74939032701510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 7.0 X 200 150 -,SUP-H74939032702110,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 7.0 X 220 150 -,SUP-H74939032702210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 7.0 X 30 135 -,SUP-H74939032703010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 7.0 X 40 135 -,SUP-H74939032704010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 7.0 X 60 135 -,SUP-H74939032706010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 7.0 X 80 135 -,SUP-H74939032708010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 8.0 X 30 135 -,SUP-H74939032803010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 8.0 X 40 135 -,SUP-H74939032804010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 8.0 X 60 135 -,SUP-H74939032806010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 8.0 X 80 135 -,SUP-H74939032808010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 9.0 X 60 135 -,SUP-H74939032906010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B STERLING OTW 9.0 X 80 135 -,SUP-H74939032908010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4.5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912412200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X12MM NC QUANTM APEX MONORAIL UL-LPRO NC -,SUP-H7493912412270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X12MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912412320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X12MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912412370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X12MM NC QUANTM APEX MONORAIL RX UL -LPRO NC -,SUP-H7493912412400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4.5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912412450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912412500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X15MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912415270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X15MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912415320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X15MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912415370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4.5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912420200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X20MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912420270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X20MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912420320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X20MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912420370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4.5X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912420450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5 X 20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912430200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4732.06,3312.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4732.06,3312.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4.5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4.5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4.5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4.5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X40MM COYOTE ES MONORAIL 145CM RX SEM-COM PERIPH -,SUP-H74939134204010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON COYOTE 2.5MM X 40MM X 145CM  .014 -,SUP-H74939134254010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X20MM COYOTE ES 143CM OTW UL-LPRO SEM-COM PERIPH -,SUP-H74939134302010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X30MM COYOTE ES 144MM OTW UL-LPRO SEM-COM PERIPH -,SUP-H74939134303010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X40MM COYOTE ES 145CM OTW UL-LPRO SEM-COM PERIPH -,SUP-H74939134404010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X20MM COYOTE ES MONORAIL 143CM RX SEM-COM -,SUP-H74939135152010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X20MM COYOTE ES MONORAIL 143CM RX SEM-COM PERIPH -,SUP-H74939135202010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X20MM COYOTE ES MONORAIL 144CM RX SEM-COM PERIPH -,SUP-H74939135302010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X30MM COYOTE ES MONORAIL 145CM RX SEM-COM PERIPH -,SUP-H74939135303010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X40MM COYOTE ES MONORAIL 146CM RX SEM-COM PERIPH -,SUP-H74939135304010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X20MM COYOTE ES MONORAIL 144CM RX SEM-COM -,SUP-H74939135352010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X30MM COYOTE ES MONORAIL 145CM RX SEM-COM -,SUP-H74939135353010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X20MM COYOTE ES MONORAIL 144CM RX SEM-COM PERIPH -,SUP-H74939135402010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X30MM COYOTE ES MONORAIL 145CM RX SEM-COM PERIPH -,SUP-H74939135403010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X40MM COYOTE ES MONORAIL 146CM RX SEM-COM PERIPH -,SUP-H74939135404010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X100MM STERLNG SL 150CM OTW COAX SEM-COM PERIPH -,SUP-H74939148401510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 3.0 X 20 135CM -,SUP-H74939171030210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171030270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 3.0 X 40 135CM -,SUP-H74939171030410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
3MM X 40MM X 40CM MUSTANG -,SUP-H74939171030440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171030470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 3.0 X 60 135CM -,SUP-H74939171030610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
MUSTANG 3 X 60 X 75 -,SUP-H74939171030670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 3.0 X 80 135CM -,SUP-H74939171030810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 3.0 X 100 135C -,SUP-H74939171031010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 3.0 X 120 135C -,SUP-H74939171031210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 3.0 X 150 135C -,SUP-H74939171031510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 3.0 X 180 135C -,SUP-H74939171031810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 3.0 200 135CM -,SUP-H74939171032010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 4.0 X 20 135CM -,SUP-H74939171040210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171040270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 4.0 X 40 135CM -,SUP-H74939171040410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
MUSTANG 4MM X 40MM X 40CM -,SUP-H74939171040440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171040470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 4.0 X 60 135CM -,SUP-H74939171040610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171040670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 4.0 X 80 135CM -,SUP-H74939171040810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
MUSTANG 4MM X 80MM X 40CM -,SUP-H74939171040840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 4.0 X 100 135C -,SUP-H74939171041010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171041070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 4.0 X 120 135C -,SUP-H74939171041210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 4.0 X 150 135C -,SUP-H74939171041510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 4.0 X 180 135C -,SUP-H74939171041810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 4.0X200 135CM -,SUP-H74939171042010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 5.0 X 20 135CM -,SUP-H74939171050210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X30MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 5.0 X 40 135CM -,SUP-H74939171050410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
MUSTANG 5MM X 40MM X 40 CM -,SUP-H74939171050440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 5.0 X 60 135CM -,SUP-H74939171050610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 5.0 X 80 135CM -,SUP-H74939171050810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
MUSTANG 5MM X 80MM X 40CM -,SUP-H74939171050840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 5.0 X 100 135C -,SUP-H74939171051010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171051070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 5.0 X 120 135C -,SUP-H74939171051210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 5.0 X 150 135C -,SUP-H74939171051510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 5.0 180 135CM -,SUP-H74939171051810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 5.0 200 135CM -,SUP-H74939171052010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 6.0 X 20 135CM -,SUP-H74939171060210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 6.0 X 40 135CM -,SUP-H74939171060410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6X40MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1079.48,755.636,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
MUSTANG 6MM X 40MM X 40CM -,SUP-H74939171060440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 6.0 X 60 135CM -,SUP-H74939171060610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 6.0 X 80 135CM -,SUP-H74939171060810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
6MM X 80MM X 40CM MUSTANG PTA -,SUP-H74939171060840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
MUSTANG 6MM X 80MM X 40CM -,SUP-H74939171060840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 6.0 X 100 135C -,SUP-H74939171061010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 6.0 X 120 135C -,SUP-H74939171061210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6X150MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171061510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6X150MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171061570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 6.0 180 135CM -,SUP-H74939171061810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6X200MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171062010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 7.0 X 20 135CM -,SUP-H74939171070210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 7.0 X 40 135cm -,SUP-H74939171070410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
7MM X 40MM X 40CM MUSTANG -,SUP-H74939171070440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 7.0 X 60 135CM -,SUP-H74939171070610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7X80MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 7.0 X 100 135C -,SUP-H74939171071010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171071070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 7.0 X 120 135C -,SUP-H74939171071210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7X150MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171071510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7X150MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171071570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 7.0 180 135CM -,SUP-H74939171071810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7X200MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171072010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7X200MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171072070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 8.0 X 20 135CM -,SUP-H74939171080210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 8X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171080270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 8.0 X 40 135CM -,SUP-H74939171080410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
8MM X 40MM X 40CM MUSTANG -,SUP-H74939171080440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON MUSTANG 8MM X 40MM X 40CM -,SUP-H74939171080440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON MUSTANG 7.0MM X 80MM X 40CM -,SUP-H74939171080440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 8X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171080470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 8.0 X 60 135CM -,SUP-H74939171080610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 8.0 X 80 135CM -,SUP-H74939171080810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
8MM X 80MM X 40CM MUSTANG PTA -,SUP-H74939171080840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 8X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171080870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 8.0 X 100 135C -,SUP-H74939171081010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 8X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171081070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 8.0 X 120 135C -,SUP-H74939171081210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 8X150MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171081570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 8.0 180 135CM -,SUP-H74939171081810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 8X200MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171082010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 8X200MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171082070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 9.0 X 20 135CM -,SUP-H74939171090210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 9X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 9.0 X 40 135CM -,SUP-H74939171090410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 9X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 9X60MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 9X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 9.0 X 80 135CM -,SUP-H74939171090810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 9X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 10.0 X 20 135C -,SUP-H74939171100210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 10X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 10.0X40 135CM -,SUP-H74939171100410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
MUSTANG BALLOON 10MM X 40MM X 40CM -,SUP-H74939171100440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 10X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 10.0 X 60 135C -,SUP-H74939171100610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 10X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 10.0 X 80 135C -,SUP-H74939171100810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
MUSTANG 10MM X 80MM X 40CM -,SUP-H74939171100840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 10X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 12.0X20 135CM -,SUP-H74939171120210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 12X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171120270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 12.0X40 135CM -,SUP-H74939171120410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 12X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171120470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 12X60MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171120610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 12X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171120670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 12.0 X 80 135C -,SUP-H74939171120810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B MUSTANG PTA 12MM X 80MM 40CM -,SUP-H74939171120840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 1.5X40X150 -,SUP-H74939186150410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 2X60X150 -,SUP-H74939186200610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 2X80X150 -,SUP-H74939186200810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 2X100X150 -,SUP-H74939186201010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 2X120X150 -,SUP-H74939186201210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 2X220X150 -,SUP-H74939186202210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
COYOTE 2 X 220 -,SUP-H74939186202290,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 2.5X60X150 -,SUP-H74939186250610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 2.5X80X150 -,SUP-H74939186250810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OW 2.5X100X150 -,SUP-H74939186251010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OW 2.5X120X150 -,SUP-H74939186251210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OW 2.5X220X150 -,SUP-H74939186252210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 3X60X150 -,SUP-H74939186300610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 3X80X150 -,SUP-H74939186300810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 3X100X150 -,SUP-H74939186301010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 3X120X150 -,SUP-H74939186301210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 3X150X150 -,SUP-H74939186301510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 3X220X150 -,SUP-H74939186302210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 3.5X60X150 -,SUP-H74939186350610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 3.5X80X150 -,SUP-H7493918635081,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1637.85,1146.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OW 3.5X100X150 -,SUP-H74939186351010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OW 3.5X120X150 -,SUP-H74939186351210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OW 3.5X150X150 -,SUP-H74939186351510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OW 3.5X220X150 -,SUP-H74939186352210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 4X60X150 -,SUP-H74939186400610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 4X80X150 -,SUP-H74939186400810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 4X100X150 -,SUP-H74939186401010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1637.85,1146.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 4X120X150 -,SUP-H74939186401210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1637.85,1146.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 4X150X150 -,SUP-H74939186401510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH COYOTE OTW 4X220X150 -,SUP-H74939186402210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 1.20MM X 8MM -,SUP-H7493918908120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 1.50MM X 8MM -,SUP-H7493918908150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 2.00 MM X 8MM -,SUP-H7493918908200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 2.50 MM X 8MM -,SUP-H7493918908250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 2.75 MM X 8MM -,SUP-H7493918908270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 3.00 MM X 8MM -,SUP-H7493918908300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 3.25 MM X 8MM -,SUP-H7493918908320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 3.50 MM X 8MM -,SUP-H7493918908350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 3.75 MM X 8MM -,SUP-H7493918908370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 4.00MM X 8MM -,SUP-H7493918908400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 1.20MM X 12MM -,SUP-H7493918912120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 1.50MM X 12MM -,SUP-H7493918912150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 2.00 MM X 12 MM -,SUP-H7493918912200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 2.25 MM X 12MM -,SUP-H7493918912220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 2.50 MM X 12 MM -,SUP-H7493918912250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 2.75 MM X 12MM -,SUP-H7493918912270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 3.00 MM X 12MM -,SUP-H7493918912300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 3.25 MM X 12MM -,SUP-H7493918912320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 3.50 MM X 12MM -,SUP-H7493918912350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 3.75 MM X 12MM -,SUP-H7493918912370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 4.00MM X 12MM -,SUP-H7493918912400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 1.20MM X 15MM -,SUP-H7493918915120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 1.50MM X 15MM -,SUP-H7493918915150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 2.00 MM X 15 MM -,SUP-H7493918915200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 2.25 MM X 15MM -,SUP-H7493918915220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 2.50 MM X 15MM -,SUP-H7493918915250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 2.75 MM X 15MM -,SUP-H7493918915270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 3.00 MM X 15MM -,SUP-H7493918915300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 3.25 MM X 15MM -,SUP-H7493918915320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 3.50 MM X 15MM -,SUP-H7493918915350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 3.75 MM X 15MM -,SUP-H7493918915370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 4.00MM X 15MM -,SUP-H7493918915400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 1.20MM X 20MM -,SUP-H7493918920120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 1.50MM X 20MM -,SUP-H7493918920150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 2.00 MM X 20 MM -,SUP-H7493918920200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 2.25 MM X 20MM -,SUP-H7493918920220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 2.50 MM X 20 MM -,SUP-H7493918920250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 2.75 MM X 20MM -,SUP-H7493918920270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 3.00 MM X 20 MM -,SUP-H7493918920300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 3.25 MM X 20MM -,SUP-H7493918920320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 3.50 MM X 20MM -,SUP-H7493918920350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 3.75 MM X 20MM -,SUP-H7493918920370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 4.00MM X 20MM -,SUP-H7493918920400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 2.00 MM X 30MM -,SUP-H7493918930200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 2.25 MM X 30MM -,SUP-H7493918930220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 2.50 MM X 30MM -,SUP-H7493918930250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 2.75 MM X 30MM -,SUP-H7493918930270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 3.00 MM X 30MM -,SUP-H7493918930300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 3.25 MM X 30MM -,SUP-H7493918930320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 3.50 MM X 30MM -,SUP-H7493918930350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 3.75 MM X 30MM -,SUP-H7493918930370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE MR 4.00MM X 30MM -,SUP-H7493918930400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE PUSH MR 1.20MM X 8MM -,SUP-H7493919008120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE PUSH MR 1.50MM X 8MM -,SUP-H7493919008150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE PUSH MR 1.20MM X 12MM -,SUP-H7493919012120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE PUSH MR 1.50MM X 12MM -,SUP-H7493919012150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE PUSH MR 1.20MM X 15MM -,SUP-H7493919015120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE PUSH MR 1.50MM X 15MM -,SUP-H7493919015150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE PUSH MR 1.20MM X 20MM -,SUP-H7493919020120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE PUSH MR 1.50MM X 20MM -,SUP-H7493919020150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 1.20MM X 8MM -,SUP-H7493919108120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 1.50MM X 8MM -,SUP-H7493919108150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 2.00MM X 8MM -,SUP-H7493919108200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 2.25MM X 8MM -,SUP-H7493919108220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 2.50MM X 8MM -,SUP-H7493919108250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 2.75MM X 8MM -,SUP-H7493919108270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 3.00MM X 8MM -,SUP-H7493919108300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 3.25MM X 8MM -,SUP-H7493919108320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 3.50MM X 8MM -,SUP-H7493919108350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 3.75MM X 8MM -,SUP-H7493919108370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 4.00MM X 8MM -,SUP-H7493919108400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 1.20MM X 12MM -,SUP-H7493919112120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 1.50MM X 12MM -,SUP-H7493919112150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 2.00MM X 12MM -,SUP-H7493919112200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 2.25MM X 12MM -,SUP-H7493919112220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 2.50MM X 12MM -,SUP-H7493919112250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 2.75MM X 12MM -,SUP-H7493919112270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 3.00MM X 12MM -,SUP-H7493919112300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 3.25MM X 12MM -,SUP-H7493919112320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 3.50MM X 12MM -,SUP-H7493919112350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 3.75MM X 12MM -,SUP-H7493919112370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 4.00MM X 12MM -,SUP-H7493919112400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 1.20MM X 15MM -,SUP-H7493919115120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 1.50MM X 15MM -,SUP-H7493919115150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 2.00MM X 15MM -,SUP-H7493919115200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 2.25MM X 15MM -,SUP-H7493919115220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 2.50MM X 15MM -,SUP-H7493919115250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 2.75MM X 15MM -,SUP-H7493919115270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 3.00MM X 15MM -,SUP-H7493919115300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 3.25MM X 15MM -,SUP-H7493919115320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 3.50MM X 15MM -,SUP-H7493919115350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 3.75MM X 15MM -,SUP-H7493919115370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 4.00MM X 15MM -,SUP-H7493919115400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 1.20MM X 20MM -,SUP-H7493919120120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 1.50MM X 20MM -,SUP-H7493919120150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 2.25MM X 20MM -,SUP-H7493919120220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 2.50MM X 20MM -,SUP-H7493919120250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 2.75MM X 20MM -,SUP-H7493919120270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 3.00MM X 20MM -,SUP-H7493919120300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 3.25MM X 20MM -,SUP-H7493919120320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 3.50MM X 20MM -,SUP-H7493919120350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 3.75MM X 20MM -,SUP-H7493919120370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 4.00MM X 20MM -,SUP-H7493919120400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 2.00MM X 30MM -,SUP-H7493919130200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 2.00MM X 20MM -,SUP-H7493919130200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 2.25MM X 30MM -,SUP-H7493919130220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 2.50MM X 30MM -,SUP-H7493919130250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 2.75MM X 30MM -,SUP-H7493919130270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 3.00MM X 30MM -,SUP-H7493919130300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 3.25MM X 30MM -,SUP-H7493919130320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 3.50MM X 30MM -,SUP-H7493919130350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 3.75MM X 30MM -,SUP-H7493919130370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE OTW 4.00MM X 30MM -,SUP-H7493919130400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE PUSH OTW 1.20MM X 8MM -,SUP-H7493919208120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE PUSH OTW 1.50MM X 8MM -,SUP-H7493919208150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE PUSH OTW 1.20MM X 12MM -,SUP-H7493919212120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE PUSH OTW 1.50MM X 12MM -,SUP-H7493919212150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE PUSH OTW 1.20MM X 15MM -,SUP-H7493919215120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE PUSH OTW 1.50MM X 15MM -,SUP-H7493919215150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE PUSH OTW 1.20MM X 20MM -,SUP-H7493919220120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON EMERGE PUSH OTW 1.50MM X 20MM -,SUP-H7493919220150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER BALLOON 3 X 20 X 135 -,SUP-H74939206030210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER BALLOON 3 X 20 X 75 -,SUP-H74939206030270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER BALLOON 3MM X 40MM X 130CM -,SUP-H74939206030410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER BALLOON 3MM X 80MM X 135CM -,SUP-H74939206030810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
3MM X 100MM X 135CM CHARGER -,SUP-H74939206031010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CHARGER 3MM X 120MM -,SUP-H74939206031210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
3.0MM X 150MM X 135CM CHARGER BALLOON -,SUP-H74939206031510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER 3MM X 200MM X 135CM -,SUP-H74939206032010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER OTW 4 X 20MM X135CM BALLOON -,SUP-H74939206040210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
4MM X 20MM X 75CM CHARGER BALLOON -,SUP-H74939206040270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
PTA BALLOON 5F -,SUP-H74939206040670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER BALLOON 4MM X 80MM X 75CM -,SUP-H74939206040870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER 4MM X 100MM X 135CM -,SUP-H74939206041010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
4MM X 100MM X 75CM CHARGER BALLOON -,SUP-H74939206041070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER BALLOON 4MM X 150MM X 135CM -,SUP-H74939206041510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
5MM X 20MM X 75CM .035 CHARGER SHORT SHAFT -,SUP-H74939206050270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER 5MM X 40MM X 135CM -,SUP-H74939206050410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER BALLOON 5MM X 60MM X 135CM -,SUP-H74939206050610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER BALLOON 5MM X 80MM X 135CM -,SUP-H74939206050810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
5MM X 80MM X 75CM CHARGER BALLOON -,SUP-H74939206050870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER 5MM X 100MM X 135CM -,SUP-H74939206051010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER 5MM X 120MM X 135CM -,SUP-H74939206051210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER BALLOON 5 X 150MM -,SUP-H74939206051510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
5MM X 200MM X 135CM CHARGER -,SUP-H74939206052010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
6MM X 20MM X 135CM CHARGER -,SUP-H74939206060210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
6MM X 20MM X 75CM .035 CHARGER SHORT SHAFT -,SUP-H74939206060270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER BALLOON 6MM X 40MM X 135CM -,SUP-H74939206060410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER 6MM X 40MM X 75CM BALLOON -,SUP-H74939206060470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
6.0MM X 60MM X 75CM CHARGER -,SUP-H74939206060670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
6MM X 8MM X 135CM CHARGER -,SUP-H74939206060810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER 6.0MM X 80MM X 75CM -,SUP-H74939206060870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER BALLOON 6MM X 100MM X 135CM -,SUP-H74939206061010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER 6MM X 100MM X 75CM -,SUP-H74939206061070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER BALLOON 6MM X 150MM X 135CM -,SUP-H74939206061510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
7MM X 20MM X 135CM CHARGER -,SUP-H74939206070210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
7MM X 40MM X 135CM CHARGER BALLOON -,SUP-H74939206070410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
7MM X 40MM X 75CM CHARGER BALLOON -,SUP-H74939206070470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER 7MM X 80MM X 135CM -,SUP-H74939206070610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER BALLOON .035 7MM X 60MM X 75CM -,SUP-H74939206070670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
7MM X 80MM X 75CM CHARGER BALLOON -,SUP-H74939206070870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
7MM X 100MM X 135CM CHARGER BALLOON -,SUP-H74939206071010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
7MM X 100MM X 75CM CHARGER PTA -,SUP-H74939206071070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER BALLOON 8MM X 40MM X 135CM -,SUP-H74939206080410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER 8MM X 40MM X 75CM -,SUP-H74939206080470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
8MM X 60MM X 75CM CHARGER PTA -,SUP-H74939206080670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
8MM X 80MM X 135CM CHARGER BALLOON -,SUP-H74939206080810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
8.0MM X 80MM X 75CM CHARGER -,SUP-H74939206080870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER PTA 8MM X 100MM X 135CM -,SUP-H74939206081010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
8MM X 100MM X 75CM CHARGER PTA -,SUP-H74939206081070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER 8MM X 180MM X 135CM -,SUP-H74939206081810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
8.0MM X 200MM X 135XM CHARGER BALLOON -,SUP-H74939206082010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
9MM X 40MM X 135CM CHARGER BALLOON -,SUP-H74939206090410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
9MM X 40MM X 75CM CHARGER BALLOON -,SUP-H74939206090470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CHARGER 9MM X 60MM X 75CM -,SUP-H74939206090670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER OTW 10 X 20 BALLOON 135CM -,SUP-H74939206100210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CHARGER .035 10MM X 40MM X 135CM -,SUP-H74939206100410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
10MM X 40MM X 75CM CHARGER PTA -,SUP-H74939206100470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
10.0MM X 80MM X 75CM CHARGER BALLOON -,SUP-H74939206100870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
12MM X 20MM X 75CM CHARGER -,SUP-H74939206120270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
12MM X 40MM X 135CM CHARGER -,SUP-H74939206120410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
12MM X 40MM X 75CM CHARGER -,SUP-H74939206120470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CHARGER 12MM X 60MM X 75CM -,SUP-H74939206120670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CHARGER 12MM X 80MM X 75CM -,SUP-H74939206120870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.00MM x 6MM -,SUP-H7493926706200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.25MM x 6MM -,SUP-H7493926706220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.50MM x 6MM -,SUP-H7493926706250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.75MM x 6MM -,SUP-H7493926706270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.00MM x 6MM -,SUP-H7493926706300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.25MM x 6MM -,SUP-H7493926706320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.50MM x 6MM -,SUP-H7493926706350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.75MM x 6MM -,SUP-H7493926706370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 4.00MM X 6MM -,SUP-H7493926706400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 4.50MM x 6MM -,SUP-H7493926706450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 5.00MM x 6MM -,SUP-H7493926706500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.00MM x 8MM -,SUP-H7493926708200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.25MM x 8MM -,SUP-H7493926708220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.50MM x 8MM -,SUP-H7493926708250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.75MM x 8MM -,SUP-H7493926708270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.00MM x 8MM -,SUP-H7493926708300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.25MM x 8MM -,SUP-H7493926708320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.50MM x 8MM -,SUP-H7493926708350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.75MM x 8MM -,SUP-H7493926708370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 4.0 MM X 8 MM -,SUP-H7493926708400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 4.50MM x 8MM -,SUP-H7493926708450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 5.00MM x 8MM -,SUP-H7493926708500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 5.50MM x 8MM -,SUP-H7493926708550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 6.00MM x 8MM -,SUP-H7493926708600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.00MM X 12MM -,SUP-H7493926712200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.25MM x 12MM -,SUP-H7493926712220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.50 MM X 12 MM -,SUP-H7493926712250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.75MM x 12MM -,SUP-H7493926712270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.00MM x 12MM -,SUP-H7493926712300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.25MM x 12MM -,SUP-H7493926712320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.50MM x 12MM -,SUP-H7493926712350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.75MM x 12MM -,SUP-H7493926712370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 4.00MM x 12MM -,SUP-H7493926712400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 4.50MM x 12MM -,SUP-H7493926712450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 5.0 MM X 12 MM -,SUP-H7493926712500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 5.50MM x 12MM -,SUP-H7493926712550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 6.00MM x 12MM -,SUP-H7493926712600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.00MM x 15MM -,SUP-H7493926715200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.25MM x 15MM -,SUP-H7493926715220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.50 MM X 15 MM -,SUP-H7493926715250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.75MM x 15MM -,SUP-H7493926715270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.0 MM X 15 MM -,SUP-H7493926715300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.25MM x 15MM -,SUP-H7493926715320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.50MM x 15MM -,SUP-H7493926715350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.75MM x 15MM -,SUP-H7493926715370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 4.00MM X 15MM -,SUP-H7493926715400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 4.50MM x 15MM -,SUP-H7493926715450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 5.00MM x 15MM -,SUP-H7493926715500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 5.50MM x 15MM -,SUP-H7493926715550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 6.00MM x 15MM -,SUP-H7493926715600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.00MM x 20MM -,SUP-H7493926720200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.25MM x 20MM -,SUP-H7493926720220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.50 MM X 20 MM -,SUP-H7493926720250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.75MM x 20MM -,SUP-H7493926720270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.0 MM X 20 MM -,SUP-H7493926720300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.25MM x 20MM -,SUP-H7493926720320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.50MM x 20MM -,SUP-H7493926720350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.75MM x 20MM -,SUP-H7493926720370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 4.00MM x 20MM -,SUP-H7493926720400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 4.50MM x 20MM -,SUP-H7493926720450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 5.00MM x 20MM -,SUP-H7493926720500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 5.50MM x 20MM -,SUP-H7493926720550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 6.00MM x 20MM -,SUP-H7493926720600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.00MM x 30MM -,SUP-H7493926730200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.25MM x 30MM -,SUP-H7493926730220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.50MM x 30MM -,SUP-H7493926730250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 2.75MM x 30MM -,SUP-H7493926730270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.00MM x 30MM -,SUP-H7493926730300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.25MM x 30MM -,SUP-H7493926730320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.50MM x 30MM -,SUP-H7493926730350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 3.75MM x 30MM -,SUP-H7493926730370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE MR 4.00MM x 30MM -,SUP-H7493926730400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.00MM x 6MM -,SUP-H7493926806200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.25MM x 6MM -,SUP-H7493926806220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.50MM x 6MM -,SUP-H7493926806250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.75MM x 6MM -,SUP-H7493926806270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.00MM x 6MM -,SUP-H7493926806300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.25MM x 6MM -,SUP-H7493926806320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.50MM x 6MM -,SUP-H7493926806350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.75MM x 6MM -,SUP-H7493926806370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 4.00MM x 6MM -,SUP-H7493926806400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 4.50MM x 6MM -,SUP-H7493926806450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 5.00MM x 6MM -,SUP-H7493926806500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.00MM x 8MM -,SUP-H7493926808200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.25MM x 8MM -,SUP-H7493926808220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.50MM x 8MM -,SUP-H7493926808250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.75MM x 8MM -,SUP-H7493926808270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.00MM x 8MM -,SUP-H7493926808300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.25MM x 8MM -,SUP-H7493926808320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.50MM x 8MM -,SUP-H7493926808350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.75MM x 8MM -,SUP-H7493926808370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 4.00MM x 8MM -,SUP-H7493926808400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 4.50MM x 8MM -,SUP-H7493926808450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 5.00MM x 8MM -,SUP-H7493926808500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 5.50MM x 8MM -,SUP-H7493926808550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 6.00MM x 8MM -,SUP-H7493926808600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.00MM x 12MM -,SUP-H7493926812200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.25MM x 12MM -,SUP-H7493926812220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.50MM x 12MM -,SUP-H7493926812250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.75MM X 12MM -,SUP-H7493926812270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.00MM x 12MM -,SUP-H7493926812300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.25MM x 12MM -,SUP-H7493926812320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.50MM x 12MM -,SUP-H7493926812350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.75MM x 12MM -,SUP-H7493926812370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 4.00MM x 12MM -,SUP-H7493926812400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 4.50MM x 12MM -,SUP-H7493926812450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 5.00MM x 12MM -,SUP-H7493926812500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 5.50MM x 12MM -,SUP-H7493926812550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 6.00MM x 12MM -,SUP-H7493926812600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.00MM x 15MM -,SUP-H7493926815200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.25MM x 15MM -,SUP-H7493926815220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.50MM x 15MM -,SUP-H7493926815250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.75MM x 15MM -,SUP-H7493926815270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.00MM x 15MM -,SUP-H7493926815300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.25MM x 15MM -,SUP-H7493926815320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.50MM x 15MM -,SUP-H7493926815350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.75MM x 15MM -,SUP-H7493926815370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 4.00MM x 15MM -,SUP-H7493926815400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 4.50MM x 15MM -,SUP-H7493926815450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 5.00MM x 15MM -,SUP-H7493926815500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 5.50MM x 15MM -,SUP-H7493926815550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 6.00MM x 15MM -,SUP-H7493926815600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.00MM x 20MM -,SUP-H7493926820200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.25MM x 20MM -,SUP-H7493926820220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.50MM x 20MM -,SUP-H7493926820250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.75MM x 20MM -,SUP-H7493926820270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.00MM x 20MM -,SUP-H7493926820300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.25MM x 20MM -,SUP-H7493926820320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.50MM x 20MM -,SUP-H7493926820350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.75MM x 20MM -,SUP-H7493926820370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 4.00MM x 20MM -,SUP-H7493926820400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 4.50MM x 20MM -,SUP-H7493926820450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 5.00MM x 20MM -,SUP-H7493926820500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 5.50MM x 20MM -,SUP-H7493926820550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 6.00MM x 20MM -,SUP-H7493926820600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.00MM x 30MM -,SUP-H7493926830200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.25MM x 30MM -,SUP-H7493926830220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.50MM x 20MM -,SUP-H7493926830250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 2.75MM x 30MM -,SUP-H7493926830270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.00MM x 30MM -,SUP-H7493926830300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.25MM x 30MM -,SUP-H7493926830320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.50MM x 30MM -,SUP-H7493926830350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 3.75MM x 30MM -,SUP-H7493926830370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NC EMERGE OTW 4.00MM x 30MM -,SUP-H7493926830400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CUTTING 6MMX2.0MM WOLVERINE -,SUP-H74939401062000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CUTTING 6MMX2.5MM WOLVERINE -,SUP-H74939401062500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CUTTING 6MMX3.0MM WOLVERINE -,SUP-H74939401063000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CUTTING 6MMX3.5MM WOLVERINE -,SUP-H74939401063500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CUTTING 6MMX4.0MM WOLVERINE -,SUP-H74939401064000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CUTTING 10MMX2.0MM WOLVERINE -,SUP-H74939401102000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CUTTING 10MMX2.5MM WOLVERINE -,SUP-H74939401102500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CUTTING 10MMX3.0MM WOLVERINE -,SUP-H74939401103000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CUTTING 10MMX3.5MM WOLVERINE -,SUP-H74939401103500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CUTTING 10MMX4.0MM WOLVERINE -,SUP-H74939401104000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CUTTING 15MX2.00MM WOLVERINE -,SUP-H74939401152000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CUTTING 15MX2.50MM WOLVERINE -,SUP-H74939401152500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON CUTTING 15MMX3.0MM WOLVERINE -,SUP-H74939401153000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
RANGER GLOBAL DCB OTW 6.0 X 150MM 150CM -,SUP-H74939419601510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
RANGER DCB OTW  7.0MM x 40MM x 80CM -,SUP-H74939419700480,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT BLN -,SUP-H749CBM3200100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X6MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3225060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3225100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X6MM FLEXTOME CUT BLN MONORAIL 142CM RX -,SUP-H749CBM3250060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3250100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3250150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3275100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3275150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT BLN -,SUP-H749CBM3300100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT BLN -,SUP-H749CBM3300150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3325100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X15MM FLEXTOME CUT BLN MONORAIL 142CM RX -,SUP-H749CBM3325150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3350100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3350150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3375100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3200060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3200100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3225060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3225100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X15MM FLEXTOME BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3225150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3250060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3250100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X15MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3250150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3275100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X15MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3275150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3300060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X15MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3300150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3325100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X15MM FLEXTOME CUT BLN 142CM CUT BLN NC -,SUP-H749CBO3325150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN -,SUP-H749CBO3350100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH DX 2.4FR ID 3.4FR RND TIP 135CM CROSSBOSS XING MUL-WIRE -,SUP-H749M2000A0,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4648.07,3253.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH ANG 0.045IN 5FR FR4 125CM EXPO FUL-R WIRE BRD ROBST -,SUP-H759085262251,CDM,C1725,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER IABP 7.5FR 40CC ULTRA FLEX REF: IAB-06840-U -,SUP-IAB-06840-U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER IABP 8FR 40CC REDIGUARD REF: IAB-S840C -,SUP-IAB-S840C,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4010.16,2807.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
INFLATION KIT 30/30 BASIX -,SUP-IN4530,CDM,C1725,HCPCS,272,RC,,,outpatient,,,364.57,255.199,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X220MM LUTONIX -,SUP-LX3513052205F,CDM,C1725,HCPCS,272,RC,,,outpatient,,,8063.6,5644.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
LUTONIX BALLOON 7MM X 80MM -,SUP-LX351307805F,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5305,3713.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
LUTONIX PTA 5MM X 60MM X 75CM -,SUP-LX3575560V,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
LUTONIX BALLOON 7 X 80 -,SUP-LX3575780V,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
LUTONIX 8 X 80 -,SUP-LX3575880V,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B XXL 14MM 4CM 75 14-514 -,SUP-M001145140,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH XXL VASC 12 X 6 X 75CM -,SUP-M001145300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 14X60MM 2XL 75CM LPRO F/PTA PERIPH NYBAX LUB -,SUP-M001145320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON XXL 16 X 4  5.8/120 -,SUP-M001145530,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON XXL 16 X 4 X 75 -,SUP-M001145530,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 16X60MM 2XL 75CM LPRO PERIPH NYBAX LUB BIOSLD CTD -,SUP-M001145540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH XXL 18MM X 4CM 120CM -,SUP-M001145580,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH DIL 18MM 8FR SHEA 0.037IN TIP 5.8FRX75CM 6CM BLN GALWAY -,SUP-M001145590,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X40MM ULTR-THN DMD 75CM F/PTA PERIPH 5FR SHTH -,SUP-M001164230,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6X20MM ULTR-THN DMD 75CM F/PTA PERIPH 5FR SHTH -,SUP-M001164570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7X20MM ULTR-THN DMD 75CM F/PTA PERIPH 5FR SHTH -,SUP-M001164770,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B DUT 8MM 4CM 75CM  16-505 -,SUP-M001165050,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
AST-GN45 -,SUP-M001NC20000001,CDM,C1725,HCPCS,272,RC,,,outpatient,,,358.85,251.195,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7X40MM POLAR 120CM COAX F/PTA CLD THRP PERIPH -,SUP-M001P740120010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2807.11,1964.977,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7X60MM POLAR 120CM COAX F/PTA CLD THRP PERIPH -,SUP-M001P760120010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2807.11,1964.977,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 8X20MM POLAR 120CM COAX F/PTA CLD THRP PERIPH -,SUP-M001P820120010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
DEVICE INFL POLAR N2O -,SUP-M001PCIU400000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4927.28,3449.096,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X40MM POLAR 150CM COAX F/PTA CLD THRP PERIPH -,SUP-M001T3040150010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X40MM POLAR 150CM COAX F/PTA CLD THRP PERIPH -,SUP-M001T4040150010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
RETRACTOR ORTHO HHMN 18MMX9.25IN STN FNSH SS V. MUELLER -,SUP-M001T5040135010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6X40MM POLAR 135CM COAX F/PTA CLD THRP PERIPH -,SUP-M001T6040135010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER  SHOCKWAVE M5+ IVL CATHETER 5.0X60MM -,SUP-M5PIVL5060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER SHOCKWAVE 5.5 X 60 MM M5+ -,SUP-M5PIVL5560,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER- SHOCKWAVE M5+ IVL CATHETER- 6.0X60MM -,SUP-M5PIVL6060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER- SHOCKWAVE M5+ IVL CATHETER- 7.0X60MM -,SUP-M5PIVL7060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER- SHOCKWAVE M5+ IVL CATHETER- 8.0X60MM -,SUP-M5PIVL8060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP2006X NCEUPHORA RX -,SUP-NCEUP2006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP2008X NCEUPHORA RX -,SUP-NCEUP2008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP2012X NCEUPHORA RX -,SUP-NCEUP2012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP2015X NCEUPHORA RX -,SUP-NCEUP2015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP2020X NCEUPHORA RX -,SUP-NCEUP2020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP22506X NCEUPHORA RX -,SUP-NCEUP22506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP22508X NCEUPHORA RX -,SUP-NCEUP22508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP22512X NCEUPHORA RX -,SUP-NCEUP22512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP22515X NCEUPHORA RX -,SUP-NCEUP22515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP22520X NCEUPHORA RX -,SUP-NCEUP22520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP2506X NCEUPHORA RX -,SUP-NCEUP2506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP2508X NCEUPHORA RX -,SUP-NCEUP2508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP2512X NCEUPHORA RX -,SUP-NCEUP2512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP2515X NCEUPHORA RX -,SUP-NCEUP2515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP2520X NCEUPHORA RX -,SUP-NCEUP2520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP2527X NCEUPHORA RX -,SUP-NCEUP2527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP27506X NCEUPHORA RX -,SUP-NCEUP27506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP27508X NCEUPHORA RX -,SUP-NCEUP27508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP27512X NCEUPHORA RX -,SUP-NCEUP27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP27515X NCEUPHORA RX -,SUP-NCEUP27515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP27520X NCEUPHORA RX -,SUP-NCEUP27520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP27527X NCEUPHORA RX -,SUP-NCEUP27527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP3006X NCEUPHORA RX -,SUP-NCEUP3006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP3008X NCEUPHORA RX -,SUP-NCEUP3008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP3012X NCEUPHORA RX -,SUP-NCEUP3012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP3015X NCEUPHORA RX -,SUP-NCEUP3015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP3020X NCEUPHORA RX -,SUP-NCEUP3020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP3027X NCEUPHORA RX -,SUP-NCEUP3027X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP32506X NCEUPHORA RX -,SUP-NCEUP32506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP32508X NCEUPHORA RX -,SUP-NCEUP32508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP32512X NCEUPHORA RX -,SUP-NCEUP32512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP32515X NCEUPHORA RX -,SUP-NCEUP32515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP32520X NCEUPHORA RX -,SUP-NCEUP32520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP32527X NCEUPHORA RX -,SUP-NCEUP32527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP3506X NCEUPHORA RX -,SUP-NCEUP3506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP3508X NCEUPHORA RX -,SUP-NCEUP3508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP3512X NCEUPHORA RX -,SUP-NCEUP3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP3515X NCEUPHORA RX -,SUP-NCEUP3515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP3520X NCEUPHORA RX -,SUP-NCEUP3520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP3527X NCEUPHORA RX -,SUP-NCEUP3527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP37506X NCEUPHORA RX -,SUP-NCEUP37506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP37508X NCEUPHORA RX -,SUP-NCEUP37508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP37512X NCEUPHORA RX -,SUP-NCEUP37512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP37515X NCEUPHORA RX -,SUP-NCEUP37515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP37520X NCEUPHORA RX -,SUP-NCEUP37520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP37527X NCEUPHORA RX -,SUP-NCEUP37527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP4006X NCEUPHORA RX -,SUP-NCEUP4006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP4008X NCEUPHORA RX -,SUP-NCEUP4008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP4012X NCEUPHORA RX -,SUP-NCEUP4012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP4015X NCEUPHORA RX -,SUP-NCEUP4015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP4020X NCEUPHORA RX -,SUP-NCEUP4020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP4027X NCEUPHORA RX -,SUP-NCEUP4027X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP4508X NCEUPHORA RX -,SUP-NCEUP4508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP4512X NCEUPHORA RX -,SUP-NCEUP4512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP4515X NCEUPHORA RX -,SUP-NCEUP4515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP4520X NCEUPHORA RX -,SUP-NCEUP4520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP5008X NCEUPHORA RX -,SUP-NCEUP5008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP5012X NCEUPHORA RX -,SUP-NCEUP5012,CDM,C1725,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
BALLOON NCEUP5015X NCEUPHORA RX -,SUP-NCEUP5015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X6MM NC STRMR 138CM OTW NC COR 3- FOLD FLCRM + -,SUP-NCS2506W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X11MM NC STRMR 138CM OTW NC COR 3- FOLD FLCRM + -,SUP-NCS2511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS2514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X6MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS27506W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X11MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM -,SUP-NCS27511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS27514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X16MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS27516W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X6MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS3006W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X11MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS3011W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS3014W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X16MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS3016W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X11MM NC STRMR 138CM OTW NC COR 5- FOLD FLCRM -,SUP-NCS32511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS32514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X11MM NC STRMR 138CM OTW NC COR 5- FOLD FLCRM + -,SUP-NCS3511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X16MM NC STRMR 138CM OTW NC COR 5- FOLD FLCRM + -,SUP-NCS3516W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X11MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS37511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS37514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X11MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS4011W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X16MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS4016W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X21MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS4021W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X6MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP2506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP2512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP2515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X6MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP27506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X21MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP27521X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X6MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT FLCRM -,SUP-NCSP3006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X21MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3021X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X12MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP32512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X15MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP32515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X27MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X12MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP37512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.75X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP37515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X21MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4021X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4.5X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5X15MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP5015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
PALADIN CAROTID PTA CATHETER WITH INTEGRATED EMB PRO -,SUP-PD-5520-140-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER ADVANCE MICRO 14 ULTRA LOW PROFILE BALLOON -,SUP-PTA3-14-90-2.5-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2289.76,1602.832,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER PTA BALLOON DILATION 18LP ADVANCE LP 2MM X 20CM -,SUP-PTA4-18-150-2-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX10CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX6CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-8,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
B CATH ADVANCE 18LP 5X10 150 -,SUP-PTA4-18-150-510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-5-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-5-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX6CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-5-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX10CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-6-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-6-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH ANG 4FR 0.018/ 150CM/6MM DIA 6CM ADVANCE RNL POPLT PTA -,SUP-PTA4-18-150-6-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MMX10CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-710,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MMX6CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 7MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-8,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 10MMX3CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-PTA5-35-135-103,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-PTA5-35-135-44,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-PTA5-35-13562.0,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 8MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-PTA5-35-135-8-8,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-PTAX4141702.520,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-PTAX414170312,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 26MM 12FRX2.5CM INOUE 70CM PVC 0.025IN GW COMP -,SUP-PTMC-26,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10025.1,7017.57,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 28MM 12FRX2.5CM INOUE 70CM PVC 0.025IN GW COMP -,SUP-PTMC-28,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10025.1,7017.57,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 30MM 12FRX2.5CM INOUE 70CM PVC 0.025IN GW COMP -,SUP-PTMC-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10025.1,7017.57,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
SHOCKWAVE 3.0 X 40MM IVL KIT -,SUP-S4IVLK3040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ADV SERENITY 14 HYDROPHILIC PTA BALL DIL CATH 2.5X60X150CM -,SUP-SER14-150-25-60,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ADVANCE SERENITY 14 HYDROPHILIC PTA BALLOON DIL CATH -,SUP-SER14-150-30-60,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.25X6MM SPRINTER LEGEND 152CM OTW SEM-COM COR -,SUP-SPL12506WL,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.25X6MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.25X10MM SPRINTER LEGEND 152CM OTW SEM-COM COR -,SUP-SPL12510WL,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.25X10MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.25X12MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.25X15MM SPRINTER LEGEND 152CM OTW SEM-COM COR -,SUP-SPL12515WL,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.25X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X6MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL15006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL15012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL15015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL20012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL20015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X20MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL20020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X6MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL22506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL22515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL25012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL25015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X20MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL25020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X25MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL25025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X12MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL27515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X20MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL27520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL30012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL30015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X20MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL30020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X12MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL40012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL40015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR1512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 1.5X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR1515W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2012W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2015W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X20MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2020W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X25MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2025W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.25X12MM SPRINTER 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR22512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X6MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2506W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2515W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5X20MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2520W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR27512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.75X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR27515W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3012W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3015W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3X20MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3020W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.25X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR32512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3.5X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR4015W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ENROUTE ENFLATE TRANSCAROTID RX BALLOON -,SUP-SR-4525-BC,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2008.89,1406.223,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
ENROUTE ENFLATE TRANSCAROTID RX BALLOON -,SUP-SR-5035-BC,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2008.89,1406.223,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH ANG 4FR STR 125CM TEMPO AQ SLCT BRD SHFT NO SH NYL -,SUP-SRD6667,CDM,C1725,HCPCS,272,RC,,,outpatient,,,269.58,188.706,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER BALLOON TRUE FLOW 24 MM x 3.5CM REF: TF0243514 -,SUP-TF0243514,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6153.8,4307.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CABLE ADPTR IABP -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,344.79,241.353,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4X15MM 140CM OTW PERIPH -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4134.28,2893.996,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH SHEATH RITESITE C315H1802 -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2X15MM 140CM OTW PERIPH -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4134.28,2893.996,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2MMX2CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V142020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V142040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 2.5MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V142540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3MMX2CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V143020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3319.12,2323.384,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V143040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 3MMX6CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V143060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX12CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V1840120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 4MMX8CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V184080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V185040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 5MMX6CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V185060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATH PTCA 6MMX12CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V1860120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
CATHETER PTV DILATATION 26MX4CM VIDA REF:VDA100264 -,SUP-VDA100264,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2802.82,1961.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.650485,9184.66245,other,OPPS APC,,
DILATOR 6-30FR DIA TIP 30CM PE/PTFE -,SUP-118768,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1395.36,976.752,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
LEAD DEFIB IMPL BIPLR PERMNT PCNG ETAK RELIANCE G_59CM -,SUP-5843,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
KT MNMTRY BLN ADLT RCTL BLN -,SUP-A86-1070,CDM,C1726,HCPCS,272,RC,,,outpatient,,,52.52,36.764,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH DIL 6MMX16MM RELIEVA ULTIRRA SIN 2LUM SHFT ENDO F/IRR -,SUP-BC0616RU,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3728.49,2609.943,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH DIL 6MMX16MM RELIEVA SOLO PRO SIN 2LUM SHFT ENDO F/IRR -,SUP-BC0616SP,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3265.42,2285.794,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
KIT CATHETER SURGILUBE VINYL PEDIATRIC FEMALE OD8 FR SOFT LF -,SUP-CKF105L,CDM,C1726,HCPCS,272,RC,,,outpatient,,,18.96,13.272,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
KIT CATHETER SURGILUBE VINYL PEDIATRIC FEMALE OD8 FR SOFT LF -,SUP-CKF105L,CDM,C1726,HCPCS,272,RC,,,outpatient,,,18.99,13.293,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
TRAY URETHRAL 8FR FEMALE VINYL PVP URINE COLLECTION DEVICE -,SUP-CKF105L,CDM,C1726,HCPCS,272,RC,,,outpatient,,,18.15,12.705,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
BALLOON CERVICAL RIPENING W/STYLET -,SUP-G19891,CDM,C1726,HCPCS,272,RC,,,outpatient,,,243.61,170.527,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
IMPLANT PIP MCP SZ5 SWNSN SIL -,SUP-G470-0005,CDM,C1726,HCPCS,272,RC,,,outpatient,,,4413.76,3089.632,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
HURRICANE RX 4 X 4 -,SUP-G49219,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
HURRICANE RX 6 X 4 -,SUP-G49220,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
HURRICANE RX 8 X 4 -,SUP-G49221,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
HURRICANE RX 10 X 4 -,SUP-G49222,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH DIL 7FR CATH 7-5FR TIP 200CM 2CM BLN FUSION BIL TAPR -,SUP-G49571,CDM,C1726,HCPCS,272,RC,,,outpatient,,,676.86,473.802,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH DIL 8.5FR CATH 8.5-6FR TAPR 200CM 2CM BLN FUSION BIL -,SUP-G49572,CDM,C1726,HCPCS,272,RC,,,outpatient,,,676.86,473.802,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH DIL 7FR TAPR 200CM 2CM BLN FUSION BIL DOME TIP ENDO -,SUP-G49573,CDM,C1726,HCPCS,272,RC,,,outpatient,,,676.86,473.802,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH PTCA 6X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171061070,CDM,C1726,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
B CUTTING 5 X 2 X 135 -,SUP-M001PCB50201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
BALLOON 2CM PERIPHERAL CUTTING -,SUP-M001PCB50201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH PTCA 5MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-M001PCB50201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
PERIPHERAL CUTTING BALLOON  5MM X 2CM  50CM -,SUP-M001PCB5020500,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
B 6 X 2 X 135 CUTTING BAL -,SUP-M001PCB60201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
B CUTTING 7 X 2 X 135 -,SUP-M001PCB70201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH PTCA 7MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-M001PCB70201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH PTCA 7X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-M001PCB7020900,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
B CUTTING 8 X 2 X 135 -,SUP-M001PCB80201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH PTCA 8MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-M001PCB80201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH PTCA 8X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-M001PCB8020900,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH PTCA 1.5X3MM CUT BLN 140CM OTW PERIPH 0.018IN GW COMP -,SUP-M001PCBO3015140,CDM,C1726,HCPCS,272,RC,,,outpatient,,,4134.28,2893.996,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
B PERIPHERAL 6F 3.0X15X140 M00 -,SUP-M001PCBO3015140F0,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
B PER CUT OTW FLEX 4X15X140 M0 -,SUP-M001PCBO4015140F0,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CUTTING BALLOON 4MM X 1.5CM  X 135CM -,SUP-M001PCBO4015140F0,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH DIL 5.8FR 6MM BLN 180CM 4CM BLN HURRCN SS BIL RX ENDO -,SUP-M00545920,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH DIL 5.8FR 8MM BLN 180CM 4CM BLN HURRCN SS BIL RX ENDO -,SUP-M00545940,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATHETER CHOLANGIOGRAM SPYGLASS 65CM CHOLANGIOSCOPY -,SUP-M00546780,CDM,C1726,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
DILATOR BLN 36-40.5-45FR OD BLN 75CM 5.5CM CRE ESPH WG ENDO -,SUP-M00550300,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1649.04,1154.328,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
DILATOR BLN 24-27-30FR OD BLN 75CM 3CM CRE ESPH WG ENDO -,SUP-M00550330,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1649.04,1154.328,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
DILATOR BLN 30-33-36FR OD BLN 75CM 3CM CRE ESPH WG ENDO -,SUP-M00550340,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1649.04,1154.328,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
DILATOR BALLOON 35MM RIGIFLEX -,SUP-M00554510,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3112.17,2178.519,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
DILATOR BLN 7.5FR 6-7-8 MMX180CM 5.5CM BLN CRE PEBAX ESPH FX -,SUP-M00556860,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CRE 8-10MM 8CM F/G -,SUP-M00558340,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CRE 10-12MM 8CM F/G -,SUP-M00558350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CRE 12-15MM 8CM F/G -,SUP-M00558360,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
DILATOR BLN 6FR 12-13.5-15 MMX180CM 8CM BLN CRE PEBAX ESPH -,SUP-M00558360,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CRE 15-18MM 8CM F/G -,SUP-M00558370,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CRE 18-20MM 8CM F/G -,SUP-M00558380,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
DILATOR BLN 6FR 18-19-20 MMX180CM 8CM BLN CRE PEBAX ESPH FX -,SUP-M00558380,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
DILATOR WIREGUIDED CRE 15-18 180CM -,SUP-M00558430,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
DILATOR BLN 7.5FR 10-11-12 MMX240CM 5.5CM BLN CRE PEBAX ESPH -,SUP-M00558470,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
DILATOR BLN 7.5FR 12-13.5-15 MMX240CM 5.5CM BLN CRE PEBAX -,SUP-M00558480,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
DILATOR WIREGUIDED CRE 8-10 180CM -,SUP-M00558610,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
DILATOR WIREGUIDED CRE 10-12 180CM -,SUP-M00558620,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
DILATOR WIREGUIDED CRE 12-15 180CM -,SUP-M00558630,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CRE PRO WIREGUIDED 6-7-8MM 240CM -,SUP-M00558660,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CRE PRO WIREGUIDE 8-9-10MM 240 -,SUP-M00558670,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CRE PRO WIREGUIDE 10-11-12MM 240 -,SUP-M00558680,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CRE PRO WIREGUIDE 12-13.5-15MM 240 -,SUP-M00558690,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
DILATOR BLN 7.5FR 15-16.5-18 MMX240CM 5.5CM BLN CRE PEBAX -,SUP-M00558700,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CRE PRO WIREGUIDE 15-16.5-18MM 240 -,SUP-M00558700,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CRE PRO WIREGUIDE 18-19-20MM 240 -,SUP-M00558710,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH BILIARY BALLOON DILATATION CRE 8-10 3CM -,SUP-M00558920,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1517,1061.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH BILIARY BALLOON DILATATION CRE 10-12 3CM -,SUP-M00558930,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1517,1061.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH BILIARY BALLOON DILATATION CRE 12-15 3CM -,SUP-M00558940,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1517,1061.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH NEPH DIL 7FR 30FR BLN LPRO NPHRMX LF MRKR STPCK 17CM -,SUP-M0062101170,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1232.21,862.547,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH NEPH 7FR 10MM NPHRMX LF MRKR PTFE SHTH STPCK INFL DVC -,SUP-M0062101180,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1347.23,943.061,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH NEPH DIL 7FR 30FR BLN LPRO NPHRMX LF MRKR STPCK 20CM -,SUP-M0062101440,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1303.92,912.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH URET 4MM BLN 12FR INFL 3FR SHFT 150CM HYDRPLS CTD SS -,SUP-M0062181100,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1434.32,1004.024,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
PASSPORT BALLOON CATH 2CM -,SUP-M0062181200,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1540.27,1078.189,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH URET 5.8FRX4MM OD BLN 12FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251000,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1208.3,845.81,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
URO-MAX 2Q 4CM BALLOON KIT -,SUP-M0062251010,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1252.72,876.904,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH URET 5.8FRX10MM OD BLN 30FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251050,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1170.62,819.434,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
UROMAX 2/Q CATH 6CM 15FR SINGLE -,SUP-M0062251070,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1170.62,819.434,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH UROMAX U2Q\8-8 SINGLE -,SUP-M0062251100,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1170.62,819.434,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
UROMAX 2/Q CATH 10CM 15FR -,SUP-M0062251160,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1252.72,876.904,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH URET 5.8FRX6MM OD BLN 15FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251360,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1464.74,1025.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH URET 5.8FRX6MM OD BLN 18FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251370,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1384.17,968.919,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
APPLICATOR ENDO BLN US F /BF-UC16F-OL8 LTX STRL -,SUP-MAJ-1351,CDM,C1726,HCPCS,272,RC,,,outpatient,,,191.19,133.833,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CUFF BLN ADLT ENDO US F -,SUP-MAJ-249,CDM,C1726,HCPCS,272,RC,,,outpatient,,,157.36,110.152,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH ESPH 4.2MMX1CM SPC HI-RESOLTN CHNLX36 MANOSCAN -,SUP-MSC-1286,CDM,C1726,HCPCS,272,RC,,,outpatient,,,25903.5,18132.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATHETER HEMOSTATIC BALLOON NEXPOWDER -,SUP-NHS03,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH ATHRCMY PERIPH CUT BLN 4MMX140MM OTW PERIPH -,SUP-PCB04015140F,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH PTCA 6MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-PCB6020135,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH PTCA 7X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-PCB702090,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
CATH PTCA 8X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-PCB802090,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.074675,18572.8095,other,OPPS APC,,
HERNIA BALLOON #OMS-PDBS2 -,SUP-OMS-PDBS2,CDM,C1727,HCPCS,272,RC,,,outpatient,,,1296.65,907.655,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,291.097925,929.69805,other,OPPS APC,,
CATH BRCHTX MULTLUM 4-5CM CONTURA STRL -,SUP-B01245,CDM,C1728,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,195.18479,8389.93965,,,,
APPLICATOR BRCHTX MULTLUM 5-6CM BLN CONTURA STRL SUD -,SUP-B01256,CDM,C1728,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,195.18479,8389.93965,,,,
CATH BRCHTX 5-6CM CONTURAFLEX LF -,SUP-B13256,CDM,C1728,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,195.18479,8389.93965,,,,
CATH BRCHTX F/CVTY MNTN CONTURA -,SUP-B90012,CDM,C1728,HCPCS,272,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,195.18479,8389.93965,,,,
TRY APPLICATOR BRCHTX SAVI 6-1 -,SUP-SAVI-06,CDM,C1728,HCPCS,272,RC,,,outpatient,,,9468.15,6627.705,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,195.18479,8389.93965,,,,
APPLICATOR BRCHTX SGL-ENTRY MUL-CATH SAVI PREP -,SUP-SPC-01,CDM,C1728,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,195.18479,8389.93965,,,,
CT/MR APPLICATOR W/BASE PLATE -,SUP-UNDEFINED,CDM,C1728,HCPCS,272,RC,,,outpatient,,,11701.45,8191.015,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,195.18479,8389.93965,,,,
DRAIN PENROSE19MM 30CM 32MM FLAT -,SUP-00000,CDM,C1729,HCPCS,272,RC,,,outpatient,,,4.14,2.898,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH NEPH PEZ 28FR EYEX2 PRPRTN HEAD LTX MSHRM SHP -,SUP-064028,CDM,C1729,HCPCS,272,RC,,,outpatient,,,44.17,30.919,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH NEPH MLCT 14FR WNGX4 LTX -,SUP-086014,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.82,46.074,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH MALECOT 18FR BARD -,SUP-086018,CDM,C1729,HCPCS,272,RC,,,outpatient,,,49.29,34.503,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH MALECOT 20FR BARD -,SUP-086020,CDM,C1729,HCPCS,272,RC,,,outpatient,,,49.29,34.503,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH MALECOT 22FR BARD -,SUP-086022,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.06,45.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH MALECOT 24FR BARD -,SUP-086024,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.07,45.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH MALECOT 34FR PROPORTIONATE HEAD LATEX -,SUP-086034,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.07,45.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH NEPH MLCT 38FR WNGX4 LTX -,SUP-086038,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.06,45.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH NEPH MLCT 40FR WNGX4 LTX -,SUP-086040,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.89,45.423,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
24FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14024,CDM,C1729,HCPCS,272,RC,,,outpatient,,,123.9,86.73,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
28FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14028,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
32 FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14032,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
36FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14036,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH DRN 10.2FRX25CM SDPRTX6 COOK-COPE TY LCK LOOP -,SUP-192550,CDM,C1729,HCPCS,272,RC,,,outpatient,,,429.81,300.867,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH DRN 16FRX25CM SDPRTX6 COOK-COPE TY LCK LOOP -,SUP-193581,CDM,C1729,HCPCS,272,RC,,,outpatient,,,609.7,426.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH BIL DRN 12FRX40CM SDPRTX32 MA C -LOC LCK LOOP -,SUP-228702,CDM,C1729,HCPCS,272,RC,,,outpatient,,,545.51,381.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH DRN 12 FR X 25CM J-CRV THAL-QUICK PVC SDPRTX3 -,SUP-228707,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH DRN 14FRX25CM SDPRTX6 MA C -LOC LCK LOOP -,SUP-228709,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
TUBE VACUTNR 4ML GRN CAP NAHEP SAFTY PLST PPR LBL STRL HG-FR -,SUP-367871,CDM,C1729,HCPCS,272,RC,,,outpatient,,,0.94,0.658,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
THORACENTESIS TRAY/P4340A -,SUP-4340A,CDM,C1729,HCPCS,272,RC,,,outpatient,,,176.04,123.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
TRY THORCNTS 14GAX2IN L INTRO NDLX4 3WAY STP C LOCK BTRFLY -,SUP-4341B,CDM,C1729,HCPCS,272,RC,,,outpatient,,,228.45,159.915,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH VNTRC DRN 80CM TUOHY NDL FX TAB BLNT NDL STRN RLF OPN -,SUP-464-20,CDM,C1729,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
THORACENTESIS 30IN TUBING 4653 -,SUP-4653-48,CDM,C1729,HCPCS,272,RC,,,outpatient,,,23.96,16.772,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
SYS VNTRC DRN 35CM DUET W/ICP LN NDL-FR PRTX3 DRP CHMBR TBG -,SUP-469-13,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1120.58,784.406,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
SYS BAG VNTRC DRN REPL 35CM INTLNK NDL-FR INJ SITE -,SUP-469-14,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1120.58,784.406,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
KIT CSF DRAINAGE W CATH -,SUP-46916,CDM,C1729,HCPCS,272,RC,,,outpatient,,,2091.05,1463.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATHETER PLEURAL PLEURX KIT -,SUP-50-7000B,CDM,C1729,HCPCS,272,RC,,,outpatient,,,3841.3,2688.91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH WORD BARTHOLIN GLAND 10FR 5CM -,SUP-564000,CDM,C1729,HCPCS,272,RC,,,outpatient,,,104.15,72.905,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATHETER THORACIC 28F STRAIGHT -,SUP-8028,CDM,C1729,HCPCS,272,RC,,,outpatient,,,35.56,24.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATHETER THORACIC 32FR STERILE -,SUP-8032,CDM,C1729,HCPCS,272,RC,,,outpatient,,,35.05,24.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATHETER THORACIC 36F STRAIGHT -,SUP-8036,CDM,C1729,HCPCS,272,RC,,,outpatient,,,35.88,25.116,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATHETER THORACIC 24FR RT ANGL -,SUP-8124,CDM,C1729,HCPCS,272,RC,,,outpatient,,,57.26,40.082,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATHETER THORACIC  32F RT ANGLE -,SUP-8132,CDM,C1729,HCPCS,272,RC,,,outpatient,,,54.52,38.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
DRAIN CATH LUMBAR KTXTRN DRN 0.76MM 1.65MMX46CM -,SUP-82-1706,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1526.54,1068.578,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH VNTRC DRN 1.5MM BCTSL EVD SIL 0.15% CLNDMCN -,SUP-82-1745,CDM,C1729,HCPCS,272,RC,,,outpatient,,,2522.1,1765.47,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
DRAIN PENROSE 5/8 WND 0.625X12IN GRVTY  FLT LTX -,SUP-8888515007,CDM,C1729,HCPCS,272,RC,,,outpatient,,,223.25,156.275,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH TROCAR 12FR ARGYLE -,SUP-8888561027,CDM,C1729,HCPCS,272,RC,,,outpatient,,,106.84,74.788,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH TROCAR 20FR X 16 ARGYLE -,SUP-8888561043,CDM,C1729,HCPCS,272,RC,,,outpatient,,,78.42,54.894,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH TROCAR 28FR X 16 ARGYLE -,SUP-8888561068,CDM,C1729,HCPCS,272,RC,,,outpatient,,,110.81,77.567,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
KT DRN 20FRX10IN ARGYLE PVC GLVX2 PREP SWB /CUPX2 FEN DRAPE -,SUP-8888565036,CDM,C1729,HCPCS,272,RC,,,outpatient,,,192.93,135.051,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATHETER TROCAR KIT 28 FR NSQ -,SUP-8888565044,CDM,C1729,HCPCS,272,RC,,,outpatient,,,199.28,139.496,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH THORACIC 12FR MAR -,SUP-8888570507,CDM,C1729,HCPCS,272,RC,,,outpatient,,,55.61,38.927,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH THORACIC 16FR MAR -,SUP-8888570515,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.3,26.81,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATHETER THORACIC 16FR -,SUP-8888570515,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.3,26.81,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH THORACIC 20FR MAR -,SUP-8888570523,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.68,27.076,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
"CATHETER THORACIC 20FR X 20"" RADIOPAQUE 5 EYELETS -",SUP-8888570523,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.69,27.083,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH THORACIC 24FR MAR -,SUP-8888570531,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.18,27.426,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATHETER THORACIC 24FR -,SUP-8888570531,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.15,27.405,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH THORACIC 28FR MAR -,SUP-8888570549,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.44,27.608,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATHETER THORACIC 28FR -,SUP-8888570549,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.44,27.608,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATHETER THORACIC 32FR -,SUP-8888570556,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.85,27.895,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH THORACIC 32FR MAR -,SUP-8888570556,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.85,27.895,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATHETER THORACIC 36FR -,SUP-8888570564,CDM,C1729,HCPCS,272,RC,,,outpatient,,,40.26,28.182,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH THORACIC 36FR MAR -,SUP-8888570564,CDM,C1729,HCPCS,272,RC,,,outpatient,,,40.24,28.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH THORACIC 40FR MAR -,SUP-8888570572,CDM,C1729,HCPCS,272,RC,,,outpatient,,,40.63,28.441,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
TUBE CHEST RIGHT ANGLE 28 -,SUP-8888571042,CDM,C1729,HCPCS,272,RC,,,outpatient,,,77.11,53.977,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH THORCNTS 18FRX20IN LT VNTRC -,SUP-8888590216,CDM,C1729,HCPCS,272,RC,,,outpatient,,,193.84,135.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
KIT LUMBAR DRAINAGE CATH -,SUP-910121,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1076.58,753.606,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH DISTAL ATRIAL PERITONEAL SOPHYSA -,SUP-B905S,CDM,C1729,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATHETER VENTRICULAR STR 1.3 X 2.5 MM (INCL IN ITEM 0154508) -,SUP-BO19-10,CDM,C1729,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
TRAY CHEST TUBE 10FR THAL QUICK LUMX1 SDPRTX3 18GA ECHOTIP -,SUP-C-TQTSY-1000,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1096.98,767.886,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH PERFUS 12FR STR PVC -,SUP-EM012,CDM,C1729,HCPCS,272,RC,,,outpatient,,,263.92,184.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
EVACUATOR TBG UNIV ELLIK -,SUP-ET,CDM,C1729,HCPCS,272,RC,,,outpatient,,,74.71,52.297,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
BILIARY DRAINAGE CATH 8.5FR. -,SUP-G09497,CDM,C1729,HCPCS,272,RC,,,outpatient,,,545.51,381.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH BIL DRN 10.2FRX40CM MAC-LOC SDPRTX32 MA C -LOC LCK LOOP -,SUP-G09498,CDM,C1729,HCPCS,272,RC,,,outpatient,,,545.51,381.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH DRN 8.5FRX25CM LCK LOOP -,SUP-G09501,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH DRN 10FR NEPHROSTOMY TUBE -,SUP-G09502,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH MP DRAINAGE 10.2F 45CM UL -,SUP-G09766,CDM,C1729,HCPCS,272,RC,,,outpatient,,,554.27,387.989,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH DRN 12FRX45CM BND SDPRTX6 MA C -LOC LCK LOOP -,SUP-G09767,CDM,C1729,HCPCS,272,RC,,,outpatient,,,554.27,387.989,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH DRN 6FR UNIV 25CM CRV SDPRTX3 -,SUP-G10956,CDM,C1729,HCPCS,272,RC,,,outpatient,,,539.68,377.776,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
SET COLON DECOMPRESION 14FR -,SUP-G22181,CDM,C1729,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
Set Fuhrman Pleural Pneumopericardial Drainage -,SUP-G55723,CDM,C1729,HCPCS,272,RC,,,outpatient,,,711.87,498.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
Tray Fuhrman Pleural Pneumopericardial Drainage -,SUP-G55724,CDM,C1729,HCPCS,272,RC,,,outpatient,,,968.61,678.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
UNIV. LOOP DRAINAGE SET 10FR -,SUP-G55802,CDM,C1729,HCPCS,272,RC,,,outpatient,,,887.5,621.25,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
UNIV.  LOOP DRAINAGE SET 14FR X 30 -,SUP-G55804,CDM,C1729,HCPCS,272,RC,,,outpatient,,,887.5,621.25,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
ST UNIVERSA MALEOCOT16FRX22CM BLN SS NDL OBTR CON TUBE 3ML -,SUP-G55825,CDM,C1729,HCPCS,272,RC,,,outpatient,,,307.21,215.047,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
TRAY WAYNE PNEUMOTHORAX CATHETER 14.0 FR 29 CM -,SUP-G56537,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1250.92,875.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH PERC DRN 8FRX25CM STD LOOP TIP EXODUS LF -,SUP-H965101431,CDM,C1729,HCPCS,272,RC,,,outpatient,,,511.85,358.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH DRN 10FRX20CM EXODUS LF -,SUP-H965101511,CDM,C1729,HCPCS,272,RC,,,outpatient,,,511.85,358.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATHETER DRN 8FRX25CM EXODUS TIGHT TIP LOOP -,SUP-H965104031,CDM,C1729,HCPCS,272,RC,,,outpatient,,,537.4,376.18,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH DRN 10FRX25CM EXODUS TIGHT TIP LOOP -,SUP-H965104111,CDM,C1729,HCPCS,272,RC,,,outpatient,,,537.4,376.18,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH MULTIPURPOSE 14FR  25CM STD ;OOP W/MARKER BAND -,SUP-H965105621,CDM,C1729,HCPCS,272,RC,,,outpatient,,,2440.88,1708.616,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
SYSTEM EXTERNAL DRAINAGE WITHOUT VENTRICULAR CATH ACCUDRAIN -,SUP-INS8401,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1401.56,981.092,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH NEPH 14FR VTC -,SUP-M001245290,CDM,C1729,HCPCS,272,RC,,,outpatient,,,570.95,399.665,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH DRN 6FRX25CM PIGTL FOGARTY LOOP -,SUP-M001271380,CDM,C1729,HCPCS,272,RC,,,outpatient,,,468.26,327.782,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH DRN MP 10FR UNIV 30CM LCK PIGTL HUB LOCK CANN NTNL NAVR -,SUP-NNU10LPT,CDM,C1729,HCPCS,272,RC,,,outpatient,,,661.69,463.183,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
DRAIN SURG 30CM 12FR UNIV NTNL PIGTL MP -,SUP-NNU12LPT,CDM,C1729,HCPCS,272,RC,,,outpatient,,,661.69,463.183,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATH DRN MP 8FR UNIV 30CM NTNL LCK PIGTL HUB LOCK CANN NAVR -,SUP-NNU8LPT,CDM,C1729,HCPCS,272,RC,,,outpatient,,,661.69,463.183,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
KIT PERICARDIOCENTESIS 6F PIGTAIL CATH -,SUP-PC101,CDM,C1729,HCPCS,272,RC,,,outpatient,,,542.95,380.065,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
KT PERICRDCTS PIGTL 8.3FRX40CM ACC LF -,SUP-PC801,CDM,C1729,HCPCS,272,RC,,,outpatient,,,676.86,473.802,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
VALVE POLARIS ADJ 30-200 SHUNT WITH ITEM BO19-10 INCL -,SUP-SPVA-2010,CDM,C1729,HCPCS,272,RC,,,outpatient,,,14425.01,10097.507,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
CATHETER FIXATION SYSTEM 8F -,SUP-TFK-08,CDM,C1729,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
TRAY THORACENTESIS PARACENTESIS -,SUP-TPT1000SP,CDM,C1729,HCPCS,272,RC,,,outpatient,,,195.82,137.074,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21103,10342.73217,other,OPPS APC,,
ELECTRODE PCNG 5FRX110CM BIPLR NON- HEP BND -,SUP-006173P,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1018.79,713.153,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH QUAD  MARINR-MDT -,SUP-072322M,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1378.13,964.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH EP P- TY CRV 5FR 2-8-2MM SPC 110CM DECAPL MP POLEX10 -,SUP-1085122RT,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1505.34,1053.738,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH ACHIEVE ADVANCE 2ACH20 MAPPING -,SUP-2ACH20,CDM,C1730,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH ACHIEVE ADVANCE 2ACH20 REPROCESS MAPPING -,SUP-2ACH20,CDM,C1730,HCPCS,272,RC,,,outpatient,,,2983.75,2088.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH EP RESPONSE CRD-SJM QUAD 6FR -,SUP-401226,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH RESPONSE CRD -REPROC QUAD 6FR -,SUP-401226,CDM,C1730,HCPCS,272,RC,,,outpatient,,,185.14,129.598,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH EP RESPONSE JSN -SJM QUAD  6FR -,SUP-401227,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH RESPONSE JSN-REPROC 6FR -,SUP-401227,CDM,C1730,HCPCS,272,RC,,,outpatient,,,185.14,129.598,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH EP RESPONSE CRD-SJM  DECAPOLAR -,SUP-401305,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1081.3,756.91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH EP RESPONSE CSL-SJM 6FR  DECAPOLAR  STEER -,SUP-401381,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH RESPONSE DEC CSL-REPROC -,SUP-401381,CDM,C1730,HCPCS,272,RC,,,outpatient,,,349.87,244.909,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH EP SPRM JSPHSN CRV 6FR 2-5-2MM ELCTRD SPC 120CM FX QDPL -,SUP-401451,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH EP LIVEWIRE MED SWEEP-SJM DECAPOLAR -,SUP-401575,CDM,C1730,HCPCS,272,RC,,,outpatient,,,2056.59,1439.613,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH EP LIVEWIRE MED SWEEP-REPROC DECAPOLAR -,SUP-401575,CDM,C1730,HCPCS,272,RC,,,outpatient,,,588.34,411.838,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH LIVEWIRE QUAD STEERABLE REPROC -,SUP-401606,CDM,C1730,HCPCS,272,RC,,,outpatient,,,593.19,415.233,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH EP LIVEWIRE LRG SWP-SJM  QUAD STEERABLE  2-5-2 -,SUP-401606,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1876.38,1313.466,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC,,
BIPOLAR PACING CATH BALLOON TIP 5 FR 110CM- PACEL REF:401763 -,SUP-401763,CDM,C1730,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH EP LIVEWIRE SUPER LRG CURL- SJM DECA 2-10-2 -,SUP-401904,CDM,C1730,HCPCS,272,RC,,,outpatient,,,4392.08,3074.456,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH  LIVEWIRE 7F DUO SUPER LRG CURL-REPROC 2/10 -,SUP-401904,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1154.02,807.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH LIVEWIRE MED CRL-REPROC 2-2-2 NO SPACE -,SUP-401908,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1591.63,1114.141,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH EP  LIVEWIRE EXTRA LGE CURL-SJM  DECAPL 2-5-2 -,SUP-401915,CDM,C1730,HCPCS,272,RC,,,outpatient,,,2258.01,1580.607,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH EP LIVEWIRE EXTRA LGE CURL-REPROC  DECAPL 2-5-2 -,SUP-401915,CDM,C1730,HCPCS,272,RC,,,outpatient,,,612.91,429.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH  LIVEWIRE DUO DEC SUPER LGE CURL-REPROC 2-8-2-60-2-8-2 -,SUP-401932,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1208.14,845.698,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH EP LIVEWIRE LRG SWP -SJM  QUAD STEER 5-5-5 NO SPACE -,SUP-401934,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1876.38,1313.466,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH EP LIVEWIRE LRG SWP -REPROC  QUAD STEER 5-5-5 NO SPACE -,SUP-401934,CDM,C1730,HCPCS,272,RC,,,outpatient,,,593.19,415.233,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH EP SUPREME CRD-2 -SJM QUAD -,SUP-402004,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH RESPONSE CRD-2 REPROC 6FR -,SUP-402004,CDM,C1730,HCPCS,272,RC,,,outpatient,,,193.84,135.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC,,
INQUIRY STEERABLE  SJM EP CATH 6FR -,SUP-81102,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH 20MM ACHIEVE MAPPING EP CRV 3.3FRX6MM SPC 165CM BIPLR -,SUP-990063020,CDM,C1730,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC,,
MEDIGUIDE LV CATH MED SWEEP MODEL D402058 -,SUP-D402058,CDM,C1730,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC,,
ADVISOR HD GRID MAPPING CATHETER D-AVHD-DF 16 REPRO -,SUP-D-AVHD-DF-16,CDM,C1730,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC,,
ADVISOR HD GRID MAPPING CATHETER D-AVHD-DF16 -,SUP-D-AVHD-DF-16,CDM,C1730,HCPCS,272,RC,,,outpatient,,,9090.65,6363.455,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC,,
EPSTAR CATHETER DCF-2-8-55-130 -,SUP-DCF-2-8-55-130,CDM,C1730,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATHETER INQUIRY STEER 4 FR DEC 1110-4-2-M IBI-81530 -,SUP-IBI-81530,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC,,
CATH EP POLARISX270DG ANG 6FR 2.5-5-2.5MM SPC 105CM QDPL -,SUP-M0047003D0,CDM,C1730,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.56393,6517.99605,other,OPPS APC,,
BLAZER DX -20 CATHETER SUPERLARGE CURVE -,SUP-20SL2860,CDM,C1731,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,4619.19363,other,OPPS APC,,
CATH EP LIVEWIRE MED CURL-SJM  2-2-2 -,SUP-401908,CDM,C1731,HCPCS,272,RC,,,outpatient,,,4392.08,3074.456,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,4619.19363,other,OPPS APC,,
CATH EP LIVEWIRE SUPER LGE CURL-SJM 2-8-2-60-2-8-2 -,SUP-401932,CDM,C1731,HCPCS,272,RC,,,outpatient,,,4596.25,3217.375,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,4619.19363,other,OPPS APC,,
CATH EP REFLEXION SPIRAL SJM -,SUP-D402893,CDM,C1731,HCPCS,272,RC,,,outpatient,,,6442.39,4509.673,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,4619.19363,other,OPPS APC,,
CATH ABLT BLAZER D X-20 SUPER LRG 7FR SHFT 2-10-2MM SPC -,SUP-M00420SL21020,CDM,C1731,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,4619.19363,other,OPPS APC,,
CATH ACHIEVE ADVANCE 2ACH15 REPROCESS MAPPING -,SUP-2ACH15,CDM,C1732,HCPCS,272,RC,,,outpatient,,,2983.75,2088.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC,,
CATH ACHIEVE ADVANCE 2ACH15 MAPPING -,SUP-2ACH15,CDM,C1732,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC,,
CATH ACHIEVE ADVANCE 2ACH25  MAPPING -,SUP-2ACH25,CDM,C1732,HCPCS,272,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC,,
SOFTWARE MED ENSITE FUSION REGST MOD XPD F/SEG CT -,SUP-75-05772-001,CDM,C1732,HCPCS,272,RC,,,outpatient,,,27847.5,19493.25,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC,,
CATHETER PVAC GOLD - REF:990078 -,SUP-990078,CDM,C1732,HCPCS,272,RC,,,outpatient,,,25991,18193.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC,,
CATH ABLT THERMOCOOL SF CARTO XP D-F CRV 8FR 2-5-2MM SPC -,SUP-BNI35DFH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,11324.65,7927.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC,,
CATH ABLT THERMOCOOL SF NAV F-J CRV 8FR 2-5-2MM SPC 115CM -,SUP-BNI35FJH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,11324.65,7927.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC,,
CATH EP LASSO NAV ECO D-TYP CRV 7FR 4FR LOOP 25-15MM 2-6-2MM -,SUP-D134301,CDM,C1732,HCPCS,272,RC,,,outpatient,,,7257.24,5080.068,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC,,
CATH EP WEBSTER CS CS-D CRV 6FR 2-8-2MM SPC 115CM SGL-BRD -,SUP-D135303,CDM,C1732,HCPCS,272,RC,,,outpatient,,,2644.95,1851.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC,,
CATH EP WEBSTER CS CS-F CRV 6FR2MM TIP 2-8-2MM SPC 115CM FX -,SUP-D135304,CDM,C1732,HCPCS,272,RC,,,outpatient,,,2014.19,1409.933,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC,,
CATH ABLT NAVISTAR C F-TY CRV 7FR EP -,SUP-D17TCFLRT,CDM,C1732,HCPCS,272,RC,,,outpatient,,,7057.77,4940.439,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC,,
POLARX FIT BALLOON CATHETER ST REF:M004CRBS2060 -,SUP-M004CRBS2060,CDM,C1732,HCPCS,272,RC,,,outpatient,,,14852,10396.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC,,
POLARX FIT BALLOON CATHETER LT REF:M004CRBS2160 -,SUP-M004CRBS2160,CDM,C1732,HCPCS,272,RC,,,outpatient,,,14852,10396.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC,,
CATH POLARMAP CIRCULAR DX MAPPING CATHETER REF:M004CRBS7210 -,SUP-M004CRBS7210,CDM,C1732,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC,,
CATHETER INTELLANAV ST 7/110/2.5/7-4 QUAD STD -,SUP-M004R5031TH0,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC,,
CATHETER INTELLANAV ST K2 7/110/2.5/7-4 QUAD -,SUP-M004R5031THK20,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC,,
INTELLAMAP ORION CATHETER M004RC64S0 -,SUP-M004RC64S0,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC,,
CATH ABLT NAVISTAR THERMOCOOL D-CRV 8FR 2-5-2MM SPC 115CM -,SUP-NI75TCDH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC,,
CATH ABLT THERMOCOOL F-TY CRV 7.5FR 2-5-2MM SPC 115CM COOL -,SUP-NI75TCFH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC,,
CATH ABLT NAVISTAR C D-TYP CRV 7FR 1-7-4MM SPC 4MM TIP 115CM -,SUP-NS7TCDL174HS,CDM,C1732,HCPCS,272,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC,,
CATH ABLT NAVISTAR DS F-TY CRV 7FR 1-7-4MM SPC 8MM TIP 115CM -,SUP-NS7TCF8L174HS,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC,,
CATH ABLT NAVISTAR F-TY CRV 7FR 1-7-4MM SPC 4MM TIP 115CM -,SUP-NS7TCFL174HS,CDM,C1732,HCPCS,272,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19966.6575,other,OPPS APC,,
CATH ABLT FREEZOR 4MM TIP MDT -,SUP-207F3,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH CRYABL FREEZOR MAX CRV 9FR 3-5-2MM SPC 90CM STEER BIDIR -,SUP-209F3,CDM,C1733,HCPCS,272,RC,,,outpatient,,,9124.6,6387.22,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABLT FREEZOR XTRA 6MM 7FR 2-5-2MM SPC 108CM -,SUP-217F3,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABLT FREEZOR XTRA LG CURVE 6MM 7FR REF:217F5 -,SUP-217F5,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH CRYABL ARCTIC FRN 23MM STEER BIDIR EP -,SUP-2AF234,CDM,C1733,HCPCS,272,RC,,,outpatient,,,16337.2,11436.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH CRYABL ARCTIC FRN 28MM STEER BIDIR EP -,SUP-2AF284,CDM,C1733,HCPCS,272,RC,,,outpatient,,,16337.2,11436.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ESPH ABLT 18MM 360DG ELCTRD ARRAY 85CM BARRX RF -,SUP-32041-18,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8339.46,5837.622,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH PCNG 5FRX2.5CM SPC 110CM PACEL TEMP BIPLR 60DG CRV RT -,SUP-401775,CDM,C1733,HCPCS,272,RC,,,outpatient,,,513.48,359.436,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABLT SAFIRE MED SWP 7FR 2-5-2MM SPC 115CM QDPL BIDIR -,SUP-402807,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3010.01,2107.007,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABL SAFIRE LRG SWP 7FR -,SUP-402808,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3208.13,2245.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH SAFIRE 7F 4MM SM CRL US -,SUP-402809,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3010.01,2107.007,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABLT SAFIRE MED CURL 7FR 2-5-2MM SPC 115CM 7MM BIDIR -,SUP-402810,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3208.13,2245.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABLT SAFIRE LRG CRV 7FR 2-5-2MM SPC 115CM QDPL BIDIR -,SUP-402811,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3208.13,2245.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABLT SAFIRE LRG CRV 7FR 2-5-2MM 115CM 5MM QDPL BIDIR -,SUP-402817,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3232,2262.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH SAFIRE TX  MED 7F 8 MM BI-DIR -,SUP-402839,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4501.88,3151.316,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH SAFIRE TX  LRG  BI-DIR  7F 8MM -,SUP-402840,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4501.88,3151.316,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
FARAWAVE PFA CATHETER REF:41C601 -,SUP-41C601,CDM,C1733,HCPCS,272,RC,,,outpatient,,,25062.75,17543.925,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
FARAWAVE PFA CATHETER 35MM REF:41C602 -,SUP-41C602,CDM,C1733,HCPCS,272,RC,,,outpatient,,,25062.75,17543.925,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATHETER BARRX RFA EXPRESS RFA BALLOON -,SUP-64082,CDM,C1733,HCPCS,272,RC,,,outpatient,,,10218.18,7152.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABLT THRP 7FR 2-5-2 MMMEDX110CM 4MM -,SUP-83365,CDM,C1733,HCPCS,272,RC,,,outpatient,,,2491.24,1743.868,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABLT THRP 7FR 2-5-2 MMX110CM 4MM -,SUP-83366,CDM,C1733,HCPCS,272,RC,,,outpatient,,,2634.35,1844.045,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABLT THRP 2-5-2 MMMEDX110CM DL -8 -,SUP-83371,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABLT THRP 7FR MED 8MM DL -,SUP-83372,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3542.31,2479.617,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABLT THRP DL -8 EXTEND REACH CRV 7FR 2-5-2MM SPC 110CM -,SUP-83374,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATHETER BARRX FOCAL 90 RFA 20MMX 13MM -,SUP-90-9100,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8492.24,5944.568,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATHETER BARRX FOCAL 90 RFA 40MM X 13MM -,SUP-90-9500,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7469.44,5228.608,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABLT SAFIRE BLU LRG CURL DIST REACH CRV 7FR 2-5-2MM SPC -,SUP-A088109,CDM,C1733,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH CRYABL ARCTIC FRN ADVANCED PRO 28MM STEER BIDIR EP -,SUP-AFAPRO28,CDM,C1733,HCPCS,272,RC,,,outpatient,,,16337.2,11436.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
FLEXABILITY SENSOR ENABLED BI DIR IRR CATH FJ CURVE -,SUP-A-FASE-FJ,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8190.92,5733.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH 7F D/F BI-DIRECT CS REPROC -,SUP-BD710DF282RTS,CDM,C1733,HCPCS,272,RC,,,outpatient,,,1132.05,792.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABLT WEBSTER EZ STEER D-F ASYM CRV 7FR 2-8-2MM SPC -,SUP-BD710DF282RTS,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3547.08,2482.956,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH CV 7FRX3CM SIL CLSR FST LF ACC -,SUP-CF7-3-60,CDM,C1733,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ELCSURG 7FRX60CM RF FLXB CLSR FST -,SUP-CF7-7-60,CDM,C1733,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
AGILLIS NXT STEERABLE INTRO DUAL-REACH REF: I-V2-MED -,SUP-I-V2-MED,CDM,C1733,HCPCS,624,RC,,,outpatient,,,5.89,4.123,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABLT BLAZER II STD CRV 7FRX2.5MM SPC 4MM TIP QDPL DIST -,SUP-M0045031TH0,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABLT BLAZER II STD CRV 7FRX2.5MM SPC QDPL EXTEND DIST -,SUP-M0045086TL0,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABLT BLAZER PRIM XP LRG CRV 8MM TIP QDPL EP -,SUP-M004P4500THK20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7427,5198.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABLT BLAZER PRIM XP STD CRV STR 7FR 8FR TIP 2.5MM SPC -,SUP-M004P4790TH0,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7639.2,5347.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABLT BLAZER PRIM XP LRG CRV 10mm  8FRX2.5MM SPC 110CM -,SUP-M004P4790THK20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7639.2,5347.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABLT BLAZER PRIM HTD ASYM CRV 7FRX2.5MM SPC 110CM QDPL -,SUP-M004P5031THN40,CDM,C1733,HCPCS,272,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABLT INTELLATIP MIFI XP STD CRV STR 7FR 8FR TIP 2.5MM -,SUP-M004PM45000,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATH ABLT INTELLATIP MIFI XP LRG CRV STR 7FR 8FR TIP 2.5MM -,SUP-M004PM4500K20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATHETER INTELLANAV MIFI OI 7.5/110/2.5.4.5 STD -,SUP-M004PMR96200,CDM,C1733,HCPCS,272,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATHETER INTELLANAV MIFI K2 OI 7.5/110/2.5/4.5 -,SUP-M004PMR9620K20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
PULSESELECT PFA LOOP CATHETER REF: PSCC100 -,SUP-PSCC100,CDM,C1733,HCPCS,272,RC,,,outpatient,,,23763.2,16634.24,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
VOLT PFA CATHETER REF: P-SPI-DF8 -,SUP-VOLT PFA CATHETER REF: P-SPI-DF8,CDM,C1733,HCPCS,624,RC,,,outpatient,,,5.89,4.123,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.322305,17969.99175,other,OPPS APC,,
CATHETER 27CM GLIDEPATH LONG TERM HEMO -,SUP-5393270,CDM,C1750,HCPCS,278,RC,,,outpatient,,,2210.31,1547.217,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC,,
CATH HMDLYS HEMOSPLIT 14.5FRX31CM -,SUP-5733310,CDM,C1750,HCPCS,278,RC,,,outpatient,,,2390.53,1673.371,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC,,
CATH SHNT 1.2X2.5MM HLTR 65CM SIL RBR T-SHP 1PC -,SUP-82-1699,CDM,C1750,HCPCS,278,RC,,,outpatient,,,2533.64,1773.548,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC,,
CATH PERITONEALTENCKHOFF42CM -,SUP-8810888003,CDM,C1750,HCPCS,278,RC,,,outpatient,,,255.92,179.144,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC,,
CATH TENCKHOFF 15FRX62CM -,SUP-8811313010,CDM,C1750,HCPCS,278,RC,,,outpatient,,,366.38,256.466,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC,,
KIT CATHETER PERITONEAL DIALYSIS ARGYLE 62CM SILICONE CURLED -,SUP-8817278006,CDM,C1750,HCPCS,278,RC,,,outpatient,,,450.39,315.273,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC,,
KT DLYS 60CM CURL STYL 60CM PREPERITONEIAL CUF CLMP ADPTR -,SUP-8817278010,CDM,C1750,HCPCS,278,RC,,,outpatient,,,537.58,376.306,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC,,
KT HMDLYS PRMCTH 36CM SIL RBR LUMX2 -,SUP-8817748001,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1012.58,708.806,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC,,
CATH HMDLYS MHRKR 11.5FRX16CM PU ACUTE LUMX2 ACC -,SUP-8817749001,CDM,C1750,HCPCS,278,RC,,,outpatient,,,923.47,646.429,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC,,
CATH HMDLYS PALINDROME 14.5FRX19CM -,SUP-8888119360P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1259.4,881.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC,,
KIT CATHETER PALINDROME 14.5FR X 19CM -,SUP-8888145014P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC,,
KIT CATHETER PALINDROME 14.5FR X 23CM -,SUP-8888145015P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC,,
KIT CATHETER PALINDROME 14.5FR X 28CM -,SUP-8888145016P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC,,
KIT CATHETER PALINDROME 14.5FR X 33CM -,SUP-8888145042P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC,,
STENCIL PERITONEAL DIALYSIS RITUS PRE-OPERATIVE -,SUP-8888412305,CDM,C1750,HCPCS,278,RC,,,outpatient,,,55.72,39.004,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC,,
KIT CATHETER PERITONEAL DIALYSIS ARGYLE 62.5CM SILICONE -,SUP-8888413823,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1150.95,805.665,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC,,
KT HMDLYS PALINDROME 15FRX43CM CRBTHN ACC -,SUP-8888541023P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1612.03,1128.421,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC,,
KT HMDLYS PALINDROME 15FRX48CM CRBTHN ACC -,SUP-8888541028P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1612.03,1128.421,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC,,
CATH TESIO LEFT BFL-6 -,SUP-BFL-6,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1595.45,1116.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC,,
CATH HMDLYS BFL TSO 10FR 22CM/25CM CUF -,SUP-BFR-6,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1690.86,1183.602,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC,,
ST HMDLYS TESIO 10FRX52CM PU LUMX2 INTRO NDL GW TUNNLER -,SUP-BFR-6E,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1881.68,1317.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC,,
CATH ARROW NEXT STEP 23CM HEMODIALYSIS -,SUP-CS-15232-X,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1436.44,1005.508,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC,,
CATH ARROW NEXT STEP 27CM HEMODIALSIS -,SUP-CS-15272-X,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1436.44,1005.508,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC,,
CATHETER KIT DIALYSIS 15FR ARROW -,SUP-CS-15282-SPM,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.50914,1945.83552,other,OPPS APC,,
HC Try Cv Lumx3 5fr Triple Powerpicc Acc,PX-27200312,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1544,1080.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
HC Needle Provena 4fr Dl Picc 4fr Dl Max Barrier,PX-27200313,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1417,991.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
HC Needle Provena 4fr Dl Provena Midline Max Barrier,PX-27200314,CDM,C1751,HCPCS,272,RC,,,outpatient,,,967,676.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
HC Cath Cv Lumx2 4frx20 Cm Dual Mdln,PX-27200315,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1012,708.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
HC Needle Provena 3fr Sl Provena Midline Max Barrier,PX-27200316,CDM,C1751,CPT,272,RC,,,outpatient,,,831,581.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
KIT URETERAL IRIS INFRARED -,SUP-0220180518,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1863.01,1304.107,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
TRY CV LUMX2 9FRX90CM SIL PED HKMN LF ACC -,SUP-0600604,CDM,C1751,HCPCS,272,RC,,,outpatient,,,2291.14,1603.798,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH SWAN GANZ TD 6FR X 110 - 096F6P -,SUP-096F6P,CDM,C1751,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH GUIDE ECHELON 14 MICRO STR AIGHT REF:105-5092-150 -,SUP-105-5092-150,CDM,C1751,HCPCS,272,RC,,,outpatient,,,4838.16,3386.712,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
TRY CV LUMX1 4FR PU POWERPICC LF ACC SINGLE -,SUP-1174108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1252.61,876.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
5FR POWERPICC TRAY CV LUMX2 DBL PU  LF ACC -,SUP-1275108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1232.53,862.771,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH SWAN GANZ TD 7FR 131F7P -,SUP-131F7P,CDM,C1751,HCPCS,272,RC,,,outpatient,,,501.81,351.267,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATHETER IV JELCO PROTECTIV 24G X 3/4IN YELLOW -,SUP-305306,CDM,C1751,HCPCS,272,RC,,,outpatient,,,12.2,8.54,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATHETER IV WINGED HUB PEDI 24G X 5/8â€ PERIPHERAL RADIOPAQUE -,SUP-307300,CDM,C1751,HCPCS,272,RC,,,outpatient,,,11.94,8.358,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
TRY CV LUMX1 5FRX55CM PU POWERPICC LF ACC -,SUP-3175155,CDM,C1751,HCPCS,272,RC,,,outpatient,,,456.94,319.858,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV PROTECTIVE 22 X 1 -,SUP-326010,CDM,C1751,HCPCS,272,RC,,,outpatient,,,12.05,8.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV PROT 22GAX1IN FEP PLYMR SAFTY STR HUB WNG INDWL VPNT -,SUP-326010,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.66,7.462,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV PROT 24GAX.75IN FEP PLYMR SAFTY STR HUB WNG INDWL -,SUP-326310,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.68,7.476,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV PROTECTIVE 24 X 3/4 RA -,SUP-326310,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.68,7.476,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV PROTECTIVE 20 X 1 -,SUP-326710,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.28,6.496,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV PROT 20GAX1IN FEP PLYMR SAFTY STR HUB WNG INDWL VPNT -,SUP-326710,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.28,6.496,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV 14GA X 1.25 IN VIAVALVE -,SUP-3268,CDM,C1751,HCPCS,272,RC,,,outpatient,,,12.05,8.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
TRY CV LUMX2 5FRX55CM PU POWERPICC LF ACC -,SUP-3275335,CDM,C1751,HCPCS,272,RC,,,outpatient,,,602.11,421.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV ANGIOCATH 14 X 1.88 -,SUP-381167,CDM,C1751,HCPCS,272,RC,,,outpatient,,,22.71,15.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV 24G X .56 IN INSYTE BD -,SUP-381411,CDM,C1751,HCPCS,272,RC,,,outpatient,,,14.41,10.087,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV 20G X 1.88 IN INSYTE BD -,SUP-381437,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.86,6.902,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV INSYT AUTOGRD 20GAX48MM VIALON SAFTY WNG INDWL BLD -,SUP-381437,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.86,6.902,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV 14G X 1.75 IN INSYTE BD -,SUP-381467,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.87,6.909,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV 24G X .56 IN INSYTE BD -,SUP-381511,CDM,C1751,HCPCS,272,RC,,,outpatient,,,14.42,10.094,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV 22G x 1 IN INSYTE AUTOGUARD BC -,SUP-382523,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.12,7.084,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV 16G X 1.16 IN INSYTE BD -,SUP-382554,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.86,6.902,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV SAF-T-INTIMA 23GAX0.75IN VIALON SAFTY WNG INDWL -,SUP-383323,CDM,C1751,HCPCS,272,RC,,,outpatient,,,20.11,14.077,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV SAF-T-INTIMA 20GAX1IN VIALON SAFTY WNG INDWL SLFBNT -,SUP-383336,CDM,C1751,HCPCS,272,RC,,,outpatient,,,19.62,13.734,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV 24G X .75 IN NEXIVA BD -,SUP-383511,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV 22GA X 1 IN NEXIVA BD -,SUP-383512,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV 20GA X 1 IN NEXIVA BD -,SUP-383516,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV 18GA X 1.25 IN NEXIVA BD -,SUP-383519-A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
ST NEEDLE INFS 24GAX0.75IN NEXIVA SAFTY LRG BORE WNG DL PRT -,SUP-383531,CDM,C1751,HCPCS,272,RC,,,outpatient,,,31.28,21.896,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
KT ARTERIAL LN 20GAX20CM 1ST MI D CATH MDLN SFN -,SUP-384304,CDM,C1751,HCPCS,272,RC,,,outpatient,,,468.67,328.069,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATHETER IV 16 X 2 SFR -,SUP-4082,CDM,C1751,HCPCS,272,RC,,,outpatient,,,11.6,8.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV 14 X 2.25in JELCO -,SUP-4088,CDM,C1751,HCPCS,272,RC,,,outpatient,,,20.36,14.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
TRY MIDLINE CATH 4FR 18GA LUM LUMX1 LF -,SUP-4154108,CDM,C1751,HCPCS,272,RC,,,outpatient,,,526.32,368.424,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
TRY CV LUMX1 4FR PU LF ACC -,SUP-4154108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1151.36,805.952,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV INTROCAN SAFTY 20GAX1.75IN FEP POYMER SAFTY STR HUB -,SUP-4252527-02,CDM,C1751,HCPCS,272,RC,,,outpatient,,,7.39,5.173,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH IV INTROCAN SAFTY 18GAX2.5IN TFLN FEP PLYMR SAFTY STR -,SUP-4252561-02,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.22,6.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH CV 5FRX8CM POWERWAND PWR-INJ MDLN QCK CHRNFLX C -,SUP-72135,CDM,C1751,HCPCS,272,RC,,,outpatient,,,811.07,567.749,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
PICC LINE CHANGE KIT IVAD ACCE -,SUP-73240B,CDM,C1751,HCPCS,272,RC,,,outpatient,,,17.27,12.089,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
PORT INFS 8FR 1LUM -,SUP-7711802,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1505.34,1053.738,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH PA 8FRX110CM SWAN-GNZ C CMB VOL LUMX7 INJ PRT ANTMIC -,SUP-777HF8,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1446.77,1012.739,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
SWAN-GANZ VIP/ OXIMETRY THERMOD CATHETER -,SUP-782F75M,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1519.92,1063.944,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
KT IT F/LEGEND SYNCHROMED INFS PMP RPR -,SUP-8590-9,CDM,C1751,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
TRY CV LUMX1 4FRX60CM PU POLY P-Q-CTH LF ACC -,SUP-9154108,CDM,C1751,HCPCS,272,RC,,,outpatient,,,908.45,635.915,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
TRY CV LUMX1 4FR STD 55CM PU POWERPICC LF ACC -,SUP-9174108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1953.71,1367.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH CV 5FRX10CM POWERWAND PWR-INJ MDLN CHRNFLX C -,SUP-92006,CDM,C1751,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
TRY CV LUMX2 5FRX60CM PU POLY P-Q-CTH LF ACC -,SUP-9255108,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1040.96,728.672,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH PA 7.5FRX110CM SWAN-GNZ PCNG LUMX5 AMC THRMBSHLD HPCT -,SUP-931HF75,CDM,C1751,HCPCS,272,RC,,,outpatient,,,303.24,212.268,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
TRY CV LUMX3 6FR STD 55CM PU POWERPICC LF ACC -,SUP-9386108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,2085.78,1460.046,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH PA 8FRX110CM SWAN-GNZ A-V PCNG LUMX6 INJ PRT ANTMIC AMC -,SUP-991HF8,CDM,C1751,HCPCS,272,RC,,,outpatient,,,787.2,551.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
"ACCUCATH 22G 1.25"" BASIC KIT -",SUP-AC0221250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,133.27,93.289,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
KIT CATHETER ACCUCATH ACE 18G 2.25 BASIC -,SUP-AC1182250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,254.41,178.087,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
"ACCUCATH 20G 1.25"" BASIC KIT -",SUP-AC1201250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,133.27,93.289,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
ACCUCATH ACE 20G X 2.25IN BASIC KIT -,SUP-AC1202250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,254.41,178.087,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH PRSS MONTR BLN WDG 5FR -,SUP-AI-07124,CDM,C1751,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH A-LN BLN WDG LUMX2 6FRX110CM PA INDWL 1ML CTRL STRK SYR -,SUP-AI-07126,CDM,C1751,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH PA 6FRX110CM BLN -,SUP-AI-07365-NHL,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
ST ARTERIAL CATH 20GAX1.75IN SHRP SAFTY LF -,SUP-AK-04020-SPC,CDM,C1751,HCPCS,272,RC,,,outpatient,,,145.29,101.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
KT A-LN 20GAX5IN PA INDWL 0.25IN SPR STR SFT TIP JTP GW -,SUP-AK-04510-S,CDM,C1751,HCPCS,272,RC,,,outpatient,,,164.55,115.185,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
KIT CENTRAL VENOUS TWO LUMEN -,SUP-AK-11142-D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,568.91,398.237,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
KT CV LUMX2 4FRX8CM PU ARROW G+ARD LF ACC -,SUP-AK-25402,CDM,C1751,HCPCS,272,RC,,,outpatient,,,431.79,302.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
FEMORAL ARTERY CATH KIT  5FR REF: G58398 -,SUP-APM-5.0-35J-1-15-NY,CDM,C1751,HCPCS,272,RC,,,outpatient,,,259.07,181.349,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
KT CV MULTLUM 20CM ARROW G+ARD LF ACC -,SUP-ASK-45703-PSCH,CDM,C1751,HCPCS,272,RC,,,outpatient,,,847.94,593.558,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
KIT CATH TRIPLE LUMEN 20CM CEN -,SUP-ASK-45703-PSCH,CDM,C1751,HCPCS,272,RC,,,outpatient,,,847.94,593.558,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
KT CV LUMX3 7FRX16CM PU ARW HWS LF ACC -,SUP-CDC-12703-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,352.9,247.03,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
KT CV LUMX3 7FRX20CM PU ARW HWS LF ACC -,SUP-CDC-15703-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,408.63,286.041,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
KT CV LUMX1 16GAX20CM PU ARROW G+ARD LF ACC -,SUP-CDC-24301-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,395.61,276.927,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
KT CV LUMX1 16GAX20CM PU ARROW G+ARD LF ACC -,SUP-CDC-24301-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,395.61,276.927,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
ARROW PEDI CENTRAL LINE KIT 13CM -,SUP-CDC-24402-X1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,754.66,528.262,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
SWAN -GANZ TEMP PACR STR EDWARDS -,SUP-D97120F5,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1130.07,791.049,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
SWAN-GANZ BIPOLAR PACING CATH J-TIP 5 FR 90CM -,SUP-D97130F5,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1130.07,791.049,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH PERFUS 20FRX.25IN ACPT 6CM PRFX STR PVC -,SUP-E063,CDM,C1751,HCPCS,272,RC,,,outpatient,,,239.59,167.713,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
ST ARTERIAL CATH 18GAX4.25IN LF -,SUP-FA-04018,CDM,C1751,HCPCS,272,RC,,,outpatient,,,81.46,57.022,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CENTRAL VENOUS CATHETER TRAY 4.0FR -,SUP-G02138,CDM,C1751,HCPCS,272,RC,,,outpatient,,,245.65,171.955,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH INFS 3FR STR 135CM SLIP-CATH NYL SS HYDRCT 0.025IN GW -,SUP-G12044,CDM,C1751,HCPCS,272,RC,,,outpatient,,,283,198.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH INFS 3FR STR 150CM SLIP-CATH NYL SS HYDRCT 0.025IN GW -,SUP-G12045,CDM,C1751,HCPCS,272,RC,,,outpatient,,,283,198.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
KT BLOOD GS ART 182CM CHMBR IV SPK 3W STPCKX2 122IN PRESSMNT -,SUP-H965700361481,CDM,C1751,HCPCS,272,RC,,,outpatient,,,164.55,115.185,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH INFS 4FRX135CM 10CM INFS ACCESSPLUS VLV PEBAX OCL WIRE -,SUP-IS4-135-10,CDM,C1751,HCPCS,272,RC,,,outpatient,,,793.56,555.492,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH INFS 4FRX135CM 20CM INFS ACCESSPLUS VLV PEBAX OCL WIRE -,SUP-IS4-135-20,CDM,C1751,HCPCS,272,RC,,,outpatient,,,793.56,555.492,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
KT INTRAVENOUS CATH 20GAX8CM POWERGLIDE LF -,SUP-M020081,CDM,C1751,HCPCS,272,RC,,,outpatient,,,493.06,345.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
KT INTRAVENOUS CATH 20GAX10CM POWERGLIDE -,SUP-M020101,CDM,C1751,HCPCS,272,RC,,,outpatient,,,493.06,345.142,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH VASC ACCESS 3FR LUMX1 MDLN PU PRELD STYL INTRO GW SYR -,SUP-ML3S20FN,CDM,C1751,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH CV LUMX1 4FRX200CM SINGLE MDLN -,SUP-MLCT4S20FN,CDM,C1751,HCPCS,272,RC,,,outpatient,,,805.52,563.864,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH PICC LUMX1 6FR PWR PICC -,SUP-MR17036306MB,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1081.3,756.91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
ARTERIAL CATHETERIZATION KIT 20G -,SUP-NA-04550-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,303.42,212.394,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH CV LUMX2 4FRX20 CM DUAL MDLN -,SUP-P4254108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,982.38,687.666,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH RADIAL ARTERY 20G -,SUP-RA-04020,CDM,C1751,HCPCS,272,RC,,,outpatient,,,55.96,39.172,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
CATH SET RADIAL ARTERY 20GX1.5 -,SUP-RA-04220,CDM,C1751,HCPCS,272,RC,,,outpatient,,,70.49,49.343,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
SET RAPID INFUSION 7FR CATHETER EXCHANGE -,SUP-RC-09700,CDM,C1751,HCPCS,272,RC,,,outpatient,,,61.73,43.211,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
SET RAPID INFUSION 8.5FR CATHETER EXCHANGE -,SUP-RC-09850,CDM,C1751,HCPCS,272,RC,,,outpatient,,,59.52,41.664,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
STYLET ELCSURG 6FRX12CM RF D MRKNG CLOSURERFS -,SUP-RFS2612,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1908.18,1335.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
TRY CV LUMX3 5FR TRIPLE  POWERPICC ACC -,SUP-S1385108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1499.41,1049.587,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
MULTI-LUMEN VENOUS CATH 8FR -,SUP-SS-14703,CDM,C1751,HCPCS,272,RC,,,outpatient,,,187.89,131.523,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
C 6FR TRIPLE LUMEN PICC -,SUP-UNDEFINED,CDM,C1751,HCPCS,272,RC,,,outpatient,,,669.86,468.902,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.659055,3468.96072,other,OPPS APC,,
KT HMDLYS PWR TRIALYSIS 13FRX20CM LUMX3 SHRT TERM -,SUP-5603200,CDM,C1752,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.92327,4457.91882,,,,
TRY HMDLYS PWR TRIALYSIS 13FRX15CM PU ACUTE SHRT TERM LUMX3 -,SUP-5605150,CDM,C1752,HCPCS,272,RC,,,outpatient,,,6217.46,4352.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.92327,4457.91882,,,,
KT HMDLYS PWR -TRIALYSIS 13FRX20CM SHRT TERM LUMX3 ACC -,SUP-5605200,CDM,C1752,HCPCS,272,RC,,,outpatient,,,6217.46,4352.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.92327,4457.91882,,,,
KT HMDLYS PWR -TRIALYSIS 13FRX20CM SHRT TERM LUMX3 ACC -,SUP-5605200,CDM,C1752,HCPCS,272,RC,,,outpatient,,,1553.05,1087.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.92327,4457.91882,,,,
KT HMDLYS PWR -TRIALYSIS 13FRX15CM SHRT TERM LUMX3 ACC -,SUP-5613150,CDM,C1752,HCPCS,272,RC,,,outpatient,,,1372.83,960.981,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.92327,4457.91882,,,,
MAHUKAR CATH DUAL 19FR. -,SUP-8813793009,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.92327,4457.91882,,,,
MAHUKUR CATH DUAL 10 FR. -,SUP-8817146007,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.92327,4457.91882,,,,
KT HMDLYS MHRKR 11.5FR LNG EXTEND 16CM LUMX2 ACUTE ACC -,SUP-8830415001,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.92327,4457.91882,,,,
TRY HMDLYS MHRKR 11.5FRX24CM PU 1% 5ML LIDOCN LUMX2 ACC -,SUP-8831663001,CDM,C1752,HCPCS,272,RC,,,outpatient,,,443.65,310.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.92327,4457.91882,,,,
CATH MAHURKAR CURVED 12FR 16CM -,SUP-8888101002HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,553.17,387.219,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.92327,4457.91882,,,,
MAHURKER CATH DUAL 13.5 FR. -,SUP-8888135192,CDM,C1752,HCPCS,272,RC,,,outpatient,,,415.92,291.144,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.92327,4457.91882,,,,
MAHURKAR STRAIGHT CATH KIT 12FR -,SUP-8888221220,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.92327,4457.91882,,,,
TRY MHRKR ELITE ACUTE 12FRX20CM -,SUP-8888233420,CDM,C1752,HCPCS,272,RC,,,outpatient,,,859.55,601.685,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.92327,4457.91882,,,,
KT HMDLYS MHRKR 12FRX20CM PU LUMX3 ACUTE ACC -,SUP-8888340629HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,471.37,329.959,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.92327,4457.91882,,,,
KIT HEMODIALYSIS MAHURKAR 12FRX24CM PU LUMX3 ACUTE ACC -,SUP-8888340637HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,489.29,342.503,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.92327,4457.91882,,,,
KT HMDLYS MHRKR 12FRX16CM PU LUMX3 ACUTE ACC -,SUP-8888345611HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,471.37,329.959,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.92327,4457.91882,,,,
KT HEMODIALYSIS MHRKR TLC- C E 12FRX20CM LF -,SUP-8888345637,CDM,C1752,HCPCS,272,RC,,,outpatient,,,499.18,349.426,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.92327,4457.91882,,,,
KT HMDLYS 12FR PU LUMX3 ACUTE ACC CVD -,SUP-8888345637HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,471.37,329.959,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,80.92327,4457.91882,,,,
IVUS 0.014P RX CATHETER -,SUP-014R,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7720.4409,other,OPPS APC,,
CATH US 8FRX90CM ACUNAV 4W STEER -,SUP-10135936,CDM,C1753,HCPCS,272,RC,,,outpatient,,,10767.7,7537.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7720.4409,other,OPPS APC,,
CATH DRAGONFLY OPSTAR REF: 1014651 -,SUP-1014651,CDM,C1753,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7720.4409,other,OPPS APC,,
CATH US 5FR20MM IMG TAPR 150CM EAGLE EYE GOLD OTW COR PERIPH -,SUP-85900,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7720.4409,other,OPPS APC,,
CATH US 5FR ID 20MM STR 150CM EAGLE EYE RX COR GLYDX PLTNM -,SUP-85900P,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7720.4409,other,OPPS APC,,
CATH US EAGLE EYE PLATINUM REF: 85900P -,SUP-85900P,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7720.4409,other,OPPS APC,,
CATH US EAGLE EYE PLTNM SHORT TIP -,SUP-85900PST,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7720.4409,other,OPPS APC,,
CATH VISIONS PV 0.018 -,SUP-86700,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7720.4409,other,OPPS APC,,
C VOLCANO IVUS PV035 -,SUP-88901,CDM,C1753,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7720.4409,other,OPPS APC,,
CATH DX VIEWFLEXX ICE 4W -,SUP-D087031,CDM,C1753,HCPCS,272,RC,,,outpatient,,,8496.49,5947.543,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7720.4409,other,OPPS APC,,
CATH DX VIEWFLEX ECO ICE CATHERTER REPROC REF: D087031-R -,SUP-D087031-R,CDM,C1753,HCPCS,272,RC,,,outpatient,,,5544.79,3881.353,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7720.4409,other,OPPS APC,,
ECHO ATLANTIS ICE -,SUP-H749389790,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7720.4409,other,OPPS APC,,
CATHETER OPTICROSS HD IVUS 5FR -,SUP-H74939352040,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3843.07,2690.149,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7720.4409,other,OPPS APC,,
CATHETER OPTICROSS HD IVUS 6FR -,SUP-H74939354080,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3843.07,2690.149,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7720.4409,other,OPPS APC,,
CATH US 9FR 9 MHZ 110CM ULTRA ICE IMG COR -,SUP-M00499000,CDM,C1753,HCPCS,272,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7720.4409,other,OPPS APC,,
CATH US 6FR CRV NDL 120CM PIONEER + TRPL BRD SHFT PERC -,SUP-PPLUS120,CDM,C1753,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7720.4409,other,OPPS APC,,
KIT EPIDURAL MINI BREVI-XL -,SUP-181-2340,CDM,C1755,HCPCS,278,RC,,,outpatient,,,481.1,336.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC,,
ST NEEDLE NRV BLCK CONTIPLEX -,SUP-331686,CDM,C1755,HCPCS,278,RC,,,outpatient,,,209.88,146.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC,,
TRAY EPIDURAL PERIFIX 17GA -,SUP-332079,CDM,C1755,HCPCS,278,RC,,,outpatient,,,140.22,98.154,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC,,
TRAY EPIDURAL WITH DURAPREP -,SUP-332215,CDM,C1755,HCPCS,278,RC,,,outpatient,,,192.5,134.75,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC,,
EPIDURAL CATHETER SET 20GA -,SUP-333540,CDM,C1755,HCPCS,278,RC,,,outpatient,,,46,32.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC,,
TRY EPDRL/SPIN CONT TUOHY WHITACRE 18GA PERISAFE 1% LIDOCN -,SUP-406048,CDM,C1755,HCPCS,278,RC,,,outpatient,,,114.89,80.423,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC,,
TRAY SPINAL LIDOCAINE 25GA X 3.5IN WHITACRE 0.75% HCL D8.25W -,SUP-406704,CDM,C1755,HCPCS,278,RC,,,outpatient,,,159.23,111.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC,,
LUMBAR PUNCTURE TRAY PEDI 22GA 1.5IN -,SUP-646,CDM,C1755,HCPCS,278,RC,,,outpatient,,,75.04,52.528,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC,,
TRAY LUMBAR PUNCTURE 20G -,SUP-648,CDM,C1755,HCPCS,278,RC,,,outpatient,,,92.06,64.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC,,
PASSER SURG SS HOL OBTR STRL -,SUP-8591-38,CDM,C1755,HCPCS,278,RC,,,outpatient,,,571.83,400.281,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC,,
KT IT 4FR CLSD TIP SIL MRKNG GW SPIN NDL ANCHR RLR -,SUP-8598A,CDM,C1755,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC,,
KT IT SIL RBR CLSD TIP SIL MRKNG GW SPIN NDL ANCHR RLR -,SUP-8709SC,CDM,C1755,HCPCS,278,RC,,,outpatient,,,3150.84,2205.588,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC,,
CATH IT 0.53MM 1.4MM/2.2MM SPIN/PMP SEG SIL RBR TRMBL CLSD -,SUP-8731SC,CDM,C1755,HCPCS,278,RC,,,outpatient,,,3150.84,2205.588,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC,,
CATHETER INTRA MEDTRONIC -,SUP-8780,CDM,C1755,HCPCS,278,RC,,,outpatient,,,4430.74,3101.518,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC,,
CATHETER INTRATHECAL  MEDTRONIC -,SUP-8781,CDM,C1755,HCPCS,278,RC,,,outpatient,,,4430.74,3101.518,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC,,
PROCEDURE 20GA 3.5IN NDL SF-T + F/LP -,SUP-974,CDM,C1755,HCPCS,278,RC,,,outpatient,,,130.65,91.455,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC,,
PROCEDURE 20GA 3.5IN NDL SF-T + F/LP -,SUP-974,CDM,C1755,HCPCS,278,RC,,,outpatient,,,130.65,91.455,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC,,
KIT SINGLE SHOT EPIDURAL -,SUP-A4082-20,CDM,C1755,HCPCS,278,RC,,,outpatient,,,85.52,59.864,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC,,
KT NEEDLE NRV BLCK 20GA STIMUCATH CONT INSL 4CM -,SUP-AB-20604-KS,CDM,C1755,HCPCS,278,RC,,,outpatient,,,518.08,362.656,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC,,
ST NEEDLE NRV BLCK 20GA STIMUCATH CONT INSL -,SUP-AB-20604-S,CDM,C1755,HCPCS,278,RC,,,outpatient,,,369.64,258.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC,,
KT NEEDLE NRV BLCK 20GA STIMUCATH CONT INSL 8CM -,SUP-AB-20608-KS,CDM,C1755,HCPCS,278,RC,,,outpatient,,,256.13,179.291,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC,,
SPACEOAR KITS -,SUP-SO-2101,CDM,C1755,HCPCS,278,RC,,,outpatient,,,11779.68,8245.776,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC,,
SPINAL -,SUP-UNDEFINED,CDM,C1755,HCPCS,278,RC,,,outpatient,,,80.87,56.609,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.327,9046.79424,other,OPPS APC,,
POWER PULSE KIT ANGIO JET Y SE -,SUP-104834-0020,CDM,C1757,HCPCS,272,RC,,,outpatient,,,214.56,150.192,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
SET POWER PULSE Y SPIKE ANGIO -,SUP-104834-0021,CDM,C1757,HCPCS,272,RC,,,outpatient,,,214.56,150.192,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
C ANGIOJET AVX -,SUP-105039-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,3746.49,2622.543,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
DISC INJ F/THRMB -,SUP-105040001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,5326.22,3728.354,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH THRMB 5FRX140CM ANGIOJET XVG HYDRCT -,SUP-105042-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,6917.72,4842.404,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
THROMBECTOMY 16.5INX54INX25IN D ANGIOJET -,SUP-105650-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,85111.5,59578.05,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH THRMB 4.2FR FETCH -,SUP-106127-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH THRMB 4FRX135CM ANGIOJET SPIROFLEX RX CX-STRM TECH -,SUP-106553-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10062.52,7043.764,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH THRMB 5FRX135CM ANGIOJET SPIROFLEXVG RX CX-STRM TECH -,SUP-106608-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10062.52,7043.764,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH THRMB 6FRX90CM ANGIOJET SOLENT PROXI OTW SPRL CUT PROX -,SUP-109676-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10503.9,7352.73,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
6FR 120CM ANGIOJET SOLENT OMNI -,SUP-109681-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9202.73,6441.911,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
4FRX145CM ANGIOJET  SOLENT DISTA THROMBECTOMY SE -,SUP-111303-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11183.56,7828.492,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
ANGIOIJET ZELANTEDVT 8X105CM -,SUP-114610-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10452.1,7316.47,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH FOGARTY 3FR EMB 3 / SHORT -,SUP-120403FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH FOGARTY 4FR EMB 4 SHORT -,SUP-120404FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH FOGARTY 2FR / EMB 2 SHORT -,SUP-120602FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,493.23,345.261,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH FOGARTY 3FR / EMB 3 -,SUP-120803FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH FOGARTY 4FR 9MM  EMB 4 -,SUP-120804F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH EMBCMT 4FR 9MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120804FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH EMBCMT 5FR 11MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120805FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH EMBCMT 6FR 13MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120806FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH EMBCMT 7FR 14MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120807FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
C FOGARTY 3FR 12TLW403F -,SUP-12TLW403F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
C FOGARTY 4FR 12TLW404F -,SUP-12TLW404F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
C FOGARTY 5F 40 CM -,SUP-12TLW405F35,CDM,C1757,HCPCS,272,RC,,,outpatient,,,567.98,397.586,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
C FOGARTY 6FR 40CM -,SUP-12TLW406F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH FOGARTY THRU LUMEN 3 -,SUP-12TLW803F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
C FOGARTY 4 80CM -,SUP-12TLW804F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
C FOGARTY 5.5 80CM OTW -,SUP-12TLW805F35,CDM,C1757,HCPCS,272,RC,,,outpatient,,,567.98,397.586,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
C FOGARTY 6 80CM -,SUP-12TLW806F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,567.98,397.586,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH EMBCMT 7FRX14MM/8FR INFL/DFLT BLN 80CM FOGARTY OTW -,SUP-12TLW807F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH FOGARTY 6FR. ACC 6/10 -,SUP-1408010,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1347.12,942.984,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH FOGARTY 6FR. / EMB 6 -,SUP-160246F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1992.72,1394.904,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH THRMB 5.5FR 138CM PRONTO V4 LRG LUM LNGTDNL WIRE HYDRCT -,SUP-4005,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1765.07,1235.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH PTCA 4MMX4CM SAVVY 120CM OTW COAX MOD PRSS PERIPH TAPR -,SUP-435-404L,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1155.51,808.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH US 5.2FRX106CM 12CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-55112,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH US 5.2FRX106CM 18CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-55118,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH US 5.2FRX106CM 24CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-55124,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH US 5.2FRX135CM 12CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56112,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH US 5.2FRX135CM 30CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56130,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH US 5.2FRX135CM 40CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56140,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH US 5.2FRX135CM 50CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56150,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH THRMB 0.066IN 6FRX140CM WKG PRONTO LP LPRO XTRCT HYDRCT -,SUP-5010,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1929.38,1350.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CLOT TRIEVER SHEATH -,SUP-50-101,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CLOTTRIEVER SHEATH 16FR X 15CM -,SUP-51-101,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
INDIGO CATHETER 5 + LARGE LUMEN ASPIRATION TUBING -,SUP-90178584,CDM,C1757,HCPCS,272,RC,,,outpatient,,,6599.42,4619.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
INDIGO CATHETER 6 + LARGE LUMEN ASPIRATION TUBING -,SUP-90178585,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9782.42,6847.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH INFS 6FR 3-10 MMX80CM 10CM BLN TRELLIS OTW MULTLUM INFS -,SUP-BVT608010,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8891.18,6223.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH THRMB 8FRX80CM 15CM TRELLIS INFS PTRN -,SUP-BVT808015,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8891.18,6223.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH THRMB 8FRX80CM 30CM TRELLIS INFS PTRN -,SUP-BVT808030,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9145.82,6402.074,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH INFS 8FR 5-16 MMX120CM 30CM BLN TRELLIS OTW MULTLUM -,SUP-BVT812030,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8891.18,6223.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH THRMB 0.041IN/0.032IN ID 4.1FR/3.4FR P/D 150CM INDIGO -,SUP-CAT3,CDM,C1757,HCPCS,272,RC,,,outpatient,,,5114.02,3579.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH THRMB 0.064IN/0.054IN ID 6FR/5FR P/D 132CM INDIGO -,SUP-CAT5,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4753.28,3327.296,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH THRMB 6FRX135CM INDIGO -,SUP-CAT6,CDM,C1757,HCPCS,272,RC,,,outpatient,,,7936.28,5555.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
INDIGO CATHETER 7D PLUS DYNAMIC ASPIRATION TUBING -,SUP-CAT7DKIT,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9913.71,6939.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH THRMB 8FRX115CM INDIGO -,SUP-CAT8XTORQ115,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10804.83,7563.381,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATHETER D + INDIGO LARGE LUMEN ASPIRATING TUBING -,SUP-CATD,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9913.71,6939.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
INDIGO CATHETER RX 140 CM + LG LUMEN ASPIRATION TUBING -,SUP-CATRXKIT,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8063.6,5644.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATHETER SILICONE EMBOLECTOMY 4FR 80CM -,SUP-E1801-48,CDM,C1757,HCPCS,272,RC,,,outpatient,,,811.07,567.749,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATHETER SILICONE EMBOLECTOMY 5FR 80CM -,SUP-E1801-58,CDM,C1757,HCPCS,272,RC,,,outpatient,,,811.07,567.749,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
EXCIPIO SV THROMBECTOMY DEVICE 8MM -,SUP-EXC-0940-165,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11101.87,7771.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH EXPORT AP ASPIRATION 6F 0 -,SUP-EXPORTAP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH PTCA 4MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50233,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH EMBCMT 7FRX145CM EXPORT AP BRD ASPIR SFT TIP FLXB -,SUP-GEZ6200US7B,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
EKOS+ KIT 106CM 8 CM -,SUP-H74939605106080,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
DEVICE THROMBECTOMY EKOS+ 106CM X 2.62CM TREATMENT ZONE 12CM -,SUP-H74939605106120,CDM,C1757,HCPCS,272,RC,,,outpatient,,,13181.15,9226.805,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
EKOS+ KIT 106CM 16 CM -,SUP-H74939605106160,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
EKOS+ KIT 106CM 20 CM -,SUP-H74939605106200,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
EKOS+ KIT 135CM 20 CM -,SUP-H74939605135200,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
INDIGO CATHETER 12 115CM HTORQ -,SUP-LITNG12HTORQ115,CDM,C1757,HCPCS,272,RC,,,outpatient,,,25137.01,17595.907,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
INDIGO CATHETER 7 130CM XTORQ -,SUP-LITNG7XTORQ130,CDM,C1757,HCPCS,272,RC,,,outpatient,,,20681.41,14476.987,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
INDIGO CATHETER 8 115CM XTORQ -,SUP-LITNG8XTORQ115,CDM,C1757,HCPCS,272,RC,,,outpatient,,,21424.01,14996.807,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-5080-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-5120-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-6080-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-6120-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-6200-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
ACCESSORY KIT JETI NON STERILE DISPOSABLE -,SUP-WV1500,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
JETI CATHETER KIT 6FR -,SUP-WV6203A,CDM,C1757,HCPCS,272,RC,,,outpatient,,,12141.51,8499.057,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
JETI CATHETER KIT 8FR -,SUP-WV8803A,CDM,C1757,HCPCS,272,RC,,,outpatient,,,17109.5,11976.65,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.14178,61024.9455,other,OPPS APC,,
CATH URETH 5FR TIGTL PU LF 70CM NPRT EYE FLXB OPN TIP -,SUP-0139005,CDM,C1758,HCPCS,272,RC,,,outpatient,,,549.07,384.349,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,11.97932,751.60242,other,OPPS APC,,
CATH URETERAL POLLACK 5 70 -,SUP-021305,CDM,C1758,HCPCS,272,RC,,,outpatient,,,94.44,66.108,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,11.97932,751.60242,other,OPPS APC,,
CATH FOLEY 6FR 2W LUBRI-SIL SIL LF PED -,SUP-175806N,CDM,C1758,HCPCS,272,RC,,,outpatient,,,146.07,102.249,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,11.97932,751.60242,other,OPPS APC,,
CATH URET 6FRX70CM PVC OP-EN TIP LF PVC SOF-FLEX -,SUP-G15942,CDM,C1758,HCPCS,272,RC,,,outpatient,,,65.41,45.787,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,11.97932,751.60242,other,OPPS APC,,
CATH URET 5FRX80CM VNYL LUMX1 LF BUSH SL CATHX2 CMN L/S -,SUP-G16746,CDM,C1758,HCPCS,272,RC,,,outpatient,,,1048.26,733.782,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,11.97932,751.60242,other,OPPS APC,,
CATH ANG 5FR KMP 100CM SLIP-CATH BRD HYDRCT -,SUP-G28535,CDM,C1758,HCPCS,272,RC,,,outpatient,,,379.26,265.482,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,11.97932,751.60242,other,OPPS APC,,
CATHETER ACCESS 6FR AXXCESS -,SUP-M0064001161,CDM,C1758,HCPCS,272,RC,,,outpatient,,,61.04,42.728,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,11.97932,751.60242,other,OPPS APC,,
CATH 5FR X 70 CONE TIP BX/20 -,SUP-M0064002111,CDM,C1758,HCPCS,272,RC,,,outpatient,,,53.36,37.352,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,11.97932,751.60242,other,OPPS APC,,
CATH DUAL LUMEN URETERAL -,SUP-M0064051000,CDM,C1758,HCPCS,272,RC,,,outpatient,,,384.35,269.045,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,11.97932,751.60242,other,OPPS APC,,
CATHETER 5.5 S2 -,SUP-1000100,CDM,C1759,HCPCS,272,RC,,,outpatient,,,101147,70802.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,72522.399,,,,
CATH US 10FRX90CM 5.5-10 MHZ SOUNDSTAR NAV COR -,SUP-SNDSTR10,CDM,C1759,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,72522.399,,,,
DEVICE SUT -,SUP-123250101,CDM,C1760,HCPCS,278,RC,,,outpatient,,,116.7,81.69,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC,,
CLOSURE PERCLOSE PROGLIDE 6F -,SUP-12673-03,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC,,
PERCLOSE PROSTYLE -,SUP-12773-03,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC,,
DEVICE VASC CLSR 56FR STARCLOSE SE -,SUP-14679-01,CDM,C1760,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC,,
STAR CLOSE SELF -,SUP-14679-01,CDM,C1760,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC,,
ANGIO SEAL STS VIP/PLUS 6FR -,SUP-610119,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC,,
ANGIO SEAL STS VIP/PLUS 8FR -,SUP-610121,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC,,
DEVICE VASC CLSR 6FR ANGIO-SEAL VIP -,SUP-610130,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC,,
DEVICE VASC CLSR 8FR ANGIO-SE  70CM -,SUP-610131,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC,,
VASCADE MVP - VENOUS VASCULAR CLOSURE SYSTEM 6-12F -,SUP-800-612C-10U,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC,,
SYS ATRICLIP STD 40 -,SUP-ACH140,CDM,C1760,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC,,
SYS ATRICLIP STD 45 -,SUP-ACH145,CDM,C1760,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC,,
DEVICE VASC CLSR 5FR EXOSEAL -,SUP-EX500,CDM,C1760,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC,,
DEVICE VASC CLSR 6FR EXOSEAL -,SUP-EX600,CDM,C1760,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC,,
PAS-PORT PROXIMAL ANASTOMOSIS -,SUP-FG-000001-13,CDM,C1760,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC,,
CELT ACD 5FR CLOSURE DEVICE -,SUP-KCLT-05,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC,,
CELT ACD 6FR CLOSURE DEVICE -,SUP-KCLT-06,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC,,
CELT ACD 7FR CLOSURE DEVICE -,SUP-KCLT-07,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC,,
MYNX GRIP 5FR CLOSURE DEVICE M - MULTIPLES OF 10 ONLY -,SUP-M465MX50210C,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC,,
DEVICE VASC CLSR 6FR MYNXGRIP -,SUP-MX6721,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC,,
DEVICE 6F/7F MYNX GRIP CLOSURE -,SUP-MX6721,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC,,
VENASEAL SYSTEM CLOSURE -,SUP-VS-404,CDM,C1760,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3585.3312,other,OPPS APC,,
BALLOON SHOCKWAVE C2 + IVL CATHETER 2.5X12 REF: C2PIVL2512 -,SUP-C2PIVL2512,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,14791.55236,other,OPPS APC,,
BALLOON SHOCKWAVE C2 + IVL CATHETER 3.0X12 REF: C2PIVL3012 -,SUP-C2PIVL3012,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,14791.55236,other,OPPS APC,,
BALLOON SHOCKWAVE C2 + IVL CATHETER 3.5X12 REF: C2PIVL3512 -,SUP-C2PIVL3512,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,14791.55236,other,OPPS APC,,
BALLOON SHOCKWAVE C2 + IVL CATHETER 4.0X12 REF: C2PIVL4012 -,SUP-C2PIVL4012,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,14791.55236,other,OPPS APC,,
CATHETER  SHOCKWAVE L6 1VL- 8.0 X 30 MM -,SUP-L6IVL080030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,14791.55236,other,OPPS APC,,
CATHETER  SHOCKWAVE L6 1VL- 9.0 X 30 MM -,SUP-L6IVL090030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,14791.55236,other,OPPS APC,,
CATHETER  SHOCKWAVE L6 1VL- 10.0 X 30 MM -,SUP-L6IVL100030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,14791.55236,other,OPPS APC,,
CATHETER  SHOCKWAVE L6 1VL- 12.0 X 30 MM -,SUP-L6IVL120030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,14791.55236,other,OPPS APC,,
CATHETER SHOCKWAVE 6.5 X 60 MM M5+ -,SUP-M5PIVL6560,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,14791.55236,other,OPPS APC,,
TENDON SEMITENINOSIS -,SUP-004023,CDM,C1762,HCPCS,278,RC,,,outpatient,,,5817.25,4072.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC,,
GRAFT HUM TIS NAT DENOVO LF -,SUP-00560600010,CDM,C1762,HCPCS,278,RC,,,outpatient,,,17339.71,12137.797,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC,,
ADVANCE NERVE GRAFT D 1-2MM X 15MM -,SUP-111215,CDM,C1762,HCPCS,278,RC,,,outpatient,,,8649.27,6054.489,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC,,
ADVANCE NERVE ALLOGRAFT -,SUP-111230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC,,
STRATTICE RECONSTRUCTIVE TISSUE MATRIX 16 X 20CM -,SUP-1620002,CDM,C1762,HCPCS,278,RC,,,outpatient,,,30012.18,21008.526,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC,,
STRATTICE RECONSTRUCTIVE TISSUE MATRIX 20 X 20CM -,SUP-2020002,CDM,C1762,HCPCS,278,RC,,,outpatient,,,24926.57,17448.599,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC,,
GRAFT HUM TIS SPORTSMED TIB IRRAD LF -,SUP-208002,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC,,
GRAFT HUM TIS SPORTSMED TIB TNDN POST TIB IRRAD LF -,SUP-208003,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC,,
AVANCE NERVE GRAFT 2MM DIAM / 30MM LENGTH -,SUP-211230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC,,
ADVANCE NERVE GRAFT 3-4MM X 30MM -,SUP-311230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC,,
AXOGEN ADVANCE NERVE GRAFT 3.4MM X 70MM -,SUP-311270,CDM,C1762,HCPCS,278,RC,,,outpatient,,,25322.66,17725.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC,,
NERVE GRAFT ADVANCED 4-5MM X 30MM -,SUP-411230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC,,
AXOGEN ADVANCE NERVE GRAFT 4.5MM X 70MM -,SUP-411270,CDM,C1762,HCPCS,278,RC,,,outpatient,,,25322.66,17725.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC,,
GRAFT HUM TIS FRZN 6-12 MMX20-38CM ANT TIB TNDN LF -,SUP-430335,CDM,C1762,HCPCS,278,RC,,,outpatient,,,8376.38,5863.466,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC,,
TENDON TIBIALIS POSTERIOR -,SUP-430343,CDM,C1762,HCPCS,278,RC,,,outpatient,,,8168.81,5718.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC,,
GRAFT HUM TIS FRZN 3-10 MMX26-38CM SEMITNDS TNDN LF -,SUP-430350,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC,,
GRAFT HUM TIS FRZN 3-10 MMX20-25.9CM ANT TIB TNDN LF -,SUP-430355,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC,,
IMPLANT HUM TIS PS 10MM TNDN ACH -,SUP-450200,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10971.92,7680.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC,,
GRAFT HUM TIS FRZDR 2X14CM IOPATCH TUTOPLAST FSCA LATA -,SUP-68021,CDM,C1762,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC,,
GRAFT HUM TIS DHYDR 1.5X1.5CM IOPATCH TUTOPLAST PROC -,SUP-68250,CDM,C1762,HCPCS,278,RC,,,outpatient,,,1404.63,983.241,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC,,
GRAFT HUM TIS PTCH DHYDR 1X3CM IOPATCH TUTOPLAST SCLR IRRAD -,SUP-68334,CDM,C1762,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC,,
GRAFT HTM NMSH SFT REGEN 5X5CM STD GRAFTJACKET ACLR DERM 1MM -,SUP-8600-5X05,CDM,C1762,HCPCS,278,RC,,,outpatient,,,9761.2,6832.84,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC,,
GRAFT HTM FRZDR SFT REGEN 2X4CM GRAFTJACKET COLL 1.5MM UND -,SUP-86MX-2X04,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10752.85,7526.995,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC,,
PATELLA TENDON W/ EXTENSION MECHANISM -,SUP-92-3300,CDM,C1762,HCPCS,278,RC,,,outpatient,,,26622.21,18635.547,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC,,
GRAFT HUM TIS SPLT THK VSNGRFT CRNA NON-IMMUNOGENIC XLNK -,SUP-C0301AL-90,CDM,C1762,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC,,
CORNEA HUMAN -,SUP-CORNEA,CDM,C1762,HCPCS,278,RC,,,outpatient,,,16467.16,11527.012,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC,,
IMPLANT HUM TIS BLCK AT -,SUP-FATB,CDM,C1762,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC,,
IMPLANT HUM TIS ALLOGRAFT BIOCLEANSE GRCLS TNDN FRZN -,SUP-FGRACILIS,CDM,C1762,HCPCS,278,RC,,,outpatient,,,5267.78,3687.446,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC,,
GRAFT HUM TIS FRZDR 30X150MM MED RDIGRF FSCA LATA LF -,SUP-FLM,CDM,C1762,HCPCS,278,RC,,,outpatient,,,4565.66,3195.962,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC,,
GRAFT HUM TIS SFT 230MM 7.5MM FLEXIGRAFT POST TIB TNDN FRZN -,SUP-FPOST.TIBIAL,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7087.1,4960.97,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC,,
FLEXIGRAFT QUADLINK-ZORC -,SUP-FQL,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10482.68,7337.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC,,
GRAFT HUM TIS HAMSTRING FRZN >150MM4MM-5.5MM DIA FLEXIGRAFT -,SUP-FROPE,CDM,C1762,HCPCS,278,RC,,,outpatient,,,3719.57,2603.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC,,
GRAFT HUM TIS HAMSTRING FRZN 160-250MM 4-6MM FLEXIGRAFT -,SUP-FSTP,CDM,C1762,HCPCS,278,RC,,,outpatient,,,3657.31,2560.117,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC,,
SLING TRNVAG RPLFRM COLL 5X10CM NABSB FEM FRZDR SLF-ANCHR -,SUP-M0068202450,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7456.11,5219.277,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC,,
SLING TRNVAG RPLFRM COLL 6X12CM NABSB FEM FRZDR SLF-ANCHR -,SUP-M0068202460,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7882.17,5517.519,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC,,
MACROFORM COMPOSITE NOVABONE 10CC -,SUP-NB1003,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC,,
NOVABONE BIOACTIVE BONE GRAFT 10CC LONG STRIP -,SUP-NB2310L,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC,,
NOVABONE 10CC STRIP -,SUP-NB2310S,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC,,
NOVABONE 2.5CC PUTTY -,SUP-NB2602,CDM,C1762,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC,,
NOVABONE 5CC PUTTY -,SUP-NB2605,CDM,C1762,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC,,
NOVABONE 10CC PUTTY SYRINGE -,SUP-NB2610,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC,,
GRAFT HUM TIS FRZN >=150MM TIB POST TNDN LF -,SUP-X30820,CDM,C1762,HCPCS,278,RC,,,outpatient,,,6302.34,4411.638,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,315.339435,23049.35424,other,OPPS APC,,
IMPLANT BIO TISS 15X20CM RECT PRCN COLL MATRIX NXLNK XENMTRX -,SUP-1161520,CDM,C1763,HCPCS,278,RC,,,outpatient,,,31189.2,21832.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC,,
EPIDISK -,SUP-1417100,CDM,C1763,HCPCS,278,RC,,,outpatient,,,1203.21,842.247,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC,,
IMPLANT COLL MEMBR 50X40MM GEISTLICH BIO-GIDE BILAYER RESRB -,SUP-20153,CDM,C1763,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC,,
SHEET MEDPOR 38 X 50 X 0.85 ORBITAL IMPLANT -,SUP-7210,CDM,C1763,HCPCS,278,RC,,,outpatient,,,2390.53,1673.371,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC,,
SUBSTITUTE CA SLPHT 5ML GRNL MIIGX3 RESRB SYNTH PREFL -,SUP-84XS-0405,CDM,C1763,HCPCS,278,RC,,,outpatient,,,7940.52,5558.364,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC,,
SUBSTITUTE CA SLPHT 5ML GRNL MIIGX3 RESRB SYNTH PREFL -,SUP-84XS-0405,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9145.82,6402.074,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC,,
GRID CRNL 106X97MM 6MM MEDPOR FLEXBLOCK -,SUP-9524,CDM,C1763,HCPCS,278,RC,,,outpatient,,,15136.27,10595.389,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC,,
NERVE PROTECTOR WRAP 2MM X 20MM -,SUP-AG0220,CDM,C1763,HCPCS,278,RC,,,outpatient,,,8118.77,5683.139,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC,,
NERVE PROTECTOR WRAP 3.5MM X 20MM -,SUP-AG0320,CDM,C1763,HCPCS,278,RC,,,outpatient,,,8118.77,5683.139,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC,,
NERVE WRAP AVANCE 3.5MM X 40MM -,SUP-AG0340,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9921.14,6944.798,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC,,
NERVE WRAP AVANCE 3.5MM X 40MM -,SUP-AG0340,CDM,C1763,HCPCS,278,RC,,,outpatient,,,10525.12,7367.584,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC,,
NERVE PROTECTOR 7MM X 40MM - USE 0169678 -,SUP-AG0740,CDM,C1763,HCPCS,278,RC,,,outpatient,,,10121.64,7085.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC,,
NERVE PROTECTOR 7MM X 40MM -,SUP-AG0740,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9442.16,6609.512,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC,,
AXOGUARD NERVE PROTECTOR 40MM 10MM -,SUP-AG1040,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9442.16,6609.512,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC,,
AXOGAURD NERVE CONNECTOR 2 X 15 -,SUP-AGX215,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC,,
AXOGAURD NERVE CONNECTOR D 3MM L 15MM -,SUP-AGX315,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC,,
AXOGAURD NERVE CONNECTOR D 4MM L 15MM -,SUP-AGX415,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC,,
CONNECTOR AXOGUARD NERVE D 5MM L 15MM -,SUP-AGX515,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC,,
PLUG ANAL FISTULA -,SUP-G53614,CDM,C1763,HCPCS,278,RC,,,outpatient,,,5071.58,3550.106,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC,,
IMPLANT GYN 17X70CM SYNTH UPHOLD LT -,SUP-M0068317170,CDM,C1763,HCPCS,278,RC,,,outpatient,,,8668.37,6067.859,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC,,
SURGICAL MATRIX THICK 10 X 20CM -,SUP-PSMT1020,CDM,C1763,HCPCS,278,RC,,,outpatient,,,20941.32,14658.924,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC,,
5 X 5CM 6 LAYER GENTRIX SURGICAL MATRIX DRESSING -,SUP-PSMX0505,CDM,C1763,HCPCS,278,RC,,,outpatient,,,3471.65,2430.155,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC,,
ROD TNDN 3X250MM PLYSTR COR SIL PSS KNOB END HNTR STRL STR -,SUP-PT300000,CDM,C1763,HCPCS,278,RC,,,outpatient,,,5254.07,3677.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC,,
ROD TNDN 5X250MM PLYSTR COR SIL PSS KNOB END HNTR STRL STR -,SUP-PT500000,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6315.07,4420.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC,,
ROD TNDN STD 4X245MM PLYSTR COR SIL PSS HNTR STRL STR -,SUP-TR400000,CDM,C1763,HCPCS,278,RC,,,outpatient,,,5254.07,3677.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC,,
WOUND MATRIX 6 LAYER 10 X 15 -,SUP-WSX1015,CDM,C1763,HCPCS,278,RC,,,outpatient,,,16411.46,11488.022,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,270.120645,23953.3056,other,OPPS APC,,
RECORDER LOOP 2-AF BIOMONITOR -,SUP-398493,CDM,C1764,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,14243.66592,other,OPPS APC,,
MONITOR CARD IMPL REVEAL XT 19X62MM TI 9ML 15GM -,SUP-9529,CDM,C1764,HCPCS,278,RC,,,outpatient,,,13348.24,9343.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,14243.66592,other,OPPS APC,,
MONITOR CARD IMPL CNFRM 18.5MMX56.3MM 6.5ML 12GM FRZDR LRDTC -,SUP-DM2100,CDM,C1764,HCPCS,278,RC,,,outpatient,,,11346.93,7942.851,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,14243.66592,other,OPPS APC,,
LOOP RECORDER NEXT GEN JOT DX REF: DM4500 -,SUP-DM4500,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,14243.66592,other,OPPS APC,,
LOOP RECORDER ASSERT IQ3+ ICM REF: DM5300 -,SUP-DM5300,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,14243.66592,other,OPPS APC,,
LOOP RECORDER ASSERT IQ EL+ ICM REF: DM5500 -,SUP-DM5500,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17636.75,12345.725,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,14243.66592,other,OPPS APC,,
REVEAL LINQ ICM SYSTEM LOOP RECORDER MDT -,SUP-LINQSYS,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17246.89,12072.823,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,14243.66592,other,OPPS APC,,
LOOP RECORDER REVEAL LINQ II SYSTEM REF: LNQ22SYS -,SUP-LNQ22SYS,CDM,C1764,HCPCS,278,RC,,,outpatient,,,18546.44,12982.508,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,14243.66592,other,OPPS APC,,
LUX DX INSERTABLE CARDIAC MONITOR M301 -,SUP-M301,CDM,C1764,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,14243.66592,other,OPPS APC,,
LUX -DX II+ INSERTABLE CARDIAC MONITOR REF: M312 -,SUP-M312,CDM,C1764,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,14243.66592,other,OPPS APC,,
GELFILM OPTH -,SUP-0009-0297-03,CDM,C1765,HCPCS,278,RC,,,outpatient,,,1102.46,771.722,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,247.50227,1378.95936,other,OPPS APC,,
"BARRIER ADHESION SEPRAFILM 5 X 6"" -",SUP-430102,CDM,C1765,HCPCS,278,RC,,,outpatient,,,1691.39,1183.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,247.50227,1378.95936,other,OPPS APC,,
BARRIER INTERCEED 3X4 -,SUP-4350,CDM,C1765,HCPCS,278,RC,,,outpatient,,,1795.52,1256.864,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,247.50227,1378.95936,other,OPPS APC,,
FLEXCATH CONTOUR STERERABLE SHEATH REF:10FCC13 -,SUP-10FCC13,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,109.158635,4260.1272,other,OPPS APC,,
FLEXCATH CONTOUR STERRABLE SHEATH 10FRX20MM REF:10FCC20 -,SUP-10FCC20,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,109.158635,4260.1272,other,OPPS APC,,
FLEXCATH CONTOUR STEERABLE SHEATH 12FRx13MM REF:12FCC13 -,SUP-12FCC13,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,109.158635,4260.1272,other,OPPS APC,,
FLEXCATH CONTOUR STEERABLE SHEATH 12FRx20MM REF:12FCC20 -,SUP-12FCC20,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,109.158635,4260.1272,other,OPPS APC,,
FARADRIVE STEERABLE SHEATH REF: 21C602 -,SUP-21C602,CDM,C1766,HCPCS,272,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,109.158635,4260.1272,other,OPPS APC,,
AGILIS SHEATH SMALL -SJM  8.5FRX91CM -,SUP-408309,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4139.92,2897.944,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,109.158635,4260.1272,other,OPPS APC,,
SHEATH AGILIS SM- REPROC 8.5FR -,SUP-408309,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2639.83,1847.881,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,109.158635,4260.1272,other,OPPS APC,,
AGILIS SHEATH  MED - SJM 8.5FR X 91CM -,SUP-408310,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4267.96,2987.572,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,109.158635,4260.1272,other,OPPS APC,,
INTRO SHTH FLEXCATH ADVANCE 12FR -,SUP-4FC12,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,109.158635,4260.1272,other,OPPS APC,,
CATH ABLT CARTO 3 XTRN REF -,SUP-CREFP6,CDM,C1766,HCPCS,272,RC,,,outpatient,,,486.23,340.361,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,109.158635,4260.1272,other,OPPS APC,,
SHEATH AGILIS LGE- REPROC  8.5FR -,SUP-G408234,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2473.84,1731.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,109.158635,4260.1272,other,OPPS APC,,
AGILIS SHEATH LRG CURL SFT 3MM J FNGR SJM -,SUP-G408324,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4172.48,2920.736,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,109.158635,4260.1272,other,OPPS APC,,
SHEATH POLARSHEATH STEERABLE SHEATH REF:M004CRBS3150 -,SUP-M004CRBS3150,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,109.158635,4260.1272,other,OPPS APC,,
AMULET STEERABLE DELIVERY SHEATH REF: STRBL-14F-075 -,SUP-STRBL-14F-075,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,109.158635,4260.1272,other,OPPS APC,,
TOURGUIDE 7FR X 55CM -,SUP-TG0705509,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,109.158635,4260.1272,other,OPPS APC,,
SHEATH 6.5 FR. 55CM -,SUP-UNDEFINED,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,109.158635,4260.1272,other,OPPS APC,,
SHEATH GRAFT 7FR. 9MM 45CM -,SUP-UNDEFINED,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,109.158635,4260.1272,other,OPPS APC,,
GENERATOR NEURSTM INTSTM TI 60MMX55MM SCRL NRV MRI-COND -,SUP-3023,CDM,C1767,HCPCS,278,RC,,,outpatient,,,36758.7,25731.09,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,39874.22976,other,OPPS APC,,
INTERSTIM STIMULATOR EXTERNAL NEURO -,SUP-353101,CDM,C1767,HCPCS,278,RC,,,outpatient,,,1987.69,1391.383,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,39874.22976,other,OPPS APC,,
PROCLAIM 5 ELITE -,SUP-3660ANS,CDM,C1767,HCPCS,278,RC,,,outpatient,,,40409.46,28286.622,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,39874.22976,other,OPPS APC,,
NEUROSTIMULATOR PROCLAIM 5 -,SUP-3661,CDM,C1767,HCPCS,278,RC,,,outpatient,,,45984.88,32189.416,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,39874.22976,other,OPPS APC,,
PROCLAIM 7 PULSE GENERATOR -,SUP-3663,CDM,C1767,HCPCS,278,RC,,,outpatient,,,44998.08,31498.656,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,39874.22976,other,OPPS APC,,
PROCLAIM DRG IPG 5.3AHG MRI EIFU RED -,SUP-3664,CDM,C1767,HCPCS,278,RC,,,outpatient,,,51919.57,36343.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,39874.22976,other,OPPS APC,,
DEVICE NEURSTM PRIM ADVANCED 2.6INX1.9IN PERC MRI-COND -,SUP-377-02,CDM,C1767,HCPCS,278,RC,,,outpatient,,,29604,20722.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,39874.22976,other,OPPS APC,,
NEURSTM PRGM ITREL 60MMX55MM SPIN CRD PRIM CELL -,SUP-377-03,CDM,C1767,HCPCS,278,RC,,,outpatient,,,27012.08,18908.456,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,39874.22976,other,OPPS APC,,
INS 977006 PAIN PC M -,SUP-977006,CDM,C1767,HCPCS,278,RC,,,outpatient,,,50457.55,35320.285,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,39874.22976,other,OPPS APC,,
NEURSTM IMPL PRIM ADVANCED 65X49X15MM SPIN CRD MRI-COND -,SUP-9770-2,CDM,C1767,HCPCS,278,RC,,,outpatient,,,32564.4,22795.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,39874.22976,other,OPPS APC,,
INTELLIS BATTERY #97715 -,SUP-97715,CDM,C1767,HCPCS,278,RC,,,outpatient,,,44376.4,31063.48,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,39874.22976,other,OPPS APC,,
INTERSTIM X NEUROSTIMULATOR IMPLANT -,SUP-97800,CDM,C1767,HCPCS,278,RC,,,outpatient,,,26510.38,18557.266,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,39874.22976,other,OPPS APC,,
PLEDGET FELT PTFE BARD 6 X 6IN -,SUP-007837,CDM,C1768,HCPCS,278,RC,,,outpatient,,,589.34,412.538,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT HEMA MDV BIF 20 10 40 -,SUP-0085201,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 20MM 15CM HEMASHLD GOLD STR KNTD DBL VELR AOR BVN -,SUP-095120,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1996.38,1397.466,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT HEMA 16MM 30CM MDV -,SUP-095216,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2628.78,1840.146,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT HEMA 18MM 30CM MDV -,SUP-095218,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2628.78,1840.146,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 22MM 30CM HEMASHLD GOLD STR KNTD DBL VELR AOR BVN -,SUP-095222,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2628.78,1840.146,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 1X6CM GORE-TEX 0.6MM PTCH -,SUP-1702515006,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2581.34,1806.938,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT HEMASHIELD D:28MM L:30CM -,SUP-175428P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 32MM 32X30CM HEMASHLD PLTNM STR WVN AOR COLL -,SUP-175432P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 38MMX30CM HEMASHLD PLTNM FINESSE STR WVN AOR BVN -,SUP-175438P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 20MM THOR 10MM BRNCH 50CM HEMASHLD PLTNM STR 20CM -,SUP-175820P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5377.66,3764.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 26MM THOR 10MM/10MM/8MM/8MM ID BRNCH 50CM -,SUP-175926P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6299.92,4409.944,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 7X10CM GORE-HYBRID PRECLUDE 0.1MM MEMBR PERICARD -,SUP-1PCM001,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1812.77,1268.939,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT ATRIUM VXT 4 7 45CM  - DISCONTINUED DO NOT USE -,SUP-22115,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2091.84,1464.288,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
KT INFL 20/20 PRIORITY PACK -,SUP-22297,CDM,C1768,HCPCS,278,RC,,,outpatient,,,227.57,159.299,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 6MM 50CM FLIXENE STR GRAD WL REINF SFT WRP TNLR -,SUP-25058,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5114.4,3580.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 6MM 40CM FLIXENE STR GRAD WL REINF SFT WRP TNLR -,SUP-25061,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4720.98,3304.686,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 4-7MM 30CM FLIXENE STR REINF SFT-WRP TNLR ATTCH -,SUP-25098,CDM,C1768,HCPCS,278,RC,,,outpatient,,,9358.02,6550.614,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT FLIXENE GTW GW 4 7 35 -,SUP-25129,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6294.62,4406.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 8MM 80CM STR HEP FUSION BIOLINE CTD RNG SUPP -,SUP-503088B,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10403.74,7282.618,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
VALVE AOR 6-30MM CRYOVALVE CONDT -,SUP-AV00,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39965.4,27975.78,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT STENT BIFURCATED -,SUP-BEA22-70/I16-30,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
AFX2 BIFURCATED ENDOGRAFT SYSTEM -,SUP-BEA25-80/113-40,CDM,C1768,HCPCS,278,RC,,,outpatient,,,14944.83,10461.381,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT STENT BIFURCATED -,SUP-BEA25-80/I20-40,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT STENT 90MM 28MM 16MM AFX2 2 BRANCH MAIN BODY ILIAC LIM -,SUP-BEA28-90/I16-30,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 7X15CM CORMATRIX PERICARD COLL GRW FACT PRTN -,SUP-CMCV-003-402,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT DISTAFLO VASCULAR 6X70 -,SUP-DFM7006SC,CDM,C1768,HCPCS,278,RC,,,outpatient,,,30067.87,21047.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
PATCH BOVINE 0.8 X 8CM DURAVESS PERICARDIAL -,SUP-DP08X8,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1126.45,788.515,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
PATCH BOVINE 2 X 9 DURAVESS PERICARDIUM -,SUP-DP2X9,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1655.24,1158.668,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 4-7MM 45CM ACUSEAL -,SUP-ECH470045A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6675.81,4673.067,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT ZENITH FLEX LEG 20X56 -,SUP-G55241,CDM,C1768,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT GORE PROPATEN 6 X 40 -,SUP-H060040A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4766.01,3336.207,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT GORE H470045A -,SUP-H470045A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5661.5,3963.05,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
PROPATEN AXILLO BIFEMORAL VASC GRAFT -,SUP-HAX02A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,17306.29,12114.403,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 26X34MM SKRT 15CM CARDIOROOT 26MM SKRT 10MM CLLR -,SUP-HEWROOT0026,CDM,C1768,HCPCS,278,RC,,,outpatient,,,8640.74,6048.518,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 6MM 70CM HEMAGARD STR 0.49MM KNTD RVRS LOCKNIT -,SUP-HGK000670,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2112.2,1478.54,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC PROPATEN 6 X 80 -,SUP-HT066080A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10957.06,7669.942,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
PROPATEN VASCULAR GRAFT 7MM X 80CM -,SUP-HT076080A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10957.06,7669.942,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT PROPATEN 8 X 70 -,SUP-HT087080A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,11287.52,7901.264,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT FUSION BIOLINE 6 X 80 RING SUPPORTED -,SUP-M00201503086B0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10403.74,7282.618,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT CARDIOVASCULAR HEMASHIELD GOLD MDV BIF 14X7 40CM -,SUP-M002020851470,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT 16X8 40CM HEMA BIF MDV -,SUP-M002020851680,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT HEMA MDV BIF 18X9 40CM -,SUP-M002020851890,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT HEMA MDV BIF 22X11X40 -,SUP-M002020852210,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT HEMASHIELD D:6MM L:15CM GOLD -,SUP-M002020951060,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1879.03,1315.321,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT HEMASHIELD D:8MM L:15CM GOLD -,SUP-M002020951080,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1879.03,1315.321,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT HEMASHIELD D:10MM L:30CM GOLD -,SUP-M002020954100,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2538.41,1776.887,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT HEMASHIELD GOLD 10MM X 30CM -,SUP-M002020954100,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2538.41,1776.887,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 8MM 30CM HEMASHLD PLTNM STR WVN DBL VELR AOR BVN -,SUP-M00202175208P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2473.41,1731.387,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT HEMASHIELD 22MM X 30CM -,SUP-M00202175422P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2644.27,1850.989,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT HEMASHIELD D:24MM L:30CM -,SUP-M00202175424P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2644.27,1850.989,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT HEMASHIELD D:26MM L:30CM -,SUP-M00202175426P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT HEMASHIELD D:30MM L:30CM -,SUP-M00202175430P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT HEMASHIELD D:32MM L:30CM -,SUP-M00202175432P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
PERICARDIUM PERIGUARD 6X8 -,SUP-PC0608SNBIO,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2602.81,1821.967,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
PERICARDIUM PEROGIARD 8X14 -,SUP-PC0814SNBIO,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3079.33,2155.531,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 6MM 40CM GORE-TEX STR 30CM RNG SECT THNWL STRCH -,SUP-RRT06030040L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3933.78,2753.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 6MM 70CM GORE-TEX STR 60CM RNG SECT THNWL STRCH -,SUP-RRT06060070L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5648.76,3954.132,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 8MM 40CM GORE-TEX STR 30CM RNG SECT THNWL STRCH -,SUP-RRT08030040L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3933.78,2753.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 6MM 50CM GORE-TEX STR STD WL STRCH EPTFE -,SUP-S0605,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3403.86,2382.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 14X7MM 40CM GORE-TEX BIFUR THNWL STRCH EPTFE -,SUP-SBT1401D,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4303.42,3012.394,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 16X8MM 40CM GORE-TEX BIFUR THNWL STRCH -,SUP-SBT1601,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4000.61,2800.427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
STRETCH THIN WALL BIFURCATED GRAFT 16-8MM X 50CM -,SUP-SBT1602D,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5377.15,3764.005,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 8MM 40CM GORE-TEX STR THNWL STRCH LN REM RNG AOR -,SUP-SRRT08030040L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4387.31,3071.117,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 8MM 80CM GORE-TEX STR 70CM RNG SECT THNWL -,SUP-SRRT08070080L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,7032.31,4922.617,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 6MM 40CM GORE-TEX STR THNWL STRCH AOR EPTFE -,SUP-ST0604,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3232,2262.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 6MM 80CM GORE-TEX -,SUP-ST0608,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5330.46,3731.322,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
AORTIC BODY ALTO TM ABDOMINAL STENT GRAFT -,SUP-TV-AB2080-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
ALTO ABDOMINAL STENT GRAFT SYSTEM 23MM -,SUP-TV-AB2380-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
ALTO ABDOMINAL STENT GRAFT SYSTEM 26MM -,SUP-TV-AB2680-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
OVATION IX ABDOMINAL STENT GRAFT SYSTEM 29MM ALTO -,SUP-TV-AB2980-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
ALTO ABDOMINAL STENT GRAFT SYSTEM 34MM -,SUP-TV-AB3480-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
ILIAC GRAFT OVATION IX 10 X 160MM -,SUP-TV-IL1410160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT STENT TRIVASCULAR OVATION IX 12 X 140 ILIAC LIMB -,SUP-TV-IL1412140-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
ILIAC GRAFT 14 X 100MM -,SUP-TV-IL1414100-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
OVATION IX ILAC STENT GRAFT 14 X 160MM -,SUP-TV-IL1414160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
OVATION IX ILIAC STENT GRAFT 18MM X 140MM -,SUP-TV-IL1418140-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT STENT OVATION IX ILIAC LIMB 18 X 160MM -,SUP-TV-IL1418160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
OVATION IX 22 X 100MM -,SUP-TV-IL1422100-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT STENT TRIVASCULAR OVATION IX 28 X 120 ILIAC LIMB -,SUP-TV-IL1428120-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT STENT TRIVASCULAR OVATION IX 28 X 160 ILIAC LIMB -,SUP-TV-IL1428160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT HUM TIS VEIN CRYPRSR CRYOVEIN SAPHENOUS -,SUP-V010,CDM,C1768,HCPCS,278,RC,,,outpatient,,,30011.06,21007.742,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 6MM 50CM VENAFLO II STR CRBN IMPREG EPTFE CUF -,SUP-VL5006C,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6999.2,4899.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GRAFT VASC 6MM 80CM GORE-TEX THNWL LN EPTFE -,SUP-VT06080L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4621.23,3234.861,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,51.089465,30693.4272,other,OPPS APC,,
GUIDEWIRE SPRING TIP REUSABLE MARKED -,SUP-000150,CDM,C1769,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.038INX260CM 3MM JTP TAPR FXCR STD PTFE-CTD 6CM -,SUP-00-8634,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.43,38.801,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW CATH 0.025IN GW LNR SS PTFE-CTD -,SUP-0684-00-0254-09,CDM,C1769,HCPCS,272,RC,,,outpatient,,,123.7,86.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM HTORQ ALL STAR STR XTR SUPP INTMD -,SUP-1001741,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
HI-TORQUE SUPRACORE 35 (300cm) -,SUP-1002703-02,CDM,C1769,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.018INX190CM HTORQ STLCOR 18 STR FLXB SFT SS MICGLD -,SUP-1003281,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.018INX300CM HTORQ STLCOR 18 STR FLXB SFT SS MICGLD -,SUP-1003282,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX190CM HTORQ XIT 100XT STR SS/CTD 3CM 1.7GM -,SUP-1003309H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
SPARTA CORE 190CM ST -,SUP-1005202,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
SPARTACORE 14 WIRE (0.014IN- 300CM) -,SUP-1005203,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX190CM HTORQ SPARTACORE STR SFT SS SHFT -,SUP-1005205,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM HTORQ SPARTACORE STR SFT SS SHFT -,SUP-1005206,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX190CM HTORQ  WHISPER MS STR SFT DURASTEEL -,SUP-1005357H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM HTORQ WHISPER MS STR SFT DURASTEEL/ -,SUP-1005359H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX190CM HTORQ BAL MDWT UNIV STR RBN INTMD -,SUP-1009660,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE HI-TORQUE BALANCE MIDDLEWEIGHT UNIVERSAL II 190CM -,SUP-1009664,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX190CM HTORQ PILOT 50 STR SFT DURASTEEL/ -,SUP-1010480-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX190CM HTORQ PILOT 150 STR STF DURASTEEL/ -,SUP-1010481-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX190CM HTORQ PILOT 200 STR DURASTEEL/ SS/CTD -,SUP-1010482-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM HTORQ PILOT 50 STR SFT DURASTEEL/ -,SUP-1010483-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM HTORQ PILOT 150 STR DURASTEEL/ SS/CTD -,SUP-1010484-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM HTORQ PILOT 200 STR SFT DURASTEEL -,SUP-1010485-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
HI-TORQUE WHISPER GUIDE WIRE -,SUP-1011835H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX180CM ASAHI FIELDER F C STR XTR SUPP CTD 3CM -,SUP-1011895-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE HI-TORQUE COMMAND 18 ST WORKHORSE 0.018IN x 210CM -,SUP-1013730,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.018INX300CM HTORQ COMMAND ES SS/NTNL/CTD 30CM -,SUP-1013731,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE VERRATA 185 CM STRAIGHT TIP -,SUP-10185,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE VERRATA 185 CM J-TIP -,SUP-10185J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE VERRATA PLUS 185 CM J-TIP -,SUP-10185JP,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE VERRATA 300 CM STRAIGHT TIP -,SUP-10300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE VERRATA 300 CM J-TIP -,SUP-10300J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE VERRATA PLUS 300 CM J-TIP -,SUP-10300JP,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE VERRATA PLUS 300 CM STRAIGHT TIP -,SUP-10300P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
ST INTUB 11FRX110CM RTRGD 0.38IN STR/3MM J WG INTRO NDL SYR -,SUP-110-70-38J-110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1022.29,715.603,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INSHRTX182CM CHC STR SPR COIL HYDRCT SS -,SUP-12132-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,480.8,336.56,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE ASAHI PROWATER 180 L -,SUP-12776-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM ASAHI MIRACLEBROS 3 STR STEER FLXB SS -,SUP-14937-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW URO 0.38IN NTNL -,SUP-150NSA38,CDM,C1769,HCPCS,272,RC,,,outpatient,,,221.73,155.211,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW URO 0.038INX150CM NICORE NTNL HYDRCT STR STF COR -,SUP-150NSS38,CDM,C1769,HCPCS,272,RC,,,outpatient,,,221.73,155.211,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.009INX180CM ASAHI CONFIANZA PRO PTCA STR STEER -,SUP-20629-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE VASCULAR HI-TORQUE COMMAND 0.014IN X 190CM -,SUP-2078174,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM HTORQ COMMAND ES SS/NTNL/CTD 30CM -,SUP-2078175,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014IN/0.018IN DIA 145CM -,SUP-22260,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX190CM HTORQ FLPY II JTP RBN LGT SUPP SFT SS -,SUP-22339MJ,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM HTORQ FLPY II STR RBN LGT SUPP SFT SS -,SUP-22359M,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM HTORQ FLPY II JTP RBN LGT SUPP SFT SS -,SUP-22359MJ,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM HTORQ WIGGLE STR RBN SS HYDRPHB -,SUP-22359M-W2,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM HTORQ TRAV STR STD SHFT SS/CTD 3CM -,SUP-22379H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE FLTR DLV BAREWIRE 0.014INX315CM SS COR PTFE-CTD -,SUP-22440-31,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX180CM RUNTHROUGH NS STR STEER EXTEND WIRE SS -,SUP-25-1011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM RUNTHROUGH NS STR WIRE SS -,SUP-25-1013,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDE WIRE PTCA RUNTHROUGH NS HYPERCOAT 0.014X180CM -,SUP-25-3011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX150CM RUNTHROUGH NS STEER EXTEND WIRE SS -,SUP-25-9092,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX260CM STR FXCR PTFE-CTD -,SUP-395369,CDM,C1769,HCPCS,272,RC,,,outpatient,,,218.81,153.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX200CM STR FXCR PTFE-CTD -,SUP-395703,CDM,C1769,HCPCS,272,RC,,,outpatient,,,218.81,153.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC GUIDERIGHT 0.035INX150CM  3MM J REF:404570 -,SUP-404570,CDM,C1769,HCPCS,272,RC,,,outpatient,,,40.85,28.595,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE GUIDERIGHT 3 MM J CURVE  L180 CM L5 CM OD.035 -,SUP-404571,CDM,C1769,HCPCS,272,RC,,,outpatient,,,43.76,30.632,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE VASCULAR GUIDERIGHT J CURVE L260 CM L5 CM OD.35 -,SUP-404577,CDM,C1769,HCPCS,272,RC,,,outpatient,,,93.36,65.352,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE VASCULAR GUIDERIGHT BENTSON L150 CM L15 CM OD.035 -,SUP-404843,CDM,C1769,HCPCS,272,RC,,,outpatient,,,54.27,37.989,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 190CM WHISPER VW HTORQ -,SUP-4483,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC WHISPER VW HTORQ -,SUP-4639,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE EMERALD 0.35INx260CM J TIP  FLEX FIXED CORE PTFE -,SUP-502455,CDM,C1769,HCPCS,272,RC,,,outpatient,,,52.52,36.764,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.038INX150CM EMERLD 3MM JTP FXCR FLXB STD PTFE-CTD -,SUP-502-520,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.14,38.598,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.032INX150CM EMERLD 3MM JTP FXCR FLXB STD PTFE-CTD -,SUP-502-526,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.14,38.598,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX150CM EMERLD STR FXCR FLXB STD PTFE-CTD 7CM -,SUP-502-542,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.14,38.598,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX300CM STORQ ANG STEER 1PC COR SFT SGL OUTR -,SUP-503-356Y,CDM,C1769,HCPCS,272,RC,,,outpatient,,,404.37,283.059,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM STBR + STR STEER S-SFT 3CM -,SUP-507-114X,CDM,C1769,HCPCS,272,RC,,,outpatient,,,349.22,244.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM STBR XS STR STEER XTR SUPP SFT -,SUP-527-300E,CDM,C1769,HCPCS,272,RC,,,outpatient,,,560.16,392.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
PLATE LEFT ANTER LATERAL -,SUP-630111,CDM,C1769,HCPCS,272,RC,,,outpatient,,,10381.67,7267.169,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE WARRIOR 200CM REF: 7388 -,SUP-7388,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1131.99,792.393,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE R350 350CM REF: 7390 -,SUP-7390,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1367.53,957.271,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE BANDIT 200CM REF: 7444 -,SUP-7444,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1131.99,792.393,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE GUIDE .035X260 STIFF SUPER -,SUP-80129-406,CDM,C1769,HCPCS,272,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM ASAHI PROWATER FLEX STR FLXB SPR COIL -,SUP-82358-02,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
"GUIDEWIRE 0.014"" X300CM PTCA STRAIGHT -",SUP-82902-02,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
PRESSURE GUIDEWIRE OMNIWIRE 185CM STRAIGHT TIP REF:89185 -,SUP-89185,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
PRESSURE GUIDEWIRE OMNIWIRE 185CM J-TIP REF:89185J -,SUP-89185J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX260CM AMPLATZER MOD 1.5MM JTP NOODLEWIRE -,SUP-9-GW-002,CDM,C1769,HCPCS,272,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
EXTENSION GW ASAHI -,SUP-AG14900-0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE VASCULAR MIRACLEBROS 6 L180 CM OD.014 IN STERILE L -,SUP-AG14M060,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE ASAHI MIRACLEBROS 6 300CM DUPLICATE -,SUP-AG14M360,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
W VASC 0.014INX300CM ASAHI MIRACLEBROS 12 STR STEER FLXB SS -,SUP-AG14M370,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM ASAHI CONFIANZA 9 STR XTR SUPP SPR -,SUP-AGH143390,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE ASAHI PROWATER 300 CM .014 -,SUP-AGH146300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.009INX180CM ASAHI FIELDER F C PTCA JTP 1.2GM LD -,SUP-AGP1400-01J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.009INX190CM ASAHI FIELDER XT STR SPR COIL -,SUP-AGP140002,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.009INX300CM ASAHI FIELDER XT STR SPR COIL -,SUP-AGP140302,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDE WIRE ASAHI SION BLUE 180/190CM -,SUP-AHW14R004S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GAIA FIRST 190CM MICRO J -,SUP-AHW14R007P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GAIA SECOND 190CM MICRO J -,SUP-AHW14R008P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GAIA THIRD 190CM MICRO J -,SUP-AHW14R011P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM ASAHI SOFT STR STEER COR-TO-TIP SS -,SUP-AHW14R304S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,490.14,343.098,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW GLADIUS MONGO190CM REF: AP14R023S -,SUP-AP14R023S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW FIELDER XT-A 190CM REF: APW14R009S -,SUP-APW14R009S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDE WIRE ASAHI SION BLACK 190CM STRAIGHT REF:APW14R010S -,SUP-APW14R010S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,566,396.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDE WIRE DOUBLE ENDED TROCAR .86MM -,SUP-AR-8737-39KD,CDM,C1769,HCPCS,272,RC,,,outpatient,,,175.05,122.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDE SPRING WIRE .018D 25CM -,SUP-AW-04018,CDM,C1769,HCPCS,272,RC,,,outpatient,,,53.92,37.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.018INX25CM 2FLX STR DBL END SPR WIRE SS -,SUP-AW-04018,CDM,C1769,HCPCS,272,RC,,,outpatient,,,53.92,37.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
"GUIDE SPRING WIRE .032"" -",SUP-AW-04432,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.08,38.556,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 175CM PRESSUREWIRE CERTUS SS NTNL PTFE-CTD -,SUP-C12008,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
PRESSUREWIRE X GUIDEWIRE 0.014INX175CM -,SUP-C12059,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 300CM PRESSUREWIRE CERTUS STEER CTD -,SUP-C12308,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
PRESSUREWIRE X GUIDEWIRE .014MMX300CM -,SUP-C12358,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX260CM TIGRWRE ANG TAPR STEER FLXB FLPY SFT -,SUP-C405085,CDM,C1769,HCPCS,272,RC,,,outpatient,,,390.95,273.665,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX180CM TIGRWRE ANG TAPR STEER FLXB FLPY SFT -,SUP-C405086,CDM,C1769,HCPCS,272,RC,,,outpatient,,,390.95,273.665,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
INTRO LAP 6MM SHTH 18GA 50CM -,SUP-C-LASS-6-10,CDM,C1769,HCPCS,272,RC,,,outpatient,,,431.79,302.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
ST CRICO MLKR 5MM PTFE XSTIF WG ENTRY NDLHLDR CUP GZE -,SUP-C-TCCSB-500-UNI,CDM,C1769,HCPCS,272,RC,,,outpatient,,,2450.49,1715.343,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
CPS EXCEL MEDIGUIDE MEDIUM GUIDEWIRE -,SUP-DS2M028,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
CPS EXCEL MEDIGUIDE STIFF GUIDEWIRE -,SUP-DS2M029,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
MEDIGUIDE GUIDEWIRE TORQUE CLIP -,SUP-DS2M030,CDM,C1769,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX145CM STR 3MM JTP DBL END FLPY SS HEP -,SUP-G00362,CDM,C1769,HCPCS,272,RC,,,outpatient,,,93.3,65.31,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
W 15J .035 145CM x 15MM CURVE -,SUP-G00509,CDM,C1769,HCPCS,272,RC,,,outpatient,,,67.04,46.928,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX145CM 3MM JTP CRV FXCR STD FLXB SS NO HEP -,SUP-G00511,CDM,C1769,HCPCS,272,RC,,,outpatient,,,67.04,46.928,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE GUIDE .035 260 SAFE-T-J T -,SUP-G00517,CDM,C1769,HCPCS,272,RC,,,outpatient,,,104.97,73.479,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX50CM 3MM NWTN JTP FNGR STR FXCR FLXB FLPY -,SUP-G00524,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.63,57.141,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE GUIDE FIXED CORE 3MM J CURVED -,SUP-G00524,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.63,57.141,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.038INX145CM 3MM JTP FXCR FLXB SS HEP PTFE-CTD 6CM -,SUP-G00541,CDM,C1769,HCPCS,272,RC,,,outpatient,,,67.04,46.928,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE GUIDE FIXED CORE STRAIGHT -,SUP-G00650,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.37,38.759,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
W BENTSON .035 145CM -,SUP-G00691,CDM,C1769,HCPCS,272,RC,,,outpatient,,,87.47,61.229,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX180CM SAFE-T-J-TIP FXCR FLPY SS PTFE-CTD -,SUP-G00902,CDM,C1769,HCPCS,272,RC,,,outpatient,,,72.88,51.016,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
W .035 260 BENTSON TSFB-35-260 -,SUP-G01063,CDM,C1769,HCPCS,272,RC,,,outpatient,,,116.64,81.648,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX260CM CRV RSN TIP FXCR FLPY W/OUT HEP -,SUP-G01253,CDM,C1769,HCPCS,272,RC,,,outpatient,,,104.97,73.479,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
THSCF 35 260 1.5 ROSEN 43700 -,SUP-G01253,CDM,C1769,HCPCS,272,RC,,,outpatient,,,104.97,73.479,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
W THSCF-35-180-1.5 ROSEN WIRE -,SUP-G01264,CDM,C1769,HCPCS,272,RC,,,outpatient,,,78.71,55.097,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WTSFB-35-180 BENTSON -,SUP-G01290,CDM,C1769,HCPCS,272,RC,,,outpatient,,,96.22,67.354,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.025INX180CM 3MM JTP FXCR STD FLXB SS HEP PTFE-CTD -,SUP-G01602,CDM,C1769,HCPCS,272,RC,,,outpatient,,,84.55,59.185,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE GUIDE 0.032 IN X180CM SAFE T JTP PTFE-C  - G02335 -,SUP-G02335,CDM,C1769,HCPCS,272,RC,,,outpatient,,,84.55,59.185,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE GUIDE 0.032 IN X260CM SAFE T J HEAVY DUTY - G03133 -,SUP-G03133,CDM,C1769,HCPCS,272,RC,,,outpatient,,,294.61,206.227,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE AMPLATZ  0.035 INX145CM J CRV TIP XSTIF FLPY SS -,SUP-G03203,CDM,C1769,HCPCS,272,RC,,,outpatient,,,169.16,118.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE AMPLATZ  0.025 IN X 145 OR 180 CM SAFE-T-J XTR-STF -,SUP-G03304,CDM,C1769,HCPCS,272,RC,,,outpatient,,,457.99,320.593,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX180CM AMP STR XSTIF SS PTFE-CTD 7CM TAPR 3CM -,SUP-G03330,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.31,89.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE AMPLATZ 0.032 IN X180CM JTP XSTIF FLPY SS PTFE-CTD -,SUP-G03584,CDM,C1769,HCPCS,272,RC,,,outpatient,,,125.39,87.773,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.038INX80CM AMP STR XSTIF FLPY SS PTFE-CTD 9.5CM -,SUP-G04003,CDM,C1769,HCPCS,272,RC,,,outpatient,,,148.73,104.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
SET CRIC MELKER 3.5MM 3.8CM -,SUP-G06245,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1139.28,797.496,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE ROADRUNNER EXTRA SUP -,SUP-G07640,CDM,C1769,HCPCS,272,RC,,,outpatient,,,676.8,473.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 60CM NTNL -,SUP-G08427,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.18,167.426,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
W PMG-18SP-60-COPE-NT -,SUP-G08427,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.18,167.426,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
W PMG-18SP-COPE-NT -,SUP-G08733,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.18,167.426,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
COPE WIRE 60CM ST -,SUP-G09395,CDM,C1769,HCPCS,272,RC,,,outpatient,,,262.52,183.764,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX180CM AMP STR ULTRA STF FLPY SS PTFE-CTD -,SUP-G09956,CDM,C1769,HCPCS,272,RC,,,outpatient,,,119.56,83.692,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
SHORT TAPER AMPLATZ WIRE 1CM -,SUP-G23639,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.31,89.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIREGLIDE AMPLATZ EXTRA STIFF 0.035 X 180CM -,SUP-G23639,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.31,89.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE UNIGLIDE ANG .018 260CM -,SUP-G30489,CDM,C1769,HCPCS,272,RC,,,outpatient,,,251.48,176.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE UNIGLIDE ANG. .035 260CM -,SUP-G30492,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE UNIGLIDE SIFF STR .035 260CM -,SUP-G30496,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.018INX260CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-G30500,CDM,C1769,HCPCS,272,RC,,,outpatient,,,269.57,188.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE UNIGLIDE STR .018 260CM -,SUP-G30500,CDM,C1769,HCPCS,272,RC,,,outpatient,,,269.57,188.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE UNIGLIDE STR .035 260CM -,SUP-G30502,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE UNIGLIDE STIFF ANG .035 260CM -,SUP-G30506,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX260CM LNDRQST STR XSTIF FLXB SS PTFE-CTD 4CM -,SUP-G31453,CDM,C1769,HCPCS,272,RC,,,outpatient,,,919.6,643.72,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW ENDO 0.035INX260CM TRACER METRO DRCT -,SUP-G31914,CDM,C1769,HCPCS,272,RC,,,outpatient,,,770.22,539.154,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
ACROBAT STR WIRE GUIDE 260 .03 -,SUP-G34265,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1042.19,729.533,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
SET GASTRONOMY ENTUIT START INIT PLCMT SM FOR 12/14FR -,SUP-G34442,CDM,C1769,HCPCS,272,RC,,,outpatient,,,551.35,385.945,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE GUIDE HIWIRE HYDROPHILIC ANGLED 35 -,SUP-G36284,CDM,C1769,HCPCS,272,RC,,,outpatient,,,215.3,150.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE HI .035 X 150CM STIFF ANGLED -,SUP-G36290,CDM,C1769,HCPCS,272,RC,,,outpatient,,,215.3,150.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE HI .035 X 260CM STIFF STRAIGHT -,SUP-G36327,CDM,C1769,HCPCS,272,RC,,,outpatient,,,308.08,215.656,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE GUIDE EX-STIFF 35-300 LUN -,SUP-G45408,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1025.79,718.053,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX450CM ACROBAT 2 CTD -,SUP-G47616,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1038.63,727.041,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX190CM PRO-LT NTNL/PTFE-CTD/SS/PD 8CM TAPR -,SUP-G47736,CDM,C1769,HCPCS,272,RC,,,outpatient,,,339.6,237.72,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
LUNDERQUIST WIRE 0.035 x 180CM -,SUP-G49228,CDM,C1769,HCPCS,272,RC,,,outpatient,,,593.41,415.387,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE METRO TRACER .035 X 600 -,SUP-G50660,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX190CM CTO MICROWIRE FLPY SS/PTFE-CTD/PLTNM -,SUP-G50788,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
CATH CTO 25 GRAM X 014 X 190CM -,SUP-G50789,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
W CTO 6G CMW-14-300-6G -,SUP-G50790,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
W CTO 12G CMW-14-300-12G -,SUP-G50791,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
W CTO 18G GUIDE WIRE -,SUP-G50792,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
W CTO 25G -,SUP-G50793,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX190CM HYDR ST MICRO FLPY SS/PTFE-CTD/PLTNM -,SUP-G52938,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1038.57,726.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM HYDR ST MICRO FLPY SS/PTFE-CTD/PLTNM -,SUP-G52939,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1038.57,726.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.018INX180CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-G56141,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE UNIGLIDE STR .018 180CM -,SUP-G56141,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE UNIGLIDE STR .035 180CM -,SUP-G56150,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE UNIGLIDE STIFF STR .035 180CM -,SUP-G56153,CDM,C1769,HCPCS,272,RC,,,outpatient,,,260.81,182.567,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
W GLIDE STIFF .035 180 STR -,SUP-G56153,CDM,C1769,HCPCS,272,RC,,,outpatient,,,308.15,215.705,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE UNIGLIDE ANG .018 180CM -,SUP-G56160,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE UNIGLIDE STR .035 260CM -,SUP-G56174,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE UNIGLIDE STIFF ANG .035 180CM -,SUP-G56177,CDM,C1769,HCPCS,272,RC,,,outpatient,,,260.81,182.567,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GLIDEWIRE ADV .014 300CM ANG -,SUP-GA1430,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
W GLIDE ADVANTAGE 300 .018 -,SUP-GA1830,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1431.14,1001.798,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX150CM GLIDEWIR ADVANTG ANG STF SHFT FLXB STD -,SUP-GA3501,CDM,C1769,HCPCS,272,RC,,,outpatient,,,933.6,653.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
W GLIDE ADVANTAGE 260 .035 -,SUP-GA3502,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.018INX300CM GLIDEWIR GOLD 45DG ANG FLXB -,SUP-GM1831,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1115.94,781.158,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.018INX300CM GLIDEWIR 70DG ANG GOLDBAND FLXB TIP -,SUP-GM1832,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1115.94,781.158,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE .018/180 STRAIGHT -,SUP-GR1803,CDM,C1769,HCPCS,272,RC,,,outpatient,,,354.24,247.968,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GLIDEWIRE .018 150 ANGLED -,SUP-GR1805,CDM,C1769,HCPCS,272,RC,,,outpatient,,,354.24,247.968,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE GLIDEWIRE 0.018INX180CM ANG STD FLXB -,SUP-GR1806,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.018INX260CM GLIDEWIR ANG STF SHFT STD FLXB -,SUP-GR1807,CDM,C1769,HCPCS,272,RC,,,outpatient,,,251.48,176.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
W GLIDE .035 180 STR -,SUP-GR3503,CDM,C1769,HCPCS,272,RC,,,outpatient,,,261.7,183.19,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE GLIDE .035 260 STR -,SUP-GR3504,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX150CM GLIDEWIR ANG STF SHFT STD FLXB -,SUP-GR3506,CDM,C1769,HCPCS,272,RC,,,outpatient,,,194.95,136.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE GLIDE .035 180 ANG  GR3508 -,SUP-GR3508,CDM,C1769,HCPCS,272,RC,,,outpatient,,,261.7,183.19,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE GLIDE .035 260 ANGLED -,SUP-GR3509,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.038INX180CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-GR3803,CDM,C1769,HCPCS,272,RC,,,outpatient,,,261.7,183.19,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.038INX260CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-GR3804,CDM,C1769,HCPCS,272,RC,,,outpatient,,,292.57,204.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE VASCULAR GLIDEWIRE NITINOL STRAIGHT 260CM -,SUP-GS3504,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE GLIDE 0.035 IN X 80 CM ANG STIFF -,SUP-GS3505,CDM,C1769,HCPCS,272,RC,,,outpatient,,,297.59,208.313,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE GLIDE STIFF .035 180CM -,SUP-GS3508,CDM,C1769,HCPCS,272,RC,,,outpatient,,,260.81,182.567,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE VASCULAR GLIDEWIRE NITINOL HYDROPHILIC ANGLE 260CM -,SUP-GS3509,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX270CM LINEARGUIDEV ANG PTFE-CTD -,SUP-G-V210-3527A,CDM,C1769,HCPCS,272,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC VIPERWIRE .014IN TIP X 325CM -,SUP-GWC-12325LG-FLP,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC VIPERWIRE W/FLEX TIP .014IN TIP X 325CM -,SUP-GWC-12325LG-FT,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM MLMN STR SUPER RAIL SUPP FLXB SPR COIL -,SUP-H74912120012,CDM,C1769,HCPCS,272,RC,,,outpatient,,,480.8,336.56,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE MAILMAN 182CM STRAIGHT TIP 0.014 -,SUP-H74912136011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,480.8,336.56,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.14X190CM PLTNM + STR SUPER RAIL SUPP INTMD SPR -,SUP-H74917511,CDM,C1769,HCPCS,272,RC,,,outpatient,,,485.59,339.913,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX300CM PLTNM + STR SUPER RAIL SUPP INTMD SPR -,SUP-H74917521,CDM,C1769,HCPCS,272,RC,,,outpatient,,,485.61,339.927,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.018INX300CM PLTNM + STR SUPER RAIL SUPP INTMD SPR -,SUP-H74917541,CDM,C1769,HCPCS,272,RC,,,outpatient,,,485.61,339.927,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM VCT 14 CTRL WIRE STR SHRT TAPR ICE CTD -,SUP-H74939216730010,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
PRESSURE WIRE COMET II -,SUP-H74939359110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3926.81,2748.767,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE SAFARI2  0.035 x 0275 CM XSMALL CURVE -,SUP-H74939406XS1,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3007.62,2105.334,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX330CM RTBLTR RTWR FLXB FLPY SS/CTD 2.2CM -,SUP-H74939462005,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1518.31,1062.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.009INX330CM RTWR 1.5MM RSN JTP CRV STF XTR SUPP -,SUP-H74939463005,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1518.31,1062.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM VCT 14 12GM CTRL WIRE STR LNG TAPR -,SUP-H74939470300120,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1219.12,853.384,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM VCT 14 18GM CTRL WIRE STR LNG TAPR -,SUP-H74939470300180,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1219.12,853.384,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM VCT 14 25GM CTRL WIRE STR LNG TAPR -,SUP-H74939471300250,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM VCT 14 30GM CTRL WIRE STR LNG TAPR -,SUP-H74939471300300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
COMET FFR WIRE 555111 -,SUP-H7495551110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3414.6,2390.22,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM STINGRAY CTD CONN -,SUP-H749M3004A0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1625.29,1137.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX145CM STINGRAY CTD CONN -,SUP-H749M3010A0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,521.24,364.868,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX185CM STINGRAY CTD CONN -,SUP-H749M3012A0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1789.24,1252.468,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX180CM INTUITION STR SS SIL CTD -,SUP-INTU180SS,CDM,C1769,HCPCS,272,RC,,,outpatient,,,169.22,118.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE GUIDE .035 260 INQWIRE REF: IQ35F260J3 -,SUP-IQ35F260J3,CDM,C1769,HCPCS,272,RC,,,outpatient,,,59.63,41.741,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE AMPLATZ INQWIRE 0.035 X 71IN STRAIGHT SHORT TIP -,SUP-IQA511,CDM,C1769,HCPCS,272,RC,,,outpatient,,,255.63,178.941,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX150CM ZIPWIRE STR STEER STF SHFT FLXB -,SUP-M00146306B1,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.24,167.468,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW AMPLATZ 0.035INX180CM J-TIP SUPER STIFF -,SUP-M001465011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
AMPLATZ WIRE SUPER STIFF  0.035 X 260 J -,SUP-M001465021,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035IN X 260CM SUPER STIFF AMP STR SHRT TAPR FLXB -,SUP-M001465091,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
W AMPLATZ SS ST 35 145 BX/5 GU -,SUP-M001465231,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX145CM SUPER STIFF AMP STR SHRT TAPR STD -,SUP-M001465241,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX180CM SUPER STIFF AMP STR STD STEER SHFT -,SUP-M001465251,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
W AMPL SS EXCHANGE 260 STR -,SUP-M001465261,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
MAGIC TORQUE DLVR GW .035/315CM -,SUP-M001465301,CDM,C1769,HCPCS,272,RC,,,outpatient,,,805.23,563.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
W TORQUE 35 180 MAGIC 46-591 -,SUP-M001465911,CDM,C1769,HCPCS,272,RC,,,outpatient,,,443.46,310.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE MAGIC TORQUE STRAIGHT 35-260 -,SUP-M001465921,CDM,C1769,HCPCS,272,RC,,,outpatient,,,443.46,310.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.018INX260CM PLTNM + SHRT TAPR STEER STF SHFT FLXB -,SUP-M001466050,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE PLATINUM PLUS PTFE .014 X -,SUP-M001467120,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
W CON V18 8 200 46-852 -,SUP-M001468520,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE V18 18 300    46-854 -,SUP-M001468540,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.018INX200CM 12CM V-18 CTRL WIRE STR STEER SFT SCTN -,SUP-M001468580,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX150CM STRTR 3MM J FNGR STR FXCR STD SPR COIL -,SUP-M001491181,CDM,C1769,HCPCS,272,RC,,,outpatient,,,70.02,49.014,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
J WIRE 0.035 X 180CM -,SUP-M001491201,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.69,57.183,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX260CM STRTR 3MM J FNGR STR FXCR STD SPR COIL -,SUP-M001491211,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.69,57.183,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.018INX190CM THRUWAY STR SHRT TAPR STEER SFT FLXB -,SUP-M001492791,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.018INX300CM THRUWAY STR SHRT TAPR STEER SFT FLXB -,SUP-M001492831,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
BSX THRUWAY 190CM 0.014 WIRE -,SUP-M001492921,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE THRUWAY .014 X 300 STR -,SUP-M001492971,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.016INX180CM FATHOM 16 STR STEER NTNL ALY/PLTNM -,SUP-M001509100,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1563.65,1094.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW ENDO 0.035INX180CM JGWR -,SUP-M00515171,CDM,C1769,HCPCS,272,RC,,,outpatient,,,735.47,514.829,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
NOVAGOLD .018/260 -,SUP-M00552000,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1082.39,757.673,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW ENDO 0.035INX260CM HYD JGWR STF SHFT -,SUP-M00556061,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
DREAMWIRE .035/260 -,SUP-M00556100,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
DREAMWIRE .035/260 ANGLED -,SUP-M00556110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
DREAMWIRE .035/260 STIFF -,SUP-M00556120,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
DREAMWIRE .035/450 -,SUP-M00556140,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW ENDO 0.035IN STD 450CM DREAMWIRE HI-PRFRM DIST TIP -,SUP-M00556141,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
DREAMWIRE ANGLED 0.035 X 450CM -,SUP-M00556150,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW ENDO 0.035INX450CM DREAMWIRE HIPERF STF -,SUP-M00556161,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
JAGWIRE .038 / 260CM STRIAGHT -,SUP-M00556620,CDM,C1769,HCPCS,272,RC,,,outpatient,,,594.64,416.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
JAG-REVOLUTION WIRE .025/260 -,SUP-M00557000,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE JAG REVOLUTION .025/450 -,SUP-M00557021,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
TUBE PEG 24FR ENDOVIVE LPRO PUL LF -,SUP-M00566480,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
"SPHINTEROTOME JAGTOME RX 44 0.35"" X 260CM -",SUP-M00573040,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1685.56,1179.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE .038 -,SUP-M0066201010,CDM,C1769,HCPCS,272,RC,,,outpatient,,,65.06,45.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW URO 0.035INX150CM ZIPWIRE NTNL COR HYDRCT STR STD SHFT -,SUP-M006630205B1,CDM,C1769,HCPCS,272,RC,,,outpatient,,,219.51,153.657,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE SENSOR .038 ANGLED -,SUP-M0066703021,CDM,C1769,HCPCS,272,RC,,,outpatient,,,241.45,169.015,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE SENSOR -,SUP-M0066703091,CDM,C1769,HCPCS,272,RC,,,outpatient,,,230.6,161.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW URO 0.018IN X 150CM STD ZIPWIRE STRAIGHT -,SUP-M0066802001,CDM,C1769,HCPCS,272,RC,,,outpatient,,,298.43,208.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GLIDEWIRE STRAIGHT STIFF .035 SS -,SUP-M0066802221,CDM,C1769,HCPCS,272,RC,,,outpatient,,,302.94,212.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GLIDEWIRE STRAIGHT .038 SS -,SUP-M0066802251,CDM,C1769,HCPCS,272,RC,,,outpatient,,,302.94,212.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GLIDEWIRE ANGLED .038 SS STIFF -,SUP-M0066802261,CDM,C1769,HCPCS,272,RC,,,outpatient,,,302.94,212.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.018INX40CM SS -,SUP-MAK001,CDM,C1769,HCPCS,272,RC,,,outpatient,,,114.37,80.059,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.018INX40CM NTNL PLTNM -,SUP-MAK001N,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.37,89.859,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW METRO TRACER .035 X 480 -,SUP-METII-35-480,CDM,C1769,HCPCS,272,RC,,,outpatient,,,770.22,539.154,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE W/NITREX .018 80CM STRAIGHT -,SUP-N180801,CDM,C1769,HCPCS,272,RC,,,outpatient,,,348.82,244.174,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014/ 0.008INX300CM ASTATO XS 20 STR TAPR PTFE-CTD -,SUP-PAGH143392,CDM,C1769,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.0180.0 13INX300CM ASTATO 30 STR PTFE-CTD 15CM 30GM -,SUP-PAGH18M371,CDM,C1769,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX300CM REGALIA XS 1 STR STF SHFT FLXB SPR -,SUP-PAGP140300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
TUBE JEJUNAL 12FR X 60CM PEG24 -,SUP-PEGJ-12-24,CDM,C1769,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
PHOENIX .014 FLOPPY TIP WIRE EXTRA SUPPORT -,SUP-PG14300XF,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
PIGTAIL WIRE PRO TRACK 175CM -,SUP-PTW-25-175,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1120.32,784.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE DX 0.025IN BD PIGTL 230CM PROTRACK -,SUP-PTW-25-230,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1120.32,784.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
ILLUMINATION RELIEVA LUMA SENTRY -,SUP-SIS-100B,CDM,C1769,HCPCS,272,RC,,,outpatient,,,2273.91,1591.737,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDEWIRE 0.014 TCAR ENROUTE -,SUP-SR-014-GW,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE SAFESEPT TRASEPTAL  0.014INX135CM -,SUP-SS-135,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1102.82,771.974,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
PK PROC CUST CARD CATHETERISATION LAB SLHSFR -,SUP-STLM004-13,CDM,C1769,HCPCS,272,RC,,,outpatient,,,288.66,202.062,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
DEVICE TRQ SGL HND F/0.010-0.038IN GW MUL-TRQ VISE STRL -,SUP-TD01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,38.34,26.838,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE AMPLATZ 0.035 IN X 260CM CRV TIP XSTIF FLXB SS PTFE-CTD -,SUP-THSCF-025-260-3,CDM,C1769,HCPCS,272,RC,,,outpatient,,,166.24,116.368,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.032INX260CM AMP CRV JTP XSTIF FLPY SS PTFE-CTD 8CM -,SUP-THSCF322603AES,CDM,C1769,HCPCS,272,RC,,,outpatient,,,166.24,116.368,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX145CM CRV RSN TIP FXCR FLXB FLPY SS PTFE-CTD -,SUP-THSCF351451.5R,CDM,C1769,HCPCS,272,RC,,,outpatient,,,78.71,55.097,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDE WIRE TORAY TRG-25230 -,SUP-TRG-25230,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.021INX180CM 3MM JTP FXCR FLXB SS PTFE-CTD 7CM TAPR -,SUP-TSCF-21-180-3BH,CDM,C1769,HCPCS,272,RC,,,outpatient,,,96.04,67.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX180CM 3MM JTP FXCR FLXB SS HEP PTFE-CTD 6CM -,SUP-TSCF-35-180-3,CDM,C1769,HCPCS,272,RC,,,outpatient,,,72.88,51.016,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.035INX260CM LNDRQST FLXB LO SURF FRCTN EXTEND CRV -,SUP-TSCMG35260ELESD,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1025.79,718.053,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
WIRE GUIDE LUNDERQUIST .035 -,SUP-TSCMG35260LESDC,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1025.79,718.053,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC HTORQ WHISPER VW EDS -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
LOOP TIP WIRE GUIDE .035 X 480 -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1085.31,759.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
W MOVEABLE CORE 3J 035 145CM -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,151.71,106.197,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
W MOVEABLE CORE 1.5J 035 145CM -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,151.71,106.197,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDE WIRE VIPER .014 TIP -,SUP-VPR-GW-14,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GUIDE WIRE VIPER .017 335CM -,SUP-VPR-GW-FLEX18,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
GW VASC 0.014INX180CM ZINGER LS RSN JTP CRV LGT SUPP FRMG -,SUP-ZNGRLS180J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,169.22,118.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.60733,7443.65739,other,OPPS APC,,
COIL MRI ENDORECTAL DISP BPX15 -,SUP-BPX 15,CDM,C1770,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,144.095325,460.20645,,,,
SYS SLING MALE VIRTUE -,SUP-50020,CDM,C1771,HCPCS,278,RC,,,outpatient,,,20164.56,14115.192,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,248.891925,15486.38208,other,OPPS APC,,
SLING SINGLE INCISION ALTIS -,SUP-519650,CDM,C1771,HCPCS,278,RC,,,outpatient,,,6206.85,4344.795,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,248.891925,15486.38208,other,OPPS APC,,
SYS SLING URETH ADVANCE MALE 3.55X36CM NABSB MSH NDLHLDRX2 -,SUP-720088-01,CDM,C1771,HCPCS,278,RC,,,outpatient,,,18026.62,12618.634,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,248.891925,15486.38208,other,OPPS APC,,
MESH SURG MINI ARC SLNG -,SUP-720095-01,CDM,C1771,HCPCS,278,RC,,,outpatient,,,5623.3,3936.31,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,248.891925,15486.38208,other,OPPS APC,,
MESH MINI ARC SLING PRECISE - DISCONTINUED -,SUP-720191-01,CDM,C1771,HCPCS,278,RC,,,outpatient,,,6578.45,4604.915,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,248.891925,15486.38208,other,OPPS APC,,
PROSTHESIS PENL MONARCH + 1.1CMX35CM SAL FIL CYL NABSB -,SUP-724041-93,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4807.35,3365.145,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,248.891925,15486.38208,other,OPPS APC,,
SLING GYN TVT PP 1.1X45CM URETH FEM MECH CUT -,SUP-810041B,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4965.48,3475.836,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,248.891925,15486.38208,other,OPPS APC,,
KIT TRANS OBTURATOR W TAPE INC -,SUP-93-4001,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4720.05,3304.035,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,248.891925,15486.38208,other,OPPS APC,,
ANCHORSURE SACROSPINOUS LIGAMENT FIXATION -,SUP-A-SURE,CDM,C1771,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,248.891925,15486.38208,other,OPPS APC,,
NEOMEDIC ANCHORSURE ANCHOR SYSTEM 2 ANCHORS -,SUP-A-SURE02,CDM,C1771,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,248.891925,15486.38208,other,OPPS APC,,
SLING URETH PP NABSB FEM -,SUP-M006850200051,CDM,C1771,HCPCS,278,RC,,,outpatient,,,3571.91,2500.337,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,248.891925,15486.38208,other,OPPS APC,,
SLING ADVANTAGE TRAN VAGINAL -,SUP-M0068502110,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4616.84,3231.788,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,248.891925,15486.38208,other,OPPS APC,,
SLING GYN ADVANTG FIT PP TRNVAG MI D URETH FEM -,SUP-M0068502110,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4616.84,3231.788,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,248.891925,15486.38208,other,OPPS APC,,
SLING LYNX MID URETHRAL SUPRAPUBIC BLUE SYSTEM -,SUP-M0068503010,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4439.29,3107.503,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,248.891925,15486.38208,other,OPPS APC,,
SLING GYN OBTRYX II -,SUP-M0068505110,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4420,3094,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,248.891925,15486.38208,other,OPPS APC,,
SLING GYN SOLYX SGL-INCS -,SUP-ML00001621,CDM,C1771,HCPCS,278,RC,,,outpatient,,,5030.63,3521.441,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,248.891925,15486.38208,other,OPPS APC,,
PUMP IT 87.5MM 19.5MM 20ML 165/185 GM EMTY/FUL 0.22UM FLTR -,SUP-8637-20,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29090.86,20363.602,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,23012.49024,other,OPPS APC,,
PUMP IT 87.5X26MM THK 40ML 175/215 GM EMTY/FUL 0.22UM FLTR -,SUP-8637-40,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29090.86,20363.602,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,23012.49024,other,OPPS APC,,
PUMP 8667-20 SYNCHROMEDIII INFUSION 20ML -,SUP-8667-20,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29964.18,20974.926,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,23012.49024,other,OPPS APC,,
PUMP 8667-40 SYNCHROMEDIII INFUSION 40ML -,SUP-8667-40,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29964.18,20974.926,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,23012.49024,other,OPPS APC,,
TIGHTRAIL SUB-C  9FR 560-009 -,SUP-560-009,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7193.58,5035.506,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC,,
TIGHTRAIL SUB-C 11FR 560-011 -,SUP-560-011,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7830.18,5481.126,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC,,
TIGHTRAIL SUB-C 13FR 560-013 -,SUP-560-013,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7830.18,5481.126,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC,,
SHEATH CATH DLV 10FRX80CM AMPLATZER TORQVUE VASC 45DG ANG -,SUP-9-ATV10F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC,,
SHEATH CATH DLV 9FRX80CM AMPLATZER TORQVUE VASC 45DG ANG SFT -,SUP-9-EITV09F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC,,
SHEATH CATH DLV 12FRX80CM AMPLATZER TORQVUE VASC 45DG ANG -,SUP-9-EITV12F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC,,
SYSTEM AMPLATZER DELIVERY TORQVUE 9-ITV06F 180/80 -,SUP-9-ITV06F 180/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,3909.91,2736.937,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC,,
SHEATH CATH DLV 6FRX60CM AMPLATZER TORQVUE VASC 45DG ANG SFT -,SUP-9-ITV06F45/60,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC,,
SHEATH CATH DLV 7FRX80CM AMPLATZER TORQVUE VASC 180DG ANG -,SUP-9-ITV07F180/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC,,
SHEATH CATH DLV 7FRX80CM AMPLATZER TORQVUE VASC 45DG ANG SFT -,SUP-9-ITV07F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC,,
SHEATH CATH DLV AMPLATZER TORQVUE/TREVISIO VASC 45DG ANG SFT -,SUP-9-ITV08F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC,,
SHEATH CATH DLV 9FRX80CM AMPLATZER TORQVUE VASC 45DG ANG -,SUP-9-ITV09F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC,,
SHEATH CATH DLV 12FRX80CM AMPLATZER TORQVUE VASC 45DG ANG- -,SUP-9-ITV12F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC,,
AMPLATZER TALISMAN DELIVERY SHEATH 8F 80 -,SUP-9-TDS-08F45-80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC,,
AMPLATZER TALISMAN DELIVERY SHEATH 9FR 80 -,SUP-9-TDS-09F45-80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC,,
COMP LOADING SYS CLS-3000- 18F -,SUP-CLS-3000-18F-US,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2067.2,1447.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC,,
VALVE DEL SYS COMM 26/29/31 -,SUP-DCS-C4-18F-US,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC,,
CATH DELIVERY EVOLUT FX 23-29 REF: D-EVOLUTFX-2329 -,SUP-D-EVOLUTFX-2329,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC,,
CATH DELIVERY EVOLUT FX 34 REF: D-EVOLUTFX-34 -,SUP-D-EVOLUTFX-34,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC,,
CATH DELIVERY EVPROP2329US -,SUP-D-EVPROP2329US,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC,,
SNARE ENSNARE SYSTEM 9-15 120 -,SUP-EN2006015,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1779.27,1245.489,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC,,
SNARE ENSNARE 18 30 CM -,SUP-EN2007030,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC,,
SNARE VASC EN SNR 27-45MM 7FR CATH 120CM 3 PREFRM LOOP NTNL -,SUP-EN2007045,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2644.95,1851.465,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC,,
GTRS-200-RB RETREIVAL SET TULI -,SUP-G13287,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1590.1,1113.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC,,
EXTRACTION TOOL 13FR MANUAL CONTROL ROTATION DILATOR SHEATH -,SUP-G23747,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7285.21,5099.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC,,
SHEATH DILATOR 11FR EVOLUTION SHORTIE RL PERC -,SUP-G23749,CDM,C1773,HCPCS,272,RC,,,outpatient,,,5843.14,4090.198,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC,,
SNARE VASC EYE SNR 13MMX94CM FLSH PRT NTNL 16FR WRKSTN -,SUP-G26517,CDM,C1773,HCPCS,272,RC,,,outpatient,,,5674.23,3971.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC,,
SNARE VASC AMP GOOSENECK 15MM/6FR LOOP/CATH 120CM GOLD TUNG -,SUP-GN1500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC,,
SNARE EV AMP GOOSENECK 20X120MM GOLD TUNG NTNL 6FRX102CM -,SUP-GN2000,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC,,
SNARE VASC AMP GOOSENECK 25MM/6FR LOOP/CATH 120CM GOLD TUNG -,SUP-GN2500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC,,
KIT GOOSE NECK SNARE 25MM LOOP -,SUP-GN3000,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC,,
SNARE GOOSENECK GN3500 -,SUP-GN3500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC,,
SNARE AMPLATZ GN 5MM -,SUP-GN500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC,,
STYLET LD LIBERATOR 140CM -,SUP-LR-OFA01,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2639.4,1847.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC,,
CATHETER INTRODUCER AVEIR 50CM REF:LSN25501 -,SUP-LSN25501,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC,,
BASKET STONE SEGURA -,SUP-M0063801120,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1030.93,721.651,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC,,
SNARE ONE700 175CM 7MM LOOP -,SUP-ONE700,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2851.99,1996.393,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC,,
SNARE ONE701 200CM 7MM LOOP -,SUP-ONE701,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2959.88,2071.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC,,
SNARE VASC AMP GOOSENECK 7X175MM GOLD TUNG NTNL -,SUP-SK700,CDM,C1773,HCPCS,272,RC,,,outpatient,,,3126.44,2188.508,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,231.443785,6420.62028,other,OPPS APC,,
HEAD FEM 12/ 1440MMX3.5MM NK TAPR -,SUP-00080184001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 40MM -,SUP-00080184002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 15X190MM WAGNER SL REVISN PROTASUL-100 POR CTD -,SUP-00100101915,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 18X225MM WAGNER SL REVISN PROTASUL-100 POR CTD -,SUP-00100102218,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 9MM PRFT ANTMC 110MM PROTASUL-100 UNCEM TAPR SHLDR -,SUP-00104201092,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 40X14MM -,SUP-00104212400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 44X16MM PROTASUL-21 WF ANTMCREM -,SUP-00104212440,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 46X16MM PROTASUL-21 WF ANTMC REM -,SUP-00104212460,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 48X17MM ANTMC SHLDR PROTASUL-21 REM -,SUP-00104212480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 50X18MM PROTASUL-21 WF ANTMC REM -,SUP-00104212500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP 24MM SM ANTMC SHLDR 16MM PE PG CMNT -,SUP-00104214340,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP 28MM MED ANTMC SHLDR 19MM PE PG CMNT -,SUP-00104214370,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ3 39.68MM OFST 141MM AVENIR MULLER STD 56.11MM NK -,SUP-00106010003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ4 40.22MM OFST 147MM AVENIR MULLER STD 56.88MM NK -,SUP-00106010004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM LAT AVENIR MUELLER SZ 4 -,SUP-00106010104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 12/14 TAPR M/L HIP -,SUP-00106010107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
WEDGE ANKL JNT OSSEOTI 15X15MM POR MTL -,SUP-00110003821,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8785.08,6149.556,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CEMENT BN PLYMTHL MTHCRYLT 40GM PLC R HVISC -,SUP-00111214001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INTEGRAL SHORT GTR W/2 CABLES 23 X 53 -,SUP-00223200204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6861.23,4802.861,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 46X18MM BGLNI/FLTW STD ZML MODULAR OFST -,SUP-00430004618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP 40MM BGLNI/FLTW SHLDR UHMWPE SS PG -,SUP-00430008500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP 46MM BGLNI/FLTW SHLDR UHMWPE SS PG -,SUP-00430008600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 40X18MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 40X21MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP 40MM 46MM ARTC SURF BGLNI/FLTW SHLDR UHMWPE SS PG -,SUP-00430204046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 46X15MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204615,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 46X17MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 46MM OFST MODULAR -,SUP-00430204618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 46X19MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 46X27MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204627,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP 46MM BGLNI/FLTW SHLDR W/52MM SS PG -,SUP-00430204652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BF OFFSET HUM HEAD 18MM X 52MM -,SUP-00430205218,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 52X19MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430205219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 52X21MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430205221,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 10MM INTOP FLXB 130MM TM 42DG ANG NK SHLDR -,SUP-00434211013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 11MM INTOP FLXB 130MM TM 42DG ANG NK SHLDR -,SUP-00434211113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 6MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434810613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 8MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434810813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 9MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434810913,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 10MM TM 130MM 48DG ANG SHLDR -,SUP-00434811013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 11MM TM 130MM 48DG ANG SHLDR -,SUP-00434811113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 12MM TM 130MM 48DG ANG SHLDR -,SUP-00434811213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 13MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434811313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 12MM RVRS 130MM TM LPRO SHLDR -,SUP-00434901213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18477.37,12934.159,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 32X53MM EPSLN STD DRSL UHMWPE PRIM HD -,SUP-00437732053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 42MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500104200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 43MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500104300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 28X47-49MM VERSYS BIPLR UHMWPE -,SUP-00500104728,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 49MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500104900,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 28X50-52MM VERSYS BIPLR UHMWPE -,SUP-00500105028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 51MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 52MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 28X53-55MM VERSYS BIPLR UHMWPE -,SUP-00500105328,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 54MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 55MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 60MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500106000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT LMRL KN SZ2 27MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800227,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HALF BLOCK TRABECULAR TIBIAL AUGMENT RT LATERAL/LT MEDIAL -,SUP-00-5448-002-28,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10465.7,7325.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT RM/LL KN SZ2 37MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800237,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HALF BLOCK TRABECULAR TIBIAL AUGMENT LT LATERAL/RT MEDIAL -,SUP-00-5448-002-38,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10465.7,7325.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT LMRL KN SZ3 27MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800327,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT LMRL KN SZ3 26MM NEXGEN 5MM WDG FUL BLCK TM TIV PMMA -,SUP-00544800337,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT LMRL KN SZ5 27MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800527,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT RM/LL KN SZ5 37MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT KN 31MMMEDX31MM TM -,SUP-00545001331,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15863.61,11104.527,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT KN 36MM MED 25MMX36MM TM -,SUP-00545001336,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CONE TIBIAL TM LARGE 51 X 34 RIGHT -,SUP-00-5450-013-52,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CONE FEMORAL LT SM 30MM -,SUP-00545001730,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT RT DPHSL KN SZ30 SM TM -,SUP-00545001731,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT RT DPHSL KN SZ30 MED TM -,SUP-00545001831,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TM FEM DIAPHYSEAL CONE- 30 LARGE- RIGHT -,SUP-00-5450-019-31,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT KN SZ48 XS NEXGEN 15MM TM -,SUP-00545004801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19404.14,13582.898,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT TRAB METALTIB SZ 52-51MM FULL SMALL -,SUP-00-5450-052-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19404.14,13582.898,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT DIST KN SZ-D NEXGEN 5MM BLCK REVISN TM TIV -,SUP-00549003401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT KN SZ-D NEXGEN 5MM DIST BLCK REVISN TM TIV -,SUP-00549003410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT KN SZ-D NEXGEN 10MM BLCK REVISN TM TIV -,SUP-00549003420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT POST 5MM BLCK SZ-E NEXGEN BLCK REVISN TM TIV -,SUP-00549003501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT DIST KN SZ-E NEXGEN 5MM BLCK REVISN TM TIV -,SUP-00549003510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT KN SZ-E NEXGEN 10MM DIST BLCK REVISN TM TIV -,SUP-00549003520,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT POST KN SZ-F NEXGEN 5MM DIST BLCK REVISN TM TIV -,SUP-00549003601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT KN SZ-F NEXGEN 10MM POST BLCK REVISN TM TIV -,SUP-00549003602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT DIST KN SZ-F NEXGEN 5MM DIST BLCK REVISN TM TIV -,SUP-00549003610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-E MINUS NEXGEN GENDR SOL LT KN CR CMNT ZML PMMA -,SUP-00575001505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-E MINUS NEXGEN GENDR SOL LT KN CR CMNT COCR FLEX -,SUP-00575201505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-E MINUS NEXGEN GENDR SOL RT KN CR CMNT COCR FLEX -,SUP-00575201506,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-D NEXGEN LEGC GENDR SOL LT KN PS CMNT ZML FLEX -,SUP-00576401451,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-E NEXGEN LEGC GENDR SOL LT KN PS CMNT ZML FLEX -,SUP-00576401551,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-E NEXGEN LEGC GENDR SOL RT KN PS CMNT ZML FLEX -,SUP-00576401552,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-F NEXGEN LEGC GENDR SOL LT KN PS CMNT ZML FLEX -,SUP-00576401651,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBPLT SZ2 44/25MM LMRL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBPLT SZ3 47/27MM LMRL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBPLT SZ4 50/29MM LL/RM KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBPLT SZ5 53/31MM LMRL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBPLT SZ5 53/31MM RM/LL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-D 23/48MM NEXGEN LMRL CONDL UNICMPT ZML HI FLEX -,SUP-00584201401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-E 24/51.5MM NEXGEN LMRL CONDL UNICMPT ZML HI -,SUP-00584201501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-F 25/55.5MM NEXGEN LMRL CONDL UNICMPT ZML HI -,SUP-00584201601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-F 25/55.5MM NEXGEN LL/RM KN UNICMPT ZML HI FLEX -,SUP-00584201602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL SIZE G RM/LL -,SUP-00584201702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
ARTICULAR SURFACE SIZE 2 11MM -,SUP-00584202211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 8MM UNICMPT ARTCSURF NET SHP KN-HI FLEX MLD -,SUP-00584202308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
ARTICULAR SURFACE SIZE 5 8MM -,SUP-00584202508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ2 9MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3229.61,2260.727,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 8MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ4 8MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ4 10MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4521.46,3165.022,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5 8MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 32MM MED 19.5MM TM PMMA NEXGEN -,SUP-00587601019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16244.38,11371.066,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 29MM MICRO 10MM PEGX3 POR -,SUP-00587806129,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 32X10MM THK TM PMMA NEXGEN PRIM POR -,SUP-00587806532,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
NEXGEN POROUS TM PATELLA 10MM X 32MM -,SUP-00-5878-065-32,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 38X10MM THK TM PMMA NEXGEN PRIM POR -,SUP-00-5878-065-41,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIB SZ C-H FEM 3 TIB 10X67/43MM NEXGEN PRFT CR MBLK -,SUP-00588604310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12109.95,8476.965,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIB SZ C-H FEM 5 TIB 10X75/47.5MM NEXGEN PRFT CR MBLK -,SUP-00588604510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10860.53,7602.371,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SCREW HEADED HEX 3.5MM X -,SUP-00-5901-035-33,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ1 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ2 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT. -,SUP-00592601201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ2 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ3 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ3 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ4 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ4 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
NEXTGEN CR FLEX PROLONG ART SURF C-H/1-2 SPUR- 14MM -,SUP-00-5952.021-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
NEXGEN CR FLEX PROLONG  ART SURF -,SUP-00-5952-021-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ A-B/1-2 10MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596202010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ C-D/1-2 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596202212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ C-D SZ1-2 FEM 14MM NEXGEN PS ARTCSURF KN FLEX -,SUP-00596202214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ C-D/1-2 17MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596202217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ-E SZ1-2 FEM 10MM NEXGEN PS ARTCSURF KN FLEX FX -,SUP-00596202410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ E-F/3-4 10MM NEXGEN LEGACY ARTCSURF KN PS FLEX -,SUP-00596203210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ E-F/3-4 14MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596203214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ E-F/3-4 17MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596203217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
NEXTGEN LPS-FLEX FIXED PROLONG ART SUR EF 3-4- 20MM -,SUP-00-5962-032-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ E-F/5-6 10MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ E-F/5-6 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ E-F/5-6 17MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ G-H/5-6 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ G-H/5-6 14MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ E-F/7-10 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596205112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-E 68/62.5MM NEXGEN LEGC RT KN PS CMNT ZML FLEX -,SUP-00596401552,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-F 72/65.5MM NEXGEN LEGC R/L KN PS CMNT ZML FLEX -,SUP-00596401652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-G 76.5/71.5MM NEXGEN LEGC L/L KN PS CMNT ZML -,SUP-00596401751,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-G 76.5/71.5MM NEXGEN LEGC R/L KN PS CMNT ZML -,SUP-00596401752,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ C-D/3-4 14MM NEXGEN LPS ARTCSURF NET SHP KN -,SUP-00596403012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-D NEXGEN LEGC LT KN PS CMNT TIV NPOR FLEX FX -,SUP-00596801451,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-F NEXGEN LEGC LT KN PS CMNT TIV NPOR FLEX FX -,SUP-00596801651,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-G NEXGEN LEGC RT KN PS CMNT TIV NPOR FLEX FX -,SUP-00596801752,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 29MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206529,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 32MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206532,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 35MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 38MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206538,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 29MM PRLNG NEXGEN ON ST -,SUP-00597206629,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 32MM PRLNG NEXGEN ON ST -,SUP-00597206632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PATELLA NEXGEN PROLONG ALLPOLY 35MM -,SUP-00597206635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 38MM PRLNG NEXGEN ON ST -,SUP-00597206638,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
NEXGEN AC ART SURF 5-6 GREEN 12MM -,SUP-00597604012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT KN SZ3 NEXGEN 5MM CR PRCTD TIV PMMA -,SUP-00-5988-003-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5398.37,3778.859,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT L/R KN SZ4 NEXGEN 10MM HLF BLCK CR TIV PMMA -,SUP-00598800427,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5398.37,3778.859,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 11MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 12MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SCISSORS OPTH KNAPP 4IN SS CRV V. MUELLER MIRR FNSH S/S IRIS -,SUP-00-5988-010-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 16MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 18MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 20MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 16MM NEXGEN 155MM TIV ALY STR FEM/TBL KN -,SUP-00598801116,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 12.7MM NEXGEN 30MM TIV ALY STR FEM/TBL KN -,SUP-00598801212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 15MM NEXGEN 30MM TIV ALY STR FEM/TBL KN -,SUP-00598801215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SCISSORS OPTH STVNS 4IN SS STR V. MUELLER MIRR FNSH -,SUP-00598802011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SCOOP SURG SM 11IN SLVR PLT CMN DCT MLBL V. MUELLER -,SUP-00598802012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 13MM NEXGEN OFST 100MM TIV ALY FEM/TBL KN -,SUP-00598802013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 14MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 15MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 16MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 17MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 12MM NEXGEN OFST 155MM TIV ALY FEM/TBL KN -,SUP-00598802112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 11MM NEXGEN OFST 155MM TIV ALY FEM/TBL KN -,SUP-00598802115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT ANT KN SZ-D NEXGEN 5MM WDG BLCK TIV PMMA -,SUP-00599003431,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5398.37,3778.859,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-C 60/53.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401392,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-D 64/57.5MM NEXGEN LEGC LT CONDL KN CNSTRN -,SUP-00599401491,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-D 64/57.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401492,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-E 68/61.5MM NEXGEN LEGC LT CONDL KN CNSTRN -,SUP-00599401591,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-E 68/61.5MM NEXGEN LEGC RT KN REVISN CNSTRN -,SUP-00599401592,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-F 72/65.5MM NEXGEN LEGC LT KN REVISN CNSTRN -,SUP-00599401691,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-F 72/65.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401692,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-G 76.5/70.5MM NEXGEN LEGC LT KN REVISN CNSTRN -,SUP-00599401791,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ-G 76.5/70.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401792,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ C-D/1-2 MICRO 10X58/40MM NEXGEN LEGC CNSTRN -,SUP-00599402210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ C-D/1-2 MICRO 12X58/40MM NEXGEN LEGC CNSTRN -,SUP-00599402212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ C-D/1-2 MICRO 14X58/40MM NEXGEN LEGC CNSTRN -,SUP-00599402214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB 0.5X20MM THK 58MM/40MM M/L A/P NEXGEN LEGC CNSTRN -,SUP-00599402220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ C-D/3-4 17X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ C-D/3-4 20X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ E-F/3-4 10X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ E-F/3-4 12X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ E-F/3-4 14X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ E-F SZ3-4 FEM 17MM 66MM/42MM M/L/A/P NEXGEN -,SUP-00599403217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
NEXGEN LCCK ART SURF EF 3-4/STR YELLOW 20MM -,SUP-00599403220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9695.93,6787.151,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ E-F/5-6 10X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ E-F/5-6 14X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ E-F/5-6 17X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ E-F/5-6 20X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ-G 5-6 17X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ G-H/7-10 14X82/50MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599405014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIA ALL POLY NEXGEN LPS SZ 8 BLUE 14MM FEM G H -,SUP-00599600814,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4638.69,3247.083,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 32X50MM TRILOGY 10DG TIV ALY UHMWPE 6.3MM PRIM -,SUP-00615405032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8097.55,5668.285,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 32X68MM TRILOGY 10DG TIV ALY UHMWPE 12.4MM PRIM -,SUP-00615406832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8097.55,5668.285,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 54MM TRILOGY PRIM MUL-HL TIV POR CTD SLD HMSPHR -,SUP-00620005420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6960.16,4872.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 44MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620204420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 48MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620204820,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 50MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620205020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 54MM PRIM MODULAR REVISN CLUS-HL TM TNTLM TIV SLD -,SUP-00620205422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 56MM PRIM MODULAR REVISN NO-HL TM TNTLM TIV SLD -,SUP-00620205620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 22X62MM TRILOGY PRIM MODULAR REVISN CLUS-HL TM -,SUP-00620206220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 68MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620206820,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 32X48MM XL TRILOGY 0DG STD LNGVT XLPE 5.3MM PRIM -,SUP-00630504832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 36X50MM TRILOGY 0DG STD LNGVT XLPE 6.8MM PRIM -,SUP-00630505036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 28X44MM TRILOGY 10DG ELEV RM LNGVT XLPE 5.2MM -,SUP-00631004428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 28X46MM TRILOGY 10DG ELEV RM LNGVT XLPE 6.3MM -,SUP-00631004628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 36X58MM XL TRILOGY 10DG STD LNGVT XLPE 8.9MM PRIM -,SUP-00631005836,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 32X62MM TRILOGY 10DG LNGVT XLPE 9.3MM PRIM -,SUP-00631006236,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 28X44MM TRILOGY 20DG ELEV RM LNGVT XLPE 5.2MM -,SUP-00632004428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 28X46MM TRILOGY 20DG ELEV RM LNGVT XLPE 6.3MM -,SUP-00632004628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 32X48MM TRILOGY 20DG ELEV RM LNGVT XLPE 5.3MM -,SUP-00632004832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 32X56MM TRILOGY 20DG ELEV RM LNGVT XLPE 6.4MM -,SUP-00632005632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 28X50MM TRILOGY LNGVT XLPE 7.2MM CNSTRN MODULAR -,SUP-00633405028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14191.09,9933.763,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 32X56MM TRILOGY LNGVT XLPE 6.4MM CNSTRN MODULAR -,SUP-00633405632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14191.09,9933.763,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRABECULAR METAL REVISION SHELL 56MM -,SUP-00700005620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16582.26,11607.582,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BLADE EXPLANT TRUNCATED 60MM -,SUP-00705306010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BLADE FULL EXPLANT 60MM -,SUP-00705306020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 6X111MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 TAPR -,SUP-00771100600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 10X119MM PRFT EXTEND OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 11X121MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 12.5X124MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 15X129MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM VERSYS 41MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM VERSYS 43MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM VERSYS 44MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM VERSYS 47MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM VERSYS 50MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781805000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM VERSYS 51MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781805100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM VERSYS 52MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781805200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
ADAPTER HIP VERSYS ENPROS TIV TAPR. -,SUP-00781809901,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ11 120MM VERSYS LD/FX PRFT ZML CMNT HIP -,SUP-00783301100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ12 125MM VERSYS LD/FX PRFT ZML CMNT HIP -,SUP-00783301200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ14 135MM VERSYS LD/FX PRFT ZML CMNT HIP -,SUP-00783301400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
NECK FEM SZ K2 KINECTIV M/L HIP MODULAR COCR -,SUP-00784802001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
NECK FEM SZ S2 KINECTIV M/L HIP MODULAR COCR -,SUP-00784803001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
NECK FEM SZ P2 KINECTIV M/L HIP MODULAR COCR STR 12/14 TAPR -,SUP-00784803101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
KINECTIV MODULAR NECK G2 -,SUP-00784803201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4916.67,3441.669,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
NECK FEM SZ R2 KINECTIV M/L HIP MODULAR COCR STR 12/14 TAPR -,SUP-00784804201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ13 130MM VERSYS ADVCT PRIM STD OFST NON V-LIGN -,SUP-00785001300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM VERSYS CMTD STD 14X135 -,SUP-00785001400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CENTRALIZER DIST FEM HIP 11MM VERSYS PMMA CMNT -,SUP-00785901100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CENTRALIZER DIST FEM HIP 13MM VERSYS PMMA CMNT -,SUP-00785901300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 14X135MM VERSYS PRIM EXTEND OFST TIV POR CTD FM -,SUP-00786201420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 16X145MM VERSYS PRIM STD OFST TIV POR CTD FM TAPR -,SUP-00786201600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 16X145MM VERSYS PRIM EXTEND OFST TIV POR CTD FM -,SUP-00786201620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 18X155MM VERSYS PRIM STD LRG OFST TIV POR CTD FM -,SUP-00786201830,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 20X155MM VERSYS PRIM EXTEND LRG OFST TIV POR CTD FM -,SUP-00786202050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 13X170MM VERSYS REVISN ZML CMNT CLCR HIP -,SUP-00787101360,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21520.55,15064.385,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 13X210MM VERSYS REVISN ZML CMNT CLCR HIP -,SUP-00-7871-013-61,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21520.55,15064.385,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ15 220MM VERSYS REVISN ZML CMNT CLCR HIP -,SUP-00787101561,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21520.55,15064.385,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM VERSYS 28X0MM NK ZML 12/14 TAPR STRL -,SUP-00801802802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM VERSYS 28MM +3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801802803,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM VERSYS 28MM +7MM NK ZML 12/14 TAPR STRL -,SUP-00801802814,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM VERSYS 32MM-3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM VERSYS 32MM +3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM VERSYS 32MM +7MM NK ZML 12/14 TAPR STRL -,SUP-00801803214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM VERSYS 36MM-3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM VERSYS 36X0MM NK ZML 12/14 TAPR STRL -,SUP-00801803602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM VERSYS 36MM +3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803603,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ELEV RIM 32MM I.D. LONGE -,SUP-00875200832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 36X52MM II SHL CONTIN ELEV LNGVT XLPE 4.7MM F -,SUP-00875201036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
RIM LINER 36MM SIZE JJ LONGEVITY HIGHLY CROSSLINKED POLY -,SUP-00-8752-011-36,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ EE 44MM CONTIN CLUS-HL TM TIV SNP FIT LCK GRV -,SUP-00875704401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ FF 46MM CONTIN MUL-HL TM TIV SNP FIT LCK GRV -,SUP-00875704602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ GG 48MM CONTIN CLUS-HL TM TIV SNP FIT LCK GRV -,SUP-00875704801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ HH 50MM CONTIN CLUS-HL TM TIV SNP FIT LCK GRV -,SUP-00875705001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ II LINER 52MM CONTIN CLUS-HL TM TIV SNP FIT -,SUP-00875705201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ II 52MM CONTIN MUL-HL TM TIV SNP FIT LCK GRV -,SUP-00875705202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ JJ LINER 54MM CONTIN MUL-HL TM TIV SNP FIT LCK -,SUP-00875705401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 28MMX-3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877502801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BIOLOX DELTA FEM HEAD 28MM +0MM -,SUP-00877502802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 32MM-3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 32MM +0MML NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 36MM-3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEMORAL 36MM CERAMIC -,SUP-00-8775-036-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 36MM +3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503603,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 36MM +7MM BIOLOX DELTA CER -,SUP-00-8775-036-04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BIOLOX DELTA OPTION FEM HEAD 28MM +0MM -,SUP-00-8777-028-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3150.84,2205.588,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BIOLOX OPTION HEAD 36/+3.5 TAPER 12/14 -,SUP-00-8777-036-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9780.3,6846.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BIOLOX OPTION HEAD XL 36/+7 TAPER 12/14 -,SUP-00-8777-036-04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9780.3,6846.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 28X44MM EE SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 28X46MM FF SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200728,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 32X48MM GG SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 32X50MM HH SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200932,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 36NN ID 52MM II SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885201036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 36X54MM JJ SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885201136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 22MMLNGX5.5MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902602300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 28MM SHRT +0MML NK ZML 6DG TAPR ANTMC STRL -,SUP-00902602800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 28MMMEDX+7MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902602900,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 28MMLNGX+14MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902603000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 32MMSHRTX3.5MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902603235,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD 6DEGREE COCR FEM 36MM +3.5 S+ -,SUP-00-9026-036-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD 6 DEGREE COCR FEM 36MM +7 M -,SUP-00-9026-036-07,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 15X185MM ZMR REVISN MODULAR TIV PLASM SPRY POR CTD -,SUP-00998201518,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14636.65,10245.655,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BODY HIP SZ A 17.7MM BD 40MM OFST ZMR REVISN MODULAR 45MM NK -,SUP-00999601745,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21253.21,14877.247,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM WAGNER REVISION 135 NK ANGLE 18MM X 265MM -,SUP-01.00102.618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB DURAM -,SUP-01.00214.152,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16626.81,11638.767,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CONE WAGNER 135 DEG X 21MM -,SUP-01.00561.321,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13856.92,9699.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SIDUS STEM-FREE SHOULDER HUMERAL HEAD 48-17 -,SUP-01.04555.480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM AVENIR STANDARD CEM 4 -,SUP-01.06010.204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM STD CEMENTED 7 TAPER 12/14 AVENIR -,SUP-01.06010.207,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AVENIR LATERAL STEM CEM 4 -,SUP-01.06010.304,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM AVENIR LATERAL CEM 8 -,SUP-01.06010.308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP RVRS 25MM BSPLT HA+ADPTR -,SUP-010000589,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL G7 ACETABULAR PPS LTD 46B -,SUP-010000660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 PPS LTD ACET SHELL 48C -,SUP-010000661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 PPS LTD ACET SHELL 50D -,SUP-010000662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL G7 ACETABULAR PPS LTD 52E -,SUP-010000663,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL G7 ACET PPS LTD SHELL 54F -,SUP-010000664,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 PPS LTD ACET SHELL 56F -,SUP-010000665,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 PPS LTD ACET SHELL 60G -,SUP-010000667,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL G7 PPS LTD ACET 46 B -,SUP-010000719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER G7 NEUTRAL ARCOMXL 32MM B -,SUP-010000729,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 NEUTRAL ARCOMXL LNR 36MM D -,SUP-010000739,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 NEUTRAL ARCOMXL LNR 36MM E -,SUP-010000740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ARCOMXL G7 NEUTRAL 36MM F -,SUP-010000741,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 ACETABULAR LINER 36MM / G -,SUP-010000742,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 NEUTRAL ARCOMXL LNR 40MM G -,SUP-010000748,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 NEUTRAL E1 LINER 28MM C -,SUP-010000837,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 NEUTRAL E1 LINER 32MM -,SUP-010000846,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 NEUTRAL E1 LINER 32MM C -,SUP-010000847,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 NEUTRAL E1 LINER 36MM D -,SUP-010000856,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 NEUTRAL E1 LINER 36MM F -,SUP-010000858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 FREEDOM CONST E1 LNR 36MM -,SUP-010000982,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 FREEDOM COSTR E1 LNR 36MM G -,SUP-010000985,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD COCR FEM 40MM TYPE 1 +9MM -,SUP-010001032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COCR FEM HD 40MM TYPE 1 +6MM -,SUP-010001033,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEMORAL COCR 40MM TYPE 1 STD -,SUP-010001035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COCR FEM HD 40MM TYPE 1-3MM -,SUP-010001036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
WAGNER SL REVISION STEM 135 NK ANGLE 15MM X 225MM -,SUP-0100102215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
WAGNER SL REV STEM 135 NK ANGLE 14 X 265 -,SUP-0100102614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CONE WAGNER 125 DEG X 19MM -,SUP-0100561219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13856.92,9699.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
ADAPTER ANTMC BGLNI 42 -,SUP-0104250042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AS B/F ADAPTOR 48 DEG -,SUP-0104250048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AC-CONNECTOR -,SUP-0104440000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM AVENIR 5 TAPER 12/14 MULL -,SUP-0106010005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM AVENIR 6 TAPER 12/14 MULL -,SUP-0106010006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
MORSE TAPER HEAD +5 OFFSET WITH LFIT 32MM -,SUP-01-3205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PLATE 2.7/3.5 VA ANTLAT DSTL TIB PL/10 H/LFT -,SUP-02.118.209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10401.04,7280.728,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BONE PREP KIT 21-1000 SFN -,SUP-0206-710-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,740.32,518.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LOW FRICTION ION TREATMENT -,SUP-06-2200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
C-TAPER LFIT HEAD LOW FRI ION TREATMENT -,SUP-06-2205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 26X0MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-06-2600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEMORAL LFIT COCR +5 MM OFFSET C TAPER 26MM HIP -,SUP-06-2605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
C-TAPER LFIT HEAD LOW FRICTION SZ. 26MM / +10 -,SUP-06-2610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 28X0MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-062800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
C-TAPER LFIT HEAD LOW FRICTION SZ. 28MM / +10 -,SUP-06-2810,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 32X0MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-063200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 32MM-5MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-063299,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 36MM +0MML NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-063600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 40MM-2.5MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-064097,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM PLASMA SPRAY STD SIZE 2 TI6AI4V -,SUP-101-0002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HIP STEM PLASAM STD SZ 3 -,SUP-101-0003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ4 37MM OFST 110MM OVATN STD OFST 29MM 7MM M/L/A/P -,SUP-101-0004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ5 OVATN STD OFST TI PLASM SPRY CTD 12/14 TAPR -,SUP-101-0005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ6 38MM OFST 118MM OVATN STD OFST 31MM 9MM M/L/A/P -,SUP-101-0006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ7 32MM OFST 122MM OVATN STD OFST 32MM 10MM -,SUP-101-0007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ8 43MM OFST 126MM OVATN STD OFST 34MM 11MM -,SUP-101-0008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ9 44MM OFST 130MM OVATN STD OFST 36MM 13MM -,SUP-101-0009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ10 47MM OFST 134MM OVATN STD OFST 38MM 16MM -,SUP-101-0010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ5 44MM OFST 114MM OVATN EXTEND OFST 30MM 8MM -,SUP-101-1005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8233.36,5763.352,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ6 9/31X118MM OVATN EXTEND OFST 33MM LEG 44MM HZNT -,SUP-101-1006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ7 49MM OFST 122MM OVATN EXTEND OFST 32MM 10MM -,SUP-101-1007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ8 50MM OFST 126MM OVATN EXTEND OFST 34MM 11MM -,SUP-101-1008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ9 STD OVATN EXTEND OFST TI PLASM SPRY CTD 12/14 -,SUP-101-1009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ10 55MM OFST 134MM TI PLASM SPRY CTD HIP OVATN -,SUP-101-1010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SELF CENT HIP 41X28 RUST -,SUP-1035-41-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
WIRE EXTFIX 1.8MM BAYNT PNT -,SUP-104.690,CDM,C1776,HCPCS,278,RC,,,outpatient,,,367.02,256.914,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
RING ACTB SZ23 TI HIP LCK LINER YEL RINGLOC STRL SUD -,SUP-1054-23,CDM,C1776,HCPCS,278,RC,,,outpatient,,,770.22,539.154,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SPACER DIST HIP 10MM ACCOLADE C SZ SMALL -,SUP-1059-2310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SPACER FEM CMNT RNG STYL MED 12MM DIST F/STM 4/5 ACCOLADE -,SUP-1059-4512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
RINGLOC + HIP SYSTEM SZ 21 -,SUP-106021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SPACER DIST FEM HIP UNIV 8MM ACCOLADE CMNT -,SUP-1067-0008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SPACER DIST FEM HIP 9MM UNIV CMNT -,SUP-1067-0009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SPACER DIST FEM HIP 10MM UNIV CMNT -,SUP-1067-0010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SPACER DIST FEM HIP 11MM UNIV RECON CMNT -,SUP-1067-0011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SPACER DIST FEM HIP 12MM UNIV CMNT -,SUP-1067-0012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SPACER DIST FEM HIP 13MM UNIV CMNT -,SUP-1067-0013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SPACER DIST FEM HIP 14MM UNIV CMNT -,SUP-1067-0014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SPACER DIST FEM HIP 15MM UNIV CMNT -,SUP-1067-0015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
OMNIFIT UNIVERSAL DISTAL CEMENT SPACER 16MM -,SUP-1067-0016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CEMENT SPACER UNIVERSAL DISTAL -,SUP-1067-0017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
VARIO CUP 28MM X 47MM -,SUP-107-220/47,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5160.7,3612.49,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
VARIO CUP 28MM X 48MM -,SUP-107-220/48,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5160.7,3612.49,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
VARIO-CUP SYSTEM OUTER 50MM HEAD 28MM -,SUP-107-220/50,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5160.7,3612.49,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 OSSEOTI 3 HOLE SHELL 50MM D -,SUP-110010243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 OSSEOTI MULTIHOLE 50MM D -,SUP-110010263,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 MULTIHOLE 52MM -,SUP-110010264,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 OSSEOTI MULTIHOLE 54MM F -,SUP-110010265,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 OSSEOTI MULTIHOLE 56MM F -,SUP-110010266,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 OSSEO TI ACETABULAR SHELL 58MM / G -,SUP-110010267,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 OSSEO TI MULTIHOLE 60MM G -,SUP-110010268,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL G7 OSSEO TI MULTIHOLE 62MM H -,SUP-110010269,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 OSSEO TI MULTIHOLE 64MM H -,SUP-110010270,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER G7 DUAL MOBILITY 38MM C -,SUP-110024461,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 DUAL MOBILITY LINER 42MM E -,SUP-110024463,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 DUAL MOBILITY LINER 44MM F -,SUP-110024464,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 DUAL MOBILITY LINER 50MM H -,SUP-110024466,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPR VRS GLEN PPS MIN TPR ADR -,SUP-110027734,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26395.72,18477.004,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PRX HUM LO PLT LT 4H 83MM -,SUP-110030101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6875.28,4812.696,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
40MM VERSA-DIAL GLEN STD -,SUP-110030776,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
40MM VERSA-DIAL GLEN +3 -,SUP-110030777,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BEARING VIVACIT-E DM 28 X 44MM -,SUP-110031012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BEARING VIVACIT-E DM 28 X 50MM -,SUP-110031015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
VERSA-DIAL TAPER ADAPTOR 25MM -,SUP-110031378,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HMRL TRAY STD STD -,SUP-110031399,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRAY HMRL STD SHOULDER REVERSE TI -,SUP-110031408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HMRLBEARING 36MM +3 PRLNG -,SUP-110031419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HMRL BEARING 40MM STD PRLNG -,SUP-110031421,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HMRL BEARING 36 MM STD VITE -,SUP-110031424,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HMRL BEARING 36 MM +3 VITE -,SUP-110031425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BEARING HUMERAL 40MM STD VITE -,SUP-110031427,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPR AUG BSPLT W ADP SM -,SUP-110032410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPR AUG BSPLT W ADP MD -,SUP-110032420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPR AUG BSPLT W ADP LG -,SUP-110032430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HMRL BEARING 36MM STD PRLNG -,SUP-11031418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FREEDOM CONSTR HD 36MM T1 -,SUP-11-107016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7259.36,5081.552,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FREEDOM CONSTR 36MM T1 +9MM -,SUP-11-107021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7259.36,5081.552,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 6MM MAC PRIM RVRS CMPRHNSV 140MM COCR PLASM CTD -,SUP-11-113556,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PROXIMAL FEMORAL OMPONENT RHS LEFT -,SUP-1115-9110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22682.72,15877.904,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL CHECKPOINT STERILE -,SUP-111651,CDM,C1776,HCPCS,278,RC,,,outpatient,,,260.65,182.455,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
RINGLOC BIPOLAR 28X49MM -,SUP-11-165222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD RADL SZ12 22MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6332.05,4432.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD RADL SZ14 24MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM RADL SZ7 26MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7295.44,5106.808,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM RADL SZ8 28MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210063,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7507.64,5255.348,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM STR DIST ARCOS 23MM X 150MM TAPER -,SUP-11-300823,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STS DISTAL STEM 15 X 190MM -,SUP-11-300915,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
DIST ARCOS 19 X 190MM SPL TPR -,SUP-11-300919,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CON ARCOS SZ A STD 60MM -,SUP-11-301301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CON ARCOS SZ A STD HI 50MM -,SUP-11-301310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
ARCOS CON SIZE E HI 70MM -,SUP-11-301335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STANDARD CONE PROX BODY 80MM -,SUP-11-301342,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
ARCOS CON SIZE B HI 80MM -,SUP-11-301352,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
VERSA-DIAL 38 X 19 X 39 HUM HEAD -,SUP-113022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
VERSA-DIAL 38X21X38 HUM HEAD -,SUP-113024,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 42MM 46X18MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
VERSA DIAL 42 X 21 X 43 HUM HEAD -,SUP-113034,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 46X53MM 18MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 46X50MM 24MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 46X46MM 27MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 50MM 57X21MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 50X50MM 27MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113057,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
MODULAR HEAD 54MM 21MM 64MM -,SUP-113063,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TAPER ADAPTER 54MM X 24MM -,SUP-113065,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM VERSA-DIAL 54X27X55 -,SUP-113067,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HUM HEAD VERSA-DIAL 58 X 24 X 64 -,SUP-113075,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE COMP FX HUM POS 8MM -,SUP-113576,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE COMP FX HUM POS 9MM -,SUP-113577,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
POSTIONING SLEEVE COMP FX HUM 10MM -,SUP-113578,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE COMP FX HUM POS 11MM -,SUP-113579,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FX HUM POS SLEEVE 12MM -,SUP-113580,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FX HUM POS SLEEVE 13MM -,SUP-113581,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PRIMARY STEM 9MM MICRO -,SUP-113609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PRIMARY STEM 10MM MICRO -,SUP-113610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PRIMARY STEM 11MM MICRO -,SUP-113611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PRIMARY STEM 12MM MICRO -,SUP-113612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM COMP PRIMARY MICRO 13MM -,SUP-113613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM COMP PRIMARY MICRO 14MM -,SUP-113614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PRIMARY STEM 15MM MICRO -,SUP-113615,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PRIMARY STEM 17MM MICRO -,SUP-113617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PRIMARY STEM 19MM MICRO -,SUP-113619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM COMP PRIMARY 5MM MINI -,SUP-113625,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM COMP PRIMARY 6MM MINI -,SUP-113626,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PRIMARY STEM 7MM MINI -,SUP-113627,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM COMP PRIMARY 8MM MINI -,SUP-113628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPREHENSIVE HUMERAL STEM 9MM MINI -,SUP-113629,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
POROUS PLASMA 10MM 83MM LONG -,SUP-113630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PRIMARY STEM 11MM MINI -,SUP-113631,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPREHENSIVE HUMERAL STEM 12MM MINI -,SUP-113632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM COMP PRIMARY 13MM MINI -,SUP-113633,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM COMP PRIMARY 14MM MINI -,SUP-113634,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM COMP PRIMARY 15MM MINI -,SUP-113635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM COMP PRIMARY 16MM MINI -,SUP-113636,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD MOD 36MM COCR 3MM -,SUP-11-363661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD COCR MOD HD STD 36MM -,SUP-11-363662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD 36MM COCR MOD +36MM -,SUP-11-363663,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM COMP PRIMARY 17MM MINI -,SUP-113637,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 7MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113647,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 8MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113648,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 12MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 15MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113655,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 16MM STD PRIM PRFT RVRS CMPRHNSV 122MM COCR PLASM -,SUP-113656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP MODULAR HYBRID SHLDR POST 4MM UHMWPE PG -,SUP-113951,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP SM MODULAR HYBRID SHLDR BS 4MM UHMWPE PG -,SUP-113952,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP MED MODULAR HYBRID SHLDR BS 4MM UHMWPE PG -,SUP-113954,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SPHERE GLND 36MM STD CMPRHNSV VERSA-DIAL RVRS HAP POR CTD -,SUP-115310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SPHERE GLND +3MM 36MM CMPRHNSV VERSA-DIAL RVRS HAP POR CTD -,SUP-115313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE 28MM CMPRHNSV SHLDR RVRS -,SUP-115330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRY HUMERAL STD 44MM COCR SHLDR RVRS CMPRHNSV STRL SUD -,SUP-115370,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PIN INSRTR 24.5CM FRLCK F/VFX2 FEM FX SYS -,SUP-118001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
KT BONE CMNT PREP-IM -,SUP-121010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3685.53,2579.871,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM COMPR 6MM HUM FRACT PPS -,SUP-12-113556,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPR 8MM HUM FRACT STEM PPS -,SUP-12-113558,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPR 10MM HUM FRACT STEM PPS -,SUP-12-113560,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPR 12NN HUM FRACT STEM PPS -,SUP-12-113562,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD MODULAR CER BIOLOXD 28MM -3 NK -,SUP-12-115109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CER BIOLOXD MOD HD 28MM STD NK -,SUP-12-115110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CER BIOLOXD MOD HD 28MM +3 NK -,SUP-12-115111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CER BIOLOXD MOD HD 32MM-3NK -,SUP-12-115114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD CERAMIC BIOLOX STANDARD NECK -,SUP-12-115115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CER BIOLOXD MOD HD 36MM STD NK -,SUP-12-115121,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CER BIOLOXD MOD HD 36MM +3 NK -,SUP-12-115122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CER BIOLOXD MOD HD 36MM +6 NK -,SUP-12-115123,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD ENDO II MOD SIZE 49 -,SUP-12-139022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 54MM PINNCL NO-HL POR CTD LCK RNG SLD -,SUP-1217-01-054,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4847.45,3393.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 58MM PINNCL NO-HL POR CTD LCK RNG SLD -,SUP-1217-01-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4992.9,3495.03,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 60MM PINNCL NO-HL POR CTD LCK RNG SLD -,SUP-1217-01-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4992.9,3495.03,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 46MM PINNCL MUL-HL BANTAM POR CTD PLASM SPRY LCK -,SUP-1217-20-046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6137.89,4296.523,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 48MM PINNCL MUL-HL BANTAM PE POR CTD LCK RNG SLD -,SUP-1217-22-048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6215.13,4350.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 52MM PINNCL MUL-HL BANTAM SECT PE POR CTD LCK RNG -,SUP-1217-22-052,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4847.45,3393.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 54MM PINNCL MUL-HL BANTAM SECT PE POR CTD LCK RNG -,SUP-1217-22-054,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4706.3,3294.41,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 62MM PINNCL PRFT NO-HL GRIPTN -,SUP-1217-31-062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16040.16,11228.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 48MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CUP ACETABULAR 50MM -,SUP-1217-32-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 52MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-052,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10299.17,7209.419,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 54MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-054,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 56MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10299.17,7209.419,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 58MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10509.65,7356.755,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 60MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10299.17,7209.419,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 62MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACETABULAR PINNACLE 54 47 -,SUP-121854047,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13117.66,9182.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PINNACLE DM LINER 56 49 -,SUP-121856049,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13117.66,9182.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER DUR MAR +4 10D 36 X 54 -,SUP-122036554,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 32X50MM PINNCL NEUT ALTRX BLU -,SUP-1221-32-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 32X48MM PINNCL +4 10DG ALTRX BLU -,SUP-1221-32-148,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 32X50MM PINNCL +4 10DG ALTRX BLU -,SUP-1221-32-150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 36X58MM PINNCL NEUT ALTRX ORNG -,SUP-1221-36-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 36X52MM PINNCL +4 10DG ALTRX ORNG -,SUP-1221-36-152,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 36X54MM PINNCL +4 10DG ALTRX ORNG -,SUP-1221-36-154,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 36X56MM PINNCL +4 10DG ALTRX ORNG -,SUP-1221-36-156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 40X56MM PINNCL NEUT ALTRX -,SUP-1221-40-056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 40X58MM PINNCL NEUT ALTRX WHT -,SUP-1221-40-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 40X62MM PINNCL NEUT ALTRX -,SUP-1221-40-062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 40X56MM PINNCL LD +4 10DG ALTRX PNK -,SUP-1221-40-156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 40X58MM PINNCL LD +4 10DG ALTRX PNK -,SUP-1221-40-158,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
ALTRX +4 10D 40IDX620D -,SUP-1221-40-162,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CATALYST R1 SHORT STEM HUMERAL SIZE 36S -,SUP-1230-7501-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CATALYST R1 POLY INSERT IMPLANT36 +0 -,SUP-1230-7504-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CATALYST R1 POLY INSERT SIZE 36 +4 -,SUP-1230-7504-002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CATALYST R1 STANDARD BASEPLATE IMPLANT -,SUP-1230-7506-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10674.88,7472.416,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CATALYST R1 GLENOSHERE SIZE 36 STD -,SUP-1230-7513-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9761.2,6832.84,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 52MM RESTOR ADM X3 PRFT MBL BRNG CMNTLS SLF-LCK -,SUP-1235-2-521,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 54MM RESTOR ADM X3 PRFT MBL BRNG CMNTLS SLF-LCK -,SUP-1235-2-541,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 60MM RESTOR ADM PRIM -,SUP-1235-2-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 28X48MM RESTOR ADM 0DG DURATION PE 6.9MM -,SUP-1235-2-848,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 28X54MM RESTOR ADM 0DG DURATION PE 9.9MM -,SUP-1235-2-854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 28X60MM RESTOR ADM 0DG DURATION PE 12.9MM -,SUP-1235-2-860,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 36X22.2MM RECON ADM MDM X3 UHMWPE PRIM ASYM -,SUP-1236-2-242,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 38X22.2MM RECON ADM MDM X3 UHMWPE PRIM ASYM -,SUP-1236-2-244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT RESTORATION ADM/MD/ 29MM X 28/48 SIZE 42E X3 -,SUP-1236-2-848,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 28X48MM RESTOR ADM X3 PE 6.9MM REVISN -,SUP-1236-2-848,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 28X52MM RESTOR ADM X3 PE 8.9MM REVISN -,SUP-1236-2-852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT RESTORATION ADM/MD/ 28MM X 28/52 SIZE 46F X3 -,SUP-1236-2-852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 28X54MM RESTOR ADM X3 PE 9.9MM REVISN -,SUP-1236-2-854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT RESTORATION ADM/MDM 28MM X 52H X3 SZ 28/58MM -,SUP-1236-2-858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
RES INSERT ADM/MDM 28MM SZ54I -,SUP-1236-2-860,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PROSTHESIS HEAD A 28MM NECK L S +3.5 TAPER 12/14 -,SUP-128-791/03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PROSTHESIS HEAD A 32MM MED 12/14 -,SUP-128-792/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PROSTHESIS HEAD A 36MM NECK L S -4 TAPER 12/14 -,SUP-128-793/01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PROSTHESIS HEAD A 36MM NECK M NECK LEN 0 TAPER 12/14 -,SUP-128-793/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PROSTHESIS HEAD A 36MM NECK LARGE +4 TAPER 12/14 -,SUP-128-793/03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINK PROSTHESIS HEAD A CERAMIC 8MM -,SUP-128-793/04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PROSTHESIS HEAD A 40MM NECK M TAPER 12/14 -,SUP-128-794/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD PROSTESIS B 24MM 12/14 M -,SUP-128-824/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PROSTHESIS HEAD B 28MM M NEC L 0 12/14 -,SUP-128-828/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PROSTHESIS HEAD B NECK XL +10.5 -,SUP-128-828/04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINK PROSTHESIS HEAD B 36MM +4 -,SUP-128-836/03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ2.5 69.6/45.8MM KN CMNT STM SIGMA COCR PS -,SUP-1294-33-125,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ3 KN CMNT STM SIGMA COCR PS TCMPRTMNTL MBL -,SUP-1294-33-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ5 KN CMNT STM SIGMA COCR PS TCMPRTMNTL MBL -,SUP-1294-33-150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ6 KN CMNT STM SIGMA COCR PS TCMPRTMNTL MBL -,SUP-1294-33-160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ2.5 67/44MM KN CMNT SIGMA COCR PS REVISN MBL -,SUP-1294-35-125,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ3 70MM M/L 46MM A/P KN CMNT SIGMA COCR PS -,SUP-1294-35-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIB TRAY ROT PLAT MBT REV SZ 4 -,SUP-129435140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
REV MBT TIBIAL ROT PLAT TRAY SZ. 3 -,SUP-1294-35-315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
REVISION MBT TIBIAL TRAY SZ. 4 / 15MM -,SUP-1294-35-415,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRAY TIBIAL ROTATING PLAT MBT REV SZ 4 25MM THICK CEMENTED -,SUP-1294-35-425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE FEMORAL UNIV DISTAL PORUS 34MM -,SUP-1294-53-225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE UNIV FEMORAL 48MM FULL POROUS -,SUP-1294-53-246,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE TIB 29X29/26MM LCS COMPL MODULAR REVISN BEAR KN RP -,SUP-1294-54-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE TIB 37X37/27MM LCS COMPL MODULAR REVISN BEAR KN RP -,SUP-1294-54-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE TIB 45X45/27MM LCS COMPL MODULAR REVISN BEAR KN RP -,SUP-1294-54-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE METAPHYSEAL 53MM POUROUS MBT REV -,SUP-1294-54-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
METAPHYSEAL SLEEVE POROUS -,SUP-1294-54-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
METAPHYSEAL SLEEVE 29MM CEMENTED REV -,SUP-1294-54-140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
UNITED HIP FULL XPE CUP I.D. 32MM O.D. 48MM -,SUP-1302-3248,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
UNITED HIP FULL XPE CUP I.D. 32MM O.D. 50MM -,SUP-1302-3250,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
UNITED HIP FULL XPE CUP I.D. 28MM O.D. 46MM -,SUP-1302-3846,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
UNITED HIP LOCKING CAGE OD58MM LEFT -,SUP-1308-1158,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
UNITED HIP LOCKING CAGE OD54MM RIGHT -,SUP-1308-1254,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
UNITED HIP LOCKING CAGE OD 58MM RIGHT -,SUP-1308-1258,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
UNITED HIP SYS LOCKING CAGE 62MM RIGHT -,SUP-1308-1262,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
UNIPOLAR 42MM OD -,SUP-132-0042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD SOLITUDE UNIPOLAR 43MM -,SUP-132-0043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
UNIPOLAR 47MM -,SUP-132-0047,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
UNIPOLAR 53MM SOLITUDE -,SUP-132-0053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
UNIPOLAR SOLITUDE 55MM -,SUP-132-0055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
UNIPOLAR 57MM -,SUP-132-0057,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
ADAPTER SOLITUDE UNIPOLAR +0MM -,SUP-132-1200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
ADAPTER +6MM 12/14 -,SUP-132-1206,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
ADAPTER OFFSET 9MM 12/14 -,SUP-132-1209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP 3MM SOLITUDE OFST ADPTR UNIPL COCR 12/14 TAPR -,SUP-132-1230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL BIPOLAR PIVOT 22 X 40 ACETABULAR -,SUP-133-2240,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PIVOT BIPOLAR 22 X 43MM BIPOLAR -,SUP-133-2243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM 22X44MM SHL OFST L CUP BIPLR TI COCR UHMWPE -,SUP-133-2244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM 28X46MM SHL OFST L CUP BIPLR TI COCR UHMWPE -,SUP-133-2846,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CUP BIPOLAR MOD COCR 28X47MM -,SUP-133-2847,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PIVOT BIPOLAR 28 X 49 -,SUP-133-2849,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PIVOT BIPOLAR 28 X 50MM -,SUP-133-2850,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BIPOLAR 28MM ID 51MM OD -,SUP-133-2851,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PIVOT BIPOLAR 28 X 52 BIPOLAR -,SUP-133-2852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL BIPOLAR PIVOT 28MM X 53MM -,SUP-133-2853,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL BIPOLAR PIVOT 28X54MM -,SUP-133-2854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PIVOT BIPOLAR 28 X 55 -,SUP-133-2855,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PIVOT BIPOLAR 28X56MM BIPOLAR -,SUP-133-2856,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PIVOT BIPOLAR 28MM X 57MM -,SUP-133-2857,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEMORAL CERAMIC 28MM -,SUP-136-2800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEMORAL CERAMIC DELTA 28MM 3 BIOLOX -,SUP-136-2830,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TAPERED SPACER ARTICUL/EZE -3 -,SUP-136308000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SPACER HIP ARTICL/EZ MODULAR CATHCART UNIPL +0MML NK 12/14 -,SUP-1363-10-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1144.83,801.381,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SPACER HIP ARTICL/EZ MODULAR CATHCART UNIPL +5MM NK 12/14 -,SUP-1363-12-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1144.83,801.381,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL HEAD 32MM -3 CERAMIC 12/14 TAPER -,SUP-136-3230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 51MM UNIPL MODLR CATHCART BALL ORTHCNTRC DSGN -,SUP-1363-51-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1933.62,1353.534,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
MODULAR CATHCART BALL 53MM OD -,SUP-136353000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD 36MM +0 BIOLOX DELTA CERAMIC FEMORAL -,SUP-136-3600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM BIOLOX DELTA 36MM XL MODULAR -,SUP-136-3604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEMORAL 36MM +3 BIOLOX DELTA CERAMIC -,SUP-136-3613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEMORAL 36MM +6 CERAMIC 12/14 TAPER -,SUP-136-3616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEMORAL BIOLOX DELTA CERAMIC 36MM -3 -,SUP-136-3630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FERMORAL HEAD BIOLOX DELTA CERAMIC 36MM -6 -,SUP-136-3660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD CERAMIC FEMORAL DELTA -,SUP-136-4000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 40MMMEDX-1MM NK BIOLOX DELTA 12/14 TAPR -,SUP-136-4002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2570.74,1799.518,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL HEAD CERAMIC 40MM +3 BIOLOX -,SUP-136-4013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL CERAMIC HEAD 40MM +9 -,SUP-136-4019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL HEAD CERAMIC 40MM -3 BIOLOX -,SUP-136-4030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
ARTICUL/EZE BALL 28 +1.5 GR -,SUP-136511000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM ARTICL/EZ 28MMSTDX+8.5MM NK BIOLOX DELTA TS CERM -,SUP-1365-13-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
ARTIUL/EZE BALL 28 +12 BLK -,SUP-136514000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4405.7,3083.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEMORAL BIOLOX DELTA 28MM +5 12/14 TAPER CERAMIC REV -,SUP-1365-28-720,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8563.54,5994.478,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
ARTICUL/EZE BALL 22.225+4 NK -,SUP-136529000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4405.7,3083.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD S-ROM M 36MM +0 -,SUP-136531000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL HEAD M-SPEC METAL 36MM +3 11/13 -,SUP-1365-32-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CERAMIC FEMORAL HEAD 32MM +0 11/13 TAPER -,SUP-1365-32-210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12117,8481.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD BIOLOX DELTA CERAMIC FEMORAL 36MM -,SUP-1365-36-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4487.56,3141.292,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CERAMIC FEMORAL HEAD 40MM X +8.5 BIOLOX DELTA TS 12/14 TAPER -,SUP-1365-40-730,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CERAMIC FEMORAL HEAD 40MM +12 BIOLOX DELTA TS -,SUP-1365-40-740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM ARTICL/EZ 44MM +1.5MM NK COCR 12/14 TAPR CONTR -,SUP-1365-61-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CEMENTRALIZER 11.0 -,SUP-137620000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 22MM BIPLR COCR MODLR -,SUP-138-2200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL HEAD 22MM +3 COCR -,SUP-138-2203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL HEAD COCR 22MM -3 -,SUP-138-2230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM OVATN 28MM +0MML NK COCR 12/14 TAPR STRL -,SUP-138-2800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL HEAD 28MM +9 12/14 TAPER -,SUP-138-2809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEMORAL COCR 28MM -,SUP-138-2830,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM OVATN 36MM +0MML NK COCR 12/14 TAPR -,SUP-138-3600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL HEAD COCR 36MM +6 -,SUP-138-3606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL HEAD COCR 36MM +9 -,SUP-138-3609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM OVATN 36MM-3MM NK COCR 12/14 TAPR -,SUP-138-3630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL HEAD 40MM +3 -,SUP-138-4003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COCR FEMORAL HEAD -,SUP-138-4009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ENDO II TAPER STD 0MM T -,SUP-139247,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FRDM CNSTR 36MM T12/14 -6MM -,SUP-14-107016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7206.31,5044.417,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FRDM CNSTR HD 36MM T 12/14 - 14-107018 -,SUP-14-107018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7206.31,5044.417,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BAR ORTHO INTLOK TI ASCENT MAXIM L/R KN CR PRIM STRL -,SUP-141205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1136.02,795.214,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRAY TIBIAL ILOK PRI 79MM BIOMET -,SUP-141215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL PLATE 67MM -,SUP-141232,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRAY COCR CRUCIATE 71MM CC BIOMET -,SUP-141233,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HIP FINNED PRI 80 X 10MM BIOMET -,SUP-141316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PIN FX STNMN 2MMX6IN SMTH PLN BAYNT PNT FA KN -,SUP-141796,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7206.31,5044.417,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM BMT SPLINED KNEE V2 12 X 40 -,SUP-148287,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM BMT SPLINED KNEE V2 14 X 40 -,SUP-148289,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SPLINED KNEE STEM V2 -,SUP-148291,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM BMT SPLINED KNEE V2 10 X 80 -,SUP-148300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 7MM PRSRVN RM/LL KN -,SUP-1498-11-306,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5824.89,4077.423,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 9.5MM PRSRVN RM/LL KN -,SUP-1498-11-308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5824.89,4077.423,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM OSS CEMENTED IM 9MM X 90MM -,SUP-150358,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9594.39,6716.073,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM OSS CEMENTED IM 12MM X 90MM -,SUP-150361,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9594.39,6716.073,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
OSS CEMENTED IM STEM 13MM X 90MM -,SUP-150362,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9594.39,6716.073,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
OSS CEMENTED IM STEM 13X150 -,SUP-150367,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10426.1,7298.27,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM OSS POUROUS IM 11.5MM X 90MM -,SUP-150382,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ3 ATTUNE LT KN CR CMNT -,SUP-1504-00-103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ9 ATTUNE LT KN CR CMNT -,SUP-1504-00-109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
OSS POROUS IM STEM 12.5 X 225 -,SUP-150402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
OSS POROUS IM STEM 14.5 X 225 -,SUP-150403,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
OSS POROUS IM STEM 18.5 X 225 -,SUP-150405,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
OSS TIBAL POLY BEARING 14MM -,SUP-150411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7469.44,5228.608,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
OSS TIBAL POLY BEARING 18MM -,SUP-150413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7469.44,5228.608,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PLATE OSS NON-MOD TIBAL SHORT 67MM -,SUP-150417,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19307.6,13515.32,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
OSS MOD TIBAL BASEPLATE 71MM -,SUP-150422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20436.35,14305.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BLOCK OSS TIB 20 X 63/67 MR/LL -,SUP-150429,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BLOCK OSS TIB 20 X 63/67 MR/LR -,SUP-150430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
REVISION CRS FEMORAL SZ 7 LEFT CEMENTED -,SUP-1504-40-107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24255.17,16978.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
OSS FINN MOD PROX FMRL RT 7CM -,SUP-150457,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26939.64,18857.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT OSS LETSON MOD PROX FMRL R 7CM -,SUP-150459,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26939.64,18857.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
OSS 3CM ELLIP DIAPHYSEAL SEG -,SUP-150461,CDM,C1776,HCPCS,278,RC,,,outpatient,,,35466.58,24826.606,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
OSS POLY TIBIAL BUSHING -,SUP-150476,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2501.84,1751.288,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
OSS POLY FEMORAL BUSHINGS 2PK -,SUP-150477,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1738.56,1216.992,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
OSS AXLE -,SUP-150480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3399.09,2379.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
OSS REINFORCED YOKE -,SUP-150493,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6994.11,4895.877,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL BASE FIXED BEARING -,SUP-1506-40-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12048.69,8434.083,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASE TIBIAL REV RP SIZE 4 CEM -,SUP-1506-60-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18338.51,12836.957,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIA SLV M/L ATUNE 29MM FULL POR -,SUP-1511-11-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13490.44,9443.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
REVISED CEMENTED SYSTEM -,SUP-1512-14-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4423.31,3096.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM PRESSFIT STR ATUNE 16 X 60MM -,SUP-1513-16-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.93,4893.651,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 6MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-306,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5 10MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ6 6MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ9 7MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-907,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT FIXED BEARING POSTERIOR STABILIZED -,SUP-1516-40-412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBAL INSERT FIXED BEARING POST STAB 7X10MM -,SUP-1516-40-710,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT PS RP SZ 5 ATTUNE 16MM -,SUP-1516-50-516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 41MM ATTUNE MDL DOME -,SUP-1518-20-041,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2364.02,1654.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUG TIBIL UNIV ATUE SZ 3/4 X 5MM -,SUP-1523-03-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5835.5,4084.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ1 41MM OFST 120MM PROSTALAC HI OFST 26MM LEG COCR -,SUP-1541-06-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19493.25,13645.275,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CUP ACTB PROSTALAC CMNT PE 32X42MM -,SUP-1541-42-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3762.63,2633.841,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
OXFORD PARTIAL KNEE SYM FIXED LATERAL TIBIAL LEFT -,SUP-154335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FIXED LATERAL TIBIAL COSTRUCT LEFT  (E3) -,SUP-154340,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
OXF FIX LAT BRG E4 LEFT -,SUP-154341,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
OXF FIX LAT BRG B3 RIGHT -,SUP-154355,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
OXFORD FIX LAT BRG E5 RIGHT -,SUP-154372,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
OXFORD FIX LAT BRG F3 RIGHT -,SUP-154375,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SM OXFORD KN UNICMPT COCR -,SUP-154600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM MED OXFORD KN UNICMPT COCR -,SUP-154601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9586.97,6710.879,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
REVISION DISTAL FEMORAL AUGMENT SZ 7X4MM CEMENTED -,SUP-1547-07-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5135.24,3594.668,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ A LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154718,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ A R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ B LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154720,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ B R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154721,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ-C LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154722,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ-C L/M PMA ARTC OXFORD TI NIOBM NTRD CTD UHMWP -,SUP-154722,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ-C R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154723,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ-D LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154724,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ-D R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154725,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ-E R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154727,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
REVISION POSTERIOR FEMORAL AUGMENT SZ 7X4MM -,SUP-1549-07-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5135.24,3594.668,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SUMMIT BASIC CEMENTED SZ 6 -,SUP-157006120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ4 OFST 12/14 TAPR W/ POROCOAT -,SUP-1570-11-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL STEM 12/14 TAPER / SZ 5 / 145MM -,SUP-1570-11-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ6 12/14 TAPER W/ PORCOAT -,SUP-1570-11-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL STEM 12/14 TAPER SZ7X155MM -,SUP-1570-11-135,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB XS OXFORD UNICMPT ANTMC BEAR LT FEM MNSCL KN -,SUP-159530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
OXFORD KNEED RIGHT MEDIAL TIBIAL TRAY SZAA -,SUP-159532,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SM SZ4 PMA OXFORD UNICMPT ANTMC BRG LT MNSCL -,SUP-159541,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SM 5MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159542,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SM 6MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159543,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SM 9MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159546,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB MED 3MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159547,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB MED 4MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159548,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB MED 6MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159550,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB LRG 3MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159554,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB LRG 6MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159557,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB XL 4MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159562,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB XL 5MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159563,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SM 3MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159568,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SM 6MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159571,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SM 7MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159572,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SM 8MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159573,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SM 9MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159574,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB MED 3MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159575,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB MED 4MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159576,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
OXF ANAT BRG RT MD SZ 5 PMA -,SUP-159577,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB MED 6MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159578,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB MED 7MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159579,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB MED 8MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159580,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB LRG 3MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159582,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB LRG 4MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159583,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB LRG 5MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159584,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB LRG 6MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159585,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB XL 3MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL KN -,SUP-159589,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB XL 4MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL KN -,SUP-159590,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB XS 4MM OXFORD UNICMPT ANTMC ARTC BEAR LT MNSCL KN -,SUP-159791,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ5 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-05132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ6 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD. -,SUP-1601-06127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ6 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-06132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ7 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD. -,SUP-1601-07127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ7 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-07132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ8 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD. -,SUP-1601-08127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ8 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-08132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8806.3,6164.41,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ9 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-09127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HIP STEM SZ.9 34MM 142MM V40 -,SUP-1601-09132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HIP STEM SZ.10 34MM / 148MM -,SUP-1601-10132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ11 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-11132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB XS 4MM OXFORD UNIV ANTMC ARTC BEAR RT KN -,SUP-160791,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
OSS 3CM PROXIMAL TIBIAL SLEEVE -,SUP-161000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13099.46,9169.622,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
OSS RS 3 CM RESURF FMRL-LT -,SUP-161006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26742.28,18719.596,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
OSS RS 7 CM MOD SEG FMRL-RT -,SUP-161011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28518.52,19962.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE OSS RS 3 CM PROX TIBIAL -,SUP-161023,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13663.84,9564.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BUSHING OSS RS POLY FEM SET/2 -,SUP-161034,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3131.74,2192.218,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AXLE OSS RS -,SUP-161035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3399.09,2379.363,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SEGMENT OSS 3CM LG ELLIPT DIAPH -,SUP-161079,CDM,C1776,HCPCS,278,RC,,,outpatient,,,35466.58,24826.606,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
MOD BEARING TIBIAL OSS RS 63MM -,SUP-161088,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21683.92,15178.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BEARING TIBIAL OSS RS 12MM LS -,SUP-161094,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BEARING TIBIAL OSS RS 16MM LS -,SUP-161096,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BEARING TIBIAL OSS RS 18MM LS -,SUP-161097,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT LT SZ 2 FEMORAL PS NONPOROUS -,SUP-161-1201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL PS RIGHT SZ 2 NON-POROUS -,SUP-161-1202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SEG OSS RS 8.5CM FMRL LEFT -,SUP-161124,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29722.42,20805.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ3 BAL KN LT PS NPOR -,SUP-161-1301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ3 BAL KN RT KN PS NPOR -,SUP-161-1302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ4 BAL KN LT KN PS NPOR -,SUP-161-1401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ4 BAL KN RT KN PS NPOR -,SUP-161-1402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT FEMORAL BALANCED KNEE COCR NONPOROUS 4N KNEE LEFT -,SUP-161-1405,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL PS NARROW RIGHT SZ 4 NON-POROUS -,SUP-161-1406,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 BAL KN LT KN PS NPOR -,SUP-161-1501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 BAL KN RT KN PS NPOR -,SUP-161-1502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL PS NARROW LEFT SZ 5 NON-POROUS -,SUP-161-1505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL PS NARROW RIGHT SZ 5 NON-POROUS -,SUP-161-1506,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ6 BAL KN LT KN PS NPOR -,SUP-161-1601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ6 BAL KN RT KN PS NPOR -,SUP-161-1602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ7 BAL KN LT KN PS NPOR -,SUP-161-1701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ7 BAL KN RT KN PS NPOR -,SUP-161-1702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
RT SIZE 2 FEMORAL CR NONPOROUS -,SUP-161-3202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ4 BAL KN LT KN CR NPOR -,SUP-161-3401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 BAL KN LT KN CR NPOR -,SUP-161-3501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 BAL KN RT KN CR NPOR -,SUP-161-3502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ6 BAL KN LT KN CR NPOR -,SUP-161-3601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ6 BAL KN RT KN CR NPOR -,SUP-161-3602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM XS OXFORD KN TWN PG PRT CMNT COCR MLYBDNM ALY -,SUP-161467,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SM OXFORD KN TWN PG PRT CMNT COCR MLYBDNM ALY -,SUP-161468,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM MED OXFORD KN TWN PG PRT CMNT COCR MLYBDNM ALY -,SUP-161469,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TWIN PEGGED FEMORAL LRG KNEE -,SUP-161470,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ2 BAL KN NPOR -,SUP-162-1200A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ3 BAL KN NPOR -,SUP-162-1300A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ4 BAL KN NPOR -,SUP-162-1400A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ5 BAL KN NPOR -,SUP-162-1500A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ6 BAL KN NPOR -,SUP-162-1600A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL TRAY NONPOROUS SIZE 7 -,SUP-162-1700A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 11MM PS KN -,SUP-163-1311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5 8MM PS KN -,SUP-163-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5 13MM PS KN -,SUP-163-1513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ6 12MM PS KN -,SUP-163-1612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ2 13MM UL CONG KN -,SUP-163-3213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 11MM UL CONG KN -,SUP-163-3311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 16MM UL CONG KN -,SUP-163-3316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ4 9MM UL CONG KN PE -,SUP-163-3409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5 14MM UL CONG KN -,SUP-163-3514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2726.14,1908.298,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ6 10MM UL CONG KN -,SUP-163-3610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ6 11MM UL CONG KN -,SUP-163-3611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ6 14MM UL CONG KN -,SUP-163-3614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
MODULAR HEAD COMPONENT 32MM DIA HD 3MM NK -,SUP-163661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
28MM DIA COCR MOD HD -,SUP-163665,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
MODULAR HEAD COMPONENT 32MM -,SUP-163674,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PATELLA  29MM VITAMIN 3 -,SUP-164-5029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PATELLA 32MM VITAMIN E -,SUP-164-5032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PATELLA 35MM VITAMIN E -,SUP-164-5035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PATELLA 38MM VITAMIN E -,SUP-164-5038,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
41MM PATELLA VITAMIN E -,SUP-164-5041,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL PS RIGHT SZ 4 NON-POROUS -,SUP-165-1402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL CR LEFT SZ 6 NON-POROUS -,SUP-165-3601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT PS SIZE 2 7MM VITAMIN E -,SUP-166-5207,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT BKS E-VITALIZE 9MM SZ 2 -,SUP-166-5209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT PS TIBIAL 10MM SIZE 2 V -,SUP-166-5210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT PS TIBIAL SIZE 2 11MM VITAMIN E -,SUP-166-5211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT PS VITAMIN E SIZE 2 12MM -,SUP-166-5212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT PS TIBIAL SIZE 3 7MM VITAMIN E -,SUP-166-5307,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL PS SIZE 3 8MM VITAMIN E -,SUP-166-5308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SIZE 3 9MM TIBIAL INSERT PS VITAMIN E -,SUP-166-5309,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL PS SIZE 3 10MM VITAMIN E -,SUP-166-5310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT PS TIBIAL 10MM SIZE 3 V -,SUP-166-5310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL PS 11MM SIZE 3 V -,SUP-166-5311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL PS 12MM SIZE 3 V -,SUP-166-5312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL PS 13MM SIZE 3 V -,SUP-166-5313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT PS TIBIAL 14MM SIZE 3 V -,SUP-166-5314,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL PS 16MM SIZE 3 V -,SUP-166-5316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SIZE 3 18MM VIT E -,SUP-166-5318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SIZE 3 20MM -,SUP-166-5320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT PS VITAMIN E SZ4 7MM -,SUP-166-5407,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL PS 8MM SIZE 4 VITAMIN E -,SUP-166-5408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT PS TIBIAL 9MM SIZE 4 HI -,SUP-166-5409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL PS SIZE 4 10MM VITAMIN E -,SUP-166-5410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT PS TIBIAL 10MM SIZE 4 V -,SUP-166-5410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT PS VITAMIN E SZ 4 10MM -,SUP-166-5410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL PS 11MM SIZE 4 V -,SUP-166-5411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL PS 11MM SIZE 4 VITAMIN E -,SUP-166-5411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT PS TIBIAL 12MM SIZE 4 H -,SUP-166-5412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL PS SIZE 4 12MM VITAMIN E -,SUP-166-5412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT PS TIBIAL 13MM SIZE 4 H -,SUP-166-5413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL 14MM SIZE 4 HIGH -,SUP-166-5414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SIZE 4 16MM VIT E -,SUP-166-5416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT PS SIZE 4 18MM -,SUP-166-5418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT PS VIT 3 SIZE 4 20MM -,SUP-166-5420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT PS SIZE 5 7 MM VIT E -,SUP-166-5507,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIIAL PS SIZE 5 8MM VITAMIN E -,SUP-166-5508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT PS SIZE 5 9MM TIBIAL VITAMIN E -,SUP-166-5509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL PS SIZE 5 10MM VITAMIN E -,SUP-166-5510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL PS 10MM SIZE 5 V -,SUP-166-5510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL 11MM PS SIZE 5 HIGH FLEX VITAMIN E -,SUP-166-5511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL NONPOROUS SIZE 5 -,SUP-166-5511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL PS 12MM SIZE 5 V -,SUP-166-5512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL PS SIZE 5 12MM VITAMIN E -,SUP-166-5512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL PS 14MM SIZE 5 H -,SUP-166-5514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SIZE 5 16MM VIT E -,SUP-166-5516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SIZE 5 20MM -,SUP-166-5520,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SIZE 6 7MM -,SUP-166-5607,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SIZE 6 8MM VIT E -,SUP-166-5608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SZ 6 9MM PS -,SUP-166-5609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL PS 10MM SIZE 6 H -,SUP-166-5610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SIZE 6 10MM TIBIAL INSERT PS VITAMIN E -,SUP-166-5610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL PS 11MM SIZE 6 VITAMIN E -,SUP-166-5611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SIZE 6 12MM VIT E -,SUP-166-5612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SIZE6 14MM VITAMIN E -,SUP-166-5614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT PS SZ 6 16MM VITAMN-E -,SUP-166-5616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT INSERT PS SIZE 7 10MM VIT E XLPE -,SUP-166-5710,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT CR SZ 5 10MM VITAMIN E -,SUP-166-6510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SZ 2 12MM VIT E -,SUP-166-7212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT UC SZ 3 9MM VIT-E -,SUP-166-7309,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SIZE 3 11MM VIT E XLPE -,SUP-166-7311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT UC SZ 4 8MM VIT E -,SUP-166-7408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SZ 4 9MM VIT E -,SUP-166-7409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT UC SIZE 4 10MM VIT E -,SUP-166-7410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SIZE 4 11MM VIT E -,SUP-166-7411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SIZE 4 12MM VIT E -,SUP-166-7412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SIZE 4 13MM -,SUP-166-7413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT UC SZ 4 14MM VIT E -,SUP-166-7414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SZ 5 7MM VIT E -,SUP-166-7507,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT UC SZ 5 8MM VITAMIN-E -,SUP-166-7508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL UC SZ 5 9MM E-VITALIZE KNEE -,SUP-166-7509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SIZE 5 10MM VIT E -,SUP-166-7510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT BKS E-VITALIZE 11MM SZ 5 -,SUP-166-7511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT UC SZ 5 12MM VIT-E -,SUP-166-7512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SIZE 5 13MM VITAMIN E -,SUP-166-7513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SIZE 5 14MM VIT E -,SUP-166-7514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT UC SIZE 5 16MM VIT-E -,SUP-166-7516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SIZE 6 10MM VIT E -,SUP-166-7610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SIZE 6 11MM VITAMIN E -,SUP-166-7611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SIZE 6 12MM VIT E -,SUP-166-7612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT UC SIZE 6 13MM VIT E -,SUP-166-7613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SIZE 6 14MM VIT E -,SUP-166-7614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT SIZE 7 11MM VIT E -,SUP-166-7711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE HIP UNITRAX V40 UNIPL TI -,SUP-170000E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL THREE HOLE 44MM -,SUP-170-0144,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 48MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0148,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4630.78,3241.546,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 50MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 52MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0152,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 56MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 58MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0158,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 60MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 62MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0162,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ESCALADE 68MM THREE HOLE -,SUP-170-0168,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACETABULAR LEGEND OD50 MM 3 HOLE -,SUP-170-0550,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
POROUS ACET SHELL THREE HOLE 52MM OD -,SUP-170-0552,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
POROUS ACETABULAR SHELL THREE-HOLE 54MM OD -,SUP-170-0554,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
POROUS ACETABULAR SHELL THREE HOLE 56MM OD -,SUP-170-0556,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4630.78,3241.546,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 32MM X 52MM NEUTRAL HXLPE -,SUP-170-3252,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 36MM 52MM SHL ESCALADE +3 NEUT -,SUP-170-3652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 36MM 54MM SHL ESCALADE +1 NEUT -,SUP-170-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 36MM 56MM SHL ESCALADE +0 NEUT -,SUP-170-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 36MM 58MM SHL ESCALADE +0 NEUT -,SUP-170-3658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 36MM 60MM SHL ESCALADE +0 NEUT -,SUP-170-3660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 36X62MM ESCALDE +ODEG NEUT F/T/H ARTHPL -,SUP-170-3662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER +3 NEUTRAL 40 X 56MM HXL -,SUP-170-4056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER NEUTRAL +1 ESCALADE -,SUP-170-4058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 40X60MM ESCALDE +ODEG NEUT F/T/H ARTHPL -,SUP-170-4060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 40X62MM ESCALDE +ODEG NEUT F/T/H ARTHPL -,SUP-170-4062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
ACETABULAR LINER 36 X 52 +3 HOODED HXLPE -,SUP-171-3652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACETABULAR 36 X 54 HOODED -,SUP-171-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 36X56MM ESCALDE +ODEG HD F/T/H ARTHPL -,SUP-171-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER 28MM ID 44MM OD NEUTRAL HXLPE -,SUP-172-2844,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER 32MM ID 46MM OD NEUTRAL HXLPE -,SUP-172-3246,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER 36MM ID 50MM OD NEUTRAL HXLPE -,SUP-172-3650,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER 36MM ID 52MM OD NEUTRAL HXLPE -,SUP-172-3652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER 36MM ID 54MM OD NEUTRAL HXLPE -,SUP-172-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER 36MM ID 56MM OD NEUTRAL HXLPE -,SUP-172-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER 36MM ID 58MM OD NEUTRAL HXLPE -,SUP-172-3658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER 36MM ID 60MM OD NEUTRAL HXLPE -,SUP-172-3660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER 36MM 64-70MM OD NEUTRAL -,SUP-172-3664,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER 40MM ID 56MM OD NEUTRAL HXLPE -,SUP-172-4056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER 40MM ID 58MM OD NEUTRAL HXLPE -,SUP-172-4058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER 40MM ID 60MM OD NEUTRAL HXLPE -,SUP-172-4060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM WITH MICROPOUROUS SUR 14MM X 12MM X 180CM -,SUP-172-918/14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM WITH MICROPOROUS SURGACE 14MM X 16MM L 180MM -,SUP-172-918/16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM WITH MICROPOROUS SURFACE 18MM X 16MM L180MM -,SUP-172-918/18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEMORAL LINK W/MICROPOROUS CEMTLESS 20MM X 18MM X 180MM -,SUP-172-918/20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINK STEM WITH MICROP SUR 14MM X 16MM -,SUP-172-921/16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM WITH MICROPOROUS SURFACE 16 X 18 X 210 -,SUP-172-921/18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINK STEM WITH MICROP SUR 14MM X 11MM X 120MM -,SUP-172-925/14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM WITH MICROPOROUS SURFACE 12.5MM X 16MM L 250MM -,SUP-172-925/16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM MICROPOROUS SURF 14.5MM X 18MM L 250MM CEMENTLESS -,SUP-172-925/18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SPACER PROXIMAL 20MM X 14MM COCRMO -,SUP-172-950/20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1484.14,1038.898,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINK NECK SEGMENT WITHOUT COLLAR CEMLESS 65MM 126CCD -,SUP-172-964/26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
NECK FEMORAL W/O COLLAR CEMENTLESS TILASTAN TI6AI-4V LINK -,SUP-172-964/35,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
NECK SEGMENT WITHOUT COLLAR CEMENTLESS -,SUP-172-965/26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
NECK SEGMENT XXL W/O COLLAR 65MM 12/14MM CEMENTLESS -,SUP-172-984/26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINK NECK SEG XXL WITHOUT COLLAR CEMENLESS 65MM -,SUP-172-984/35,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER 36MM ID 50MM OD HOODED HXLPE -,SUP-173-3650,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER 36MM ID 54MM OD HOODED HXLPE -,SUP-173-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER 36MM ID 56MM OD HOODED -,SUP-173-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER 36MM ID 58MM OD HOODED HXLPE -,SUP-173-3658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM ABC 36X0MM NK ALMN C-TAPR PRIM -,SUP-173600E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
ASCENT ANT STBLZD TIBIAL BEARING 14 X 67 -,SUP-179822,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5551.15,3885.805,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP RESTORIS SZ 3 LEFT MAKO PATELLOFEMORAL COCRMO -,SUP-180403,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT RESTORIS MCK SIZE 4 LEFT PATELLOFEMORAL COCRMO -,SUP-180404,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP RESTORIS MCK PAT/FEM SZ 5 RIGHT COCRMO -,SUP-180415,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT FEMORAL RESTORIS MCK SIZE 1 LM/RL -,SUP-180501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT FEMORAL SZ 3 LM/RL RESTORIS MAKO COCRMO -,SUP-180503,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT FEMORAL SIZE 4 LM/RL RESTORIS MCK COCRMO -,SUP-180504,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT FEMORAL SZ 5 LM/RL RESTORIS MAKO COCRMO -,SUP-180505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT FEMORAL SZ 6 LM/RL RESTORIS MAKO COCRMO -,SUP-180506,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT FEMORAL SZ 1 RM/LL RESTORIS MAKO COCRMO -,SUP-180511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT FEM ONLAY SZ 3 RM/LL RESTORIS MAKO COCRMO -,SUP-180513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT FEMORAL SZ 4 RM/LL RESTORIS MAKO COCRMO -,SUP-180514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT FEMORAL RESTORIS MCK SZ 5 RM/LL COCRMO MAKO -,SUP-180515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT FEMORAL RESTORIS MCK SZ 6 RM/LL COCRMO MAKO -,SUP-180516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT FEM RESTORIS MCK SZ 7 RM/LL COCRMO -,SUP-180517,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIBIAL RESTORIS MCK ONLAY SIZE 2 LM/RL -,SUP-180602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIBIAL RESTORIS SZ 3 LM/RL T/6A/4V ONLAY MAKO -,SUP-180603,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE ONLAY TIBIAL SZ 4 LM/RL T/6A/4V RESTORIS MAKO -,SUP-180604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE ONLAY TIBIAL 5 LM/RL RESTORIS MCK -,SUP-180605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE ONLAY TIBIAL 6 LM/RL RESTORIS MCK -,SUP-180606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE ONLAY TIBIAL SZ 2 RM/LL Ti6AI4V RESTORIS MAKO -,SUP-180612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE ONLAY TIBIAL SIZE 3 RM/LL RESTORIS MCK TI6AI4V -,SUP-180613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE ONLAY TIBIAL SZ 4 RM/LL Ti6AI4V RESTORIS MAKO -,SUP-180614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIBIAL RESTORIS MCK SZ 5 RM/LL ONLAY MAKO TI6AI4V -,SUP-180615,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE ONLAY TIBIAL 6 RM/LL RESTORIS MCK -,SUP-180616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE ONLAY TIBIAL 7 RM/LL RESTORIS MCK TI6A14V -,SUP-180617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIBIAL RESTORIS MCK SZ 8 RM/LL TI6I4V -,SUP-180618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL SIZE 2 UNI X 8MM MAKO X3 ONLAY -,SUP-180732-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL MAKO X3 UNI ONLAY SIZE 2 X 8MM -,SUP-180732-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL MAKO X3 3 X 8 MM KNEE ONLAY -,SUP-180733-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ONLAY TIBIAL SZ 4 X 8MM MAKO X3 UNI -,SUP-180734-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL SIZE 4 X 8MM UNI ONLAY MAKO X3 -,SUP-180734-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL UNI ONLAY SIZE 4 X 9MM THKNS MAKO X3 -,SUP-180734-2,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL ONLAY SZ 5 X 8MM MAKO X3 UNI -,SUP-180735-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL ONLAY SZ 5 X 9MM MAKO X3 UNI -,SUP-180735-2,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ONLAY TIBIAL SZ 6 X 8MM MAKO X3 UNI -,SUP-180736-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL ONLAY SZ 6 X 8MM MAKO X3 UNI -,SUP-180736-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ONLAY TIBIAL SZ 7 X 8MM MAKO X3 UNI -,SUP-180737-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ONLAY TIBIAL MAKO X3 UNI SZ 8 X 8MM THKNS -,SUP-180738-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 28MM +0MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-18-2800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM 55MM VANGRD RT KN CR ANTMC CMNT COCR NPOR INTLOK -,SUP-183000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM 62.5MM VANGRD RT KN CR ANTMC CMNT COCR NPOR INTLOK -,SUP-183006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMUR CR INTERLOCK RIGHT 65MM VANGUARD -,SUP-183008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
VANGUARD CR ILOK FEM-LT 62.5 -,SUP-183026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM 57.5MM VANGRD LT KN CR ANTMC CMNTLS TI POR -,SUP-183062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM 62.5MM VANGRD LT KN CR ANTMC CMNTLS TI POR -,SUP-183066,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM 70MM VANGRD LT KN CR ANTMC CMNTLS TI POR -,SUP-183072,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM 57.5MM VANGRD RT FEM OPN BX CMNT COCR -,SUP-183102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM 60MM VANGRD RT KN PS OPN BX CMNT COCR NPOR INTLOK -,SUP-183104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PS OPEN BOX FEMORAL - LEFT 62.5MM -,SUP-183126,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PLATE VN PS OPEN INTL FEM-LT 70 -,SUP-183132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 32MM +0MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 32MM +5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB 10X63/67MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-183520,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB 16X63/67MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-183526,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 36MM +0MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 36MM +5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB 12X63/67MM VANGRD PS MODULAR ARTC BEAR 0DG SLP KN -,SUP-183622,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 36MM -5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-18365,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 36MM +7.5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183675,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL BEARING 14MM X 63/67 MM -,SUP-183724,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BRIDGE VANGUARD PS+TIB 20 X63/67MM -,SUP-183730,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL BEARING 14MM X 71/75MM -,SUP-183744,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BRIDGE VNGD PS+TIB 24 X79/83MM -,SUP-183774,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
VNGD SSK PSC TIB BRG 20 X 71/75 -,SUP-183890,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9735.49,6814.843,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 31MM STD 8MM TI SS UNMWPE PEGX3 VANGRD -,SUP-184764,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SERIES A ASYMMETRIC PAT 31X8 -,SUP-184792,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SERIES-A ASYMMETRICAL PATELLA 31MM / 8MM -,SUP-184792,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SERIES A ASYMMETRIC PAT 34X8.5 -,SUP-184793,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
DRILL HEADLESS TROCAR PIN 75MM -,SUP-185086,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9557.26,6690.082,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL TRAY WITH TI LCK BAR AND SCREW -,SUP-185203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11606.84,8124.788,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
OFFSET ADAPTER WITH SCREWS -,SUP-185210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4611.68,3228.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
ADAPTER OFFSET BMT 360 TIB 6.0 -,SUP-185211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4611.68,3228.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT BMT 360 TIBIAL 7 X 5MM -,SUP-185223,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5321.98,3725.386,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT BMT 360 TIBIAL 71 X 15MM RL/LM -,SUP-185243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5321.98,3725.386,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT BMT 360 TIBIAL 71 X 15MM LL/RM -,SUP-185253,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5321.98,3725.386,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
VNGD SSK 360 L FEMORAL R 67.5 -,SUP-185265,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29741.13,20818.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
VNGD SSK 360 L FEMORAL 65MM -,SUP-185284,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29741.13,20818.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT VG 360 DIST FM 67.5 X 5 RL/LM -,SUP-185305,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT VG 360 DIST FM 67.5 X 5 LL/RM -,SUP-185325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT VG 360 UNIV PST FM 65 X 10 -,SUP-185424,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT VG 360 UNIV PST FM 67.5 X 10 -,SUP-185425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
WING BMT 360 TIBIAL SM CRUCIATE -,SUP-185650,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
VANGUARD ANT STBLZD BRG 12X67 -,SUP-189042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BRIDGE VANGUARD ANT STBLZD 14 X 67 -,SUP-189044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BRIDGE ANT TIBIAL STABILIZED10 X 71MM VANGD -,SUP-189060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE HIP UNIV TRIDENT PRIM ADPTR +0MML NK OFST BIOLOX -,SUP-19-0000T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
ADAPTER UNIV C-TAPER +5MM SLEE -,SUP-19-0005T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
UNIVERSAL C-TAPER +2.5MM ADAPTER SLEEVE -,SUP-19-0025T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
UNITED HIP SYSTEM ISCHIAL FLANGE -,SUP-1908-5401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6459.37,4521.559,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM ECHO POR FEMORAL LAT NC 28 X 44MM -,SUP-192114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BOLT LOCKING CONICAL PROX BODY CEMENTLESS 24 X 95 -,SUP-1975-24-095,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17895.36,12526.752,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM DISTAL TAPERED 15 X 190 STRAIGHT -,SUP-1976-15-190,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15238.52,10666.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ7 FNDTN LT KN CR TI NPOR -,SUP-201-01-107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 LONGEVITY NEUTRIAL 32MM C -,SUP-20103203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 LONGEVITY NEUTRIAL 32MM D -,SUP-20103204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3174.71,2222.297,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL G7 LONGEVITY NEUTRIAL 32MM D -,SUP-20103204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 LONGEVITY NEUTRIAL 32MM E -,SUP-20103205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 LONGEVITY NEUTRAL 36MM D -,SUP-20103604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 LONGEVITY NEUTRAL 36MM E -,SUP-20103605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 LONGEVITY NEUTRAL 36MM F -,SUP-20103606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 LONGEVITY NEUTRAL 36MM G -,SUP-20103607,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 LONGEVITY NEUTRAL 40MM F -,SUP-20104006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 LONGEVITY NEUTRAL 40MM G -,SUP-20104007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 FNDTN RT KN CR TI NPOR -,SUP-202-01-105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ7 FNDTN RT KN CR TI NPOR -,SUP-202-01-107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 28X58-60MM SHL OMNIFIT 10DG CROSSFIRE 13.1MM -,SUP-2041C-2858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4587.76,3211.432,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT OMNIFIT SERIES II 20 DEGREE 32MM -,SUP-2042-3250,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3800.96,2660.672,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
JIG TOT JNT RT TIB KN PERSONA ROT -,SUP-20-8070-002-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
JIG TOT JNT LT KN PERSONA PREF -,SUP-20-8070-010-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
GW ORTHO TM PT SPEC INST -,SUP-20-8075-001-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 28X58MM OSTEONICS 0DG BIPLR PE 5.8-10.4MM THK -,SUP-2099-2858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9662.67,6763.869,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR KNEE SYS FEMORAL COMPONENT HINGED #3 LEFT -,SUP-2115-1330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR II KNEE SYSTEM FEMORAL COMPONENT HINGED #4 LEFT -,SUP-2115-1340,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR KNEE FEMORAL COMPONENT HINGED #5 LEFT -,SUP-2115-1350,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
UNITED II KNEE FEMORAL COMPONENT HINGED #6 HINGED -,SUP-2115-1360,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
URSTAR II KNEE SYSTEM FEMORAL COMPONENT HINGED #3 RIGHT -,SUP-2115-1430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR II KNEE FEMORAL COMPONENT HINGED #5 RIGHT -,SUP-2115-1450,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR II KNEE DISTAL FEMORAL COMPONENT RHS S LEFT -,SUP-2115-3310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30242.39,21169.673,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR II KNEE DISTAL FEMORAL COMP RHS S RIGHT -,SUP-2115-3410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30242.39,21169.673,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ4 FNDTN LT KN PS TI NPOR -,SUP-213-01-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ8 FNDTN LT KN PS TI NPOR -,SUP-213-01-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ8 FNDTN RT KN PS TI NPOR -,SUP-214-01-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ12 FNDTN RT KN PS TI NPOR -,SUP-214-01-012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
IMPLANT  CUSTOM PFR KINEMATCH -,SUP-22-100-1001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19864.55,13905.185,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR II TIBIAL BASEPLATE HINGED #1 -,SUP-2215-1410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIBIAL USTAR II HINGED 2 KNEE -,SUP-2215-1420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIBIAL SYSTEM USTAR II HINGED 3 -,SUP-2215-1430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIBIAL USTAR II HINGED 4 KNEE -,SUP-2215-1440,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT TIBIAL USTAR II KNEE PROXIMAL RHS S -,SUP-2215-3410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,34950.47,24465.329,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL KNEE USTAR II XPE SMALL 12MM -,SUP-2315-3211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL USTAR II KNEE XPE S 14MM -,SUP-2315-3212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL USTAR II KNEE XPE S 17MM -,SUP-2315-3213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL USTAR II XPE H20 SMALL 20MM -,SUP-2315-3214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR II KNEE XPE TIBIAL INSERT M 17MM -,SUP-2315-3243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR II KNEE XPE TIBIAL INSERT M 20MM -,SUP-2315-3244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL USTAR II KNEW XPE M 23MM -,SUP-2315-3245,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT FEMORAL U2 PSA COCR 5 4MM POSTERIOR SET -,SUP-2603-5051,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5852.48,4096.736,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AGUMENT FEMORAL U2 TOTAL KNEE SET DISTAL #5 12MM -,SUP-2603-5353,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5852.48,4096.736,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEADED PIN 17-4 PH S.S. -,SUP-262-0520A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PS Insert Trial Size 2  14mm -,SUP-263-1214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 40X17MM COCR -,SUP-265 108,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9253.24,6477.268,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
U2 TOTAL KNEE STRAIGHT STEM PSA 14MM X 75MM -,SUP-2703-5013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TIBIAL U2 PSA TI STRAIGHT 16MM X 75MM KNEE -,SUP-2703-5014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
U2 TOTAL KNEE SYSTEM STRAIGHT STEM PSA 22MM DIA 75MM STEM -,SUP-2703-5017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
U2 TOTAL  KNEE STRAIGHT STEM PSA 24MM DIA 75MM STEM LENGTH -,SUP-2703-5018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
U2 TOTAL KNEE STRAIGHT STEM PSA 12MM DIA 100MM STEM LENGTH -,SUP-2703-5022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TIBIAL U2 PSA STRAIGHT 20MM X 150MM TOTAL KNEE -,SUP-2703-5056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR II KNEE CEMENTED STRT STEM RHS NON COAT 9 X 100 -,SUP-2715-3009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR II KNEE SYS CEMENTED STR STEM RHS NON-COAT 11X100 -,SUP-2715-3011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR II KNEE CEMENTED STRAIGHT STEM RHS NON COATED 13 X 100 -,SUP-2715-3013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR II KNEE CEMENTED STRT STEM RHS NON COATED 15 X 100 -,SUP-2715-3015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR II KNEE CEMENTED STRAIGHT STEM RHS NON COAT 17X100 -,SUP-2715-3017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CEMENTED STRAIGHT STEM RHS COLLARLESS 9 X 125MM -,SUP-2715-3109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR II KNEE CEMENTED STRAIGHT STEM RHS NON COATED 11X125 -,SUP-2715-3111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR CEMENTED STRAIGHT STEM RHS NON COATED 13 X 125MM -,SUP-2715-3113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
KNEE SYSTEM CEMENTED STRAIGHT STEM RHS NON COATED 15 X 125MM -,SUP-2715-3115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR II KEE CEMENTED TIBIAL STEM 9MM X 20MM STEM LENG -,SUP-2715-5109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR II KNEE CEMENTED TIBIAL STEM 9MM X 45MM STEM -,SUP-2715-5209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TIBIAL USTAR II 9MM X 95MM KNEE CEMENT -,SUP-2715-5409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR II KNEE TIBIAL STEM 12.5MM X 70MM -,SUP-2715-7312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR II KNEE TIBIAL AUGMENT #2 10MM THICK -,SUP-2815-1022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5215.88,3651.116,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR SEGMENT PART RHS 50MM LENGTH -,SUP-2915-1050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22014.38,15410.066,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
USTAR II KNEE SEGMENT PART RHS 70MM LENGTH -,SUP-2915-1070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22014.38,15410.066,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 11MM 8.5MM MDL OFST PRIM PRFT EQUINOXE 110MM TI ALY -,SUP-300-01-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 15MM 9.5MM MDL OFST PRIM PRFT EQUINOXE 120MM TI ALY -,SUP-300-01-15,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PLATE BN EQUINOXE F/RVRS SYS ANTMC REPLICATOR TI ALY 4.5MM -,SUP-300-10-45,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4686.87,3280.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER G7 VIT E NEUTRAL 36MM E -,SUP-30103605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER G7 VIT E NEUTRAL 36MM F -,SUP-30103606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
G7 VIT E HIGH WALL LNR 36MM D -,SUP-30123604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER G7 VIT E HIGH WALL 36MM F -,SUP-30123606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER G7 VIT E HIGH WALL 40MM H -,SUP-30124008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER G7 VIT E +5MM 40MM H -,SUP-30154008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8963.33,6274.331,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 47MM SHRT 18MM EQUINOXE 1.5MM OFST COCR -,SUP-310-01-47,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7808.96,5466.272,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 53MM SHRT EQUINOXE -,SUP-310-21-53,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6472.1,4530.47,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP B MED EQUINOXE SHLDR PG -,SUP-314-02-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4010.16,2807.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SPHERE GLND 38MM EQUINOXE RVRS -,SUP-320-01-38,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRY ADAPTER HUM WDG +0MM RVRS BALL SCKT EQUINOXE -,SUP-320-10-00,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 10MM FNDTN MODULAR REVISN 100MM TIB KN -,SUP-320-10-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER HUM 38MM STD EQUINOXE -,SUP-320-38-00,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4559.17,3191.419,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER HUM 38MM STD RVRS EQUINOXE -,SUP-320-38-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4559.17,3191.419,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BLOCK CUT SZ4 10MM RM/LL FNDTN KN REVISN F/SPCR -,SUP-321-101-04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ4 RT KN STM FNDTN REVISN MODULAR NPOR -,SUP-322-01-104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BLOCK CUT SZ4 5MM RL/LM FNDTN KN REVISN F/SPCR -,SUP-322-05-104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BLOCK CUT SZ4 10MM RL/LM FNDTN KN REVISN F/SPCR -,SUP-322-10-104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ2 10.9MM FNDTN PS ARTC CONGR KN COMPR MLD -,SUP-360-09-510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ2 11MM FNDTN PS ARTC CONGR KN COMPR MLD UHMWPE -,SUP-360-11-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ2 13MM FNDTN PS ARTC CONGR KN COMPR MLD UHMWPE -,SUP-360-13-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB 4MM AXSOS LCK -,SUP-370002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,240.4,168.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ORTHO 14X8.5MM DIA FEM LCK 5MM HL AXSOS NS -,SUP-370003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,274.83,192.381,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ2 13MM FNDTN CR PRIM CNSTRN ARTC CONGR L/R KN -,SUP-385-13-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CENTRALIZER DIST HIP TI ALY -,SUP-400-03-002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 36MM +4MM NK BIOLOX DELTA CERM -,SUP-400-03-363,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4487.56,3141.292,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM BIOLOX DELTA 40MM NEUT CERM -,SUP-400-03-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP REV SHLDER 9 IN STEINMANN -,SUP-405800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SEASPINE TULIP HEADS -,SUP-41-1000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE HIP NEUT OFST UNIPL ANG -,SUP-411-00-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 46MM UNIPL -,SUP-411-00-146,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PLUG SMALL DIA CEMENT 8MM -,SUP-414993,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
KT THR SZ3 FEM 3 TIB RT HIP TRUMATCH -,SUP-420859,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
KT TKR LT HIPERF 3T/3F -,SUP-420878,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
KT TKR RT HIPERF -,SUP-420890,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMUR PERSONA CEMENTED CCR NARROW SIZE 5 R -,SUP-42500005802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMUR PERSONA CEMENTED NARROW PS LT SZ 6 -,SUP-42500006001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMUR PERSONA CEMENTED CCR NARROW SIZE 8 R -,SUP-42-5000-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT PSN FEM PS CMT CCR SZ 7 R STD -,SUP-42-5006-062-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT PSN FEM PS CCR STD SIZE 10 L -,SUP-42500606801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ3 PERSONA RT KN CR CMNT COCR NRW -,SUP-42-5020-054-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ6 PERSONA LT KN CR CMNT COCR NRW -,SUP-42-5020-060-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ7 PERSONA LT KN CR CMNT COCR NRW -,SUP-42-5020-062-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ7 PERSONA RT KN CR CMNT COCR NRW -,SUP-42-5020-062-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMUR PERSONA CEMENTED CR NARROW RT SZ 9 -,SUP-42502006602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMUR PERSONA CEMENTED KNEE CR   RT SZ10 -,SUP-42-5020-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 PERSONA LT KN CR CMNT COCR POR NRW -,SUP-42-5022-058-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ6 PERSONA LT KN CR CMNT COCR POR NRW -,SUP-42-5022-060-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMUR FEMORAL CR POR CCR NRW SIZE 6 RIGHT PERSONA -,SUP-42-5022-060-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ7 PERSONA RT KN CR CMNT COCR POR NRW -,SUP-42-5022-062-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PSN FEM SZ 10 R CR CCR POR NRW -,SUP-42-5022-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ6 LEFT PERSONA KN CR STD CMNT CCR -,SUP-42-5026-060-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PERSONA FEMUR CMNT STD CCR SIZE 7 RIGHT -,SUP-42502606202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ8 PERSONA LT KN CR STD CMNT COCR NRW -,SUP-42-5026-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ8 RIGHT PERSONA KN CR STD CMNT COCR -,SUP-42-5026-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ10 PERSONA RT KN CR STD CMNT COCR NRW -,SUP-42-5026-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PSN FEM CR POR CCR STD SZ7 L -,SUP-42-5028-062-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ8 PERSONA LT KN CR STD COCR POR -,SUP-42-5028-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ8 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ9 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-066-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PERSONA KNEE SYSTEM FEMUR -,SUP-42-5028-068-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ10 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ11 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-070-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ12 R PERSONA RT KN CCR STD COCR POR -,SUP-42-5028-074-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PSN REV FEM CMT CCR STD SZ 5 R -,SUP-42-5046-058-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,33973.95,23781.765,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PSN REV FEM CMT CCR STD SZ 9 L -,SUP-42-5046-066-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,31746.15,22222.305,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PSN ASF CR 12MM PLY L 3-11 EF -,SUP-42-5110-005-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ8 139MM LNR PRFT LAT OFST CLLRLS 47.4MM NK TI POR -,SUP-425-11-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ13 148.5MM LNR PRFT LAT OFST CLLRLS 49.8MM NK TI -,SUP-425-11-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SYS PERSONA KNEE ASF UC 18MM PLY L-4-11 EF -,SUP-42-5112-005-18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PERSONA KNEE SYSTEM ARTICULAR SURFACE -,SUP-42-5112-006-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ C-D/3-9 10MM PERSONA CR ARTCSURF LT KN PE -,SUP-42-5120-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ C-D/3-9 11MM PERSONA CR ARTCSURF LT KN PE -,SUP-42-5120-004-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ C-D/3-9 12MM PERSONA CR ARTCSURF LT KN PE -,SUP-42-5120-004-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ E-F SZ3-11 FEM 10MM PERSONA ARTCSURF LT KN PE -,SUP-42-5120-005-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PSN ASF CR 12MM VE L 3-11EF -,SUP-42-5120-005-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PERSONA ARTICULAR SURFACE LEFT 11MM -,SUP-42-5121-007-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PSN MC VE ASF L 12MM 12/GH -,SUP-42-5121-010-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ C-D SZ3-7 FEM 12MM PERSONA CR ARTCSURF LT KN -,SUP-42-5122-004-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SURFACE ARTICULAR PERSONA VIVACIT-E 3-7 UC C-D 10MM KNEE LFT -,SUP-42512200410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PERSONA ARTICULAR FIXED BEARING LEFT 16MM -,SUP-42512200516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PERSONA ARTICULAR SURFACE 10MM -,SUP-42-5122-006-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
ARTICULAR SURFACE PERSONA LT 16MM -,SUP-42512600516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PSN ASF CPS 14MM VE L 6-9 GH -,SUP-42-5126-009-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PSN PK VE PLY- LM- SZ E- 8MM -,SUP-42-5182-005-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ7 PERSONA LT KN CR STD COCR POR -,SUP-42-5208-062-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PSN FEMORALASF UC 10MM POLY R 4-11 EF -,SUP-42-5212-00-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BEARING FIXED ASF UC 12MM PLY 3-7CD PERSONA -,SUP-42-5212-004-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BEARING FIXED ASF UC 12MM PLY R 4-11 EF PERSONA -,SUP-42-5212-005-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BEARING PSN ASF UC 10MM PLY R 7-12 GH -,SUP-42521200610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PSN ASF UC 12MM PLY R 7-12 GH -,SUP-42-5212-006-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ C-D SZ3-9 FEM 10MM PERSONA CR ARTCSURF RT KN -,SUP-42-5220-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ C-D/3-9 11MM PERSONA CR ARTCSURF RT KN PE -,SUP-42-5220-004-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ E-F/3-11 11MM PERSONA CR ARTCSURF RT KN PE -,SUP-42-5220-005-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SURFACE ARTICULAR 10MM HEIGHT RIGHT -,SUP-42-5221-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
ARTICULAR SURFACE PERSONA MC VE RT 13MM -,SUP-42522100513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
ARTICULAR SURFACE PERSONA MC RT 10MM -,SUP-42522100810,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
ARTICULAR SURFACE RIGHT 10MM /SIZES E-F/CR 8-11 -,SUP-42-5221-008-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
ARTICULAR SURFACE PERSONA MC RT 11MM -,SUP-42-5221-008-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SURFACE ARTICULAR PERSONA RIGHT 10MM X 12/GH MC VE ASF -,SUP-42-5221-010-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ C-D/3-7 10MM PERSONA ARTCSURF UL CONG RT KN PE -,SUP-42-5222-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ E-F 10MM PERSONA UL CONG ARTCSURF RT KN PE -,SUP-42-5222-005-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HIGHLY CROSSLINKED POLY ARTICULAR FIXED BEARING -,SUP-42-5222-005-18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
VIVICIT-E PERSONA ASF UC 11MM 7 - 12GH -,SUP-42-5222-006-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CD PERSONA ASF PS 16MM VE R 3-5 -,SUP-42522400416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL PSN ASF PS 13MM VE R 6-9 CD -,SUP-42-5224-005-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PSN ASF CPS 14MM VE R 3-5CD -,SUP-42-5226-004-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PERSONA HIGHLY CROSSLINKED POLY 6-9EF VE R -,SUP-42-5226-007-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PERSONA HIGHLY CROSSLINKED POLYETHLENE 6-9EF -,SUP-42-5226-007-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PSN REV CCK ART SURF VE 12MM R 7-9+ CD -,SUP-42522800512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIB SZ-C PERSONA PEGX2 LT KN POR TM -,SUP-42-5300-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIB SZ-D PERSONA PEGX2 RT KN POR TM -,SUP-42-5300-067-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PSN TIB POR 2 PEG SZ E L -,SUP-42-5300-071-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIB SZ-F PERSONA PEGX2 RT KN POR TM -,SUP-42-5300-075-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PSN TIB POR 2 PEG SZ G L -,SUP-42-5300-079-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PSN TIB POR 2 PEG SZ G R -,SUP-42530007902,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PSN TIB POR 2 PEG SZ H R -,SUP-42-5300-083-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TIB SZ-C 5DG PERSONA LT KN -,SUP-42-5320-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM PERSONA ASF 16MM VE 3-5 R CD -,SUP-42532006402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TIB SZ-C 5DG PERSONA RT KN -,SUP-42-5320-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TIB 5DG SZ-D PERSONA LT KN -,SUP-42-5320-067-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TIB SZ-D 5DG PERSONA RT KN -,SUP-42-5320-067-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TIB 5DG SZ-E PERSONA LT KN -,SUP-42-5320-071-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIA PERSONA CEMENTED STEMMED RT SZ E -,SUP-42532007102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
NAT TIBIA CEME 5 DG SIZE F -,SUP-42-5320-075-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TIB SZ-F 5DG PERSONA RT KN -,SUP-42-5320-075-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PSN PK CMT TIB- LM- SZ E -,SUP-42-5380-005-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT PATELLAR PERSONA ALL POLY PAT PLY 41MM -,SUP-42540000041,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
DIA ALL POLY PAT PERSONA  29MM -,SUP-42540200029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 29MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-29,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 32MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-32,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 35MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-35,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 41MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-41,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ8 SHRT TAPR FIL TI POR CTD P-SQUARED HIP -,SUP-425-41-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ15 SHRT TAPR FIL TI POR CTD P-SQUARED HIP -,SUP-425-41-015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
KEEL PSN REV TIB FIXED CMT SIZE C R -,SUP-42-5420-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11361.78,7953.246,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PSN REV TIB FIXED KEEL CMT SZ G L -,SUP-42-5420-079-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11361.78,7953.246,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUG PSN REV FEM DISTAL SZ 5 5MM -,SUP-42-5566-058-05,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5602.08,3921.456,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTENSION PERSONA CEMETED TPRD 14MM X +30MM -,SUP-42557000114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PSN PK CMT FEM- LM- SZ 3 -,SUP-42-5580-003-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PSN PK CMT FEM- RM SZ.4 -,SUP-42558000402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PSN REV TAPERED SMOOTH STEM EXT 14 X 75MM -,SUP-42-5600-075-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8199.41,5739.587,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM PSN REV 6MM OFFSET EXT 10MM X 135MM -,SUP-42-5606-135-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11584.56,8109.192,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMUR PSN CR CMT TIN NRW SIZE 6R -,SUP-42-5720-060-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT FEMORAL PERSONA 7 KNEE -,SUP-42572606201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT PSN FEMORAL TIN STD SIZE 9L -,SUP-42-5726-066-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ8 109MM TAPR FIL PRFT LAT OFST 37MM NK TI POR CTD -,SUP-425-96-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ8 109MM TAPR FIL PRFT LAT OFST 42.5MM NK TI POR -,SUP-425-97-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ9 111MM TAPR FIL PRFT LAT OFST 42.5MM NK TI POR -,SUP-425-97-009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ12 LRG TAPR FIL PRFT LAT OFST TI POR COAT -,SUP-425-97-012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ13 117MM TAPR FIL PRFT LAT OFST 42.5MM NK TI POR -,SUP-425-97-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 13MM STD BGLNI/FLTW 130MM -,SUP-4300-13-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5470.69,3829.483,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 46X21MM BGLNI/FLTW ZML MODULAR OFST -,SUP-4302-46-21,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 48MM POR STRUCTURED TECH HMSPHR -,SUP-430-98-048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM STAGEONE SLCT 56MM SIL MODULAR SPCR STRL -,SUP-431183,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5199.96,3639.972,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
ADAPTER STD STAGEONE CMNT MLD SPCR -,SUP-431186,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1636.53,1145.571,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HIP ADAPTER STD STAGEONE 6MM -,SUP-431188,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1428.48,999.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 15X155MM STG 1 HIP -,SUP-431193,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6510.3,4557.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HIP MOLD STEM W/REINF 13 X 200 -,SUP-431197,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6510.3,4557.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 12MM FNDTN CLLR FRG COCR CMNT 132DG ANG TAPR HIP -,SUP-450-01-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD RADL 26MM 10.5MM EVOLVE PROLINE COCR MODULAR -,SUP-496H026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7999.94,5599.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 28MM SHRT -3.5MM NK COCR MODULAR -,SUP-497-28-035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ-G 62MM RIM TRIDENT PRIM MODULAR HAP CTD -,SUP-500-01-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ-C 48MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-48C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ-D 50MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ-D 52MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-52D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ-E 54MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ-E 56MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-56E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ-F 58MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL SOLID BACK 60MM F -,SUP-500-03-60F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 48MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-5001-48,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ-C 46MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-01-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ-C 48MM RIM TRIDENT PRIM MODULAR CLUS-HL. -,SUP-502-03-48C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB 50MM TRIDENT PRIM MODULAR CLUS-HL X3 TRTNM LCK -,SUP-502-03-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ-D 52MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-03-52D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL HEMISPHERICAL 54MM SZ-E RIM CLUSTER HOLE -,SUP-502-03-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ-E 56MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-03-56E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ-D 50MM RIM TRIDENT PRIM.MODULAR CLUS-HL -,SUP-502-03-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ-F 60MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-03-60F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ-D 50MM RIM TRIDENT PRIM MODULAR.CLUS-HL -,SUP-502-11-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
ANATOMIC HEMISPHERICAL SHELL  56MM D RT -,SUP-504-02-56D-R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12514.18,8759.926,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEMISPHERICAL SHELL ANATOMIC RESTORATION -,SUP-504-02-58D-L,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12514.18,8759.926,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEMISPHERICAL SHELL 64MM -,SUP-504-02-64E-R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12514.18,8759.926,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT HUM 4MM 32MM STD PE RVRS SCKT F/RSP STRL -,SUP-508-00-432,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4559.17,3191.419,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL TRIDENT HEMISPHERICAL ACETABULAR 46MM C -,SUP-508-11-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL HEMI ACETABULAR 48MM -,SUP-508-11-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ-D 50MM RIM TRIDENT PRIM MODULAR MUL-HL -,SUP-508-11-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
ACETABULAR SHELL 52MM -,SUP-508-11-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ-E 54MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL HEMISPHERICAL 56MM E TRI -,SUP-509-02-56E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ-F 58MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ-F 60MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-60F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ-G 62MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ-G 64MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-64G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ H LINER 66MM RIM TRIDENT REVISN MUL-HL -,SUP-509-02-66H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ H LINER 68MM RIM TRIDENT REVISN MUL-HL -,SUP-509-02-68H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIDENT TRITANIUM HEMI SHELL SZ 70MM -,SUP-509-02-70I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT ACTB 50MM RESTOR REVISN RECON HIP 15MM -,SUP-5096-5015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT ACTB 50MM RESTOR REVISN RECON HIP 20MM -,SUP-5096-5020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
WEDGE AUGMENT RESTORATION ACET 54MM X 56MM X 15MM -,SUP-5096-5415,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT ACTB 58MM RESTOR REVISN RECON HIP -,SUP-5096-5815,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 6MM PRIM MBLK RVRS RSP 101MM CMNT 150DG ANG NK CYL -,SUP-510-00-006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19030.28,13321.196,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TPRLC 133 FP TYPE 1 PPS SO 5.0 -,SUP-51-100050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TPRLC 133 FP TYPE 1 PPS SO 6.0 -,SUP-51-100060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TPRLC 133 FP TYPE1 PPS SO 7.0 -,SUP-51-100070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TPRLC 133 FP TYPE1 PPS SO 8.0 -,SUP-51-100080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEMORAL TPRLC 133 FP PPS TYPE 1  6.0 H -,SUP-51-101060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TPRLC 133 FP PPS TYPE 1 HO 7.0 -,SUP-51-101070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TPRLC 133 FP PPS TYPE 1 HO 8.0 -,SUP-51-101080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TPRLC XR FP TYPE 1 PPS 5 X 130MM -,SUP-51-102050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TPRLC XR FP TYPE 1 PPS 6 X 132MM -,SUP-51-102060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TPRLC XR FP TYPE 1 PPS 8 X 136MM -,SUP-51-102080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TPRLC 133 TYPE 1 PPS SO 9 X 137MM -,SUP-51-103090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TPRLC 133 TYPE 1 PPS SO 10 X 140MM -,SUP-51-103100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TPRLC 133 TYPE 1 PPS SO 11 X 142MM -,SUP-51-103110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TPRLC 133 T1 PPS SO 12 X 144MM -,SUP-51-103120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TPRLC 133 T1 PPS SO 13 X 146MM -,SUP-51-103130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TPRLC 133 T1 PPS SO 14 X 148MM -,SUP-51-103140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TPRLC 133 TYPE 1 PPS SO 15 X 150MM -,SUP-51-103150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TAPERLOC 133 T1 9 X 137MM -,SUP-51-104090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TPRLC 133 T1 PPS 11 X 142MM -,SUP-51-104110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TPRLC 133 T1 PPS HO 13 X 146MM -,SUP-51-104130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TPRLC TYPE 1 PPS HO 14 X 148MM FEM POR -,SUP-51-104140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TPRLC TYPE 1 PPS HO 15 X 150MM FEM POR -,SUP-51-104150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TPRLC 133 TYPE 1 PPS HO 16 X 152MM -,SUP-51-104160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TAPERLOC 133 T1 PPS HO 20 X 160MM -,SUP-51-104200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TAPERLOC 10 X 140MM COMP XR FEM POR T1 TAPER -,SUP-51-105100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TAPERLOC 11 X 142MM COMP XR 123 FEM POR T1 TAPER -,SUP-51-105110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TPRLC 133 MP TYPE 1 PPS SO 11.0 -,SUP-51-106110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TPRLC 133 MP TYPE1 PPS HO 9.0 -,SUP-51-107090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TPRLC 133 MP TYPE1 PPS HO 14.0 -,SUP-51-107140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TPRLC 133 MP TYPE1 PPS HO 16.0 -,SUP-51-107160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TPRLC 133 MP TYPE1 PPS HO 17.0 -,SUP-51-107170,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TPRL 133 MP TYPE1 PPS SO 4.0 -,SUP-51-108040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TPRLC 133 MP T1 PPS SO 5X95MM -,SUP-51-108050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TPRLC133 MP 6X97.5MM -,SUP-51-108060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TPRLC 133 MP T1 PPS SO 8X101MM -,SUP-51-108080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TLOC 133 MP SP T1 PPSHO 6X97.5 -,SUP-51-109060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TLOC 133 MP SP T1 PPS HO 8X101 -,SUP-51-109080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM S-ROM 28MMSTDX+6MM NK COCR 11/13 TAPR MODULAR -,SUP-52-2029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4824.58,3377.206,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SCREW 2.3X12MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23212E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 45X15MM -,SUP-5350-4515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6472.1,4530.47,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 12MM SOLAR 130MM TI SHLDR -,SUP-5351-4108,CDM,C1776,HCPCS,278,RC,,,outpatient,,,33064.27,23144.989,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 40X15MM OFST -,SUP-5352-4015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6472.1,4530.47,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACTB SZ-D 46MM 47.8MM RIM TRIDENT PSL PRIM MODULAR HAP -,SUP-540-11-46D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ1 TRIATH LT KN CR CMNT -,SUP-5510-F-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ1 TRIATH RT KN CR CMNT -,SUP-5510-F-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ2 TRIATH LT KN CR CMNT -,SUP-5510-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ2 TRIATH RT KN CR CMNT -,SUP-5510-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ3 TRIATH LT KN CR CMNT -,SUP-5510-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ3 TRIATH RT KN CR CMNT -,SUP-5510-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ4 TRIATH LT KN CR CMNT -,SUP-5510-F-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ4 TRIATH RT KN CR CMNT -,SUP-5510-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 TRIATH LT KN CR CMNT -,SUP-5510-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 TRIATH RT KN CR CMNT -,SUP-5510-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ6 TRIATH LT KN CR CMNT -,SUP-5510-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ6 TRIATH RT KN CR CMNT -,SUP-5510-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ7 TRIATH LT KN CR CMNT -,SUP-5510-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ7 TRIATH RT KN CR CMNT -,SUP-5510-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ8 TRIATH LT KN CR CMNT -,SUP-5510-F-801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ1 59/53MM TRIATH RT KN TOTAL STABILIZED REVISN -,SUP-5512-F-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ2 62/56MM TRIATH LT KN TOTAL STABILIZED REVISN -,SUP-5512-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT FEMORAL TOTAL STABILIZER #2 RT TS -,SUP-5512-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ3 65/59MM TRIATH LT KN CRCTE STAB REVISN COCR -,SUP-5512-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ3 65/59MM TRIATH RT KN CRCTE STAB REVISN COCR -,SUP-5512-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ4 68/62MM TRIATH LT KN CRCTE STAB REVISN COCR -,SUP-5512-F-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ4 68/62MM TRIATH RT KN CRCTE STAB REVISN COCR -,SUP-5512-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 71/65MM TRIATH LT KN CRCTE STAB REVISN COCR -,SUP-5512-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 71/65MM TRIATH RT KN CRCTE STAB REVISN COCR -,SUP-5512-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ6 74/68MM TRIATH LT KN TOTAL STABILIZED REVISN -,SUP-5512-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TOTAL STABILIZER COMPONET FEMORAL -,SUP-5512-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ7 77/71MM TRIATH LT KN TOTAL STABILIZED REVISN -,SUP-5512-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STABILIZER TOTAL FEM COMP SZ 7 RIGHT TS TRIATHLON -,SUP-5512-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ8 80/75MM TRIATH RT KN TOTAL STABILIZED REVISN -,SUP-5512-F-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ1 TRIATH LT KN PS CMNT -,SUP-5515-F-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ2 TRIATH LT KN PS CMNT -,SUP-5515-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ2 TRIATH RT KN PS CMNT -,SUP-5515-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ3 TRIATH LT KN PS CMNT -,SUP-5515-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ3 TRIATH RT KN PS CMNT -,SUP-5515-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ4 TRIATH RT KN PS CMNT -,SUP-5515-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 TRIATH LT KN PS CMNT -,SUP-5515-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 TRIATH RT KN PS CMNT -,SUP-5515-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ6 TRIATH LT KN PS CMNT -,SUP-5515-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ6 TRIATH RT KN PS CMNT -,SUP-5515-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ7 TRIATH LT KN PS CMNT -,SUP-5515-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ7 TRIATH RT KN PS CMNT -,SUP-5515-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIATHLON PS FEM COMP SZ 8 CEMENTED -,SUP-5515-F-801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ8 TRIATH RT KN PS CMNT -,SUP-5515-F-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
POSTERIOR STABILIZED FEMORAL -,SUP-5516-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIATHLON CRUCLATE RETAINING FEMORAL SZ #1 LEFT CR -,SUP-5517-F-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIATHLON CRUCLATE RETAINING FEMORAL SZ #1 RIGHT CR -,SUP-5517-F-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIATHLON CR FEM COMPONENT - BEADED W/PA -,SUP-5517-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ2 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ3 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ3 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ4 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ4 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ6 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ6 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ7 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ7 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ8 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIATHLON CRUCIATE RETAINING FEMORAL -,SUP-5517-F-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ1 KN CMNT TRIATH PRIM -,SUP-5520-B-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ2 KN CMNT TRIATH PRIM -,SUP-5520-B-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ3 KN CMNT TRIATH PRIM -,SUP-5520-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ4 KN CMNT TRIATH PRIM -,SUP-5520-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ5 KN CMNT TRIATH PRIM -,SUP-5520-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ6 KN CMNT TRIATH PRIM -,SUP-5520-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ7 KN CMNT TRIATH PRIM -,SUP-5520-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ8 KN CMNT TRIATH PRIM -,SUP-5520-B-800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ1 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ2 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ3 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL BASEPLATE TRIATHLON UNIV SIZE 4 -,SUP-5521-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ5 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ6 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ7 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ8 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ3 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ4 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ5 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ6 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ7 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ1 9MM TRIATH CR ARTC KN X3 -,SUP-5530-G-109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ1 11MM TRIATH CR ARTC KN X3 -,SUP-5530-G-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ1 13MM TRIATH CR ARTC KN X3 -,SUP-5530-G-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ1 16MM TRIATH CR ARTC KN X3 -,SUP-5530-G-116,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ1 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-119,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL BEARING INSERT CR SZ2 9MM -,SUP-5530-G-209-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ2 13MM TRIATH CR ARTC KN X3 -,SUP-5530-G-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ2 16MM TRIATH CR ARTC KN X3 -,SUP-5530-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ2 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL BEARING SZ 3 X 10MM CR X3 TRIATHLON -,SUP-5530-G-310-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL BEARING CR SZ4 9MM -,SUP-5530-G-409-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL BEARING CR SZ4 10MM TRIATHLON X3 -,SUP-5530-G-410-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL BEARING INSERT CR SZ4 11MM -,SUP-5530-G-411-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ4 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5 10MM TRIATH CR ARTCSURF KN X3 UHMWPE -,SUP-5530-G-510-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-519,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL BEARING SZ6 10MM TRIATH X3 CR -,SUP-5530-G-610-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ6 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBAL BEARING CR SZ 7 X 9MM TRIATHLON X3 -,SUP-5530-G-709-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBAL BEARING CR SZ 7 X 10MM TRIATHLON X3 -,SUP-5530-G-710-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ7 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ8 13MM TRIATH CR ARTC KN X3 -,SUP-5530-G-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ8 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-819,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIATHALON INSERT CS #1 12MM X3 -,SUP-5531-G-112-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ2 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-209-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL BEARING CS SZ 2 X 10MM TRIATHLON X3 -,SUP-5531-G-210-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ2 11MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT BEARING TIBIAL CS SIZE 2 X 11MM TRIATHLON X3 -,SUP-5531-G-211-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL BEARING CS SZ 2 X 12MM TRIATHLON X3 -,SUP-5531-G-212-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ2 13MM TRIATH CS BEAR KN X3 -,SUP-5531-G-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TRIATHLON X3 TIBIAL BEARING SIZE 2 X 13MM CS -,SUP-5531-G-213-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ2 16MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-309-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 11MM TRIATH CS BEAR KN X3 -,SUP-5531-G-311-A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL BEARING INSERT  SZ.3 / CS / 12MM -,SUP-5531-G-312-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 13MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL BEARING CS SIZE 3 X 13MM TRIATHLON X3 -,SUP-5531-G-313-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 16MM TRIATH CS ARTCSURF KN X3 UHMWPE -,SUP-5531-G-316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 19MM TRIATH ARTCSURF KN X3 UHMWPE -,SUP-5531-G-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ4 9MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-409-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ4 11MM TRIATH CS BEAR X3 -,SUP-5531-G-411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ4 11MM TRIATH CS BEAR KN X3 -,SUP-5531-G-411-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ4 13MM TRIATH CS BEAR KN X3 -,SUP-5531-G-413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT BEARING TIBIAL CS SIZE 4 X 13MM TRIATHLON X3 -,SUP-5531-G-413-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ4 16MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ4 19MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL BEARING SZ 5 CS 9MM TRIATHLON X3 -,SUP-5531-G-509-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL BEARING INSERT  SZ. 5 / 10MM -,SUP-5531-G-510-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5 11MM TRIATH CS BEAR KN X3 -,SUP-5531-G-511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TRIATHLON X3 TIBIAL BEARING CS -,SUP-5531-G-512-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5 13MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
X3 TRIATHILON CS INS SIZE 5 13MM -,SUP-5531-G-513-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5 16MM TRIATH CS BEAR KN X3 -,SUP-5531-G-516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL BEARING CS SIZE 5 X 19MM TRIATHLON X3 -,SUP-5531-G-519-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ6 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-609-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ6 11MM TRIATH CONDL STAB BEAR KN -,SUP-5531-G-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ6 11MM TRIATH CONDL STAB BEAR CS X3 -,SUP-5531-G-611-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ6 13MM TRIATH CS BEAR KN X3 -,SUP-5531-G-613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ6 13MM TRIATH X3 CS BEAR X3 -,SUP-5531-G-613-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ6 16MM TRIATH ARTCSURF KN X3 UHMWPE -,SUP-5531-G-616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ6 19MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ7 9MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-709-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ7 11MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ7 13MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-713,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ7 16MM TRIATH CS BEAR KN X3 -,SUP-5531-G-716,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL TRIATHLON X3 SZ 7 16MM BEARING INSERT-CS -,SUP-5531-G-716-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ8 9MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIATHLON TIBIAL BEARING INSERT - CS SZ8 11MM -,SUP-5531-G-811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ1 13MM TRIATH PS ARTC KN X3 -,SUP-5532-G-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ2 9MM TRIATH PS ARTC KN X3 -,SUP-5532-G-209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIATHLON PS X3 TIBIAL INSERT -,SUP-5532-G-209-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ2 11MM TRIATH PS ARTCSURF KN X3 UHMWPE -,SUP-5532-G-211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB H TRTHLN PS 2-13MM -,SUP-5532-G-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ2 16MM TRIATH PS ARTC KN X3 -,SUP-5532-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ2 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL BEARING PS SZ 3 X 16MM TRIATHLON X3 -,SUP-5532-G-316-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL BEARING PS SZ 4 X 11MM TRIATHLON X3 -,SUP-5532-G-411-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ4 16MM TRIATH PS ARTCSURF KN X3 UHMWPE -,SUP-5532-G-416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ4 19MM TRIATH PS ARTC KN X3 -,SUP-5532-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ4 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5 22MM TRIATH PS ARTC KN X3 -,SUP-5532-G-522,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-525,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL BEARING INSERT TRI - PS SZ.6 / 9MM -,SUP-5532-G-609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ6 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-625,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ7 9MM TRIATH PS ARTC KN X3 -,SUP-5532-G-709,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ7 16MM TRIATH PS ARTC KN X3 -,SUP-5532-G-716,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL BEARING / SZ. 7  / 19MM -,SUP-5532-G-719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ7 22MM TRIATH PS ARTC KN X3 -,SUP-5532-G-722,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ7 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-725,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ8 9MM TRIATH PS ARTC KN X3 -,SUP-5532-G-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIATHLON PS X3 TIBIAL INSERT SZ 8 -,SUP-5532-G-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT TIBIAL SIZE 2 X 16MM PS TRIATHLON ALL POLY -,SUP-5535-A-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT TIBIAL SIZE 5 X 9MM PS TRIATHLON ALL POLY -,SUP-5535-A-509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT TRIATHLON ALL POLY TIBIAL PS SIZE 5 13MM -,SUP-5535-A-513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT TRIATHLON ALL POLY TIBIAL PS SIZE 6 16MM -,SUP-5535-A-616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL COMPONENT TRITANIUM #2 -,SUP-5536-B-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ3 KN TRIATH TRTNM -,SUP-5536-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ4 KN TRIATH TRTNM -,SUP-5536-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ5 KN TRIATH TRTNM -,SUP-5536-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ6 KN TRIATH TRTNM -,SUP-5536-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ7 KN TRIATH TRTNM -,SUP-5536-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIATHLON TIBIAL COMPONENT -,SUP-5536-B-800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ1 19MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-119,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ2 11MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ2 10MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT TOTAL STABILIZER #2 19MM TS -,SUP-5537-G-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ2 22MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
NO 3 TRIATHLON TS PLUS TIBIAL INSERT X3 POLY -,SUP-5537-G-309-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 19MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 22MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 25MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TOTAL STABILIZER+ TIBIAL INSERT -,SUP-5537-G-409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL TOTAL STABILIZER + SIZE 4 X 9MM TS TRIATH X3 -,SUP-5537-G-409-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT TRIATHLON X3 TOTAL STABILIZER SIZE F 11MM TS -,SUP-5537-G-411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ4 13MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ4 16MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
NO 4 TRIATHLON TS PLUS TIBIAL INSERT X3 POLY 16MM -,SUP-5537-G-416-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ4 19MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ4 22MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ4 25MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ4 28MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL TOTAL STAB SIZE 5 X 16MM TS TRIATHLON X3 -,SUP-5537-G-516-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL TOTAL STABILIZER+ SIZE 5 X 19MM TRIATHLON X3 -,SUP-5537-G-519-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5 22MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-522,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5 28MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-528,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5 31MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-531,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ6 9MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ6 11MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ6 16MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ6 19MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ6 25MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-625,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TOTAL STABILIZER TIBIAL INSERT SZ7 -,SUP-5537-G-711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ7 16MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-716,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ8 22MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-822,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT RT DIST KN SZ1 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT LT DIST KN SZ2 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL DISTAL AUGMENT - RIGHT -,SUP-5540-A-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT LT DIST KN SZ4 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT RT DIST KN SZ4 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL DISTAL AUGMENT - RIGHT -,SUP-5540-A-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT RT DIST KN SZ8 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL DISTAL AUGMENT RIGHT #2 10MM -,SUP-5541-A-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT FEMORAL DISTAL LEFT TRIATHLON SIZE 3 10MM -,SUP-5541-A-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT LT DIST KN SZ4 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5541-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT LT DIST KN SZ5 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5541-A-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT FEMORAL DISTAL RIGHT SZ 7 X 10MM TRIATHLON -,SUP-5541-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT FEMORAL DISTAL RIGHT SZ 7 X 5MM TRIATHLON -,SUP-5541-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIATHLON FEMORAL DISTAL SUGMENT 15MM SIZE 4 LEFT -,SUP-5542-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4581.78,3207.246,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT FEMORAL DISTAL RIGHT SZ 7 X 15MM TRIATHLON -,SUP-5542-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4581.78,3207.246,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP SZ48 7MM REUNION ALLOGRAFT SHOLUDER PG -,SUP-5542-P-0048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP SZ56 7MM REUNION ALLOGRAFT SHOLUDER PG -,SUP-5542-P-0056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT POST KN SZ1 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT POST KN SZ2 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT POST KN SZ3 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT POST KN SZ4 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT POST KN SZ5 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT POST KN SZ6 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT POST KN SZ7 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT POST KN SZ2 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT POST KN SZ3 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT POST KN SZ4 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT POST KN SZ5 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT POST KN SZ6 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HALF BLOCK TIBIAL AUGMENT SIZE 3 X 5MM TRIATHLON -,SUP-5545-A-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT RM/LL KN SZ3 TRIATH 5MM BLCK TOTAL STABILIZED AUG -,SUP-5545-A-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT LMRL KN SZ7 TRIATH 5MM BLCK TOTAL STABILIZED AUG -,SUP-5545-A-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT RM/LL KN SZ7 TRIATH 5MM BLCK TOTAL STABILIZED AUG -,SUP-5545-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT LMRL KN SZ1 TRIATH 10MM BLCK TOTAL STABILIZED AUG -,SUP-5546-A-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT RM/LL KN SZ1 TRIATH 10MM BLCK TOTAL STABILIZED AUG -,SUP-5546-A-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL AUGMENT HALF BLOCK -,SUP-5546-A-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL AUGMENT HALF BLOCK - 10MM -,SUP-5546-A-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT LMRL KN SZ3 TRIATH 10MM HLF BLCK TOTAL STABILIZED -,SUP-5546-A-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL AUGMENT HALF BLOCK / SZ.3 -,SUP-5546-A-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT LMRL KN SZ4 TRIATH 10MM HLF BLCK TOTAL STABILIZED -,SUP-5546-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT RM/LL KN SZ4 TRIATH 10MM HLF BLCK TOTAL STABILIZED -,SUP-5546-A-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL SYMMETRIC CONE AUGMENT SIZE A -,SUP-5549-A-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13500.17,9450.119,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL SYMMETRIC CONE AUGMENT -,SUP-5549-A-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13500.17,9450.119,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL SYMMETRIC CONE AUGMENT SIZE C -,SUP-5549-A-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13500.17,9450.119,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL CONE AUGMENT SZ 1&2 RT -,SUP-5549-A-322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15374.42,10762.094,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIATH TRITNUM CNTRLFEMCONE AUG SZ 3&4 LEFT -,SUP-5549-A-641,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15375.53,10762.871,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIATH TRITNUM CNTRLFEMCONE AUG SZ 3 & 4 RIGHT -,SUP-5549-A-642,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15375.53,10762.871,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT CENTRAL FEM CONE SZ 7&8 RIGHT TRIATHLON -,SUP-5549-A-672,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15375.53,10762.871,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PATELLA SYMMETRIC SZ S27MM X 8MM TRIATHLON X3 -,SUP-5550-G-278-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIATHLON SYMMETRIC X3 PATELLA -,SUP-5550-G-298-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIATHLON X3 SYMMETRIC PATELLA 31MM 9MM -,SUP-5550-G-319-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 33X9MM THK X3 TRIATH PRIM SYM -,SUP-5550-G-339,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 39X11MM THK X3 TRIATH PRIM SYM -,SUP-5550-G-391,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 29X9MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-299-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 32X10MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-320-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 35X10MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-350-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 38X11MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-381-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SINGLE RADIUS HUMERAL HEAD SIZE 44 19MM -,SUP-5552-E-4419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13563.59,9494.513,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 4MM OFST 52X17 REUNION -,SUP-5552-E-5217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 29X9MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-299,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 32X10MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 35X10MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-350,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 38X11MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-381,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PATELLA ASYMMETRIC A40/11MM -,SUP-5552-L-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 56MM STD REUNION SGL RAD -,SUP-5552-S-5622,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 32X10MM THK X3 PERIAPATITE TRIATH ASYM MTL BK -,SUP-5554-L-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 35X10MM THK X3 PERIAPATITE TRIATH ASYM MTL BK -,SUP-5554-L-350,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 38X11MM THK X3 PERIAPATITE ASYM BEADX3 MTL BK -,SUP-5554L381,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 40X11MM THK X3 PERIAPATITE ASYM BEADX3 MTL BK -,SUP-5554L401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND SZ1 12MM TRIATH TOTAL STABILIZED 50MM COCR FEM -,SUP-5560-S-112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TOTAL KNEE 9MM X 100MM -,SUP-5560-S-209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND SZ2 12MM TRIATH TOTAL STABILIZED 100MM COCR FEM -,SUP-5560-S-212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND SZ2 15MM TRIATH TOTAL STABILIZED 50MM COCR FEM -,SUP-5560-S-215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND SZ3 12MM TRIATH TOTAL STABILIZED 50MM COCR FEM -,SUP-5560-S-312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 10MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 11MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 12MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 13MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 14MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 15MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 16MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 17MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FLUTED STEM 18MM / 100MM / TS -,SUP-5565-S-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 18MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 19MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 20MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 21MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 22MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 13MM TRIATH PRFT REVISN TOTAL STABILIZED 150MM -,SUP-5566-S-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4789.23,3352.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FLUTED STEM 14MM / 150MM / TS -,SUP-5566-S-014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4789.23,3352.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HUMERAL FRATURE STEM 7 X 113 -,SUP-5568-0007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,32158.29,22510.803,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
REUNION RFX-HUMERAL FRACTURE STEM 9MM -,SUP-5568-0009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,31160.68,21812.476,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUMERAL FRACTURE 11MM X 123MM REUNION RFX -,SUP-5568-0011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,33766.02,23636.214,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HUMERAL CUP 36MM DIA X 4MM THK -,SUP-5570-3604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16968.41,11877.887,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
ADAPTER FEM 2MM OFST TRIATH RECON KN REVISN TOTAL STABILIZED -,SUP-5570-S-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4348.4,3043.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
ADAPTER FEM 4MM OFST TRIATH RECON KN REVISN TOTAL STABILIZED -,SUP-5570-S-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4348.4,3043.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
ADAPTER FEM 6MM OFST TRIATH RECON KN REVISN TOTAL STABILIZED -,SUP-5570-S-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4348.4,3043.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
EXTENDER STEM TRIATHLON 25MM LENGTH -,SUP-5571-S-025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4512.24,3158.568,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
X3 HUMERAL INSERT 36MM X 4MM STANDARD -,SUP-5571-S-3604-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13571.02,9499.714,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE 28MM X 10.05MM -,SUP-5572-2802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18676.39,13073.473,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
GLENOSPHERE 36MM DIA X 2MM THK CONCENTRIC -,SUP-5573-C-3602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16968.41,11877.887,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ2 TRIATH LMRL KN UNICMPT PRIM PRT RSRFC COCR -,SUP-5610-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ2 TRIATH RM/LL KN UNICMPT PRIM PRT RSRFC COCR -,SUP-5610-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL REVISION LEFT SZ 2 NON-POROUS -,SUP-561-1201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ3 BAL KN MODULAR REVISN RT KN -,SUP-561-1302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ4 BAL KN MODULAR REVISN LT KN -,SUP-561-1401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ4 BAL KN RT KN MODULAR REVISN SYS -,SUP-561-1402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 BAL KN LT KN MODULAR REVISN SYS -,SUP-561-1501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 BAL KN RT KN MODULAR REVISN SYS -,SUP-561-1502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ6 BAL KN LT KN MODULAR REVISN SYS -,SUP-561-1601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
MODULAR FEMORAL LEFT SIZE 7 -,SUP-561-1701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
MODULAR FEMORAL SIZE 7 -,SUP-561-1702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ3 27/47MM LMRL KN TRIATH COCR PRIM REVISN -,SUP-5620-B-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ3 27/47MM RM/LL KN TRIATH COCR PRIM REVISN -,SUP-5620-B-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ2 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRAY TIBIAL REVISION SZ 2 NEUTRAL NON-POROUS -,SUP-562-1200A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ3 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL TRAY REVISION SZ 3 NEUTRAL NON-POROUS -,SUP-562-1300A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ4 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL TRAY REVISION SZ 4 NEUTRAL NON-POROUS -,SUP-562-1400A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ5 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL TRAY REVISION SZ 5 NEUTRAL NON-POROUS -,SUP-562-1500A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ6 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL TRAY SLOPED SIZE 5 MODULAR -,SUP-562-2500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9431.02,6601.714,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CONE TIBIAL CENTRAL 31MM -,SUP-562-7031,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12705.89,8894.123,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CONE TIBIAL CENTRAL 34MM -,SUP-562-7034,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12705.89,8894.123,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CONE TIBIAL CENTRAL 36MM -,SUP-562-7036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12705.89,8894.123,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CONE TIBIAL 25MM M-L 35MM A-P -,SUP-562-7135,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12223.2,8556.24,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CONE TIBIAL LARGE 47MM M/L 31MM A/P -,SUP-562-7247,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15108.2,10575.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 8MM TRIATH BEAR LMRL KN X3 UHMWPE -,SUP-5630-G-308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 8MM TRIATH BEAR RM/LL KN X3 UHMWPE -,SUP-5630-G-328,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 8MM CNSTRN -,SUP-563-1308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 10MM CNSTRN -,SUP-563-1310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 12MM CNSTRN -,SUP-563-1312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 14MM CNSTRN -,SUP-563-1314,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 16MM CNSTRN -,SUP-563-1316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 18MM CNSTRN -,SUP-563-1318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 20MM CNSTRN -,SUP-563-1320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SROM*ST XL 36+8LINK 18 X 13 X 255L -,SUP-563138L,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27357.55,19150.285,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL CK SZ 4 8MM -,SUP-563-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT CK SIZE 4 18MM -,SUP-563-1418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT CK SIZE 4 24MM -,SUP-563-1424,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5 8MM CNSTRN -,SUP-563-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5 10MM CNSTRN -,SUP-563-1510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5 12MM CNSTRN -,SUP-563-1512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT CK SIZE 6 8MM -,SUP-563-1608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ6 10MM CNSTRN -,SUP-563-1610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT CK SIZE 6 14MM -,SUP-563-1614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SZ 2 10MM -,SUP-563-2210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SZ 2 12MM -,SUP-563-2212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL REVISION CK SZ 2 14MM -,SUP-563-2214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SZ 2 18MM -,SUP-563-2218,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SZ 2 20MM -,SUP-563-2220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SZ 2 22MM -,SUP-563-2222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SZ 3 8MM -,SUP-563-2308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SZ 3 12MM -,SUP-563-2312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SZ 3 14MM -,SUP-563-2314,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SZ 3 18MM -,SUP-563-2318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL REV CK SZ 3 20MM -,SUP-563-2320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SZ 3 24MM -,SUP-563-2324,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SZ 4 8MM -,SUP-563-2408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SZ 4 10MM -,SUP-563-2410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SZ 4 12MM -,SUP-563-2412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SZ 4 14MM -,SUP-563-2414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SZ 4 16MM -,SUP-563-2416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SZ 4 18MM -,SUP-563-2418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SZ 4 22MM -,SUP-563-2422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SZ 5 10MM -,SUP-563-2510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SZ 5 12MM -,SUP-563-2512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SZ5 14MM -,SUP-563-2514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SZ 5 16MM -,SUP-563-2516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL REVISION CK SZ 6.8MM -,SUP-563-2608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT REVISION CK SIZE 6 14MM -,SUP-563-2614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM 12MM X 50MM CEMENTED -,SUP-565-1205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM 12 X 80 CEMENTED -,SUP-565-1208,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXT CEMENTED 12MM X 110MM -,SUP-565-1211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTENSION CEMENTED 14MM X 30MM -,SUP-565-1403,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4481.66,3137.162,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM 14MM X 50MM CEMENTED -,SUP-565-1405,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 14MM BAL KN 80MM CMNT -,SUP-565-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4481.66,3137.162,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 10MM BAL KN 80MM FEM/TBL -,SUP-566-1008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM 10 X 150MM EXT FLUTED -,SUP-566-1015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 12MM BAL KN 80MM FEM/TBL -,SUP-566-1208,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 13MM BAL KN 80MM FEM/TBL -,SUP-566-1308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 13MM BAL KN 150MM FEM/TBL -,SUP-566-1315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 14MM BAL KN 80MM FEM/TBL -,SUP-566-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTENSION FLUTED 14 X 110 -,SUP-566-1411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 15MM BAL KN 80MM FEM/TBL -,SUP-566-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 16MM BAL KN 80MM FEM/TBL -,SUP-566-1608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 17MM BAL KN 80MM FEM/TBL -,SUP-566-1708,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTENSION FLUTED 17MM X 110MM -,SUP-566-1711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 18MM BAL KN 80MM FEM/TBL -,SUP-566-1808,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM 18MM X 110MM FLUTED -,SUP-566-1811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 20MM BAL KN 80MM FEM/TBL -,SUP-566-2008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTENSION FLUTED 20 X 110 -,SUP-566-2011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTENSION FLUTED 24 X 80MM -,SUP-566-2408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTENSION FLUTED 24 X 110MM -,SUP-566-2411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT RM/LL KN SZ3 BAL KN 5MM BLCK REVISN -,SUP-567-5103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL AUGMENT BLOCK 5MM RT LAT LT MED SIZE 4 -,SUP-567-5104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT RM/LL KN SZ3 BAL KN BLCK REVISN -,SUP-567-5203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL AUGMENT SZ 3 15MM BLOCK LT LATERAL RT MEDIAL -,SUP-567-7203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT DIST KN SZ3 BAL KN 4MM REVISN -,SUP-568-1304,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL AUGMENT DISTAL SIZE 3 8MM -,SUP-568-1308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT DIST KN SZ4 BAL KN 4MM REVISN -,SUP-568-1404,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT FEMORAL SZ 4 4MM DISTAL -,SUP-568-1404A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT DIST KN SZ4 BAL KN 8MM REVISN -,SUP-568-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL AUGMENT SZ 4 8MM DISTAL -,SUP-568-1408A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT DIST KN SZ5 BAL KN 4MM REVISN -,SUP-568-1504,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL AUGMENT SZ 5 4MM DISTAL -,SUP-568-1504A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL AUGMENT DISTA SIZE 5 8MM -,SUP-568-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL AUGMENT DISTAL 12MM -,SUP-568-1512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT DISTAL 4MM SIZE 6 -,SUP-568-1604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL AUGMENT SZ 6 8MM DISTAL -,SUP-568-1608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT POST KN SZ4 BAL KN 4MM REVISN -,SUP-568-2404,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FERMORAL AUGMENT POSTERIOR 4MM SIZE 6 -,SUP-568-2604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 14MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-5988-10-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4394.75,3076.325,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 14MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-5988-10-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
EXTENSION STM 15X30MM -,SUP-5988-12-15,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4394.75,3076.325,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ0 33MM OFST 86MM ACCOLADE PRFT STD OFST 30MM NK -,SUP-6020-0030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ1 34MM OFST 110MM RECON ACCOLADE PRFT PRIM STD -,SUP-6020-0130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ2 35MM OFST 115MM ACCOLADE PRFT STD OFST 30MM NK -,SUP-6020-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ3 39MM OFST 120MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-0335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ4 40MM OFST 125MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ5 44MM OFST 130MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-0537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ2.5 36MM OFST 118MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-2530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ3.5 39MM OFST 124MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-3535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ4.5 41MM OFST 129MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-4535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ5.5 45MM OFST 133MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-5537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ0 +0MM 37MM OFST 86MM ACCOLADE PRFT EXTEND OFST -,SUP-6021-0030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ1 +0MM 38MM OFST 110MM ACCOLADE PRFT EXTEND OFST -,SUP-6021-0130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ2 39MM OFST 115MM ACCOLADE PRFT PRIM EXTEND OFST -,SUP-6021-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ3 43MM OFST 120MM ACCOLADE RECON PRFT PRIM HI -,SUP-6021-0335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ4 44MM OFST 125MM ACCOLADE RECON PRFT PRIM HI -,SUP-6021-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ5 48MM OFST 130MM ACCOLADE RECON PRFT PRIM EXTEND -,SUP-6021-0537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ2.5 40MM OFST 118MM ACCOLADE RECON PRFT PRIM -,SUP-6021-2530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ3.5 124MM RECON ACCOLADE PRFT PRIM EXTEND OFST -,SUP-6021-3535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ4.5 45MM OFST 130MM ACCOLADE RECON PRFT PRIM -,SUP-6021-4535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ5.5 49MM OFST 133MM ACCOLADE PRFT EXTEND OFST -,SUP-6021-5537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ4 OMNIFIT PRIM CLLR CMNT MDL CLCR HIP -,SUP-6034-0425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ6 30MM OFST 132MM SECUR-FIT PRFT PRIM 25MM -,SUP-6051-0625S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ7 35.1MM OFST 132MM SECUR-FIT MAX PRFT PRIM 30MM -,SUP-6051-0730S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ8 132MM RECON SECUR-FIT MAX PRFT PRIM TI HAP CTD -,SUP-6051-0830S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ9 40.8MM OFST 132MM SECUR-FIT MAX PRFT PRIM 35MM -,SUP-6051-0935S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ10 132MM RECON SECUR-FIT MAX PRFT PRIM TI HAP CTD -,SUP-6051-1035S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ11 132MM RECON SECUR-FIT MAX PRFT PRIM TI HAP CTD -,SUP-6051-1140S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ12 47.3MM OFST 132MM SECUR-FIT MAX PRFT PRIM 40MM -,SUP-6051-1240S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HIP STEM SIZE 6 25MM C-TPR -,SUP-6052-0625S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ7 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-0730S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ8 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-0830S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ9 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-0935S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ10 127 DEG SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-1035S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ13 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-1340S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HIP SECUR-FIT PLUS MAX SZ 11 C-TPR 40MM X 170MM -,SUP-6054-1115S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HIP 127 DEG NECK ANGLE SZ 12 C-TPR 40MM X 170MM -,SUP-6054-1216S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HIP STEM 127 DEG CEMENTED SZ 2 V40 TPR 30MM X 124MM ACCOLADE -,SUP-6057-0230D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HIP ACCOLADE 127 DEG CEM NK 35MM SZ 3 V40 131MM LGTH -,SUP-6057-0335D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HIP CEM SZ4 V40 TPR 35MM X 137MM 127 DEG -,SUP-6057-0435D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HIP ACCOLADE 127 DEC CEM NK 37MM SZ 5 V40 145MM LGTH -,SUP-6057-0537D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HIP ACCOLADE 127 DEG CEM NK 37MM SZ 6 V40 158MM LGTH -,SUP-6057-0637D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HIP 127 DEG CEMENTED SZ 7 V40 TPR 40MM X 158MM ACCOLADE -,SUP-6057-0740D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HIP 132 DEG SIZE 3 V40 X 35MM X 131MM CEM ACCOLADE C -,SUP-6058-0335D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HIP 132 DEG CEMENTED SZ 4 V40 35MM X 137MM ACCOLADE -,SUP-6058-0435D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HIP STEM 132 DEG CEMENTED SZ 5 V40 TPR 37MM X 145MM -,SUP-6058-0537D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ10 42MM OFST 160MM OMNIFIT HFX RECON PRIM 35MM NK -,SUP-6070-1035A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ11 132MM OMNIFIT HFX PRIM COCR CMNT HIP -,SUP-6070-1140A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ5 35MM OFST 110MM RECON OMNIFIT HFX PRIM 25MM NK -,SUP-6076-0525A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ6 36MM OFST 120MM OMNIFIT HFX PRIM 25MM NK COCR -,SUP-6076-0625A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ7 41MM OFST 130MM OMNIFIT HFX PRIM 30MM NK COCR -,SUP-6076-0730A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ8 42MM OFST 140MM RECON OMNIFIT HFX PRIM 30MM NK -,SUP-6076-0830A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ2 +0MM 43MM OFST 120MM ACCOLADE HFX PRFT PRIM -,SUP-6077-0335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ4 +0MM 44MM OFST 125MM ACCOLADE HFX PRFT PRIM -,SUP-6077-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ5 +0MM 48MM OFST 130MM ACCOLADE HFX PRFT PRIM -,SUP-6077-0537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
OMNIFIT CEMENTED LONG STEM RIGHT -,SUP-6088-0730-200R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17512.18,12258.526,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ4 33MM OFST 100MM OMNIFIT EON PRIM EXTEND OFST -,SUP-6097-0425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ5 8.9MM DIST TIP 39MM OFST 110MM OMNIFIT EON PRIM -,SUP-6097-0530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ6 9.6MM DIST TIP 40MM OFST 120MM OMNIFIT EON PRIM -,SUP-6097-0630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ7 10.4MM DIST TIP 45MM OFST 130MM OMNIFIT EON -,SUP-6097-0735,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ8 46MM OFST 135MM OMNIFIT EON PRIM EXTEND OFST -,SUP-6097-0835,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HIP OMNIFIT EON PLUS SIZE 11 C-TPR 40MM X 150MM -,SUP-6097-1140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ5 8.9MM DIST TIP 35MM OFST 110MM OMNIFIT EON STD -,SUP-6098-0530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ6 9.6MM DIST TIP 36MM OFST 120MM OMNIFIT EON PRIM -,SUP-6098-0630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ7 9.6MM DIST TIP 41MM OFST 130MM OMNIFIT EON PRIM -,SUP-6098-0735,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ8 11.3MM DIST TIP 42MM OFST 135MM OMNIFIT EON STD -,SUP-6098-0835,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ9 46MM OFST 140MM OMNIFIT EON STD OFST 40MM NK -,SUP-6098-0940,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
MODULAR CUP REPLACEMTN LOCK RING 54MM -,SUP-6201-54,CDM,C1776,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRABECULAR METAL LOCKING RING -,SUP-6201-56,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL MULTI HOLE TRABECULAR METAL 54MM -,SUP-6202-54-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9990.38,6993.266,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 36X58-60MM G SHL TRIDENT 0DG CROSSFIRE PRIM -,SUP-621-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 28X46-48MM D SHL TRIDENT 0DG NEUT X3 7.9MM PRIM -,SUP-623-00-28D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 32X44MM C SHL TRIDENT 0DG NEUT X3 4.9MM PRIM -,SUP-623-00-32C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT 00 DEG X3 32MM ID TRIDENT -,SUP-623-00-32C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT POLYETHLENE 0 DEG 32MM CODE D TRIDENT X3 -,SUP-623-00-32D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 32X54-56MM F SHL TRIDENT 0DG NEUT X3 9.9MM PRIM -,SUP-623-00-32F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT POLYETHLENE 0 DEG 36MM CODE D TRIDENT X3 -,SUP-623-00-36D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT POLYETHLENE 0 DEG 36MM CODE E TRIDENT X3 -,SUP-623-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 36X54-56MM F SHL TRIDENT 0DG NEUT X3 7.9MM PRIM -,SUP-623-00-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT POLYETHLENE 0 DEG 36MM CODE F TRIDENT X3 -,SUP-623-00-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT POLY ZERO DEGREE 36MM X ALPHA G TRIDENT X3 -,SUP-623-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 36X58-60MM G SHL TRIDENT 0DG NEUT X3 9.4MM PRIM -,SUP-623-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACET TRIDENT X3 0 DEG POLY 36MM H -,SUP-623-00-36H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIDENT X3 0 DG  POLY INSERT 40MM SZ E -,SUP-623-00-40E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIDENT X3 0 DG POLYETTHYLENE INSERT 40MM SZ E RIM -,SUP-623-00-40E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT 0 DEG POLYETHYLENE 40MM ALPHA CODE F TRIDENT X3 -,SUP-623-00-40F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 40X58-60MM G SHL TRIDENT 0DG X3 7.4MM PRIM -,SUP-623-00-40G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT POLY ZERO DEGREE 40MM X ALPHA G TRIDENT X3 -,SUP-623-00-40G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT POLY ZERO DEGREE 40MM X ALPHA H TRIDENT X3 -,SUP-623-00-40H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 40X62-64MM H SHL TRIDENT 0DG X3 9.1MM PRIM -,SUP-623-00-40H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TRIDENT X3 0 D POLY 40MM ALPHA I -,SUP-623-00-40I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 44X54-56MM F SHL TRIDENT 0DG X3 3.8MM PRIM -,SUP-623-00-44F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 44X58-60MM G SHL TRIDENT 0DG X3 5.4MM PRIM -,SUP-623-00-44G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 44X62-64MM H SHL TRIDENT 0DG X3 7.1MM PRIM -,SUP-623-00-44H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TRIDENT X3 0 DEGREE POLY 44MM ALPHA I -,SUP-623-00-44I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 22X42MM B SHL TRIDENT 10DG X3 8.8MM PRIM -,SUP-623-10-22B,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 32X54-56MM F SHL TRIDENT 10DG X3 9.9MM PRIM -,SUP-623-10-32F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT 10 DEG POLYETHYLENE 36MM E TRIDENT X3 -,SUP-623-10-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 36X50-52MM E SHL TRIDENT 10DG X3 5.9MM PRIM -,SUP-623-10-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT 10 DEG X3 36MM ID TRIDENT -,SUP-623-10-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 36X54-56MM F SHL TRIDENT 10DG X3 7.9MM PRIM -,SUP-623-10-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT 10 DEGREE POLY 36MM G TRIDENT X3 -,SUP-623-10-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 36X58-60MM G SHL TRIDENT 10DG X3 9.4MM PRIM -,SUP-623-10-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 36X66-68MM I SHL TRIDENT 10DG X3 12.7MM PRIM -,SUP-623-10-36I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM DISTAL 19MM DIA CENTRALIZER-CEMENTED -,SUP-6259-8-180,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 32X50-52MM E SHL TRIDENT 0DG ALMN CERM PRIM -,SUP-625-OT-32E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 36MM D SHL RECON MDM CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-36C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 38MM D SHL MDM RECON CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-38D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 42MM E SHL RECON MDM CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-42E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 46MM F SHL RECON MDM CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-46F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 48MM G SHL MDM RECON CMNTLS COCR REVISN MODULAR -,SUP-626-00-48G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER MDM 52MM H CEMENTLESS -,SUP-626-00-52H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 22.2MMSTDX0MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-4-122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 26MM-3MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 26MM +4MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-226,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 26MM +8MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-326,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 26MM +12MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-426,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 26MM -3MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 40MM -4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 44MM -4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 22MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 26MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-126,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V40 28MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-128,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 36MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 40MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL HEAD LFIT V40 22.2MM +3MM -,SUP-6260-9-222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 26MM +4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-226,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 28MM +4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-228,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 40MM +4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-240,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 26MM +8MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-326,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 28MM +8MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-328,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 32MM +8MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-332,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 36MM +10MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-336,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 26MM +12MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-426,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V40 28MM +12MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL HEAD LFIT ANATOMIC V40 6.5MM X 16MM -,SUP-6260-9-440,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ15 47MM OFST 140MM PARTNERSHIP RELIANCE PF PRFT -,SUP-6265-2-005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ6 50MM OFST 150MM PARTNERSHIP RELIANCE PF PRFT -,SUP-6265-2-006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CENTRALIZER DIST HIP 13MM TY A -,SUP-6265-4-413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,601.24,420.868,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CENTRALIZER DIST HIP 14MM TY A -,SUP-6265-4-414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,601.24,420.868,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CENTRALIZER DIST HIP 15MM TY B -,SUP-6265-4-515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,601.24,420.868,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ1 10X34MM OFST 115MM PARTNERSHIP CITNN PRFT PRIM -,SUP-6265-5101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ2 36MM OFST 120MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ4 44MM OFST 130MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ5 47MM OFST 135MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ0 9X34MM OFST 110MM PARTNERSHIP CITNN PRFT PRIM -,SUP-6265-5110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ1 34MM OFST 118MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ2 36MM OFST 120MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ3 40MM OFST 133MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ4 44MM OFST 130MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ5 47MM OFST 135MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BODY PROX HIP 21MM STD RESTOR MODULAR REVISN BOLT CNCL -,SUP-6276-1-021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SYS HIP RESTORATION MODULAR SZ 21MM +0 HT V40 TPR -,SUP-6276-1-021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BODY PROX HIP 25MM STD RESTOR MODULAR REVISN BOLT CNCL -,SUP-6276-1-025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BODY PROX HIP 19MM RESTOR MODULAR REVISN BOLT +10MM NK CNCL -,SUP-6276-1-119,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BODY PROX HIP 21MM RESTOR MODULAR REVISN BOLT +11MM NK CNCL -,SUP-6276-1-121,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIP SUCT ACORN STD V. MUELLER 1.0625IN SIL RBR -,SUP-6276-1-123,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
MODULAR HIP SYSTEM RESTORATION 25MM X +10 X V40 TPR -,SUP-6276-1-125,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SYSTEM HIP MODULAR 27MM X +10 X V40 TPR RESTORAITON -,SUP-6276-1-127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BODY PROX HIP 19MM RESTOR MODULAR REVISN BOLT +20MM NK CNCL -,SUP-6276-1-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BODY PROX HIP 21MM RESTOR MODULAR REVISN BOLT +20MM NK CNCL -,SUP-6276-1-221,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BODY PROX HIP 25MM RESTOR MODULAR REVISN BOLT +10MM NK CNCL -,SUP-6276-1-225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BODY PROX HIP 19MM RESTOR MODULAR REVISN BOLT +30MM NK CNCL -,SUP-6276-1-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BODY PROX HIP 21MM RESTOR MODULAR REVISN BOLT +30MM NK CNCL -,SUP-6276-1-321,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BODY PROX HIP 23MM RESTOR MODULAR REVISN BOLT +30MM NK CNCL -,SUP-6276-1-323,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
RESTORATION MODULAR HIP SYSTEM 25MM X 30 V40 -,SUP-6276-1-325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 14X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 15X155MM RESTOR REVISN MODULAR STR CNCL DIST HIP -,SUP-6276-7-015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 16X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 17X155MM RESTOR REVISN MODULAR STR CNCL DIST HIP -,SUP-6276-7-017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 18X155MM RESTOR REVISN MODULAR STR CNCL DIST HIP -,SUP-6276-7-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 19X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HIP RESTORATION MODULAR 20MM X 155MM -,SUP-6276-7-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
RESTORATION MODULAR HIP SYS 22MM X 155MM -,SUP-6276-7-022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 23X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-023,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 14X195MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10547.44,7383.208,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 14X195MM RESTOR REVISN MODULAR HIP -,SUP-6276-7-214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 15X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 16X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 19X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 21X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
RESTORATION MODULAR HIP SYSTEM 21MM X 195MM -,SUP-6276-7-221,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 24X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-224,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 15X235MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11716.67,8201.669,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
RESTORATION HIP STEM 235MM X 19MM -,SUP-6276-7-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11716.67,8201.669,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 22X235MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11716.67,8201.669,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SYS RESTORATION MOD HIP 18MM X 115MM -,SUP-6276-7-418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24628.33,17239.831,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM PCA 28X0MM NK COCR REVISN -,SUP-6280-0-136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM PCA 32MM +5MM NK COCR REVISN -,SUP-6280-0-232,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM PCA 36MM +5MM NK COCR REVISN -,SUP-6280-0-236,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM PCA 32MM +10MM NK COCR REVISN -,SUP-6280-0-332,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM PCA 36MM +10MM NK COCR REVISN -,SUP-6280-0-336,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 32X52-55MM DURATION 10DG UHMWPE PCA -,SUP-6299-7-525,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4020.85,2814.595,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINEAR STANDARD TRILOGY ACETABULAR SYSTEM -,SUP-6305-50-36,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5260.44,3682.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB SZ P6 28X62-64MM SHL S12 +4 10DG CROSSFIRE CONGR -,SUP-6352-5-076,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4458.11,3120.677,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CROSSFIRE SYSTEM 12 POLYETHYLENE INSERT 10 -,SUP-6352-5-105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4458.11,3120.677,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR SM 9MM PE PEGX3 AVON RND DOME REVISN OFST -,SUP-6430-0-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4079.19,2855.433,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR MED 9.5MM PE PEGX3 AVON RND DOME REVISN OFST -,SUP-6430-0-030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4079.19,2855.433,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR LRG 10MM PE PEGX3 AVON RND DOME REVISN OFST -,SUP-6430-0-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4079.19,2855.433,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM XS 43.5MMX42.5MM AVON KN CMNT PEGX4 COCR -,SUP-6430-0-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14140.63,9898.441,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM MED 50.3MMX47.5MM AVON KN CMNT PEGX4 COCR -,SUP-6430-0-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14140.63,9898.441,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 36MM E SHL TRIDENT 0DG ELEV RM ECCT X3 PRIM -,SUP-643-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIDENT ELEVATED RIM INSERT 36MM G -,SUP-643-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND XS KINEMAX PLUS PRFT REVISN MODULAR 80MM COCR -,SUP-6476-8-260,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3594.54,2516.178,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 14MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 16MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 19MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-645,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 23MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-665,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TITANIUM FLUTED 16MM X 155MM -,SUP-6478-6-715,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 17MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-720,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 21MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 SM M LT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 SM M RT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 MED M LT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 LRG M RT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-131,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
MRH KNEE FEMORAL DISTAL BLOCK MED 10MM -,SUP-6481-1-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3438.71,2407.097,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIB STD XS XL KN GMRS COCR MRH -,SUP-6481-2-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11254.62,7878.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL BEARING COMPONENT MRH -,SUP-6481-2-103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11254.62,7878.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ7 STD GMRS KN MODULAR REVISN BUSHNG COCR ROT HNG -,SUP-6481-2-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1628.47,1139.929,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ7 STD GMRS KN MODULAR REVISN AXLE COCR ROT HNG -,SUP-6481-2-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4454.42,3118.094,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB BEAR KN PE -,SUP-6481-2-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3005.95,2104.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
MRH KNEE BUMPER INSERT 3 DEGREES -,SUP-6481-2-133,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3005.95,2104.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE TIB SZ4 MODULAR BMPR DIST KN ROT HNG DURATION -,SUP-6481-2-140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2514.7,1760.29,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ1 KN GMRS COCR MODULAR KLD ROT HNG -,SUP-6481-3-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12573.67,8801.569,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ2 SM KN GMRS COCR MODULAR KLD ROT HNG -,SUP-6481-3-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12573.67,8801.569,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ2 LRG KN GMRS COCR MODULAR KLD ROT HNG -,SUP-6481-3-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12573.67,8801.569,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ1-2 XS/SM 10MM PS ARTCSURF KN PE -,SUP-6481-3-210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ1-2 XS/SM 13MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ1-2 XS/SM 16MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ1-2 XS/SM 20MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB MED 2/ L2 13MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5011.74,3508.218,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB MED 2/ L2 24MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-324,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5011.74,3508.218,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
KINEMATIC ROTATING HINGE KNEE XSM 8MM -,SUP-6485-2-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HINGE KNEE ROTATING SIZE XSM 11MM THKNS KINEMATIC -,SUP-6485-2-011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
KINEMATIC ROTATING HINGE KNEE -,SUP-6485-2-016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
KINEMATIC ROTATING  HINGE KNEE SM 8MM -,SUP-6485-2-108,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
KINEMATIC ROTATING HINGE KNEE -,SUP-6485-2-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
KINEMATIC ROTATING HINGE KNEE 16MM MEDIUM -,SUP-6485-2-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
KINEMATIC ROTATING HINGE KNEE LARGE 21MM -,SUP-6485-2-321,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM STRAIGHT CEMENTED 10MM X 102MM -,SUP-6485-3-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM REPLACEMENT STRAIGHT CEMENTED 8MM X 102MM -,SUP-6485-3-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM REPLACEMENT STRAIGHT 9MM X 102MM -,SUP-6485-3-019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM CEMENTED STRAIGHT 11 X 127 -,SUP-6485-3-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM MRS STRAIGHT CEMENTED 13 X 127 -,SUP-6485-3-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM-REPLACEMENT CURVED CEMENTED 10MM X 102MM -,SUP-6485-3-310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM REPLACEMENT CURVED CEMENTED 8MM X 102MM -,SUP-6485-3-318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM REPLACEMENT CURVED CEMENTED -,SUP-6485-3-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 11MM LNG GMRS MODULAR 203MM TI HAP PLASM SPRY CTD -,SUP-6485-3-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14897,10427.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 17X203MM MRS MODULAR COCR POR CTD CMNT CRV DIST HIP -,SUP-6485-3-617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14897,10427.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
MRS CURVED CEMENTED STEM 11MM X 127MM -,SUP-6485-3-811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
MRS CURVED CEMENTED STEM 13MM X 127MM -,SUP-6485-3-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM CEMENTED STEM 15 X 127 -,SUP-6485-3-815,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM CEMENTED 17MM X 127MM CURVED -,SUP-6485-3-817,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
GMRS PROXIMAL FEMORAL COMPONENT V40 -,SUP-6495-1-002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19014.24,13309.968,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT DISTAL FEMORAL SMALL LEFT 65MM -,SUP-6495-2-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27396.07,19177.249,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
DISTAL FEMORAL COMPONENT SMALL RT 65MM -,SUP-6495-2-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27396.07,19177.249,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM STD 65MM GMRS LT DIST KN MODULAR COCR ROT HNG -,SUP-6495-2-030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27152.28,19006.596,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM STD 65MM GMRS RT DIST KN MODULAR COCR ROT HNG -,SUP-6495-2-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27152.28,19006.596,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BUSHING FOR SMALL DISTAL FEMUR -,SUP-6495-2-105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1672.63,1170.841,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AXLE GMRS -,SUP-6495-2-115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4462.74,3123.918,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT FOR SMALL PROXIMAL TIBIAL COMPONENT 13MM -,SUP-6495-3-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT FOR SMALL PROXIMAL TIBIAL COMPONENT 24MM -,SUP-6495-3-024,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PROXIMAL TIBIA GMRS SM 80MM -,SUP-6495-3-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27343.31,19140.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIA PROXIMAL STD 80MM -,SUP-6495-3-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27343.31,19140.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL ROTATING COMPONENT SM -,SUP-6495-3-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11240.07,7868.049,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND GMRS REVISN MODULAR 30MM FEM KN -,SUP-6495-6-030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PIECE EXTENSION GMRS 40MM LENGTH -,SUP-6495-6-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
GMRS EXTENSION PIECE 50MM -,SUP-6495-6-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
EXTENSION PIECE GMRS -,SUP-6495-6-070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
GMRS EXTENSION PIECE 120MM -,SUP-6495-6-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
GRAFT HUM TIS 6X10CM TISSUEMEND COLL -,SUP-6495-9-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10181.42,7126.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD DELTA CERAMIC FEMORAL 36/-3MM -,SUP-650-0660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD DELTA CERAMIC FEMORAL 36/0MM -,SUP-650-0661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD DELTA CERAMIC FEMORAL 36/+3MM -,SUP-650-0662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CERAMIC HEAD BIOLOX DELTA  OP HIP SYSTEM 28MM -,SUP-650-1055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD CER BIOLOX D OPTION 28MM -,SUP-650-1055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD CER BIOLOXD OPTION 36MM -,SUP-650-1057,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CER OPTION TYPE 1 TPR SLEEVE +3 -,SUP-650-1067,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
+6MM NECK BIOLOCK OPTION HIP SYSTEM -,SUP-650-1068,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEMORAL G7 BIOLOX DELTA -3 MM OFFSET OD28 MM HIP -,SUP-650-1159,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL HEAD UNIVERSAL TAPER 28MM OD BIOLOX DELTA -,SUP-6519-1-028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL HEAD UNIVERSAL TAPER BIOLOX DELTA -,SUP-6519-1-032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 36MM UNIV +0MML NK BIOLOX DELTA CERM TAPR PRIM -,SUP-6519-1-036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEMORAL 40MM BIOLOX DELTA -,SUP-6519-1-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
UNIVERSAL V40  -2.5MM ADAPTER SLEEVE (TI) -,SUP-6519-T-025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE HIP UNIV V-40 RECON PRIM ADPTR +0MML NK OFST TI TAPR -,SUP-6519-T-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE HIP +4MM OFST UNIV V-40 RECON PRIM ADPTR TI TAPR -,SUP-6519-T-204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
IMPACTOR SURG F/TIB INS TRIATH -,SUP-6541-4-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2125.24,1487.668,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 36MM-5MM NK ALMN PRIM -,SUP-6565-0-036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 32X0MM NK ALMN PRIM -,SUP-6565-0-132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 28MM -2.7MM OFST BIOLOX DELTA CERAMIC -,SUP-6570-0-028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 32MM -4MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 36MM -5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 28MM +0MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-128,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 32MM +0MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 36MM +0MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 28MM +4MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-228,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 32MM +4MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-232,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 36MM +5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-236,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 36MM -2.5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-436,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 36MM +2.5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-536,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM V-40 36MM +7.5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-736,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 36X54-56MM F SHL TRIDENT 0DG ECCT X3 PRIM -,SUP-663-00-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT KN SZ1 SM DURACN 10MM WDG BLCK REVISN VITAL -,SUP-6630-6-510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5255.98,3679.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
DURACON TOTAL KNEE FULL FLAT TIBIAL WEDGE SM-2 10MM -,SUP-6630-6-515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5255.98,3679.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 32X46-48MM D SHL TRIDENT 10DG ECCT X3 16.8MM -,SUP-663-10-32D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 36X58-60MM G SHL TRIDENT 10DG ECCT X3 18.8MM -,SUP-663-10-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 36X62-64MM H SHL TRIDENT 10DG ECCT X3 20.4MM -,SUP-663-10-36H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CK Insert Trial Sz 4 8mm -,SUP-663-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CK Insert Trial Sz 5 16mm -,SUP-663-1516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB LRG 9X77/53MM DURACN CR A/P LIP ARTC L/R KN -,SUP-6642-1-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3601.27,2520.889,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT A-P LIPPED DURACON XLGE 9MM -,SUP-6642-1-909,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3601.27,2520.889,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR XS PE DURACON DURATION ASYM -,SUP-6642-2-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR MED PE DURACON DURATION ASYM -,SUP-6642-2-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SM 11MMX45MM A/P DURACN CNSTRN ARTC L/R KN -,SUP-6642-9-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB LRG 9MMX55MM ARTCSURF L/R KN PE -,SUP-6642-9-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB LRG 11MMX55MM A/P DURACN CNSTRN ARTC L/R KN -,SUP-6642-9-811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB LRG 13MMX55MM A/P DURACN CNSTRN ARTC L/R KN -,SUP-6642-9-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TibAugSz1Trial20Â°WedgeLtLat/RtMed -,SUP-667-2201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TibAugSz2Trial20Â°WedgeLtLat/RtMed -,SUP-667-2202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ2 33MM OFST 99MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ3 35MM OFST 102MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ4 38MM OFST 105MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ5 35MM OFST 108MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ6 41MM OFST 111MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ7 46MM OFST 114MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0737,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HIP ACCOLADE 132 SZ 8 -,SUP-6720-0837,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HIP 132 DEG SZ #9 37MM X 120MM V40 ANGLE ACCOLADE II -,SUP-6720-0937,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
NECK ANGLE HIP STEM SZ# 0 / 27MM / 93MM / V40 -,SUP-6721-0027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ1 34MM OFST 96MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ2 37MM OFST 99MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ3 30MM OFST 102MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ4 42MM OFST 105MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
ACCOLADE II SZ5 35MM NECK ANGLE HIP STEM 108MM V40 -,SUP-6721-0535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ6 35MM OFST 111MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ7 50MM OFST 114MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0737,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ8 51MM OFST 117MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0837,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ9 53MM OFST 120MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0937,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM SZ10 57MM OFST 123MM ACCOLADE II V40 PRFT PRIM -,SUP-6721-1040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SM 9MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4186.89,2930.823,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SM 11MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4186.89,2930.823,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SM 16MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-116,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4186.89,2930.823,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ2 16MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB LRG 9MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-309,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 11MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB LRG 16MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 22X50-52MM D SHL TRIDENT 0DG ECCT UHMWPE CNSTRN -,SUP-690-00-22D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 22X50-52MM E SHL TRIDENT 0DG ECCT UHMWPE CNSTRN -,SUP-690-00-22E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 22X54-56MM F SHL TRIDENT 0DG ECCT UHMWPE CNSTRN -,SUP-690-00-28F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIDENT 0 DG ACETABULAR INSERT SZ H -,SUP-690-00-32H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIDENT ALL POLY CONSTRAINED ACETABULAR INSERT -,SUP-69-2244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10027.4,7019.18,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
ALL POLY CONSTRAINED INSERT 46MM -,SUP-69-2246,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10027.4,7019.18,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM UNITRAX 40MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM UNITRAX 42MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM UNITRAX 43MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM UNITRAX 46MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM UNITRAX 47MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-047,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE HIP UNITRAX V40 PRIM MODULAR UNIPL -4MM NK TAPR -,SUP-6942-6-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE HIP UNITRAX V40 PRIM MODULAR UNIPL +0MML NK TAPR -,SUP-6942-6-065,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE HIP UNITRAX V40 PRIM MODULAR UNIPL +8MM NK TAPR -,SUP-6942-6-075,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE HIP UNITRAX C UNIPL -3MM NK C-TAPR -,SUP-6942-7-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE HIP UNITRAX C UNIPL +0MML NK C-TAPR -,SUP-6942-7-065,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE HIP UNITRAX C UNIPL +5MM NK C-TAPR -,SUP-6942-7-075,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE HIP UNITRAX C UNIPL +10MM NK C-TAPR -,SUP-6942-7-085,CDM,C1776,HCPCS,278,RC,,,outpatient,,,810.6,567.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HIP HIGH OFFSET INSIGNIA SZ 4 X 36MM X 103MM -,SUP-7000-6604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL CLUSTERHOLE ACET 46MM C TRIDENT TRITANIUM -,SUP-702-04-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIDENT IITRITANIUM CLUSTERHOLE 48MM D -,SUP-702-04-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL TRIDENT II TRITANIUM CLUSTERHOLE ACETABULAR 50MM D -,SUP-702-04-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIDENT II TRITANIUM CLUSTERHOLE ACETABULAR SHELL -,SUP-702-04-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIDENT II TRITANIUM CLUSTERHOLE ACET SHELL 54MM -,SUP-702-04-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIDENT II TRITANIUM CLUSTERHOLE ACE SHELL 56MM F -,SUP-702-04-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIDENT II TRITANIUM CLUSTERHOLE ACE SHELL 58MM F -,SUP-702-04-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIDENT II TRITANIUM CLUST ACE SHELL SZ 60MM G -,SUP-702-04-60G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL CLUSTERHOLE ACET SIZE 62MM G TRIDENT II TRITANIUM -,SUP-702-04-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACET 64MM H TRIDENT II TRIT CLUSTERHOLE -,SUP-702-04-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
44MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-44B,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
46MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
48MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
52MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
54MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
56MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
58MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
60MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-60G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
62MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
64MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
66MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-66H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIDENT II TRITANIUM MULTIHOLE ACE SHELL 48MM D -,SUP-709-04-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL TRIDENT II TITAN MLTHLE ACE SIZE 52MM E -,SUP-709-04-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL TRIDENT II TRITANIUM MLTHOLE ACE 54MM E -,SUP-709-04-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIDENT II TRITANIUM MULTHL SHELL 56MM F -,SUP-709-04-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL MULTIHOLE ACETABULAR 62MM X G TRIDENT II TRITANIUM -,SUP-709-04-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL TRIDENT II TITANIUM 64MM H MULTIHOLE -,SUP-709-04-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL MULTIHOLE ACET SZ 66MM H TRIDENT II TRITANIUM -,SUP-709-04-66H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACETABULAR 68MM ALPHA I MULTIHOLE TRIDENT II TRITANIUM -,SUP-709-04-68I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP ACTB 22X42MM SHL TANDEM AN-ROT BIPLR COCR UHMWPE MAX -,SUP-71322042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2755.51,1928.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
REF XLPE 36 20 DEG 54-56F -,SUP-7133-3345,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9094.89,6366.423,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
ACET LINER 36 X 58 R3 20 DEG XLPE -,SUP-71335758,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6230.19,4361.133,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COVER SCR HL HIP THRD R3 REFLC STRL -,SUP-71336500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,407.81,285.467,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SHELL ACETABULAR 58MM R3 MULTI HOLE -,SUP-71338668,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8734.15,6113.905,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
OXINIUM HD 12/14 22MM +4 -,SUP-71342204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7011.09,4907.763,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM 36MM +0MML NK OXNM 12/14 TAPR STRL -,SUP-71343600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8339.46,5837.622,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
GNS II CMT TIB SIZE 2 LEFT -,SUP-71420162,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
GNS II CMT TIBIAL SIZE 3 LEFT -,SUP-71420164,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
GNS II CMT TIB SIZE 5 LEFT -,SUP-71420168,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ3 64/48MM RT KN CMNT GENESIS II NPOR -,SUP-71420182,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4286.44,3000.508,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
GNS II CMT TIB SIZE 4 RIGHT -,SUP-71420184,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
GNS II CMT TIB SIZE 6 RIGHT -,SUP-71420188,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
GNSII CON INS SZ3-4 11MM -,SUP-71420524,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT GENESIS II SZ 3-4 13MM -,SUP-71420526,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3-4 15MM 68-71MM M/L 48-50MM A/P GENESIS II -,SUP-71420528,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
GNS II CON INS SZ 3-4 18MM -,SUP-71420530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
GNS II CON INS SZ5-6 15MM -,SUP-71420542,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
GNS II RESUR PAT 29MM -,SUP-71420574,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
RESURF PAT GEN II 32MM -,SUP-71420576,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 35X9MM THK UHMWPE PEGX3 RSRFC GENESIS II -,SUP-71420578,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
GNS II RESURF PAT 26MM -,SUP-71420580,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5-6 13MM 74-77MM M/L 52-54MM A/P GENESIS II PS -,SUP-71420834,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2502.77,1751.939,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEGION CON ART INS 9MM SZ 1-2 -,SUP-71420959,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT G2 CONST SZ1-2 11MM -,SUP-71420960,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ARTICULAR G2 CONST SIZE 1-2 13MM -,SUP-71420962,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEMORAL SIZE 4 RIGHT LEGI -,SUP-71420964,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ1-2 18MM 60-64MM M/L 42-45MM A/P GENESIS II -,SUP-71420966,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LGN HM ST 3-4 5MM LTMD-RTLA -,SUP-71421142,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6854.06,4797.842,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ3 LEGION LT KN CNSTRN REVISN OXNM -,SUP-71421163,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LGN OX CONSTRAINED FEM 4 LT -,SUP-71421164,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LGN OX CONSTRAINED FEM 6 LT -,SUP-71421166,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT FEMORAL SIZE 4 RIGHT -,SUP-71421174,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29666.87,20766.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEGION OX CONSTRAINED FEM 5 RT -,SUP-71421175,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEGION PS OIN FEM SZ3 RT -,SUP-71421203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ4 LEGION RT KN PS OXNM POR -,SUP-71421204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10489.23,7342.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 LEGION RT KN PS OXNM POR -,SUP-71421205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ6 LEGION PS OXIN RIGHT -,SUP-71421206,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEGION PS OXIN FEM SZ4 LT -,SUP-71421214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEGION PS OXIN FEM SZ6 LT -,SUP-71421216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 LEGION RT KN CR REVISN OXNM POR -,SUP-71421225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9893.85,6925.695,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEGION CR OXIN FEM SZ6 RT -,SUP-71421226,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEGION NARROW PS OXIN SZ 4N LT -,SUP-71421264,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEGION NARROW PS OXIN SZ 6N LT -,SUP-71421266,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEGION NARROW PS OXIN SZ 5N RT -,SUP-71421275,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEGION NARROW PS OXIN SZ 6N RT -,SUP-71421276,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9574.46,6702.122,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3-4 13MM GENESIS II PS ARTC L/R KN-HI FLEX OXNM -,SUP-71421510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3539.59,2477.713,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
GEN II PS HIGH FLEXION ARTICULAR INSERT SZ 5-6 13 -,SUP-71421517,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5975.55,4182.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT DIST KN SZ3 LEGION 10MM WDG BLCK -,SUP-71421658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
WEDGE FEM LGN SCRW DIS SZ4 5MM -,SUP-71421661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEGION SCREW DIS FEM WDG SZ5 5MM -,SUP-71421664,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6068.92,4248.244,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEGION SCW LWDG S5 5D X 5P -,SUP-71421741,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8891.18,6223.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
JUNI OX FB FEM SZ 3 LM RL -,SUP-71422343,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
JUNI OX FB FEM SZ 5 LM RL -,SUP-71422345,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
JUNI OX FB FEM SZ 7 LM RL -,SUP-71422347,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT FEMORAL JOURNEY OXINIUM SZ 5 RM LL -,SUP-71422355,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LGN RK/HK HEMI SZ 3-4 LL/RM 5MM -,SUP-71423420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8496.49,5947.543,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LGN RK/HK HEMI SZ 3-4 LM/RL 5MM -,SUP-71423432,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8496.49,5947.543,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEGION REVISION TIBIAL BASEPLATE -,SUP-71424001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE REVISION LONG TIBIA SIZE 2 LT -,SUP-71424002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIA BASE LGN REV SIZE 4 LT -,SUP-71424004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LGN REV TIBIA BASE SZ 5 LT -,SUP-71424005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIBIAL SIZE 2 RIGHT -,SUP-71424012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11863.04,8304.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE TIB SZ3 RT KN LEGION TI REVISN -,SUP-71424013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEGION REV TIBIA BASE SZ 5 RT -,SUP-71424015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM PRESSFIT LONG 10MM X 120MM -,SUP-71424023,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LGN PRESSFIT STEM 12MM X 120MM -,SUP-71424025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 13MM LEGION PRFT REVISN 120MM TI FEM KN -,SUP-71424026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM STRAIGHT 14MM X 120MM LEG -,SUP-71424027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM LGN PRESSFIT 15MM X 120MM -,SUP-71424028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LGN PRESSFIT STEM 16MM X 120MM -,SUP-71424029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTENSION LEGION TI PRESSFIT 18MM X 120MM -,SUP-71424031,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LGN PRESSFIT STEM 11MM X 160MM -,SUP-71424044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM LGN PRESSFIT 12MM X 160MM -,SUP-71424045,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM LGN PRESSFIT 13MM X 160MM -,SUP-71424046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LGN PRESSFIT STEM 15MM X 160MM -,SUP-71424048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 16MM LEGION PRFT REVISN 160MM TI FEM KN -,SUP-71424049,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM LGN CEMENT 14MM X 160MM STRT -,SUP-71424206,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6527.27,4569.089,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LGN OFFSET COUPLER 2MM -,SUP-71424223,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6132.58,4292.806,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LGN OFFSET COUPLER 4MM -,SUP-71424225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6132.58,4292.806,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LGN CR HIGH FLEX XLPE SZ 3-4 9MM -,SUP-71453111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT LEGION CR HIGH FLEX XLPE SZ 3-4 -,SUP-71453112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3-4 9MM LEGION CR KN XLPE -,SUP-71453146,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LGN PS HIGH FLEX XLPE SZ 1-2 10MM -,SUP-71453171,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LGN PS HIGH FLEX XLPE SZ 3-4 12MM -,SUP-71453174,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LGN PS HIGH FLEX XLPE SZ 1-2 15MM -,SUP-71453204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LGN PS HIGH FLEX XLPE SZ 3-4 9MM -,SUP-71453211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEGION PS HIGH FLEX XLPE SZ 3-4 11MM -,SUP-71453212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LGN PS HIGH FLEX SLPE SZ 3-4 13MM -,SUP-71453213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEGION PS HIGH FLEX XLPE SZ 3-4 15MM -,SUP-71453214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4308.51,3015.957,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LGN PS HIGH FLEX XLPE SZ 5-6 15MM -,SUP-71453224,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3-4 13MM PS KN LEGION XLPE -,SUP-71453248,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LGN XLPE DISHED ISRT SZ 5-6 15MM -,SUP-71453287,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
JOURNEY PFJ IMPLANT X-SM LT -,SUP-71461010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
JOURNEY PFJ IMPLANT X-SMALL RIGHT -,SUP-71461011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12604.89,8823.423,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
JOURNEY PFJ IMPLANT SM LT -,SUP-71461012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
JOURNEY PF IMPLANT SM RT -,SUP-71461013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SCREW 5MMX55MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642255,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
UNIPL -,SUP-71701035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14184.25,9928.975,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 38X9MM THK GENESIS II REVISN PS -,SUP-71926225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
GEN II 7.5MM RESUR PAT 26MM -,SUP-71932634,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
GEN II 7.5MM RESUR PAT 29MM -,SUP-71932635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3366.62,2356.634,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEGION REV TIB BASE W/JRNY LOCK SZ 5 -,SUP-71933571,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11863.04,8304.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CONE TIB LGN ID 18 SHORT -,SUP-71935386,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22278,15594.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
WEDGE TIB LEGION CONE ID 20 SHORT -,SUP-71935387,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21210.51,14847.357,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEGION TIB CONE ID 22 SHORT -,SUP-71935388,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21210.51,14847.357,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL CONE LEGION 18 LONG -,SUP-71935393,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22927.78,16049.446,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEGION TIB CONE ID 22 LONG -,SUP-71935395,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21210.51,14847.357,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEM CONE LGN ID 18MM LEFT -,SUP-71935400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22324.41,15627.087,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEGION FEM CONE ID 20MM LEFT -,SUP-71935401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22324.41,15627.087,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEGION FEM CONE ID 22MM LEFT -,SUP-71935402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22324.41,15627.087,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
WEDGE FEMORAL LEGION CONE ID 18MM KNEE RIGHT -,SUP-71935407,CDM,C1776,HCPCS,278,RC,,,outpatient,,,23447.6,16413.32,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEMORAL ANTHOLOGY AFIT SO POR PL HA SZ7 -,SUP-71935567,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6009.5,4206.65,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SCROPIO-FLEX X3 TIBIAL BEARING INSERT CR SZ11 -,SUP-72-26-1110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 36X46-48MM D SHL TRIDENT 0DG NEUT X3 3.9MM PRIM -,SUP-723-00-36D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 36X50-52MM E SHL TRIDENT 0DG NEUT X3 5.9MM PRIM -,SUP-723-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 40X54-56MM G SHL TRIDENT 0DG X3 5.8MM PRIM -,SUP-723-00-40F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ACTB 28MM X 54MM RESTOR ADM/MDM X3 48G -,SUP-7236-2-854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ7 24X71/47MM 18X27MM SCORP CNSTRN TOTAL -,SUP-72-4-0724,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5828.45,4079.915,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PIN NONRIM SPEED 65 STERILE -,SUP-74013480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,128.37,89.859,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PIN NONRIM SPEED 80 STERILE -,SUP-74013490,CDM,C1776,HCPCS,278,RC,,,outpatient,,,122.54,85.778,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
JOURNEY II CR FEM OX NP RT SZ. 4 -,SUP-74021154,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP JRNY II CR FEM OX NP LT SZ 4 -,SUP-74021164,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
JRNY II BCS FEMORAL OXIN RT SZ 3 -,SUP-74022113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
JOURNEY TIBIA BASE NP RT SZ 2 -,SUP-74022212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
JOURNEY TIBIA BASE NP RT SZ 3 -,SUP-74022213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
JOURNEY TIBA BASE NP RT SZ. 4 -,SUP-74022214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4218.31,2952.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
JOURNEY TIBIA BASE NP LT SZ3 -,SUP-74022223,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
JOURNEY BCS PAT RESRF RD 32 MM STD -,SUP-74024832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2017.9,1412.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
JOURNEY II CR ISRT XLPE RT SZ 3-4 9MM -,SUP-74025631,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
JRNY II ISRT XLPE DD LT SZ 3-4 9MM -,SUP-74025741,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
JRNY II BCS XLPE ART ISRT SZ 1-2 RT 12MM -,SUP-74027214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
JRNY II BCS XLPE ART ISRT SZ 5-6 LT 12MM -,SUP-74027264,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
44MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-44B,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
48MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
50MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
52MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
54MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
56MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
58MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
64MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
POLARCUP XLPE INSERT 43/22 NON-CEM -,SUP-75018942,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4478.01,3134.607,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
POLARCUP SHELL 43 CEMENTED -,SUP-75100451,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT DIST KN SZ7 SCORP 5MM WDG BLCK CMNT SPCR TOTAL -,SUP-75-1-0705,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4305.81,3014.067,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT POST KN SZ7 SCORP 5MM WDG BLCK SPCR TOTAL STABILIZED -,SUP-75-2-0705,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4305.81,3014.067,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL LEFT MEDIAL SZ 4 NON-POROUS -,SUP-761-1401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL LEFT MEDIAL SIZE 6 NON-POROUS -,SUP-761-1601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL TRAY LEFT MEDIAL SIZE 3 NON-POROUS -,SUP-762-3100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL TRAY LEFT MEDIAL SZ 4 NON-POROUS -,SUP-762-4100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TRIDENT X3 ECCENTRIC 0DEG 36MM -,SUP-763-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT LEFT MEDIAL SZ 4 7MM -,SUP-763-4071,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ7 66MM M/L 60-62MM A/P SCORP LT KN TOTAL -,SUP-76-4107L,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17711.12,12397.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL HEAD 12/14 COCR 36MM +3.5 -,SUP-8018-36-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD 12/14 COCR FRDM 36MM X +6 -,SUP-802403605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7259.36,5081.552,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
3.5MM CORT LOCK SCR 48MM NS -,SUP-816135048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,882.25,617.575,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SPACER NO PROFILE 16 X 14 X 8MM 7IN STERILE SHORELINE -,SUP-85-0208-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9039.72,6327.804,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ4 76/51MM L/R KN PFC TI CR MODULAR + NPOR -,SUP-86-0124,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11851.9,8296.33,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ2 64/43MM L/R KN PFC SIG KLD NPOR -,SUP-86-4180,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TAPER SIDMA 13 X 120 CEMENTED -,SUP-86-6498,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM TAPER 13 X 150 -,SUP-86-6499,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 12MM UNIV PFC PRFT MODULAR 75MM CMNT TIB KN -,SUP-86-7412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM EXTEND 14MM UNIV PFC PRFT MODULAR 75MM CMNT TIB KN -,SUP-86-7414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM UNIVERSAL FLUTED 75MM X 18MM -,SUP-86-7418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM UNIVERSAL FLUTED 75MM X 24MM -,SUP-86-7421,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FLUTED 115 X 16MM -,SUP-86-7430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM UNIVERSAL FLUTED 115MM X 18MM -,SUP-86-7432,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM UNIVERSAL FLUTED 115MM X 20MM -,SUP-86-7433,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM RADIAL ALIGN TITANIUM 11MM X 0MM -,SUP-90176510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10481.8,7337.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 28X48-50MM X-ALT 0DG NEUT STD HXLPE 6MM NON- HD F -,SUP-931-28-248,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB 36X52-54MM X-ALT 0DG NEUT STD HXLPE 6MM HD F /FMP -,SUP-932-36-252,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ2.5 63/59MM SIGMA FB RT KN CR CMNT COCR NPOR -,SUP-96-0018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7199.14,5039.398,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SIGMA TC3 FEM RT SZ2 -,SUP-96-0087,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL TC3 CEMENTED SIGMA SIZE 5 RIGHT -,SUP-96-0090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
FEMORAL TC3 CEMENTED SIGMA SIZE 2.5 RIGHT -,SUP-96-0092,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 32MM XS UHMWPE PEGX3 PFC SIG OVL DOME -,SUP-96-0100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 38MM STD UHMWPE PEGX3 PFC SIG OVL DOME -,SUP-96-0102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP PTLR 41MM LRG UHMWPE PEGX3 PFC SIG OVL DOME -,SUP-96-0103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
ADAPTER FEM 5DG PFC SIGMA TC3 KN REVISN CMNT TI -,SUP-96-0781,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8615.53,6030.871,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BOLT FEMORAL ADAPTER +2/-2 OFF -,SUP-96-0784,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1623.81,1136.667,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
DISTAL AUGMENT SIZE 2 4MM RIGHT -,SUP-96-0821,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
DISTAL AUGMENT SIZE 2 8MM RIGHT -,SUP-96-0823,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
DISTAL AUGMENT SIZE 2.5 8MM RIGHT -,SUP-96-0843,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
DISTAL  AUGMENT  COMBO  SIZE 2.5 16MM RIGHT -,SUP-96-0852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT FEM SZ4 PFC SIG POST KN WDG/BLCK 4MM COCR -,SUP-96-0886,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMBO PFC SIGMA POST AUG CEMENTED SIZE 5 X 8MM -,SUP-960908,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMBO PFC SIGMA DIST AUG CEMENTED SIZE 6 X 12MM LEFT -,SUP-96-0909,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMBO PFC SIGMA DIST AUG CEMENTED SIZE 6 X 16MM LEFT -,SUP-96-0911,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5 10MM 74MM/47MM M/L/A/P PFC SIG PS ARTCSURF -,SUP-96-2051,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT ROTATING PLTFRM SIZE 3 X 12.5MM -,SUP-96-2132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBAL INSERT ROT PLAT STAB SZ4 12.5MM -,SUP-96-2142,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBAL INSERT ROTATING PLATFORM (STAB) 4- 20MM -,SUP-96-2145,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT ROT PLTFRM TC3 SZ 2 12.5MM -,SUP-96-2322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT ROTATING PLATFORM SIZE 2 20MM -,SUP-96-2325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT ROTATING PLATFORM TC3 SZ 12.5 -,SUP-96-2332,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT ROTATING PLTFRM SZ3 30MM -,SUP-96-2348,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL INSERT TC3 RP S4 12.5 -,SUP-96-2352,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL PLATFORM TCS SZ 5 GVF 22.5MM -,SUP-96-2366,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBTRY SZ3 8MM KN PFC SIG UHMWPE CR POST LIP -,SUP-96-2540,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6645.51,4651.857,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ5 15X89/55MM PFC SIG PS TCMPRTMNTL BEAR ARTC -,SUP-97-0473,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM UNIPL COCR POR -,SUP-98000100400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12559.22,8791.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
KT THR PRFT SUMMIT -,SUP-98-0001-006-00,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12559.22,8791.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB LRG VIVACIT VIT-E XLNK PE CNSTRN F/T/H ARTHPL -,SUP-98000125053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21605.69,15123.983,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
KT THR PRIM KINECTIV -,SUP-98000132001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21605.69,15123.983,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
KT THR PERSONA -,SUP-98-0002-415-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21605.69,15123.983,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SYS TKR PRIM CONSTRUT -,SUP-98000600000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20654.23,14457.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ3 10MM PFC SIG MODULAR CS STAB ANTMC KN POR CTD -,SUP-98-6061,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINK NECK SEGMENT WITHOUTH COLLAR 12/14MM 126 DEG 65MM -,SUP-99-0984/30,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19311.31,13517.917,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE HIP +5MM 12/14 TAPR ASR UNIPL -,SUP-9998-00-315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1022.29,715.603,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SLEEVE HIP +8MM 12/14 TAPR ASR ADPR UNIPL -,SUP-9998-00-318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
RADIAL HEAD 22MM -,SUP-ALN-RH1-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9803.64,6862.548,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD RADIAL 20MM -,SUP-ALN-RHI-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9803.64,6862.548,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
RADIAL HEAD 24MM -,SUP-ALN-RHI-240,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9803.64,6862.548,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM 8MM X 0MM -,SUP-ALN-RST-0800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM 8MM X 2MM -,SUP-ALN-RST-0802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
RADAIL STEM ALIGN 9MM X 0MM -,SUP-ALN-RST-0900,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM 10MM X 0MM -,SUP-ALN-RST-1000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PACKAGED RADIAL STEM 11MM X 2MM -,SUP-ALN-RST-1102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT KN 7DG 8DG XL LRG 9.83 MDL OPN 78-88MM 88-96 MM -,SUP-AR-13400L-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT KN 11DG 12DG XL LRG 14.13 MDL OPN 78-88MM 88-96 MM -,SUP-AR-13400L-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PIP DART PEEK 10 DEGREE 2.5X30MM -,SUP-AR-4154PS-3010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
IMPLANT PIP 3MM PEEK 30MM 10DG ANG -,SUP-AR-4155PS-3010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SCREW 7X12 PROSTOP ARTHROEREISIS -,SUP-AR-4207-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SCREW 8 X 14 MM PROSTOP SFT THRD -,SUP-AR-4208-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6154.44,4308.108,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SCREW 9X14 PROSTOP ARTHROEREISIS -,SUP-AR-4209-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SCREW 10X14MM PROSTOP SFT THRD CNCL TI F /ARTHROEREISIS -,SUP-AR-4210-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SCREW 11X16MM PROSTOP SFT THRD CNCL TI F /ARTHROEREISIS -,SUP-AR-4211-16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SCREW 12X16 PROSTOP ARTHROEREISI S -,SUP-AR-4212-16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
"GUIDE WIRE .045"" X 5.91"" -",SUP-AR-8933K,CDM,C1776,HCPCS,278,RC,,,outpatient,,,40.85,28.595,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUMERAL UNIVERS  SZ 6 -,SUP-AR-9100-06P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13645.28,9551.696,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 10MM UNIVERS II 148MM SHLDR -,SUP-AR-9100-10P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13645.28,9551.696,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
GLENOID UNIV BASEPLATE SMALL -,SUP-AR-9120-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7278.46,5094.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 54X23MM UNIVERS II ECCT -,SUP-AR-9154-23P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
ANATOEMIC PROSTHESIS 17MM -,SUP-AR-9500-170,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
ANATOEMIC PROSTHESIS 18.5MM -,SUP-AR-9500-185,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
ANATOEMIC PROSTHESIS 20MM -,SUP-AR-9500-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
ANATOEMIC PROSTHESIS 21.5 MM -,SUP-AR-9500-215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
RESTRICTOR CEMENT REV 30MM -,SUP-B000-0300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
REVERSE BODY STANDARD AND REVERSE BODY SCREW -,SUP-BBS-0960-21STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS PRIMARY PROXIMAL BODY 2.5 08STD -,SUP-BOD-0923-020-08STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BODY TSS PRIMARY PROXIMAL 10 LRG -,SUP-BOD-0923-020-10LRG,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BODY TSS PRIMARY PROXIMAL 10 STD -,SUP-BOD-0923-020-10STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BODY TSS PRIMARY PROXIMAL 2.5 X 12 STD -,SUP-BOD-0923-020-12STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BODY HUM LRG 40MM TI PROX GFT TITAN F/MODULAR SHLDR SYS -,SUP-BOD-0923-020-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6836.57,4785.599,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BODY TSS PRIMARY PROX 2.5 14 LRG -,SUP-BOD-0923-020-14LRG,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS PRIMARY PROXIMAL BODY 2.5 14STD -,SUP-BOD-0923-020-14STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS FRACTURE BODY 2.5 08LRG -,SUP-BOD-0923-021-08LRG,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS FRACTURE BODY 2.5 08STD -,SUP-BOD-0923-021-08STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
ULNAR STEM 5.0MM 2CM EXT STEM -,SUP-DRUJ-IS250,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9932.28,6952.596,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AEQREVSD FX/ADAPTER LATRLZD HMRL INSRT 36MM 9MM -,SUP-DWD861,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8929.38,6250.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AEQUALIS REVERSED FX STEM 11MM X 130MM -,SUP-DWD903,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24223.61,16956.527,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TORNIER PERFORM REVERSED STANDARD GLENOSPHERE DIA 36MM -,SUP-DWJ012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15178.74,10625.118,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LINER ACTB SZ23 36MM MAX-ROM RINGLOC +3 HW E1 -,SUP-EP108323,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BEARING E1 44-36 STD HMRL -,SUP-EP-115393,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB 10X71/75MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-EP-183540,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB 12X71/75MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-EP-183542,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB 18MMX67MM M/L VANGRD ANT STAB MODULAR ARTC BEAR -,SUP-EP-189048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
ACT ARTIC E1 HIP BRG 28X42MM -,SUP-EP-200148,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
ACT ARTIC E1 HIP BRG 28X44MM -,SUP-EP-200150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
ACT ARTIC E1 HIP BRG 28 X 50MM -,SUP-EP-200156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
IMPLANT TOE JOINT PRIMUS SIZE 40 -,SUP-FGT-40T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6915.85,4841.095,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
RSS GLENOID BASEPLATE-S -,SUP-GBP-0961-094-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS PEGGED GLENOID XS -,SUP-GLN-0920-030-00P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9802.32,6861.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
GLENOID TSS PEGGED S -,SUP-GLN-0920-030-01P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4010.16,2807.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS PEGGED GLENOID S -,SUP-GLN-0920-030-01P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9802.32,6861.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS PEGGED GLENOID -,SUP-GLN-0920-030-02P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9802.32,6861.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS PEGGED GLENOID L -,SUP-GLN-0920-030-03P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4010.16,2807.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
GLENDOID S FIN-LOCK -,SUP-GLN-0926-030-01A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5882.18,4117.526,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
RSS GLENOSPHERE CONCENTRIC -S 2MM -,SUP-GLS-0961-02C-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
RSS GLENOSPHERE CONCENTRIC -S 5MM -,SUP-GLS-0961-05C-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS PEGGED GLENOID XS -,SUP-GN092003000P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10292.44,7204.708,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
KEY SURG 26MM F /UHR ACTB HEAD REM -,SUP-HIUHRK26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1195.26,836.682,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASE PLATE ASSEMBLY IJS-E -,SUP-IJS-ELB-BPA,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21316.33,14921.431,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STANDARD POLY LINER +0 -,SUP-LNR-0960-00S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
RSS HXL LINER STANDARD +35 -,SUP-LNR-0960-191-3S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
RSS HXL LINER STANDARD +65 -,SUP-LNR-0960-191-6S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
RSS HXL LINER STANDARD +9S -,SUP-LNR-0960-191-9S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
RSS HXL LINER STANDARD +OS -,SUP-LNR-0960-191-OS,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
RSS HXL LINER RETENTIVE +6R -,SUP-LNR-0960-192-6R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SYSTEM GREAT TOE MOVEMENT PROX PHALANX HEMI -,SUP-MGT-890-20PPH,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10627.83,7439.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SYS MOVEMENT GREAT TOE SIZE 40 HEMI PROX PHALANX -,SUP-MGT89040PPH,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10627.83,7439.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM 44X19MM TITAN 2.5 ECCT COCR -,SUP-MHH-0920-010-4419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6991.01,4893.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS COCR ECCENTRIC HEAD 2.5 40 X 15MM -,SUP-MHH-0923-010-4015E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS COCR CONCENTRIC HEAD 2.5 44 X 19MM -,SUP-MHH-0923-010-4419C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD TSS COCR ECCENTRIC 2.5 44 X 19MM -,SUP-MHH-0923-010-4419E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CONCENTRIC HEAD TSS COCR 2.5 46 X 14MM -,SUP-MHH-0923-010-4614C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS COCR ECCENTRIC HEAD 2.5 46 X 14MM -,SUP-MHH-0923-010-4614E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD CONCENTRIC TSS COCR 2.5 46MM X 17MM -,SUP-MHH-0923-010-4617C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD TSS COCR ECCENTRIC 2.5 46 X 17MM -,SUP-MHH-0923-010-4617E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS COCR CONCENTRIC HEAD 2.5 46 X 20MM -,SUP-MHH-0923-010-4620C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS COCR CONCENTRIC HEAD 2.5 48 X 18MM -,SUP-MHH-0923-010-4818C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD HUM COCR CONC 2.5 X 48 X 21MM TSS -,SUP-MHH-0923-010-4821C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD TSS COCR ECCENTRIC 2.5 48 X 21MM -,SUP-MHH-0923-010-4821E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS COCR CONCENTRIC HEAD 2.5 50 X 19MM -,SUP-MHH-0923-010-5019C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS COCR CONCENTRIC HEAD 2.5 50 X 22MM -,SUP-MHH-0923-010-5022C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD TSS COCR CONCENTRIC 2.5 52 X 20MM -,SUP-MHH-0923-010-5220C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
IMPLANT SZ30 -,SUP-MHT-30,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6017.99,4212.593,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT LT SIZE 7 FEMORAL CR NONPOROUS COCR -,SUP-ORTHO DEV,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEMORAL 36MM +3 BIOLOX DELTA -,SUP-ORTHO DEV,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL PS 8MM SIZE 5 VITAMIN E -,SUP-ORTHO DEV,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM PLASMA SPRAY STD SIZE 11 -,SUP-ORTHO DEVELOPMENT,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIB SZ1 STRIDE LL/RM -,SUP-PFSI-00001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIB SZ2 STRIDE LL/RM -,SUP-PFSI-00003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIB SZ2 STRIDE RL/LM -,SUP-PFSI-00004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STRIDE TIBIA BASEPLATE SIZE 3 RM/LL -,SUP-PFSI00005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIB SZ3 STRIDE LL/RM -,SUP-PFSI-00005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIB SZ3 STRIDE RL/LM -,SUP-PFSI-00006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIBIAL STRIDE SZ 4 RMLL -,SUP-PFSI00007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STRIDE TIBIA BASEPLATE SZ. 4 LM/RL -,SUP-PFSI00008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIB SZ4 STRIDE RL/LM -,SUP-PFSI-00008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP TIB SZ5 STRIDE LL/RM -,SUP-PFSI-00009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5156.46,3609.522,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL 8MM SIZE A -,SUP-PFSI00021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ A 9MM -,SUP-PFSI-00022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIB SZ B 8MM -,SUP-PFSI00027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STRIDE POLY INSERT SZ. B 8MM -,SUP-PFSI00027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STRIDE POLY INSERT TIB SZ-C 8MM -,SUP-PFSI00033,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ1 STRIDE LL/RM -,SUP-PFSI-00052,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STRIDE FEMUR SZ. 3 LM/RL -,SUP-PFSI00055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10492.44,7344.708,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ3 STRIDE LL/RM -,SUP-PFSI00056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10492.44,7344.708,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STRIDE FEMUR SIZE 4 RM/LL -,SUP-PFSI00058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10492.44,7344.708,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP FEM SZ5 STRIDE LL/RM -,SUP-PFSI-00060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP COMPREHESIVE MODULAR HYBRID REGNREX SHLDR POST -,SUP-PT-113950,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 9MM LNG REUNION COCR HAP CTD SHLDR -,SUP-R53514509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SPACER KN 46MM FEM MODHD ANTBTC REMEDY -,SUP-RHHDSM,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8093.31,5665.317,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM MED MODULAR -,SUP-RHSTMD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD FEM REFLEX HYBRID 32MM +2.5MM NK COCR C-TAPR PRIM LFRIC -,SUP-S1400HH32,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
C-TAPER LFIT INTER HEAD 28MM +2.5 -,SUP-S-1400-HH82,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
C-TAPER HEAD +7.5 OFFSET LFIT SZ. 28MM / +7.5 -,SUP-S-1400-HH84,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PEG 4 MOD GLEN SZ 2 -,SUP-SAGL2042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
4 PEG MOD GLEN SZ 3 -,SUP-SAGL2043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PEG 4 MOD GLEN SZ 4 -,SUP-SAGL2044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PEG 4 MOD GLEN SZ5 -,SUP-SAGL2045,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT 4 PEG MOD GLEN LT AUG SZ 2 -,SUP-SAGL2142,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
4 PEG MOD GLEN LT AUG SZ 3 -,SUP-SAGL2143,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PEG 4 MOD GLEN LT AUG SZ 5 -,SUP-SAGL2145,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
4 PEG MOD GLEN RT AUG SZ 2 -,SUP-SAGL2242,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
4 PEG MOD GLEN RT AUG SZ 3 -,SUP-SAGL2243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
4 PEG MOD GLEN RT AUG SZ 4 -,SUP-SAGL2244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PEG 4 MOD GLEN RT AUG SZ 5 -,SUP-SAGL2245,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
MODULAR POST PPS -,SUP-SAGP0001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
MODULAR POST TM -,SUP-SAGP0002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 10MM SHLDR -,SUP-SEM092002510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
OXINIUM LEGION PS-SPC FEMUR LEFT SIZE 5 -,SUP-SMITH & NE,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9155.58,6408.906,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 16.7MM PROX 10MM DIST SM 150MM INTSPC HI RELS 25MM -,SUP-SPC0022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12735.59,8914.913,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 10.5MM/21.9MM DIA P/D MED/SHRT 156MM INTSPC HI RELS -,SUP-SPC0122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12364.29,8655.003,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SPACER THR CMNT XL 54MM HIP REVISN INTSPC -,SUP-SPC0421,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11101.87,7771.309,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM FEM 10.5MM/21.9MM DIA P/D MED LNG 271MM INTSPC HI RELS -,SUP-SPC0422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SPACER THR CMNT LNG STM 60MM HIP REVISN INTSPC -,SUP-SPC0522,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
SMART TOE INTRAMEDULLARY ARTHRODEAL 11MM -,SUP-ST0XS-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6409.29,4486.503,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS PRESS FIT STEM SZ. O7 -,SUP-STEM-0920-025-07,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS PRESS FIT STEM SIZE 08 -,SUP-STEM-0920-025-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS PRESS FIT HUM STEM SIZE 09 -,SUP-STEM-0920-025-09,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 12MM PRFT TITAN -,SUP-STEM-0920-025-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS PRESS FIT STEM SZ 10 -,SUP-STEM-0920-025-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 11MM PRFT TITAN -,SUP-STEM-0920-025-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM PRESS FIT TSS SZ 12 -,SUP-STEM-0920-025-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HUM 13MM PRFT TITAN -,SUP-STEM-0920-025-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS PRESS FIT STEM SZ 14 -,SUP-STEM-0920-025-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM PRESS FIT TSS SZ 15 -,SUP-STEM-0920-025-15,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS PRESS FIT STEM SIZE 16 -,SUP-STEM-0920-025-16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TSS CEMENTED STEM SZ 08 -,SUP-STEM-0950-025-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT ECCENTRIC CUP 10' X 36MM X3 CODE E TRIDENT -,SUP-STRYKER,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
WEDGE ACETABULAR AUGMENT 54MM X 56MM X 15MM -,SUP-STRYKER,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP VRSDL GLNSPR 36MM TI -,SUP-TI-115310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP ACTB 26X42MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-42-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP ACTB 26X43MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-43-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP ACTB 26X44MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-44-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP ACTB 26X45MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-45-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP ACTB 26X46MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-46-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP ACTB 26X47MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-47-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP ACTB 26X48MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-48-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP ACTB 26X50MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-50-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP ACTB 26X51MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-51-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP ACTB 26X52MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-52-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP ACTB 26X53MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-53-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP ACTB 26X54MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-54-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP ACTB 26X55MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-55-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP ACTB 26X56MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-56-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMP ACTB 26X58MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-58-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT TIBIAL HALF BLOCK #6 T -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE MED GLENOID UNIVER -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7278.46,5094.922,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
AUGMENT FEM DIST 12MM SIZE 4 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BASEPLATE 3LT REV TIBIA LNG -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
GLENOID REVERS 39 +4 LAT -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CONE FEMORAL MEDIUM LEFT 30MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CONE TIBIAL 31 X 31 X 25MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CONE PROX BODY SIZE 0 60MM TYP -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT LGN OX FEMORAL 5LT C -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPONENT LT MOD FEM SIZE 3 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CUP PIVOT BIPOLAR 22 X 45MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
CUP UNIVERS REVERS 39 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7575.54,5302.878,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HEAD 40 CER 16/18 TAPER BIOLOXD -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
HUMERAL HEAD UNIVERS 44/17 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
GLENOID POLY WITH PEG LG -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
GLENOID POLY WITH PEG SMALL -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT HUMERAL M/39 +3 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
POSTERIOR FEM AUGMENT 8MM SZ 4 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
INSERT TIBIAL #5 13MM TS -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM DIST CONICAL 21MM X 155MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM STR DIST 21MM X 150MM TAP -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBAL INSERT TOTAL STAB SZ.3 9 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIAL CONE MED 31 X 31 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2768.92,1938.244,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TRIAL KNEE INSERT 3X12 PS ORTH -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
WEDGE ACET AUGMENT 46MM X 15MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM STR DIST 21MM X 90MM TAPE -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HIP MODULAR 12MM X 127MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10941.84,7659.288,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM HIP MODULAR 13MM X 127MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10941.84,7659.288,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
STEM UNIVERS SZ10 CAP COATED -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10546.34,7382.438,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIB TRAY ROTATING REV  SZ 2 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
TIBIAL HALF BLOCK #6 5MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPR NANO HMRL PPS 36MM -,SUP-US-115736,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24134.5,16894.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPR NANO HMRL PPS 38MM -,SUP-US-115738,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24134.5,16894.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
COMPR NANO HMRL PPS 40MM -,SUP-US-115740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24134.5,16894.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
BEARING HUM 44-36MM XL STD RVRS CMPRHNSV ARCM -,SUP-XL115363,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
ARCOM XL 44-36 STD HMRL BRNG -,SUP-XL-115363,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
44MM X 36MM CURV HUMERAL BEARING -,SUP-XL-115364,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
PERSONA FEMUR CEMENTED STD CCR SIZE 7 LEFT -,SUP-ZIMMER,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.170825,27238.33344,other,OPPS APC,,
LEAD DEFIB IMPL BIPLR PERMNT PCNG ETAK RELIANCE 59CM 9FR -,SUP-0137,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC,,
ENDOTAK RELIANCE S 64CM REF: 0138 -,SUP-0138,CDM,C1777,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC,,
LEAD PCNG 64CM ETAK RELIANCE SG -,SUP-0181,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC,,
ENDOTAK RELIANCE S 0272 59CM -,SUP-0272-59,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC,,
ENDOTAK RELIANCE S 0273 64CM -,SUP-0273-64,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC,,
LEAD ENDOTAK RELIANCE SINGLE C -,SUP-0292,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC,,
LEAD DEFIB PCNG ETAK RELIANCE 59CM GORE-HYBRID ETFE CTD STRD -,SUP-0292-59,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC,,
LEAD ICD RELIANCE 4-FRONT DEFIB -,SUP-0672-59,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC,,
LEAD DEFIB IMPL LINOX SMRT S 65CM ECRD SIL INSL SGL COIL -,SUP-369818,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC,,
LEAD DEFIB IMPL LINOX SMRT S 60CM ECRD SIL INSL SGL COIL -,SUP-375012,CDM,C1777,HCPCS,278,RC,,,outpatient,,,12976.94,9083.858,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC,,
LEAD PCNG PROTEGO T FX -,SUP-379967,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC,,
DEFIBRILLATOR PROTEGO S SGL COIL 75CM LD CARD IMPL -,SUP-379968,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC,,
DEFIBRILLATOR PROTEGO S SGL COIL 60CM LD CARD IMPL -,SUP-379970,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC,,
PLEXA PROMRI DF-1 S DS 65/15 -,SUP-414005,CDM,C1777,HCPCS,278,RC,,,outpatient,,,10734.28,7513.996,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC,,
LEAD DEFIB TRIPLR SPRNT QUATTRO 58CM 8.6FRX12MM SPC RT ECRD -,SUP-6935-58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC,,
LEAD DEFIB TRIPLR SPRNT QUATTRO 75CM 8.6FRX12MM SPC SIL -,SUP-6935M,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC,,
LEAD DEFIB TRIPLR SPRNT QUATTRO 72CM 8.6FRX12MM SPC SIL -,SUP-6935M72,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC,,
LEAD DEFIB UNIPL 58CM 7.5FR SUBQ SIL INSL SUT ON ANCHR SLV -,SUP-6996SQ58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC,,
LEAD DEFIB TRUE BIPLR DURATA 60CM 7FR VNTRC OPTIM INSL STRD -,SUP-7122/60,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC,,
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FR VNTRC OPTIM INSL STRD -,SUP-7122/65,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC,,
LEAD DEFIB TRUE BIPLR DURATA 52CM 7FR VNTRC OPTIM INSL SGL. -,SUP-7122Q/52,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC,,
LEAD DEFIB 7FRX58CM DURATA TRUE BIPLR HLCL TIP AV SGL SHOCK. -,SUP-7122Q/58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC,,
LEAD DEFIB 7FRX65CM DURATA TRUE BIPLR HLCL TIP AV SGL SHOCK -,SUP-7122Q/65,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC,,
LEAD DEFIB 8FR INTRO 58CM OPTISURE TRUE BIPLR SGL COIL -,SUP-LDA210Q/58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC,,
LEAD DEFIB 8FR INTRO 65CM OPTISURE TRUE BIPLR SGL COIL -,SUP-LDA210Q-65,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9966.28992,other,OPPS APC,,
PK LEAD NEURSTM ACC -,SUP-30571SC,CDM,C1778,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC,,
KT LEAD NEURSTM OCTRODE 60CM ACC -,SUP-3186,CDM,C1778,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC,,
OCTRODE -,SUP-3189,CDM,C1778,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC,,
LEAD NEURSTM PENTA 60CM PDL -,SUP-3228,CDM,C1778,HCPCS,278,RC,,,outpatient,,,14480.7,10136.49,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC,,
KT LEAD NEURSTM LMTRD S-8 60CM ACC -,SUP-3286,CDM,C1778,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC,,
KT 8MMX60CM LDX1 REVISN F/MDTRNC DEEP BRN STIM DBS -,SUP-3550-27,CDM,C1778,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC,,
KT EXTENSION NEURSTM 40CM ACC -,SUP-3708140,CDM,C1778,HCPCS,278,RC,,,outpatient,,,3007.62,2105.334,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC,,
KT LEAD NEURSTM PLTNM-IRDM ELCTRD 60CM STD ACC -,SUP-3777-60,CDM,C1778,HCPCS,278,RC,,,outpatient,,,7193.58,5035.506,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC,,
KT LEAD NEURSTM 60CM PERC CMPCT ACC -,SUP-3778-60,CDM,C1778,HCPCS,278,RC,,,outpatient,,,7193.58,5035.506,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC,,
KT LEAD NEURSTM PLTNM-IRDM ELCTRD PU SLVR COR 75CM PERC -,SUP-3778-75,CDM,C1778,HCPCS,278,RC,,,outpatient,,,7193.58,5035.506,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC,,
LEAD PCNG 56CM TIP PISCES QUAD -,SUP-3887-56,CDM,C1778,HCPCS,278,RC,,,outpatient,,,4498.64,3149.048,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC,,
KT LEAD NEURSTM SPEC FLRPLYMR PLTNM-IRDM SIL RBR PLYSTR PU -,SUP-3956530,CDM,C1778,HCPCS,278,RC,,,outpatient,,,17822.4,12475.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC,,
KT LEAD NEURSTM SPEC 65CM SPIN CRD 5-6-5 LD ACC -,SUP-3956565,CDM,C1778,HCPCS,278,RC,,,outpatient,,,17822.4,12475.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC,,
REACTIV8 IMPLANTABLE LEAD 45CM -,SUP-8145,CDM,C1778,HCPCS,278,RC,,,outpatient,,,11127.86,7789.502,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC,,
STIMULATOR NERVE SPRINT ENDURA PNS SYSTEM -,SUP-9244-6001,CDM,C1778,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC,,
STIMULATOR NERVE SPRINT EXTENSA PNS SYSTEM -,SUP-9288-6002,CDM,C1778,HCPCS,278,RC,,,outpatient,,,30075.3,21052.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC,,
LEAD NEURSTM VECTRIS SURECAN 60CM PERC IMPL -,SUP-977A260,CDM,C1778,HCPCS,278,RC,,,outpatient,,,8347.95,5843.565,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC,,
SYS PROGRAMMER NEURSTM VECTRIS SURSCN 75CM SPIN CRD CMPCT -,SUP-977A275,CDM,C1778,HCPCS,278,RC,,,outpatient,,,8347.95,5843.565,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC,,
SURESCAN MRI -,SUP-977C165,CDM,C1778,HCPCS,278,RC,,,outpatient,,,20681.41,14476.987,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC,,
LEAD SPECIFY SURESCAN MRI LEAD -,SUP-977C265,CDM,C1778,HCPCS,278,RC,,,outpatient,,,20681.41,14476.987,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC,,
SURESCAN 2 X 8 PADDLE LEAD -,SUP-977C290,CDM,C1778,HCPCS,278,RC,,,outpatient,,,20681.41,14476.987,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC,,
LEAD INTERSTIM MICRO 28CM SSMRI TINED -,SUP-978A128,CDM,C1778,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC,,
INTERSTIM MRI LEAD KIT 2.16MM X 28CM -,SUP-978B128,CDM,C1778,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC,,
LEAD NEUROSTIMULATOR INTERSTIM L41 CM TINE SSMRI -,SUP-978B133,CDM,C1778,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC,,
FREEDOM 4A NEUROSTIMULATOR FR4A-TRL-A0 -,SUP-FR4A-TRL-A0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC,,
FREEDOM 4A NEUROSTIMULATOR FR4A-TRL-B0 -,SUP-FR4A-TRL-B0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC,,
FREEDOM-8A TRIAL KIT CH A US -,SUP-FR8A-TRL-A0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC,,
FREEDOM 8A NEUROSTIMULATOR FR8A-TRL-B0 -,SUP-FR8A-TRL-B0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC,,
KIT INTELLIS TRIAL LEAD 2 -,SUP-INTELTRIAL2,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC,,
BLUE PERC LEAD KIT -,SUP-LEAD1058-70B,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC,,
NEVRO 70CM SURGICAL LEAD KIT -,SUP-LEAD3005-70B,CDM,C1778,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC,,
KT NEURSTM PRGMR PRECISN ACC -,SUP-M365SC550040,CDM,C1778,HCPCS,278,RC,,,outpatient,,,6196.24,4337.368,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC,,
VECTRIS SURESCAN MRI COMPACT LEAD KIT 1 X 8 SC -,SUP-MEDTRONIC INC,CDM,C1778,HCPCS,278,RC,,,outpatient,,,8347.95,5843.565,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC,,
SLIM TIP DRG -,SUP-MN10450-50A,CDM,C1778,HCPCS,278,RC,,,outpatient,,,9331.07,6531.749,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC,,
SLIMTIP DRG 90A -,SUP-MN10450-90A,CDM,C1778,HCPCS,278,RC,,,outpatient,,,9509.36,6656.552,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC,,
KIT NEUROSTIMULATOR TUNNEL TOOL -,SUP-MN15000,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2572.47,1800.729,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC,,
FREEDOM -4A PNS SYSTEM -,SUP-Q4SP-1-US DW,CDM,C1778,HCPCS,278,RC,,,outpatient,,,40705.5,28493.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC,,
FREEDOM -4A PNS SYSTEM -,SUP-Q4SP-2-US,CDM,C1778,HCPCS,278,RC,,,outpatient,,,44406,31084.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC,,
COVEREDGE 32 MRI PADDLE LEAD 50CM -,SUP-SC-8436-50,CDM,C1778,HCPCS,278,RC,,,outpatient,,,29704,20792.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC,,
TRIAL LEAD KIT -,SUP-TLEAD1058-70B,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,34103.808,other,OPPS APC,,
LEAD PCNG 9FRX12MM SPC AV + DX PERMNT BIPLR STRD ELUT TND FX -,SUP-1368,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2035.392,other,OPPS APC,,
LEAD PCNG 9FRX12MM SPC 52CM AV + DX PERMNT BIPLR STRD ELUT -,SUP-1368/52,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2035.392,other,OPPS APC,,
LEAD PCNG 9FRX12MM SPC 58CM AV + DX PERMNT BIPLR STRD ELUT -,SUP-1368/58,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2035.392,other,OPPS APC,,
PACING  LEAD TENDRIL STS 2088TC-65 -,SUP-2088TC-65,CDM,C1779,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2035.392,other,OPPS APC,,
LEAD PCNG 58CM SOLOX IMPL BIPLR ECRD SGL -PASS PSS FX -,SUP-333900,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2035.392,other,OPPS APC,,
MESH SURG LRG 5.4X7IN OVL PP EPTFE CMPSX KL NABSB PTCH -,SUP-0010202,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5029.22,3520.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG SM 3.1X4.7IN OVL MONO PP PDS EPTFE VENTRIO PRT -,SUP-0010211,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3818.72,2673.104,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG LRG 5.4X7IN OVL MONO PP PDS EPTFE VENTRIO PRT ABSB -,SUP-0010212,CDM,C1781,HCPCS,278,RC,,,outpatient,,,7123.55,4986.485,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG 4.5IN LRG CIR MONO PP PDS EPTFE VENTRIO PRT ABSB -,SUP-0010214,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4340.04,3038.028,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG MED 4.3X5.5IN OVL MONO PP PDS EPTFE VENTRIO PRT -,SUP-0010215,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5013.01,3509.107,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG 8CM LRG 3.2X3.2IN CIR PP EPTFE VENTRALEX NABSB -,SUP-0010303,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4167.7,2917.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PERFIX PLUG MED -,SUP-0112760,CDM,C1781,HCPCS,278,RC,,,outpatient,,,984.1,688.87,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PERFIX PLUG LRG -,SUP-0112770,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1660.12,1162.084,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PLUG PERFIX X-LRG -,SUP-0112780,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1159.39,811.573,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH 3DMAX DAVOL LRG LEFT -,SUP-0115311,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH 3DMAX DAVOL X-LRG LEFT -,SUP-0115312,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1187.9,831.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH 3DMAX DAVOL LRG RIGHT -,SUP-0115321,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH 3DMAX DAVOL X-LRG RIGHT -,SUP-0115322,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1187.9,831.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH MOD KUGEL 3.5 X 5 -,SUP-0115816,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG 4X6IN ELLIP MONO PP EPTFE COMPOSIX E /X NABSB -,SUP-0123460,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2954.63,2068.241,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH ATRIUM 1 X 4 - DISC DO NOT USE -,SUP-1000104-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,116.7,81.69,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH ATRIUM 2 X 4 -  DISC DO NOT USE -,SUP-1000204-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,128.37,89.859,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH ATRIUM 6 X 6 - DO NOT USE DISCONTINUED -,SUP-1000606-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,163.38,114.366,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH ATRIUM 6X6 - DISCONTINUED DO NOT USE -,SUP-1000606-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,163.38,114.366,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG 10X14IN PP KNTD PROLITE NABSB SHT -,SUP-1001014-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,478.47,334.929,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH ATRIUM PRE SHAPED -,SUP-1010306-02,CDM,C1781,HCPCS,278,RC,,,outpatient,,,192.56,134.792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG 20X30CM RECT EPTFE GORE-TEX PTCH -,SUP-1320030020,CDM,C1781,HCPCS,278,RC,,,outpatient,,,18928.87,13250.209,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG 5X10CM EPTFE GORE-TEX PTCH -,SUP-1405010010,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1754.47,1228.129,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG 10X15CM OVL EPTFE GORE-TEX PLG -,SUP-1410015010,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4014.93,2810.451,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
IMPLANT ARTELON 0.3X16CM -,SUP-31052,CDM,C1781,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
IMPLANT ARTELON 0.7X16CM -,SUP-31056,CDM,C1781,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PROLENE 3D PATCH LRG -,SUP-3DPL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3399.12,2379.384,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PROLENE 3D PATCH MED -,SUP-3DPM,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3399.12,2379.384,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH RESTORELLE 24CM X 4CM -,SUP-501420,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4419.28,3093.496,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH VENTRALEX ST SM 4.3CM -,SUP-5950007,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2292.25,1604.575,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH VENTRALEX ST MD 6.4CM -,SUP-5950008,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2488.78,1742.146,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH VENTRALEX ST LRG 8.0CM -,SUP-5950009,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3167.55,2217.285,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG 3IN SM CIR MONO PP CO-KNTD VENTRALEX ST ECHO PS -,SUP-5950010,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3765.73,2636.011,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG SM 3.1X4.7IN OVL MONO PP CO-KNTD VENTRALEX ST ECHO -,SUP-5950030,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4634.12,3243.884,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG MED 4.3.X5.5IN OVL MONO PP CO-KNTD VENTRALEX ST -,SUP-5950040,CDM,C1781,HCPCS,278,RC,,,outpatient,,,6128.34,4289.838,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG XL 8.7X10.7IN OVL MONO PP PTFE HYDRGL CO-KNTD -,SUP-5950080,CDM,C1781,HCPCS,278,RC,,,outpatient,,,12018.24,8412.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG 4X6IN ELLIP MONO PP PTFE HYDRGL CO-KNTD -,SUP-5954460,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3720.86,2604.602,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG 15CM MED RND ACCUMESH PSTN -,SUP-AMPPCO15X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3904.18,2732.926,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG 20CM MED RND ACCUMESH PSTN -,SUP-AMPPCO20X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4655.67,3258.969,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PARIETEX 15CM X 10CM RT -,SUP-AUTO-VTX1510,CDM,C1781,HCPCS,278,RC,,,outpatient,,,465.28,325.696,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH DEXTILE MEDIUM LEFT 13 X 9CM ANATOMICAL -,SUP-DXT1309AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH DEXTILE MEDIUM RIGHT 13 X 9CM ANATOMICAL -,SUP-DXT1309AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH DEXTILE LARGE LEFT 15 X 10CM ANATOMICAL -,SUP-DXT1510AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,846.08,592.256,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH DEXTILE LARGE RIGHT 15 X 10CM ANATOMICAL -,SUP-DXT1510AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,846.08,592.256,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH DEXTILE XL LEFT 16 X 12CM ANATOMICAL -,SUP-DXT1612AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH DEXTILE XL RIGHT 16 X 12CM ANATOMICAL -,SUP-DXT1612AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
PATCH BOVINE 0.8 X 8CM -,SUP-E0.8P8,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1160.81,812.567,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
PATCH BOVINE 2.0 X 9CM -,SUP-E2P9,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2008.89,1406.223,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
GORE BIOABSORBABLE SYNTHETIC MESH 7CM X 10CM -,SUP-HH0710,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH LAP PROGRIP 15 X 10 -,SUP-LPG1510,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1664.57,1165.199,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PROGRIP ANATOM 15x10 L -,SUP-LPG1510AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1878.87,1315.209,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PROGRIP ANATOM 15x10 R -,SUP-LPG1510AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1878.87,1315.209,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PROGRIP LAPAROSCOPIC SELF-FIX 16 X 12 -,SUP-LPG1612,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1888.04,1321.628,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PROGRIP ANATOM 16X12 L -,SUP-LPG1612AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2098.94,1469.258,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PROGRIP ANATOMICAL RIGHT 16CM X 12CM -,SUP-LPG1612AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2098.94,1469.258,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
UPSYLON TRADITIONAL Y MESH -,SUP-M0068318200,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4180.97,2926.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PROCEED 6IN X 8IN -,SUP-PCDG1,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4886.8,3420.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PROCEED 4IN X 6IN -,SUP-PCDN1,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2936.68,2055.676,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
IMPLANT BIO TISS 10X15CM 3D RND PLYSTR PRCN COLL OPN SKRT -,SUP-PCO1510OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2440.67,1708.469,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
IMPLANT PLYSTR PRCN COLL 10X15CM PRTX 1.7MM ABSB 3D RND KNTD -,SUP-PCO1510X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1920.48,1344.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
IMPLANT BIO TISS 15CM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCO15X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2513.71,1759.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
IMPLANT BIO TISS 15X20CM 3D RECT PLYSTR PRCN COLL KNTD PRTX -,SUP-PCO2015OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3387.39,2371.173,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
IMPLANT BIO TISS 15X20CM 3D RND PLYSTR PRCN COLL KNTD PRTX -,SUP-PCO2015X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3237.25,2266.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PARIETEX HEART SHAPED -,SUP-PCO2H1,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1862.49,1303.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PARIETEX HORSE SHOE -,SUP-PCO2H3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1999.72,1399.804,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
IMPLANT BIO TISS 20X30CM 3D RECT PLYSTR PRCN COLL KNTD PRTX -,SUP-PCO3020X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5125.65,3587.955,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
PATCH VENTRAL PARITEX 4.6CM -,SUP-PCO4VP,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1712.49,1198.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
PATCH VENTRAL PARITEX 6.6CM -,SUP-PCO6VP,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2052.19,1436.533,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
IMPLANT BIO TISS 8CM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCO8OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2128.52,1489.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
IMPLANT BIO TISS 8CM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCO8OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2365.35,1655.745,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
PATCH VENTRAL PARITEX 8.6CM -,SUP-PCO8VP,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2635.99,1845.193,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
IMPLANT BIO TISS 50MM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCOPM15H50,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2579.06,1805.342,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PROLENE HERNIA SYSTEM LARGE -,SUP-PHSL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2038.93,1427.251,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PROLENE HERNIA SYSTEM MEDIUM -,SUP-PHSM,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2038.93,1427.251,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PARIENTENE PROGRIP 15CM X 9CM -,SUP-PP1509G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1083.58,758.506,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PARITENE MACROPOROUS 15 X 10 -,SUP-PPM1510X3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,223.71,156.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PARITENE MACROPOROUS 15 X 15 -,SUP-PPM1515X3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,259.54,181.678,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PARIETENE 20 X 20 -,SUP-PPM2020,CDM,C1781,HCPCS,278,RC,,,outpatient,,,301.09,210.763,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PARIETENE 30 X 30 -,SUP-PPM3030,CDM,C1781,HCPCS,278,RC,,,outpatient,,,563.14,394.198,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PARIETENE 45 X 30 -,SUP-PPM4530,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1191.23,833.861,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
DURASORB PTM 0616 6 X 16 -,SUP-PTM 0616,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
DURASORB PTM1 025 10 X 25 -,SUP-PTM1025,CDM,C1781,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
DURASORB PTM 2025 -,SUP-PTM2025,CDM,C1781,HCPCS,278,RC,,,outpatient,,,20050.2,14035.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG 6X11CM RECT PLYSTR KNTD MERSILN NABSB SHT -,SUP-RMS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,992.11,694.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SYMBOTEX 25 X 20 0118362 -,SUP-SMY2520OS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,6454.57,4518.199,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SYMBOTEX VENTRAL 12CM -,SUP-SYM12,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1989.6,1392.72,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SYMBOTEX VENTRAL 15CM -,SUP-SYM15,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2490.4,1743.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SYMBOTEX VENTRAL 15CM -,SUP-SYM15,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2571.48,1800.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SYMBOTEX VENTRAL 15 X 10 NON SKIRTED -,SUP-SYM1510,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1808.74,1266.118,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SYMBOTEX 15 X 10 -,SUP-SYM1510OS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2418.08,1692.656,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SYMBOTEX 2012E -,SUP-SYM2012E,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2774.79,1942.353,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SYMBOTEX 20 X 15 CM -,SUP-SYM2015,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2613.29,1829.303,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SYMBOTEX 20 X 15 SKIRTED -,SUP-SYM2015OS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3726.15,2608.305,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG 25X15CM ELLIP MONO PLYSTR COLL SYMBOTEX NABSB -,SUP-SYM2515E,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4592.69,3214.883,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PARIETENE DS COMPOSITE 25CM X 20CM -,SUP-SYM2520,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4274.74,2992.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SYMBOTEX 25 X 20 -,SUP-SYM2520,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4118.24,2882.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SYMBOTEX 30 X 20 -,SUP-SYM3020,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5381.94,3767.358,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SYMBOTEX COMPOSITE -,SUP-SYM3728,CDM,C1781,HCPCS,278,RC,,,outpatient,,,6391.04,4473.728,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
Symbotexâ„¢ Composite Mesh- 42 x 32 cm -,SUP-SYM4232,CDM,C1781,HCPCS,278,RC,,,outpatient,,,7515.87,5261.109,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SYMBOTEX VENTRAL 9CM -,SUP-SYM9,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1450.75,1015.525,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG 10X15CM PLYSTR KNTD PRTX SHT -,SUP-TECT1510ADPL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,734.63,514.241,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
"MESH PARIETEX ANATOMICAL LEFT 6X4"" -",SUP-TECT1510AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,648.04,453.628,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
"MESH PARIETEX ANATOMICAL RIGHT 6X4"" -",SUP-TECT1510AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,648.04,453.628,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG 8X12CM MONO PLYSTR KNTD PRTX PROGRIP PRT -,SUP-TEM1208GL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1175.76,823.032,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG 8X12CM MONO PLYSTR KNTD PRTX PROGRIP PRT ABSB -,SUP-TEM1208GR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1175.76,823.032,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PARIETEX PROGRIP 15cm x 9cm -,SUP-TEM1509G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1083.58,758.506,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PARIETEX PROGRIP 15 X 15CM -,SUP-TEM1515G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1131.55,792.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PARIETEX PROGRIP 20X15 -,SUP-TEM2015G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1382.48,967.736,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH PARIETEX PROGRIP 30X15 -,SUP-TEM3015G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1925.62,1347.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG 30X30CM 3D PLYSTR KNTD PRTX EASEGRIP SHT -,SUP-TET3030,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1054.85,738.395,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH SURG 3X6IN RECT MONO PLGCPRN-25 PP KNTD ULTRAPRO PRT -,SUP-UMR3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,908.96,636.272,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
GRAFT HEMASHIELD 10MM X100CM G -,SUP-UNDEFINED,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2550.8,1785.56,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH VENTRIO XL 10 X 13 -,SUP-UNDEFINED,CDM,C1781,HCPCS,278,RC,,,outpatient,,,8233.36,5763.352,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
MESH VICRYL WOVEN FLAT12IN x 12IN ABSORBABLE HERNIA REPAIR -,SUP-VWML,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4702.1,3291.47,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,15398.5536,other,OPPS APC,,
STENT DES 2.25X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332220,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,200.09685,4563.1488,,,,
STENT DES 2.5X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332250,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,200.09685,4563.1488,,,,
STENT DES 3X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332300,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,200.09685,4563.1488,,,,
STENT DES 3.5X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332350,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,200.09685,4563.1488,,,,
STENT DES 4X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332400,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,200.09685,4563.1488,,,,
STENT DES 2.75X38MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902338270,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,200.09685,4563.1488,,,,
STENT DES 3.5X38MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902338350,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,200.09685,4563.1488,,,,
STENT DES 4X38MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902338400,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,200.09685,4563.1488,,,,
IMPLANT BIO TISS 6.5CM 3D RND PLYSTR PRCN COLL KNTD PRTX -,SUP-PNP6X3,CDM,C1784,HCPCS,278,RC,,,outpatient,,,891.3,623.91,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,200.09685,4563.1488,,,,
PACEMAKER UNIPL BIPLR INSGA I ULTRA 2CHMBR RR 10.8ML 25.4GM -,SUP-1290,CDM,C1785,HCPCS,275,RC,,,outpatient,,,21052.71,14736.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER UNIPL BIPLR EVIA 2CHMBR 44.5X53MM 6.5MM 12ML 25GM -,SUP-359529,CDM,C1785,HCPCS,275,RC,,,outpatient,,,11220.69,7854.483,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER UNIPL BIPLR EVIA 2CHMBR RR 44.5X53MM 6.5MM 12ML -,SUP-377848,CDM,C1785,HCPCS,275,RC,,,outpatient,,,14573.53,10201.471,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER IMPL ENTOVIS PROMRI 2CHMBR IS-1 CONN SR-T ACC -,SUP-404722,CDM,C1785,HCPCS,275,RC,,,outpatient,,,18565,12995.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER IMPL UNIPL VERITY ADX MS DR 2CHMBR RR 45X52MM 6MM -,SUP-5357M/S,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9332.85,6532.995,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC,,
GENERATOR TEMP PLS 2CHMBR 5392 ACC -,SUP-5392KIT,CDM,C1785,HCPCS,275,RC,,,outpatient,,,27828.94,19480.258,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER IMPL UNIPL BIPLR VCT DR 2CHMBR RR V- PCNG RDC -,SUP-5810,CDM,C1785,HCPCS,275,RC,,,outpatient,,,13842.06,9689.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER IMPL UNIPL BIPLR VCT XL DR 2CHMBR RR V- PCNG RDC -,SUP-5816,CDM,C1785,HCPCS,275,RC,,,outpatient,,,13842.06,9689.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER IMPL UNIPL BIPLR ZPHR 2CHMBR RR 43X44MM 6MM 8.5ML -,SUP-5820,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9332.85,6532.995,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER IMPL UNIPL BIPLR ZPHR 2CHMBR RR 43X44MM 6MM 8.5ML -,SUP-5820,CDM,C1785,HCPCS,275,RC,,,outpatient,,,22278,15594.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER IMPL UNIPL BIPLR ZPHR DR 2CHMBR RR 44X52MM 6MM -,SUP-5826,CDM,C1785,HCPCS,275,RC,,,outpatient,,,18565,12995.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER IMPL SURSCN ADVISA 2CHMBR RR MUL-PRGM IS-1 CONN SR -,SUP-A2DR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16337.2,11436.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER IMPL UNIPL ADAPTA DR 2CHMBR RR 12ML 21GM IS-1 -,SUP-ADAPTADRK2,CDM,C1785,HCPCS,275,RC,,,outpatient,,,27828.94,19480.258,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER IMPL BIPLR ADAPT 2CHMBR RR 13.1ML 31.3GM IS-1 CONN -,SUP-ADDRL1,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16567.96,11597.572,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER IMPL UNIPL BIPLR ADAPTA 2CHMBR RR 42.9MMX44.7MM -,SUP-ADDRS1,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16567.96,11597.572,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC,,
GENERATOR 2CHMBR -,SUP-DR2550,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16708.5,11695.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER ESSENTIO DR DYNMC ADJ TI ACC -,SUP-L101,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9341.91,6539.337,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER ESSENTIO DR MRI L111 -,SUP-L111,CDM,C1785,HCPCS,275,RC,,,outpatient,,,12460.83,8722.581,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER IMPL ESSENTIO EL DR 2CHMBR 4.45X5.88X0.75IN 29.1GM -,SUP-L121,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9341.91,6539.337,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER ACCOLADE DR -REF: L301 -,SUP-L301,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9442.9,6610.03,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER ACCOLADE MRI DR L311 -,SUP-L311,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10582.05,7407.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER IMPL UNIPL BIPLR ACCENT DR 2CHMBR RR WRLS TELEM -,SUP-PM2110,CDM,C1785,HCPCS,275,RC,,,outpatient,,,12438.55,8706.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER ENDURITY 2CHMBR 50X46MM 6MM 10.4ML 19GM IS-1 CONN -,SUP-PM2160,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10470.66,7329.462,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER IMPL ACCENT DR 2CHMBR RR 52X52MM 6MM 12.8ML 23GM -,SUP-PM2210,CDM,C1785,HCPCS,275,RC,,,outpatient,,,12438.55,8706.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER IMPL ASSURITY 2CHMBR RR 50X47MM 6MM 10.4ML 20GM -,SUP-PM2240,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10732.43,7512.701,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC,,
ASSURITY MRI PACEMAKER DR-RF PM2272 -,SUP-PM2272,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10582.05,7407.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER IMPL BIPLR REVO 2CHMBR RR SURSCN PCNG -,SUP-REVOMRIPEEM,CDM,C1785,HCPCS,275,RC,,,outpatient,,,23622.66,16535.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER IMPL BIPLR REVO SURSCN 2CHMBR RR 45X51X8MM 12.7ML -,SUP-RVDR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,17439.96,12207.972,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER ALTRUA 20 DDDR MUL-PRGM 43X49X8MM 29.6GM 12.6ML -,SUP-S202,CDM,C1785,HCPCS,275,RC,,,outpatient,,,17451.1,12215.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER ALTRUA 20 MUL-PRGM 42X44X8MM 25.4GM 10.8ML IS-1 -,SUP-S203,CDM,C1785,HCPCS,275,RC,,,outpatient,,,14373.02,10061.114,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER BIPLR ALTRUA 60 2CHMBR RR 42X44MM 8MM 10.8ML -,SUP-S603,CDM,C1785,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER IMPL UNIPL BIPLR SENSIA 2CHMBR RR -,SUP-SEDR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10396.4,7277.48,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC,,
GENERATOR VERSA DUAL CHAMBER -,SUP-UNDEFINED,CDM,C1785,HCPCS,275,RC,,,outpatient,,,20402.94,14282.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER ALTRUA 20 DR 2 LD -,SUP-UNDEFINED,CDM,C1785,HCPCS,275,RC,,,outpatient,,,19827.42,13879.194,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC,,
VERSA DR VEDR01 -,SUP-VEDR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10396.4,7277.48,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER MRI AZURE XT DR SURESCAN -,SUP-W1DR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,18565,12995.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC,,
Azure S DR MRI Surescan W3DR01 -,SUP-W3DR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16708.5,11695.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21372.62592,other,OPPS APC,,
PACEMAKER BIPLR INSGA ULTRA SR SGL-CHMBR RR 10ML 23.4GM IS-1 -,SUP-1190,CDM,C1786,HCPCS,275,RC,,,outpatient,,,17451.1,12215.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC,,
PACEMAKER RELAY INTMD UNIPL CARD 5MM -,SUP-293-03,CDM,C1786,HCPCS,275,RC,,,outpatient,,,16151.55,11306.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC,,
PACEMAKER UNIPL BIPLR EVIA SR-T SGL-CHMBR RR 39X53MM 6.5MM -,SUP-359 533,CDM,C1786,HCPCS,275,RC,,,outpatient,,,10983.05,7688.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC,,
PACEMAKER IMPL ENTOVIS SR-T PROMRI SGL-CHMBR ACC -,SUP-404723,CDM,C1786,HCPCS,275,RC,,,outpatient,,,10457.22,7320.054,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC,,
GENERATOR IMPL VERF SGL-CHMBR -,SUP-5156,CDM,C1786,HCPCS,275,RC,,,outpatient,,,11792.49,8254.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC,,
PACEMAKER IMPL UNIPL VERITY ADX MS DR SGL-CHMBR RR 42X52MM -,SUP-5157M/S,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8533.24,5973.268,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC,,
PACEMAKER IMPL UNIPL BIPLR ZPHR SGL-CHMBR RR 41X44MM 6MM 8ML -,SUP-5620,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8533.24,5973.268,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC,,
PACEMAKER IMPL UNIPL BIPLR ZPHR XL SR SGL-CHMBR RR 52X42MM -,SUP-5626,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8533.24,5973.268,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC,,
PACEMAKER IMPL SURSCN ADVISA 1CHMBR IS-1 CONN SR -,SUP-A3SR01,CDM,C1786,HCPCS,275,RC,,,outpatient,,,14852,10396.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC,,
PACEMAKER IMPL UNIPL ADAPTA SR SGL-CHMBR RR 7.5MM 11ML -,SUP-ADSR06,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9952.18,6966.526,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC,,
GENERATOR PCMKR  SR SSIR -,SUP-ICV1122,CDM,C1786,HCPCS,275,RC,,,outpatient,,,12497.96,8748.572,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC,,
ESSENTIO 4.45X4.81X0.75 CM D 13.2ML TI -,SUP-L100,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8899.67,6229.769,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC,,
PACEMAKER ESSENTIO SR MRI -,SUP-L110,CDM,C1786,HCPCS,275,RC,,,outpatient,,,10901.37,7630.959,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC,,
PACEMAKER ACCOLADE SR -REF: L300 -,SUP-L300,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC,,
ACCOLADE MRI SR PACEMAKER L310 -,SUP-L310,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC,,
PACEMAKER LEADLESS SINGLE AVEIR RV REF: LSP112V -,SUP-LSP112V,CDM,C1786,HCPCS,275,RC,,,outpatient,,,37130,25991,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC,,
MICRA MDT TRANSCATHER PACING MICRA SYSTEM -,SUP-MC1VR01,CDM,C1786,HCPCS,275,RC,,,outpatient,,,26520.25,18564.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC,,
MICRA AV TRANSCATHETER  MC1AVR1 -,SUP-MICRAAVTCPSYSTEM,CDM,C1786,HCPCS,275,RC,,,outpatient,,,38855.25,27198.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC,,
TRANSCATHETER PACING SYSTEM INC:CAPSULEDELIV CATHINTROD -,SUP-MICRATCPSYSTEM,CDM,C1786,HCPCS,275,RC,,,outpatient,,,26520.25,18564.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC,,
PACEMAKER IMPL UNIPL BIPLR ACCENT SR SGL-CHMBR RR WRLS TELEM -,SUP-PM1110,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9375.33,6562.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC,,
PACEMAKER ENDURITY SGL-CHMBR 50X41X6MM 6MM 19GM 9.7ML IS-1 -,SUP-PM1160,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC,,
PACEMAKER IMPL UNIPL BIPLR ACCENT SR SGL-CHMBR RR WRLS TELEM -,SUP-PM1210,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9375.33,6562.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC,,
PACEMAKER IMPL ASSURITY SGL-CHMBR RR 50X47MM 6MM 10.4ML 20GM -,SUP-PM1240,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC,,
ASSURITY MRI PACEMAKER SR-RF -,SUP-PM1272,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC,,
PACEMAKER ALTRUA 40 SR SGL-CHMBR RR 42X42X8MM 10ML 23.4GM -,SUP-S401,CDM,C1786,HCPCS,275,RC,,,outpatient,,,12887.82,9021.474,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC,,
SYS ADAPTER PCMKR F/SR -,SUP-UNDEFINED,CDM,C1786,HCPCS,275,RC,,,outpatient,,,23744.64,16621.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC,,
DEFIBRILLATOR VIVA QUAD S CRTN -,SUP-VIVA QUAD S CRT-D,CDM,C1786,HCPCS,275,RC,,,outpatient,,,60532.78,42372.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC,,
Azure S SR NRI SureScan W3SR01 -,SUP-W3SR01,CDM,C1786,HCPCS,275,RC,,,outpatient,,,16708.5,11695.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46489.17504,other,OPPS APC,,
GENERATOR PROCLAIM 7 ELITE -,SUP-3662,CDM,C1787,HCPCS,272,RC,,,outpatient,,,40409.46,28286.622,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,28973.58282,other,OPPS APC,,
PROGRAMMER NEURSTM MYSTIM HNDHLD DVC -,SUP-377-44,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4606.91,3224.837,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,28973.58282,other,OPPS APC,,
PROGRAMMER NEURSTM MYSTIM 2.2X3.7X1.1IN -,SUP-377-46,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4606.91,3224.837,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,28973.58282,other,OPPS APC,,
PROGRAMMER NEURSTM IMMG-LN -,SUP-3852,CDM,C1787,HCPCS,272,RC,,,outpatient,,,2517.74,1762.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,28973.58282,other,OPPS APC,,
PRODIGY 3856 -,SUP-3856,CDM,C1787,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,28973.58282,other,OPPS APC,,
PROCLAIM DRG CONTROLLER LEAD -,SUP-7883,CDM,C1787,HCPCS,272,RC,,,outpatient,,,6212.96,4349.072,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,28973.58282,other,OPPS APC,,
PROGRAMMER PATIENT 97740 -,SUP-97740,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4507.13,3154.991,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,28973.58282,other,OPPS APC,,
CONTROLLER 97745NT INTELLIS PTM NONTRIAL -,SUP-97745NT,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4507.13,3154.991,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,28973.58282,other,OPPS APC,,
INTERSTIM KIT COMM W/HANDSET GU US -,SUP-TH90Q01,CDM,C1787,HCPCS,272,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,28973.58282,other,OPPS APC,,
PORT IMPLINFN NPWR 8FRX1.6MM ID 12.7MM X- PRT ISP PU LF -,SUP-0607540,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1620.15,1134.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC,,
PORT IMPLINFN NPWR 9.5FR CATH X- PRT PLST PRT LF MRI-COND -,SUP-0607675,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2417.77,1692.439,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC,,
PORT POWER LOW PROFILE 8F -,SUP-1708060,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2318.07,1622.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC,,
PORT IMPLINFN PWR INJ 6FR CATH PWR PRT TI LF 1LUM -,SUP-1716000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2242.11,1569.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC,,
PORT POWER 8F #1808000 -,SUP-1808000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2243.33,1570.331,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC,,
PORT IMPLINFN PWR INJ 8FR CATH PWR PRT M R I ISP PU LF 1LUM -,SUP-1808000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2243.33,1570.331,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC,,
PORT INFS 9FR CATH PWR PRT DUO M R I PLST LF LUMX2 -,SUP-1829500,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2559.29,1791.503,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC,,
KT NEEDLE INFS 20GAX1IN POWERLOC PRT ACCESS SAFTY YST NACL -,SUP-2672010,CDM,C1788,HCPCS,278,RC,,,outpatient,,,99.2,69.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC,,
PORT INFS PWR INJ 8FR CATH PWR PRT VUE ISP PU CATH LF -,SUP-5608062,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1261.52,883.064,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC,,
PORT INFS 8FR MRI-SF PWR SLIM -,SUP-5618000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1261.52,883.064,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC,,
TRY CV LUMX2 9.5FRX60CM GRSHNG LF ACC -,SUP-7726952,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1902.88,1332.016,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC,,
CATH INFS PRT 6.6FR SMRT PRT CT TI /CARBOTHAN/ PU LPRO INJ -,SUP-CT66LTPD,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC,,
CATH INFS PRT 8FR SMRT PRT CT TI/SIL INJ -,SUP-CT75STSD,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC,,
CATH INFS PRT 8FR SMRT PRT CT FLUOROMAX TI/PU INJ -,SUP-CT80STPD,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC,,
CATH INFS PRT 6.6FR MINI SMRT PRT CT TI /CARBOTHAN/ PU INJ -,SUP-H787CT66PTPD0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC,,
SMARTPORT PLASTIC W/VORTEX TECH IF FILLED DETATCHED -,SUP-H787CT80LPPDVI0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC,,
CATH INFS PRT 9.6FR SMRT PRT CT FLUOROMAX TI/SIL INJ -,SUP-H787CT96STSD0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC,,
CATH INFS PRT 12/11.4 FR DIA INTRO/CATH VORT LP TI SIL DL -,SUP-H787LVTX52130,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC,,
PORT IMPLINFN 8FR INTRO 7.2FR CATH VORT VX TI SIL LF -,SUP-H787P12355K0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC,,
PORT VORTEX VASC 9.6 -,SUP-H787P5455K0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC,,
PORT XCELA PLUS POWER INDECTABLE 8F FILLED DETATCHED -,SUP-H965440320,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC,,
PORT INFS 8FR MED DIGNITY -,SUP-MRDP80AMS,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1404.63,983.241,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.2704,1965.53472,other,OPPS APC,,
EXPANDER TISSUE SMOOTH 600CC NATRELLE FULL HT VAR -,SUP-133S-FV-14-T,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BRST 397ML 13.1CM NATRLL 4.2CM PRJCT -,SUP-15-397,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BRST 125ML SIL GEL MOD+ RND 8.9CM MEMORYGEL 2.8CM -,SUP-350-1251BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BRST SIL GEL MOD+ RND 150CC -,SUP-350-1501BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BRST 175ML SIL GEL MOD+ RND 10CM MEMORYGEL 3.1CM -,SUP-350-1751BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BRST 200ML SIL GEL MOD+ RND 10.5CM MEMORYGEL 3.2CM -,SUP-350-2001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BRST 350-420ML SAL MOD+ RND 12.1-11.7CM MENTOR -,SUP-350-2350,CDM,C1789,HCPCS,278,RC,,,outpatient,,,2597.25,1818.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BRST 250ML SIL GEL HPRO RND 10.5CM MEMORYGEL 4.3CM -,SUP-350-2504BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BRST 600ML SIL GEL MOD+ RND 15CM MEMORYGEL 4.6CM -,SUP-350-6001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4320.47,3024.329,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BRST 650ML SIL GEL MOD+ RND 15.4CM MEMORYGEL 4.7CM -,SUP-350-6501BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4320.47,3024.329,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BRST 650ML SIL GEL HPRO RND 14.4CM MEMORYGEL 5.7CM -,SUP-350-6504BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BRST 700ML SIL GEL MOD+ RND 15.8CM MEMORYGEL 4.9CM -,SUP-350-7001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4320.47,3024.329,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BRST 130ML SIL GEL MOD CLASS RND 9.6CM MEMORYGEL -,SUP-350-7130MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BRST 150ML SIL GEL MOD CLASS RND 10.3CM MEMORYGEL -,SUP-350-7150MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BRST SIL GEL MOD+ RND CLSSC 190CC -,SUP-350-7190MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BRST SIL GEL MOD+ RND CLSSC 215CC -,SUP-350-7215MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BRST 750ML SIL GEL MOD CLASS RND 16.1CM MEMORYGEL -,SUP-350-7501BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
BREAST IMPLANT SMOOTH ROUND MODERATE 750CC -,SUP-350-7750MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
BREAST IMPLANT SMOOTH ROUND MODERATE 800CC -,SUP-350-7800MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BRST 800ML SIL GEL HPRO RND 16.5CM MEMORYGEL 5.1CM -,SUP-350-8001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BRST 800ML SIL GEL HPRO RND 15.5CM MEMORYGEL 6CM -,SUP-350-8004BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BRST 330-350ML SIL SAL BIOCELL PTOTIC SHP NATRLL -,SUP-363LF-330,CDM,C1789,HCPCS,278,RC,,,outpatient,,,3628.24,2539.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
NATRELLE SALINE FILLED SMOOTH ROUND IMLANTS 640CC -,SUP-68HP-600,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1637.85,1146.495,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
NATRELLE SMOOTH ROUND SALINE IMPLANTS 68LP-225 -,SUP-68LP-225,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
NATRELLE SMOOTH ROUND SALINE IMPLANTS 250CC -,SUP-68LP-250,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
NATRELLE SMOOTH ROUND SALINE IMPLANTS 275CC -,SUP-68LP-275,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
SIZER IMPLANT NATRELLE INSPIRA 295CC FULL PROFILE -,SUP-MSZ-F295,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
SIZER NATRELLE INSPIRA 335CC FULL -,SUP-MSZ-F335,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
SIZER IMPLANT NATRELLE INSPIRA 650CC FULL PROFILE -,SUP-MSZ-F650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 200CC NATRELLE INSPIRA FULL -,SUP-SCF-200,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 240CC NATRELLE INSPIRA FULL -,SUP-SCF-240,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 265CC NATRELLE INSPIRA FULL -,SUP-SCF-265,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 295CC NATRELLE INSPIRA FULL -,SUP-SCF-295,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 335CC NATRELLE INSPIRA FULL -,SUP-SCF-335,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 345CC NATRELLE INSPIRA FULL -,SUP-SCF-345,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 365CC NATRELLE INSPIRA FULL -,SUP-SCF-365,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 385CC NATRELLE INSPIRA FULL -,SUP-SCF-385,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 415CC NATRELLE INSPIRA FULL -,SUP-SCF-415,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 450CC NATRELLE INSPIRA FULL -,SUP-SCF-450,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 485CC NATRELLE INSPIRA FULL -,SUP-SCF-485,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4787.23,3351.061,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 520CC NATRELLE INSPIRA FULL -,SUP-SCF-520,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 560CC NATRELLE INSPIRA FULL -,SUP-SCF-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 605CC NATRELLE INSPIRA FULL -,SUP-SCF-605,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5623.3,3936.31,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 650CC NATRELLE INSPIRA FULL -,SUP-SCF-650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHES GEL 695CC NATRELLE INSPIRA FULL -,SUP-SCF-695,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
NATRELLE INSPIRA COHESIVE IMPLANT 745 -,SUP-SCF-745,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
NATRELLE INSPIRA COHESIVE IMPLANT 770 -,SUP-SCF-770,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST 460CC NATRELLE SMOOTH ROUND -,SUP-SCL-460,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST 490CC SMOOTH COHESIVE LOW PLUS PROFILE -,SUP-SCLP-490,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST 540CC SMOOTH COHESIVE LOW PLUS PROFILE -,SUP-SCLP-540,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST 330CC NATRELLE SMOOTH ROUND -,SUP-SCM-330,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST 360CC NATRELLE SMOOTH ROUND -,SUP-SCM-360,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST 375CC NATRELLE SMOOTH ROUND -,SUP-SCM-375,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SILICONE 375CC NATRELLE INSPIRA STYLE MODERAT -,SUP-SCM-375,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST 405CC NATRELLE SMOOTH ROUND -,SUP-SCM-405,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHES 485CC NATRELLE INSPIRA MODERATE -,SUP-SCM-485,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 560CC NATRELLE INSPIRA MOD -,SUP-SCM-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 600CC NATRELLE INSPIRA MOD -,SUP-SCM-600,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 640CC NAT INSPIRA MOD -,SUP-SCM-640,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHES GEL 685CC NATRELLE INSPIRA MOD -,SUP-SCM-685,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHES GEL 755CC NATRELLE INSPIRA MOD -,SUP-SCM-755,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 340CC NATRELLE INSPIRA FULL -,SUP-SCX-340,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 375CC NATRELLE INSP EXTRA FUL -,SUP-SCX-375,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 525CC NATRELLE INSPIRA FULL -,SUP-SCX-525,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 545CC NATRELLE INSPIRA FULL -,SUP-SCX-545,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST 560CC SMOOTH COHESIVE NATRELLE INSPIRA FULL -,SUP-SCX-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST 580CC SMOOTH COHESIVE NATRELLE INSPIRA FULL -,SUP-SCX-580,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST 615CC SMOOTH COHESIVE NATRELLE INSPIRA FULL -,SUP-SCX-615,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH COHESIVE 650CC NATRELLE INSP EX-FULL -,SUP-SCX-650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
NATRELLE INSPIRA COHESIVE IMPLANT 700 -,SUP-SCX-700,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
NATRELLE INSPIRA COHESIVE IMPLANT 750 -,SUP-SCX-750,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
NATRELLE INSPIRA COHESIVE IMPLANT 800CC -,SUP-SCX-800,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT SMOOTH HIGH PROFILE XTRA 755 CC -,SUP-SHPX755,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5211.63,3648.141,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT SMOOTH HIGH PROFILE XTRA 790 CC -,SUP-SHPX790,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5211.63,3648.141,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH FULL 450CC NATRELLE INSPIRA FULL -,SUP-SSF-450,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH FULL 520CC NATRELLE INSPIRA FULL -,SUP-SSF-520,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH FULL 560CC NATRELLE INSPIRA FULL -,SUP-SSF-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH FULL 650CC NATRELLE INSPIRA FULL -,SUP-SSF-650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH FULL 695CC NATRELLE INSPIRA FULL -,SUP-SSF-695,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH FULL 745CC NATRELLE INSPIRA FULL -,SUP-SSF-745,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH SOFT TOUCH 330CC NATRELLE INSPIRA MOD -,SUP-SSM-330,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH SOFT TOUCH 445CC NATRELLE INSPIRA MOD -,SUP-SSM-445,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH SOFT TOUCH 485CC NATRELLE INSPIRA MOD -,SUP-SSM-485,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST SMOOTH SOFT TOUCH 520CC NATRELLE INSPIRA MOD -,SUP-SSM-520,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST EXTRA FULL SOFT TOUCH 750CC -,SUP-SSX-750,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
IMPLANT BREAST EXTRA FULL SOFT TOUCH 800CC -,SUP-SSX-800,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,261.9915,4400.1792,other,OPPS APC,,
PROSTHESIS PENL CL SPCTR MALE 9.5MMX12CM CNCLBL SNP FIT TIP -,SUP-720054-01,CDM,C1813,HCPCS,278,RC,,,outpatient,,,20421.5,14295.05,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC,,
PROSTHESIS PENL CL SPCTR MALE 9.5MMX16CM SIL PE TI SEG -,SUP-720054-02,CDM,C1813,HCPCS,278,RC,,,outpatient,,,21238.36,14866.852,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC,,
PROSTHESIS PENL AMS SPCTR MALE 12MMX20CM SIL PE TI SEG CYL -,SUP-720074-03,CDM,C1813,HCPCS,278,RC,,,outpatient,,,28358.17,19850.719,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC,,
PROSTHESIS PENL AMS 700 LGX 100CM SAL FIL INFL MOMNTRY SQZ -,SUP-720185-01,CDM,C1813,HCPCS,278,RC,,,outpatient,,,12122.95,8486.065,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC,,
AMS 800 PRESSURE REGULATION BALLOON -,SUP-72400024,CDM,C1813,HCPCS,278,RC,,,outpatient,,,12791.29,8953.903,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC,,
KT PROSTHESIS PENL URIN ARTF SPHNCR IMPL SAL FIL SCRT CYL -,SUP-724000-95,CDM,C1813,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC,,
PUMP URIN SPHNCR AMS 800 MALE SIL CNCLD FLD-FIL W/O INHBZN -,SUP-724000-98,CDM,C1813,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC,,
PROSTHESIS PENL AMBICOR 11MM/12.5MM DIA FIL PMP 16CM SAL FIL -,SUP-72401451,CDM,C1813,HCPCS,278,RC,,,outpatient,,,31752.76,22226.932,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC,,
AMS AMBICOR PENILE PROTHESIS -,SUP-72401452,CDM,C1813,HCPCS,278,RC,,,outpatient,,,34352.98,24047.086,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC,,
AMS AMBICOR PENILE PROTHESIS 18CM X 14 MM -,SUP-72401454,CDM,C1813,HCPCS,278,RC,,,outpatient,,,31752.76,22226.932,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC,,
RESERVOIR PROS -,SUP-724014-77,CDM,C1813,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC,,
PROSTHESIS PENL AMS 700 LGX 65CM SAL FIL INFL MOMNTRY SQZ -,SUP-724041-55,CDM,C1813,HCPCS,278,RC,,,outpatient,,,12122.95,8486.065,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC,,
PROSTHESIS PENL AMS 700 CX MALE 100ML SAL FIL INFL CYL TIP -,SUP-72404156,CDM,C1813,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC,,
PROSTHESIS PENL PMP AMS 700 CX MALE SAL FIL INFL STRL -,SUP-724042-09,CDM,C1813,HCPCS,278,RC,,,outpatient,,,15498.06,10848.642,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC,,
18CM 700CX -,SUP-72404232,CDM,C1813,HCPCS,278,RC,,,outpatient,,,25200.41,17640.287,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC,,
PUMP AMS 700 12MM X 18CM CX MS PENILE -,SUP-72404232-10,CDM,C1813,HCPCS,278,RC,,,outpatient,,,31466.59,22026.613,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC,,
AMS 700 CX MS PUMP IZ 21CM -,SUP-72404233-12,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26705.28,18693.696,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC,,
PROSTHESIS PENL AMS 700 LGX 15MM CL INFL PRECNCT W/MS PMP -,SUP-724042-51,CDM,C1813,HCPCS,278,RC,,,outpatient,,,28543.19,19980.233,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC,,
PROSTHESIS PENL AMS 700 LGX 18CM SAL FIL INFL MOMNTRY SQZ -,SUP-72404252,CDM,C1813,HCPCS,278,RC,,,outpatient,,,36034.67,25224.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC,,
AMS 700 LGX MS PUMP IZ 21CM X 12MM -,SUP-72404253-12,CDM,C1813,HCPCS,278,RC,,,outpatient,,,32354.71,22648.297,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC,,
PROSTHESIS PENL AMS 700 CXR 14CM X 9.5MM -,SUP-72404262,CDM,C1813,HCPCS,278,RC,,,outpatient,,,25200.41,17640.287,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC,,
AMS CXR MS PUMP IZ -,SUP-72404264,CDM,C1813,HCPCS,278,RC,,,outpatient,,,32749.43,22924.601,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC,,
EXTENDER PENL AMS SPCTR 12MM/14MM DIA CL 3CM REAR TIP -,SUP-724043-23,CDM,C1813,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC,,
IMPLANT PENL RSVR CLPLST 75ML HYDRPHL CTD LKOUT VLV STRL -,SUP-90-9075K-LOC,CDM,C1813,HCPCS,278,RC,,,outpatient,,,5602.08,3921.456,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC,,
PROSTHESIS PENL TITAN 16CM HYDRPHL RST CTD CYL 3 PRT REFL -,SUP-90-9916SC,CDM,C1813,HCPCS,278,RC,,,outpatient,,,24505.8,17154.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC,,
PROSTHESIS PENL STD 18CM BIOFLEX/SIL MALE SCRT CL/PMP ST -,SUP-90-9918SNCOTR,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26752.17,18726.519,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC,,
PROSTHESIS PENL STD 20CM BIOFLEX/SIL MALE SCRT CL/PMP ST -,SUP-90-9920SCOTR,CDM,C1813,HCPCS,278,RC,,,outpatient,,,24505.8,17154.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC,,
KT PROSTHESIS PENL TITAN MALE NRW BS EXTEND ESSAY NDLX1 -,SUP-91-9480SNC,CDM,C1813,HCPCS,278,RC,,,outpatient,,,2507.14,1754.998,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC,,
PROSTHESIS PENL RSVR TITAN 75ML BIOFLEX SIL INFL SLF-CNTN -,SUP-ER8075,CDM,C1813,HCPCS,278,RC,,,outpatient,,,6938.94,4857.258,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC,,
ST PROSTHESIS PENL TITAN 18CM BIOFLEX SIL CYL INFL SLF-CNTN -,SUP-ES2918,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26956.38,18869.466,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC,,
ST PROSTHESIS TITAN 22CM BIOFLEX SIL TCH ZERO DG CL PMP -,SUP-ES2922,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26956.38,18869.466,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC,,
PROSTHESIS PENL TITAN 18CM 0DG ANG CYL INFL 1-TCH RELS -,SUP-ESR918,CDM,C1813,HCPCS,278,RC,,,outpatient,,,27550.46,19285.322,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC,,
ST UROLOGICAL PMP/CL TITAN 20CM BIOFLEX SIL 0DG ANG PENL -,SUP-ESR920,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26752.17,18726.519,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC,,
AMS AMBICOR 16CM X 14MM -,SUP-UNDEFINED,CDM,C1813,HCPCS,278,RC,,,outpatient,,,30531.59,21372.113,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,150.646235,27674.62656,other,OPPS APC,,
PROSTHESIS PENL 3.5CM INFL SCRT INHBZN CONTINENCE -,SUP-720157-01,CDM,C1815,HCPCS,278,RC,,,outpatient,,,16337.2,11436.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21443.91168,,,,
PUMP CORTIAL 700 PROSTHESIS -,SUP-72404127,CDM,C1815,HCPCS,278,RC,,,outpatient,,,26900.69,18830.483,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21443.91168,,,,
SYS UROLOGICAL AMS 800 4CM CUF BLT W/IZ -,SUP-724041-30,CDM,C1815,HCPCS,278,RC,,,outpatient,,,27921.76,19545.232,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21443.91168,,,,
PROSTHESIS PENL AMS 800 4.5CM SAL FIL CNCLD CYL SCRT INHBZN -,SUP-72404131,CDM,C1815,HCPCS,278,RC,,,outpatient,,,27921.76,19545.232,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21443.91168,,,,
PROSTHESIS PENL AMS 800 5.0CM SAL FIL CNCLD CYL SCRT INHBZN -,SUP-72404132,CDM,C1815,HCPCS,278,RC,,,outpatient,,,26585.08,18609.556,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21443.91168,,,,
PROSTHESIS PENL AMS 800 6.0CM SAL FIL ARTIF URINARY SPHINCTR -,SUP-72404134,CDM,C1815,HCPCS,278,RC,,,outpatient,,,25935.31,18154.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,21443.91168,,,,
OCCLUDERS FLO RESTER 1.5 -,SUP-50150,CDM,C1817,HCPCS,278,RC,,,outpatient,,,470.8,329.56,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDERS FLO RESTER 2.5 -,SUP-50250,CDM,C1817,HCPCS,278,RC,,,outpatient,,,470.8,329.56,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER VASC 2MM BLB 30MM INTNL VES FLO-RST DISP -,SUP-60200,CDM,C1817,HCPCS,278,RC,,,outpatient,,,443.78,310.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
AMPLATZER AMULET 16MM WW REF: 9-ACP2-007-016 -,SUP-9-ACP2-007-016,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
AMPLATZER AMULET 18MM WW REF: 9-ACP2-007-018 -,SUP-9-ACP2-007-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
AMPLATZER AMULET 20 MM WW REF: 9-ACP2-007-020 -,SUP-9-ACP2-007-020,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
AMPLATZER AMULET 22 MM WW REF: 9-ACP2-007-022 -,SUP-9-ACP2-007-022,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
AMPLATZER AMULET 25 MM WW REF: 9-ACP2-010-025 -,SUP-9-ACP2-010-025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
AMPLATZER AMULET 28 MM WW REF: 9-ACP2-010-028 -,SUP-9-ACP2-010-028,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
AMPLATZER AMULET 31 MM WW REF: 9-ACP2-010-031 -,SUP-9-ACP2-010-031,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
AMPLATZER AMULET 34 MM WW REF: 9-ACP2-010-034 -,SUP-9-ACP2-010-034,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER AMPLATZER SEPTAL 5MM  REF: 9-ASD-005 -,SUP-9-ASD-005,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER AMPLATZER SEPTAL 6MM  REF: 9-ASD-006 -,SUP-9-ASD-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 08MM WST 16MM/20MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-008,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 10MM WST 18MM/22MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-010,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 11MM WST 21MM/25MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-011,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 12MM WST 22MM/26MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-012,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 13MM WST 23MM/27MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-013,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 14MM WST 24MM/28MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-014,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 15MM WST 25MM/29MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-015,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 16MM WST 26MM/30MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-016,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 18MM WST 28MM/32MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 19MM WST 28MM/32MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-019,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 20MM WST 30MM/34MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-020,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 22MM WST 32MM/36MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-022,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 24MM WST 34MM/38MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-024,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 26MM WST 36MM/40MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-026,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 28MM WST 38MM/42MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-028,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 30MM WST 40MM/44MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-030,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 32MM WST 42MM/46MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-032,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 34MM WST 44MM/50MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-034,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 36MM WST 46MM/52MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-036,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 18MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 25MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 30MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-030,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER SPT 35MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-035,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
GRAFT VASC 5MMX12.5MM AMPLATZER OCLR SE FUL CX-SECT CVRGLS -,SUP-9-AVP038-005,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
GRAFT VASC 6X11MM AMPLATZER PLG SE FUL CX-SECT CVRGLS LT ATR -,SUP-9-AVP038-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
GRAFT VASC 7MMX12.5MM AMPLATZER PLG OCLR SE FUL CX-SECT -,SUP-9-AVP038-007,CDM,C1817,HCPCS,278,RC,,,outpatient,,,5177.68,3624.376,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
PLUG VASCULAR AMPLATZER 6MM REF:09-AVP2-006 -,SUP-9-AVP2-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
PLUG VASCULAR AMPLATZER 8 -,SUP-9-AVP2-008,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
PLUG VASCULAR AMPLATZER 10 011 -,SUP-9-AVP2-010,CDM,C1817,HCPCS,278,RC,,,outpatient,,,3971.97,2780.379,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
PLUG VASCULAR AMPLATZER 12 -,SUP-9-AVP2-012,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
PLUG VASCULAR AMPLATZER 16 -,SUP-9-AVP2-016,CDM,C1817,HCPCS,278,RC,,,outpatient,,,3971.97,2780.379,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
PLUG VASCULAR AMPLATZER 18 -,SUP-9-AVP2-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
GRAFT VASC 22X6MM AMPLATZER PLG SE MUL-LOBE LT ATR NTNL -,SUP-9-AVP2-022,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER DCT 5MM/4MM DIA DSCND AOR/PA AMPLATZER NTNL INTRWVN -,SUP-9-PDA-003,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER DCT 6MM/4MM DIA DSCND AOR/PA AMPLATZER NTNL INTRWVN -,SUP-9-PDA-004,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER DCT 8MM/6MM DIA DSCND AOR/PA AMPLATZER NTNL INTRWVN -,SUP-9-PDA-005,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
10/8 AMPLATZER DUCT OCCLUDER -,SUP-9-PDA-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER VASC DCT 12MM/10MM DIA/DSCND/PULM AOR 7FRX8MM NTNL -,SUP-9-PDA-007,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER DUCT II AMPLATZER 3MMX4MM -,SUP-9-PDA2-03-04,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER DCT 5MM/4MM DIA WST/DISC AMPLATZER NTNL DBL DISC -,SUP-9-PDA2-05-04,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER DCT 5MM/6MM DIA WST/DISC AMPLATZER NTNL DBL DISC. -,SUP-9-PDA2-05-06,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER DUCT II AMPLATZER 6MMX4MM -,SUP-9-PDA2-06-04,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER DUCT II AMPLATZER 6MMX6MM -,SUP-9-PDA2-06-06,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER DCT 5MM/11MM DIA WST/DISC AMPLATZER NTNL DBL DISC.. -,SUP-9-PDA2-06-06,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCULUDER AMPLATZER PFO 18MM -,SUP-9-PFO-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER AMPLATZER PFO 25MM -,SUP-9-PFO-025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
OCCLUDER AMPLATZER PFO 35MM -,SUP-9-PFO-035,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
AMPLATZER TALISMAN PFO OCCLUDER 8FR 18MM REF:9-PFO-1818 -,SUP-9-PFO-1818,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
AMPLATZER TALISMAN PFO OCCLUDER 25-18MM -,SUP-9-PFO-2518,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
AMPLATZER TALISMAN PFO OCCLUDER 30-25MM -,SUP-9-PFO-3025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
TORQVUE SHEATH 12F 80CM 45X45 REF: 9-TV45X45-12F-080 -,SUP-9-TV45X45-12F-080,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4676.89,3273.823,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
CLOSURE DEVICE WATCHMAN FLEX 27MM -,SUP-M635WU0270,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
SHEATH WATCHMAN 21MM 12FR CLSR 75CM TRNSEPT -,SUP-M635WU21060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
SHEATH WATCHMAN 24MM 12FR CLSR 75CM  TRNSEPT -,SUP-M635WU24060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
SHEATH WATCHMAN 27MM 12FR CLSR 75CM  TRNSEPT -,SUP-M635WU27060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
SHEATH WATCHMAN 30MM 12FR CLSR 75CM TRNSEPT -,SUP-M635WU30060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
SHEATH WATCHMAN 33MM 12FR CLSR 75CM TRANSEPT -,SUP-M635WU33060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
CLOSURE DEVICE WATCHMAN FLEX 20MM -,SUP-M635WU50200,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
CLOSURE DEVICE WATCHMAN FLEX 31MM -,SUP-M635WU50310,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
CLOSURE DEVICE WATCHMAN FLEX 35MM -,SUP-M635WU50350,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
CLOSURE DEVICE WATCHMAN FLEX PRO 20MM REF:M635WU60200 -,SUP-M635WU60200,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
CLOSURE DEVICE WATCHMAN FLEX PRO 24MM REF:M635WU60240 -,SUP-M635WU60240,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
CLOSURE DEVICE WATCHMAN FLEX PRO 27MM REF:M635WU60270 -,SUP-M635WU60270,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
CLOSURE DEVICE WATCHMAN FLEX PRO 31MM REF:M635WU60310 -,SUP-M635WU60310,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
CLOSURE DEVICE WATCHMAN FLEX PRO 35MM REF:M635WU60350 -,SUP-M635WU60350,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
CLOSURE DEVICE WATCHMAN FLEX PRO 40MM REF:M635WU60400 -,SUP-M635WU60400,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
CLOSURE DEVICE WATCHMAN FLEX 24MM -,SUP-M63WU50240,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,99.62861,33156.48,other,OPPS APC,,
TULOC LOCALIZATION WIRE 20G X 5CM -,SUP-271660,CDM,C1819,HCPCS,278,RC,,,outpatient,,,200.72,140.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,45.06164,416.02,other,OPPS APC,,
TULOC LOCALIZATION WIRE 20G X 9CM -,SUP-271661,CDM,C1819,HCPCS,278,RC,,,outpatient,,,200.72,140.504,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,45.06164,416.02,other,OPPS APC,,
TULOC PREMIUM LOCALIZATION WIRE 20G X 5CM -,SUP-271880,CDM,C1819,HCPCS,278,RC,,,outpatient,,,256.74,179.718,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,45.06164,416.02,other,OPPS APC,,
TULOC PREMIUM LOCALIZATION WIRE 20G X 9CM -,SUP-271881,CDM,C1819,HCPCS,278,RC,,,outpatient,,,256.74,179.718,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,45.06164,416.02,other,OPPS APC,,
ETERNA IMPLANTABLE PULSE GENERATOR -,SUP-32400,CDM,C1820,HCPCS,278,RC,,,outpatient,,,45639.5,31947.65,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,41625.59232,other,OPPS APC,,
PRODIGY 3730 -,SUP-3730,CDM,C1820,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,41625.59232,other,OPPS APC,,
SYS GENERATOR NEURSTM RSTOR ADVANCED PERC MUL-PRGM RCHG ACC -,SUP-377-13,CDM,C1820,HCPCS,278,RC,,,outpatient,,,31108.87,21776.209,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,41625.59232,other,OPPS APC,,
NEURSTM IMPL RESTORESENSOR 2.1INX2.1IN PERC SMALLEST -,SUP-377-14,CDM,C1820,HCPCS,278,RC,,,outpatient,,,38238.5,26766.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,41625.59232,other,OPPS APC,,
PRODIGY MRI -,SUP-3772,CDM,C1820,HCPCS,278,RC,,,outpatient,,,38929.26,27250.482,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,41625.59232,other,OPPS APC,,
NEURSTM IMPL RESTORESENSOR SURSCN 9X54X54MM SPIN CRD RCHG -,SUP-97714,CDM,C1820,HCPCS,278,RC,,,outpatient,,,38238.5,26766.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,41625.59232,other,OPPS APC,,
INTERSTIM MICRO MRI RECHARGEABLE NEUROSTIMULATOR -,SUP-97810,CDM,C1820,HCPCS,278,RC,,,outpatient,,,25644.47,17951.129,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,41625.59232,other,OPPS APC,,
MICROSTIMULATOR INS 97810 RECHARGEABLE -,SUP-97810,CDM,C1820,HCPCS,278,RC,,,outpatient,,,25644.47,17951.129,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,41625.59232,other,OPPS APC,,
KT GENERATOR NEURSTM PRECISN SPCTR -,SUP-M365SC1110020,CDM,C1820,HCPCS,278,RC,,,outpatient,,,54199.99,37939.993,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,41625.59232,other,OPPS APC,,
VERTIFLEX SUPERION IDS-10MM -,SUP-101-9810,CDM,C1821,HCPCS,278,RC,,,outpatient,,,25619.7,17933.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
VERTIFLEX SUPERION IDS-12MM -,SUP-101-9812,CDM,C1821,HCPCS,278,RC,,,outpatient,,,25619.7,17933.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
VERTIFLEX SUPERION IDS -14MM -,SUP-101-9814,CDM,C1821,HCPCS,278,RC,,,outpatient,,,25619.7,17933.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
SPACER CERV 8X27MMX0.016IN ZYSTON -,SUP-14-533108,CDM,C1821,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
SPACER ANT CERV 19-25MMH FORTIFY OPTMZ FIT TI -,SUP-151.051,CDM,C1821,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
SPACER ANT CERV 15X18MM FTPRNT FORTIFY 7DG OPTMZ FIT TI -,SUP-151.334,CDM,C1821,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
SPACER ANT CERV 15X18MM FTPRNT FORTIFY 7DG OPTMZ FIT TI. -,SUP-151.384,CDM,C1821,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
MESH 14MM ROUND 30MM HGT -,SUP-176014030,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11221.61,7855.127,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
MESH SURG 23X27MM DIA 12X14MM OBLNG TRPZD TI HARMS -,SUP-1763-02-012,CDM,C1821,HCPCS,278,RC,,,outpatient,,,14854.78,10398.346,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
RISE SPACER 8 X 22MM- 7-13MM -,SUP-193.001,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
SPACER RISE 8 X 22MM 8-14MM 10 DEG -,SUP-193.021,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
SPACER RISE 10 X 22 7-13 -,SUP-193.101,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
SPACER RISE 10 X 26MM 7-14MM -,SUP-193.102,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
SPACER RISE 10 X 26MM 10-17MM -,SUP-193.112,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
RISE SPACER 10X22MM 8-14MM 10 DEGREES -,SUP-193.121,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
RISE SPACER 10MM X 26MM 8-15MM 10 DEGREES -,SUP-193.122,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
SPACER SPINAL RISE 10MM X 30MM 8-15MM 10 DEG -,SUP-193.123,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
RISE SPACER 10 X 26MM 10-17MM -,SUP-193.142,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
RISER SPACER 10X22MM- 9-15MM -,SUP-193.151,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
NORMANDY 12X14 30MM 10DEGREES -,SUP-250-1214-30-10,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19597.21,13718.047,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
CAGE 12X14 44-76 10 DEGREE -,SUP-250-1214-4410,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19597.21,13718.047,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
SPACER THORLUM VERT 12X26X12MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.972,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
SPACER SMALL 12 X 14 ZERO DEG 19MM NIKO CORPECTOMY -,SUP-342.719,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11547.43,8083.201,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
SPACER SPINAL NIKO PEEK 7 D D12 MM SMALL 14X15MM CORPECTOMY -,SUP-342.815,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11547.43,8083.201,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
SEASPINE 7H CAGE -,SUP-AC4-143077,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9901.25,6930.875,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
SEASPINE CAGE 16X14X6MM 7 DEGREE 3D INTERBODY -,SUP-AC4-264067,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
GENESYS 6H CAGE -,SUP-ACC804-06S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
CAGE 9 X 26 X 12 6-20 DEGREES -,SUP-ET1-102612,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19678.9,13775.23,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
SEASPINE 9 X 26 0-14 DEGREE LORDOTIC CAGE -,SUP-ET1-142608,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
SEASPINE 10H 17 DEGREE CAGE -,SUP-ET1-172610,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
CAGE EXPANDABLE SEASPINE 10H 9W 30L -,SUP-ET1-173010,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
SEASPINE 10-14MM 8 DEGREE CAGE -,SUP-ET1-382810,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
APACHE SPACER 8MM -,SUP-GAC-08SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
TITANIUM APACHE CAGE 5MM -,SUP-GAC3D-05SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
TITANIUM APACHE CAGE 6MM -,SUP-GAC3D-06SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
7MM CAGE APACHE -,SUP-GAC3D-07SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
CAGE TLIF 7MM X 30MM -,SUP-GP-07-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
CAGE APACHE PEEK SPACER 8 X 30 -,SUP-GP-08-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
CAGE 25 STRAIGHT 9MM -,SUP-GP-09,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
CAGE 9 X 30 -,SUP-GP-09-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
CAGE 10MM STANDARD PLIF -,SUP-GP-10,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
CAGE PEEK 30 X 10MM -,SUP-GP-10-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
CAGE APACHE 11MM -,SUP-GP-11,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
CAGE 8MM BI-CONVEX PLIF -,SUP-GPC2-08,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
CAGE 9MM CONVEX PLIF -,SUP-GPC2-09,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
SPACER PEEK 10 X 24 CONVEX -,SUP-GPC2-10,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
CAGE PEEK APACHE 11MM -,SUP-GPC2-11,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
SPINEART LUMBAR POSTERIOR TI CAGE L24 W10.5 H08 12 DEG -,SUP-JUT-PX 24 08-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
JULIET TI PO LUMBAR POSTERIOR TI CAGE L24 W10.5 H10 12DEG -,SUP-JUT-PX 24 10-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
CAGE LUMBAR POSTERIOR TI L24 W10.5 H11 12 DEG -,SUP-JUT-PX 24 11-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
CAGE LUMBAR POSTERIOR TI L24 W10.5 H12 -,SUP-JUT-PX 24 12-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
CAGE TRANSORAMINAL LUMBAR TI L 30 W 10.5 H 14 -,SUP-JUT-T6 30 14-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
TRANSFORMATIONAL LUMBAR TI CAGE L34 W10.5 H12 06 DEG -,SUP-JUT-T6 34 12-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
CAGE CERV 7MM/4.1MM H A/P ROI- C LRDTC -,SUP-MC1443P,CDM,C1821,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
CAGE CERV 10MM/7.1MM H A/P ROI- C LRDTC -,SUP-MC1446P,CDM,C1821,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
PATHLOC LUMBAR INTERBODY FUSION CAGE 12MM 15 DEGREES -,SUP-PT2211-0815S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19678.9,13775.23,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
SCARLET AL-T SECURED ANTERIOR CAGE SMALL H12 15' -,SUP-SCA-LS 15 12-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
CAGE 11MM LUCENT STR -,SUP-UNDEFINED,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11695.95,8187.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,19675.9296,other,OPPS APC,,
NPG IMPLANT AND CHARGER -,SUP-HFX-D,CDM,C1822,HCPCS,278,RC,,,outpatient,,,60441.5,42309.05,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46419.072,other,OPPS APC,,
KIT BLUE LEAD 90CM WITH 5MM SPACING -,SUP-LEAD1058-90B,CDM,C1822,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46419.072,other,OPPS APC,,
IPG KIT -,SUP-NIPG2500,CDM,C1822,HCPCS,278,RC,,,outpatient,,,60441.5,42309.05,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46419.072,other,OPPS APC,,
NEVRO IPG KIT WITH NEW BATTERY -,SUP-NIPG3000,CDM,C1822,HCPCS,278,RC,,,outpatient,,,60441.5,42309.05,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,46419.072,other,OPPS APC,,
STENT DES 4X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-10074400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X15MM XIENCE V RX BE PRMNT 143CM EVEROL CMPLNT -,SUP-1009541-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT 2.8X16MM GRAFTMS RX 143CM SEM-COM HYDRCT -,SUP-1012580-16,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT 4X16MM GRAFTMS RX 143CM SEM-COM HYDRCT -,SUP-1012582-16,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT 4X26MM GRAFTMS RX 143CM SEM-COM HYDRCT -,SUP-1012582-26,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.25X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.25X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.25X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.25X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.25X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.25X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.25X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.25X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125225-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125275-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.25X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.25X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.25X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35644.8,24951.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.25X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.25X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT 3X19MM JOST GRAFTMS OTW BE 143CM SEM-COM HYDREX CTD -,SUP-12744-19,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT 4X19MM JOST GRAFTMS OTW BE 143CM SEM-COM HYDREX CTD -,SUP-12746-19,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X8MM XIENCE SKYPOINT -,SUP-1804225-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X12MM XIENCE SKYPOINT -,SUP-1804225-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X15MM XIENCE SKYPOINT -,SUP-1804225-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X18MM XIENCE SKYPOINT -,SUP-1804225-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X28MM XIENCE SKYPOINT -,SUP-1804225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X23MM XIENCE SKYPOINT -,SUP-1804225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X33MM XIENCE SKYPOINT -,SUP-1804225-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X38MM XIENCE SKYPOINT -,SUP-1804225-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X8MM XIENCE SKYPOINT -,SUP-1804250-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X12MM XIENCE SKYPOINT -,SUP-1804250-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X15MM XIENCE SKYPOINT -,SUP-1804250-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X18MM XIENCE SKYPOINT -,SUP-1804250-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X23MM XIENCE SKYPOINT -,SUP-1804250-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X28MM XIENCE SKYPOINT -,SUP-1804250-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X33MM XIENCE SKYPOINT -,SUP-1804250-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X38MM XIENCE SKYPOINT -,SUP-1804250-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X8MM XIENCE SKYPOINT -,SUP-1804275-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X12MM XIENCE SKYPOINT -,SUP-1804275-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X15MM XIENCE SKYPOINT -,SUP-1804275-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X18MM XIENCE SKYPOINT -,SUP-1804275-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X23MM XIENCE SKYPOINT -,SUP-1804275-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X28MM XIENCE SKYPOINT -,SUP-1804275-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X33MM XIENCE SKYPOINT -,SUP-1804275-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X38MM XIENCE SKYPOINT -,SUP-1804275-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.0X8MM XIENCE SKYPOINT -,SUP-1804300-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.0X12MM XIENCE SKYPOINT -,SUP-1804300-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.0X15MM XIENCE SKYPOINT -,SUP-1804300-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.0X18MM XIENCE SKYPOINT -,SUP-1804300-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.0X23MM XIENCE SKYPOINT -,SUP-1804300-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.0X28MM XIENCE SKYPOINT -,SUP-1804300-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.0X33MM XIENCE SKYPOINT -,SUP-1804300-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.0X38MM XIENCE SKYPOINT -,SUP-1804300-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.25X8MM XIENCE SKYPOINT -,SUP-1804325-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.25X12MM XIENCE SKYPOINT -,SUP-1804325-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.25X15MM XIENCE SKYPOINT -,SUP-1804325-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.25X18MM XIENCE SKYPOINT -,SUP-1804325-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.25X23MM XIENCE SKYPOINT -,SUP-1804325-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.25X28MM XIENCE SKYPOINT -,SUP-1804325-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.25X33MM XIENCE SKYPOINT -,SUP-1804325-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.25X38MM XIENCE SKYPOINT -,SUP-1804325-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X8MM XIENCE SKYPOINT -,SUP-1804350-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X12MM XIENCE SKYPOINT -,SUP-1804350-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X15MM XIENCE SKYPOINT -,SUP-1804350-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X18MM XIENCE SKYPOINT -,SUP-1804350-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X23MM XIENCE SKYPOINT -,SUP-1804350-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X28MM XIENCE SKYPOINT -,SUP-1804350-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X33MM XIENCE SKYPOINT -,SUP-1804350-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X38MM XIENCE SKYPOINT -,SUP-1804350-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4.0X8MM XIENCE SKYPOINT -,SUP-1804400-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4.0X12MM XIENCE SKYPOINT -,SUP-1804400-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4.0X15MM XIENCE SKYPOINT -,SUP-1804400-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4.0X18MM XIENCE SKYPOINT -,SUP-1804400-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4.0X23MM XIENCE SKYPOINT -,SUP-1804400-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4.0X28MM XIENCE SKYPOINT -,SUP-1804400-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4.0X33MM XIENCE SKYPOINT -,SUP-1804400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4.0X38MM XIENCE SKYPOINT -,SUP-1804400-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4.5 X12MM XIENCE SKYPOINT -,SUP-1804450-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4.5 X15MM XIENCE SKYPOINT -,SUP-1804450-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4.5 X18MM XIENCE SKYPOINT -,SUP-1804450-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4.5 X23MM XIENCE SKYPOINT -,SUP-1804450-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4.5 X28MM XIENCE SKYPOINT -,SUP-1804450-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4.5 X33MM XIENCE SKYPOINT -,SUP-1804450-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 5.0 X12MM XIENCE SKYPOINT -,SUP-1804500-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 5.0 X15MM XIENCE SKYPOINT -,SUP-1804500-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 5.0 X18MM XIENCE SKYPOINT -,SUP-1804500-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 5.0 X23MM XIENCE SKYPOINT -,SUP-1804500-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 5.0 X28MM XIENCE SKYPOINT -,SUP-1804500-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 5.0 X33MM XIENCE SKYPOINT -,SUP-1804500-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 30MM PROX 30MM DIST 25-27MM OD AOR 140MM ZENITH TX2 -,SUP-2TEG-2P-30-140-,CDM,C1874,HCPCS,278,RC,,,outpatient,,,29835.9,20885.13,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
DETACHABLE COIL 4MM X 8MM -,SUP-36-152,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PK PAPYRUS 2.5/15 -,SUP-434887,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PK PAPYRUS 3.0/15 -,SUP-434888,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PK PAPYRUS 3.5/15 -,SUP-434889,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PK PAPYRUS 4.0/15 -,SUP-434890,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PK PAPYRUS 4.5/15 -,SUP-434891,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PK PAPYRUS 5.0/15 -,SUP-434892,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PK PAPYRUS 2.5/20 -,SUP-434893,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PK PAPYRUS 3.0/20 -,SUP-434894,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PK PAPYRUS 3.5/20 -,SUP-434895,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PK PAPYRUS 4.0/20 -,SUP-434896,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PK PAPYRUS 4.5/20 -,SUP-434897,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PK PAPYRUS 5.0/20 -,SUP-434898,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PK PAPYRUS 3.0/26 -,SUP-434899,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PK PAPYRUS 3.5/26 -,SUP-434900,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PK PAPYRUS 4.0/26 -,SUP-434901,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PK PAPYRUS 4.5/26 -,SUP-434902,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PK PAPYRUS 5.0/26 -,SUP-434903,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
COVERA VASCULAR COVERED STENT 6 x 60 Ref: AVFM06060 -,SUP-AVFM06060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
COVERA VASCULAR COVERED STENT 7 X 80 8F -,SUP-AVFM07080,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
COVERA 8MM X 40MM FLARED -,SUP-AVFM08040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
COVERA 8MM X 60MM FLARED -,SUP-AVFM08060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT VASCULAR COVERA FLARE 8MM X 80MM -,SUP-AVFM08080,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
COVERA STENT GRAFT 10 X 40 -,SUP-AVFM10040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
COVERA VASCULAR COVERED STENT 6 x 40 Ref: AVSM06040 -,SUP-AVSM06040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
COVERA AV STENT GRAFT 8MM X 60MM X 80MM -,SUP-AVSM08060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT COVERA AV GRAFT 8MM X 80MM X 80MM -,SUP-AVSM08080,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT COVERA AV GRAFT 10MM X 60MM 80CM STRAIGHT -,SUP-AVSM10060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
VIABAHN BALLOON EXPANDABLE 7MM X 29MM STENT -,SUP-BXA072902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12468.25,8727.775,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
BALLOON EXPANDABLE ENDOPROSTHESIS VIABAHN 8-11 7FR 29LGTH -,SUP-BXA082902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13199.72,9239.804,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
BALLOON EXPANDABLE ENDOPROSTHESIS VIABAHN 8-11 7FR 39LGTH -,SUP-BXA083902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
BALLOON EXPANDABLE ENDOPROSTHESIS VIABAHN 8-11 7FR 59 LGTH -,SUP-BXA085902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12468.25,8727.775,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT VIABAHN 11MM X 39CM GORE -,SUP-BXA113902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11844.47,8291.129,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
VIABAHN BALLOON EXPANDABLE 1MM X 59MM STENT -,SUP-BXA115902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT VIABAHN VBX BALLOON EXPANDABLE ENDOPROSTHESIS 2 -,SUP-BXAL082901A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
VIABAHN VBX BALLOON EXPANDABLE ENDOPROSTHESIS -,SUP-BXAL082902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT VIABAHN VBX 8MM X 39MM BALLOON EXPANDABLE -,SUP-BXAL083901A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
VIABAHN VBX 8MM X 59MM BALLOON AXPANDABLE STENT -,SUP-BXAL085901A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
VIABAHN VBX BALLOON EXPANDABLE ENDOPROSTHESIS -,SUP-BXAL085902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
EXCLUDER CONFORM AAA EXT ENDO 26MM X 4.5CM 15FR -,SUP-CXA260005,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19511.82,13658.274,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT 3.5X15MM DRIVER OTW BE  143CM 0.014IN GW COMP -,SUP-DRV35015W,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 22X39MM ZENITH FLEX BIFUR MAIN BD EXTEND Z-TRAK -,SUP-ESBE-22-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 24X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-24-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 26X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-26-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 28MM DI 39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK -,SUP-ESBE-28-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 30X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-30-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 32X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-32-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 36X50MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-36-50-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT STENT ENDURANT 23MM -,SUP-ESBF2314C103E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 28/14X103MM ENDURANT IIS BIFUR STNT PRELD PROX -,SUP-ESBF2814C103E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,36592.73,25614.911,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 32/14X103MM ENDURANT IIS BIFUR STNT PRELD PROX -,SUP-ESBF3214C103E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
CONVERTER EV 12MM DIST 24MM PROX 80MM ZENITH FLEX Z-TRAK -,SUP-ESC-24-12-80-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
CONVERTER EV 28MMX12MMX80MM ZENITH FLEX Z-TRAK INTRO SYS -,SUP-ESC-28-12-80ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
CONVERTER EV 32MMX12MMX80MM ZENITH FLEX Z-TRAK INTRO SYS -,SUP-ESC-32-12-80-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
CONVERTER EV 36MMX12MMX82MM ZENITH FLEX Z-TRAK INTRO SYS -,SUP-ESC-36-12-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 18X55MM ZENITH AOR -,SUP-ESLE-18-55-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8246.09,5772.263,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
SYS STENT ENDURANT II GRAFT BI -,SUP-ETBF2316C145E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT GRAFT ENDURANT II AORTIC EXTENSION 49E -,SUP-ETCF2323C49E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14726.69,10308.683,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT GRAFT ENDURANT II AO EXT -,SUP-ETCF2828C49E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15079.42,10555.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STEN GRAFT ENDURANT II AORTIC EXT 49E -,SUP-ETCF3232C49E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16783.13,11748.191,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT GRAFT ENDURANTII ILEXT -,SUP-ETEW1313C82E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16402.18,11481.526,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT GRAFT ENDUR II LIMB -,SUP-ETLW1610C156E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT STENT ENDUR II LIMB -,SUP-ETLW1610C199E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,22910.14,16037.098,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT STENT ENDUR IIS LIMB -,SUP-ETLW1610C93E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17372.2,12160.54,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 16/13X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1613C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17548.57,12283.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 16/13X156MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1613C156E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,24713.73,17299.611,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 16/16X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1616C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,18067.09,12646.963,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 16/16X82MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1616C82E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17280.3,12096.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 16/20X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1620C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17548.57,12283.999,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 16/20X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1620C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,18250.51,12775.357,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT GRAFT ENDUR II LIMB -,SUP-ETLW1624C156E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT GRAFT CONTRAL ENDURANT -,SUP-ETLW1624C93E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17372.2,12160.54,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT GRAFT ENDURANT II AUI -,SUP-ETUF2314C102E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 28/14X102MM ENDURANT II BIFUR STNT AOR ILC PRELD -,SUP-ETUF2814C102E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT STENT ENDURANT II 14MM X 36 X102MM -,SUP-ETUF3614C102E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 7MM 9FR CATH 50MM 120CM TOT 80CM DLV SYS FLAIR FLR -,SUP-FAF07050,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 8MM 9FR CATH 40MM 800CM TOT 80CM DLV SYS FLAIR FLR -,SUP-FAF08040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 7MM 9FR CATH 40MM 120CM TOT 80CM DLV SYS FLAIR STR -,SUP-FAS07040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9995.4,6996.78,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 10MM 9FR CATH 40MM FLUENCY+ 117CM TRACHBR SE -,SUP-FTL10040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9825.92,6878.144,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 7MM 8FR CATH 60MM FLUENCY+ 80CM TRACHBR SE -,SUP-FTM07060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10077.08,7053.956,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 8MM 9FR CATH 40MM FLUENCY+ 80CM TRACHBR SE -,SUP-FTM08040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10077.08,7053.956,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 12X54MM ZENITH AAA CNTRLAT ILC LEG WVN PLYSTR -,SUP-G12446,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 12MM IPSI LEG DIA 106MM DIST LEG 28MM DIST BD -,SUP-G32500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 30MM PROX 24-26MM OD AOR 94MM PROX BD ZENITH FEN -,SUP-G32533,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
ZENITH FENESTRATED PROXIMAL BODY -,SUP-G32537,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7045.04,4931.528,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT CUST ZFEN-P 2-24-124-R -,SUP-G32540,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 28MM PROX 23-24MM OD AOR 124MM PROX BD ZENITH FEN -,SUP-G32542,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 30MM PROX 24-26MM OD AOR 124MM PROX BD ZENITH FEN -,SUP-G32543,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT ZENITH FEN PROXIMAL BODY - ZFEN-P-2-32-124-R -,SUP-G32544,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 36MM PROX 29-31MM OD AOR 122MM PROX BD ZENITH FEN -,SUP-G32548,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT ZENITH DISTAL BODY - ZFEN-12-28-91 -,SUP-G32554,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 24/12X113MM ZENITH RENU ANCLRY CNVTR H&L-B 1-SHOT -,SUP-G36155,CDM,C1874,HCPCS,278,RC,,,outpatient,,,24186.48,16930.536,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
DRUG ELUTING STENT 80 PTX -,SUP-G38480,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
S ZILVER PTX 6 X 120 X 125 DRU -,SUP-G38482,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9315.54,6520.878,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PTX 7MM X 40MM -,SUP-G38486,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5487.45,3841.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
DRUG ELUTING STENT 7 - 60 PTX -,SUP-G38487,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6981.34,4886.938,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
DRUG ELUTING STENT 7 - 100 PTX -,SUP-G38489,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ZILVER PTX 7MM X 120MM P -,SUP-G38490,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9315.54,6520.878,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT 8mm x 40mm PTX ZILVER -,SUP-G38495,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5487.45,3841.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ZILVER 8MM X 80MM PTX DRUG ELUTING PERIP -,SUP-G38518,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ZIV6-35-125-8-120-PTX -,SUP-G38532,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9315.54,6520.878,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 20X30MM ZENITH FLEX BIFUR ILC PLG H&L-B 1-SHOT -,SUP-G43055,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7775.01,5442.507,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 36MMX11.3CM ZENITH FLEX AAA BIFUR STNT 20FR DLV SYS -,SUP-G43357,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30491.16,21343.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 36MMX12MMX127MM ZENITH RENU ANCLRY CNVTR H&L-B -,SUP-G43366,CDM,C1874,HCPCS,278,RC,,,outpatient,,,23484.73,16439.311,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
ZENITH TX2 DISSECTION ENDOVASCULAR GRAFT STRAIGHT COMPONENT -,SUP-G47454,CDM,C1874,HCPCS,278,RC,,,outpatient,,,49547.23,34683.061,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
COMPONENT STRAIGHT ENDO GRAFT ZENITH TX2 DISSECTION -,SUP-G47457,CDM,C1874,HCPCS,278,RC,,,outpatient,,,43823.79,30676.653,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
ZENITH FLEX AAA ENDOVASC GRAFT MAIN BODY -,SUP-G48403,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 24MM BD 20-21MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-G48408,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT ZENITH FLEX AAA ENDOVASCULAR BIFURC MAIN BODY -,SUP-G48409,CDM,C1874,HCPCS,278,RC,,,outpatient,,,34530.9,24171.63,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
ENDOGRAFT 32-82 ZENITH FLEX -,SUP-G48427,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 36MM BD 29-32MM OD AOR 95MM ZENITH FLEX BIFUR MAIN -,SUP-G48428,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
ZENITH FLEX AAA ENDOVASCULAR GRAFT 20FR -,SUP-G48429,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT ZEINTH 36X95MM ENDOVAS A -,SUP-G48432,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 36MM BD 29-32MM OD AOR 113MM ZENITH FLEX BIFUR MAIN -,SUP-G48433,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 14MM MAIN BD 37MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-G48454,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 22MM MAIN BD 39MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-G48472,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11454.61,8018.227,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 24MM MAIN BD 39MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-G48476,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11454.61,8018.227,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT COLONIC 18MM X 23MM X 12 -,SUP-G51183,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ESOPHAGEAL EVOLUTION FULLY COVERED 20-25-8 -,SUP-G52225,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 38MM PROX 38MM DIST 33-34MM OD AOR 202MM ZENITH TX2 -,SUP-G53435,CDM,C1874,HCPCS,278,RC,,,outpatient,,,29835.9,20885.13,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT ZENITH FLES Z-TRAK AAA ENDOVASC MAIN BODY EXT -,SUP-G55213,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9273.14,6491.198,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
ZENITH FLEX WITH SPIRAL Z ENDOVASCULAR GRAFT -,SUP-G55221,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT ZENITH FLEX LEG 13X56 -,SUP-G55231,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 16MM DIST 56MM ZENITH SPRL-Z CNTRLAT IPSI ILC LEG -,SUP-G55237,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT ZENITH FLEX LEG 16X74 14FR -,SUP-G55238,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT ZENITH FLEX LEG 20MM X 39MM -,SUP-G55240,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 24MM DIST 90MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-G55247,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT ZENITH 22 X 113 -,SUP-G55357,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30944.14,21660.898,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
ZENITH RENU AAA ANCILLARY GRAFT CON 12MM X 28MM X 113MM -,SUP-G55376,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30944.14,21660.898,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
ICAST COVERED STENT- 9MMX38MMX120CM -,SUP-G60511,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9841.79,6889.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
SYNERGY II US MR 2.5X8 -,SUP-H493926008250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
SYNERGY II US MR 2.75X8 -,SUP-H493926008270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
SYNERGY II US MR 3.5X8 -,SUP-H7433926008350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X24MM TAXUS EXPR2 OTW BE PRMNT 135CM PACLIT -,SUP-H7493896824250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X16MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902316250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X16MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902316400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X20MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902320270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X20MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902320300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X20MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902320400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X16MM ION MONORAIL RX BE PRMNT 144CM PACLIT -,SUP-H7493902416220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X16MM ION MONORAIL RX BE PRMNT 144CM PACLIT -,SUP-H7493902416270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X20MM ION MONORAIL RX BE PRMNT 144CM PACLIT THN -,SUP-H7493902420300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X28MM ION MONORAIL RX BE PRMNT 144CM PACLIT THN -,SUP-H7493902428300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X32MM ION MONORAIL RX BE PRMNT 144CM PACLIT THN -,SUP-H7493902432250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X32MM ION MONORAIL RX BE PRMNT 144CM PACLIT -,SUP-H7493902432270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X32MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911432220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X32MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911432250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X32MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911432350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SV -,SUP-H7493911608220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911608250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911608270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL WKHRS -,SUP-H7493911608300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911608400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911612250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911612400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911616400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911620400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911624400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911628250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911628400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.25X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911632250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911632400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.5X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911638250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911638270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911638300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3.5X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911638350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911638400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.25 X 8 -,SUP-H7493926008220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
SYNERGY II US MR 2.25X8 -,SUP-H7493926008220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.50 X 8 -,SUP-H7493926008250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.75 X 8 -,SUP-H7493926008270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 3.00 X 8 -,SUP-H7493926008300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
SYNERGY II US MR 3.00X8 -,SUP-H7493926008300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 3.50 X 8 -,SUP-H7493926008350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 4.00 X 8 -,SUP-H7493926008400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
SYNERGY II US MR 4.0X8 -,SUP-H7493926008400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.25 X 12 -,SUP-H7493926012220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.50 X 12 -,SUP-H7493926012250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.75 X 12 -,SUP-H7493926012270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 3.00 X 12 -,SUP-H7493926012300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 3.50 X 12 -,SUP-H7493926012350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 4.00 X 12 -,SUP-H7493926012400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.25 X 16 -,SUP-H7493926016220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.50 X 16 -,SUP-H7493926016250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.75 X 16 -,SUP-H7493926016270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 3.00 X 16 -,SUP-H7493926016300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 3.50 X 16 -,SUP-H7493926016350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 4.00 X 16 -,SUP-H7493926016400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.25 X 20 -,SUP-H7493926020220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.50 X 20 -,SUP-H7493926020250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.50 X 24 -,SUP-H7493926020250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.50 X 28 -,SUP-H7493926020250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.75 X 20 -,SUP-H7493926020270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 3.00 X 20 -,SUP-H749392602030,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 3.50 X 20 -,SUP-H7493926020350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 4.00 X 20 -,SUP-H7493926020400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.25 X 24 -,SUP-H7493926024220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.75 X 24 -,SUP-H7493926024270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 3.00 X 24 -,SUP-H7493926024300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 3.50 X 24 -,SUP-H7493926024350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 4.00 X 24 -,SUP-H7493926024400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.25 X 28 -,SUP-H7493926028220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.75 X 28 -,SUP-H7493926028270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 3.00 X 28 -,SUP-H7493926028300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 3.50 X 28 -,SUP-H7493926028350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 4.00 X 28 -,SUP-H7493926028400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.50 X 32 -,SUP-H7493926032250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.75 X 32 -,SUP-H7493926032270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 3.00 X 32 -,SUP-H7493926032300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 3.50 X 32 -,SUP-H7493926032350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 4.00 X 32 -,SUP-H7493926032400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.25 X 38 -,SUP-H7493926038220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.50 X 38 -,SUP-H7493926038250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 2.75 X 38 -,SUP-H7493926038270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 3.00 X 38 -,SUP-H7493926038300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 3.50 X 38 -,SUP-H7493926038350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES MR 4.00 X 38 -,SUP-H7493926038400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.25 X 8 -,SUP-H7493926108220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.50 X 8 -,SUP-H7493926108250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.75 X 8 -,SUP-H7493926108270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 3.00 X 8 -,SUP-H7493926108300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 3.50 X 8 -,SUP-H7493926108350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 4.00 X 8 -,SUP-H7493926108400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.25 X 12 -,SUP-H7493926112220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.50 X 12 -,SUP-H7493926112250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.75 X 12 -,SUP-H7493926112270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 3.00 X 12 -,SUP-H7493926112300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 3.50 X 12 -,SUP-H7493926112350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 4.00 X 12 -,SUP-H7493926112400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.25 X 16 -,SUP-H7493926116220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.50 X 16 -,SUP-H7493926116250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.75 X 16 -,SUP-H7493926116270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 3.00 X 16 -,SUP-H7493926116300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 3.50 X 16 -,SUP-H7493926116350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 4.00 X 16 -,SUP-H7493926116400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.25 X 20 -,SUP-H7493926120220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.50 X 20 -,SUP-H7493926120250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.75 X 20 -,SUP-H7493926120270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 3.00 X 20 -,SUP-H7493926120300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 3.50 X 20 -,SUP-H7493926120350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 4.00 X 20 -,SUP-H7493926120400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.25 X 24 -,SUP-H7493926124220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.50 X 24 -,SUP-H7493926124250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.75 X 24 -,SUP-H7493926124270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 3.00 X 24 -,SUP-H7493926124300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 3.50 X 24 -,SUP-H7493926124350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 4.00 X 24 -,SUP-H7493926124400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.25 X 28 -,SUP-H7493926128220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.50 X 28 -,SUP-H7493926128250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.75 X 28 -,SUP-H7493926128270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 3.00 X 28 -,SUP-H7493926128300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 3.50 X 28 -,SUP-H7493926128350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 4.00 X 28 -,SUP-H7493926128400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.25 X 32 -,SUP-H7493926132220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.50 X 32 -,SUP-H7493926132250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.75 X 32 -,SUP-H7493926132270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 3.00 X 32 -,SUP-H7493926132300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 3.50 X 32 -,SUP-H7493926132350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 4.00 X 32 -,SUP-H7493926132400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.25 X 38 -,SUP-H7493926138220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.50 X 38 -,SUP-H7493926138250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 2.75 X 38 -,SUP-H7493926138270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 3.00 X 38 -,SUP-H7493926138300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 3.50 X 38 -,SUP-H7493926138350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY DES OTW 4.00 X 38 -,SUP-H7493926138400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
ELUVIA US 6MM X 40MM X 130CM -,SUP-H74939294600410,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
ELUVIA US 6MM X 60MM X 130CM -,SUP-H74939294600610,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
ELUVIA US 6MM X 80MM X 130CM -,SUP-H74939294600810,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
ELUVIA US 6MM X 100MM X 130CM -,SUP-H74939294601010,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
ELUVIA US 6MM X 120MM X 130CM -,SUP-H74939294601210,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10749.14,7524.398,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
ELUVIA US 6X150 130 cm -,SUP-H74939294601510,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13719.54,9603.678,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
ELUVIA 7MM x 40MM x 130CM -,SUP-H74939294700410,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
ELUVIA 7MM x 60MM x 130CM -,SUP-H74939294700610,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
ELUVIA DRUG-ELUTING VASCULAR STENT SYSTEM 7MM X 80MM X 130CM -,SUP-H74939294700810,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
ELUVIA 7MM x 100MM x 130CM -,SUP-H74939294701010,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
ELUVIA 7MM x 120MM x 130CM -,SUP-H74939294701210,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10749.14,7524.398,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
ELUVIA US 7X150 130 cm -,SUP-H74939294701510,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13719.54,9603.678,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PROMUS ELITE US MR 4.0 X 8MM -,SUP-H7493941208400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PROMUS ELITE US MR 4.0 X 12MM -,SUP-H7493941212400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PROMUS ELITE US MR 2.50 X 32MM -,SUP-H7493941232250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PROMUS ELITE US MR 3.50 X 32MM -,SUP-H7493941232350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PROMUS ELITE US MR 3.50 X 38MM -,SUP-H7493941238350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.25 X 8 -,SUP-H7493941808220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.50 X 8 -,SUP-H7493941808250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.75 X 8 -,SUP-H7493941808270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 3.0 X 8 -,SUP-H7493941808300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 3.5 X 8 -,SUP-H7493941808350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 4.0 X 8 -,SUP-H7493941808400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.25 X 12 -,SUP-H7493941812220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.50 X 12 -,SUP-H7493941812250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.75 X 12 -,SUP-H7493941812270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 3.0 X 12 -,SUP-H7493941812300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 3.5 X 12 -,SUP-H7493941812350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 4.0 X 12 -,SUP-H7493941812400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 4.5 X 12 -,SUP-H7493941812450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 5.0 X 12 -,SUP-H7493941812500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.25 X 16 -,SUP-H7493941816220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.50 X 16 -,SUP-H7493941816250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.75 X 16 -,SUP-H7493941816270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 3.0 X 16 -,SUP-H7493941816300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 3.5 X 16 -,SUP-H7493941816350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 4.0 X 16 -,SUP-H7493941816400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 4.5 X 16 -,SUP-H7493941816450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 5.0 X 16 -,SUP-H7493941816500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.25 X 20 -,SUP-H7493941820220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.50 X 20 -,SUP-H7493941820250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.75 X 20 -,SUP-H7493941820270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 3.0 X 20 -,SUP-H7493941820300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 3.5 X 20 -,SUP-H7493941820350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 4.0 X 20 -,SUP-H7493941820400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 4.5 X 20 -,SUP-H7493941820450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 5.0 X 20 -,SUP-H7493941820500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.25 X 24 -,SUP-H7493941824220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.50 X 24 -,SUP-H7493941824250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.75 X 24 -,SUP-H7493941824270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 3.0 X 24 -,SUP-H7493941824300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 3.5 X 24 -,SUP-H7493941824350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 4.0 X 24 -,SUP-H7493941824400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 4.5 X 24 -,SUP-H7493941824450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 5.0 X 24 -,SUP-H7493941824500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.25 X 28 -,SUP-H7493941828220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.50 X 28 -,SUP-H7493941828250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.75 X 28 -,SUP-H7493941828270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 3.0 X 28 -,SUP-H7493941828300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 3.5 X 28 -,SUP-H7493941828350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 4.0 X 28 -,SUP-H7493941828400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 4.5 X 28 -,SUP-H7493941828450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 5.0 X 28 -,SUP-H7493941828500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.25 X 32 -,SUP-H7493941832220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.50 X 32 -,SUP-H7493941832250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.75 X 32 -,SUP-H7493941832270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 3.0 X 32 -,SUP-H7493941832300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 3.5 X 32 -,SUP-H7493941832350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 4.0 X 32 -,SUP-H7493941832400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 4.5 X 32 -,SUP-H7493941832450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 5.0 X 32 -,SUP-H7493941832500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.25 X 38 -,SUP-H7493941838220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.50 X 38 -,SUP-H7493941838250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 2.75 X 38 -,SUP-H7493941838270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 3.0 X 38 -,SUP-H7493941838300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 3.5 X 38 -,SUP-H7493941838350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR 4.0 X 38 -,SUP-H7493941838400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR US 2.5 X 48MM REF:H7493941848250 -,SUP-H7493941848250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR US 2.75 X 48MM REF:H7493941848270 -,SUP-H7493941848270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR US 3 X 48MM REF:H7493941848300 -,SUP-H7493941848300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR US 3.5 X 48MM REF:H7493941848350 -,SUP-H7493941848350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT SYNERGY XD DES MR US 4 X 48MM REF:H7493941848400 -,SUP-H7493941848400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT S MEGATRON DES US MR 3.5 X 16MM REF:H7493942816350 -,SUP-H7493942816350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT S MEGATRON DES US MR 3.5 X 20MM REF:H7493942820350 -,SUP-H7493942820350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT S MEGATRON DES US MR 4 X 20MM REF:H7493942820400 -,SUP-H7493942820400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT S MEGATRON DES US MR 4.5 X 20MM REF:H7493942820450 -,SUP-H7493942820450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT S MEGATRON DES US MR 5 X 20MM REF:H7493942820500 -,SUP-H7493942820500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT S MEGATRON DES US MR 3.5 X 24MM REF:H7493942824350 -,SUP-H7493942824350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT S MEGATRON DES US MR 4 X 24MM REF:H7493942824400 -,SUP-H7493942824400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT S MEGATRON DES US MR 4.5 X 24MM REF:H7493942824450 -,SUP-H7493942824450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT S MEGATRON DES US MR 5 X 24MM REF:H7493942824500 -,SUP-H7493942824500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT S MEGATRON DES US MR 3.5 X 28MM REF:H7493942828350 -,SUP-H7493942828350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT S MEGATRON DES US MR 4.0 X 28MM REF:H7493942828400 -,SUP-H7493942828400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT S MEGATRON DES US MR 4.5 X 28MM REF:H7493942828450 -,SUP-H7493942828450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT S MEGATRON DES US MR 5.0 X 28MM REF:H7493942828500 -,SUP-H7493942828500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT S MEGATRON DES US MR 3.5 X 32MM REF:H7493942832350 -,SUP-H7493942832350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT S MEGATRON DES US MR 4.0 X 32MM REF:H7493942832400 -,SUP-H7493942832400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT S MEGATRON DES US MR 4.5 X 32MM REF:H7493942832450 -,SUP-H7493942832450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT S MEGATRON DES US MR 5.0 X 32MM REF:H7493942832500 -,SUP-H7493942832500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
SYNERGY II US MR 2.25X12 -,SUP-H749396012220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT BIL 10X60MM 194CM CATH WALLSTNT SE UNCNTSTR CVR ENPROS -,SUP-H965431100,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7116.04,4981.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT BALLOON EXPANDABLE VASC COVERED -,SUP-LSMU0800737,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT LIFESTREAM 7MM X 58MM BALLOON EXP -,SUP-LSMU0800758,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
LIFESTREAM BALLOON EP VASC COVERED STENT 80CM X 26MM -,SUP-LSMU0800826,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
12MM X 38MM LIFE STREAM -,SUP-LSMU0801238,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT LIFESTREAM 5MM X 26MM -,SUP-LSMU1350526,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
LIFESTREAM 12MM X 38MM X 80CM -,SUP-LSMU1350626,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
FIBERED PLATINUM COIL 2 X 5MM -,SUP-M0013120211,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2243.7,1570.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
FIBERED PLATNUM COIL 4 X 4MM -,SUP-M0013120221,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2243.7,1570.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
DETACHABLE COIL 3MM X 6MM -,SUP-M001361500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2622.16,1835.512,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
DETACHABLE COIL 6MM X 10MM -,SUP-M001361560,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
PUSHER SURG ARSCP 0.016INX177CM VASC COIL 16 -,SUP-M0014012160,CDM,C1874,HCPCS,278,RC,,,outpatient,,,1036.3,725.41,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ESPH 18MM BD 13MM BD 23MM FLR 15CM POLYFLEX SE SIL LF -,SUP-M00514320,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8623.21,6036.247,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ESPH 18MM 25/23MM OD P/D FLR 18.5FR CATH 10CM WALLFLX -,SUP-M00516700,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ESPH 18MM 25/23MM OD P/D FLR 12CM WALLFLX SE BRD FLLY -,SUP-M00516710,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
WALLFLEX ESOPHAGEAL FULLY COVERED 18 X 15 -,SUP-M00516720,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ESPH 23MM 28/28MM OD P/D FLR 10CM WALLFLX SE BRD FLLY -,SUP-M00516730,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
WALLFLEX ESOPHAGEAL FULLY COVERED 23 X 10 -,SUP-M00516730,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
WALLFLEX ESOPHAGEAL FULLY COVERED 23 X 12 -,SUP-M00516740,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ESPH 23MM 28/28MM OD P/D FLR 12CM WALLFLX SE BRD FLLY -,SUP-M00516740,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
WALLFLEX ESOPHAGEAL FULLY COVERED 18 X 15 -,SUP-M00516750,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ESPH 18MM 23/23MM OD P/D FLR 10CM WALLFLX SE BRD FLLY -,SUP-M00516900,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9314.91,6520.437,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
WALLFLEX ESOPHAGEAL PARTIALLY COVERED 18 X 10 -,SUP-M00516900,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
WALLFLEX ESOPHAGEAL PARTIALLY COVERED 18 X 12 -,SUP-M00516910,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ESPH 18MM 23/23MM OD P/D FLR 123MM WALLFLX SE BRD FLLY -,SUP-M00516910,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
WALLFLEX PC ESOPH STENT 23/28MM X 105MM -,SUP-M00516930,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
WALLFLEX ESOPHAGEAL PARTIALLY COVERED 23 X 12 -,SUP-M00516940,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT AXIOS ELECTROCAUTERY-ENHANCED 15mm X 10mm -,SUP-M00553650,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17317.43,12122.201,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT CYST GASTROSTOMY AXIOS -,SUP-M00553650,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19659.22,13761.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT AXIOS 10 X 20 EE LO -,SUP-M00553660,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19659.22,13761.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT BIL 10X60MM WALLSTNT RX SE PRT CVR MTL 0.035IN GW COMP -,SUP-M00569710,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7266.24,5086.368,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT WALLFLEX BILIARY FULLY COVERED -,SUP-M00570350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
S WALLFLEX BILI 10X40 RX COV -,SUP-M00570360,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT BIL 10X60MM WALLFLX RX SE FLLY CVR PLATINOL 0.035IN GW -,SUP-M00570370,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT BIL 10X80MM WALLFLX RX SE FLLY CVR PLATINOL 0.035IN GW -,SUP-M00570380,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT PARTIALLY COVERED 8 X 100 -,SUP-M00570730,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9639.76,6747.832,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ULTRAFLEX 8 X 40 25MM TR -,SUP-M00576520,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT TRACHBR 10MM XPND 18FR COMPRESS 30MM ULFLX PRT CVR -,SUP-M00576530,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT RX COVRD 15 X 30 -,SUP-M00576550,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT RX COVRD 25 X 40 -,SUP-M00576560,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT CVRD ULTRAFLEX 14 X 40 -,SUP-M00576580,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT CVRD ULTRAFLEX 14 X 60 -,SUP-M00576590,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT TRACHBR 16MMX40MM ULFLX CVR DIST RELS SIL DIST RELS -,SUP-M00576610,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ULTRAFLEX 16X45 -,SUP-M00576620,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT CVRD ULTRAFLEX 18 X 40 -,SUP-M00576640,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT CVRD ULTRAFLEX 20 X 40 -,SUP-M00576670,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11747.93,8223.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT CVRD ULTRAFLEX 20 X 80 -,SUP-M00576690,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ESOPHAGEAL 23 X 150 ENDO -,SUP-MAXX-2315,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9175.53,6422.871,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.00 x 08MM -,SUP-ONYXNG20008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.00 x 12MM -,SUP-ONYXNG20012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.00 x 15MM -,SUP-ONYXNG20015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.00 x 18MM -,SUP-ONYXNG20018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.00 x 30MM -,SUP-ONYXNG20030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.25 x 08MM -,SUP-ONYXNG22508UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.25 x 12MM -,SUP-ONYXNG22512UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.25 x 15MM -,SUP-ONYXNG22515UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.25 x 18MM -,SUP-ONYXNG22518UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.25 x 22MM -,SUP-ONYXNG22522UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.25 x 26MM -,SUP-ONYXNG22526UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.25 x 30MM -,SUP-ONYXNG22530UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.25 x 34MM -,SUP-ONYXNG22534UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.25 x 38MM -,SUP-ONYXNG22538UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.50 x 08MM -,SUP-ONYXNG25008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.50 x 12MM -,SUP-ONYXNG25012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.50 x 15MM -,SUP-ONYXNG25015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.50 x 18MM -,SUP-ONYXNG25018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.50 x 22MM -,SUP-ONYXNG25022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.50 x 26MM -,SUP-ONYXNG25026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.50 x 30MM -,SUP-ONYXNG25030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.50 x 34MM -,SUP-ONYXNG25034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.50 x 38MM -,SUP-ONYXNG25038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.75 x 08MM -,SUP-ONYXNG27508UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.75 x 12MM -,SUP-ONYXNG27512UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.75 x 15MM -,SUP-ONYXNG27515UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.75 x 18MM -,SUP-ONYXNG27518UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.75 x 22MM -,SUP-ONYXNG27522UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.75 x 26MM -,SUP-ONYXNG27526UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.75 x 30MM -,SUP-ONYXNG27530UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.75 x 34MM -,SUP-ONYXNG27534UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  2.75 x 38MM -,SUP-ONYXNG27538UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  3.0 x 08MM -,SUP-ONYXNG30008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  3.0 x 12MM -,SUP-ONYXNG30012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  3.0 x 15MM -,SUP-ONYXNG30015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  3.0 x 18MM -,SUP-ONYXNG30018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  3.0 x 22MM -,SUP-ONYXNG30022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  3.0 x 26MM -,SUP-ONYXNG30026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  3.0 x 30MM -,SUP-ONYXNG30030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  3.0 x 34MM -,SUP-ONYXNG30034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  3.0 x 38MM -,SUP-ONYXNG30038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  3.5 x 08MM -,SUP-ONYXNG35008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  3.5 x 12MM -,SUP-ONYXNG35012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  3.5 x 15MM -,SUP-ONYXNG35015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  3.5 x 18MM -,SUP-ONYXNG35018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  3.5 x 22MM -,SUP-ONYXNG35022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  3.5 x 26MM -,SUP-ONYXNG35026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  3.5 x 30MM -,SUP-ONYXNG35030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  3.5 x 34MM -,SUP-ONYXNG35034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  3.5 x 38MM -,SUP-ONYXNG35038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  4.0 x 12MM -,SUP-ONYXNG40012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  4.0 x 15MM -,SUP-ONYXNG40015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  4.0 x 18MM -,SUP-ONYXNG40018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  4.0 x 22MM -,SUP-ONYXNG40022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  4.0 x 26MM -,SUP-ONYXNG40026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  4.0 x 30MM -,SUP-ONYXNG40030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  4.0 x 34MM -,SUP-ONYXNG40034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  4.0 x 38MM -,SUP-ONYXNG40038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  4.5 x 12MM -,SUP-ONYXNG45012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  4.5 x 15MM -,SUP-ONYXNG45015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  4.5 x 18MM -,SUP-ONYXNG45018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  4.5 x 22MM -,SUP-ONYXNG45022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  4.5 x 26MM -,SUP-ONYXNG45026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  4.5 x 30MM -,SUP-ONYXNG45030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  5.0 x 18MM -,SUP-ONYXNG50018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  5.0 x 22MM -,SUP-ONYXNG50022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ONYX DES  5.0 x 30MM -,SUP-ONYXNG50030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT BIL 5X18MM 135CM PALMZ GENESIS RX BE TRNSHEP SS -,SUP-PG1850BAX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4882.72,3417.904,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
EXCLUDER AAA ENDO EXTENDER 26MMX3.3CM 16FR -,SUP-PLA260300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13934.89,9754.423,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 32MM 27-29MM AOR 4.5CM EXCLDR AOR EXTEND LPRO SULS -,SUP-PLA320400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13934.89,9754.423,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
EXCLUDER AAA ENDO EXTENDER 36MM X 4.5CM 18FR -,SUP-PLA360400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13934.89,9754.423,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
EXCLUDER AAA ENDOPROSTHESIS L 16MM X 12MM X 14CM 12F -,SUP-PLC121400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
EXCLUDER CONTRALATERAL LEG 16MM X 14.5MM X 10CM 12F -,SUP-PLC141000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GORE EXCLUDER AAA ENDOPROSTHESIS -,SUP-PLC141200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 13.5-14.5MM 16MM ILC 9.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PLC161000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 13.5-14.5MM 16MM ILC 11.5CM EXCLDR CNTRLAT LEG ILC -,SUP-PLC161200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 13.5-14.5MM 16MM ILC 13.5CM EXCLDR CNTRLAT LEG ILC -,SUP-PLC161400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EXCLUDER AAA ENDO CONTRA LEG 16 X 18 X 9.5CM 12FR -,SUP-PLC181000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
EXCLUDER AAA ENDO CONTRA LEG 16MM X 20MM X 11.5CM 12FR -,SUP-PLC201200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
EXCLUDER AAA ENDO CONTRA LEG 16 X 23 X 12 14FR -,SUP-PLC231200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
EXCLUDER AAA ENDO CONTRA LEG 16MM X 23MM X 14CM 14FR -,SUP-PLC231400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GORE EXCLUDER AAA CONTRALATERAL LEG 16 X 27 X 100MM -,SUP-PLK271000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GORE VIATORR 10MM X 6CM -,SUP-PTB8106275,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17651.6,12356.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GORE VIATORR 10MM X 7CM -,SUP-PTB8107275,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17651.6,12356.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 10-11MM 12MM ILC 10CM EXCLDR CNTRLAT LEG LPRO SULS -,SUP-PXC121000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 12-13.5MM 14.5MM ILC 12CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC141200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 13.5-14.5 MM 6MMX11.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC161200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 16.5-18.5 MM 20MMX11.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC201200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 16.5-18.5 MM 20MMX13.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC201400-L,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 10MMX7CM EXCLDR ILC EXTEND LPRO SULS CNSTRCT SEAL -,SUP-PXL161007,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11510.3,8057.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 12MMX7CM EXCLDR ILC EXTEND LPRO SULS CNSTRCT SEAL -,SUP-PXL161207,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10953.35,7667.345,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 27-29/12-13.5MM 31/14.5MM DIA AOR/ILC 18CM EXCLDR -,SUP-RLT311413,CDM,C1874,HCPCS,278,RC,,,outpatient,,,32100.6,22470.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 2.75X18MM RESOLUT IN RX BE PRMNT 140CM ZOTARO -,SUP-RSINT27518UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30022W,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30026W,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 3X38MM RESOLUT IN RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT30038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT DES 4X38MM RESOLUT IN RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT40038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 22MM 18FR SHTH 8.2CM BIFUR -,SUP-TFFB-22-82,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30491.16,21343.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT 22X82 ZENITH ENDOVASC AA -,SUP-TFFB-22-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 22MM BD 18-19MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-22-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT ZENITH 24X82 ENDOVASC -,SUP-TFFB-24-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 26MM BD 22MM AOR 111MM ZENITH FLEX BIFUR MAIN BD -,SUP-TFFB-26-111-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT 26X82 ZEINTH ENDOV AAA -,SUP-TFFB-26-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 26MM BD 22MM AOR 96MM ZENITH FLEX BIFUR MAIN BD -,SUP-TFFB-26-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 28MM BD 23-24MM OD AOR 111MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-28-111-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 28MM BD 23-24MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-28-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 30MM BD 25-26MM OD AOR 11.1CM ZENITH FLEX BIFUR -,SUP-TFFB-30-111,CDM,C1874,HCPCS,278,RC,,,outpatient,,,31404.55,21983.185,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 30MM BD 25-26MM OD AOR 111MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-30-111-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT 30X82 ZEINTH ENDOVASC AB -,SUP-TFFB-30-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV ZENITH FLEX 30MM 20FRX9.6MM BIFUR MAIN BD EXTEND -,SUP-TFFB-30-96,CDM,C1874,HCPCS,278,RC,,,outpatient,,,29150.76,20405.532,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 30MM BD 25-26MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-30-96-2T,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
COOK GRAFT TFFB-30-96-ZT -,SUP-TFFB-30-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 12X71MM ZENITH AAA CNTRLAT ILC LEG WVN PLYSTR -,SUP-TFLE-12-71,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 14X54MM ZENITH AAA CNTRLAT ILC LEG WVN PLYSTR -,SUP-TFLE-14-54,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 14MM MAIN 56MM LEG ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-TFLE-14-56-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11454.61,8018.227,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 14MM MAIN BD 73MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-TFLE-14-73,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 14X56MM ZENITH FLEX AAA Z-TRAK BIFUR ILC CNTRLAT -,SUP-TFLE-15-56,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 18MM 16FR SHTH 54MM ZENITH AAA CNTRLAT ILC LEG -,SUP-TFLE-18-54,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT ZENITH FLEX AAA 28X82M -,SUP-TTFB-28-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GORE VIATORR 10MM X 8CM -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16385.47,11469.829,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT STENT ENDUR IIS BIF BODY -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
S VIABAHN 7MM X 7CM VIA VAS -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ESOPHAGEAL 21X150 -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9175.53,6422.871,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT POLYFLEX AIRWAY 16X40 -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8267.48,5787.236,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
VALIANT THORACIC CAPTIVA STENT GRAFT 26MM X 112MM 22FR -,SUP-VAMF2626C100TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,40668.87,28468.209,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT GRAFT VALIANT CAPTIVA WITH DELIVERY SYSTEM -,SUP-VAMF2828C100TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,40668.5,28467.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 5MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART. -,SUP-VBH051002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12063.54,8444.478,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 6MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART. -,SUP-VBH061002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12152.65,8506.855,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 6MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC_ART. -,SUP-VBH061502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13968.31,9777.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 7MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBH071002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12152.65,8506.855,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 8MMX10CM 120CM VIABAHN SE LPRO TIP TO HUB DPLY -,SUP-VBH081002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12152.65,8506.855,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 9MMX15CM 120CM VIABAHN SE LPRO TIP TO HUB DPLY -,SUP-VBH091502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13968.31,9777.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
S 10MMX 5.0CM VIA VASC 120CM -,SUP-VBH100502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11785.06,8249.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 10MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBH101502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14495.55,10146.885,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GORE VIABAHN ENDOPROSTHESIS- 7MMX5CM 8FR 120CMCATH -,SUP-VBHR070502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12910.1,9037.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 8MM 8FR DVC 5CM GORE-HYBRID VIABAHN 120CM NTNL -,SUP-VBHR080502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12910.1,9037.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 6MMX5CM 120CM VIABAHN FEM ILC ART TIP TO HUB -,SUP-VBJ060502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11268.96,7888.272,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 6MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART. -,SUP-VBJ061502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14347.03,10042.921,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 6MMX25CM 120CM GORE-HYBRID VIABAHN SUPRFC FEM -,SUP-VBJ062502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,23555.27,16488.689,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 7MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJ071502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14347.03,10042.921,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 8MMX5CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJ080502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10923.65,7646.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 8MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJ081002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12445.98,8712.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 5MM 6FRX5CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR050502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11669.96,8168.972,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 5MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR051002A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12761.58,8933.106,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 5MMX15CM VIABAHN 120MM CATH -,SUP-VBJR051502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14885.42,10419.794,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 5MM 6FRX25CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR052502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,24297.87,17008.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 6MMX5CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR060502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13403.93,9382.751,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 6MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR061002A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 6MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR061502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14224.5,9957.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 6MM 6FRX25CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR062502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,23351.06,16345.742,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 7MM 7FRX5CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR070502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12226.91,8558.837,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 7MM 7FRX10CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR071002A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT ENPROS 7MMX25CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR072502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26414.28,18489.996,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
VALIANT NAVION THORACIC STENT GRAFT SYSTEM -,SUP-VNMC2020C94TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
THORACIC STENT GRAFT 94MM 25MM -,SUP-VNMC2525C94TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT GRAFT VALION NAVION THORACIC -,SUP-VNMC4040C55TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT GORE VIABIL 10MM X 6CM BILIARY -,SUP-VSWVN1006,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT GORE VIABIL 10MM X 8CM BILIARY -,SUP-VSWVN1008,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 28MM PROX BD DIA 94MM PROX BD ZENITH FEN INTNL -,SUP-ZFEN-9-2-28-94R,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 12MM IPSI LEG DIA 121MM DIST LEG 28MM DIST BD -,SUP-ZFEN-D-1228121C,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
FENESTRATED DISTAL BODY -,SUP-ZFEN-D-12-2876C,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT HUM TIS FEN 26MM ZENITH EV PROX BD LF -,SUP-ZFEN-P-226124-R,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 36MM PROX 29-31MM OD AOR 107MM PROX BD ZENITH FEN -,SUP-ZFEN-P-2-36107R,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT VASC DES ZILVER PTX 6X100MM 125CM OTW SE PRELD -,SUP-ZISV6351256100,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT VASC DES ZILVER PTX 6X60MM 125CM OTW SE PRELD -,SUP-ZIV6-35-125660,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6981.34,4886.938,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT VASC DES ZILVER PTX 7X100MM 125CM OTW SE PRELD -,SUP-ZIV6351257100PT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7617.98,5332.586,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT VASC DES ZILVER PTX 7X80MM 125CM OTW SE PRELD -,SUP-ZIV635125780PTX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7617.98,5332.586,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 11MM DIST 56MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-ZSLE-11-56-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14387.88,10071.516,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 11MM DIST 74MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-ZSLE-11-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT ZENITH FLEX LEG 13X74 -,SUP-ZSLE-13-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT ZENITH AAA LEG 13X90MM -,SUP-ZSLE-13-90-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 16MMX90MM ZENITH SPRL -Z BIFUR CNTRLAT IPSI -,SUP-ZSLE-16-16-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 16MM DIST 39MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-ZSLE-16-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT ZENITH AAA LEG 20X74MM -,SUP-ZSLE-20-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT ZENITH AAA 24 X 56MM LEG -,SUP-ZSLE-24-56-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
GRAFT EV 24MM 16FR ID 6MM INTRO SHTH 74MM ZENITH SPRL -Z -,SUP-ZSLE-24-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,232.64935,38052.27264,other,OPPS APC,,
STENT 4.5X13MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003381-13,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4.5X18MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003381-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4.5X28MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003381-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 5X13MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003382-13,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2X8MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2X12MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2X15MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2X18MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2X23MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2X28MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X8MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X12MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X15MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X18MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X23MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X28MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X8MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X12MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X15MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X18MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X23MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X28MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.75X8MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007847-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.75X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007847-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.75X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007847-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3X8MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3X23MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X8MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X23MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007850-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4X23MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007850-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007850-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.75X15MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010142-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.75X23MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010142-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3X8MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010143-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3X15MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010143-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VISION OTW 3.5 X 15 -,SUP-1010144-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VISION OTW 3.5 X 23 -,SUP-1010144-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X28MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010144-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4X18MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010145-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4X23MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010145-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2X8MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X12MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2X15MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X18MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2X23MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2X28MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X8MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X12MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X15MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X18MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X23MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X28MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X8MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X12MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X15MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X18MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X23MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ACCULINK 5X20MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011337-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ACCULINK 5X30MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011337-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ACCULINK 5X40MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011337-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S RX ACCULINK 7.0MM X 30MM X 132CM -,SUP-1011339-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ACCULINK 7X40MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011339-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
6-8 mm X 30mm RX ACCULINK STENT -,SUP-1011343-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ACCULINK 6-8X40MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011343-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
ACCULINK STENT 7-10 X 40MM -,SUP-1011344-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 4X12MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011487-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 4X18MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011487-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 4.5X15MM 135CM DLV CATH HERCULINK ELITE RX BE -,SUP-1011490-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 5X15MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011493-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 5X18MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011493-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 6.0MM X 100MM X 80CM -,SUP-1012528-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 6.0MM X 20MM X 80CM -,SUP-1012528-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 6.0MM X 30MM X 80CM -,SUP-1012528-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 6.0MM X 40MM X 80CM -,SUP-1012528-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SEL-EXPANDING 6.0MM X 60MM X 80CM -,SUP-1012528-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAT SELF-EXPANDING 6.0MM X 80MM X 80CM -,SUP-1012528-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 100MM X 80CM -,SUP-1012529-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 20MM X 80CM -,SUP-1012529-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 30MM X 80CM -,SUP-1012529-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 40MM X 80CM -,SUP-1012529-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 60MM X 80CM -,SUP-1012529-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 80MM X 80CM -,SUP-1012529-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
ABSOLUTE PRO 8 X 100MM X 80CM -,SUP-1012530-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCUALR SELF-EXPANDING 8.0MM X 20MM X 80CM -,SUP-1012530-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 8.0MM X 30MM X 80CM -,SUP-1012530-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
ABSOLUTE PRO VASCULAR SELF-EXPANDING STENT SYS 8 X 40 -,SUP-1012530-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
ABSOLUTE PRO 8 X 60MM X 80CM -,SUP-1012530-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
ABSOLUTE PRO 8 X 80MM X 80CM -,SUP-1012530-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 9.0MM X 100MM X 80CM -,SUP-1012531-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 9.0MM 20MM X 80CM -,SUP-1012531-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 9.0MM X 30MM X 80CM -,SUP-1012531-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 9.0MM X 40MM X 80CM -,SUP-1012531-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 9.0MM X 60MM X 80CM -,SUP-1012531-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 9.0MM X 80MM X 80CM -,SUP-1012531-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 100MM X 80CM -,SUP-1012532-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 20MM X 80CM -,SUP-1012532-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 30MM X 80CM -,SUP-1012532-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT ABSOLUTE PRO 10 X 40MM X 80CM -,SUP-1012532-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ABSOLUTE PRO 10X60CM -,SUP-1012532-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
ABSOLUTE PRO SELF EXPANDING STENT 10MM X 80MM C 80CM -,SUP-1012532-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ABSOLUTE PRO 6X100MM 135CM OTW SE PRMNT -,SUP-1012534-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ABSOLUTE PRO 6X40MM 135CM OTW SE PRMNT -,SUP-1012534-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ABSOLUTE PRO 7.0X100MM 135CM -,SUP-1012535-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 20MM X 135CM -,SUP-1012535-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 30MM X 135CM -,SUP-1012535-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ABSOLUTE PRO 7X40MM 135CM OTW SE PRMNT -,SUP-1012535-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ABSOLUTE PRO 7X60MM 135CM OTW SE PRMNT -,SUP-1012535-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 80MM X 135CM -,SUP-1012535-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 8.0MM X 100MM X 135CM -,SUP-1012536-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 8.0MM X 20MM X 135CM -,SUP-1012536-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 8.0MM X 30MM X 135CM -,SUP-1012536-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 8.0MM X 40MM X 135CM -,SUP-1012536-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ABSOLUTE PRO 8.0 X 60MM X 135CM -,SUP-1012536-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 9.0MM X 100MM X 135CM -,SUP-1012537-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDED 9.0MM X 40MM X 135CM -,SUP-1012537-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 9.0MM X 80MM X 135CM -,SUP-1012537-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 100MM X 135CM -,SUP-1012538-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 20MM X 135CM -,SUP-1012538-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 30MM X 135CM -,SUP-1012538-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 40MM X 135CM -,SUP-1012538-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 60MM X 135CM -,SUP-1012538-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 80MM X 135CM -,SUP-1012538-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR BALLOON-EXPANDABLE 6.0MM X 16MM X 80CM -,SUP-1012622-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 6X19MM 80CM OTW BE PRMNT -,SUP-1012622-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 6X29MM 80CM OTW BE PRMNT -,SUP-1012622-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 6X39MM 80CM OTW BE PRMNT -,SUP-1012622-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 6X59MM 80CM OTW BE PRMNT -,SUP-1012622-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 12MM X 80CM -,SUP-1012623-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 16MM X 80CM -,SUP-1012623-16,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 7X19MM 80CM OTW BE PRMNT -,SUP-1012623-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 7X29MM 80CM OTW BE PRMNT -,SUP-1012623-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 7X39MM 80CM OTW BE PRMNT -,SUP-1012623-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 7X59MM 80CM OTW BE PRMNT -,SUP-1012623-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 8X19MM 80CM OTW BE PRMNT -,SUP-1012624-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 8X29MM 80CM OTW BE PRMNT -,SUP-1012624-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 8X39MM 80CM OTW BE PRMNT -,SUP-1012624-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 8X59MM 80CM OTW BE PRMNT -,SUP-1012624-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 9X19MM 80CM OTW BE PRMNT -,SUP-1012625-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 9X29MM 80CM OTW BE PRMNT -,SUP-1012625-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 9X39MM 80CM OTW BE PRMNT -,SUP-1012625-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 9X59MM 80CM OTW BE PRMNT -,SUP-1012625-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 10X19MM 80CM OTW BE PRMNT -,SUP-1012626-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 10X29MM 80CM OTW BE PRMNT -,SUP-1012626-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 10X39MM 80CM OTW BE PRMNT -,SUP-1012626-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 10X59MM 80CM OTW BE PRMNT -,SUP-1012626-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR BALLOON-EXPANDABLE 6.0MM X 16MM X 135 -,SUP-1012629-16,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 6X19MM 135CM OTW BE PRMNT -,SUP-1012629-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 6X29MM 135CM OTW BE PRMNT -,SUP-1012629-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 6X39MM 135CM OTW BE PRMNT -,SUP-1012629-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 6X59MM 135CM OTW BE PRMNT -,SUP-1012629-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 12MM X 135CM -,SUP-1012630-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 16MM X 135CM -,SUP-1012630-16,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 7X19MM 135CM OTW BE PRMNT -,SUP-1012630-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 7X29MM 135CM OTW BE PRMNT -,SUP-1012630-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 7X39MM 135CM OTW BE PRMNT -,SUP-1012630-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 7X59MM 135CM OTW BE PRMNT -,SUP-1012630-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 8X19MM 135CM OTW BE PRMNT -,SUP-1012631-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 8X29MM 135CM OTW BE PRMNT -,SUP-1012631-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 8X39MM 135CM OTW BE PRMNT -,SUP-1012631-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 8X59MM 135CM OTW BE PRMNT -,SUP-1012631-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 9X19MM 135CM OTW BE PRMNT -,SUP-1012632-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 9X29MM 135CM OTW BE PRMNT -,SUP-1012632-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 9X39MM 135CM OTW BE PRMNT -,SUP-1012632-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 9X59MM 135CM OTW BE PRMNT -,SUP-1012632-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 10X19MM 135CM OTW BE PRMNT -,SUP-1012633-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 10X29MM 135CM OTW BE PRMNT -,SUP-1012633-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 10X39MM 135CM OTW BE PRMNT -,SUP-1012633-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC OMNILINK ELITE 10X59MM 135CM OTW BE PRMNT -,SUP-1012633-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4X12MM JOST GRAFTMS OTW BE 143CM SEM-COM HYDREX CTD -,SUP-12746-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
BIOMIMICS 3-D STENT 5MM X 60MM -,SUP-142122-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
BIOMIMICS 3-D STENT 6MM X 60MM -,SUP-142122-02,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
BIOMIMICS 3-D STENT 7MM X 60MM -,SUP-142122-03,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
BIOMIMICS 3-D STENT 5MM X 80MM -,SUP-142122-05,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
BIOMIMICS 3-D STENT 6MM X 80MM -,SUP-142122-06,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
BIOMIMICS 3-D STENT 7MM X 80MM -,SUP-142122-07,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
BIOMIMICS 3-D STENT 5MM X 100MM -,SUP-142122-09,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
BIOMIMICS 3-D STENT 6MM X 100MM -,SUP-142122-10,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
BIOMIMICS 3-D STENT 7MM X 100MM -,SUP-142122-11,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
BIOMIMICS 3-D STENT 5MM X 125MM -,SUP-142122-13,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
BIOMIMICS 3-D STENT 6MM X 125MM -,SUP-142122-14,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
BIOMIMICS 3-D STENT 7MM X 125MM -,SUP-142122-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
BIOMIMICS 3-D STENT 5MM X 150MM -,SUP-144700-05,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
BIOMIMICS 3-D STENT 6MM X 150MM -,SUP-144700-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
BIOMIMICS 3-D STENT 7MM X 150MM -,SUP-144700-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S BILIARY LD PMTD 8 X 37 X75 6 -,SUP-38046-84075,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X37MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38046-84075,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 9 X 25MM 75CM EXP LD -,SUP-38046-92075,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 10X25MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-12013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 10X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-16013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-63013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-76013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S BILIARY EXPRESS 8X37X135CM L -,SUP-38047-84013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-38047-84013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
PULSAR 18 - 6 X 40 X 135 -,SUP-390724,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
PULSAR 18 - 6 X 120 X 135 -,SUP-390728,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
PULSAR 18 - 6 X 150 X 135 -,SUP-390729,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
PULSAR 18  7X40X135  .018 -,SUP-390734,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC OTW 6 X 120 X 120 -,SUP-39200-06122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC EPIC 6X120MM 120CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-39200-06122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 7X118X120 -,SUP-39200-07122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC EPIC 7X120MM 163CM/120CM WKG CATH SE MTLC ILC -,SUP-39200-07122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 7X79X120 -,SUP-39200-07802,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC EPIC 7X80MM 120CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-39200-07802,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 9X40X120 -,SUP-39200-09402,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
EPIC STENT 10MM X 40MM X 120CM -,SUP-39200-10402,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
EPIC STENT 10MM X 60MM X 120CM -,SUP-39200-10602,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
EPIC STENT 12MM X 60MM X 120CM -,SUP-39200-12602,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT ENPROS 24MM 11FR CATH 70MM WALLSTNT RP 100CM TOT 75CM -,SUP-40512,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PULSAR - 18 T3 4/20/135 -,SUP-430477,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PULSAR - 18 T3 4/40/135 -,SUP-430479,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PULSAR - 18 T3 4/80/135 -,SUP-430481,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PULSAR - 18 T3  5/80/135 -,SUP-430491,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PULSAR - 18 T3 5/120/135 -,SUP-430493,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PULSAR - 18 T3 5/200/135 -,SUP-430496,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PULSAR - 18 T3 6/40/135 -,SUP-430499,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PULSAR - 18 T3 6/80/135 -,SUP-430501,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PULSAR - 18 T3 6/120/135 -,SUP-430503,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PULSAR - 18 T3 6/150/135 -,SUP-430504,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PULSAR - 18 T3 6/200/135 -,SUP-430506,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PULSAR - 18 T3 7/120/135 -,SUP-430513,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PULSAR - 18 T3 7/150/135 -,SUP-430514,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
WRENCH SPLTY HX F /CPI -,SUP-6563,CDM,C1876,HCPCS,278,RC,,,outpatient,,,175.05,122.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT URET 6FR 22-32CM INLAY OPTM PLYMR BLND DBL PIGTL TAPR -,SUP-788600,CDM,C1876,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC XACT 7-9X40MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82086-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC XACT 7-9X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82087-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC XACT 9X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82088-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC XACT 9X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82089-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC XACT 6-8X40MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82090-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC XACT 6-8X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82091-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC XACT 8X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82092-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC XACT 8X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82093-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC XACT 7X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82094-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC XACT 7X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82095-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC XACT 10.8MM X 40MM X 136CM -,SUP-82096-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC XACT 10X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82098-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC XACT 10X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82099-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
ABRE STENTS 16MM X 80MM -,SUP-AB9U16080090,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6896.5,4827.55,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
ABRE STENTS 18MM X 100MM -,SUP-AB9U18100090,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6896.5,4827.55,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
ABRE STENTS 18MM X 120MM -,SUP-AB9U18120090,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6896.5,4827.55,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
COVERA AV STENT GRAFT 7MM X 60MM X 80MM -,SUP-AVSM07060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 6X30MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06030ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 6X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 6X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 6X80MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06080ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 6X100MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06100ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 6X120MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06120ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 6X150MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06150ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 7X30MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07030ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 7X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 7X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 7X80MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07080ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 7X100MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07100ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 7X120MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07120ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 7X150MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07150ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 8X30MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08030ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 8X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 8X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 8X80MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08080ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 8X100MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08100ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 8X120MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08120ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 8X150MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08150ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 10X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C10040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SMART CONT 10X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C10060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 12X40MM 120CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-C12040MB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 12X60MM 120CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-C12060MB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 12X60MM 80CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-C12060SB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X100MM 130CM LIFESTENT SE HLCL NTNL 0.035IN GW -,SUP-EX061003CD,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9230.7,6461.49,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC LIFESTENT 6X150MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX061503CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC LIFESTENT 6X170MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX061703CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC LIFESTENT 6X200MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX062003CL,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC LIFESTENT 7X60MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX070603CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
GRAFT EV 8MM 9FR CATH 40MM 120CM TOT 80CM DLV SYS FLAIR STR -,SUP-FAS08040,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11020.18,7714.126,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
COIL MICRONESTER EMBOLIZATION 0.018 X 5CM X 3MM -,SUP-G23520,CDM,C1876,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 5MM 7FR GUID CATH 30MM 125CM ZILVER 518 OTW SE -,SUP-G31351,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S ZILVER 518 5X40 125CM S-E ZI -,SUP-G31352,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 4X40MM 125CM ZILVER 518 OTW SE PRELD FLXB SLT TUBE -,SUP-G31439,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8MM 6FRX40MM 80CM SE PRELD MTL NTNL 5FR SHTH MUL -,SUP-G32020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S ZILVER .035 125CM 5 X 60 -,SUP-G32033,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X80MM MTL SE 6FRX125CM PRELD DLV SYS NTNL 6FR -,SUP-G36025,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S ZILVER 518 5X80 125CM S-E -,SUP-G36048,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 14X30MM 80CM ZILVER 635 OTW SE PRELD FLXB SLT TUBE -,SUP-G36233,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 12MM 8FR GUID CATH 40MM 125CM ZILVER 635 OTW SE -,SUP-G36239,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
12MM X 8CM ZILVER 635 STENT -,SUP-G36241,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 14MM 8FR GUID CATH 40MM 125CM ZILVER 635 OTW SE -,SUP-G36244,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 14X60MM 125CM ZILVER 635 OTW SE PRELD 0.035IN GW -,SUP-G36245,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 5X20MM 135CM FRMLA 418 BLN-XPD GUID CATH 5/6 FR -,SUP-G42956,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4034.03,2823.821,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X24MM 135CM FRMLA 418 OTW BE U STRUT TAPR 0.018IN -,SUP-G42962,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S ZILVER 518 VASC 6X40 125CM S -,SUP-G43771,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S ZILVER518 VASC 6X60 125CM -,SUP-G43772,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S ZILVER 518 VASC 6X80 125CM S -,SUP-G43773,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
7x40x125 ZILVER STENT 0.018 -,SUP-G43776,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ZILVER 518 7X80MM 125CM OTW SE 0.018IN/5FR -,SUP-G43778,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ZILVER 518 8X60MM 125CM OTW SE 0.018IN/5FR -,SUP-G43782,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S ZILVER .035 125CM 6 X 60 012 -,SUP-G43822,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S ZILVER .035 125CM 6 X 80 012 -,SUP-G43823,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ZILVER 635 7X30MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43825,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ZILVER 635 7X40MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43826,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ZILVER 635 7X60MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43827,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ZILVER 635 7X80MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43828,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ZILVER 635 8X30MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ZILVER 635 8X40MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43831,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ZILVER 635 8X60MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43832,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ZILVER 635 8X80MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43833,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ZILVER 635 10X40MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43841,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ZILVER 635 10X60MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43842,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ZILVER 635 10X80MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43843,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
COIL NESTOR 3 X 5 -,SUP-G47334,CDM,C1876,HCPCS,278,RC,,,outpatient,,,577.61,404.327,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
COIL MICRONESTOR EMBOLIZATION .018 X 7CM X 4MM PLAT -,SUP-G47339,CDM,C1876,HCPCS,278,RC,,,outpatient,,,638.87,447.209,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
ZENITH DISSECTION ENDOVASCULAR STENT -,SUP-G47492,CDM,C1876,HCPCS,278,RC,,,outpatient,,,41924.2,29346.94,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
ZENITH DISSECTION ENDOVASCULAR STENT -,SUP-G47493,CDM,C1876,HCPCS,278,RC,,,outpatient,,,41924.2,29346.94,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT ENDOVASCULAR DISSECTION ZENITH -,SUP-G47496,CDM,C1876,HCPCS,278,RC,,,outpatient,,,37318.31,26122.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DUODENAL EVOLUTION CONTROL RELEASE 22-27-9 -,SUP-G48026,CDM,C1876,HCPCS,278,RC,,,outpatient,,,8886.94,6220.858,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S ZILVER .035 125CM 5 X 100 -,SUP-G50162,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7MM 8FR GUID CATH LNG 100MM 125CM ZILVER FLEX 35 -,SUP-G50168,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7MM 8FR GUID CATH LNG 120MM 125CM ZILVER FLEX 35 -,SUP-G50169,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7X140MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-G50170,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X100MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-G50171,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8MM 8FR GUID CATH LNG 140MM 125CM ZILVER FLEX 35 -,SUP-G50173,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 10X100MM 80CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-G50177,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
Z STENT BILIARY 8 X 8 -,SUP-G50623,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC FRMLA 418 5X16MM 80CM OTW BE PRMNT -,SUP-G56609,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC FRMLA 418 5X20MM 80CM OTW BE PRMNT -,SUP-G56610,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC FRMLA 418 6X12MM 80CM OTW BE PRMNT -,SUP-G56611,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC FRMLA 418 6X16MM 80CM OTW BE PRMNT -,SUP-G56613,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC FRMLA 418 6X20MM 80CM OTW BE PRMNT -,SUP-G56614,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC FRMLA 418 7X16MM 80CM -,SUP-G56617,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC FRMLA 418 5X12MM 80CM OTW BE PRMNT -,SUP-G56631,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC FRMLA 414 5X20MM 80CM RX BE PRMNT 0.014IN/5FR/6FR -,SUP-G56950,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC FRMLA 414 5X16MM 135CM RX BE PRMNT -,SUP-G56958,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
0.14 ZILVER 5MM X 120MM X 135CM -,SUP-G56966,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC FRMLA 414 5X20MM 135CM RX BE PRMNT -,SUP-G56969,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC FRMLA 414 6X12MM 135CM RX BE PRMNT -,SUP-G56970,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC FRMLA 414 6X16MM 135CM RX BE PRMNT -,SUP-G56971,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC FRMLA 414 6X20MM 135CM RX BE PRMNT -,SUP-G56972,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
0.14 ZILVER 7MM X 160MM X 135CM -,SUP-G56974,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC FRMLA 414 7X20MM 135CM RX BE PRMNT -,SUP-G56975,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
US PRE PP-CA-397 P&B BARE METAL STENT ZVT7-35-120-16-60 -,SUP-G57453,CDM,C1876,HCPCS,278,RC,,,outpatient,,,8016.87,5611.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
SYS STENT VASCULAR ZILVER VENA 16MM 100MM 120CM VEIN OTW -,SUP-G57454,CDM,C1876,HCPCS,278,RC,,,outpatient,,,8016.87,5611.809,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
VENOUS WALLSTENT 10X94X75CM -,SUP-H74912044109470,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
VENOUS WALLSTENT 12X60X75CM -,SUP-H74912044126070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
VENOUS WALLSTENT 12X90X75CM -,SUP-H74912044129070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
VENOUS WALLSTENT 14X60X75CM -,SUP-H74912044146070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
VENOUS WALLSTENT 14X90X75CM -,SUP-H74912044149070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
VENOUS WALLSTENT 16X40X75CM -,SUP-H74912044164070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
VENOUS WALLSTENT 16X60X75CM -,SUP-H74912044166070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
VENOUS WALLSTENT 16X90X75CM -,SUP-H74912044169070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
VENOUS WALLSTENT 18X40X75CM -,SUP-H74912044184070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
VENOUS WALLSTENT 18X60X75CM -,SUP-H74912044186070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
VENOUS WALLSTENT 18X90X75CM -,SUP-H74912044189070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
VENOUS WALLSTENT 20X40X75CM -,SUP-H74912044204070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
VENOUS WALLSTENT 20X55X75CM -,SUP-H74912044205570,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
VENOUS WALLSTENT 20X80X75CM -,SUP-H74912044208070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
VICI VENOUS STENT 12MM X60MM X 100CM -,SUP-H74912060100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
VICI VENOUS STENT 14MM X 60MM X 100CM -,SUP-H74914060100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
VICI VENOUS STENT 14MM X 90MM X 100CM -,SUP-H74914090100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
VICI VENOUS STENT 16MM X 60MM X 100CM -,SUP-H74916060100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
VICI VENOUS STENT 16MM X90MM X 100CM -,SUP-H74916090100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X14MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937911614150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
FG EXP SD RENAL-BILIARY 7.0mmX15mmX150cm -,SUP-H74937911715150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 4X19MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912419150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 5X19MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912519150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X18MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912618150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7X19MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912719150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 10X37MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046104070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 10X57MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046106070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S BIL EXPRESS PMTD  6X27X75 -,SUP-H74938046630750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X27MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046630750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S BILIARY LD PMTD 6X37X75 6FR -,SUP-H74938046640750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X37MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046640750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S BILI LD PMTD 6 X 57 X 75 EXP -,SUP-H74938046660750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X57MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046660750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7X27MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046730750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S BILIARY LD PMTD 7X37X75 40CM -,SUP-H74938046740750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S  BILI LD PMTD 7 X 57 X 75 EX -,SUP-H74938046760750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EXPRESS B-I LD 8 X 27 X 75 P -,SUP-H74938046830750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X27MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046830750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
BEACON 8MM X 37MM X 75CM  ILIAC STENT -,SUP-H74938046840750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
8 X 57 X 75CM EXPRESS STENT -,SUP-H74938046860750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S BILI LD PMTD 8 X 57 X 75 EXP -,SUP-H74938046860750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 9X57MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046960750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 10X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047140130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 5X17MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047520130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 5X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047530130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 5X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047540130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 5X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047560130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X17MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047620130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047640130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047660130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7X17MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047720130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047730130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047740130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
7 X 57MM EXPRESS ILIAC / BILIARY STENT 135CM -,SUP-H74938047760130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047830130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047860130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 9X25MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047920130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 9X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047940130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 9X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047960130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3X16MM VERIFLEX OTW BE PRMNT LO XING THN STRUT HYDRCT -,SUP-H7493893516300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3294.06,2305.842,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 6X100X120 -,SUP-H74939200061020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 6X19X120 -,SUP-H74939200062020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 6X29X120 -,SUP-H74939200063020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 6X40X120 -,SUP-H74939200064020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 6X51X120 -,SUP-H74939200065020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 6X61X120 -,SUP-H74939200066020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 6X71X120 -,SUP-H74939200067020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 6X80X120 -,SUP-H74939200068020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 7X99X120 -,SUP-H74939200071020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 7X19X120 -,SUP-H74939200072020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 7X29X120 -,SUP-H74939200073020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 7X41X120 -,SUP-H74939200074020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 7X50X120 -,SUP-H74939200075020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 7X60X120 -,SUP-H74939200076020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 7X70X120 -,SUP-H74939200077020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 8X100X120 -,SUP-H74939200081020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 8X120X120 -,SUP-H74939200081220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 8X20X120 -,SUP-H74939200082020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 8X31X120 -,SUP-H74939200083020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 8X41X120 -,SUP-H74939200084020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 8X51X120 -,SUP-H74939200085020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 8X61X120 -,SUP-H74939200086020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 8X72X120 -,SUP-H74939200087020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 8X82X120 -,SUP-H74939200088020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 9X99X120 -,SUP-H74939200091020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 9X21X120 -,SUP-H74939200092020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 9X30X120 -,SUP-H74939200093020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 9X51X120 -,SUP-H74939200095020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 9X61X120 -,SUP-H74939200096020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 9X81X120 -,SUP-H74939200098020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 10X98X120 -,SUP-H74939200101020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-EXP 10X20X120 -,SUP-H74939200102020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-EXP 10X30X120 -,SUP-H74939200103020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 10X40X120 -,SUP-H74939200104020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 10X50X120 -,SUP-H74939200105020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC EPIC 10X60MM 120CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939200106020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 10X71X120 -,SUP-H74939200107020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 10X80X120 -,SUP-H74939200108020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-EXP 12X32X120 -,SUP-H74939200123020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 12X42X120 -,SUP-H74939200124020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 12X52X120 -,SUP-H74939200125020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S EPIC ILIAC S-XPD 12X61X120 -,SUP-H74939200126020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.2X8MM REBEL MR RX BE -,SUP-H7493927408220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X8MM REBEL MR RX BE -,SUP-H7493927408250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.75X8MM REBEL MR RX BE -,SUP-H7493927408270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3X8MM REBEL MR RX BE -,SUP-H7493927408300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X8MM REBEL MR RX BE -,SUP-H7493927408350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4X8MM REBEL MR RX BE -,SUP-H7493927408400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X12MM REBEL MR RX BE -,SUP-H7493927412220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X12MM REBEL MR RX BE -,SUP-H7493927412250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.75X12MM REBEL MR RX BE -,SUP-H7493927412270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3X12MM REBEL MR RX BE -,SUP-H7493927412300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X12MM REBEL MR RX BE -,SUP-H7493927412350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4X12MM REBEL MR RX BE -,SUP-H7493927412400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4.5X12MM REBEL MR RX BE -,SUP-H7493927412450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X16MM REBEL MR RX BE -,SUP-H7493927416220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X16MM REBEL MR RX BE -,SUP-H7493927416250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.75X16MM REBEL MR RX BE -,SUP-H7493927416270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3X16MM REBEL MR RX BE -,SUP-H7493927416300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X16MM REBEL MR RX BE -,SUP-H7493927416350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4X16MM REBEL MR RX BE -,SUP-H7493927416400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4.5X16MM REBEL MR RX BE -,SUP-H7493927416450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X20MM REBEL MR RX BE -,SUP-H7493927420220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X20MM REBEL MR RX BE -,SUP-H7493927420250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.75X20MM REBEL MR RX BE -,SUP-H7493927420270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3X20MM REBEL MR RX BE -,SUP-H7493927420300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X20MM REBEL MR RX BE -,SUP-H7493927420350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4X20MM REBEL MR RX BE -,SUP-H7493927420400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4.5X20MM REBEL MR RX BE -,SUP-H7493927420450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X24MM REBEL MR RX BE -,SUP-H7493927424220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X24MM REBEL MR RX BE -,SUP-H7493927424250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.75X24MM REBEL MR RX BE -,SUP-H7493927424270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3X24MM REBEL MR RX BE -,SUP-H7493927424300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X24MM REBEL MR RX BE -,SUP-H7493927424350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4X24MM REBEL MR RX BE -,SUP-H7493927424400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4.5X24MM REBEL MR RX BE -,SUP-H7493927424450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X28MM REBEL MR RX BE -,SUP-H7493927428220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X28MM REBEL MR RX BE -,SUP-H7493927428250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.75X28MM REBEL MR RX BE -,SUP-H7493927428270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3X28MM REBEL MR RX BE -,SUP-H7493927428300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X28MM REBEL MR RX BE -,SUP-H7493927428350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4X28MM REBEL MR RX BE -,SUP-H7493927428400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4.5X28MM REBEL MR RX BE -,SUP-H7493927428450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.75X32MM REBEL MR RX BE -,SUP-H7493927432270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3X32MM REBEL MR RX BE -,SUP-H7493927432300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X32MM REBEL MR RX BE -,SUP-H7493927432350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4X32MM REBEL MR RX BE -,SUP-H7493927432400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4.5X32MM REBEL MR RX BE -,SUP-H7493927432450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X8MM REBEL OTW BE -,SUP-H7493927508220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X8MM REBEL OTW BE -,SUP-H7493927508250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.75X8MM REBEL OTW BE -,SUP-H7493927508270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3X8MM REBEL OTW BE -,SUP-H7493927508300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X8MM REBEL OTW BE -,SUP-H7493927508350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4X8MM REBEL OTW BE -,SUP-H7493927508400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X12MM REBEL OTW BE -,SUP-H7493927512220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X12MM REBEL OTW BE -,SUP-H7493927512250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.75X12MM REBEL OTW BE -,SUP-H7493927512270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3X12MM REBEL OTW BE -,SUP-H7493927512300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X12MM REBEL OTW BE -,SUP-H7493927512350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4X12MM REBEL OTW BE -,SUP-H7493927512400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4.5X12MM REBEL OTW BE -,SUP-H7493927512450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X16MM REBEL OTW BE -,SUP-H7493927516220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X16MM REBEL OTW BE -,SUP-H7493927516250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.75X16MM REBEL OTW BE -,SUP-H7493927516270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3X16MM REBEL OTW BE -,SUP-H7493927516300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X16MM REBEL OTW BE -,SUP-H7493927516350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4X16MM REBEL OTW BE -,SUP-H7493927516400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4.5X16MM REBEL OTW BE -,SUP-H7493927516450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X20MM REBEL OTW BE -,SUP-H7493927520220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X20MM REBEL OTW BE -,SUP-H7493927520250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.75X20MM REBEL OTW BE -,SUP-H7493927520270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3X20MM REBEL OTW BE -,SUP-H7493927520300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X20MM REBEL OTW BE -,SUP-H7493927520350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4X20MM REBEL OTW BE -,SUP-H7493927520400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4.5X20MM REBEL OTW BE -,SUP-H7493927520450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X24MM REBEL OTW BE -,SUP-H7493927524220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X24MM REBEL OTW BE -,SUP-H7493927524250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.75X24MM REBEL OTW BE -,SUP-H7493927524270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3X24MM REBEL OTW BE -,SUP-H7493927524300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X24MM REBEL OTW BE -,SUP-H7493927524350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4X24MM REBEL OTW BE -,SUP-H7493927524400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4.5X24MM REBEL OTW BE -,SUP-H7493927524450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.25X28MM REBEL OTW BE -,SUP-H7493927528220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.5X28MM REBEL OTW BE -,SUP-H7493927528250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.75X28MM REBEL OTW BE -,SUP-H7493927528270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3X28MM REBEL OTW BE -,SUP-H7493927528300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X28MM REBEL OTW BE -,SUP-H7493927528350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4X28MM REBEL OTW BE -,SUP-H7493927528400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4.5X28MM REBEL OTW BE -,SUP-H7493927528450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 2.75X32MM REBEL OTW BE -,SUP-H7493927532270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3X32MM REBEL OTW BE -,SUP-H7493927532300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X32MM REBEL OTW BE -,SUP-H7493927532350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4X32MM REBEL OTW BE -,SUP-H7493927532400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 4.5X32MM REBEL OTW BE -,SUP-H7493927532450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 5X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293050230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 5X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 5X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 5X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 5X180MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 5X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293052030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9018.5,6312.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 5X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293054030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 5X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293056030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 5X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293058030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 6X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293060230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 6X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 6X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 6X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 6X180MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 6X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293062030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 6X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293064030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 6X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293066030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 6X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293068030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 7X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293070230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 7X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293071030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 7X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293071230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 7X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293071530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 7X180X130 SE ILC -,SUP-H74939293071830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 7X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293072030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 7X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293074030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 7X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293076030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 7X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293078030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 8X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293080230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 8X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293081030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 8X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293081230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 8X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293081530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 8X180X130 SE ILC -,SUP-H74939293081830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 8X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293082030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 8X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293084030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 8X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293086030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC INNOVA 8X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293088030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT ENPROS 22MM 10FR CATH 45MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965404510,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT ENPROS 22MM 10FR CATH 70MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965404520,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT ENPROS 24MM 11FR CATH 35MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965405100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT ENPROS 24MM 11FR CATH 45MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965405110,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
WALLSTENT 24X70 X 75CM/11F UNI PLUS 1 -,SUP-H965405120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.25X8MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22508UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.25X8MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.25X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22512UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.25X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.25X14MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22514UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.25X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22518UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.25X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.25X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22522UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.25X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.25X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22526UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.25X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.5X8MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25008UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.5X8MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25008W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.5X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.5X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.5X14MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25014UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS #1 27IN INTGRTY MO-4 DTCH 140CM MONO GUT TAPR PNT -,SUP-INT25014W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.5X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.5X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.5X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.5X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.5X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.5X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.75X8MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27508UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.75X8MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.75X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27512UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.75X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.75X14MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27514UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.75X14MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27514W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.75X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27518UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.75X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.75X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27522UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.75X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.75X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27526UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.75X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3X9MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30009UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3X9MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3X15MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30015UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3X15MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3X30MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30030UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3.5X9MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35009UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3.5X9MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3.5X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3.5X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3.5X15MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35015UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3.5X15MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3.5X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3.5X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3.5X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3.5X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3.5X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3.5X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3.5X30MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35030UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 3.5X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 4X9MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40009UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 4X9MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 4X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 4X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 4X15MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40015UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 4X15MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 4X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 4X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 4X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 4X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 4X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 4X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 4X30MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40030UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 4X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT LIFESTREAM 7MM X 26MM X 80MM -,SUP-LSMU0800726,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT ENPROS 8MM 6FR CATH 80MM WALLSTNT RP 100CM TOT 75CM -,SUP-M001711300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7320.9,5124.63,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT ESPH 18MM BD 23MMX7CM ULFLX NON- CVR FLR END MTL LF -,SUP-M00514070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DUOD 22MMX6CM WALLFLX 230CM DLV SYS TTS/ OTW NTNL FLR -,SUP-M00565010,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT WALLFLEX DUODENAL 22 X 60 -,SUP-M00565010,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DUOD 22MMX9CM WALLFLX 230CM NON- CVR NTNL LF -,SUP-M00565020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT WALLFLEX DUODENAL 22 X 90 -,SUP-M00565020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT WALLFLEX DUODENAL 22 X 120 -,SUP-M00565030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT WALLFLEX COLONIC 25 X 60 -,SUP-M00565040,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT WALLFLEX COLONIC 25 X 90 -,SUP-M00565050,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT WALLFLEX COLONIC 25 X 120 -,SUP-M00565060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT WALLFLEX COLONIC 22 X 60 -,SUP-M00565100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT WALLFLEX COLONIC 22 X 90 -,SUP-M00565110,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT WALLFLEX COLONIC 22 X 120 -,SUP-M00565120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT ENPROS 10FR 20X60MM WALLSTNT 135CM HRP -,SUP-M00565620,CDM,C1876,HCPCS,278,RC,,,outpatient,,,116.7,81.69,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT COLN 22MM BD 10FR CATH 6CM WALLSTNT 135CM CATH 160CM -,SUP-M00565640,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7434.26,5203.982,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 10X80MM WALLSTNT RX SE UNCVR MTL 0.035IN GW COMP -,SUP-M00569660,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6340.15,4438.105,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X80MM WALLFLX RX SE UNCVR PLATINOL 0.035IN GW -,SUP-M00570620,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X100MM WALLFLX RX SE NON- CVR PLATINOL 0.035IN GW -,SUP-M00570630,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 10X60MM WALLFLX RX SE NON- CVR PLATINOL 0.035IN GW -,SUP-M00570640,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
CATH GUID 6FRX68CM ACUITY BREAK-AWAY COR CS-IC 130 -,SUP-M00570650,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
WALLFLEX BILIARY RX UNCOVERED 10 X 80 -,SUP-M00570650,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
WALLFLEX RX UNCOVERED BILIARY STENT 10MM X 100MM -,SUP-M00570660,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
WALLFLEX BILIARY RX UNCOVERED 10 X 40 -,SUP-M00570890,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 14X60MM 120CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-N1460BB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PULSAR - 18 T3 5/40/135 -,SUP-NO MANUFACTURE IN DICTIONARY,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 10X30MM PALMZ XL BE UNMT TRNSHEP CLSD CELLFLEX SEG -,SUP-P3110,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 5X15MM 135CM PALMZ BLU RX BE TRNSHEP COCR 0.014IN -,SUP-PB1550BAX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4882.72,3417.904,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 5X15MM 135CM PALMZ BLU OTW BE TRNSHEP COCR 0.018IN -,SUP-PB1550BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X18MM 80CM PALMZ BLU OTW BE TRNSHEP COCR 0.014IN -,SUP-PB1860BSS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X18MM 135CM PALMZ BLU OTW BE TRNSHEP COCR 0.018IN -,SUP-PB1860BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X24MM 135CM PALMZ BLU OTW BE TRNSHEP COCR 0.018IN -,SUP-PB2460BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X18MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG1860BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X18MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG1860BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 9X19MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG1990BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X24MM 135CM PALMZ GENESIS RX BE TRNSHEP SS -,SUP-PG2460BAX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4948.93,3464.251,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X24MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2460BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X24MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG2480BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 10X29MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2910BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 5X29MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG2950BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 5X30MM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW COMP -,SUP-PG2950BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2960BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2970BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN. -,SUP-PG2970BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN. -,SUP-PG2980BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN- -,SUP-PG2980BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 10X39MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3910BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3960BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3970BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X29MM 135CM PALMZ_GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3980BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3980BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7X59MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG5970BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7X59MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG5970BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X59MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG5980BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X79MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG7960BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X20MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506020120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X40MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X60MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X80MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506080120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X100MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506100120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X120MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506120120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X150MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506150120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X200MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506200120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,12141.51,8499.057,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7X20MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507020120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7X40MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7X60MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7X80MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507080120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7X120MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507120120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7X150MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507150120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X40MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3508040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X60MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3508060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X80MM 120CM EVERFLX SE SUPRFC FEM/PROX POPLT ART -,SUP-PRB3508080120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC EVERFLX 10X120MM 120CM SE 3-WV PEAK DSGN PRECISN -,SUP-PRB3508100120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 12X120MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT -,SUP-PRB3508120120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X150MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3508150120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7X37MM 135CM VISI-PRO BE MNT SS 0.035IN/6FR -,SUP-PXB350737135,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X27MM 135CM VISI-PRO BE MNT SS 0.035IN/6FR -,SUP-PXB350827135,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X37MM 135CM VISI-PRO BE MNT SS 0.035IN/6FR -,SUP-PXB350837135,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 2.25X8MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 2.25X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 2.25X14MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22514W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 2.25X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 2.25X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 2.25X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BMS 2.25X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22530W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 2.5X8MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25008W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 2.5X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 2.5X14MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25014W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 2.5X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 2.5X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 2.5X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 2.5X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 2.75X8MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 2.75X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 2.75X14MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27514W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 2.75X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 2.75X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 2.75X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 2.75X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27530W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 3X9MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT30009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 3X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 3X15MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 3X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 3X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 3.5X9MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 3.5X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 3.5X15MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 3.5X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 3.5X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 3.5X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 3.5X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 4X9MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT40009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 4X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 4X15MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 4X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 4X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 4X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT DES 4X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 4MM 6FR CATH 60MM 120CM SUPERA TRNSHEP -,SUP-S-04-060-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 5MM 6FR CATH 40MM 120CM SUPERA TRNSHEP -,SUP-S-05-040-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 5MM 6FR CATH 80MM 120CM SUPERA TRNSHEP -,SUP-S-05-080-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6599.42,4619.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 5MM 6FR CATH 100MM 120CM SUPERA TRNSHEP -,SUP-S-05-100-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6599.42,4619.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6MM 6FR CATH 40MM 120CM SUPERA TRNSHEP -,SUP-S-06-040-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7617.98,5332.586,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 7MM 6FR CATH 60MM 120CM SUPERA TRNSHEP -,SUP-S-07-060-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 8X100MM 120CM SUPERA TRNSHEP -,SUP-S-08-100-120-G3,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6599.42,4619.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PERIPHERAL 4.5MM X 20MM X 120CM  6F -,SUP-S-45-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PERIPHERAL 4.5MM X 30MM X 120CM  6F -,SUP-S-45-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SUPERA 4.5X40MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-45-040-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SUPERA 4.5X60MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-45-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PERIPHERAL 4.5MM X 80MM X 120CM  6F -,SUP-S-45-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PERIPHERAL 4.5MM X 100MM X 120CM  6F -,SUP-S-45-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SUPERA 4.5X120MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-45-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PERIPHERAL 5MM X 20MM X 120CM  6F -,SUP-S-50-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PERIPHERAL 5MM X 30MM X 120CM  6F -,SUP-S-50-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SUPERA 5 X 60MM 120 -,SUP-S-50-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT  VASC SUPERA 5 X 80MM x 120 -,SUP-S-50-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
5MM X 100MM X 120CM SUPERA STENT -,SUP-S-50-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
5MM x 120MM x 120CM SUPERA STENT -,SUP-S-50-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SUPERA 5.5X40MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-040-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SUPERA 5.5X60MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SUPERA 5.5X80MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
SUPERA PERIPHERAL STENT SYSTEM 5.5MM X 100MM X 120CM -,SUP-S-55-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5495.98,3847.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SUPERA 5.5X120MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SUPERA 5.5X150MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-150-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PERIPHERAL 6MM X 30MM X 120CM  6F -,SUP-S-60-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT SUPERA 6.0MM X 80 X 120CM -,SUP-S-60-080-120-P,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5920.38,4144.266,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT SUPERA 6MM X 80 X 120CM -,SUP-S-60-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S SUPERA 6.0MM X 100 X 120CM -,SUP-S-60-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S SUPERA 6.0MM X 120 X 120CM -,SUP-S-60-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S SUPERA 6.0MM X 150 X 120CM -,SUP-S-60-150-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PERIPHERAL  6.5MM X 20MM X 120CM 6F -,SUP-S-65-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PERIPHERAL 6.5MM X 30MM X 120CM  6F -,SUP-S-65-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SUPERA 6.5X40MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-040-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SUPERA 6.5X60MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SUPERA 6.5X80MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SUPERA 6.5X100MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SUPERA 6.5X120MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC SUPERA 6.5X150MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-150-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PERIPHERAL 7.0MM X 020MM X 120CM  6F -,SUP-S-70-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT PERIPHERAL 7.0MM X 030MM X 120CM  6F -,SUP-S-70-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 10X40MM 120CM PROTEGE GPS OTW SE PRMNT OPN LATTICE -,SUP-SERB651040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 10X60MM 120CM PROTEGE GPS OTW SE PRMNT OPN LATTICE -,SUP-SERB651060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 12X20MM 120CM PROTEGE GPS OTW SE PRMNT OPN LATTICE -,SUP-SERB651220120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
7MM X 30MM TCAR STENT ENROUTE -,SUP-SR-0730-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
7MM X 40MM STENT TCAR ENROUTE -,SUP-SR-0740-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
8MM X 30MM STENT TCAR ENROUTE -,SUP-SR-0830-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
8MM X 40MM STENT TCAR ENROUTE -,SUP-SR-0840-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
9MM X 30MM STENT TCAR ENROUTE -,SUP-SR-0930-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
9MM X 40MM STENT TCAR ENROUTE -,SUP-SR-0940-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
ENROUTE TANSCAROTID STENT SYSTEM SR-1030-CS -,SUP-SR-1030-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
ENROUTE TANSCAROTID STENT -,SUP-SR-1040-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC MISAGO 6MM X120MM X 200CM RX R -,SUP-SXR06120R,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC MISAGO 6X150MM 135CM SELF EXPANDING -,SUP-SXR06150R,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
GRAFT EV 14X40 ILC -,SUP-UNDEFINED,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S BILI EXPRESS 5X15X150 -,SUP-UNDEFINED,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 5X18 GENESIS AVIATOR -,SUP-UNDEFINED,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
VENOUS 8F 10mm x 80 mm 120cm CATHETER LENGTH -,SUP-VENUM10080,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
VENOVO VENOUS STENT 12MM X 60MM -,SUP-VENUM12060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
16MM x 60MM x 80CM VENOVO STENT -,SUP-VENUM16060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
VENOUS STENT 14MM x 100MM 120CM CATHETER LENGTH -,SUP-VENUM16080,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
VENOVO VENOUS STENT 18MM X 100MM X 80CM -,SUP-VENUM18100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
VENOUS STENT SYSTEM 18X 120MM 80CM CATH LENGTH -,SUP-VENUM18120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
VENOVO 10FR 20MM X 60MM- 80CM CATHETER LENGTH -,SUP-VENUM20060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 4MMX6CM 125CM ZILVER 518 OTW SE PRELD SLT TUBE -,SUP-ZIB5-125-4.0-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 4MMX8CM 125CM ZILVER 518 OTW SE PRELD SLT TUBE -,SUP-ZIB5-125-4.0-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S ZILVER 518 5X60 125CM S-E -,SUP-ZIB5-125-5.0-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 12MM 8FR GUID CATH 60MM 125CM ZILVER 635 OTW SE -,SUP-ZIB6-125-12.060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S ZILVER .035 120CM 5 X 40 -,SUP-ZIB6-125-5.0-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S ZILVER .035 125CM 5 X 80 -,SUP-ZIB6-125-5.0-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X100MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-ZIB6-35-1256100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT BIL 6X140MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-ZIB6-35-1256140,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT ZILVER 6MM X 60MM X 125MM -,SUP-ZIV5-18-125-6-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ZILVER 518 8X40MM 125CM OTW SE 0.018IN/5FR -,SUP-ZIV5-18-125-840,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC ZILVER 518 8X80MM 125CM OTW SE 0.018IN/5FR -,SUP-ZIV5-18-125-880,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
S ZILVER 6 X 30 -,SUP-ZIV6-35-125-630,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT ZILVER 6 X 40 -,SUP-ZIV6-35-125-640,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT VASC DES ZILVER PTX 6X40MM 125CM OTW SE PRELD -,SUP-ZIV635125640PTX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5487.45,3841.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,32197.7856,other,OPPS APC,,
STENT 3.5X18MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010144-18,CDM,C1877,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,198.065125,7007.6928,other,OPPS APC,,
CATH GUID 7FR AL 0.75 SH 100CM -,SUP-G782AL75,CDM,C1877,HCPCS,278,RC,,,outpatient,,,882.25,617.575,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,198.065125,7007.6928,other,OPPS APC,,
STENT ESPH 18MM 23/23MM OD P/D FLR 153MM WALLFLX SE BRD FLLY -,SUP-M00516920,CDM,C1877,HCPCS,278,RC,,,outpatient,,,9124.6,6387.22,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,198.065125,7007.6928,other,OPPS APC,,
PALMAZ UNMOUNTED STENT DIA 1 -,SUP-P4010,CDM,C1877,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,198.065125,7007.6928,other,OPPS APC,,
STENT BIL 10X59MM PALMZ GENESIS BE UNMT TRNSHEP SS 0.035IN -,SUP-PG5910B,CDM,C1877,HCPCS,278,RC,,,outpatient,,,3986.29,2790.403,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,198.065125,7007.6928,other,OPPS APC,,
IMPLANT VOCAL CRD PST PROLARYN PLUS 1ML SYR -,SUP-8044M0K5,CDM,C1878,HCPCS,278,RC,,,outpatient,,,3246.32,2272.424,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2621.49888,other,OPPS APC,,
IMPLANT VOCAL CORD PROLARYN GEL 1CC NEEDLE -,SUP-8602M0K5,CDM,C1878,HCPCS,278,RC,,,outpatient,,,3413.41,2389.387,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2621.49888,other,OPPS APC,,
IMPLANT THYRPL MONT SZ9 SIL EAR FEM STRL -,SUP-MTF.09,CDM,C1878,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2621.49888,other,OPPS APC,,
KIT THYROPLASTY MALE -,SUP-MT-SPM,CDM,C1878,HCPCS,278,RC,,,outpatient,,,3308.38,2315.866,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2621.49888,other,OPPS APC,,
FILTER VASC BIRDS NEST 40MMX40CM SS VC MRKR -,SUP-178242,CDM,C1880,HCPCS,278,RC,,,outpatient,,,9467.05,6626.935,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.22547,6153.5825,other,OPPS APC,,
FILTER EMBL PROT OPTEASE 6FR ID 8FR INTRO SHTH 55CM SLF CNTR -,SUP-466-F220A,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3189.03,2232.321,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.22547,6153.5825,other,OPPS APC,,
FILTER OPTEASE FEMORAL 55CM -,SUP-466-F230AF,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3189.03,2232.321,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.22547,6153.5825,other,OPPS APC,,
FILTER VASC BIRD S NEST 40MM 11FR CATH 12FR INTRO 75CM SS VC -,SUP-BNF-75-PB,CDM,C1880,HCPCS,278,RC,,,outpatient,,,9467.05,6626.935,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.22547,6153.5825,other,OPPS APC,,
FILTER EMBL NAVALIGN CELECT 30X48MM FEM VC -,SUP-G03767,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.22547,6153.5825,other,OPPS APC,,
FILTER CELECT VENA CAVA UNI -,SUP-G34505,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4773.95,3341.765,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.22547,6153.5825,other,OPPS APC,,
VENA CAVA FILTER FEMORAL & JUG -,SUP-G34505,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4773.95,3341.765,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.22547,6153.5825,other,OPPS APC,,
FILTER EMBL CELECT 30MM 7FR INTRO SHTH 48MM UNISET VC -,SUP-G52915,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.22547,6153.5825,other,OPPS APC,,
FILTER EMBL GUNTHER TULIP 30X50MM FEM VC -,SUP-G52917,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3819.15,2673.405,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.22547,6153.5825,other,OPPS APC,,
FILTER VASC NAVALIGN CELECT 30MM 7FR CATH UNIV 49MM UNISET -,SUP-IGTCFS651UNICEL,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4773.95,3341.765,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.22547,6153.5825,other,OPPS APC,,
FILTER VASC GUNTHER TULIP 30MM 8.5FR INTRO SHTH 50MM PRELD -,SUP-IGTCFS-65-FEM,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.22547,6153.5825,other,OPPS APC,,
FILTER VENA CAVA TULIP UNI GUNTHER -,SUP-IGTCFS-65-UNI,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3819.15,2673.405,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.22547,6153.5825,other,OPPS APC,,
FILTER VASC GUNTHER TULIP 30MM 8.5FR INTRO SHTH 50MM- -,SUP-IGTCFS-65-UNI,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.22547,6153.5825,other,OPPS APC,,
FILTER GREENFIELD JUG -,SUP-M001503000,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4249.67,2974.769,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.22547,6153.5825,other,OPPS APC,,
FILTER GREENFIELD FEM -,SUP-M001503010,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4249.67,2974.769,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.22547,6153.5825,other,OPPS APC,,
DILATOR VASC 18GA GW 0.038IN DILATOR 8/10/12 FR DIA SYR -,SUP-M001503500,CDM,C1880,HCPCS,278,RC,,,outpatient,,,776.06,543.242,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.22547,6153.5825,other,OPPS APC,,
FILTER VASC MERIDIAN NTNL VC -,SUP-MD800F,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.22547,6153.5825,other,OPPS APC,,
FILTER VASC MERIDIAN NTNL SBCLVN VC -,SUP-MD800J,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.22547,6153.5825,other,OPPS APC,,
FILTER OPTEASE JUGULAR 55CM -,SUP-UNDEFINED,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3189.03,2232.321,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.22547,6153.5825,other,OPPS APC,,
FILTER OPTEASE JUGULAR 90CM -,SUP-UNDEFINED,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,174.22547,6153.5825,other,OPPS APC,,
DEFIBRILLATOR PRMT RF DF-1 2CHMBR 50X81MM 14MM 43ML 82GM -,SUP-3207-36,CDM,C1882,HCPCS,275,RC,,,outpatient,,,59022.98,41316.086,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR LUMAX 540 HF-T DF-1 IS-1 CONN 3 CHMBR RR. -,SUP-360347,CDM,C1882,HCPCS,275,RC,,,outpatient,,,38238.5,26766.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR LUMAX 740 HF-T BIVEN PCNG CARD IMPL W/HOME -,SUP-365608,CDM,C1882,HCPCS,275,RC,,,outpatient,,,40705.5,28493.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR ILESTO HF-T DF-1 BIVEN PCNG RDC HI ENRG CARD -,SUP-383547,CDM,C1882,HCPCS,275,RC,,,outpatient,,,40705.5,28493.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR ILESTO HF-T DF-4 BIVEN PCNG HI ENRG CARD IMPL -,SUP-383549,CDM,C1882,HCPCS,275,RC,,,outpatient,,,32036.46,22425.522,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR LUMAX 740 HF-T CARD IMPL W/HOME MNTR MBL -,SUP-393803,CDM,C1882,HCPCS,275,RC,,,outpatient,,,39472,27630.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIB HI ENRG BIVEN CARD IMPL TI -,SUP-401662,CDM,C1882,HCPCS,275,RC,,,outpatient,,,34503.46,24152.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR PRMT + DF-4 RR V- PCNG RDC 50X75MM 14MM 42ML -,SUP-CD3211-36Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR UNIFY IS-1 CONN 40X79MM 14MM 36ML 78GM CARD -,SUP-CD3231-40,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR UNIFY QUADRA DF-4 IS-4 IS-1 CONN 41X75MM 14MM -,SUP-CD3249-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43251.44,30276.008,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR UNIFY ASSURA DF-1 IS-1 DF-4 BIVEN PCNG 40X79MM -,SUP-CD3257-40,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR UNIFY ASSURA DF-4 TELEM 2CHMBR 40X73MM 14MM -,SUP-CD3257-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR QUADRA ASSURA DF-1 BIVEN PCNG 41X83MM 14MM -,SUP-CD3265-40,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43251.44,30276.008,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR QUADRA ASSURA DF-4 IS-4 IS-1 CONN BIVEN PCNG -,SUP-CD3265-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43251.44,30276.008,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR UNIFY ASSURA CARD IMPL PARYLENE CTD -,SUP-CD3357-40C,CDM,C1882,HCPCS,275,RC,,,outpatient,,,29974.05,20981.835,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
UNIFY ASSURA NXGEN CRT-D 40 MEDIGUIDE -,SUP-CD3357-40C,CDM,C1882,HCPCS,275,RC,,,outpatient,,,47726.58,33408.606,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR UNIFY ASSURA DF-4 CARD IMPL PARYLENE CTD CD -,SUP-CD3357-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,29974.05,20981.835,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
CRT-D 40 QUADRA ASSURA -,SUP-CD3365-40C CELL,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35225.31,24657.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR QUADRA ASSURA DF-4 SGL/2CHMBR 41X75MM 14MM -,SUP-CD3365-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35225.31,24657.717,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
CRT-D QUADRA ASSURA MP CD3369-40C -,SUP-CD3369-40C,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
CRT-D QUADRA ASSURA MP DFR CON -,SUP-CD3369-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
ENTRANT CRT-D CDHFA300Q -,SUP-CDHFA300Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35771.5,25040.05,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
ENTRANT HF CRT-D DF1 CONNECTOR REF: CDHFA300T -,SUP-CDHFA300T,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35771.5,25040.05,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
GALLANT CRT-D CDHFA500Q -,SUP-CDHFA500Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,38238.5,26766.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
GALLANT HF CRT-D DF1 CONNECTOR REF: CDHFA500T -,SUP-CDHFA500T,CDM,C1882,HCPCS,275,RC,,,outpatient,,,38238.5,26766.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR INOGEN MUL PRGM OPTN EXTEND LNGVT VR -,SUP-D141,CDM,C1882,HCPCS,275,RC,,,outpatient,,,28370.5,19859.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR CONSULTA DF-1 IS-1 CONN WRLS TELEM 2CHMBR RR -,SUP-D224TRK,CDM,C1882,HCPCS,275,RC,,,outpatient,,,48626.05,34038.235,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR PROTECTA DF-4 CARD IMPL -,SUP-D334TRM,CDM,C1882,HCPCS,275,RC,,,outpatient,,,39911.13,27937.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
EVERA MRI MRT XT DR DDMB1D4 -,SUP-DDMB1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,37251.7,26076.19,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
VIVA CARD IMPL -,SUP-DTBA1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50599.65,35419.755,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR VIVA XT IS-1 DF-1 ADPTVCRT PHYCRV SMRTSHCK -,SUP-DTBA1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50599.65,35419.755,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR VIVA S DF-4 IS-1 CONN SGL-CHMBR CARD IMPL -,SUP-DTBB1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,42839.46,29987.622,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR VIVA S DF-4 IS-1 CONN SGL-CHMBR CARD IMPL. -,SUP-DTBB1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,42839.46,29987.622,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIB  VIVA QUAD S CRT-D DF-1 IS-4 CONN CARD IMPL -,SUP-DTBB1Q1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43172.5,30220.75,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR VIVA QUAD S DF-4 IS-4 CONN CARD IMPL -,SUP-DTBB1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,42839.46,29987.622,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
CLARIA MRI CRT-D DTMA1D1 -,SUP-DTMA1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49006.96,34304.872,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
CLARIA MRI CRT-D MODEL DTMA1D1 -,SUP-DTMA1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49006.96,34304.872,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
CLARIA MRI CRT-D DTMA1D4 -,SUP-DTMA1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49006.96,34304.872,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
CLARIA MRI QUAD CRT-D DTMA1QQ -,SUP-DTMA1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50326.8,35228.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
CLARIA MRI QUAD CRT-D Model DTMA1QQ -,SUP-DTMA1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50326.8,35228.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
AMPLIA MRI CRT-D DTMB1D1 -,SUP-DTMB1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,47773.46,33441.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
CRTD DTMB1D1 AMPLIA MRI US DF1 -,SUP-DTMB1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,47773.46,33441.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
AMPLIA CRT-D MRI DEVICE -,SUP-DTMB1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,54249.33,37974.531,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
AMPLIA MRI QUAD CRT-D -,SUP-DTMB1Q1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
AMPLIA MRI QUAD CRT-D SURESCAN DTMB1Q1 -,SUP-DTMB1Q1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
AMPLIA CRT-D DTMB 1 QQ -,SUP-DTMB1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
ICD COBALT HF CRT-D MRI SURESCAN REF: DTPB2D1 -,SUP-DTPB2D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,48237.25,33766.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
COBALT HF QUAD CRTD REF: DTPB2QQ -,SUP-DTPB2QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,52793.8,36955.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
CROME MRI CRTD REF: DTPC2D4 -,SUP-DTPC2D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50240.46,35168.322,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
CRT-D MOMENTUM IS1 DF4 G124 -,SUP-G124,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
CRT-D MOMENTUM IS1 DF1 G125 -,SUP-G125,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
CRT-D MOMENTUM LV-1 G126 -,SUP-G126,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
CRT-D MOMENTUM X4 IS4-DF1 G138 -,SUP-G138,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
PACEMAKER INOGEN CARD -,SUP-G140,CDM,C1882,HCPCS,275,RC,,,outpatient,,,39225.3,27457.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR INOGEN CARD -,SUP-G141,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR INOGEN DF-1 SGL-CHMBR 5.37CMX8.08CMX0.99CM D -,SUP-G146,CDM,C1882,HCPCS,275,RC,,,outpatient,,,41692.3,29184.61,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
DEFIBRILLATOR INOGEN DF-4 5.37CMX8.08CMX0.99CM D 32ML CARD -,SUP-G148,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
DYNAGEN CRT-D MODEL G150 -,SUP-G150,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
DYNAGEN CRT-D G-154 DEFIBRILLATOR -,SUP-G154,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
CRT-D DYNAGEN X4 G156 -,SUP-G156,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33218.16,23252.712,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
CRT-D VIGILANT X4 IS4 DF4 MRI CONDITIONAL -,SUP-G247,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
COMPIA CRT-D MRI QUAD -,SUP-UNDEFINED,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,45329.64864,other,OPPS APC,,
ANCHOR LD C IN 94IN LF ACC -,SUP-1194,CDM,C1883,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3519.77472,,,,
KIT EXTENSION INTERSTIM 10CM S  - DISCONTINUED DO NOT USE -,SUP-3095-10,CDM,C1883,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3519.77472,,,,
KIT REVISION INTERSTIM -,SUP-3550-05,CDM,C1883,HCPCS,278,RC,,,outpatient,,,1079.48,755.636,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3519.77472,,,,
KT EXTENSION NEURSTM INTSTM 60CM PERC MRI-COND INSL MULI- -,SUP-3708160,CDM,C1883,HCPCS,278,RC,,,outpatient,,,3007.62,2105.334,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3519.77472,,,,
LEAD ADPTR -,SUP-5866,CDM,C1883,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3519.77472,,,,
CABLE PCNG -,SUP-5867AS,CDM,C1883,HCPCS,278,RC,,,outpatient,,,116.7,81.69,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3519.77472,,,,
EXTENDER LD UNIPL -,SUP-6981M,CDM,C1883,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3519.77472,,,,
EXTENDER LD BIPLR MRI-COND -,SUP-6984M,CDM,C1883,HCPCS,278,RC,,,outpatient,,,1079.48,755.636,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3519.77472,,,,
ADAPTER NEURSTM 27.4CM SPIN CRD 2X4 PCKT -,SUP-740-02,CDM,C1883,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,26.19915,3519.77472,,,,
FILTER EMBL PROT EMBOSHIELD NAV6 5MMX190CM WIRE UNCNTSTR -,SUP-22437-19,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,5331.24633,other,OPPS APC,,
FILTER EMBL PROT EMBOSHIELD NAV6 7.2MMSMX190CM WIRE UNCNTSTR -,SUP-22438-19,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,5331.24633,other,OPPS APC,,
FILTER EMBL PROT FLTWR EZ 3.2FRX190CM WIRE NTNL LOOP CRTD -,SUP-H749201001900,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6875.28,4812.696,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,5331.24633,other,OPPS APC,,
FILTER EMBL PROT FLTWR EZ 3.2FRX300CM WIRE NTNL LOOP CRTD -,SUP-H749201003000,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7078.99,4955.293,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,5331.24633,other,OPPS APC,,
EMBOLIC PROT FLTWR EZ 0.042IN 0.014 DIA GW 110U FLTR 190CM -,SUP-H749390711900,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7435.49,5204.843,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,5331.24633,other,OPPS APC,,
FILTERWIRE EMBL EZ 2.25MM 3.5MMX300CM FEM VC -,SUP-H74939071300,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6457.03,4519.921,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,5331.24633,other,OPPS APC,,
DEVICE EMBL PROT SPIDERFX 3MM FLTR BSKT 0.014IN GW 0.066IN -,SUP-SPD2US030320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,5331.24633,other,OPPS APC,,
DEVICE EMBL PROT SPIDERFX 4MM FLTR BSKT 0.014IN GW 0.066IN -,SUP-SPD2US040320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,5331.24633,other,OPPS APC,,
SPIDER FX 5MM 320 .014 EMBOLIC -,SUP-SPD2US050320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,5331.24633,other,OPPS APC,,
SPIDER FX 6MM 320 .014 EMBOLIC -,SUP-SPD2US060320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,5331.24633,other,OPPS APC,,
DEVICE EMBL PROT SPIDERFX 7MM FLTR BSKT 0.014IN GW 0.066IN -,SUP-SPD2US070320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,5331.24633,other,OPPS APC,,
CATHETER LASER CORONARY ATHETECTOMY 0.9X80 ELACX-80 -,SUP-110-004,CDM,C1885,HCPCS,272,RC,,,outpatient,,,10588.78,7412.146,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7592.15526,other,OPPS APC,,
CATHETER 1.4MM ELCA CORONARY LASER ATHE -,SUP-114-009,CDM,C1885,HCPCS,272,RC,,,outpatient,,,10588.78,7412.146,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7592.15526,other,OPPS APC,,
C 1.7M .018IN OTW TURBO ELITE -,SUP-417-152,CDM,C1885,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7592.15526,other,OPPS APC,,
CATH ABLT 4MM 90DG 160CM BARRX ULTRA LNG LF -,SUP-90-9200,CDM,C1886,HCPCS,272,RC,,,outpatient,,,9419.88,6593.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7607.37,other,OPPS APC,,
CATHETER BRONCHIAL THERMOPLAST -,SUP-M005ATS25010,CDM,C1886,HCPCS,272,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7607.37,other,OPPS APC,,
CATH SHEATH RITESITE C315H40,SUP-,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
GUIDE 8F MARK 1 AL 2 -,SUP-34358-20,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
GUIDE 8F MARK 1 IM -,SUP-34358-26,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
LEAD PCNG 6.6FR 7FR INTRO 53CM TILDA HELIX ELECTRICALLY -,SUP-382889,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
LEAD PCNG 6.6FR 7FR INTRO 60CM TILDA HELIX ELECTRICALLY -,SUP-382895,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER GUIDE 6FR X 85CM INTERNAL MAMMARY -,SUP-38969-122/H749389691220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 5FR IL-3.5 HEARTRAIL III NO SH COR SS FLTWR PTFE -,SUP-40-5370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 5FR IKARI RT 2 HEARTRAIL III NO SH COR SS FLTWR -,SUP-40-5382,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 6FR ID 0.081IN IL-3.5 100CM HEARTRAIL III LRG LUM -,SUP-40-6370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 6FR ID 0.081IN IL-4.5 100CM HEARTRAIL III LRG LUM -,SUP-40-6375,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
MICRO GUIDE CATH NHANCER RX REF: 451669 -,SUP-451669,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER GUIDE -,SUP-490107,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX 0.039/0.026IN DIA P/D 45DG ANG TAPR 135CM QCK-CX -,SUP-518-032,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX 0.044/0.030IN DIA P/D 15MM SPC 45DG ANG TAPR 90CM -,SUP-518-033,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
C QUICKCROSS .018 150CM -,SUP-518-035,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX 0.063/0.050IN DIA P/D 15MM SPC 45DG ANG TAPR 90CM -,SUP-518-036,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
C QUICKCROSS .035 135CM -,SUP-518-037,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
C QUICKCROSS .035 150CM -,SUP-518-038,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
C 0.014-150CM QUICK CROSS -,SUP-518-065,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX 0.052/0.059IN DIA P/D 15MM SPC 45DG ANG TAPR 135CM -,SUP-518-081,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
C QUICK CROSS SEL .035 150CM -,SUP-518-083,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
C QUICK CROSS SEL .014 150 -,SUP-518-087,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
C QUICK CROSS SEL .018 150 -,SUP-518-093,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX 3FR ID 1.9FRX140CM TWN PASS RX LPRO LUMX2 COR PERIPH -,SUP-5200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2003.59,1402.513,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER SUPERCROSS 45 ANGLED 0.014 X 130CM -,SUP-5302,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
SUPERCROSS 90 ANGLED TIP CATH -,SUP-5305,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2279.22,1595.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
MICRO GUIDE CATH SUPERCROSS 120 ANGLED TIP REF: 5306 -,SUP-5306,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2472.93,1731.051,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ANG INFINITI 5FR JR4 REF: 534521T -,SUP-534521T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ANG 5FR 145 PIGTL 110CM INFINITI REF: 534-552S -,SUP-534552S,CDM,C1887,HCPCS,272,RC,,,outpatient,,,43.47,30.429,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ANG 5FR IMA CRV 100CM INFIN SLCT 3 STG BRD NBRD PROX -,SUP-534-560T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ANG INFINITI 6FR JL4 REF: 534620T -,SUP-534620T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ANG INFINITI 6FR JR4 REF: 534-621T -,SUP-534-621T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ANG INFINITI 6FR AR MOD REF: 534648T -,SUP-534648T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ANG INFINITI 6FR RCB REF: 534670T -,SUP-534670T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ANG INFINITI 6FR LCB REF: 534672T -,SUP-534672T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
SHEATH GUID 5FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-54-54501,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX 6FR 145DG PIGTL 110CM LANGSTON BRD LUMX2 LO XING -,SUP-5540,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1088.81,762.167,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.056IN 5FRX100CM 2.5MM VISTA BRITE TIP SS PTFE -,SUP-556-002-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.056IN 5FR JL3.5 100CM VISTA BRITE TIP BRD -,SUP-556-002-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.056IN 5FR LT COR EBU 3.5 100CM 2.5MM VISTA BRITE -,SUP-556-054-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.056IN 5FR  XBLAD 3.5 LBT 100CM 2.5MM VISTA -,SUP-556-060-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.056IN 5FR BARB 100CM VISTA BRITE TIP BRD MUL-SEG -,SUP-556-174-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER 6FRX150CM TRAPLINER REF:5566 -,SUP-5566,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3652.11,2556.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER 7FRX150CM TRAPLINER REF:5567 -,SUP-5567,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3652.11,2556.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX 6FRX150CM GUIDELINER V2 RX COAX PERIPH -,SUP-5571,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2183.81,1528.667,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX 7FRX150CM GUIDELINER V2 RX COAX PERIPH -,SUP-5572,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2183.81,1528.667,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX 8FRX150CM GUIDELINER V2 RX COAX PERIPH -,SUP-5573,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2173.21,1521.247,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
TURNPIKE GOLD 135CM MICRO CATH -,SUP-5621,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3294.06,2305.842,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
TURNPIKE LP 135 ON MICRO CATHETER -,SUP-5638,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3771.46,2640.022,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
TURNPIKE LP 150CM MICRO CATH -,SUP-5639,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2931.24,2051.868,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER TURNPIKE SPIRAL 135CM -,SUP-5640,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3771.46,2640.022,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.018IN 3.5FR SHFT 70CM 8MM VENTURE OTW CS PED -,SUP-5822,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3146.07,2202.249,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.088IN 8FR JL4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-588-823,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.088IN 8FR LT COR EBU3 100CM 2.5MM VISTA BRITE -,SUP-588-829,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.088IN 8FR JR4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-588-830,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.088IN 8FR JL3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-588-851,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID VISTA 8FR XB 3.5 -,SUP-588-882,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.088IN 8FR LT COR EBU 4 100CM 2.5MM VISTA BRIT -,SUP-588-894,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX 0.054IN 6FRX100CM 2CM PERFORM ULTMT 2 -,SUP-610038ULT2,CDM,C1887,HCPCS,272,RC,,,outpatient,,,140.74,98.518,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 130DG CRV ATTAIN SELECT COR STR 5.5FR INR CATH -,SUP-6248DEL,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER ATTAIN SELECT REF: 6248V-130 -,SUP-6248V-130,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1284.84,899.388,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH 6248V-90 ATTAIN SELECT II -,SUP-6248V-90,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1284.84,899.388,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER  CRDM Adaptor 6250V-EH -,SUP-6250V-EH,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER ATTAIN COMMAND REF: 6250V-MPR -,SUP-6250V-MPR,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.96MM/MIN 2.4MM/MAX MPX COR 50CM ATTAIN COMMAND -,SUP-6250VMPX,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR JL3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-002-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR JL4 100CM VISTA BRITE TIP BRD -,SUP-670-004-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR JL4 SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-005-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR JL4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-014-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR AL1 100CM .75MM SH VISTA BRITE TIP -,SUP-67003500,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR ALC1 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-036-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR ALC2 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-040-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR  XB3 100CM 1.8MM VISTA BRITE TIP -,SUP-670-052-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR XB 3 SH 100CM VISTA BRITE TIP -,SUP-670-053-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUIDING 6FR XB 3.5 VISTA -,SUP-670-054-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUIDING 6FR XB 3.5 VISTA LBT -,SUP-670-054-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,253.82,177.674,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR LT COR EBU3.5 SH 100CM 2.5MM VISTA -,SUP-670-055-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR XB4 100CM 2.5MM VISTA BRITE TIP -,SUP-670-056-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR XB4.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-67005800,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR XBLAD 3.5 100CM  VISTA BRITE -,SUP-670-060-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR XBLAD 4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-062-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 6FR XBLAD 4.5 100CM VISTA BRITE TIP -,SUP-67006400,CDM,C1887,HCPCS,272,RC,,,outpatient,,,198.39,138.873,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR XBLAD 3 100CM VISTA BRITE TIP -,SUP-670-066-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR JR3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-080-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR JR4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-67008200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR JR4 55CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-082-55,CDM,C1887,HCPCS,272,RC,,,outpatient,,,355.35,248.745,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR JR4 SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-083-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR ARC1 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-67011000,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR XBRCA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-126-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 6FR JFL LT REF: 670-166-00 -,SUP-670-166-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR JEAN- FJL 100CM 2.5MM VISTA BRITE TIP -,SUP-670-166-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR BARB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-174-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR LCB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-180-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR LCB 90CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-180-90,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR RCB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-182-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR RCB 90CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-182-90,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR IMA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-190-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR VERT 55CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-190-55,CDM,C1887,HCPCS,272,RC,,,outpatient,,,355.35,248.745,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR IM SH REF: 670-191-00 -,SUP-670-191-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 6FR IM VB-1 100CM VISTA BRITE TIP -,SUP-67019200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,198.39,138.873,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR RNL CRV 55CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-212-55,CDM,C1887,HCPCS,272,RC,,,outpatient,,,355.35,248.745,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR HS 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-278-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR HS SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-279-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.078IN 7FR JL4 100CM 2.5MM VISTA BRITE TIP BD -,SUP-778-004-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER GUIDING 7FR JL 5 SH JUDKINS -,SUP-77800900,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUIDE 7FR AL2 REF: 778704000 -,SUP-77804000,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.078IN 7FR LT EBU LAD 3 100CM 2.5MM VISTA BRITE -,SUP-778-052-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.078IN 7FR XB 3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-054-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUIDING  7FR XB3.5 SH VIS -,SUP-778-055-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.078IN 7FR XB4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-056-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.078IN 7FR LT EBU LAD 4.5 100CM 2.5MM VISTA BRITE -,SUP-778-058-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUIDING 7FR XBLAD 3.5 100CM 2.5MM VISTA -,SUP-778-060-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.078IN 7FR LT COR EBU LAD 4 100CM 2.5MM VISTA -,SUP-778-062-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.078IN 7FR JR4 100CM 2.5MM VISTA BRITE BRD -,SUP-778-082-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.078IN 7FR JR4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-083-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.078IN 7FR ARC1 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-110-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.078IN 7FR ARC2 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-112-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.078IN 7FR RCB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-182-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.078IN 7FR IMA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-190-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.078IN 7FR MPA-1 COR 100CM 2.5MM VISTA BRITE TIP -,SUP-778-270-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.078IN 7FR HS 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-278-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.078IN 7FR HS SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-279-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH BLN OCCULSION 2.1FRX135CM ASAHI TORNUS SUPP CHRNC OTW -,SUP-82380-01,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX 2.6FRX135CM ASAHI TORNUS SUPP OTW THRD COR SS -,SUP-82381-01,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3795.33,2656.731,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER CENTER POINT REF:9181 -,SUP-9181,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER CENTER POINT REF:9182 -,SUP-9182,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER CENTER POINT REF:9183 -,SUP-9183,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER CENTER POINT REF:9184 -,SUP-9184,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH SHEATH RITESITE C315H2002 -,SUP-C315H2002,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH SHEATH RITESITE C315H4002 -,SUP-C315H4002,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH SHEATH C315HIS02 -,SUP-C315HIS02,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
HIS SHEATH DELIVERY SYSTEM C315HIS02 -,SUP-C315HIS02,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH SHEATH RITESITE C315J02 -,SUP-C315J02,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH SHEATH RITESITE C315S1002 -,SUP-C315S1002,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH SHEATH RITESITE C315S402 -,SUP-C315S402,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH SHEATH RITESITE C315S502 -,SUP-C315S502,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ELCSURG 7FRX100CM RF FLXB CLSR FST -,SUP-CF7-7-100,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
GLIDECATH MG1 4F 125CM  LONG -,SUP-CG440,CDM,C1887,HCPCS,272,RC,,,outpatient,,,295.54,206.878,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
GLIDECATH MG2 4F 135CM  LONG -,SUP-CG441,CDM,C1887,HCPCS,272,RC,,,outpatient,,,295.54,206.878,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ABLT CLSR FST 65CM PROC KT MIS-7F11 INTRO -,SUP-CPK6511,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1908.18,1335.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ABLT CLSR FST 73CM PROC KT MIS-7F11 INTRO -,SUP-CPK8511,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1908.18,1335.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
ASAHI CARAVEL MICROCATHETER 150 CM -,SUP-CRV150-19P,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER CORSAIR PRO XS 150CM REF: CSR150-21S -,SUP-CSR150-21S,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER CORSAIR PRO 150CM CSR150-26P ASAHI -,SUP-CSR150-26P,CDM,C1887,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
"CATHETER CXI SUPPORT 4.OFR X 135CM STR TIP .035"" MAX GUIDEWR -",SUP-CXI-4.0-35-135-P-NS-O,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER CPS LOCATOR 3D- SMALL REF:DS2C100-42 -,SUP-DS2C100-42,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER CPS LOCATOR 3D- MEDIUM REF:DS2C200-42 -,SUP-DS2C200-42,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER CPS LOCATOR 3D- LAGE REF:DS2C300-42 -,SUP-DS2C300-42,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER AGILIS HISPRO DS3H010-38  BUNDLE -,SUP-DS3H010-38,CDM,C1887,HCPCS,272,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER AGILIS HISPRO DS3H010-38 -,SUP-DS3H010-38,CDM,C1887,HCPCS,272,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ANG 0.056IN 6FR AR1 100CM DXTERITY REF: DXT6AR10 -,SUP-DXT6AR10,CDM,C1887,HCPCS,272,RC,,,outpatient,,,9.92,6.944,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
RING TRANS-JUG ACCESS SET WITH 10fr -,SUP-G06541,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2542.11,1779.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
TRANSJUGLAR LIVER ACCESS SET R -,SUP-G06929,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2558.82,1791.174,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
BEACON TIP 5.0 FR ANGIOGRAPHIC CATHETER - C2 -,SUP-G08442,CDM,C1887,HCPCS,272,RC,,,outpatient,,,151.7,106.19,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER RIM 5FR X 100CM -,SUP-G12870,CDM,C1887,HCPCS,272,RC,,,outpatient,,,758.49,530.943,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX 2.6FR STR 65CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G18367,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1051.93,736.351,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER CXI SUPPORT -,SUP-G18368,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1051.93,736.351,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CXI-2.3-14-65-0 -,SUP-G18369,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH CXI 2.3FR X 65CM X 014 SU -,SUP-G18370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH CXI 2.3FR X 90CM X 014 SU -,SUP-G18371,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CXI-2.3-14-90-ANG -,SUP-G18372,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CXI-2.3-14-150-ANG -,SUP-G18376,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX 2.6FR ANG 150CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G50003,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX 2.6FR STR 90CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G50004,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX 3FR/1.9FR P/D STR 135CM CROSSCATH SUPP LUMX1 PERIPH -,SUP-G51573,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX 4.8FR/3.7FR P/D STR 90CM CROSSCATH SUPP LUMX1 PERIPH -,SUP-G51580,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX 4.8FR/3.7FR P/D STR 135CM CROSSCATH SUPP LUMX1 -,SUP-G51581,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX 3.4FR/2.2FR P/D STR 135CM CROSSCATH SUPP LUMX1 -,SUP-G51583,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX 4FR DAV 135CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G52543,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
C NAVICROSS ANG 150CM .035 -,SUP-G52545,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX 4FR DAV 150CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G52545,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER CXI SUPPORT 4FR X 90CM STR TIP .035 MAX GUIDEWRE -,SUP-G52546,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX 4FR DAV 90CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G52547,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ANG 90CM NAVICROSS -,SUP-G52547,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 7FR XBRCA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-G778126,CDM,C1887,HCPCS,272,RC,,,outpatient,,,882.25,617.575,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID RELIEVA FLEX SIN S-0 SFT DIST TIP ENDO -,SUP-GC000RF,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1961.19,1372.833,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID RELIEVA FLEX SIN F-70 C SFT DIST TIP ENDO -,SUP-GC070CRF,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1961.19,1372.833,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID RELIEVA FLEX SIN M-110 SFT DIST TIP ENDO -,SUP-GC110RF,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1961.19,1372.833,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ANGIO IMPULSE 5FR FL3.5 REF:H74916391212 -,SUP-H74916391212,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER 5FR FL4 IMPULSE REF:H74916391222 -,SUP-H74916391222,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ANGIO IMPULSE 5FR AR1 REF:H74916391842 -,SUP-H74916391842,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ANG 0.045IN 5FR AL1 100CM IMPULSE REF:H74916391962 -,SUP-H74916391962,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER 5FR AL2 IMPULSE REF:H74916391982 -,SUP-H74916391982,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
ANGIO CATH PIG 6F IMPULSE -,SUP-H74916599412,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR AL3 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934356210,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER GUIDING 6FR Mach 1 AL .75 -,SUP-H74934356220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 6FR MACH 1 ML 3.5 REF: H749343565370 -,SUP-H749343565370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.081IN 7FR FL3 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934357050,CDM,C1887,HCPCS,272,RC,,,outpatient,,,306.51,214.557,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.081IN 7FR FL3.5 100CM MACH1 4X2 RND BRD LRG LUM -,SUP-H74934357060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 7FR IM 85CM MACH1 -,SUP-H749343571220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 7FR AL.75 100CM MACH1 REF:H74934357220 -,SUP-H74934357220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.081IN 7FR RCB 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934357240,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.081IN 7FR Q- TY CRV 4 100CM MACH1 4X2 RND BRD -,SUP-H749343572940,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 7FR Q4.5 MACH 1 -,SUP-H749343572950,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.081IN 7FR MP1 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934357380,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUIDE 7FR MP2 REF: H74934357390 -,SUP-H74934357390,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.081IN 7FR FR3.5 SH 100CM MACH1 2X2 RND BRD -,SUP-H74934357470,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.081IN 7FR FL4.5 100CM MACH1 2X2 RND BRD LRG LUM -,SUP-H74934357540,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.081IN 7FR CNTRLAT 3 100CM MACH1 2X2 RND BRD LRG -,SUP-H749343575730,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.081IN 7FR CLS 3.5 100CM MACH1 4X2 RND BRD LRG -,SUP-H749343575740,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.081IN 7FR VL3 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934357710,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.081IN 7FR VL3.5 100CM MACH1 4X2 RND BRD LRG LUM -,SUP-H74934357720,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.081IN 7FR FR4 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934357920,CDM,C1887,HCPCS,272,RC,,,outpatient,,,306.51,214.557,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.091IN 8FR FR3.5 100CM MACH1 2X2 RND BRD SD HOL -,SUP-H74934358010,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.091IN 8FR FR4 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934358020,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.091IN 8FR FL3.5 100CM MACH1 4X2 RND BRD LRG LUM -,SUP-H74934358060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.091IN 8FR FL4.5 100CM MACH1 2X2 RND BRD LRG LUM -,SUP-H74934358080,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID MACH1 8FR AL.75 SH  90CM - H749343581920 -,SUP-H749343581920,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.091IN 8FR LCB 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934358250,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.091IN 8FR FR4 100CM MACH1 4X2 RND BRD LRG LUM SH -,SUP-H74934358480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR FR3.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969010,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR FR4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969020,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR FL3 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969050,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR FL3.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR FL4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969070,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR FL4.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969080,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR FEM HS 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H749389691410,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR AR2 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969180,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR AL1 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969190,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR AL2 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR FRC BYPS 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H74938969240,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR LCB RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969250,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR IMA RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969260,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR FL4 ST RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H74938969290,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR Q3.5 -,SUP-H749389692930,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR Q4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389692940,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR Q4.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389692950,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR MP1 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969380,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR FEM MP 2 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H74938969390,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR HS RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969410,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR IMA 90CM RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389694460,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR RC 4 SC RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389694480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR RC 3.5 SC RUNWAY 2X2 RND BRD LRG LUM -,SUP-H74938969460,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR FR3.5 RUNWAY 2X2 RND BRD LRG LUM SH -,SUP-H74938969470,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR FR4 RUNWAY 2X2 RND BRD LRG LUM SH FEM -,SUP-H74938969480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR ART3 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389694960,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR ART3.5 RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389694980,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR ART3.5 RUNWAY 2X2 RND BRD LRG LUM SH -,SUP-H749389694990,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR ART4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389695000,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR FL 3.5 SH RUNWAY 2X2 RND BRD LRG -,SUP-H74938969520,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR MUTA LT 3 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695360,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR MUTA LT 3.5 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR MUTA LT 4 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695380,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR MUTA LT 4.5 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695390,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR FEM CLS 3 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H749389695730,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR CLS 3.5 RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389695740,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR CLS 4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389695750,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR CLS 3.5 RUNWAY 2X2 RND BRD LRG LUM SH -,SUP-H749389695780,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUIDE RUNWAY 6F CLS4 SH -,SUP-H749389695790,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR KRT HZNT 3H RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389696480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.081IN 7FR VL3.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389696620,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR FEM JL5 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H749389696640,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.07IN 6FR FEM AL1 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H74938969680,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR VL3 RUNWAY -,SUP-H74938969710,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR FL BK -UP 4 100CM RUNWAY 2X2 RND BRD -,SUP-H749389697160,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR FR4 ST RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H74938969920,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.070IN 6FR MP1 125CM RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389699530,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
MICRO GUIDE CATH MAMBA FLEX 135 REF: H7493928713540 -,SUP-H7493928713540,CDM,C1887,HCPCS,272,RC,,,outpatient,,,5071.58,3550.106,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
STINGRAY LP BALLOON 3.2FR -,SUP-H749393120SR0,CDM,C1887,HCPCS,272,RC,,,outpatient,,,6490.48,4543.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
GUIDE EXTENSION CATHETER GUIDEZILLA II 6F -,SUP-H7493933515060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
GUIDE EXTENSION CATHETER GUIDEZILLA II 6F LONG -,SUP-H74939335150610,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
GUIDE EXTENSION CATHETER GUIDEZILLA II 7F -,SUP-H7493933515070,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
GUIDE EXTENSION CATHETER GUIDEZILLA II 8F -,SUP-H7493933515080,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH PTCA 135CM CROSSBOSS STINGRAY F/COR CTO -,SUP-H749M1000A0,CDM,C1887,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ANG 4FR STR 65CM RADIFOCUS GLIDECATH DBL BRD SM-PRFL -,SUP-H787117140155,CDM,C1887,HCPCS,272,RC,,,outpatient,,,388.61,272.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
4FR GLIDECATH LONG 100CM STRAIGHT -,SUP-H787117140225,CDM,C1887,HCPCS,272,RC,,,outpatient,,,295.54,206.878,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ANG 5FR ANG TAPR 65CM RADIFOCUS GLIDECATH SGL-BRD LRG -,SUP-H787117221045,CDM,C1887,HCPCS,272,RC,,,outpatient,,,388.61,272.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ANG 5FR STR TAPR 65CM RADIFOCUS GLIDECATH SGL-BRD LRG -,SUP-H787117315025,CDM,C1887,HCPCS,272,RC,,,outpatient,,,388.61,272.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ANG 4FR JB3 TIP 100CM TORCONNB ADVANTG BEACN BRD PERIPH -,SUP-HNBR4.0-35-100-P-NS-JB3,CDM,C1887,HCPCS,272,RC,,,outpatient,,,227.57,159.299,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.071IN 5FR EBU3.5 100CM LAUNCHR BRD LRG LUM DIST -,SUP-LA5EBU35,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 6FR 3D RIGHT LAUNCHR REF: LA63DRIGHT -,SUP-LA63DRIGHT,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.071IN 6FR AL1 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6AL10,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 6FR AL75 100CM LAUNCHR REF: LA6AL75 -,SUP-LA6AL75,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.071IN 6FR AR1 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6AR10,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.071IN 6FR BU LT EBU 3 100CM LAUNCHR BRD LRG LUM -,SUP-LA6EBU30,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.071IN 6FR BU LT EBU 3.5 100CM LAUNCHR BRD LRG -,SUP-LA6EBU35,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.071IN 6FR BU LT EBU 3.75 100CM LAUNCHR BRD LRG -,SUP-LA6EBU375,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.071IN 6FR BU LT EBU 4 100CM LAUNCHR BRD LRG LUM -,SUP-LA6EBU40,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.071IN 6FR EBU 4.5 100CM LAUNCHR -,SUP-LA6EBU45,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.071IN 6FR BYPS IMA 90CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6IMAD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.071IN 6FR STD JR4 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6JR40,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 7FR 3D RIGHT LAUNCHR REF: LA73DRIGHT -,SUP-LA73DRIGHT,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUIDE 7 FR AL.75 SH D REF: LA7AL75SHD -,SUP-LA7AL75SHD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.081IN 7FR COR EBU3.5 100CM LAUNCHR BRD LRG LUM -,SUP-LA7EBU35,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.081IN 7FR COR EBU4 100CM LAUNCHR BRD LRG LUM -,SUP-LA7EBU40,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.081IN 7FR EBU4.5 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA7EBU45,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 7FR JR4 90CM LAUNCHR -,SUP-LA7JR40D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,256.74,179.718,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
GUIDE 8F AL 1.0 SH 90CM -,SUP-LA8AL10D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
GUIDE 8F AL 2.0 90CM MICR CATH -,SUP-LA8AL20D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
GUIDE 8F AL .75 90CM CATH -,SUP-LA8AL75D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
GUIDE 8F EBU 3.5 90CM -,SUP-LA8EBU35D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
GUIDE 8F EBU 3.5 SH 90CM -,SUP-LA8EBU35D SHD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
GUIDE 8F EBU 4.0 90CM -,SUP-LA8EBU40D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
GUIDE 8F JL 4.0 90CM -,SUP-LA8JL40D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
GUIDE 8F JL 4.0 SH 90CM -,SUP-LA8JL40D SHD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 105CM 20CM -,SUP-M001181250,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2497.81,1748.467,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D C 1 130CM 20CM -,SUP-M001181310,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2497.81,1748.467,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 150CM 20CM STC-18 -,SUP-M001181370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2497.81,1748.467,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 130CM 20CM -,SUP-M001182520,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1981.8,1387.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 150CM 20CM -,SUP-M001182530,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2297.77,1608.439,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
C RENEGADE HI-FLO MICROCATH -,SUP-M001183030,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2589.9,1812.93,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
MICROCATH INTVN 0.021IN SWAN 130CM DIREXION HI-FLO -,SUP-M001195300,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3221.16,2254.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH MICRO DREXION HI FLO J TO -,SUP-M001195470,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2566.03,1796.221,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.081IN 7FR LIMA 55CM MACH1 4X2 RND BRD LRG LUM -,SUP-M001197620,CDM,C1887,HCPCS,272,RC,,,outpatient,,,560.22,392.154,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH GUID 0.091IN 8FR LIMA 55CM MACH1 RND BRD LRG LUM PERIPH -,SUP-M001198620,CDM,C1887,HCPCS,272,RC,,,outpatient,,,560.22,392.154,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ANG 4FR PIGTL 65CM IMAGER II SLCT FLSH BRD TRQ TUNG -,SUP-M001315091,CDM,C1887,HCPCS,272,RC,,,outpatient,,,58.24,40.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ANG 4FR PIGTL 90CM IMAGER II FLSH BRD TRQ MED-GLD CTD -,SUP-M001315111,CDM,C1887,HCPCS,272,RC,,,outpatient,,,58.24,40.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH ANG 4FR CNTRLAT 2 CRV 65CM IMAGER II SLCT BRD TRQ SDE -,SUP-M001316581,CDM,C1887,HCPCS,272,RC,,,outpatient,,,58.24,40.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
MICRO GUIDE CATH FINECROSS M3 2.5 Fr 130 CM REF: M3-1430 -,SUP-M3-1430,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
MICRO GUIDE CATH FINECROSS M3 2.5 Fr 150 CM REF: M3-1450 -,SUP-M3-1450,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
PROGREAT 2.0 70 DEGREE ANGLE  150CM -,SUP-MC*PC2015ZRA,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3652.11,2556.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
PROGREAT COAXIAL MICROCATHETER2.4 FR  150CM   DEGREE ANGLE -,SUP-MC*PE24151YV,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2673.44,1871.408,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
PROGREAT COAXIAL 2.8 FR  150CM   RO MARKER BAND -,SUP-MC*PE28151YV,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2673.44,1871.408,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
PROGREAT 2.4  70 DEGREE ANGLE  150CM -,SUP-MC*PV2415ZRA,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2061.89,1443.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
PROGREAT MICROCATHETER 2.4x150CM -,SUP-MCPV2415Y,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1749.17,1224.419,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER NAVICROSS 018 65CM ANGLED STAINLESS STEEL -,SUP-NC18651,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER NAVICROSS 018 90CM ANGLED STAINLESS STEEL -,SUP-NC18901,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
C NAVICROSS 135CM .035 STR T -,SUP-NC35130,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
C NAVICROSS 135CM .035 ANGLE -,SUP-NC35131,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH INTVN 12MM TIP STR TAPR 150CM NAVICROSS SUPP DBL BRD -,SUP-NC35150,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER SUPPORT NAVICROSS 0.035 150CM ANGLED -,SUP-NC35151,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
SHEATH GUID 6FRX90CM PINNACLE -,SUP-RSC03,CDM,C1887,HCPCS,272,RC,,,outpatient,,,743.96,520.772,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
SHEATH GUID 6FRX90CM PINNCL DSTNTN VASC STR CRV GOLD COIL. -,SUP-RSC05,CDM,C1887,HCPCS,272,RC,,,outpatient,,,743.96,520.772,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
SHEATH GUID 6FRX90CM PINNCL DSTNTN VASC MP CRV GOLD COIL -,SUP-RSC07,CDM,C1887,HCPCS,272,RC,,,outpatient,,,743.96,520.772,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
SHEATH GUID 6FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL- -,SUP-RSR01,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
SHEATH GUID 7FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-RSR04,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
SHEATH GUID 7FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-RSR04,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
TIP GUIDE CATH RELIEVA SPIN SPND SIN S-0 SHP TIP BLN WND ORT -,SUP-RSS0,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1696.16,1187.312,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH DX TAPR 65CM TRAILBLAZER SUPP HYDRCT -,SUP-SC035065,CDM,C1887,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATHETER GUIDING 6FR X 125 JL 5 JUDKINS -,SUP-SM7361,CDM,C1887,HCPCS,272,RC,,,outpatient,,,882.25,617.575,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
SHEATH 6.5 FR X 55CM X 17MM -,SUP-TG0655517,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH SHEATH RITESITE C315H2001 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH SHEATH RITESITE C315H40 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH SHEATH RITESITE C315J01 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH SHEATH RITESITE C315S10 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
COIL MICRO RENEGADE STR FIBER -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2297.77,1608.439,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH SHEATH RITESITE C315H4001 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH SHEATH RITESITE C315S401 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH SHEATH RITESITE C315S501 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH SHEATH RITESITE C315H20 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH SHEATH RITESITE C315J -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH SHEATH RITESITE C315S1001 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH SHEATH RITESITE C315S4 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH SHEATH RITESITE C315S5 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH SHEATH RITESITE C315G -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH OCL 0.97MM 6FR SHTH 110CM WILDCAT FLSH OTW 2MM XING -,SUP-W400,CDM,C1887,HCPCS,272,RC,,,outpatient,,,6769.18,4738.426,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
CATH OCL 0.43MM 5FR SHTH 150CM KITTYCAT 2 OTW 1.7MM XING -,SUP-W550,CDM,C1887,HCPCS,272,RC,,,outpatient,,,6769.18,4738.426,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.22704,7607.37,other,OPPS APC,,
TUBE PEG 20FR PONSKY NBR NON BALLOON REPLACEMENT -,SUP-000700,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1250.92,875.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
TUBE JJUNO 16FRX108IN PVC/PLST 15ML BLN LUMX2 -,SUP-0042510,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1602.34,1121.638,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
TUBE GASTROSTOMY 14 FR -,SUP-0100-14LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
TUBE GASTROSTOMY FEEDING 16 FR -,SUP-010016LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,220.33,154.231,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
TUBE GASTROSTOMY 16FR -,SUP-0100-16LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
TUBE GASTROSTOMY FEEDING 18FR -,SUP-0100-18,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
MIC GASTROSTOMY TUBE 20 FR -,SUP-0100-20,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
TUBE GASTROSTOMY FEEDING 20 FR -,SUP-0100-20,CDM,C1889,HCPCS,278,RC,,,outpatient,,,45.16,31.612,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
TUBE GASTROSTOMY FEEDING 22 FR -,SUP-0100-22,CDM,C1889,HCPCS,278,RC,,,outpatient,,,225.87,158.109,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
MIC GASTROSTOMY TUBE 24 FR -,SUP-0100-24,CDM,C1889,HCPCS,278,RC,,,outpatient,,,43.52,30.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
TUBE GASTROSTOMY 26 FR -,SUP-0100-26,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
TUBE JJUNO 12FR SIL MI C SECUR-LOK XTRN RETEN RNG -,SUP-0200-12LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
TUBE JJUNO 14FR SIL 7-10ML BLN MI C SECUR-LOK XTRN RETEN RNG -,SUP-0200-14,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
TUBE FEEDING JEJUNAL 16F -,SUP-0200-16,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
TUBE JJUNO 18FR SIL 7-10ML BLN MIC-KEY SECUR-LOK XTRN RETEN -,SUP-0200-18,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
TUBE JEJUNOSTOMY 22FR MIC SECUR-LOK SILICONE -,SUP-0200-22,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
TUBE JJUNO 22FRX45CM SIL 7-10ML BLN MIC-KEY LPRO -,SUP-0250-22,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1221.18,854.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
TUBE MIC JEJUNOSTOMY 14FR / DR. GLEESON -,SUP-0301-14,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1113.49,779.443,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
TUBE NG 6FR SALEM SMP 60CM VYGON -,SUP-1340.06,CDM,C1889,HCPCS,278,RC,,,outpatient,,,79.12,55.384,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
CONNECTOR CATHETER NYLON STRAIGHT 1.5 X 1.0 X 1.9 -,SUP-45103,CDM,C1889,HCPCS,278,RC,,,outpatient,,,481.1,336.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
CONNECTOR CSF CATH STRAIGHT 3 WAY IMP 2 X 1.5 X 1.8 X 1.0 -,SUP-45105,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1359.53,951.671,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
AZUR 18D SYSTEM 4MM X 5CM -,SUP-45-480405,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3570.95,2499.665,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
AZUR CX 35D 4MM X 7C3 DETACHABLE -,SUP-45-750407,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
AZUR CX .035 5MM X 11CM DETACH -,SUP-45-750511,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
AZUR CX DETACH 035 6MMX17CM -,SUP-45-750617,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
AZUR CK DETACHABLE 035 8MM X 12CM -,SUP-45-750812,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
AZUR CX DETACH 035 8MMX24CM -,SUP-45-750824,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
AZUR CX DETACH 035 10MMX19CM -,SUP-45-751019,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
AZUR CX 35 DETACH 13MMX24CM CX COIL -,SUP-45-751324,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
AZUR CX 35D 16MM X 32 CM -,SUP-45-751632,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
AZUR CX 35D 20MM X 39 CM -,SUP-45-752039,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
AZUR CX DETACHABLE 018 6MM X 20CM -,SUP-45-780620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
AZUR CX DETACHABLE 018 7MM X 24CM -,SUP-45-780724,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
AZUR CX DETACHABLE 018 8MM X 28CM -,SUP-45-780828,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBOLIZATION POD 0.020IN 4MM 30CM FULLY DETACHABLE RESH -,SUP-90178538,CDM,C1889,HCPCS,278,RC,,,outpatient,,,8190.92,5733.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
KIT INTRO GASTROSTOMY FEED -,SUP-98432,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1149.84,804.888,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
SENTINEL CEREBRAL PROTECTION SYSTEM REF: CMS15-10C-US -,SUP-CMS15-10C-US,CDM,C1889,HCPCS,278,RC,,,outpatient,,,14852,10396.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBOLIZATION NESTER MICROCOIL PLATINUM L3 CM OD2 MM . -,SUP-G47331,CDM,C1889,HCPCS,278,RC,,,outpatient,,,577.61,404.327,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
14X14 NESTER COIL 0.035 -,SUP-G47347,CDM,C1889,HCPCS,278,RC,,,outpatient,,,705.98,494.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
CATH COOK AIRWAY EXCHANGE 14FR 83CM. -,SUP-G57622,CDM,C1889,HCPCS,278,RC,,,outpatient,,,374.02,261.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
SPACER BONE CERVICAL LOR 6MM -,SUP-LGAL906,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
SPACER BONE CERVICAL LOR 7MM -,SUP-LGAL907,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
SPACER BONE CERVICAL LOR 8MM -,SUP-LGAL908,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
SPACER BONE CERVICAL PAR 6MM -,SUP-LGAP906-P,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
SPACER BONE CERVICAL PAR 7MM -,SUP-LGAP907-P,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
SPACER BONE CERVICAL PAR 8MM -,SUP-LGAP908-P,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
CATHETER DELIVERY AVEIR REF:LSCD111 -,SUP-LSCD111,CDM,C1889,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
BASKET SPECIMEN RETRIEVAL ZERO TIP 0.8MM 12MM ENDOSCOPIC -,SUP-M00513200,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1398.8,979.16,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
PROBE BILIARY EHL -,SUP-M00546620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2273.91,1591.737,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
TUBE PEG 16FR ENDOVIVE LPRO PUL LF -,SUP-M00582060,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
TUBE PEG 18FR ENDOVIVE LPRO PUL LF -,SUP-M00582070,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
KIT BALLOON REPLACEMENT STRAIGHT BOLSTER 20FR -,SUP-M00582080,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
KT TUBE PEG 24FR ENDOVIVE LPRO PUL LF -,SUP-M00582090,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
KIT BALLOON REPLACEMENT RIGHT ANGLE BOLSTER 20FR -,SUP-M00582150,CDM,C1889,HCPCS,278,RC,,,outpatient,,,192.44,134.708,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
TUBE PEG 24FR 3ML BLN SIL ENDOVIVE RT ANG LF -,SUP-M00582160,CDM,C1889,HCPCS,278,RC,,,outpatient,,,192.44,134.708,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
WATCHMAN FXD CURVE ACCESS SYSTEM SGL US REF: M635TU80010 -,SUP-M635TU80010,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
WATCHMAN FXD CURVE ACCESS SYSTEM DBL US REF: M635TU80020 -,SUP-M635TU80020,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
TUBE PEG 14FR 5ML BALLON TRITON LTX -,SUP-PEG-14-BRT-TR1,CDM,C1889,HCPCS,278,RC,,,outpatient,,,233.4,163.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 3MMX5CM RUBY MICRO CMPLX STD FRM FLLY DTCH RSHEATH -,SUP-RBY2C0305,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 3MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0320,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4769.23,3338.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 4MMX10CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0410,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 4MMX15CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0415,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 4MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0420,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 4MMX35CM RUBY CMPLX STD FRM FLLY DTCH RSHEATH -,SUP-RBY2C0435,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 5MMX12CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0512,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 5MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0520,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 5MMX30CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0530,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 6MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4769.23,3338.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 6MMX30CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0630,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 7MMX25CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0725,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 8MMX25CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0825,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 8MMX40CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0840,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 9MMX30CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0930,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 10MMX35CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1035,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 12MMX40CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1240,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 12MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1260,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 14MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1460,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 16MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1660,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 18MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1857,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 20MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C2060,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 24MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C2457,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 28MMX60CM RUBY MICRO CMPLX STD FRM FLLY -,SUP-RBY2C2860,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 32MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C3260,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
RUBYCOIL 36MM X 60MM STANDARD -,SUP-RBY2C3660,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
RUBYCOIL 40MM X 60MM STANDARD -,SUP-RBY2C4060,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 2MMX4CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH PLTNM -,SUP-RBY4C0204,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3814.43,2670.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 3MMX5CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH PLTNM -,SUP-RBY4C0305,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 3MMX15CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0315,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 4MMX6CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH PLTNM -,SUP-RBY4C0406,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 4MMX15CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0415,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 6MMX20CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 6MMX30CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0630,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 8MMX35CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0835,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 8MMX60CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0860,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
COIL EMBL 16MMX50CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C1650,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
RUBY COIL LP- 1 MM x 5 CM PERIPHERAL EMBOLIZATION COILS -,SUP-RBYLP0105,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
RUBY COIL LP- 2 MM x 10 CM PERIPHERAL EMBOLIZATION COILS -,SUP-RBYLP0210,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
RUBY COIL LP- 3 MM x 4 CM PERIPHERAL EMBOLIZATION COILS -,SUP-RBYLP0304,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
PENUMBRA RUBY POD 6MM X 50CM -,SUP-RBYPOD6,CDM,C1889,HCPCS,278,RC,,,outpatient,,,8190.92,5733.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
SPACE OAR VUE HYDROGEL -,SUP-SV-2101,CDM,C1889,HCPCS,278,RC,,,outpatient,,,12791.29,8953.903,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.77024,11406.336,other,OPPS APC,,
INTRO SHTH 6FRX14CM J SHP TIP 12ML SYR DI-LOK DILATOR 18GA -,SUP-405104,CDM,C1892,HCPCS,272,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.121935,3080.6622,other,OPPS APC,,
INTRO SHTH 7FRX14CM 0.038INX50CM JTP GW 18GA XTW NDL 12ML -,SUP-405108,CDM,C1892,HCPCS,272,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.121935,3080.6622,other,OPPS APC,,
KT 12FR 18GAX14CM 0.38INX50CM GW CV 3MM JTP PEEL-AWAY -,SUP-405120,CDM,C1892,HCPCS,272,RC,,,outpatient,,,186.72,130.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.121935,3080.6622,other,OPPS APC,,
INTRO SHTH 10.5FRX14CM 0.038INX50CM JTP GW 18GA XTW NDL 12ML -,SUP-405122,CDM,C1892,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.121935,3080.6622,other,OPPS APC,,
INTRO SHTH 8T-TW FR DIA 14CM 0.038INX50CM JTP GW 18GA XTW -,SUP-405129,CDM,C1892,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.121935,3080.6622,other,OPPS APC,,
INTRO SHTH 8FRX14CM J SHP TIP 12ML SYR DI-LOK DILATOR 18GA -,SUP-405145,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.121935,3080.6622,other,OPPS APC,,
INTRO LD 9FR PEEL-AWAY SHTH SGL-CHMBR -,SUP-405147,CDM,C1892,HCPCS,272,RC,,,outpatient,,,320.93,224.651,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.121935,3080.6622,other,OPPS APC,,
INTRO SHTH 8FRX14CM 0.038IN GW DI- LOCK DILATOR -,SUP-405412,CDM,C1892,HCPCS,272,RC,,,outpatient,,,90.56,63.392,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.121935,3080.6622,other,OPPS APC,,
INTRO SHTH 9FRX14CM 0.038IN GW DI- LOCK DILATOR -,SUP-405416,CDM,C1892,HCPCS,272,RC,,,outpatient,,,89.63,62.741,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.121935,3080.6622,other,OPPS APC,,
TRANSDC TRANSTHORACIC BTRY PK VIEWMATE -,SUP-405422,CDM,C1892,HCPCS,272,RC,,,outpatient,,,175.05,122.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.121935,3080.6622,other,OPPS APC,,
INTRO SHTH 11FRX14CM 0.038INX50CM JTP GW 18GA XTW NDL 12ML -,SUP-405424,CDM,C1892,HCPCS,272,RC,,,outpatient,,,175.05,122.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.121935,3080.6622,other,OPPS APC,,
INTRO VASC 8FR SUPER SHTH INFS SDPRT -,SUP-CLS-1008,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.121935,3080.6622,other,OPPS APC,,
INTRO VASC 8.5FR SUPER SHTH INFS SDPRT -,SUP-CLS-1008.5,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.121935,3080.6622,other,OPPS APC,,
INTRO VASC 10.5FR SUPER SHTH INFS SDPRT -,SUP-CLS-1010.5,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.121935,3080.6622,other,OPPS APC,,
INTRO VASC 8FR LNG SUPER SHTH INFS SDPRT -,SUP-CLS-2508,CDM,C1892,HCPCS,272,RC,,,outpatient,,,301.67,211.169,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.121935,3080.6622,other,OPPS APC,,
CPS DIRECT MEDI GUIDE ENABLED OUT CATH  RIGHT -,SUP-DS2M044,CDM,C1892,HCPCS,272,RC,,,outpatient,,,4296.6,3007.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.121935,3080.6622,other,OPPS APC,,
SET INTRODUCER PEEL-AWAY SAFE-T-J -,SUP-G04496,CDM,C1892,HCPCS,272,RC,,,outpatient,,,397.66,278.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.121935,3080.6622,other,OPPS APC,,
SHEATH SAFE PRELUDE 6F 13CM LN -,SUP-PLS-1006,CDM,C1892,HCPCS,272,RC,,,outpatient,,,274.25,191.975,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.121935,3080.6622,other,OPPS APC,,
INTRODUCER MERIT PRELUDE 9F 25CM -,SUP-PLS-2509,CDM,C1892,HCPCS,272,RC,,,outpatient,,,301.67,211.169,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.121935,3080.6622,other,OPPS APC,,
INTRODUCER 9FR OPTISEAL -,SUP-UNDEFINED,CDM,C1892,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,20.121935,3080.6622,other,OPPS APC,,
CATH GUID 7FR COR -,SUP-358735,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2448.83,1714.181,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,165.054645,2224.9227,other,OPPS APC,,
INTRO  SL1  CURVE - SJM 8.5FRX 63CM -,SUP-406849,CDM,C1893,HCPCS,272,RC,,,outpatient,,,892.76,624.932,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,165.054645,2224.9227,other,OPPS APC,,
INTRO GUID 8.5FRX60CM FAST-CATH SWARTZ TRNSEPT SAFL CRV -,SUP-406868,CDM,C1893,HCPCS,272,RC,,,outpatient,,,898.59,629.013,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,165.054645,2224.9227,other,OPPS APC,,
INTRO GUID 8FRX60CM FAST-CATH SWARTZ TRNSEPT SAFL CRV -,SUP-406871,CDM,C1893,HCPCS,272,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,165.054645,2224.9227,other,OPPS APC,,
INTRO GUID 8FRX60CM FAST-CATH SWARTZ TRNSEPT SEPT CRV -,SUP-406885,CDM,C1893,HCPCS,272,RC,,,outpatient,,,904.43,633.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,165.054645,2224.9227,other,OPPS APC,,
INTRO SEPT CURVE-SJM  8.5FRX60CM -,SUP-406894,CDM,C1893,HCPCS,272,RC,,,outpatient,,,898.59,629.013,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,165.054645,2224.9227,other,OPPS APC,,
INTRO  RAMP  CURVE - SJM 8.5FRX 63CM -,SUP-406965,CDM,C1893,HCPCS,272,RC,,,outpatient,,,735.21,514.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,165.054645,2224.9227,other,OPPS APC,,
SHEATH GUIDE LAMP 45 407363 -,SUP-407363,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1015.29,710.703,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,165.054645,2224.9227,other,OPPS APC,,
INTRODUCER CATHETER BRITE TIP RADIANZ GUIDING 6FR 110CM -,SUP-687280110,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1363.55,954.485,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,165.054645,2224.9227,other,OPPS APC,,
INTRODUCER CATHETER BRITE TIP RADIANZ GUIDING 6FR 135CM -,SUP-687280135,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1363.55,954.485,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,165.054645,2224.9227,other,OPPS APC,,
TRANSSEPTAL ACCESS STYSTEM ACQCROSS QX AG 71 CM REF: 900301 -,SUP-900301,CDM,C1893,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,165.054645,2224.9227,other,OPPS APC,,
TRANSSEPTAL ACCESS STYSTEM ACQCROSS QX - FC 65CM REF: 900304 -,SUP-900304,CDM,C1893,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,165.054645,2224.9227,other,OPPS APC,,
TRANSSEPTAL ACCESS STYSTEM ACQCROSS  WT 75CM REF: 900308 -,SUP-900308,CDM,C1893,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,165.054645,2224.9227,other,OPPS APC,,
FLEXCATH CROSS FCC 65CM 10FR REF:900310 -,SUP-900310,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,165.054645,2224.9227,other,OPPS APC,,
FLEXCATH CROSS FCC 65CM 12FR REF:900311 -,SUP-900311,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,165.054645,2224.9227,other,OPPS APC,,
CATHETER CPS LOCATOR 3D- LAGE EXTRA LONG REF:DS2C300-45 -,SUP-DS2C300-45,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,165.054645,2224.9227,other,OPPS APC,,
SHEATH GUID WORLEY RNL TLSCP GUIDE -,SUP-LVI7556207RE,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2464.73,1725.311,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,165.054645,2224.9227,other,OPPS APC,,
TORFLEX TRANSSEPTAL GUIDING SH -,SUP-TF85-32-63-45,CDM,C1893,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,165.054645,2224.9227,other,OPPS APC,,
DILATOR VESSEL 5 FR 35 -,SUP-040037A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,23.34,16.338,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
MICINTRO VASC 4.5FRX50CM MICRO EZ FNL DSGN SMTH DILATOR PTFE -,SUP-0928945,CDM,C1894,HCPCS,272,RC,,,outpatient,,,205.74,144.018,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
MICINTRO VASC 5FRX50CM MICRO EZ FNL DSGN SMTH DILATOR PTFE -,SUP-0928950,CDM,C1894,HCPCS,272,RC,,,outpatient,,,213.56,149.492,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
MICINTRO VASC 6FRX50CM MICRO EZ SMTH DILATOR PTFE 7CM A BVL -,SUP-0928960,CDM,C1894,HCPCS,272,RC,,,outpatient,,,189.64,132.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH INTRO 6FRX10CM PINNCL TIF TIP PERIPH 0.038INX45CM SS -,SUP-10-2032,CDM,C1894,HCPCS,272,RC,,,outpatient,,,72.94,51.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO INFS 7FR PEEL-AWAY -,SUP-120089,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.83,253.281,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH INTRO 5FRX10CM GLIDESHEATH RADL STR GOLD COIL MRKR -,SUP-20 -1050,CDM,C1894,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH INTRO 6FRX10CM GLIDESHEATH RADL STR GOLD COIL MRKR -,SUP-20 -1060,CDM,C1894,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
S COOK 7FR X 6CM -,SUP-242381,CDM,C1894,HCPCS,272,RC,,,outpatient,,,170.73,119.511,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH INTRO 5FRX10CM GLIDESHEATH RADL STR CRV GOLD COIL -,SUP-30-1050,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.48,364.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH INTRO 6FRX10CM GLIDESHEATH RADL STR CRV GOLD COIL -,SUP-30-1060,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.48,364.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH INTRO 6FRX10CM GLIDESHEATH RADL  STR CRV GOLD COIL -,SUP-30-1065,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.48,364.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 0.110IN 8FRX62CM PREFACE MP ST TAPR PRFL -,SUP-301803MS,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO CATH 4FRX3.2CM INTRSYT-N PERC SHLD -,SUP-384011,CDM,C1894,HCPCS,272,RC,,,outpatient,,,234.57,164.199,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO CATH 1.9FRX1.9CM INTRSYT-N PERC SHLD -,SUP-384021,CDM,C1894,HCPCS,272,RC,,,outpatient,,,280.08,196.056,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
FORTRESS SHEALTH 5FRx45CM -,SUP-386591,CDM,C1894,HCPCS,272,RC,,,outpatient,,,102.7,71.89,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
FORTRESS SHEATH 5FR x 45CM -,SUP-386591,CDM,C1894,HCPCS,272,RC,,,outpatient,,,102.7,71.89,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 10FRX11CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-011M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
S BRITE TIP 10FR 11CM  RB -,SUP-401-011M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH BRITE TIP 4F 11CM -,SUP-401411M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 5FR 11CM BRITE TIP -,SUP-401511M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 5FR BRITE TIP 23CM -,SUP-401-523M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 5FRX55CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-555M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 6FRX5.5CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401605M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 6FRX5.5CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-605M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 6FR 11CM BRITE TIP -,SUP-401-611M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 6FRX5.5CM X 23CM CANN BRT TIP PERC TAPR SMTH -,SUP-401-623M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 6F 23CM BRITE TIP -,SUP-401-623M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 6FRX55CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-655M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 7 FR 11CM BRITE TIP -,SUP-401-711M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 7FR X 23CM BRITE TIP -,SUP-401-723M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 7FRX45CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-745M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 8FR 11CM BRITE TIP -,SUP-401-811M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
S BRITE TIP 8FR 23CM RB -,SUP-401-823M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 8FRX45CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-845M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
S BRITE TIP 9FR X 11CM RB -,SUP-401-911M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHTH INTRO 11FR X 11CM CANN BRT -,SUP-402611X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,43.18,30.226,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 6FR STD L 11CM REF: 402656X -,SUP-402656X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,43.18,30.226,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 2MM ANCURE -,SUP-40320,CDM,C1894,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
HEMOSTASIS INTRODUCER FAST CATH 10FRX30CM REF: 406180 -,SUP-406180,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.77,253.239,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
HEMOSTASIS INTRODUCER FAST CATH 14FRX30CM REF: 406188 -,SUP-406188,CDM,C1894,HCPCS,272,RC,,,outpatient,,,385.11,269.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
FAST CATH DUO SHEATH 12F  12CM -,SUP-406301,CDM,C1894,HCPCS,272,RC,,,outpatient,,,140.04,98.028,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 7FRX12CM FAST-CATH CATH-LOCK PERC JTP STR SNP -,SUP-406702,CDM,C1894,HCPCS,272,RC,,,outpatient,,,62.26,43.582,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 8FRX12CM FAST-CATH CATH-LOCK PERC JTP STR SNP -,SUP-406706,CDM,C1894,HCPCS,272,RC,,,outpatient,,,105.03,73.521,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 4FRX12CM FAST-CATH CATH-LOCK PERC JTP STR SNP -,SUP-406709,CDM,C1894,HCPCS,272,RC,,,outpatient,,,105.03,73.521,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 8FRX60CM FAST-CATH TRNSEPT MLNS CRV SNP LOCK -,SUP-406805,CDM,C1894,HCPCS,272,RC,,,outpatient,,,501.81,351.267,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SR0 CURVE-SJM -,SUP-406853,CDM,C1894,HCPCS,272,RC,,,outpatient,,,898.59,629.013,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH AGILIS MED-REPROC  8.5X 71CM -,SUP-408310,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2473.84,1731.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 4FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-604X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 6FR MI D L 23CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-606D,CDM,C1894,HCPCS,272,RC,,,outpatient,,,93.36,65.352,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 7FR MI D L 23CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-607T,CDM,C1894,HCPCS,272,RC,,,outpatient,,,93.36,65.352,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH INTRODUCER AVANTI 7FR X 11 CM -,SUP-504-607X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 8FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-608X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 9FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-609X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 10FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504610X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 11FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-611X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 5MS FR DIA MI D L 23CM CANN AVANTI + PERC TAPR SS -,SUP-504-655T,CDM,C1894,HCPCS,272,RC,,,outpatient,,,103.57,72.499,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 5MS DIA STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-655X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 5MS DIA STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-655X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 6MS FR DIA MI D L 23CM CANN AVANTI + PERC TAPR SS -,SUP-504-656T,CDM,C1894,HCPCS,272,RC,,,outpatient,,,93.36,65.352,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 6FR STD L 11CM CANN AVANTI  PERC TAPR SS W/O -,SUP-504-656X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 6FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-656X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
MONITORING SHEATH 7 FR INTRO -,SUP-504-657X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 8MS DIA STD L 11CM CANN AVANTI PERC TAPR SS W/O -,SUP-504-658X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
TIGHTRAIL MINI 11FR 545-011 -,SUP-540-011,CDM,C1894,HCPCS,272,RC,,,outpatient,,,7193.58,5035.506,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
TIGHTRAIL MINI  9FR 545-009 -,SUP-545-009,CDM,C1894,HCPCS,272,RC,,,outpatient,,,7193.58,5035.506,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
TIGHTRAIL LONG  9FR 545-509 -,SUP-545-509,CDM,C1894,HCPCS,272,RC,,,outpatient,,,10121.94,7085.358,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
TIGHTRAIL LONG 11FR 545-511 -,SUP-545-511,CDM,C1894,HCPCS,272,RC,,,outpatient,,,10121.94,7085.358,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
TIGHTRAIL LONG 13FR 545-513 -,SUP-545-513,CDM,C1894,HCPCS,272,RC,,,outpatient,,,10121.94,7085.358,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 8FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-54-84501,CDM,C1894,HCPCS,272,RC,,,outpatient,,,609.76,426.832,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
GLIDESHEATH SLENDER 6FR X 10CM X .021CM SS GLIDEWIRE -,SUP-60-1060,CDM,C1894,HCPCS,272,RC,,,outpatient,,,353.02,247.114,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
GLIDESHEATH SLENDER A KIT 0.025 GW 6FR 10CM -,SUP-60-1065,CDM,C1894,HCPCS,272,RC,,,outpatient,,,619.97,433.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
GLIDESHEATH SLENDER A KIT 0.025 GW 7FR 10CM -,SUP-60-1075,CDM,C1894,HCPCS,272,RC,,,outpatient,,,619.97,433.979,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 7FRX11CM INPUT PS PERC 0.038IN GW COMP VES -,SUP-700-11,CDM,C1894,HCPCS,272,RC,,,outpatient,,,56.02,39.214,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRODUCER SET 11 FR - DISCONTINUED DO NOT USE -,SUP-7097,CDM,C1894,HCPCS,272,RC,,,outpatient,,,320.93,224.651,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
GLIDESHEATH SLENDER SS KIT 0.025 GW 6FR 10CM -,SUP-80-1065,CDM,C1894,HCPCS,272,RC,,,outpatient,,,353.02,247.114,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
GLIDESHEATH SLENDER SS KIT 0.025 GW 7FR 10CM -,SUP-80-1075,CDM,C1894,HCPCS,272,RC,,,outpatient,,,353.02,247.114,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
AMPLATZER DELIVERY SHEATH TORQVUE 2 5FR REF: 9-TV2-05F120 -,SUP-90176109,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
AMPLATZER DELIVERY SHEATH TORQVUE 2 6FR REF: 9-TV2-06F120 -,SUP-9-TV2-06F120,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
TORQVUE SHEATH 14F 80CM 45X45 REF: 9-TV45X45-14F-080 -,SUP-9-TV45X45-14F-080,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4676.89,3273.823,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
OBTURATOR VASC 8FR SHRT -,SUP-AO-09000,CDM,C1894,HCPCS,272,RC,,,outpatient,,,13.65,9.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
CATH PA 7FR X 110CM SWAN-GNZ LUMX4 PLYMR BLND -,SUP-C146F7,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2531.31,1771.917,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRODUCER SHEATH 8.5FR CATH-GARD PERC ARROW KIT -,SUP-CDC-09803-1A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,430.62,301.434,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
9FR. PERC SHEATH INTRO KIT -,SUP-CDC-09903-1A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,418.37,292.859,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 10FRX35CM SUPER ARROW-FLEX PERC SNP-LOCK MIN -,SUP-CL-07035,CDM,C1894,HCPCS,272,RC,,,outpatient,,,547.82,383.474,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 5FR SHTH 4.375IN SHTH 0.035-0.038IN GW HEMSTS VLV -,SUP-CL-07511,CDM,C1894,HCPCS,272,RC,,,outpatient,,,182.55,127.785,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 6FRX24CM SUPER ARROW-FLEX PERC 0.038IN GW COMP -,SUP-CL-07624,CDM,C1894,HCPCS,272,RC,,,outpatient,,,431.79,302.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 6FRX45CM SUPER ARROW-FLEX PERC ANTMIC SURF PU -,SUP-CL-07645,CDM,C1894,HCPCS,272,RC,,,outpatient,,,553.38,387.366,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 7FRX24CM SUPER ARROW-FLEX PERC INTGR HEMSTS -,SUP-CL-07724,CDM,C1894,HCPCS,272,RC,,,outpatient,,,379.08,265.356,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 7FRX45CM SUPER ARROW-FLEX PERC ANTMIC SURF PU -,SUP-CL-07745,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.82,364.574,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH CLASSICSHEATH 6FR STD 13CM CRV GRN CAP -,SUP-CLS-1006,CDM,C1894,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO VASC 7FR SAFESHEATH INFS SDPRT -,SUP-CLS-1007,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.77,253.239,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO VASC 10FR SUPER SHTH INFS SDPRT -,SUP-CLS-1010,CDM,C1894,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 5FRX11CM SUPER ARROW-FLEX PERC 0.035IN GW COMP -,SUP-CP-07511,CDM,C1894,HCPCS,272,RC,,,outpatient,,,148.79,104.153,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
DRYSEAL FLEX INTRODUCER SHEATH - 1233 -,SUP-DSF1233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3695.08,2586.556,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH INTRO 12FRX28CM DRYSEAL HYDRCT -,SUP-DSF1233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3695.08,2586.556,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH DRYSEAL INTRODUCER -,SUP-DSF1245,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4821.18,3374.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
DRYSEAL FLEX INTRODUCER SHEATH 14FR REF: DSF1433 -,SUP-DSF1433,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
GORE INTRODUCER SHEATH 16 -,SUP-DSF1633,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3695.08,2586.556,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
DRYSEAL SHEATH--16 FR X 65CM -,SUP-DSF1665,CDM,C1894,HCPCS,272,RC,,,outpatient,,,5780.33,4046.231,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
GORE INTRODUCER SHEATH 18 -,SUP-DSF1833,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
22FR X 33CM DRYSEAL SHEATH -,SUP-DSF2233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
GORE DRY SEAL SHEATH 22F X 33CM -,SUP-DSF2233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
22FR X 65CM DRYSEAL SHEATH -,SUP-DSF2265,CDM,C1894,HCPCS,272,RC,,,outpatient,,,5780.33,4046.231,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
GORE DRY SEAL SHEATH 26F X 33CM -,SUP-DSF2633,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH INTRO 18FRX28CM DRYSEAL HYDRCT -,SUP-DSL1828,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
URETHRAL ACCESS SHTH 9.5FR ID AQ HYDRCT TAPR LUMX1 DILATOR -,SUP-FUS-095045,CDM,C1894,HCPCS,272,RC,,,outpatient,,,774.6,542.22,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
URETHRAL ACCESS SHTH 14FRX28CM AQ HYDRCT FLEXOR TAPR LUMX1 -,SUP-FUS-120028,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
URETHRAL ACCESS SHTH 12FR ID HYDRCT LUMX1 DILATOR -,SUP-FUS-120035,CDM,C1894,HCPCS,272,RC,,,outpatient,,,762.34,533.638,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
URETHRAL ACCESS SHTH 12FRX45CM HYDRCT TAPR LUMX1 DILATOR -,SUP-FUS-120045,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
DILATOR VASCULAR 16FR 20CM REF G01212 -,SUP-G01212,CDM,C1894,HCPCS,272,RC,,,outpatient,,,49.54,34.678,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH MICROPUN TRANSTLS TIP 0.018INX40CM GW PEDAL -,SUP-G02972,CDM,C1894,HCPCS,272,RC,,,outpatient,,,349.52,244.664,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 16FRX30CM PEEL-AWAY 0.038IN GW COMP -,SUP-G02997,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO CATH 22FRX13CM PEEL-AWAY LNG COONS TAPR STR 0.038IN GW -,SUP-G04096,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.57,194.299,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 18FRX15.5CM PEEL-AWAY LNG COONS TAPR STR 20CM VES -,SUP-G06444,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 20FRX13CM PEEL-AWAY PERC STR 20CM VES DILATOR W/O -,SUP-G06445,CDM,C1894,HCPCS,272,RC,,,outpatient,,,273.6,191.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 24FRX13CM PEEL-AWAY PERC STR 20CM VES DILATOR W/O -,SUP-G06446,CDM,C1894,HCPCS,272,RC,,,outpatient,,,273.6,191.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 12FRX15.5CM PEEL-AWAY PERC STR 0.038IN GW COMP -,SUP-G06492,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 14FRX15.5CM PEEL-AWAY PERC STR 0.038IN GW COMP -,SUP-G06496,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SET INTRODUCER PEEL-AWAY .038IN 15.5CM 15FR -,SUP-G06497,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
RING TRANS-JUG ACCESS SET WITH 9Fr -,SUP-G06541,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2759.32,1931.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 4MM 12FRX13CM PERFORM JTP 0.038IN GW COMP -,SUP-G07369,CDM,C1894,HCPCS,272,RC,,,outpatient,,,293.56,205.492,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 2.9MM 8FRX13CM FLEXOR 0.038IN GW SM CHECK-FLO VLV -,SUP-G07856,CDM,C1894,HCPCS,272,RC,,,outpatient,,,243.44,170.408,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH CHECKFLO PERFORMA 10FRX30CM -,SUP-G08686,CDM,C1894,HCPCS,272,RC,,,outpatient,,,419.77,293.839,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRODUCER CHECK-FLO PERFORMER 12FR 30CM -,SUP-G08956,CDM,C1894,HCPCS,272,RC,,,outpatient,,,419.77,293.839,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRODUCER CHECK-FLO PERFORMER 14FR 30CM -,SUP-G08957,CDM,C1894,HCPCS,272,RC,,,outpatient,,,419.77,293.839,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
CHECK FLOW PERFORMER INTRODUCER 16FR 70CM REF:G09582 -,SUP-G09582,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRODUCER CHECK-FLO PERFORMER 16FR 30CM -,SUP-G09691,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SET INTRODUCER CHECK-FLO EXTRA LARGE 18FR 40CM -,SUP-G10626,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 2.2MM 6FRX45CM FLEXOR CHECK-FLO BLKN UP/ OVR -,SUP-G10634,CDM,C1894,HCPCS,272,RC,,,outpatient,,,313.51,219.457,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
S COOK 6FR X 6CM -,SUP-G10675,CDM,C1894,HCPCS,272,RC,,,outpatient,,,170.73,119.511,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SET INTRODUCER CATHETER NEFF 4/6FR -,SUP-G10797,CDM,C1894,HCPCS,272,RC,,,outpatient,,,513.42,359.394,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 5FRX9CM PEEL-AWAY MICROPUNCTURE DENNY MOD LCK -,SUP-G11566,CDM,C1894,HCPCS,272,RC,,,outpatient,,,465.11,325.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 6FRX9CM PEEL-AWAY PERC DENNY MOD 0.018IN GW COMP -,SUP-G11568,CDM,C1894,HCPCS,272,RC,,,outpatient,,,465.11,325.577,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 8FRX9CM PEEL-AWAY PERC DENNY MOD 0.038IN GW COMP -,SUP-G11570,CDM,C1894,HCPCS,272,RC,,,outpatient,,,375.77,263.039,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
VALVE CHECK-FLO 7F 55C RAABE K -,SUP-G11633,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH RAABE FLEXOR 7FR X 90CM -,SUP-G11634,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 7FRX70CM FLEXOR CHECK-FLO RAABE MOD STR 0.038IN -,SUP-G11635,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 6FRX70CM FLEXOR CHECK-FLO RAABE MOD STR 0.038IN -,SUP-G11636,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 2.9MM 8FRX70CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G11637,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 2.2MM 6FRX55CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G11638,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 6FR STRAIGHT FLEXOR -,SUP-G11638,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
CHECK FLOW PERFORMER INTRODUCER 18FR X 30CM -,SUP-G11672,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
VALVE CHECK-FLO 8F 55C RAABE K -,SUP-G12242,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 6FR 90CM RAABE KCFW-6.0 -,SUP-G12266,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 3.2MM 9FRX70CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G12606,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRODUCER CHECK-FLO PERFORMER 22FR 25CM -,SUP-G12831,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2364.02,1654.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 2.5MM 7FRX90CM FLEXOR SHTL SFT TIP HYDRCT -,SUP-G12835,CDM,C1894,HCPCS,272,RC,,,outpatient,,,611.39,427.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 1.9MM 5FRX55CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G13009,CDM,C1894,HCPCS,272,RC,,,outpatient,,,268.41,187.887,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 1.9MM 5FRX90CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G13069,CDM,C1894,HCPCS,272,RC,,,outpatient,,,348.58,244.006,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 5FRX70CM FLEXOR CHECK-FLO RAABE MOD STR 0.038IN -,SUP-G13091,CDM,C1894,HCPCS,272,RC,,,outpatient,,,268.41,187.887,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 6FR. 80CM -,SUP-G13539,CDM,C1894,HCPCS,272,RC,,,outpatient,,,611.39,427.973,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
URETHRAL ACCESS SHTH 9.5FR ID HYDRCT TAPR LUMX1 DILATOR -,SUP-G19174,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
URETHRAL ACCESS SHTH 9.5FRX28CM AQ HYDRCT FLEXOR TAPR LUMX1 -,SUP-G19176,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 20F X 25CM COOK -,SUP-G28999,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2364.02,1654.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 12FRX24CM PEEL-AWAY PERC CRV 0.038IN GW COMP 34CM -,SUP-G29839,CDM,C1894,HCPCS,272,RC,,,outpatient,,,689.99,482.993,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 14FRX24CM PEEL-AWAY CRV 0.038IN GW COMP 18GA 12ML -,SUP-G29840,CDM,C1894,HCPCS,272,RC,,,outpatient,,,689.99,482.993,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 2.5MM 7FRX45CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29885,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
5Fr. 45cm ANSEL SHEATH WITH ANGLE KCFW-5.0-18/38/45-RB-ANL1- -,SUP-G29981,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 1.9MM 5FRX45CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29981,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 1.9MM 5FRX90MM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29988,CDM,C1894,HCPCS,272,RC,,,outpatient,,,586.83,410.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 6F ANSEL 90CM FLEXOR KC -,SUP-G29989,CDM,C1894,HCPCS,272,RC,,,outpatient,,,586.83,410.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 2.2MM 6FRX55MM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29996,CDM,C1894,HCPCS,272,RC,,,outpatient,,,420.18,294.126,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 2.2MM 6FRX55MM FLEXOR CHECK-FLO ANSEL MOD RNL -,SUP-G29997,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHUTTLE SELECT GUIDE SHEATH KS -,SUP-G31138,CDM,C1894,HCPCS,272,RC,,,outpatient,,,617.11,431.977,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH CHECKFLOW 3.4MM 10FRX40CM FLEXOR -,SUP-G32233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,385.81,270.067,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 4.1MM 12FRX40CM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-G32373,CDM,C1894,HCPCS,272,RC,,,outpatient,,,444.22,310.954,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SET MICROPUNCTURE 5.0F 10CM -,SUP-G36333,CDM,C1894,HCPCS,272,RC,,,outpatient,,,159.7,111.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 3.2MM 9FRX55CM FLEXOR CHECK-FLO RAABE MOD -,SUP-G36393,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
MICRO PUNCTURE  5FR X 10CM  0.018INX40CM -,SUP-G43870,CDM,C1894,HCPCS,272,RC,,,outpatient,,,191.21,133.847,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 5F ANSEL 45CM ANLO -,SUP-G44153,CDM,C1894,HCPCS,272,RC,,,outpatient,,,300.62,210.434,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 6F ANSEL 45CM -,SUP-G44154,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH MICROPUNCTURE TRANSTLS TIP 0.018INX40CM PLTNM TIP -,SUP-G47942,CDM,C1894,HCPCS,272,RC,,,outpatient,,,190.1,133.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
MICROPUNCTURE STIFF 4F NIT -,SUP-G48003,CDM,C1894,HCPCS,272,RC,,,outpatient,,,281.36,196.952,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
MICROPUNCTURE TRANSITIONLESS STIFFENED CANNULA ACCESS SET -,SUP-G48005,CDM,C1894,HCPCS,272,RC,,,outpatient,,,281.36,196.952,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
WIRE FOR  MICROPUNCTURE 0.018 IN X 40 CM PLTNM TIP -,SUP-G48007,CDM,C1894,HCPCS,272,RC,,,outpatient,,,281.36,196.952,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 1.5MM 4FRX45MM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-G48186,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 4F ANSEL 90CM -,SUP-G48188,CDM,C1894,HCPCS,272,RC,,,outpatient,,,620.26,434.182,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 5F 90 RB ANSEL KCF-5.0- -,SUP-G48189,CDM,C1894,HCPCS,272,RC,,,outpatient,,,620.26,434.182,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 7F X 55CM ANSEL 1 -,SUP-G49043,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 2.9MM 8FRX45CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G49100,CDM,C1894,HCPCS,272,RC,,,outpatient,,,356.11,249.277,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 3.2MM 9FRX45MM FLEXOR CHECK-FLO ANSEL MOD ANL1 -,SUP-G49102,CDM,C1894,HCPCS,272,RC,,,outpatient,,,356.11,249.277,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 6FRX70CM FLEXOR 0.038IN GW COMP HYDRCT -,SUP-G56221,CDM,C1894,HCPCS,272,RC,,,outpatient,,,452.45,316.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUIDING 7FR x 70CM STRAIGHT -,SUP-G56222,CDM,C1894,HCPCS,272,RC,,,outpatient,,,452.45,316.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 2.2MM 6FRX70CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G56226,CDM,C1894,HCPCS,272,RC,,,outpatient,,,452.45,316.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 1.9MM 5FRX55CM FLEXOR CHECK-FLO ANSEL MOD STR. -,SUP-G56230,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUID 1.9MM 5FRX55CM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-G56235,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 6F X 55 ANSEL 1 -,SUP-G56236,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH FLEXOR PARALLEL 9.5CM x 28CM - URETERAL -,SUP-G56429,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1012.66,708.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH FLEXOR PARALLEL 9.5FR x 45CM URETERAL -,SUP-G56431,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1012.66,708.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SET MICROPUNCTURE INTRODUCER 21G -,SUP-G84006,CDM,C1894,HCPCS,272,RC,,,outpatient,,,252.07,176.449,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH GUIDING DESTINATION SLENDER 105CM 6FR STRAIGHT -,SUP-GS-R6ST1C10W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1599.43,1119.601,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SYS SHEATH RTRVL 4FR BNTP EMBL PROT FLTWR EZ -,SUP-H749501001500,CDM,C1894,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
COAXIAL MICROINTRODUCER KIT 4FR -,SUP-H965457531,CDM,C1894,HCPCS,272,RC,,,outpatient,,,175.05,122.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO PERC 6FR SHTH INTROFLEX -,SUP-I500-F6,CDM,C1894,HCPCS,272,RC,,,outpatient,,,288.25,201.775,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 9FR STD INTROFLEX PERC W/O LIDOCN -,SUP-I505BF9C,CDM,C1894,HCPCS,272,RC,,,outpatient,,,243.32,170.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 5FRX10CM MICROPUNCTURE STF CANN COAX CATH PR -,SUP-JCD5.01810.0MPI,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.06,81.242,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
10fr 0.035 Flexer Guiding Sheath -,SUP-KCFW-10.0-35-RB-RTPS-100,CDM,C1894,HCPCS,272,RC,,,outpatient,,,641.79,449.253,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 2.2MM 6FRX30CM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-KCFW6.0-38-30RB,CDM,C1894,HCPCS,272,RC,,,outpatient,,,268.35,187.845,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO CATH 6FRX13CM SHTH FLEXOR NTPR 0.038IN GW VES DILATOR -,SUP-KCFW-6.0-38-RB,CDM,C1894,HCPCS,272,RC,,,outpatient,,,243.44,170.408,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO 4.5FRX5CM MICRO-ACCESS TEARAWAY 0.018INX4.CM MRK NTNL -,SUP-KIT-010-03,CDM,C1894,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
CATHETER RETRIEVAL AVEIR REF:LSCR111 -,SUP-LSCR111,CDM,C1894,HCPCS,272,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
LOADING SYSTEM ENVEO R  LS-MDT2-2629-US -,SUP-LS-MDT2-2629-US,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2067.2,1447.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
CATHETER INTRODUCER AVEIR 30CM REF:LSN25301 -,SUP-LSN25301,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 21GA ACCUSTICK II STF CANN -,SUP-M001207020,CDM,C1894,HCPCS,272,RC,,,outpatient,,,416.39,291.473,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH INTRO 8.5FRX60CM HEARTSPAN TRNSEPT 55DG CRV TAPR -,SUP-M0045660550,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1108.65,776.055,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH URET 11/13FRX36CM NAVIGATOR -,SUP-M0062502021,CDM,C1894,HCPCS,272,RC,,,outpatient,,,567.91,397.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH NAVIGATOR HD 11/13 X 28 -,SUP-M0062502210,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH NAVIGATOR HD 11 13 36 -,SUP-M0062502220,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH NAVIGATOR HD 11 13 46 -,SUP-M0062502230,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH NAVIGATOR HD 12 14 36 -,SUP-M0062502250,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH NAVIGATOR 12F/14F X 46CM -,SUP-M0062502260,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
ST DILATOR URETH 8-30FR OD 35CM 30CM SHTH TFLN-CT TAPR GRAD -,SUP-M0062601000,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1208.3,845.81,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
ST DILATOR URETH SHTH 8FR/10FR 70CM/35CM L PTFE TAPR LF -,SUP-M0062601200,CDM,C1894,HCPCS,272,RC,,,outpatient,,,280.31,196.217,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
URETHRAL ACCESS SHTH 34FR TAPR -,SUP-M0062601600,CDM,C1894,HCPCS,272,RC,,,outpatient,,,344.5,241.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
MICRO PUNCTURE 4FR X 10 CM NTNL 0.018X 40 -,SUP-MAK401NPD,CDM,C1894,HCPCS,272,RC,,,outpatient,,,91.84,64.288,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
MICRO PUNCTURE  5FR X 10CM  0.018INX40CM - MAK501N -,SUP-MAK501N,CDM,C1894,HCPCS,272,RC,,,outpatient,,,151.42,105.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
MICRA INTRO SHEATH HYDRO COAT -,SUP-MI2355A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
MICINTRO SHTH 7FRX7CM VENEFIT ECHGNC TIP 21GA -,SUP-MIS7F07,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
MICRO INTRO SHEATH 7F 11CM -,SUP-MIS-7F11,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH MICROPUNCTURE TRANSTLS TIP 0.018INX40CM PLTNM TIP -,SUP-MPIS-401-NT,CDM,C1894,HCPCS,272,RC,,,outpatient,,,190.1,133.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 4FR MICROPUNCTURE TRANSTLS TIP 0.018INX40CM PLTNM -,SUP-MPIS401PEDNTSST,CDM,C1894,HCPCS,272,RC,,,outpatient,,,197.05,137.935,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 5FRX10CM MICROPUNCTURE TRANSTLS TIP 0.018INX40CM -,SUP-MPIS-501-NT,CDM,C1894,HCPCS,272,RC,,,outpatient,,,191.21,133.847,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO ORTHO 4FR MICRO-STK NTNL WIRE -,SUP-MR190421,CDM,C1894,HCPCS,272,RC,,,outpatient,,,105.03,73.521,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 18FRX85CM PERFORM 0.038IN GW 97CM VES DILATOR -,SUP-RCFW18.0P3885RB,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 2.6MM 8FRX63CM PERFORM MLNS CRV 0.038IN GW COMP -,SUP-RCFW8.0-38-63,CDM,C1894,HCPCS,272,RC,,,outpatient,,,433.42,303.394,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH INTRO 6FRX10CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB602,CDM,C1894,HCPCS,272,RC,,,outpatient,,,152.29,106.603,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH INTRO 7FR X 10CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB702,CDM,C1894,HCPCS,272,RC,,,outpatient,,,152.29,106.603,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH INTRO 8FRX25CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB803,CDM,C1894,HCPCS,272,RC,,,outpatient,,,193.72,135.604,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH INTRO 9FRX10CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB902,CDM,C1894,HCPCS,272,RC,,,outpatient,,,152.29,106.603,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH INTRO 9FRX25CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB903,CDM,C1894,HCPCS,272,RC,,,outpatient,,,193.72,135.604,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH INTRO 5FRX10CM PINNCL PERIPH STR CRV 0.035IN GW COMP -,SUP-RSS501,CDM,C1894,HCPCS,272,RC,,,outpatient,,,63.43,44.401,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 8FR 10CM PINNACLE -,SUP-RSS802,CDM,C1894,HCPCS,272,RC,,,outpatient,,,60.68,42.476,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 9FR 10CM PINNACLE -,SUP-RSS901,CDM,C1894,HCPCS,272,RC,,,outpatient,,,63.43,44.401,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 14FRX28CM SENTRANT 0.035IN GW HYDRCT -,SUP-SENSH1428W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1108.65,776.055,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
INTRO SHTH 16FRX28CM SENTRANT 0.035IN GW COMP HYDRCT -,SUP-SENSH1628W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1123.71,786.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 18FR MEDTRONIC -,SUP-SENSH1828W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1123.71,786.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH 20FR X 28CM MEDTRONIC -,SUP-SENSH2028W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1258.87,881.209,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
MICRO PUNCTURE  5FR X 10CM  0.018INX40CM STIFF- S-MAK501N -,SUP-S-MAK501N,CDM,C1894,HCPCS,272,RC,,,outpatient,,,210.06,147.042,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH NAVIGATOR 12F/14F X 28CM -,SUP-STRYKER INSTRUMENTS,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
9.5F SAFESHEATH PEEL AWAY HEMO -,SUP-UNDEFINED,CDM,C1894,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SHEATH INTRO 6FR BRT TIP -,SUP-UNDEFINED,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
CATAPULT US 5F 15CM STRAIGHT 5PK -,SUP-US-35015-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,519.32,363.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
CATAPULT US 5F 45CM STRAIGHT 5PK -,SUP-US-35045-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,636.02,445.214,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
CATAPULT US 5F 60CM STRAIGHT 5PK -,SUP-US-35060-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,694.37,486.059,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
CATAPULT US 5F 90CM STRAIGHT 5PK -,SUP-US-35090-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
TRANSEPTAL ACCESS SET VERSACROSS REF: VXSK0032 -,SUP-VXSK0032,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4630.78,3241.546,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
SET INTRODUCER CHECK-FLO EXTRA LARGE 20FR 40CM -,SUP-XVCFW-20.0-35-40,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2364.02,1654.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.064425,7986.663,other,OPPS APC,,
LEAD DEFIB IMPL BIPLR PERMNT PCNG ETAK RELIANCE 59CM 8FR -,SUP-0157,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB ETAK RELIANCE 59CM -,SUP-0275-59,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB ETAK RELIANCE 64CM -,SUP-0276-64,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB ENDOTAK RELIANCE G 64CM -,SUP-0286,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB PCNG ETAK RELIANCE 64CM GORE-HYBRID ETFE CTD STRD -,SUP-0293-64,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10470.66,7329.462,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB IMPL BIPLR ETAK RELIANCE 4- SITE 59CM RT ECRD -,SUP-0295,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB IMPL BIPLR ETAK RELIANCE 4- SITE 64CM RT ECRD -,SUP-0296,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD RELIANCE 4-FRONT 0673 64 CM -,SUP-0673-64,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB BIPLR PERMNT PCNG KENTROX SL 65CM 7.8FRX180MM SPC -,SUP-350054,CDM,C1895,HCPCS,278,RC,,,outpatient,,,14265.35,9985.745,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB IMPL LINOX SMRT SD 65CM 18CM ECRD SIL INSL DL -,SUP-359067,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD PCNG 60MM LINOX SD IMPL BIPLR RV STRD ELUT ACT -,SUP-363303,CDM,C1895,HCPCS,278,RC,,,outpatient,,,14265.35,9985.745,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB TRIPLR SPRNT QUATTRO 65CM 8.6FRX12MM SPC RT ECRD -,SUP-6935-65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB 8.6FRX12MM SPC 55CM SPRNT QUATTRO TRIPLR STRD -,SUP-6935M55,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB TRIPLR SPRNT QUATTRO 62CM 8.6FRX12MM SPC SIL -,SUP-6935M62,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD PCNG 8.6FRX12MM SPC 58CM SPRNT QUATTRO PERMNT QDPL -,SUP-6947-58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD PCNG 8.6FRX12MM SPC 65CM SPRNT QUATTRO PERMNT QDPL -,SUP-6947-65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB QDPL SPRNT QUATTRO 55CM 8.6FRX12MM SPC RT ECRD -,SUP-6947M55,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB QDPL SPRNT QUATTRO 62CM 8.6FRX12MM SPC RT ECRD -,SUP-6947M62,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB QDPL SPRNT QUATTRO 72CM 8.6FRX12MM SPC RT ECRD -,SUP-6947M72,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FRX170MM SPC VNTRC OPTIM -,SUP-7120/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB TRUE BIPLR DURATA 52CM 7FRX170MM SPC VNTRC OPTIM -,SUP-7120Q/52,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB TRUE BIPLR DURATA 58CM 7FR VNTRC OPTIM INSL SGL -,SUP-7120Q/58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FR VNTRC OPTIM INSL SGL -,SUP-7120Q/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIBRILLATOR DURATA OPTIM L21 CM OD7 FR 2 COIL -,SUP-7121,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11031.32,7721.924,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FRX210MM SPC VNTRC OPTIM -,SUP-7121/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB TRUE BIPLR DURATA 52CM 7FR VNTRC OPTIM INSL SGL -,SUP-7121Q/52,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB DURATA IMPL -,SUP-7131,CDM,C1895,HCPCS,278,RC,,,outpatient,,,17543.93,12280.751,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB TRUE BIPLR DURATA 58CM 17CM-TO-PROX COIL 7FR -,SUP-7170Q/58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB TRUE BIPLR DURATA 58CM 21CM-TO-PROX COIL 7FR -,SUP-7171Q/58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC,,
LEAD DEFIB 8FR INTRO 65CM OPTISURE TRUE BIPLR XTD-RETRAC -,SUP-LDA230Q/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,13473.73824,other,OPPS APC,,
ELECTRODE DEFIB 12FR DIST TIP 9FR COIL 45CM Q-TRAK TRIPLR -,SUP-3400,CDM,C1896,HCPCS,278,RC,,,outpatient,,,14852,10396.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,11406.336,other,OPPS APC,,
ELECTRODE DEFIB 12FR DIST TIP 45CM EMBLEM TRIPLR SUBQ DIST -,SUP-3401,CDM,C1896,HCPCS,278,RC,,,outpatient,,,14852,10396.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,11406.336,other,OPPS APC,,
EMBLEM S-ICD LEAD 3501-45CM -,SUP-3501-45,CDM,C1896,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,11406.336,other,OPPS APC,,
LEAD EPICARDIAC 5071 -,SUP-5071,CDM,C1896,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,11406.336,other,OPPS APC,,
LEAD PCNG 58CM TRANSVENE IMPL UNIPL ECRD CS SVC -,SUP-6937A58,CDM,C1896,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,11406.336,other,OPPS APC,,
OPTISURE DEFIBRILLATION LEAD DF1 SINGLE COIL LDA210-65 -,SUP-LDA210-65,CDM,C1896,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,11406.336,other,OPPS APC,,
KT LEAD NEURSTM OCTRODE 60CM PERC ACC -,SUP-3086ANS,CDM,C1897,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,196.493625,28414.1568,other,OPPS APC,,
KT LEAD NEURSTM 60CM PERC ACC 6MM -,SUP-3873-60,CDM,C1897,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,196.493625,28414.1568,other,OPPS APC,,
KT LEAD NEURSTM 60CM PERC SUBCOMPACT ACC -,SUP-3875-60,CDM,C1897,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,196.493625,28414.1568,other,OPPS APC,,
REACTIV8 IMPLANTABLE PULSE GENERATOR -,SUP-5100,CDM,C1897,HCPCS,278,RC,,,outpatient,,,36997.6,25898.32,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,196.493625,28414.1568,other,OPPS APC,,
KT IT REVISN INTFC TRANSP STRN RLF SLVX2 NS RLR F/SULS PMP -,SUP-8578,CDM,C1897,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,196.493625,28414.1568,other,OPPS APC,,
LEAD NEURSTM VECTRIS SURSCN 60CM PERC SPIN CRD MRI-COND -,SUP-977D260,CDM,C1897,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,196.493625,28414.1568,other,OPPS APC,,
SLIM TIP DRG TRIAL LEAD KIT -,SUP-MN10350-50A,CDM,C1897,HCPCS,278,RC,,,outpatient,,,4874.15,3411.905,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,196.493625,28414.1568,other,OPPS APC,,
SLIP TIP DRG -,SUP-MN10350-90A,CDM,C1897,HCPCS,278,RC,,,outpatient,,,4909.5,3436.65,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,196.493625,28414.1568,other,OPPS APC,,
STIMWAVE NEUROSTIMULATOR RECEIVER KIT -,SUP-STQ4-RCV-A0,CDM,C1897,HCPCS,278,RC,,,outpatient,,,32936.92,23055.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,196.493625,28414.1568,other,OPPS APC,,
PNS PERMANENT TINED RECEIVER KIT CHANNEL B -,SUP-STQ4-RCV-B0,CDM,C1897,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,196.493625,28414.1568,other,OPPS APC,,
LEAD NRV STIM 50CM F/TRL -,SUP-UNDEFINED,CDM,C1897,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,196.493625,28414.1568,other,OPPS APC,,
LEAD PCNG 8FR INTRO 58CM TENDRIL DX PERMNT BIPLR AV -,SUP-1388TC/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 1642T X 46 -,SUP-1642T/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 7FR INTRO 10MM SPC 52CM ISFLX PERMNT BIPLR STR AV -,SUP-1646T/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 1646T-58 ISFLX PERMNT BIPLR_STR AV -,SUP-1646T/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 46CM TENDRIL -,SUP-1688TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
TENDRIL SDX 1688TC/46 -,SUP-1688TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD TENDRIL 1688 TC/58 -,SUP-1688TC-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 6FR INTRO 10MM SPC 52CM TENDRILL SDX PERMNT BIPLR -,SUP-1788TC/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 6FR INTRO 10MM SPC 58CM TENDRILL SDX PERMNT BIPLR -,SUP-1788TC/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 7FR INTRO 10MM SPC 46CM TENDRILL ST PERMNT BIPLR -,SUP-1882TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 7FR INTRO 10MM SPC 52CM TENDRILL ST PERMNT BIPLR -,SUP-1882TC/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 6FR INTRO 10MM SPC 46CM TENDRILL ST PERMNT BIPLR -,SUP-1888TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 6FR INTRO 10MM SPC 52CM TENDRILL ST PERMNT BIPLR -,SUP-1888TC/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 6FR INTRO 10MM SPC 58CM TENDRILL ST PERMNT BIPLR -,SUP-1888TC/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD ISOFLEX OPTIM J 1944-46CM -,SUP-1944/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 7FR INTRO 10MM SPC 52CM ISFLX PERMNT BIPLR J-SHP -,SUP-1944/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG ISOFLEX 1948-52 ISFLX PERMNT BIPLR STR AV. -,SUP-1948/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 7FR INTRO 10MM SPC 58CM ISFLX PERMNT BIPLR STR AV -,SUP-1948/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD OPINSENSE  MODEL 1999-52 -,SUP-1999/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD CATH DELIVERED 3830 69CM,SUP-2,CDM,C1898,HCPCS,275,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 6FRX46CM TENDRIL STS IMPL BIPLR RAV ACT SCR IN FX -,SUP-2088TC-46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 6FRX52CM TENDRIL STS IMPL BIPLR RAV ACT SCR IN FX -,SUP-2088TC-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 6FRX58CM TENDRIL STS IMPL BIPLR RAV ACT SCR IN FX -,SUP-2088TC-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 6.6FRX15MM SPC 60CM SELOX ST 60 PERMNT IMPL BIPLR -,SUP-346367,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 6.6FRX15MM SPC 53CM SELOX JT 53 PERMNT IMPL BIPLR -,SUP-346368,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 6.6FRX10MM SPC 45CM SETROX DX PERMNT IMPL BIPLR -,SUP-350973,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 7FRX10MM SPC 53CM SETROX DX PERMNT IMPL BIPLR HLCL -,SUP-350974,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 6.6FRX10MM SPC 60CM SETROX DX PERMNT IMPL BIPLR -,SUP-350975,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 6.6FR 7FR INTRO 53CM TILDA STR PSS FX -,SUP-382872,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD CATH DELIVERED 3830 69 CM -,SUP-383069,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 52CM SELUTE PICOTIP COMPLIANCE PRACTITIONERS -,SUP-4064,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 5.7FRX10MM SPC 35CM CAP NOV PERMNT BIPLR AV STRD -,SUP-4076-35,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2570.74,1799.518,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PPM 45CM CAPSURE FIX NOVUS 4076-45 -,SUP-4076-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 5.7FRX10MM SPC 45CM CAP NOV IMPL BIPLR AV STRD -,SUP-4076-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 5.3FRX9MM SPC 52CM CPSR SP NOVUS PERMNT BIPLR AV -,SUP-4092-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 5.3FRX9MM SPC 58CM CPSR SP NOVUS PERMNT BIPLR AV -,SUP-4092-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 6.7FRX10MM SPC 53CM DEXTRUS PERMNT BIPLR HLCL TIP -,SUP-4136-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 6.7FRX10MM SPC 60CM DEXTRUS PERMNT BIPLR HLCL TIP -,SUP-4137,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 5.7FRX16MM SPC 58CM FNLN STRX PERMNT BIPLR STR -,SUP-4457,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 1.7X16MM SPC_45CM FINELINE II EZ STEROX PERMNT -,SUP-4469,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 1.7X16MM SPC 45CM FINELINE II EZ STEROX PERMNT -,SUP-4469-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 1.7X16MM SPC 52CM FINELINE II EZ STEROX PERMNT -,SUP-4470-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 1.7X16MM SPC 58CM FINELINE II EZ STEROX PERMNT -,SUP-4471,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 5.7FRX45CM FNLN STRX AJ PERMNT BIPLR JTP RA ECRD -,SUP-4479,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 5.7FRX52CM FNLN STRX AJ PERMNT BIPLR JTP RA ECRD -,SUP-4480-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 5.3FRX9MM SPC 45CM CPSR SP NOVUS PERMNT BIPLR JTP -,SUP-4592-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 5.3FR CPSR SP NOVUS J-SHP ATR BIPLR -,SUP-4592-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD MEDTRONIC CAPSURE VDD-2 5038S-52 -,SUP-5038S-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD MEDTRONIC CAPSURE VDD-2 5038S-58 -,SUP-5038S-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG EPCRD -,SUP-5071-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PPM 45CM CAPSUREFIX SURSCN NOVUS 5076-45 -,SUP-5076-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 6.2FRX10MM SPC 52CM CAPSUREFIX SURSCN NOVUS IMPL -,SUP-5076-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 6.2FR X10MM SPC 58CM CAPSUREFIX SURSCN NOVUS IMPL -,SUP-5076-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 6.2FRX10MM SPC 65CM CAPSUREFIX SURSCN NOVUS IMPL -,SUP-5076-65,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 7FRX45CM CPSR FX MRI BIPLR STR AV ACT SCR IN FX -,SUP-5086MRI-45CM,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 7FRX52CM CPSR FX MRI BIPLR STR AV ACT SCR IN FX -,SUP-5086MRI-52CM,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 7FRX58CM CAPSUREFIX BIPLR STR AV ACT SCR IN FX -,SUP-5086MRI-58CM,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 35MM MYOPORE IMPL BIPLR EPCRD AV STRD ELUT ACT SCR -,SUP-511211,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD MYOPORE BIPOLAR 511211 -,SUP-511211,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 54CM MYOPORE IMPL BIPLR EPCRD AV STRD ELUT ACT SCR -,SUP-511212,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 7.2FRX53CM CAPSUREFIX PERMNT BIPLR J-SHP TIP ATR -,SUP-5568-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
BIPOLAR TEMPORARY MYOCARDIAL PACING LEAD -,SUP-6495F,CDM,C1898,HCPCS,278,RC,,,outpatient,,,408.45,285.915,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
OIL MNRL F/EZ INS STYL -,SUP-6529,CDM,C1898,HCPCS,278,RC,,,outpatient,,,175.05,122.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD INGEVITY MRI 7731 52 CM P -,SUP-7731,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD INGEVITY MRI 7732-59 ( PASSIVE ) -,SUP-7732,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD INGEVITY MRI 7732 59 -,SUP-7732-59,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
INGEVITY MRI  MODEL 7735-45 -,SUP-7735,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD INGEVITY MRI 7736-52 ( PASSIVE J ) -,SUP-7736,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD INGEVITY MRI 7740 -,SUP-7740,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD INGEVITY MRI 7741 52CM -,SUP-7741,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD INGEVITY MRI 7742 59CM -,SUP-7742,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
INGEVITY + 7840-45cm -,SUP-7840,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
INGEVITY + 7841/52 -,SUP-7841/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
INGEVITY + 7842/59 LEAD -,SUP-7842/59,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG ELAFIX ATR -,SUP-ELAFIX P2 752,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2549.32,1784.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 7FRX52CM BIPLR ECRD THN TND -,SUP-ELAPASSP752,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 7FRX58CM BIPLR ECRD THN TND -,SUP-ELAPASSP758,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2549.32,1784.524,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 7FRX52CM BIPLR J-SHP ECRD THN TND -,SUP-ELAPASSPJ752,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
TENDRIL MRI LEAD 46CM -,SUP-LPA1200M/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
TENDRIL MRI LEAD- 52CM -,SUP-LPA1200M/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
TENDRIL MRI LEAD- 58CM -,SUP-LPA1200M/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD GENTR -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD CATH DELIVERED 3830 59CM -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD CATH DELIVERED 3830 49CM -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD CATH DELIVERED 3830 74CM -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,39.298725,2053.20192,other,OPPS APC,,
LEAD PCNG 7FR INTRO 20MM SPC 86CM QUICKFLEX PERMNT BIPLR -,SUP-1156T/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD PCNG 5FRX20MM SPC 75CM QUICKFLEX U BIPLR STYP CRV LH -,SUP-1258T/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD PCNG 5FRX20MM SPC 86CM QUICKFLEX U BIPLR STYP CRV LH -,SUP-1258T/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD PCNG 5FRX20MM SPC 92CM QUICKFLEX U BIPLR STYP CRV LH -,SUP-1258T/92,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC,,
Lead Quartet 1456/75Q LV Lead -,SUP-1456/75Q,CDM,C1900,HCPCS,278,RC,,,outpatient,,,8445.56,5911.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD QUARTET 1456Q/86 LV LEAD -,SUP-1456/86Q,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC,,
QUARTET LEAD DOUBLE BEND- 75 CM MODEL 1457Q/75 -,SUP-1457Q/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC,,
QUARTET LEAD DOUBLE BEND-86CM MODEL 1457Q/86 -,SUP-1457Q/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD PCNG 7FR INTRO 75CMX16MM QRTT CRT STYP CRV LH LPRO -,SUP-1458Q/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD PCNG 7FR INTRO 86CMX16MM QRTT CRT STYP CRV LH LPRO -,SUP-1458Q/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD QUARTET 75 WIDE SPACING -,SUP-1458QL/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD QUARTET 1458QL 86 WIDE SPACING -,SUP-1458QL/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD PCNG 5.4FRX18MM SPC 77CM COROX PERMNT IMPL BIPLR HMSPHR -,SUP-355148,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5228.61,3660.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD SENTUS OTW QP L-75 -,SUP-386835,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD SENTUS OTW QP S-75 -,SUP-400719,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC,,
LV LEAD SENTUS OTW QP L 75/49 -,SUP-408718,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC,,
LV LEAD SENTUS OTW QP L 85/49 -,SUP-408719,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD PCNG 5FRX88CM ATTAIN PERMNT UNIPL CANTED LT VNTRC OTW -,SUP-4195-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD PCNG 4FRX21MM SPC 88CM ATTAIN PERMNT BIPLR ANG LT VNTRC -,SUP-4196-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD PCNG 5.3FRX21MM SPC 88CM ATTAIN ABILITY + IMPL BIPLR -,SUP-4296-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD ATTAIN PERFORMA LV REF:429878 -,SUP-429878,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD PCNG 5.3FRX21MM SPC 78CM ATTAIN PERFORM QDPL DBL CRV LT -,SUP-4298-78,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD ATTAIN PERFORM 4298-88 CM QDPL DBL CRV LT -,SUP-4298-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD ATTAIN PERFORMA QUAD LV  88 -,SUP-439888,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD PCNG 6FRX11MM SPC 80CM EASYTRAK 2 IMPL UNIPL BIPLR LT -,SUP-4542,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5585.1,3909.57,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD PCNG 6FRX11MM SPC 90CM EASYTRAK 2 IMPL UNIPL BIPLR LT -,SUP-4543,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5585.1,3909.57,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD PCNG 6FRX11MM SPC 90CM EASYTRAK 3 IMPL UNIPL BIPLR LT -,SUP-4549,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5585.1,3909.57,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD PCNG 4.5FRX90CM ACUITY IMPL UNIPL LT ECRD VNTRC SPRL FX -,SUP-4592,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD ATTAIN PERFORMA LV 4598-78 -,SUP-4598-78,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD ATTAIN PERFORMA LV 4598-88 -,SUP-4598-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD ACUITY X4 86CM STRAIGHT -,SUP-4671,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD ACUITY X4 95CM STRAIGHT -,SUP-4672-95,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC,,
LV LEAD ACUTIY SPIRAL S MODEL 4674-86 -,SUP-4674,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD ACUITY X4 95CM SPIRAL S -,SUP-4675-95,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD ACUITY X4 86CM SPIRAL L -,SUP-4677,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD ACUITY X4 95CM SPIRAL L -,SUP-4678-95,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD ATTAIN STABILITY QUAD MRI SURESCAN LV LEAD REF:4798-88 -,SUP-4798-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10247.88,7173.516,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC,,
LV LEAD SENTUS OTW QP S 75/49 MODEL 406081 -,SUP-706081,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD COROX OTW-L 85-BP -,SUP-UNDEFINED,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5228.61,3660.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC,,
LEAD COROX OTW-L 75-BP -,SUP-UNDEFINED,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5228.61,3660.027,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,9410.2272,other,OPPS APC,,
PROBE PERC SPIN 17GAX6IN -,SUP-0407-250-000,CDM,C2614,HCPCS,270,RC,,,outpatient,,,8309.75,5816.825,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6381.888,,,,
SIR-SPHERES Y-90 RESIN MICROSPHERES -,SUP-SIR-Y001,CDM,C2616,HCPCS,278,RC,,,outpatient,,,44393.67,31075.569,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19676.26496,,,19676.26496,399.86,42246.08608,other,OPPS APC,,
STENT BLDR 14F/7FRX24CM RETROMAX + PERCUFLEX HYDRPLS CTD -,SUP-145-148,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1085.19,759.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT 6FR OPEN END -,SUP-160205,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 8FRX80CM PERCUFLEX STR OPEN TIP -,SUP-160215,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
URINARY STENT 7FR CLOSED TIP -,SUP-160230,CDM,C2617,HCPCS,278,RC,,,outpatient,,,535.8,375.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PANC 7FR PSHR CATH 5CM FREEMN -ALIPERT FLEX-STNT -,SUP-6521,CDM,C2617,HCPCS,278,RC,,,outpatient,,,320.93,224.651,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PANC 7FRX9CM FREEMN FLX-STNT SGL PIGTL DBL XTRN FLNG -,SUP-6575,CDM,C2617,HCPCS,278,RC,,,outpatient,,,268.41,187.887,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 4.7FRX26CM INLAY DBL PIGTL TAPR -,SUP-778426,CDM,C2617,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT BIL 10FRX5CM COTTON-LEUNG CRV TAPR PE -,SUP-CLSO 10-5,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT BIL 7FRX7CM COTTON-LEUNG CRV TAPR PE P/D FLP -,SUP-CLSO 7-7,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT BILIARY ZIMMON 8FR 12CM 0.035IN GW 3.2MM -,SUP-G21404,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT BIL 10FRX7CM COTTON-LEUNG CRV TAPR PE -,SUP-G21469,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT BIL 10FRX8CM COTTON-LEUNG CRV TAPR PE P/D FLP -,SUP-G21472,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT BIL 10FRX10CM COTTON-LEUNG CRV TAPR PE P/D FLP -,SUP-G21807,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT BILIARY ZIMMON 10-5 -,SUP-G21975,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PANC 5FRX5CM ZIMMON SPRL SH PE PIGTL TAPR FLP LF MRI -,SUP-G22980,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PANC 3FRX4CM ZIMMON SPRL SH PE PIGTL TAPR OPTN DCT FLP -,SUP-G24566,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PANC 5FRX9CM GEENEN SPRL SH SOF-FLEX OFST PROX FLP LF -,SUP-G49666,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PANC 5FR 7CM GEENEN SOF-FLEX NO INTERNAL FLAP -,SUP-G49670,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PANC 5FR 9CM GEENEN SOF-FLEX NO INTERNAL FLAP -,SUP-G49671,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT BIL 7FRX5CM COMPASS BDS DBL PIGTL TAPR PLST 0.035IN GW -,SUP-G55519,CDM,C2617,HCPCS,278,RC,,,outpatient,,,414.29,290.003,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PANC 5FR 3CM GEENEN SOF-FLEX NO INTERNAL FLAP -,SUP-GPSOS-SF-5-3,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PANC 5FR 5CM GEENEN SOF-FLEX NO INTERNAL PLAP -,SUP-GPSOS-SF-5-5,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 8FRX22CM PERCUFLEX DBL PIGTL FLXB STF -,SUP-M001245500,CDM,C2617,HCPCS,278,RC,,,outpatient,,,826.41,578.487,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 6FRX22CM PERCUFLEX DBL PIGTL -,SUP-M001245730,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 6FRX24CM PERCUFLEX DBL PIGTL -,SUP-M001245740,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 6FRX26CM PERCUFLEX DBL PIGTL -,SUP-M001245750,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 6FRX28CM PERCUFLEX DBL PIGTL -,SUP-M001245760,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 8FRX26CM FLEXIMA DBL PIGTL -,SUP-M001274030,CDM,C2617,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT ADVANIX 7FR X 3CM DOUBLE PIGTAIL -,SUP-M00532160,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
ADVANIX DOUBLE PIGTAIL 7FR X 5CM -,SUP-M00532180,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
ADVANIX DOUBLE PIGTAIL 7FR X 7CM -,SUP-M00532190,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
ADVANIX DOUBLE PIGTAIL 7FR X 10CM -,SUP-M00532210,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
ADVANIX DOUBLE PIGTAIL 10FR X 5CM -,SUP-M00532260,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT BIL 10FRX5CM ADVANIX RX SGL DBL PIGTL PLST 4.2MM WKG -,SUP-M00532260,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
ADVANIX DOUBLE PIGTAIL 10FR X 7CM -,SUP-M00532270,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT BIL 10FRX15CM WALLSTNT DUOD BND PERCUFLEX -,SUP-M00533700,CDM,C2617,HCPCS,278,RC,,,outpatient,,,290.87,203.609,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 8FRX22CM PERCUFLEX DBL PIGTL PSTNR -,SUP-M0061453800,CDM,C2617,HCPCS,278,RC,,,outpatient,,,441.13,308.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
SCISSORS SURG KAYE CRV 7.5IN SERR DSCT V. MUELLER LF -,SUP-M0061552310,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 6FRX24CM POLARIS LOOP PERCUFLEX -,SUP-M0061552320,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 6FRX26CM POLARIS LOOP PERCUFLEX -,SUP-M0061552330,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 6FRX28CM POLARIS LOOP PERCUFLEX -,SUP-M0061552340,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 8FRX26CM POLARIS LOOP PERCUFLEX -,SUP-M0061552530,CDM,C2617,HCPCS,278,RC,,,outpatient,,,836.51,585.557,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 7FRX80CM PERCUFLEX STR LF -,SUP-M006160210,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PERC PLUS 4.8 X 24 -,SUP-M0061752520,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PERC PLUS 4.8 X 26 -,SUP-M0061752530,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PERC PLUS 4.8 X 28 -,SUP-M0061752540,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PERCUFLEX PLUS 6 X 22 -,SUP-M0061752610,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PERCUFLEX PLUS 6 X 24 -,SUP-M0061752620,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PERCUFLEX PLUS 6 X 26 -,SUP-M0061752630,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PERCUFLEX PLUS 6 X 28 -,SUP-M0061752640,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PERCUFLEX PLUS 6 X 30 -,SUP-M0061752650,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PERCUFLEX PLUS 7FR X 24CM -,SUP-M0061752720,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PERCUFLEX PLUS 7FR X 26CM -,SUP-M0061752730,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PERCUFLEX PLUS 8 X 26 -,SUP-M0061752830,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PERCUFLEX PLUS 8 X 28 NO -,SUP-M0061752840,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 8FRX30CM PERCUFLEX DBL PIGTL TAPR -,SUP-M0061752850,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 4.8FR 22-30CM CONTR VL PERCUFLEX DBL PIGTL TAPR -,SUP-M0061801550,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 6FR 22-30CM CONTR VL PERCUFLEX DBL PIGTL TAPR -,SUP-M0061801560,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET CONTOUR 6 X 22 -,SUP-M0061802210,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET CONTOUR 6 X 28 -,SUP-M0061802240,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 8FRX28CM PERCUFLEX TAPR LF -,SUP-M00618022440,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET CONTOUR 8 X 24 -,SUP-M0061802420,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 6FRX22CM NTNL/PTFE DBL PIGTL -,SUP-M006190131090,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1073.17,751.219,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 6FRX24CM NTNL/PTFE DBL PIGTL -,SUP-M006190132090,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1073.17,751.219,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 6FRX22CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921310,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 6FRX24CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921320,CDM,C2617,HCPCS,278,RC,,,outpatient,,,791.28,553.896,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 6FRX26CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921330,CDM,C2617,HCPCS,278,RC,,,outpatient,,,791.28,553.896,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 6FRX28CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921340,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 8FRX22CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921510,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT URET 8FRX26CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921530,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT PANC 5FRX5CM ZIMMON SPRL SH PE PIGTL TAPR OPTN DCT FLP -,SUP-SPSOF-5-5,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT BIL 7FRX10CM ZIMMON DBL PIGTL TAPR PE -,SUP-ZSO-7-10,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
STENT BIL 7FRX7CM ZIMMON DBL PIGTL TAPR PE -,SUP-ZSO-7-7,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,734.3115,other,OPPS APC,,
PROBE CRYOSPHERE 11IN -,SUP-CRYOS,CDM,C2618,HCPCS,272,RC,,,outpatient,,,10397.8,7278.46,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7607.37,other,OPPS APC,,
PROBE CRYOSPHERE 18IN -,SUP-CRYOS-L,CDM,C2618,HCPCS,272,RC,,,outpatient,,,9468.15,6627.705,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7607.37,other,OPPS APC,,
ICEROD 1.5C X 90 NEEDLE -,SUP-FPRPR3533,CDM,C2618,HCPCS,272,RC,,,outpatient,,,8042.38,5629.666,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7607.37,other,OPPS APC,,
NEEDLE ICEROD CX 90 VL -,SUP-FPRPR3533,CDM,C2618,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7607.37,other,OPPS APC,,
NEEDLE ICEPEARL  2.1C X 90 -,SUP-FPRPR3601,CDM,C2618,HCPCS,272,RC,,,outpatient,,,8042.38,5629.666,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7607.37,other,OPPS APC,,
NEEDLE ICEFORCE 2.1 X 90 -,SUP-FPRPR3602,CDM,C2618,HCPCS,272,RC,,,outpatient,,,10610,7427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,7607.37,other,OPPS APC,,
PACEMAKER IMPL BIPLR ADAPTA VDD SGL-CHMBR RR 11.1ML 23.6GM -,SUP-ADVDD01,CDM,C2619,HCPCS,275,RC,,,outpatient,,,16567.96,11597.572,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,12724.19328,,,,
PACEMAKER IMPL EVIA HF-T TRI CHMBR 14ML 27GM IS-1 CONN -,SUP-377208,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25991,18193.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24381.0432,other,OPPS APC,,
PACEMAKER IMPL SYNCRA 15ML 26GM DR -,SUP-C2TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24381.0432,other,OPPS APC,,
PACEMAKER IMPL CONSULTA CRT-P SGL-CHMBR 15ML 26GM IS-1 CONN -,SUP-C4TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24381.0432,other,OPPS APC,,
PACEMAKER IMPL ANTHEM 2CHMBR RR 52X58MM 6MM 13.7ML 25GM IS-1 -,SUP-PM3210,CDM,C2621,HCPCS,275,RC,,,outpatient,,,19897.97,13928.579,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24381.0432,other,OPPS APC,,
PACEMAKER IMPL ALLURE RF 59X55MM 6MM 14ML 24GM IS-1 CONN -,SUP-PM3222,CDM,C2621,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24381.0432,other,OPPS APC,,
PACEMAKER IMPL QDPL ALLURE QUADRA RF 2CHMBR RR 59X56MM 6MM -,SUP-PM3242,CDM,C2621,HCPCS,275,RC,,,outpatient,,,20792.8,14554.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24381.0432,other,OPPS APC,,
CRT-PACER QUADRA ALLURE MP  RF -,SUP-PM3262,CDM,C2621,HCPCS,275,RC,,,outpatient,,,21813.88,15269.716,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24381.0432,other,OPPS APC,,
QUADRA ALLURE MP MRI PM3562 -,SUP-PM3562,CDM,C2621,HCPCS,275,RC,,,outpatient,,,20792.8,14554.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24381.0432,other,OPPS APC,,
PACEMAKER ALTRUA 60 49MMX43X8MM 12.1ML TI -,SUP-S606 DR EL,CDM,C2621,HCPCS,275,RC,,,outpatient,,,18193.7,12735.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24381.0432,other,OPPS APC,,
VALITUDE CRT-P U125 -,SUP-U125,CDM,C2621,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24381.0432,other,OPPS APC,,
CRT-P VALITUDE MODEL - U128 -,SUP-U128,CDM,C2621,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24381.0432,other,OPPS APC,,
VISIONIST CRT-P MODEL U226 BI-V PACEMAKER -,SUP-U226,CDM,C2621,HCPCS,275,RC,,,outpatient,,,27736.11,19415.277,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24381.0432,other,OPPS APC,,
CRT-P VISIONIST X4 - U228 -,SUP-U228,CDM,C2621,HCPCS,275,RC,,,outpatient,,,20313.82,14219.674,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24381.0432,other,OPPS APC,,
PACEMAKER IMPL INVIVE CRT-PS SMARTDELAY ALGORITHM RPM -,SUP-V172,CDM,C2621,HCPCS,275,RC,,,outpatient,,,31746.15,22222.305,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24381.0432,other,OPPS APC,,
PACEMAKER INTUA CARD -,SUP-V272,CDM,C2621,HCPCS,275,RC,,,outpatient,,,28590.1,20013.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24381.0432,other,OPPS APC,,
PACEMAKER PERCEPTA CRT-P MRI W1TR01 -,SUP-W1TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25991,18193.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24381.0432,other,OPPS APC,,
SOLARA CRT-P MRI W1TR03 -,SUP-W1TR03,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24381.0432,other,OPPS APC,,
PACEMAKER PERCEPTA QUAD CRT-P MRI W4TR01 -,SUP-W4TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25991,18193.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24381.0432,other,OPPS APC,,
PACEMAKER SERENA QUAD CRT-P MRI W4TR02 -,SUP-W4TR02,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25248.4,17673.88,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24381.0432,other,OPPS APC,,
SOLARA QUAD CRT-P MRI W4TR03 -,SUP-W4TR03,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24381.0432,other,OPPS APC,,
PROSTHESIS PENL CNCLBL 14MMX16CM ANG RGD CONN MIN SPR BK -,SUP-720056-02,CDM,C2622,HCPCS,278,RC,,,outpatient,,,24383.27,17068.289,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,23086.3872,,,,
IMPLANT PENL CL 12MMX12CM SIL PE TI SEG MALE CNCLBL SNP FIT -,SUP-720074-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,20421.5,14295.05,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,23086.3872,,,,
PROSTHESIS TACTRA 9.5MM X 14CM-23CM MALLEABLE -,SUP-720080-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,30060.4,21042.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,23086.3872,,,,
TACTRA 11CM MALLEABLE PROSTHESIS -,SUP-720081-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,30060.4,21042.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,23086.3872,,,,
TACTRA 13MM X 18CM-27CM MALLEABLE PROSTHESIS -,SUP-720082-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,28358.17,19850.719,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,23086.3872,,,,
IMPLANT PENL DURA 11 10MMX14CM CL HX WRNCH STRL -,SUP-720093-10,CDM,C2622,HCPCS,278,RC,,,outpatient,,,15579.75,10905.825,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,23086.3872,,,,
TIP PROS DURA II 10MMX1CM UNIV PENL STRL -,SUP-720093-12,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,23086.3872,,,,
TIP PROS DURA II 10MMX5CM PROX PENL STRL -,SUP-720093-16,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,23086.3872,,,,
TIP PROS DURA II 10MMX4CM DIST PENL STRL -,SUP-720093-23,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,23086.3872,,,,
TIP PROS DURA II 10MMX2CM UNIV PENL STRL -,SUP-720093-60,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,23086.3872,,,,
KT PROSTHESIS PENL 11MMX25CM MALE CYL MLBL TRMBL ADPR W/TAIL -,SUP-91-9511SC,CDM,C2622,HCPCS,278,RC,,,outpatient,,,20291.55,14204.085,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,23086.3872,,,,
BARD BALLOON LUTONIX .035 4.0 X 150MM -,SUP-BSLX3513041505F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8912.4,6238.68,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
CATH PTCA 6MMX130CM LUTONIX 60MM DRG CTD 0.035IN GW COMP -,SUP-BSLX351306605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
LUTONIX BALLOON 6MM X 80MM -,SUP-BSLX351306805F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,7214.8,5050.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER DCB OTW  4.0MM x 40MM x 135CM -,SUP-H74939419400410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER GLOBAL DCB OTW 4.0 X 80MM 135CM -,SUP-H74939419400810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER GLOBAL DCB OTW 4.0 X 100MM 135CM -,SUP-H74939419401010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER GLOBAL DCB OTW 4.0 X 150MM 150CM -,SUP-H74939419401510,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER GLOBAL DCB OTW 4.0 X 200MM 150CM -,SUP-H74939419402010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER GLOBAL DCB OTW 4.0 X 200MM 150CM -,SUP-H74939419500410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER GLOBAL DCB OTW 5.0 X 60MM 135CM -,SUP-H74939419500610,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
CATH BALLOON RANGER GLOBAL 5.0 X 80MM X 135CM GLOBAL DCB OTW -,SUP-H74939419500810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER GLOBAL DCB OTW 5.0 X 100MM 135CM -,SUP-H74939419501010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER GLOBAL DCB OTW 5.0 X 120MM 150CM -,SUP-H74939419501210,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5708.18,3995.726,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER GLOBAL DCB OTW 5.0 X 150MM 150CM -,SUP-H74939419501510,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER DCB OTW 5.0MM x 200MM x 150CM -,SUP-H74939419502010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER GLOBAL DCB OTW 5.0 X 200MM 90CM -,SUP-H74939419502090,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER GLOBAL DCB OTW 6.0 X 40MM 135CM -,SUP-H74939419600410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER GLOBAL DCB OTW 6.0 X 60MM 135CM -,SUP-H74939419600610,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
CATH BALLOON RANGER GLOBAL 6.0 X 80MM X 135CM GLOBAL DCB OTW -,SUP-H74939419600810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER GLOBAL DCB OTW 6.0 X 100MM 135CM -,SUP-H74939419601010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER GLOBAL DCB OTW 6.0 X 200MM 150CM -,SUP-H74939419602010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER GLOBAL DCB OTW 7.0 X 40MM 135CM -,SUP-H74939419700410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER GLOBAL DCB OTW 7.0 X 60MM 135CM -,SUP-H74939419700610,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER GLOBAL DCB OTW 7.0 X 80MM 135CM -,SUP-H74939419700810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER GLOBAL DCB OTW 7.0 X 100MM 135CM -,SUP-H74939419701010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER GLOBAL DCB OTW 7.0 X 150MM 150CM -,SUP-H74939419701510,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
RANGER GLOBAL DCB OTW 7.0 X 200MM 150CM -,SUP-H74939419702010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
LUTONIX 018 6 X 80MM -,SUP-LX181306805F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
CATH PTCA 4MMX130CM LUTONIX 40MM DRG CTD 0.035IN GW COMP -,SUP-LX351304405F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
CATH PTCA 4MMX130CM LUTONIX 60MM DRG CTD 0.035IN GW COMP -,SUP-LX351304605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
CATH PTCA 5MMX130CM LUTONIX 100MM DRG CTD 0.035IN GW COMP -,SUP-LX3513051005F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
CATH PTCA 5X150MM LUTONIX 130CM -,SUP-LX3513051505F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
CATH PTCA 5MMX130CM LUTONIX 60MM DRG CTD 0.035IN GW COMP -,SUP-LX351305605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
B LUTONIX 6MM X 100MM X 130 -,SUP-LX3513061005F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
CATH PTCA 6X150MM LUTONIX 130CM -,SUP-LX3513061505F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
LUTONIX BALLOON -,SUP-LX3513062205F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8700.2,6090.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
CATH PTCA LUTONIX 0.035 X 6.0MM X 130CM 6FR DRG CTD GW GROUP -,SUP-LX351306605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
CATH PTCA 6MMX130CM LUTONIX 80MM DRG CTD 0.035IN GW COMP -,SUP-LX351306805F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
LUTONIX BALLOON 7MM X 100MM X 130M -,SUP-LX3513071005F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
S LUTONIX 7 X 40 X 130 -,SUP-LX351307405F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
S LUTONIX 7 X 60 X 130 -,SUP-LX351307605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
BALLOON LUTONIX .035 X 10MM X 40MM -,SUP-LX35751040V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
BALLOON LUTONIX .035 X 10MM X 60MM -,SUP-LX35751060V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
LUTONIX 12MM X 40MMX 75CM -,SUP-LX35751240V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6896.5,4827.55,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
BALLOON LUTONIX .035  4.0MM X 40MM -,SUP-LX3575440V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
CATH LUTONIX BALLOON DILATATION 6MM 75CM 40MM PACLITAXEL LF -,SUP-LX3575640V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
CATH LUTONIX BALLOON DILATATION 6MM 75CM 60MM PACLITAXEL LF -,SUP-LX3575660V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
LUTONIX DCB BALLOON 6 X 80 X 75 -,SUP-LX3575680V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
BALLOON LUTONIX .035  7.0MM X 40MM -,SUP-LX3575740V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
BALLOON LUTONIX .035  4 X 60 X 75 -,SUP-LX3575760V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
BALLOON LUTONIX .035 X 8MM X 40MM X 75CM -,SUP-LX3575840V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
BALLOON LUTONIX  .035 8 X 60 X 75 -,SUP-LX3575860V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
BALLOON LUTONIX .035 9.0MM X 40MM X 75CM -,SUP-LX3575940V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,6390.1908,other,OPPS APC,,
STENT NEPHURET 8.5FRX22CM ULTRATHANE COPE DBL PIGTL BND -,SUP-240735,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT NEPHURET 8.5FRX24CM ULTRATHANE COPE DBL PIGTL BND -,SUP-240736,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT NEPHURET 8.5FRX28 CM ULTRATHANE COPE DBL PIGTL BND -,SUP-244806,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT URET 4.7FRX24CM INLAY DBL PIGTL TAPR -,SUP-778424,CDM,C2625,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
8FR X 22 BARD OPTIMA INLAY URETERAL STENT -,SUP-778822,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
8FR X 24 BARD OPTIMA INLAY URETERAL STENT -,SUP-778824,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
8FR X 26 BARD OPTIMA INLAY URETERAL STENT -,SUP-778826,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
8FR X 28 BARD OPTIMA INLAY URETERAL STENT -,SUP-778828,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT URETERAL INLAY 6F 20 OPT -,SUP-788620,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT URETERAL INLAY 6F 22 OPT -,SUP-788622,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT URETERAL INLAY 6F 24 -,SUP-788624,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT URETERAL INLAY 6F 26 -,SUP-788626,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT URETERAL INLAY 6F 28 -,SUP-788628,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT URETERAL INLAY 6F 30 -,SUP-788630,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
BARD OPTIMA INLAY STENT 7 X 24 -,SUP-788724,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
BARD OPTIMA INLAY STENT 7 X 26 -,SUP-788726,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
BARD OPTIMA INLAY STENT 7 X 28 -,SUP-788728,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT BIL 7FRX5CM COTTON-LEUNG CRV TAPR PE P/D FLP PSH CATH -,SUP-CLBS-7-5,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT FANELLI BILIARY -,SUP-G13699,CDM,C2625,HCPCS,278,RC,,,outpatient,,,2999.5,2099.65,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT URET 7FRX75CM BNDR RT SOF-FLEX -,SUP-G14779,CDM,C2625,HCPCS,278,RC,,,outpatient,,,446.79,312.753,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT URET 7FRX75CM BNDR PTFE -,SUP-G14780,CDM,C2625,HCPCS,278,RC,,,outpatient,,,451.1,315.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT BILIARY DOUBLE PIGTAIL 7 X 7 -,SUP-G21396,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT BILIARY DOUBLE PIGTAIL 7 X 9 -,SUP-G21398,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT GEENAN PANCREATIC 7X7 -,SUP-G21479,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT GEENAN PANCREATIC 7X9 -,SUP-G21480,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT SET ZIMMON BILIARY 7-12 -,SUP-G21526,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT ZIMON BILIARY 7 X 15 -,SUP-G21529,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT ZIMMON DBL PIGTAIL 10X4 -,SUP-G21781,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT BIL 10MMX5CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN -,SUP-G25379,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT BIL 10MMX7CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN -,SUP-G25380,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT BIL 7MMX5CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN GW -,SUP-G25656,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT BIL 7MMX7CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN GW -,SUP-G25657,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT SOLUS DOUBLE PIGTAIL 10FR 3CM -,SUP-G25670,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT SOLUS DBL PIGTAIL 10 X 4 -,SUP-G25671,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT SOLUS DBL PIGTAIL 10 X 5 -,SUP-G25672,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT DBLE PIGTAIL 10F 1CM -,SUP-G26829,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT SOLUS DOUBLE PIGTAIL 10FR 1CM -,SUP-G26829,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT NEPHURET 10.2FRX22CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48162,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT NEPHURET 8.5FRX24CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48176,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT NEPHURET 8.5FRX26CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48180,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT NEPHURET 8.5FRX26CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48180,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
COMPASS BDS BILIARY STENT 7FR 15CM -,SUP-G58990,CDM,C2625,HCPCS,278,RC,,,outpatient,,,408.45,285.915,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT PANC 3FRX4CM GEENEN 170CM/320CM PSH/GUID CATH SPRL SH -,SUP-GEPD3-4,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
TUBE LRNCMY JCKSN SZ8 12MMX7CM OSDE V. MUELLER CRV MIRR FNSH -,SUP-GEPD3-5,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
CATH DRN 10FR NAVIFLEX RX -,SUP-M00533580,CDM,C2625,HCPCS,278,RC,,,outpatient,,,512.08,358.456,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT ADVANIX RX 7FR X 5CM PRELOADED -,SUP-M00534200,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT ADVANIX RX 7FR X 7CM PRELOADED -,SUP-M00534210,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT ADVANIX RX 7FR X 9CM PRELOADED -,SUP-M00534220,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT BIL 2.3MMX9CM ADVANIX RX PRELD DUOD BND PLST 3.2MM WKG -,SUP-M00534220,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT ADVANIX RX 7FR X 12CM PRELOADED -,SUP-M00534230,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT ADVANIX RX 10FR X 5CM PRELOADED -,SUP-M00534320,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT ADVANIX RX 10FR X 5CM PRELOADED -,SUP-M00534330,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT ADVANIX RX 10FR X 9CM PRELOADED -,SUP-M00534340,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT BIL 10FRX9CM ADVANIX RX PRELD DUOD BND PLST 4.2MM WKG -,SUP-M00534340,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT ADVANIX RX 10FR X 12CM PRELOADED -,SUP-M00534350,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT BIL 10FRX12CM ADVANIX RX PRELD DUOD BND PLST 4.2MM WKG -,SUP-M00534350,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT BIL 10FRX15CM ADVANIX RX PRELD DUOD BND PLST 4.2MM WKG -,SUP-M00534360,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT ADVANIX RX 10FR X 15CM -,SUP-M00534360,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT BIL 8.5FRX7CM ADVANIX RX PRELD CTR BND PLST 3.2MM WKG -,SUP-M00534630,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT BIL 8.5FRX9CM ADVANIX RX PRELD CTR BND PLST 3.2MM WKG -,SUP-M00534640,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT BIL 10FRX7CM ADVANIX RX PRELD CTR BND PLST 4.2MM WKG -,SUP-M00534690,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT BIL 10FRX12CM ADVANIX RX PRELD CTR BND PLST 4.2MM WKG -,SUP-M00534710,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT ADVANTIX 5X3 PANCREATIC NO LEADING BARB SINGLE PIGTAIL -,SUP-M00537390,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT ADVANTIX 5 X 4 PANCREATIC - NO LEADING BARB -,SUP-M00537400,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT ADVANTIX 5X5 PANCREATIC NO LEADING BARB SINGLE PIGTAIL -,SUP-M00537410,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT ADVANTIX 5 X 3 PANCREATIC -LEADING BARB -,SUP-M00537430,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT ADVANTIX 5 X 4 PANCREATIC -LEADING BARB -,SUP-M00537440,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT ADVANTIX 5X3 PANCREATIC NO LEADING BARB STRAIGHT -,SUP-M00537500,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT ADVANTIX 5X5 PANCREATIC NO LEADING BARB STRAIGHT -,SUP-M00537520,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT KIT PANCREATIC 5FR X 3CM -,SUP-M00537540,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
STENT BIL 7FRX4CM ZIMMON DBL PIGTL TAPR PE 170CM PSH CATH -,SUP-ZEBD-7-4,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,89.07711,1949.675,other,OPPS APC,,
PAIN CONTROL DEVICE BEELINE -,SUP-UNDEFINED,CDM,C2626,HCPCS,278,RC,,,outpatient,,,758.55,530.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,170.294475,582.5664,,,,
HC Cath Stamey Suprapubic 14,PX-27200045,CDM,C2627,HCPCS,272,RC,,,outpatient,,,306,214.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,24.890315,416.02,,,,
ST SUPRAPUBIC 12FRX25CM CONN TUBEX1/NDL OBTURATORX1/ 1W -,SUP-G14313,CDM,C2627,HCPCS,272,RC,,,outpatient,,,357.1,249.97,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,24.890315,416.02,,,,
CATHETER MALECOT DRAINAGE 14FR 30CM -,SUP-G55824,CDM,C2627,HCPCS,272,RC,,,outpatient,,,307.21,215.047,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,24.890315,416.02,,,,
LAWRENCE SUPRA-FOLEY 16F -,SUP-SF-S16-851,CDM,C2627,HCPCS,272,RC,,,outpatient,,,110.87,77.609,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,24.890315,416.02,,,,
OCCULSION BALLOON CATH 90CM BR -,SUP-590-001,CDM,C2628,HCPCS,272,RC,,,outpatient,,,4415.95,3091.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,23.64434,10635.57648,other,OPPS APC,,
CATH OCL 6FRX10MM BLN ATTAIN COR -,SUP-6215,CDM,C2628,HCPCS,272,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,23.64434,10635.57648,other,OPPS APC,,
CATHETER PRUITT OCCLUSION 3F 7MM 27CM -,SUP-E2103-36,CDM,C2628,HCPCS,272,RC,,,outpatient,,,1743.86,1220.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,23.64434,10635.57648,other,OPPS APC,,
CATH ANG 5FR SHTH 135CM 3.75X20X1.5MM BLN ENTEER PERIPH -,SUP-ENB37520135,CDM,C2628,HCPCS,272,RC,,,outpatient,,,10273.24,7191.268,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,23.64434,10635.57648,other,OPPS APC,,
CATHETER OCCLUSION ER-REBOA PLUS -,SUP-ER7232PLUS,CDM,C2628,HCPCS,272,RC,,,outpatient,,,14833.44,10383.408,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,23.64434,10635.57648,other,OPPS APC,,
CATH HSG 5FRX30CM SIL 1ML BLN/SYR OPN TIP MRI-COND STRL SUD -,SUP-G17147,CDM,C2628,HCPCS,272,RC,,,outpatient,,,171.9,120.33,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,23.64434,10635.57648,other,OPPS APC,,
B CODA-2-10.0-35-140-46 -,SUP-G23773,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2702.08,1891.456,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,23.64434,10635.57648,other,OPPS APC,,
CODA BALLOON 46MM -,SUP-G23773,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2702.08,1891.456,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,23.64434,10635.57648,other,OPPS APC,,
CATH URET 6.2FRX26CM LF W/HSG/SHG MLBL STYL -,SUP-J-UHSG-062026,CDM,C2628,HCPCS,272,RC,,,outpatient,,,105.32,73.724,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,23.64434,10635.57648,other,OPPS APC,,
KIT CATHETER REBOA CONVENIENCE -,SUP-KT1835C,CDM,C2628,HCPCS,272,RC,,,outpatient,,,1192.61,834.827,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,23.64434,10635.57648,other,OPPS APC,,
CATHETER BALLOON MOLDING OCCLUSION 10MM X 37MM 10FR -,SUP-MOB37,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2740.28,1918.196,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,23.64434,10635.57648,other,OPPS APC,,
CATH OUTBACK RE-ENTRY 120CM -,SUP-OTB59120A,CDM,C2628,HCPCS,272,RC,,,outpatient,,,8021.16,5614.812,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,23.64434,10635.57648,other,OPPS APC,,
Q50X STENT GRAFT BALLOON CATHETER -,SUP-Q50-100-X,CDM,C2628,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,23.64434,10635.57648,other,OPPS APC,,
CATH GUID 8FR 10-46MM INFL 100CM RELIANT PU 12FR SHTH -,SUP-REL46,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2500.25,1750.175,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,23.64434,10635.57648,other,OPPS APC,,
MICRO INTRO KIT 21G 4FR 7CM TCAR - MULT'S OF 10EA -,SUP-SR-4F21G7D-MP,CDM,C2628,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,23.64434,10635.57648,other,OPPS APC,,
HSG CATHETER -,SUP-UNDEFINED,CDM,C2628,HCPCS,272,RC,,,outpatient,,,207.35,145.145,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,23.64434,10635.57648,other,OPPS APC,,
CATH ABLT THRP COOL PATH MED CURL 7FR 2-5-2MM SPC 110CM QDPL -,SUP-A088047,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT THRP COOL PATH LRG CURL 7FR 2-5-2MM SPC 110CM QDPL -,SUP-A088049,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT SAFIRE BLU MED SWP DIST REACH CRV 7FR 2-5-2MM SPC -,SUP-A088106,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT SAFIRE BLU MED CURL DIST REACH CRV 7FR 2-5-2MM SPC -,SUP-A088107,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT SAFIRE BLU LRG SWP 7FR 2-5-2MM SPC LRG SWP 110CM -,SUP-A088108,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT SAFIRE BLU MED CURL DIST REACH CRV 7FR HGH TRQ -,SUP-A402871,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT SAFIRE BLU LRG CURL DIST REACH CRV HGH TRQ SHFT -,SUP-A402872,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT SAFIRE BLU MED CURL CRV EP DUO -,SUP-A700455,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT TACTICATH SE BI-D DF -,SUP-A-TCSE-DF,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10440.96,7308.672,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT TACTI SE BI-D FJ -,SUP-A-TCSE-FJ,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10440.96,7308.672,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT TACTIFLEX SE BID DF REF: A-TFSE-DF -,SUP-A-TFSE-DF,CDM,C2630,HCPCS,272,RC,,,outpatient,,,14387.88,10071.516,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT TACTIFLEX SE BID FJ REF: A-TFSE-FJ -,SUP-A-TFSE-FJ,CDM,C2630,HCPCS,272,RC,,,outpatient,,,14387.88,10071.516,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT THERMOCOOL SF F-J CRV 8FR 2-5-2MM SPC 115CM BIDIR -,SUP-BDI35FJRT,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7957.5,5570.25,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT THERMOCOOL SF B- CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131601,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT THERMOCOOL SF D-CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131602,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT THERMOCOOL SF F-CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131603,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT THERMOCOOL SF J-CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131604,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT THERMOCOOL SF CARTO XP F-TY CRV STEER UNI- DRCT -,SUP-D131803,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT THERMOCOOL SF CARTO XP J CRV STEER UNI- DRCT HTORQ -,SUP-D131804,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT CHILLI II STD CRV 7.5FRX2.5MM SPC 4MM TIP 110CM -,SUP-M00490310,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7151.14,5005.798,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT THRMCPL CRV 7.5FR LRG 110CM 2.5/2.5MM SPC -,SUP-M0049031K20,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7151.14,5005.798,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT TACTICATH 65 MM -,SUP-PN-004 065,CDM,C2630,HCPCS,272,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC,,
CATH ABLT TACTICATH 75MM -,SUP-PN-004075,CDM,C2630,HCPCS,272,RC,,,outpatient,,,11139,7797.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10316.10996,other,OPPS APC,,
DEVICE SUTCAP 12MM OPN ACCESS -,SUP-M0068311251,CDM,C2631,HCPCS,272,RC,,,outpatient,,,2073.95,1451.765,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,1487.02215,,,,
HC Mra- W/Dye- Upper Extremity,PX-61000005,CDM,C8934,CPT,610,RC,,,outpatient,,,2034,1423.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,399.86,1724.0184,other,OPPS APC,,
HC Mra- W/O Dye- Upper Extr,PX-61000006,CDM,C8935,CPT,610,RC,,,outpatient,,,1745,1221.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,267.439885,,,267.439885,267.439885,1479.062,other,OPPS APC,,
HC Mra- W/O&W/Dye- Upper Extr,PX-61000007,CDM,C8936,CPT,610,RC,,,outpatient,,,3036,2125.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,419.73411,,,419.73411,399.86,2573.3136,other,OPPS APC,,
HC Cad Breast MRI,PX-61000089,CDM,C8937,HCPCS,610,RC,,,outpatient,,,344,240.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,77.228,836,other,OPPS APC,,
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML IJ SOLN,RX-155306,CDM,C9088,HCPCS,636,RC,47426-0301-02,NDC,outpatient,14,ML,1200.46,840.322,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.8808895,,,0.8808895,0.71,921.95328,other,OPPS APC,,
COCAINE HCL 4 % EX SOLN,RX-1792,CDM,C9143,HCPCS,636,RC,70839-0362-04,NDC,outpatient,4,ML,1089.63,762.741,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.4,836.83584,,,,
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-10,NDC,outpatient,50,ML,344.88,241.416,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,,,,,3.39,416.02,,,,
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-10,NDC,outpatient,50,ML,360.88,252.616,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.39,416.02,,,,
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-01,NDC,outpatient,50,ML,344.88,241.416,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,,,,,3.39,416.02,,,,
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-01,NDC,outpatient,50,ML,360.88,252.616,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.39,416.02,,,,
LACOSAMIDE 200 MG/20ML IV SOLN,RX-96972,CDM,C9254,HCPCS,636,RC,00131-1810-67,NDC,outpatient,20,ML,278.22,194.754,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.31,416.02,,,,
LACOSAMIDE 200 MG/20ML IV SOLN,RX-96972,CDM,C9254,HCPCS,636,RC,72603-0140-01,NDC,outpatient,20,ML,100.4,70.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.31,416.02,,,,
LACOSAMIDE 200 MG/20ML IV SOLN,RX-96972,CDM,C9254,HCPCS,636,RC,72603-0140-02,NDC,outpatient,20,ML,100.4,70.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.31,416.02,,,,
BUPIVACAINE LIPOSOME 1.3 % IJ SUSP,RX-112781,CDM,C9290,HCPCS,636,RC,65250-0266-09,NDC,outpatient,20,ML,1495.03,1046.521,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.36,1148.18304,other,OPPS APC,,
BUPIVACAINE LIPOSOME 1.3 % IJ SUSP,RX-112781,CDM,C9290,HCPCS,636,RC,65250-0266-20,NDC,outpatient,20,ML,1495.03,1046.521,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.36,1148.18304,other,OPPS APC,,
CAP NERVE AXOGEN 2MM X 15MM -,SUP-AGT215,CDM,C9353,HCPCS,278,RC,,,outpatient,,,6688.54,4681.978,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,5136.79872,other,OPPS APC,,
CAP NERVE AXOGEN 3MM X 15MM -,SUP-AGT315,CDM,C9353,HCPCS,278,RC,,,outpatient,,,6688.54,4681.978,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,5136.79872,other,OPPS APC,,
CAP NERVE AXOGEN 4 X 15 -,SUP-AGT415,CDM,C9353,HCPCS,278,RC,,,outpatient,,,6688.54,4681.978,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,5136.79872,other,OPPS APC,,
NEUROMATRIX 6.0MM DIAMETER 2.5CM LENGTH -,SUP-CNC6025,CDM,C9355,HCPCS,278,RC,,,outpatient,,,5756.22,4029.354,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,182.24,5164.04736,other,OPPS APC,,
NEUROFLEX NERVE 4MM X 2.5CM -,SUP-CNCF4025,CDM,C9355,HCPCS,278,RC,,,outpatient,,,6724.02,4706.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,182.24,5164.04736,other,OPPS APC,,
NEUROFLEX NERVE 6MM X 2.5CM -,SUP-CNCF6025,CDM,C9355,HCPCS,278,RC,,,outpatient,,,6724.02,4706.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,182.24,5164.04736,other,OPPS APC,,
MESH SURGIMEND 5X6CM 1.0MM -,SUP-606-001-002,CDM,C9358,HCPCS,636,RC,,,outpatient,,,2525.06,1767.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24858.15552,other,OPPS APC,,
MESH SURGIMEND 5X6CM 1.0MM - C -,SUP-606-001-002,CDM,C9358,HCPCS,636,RC,,,outpatient,,,2525.06,1767.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24858.15552,other,OPPS APC,,
MESH SURGIMEND BOVINE 10 X 15CM -,SUP-606-001-006,CDM,C9358,HCPCS,636,RC,,,outpatient,,,9819.33,6873.531,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24858.15552,other,OPPS APC,,
IMPLANT NDNTR COLL 4X7CM SRGMND RECT -,SUP-606-001-013,CDM,C9358,HCPCS,636,RC,,,outpatient,,,2616.64,1831.648,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24858.15552,other,OPPS APC,,
SURGIMEND PRS 10CM X 20CM RECT -,SUP-606-004-102,CDM,C9358,HCPCS,636,RC,,,outpatient,,,16238.36,11366.852,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24858.15552,other,OPPS APC,,
MESH SURGIMEND 8CM X 16CM SEMI OVAL FENESTRAED -,SUP-606-004-103,CDM,C9358,HCPCS,636,RC,,,outpatient,,,10392.54,7274.778,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24858.15552,other,OPPS APC,,
GRAFT FTL BVN NDNTR COLL MATRIX 20X30CM SRGMND 2MM SHT RECT -,SUP-606-200-017,CDM,C9358,HCPCS,636,RC,,,outpatient,,,27546.57,19282.599,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24858.15552,other,OPPS APC,,
MESH SURGIMEND 3.0 13 X 25CM -,SUP-606-300-009,CDM,C9358,HCPCS,636,RC,,,outpatient,,,26387.33,18471.131,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24858.15552,other,OPPS APC,,
MESH SURGIMEND 20 X 30 X 3MM -,SUP-606-300-017,CDM,C9358,HCPCS,636,RC,,,outpatient,,,32367.39,22657.173,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24858.15552,other,OPPS APC,,
GENTRIX SURGICAL MATRIX HIATAL 7.5 X 6CM -,SUP-HIAT0706,CDM,C9358,HCPCS,636,RC,,,outpatient,,,4704.78,3293.346,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,24858.15552,other,OPPS APC,,
MESH SURGIMEND 3.0 10 X 15CM -,SUP-603-300-006,CDM,C9360,HCPCS,636,RC,,,outpatient,,,12178.79,8525.153,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,41430.25152,,,,
MESH SURGIMEND 10 X 15CM 2.0 -,SUP-606-200-006,CDM,C9360,HCPCS,636,RC,,,outpatient,,,10364.84,7255.388,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,41430.25152,,,,
IMPLANT NDNTR COLL 13X20CM SRGMND RECT -,SUP-606-200-009,CDM,C9360,HCPCS,636,RC,,,outpatient,,,22457.19,15720.033,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,41430.25152,,,,
MESH SURGIMEND 25X40 X 3.0MM -,SUP-606-300-016,CDM,C9360,HCPCS,636,RC,,,outpatient,,,53945.64,37761.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,41430.25152,,,,
NEUROMEND12MM X 2.5CM -,SUP-CNW12025,CDM,C9361,HCPCS,636,RC,,,outpatient,,,6724.07,4706.849,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,177.26,5164.08576,other,OPPS APC,,
NEUROMEND 4MM X 2.25CM -,SUP-CNW4025,CDM,C9361,HCPCS,636,RC,,,outpatient,,,6464.93,4525.451,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,177.26,5164.08576,other,OPPS APC,,
IMPLANT BIO TISS 3X8CM 3D HYDR PRCN COLL MATRIX PERMACOL SHT -,SUP-P100308,CDM,C9364,HCPCS,636,RC,,,outpatient,,,2987.95,2091.565,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,18.39,18739.8144,,,,
MESH PERMACOL 5X10CM 1.0MM -,SUP-P100510,CDM,C9364,HCPCS,636,RC,,,outpatient,,,4648.41,3253.887,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,18.39,18739.8144,,,,
IMPLANT BIO TISS 10X10CM 3D HYDR PRCN DERM COLL PERMACOL SHT -,SUP-P101010,CDM,C9364,HCPCS,636,RC,,,outpatient,,,9294.36,6506.052,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,18.39,18739.8144,,,,
IMPLANT BIO TISS 15X20CM 3D HYDR PRCN COLL MATRIX PERMACOL -,SUP-P151520,CDM,C9364,HCPCS,636,RC,,,outpatient,,,24400.8,17080.56,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,18.39,18739.8144,,,,
CANGRELOR TETRASODIUM 50 MG IV SOLR,RX-131579,CDM,C9460,HCPCS,636,RC,10122-0620-01,NDC,outpatient,1,UN,2428.93,1700.251,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,21.562892,,,21.562892,18.2,1865.41824,other,OPPS APC,,
CANGRELOR TETRASODIUM 50 MG IV SOLR,RX-131579,CDM,C9460,HCPCS,636,RC,10122-0620-10,NDC,outpatient,1,UN,2428.93,1700.251,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,21.562892,,,21.562892,18.2,1865.41824,other,OPPS APC,,
HC Perc Drug-El Cor Stent Sing,PX-48100003,CDM,C9600,CPT,481,RC,,,outpatient,,,32584,22808.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12006.91336,,,12006.91336,399.86,25024.512,other,OPPS APC,,
HC Perc Drug-El Cor Stent Bran,PX-48100004,CDM,C9601,CPT,481,RC,,,outpatient,,,33887,23720.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,26025.216,other,OPPS APC,,
HC Perc D-E Cor Stent Ather S,PX-48100005,CDM,C9602,CPT,481,RC,,,outpatient,,,33887,23720.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19138.22361,,,19138.22361,399.86,26793.51305,other,OPPS APC,,
HC Perc D-E Cor Revasc T Cabg S,PX-48100007,CDM,C9604,CPT,481,RC,,,outpatient,,,33887,23720.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12006.91336,,,12006.91336,399.86,26025.216,other,OPPS APC,,
HC Perc D-E Cor Revasc T Cabg B,PX-48100008,CDM,C9605,CPT,481,RC,,,outpatient,,,33887,23720.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,26025.216,,,,
HC Perc D-E Cor Revasc Chro Sin,PX-48100010,CDM,C9607,CPT,481,RC,,,outpatient,,,33887,23720.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,19138.22361,,,19138.22361,399.86,26793.51305,other,OPPS APC,,
HC Perc D-E Cor Revasc Chro Add,PX-48100011,CDM,C9608,CPT,481,RC,,,outpatient,,,33887,23720.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,26025.216,other,OPPS APC,,
HC Admin Influenza Virus Vac,PX-77100001,CDM,G0008,CPT,771,RC,,,outpatient,,,193,135.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,51.84533,,,51.84533,19.95,416.02,other,OPPS APC,,
HC Immuniz-Admin-Each Addl,PX-77100005,CDM,G0008,CPT,771,RC,,,outpatient,,,215,150.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,51.84533,,,51.84533,19.95,416.02,other,OPPS APC,,
HC Admin Pneumococcal Vaccine,PX-77100002,CDM,G0009,CPT,771,RC,,,outpatient,,,193,135.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,51.84533,,,51.84533,19.95,416.02,other,OPPS APC,,
HC Immuniz-Admin-Each Addl,PX-77100006,CDM,G0009,CPT,771,RC,,,outpatient,,,215,150.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,51.84533,,,51.84533,19.95,416.02,other,OPPS APC,,
HC Admin Hepatitis B Vaccine,PX-77100003,CDM,G0010,CPT,771,RC,,,outpatient,,,193,135.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,51.84533,,,51.84533,19.95,416.02,other,OPPS APC,,
HC Immuniz-Admin-Each Addl,PX-77100007,CDM,G0010,CPT,771,RC,,,outpatient,,,215,150.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,51.84533,,,51.84533,19.95,416.02,other,OPPS APC,,
HC Inject for Sacroiliac Joint,PX-36900022,CDM,G0259,CPT,369,RC,,,outpatient,,,827,578.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,185.6615,1592,,,,
HC Inj for Sacroiliac Jt Anesth,PX-36900023,CDM,G0260,CPT,369,RC,,,outpatient,,,1722,1205.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,754.76995,,,754.76995,386.589,2141,other,OPPS APC,,
HC Occlusive Device in Vein Art,PX-48100001,CDM,G0269,CPT,481,RC,,,outpatient,,,202,141.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,45.349,1592,other,OPPS APC,,
HC Iliac Art Angio-Cardiac Cath,PX-32000003,CDM,G0278,CPT,320,RC,,,outpatient,,,113,79.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,25.3685,416.02,other,OPPS APC,,
HC Elec Stim Other Than Wound,PX-42000003,CDM,G0283,CPT,420,RC,,,outpatient,,,123,86.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12.01,,,12.01,12.01,416.02,other,OPPS APC,,
HC Observation Time,PX-76200003,CDM,G0378,CPT,762,RC,,,outpatient,,,101,70.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.6745,6652,other,OPPS APC,,
HC Observation Carve-Out,PX-76200004,CDM,G0378,CPT,762,RC,,,outpatient,,,101,70.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,22.6745,6652,other,OPPS APC,,
HC Direct Refer Hospital Observ,PX-76200001,CDM,G0379,CPT,762,RC,,,outpatient,,,1442,1009.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,701.034545,,,701.034545,104.83,6652,other,OPPS APC,,
HC PR Trauma Respons W/Hosp Criti,PX-68200001,CDM,G0390,HCPCS,682,RC,,,outpatient,,,10370,7259,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1494.270385,,,1494.270385,399.86,7964.16,other,OPPS APC,,
HC Full Trauma,PX-68200002,CDM,G0390,HCPCS,682,RC,,,outpatient,,,10370,7259,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1494.270385,,,1494.270385,399.86,7964.16,other,OPPS APC,,
HC Partial Trauma,PX-68200003,CDM,G0390,HCPCS,682,RC,,,outpatient,,,7029,4920.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1494.270385,,,1494.270385,399.86,7964.16,other,OPPS APC,,
HC Mod Sedat Endo Service >5yrs,PX-37000025,CDM,G0500,HCPCS,370,RC,,,outpatient,,,240,168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,53.88,416.02,other,OPPS APC,,
ABATACEPT 250 MG IV SOLR,RX-70287,CDM,J0129,HCPCS,636,RC,00003-2187-13,NDC,outpatient,1,UN,3823.57,2676.499,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,49.7570835,,,49.7570835,43.27,2936.50176,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0131,HCPCS,636,RC,67457-0940-10,NDC,outpatient,100,ML,44.93,31.451,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.04,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0131,HCPCS,636,RC,36000-0306-60,NDC,outpatient,100,ML,53.83,37.681,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.04,416.02,other,OPPS APC,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0131,HCPCS,636,RC,67457-0940-10,NDC,outpatient,100,ML,44.93,31.451,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.04,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0131,HCPCS,636,RC,67457-0940-10,NDC,outpatient,100,ML,44.93,31.451,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.04,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0131,HCPCS,636,RC,36000-0306-60,NDC,outpatient,100,ML,53.83,37.681,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.04,416.02,other,OPPS APC,,
ACETYLCYSTEINE 200 MG/ML IV SOLN,RX-38303,CDM,J0132,HCPCS,636,RC,00574-0805-30,NDC,outpatient,30,ML,278.49,194.943,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.57,416.02,,,,
ACETYLCYSTEINE 200 MG/ML IV SOLN,RX-38303,CDM,J0132,HCPCS,636,RC,00574-0805-00,NDC,outpatient,30,ML,278.49,194.943,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.57,416.02,,,,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,55150-0154-10,NDC,outpatient,10,ML,11.47,8.029,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.02,416.02,other,OPPS APC,,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,55150-0155-20,NDC,outpatient,20,ML,19.14,13.398,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.02,416.02,other,OPPS APC,,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-03,NDC,outpatient,10,ML,8.9,6.23,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.02,416.02,other,OPPS APC,,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-10,NDC,outpatient,10,ML,8.9,6.23,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.02,416.02,other,OPPS APC,,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-09,NDC,outpatient,20,ML,18.52,12.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.02,416.02,other,OPPS APC,,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-20,NDC,outpatient,20,ML,18.52,12.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.02,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,40.48,28.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,24.48,17.136,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,40.48,28.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,24.48,17.136,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,40.48,28.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,24.48,17.136,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,40.48,28.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,24.48,17.136,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,40.48,28.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,24.48,17.136,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,40.48,28.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,24.48,17.136,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.0469655,,,0.0469655,0.04,416.02,other,OPPS APC,,
ADALIMUMAB 40 MG/0.8ML SC PSKT,RX-129739,CDM,J0135,HCPCS,636,RC,00074-3799-02,NDC,outpatient,1,UN,9266.62,6486.634,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2101.412877,,,2101.412877,336.23,7116.76416,other,OPPS APC,,
ADALIMUMAB 40 MG/0.8ML SC PNKT,RX-129742,CDM,J0135,HCPCS,636,RC,00074-4339-02,NDC,outpatient,1,UN,9266.62,6486.634,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2101.412877,,,2101.412877,336.23,7116.76416,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,39.59,27.713,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.054984,,,0.054984,0.05,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0136,HCPCS,636,RC,00264-4100-95,NDC,outpatient,100,ML,39.59,27.713,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.054984,,,0.054984,0.05,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,23.59,16.513,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.054984,,,0.054984,0.05,416.02,other,OPPS APC,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,39.59,27.713,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.054984,,,0.054984,0.05,416.02,other,OPPS APC,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,23.59,16.513,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.054984,,,0.054984,0.05,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0136,HCPCS,636,RC,00264-4100-95,NDC,outpatient,100,ML,39.59,27.713,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.054984,,,0.054984,0.05,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,39.59,27.713,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.054984,,,0.054984,0.05,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,23.59,16.513,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.054984,,,0.054984,0.05,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,34.69,24.283,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,18.69,13.083,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,34.69,24.283,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,18.69,13.083,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,34.69,24.283,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,18.69,13.083,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,34.69,24.283,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,18.69,13.083,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,18.69,13.083,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,34.69,24.283,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,34.69,24.283,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,18.69,13.083,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.0607115,,,0.0607115,0.05,416.02,other,OPPS APC,,
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,RX-15330,CDM,J0153,HCPCS,636,RC,16714-0997-01,NDC,outpatient,30,ML,109.72,76.804,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,631.24992,other,OPPS APC,,
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,RX-15330,CDM,J0153,HCPCS,636,RC,55150-0193-01,NDC,outpatient,30,ML,91.83,64.281,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,631.24992,other,OPPS APC,,
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,RX-15330,CDM,J0153,HCPCS,636,RC,67457-0857-30,NDC,outpatient,30,ML,821.94,575.358,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,631.24992,other,OPPS APC,,
ADENOSINE 6 MG/2ML IV SOLN,RX-38703,CDM,J0153,HCPCS,636,RC,67457-0855-00,NDC,outpatient,2,ML,24.68,17.276,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,631.24992,other,OPPS APC,,
ADENOSINE 6 MG/2ML IV SOLN,RX-38703,CDM,J0153,HCPCS,636,RC,67457-0855-02,NDC,outpatient,2,ML,24.68,17.276,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,631.24992,other,OPPS APC,,
EPINEPHRINE 0.15 MG/0.3ML IJ SOAJ,RX-124855,CDM,J0171,HCPCS,636,RC,49502-0101-02,NDC,outpatient,1,UN,616.75,431.725,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.73,960.94464,other,OPPS APC,,
EPINEPHRINE 0.15 MG/0.3ML IJ SOAJ,RX-124855,CDM,J0171,HCPCS,636,RC,49502-0501-02,NDC,outpatient,1,UN,1251.23,875.861,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.73,960.94464,other,OPPS APC,,
EPINEPHRINE 0.15 MG/0.3ML IJ SOAJ,RX-124855,CDM,J0171,HCPCS,636,RC,49502-0101-01,NDC,outpatient,1,UN,616.75,431.725,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.73,960.94464,other,OPPS APC,,
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,00115-1694-49,NDC,outpatient,1,UN,506.88,354.816,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.73,960.94464,other,OPPS APC,,
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,49502-0500-02,NDC,outpatient,1,UN,1251.23,875.861,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.73,960.94464,other,OPPS APC,,
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,00115-1694-30,NDC,outpatient,1,UN,506.88,354.816,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.73,960.94464,other,OPPS APC,,
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,49502-0102-01,NDC,outpatient,1,UN,616.75,431.725,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.73,960.94464,other,OPPS APC,,
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,49502-0102-02,NDC,outpatient,1,UN,616.75,431.725,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.73,960.94464,other,OPPS APC,,
EPINEPHRINE INFUSION PREMIX 1 MG IN 250 ML,RX-4080061,CDM,J0171,HCPCS,636,RC,99999-0001-65,NDC,outpatient,250,ML,83.79,58.653,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.73,960.94464,other,OPPS APC,,
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER,RX-4080099,CDM,J0171,HCPCS,636,RC,42023-0159-01,NDC,outpatient,1,ML,57.57,40.299,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.73,960.94464,other,OPPS APC,,
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER,RX-4080099,CDM,J0171,HCPCS,636,RC,42023-0159-25,NDC,outpatient,1,ML,57.57,40.299,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.73,960.94464,other,OPPS APC,,
EPINEPHRINE HCL 0.1 MG/ML IJ WRAPPER,RX-4080103,CDM,J0171,HCPCS,636,RC,76329-3318-01,NDC,outpatient,10,ML,42.5,29.75,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.73,960.94464,other,OPPS APC,,
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER FOR CODE NARRATOR,RX-4081384,CDM,J0171,HCPCS,636,RC,42023-0159-25,NDC,outpatient,1,ML,57.57,40.299,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.73,960.94464,other,OPPS APC,,
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER FOR CODE NARRATOR,RX-4081384,CDM,J0171,HCPCS,636,RC,42023-0159-01,NDC,outpatient,1,ML,57.57,40.299,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.73,960.94464,other,OPPS APC,,
EPINEPHRINE PF 1 MG/ML IJ SOLN,RX-140555,CDM,J0173,HCPCS,636,RC,54288-0103-01,NDC,outpatient,1,ML,35.98,25.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.3013095,,,2.3013095,1.61,416.02,other,OPPS APC,,
EPINEPHRINE PF 1 MG/ML IJ SOLN,RX-140555,CDM,J0173,HCPCS,636,RC,54288-0103-10,NDC,outpatient,1,ML,35.98,25.186,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.3013095,,,2.3013095,1.61,416.02,other,OPPS APC,,
AGALSIDASE BETA 35 MG IV SOLR,RX-35775,CDM,J0180,HCPCS,636,RC,58468-0040-01,NDC,outpatient,1,UN,20575.06,14402.542,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,256.044451,,,256.044451,215.38,15801.64608,other,OPPS APC,,
AGALSIDASE BETA 5 MG IV SOLR,RX-38494,CDM,J0180,HCPCS,636,RC,58468-0041-01,NDC,outpatient,1,UN,2938.8,2057.16,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,256.044451,,,256.044451,215.38,15801.64608,other,OPPS APC,,
ALGLUCOSIDASE ALFA 50 MG IV SOLR,RX-76353,CDM,J0221,HCPCS,636,RC,58468-0160-01,NDC,outpatient,1,UN,2661.83,1863.281,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,231.3509075,,,231.3509075,194.92,2044.28544,other,OPPS APC,,
REMDESIVIR 100 MG IV SOLR,RX-150611,CDM,J0248,HCPCS,636,RC,61958-2901-02,NDC,outpatient,1,UN,1654.57,1158.199,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7.278507,,,7.278507,5.51,1270.70976,other,OPPS APC,,
ALPHA1-PROTEINASE INHIBITOR 1000 MG/20ML IV SOLN,RX-141646,CDM,J0256,HCPCS,636,RC,13533-0705-01,NDC,outpatient,1,UN,1462.8,1023.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5.6530425,,,5.6530425,4.88,1606.272,other,OPPS APC,,
ALPHA1-PROTEINASE INHIBITOR 1000 MG/20ML IV SOLN,RX-141646,CDM,J0256,HCPCS,636,RC,13533-0705-11,NDC,outpatient,1,UN,1462.8,1023.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5.6530425,,,5.6530425,4.88,1606.272,other,OPPS APC,,
ZEMAIRA 1000 MG IV SOLR,RX-36564,CDM,J0256,HCPCS,636,RC,00053-7201-02,NDC,outpatient,1,UN,2091.5,1464.05,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5.6530425,,,5.6530425,4.88,1606.272,other,OPPS APC,,
ALPROSTADIL 500 MCG/ML IJ SOLN,RX-9001,CDM,J0270,HCPCS,636,RC,00009-3169-01,NDC,outpatient,1,ML,564.52,395.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.98,4260,other,Status Indicator B on TOB 12x or 13x: Research Alt,,
ALPROSTADIL 500 MCG/ML IJ SOLN,RX-9001,CDM,J0270,HCPCS,636,RC,00009-3169-06,NDC,outpatient,1,ML,564.52,395.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.98,4260,other,Status Indicator B on TOB 12x or 13x: Research Alt,,
AMIKACIN SULFATE 500 MG/2ML IJ SOLN,RX-108131,CDM,J0278,HCPCS,636,RC,23155-0290-41,NDC,outpatient,2,ML,17.6,12.32,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.77,416.02,,,,
AMIKACIN SULFATE 500 MG/2ML IJ SOLN,RX-108131,CDM,J0278,HCPCS,636,RC,23155-0290-31,NDC,outpatient,2,ML,17.6,12.32,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.77,416.02,,,,
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5922-16,NDC,outpatient,20,ML,38.54,26.978,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.51,416.02,other,OPPS APC,,
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5921-01,NDC,outpatient,10,ML,61.06,42.742,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.51,416.02,other,OPPS APC,,
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5922-01,NDC,outpatient,20,ML,38.54,26.978,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.51,416.02,other,OPPS APC,,
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5921-16,NDC,outpatient,10,ML,61.06,42.742,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.51,416.02,other,OPPS APC,,
AMIODARONE HCL IN DEXTROSE 900-5 MG/500ML-% IV SOLN,RX-135815,CDM,J0282,HCPCS,636,RC,70092-1005-38,NDC,outpatient,500,ML,218.97,153.279,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.46,416.02,other,OPPS APC,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,00143-9875-01,NDC,outpatient,3,ML,3.58,2.506,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.46,416.02,other,OPPS APC,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,00143-9875-25,NDC,outpatient,3,ML,3.58,2.506,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.46,416.02,other,OPPS APC,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-03,NDC,outpatient,3,ML,9.41,6.587,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.46,416.02,other,OPPS APC,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-09,NDC,outpatient,9,ML,22.43,15.701,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.46,416.02,other,OPPS APC,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-01,NDC,outpatient,3,ML,9.41,6.587,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.46,416.02,other,OPPS APC,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-02,NDC,outpatient,9,ML,22.43,15.701,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.46,416.02,other,OPPS APC,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,67457-0153-03,NDC,outpatient,3,ML,16.55,11.585,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.46,416.02,other,OPPS APC,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,67457-0153-18,NDC,outpatient,18,ML,55.43,38.801,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.46,416.02,other,OPPS APC,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,67457-0153-00,NDC,outpatient,3,ML,16.55,11.585,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.46,416.02,other,OPPS APC,,
AMPHOTERICIN B 50 MG IV SOLR,RX-464,CDM,J0285,HCPCS,636,RC,39822-1055-05,NDC,outpatient,1,UN,155.22,108.654,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,34.84689,416.02,,,,
AMPHOTERICIN B LIPID 5 MG/ML IV SUSP,RX-22981,CDM,J0287,HCPCS,636,RC,57665-0101-41,NDC,outpatient,20,ML,431.74,302.218,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12.749415,,,12.749415,11.13,416.02,other,OPPS APC,,
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,RX-21900,CDM,J0289,HCPCS,636,RC,00469-3051-30,NDC,outpatient,1,UN,1268.66,888.062,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,26.7187875,,,26.7187875,23.33,974.33088,other,OPPS APC,,
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,RX-21900,CDM,J0289,HCPCS,636,RC,62756-0233-01,NDC,outpatient,1,UN,328.95,230.265,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,26.7187875,,,26.7187875,23.33,974.33088,other,OPPS APC,,
AMPICILLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080940,CDM,J0290,HCPCS,636,RC,25021-0136-10,NDC,outpatient,1,UN,10.62,7.434,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,other,OPPS APC,,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,00781-3407-95,NDC,outpatient,1,UN,4.29,3.003,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,other,OPPS APC,,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,65219-0016-01,NDC,outpatient,1,UN,5.52,3.864,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,other,OPPS APC,,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,65219-0016-10,NDC,outpatient,1,UN,5.52,3.864,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,other,OPPS APC,,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,00781-3407-78,NDC,outpatient,1,UN,4.29,3.003,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,other,OPPS APC,,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,67850-0024-00,NDC,outpatient,1,UN,8.62,6.034,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,other,OPPS APC,,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,67850-0024-10,NDC,outpatient,1,UN,8.62,6.034,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,other,OPPS APC,,
AMPICILLIN SODIUM 1 G IJ SOLR,RX-469,CDM,J0290,HCPCS,636,RC,25021-0136-10,NDC,outpatient,1,UN,10.62,7.434,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,other,OPPS APC,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,72485-0422-10,NDC,outpatient,1,UN,18.51,12.957,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,other,OPPS APC,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,44567-0103-10,NDC,outpatient,1,UN,45.23,31.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,other,OPPS APC,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,65219-0020-03,NDC,outpatient,1,UN,32.57,22.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,other,OPPS APC,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,65219-0020-23,NDC,outpatient,1,UN,32.57,22.799,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,other,OPPS APC,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,72485-0422-01,NDC,outpatient,1,UN,18.51,12.957,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,other,OPPS APC,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,25021-0137-20,NDC,outpatient,1,UN,16.54,11.578,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,other,OPPS APC,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,55150-0114-20,NDC,outpatient,1,UN,13.5,9.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,other,OPPS APC,,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,67850-0024-00,NDC,outpatient,1,UN,8.62,6.034,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,other,OPPS APC,,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,65219-0016-10,NDC,outpatient,1,UN,5.52,3.864,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,other,OPPS APC,,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,67850-0024-10,NDC,outpatient,1,UN,8.62,6.034,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,other,OPPS APC,,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,00781-3407-78,NDC,outpatient,1,UN,4.29,3.003,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,other,OPPS APC,,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,65219-0016-01,NDC,outpatient,1,UN,5.52,3.864,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,other,OPPS APC,,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,00781-3407-95,NDC,outpatient,1,UN,4.29,3.003,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,other,OPPS APC,,
AMPICILLIN-SULBACTAM SODIUM 15 (10-5) G IV SOLR,RX-105616,CDM,J0295,HCPCS,636,RC,00049-0024-28,NDC,outpatient,1,UN,84.11,58.877,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.600685,416.02,other,OPPS APC,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IV SOLR,RX-27283,CDM,J0295,HCPCS,636,RC,00409-2987-03,NDC,outpatient,1,UN,24.87,17.409,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.600685,416.02,other,OPPS APC,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IV SOLR,RX-27283,CDM,J0295,HCPCS,636,RC,00409-2987-23,NDC,outpatient,1,UN,24.87,17.409,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.600685,416.02,other,OPPS APC,,
AMPICILLIN-SULBACTAM 3 G 100 ML ADD-VANTAGE BAG,RX-400006,CDM,J0295,HCPCS,636,RC,99999-0003-15,NDC,outpatient,100,ML,43.51,30.457,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.600685,416.02,other,OPPS APC,,
AMPICILLIN-SULBACTAM 3 G 100 ML IVPB BATCHED,RX-4081206,CDM,J0295,HCPCS,636,RC,99999-0003-29,NDC,outpatient,100,ML,29.73,20.811,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.600685,416.02,other,OPPS APC,,
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR,RX-9083,CDM,J0295,HCPCS,636,RC,71288-0031-21,NDC,outpatient,1,UN,21.1,14.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.600685,416.02,other,OPPS APC,,
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR,RX-9083,CDM,J0295,HCPCS,636,RC,71288-0031-20,NDC,outpatient,1,UN,21.1,14.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.600685,416.02,other,OPPS APC,,
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR,RX-9083,CDM,J0295,HCPCS,636,RC,55150-0116-20,NDC,outpatient,1,UN,7.13,4.991,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.600685,416.02,other,OPPS APC,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,70594-0082-02,NDC,outpatient,1,UN,37.01,25.907,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.600685,416.02,other,OPPS APC,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,55150-0117-10,NDC,outpatient,1,UN,13.78,9.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.600685,416.02,other,OPPS APC,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,71288-0032-20,NDC,outpatient,1,UN,33.6,23.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.600685,416.02,other,OPPS APC,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,71288-0032-21,NDC,outpatient,1,UN,33.6,23.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.600685,416.02,other,OPPS APC,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,72485-0417-01,NDC,outpatient,1,UN,18.05,12.635,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.600685,416.02,other,OPPS APC,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,00641-6117-01,NDC,outpatient,1,UN,28.2,19.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.600685,416.02,other,OPPS APC,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,00641-6117-10,NDC,outpatient,1,UN,28.2,19.74,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.600685,416.02,other,OPPS APC,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,25021-0143-30,NDC,outpatient,1,UN,36.19,25.333,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.600685,416.02,other,OPPS APC,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,55150-0117-01,NDC,outpatient,1,UN,13.78,9.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.600685,416.02,other,OPPS APC,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,55150-0117-20,NDC,outpatient,1,UN,13.78,9.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.600685,416.02,other,OPPS APC,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,70594-0082-01,NDC,outpatient,1,UN,37.01,25.907,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.600685,416.02,other,OPPS APC,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,72485-0417-10,NDC,outpatient,1,UN,18.05,12.635,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.600685,416.02,other,OPPS APC,,
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,69374-0920-05,NDC,outpatient,5,ML,14.14,9.898,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.82,416.02,other,OPPS APC,,
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,70004-0910-09,NDC,outpatient,5,ML,31.6,22.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.82,416.02,other,OPPS APC,,
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,70092-1086-44,NDC,outpatient,5,ML,84.42,59.094,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.82,416.02,other,OPPS APC,,
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,70004-0908-09,NDC,outpatient,5,ML,95.5,66.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.82,416.02,other,OPPS APC,,
ANIDULAFUNGIN 100 MG IV SOLR,RX-88093,CDM,J0348,HCPCS,636,RC,00049-0116-28,NDC,outpatient,1,UN,139.38,97.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.46,416.02,,,,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,63323-0614-00,NDC,outpatient,1,ML,14.49,10.143,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.732165,416.02,other,OPPS APC,,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,00641-6231-25,NDC,outpatient,1,ML,12.17,8.519,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.732165,416.02,other,OPPS APC,,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,55150-0400-01,NDC,outpatient,1,ML,14.72,10.304,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.732165,416.02,other,OPPS APC,,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,55150-0400-25,NDC,outpatient,1,ML,14.72,10.304,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.732165,416.02,other,OPPS APC,,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,00641-6231-01,NDC,outpatient,1,ML,12.17,8.519,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.732165,416.02,other,OPPS APC,,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,63323-0614-01,NDC,outpatient,1,ML,14.49,10.143,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.732165,416.02,other,OPPS APC,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,00069-3150-83,NDC,outpatient,1,UN,24.39,17.073,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.834165,416.02,other,OPPS APC,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,55150-0174-10,NDC,outpatient,1,UN,9.22,6.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.834165,416.02,other,OPPS APC,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,63323-0398-01,NDC,outpatient,1,UN,8.17,5.719,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.834165,416.02,other,OPPS APC,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70095-0025-02,NDC,outpatient,1,UN,8.79,6.153,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.834165,416.02,other,OPPS APC,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70436-0019-82,NDC,outpatient,1,UN,12.13,8.491,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.834165,416.02,other,OPPS APC,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70860-0100-10,NDC,outpatient,1,UN,13.9,9.73,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.834165,416.02,other,OPPS APC,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70860-0100-41,NDC,outpatient,1,UN,13.9,9.73,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.834165,416.02,other,OPPS APC,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70095-0025-01,NDC,outpatient,1,UN,8.79,6.153,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.834165,416.02,other,OPPS APC,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,00069-3150-84,NDC,outpatient,1,UN,24.39,17.073,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.834165,416.02,other,OPPS APC,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,63323-0398-10,NDC,outpatient,1,UN,8.17,5.719,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.834165,416.02,other,OPPS APC,,
AZITHROMYCIN 500 MG IN 250 ML NS PREMIX,RX-4080917,CDM,J0456,HCPCS,636,RC,99999-0001-37,NDC,outpatient,255,ML,46.12,32.284,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.834165,416.02,other,OPPS APC,,
AZTREONAM 1 G IJ SOLR 100 MG/ML,RX-4081004,CDM,J0457,HCPCS,636,RC,00409-0829-11,NDC,outpatient,1,UN,98.69,69.083,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC,,
AZTREONAM 1 G IJ SOLR 100 MG/ML,RX-4081004,CDM,J0457,HCPCS,636,RC,00003-2560-16,NDC,outpatient,1,UN,122.23,85.561,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC,,
AZTREONAM 1 G IJ SOLR 100 MG/ML,RX-4081004,CDM,J0457,HCPCS,636,RC,00409-0829-01,NDC,outpatient,1,UN,98.69,69.083,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC,,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,00003-2570-16,NDC,outpatient,1,UN,244.45,171.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC,,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,00409-0830-11,NDC,outpatient,1,UN,201.48,141.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC,,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,63323-0402-01,NDC,outpatient,1,UN,201.48,141.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC,,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,63323-0402-20,NDC,outpatient,1,UN,201.48,141.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC,,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,00409-0830-01,NDC,outpatient,1,UN,201.48,141.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC,,
AZTREONAM 1 G IJ SOLR,RX-9185,CDM,J0457,HCPCS,636,RC,00003-2560-16,NDC,outpatient,1,UN,122.23,85.561,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC,,
AZTREONAM 1 G IJ SOLR,RX-9185,CDM,J0457,HCPCS,636,RC,00409-0829-11,NDC,outpatient,1,UN,98.69,69.083,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC,,
AZTREONAM 1 G IJ SOLR,RX-9185,CDM,J0457,HCPCS,636,RC,00409-0829-01,NDC,outpatient,1,UN,98.69,69.083,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC,,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,00003-2570-16,NDC,outpatient,1,UN,244.45,171.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC,,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,00409-0830-11,NDC,outpatient,1,UN,201.48,141.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC,,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,63323-0402-01,NDC,outpatient,1,UN,201.48,141.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC,,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,63323-0402-20,NDC,outpatient,1,UN,201.48,141.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC,,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,00409-0830-01,NDC,outpatient,1,UN,201.48,141.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.261217,,,2.261217,1.97,416.02,other,OPPS APC,,
ATROPINE SULFATE 0.1 MG/ML IJ SOLN WRAPPER,RX-4080930,CDM,J0461,HCPCS,636,RC,76329-3340-01,NDC,outpatient,10,ML,42.72,29.904,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
ATROPINE SULFATE 0.4 MG/ML IJ SOLN WRAPPER,RX-4080931,CDM,J0461,HCPCS,636,RC,00517-1004-01,NDC,outpatient,1,ML,19.31,13.517,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
ATROPINE SULFATE 0.4 MG/ML IJ SOLN WRAPPER,RX-4080931,CDM,J0461,HCPCS,636,RC,00517-1004-25,NDC,outpatient,1,ML,19.31,13.517,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
ATROPINE SULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4081335,CDM,J0461,HCPCS,636,RC,00517-1001-01,NDC,outpatient,1,ML,30.76,21.532,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
ATROPINE SULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4081335,CDM,J0461,HCPCS,636,RC,00517-1001-25,NDC,outpatient,1,ML,30.76,21.532,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
ATROPINE SULFATE 0.25 MG/5ML IJ SOSY,RX-729,CDM,J0461,HCPCS,636,RC,00409-9630-05,NDC,outpatient,5,ML,87.58,61.306,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
ATROPINE SULFATE 0.25 MG/5ML IJ SOSY,RX-729,CDM,J0461,HCPCS,636,RC,00409-9630-15,NDC,outpatient,5,ML,87.58,61.306,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
BACLOFEN 10000 MCG/20ML IT WRAPPER,RX-4081072,CDM,J0475,HCPCS,636,RC,66794-0155-01,NDC,outpatient,20,ML,794.33,556.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,199.9825355,,,199.9825355,174.58,1359.95136,other,OPPS APC,,
BACLOFEN 20000 MCG/20ML IT WRAPPER,RX-4081073,CDM,J0475,HCPCS,636,RC,66794-0156-02,NDC,outpatient,20,ML,1497.87,1048.509,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,199.9825355,,,199.9825355,174.58,1359.95136,other,OPPS APC,,
BACLOFEN 40000 MCG/20ML IT WRAPPER,RX-4081074,CDM,J0475,HCPCS,636,RC,66794-0157-02,NDC,outpatient,20,ML,1770.77,1239.539,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,199.9825355,,,199.9825355,174.58,1359.95136,other,OPPS APC,,
BACLOFEN 50 MCG/ML IT SOSY,RX-107798,CDM,J0476,HCPCS,636,RC,66794-0151-01,NDC,outpatient,1,ML,326.81,228.767,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,40.38,416.02,other,OPPS APC,,
BELIMUMAB 120 MG IV SOLR,RX-108842,CDM,J0490,HCPCS,636,RC,49401-0101-01,NDC,outpatient,1,UN,1753.47,1227.429,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,62.0276795,,,62.0276795,50.93,4488.66816,other,OPPS APC,,
BELIMUMAB 400 MG IV SOLR,RX-108843,CDM,J0490,HCPCS,636,RC,49401-0102-01,NDC,outpatient,1,UN,5844.62,4091.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,62.0276795,,,62.0276795,50.93,4488.66816,other,OPPS APC,,
DICYCLOMINE HCL 10 MG/ML IM SOLN,RX-2417,CDM,J0500,HCPCS,636,RC,14789-0010-02,NDC,outpatient,2,ML,41.12,28.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.23144,416.02,,,,
DICYCLOMINE HCL 10 MG/ML IM SOLN,RX-2417,CDM,J0500,HCPCS,636,RC,58914-0080-52,NDC,outpatient,2,ML,345.64,241.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.23144,416.02,,,,
DICYCLOMINE HCL 10 MG/ML IM SOLN,RX-2417,CDM,J0500,HCPCS,636,RC,14789-0010-07,NDC,outpatient,2,ML,41.12,28.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.23144,416.02,,,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9233-05,NDC,outpatient,2,ML,97.73,68.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,16.21,416.02,,,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,68382-0860-10,NDC,outpatient,2,ML,102.98,72.086,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,16.21,416.02,,,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9233-01,NDC,outpatient,2,ML,97.73,68.411,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,16.21,416.02,,,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9729-01,NDC,outpatient,2,ML,114.01,79.807,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,16.21,416.02,,,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,68382-0860-02,NDC,outpatient,2,ML,102.98,72.086,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,16.21,416.02,,,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9729-05,NDC,outpatient,2,ML,114.01,79.807,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,16.21,416.02,,,,
PENICILLIN G BENZATHINE & PROC 1200000 UNIT/2ML IM SUSP,RX-108051,CDM,J0558,HCPCS,636,RC,60793-0600-02,NDC,outpatient,2,ML,908.68,636.076,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,22.3635965,,,22.3635965,15.67,697.86624,other,OPPS APC,,
PENICILLIN G BENZATHINE & PROC 1200000 UNIT/2ML IM SUSP,RX-108051,CDM,J0558,HCPCS,636,RC,60793-0600-10,NDC,outpatient,2,ML,908.68,636.076,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,22.3635965,,,22.3635965,15.67,697.86624,other,OPPS APC,,
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SUSY,RX-158171,CDM,J0561,HCPCS,636,RC,60793-0700-10,NDC,outpatient,1,ML,595.58,416.906,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,27.913544,,,27.913544,20.17,1623.552,other,OPPS APC,,
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SUSY,RX-158171,CDM,J0561,HCPCS,636,RC,60793-0700-01,NDC,outpatient,1,ML,595.58,416.906,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,27.913544,,,27.913544,20.17,1623.552,other,OPPS APC,,
PENICILLIN G BENZATHINE 1200000 UNIT/2ML IM SUSY,RX-158172,CDM,J0561,HCPCS,636,RC,60793-0701-10,NDC,outpatient,2,ML,1139.95,797.965,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,27.913544,,,27.913544,20.17,1623.552,other,OPPS APC,,
PENICILLIN G BENZATHINE 1200000 UNIT/2ML IM SUSY,RX-158172,CDM,J0561,HCPCS,636,RC,60793-0701-02,NDC,outpatient,2,ML,1139.95,797.965,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,27.913544,,,27.913544,20.17,1623.552,other,OPPS APC,,
PENICILLIN G BENZATHINE 2400000 UNIT/4ML IM SUSY,RX-162947,CDM,J0561,HCPCS,636,RC,60793-0702-04,NDC,outpatient,4,ML,2114,1479.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,27.913544,,,27.913544,20.17,1623.552,other,OPPS APC,,
PENICILLIN G BENZATHINE 2400000 UNIT/4ML IM SUSY,RX-162947,CDM,J0561,HCPCS,636,RC,60793-0702-10,NDC,outpatient,4,ML,2114,1479.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,27.913544,,,27.913544,20.17,1623.552,other,OPPS APC,,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,16729-0275-03,NDC,outpatient,1,UN,294.51,206.157,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.17,416.02,other,OPPS APC,,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,16729-0275-67,NDC,outpatient,1,UN,294.51,206.157,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.17,416.02,other,OPPS APC,,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,00781-3158-94,NDC,outpatient,1,UN,308.39,215.873,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.17,416.02,other,OPPS APC,,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,55150-0210-10,NDC,outpatient,1,UN,189.45,132.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.17,416.02,other,OPPS APC,,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,00781-3158-95,NDC,outpatient,1,UN,308.39,215.873,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.17,416.02,other,OPPS APC,,
ONABOTULINUMTOXINA 100 UNITS IJ SOLR,RX-100610,CDM,J0585,HCPCS,636,RC,00023-1145-01,NDC,outpatient,1,UN,1749.84,1224.888,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7.338073,,,7.338073,6.15,1343.87712,other,OPPS APC,,
BUPRENORPHINE HCL 0.3 MG/ML IJ SOLN,RX-9320,CDM,J0592,HCPCS,636,RC,42023-0179-05,NDC,outpatient,1,ML,53.16,37.212,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.03,416.02,,,,
BUPRENORPHINE HCL 0.3 MG/ML IJ SOLN,RX-9320,CDM,J0592,HCPCS,636,RC,42023-0179-01,NDC,outpatient,1,ML,53.16,37.212,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.03,416.02,,,,
BUTORPHANOL TARTRATE 2 MG/ML IJ SOLN,RX-9334,CDM,J0595,HCPCS,636,RC,00409-1626-21,NDC,outpatient,1,ML,29.94,20.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.06,416.02,other,OPPS APC,,
BUTORPHANOL TARTRATE 2 MG/ML IJ SOLN,RX-9334,CDM,J0595,HCPCS,636,RC,00409-1626-01,NDC,outpatient,1,ML,29.94,20.958,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.06,416.02,other,OPPS APC,,
EDETATE CALCIUM DISODIUM 1 GM/5ML IJ SOLN,RX-108094,CDM,J0600,HCPCS,250,RC,64980-0588-05,NDC,outpatient,5,ML,16465.83,11526.081,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6971.878415,,,6971.878415,60.43,12645.75744,other,OPPS APC,,
EDETATE CALCIUM DISODIUM 1 GM/5ML IJ SOLN,RX-108094,CDM,J0600,HCPCS,250,RC,64980-0588-51,NDC,outpatient,5,ML,16465.83,11526.081,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6971.878415,,,6971.878415,60.43,12645.75744,other,OPPS APC,,
CALCIUM GLUCONATE 10 % IV SOLN,RX-1312,CDM,J0612,HCPCS,636,RC,63323-0360-19,NDC,outpatient,10,ML,36.54,25.578,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0446745,,,0.0446745,0.04,416.02,other,OPPS APC,,
CALCIUM GLUCONATE 10 % IV SOLN,RX-1312,CDM,J0612,HCPCS,636,RC,63323-0360-01,NDC,outpatient,10,ML,36.54,25.578,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0446745,,,0.0446745,0.04,416.02,other,OPPS APC,,
CALCIUM GLUCONATE-NACL 1-0.8 GM/100ML-% IV SOLN,RX-156703,CDM,J0613,HCPCS,636,RC,44567-0622-24,NDC,outpatient,100,ML,37.38,26.166,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.100804,,,0.100804,0.08,416.02,other,OPPS APC,,
CALCIUM GLUCONATE-NACL 1-0.8 GM/100ML-% IV SOLN,RX-156703,CDM,J0613,HCPCS,636,RC,44567-0622-01,NDC,outpatient,100,ML,37.38,26.166,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.100804,,,0.100804,0.08,416.02,other,OPPS APC,,
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-01,NDC,outpatient,100,ML,53.38,37.366,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.100804,,,0.100804,0.08,416.02,other,OPPS APC,,
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-24,NDC,outpatient,100,ML,53.38,37.366,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.100804,,,0.100804,0.08,416.02,other,OPPS APC,,
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-24,NDC,outpatient,100,ML,37.38,26.166,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.100804,,,0.100804,0.08,416.02,other,OPPS APC,,
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-01,NDC,outpatient,100,ML,37.38,26.166,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.100804,,,0.100804,0.08,416.02,other,OPPS APC,,
CALCITONIN (SALMON) 200 UNIT/ML IJ SOLN,RX-9347,CDM,J0630,HCPCS,636,RC,67457-0675-02,NDC,outpatient,2,ML,2806.57,1964.599,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1343.739085,,,1343.739085,399.86,2155.44576,other,OPPS APC,,
CALCITONIN (SALMON) 200 UNIT/ML IJ SOLN,RX-9347,CDM,J0630,HCPCS,636,RC,42023-0205-01,NDC,outpatient,2,ML,2193.21,1535.247,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1343.739085,,,1343.739085,399.86,2155.44576,other,OPPS APC,,
LEUCOVORIN CALCIUM IM INJECTION,RX-4080923,CDM,J0640,HCPCS,636,RC,25021-0813-10,NDC,outpatient,50,ME,16.97,11.879,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.68951,416.02,other,OPPS APC,,
LEUCOVORIN CALCIUM 350 MG IJ SOLR,RX-4393,CDM,J0640,HCPCS,636,RC,00143-9552-01,NDC,outpatient,1,UN,106.72,74.704,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.68951,416.02,other,OPPS APC,,
LEUCOVORIN CALCIUM 50 MG IJ SOLR,RX-4394,CDM,J0640,HCPCS,636,RC,25021-0813-10,NDC,outpatient,50,ME,11.98,8.386,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.68951,416.02,other,OPPS APC,,
LEVOTHYROXINE SODIUM 100 MCG IV SOLR,RX-113060,CDM,J0651,HCPCS,250,RC,63323-0885-10,NDC,outpatient,5,ML,293.44,205.408,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4.2921885,,,4.2921885,4.2921885,416.02,other,OPPS APC,,
LEVOTHYROXINE SODIUM 100 MCG IV SOLR,RX-113060,CDM,J0651,HCPCS,250,RC,63323-0649-07,NDC,outpatient,1,UN,279.46,195.622,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4.2921885,,,4.2921885,4.2921885,416.02,other,OPPS APC,,
LEVOTHYROXINE SODIUM 100 MCG IV SOLR,RX-113060,CDM,J0651,HCPCS,250,RC,63323-0885-12,NDC,outpatient,5,ML,293.44,205.408,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4.2921885,,,4.2921885,4.2921885,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-18,NDC,outpatient,10,ML,8.79,6.153,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1559-19,NDC,outpatient,30,ML,19.59,13.713,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00143-9330-01,NDC,outpatient,10,ML,7.82,5.474,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00143-9330-10,NDC,outpatient,10,ML,7.82,5.474,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-01,NDC,outpatient,10,ML,8.79,6.153,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,55150-0167-10,NDC,outpatient,10,ML,10.85,7.595,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,55150-0168-30,NDC,outpatient,30,ML,11.11,7.777,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,63323-0464-01,NDC,outpatient,10,ML,6.48,4.536,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,63323-0464-17,NDC,outpatient,10,ML,6.48,4.536,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-02,NDC,outpatient,30,ML,8.79,6.153,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-19,NDC,outpatient,30,ML,8.79,6.153,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1559-30,NDC,outpatient,30,ML,19.59,13.713,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,63323-0466-01,NDC,outpatient,30,ML,9.57,6.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1560-18,NDC,outpatient,10,ML,19.43,13.601,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,63323-0466-37,NDC,outpatient,30,ML,9.57,6.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1162-01,NDC,outpatient,10,ML,10.08,7.056,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1162-02,NDC,outpatient,30,ML,9.72,6.804,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1560-19,NDC,outpatient,30,ML,17.89,12.523,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,55150-0170-30,NDC,outpatient,30,ML,12.34,8.638,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,00409-1165-19,NDC,outpatient,30,ML,16.97,11.879,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,00409-1165-02,NDC,outpatient,30,ML,16.97,11.879,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,63323-0472-01,NDC,outpatient,30,ML,12.8,8.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,63323-0472-37,NDC,outpatient,30,ML,12.8,8.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL 0.25 % IJ SOLN,RX-1222,CDM,J0665,HCPCS,636,RC,63323-0465-01,NDC,outpatient,5,ML,5.5,3.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL 0.25 % IJ SOLN,RX-1222,CDM,J0665,HCPCS,636,RC,63323-0465-57,NDC,outpatient,5,ML,5.5,3.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL 0.5 % IJ SOLN,RX-1223,CDM,J0665,HCPCS,636,RC,00409-1163-18,NDC,outpatient,5,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE HCL 0.5 % IJ SOLN,RX-1223,CDM,J0665,HCPCS,636,RC,00409-1163-01,NDC,outpatient,5,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE IN DEXTROSE 0.75-8.25 % IT SOLN,RX-9316,CDM,J0665,HCPCS,636,RC,00409-1761-18,NDC,outpatient,2,ML,20.36,14.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
BUPIVACAINE IN DEXTROSE 0.75-8.25 % IT SOLN,RX-9316,CDM,J0665,HCPCS,636,RC,00409-1761-10,NDC,outpatient,2,ML,20.36,14.252,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.0126005,,,0.0126005,0.01,416.02,other,OPPS APC,,
MEPIVACAINE HCL (PF) 2 % IJ SOLN,RX-105638,CDM,J0670,HCPCS,636,RC,63323-0294-27,NDC,outpatient,20,ML,27.95,19.565,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.08,416.02,other,OPPS APC,,
MEPIVACAINE HCL (PF) 2 % IJ SOLN,RX-105638,CDM,J0670,HCPCS,636,RC,63323-0294-01,NDC,outpatient,20,ML,27.95,19.565,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.08,416.02,other,OPPS APC,,
CEFAZOLIN IVPB 2 G IN 100 ML D4W PREMIX,RX-4080727,CDM,J0689,HCPCS,636,RC,00338-3508-41,NDC,outpatient,100,ML,42.74,29.918,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.44333,,,1.44333,1.22,416.02,other,OPPS APC,,
CEFAZOLIN IVPB 2 G IN 100 ML D4W PREMIX|DISCARDED DRUG NOT ADMINISTERED,RX-4080727,CDM,J0689,HCPCS,636,RC,00338-3508-41,NDC,outpatient,100,ML,26.74,18.718,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,1.44333,,,1.44333,1.22,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,25021-0101-10,NDC,outpatient,1,UN,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,00143-9924-90,NDC,outpatient,1,UN,5.85,4.095,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,44567-0707-25,NDC,outpatient,1,UN,7.84,5.488,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,60505-6142-00,NDC,outpatient,1,UN,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,60505-6142-05,NDC,outpatient,1,UN,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 10 G IJ SOLR,RX-1446,CDM,J0690,HCPCS,636,RC,00143-9983-03,NDC,outpatient,1,UN,40.9,28.63,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 10 G IJ SOLR,RX-1446,CDM,J0690,HCPCS,636,RC,00143-9983-91,NDC,outpatient,1,UN,40.9,28.63,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 500 MG IJ SOLR,RX-1448,CDM,J0690,HCPCS,636,RC,44567-0706-25,NDC,outpatient,1,UN,4.28,2.996,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 2 G IJ SOLR,RX-158156,CDM,J0690,HCPCS,636,RC,60505-6231-05,NDC,outpatient,1,UN,18.74,13.118,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 2 G IJ SOLR,RX-158156,CDM,J0690,HCPCS,636,RC,60505-6231-00,NDC,outpatient,1,UN,18.74,13.118,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 1 G IV SOLR ADD-VANTAGE,RX-27297,CDM,J0690,HCPCS,636,RC,00409-2585-01,NDC,outpatient,1,UN,12.17,8.519,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 1 G IV SOLR ADD-VANTAGE,RX-27297,CDM,J0690,HCPCS,636,RC,00409-2585-11,NDC,outpatient,1,UN,12.17,8.519,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,25021-0101-10,NDC,outpatient,1,UN,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,00143-9924-90,NDC,outpatient,1,UN,5.85,4.095,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,60505-6142-00,NDC,outpatient,1,UN,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,60505-6142-05,NDC,outpatient,1,UN,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,44567-0707-25,NDC,outpatient,1,UN,7.84,5.488,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,44567-0707-25,NDC,outpatient,1,UN,7.84,5.488,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,25021-0101-10,NDC,outpatient,1,UN,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,60505-6142-00,NDC,outpatient,1,UN,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,60505-6142-05,NDC,outpatient,1,UN,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,00143-9924-90,NDC,outpatient,1,UN,5.85,4.095,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC,,
CEFAZOLIN SODIUM 1 G 100 ML ADD-VANTAGE BAG,RX-4081138,CDM,J0690,HCPCS,636,RC,99999-0003-01,NDC,outpatient,100,ML,32.9,23.03,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC,,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,00409-9566-01,NDC,outpatient,1,UN,16.63,11.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,44567-0240-10,NDC,outpatient,1,UN,23.44,16.408,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,60505-6146-00,NDC,outpatient,1,UN,12,8.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,00409-9566-10,NDC,outpatient,1,UN,16.63,11.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,25021-0121-20,NDC,outpatient,1,UN,17.97,12.579,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,60505-6146-04,NDC,outpatient,1,UN,12,8.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,00409-9735-10,NDC,outpatient,1,UN,25.5,17.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,70594-0090-02,NDC,outpatient,1,UN,40.3,28.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,00409-9735-01,NDC,outpatient,1,UN,25.5,17.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,25021-0122-50,NDC,outpatient,1,UN,32.22,22.554,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,60505-6246-04,NDC,outpatient,1,UN,19.47,13.629,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,70594-0090-01,NDC,outpatient,1,UN,40.3,28.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,44567-0241-10,NDC,outpatient,1,UN,40.3,28.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,60505-6246-00,NDC,outpatient,1,UN,19.47,13.629,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME IVPB 1 G IN 100 ML NS COMPOUNDED,RX-4080828,CDM,J0692,HCPCS,636,RC,99999-0001-09,NDC,outpatient,100,ML,48.93,34.251,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,60505-6147-04,NDC,outpatient,1,UN,19.47,13.629,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,70594-0090-01,NDC,outpatient,1,UN,40.3,28.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,00409-9735-01,NDC,outpatient,1,UN,25.5,17.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,00409-9735-10,NDC,outpatient,1,UN,25.5,17.85,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,60505-6147-00,NDC,outpatient,1,UN,34.31,24.017,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,70594-0090-02,NDC,outpatient,1,UN,40.3,28.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,44567-0241-10,NDC,outpatient,1,UN,40.3,28.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,25021-0121-20,NDC,outpatient,1,UN,17.97,12.579,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,00409-9566-01,NDC,outpatient,1,UN,16.63,11.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,44567-0240-10,NDC,outpatient,1,UN,23.44,16.408,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,60505-6146-04,NDC,outpatient,1,UN,12,8.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,00409-9566-10,NDC,outpatient,1,UN,16.63,11.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC,,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,60505-6146-00,NDC,outpatient,1,UN,12,8.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.22,416.02,other,OPPS APC,,
CEFOXITIN SODIUM-DEXTROSE 2-2.2 GM-%(50ML) IV SOLR,RX-144407,CDM,J0694,HCPCS,636,RC,00264-3125-11,NDC,outpatient,1,UN,147.33,103.131,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.679555,416.02,other,OPPS APC,,
CEFOXITIN IVPB 2 G IN 100 ML NS COMPOUNDED,RX-4080864,CDM,J0694,HCPCS,636,RC,99999-0001-16,NDC,outpatient,100,ML,46.14,32.298,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.679555,416.02,other,OPPS APC,,
CEFOXITIN SODIUM 1 G IV SOLR 1000 MG/10.5 ML,RX-4080998,CDM,J0694,HCPCS,636,RC,25021-0109-10,NDC,outpatient,1,UN,16.39,11.473,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.679555,416.02,other,OPPS APC,,
CEFOXITIN SODIUM 1 G IV SOLR 1000 MG/10.5 ML,RX-4080998,CDM,J0694,HCPCS,636,RC,44567-0245-25,NDC,outpatient,1,UN,40.92,28.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.679555,416.02,other,OPPS APC,,
CEFOXITIN SODIUM 2 G IV SOLR 2000 MG/11.1 ML,RX-4081009,CDM,J0694,HCPCS,636,RC,25021-0110-20,NDC,outpatient,1,UN,30.34,21.238,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.679555,416.02,other,OPPS APC,,
CEFOXITIN SODIUM 2 G IV SOLR 2000 MG/11.1 ML,RX-4081009,CDM,J0694,HCPCS,636,RC,44567-0246-25,NDC,outpatient,1,UN,82.04,57.428,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.679555,416.02,other,OPPS APC,,
CEFOXITIN SODIUM 1 G IV SOLR,RX-9461,CDM,J0694,HCPCS,636,RC,25021-0109-10,NDC,outpatient,1,UN,16.39,11.473,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.679555,416.02,other,OPPS APC,,
CEFOXITIN SODIUM 1 G IV SOLR,RX-9461,CDM,J0694,HCPCS,636,RC,44567-0245-25,NDC,outpatient,1,UN,40.92,28.644,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.679555,416.02,other,OPPS APC,,
CEFOXITIN SODIUM 2 G IV SOLR,RX-9463,CDM,J0694,HCPCS,636,RC,25021-0110-20,NDC,outpatient,1,UN,30.34,21.238,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.679555,416.02,other,OPPS APC,,
CEFOXITIN SODIUM 2 G IV SOLR,RX-9463,CDM,J0694,HCPCS,636,RC,44567-0246-25,NDC,outpatient,1,UN,82.04,57.428,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.679555,416.02,other,OPPS APC,,
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G IV SOLR,RX-129169,CDM,J0695,HCPCS,636,RC,67919-0030-01,NDC,outpatient,1,UN,652.32,456.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9.427465,,,9.427465,7.54,500.98176,other,OPPS APC,,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00781-3208-95,NDC,outpatient,1,UN,17.99,12.593,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,25021-0106-10,NDC,outpatient,1,UN,9.22,6.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,44567-0701-25,NDC,outpatient,1,UN,4.75,3.325,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00143-9857-01,NDC,outpatient,1,UN,5.23,3.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00143-9857-25,NDC,outpatient,1,UN,5.23,3.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00781-3208-85,NDC,outpatient,1,UN,17.99,12.593,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00143-9856-01,NDC,outpatient,1,UN,9.12,6.384,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00143-9856-25,NDC,outpatient,1,UN,9.12,6.384,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,44567-0702-25,NDC,outpatient,1,UN,9.03,6.321,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00781-3209-90,NDC,outpatient,1,UN,11.14,7.798,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00781-3209-95,NDC,outpatient,1,UN,11.14,7.798,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,25021-0107-20,NDC,outpatient,1,UN,18.72,13.104,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00143-9857-01,NDC,outpatient,1,UN,5.23,3.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00143-9857-25,NDC,outpatient,1,UN,5.23,3.661,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00409-7332-01,NDC,outpatient,1,UN,6.94,4.858,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00409-7332-11,NDC,outpatient,1,UN,6.94,4.858,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00781-3208-95,NDC,outpatient,1,UN,17.99,12.593,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,25021-0106-10,NDC,outpatient,1,UN,9.22,6.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00781-3208-85,NDC,outpatient,1,UN,17.99,12.593,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,44567-0701-25,NDC,outpatient,1,UN,4.75,3.325,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00781-3209-95,NDC,outpatient,1,UN,11.14,7.798,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00781-3209-90,NDC,outpatient,1,UN,11.14,7.798,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00143-9856-01,NDC,outpatient,1,UN,9.12,6.384,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00143-9856-25,NDC,outpatient,1,UN,9.12,6.384,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,25021-0107-20,NDC,outpatient,1,UN,18.72,13.104,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,44567-0702-25,NDC,outpatient,1,UN,9.03,6.321,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00143-9859-25,NDC,outpatient,1,UN,4.32,3.024,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00409-7337-11,NDC,outpatient,1,UN,3.47,2.429,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00781-3206-85,NDC,outpatient,1,UN,6.33,4.431,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00143-9859-01,NDC,outpatient,1,UN,4.32,3.024,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00409-7337-01,NDC,outpatient,1,UN,3.47,2.429,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC,,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00781-3206-95,NDC,outpatient,1,UN,6.33,4.431,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,other,OPPS APC,,
CEFUROXIME SODIUM 750 MG IJ SOLR,RX-1465,CDM,J0697,HCPCS,636,RC,00143-9979-90,NDC,outpatient,1,UN,12.5,8.75,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.88,416.02,,,,
CEFUROXIME SODIUM 750 MG IJ SOLR,RX-1465,CDM,J0697,HCPCS,636,RC,00143-9979-22,NDC,outpatient,1,UN,12.5,8.75,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.88,416.02,,,,
CEFUROXIME SODIUM 750 MG IJ SOLR,RX-1465,CDM,J0697,HCPCS,636,RC,25021-0118-10,NDC,outpatient,1,UN,9.6,6.72,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.88,416.02,,,,
CEFUROXIME SODIUM 1.5 G IV SOLR,RX-27299,CDM,J0697,HCPCS,636,RC,00143-9977-22,NDC,outpatient,1,UN,21.64,15.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.88,416.02,,,,
CEFUROXIME SODIUM 1.5 G IV SOLR,RX-27299,CDM,J0697,HCPCS,636,RC,00143-9977-90,NDC,outpatient,1,UN,21.64,15.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.88,416.02,,,,
CEFUROXIME SODIUM 750 MG IJ SOLR 750 MG/8.3 ML,RX-4080994,CDM,J0697,HCPCS,636,RC,25021-0118-10,NDC,outpatient,1,UN,9.6,6.72,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.88,416.02,,,,
CEFUROXIME SODIUM 750 MG IJ SOLR 750 MG/8.3 ML,RX-4080994,CDM,J0697,HCPCS,636,RC,00143-9979-90,NDC,outpatient,1,UN,12.5,8.75,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.88,416.02,,,,
CEFUROXIME SODIUM 750 MG IJ SOLR 750 MG/8.3 ML,RX-4080994,CDM,J0697,HCPCS,636,RC,00143-9979-22,NDC,outpatient,1,UN,12.5,8.75,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.88,416.02,,,,
CEFUROXIME SODIUM 1.5 G IJ SOLR IN 16 ML,RX-4081008,CDM,J0697,HCPCS,636,RC,00143-9977-22,NDC,outpatient,1,UN,21.64,15.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.88,416.02,,,,
CEFUROXIME SODIUM 1.5 G IJ SOLR IN 16 ML,RX-4081008,CDM,J0697,HCPCS,636,RC,00143-9977-90,NDC,outpatient,1,UN,21.64,15.148,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.88,416.02,,,,
BETAMETHASONE SOD PHOS & ACET 6 (3-3) MG/ML IJ SUSP,RX-9266,CDM,J0702,HCPCS,636,RC,78206-0118-01,NDC,outpatient,5,ML,170.75,119.525,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,6.96,416.02,other,OPPS APC,,
BETAMETHASONE SOD PHOS & ACET 6 (3-3) MG/ML IJ SUSP,RX-9266,CDM,J0702,HCPCS,636,RC,00517-0720-01,NDC,outpatient,5,ML,143.92,100.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,6.96,416.02,other,OPPS APC,,
CAFFEINE CITRATE 60 MG/3ML IV SOLN,RX-109034,CDM,J0706,HCPCS,636,RC,51754-0500-01,NDC,outpatient,3,ML,26.75,18.725,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.65,416.02,,,,
CEFTAROLINE FOSAMIL 400 MG IV SOLR,RX-107670,CDM,J0712,HCPCS,636,RC,00456-0400-10,NDC,outpatient,1,UN,806.58,564.606,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4.5075425,,,4.5075425,3.89,619.45344,other,OPPS APC,,
CEFTAROLINE FOSAMIL 400 MG IV SOLR,RX-107670,CDM,J0712,HCPCS,636,RC,00456-0400-01,NDC,outpatient,1,UN,806.58,564.606,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4.5075425,,,4.5075425,3.89,619.45344,other,OPPS APC,,
CEFTAROLINE FOSAMIL 600 MG IV SOLR,RX-107671,CDM,J0712,HCPCS,636,RC,00456-0600-01,NDC,outpatient,1,UN,806.58,564.606,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4.5075425,,,4.5075425,3.89,619.45344,other,OPPS APC,,
CEFTAROLINE FOSAMIL 600 MG IV SOLR,RX-107671,CDM,J0712,HCPCS,636,RC,00456-0600-10,NDC,outpatient,1,UN,806.58,564.606,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4.5075425,,,4.5075425,3.89,619.45344,other,OPPS APC,,
CEFTAZIDIME 2 G IV SOLR,RX-27291,CDM,J0713,HCPCS,636,RC,25021-0128-50,NDC,outpatient,1,UN,37.01,25.907,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.66,416.02,other,OPPS APC,,
CEFTAZIDIME 2 G IV SOLR,RX-27291,CDM,J0713,HCPCS,636,RC,44567-0236-10,NDC,outpatient,1,UN,23.52,16.464,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.66,416.02,other,OPPS APC,,
CEFTAZIDIME 1 MG/ML IJ SOLR,RX-4080666,CDM,J0713,HCPCS,636,RC,00409-5082-16,NDC,outpatient,1,UN,14.25,9.975,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.66,416.02,other,OPPS APC,,
CEFTAZIDIME 1 G IJ SOLR 1000 MG/10.8 ML,RX-4081001,CDM,J0713,HCPCS,636,RC,00409-5082-16,NDC,outpatient,1,UN,14.25,9.975,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.66,416.02,other,OPPS APC,,
CEFTAZIDIME 2 G IJ SOLR 2000 MG/11.5 ML,RX-4081002,CDM,J0713,HCPCS,636,RC,25021-0128-50,NDC,outpatient,1,UN,37.01,25.907,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.66,416.02,other,OPPS APC,,
CEFTAZIDIME 1 G IJ SOLR,RX-9474,CDM,J0713,HCPCS,636,RC,00409-5082-16,NDC,outpatient,1,UN,14.25,9.975,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.66,416.02,other,OPPS APC,,
CEFTAZIDIME 1 G IJ SOLR,RX-9474,CDM,J0713,HCPCS,636,RC,44567-0235-25,NDC,outpatient,1,UN,13.87,9.709,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.66,416.02,other,OPPS APC,,
CEFTAZIDIME 1 G IJ SOLR,RX-9474,CDM,J0713,HCPCS,636,RC,00409-5082-11,NDC,outpatient,1,UN,14.25,9.975,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.66,416.02,other,OPPS APC,,
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G IV SOLR,RX-130403,CDM,J0714,HCPCS,636,RC,00456-2700-01,NDC,outpatient,1,UN,1625.76,1138.032,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,115.216681,,,115.216681,92.48,1248.58368,other,OPPS APC,,
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G IV SOLR,RX-130403,CDM,J0714,HCPCS,636,RC,00456-2700-10,NDC,outpatient,1,UN,1625.76,1138.032,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,115.216681,,,115.216681,92.48,1248.58368,other,OPPS APC,,
CLONIDINE HCL (ANALGESIA) 100 MCG/ML EP SOLN,RX-19333,CDM,J0735,HCPCS,636,RC,67457-0218-10,NDC,outpatient,10,ML,45.22,31.654,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.15189,416.02,other,OPPS APC,,
CLONIDINE HCL (ANALGESIA) 500 MCG/ML EP SOLN,RX-27113,CDM,J0735,HCPCS,636,RC,39822-2010-01,NDC,outpatient,10,ML,402.95,282.065,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.15189,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE 150 MG/ML IJ WRAPPER,RX-4080195,CDM,J0736,HCPCS,636,RC,00009-0775-26,NDC,outpatient,4,ML,13.99,9.793,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.8236575,,,2.8236575,1.61,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE 150 MG/ML IJ WRAPPER,RX-4080195,CDM,J0736,HCPCS,636,RC,00009-0775-20,NDC,outpatient,4,ML,13.99,9.793,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.8236575,,,2.8236575,1.61,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0736,HCPCS,636,RC,00781-3288-91,NDC,outpatient,50,ML,48.27,33.789,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.8236575,,,2.8236575,1.61,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0736,HCPCS,636,RC,00781-3288-09,NDC,outpatient,50,ML,48.27,33.789,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.8236575,,,2.8236575,1.61,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-09,NDC,outpatient,50,ML,64.73,45.311,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.8236575,,,2.8236575,1.61,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-91,NDC,outpatient,50,ML,64.73,45.311,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.8236575,,,2.8236575,1.61,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-09,NDC,outpatient,50,ML,48.73,34.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,2.8236575,,,2.8236575,1.61,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-91,NDC,outpatient,50,ML,48.73,34.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,2.8236575,,,2.8236575,1.61,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0737,HCPCS,636,RC,00338-3410-24,NDC,outpatient,50,ML,30.91,21.637,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0737,HCPCS,636,RC,00338-3410-50,NDC,outpatient,50,ML,30.91,21.637,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-24,NDC,outpatient,50,ML,18.25,12.775,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-50,NDC,outpatient,50,ML,18.25,12.775,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-24,NDC,outpatient,50,ML,18.25,12.775,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-50,NDC,outpatient,50,ML,18.25,12.775,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-24,NDC,outpatient,50,ML,34.25,23.975,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-50,NDC,outpatient,50,ML,34.25,23.975,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-50,NDC,outpatient,50,ML,34.25,23.975,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-24,NDC,outpatient,50,ML,34.25,23.975,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-24,NDC,outpatient,50,ML,38.7,27.09,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-50,NDC,outpatient,50,ML,38.7,27.09,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-24,NDC,outpatient,50,ML,22.7,15.89,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC,,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-50,NDC,outpatient,50,ML,22.7,15.89,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,3.2245825,,,3.2245825,2.59,416.02,other,OPPS APC,,
IMIPENEM-CILASTATIN 250 MG IV SOLR,RX-9602,CDM,J0743,HCPCS,636,RC,63323-0349-25,NDC,outpatient,1,UN,25.58,17.906,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,5.74271,416.02,,,,
IMIPENEM-CILASTATIN 500 MG IV SOLR,RX-9603,CDM,J0743,HCPCS,636,RC,63323-0322-01,NDC,outpatient,1,UN,43.92,30.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,5.74271,416.02,,,,
IMIPENEM-CILASTATIN 500 MG IV SOLR,RX-9603,CDM,J0743,HCPCS,636,RC,63323-0322-25,NDC,outpatient,1,UN,43.92,30.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,5.74271,416.02,,,,
CIPROFLOXACIN IN D5W 200 MG/100ML IV SOLN,RX-108130,CDM,J0744,HCPCS,636,RC,00409-2300-24,NDC,outpatient,100,ML,26.8,18.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.86,416.02,other,OPPS APC,,
CIPROFLOXACIN IN D5W 200 MG/100ML IV SOLN,RX-108130,CDM,J0744,HCPCS,636,RC,00409-2300-01,NDC,outpatient,100,ML,26.8,18.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.86,416.02,other,OPPS APC,,
CIPROFLOXACIN IN D5W 400 MG/200ML IV SOLN,RX-108132,CDM,J0744,HCPCS,636,RC,25021-0114-87,NDC,outpatient,200,ML,42.7,29.89,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.86,416.02,other,OPPS APC,,
COLISTIMETHATE SODIUM (CBA) 150 MG IJ SOLR,RX-142413,CDM,J0770,HCPCS,636,RC,70594-0023-04,NDC,outpatient,1,UN,46.34,32.438,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.40333,416.02,,,,
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,00713-0351-02,NDC,outpatient,2,ML,13.73,9.611,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.01,416.02,other,OPPS APC,,
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,00713-0351-09,NDC,outpatient,2,ML,15.66,10.962,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.01,416.02,other,OPPS APC,,
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,00713-0351-25,NDC,outpatient,2,ML,13.73,9.611,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.01,416.02,other,OPPS APC,,
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,14789-0700-02,NDC,outpatient,2,ML,14.97,10.479,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.01,416.02,other,OPPS APC,,
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,14789-0700-07,NDC,outpatient,2,ML,14.97,10.479,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.01,416.02,other,OPPS APC,,
COSYNTROPIN 0.25 MG IJ SOLR,RX-9686,CDM,J0834,HCPCS,636,RC,00781-3440-71,NDC,outpatient,1,UN,356.89,249.823,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,16.61749,416.02,other,OPPS APC,,
COSYNTROPIN 0.25 MG IJ SOLR,RX-9686,CDM,J0834,HCPCS,636,RC,00781-3440-95,NDC,outpatient,1,UN,356.89,249.823,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,16.61749,416.02,other,OPPS APC,,
COSYNTROPIN 0.25 MG IJ SOLR,RX-9686,CDM,J0834,HCPCS,636,RC,00548-5900-00,NDC,outpatient,1,UN,74.02,51.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,16.61749,416.02,other,OPPS APC,,
DAPTOMYCIN 500 MG IV SOLR,RX-36989,CDM,J0873,HCPCS,636,RC,70594-0034-01,NDC,outpatient,1,UN,65.78,46.046,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.04,416.02,other,OPPS APC,,
DALBAVANCIN HCL 500 MG IV SOLR,RX-125774,CDM,J0875,HCPCS,636,RC,57970-0100-01,NDC,outpatient,1,UN,2550.24,1785.168,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,17.883546,,,17.883546,14.7,4668.927562,other,OPPS APC,,
DAPTOMYCIN 350 MG IV SOLR,RX-143414,CDM,J0878,HCPCS,636,RC,16729-0434-45,NDC,outpatient,1,UN,201.59,141.113,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.03,416.02,other,OPPS APC,,
DAPTOMYCIN 350 MG IV SOLR,RX-143414,CDM,J0878,HCPCS,636,RC,16729-0434-05,NDC,outpatient,1,UN,201.5,141.05,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.03,416.02,other,OPPS APC,,
DAPTOMYCIN 500 MG IV SOLR,RX-36989,CDM,J0878,HCPCS,636,RC,00143-9378-01,NDC,outpatient,1,UN,57.59,40.313,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.03,416.02,other,OPPS APC,,
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0883,HCPCS,636,RC,00143-9559-01,NDC,outpatient,50,ML,438.53,306.971,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.4398935,,,1.4398935,1.35,1059.84,other,OPPS APC,,
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0883,HCPCS,636,RC,25021-0414-50,NDC,outpatient,50,ML,333.29,233.303,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.4398935,,,1.4398935,1.35,1059.84,other,OPPS APC,,
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0883,HCPCS,636,RC,00143-9559-01,NDC,outpatient,50,ML,422.53,295.771,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,1.4398935,,,1.4398935,1.35,1059.84,other,OPPS APC,,
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0883,HCPCS,636,RC,16729-0430-43,NDC,outpatient,50,ML,358.65,251.055,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.4398935,,,1.4398935,1.35,1059.84,other,OPPS APC,,
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0883,HCPCS,636,RC,25021-0414-50,NDC,outpatient,50,ML,317.29,222.103,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,1.4398935,,,1.4398935,1.35,1059.84,other,OPPS APC,,
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0883,HCPCS,636,RC,16729-0430-43,NDC,outpatient,50,ML,342.65,239.855,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,1.4398935,,,1.4398935,1.35,1059.84,other,OPPS APC,,
ARGATROBAN 250 MG/2.5ML IV SOLN,RX-28947,CDM,J0883,HCPCS,636,RC,00143-9674-01,NDC,outpatient,2.5,ML,1380,966,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.4398935,,,1.4398935,1.35,1059.84,other,OPPS APC,,
ARGATROBAN 250 MG/2.5ML IV SOLN,RX-28947,CDM,J0883,HCPCS,636,RC,63323-0526-03,NDC,outpatient,2.5,ML,1328.82,930.174,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.4398935,,,1.4398935,1.35,1059.84,other,OPPS APC,,
ARGATROBAN 250 MG/2.5ML IV SOLN,RX-28947,CDM,J0883,HCPCS,636,RC,00409-1140-01,NDC,outpatient,2.5,ML,226.15,158.305,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.4398935,,,1.4398935,1.35,1059.84,other,OPPS APC,,
EPOETIN ALFA 10000 UNIT/ML IJ SOLN,RX-9938,CDM,J0885,HCPCS,636,RC,59676-0310-00,NDC,outpatient,1,ML,622.94,436.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8.623324,,,8.623324,6.88,478.41792,other,OPPS APC,,
EPOETIN ALFA 10000 UNIT/ML IJ SOLN,RX-9938,CDM,J0885,HCPCS,636,RC,59676-0310-01,NDC,outpatient,1,ML,622.94,436.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8.623324,,,8.623324,6.88,478.41792,other,OPPS APC,,
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,59676-0304-01,NDC,outpatient,1,ML,456.83,319.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8.623324,,,8.623324,6.88,478.41792,other,OPPS APC,,
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,55513-0148-10,NDC,outpatient,1,ML,283.41,198.387,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8.623324,,,8.623324,6.88,478.41792,other,OPPS APC,,
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,59676-0304-00,NDC,outpatient,1,ML,456.83,319.781,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8.623324,,,8.623324,6.88,478.41792,other,OPPS APC,,
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,55513-0148-01,NDC,outpatient,1,ML,283.41,198.387,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8.623324,,,8.623324,6.88,478.41792,other,OPPS APC,,
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0891,HCPCS,636,RC,16729-0430-11,NDC,outpatient,50,ML,342.65,239.855,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,4.808809,,,4.808809,0.46,416.02,other,OPPS APC,,
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0891,HCPCS,636,RC,16729-0430-11,NDC,outpatient,50,ML,358.65,251.055,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4.808809,,,4.808809,0.46,416.02,other,OPPS APC,,
DECITABINE 50 MG IV SOLR,RX-76364,CDM,J0894,HCPCS,636,RC,16729-0224-05,NDC,outpatient,1,UN,335.38,234.766,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.63,416.02,other,OPPS APC,,
DEFEROXAMINE MESYLATE 500 MG IJ SOLR,RX-9723,CDM,J0895,HCPCS,636,RC,60505-6236-00,NDC,outpatient,1,UN,46.34,32.438,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,6.78,416.02,,,,
DEFEROXAMINE MESYLATE 500 MG IJ SOLR,RX-9723,CDM,J0895,HCPCS,636,RC,60505-6236-06,NDC,outpatient,1,UN,46.34,32.438,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,6.78,416.02,,,,
DENOSUMAB 120 MG/1.7ML SC SOLN,RX-106804,CDM,J0897,HCPCS,636,RC,55513-0730-01,NDC,outpatient,1.7,ML,8861.12,6202.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,30.88268,,,30.88268,24.19,6805.34016,other,OPPS APC,,
DENOSUMAB 60 MG/ML SC SOSY,RX-146195,CDM,J0897,HCPCS,636,RC,55513-0710-01,NDC,outpatient,1,ML,4649.31,3254.517,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,30.88268,,,30.88268,24.19,6805.34016,other,OPPS APC,,
TESTOSTERONE CYPIONATE 200 MG/ML IM SOLN,RX-7784,CDM,J1071,HCPCS,636,RC,00009-0417-01,NDC,outpatient,1,ML,41.92,29.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.03,416.02,,,,
DEXAMETHASONE SOD PHOSPHATE PF 10 MG/ML IJ SOLN,RX-116345,CDM,J1100,HCPCS,636,RC,99999-0003-18,NDC,outpatient,1,ML,8.17,5.719,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.11,416.02,other,OPPS APC,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,67457-0423-00,NDC,outpatient,1,ML,3.69,2.583,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.11,416.02,other,OPPS APC,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,63323-0165-01,NDC,outpatient,1,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.11,416.02,other,OPPS APC,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,67457-0423-12,NDC,outpatient,1,ML,3.69,2.583,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.11,416.02,other,OPPS APC,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,63323-0165-02,NDC,outpatient,1,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.11,416.02,other,OPPS APC,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,00641-6145-01,NDC,outpatient,1,ML,4.14,2.898,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.11,416.02,other,OPPS APC,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,00641-6145-25,NDC,outpatient,1,ML,4.14,2.898,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.11,416.02,other,OPPS APC,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,55150-0237-01,NDC,outpatient,1,ML,4.01,2.807,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.11,416.02,other,OPPS APC,,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,70069-0021-01,NDC,outpatient,1,ML,8.17,5.719,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.11,416.02,other,OPPS APC,,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,00641-0367-21,NDC,outpatient,1,ML,6.11,4.277,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.11,416.02,other,OPPS APC,,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,63323-0506-01,NDC,outpatient,1,ML,6.99,4.893,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.11,416.02,other,OPPS APC,,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,00641-0367-25,NDC,outpatient,1,ML,6.11,4.277,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.11,416.02,other,OPPS APC,,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,70069-0021-25,NDC,outpatient,1,ML,8.17,5.719,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.11,416.02,other,OPPS APC,,
DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN,RX-9859,CDM,J1110,HCPCS,636,RC,81284-0411-00,NDC,outpatient,1,ML,179.49,125.643,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,40.295505,416.02,,,,
DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN,RX-9859,CDM,J1110,HCPCS,636,RC,81284-0411-10,NDC,outpatient,1,ML,179.49,125.643,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,40.295505,416.02,,,,
DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN,RX-9859,CDM,J1110,HCPCS,636,RC,81284-0411-05,NDC,outpatient,1,ML,220.97,154.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,40.295505,416.02,,,,
ACETAZOLAMIDE SODIUM 500 MG IJ SOLR,RX-114,CDM,J1120,HCPCS,636,RC,00143-9503-01,NDC,outpatient,1,UN,178.94,125.258,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.29108,416.02,other,OPPS APC,,
ACETAZOLAMIDE SODIUM 500 MG IJ SOLR,RX-114,CDM,J1120,HCPCS,636,RC,23155-0313-31,NDC,outpatient,1,UN,45.84,32.088,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.29108,416.02,other,OPPS APC,,
ACETAZOLAMIDE SODIUM 500 MG IJ SOLR,RX-114,CDM,J1120,HCPCS,636,RC,67457-0853-50,NDC,outpatient,1,UN,164.43,115.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.29108,416.02,other,OPPS APC,,
DIGOXIN 0.25 MG/ML IJ SOLN,RX-2442,CDM,J1160,HCPCS,636,RC,00641-1410-31,NDC,outpatient,2,ML,14.62,10.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.28219,416.02,other,OPPS APC,,
DIGOXIN 0.25 MG/ML IJ SOLN,RX-2442,CDM,J1160,HCPCS,636,RC,00641-1410-35,NDC,outpatient,2,ML,14.62,10.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.28219,416.02,other,OPPS APC,,
DIGOXIN 0.1 MG/ML IJ SOLN,RX-9853,CDM,J1160,HCPCS,636,RC,70515-0263-10,NDC,outpatient,1,ML,449.39,314.573,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.28219,416.02,other,OPPS APC,,
DIGOXIN IMMUNE FAB 40 MG IV SOLR,RX-31432,CDM,J1162,HCPCS,636,RC,50633-0120-11,NDC,outpatient,1,UN,12197.8,8538.46,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5599.323132,,,5599.323132,399.86,9367.9104,other,OPPS APC,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-30,NDC,outpatient,5,ML,10.7,7.49,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,,,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,00641-0493-21,NDC,outpatient,2,ML,5.82,4.074,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,,,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-10,NDC,outpatient,2,ML,10.45,7.315,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,,,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,00641-0493-25,NDC,outpatient,2,ML,5.82,4.074,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,,,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-05,NDC,outpatient,5,ML,10.7,7.49,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,,,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-02,NDC,outpatient,2,ML,10.45,7.315,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.44,416.02,,,,
DEXRAZOXANE HCL 500 MG IV SOLR,RX-146172,CDM,J1190,HCPCS,636,RC,51991-0942-98,NDC,outpatient,1,UN,575.66,402.962,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,100.224377,,,100.224377,87.49,442.10688,other,OPPS APC,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-00,NDC,outpatient,1,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,00641-0376-25,NDC,outpatient,1,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,72485-0101-01,NDC,outpatient,1,ML,4.75,3.325,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,72485-0101-25,NDC,outpatient,1,ML,4.75,3.325,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-01,NDC,outpatient,1,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-41,NDC,outpatient,1,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,00641-0376-21,NDC,outpatient,1,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-16,NDC,outpatient,1,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC,,
CHLOROTHIAZIDE SODIUM 500 MG IV SOLR,RX-9526,CDM,J1205,HCPCS,636,RC,25021-0305-20,NDC,outpatient,1,UN,139.6,97.72,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,31.3402,416.02,,,,
DIMETHYL SULFOXIDE 50 % IS SOLN,RX-9873,CDM,J1212,HCPCS,636,RC,67457-0177-50,NDC,outpatient,50,ML,1852.55,1296.785,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,820.0645955,,,820.0645955,399.86,1422.7584,other,OPPS APC,,
METHADONE HCL 10 MG/ML IJ SOLN,RX-10546,CDM,J1230,HCPCS,636,RC,67457-0217-20,NDC,outpatient,20,ML,869.71,608.797,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.763505,945.2928,,,,
METHADONE HCL 10 MG/ML IJ SOLN,RX-10546,CDM,J1230,HCPCS,636,RC,99999-0000-89,NDC,outpatient,1,ML,43.49,30.443,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.763505,945.2928,,,,
METHADONE 10 MG/ML PCA,RX-4080162,CDM,J1230,HCPCS,636,RC,99999-0000-13,NDC,outpatient,50,ML,1230.85,861.595,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.763505,945.2928,,,,
METHADONE 1 MG/ML IV INFUSION PREMIX,RX-4080178,CDM,J1230,HCPCS,636,RC,99999-0000-27,NDC,outpatient,200,ML,874.19,611.933,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.763505,945.2928,,,,
DIPYRIDAMOLE 5 MG/ML IV SOLN,RX-9891,CDM,J1245,HCPCS,636,RC,00641-2569-41,NDC,outpatient,10,ML,75.79,53.053,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.78,416.02,,,,
DIPYRIDAMOLE 5 MG/ML IV SOLN,RX-9891,CDM,J1245,HCPCS,636,RC,00641-2569-44,NDC,outpatient,10,ML,75.79,53.053,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.78,416.02,,,,
DOBUTAMINE-DEXTROSE 1-5 MG/ML-% IV SOLN,RX-18314,CDM,J1250,HCPCS,636,RC,00338-1073-02,NDC,outpatient,250,ML,38.25,26.775,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.15774,416.02,other,OPPS APC,,
DOBUTAMINE-DEXTROSE 1-5 MG/ML-% IV SOLN,RX-18314,CDM,J1250,HCPCS,636,RC,00409-2346-32,NDC,outpatient,250,ML,52.72,36.904,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.15774,416.02,other,OPPS APC,,
DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN,RX-18315,CDM,J1250,HCPCS,636,RC,00409-2347-31,NDC,outpatient,250,ML,72.74,50.918,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.15774,416.02,other,OPPS APC,,
DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN,RX-18315,CDM,J1250,HCPCS,636,RC,00409-2347-32,NDC,outpatient,250,ML,72.74,50.918,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.15774,416.02,other,OPPS APC,,
DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN,RX-18315,CDM,J1250,HCPCS,636,RC,00338-1075-02,NDC,outpatient,250,ML,52.72,36.904,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.15774,416.02,other,OPPS APC,,
DOBUTAMINE 50 MG IN D5W 50 ML SYRINGE FROM PREMIX BAG (NEO/PED),RX-4081532,CDM,J1250,HCPCS,636,RC,99999-0004-34,NDC,outpatient,50,ML,24.49,17.143,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.15774,416.02,other,OPPS APC,,
DOBUTAMINE HCL 250 MG/20ML IV SOLN,RX-77318,CDM,J1250,HCPCS,636,RC,00143-9141-01,NDC,outpatient,20,ML,18.52,12.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.15774,416.02,other,OPPS APC,,
DOBUTAMINE HCL 250 MG/20ML IV SOLN,RX-77318,CDM,J1250,HCPCS,636,RC,00409-2344-01,NDC,outpatient,20,ML,27.59,19.313,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.15774,416.02,other,OPPS APC,,
DOBUTAMINE HCL 250 MG/20ML IV SOLN,RX-77318,CDM,J1250,HCPCS,636,RC,00143-9141-10,NDC,outpatient,20,ML,18.52,12.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.15774,416.02,other,OPPS APC,,
DOPAMINE-DEXTROSE 0.8-5 MG/ML-% IV SOLN,RX-14844,CDM,J1265,HCPCS,636,RC,00338-1005-02,NDC,outpatient,250,ML,41.59,29.113,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.7,416.02,,,,
DOPAMINE-DEXTROSE 1.6-5 MG/ML-% IV SOLN,RX-14845,CDM,J1265,HCPCS,636,RC,00409-7809-22,NDC,outpatient,250,ML,50.49,35.343,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.7,416.02,,,,
DOPAMINE-DEXTROSE 1.6-5 MG/ML-% IV SOLN,RX-14845,CDM,J1265,HCPCS,636,RC,00338-1007-02,NDC,outpatient,250,ML,48.27,33.789,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.7,416.02,,,,
DOPAMINE-DEXTROSE 1.6-5 MG/ML-% IV SOLN,RX-14845,CDM,J1265,HCPCS,636,RC,00409-7809-11,NDC,outpatient,250,ML,50.49,35.343,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.7,416.02,,,,
DOPAMINE HCL 40 MG/ML IV SOLN,RX-2595,CDM,J1265,HCPCS,636,RC,00409-9104-21,NDC,outpatient,10,ML,13.16,9.212,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.7,416.02,,,,
DOPAMINE HCL 40 MG/ML IV SOLN,RX-2595,CDM,J1265,HCPCS,636,RC,00409-9104-20,NDC,outpatient,10,ML,13.16,9.212,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.7,416.02,,,,
DOPAMINE 40 MG IN D5W 50 ML SYRINGE FROM PREMIX BAG (NEO/PED),RX-4081531,CDM,J1265,HCPCS,636,RC,99999-0004-33,NDC,outpatient,50,ML,21.92,15.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.7,416.02,,,,
ECULIZUMAB 300 MG/30ML IV SOLN,RX-81696,CDM,J1300,HCPCS,636,RC,25682-0001-01,NDC,outpatient,30,ML,18003.46,12602.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,257.3171015,,,257.3171015,224.63,13826.65728,other,OPPS APC,,
VELETRI 1.5 MG IV SOLR,RX-106514,CDM,J1325,HCPCS,636,RC,66215-0402-01,NDC,outpatient,1,UN,260.55,182.385,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,15.86,416.02,,,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00143-9398-01,NDC,outpatient,1,UN,100.74,70.518,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,42023-0221-01,NDC,outpatient,1,UN,95.49,66.843,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,60505-6196-00,NDC,outpatient,1,UN,127.17,89.019,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00143-9398-10,NDC,outpatient,1,UN,100.74,70.518,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00409-3510-22,NDC,outpatient,1,UN,135.69,94.983,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00409-3510-21,NDC,outpatient,1,UN,135.69,94.983,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,16714-0889-10,NDC,outpatient,1,UN,129.15,90.405,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,42023-0221-10,NDC,outpatient,1,UN,95.49,66.843,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,55150-0282-20,NDC,outpatient,1,UN,111.68,78.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,60505-6196-04,NDC,outpatient,1,UN,127.17,89.019,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,16714-0889-01,NDC,outpatient,1,UN,129.15,90.405,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00143-9398-10,NDC,outpatient,1,UN,100.74,70.518,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,55150-0282-20,NDC,outpatient,1,UN,111.68,78.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,42023-0221-01,NDC,outpatient,1,UN,95.49,66.843,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,42023-0221-10,NDC,outpatient,1,UN,95.49,66.843,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,60505-6196-00,NDC,outpatient,1,UN,127.17,89.019,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00409-3510-22,NDC,outpatient,1,UN,135.69,94.983,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,16714-0889-01,NDC,outpatient,1,UN,129.15,90.405,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00143-9398-01,NDC,outpatient,1,UN,100.74,70.518,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00409-3510-21,NDC,outpatient,1,UN,135.69,94.983,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,16714-0889-10,NDC,outpatient,1,UN,129.15,90.405,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,60505-6196-04,NDC,outpatient,1,UN,127.17,89.019,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.42,416.02,other,OPPS APC,,
ERYTHROMYCIN LACTOBIONATE 500 MG IV SOLR,RX-2903,CDM,J1364,HCPCS,636,RC,00409-6482-01,NDC,outpatient,1,UN,236.03,165.221,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,74.8916445,,,74.8916445,52.988735,416.02,other,OPPS APC,,
ERYTHROMYCIN LACTOBIONATE 500 MG IV SOLR,RX-2903,CDM,J1364,HCPCS,636,RC,00409-6482-11,NDC,outpatient,1,UN,236.03,165.221,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,74.8916445,,,74.8916445,52.988735,416.02,other,OPPS APC,,
ESTROGENS CONJUGATED 25 MG IJ SOLR,RX-9972,CDM,J1410,HCPCS,636,RC,00046-0749-05,NDC,outpatient,1,UN,1513.36,1059.352,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,438.481363,,,438.481363,339.74932,1162.26048,other,OPPS APC,,
FERRIC CARBOXYMALTOSE 750 MG/15ML IV SOLN,RX-122648,CDM,J1439,HCPCS,636,RC,00517-0650-01,NDC,outpatient,15,ML,2478.29,1734.803,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.2611955,,,1.2611955,1.1,1903.32672,other,OPPS APC,,
FLUCONAZOLE IN SODIUM CHLORIDE 200-0.9 MG/100ML-% IV SOLN,RX-10049,CDM,J1450,HCPCS,636,RC,25021-0184-82,NDC,outpatient,100,ML,36.03,25.221,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.61,416.02,other,OPPS APC,,
FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN,RX-10050,CDM,J1450,HCPCS,636,RC,00409-4688-16,NDC,outpatient,200,ML,35.54,24.878,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.61,416.02,other,OPPS APC,,
FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN,RX-10050,CDM,J1450,HCPCS,636,RC,00409-4688-12,NDC,outpatient,200,ML,35.54,24.878,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.61,416.02,other,OPPS APC,,
FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN,RX-10050,CDM,J1450,HCPCS,636,RC,69784-0003-06,NDC,outpatient,200,ML,35.58,24.906,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.61,416.02,other,OPPS APC,,
FLUCONAZOLE IVPB,RX-4080630,CDM,J1450,HCPCS,636,RC,99999-0001-23,NDC,outpatient,50,ML,23.46,16.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.61,416.02,other,OPPS APC,,
FOMEPIZOLE 1 GM/ML IV SOLN,RX-22185,CDM,J1451,HCPCS,636,RC,70710-1478-01,NDC,outpatient,1.5,ML,2014.79,1410.353,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7.3781655,,,7.3781655,7.3781655,1590,other,OPPS APC,,
FOMEPIZOLE 1 GM/ML IV SOLN,RX-22185,CDM,J1451,HCPCS,636,RC,67457-0211-02,NDC,outpatient,1.5,ML,1680.9,1176.63,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7.3781655,,,7.3781655,7.3781655,1590,other,OPPS APC,,
FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR,RX-106783,CDM,J1453,HCPCS,636,RC,00006-3061-00,NDC,outpatient,1,UN,1375.94,963.158,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.14,1056.72192,other,OPPS APC,,
FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR,RX-106783,CDM,J1453,HCPCS,636,RC,00006-3061-01,NDC,outpatient,1,UN,1375.94,963.158,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.14,1056.72192,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0437-10,NDC,outpatient,100,ML,2692.38,1884.666,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,55.6472445,,,55.6472445,47.99,8270.99136,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0439-93,NDC,outpatient,400,ML,10769.52,7538.664,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,55.6472445,,,55.6472445,47.99,8270.99136,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0436-05,NDC,outpatient,100,ML,2692.38,1884.666,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,55.6472445,,,55.6472445,47.99,8270.99136,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0438-20,NDC,outpatient,200,ML,5384.76,3769.332,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,55.6472445,,,55.6472445,47.99,8270.99136,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0436-90,NDC,outpatient,100,ML,2692.38,1884.666,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,55.6472445,,,55.6472445,47.99,8270.99136,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0437-91,NDC,outpatient,100,ML,2692.38,1884.666,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,55.6472445,,,55.6472445,47.99,8270.99136,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0439-40,NDC,outpatient,400,ML,10769.52,7538.664,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,55.6472445,,,55.6472445,47.99,8270.99136,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) IM INJ,RX-15342,CDM,J1460,HCPCS,636,RC,13533-0335-04,NDC,outpatient,2,ML,422.8,295.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,57.105466,,,57.105466,48.47,416.02,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) IM INJ,RX-15342,CDM,J1460,HCPCS,636,RC,13533-0335-40,NDC,outpatient,2,ML,422.8,295.96,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,57.105466,,,57.105466,48.47,416.02,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-25,NDC,outpatient,200,ML,4199.62,2939.734,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,55.9061275,,,55.9061275,48.81,6450.61632,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-40,NDC,outpatient,400,ML,8399.24,5879.468,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,55.9061275,,,55.9061275,48.81,6450.61632,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-24,NDC,outpatient,200,ML,4199.62,2939.734,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,55.9061275,,,55.9061275,48.81,6450.61632,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-72,NDC,outpatient,100,ML,2099.81,1469.867,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,55.9061275,,,55.9061275,48.81,6450.61632,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-20,NDC,outpatient,100,ML,2099.81,1469.867,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,55.9061275,,,55.9061275,48.81,6450.61632,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-41,NDC,outpatient,400,ML,8399.24,5879.468,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,55.9061275,,,55.9061275,48.81,6450.61632,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-71,NDC,outpatient,100,ML,2099.81,1469.867,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,55.9061275,,,55.9061275,48.81,6450.61632,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-21,NDC,outpatient,100,ML,2099.81,1469.867,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,55.9061275,,,55.9061275,48.81,6450.61632,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD S/D  5 % IGA <=2.2,RX-4080223,CDM,J1566,HCPCS,636,RC,00944-2620-03,NDC,outpatient,5,GR,934.5,654.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,94.150936,,,94.150936,77.77,1531.4,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD S/D  5 % IGA <= 1,RX-4080224,CDM,J1566,HCPCS,636,RC,00944-2656-03,NDC,outpatient,5,GR,577.48,404.236,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,94.150936,,,94.150936,77.77,1531.4,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD S/D  5 % IGA <= 1,RX-4080224,CDM,J1566,HCPCS,636,RC,00944-2658-04,NDC,outpatient,10,GR,1154.96,808.472,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,94.150936,,,94.150936,77.77,1531.4,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) OCTAGAM 5 % IV SOLN,RX-4080225,CDM,J1568,HCPCS,636,RC,68209-0843-03,NDC,outpatient,200,ML,1884.53,1319.171,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,56.1237725,,,56.1237725,44.12,1447.31904,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) OCTAGAM 5 % IV SOLN,RX-4080225,CDM,J1568,HCPCS,636,RC,68209-0843-04,NDC,outpatient,200,ML,1884.53,1319.171,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,56.1237725,,,56.1237725,44.12,1447.31904,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-04,NDC,outpatient,100,ML,2726.33,1908.431,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-06,NDC,outpatient,200,ML,5452.66,3816.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-09,NDC,outpatient,100,ML,2726.33,1908.431,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-11,NDC,outpatient,100,ML,2726.33,1908.431,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-02,NDC,outpatient,100,ML,2726.33,1908.431,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-05,NDC,outpatient,100,ML,2726.33,1908.431,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-08,NDC,outpatient,100,ML,2726.33,1908.431,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-12,NDC,outpatient,200,ML,5452.66,3816.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-03,NDC,outpatient,100,ML,2726.33,1908.431,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-07,NDC,outpatient,300,ML,8178.99,5725.293,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-10,NDC,outpatient,100,ML,2726.33,1908.431,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-13,NDC,outpatient,300,ML,8178.99,5725.293,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,56.922186,,,56.922186,46.03,6281.46432,other,OPPS APC,,
GANCICLOVIR SODIUM 500 MG IV SOLR,RX-10101,CDM,J1570,HCPCS,636,RC,70436-0089-55,NDC,outpatient,1,UN,165.87,116.109,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,36.41,416.02,,,,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-08,NDC,outpatient,200,ML,2125.2,1487.64,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,64.280878,,,64.280878,48.52,3264.3072,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-03,NDC,outpatient,200,ML,2125.2,1487.64,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,64.280878,,,64.280878,48.52,3264.3072,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-04,NDC,outpatient,200,ML,2125.2,1487.64,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,64.280878,,,64.280878,48.52,3264.3072,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-05,NDC,outpatient,400,ML,4250.4,2975.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,64.280878,,,64.280878,48.52,3264.3072,other,OPPS APC,,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-00,NDC,outpatient,400,ML,4250.4,2975.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,64.280878,,,64.280878,48.52,3264.3072,other,OPPS APC,,
GENTAMICIN 80 MG IN NS 50 ML IV SOLN PREMIX,RX-15911,CDM,J1580,HCPCS,636,RC,00338-0509-41,NDC,outpatient,50,ML,25,17.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.23924,416.02,other,OPPS APC,,
GENTAMICIN 80 MG IN NS 50 ML IV SOLN PREMIX,RX-15911,CDM,J1580,HCPCS,636,RC,99999-0002-93,NDC,outpatient,50,ML,25.25,17.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.23924,416.02,other,OPPS APC,,
GENTAMICIN SULFATE 10 MG/ML IJ SOLN,RX-3425,CDM,J1580,HCPCS,636,RC,63323-0173-02,NDC,outpatient,2,ML,9.88,6.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.23924,416.02,other,OPPS APC,,
GENTAMICIN SULFATE 10 MG/ML IJ SOLN,RX-3425,CDM,J1580,HCPCS,636,RC,63323-0173-01,NDC,outpatient,2,ML,9.88,6.916,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.23924,416.02,other,OPPS APC,,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-20,NDC,outpatient,20,ML,102.62,71.834,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.23924,416.02,other,OPPS APC,,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,00409-1207-13,NDC,outpatient,2,ML,12.55,8.785,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.23924,416.02,other,OPPS APC,,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-01,NDC,outpatient,2,ML,5.52,3.864,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.23924,416.02,other,OPPS APC,,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-02,NDC,outpatient,2,ML,5.52,3.864,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.23924,416.02,other,OPPS APC,,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-03,NDC,outpatient,20,ML,102.62,71.834,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.23924,416.02,other,OPPS APC,,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,00409-1207-03,NDC,outpatient,2,ML,12.55,8.785,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.23924,416.02,other,OPPS APC,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,00143-9682-25,NDC,outpatient,1,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.51,416.02,other,OPPS APC,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,00517-4601-25,NDC,outpatient,1,ML,7.56,5.292,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.51,416.02,other,OPPS APC,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,70121-1394-05,NDC,outpatient,1,ML,17.13,11.991,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.51,416.02,other,OPPS APC,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,00143-9682-01,NDC,outpatient,1,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.51,416.02,other,OPPS APC,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,70121-1394-01,NDC,outpatient,1,ML,17.13,11.991,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.51,416.02,other,OPPS APC,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,71288-0414-03,NDC,outpatient,1,ML,4.37,3.059,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.51,416.02,other,OPPS APC,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,16714-0536-01,NDC,outpatient,1,ML,5.69,3.983,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.51,416.02,other,OPPS APC,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,16714-0536-25,NDC,outpatient,1,ML,5.69,3.983,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.51,416.02,other,OPPS APC,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,71288-0414-01,NDC,outpatient,1,ML,4.37,3.059,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.51,416.02,other,OPPS APC,,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00597-0053-01,NDC,outpatient,1,UN,403.75,282.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,220.2830865,,,220.2830865,90.641875,579.456,other,OPPS APC,,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00597-0053-45,NDC,outpatient,1,UN,403.75,282.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,220.2830865,,,220.2830865,90.641875,579.456,other,OPPS APC,,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00548-5850-00,NDC,outpatient,1,UN,754.5,528.15,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,220.2830865,,,220.2830865,90.641875,579.456,other,OPPS APC,,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00597-0260-10,NDC,outpatient,1,UN,403.75,282.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,220.2830865,,,220.2830865,90.641875,579.456,other,OPPS APC,,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1611,HCPCS,636,RC,63323-0596-11,NDC,outpatient,1,UN,610.61,427.427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,124.7735875,,,124.7735875,101.41,468.94848,other,OPPS APC,,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1611,HCPCS,636,RC,63323-0593-03,NDC,outpatient,1,UN,610.59,427.413,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,124.7735875,,,124.7735875,101.41,468.94848,other,OPPS APC,,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1611,HCPCS,636,RC,63323-0596-13,NDC,outpatient,1,UN,610.61,427.427,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,124.7735875,,,124.7735875,101.41,468.94848,other,OPPS APC,,
GRANISETRON HCL 1 MG/ML IV SOLN,RX-12552,CDM,J1626,HCPCS,636,RC,00143-9744-10,NDC,outpatient,1,ML,11.46,8.022,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.28,416.02,,,,
GRANISETRON HCL 1 MG/ML IV SOLN,RX-12552,CDM,J1626,HCPCS,636,RC,00143-9744-01,NDC,outpatient,1,ML,11.46,8.022,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.28,416.02,,,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,00143-9501-01,NDC,outpatient,1,ML,7.22,5.054,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,76045-0737-01,NDC,outpatient,1,ML,15.64,10.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,63323-0474-01,NDC,outpatient,1,ML,3.76,2.632,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,76045-0737-10,NDC,outpatient,1,ML,15.64,10.948,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,67457-0426-12,NDC,outpatient,1,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,00143-9501-25,NDC,outpatient,1,ML,7.22,5.054,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,63323-0474-00,NDC,outpatient,1,ML,3.76,2.632,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,67457-0426-00,NDC,outpatient,1,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC,,
HEPARIN LOCK FLUSH 100 UNIT/ML IV SOLN WRAPPER,RX-4080200,CDM,J1642,HCPCS,636,RC,08290-3064-24,NDC,outpatient,5,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.02,416.02,other,OPPS APC,,
HEPARIN LOCK FLUSH 100 UNIT/ML IV SOLN WRAPPER,RX-4080200,CDM,J1642,HCPCS,636,RC,64253-0333-35,NDC,outpatient,5,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.02,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,25021-0400-01,NDC,outpatient,1,ML,5.04,3.528,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0276-01,NDC,outpatient,2,ML,21.8,15.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-15,NDC,outpatient,10,ML,18.71,13.097,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-33,NDC,outpatient,30,ML,21.77,15.239,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-36,NDC,outpatient,30,ML,21.77,15.239,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0920-11,NDC,outpatient,1,ML,3.83,2.681,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0385-99,NDC,outpatient,10,ML,19.64,13.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,71288-0400-02,NDC,outpatient,2,ML,19.86,13.902,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0276-02,NDC,outpatient,2,ML,21.8,15.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,00409-2720-31,NDC,outpatient,10,ML,15.99,11.193,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0920-25,NDC,outpatient,1,ML,3.83,2.681,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0931-14,NDC,outpatient,10,ML,10.28,7.196,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0931-28,NDC,outpatient,10,ML,10.28,7.196,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0372-99,NDC,outpatient,1,ML,13.11,9.177,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0385-10,NDC,outpatient,10,ML,19.64,13.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,71288-0400-03,NDC,outpatient,2,ML,19.86,13.902,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,00409-2720-02,NDC,outpatient,10,ML,15.99,11.193,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,25021-0400-10,NDC,outpatient,10,ML,16.81,11.767,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-05,NDC,outpatient,10,ML,18.71,13.097,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0372-12,NDC,outpatient,1,ML,13.11,9.177,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 20000 UNIT/ML IJ SOLN,RX-10178,CDM,J1644,HCPCS,636,RC,63739-0986-11,NDC,outpatient,1,ML,33.86,23.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 20000 UNIT/ML IJ SOLN,RX-10178,CDM,J1644,HCPCS,636,RC,63739-0986-25,NDC,outpatient,1,ML,33.86,23.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,00409-2723-31,NDC,outpatient,1,ML,3.99,2.793,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,63739-0953-25,NDC,outpatient,1,ML,6.36,4.452,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,00409-2723-02,NDC,outpatient,1,ML,3.99,2.793,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,71288-0403-01,NDC,outpatient,1,ML,3.33,2.331,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,71288-0403-02,NDC,outpatient,1,ML,3.33,2.331,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,63739-0953-11,NDC,outpatient,1,ML,6.36,4.452,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN (PORCINE) IN NACL 25000-0.45 UT/250ML-% IV SOLN,RX-135728,CDM,J1644,HCPCS,636,RC,00409-7650-52,NDC,outpatient,250,ML,63.84,44.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN (PORCINE) IN NACL 25000-0.45 UT/250ML-% IV SOLN,RX-135728,CDM,J1644,HCPCS,636,RC,00409-7650-62,NDC,outpatient,250,ML,63.84,44.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SOD (PORCINE) IN D5W 100 UNIT/ML IV SOLN,RX-24329,CDM,J1644,HCPCS,636,RC,00264-9587-20,NDC,outpatient,250,ML,77.19,54.033,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SOD (PORCINE) IN D5W 100 UNIT/ML IV SOLN,RX-24329,CDM,J1644,HCPCS,636,RC,63323-0523-74,NDC,outpatient,250,ML,44.93,31.451,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SOD (PORCINE) IN D5W 100 UNIT/ML IV SOLN,RX-24329,CDM,J1644,HCPCS,636,RC,63323-0523-01,NDC,outpatient,250,ML,44.93,31.451,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SOD (PORCINE) PREMIX 30000 UNITS IN 1L NS,RX-4080227,CDM,J1644,HCPCS,636,RC,70092-1281-08,NDC,outpatient,1000,ML,120.09,84.063,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN SOD (PORCINE) PREMIX 30000 UNITS IN 1L NS,RX-4080227,CDM,J1644,HCPCS,636,RC,99999-0921-33,NDC,outpatient,1000,ML,91.43,64.001,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-7620-03,NDC,outpatient,500,ML,33.99,23.793,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-7620-13,NDC,outpatient,500,ML,33.99,23.793,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00264-9872-10,NDC,outpatient,500,ML,33.8,23.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00338-0424-18,NDC,outpatient,500,ML,28.85,20.195,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,63323-0519-77,NDC,outpatient,500,ML,31.42,21.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,99999-0001-71,NDC,outpatient,500,ML,22,15.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,99999-0002-94,NDC,outpatient,5,ML,16.13,11.291,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-1005-20,NDC,outpatient,500,ML,33.99,23.793,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-1005-01,NDC,outpatient,500,ML,33.99,23.793,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,63323-0519-02,NDC,outpatient,500,ML,31.42,21.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,99999-0001-81,NDC,outpatient,1000,ML,22.86,16.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN (PORCINE) IN NACL 25000-0.9 UT/250ML-% IV SOLN,RX-4081544,CDM,J1644,HCPCS,636,RC,99999-0003-32,NDC,outpatient,250,ML,30.4,21.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
HEPARIN (PORCINE) IN NACL 25000-0.9 UT/250ML-% IV SOLN,RX-4081544,CDM,J1644,HCPCS,636,RC,99999-0003-31,NDC,outpatient,250,ML,42.73,29.911,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,other,OPPS APC,,
ENOXAPARIN SODIUM 30 MG/0.3ML IJ SOSY,RX-158184,CDM,J1650,HCPCS,636,RC,00548-5601-00,NDC,outpatient,0.3,ML,20.03,14.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.57,416.02,other,OPPS APC,,
ENOXAPARIN SODIUM 40 MG/0.4ML IJ SOSY,RX-158185,CDM,J1650,HCPCS,636,RC,00548-5602-00,NDC,outpatient,0.4,ML,26.7,18.69,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.57,416.02,other,OPPS APC,,
ENOXAPARIN SODIUM 60 MG/0.6ML IJ SOSY,RX-158186,CDM,J1650,HCPCS,636,RC,00548-5603-00,NDC,outpatient,0.6,ML,40.05,28.035,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.57,416.02,other,OPPS APC,,
ENOXAPARIN SODIUM 80 MG/0.8ML IJ SOSY,RX-158187,CDM,J1650,HCPCS,636,RC,00548-5604-00,NDC,outpatient,0.8,ML,53.4,37.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.57,416.02,other,OPPS APC,,
ENOXAPARIN SODIUM 100 MG/ML IJ SOSY,RX-158188,CDM,J1650,HCPCS,636,RC,00548-5605-00,NDC,outpatient,1,ML,66.75,46.725,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.57,416.02,other,OPPS APC,,
ENOXAPARIN SODIUM 120 MG/0.8ML IJ SOSY,RX-158189,CDM,J1650,HCPCS,636,RC,00548-5606-00,NDC,outpatient,0.8,ML,80.1,56.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.57,416.02,other,OPPS APC,,
ENOXAPARIN SODIUM 150 MG/ML IJ SOSY,RX-158190,CDM,J1650,HCPCS,636,RC,00548-5607-00,NDC,outpatient,1,ML,100.13,70.091,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.57,416.02,other,OPPS APC,,
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,67457-0583-00,NDC,outpatient,0.4,ML,146.14,102.298,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,,,,
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,55150-0231-00,NDC,outpatient,0.4,ML,58.52,40.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,,,,
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,55150-0231-10,NDC,outpatient,0.4,ML,58.52,40.964,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,,,,
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,67457-0583-04,NDC,outpatient,0.4,ML,146.14,102.298,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,,,,
FONDAPARINUX SODIUM 7.5 MG/0.6ML SC SOLN,RX-108028,CDM,J1652,HCPCS,636,RC,55111-0680-11,NDC,outpatient,0.6,ML,45.65,31.955,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,,,,
FONDAPARINUX SODIUM 7.5 MG/0.6ML SC SOLN,RX-108028,CDM,J1652,HCPCS,636,RC,55111-0680-10,NDC,outpatient,0.6,ML,45.65,31.955,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,,,,
FONDAPARINUX SODIUM 10 MG/0.8ML SC SOLN,RX-108029,CDM,J1652,HCPCS,636,RC,67457-0585-08,NDC,outpatient,0.8,ML,146.14,102.298,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,,,,
FONDAPARINUX SODIUM 10 MG/0.8ML SC SOLN,RX-108029,CDM,J1652,HCPCS,636,RC,67457-0585-00,NDC,outpatient,0.8,ML,146.14,102.298,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,,,,
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55111-0678-10,NDC,outpatient,0.5,ML,21,14.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,,,,
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55150-0230-00,NDC,outpatient,0.5,ML,20.75,14.525,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,,,,
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55111-0678-11,NDC,outpatient,0.5,ML,21,14.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,,,,
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55150-0230-10,NDC,outpatient,0.5,ML,20.75,14.525,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,,,,
TETANUS IMMUNE GLOBULIN 250 UNIT/ML IM SOSY,RX-156399,CDM,J1670,HCPCS,636,RC,13533-0634-02,NDC,outpatient,1,ML,1484.53,1039.171,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,666.4255535,,,666.4255535,333.276985,1140.11904,other,OPPS APC,,
TETANUS IMMUNE GLOBULIN 250 UNIT/ML IM SOSY,RX-156399,CDM,J1670,HCPCS,636,RC,13533-0634-20,NDC,outpatient,1,ML,1484.53,1039.171,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,666.4255535,,,666.4255535,333.276985,1140.11904,other,OPPS APC,,
HYDROCORTISONE SOD SUC (PF) 250 MG IJ SOLR,RX-160127,CDM,J1720,HCPCS,636,RC,00009-0013-05,NDC,outpatient,1,UN,153.4,107.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,13.56878,416.02,other,OPPS APC,,
HYDROCORTISONE SOD SUC (PF) 500 MG IJ SOLR,RX-160129,CDM,J1720,HCPCS,636,RC,00009-0016-12,NDC,outpatient,1,UN,308.7,216.09,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,13.56878,416.02,other,OPPS APC,,
HYDROCORTISONE NA SUCCINATE PF 100 MG IJ WRAPPER,RX-4080176,CDM,J1720,HCPCS,636,RC,00009-0011-04,NDC,outpatient,1,UN,83.69,58.583,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,13.56878,416.02,other,OPPS APC,,
HYDROCORTISONE NA SUCCINATE PF 100 MG IJ WRAPPER,RX-4080176,CDM,J1720,HCPCS,636,RC,00009-0825-01,NDC,outpatient,1,UN,60.44,42.308,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,13.56878,416.02,other,OPPS APC,,
IBANDRONATE SODIUM 3 MG/3ML IV SOLN,RX-110306,CDM,J1740,HCPCS,636,RC,60505-6097-00,NDC,outpatient,3,ML,291.8,204.26,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,27.14,416.02,other,OPPS APC,,
IBUTILIDE FUMARATE 1 MG/10ML IV SOLN,RX-100740,CDM,J1742,HCPCS,636,RC,00009-3794-01,NDC,outpatient,10,ML,380.26,266.182,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,276.5271365,,,276.5271365,85.36837,416.02,other,OPPS APC,,
INFLIXIMAB 100 MG IV SOLR,RX-23796,CDM,J1745,HCPCS,636,RC,57894-0030-01,NDC,outpatient,1,UN,3124.93,2187.451,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,36.9114465,,,36.9114465,32.22,2399.94624,other,OPPS APC,,
IRON DEXTRAN 50 MG/ML IJ SOLN,RX-3990,CDM,J1750,HCPCS,636,RC,00023-6082-10,NDC,outpatient,2,ML,145.94,102.158,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,20.2398395,,,20.2398395,17.18,416.02,other,OPPS APC,,
IRON DEXTRAN 50 MG/ML IJ SOLN,RX-3990,CDM,J1750,HCPCS,636,RC,00023-6082-01,NDC,outpatient,2,ML,145.94,102.158,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,20.2398395,,,20.2398395,17.18,416.02,other,OPPS APC,,
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2340-01,NDC,outpatient,5,ML,137.29,96.103,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21,416.02,other,OPPS APC,,
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2310-01,NDC,outpatient,10,ML,278.93,195.251,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21,416.02,other,OPPS APC,,
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2340-10,NDC,outpatient,5,ML,131.72,92.204,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21,416.02,other,OPPS APC,,
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2310-05,NDC,outpatient,10,ML,278.93,195.251,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.21,416.02,other,OPPS APC,,
DROPERIDOL 2.5 MG/ML IJ SOLN,RX-2654,CDM,J1790,HCPCS,636,RC,00517-9702-25,NDC,outpatient,2,ML,31.33,21.931,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.83,416.02,,,,
DROPERIDOL 2.5 MG/ML IJ SOLN,RX-2654,CDM,J1790,HCPCS,636,RC,00517-9702-01,NDC,outpatient,2,ML,31.33,21.931,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.83,416.02,,,,
PROPRANOLOL HCL 1 MG/ML IV SOLN,RX-29335,CDM,J1800,HCPCS,636,RC,63323-0604-00,NDC,outpatient,1,ML,8.17,5.719,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.834165,416.02,,,,
PROPRANOLOL HCL 1 MG/ML IV SOLN,RX-29335,CDM,J1800,HCPCS,636,RC,63323-0604-01,NDC,outpatient,1,ML,8.17,5.719,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.834165,416.02,,,,
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN,RX-29805,CDM,J1805,HCPCS,636,RC,67457-0657-25,NDC,outpatient,250,ML,426.52,298.564,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.222227,,,0.222227,0.19,416.02,other,OPPS APC,,
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN,RX-29805,CDM,J1805,HCPCS,636,RC,25021-0308-84,NDC,outpatient,250,ML,336.4,235.48,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.222227,,,0.222227,0.19,416.02,other,OPPS APC,,
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-29805,CDM,J1805,HCPCS,636,RC,25021-0308-84,NDC,outpatient,250,ML,320.4,224.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.222227,,,0.222227,0.19,416.02,other,OPPS APC,,
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-29805,CDM,J1805,HCPCS,636,RC,67457-0657-25,NDC,outpatient,250,ML,410.52,287.364,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.222227,,,0.222227,0.19,416.02,other,OPPS APC,,
ESMOLOL HCL 100 MG/10ML IV SOLN,RX-82085,CDM,J1805,HCPCS,636,RC,67457-0182-10,NDC,outpatient,10,ML,17.12,11.984,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.222227,,,0.222227,0.19,416.02,other,OPPS APC,,
ESMOLOL HCL 100 MG/10ML IV SOLN,RX-82085,CDM,J1805,HCPCS,636,RC,55150-0194-10,NDC,outpatient,10,ML,10.39,7.273,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.222227,,,0.222227,0.19,416.02,other,OPPS APC,,
ESMOLOL HCL 100 MG/10ML IV SOLN,RX-82085,CDM,J1805,HCPCS,636,RC,67457-0182-00,NDC,outpatient,10,ML,17.12,11.984,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.222227,,,0.222227,0.19,416.02,other,OPPS APC,,
ESMOLOL HCL 2500 MG/250ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-142051,CDM,J1806,HCPCS,636,RC,44567-0811-10,NDC,outpatient,250,ML,414.97,290.479,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.410089,,,0.410089,0.36,416.02,other,OPPS APC,,
ESMOLOL HCL 2500 MG/250ML IV SOLN,RX-142051,CDM,J1806,HCPCS,636,RC,44567-0811-10,NDC,outpatient,250,ML,430.97,301.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.410089,,,0.410089,0.36,416.02,other,OPPS APC,,
INTERFERON BETA-1B 0.3 MG SC KIT,RX-124318,CDM,J1830,HCPCS,636,RC,50419-0524-01,NDC,outpatient,1,UN,1865.02,1305.514,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,114.43,1432.33536,,,,
INTERFERON BETA-1B 0.3 MG SC KIT,RX-124318,CDM,J1830,HCPCS,636,RC,50419-0524-35,NDC,outpatient,1,UN,1865.02,1305.514,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,114.43,1432.33536,,,,
ISAVUCONAZONIUM SULFATE 372 MG IV SOLR,RX-130407,CDM,J1833,HCPCS,636,RC,00469-0420-01,NDC,outpatient,1,UN,1572.32,1100.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.12259,,,1.12259,1,1207.54176,other,OPPS APC,,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-01,NDC,outpatient,100,ML,24.23,16.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.029783,,,0.029783,0.02,416.02,other,OPPS APC,,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,25021-0131-82,NDC,outpatient,100,ML,25.77,18.039,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.029783,,,0.029783,0.02,416.02,other,OPPS APC,,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,00338-1055-48,NDC,outpatient,100,ML,5.14,3.598,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.029783,,,0.029783,0.02,416.02,other,OPPS APC,,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-24,NDC,outpatient,100,ML,8.23,5.761,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.029783,,,0.029783,0.02,416.02,other,OPPS APC,,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,25021-0131-82,NDC,outpatient,100,ML,9.77,6.839,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.029783,,,0.029783,0.02,416.02,other,OPPS APC,,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,47335-0993-01,NDC,outpatient,100,ML,7.2,5.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.029783,,,0.029783,0.02,416.02,other,OPPS APC,,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,00338-1055-48,NDC,outpatient,100,ML,21.14,14.798,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.029783,,,0.029783,0.02,416.02,other,OPPS APC,,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-24,NDC,outpatient,100,ML,24.23,16.961,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.029783,,,0.029783,0.02,416.02,other,OPPS APC,,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,47335-0993-01,NDC,outpatient,100,ML,23.2,16.24,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.029783,,,0.029783,0.02,416.02,other,OPPS APC,,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-01,NDC,outpatient,100,ML,8.23,5.761,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,0.029783,,,0.029783,0.02,416.02,other,OPPS APC,,
METRONIDAZOLE IN NACL IVPB,RX-4080369,CDM,J1836,HCPCS,636,RC,99999-0001-74,NDC,outpatient,50,ML,20.37,14.259,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.029783,,,0.029783,0.02,416.02,other,OPPS APC,,
METRONIDAZOLE IV SYRINGE (PEDIATRIC),RX-40840043,CDM,J1836,HCPCS,636,RC,99999-0001-74,NDC,outpatient,50,ML,20.37,14.259,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.029783,,,0.029783,0.02,416.02,other,OPPS APC,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,63323-0162-01,NDC,outpatient,1,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.55,416.02,other,OPPS APC,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,00409-3795-01,NDC,outpatient,1,ML,18.43,12.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.55,416.02,other,OPPS APC,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,62332-0600-01,NDC,outpatient,1,ML,9.77,6.839,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.55,416.02,other,OPPS APC,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,72266-0118-25,NDC,outpatient,1,ML,4.8,3.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.55,416.02,other,OPPS APC,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,00338-0072-25,NDC,outpatient,1,ML,3.57,2.499,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.55,416.02,other,OPPS APC,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,62332-0600-25,NDC,outpatient,1,ML,9.77,6.839,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.55,416.02,other,OPPS APC,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,63323-0162-00,NDC,outpatient,1,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.55,416.02,other,OPPS APC,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,00409-3795-19,NDC,outpatient,1,ML,18.43,12.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.55,416.02,other,OPPS APC,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,72266-0118-01,NDC,outpatient,1,ML,4.8,3.36,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.55,416.02,other,OPPS APC,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,00409-2267-54,NDC,outpatient,40,ML,40.77,28.539,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.3058485,,,0.3058485,0.24,416.02,other,OPPS APC,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,00409-2339-24,NDC,outpatient,4,ML,35.3,24.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.3058485,,,0.3058485,0.24,416.02,other,OPPS APC,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,00409-2339-34,NDC,outpatient,4,ML,35.3,24.71,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.3058485,,,0.3058485,0.24,416.02,other,OPPS APC,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,25021-0317-20,NDC,outpatient,20,ML,9.98,6.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.3058485,,,0.3058485,0.24,416.02,other,OPPS APC,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,36000-0320-01,NDC,outpatient,4,ML,16.17,11.319,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.3058485,,,0.3058485,0.24,416.02,other,OPPS APC,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,36000-0320-10,NDC,outpatient,4,ML,16.17,11.319,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.3058485,,,0.3058485,0.24,416.02,other,OPPS APC,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,72266-0102-01,NDC,outpatient,20,ML,12.14,8.498,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.3058485,,,0.3058485,0.24,416.02,other,OPPS APC,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1921,HCPCS,636,RC,00143-9623-01,NDC,outpatient,40,ML,18.87,13.209,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.8683105,,,1.8683105,1.24,416.02,other,OPPS APC,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1921,HCPCS,636,RC,00143-9622-01,NDC,outpatient,20,ML,8.85,6.195,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.8683105,,,1.8683105,1.24,416.02,other,OPPS APC,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6008-01,NDC,outpatient,4,ML,14.21,9.947,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.62,416.02,other,OPPS APC,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0570-01,NDC,outpatient,4,ML,8.04,5.628,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.62,416.02,other,OPPS APC,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0572-10,NDC,outpatient,10,ML,8.64,6.048,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.62,416.02,other,OPPS APC,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6007-10,NDC,outpatient,10,ML,15.42,10.794,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.62,416.02,other,OPPS APC,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0570-04,NDC,outpatient,4,ML,8.04,5.628,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.62,416.02,other,OPPS APC,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,72205-0101-01,NDC,outpatient,4,ML,12.36,8.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.62,416.02,other,OPPS APC,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,72205-0101-07,NDC,outpatient,4,ML,12.36,8.652,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.62,416.02,other,OPPS APC,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6007-01,NDC,outpatient,10,ML,15.42,10.794,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.62,416.02,other,OPPS APC,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6008-10,NDC,outpatient,4,ML,14.21,9.947,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.62,416.02,other,OPPS APC,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0572-01,NDC,outpatient,10,ML,8.64,6.048,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.62,416.02,other,OPPS APC,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-32,NDC,outpatient,4,ML,4.75,3.325,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,416.02,other,OPPS APC,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,25021-0311-10,NDC,outpatient,10,ML,7.25,5.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,416.02,other,OPPS APC,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,63323-0280-26,NDC,outpatient,4,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,416.02,other,OPPS APC,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,00409-6102-04,NDC,outpatient,4,ML,9.24,6.468,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,416.02,other,OPPS APC,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,63323-0280-03,NDC,outpatient,4,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,416.02,other,OPPS APC,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,70860-0302-42,NDC,outpatient,4,ML,4.94,3.458,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,416.02,other,OPPS APC,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,71288-0203-05,NDC,outpatient,4,ML,3.66,2.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,416.02,other,OPPS APC,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,72603-0251-01,NDC,outpatient,4,ML,3.79,2.653,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,416.02,other,OPPS APC,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,00409-6102-18,NDC,outpatient,4,ML,9.24,6.468,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,416.02,other,OPPS APC,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-42,NDC,outpatient,4,ML,4.75,3.325,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,416.02,other,OPPS APC,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,36000-0283-25,NDC,outpatient,4,ML,5.41,3.787,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,416.02,other,OPPS APC,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,36000-0284-25,NDC,outpatient,10,ML,8.33,5.831,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,416.02,other,OPPS APC,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,72603-0251-25,NDC,outpatient,4,ML,3.79,2.653,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,416.02,other,OPPS APC,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-33,NDC,outpatient,10,ML,7.2,5.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,416.02,other,OPPS APC,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-44,NDC,outpatient,10,ML,7.2,5.04,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,416.02,other,OPPS APC,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,63323-0280-04,NDC,outpatient,4,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,416.02,other,OPPS APC,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,70860-0302-04,NDC,outpatient,4,ML,4.94,3.458,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,416.02,other,OPPS APC,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,71288-0203-04,NDC,outpatient,4,ML,3.66,2.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.4,416.02,other,OPPS APC,,
LEUPROLIDE ACETATE 3.75 MG IM KIT,RX-13691,CDM,J1950,HCPCS,636,RC,00074-3641-03,NDC,outpatient,1,UN,4758.7,3331.09,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1853.014639,,,1853.014639,399.86,10964.15232,other,OPPS APC,,
LEUPROLIDE ACETATE (3 MONTH) 11.25 MG IM KIT,RX-21044,CDM,J1950,HCPCS,636,RC,00074-3663-03,NDC,outpatient,1,UN,14276.24,9993.368,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1853.014639,,,1853.014639,399.86,10964.15232,other,OPPS APC,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,43598-0636-10,NDC,outpatient,100,ML,87.65,61.355,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,67457-0265-00,NDC,outpatient,100,ML,64.06,44.842,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,44567-0502-01,NDC,outpatient,100,ML,49.38,34.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,14789-0220-08,NDC,outpatient,100,ML,48.49,33.943,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,14789-0220-10,NDC,outpatient,100,ML,48.49,33.943,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,43598-0636-52,NDC,outpatient,100,ML,87.65,61.355,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,44567-0502-10,NDC,outpatient,100,ML,49.38,34.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,67457-0265-10,NDC,outpatient,100,ML,64.06,44.842,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,70860-0603-41,NDC,outpatient,100,ML,63.62,44.534,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,70860-0603-82,NDC,outpatient,100,ML,63.62,44.534,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,00264-1009-90,NDC,outpatient,100,ML,43.15,30.205,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC,,
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,44567-0503-01,NDC,outpatient,100,ML,60.06,42.042,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC,,
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,44567-0503-10,NDC,outpatient,100,ML,60.06,42.042,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC,,
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,70860-0604-82,NDC,outpatient,100,ML,79.64,55.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC,,
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,70860-0604-41,NDC,outpatient,100,ML,79.64,55.748,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC,,
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,00409-1886-22,NDC,outpatient,5,ML,6.38,4.466,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC,,
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,00409-1886-02,NDC,outpatient,5,ML,6.38,4.466,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC,,
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,55150-0177-05,NDC,outpatient,5,ML,5.07,3.549,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC,,
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,67457-0790-00,NDC,outpatient,5,ML,10.7,7.49,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC,,
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,67457-0790-05,NDC,outpatient,5,ML,10.7,7.49,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC,,
LEVOFLOXACIN IN D5W 250 MG/50ML IV SOLN,RX-108118,CDM,J1956,HCPCS,636,RC,25021-0132-81,NDC,outpatient,50,ML,25.26,17.682,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,other,OPPS APC,,
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00143-9721-01,NDC,outpatient,100,ML,25.77,18.039,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,other,OPPS APC,,
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00143-9721-24,NDC,outpatient,100,ML,25.77,18.039,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,other,OPPS APC,,
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,25021-0132-82,NDC,outpatient,100,ML,26.28,18.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,other,OPPS APC,,
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00409-0528-23,NDC,outpatient,100,ML,28.85,20.195,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,other,OPPS APC,,
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00409-0528-25,NDC,outpatient,100,ML,28.85,20.195,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,other,OPPS APC,,
LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN,RX-108120,CDM,J1956,HCPCS,636,RC,00409-0528-35,NDC,outpatient,150,ML,32.2,22.54,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,other,OPPS APC,,
LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN,RX-108120,CDM,J1956,HCPCS,636,RC,25021-0132-83,NDC,outpatient,150,ML,33.74,23.618,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,other,OPPS APC,,
LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN,RX-108120,CDM,J1956,HCPCS,636,RC,00409-0528-31,NDC,outpatient,150,ML,32.2,22.54,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,other,OPPS APC,,
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,00143-9722-24,NDC,outpatient,50,ML,23.97,16.779,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,other,OPPS APC,,
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,25021-0132-81,NDC,outpatient,50,ML,25.26,17.682,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,other,OPPS APC,,
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,63323-0355-50,NDC,outpatient,50,ML,45.6,31.92,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,other,OPPS APC,,
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,36000-0046-24,NDC,outpatient,50,ML,26.54,18.578,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92,416.02,other,OPPS APC,,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,55150-0242-51,NDC,outpatient,300,ML,53.38,37.366,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.08,416.02,other,OPPS APC,,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,63323-0713-03,NDC,outpatient,300,ML,49.38,34.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.08,416.02,other,OPPS APC,,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,00781-3433-46,NDC,outpatient,300,ML,100.11,70.077,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.08,416.02,other,OPPS APC,,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,57664-0683-31,NDC,outpatient,300,ML,46.71,32.697,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.08,416.02,other,OPPS APC,,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,63323-0713-13,NDC,outpatient,300,ML,49.38,34.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.08,416.02,other,OPPS APC,,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,57664-0683-57,NDC,outpatient,300,ML,46.71,32.697,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.08,416.02,other,OPPS APC,,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,00781-3433-95,NDC,outpatient,300,ML,100.11,70.077,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.08,416.02,other,OPPS APC,,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,00781-3433-46,NDC,outpatient,300,ML,100.11,70.077,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.08,416.02,other,OPPS APC,,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,57664-0683-31,NDC,outpatient,300,ML,46.71,32.697,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.08,416.02,other,OPPS APC,,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,00781-3433-95,NDC,outpatient,300,ML,100.11,70.077,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.08,416.02,other,OPPS APC,,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,55150-0242-51,NDC,outpatient,300,ML,53.38,37.366,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.08,416.02,other,OPPS APC,,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,63323-0713-03,NDC,outpatient,300,ML,49.38,34.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.08,416.02,other,OPPS APC,,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,57664-0683-57,NDC,outpatient,300,ML,46.71,32.697,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.08,416.02,other,OPPS APC,,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,63323-0713-13,NDC,outpatient,300,ML,49.38,34.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.08,416.02,other,OPPS APC,,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00409-1985-30,NDC,outpatient,1,ML,16.06,11.242,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.85,416.02,other,OPPS APC,,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6044-25,NDC,outpatient,1,ML,4.94,3.458,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.85,416.02,other,OPPS APC,,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6207-25,NDC,outpatient,1,ML,5.04,3.528,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.85,416.02,other,OPPS APC,,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6044-01,NDC,outpatient,1,ML,4.94,3.458,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.85,416.02,other,OPPS APC,,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00409-1985-03,NDC,outpatient,1,ML,16.06,11.242,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.85,416.02,other,OPPS APC,,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6207-01,NDC,outpatient,1,ML,5.04,3.528,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.85,416.02,other,OPPS APC,,
LORAZEPAM INFUSION PREMIX,RX-4080084,CDM,J2060,HCPCS,636,RC,SH408-0084-01,NDC,outpatient,100,ML,126.59,88.613,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.85,416.02,other,OPPS APC,,
MANNITOL 25 % IV SOLN,RX-4750,CDM,J2150,HCPCS,636,RC,00409-4031-01,NDC,outpatient,50,ML,10.28,7.196,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.30786,416.02,other,OPPS APC,,
MANNITOL 25 % IV SOLN,RX-4750,CDM,J2150,HCPCS,636,RC,00409-4031-16,NDC,outpatient,50,ML,10.28,7.196,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.30786,416.02,other,OPPS APC,,
MEPERIDINE 10 MG/ML PCA,RX-400415,CDM,J2175,HCPCS,636,RC,99999-0000-09,NDC,outpatient,50,ML,59.93,41.951,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.386435,416.02,other,OPPS APC,,
MEPERIDINE HCL 25 MG/ML IJ SOLN,RX-4903,CDM,J2175,HCPCS,636,RC,00641-6052-01,NDC,outpatient,1,ML,10.63,7.441,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.386435,416.02,other,OPPS APC,,
MEPERIDINE HCL 25 MG/ML IJ SOLN,RX-4903,CDM,J2175,HCPCS,636,RC,00641-6052-25,NDC,outpatient,1,ML,10.63,7.441,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.386435,416.02,other,OPPS APC,,
MEPERIDINE HCL 50 MG/ML IJ SOLN,RX-4904,CDM,J2175,HCPCS,636,RC,00641-6053-25,NDC,outpatient,1,ML,11.08,7.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.386435,416.02,other,OPPS APC,,
MEPERIDINE HCL 50 MG/ML IJ SOLN,RX-4904,CDM,J2175,HCPCS,636,RC,00641-6053-01,NDC,outpatient,1,ML,11.08,7.756,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.386435,416.02,other,OPPS APC,,
MEPOLIZUMAB 100 MG SC SOLR,RX-131231,CDM,J2182,HCPCS,636,RC,00173-0881-01,NDC,outpatient,1,UN,8145.21,5701.647,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,34.8632925,,,34.8632925,29.75,6255.52128,other,OPPS APC,,
MEROPENEM 500 MG IV SOLR,RX-17379,CDM,J2185,HCPCS,636,RC,55150-0207-20,NDC,outpatient,1,UN,7.45,5.215,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.35,416.02,other,OPPS APC,,
MEROPENEM 500 MG IV SOLR,RX-17379,CDM,J2185,HCPCS,636,RC,63323-0507-20,NDC,outpatient,1,UN,14.25,9.975,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.35,416.02,other,OPPS APC,,
MEROPENEM 500 MG IV SOLR,RX-17379,CDM,J2185,HCPCS,636,RC,63323-0507-01,NDC,outpatient,1,UN,14.25,9.975,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.35,416.02,other,OPPS APC,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,55150-0208-30,NDC,outpatient,1,UN,17.23,12.061,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.35,416.02,other,OPPS APC,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00781-3098-94,NDC,outpatient,1,UN,48.95,34.265,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.35,416.02,other,OPPS APC,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,70121-1453-01,NDC,outpatient,1,UN,45.95,32.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.35,416.02,other,OPPS APC,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,70121-1453-07,NDC,outpatient,1,UN,45.95,32.165,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.35,416.02,other,OPPS APC,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00409-1391-21,NDC,outpatient,1,UN,20.02,14.014,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.35,416.02,other,OPPS APC,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00781-3098-95,NDC,outpatient,1,UN,48.95,34.265,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.35,416.02,other,OPPS APC,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00409-1391-22,NDC,outpatient,1,UN,20.02,14.014,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.35,416.02,other,OPPS APC,,
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,00517-0740-01,NDC,outpatient,1,ML,89.19,62.433,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,15.18518,416.02,other,OPPS APC,,
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,00517-0740-20,NDC,outpatient,1,ML,89.19,62.433,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,15.18518,416.02,other,OPPS APC,,
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,51991-0144-99,NDC,outpatient,1,ML,67.64,47.348,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,15.18518,416.02,other,OPPS APC,,
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,51991-0144-17,NDC,outpatient,1,ML,67.64,47.348,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,15.18518,416.02,other,OPPS APC,,
METHYLNALTREXONE BROMIDE 12 MG/0.6ML SC SOLN,RX-91651,CDM,J2212,HCPCS,636,RC,65649-0551-02,NDC,outpatient,0.6,ML,659.14,461.398,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.07677,,,1.07677,1.07677,506.21952,other,OPPS APC,,
MICAFUNGIN SODIUM 50 MG IV SOLR,RX-41144,CDM,J2248,HCPCS,636,RC,00469-3250-10,NDC,outpatient,1,UN,384.44,269.108,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.29,590.53056,,,,
MICAFUNGIN SODIUM 50 MG IV SOLR,RX-41144,CDM,J2248,HCPCS,636,RC,70710-1724-01,NDC,outpatient,1,UN,160.37,112.259,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.29,590.53056,,,,
MICAFUNGIN SODIUM 50 MG IV SOLR,RX-41144,CDM,J2248,HCPCS,636,RC,70710-1724-06,NDC,outpatient,1,UN,160.37,112.259,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.29,590.53056,,,,
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,00469-3211-10,NDC,outpatient,1,UN,768.92,538.244,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.29,590.53056,,,,
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,25021-0191-10,NDC,outpatient,1,UN,136.09,95.263,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.29,590.53056,,,,
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,70710-1725-06,NDC,outpatient,1,UN,320.73,224.511,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.29,590.53056,,,,
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,70710-1725-01,NDC,outpatient,1,UN,320.73,224.511,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.29,590.53056,,,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,00409-2305-16,NDC,outpatient,2,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.13,416.02,other,OPPS APC,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,23155-0600-41,NDC,outpatient,2,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.13,416.02,other,OPPS APC,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,00409-2305-17,NDC,outpatient,2,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.13,416.02,other,OPPS APC,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-12,NDC,outpatient,2,ML,6.08,4.256,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.13,416.02,other,OPPS APC,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-15,NDC,outpatient,2,ML,6.08,4.256,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.13,416.02,other,OPPS APC,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,23155-0600-31,NDC,outpatient,2,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.13,416.02,other,OPPS APC,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-18,NDC,outpatient,5,ML,13.45,9.415,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.13,416.02,other,OPPS APC,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-25,NDC,outpatient,5,ML,13.45,9.415,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.13,416.02,other,OPPS APC,,
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2250,HCPCS,636,RC,70004-0411-59,NDC,outpatient,100,ML,159.16,111.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.13,416.02,other,OPPS APC,,
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2250,HCPCS,636,RC,99999-0001-46,NDC,outpatient,100,ML,75.72,53.004,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.13,416.02,other,OPPS APC,,
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00409-2308-01,NDC,outpatient,1,ML,3.95,2.765,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.13,416.02,other,OPPS APC,,
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00409-2308-21,NDC,outpatient,1,ML,3.95,2.765,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.13,416.02,other,OPPS APC,,
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00641-6060-01,NDC,outpatient,10,ML,8.07,5.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.13,416.02,other,OPPS APC,,
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00641-6060-10,NDC,outpatient,10,ML,8.07,5.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.13,416.02,other,OPPS APC,,
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2251,HCPCS,636,RC,44567-0611-01,NDC,outpatient,100,ML,77.41,54.187,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.18,416.02,,,,
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2251,HCPCS,636,RC,44567-0611-10,NDC,outpatient,100,ML,77.41,54.187,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.18,416.02,,,,
MILRINONE IN DEXTROSE 20 MG/100ML IV SOLN,RX-122186,CDM,J2260,HCPCS,636,RC,00143-9719-01,NDC,outpatient,100,ML,44.93,31.451,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.41,416.02,,,,
MILRINONE IN DEXTROSE 20 MG/100ML IV SOLN,RX-122186,CDM,J2260,HCPCS,636,RC,00143-9719-10,NDC,outpatient,100,ML,44.93,31.451,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.41,416.02,,,,
MILRINONE IN DEXTROSE 20 MG/100ML IV SOLN,RX-122186,CDM,J2260,HCPCS,636,RC,25021-0313-82,NDC,outpatient,100,ML,50.27,35.189,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.41,416.02,,,,
MILRINONE LACTATE 10 MG/10ML IV SOLN,RX-122188,CDM,J2260,HCPCS,636,RC,00143-9710-10,NDC,outpatient,10,ML,16.45,11.515,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.41,416.02,,,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00409-1891-01,NDC,outpatient,1,ML,9.04,6.328,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.02948,416.02,other,OPPS APC,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00641-6125-25,NDC,outpatient,1,ML,10.46,7.322,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.02948,416.02,other,OPPS APC,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00641-6125-01,NDC,outpatient,1,ML,10.46,7.322,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.02948,416.02,other,OPPS APC,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00409-1891-03,NDC,outpatient,1,ML,9.04,6.328,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.02948,416.02,other,OPPS APC,,
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2270,HCPCS,636,RC,00641-6127-01,NDC,outpatient,1,ML,10.68,7.476,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.02948,416.02,other,OPPS APC,,
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2270,HCPCS,636,RC,00641-6127-25,NDC,outpatient,1,ML,10.68,7.476,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.02948,416.02,other,OPPS APC,,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2270,HCPCS,636,RC,52533-0161-45,NDC,outpatient,1,ML,33.38,23.366,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.02948,416.02,other,OPPS APC,,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2270,HCPCS,636,RC,00409-1890-01,NDC,outpatient,1,ML,9.93,6.951,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.02948,416.02,other,OPPS APC,,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2270,HCPCS,636,RC,00409-1890-03,NDC,outpatient,1,ML,9.93,6.951,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.02948,416.02,other,OPPS APC,,
MORPHINE SULFATE 50 MG/ML IV SOLN,RX-27393,CDM,J2270,HCPCS,636,RC,00409-1134-05,NDC,outpatient,50,ML,115.7,80.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.02948,416.02,other,OPPS APC,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2272,HCPCS,636,RC,63323-0454-00,NDC,outpatient,1,ML,8.51,5.957,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.816205,416.02,other,OPPS APC,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2272,HCPCS,636,RC,76045-0005-10,NDC,outpatient,1,ML,8.79,6.153,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.816205,416.02,other,OPPS APC,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2272,HCPCS,636,RC,63323-0454-01,NDC,outpatient,1,ML,8.51,5.957,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.816205,416.02,other,OPPS APC,,
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2272,HCPCS,636,RC,63323-0451-00,NDC,outpatient,1,ML,9.36,6.552,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.816205,416.02,other,OPPS APC,,
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2272,HCPCS,636,RC,63323-0451-01,NDC,outpatient,1,ML,9.36,6.552,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.816205,416.02,other,OPPS APC,,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2272,HCPCS,636,RC,63323-0452-01,NDC,outpatient,1,ML,8.27,5.789,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.816205,416.02,other,OPPS APC,,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2272,HCPCS,636,RC,63323-0452-00,NDC,outpatient,1,ML,8.27,5.789,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.816205,416.02,other,OPPS APC,,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2272,HCPCS,636,RC,76045-0004-10,NDC,outpatient,1,ML,8.09,5.663,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.816205,416.02,other,OPPS APC,,
MORPHINE SULFATE (PF) 1 MG/ML IJ SOLN,RX-15852,CDM,J2274,HCPCS,636,RC,00641-6019-01,NDC,outpatient,10,ML,82.11,57.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.46,1022.48448,other,OPPS APC,,
MORPHINE SULFATE (PF) 1 MG/ML IJ SOLN,RX-15852,CDM,J2274,HCPCS,636,RC,00641-6019-10,NDC,outpatient,10,ML,82.11,57.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.46,1022.48448,other,OPPS APC,,
MORPHINE SULF MICROINFUSION PF 200 MG/20ML (10 MG/ML) IJ SOLN,RX-77009,CDM,J2274,HCPCS,636,RC,00641-6039-01,NDC,outpatient,20,ML,695.45,486.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.46,1022.48448,other,OPPS APC,,
MORPHINE SULF MICROINFUSION PF 500 MG/20ML (25 MG/ML) IJ SOLN,RX-77010,CDM,J2274,HCPCS,636,RC,00641-6040-01,NDC,outpatient,20,ML,1331.36,931.952,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,10.46,1022.48448,other,OPPS APC,,
NALBUPHINE HCL 10 MG/ML IJ SOLN,RX-5339,CDM,J2300,HCPCS,636,RC,00409-1463-01,NDC,outpatient,1,ML,17.79,12.453,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.72,416.02,,,,
NALBUPHINE HCL 10 MG/ML IJ SOLN,RX-5339,CDM,J2300,HCPCS,636,RC,00409-1463-71,NDC,outpatient,1,ML,17.79,12.453,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.72,416.02,,,,
NITROGLYCERIN IN D5W 400-5 MCG/ML-% IV SOLN,RX-14895,CDM,J2305,HCPCS,636,RC,00338-1051-02,NDC,outpatient,250,ML,62.73,43.911,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.612864,,,1.612864,1.3,416.02,other,OPPS APC,,
NITROGLYCERIN IN D5W 400-5 MCG/ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-14895,CDM,J2305,HCPCS,636,RC,00338-1051-02,NDC,outpatient,250,ML,46.73,32.711,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,1.612864,,,1.612864,1.3,416.02,other,OPPS APC,,
NITROGLYCERIN IN D5W 100-5 MCG/ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-15858,CDM,J2305,HCPCS,636,RC,00338-1047-02,NDC,outpatient,250,ML,40.05,28.035,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,1.612864,,,1.612864,1.3,416.02,other,OPPS APC,,
NITROGLYCERIN IN D5W 100-5 MCG/ML-% IV SOLN,RX-15858,CDM,J2305,HCPCS,636,RC,00338-1047-02,NDC,outpatient,250,ML,56.05,39.235,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.612864,,,1.612864,1.3,416.02,other,OPPS APC,,
NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN,RX-15859,CDM,J2305,HCPCS,636,RC,99999-0004-40,NDC,outpatient,250,ML,45.49,31.843,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.612864,,,1.612864,1.3,416.02,other,OPPS APC,,
NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN,RX-15859,CDM,J2305,HCPCS,636,RC,00338-1049-02,NDC,outpatient,250,ML,58.28,40.796,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.612864,,,1.612864,1.3,416.02,other,OPPS APC,,
NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-15859,CDM,J2305,HCPCS,636,RC,00338-1049-02,NDC,outpatient,250,ML,42.28,29.596,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,1.612864,,,1.612864,1.3,416.02,other,OPPS APC,,
NITROGLYCERIN 5 MG/ML IV SOLN,RX-5599,CDM,J2305,HCPCS,636,RC,00517-4810-01,NDC,outpatient,10,ML,51.4,35.98,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.612864,,,1.612864,1.3,416.02,other,OPPS APC,,
NITROGLYCERIN 5 MG/ML IV SOLN,RX-5599,CDM,J2305,HCPCS,636,RC,00517-4810-25,NDC,outpatient,10,ML,51.4,35.98,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.612864,,,1.612864,1.3,416.02,other,OPPS APC,,
NALOXONE HCL 2 MG/2ML IJ SOSY,RX-136113,CDM,J2310,HCPCS,636,RC,76329-3369-01,NDC,outpatient,2,ML,42.08,29.456,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.03075,416.02,other,OPPS APC,,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,00409-1215-01,NDC,outpatient,1,ML,63.16,44.212,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.03075,416.02,other,OPPS APC,,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,00409-1215-21,NDC,outpatient,1,ML,63.16,44.212,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.03075,416.02,other,OPPS APC,,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,67457-0292-00,NDC,outpatient,1,ML,15.44,10.808,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.03075,416.02,other,OPPS APC,,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,36000-0308-10,NDC,outpatient,1,ML,13.5,9.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.03075,416.02,other,OPPS APC,,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,67457-0292-02,NDC,outpatient,1,ML,15.44,10.808,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.03075,416.02,other,OPPS APC,,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,36000-0308-01,NDC,outpatient,1,ML,13.5,9.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.03075,416.02,other,OPPS APC,,
OCTREOTIDE ACETATE 50 MCG/ML IJ SOLN,RX-91278,CDM,J2354,HCPCS,636,RC,67457-0239-00,NDC,outpatient,1,ML,17.58,12.306,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.86,416.02,,,,
OCTREOTIDE ACETATE 50 MCG/ML IJ SOLN,RX-91278,CDM,J2354,HCPCS,636,RC,67457-0239-01,NDC,outpatient,1,ML,17.58,12.306,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.86,416.02,,,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,00641-6175-10,NDC,outpatient,1,ML,7.84,5.488,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.86,416.02,,,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,23155-0688-41,NDC,outpatient,1,ML,11.88,8.316,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.86,416.02,,,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,63323-0376-00,NDC,outpatient,1,ML,11.92,8.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.86,416.02,,,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,23155-0688-31,NDC,outpatient,1,ML,11.88,8.316,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.86,416.02,,,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,00641-6175-01,NDC,outpatient,1,ML,7.84,5.488,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.86,416.02,,,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,63323-0376-01,NDC,outpatient,1,ML,11.92,8.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.86,416.02,,,,
OCTREOTIDE ACETATE 200 MCG/ML IJ SOLN,RX-91280,CDM,J2354,HCPCS,636,RC,00641-6177-01,NDC,outpatient,0.5,ML,25.17,17.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.86,416.02,,,,
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,00641-6176-10,NDC,outpatient,1,ML,46.52,32.564,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.86,416.02,,,,
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,00641-6176-01,NDC,outpatient,1,ML,46.52,32.564,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.86,416.02,,,,
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,63323-0377-00,NDC,outpatient,1,ML,41.91,29.337,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.86,416.02,,,,
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,63323-0377-01,NDC,outpatient,1,ML,41.91,29.337,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.86,416.02,,,,
OMALIZUMAB 150 MG/ML SC SOSY,RX-144954,CDM,J2357,HCPCS,636,RC,50242-0215-01,NDC,outpatient,1,ML,3822.49,2675.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,43.8646315,,,43.8646315,38.29,2935.67232,other,OPPS APC,,
OMALIZUMAB 75 MG/0.5ML SC SOSY,RX-144955,CDM,J2357,HCPCS,636,RC,50242-0214-01,NDC,outpatient,0.5,ML,1911.25,1337.875,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,43.8646315,,,43.8646315,38.29,2935.67232,other,OPPS APC,,
OMALIZUMAB 150 MG SC SOLR,RX-36151,CDM,J2357,HCPCS,636,RC,50242-0040-62,NDC,outpatient,1,UN,3822.49,2675.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,43.8646315,,,43.8646315,38.29,2935.67232,other,OPPS APC,,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00781-9105-72,NDC,outpatient,1,UN,62.44,43.708,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.049278,,,1.049278,0.92,416.02,other,OPPS APC,,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00002-7597-01,NDC,outpatient,1,UN,206.8,144.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.049278,,,1.049278,0.92,416.02,other,OPPS APC,,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,55150-0308-01,NDC,outpatient,1,UN,77.39,54.173,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.049278,,,1.049278,0.92,416.02,other,OPPS APC,,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00517-0955-01,NDC,outpatient,1,UN,115.66,80.962,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.049278,,,1.049278,0.92,416.02,other,OPPS APC,,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00781-3159-72,NDC,outpatient,1,UN,62.44,43.708,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.049278,,,1.049278,0.92,416.02,other,OPPS APC,,
ORPHENADRINE CITRATE 30 MG/ML IJ SOLN,RX-5886,CDM,J2360,HCPCS,636,RC,00641-6182-01,NDC,outpatient,2,ML,19.23,13.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.317135,416.02,,,,
ORPHENADRINE CITRATE 30 MG/ML IJ SOLN,RX-5886,CDM,J2360,HCPCS,636,RC,00641-6182-10,NDC,outpatient,2,ML,19.23,13.461,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.317135,416.02,,,,
PHENYLEPHRINE HCL 100 MCG/ML SYRINGE,RX-4080501,CDM,J2371,HCPCS,636,RC,70092-1046-46,NDC,outpatient,10,ML,24.79,17.353,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.01,416.02,other,OPPS APC,,
PHENYLEPHRINE HCL 100 MCG/ML SYRINGE,RX-4080501,CDM,J2371,HCPCS,636,RC,70004-0810-12,NDC,outpatient,10,ML,25.28,17.696,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.01,416.02,other,OPPS APC,,
PHENYLEPHRINE HCL 100 MCG/ML SYRINGE,RX-4080501,CDM,J2371,HCPCS,636,RC,70004-0810-11,NDC,outpatient,5,ML,23.81,16.667,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.01,416.02,other,OPPS APC,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,00781-3422-92,NDC,outpatient,1,ML,12.34,8.638,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.01,416.02,other,OPPS APC,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1577-05,NDC,outpatient,1,ML,9.89,6.923,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.01,416.02,other,OPPS APC,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1578-01,NDC,outpatient,5,ML,19.7,13.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.01,416.02,other,OPPS APC,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,00781-3422-71,NDC,outpatient,1,ML,12.34,8.638,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.01,416.02,other,OPPS APC,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,25021-0315-01,NDC,outpatient,1,ML,3.42,2.394,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.01,416.02,other,OPPS APC,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70069-0801-01,NDC,outpatient,1,ML,6.49,4.543,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.01,416.02,other,OPPS APC,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1577-01,NDC,outpatient,1,ML,9.89,6.923,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.01,416.02,other,OPPS APC,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1578-07,NDC,outpatient,5,ML,19.7,13.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.01,416.02,other,OPPS APC,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70069-0801-25,NDC,outpatient,1,ML,6.49,4.543,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.01,416.02,other,OPPS APC,,
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,00143-9209-01,NDC,outpatient,20,ML,51.18,35.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.032074,,,0.032074,0.03,416.02,other,OPPS APC,,
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,63323-0477-27,NDC,outpatient,20,ML,78.86,55.202,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.032074,,,0.032074,0.03,416.02,other,OPPS APC,,
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,00143-9209-10,NDC,outpatient,20,ML,51.18,35.826,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.032074,,,0.032074,0.03,416.02,other,OPPS APC,,
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,63323-0477-01,NDC,outpatient,20,ML,78.86,55.202,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.032074,,,0.032074,0.03,416.02,other,OPPS APC,,
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,00143-9210-10,NDC,outpatient,20,ML,54.03,37.821,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.032074,,,0.032074,0.03,416.02,other,OPPS APC,,
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,63323-0478-01,NDC,outpatient,20,ML,82.77,57.939,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.032074,,,0.032074,0.03,416.02,other,OPPS APC,,
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,00143-9210-01,NDC,outpatient,20,ML,54.03,37.821,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.032074,,,0.032074,0.03,416.02,other,OPPS APC,,
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,63323-0478-27,NDC,outpatient,20,ML,82.77,57.939,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.032074,,,0.032074,0.03,416.02,other,OPPS APC,,
NICARDIPINE HCL 2.5 MG/ML IV SOLN,RX-12370,CDM,J2404,HCPCS,636,RC,00143-9689-10,NDC,outpatient,10,ML,41.12,28.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.54,416.02,,,,
NICARDIPINE HCL 2.5 MG/ML IV SOLN,RX-12370,CDM,J2404,HCPCS,636,RC,00143-9689-01,NDC,outpatient,10,ML,41.12,28.784,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.54,416.02,,,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00409-4755-03,NDC,outpatient,2,ML,6.09,4.263,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,36000-0012-25,NDC,outpatient,2,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,60505-6130-00,NDC,outpatient,2,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00641-6078-01,NDC,outpatient,2,ML,3.61,2.527,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00641-6078-25,NDC,outpatient,2,ML,3.61,2.527,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,23155-0547-42,NDC,outpatient,2,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00409-4755-18,NDC,outpatient,2,ML,6.09,4.263,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,23155-0547-31,NDC,outpatient,2,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,23155-0549-31,NDC,outpatient,20,ML,18.1,12.67,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,60505-6130-05,NDC,outpatient,2,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
PAMIDRONATE DISODIUM 30 MG/10ML IV SOLN,RX-32589,CDM,J2430,HCPCS,636,RC,67457-0430-10,NDC,outpatient,10,ML,36.81,25.767,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.263845,416.02,other,OPPS APC,,
PAMIDRONATE DISODIUM 30 MG/10ML IV SOLN,RX-32589,CDM,J2430,HCPCS,636,RC,61703-0324-18,NDC,outpatient,10,ML,46.42,32.494,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,8.263845,416.02,other,OPPS APC,,
PALONOSETRON HCL 0.25 MG/5ML IV SOLN,RX-36591,CDM,J2469,HCPCS,636,RC,55111-0694-07,NDC,outpatient,5,ML,25.1,17.57,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.62,416.02,other,OPPS APC,,
PALONOSETRON HCL 0.25 MG/5ML IV SOLN,RX-36591,CDM,J2469,HCPCS,636,RC,60505-6193-01,NDC,outpatient,5,ML,13.32,9.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.62,416.02,other,OPPS APC,,
PARICALCITOL 5 MCG/ML IV SOLN,RX-22960,CDM,J2501,HCPCS,636,RC,00074-1658-01,NDC,outpatient,1,ML,40.71,28.497,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.5,416.02,,,,
PEGLOTICASE 8 MG/ML IV SOLN,RX-107664,CDM,J2507,HCPCS,636,RC,75987-0080-10,NDC,outpatient,1,ML,59467.57,41627.299,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3988.807407,,,3988.807407,399.86,45671.09376,other,OPPS APC,,
PENICILLIN G POT IN DEXTROSE 60000 UNIT/ML IV WRAPPER,RX-4080111,CDM,J2540,HCPCS,636,RC,00338-1025-41,NDC,outpatient,50,ML,55.67,38.969,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.01,416.02,other,OPPS APC,,
PENICILLIN G POTASSIUM 5000000 UNITS IJ SOLR,RX-6086,CDM,J2540,HCPCS,636,RC,44567-0311-10,NDC,outpatient,1,UN,17.93,12.551,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.01,416.02,other,OPPS APC,,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,55150-0121-50,NDC,outpatient,1,UN,18.43,12.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.1,416.02,other,OPPS APC,,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,00781-3114-95,NDC,outpatient,1,UN,30.55,21.385,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.1,416.02,other,OPPS APC,,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,00781-3114-91,NDC,outpatient,1,UN,30.55,21.385,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.1,416.02,other,OPPS APC,,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,72485-0404-10,NDC,outpatient,1,UN,18.51,12.957,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.1,416.02,other,OPPS APC,,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,44567-0803-10,NDC,outpatient,1,UN,27.96,19.572,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.1,416.02,other,OPPS APC,,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,72485-0404-01,NDC,outpatient,1,UN,18.51,12.957,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.1,416.02,other,OPPS APC,,
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,60505-6157-00,NDC,outpatient,1,UN,9.79,6.853,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.1,416.02,other,OPPS APC,,
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,64679-0056-02,NDC,outpatient,1,UN,13.78,9.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.1,416.02,other,OPPS APC,,
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,55150-0120-30,NDC,outpatient,1,UN,12.91,9.037,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.1,416.02,other,OPPS APC,,
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,60505-6157-04,NDC,outpatient,1,UN,9.79,6.853,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.1,416.02,other,OPPS APC,,
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,64679-0056-01,NDC,outpatient,1,UN,13.78,9.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.1,416.02,other,OPPS APC,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00781-3110-95,NDC,outpatient,1,UN,17.66,12.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.1,416.02,other,OPPS APC,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00781-3110-90,NDC,outpatient,1,UN,17.66,12.362,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.1,416.02,other,OPPS APC,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,55150-0119-30,NDC,outpatient,1,UN,8.76,6.132,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.1,416.02,other,OPPS APC,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00409-3383-02,NDC,outpatient,1,UN,25.13,17.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.1,416.02,other,OPPS APC,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00409-3383-11,NDC,outpatient,1,UN,25.13,17.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.1,416.02,other,OPPS APC,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,44567-0801-10,NDC,outpatient,1,UN,14.21,9.947,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.1,416.02,other,OPPS APC,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,60505-6156-00,NDC,outpatient,1,UN,7.94,5.558,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.1,416.02,other,OPPS APC,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,60505-6156-04,NDC,outpatient,1,UN,7.94,5.558,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.1,416.02,other,OPPS APC,,
PROMETHAZINE HCL 25 MG/ML IJ SOLN,RX-6618,CDM,J2550,HCPCS,636,RC,00641-1495-31,NDC,outpatient,1,ML,7.75,5.425,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.739875,416.02,other,OPPS APC,,
PROMETHAZINE HCL 25 MG/ML IJ SOLN,RX-6618,CDM,J2550,HCPCS,636,RC,00641-1495-35,NDC,outpatient,1,ML,7.75,5.425,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.739875,416.02,other,OPPS APC,,
PHENOBARBITAL SODIUM 130 MG/ML IJ SOLN,RX-6221,CDM,J2560,HCPCS,636,RC,00641-0477-25,NDC,outpatient,1,ML,155.87,109.109,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,13.89655,416.02,,,,
PHENOBARBITAL SODIUM 130 MG/ML IJ SOLN,RX-6221,CDM,J2560,HCPCS,636,RC,00641-0477-21,NDC,outpatient,1,ML,155.87,109.109,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,13.89655,416.02,,,,
PHENOBARBITAL SODIUM 65 MG/ML IJ SOLN,RX-6224,CDM,J2560,HCPCS,636,RC,00641-0476-21,NDC,outpatient,1,ML,61.9,43.33,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,13.89655,416.02,,,,
PHENOBARBITAL SODIUM 65 MG/ML IJ SOLN,RX-6224,CDM,J2560,HCPCS,636,RC,00641-0476-25,NDC,outpatient,1,ML,61.9,43.33,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,13.89655,416.02,,,,
OXYTOCIN 10 UNIT/ML IJ SOLN,RX-5944,CDM,J2590,HCPCS,636,RC,63323-0012-06,NDC,outpatient,0.3,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC,,
OXYTOCIN 10 UNIT/ML IJ SOLN,RX-5944,CDM,J2590,HCPCS,636,RC,63323-0012-10,NDC,outpatient,0.3,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC,,
OXYTOCIN 10 UNIT/ML IJ SOLN,RX-5944,CDM,J2590,HCPCS,636,RC,42023-0116-25,NDC,outpatient,1,ML,7.42,5.194,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.74534,416.02,other,OPPS APC,,
DESMOPRESSIN ACETATE 4 MCG/ML IJ SOLN WRAPPER,RX-4081353,CDM,J2597,HCPCS,636,RC,69918-0899-01,NDC,outpatient,1,ML,91.9,64.33,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6.20861,,,6.20861,5.42,416.02,other,OPPS APC,,
DESMOPRESSIN ACETATE 4 MCG/ML IJ SOLN WRAPPER,RX-4081353,CDM,J2597,HCPCS,636,RC,69918-0899-10,NDC,outpatient,1,ML,91.9,64.33,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6.20861,,,6.20861,5.42,416.02,other,OPPS APC,,
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-01,NDC,outpatient,100,ML,534.45,374.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,1.8545645,,,1.8545645,1.62,422.7456,other,OPPS APC,,
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-01,NDC,outpatient,100,ML,550.45,385.315,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.8545645,,,1.8545645,1.62,422.7456,other,OPPS APC,,
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-10,NDC,outpatient,100,ML,534.45,374.115,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,1.8545645,,,1.8545645,1.62,422.7456,other,OPPS APC,,
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-10,NDC,outpatient,100,ML,550.45,385.315,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.8545645,,,1.8545645,1.62,422.7456,other,OPPS APC,,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42023-0164-25,NDC,outpatient,1,ML,50.82,35.574,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.8545645,,,1.8545645,1.62,422.7456,other,OPPS APC,,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42367-0570-87,NDC,outpatient,0.25,ML,175.83,123.081,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.8545645,,,1.8545645,1.62,422.7456,other,OPPS APC,,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,55150-0370-01,NDC,outpatient,0.25,ML,21.94,15.358,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.8545645,,,1.8545645,1.62,422.7456,other,OPPS APC,,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42367-0570-22,NDC,outpatient,0.25,ML,175.83,123.081,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.8545645,,,1.8545645,1.62,422.7456,other,OPPS APC,,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,55150-0370-25,NDC,outpatient,0.25,ML,21.94,15.358,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.8545645,,,1.8545645,1.62,422.7456,other,OPPS APC,,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42023-0164-01,NDC,outpatient,1,ML,50.82,35.574,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.8545645,,,1.8545645,1.62,422.7456,other,OPPS APC,,
FLUPHENAZINE HCL 2.5 MG/ML IJ SOLN,RX-3216,CDM,J2679,HCPCS,636,RC,63323-0281-10,NDC,outpatient,0.5,ML,19.62,13.734,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.40469,416.02,,,,
FLUPHENAZINE DECANOATE 25 MG/ML IJ SOLN,RX-3215,CDM,J2680,HCPCS,636,RC,42023-0129-01,NDC,outpatient,0.5,ML,20.43,14.301,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.586535,416.02,,,,
FLUPHENAZINE DECANOATE 25 MG/ML IJ SOLN,RX-3215,CDM,J2680,HCPCS,636,RC,63323-0272-05,NDC,outpatient,0.5,ML,32.89,23.023,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.586535,416.02,,,,
PROCAINAMIDE HCL 100 MG/ML IJ SOLN,RX-6562,CDM,J2690,HCPCS,636,RC,00409-1902-11,NDC,outpatient,1,ML,24.43,17.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,625.518603,,,625.518603,5.484535,1082.90304,other,OPPS APC,,
PROCAINAMIDE HCL 100 MG/ML IJ SOLN,RX-6562,CDM,J2690,HCPCS,636,RC,00409-1902-01,NDC,outpatient,1,ML,24.43,17.101,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,625.518603,,,625.518603,5.484535,1082.90304,other,OPPS APC,,
PROCAINAMIDE HCL 500 MG/ML IJ SOLN,RX-6563,CDM,J2690,HCPCS,636,RC,14789-0900-02,NDC,outpatient,2,ML,1410.03,987.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,625.518603,,,625.518603,5.484535,1082.90304,other,OPPS APC,,
PROCAINAMIDE HCL 500 MG/ML IJ SOLN,RX-6563,CDM,J2690,HCPCS,636,RC,14789-0900-07,NDC,outpatient,2,ML,1410.03,987.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,625.518603,,,625.518603,5.484535,1082.90304,other,OPPS APC,,
OXACILLIN SODIUM 10 G IV SOLR,RX-150085,CDM,J2700,HCPCS,636,RC,63323-0811-00,NDC,outpatient,1,UN,137.38,96.166,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.87,416.02,,,,
OXACILLIN SODIUM 10 G IV SOLR,RX-150085,CDM,J2700,HCPCS,636,RC,25021-0163-99,NDC,outpatient,1,UN,489.5,342.65,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.87,416.02,,,,
OXACILLIN SODIUM 10 G IV SOLR,RX-150085,CDM,J2700,HCPCS,636,RC,55150-0129-99,NDC,outpatient,1,UN,150.46,105.322,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.87,416.02,,,,
OXACILLIN SODIUM 1 G IJ SOLR,RX-5924,CDM,J2700,HCPCS,636,RC,64679-0698-01,NDC,outpatient,1,UN,20.97,14.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.87,416.02,,,,
OXACILLIN SODIUM 1 G IJ SOLR,RX-5924,CDM,J2700,HCPCS,636,RC,55150-0127-15,NDC,outpatient,1,UN,19.11,13.377,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.87,416.02,,,,
OXACILLIN SODIUM 1 G IJ SOLR,RX-5924,CDM,J2700,HCPCS,636,RC,64679-0698-02,NDC,outpatient,1,UN,20.97,14.679,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.87,416.02,,,,
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,63323-0812-01,NDC,outpatient,1,UN,25.17,17.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.87,416.02,,,,
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,63323-0812-20,NDC,outpatient,1,UN,25.17,17.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.87,416.02,,,,
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,64679-0699-01,NDC,outpatient,1,UN,38.24,26.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.87,416.02,,,,
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,64679-0699-02,NDC,outpatient,1,UN,38.24,26.768,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.87,416.02,,,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0209-01,NDC,outpatient,20,ML,9.98,6.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0234-20,NDC,outpatient,50,ML,21.59,15.113,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-24,NDC,outpatient,100,ML,36.94,25.858,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-53,NDC,outpatient,50,ML,18.47,12.929,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0690-01,NDC,outpatient,100,ML,32.93,23.051,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0690-10,NDC,outpatient,100,ML,32.93,23.051,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,25021-0608-20,NDC,outpatient,20,ML,10.49,7.343,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,25021-0608-51,NDC,outpatient,100,ML,57.41,40.187,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,43598-0548-21,NDC,outpatient,50,ML,20.47,14.329,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0209-10,NDC,outpatient,20,ML,9.98,6.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-33,NDC,outpatient,50,ML,18.47,12.929,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-54,NDC,outpatient,100,ML,36.94,25.858,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0977-01,NDC,outpatient,50,ML,18.69,13.083,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0977-20,NDC,outpatient,50,ML,18.69,13.083,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,63323-0269-29,NDC,outpatient,20,ML,9.57,6.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0234-01,NDC,outpatient,50,ML,21.59,15.113,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0248-01,NDC,outpatient,100,ML,43.17,30.219,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0248-10,NDC,outpatient,100,ML,43.17,30.219,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0528-01,NDC,outpatient,20,ML,8.95,6.265,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0528-10,NDC,outpatient,20,ML,9.98,6.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,25021-0608-50,NDC,outpatient,50,ML,28.71,20.097,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,43598-0548-50,NDC,outpatient,50,ML,20.47,14.329,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,63323-0269-22,NDC,outpatient,20,ML,9.57,6.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0234-20,NDC,outpatient,50,ML,37.59,26.313,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0248-10,NDC,outpatient,100,ML,59.17,41.419,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-33,NDC,outpatient,50,ML,34.47,24.129,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0690-01,NDC,outpatient,100,ML,48.93,34.251,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0977-01,NDC,outpatient,50,ML,34.69,24.283,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0977-20,NDC,outpatient,50,ML,34.69,24.283,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,25021-0608-51,NDC,outpatient,100,ML,73.41,51.387,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,43598-0548-50,NDC,outpatient,50,ML,36.47,25.529,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-24,NDC,outpatient,100,ML,52.94,37.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-53,NDC,outpatient,50,ML,34.47,24.129,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0234-01,NDC,outpatient,50,ML,37.59,26.313,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0248-01,NDC,outpatient,100,ML,59.17,41.419,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0690-10,NDC,outpatient,100,ML,48.93,34.251,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,43598-0548-21,NDC,outpatient,50,ML,36.47,25.529,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-54,NDC,outpatient,100,ML,52.94,37.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,25021-0608-50,NDC,outpatient,50,ML,44.71,31.297,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,other,OPPS APC,,
NEOSTIGMINE METHYLSULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4080613,CDM,J2710,HCPCS,636,RC,70121-1479-01,NDC,outpatient,10,ML,34.98,24.486,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.43,416.02,other,OPPS APC,,
NEOSTIGMINE METHYLSULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4080613,CDM,J2710,HCPCS,636,RC,70121-1479-07,NDC,outpatient,10,ML,34.98,24.486,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.43,416.02,other,OPPS APC,,
PROTAMINE SULFATE 10 MG/ML IV SOLN,RX-6677,CDM,J2720,HCPCS,636,RC,63323-0229-30,NDC,outpatient,25,ML,134.62,94.234,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.95,416.02,other,OPPS APC,,
PROTAMINE SULFATE 10 MG/ML IV SOLN,RX-6677,CDM,J2720,HCPCS,636,RC,63323-0229-05,NDC,outpatient,5,ML,44.82,31.374,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.95,416.02,other,OPPS APC,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,76045-0101-20,NDC,outpatient,2,ML,9.08,6.356,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92943,416.02,other,OPPS APC,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-3414-18,NDC,outpatient,2,ML,4.14,2.898,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92943,416.02,other,OPPS APC,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-5255-25,NDC,outpatient,2,ML,4.14,2.898,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92943,416.02,other,OPPS APC,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-3414-01,NDC,outpatient,2,ML,4.14,2.898,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92943,416.02,other,OPPS APC,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00703-4502-04,NDC,outpatient,2,ML,17.23,12.061,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92943,416.02,other,OPPS APC,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-5255-02,NDC,outpatient,2,ML,4.14,2.898,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92943,416.02,other,OPPS APC,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00703-4502-01,NDC,outpatient,2,ML,17.23,12.061,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.92943,416.02,other,OPPS APC,,
QUINUPRISTIN-DALFOPRISTIN 500 MG IV SOLR,RX-26335,CDM,J2770,HCPCS,636,RC,61570-0260-01,NDC,outpatient,1,UN,1916.14,1341.298,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7.136465,,,7.136465,7.136465,1471.59552,other,OPPS APC,,
QUINUPRISTIN-DALFOPRISTIN 500 MG IV SOLR,RX-26335,CDM,J2770,HCPCS,636,RC,61570-0260-10,NDC,outpatient,1,UN,1916.14,1341.298,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,7.136465,,,7.136465,7.136465,1471.59552,other,OPPS APC,,
RASBURICASE 1.5 MG IV SOLR,RX-33591,CDM,J2783,HCPCS,636,RC,00024-5150-10,NDC,outpatient,1,UN,3073.12,2151.184,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,425.3161315,,,425.3161315,357.36,11800.75008,other,OPPS APC,,
RASBURICASE 7.5 MG IV SOLR,RX-76868,CDM,J2783,HCPCS,636,RC,00024-5151-75,NDC,outpatient,1,UN,15365.56,10755.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,425.3161315,,,425.3161315,357.36,11800.75008,other,OPPS APC,,
REGADENOSON 0.4 MG/5ML IV SOLN,RX-91408,CDM,J2785,HCPCS,636,RC,71288-0201-85,NDC,outpatient,5,ML,30.71,21.497,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.88,455.8464,other,OPPS APC,,
REGADENOSON 0.4 MG/5ML IV SOLN,RX-91408,CDM,J2785,HCPCS,636,RC,00469-6501-89,NDC,outpatient,5,ML,593.55,415.485,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.88,455.8464,other,OPPS APC,,
REGADENOSON 0.4 MG/5ML IV SOLN,RX-91408,CDM,J2785,HCPCS,636,RC,67457-0994-05,NDC,outpatient,5,ML,26.97,18.879,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.88,455.8464,other,OPPS APC,,
RHO D IMMUNE GLOBULIN 1500 UNIT/2ML IJ SOSY,RX-129748,CDM,J2791,HCPCS,636,RC,44206-0300-10,NDC,outpatient,2,ML,207.1,144.97,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,,,other,OPPS APC,,
RHO D IMMUNE GLOBULIN 1500 UNIT/2ML IJ SOSY,RX-129748,CDM,J2791,HCPCS,636,RC,44206-0300-01,NDC,outpatient,2,ML,207.1,144.97,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,,,other,OPPS APC,,
RHO D IMMUNE GLOBULIN 1500 UNIT/2ML IJ SOSY,RX-129748,CDM,J2791,HCPCS,636,RC,44206-0300-90,NDC,outpatient,2,ML,78.48,54.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,,,other,OPPS APC,,
RHO D IMMUNE GLOBULIN 5000 UNIT/4.4ML IJ SOLN,RX-70574,CDM,J2792,HCPCS,636,RC,70257-0310-51,NDC,outpatient,4.4,ML,3912.94,2739.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,39.331888,,,39.331888,33.71,3005.13792,other,OPPS APC,,
RHO D IMMUNE GLOBULIN 5000 UNIT/4.4ML IJ SOLN,RX-70574,CDM,J2792,HCPCS,636,RC,70257-0310-04,NDC,outpatient,4.4,ML,3912.94,2739.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,39.331888,,,39.331888,33.71,3005.13792,other,OPPS APC,,
RISPERIDONE MICROSPHERES ER 37.5 MG IM SRER,RX-148032,CDM,J2794,HCPCS,636,RC,50458-0307-11,NDC,outpatient,1,UN,2304,1612.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12.9430045,,,12.9430045,10.7,2359.38048,other,OPPS APC,,
RISPERIDONE MICROSPHERES ER 50 MG IM SRER,RX-148033,CDM,J2794,HCPCS,636,RC,50458-0308-11,NDC,outpatient,1,UN,3072.11,2150.477,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,12.9430045,,,12.9430045,10.7,2359.38048,other,OPPS APC,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-01,NDC,outpatient,20,ML,59.55,41.685,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-20,NDC,outpatient,20,ML,59.55,41.685,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,70069-0064-01,NDC,outpatient,30,ML,20.21,14.147,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,43066-0023-10,NDC,outpatient,30,ML,15.73,11.011,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,55150-0198-30,NDC,outpatient,30,ML,20.21,14.147,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-11,NDC,outpatient,30,ML,20.56,14.392,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,43066-0023-01,NDC,outpatient,30,ML,15.73,11.011,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-35,NDC,outpatient,30,ML,20.56,14.392,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC,,
ROMIPLOSTIM 125 MCG SC SOLR,RX-148858,CDM,J2796,HCPCS,636,RC,55513-0223-01,NDC,outpatient,1,UN,3455.52,2418.864,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,115.755066,,,115.755066,95.47,5307.61728,other,OPPS APC,,
ROMIPLOSTIM 125 MCG SC SOLR|DISCARDED DRUG NOT ADMINISTERED,RX-148858,CDM,J2796,HCPCS,636,RC,55513-0223-01,NDC,outpatient,1,UN,3455.52,2418.864,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,115.755066,,,115.755066,95.47,5307.61728,other,OPPS APC,,
ROMIPLOSTIM 250 MCG SC SOLR,RX-93566,CDM,J2796,HCPCS,636,RC,55513-0221-01,NDC,outpatient,1,UN,6910.96,4837.672,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,115.755066,,,115.755066,95.47,5307.61728,other,OPPS APC,,
SILTUXIMAB 100 MG IV SOLR,RX-125552,CDM,J2860,HCPCS,636,RC,73090-0420-01,NDC,outpatient,1,UN,4143.92,2900.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,179.925976,,,179.925976,139.22,12730.14528,other,OPPS APC,,
SILTUXIMAB 400 MG IV SOLR,RX-125553,CDM,J2860,HCPCS,636,RC,73090-0421-01,NDC,outpatient,1,UN,16575.71,11602.997,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,179.925976,,,179.925976,139.22,12730.14528,other,OPPS APC,,
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00024-2792-10,NDC,outpatient,5,ML,35.83,25.081,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.12,416.02,,,,
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00143-9570-01,NDC,outpatient,5,ML,61.68,43.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.12,416.02,,,,
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00143-9570-10,NDC,outpatient,5,ML,61.68,43.176,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.12,416.02,,,,
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00024-2792-01,NDC,outpatient,5,ML,35.83,25.081,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.12,416.02,,,,
ALTEPLASE 2 MG IJ SOLR,RX-31310,CDM,J2997,HCPCS,636,RC,50242-0041-64,NDC,outpatient,1,UN,725.13,507.591,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,104.778885,,,104.778885,89.15,17236.24704,other,OPPS APC,,
ALTEPLASE 2 MG IJ SOLR,RX-31310,CDM,J2997,HCPCS,636,RC,99999-0000-50,NDC,outpatient,2,ML,723.71,506.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,104.778885,,,104.778885,89.15,17236.24704,other,OPPS APC,,
ALTEPLASE 100 MG IV SOLR,RX-9002,CDM,J2997,HCPCS,636,RC,50242-0085-27,NDC,outpatient,1,UN,22443.03,15710.121,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,104.778885,,,104.778885,89.15,17236.24704,other,OPPS APC,,
ALTEPLASE 50 MG IV SOLR,RX-9003,CDM,J2997,HCPCS,636,RC,50242-0044-13,NDC,outpatient,1,UN,11221.53,7855.071,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,104.778885,,,104.778885,89.15,17236.24704,other,OPPS APC,,
STREPTOMYCIN SULFATE 1 G IM SOLR,RX-7508,CDM,J3000,HCPCS,636,RC,39822-0706-02,NDC,outpatient,1,UN,186.61,130.627,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,31.57,416.02,,,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-12,NDC,outpatient,2,ML,7.42,5.194,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.84,416.02,other,OPPS APC,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-13,NDC,outpatient,5,ML,9.41,6.587,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.84,416.02,other,OPPS APC,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00641-6027-25,NDC,outpatient,2,ML,6.08,4.256,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.84,416.02,other,OPPS APC,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-22,NDC,outpatient,2,ML,7.31,5.117,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.84,416.02,other,OPPS APC,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-61,NDC,outpatient,50,ML,40.05,28.035,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.84,416.02,other,OPPS APC,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-02,NDC,outpatient,2,ML,7.42,5.194,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.84,416.02,other,OPPS APC,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-05,NDC,outpatient,5,ML,9.41,6.587,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.84,416.02,other,OPPS APC,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-12,NDC,outpatient,2,ML,7.31,5.117,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.84,416.02,other,OPPS APC,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-41,NDC,outpatient,50,ML,40.05,28.035,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.84,416.02,other,OPPS APC,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00641-6027-01,NDC,outpatient,2,ML,6.08,4.256,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.84,416.02,other,OPPS APC,,
TENECTEPLASE 50 MG IV KIT,RX-28530,CDM,J3101,HCPCS,636,RC,50242-0120-47,NDC,outpatient,1,UN,19380.84,13566.588,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,180.672842,,,180.672842,152.7,14884.48512,other,OPPS APC,,
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,00143-9746-10,NDC,outpatient,1,ML,6.05,4.235,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.358225,416.02,other,OPPS APC,,
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,63323-0665-01,NDC,outpatient,1,ML,6.42,4.494,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.358225,416.02,other,OPPS APC,,
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,00143-9746-01,NDC,outpatient,1,ML,6.05,4.235,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.358225,416.02,other,OPPS APC,,
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,63323-0665-00,NDC,outpatient,1,ML,6.42,4.494,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.358225,416.02,other,OPPS APC,,
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,00641-1398-31,NDC,outpatient,2,ML,108.05,75.635,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.63291,416.02,,,,
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,00641-1398-35,NDC,outpatient,2,ML,108.05,75.635,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.63291,416.02,,,,
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,55150-0318-01,NDC,outpatient,1,ML,65.18,45.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.63291,416.02,,,,
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,55150-0318-25,NDC,outpatient,1,ML,65.18,45.626,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.63291,416.02,,,,
THYROTROPIN ALFA 0.9 MG IM SOLR,RX-156409,CDM,J3240,HCPCS,636,RC,58468-0030-02,NDC,outpatient,1,UN,5457.19,3820.033,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2375.012116,,,2375.012116,399.86,4191.12192,other,OPPS APC,,
TIGECYCLINE 50 MG IV SOLR,RX-41652,CDM,J3243,HCPCS,636,RC,55150-0228-10,NDC,outpatient,1,UN,119.66,83.762,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.52,416.02,,,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0430-01,NDC,outpatient,250,ML,529.98,370.986,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4.382683,,,4.382683,3.83,567.65184,other,OPPS APC,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-02,NDC,outpatient,250,ML,723.13,506.191,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,4.382683,,,4.382683,3.83,567.65184,other,OPPS APC,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-03,NDC,outpatient,100,ML,198.47,138.929,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,4.382683,,,4.382683,3.83,567.65184,other,OPPS APC,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-01,NDC,outpatient,100,ML,301.69,211.183,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4.382683,,,4.382683,3.83,567.65184,other,OPPS APC,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-02,NDC,outpatient,250,ML,739.13,517.391,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4.382683,,,4.382683,3.83,567.65184,other,OPPS APC,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-03,NDC,outpatient,100,ML,214.47,150.129,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4.382683,,,4.382683,3.83,567.65184,other,OPPS APC,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-01,NDC,outpatient,100,ML,285.69,199.983,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,4.382683,,,4.382683,3.83,567.65184,other,OPPS APC,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0429-01,NDC,outpatient,100,ML,219.39,153.573,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,4.382683,,,4.382683,3.83,567.65184,other,OPPS APC,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0430-01,NDC,outpatient,250,ML,513.98,359.786,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,4.382683,,,4.382683,3.83,567.65184,other,OPPS APC,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0429-01,NDC,outpatient,100,ML,235.39,164.773,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4.382683,,,4.382683,3.83,567.65184,other,OPPS APC,,
TRIMETHOBENZAMIDE HCL 100 MG/ML IM SOLN,RX-8178,CDM,J3250,HCPCS,636,RC,42023-0119-25,NDC,outpatient,2,ML,199.22,139.454,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,44.72489,416.02,,,,
TOBRAMYCIN SULFATE 1.2 G IJ SOLR,RX-11565,CDM,J3260,HCPCS,636,RC,39822-0412-01,NDC,outpatient,1,UN,217.92,152.544,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.882285,416.02,other,OPPS APC,,
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,00409-3578-01,NDC,outpatient,2,ML,13.74,9.618,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.882285,416.02,other,OPPS APC,,
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,67457-0473-00,NDC,outpatient,2,ML,3.93,2.751,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.882285,416.02,other,OPPS APC,,
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,63323-0306-02,NDC,outpatient,2,ML,16.01,11.207,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.882285,416.02,other,OPPS APC,,
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,00409-3578-11,NDC,outpatient,2,ML,13.74,9.618,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.882285,416.02,other,OPPS APC,,
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,67457-0473-22,NDC,outpatient,2,ML,3.93,2.751,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.882285,416.02,other,OPPS APC,,
TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN,RX-97790,CDM,J3260,HCPCS,636,RC,67457-0428-30,NDC,outpatient,30,ML,45.26,31.682,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.882285,416.02,other,OPPS APC,,
TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN,RX-97790,CDM,J3260,HCPCS,636,RC,63323-0306-30,NDC,outpatient,30,ML,60.48,42.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.882285,416.02,other,OPPS APC,,
TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN,RX-97790,CDM,J3260,HCPCS,636,RC,67457-0428-00,NDC,outpatient,30,ML,45.26,31.682,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.882285,416.02,other,OPPS APC,,
TOCILIZUMAB 20 MG/ML IV WRAPPER,RX-4080174,CDM,J3262,HCPCS,636,RC,50242-0135-01,NDC,outpatient,4,ML,1422.05,995.435,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6.829471,,,6.829471,5.91,5460.64128,other,OPPS APC,,
TOCILIZUMAB 20 MG/ML IV WRAPPER,RX-4080174,CDM,J3262,HCPCS,636,RC,50242-0137-01,NDC,outpatient,20,ML,7110.21,4977.147,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6.829471,,,6.829471,5.91,5460.64128,other,OPPS APC,,
TOCILIZUMAB 20 MG/ML IV WRAPPER,RX-4080174,CDM,J3262,HCPCS,636,RC,50242-0136-01,NDC,outpatient,10,ML,3555.08,2488.556,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6.829471,,,6.829471,5.91,5460.64128,other,OPPS APC,,
TRIAMCINOLONE ACETONIDE 10 MG/ML IJ SUSP,RX-11584,CDM,J3301,HCPCS,636,RC,00003-0494-20,NDC,outpatient,5,ML,49.71,34.797,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.9,416.02,other,OPPS APC,,
TRIAMCINOLONE ACETONIDE 40 MG/ML IJ SUSP,RX-8120,CDM,J3301,HCPCS,636,RC,00003-0293-05,NDC,outpatient,1,ML,38.5,26.95,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.9,416.02,other,OPPS APC,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,76045-0204-00,NDC,outpatient,2,ML,59.63,41.741,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,5.25,416.02,other,OPPS APC,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00409-1273-03,NDC,outpatient,2,ML,106.04,74.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,5.25,416.02,other,OPPS APC,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00409-1273-32,NDC,outpatient,2,ML,106.04,74.228,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,5.25,416.02,other,OPPS APC,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00641-6244-01,NDC,outpatient,2,ML,60.45,42.315,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,5.25,416.02,other,OPPS APC,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00641-6244-10,NDC,outpatient,2,ML,60.45,42.315,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,5.25,416.02,other,OPPS APC,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,76045-0204-20,NDC,outpatient,2,ML,59.63,41.741,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,5.25,416.02,other,OPPS APC,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,69339-0136-03,NDC,outpatient,2,ML,63.74,44.618,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,5.25,416.02,other,OPPS APC,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,69339-0136-34,NDC,outpatient,2,ML,63.74,44.618,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,5.25,416.02,other,OPPS APC,,
VANCOMYCIN HCL IN DEXTROSE 750 MG/150ML IV SOLN,RX-108740,CDM,J3370,HCPCS,636,RC,00338-3580-48,NDC,outpatient,150,ML,49.93,34.951,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC,,
VANCOMYCIN HCL IN DEXTROSE 750 MG/150ML IV SOLN,RX-108740,CDM,J3370,HCPCS,636,RC,99999-0000-88,NDC,outpatient,150,ML,35.17,24.619,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC,,
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,63323-0314-61,NDC,outpatient,10,GR,107.34,75.138,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC,,
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,67457-0342-10,NDC,outpatient,10,GR,875.85,613.095,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC,,
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,25021-0158-99,NDC,outpatient,10,GR,205.59,143.913,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC,,
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,70594-0048-01,NDC,outpatient,10,GR,267,186.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC,,
VANCOMYCIN HCL IN DEXTROSE 500 MG/100ML IV SOLN,RX-11632,CDM,J3370,HCPCS,636,RC,00338-3551-48,NDC,outpatient,100,ML,52.94,37.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC,,
VANCOMYCIN HCL IN NACL 750-0.9 MG/150ML-% IV SOLN,RX-134904,CDM,J3370,HCPCS,636,RC,00338-3582-01,NDC,outpatient,150,ML,73.41,51.387,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC,,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,16714-0309-01,NDC,outpatient,1,UN,11.19,7.833,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC,,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,16714-0309-10,NDC,outpatient,1,UN,11.19,7.833,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC,,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,00143-9357-01,NDC,outpatient,1,UN,12.35,8.645,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC,,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,67457-0340-00,NDC,outpatient,1,UN,16.63,11.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC,,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,67457-0340-01,NDC,outpatient,1,UN,16.63,11.641,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC,,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,00143-9357-10,NDC,outpatient,1,UN,12.35,8.645,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC,,
VANCOMYCIN HCL 5 G IV SOLR,RX-144290,CDM,J3370,HCPCS,636,RC,00409-6509-01,NDC,outpatient,5,GR,364.64,255.248,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC,,
VANCOMYCIN HCL 5 G IV SOLR,RX-144290,CDM,J3370,HCPCS,636,RC,67457-0341-05,NDC,outpatient,5,GR,361.57,253.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC,,
VANCOMYCIN HCL 5 G IV SOLR,RX-144290,CDM,J3370,HCPCS,636,RC,25021-0157-99,NDC,outpatient,5,GR,81.22,56.854,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC,,
VANCOMYCIN HCL 1.5 G IV SOLR,RX-145320,CDM,J3370,HCPCS,636,RC,00409-3515-11,NDC,outpatient,1,UN,51.81,36.267,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC,,
VANCOMYCIN HCL 1.5 G IV SOLR,RX-145320,CDM,J3370,HCPCS,636,RC,00409-3515-01,NDC,outpatient,1,UN,51.81,36.267,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC,,
VANCOMYCIN HCL 500 MG IV SOLR,RX-8443,CDM,J3370,HCPCS,636,RC,72611-0761-01,NDC,outpatient,1,UN,15.42,10.794,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC,,
VANCOMYCIN HCL 500 MG IV SOLR,RX-8443,CDM,J3370,HCPCS,636,RC,72611-0761-10,NDC,outpatient,1,UN,15.42,10.794,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC,,
VANCOMYCIN HCL IN DEXTROSE 1 GM/200ML IV SOLN,RX-92895,CDM,J3370,HCPCS,636,RC,00338-3552-48,NDC,outpatient,200,ML,52.27,36.589,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.16,672.6528,other,OPPS APC,,
VEDOLIZUMAB 300 MG IV SOLR,RX-125757,CDM,J3380,HCPCS,636,RC,64764-0300-20,NDC,outpatient,1,UN,23919.77,16743.839,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,25.49883,,,25.49883,22.26,18370.38336,other,OPPS APC,,
HYDROXYZINE HCL 50 MG/ML IM SOLN,RX-3770,CDM,J3410,HCPCS,636,RC,00517-5601-25,NDC,outpatient,1,ML,82.29,57.603,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.41,416.02,other,OPPS APC,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,25021-0500-02,NDC,outpatient,0.5,ML,4.68,3.276,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.88453,416.02,other,OPPS APC,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,67457-0196-02,NDC,outpatient,0.5,ML,3.94,2.758,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.88453,416.02,other,OPPS APC,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,00641-6228-01,NDC,outpatient,0.5,ML,4.75,3.325,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.88453,416.02,other,OPPS APC,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,00641-6228-25,NDC,outpatient,0.5,ML,4.75,3.325,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.88453,416.02,other,OPPS APC,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,55150-0273-01,NDC,outpatient,0.5,ML,4.61,3.227,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.88453,416.02,other,OPPS APC,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,55150-0273-25,NDC,outpatient,0.5,ML,4.61,3.227,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.88453,416.02,other,OPPS APC,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,67457-0196-00,NDC,outpatient,0.5,ML,3.94,2.758,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.88453,416.02,other,OPPS APC,,
PYRIDOXINE HCL 100 MG/ML IJ SOLN,RX-6744,CDM,J3415,HCPCS,636,RC,63323-0180-00,NDC,outpatient,0.5,ML,20.17,14.119,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.528165,416.02,,,,
PYRIDOXINE HCL 100 MG/ML IJ SOLN,RX-6744,CDM,J3415,HCPCS,636,RC,63323-0180-01,NDC,outpatient,0.5,ML,20.17,14.119,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.528165,416.02,,,,
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,63323-0044-01,NDC,outpatient,1,ML,6.18,4.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.15,416.02,other,OPPS APC,,
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,63323-0044-00,NDC,outpatient,1,ML,6.18,4.326,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.15,416.02,other,OPPS APC,,
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,00143-9621-01,NDC,outpatient,1,ML,10.83,7.581,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.15,416.02,other,OPPS APC,,
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,00143-9621-25,NDC,outpatient,1,ML,10.83,7.581,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.15,416.02,other,OPPS APC,,
HYDROXOCOBALAMIN 5 G IV SOLR,RX-111437,CDM,J3424,HCPCS,250,RC,50633-0310-11,NDC,outpatient,1,UN,2471.2,1729.84,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,5.7653015,,,5.7653015,5.69,1897.8816,other,OPPS APC,,
PHYTONADIONE 1 MG/0.5ML IJ SOLN WRAPPER,RX-4080206,CDM,J3430,HCPCS,636,RC,76329-1240-01,NDC,outpatient,0.5,ML,98.15,68.705,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.51,416.02,,,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,43598-0405-16,NDC,outpatient,1,ML,78.97,55.279,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.51,416.02,,,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,69097-0708-31,NDC,outpatient,1,ML,82.7,57.89,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.51,416.02,,,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,69097-0708-96,NDC,outpatient,1,ML,82.7,57.89,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.51,416.02,,,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,00409-9158-31,NDC,outpatient,1,ML,85.53,59.871,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.51,416.02,,,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,00409-9158-01,NDC,outpatient,1,ML,85.53,59.871,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.51,416.02,,,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,00409-9158-50,NDC,outpatient,1,ML,85.53,59.871,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.51,416.02,,,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,43598-0405-11,NDC,outpatient,1,ML,78.97,55.279,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.51,416.02,,,,
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,00781-3416-94,NDC,outpatient,1,UN,325.92,228.144,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,,,,
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,70436-0029-80,NDC,outpatient,1,UN,78.41,54.887,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,,,,
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,00049-3190-28,NDC,outpatient,1,UN,59.15,41.405,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,,,,
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,39822-1077-01,NDC,outpatient,1,UN,89.45,62.615,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.78,416.02,,,,
HYALURONIDASE HUMAN 15 UNIT/ML INJECTION SYRINGE,RX-4081350,CDM,J3473,HCPCS,636,RC,99999-0004-00,NDC,outpatient,1,ML,164.85,115.395,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.36,416.02,other,OPPS APC,,
HYALURONIDASE HUMAN 150 UNIT/ML IJ SOLN,RX-76338,CDM,J3473,HCPCS,636,RC,18657-0117-04,NDC,outpatient,1,ML,164.85,115.395,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.36,416.02,other,OPPS APC,,
HYALURONIDASE HUMAN 150 UNIT/ML IJ SOLN,RX-76338,CDM,J3473,HCPCS,636,RC,18657-0117-01,NDC,outpatient,1,ML,164.85,115.395,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.36,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00338-1709-40,NDC,outpatient,100,ML,22.17,15.519,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,63323-0108-01,NDC,outpatient,100,ML,26.28,18.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00409-6727-11,NDC,outpatient,100,ML,46.71,32.697,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00409-6727-23,NDC,outpatient,100,ML,46.71,32.697,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00264-4400-54,NDC,outpatient,100,ML,30.4,21.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,63323-0108-00,NDC,outpatient,100,ML,26.28,18.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,67457-0567-00,NDC,outpatient,100,ML,30.4,21.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,00409-6729-24,NDC,outpatient,50,ML,36.31,25.417,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,63323-0106-02,NDC,outpatient,50,ML,32.45,22.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,63323-0106-05,NDC,outpatient,50,ML,32.45,22.715,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,67457-0553-00,NDC,outpatient,50,ML,33.74,23.618,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,00338-1708-40,NDC,outpatient,50,ML,28.6,20.02,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,00409-6729-11,NDC,outpatient,50,ML,36.31,25.417,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,25021-0612-81,NDC,outpatient,50,ML,24.74,17.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,44567-0420-00,NDC,outpatient,50,ML,43.82,30.674,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,44567-0420-24,NDC,outpatient,50,ML,43.82,30.674,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,47335-0992-01,NDC,outpatient,50,ML,28.85,20.195,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 40 MG/ML SOLN WRAPPER,RX-4080721,CDM,J3475,HCPCS,636,RC,00409-2050-20,NDC,outpatient,500,ML,38.25,26.775,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 40 MG/ML SOLN WRAPPER,RX-4080721,CDM,J3475,HCPCS,636,RC,63323-0106-15,NDC,outpatient,500,ML,33.99,23.793,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 40 MG/ML SOLN WRAPPER,RX-4080721,CDM,J3475,HCPCS,636,RC,00409-2050-01,NDC,outpatient,500,ML,38.25,26.775,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-04,NDC,outpatient,10,ML,6.53,4.571,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,99999-0002-95,NDC,outpatient,2,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-11,NDC,outpatient,10,ML,6.53,4.571,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0642-50,NDC,outpatient,2,ML,3.32,2.324,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-01,NDC,outpatient,2,ML,5.46,3.822,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-03,NDC,outpatient,2,ML,5.46,3.822,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0642-02,NDC,outpatient,50,ML,55.41,38.787,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.47,416.02,other,OPPS APC,,
POTASSIUM CHLORIDE 10 MEQ/100ML IV SOLN,RX-11074,CDM,J3480,HCPCS,636,RC,00338-0709-48,NDC,outpatient,100,ML,26.8,18.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC,,
POTASSIUM CHLORIDE 10 MEQ/100ML IV SOLN,RX-11074,CDM,J3480,HCPCS,636,RC,00990-7074-26,NDC,outpatient,100,ML,36.92,25.844,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC,,
POTASSIUM CHLORIDE 20 MEQ/100ML IV SOLN,RX-11076,CDM,J3480,HCPCS,636,RC,00338-0705-48,NDC,outpatient,100,ML,26.8,18.76,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC,,
POTASSIUM CHLORIDE 20 MEQ/100ML IV SOLN,RX-11076,CDM,J3480,HCPCS,636,RC,00990-7075-26,NDC,outpatient,100,ML,37.81,26.467,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC,,
POTASSIUM CHLORIDE 20 MEQ/50ML IV SOLN,RX-11077,CDM,J3480,HCPCS,636,RC,00338-0703-41,NDC,outpatient,50,ML,26.28,18.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC,,
POTASSIUM CHLORIDE 20 MEQ/50ML IV SOLN,RX-11077,CDM,J3480,HCPCS,636,RC,00990-7077-14,NDC,outpatient,50,ML,37.59,26.313,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC,,
POTASSIUM CHLORIDE IN NACL 20-0.9 MEQ/L-% IV SOLN,RX-11081,CDM,J3480,HCPCS,636,RC,00338-0691-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC,,
POTASSIUM CHLORIDE IN NACL 40-0.9 MEQ/L-% IV SOLN,RX-11082,CDM,J3480,HCPCS,636,RC,00338-0695-04,NDC,outpatient,1000,ML,31.42,21.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC,,
KCL IN NACL 0.9% 10 MEQ/100ML IV SOLN,RX-166975,CDM,J3480,HCPCS,636,RC,99999-0001-77,NDC,outpatient,100,ML,26.28,18.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC,,
POTASSIUM CHLORIDE IN NACL 20-0.45 MEQ/L-% IV SOLN,RX-36046,CDM,J3480,HCPCS,636,RC,00338-0704-34,NDC,outpatient,1000,ML,26.28,18.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC,,
POTASSIUM CHLORIDE IN NACL 20 MEQ/50ML IV SOLN,RX-4081006,CDM,J3480,HCPCS,636,RC,99999-0001-79,NDC,outpatient,50,ML,31.17,21.819,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC,,
POTASSIUM CHLORIDE IN NACL 20 MEQ/100ML IV SOLN,RX-4081007,CDM,J3480,HCPCS,636,RC,99999-0001-78,NDC,outpatient,100,ML,30.91,21.637,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC,,
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN,RX-6429,CDM,J3480,HCPCS,636,RC,63323-0965-20,NDC,outpatient,20,ML,6.48,4.536,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC,,
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN,RX-6429,CDM,J3480,HCPCS,636,RC,63323-0965-02,NDC,outpatient,20,ML,6.48,4.536,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC,,
POTASSIUM CL IN DEXTROSE 5% 20 MEQ/L IV SOLN,RX-9791,CDM,J3480,HCPCS,636,RC,00338-0683-04,NDC,outpatient,1000,ML,31.42,21.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC,,
KCL IN DEXTROSE-NACL 20-5-0.9 MEQ/L-%-% IV SOLN,RX-9795,CDM,J3480,HCPCS,636,RC,00264-7652-00,NDC,outpatient,1000,ML,38.25,26.775,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC,,
KCL IN DEXTROSE-NACL 20-5-0.9 MEQ/L-%-% IV SOLN,RX-9795,CDM,J3480,HCPCS,636,RC,00338-0803-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC,,
KCL IN DEXTROSE-NACL 10-5-0.45 MEQ/L-%-% IV SOLN,RX-9799,CDM,J3480,HCPCS,636,RC,00338-0669-04,NDC,outpatient,1000,ML,31.42,21.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC,,
KCL IN DEXTROSE-NACL 10-5-0.45 MEQ/L-%-% IV SOLN,RX-9799,CDM,J3480,HCPCS,636,RC,00990-7993-09,NDC,outpatient,1000,ML,47.15,33.005,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC,,
KCL IN DEXTROSE-NACL 20-5-0.2 MEQ/L-%-% IV SOLN,RX-9800,CDM,J3480,HCPCS,636,RC,00338-0663-04,NDC,outpatient,1000,ML,31.42,21.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC,,
KCL IN DEXTROSE-NACL 20-5-0.2 MEQ/L-%-% IV SOLN,RX-9800,CDM,J3480,HCPCS,636,RC,00264-7645-00,NDC,outpatient,1000,ML,47.15,33.005,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC,,
KCL IN DEXTROSE-NACL 20-5-0.45 MEQ/L-%-% IV SOLN,RX-9801,CDM,J3480,HCPCS,636,RC,00338-0671-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC,,
KCL IN DEXTROSE-NACL 40-5-0.45 MEQ/L-%-% IV SOLN,RX-9807,CDM,J3480,HCPCS,636,RC,00338-0675-04,NDC,outpatient,1000,ML,31.42,21.994,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC,,
ZIDOVUDINE 10 MG/ML IV SOLN,RX-11691,CDM,J3485,HCPCS,636,RC,49702-0213-01,NDC,outpatient,20,ML,126.03,88.221,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.51,416.02,,,,
ZIDOVUDINE 10 MG/ML IV SOLN,RX-11691,CDM,J3485,HCPCS,636,RC,49702-0213-26,NDC,outpatient,20,ML,126.03,88.221,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.51,416.02,,,,
ZIPRASIDONE MESYLATE 20 MG IM SOLR,RX-33175,CDM,J3486,HCPCS,636,RC,00049-3920-20,NDC,outpatient,1,UN,264.92,185.444,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,7.43,416.02,,,,
ZIPRASIDONE MESYLATE 20 MG IM SOLR,RX-33175,CDM,J3486,HCPCS,636,RC,00049-3920-83,NDC,outpatient,1,UN,264.92,185.444,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,7.43,416.02,,,,
ZOLEDRONIC ACID 4 MG/5ML IV CONC,RX-35640,CDM,J3489,HCPCS,636,RC,67457-0390-54,NDC,outpatient,5,ML,30.53,21.371,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,6.47,416.02,other,OPPS APC,,
ZOLEDRONIC ACID 5 MG/100ML IV SOLN,RX-81434,CDM,J3489,HCPCS,636,RC,55111-0688-52,NDC,outpatient,100,ML,126.81,88.767,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,6.47,416.02,other,OPPS APC,,
ZOLEDRONIC ACID 5 MG/100ML IV SOLN,RX-81434,CDM,J3489,HCPCS,636,RC,67457-0619-10,NDC,outpatient,100,ML,182.43,127.701,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,6.47,416.02,other,OPPS APC,,
IDARUCIZUMAB 2.5 GM/50ML IV SOLN,RX-132721,CDM,J3590,HCPCS,636,RC,00597-0197-05,NDC,outpatient,100,ML,13473.22,9431.254,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,10347.43296,,,,
SODIUM CHLORIDE 0.45 % IV SOLN,RX-7318,CDM,J7030,HCPCS,250,RC,00338-0043-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.54,416.02,,,,
SODIUM CHLORIDE 0.45 % IV SOLN,RX-7318,CDM,J7030,HCPCS,250,RC,00338-0043-03,NDC,outpatient,500,ML,23.71,16.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.54,416.02,,,,
DEXTROSE-SODIUM CHLORIDE 5-0.9 % IV SOLN,RX-9815,CDM,J7042,HCPCS,636,RC,00338-0089-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.14,416.02,other,OPPS APC,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-03,NDC,outpatient,500,ML,23.71,16.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.81,416.02,other,OPPS APC,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-31,NDC,outpatient,50,ML,22.43,15.701,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.81,416.02,other,OPPS APC,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-11,NDC,outpatient,50,ML,22.43,15.701,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.81,416.02,other,OPPS APC,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-48,NDC,outpatient,100,ML,22.69,15.883,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.81,416.02,other,OPPS APC,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,63323-0624-74,NDC,outpatient,250,ML,25,17.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.81,416.02,other,OPPS APC,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-02,NDC,outpatient,250,ML,22.43,15.701,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.81,416.02,other,OPPS APC,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-38,NDC,outpatient,100,ML,22.17,15.519,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.81,416.02,other,OPPS APC,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00409-7100-02,NDC,outpatient,250,ML,30.14,21.098,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.81,416.02,other,OPPS APC,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00409-7100-04,NDC,outpatient,250,ML,30.14,21.098,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.81,416.02,other,OPPS APC,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-41,NDC,outpatient,50,ML,22.94,16.058,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.81,416.02,other,OPPS APC,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,63323-0624-04,NDC,outpatient,250,ML,25,17.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.81,416.02,other,OPPS APC,,
DEXTROSE 5 % IV PVC FREE SOLN,RX-4080550,CDM,J7060,HCPCS,636,RC,00338-6346-03,NDC,outpatient,500,ML,42.7,29.89,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.81,416.02,other,OPPS APC,,
DEXTROSE 5 % IV PVC FREE SOLN,RX-4080550,CDM,J7060,HCPCS,636,RC,00264-7510-10,NDC,outpatient,500,ML,33.99,23.793,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.81,416.02,other,OPPS APC,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7070,HCPCS,636,RC,00338-0017-04,NDC,outpatient,1000,ML,21.14,14.798,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.62,416.02,other,OPPS APC,,
DEXTRAN 40 IN D5W 10 % IV SOLN,RX-9759,CDM,J7100,HCPCS,636,RC,00409-7418-03,NDC,outpatient,500,ML,116.13,81.291,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.23,416.02,,,,
DEXTRAN 40 IN D5W 10 % IV SOLN,RX-9759,CDM,J7100,HCPCS,636,RC,00409-7418-13,NDC,outpatient,500,ML,116.13,81.291,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,19.23,416.02,,,,
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00264-7750-20,NDC,outpatient,250,ML,33.8,23.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.39,416.02,other,OPPS APC,,
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00338-0117-03,NDC,outpatient,500,ML,23.71,16.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.39,416.02,other,OPPS APC,,
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00338-0117-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.39,416.02,other,OPPS APC,,
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00338-0117-02,NDC,outpatient,250,ML,22.43,15.701,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.39,416.02,other,OPPS APC,,
DEXTROSE IN LACTATED RINGERS 5 % IV SOLN,RX-9788,CDM,J7121,HCPCS,636,RC,00338-0125-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,5.89986,416.02,,,,
PROTHROMBIN COMPLEX CONC HUMAN 500 UNITS IV KIT,RX-122122,CDM,J7168,HCPCS,636,RC,63833-0386-02,NDC,outpatient,1,UN,3022.2,2115.54,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.568211,,,2.568211,2.568211,4642.0992,other,OPPS APC,,
PROTHROMBIN COMPLEX CONC HUMAN 1000 UNITS IV KIT,RX-125272,CDM,J7168,HCPCS,636,RC,63833-0387-02,NDC,outpatient,1,UN,6044.4,4231.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.568211,,,2.568211,2.568211,4642.0992,other,OPPS APC,,
ANTIHEMOPHILIC FACTOR-VWF 500-500 UNITS IV KIT,RX-134441,CDM,J7183,HCPCS,636,RC,68982-0182-01,NDC,outpatient,1,UN,1449,1014.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.46624,,,1.46624,1.26,2225.664,other,OPPS APC,,
ANTIHEMOPHILIC FACTOR-VWF 1000-1000 UNITS IV KIT,RX-134442,CDM,J7183,HCPCS,636,RC,68982-0182-02,NDC,outpatient,1,UN,2898,2028.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.46624,,,1.46624,1.26,2225.664,other,OPPS APC,,
ANTIHEMOPHILIC FACTOR-VWF 250-600 UNITS IV SOLR,RX-70404,CDM,J7187,HCPCS,636,RC,63833-0625-01,NDC,outpatient,1,UN,1821.6,1275.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.5979725,,,1.5979725,1.23,3240,other,OPPS APC,,
ANTIHEMOPHILIC FACTOR-VWF 250-600 UNITS IV SOLR,RX-70404,CDM,J7187,HCPCS,636,RC,63833-0615-02,NDC,outpatient,1,UN,1821.6,1275.12,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.5979725,,,1.5979725,1.23,3240,other,OPPS APC,,
ANTIHEMOPHILIC FACTOR-VWF 500-1200 UNITS IV SOLR,RX-70405,CDM,J7187,HCPCS,636,RC,63833-0626-01,NDC,outpatient,1,UN,3643.2,2550.24,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.5979725,,,1.5979725,1.23,3240,other,OPPS APC,,
ANTIHEMOPHILIC FACTOR-VWF 500-1200 UNITS IV SOLR,RX-70405,CDM,J7187,HCPCS,636,RC,63833-0616-02,NDC,outpatient,1,UN,3643.2,2550.24,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.5979725,,,1.5979725,1.23,3240,other,OPPS APC,,
ANTIHEMOPHILIC FACTOR-VWF 1000-2400 UNITS IV SOLR,RX-70406,CDM,J7187,HCPCS,636,RC,63833-0617-02,NDC,outpatient,1,UN,3036,2125.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.5979725,,,1.5979725,1.23,3240,other,OPPS APC,,
ANTIHEMOPHILIC FACTOR-VWF 1000-2400 UNITS IV SOLR,RX-70406,CDM,J7187,HCPCS,636,RC,63833-0627-01,NDC,outpatient,1,UN,3036,2125.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.5979725,,,1.5979725,1.23,3240,other,OPPS APC,,
COAGULATION FACTOR VIIA RECOMB 1 MG IV SOLR,RX-92853,CDM,J7189,HCPCS,636,RC,00169-7211-11,NDC,outpatient,1,UN,6342.76,4439.932,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.8832235,,,2.8832235,2.13,24356.18304,other,OPPS APC,,
COAGULATION FACTOR VIIA RECOMB 1 MG IV SOLR,RX-92853,CDM,J7189,HCPCS,636,RC,00169-7201-01,NDC,outpatient,1,UN,6342.76,4439.932,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.8832235,,,2.8832235,2.13,24356.18304,other,OPPS APC,,
COAGULATION FACTOR VIIA RECOMB 2 MG IV SOLR,RX-92854,CDM,J7189,HCPCS,636,RC,00169-7212-11,NDC,outpatient,1,UN,12685.52,8879.864,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.8832235,,,2.8832235,2.13,24356.18304,other,OPPS APC,,
COAGULATION FACTOR VIIA RECOMB 2 MG IV SOLR,RX-92854,CDM,J7189,HCPCS,636,RC,00169-7202-01,NDC,outpatient,1,UN,12685.52,8879.864,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.8832235,,,2.8832235,2.13,24356.18304,other,OPPS APC,,
COAGULATION FACTOR VIIA RECOMB 5 MG IV SOLR,RX-92855,CDM,J7189,HCPCS,636,RC,00169-7205-01,NDC,outpatient,1,UN,31713.78,22199.646,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.8832235,,,2.8832235,2.13,24356.18304,other,OPPS APC,,
ANTIHEMOPHILIC FACTOR VIII RAHF-PFM 500 UNITS IV SOLR,RX-76366,CDM,J7192,HCPCS,636,RC,00944-3052-02,NDC,outpatient,1,UN,1863,1304.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.773234,,,1.773234,1.25,2861.568,other,OPPS APC,,
ANTIHEMOPHILIC FACTOR VIII RAHF-PFM 1000 UNITS IV SOLR,RX-76367,CDM,J7192,HCPCS,636,RC,00944-3053-02,NDC,outpatient,1,UN,3726,2608.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.773234,,,1.773234,1.25,2861.568,other,OPPS APC,,
ANTITHROMBIN III (HUMAN) 500 UNITS IV SOLR,RX-9116,CDM,J7197,HCPCS,636,RC,13533-0606-12,NDC,outpatient,1,UN,4954.2,3467.94,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4.4136115,,,4.4136115,3.35,3804.8256,other,OPPS APC,,
ANTITHROMBIN III (HUMAN) 500 UNITS IV SOLR,RX-9116,CDM,J7197,HCPCS,636,RC,13533-0602-50,NDC,outpatient,1,UN,4954.2,3467.94,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4.4136115,,,4.4136115,3.35,3804.8256,other,OPPS APC,,
ANTIINHIBITOR COAGULANT CMPLX 2500 UNITS IV SOLR,RX-146201,CDM,J7198,HCPCS,636,RC,64193-0425-02,NDC,outpatient,1,UN,13869,9708.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2.685052,,,2.685052,1.94,10651.392,other,OPPS APC,,
SODIUM HYALURONATE (VISCOSUP) 25 MG/2.5ML IX SOSY,RX-127543,CDM,J7321,HCPCS,636,RC,89130-4444-01,NDC,outpatient,2.5,ML,1023.91,716.737,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,73.22,786.36288,other,OPPS APC,,
AZATHIOPRINE 50 MG ORAL TABS,RX-9183,CDM,J7500,HCPCS,259,RC,68084-0229-11,NDC,outpatient,1,UN,2.39,1.673,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.536555,416.02,,,,
AZATHIOPRINE 50 MG ORAL TABS,RX-9183,CDM,J7500,HCPCS,259,RC,68084-0229-01,NDC,outpatient,1,UN,2.39,1.673,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.536555,416.02,,,,
CYCLOSPORINE 50 MG/ML IV SOLN,RX-9705,CDM,J7516,HCPCS,636,RC,00574-0866-10,NDC,outpatient,5,ML,142.85,99.995,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,15.32,416.02,,,,
MYCOPHENOLATE MOFETIL HCL 500 MG IV SOLR,RX-23968,CDM,J7519,HCPCS,636,RC,00004-0298-09,NDC,outpatient,1,UN,298.3,208.81,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.5922235,,,0.5922235,0.52,416.02,other,OPPS APC,,
MYCOPHENOLATE MOFETIL HCL 500 MG IV SOLR,RX-23968,CDM,J7519,HCPCS,636,RC,71288-0803-20,NDC,outpatient,1,UN,89.27,62.489,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.5922235,,,0.5922235,0.52,416.02,other,OPPS APC,,
METHACHOLINE CHLORIDE 100 MG IN SOLR,RX-27032,CDM,J7674,HCPCS,636,RC,64281-0100-06,NDC,outpatient,1,UN,341.28,238.896,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.86,416.02,other,OPPS APC,,
METHACHOLINE CHLORIDE 100 MG IN SOLR,RX-27032,CDM,J7674,HCPCS,636,RC,64281-0100-00,NDC,outpatient,1,UN,341.28,238.896,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.86,416.02,other,OPPS APC,,
ETOPOSIDE 50 MG ORAL CAPS,RX-10001,CDM,J8560,HCPCS,636,RC,00378-3266-32,NDC,outpatient,1,UN,309.74,216.818,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,87.818612,,,87.818612,69.53663,416.02,other,OPPS APC,,
ETOPOSIDE 50 MG ORAL CAPS,RX-10001,CDM,J8560,HCPCS,636,RC,00378-3266-94,NDC,outpatient,1,UN,309.74,216.818,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,87.818612,,,87.818612,69.53663,416.02,other,OPPS APC,,
MERCAPTOPURINE 50 MG ORAL TABS,RX-10531,CDM,J8999,HCPCS,259,RC,00054-4581-11,NDC,outpatient,1,UN,14.11,9.877,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.370425,416.02,other,Status Indicator B on TOB 12x or 13x: Research Alt,,
MERCAPTOPURINE 50 MG ORAL TABS,RX-10531,CDM,J8999,HCPCS,259,RC,00378-3547-52,NDC,outpatient,1,UN,4.39,3.073,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.370425,416.02,other,Status Indicator B on TOB 12x or 13x: Research Alt,,
BICALUTAMIDE 50 MG ORAL TABS,RX-15746,CDM,J8999,HCPCS,259,RC,16729-0023-10,NDC,outpatient,1,UN,2.86,2.002,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.370425,416.02,other,Status Indicator B on TOB 12x or 13x: Research Alt,,
ANASTROZOLE 1 MG ORAL TABS,RX-16205,CDM,J8999,HCPCS,259,RC,60687-0112-11,NDC,outpatient,1,UN,3.22,2.254,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.370425,416.02,other,Status Indicator B on TOB 12x or 13x: Research Alt,,
ANASTROZOLE 1 MG ORAL TABS,RX-16205,CDM,J8999,HCPCS,259,RC,60687-0112-21,NDC,outpatient,1,UN,3.22,2.254,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.370425,416.02,other,Status Indicator B on TOB 12x or 13x: Research Alt,,
MEGESTROL ACETATE 40 MG ORAL TABS,RX-4871,CDM,J8999,HCPCS,259,RC,64380-0159-01,NDC,outpatient,1,UN,1.65,1.155,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.370425,416.02,other,Status Indicator B on TOB 12x or 13x: Research Alt,,
MEGESTROL ACETATE 400 MG/10ML ORAL SUSP,RX-76824,CDM,J8999,HCPCS,259,RC,00121-0945-10,NDC,outpatient,10,ML,15.58,10.906,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.370425,416.02,other,Status Indicator B on TOB 12x or 13x: Research Alt,,
MEGESTROL ACETATE 400 MG/10ML ORAL SUSP,RX-76824,CDM,J8999,HCPCS,259,RC,00121-0945-40,NDC,outpatient,10,ML,15.58,10.906,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.370425,416.02,other,Status Indicator B on TOB 12x or 13x: Research Alt,,
MEGESTROL ACETATE 400 MG/10ML ORAL SUSP,RX-76824,CDM,J8999,HCPCS,259,RC,99999-0003-95,NDC,outpatient,10,ML,8.73,6.111,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.370425,416.02,other,Status Indicator B on TOB 12x or 13x: Research Alt,,
TAMOXIFEN CITRATE 10 MG ORAL TABS,RX-7711,CDM,J8999,HCPCS,259,RC,63739-0143-10,NDC,outpatient,1,UN,1.98,1.386,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.370425,416.02,other,Status Indicator B on TOB 12x or 13x: Research Alt,,
DOXORUBICIN HCL 2 MG/ML IV PUSH SOLN,RX-2616,CDM,J9000,HCPCS,636,RC,00069-3032-20,NDC,outpatient,25,ML,44.02,30.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.5,525.12,other,OPPS APC,,
DOXORUBICIN HCL 2 MG/ML IV PUSH SOLN,RX-2616,CDM,J9000,HCPCS,636,RC,00069-3030-20,NDC,outpatient,5,ML,19.68,13.776,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.5,525.12,other,OPPS APC,,
DOXORUBICIN HCL 2 MG/ML IV PUSH SOLN,RX-2616,CDM,J9000,HCPCS,636,RC,00069-3031-20,NDC,outpatient,10,ML,34.71,24.297,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.5,525.12,other,OPPS APC,,
DOXORUBICIN HCL 10 MG IV SOLR,RX-2617,CDM,J9000,HCPCS,636,RC,00143-9092-01,NDC,outpatient,1,UN,143.64,100.548,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.5,525.12,other,OPPS APC,,
DOXORUBICIN HCL 50 MG IV SOLR,RX-2619,CDM,J9000,HCPCS,636,RC,00143-9277-01,NDC,outpatient,1,UN,683.75,478.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.5,525.12,other,OPPS APC,,
ARSENIC TRIOXIDE 12 MG/6ML IV SOLN,RX-141420,CDM,J9017,HCPCS,636,RC,63459-0601-06,NDC,outpatient,6,ML,3082.97,2158.079,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8.2464545,,,8.2464545,7.2,2367.72096,other,OPPS APC,,
ARSENIC TRIOXIDE 12 MG/6ML IV SOLN,RX-141420,CDM,J9017,HCPCS,636,RC,63459-0601-11,NDC,outpatient,6,ML,3082.97,2158.079,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8.2464545,,,8.2464545,7.2,2367.72096,other,OPPS APC,,
AZACITIDINE 100 MG IJ SUSR,RX-78420,CDM,J9025,HCPCS,636,RC,43598-0305-62,NDC,outpatient,1,UN,83.86,58.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.32,416.02,other,OPPS APC,,
AZACITIDINE 100 MG IJ SUSR,RX-78420,CDM,J9025,HCPCS,636,RC,63323-0771-39,NDC,outpatient,1,UN,117.36,82.152,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.32,416.02,other,OPPS APC,,
BENDAMUSTINE HCL 5 MG/ML IV SOLR WRAPPER,RX-4080211,CDM,J9033,HCPCS,636,RC,63459-0390-08,NDC,outpatient,5,ML,889.43,622.601,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6.2212105,,,6.2212105,5.43,2152.77312,other,OPPS APC,,
BENDAMUSTINE HCL 5 MG/ML IV SOLR WRAPPER,RX-4080211,CDM,J9033,HCPCS,636,RC,63459-0391-20,NDC,outpatient,20,ML,2803.09,1962.163,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,6.2212105,,,6.2212105,5.43,2152.77312,other,OPPS APC,,
BENDAMUSTINE HCL 100 MG/4ML IV SOLN,RX-133070,CDM,J9034,HCPCS,636,RC,63459-0348-04,NDC,outpatient,4,ML,5078.48,3554.936,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,14.829643,,,14.829643,12.95,3900.27264,other,OPPS APC,,
BEVACIZUMAB 25 MG/ML IV WRAPPER,RX-4080193,CDM,J9035,HCPCS,636,RC,50242-0060-01,NDC,outpatient,4,ML,2279.25,1595.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,83.282432,,,83.282432,72.7,7001.856,other,OPPS APC,,
BEVACIZUMAB 25 MG/ML IV WRAPPER,RX-4080193,CDM,J9035,HCPCS,636,RC,50242-0061-01,NDC,outpatient,16,ML,9117,6381.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,83.282432,,,83.282432,72.7,7001.856,other,OPPS APC,,
BLEOMYCIN SULFATE 30 UNITS IJ SOLR,RX-17012,CDM,J9040,HCPCS,636,RC,63323-0137-20,NDC,outpatient,1,UN,120.16,84.112,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.931495,416.02,other,OPPS APC,,
BLEOMYCIN SULFATE 15 UNITS IJ SOLR *TEST DOSE*,RX-9289,CDM,J9040,HCPCS,636,RC,16714-0886-01,NDC,outpatient,1,UN,66.51,46.557,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,14.931495,416.02,other,OPPS APC,,
BORTEZOMIB 3.5 MG IJ SOLR,RX-123070,CDM,J9041,HCPCS,636,RC,00143-9098-01,NDC,outpatient,1,UN,58.7,41.09,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.800726,,,1.800726,1.57,905.322979,other,OPPS APC,,
BORTEZOMIB 3.5 MG IJ SOLR,RX-123070,CDM,J9041,HCPCS,636,RC,10019-0991-01,NDC,outpatient,1,UN,147.6,103.32,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,1.800726,,,1.800726,1.57,905.322979,other,OPPS APC,,
BRENTUXIMAB VEDOTIN 50 MG IV SOLR,RX-111348,CDM,J9042,HCPCS,636,RC,51144-0050-01,NDC,outpatient,1,UN,32323.72,22626.604,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,274.755048,,,274.755048,221.96,24824.61696,other,OPPS APC,,
CABAZITAXEL 60 MG/1.5ML IV SOLN,RX-105644,CDM,J9043,HCPCS,636,RC,00024-5824-11,NDC,outpatient,6,ML,39665.77,27766.039,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,247.9492025,,,247.9492025,206.03,30463.31136,other,OPPS APC,,
CARBOPLATIN 10 MG/ML IV SOLN WRAPPER,RX-4080212,CDM,J9045,HCPCS,636,RC,00703-4248-01,NDC,outpatient,45,ML,63.71,44.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.41,416.02,other,OPPS APC,,
CARBOPLATIN 10 MG/ML IV SOLN WRAPPER,RX-4080212,CDM,J9045,HCPCS,636,RC,61703-0339-50,NDC,outpatient,45,ML,157.96,110.572,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.41,416.02,other,OPPS APC,,
CARFILZOMIB 60 MG IV SOLR,RX-117047,CDM,J9047,HCPCS,636,RC,76075-0101-01,NDC,outpatient,1,UN,8945.66,6261.962,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,56.7904535,,,56.7904535,47.04,6870.26688,other,OPPS APC,,
CETUXIMAB 200 MG/100ML IV SOLN,RX-108072,CDM,J9055,HCPCS,636,RC,66733-0958-23,NDC,outpatient,100,ML,4373.8,3061.66,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,86.4611945,,,86.4611945,72.08,3359.0784,other,OPPS APC,,
CETUXIMAB 100 MG/50ML IV SOLN,RX-37989,CDM,J9055,HCPCS,636,RC,66733-0948-23,NDC,outpatient,50,ML,2186.9,1530.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,86.4611945,,,86.4611945,72.08,3359.0784,other,OPPS APC,,
CISPLATIN 1 MG/ML IV WRAPPER,RX-4080194,CDM,J9060,HCPCS,636,RC,00703-5748-11,NDC,outpatient,100,ML,67.89,47.523,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.37,416.02,other,OPPS APC,,
CLADRIBINE 1 MG/ML IV SOLN WRAPPER,RX-4080791,CDM,J9065,HCPCS,636,RC,63323-0140-10,NDC,outpatient,10,ML,347.72,243.404,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,16.3176475,,,16.3176475,14.25,416.02,other,OPPS APC,,
CYTARABINE (PF) 100 MG/ML IJ SOLN,RX-20156,CDM,J9100,HCPCS,636,RC,63323-0120-20,NDC,outpatient,20,ML,40.95,28.665,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.77,416.02,other,OPPS APC,,
CYTARABINE (PF) 100 MG/ML IJ SOLN,RX-20156,CDM,J9100,HCPCS,636,RC,61703-0319-22,NDC,outpatient,20,ML,53.29,37.303,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.77,416.02,other,OPPS APC,,
CYTARABINE (PF) 20 MG/ML IJ SOLN,RX-96982,CDM,J9100,HCPCS,636,RC,61703-0303-46,NDC,outpatient,50,ML,62.44,43.708,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.77,416.02,other,OPPS APC,,
CYTARABINE (PF) 20 MG/ML IJ SOLN,RX-96982,CDM,J9100,HCPCS,636,RC,61703-0305-38,NDC,outpatient,5,ML,16.81,11.767,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.77,416.02,other,OPPS APC,,
CYTARABINE (PF) 20 MG/ML IJ SOLN,RX-96982,CDM,J9100,HCPCS,636,RC,61703-0305-58,NDC,outpatient,5,ML,16.81,11.767,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.77,416.02,other,OPPS APC,,
CYTARABINE 20 MG/ML IJ SOLN,RX-9709,CDM,J9100,HCPCS,636,RC,61703-0304-36,NDC,outpatient,25,ML,34.67,24.269,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.77,416.02,other,OPPS APC,,
DACARBAZINE 200 MG IV SOLR,RX-2091,CDM,J9130,HCPCS,636,RC,00143-9245-01,NDC,outpatient,1,UN,16.44,11.508,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.69078,416.02,other,OPPS APC,,
DACARBAZINE 200 MG IV SOLR,RX-2091,CDM,J9130,HCPCS,636,RC,00143-9245-10,NDC,outpatient,1,UN,16.44,11.508,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.69078,416.02,other,OPPS APC,,
DEGARELIX ACETATE(240 MG DOSE) 120 MG/VIAL SC SOLR,RX-150086,CDM,J9155,HCPCS,636,RC,55566-8403-01,NDC,outpatient,1,UN,1744.22,1220.954,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4.783608,,,4.783608,4.18,1339.56096,other,OPPS APC,,
DEGARELIX ACETATE 80 MG SC SOLR,RX-96986,CDM,J9155,HCPCS,636,RC,55566-8303-01,NDC,outpatient,1,UN,1117.94,782.558,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4.783608,,,4.783608,4.18,1339.56096,other,OPPS APC,,
DOCETAXEL 20 MG/ML IV CONC WRAPPER,RX-4080197,CDM,J9171,HCPCS,636,RC,16729-0267-65,NDC,outpatient,8,ML,615.8,431.06,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.79,1115.136,other,OPPS APC,,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,00409-0201-20,NDC,outpatient,16,ML,345.35,241.745,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.79,1115.136,other,OPPS APC,,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,43066-0006-01,NDC,outpatient,8,ML,120.55,84.385,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.79,1115.136,other,OPPS APC,,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,00409-0201-02,NDC,outpatient,2,ML,45.67,31.969,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.79,1115.136,other,OPPS APC,,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,66758-0050-01,NDC,outpatient,2,ML,181.5,127.05,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.79,1115.136,other,OPPS APC,,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,66758-0050-02,NDC,outpatient,8,ML,726,508.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.79,1115.136,other,OPPS APC,,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,66758-0050-03,NDC,outpatient,16,ML,1452,1016.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.79,1115.136,other,OPPS APC,,
EPIRUBICIN HCL 2 MG/ML IV SOLN WRAPPER,RX-4080365,CDM,J9178,HCPCS,636,RC,00009-5091-01,NDC,outpatient,25,ML,112.35,78.645,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.34,416.02,,,,
ERIBULIN MESYLATE 1 MG/2ML IV PUSH SOLN,RX-106773,CDM,J9179,HCPCS,636,RC,62856-0389-01,NDC,outpatient,2,ML,4032.6,2822.82,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,155.5417175,,,155.5417175,128.78,3097.0368,other,OPPS APC,,
ETOPOSIDE 100 MG/5ML IV SOLN,RX-124543,CDM,J9181,HCPCS,636,RC,16729-0114-08,NDC,outpatient,25,ML,169.25,118.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.7,416.02,other,OPPS APC,,
ETOPOSIDE 100 MG/5ML IV SOLN,RX-124543,CDM,J9181,HCPCS,636,RC,16729-0114-31,NDC,outpatient,5,ML,33.84,23.688,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.7,416.02,other,OPPS APC,,
FLUDARABINE PHOSPHATE 25 MG/ML IV WRAPPER,RX-4080526,CDM,J9185,HCPCS,636,RC,25021-0242-02,NDC,outpatient,2,ML,278.39,194.873,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,153.673407,,,153.673407,62.498555,604.75,other,OPPS APC,,
FLUOROURACIL 50 MG/ML IV SOLN WRAPPER,RX-4080199,CDM,J9190,HCPCS,636,RC,16729-0276-11,NDC,outpatient,50,ML,99.65,69.755,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.83,416.02,other,OPPS APC,,
FLUOROURACIL 500 MG/10ML IV PUSH SOLN,RX-82200,CDM,J9190,HCPCS,636,RC,63323-0117-10,NDC,outpatient,10,ML,8.43,5.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.83,416.02,other,OPPS APC,,
FLUOROURACIL 500 MG/10ML IV PUSH SOLN,RX-82200,CDM,J9190,HCPCS,636,RC,63323-0117-00,NDC,outpatient,10,ML,8.43,5.901,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.83,416.02,other,OPPS APC,,
GEMCITABINE HCL 200 MG/5.26ML IV SOLN,RX-112786,CDM,J9201,HCPCS,636,RC,00409-0183-01,NDC,outpatient,5.26,ML,31.43,22.001,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.79,416.02,other,OPPS APC,,
GEMCITABINE HCL 1 GM/26.3ML IV SOLN,RX-112787,CDM,J9201,HCPCS,636,RC,00409-0181-01,NDC,outpatient,26.3,ML,133.66,93.562,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.79,416.02,other,OPPS APC,,
GEMCITABINE HCL 200 MG IV SOLR,RX-17121,CDM,J9201,HCPCS,636,RC,25021-0234-10,NDC,outpatient,1,UN,27.81,19.467,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.79,416.02,other,OPPS APC,,
GEMCITABINE HCL 1 G IV SOLR,RX-17122,CDM,J9201,HCPCS,636,RC,16714-0930-01,NDC,outpatient,1,UN,63.54,44.478,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.79,416.02,other,OPPS APC,,
GOSERELIN ACETATE 3.6 MG SC IMPL,RX-10137,CDM,J9202,HCPCS,636,RC,70720-0950-36,NDC,outpatient,1,UN,2706.82,1894.774,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,772.951326,,,772.951326,399.86,5828.5824,other,OPPS APC,,
GOSERELIN ACETATE 10.8 MG SC IMPL,RX-16254,CDM,J9202,HCPCS,636,RC,70720-0951-30,NDC,outpatient,1,UN,7589.3,5312.51,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,772.951326,,,772.951326,399.86,5828.5824,other,OPPS APC,,
IRINOTECAN HCL 20 MG/ML IV SOLN WRAPPER,RX-4080202,CDM,J9206,HCPCS,636,RC,60505-6128-01,NDC,outpatient,5,ML,26.29,18.403,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.5,416.02,other,OPPS APC,,
IRINOTECAN HCL 20 MG/ML IV SOLN WRAPPER,RX-4080202,CDM,J9206,HCPCS,636,RC,61703-0349-09,NDC,outpatient,5,ML,56.89,39.823,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.5,416.02,other,OPPS APC,,
IRINOTECAN HCL 20 MG/ML IV SOLN WRAPPER,RX-4080202,CDM,J9206,HCPCS,636,RC,61703-0349-16,NDC,outpatient,2,ML,43.49,30.443,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.5,416.02,other,OPPS APC,,
IXABEPILONE 15 MG IV SOLR,RX-88652,CDM,J9207,HCPCS,636,RC,70020-1910-01,NDC,outpatient,1,UN,5537.91,3876.537,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,153.5622935,,,153.5622935,122.55,12759.31392,other,OPPS APC,,
IXABEPILONE 45 MG IV SOLR,RX-88653,CDM,J9207,HCPCS,636,RC,70020-1911-01,NDC,outpatient,1,UN,16613.69,11629.583,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,153.5622935,,,153.5622935,122.55,12759.31392,other,OPPS APC,,
IFOSFAMIDE 1 G IV SOLR,RX-10248,CDM,J9208,HCPCS,636,RC,10019-0925-82,NDC,outpatient,1,UN,94.35,66.045,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,21.181575,416.02,other,OPPS APC,,
IFOSFAMIDE 1 G IV SOLR,RX-10248,CDM,J9208,HCPCS,636,RC,10019-0925-01,NDC,outpatient,1,UN,94.35,66.045,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,21.181575,416.02,other,OPPS APC,,
IFOSFAMIDE 3 G IV SOLR,RX-10249,CDM,J9208,HCPCS,636,RC,00338-3993-01,NDC,outpatient,1,UN,350.95,245.665,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,21.181575,416.02,other,OPPS APC,,
IFOSFAMIDE 3 G IV SOLR,RX-10249,CDM,J9208,HCPCS,636,RC,10019-0926-16,NDC,outpatient,1,UN,288.44,201.908,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,21.181575,416.02,other,OPPS APC,,
IFOSFAMIDE 3 G IV SOLR,RX-10249,CDM,J9208,HCPCS,636,RC,10019-0926-02,NDC,outpatient,1,UN,288.44,201.908,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,21.181575,416.02,other,OPPS APC,,
MESNA 100 MG/ML IV SOLN,RX-10537,CDM,J9209,HCPCS,636,RC,63323-0733-11,NDC,outpatient,10,ML,222.31,155.617,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.67,416.02,other,OPPS APC,,
MESNA 100 MG/ML IV SOLN,RX-10537,CDM,J9209,HCPCS,636,RC,00338-1305-01,NDC,outpatient,10,ML,28.36,19.852,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.67,416.02,other,OPPS APC,,
IDARUBICIN HCL 1 MG/ML IV SOLN WRAPPER,RX-4080583,CDM,J9211,HCPCS,636,RC,00013-2576-91,NDC,outpatient,5,ML,121.76,85.232,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,27.33512,416.02,,,,
LEUPROLIDE ACETATE 7.5 MG IM KIT,RX-10392,CDM,J9217,HCPCS,636,RC,00074-3642-03,NDC,outpatient,1,UN,5670.76,3969.532,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,202.192205,,,202.192205,165.86,17420.48256,other,OPPS APC,,
LEUPROLIDE ACETATE (3 MONTH) 22.5 MG IM KIT,RX-21045,CDM,J9217,HCPCS,636,RC,00074-3346-03,NDC,outpatient,1,UN,17012.14,11908.498,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,202.192205,,,202.192205,165.86,17420.48256,other,OPPS APC,,
LEUPROLIDE ACETATE (4 MONTH) 30 MG IM KIT,RX-21108,CDM,J9217,HCPCS,636,RC,00074-3683-03,NDC,outpatient,1,UN,22682.92,15878.044,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,202.192205,,,202.192205,165.86,17420.48256,other,OPPS APC,,
LEUPROLIDE ACETATE (4 MONTH) 30 MG SC KIT,RX-35236,CDM,J9217,HCPCS,636,RC,62935-0303-30,NDC,outpatient,1,UN,1549.29,1084.503,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,202.192205,,,202.192205,165.86,17420.48256,other,OPPS APC,,
IPILIMUMAB 5 MG/ML IV SOLN WRAPPER,RX-4080201,CDM,J9228,HCPCS,636,RC,00003-2327-11,NDC,outpatient,10,ML,24402.93,17082.051,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,202.620622,,,202.620622,167.93,74965.60128,other,OPPS APC,,
IPILIMUMAB 5 MG/ML IV SOLN WRAPPER,RX-4080201,CDM,J9228,HCPCS,636,RC,00003-2328-22,NDC,outpatient,40,ML,97611.46,68328.022,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,202.620622,,,202.620622,167.93,74965.60128,other,OPPS APC,,
METHOTREXATE SODIUM (PF) 25 MG/ML IJ SOLN WRAPPER,RX-4080789,CDM,J9260,HCPCS,636,RC,00143-9519-10,NDC,outpatient,2,ML,6.58,4.606,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.47721,416.02,other,OPPS APC,,
METHOTREXATE SODIUM (PF) 25 MG/ML IJ SOLN WRAPPER,RX-4080789,CDM,J9260,HCPCS,636,RC,00143-9519-01,NDC,outpatient,2,ML,6.58,4.606,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.47721,416.02,other,OPPS APC,,
NELARABINE 5 MG/ML IV SOLN,RX-70267,CDM,J9261,HCPCS,636,RC,00078-0683-61,NDC,outpatient,50,ML,2241.96,1569.372,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,83.0796785,,,83.0796785,72.53,1721.82528,other,OPPS APC,,
OXALIPLATIN 5 MG/ML IV SOLR WRAPPER,RX-4080205,CDM,J9263,HCPCS,636,RC,67457-0469-10,NDC,outpatient,10,ML,50.32,35.224,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC,,
OXALIPLATIN 5 MG/ML IV SOLR WRAPPER,RX-4080205,CDM,J9263,HCPCS,636,RC,00703-3986-01,NDC,outpatient,20,ML,216.64,151.648,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.06,416.02,other,OPPS APC,,
PACLITAXEL PROTEIN-BOUND PART 100 MG IV SUSR,RX-40475,CDM,J9264,HCPCS,636,RC,68817-0134-50,NDC,outpatient,1,UN,4383.41,3068.387,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15.285552,,,15.285552,12.06,3366.45888,other,OPPS APC,,
PACLITAXEL 6 MG/ML IV CONC WRAPPER,RX-4080637,CDM,J9267,HCPCS,636,RC,61703-0342-50,NDC,outpatient,50,ML,238.31,166.817,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC,,
PACLITAXEL 6 MG/ML IV CONC WRAPPER,RX-4080637,CDM,J9267,HCPCS,636,RC,63323-0763-50,NDC,outpatient,50,ML,433.61,303.527,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.1,416.02,other,OPPS APC,,
PENTOSTATIN 10 MG IV SOLR,RX-10910,CDM,J9268,HCPCS,636,RC,00409-0801-01,NDC,outpatient,1,UN,6377.89,4464.523,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,2911.602117,,,2911.602117,399.86,4898.21952,other,OPPS APC,,
PEMBROLIZUMAB 25 MG/ML IV SOLN WRAPPER,RX-4080564,CDM,J9271,HCPCS,636,RC,00006-3026-02,NDC,outpatient,4,ML,16212.43,11348.701,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.686428,,,66.686428,54.81,12451.14624,other,OPPS APC,,
MITOMYCIN 20 MG IV SOLR,RX-10630,CDM,J9280,HCPCS,636,RC,16729-0108-11,NDC,outpatient,1,UN,505.56,353.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,48.6894775,,,48.6894775,42.51,2565.35808,other,OPPS APC,,
MITOMYCIN 40 MG IV SOLR,RX-10631,CDM,J9280,HCPCS,636,RC,16729-0116-38,NDC,outpatient,1,UN,3340.2,2338.14,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,48.6894775,,,48.6894775,42.51,2565.35808,other,OPPS APC,,
MITOMYCIN 40 MG IV SOLR,RX-10631,CDM,J9280,HCPCS,636,RC,00143-9280-01,NDC,outpatient,1,UN,3340.31,2338.217,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,48.6894775,,,48.6894775,42.51,2565.35808,other,OPPS APC,,
MITOMYCIN 5 MG IV SOLR,RX-10632,CDM,J9280,HCPCS,636,RC,16729-0115-05,NDC,outpatient,1,UN,734.35,514.045,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,48.6894775,,,48.6894775,42.51,2565.35808,other,OPPS APC,,
MITOXANTRONE HCL 20 MG/10ML IV CONC,RX-93748,CDM,J9293,HCPCS,636,RC,61703-0343-18,NDC,outpatient,10,ML,279.99,195.993,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,62.6027205,,,62.6027205,29.06,416.02,other,OPPS APC,,
NIVOLUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080562,CDM,J9299,HCPCS,636,RC,00003-3772-11,NDC,outpatient,4,ML,3567.83,2497.481,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,36.369625,,,36.369625,30.46,16440.55296,other,OPPS APC,,
NIVOLUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080562,CDM,J9299,HCPCS,636,RC,00003-3774-12,NDC,outpatient,10,ML,8919.54,6243.678,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,36.369625,,,36.369625,30.46,16440.55296,other,OPPS APC,,
NIVOLUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080562,CDM,J9299,HCPCS,636,RC,00003-3734-13,NDC,outpatient,24,ML,21406.97,14984.879,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,36.369625,,,36.369625,30.46,16440.55296,other,OPPS APC,,
OBINUTUZUMAB 1000 MG/40ML IV SOLN,RX-124650,CDM,J9301,HCPCS,636,RC,50242-0070-01,NDC,outpatient,40,ML,23571.67,16500.169,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,85.440554,,,85.440554,70.55,18103.04256,other,OPPS APC,,
PANITUMUMAB 20 MG/ML IV SOLN WRAPPER,RX-4080216,CDM,J9303,HCPCS,636,RC,55513-0956-01,NDC,outpatient,20,ML,18284.9,12799.43,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,182.507933,,,182.507933,149.71,14042.8032,other,OPPS APC,,
PANITUMUMAB 20 MG/ML IV SOLN WRAPPER,RX-4080216,CDM,J9303,HCPCS,636,RC,55513-0954-01,NDC,outpatient,5,ML,4571.26,3199.882,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,182.507933,,,182.507933,149.71,14042.8032,other,OPPS APC,,
PEMETREXED DISODIUM 500 MG IV SOLR,RX-37894,CDM,J9305,HCPCS,636,RC,00002-7623-01,NDC,outpatient,1,UN,11216.1,7851.27,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4.792772,,,4.792772,4.18,8613.9648,other,OPPS APC,,
PEMETREXED DISODIUM 100 MG IV SOLR,RX-89350,CDM,J9305,HCPCS,636,RC,00002-7640-01,NDC,outpatient,1,UN,2243.22,1570.254,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,4.792772,,,4.792772,4.18,8613.9648,other,OPPS APC,,
PERTUZUMAB 420 MG/14ML IV SOLN,RX-116596,CDM,J9306,HCPCS,636,RC,50242-0145-01,NDC,outpatient,14,ML,18666.61,13066.627,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,18.463169,,,18.463169,15.37,14335.95648,other,OPPS APC,,
PRALATREXATE 20 MG/ML IV SOLN WRAPPER,RX-4080207,CDM,J9307,HCPCS,636,RC,72893-0003-01,NDC,outpatient,1,ML,20371.07,14259.749,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,428.151244,,,428.151244,356.51,15644.98176,other,OPPS APC,,
RAMUCIRUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080567,CDM,J9308,HCPCS,636,RC,00002-7678-01,NDC,outpatient,50,ML,20423.69,14296.583,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,81.4118305,,,81.4118305,68.87,15685.39392,other,OPPS APC,,
RAMUCIRUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080567,CDM,J9308,HCPCS,636,RC,00002-7669-01,NDC,outpatient,10,ML,4084.74,2859.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,81.4118305,,,81.4118305,68.87,15685.39392,other,OPPS APC,,
RITUXIMAB 10 MG/ML IV SOLN WRAPPER,RX-4080719,CDM,J9312,HCPCS,636,RC,50242-0053-06,NDC,outpatient,50,ML,13435.14,9404.598,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,88.563187,,,88.563187,77.31,10318.18752,other,OPPS APC,,
RITUXIMAB 10 MG/ML IV SOLN WRAPPER,RX-4080719,CDM,J9312,HCPCS,636,RC,50242-0051-21,NDC,outpatient,10,ML,2687.03,1880.921,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,88.563187,,,88.563187,77.31,10318.18752,other,OPPS APC,,
STREPTOZOCIN 1 G IV SOLR,RX-11436,CDM,J9320,HCPCS,636,RC,00703-4636-01,NDC,outpatient,1,UN,1171.99,820.393,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,424.045772,,,424.045772,223.44,900.08832,other,OPPS APC,,
TEMSIROLIMUS 25 MG/ML IV SOLN,RX-82228,CDM,J9330,HCPCS,636,RC,00008-1179-01,NDC,outpatient,2.5,ML,5549.29,3884.503,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,36.896555,,,36.896555,32.21,4261.85472,other,OPPS APC,,
TOPOTECAN HCL 1 MG/ML IV SOLN WRAPPER,RX-4080561,CDM,J9351,HCPCS,636,RC,16729-0151-31,NDC,outpatient,1,UN,263.29,184.303,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.5,416.02,other,OPPS APC,,
ADO-TRASTUZUMAB EMTANSINE 100 MG IV SOLR,RX-120086,CDM,J9354,HCPCS,636,RC,50242-0088-01,NDC,outpatient,1,UN,11130.41,7791.287,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,46.3297475,,,46.3297475,38.33,13677.02016,other,OPPS APC,,
ADO-TRASTUZUMAB EMTANSINE 160 MG IV SOLR,RX-120087,CDM,J9354,HCPCS,636,RC,50242-0087-01,NDC,outpatient,1,UN,17808.62,12466.034,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,46.3297475,,,46.3297475,38.33,13677.02016,other,OPPS APC,,
TRASTUZUMAB 21 MG/ML IV SOLR WRAPPER,RX-4080954,CDM,J9355,HCPCS,636,RC,50242-0132-01,NDC,outpatient,150,ME,4754.01,3327.807,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,89.28027,,,89.28027,77.94,3651.07968,other,OPPS APC,,
TRASTUZUMAB 21 MG/ML IV SOLR WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080954,CDM,J9355,HCPCS,636,RC,50242-0132-01,NDC,outpatient,150,ME,4456.89,3119.823,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,89.28027,,,89.28027,77.94,3651.07968,other,OPPS APC,,
VINBLASTINE SULFATE 1 MG/ML IV SOLN IV PUSH,RX-8594,CDM,J9360,HCPCS,636,RC,63323-0278-10,NDC,outpatient,10,ML,173.56,121.492,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.95,416.02,other,OPPS APC,,
VINCRISTINE SULFATE 1 MG/ML IV SOLN,RX-8597,CDM,J9370,HCPCS,636,RC,61703-0309-06,NDC,outpatient,2,ML,92.35,64.645,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,7.49,416.02,other,OPPS APC,,
VINCRISTINE SULFATE 1 MG/ML IV SOLN,RX-8597,CDM,J9370,HCPCS,636,RC,61703-0309-16,NDC,outpatient,2,ML,46.03,32.221,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,7.49,416.02,other,OPPS APC,,
VINORELBINE TARTRATE 10 MG/ML IV SOLN WRAPPER,RX-4080209,CDM,J9390,HCPCS,636,RC,25021-0204-05,NDC,outpatient,5,ML,163.03,114.121,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,7.59,416.02,other,OPPS APC,,
FULVESTRANT 250 MG/5ML IM SOSY,RX-160451,CDM,J9394,HCPCS,636,RC,63323-0715-05,NDC,outpatient,10,ML,518.07,362.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7115,,,60.7115,1.65,1060,other,OPPS APC,,
FULVESTRANT 250 MG/5ML IM SOSY,RX-160451,CDM,J9394,HCPCS,636,RC,63323-0715-01,NDC,outpatient,10,ML,518.07,362.649,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7115,,,60.7115,1.65,1060,other,OPPS APC,,
COLLAR CERV FOAM LARGE -,SUP-00273900400,CDM,L0120,HCPCS,274,RC,,,outpatient,,,175.05,122.535,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,29.2,,,29.2,4.41367,416.02,other,OPPS APC,,
COLLAR SM 20.5INX3.5IN SFT DENS BRTHBL STCKNT CVR FOAM/CTTN -,SUP-1018-02,CDM,L0120,HCPCS,274,RC,,,outpatient,,,22.99,16.093,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,29.2,,,29.2,4.41367,416.02,other,OPPS APC,,
COLLAR CERVICAL STAT MEDIUM -,SUP-1018-03,CDM,L0120,HCPCS,274,RC,,,outpatient,,,19.66,13.762,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,29.2,,,29.2,4.41367,416.02,other,OPPS APC,,
CERVICAL COLLAR XL SOFT 22x3.5 -,SUP-1050-24,CDM,L0120,HCPCS,274,RC,,,outpatient,,,23.75,16.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,29.2,,,29.2,4.41367,416.02,other,OPPS APC,,
COLLAR PHILADELPHIA CERVICAL SM TRACH 2PC 4.25IN X 10-13IN -,SUP-1044-11,CDM,L0172,HCPCS,274,RC,,,outpatient,,,126.85,88.795,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.68,,,139.68,12.10504,416.02,other,OPPS APC,,
COLLAR PHILADELPHIA CERVICAL MD TRACH 2PC 4.25IN X 13-16IN -,SUP-1044-12,CDM,L0172,HCPCS,274,RC,,,outpatient,,,126.85,88.795,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.68,,,139.68,12.10504,416.02,other,OPPS APC,,
COLLAR PHILADELPHIA CERVICAL LRG TRACH 2PC 4.25IN X 16-19IN -,SUP-1044-13,CDM,L0172,HCPCS,274,RC,,,outpatient,,,126.85,88.795,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.68,,,139.68,12.10504,416.02,other,OPPS APC,,
COLLAR CERVICAL RIGID MED TRACH 2PC 3.25IN X 13-16IN -,SUP-1113MPP,CDM,L0172,HCPCS,274,RC,,,outpatient,,,53.92,37.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.68,,,139.68,12.10504,416.02,other,OPPS APC,,
COLLAR CERVICAL RIGID SM TRACH 2PC 3.25IN X 10-13IN -,SUP-1113SPP,CDM,L0172,HCPCS,274,RC,,,outpatient,,,53.92,37.744,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.68,,,139.68,12.10504,416.02,other,OPPS APC,,
COLLAR PHILADELPHIA SM 3.25IN 10-13 IN -,SUP-79-83133,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.23,46.361,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.68,,,139.68,12.10504,416.02,other,OPPS APC,,
COLLAR PHILADELPHIA MD 3.25IN x 13-16 IN -,SUP-79-83135,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.23,46.361,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.68,,,139.68,12.10504,416.02,other,OPPS APC,,
COLLAR PHILADELPHIA LG 3.25IN x 16-19IN -,SUP-79-83137,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.23,46.361,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.68,,,139.68,12.10504,416.02,other,OPPS APC,,
COLLAR PHILADELPHIA SM 4.25IN x 10-13IN -,SUP-79-83143,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.46,46.522,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.68,,,139.68,12.10504,416.02,other,OPPS APC,,
COLLAR PHILADELPHIA LG 4.25IN x 16-19IN -,SUP-79-83147,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.46,46.522,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,139.68,,,139.68,12.10504,416.02,other,OPPS APC,,
KNEE SUPPORT- HINGED PULL UP- MEDIUM -,SUP-NE7711-73,CDM,L1820,HCPCS,274,RC,,,outpatient,,,136.07,95.249,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,167.47,,,167.47,29.06826,416.02,other,OPPS APC,,
KNEE SUPPORT HINGED PULL UP- LRG -,SUP-NE7711-74,CDM,L1820,HCPCS,274,RC,,,outpatient,,,129.48,90.636,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,167.47,,,167.47,29.06826,416.02,other,OPPS APC,,
SUPPORT KNEE HINGED PULL UP LARGE -,SUP-NE7711-74,CDM,L1820,HCPCS,274,RC,,,outpatient,,,136.13,95.291,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,167.47,,,167.47,29.06826,416.02,other,OPPS APC,,
KNEE SUPPORT HINGED PULL UP X-LRG -,SUP-NE7711-75,CDM,L1820,HCPCS,274,RC,,,outpatient,,,136.07,95.249,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,167.47,,,167.47,29.06826,416.02,other,OPPS APC,,
SUPPORT KNEE HINGED PULL UP X-LARGE -,SUP-NE7711-75,CDM,L1820,HCPCS,274,RC,,,outpatient,,,129.48,90.636,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,167.47,,,167.47,29.06826,416.02,other,OPPS APC,,
BRACE KNEE ENHANCED TROM - DONJOY -,SUP-11-9114-9,CDM,L1832,HCPCS,274,RC,,,outpatient,,,544.99,381.493,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,873.34,,,873.34,110.03643,1222.676,fee schedule,,,
KNEE BRACE HINGED TROM DONJOY -,SUP-11-9114-9,CDM,L1832,HCPCS,274,RC,,,outpatient,,,544.99,381.493,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,873.34,,,873.34,110.03643,1222.676,fee schedule,,,
BRACE KN POSTOP 18-26IN FIT UPTO 34IN THG 6IN ABV MI D PTLR -,SUP-75-7500-000,CDM,L1832,HCPCS,274,RC,,,outpatient,,,490.14,343.098,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,873.34,,,873.34,110.03643,1222.676,fee schedule,,,
ANKLE BRACE SPORTS ORTHOSIS LACE UP BOA SMALL -,SUP-AB3000-12,CDM,L1902,HCPCS,274,RC,,,outpatient,,,105.56,73.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,101.16,,,101.16,23.579235,416.02,other,OPPS APC,,
ANKLE BRACE SPORTS ORTHOSIS LACE UP BOA MEDIUM -,SUP-AB3000-14,CDM,L1902,HCPCS,274,RC,,,outpatient,,,105.03,73.521,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,101.16,,,101.16,23.579235,416.02,other,OPPS APC,,
BRACE ANKLE SPORTS ORTHOSIS LACE UP BOA LARGE -,SUP-AB3000-16,CDM,L1902,HCPCS,274,RC,,,outpatient,,,105.56,73.892,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,101.16,,,101.16,23.579235,416.02,other,OPPS APC,,
BRACE ANKLE- SPORTS ORTHOSIS LACE UP BOA- XL -,SUP-AB3000-18,CDM,L1902,HCPCS,274,RC,,,outpatient,,,111.45,78.015,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,101.16,,,101.16,23.579235,416.02,other,OPPS APC,,
SPLINT ORTHO LT ANKL/FT LRG SZ8-10 PLST CLSD HL MLD HK/LOP -,SUP-A508LL,CDM,L1930,HCPCS,274,RC,,,outpatient,,,180.48,126.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,300.36,,,300.36,34.77954,420.504,other,OPPS APC,,
SPLINT ORTHO LT ANKL/FT MED SZ8-10 PLST CLSD HL MLD HK/LOP -,SUP-A508LM,CDM,L1930,HCPCS,274,RC,,,outpatient,,,179.78,125.846,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,300.36,,,300.36,34.77954,420.504,other,OPPS APC,,
SPLINT ORTHO RT ANKL/FT LRG SZ8-10 MALE PLST CLSD HL MLD -,SUP-A508RL,CDM,L1930,HCPCS,274,RC,,,outpatient,,,180.48,126.336,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,300.36,,,300.36,34.77954,420.504,other,OPPS APC,,
SPLINT ORTHO RT ANKL/FT LRG SZ8-10 PLST CLSD HL MLD HK/LOP -,SUP-A508RM,CDM,L1930,HCPCS,274,RC,,,outpatient,,,175.28,122.696,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,300.36,,,300.36,34.77954,420.504,other,OPPS APC,,
SPLINT ORTHO RT ANKL/FT SM SZ3-6 FEM PLST CLSD HL MLD HK/LOP -,SUP-A508RS,CDM,L1930,HCPCS,274,RC,,,outpatient,,,226.22,158.354,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,300.36,,,300.36,34.77954,420.504,other,OPPS APC,,
AFO FOR FOOT AND ANKLE -,SUP-XEE64330,CDM,L1930,HCPCS,274,RC,,,outpatient,,,154.92,108.444,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,300.36,,,300.36,34.77954,420.504,other,OPPS APC,,
AFO FOR FOOT AND ANKLE -,SUP-XEE64331,CDM,L1930,HCPCS,274,RC,,,outpatient,,,154.92,108.444,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,300.36,,,300.36,34.77954,420.504,other,OPPS APC,,
SYS FOOT OTHTC SM PEGASSIST DARCO -,SUP-PW1,CDM,L3002,HCPCS,274,RC,,,outpatient,,,73.46,51.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,185.48,,,185.48,16.49177,416.02,other,OPPS APC,,
SYS FOOT OTHTC MED PEGASSIST DARCO -,SUP-PW2,CDM,L3002,HCPCS,274,RC,,,outpatient,,,73.46,51.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,185.48,,,185.48,16.49177,416.02,other,OPPS APC,,
SYS FOOT OTHTC XL PEGASSIST DARCO -,SUP-PW4,CDM,L3002,HCPCS,274,RC,,,outpatient,,,73.46,51.422,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,185.48,,,185.48,16.49177,416.02,other,OPPS APC,,
SHOE POSTOP SZ5-6.5 SM MALE RT/LT LACE-UP CLSR -,SUP-2020-01,CDM,L3260,HCPCS,274,RC,,,outpatient,,,31.86,22.302,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,,,
SHOE POSTOP SZ7-8.5 MED MALE RT/LT LACE-UP CLSR -,SUP-2020-02,CDM,L3260,HCPCS,274,RC,,,outpatient,,,31.86,22.302,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,,,
SHOE POSTOP SZ9-11 LRG MALE RT/LT LACE-UP CLSR -,SUP-2020-03,CDM,L3260,HCPCS,274,RC,,,outpatient,,,31.86,22.302,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,,,
SHOE POSTOP SZ4-6 SM FEM RT/LT LACE-UP CLSR -,SUP-2021-01,CDM,L3260,HCPCS,274,RC,,,outpatient,,,30.87,21.609,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,,,
SHOE POSTOP SZ6.5-8 MED FEM RT/LT LACE-UP CLSR -,SUP-2021-02,CDM,L3260,HCPCS,274,RC,,,outpatient,,,30.87,21.609,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,,,
SHOE POSTOP SZ8.5-10 LRG L/R ANKL OPN TOE CLSD HL CNVS RBR -,SUP-2021-03,CDM,L3260,HCPCS,274,RC,,,outpatient,,,30.87,21.609,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,,,
BOOT CAST SM 4.5X8.5IN CNVS FT RCKR SOLE NSLIP HK/LOP CLSR -,SUP-2035-02,CDM,L3260,HCPCS,274,RC,,,outpatient,,,27.25,19.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,,,
CAST SHOE MED CANVAS ROCKER -,SUP-2035-03,CDM,L3260,HCPCS,274,RC,,,outpatient,,,27.6,19.32,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,,,
SHOE CAST LRG 5.25X11.5IN CNVS FT RCKR SOLE NSLIP HK/LOP -,SUP-2035-04,CDM,L3260,HCPCS,274,RC,,,outpatient,,,27.25,19.075,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,,,
SURGICAL SHOE MENS XL -,SUP-5701024,CDM,L3260,HCPCS,274,RC,,,outpatient,,,39.56,27.692,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,,,
SHOE ORTHO ANKL SM SZ7.5-10 MSH CLSD HL CLSD TOE HK/LOP STRP -,SUP-92732502,CDM,L3260,HCPCS,274,RC,,,outpatient,,,221.73,155.211,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,,,
SHOE ORTHO ANKL MED SZ8.5-10 MALE MSH CLSD HL CLSD TOE -,SUP-92732503,CDM,L3260,HCPCS,274,RC,,,outpatient,,,214.44,150.108,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,,,
SHOE ORTHO ANKL LRG SZ10.5-12 MSH CLSD HL CLSD TOE HK/LOP -,SUP-92732504,CDM,L3260,HCPCS,274,RC,,,outpatient,,,214.44,150.108,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,,,
SHOE CAST SZ6-8 MALE SZ7.5-10 FEM SM FT DARCO HEELWEDGE -,SUP-92732602,CDM,L3260,HCPCS,274,RC,,,outpatient,,,116.41,81.487,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,,,
SHOE CAST SZ8.5-10 MALE 10.5-13 FEM MED FT DARCO HEELWEDGE -,SUP-92732603,CDM,L3260,HCPCS,274,RC,,,outpatient,,,124.52,87.164,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,,,
SHOE POST-OP NYLON RUBBER HOOK/LOOP MALE SMALL -,SUP-A152305,CDM,L3260,HCPCS,274,RC,,,outpatient,,,20.66,14.462,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,,,
POST OP SHOE NYLON RUBBER HOOK/LOOP MALE LRG -,SUP-A152307,CDM,L3260,HCPCS,274,RC,,,outpatient,,,22.29,15.603,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,,,
SHOE POSTOP MENS SM SIZES 6-8 MEDSURG -,SUP-MQM1B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,,,
SHOE POSTOP MENS MED SIZES 8.5-10 MEDSURG -,SUP-MQM2B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,,,
SHOE POSTOP MENS LG SIZES 10.5-12 MEDSURG -,SUP-MQM3B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,,,
SHOE POSTOP MENS XL SIZES 12.5-14 MEDSURG -,SUP-MQM4B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,,,
SHOE POSTOP WOMENS SM SIZES 4-6 MEDSURG -,SUP-MQW1B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,,,
SHOE POSTOP SZ6.5-8 FEM MED MEDSURG OPN TOE CLSD HL RCKR BTM -,SUP-MQW2B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,110.4,77.28,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,,,
SHOE POSTOP WOMENS MED SIZES 6.5- 8 MEDSURG -,SUP-MQW2B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,,,
SHOE POSTOP WOMENS LG SIZES  8.5 -10 MEDSURG -,SUP-MQW3B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,,,
SHOE DARCO SURGICAL MENS SMALL -,SUP-MSM1N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,28.47,19.929,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,,,
SHOES DARCO MENS MEDIUM -,SUP-MSM2N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,47.21,33.047,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,,,
SHOES DARCO MENS LARGE -,SUP-MSM3N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,48.55,33.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,,,
SHOES DARCO WOMENS SMALL -,SUP-MSW1N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,48.55,33.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,,,
SHOES DARCO WOMENS MEDIUM -,SUP-MSW2N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,28.47,19.929,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,,,
SHOES DARCO WOMENS LARGE -,SUP-MSW3N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,45.63,31.941,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,,,
BOOT CAST REG FT PD WVN TCC-EZ -,SUP-TCC21100,CDM,L3260,HCPCS,274,RC,,,outpatient,,,393.57,275.499,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,,,
BOOT CAST LRG FT PD WVN TCC-EZ -,SUP-TCC21114,CDM,L3260,HCPCS,274,RC,,,outpatient,,,444.34,311.038,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,,,
BOOT CAST LRG FT CHARCOT PD WVN TCC-EZ -,SUP-TCC21116,CDM,L3260,HCPCS,274,RC,,,outpatient,,,538.28,376.796,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,,,
SYS CAST 3IN FT CHARCOT PD WVN W/REGULARX2 BT TCC-EZ -,SUP-TCC23000,CDM,L3260,HCPCS,274,RC,,,outpatient,,,627.97,439.579,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,,,
SYS CAST SZ4 IN FT PD WVN W/2 REG BT TCC-EZ -,SUP-TCC24000,CDM,L3260,HCPCS,274,RC,,,outpatient,,,627.97,439.579,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,4.63817,482.28096,,,,
IMMOBILIZER SHLDR LRG ELAS HUM CUF RB WRP -,SUP-00078300300,CDM,L3670,HCPCS,274,RC,,,outpatient,,,291.75,204.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,121.74,,,121.74,3.81201,416.02,fee schedule,,,
IMMOBILIZER SHLDR LRG ELAS HUM CUF CONTR RB WRP -,SUP-00078400300,CDM,L3670,HCPCS,274,RC,,,outpatient,,,233.4,163.38,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,121.74,,,121.74,3.81201,416.02,fee schedule,,,
IMMOBILIZER SHLDR SMALL ULTRASLING III BLACK -,SUP-11-0449-2,CDM,L3670,HCPCS,274,RC,,,outpatient,,,305.46,213.822,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,121.74,,,121.74,3.81201,416.02,fee schedule,,,
IMMOBILIZER SHLDR MED ULTRASLING III BLACK -,SUP-11-0449-3,CDM,L3670,HCPCS,274,RC,,,outpatient,,,305.46,213.822,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,121.74,,,121.74,3.81201,416.02,fee schedule,,,
SUPPORT RT SHLDR SM 11IN MSH FBRC ULSNG ER HUM CUF 15DEG -,SUP-11-1343-2-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,121.74,,,121.74,3.81201,416.02,fee schedule,,,
SUPPORT LT SHLDR ARM SM UPTO 11IN MSH FBRC ULSNG ER BRTHBL -,SUP-11-1344-2-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,121.74,,,121.74,3.81201,416.02,fee schedule,,,
SUPPORT LT SHLDR ARM LRG ABV 13IN MSH FBRC ULSNG ER BRTHBL -,SUP-11-1344-4-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,121.74,,,121.74,3.81201,416.02,fee schedule,,,
SUPPORT RT SHLDR SM 11IN MSH FBRC ULSNG ER HUM CUF 30DEG -,SUP-11-1345-2,CDM,L3670,HCPCS,274,RC,,,outpatient,,,371.22,259.854,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,121.74,,,121.74,3.81201,416.02,fee schedule,,,
SUPPORT RT SHLDR LRG 13-15IN MSH FBRC ULSNG ER HUM 30DEG -,SUP-11-1345-4-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,121.74,,,121.74,3.81201,416.02,fee schedule,,,
SUPPORT LT SHLDR LRG 13-15IN MSH FBRC ULSNG ER BRTHBL HUM -,SUP-11-1346-4-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,121.74,,,121.74,3.81201,416.02,fee schedule,,,
IMMOBILIZER SHLDR SLING MED 7IN X 17IN -,SUP-11630006,CDM,L3670,HCPCS,274,RC,,,outpatient,,,243.14,170.198,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,121.74,,,121.74,3.81201,416.02,fee schedule,,,
IMMOBILIZER SHLDR SLING LRG 7IN X 18IN -,SUP-11630007,CDM,L3670,HCPCS,274,RC,,,outpatient,,,243.14,170.198,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,121.74,,,121.74,3.81201,416.02,fee schedule,,,
IIMMOBILIZER SHOULDER VELPEAU M -,SUP-23-1872,CDM,L3670,HCPCS,274,RC,,,outpatient,,,29.7,20.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,121.74,,,121.74,3.81201,416.02,fee schedule,,,
IMMOBILIZER SHOULDER VELPEAU L -,SUP-23-1873-000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,29.7,20.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,121.74,,,121.74,3.81201,416.02,fee schedule,,,
IMMOBILIZER SHLDR SM PD WRST/HUM CUF SHLDR/WST STRP -,SUP-667110,CDM,L3670,HCPCS,274,RC,,,outpatient,,,343.1,240.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,121.74,,,121.74,3.81201,416.02,fee schedule,,,
IMMOBILIZER RT/LT SHLDR XS CTTN CLTH 6X12.5IN PCH CLSD/OPN -,SUP-9002-01,CDM,L3670,HCPCS,274,RC,,,outpatient,,,29.12,20.384,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,121.74,,,121.74,3.81201,416.02,fee schedule,,,
IMMOBILIZER SHOULDER UNIVERSAL -,SUP-9013-00,CDM,L3670,HCPCS,274,RC,,,outpatient,,,56.25,39.375,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,121.74,,,121.74,3.81201,416.02,fee schedule,,,
SHOULDER IMMOBILIZER W/FOAM SMALL -,SUP-A111015,CDM,L3670,HCPCS,274,RC,,,outpatient,,,19.02,13.314,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,121.74,,,121.74,3.81201,416.02,fee schedule,,,
SHOULDER IMMOBILIZER W/FOAM WAIST STRAP M -,SUP-A111016,CDM,L3670,HCPCS,274,RC,,,outpatient,,,19.02,13.314,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,121.74,,,121.74,3.81201,416.02,fee schedule,,,
IMMOBILIZER SHLDR X-LRG 9IN X 22.5IN -,SUP-A111018,CDM,L3670,HCPCS,274,RC,,,outpatient,,,16.98,11.886,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,121.74,,,121.74,3.81201,416.02,fee schedule,,,
IMMOBILIZER SHOULDER VELP XLG -,SUP-TX9023-04,CDM,L3670,HCPCS,274,RC,,,outpatient,,,31.1,21.77,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,121.74,,,121.74,3.81201,416.02,fee schedule,,,
SPLINT RT HND SM 6.5-7.25IN ALIFLEECE LINER THRMPLST DLX FIG -,SUP-5183,CDM,L3807,HCPCS,274,RC,,,outpatient,,,286.27,200.389,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,261.35,,,261.35,31.76675,416.02,other,OPPS APC,,
SPLINT RT HND LRG 8.25-9.25IN ALIFLEECE LINER THRMPLST DLX -,SUP-5187,CDM,L3807,HCPCS,274,RC,,,outpatient,,,284.4,199.08,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,261.35,,,261.35,31.76675,416.02,other,OPPS APC,,
SPLINT LT SM RST -,SUP-5812,CDM,L3807,HCPCS,274,RC,,,outpatient,,,273.08,191.156,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,261.35,,,261.35,31.76675,416.02,other,OPPS APC,,
SPLINT WRST MED POLY FOAM CCKUP -,SUP-A1601P,CDM,L3807,HCPCS,274,RC,,,outpatient,,,141.5,99.05,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,261.35,,,261.35,31.76675,416.02,other,OPPS APC,,
EXTERNAL FIX DIGIT WIDGET -,SUP-DWD-232,CDM,L3921,HCPCS,274,RC,,,outpatient,,,7002.6,4901.82,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,335.72,,,335.72,335.72,5377.9968,fee schedule,,,
SPLINT THUMB SPICA RIGHT MED/LRG 3.5IN - 4.25IN -,SUP-340M/LR,CDM,L3924,HCPCS,274,RC,,,outpatient,,,68.27,47.789,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,124.86,,,124.86,15.326615,416.02,other,OPPS APC,,
THUMB SPLINT COMFORT COOL CMC LT MEDIUM -,SUP-348ML,CDM,L3924,HCPCS,274,RC,,,outpatient,,,92.66,64.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,124.86,,,124.86,15.326615,416.02,other,OPPS APC,,
THUMB SPLINT COMFORT COOL CMC RT MEDIUM -,SUP-348MR,CDM,L3924,HCPCS,274,RC,,,outpatient,,,92.66,64.862,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,124.86,,,124.86,15.326615,416.02,other,OPPS APC,,
LMB SPRING PIP EXTENSION ASSIST -,SUP-704103,CDM,L3925,HCPCS,274,RC,,,outpatient,,,89.16,62.412,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,56.18,,,56.18,17.225885,416.02,other,OPPS APC,,
SPLINT FINGER EXTENSION LMB SPRING SIZE A -,SUP-704200,CDM,L3925,HCPCS,274,RC,,,outpatient,,,76.73,53.711,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,56.18,,,56.18,17.225885,416.02,other,OPPS APC,,
SPLINT FINGER EXTENSION SPRING LMB SIZE C -,SUP-704202,CDM,L3925,HCPCS,274,RC,,,outpatient,,,76.79,53.753,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,56.18,,,56.18,17.225885,416.02,other,OPPS APC,,
BOOT WALKER LRG AIRCAST SZ10-13 MALE SZ11-15 FEM PED -,SUP-01EF-L,CDM,L4361,HCPCS,274,RC,,,outpatient,,,269.52,188.664,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,406.17,,,406.17,50.613525,568.638,fee schedule,,,
BOOT WALKER MED AIRCAST SZ7-10 MALE SZ8-11 FEM -,SUP-01EF-M,CDM,L4361,HCPCS,274,RC,,,outpatient,,,269.52,188.664,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,406.17,,,406.17,50.613525,568.638,fee schedule,,,
BOOT WALKER SM AIRCAST SZ4-7 MALE SZ5-8 FEM -,SUP-01F-S,CDM,L4361,HCPCS,274,RC,,,outpatient,,,263.86,184.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,406.17,,,406.17,50.613525,568.638,fee schedule,,,
BOOT WALKER XL AIRCAST SZ 13+ MALE SZ 15+ FEM -,SUP-01F-XL,CDM,L4361,HCPCS,274,RC,,,outpatient,,,263.86,184.702,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,406.17,,,406.17,50.613525,568.638,fee schedule,,,
BOOT WALKER LRG SHELL 10-13M/11-15F -,SUP-1175LPP,CDM,L4361,HCPCS,274,RC,,,outpatient,,,225.45,157.815,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,406.17,,,406.17,50.613525,568.638,fee schedule,,,
WALKER FULL SHELL 2 SHORT- SMALL -,SUP-15500047,CDM,L4361,HCPCS,274,RC,,,outpatient,,,274.6,192.22,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,406.17,,,406.17,50.613525,568.638,fee schedule,,,
WALKER- FULL SHELL 2 SHORT- MEDIUM -,SUP-15500048,CDM,L4361,HCPCS,274,RC,,,outpatient,,,249.74,174.818,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,406.17,,,406.17,50.613525,568.638,fee schedule,,,
WALKER FULL SHELL 2 SHORT LARGE -,SUP-1550049,CDM,L4361,HCPCS,274,RC,,,outpatient,,,234.33,164.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,406.17,,,406.17,50.613525,568.638,fee schedule,,,
BOOT ORTHO FT MED/L FLEECE LINER OPN TOE SEMI- FLXB SHL -,SUP-6963,CDM,L4394,HCPCS,274,RC,,,outpatient,,,127.09,88.963,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,20.61,,,20.61,20.61,416.02,other,OPPS APC,,
VALVE SPK 15X23MM PASSY-MUIR WHITE -,SUP-PMV 005,CDM,L8501,HCPCS,274,RC,,,outpatient,,,429.46,300.622,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,188.78,,,188.78,52.37136,418.655068,other,OPPS APC,,
VALVE SPK PASSY-MUIR PMV 15X22MM LPRO REUS FLEX AQUA -,SUP-PMV 007,CDM,L8501,HCPCS,274,RC,,,outpatient,,,493.93,345.751,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,188.78,,,188.78,52.37136,418.655068,other,OPPS APC,,
VALVE SPK/SWALW IN G 15X23MM PASSY-MUIR PMV 1W  CLEAR -,SUP-PMV 2000,CDM,L8501,HCPCS,274,RC,,,outpatient,,,429.46,300.622,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,188.78,,,188.78,52.37136,418.655068,other,OPPS APC,,
VALVE PASSY MUIR PURPLE SPEAK SWALLOW IN G 15X23MM PMV -,SUP-PMV 2001,CDM,L8501,HCPCS,274,RC,,,outpatient,,,429.46,300.622,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,188.78,,,188.78,52.37136,418.655068,other,OPPS APC,,
VALVE SPK SHILEY 0.66MM MINI STRL MONOKA PHONATE W/O O2 PRT -,SUP-SSV,CDM,L8501,HCPCS,274,RC,,,outpatient,,,233.28,163.296,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,188.78,,,188.78,52.37136,418.655068,other,OPPS APC,,
PROSTHESIS VOCAL CRD BLOM-SINGER CLASSIC 20FRX8MM INDWL STRL -,SUP-IN 2008-SO,CDM,L8509,HCPCS,274,RC,,,outpatient,,,1378.13,964.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,125.65,,,125.65,125.65,1058.40384,other,OPPS APC,,
PROSTHESIS VOCAL CRD BLOM-SINGER 20FRX14MM INDWL STRL -,SUP-IN2014-SO,CDM,L8509,HCPCS,274,RC,,,outpatient,,,1378.13,964.691,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,125.65,,,125.65,125.65,1058.40384,other,OPPS APC,,
IMPLANT BRST 600ML SIL GEL HPRO RND 14CM MEMORYGEL 5.6CM -,SUP-350-6004BC,CDM,L8600,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,3409.78176,,,,
BULKAMID URETHRAL BULKING SYSTEM -,SUP-50050,CDM,L8606,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,252.25,3748.3008,other,OPPS APC,,
COAPTITE SYRINGE 1ML -,SUP-M0068903000,CDM,L8606,HCPCS,278,RC,,,outpatient,,,1975.44,1382.808,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,252.25,3748.3008,other,OPPS APC,,
SPHERE EYE 18MM -,SUP-14254,CDM,L8610,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,70.737705,686.06,,,,
IMPLANT OSS PRT WIET 1.14MM SHFT 3.25MMX5MM OFF-CTR HAP FLEX -,SUP-0516,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC,,
PROSTHESIS OSS PRT 4X5MM CTR HAP FLEX TI MLBL -,SUP-0550,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2565.44,1795.808,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC,,
MNP TOTAL TITANIUM .2 X 3.00MM -,SUP-1004434,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC,,
MNP TOTAL TITANIUM .2 X 3.5MM -,SUP-1004436,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC,,
OMEGA CONNECTOR 1.5MM X 8MMX0.5 -,SUP-1004930,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1219.12,853.384,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC,,
PROSTHESIS OSS ASTN PLAS-PR MOD PORP 3MM FLNG DIA 1MM SHFT -,SUP-14-0063,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1300.05,910.035,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC,,
PISTON OTO SCHKNT 0.8MMX4.25MM WIRE LOOP FLPLS SS -,SUP-14-0105,CDM,L8613,HCPCS,278,RC,,,outpatient,,,628.66,440.062,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC,,
LOOP WIRE HOUSE TYPE .12 X 4.0 -,SUP-140184,CDM,L8613,HCPCS,278,RC,,,outpatient,,,268.41,187.887,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC,,
LOOP WIRE HOUSE TYPE .12 X 4.25 -,SUP-140184,CDM,L8613,HCPCS,278,RC,,,outpatient,,,346.6,242.62,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC,,
PISTON OTO RCHRD 0.6MMX3.50MM RBN LOOP FLPLS PLTNM -,SUP-14-0781,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC,,
PISTON OTO RCHRD 0.6X4MM RBN LOOP FLPLS PLTNM -,SUP-14-0783,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC,,
PISTON OTO RCHRD 0.6MMX4.25MM RBN LOOP FLPLS PLTNM -,SUP-14-0784,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC,,
PISTON OTO RCHRD 0.8X4MM RBN LOOP FLPLS PLTNM -,SUP-14-0792,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1024.74,717.318,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC,,
PISTON OTO RCHRD 0.8MMX4.5MM RBN LOOP FLPLS PLTNM -,SUP-14-0794,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC,,
PLATE OSS MED 10MM POR HAP ATTIC DFCT -,SUP-14-0863,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1063.14,744.198,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC,,
PLATE OSS 14MM LRG POR HAP ATTIC DFCT -,SUP-14-0864,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1072.41,750.687,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC,,
PROSTHESIS OSS APLBM SM 2X2MM 1MM CANN HAP INCSTP -,SUP-14-0956,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2182.32,1527.624,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC,,
PROSTHESIS OSS PRT GLDNBRG 1.5MM 1.14MM FLLY CANN HAP EAR -,SUP-14-0963,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2038.36,1426.852,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC,,
PROSTHESIS OSS APLBM 2.5X3MM HAP INCUS -,SUP-14-0973,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2205.54,1543.878,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC,,
PROSTHESIS OSS RCHRD 0.4MM PSTN 1MM WELL 4.50MM CUP PED -,SUP-142152,CDM,L8613,HCPCS,278,RC,,,outpatient,,,761.58,533.106,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC,,
Eclipse Flat Ribbon Piston .6MM X 4.50MM -,SUP-472-450,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1863.34,1304.338,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC,,
Eclipse Flat Ribbon Piston .6MM X 4.75MM -,SUP-472-475,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1863.34,1304.338,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC,,
Eclipse Flat Ribbon Piston .6MM X 5.00MM -,SUP-472-500,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1863.34,1304.338,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC,,
PROSTHESIS OSS UM TORP 2X10MM CTR TI ADJ -,SUP-7014-1044,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1852.68,1296.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC,,
PROSTHESIS OSS UM TORP 2X5MM CTR TI ADJ -,SUP-7014-1046,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1852.68,1296.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC,,
PISTON OSS SMRT 0.6X4MM WIRE LOOP FLPLS NTNL STPS ADLT -,SUP-70145926,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1601.92,1121.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC,,
PISTON OSS SMRT 0.6MMX4.25MM WIRE LOOP FLPLS NTNL STPS ADLT -,SUP-70145927,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1601.92,1121.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC,,
PISTON OSS SMRT 0.6MMX4.50MM WIRE LOOP FLPLS NTNL STPS ADLT -,SUP-70145928,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1601.92,1121.344,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC,,
DISTANCE PLATES REPLACEMENT 0.1 /0.2 /0.3 -,SUP-8000140,CDM,L8613,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,60.258045,2016.5376,other,OPPS APC,,
JOINT FINGER SWANSON 1 MCP FLEXIBLE STERILE W/O GROMMETS SIL -,SUP-4700001,CDM,L8630,HCPCS,278,RC,,,outpatient,,,4602.62,3221.834,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,3534.81216,other,OPPS APC,,
IMPLANT PIP MCP SZ4 SWNSN SIL -,SUP-G470-0004,CDM,L8630,HCPCS,278,RC,,,outpatient,,,4413.76,3089.632,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,3534.81216,other,OPPS APC,,
PROSTHESIS PENL TOROSA LRG SAL FIL CYL INFL PRECNCT SCRT -,SUP-450-1329,CDM,L8699,HCPCS,278,RC,,,outpatient,,,8471.02,5929.714,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,163.74581,6505.74336,other,OPPS APC,,
PROSTHESIS TSTCLR 2.9CMX4.5IN -,SUP-96-450-1329,CDM,L8699,HCPCS,278,RC,,,outpatient,,,7002.6,4901.82,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,163.74581,6505.74336,other,OPPS APC,,
LEAD ANCHOR KIT -,SUP-ACCK5300,CDM,L8699,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,163.74581,6505.74336,other,OPPS APC,,
WEIGHT EYELID THN 0.6MM PLTNM 0.6GM SPHRCL CRV TAPR EDGE RND -,SUP-LL 6006,CDM,L8699,HCPCS,278,RC,,,outpatient,,,1749.17,1224.419,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,163.74581,6505.74336,other,OPPS APC,,
UROLIFT ATC IMPLANT CARTRIDGE -,SUP-UL2ATC-C,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4986.7,3490.69,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,163.74581,6505.74336,other,OPPS APC,,
IMPLANT UROLOGICAL UROLIFT 2 CARTRIDGE -,SUP-UL2-C,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,163.74581,6505.74336,other,OPPS APC,,
IMPLANT CARTRIDGE UROLIFT -,SUP-UL2-C,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4350.1,3045.07,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,163.74581,6505.74336,other,OPPS APC,,
IMPLANT HANDLE CARTRIDGE UROLIFT -,SUP-UL2-CHK,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,163.74581,6505.74336,other,OPPS APC,,
KIT HANDLE UROLIFT DELIVERY HANDLE IMPLANT CARTRIDGE -,SUP-UL2-CHK,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,163.74581,6505.74336,other,OPPS APC,,
HC Bebtelovimab Injection,PX-26000018,CDM,M0222,HCPCS,260,RC,,,outpatient,,,1455,1018.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,401.49775,,,401.49775,326.6475,1117.44,other,OPPS APC,,
HC Cryoprecipitate Each Unit,PX-39000006,CDM,P9012,CPT,390,RC,,,outpatient,,,1227,858.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,68.581085,,,68.581085,49.4,942.336,other,OPPS APC,,
HC RBC Leukocytes Reduced,PX-39000007,CDM,P9016,CPT,390,RC,,,outpatient,,,551,385.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,207.12931,,,207.12931,123.6995,423.168,other,OPPS APC,,
HC Plasma 1 Donor Frz W/in 8 Hr,PX-39000008,CDM,P9017,CPT,390,RC,,,outpatient,,,379,265.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,91.59418,,,91.59418,71.53,416.02,other,OPPS APC,,
HC Red Blood Cells Unit,PX-39000009,CDM,P9021,CPT,390,RC,,,outpatient,,,471,329.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,156.372205,,,156.372205,105.7395,416.02,other,OPPS APC,,
HC Washed Red Blood Cells Unit,PX-39000010,CDM,P9022,CPT,390,RC,,,outpatient,,,1028,719.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,454.90096,,,454.90096,163,871.3328,other,OPPS APC,,
HC Platelets Leukocytes Reduced,PX-39000011,CDM,P9031,CPT,390,RC,,,outpatient,,,1397,977.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,149.92304,,,149.92304,136.61,1072.896,other,OPPS APC,,
HC Platelets Leukoreduced Irrad,PX-39000012,CDM,P9033,CPT,390,RC,,,outpatient,,,1633,1143.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,264.186665,,,264.186665,163,1384.1308,other,OPPS APC,,
HC Platelet Pheres Leukoreduced,PX-39000013,CDM,P9035,CPT,390,RC,,,outpatient,,,1233,863.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,541.054015,,,541.054015,163,1119.53,other,OPPS APC,,
HC Plate Pheres Leukoredu Irrad,PX-39000014,CDM,P9037,CPT,390,RC,,,outpatient,,,1624,1136.8,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,770.32584,,,770.32584,163,1476.21,other,OPPS APC,,
HC RBC Deglycerolized,PX-39000015,CDM,P9039,CPT,390,RC,,,outpatient,,,2586,1810.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,356.376505,,,356.376505,163,2191.8936,other,OPPS APC,,
HC RBC Leukoreduced Irradiated,PX-39000016,CDM,P9040,CPT,390,RC,,,outpatient,,,636,445.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,289.21584,,,289.21584,142.782,598.2,other,OPPS APC,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,68516-5214-01,NDC,outpatient,250,ML,168.42,117.894,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7997035,,,60.7997035,25.321355,416.02,other,OPPS APC,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,76125-0790-26,NDC,outpatient,250,ML,171.75,120.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7997035,,,60.7997035,25.321355,416.02,other,OPPS APC,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,44206-0310-90,NDC,outpatient,250,ML,199.57,139.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7997035,,,60.7997035,25.321355,416.02,other,OPPS APC,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,68516-5214-03,NDC,outpatient,250,ML,168.42,117.894,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7997035,,,60.7997035,25.321355,416.02,other,OPPS APC,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,00944-0495-05,NDC,outpatient,250,ML,112.79,78.953,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7997035,,,60.7997035,25.321355,416.02,other,OPPS APC,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,76125-0790-25,NDC,outpatient,250,ML,171.75,120.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7997035,,,60.7997035,25.321355,416.02,other,OPPS APC,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,00944-0495-06,NDC,outpatient,250,ML,112.79,78.953,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7997035,,,60.7997035,25.321355,416.02,other,OPPS APC,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,44206-0310-25,NDC,outpatient,250,ML,199.57,139.699,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7997035,,,60.7997035,25.321355,416.02,other,OPPS APC,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,68982-0623-03,NDC,outpatient,500,ML,363.1,254.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7997035,,,60.7997035,25.321355,416.02,other,OPPS APC,,
ALBUMIN HUMAN 5 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8982,CDM,P9045,HCPCS,636,RC,68982-0623-03,NDC,outpatient,500,ML,347.1,242.97,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,60.7997035,,,60.7997035,25.321355,416.02,other,OPPS APC,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-00,NDC,outpatient,100,ML,309.7,216.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC,,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-04,NDC,outpatient,100,ML,32.49,22.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC,,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-04,NDC,outpatient,100,ML,304.83,213.381,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-04,NDC,outpatient,100,ML,48.49,33.943,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-01,NDC,outpatient,50,ML,168.42,117.894,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-02,NDC,outpatient,100,ML,320.83,224.581,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-03,NDC,outpatient,50,ML,168.42,117.894,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC,,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-00,NDC,outpatient,100,ML,293.7,205.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-01,NDC,outpatient,50,ML,209.58,146.706,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-02,NDC,outpatient,100,ML,48.49,33.943,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,64208-2512-07,NDC,outpatient,100,ML,309.7,216.79,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-04,NDC,outpatient,100,ML,320.83,224.581,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-08,NDC,outpatient,100,ML,430.3,301.21,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC,,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,64208-2512-07,NDC,outpatient,100,ML,293.7,205.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-03,NDC,outpatient,50,ML,209.58,146.706,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC,,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-02,NDC,outpatient,100,ML,32.49,22.743,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC,,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-02,NDC,outpatient,100,ML,304.83,213.381,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC,,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-08,NDC,outpatient,100,ML,414.3,290.01,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],JW,60.7997035,,,60.7997035,7.294005,416.02,other,OPPS APC,,
HC Platelets- Hla-M- L/R- Unit,PX-39000026,CDM,P9052,HCPCS,390,RC,,,outpatient,,,1807,1264.9,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,825.527485,,,825.527485,163,1698,other,OPPS APC,,
HC RBC- Frz/Deg/Wsh- L/R- Irrad,PX-39000023,CDM,P9057,CPT,390,RC,,,outpatient,,,2062,1443.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,564.38785,,,564.38785,163,1747.7512,other,OPPS APC,,
HC RBC- L/R- Cmv-Neg- Irrad,PX-39000024,CDM,P9058,CPT,390,RC,,,outpatient,,,1235,864.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,277.05063,,,277.05063,163,1046.786,other,OPPS APC,,
HC Plasma- Frz Between 8-24hour,PX-39000025,CDM,P9059,CPT,390,RC,,,outpatient,,,222,155.4,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,83.128935,,,83.128935,49.839,416.02,other,OPPS APC,,
HC Platelets- Pheresis- Pathogen-Reduced- Each Unit,PX-39000028,CDM,P9073,HCPCS,390,RC,,,outpatient,,,1626,1138.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,631.49124,,,631.49124,163,1265.41,other,OPPS APC,,
HC Pathogen Test for Platelets,PX-30000897,CDM,P9100,HCPCS,300,RC,,,outpatient,,,89,62.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,66.75974,,,66.75974,19.9805,416.02,other,OPPS APC,,
FERUMOXYTOL 510 MG/17ML IV SOLN,RX-98312,CDM,Q0138,HCPCS,636,RC,59338-0775-01,NDC,outpatient,17,ML,945.71,661.997,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.387179,,,0.387179,0.34,726.30528,other,OPPS APC,,
ONDANSETRON HCL 4 MG ORAL TABS,RX-10778,CDM,Q0162,HCPCS,259,RC,00904-6551-61,NDC,outpatient,1,UN,1.57,1.099,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.01,416.02,other,OPPS APC,,
ONDANSETRON 4 MG ORAL TBDP,RX-27697,CDM,Q0162,HCPCS,259,RC,68462-0157-13,NDC,outpatient,1,UN,0.99,0.693,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.01,416.02,other,OPPS APC,,
ONDANSETRON 4 MG ORAL TBDP,RX-27697,CDM,Q0162,HCPCS,259,RC,68462-0157-40,NDC,outpatient,1,UN,0.99,0.693,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.01,416.02,other,OPPS APC,,
ONDANSETRON 4 MG ORAL TBDP,RX-27697,CDM,Q0162,HCPCS,259,RC,65862-0390-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.01,416.02,other,OPPS APC,,
PROCHLORPERAZINE MALEATE 5 MG ORAL TABS,RX-6583,CDM,Q0164,HCPCS,259,RC,50268-0684-15,NDC,outpatient,1,UN,3.56,2.492,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.35,416.02,other,OPPS APC,,
PROCHLORPERAZINE MALEATE 5 MG ORAL TABS,RX-6583,CDM,Q0164,HCPCS,259,RC,50268-0684-11,NDC,outpatient,1,UN,3.56,2.492,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.35,416.02,other,OPPS APC,,
DRONABINOL 2.5 MG ORAL CAPS,RX-9904,CDM,Q0167,HCPCS,259,RC,60687-0375-11,NDC,outpatient,1,UN,18.82,13.174,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.73,416.02,,,,
DRONABINOL 2.5 MG ORAL CAPS,RX-9904,CDM,Q0167,HCPCS,259,RC,60687-0375-21,NDC,outpatient,1,UN,18.82,13.174,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.73,416.02,,,,
PROMETHAZINE HCL 25 MG ORAL TABS,RX-6622,CDM,Q0169,HCPCS,259,RC,00904-7304-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,,,,
PROMETHAZINE HCL 25 MG ORAL TABS,RX-6622,CDM,Q0169,HCPCS,259,RC,68382-0041-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.09,416.02,,,,
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,63323-0403-02,NDC,outpatient,2,ML,19.75,13.825,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3.6656,,,3.6656,2.55,416.02,other,OPPS APC,,
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,00069-6001-21,NDC,outpatient,10,ML,77.92,54.544,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3.6656,,,3.6656,2.55,416.02,other,OPPS APC,,
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,00069-6001-10,NDC,outpatient,10,ML,77.92,54.544,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3.6656,,,3.6656,2.55,416.02,other,OPPS APC,,
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,63323-0403-01,NDC,outpatient,2,ML,19.75,13.825,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,3.6656,,,3.6656,2.55,416.02,other,OPPS APC,,
DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ,RX-27431,CDM,Q2050,HCPCS,636,RC,00338-0067-01,NDC,outpatient,25,ML,1408.44,985.908,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,152.44314,,,152.44314,87.98,1653.428703,other,OPPS APC,,
DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ,RX-27431,CDM,Q2050,HCPCS,636,RC,47335-0050-40,NDC,outpatient,25,ML,1589.76,1112.832,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,152.44314,,,152.44314,87.98,1653.428703,other,OPPS APC,,
IMPLANT TY I COLL 1X1IN DURAMATRIX-ONLAY -,SUP-CDSLM11,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,1553.95,1087.765,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,348.861775,3862.93248,other,OPPS APC,,
DURAMATRIX SUTURABLE 2 X 2 -,SUP-DMS22,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,2490.5,1743.35,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,348.861775,3862.93248,other,OPPS APC,,
DURAMATRIX SUTURABLE  3x3 -,SUP-DMS33,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,4042.29,2829.603,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,348.861775,3862.93248,other,OPPS APC,,
DURAMATRIX SUTURABLE 4 X 5 -,SUP-DMS45,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,5029.86,3520.902,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,348.861775,3862.93248,other,OPPS APC,,
HC Skin Apligraf,PX-63600004,CDM,Q4101,HCPCS,636,RC,,,outpatient,,,8745,6121.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,30.42,6716.16,,,,
HC Matrix Wound Oasis by Sq Cm,PX-63600006,CDM,Q4102,HCPCS,636,RC,,,outpatient,,,65,45.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.25,659.42016,,,,
DRESSING WND 3 X 3.5CM OASIS WND MATRIX -,SUP-8213-1000-33,CDM,Q4102,CPT,278,RC,,,outpatient,,,858.62,601.034,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,12.25,659.42016,,,,
INTEGRA BILAYER MATRIX WOUND DRESSING 4 x 5 -,SUP-BMW4051,CDM,Q4104,HCPCS,278,RC,,,outpatient,,,24698.88,17289.216,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.96,24594.91584,other,OPPS APC,,
MATRIX MESHED BILAYER 2X2 INTE -,SUP-MWM2021,CDM,Q4104,HCPCS,278,RC,,,outpatient,,,20440.07,14308.049,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.96,24594.91584,other,OPPS APC,,
MATRIX MESH BILAYER 4 X 5 -,SUP-MWM4051,CDM,Q4104,HCPCS,278,RC,,,outpatient,,,32024.63,22417.241,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,48.96,24594.91584,other,OPPS APC,,
HC Primatrix Mesh by Sq Cm,PX-63600008,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,186,130.2,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.757,4074.24,other,OPPS APC,,
PRIMATRIX 0.2 x 26.5 ROPE 3 UNITS/BOX -,SUP-607-001-009,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,2157.3,1510.11,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.757,4074.24,other,OPPS APC,,
PRIMATRIX 2X2 MESHED -,SUP-607-005-220,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,2364.02,1654.814,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.757,4074.24,other,OPPS APC,,
PRIMATRIX 3X3 MESHED -,SUP-607-005-330,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,2506.35,1754.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.757,4074.24,other,OPPS APC,,
PRIMATRIX 4 X 4CM  MESH -,SUP-607-005-440,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,3074.46,2152.122,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.757,4074.24,other,OPPS APC,,
PRIMATRIX 6 X 6 MESH -,SUP-607-005-660,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,5305,3713.5,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.757,4074.24,other,OPPS APC,,
PRIMATRIX 4X4 AG -,SUP-UNDEFINED,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,41.757,4074.24,other,OPPS APC,,
ALLODERM LARGE THK1.04-2.28 MM THICK L12 CM X W4 CM 48CM2 -,SUP-102050,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,5700.37,3990.259,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,31.11,14996.48256,other,OPPS APC,,
ALLODERM LARGE THK2-2.8 MM THICK L12CM X W6CM 72CM2 -,SUP-151972,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,4655.67,3258.969,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,31.11,14996.48256,other,OPPS APC,,
GRAFT SOFT TISSUE AXIS TUTOPLAST DERMIS 12CM X 8CM ALLODERM -,SUP-939812,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,10961.89,7673.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,31.11,14996.48256,other,OPPS APC,,
ALLODERM CONTOUR LARGE PERF L21.5 CM X W10 230.05CM2 -,SUP-CL1519P,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,19526.67,13668.669,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,31.11,14996.48256,other,OPPS APC,,
ALLODERM CONTOUR MED PERF THICK 19.3 CM X 9.6 CM 185.28CM2 -,SUP-CM1519P,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,15267.86,10687.502,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,31.11,14996.48256,other,OPPS APC,,
ACELL MICROMATRIX POWDER 200MG -,SUP-MM0200,CDM,Q4118,HCPCS,278,RC,,,outpatient,,,2929.8,2050.86,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.5,8051.0208,other,OPPS APC,,
ACELL MICRO MATRIX 500 MG -,SUP-MM0500,CDM,Q4118,HCPCS,278,RC,,,outpatient,,,5728.55,4009.985,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.5,8051.0208,other,OPPS APC,,
ACELL MICRO MATRIX 1000 MG -,SUP-MM1000,CDM,Q4118,HCPCS,278,RC,,,outpatient,,,10483.1,7338.17,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,2.5,8051.0208,other,OPPS APC,,
SURGICLOSE MICRO 38CM2 -,SUP-50205P04D0D,CDM,Q4121,HCPCS,636,RC,,,outpatient,,,8488,5941.6,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,46.98,6518.784,other,OPPS APC,,
HC Matrix Wound Oasis Ultra by Sq Cm,PX-63600010,CDM,Q4124,HCPCS,636,RC,,,outpatient,,,61,42.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.16,4034.304,,,,
HC Matrix Oasis Ultra 7 X 10,PX-63600014,CDM,Q4124,HCPCS,636,RC,,,outpatient,,,5253,3677.1,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,9.16,4034.304,,,,
GRAFT ARTHROFLEX DERMIS THK1.5MM 35MM X 35MM 12.25CM2 -,SUP-AFLEX100,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,7779.25,5445.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,209.5932,10851.38688,other,OPPS APC,,
DERMIS DECELLULARIZED 35MM X 35MM X 2.0MM 12.25SQCM -,SUP-AFLEX200,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,11781.35,8246.945,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,209.5932,10851.38688,other,OPPS APC,,
ARTHROFLEX 40MM X 70MM X 3.0 DERMIS DECELLULARIZED 28SQCM -,SUP-AFLEX301,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,14129.41,9890.587,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,209.5932,10851.38688,other,OPPS APC,,
ARTHROFLEX 25 X 30 X 1MM 7.5SQCM -,SUP-AFLEX403,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,209.5932,10851.38688,other,OPPS APC,,
CONNECT PRE-SUTURED TENDON-ZORC 4.5 x 160MM -,SUP-FCON,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,5187.44,3631.208,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,209.5932,10851.38688,other,OPPS APC,,
SURGICLOSE 7 X 10CM- 70SQCM -,SUP-50205N03D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,16121.85,11285.295,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.06,20434.45248,other,OPPS APC,,
SURGICLOSE 6 X 8 MESHED 2:1 UP TO 86CM2 -,SUP-50205N18D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,10804.83,7563.381,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.06,20434.45248,other,OPPS APC,,
SURGICLOSE MESHED 2:1 4X6 CM- 24SQCM -,SUP-50205N20D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,6934.7,4854.29,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.06,20434.45248,other,OPPS APC,,
SURGICLOSE MESHED 7 X 20 -,SUP-50205N21D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,26607.36,18625.152,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.06,20434.45248,other,OPPS APC,,
SURGICLOSE MICRO 95 CM2 -,SUP-50205P31D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,15965.9,11176.13,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,3.06,20434.45248,other,OPPS APC,,
ACELL WOUND/BURN MATRIX 2 LAYER -,SUP-BMM0710,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,4509.25,3156.475,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,18.9,9453.0048,other,OPPS APC,,
CYTAL BURN MATRIX -,SUP-BMM1015,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,8116.65,5681.655,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,18.9,9453.0048,other,OPPS APC,,
CYTAL WOUND MATRIX 1 LAYER 3 X 7CM -,SUP-WS0307,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,853.08,597.156,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,18.9,9453.0048,other,OPPS APC,,
MATRIX WOUND ACELL GENTRIX 5M X 5CM 25CM2 3 LAYERS -,SUP-WSR0505,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,4118.77,2883.139,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,18.9,9453.0048,other,OPPS APC,,
WOUND MATRIX CYTEL 3 LAYER 7 X 10CM -,SUP-WSR0710,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,8206.84,5744.788,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,18.9,9453.0048,other,OPPS APC,,
WOUND MATRIX 3 LAYER 10 X 15CM -,SUP-WSR1015,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,12308.6,8616.02,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,18.9,9453.0048,other,OPPS APC,,
ACELL WOUND MATRIX 6-LAYER MESH -,SUP-WSX0505,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,4869.99,3408.993,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,18.9,9453.0048,other,OPPS APC,,
CYTAL WOUND MATRIX 6 LAYER 7 X 10CM -,SUP-WSX0710,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,9562.83,6693.981,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,18.9,9453.0048,other,OPPS APC,,
HC Epifix- per Square Centimeter,PX-63600024,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,501,350.7,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,112.4745,3643.99872,other,OPPS APC,,
EPIFIX DISK 14MM -,SUP-GS-5140,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,1746.51,1222.557,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,112.4745,3643.99872,other,OPPS APC,,
EPIFIX DISK 18MM -,SUP-GS-5180,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,3733.27,2613.289,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,112.4745,3643.99872,other,OPPS APC,,
EPIFIX 2 X 2 CM -,SUP-GS-5220,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,4744.79,3321.353,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,112.4745,3643.99872,other,OPPS APC,,
PURAPLY AM 2CMX2CM -,SUP-00000000000000000000000000000,CDM,Q4196,HCPCS,636,RC,,,outpatient,,,4057.9,2840.53,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,102.28,3422.3616,other,OPPS APC,,
PURAPLY AM 2CMX4CM -,SUP-PURAPLYAM-COM 2X4,CDM,Q4196,HCPCS,636,RC,,,outpatient,,,4456.2,3119.34,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,102.28,3422.3616,other,OPPS APC,,
FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY,RX-132201,CDM,Q5101,HCPCS,636,RC,61314-0318-01,NDC,outpatient,0.5,ML,603.11,422.177,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.414671,,,0.414671,0.18,741.12768,other,OPPS APC,,
FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY,RX-132201,CDM,Q5101,HCPCS,636,RC,61314-0318-05,NDC,outpatient,0.5,ML,603.14,422.198,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.414671,,,0.414671,0.18,741.12768,other,OPPS APC,,
FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY,RX-132201,CDM,Q5101,HCPCS,636,RC,61314-0318-10,NDC,outpatient,0.5,ML,603.14,422.198,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.414671,,,0.414671,0.18,741.12768,other,OPPS APC,,
FILGRASTIM-SNDZ 480 MCG/0.8ML IJ SOSY,RX-132202,CDM,Q5101,HCPCS,636,RC,61314-0326-05,NDC,outpatient,0.8,ML,965.01,675.507,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.414671,,,0.414671,0.18,741.12768,other,OPPS APC,,
FILGRASTIM-SNDZ 480 MCG/0.8ML IJ SOSY,RX-132202,CDM,Q5101,HCPCS,636,RC,61314-0326-10,NDC,outpatient,0.8,ML,965.01,675.507,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,0.414671,,,0.414671,0.18,741.12768,other,OPPS APC,,
INFLIXIMAB-DYYB 100 MG IV SOLR,RX-136637,CDM,Q5103,HCPCS,636,RC,00069-0809-01,NDC,outpatient,1,UN,1389.66,972.762,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,15.599419,,,15.599419,13.62,1653.428703,other,OPPS APC,,
INFLIXIMAB-ABDA 100 MG IV SOLR,RX-139995,CDM,Q5104,HCPCS,636,RC,00006-4305-01,NDC,outpatient,1,UN,1902.38,1331.666,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,31.136981,,,31.136981,27.18,1653.428703,other,OPPS APC,,
INFLIXIMAB-ABDA 100 MG IV SOLR,RX-139995,CDM,Q5104,HCPCS,636,RC,00006-4305-02,NDC,outpatient,1,UN,1902.38,1331.666,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,31.136981,,,31.136981,27.18,1653.428703,other,OPPS APC,,
EPOETIN ALFA-EPBX 2000 UNIT/ML IJ SOLN,RX-143174,CDM,Q5106,HCPCS,636,RC,00069-1305-10,NDC,outpatient,1,ML,79.46,55.622,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8.726419,,,8.726419,7.5,416.02,other,OPPS APC,,
EPOETIN ALFA-EPBX 2000 UNIT/ML IJ SOLN,RX-143174,CDM,Q5106,HCPCS,636,RC,00069-1305-01,NDC,outpatient,1,ML,79.46,55.622,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8.726419,,,8.726419,7.5,416.02,other,OPPS APC,,
EPOETIN ALFA-EPBX 3000 UNIT/ML IJ SOLN,RX-143175,CDM,Q5106,HCPCS,636,RC,00069-1306-01,NDC,outpatient,1,ML,119.19,83.433,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8.726419,,,8.726419,7.5,416.02,other,OPPS APC,,
EPOETIN ALFA-EPBX 3000 UNIT/ML IJ SOLN,RX-143175,CDM,Q5106,HCPCS,636,RC,00069-1306-10,NDC,outpatient,1,ML,119.19,83.433,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8.726419,,,8.726419,7.5,416.02,other,OPPS APC,,
EPOETIN ALFA-EPBX 4000 UNIT/ML IJ SOLN,RX-143176,CDM,Q5106,HCPCS,636,RC,00069-1307-10,NDC,outpatient,1,ML,158.92,111.244,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8.726419,,,8.726419,7.5,416.02,other,OPPS APC,,
EPOETIN ALFA-EPBX 4000 UNIT/ML IJ SOLN,RX-143176,CDM,Q5106,HCPCS,636,RC,00069-1307-01,NDC,outpatient,1,ML,158.92,111.244,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8.726419,,,8.726419,7.5,416.02,other,OPPS APC,,
EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN,RX-143177,CDM,Q5106,HCPCS,636,RC,00069-1308-10,NDC,outpatient,1,ML,377.7,264.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8.726419,,,8.726419,7.5,416.02,other,OPPS APC,,
EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN,RX-143177,CDM,Q5106,HCPCS,636,RC,00069-1308-01,NDC,outpatient,1,ML,377.7,264.39,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8.726419,,,8.726419,7.5,416.02,other,OPPS APC,,
EPOETIN ALFA-EPBX 40000 UNIT/ML IJ SOLN,RX-143178,CDM,Q5106,HCPCS,636,RC,00069-1309-01,NDC,outpatient,0.05,ML,75.54,52.878,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8.726419,,,8.726419,7.5,416.02,other,OPPS APC,,
EPOETIN ALFA-EPBX 40000 UNIT/ML IJ SOLN,RX-143178,CDM,Q5106,HCPCS,636,RC,00069-1309-04,NDC,outpatient,0.05,ML,75.54,52.878,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,8.726419,,,8.726419,7.5,416.02,other,OPPS APC,,
RITUXIMAB-ABBS 10 MG/ML IV SOLN WRAPPER,RX-4081244,CDM,Q5115,HCPCS,636,RC,63459-0103-10,NDC,outpatient,10,ML,1691.22,1183.854,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,38.481927,,,38.481927,33.59,7269.974281,other,OPPS APC,,
RITUXIMAB-ABBS 10 MG/ML IV SOLN WRAPPER,RX-4081244,CDM,Q5115,HCPCS,636,RC,63459-0104-50,NDC,outpatient,50,ML,6662.37,4663.659,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,38.481927,,,38.481927,33.59,7269.974281,other,OPPS APC,,
INFLIXIMAB-AXXQ 100 MG IV SOLR,RX-150921,CDM,Q5121,HCPCS,636,RC,55513-0670-01,NDC,outpatient,1,UN,2071.48,1450.036,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,24.387695,,,24.387695,21.29,1590.89664,other,OPPS APC,,
MEDIA CONTR PRFLTRN LPD MICSPHR INJ SUSP VL DEFINITY -,SUP-DE16,CDM,Q9957,CPT,636,RC,,,outpatient,,,554.33,388.031,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,40.92,438.4896,other,OPPS APC,,
DEFINITY DE-4 -,SUP-DE4,CDM,Q9957,CPT,636,RC,,,outpatient,,,570.95,399.665,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,40.92,438.4896,other,OPPS APC,,
DIATRIZOATE MEGLUMINE & SODIUM 66-10 % ORAL SOLN,RX-9828,CDM,Q9963,HCPCS,636,RC,00270-0445-40,NDC,outpatient,7.5,ML,3.71,2.597,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.22,416.02,,,,
IOHEXOL 180 MG/ML IJ SOLN,RX-10319,CDM,Q9965,HCPCS,636,RC,00407-1411-10,NDC,outpatient,3,ML,16.35,11.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.56,416.02,other,OPPS APC,,
IOHEXOL 180 MG/ML IJ SOLN,RX-10319,CDM,Q9965,HCPCS,636,RC,99999-0004-10,NDC,outpatient,3,ML,16.35,11.445,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,1.56,416.02,other,OPPS APC,,
IOPAMIDOL 41 % IJ SOLN,RX-10325,CDM,Q9966,HCPCS,636,RC,00270-1411-11,NDC,outpatient,10,ML,98.1,68.67,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.38,416.02,other,OPPS APC,,
IOHEXOL 240 MG/ML IJ SOLN,RX-119843,CDM,Q9966,HCPCS,636,RC,00407-1412-30,NDC,outpatient,10,ML,32.7,22.89,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.38,416.02,other,OPPS APC,,
IOHEXOL 240 MG/ML IJ SOLN,RX-119843,CDM,Q9966,HCPCS,636,RC,99999-0004-07,NDC,outpatient,10,ML,32.7,22.89,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.38,416.02,other,OPPS APC,,
IOHEXOL 240 MG/ML IJ SOLN,RX-119843,CDM,Q9966,HCPCS,636,RC,00407-1412-33,NDC,outpatient,10,ML,32.7,22.89,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.38,416.02,other,OPPS APC,,
IOPAMIDOL 61 % IJ SOLN,RX-10327,CDM,Q9967,HCPCS,636,RC,00270-1412-15,NDC,outpatient,15,ML,81.75,57.225,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.14,416.02,other,OPPS APC,,
IOPAMIDOL 76 % IV SOLN,RX-10328,CDM,Q9967,HCPCS,636,RC,00270-1316-35,NDC,outpatient,50,ML,272.5,190.75,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.14,416.02,other,OPPS APC,,
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-61,NDC,outpatient,5,ML,10.9,7.63,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.14,416.02,other,OPPS APC,,
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-10,NDC,outpatient,5,ML,10.9,7.63,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.14,416.02,other,OPPS APC,,
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-58,NDC,outpatient,5,ML,10.9,7.63,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.14,416.02,other,OPPS APC,,
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-59,NDC,outpatient,5,ML,10.9,7.63,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.14,416.02,other,OPPS APC,,
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-63,NDC,outpatient,5,ML,10.9,7.63,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.14,416.02,other,OPPS APC,,
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,99999-0004-09,NDC,outpatient,5,ML,10.9,7.63,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.14,416.02,other,OPPS APC,,
IOPAMIDOL 61 % IV SOLN,RX-27737,CDM,Q9967,HCPCS,636,RC,00270-1315-25,NDC,outpatient,30,ML,163.5,114.45,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.14,416.02,other,OPPS APC,,
IOVERSOL 68 % IJ SOLN,RX-39700,CDM,Q9967,HCPCS,636,RC,00019-1323-02,NDC,outpatient,20,ML,109,76.3,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,0.14,416.02,other,OPPS APC,,
ISOSULFAN BLUE 1 % SC SOLN,RX-10358,CDM,Q9968,HCPCS,636,RC,67457-0220-05,NDC,outpatient,5,ML,2840.8,1988.56,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9.775697,,,9.775697,9.53,2181.7344,other,OPPS APC,,
ISOSULFAN BLUE 1 % SC SOLN,RX-10358,CDM,Q9968,HCPCS,636,RC,67457-0220-00,NDC,outpatient,5,ML,2840.8,1988.56,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,9.775697,,,9.775697,9.53,2181.7344,other,OPPS APC,,
IOL 16D 5.5X12.5MM PMMA AC CNVXPLN ACRYSOF MTA3U0 -,SUP-MTA3U0.160,CDM,V2630,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,129.686915,921.62304,,,,
IOL 9.5D 5.5MMX12.5MM AC CNVXPLN -,SUP-MTA3UO.095,CDM,V2630,HCPCS,276,RC,,,outpatient,,,577.67,404.369,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,129.686915,921.62304,,,,
IOL 10.5D 5.5MMX12.5MM AC CNVXPLN -,SUP-MTA3UO.105,CDM,V2630,HCPCS,276,RC,,,outpatient,,,577.67,404.369,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,129.686915,921.62304,,,,
IOL 20D 5.5MMX12.5MM AC CNVXPLN -,SUP-MTA3UO.200,CDM,V2630,HCPCS,276,RC,,,outpatient,,,1200.03,840.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,129.686915,921.62304,,,,
IOL 22D 5.5X13MM AC CNVXPLN -,SUP-MTA4UO.220,CDM,V2630,HCPCS,276,RC,,,outpatient,,,1200.03,840.021,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,129.686915,921.62304,,,,
IOL 12.5D 5.5MMX13.5MM AC CNVXPLN -,SUP-MTA5U0.125,CDM,V2630,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,129.686915,921.62304,,,,
IOL 10.5D X 13.5OP AC CNVXPLN -,SUP-MTA5UO.105,CDM,V2630,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,129.686915,921.62304,,,,
IOL 8.5D PC -,SUP-AR40MN085,CDM,V2632,HCPCS,276,RC,,,outpatient,,,1021.13,714.791,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 23D 6X13MM CLARIFLEX CLRFLXC 3PC PC BICNVX SIL BLU COR -,SUP-CLRFLXC.230,CDM,V2632,HCPCS,276,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 26.5D CLARIFLEX PC -,SUP-CLRFLXC.265,CDM,V2632,HCPCS,276,RC,,,outpatient,,,612.68,428.876,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 16.5D 6X13MM ACRYSF MA60AC 3PC PC BICNVX BLU ACRYLT -,SUP-MA60AC.165,CDM,V2632,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL +1D 6X13MM ACRYSF MA60MA MULPC PC MNSCS BLU ACRYLT -,SUP-MA60MA.010,CDM,V2632,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 3D 6X13MM ACRYSF MA60MA MULPC PC MNSCS BLU ACRYLT -,SUP-MA60MA.030,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL -4D 6X13MM ACRYSF XPD SRS MULPC PC BICNVX BLU ACRYLT -,SUP-MA60MA-4.0,CDM,V2632,HCPCS,276,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
LENS I/O X.010 NEGATIVE D -,SUP-MA60MAN010,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 4D 6X13MM ACRYSF XPD SRS MULPC PC BICNVX BLU ACRYLT -,SUP-MA60MAN040,CDM,V2632,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
LENS I/O MN60AC X 8.0 -,SUP-MN60AC.080,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 28D 6X13MM ACRYSF MN60AC MULPC PC BICNVX NAT YEL ACRYLT -,SUP-MN60AC.280,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 2.0 DIA 6X13MM ACRYSF XPD SRS MULPC PC MNSCS NAT -,SUP-MN60MA.020,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 3D 6X13MM ACRYSF XPD SRS MULPC PC MNSCS NAT -,SUP-MN60MA.030,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
LENS IOL 5.0D MN60MA 6X13MM ACRYSF MULPC PC MNSCS BLU ACRYLT -,SUP-MN60MA.050,CDM,V2632,HCPCS,276,RC,,,outpatient,,,875.25,612.675,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 9D 6X13MM ACRYSF SA60AT 1-PC PC BICNVX CLR ACRYLT -,SUP-SA60AT.090,CDM,V2632,HCPCS,276,RC,,,outpatient,,,781.89,547.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 30D 6X13MM ACRYSF 1-PC PC BICNVX NAT ANT ASYM -,SUP-SN60AT.300,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 31D 6X13MM 31  ACRYSF SA60AT 1-PC PC BICNVX CLR ACRYLT -,SUP-SN60AT.310,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 34D 6X13MM ACRYSF SA60AT 1-PC PC BICNVX CLR ACRYLT -,SUP-SN60AT.340,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 6.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.065,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 7D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.070,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 9D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.090,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 9.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.095,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 10D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.100,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 10.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.105,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 11D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.110,CDM,V2632,HCPCS,276,RC,,,outpatient,,,781.89,547.323,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 11.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.115,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 12D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.120,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 13D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.130,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 13.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.135,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 14D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.140,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 14.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.145,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 16D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.160,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 16.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.165,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 17D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.170,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 17.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.175,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 18D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.180,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 19D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.190,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 20D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.200,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 21D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.210,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 21.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.215,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 22D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.220,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 22.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.225,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 23D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.230,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 24D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.240,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 24.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.245,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 25D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.250,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 26D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.260,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 26.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.265,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 19D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.190,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 20D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.200,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 20.5D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.205,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 21D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.210,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 21.5D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.215,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
LENS I/O MA60MA x 1.0 -,SUP-UNDEFINED,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
IOL 24.5D 6X13MM TECNIS ZA9003 3PC PC BICNVX HYDRPHB ACRL -,SUP-ZA9003.245,CDM,V2632,HCPCS,276,RC,,,outpatient,,,816.9,571.83,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,137.54666,3281.45664,other,OPPS APC,,
LENS ACRYSOF TORIC IQ  SN6AT3 X 9.5D -,SUP-SN6AT3.095,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,,,
IOL TORIC LENS  SN6AT3  12.0 -,SUP-SN6AT3.120,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,,,
IOL 15.5D 6X13MM ACRYSF SN6AT3 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT3.155,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,,,
IOL 16.0D  6X13MM ACRYSF  SN6AT3 -,SUP-SN6AT3.160,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,,,
IOL 17.0D  6X13MM ACRYSF  SN6AT3 -,SUP-SN6AT3.170,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,,,
IOL 18.0 D 6X13MM ACRYSF SN6AT3 -,SUP-SN6AT3.180,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,,,
IOL 19.5D 6X13MM ACRYSF SN6AT3 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT3.195,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,,,
IOL 24D 6X13MM ACRYSF  SN6 -,SUP-SN6AT3.240,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,,,
IOL 13.5D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.135,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,,,
IOL 19D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.190,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,,,
IOL 19.5D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.195,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,,,
IOL 21D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.210,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,,,
IOL 16D 6X13MM ACRYSF SN6AT5 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT5.160,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,,,
LENS ACRYSOF IQ  SN6AT5.180 -,SUP-SN6AT5.180,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,,,
IOL 21D 6X13MM ACRYSF SN6AT5 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT5.210,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,,,
IOL 23D 6X13MM ACRYSF SN6AT5 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT5.230,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,,,
IOL 11D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT6.110,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,,,
IOL 13.5D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT -,SUP-SN6AT6.135,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,,,
IOL 14D 6X13MM  ACRYSF  SN6AT6 -,SUP-SN6AT6.140,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,,,
IOL LENS SN6AT6 X 18.0 D -,SUP-SN6AT6.180,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,,,
IOL 20D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT6.200,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,,,
IOL 20.5D 6X13MM ACRYSF SN6AT6 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT6.205,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2093.7,1465.59,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,,,
IOL TORIC LENS 23.5 DIOPTER -,SUP-SN6AT6.235,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,,,
IOL 22D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT6U220,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,,,
IOL 20D 6X13MM  ACRYSF -,SUP-SN6AT7.200,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,,,
IOL 23.5D  6X13MM  ACRYSF   SN6AT7 -,SUP-SN6AT7.235,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,2223.8905,,,,
AMNIOGRAFT AMNIO MEMBR HUM TIS FRZN 3.5X3.5CM SZ-C -,SUP-AG-3535,CDM,V2790,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,3992.7552,other,OPPS APC,,
GRAFT HUM TIS 3.5X3.5CM SZ-C AMNIOGRFT AMNIO MEMBR 50-100U -,SUP-AG-3535F,CDM,V2790,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],,,,,,399.86,3992.7552,other,OPPS APC,,
Bilateral procedure,,,,,,,,,,,,,,BCBS MASS MEDICARE MANAGED CARE [1010302],BCBS MASS MEDICARE MANAGED CARE [101030201],50,,150,,,,,,150% payment adjustment for the item or service to which the modifier is appended.,,
HC Semi-Private Unit,PX-12100001,CDM,12100001,LOCAL,121,RC,,,inpatient,,,1577,1103.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,525.9295,1261.6,,,,
HC Med/Surg Stepdown,PX-12100003,CDM,12100003,LOCAL,121,RC,,,inpatient,,,2423,1696.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,808.0705,1938.4,,,,
HC Maternity Unit,PX-12200001,CDM,12200001,LOCAL,122,RC,,,inpatient,,,2193,1535.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,731.3655,1754.4,,,,
HC Pediatric Semi-Private Unit,PX-12300001,CDM,12300001,LOCAL,123,RC,,,inpatient,,,3323,2326.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1108.2205,2658.4,,,,
HC S.E. Rehab Semi-Private Unit,PX-12800001,CDM,12800001,LOCAL,128,RC,,,inpatient,,,1783,1248.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,955.5,,,955.5,594.6305,2483,per diem,,,
HC Nursery,PX-17000001,CDM,17000001,LOCAL,170,RC,,,inpatient,,,1333,933.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,444.5555,1066.4,,,,
HC Nursery Boarder,PX-17900001,CDM,17900001,LOCAL,179,RC,,,inpatient,,,1195,836.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,398.5325,956,,,,
HC Icu/Ccu Unit,PX-20000001,CDM,20000001,LOCAL,200,RC,,,inpatient,,,4009,2806.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1337.0015,3207.2,,,,
HC Icu Surgical Unit,PX-20100001,CDM,20100001,LOCAL,201,RC,,,inpatient,,,3646,2552.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1215.941,2916.8,,,,
HC Telemetry Unit,PX-20600001,CDM,20600001,LOCAL,206,RC,,,inpatient,,,2015,1410.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,672.0025,1612,,,,
HC Trauma,PX-20800001,CDM,20800001,LOCAL,208,RC,,,inpatient,,,4810,3367,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1604.135,3848,,,,
HC Onc. Vad Kit,PX-27000020,CDM,27000020,LOCAL,270,RC,,,inpatient,,,90,63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.205,72,,,,
HC Imed Pump for Lvl II,PX-27000021,CDM,27000021,LOCAL,270,RC,,,inpatient,,,118,82.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.491,94.4,,,,
HC Imed Pump,PX-27000022,CDM,27000022,LOCAL,270,RC,,,inpatient,,,113,79.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,25.3685,90.4,,,,
HC Local Anesth Supplies,PX-27000023,CDM,27000023,LOCAL,270,RC,,,inpatient,,,80,56,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,17.96,64,,,,
HC Periop O2,PX-27000044,CDM,27000044,LOCAL,270,RC,,,inpatient,,,79,55.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,17.7355,63.2,,,,
HC Bone Bx Kit,PX-27000050,CDM,27000050,LOCAL,270,RC,,,inpatient,,,267,186.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,59.9415,213.6,,,,
HC Kit Portex Nerve Block,PX-27000051,CDM,27000051,LOCAL,270,RC,,,inpatient,,,90,63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.205,72,,,,
HC Cannister Vac W/O Gel Ats,PX-27000052,CDM,27000052,LOCAL,270,RC,,,inpatient,,,282,197.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,63.309,225.6,,,,
HC Dressing Kci Small 5/Cs,PX-27000053,CDM,27000053,LOCAL,270,RC,,,inpatient,,,268,187.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.166,214.4,,,,
HC Cannister W/Gel Ats,PX-27000054,CDM,27000054,LOCAL,270,RC,,,inpatient,,,283,198.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,63.5335,226.4,,,,
HC Compression Stocking A6530,PX-27000055,CDM,27000055,LOCAL,270,RC,,,inpatient,,,285,199.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,63.9825,228,,,,
HC Custom Molded Insert,PX-27000056,CDM,27000056,LOCAL,270,RC,,,inpatient,,,287,200.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,64.4315,229.6,,,,
HC Dressing Kci Medium 10/Cs,PX-27000057,CDM,27000057,LOCAL,270,RC,,,inpatient,,,307,214.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,68.9215,245.6,,,,
HC Surgical Boot/Shoe L3260,PX-27000058,CDM,27000058,LOCAL,270,RC,,,inpatient,,,423,296.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,94.9635,338.4,,,,
HC Vaccum Assisted Closure Pump,PX-27000059,CDM,27000059,LOCAL,270,RC,,,inpatient,,,438,306.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,98.331,350.4,,,,
HC Ortho Wedge Shoe,PX-27000060,CDM,27000060,LOCAL,270,RC,,,inpatient,,,529,370.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,118.7605,423.2,,,,
HC Foot Pressure Support A9283,PX-27000061,CDM,27000061,LOCAL,270,RC,,,inpatient,,,529,370.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,118.7605,423.2,,,,
HC Sensor Nicom,PX-27000062,CDM,27000062,LOCAL,270,RC,,,inpatient,,,816,571.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,183.192,652.8,,,,
HC 6 Channel Pneumogram,PX-27000063,CDM,27000063,LOCAL,270,RC,,,inpatient,,,3884,2718.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,871.958,3107.2,,,,
HC Pneumogram 4-Channel,PX-27000064,CDM,27000064,LOCAL,270,RC,,,inpatient,,,4891,3423.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1098.0295,3912.8,,,,
HC Pad Artic Gel Large,PX-27000065,CDM,27000065,LOCAL,270,RC,,,inpatient,,,5242,3669.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1176.829,4193.6,,,,
HC Pneumogram 6- Channel,PX-27000066,CDM,27000066,LOCAL,270,RC,,,inpatient,,,5466,3826.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1227.117,4372.8,,,,
HC Therapy Polar Cooler,PX-27000068,CDM,27000068,LOCAL,270,RC,,,inpatient,,,667,466.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,149.7415,533.6,,,,
HC Liner Foam Permanently Med,PX-27000069,CDM,27000069,LOCAL,270,RC,,,inpatient,,,353,247.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,79.2485,282.4,,,,
HC Dressing Kci Vac Small,PX-27000070,CDM,27000070,LOCAL,270,RC,,,inpatient,,,327,228.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,73.4115,261.6,,,,
HC Dressing Kci Vac Large,PX-27000071,CDM,27000071,LOCAL,270,RC,,,inpatient,,,390,273,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,87.555,312,,,,
HC Developmental Aides,PX-27000072,CDM,27000072,LOCAL,270,RC,,,inpatient,,,707,494.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,158.7215,565.6,,,,
"HC Ez Reacher 30"" Suction",PX-27100004,CDM,27100004,LOCAL,271,RC,,,inpatient,,,144,100.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,32.328,122.0544,,,,
HC Support Bra Ez-on Med 958,PX-27100005,CDM,27100005,LOCAL,271,RC,,,inpatient,,,262,183.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,58.819,222.0712,,,,
HC Support Bra Ez-on Lrg 958,PX-27100006,CDM,27100006,LOCAL,271,RC,,,inpatient,,,272,190.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,61.064,230.5472,,,,
HC Support Bra Ez-on X-Lrg 958,PX-27100007,CDM,27100007,LOCAL,271,RC,,,inpatient,,,306,214.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,68.697,259.3656,,,,
HC Support Bra Ez-on Queen,PX-27100008,CDM,27100008,LOCAL,271,RC,,,inpatient,,,377,263.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,84.6365,319.5452,,,,
HC Bra Ez-on Super Queen,PX-27100009,CDM,27100009,LOCAL,271,RC,,,inpatient,,,471,329.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,105.7395,399.2196,,,,
HC Gradient Com Stocking,PX-27100010,CDM,27100010,LOCAL,271,RC,,,inpatient,,,490,343,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,110.005,415.324,,,,
HC Kit Flexi Seal Fecal,PX-27100011,CDM,27100011,LOCAL,271,RC,,,inpatient,,,939,657.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,210.8055,795.8964,,,,
HC Port Power Loc Access Kit,PX-27200054,CDM,27200054,LOCAL,272,RC,,,inpatient,,,88,61.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.756,74.5888,,,,
HC Dressing Kci Vac White Lg,PX-27200055,CDM,27200055,LOCAL,272,RC,,,inpatient,,,95,66.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,21.3275,80.522,,,,
HC Sheath Brite Tip 11cm,PX-27200056,CDM,27200056,LOCAL,272,RC,,,inpatient,,,108,75.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,24.246,91.5408,,,,
HC Kit Refill Syncromed Sys. Pain,PX-27200057,CDM,27200057,LOCAL,272,RC,,,inpatient,,,128,89.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,28.736,108.4928,,,,
HC Sock Fracture,PX-27200058,CDM,27200058,LOCAL,272,RC,,,inpatient,,,193,135.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,43.3285,163.5868,,,,
HC Tube Gastrostomy Replacement,PX-27200059,CDM,27200059,LOCAL,272,RC,,,inpatient,,,195,136.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,43.7775,165.282,,,,
HC Mod of Depth Shoe,PX-27200060,CDM,27200060,LOCAL,272,RC,,,inpatient,,,225,157.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,50.5125,190.71,,,,
HC Catheter Broncho 39l,PX-27200061,CDM,27200061,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,78.3505,295.8124,,,,
HC Catheter Bronch 35 Left 95892,PX-27200062,CDM,27200062,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,78.3505,295.8124,,,,
HC Endo-Bronch Tube 37fr Left,PX-27200063,CDM,27200063,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,78.3505,295.8124,,,,
HC Tube Endo Bronch #35 Left,PX-27200064,CDM,27200064,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,78.3505,295.8124,,,,
HC Endo Bronch Tube #39,PX-27200065,CDM,27200065,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,78.3505,295.8124,,,,
HC Catheter Broncho 41l,PX-27200066,CDM,27200066,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,78.3505,295.8124,,,,
HC Kit Arterial Line Arrow,PX-27200067,CDM,27200067,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,78.3505,295.8124,,,,
HC Cassette Kci Veralink,PX-27200068,CDM,27200068,LOCAL,272,RC,,,inpatient,,,357,249.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.1465,302.5932,,,,
HC Shiley Trach Tube 6lpc,PX-27200069,CDM,27200069,LOCAL,272,RC,,,inpatient,,,357,249.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.1465,302.5932,,,,
HC Tube Trach Shiley 8lpc,PX-27200070,CDM,27200070,LOCAL,272,RC,,,inpatient,,,357,249.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.1465,302.5932,,,,
HC Catheter Single 4fr Bard,PX-27200071,CDM,27200071,LOCAL,272,RC,,,inpatient,,,374,261.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,83.963,317.0024,,,,
HC Bivona #7 Trach Uncuffed,PX-27200072,CDM,27200072,LOCAL,272,RC,,,inpatient,,,396,277.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,88.902,335.6496,,,,
HC Retractor C Section Large,PX-27200073,CDM,27200073,LOCAL,272,RC,,,inpatient,,,402,281.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,90.249,340.7352,,,,
HC Midline 4fr Bd#384308,PX-27200074,CDM,27200074,LOCAL,272,RC,,,inpatient,,,409,286.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,91.8205,346.6684,,,,
HC Transducer Triple W/Vamp Pls,PX-27200075,CDM,27200075,LOCAL,272,RC,,,inpatient,,,418,292.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,93.841,354.2968,,,,
HC B Pleurx Drainage Kit,PX-27200076,CDM,27200076,LOCAL,272,RC,,,inpatient,,,417,291.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,93.6165,353.4492,,,,
HC Catheter Swan Ganz J Pacing,PX-27200078,CDM,27200078,LOCAL,272,RC,,,inpatient,,,446,312.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,100.127,378.0296,,,,
HC Tube Trach Distal Xlt 5.0,PX-27200079,CDM,27200079,LOCAL,272,RC,,,inpatient,,,451,315.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,101.2495,382.2676,,,,
HC Tube Trach Distal Xlt 6.0,PX-27200080,CDM,27200080,LOCAL,272,RC,,,inpatient,,,466,326.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,104.617,394.9816,,,,
HC Tube Trach 8 Cuff Non X Long,PX-27200081,CDM,27200081,LOCAL,272,RC,,,inpatient,,,466,326.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,104.617,394.9816,,,,
HC Sling Sam Pelvic Medium,PX-27200082,CDM,27200082,LOCAL,272,RC,,,inpatient,,,470,329,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,105.515,398.372,,,,
HC Set Tube Kaci Veratrac Duo,PX-27200083,CDM,27200083,LOCAL,272,RC,,,inpatient,,,488,341.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,109.556,413.6288,,,,
HC Retractor C Section Xlarge,PX-27200084,CDM,27200084,LOCAL,272,RC,,,inpatient,,,516,361.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,115.842,437.3616,,,,
HC Kit Mini 4fr Single Lumen,PX-27200085,CDM,27200085,LOCAL,272,RC,,,inpatient,,,519,363.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,116.5155,439.9044,,,,
HC Trach Bivona Tis 6id,PX-27200086,CDM,27200086,LOCAL,272,RC,,,inpatient,,,523,366.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,117.4135,443.2948,,,,
HC Pack C Section Custom Disp,PX-27200087,CDM,27200087,LOCAL,272,RC,,,inpatient,,,541,378.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,121.4545,458.5516,,,,
HC Trach Bivona Tts 8mm,PX-27200088,CDM,27200088,LOCAL,272,RC,,,inpatient,,,541,378.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,121.4545,458.5516,,,,
HC Trach Bivona 7.5 X 10,PX-27200089,CDM,27200089,LOCAL,272,RC,,,inpatient,,,556,389.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,124.822,471.2656,,,,
HC Tube Feeding Mic Key 14f 1.7,PX-27200091,CDM,27200091,LOCAL,272,RC,,,inpatient,,,674,471.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,151.313,571.2824,,,,
HC Kit Mic-Key G Feeding 16-3.5,PX-27200092,CDM,27200092,LOCAL,272,RC,,,inpatient,,,694,485.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,155.803,588.2344,,,,
HC Kit Mic-Key G Feeding 24-3.5,PX-27200093,CDM,27200093,LOCAL,272,RC,,,inpatient,,,694,485.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,155.803,588.2344,,,,
HC Mic Key G Tube 20fr 3.5cm,PX-27200094,CDM,27200094,LOCAL,272,RC,,,inpatient,,,694,485.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,155.803,588.2344,,,,
HC Device Support Foot,PX-27200095,CDM,27200095,LOCAL,272,RC,,,inpatient,,,703,492.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,157.8235,595.8628,,,,
HC Catheter 4 Fr Mid Line,PX-27200096,CDM,27200096,LOCAL,272,RC,,,inpatient,,,719,503.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,161.4155,609.4244,,,,
HC Tcc Size 3,PX-27200097,CDM,27200097,LOCAL,272,RC,,,inpatient,,,722,505.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,162.089,611.9672,,,,
HC Femostop Gold Compress Sys,PX-27200098,CDM,27200098,LOCAL,272,RC,,,inpatient,,,731,511.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,164.1095,619.5956,,,,
HC Dot Poly Midline 4fr Sl Full,PX-27200099,CDM,27200099,LOCAL,272,RC,,,inpatient,,,765,535.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,171.7425,648.414,,,,
HC Powerwand 5fr 10cm,PX-27200100,CDM,27200100,LOCAL,272,RC,,,inpatient,,,776,543.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.212,657.7376,,,,
HC Powerwand Single Sterile 5fr,PX-27200101,CDM,27200101,LOCAL,272,RC,,,inpatient,,,776,543.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.212,657.7376,,,,
HC Needle Intraosseous Pd 15g,PX-27200102,CDM,27200102,LOCAL,272,RC,,,inpatient,,,845,591.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,189.7025,716.222,,,,
HC Needle Intraosseous Ad 15g,PX-27200103,CDM,27200103,LOCAL,272,RC,,,inpatient,,,845,591.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,189.7025,716.222,,,,
HC Needle Intraosseous,PX-27200104,CDM,27200104,LOCAL,272,RC,,,inpatient,,,845,591.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,189.7025,716.222,,,,
HC Kit Triple Lumen Cath 7 X 6,PX-27200105,CDM,27200105,LOCAL,272,RC,,,inpatient,,,895,626.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,200.9275,758.602,,,,
HC Multi Lumen Cvc Kit Toh Cust,PX-27200106,CDM,27200106,LOCAL,272,RC,,,inpatient,,,895,626.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,200.9275,758.602,,,,
HC Pad Zoll Aed Cprd Access Kit,PX-27200107,CDM,27200107,LOCAL,272,RC,,,inpatient,,,827,578.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,185.6615,700.9652,,,,
HC Kit Flexi Seal Fecal,PX-27200108,CDM,27200108,LOCAL,272,RC,,,inpatient,,,939,657.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,210.8055,795.8964,,,,
HC Powerwand Quick Kit 5fr,PX-27200109,CDM,27200109,LOCAL,272,RC,,,inpatient,,,979,685.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,219.7855,829.8004,,,,
HC Mahurkar Dual Lumen Subclav Ca,PX-27200110,CDM,27200110,LOCAL,272,RC,,,inpatient,,,1581,1106.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,354.9345,1340.0556,,,,
HC Catheter With Curved Extension,PX-27200111,CDM,27200111,LOCAL,272,RC,,,inpatient,,,1581,1106.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,354.9345,1340.0556,,,,
HC Set Cath Cricothyroidotomy,PX-27200112,CDM,27200112,LOCAL,272,RC,,,inpatient,,,1136,795.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,255.032,962.8736,,,,
HC Rusch Quick Trac Small 2.0,PX-27200113,CDM,27200113,LOCAL,272,RC,,,inpatient,,,1269,888.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,284.8905,1075.6044,,,,
HC Set Prism Prewarm M100'2,PX-27200114,CDM,27200114,LOCAL,272,RC,,,inpatient,,,1319,923.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,296.1155,1117.9844,,,,
HC Set Prismaflex M100's,PX-27200115,CDM,27200115,LOCAL,272,RC,,,inpatient,,,1399,979.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,314.0755,1185.7924,,,,
HC Bakri Postpartum Balloon,PX-27200116,CDM,27200116,LOCAL,272,RC,,,inpatient,,,1408,985.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,316.096,1193.4208,,,,
HC Flo Trac Sensor Mhd6,PX-27200117,CDM,27200117,LOCAL,272,RC,,,inpatient,,,2027,1418.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,455.0615,1718.0852,,,,
HC Pad Universal Artic Gel,PX-27200118,CDM,27200118,LOCAL,272,RC,,,inpatient,,,2219,1553.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,498.1655,1880.8244,,,,
HC Cath Presep 8.5 Oximetry,PX-27200119,CDM,27200119,LOCAL,272,RC,,,inpatient,,,2602,1821.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,584.149,2205.4552,,,,
HC Set Cricothyrotomy Cath,PX-27200120,CDM,27200120,LOCAL,272,RC,,,inpatient,,,2943,2060.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,660.7035,2494.4868,,,,
HC Pad Artic Gel Small,PX-27200121,CDM,27200121,LOCAL,272,RC,,,inpatient,,,5565,3895.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1249.3425,4716.894,,,,
HC Pad Gel Artic Medium,PX-27200122,CDM,27200122,LOCAL,272,RC,,,inpatient,,,5512,3858.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1237.444,4671.9712,,,,
HC Rhino G2 Blue,PX-27200123,CDM,27200123,LOCAL,272,RC,,,inpatient,,,4120,2884,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,924.94,3492.112,,,,
HC Pad Artic Gel Lrg,PX-27200124,CDM,27200124,LOCAL,272,RC,,,inpatient,,,5512,3858.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1237.444,4671.9712,,,,
HC Bag External Drainage Collect,PX-27200125,CDM,27200125,LOCAL,272,RC,,,inpatient,,,1349,944.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,302.8505,1143.4124,,,,
HC Catheter Thoracic 28fr,PX-27200126,CDM,27200126,LOCAL,272,RC,,,inpatient,,,39,27.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.7555,33.0564,,,,
HC Tube Endo Bronch Left 37,PX-27200127,CDM,27200127,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,78.3505,295.8124,,,,
HC Electrode Temporary Pacing 6,PX-27200128,CDM,27200128,LOCAL,272,RC,,,inpatient,,,1238,866.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,277.931,1049.3288,,,,
HC Set Pneumothorax,PX-27200129,CDM,27200129,LOCAL,272,RC,,,inpatient,,,1113,779.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,249.8685,943.3788,,,,
HC System External Drainage III,PX-27200130,CDM,27200130,LOCAL,272,RC,,,inpatient,,,1887,1320.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,423.6315,1599.4212,,,,
HC Electrode Temporary Pacing 5,PX-27200131,CDM,27200131,LOCAL,272,RC,,,inpatient,,,1097,767.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,246.2765,929.8172,,,,
HC Tray Tru Close Thoracic Vent,PX-27200132,CDM,27200132,LOCAL,272,RC,,,inpatient,,,1504,1052.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,337.648,1274.7904,,,,
HC Tube Trach Flex Laser 6.0 Mm,PX-27200133,CDM,27200133,LOCAL,272,RC,,,inpatient,,,319,223.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,71.6155,270.3844,,,,
HC Pack Cesarean Custom,PX-27200134,CDM,27200134,LOCAL,272,RC,,,inpatient,,,462,323.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,103.719,391.5912,,,,
HC Hemostat Instat 1gm,PX-27200135,CDM,27200135,LOCAL,272,RC,,,inpatient,,,1077,753.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,241.7865,912.8652,,,,
HC Tube Trach Distal Xlt 7.0,PX-27200136,CDM,27200136,LOCAL,272,RC,,,inpatient,,,486,340.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,109.107,411.9336,,,,
HC Surgicel 2 X 14 #1951,PX-27200137,CDM,27200137,LOCAL,272,RC,,,inpatient,,,447,312.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,100.3515,378.8772,,,,
HC Ligator Saeed Sx Shoot,PX-27200138,CDM,27200138,LOCAL,272,RC,,,inpatient,,,1332,932.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,299.034,1129.0032,,,,
HC Cath Swan Ganz 7.5 Vip Port,PX-27200139,CDM,27200139,LOCAL,272,RC,,,inpatient,,,297,207.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,66.6765,251.7372,,,,
HC Cath Multilumen Access,PX-27200140,CDM,27200140,LOCAL,272,RC,,,inpatient,,,537,375.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,120.5565,455.1612,,,,
HC Trach Bivona Tts 7mm,PX-27200141,CDM,27200141,LOCAL,272,RC,,,inpatient,,,565,395.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,126.8425,478.894,,,,
HC Kit Pleurx Drainage W Bottle,PX-27200142,CDM,27200142,LOCAL,272,RC,,,inpatient,,,417,291.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,93.6165,353.4492,,,,
HC Retractor Wound Alexis Lrg,PX-27200143,CDM,27200143,LOCAL,272,RC,,,inpatient,,,412,288.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,92.494,349.2112,,,,
HC Unit Cold Therapy Deroyal,PX-27200144,CDM,27200144,LOCAL,272,RC,,,inpatient,,,691,483.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,155.1295,585.6916,,,,
HC Dressing Kci Vac Silver Med,PX-27200145,CDM,27200145,LOCAL,272,RC,,,inpatient,,,506,354.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,113.597,428.8856,,,,
HC Kit Midline Cath 20ga X 20cm,PX-27200146,CDM,27200146,LOCAL,272,RC,,,inpatient,,,424,296.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,95.188,359.3824,,,,
HC Cath Mahurkar 3 Lumen 12x20,PX-27200147,CDM,27200147,LOCAL,272,RC,,,inpatient,,,594,415.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,133.353,503.4744,,,,
HC Retractor Alexis Wound Xlg,PX-27200148,CDM,27200148,LOCAL,272,RC,,,inpatient,,,529,370.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,118.7605,448.3804,,,,
HC Surgiflo Hemostatic Matrix,PX-27200149,CDM,27200149,LOCAL,272,RC,,,inpatient,,,906,634.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,203.397,767.9256,,,,
HC Kit Monitoring Press Abviser,PX-27200150,CDM,27200150,LOCAL,272,RC,,,inpatient,,,648,453.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,145.476,549.2448,,,,
HC Tray Fuhrman Pleural Drain,PX-27200151,CDM,27200151,LOCAL,272,RC,,,inpatient,,,990,693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,222.255,839.124,,,,
HC Kit Cath Triple Lumen 20cm,PX-27200152,CDM,27200152,LOCAL,272,RC,,,inpatient,,,865,605.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,194.1925,733.174,,,,
HC Dressing Kci Simplace Med,PX-27200153,CDM,27200153,LOCAL,272,RC,,,inpatient,,,433,303.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,97.2085,367.0108,,,,
HC Tube Non Balloon Replace Peg,PX-27200154,CDM,27200154,LOCAL,272,RC,,,inpatient,,,394,275.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,88.453,333.9544,,,,
HC Cath 12fr Hp Triple Lumen,PX-27200155,CDM,27200155,LOCAL,272,RC,,,inpatient,,,606,424.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,136.047,513.6456,,,,
HC Cath Pneumothorax Ak01500,PX-27200156,CDM,27200156,LOCAL,272,RC,,,inpatient,,,700,490,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,157.15,593.32,,,,
HC Kit Cranial Access 826614,PX-27200158,CDM,27200158,LOCAL,272,RC,,,inpatient,,,2205,1543.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,495.0225,1868.958,,,,
"HC Sensor Flotrac W Vamp 60""",PX-27200159,CDM,27200159,LOCAL,272,RC,,,inpatient,,,1336,935.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,299.932,1132.3936,,,,
HC Trach Lg 4.0 Quick Rusch,PX-27200160,CDM,27200160,LOCAL,272,RC,,,inpatient,,,1094,765.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,245.603,927.2744,,,,
HC Tray Pericardiocentesis Stra,PX-27200161,CDM,27200161,LOCAL,272,RC,,,inpatient,,,1188,831.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,266.706,1006.9488,,,,
HC Trocar Endo Ethicon 12 512sd,PX-27200162,CDM,27200162,LOCAL,272,RC,,,inpatient,,,1154,807.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,259.073,978.1304,,,,
HC Tube Laryngectomy 12mm Metal,PX-27200163,CDM,27200163,LOCAL,272,RC,,,inpatient,,,1154,807.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,259.073,978.1304,,,,
HC Tray Midline CT 4f 20cm Single,PX-27200164,CDM,27200164,LOCAL,272,RC,,,inpatient,,,785,549.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,176.2325,665.366,,,,
HC Tray Midline CT 5f 20cm Dual,PX-27200165,CDM,27200165,LOCAL,272,RC,,,inpatient,,,779,545.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.8855,660.2804,,,,
HC Mahurkar Triple Lumen Cath Tray #16,PX-27200166,CDM,27200166,LOCAL,272,RC,,,inpatient,,,1191,833.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,267.3795,1009.4916,,,,
HC Mahurkar Triple Lumen Cath Tray #20,PX-27200167,CDM,27200167,LOCAL,272,RC,,,inpatient,,,983,688.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,220.6835,833.1908,,,,
HC Compartment Pressure Monitoring Kit,PX-27200168,CDM,27200168,LOCAL,272,RC,,,inpatient,,,457,319.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,102.5965,387.3532,,,,
HC Kit Perc Sheath Introducer 8.5,PX-27200169,CDM,27200169,LOCAL,272,RC,,,inpatient,,,471,329.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,105.7395,399.2196,,,,
HC Cath Arrow Cvc Kit Latex Free,PX-27200170,CDM,27200170,LOCAL,272,RC,,,inpatient,,,465,325.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,104.3925,394.134,,,,
HC Electrode Temporary Pacing 4,PX-27200171,CDM,27200171,LOCAL,272,RC,,,inpatient,,,823,576.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,184.7635,697.5748,,,,
HC Catheter Bipolar Pacing 5,PX-27200172,CDM,27200172,LOCAL,272,RC,,,inpatient,,,619,433.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,138.9655,524.6644,,,,
HC Set Emergency Pneumothorax,PX-27200173,CDM,27200173,LOCAL,272,RC,,,inpatient,,,795,556.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,178.4775,673.842,,,,
HC Kit Pneumothorax,PX-27200174,CDM,27200174,LOCAL,272,RC,,,inpatient,,,722,505.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,162.089,611.9672,,,,
HC Impella Purge Cassette,PX-27200175,CDM,27200175,LOCAL,272,RC,,,inpatient,,,245,171.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,55.0025,207.662,,,,
HC Tray Midline CT 4f 20cm Singl,PX-27200176,CDM,27200176,LOCAL,272,RC,,,inpatient,,,954,667.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,214.173,808.6104,,,,
HC Tray Midline CT 5f 20cm Dual F,PX-27200177,CDM,27200177,LOCAL,272,RC,,,inpatient,,,1154,807.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,259.073,978.1304,,,,
HC Kit Microez Mst Nitinol 4.5 7c,PX-27200178,CDM,27200178,LOCAL,272,RC,,,inpatient,,,497,347.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,111.5765,421.2572,,,,
HC Kit Microez Mst 5f Nsx,PX-27200179,CDM,27200179,LOCAL,272,RC,,,inpatient,,,251,175.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,56.3495,212.7476,,,,
HC Electrode One Step Cpr Adult,PX-27200180,CDM,27200180,LOCAL,272,RC,,,inpatient,,,408,285.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,91.596,345.8208,,,,
HC Electrode One Step Pediatric,PX-27200181,CDM,27200181,LOCAL,272,RC,,,inpatient,,,447,312.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,100.3515,378.8772,,,,
HC Ambu® Ascopetm 4 Broncho Large (5.8/2.8),PX-27200196,CDM,27200196,LOCAL,272,RC,,,inpatient,,,359,251.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.5955,304.2884,,,,
HC Ambu® Ascopetm 4 Broncho Regular (5.0/2.2),PX-27200197,CDM,27200197,LOCAL,272,RC,,,inpatient,,,312,218.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,70.044,264.4512,,,,
HC Ambu® Ascopetm 4 Broncho Slim (3.8/1.2),PX-27200198,CDM,27200198,LOCAL,272,RC,,,inpatient,,,312,218.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,70.044,264.4512,,,,
HC Tray Pneumothorax Turkel 9 Cm Sys,PX-27200199,CDM,27200199,LOCAL,272,RC,,,inpatient,,,622,435.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,139.639,527.2072,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400003,CDM,27400003,LOCAL,274,RC,,,inpatient,,,552,386.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,123.924,467.8752,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400005,CDM,27400005,LOCAL,274,RC,,,inpatient,,,1221,854.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,274.1145,1034.9196,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400008,CDM,27400008,LOCAL,274,RC,,,inpatient,,,3772,2640.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,846.814,3197.1472,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400012,CDM,27400012,LOCAL,274,RC,,,inpatient,,,1954,1367.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,438.673,1656.2104,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400015,CDM,27400015,LOCAL,274,RC,,,inpatient,,,3806,2664.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,854.447,3225.9656,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400030,CDM,27400030,LOCAL,274,RC,,,inpatient,,,661,462.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,148.3945,560.2636,,,,
HC Brace Knee Enhanced Trom,PX-27400038,CDM,27400038,LOCAL,274,RC,,,inpatient,,,570,399,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,127.965,483.132,,,,
HC Brace Enhanced Trom Donjoy,PX-27400039,CDM,27400039,LOCAL,274,RC,,,inpatient,,,570,399,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,127.965,483.132,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400047,CDM,27400047,LOCAL,274,RC,,,inpatient,,,3385,2369.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,759.9325,2869.126,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400050,CDM,27400050,LOCAL,274,RC,,,inpatient,,,3185,2229.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,715.0325,2699.606,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400107,CDM,27400107,LOCAL,274,RC,,,inpatient,,,380,266,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,85.31,322.088,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400117,CDM,27400117,LOCAL,274,RC,,,inpatient,,,779,545.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.8855,660.2804,,,,
HC Add. to Lower Extremity L2210,PX-27400184,CDM,27400184,LOCAL,274,RC,,,inpatient,,,330,231,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,74.085,279.708,,,,
HC Lift Elevation Heel & Sole,PX-27400185,CDM,27400185,LOCAL,274,RC,,,inpatient,,,382,267.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,85.759,323.7832,,,,
HC Add. Lower Extremity Orthosis,PX-27400186,CDM,27400186,LOCAL,274,RC,,,inpatient,,,448,313.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,100.576,379.7248,,,,
HC Depth Shoe A5500,PX-27400187,CDM,27400187,LOCAL,274,RC,,,inpatient,,,473,331.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,106.1885,400.9148,,,,
HC Compression Stocking A6533,PX-27400188,CDM,27400188,LOCAL,274,RC,,,inpatient,,,502,351.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,112.699,425.4952,,,,
HC Collar L0172,PX-27400189,CDM,27400189,LOCAL,274,RC,,,inpatient,,,658,460.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,147.721,557.7208,,,,
HC Ko Elastic Knee Joint L1820,PX-27400190,CDM,27400190,LOCAL,274,RC,,,inpatient,,,661,462.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,148.3945,560.2636,,,,
HC Procedure Ortho Shoe/L3649,PX-27400191,CDM,27400191,LOCAL,274,RC,,,inpatient,,,703,492.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,157.8235,595.8628,,,,
HC Air Cast Boot L4386,PX-27400192,CDM,27400192,LOCAL,274,RC,,,inpatient,,,745,521.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,167.2525,631.462,,,,
HC Static Afa L4396,PX-27400193,CDM,27400193,LOCAL,274,RC,,,inpatient,,,785,549.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,176.2325,665.366,,,,
HC Brace Tlso,PX-27400194,CDM,27400194,LOCAL,274,RC,,,inpatient,,,901,630.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,202.2745,763.6876,,,,
HC Lumbar Corsette L0450,PX-27400195,CDM,27400195,LOCAL,274,RC,,,inpatient,,,915,640.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,205.4175,775.554,,,,
HC Brace Warm and Form,PX-27400196,CDM,27400196,LOCAL,274,RC,,,inpatient,,,1117,781.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,250.7665,946.7692,,,,
HC Afo L1940,PX-27400197,CDM,27400197,LOCAL,274,RC,,,inpatient,,,2560,1792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,574.72,2169.856,,,,
HC Ankle Foot Orthosis L1940,PX-27400198,CDM,27400198,LOCAL,274,RC,,,inpatient,,,2560,1792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,574.72,2169.856,,,,
HC POS OP Knee Brace L1832,PX-27400199,CDM,27400199,LOCAL,274,RC,,,inpatient,,,2974,2081.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,667.663,2520.7624,,,,
HC Afo Plastic L1960,PX-27400200,CDM,27400200,LOCAL,274,RC,,,inpatient,,,3011,2107.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,675.9695,2552.1236,,,,
HC Ankle/Foot Orthosis Afo,PX-27400201,CDM,27400201,LOCAL,274,RC,,,inpatient,,,3011,2107.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,675.9695,2552.1236,,,,
HC Left Afo Brace/Atlantic Pros,PX-27400202,CDM,27400202,LOCAL,274,RC,,,inpatient,,,3165,2215.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,710.5425,2682.654,,,,
HC Afo L1932,PX-27400203,CDM,27400203,LOCAL,274,RC,,,inpatient,,,3418,2392.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,767.341,2897.0968,,,,
HC Ankle Foot Orthosis L1970,PX-27400204,CDM,27400204,LOCAL,274,RC,,,inpatient,,,3462,2423.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,777.219,2934.3912,,,,
HC Back Brace Tlso Lo486,PX-27400205,CDM,27400205,LOCAL,274,RC,,,inpatient,,,6597,4617.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1481.0265,5591.6172,,,,
HC Cervical Collar L0172,PX-27400206,CDM,27400206,LOCAL,274,RC,,,inpatient,,,658,460.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,147.721,557.7208,,,,
HC Philly Collar No Extension,PX-27400207,CDM,27400207,LOCAL,274,RC,,,inpatient,,,658,460.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,147.721,557.7208,,,,
HC Cervical Collar 2/Piece L0174,PX-27400208,CDM,27400208,LOCAL,274,RC,,,inpatient,,,1232,862.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,276.584,1044.2432,,,,
HC Lumbar Orthosis L0627,PX-27400209,CDM,27400209,LOCAL,274,RC,,,inpatient,,,1750,1225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,392.875,1483.3,,,,
HC Lso Sagoro Rigid Frame L0631,PX-27400210,CDM,27400210,LOCAL,274,RC,,,inpatient,,,3933,2753.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,882.9585,3333.6108,,,,
HC Lso Sagittal Coronal L0637,PX-27400211,CDM,27400211,LOCAL,274,RC,,,inpatient,,,4114,2879.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,923.593,3487.0264,,,,
HC Hip Abduction Orthosis L1686,PX-27400212,CDM,27400212,LOCAL,274,RC,,,inpatient,,,4461,3122.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1001.4945,3781.1436,,,,
HC Knee Orthosis L1830,PX-27400213,CDM,27400213,LOCAL,274,RC,,,inpatient,,,466,326.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,104.617,394.9816,,,,
HC Knee Orthosis L1832,PX-27400214,CDM,27400214,LOCAL,274,RC,,,inpatient,,,2974,2081.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,667.663,2520.7624,,,,
HC Knee Orthosis L1832,PX-27400215,CDM,27400215,LOCAL,274,RC,,,inpatient,,,2974,2081.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,667.663,2520.7624,,,,
HC Knee Osthosis L1832,PX-27400216,CDM,27400216,LOCAL,274,RC,,,inpatient,,,2974,2081.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,667.663,2520.7624,,,,
HC Afo L1930,PX-27400217,CDM,27400217,LOCAL,274,RC,,,inpatient,,,1062,743.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,238.419,900.1512,,,,
HC Adj. Dorsal Splint L1930,PX-27400218,CDM,27400218,LOCAL,274,RC,,,inpatient,,,1062,743.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,238.419,900.1512,,,,
HC L'nard Boot L1930,PX-27400219,CDM,27400219,LOCAL,274,RC,,,inpatient,,,1062,743.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,238.419,900.1512,,,,
HC Hip Adj Ext L2624,PX-27400220,CDM,27400220,LOCAL,274,RC,,,inpatient,,,1445,1011.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,324.4025,1224.782,,,,
HC Bk Soft Interface L2820,PX-27400221,CDM,27400221,LOCAL,274,RC,,,inpatient,,,448,313.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,100.576,379.7248,,,,
HC Lift Elevation L3332,PX-27400222,CDM,27400222,LOCAL,274,RC,,,inpatient,,,347,242.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,77.9015,294.1172,,,,
HC Wrist Hand/Finger Ortho L3807,PX-27400223,CDM,27400223,LOCAL,274,RC,,,inpatient,,,1065,745.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,239.0925,902.694,,,,
HC Wrist Cockup Nonmolded L3908,PX-27400224,CDM,27400224,LOCAL,274,RC,,,inpatient,,,353,247.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,79.2485,299.2028,,,,
HC Orthosis Upper Limb Hum. Frac,PX-27400225,CDM,27400225,LOCAL,274,RC,,,inpatient,,,1413,989.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,317.2185,1197.6588,,,,
HC Walking Boot L4360,PX-27400226,CDM,27400226,LOCAL,274,RC,,,inpatient,,,1290,903,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,289.605,1093.404,,,,
HC Walking Boot Prefab L4360,PX-27400227,CDM,27400227,LOCAL,274,RC,,,inpatient,,,1290,903,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,289.605,1093.404,,,,
HC Walking Boot L4360,PX-27400228,CDM,27400228,LOCAL,274,RC,,,inpatient,,,2135,1494.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,479.3075,1809.626,,,,
HC Cam Walker L4386,PX-27400229,CDM,27400229,LOCAL,274,RC,,,inpatient,,,745,521.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,167.2525,631.462,,,,
HC Bk Stump Shrinker L8440,PX-27400230,CDM,27400230,LOCAL,274,RC,,,inpatient,,,262,183.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,58.819,222.0712,,,,
HC Stump Shrinker L8440,PX-27400231,CDM,27400231,LOCAL,274,RC,,,inpatient,,,262,183.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,58.819,222.0712,,,,
HC Liner Foam Permanently Lg,PX-27400232,CDM,27400232,LOCAL,274,RC,,,inpatient,,,353,247.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,79.2485,299.2028,,,,
HC Kit Electrode Pacing,PX-27500027,CDM,27500027,LOCAL,275,RC,,,inpatient,,,1286,900.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,288.707,1090.0136,,,,
HC Medical/Surgical Supplies: Other Implants,PX-27800095,CDM,27800095,LOCAL,278,RC,,,inpatient,,,649,454.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,145.7005,550.0924,,,,
HC Leg Post Rigid Brace/Sc Ortho,PX-27800096,CDM,27800096,LOCAL,278,RC,,,inpatient,,,758,530.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,170.171,642.4808,,,,
HC Kit Picc 4fr per-Q Poly Cath,PX-27800097,CDM,27800097,LOCAL,278,RC,,,inpatient,,,1063,744.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,238.6435,900.9988,,,,
HC Floseal Matrix Hemostatic,PX-27800098,CDM,27800098,LOCAL,278,RC,,,inpatient,,,1093,765.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,245.3785,926.4268,,,,
HC Kit Picc 5fr per-Q Poly Cath,PX-27800099,CDM,27800099,LOCAL,278,RC,,,inpatient,,,1217,851.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,273.2165,1031.5292,,,,
HC Tray Power Picc Dual 5f,PX-27800100,CDM,27800100,LOCAL,278,RC,,,inpatient,,,1355,948.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,304.1975,1148.498,,,,
HC Tray Power Picc Single 4f,PX-27800101,CDM,27800101,LOCAL,278,RC,,,inpatient,,,1398,978.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,313.851,1184.9448,,,,
HC Tray Power Picc Triple 5fr,PX-27800102,CDM,27800102,LOCAL,278,RC,,,inpatient,,,1474,1031.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,330.913,1249.3624,,,,
HC Tray Power Picc Triple 6f,PX-27800103,CDM,27800103,LOCAL,278,RC,,,inpatient,,,1499,1049.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,336.5255,1270.5524,,,,
HC Sepafilm/5x6,PX-27800104,CDM,27800104,LOCAL,278,RC,,,inpatient,,,1773,1241.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,398.0385,1502.7948,,,,
HC 3cg Power Picc Max 4fr Sl,PX-27800105,CDM,27800105,LOCAL,278,RC,,,inpatient,,,1585,1109.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,355.8325,1343.446,,,,
HC 3cg Power Picc Max 5fr Dl,PX-27800106,CDM,27800106,LOCAL,278,RC,,,inpatient,,,1636,1145.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,367.282,1386.6736,,,,
HC 3cg Power Picc Max 6fr Tl,PX-27800107,CDM,27800107,LOCAL,278,RC,,,inpatient,,,1749,1224.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,392.6505,1482.4524,,,,
HC Valve Passy Muir Aqua,PX-27800108,CDM,27800108,LOCAL,278,RC,,,inpatient,,,474,331.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,106.413,401.7624,,,,
HC Passy Muir Valve - Clear,PX-27800113,CDM,27800113,LOCAL,278,RC,,,inpatient,,,474,331.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,106.413,401.7624,,,,
HC Valve Passy Muir Purple,PX-27800114,CDM,27800114,LOCAL,278,RC,,,inpatient,,,474,331.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,106.413,401.7624,,,,
HC Liner Foam Permanently X-Lg,PX-27800115,CDM,27800115,LOCAL,278,RC,,,inpatient,,,328,229.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,73.636,278.0128,,,,
HC Tube Trach Proximal Xlt 7.0,PX-27800117,CDM,27800117,LOCAL,278,RC,,,inpatient,,,486,340.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,109.107,411.9336,,,,
HC Barrier Seprafilm 3x5in,PX-27800118,CDM,27800118,LOCAL,278,RC,,,inpatient,,,1773,1241.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,398.0385,1502.7948,,,,
HC Tube Feeding Low Profile 20f,PX-27800119,CDM,27800119,LOCAL,278,RC,,,inpatient,,,694,485.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,155.803,588.2344,,,,
HC Valve Speaking White #005,PX-27800121,CDM,27800121,LOCAL,278,RC,,,inpatient,,,474,331.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,106.413,401.7624,,,,
HC Tray Percu Introducer 8.5fr,PX-27800122,CDM,27800122,LOCAL,278,RC,,,inpatient,,,475,332.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,106.6375,402.61,,,,
HC Basket Zerotip Airway Retriv,PX-27800125,CDM,27800125,LOCAL,278,RC,,,inpatient,,,1710,1197,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,383.895,1449.396,,,,
HC Indwelling Prosthesis 20fr 8mm,PX-27800126,CDM,27800126,LOCAL,278,RC,,,inpatient,,,1327,928.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,297.9115,1124.7652,,,,
HC Indwelling Prosthesis 2.0,PX-27800127,CDM,27800127,LOCAL,278,RC,,,inpatient,,,1327,928.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,297.9115,1124.7652,,,,
HC Prosthesis Blom - 8mm,PX-27800128,CDM,27800128,LOCAL,278,RC,,,inpatient,,,1300,910,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,291.85,1101.88,,,,
HC Drug Collection,PX-30000005,CDM,30000005,LOCAL,300,RC,,,inpatient,,,32,22.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7.184,27.1232,,,,
HC Cardiac Mnr Thoracic Prcd,PX-36000003,CDM,36000003,LOCAL,360,RC,,,inpatient,,,142,99.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,31.879,120.3592,,,,
HC Non-Pump Open Heart Other,PX-36000004,CDM,36000004,LOCAL,360,RC,,,inpatient,,,157,109.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,35.2465,133.0732,,,,
HC Pump Procedure,PX-36000005,CDM,36000005,LOCAL,360,RC,,,inpatient,,,152,106.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,34.124,128.8352,,,,
HC Non Pump Procedure,PX-36000006,CDM,36000006,LOCAL,360,RC,,,inpatient,,,208,145.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,46.696,176.3008,,,,
HC Sub Minor Proc,PX-36000014,CDM,36000014,LOCAL,360,RC,,,inpatient,,,60,42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,13.47,50.856,,,,
HC Pain Mgmt Proc,PX-36000015,CDM,36000015,LOCAL,360,RC,,,inpatient,,,75,52.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,16.8375,63.57,,,,
HC Endoscopy,PX-36000016,CDM,36000016,LOCAL,360,RC,,,inpatient,,,60,42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,13.47,50.856,,,,
HC Minor Proc,PX-36000017,CDM,36000017,LOCAL,360,RC,,,inpatient,,,75,52.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,16.8375,63.57,,,,
HC Major Proc,PX-36000019,CDM,36000019,LOCAL,360,RC,,,inpatient,,,99,69.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2255,83.9124,,,,
HC Intensive Major Procedure,PX-36000020,CDM,36000020,LOCAL,360,RC,,,inpatient,,,140,98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,31.43,118.664,,,,
HC Ercp,PX-36000021,CDM,36000021,LOCAL,360,RC,,,inpatient,,,138,96.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,30.981,116.9688,,,,
HC Cardiac Maj Thoracic Prcd,PX-36000022,CDM,36000022,LOCAL,360,RC,,,inpatient,,,159,111.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,35.6955,134.7684,,,,
HC Anesthesia Block,PX-37000001,CDM,37000001,LOCAL,370,RC,,,inpatient,,,700,490,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,157.15,593.32,,,,
HC Anesthesia Spinal,PX-37000002,CDM,37000002,LOCAL,370,RC,,,inpatient,,,850,595,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,190.825,720.46,,,,
HC Anesthesia General Minor,PX-37000003,CDM,37000003,LOCAL,370,RC,,,inpatient,,,1662,1163.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,373.119,1408.7112,,,,
HC Anesthesia Epidural,PX-37000004,CDM,37000004,LOCAL,370,RC,,,inpatient,,,950,665,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,213.275,805.22,,,,
HC Anesthesia General Major,PX-37000005,CDM,37000005,LOCAL,370,RC,,,inpatient,,,2924,2046.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,656.438,2478.3824,,,,
HC Anesthesia Gen/Epi,PX-37000006,CDM,37000006,LOCAL,370,RC,,,inpatient,,,1200,840,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,269.4,1017.12,,,,
HC Anesthesia General Intensive,PX-37000007,CDM,37000007,LOCAL,370,RC,,,inpatient,,,4262,2983.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,956.819,3612.4712,,,,
HC Anesthesia General Cvs Bypass Pump,PX-37000008,CDM,37000008,LOCAL,370,RC,,,inpatient,,,9166,6416.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2057.767,7769.1016,,,,
HC Anesthesia Mac,PX-37000009,CDM,37000009,LOCAL,370,RC,,,inpatient,,,1200,840,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,269.4,1017.12,,,,
HC Endo Level I,PX-49000001,CDM,49000001,LOCAL,490,RC,,,inpatient,,,3749,2624.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,841.6505,3177.6524,,,,
HC Endo Level II,PX-49000002,CDM,49000002,LOCAL,490,RC,,,inpatient,,,5356,3749.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1202.422,4539.7456,,,,
HC Endo Level III,PX-49000003,CDM,49000003,LOCAL,490,RC,,,inpatient,,,9641,6748.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2164.4045,8171.7116,,,,
HC Recovery Room,PX-71000001,CDM,71000001,LOCAL,710,RC,,,inpatient,,,25,17.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.6125,21.19,,,,
HC Second Stage Recovery per Minute,PX-71000002,CDM,71000002,LOCAL,710,RC,,,inpatient,,,22,15.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.939,18.6472,,,,
HC Recovery - Sub Minor Proc,PX-71000003,CDM,71000003,LOCAL,710,RC,,,inpatient,,,23,16.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.1635,19.4948,,,,
HC Recovery Rm - Minor Procedure,PX-71000004,CDM,71000004,LOCAL,710,RC,,,inpatient,,,28,19.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6.286,23.7328,,,,
HC Recovery Rm,PX-71000005,CDM,71000005,LOCAL,710,RC,,,inpatient,,,29,20.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6.5105,24.5804,,,,
HC Recovery Rm - Major Procedure,PX-71000006,CDM,71000006,LOCAL,710,RC,,,inpatient,,,33,23.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7.4085,27.9708,,,,
HC Recovery Rm - Intensive Major,PX-71000007,CDM,71000007,LOCAL,710,RC,,,inpatient,,,38,26.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.531,32.2088,,,,
HC Extended Recovery Overnight,PX-71000009,CDM,71000009,LOCAL,710,RC,,,inpatient,,,1500,1050,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,336.75,1271.4,,,,
HC Observation Nursing Time,PX-76200006,CDM,76200006,LOCAL,762,RC,,,inpatient,,,101,70.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.6745,6652,,,,
HC Tandem Dialysis,PX-80100001,CDM,80100001,LOCAL,801,RC,,,inpatient,,,1142,799.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,256.379,967.9592,,,,
HC Single Dialysis,PX-80100002,CDM,80100002,LOCAL,801,RC,,,inpatient,,,1142,799.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,256.379,967.9592,,,,
HC Unscheduled/Emergent Dialysis,PX-80100003,CDM,80100003,LOCAL,801,RC,,,inpatient,,,1142,799.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,256.379,967.9592,,,,
HC Weekend/Holiday Dialysis,PX-80100004,CDM,80100004,LOCAL,801,RC,,,inpatient,,,1142,799.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,256.379,967.9592,,,,
HC Capd per:Exchange,PX-80300001,CDM,80300001,LOCAL,803,RC,,,inpatient,,,569,398.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,127.7405,482.2844,,,,
HC Ccpd ER,PX-80400001,CDM,80400001,LOCAL,804,RC,,,inpatient,,,569,398.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,127.7405,482.2844,,,,
HC Ccpd,PX-80400002,CDM,80400002,LOCAL,804,RC,,,inpatient,,,1142,799.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,256.379,967.9592,,,,
HC Dietary Services per 15 Mins,PX-99000006,CDM,99000006,LOCAL,990,RC,,,inpatient,,,29,20.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6.5105,24.5804,,,,
HC Hearing Aid Batteries,PX-99000034,CDM,99000034,LOCAL,479,RC,,,inpatient,,,7,4.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.5715,163,,,,
HC Hearing Aid Tune Up,PX-99000037,CDM,99000037,LOCAL,479,RC,,,inpatient,,,43,30.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.6535,163,,,,
HC Hearing Aid Fit,PX-99000038,CDM,99000038,LOCAL,479,RC,,,inpatient,,,171,119.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,38.3895,163,,,,
HC Full Trauma No Notification,PX-45000633,CDM,TR450,LOCAL,450,RC,,,inpatient,,,10370,7259,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9291.52,,,,
HC Partial Trauma No Notification,PX-45000634,CDM,TR450,LOCAL,450,RC,,,inpatient,,,7029,4920.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6297.984,,,,
Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face- Mouth And Neck With Major O.R. Procedures,3,MS-DRG,,,,,,,inpatient,,,404600.26,283220.182,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,434261.5728,,,,
Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face- Mouth And Neck Without Major O.R. Procedures,4,MS-DRG,,,,,,,inpatient,,,379341.67,265539.169,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,303473.336,,,,
Tracheostomy For Face- Mouth And Neck Diagnoses Or Laryngectomy With McC,11,MS-DRG,,,,,,,inpatient,,,57485.95,40240.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,109336.4384,,,,
Tracheostomy For Face- Mouth And Neck Diagnoses Or Laryngectomy With Cc,12,MS-DRG,,,,,,,inpatient,,,82266.47,57586.529,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,83151.2976,,,,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With McC Or Chemotherapy Implant Or Epilepsy With Neurostimulator,23,MS-DRG,,,,,,,inpatient,,,82526.76,57768.732,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,115600.0408,,,,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without McC,24,MS-DRG,,,,,,,inpatient,,,54359.41,38051.587,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,77031.5696,,,,
Craniotomy And Endovascular Intracranial Procedures With McC,25,MS-DRG,,,,,,,inpatient,,,91861.46,64303.022,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,90620.608,,,,
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,,,inpatient,,,74058,51840.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,61975.4176,,,,
Craniotomy And Endovascular Intracranial Procedures Without Cc/McC,27,MS-DRG,,,,,,,inpatient,,,61484.65,43039.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,50003.4464,,,,
Spinal Procedures With McC,28,MS-DRG,,,,,,,inpatient,,,148126.56,103688.592,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,123186.8824,,,,
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,inpatient,,,74991.36,52493.952,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,68016.116,,,,
Spinal Procedures Without Cc/McC,30,MS-DRG,,,,,,,inpatient,,,28580.9,20006.63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,45091.4528,,,,
Ventricular Shunt Procedures With McC,31,MS-DRG,,,,,,,inpatient,,,61588.79,43112.153,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,84912.2392,,,,
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,,,inpatient,,,117340.84,82138.588,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,93872.672,,,,
Ventricular Shunt Procedures Without Cc/McC,33,MS-DRG,,,,,,,inpatient,,,50092.67,35064.869,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,40074.136,,,,
Carotid Artery Stent Procedures With McC,34,MS-DRG,,,,,,,inpatient,,,80412.35,56288.645,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,78796.564,,,,
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,inpatient,,,59060.84,41342.588,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,47248.672,,,,
Carotid Artery Stent Procedures Without Cc/McC,36,MS-DRG,,,,,,,inpatient,,,55590.26,38913.182,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,44472.208,,,,
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,inpatient,,,47239.38,33067.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,37791.504,,,,
Extracranial Procedures Without Cc/McC,39,MS-DRG,,,,,,,inpatient,,,40302.61,28211.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,32242.088,,,,
Peripheral- Cranial Nerve And Other Nervous System Procedures With McC,40,MS-DRG,,,,,,,inpatient,,,42423.5,29696.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,76431.7552,,,,
Peripheral- Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator,41,MS-DRG,,,,,,,inpatient,,,29478.8,20635.16,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,45768.2704,,,,
Peripheral- Cranial Nerve And Other Nervous System Procedures Without Cc/McC,42,MS-DRG,,,,,,,inpatient,,,40958.56,28670.992,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,35613.98,,,,
Spinal Disorders And Injuries With Cc/McC,52,MS-DRG,,,,,,,inpatient,,,14188.67,9932.069,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4731.921445,40779.2736,,,,
Spinal Disorders And Injuries Without Cc/McC,53,MS-DRG,,,,,,,inpatient,,,42918.11,30042.677,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,34334.488,,,,
Nervous System Neoplasms With McC,54,MS-DRG,,,,,,,inpatient,,,16507.92,11555.544,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5505.39132,30377.7624,,,,
Nervous System Neoplasms Without McC,55,MS-DRG,,,,,,,inpatient,,,15148.1,10603.67,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5051.89135,22105.9976,,,,
Degenerative Nervous System Disorders With McC,56,MS-DRG,,,,,,,inpatient,,,32807.03,22964.921,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,50741.056,,,,
Degenerative Nervous System Disorders Without McC,57,MS-DRG,,,,,,,inpatient,,,21955.44,15368.808,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7322.13924,27046.3608,,,,
Multiple Sclerosis And Cerebellar Ataxia With McC,58,MS-DRG,,,,,,,inpatient,,,18732.22,13112.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6247.19537,37401.2648,,,,
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,inpatient,,,30559.84,21391.888,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,24793.004,,,,
Multiple Sclerosis And Cerebellar Ataxia Without Cc/McC,60,MS-DRG,,,,,,,inpatient,,,18686.21,13080.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6231.851035,18083.5936,,,,
Ischemic Stroke- Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With McC,61,MS-DRG,,,,,,,inpatient,,,81185.85,56830.095,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,64948.68,,,,
Ischemic Stroke- Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc,62,MS-DRG,,,,,,,inpatient,,,55465.6,38825.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,44372.48,,,,
Ischemic Stroke- Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/McC,63,MS-DRG,,,,,,,inpatient,,,65826.61,46078.627,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,52661.288,,,,
Intracranial Hemorrhage Or Cerebral Infarction With McC,64,MS-DRG,,,,,,,inpatient,,,31988.78,22392.146,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,40307.1224,,,,
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,inpatient,,,20095.65,14066.955,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6701.899275,20608.488,,,,
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/McC,66,MS-DRG,,,,,,,inpatient,,,17438.35,12206.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5143.64,13950.68,,,,
Nonspecific Cva And Precerebral Occlusion Without Infarction With McC,67,MS-DRG,,,,,,,inpatient,,,38053.25,26637.275,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,30442.6,,,,
Nonspecific Cva And Precerebral Occlusion Without Infarction Without McC,68,MS-DRG,,,,,,,inpatient,,,27888.66,19522.062,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6429.37,22310.928,,,,
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,inpatient,,,17825.05,12477.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5687.74,16215.2528,,,,
Nonspecific Cerebrovascular Disorders With McC,70,MS-DRG,,,,,,,inpatient,,,36237.19,25366.033,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,35233.0168,,,,
Nonspecific Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,inpatient,,,26346.94,18442.858,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7313.53,21354.2032,,,,
Cranial And Peripheral Nerve Disorders With McC,73,MS-DRG,,,,,,,inpatient,,,24367.12,17056.984,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,31318.012,,,,
Cranial And Peripheral Nerve Disorders Without McC,74,MS-DRG,,,,,,,inpatient,,,24431.87,17102.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7368.52,21123.1936,,,,
Viral Meningitis With Cc/McC,75,MS-DRG,,,,,,,inpatient,,,38318.52,26822.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,34902.7136,,,,
Viral Meningitis Without Cc/McC,76,MS-DRG,,,,,,,inpatient,,,18360.72,12852.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6123.30012,18580.0616,,,,
Hypertensive Encephalopathy With McC,77,MS-DRG,,,,,,,inpatient,,,24086.79,16860.753,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,31332.1968,,,,
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,,,inpatient,,,18407.7,12885.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6138.96795,20219.4192,,,,
Nontraumatic Stupor And Coma With McC,80,MS-DRG,,,,,,,inpatient,,,17643.44,12350.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5884.08724,40280.7792,,,,
Traumatic Stupor And Coma >1 Hour With McC,82,MS-DRG,,,,,,,inpatient,,,45789.39,32052.573,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,47014.5064,,,,
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,inpatient,,,24521.38,17164.966,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,28173.0392,,,,
Traumatic Stupor And Coma >1 Hour Without Cc/McC,84,MS-DRG,,,,,,,inpatient,,,12382.21,8667.547,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4129.467035,19372.384,,,,
Traumatic Stupor And Coma <1 Hour With McC,85,MS-DRG,,,,,,,inpatient,,,44820.5,31374.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,45916.1976,,,,
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,inpatient,,,22755.94,15929.158,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7589.10599,26578.2624,,,,
Traumatic Stupor And Coma <1 Hour Without Cc/McC,87,MS-DRG,,,,,,,inpatient,,,19756.53,13829.571,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6241.25,17913.376,,,,
Concussion With McC,88,MS-DRG,,,,,,,inpatient,,,61939.59,43357.713,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,49551.672,,,,
Concussion With Cc,89,MS-DRG,,,,,,,inpatient,,,38694.98,27086.486,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7678.2,30955.984,,,,
Other Disorders Of Nervous System With McC,91,MS-DRG,,,,,,,inpatient,,,27946.92,19562.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,36937.2192,,,,
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,inpatient,,,23877.59,16714.313,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7134.82,21455.5232,,,,
Other Disorders Of Nervous System Without Cc/McC,93,MS-DRG,,,,,,,inpatient,,,19087.94,13361.558,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5653.01,15994.3752,,,,
Bacterial And Tuberculous Infections Of Nervous System With McC,94,MS-DRG,,,,,,,inpatient,,,86655,60658.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,73931.1776,,,,
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,,,inpatient,,,61521.3,43064.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,49217.04,,,,
Bacterial And Tuberculous Infections Of Nervous System Without Cc/McC,96,MS-DRG,,,,,,,inpatient,,,33095.5,23166.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,48572.808,,,,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With McC,97,MS-DRG,,,,,,,inpatient,,,90065.06,63045.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,72642.3872,,,,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,inpatient,,,23740.04,16618.028,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,43954.6424,,,,
Seizures With McC,100,MS-DRG,,,,,,,inpatient,,,22104.14,15472.898,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7371.73069,40228.0928,,,,
Seizures Without McC,101,MS-DRG,,,,,,,inpatient,,,15944.38,11161.066,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5317.45073,18675.3024,,,,
Headaches With McC,102,MS-DRG,,,,,,,inpatient,,,25624.62,17937.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,23494.0816,,,,
Headaches Without McC,103,MS-DRG,,,,,,,inpatient,,,20277.76,14194.432,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5992.35,17228.4528,,,,
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,,,inpatient,,,26970.92,18879.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,31022.1576,,,,
Neurological Eye Disorders,123,MS-DRG,,,,,,,inpatient,,,18842.87,13190.009,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5537.24,16276.0448,,,,
Sinus And Mastoid Procedures With Cc/McC,135,MS-DRG,,,,,,,inpatient,,,60852.06,42596.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,48854.4776,,,,
Mouth Procedures Without Cc/McC,138,MS-DRG,,,,,,,inpatient,,,12689.7,8882.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4232.01495,16484.764,,,,
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,inpatient,,,50999.49,35699.643,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,43533.1512,,,,
Major Head And Neck Procedures Without Cc/McC,142,MS-DRG,,,,,,,inpatient,,,31036.34,21725.438,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,31861.0872,,,,
Other Ear- Nose- Mouth And Throat O.R. Procedures With McC,143,MS-DRG,,,,,,,inpatient,,,146130.64,102291.448,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,116904.512,,,,
Other Ear- Nose- Mouth And Throat O.R. Procedures With Cc,144,MS-DRG,,,,,,,inpatient,,,29177.65,20424.355,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,35595.7424,,,,
Ear- Nose- Mouth And Throat Malignancy With Cc,147,MS-DRG,,,,,,,inpatient,,,20455.22,14318.654,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6821.81587,25222.6008,,,,
Ear- Nose- Mouth And Throat Malignancy Without Cc/McC,148,MS-DRG,,,,,,,inpatient,,,18282.89,12798.023,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5689.187157,16225.3848,,,,
Dysequilibrium,149,MS-DRG,,,,,,,inpatient,,,21458.09,15020.663,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5321.63,17166.472,,,,
Epistaxis With McC,150,MS-DRG,,,,,,,inpatient,,,36459.7,25521.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,29167.76,,,,
Epistaxis Without McC,151,MS-DRG,,,,,,,inpatient,,,17762.28,12433.596,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5332.48243,15360.112,,,,
Otitis Media And Uri With McC,152,MS-DRG,,,,,,,inpatient,,,22895.06,16026.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7635.50251,22993.5608,,,,
Otitis Media And Uri Without McC,153,MS-DRG,,,,,,,inpatient,,,11257.92,7880.544,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3754.51632,14421.8888,,,,
Other Ear- Nose- Mouth And Throat Diagnoses With McC,154,MS-DRG,,,,,,,inpatient,,,33108.79,23176.153,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,32953.3168,,,,
Other Ear- Nose- Mouth And Throat Diagnoses With Cc,155,MS-DRG,,,,,,,inpatient,,,14149.33,9904.531,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4718.801555,18918.4704,,,,
Other Ear- Nose- Mouth And Throat Diagnoses Without Cc/McC,156,MS-DRG,,,,,,,inpatient,,,3168.14,2217.698,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1056.57469,13625.5136,,,,
Dental And Oral Diseases With McC,157,MS-DRG,,,,,,,inpatient,,,25823.75,18076.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,33180.2736,,,,
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,inpatient,,,17794.61,12456.227,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5934.502435,19058.292,,,,
Dental And Oral Diseases Without Cc/McC,159,MS-DRG,,,,,,,inpatient,,,15217,10651.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4744.97,13366.1344,,,,
Major Chest Procedures With McC,163,MS-DRG,,,,,,,inpatient,,,128830.68,90181.476,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,103064.544,,,,
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,inpatient,,,83811.85,58668.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,67049.48,,,,
Major Chest Procedures Without Cc/McC,165,MS-DRG,,,,,,,inpatient,,,63087.07,44160.949,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,50469.656,,,,
Other Respiratory System O.R. Procedures With McC,166,MS-DRG,,,,,,,inpatient,,,68518.66,47963.062,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,78036.664,,,,
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,inpatient,,,50504.64,35353.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,40403.712,,,,
Other Respiratory System O.R. Procedures Without Cc/McC,168,MS-DRG,,,,,,,inpatient,,,36816.23,25771.361,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,29452.984,,,,
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,inpatient,,,76600.57,53620.399,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,62178.0576,,,,
Pulmonary Embolism With McC Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,inpatient,,,27323.68,19126.576,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,28554.0024,,,,
Pulmonary Embolism Without McC,176,MS-DRG,,,,,,,inpatient,,,16280.09,11396.063,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5429.410015,16505.028,,,,
Respiratory Infections And Inflammations With McC,177,MS-DRG,,,,,,,inpatient,,,30316.04,21221.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,32756.756,,,,
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,inpatient,,,21346.77,14942.739,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7119.147795,20103.9144,,,,
Respiratory Infections And Inflammations Without Cc/McC,179,MS-DRG,,,,,,,inpatient,,,20533.98,14373.786,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6302.75,16427.184,,,,
Respiratory Neoplasms With McC,180,MS-DRG,,,,,,,inpatient,,,24678.76,17275.132,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,35415.3928,,,,
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,inpatient,,,15915.05,11140.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5307.669175,22497.0928,,,,
Major Chest Trauma With McC,183,MS-DRG,,,,,,,inpatient,,,30366.68,21256.676,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,32163.0208,,,,
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,inpatient,,,23252.15,16276.505,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7520.46,21641.952,,,,
Major Chest Trauma Without Cc/McC,185,MS-DRG,,,,,,,inpatient,,,26254.04,18377.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5597.297704,21003.232,,,,
Pleural Effusion With McC,186,MS-DRG,,,,,,,inpatient,,,23322.86,16326.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,32017.12,,,,
Pleural Effusion With Cc,187,MS-DRG,,,,,,,inpatient,,,25224.41,17657.087,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7468.37,20343.0296,,,,
Pleural Effusion Without Cc/McC,188,MS-DRG,,,,,,,inpatient,,,14227.72,9959.404,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4744.94462,14875.8024,,,,
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,inpatient,,,23597.45,16518.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,25076.7,,,,
Chronic Obstructive Pulmonary Disease With McC,190,MS-DRG,,,,,,,inpatient,,,20380.17,14266.119,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6796.786695,22762.5512,,,,
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,inpatient,,,18415.04,12890.528,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6141.41584,17408.8024,,,,
Chronic Obstructive Pulmonary Disease Without Cc/McC,192,MS-DRG,,,,,,,inpatient,,,15021,10514.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5009.5035,13114.8608,,,,
Simple Pneumonia And Pleurisy With McC,193,MS-DRG,,,,,,,inpatient,,,24854.58,17398.206,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,26703.8992,,,,
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,inpatient,,,16852.25,11796.575,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5620.225375,16616.48,,,,
Simple Pneumonia And Pleurisy Without Cc/McC,195,MS-DRG,,,,,,,inpatient,,,11327.34,7929.138,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3777.66789,12620.4192,,,,
Interstitial Lung Disease With McC,196,MS-DRG,,,,,,,inpatient,,,25824.88,18077.416,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,38181.4288,,,,
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,inpatient,,,14747.43,10323.201,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4918.267905,20059.3336,,,,
Interstitial Lung Disease Without Cc/McC,198,MS-DRG,,,,,,,inpatient,,,102750.94,71925.658,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5370.829997,82200.752,,,,
Pneumothorax With McC,199,MS-DRG,,,,,,,inpatient,,,30942.21,21659.547,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,35770.0128,,,,
Pneumothorax With Cc,200,MS-DRG,,,,,,,inpatient,,,23899.07,16729.349,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,22440.3536,,,,
Pneumothorax Without Cc/McC,201,MS-DRG,,,,,,,inpatient,,,14142.03,9899.421,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4716.367005,13716.7016,,,,
Bronchitis And Asthma With Cc/McC,202,MS-DRG,,,,,,,inpatient,,,14008.78,9806.146,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4671.92813,19589.2088,,,,
Bronchitis And Asthma Without Cc/McC,203,MS-DRG,,,,,,,inpatient,,,8434.66,5904.262,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2812.95911,14109.8232,,,,
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,inpatient,,,19382.31,13567.617,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5734.05,16432.0776,,,,
Other Respiratory System Diagnoses With McC,205,MS-DRG,,,,,,,inpatient,,,29471.66,20630.162,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,38252.3528,,,,
Other Respiratory System Diagnoses Without McC,206,MS-DRG,,,,,,,inpatient,,,18289.13,12802.391,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6099.424855,18355.1312,,,,
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,inpatient,,,153413.76,107389.632,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,131061.4728,,,,
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,inpatient,,,60056.19,42039.333,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,54390.6024,,,,
Other Heart Assist System Implant,215,MS-DRG,,,,,,,inpatient,,,163000.7,114100.49,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,214680.8688,,,,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/McC,218,MS-DRG,,,,,,,inpatient,,,144438.6,101107.02,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,120552.5624,,,,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/McC,221,MS-DRG,,,,,,,inpatient,,,282573.82,197801.674,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,226059.056,,,,
Other Cardiothoracic Procedures With McC,228,MS-DRG,,,,,,,inpatient,,,215439.26,150807.482,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,172351.408,,,,
Coronary Bypass With Cardiac Catheterization Or Open Ablation With McC,233,MS-DRG,,,,,,,inpatient,,,335724.2,235006.94,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,268579.36,,,,
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without McC,234,MS-DRG,,,,,,,inpatient,,,168474.77,117932.339,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,134779.816,,,,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With McC,239,MS-DRG,,,,,,,inpatient,,,57370.89,40159.623,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,102059.636,,,,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,inpatient,,,51903.54,36332.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,59008.768,,,,
Permanent Cardiac Pacemaker Implant With McC,242,MS-DRG,,,,,,,inpatient,,,86942.73,60859.911,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,69554.184,,,,
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,inpatient,,,65531.01,45871.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,52424.808,,,,
Permanent Cardiac Pacemaker Implant Without Cc/McC,244,MS-DRG,,,,,,,inpatient,,,63411.07,44387.749,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,50728.856,,,,
Aicd Generator Procedures,245,MS-DRG,,,,,,,inpatient,,,15907.12,11134.984,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5305.02452,99020.036,,,,
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without McC,251,MS-DRG,,,,,,,inpatient,,,55424.98,38797.486,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,44339.984,,,,
Other Vascular Procedures With McC,252,MS-DRG,,,,,,,inpatient,,,85181.97,59627.379,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,69509.5728,,,,
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,inpatient,,,82797.33,57958.131,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,66237.864,,,,
Other Vascular Procedures Without Cc/McC,254,MS-DRG,,,,,,,inpatient,,,61488.65,43042.055,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,49190.92,,,,
Upper Limb And Toe Amputation For Circulatory System Disorders With McC,255,MS-DRG,,,,,,,inpatient,,,163135.56,114194.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,130508.448,,,,
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,inpatient,,,13744.76,9621.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4583.87746,34319.1104,,,,
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/McC,257,MS-DRG,,,,,,,inpatient,,,13802.75,9661.925,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4603.217125,18073.4616,,,,
Cardiac Pacemaker Device Replacement Without McC,259,MS-DRG,,,,,,,inpatient,,,51584.98,36109.486,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,41267.984,,,,
Cardiac Pacemaker Revision Except Device Replacement With McC,260,MS-DRG,,,,,,,inpatient,,,218275.68,152792.976,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,174620.544,,,,
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,inpatient,,,57651.04,40355.728,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,46120.832,,,,
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,inpatient,,,28475.53,19932.871,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,70820.6536,,,,
Aortic And Heart Assist Procedures Except Pulsation Balloon With McC,268,MS-DRG,,,,,,,inpatient,,,101907.56,71335.292,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,135104.1408,,,,
Aortic And Heart Assist Procedures Except Pulsation Balloon Without McC,269,MS-DRG,,,,,,,inpatient,,,145888.49,102121.943,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,116710.792,,,,
Other Major Cardiovascular Procedures With McC,270,MS-DRG,,,,,,,inpatient,,,185659.89,129961.923,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,148527.912,,,,
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,inpatient,,,127626.27,89338.389,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,102101.016,,,,
Other Major Cardiovascular Procedures Without Cc/McC,272,MS-DRG,,,,,,,inpatient,,,104134.1,72893.87,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,83307.28,,,,
Percutaneous And Other Intracardiac Procedures Without McC,274,MS-DRG,,,,,,,inpatient,,,98959.28,69271.496,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,79167.424,,,,
Cardiac Defibrillator Implant With Cardiac Catheterization And McC,275,MS-DRG,,,,,,,inpatient,,,167450.04,117215.028,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,143195.556,,,,
Cardiac Defibrillator Implant Without McC,277,MS-DRG,,,,,,,inpatient,,,278318.05,194822.635,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,222654.44,,,,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With McC,278,MS-DRG,,,,,,,inpatient,,,130044.83,91031.381,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,104035.864,,,,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without McC,279,MS-DRG,,,,,,,inpatient,,,135336.66,94735.662,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,108269.328,,,,
Acute Myocardial Infarction- Discharged Alive With McC,280,MS-DRG,,,,,,,inpatient,,,31571.18,22099.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,33263.356,,,,
Acute Myocardial Infarction- Discharged Alive With Cc,281,MS-DRG,,,,,,,inpatient,,,22298.62,15609.034,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6744.11,18679.3552,,,,
Acute Myocardial Infarction- Discharged Alive Without Cc/McC,282,MS-DRG,,,,,,,inpatient,,,15726.17,11008.319,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5244.677695,14693.4264,,,,
Acute Myocardial Infarction- Expired With McC,283,MS-DRG,,,,,,,inpatient,,,47695.81,33387.067,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,39624.2256,,,,
Acute Myocardial Infarction- Expired With Cc,284,MS-DRG,,,,,,,inpatient,,,30935.67,21654.969,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5312.22,24748.536,,,,
Circulatory Disorders Except Ami- With Cardiac Catheterization With McC,286,MS-DRG,,,,,,,inpatient,,,48769.97,34138.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,44850.3112,,,,
Circulatory Disorders Except Ami- With Cardiac Catheterization Without McC,287,MS-DRG,,,,,,,inpatient,,,33854.25,23697.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,27083.4,,,,
Acute And Subacute Endocarditis With McC,288,MS-DRG,,,,,,,inpatient,,,36276.49,25393.543,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,55347.0632,,,,
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,inpatient,,,34648,24253.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,31948.2224,,,,
Heart Failure And Shock With McC,291,MS-DRG,,,,,,,inpatient,,,22051.33,15435.931,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7354.118555,26442.4936,,,,
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,inpatient,,,17435.09,12204.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5814.602515,17453.3832,,,,
Cardiac Arrest- Unexplained With McC,296,MS-DRG,,,,,,,inpatient,,,34260.06,23982.042,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,33198.5112,,,,
Peripheral Vascular Disorders With McC,299,MS-DRG,,,,,,,inpatient,,,30642.24,21449.568,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,32781.0728,,,,
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,inpatient,,,19909.9,13936.93,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6639.95165,21692.612,,,,
Peripheral Vascular Disorders Without Cc/McC,301,MS-DRG,,,,,,,inpatient,,,15022.69,10515.883,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5010.067115,14454.3112,,,,
Atherosclerosis With McC,302,MS-DRG,,,,,,,inpatient,,,19965.6,13975.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6658.5276,23571.0848,,,,
Atherosclerosis Without McC,303,MS-DRG,,,,,,,inpatient,,,16291.73,11404.211,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4894.02,13625.5136,,,,
Hypertension With McC,304,MS-DRG,,,,,,,inpatient,,,26689.62,18682.734,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,23806.1472,,,,
Hypertension Without McC,305,MS-DRG,,,,,,,inpatient,,,17122.11,11985.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5343.34,15212.1848,,,,
Cardiac Congenital And Valvular Disorders With McC,306,MS-DRG,,,,,,,inpatient,,,18809.29,13166.503,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6272.898215,30343.3136,,,,
Cardiac Congenital And Valvular Disorders Without McC,307,MS-DRG,,,,,,,inpatient,,,16249.07,11374.349,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5419.064845,18770.5432,,,,
Cardiac Arrhythmia And Conduction Disorders With McC,308,MS-DRG,,,,,,,inpatient,,,21486.31,15040.417,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7165.684385,24438.384,,,,
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,inpatient,,,15843.59,11090.513,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5283.837265,14981.1752,,,,
Cardiac Arrhythmia And Conduction Disorders Without Cc/McC,310,MS-DRG,,,,,,,inpatient,,,13559.61,9491.727,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4040.24,11337.708,,,,
Angina Pectoris,311,MS-DRG,,,,,,,inpatient,,,18298.95,12809.265,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5043.07,14639.16,,,,
Syncope And Collapse,312,MS-DRG,,,,,,,inpatient,,,18654.24,13057.968,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6057.47,17656.0232,,,,
Chest Pain,313,MS-DRG,,,,,,,inpatient,,,18746.43,13122.501,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5215.27,14997.144,,,,
Other Circulatory System Diagnoses With McC,314,MS-DRG,,,,,,,inpatient,,,33351.93,23346.351,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,43636.4976,,,,
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,inpatient,,,17192.63,12034.841,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5733.742105,19500.0472,,,,
Other Circulatory System Diagnoses Without Cc/McC,316,MS-DRG,,,,,,,inpatient,,,16812.59,11768.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5422.92,13832.2064,,,,
Percutaneous Cardiovascular Procedures With Intraluminal Device With McC Or 4+ Arteries/Intraluminal Devices,321,MS-DRG,,,,,,,inpatient,,,107897.8,75528.46,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,86318.24,,,,
Percutaneous Cardiovascular Procedures With Intraluminal Device Without McC,322,MS-DRG,,,,,,,inpatient,,,85234.32,59664.024,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,68187.456,,,,
Coronary Intravascular Lithotripsy With Intraluminal Device With McC,323,MS-DRG,,,,,,,inpatient,,,110878.49,77614.943,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,88702.792,,,,
Coronary Intravascular Lithotripsy With Intraluminal Device Without McC,324,MS-DRG,,,,,,,inpatient,,,99829.51,69880.657,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,79863.608,,,,
Stomach- Esophageal And Duodenal Procedures With McC,326,MS-DRG,,,,,,,inpatient,,,70344.55,49241.185,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,102914.7768,,,,
Stomach- Esophageal And Duodenal Procedures With Cc,327,MS-DRG,,,,,,,inpatient,,,76692.68,53684.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,61354.144,,,,
Stomach- Esophageal And Duodenal Procedures Without Cc/McC,328,MS-DRG,,,,,,,inpatient,,,58306.69,40814.683,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,46645.352,,,,
Major Small And Large Bowel Procedures With McC,329,MS-DRG,,,,,,,inpatient,,,143675.4,100572.78,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,93046.2088,,,,
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,inpatient,,,66292.87,46405.009,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,53034.296,,,,
Major Small And Large Bowel Procedures Without Cc/McC,331,MS-DRG,,,,,,,inpatient,,,44944.36,31461.052,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,35955.488,,,,
Rectal Resection With McC,332,MS-DRG,,,,,,,inpatient,,,65516.56,45861.592,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,70285.684,,,,
Rectal Resection With Cc,333,MS-DRG,,,,,,,inpatient,,,51060.47,35742.329,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,43063.0264,,,,
Peritoneal Adhesiolysis With McC,335,MS-DRG,,,,,,,inpatient,,,76073.75,53251.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,73434.7096,,,,
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,inpatient,,,39391.39,27573.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,42805.6736,,,,
Peritoneal Adhesiolysis Without Cc/McC,337,MS-DRG,,,,,,,inpatient,,,43856.45,30699.515,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,35085.16,,,,
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,inpatient,,,22777.13,15943.991,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7596.172855,30177.1488,,,,
Minor Small And Large Bowel Procedures Without Cc/McC,346,MS-DRG,,,,,,,inpatient,,,25360.83,17752.581,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,25232.7328,,,,
Anal And Stomal Procedures With McC,347,MS-DRG,,,,,,,inpatient,,,33046.94,23132.858,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,47956.7824,,,,
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,inpatient,,,21678.05,15174.635,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7229.629675,25508.3232,,,,
Anal And Stomal Procedures Without Cc/McC,349,MS-DRG,,,,,,,inpatient,,,20851.83,14596.281,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6954.085305,17850.5576,,,,
Inguinal And Femoral Hernia Procedures With McC,350,MS-DRG,,,,,,,inpatient,,,123839.74,86687.818,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,99071.792,,,,
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,inpatient,,,41444.06,29010.842,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,33155.248,,,,
Inguinal And Femoral Hernia Procedures Without Cc/McC,352,MS-DRG,,,,,,,inpatient,,,27314.17,19119.919,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,22341.06,,,,
Hernia Procedures Except Inguinal And Femoral With McC,353,MS-DRG,,,,,,,inpatient,,,60356.38,42249.466,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,59430.2592,,,,
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,inpatient,,,30185.36,21129.752,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,34471.0904,,,,
Hernia Procedures Except Inguinal And Femoral Without Cc/McC,355,MS-DRG,,,,,,,inpatient,,,34745.89,24322.123,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,27796.712,,,,
Other Digestive System O.R. Procedures With McC,356,MS-DRG,,,,,,,inpatient,,,122041.99,85429.393,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,97633.592,,,,
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,inpatient,,,40025.14,28017.598,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,45632.5016,,,,
Other Digestive System O.R. Procedures Without Cc/McC,358,MS-DRG,,,,,,,inpatient,,,22899.78,16029.846,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7637.07663,27457.72,,,,
Major Esophageal Disorders With McC,368,MS-DRG,,,,,,,inpatient,,,52357.14,36649.998,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,41885.712,,,,
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,inpatient,,,25013.89,17509.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,20620.6464,,,,
Major Gastrointestinal Disorders And Peritoneal Infections With McC,371,MS-DRG,,,,,,,inpatient,,,31663.98,22164.786,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,35427.5512,,,,
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,inpatient,,,22657.22,15860.054,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7435.09,20857.7352,,,,
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/McC,373,MS-DRG,,,,,,,inpatient,,,16862.96,11804.072,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5379.51,14697.4792,,,,
Digestive Malignancy With McC,374,MS-DRG,,,,,,,inpatient,,,35452.33,24816.631,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,42787.436,,,,
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,inpatient,,,28899.99,20229.993,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,24898.3768,,,,
Digestive Malignancy Without Cc/McC,376,MS-DRG,,,,,,,inpatient,,,13461.5,9423.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4489.41025,17891.0856,,,,
Gastrointestinal Hemorrhage With McC,377,MS-DRG,,,,,,,inpatient,,,36368.06,25457.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,36841.9784,,,,
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,inpatient,,,26039.38,18227.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7186.19,20831.504,,,,
Gastrointestinal Hemorrhage Without Cc/McC,379,MS-DRG,,,,,,,inpatient,,,12685.62,8879.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4230.65427,12900.0624,,,,
Complicated Peptic Ulcer With McC,380,MS-DRG,,,,,,,inpatient,,,33309.68,23316.776,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,38994.0152,,,,
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,inpatient,,,25551.79,17886.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7667.34,22069.5224,,,,
Uncomplicated Peptic Ulcer With McC,383,MS-DRG,,,,,,,inpatient,,,17337.01,12135.907,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5781.892835,25617.7488,,,,
Uncomplicated Peptic Ulcer Without McC,384,MS-DRG,,,,,,,inpatient,,,17367.77,12157.439,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5792.151295,17621.5744,,,,
Inflammatory Bowel Disease With McC,385,MS-DRG,,,,,,,inpatient,,,26393.7,18475.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,32922.9208,,,,
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,inpatient,,,16705.38,11693.766,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5571.24423,20109.9936,,,,
Inflammatory Bowel Disease Without Cc/McC,387,MS-DRG,,,,,,,inpatient,,,12511.84,8758.288,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4172.69864,13582.9592,,,,
Gastrointestinal Obstruction With McC,388,MS-DRG,,,,,,,inpatient,,,25855.59,18098.913,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,29788.08,,,,
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,inpatient,,,16977.78,11884.446,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5662.08963,16245.6488,,,,
Gastrointestinal Obstruction Without Cc/McC,390,MS-DRG,,,,,,,inpatient,,,12959.35,9071.545,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4215.34,11086.4344,,,,
Esophagitis- Gastroenteritis And Miscellaneous Digestive Disorders With McC,391,MS-DRG,,,,,,,inpatient,,,20838.16,14586.712,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6949.52636,26037.2136,,,,
Esophagitis- Gastroenteritis And Miscellaneous Digestive Disorders Without McC,392,MS-DRG,,,,,,,inpatient,,,16987.8,11891.46,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5530.73,15811.9992,,,,
Other Digestive System Diagnoses With McC,393,MS-DRG,,,,,,,inpatient,,,37534.54,26274.178,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,33555.1576,,,,
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,inpatient,,,23011.57,16108.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6791.14,19074.5032,,,,
Other Digestive System Diagnoses Without Cc/McC,395,MS-DRG,,,,,,,inpatient,,,17300.89,12110.623,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4700.83,13840.712,,,,
Appendix Procedures With McC,397,MS-DRG,,,,,,,inpatient,,,61991.24,43393.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,50206.0864,,,,
Appendix Procedures With Cc,398,MS-DRG,,,,,,,inpatient,,,56760.43,39732.301,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,45408.344,,,,
Appendix Procedures Without Cc/McC,399,MS-DRG,,,,,,,inpatient,,,27586.47,19310.529,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,22778.7624,,,,
Pancreas- Liver And Shunt Procedures With McC,405,MS-DRG,,,,,,,inpatient,,,46019.16,32213.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,110001.0976,,,,
Pancreas- Liver And Shunt Procedures With Cc,406,MS-DRG,,,,,,,inpatient,,,55926.32,39148.424,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,56905.3648,,,,
Pancreas- Liver And Shunt Procedures Without Cc/McC,407,MS-DRG,,,,,,,inpatient,,,51764.06,36234.842,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,43275.7984,,,,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,inpatient,,,23884.65,16719.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,42479.4232,,,,
Laparoscopic Cholecystectomy Without C.D.E. With McC,417,MS-DRG,,,,,,,inpatient,,,63968.01,44777.607,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,51174.408,,,,
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,inpatient,,,44129.12,30890.384,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,35303.296,,,,
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/McC,419,MS-DRG,,,,,,,inpatient,,,36100.79,25270.553,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,28880.632,,,,
Hepatobiliary Diagnostic Procedures With McC,420,MS-DRG,,,,,,,inpatient,,,75254.61,52678.227,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,71515.7088,,,,
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,,,inpatient,,,37061.98,25943.386,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,33182.3,,,,
Hepatobiliary Diagnostic Procedures Without Cc/McC,422,MS-DRG,,,,,,,inpatient,,,34064.62,23845.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,29773.8952,,,,
Other Hepatobiliary Or Pancreas O.R. Procedures With McC,423,MS-DRG,,,,,,,inpatient,,,81747.41,57223.187,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,82415.7144,,,,
Cirrhosis And Alcoholic Hepatitis With McC,432,MS-DRG,,,,,,,inpatient,,,29574.59,20702.213,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,39699.2024,,,,
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,inpatient,,,21623.94,15136.758,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7211.58399,21676.4008,,,,
Cirrhosis And Alcoholic Hepatitis Without Cc/McC,434,MS-DRG,,,,,,,inpatient,,,14349.7,10044.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4483.05,14111.8496,,,,
Malignancy Of Hepatobiliary System Or Pancreas With McC,435,MS-DRG,,,,,,,inpatient,,,41847.14,29292.998,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,36971.668,,,,
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,inpatient,,,20489.14,14342.398,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6833.12819,22849.6864,,,,
Disorders Of Pancreas Except Malignancy With McC,438,MS-DRG,,,,,,,inpatient,,,28902.5,20231.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,33715.2432,,,,
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,inpatient,,,16481.74,11537.218,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5496.66029,17431.0928,,,,
Disorders Of Pancreas Except Malignancy Without Cc/McC,440,MS-DRG,,,,,,,inpatient,,,15295.1,10706.57,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4383.92,12464.3864,,,,
Disorders Of Liver Except Malignancy- Cirrhosis Or Alcoholic Hepatitis With McC,441,MS-DRG,,,,,,,inpatient,,,34043.85,23830.695,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,38305.0392,,,,
Disorders Of Liver Except Malignancy- Cirrhosis Or Alcoholic Hepatitis With Cc,442,MS-DRG,,,,,,,inpatient,,,21274.77,14892.339,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6740.49,19579.0768,,,,
Disorders Of Liver Except Malignancy- Cirrhosis Or Alcoholic Hepatitis Without Cc/McC,443,MS-DRG,,,,,,,inpatient,,,11297.88,7908.516,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3767.84298,14237.4864,,,,
Disorders Of The Biliary Tract With McC,444,MS-DRG,,,,,,,inpatient,,,39694.28,27785.996,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,34134.708,,,,
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,inpatient,,,32558.38,22790.866,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,26046.704,,,,
Disorders Of The Biliary Tract Without Cc/McC,446,MS-DRG,,,,,,,inpatient,,,33146.93,23202.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5905.53,26517.544,,,,
Combined Anterior And Posterior Spinal Fusion With McC,453,MS-DRG,,,,,,,inpatient,,,126551.26,88585.882,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,101241.008,,,,
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,,,inpatient,,,108469.17,75928.419,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,86775.336,,,,
Combined Anterior And Posterior Spinal Fusion Without Cc/McC,455,MS-DRG,,,,,,,inpatient,,,115580.93,80906.651,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,92464.744,,,,
Spinal Fusion Except Cervical With Spinal Curvature- Malignancy- Infection Or Extensive Fusions With Cc,457,MS-DRG,,,,,,,inpatient,,,143333.97,100333.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,116295.096,,,,
Spinal Fusion Except Cervical With McC,459,MS-DRG,,,,,,,inpatient,,,98009.72,68606.804,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,78407.776,,,,
Spinal Fusion Except Cervical Without McC,460,MS-DRG,,,,,,,inpatient,,,99867.86,69907.502,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,79894.288,,,,
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With McC,461,MS-DRG,,,,,,,inpatient,,,327456.17,229219.319,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,261964.936,,,,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With McC,463,MS-DRG,,,,,,,inpatient,,,128878.42,90214.894,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,109439.7848,,,,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With Cc,464,MS-DRG,,,,,,,inpatient,,,40970.26,28679.182,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,59750.4304,,,,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Without Cc/McC,465,MS-DRG,,,,,,,inpatient,,,35885.97,25120.179,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,35176.2776,,,,
Revision Of Hip Or Knee Replacement With McC,466,MS-DRG,,,,,,,inpatient,,,84828.36,59379.852,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,103230.8952,,,,
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,inpatient,,,45864.06,32104.842,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,69402.1736,,,,
Revision Of Hip Or Knee Replacement Without Cc/McC,468,MS-DRG,,,,,,,inpatient,,,88973.4,62281.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,71178.72,,,,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With McC Or Total Ankle Replacement,469,MS-DRG,,,,,,,inpatient,,,112079.98,78455.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,89663.984,,,,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without McC,470,MS-DRG,,,,,,,inpatient,,,49135.63,34394.941,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,39308.504,,,,
Cervical Spinal Fusion With McC,471,MS-DRG,,,,,,,inpatient,,,68213.66,47749.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,98422.248,,,,
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,inpatient,,,62194.58,43536.206,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,58704.808,,,,
Cervical Spinal Fusion Without Cc/McC,473,MS-DRG,,,,,,,inpatient,,,60389.67,42272.769,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,48311.736,,,,
Amputation For Musculoskeletal System And Connective Tissue Disorders With McC,474,MS-DRG,,,,,,,inpatient,,,118369.6,82858.72,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,94695.68,,,,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,inpatient,,,42743.34,29920.338,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,43711.4744,,,,
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/McC,476,MS-DRG,,,,,,,inpatient,,,10865.65,7605.955,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3623.694275,23567.032,,,,
Biopsies Of Musculoskeletal System And Connective Tissue With McC,477,MS-DRG,,,,,,,inpatient,,,79298.26,55508.782,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,69683.8432,,,,
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,inpatient,,,43683.25,30578.275,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,47385.3376,,,,
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/McC,479,MS-DRG,,,,,,,inpatient,,,48180.79,33726.553,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,38544.632,,,,
Hip And Femur Procedures Except Major Joint With McC,480,MS-DRG,,,,,,,inpatient,,,63845.68,44691.976,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,59596.424,,,,
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,inpatient,,,51147.69,35803.383,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,42045.7736,,,,
Hip And Femur Procedures Except Major Joint Without Cc/McC,482,MS-DRG,,,,,,,inpatient,,,37492.92,26245.044,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,32146.8096,,,,
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,inpatient,,,82685.37,57879.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,66148.296,,,,
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,inpatient,,,54953.11,38467.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,43962.488,,,,
Knee Procedures With Principal Diagnosis Of Infection Without Cc/McC,487,MS-DRG,,,,,,,inpatient,,,28558.04,19990.628,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,32019.1464,,,,
Knee Procedures Without Principal Diagnosis Of Infection With Cc/McC,488,MS-DRG,,,,,,,inpatient,,,29907.22,20935.054,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,39824.8392,,,,
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/McC,489,MS-DRG,,,,,,,inpatient,,,28726.07,20108.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,25098.9904,,,,
Lower Extremity And Humerus Procedures Except Hip- Foot And Femur With McC,492,MS-DRG,,,,,,,inpatient,,,73476.69,51433.683,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,71957.464,,,,
Lower Extremity And Humerus Procedures Except Hip- Foot And Femur With Cc,493,MS-DRG,,,,,,,inpatient,,,59232.47,41462.729,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,48653.864,,,,
Lower Extremity And Humerus Procedures Except Hip- Foot And Femur Without Cc/McC,494,MS-DRG,,,,,,,inpatient,,,55024.26,38516.982,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,44019.408,,,,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/McC,497,MS-DRG,,,,,,,inpatient,,,25582.79,17907.953,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,27214.552,,,,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/McC,498,MS-DRG,,,,,,,inpatient,,,53889.53,37722.671,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,51160.5208,,,,
Soft Tissue Procedures With McC,500,MS-DRG,,,,,,,inpatient,,,39746.36,27822.452,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,64206.484,,,,
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,inpatient,,,35413.37,24789.359,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,36169.2136,,,,
Soft Tissue Procedures Without Cc/McC,502,MS-DRG,,,,,,,inpatient,,,46820.44,32774.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,37456.352,,,,
Foot Procedures With McC,503,MS-DRG,,,,,,,inpatient,,,139085.96,97360.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,111268.768,,,,
Foot Procedures With Cc,504,MS-DRG,,,,,,,inpatient,,,58509.52,40956.664,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,46807.616,,,,
Foot Procedures Without Cc/McC,505,MS-DRG,,,,,,,inpatient,,,18215.65,12750.955,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6074.919275,35575.4784,,,,
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,inpatient,,,34935.4,24454.78,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,30375.736,,,,
Major Shoulder Or Elbow Joint Procedures With Cc/McC,507,MS-DRG,,,,,,,inpatient,,,46308.19,32415.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,39273.6584,,,,
Major Shoulder Or Elbow Joint Procedures Without Cc/McC,508,MS-DRG,,,,,,,inpatient,,,21924.51,15347.157,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7311.824085,26152.7184,,,,
Arthroscopy,509,MS-DRG,,,,,,,inpatient,,,27294.99,19106.493,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,35593.716,,,,
Shoulder- Elbow Or Forearm Procedures- Except Major Joint Procedures With McC,510,MS-DRG,,,,,,,inpatient,,,62572,43800.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,57914.512,,,,
Shoulder- Elbow Or Forearm Procedures- Except Major Joint Procedures With Cc,511,MS-DRG,,,,,,,inpatient,,,55415.55,38790.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,44332.44,,,,
Shoulder- Elbow Or Forearm Procedures- Except Major Joint Procedures Without Cc/McC,512,MS-DRG,,,,,,,inpatient,,,47238.2,33066.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,37790.56,,,,
Hand Or Wrist Procedures- Except Major Thumb Or Joint Procedures With Cc/McC,513,MS-DRG,,,,,,,inpatient,,,43600.38,30520.266,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,34880.304,,,,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With McC,515,MS-DRG,,,,,,,inpatient,,,49277.7,34494.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,62660.3408,,,,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,inpatient,,,53176.69,37223.683,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,42541.352,,,,
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/McC,517,MS-DRG,,,,,,,inpatient,,,52111.68,36478.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,41689.344,,,,
Back And Neck Procedures Except Spinal Fusion With McC Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,inpatient,,,37618.21,26332.747,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,72622.1232,,,,
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,inpatient,,,45454.66,31818.262,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,39954.5288,,,,
Back And Neck Procedures Except Spinal Fusion Without Cc/McC,520,MS-DRG,,,,,,,inpatient,,,30414.64,21290.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,29040.3384,,,,
Hip Replacement With Principal Diagnosis Of Hip Fracture With McC,521,MS-DRG,,,,,,,inpatient,,,66299.82,46409.874,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,59061.4544,,,,
Hip Replacement With Principal Diagnosis Of Hip Fracture Without McC,522,MS-DRG,,,,,,,inpatient,,,59172.56,41420.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,47338.048,,,,
Fractures Of Femur With McC,533,MS-DRG,,,,,,,inpatient,,,15534.08,10873.856,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5180.61568,30898.5472,,,,
Fractures Of Femur Without McC,534,MS-DRG,,,,,,,inpatient,,,23461.3,16422.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5705.828554,18769.04,,,,
Fractures Of Hip And Pelvis With McC,535,MS-DRG,,,,,,,inpatient,,,19899.42,13929.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6636.45657,26949.0936,,,,
Fractures Of Hip And Pelvis Without McC,536,MS-DRG,,,,,,,inpatient,,,17540.07,12278.049,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5582.83,16432.0776,,,,
Sprains- Strains- And Dislocations Of Hip- Pelvis And Thigh With Cc/McC,537,MS-DRG,,,,,,,inpatient,,,18243.05,12770.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6084.057175,18620.5896,,,,
Sprains- Strains- And Dislocations Of Hip- Pelvis And Thigh Without Cc/McC,538,MS-DRG,,,,,,,inpatient,,,12750.59,8925.413,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4252.321765,13607.276,,,,
Osteomyelitis With McC,539,MS-DRG,,,,,,,inpatient,,,15126.14,10588.298,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5044.56769,40987.9928,,,,
Osteomyelitis With Cc,540,MS-DRG,,,,,,,inpatient,,,18734.75,13114.325,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6248.039125,26229.7216,,,,
Osteomyelitis Without Cc/McC,541,MS-DRG,,,,,,,inpatient,,,13958.41,9770.887,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4655.129735,17726.9472,,,,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With McC,542,MS-DRG,,,,,,,inpatient,,,18971.85,13280.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6327.111975,37790.3336,,,,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,inpatient,,,20157.83,14110.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6722.636305,21496.0512,,,,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/McC,544,MS-DRG,,,,,,,inpatient,,,15770.25,11039.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5259.378375,15313.5048,,,,
Connective Tissue Disorders With McC,545,MS-DRG,,,,,,,inpatient,,,29219.27,20453.489,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,51201.0488,,,,
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,inpatient,,,19656.15,13759.305,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6555.326025,23459.6328,,,,
Connective Tissue Disorders Without Cc/McC,547,MS-DRG,,,,,,,inpatient,,,8610.08,6027.056,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2871.46168,15120.9968,,,,
Septic Arthritis With Cc,549,MS-DRG,,,,,,,inpatient,,,46061.25,32242.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,36849,,,,
Medical Back Problems With McC,551,MS-DRG,,,,,,,inpatient,,,27883.52,19518.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,34576.4632,,,,
Medical Back Problems Without McC,552,MS-DRG,,,,,,,inpatient,,,22361.84,15653.288,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6815.74,19530.4432,,,,
Bone Diseases And Arthropathies With McC,553,MS-DRG,,,,,,,inpatient,,,13901.34,9730.938,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4636.09689,26470.8632,,,,
Bone Diseases And Arthropathies Without McC,554,MS-DRG,,,,,,,inpatient,,,18962.8,13273.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5718.85,16912.3344,,,,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without McC,556,MS-DRG,,,,,,,inpatient,,,20178.82,14125.174,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5833.89,16545.556,,,,
Tendonitis- Myositis And Bursitis With McC,557,MS-DRG,,,,,,,inpatient,,,32769.21,22938.447,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,31403.1208,,,,
Tendonitis- Myositis And Bursitis Without McC,558,MS-DRG,,,,,,,inpatient,,,15272.59,10690.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5093.408765,17504.0432,,,,
Aftercare- Musculoskeletal System And Connective Tissue With McC,559,MS-DRG,,,,,,,inpatient,,,16267.53,11387.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5425.221255,37612.0104,,,,
Aftercare- Musculoskeletal System And Connective Tissue With Cc,560,MS-DRG,,,,,,,inpatient,,,15449.56,10814.692,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5152.42826,23076.6432,,,,
Aftercare- Musculoskeletal System And Connective Tissue Without Cc/McC,561,MS-DRG,,,,,,,inpatient,,,9300.65,6510.455,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3101.766775,16567.8464,,,,
Fracture- Sprain- Strain And Dislocation Except Femur- Hip- Pelvis And Thigh With McC,562,MS-DRG,,,,,,,inpatient,,,32385.67,22669.969,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,29660.4168,,,,
Fracture- Sprain- Strain And Dislocation Except Femur- Hip- Pelvis And Thigh Without McC,563,MS-DRG,,,,,,,inpatient,,,24167.6,16917.32,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6300.58,19334.08,,,,
Other Musculoskeletal System And Connective Tissue Diagnoses With McC,564,MS-DRG,,,,,,,inpatient,,,25802.93,18062.051,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,31798.2688,,,,
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,inpatient,,,22006.13,15404.291,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7280.97,20661.1744,,,,
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/McC,566,MS-DRG,,,,,,,inpatient,,,6764.1,4734.87,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2255.82735,15157.472,,,,
Skin Debridement With McC,570,MS-DRG,,,,,,,inpatient,,,33594.41,23516.087,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,61002.7456,,,,
Skin Debridement With Cc,571,MS-DRG,,,,,,,inpatient,,,26173.08,18321.156,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,33938.1472,,,,
Skin Graft For Skin Ulcer Or Cellulitis With McC,573,MS-DRG,,,,,,,inpatient,,,229287.37,160501.159,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,183429.896,,,,
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,inpatient,,,76990.64,53893.448,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,70208.6808,,,,
Other Skin- Subcutaneous Tissue And Breast Procedures With McC,579,MS-DRG,,,,,,,inpatient,,,44370,31059,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,66042.4024,,,,
Other Skin- Subcutaneous Tissue And Breast Procedures With Cc,580,MS-DRG,,,,,,,inpatient,,,32530.15,22771.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,35926.0456,,,,
Other Skin- Subcutaneous Tissue And Breast Procedures Without Cc/McC,581,MS-DRG,,,,,,,inpatient,,,34001.93,23801.351,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,29161.9224,,,,
Mastectomy For Malignancy Without Cc/McC,583,MS-DRG,,,,,,,inpatient,,,26986.11,18890.277,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,33283.62,,,,
Breast Biopsy- Local Excision And Other Breast Procedures With Cc/McC,584,MS-DRG,,,,,,,inpatient,,,15783.7,11048.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5263.86395,41486.4872,,,,
Skin Ulcers With McC,592,MS-DRG,,,,,,,inpatient,,,11607.65,8125.355,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3871.151275,41666.8368,,,,
Skin Ulcers With Cc,593,MS-DRG,,,,,,,inpatient,,,11196.69,7837.683,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3734.096115,24774.7664,,,,
Skin Ulcers Without Cc/McC,594,MS-DRG,,,,,,,inpatient,,,9029.64,6320.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3011.38494,17196.0304,,,,
Major Skin Disorders With McC,595,MS-DRG,,,,,,,inpatient,,,27847.46,19493.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,42858.36,,,,
Major Skin Disorders Without McC,596,MS-DRG,,,,,,,inpatient,,,30386.11,21270.277,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7157.25,24308.888,,,,
Malignant Breast Disorders With McC,597,MS-DRG,,,,,,,inpatient,,,49956.04,34969.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,39964.832,,,,
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,inpatient,,,27430.15,19201.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,21944.12,,,,
Non-Malignant Breast Disorders With Cc/McC,600,MS-DRG,,,,,,,inpatient,,,13956.43,9769.501,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4654.469405,19396.7008,,,,
Non-Malignant Breast Disorders Without Cc/McC,601,MS-DRG,,,,,,,inpatient,,,9383.02,6568.114,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3129.23717,12148.268,,,,
Cellulitis With McC,602,MS-DRG,,,,,,,inpatient,,,27986.19,19590.333,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,29775.9216,,,,
Cellulitis Without McC,603,MS-DRG,,,,,,,inpatient,,,16886.67,11820.669,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5631.704445,17850.5576,,,,
Trauma To The Skin- Subcutaneous Tissue And Breast With McC,604,MS-DRG,,,,,,,inpatient,,,38556.84,26989.788,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,30845.472,,,,
Trauma To The Skin- Subcutaneous Tissue And Breast Without McC,605,MS-DRG,,,,,,,inpatient,,,21359.36,14951.552,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6578.42,18717.8568,,,,
Minor Skin Disorders With McC,606,MS-DRG,,,,,,,inpatient,,,6185.67,4329.969,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2062.920945,32627.0664,,,,
Minor Skin Disorders Without McC,607,MS-DRG,,,,,,,inpatient,,,19860.65,13902.455,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5973.54,17514.1752,,,,
Adrenal And Pituitary Procedures With Cc/McC,614,MS-DRG,,,,,,,inpatient,,,37769.13,26438.391,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,46177.6032,,,,
Adrenal And Pituitary Procedures Without Cc/McC,615,MS-DRG,,,,,,,inpatient,,,58015.91,40611.137,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,46412.728,,,,
Amputation Of Lower Limb For Endocrine- Nutritional And Metabolic Disorders With McC,616,MS-DRG,,,,,,,inpatient,,,66449.27,46514.489,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,78318.3336,,,,
Amputation Of Lower Limb For Endocrine- Nutritional And Metabolic Disorders With Cc,617,MS-DRG,,,,,,,inpatient,,,29882.58,20917.806,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,39154.1008,,,,
Amputation Of Lower Limb For Endocrine- Nutritional And Metabolic Disorders Without Cc/McC,618,MS-DRG,,,,,,,inpatient,,,10245.69,7171.983,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3416.937615,25228.68,,,,
Skin Grafts And Wound Debridement For Endocrine- Nutritional And Metabolic Disorders With McC,622,MS-DRG,,,,,,,inpatient,,,103303.17,72312.219,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,82642.536,,,,
Skin Grafts And Wound Debridement For Endocrine- Nutritional And Metabolic Disorders With Cc,623,MS-DRG,,,,,,,inpatient,,,20666.05,14466.235,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6892.127675,38785.296,,,,
Thyroid- Parathyroid And Thyroglossal Procedures With Cc,626,MS-DRG,,,,,,,inpatient,,,27302.86,19112.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,30582.4288,,,,
Thyroid- Parathyroid And Thyroglossal Procedures Without Cc/McC,627,MS-DRG,,,,,,,inpatient,,,31328.53,21929.971,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,25670.4352,,,,
Other Endocrine- Nutritional And Metabolic O.R. Procedures With McC,628,MS-DRG,,,,,,,inpatient,,,48752.32,34126.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,79967.8232,,,,
Other Endocrine- Nutritional And Metabolic O.R. Procedures With Cc,629,MS-DRG,,,,,,,inpatient,,,41481.26,29036.882,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,45596.0264,,,,
Diabetes With McC,637,MS-DRG,,,,,,,inpatient,,,33585.6,23509.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,29510.4632,,,,
Diabetes With Cc,638,MS-DRG,,,,,,,inpatient,,,16607.1,11624.97,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5538.46785,18586.1408,,,,
Diabetes Without Cc/McC,639,MS-DRG,,,,,,,inpatient,,,15715.82,11001.074,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4408.52,12697.4224,,,,
Miscellaneous Disorders Of Nutrition- Metabolism- Fluids And Electrolytes With McC,640,MS-DRG,,,,,,,inpatient,,,19706.61,13794.627,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6572.154435,26912.6184,,,,
Miscellaneous Disorders Of Nutrition- Metabolism- Fluids And Electrolytes Without McC,641,MS-DRG,,,,,,,inpatient,,,15211.2,10647.84,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5072.9352,15836.316,,,,
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,inpatient,,,44600.9,31220.63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,35680.72,,,,
Endocrine Disorders With McC,643,MS-DRG,,,,,,,inpatient,,,24319.36,17023.552,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,33583.5272,,,,
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,inpatient,,,18127.98,12689.586,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6045.68133,20942.844,,,,
Endocrine Disorders Without Cc/McC,645,MS-DRG,,,,,,,inpatient,,,13087.48,9161.236,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4364.67458,15785.656,,,,
Major Bladder Procedures With McC,653,MS-DRG,,,,,,,inpatient,,,74103.71,51872.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,112955.5888,,,,
Major Bladder Procedures With Cc,654,MS-DRG,,,,,,,inpatient,,,32847.58,22993.306,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,57182.9816,,,,
Kidney And Ureter Procedures For Neoplasm With McC,656,MS-DRG,,,,,,,inpatient,,,74882.24,52417.568,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,66014.0328,,,,
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,inpatient,,,35825.52,25077.864,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,37042.592,,,,
Kidney And Ureter Procedures For Neoplasm Without Cc/McC,658,MS-DRG,,,,,,,inpatient,,,45531.4,31871.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,36425.12,,,,
Kidney And Ureter Procedures For Non-Neoplasm With McC,659,MS-DRG,,,,,,,inpatient,,,43577.66,30504.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,52366.2288,,,,
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,inpatient,,,27744.56,19421.192,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,27151.7336,,,,
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/McC,661,MS-DRG,,,,,,,inpatient,,,23214.29,16250.003,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7701.35,20803.0224,,,,
Minor Bladder Procedures With McC,662,MS-DRG,,,,,,,inpatient,,,26200.57,18340.399,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,63211.5216,,,,
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,inpatient,,,51470.37,36029.259,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,41176.296,,,,
Minor Bladder Procedures Without Cc/McC,664,MS-DRG,,,,,,,inpatient,,,21663.46,15164.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7224.76391,21881.0672,,,,
Prostatectomy With McC,665,MS-DRG,,,,,,,inpatient,,,440302,308211.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,352241.6,,,,
Prostatectomy With Cc,666,MS-DRG,,,,,,,inpatient,,,21861.75,15303.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7290.893625,33378.8608,,,,
Prostatectomy Without Cc/McC,667,MS-DRG,,,,,,,inpatient,,,16201.02,11340.714,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5403.04017,20825.3128,,,,
Transurethral Procedures With McC,668,MS-DRG,,,,,,,inpatient,,,48931.22,34251.854,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,59091.8504,,,,
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,inpatient,,,33035.66,23124.962,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,31358.54,,,,
Transurethral Procedures Without Cc/McC,670,MS-DRG,,,,,,,inpatient,,,33732.79,23612.953,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7065.36,26986.232,,,,
Other Kidney And Urinary Tract Procedures With McC,673,MS-DRG,,,,,,,inpatient,,,60478,42334.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,84906.16,,,,
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,inpatient,,,73440.29,51408.203,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,58752.232,,,,
Renal Failure With McC,682,MS-DRG,,,,,,,inpatient,,,25189.25,17632.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,30436.528,,,,
Renal Failure With Cc,683,MS-DRG,,,,,,,inpatient,,,17753.72,12427.604,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5920.86562,18012.6696,,,,
Renal Failure Without Cc/McC,684,MS-DRG,,,,,,,inpatient,,,9135.38,6394.766,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3046.64923,12310.38,,,,
Kidney And Urinary Tract Neoplasms With McC,686,MS-DRG,,,,,,,inpatient,,,27497.1,19247.97,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,38209.7984,,,,
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,inpatient,,,25492.34,17844.638,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7581.24,21329.8864,,,,
Kidney And Urinary Tract Infections With McC,689,MS-DRG,,,,,,,inpatient,,,20757.97,14530.579,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6922.782995,23716.9856,,,,
Kidney And Urinary Tract Infections Without McC,690,MS-DRG,,,,,,,inpatient,,,16632.65,11642.855,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5546.988775,16263.8864,,,,
Urinary Stones With McC,693,MS-DRG,,,,,,,inpatient,,,4007.39,2805.173,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1336.464565,29794.1592,,,,
Urinary Stones Without McC,694,MS-DRG,,,,,,,inpatient,,,15019.62,10513.734,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5009.04327,15834.2896,,,,
Kidney And Urinary Tract Signs And Symptoms With McC,695,MS-DRG,,,,,,,inpatient,,,29850.37,20895.259,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,23880.296,,,,
Kidney And Urinary Tract Signs And Symptoms Without McC,696,MS-DRG,,,,,,,inpatient,,,12055.26,8438.682,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4020.42921,14016.6088,,,,
Other Kidney And Urinary Tract Diagnoses With McC,698,MS-DRG,,,,,,,inpatient,,,25421.96,17795.372,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,34061.7576,,,,
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,inpatient,,,18359.1,12851.37,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6122.75985,20665.2272,,,,
Other Kidney And Urinary Tract Diagnoses Without Cc/McC,700,MS-DRG,,,,,,,inpatient,,,8380.95,5866.665,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2795.046825,14065.2424,,,,
Major Male Pelvic Procedures Without Cc/McC,708,MS-DRG,,,,,,,inpatient,,,55574.17,38901.919,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,44459.336,,,,
Penis Procedures With Cc/McC,709,MS-DRG,,,,,,,inpatient,,,18738.26,13116.782,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6249.20971,45533.208,,,,
Transurethral Prostatectomy With Cc/McC,713,MS-DRG,,,,,,,inpatient,,,28299.1,19809.37,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,29299.7176,,,,
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/McC,717,MS-DRG,,,,,,,inpatient,,,29999.37,20999.559,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,37597.8256,,,,
Malignancy- Male Reproductive System With Cc,723,MS-DRG,,,,,,,inpatient,,,3972.81,2780.967,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1324.932135,22754.4456,,,,
Benign Prostatic Hypertrophy Without McC,726,MS-DRG,,,,,,,inpatient,,,40258.34,28180.838,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5378.07,32206.672,,,,
Inflammation Of The Male Reproductive System With McC,727,MS-DRG,,,,,,,inpatient,,,22656.48,15859.536,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7555.93608,29773.8952,,,,
Inflammation Of The Male Reproductive System Without McC,728,MS-DRG,,,,,,,inpatient,,,13639.47,9547.629,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4548.763245,16557.7144,,,,
Other Male Reproductive System Diagnoses With Cc/McC,729,MS-DRG,,,,,,,inpatient,,,16117.99,11282.593,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5375.349665,22306.6112,,,,
Other Male Reproductive System Diagnoses Without Cc/McC,730,MS-DRG,,,,,,,inpatient,,,5959.58,4171.706,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1987.51993,12298.2216,,,,
Uterine And Adnexa Procedures For Non-Malignancy With Cc/McC,742,MS-DRG,,,,,,,inpatient,,,28503.79,19952.653,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,37014.2224,,,,
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/McC,743,MS-DRG,,,,,,,inpatient,,,26776.68,18743.676,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,24288.4304,,,,
D&C- Conization- Laparoscopy And Tubal Interruption With Cc/McC,744,MS-DRG,,,,,,,inpatient,,,42207.27,29545.089,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,39593.8296,,,,
D&C- Conization- Laparoscopy And Tubal Interruption Without Cc/McC,745,MS-DRG,,,,,,,inpatient,,,41300.62,28910.434,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,33040.496,,,,
Vagina- Cervix And Vulva Procedures With Cc/McC,746,MS-DRG,,,,,,,inpatient,,,54026.22,37818.354,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,43220.976,,,,
Vagina- Cervix And Vulva Procedures Without Cc/McC,747,MS-DRG,,,,,,,inpatient,,,14150.78,9905.546,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4719.28513,19354.1464,,,,
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,,,inpatient,,,71661.69,50163.183,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,57329.352,,,,
Other Female Reproductive System O.R. Procedures With Cc/McC,749,MS-DRG,,,,,,,inpatient,,,40397.2,28278.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,52451.3376,,,,
Malignancy- Female Reproductive System With McC,754,MS-DRG,,,,,,,inpatient,,,31179.58,21825.706,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,36661.6288,,,,
Malignancy- Female Reproductive System With Cc,755,MS-DRG,,,,,,,inpatient,,,7660.86,5362.602,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2554.89681,22495.0664,,,,
Malignancy- Female Reproductive System Without Cc/McC,756,MS-DRG,,,,,,,inpatient,,,11168.92,7818.244,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3724.83482,19350.0936,,,,
Infections- Female Reproductive System With Cc,758,MS-DRG,,,,,,,inpatient,,,20130.99,14091.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6713.685165,20655.0952,,,,
Infections- Female Reproductive System Without Cc/McC,759,MS-DRG,,,,,,,inpatient,,,18187.49,12731.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4943.22,14549.992,,,,
Menstrual And Other Female Reproductive System Disorders With Cc/McC,760,MS-DRG,,,,,,,inpatient,,,19375.46,13562.822,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6461.71591,19970.172,,,,
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,inpatient,,,14024.34,9817.038,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4677.11739,22215.4232,,,,
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,inpatient,,,9265.92,6486.144,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3090.18432,28156.828,,,,
Abortion With D&C- Aspiration Curettage Or Hysterotomy,770,MS-DRG,,,,,,,inpatient,,,25214.53,17650.171,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6425.75,21802.0376,,,,
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,inpatient,,,8836.34,6185.438,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2946.91939,14456.3376,,,,
Cesarean Section With Sterilization With McC,783,MS-DRG,,,,,,,inpatient,,,17734.56,12414.192,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5914.47576,37326.288,,,,
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,inpatient,,,18719.59,13103.713,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6242.983265,21945.912,,,,
Cesarean Section With Sterilization Without Cc/McC,785,MS-DRG,,,,,,,inpatient,,,17872.29,12510.603,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5885.66803,17728.9736,,,,
Cesarean Section Without Sterilization With McC,786,MS-DRG,,,,,,,inpatient,,,21072.73,14750.911,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7027.755455,32742.5712,,,,
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,inpatient,,,18455.52,12918.864,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6154.91592,21516.3152,,,,
Cesarean Section Without Sterilization Without Cc/McC,788,MS-DRG,,,,,,,inpatient,,,17822.26,12475.582,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5943.72371,18338.92,,,,
Neonates- Died Or Transferred To Another Acute Care Facility,789,MS-DRG,,,,,,,inpatient,,,6500.45,4550.315,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2167.900075,36529.9128,,,,
Extreme Immaturity Or Respiratory Distress Syndrome- Neonate,790,MS-DRG,,,,,,,inpatient,,,71335.38,49934.766,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,120469.48,,,,
Prematurity With Major Problems,791,MS-DRG,,,,,,,inpatient,,,39411.64,27588.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,82273.8664,,,,
Prematurity Without Major Problems,792,MS-DRG,,,,,,,inpatient,,,10975.85,7683.095,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3660.445975,49642.7472,,,,
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,inpatient,,,8093.71,5665.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2699.252285,84513.0384,,,,
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,inpatient,,,5349.51,3744.657,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1784.061585,29913.7168,,,,
Normal Newborn,795,MS-DRG,,,,,,,inpatient,,,4927.51,3449.257,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1378.34,7947.23,,,,
Vaginal Delivery With Sterilization And/Or D&C With McC,796,MS-DRG,,,,,,,inpatient,,,17976.19,12583.333,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5995.059365,25869.0224,,,,
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,inpatient,,,23001.33,16100.931,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6655.835261,19619.6048,,,,
Vaginal Delivery With Sterilization And/Or D&C Without Cc/McC,798,MS-DRG,,,,,,,inpatient,,,14819.75,10373.825,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4942.386625,19619.6048,,,,
Splenic Procedures With McC,799,MS-DRG,,,,,,,inpatient,,,81427.43,56999.201,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,96345.188,,,,
Splenic Procedures Without Cc/McC,801,MS-DRG,,,,,,,inpatient,,,60652.11,42456.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,48521.688,,,,
Other O.R. Procedures Of The Blood And Blood Forming Organs With McC,802,MS-DRG,,,,,,,inpatient,,,94944.09,66460.863,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,75955.272,,,,
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/McC,804,MS-DRG,,,,,,,inpatient,,,22075,15452.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7362.0125,22401.852,,,,
Vaginal Delivery Without Sterilization Or D&C With McC,805,MS-DRG,,,,,,,inpatient,,,13956.78,9769.746,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4654.58613,20221.4456,,,,
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,inpatient,,,13483.61,9438.527,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4496.783935,14661.004,,,,
Vaginal Delivery Without Sterilization Or D&C Without Cc/McC,807,MS-DRG,,,,,,,inpatient,,,13157.23,9210.061,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4387.936205,12912.2208,,,,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With McC,808,MS-DRG,,,,,,,inpatient,,,31882.27,22317.589,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,46412.6656,,,,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With Cc,809,MS-DRG,,,,,,,inpatient,,,26642.66,18649.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,25096.964,,,,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders Without Cc/McC,810,MS-DRG,,,,,,,inpatient,,,85706.42,59994.494,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6951.04,68565.136,,,,
Red Blood Cell Disorders With McC,811,MS-DRG,,,,,,,inpatient,,,33080.94,23156.658,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,28507.3952,,,,
Red Blood Cell Disorders Without McC,812,MS-DRG,,,,,,,inpatient,,,21914.25,15339.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6364.97,18701.6456,,,,
Coagulation Disorders,813,MS-DRG,,,,,,,inpatient,,,31592.62,22114.834,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,31366.6456,,,,
Reticuloendothelial And Immunity Disorders With McC,814,MS-DRG,,,,,,,inpatient,,,15313.53,10719.471,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5107.062255,42357.8392,,,,
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,inpatient,,,14949.63,10464.741,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4985.701605,20590.2504,,,,
Other Antepartum Diagnoses With O.R. Procedures With McC,817,MS-DRG,,,,,,,inpatient,,,35079.77,24555.839,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,51371.2664,,,,
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,inpatient,,,56068.99,39248.293,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,44855.192,,,,
Other Antepartum Diagnoses With O.R. Procedures Without Cc/McC,819,MS-DRG,,,,,,,inpatient,,,15513.53,10859.471,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5173.762255,16545.556,,,,
Lymphoma And Leukemia With Major O.R. Procedures With McC,820,MS-DRG,,,,,,,inpatient,,,86514.51,60560.157,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,117974.9816,,,,
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,inpatient,,,70253.02,49177.114,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,56202.416,,,,
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/McC,822,MS-DRG,,,,,,,inpatient,,,27823.59,19476.513,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,23173.9104,,,,
Lymphoma And Non-Acute Leukemia With Other Procedures With McC,823,MS-DRG,,,,,,,inpatient,,,49236.57,34465.599,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,94819.3088,,,,
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/McC,825,MS-DRG,,,,,,,inpatient,,,56788.87,39752.209,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,45431.096,,,,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With McC,826,MS-DRG,,,,,,,inpatient,,,115032.85,80522.995,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,96764.6528,,,,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without Cc/McC,828,MS-DRG,,,,,,,inpatient,,,37373.35,26161.345,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,32479.1392,,,,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/McC,829,MS-DRG,,,,,,,inpatient,,,26899.5,18829.65,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,62486.0704,,,,
Other Antepartum Diagnoses Without O.R. Procedures With McC,831,MS-DRG,,,,,,,inpatient,,,8108.51,5675.957,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2704.188085,23321.8376,,,,
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,inpatient,,,9811.14,6867.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3272.01519,15143.2872,,,,
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/McC,833,MS-DRG,,,,,,,inpatient,,,8494.15,5945.905,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2832.799025,10533.2272,,,,
Acute Leukemia Without Major O.R. Procedures With McC,834,MS-DRG,,,,,,,inpatient,,,33540.42,23478.294,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,111997.1016,,,,
Acute Leukemia Without Major O.R. Procedures With Cc,835,MS-DRG,,,,,,,inpatient,,,15922.85,11145.995,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5310.270475,43279.8512,,,,
Lymphoma And Non-Acute Leukemia With McC,840,MS-DRG,,,,,,,inpatient,,,35119.86,24583.902,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,64630.0016,,,,
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,inpatient,,,17465.46,12225.822,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5824.73091,31771.9256,,,,
Lymphoma And Non-Acute Leukemia Without Cc/McC,842,MS-DRG,,,,,,,inpatient,,,22518.92,15763.244,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7510.05982,21313.6752,,,,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With McC,843,MS-DRG,,,,,,,inpatient,,,21080.37,14756.259,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7030.303395,38361.7784,,,,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,inpatient,,,11557.79,8090.453,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3854.522965,24217.5064,,,,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/McC,845,MS-DRG,,,,,,,inpatient,,,13919.38,9743.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4642.11323,16954.8888,,,,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With McC,846,MS-DRG,,,,,,,inpatient,,,22506.34,15754.438,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7505.86439,51746.1504,,,,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,inpatient,,,14849.65,10394.755,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4952.358275,25747.4384,,,,
Infectious And Parasitic Diseases With O.R. Procedures With McC,853,MS-DRG,,,,,,,inpatient,,,91139.43,63797.601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,101350.396,,,,
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,inpatient,,,41334.13,28933.891,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,40491.5248,,,,
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/McC,855,MS-DRG,,,,,,,inpatient,,,41292.75,28904.925,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,33034.2,,,,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With McC,856,MS-DRG,,,,,,,inpatient,,,65177.47,45624.229,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,91416.9832,,,,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,inpatient,,,33908.27,23735.789,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,44153.2296,,,,
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/McC,858,MS-DRG,,,,,,,inpatient,,,18266.15,12786.305,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6091.761025,26108.1376,,,,
Postoperative And Post-Traumatic Infections With McC,862,MS-DRG,,,,,,,inpatient,,,32409.02,22686.314,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,37257.3904,,,,
Postoperative And Post-Traumatic Infections Without McC,863,MS-DRG,,,,,,,inpatient,,,26972.96,18881.072,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7071.87,21578.368,,,,
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,inpatient,,,18759.94,13131.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6256.43999,18195.0456,,,,
Viral Illness With McC,865,MS-DRG,,,,,,,inpatient,,,22475.35,15732.745,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7495.529225,29907.6376,,,,
Viral Illness Without McC,866,MS-DRG,,,,,,,inpatient,,,13589.18,9512.426,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4531.99153,17927.5608,,,,
Other Infectious And Parasitic Diseases Diagnoses With McC,867,MS-DRG,,,,,,,inpatient,,,29124.07,20386.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,43450.0688,,,,
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,inpatient,,,22783.92,15948.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7598.43732,21277.2,,,,
Other Infectious And Parasitic Diseases Diagnoses Without Cc/McC,869,MS-DRG,,,,,,,inpatient,,,6491.58,4544.106,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2164.94193,14579.948,,,,
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,inpatient,,,165811.55,116068.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,140966.516,,,,
Septicemia Or Severe Sepsis Without Mv >96 Hours With McC,871,MS-DRG,,,,,,,inpatient,,,32860.99,23002.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,39764.0472,,,,
Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC,872,MS-DRG,,,,,,,inpatient,,,22133.41,15493.387,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7381.492235,20892.184,,,,
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,,,inpatient,,,167914.64,117540.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,134331.712,,,,
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,inpatient,,,22889.31,16022.517,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6248.48,19425.0704,,,,
Depressive Neuroses,881,MS-DRG,,,,,,,inpatient,,,44762.95,31334.065,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5798.441546,35810.36,,,,
Neuroses Except Depressive,882,MS-DRG,,,,,,,inpatient,,,10863.25,7604.275,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3622.893875,19491.9416,,,,
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,inpatient,,,35747.4,25023.18,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,33842.9064,,,,
Psychoses,885,MS-DRG,,,,,,,inpatient,,,20082.8,14057.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6697.6138,28562.108,,,,
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,inpatient,,,10508,7355.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3504.418,36402.2496,,,,
Alcohol- Drug Abuse Or Dependence- Left Ama,894,MS-DRG,,,,,,,inpatient,,,15836.23,11085.361,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3961.38,12668.984,,,,
Alcohol- Drug Abuse Or Dependence Without Rehabilitation Therapy With McC,896,MS-DRG,,,,,,,inpatient,,,35553.78,24887.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,36086.1312,,,,
Alcohol- Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC,897,MS-DRG,,,,,,,inpatient,,,18541.81,12979.267,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5972.81,17876.9008,,,,
Wound Debridements For Injuries With McC,901,MS-DRG,,,,,,,inpatient,,,46387.19,32471.033,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,89773.5728,,,,
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,inpatient,,,59864.86,41905.402,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,47891.888,,,,
Wound Debridements For Injuries Without Cc/McC,903,MS-DRG,,,,,,,inpatient,,,13693.85,9585.695,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4566.898975,24701.816,,,,
Skin Grafts For Injuries With Cc/McC,904,MS-DRG,,,,,,,inpatient,,,114417.1,80091.97,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,91533.68,,,,
Hand Procedures For Injuries,906,MS-DRG,,,,,,,inpatient,,,51389.12,35972.384,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,44224.1536,,,,
Other O.R. Procedures For Injuries With McC,907,MS-DRG,,,,,,,inpatient,,,48914.02,34239.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,80721.644,,,,
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,inpatient,,,44494.39,31146.073,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,40872.488,,,,
Other O.R. Procedures For Injuries Without Cc/McC,909,MS-DRG,,,,,,,inpatient,,,14125.93,9888.151,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4710.997655,25698.8048,,,,
Traumatic Injury With McC,913,MS-DRG,,,,,,,inpatient,,,57017.38,39912.166,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,45613.904,,,,
Traumatic Injury Without McC,914,MS-DRG,,,,,,,inpatient,,,28970.93,20279.651,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6429.37,23176.744,,,,
Allergic Reactions With McC,915,MS-DRG,,,,,,,inpatient,,,42664.44,29865.108,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,35214.7792,,,,
Allergic Reactions Without McC,916,MS-DRG,,,,,,,inpatient,,,12818.09,8972.663,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4274.833015,13455.296,,,,
Poisoning And Toxic Effects Of Drugs With McC,917,MS-DRG,,,,,,,inpatient,,,41573.69,29101.583,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,33258.952,,,,
Poisoning And Toxic Effects Of Drugs Without McC,918,MS-DRG,,,,,,,inpatient,,,19845.67,13891.969,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5723.92,17921.4816,,,,
Complications Of Treatment With McC,919,MS-DRG,,,,,,,inpatient,,,48229.35,33760.545,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,38583.48,,,,
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,inpatient,,,20650.21,14455.147,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6886.845035,20584.1712,,,,
Complications Of Treatment Without Cc/McC,921,MS-DRG,,,,,,,inpatient,,,18737.44,13116.208,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5002.55,14989.952,,,,
Other Injury- Poisoning And Toxic Effect Diagnoses With McC,922,MS-DRG,,,,,,,inpatient,,,42436.37,29705.459,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,34229.9488,,,,
Other Injury- Poisoning And Toxic Effect Diagnoses Without McC,923,MS-DRG,,,,,,,inpatient,,,18119.88,12683.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6042.97998,20665.2272,,,,
Non-Extensive Burns,935,MS-DRG,,,,,,,inpatient,,,6946.99,4862.893,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2316.821165,44505.8232,,,,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,inpatient,,,22686.24,15880.368,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7565.86104,42783.3832,,,,
Signs And Symptoms With McC,947,MS-DRG,,,,,,,inpatient,,,29399.47,20579.629,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,26061.5304,,,,
Signs And Symptoms Without McC,948,MS-DRG,,,,,,,inpatient,,,16042.18,11229.526,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5350.06703,16099.748,,,,
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,inpatient,,,5109.91,3576.937,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1704.154985,11487.6616,,,,
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,,,inpatient,,,149455.54,104618.878,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,138360.5656,,,,
Limb Reattachment- Hip And Femur Procedures For Multiple Significant Trauma,956,MS-DRG,,,,,,,inpatient,,,64530.82,45171.574,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,77453.0608,,,,
Other O.R. Procedures For Multiple Significant Trauma With McC,957,MS-DRG,,,,,,,inpatient,,,104697.23,73288.061,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,151244.4168,,,,
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,inpatient,,,68495.96,47947.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,83274.908,,,,
Other Multiple Significant Trauma With McC,963,MS-DRG,,,,,,,inpatient,,,43017.73,30112.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,55049.1824,,,,
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,inpatient,,,32958.94,23071.258,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,30400.0528,,,,
Hiv With Major Related Condition With McC,974,MS-DRG,,,,,,,inpatient,,,42445.87,29712.109,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,60508.304,,,,
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,,,inpatient,,,19415.36,13590.752,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6475.02256,28801.2232,,,,
Hiv With Major Related Condition Without Cc/McC,976,MS-DRG,,,,,,,inpatient,,,36673.45,25671.415,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6867.108649,29338.76,,,,
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,inpatient,,,53209.61,37246.727,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,42567.688,,,,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC,981,MS-DRG,,,,,,,inpatient,,,96543.58,67580.506,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,96341.1352,,,,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,inpatient,,,54470.12,38129.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,49616.404,,,,
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/McC,983,MS-DRG,,,,,,,inpatient,,,18703.75,13092.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6237.700625,33802.3784,,,,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC,987,MS-DRG,,,,,,,inpatient,,,51141.58,35799.106,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,70984.792,,,,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,inpatient,,,31104,21772.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,34773.024,,,,
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,,,inpatient,,,13700.33,9590.231,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4569.060055,10960.264,,,,
Ungroupable,999,MS-DRG,,,,,,,inpatient,,,28509.33,19956.531,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7771.48,22807.464,,,,
LIVER TRANSPLANT AND/OR INTESTINAL TRANSPLANT,001-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,154357.8,,,154357.8,127777.5356,154357.7988,case rate,,,
LIVER TRANSPLANT AND/OR INTESTINAL TRANSPLANT,001-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,173852.18,,,173852.18,127777.5356,173852.1792,case rate,,,
LIVER TRANSPLANT AND/OR INTESTINAL TRANSPLANT,001-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,207431.81,,,207431.81,173454.278,207431.8056,case rate,,,
LIVER TRANSPLANT AND/OR INTESTINAL TRANSPLANT,001-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,358797.58,,,358797.58,358797.5832,362921.9528,case rate,,,
HEART AND/OR LUNG TRANSPLANT,002-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,220807.17,,,220807.17,220807.1652,250859.2732,case rate,,,
HEART AND/OR LUNG TRANSPLANT,002-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,257571.28,,,257571.28,257571.282,266319.1256,case rate,,,
HEART AND/OR LUNG TRANSPLANT,002-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,347079.46,,,347079.46,312406.3616,347079.4584,case rate,,,
HEART AND/OR LUNG TRANSPLANT,002-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,561267.68,,,561267.68,561267.6828,723409.9688,case rate,,,
TRACHEOSTOMY WITH MV >96 HOURS WITH EXTENSIVE PROCEDURE,004-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,114506.68,,,114506.68,114506.676,149034.0552,case rate,,,
TRACHEOSTOMY WITH MV >96 HOURS WITH EXTENSIVE PROCEDURE,004-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,171472.56,,,171472.56,149034.0552,171472.56,case rate,,,
TRACHEOSTOMY WITH MV >96 HOURS WITH EXTENSIVE PROCEDURE,004-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,249412.59,,,249412.59,208783.6792,249412.5876,case rate,,,
TRACHEOSTOMY WITH MV >96 HOURS WITH EXTENSIVE PROCEDURE,004-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,364464.18,,,364464.18,364464.1764,374670.7772,case rate,,,
TRACHEOSTOMY WITH MV >96 HOURS WITHOUT EXTENSIVE PROCEDURE,005-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,107510.3,,,107510.3,107510.2956,118091.5452,case rate,,,
TRACHEOSTOMY WITH MV >96 HOURS WITHOUT EXTENSIVE PROCEDURE,005-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,129466.78,,,129466.78,121149.5152,129466.782,case rate,,,
TRACHEOSTOMY WITH MV >96 HOURS WITHOUT EXTENSIVE PROCEDURE,005-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,176871.7,,,176871.7,176871.696,191412.3364,case rate,,,
TRACHEOSTOMY WITH MV >96 HOURS WITHOUT EXTENSIVE PROCEDURE,005-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,240189.06,,,240189.06,240189.0636,285883.914,case rate,,,
PANCREAS TRANSPLANT,006-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,152030.67,,,152030.67,104808.5528,152030.6712,case rate,,,
PANCREAS TRANSPLANT,006-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,193411.55,,,193411.55,104808.5528,193411.5492,case rate,,,
PANCREAS TRANSPLANT,006-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,222799.35,,,222799.35,151637.9944,222799.3464,case rate,,,
PANCREAS TRANSPLANT,006-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,316859.29,,,316859.29,158369.6748,316859.2944,case rate,,,
ALLOGENEIC BONE MARROW TRANSPLANT,007-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,151033.33,,,151033.33,151033.3308,151033.3308,case rate,,,
ALLOGENEIC BONE MARROW TRANSPLANT,007-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,169620.36,,,169620.36,169620.3564,169620.3564,case rate,,,
ALLOGENEIC BONE MARROW TRANSPLANT,007-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,216847.8,,,216847.8,216847.7988,216847.7988,case rate,,,
ALLOGENEIC BONE MARROW TRANSPLANT,007-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,367958.62,,,367958.62,367958.6172,367958.6172,case rate,,,
AUTOLOGOUS BONE MARROW TRANSPLANT,008-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,73690.71,,,73690.71,73690.7076,73690.7076,case rate,,,
AUTOLOGOUS BONE MARROW TRANSPLANT,008-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,98064.31,,,98064.31,98064.3072,98064.3072,case rate,,,
AUTOLOGOUS BONE MARROW TRANSPLANT,008-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,117206.24,,,117206.24,117206.244,117206.244,case rate,,,
AUTOLOGOUS BONE MARROW TRANSPLANT,008-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,186135.21,,,186135.21,186135.2136,186135.2136,case rate,,,
EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO),009-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,98439.25,,,98439.25,98439.2472,98439.2472,case rate,,,
EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO),009-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,119948.31,,,119948.31,119948.3052,119948.3052,case rate,,,
EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO),009-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,164456.18,,,164456.18,164456.1828,164456.1828,case rate,,,
EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO),009-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,356820.4,,,356820.4,356820.3996,356820.3996,case rate,,,
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,011-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,67231.74,,,67231.74,67231.7412,67231.7412,case rate,,,
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,011-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,99759.04,,,99759.04,99759.036,99759.036,case rate,,,
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,011-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,188332.36,,,188332.36,188332.362,188332.362,case rate,,,
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,011-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,382613.77,,,382613.77,382613.772,382613.772,case rate,,,
OPEN CRANIOTOMY FOR TRAUMA,020-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,51019.34,,,51019.34,37019.0592,51019.3356,case rate,,,
OPEN CRANIOTOMY FOR TRAUMA,020-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,61290.19,,,61290.19,46758.9528,61290.192,case rate,,,
OPEN CRANIOTOMY FOR TRAUMA,020-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,83861.58,,,83861.58,73441.0368,83861.58,case rate,,,
OPEN CRANIOTOMY FOR TRAUMA,020-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,131104.02,,,131104.02,131104.02,138697.08,case rate,,,
OPEN CRANIOTOMY EXCEPT TRAUMA,021-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,47827.35,,,47827.35,39268.4812,47827.3464,case rate,,,
OPEN CRANIOTOMY EXCEPT TRAUMA,021-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,60880.26,,,60880.26,55503.7104,60880.2576,case rate,,,
OPEN CRANIOTOMY EXCEPT TRAUMA,021-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,91082.92,,,91082.92,89808.9508,91082.9244,case rate,,,
OPEN CRANIOTOMY EXCEPT TRAUMA,021-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,142107.26,,,142107.26,142107.2592,150128.7048,case rate,,,
VENTRICULAR SHUNT PROCEDURES,022-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,32607.28,,,32607.28,26429.1536,32607.282,case rate,,,
VENTRICULAR SHUNT PROCEDURES,022-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38671.31,,,38671.31,33793.16,38671.3116,case rate,,,
VENTRICULAR SHUNT PROCEDURES,022-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53771.4,,,53771.4,53771.3952,55395.904,case rate,,,
VENTRICULAR SHUNT PROCEDURES,022-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,108595.12,,,108595.12,108595.122,111693.65,case rate,,,
SPINAL PROCEDURES,023-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38336.37,,,38336.37,34021.212,38336.3652,case rate,,,
SPINAL PROCEDURES,023-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,52556.59,,,52556.59,45734.792,52556.5896,case rate,,,
SPINAL PROCEDURES,023-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,88535.83,,,88535.83,88535.832,89072.9648,case rate,,,
SPINAL PROCEDURES,023-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,144081.94,,,144081.94,144081.9432,167558.0972,case rate,,,
OPEN EXTRACRANIAL VASCULAR PROCEDURES,024-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25615.9,,,25615.9,25615.9008,31133.2444,case rate,,,
OPEN EXTRACRANIAL VASCULAR PROCEDURES,024-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,31957.39,,,31957.39,31957.386,44169.526,case rate,,,
OPEN EXTRACRANIAL VASCULAR PROCEDURES,024-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,55846.06,,,55846.06,55846.0632,76507.2996,case rate,,,
OPEN EXTRACRANIAL VASCULAR PROCEDURES,024-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,95024.79,,,95024.79,95024.7936,140844.9152,case rate,,,
OTHER NERVOUS SYSTEM AND RELATED PROCEDURES,026-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,30210.17,,,30210.17,25431.9444,30210.1656,case rate,,,
OTHER NERVOUS SYSTEM AND RELATED PROCEDURES,026-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38273.88,,,38273.88,37234.672,38273.8752,case rate,,,
OTHER NERVOUS SYSTEM AND RELATED PROCEDURES,026-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,58518.14,,,58518.14,55321.2688,58518.1356,case rate,,,
OTHER NERVOUS SYSTEM AND RELATED PROCEDURES,026-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,109250.02,,,109250.02,109250.0172,130111.9588,case rate,,,
OTHER OPEN CRANIOTOMY,027-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,40166.07,,,40166.07,40166.0724,40166.0724,case rate,,,
OTHER OPEN CRANIOTOMY,027-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,46755.02,,,46755.02,46755.018,46755.018,case rate,,,
OTHER OPEN CRANIOTOMY,027-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,75970.34,,,75970.34,75970.3428,75970.3428,case rate,,,
OTHER OPEN CRANIOTOMY,027-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,125259.96,,,125259.96,125259.9552,125259.9552,case rate,,,
OTHER PERCUTANEOUS INTRACRANIAL PROCEDURES,029-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,45507.72,,,45507.72,45507.7176,45507.7176,case rate,,,
OTHER PERCUTANEOUS INTRACRANIAL PROCEDURES,029-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,47782.35,,,47782.35,47782.3536,47782.3536,case rate,,,
OTHER PERCUTANEOUS INTRACRANIAL PROCEDURES,029-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,61482.66,,,61482.66,61482.6612,61482.6612,case rate,,,
OTHER PERCUTANEOUS INTRACRANIAL PROCEDURES,029-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,101551.25,,,101551.25,101551.2492,101551.2492,case rate,,,
PERCUTANEOUS INTRACRANIAL AND EXTRACRANIAL VASCULAR PROCEDURES,030-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,45745.18,,,45745.18,45745.1796,45745.1796,case rate,,,
PERCUTANEOUS INTRACRANIAL AND EXTRACRANIAL VASCULAR PROCEDURES,030-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,61297.69,,,61297.69,61297.6908,61297.6908,case rate,,,
PERCUTANEOUS INTRACRANIAL AND EXTRACRANIAL VASCULAR PROCEDURES,030-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,83981.56,,,83981.56,83981.5608,83981.5608,case rate,,,
PERCUTANEOUS INTRACRANIAL AND EXTRACRANIAL VASCULAR PROCEDURES,030-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,110877.26,,,110877.26,110877.2568,110877.2568,case rate,,,
SPINAL DISORDERS AND INJURIES,040-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21426.57,,,21426.57,16915.2388,21426.5712,case rate,,,
SPINAL DISORDERS AND INJURIES,040-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,30135.18,,,30135.18,26626.1076,30135.1776,case rate,,,
SPINAL DISORDERS AND INJURIES,040-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,41848.3,,,41848.3,41848.3032,47611.038,case rate,,,
SPINAL DISORDERS AND INJURIES,040-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,67841.64,,,67841.64,56308.112,67841.6436,case rate,,,
NERVOUS SYSTEM MALIGNANCY,041-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17257.24,,,17257.24,15565.5856,17257.2384,case rate,,,
NERVOUS SYSTEM MALIGNANCY,041-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19234.42,,,19234.42,17962.2048,19234.422,case rate,,,
NERVOUS SYSTEM MALIGNANCY,041-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25408.43,,,25408.43,25408.434,30556.8948,case rate,,,
NERVOUS SYSTEM MALIGNANCY,041-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,37591.48,,,37591.48,37591.4844,56625.3116,case rate,,,
DEGENERATIVE NERVOUS SYSTEM DISORDERS EXCEPT MULTIPLE SCLEROSIS,042-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16069.93,,,16069.93,13210.4304,16069.9284,case rate,,,
DEGENERATIVE NERVOUS SYSTEM DISORDERS EXCEPT MULTIPLE SCLEROSIS,042-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20396.74,,,20396.74,18300.1364,20396.736,case rate,,,
DEGENERATIVE NERVOUS SYSTEM DISORDERS EXCEPT MULTIPLE SCLEROSIS,042-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27443.11,,,27443.11,27443.1084,37850.4124,case rate,,,
DEGENERATIVE NERVOUS SYSTEM DISORDERS EXCEPT MULTIPLE SCLEROSIS,042-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48864.68,,,48864.68,40290.5688,48864.6804,case rate,,,
"MULTIPLE SCLEROSIS, OTHER DEMYELINATING DISEASE AND INFLAMMATORY NEUROPATHIES",043-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19646.86,,,19646.86,16251.8148,19646.856,case rate,,,
"MULTIPLE SCLEROSIS, OTHER DEMYELINATING DISEASE AND INFLAMMATORY NEUROPATHIES",043-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26455.77,,,26455.77,22282.7536,26455.7664,case rate,,,
"MULTIPLE SCLEROSIS, OTHER DEMYELINATING DISEASE AND INFLAMMATORY NEUROPATHIES",043-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,41010.94,,,41010.94,41010.9372,46814.9292,case rate,,,
"MULTIPLE SCLEROSIS, OTHER DEMYELINATING DISEASE AND INFLAMMATORY NEUROPATHIES",043-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,74773.03,,,74773.03,74773.0344,122685.7564,case rate,,,
INTRACRANIAL HEMORRHAGE,044-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17877.14,,,17877.14,17877.1392,20734.0732,case rate,,,
INTRACRANIAL HEMORRHAGE,044-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25023.5,,,25023.5,25023.4956,30332.9892,case rate,,,
INTRACRANIAL HEMORRHAGE,044-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,32767.26,,,32767.26,32767.2564,43858.546,case rate,,,
INTRACRANIAL HEMORRHAGE,044-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36509.16,,,36509.16,36509.1576,57608.0084,case rate,,,
CVA AND PRECEREBRAL OCCLUSION WITH INFARCTION,045-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19026.96,,,19026.96,16529.6236,19026.9552,case rate,,,
CVA AND PRECEREBRAL OCCLUSION WITH INFARCTION,045-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23536.23,,,23536.23,23039.4716,23536.2336,case rate,,,
CVA AND PRECEREBRAL OCCLUSION WITH INFARCTION,045-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,31504.96,,,31504.96,31504.9584,35685.9916,case rate,,,
CVA AND PRECEREBRAL OCCLUSION WITH INFARCTION,045-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,47362.42,,,47362.42,47362.4208,70907.5864,case rate,,,
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION,046-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15617.5,,,15617.5,13092.258,15617.5008,case rate,,,
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION,046-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19691.85,,,19691.85,17589.0288,19691.8488,case rate,,,
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION,046-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24326.11,,,24326.11,22925.4456,24326.1072,case rate,,,
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION,046-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42695.67,,,42695.67,23955.826,42695.6676,case rate,,,
TRANSIENT ISCHEMIA,047-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15922.45,,,15922.45,10643.8088,15922.452,case rate,,,
TRANSIENT ISCHEMIA,047-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18172.09,,,18172.09,13121.2828,18172.092,case rate,,,
TRANSIENT ISCHEMIA,047-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22821.35,,,22821.35,18152.9392,22821.348,case rate,,,
TRANSIENT ISCHEMIA,047-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,37126.56,,,37126.56,18586.238,37126.5588,case rate,,,
"PERIPHERAL, CRANIAL AND AUTONOMIC NERVE DISORDERS",048-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14830.13,,,14830.13,11481.3816,14830.1268,case rate,,,
"PERIPHERAL, CRANIAL AND AUTONOMIC NERVE DISORDERS",048-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17077.27,,,17077.27,15327.1676,17077.2672,case rate,,,
"PERIPHERAL, CRANIAL AND AUTONOMIC NERVE DISORDERS",048-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23176.29,,,23176.29,22931.6652,23176.2912,case rate,,,
"PERIPHERAL, CRANIAL AND AUTONOMIC NERVE DISORDERS",048-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42970.62,,,42970.62,42970.6236,72236.5076,case rate,,,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,049-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22721.36,,,22721.36,22721.364,24148.6336,case rate,,,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,049-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,45070.29,,,45070.29,45070.2876,51604.0212,case rate,,,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,049-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,50209.47,,,50209.47,50209.4652,66352.766,case rate,,,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,049-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,84041.55,,,84041.55,84041.5512,123718.21,case rate,,,
NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS,050-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15742.48,,,15742.48,15559.366,15742.4808,case rate,,,
NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS,050-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27355.62,,,27355.62,27355.6224,28040.03,case rate,,,
NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS,050-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,43388.06,,,43388.06,43388.0568,45705.7672,case rate,,,
NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS,050-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,88873.28,,,88873.28,88873.278,110843.638,case rate,,,
VIRAL MENINGITIS,051-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11545.65,,,11545.65,11545.6524,12795.7904,case rate,,,
VIRAL MENINGITIS,051-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17389.72,,,17389.72,16237.3024,17389.7172,case rate,,,
VIRAL MENINGITIS,051-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28900.38,,,28900.38,28900.3752,31446.2976,case rate,,,
VIRAL MENINGITIS,051-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,57468.3,,,57468.3,35885.0188,57468.3036,case rate,,,
ALTERATION IN CONSCIOUSNESS,052-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13975.26,,,13975.26,11512.4796,13975.2636,case rate,,,
ALTERATION IN CONSCIOUSNESS,052-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16542.35,,,16542.35,15068.0176,16542.3528,case rate,,,
ALTERATION IN CONSCIOUSNESS,052-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21504.06,,,21504.06,20779.6836,21504.0588,case rate,,,
ALTERATION IN CONSCIOUSNESS,052-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42055.77,,,42055.77,42055.77,47210.9104,case rate,,,
SEIZURE,053-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11838.11,,,11838.11,10117.216,11838.1056,case rate,,,
SEIZURE,053-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15097.58,,,15097.58,12068.0972,15097.584,case rate,,,
SEIZURE,053-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19671.85,,,19671.85,16998.1668,19671.852,case rate,,,
SEIZURE,053-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,44760.34,,,44760.34,44760.3372,55497.4908,case rate,,,
MIGRAINE AND OTHER HEADACHES,054-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13282.87,,,13282.87,10202.2172,13282.8744,case rate,,,
MIGRAINE AND OTHER HEADACHES,054-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16172.41,,,16172.41,12692.1304,16172.412,case rate,,,
MIGRAINE AND OTHER HEADACHES,054-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20129.28,,,20129.28,16376.2068,20129.2788,case rate,,,
MIGRAINE AND OTHER HEADACHES,054-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,31434.97,,,31434.97,16676.8208,31434.9696,case rate,,,
HEAD TRAUMA WITH COMA > 1 HOUR OR HEMORRHAGE,055-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15257.56,,,15257.56,11545.6508,15257.5584,case rate,,,
HEAD TRAUMA WITH COMA > 1 HOUR OR HEMORRHAGE,055-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21491.56,,,21491.56,18192.33,21491.5608,case rate,,,
HEAD TRAUMA WITH COMA > 1 HOUR OR HEMORRHAGE,055-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,32207.35,,,32207.35,31114.5856,32207.346,case rate,,,
HEAD TRAUMA WITH COMA > 1 HOUR OR HEMORRHAGE,055-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,56905.89,,,56905.89,56905.8936,70140.5024,case rate,,,
"BRAIN CONTUSION OR LACERATION AND COMPLICATED SKULL FRACTURE, COMA < 1 HOUR OR NO COMA",056-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14505.18,,,14505.18,10766.1276,14505.1788,case rate,,,
"BRAIN CONTUSION OR LACERATION AND COMPLICATED SKULL FRACTURE, COMA < 1 HOUR OR NO COMA",056-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20704.19,,,20704.19,16618.7712,20704.1868,case rate,,,
"BRAIN CONTUSION OR LACERATION AND COMPLICATED SKULL FRACTURE, COMA < 1 HOUR OR NO COMA",056-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28507.94,,,28507.94,28507.938,29578.3444,case rate,,,
"BRAIN CONTUSION OR LACERATION AND COMPLICATED SKULL FRACTURE, COMA < 1 HOUR OR NO COMA",056-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,45660.19,,,45660.19,45660.1932,78864.528,case rate,,,
"CONCUSSION, CLOSED SKULL FRACTURE NOS, AND UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HOUR OR NO COMA",057-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13010.42,,,13010.42,8228.5308,13010.418,case rate,,,
"CONCUSSION, CLOSED SKULL FRACTURE NOS, AND UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HOUR OR NO COMA",057-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19389.4,,,19389.4,11193.2068,19389.3972,case rate,,,
"CONCUSSION, CLOSED SKULL FRACTURE NOS, AND UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HOUR OR NO COMA",057-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28555.43,,,28555.43,20076.8688,28555.4304,case rate,,,
"CONCUSSION, CLOSED SKULL FRACTURE NOS, AND UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HOUR OR NO COMA",057-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,47197.45,,,47197.45,47197.4472,61238.1816,case rate,,,
OTHER DISORDERS OF NERVOUS SYSTEM,058-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18864.48,,,18864.48,11164.182,18864.4812,case rate,,,
OTHER DISORDERS OF NERVOUS SYSTEM,058-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25313.45,,,25313.45,16231.0828,25313.4492,case rate,,,
OTHER DISORDERS OF NERVOUS SYSTEM,058-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,33162.19,,,33162.19,26211.4676,33162.1932,case rate,,,
OTHER DISORDERS OF NERVOUS SYSTEM,058-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,46145.12,,,46145.12,46145.1156,70246.2356,case rate,,,
ANOXIC AND OTHER SEVERE BRAIN DAMAGE,059-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12642.98,,,12642.98,12642.9768,12642.9768,case rate,,,
ANOXIC AND OTHER SEVERE BRAIN DAMAGE,059-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20764.18,,,20764.18,20764.1772,20764.1772,case rate,,,
ANOXIC AND OTHER SEVERE BRAIN DAMAGE,059-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,29290.31,,,29290.31,29290.3128,29290.3128,case rate,,,
ANOXIC AND OTHER SEVERE BRAIN DAMAGE,059-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,40541.01,,,40541.01,40541.0124,40541.0124,case rate,,,
ORBIT AND EYE PROCEDURES,073-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22073.97,,,22073.97,13662.388,22073.9676,case rate,,,
ORBIT AND EYE PROCEDURES,073-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28020.52,,,28020.52,17539.272,28020.516,case rate,,,
ORBIT AND EYE PROCEDURES,073-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,43847.98,,,43847.98,43847.9832,51100.2336,case rate,,,
ORBIT AND EYE PROCEDURES,073-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,84576.47,,,84576.47,53418.0712,84576.4656,case rate,,,
EYE INFECTIONS AND OTHER EYE DISORDERS,082-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13182.89,,,13182.89,10148.314,13182.8904,case rate,,,
EYE INFECTIONS AND OTHER EYE DISORDERS,082-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16199.91,,,16199.91,12304.442,16199.9076,case rate,,,
EYE INFECTIONS AND OTHER EYE DISORDERS,082-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23576.23,,,23576.23,21273.1052,23576.2272,case rate,,,
EYE INFECTIONS AND OTHER EYE DISORDERS,082-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,46580.05,,,46580.05,21870.1868,46580.046,case rate,,,
MAJOR CRANIAL OR FACIAL BONE PROCEDURES,089-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,37973.92,,,37973.92,28266.0088,37973.9232,case rate,,,
MAJOR CRANIAL OR FACIAL BONE PROCEDURES,089-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,50826.87,,,50826.87,44826.7304,50826.8664,case rate,,,
MAJOR CRANIAL OR FACIAL BONE PROCEDURES,089-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,92847.64,,,92847.64,78988.92,92847.642,case rate,,,
MAJOR CRANIAL OR FACIAL BONE PROCEDURES,089-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,133693.61,,,133693.61,133693.6056,141363.2152,case rate,,,
OTHER MAJOR HEAD AND NECK PROCEDURES,091-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,35919.25,,,35919.25,27668.9272,35919.252,case rate,,,
OTHER MAJOR HEAD AND NECK PROCEDURES,091-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53918.87,,,53918.87,53918.8716,59065.468,case rate,,,
OTHER MAJOR HEAD AND NECK PROCEDURES,091-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,95992.14,,,95992.14,76389.1272,95992.1388,case rate,,,
OTHER MAJOR HEAD AND NECK PROCEDURES,091-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,150393.43,,,150393.43,85886.4564,150393.4332,case rate,,,
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES,092-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,30647.6,,,30647.6,21801.7712,30647.5956,case rate,,,
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES,092-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,39458.69,,,39458.69,28288.814,39458.6856,case rate,,,
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES,092-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,61860.1,,,61860.1,45179.1744,61860.1008,case rate,,,
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES,092-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,118975.96,,,118975.96,118975.9608,152450.6888,case rate,,,
CLEFT LIP AND PALATE REPAIR,095-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19584.37,,,19584.37,14862.7708,19584.366,case rate,,,
CLEFT LIP AND PALATE REPAIR,095-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22621.38,,,22621.38,18803.924,22621.38,case rate,,,
CLEFT LIP AND PALATE REPAIR,095-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36556.65,,,36556.65,28742.8448,36556.65,case rate,,,
CLEFT LIP AND PALATE REPAIR,095-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,52189.15,,,52189.15,52189.1484,52731.842,case rate,,,
TONSIL AND ADENOID PROCEDURES,097-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12712.97,,,12712.97,10038.4344,12712.9656,case rate,,,
TONSIL AND ADENOID PROCEDURES,097-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18422.05,,,18422.05,14317.5192,18422.052,case rate,,,
TONSIL AND ADENOID PROCEDURES,097-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28332.97,,,28332.97,28332.966,30664.7012,case rate,,,
TONSIL AND ADENOID PROCEDURES,097-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,65079.59,,,65079.59,65079.5856,82393.1144,case rate,,,
"OTHER EAR, NOSE, MOUTH, THROAT, CRANIOFACIAL, AND NECK PROCEDURES",098-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20329.25,,,20329.25,14195.2004,20329.2468,case rate,,,
"OTHER EAR, NOSE, MOUTH, THROAT, CRANIOFACIAL, AND NECK PROCEDURES",098-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28148,,,28148,20219.9196,28147.9956,case rate,,,
"OTHER EAR, NOSE, MOUTH, THROAT, CRANIOFACIAL, AND NECK PROCEDURES",098-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,47334.93,,,47334.93,38629.9356,47334.9252,case rate,,,
"OTHER EAR, NOSE, MOUTH, THROAT, CRANIOFACIAL, AND NECK PROCEDURES",098-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,80754.58,,,80754.58,80754.5772,86276.218,case rate,,,
"EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL MALIGNANCIES",110-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17174.75,,,17174.75,7804.554759,17174.7516,case rate,,,
"EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL MALIGNANCIES",110-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19644.36,,,19644.36,10054.75053,19969.08136,case rate,,,
"EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL MALIGNANCIES",110-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28457.95,,,28457.95,18364.0221,36768.202,case rate,,,
"EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL MALIGNANCIES",110-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,46340.08,,,46340.08,29642.21606,75209.4764,case rate,,,
VERTIGO AND OTHER LABYRINTH DISORDERS,111-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13335.37,,,13335.37,4173.810074,13335.366,case rate,,,
VERTIGO AND OTHER LABYRINTH DISORDERS,111-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15320.05,,,15320.05,5069.434998,15320.0484,case rate,,,
VERTIGO AND OTHER LABYRINTH DISORDERS,111-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18497.04,,,18497.04,7409.93549,18497.04,case rate,,,
VERTIGO AND OTHER LABYRINTH DISORDERS,111-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,32429.81,,,32429.81,16098.398,32429.8104,case rate,,,
INFECTIONS OF UPPER RESPIRATORY TRACT,113-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,8018.72,,,8018.72,3541.677013,8046.0892,case rate,,,
INFECTIONS OF UPPER RESPIRATORY TRACT,113-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11833.11,,,11833.11,5316.845198,11833.1064,case rate,,,
INFECTIONS OF UPPER RESPIRATORY TRACT,113-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17242.24,,,17242.24,9272.934296,17242.2408,case rate,,,
INFECTIONS OF UPPER RESPIRATORY TRACT,113-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28197.99,,,28197.99,20706.99669,43255.2448,case rate,,,
DENTAL DISEASES AND DISORDERS,114-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,9488.48,,,9488.48,4800.994931,9924.4084,case rate,,,
DENTAL DISEASES AND DISORDERS,114-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13095.4,,,13095.4,5801.76919,13095.4044,case rate,,,
DENTAL DISEASES AND DISORDERS,114-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21031.63,,,21031.63,12922.23475,24874.2536,case rate,,,
DENTAL DISEASES AND DISORDERS,114-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36811.61,,,36811.61,22504.43179,51689.32038,case rate,,,
"OTHER EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL DIAGNOSES",115-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11040.73,,,11040.73,5154.791517,11040.7332,case rate,,,
"OTHER EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL DIAGNOSES",115-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15257.56,,,15257.56,7210.770279,15257.5584,case rate,,,
"OTHER EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL DIAGNOSES",115-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23088.81,,,23088.81,11860.84499,23439.22188,case rate,,,
"OTHER EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL DIAGNOSES",115-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42233.24,,,42233.24,23846.63213,54355.1576,case rate,,,
MAJOR RESPIRATORY AND CHEST PROCEDURES,120-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,44865.32,,,44865.32,16750.90759,44865.3204,case rate,,,
MAJOR RESPIRATORY AND CHEST PROCEDURES,120-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,55086.18,,,55086.18,22197.64314,55086.1848,case rate,,,
MAJOR RESPIRATORY AND CHEST PROCEDURES,120-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,74813.03,,,74813.03,35911.59053,74813.028,case rate,,,
MAJOR RESPIRATORY AND CHEST PROCEDURES,120-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,130499.12,,,130499.12,76282.74992,130499.1168,case rate,,,
OTHER RESPIRATORY AND CHEST PROCEDURES,121-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,32674.77,,,32674.77,12586.99393,32674.7712,case rate,,,
OTHER RESPIRATORY AND CHEST PROCEDURES,121-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42243.24,,,42243.24,16524.52726,42243.24,case rate,,,
OTHER RESPIRATORY AND CHEST PROCEDURES,121-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,64252.22,,,64252.22,32257.34188,64252.218,case rate,,,
OTHER RESPIRATORY AND CHEST PROCEDURES,121-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,106700.43,,,106700.43,50793.31406,125575.7972,case rate,,,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT > 96 HOURS,130-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,78087.5,,,78087.5,44137.97968,78087.504,case rate,,,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT > 96 HOURS,130-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,78105,,,78105,44144.16494,78105.0012,case rate,,,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT > 96 HOURS,130-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,95607.2,,,95607.2,50414.77645,95607.2004,case rate,,,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT > 96 HOURS,130-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,123842.68,,,123842.68,64377.37109,125901.2896,case rate,,,
CYSTIC FIBROSIS - PULMONARY DISEASE,131-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25918.35,,,25918.35,18351.65159,28610.16,case rate,,,
CYSTIC FIBROSIS - PULMONARY DISEASE,131-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36466.66,,,36466.66,30617.01225,37344.57067,case rate,,,
CYSTIC FIBROSIS - PULMONARY DISEASE,131-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48574.73,,,48574.73,33589.6458,52937.0888,case rate,,,
CYSTIC FIBROSIS - PULMONARY DISEASE,131-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,63052.41,,,63052.41,47173.70283,71140.134,case rate,,,
BPD AND OTHER CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,132-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,9368.5,,,9368.5,6492.043648,12236.0264,case rate,,,
BPD AND OTHER CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,132-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12300.53,,,12300.53,9144.280992,16260.1076,case rate,,,
BPD AND OTHER CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,132-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20664.19,,,20664.19,18082.29561,27318.5564,case rate,,,
BPD AND OTHER CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,132-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,32922.23,,,32922.23,27233.67777,49773.3856,case rate,,,
RESPIRATORY FAILURE,133-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10733.28,,,10733.28,6645.437972,19104.538,case rate,,,
RESPIRATORY FAILURE,133-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17719.66,,,17719.66,7074.694669,19143.9288,case rate,,,
RESPIRATORY FAILURE,133-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26685.73,,,26685.73,12283.91643,28336.4976,case rate,,,
RESPIRATORY FAILURE,133-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,44045.45,,,44045.45,20103.3158,44045.4516,case rate,,,
PULMONARY EMBOLISM,134-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14002.76,,,14002.76,4556.058833,14609.8404,case rate,,,
PULMONARY EMBOLISM,134-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18234.58,,,18234.58,6642.96387,19386.4932,case rate,,,
PULMONARY EMBOLISM,134-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26305.79,,,26305.79,10252.67869,31292.8808,case rate,,,
PULMONARY EMBOLISM,134-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,40041.09,,,40041.09,17673.74764,52999.2848,case rate,,,
MAJOR CHEST AND RESPIRATORY TRAUMA,135-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16967.28,,,16967.28,6071.446308,16967.2848,case rate,,,
MAJOR CHEST AND RESPIRATORY TRAUMA,135-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19744.34,,,19744.34,7148.917729,19744.3404,case rate,,,
MAJOR CHEST AND RESPIRATORY TRAUMA,135-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28322.97,,,28322.97,10658.43142,28322.9676,case rate,,,
MAJOR CHEST AND RESPIRATORY TRAUMA,135-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,47714.86,,,47714.86,19730.96345,47714.8644,case rate,,,
RESPIRATORY MALIGNANCY,136-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14737.64,,,14737.64,6234.73704,16070.80662,case rate,,,
RESPIRATORY MALIGNANCY,136-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20394.24,,,20394.24,8144.743784,20394.2364,case rate,,,
RESPIRATORY MALIGNANCY,136-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28992.86,,,28992.86,12849.24874,32335.7004,case rate,,,
RESPIRATORY MALIGNANCY,136-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,41100.92,,,41100.92,20995.22957,47550.9152,case rate,,,
MAJOR RESPIRATORY INFECTIONS AND INFLAMMATIONS,137-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15065.09,,,15065.09,5451.683757,15065.0892,case rate,,,
MAJOR RESPIRATORY INFECTIONS AND INFLAMMATIONS,137-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19199.43,,,19199.43,7466.839836,21370.5456,case rate,,,
MAJOR RESPIRATORY INFECTIONS AND INFLAMMATIONS,137-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26170.81,,,26170.81,9037.894606,34763.4176,case rate,,,
MAJOR RESPIRATORY INFECTIONS AND INFLAMMATIONS,137-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,37803.95,,,37803.95,15549.73107,54154.0572,case rate,,,
BRONCHIOLITIS AND RSV PNEUMONIA,138-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7101.36,,,7101.36,3455.083443,10110.9964,case rate,,,
BRONCHIOLITIS AND RSV PNEUMONIA,138-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10170.87,,,10170.87,5805.480343,13067.3796,case rate,,,
BRONCHIOLITIS AND RSV PNEUMONIA,138-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16112.42,,,16112.42,7324.578971,28295.0336,case rate,,,
BRONCHIOLITIS AND RSV PNEUMONIA,138-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,34254.52,,,34254.52,13445.50732,62687.3484,case rate,,,
OTHER PNEUMONIA,139-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11010.74,,,11010.74,4274.011205,11010.738,case rate,,,
OTHER PNEUMONIA,139-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15272.56,,,15272.56,5524.669766,15272.556,case rate,,,
OTHER PNEUMONIA,139-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21169.11,,,21169.11,8252.367221,23595.0892,case rate,,,
OTHER PNEUMONIA,139-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,31839.9,,,31839.9,13963.83169,44984.2936,case rate,,,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE,140-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13080.41,,,13080.41,4930.885286,13080.4068,case rate,,,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE,140-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16109.92,,,16109.92,6179.069745,16109.922,case rate,,,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE,140-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19534.37,,,19534.37,7526.218284,20987.0036,case rate,,,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE,140-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28890.38,,,28890.38,12126.81095,40850.3328,case rate,,,
ASTHMA,141-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,9248.52,,,9248.52,4437.301937,9818.6752,case rate,,,
ASTHMA,141-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13912.77,,,13912.77,5702.80511,13912.7736,case rate,,,
ASTHMA,141-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16732.32,,,16732.32,7042.531343,19440.3964,case rate,,,
ASTHMA,141-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,29405.29,,,29405.29,11905.37882,34247.1908,case rate,,,
INTERSTITIAL AND ALVEOLAR LUNG DISEASES,142-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15147.58,,,15147.58,6514.310566,15147.576,case rate,,,
INTERSTITIAL AND ALVEOLAR LUNG DISEASES,142-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17837.15,,,17837.15,8622.24547,17837.1456,case rate,,,
INTERSTITIAL AND ALVEOLAR LUNG DISEASES,142-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24151.14,,,24151.14,11563.95275,27590.1456,case rate,,,
INTERSTITIAL AND ALVEOLAR LUNG DISEASES,142-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36414.17,,,36414.17,17954.55821,57668.1312,case rate,,,
"OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS, SYMPTOMS AND MISCELLANEOUS DIAGNOSES",143-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12253.04,,,12253.04,5546.936684,12253.0392,case rate,,,
"OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS, SYMPTOMS AND MISCELLANEOUS DIAGNOSES",143-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17362.22,,,17362.22,7136.547219,17362.2216,case rate,,,
"OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS, SYMPTOMS AND MISCELLANEOUS DIAGNOSES",143-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24843.52,,,24843.52,11880.6378,26595.0096,case rate,,,
"OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS, SYMPTOMS AND MISCELLANEOUS DIAGNOSES",143-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38261.38,,,38261.38,18578.03192,42660.2364,case rate,,,
"RESPIRATORY SIGNS, SYMPTOMS AND MISCELLANEOUS DIAGNOSES",144-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11890.6,,,11890.6,5226.540475,11890.5972,case rate,,,
"RESPIRATORY SIGNS, SYMPTOMS AND MISCELLANEOUS DIAGNOSES",144-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15650,,,15650,6706.053471,15649.9956,case rate,,,
"RESPIRATORY SIGNS, SYMPTOMS AND MISCELLANEOUS DIAGNOSES",144-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22108.96,,,22108.96,10366.48738,22108.962,case rate,,,
"RESPIRATORY SIGNS, SYMPTOMS AND MISCELLANEOUS DIAGNOSES",144-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38556.33,,,38556.33,14954.70954,38556.33,case rate,,,
ACUTE BRONCHITIS AND RELATED SYMPTOMS,145-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11380.68,,,11380.68,4228.240318,11380.6788,case rate,,,
ACUTE BRONCHITIS AND RELATED SYMPTOMS,145-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14547.67,,,14547.67,5174.584333,14547.672,case rate,,,
ACUTE BRONCHITIS AND RELATED SYMPTOMS,145-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18769.5,,,18769.5,7909.704094,18769.4964,case rate,,,
ACUTE BRONCHITIS AND RELATED SYMPTOMS,145-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28592.92,,,28592.92,14137.01883,30354.7162,case rate,,,
MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,160-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,69513.88,,,69513.88,32815.25188,74752.23481,case rate,,,
MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,160-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,85621.3,,,85621.3,47755.1168,87402.47434,case rate,,,
MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,160-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,132108.86,,,132108.86,80727.47416,132108.8592,case rate,,,
MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,160-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,246103.12,,,246103.12,206156.9348,247472.8459,case rate,,,
IMPLANTABLE HEART ASSIST SYSTEMS,161-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,339865.61,,,339865.61,79731.80178,339865.6128,case rate,,,
IMPLANTABLE HEART ASSIST SYSTEMS,161-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,357755.25,,,357755.25,105224.0396,357755.25,case rate,,,
IMPLANTABLE HEART ASSIST SYSTEMS,161-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,445571.2,,,445571.2,172491.9223,445571.1972,case rate,,,
IMPLANTABLE HEART ASSIST SYSTEMS,161-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,581606.93,,,581606.93,352820.5528,581606.928,case rate,,,
CARDIAC VALVE PROCEDURES WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS,162-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,107445.31,,,107445.31,40249.92839,107445.306,case rate,,,
CARDIAC VALVE PROCEDURES WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS,162-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,125907.35,,,125907.35,46683.83064,125907.3516,case rate,,,
CARDIAC VALVE PROCEDURES WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS,162-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,158864.58,,,158864.58,60055.1149,158864.5776,case rate,,,
CARDIAC VALVE PROCEDURES WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS,162-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,231947.88,,,231947.88,91535.58875,231947.8824,case rate,,,
CARDIAC VALVE PROCEDURES WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS,163-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,93974.96,,,93974.96,36385.38106,93974.9616,case rate,,,
CARDIAC VALVE PROCEDURES WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS,163-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,103988.36,,,103988.36,36882.67557,103988.3592,case rate,,,
CARDIAC VALVE PROCEDURES WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS,163-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,131396.47,,,131396.47,50725.27626,131396.4732,case rate,,,
CARDIAC VALVE PROCEDURES WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS,163-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,197373.42,,,197373.42,83557.84685,197373.4152,case rate,,,
CORONARY BYPASS WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS,165-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,91047.93,,,91047.93,44446.00538,91047.93,case rate,,,
CORONARY BYPASS WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS,165-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,110872.26,,,110872.26,45162.25791,110872.2576,case rate,,,
CORONARY BYPASS WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS,165-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,133306.17,,,133306.17,45972.52631,133306.1676,case rate,,,
CORONARY BYPASS WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS,165-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,180493.62,,,180493.62,66108.00544,180493.6164,case rate,,,
CORONARY BYPASS WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS,166-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,83816.59,,,83816.59,24844.93228,83816.5872,case rate,,,
CORONARY BYPASS WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS,166-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,93327.57,,,93327.57,29920.55254,93327.5652,case rate,,,
CORONARY BYPASS WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS,166-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,110829.76,,,110829.76,37668.20295,110829.7644,case rate,,,
CORONARY BYPASS WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS,166-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,162698.96,,,162698.96,61902.03204,162698.964,case rate,,,
OTHER CARDIOTHORACIC AND THORACIC VASCULAR PROCEDURES,167-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,70466.22,,,70466.22,32102.7105,70466.2236,case rate,,,
OTHER CARDIOTHORACIC AND THORACIC VASCULAR PROCEDURES,167-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,73245.78,,,73245.78,33589.6458,73245.7788,case rate,,,
OTHER CARDIOTHORACIC AND THORACIC VASCULAR PROCEDURES,167-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,110579.8,,,110579.8,53570.49356,110579.8044,case rate,,,
OTHER CARDIOTHORACIC AND THORACIC VASCULAR PROCEDURES,167-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,177539.09,,,177539.09,99594.97601,177539.0892,case rate,,,
MAJOR ABDOMINAL VASCULAR PROCEDURES,169-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,70681.19,,,70681.19,25621.80031,70681.1892,case rate,,,
MAJOR ABDOMINAL VASCULAR PROCEDURES,169-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71633.54,,,71633.54,33672.52822,71633.5368,case rate,,,
MAJOR ABDOMINAL VASCULAR PROCEDURES,169-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,93605.02,,,93605.02,40465.17526,93605.0208,case rate,,,
MAJOR ABDOMINAL VASCULAR PROCEDURES,169-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,152280.63,,,152280.63,68057.59782,152280.6312,case rate,,,
"PERMANENT CARDIAC PACEMAKER IMPLANT WITH AMI, HEART FAILURE OR SHOCK",170-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53011.52,,,53011.52,34434.55164,56092.4992,case rate,,,
"PERMANENT CARDIAC PACEMAKER IMPLANT WITH AMI, HEART FAILURE OR SHOCK",170-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,60215.36,,,60215.36,37556.86836,60215.364,case rate,,,
"PERMANENT CARDIAC PACEMAKER IMPLANT WITH AMI, HEART FAILURE OR SHOCK",170-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,76367.78,,,76367.78,44554.86587,76367.7792,case rate,,,
"PERMANENT CARDIAC PACEMAKER IMPLANT WITH AMI, HEART FAILURE OR SHOCK",170-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,107377.82,,,107377.82,59987.07709,107377.8168,case rate,,,
"PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT AMI, HEART FAILURE OR SHOCK",171-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,39288.71,,,39288.71,15793.43012,39288.7128,case rate,,,
"PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT AMI, HEART FAILURE OR SHOCK",171-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,45050.29,,,45050.29,17834.56427,45050.2908,case rate,,,
"PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT AMI, HEART FAILURE OR SHOCK",171-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,57658.27,,,57658.27,22882.9694,61945.1428,case rate,,,
"PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT AMI, HEART FAILURE OR SHOCK",171-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,85751.28,,,85751.28,39432.23768,123641.5016,case rate,,,
PERCUTANEOUS CARDIAC INTERVENTION WITH AMI,174-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48872.18,,,48872.18,13742.39956,48872.1792,case rate,,,
PERCUTANEOUS CARDIAC INTERVENTION WITH AMI,174-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53031.51,,,53031.51,16797.91553,53031.5136,case rate,,,
PERCUTANEOUS CARDIAC INTERVENTION WITH AMI,174-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,65057.09,,,65057.09,22014.5596,65057.0892,case rate,,,
PERCUTANEOUS CARDIAC INTERVENTION WITH AMI,174-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,90917.95,,,90917.95,33365.73957,90917.9508,case rate,,,
PERCUTANEOUS CARDIAC INTERVENTION WITHOUT AMI,175-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49214.62,,,49214.62,18256.39866,49214.6244,case rate,,,
PERCUTANEOUS CARDIAC INTERVENTION WITHOUT AMI,175-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,55626.1,,,55626.1,22254.54749,55626.0984,case rate,,,
PERCUTANEOUS CARDIAC INTERVENTION WITHOUT AMI,175-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,68651.51,,,68651.51,29002.6607,68651.514,case rate,,,
PERCUTANEOUS CARDIAC INTERVENTION WITHOUT AMI,175-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,100461.42,,,100461.42,51064.22823,101808.6324,case rate,,,
"INSERTION, REVISION AND REPLACEMENTS OF PACEMAKER AND OTHER CARDIAC DEVICES",176-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,40633.5,,,40633.5,10411.02122,40633.4976,case rate,,,
"INSERTION, REVISION AND REPLACEMENTS OF PACEMAKER AND OTHER CARDIAC DEVICES",176-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48204.79,,,48204.79,17778.89697,54740.7728,case rate,,,
"INSERTION, REVISION AND REPLACEMENTS OF PACEMAKER AND OTHER CARDIAC DEVICES",176-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,74680.55,,,74680.55,31694.48367,74680.5492,case rate,,,
"INSERTION, REVISION AND REPLACEMENTS OF PACEMAKER AND OTHER CARDIAC DEVICES",176-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,123690.21,,,123690.21,71004.2533,123690.2064,case rate,,,
CARDIAC PACEMAKER AND DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,177-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,29112.84,,,29112.84,10907.07867,29112.8412,case rate,,,
CARDIAC PACEMAKER AND DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,177-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42025.77,,,42025.77,15745.18513,42025.7748,case rate,,,
CARDIAC PACEMAKER AND DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,177-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,56468.46,,,56468.46,21154.80915,56468.4636,case rate,,,
CARDIAC PACEMAKER AND DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,177-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,77912.53,,,77912.53,29189.4554,131328.9272,case rate,,,
EXTERNAL HEART ASSIST SYSTEMS,178-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,120528.21,,,120528.21,64325.41495,120528.2124,case rate,,,
EXTERNAL HEART ASSIST SYSTEMS,178-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,135133.38,,,135133.38,72120.0733,135133.3752,case rate,,,
EXTERNAL HEART ASSIST SYSTEMS,178-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145041.79,,,145041.79,77408.46633,145041.7896,case rate,,,
EXTERNAL HEART ASSIST SYSTEMS,178-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,196056.13,,,196056.13,104634.7218,196056.126,case rate,,,
DEFIBRILLATOR IMPLANTS,179-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,83736.6,,,83736.6,40680.42214,83736.6,case rate,,,
DEFIBRILLATOR IMPLANTS,179-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,94894.81,,,94894.81,45888.40685,94894.8144,case rate,,,
DEFIBRILLATOR IMPLANTS,179-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,116468.86,,,116468.86,63212.06905,116468.862,case rate,,,
DEFIBRILLATOR IMPLANTS,179-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,159731.94,,,159731.94,87251.68113,159731.9388,case rate,,,
OTHER CIRCULATORY SYSTEM PROCEDURES,180-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28537.93,,,28537.93,12224.53798,28537.9332,case rate,,,
OTHER CIRCULATORY SYSTEM PROCEDURES,180-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,35626.8,,,35626.8,14166.70805,35626.7988,case rate,,,
OTHER CIRCULATORY SYSTEM PROCEDURES,180-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49227.12,,,49227.12,23586.85142,50161.074,case rate,,,
OTHER CIRCULATORY SYSTEM PROCEDURES,180-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,90608,,,90608,48915.47064,99909.5812,case rate,,,
LOWER EXTREMITY ARTERIAL PROCEDURES,181-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,37601.48,,,37601.48,16844.92347,37601.4828,case rate,,,
LOWER EXTREMITY ARTERIAL PROCEDURES,181-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,51964.18,,,51964.18,21978.68512,51964.1844,case rate,,,
LOWER EXTREMITY ARTERIAL PROCEDURES,181-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,80757.08,,,80757.08,34020.13955,84800.0996,case rate,,,
LOWER EXTREMITY ARTERIAL PROCEDURES,181-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,125907.35,,,125907.35,57610.70212,137173.278,case rate,,,
OTHER PERIPHERAL VASCULAR AND RELATED PROCEDURES,182-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,45442.73,,,45442.73,19284.38804,45442.728,case rate,,,
OTHER PERIPHERAL VASCULAR AND RELATED PROCEDURES,182-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49347.1,,,49347.1,21353.97436,49347.1032,case rate,,,
OTHER PERIPHERAL VASCULAR AND RELATED PROCEDURES,182-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,59720.44,,,59720.44,27374.70158,66839.968,case rate,,,
OTHER PERIPHERAL VASCULAR AND RELATED PROCEDURES,182-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,106970.38,,,106970.38,54109.84779,130031.104,case rate,,,
PERCUTANEOUS STRUCTURAL CARDIAC PROCEDURES,183-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,98121.8,,,98121.8,50291.07135,98121.798,case rate,,,
PERCUTANEOUS STRUCTURAL CARDIAC PROCEDURES,183-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,100933.85,,,100933.85,52831.97411,100933.848,case rate,,,
PERCUTANEOUS STRUCTURAL CARDIAC PROCEDURES,183-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,117523.69,,,117523.69,65177.74309,117523.6932,case rate,,,
PERCUTANEOUS STRUCTURAL CARDIAC PROCEDURES,183-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,167303.23,,,167303.23,88037.20852,167303.2272,case rate,,,
ACUTE MYOCARDIAL INFARCTION,190-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18979.46,,,18979.46,4908.618368,18979.4628,case rate,,,
ACUTE MYOCARDIAL INFARCTION,190-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20691.69,,,20691.69,6489.569546,20691.6888,case rate,,,
ACUTE MYOCARDIAL INFARCTION,190-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26498.26,,,26498.26,9506.736935,30077.9856,case rate,,,
ACUTE MYOCARDIAL INFARCTION,190-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38451.35,,,38451.35,15969.09136,58323.2624,case rate,,,
CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,191-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22648.88,,,22648.88,6754.29846,22648.8756,case rate,,,
CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,191-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26550.75,,,26550.75,8429.265514,26550.7512,case rate,,,
CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,191-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,34479.48,,,34479.48,11964.75727,34479.4824,case rate,,,
CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,191-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49447.09,,,49447.09,23082.13461,70774.2145,case rate,,,
CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS,192-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24296.11,,,24296.11,7564.566865,24296.112,case rate,,,
CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS,192-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,30232.66,,,30232.66,11895.48242,30232.662,case rate,,,
CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS,192-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42398.22,,,42398.22,20402.68214,42398.2152,case rate,,,
CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS,192-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,65884.46,,,65884.46,34344.24691,85359.8636,case rate,,,
ACUTE AND SUBACUTE ENDOCARDITIS,193-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18447.05,,,18447.05,7518.795978,21391.2776,case rate,,,
ACUTE AND SUBACUTE ENDOCARDITIS,193-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27173.15,,,27173.15,11648.07222,28570.7692,case rate,,,
ACUTE AND SUBACUTE ENDOCARDITIS,193-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,35991.74,,,35991.74,15821.88229,44640.1424,case rate,,,
ACUTE AND SUBACUTE ENDOCARDITIS,193-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,55933.55,,,55933.55,19017.18502,92551.7944,case rate,,,
HEART FAILURE,194-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12637.98,,,12637.98,5170.87318,12637.9776,case rate,,,
HEART FAILURE,194-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16587.35,,,16587.35,7424.780102,16587.3456,case rate,,,
HEART FAILURE,194-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22943.83,,,22943.83,10382.56904,26820.9884,case rate,,,
HEART FAILURE,194-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,34779.43,,,34779.43,16741.01118,59882.3088,case rate,,,
CARDIAC ARREST AND SHOCK,196-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,9076.05,,,9076.05,5052.116284,12142.7324,case rate,,,
CARDIAC ARREST AND SHOCK,196-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13425.35,,,13425.35,6543.99979,13425.3516,case rate,,,
CARDIAC ARREST AND SHOCK,196-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20909.15,,,20909.15,9109.643564,20909.154,case rate,,,
CARDIAC ARREST AND SHOCK,196-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,37603.98,,,37603.98,18825.44212,43346.4656,case rate,,,
PERIPHERAL AND OTHER VASCULAR DISORDERS,197-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11608.14,,,11608.14,5903.207372,12148.952,case rate,,,
PERIPHERAL AND OTHER VASCULAR DISORDERS,197-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15505.02,,,15505.02,6915.11509,16425.9636,case rate,,,
PERIPHERAL AND OTHER VASCULAR DISORDERS,197-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21441.57,,,21441.57,9851.874164,24482.4188,case rate,,,
PERIPHERAL AND OTHER VASCULAR DISORDERS,197-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,39071.25,,,39071.25,22813.69454,59374.3748,case rate,,,
ANGINA PECTORIS AND CORONARY ATHEROSCLEROSIS,198-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11513.16,,,11513.16,4095.875861,11513.1576,case rate,,,
ANGINA PECTORIS AND CORONARY ATHEROSCLEROSIS,198-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13757.8,,,13757.8,4888.825552,13757.7984,case rate,,,
ANGINA PECTORIS AND CORONARY ATHEROSCLEROSIS,198-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18152.1,,,18152.1,6854.499591,18152.0952,case rate,,,
ANGINA PECTORIS AND CORONARY ATHEROSCLEROSIS,198-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,31559.95,,,31559.95,17462.21192,50185.9524,case rate,,,
HYPERTENSION,199-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12285.53,,,12285.53,4050.104974,12285.534,case rate,,,
HYPERTENSION,199-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15012.6,,,15012.6,5675.589988,15012.5976,case rate,,,
HYPERTENSION,199-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20679.19,,,20679.19,10229.17472,20679.1908,case rate,,,
HYPERTENSION,199-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,30197.67,,,30197.67,16997.08074,50924.0116,case rate,,,
CARDIAC STRUCTURAL AND VALVULAR DISORDERS,200-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10543.31,,,10543.31,4220.818012,12210.83862,case rate,,,
CARDIAC STRUCTURAL AND VALVULAR DISORDERS,200-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15610,,,15610,6976.96764,15610.002,case rate,,,
CARDIAC STRUCTURAL AND VALVULAR DISORDERS,200-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22573.89,,,22573.89,11180.46694,25948.1712,case rate,,,
CARDIAC STRUCTURAL AND VALVULAR DISORDERS,200-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,35029.39,,,35029.39,20948.22163,81673.714,case rate,,,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS,201-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10910.75,,,10910.75,4022.889852,10910.754,case rate,,,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS,201-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14145.24,,,14145.24,5311.896994,14145.2364,case rate,,,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS,201-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21126.62,,,21126.62,9129.43638,22492.1468,case rate,,,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS,201-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,34699.45,,,34699.45,15520.04185,52659.28,case rate,,,
CHEST PAIN,203-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11663.13,,,11663.13,3613.425971,11899.87798,case rate,,,
CHEST PAIN,203-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13795.29,,,13795.29,4734.194177,13795.2924,case rate,,,
CHEST PAIN,203-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17194.75,,,17194.75,7037.583139,17194.7484,case rate,,,
CHEST PAIN,203-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25535.91,,,25535.91,16674.21043,48828.0064,case rate,,,
SYNCOPE AND COLLAPSE,204-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13440.35,,,13440.35,4154.017258,13440.3492,case rate,,,
SYNCOPE AND COLLAPSE,204-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15799.97,,,15799.97,5446.735553,15799.9716,case rate,,,
SYNCOPE AND COLLAPSE,204-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20356.74,,,20356.74,7779.813739,20356.7424,case rate,,,
SYNCOPE AND COLLAPSE,204-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,31897.4,,,31897.4,14922.54621,43966.3524,case rate,,,
CARDIOMYOPATHY,205-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12070.57,,,12070.57,5577.862959,12182.1232,case rate,,,
CARDIOMYOPATHY,205-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15040.09,,,15040.09,7204.585024,15472.2916,case rate,,,
CARDIOMYOPATHY,205-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22263.94,,,22263.94,9117.06587,30131.8888,case rate,,,
CARDIOMYOPATHY,205-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,40016.1,,,40016.1,20627.82543,51189.07935,case rate,,,
"MALFUNCTION, REACTION, COMPLICATION OF CARDIAC OR VASCULAR DEVICE OR PROCEDURE",206-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15470.02,,,15470.02,8209.070436,16381.76726,case rate,,,
"MALFUNCTION, REACTION, COMPLICATION OF CARDIAC OR VASCULAR DEVICE OR PROCEDURE",206-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15774.98,,,15774.98,8331.538485,16672.44786,case rate,,,
"MALFUNCTION, REACTION, COMPLICATION OF CARDIAC OR VASCULAR DEVICE OR PROCEDURE",206-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23651.22,,,23651.22,13368.81016,25794.7544,case rate,,,
"MALFUNCTION, REACTION, COMPLICATION OF CARDIAC OR VASCULAR DEVICE OR PROCEDURE",206-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,46837.5,,,46837.5,21965.07756,70582.094,case rate,,,
OTHER CIRCULATORY SYSTEM DIAGNOSES,207-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12897.94,,,12897.94,4987.789632,12897.936,case rate,,,
OTHER CIRCULATORY SYSTEM DIAGNOSES,207-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16159.91,,,16159.91,7229.326044,16159.914,case rate,,,
OTHER CIRCULATORY SYSTEM DIAGNOSES,207-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22476.4,,,22476.4,10315.76829,24938.5228,case rate,,,
OTHER CIRCULATORY SYSTEM DIAGNOSES,207-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38086.41,,,38086.41,19013.47387,52389.764,case rate,,,
"MAJOR STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES",220-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,34484.48,,,34484.48,11795.28129,34484.4816,case rate,,,
"MAJOR STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES",220-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49487.08,,,49487.08,20573.39518,49487.0808,case rate,,,
"MAJOR STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES",220-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,75362.94,,,75362.94,39021.53674,75362.94,case rate,,,
"MAJOR STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES",220-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,134603.46,,,134603.46,106277.5255,146942.1964,case rate,,,
"OTHER STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES",222-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18402.06,,,18402.06,9287.778908,18402.0552,case rate,,,
"OTHER STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES",222-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,31047.53,,,31047.53,15192.22333,31047.5316,case rate,,,
"OTHER STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES",222-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,46377.58,,,46377.58,25201.20297,46377.5784,case rate,,,
"OTHER STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES",222-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,98874.18,,,98874.18,58294.79132,114730.888,case rate,,,
OTHER SMALL AND LARGE BOWEL PROCEDURES,223-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25325.95,,,25325.95,10002.79439,25325.9472,case rate,,,
OTHER SMALL AND LARGE BOWEL PROCEDURES,223-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38313.87,,,38313.87,15392.62559,38313.8688,case rate,,,
OTHER SMALL AND LARGE BOWEL PROCEDURES,223-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53848.88,,,53848.88,20923.48061,55153.3396,case rate,,,
OTHER SMALL AND LARGE BOWEL PROCEDURES,223-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,95029.79,,,95029.79,37913.13905,115653.462,case rate,,,
PERITONEAL ADHESIOLYSIS,224-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,30657.59,,,30657.59,11619.62004,30657.594,case rate,,,
PERITONEAL ADHESIOLYSIS,224-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,37911.43,,,37911.43,15476.74506,37911.4332,case rate,,,
PERITONEAL ADHESIOLYSIS,224-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53868.88,,,53868.88,20085.99709,55018.5816,case rate,,,
PERITONEAL ADHESIOLYSIS,224-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,92290.23,,,92290.23,39683.35903,115448.2152,case rate,,,
ANAL AND PERINEAL PROCEDURES,226-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20286.75,,,20286.75,8456.480636,20286.7536,case rate,,,
ANAL AND PERINEAL PROCEDURES,226-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26843.2,,,26843.2,12622.8684,26843.2044,case rate,,,
ANAL AND PERINEAL PROCEDURES,226-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,39381.2,,,39381.2,16980.99908,39381.198,case rate,,,
ANAL AND PERINEAL PROCEDURES,226-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,65829.47,,,65829.47,40645.78471,80996.23441,case rate,,,
"HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL AND UMBILICAL",227-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28880.38,,,28880.38,10607.71233,28880.3784,case rate,,,
"HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL AND UMBILICAL",227-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36129.22,,,36129.22,14005.89142,36129.2184,case rate,,,
"HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL AND UMBILICAL",227-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,51061.83,,,51061.83,21309.44053,51061.8288,case rate,,,
"HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL AND UMBILICAL",227-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,93020.11,,,93020.11,45345.34146,109334.3484,case rate,,,
"INGUINAL, FEMORAL AND UMBILICAL HERNIA PROCEDURES",228-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21943.99,,,21943.99,7252.830013,21943.9884,case rate,,,
"INGUINAL, FEMORAL AND UMBILICAL HERNIA PROCEDURES",228-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28295.47,,,28295.47,9181.392522,28295.472,case rate,,,
"INGUINAL, FEMORAL AND UMBILICAL HERNIA PROCEDURES",228-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38531.33,,,38531.33,13930.43131,38531.334,case rate,,,
"INGUINAL, FEMORAL AND UMBILICAL HERNIA PROCEDURES",228-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,66286.89,,,66286.89,31251.61941,92377.6456,case rate,,,
OTHER DIGESTIVE SYSTEM AND ABDOMINAL PROCEDURES,229-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27510.6,,,27510.6,11359.83933,27510.5976,case rate,,,
OTHER DIGESTIVE SYSTEM AND ABDOMINAL PROCEDURES,229-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,37928.93,,,37928.93,16394.6369,37928.9304,case rate,,,
OTHER DIGESTIVE SYSTEM AND ABDOMINAL PROCEDURES,229-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,57270.84,,,57270.84,27792.82482,57270.8352,case rate,,,
OTHER DIGESTIVE SYSTEM AND ABDOMINAL PROCEDURES,229-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,98826.69,,,98826.69,51088.96925,119971.9376,case rate,,,
MAJOR SMALL BOWEL PROCEDURES,230-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,32292.33,,,32292.33,12657.50583,32292.3324,case rate,,,
MAJOR SMALL BOWEL PROCEDURES,230-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,44277.91,,,44277.91,18604.00999,44277.9144,case rate,,,
MAJOR SMALL BOWEL PROCEDURES,230-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,65572.01,,,65572.01,29179.55899,65572.0068,case rate,,,
MAJOR SMALL BOWEL PROCEDURES,230-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,120643.19,,,120643.19,62337.47399,120643.194,case rate,,,
MAJOR LARGE BOWEL PROCEDURES,231-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36886.6,,,36886.6,12823.27067,36886.5972,case rate,,,
MAJOR LARGE BOWEL PROCEDURES,231-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,45292.75,,,45292.75,16192.99759,45292.752,case rate,,,
MAJOR LARGE BOWEL PROCEDURES,231-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,64742.14,,,64742.14,25410.26459,64742.1396,case rate,,,
MAJOR LARGE BOWEL PROCEDURES,231-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,106150.51,,,106150.51,40468.88641,106150.5132,case rate,,,
GASTRIC FUNDOPLICATION,232-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27970.52,,,27970.52,10726.46922,27970.524,case rate,,,
GASTRIC FUNDOPLICATION,232-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,34167.03,,,34167.03,14103.61845,34167.0324,case rate,,,
GASTRIC FUNDOPLICATION,232-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,45162.77,,,45162.77,28437.32839,45162.7728,case rate,,,
GASTRIC FUNDOPLICATION,232-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,99109.14,,,99109.14,68648.90819,138188.2062,case rate,,,
APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS,233-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25008.5,,,25008.5,9552.507822,25008.498,case rate,,,
APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS,233-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,32299.83,,,32299.83,12073.61776,32299.8312,case rate,,,
APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS,233-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,46805.01,,,46805.01,19088.93398,46805.01,case rate,,,
APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS,233-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,70018.8,,,70018.8,38855.77191,72264.54966,case rate,,,
APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS,234-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20281.75,,,20281.75,6547.710943,20281.7544,case rate,,,
APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS,234-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26195.81,,,26195.81,8606.163807,26195.808,case rate,,,
APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS,234-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38513.84,,,38513.84,12460.81472,38513.8368,case rate,,,
APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS,234-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,65592,,,65592,37529.65324,65592.0036,case rate,,,
DIGESTIVE MALIGNANCY,240-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17452.21,,,17452.21,8009.905225,17452.2072,case rate,,,
DIGESTIVE MALIGNANCY,240-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20171.77,,,20171.77,9018.10179,20171.772,case rate,,,
DIGESTIVE MALIGNANCY,240-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27508.1,,,27508.1,13940.32772,32827.0488,case rate,,,
DIGESTIVE MALIGNANCY,240-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,45217.76,,,45217.76,27582.52615,61654.8948,case rate,,,
PEPTIC ULCER AND GASTRITIS,241-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14755.14,,,14755.14,5443.0244,14755.1388,case rate,,,
PEPTIC ULCER AND GASTRITIS,241-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18367.06,,,18367.06,7158.814137,18367.0608,case rate,,,
PEPTIC ULCER AND GASTRITIS,241-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26773.22,,,26773.22,11687.65785,26773.2156,case rate,,,
PEPTIC ULCER AND GASTRITIS,241-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,52146.66,,,52146.66,26657.212,64884.9404,case rate,,,
MAJOR ESOPHAGEAL DISORDERS,242-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13460.35,,,13460.35,4658.734066,13460.346,case rate,,,
MAJOR ESOPHAGEAL DISORDERS,242-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17412.21,,,17412.21,6976.96764,17412.2136,case rate,,,
MAJOR ESOPHAGEAL DISORDERS,242-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24971,,,24971,10997.38339,25879.7556,case rate,,,
MAJOR ESOPHAGEAL DISORDERS,242-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,51244.3,,,51244.3,26074.56098,65413.6064,case rate,,,
OTHER ESOPHAGEAL DISORDERS,243-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12677.97,,,12677.97,5304.474688,12677.9712,case rate,,,
OTHER ESOPHAGEAL DISORDERS,243-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16302.39,,,16302.39,6915.11509,16302.3912,case rate,,,
OTHER ESOPHAGEAL DISORDERS,243-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23763.7,,,23763.7,11024.59851,23763.6972,case rate,,,
OTHER ESOPHAGEAL DISORDERS,243-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42805.65,,,42805.65,22461.13501,47656.6484,case rate,,,
DIVERTICULITIS AND DIVERTICULOSIS,244-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12745.46,,,12745.46,4678.526882,12745.4604,case rate,,,
DIVERTICULITIS AND DIVERTICULOSIS,244-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16652.34,,,16652.34,6540.288637,16652.3352,case rate,,,
DIVERTICULITIS AND DIVERTICULOSIS,244-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25178.47,,,25178.47,10845.22612,25178.4708,case rate,,,
DIVERTICULITIS AND DIVERTICULOSIS,244-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,43100.6,,,43100.6,19779.20844,63707.3628,case rate,,,
INFLAMMATORY BOWEL DISEASE,245-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13647.82,,,13647.82,6521.732872,13647.816,case rate,,,
INFLAMMATORY BOWEL DISEASE,245-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17404.71,,,17404.71,8877.077976,17404.7148,case rate,,,
INFLAMMATORY BOWEL DISEASE,245-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24968.5,,,24968.5,13804.25211,25253.6492,case rate,,,
INFLAMMATORY BOWEL DISEASE,245-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,43628.02,,,43628.02,24630.92246,50686.58497,case rate,,,
GASTROINTESTINAL VASCULAR INSUFFICIENCY,246-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14457.69,,,14457.69,4878.929144,14457.6864,case rate,,,
GASTROINTESTINAL VASCULAR INSUFFICIENCY,246-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18297.07,,,18297.07,6376.997905,18297.072,case rate,,,
GASTROINTESTINAL VASCULAR INSUFFICIENCY,246-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25863.36,,,25863.36,9554.981924,26800.2564,case rate,,,
GASTROINTESTINAL VASCULAR INSUFFICIENCY,246-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,37386.52,,,37386.52,21514.79099,59117.298,case rate,,,
INTESTINAL OBSTRUCTION,247-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11575.65,,,11575.65,4421.220274,11575.6476,case rate,,,
INTESTINAL OBSTRUCTION,247-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14997.6,,,14997.6,6002.171452,14997.6,case rate,,,
INTESTINAL OBSTRUCTION,247-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22418.91,,,22418.91,10741.31383,24967.5476,case rate,,,
INTESTINAL OBSTRUCTION,247-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,41358.38,,,41358.38,21418.30101,52984.7724,case rate,,,
MAJOR GASTROINTESTINAL AND PERITONEAL INFECTIONS,248-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12750.46,,,12750.46,5063.249743,12750.4596,case rate,,,
MAJOR GASTROINTESTINAL AND PERITONEAL INFECTIONS,248-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16787.31,,,16787.31,7340.660634,17547.5648,case rate,,,
MAJOR GASTROINTESTINAL AND PERITONEAL INFECTIONS,248-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24661.05,,,24661.05,11489.72969,27343.4348,case rate,,,
MAJOR GASTROINTESTINAL AND PERITONEAL INFECTIONS,248-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,44825.33,,,44825.33,19904.15059,67099.118,case rate,,,
"OTHER GASTROENTERITIS, NAUSEA AND VOMITING",249-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10815.77,,,10815.77,4322.256194,10815.7692,case rate,,,
"OTHER GASTROENTERITIS, NAUSEA AND VOMITING",249-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13520.34,,,13520.34,5654.560121,13520.3364,case rate,,,
"OTHER GASTROENTERITIS, NAUSEA AND VOMITING",249-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19554.37,,,19554.37,9362.001968,19554.3708,case rate,,,
"OTHER GASTROENTERITIS, NAUSEA AND VOMITING",249-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,35991.74,,,35991.74,19865.80201,41934.6164,case rate,,,
ABDOMINAL PAIN,251-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11383.18,,,11383.18,5001.397193,11383.1784,case rate,,,
ABDOMINAL PAIN,251-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14700.15,,,14700.15,5901.970321,14700.1476,case rate,,,
ABDOMINAL PAIN,251-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19404.39,,,19404.39,8885.737333,19404.3948,case rate,,,
ABDOMINAL PAIN,251-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,32794.75,,,32794.75,13706.52508,40143.3716,case rate,,,
"MALFUNCTION, REACTION AND COMPLICATION OF GASTROINTESTINAL DEVICE OR PROCEDURE",252-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13850.28,,,13850.28,7087.065179,13850.2836,case rate,,,
"MALFUNCTION, REACTION AND COMPLICATION OF GASTROINTESTINAL DEVICE OR PROCEDURE",252-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17144.76,,,17144.76,8288.2417,17144.7564,case rate,,,
"MALFUNCTION, REACTION AND COMPLICATION OF GASTROINTESTINAL DEVICE OR PROCEDURE",252-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24371.1,,,24371.1,13444.27027,25749.144,case rate,,,
"MALFUNCTION, REACTION AND COMPLICATION OF GASTROINTESTINAL DEVICE OR PROCEDURE",252-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,46375.08,,,46375.08,33788.81101,58758.6344,case rate,,,
OTHER AND UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,253-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13917.77,,,13917.77,5614.974489,13917.7728,case rate,,,
OTHER AND UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,253-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17984.62,,,17984.62,7647.449282,17984.622,case rate,,,
OTHER AND UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,253-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25325.95,,,25325.95,11075.3176,27712.4644,case rate,,,
OTHER AND UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,253-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,43625.52,,,43625.52,20257.94718,49049.8388,case rate,,,
OTHER DIGESTIVE SYSTEM DIAGNOSES,254-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11923.09,,,11923.09,5711.464467,11923.092,case rate,,,
OTHER DIGESTIVE SYSTEM DIAGNOSES,254-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16644.84,,,16644.84,7617.760058,16644.8364,case rate,,,
OTHER DIGESTIVE SYSTEM DIAGNOSES,254-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23933.67,,,23933.67,12753.99581,25139.6232,case rate,,,
OTHER DIGESTIVE SYSTEM DIAGNOSES,254-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42055.77,,,42055.77,23382.738,54071.1292,case rate,,,
"MAJOR PANCREAS, LIVER AND SHUNT PROCEDURES",260-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42770.66,,,42770.66,18315.77711,42770.6556,case rate,,,
"MAJOR PANCREAS, LIVER AND SHUNT PROCEDURES",260-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,54218.82,,,54218.82,22749.36789,54218.8236,case rate,,,
"MAJOR PANCREAS, LIVER AND SHUNT PROCEDURES",260-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,74310.61,,,74310.61,33478.31121,74310.6084,case rate,,,
"MAJOR PANCREAS, LIVER AND SHUNT PROCEDURES",260-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,140300.05,,,140300.05,68009.35283,153966.198,case rate,,,
MAJOR BILIARY TRACT PROCEDURES,261-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,35706.79,,,35706.79,17556.22779,35706.786,case rate,,,
MAJOR BILIARY TRACT PROCEDURES,261-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,46730.02,,,46730.02,20447.21598,46730.022,case rate,,,
MAJOR BILIARY TRACT PROCEDURES,261-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,64744.64,,,64744.64,28839.36996,64744.6392,case rate,,,
MAJOR BILIARY TRACT PROCEDURES,261-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,123320.27,,,123320.27,56363.75471,127306.9192,case rate,,,
CHOLECYSTECTOMY,263-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26193.31,,,26193.31,9202.422389,26193.3084,case rate,,,
CHOLECYSTECTOMY,263-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,33202.19,,,33202.19,11789.09603,33202.1868,case rate,,,
CHOLECYSTECTOMY,263-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42120.76,,,42120.76,16421.85203,42120.7596,case rate,,,
CHOLECYSTECTOMY,263-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,77732.56,,,77732.56,34638.66505,77732.5608,case rate,,,
"OTHER HEPATOBILIARY, PANCREAS AND ABDOMINAL PROCEDURES",264-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,32412.31,,,32412.31,14046.71411,32412.3132,case rate,,,
"OTHER HEPATOBILIARY, PANCREAS AND ABDOMINAL PROCEDURES",264-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,35461.83,,,35461.83,16510.9197,35461.8252,case rate,,,
"OTHER HEPATOBILIARY, PANCREAS AND ABDOMINAL PROCEDURES",264-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,51539.25,,,51539.25,23031.41552,59220.958,case rate,,,
"OTHER HEPATOBILIARY, PANCREAS AND ABDOMINAL PROCEDURES",264-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,109539.97,,,109539.97,61248.86911,127597.1672,case rate,,,
HEPATIC COMA AND OTHER MAJOR ACUTE LIVER DISORDERS,279-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12178.05,,,12178.05,5034.79757,12178.0512,case rate,,,
HEPATIC COMA AND OTHER MAJOR ACUTE LIVER DISORDERS,279-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14947.61,,,14947.61,7568.278018,16218.6436,case rate,,,
HEPATIC COMA AND OTHER MAJOR ACUTE LIVER DISORDERS,279-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22873.84,,,22873.84,11967.23137,28147.8364,case rate,,,
HEPATIC COMA AND OTHER MAJOR ACUTE LIVER DISORDERS,279-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,47754.86,,,47754.86,27713.65355,76812.06,case rate,,,
ALCOHOLIC LIVER DISEASE,280-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12535.49,,,12535.49,5038.508723,12535.494,case rate,,,
ALCOHOLIC LIVER DISEASE,280-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16174.91,,,16174.91,6806.254602,16174.9116,case rate,,,
ALCOHOLIC LIVER DISEASE,280-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24631.06,,,24631.06,12098.35878,26271.5904,case rate,,,
ALCOHOLIC LIVER DISEASE,280-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,51804.21,,,51804.21,27156.9806,70743.8036,case rate,,,
MALIGNANCY OF HEPATOBILIARY SYSTEM AND PANCREAS,281-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15220.06,,,15220.06,7709.301832,15295.65834,case rate,,,
MALIGNANCY OF HEPATOBILIARY SYSTEM AND PANCREAS,281-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20184.27,,,20184.27,9416.432212,20184.27,case rate,,,
MALIGNANCY OF HEPATOBILIARY SYSTEM AND PANCREAS,281-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26265.8,,,26265.8,13007.59127,28570.7692,case rate,,,
MALIGNANCY OF HEPATOBILIARY SYSTEM AND PANCREAS,281-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38616.32,,,38616.32,20094.65644,50140.342,case rate,,,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY,282-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12850.44,,,12850.44,4971.707969,12850.4436,case rate,,,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY,282-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16732.32,,,16732.32,7026.44968,16732.3224,case rate,,,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY,282-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25470.92,,,25470.92,11528.07827,28234.9108,case rate,,,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY,282-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,56403.47,,,56403.47,29874.78165,71666.3776,case rate,,,
OTHER DISORDERS OF THE LIVER,283-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12145.56,,,12145.56,6150.617572,12145.5564,case rate,,,
OTHER DISORDERS OF THE LIVER,283-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15542.51,,,15542.51,7450.758173,15542.5128,case rate,,,
OTHER DISORDERS OF THE LIVER,283-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22616.38,,,22616.38,10999.85749,24971.694,case rate,,,
OTHER DISORDERS OF THE LIVER,283-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42405.71,,,42405.71,23408.71607,53689.6604,case rate,,,
DISORDERS OF GALLBLADDER AND BILIARY TRACT,284-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15552.51,,,15552.51,6745.639103,15552.5112,case rate,,,
DISORDERS OF GALLBLADDER AND BILIARY TRACT,284-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20541.71,,,20541.71,9157.888553,20541.7128,case rate,,,
DISORDERS OF GALLBLADDER AND BILIARY TRACT,284-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28450.45,,,28450.45,13476.43359,28450.4472,case rate,,,
DISORDERS OF GALLBLADDER AND BILIARY TRACT,284-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49377.1,,,49377.1,24994.61546,61453.7944,case rate,,,
DORSAL AND LUMBAR FUSION PROCEDURE FOR CURVATURE OF BACK,303-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,101563.75,,,101563.75,46210.04011,101563.7472,case rate,,,
DORSAL AND LUMBAR FUSION PROCEDURE FOR CURVATURE OF BACK,303-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,121987.98,,,121987.98,74849.00781,121987.9788,case rate,,,
DORSAL AND LUMBAR FUSION PROCEDURE FOR CURVATURE OF BACK,303-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,167900.63,,,167900.63,89785.16158,167900.6316,case rate,,,
DORSAL AND LUMBAR FUSION PROCEDURE FOR CURVATURE OF BACK,303-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,221749.51,,,221749.51,132386.7239,225864.774,case rate,,,
DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK,304-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,68644.02,,,68644.02,30469.80318,68644.0152,case rate,,,
DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK,304-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,81546.95,,,81546.95,37658.30654,81546.9504,case rate,,,
DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK,304-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,115024.09,,,115024.09,49603.271,115024.0932,case rate,,,
DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK,304-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,170202.76,,,170202.76,73919.98251,190365.3704,case rate,,,
AMPUTATION OF LOWER LIMB EXCEPT TOES,305-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25630.9,,,25630.9,12742.86235,28220.3984,case rate,,,
AMPUTATION OF LOWER LIMB EXCEPT TOES,305-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,34177.03,,,34177.03,15330.77304,39745.3172,case rate,,,
AMPUTATION OF LOWER LIMB EXCEPT TOES,305-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,51764.22,,,51764.22,23719.21587,70113.5508,case rate,,,
AMPUTATION OF LOWER LIMB EXCEPT TOES,305-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,96094.62,,,96094.62,48347.66423,130648.9176,case rate,,,
HIP AND FEMUR FRACTURE REPAIR,308-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,34324.51,,,34324.51,12426.1773,34324.5072,case rate,,,
HIP AND FEMUR FRACTURE REPAIR,308-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,40488.52,,,40488.52,15106.86681,40488.5208,case rate,,,
HIP AND FEMUR FRACTURE REPAIR,308-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,51981.68,,,51981.68,19182.94986,56923.8524,case rate,,,
HIP AND FEMUR FRACTURE REPAIR,308-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,75132.98,,,75132.98,29528.40737,119598.7616,case rate,,,
OTHER SIGNIFICANT HIP AND FEMUR SURGERY,309-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,33297.17,,,33297.17,16540.60892,33297.1716,case rate,,,
OTHER SIGNIFICANT HIP AND FEMUR SURGERY,309-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,44285.41,,,44285.41,21734.98607,44285.4132,case rate,,,
OTHER SIGNIFICANT HIP AND FEMUR SURGERY,309-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,62982.42,,,62982.42,28908.64482,62982.4212,case rate,,,
OTHER SIGNIFICANT HIP AND FEMUR SURGERY,309-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,100746.38,,,100746.38,56593.8462,119107.4132,case rate,,,
VERTEBRAL AND INTERVERTEBRAL SPINAL PROCEDURES INCLUDING DISC PROCEDURES,310-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27105.66,,,27105.66,10533.48927,27105.6624,case rate,,,
VERTEBRAL AND INTERVERTEBRAL SPINAL PROCEDURES INCLUDING DISC PROCEDURES,310-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36544.15,,,36544.15,15069.75528,36544.152,case rate,,,
VERTEBRAL AND INTERVERTEBRAL SPINAL PROCEDURES INCLUDING DISC PROCEDURES,310-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,51141.82,,,51141.82,23419.84953,52762.94,case rate,,,
VERTEBRAL AND INTERVERTEBRAL SPINAL PROCEDURES INCLUDING DISC PROCEDURES,310-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,87965.92,,,87965.92,48989.6937,141852.4904,case rate,,,
"SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DIAGNOSES",312-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27550.59,,,27550.59,18913.27274,30354.69758,case rate,,,
"SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DIAGNOSES",312-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,44135.44,,,44135.44,26360.31976,46715.4156,case rate,,,
"SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DIAGNOSES",312-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,74548.07,,,74548.07,37950.25058,93868.2764,case rate,,,
"SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DIAGNOSES",312-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,151185.81,,,151185.81,93185.81478,186635.6836,case rate,,,
KNEE AND LOWER LEG PROCEDURES EXCEPT FOOT,313-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,31992.38,,,31992.38,13044.7028,31992.3804,case rate,,,
KNEE AND LOWER LEG PROCEDURES EXCEPT FOOT,313-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42118.26,,,42118.26,19132.23077,42118.26,case rate,,,
KNEE AND LOWER LEG PROCEDURES EXCEPT FOOT,313-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,61450.17,,,61450.17,26401.14244,61450.1664,case rate,,,
KNEE AND LOWER LEG PROCEDURES EXCEPT FOOT,313-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,95684.69,,,95684.69,49239.578,134162.9916,case rate,,,
FOOT AND TOE PROCEDURES,314-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27115.66,,,27115.66,11925.17164,27115.6608,case rate,,,
FOOT AND TOE PROCEDURES,314-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28865.38,,,28865.38,12198.55991,28865.3808,case rate,,,
FOOT AND TOE PROCEDURES,314-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38286.37,,,38286.37,16163.30837,42139.8632,case rate,,,
FOOT AND TOE PROCEDURES,314-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,69466.38,,,69466.38,30921.3268,79714.54,case rate,,,
"SHOULDER, UPPER ARM AND FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT",315-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23488.74,,,23488.74,11076.55465,23488.7412,case rate,,,
"SHOULDER, UPPER ARM AND FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT",315-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,37593.98,,,37593.98,15271.3946,37593.984,case rate,,,
"SHOULDER, UPPER ARM AND FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT",315-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,56016.04,,,56016.04,26054.76816,56016.036,case rate,,,
"SHOULDER, UPPER ARM AND FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT",315-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,91082.92,,,91082.92,41354.61493,106425.6488,case rate,,,
HAND AND WRIST PROCEDURES,316-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19796.83,,,19796.83,10506.27414,19796.832,case rate,,,
HAND AND WRIST PROCEDURES,316-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26730.72,,,26730.72,13457.87783,26730.7224,case rate,,,
HAND AND WRIST PROCEDURES,316-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,41250.9,,,41250.9,21581.59175,44223.4292,case rate,,,
HAND AND WRIST PROCEDURES,316-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,75247.96,,,75247.96,43606.04775,78407.14905,case rate,,,
"TENDON, MUSCLE AND OTHER SOFT TISSUE PROCEDURES",317-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23246.28,,,23246.28,11239.84539,23246.28,case rate,,,
"TENDON, MUSCLE AND OTHER SOFT TISSUE PROCEDURES",317-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,30067.69,,,30067.69,13519.73038,30067.6884,case rate,,,
"TENDON, MUSCLE AND OTHER SOFT TISSUE PROCEDURES",317-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,46170.11,,,46170.11,21681.79288,54064.9096,case rate,,,
"TENDON, MUSCLE AND OTHER SOFT TISSUE PROCEDURES",317-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,84321.51,,,84321.51,56003.77287,130984.776,case rate,,,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE PROCEDURES,320-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25820.87,,,25820.87,11227.47488,25820.868,case rate,,,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE PROCEDURES,320-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,35774.28,,,35774.28,13892.08273,35774.2752,case rate,,,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE PROCEDURES,320-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,52114.16,,,52114.16,22818.64275,52138.9068,case rate,,,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE PROCEDURES,320-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,88910.77,,,88910.77,40027.25921,103734.6352,case rate,,,
SPINAL FUSION AND OTHER BACK AND NECK PROCEDURES EXCEPT FOR DISC PROCEDURES,321-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42785.65,,,42785.65,19325.21072,42785.6532,case rate,,,
SPINAL FUSION AND OTHER BACK AND NECK PROCEDURES EXCEPT FOR DISC PROCEDURES,321-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,51899.19,,,51899.19,22260.73275,51899.1948,case rate,,,
SPINAL FUSION AND OTHER BACK AND NECK PROCEDURES EXCEPT FOR DISC PROCEDURES,321-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71441.07,,,71441.07,30257.03041,76762.3032,case rate,,,
SPINAL FUSION AND OTHER BACK AND NECK PROCEDURES EXCEPT FOR DISC PROCEDURES,321-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,111692.13,,,111692.13,44892.58079,146454.9944,case rate,,,
SHOULDER AND ELBOW JOINT REPLACEMENT,322-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,44342.9,,,44342.9,24056.9308,44342.904,case rate,,,
SHOULDER AND ELBOW JOINT REPLACEMENT,322-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48147.3,,,48147.3,26496.39537,48147.2952,case rate,,,
SHOULDER AND ELBOW JOINT REPLACEMENT,322-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,63224.88,,,63224.88,27937.55978,63224.8824,case rate,,,
SHOULDER AND ELBOW JOINT REPLACEMENT,322-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,84653.95,,,84653.95,46592.28886,84653.9532,case rate,,,
NON-ELECTIVE OR COMPLEX HIP JOINT REPLACEMENT,323-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,40945.95,,,40945.95,17302.63234,40945.9476,case rate,,,
NON-ELECTIVE OR COMPLEX HIP JOINT REPLACEMENT,323-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,45977.64,,,45977.64,19446.44172,45977.6424,case rate,,,
NON-ELECTIVE OR COMPLEX HIP JOINT REPLACEMENT,323-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,61192.71,,,61192.71,27206.46264,61192.7076,case rate,,,
NON-ELECTIVE OR COMPLEX HIP JOINT REPLACEMENT,323-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,85348.84,,,85348.84,39387.70384,85348.842,case rate,,,
ELECTIVE HIP JOINT REPLACEMENT,324-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36609.14,,,36609.14,18568.13551,36609.1416,case rate,,,
ELECTIVE HIP JOINT REPLACEMENT,324-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,39883.62,,,39883.62,18912.03569,39883.6176,case rate,,,
ELECTIVE HIP JOINT REPLACEMENT,324-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53828.89,,,53828.89,25482.01355,53828.886,case rate,,,
ELECTIVE HIP JOINT REPLACEMENT,324-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,85428.83,,,85428.83,33055.23977,85428.8292,case rate,,,
NON-ELECTIVE OR COMPLEX KNEE JOINT REPLACEMENT,325-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,50876.86,,,50876.86,34109.20722,50876.8584,case rate,,,
NON-ELECTIVE OR COMPLEX KNEE JOINT REPLACEMENT,325-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,59225.52,,,59225.52,35182.96749,59225.5224,case rate,,,
NON-ELECTIVE OR COMPLEX KNEE JOINT REPLACEMENT,325-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,78172.49,,,78172.49,37621.19501,78172.4904,case rate,,,
NON-ELECTIVE OR COMPLEX KNEE JOINT REPLACEMENT,325-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,108820.09,,,108820.09,47781.09488,108820.086,case rate,,,
ELECTIVE KNEE JOINT REPLACEMENT,326-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36396.68,,,36396.68,16432.98548,36396.6756,case rate,,,
ELECTIVE KNEE JOINT REPLACEMENT,326-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38638.82,,,38638.82,17557.46484,38638.8168,case rate,,,
ELECTIVE KNEE JOINT REPLACEMENT,326-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,54948.71,,,54948.71,27123.58023,54948.7068,case rate,,,
ELECTIVE KNEE JOINT REPLACEMENT,326-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,72008.48,,,72008.48,30553.92265,72008.4768,case rate,,,
FRACTURE OF FEMUR,340-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11410.67,,,11410.67,5316.845198,11410.674,case rate,,,
FRACTURE OF FEMUR,340-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14185.23,,,14185.23,6034.334778,14680.3292,case rate,,,
FRACTURE OF FEMUR,340-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20226.76,,,20226.76,8849.862854,35316.962,case rate,,,
FRACTURE OF FEMUR,340-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,29750.24,,,29750.24,16870.90154,48058.8492,case rate,,,
FRACTURE OF PELVIS OR DISLOCATION OF HIP,341-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12260.54,,,12260.54,4732.957126,12260.538,case rate,,,
FRACTURE OF PELVIS OR DISLOCATION OF HIP,341-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15037.59,,,15037.59,5737.442538,15037.5936,case rate,,,
FRACTURE OF PELVIS OR DISLOCATION OF HIP,341-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19161.93,,,19161.93,7997.534715,19946.2572,case rate,,,
FRACTURE OF PELVIS OR DISLOCATION OF HIP,341-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,35751.78,,,35751.78,15281.291,45123.20171,case rate,,,
"FRACTURES AND DISLOCATIONS EXCEPT FEMUR, PELVIS AND BACK",342-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12295.53,,,12295.53,4844.291716,12295.5324,case rate,,,
"FRACTURES AND DISLOCATIONS EXCEPT FEMUR, PELVIS AND BACK",342-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16562.35,,,16562.35,5866.095842,16562.3496,case rate,,,
"FRACTURES AND DISLOCATIONS EXCEPT FEMUR, PELVIS AND BACK",342-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23083.81,,,23083.81,9358.290815,23083.806,case rate,,,
"FRACTURES AND DISLOCATIONS EXCEPT FEMUR, PELVIS AND BACK",342-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,37916.43,,,37916.43,15367.88457,54869.3112,case rate,,,
MUSCULOSKELETAL MALIGNANCY AND PATHOLOGICAL FRACTURE DUE TO MUSCULOSKELETAL MALIGNANCY,343-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18679.51,,,18679.51,7009.130966,18679.5108,case rate,,,
MUSCULOSKELETAL MALIGNANCY AND PATHOLOGICAL FRACTURE DUE TO MUSCULOSKELETAL MALIGNANCY,343-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21953.99,,,21953.99,8775.639794,21953.9868,case rate,,,
MUSCULOSKELETAL MALIGNANCY AND PATHOLOGICAL FRACTURE DUE TO MUSCULOSKELETAL MALIGNANCY,343-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,32082.37,,,32082.37,17239.54274,44503.3112,case rate,,,
MUSCULOSKELETAL MALIGNANCY AND PATHOLOGICAL FRACTURE DUE TO MUSCULOSKELETAL MALIGNANCY,343-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,51949.19,,,51949.19,21617.46623,79855.5176,case rate,,,
"OSTEOMYELITIS, SEPTIC ARTHRITIS AND OTHER MUSCULOSKELETAL INFECTIONS",344-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16227.4,,,16227.4,7847.851544,16670.6012,case rate,,,
"OSTEOMYELITIS, SEPTIC ARTHRITIS AND OTHER MUSCULOSKELETAL INFECTIONS",344-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20586.71,,,20586.71,9243.245072,23837.6536,case rate,,,
"OSTEOMYELITIS, SEPTIC ARTHRITIS AND OTHER MUSCULOSKELETAL INFECTIONS",344-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,29530.27,,,29530.27,13350.25439,36973.4488,case rate,,,
"OSTEOMYELITIS, SEPTIC ARTHRITIS AND OTHER MUSCULOSKELETAL INFECTIONS",344-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,47417.41,,,47417.41,25700.97158,71168.8096,case rate,,,
CONNECTIVE TISSUE DISORDERS,346-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14757.64,,,14757.64,7701.879526,15165.458,case rate,,,
CONNECTIVE TISSUE DISORDERS,346-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19651.86,,,19651.86,9745.487778,19948.3304,case rate,,,
CONNECTIVE TISSUE DISORDERS,346-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,29992.7,,,29992.7,16054.44788,34475.2428,case rate,,,
CONNECTIVE TISSUE DISORDERS,346-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,62262.54,,,62262.54,31037.60959,101058.134,case rate,,,
"OTHER BACK AND NECK DISORDERS, FRACTURES AND INJURIES",347-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14497.68,,,14497.68,5435.602094,14497.68,case rate,,,
"OTHER BACK AND NECK DISORDERS, FRACTURES AND INJURIES",347-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18282.07,,,18282.07,6772.854225,18282.0744,case rate,,,
"OTHER BACK AND NECK DISORDERS, FRACTURES AND INJURIES",347-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24741.04,,,24741.04,9911.252612,24741.0408,case rate,,,
"OTHER BACK AND NECK DISORDERS, FRACTURES AND INJURIES",347-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42653.17,,,42653.17,17676.22174,65415.6796,case rate,,,
"MALFUNCTION, REACTION, COMPLICATION OF ORTHOPEDIC DEVICE OR PROCEDURE",349-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12840.45,,,12840.45,5452.920808,12840.4452,case rate,,,
"MALFUNCTION, REACTION, COMPLICATION OF ORTHOPEDIC DEVICE OR PROCEDURE",349-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18182.09,,,18182.09,7583.12263,18227.5744,case rate,,,
"MALFUNCTION, REACTION, COMPLICATION OF ORTHOPEDIC DEVICE OR PROCEDURE",349-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26118.32,,,26118.32,12562.25291,32300.456,case rate,,,
"MALFUNCTION, REACTION, COMPLICATION OF ORTHOPEDIC DEVICE OR PROCEDURE",349-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,46462.56,,,46462.56,18529.78693,74042.2648,case rate,,,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES,351-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11600.64,,,11600.64,5078.094355,11600.6436,case rate,,,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES,351-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14707.65,,,14707.65,6184.017949,14707.6464,case rate,,,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES,351-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22768.86,,,22768.86,10279.89381,23939.2404,case rate,,,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES,351-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,39998.6,,,39998.6,17155.42327,63864.926,case rate,,,
SKIN GRAFT FOR SKIN AND SUBCUTANEOUS TISSUE DIAGNOSES,361-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,33619.62,,,33619.62,14186.50087,33619.62,case rate,,,
SKIN GRAFT FOR SKIN AND SUBCUTANEOUS TISSUE DIAGNOSES,361-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,41758.32,,,41758.32,18065.8928,41758.3176,case rate,,,
SKIN GRAFT FOR SKIN AND SUBCUTANEOUS TISSUE DIAGNOSES,361-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,63677.31,,,63677.31,39833.0422,69240.7336,case rate,,,
SKIN GRAFT FOR SKIN AND SUBCUTANEOUS TISSUE DIAGNOSES,361-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128034.51,,,128034.51,86944.89248,199037.566,case rate,,,
MASTECTOMY PROCEDURES,362-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,31032.53,,,31032.53,13186.96366,31032.534,case rate,,,
MASTECTOMY PROCEDURES,362-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,44682.85,,,44682.85,21263.66964,44682.8496,case rate,,,
MASTECTOMY PROCEDURES,362-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,52956.53,,,52956.53,31751.38802,57599.7156,case rate,,,
MASTECTOMY PROCEDURES,362-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,94032.45,,,94032.45,60199.5084,98228.30879,case rate,,,
BREAST PROCEDURES EXCEPT MASTECTOMY,363-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25605.9,,,25605.9,12076.09186,25605.9024,case rate,,,
BREAST PROCEDURES EXCEPT MASTECTOMY,363-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,47132.46,,,47132.46,22093.73086,47132.4576,case rate,,,
BREAST PROCEDURES EXCEPT MASTECTOMY,363-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,59822.93,,,59822.93,24995.85251,59822.9268,case rate,,,
BREAST PROCEDURES EXCEPT MASTECTOMY,363-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,75992.84,,,75992.84,47162.56938,86414.37621,case rate,,,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND RELATED PROCEDURES",364-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18327.07,,,18327.07,7727.857597,18327.0672,case rate,,,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND RELATED PROCEDURES",364-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25320.95,,,25320.95,10091.86206,25320.948,case rate,,,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND RELATED PROCEDURES",364-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,40436.03,,,40436.03,19288.09919,41942.9092,case rate,,,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND RELATED PROCEDURES",364-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,72275.93,,,72275.93,30685.05006,110072.4076,case rate,,,
SKIN ULCERS,380-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12827.95,,,12827.95,5143.658058,14232.518,case rate,,,
SKIN ULCERS,380-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16702.33,,,16702.33,7255.304115,17296.7076,case rate,,,
SKIN ULCERS,380-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24163.63,,,24163.63,10987.48698,26905.9896,case rate,,,
SKIN ULCERS,380-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42353.22,,,42353.22,22432.68283,51670.3636,case rate,,,
MAJOR SKIN DISORDERS,381-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,9051.05,,,9051.05,5139.946905,12325.174,case rate,,,
MAJOR SKIN DISORDERS,381-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14912.61,,,14912.61,10814.29984,18256.5992,case rate,,,
MAJOR SKIN DISORDERS,381-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,29982.7,,,29982.7,16178.15298,39952.6372,case rate,,,
MAJOR SKIN DISORDERS,381-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,59035.55,,,59035.55,46947.3225,122376.8496,case rate,,,
MALIGNANT BREAST DISORDERS,382-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14382.7,,,14382.7,7409.93549,14382.6984,case rate,,,
MALIGNANT BREAST DISORDERS,382-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16937.29,,,16937.29,8736.054162,17551.24968,case rate,,,
MALIGNANT BREAST DISORDERS,382-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23988.66,,,23988.66,12394.01397,31224.4652,case rate,,,
MALIGNANT BREAST DISORDERS,382-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,35526.81,,,35526.81,22958.42951,59992.1884,case rate,,,
CELLULITIS AND OTHER SKIN INFECTIONS,383-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10528.32,,,10528.32,4840.580563,10528.3152,case rate,,,
CELLULITIS AND OTHER SKIN INFECTIONS,383-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14430.19,,,14430.19,6415.346486,14430.1908,case rate,,,
CELLULITIS AND OTHER SKIN INFECTIONS,383-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21469.06,,,21469.06,9314.99403,24503.1508,case rate,,,
CELLULITIS AND OTHER SKIN INFECTIONS,383-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,39218.72,,,39218.72,19870.75021,57916.9152,case rate,,,
"CONTUSION, OPEN WOUND AND OTHER TRAUMA TO SKIN AND SUBCUTANEOUS TISSUE",384-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13467.84,,,13467.84,4469.465263,13467.8448,case rate,,,
"CONTUSION, OPEN WOUND AND OTHER TRAUMA TO SKIN AND SUBCUTANEOUS TISSUE",384-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16879.8,,,16879.8,5931.659545,16879.7988,case rate,,,
"CONTUSION, OPEN WOUND AND OTHER TRAUMA TO SKIN AND SUBCUTANEOUS TISSUE",384-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24593.56,,,24593.56,9802.392124,24593.5644,case rate,,,
"CONTUSION, OPEN WOUND AND OTHER TRAUMA TO SKIN AND SUBCUTANEOUS TISSUE",384-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,41223.4,,,41223.4,23002.96335,46957.76136,case rate,,,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST DISORDERS",385-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10365.84,,,10365.84,5467.76542,10365.8412,case rate,,,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST DISORDERS",385-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13672.81,,,13672.81,6529.155178,13672.812,case rate,,,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST DISORDERS",385-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21229.1,,,21229.1,11117.37734,22452.756,case rate,,,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST DISORDERS",385-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42590.68,,,42590.68,21545.71727,60012.9204,case rate,,,
ADRENAL PROCEDURES,401-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,31822.41,,,31822.41,12116.91455,31822.4076,case rate,,,
ADRENAL PROCEDURES,401-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,56076.03,,,56076.03,35069.1588,56076.0264,case rate,,,
ADRENAL PROCEDURES,401-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,70371.24,,,70371.24,42096.84553,70371.2388,case rate,,,
ADRENAL PROCEDURES,401-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,118153.59,,,118153.59,73754.21767,152983.7211,case rate,,,
PROCEDURES FOR OBESITY,403-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27653.07,,,27653.07,9434.987977,27653.0748,case rate,,,
PROCEDURES FOR OBESITY,403-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,32104.86,,,32104.86,10330.6129,32104.8624,case rate,,,
PROCEDURES FOR OBESITY,403-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,45797.67,,,45797.67,21879.72104,45797.6712,case rate,,,
PROCEDURES FOR OBESITY,403-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,93542.53,,,93542.53,52066.23954,136348.1444,case rate,,,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES",404-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22673.87,,,22673.87,8439.161922,22673.8716,case rate,,,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES",404-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,33262.18,,,33262.18,13549.4196,33262.1772,case rate,,,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES",404-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,55818.57,,,55818.57,24232.59204,55818.5676,case rate,,,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES",404-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,116111.42,,,116111.42,55286.0244,116111.4192,case rate,,,
"OTHER PROCEDURES FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS",405-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,31882.4,,,31882.4,14101.14435,31882.398,case rate,,,
"OTHER PROCEDURES FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS",405-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,35949.25,,,35949.25,17777.65992,35949.2472,case rate,,,
"OTHER PROCEDURES FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS",405-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,54601.26,,,54601.26,34643.61326,61057.8132,case rate,,,
"OTHER PROCEDURES FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS",405-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,108352.66,,,108352.66,64833.84291,173902.0892,case rate,,,
DIABETES,420-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10585.81,,,10585.81,5450.446706,10585.806,case rate,,,
DIABETES,420-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13602.82,,,13602.82,6132.061807,13602.8232,case rate,,,
DIABETES,420-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20111.78,,,20111.78,9246.956225,20261.3836,case rate,,,
DIABETES,420-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,39328.71,,,39328.71,19479.8421,52659.28,case rate,,,
"MALNUTRITION, FAILURE TO THRIVE AND OTHER NUTRITIONAL DISORDERS",421-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,9700.95,,,9700.95,6843.636573,12957.5,case rate,,,
"MALNUTRITION, FAILURE TO THRIVE AND OTHER NUTRITIONAL DISORDERS",421-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14510.18,,,14510.18,10073.30629,18934.5356,case rate,,,
"MALNUTRITION, FAILURE TO THRIVE AND OTHER NUTRITIONAL DISORDERS",421-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21988.98,,,21988.98,16778.12271,28767.7232,case rate,,,
"MALNUTRITION, FAILURE TO THRIVE AND OTHER NUTRITIONAL DISORDERS",421-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42410.71,,,42410.71,28107.03577,66369.3516,case rate,,,
HYPOVOLEMIA AND RELATED ELECTROLYTE DISORDERS,422-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,8221.18,,,8221.18,4104.535218,8221.1844,case rate,,,
HYPOVOLEMIA AND RELATED ELECTROLYTE DISORDERS,422-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12235.54,,,12235.54,5026.138213,12235.542,case rate,,,
HYPOVOLEMIA AND RELATED ELECTROLYTE DISORDERS,422-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17809.65,,,17809.65,8599.978552,18700.264,case rate,,,
HYPOVOLEMIA AND RELATED ELECTROLYTE DISORDERS,422-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,31135.02,,,31135.02,13498.70051,47067.8596,case rate,,,
INBORN ERRORS OF METABOLISM,423-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12470.5,,,12470.5,7505.188417,17938.82382,case rate,,,
INBORN ERRORS OF METABOLISM,423-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16337.39,,,16337.39,12073.61776,22501.83327,case rate,,,
INBORN ERRORS OF METABOLISM,423-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25660.89,,,25660.89,21091.5376,33626.56297,case rate,,,
INBORN ERRORS OF METABOLISM,423-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,55516.12,,,55516.12,55516.116,112746.8356,case rate,,,
OTHER ENDOCRINE DISORDERS,424-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11885.6,,,11885.6,5590.233469,11885.598,case rate,,,
OTHER ENDOCRINE DISORDERS,424-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16539.85,,,16539.85,7811.977065,16539.8532,case rate,,,
OTHER ENDOCRINE DISORDERS,424-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24321.11,,,24321.11,13841.36364,24573.6396,case rate,,,
OTHER ENDOCRINE DISORDERS,424-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42985.62,,,42985.62,17585.91702,57699.2292,case rate,,,
OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,425-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10568.31,,,10568.31,4443.487192,10568.3088,case rate,,,
OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,425-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12940.43,,,12940.43,5879.703403,12940.4292,case rate,,,
OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,425-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17514.7,,,17514.7,9494.366425,20698.8288,case rate,,,
OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,425-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,34626.96,,,34626.96,16985.94728,51643.412,case rate,,,
NON-HYPOVOLEMIC SODIUM DISORDERS,426-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11280.69,,,11280.69,4412.560917,11280.6948,case rate,,,
NON-HYPOVOLEMIC SODIUM DISORDERS,426-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14942.61,,,14942.61,6490.806597,14942.6088,case rate,,,
NON-HYPOVOLEMIC SODIUM DISORDERS,426-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21841.5,,,21841.5,10221.75241,21841.5048,case rate,,,
NON-HYPOVOLEMIC SODIUM DISORDERS,426-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38723.8,,,38723.8,19425.41185,39606.92203,case rate,,,
THYROID DISORDERS,427-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11013.24,,,11013.24,4713.16431,11013.2376,case rate,,,
THYROID DISORDERS,427-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15192.57,,,15192.57,6583.585422,15192.5688,case rate,,,
THYROID DISORDERS,427-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24198.63,,,24198.63,12140.41851,24198.6276,case rate,,,
THYROID DISORDERS,427-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42263.24,,,42263.24,22892.86581,44505.67884,case rate,,,
KIDNEY TRANSPLANT,440-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,106417.97,,,106417.97,76832.792,106417.9704,case rate,,,
KIDNEY TRANSPLANT,440-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,119178.43,,,119178.43,85811.75377,119178.4284,case rate,,,
KIDNEY TRANSPLANT,440-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,138957.76,,,138957.76,90276.27083,138957.7632,case rate,,,
KIDNEY TRANSPLANT,440-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,210811.26,,,210811.26,116025.4874,215283.1612,case rate,,,
MAJOR BLADDER PROCEDURES,441-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36241.7,,,36241.7,23355.52288,36241.7004,case rate,,,
MAJOR BLADDER PROCEDURES,441-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,55153.67,,,55153.67,24085.38297,55153.674,case rate,,,
MAJOR BLADDER PROCEDURES,441-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,72115.96,,,72115.96,29608.81569,72115.9596,case rate,,,
MAJOR BLADDER PROCEDURES,441-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,142082.26,,,142082.26,79176.2122,142082.2632,case rate,,,
KIDNEY AND URINARY TRACT PROCEDURES FOR MALIGNANCY,442-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,33899.58,,,33899.58,11636.93876,33899.5752,case rate,,,
KIDNEY AND URINARY TRACT PROCEDURES FOR MALIGNANCY,442-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,39366.2,,,39366.2,13346.54324,39366.2004,case rate,,,
KIDNEY AND URINARY TRACT PROCEDURES FOR MALIGNANCY,442-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,57193.35,,,57193.35,22750.60494,58375.0924,case rate,,,
KIDNEY AND URINARY TRACT PROCEDURES FOR MALIGNANCY,442-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,100198.97,,,100198.97,44083.54944,132185.1588,case rate,,,
KIDNEY AND URINARY TRACT PROCEDURES FOR NON-MALIGNANCY,443-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28535.43,,,28535.43,11062.94709,28535.4336,case rate,,,
KIDNEY AND URINARY TRACT PROCEDURES FOR NON-MALIGNANCY,443-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,33039.71,,,33039.71,12123.0998,33039.7128,case rate,,,
KIDNEY AND URINARY TRACT PROCEDURES FOR NON-MALIGNANCY,443-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48587.22,,,48587.22,22086.30855,48587.2248,case rate,,,
KIDNEY AND URINARY TRACT PROCEDURES FOR NON-MALIGNANCY,443-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,81424.47,,,81424.47,37955.19878,105065.6296,case rate,,,
RENAL DIALYSIS ACCESS DEVICE PROCEDURES,444-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22443.91,,,22443.91,11144.59246,23252.19482,case rate,,,
RENAL DIALYSIS ACCESS DEVICE PROCEDURES,444-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,33467.14,,,33467.14,17159.13442,36216.7308,case rate,,,
RENAL DIALYSIS ACCESS DEVICE PROCEDURES,444-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49377.1,,,49377.1,25838.28424,67018.2632,case rate,,,
RENAL DIALYSIS ACCESS DEVICE PROCEDURES,444-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,84379,,,84379,48597.54854,128246.0788,case rate,,,
OTHER BLADDER PROCEDURES,445-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23348.76,,,23348.76,8854.811058,23348.7636,case rate,,,
OTHER BLADDER PROCEDURES,445-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,29707.75,,,29707.75,12878.93796,29707.746,case rate,,,
OTHER BLADDER PROCEDURES,445-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,41720.82,,,41720.82,21110.27532,41720.8236,case rate,,,
OTHER BLADDER PROCEDURES,445-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,77910.03,,,77910.03,50785.1072,79405.37778,case rate,,,
URETHRAL AND TRANSURETHRAL PROCEDURES,446-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20209.27,,,20209.27,6557.607351,20209.266,case rate,,,
URETHRAL AND TRANSURETHRAL PROCEDURES,446-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24608.56,,,24608.56,8358.753607,24608.562,case rate,,,
URETHRAL AND TRANSURETHRAL PROCEDURES,446-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38683.81,,,38683.81,15461.90045,38683.8096,case rate,,,
URETHRAL AND TRANSURETHRAL PROCEDURES,446-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,64114.74,,,64114.74,25928.58896,68185.4748,case rate,,,
"OTHER KIDNEY, URINARY TRACT AND RELATED PROCEDURES",447-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,30457.63,,,30457.63,17965.69167,30457.626,case rate,,,
"OTHER KIDNEY, URINARY TRACT AND RELATED PROCEDURES",447-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36876.6,,,36876.6,19581.28028,36876.5988,case rate,,,
"OTHER KIDNEY, URINARY TRACT AND RELATED PROCEDURES",447-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,51471.76,,,51471.76,23259.0329,60769.6384,case rate,,,
"OTHER KIDNEY, URINARY TRACT AND RELATED PROCEDURES",447-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,104930.71,,,104930.71,52201.0781,158197.5992,case rate,,,
KIDNEY AND URINARY TRACT MALIGNANCY,461-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15040.09,,,15040.09,6963.360079,16296.14042,case rate,,,
KIDNEY AND URINARY TRACT MALIGNANCY,461-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18139.6,,,18139.6,8693.994428,18328.65129,case rate,,,
KIDNEY AND URINARY TRACT MALIGNANCY,461-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26253.3,,,26253.3,13224.07519,31158.1228,case rate,,,
KIDNEY AND URINARY TRACT MALIGNANCY,461-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38003.92,,,38003.92,23208.31381,48266.1692,case rate,,,
NEPHRITIS AND NEPHROSIS,462-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10285.85,,,10285.85,6113.506042,12236.0264,case rate,,,
NEPHRITIS AND NEPHROSIS,462-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15020.1,,,15020.1,8983.464362,15020.0964,case rate,,,
NEPHRITIS AND NEPHROSIS,462-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27875.54,,,27875.54,17557.46484,29937.84867,case rate,,,
NEPHRITIS AND NEPHROSIS,462-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,62567.49,,,62567.49,42597.85119,83303.2492,case rate,,,
KIDNEY AND URINARY TRACT INFECTIONS,463-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11468.16,,,11468.16,4507.813844,11468.1648,case rate,,,
KIDNEY AND URINARY TRACT INFECTIONS,463-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14412.69,,,14412.69,5660.745376,14412.6936,case rate,,,
KIDNEY AND URINARY TRACT INFECTIONS,463-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19354.4,,,19354.4,8570.289328,20464.5572,case rate,,,
KIDNEY AND URINARY TRACT INFECTIONS,463-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,30110.18,,,30110.18,15012.85094,45216.492,case rate,,,
URINARY STONES AND ACQUIRED UPPER URINARY TRACT OBSTRUCTION,465-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12080.57,,,12080.57,4434.827835,12080.5668,case rate,,,
URINARY STONES AND ACQUIRED UPPER URINARY TRACT OBSTRUCTION,465-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14842.62,,,14842.62,4939.544643,14842.6248,case rate,,,
URINARY STONES AND ACQUIRED UPPER URINARY TRACT OBSTRUCTION,465-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24563.57,,,24563.57,10142.58115,24563.5692,case rate,,,
URINARY STONES AND ACQUIRED UPPER URINARY TRACT OBSTRUCTION,465-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42668.17,,,42668.17,14394.32544,44967.708,case rate,,,
"MALFUNCTION, REACTION, COMPLICATION OF GENITOURINARY DEVICE OR PROCEDURE",466-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10365.84,,,10365.84,4913.566572,10413.6836,case rate,,,
"MALFUNCTION, REACTION, COMPLICATION OF GENITOURINARY DEVICE OR PROCEDURE",466-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14847.62,,,14847.62,5910.629678,14847.624,case rate,,,
"MALFUNCTION, REACTION, COMPLICATION OF GENITOURINARY DEVICE OR PROCEDURE",466-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21099.12,,,21099.12,9423.854518,24121.682,case rate,,,
"MALFUNCTION, REACTION, COMPLICATION OF GENITOURINARY DEVICE OR PROCEDURE",466-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,35329.35,,,35329.35,16039.60327,48257.8764,case rate,,,
"OTHER KIDNEY AND URINARY TRACT DIAGNOSES, SIGNS AND SYMPTOMS",468-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11188.21,,,11188.21,5075.620253,11188.2096,case rate,,,
"OTHER KIDNEY AND URINARY TRACT DIAGNOSES, SIGNS AND SYMPTOMS",468-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15387.54,,,15387.54,6367.101497,15387.5376,case rate,,,
"OTHER KIDNEY AND URINARY TRACT DIAGNOSES, SIGNS AND SYMPTOMS",468-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21968.98,,,21968.98,11291.80153,24658.6408,case rate,,,
"OTHER KIDNEY AND URINARY TRACT DIAGNOSES, SIGNS AND SYMPTOMS",468-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38508.84,,,38508.84,28734.22063,58229.9684,case rate,,,
ACUTE KIDNEY INJURY,469-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11318.19,,,11318.19,4437.301937,11318.1888,case rate,,,
ACUTE KIDNEY INJURY,469-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14677.65,,,14677.65,5851.25123,15434.974,case rate,,,
ACUTE KIDNEY INJURY,469-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22908.83,,,22908.83,10456.7921,28158.2024,case rate,,,
ACUTE KIDNEY INJURY,469-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42860.64,,,42860.64,23649.94102,68442.5516,case rate,,,
CHRONIC KIDNEY DISEASE,470-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,9463.49,,,9463.49,5408.386972,10507.31509,case rate,,,
CHRONIC KIDNEY DISEASE,470-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12887.94,,,12887.94,6814.913959,14166.1756,case rate,,,
CHRONIC KIDNEY DISEASE,470-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21296.59,,,21296.59,11987.02419,24714.6172,case rate,,,
CHRONIC KIDNEY DISEASE,470-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,37301.53,,,37301.53,28924.72648,55068.3384,case rate,,,
MAJOR MALE PELVIC PROCEDURES,480-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,31872.4,,,31872.4,10733.89153,31872.3996,case rate,,,
MAJOR MALE PELVIC PROCEDURES,480-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36631.64,,,36631.64,11931.3569,36631.638,case rate,,,
MAJOR MALE PELVIC PROCEDURES,480-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,54628.76,,,54628.76,28808.44369,54628.758,case rate,,,
MAJOR MALE PELVIC PROCEDURES,480-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,89723.14,,,89723.14,53851.37,99928.78029,case rate,,,
TRANSURETHRAL PROSTATECTOMY,482-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17547.19,,,17547.19,6333.70112,17547.192,case rate,,,
TRANSURETHRAL PROSTATECTOMY,482-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21459.07,,,21459.07,7856.510901,21459.066,case rate,,,
TRANSURETHRAL PROSTATECTOMY,482-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,39028.75,,,39028.75,15105.62976,48801.0548,case rate,,,
TRANSURETHRAL PROSTATECTOMY,482-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,64947.11,,,64947.11,40045.81497,67897.58062,case rate,,,
"PENIS, TESTES AND SCROTAL PROCEDURES",483-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22598.88,,,22598.88,10968.93122,23008.83432,case rate,,,
"PENIS, TESTES AND SCROTAL PROCEDURES",483-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,30185.17,,,30185.17,13637.25022,30185.1696,case rate,,,
"PENIS, TESTES AND SCROTAL PROCEDURES",483-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,45367.74,,,45367.74,29367.59074,65958.858,case rate,,,
"PENIS, TESTES AND SCROTAL PROCEDURES",483-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,81874.4,,,81874.4,61402.26344,102854.6324,case rate,,,
OTHER MALE REPRODUCTIVE SYSTEM AND RELATED PROCEDURES,484-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26938.19,,,26938.19,9928.571326,26938.1892,case rate,,,
OTHER MALE REPRODUCTIVE SYSTEM AND RELATED PROCEDURES,484-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,34426.99,,,34426.99,10566.88964,34426.9908,case rate,,,
OTHER MALE REPRODUCTIVE SYSTEM AND RELATED PROCEDURES,484-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,41285.89,,,41285.89,14999.24338,41285.8932,case rate,,,
OTHER MALE REPRODUCTIVE SYSTEM AND RELATED PROCEDURES,484-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,91002.94,,,91002.94,44530.2628,93312.97992,case rate,,,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM",500-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12078.07,,,12078.07,6494.51775,13909.85547,case rate,,,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM",500-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16552.35,,,16552.35,9042.84281,19544.0564,case rate,,,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM",500-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25508.42,,,25508.42,14146.91524,32750.3404,case rate,,,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM",500-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,45340.24,,,45340.24,30680.10185,45340.2444,case rate,,,
MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,501-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10988.24,,,10988.24,4676.05278,10988.2416,case rate,,,
MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,501-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14745.14,,,14745.14,6501.940056,14745.1404,case rate,,,
MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,501-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21649.04,,,21649.04,9456.017844,23275.8164,case rate,,,
MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,501-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,44190.43,,,44190.43,24962.45213,44213.0632,case rate,,,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND OTHER RADICAL GYNECOLOGICAL PROCEDURES",510-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,32867.24,,,32867.24,14689.98063,32867.2404,case rate,,,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND OTHER RADICAL GYNECOLOGICAL PROCEDURES",510-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38461.35,,,38461.35,18325.67351,38461.3452,case rate,,,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND OTHER RADICAL GYNECOLOGICAL PROCEDURES",510-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,58620.62,,,58620.62,39320.90309,58620.6192,case rate,,,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND OTHER RADICAL GYNECOLOGICAL PROCEDURES",510-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,120598.2,,,120598.2,83533.10583,132877.6076,case rate,,,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN AND ADNEXAL MALIGNANCY,511-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,33049.71,,,33049.71,13689.20637,33049.7112,case rate,,,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN AND ADNEXAL MALIGNANCY,511-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,40136.08,,,40136.08,16269.69475,40136.0772,case rate,,,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN AND ADNEXAL MALIGNANCY,511-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,59110.54,,,59110.54,24194.24346,59110.5408,case rate,,,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN AND ADNEXAL MALIGNANCY,511-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,108867.58,,,108867.58,70245.94104,129085.7248,case rate,,,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY,512-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,30305.15,,,30305.15,11993.20945,30305.1504,case rate,,,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY,512-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,35854.26,,,35854.26,14775.33714,35854.2624,case rate,,,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY,512-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,56425.97,,,56425.97,20139.19028,56425.9704,case rate,,,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY,512-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,96672.03,,,96672.03,66543.44739,155560.4888,case rate,,,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA,513-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23416.25,,,23416.25,8623.482521,23416.2528,case rate,,,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA,513-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28187.99,,,28187.99,11237.37128,28187.9892,case rate,,,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA,513-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,44782.83,,,44782.83,17451.07846,44782.8336,case rate,,,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA,513-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,72678.37,,,72678.37,48770.73568,99546.7712,case rate,,,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,514-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19391.9,,,19391.9,8475.036401,20611.7544,case rate,,,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,514-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28765.4,,,28765.4,13920.5349,28765.3968,case rate,,,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,514-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,55523.61,,,55523.61,20611.7544,55523.6148,case rate,,,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,514-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,92800.15,,,92800.15,64279.64406,99535.28358,case rate,,,
DILATION AND CURETTAGE FOR NON-OBSTETRIC DIAGNOSES,517-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16377.38,,,16377.38,8457.717687,16377.3792,case rate,,,
DILATION AND CURETTAGE FOR NON-OBSTETRIC DIAGNOSES,517-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20789.17,,,20789.17,10204.4337,20789.1732,case rate,,,
DILATION AND CURETTAGE FOR NON-OBSTETRIC DIAGNOSES,517-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,34891.92,,,34891.92,17614.36919,42208.2788,case rate,,,
DILATION AND CURETTAGE FOR NON-OBSTETRIC DIAGNOSES,517-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,61375.18,,,61375.18,40275.90646,74713.92807,case rate,,,
OTHER FEMALE REPRODUCTIVE SYSTEM AND RELATED PROCEDURES,518-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19889.32,,,19889.32,8877.077976,19889.3172,case rate,,,
OTHER FEMALE REPRODUCTIVE SYSTEM AND RELATED PROCEDURES,518-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28867.88,,,28867.88,11375.921,28867.8804,case rate,,,
OTHER FEMALE REPRODUCTIVE SYSTEM AND RELATED PROCEDURES,518-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48549.73,,,48549.73,24019.81927,48604.50066,case rate,,,
OTHER FEMALE REPRODUCTIVE SYSTEM AND RELATED PROCEDURES,518-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,89040.75,,,89040.75,53627.3979,123933.8228,case rate,,,
UTERINE AND ADNEXA PROCEDURES FOR LEIOMYOMA,519-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22143.96,,,22143.96,8666.779306,22143.9564,case rate,,,
UTERINE AND ADNEXA PROCEDURES FOR LEIOMYOMA,519-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28140.5,,,28140.5,11551.58224,28140.4968,case rate,,,
UTERINE AND ADNEXA PROCEDURES FOR LEIOMYOMA,519-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,45487.72,,,45487.72,24517.11377,45487.7208,case rate,,,
UTERINE AND ADNEXA PROCEDURES FOR LEIOMYOMA,519-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,87011.08,,,87011.08,55004.23566,125403.7216,case rate,,,
FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,530-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13037.91,,,13037.91,6657.808482,13587.62814,case rate,,,
FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,530-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17554.69,,,17554.69,9229.637511,17554.6908,case rate,,,
FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,530-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25523.42,,,25523.42,12299.99809,30100.7908,case rate,,,
FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,530-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,40988.44,,,40988.44,16086.6112,51977.1972,case rate,,,
FEMALE REPRODUCTIVE SYSTEM INFECTIONS,531-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11913.09,,,11913.09,4797.283778,11913.0936,case rate,,,
FEMALE REPRODUCTIVE SYSTEM INFECTIONS,531-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15552.51,,,15552.51,6639.252717,15552.5112,case rate,,,
FEMALE REPRODUCTIVE SYSTEM INFECTIONS,531-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24013.66,,,24013.66,9031.709351,24028.388,case rate,,,
FEMALE REPRODUCTIVE SYSTEM INFECTIONS,531-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,39301.21,,,39301.21,26913.28156,45870.35111,case rate,,,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,532-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,9933.41,,,9933.41,4301.226327,9995.807368,case rate,,,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,532-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12453.01,,,12453.01,5490.032338,12453.0072,case rate,,,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,532-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19584.37,,,19584.37,8175.670059,20124.5524,case rate,,,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,532-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,32392.32,,,32392.32,21329.0816,41303.68554,case rate,,,
CESAREAN SECTION WITH STERILIZATION,539-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16009.94,,,16009.94,8315.456822,16009.938,case rate,,,
CESAREAN SECTION WITH STERILIZATION,539-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18492.04,,,18492.04,9798.680971,18492.0408,case rate,,,
CESAREAN SECTION WITH STERILIZATION,539-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26135.82,,,26135.82,14766.67779,26135.8176,case rate,,,
CESAREAN SECTION WITH STERILIZATION,539-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,54086.34,,,54086.34,27495.93258,54086.3448,case rate,,,
CESAREAN SECTION WITHOUT STERILIZATION,540-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15709.99,,,15709.99,8545.548308,16608.4052,case rate,,,
CESAREAN SECTION WITHOUT STERILIZATION,540-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19136.94,,,19136.94,10912.02687,19136.9376,case rate,,,
CESAREAN SECTION WITHOUT STERILIZATION,540-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24188.63,,,24188.63,14180.31561,24389.1248,case rate,,,
CESAREAN SECTION WITHOUT STERILIZATION,540-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,40646,,,40646,14674.8,56092.4992,case rate,,,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C,541-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16309.89,,,16309.89,8247.419017,16309.89,case rate,,,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C,541-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16997.28,,,16997.28,9564.96,16997.28,case rate,,,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C,541-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20924.15,,,20924.15,9564.96,20924.1516,case rate,,,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C,541-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28138,,,28138,9564.96,28137.9972,case rate,,,
VAGINAL DELIVERY WITH O.R. PROCEDURE EXCEPT STERILIZATION AND/OR D&C,542-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10700.79,,,10700.79,7415.735358,12337.6132,case rate,,,
VAGINAL DELIVERY WITH O.R. PROCEDURE EXCEPT STERILIZATION AND/OR D&C,542-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12173.05,,,12173.05,8497.303319,14060.4424,case rate,,,
VAGINAL DELIVERY WITH O.R. PROCEDURE EXCEPT STERILIZATION AND/OR D&C,542-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17957.13,,,17957.13,9564.96,25326.2112,case rate,,,
VAGINAL DELIVERY WITH O.R. PROCEDURE EXCEPT STERILIZATION AND/OR D&C,542-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,41235.9,,,41235.9,9564.96,41235.9012,case rate,,,
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",543-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12498,,,12498,4687.186239,12498,case rate,,,
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",543-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16544.85,,,16544.85,6346.07163,16544.8524,case rate,,,
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",543-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22371.42,,,22371.42,12108.25519,22371.42,case rate,,,
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",543-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,60722.78,,,60722.78,37334.19918,60722.7828,case rate,,,
ANTEPARTUM WITH O.R. PROCEDURE,547-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16082.43,,,16082.43,7485.395601,16082.4264,case rate,,,
ANTEPARTUM WITH O.R. PROCEDURE,547-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22486.4,,,22486.4,9248.193276,22486.4016,case rate,,,
ANTEPARTUM WITH O.R. PROCEDURE,547-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,33412.15,,,33412.15,15474.27096,33412.1532,case rate,,,
ANTEPARTUM WITH O.R. PROCEDURE,547-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,59687.95,,,59687.95,39007.92918,60186.65798,case rate,,,
POSTPARTUM AND POST ABORTION DIAGNOSIS WITH O.R. PROCEDURE,548-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10853.26,,,10853.26,5402.201717,10853.2632,case rate,,,
POSTPARTUM AND POST ABORTION DIAGNOSIS WITH O.R. PROCEDURE,548-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22506.4,,,22506.4,10036.19476,22506.3984,case rate,,,
POSTPARTUM AND POST ABORTION DIAGNOSIS WITH O.R. PROCEDURE,548-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,37598.98,,,37598.98,16562.87584,37598.9832,case rate,,,
POSTPARTUM AND POST ABORTION DIAGNOSIS WITH O.R. PROCEDURE,548-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,85846.26,,,85846.26,45282.25186,85846.2624,case rate,,,
VAGINAL DELIVERY,560-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,9281.01,,,9281.01,6405.450078,10977.594,case rate,,,
VAGINAL DELIVERY,560-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10598.3,,,10598.3,7140.828122,12132.3664,case rate,,,
VAGINAL DELIVERY,560-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13802.79,,,13802.79,9198.711236,15059.7248,case rate,,,
VAGINAL DELIVERY,560-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19436.89,,,19436.89,9564.96,35173.9112,case rate,,,
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT PROCEDURE,561-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,6518.96,,,6518.96,3781.664907,7857.428,case rate,,,
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT PROCEDURE,561-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,9898.42,,,9898.42,4975.419122,9898.416,case rate,,,
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT PROCEDURE,561-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15482.52,,,15482.52,6473.487883,15482.5224,case rate,,,
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT PROCEDURE,561-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,32714.76,,,32714.76,14762.96663,34523.97624,case rate,,,
"ABORTION WITHOUT D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",564-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7981.22,,,7981.22,4097.112912,7981.2228,case rate,,,
"ABORTION WITHOUT D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",564-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10675.79,,,10675.79,4789.861472,10675.7916,case rate,,,
"ABORTION WITHOUT D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",564-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14905.11,,,14905.11,9176.444318,14905.1148,case rate,,,
"ABORTION WITHOUT D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",564-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,39208.73,,,39208.73,15036.9196,49092.57713,case rate,,,
ANTEPARTUM WITHOUT O.R. PROCEDURE,566-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,6281.49,,,6281.49,3870.732579,7063.3924,case rate,,,
ANTEPARTUM WITHOUT O.R. PROCEDURE,566-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,8453.65,,,8453.65,5616.21154,9244.3988,case rate,,,
ANTEPARTUM WITHOUT O.R. PROCEDURE,566-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12300.53,,,12300.53,7637.552874,13602.2652,case rate,,,
ANTEPARTUM WITHOUT O.R. PROCEDURE,566-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27288.13,,,27288.13,13598.90164,35116.00202,case rate,,,
"NEONATE, TRANSFERRED < 5 DAYS OLD, NOT BORN HERE",580-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7308.83,,,7308.83,3106.94,7308.8304,case rate,,,
"NEONATE, TRANSFERRED < 5 DAYS OLD, NOT BORN HERE",580-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,9346,,,9346,3106.94,9346.0044,case rate,,,
"NEONATE, TRANSFERRED < 5 DAYS OLD, NOT BORN HERE",580-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15332.55,,,15332.55,3106.94,15332.5464,case rate,,,
"NEONATE, TRANSFERRED < 5 DAYS OLD, NOT BORN HERE",580-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25140.98,,,25140.98,3106.94,25158.51877,case rate,,,
"NEONATE, TRANSFERRED < 5 DAYS OLD, BORN HERE",581-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2544.59,,,2544.59,2088.142088,3106.94,case rate,,,
"NEONATE, TRANSFERRED < 5 DAYS OLD, BORN HERE",581-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3811.89,,,3811.89,2351.633951,3852.0056,case rate,,,
"NEONATE, TRANSFERRED < 5 DAYS OLD, BORN HERE",581-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5844.06,,,5844.06,2710.378741,5844.0648,case rate,,,
"NEONATE, TRANSFERRED < 5 DAYS OLD, BORN HERE",581-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,9778.44,,,9778.44,3106.94,10254.0472,case rate,,,
NEONATE WITH ECMO,583-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,374287.6,,,374287.6,3106.94,374287.6044,case rate,,,
NEONATE WITH ECMO,583-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,433113.19,,,433113.19,3106.94,433113.1908,case rate,,,
NEONATE WITH ECMO,583-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,587348.51,,,587348.51,3106.94,602569.6213,case rate,,,
NEONATE WITH ECMO,583-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,741583.83,,,741583.83,3106.94,741583.8276,case rate,,,
NEONATE BIRTH WEIGHT < 1500 GRAMS WITH MAJOR PROCEDURE,588-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,252589.58,,,252589.58,3106.94,400220.894,case rate,,,
NEONATE BIRTH WEIGHT < 1500 GRAMS WITH MAJOR PROCEDURE,588-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,383736.09,,,383736.09,3106.94,400220.894,case rate,,,
NEONATE BIRTH WEIGHT < 1500 GRAMS WITH MAJOR PROCEDURE,588-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,391889.79,,,391889.79,3106.94,523155.4344,case rate,,,
NEONATE BIRTH WEIGHT < 1500 GRAMS WITH MAJOR PROCEDURE,588-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,608300.16,,,608300.16,3106.94,608300.1564,case rate,,,
"NEONATE BIRTH WEIGHT < 500 GRAMS, OR BIRTH WEIGHT 500-999 GRAMS AND GESTATIONAL AGE <24 WEEKS, OR BIRTH WEIGHT 500-749 GRAMS WITH MAJOR ANOMALY OR WITHOUT LIFE SUSTAINING INTERVENTION",589-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,118848.48,,,118848.48,3106.94,284033.2549,case rate,,,
"NEONATE BIRTH WEIGHT < 500 GRAMS, OR BIRTH WEIGHT 500-999 GRAMS AND GESTATIONAL AGE <24 WEEKS, OR BIRTH WEIGHT 500-749 GRAMS WITH MAJOR ANOMALY OR WITHOUT LIFE SUSTAINING INTERVENTION",589-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,98661.71,,,98661.71,3106.94,275285.7968,case rate,,,
"NEONATE BIRTH WEIGHT < 500 GRAMS, OR BIRTH WEIGHT 500-999 GRAMS AND GESTATIONAL AGE <24 WEEKS, OR BIRTH WEIGHT 500-749 GRAMS WITH MAJOR ANOMALY OR WITHOUT LIFE SUSTAINING INTERVENTION",589-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,78477.44,,,78477.44,3106.94,250260.225,case rate,,,
"NEONATE BIRTH WEIGHT < 500 GRAMS, OR BIRTH WEIGHT 500-999 GRAMS AND GESTATIONAL AGE <24 WEEKS, OR BIRTH WEIGHT 500-749 GRAMS WITH MAJOR ANOMALY OR WITHOUT LIFE SUSTAINING INTERVENTION",589-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1664.73,,,1664.73,1664.7336,47416.99153,case rate,,,
NEONATE BIRTH WEIGHT 500-749 GRAMS WITHOUT MAJOR PROCEDURE,591-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3244.48,,,3244.48,2247.721667,214623.6845,case rate,,,
NEONATE BIRTH WEIGHT 500-749 GRAMS WITHOUT MAJOR PROCEDURE,591-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,119430.89,,,119430.89,3106.94,297672.7098,case rate,,,
NEONATE BIRTH WEIGHT 500-749 GRAMS WITHOUT MAJOR PROCEDURE,591-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,224441.58,,,224441.58,3106.94,316172.6148,case rate,,,
NEONATE BIRTH WEIGHT 500-749 GRAMS WITHOUT MAJOR PROCEDURE,591-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,383106.19,,,383106.19,3106.94,453416.6724,case rate,,,
NEONATE BIRTH WEIGHT 750-999 GRAMS WITHOUT MAJOR PROCEDURE,593-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3744.4,,,3744.4,2595.332998,223963.6496,case rate,,,
NEONATE BIRTH WEIGHT 750-999 GRAMS WITHOUT MAJOR PROCEDURE,593-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,202207.64,,,202207.64,3106.94,243214.037,case rate,,,
NEONATE BIRTH WEIGHT 750-999 GRAMS WITHOUT MAJOR PROCEDURE,593-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,255121.67,,,255121.67,3106.94,282328.376,case rate,,,
NEONATE BIRTH WEIGHT 750-999 GRAMS WITHOUT MAJOR PROCEDURE,593-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,396726.51,,,396726.51,3106.94,396726.5136,case rate,,,
NEONATE BIRTH WEIGHT 1000-1249 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION OR MAJOR ANOMALY,602-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,33644.62,,,33644.62,3106.94,134606.6564,case rate,,,
NEONATE BIRTH WEIGHT 1000-1249 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION OR MAJOR ANOMALY,602-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,171100.12,,,171100.12,3106.94,196622.288,case rate,,,
NEONATE BIRTH WEIGHT 1000-1249 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION OR MAJOR ANOMALY,602-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,224236.62,,,224236.62,3106.94,231412.6572,case rate,,,
NEONATE BIRTH WEIGHT 1000-1249 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION OR MAJOR ANOMALY,602-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,284374.49,,,284374.49,3106.94,313501.0112,case rate,,,
NEONATE BIRTH WEIGHT 1000-1249 GRAMS WITH OR WITHOUT SIGNIFICANT CONDITION,603-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3716.91,,,3716.91,3035.723154,107271.5144,case rate,,,
NEONATE BIRTH WEIGHT 1000-1249 GRAMS WITH OR WITHOUT SIGNIFICANT CONDITION,603-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,76567.75,,,76567.75,3106.94,143019.702,case rate,,,
NEONATE BIRTH WEIGHT 1000-1249 GRAMS WITH OR WITHOUT SIGNIFICANT CONDITION,603-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,155187.67,,,155187.67,3106.94,186808.4802,case rate,,,
NEONATE BIRTH WEIGHT 1000-1249 GRAMS WITH OR WITHOUT SIGNIFICANT CONDITION,603-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,318901.47,,,318901.47,3106.94,318901.4676,case rate,,,
NEONATE BIRTH WEIGHT 1250-1499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION OR MAJOR ANOMALY,607-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,54461.28,,,54461.28,3106.94,125246.1584,case rate,,,
NEONATE BIRTH WEIGHT 1250-1499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION OR MAJOR ANOMALY,607-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,131576.44,,,131576.44,3106.94,155042.1888,case rate,,,
NEONATE BIRTH WEIGHT 1250-1499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION OR MAJOR ANOMALY,607-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,169922.81,,,169922.81,3106.94,189679.1412,case rate,,,
NEONATE BIRTH WEIGHT 1250-1499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION OR MAJOR ANOMALY,607-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,218425.05,,,218425.05,3106.94,256779.1318,case rate,,,
NEONATE BIRTH WEIGHT 1250-1499 GRAMS WITH OR WITHOUT SIGNIFICANT CONDITION,608-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13172.89,,,13172.89,3106.94,87994.9008,case rate,,,
NEONATE BIRTH WEIGHT 1250-1499 GRAMS WITH OR WITHOUT SIGNIFICANT CONDITION,608-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,97231.94,,,97231.94,3106.94,117882.152,case rate,,,
NEONATE BIRTH WEIGHT 1250-1499 GRAMS WITH OR WITHOUT SIGNIFICANT CONDITION,608-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,131711.42,,,131711.42,3106.94,141466.8752,case rate,,,
NEONATE BIRTH WEIGHT 1250-1499 GRAMS WITH OR WITHOUT SIGNIFICANT CONDITION,608-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,138297.87,,,138297.87,3106.94,235257.5006,case rate,,,
NEONATE BIRTH WEIGHT 1500-2499 GRAMS WITH MAJOR PROCEDURE,609-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,85576.31,,,85576.31,3106.94,115776.5064,case rate,,,
NEONATE BIRTH WEIGHT 1500-2499 GRAMS WITH MAJOR PROCEDURE,609-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,90080.58,,,90080.58,3106.94,119983.4885,case rate,,,
NEONATE BIRTH WEIGHT 1500-2499 GRAMS WITH MAJOR PROCEDURE,609-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,189647.15,,,189647.15,3106.94,191851.4507,case rate,,,
NEONATE BIRTH WEIGHT 1500-2499 GRAMS WITH MAJOR PROCEDURE,609-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,380661.58,,,380661.58,3106.94,430881.039,case rate,,,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH MAJOR ANOMALY,611-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27863.04,,,27863.04,3106.94,51933.66,case rate,,,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH MAJOR ANOMALY,611-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,61925.09,,,61925.09,3106.94,83651.5468,case rate,,,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH MAJOR ANOMALY,611-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,108112.7,,,108112.7,3106.94,129902.5656,case rate,,,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH MAJOR ANOMALY,611-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,165985.94,,,165985.94,3106.94,216541.2751,case rate,,,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,612-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,56503.46,,,56503.46,3106.94,72939.3224,case rate,,,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,612-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,86443.67,,,86443.67,3106.94,94332.6732,case rate,,,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,612-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,111627.14,,,111627.14,3106.94,131503.076,case rate,,,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,612-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,158724.6,,,158724.6,3106.94,175674.6752,case rate,,,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH CONGENITAL OR PERINATAL INFECTION,613-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,34761.94,,,34761.94,3106.94,55232.1212,case rate,,,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH CONGENITAL OR PERINATAL INFECTION,613-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,63089.9,,,63089.9,3106.94,83500.2032,case rate,,,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH CONGENITAL OR PERINATAL INFECTION,613-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,101548.75,,,101548.75,3106.94,109408.5733,case rate,,,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH CONGENITAL OR PERINATAL INFECTION,613-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,155727.58,,,155727.58,3106.94,182804.2986,case rate,,,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH OR WITHOUT OTHER SIGNIFICANT CONDITION,614-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21714.03,,,21714.03,3106.94,41352.0472,case rate,,,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH OR WITHOUT OTHER SIGNIFICANT CONDITION,614-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,52746.56,,,52746.56,3106.94,68380.3556,case rate,,,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH OR WITHOUT OTHER SIGNIFICANT CONDITION,614-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,96004.64,,,96004.64,3106.94,104408.4252,case rate,,,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH OR WITHOUT OTHER SIGNIFICANT CONDITION,614-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,125144.97,,,125144.97,3106.94,156676.8445,case rate,,,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH MAJOR ANOMALY,621-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,9923.41,,,9923.41,3106.94,22326.0729,case rate,,,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH MAJOR ANOMALY,621-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,32142.36,,,32142.36,3106.94,53971.95178,case rate,,,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH MAJOR ANOMALY,621-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,76437.77,,,76437.77,3106.94,99259.5389,case rate,,,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH MAJOR ANOMALY,621-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,130219.16,,,130219.16,3106.94,182153.0839,case rate,,,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,622-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,35289.35,,,35289.35,3106.94,40164.1036,case rate,,,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,622-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,52781.55,,,52781.55,3106.94,54533.4528,case rate,,,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,622-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,59857.92,,,59857.92,3106.94,74755.4456,case rate,,,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,622-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,102781.05,,,102781.05,3106.94,128510.1195,case rate,,,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH CONGENITAL OR PERINATAL INFECTION,623-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21794.01,,,21794.01,3106.94,30162.9868,case rate,,,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH CONGENITAL OR PERINATAL INFECTION,623-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,35351.84,,,35351.84,3106.94,45294.34714,case rate,,,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH CONGENITAL OR PERINATAL INFECTION,623-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,77785.05,,,77785.05,3106.94,81926.863,case rate,,,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH CONGENITAL OR PERINATAL INFECTION,623-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,94327.41,,,94327.41,3106.94,128086.4919,case rate,,,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,625-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25183.47,,,25183.47,3106.94,33167.0536,case rate,,,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,625-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,34244.52,,,34244.52,3106.94,53639.9036,case rate,,,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,625-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,61932.59,,,61932.59,3106.94,72902.24431,case rate,,,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,625-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,86898.59,,,86898.59,3106.94,136351.7357,case rate,,,
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS, NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM",626-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3811.89,,,3811.89,2371.426767,4318.4756,case rate,,,
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS, NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM",626-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4446.79,,,4446.79,3106.94,8636.9512,case rate,,,
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS, NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM",626-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10528.32,,,10528.32,3106.94,27737.3428,case rate,,,
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS, NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM",626-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,58003.22,,,58003.22,3106.94,63318.7978,case rate,,,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH MAJOR CARDIOVASCULAR PROCEDURE,630-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53693.91,,,53693.91,3106.94,71500.5216,case rate,,,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH MAJOR CARDIOVASCULAR PROCEDURE,630-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,135353.34,,,135353.34,3106.94,135353.34,case rate,,,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH MAJOR CARDIOVASCULAR PROCEDURE,630-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,213335.86,,,213335.86,3106.94,213335.8608,case rate,,,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH MAJOR CARDIOVASCULAR PROCEDURE,630-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,441526.84,,,441526.84,3106.94,441526.8444,case rate,,,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER MAJOR PROCEDURE,631-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11115.72,,,11115.72,3106.94,37594.69119,case rate,,,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER MAJOR PROCEDURE,631-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,86071.23,,,86071.23,3106.94,86071.2264,case rate,,,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER MAJOR PROCEDURE,631-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,140342.54,,,140342.54,3106.94,140342.5416,case rate,,,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER MAJOR PROCEDURE,631-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,365451.52,,,365451.52,3106.94,365451.5184,case rate,,,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH MAJOR ANOMALY,633-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4536.77,,,4536.77,3106.94,8596.48447,case rate,,,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH MAJOR ANOMALY,633-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12895.44,,,12895.44,3106.94,28784.13961,case rate,,,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH MAJOR ANOMALY,633-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,45767.68,,,45767.68,3106.94,70693.97307,case rate,,,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH MAJOR ANOMALY,633-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,118356.06,,,118356.06,3106.94,165647.3831,case rate,,,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,634-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13470.34,,,13470.34,3106.94,16670.6012,case rate,,,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,634-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27630.58,,,27630.58,3106.94,30082.0623,case rate,,,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,634-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,31200.01,,,31200.01,3106.94,46692.6104,case rate,,,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,634-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,90710.48,,,90710.48,3106.94,111116.6035,case rate,,,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH CONGENITAL OR PERINATAL INFECTION,636-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12003.08,,,12003.08,3106.94,20470.7768,case rate,,,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH CONGENITAL OR PERINATAL INFECTION,636-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22481.4,,,22481.4,3106.94,27780.88,case rate,,,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH CONGENITAL OR PERINATAL INFECTION,636-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,46475.06,,,46475.06,3106.94,53190.04349,case rate,,,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH CONGENITAL OR PERINATAL INFECTION,636-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,75095.48,,,75095.48,3106.94,95108.8903,case rate,,,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,639-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,8393.66,,,8393.66,3106.94,14743.59053,case rate,,,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,639-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11480.66,,,11480.66,3106.94,27456.92353,case rate,,,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,639-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,37596.48,,,37596.48,3106.94,45195.20027,case rate,,,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,639-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,55518.62,,,55518.62,3106.94,79492.7076,case rate,,,
"NEONATE BIRTH WEIGHT > 2499 GRAMS, NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM",640-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2652.08,,,2652.08,1692.285768,3626.0268,case rate,,,
"NEONATE BIRTH WEIGHT > 2499 GRAMS, NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM",640-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3509.44,,,3509.44,2154.942842,5037.876,case rate,,,
"NEONATE BIRTH WEIGHT > 2499 GRAMS, NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM",640-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,6341.49,,,6341.49,3283.28,11197.3532,case rate,,,
"NEONATE BIRTH WEIGHT > 2499 GRAMS, NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM",640-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,47862.34,,,47862.34,3283.28,71164.92072,case rate,,,
SPLENIC PROCEDURES,650-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,33414.65,,,33414.65,17516.64216,33414.6528,case rate,,,
SPLENIC PROCEDURES,650-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,44220.42,,,44220.42,22954.71836,44220.4236,case rate,,,
SPLENIC PROCEDURES,650-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,65164.57,,,65164.57,35121.11494,65164.572,case rate,,,
SPLENIC PROCEDURES,650-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,106547.95,,,106547.95,55417.4107,118234.596,case rate,,,
OTHER PROCEDURES OF BLOOD AND BLOOD-FORMING ORGANS,651-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25815.87,,,25815.87,10462.97736,25815.8688,case rate,,,
OTHER PROCEDURES OF BLOOD AND BLOOD-FORMING ORGANS,651-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,37791.45,,,37791.45,16851.10872,37791.4524,case rate,,,
OTHER PROCEDURES OF BLOOD AND BLOOD-FORMING ORGANS,651-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,51096.82,,,51096.82,32278.37174,54677.24657,case rate,,,
OTHER PROCEDURES OF BLOOD AND BLOOD-FORMING ORGANS,651-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,117406.21,,,117406.21,78199.0308,158835.5423,case rate,,,
MAJOR HEMATOLOGIC OR IMMUNOLOGIC DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION,660-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14750.14,,,14750.14,9472.099507,15356.49847,case rate,,,
MAJOR HEMATOLOGIC OR IMMUNOLOGIC DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION,660-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17334.73,,,17334.73,10841.51496,18656.7268,case rate,,,
MAJOR HEMATOLOGIC OR IMMUNOLOGIC DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION,660-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27023.18,,,27023.18,15981.46187,31547.8844,case rate,,,
MAJOR HEMATOLOGIC OR IMMUNOLOGIC DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION,660-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,58963.06,,,58963.06,45934.17773,103203.896,case rate,,,
COAGULATION AND PLATELET DISORDERS,661-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16994.78,,,16994.78,10362.77623,20931.0272,case rate,,,
COAGULATION AND PLATELET DISORDERS,661-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22633.88,,,22633.88,12003.10585,24584.0056,case rate,,,
COAGULATION AND PLATELET DISORDERS,661-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,29240.32,,,29240.32,17730.65198,40547.6456,case rate,,,
COAGULATION AND PLATELET DISORDERS,661-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,55698.59,,,55698.59,41091.12307,94664.3852,case rate,,,
SICKLE CELL ANEMIA CRISIS,662-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12165.55,,,12165.55,7726.620546,13865.5616,case rate,,,
SICKLE CELL ANEMIA CRISIS,662-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16682.33,,,16682.33,11199.0227,20010.5264,case rate,,,
SICKLE CELL ANEMIA CRISIS,662-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23653.71,,,23653.71,14193.92317,31941.7924,case rate,,,
SICKLE CELL ANEMIA CRISIS,662-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,44472.88,,,44472.88,19756.94152,68670.6036,case rate,,,
OTHER ANEMIA AND DISORDERS OF BLOOD AND BLOOD-FORMING ORGANS,663-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11645.64,,,11645.64,5320.556351,11645.6364,case rate,,,
OTHER ANEMIA AND DISORDERS OF BLOOD AND BLOOD-FORMING ORGANS,663-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16472.36,,,16472.36,7001.70866,16472.364,case rate,,,
OTHER ANEMIA AND DISORDERS OF BLOOD AND BLOOD-FORMING ORGANS,663-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23003.82,,,23003.82,9911.252612,23020.8128,case rate,,,
OTHER ANEMIA AND DISORDERS OF BLOOD AND BLOOD-FORMING ORGANS,663-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38028.91,,,38028.91,20617.92902,48832.1528,case rate,,,
"MAJOR O.R. PROCEDURES FOR LYMPHATIC, HEMATOPOIETIC OR OTHER NEOPLASMS",680-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38263.88,,,38263.88,15089.5481,38263.8768,case rate,,,
"MAJOR O.R. PROCEDURES FOR LYMPHATIC, HEMATOPOIETIC OR OTHER NEOPLASMS",680-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,50486.92,,,50486.92,20636.48478,50486.9208,case rate,,,
"MAJOR O.R. PROCEDURES FOR LYMPHATIC, HEMATOPOIETIC OR OTHER NEOPLASMS",680-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,83031.71,,,83031.71,38646.71029,83031.7128,case rate,,,
"MAJOR O.R. PROCEDURES FOR LYMPHATIC, HEMATOPOIETIC OR OTHER NEOPLASMS",680-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,159069.54,,,159069.54,98899.75335,185474.6916,case rate,,,
"OTHER  O.R. PROCEDURES FOR LYMPHATIC, HEMATOPOIETIC OR OTHER NEOPLASMS",681-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28300.47,,,28300.47,11471.17392,28300.4712,case rate,,,
"OTHER  O.R. PROCEDURES FOR LYMPHATIC, HEMATOPOIETIC OR OTHER NEOPLASMS",681-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,37141.56,,,37141.56,16049.49967,37141.5564,case rate,,,
"OTHER  O.R. PROCEDURES FOR LYMPHATIC, HEMATOPOIETIC OR OTHER NEOPLASMS",681-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,63752.3,,,63752.3,29709.01682,79181.7276,case rate,,,
"OTHER  O.R. PROCEDURES FOR LYMPHATIC, HEMATOPOIETIC OR OTHER NEOPLASMS",681-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,135640.79,,,135640.79,68121.92447,185990.9184,case rate,,,
ACUTE LEUKEMIA,690-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20674.19,,,20674.19,20674.1916,32434.54717,case rate,,,
ACUTE LEUKEMIA,690-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,40033.59,,,40033.59,31812.00352,56364.0884,case rate,,,
ACUTE LEUKEMIA,690-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,74570.57,,,74570.57,57289.06886,125696.0428,case rate,,,
ACUTE LEUKEMIA,690-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,129836.72,,,129836.72,97509.30802,181469.2692,case rate,,,
"LYMPHOMA, MYELOMA AND NON-ACUTE LEUKEMIA",691-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21121.62,,,21121.62,11648.07222,23067.42111,case rate,,,
"LYMPHOMA, MYELOMA AND NON-ACUTE LEUKEMIA",691-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27375.62,,,27375.62,15364.17342,30766.288,case rate,,,
"LYMPHOMA, MYELOMA AND NON-ACUTE LEUKEMIA",691-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,41008.44,,,41008.44,23463.14632,52093.2964,case rate,,,
"LYMPHOMA, MYELOMA AND NON-ACUTE LEUKEMIA",691-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,76297.79,,,76297.79,43705.01183,131291.6096,case rate,,,
RADIOTHERAPY,692-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14820.13,,,14820.13,12354.1988,19865.42781,case rate,,,
RADIOTHERAPY,692-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25130.98,,,25130.98,15810.74883,34570.7116,case rate,,,
RADIOTHERAPY,692-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,45587.7,,,45587.7,28178.78473,57713.7416,case rate,,,
RADIOTHERAPY,692-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,81022.03,,,81022.03,47680.89374,94797.92966,case rate,,,
LYMPHATIC AND OTHER MALIGNANCIES AND NEOPLASMS OF UNCERTAIN BEHAVIOR,694-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14902.62,,,14902.62,6308.9601,14902.6152,case rate,,,
LYMPHATIC AND OTHER MALIGNANCIES AND NEOPLASMS OF UNCERTAIN BEHAVIOR,694-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18649.52,,,18649.52,8468.851146,20348.458,case rate,,,
LYMPHATIC AND OTHER MALIGNANCIES AND NEOPLASMS OF UNCERTAIN BEHAVIOR,694-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27408.11,,,27408.11,13250.05326,33604.4988,case rate,,,
LYMPHATIC AND OTHER MALIGNANCIES AND NEOPLASMS OF UNCERTAIN BEHAVIOR,694-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,47344.92,,,47344.92,24004.97466,70103.1848,case rate,,,
CHEMOTHERAPY FOR ACUTE LEUKEMIA,695-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13597.82,,,13597.82,9418.906314,18760.3868,case rate,,,
CHEMOTHERAPY FOR ACUTE LEUKEMIA,695-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18834.49,,,18834.49,15518.8048,20201.17517,case rate,,,
CHEMOTHERAPY FOR ACUTE LEUKEMIA,695-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,39381.2,,,39381.2,31132.86252,54472.19281,case rate,,,
CHEMOTHERAPY FOR ACUTE LEUKEMIA,695-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122195.45,,,122195.45,74918.28266,153143.1376,case rate,,,
OTHER CHEMOTHERAPY,696-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15784.97,,,15784.97,8993.36077,17082.55538,case rate,,,
OTHER CHEMOTHERAPY,696-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20101.78,,,20101.78,9808.577379,21769.49842,case rate,,,
OTHER CHEMOTHERAPY,696-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,29925.21,,,29925.21,15220.6755,36767.71615,case rate,,,
OTHER CHEMOTHERAPY,696-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,59480.48,,,59480.48,30712.26518,91104.7008,case rate,,,
INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE,710-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24978.5,,,24978.5,8477.510503,24978.5028,case rate,,,
INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE,710-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36136.72,,,36136.72,13063.25856,36136.7172,case rate,,,
INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE,710-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,59205.53,,,59205.53,22055.38228,61690.1392,case rate,,,
INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE,710-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,109187.53,,,109187.53,54399.31773,131034.5328,case rate,,,
"POST-OPERATIVE, POST-TRAUMA, OTHER DEVICE INFECTIONS WITH O.R. PROCEDURE",711-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25383.44,,,25383.44,11346.23177,25383.438,case rate,,,
"POST-OPERATIVE, POST-TRAUMA, OTHER DEVICE INFECTIONS WITH O.R. PROCEDURE",711-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,33192.19,,,33192.19,15597.97606,33192.1884,case rate,,,
"POST-OPERATIVE, POST-TRAUMA, OTHER DEVICE INFECTIONS WITH O.R. PROCEDURE",711-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,54848.72,,,54848.72,27400.67965,59602.4268,case rate,,,
"POST-OPERATIVE, POST-TRAUMA, OTHER DEVICE INFECTIONS WITH O.R. PROCEDURE",711-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,102998.52,,,102998.52,59994.4994,125136.2788,case rate,,,
SEPTICEMIA AND DISSEMINATED INFECTIONS,720-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13955.27,,,13955.27,4986.552581,13955.2668,case rate,,,
SEPTICEMIA AND DISSEMINATED INFECTIONS,720-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17947.13,,,17947.13,6671.416043,17947.128,case rate,,,
SEPTICEMIA AND DISSEMINATED INFECTIONS,720-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26380.78,,,26380.78,10689.35769,30849.216,case rate,,,
SEPTICEMIA AND DISSEMINATED INFECTIONS,720-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,46020.14,,,46020.14,22367.11913,66348.6196,case rate,,,
"POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS",721-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13525.34,,,13525.34,6469.77673,13525.3356,case rate,,,
"POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS",721-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17827.15,,,17827.15,8070.520724,17827.1472,case rate,,,
"POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS",721-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28113,,,28113,14030.63244,29679.9312,case rate,,,
"POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS",721-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,50371.94,,,50371.94,27841.06981,58692.292,case rate,,,
FEVER AND INFLAMMATORY CONDITIONS,722-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,9226.02,,,9226.02,4348.234265,10643.8088,case rate,,,
FEVER AND INFLAMMATORY CONDITIONS,722-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13842.78,,,13842.78,6099.898481,13842.7848,case rate,,,
FEVER AND INFLAMMATORY CONDITIONS,722-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18866.98,,,18866.98,8863.470415,18866.9808,case rate,,,
FEVER AND INFLAMMATORY CONDITIONS,722-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27383.12,,,27383.12,15852.80857,37151.744,case rate,,,
VIRAL ILLNESS,723-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,8851.08,,,8851.08,4109.483422,9532.5736,case rate,,,
VIRAL ILLNESS,723-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12627.98,,,12627.98,6531.62928,12627.9792,case rate,,,
VIRAL ILLNESS,723-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18949.47,,,18949.47,9405.298753,19313.36,case rate,,,
VIRAL ILLNESS,723-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,37431.51,,,37431.51,23387.68621,58763.36799,case rate,,,
OTHER INFECTIOUS AND PARASITIC DISEASES,724-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13605.32,,,13605.32,6918.826243,13605.3228,case rate,,,
OTHER INFECTIOUS AND PARASITIC DISEASES,724-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16299.89,,,16299.89,7115.517352,16299.8916,case rate,,,
OTHER INFECTIOUS AND PARASITIC DISEASES,724-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27195.65,,,27195.65,10074.54334,28255.6428,case rate,,,
OTHER INFECTIOUS AND PARASITIC DISEASES,724-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,54796.23,,,54796.23,20912.34716,75062.2792,case rate,,,
MENTAL ILLNESS DIAGNOSIS WITH O.R. PROCEDURE,740-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,62735.032,per diem,BH/SA,,
MENTAL ILLNESS DIAGNOSIS WITH O.R. PROCEDURE,740-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,62735.032,per diem,BH/SA,,
MENTAL ILLNESS DIAGNOSIS WITH O.R. PROCEDURE,740-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,62735.032,per diem,BH/SA,,
MENTAL ILLNESS DIAGNOSIS WITH O.R. PROCEDURE,740-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,102414.2121,per diem,BH/SA,,
SCHIZOPHRENIA,750-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,30820.1912,per diem,BH/SA,,
SCHIZOPHRENIA,750-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,35922.3364,per diem,BH/SA,,
SCHIZOPHRENIA,750-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,44998.806,per diem,BH/SA,,
SCHIZOPHRENIA,750-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,67191.66212,per diem,BH/SA,,
MAJOR DEPRESSIVE DISORDERS AND OTHER OR UNSPECIFIED PSYCHOSES,751-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,17790.1292,per diem,BH/SA,,
MAJOR DEPRESSIVE DISORDERS AND OTHER OR UNSPECIFIED PSYCHOSES,751-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,21897.1384,per diem,BH/SA,,
MAJOR DEPRESSIVE DISORDERS AND OTHER OR UNSPECIFIED PSYCHOSES,751-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,37218.0864,per diem,BH/SA,,
MAJOR DEPRESSIVE DISORDERS AND OTHER OR UNSPECIFIED PSYCHOSES,751-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,47849.456,per diem,BH/SA,,
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,752-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,19658.0824,per diem,BH/SA,,
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,752-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,19658.0824,per diem,BH/SA,,
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,752-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,39719.23351,per diem,BH/SA,,
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,752-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,62910.22861,per diem,BH/SA,,
BIPOLAR DISORDERS,753-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,17174.3888,per diem,BH/SA,,
BIPOLAR DISORDERS,753-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,21279.3248,per diem,BH/SA,,
BIPOLAR DISORDERS,753-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,34187.068,per diem,BH/SA,,
BIPOLAR DISORDERS,753-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,44570.94753,per diem,BH/SA,,
DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,754-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,14365.2028,per diem,BH/SA,,
DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,754-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,14365.2028,per diem,BH/SA,,
DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,754-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,17667.8104,per diem,BH/SA,,
DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,754-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,36008.34124,per diem,BH/SA,,
ADJUSTMENT DISORDERS AND NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,755-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,10579.5396,per diem,BH/SA,,
ADJUSTMENT DISORDERS AND NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,755-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,16724.5044,per diem,BH/SA,,
ADJUSTMENT DISORDERS AND NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,755-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,19860.85381,per diem,BH/SA,,
ADJUSTMENT DISORDERS AND NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,755-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,32470.60058,per diem,BH/SA,,
ACUTE ANXIETY AND DELIRIUM STATES,756-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,10119.74096,per diem,BH/SA,,
ACUTE ANXIETY AND DELIRIUM STATES,756-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,12528.55928,per diem,BH/SA,,
ACUTE ANXIETY AND DELIRIUM STATES,756-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,18559.2864,per diem,BH/SA,,
ACUTE ANXIETY AND DELIRIUM STATES,756-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,34512.12481,per diem,BH/SA,,
ORGANIC MENTAL HEALTH DISTURBANCES,757-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,16728.6508,per diem,BH/SA,,
ORGANIC MENTAL HEALTH DISTURBANCES,757-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,20286.39935,per diem,BH/SA,,
ORGANIC MENTAL HEALTH DISTURBANCES,757-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,26792.18882,per diem,BH/SA,,
ORGANIC MENTAL HEALTH DISTURBANCES,757-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,60416.49846,per diem,BH/SA,,
BEHAVIORAL DISORDERS,758-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,11153.816,per diem,BH/SA,,
BEHAVIORAL DISORDERS,758-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,23445.8188,per diem,BH/SA,,
BEHAVIORAL DISORDERS,758-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,23445.8188,per diem,BH/SA,,
BEHAVIORAL DISORDERS,758-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,30255.56933,per diem,BH/SA,,
EATING DISORDERS,759-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,26874.8916,per diem,BH/SA,,
EATING DISORDERS,759-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,27017.52262,per diem,BH/SA,,
EATING DISORDERS,759-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,43860.6192,per diem,BH/SA,,
EATING DISORDERS,759-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,81708.4556,per diem,BH/SA,,
OTHER MENTAL HEALTH DISORDERS,760-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,12464.52588,per diem,BH/SA,,
OTHER MENTAL HEALTH DISORDERS,760-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,16861.3356,per diem,BH/SA,,
OTHER MENTAL HEALTH DISORDERS,760-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,28750.30229,per diem,BH/SA,,
OTHER MENTAL HEALTH DISORDERS,760-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,36459.00884,per diem,BH/SA,,
"DRUG AND ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE",770-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,2690.585925,6198.868,per diem,BH/SA,,
"DRUG AND ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE",770-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,3943.718588,7857.428,per diem,BH/SA,,
"DRUG AND ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE",770-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,16311.9376,per diem,BH/SA,,
"DRUG AND ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE",770-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,43554.27021,per diem,BH/SA,,
ALCOHOL AND DRUG DEPENDENCE WITH REHABILITATION AND/OR DETOXIFICATION THERAPY,772-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,20526.7532,per diem,BH/SA,,
ALCOHOL AND DRUG DEPENDENCE WITH REHABILITATION AND/OR DETOXIFICATION THERAPY,772-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,20526.7532,per diem,BH/SA,,
ALCOHOL AND DRUG DEPENDENCE WITH REHABILITATION AND/OR DETOXIFICATION THERAPY,772-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,20526.7532,per diem,BH/SA,,
ALCOHOL AND DRUG DEPENDENCE WITH REHABILITATION AND/OR DETOXIFICATION THERAPY,772-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,50558.74824,per diem,BH/SA,,
OPIOID ABUSE AND DEPENDENCE,773-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,7596.2048,per diem,BH/SA,,
OPIOID ABUSE AND DEPENDENCE,773-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,10334.902,per diem,BH/SA,,
OPIOID ABUSE AND DEPENDENCE,773-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,23483.1364,per diem,BH/SA,,
OPIOID ABUSE AND DEPENDENCE,773-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,41123.4185,per diem,BH/SA,,
COCAINE ABUSE AND DEPENDENCE,774-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,3928.873976,10274.7792,per diem,BH/SA,,
COCAINE ABUSE AND DEPENDENCE,774-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,10378.4392,per diem,BH/SA,,
COCAINE ABUSE AND DEPENDENCE,774-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,16765.9684,per diem,BH/SA,,
COCAINE ABUSE AND DEPENDENCE,774-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,45820.27499,per diem,BH/SA,,
ALCOHOL ABUSE AND DEPENDENCE,775-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,9460.0116,per diem,BH/SA,,
ALCOHOL ABUSE AND DEPENDENCE,775-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,13477.8732,per diem,BH/SA,,
ALCOHOL ABUSE AND DEPENDENCE,775-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,25550.1168,per diem,BH/SA,,
ALCOHOL ABUSE AND DEPENDENCE,775-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,81254.9276,per diem,BH/SA,,
OTHER DRUG ABUSE AND DEPENDENCE,776-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,10842.836,per diem,BH/SA,,
OTHER DRUG ABUSE AND DEPENDENCE,776-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,11475.162,per diem,BH/SA,,
OTHER DRUG ABUSE AND DEPENDENCE,776-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,18763.54553,per diem,BH/SA,,
OTHER DRUG ABUSE AND DEPENDENCE,776-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4163,,,4163,4163,34820.09947,per diem,BH/SA,,
EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,792-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,33467.14,,,33467.14,15069.75528,33467.1444,case rate,,,
EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,792-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42333.23,,,42333.23,20370.51882,42333.2256,case rate,,,
EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,792-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,63072.41,,,63072.41,33589.6458,63072.4068,case rate,,,
EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,792-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,118398.55,,,118398.55,68771.37624,118398.5532,case rate,,,
MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,793-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24308.61,,,24308.61,10675.75013,24308.61,case rate,,,
MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,793-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,32242.34,,,32242.34,15087.074,32242.3404,case rate,,,
MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,793-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,47779.85,,,47779.85,23333.25596,47779.854,case rate,,,
MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,793-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,93227.58,,,93227.58,46405.49416,93227.5812,case rate,,,
NON-EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,794-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20769.18,,,20769.18,9081.191391,20769.1764,case rate,,,
NON-EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,794-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26695.73,,,26695.73,10116.60308,26695.728,case rate,,,
NON-EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,794-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38841.28,,,38841.28,18643.59562,38841.2844,case rate,,,
NON-EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,794-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,69516.38,,,69516.38,44248.07722,69516.3756,case rate,,,
HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION,810-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11050.73,,,11050.73,5887.125709,11239.64994,case rate,,,
HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION,810-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15420.03,,,15420.03,8214.01864,15420.0324,case rate,,,
HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION,810-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24233.62,,,24233.62,12911.10129,24793.47801,case rate,,,
HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION,810-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49864.52,,,49864.52,26564.43317,49864.5204,case rate,,,
ALLERGIC REACTIONS,811-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7813.75,,,7813.75,3623.322379,7813.7496,case rate,,,
ALLERGIC REACTIONS,811-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11623.14,,,11623.14,5976.193381,11623.14,case rate,,,
ALLERGIC REACTIONS,811-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22351.42,,,22351.42,10055.98758,22351.4232,case rate,,,
ALLERGIC REACTIONS,811-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,43675.51,,,43675.51,22568.75844,49700.37206,case rate,,,
POISONING OF MEDICINAL AGENTS,812-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,8626.12,,,8626.12,4079.794198,8626.1196,case rate,,,
POISONING OF MEDICINAL AGENTS,812-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12308.03,,,12308.03,5519.721562,12308.0304,case rate,,,
POISONING OF MEDICINAL AGENTS,812-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18032.11,,,18032.11,7542.299947,19073.44,case rate,,,
POISONING OF MEDICINAL AGENTS,812-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,32077.37,,,32077.37,16447.8301,45328.4448,case rate,,,
OTHER COMPLICATIONS OF TREATMENT,813-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13412.85,,,13412.85,5669.404733,13412.8536,case rate,,,
OTHER COMPLICATIONS OF TREATMENT,813-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16522.36,,,16522.36,7962.897287,16522.356,case rate,,,
OTHER COMPLICATIONS OF TREATMENT,813-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23961.17,,,23961.17,12449.68126,23961.1656,case rate,,,
OTHER COMPLICATIONS OF TREATMENT,813-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42948.13,,,42948.13,22671.43368,54185.1552,case rate,,,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES",815-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,9378.5,,,9378.5,4531.317813,9506.833022,case rate,,,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES",815-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13352.86,,,13352.86,6949.752518,13352.8632,case rate,,,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES",815-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21879,,,21879,11911.56408,22497.32659,case rate,,,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES",815-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,45947.65,,,45947.65,21705.29685,60952.7929,case rate,,,
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES,816-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12685.47,,,12685.47,4087.216504,12685.47,case rate,,,
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES,816-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13430.35,,,13430.35,5840.117771,13430.3508,case rate,,,
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES,816-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17749.66,,,17749.66,7023.975578,18266.9652,case rate,,,
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES,816-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,32034.87,,,32034.87,15849.09741,43412.808,case rate,,,
INTENTIONAL SELF-HARM AND ATTEMPTED SUICIDE,817-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,9386,,,9386,7189.740412,9385.998,case rate,,,
INTENTIONAL SELF-HARM AND ATTEMPTED SUICIDE,817-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11833.11,,,11833.11,9691.057534,11833.1064,case rate,,,
INTENTIONAL SELF-HARM AND ATTEMPTED SUICIDE,817-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19226.92,,,19226.92,13397.26233,19226.9232,case rate,,,
INTENTIONAL SELF-HARM AND ATTEMPTED SUICIDE,817-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,34904.41,,,34904.41,22312.68889,34904.4144,case rate,,,
EXTENSIVE THIRD DEGREE BURNS WITH SKIN GRAFT,841-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38711.31,,,38711.31,26814.31748,111264.4976,case rate,,,
EXTENSIVE THIRD DEGREE BURNS WITH SKIN GRAFT,841-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,44065.45,,,44065.45,30521.75932,146821.9508,case rate,,,
EXTENSIVE THIRD DEGREE BURNS WITH SKIN GRAFT,841-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,150520.91,,,150520.91,109203.1511,303576.6028,case rate,,,
EXTENSIVE THIRD DEGREE BURNS WITH SKIN GRAFT,841-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,410151.87,,,410151.87,225396.8775,410151.8652,case rate,,,
BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE THIRD DEGREE BURNS,842-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,29215.32,,,29215.32,19083.98578,44681.6064,case rate,,,
BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE THIRD DEGREE BURNS,842-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,45315.25,,,45315.25,24716.27898,58762.7808,case rate,,,
BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE THIRD DEGREE BURNS,842-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,85481.32,,,85481.32,42663.41489,93889.83445,case rate,,,
BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE THIRD DEGREE BURNS,842-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,207279.33,,,207279.33,123239.9688,216388.0481,case rate,,,
EXTENSIVE THIRD DEGREE BURNS WITHOUT SKIN GRAFT,843-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11253.2,,,11253.2,6250.818703,40871.0648,case rate,,,
EXTENSIVE THIRD DEGREE BURNS WITHOUT SKIN GRAFT,843-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17269.74,,,17269.74,7184.792208,40871.0648,case rate,,,
EXTENSIVE THIRD DEGREE BURNS WITHOUT SKIN GRAFT,843-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23401.26,,,23401.26,11055.52479,40871.0648,case rate,,,
EXTENSIVE THIRD DEGREE BURNS WITHOUT SKIN GRAFT,843-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48189.79,,,48189.79,27429.13182,92760.91211,case rate,,,
PARTIAL THICKNESS BURNS WITHOUT SKIN GRAFT,844-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,8851.08,,,8851.08,3558.995727,13461.2876,case rate,,,
PARTIAL THICKNESS BURNS WITHOUT SKIN GRAFT,844-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14342.7,,,14342.7,7095.724536,22050.5552,case rate,,,
PARTIAL THICKNESS BURNS WITHOUT SKIN GRAFT,844-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24651.06,,,24651.06,13734.97725,39019.6972,case rate,,,
PARTIAL THICKNESS BURNS WITHOUT SKIN GRAFT,844-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,56925.89,,,56925.89,37509.86042,119309.2333,case rate,,,
"PROCEDURE WITH DIAGNOSIS OF REHABILITATION, AFTERCARE OR OTHER CONTACT WITH HEALTH SERVICES",850-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,40893.46,,,40893.46,16233.82027,40893.456,case rate,,,
"PROCEDURE WITH DIAGNOSIS OF REHABILITATION, AFTERCARE OR OTHER CONTACT WITH HEALTH SERVICES",850-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,55463.62,,,55463.62,26437.01692,55463.6244,case rate,,,
"PROCEDURE WITH DIAGNOSIS OF REHABILITATION, AFTERCARE OR OTHER CONTACT WITH HEALTH SERVICES",850-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,67991.62,,,67991.62,33009.46888,67991.6196,case rate,,,
"PROCEDURE WITH DIAGNOSIS OF REHABILITATION, AFTERCARE OR OTHER CONTACT WITH HEALTH SERVICES",850-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,144451.88,,,144451.88,65129.4981,158116.7444,case rate,,,
REHABILITATION,860-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23808.69,,,23808.69,14210.00484,31767.6436,case rate,,,
REHABILITATION,860-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,29185.33,,,29185.33,17966.92872,37191.1348,case rate,,,
REHABILITATION,860-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,37171.55,,,37171.55,20564.73582,49180.4504,case rate,,,
REHABILITATION,860-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,45535.21,,,45535.21,22327.5335,49180.4504,case rate,,,
"SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS",861-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,8468.64,,,8468.64,5162.213823,10782.22233,case rate,,,
"SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS",861-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14677.65,,,14677.65,6654.097329,14677.6512,case rate,,,
"SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS",861-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20534.21,,,20534.21,10072.06924,21930.3096,case rate,,,
"SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS",861-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22178.95,,,22178.95,20888.84319,43334.0264,case rate,,,
OTHER AFTERCARE AND CONVALESCENCE,862-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11475.66,,,11475.66,4630.281893,12895.85337,case rate,,,
OTHER AFTERCARE AND CONVALESCENCE,862-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16722.32,,,16722.32,6746.876154,17745.03675,case rate,,,
OTHER AFTERCARE AND CONVALESCENCE,862-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18684.51,,,18684.51,7539.825845,26528.54827,case rate,,,
OTHER AFTERCARE AND CONVALESCENCE,862-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19619.36,,,19619.36,7915.889349,44418.31,case rate,,,
NEONATAL AFTERCARE,863-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21059.13,,,21059.13,12751.52171,21059.13,case rate,,,
NEONATAL AFTERCARE,863-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53571.43,,,53571.43,18800.7011,53571.4272,case rate,,,
NEONATAL AFTERCARE,863-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,104410.79,,,104410.79,43645.63338,104410.7916,case rate,,,
NEONATAL AFTERCARE,863-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,162726.46,,,162726.46,109858.868,225297.7466,case rate,,,
HIV WITH MULTIPLE MAJOR HIV RELATED CONDITIONS,890-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19994.3,,,19994.3,10628.74219,23085.082,case rate,,,
HIV WITH MULTIPLE MAJOR HIV RELATED CONDITIONS,890-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21046.63,,,21046.63,11189.1263,25146.31929,case rate,,,
HIV WITH MULTIPLE MAJOR HIV RELATED CONDITIONS,890-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,31397.48,,,31397.48,16691.52914,39929.832,case rate,,,
HIV WITH MULTIPLE MAJOR HIV RELATED CONDITIONS,890-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,59995.4,,,59995.4,31893.64888,80427.67131,case rate,,,
HIV WITH MAJOR HIV RELATED CONDITION,892-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16769.82,,,16769.82,8930.271169,16769.8164,case rate,,,
HIV WITH MAJOR HIV RELATED CONDITION,892-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17814.65,,,17814.65,9432.513875,19345.0292,case rate,,,
HIV WITH MAJOR HIV RELATED CONDITION,892-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24681.05,,,24681.05,12723.06954,27148.554,case rate,,,
HIV WITH MAJOR HIV RELATED CONDITION,892-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38388.86,,,38388.86,24712.56783,48398.854,case rate,,,
HIV WITH MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,893-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18472.04,,,18472.04,10636.1645,18472.044,case rate,,,
HIV WITH MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,893-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20009.3,,,20009.3,11138.4072,20009.298,case rate,,,
HIV WITH MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,893-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27928.03,,,27928.03,13720.13264,30111.1568,case rate,,,
HIV WITH MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,893-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42635.68,,,42635.68,28810.91779,50292.65865,case rate,,,
HIV WITH ONE SIGNIFICANT HIV CONDITION OR WITHOUT SIGNIFICANT RELATED CONDITIONS,894-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13617.82,,,13617.82,6723.372185,13617.8208,case rate,,,
HIV WITH ONE SIGNIFICANT HIV CONDITION OR WITHOUT SIGNIFICANT RELATED CONDITIONS,894-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17042.27,,,17042.27,8786.773253,17042.2728,case rate,,,
HIV WITH ONE SIGNIFICANT HIV CONDITION OR WITHOUT SIGNIFICANT RELATED CONDITIONS,894-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24656.05,,,24656.05,13374.99541,24656.0544,case rate,,,
HIV WITH ONE SIGNIFICANT HIV CONDITION OR WITHOUT SIGNIFICANT RELATED CONDITIONS,894-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38108.9,,,38108.9,24032.5344,41338.26131,case rate,,,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,910-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,74363.1,,,74363.1,41677.48524,77939.8808,case rate,,,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,910-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,85066.39,,,85066.39,47677.18259,85066.3872,case rate,,,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,910-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,95769.67,,,95769.67,53675.64289,95769.6744,case rate,,,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,910-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,160729.28,,,160729.28,90084.52792,189232.1738,case rate,,,
EXTENSIVE ABDOMINAL OR THORACIC PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,911-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38723.8,,,38723.8,26156.06741,40947.65814,case rate,,,
EXTENSIVE ABDOMINAL OR THORACIC PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,911-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,52459.11,,,52459.11,30735.76915,52459.1052,case rate,,,
EXTENSIVE ABDOMINAL OR THORACIC PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,911-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71461.06,,,71461.06,31043.79485,71461.0644,case rate,,,
EXTENSIVE ABDOMINAL OR THORACIC PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,911-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,151848.2,,,151848.2,67139.70597,158230.479,case rate,,,
MUSCULOSKELETAL AND OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,912-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,51666.73,,,51666.73,27601.08191,51666.732,case rate,,,
MUSCULOSKELETAL AND OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,912-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,52399.11,,,52399.11,27690.14958,52399.1148,case rate,,,
MUSCULOSKELETAL AND OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,912-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,83091.7,,,83091.7,31402.53964,83091.7032,case rate,,,
MUSCULOSKELETAL AND OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,912-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,147533.89,,,147533.89,62592.3065,157078.0712,case rate,,,
MULTIPLE SIGNIFICANT TRAUMA WITHOUT O.R. PROCEDURE,930-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18694.51,,,18694.51,8180.618263,18694.5084,case rate,,,
MULTIPLE SIGNIFICANT TRAUMA WITHOUT O.R. PROCEDURE,930-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22506.4,,,22506.4,9733.117268,22506.3984,case rate,,,
MULTIPLE SIGNIFICANT TRAUMA WITHOUT O.R. PROCEDURE,930-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,35419.33,,,35419.33,14993.05812,35419.332,case rate,,,
MULTIPLE SIGNIFICANT TRAUMA WITHOUT O.R. PROCEDURE,930-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,68199.09,,,68199.09,30959.67538,88840.39988,case rate,,,
EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,950-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,35254.36,,,35254.36,14584.83129,35254.3584,case rate,,,
EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,950-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,47919.83,,,47919.83,20831.93884,47919.8316,case rate,,,
EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,950-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,72555.89,,,72555.89,33165.33731,82811.9008,case rate,,,
EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,950-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,132376.32,,,132376.32,71562.1633,168225.6676,case rate,,,
MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,951-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26835.71,,,26835.71,11862.08204,26835.7056,case rate,,,
MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,951-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36514.16,,,36514.16,15976.51367,36514.1568,case rate,,,
MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,951-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,54886.22,,,54886.22,26771.02069,56221.0376,case rate,,,
MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,951-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,98389.26,,,98389.26,52603.11967,130095.3732,case rate,,,
NON-EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,952-1,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21918.99,,,21918.99,9786.310461,21918.9924,case rate,,,
NON-EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,952-2,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,30187.67,,,30187.67,13476.43359,30187.6692,case rate,,,
NON-EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,952-3,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48092.3,,,48092.3,25246.97386,50666.9348,case rate,,,
NON-EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,952-4,APR-DRG,,,,,,,inpatient,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,84591.46,,,84591.46,49125.76931,122973.9312,case rate,,,
HC Fine Needle Aspiration Bx W/O Img Gdn Ea Addl,PX-36900722,CDM,10004,CPT,369,RC,,,outpatient,,,79,55.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,17.7355,1592,other,SI=N Exclusions ,,
HC Fine Needle Aspiration Bx W/US Gdn 1st Lesion,PX-36900723,CDM,10005,CPT,369,RC,,,outpatient,,,2116,1481.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,789.71,,,789.71,399.86,2141,fee schedule,,,
HC Fine Needle Aspiration Bx W/US Gdn Ea Addl,PX-36900724,CDM,10006,CPT,369,RC,,,outpatient,,,258,180.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,57.921,1592,other,SI=N Exclusions ,,
HC Fine Needle Aspiration W/O Imaging Guidance,PX-36900674,CDM,10021,CPT,369,RC,,,outpatient,,,871,609.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,195.5395,1592,fee schedule,,,
HC Image-Guided Catheter Fluid Collection Drainage,PX-36900043,CDM,10030,CPT,369,RC,,,outpatient,,,692,484.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,789.71,,,789.71,155.354,2141,fee schedule,,,
HC Plcmt of Soft Tissue Loc Device(S)- Perc- First Lesion,PX-36900637,CDM,10035,CPT,369,RC,,,outpatient,,,1860,1302,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,789.71,,,789.71,291.227805,2141,fee schedule,,,
HC Plmt Sft Tiss Loclzj Dev Perq Each Addl Lesion,PX-36900889,CDM,10036,CPT,369,RC,,,outpatient,,,130,91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,29.185,1592,other,SI=N Exclusions ,,
HC Drain Skin Abscess Simple,PX-36900044,CDM,10060,CPT,761,RC,,,outpatient,,,922,645.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,240.52,,,240.52,206.989,1592,fee schedule,,,
HC Drain Skin Abscess Complic,PX-36900045,CDM,10061,CPT,761,RC,,,outpatient,,,922,645.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,206.989,1592,fee schedule,,,
HC Drainage of Hematoma/Fluid,PX-36900048,CDM,10140,CPT,761,RC,,,outpatient,,,4838,3386.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,3715.584,fee schedule,,,
HC Puncture Drainage of Lesion,PX-36100003,CDM,10160,CPT,361,RC,,,outpatient,,,916,641.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,205.642,1592,fee schedule,,,
HC Puncture Drainage of Lesion,PX-36900049,CDM,10160,CPT,761,RC,,,outpatient,,,916,641.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,205.642,1592,fee schedule,,,
HC Complex Drainage- Wound,PX-36900050,CDM,10180,CPT,761,RC,,,outpatient,,,8640,6048,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3241.89,,,3241.89,399.86,6635.52,fee schedule,,,
HC Debridement- Infected Skin- Up to 10% Bsa,PX-36900606,CDM,11000,CPT,369,RC,,,outpatient,,,1174,821.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,658.23,,,658.23,263.563,1592,fee schedule,,,
HC Debridement- Infected Skin- Ea Add 10% Bsa,PX-36900607,CDM,11001,CPT,369,RC,,,outpatient,,,53,37.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,11.8985,1592,other,SI=N Exclusions ,,
HC Debride Necrotic Skin/ Tissue- Genit & Perinm,PX-36900608,CDM,11004,CPT,369,RC,,,outpatient,,,2036,1425.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1159.73,,,1159.73,399.86,2998,fee schedule,,,
HC Dbrdmt Skn Subq T/M/F Necro Infctj Abdl Wall,PX-36900876,CDM,11005,CPT,369,RC,,,outpatient,,,2001,1400.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1573.05,,,1573.05,399.86,2998,fee schedule,,,
HC Dbrdmt Skn Subq T/M/F Necro Infctj Gent/Abdl,PX-36900877,CDM,11006,CPT,369,RC,,,outpatient,,,1815,1270.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1538.39,399.86,2998,percent of total billed charges,,,
HC Removal Prosthetic Matrl Abdl Wall for Infection,PX-36900878,CDM,11008,CPT,369,RC,,,outpatient,,,706,494.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,553.04,,,553.04,158.497,3914,fee schedule,,,
HC Dbrdmt W/Rmvl Fm Fx&/Dislc Skin&Subq Tissus,PX-36900743,CDM,11010,CPT,369,RC,,,outpatient,,,2113,1479.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,789.71,,,789.71,399.86,2141,fee schedule,,,
HC Dbrdmt W/Rmvl Fm Fx&/Dislc Skn Subq T/M/F Musc,PX-36900773,CDM,11011,CPT,369,RC,,,outpatient,,,2197,1537.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,789.71,,,789.71,399.86,2141,fee schedule,,,
HC Dbrdmt Fx&/Dislc Subq T/M/F Bone,PX-36900744,CDM,11012,CPT,369,RC,,,outpatient,,,9022,6315.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3241.89,,,3241.89,399.86,6928.896,fee schedule,,,
HC Debridement- Skin- Sub-Q Tissue-=<20 Sq Cm,PX-36900052,CDM,11042,CPT,761,RC,,,outpatient,,,1018,712.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,228.541,1592,fee schedule,,,
HC Debridement- Skin- Sub-Q Tissue-Muscle-=<20 Sq Cm,PX-36900053,CDM,11043,CPT,761,RC,,,outpatient,,,1065,745.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,658.23,,,658.23,239.0925,1592,fee schedule,,,
HC Debridement- Skin- Sub-Q Tissue-Muscle-Bone-=<20 Sq Cm,PX-36900054,CDM,11044,CPT,761,RC,,,outpatient,,,2829,1980.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2477.315575,fee schedule,,,
HC Debridement- Skin- Sub-Q Tissue-Each Add 20 Sq Cm,PX-36900055,CDM,11045,CPT,761,RC,,,outpatient,,,1203,842.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.0735,1592,other,SI=N Exclusions ,,
HC Debridement- Skin- Sub-Q Tissue-Muscle-Each Add 20 Sq Cm,PX-36900056,CDM,11046,CPT,761,RC,,,outpatient,,,1203,842.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.0735,1592,other,SI=N Exclusions ,,
HC Debridement- Skin- Sub-Q Tissue-Muscle-Bone-Each Add 20 Sq Cm,PX-36900057,CDM,11047,CPT,761,RC,,,outpatient,,,1910,1337,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,1592,other,SI=N Exclusions ,,
HC Trim Nail(S),PX-36900064,CDM,11719,CPT,761,RC,,,outpatient,,,347,242.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,76.19,,,76.19,62.19,1592,fee schedule,,,
HC Debridement of Nail(S)- 1-5,PX-36900065,CDM,11720,CPT,761,RC,,,outpatient,,,347,242.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,76.19,,,76.19,66.75974,1592,fee schedule,,,
HC Debridement Nail Any Method 6/>,PX-36900791,CDM,11721,CPT,369,RC,,,outpatient,,,212,148.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,76.19,,,76.19,47.594,1592,fee schedule,,,
HC Removal of Nail Plate,PX-36900067,CDM,11730,CPT,761,RC,,,outpatient,,,431,301.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,240.52,,,240.52,96.7595,1592,fee schedule,,,
HC Avulsion Nail Plate Partial/Comp Simple Ea Addl,PX-36900831,CDM,11732,CPT,369,RC,,,outpatient,,,139,97.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,31.2055,1592,other,SI=N Exclusions ,,
HC Evacuation Subungual Hematoma,PX-36900832,CDM,11740,CPT,369,RC,,,outpatient,,,159,111.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,35.6955,1592,fee schedule,,,
HC Removal of Nail Bed,PX-36900069,CDM,11750,CPT,761,RC,,,outpatient,,,1914,1339.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,399.86,1592,fee schedule,,,
HC Biopsy Nail Unit Separate Procedure,PX-36900763,CDM,11755,CPT,369,RC,,,outpatient,,,2197,1537.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,789.71,,,789.71,399.86,2141,fee schedule,,,
HC Repair Nail Bed,PX-36900833,CDM,11760,CPT,369,RC,,,outpatient,,,909,636.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,658.23,,,658.23,113.876282,1592,fee schedule,,,
HC Wedge Excision Skin Nail Fold,PX-36900834,CDM,11765,CPT,369,RC,,,outpatient,,,1377,963.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,156.65,1592,fee schedule,,,
HC Resuperf Wnd Body <2.5cm,PX-36900070,CDM,12001,CPT,761,RC,,,outpatient,,,505,353.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,240.52,,,240.52,113.3725,1592,fee schedule,,,
HC Resup Npterf Wnd Body 2.6-7.5 Cm,PX-36900071,CDM,12002,CPT,761,RC,,,outpatient,,,505,353.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,240.52,,,240.52,113.3725,1592,fee schedule,,,
HC Resuperf Wnd Body 7.6-12.5 Cm,PX-36900072,CDM,12004,CPT,761,RC,,,outpatient,,,445,311.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,240.52,,,240.52,99.9025,1592,fee schedule,,,
HC Resuperf Wnd Body 12.6-20 Cm,PX-36900839,CDM,12005,CPT,369,RC,,,outpatient,,,513,359.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,115.1685,1592,fee schedule,,,
HC Resuperf Wnd Body 20.1-30 Cm,PX-36900840,CDM,12006,CPT,369,RC,,,outpatient,,,648,453.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,145.476,1592,fee schedule,,,
HC Resuperf Wnd Body >30 Cm,PX-36900841,CDM,12007,CPT,369,RC,,,outpatient,,,425,297.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,240.52,,,240.52,95.4125,1592,fee schedule,,,
HC Simple Repair F/E/E/N/L/M 2.5cm/<,PX-36900758,CDM,12011,CPT,369,RC,,,outpatient,,,329,230.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,240.52,,,240.52,73.8605,1592,fee schedule,,,
HC Resuperf Wnd Face 2.6-5 Cm,PX-36900842,CDM,12013,CPT,369,RC,,,outpatient,,,400,280,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,240.52,,,240.52,89.8,1592,fee schedule,,,
HC Resuperf Wnd Face 5.1-7.5 Cm,PX-36900843,CDM,12014,CPT,369,RC,,,outpatient,,,479,335.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,240.52,,,240.52,107.5355,1592,fee schedule,,,
HC Resuperf Wnd Face 7.6-12.5 Cm,PX-36900844,CDM,12015,CPT,369,RC,,,outpatient,,,633,443.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,240.52,,,240.52,142.1085,1592,fee schedule,,,
HC Resuperf Wnd Face 12.6-20 Cm,PX-36900845,CDM,12016,CPT,369,RC,,,outpatient,,,779,545.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,174.8855,1592,fee schedule,,,
HC Simple Repair Suprfcl Wnds F/E/E/N/L/Mucs Membrnes;20.1-30.0 Cm,PX-36900846,CDM,12017,CPT,369,RC,,,outpatient,,,555,388.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,124.5975,1592,fee schedule,,,
HC Simple Repair Suprfcl Wnds F/E/E/N/L/Mucs Membrnes;Over 30.0 Cm,PX-36900847,CDM,12018,CPT,369,RC,,,outpatient,,,448,313.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,240.52,,,240.52,100.576,1592,fee schedule,,,
HC Closure Superf Wnd Dehis Simple,PX-36900848,CDM,12020,CPT,369,RC,,,outpatient,,,1377,963.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,658.23,,,658.23,309.1365,1592,fee schedule,,,
HC Closure Superf Wnd Dehis W Packing,PX-36900849,CDM,12021,CPT,369,RC,,,outpatient,,,809,566.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,181.6205,1592,fee schedule,,,
HC Repair Intermediate S/a/T/E 2.5 Cm/<,PX-36900757,CDM,12031,CPT,369,RC,,,outpatient,,,891,623.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,200.0295,1592,fee schedule,,,
HC Layr Clos Wnd Trunk-Arm-Leg 2.6-7.5 Cm,PX-36900850,CDM,12032,CPT,369,RC,,,outpatient,,,505,353.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,113.3725,1592,fee schedule,,,
HC Layr Clos Wnd Trunk-Arm-Leg 7.6-12.5 Cm,PX-36900851,CDM,12034,CPT,369,RC,,,outpatient,,,685,479.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,153.7825,1592,fee schedule,,,
HC Layr Clos Wnd Trunk-Arm-Leg 12.6-20 Cm,PX-36900852,CDM,12035,CPT,369,RC,,,outpatient,,,685,479.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,153.7825,1592,fee schedule,,,
HC Layr Clos Wnd Trunk-Arm-Leg 20.1-30 Cm,PX-36900853,CDM,12036,CPT,369,RC,,,outpatient,,,649,454.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,658.23,,,658.23,145.7005,1592,fee schedule,,,
HC Layr Clos Wnd Trunk-Arm-Leg >30 Cm,PX-36900854,CDM,12037,CPT,369,RC,,,outpatient,,,4504,3152.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2111.41,,,2111.41,399.86,3459.072,fee schedule,,,
HC Repair Intermediate N/H/F/Xtrnl Gent 2.5cm/<,PX-36900756,CDM,12041,CPT,369,RC,,,outpatient,,,634,443.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,142.333,1592,fee schedule,,,
HC Repair Intermediate Neck/Hand/Feet/Xtrnl Gent 2.6-7.5 Cm,PX-36900806,CDM,12042,CPT,369,RC,,,outpatient,,,633,443.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,142.1085,1592,fee schedule,,,
HC Layr Clos Wnd Rest Body 7.6-12.5 Cm,PX-36900855,CDM,12044,CPT,369,RC,,,outpatient,,,623,436.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,658.23,,,658.23,139.8635,1592,fee schedule,,,
HC Layr Clos Wnd Rest Body 12.6-20 Cm,PX-36900856,CDM,12045,CPT,369,RC,,,outpatient,,,627,438.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,658.23,,,658.23,140.7615,1592,fee schedule,,,
HC Layr Clos Wnd Rest Body 20.1-30 Cm,PX-36900857,CDM,12046,CPT,369,RC,,,outpatient,,,1056,739.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,237.072,2141,fee schedule,,,
HC Repair Intermediate N/H/F/Xtrnl Gent >30.0 Cm,PX-36900858,CDM,12047,CPT,369,RC,,,outpatient,,,5238,3666.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2111.41,,,2111.41,399.86,4022.784,fee schedule,,,
HC Repair Intermediate F/E/E/N/L&/Muc 2.5 Cm/<,PX-36900755,CDM,12051,CPT,369,RC,,,outpatient,,,891,623.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,200.0295,1592,fee schedule,,,
HC Layr Clos Wnd Face-Facial 2.5-5 Cm,PX-36900859,CDM,12052,CPT,369,RC,,,outpatient,,,596,417.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,133.802,1592,fee schedule,,,
HC Layr Clos Wnd Face-Facial 5.1-7.5 Cm,PX-36900860,CDM,12053,CPT,369,RC,,,outpatient,,,663,464.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,148.8435,1592,fee schedule,,,
HC Layr Clos Wnd Face-Facial 7.6-12.5 Cm,PX-36900861,CDM,12054,CPT,369,RC,,,outpatient,,,652,456.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,146.374,1592,fee schedule,,,
HC Layr Clos Wnd Face-Facial 12.6-20 Cm,PX-36900862,CDM,12055,CPT,369,RC,,,outpatient,,,749,524.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,168.1505,1592,fee schedule,,,
HC Layr Clos Wnd Face-Facial 20.1-30 Cm,PX-36900863,CDM,12056,CPT,369,RC,,,outpatient,,,1419,993.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,318.5655,1592,fee schedule,,,
HC Repair Intermediate F/E/E/N/L&/Muc >30.0 Cm,PX-36900864,CDM,12057,CPT,369,RC,,,outpatient,,,1132,792.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,254.134,1592,fee schedule,,,
HC Repair Complex Trunk 1.1-2.5 Cm,PX-36900788,CDM,13100,CPT,369,RC,,,outpatient,,,1831,1281.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,658.23,,,658.23,399.86,1592,fee schedule,,,
HC Recmpl Wnd Trunk 2.6-7.5 Cm,PX-36900865,CDM,13101,CPT,369,RC,,,outpatient,,,1090,763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,658.23,,,658.23,244.705,1592,fee schedule,,,
HC Rep-Skin-Trunk-Cmplx-+5 Cm/<,PX-36900866,CDM,13102,CPT,369,RC,,,outpatient,,,250,175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,56.125,1592,other,SI=N Exclusions ,,
HC Repair Complex Scalp/Arm/Leg 1.1-2.5 Cm,PX-36900754,CDM,13120,CPT,369,RC,,,outpatient,,,1761,1232.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,658.23,,,658.23,395.3445,1592,fee schedule,,,
HC Recmpl Wnd Scalp-Extr 2.6-7.5 Cm,PX-36900867,CDM,13121,CPT,369,RC,,,outpatient,,,735,514.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,658.23,,,658.23,165.0075,1592,fee schedule,,,
HC Rep-Skin-Scalp/Extrem+5 Cm/<,PX-36900868,CDM,13122,CPT,369,RC,,,outpatient,,,305,213.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,68.4725,1592,other,SI=N Exclusions ,,
HC Repair Complex F/C/C/M/N/Ax/G/H/F 1.1-2.5 Cm,PX-36900753,CDM,13131,CPT,369,RC,,,outpatient,,,1145,801.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,257.0525,1592,fee schedule,,,
HC Recmpl Wnd Head-Fac-Hand 2.6-7.5 Cm,PX-36900869,CDM,13132,CPT,369,RC,,,outpatient,,,723,506.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,658.23,,,658.23,162.3135,1592,fee schedule,,,
HC Repr-Face-Genital-Hand-Ft+5 Cmcm/<,PX-36900870,CDM,13133,CPT,369,RC,,,outpatient,,,578,404.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,129.761,1592,other,SI=N Exclusions ,,
HC Repair Complex Eyelid/Nose/Ear/Lip 1.1-2.5 Cm,PX-36900752,CDM,13151,CPT,369,RC,,,outpatient,,,1761,1232.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,658.23,,,658.23,395.3445,1592,fee schedule,,,
HC Recmpl Wnd Lid-Nos-Ear 2.5-7.5 Cm,PX-36900871,CDM,13152,CPT,369,RC,,,outpatient,,,743,520.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,658.23,,,658.23,166.8035,1592,fee schedule,,,
HC Repr-Eyelid-Nose-Ear-Lip+5 Cm,PX-36900872,CDM,13153,CPT,369,RC,,,outpatient,,,462,323.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,103.719,1592,other,SI=N Exclusions ,,
HC Secd Clos Surg Wnd Exten/Complic,PX-36900873,CDM,13160,CPT,369,RC,,,outpatient,,,4504,3152.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2111.41,,,2111.41,399.86,3459.072,fee schedule,,,
HC Dressing Change Under Anesthesia,PX-36900774,CDM,15852,CPT,369,RC,,,outpatient,,,1831,1281.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,658.23,,,658.23,108.7,1592,fee schedule,,,
HC Exc Coccyx/Ulcer W Suture,PX-36900598,CDM,15920,CPT,369,RC,,,outpatient,,,3425,2397.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3241.89,,,3241.89,399.86,4341.777195,fee schedule,,,
HC Exc Sacr Press Ulc W Pri Suture,PX-36900599,CDM,15931,CPT,369,RC,,,outpatient,,,7558,5290.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,5804.544,fee schedule,,,
HC Exc Sacr Press Ulc W Flap Clos,PX-36900600,CDM,15934,CPT,369,RC,,,outpatient,,,9536,6675.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3770.57,,,3770.57,399.86,7323.648,fee schedule,,,
HC Exc Sacr Press Ulc W Musc Flap Clo,PX-36900601,CDM,15936,CPT,369,RC,,,outpatient,,,5831,4081.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2111.41,,,2111.41,399.86,4478.208,fee schedule,,,
HC Exc Isch Pres Ulc W Prim Clos,PX-36900602,CDM,15940,CPT,369,RC,,,outpatient,,,7558,5290.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3241.89,,,3241.89,399.86,5804.544,fee schedule,,,
HC Exc Isch Pres Ulc W Flap Clos,PX-36900603,CDM,15944,CPT,369,RC,,,outpatient,,,5831,4081.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3770.57,,,3770.57,399.86,5481.863562,fee schedule,,,
HC Exc Isch Pres Ulc Bone Myocut Flap,PX-36900604,CDM,15946,CPT,369,RC,,,outpatient,,,9536,6675.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2111.41,,,2111.41,399.86,7323.648,fee schedule,,,
HC Exc Troc Pres Ulc W Prim Clos,PX-36900605,CDM,15950,CPT,369,RC,,,outpatient,,,7558,5290.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,5804.544,fee schedule,,,
HC Initial Tx 1st Degree Burn Local Tx,PX-36900591,CDM,16000,CPT,369,RC,,,outpatient,,,393,275.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,240.52,,,240.52,88.2285,1592,fee schedule,,,
HC Dress/Debrid Small Burn No Anes,PX-36900090,CDM,16020,CPT,761,RC,,,outpatient,,,812,568.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,240.52,,,240.52,182.294,1592,fee schedule,,,
HC Dress/Debrid Med Burn No Anesth,PX-36900091,CDM,16025,CPT,761,RC,,,outpatient,,,812,568.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,240.52,,,240.52,182.294,1592,fee schedule,,,
HC Dress/Debrid Large Burn No Anesth,PX-36900092,CDM,16030,CPT,761,RC,,,outpatient,,,845,591.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,189.7025,1592,fee schedule,,,
HC Escharotomy Each Additional Incision,PX-36900883,CDM,16036,CPT,369,RC,,,outpatient,,,670,469,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,567.89,150.415,2998,percent of total billed charges,,,
HC Destruc Cut/Vasc 10-50 Sqcm,PX-36900094,CDM,17107,CPT,369,RC,,,outpatient,,,1763,1234.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,658.23,,,658.23,395.7935,1592,fee schedule,,,
HC Punc/Aspir Breast Cyst,PX-36900096,CDM,19000,CPT,369,RC,,,outpatient,,,1637,1145.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,789.71,,,789.71,367.5065,2141,fee schedule,,,
HC Puct/Aspir Breast Cyst-Each Addn,PX-36900097,CDM,19001,CPT,369,RC,,,outpatient,,,60,42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,13.47,1592,other,SI=N Exclusions ,,
HC Bx Breast W Device 1st Lesion Stereotactic Guide,PX-36900099,CDM,19081,CPT,369,RC,,,outpatient,,,4317,3021.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,3315.456,fee schedule,,,
HC Bx Breast W Device Addl Lesion Stereotact Guide,PX-36900100,CDM,19082,CPT,369,RC,,,outpatient,,,3998,2798.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,3070.464,other,SI=N Exclusions ,,
HC Bx Breast W Device 1st Lesion Ultrasound Guide,PX-36900101,CDM,19083,CPT,369,RC,,,outpatient,,,3271,2289.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2998,fee schedule,,,
HC Bx Breast W Device Addl Lesion Ultrasound Guide,PX-36900102,CDM,19084,CPT,369,RC,,,outpatient,,,2336,1635.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,1794.048,other,SI=N Exclusions ,,
HC Bx Breast W Device 1st Lesion Magnetic Res Guide,PX-36900103,CDM,19085,CPT,369,RC,,,outpatient,,,5120,3584,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,3932.16,fee schedule,,,
HC Bx Breast W Device Addl Lesion Magnet Res Guide,PX-36900104,CDM,19086,CPT,369,RC,,,outpatient,,,2232,1562.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,1714.176,other,SI=N Exclusions ,,
HC Perq Device Placemt Breast Loc 1st Les W Guidnce,PX-36900106,CDM,19281,CPT,369,RC,,,outpatient,,,915,640.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,789.71,,,789.71,108.7,2998,fee schedule,,,
HC Perq Device Placemt Breast Loc Ea Les W Guidnce,PX-36900107,CDM,19282,CPT,369,RC,,,outpatient,,,880,616,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,197.56,1592,other,SI=N Exclusions ,,
HC Perq Breast Loc Device Placemt 1st Strtctc Guid,PX-36900108,CDM,19283,CPT,369,RC,,,outpatient,,,2116,1481.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,789.71,,,789.71,108.7,2141,fee schedule,,,
HC Perq Breast Loc Device Placemt Ea Lesion Strtctc,PX-36900109,CDM,19284,CPT,369,RC,,,outpatient,,,84,58.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,18.858,1592,other,SI=N Exclusions ,,
HC Perq Breast Loc Device Placemt 1st Lesio US Imag,PX-36900110,CDM,19285,CPT,369,RC,,,outpatient,,,1175,822.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,789.71,,,789.71,108.7,2141,fee schedule,,,
HC Perq Breast Loc Device Placemt Each Les US Image,PX-36900111,CDM,19286,CPT,369,RC,,,outpatient,,,274,191.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,61.513,1592,other,SI=N Exclusions ,,
HC Perq Breast Loc Device Placemt 1st Lesio MR Guid,PX-36900112,CDM,19287,CPT,369,RC,,,outpatient,,,2116,1481.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,789.71,,,789.71,108.7,2141,fee schedule,,,
HC Place Postop Breast Cath for Rad,PX-36900114,CDM,19296,CPT,369,RC,,,outpatient,,,14045,9831.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,11904.54,399.86,14403.82399,percent of total billed charges,,,
HC Muscle Biopsy,PX-36900115,CDM,20200,CPT,369,RC,,,outpatient,,,3700,2590,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2998,fee schedule,,,
HC Biopsy Muscle Deep,PX-36900764,CDM,20205,CPT,369,RC,,,outpatient,,,9022,6315.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3241.89,,,3241.89,399.86,6928.896,fee schedule,,,
HC Needle Biopsy-Muscle,PX-36900116,CDM,20206,CPT,369,RC,,,outpatient,,,3700,2590,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2998,fee schedule,,,
HC Bone Biopsy-Trocar/Needle Superf,PX-36900117,CDM,20220,CPT,761,RC,,,outpatient,,,3847,2692.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2954.496,fee schedule,,,
HC Bone Biopsy-Trocar/Needle Deep,PX-36900118,CDM,20225,CPT,369,RC,,,outpatient,,,3700,2590,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2998,fee schedule,,,
HC Biopsy Bone Open Superficial,PX-36900770,CDM,20240,CPT,369,RC,,,outpatient,,,9022,6315.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3241.89,,,3241.89,399.86,6928.896,fee schedule,,,
HC Biopsy Bone Open Deep,PX-36900769,CDM,20245,CPT,369,RC,,,outpatient,,,9022,6315.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3241.89,,,3241.89,399.86,6928.896,fee schedule,,,
HC Inject Sinus Tract for Dx W Xray,PX-36900120,CDM,20501,CPT,369,RC,,,outpatient,,,1451,1015.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,235.074116,1592,other,SI=N Exclusions ,,
HC Removal Foreign Body Muscle/Tendon Sheath Simple,PX-36900749,CDM,20520,CPT,369,RC,,,outpatient,,,5218,3652.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,4007.424,fee schedule,,,
HC Rmvl Foreign Body Muscle/Tendon Sheath Deep/Comp,PX-36900748,CDM,20525,CPT,369,RC,,,outpatient,,,5793,4055.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3241.89,,,3241.89,399.86,4449.024,fee schedule,,,
HC Injection of Tendon Sheath,PX-36900693,CDM,20550,CPT,369,RC,,,outpatient,,,823,576.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,337.35,,,337.35,184.7635,1592,fee schedule,,,
HC Injection Single Tendon Origin/Insertion,PX-36900793,CDM,20551,CPT,369,RC,,,outpatient,,,903,632.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,337.35,,,337.35,202.7235,1592,fee schedule,,,
HC Inject Trigger Point- 1 or 2,PX-36900123,CDM,20552,CPT,369,RC,,,outpatient,,,658,460.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,337.35,,,337.35,147.721,1592,fee schedule,,,
HC Drain/Inject Small Joint/Bursa,PX-36100004,CDM,20600,CPT,361,RC,,,outpatient,,,714,499.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,337.35,,,337.35,160.293,1592,fee schedule,,,
HC Drain/Inject Small Joint/Bursa,PX-36900125,CDM,20600,CPT,369,RC,,,outpatient,,,714,499.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,337.35,,,337.35,160.293,1592,fee schedule,,,
HC Arthrocnt Aspir&/Inj Small Jt/Bursaw/US Rec Rprt,PX-36900787,CDM,20604,CPT,369,RC,,,outpatient,,,938,656.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,337.35,,,337.35,210.581,1592,fee schedule,,,
HC Drain/Inject Intermediate Joint/Bursa,PX-36100005,CDM,20605,CPT,361,RC,,,outpatient,,,753,527.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,337.35,,,337.35,169.0485,1592,fee schedule,,,
HC Drain/Inject Intermediate Joint/Bursa,PX-36900126,CDM,20605,CPT,369,RC,,,outpatient,,,753,527.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,337.35,,,337.35,169.0485,1592,fee schedule,,,
HC Arthrocentesis Aspir&/Inj Interm Jt/Burs W/US,PX-36100030,CDM,20606,CPT,361,RC,,,outpatient,,,1844,1290.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,816.25,,,816.25,399.86,2141,fee schedule,,,
HC Drain/Inject Large Joint/Bursa,PX-36100006,CDM,20610,CPT,361,RC,,,outpatient,,,658,460.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,337.35,,,337.35,147.721,1592,fee schedule,,,
HC Drain/Inject Large Joint/Bursa,PX-36900127,CDM,20610,CPT,369,RC,,,outpatient,,,658,460.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,337.35,,,337.35,147.721,1592,fee schedule,,,
HC Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US,PX-36100031,CDM,20611,CPT,361,RC,,,outpatient,,,784,548.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,337.35,,,337.35,176.008,1592,fee schedule,,,
HC Ablate- Bone Tumor(S) Perq,PX-36900128,CDM,20982,CPT,369,RC,,,outpatient,,,16473,11531.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7769.23,,,7769.23,399.86,20110.10933,fee schedule,,,
HC Biopsy Soft Tissue Neck/Chest,PX-36900130,CDM,21550,CPT,369,RC,,,outpatient,,,4796,3357.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,3683.328,fee schedule,,,
HC Vertebroplasty Each Addl Cervicothor/Lumbosacral,PX-36900134,CDM,22512,CPT,369,RC,,,outpatient,,,1695,1186.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,380.5275,1592,other,SI=N Exclusions ,,
HC Biopsy Soft Tissue Shoulder Superficial,PX-36900138,CDM,23065,CPT,369,RC,,,outpatient,,,2502,1751.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2477.315575,fee schedule,,,
HC Inj Proc Shoulder Arthrography/CT/MRI,PX-36900139,CDM,23350,CPT,369,RC,,,outpatient,,,1114,779.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,235.074116,1592,other,SI=N Exclusions ,,
HC Clsd Tx Shoulder Dislc W/Manipulation W/O Anes,PX-36900581,CDM,23650,CPT,369,RC,,,outpatient,,,735,514.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,306.82,,,306.82,165.0075,1592,fee schedule,,,
HC Clsd Tx Shoulder Dislc W/Manipulation Req Anes,PX-36900582,CDM,23655,CPT,369,RC,,,outpatient,,,3604,2522.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1790.24,,,1790.24,399.86,2998,fee schedule,,,
HC I&D Upper Arm/Elbow Deep Abscess/Hematoma,PX-36900784,CDM,23930,CPT,369,RC,,,outpatient,,,5218,3652.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,4341.777195,fee schedule,,,
HC Incision&Drainage Upper Arm/Elbow Bursa,PX-36900751,CDM,23931,CPT,369,RC,,,outpatient,,,3342,2339.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2998,fee schedule,,,
HC Biopsy Soft Tissue Upper Arm/Elbow Superficial,PX-36900768,CDM,24065,CPT,369,RC,,,outpatient,,,5218,3652.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,4007.424,fee schedule,,,
HC Biopsy Soft Tissue Upper Arm/Elbow Area Deep,PX-36900767,CDM,24066,CPT,369,RC,,,outpatient,,,9022,6315.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3241.89,,,3241.89,399.86,6928.896,fee schedule,,,
HC Injection for Elbow Arthrogram,PX-36900143,CDM,24220,CPT,369,RC,,,outpatient,,,1224,856.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,274.788,1592,other,SI=N Exclusions ,,
HC I&D Forearm&/Wrist Deep Abscess/Hematoma,PX-36900782,CDM,25028,CPT,369,RC,,,outpatient,,,9952,6966.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3575.93,,,3575.93,399.86,7643.136,fee schedule,,,
HC Incision & Drainage Forearm&/Wrist Bursa,PX-36900783,CDM,25031,CPT,369,RC,,,outpatient,,,4983,3488.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1790.24,,,1790.24,399.86,3826.944,fee schedule,,,
HC Incision Deep Bone Cortex Forearm&/Wrist,PX-36900785,CDM,25035,CPT,369,RC,,,outpatient,,,21621,15134.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7769.23,,,7769.23,399.86,16604.928,fee schedule,,,
HC Arthrt Rdcrpl/Midcarpl Jt W/Expl Drg/Rmvl FB,PX-36900778,CDM,25040,CPT,369,RC,,,outpatient,,,9952,6966.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3575.93,,,3575.93,399.86,7643.136,fee schedule,,,
HC Biopsy Soft Tissue Forearm&/Wrist Superficial,PX-36900766,CDM,25065,CPT,369,RC,,,outpatient,,,5218,3652.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,4007.424,fee schedule,,,
HC Biopsy Soft Tissue Forearm&/Wrist Deep,PX-36900765,CDM,25066,CPT,369,RC,,,outpatient,,,9022,6315.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3241.89,,,3241.89,399.86,6928.896,fee schedule,,,
HC Injection for Wrist Arthrogram,PX-36900149,CDM,25246,CPT,369,RC,,,outpatient,,,1660,1162,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,235.074116,1592,other,SI=N Exclusions ,,
HC Cltx Dstl Rdl Fx/Epiphysl Sep W/Manj When Perf,PX-36900792,CDM,25605,CPT,369,RC,,,outpatient,,,2563,1794.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1790.24,,,1790.24,399.86,2455.793921,fee schedule,,,
HC Drainage Finger Abscess Complicated,PX-36900750,CDM,26011,CPT,369,RC,,,outpatient,,,2563,1794.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2998,fee schedule,,,
HC Drainage Tendon Sheath Digit&/Palm Each,PX-36900781,CDM,26020,CPT,369,RC,,,outpatient,,,9952,6966.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3575.93,,,3575.93,399.86,7643.136,fee schedule,,,
HC Drainage of Palmar Bursa Single Bursa,PX-36900780,CDM,26025,CPT,369,RC,,,outpatient,,,9952,6966.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3575.93,,,3575.93,399.86,7643.136,fee schedule,,,
HC Drainage of Palmar Bursa Multiple Bursa,PX-36900779,CDM,26030,CPT,369,RC,,,outpatient,,,9952,6966.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3575.93,,,3575.93,399.86,7643.136,fee schedule,,,
HC Incision Bone Cortex Hand/Finger,PX-36900786,CDM,26034,CPT,369,RC,,,outpatient,,,4983,3488.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1790.24,,,1790.24,399.86,3826.944,fee schedule,,,
HC Arthrt Expl Drg/Rmvl Loose/FB Carp/Mtcrpl Jt,PX-36900775,CDM,26070,CPT,369,RC,,,outpatient,,,4983,3488.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1790.24,,,1790.24,399.86,3826.944,fee schedule,,,
HC Arthrt Expl Drg/Rmvl Loose/FB Mtcarphlngl Jt Ea,PX-36900777,CDM,26075,CPT,369,RC,,,outpatient,,,9952,6966.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3575.93,,,3575.93,399.86,7643.136,fee schedule,,,
HC Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea,PX-36900776,CDM,26080,CPT,369,RC,,,outpatient,,,4983,3488.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1790.24,,,1790.24,399.86,3826.944,fee schedule,,,
HC Bx Soft Tissues-Pelv/Hip-Superficl,PX-36900160,CDM,27040,CPT,369,RC,,,outpatient,,,3700,2590,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2841.6,fee schedule,,,
HC Bx Soft Tissues-Pelv/Hip-Deep,PX-36900161,CDM,27041,CPT,369,RC,,,outpatient,,,3700,2590,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2841.6,fee schedule,,,
HC Injection Hip Arthrogram,PX-36900162,CDM,27093,CPT,369,RC,,,outpatient,,,1589,1112.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,235.074116,1592,other,SI=N Exclusions ,,
HC Closed Rx Prox/Neck Femur Fx-Manip,PX-36900886,CDM,27232,CPT,369,RC,,,outpatient,,,3499,2449.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1512.98,,,1512.98,399.86,2998,fee schedule,,,
HC Cltx Hip Dislocation Traumatic W/O Anesthesia,PX-36900583,CDM,27250,CPT,369,RC,,,outpatient,,,902,631.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,306.82,,,306.82,202.499,1592,fee schedule,,,
HC Cltx Hip Dislocation Traumatic Req Anesthesia,PX-36900584,CDM,27252,CPT,369,RC,,,outpatient,,,2848,1993.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1790.24,,,1790.24,399.86,2455.793921,fee schedule,,,
HC Cltx Post Hip Arthrp Dislc W/O Anes,PX-36900585,CDM,27265,CPT,369,RC,,,outpatient,,,671,469.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,306.82,,,306.82,150.6395,1592,fee schedule,,,
HC Cltx Post Hip Arthrp Dislc Req Anes,PX-36900586,CDM,27266,CPT,369,RC,,,outpatient,,,2045,1431.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1790.24,,,1790.24,399.86,2998,fee schedule,,,
HC Unlisted Procedure Pelvis/Hip Joint,PX-36900700,CDM,27299,CPT,369,RC,,,outpatient,,,715,500.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,160.5175,1592,other,Unlisted Codes,,
HC I&D Deep Absc Bursa/Hematoma Thigh/Knee Region,PX-36900814,CDM,27301,CPT,369,RC,,,outpatient,,,7663,5364.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3241.89,,,3241.89,399.86,5885.184,fee schedule,,,
HC Injection Knee Arthrography,PX-36900731,CDM,27369,CPT,369,RC,,,outpatient,,,1446,1012.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,324.627,1592,other,SI=N Exclusions ,,
HC Injection for Ankle Arthrogram,PX-36900167,CDM,27648,CPT,369,RC,,,outpatient,,,834,583.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,187.233,1592,other,SI=N Exclusions ,,
HC Closed Tx Bimalleolar Ankle Fracture W/Manj,PX-36900880,CDM,27810,CPT,369,RC,,,outpatient,,,3663,2564.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1790.24,,,1790.24,292.65,2813.184,fee schedule,,,
HC Application Cast Shoulder Hand Long Arm,PX-36900741,CDM,29065,CPT,369,RC,,,outpatient,,,664,464.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,321.12,,,321.12,149.068,1592,fee schedule,,,
HC Application Cast Elbow Finger Short Arm,PX-36900739,CDM,29075,CPT,369,RC,,,outpatient,,,893,625.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,321.12,,,321.12,200.4785,1592,fee schedule,,,
HC Application Cast Hand & Lower Forearm Gauntlet,PX-36900740,CDM,29085,CPT,369,RC,,,outpatient,,,491,343.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,183.51,,,183.51,110.2295,1592,fee schedule,,,
HC Application Cast Finger,PX-36900771,CDM,29086,CPT,369,RC,,,outpatient,,,511,357.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,183.51,,,183.51,114.7195,1592,fee schedule,,,
HC Application Long Arm Splint Shoulder Hand,PX-36900759,CDM,29105,CPT,369,RC,,,outpatient,,,453,317.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,183.51,,,183.51,101.6985,1592,fee schedule,,,
HC Application Short Arm Splint Forearm-Hand Static,PX-36900576,CDM,29125,CPT,369,RC,,,outpatient,,,354,247.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,79.473,1592,fee schedule,,,
HC Application Short Arm Splint Dynamic,PX-36900577,CDM,29126,CPT,369,RC,,,outpatient,,,354,247.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,79.473,1592,fee schedule,,,
HC Application Finger Splint Static,PX-36900579,CDM,29130,CPT,369,RC,,,outpatient,,,221,154.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,76.19,,,76.19,49.6145,1592,fee schedule,,,
HC Application Finger Splint Dynamic,PX-36900580,CDM,29131,CPT,369,RC,,,outpatient,,,218,152.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,76.19,,,76.19,48.941,1592,fee schedule,,,
HC Strapping Shoulder,PX-36900761,CDM,29240,CPT,369,RC,,,outpatient,,,405,283.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,90.9225,1592,fee schedule,,,
HC Strapping Elbow/Wrist,PX-36900760,CDM,29260,CPT,369,RC,,,outpatient,,,122,85.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,43.78,,,43.78,27.389,1592,fee schedule,,,
HC Strapping Hand/Finger,PX-36900790,CDM,29280,CPT,369,RC,,,outpatient,,,122,85.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,43.78,,,43.78,27.389,1592,fee schedule,,,
HC Application Short Leg Cast Below Knee-Toe,PX-36900818,CDM,29405,CPT,369,RC,,,outpatient,,,699,489.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,321.12,,,321.12,156.9255,1592,fee schedule,,,
HC Application Long Leg Splint Thigh Ankle/Toes,PX-36900737,CDM,29505,CPT,369,RC,,,outpatient,,,554,387.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,183.51,,,183.51,124.373,1592,fee schedule,,,
HC Application Short Leg Splint Calf Foot,PX-36900578,CDM,29515,CPT,369,RC,,,outpatient,,,354,247.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,183.51,,,183.51,79.473,1592,fee schedule,,,
HC Ctrl Nosebleed-Anter-Simple,PX-36900181,CDM,30901,CPT,369,RC,,,outpatient,,,347,242.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,77.9015,1592,fee schedule,,,
HC PR Control Nasal Hemorrhage Anterior Simple,PX-96000041,CDM,30901,CPT,960,RC,,,outpatient,,,347,242.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,77.9015,1592,fee schedule,,,
HC Control Nasal Hemorrhage Anterior Complex,PX-36900745,CDM,30903,CPT,369,RC,,,outpatient,,,289,202.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,64.8805,1592,fee schedule,,,
HC PR Control Nasal Hemorrhage Anterior Complex,PX-96000042,CDM,30903,CPT,960,RC,,,outpatient,,,289,202.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,64.8805,1592,fee schedule,,,
HC Ctrl Nsl Hemrrg Pst Nasal Packs&/Cautery 1st,PX-36900746,CDM,30905,CPT,369,RC,,,outpatient,,,486,340.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,109.107,1592,fee schedule,,,
HC Ctrl Nsl Hemrrg Pst Nasal Packs&/Cautery Subsq,PX-36900747,CDM,30906,CPT,369,RC,,,outpatient,,,510,357,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,280.99,,,280.99,114.495,1592,fee schedule,,,
HC Insert Emergency Endotrach Airway,PX-36100007,CDM,31500,CPT,361,RC,,,outpatient,,,544,380.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,280.99,,,280.99,122.128,1592,fee schedule,,,
HC Insert Emergency Endotrach Airway,PX-36900182,CDM,31500,CPT,369,RC,,,outpatient,,,544,380.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,280.99,,,280.99,122.128,1592,fee schedule,,,
HC PR Intubation Endotracheal Emergency Procedure,PX-96000038,CDM,31500,CPT,960,RC,,,outpatient,,,544,380.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,280.99,,,280.99,122.128,1592,fee schedule,,,
HC Trach Tube Change,PX-36900183,CDM,31502,CPT,369,RC,,,outpatient,,,615,430.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,280.99,,,280.99,138.0675,1592,fee schedule,,,
HC Laryngoscopy-Flex Fiber-Diagnostic,PX-36900185,CDM,31575,CPT,369,RC,,,outpatient,,,371,259.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,223.51,,,223.51,83.2895,1592,fee schedule,,,
HC Bronchoscopy-Diagnostic,PX-36900187,CDM,31622,CPT,369,RC,,,outpatient,,,3151,2205.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1866.51,,,1866.51,399.86,2998,fee schedule,,,
HC Bronchoscopy-Diagnostic W Brush,PX-36900188,CDM,31623,CPT,369,RC,,,outpatient,,,3150,2205,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1866.51,,,1866.51,399.86,2998,fee schedule,,,
HC Brnchsc W/Brncl Alveolar Lavage,PX-36900896,CDM,31624,CPT,369,RC,,,outpatient,,,3935,2754.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1866.51,,,1866.51,399.86,3022.08,fee schedule,,,
HC Bronchoscopy-Biopsy,PX-36900189,CDM,31625,CPT,369,RC,,,outpatient,,,3271,2289.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1866.51,,,1866.51,399.86,2998,fee schedule,,,
HC Needle Biopsy Pleura,PX-36900190,CDM,32400,CPT,369,RC,,,outpatient,,,3700,2590,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2998,fee schedule,,,
HC Core Needle Bx Lung/Mediastinum Perq W/Img,PX-36900808,CDM,32408,CPT,369,RC,,,outpatient,,,4594,3215.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1906.39,,,1906.39,399.86,3528.192,fee schedule,,,
HC Insertion Indwelling Tunneled Pleural Catheter,PX-36900192,CDM,32550,CPT,369,RC,,,outpatient,,,8367,5856.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4017.55,,,4017.55,399.86,6425.856,fee schedule,,,
HC Tube Thoracostomy Includes Water Seal,PX-36100008,CDM,32551,CPT,361,RC,,,outpatient,,,1951,1365.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1490.75,,,1490.75,399.86,2447.133941,fee schedule,,,
HC Tube Thoracostomy Includes Water Seal,PX-36900193,CDM,32551,CPT,369,RC,,,outpatient,,,1951,1365.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1490.75,,,1490.75,399.86,2447.133941,fee schedule,,,
HC Tube Thoracostomy Includes Water Seal,PX-36900573,CDM,32551,CPT,369,RC,,,outpatient,,,1951,1365.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1490.75,,,1490.75,399.86,2447.133941,fee schedule,,,
HC PR Tube Thoracostomy Includes Water Seal,PX-96000039,CDM,32551,CPT,960,RC,,,outpatient,,,1951,1365.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1490.75,,,1490.75,399.86,2447.133941,fee schedule,,,
HC Removal of Indwelling Tunneled Pleural Catheter With Cuff,PX-36900194,CDM,32552,CPT,369,RC,,,outpatient,,,2265,1585.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,845.15,,,845.15,399.86,2141,fee schedule,,,
HC Perc Place Intra-Thoracic Interstit Rad Therapy Guide- 1/Mult,PX-36900195,CDM,32553,CPT,369,RC,,,outpatient,,,4198,2938.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1624.73,,,1624.73,399.86,3224.064,fee schedule,,,
HC Thoracentesis Needle/Cath Pleura W/O Imaging,PX-36900196,CDM,32554,CPT,369,RC,,,outpatient,,,1874,1311.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,845.15,,,845.15,399.86,2141,fee schedule,,,
HC Thoracentesis Needle/Cath Pleura W/Imaging,PX-36100001,CDM,32555,CPT,361,RC,,,outpatient,,,1636,1145.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,845.15,,,845.15,367.282,2141,fee schedule,,,
HC Thoracentesis Needle/Cath Pleura W/Imaging,PX-36900197,CDM,32555,CPT,369,RC,,,outpatient,,,1636,1145.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,845.15,,,845.15,367.282,2141,fee schedule,,,
HC Perq Drainage Pleura Insert Cath W/O Imaging,PX-36900742,CDM,32556,CPT,369,RC,,,outpatient,,,2896,2027.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2021.99,,,2021.99,399.86,2998,fee schedule,,,
HC Perq Drainage Pleura Insert Cath W/Imaging,PX-36900198,CDM,32557,CPT,369,RC,,,outpatient,,,1882,1317.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1490.75,,,1490.75,399.86,2447.133941,fee schedule,,,
HC PR Instlj via Chest Tube/Cath Agent for Pleurodesis,PX-96000040,CDM,32560,CPT,960,RC,,,outpatient,,,2265,1585.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,845.15,,,845.15,399.86,1739.52,fee schedule,,,
HC Instlj via Ch Tube/Cath Agent Fbrnlysis 1st Day,PX-36900826,CDM,32561,CPT,369,RC,,,outpatient,,,1421,994.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,845.15,,,845.15,319.0145,2141,fee schedule,,,
HC Instlj Ch Tube/Cath Agent Fbrnlysis Sbsq Day,PX-36900827,CDM,32562,CPT,369,RC,,,outpatient,,,1421,994.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,845.15,,,845.15,319.0145,2141,fee schedule,,,
HC Pericardiocentesis W/Img Guidance When Performed,PX-36100034,CDM,33016,CPT,361,RC,,,outpatient,,,5537,3875.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2130.85,,,2130.85,399.86,4252.416,fee schedule,,,
HC Pericardiocentesis W/Img Guidance When Performed,PX-36900797,CDM,33016,CPT,369,RC,,,outpatient,,,5537,3875.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2130.85,,,2130.85,399.86,4252.416,fee schedule,,,
HC Inser Hart Pacer Xvenous Atrial,PX-36900204,CDM,33206,CPT,369,RC,,,outpatient,,,27344,19140.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13466.73,,,13466.73,399.86,21000.192,fee schedule,,,
HC Inser Hart Pacer Xvenous Ventr,PX-36900205,CDM,33207,CPT,369,RC,,,outpatient,,,36767,25736.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13466.73,,,13466.73,399.86,28237.056,fee schedule,,,
HC Inser Hart Pacer Xvenous Atr/Ventr,PX-36900206,CDM,33208,CPT,369,RC,,,outpatient,,,27344,19140.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13466.73,,,13466.73,399.86,21000.192,fee schedule,,,
HC Inser Heart Temp Pacer One Chmbr,PX-36900207,CDM,33210,CPT,369,RC,,,outpatient,,,21456,15019.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10092.69,,,10092.69,399.86,16478.208,fee schedule,,,
HC Insert Pulse Gener One Chmbr,PX-36900209,CDM,33212,CPT,369,RC,,,outpatient,,,21456,15019.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10092.69,,,10092.69,399.86,16478.208,fee schedule,,,
HC Insert Pulse Gener Dual Chmbr,PX-36900210,CDM,33213,CPT,369,RC,,,outpatient,,,27344,19140.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13466.73,,,13466.73,399.86,21000.192,fee schedule,,,
HC Upgrade of Pacemaker System,PX-36900211,CDM,33214,CPT,369,RC,,,outpatient,,,27344,19140.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13466.73,,,13466.73,399.86,21000.192,fee schedule,,,
HC Reposition Transvenous Electrode,PX-36900212,CDM,33215,CPT,369,RC,,,outpatient,,,4029,2820.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,4870.452937,fee schedule,,,
HC Revise Electrode-Pacing-Dual,PX-36900215,CDM,33217,CPT,369,RC,,,outpatient,,,21456,15019.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10092.69,,,10092.69,399.86,16478.208,fee schedule,,,
HC Reeletrode-Pacing-Single,PX-36900216,CDM,33218,CPT,369,RC,,,outpatient,,,9056,6339.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4267.29,,,4267.29,399.86,6955.008,fee schedule,,,
HC Reelectrode-Pacing-Dual,PX-36900217,CDM,33220,CPT,369,RC,,,outpatient,,,9056,6339.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4267.29,,,4267.29,399.86,6955.008,fee schedule,,,
HC Ins Pacemaker Pulse Gen Only W/Exist Mult Leads,PX-36900218,CDM,33221,CPT,369,RC,,,outpatient,,,48979,34285.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24098.62,,,24098.62,399.86,37615.872,fee schedule,,,
HC Relocation of Skin Pocket for Pacemaker,PX-36900219,CDM,33222,CPT,369,RC,,,outpatient,,,4504,3152.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2111.41,,,2111.41,399.86,3459.072,fee schedule,,,
HC Relocate Skin Pocket Cardioverter-Defibrillator,PX-36900220,CDM,33223,CPT,369,RC,,,outpatient,,,2716,1901.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2111.41,,,2111.41,399.86,2998,fee schedule,,,
HC Insrt Pacing Elect-W/Attach Prev Device,PX-36900221,CDM,33224,CPT,369,RC,,,outpatient,,,27344,19140.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13466.73,,,13466.73,399.86,21000.192,fee schedule,,,
HC Insj Eltrd Car Ven Sys Tm Insj Cvdfb/Pm Pls Gen,PX-36900222,CDM,33225,CPT,369,RC,,,outpatient,,,7571,5299.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6364,other,SI=N Exclusions ,,
HC Reposit Prev Implanted Cardiac Electrode,PX-36900223,CDM,33226,CPT,369,RC,,,outpatient,,,3644,2550.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,4870.452937,fee schedule,,,
HC Remvl Perm Pm Plse Gen W/Repl Plse Gen Sngl Lead,PX-36900224,CDM,33227,CPT,369,RC,,,outpatient,,,17786,12450.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10092.69,,,10092.69,399.86,13659.648,fee schedule,,,
HC Remvl Perm Pm Pls Gen W/Repl Plse Gen 2 Lead Sys,PX-36900225,CDM,33228,CPT,369,RC,,,outpatient,,,19652,13756.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13466.73,,,13466.73,399.86,16316.30039,fee schedule,,,
HC Remvl Perm Pm Pls Gen W/Repl Plse Gen Mult Lead,PX-36900226,CDM,33229,CPT,369,RC,,,outpatient,,,22582,15807.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24098.62,,,24098.62,399.86,29773.2518,fee schedule,,,
HC Ins Pacng Cvdfb Pls Gen Only W/Exist Dual Leads,PX-36900227,CDM,33230,CPT,369,RC,,,outpatient,,,67496,47247.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,29983.82,,,29983.82,399.86,51836.928,fee schedule,,,
HC Ins Pacng Cvdfb Pls Gen Only W/Exist Multi Leads,PX-36900228,CDM,33231,CPT,369,RC,,,outpatient,,,64998,45498.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,41788.33,,,41788.33,399.86,50269.54813,fee schedule,,,
HC Remv Perm Pacer Generator,PX-36900229,CDM,33233,CPT,369,RC,,,outpatient,,,21456,15019.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10092.69,,,10092.69,399.86,16478.208,fee schedule,,,
HC Remv Transven Pacer Electrode-1 Lead,PX-36900230,CDM,33234,CPT,369,RC,,,outpatient,,,9056,6339.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4267.29,,,4267.29,399.86,6955.008,fee schedule,,,
HC Remv Transven Pacer Electrode-2 Lead,PX-36900231,CDM,33235,CPT,369,RC,,,outpatient,,,9056,6339.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4267.29,,,4267.29,399.86,6955.008,fee schedule,,,
HC Rmv Pulse Generator-Sngl/Dual,PX-36900233,CDM,33241,CPT,369,RC,,,outpatient,,,9028,6319.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4267.29,,,4267.29,399.86,6933.504,fee schedule,,,
HC Rmv Pacer/Electrd-Transven Extrct,PX-36900234,CDM,33244,CPT,369,RC,,,outpatient,,,9056,6339.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4267.29,,,4267.29,399.86,6955.008,fee schedule,,,
HC Insert Electrd Leads/Repostion,PX-36900235,CDM,33249,CPT,369,RC,,,outpatient,,,86384,60468.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,41788.33,,,41788.33,399.86,66342.912,fee schedule,,,
HC Rem Pac Cvdfb Plse Gen &Repl Plse Gen Sngl Lead,PX-36900236,CDM,33262,CPT,369,RC,,,outpatient,,,63006,44104.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,29983.82,,,29983.82,399.86,48388.608,fee schedule,,,
HC Rem Pac Cvdfb Plse Gen &Repl Plse Gen Dual Lead,PX-36900237,CDM,33263,CPT,369,RC,,,outpatient,,,65752,46026.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,29983.82,,,29983.82,399.86,50497.536,fee schedule,,,
HC Rem Pac Cvdfb Pls Gen &Repl Plse Gen Multi Lead,PX-36900238,CDM,33264,CPT,369,RC,,,outpatient,,,65752,46026.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,41788.33,,,41788.33,399.86,50497.536,fee schedule,,,
HC Replace Aortic Valve Perq Femoral Artry Approach,PX-36900544,CDM,33361,CPT,369,RC,,,outpatient,,,27728,19409.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2738.42,,,2738.42,399.86,21295.104,fee schedule,,,
HC Replace Aortic Valve Openfemoral Artery Approach,PX-36900545,CDM,33362,CPT,369,RC,,,outpatient,,,29393,20575.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,24913.51,399.86,24913.5068,percent of total billed charges,,,
HC Replace Aortic Valve Open Axillry Artry Approach,PX-36900546,CDM,33363,CPT,369,RC,,,outpatient,,,27728,19409.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3094.93,,,3094.93,399.86,21295.104,fee schedule,,,
HC Replace Aortic Valve Open Iliac Artery Approach,PX-36900547,CDM,33364,CPT,369,RC,,,outpatient,,,29393,20575.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3192.45,,,3192.45,399.86,22573.824,fee schedule,,,
HC Replace Aortic Valve Open Transaortic Approach,PX-36900548,CDM,33365,CPT,369,RC,,,outpatient,,,29393,20575.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3593.11,,,3593.11,399.86,22573.824,fee schedule,,,
HC Transcatheter Transapical Replacemt Aortic Valve,PX-36900549,CDM,33366,CPT,369,RC,,,outpatient,,,29393,20575.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,24913.51,399.86,24913.5068,percent of total billed charges,,,
HC Replace Aortic Valve W/Byp Prq Art/Venous Apprch,PX-36900550,CDM,33367,CPT,369,RC,,,outpatient,,,27728,19409.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,23502.25,399.86,23502.2528,percent of total billed charges,,,
HC Replace Aortic Valve W/Byp Open Art/Venous Aprch,PX-36900551,CDM,33368,CPT,369,RC,,,outpatient,,,29393,20575.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,24913.51,399.86,24913.5068,percent of total billed charges,,,
HC Replace Aorta Valve W/Byp Cntrl Art/Venous Aprch,PX-36900552,CDM,33369,CPT,369,RC,,,outpatient,,,29393,20575.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,24913.51,399.86,24913.5068,percent of total billed charges,,,
HC Endovasc Taa Reincl Subcl,PX-36900241,CDM,33880,CPT,369,RC,,,outpatient,,,6951,4865.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3592.89,,,3592.89,399.86,5338.368,fee schedule,,,
HC Endovasc Taa Rew/O Subcl,PX-36900242,CDM,33881,CPT,369,RC,,,outpatient,,,5970,4179,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3084.78,,,3084.78,399.86,4584.96,fee schedule,,,
HC Insert Endovasc Prosth- Taa,PX-36900243,CDM,33883,CPT,369,RC,,,outpatient,,,4420,3094,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,3746.39,399.86,3746.392,percent of total billed charges,,,
HC Endovasc Prosth- Taa- Ea Add,PX-36900244,CDM,33884,CPT,369,RC,,,outpatient,,,1649,1154.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1397.69,370.2005,2998,percent of total billed charges,,,
HC Endovasc Dist Extens Taa Prosth- Delayed,PX-36900245,CDM,33886,CPT,369,RC,,,outpatient,,,3820,2674,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,3237.83,399.86,3237.832,percent of total billed charges,,,
HC Car-Car Bypass Grft W/ Endovas Taa Repair,PX-36900247,CDM,33891,CPT,369,RC,,,outpatient,,,4194,2935.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1897.1,,,1897.1,399.86,3220.992,fee schedule,,,
HC Remove Pul Art Emboli No Bypass,PX-36900248,CDM,33915,CPT,369,RC,,,outpatient,,,1800,1260,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1525.68,399.86,2998,percent of total billed charges,,,
HC Insert Intra-Aortic Balloon Asst Device,PX-36900249,CDM,33967,CPT,369,RC,,,outpatient,,,2513,1759.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,524.25,,,524.25,399.86,6913,fee schedule,,,
HC Rmv Aortic Balloon Device,PX-36900250,CDM,33968,CPT,369,RC,,,outpatient,,,139,97.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,117.82,31.2055,6913,percent of total billed charges,,,
HC Insj Perq Vad W/Rs&I L Hrt Arterial Access Only,PX-36900251,CDM,33990,CPT,369,RC,,,outpatient,,,4109,2876.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,860.21,,,860.21,399.86,3155.712,fee schedule,,,
HC Removal Perq Left Hrt Vad Artl/Artl&Ven Sep Insj,PX-36900252,CDM,33992,CPT,369,RC,,,outpatient,,,4188,2931.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,3549.75,399.86,3549.7488,percent of total billed charges,,,
HC Repositioning Perq R/L Vad W/Img Gdn Sep Insj,PX-36900253,CDM,33993,CPT,369,RC,,,outpatient,,,4188,2931.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,3549.75,399.86,3549.7488,percent of total billed charges,,,
HC Insj Perq Vad W/Rs&I R Heart Venous Access Only,PX-36900809,CDM,33995,CPT,369,RC,,,outpatient,,,4109,2876.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,660.2,,,660.2,399.86,3155.712,fee schedule,,,
HC Removal Perq R Heart Vad Venous Cannula Sep Insj,PX-36900810,CDM,33997,CPT,369,RC,,,outpatient,,,4188,2931.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,293.59,,,293.59,293.5896,3216.384,fee schedule,,,
HC Cardiac Surg Procedure Unlist,PX-36900254,CDM,33999,CPT,369,RC,,,outpatient,,,1770,1239,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,397.365,2141,other,Unlisted Codes,,
HC Cardiac Surg Procedure Unlist,PX-36900635,CDM,33999,CPT,369,RC,,,outpatient,,,1770,1239,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,397.365,2141,other,Unlisted Codes,,
HC Remv Art Clot Axill-Brach-Arm Incis,PX-36900255,CDM,34101,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5965.72,,,5965.72,399.86,9631.488,fee schedule,,,
HC Remv Art Clot Arm-Arm Incis,PX-36900256,CDM,34111,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5965.72,,,5965.72,399.86,9631.488,fee schedule,,,
HC Remv Art Clot Iliac-Pop-Leg Incis,PX-36900257,CDM,34201,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5965.72,,,5965.72,399.86,9631.488,fee schedule,,,
HC Remv Art Clot Low Leg-Leg Incis,PX-36900258,CDM,34203,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5965.72,,,5965.72,399.86,9631.488,fee schedule,,,
HC Aaa Repair-Iliac Artery Occlsn Device,PX-36900264,CDM,34808,CPT,369,RC,,,outpatient,,,152,106.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,420.73,,,420.73,34.124,2998,fee schedule,,,
HC Aaa Repr-Expose Femoral Art-Groin Incis,PX-36900265,CDM,34812,CPT,369,RC,,,outpatient,,,238,166.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,412.75,,,412.75,53.431,2998,fee schedule,,,
HC Aaa Repair- Femoral-Femoral Graft,PX-36900266,CDM,34813,CPT,369,RC,,,outpatient,,,167,116.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,141.55,37.4915,2998,percent of total billed charges,,,
HC Aaa Repr-Expose Iliac Art-Abd Incis- Unilat,PX-36900267,CDM,34820,CPT,369,RC,,,outpatient,,,337,235.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,285.64,75.6565,2998,percent of total billed charges,,,
HC Open Iliac Art Exp W/Conduit-Unilat,PX-36900270,CDM,34833,CPT,369,RC,,,outpatient,,,447,312.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,378.88,100.3515,2998,percent of total billed charges,,,
HC Open Brach Art Exp-Endovas Pros-Unilat,PX-36900271,CDM,34834,CPT,369,RC,,,outpatient,,,218,152.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,184.78,48.941,2998,percent of total billed charges,,,
HC Thrombectomy a-V Graft- Exc Hemodialysis,PX-36900278,CDM,35875,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5965.72,,,5965.72,399.86,9631.488,fee schedule,,,
HC Place Needle in Vein,PX-36900279,CDM,36000,CPT,369,RC,,,outpatient,,,343,240.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,77.0035,1592,other,SI=N Exclusions ,,
HC Injection Rx Extremity Pseudoaneurysm,PX-36900280,CDM,36002,CPT,369,RC,,,outpatient,,,775,542.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,845.15,,,845.15,173.9875,2141,fee schedule,,,
HC Injection Proc-Extremity-Venography,PX-36900281,CDM,36005,CPT,369,RC,,,outpatient,,,258,180.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,57.921,1592,other,SI=N Exclusions ,,
HC Place Cath in Vein-Svc-Ivc,PX-36900282,CDM,36010,CPT,369,RC,,,outpatient,,,541,378.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,121.4545,1592,other,SI=N Exclusions ,,
HC Place Cath in Vein-Select,PX-36900283,CDM,36011,CPT,369,RC,,,outpatient,,,773,541.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,173.5385,1592,other,SI=N Exclusions ,,
HC Place Cath in Vein-Subselect,PX-36900284,CDM,36012,CPT,369,RC,,,outpatient,,,909,636.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,204.0705,1592,other,SI=N Exclusions ,,
HC Place Cath in Rt Hrt-Main Pulm Art,PX-36900285,CDM,36013,CPT,369,RC,,,outpatient,,,8331,5831.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6398.208,other,SI=N Exclusions ,,
HC Place Cath in Lt/Rt Pulm Art,PX-36900286,CDM,36014,CPT,369,RC,,,outpatient,,,721,504.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,161.8645,1592,other,SI=N Exclusions ,,
HC Place Cath in Subsegmt Pulm Art,PX-36900287,CDM,36015,CPT,369,RC,,,outpatient,,,1662,1163.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,373.119,1592,other,SI=N Exclusions ,,
HC Place Cath Carot/Vert Art,PX-36900288,CDM,36100,CPT,369,RC,,,outpatient,,,628,439.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,140.986,1592,other,SI=N Exclusions ,,
HC Place Cath Extrem Artery,PX-36900290,CDM,36140,CPT,369,RC,,,outpatient,,,340,238,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,76.33,1592,other,SI=N Exclusions ,,
HC Place Cath Aorta via Translumbar,PX-36900293,CDM,36160,CPT,369,RC,,,outpatient,,,2609,1826.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,2003.712,other,SI=N Exclusions ,,
HC Place Cath Aorta,PX-36900294,CDM,36200,CPT,369,RC,,,outpatient,,,721,504.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,161.8645,1592,other,SI=N Exclusions ,,
HC Place Cath Selective Art-Neck,PX-36900295,CDM,36215,CPT,369,RC,,,outpatient,,,1030,721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.235,1592,other,SI=N Exclusions ,,
HC Place Cath Subselect Art-Neck,PX-36900296,CDM,36216,CPT,369,RC,,,outpatient,,,568,397.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,127.516,1592,other,SI=N Exclusions ,,
HC Place Cath Subsubselect Art-Neck,PX-36900297,CDM,36217,CPT,369,RC,,,outpatient,,,1545,1081.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,346.8525,1592,other,SI=N Exclusions ,,
HC Place Cath Addn Subselec Art-Neck,PX-36900298,CDM,36218,CPT,369,RC,,,outpatient,,,109,76.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,24.4705,1592,other,SI=N Exclusions ,,
HC Nonslctv Cath Thor Aorta Angio Intr/Xtrcranl Art,PX-36900299,CDM,36221,CPT,369,RC,,,outpatient,,,9691,6783.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,7442.688,fee schedule,,,
HC Slctv Cath Carotid/Innom Art Angio Xtrcranl Art,PX-36900300,CDM,36222,CPT,369,RC,,,outpatient,,,9691,6783.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,7442.688,fee schedule,,,
HC Slctv Cath Carotid/Innom Art Angio Intrcranl Art,PX-36900301,CDM,36223,CPT,369,RC,,,outpatient,,,9141,6398.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5965.72,,,5965.72,399.86,8396.844904,fee schedule,,,
HC Slctv Cath Intrnl Carotid Art Angio Intrcrnl Art,PX-36900302,CDM,36224,CPT,369,RC,,,outpatient,,,15847,11092.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5965.72,,,5965.72,399.86,12170.496,fee schedule,,,
HC Slctv Cath Subclavian Art Angio Vertebral Artery,PX-36900303,CDM,36225,CPT,369,RC,,,outpatient,,,9141,6398.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,7020.288,fee schedule,,,
HC Slctv Cath Vertebral Art Angio Vertebral Artery,PX-36900304,CDM,36226,CPT,369,RC,,,outpatient,,,15847,11092.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5965.72,,,5965.72,399.86,12170.496,fee schedule,,,
HC Slctv Cath Xtrnl Carotid Angio Xtrnl Carotd Circ,PX-36900305,CDM,36227,CPT,369,RC,,,outpatient,,,515,360.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,115.6175,1592,other,SI=N Exclusions ,,
HC Slctv Cath Intrcrnl Brnch Angio Intrl Carot/Vert,PX-36900306,CDM,36228,CPT,369,RC,,,outpatient,,,612,428.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.394,1592,other,SI=N Exclusions ,,
HC Place Cath Select Art-Abd/Pel,PX-36900307,CDM,36245,CPT,369,RC,,,outpatient,,,1107,774.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,248.5215,1592,other,SI=N Exclusions ,,
HC Place Cath Subselect Art-Abd/Pel,PX-36900308,CDM,36246,CPT,369,RC,,,outpatient,,,1236,865.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,277.482,1592,other,SI=N Exclusions ,,
HC Place Cath Subsubselect Art-Abd/Pel,PX-36900309,CDM,36247,CPT,369,RC,,,outpatient,,,1442,1009.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,323.729,1592,other,SI=N Exclusions ,,
HC Place Cath Addn Subsel Art-Abd/Pel,PX-36900310,CDM,36248,CPT,369,RC,,,outpatient,,,258,180.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,57.921,1592,other,SI=N Exclusions ,,
HC Slctv Cath 1stord W/WO Art Punct/Fluoro/S&I Uni,PX-36900311,CDM,36251,CPT,369,RC,,,outpatient,,,9430,6601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,7242.24,fee schedule,,,
HC Slctv Cath 1stord W/WO Art Punct/Fluor/S&I Bilat,PX-36900312,CDM,36252,CPT,369,RC,,,outpatient,,,9430,6601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,7242.24,fee schedule,,,
HC Supslctv Cath 2nd+Ord Renl&Acces Artery/S&I Uni,PX-36900313,CDM,36253,CPT,369,RC,,,outpatient,,,9430,6601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5965.72,,,5965.72,399.86,8396.844904,fee schedule,,,
HC Supslctv Cath 2nd+Ord Renl&Acces Arter/S&I Bilat,PX-36900314,CDM,36254,CPT,369,RC,,,outpatient,,,9430,6601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,7242.24,fee schedule,,,
Vnpnxr <3 Years Phys/Qhp Skill Other Vein,PX-36900875,CDM,36406,CPT,369,RC,,,outpatient,,,24,16.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.388,416.02,other,SI=N Exclusions ,,
HC Blood Transfusion Service,PX-39100001,CDM,36430,CPT,391,RC,,,outpatient,,,923,646.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,521.94,,,521.94,207.2135,1592,fee schedule,,,
HC Injection; Spider Veins-Limb/Trunk,PX-36900315,CDM,36468,CPT,369,RC,,,outpatient,,,909,636.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,240.52,,,240.52,156.65,1592,fee schedule,,,
HC Injection Therapy Vein-One Vein,PX-36900316,CDM,36470,CPT,369,RC,,,outpatient,,,909,636.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,204.0705,1592,fee schedule,,,
HC Injection Therapy Vein-Mult Veins,PX-36900317,CDM,36471,CPT,369,RC,,,outpatient,,,383,268.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,428.13,,,428.13,85.9835,1592,fee schedule,,,
HC Endovenous Rf- 1st Vein,PX-36900318,CDM,36475,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,6623.08,fee schedule,,,
HC Endovenous Rf- Vein Add-On,PX-36900319,CDM,36476,CPT,369,RC,,,outpatient,,,1797,1257.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,1592,other,SI=N Exclusions ,,
HC Endovenous Laser- 1st Vein,PX-36900320,CDM,36478,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,5781.504,fee schedule,,,
HC Endovenous Laser Vein Addon,PX-36900321,CDM,36479,CPT,369,RC,,,outpatient,,,1797,1257.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,1592,other,SI=N Exclusions ,,
HC Percut Portal Vein Cath,PX-36900322,CDM,36481,CPT,369,RC,,,outpatient,,,915,640.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,205.4175,1592,other,SI=N Exclusions ,,
HC Venous Select Sampling W Cath,PX-36900323,CDM,36500,CPT,369,RC,,,outpatient,,,412,288.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,92.494,1592,other,SI=N Exclusions ,,
HC Cathj Umbilical Vein Dx/Ther Nb,PX-36900588,CDM,36510,CPT,369,RC,,,outpatient,,,773,541.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,173.5385,1592,other,SI=N Exclusions ,,
HC Ther Apheresis-Platelets,PX-36900553,CDM,36513,CPT,369,RC,,,outpatient,,,1337,935.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,521.94,,,521.94,300.1565,2081.64,fee schedule,,,
HC Ther Apheresis-Plasma Pheresis,PX-36900324,CDM,36514,CPT,369,RC,,,outpatient,,,4919,3443.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1699.82,,,1699.82,399.86,3777.792,fee schedule,,,
HC Insert Non-Tunnel Cv Cath < 5 Y/O,PX-36100009,CDM,36555,CPT,361,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1490.75,,,1490.75,399.86,5781.504,fee schedule,,,
HC Insert Non-Tunnel Cv Cath < 5 Y/O,PX-36900325,CDM,36555,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1490.75,,,1490.75,399.86,5781.504,fee schedule,,,
HC Insert Non-Tunnel Cv Cath,PX-36100010,CDM,36556,CPT,361,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1490.75,,,1490.75,399.86,6012.672,fee schedule,,,
HC Insert Non-Tunnel Cv Cath,PX-36900326,CDM,36556,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1490.75,,,1490.75,399.86,6012.672,fee schedule,,,
HC PR Insj Non-Tunneled Central Venous Cath Age 5 Yr/>,PX-96000046,CDM,36556,CPT,960,RC,,,outpatient,,,7829,5480.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1490.75,,,1490.75,399.86,6012.672,fee schedule,,,
HC Insert Tunneled Cv Cath W/O Port or Pump < 5 Y/O,PX-36100011,CDM,36557,CPT,361,RC,,,outpatient,,,12541,8778.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5965.72,,,5965.72,399.86,9631.488,fee schedule,,,
HC Insert Tunneled Cv Cath W/O Port or Pump < 5 Y/O,PX-36900327,CDM,36557,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5965.72,,,5965.72,399.86,9631.488,fee schedule,,,
HC Insert Tunneled Cv Cath W/O Port or Pump,PX-36100012,CDM,36558,CPT,361,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,5781.504,fee schedule,,,
HC Insert Tunneled Cv Cath W/O Port or Pump,PX-36900328,CDM,36558,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,5781.504,fee schedule,,,
HC Insert Tunneled Cv Cath With Port <5 Y/O,PX-36100013,CDM,36560,CPT,361,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,5781.504,fee schedule,,,
HC Insert Tunneled Cv Cath With Port <5 Y/O,PX-36900329,CDM,36560,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,5781.504,fee schedule,,,
HC Insert Tunneled Cv Cath With Port,PX-36100014,CDM,36561,CPT,361,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,5781.504,fee schedule,,,
HC Insert Tunneled Cv Cath With Port,PX-36900330,CDM,36561,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,5781.504,fee schedule,,,
HC Insert Tunneled Cv Cath With Pump,PX-36100015,CDM,36563,CPT,361,RC,,,outpatient,,,12541,8778.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5965.72,,,5965.72,399.86,9631.488,fee schedule,,,
HC Insert Tunneled Cv Cath With Pump,PX-36900331,CDM,36563,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5965.72,,,5965.72,399.86,9631.488,fee schedule,,,
HC Insert Tunneled Cv Cath W 2 Access Sites- W/O Pump or Port,PX-36900332,CDM,36565,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,5781.504,fee schedule,,,
HC Insert Tunneled Cv Cath W 2 Access Sites- W/ Pump or Port,PX-36900333,CDM,36566,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5965.72,,,5965.72,399.86,9631.488,fee schedule,,,
HC Insert Picc W/O Sub-Q Port <5 Y/O,PX-36900334,CDM,36568,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,845.15,,,845.15,399.86,2840.064,fee schedule,,,
HC Insert Picc W/O Sub-Q Port,PX-36900335,CDM,36569,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1490.75,,,1490.75,399.86,2953.728,fee schedule,,,
HC PR Insj Prph Cvc W/O Subq Port/Pmp Age 5 Yr/>,PX-96000047,CDM,36569,CPT,960,RC,,,outpatient,,,3846,2692.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1490.75,,,1490.75,399.86,2953.728,fee schedule,,,
HC Insert Picc W/ Sub-Q Port <5 Y/O,PX-36900336,CDM,36570,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,5781.504,fee schedule,,,
HC Insert Picc W/ Sub-Q Port,PX-36900337,CDM,36571,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,5781.504,fee schedule,,,
HC Repair Cv Cath W/O Subq Port or Pump,PX-36900338,CDM,36575,CPT,369,RC,,,outpatient,,,1421,994.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,845.15,,,845.15,319.0145,2141,fee schedule,,,
HC Repair Cv Cath W Subq Port or Pump,PX-36900339,CDM,36576,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1490.75,,,1490.75,399.86,2840.064,fee schedule,,,
HC Replace Cv Cath- Catheter Only W Subq Pump or Port,PX-36900340,CDM,36578,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,5781.504,fee schedule,,,
HC Replace Cv Cath- Complete- Non-Tunneled- W/O Subq Port or Pump,PX-36900341,CDM,36580,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1490.75,,,1490.75,399.86,2840.064,fee schedule,,,
HC Replace Cv Cath- Complete- Tunneled- W/O Subq Port or Pump,PX-36900342,CDM,36581,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,5781.504,fee schedule,,,
HC Replace Cv Cath- Complete- Non-Tunneled- W Subq Port or Pump,PX-36900343,CDM,36582,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,5781.504,fee schedule,,,
HC Replace Cv Cath- Complete- Tunneled- W Subq Port or Pump,PX-36900344,CDM,36583,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5965.72,,,5965.72,399.86,9631.488,fee schedule,,,
HC Replace Picc W/O Port or Pump,PX-36900345,CDM,36584,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1490.75,,,1490.75,399.86,2840.064,fee schedule,,,
HC Replace Picc W Port or Pump,PX-36900346,CDM,36585,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,5781.504,fee schedule,,,
HC Removal Tunneled Cv Cath W/O Subq Port or Pump,PX-36900347,CDM,36589,CPT,369,RC,,,outpatient,,,1421,994.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,845.15,,,845.15,319.0145,2141,fee schedule,,,
HC Removal Tunneled Cv Cath W Subq Port or Pump,PX-36900348,CDM,36590,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,845.15,,,845.15,399.86,2998,fee schedule,,,
HC Collect Blood From Implant Venous Access Device,PX-76100001,CDM,36591,CPT,761,RC,,,outpatient,,,160,112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,35.92,1592,fee schedule,,,
HC Collect Blood From Catheter Venous Nos,PX-36900349,CDM,36592,CPT,369,RC,,,outpatient,,,125,87.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,28.0625,1592,fee schedule,,,
HC Declot of Cent Venous Catheter,PX-36900350,CDM,36593,CPT,369,RC,,,outpatient,,,806,564.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,393.1,,,393.1,180.947,1592,fee schedule,,,
HC Mech Remov Pericath Obstr Cv Dev via Ven Access,PX-36900351,CDM,36595,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,5781.504,fee schedule,,,
HC Mech Remov Intralum Obstr Cv Dev Thru Lumen,PX-36900352,CDM,36596,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1490.75,,,1490.75,399.86,2840.064,fee schedule,,,
HC Reposition Venous Catheter,PX-36900353,CDM,36597,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1490.75,,,1490.75,399.86,2840.064,fee schedule,,,
HC Contrast Inj Cent Ven Cath- Inc Flouro,PX-36900354,CDM,36598,CPT,369,RC,,,outpatient,,,406,284.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,255.15,,,255.15,91.147,1592,fee schedule,,,
HC Withdrawal of Arterial Blood,PX-36900355,CDM,36600,CPT,369,RC,,,outpatient,,,297,207.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,66.6765,1592,fee schedule,,,
HC Insert Cath-Art-Percut-Shortterm,PX-36900356,CDM,36620,CPT,369,RC,,,outpatient,,,309,216.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,69.3705,1592,other,SI=N Exclusions ,,
HC Catheterization Umbilical Newborn Art Dx/Therapy,PX-36900836,CDM,36660,CPT,369,RC,,,outpatient,,,10702,7491.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,9071.02,399.86,9071.0152,percent of total billed charges,,,
HC Placement Needle Intraosseous Infusion,PX-36900592,CDM,36680,CPT,369,RC,,,outpatient,,,568,397.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,474.58,,,474.58,127.516,1592,fee schedule,,,
HC PR Placement Needle Intraosseous Infusion,PX-96000050,CDM,36680,CPT,960,RC,,,outpatient,,,568,397.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,474.58,,,474.58,127.516,1592,fee schedule,,,
HC Insert Cannula-Vein-Vein,PX-36900358,CDM,36800,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5965.72,,,5965.72,399.86,9631.488,fee schedule,,,
HC Revise Av Fistula-W/O Thrombectomy,PX-36900359,CDM,36832,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5965.72,,,5965.72,399.86,9631.488,fee schedule,,,
HC Insert Transven Intrahep Portosys Shunt,PX-36900361,CDM,37182,CPT,369,RC,,,outpatient,,,4120,2884,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1648.58,,,1648.58,399.86,5756,fee schedule,,,
HC Revis Transven Intrahep Portosys Shunt,PX-36900362,CDM,37183,CPT,369,RC,,,outpatient,,,13035,9124.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,6377.4,,,6377.4,399.86,18955.84,fee schedule,,,
HC Prim Perc Mech Thrombectomy- Arterial,PX-36900363,CDM,37184,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,6377.4,,,6377.4,399.86,26793.51305,fee schedule,,,
HC Prim Perc Mech Thrombectomy- Arterial Ea Add,PX-36900364,CDM,37185,CPT,369,RC,,,outpatient,,,824,576.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,184.988,4800.911611,other,SI=N Exclusions ,,
HC Sec Perc Mech Thrombect- Arterial- W Other Proc,PX-36900365,CDM,37186,CPT,369,RC,,,outpatient,,,1236,865.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,277.482,8164.18419,other,SI=N Exclusions ,,
HC Percut Mech Thrombectomy- Venous,PX-36900366,CDM,37187,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,6377.4,,,6377.4,399.86,20286.72,fee schedule,,,
HC Percut Mech Thrombectomy- Venous- Repeat,PX-36900367,CDM,37188,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,6788.57,fee schedule,,,
HC Ins Intrvas Vc Filtr W/WO Vas Acs Vsl Selxn Rs&I,PX-36900368,CDM,37191,CPT,369,RC,,,outpatient,,,14030,9821,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5965.72,,,5965.72,399.86,10775.04,fee schedule,,,
HC Repsng Intrvas Vc Filtr W/WO Acs Vsl Selxn Rs&I,PX-36900369,CDM,37192,CPT,369,RC,,,outpatient,,,9628,6739.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,7394.304,fee schedule,,,
HC Rtrvl Intrvas Vc Filtr W/WO Acs Vsl Selxn Rs&I,PX-36900370,CDM,37193,CPT,369,RC,,,outpatient,,,9998,6998.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,7678.464,fee schedule,,,
HC Thrombolysis Cerebral IV Infusion,PX-36900762,CDM,37195,CPT,369,RC,,,outpatient,,,613,429.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,393.1,,,393.1,137.6185,1592,fee schedule,,,
HC Prq Transcatheter Rtrvl Intrvas FB With Imaging,PX-36900371,CDM,37197,CPT,369,RC,,,outpatient,,,8825,6177.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,6777.6,fee schedule,,,
HC Transcatheter Biopsy,PX-36900372,CDM,37200,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5965.72,,,5965.72,399.86,9631.488,fee schedule,,,
HC Thrombolysis Arterial Infusion W/Imaging Init Tx,PX-36900374,CDM,37211,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5965.72,,,5965.72,399.86,9631.488,fee schedule,,,
HC Thrombolysis Venous Infusion W/Imaging Init Tx,PX-36900375,CDM,37212,CPT,369,RC,,,outpatient,,,3239,2267.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,4870.452937,fee schedule,,,
HC Thrombolysis Art/Venous Infsn W/Image Subsq Tx,PX-36900376,CDM,37213,CPT,369,RC,,,outpatient,,,7224,5056.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1490.75,,,1490.75,399.86,5548.032,fee schedule,,,
HC Cessation Thrombolytic Thrpy W/Catheter Removal,PX-36900377,CDM,37214,CPT,369,RC,,,outpatient,,,7224,5056.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1490.75,,,1490.75,399.86,5548.032,fee schedule,,,
HC Transcath Stent- Cca W/Eps,PX-36900378,CDM,37215,CPT,369,RC,,,outpatient,,,553,387.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2034.53,,,2034.53,124.1485,2998,fee schedule,,,
HC Revascularize Iliac Artery-Angioplasty- Initial Vessel,PX-36900379,CDM,37220,CPT,369,RC,,,outpatient,,,15994,11195.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,6377.4,,,6377.4,399.86,12283.392,fee schedule,,,
HC Revascularize Iliac Artery-Angioplasty/Stent- Initial Vessel,PX-36900380,CDM,37221,CPT,369,RC,,,outpatient,,,16597,11617.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13180.06,,,13180.06,399.86,18955.84,fee schedule,,,
HC Revascularize Iliac Artery-Angioplasty- Ea Add Vessel,PX-36900381,CDM,37222,CPT,369,RC,,,outpatient,,,15818,11072.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,12148.224,other,SI=N Exclusions ,,
HC Revascularize Iliac Artery-Angioplasty/Stent- Ea Add Vessel,PX-36900382,CDM,37223,CPT,369,RC,,,outpatient,,,16216,11351.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,12453.888,other,SI=N Exclusions ,,
HC Revascularize Fem/Pop Artery-Angioplasty,PX-36900383,CDM,37224,CPT,369,RC,,,outpatient,,,16599,11619.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,6377.4,,,6377.4,399.86,12748.032,fee schedule,,,
HC Revascularize Fem/Pop Artery-Angioplasty/Atherectomy,PX-36900384,CDM,37225,CPT,369,RC,,,outpatient,,,34070,23849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13180.06,,,13180.06,399.86,26793.51305,fee schedule,,,
HC Revascularize Fem/Pop Artery-Angioplasty/Stent,PX-36900385,CDM,37226,CPT,369,RC,,,outpatient,,,32579,22805.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13180.06,,,13180.06,399.86,25020.672,fee schedule,,,
HC Revascularize Fem/Pop Artery-Angioplasty/Stent/Atherectomy,PX-36900386,CDM,37227,CPT,369,RC,,,outpatient,,,59005,41303.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20930.03,,,20930.03,399.86,45315.84,fee schedule,,,
HC Revascularize Tibial/Peron Artery-Angioplasty Initial,PX-36900387,CDM,37228,CPT,369,RC,,,outpatient,,,15999,11199.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13180.06,,,13180.06,399.86,16809.6787,fee schedule,,,
HC Revascularize Tibial/Peron Artery-Angioplasty/Atherectomy Initial,PX-36900388,CDM,37229,CPT,369,RC,,,outpatient,,,34866,24406.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20930.03,,,20930.03,399.86,26793.51305,fee schedule,,,
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent Initial,PX-36900389,CDM,37230,CPT,369,RC,,,outpatient,,,34070,23849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20930.03,,,20930.03,399.86,26793.51305,fee schedule,,,
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent/Atherectomy Init,PX-36900390,CDM,37231,CPT,369,RC,,,outpatient,,,58146,40702.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20930.03,,,20930.03,399.86,44656.128,fee schedule,,,
HC Revascularize Tibial/Peron Artery-Angioplasty Ea Add,PX-36900391,CDM,37232,CPT,369,RC,,,outpatient,,,16052,11236.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,12327.936,other,SI=N Exclusions ,,
HC Revascularize Tibial/Peron Artery-Angioplasty/Atherectomy Ea Add,PX-36900392,CDM,37233,CPT,369,RC,,,outpatient,,,33576,23503.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,25786.368,other,SI=N Exclusions ,,
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent Ea Add,PX-36900393,CDM,37234,CPT,369,RC,,,outpatient,,,16052,11236.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,12327.936,other,SI=N Exclusions ,,
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent/Atherectomy Ea Add,PX-36900394,CDM,37235,CPT,369,RC,,,outpatient,,,15818,11072.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,12148.224,other,SI=N Exclusions ,,
HC Open/Perq Placement Intravascular Stent Initial,PX-36900395,CDM,37236,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13180.06,,,13180.06,399.86,20286.72,fee schedule,,,
HC Open/Perq Placement Intravascular Stent Ea Addl,PX-36900396,CDM,37237,CPT,369,RC,,,outpatient,,,3978,2784.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,4532,other,SI=N Exclusions ,,
HC Open/Perq Placement Intravascular Stent Same 1st,PX-36900397,CDM,37238,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13180.06,,,13180.06,399.86,20286.72,fee schedule,,,
HC Open/Perq Placemt Intravasc Stent Same Ea Addl,PX-36900398,CDM,37239,CPT,369,RC,,,outpatient,,,3978,2784.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,4532,other,SI=N Exclusions ,,
HC Vascular Embolization or Occlusion Venous Rs&I,PX-36900399,CDM,37241,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13180.06,,,13180.06,399.86,20286.72,fee schedule,,,
HC Vascular Embolization or Occlusion Arterial Rs&I,PX-36900400,CDM,37242,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13180.06,,,13180.06,399.86,26793.51305,fee schedule,,,
HC Vascular Embolize/Occlude Organ Tumor Infarct,PX-36900401,CDM,37243,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13180.06,,,13180.06,399.86,20286.72,fee schedule,,,
HC Vascular Embolization or Occlusion Hemorrhage,PX-36100016,CDM,37244,CPT,361,RC,,,outpatient,,,26415,18490.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13180.06,,,13180.06,399.86,20286.72,fee schedule,,,
HC Vascular Embolization or Occlusion Hemorrhage,PX-36900402,CDM,37244,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13180.06,,,13180.06,399.86,20286.72,fee schedule,,,
HC Temporal Artery Ligatn or Bx,PX-36900554,CDM,37609,CPT,369,RC,,,outpatient,,,4643,3250.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,3565.824,fee schedule,,,
HC Phleb Veins - Extrem - to 20,PX-36900405,CDM,37765,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,5781.504,fee schedule,,,
HC Phleb Veins - Extrem 20+,PX-36900406,CDM,37766,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,5781.504,fee schedule,,,
HC Injection for Spleen X-Ray,PX-36900408,CDM,38200,CPT,369,RC,,,outpatient,,,381,266.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,85.5345,1592,other,SI=N Exclusions ,,
HC Bone Marrow; Aspiration Only,PX-36100017,CDM,38220,CPT,361,RC,,,outpatient,,,1973,1381.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2477.315575,fee schedule,,,
HC Bone Marrow; Aspiration Only,PX-36900409,CDM,38220,CPT,369,RC,,,outpatient,,,1973,1381.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2477.315575,fee schedule,,,
HC Bone Marrow Bx- Needle/Trocar,PX-36100018,CDM,38221,CPT,361,RC,,,outpatient,,,1972,1380.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2477.315575,fee schedule,,,
HC Bone Marrow Bx- Needle/Trocar,PX-36900410,CDM,38221,CPT,369,RC,,,outpatient,,,1972,1380.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2477.315575,fee schedule,,,
HC Dx Bone Marrow Bx & Aspir,PX-36100032,CDM,38222,CPT,361,RC,,,outpatient,,,4653,3257.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,4341.777195,fee schedule,,,
HC Dx Bone Marrow Bx & Aspir,PX-36900703,CDM,38222,CPT,369,RC,,,outpatient,,,4653,3257.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,4341.777195,fee schedule,,,
HC Needle Biopsy- Lymph Node(S),PX-36900411,CDM,38505,CPT,369,RC,,,outpatient,,,1973,1381.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2998,fee schedule,,,
HC Injection for Lymphatic Xray,PX-36900412,CDM,38790,CPT,369,RC,,,outpatient,,,500,350,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,112.25,1592,other,SI=N Exclusions ,,
HC Identify Sentinel Node,PX-36900413,CDM,38792,CPT,369,RC,,,outpatient,,,540,378,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,481.85,,,481.85,121.23,1592,fee schedule,,,
HC Biopsy of Floor of Mouth,PX-36900555,CDM,41108,CPT,369,RC,,,outpatient,,,2598,1818.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2477.315575,fee schedule,,,
HC Biopsy Salivary Gland-Needle,PX-36900414,CDM,42400,CPT,369,RC,,,outpatient,,,1637,1145.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,789.71,,,789.71,367.5065,2141,fee schedule,,,
HC Injection for Salivary X-Ray,PX-36900415,CDM,42550,CPT,369,RC,,,outpatient,,,424,296.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,95.188,1592,other,SI=N Exclusions ,,
HC Dilation/Cath of Salivary Duct,PX-36900416,CDM,42660,CPT,369,RC,,,outpatient,,,533,373.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,664.02,,,664.02,119.6585,1592,fee schedule,,,
HC Inc/Drain Peritonsil Abscess,PX-36900812,CDM,42700,CPT,369,RC,,,outpatient,,,685,479.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,280.99,,,280.99,153.7825,1592,fee schedule,,,
HC Placement Ng/Og Tube by Physician,PX-36900423,CDM,43752,CPT,369,RC,,,outpatient,,,325,227.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,474.58,,,474.58,72.9625,1592,fee schedule,,,
HC PR Naso/Oro-Gastric Tube Plmt Req Phys&Fluor Gdnce,PX-96000043,CDM,43752,CPT,960,RC,,,outpatient,,,325,227.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,474.58,,,474.58,72.9625,1592,fee schedule,,,
HC Gastric Intubatj & Aspiraj W/Phys Skill/Lavage,PX-36900575,CDM,43753,CPT,369,RC,,,outpatient,,,579,405.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,343.93,,,343.93,129.9855,1592,fee schedule,,,
HC Reposition Gastric Feeding Tube Thru Duodenum,PX-36900425,CDM,43761,CPT,369,RC,,,outpatient,,,496,347.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,315.45,,,315.45,111.352,1592,fee schedule,,,
HC Perq Replacement Gtube Not Req Revj Gstrst Trc,PX-36100033,CDM,43762,CPT,361,RC,,,outpatient,,,879,615.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,315.45,,,315.45,197.3355,1592,fee schedule,,,
HC Perq Replacement Gtube Not Req Revj Gstrst Trc,PX-36900727,CDM,43762,CPT,369,RC,,,outpatient,,,879,615.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,315.45,,,315.45,197.3355,1592,fee schedule,,,
HC Intro Long GI Tube,PX-36900427,CDM,44500,CPT,369,RC,,,outpatient,,,1673,1171.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1038.09,,,1038.09,375.5885,2998,fee schedule,,,
HC Drainage of Pelvic Abscess,PX-36900428,CDM,45000,CPT,369,RC,,,outpatient,,,2727,1908.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1335.58,,,1335.58,399.86,4005.9,fee schedule,,,
HC Drainage of Deep Rectal Abscess,PX-36900429,CDM,45020,CPT,369,RC,,,outpatient,,,6425,4497.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3182.32,,,3182.32,399.86,4934.4,fee schedule,,,
HC I&D Ischiorectal&/Perirectal Abscess Spx,PX-36900738,CDM,46040,CPT,369,RC,,,outpatient,,,3716,2601.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1335.58,,,1335.58,399.86,2998,fee schedule,,,
HC Needle Biopsy Liver,PX-36900430,CDM,47000,CPT,369,RC,,,outpatient,,,3700,2590,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2998,fee schedule,,,
HC Needle Biopsy Liver-W Othr Proc,PX-36900431,CDM,47001,CPT,369,RC,,,outpatient,,,972,680.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,218.214,1592,other,SI=N Exclusions ,,
HC Ablat-Open-1+ Liver Tumor(S)-Percut Rf,PX-36900433,CDM,47382,CPT,369,RC,,,outpatient,,,13307,9314.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,6264.7,,,6264.7,399.86,10219.776,fee schedule,,,
HC Cholecystostomy-Percutaneous- Complete,PX-36900434,CDM,47490,CPT,369,RC,,,outpatient,,,8367,5856.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4017.55,,,4017.55,399.86,6425.856,fee schedule,,,
HC Biliary Endoscopy Percut-Dil Strict,PX-36900443,CDM,47555,CPT,369,RC,,,outpatient,,,8367,5856.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4017.55,,,4017.55,399.86,6425.856,fee schedule,,,
HC Biliary Endoscopy Percut-Dil+Stent,PX-36900444,CDM,47556,CPT,369,RC,,,outpatient,,,13307,9314.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,6264.7,,,6264.7,399.86,15728.70471,fee schedule,,,
HC Needle Biopsy of Pancreas,PX-36900446,CDM,48102,CPT,369,RC,,,outpatient,,,3700,2590,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2998,fee schedule,,,
HC Anast Panc Cyst-Bowel-Direct,PX-36900447,CDM,48520,CPT,369,RC,,,outpatient,,,1740,1218,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2213.02,,,2213.02,390.63,2998,fee schedule,,,
HC Exploratory Laparotomy Celiotomy W/WO Biopsy Spx,PX-36900881,CDM,49000,CPT,369,RC,,,outpatient,,,8564,5994.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1567.5,,,1567.5,399.86,6577.152,fee schedule,,,
HC Reopening Recent Laparotomy,PX-36900882,CDM,49002,CPT,369,RC,,,outpatient,,,8564,5994.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2124.05,,,2124.05,399.86,6577.152,fee schedule,,,
HC Abdom Paracentesis Dx/Ther W/O Imaging Guidance,PX-36900448,CDM,49082,CPT,369,RC,,,outpatient,,,925,647.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1038.09,,,1038.09,207.6625,2998,fee schedule,,,
HC Abdom Paracentesis Dx/Ther W Imaging Guidance,PX-36100002,CDM,49083,CPT,361,RC,,,outpatient,,,1635,1144.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1038.09,,,1038.09,367.0575,2998,fee schedule,,,
HC Abdom Paracentesis Dx/Ther W Imaging Guidance,PX-36900449,CDM,49083,CPT,369,RC,,,outpatient,,,1635,1144.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1038.09,,,1038.09,367.0575,2998,fee schedule,,,
HC Percut Biopsy- Abdominal Mass,PX-36900450,CDM,49180,CPT,369,RC,,,outpatient,,,3700,2590,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2998,fee schedule,,,
HC Remove Peritoneal Foreign Body,PX-36900451,CDM,49402,CPT,369,RC,,,outpatient,,,8367,5856.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4017.55,,,4017.55,399.86,6425.856,fee schedule,,,
HC Image-Guide Fluid Collxn Drainage Cath Visc Perq,PX-36900452,CDM,49405,CPT,369,RC,,,outpatient,,,2870,2009,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2998,fee schedule,,,
HC Img-Guide Fluid Collxn Drainag Cath Periton Perq,PX-36900453,CDM,49406,CPT,369,RC,,,outpatient,,,2647,1852.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2998,fee schedule,,,
HC Insertion Tunnel Intraperitoneal Cath W Image Guidance,PX-36900455,CDM,49418,CPT,369,RC,,,outpatient,,,7964,5574.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4017.55,,,4017.55,399.86,6116.352,fee schedule,,,
HC Removal Tunneled Intraperitoneal Catheter,PX-36900456,CDM,49422,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3600.71,,,3600.71,399.86,5781.504,fee schedule,,,
HC Drainage Catheter Exchange,PX-36900457,CDM,49423,CPT,369,RC,,,outpatient,,,4271,2989.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2021.99,,,2021.99,399.86,3280.128,fee schedule,,,
HC Contrast Inj-Abscess/Cyst via Cath Tube,PX-36900458,CDM,49424,CPT,369,RC,,,outpatient,,,491,343.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,110.2295,1592,other,SI=N Exclusions ,,
HC Insert Gastrostomy Tube Percutaneous,PX-36900460,CDM,49440,CPT,369,RC,,,outpatient,,,4271,2989.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2021.99,,,2021.99,399.86,3280.128,fee schedule,,,
HC Convert Gastrostomy-Gastro-Jejunostomy Tube Percutaneous,PX-36900461,CDM,49446,CPT,369,RC,,,outpatient,,,4271,2989.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2021.99,,,2021.99,399.86,3280.128,fee schedule,,,
HC Replace Gastrostomy/Cecostomy Tube Percutaneous,PX-36100019,CDM,49450,CPT,361,RC,,,outpatient,,,1644,1150.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1038.09,,,1038.09,369.078,2998,fee schedule,,,
HC Replace Gastrostomy/Cecostomy Tube Percutaneous,PX-36900462,CDM,49450,CPT,369,RC,,,outpatient,,,1644,1150.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1038.09,,,1038.09,369.078,2998,fee schedule,,,
HC Replace Duodenostomy/Jejunostomy Tube Percutaneous,PX-36100020,CDM,49451,CPT,361,RC,,,outpatient,,,1692,1184.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1038.09,,,1038.09,379.854,2998,fee schedule,,,
HC Replace Duodenostomy/Jejunostomy Tube Percutaneous,PX-36900463,CDM,49451,CPT,369,RC,,,outpatient,,,1692,1184.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1038.09,,,1038.09,379.854,2998,fee schedule,,,
HC Replacement Gastro-Jejunostomy Tube Percutaneous,PX-36100021,CDM,49452,CPT,361,RC,,,outpatient,,,2617,1831.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1038.09,,,1038.09,399.86,2998,fee schedule,,,
HC Replacement Gastro-Jejunostomy Tube Percutaneous,PX-36900464,CDM,49452,CPT,369,RC,,,outpatient,,,2617,1831.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1038.09,,,1038.09,399.86,2998,fee schedule,,,
HC Obstructive Material Removal From GI Tube,PX-36900465,CDM,49460,CPT,369,RC,,,outpatient,,,2128,1489.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1038.09,,,1038.09,399.86,2998,fee schedule,,,
HC Contrast Injection Percutaneouos Radiologic Eval GI Tube,PX-36900466,CDM,49465,CPT,369,RC,,,outpatient,,,606,424.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,314.28,,,314.28,136.047,1592,fee schedule,,,
CEPHALEXIN 250 MG/5ML ORAL SUSR,RX-9502,CDM,50000,HCPCS,259,RC,99999-0002-84,NDC,outpatient,10,ML,5.17,3.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,4.38,1.160665,416.02,percent of total billed charges,,,
CEPHALEXIN 250 MG/5ML ORAL SUSR,RX-9502,CDM,50000,HCPCS,259,RC,68180-0441-01,NDC,outpatient,100,ML,50.29,35.203,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,42.63,1.160665,416.02,percent of total billed charges,,,
HC Biopsy of Kidney-Percutaneous,PX-36900467,CDM,50200,CPT,369,RC,,,outpatient,,,3700,2590,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1874.97,,,1874.97,399.86,2998,fee schedule,,,
HC Change Ureter Stent- Percut,PX-36900468,CDM,50382,CPT,369,RC,,,outpatient,,,4709,3296.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2371.48,,,2371.48,399.86,4179.83,fee schedule,,,
HC Remove Ureter Stent- Percut,PX-36900469,CDM,50384,CPT,369,RC,,,outpatient,,,4709,3296.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2371.48,,,2371.48,399.86,3616.512,fee schedule,,,
HC Change Ext Transneph Ureter Stent W/ Fluoro,PX-36900470,CDM,50387,CPT,369,RC,,,outpatient,,,4709,3296.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2371.48,,,2371.48,399.86,3616.512,fee schedule,,,
HC Remove Renal Tube W/Fluoro,PX-36900471,CDM,50389,CPT,369,RC,,,outpatient,,,1513,1059.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,766.41,,,766.41,339.6685,2141,fee schedule,,,
HC Percut Drain/Inject Renal Cyst,PX-36900472,CDM,50390,CPT,369,RC,,,outpatient,,,726,508.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,789.71,,,789.71,162.987,2141,fee schedule,,,
HC Instll Rx Agnt Into Rnal Tub,PX-36900473,CDM,50391,CPT,369,RC,,,outpatient,,,533,373.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,315.45,,,315.45,119.6585,1592,fee schedule,,,
HC Measure Kidney Pressure Thru Tube,PX-36900478,CDM,50396,CPT,369,RC,,,outpatient,,,1513,1059.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,766.41,,,766.41,334.48,2141,fee schedule,,,
HC Plmt Nephrostomy Cath Prq New Access Rs&I,PX-36900659,CDM,50432,CPT,369,RC,,,outpatient,,,5502,3851.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2371.48,,,2371.48,399.86,4225.536,fee schedule,,,
HC Renal Endoscopy-Remv FB/Stone,PX-36900480,CDM,50561,CPT,369,RC,,,outpatient,,,11603,8122.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5480.48,,,5480.48,399.86,8911.104,fee schedule,,,
HC Perc Radiofreq Ablate Renal Tumor,PX-36900481,CDM,50592,CPT,369,RC,,,outpatient,,,13307,9314.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,6264.7,,,6264.7,399.86,10219.776,fee schedule,,,
HC Inject Indwell Cath-Ureter X-Ray,PX-36900482,CDM,50684,CPT,369,RC,,,outpatient,,,374,261.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,83.963,1592,other,SI=N Exclusions ,,
HC Change of Ureterostomy Tube via Ileal Conduit,PX-36900483,CDM,50688,CPT,369,RC,,,outpatient,,,4709,3296.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2371.48,,,2371.48,399.86,3616.512,fee schedule,,,
HC Inject Retrograde/Conduit X-Ray,PX-36900484,CDM,50690,CPT,369,RC,,,outpatient,,,533,373.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,119.6585,1592,other,SI=N Exclusions ,,
HC Ureter Endoscopy Thru Ureterostomy W Biopsy,PX-36900485,CDM,50955,CPT,369,RC,,,outpatient,,,11603,8122.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5480.48,,,5480.48,399.86,8911.104,fee schedule,,,
HC Ureter Endoscopy Thru Ureterostomy Remv FB or Calculus,PX-36900486,CDM,50961,CPT,369,RC,,,outpatient,,,11603,8122.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5480.48,,,5480.48,399.86,8911.104,fee schedule,,,
HC Aspiration Bladder Needle,PX-36100022,CDM,51100,CPT,361,RC,,,outpatient,,,699,489.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,315.45,,,315.45,156.9255,1592,fee schedule,,,
HC Aspiration Bladder Needle,PX-36900488,CDM,51100,CPT,369,RC,,,outpatient,,,699,489.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,315.45,,,315.45,156.9255,1592,fee schedule,,,
HC Aspiration Bladder Trocar/Intracatheter,PX-36100023,CDM,51101,CPT,361,RC,,,outpatient,,,2419,1693.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1244.25,,,1244.25,179.53,2998,fee schedule,,,
HC Aspiration Bladder Trocar/Intracatheter,PX-36900489,CDM,51101,CPT,369,RC,,,outpatient,,,2419,1693.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1244.25,,,1244.25,179.53,2998,fee schedule,,,
HC Aspiration Bladder Insert Suprapubic Catheter,PX-36100024,CDM,51102,CPT,361,RC,,,outpatient,,,4709,3296.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2371.48,,,2371.48,399.86,3616.512,fee schedule,,,
HC Aspiration Bladder Insert Suprapubic Catheter,PX-36900490,CDM,51102,CPT,369,RC,,,outpatient,,,4709,3296.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2371.48,,,2371.48,399.86,3616.512,fee schedule,,,
HC Injection for Bladder X-Ray,PX-36900491,CDM,51600,CPT,369,RC,,,outpatient,,,1455,1018.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,235.074116,1592,other,SI=N Exclusions ,,
HC Inject for Retrograde Urethocysto,PX-36900492,CDM,51610,CPT,369,RC,,,outpatient,,,976,683.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,219.112,1592,other,SI=N Exclusions ,,
HC Bldr Irrigation Smpl Lavage &/Instlj,PX-36900732,CDM,51700,CPT,369,RC,,,outpatient,,,879,615.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,315.45,,,315.45,197.3355,1592,fee schedule,,,
HC Insert-Non-Indwelling Bladder Catheter,PX-36900494,CDM,51701,CPT,369,RC,,,outpatient,,,389,272.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,87.3305,1592,fee schedule,,,
HC Insert-Temp Indwelling Blad Cath-Simple,PX-36900495,CDM,51702,CPT,369,RC,,,outpatient,,,391,273.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,87.7795,1592,fee schedule,,,
HC Insert-Temp Indwelling Blad Cath-Comp,PX-36900496,CDM,51703,CPT,369,RC,,,outpatient,,,354,247.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,185.32,,,185.32,79.473,1592,fee schedule,,,
HC Change of Bladder Tube-Simple,PX-36900497,CDM,51705,CPT,369,RC,,,outpatient,,,456,319.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,315.45,,,315.45,102.372,1592,fee schedule,,,
HC Emg Stds Anal/Urtl Sphnctr Oth/Thn Ndl,PX-36900667,CDM,51784,CPT,369,RC,,,outpatient,,,475,332.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,185.32,,,185.32,106.6375,1592,fee schedule,,,
HC Meas Post-Voiding Residual Urine&/Bladder Cap,PX-36900733,CDM,51798,CPT,369,RC,,,outpatient,,,212,148.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,76.19,,,76.19,47.594,1592,fee schedule,,,
HC Cysto/Ureteroscopy-Tx Ureter Strict,PX-36900500,CDM,52344,CPT,369,RC,,,outpatient,,,8086,5660.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3989.66,,,3989.66,399.86,6210.048,fee schedule,,,
HC Circumcision Age >28 Days,PX-36900772,CDM,54161,CPT,369,RC,,,outpatient,,,6599,4619.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2371.48,,,2371.48,399.86,5068.032,fee schedule,,,
HC Irrigation Corpora Cavernosa Priapism,PX-36900736,CDM,54220,CPT,369,RC,,,outpatient,,,591,413.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,315.45,,,315.45,120.28264,1592,fee schedule,,,
HC Biopsy of Prostate-Needle/Punch,PX-36900501,CDM,55700,CPT,369,RC,,,outpatient,,,4709,3296.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2371.48,,,2371.48,399.86,3616.512,fee schedule,,,
HC I&D of Vulva/Perineum Abscess,PX-36900502,CDM,56405,CPT,369,RC,,,outpatient,,,829,580.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,372.13,,,372.13,186.1105,1592,fee schedule,,,
HC PR Colporrhaphy- Suture Vaginal Injury- Non-OB,PX-36900795,CDM,57200,CPT,369,RC,,,outpatient,,,5013,3509.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3218.7,,,3218.7,399.86,4777.053449,fee schedule,,,
HC Cath/Inject Hysterosalpingogram,PX-36900505,CDM,58340,CPT,369,RC,,,outpatient,,,1092,764.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,235.074116,1592,other,SI=N Exclusions ,,
HC Reopen Fallopian Tube-Transcerv Cath,PX-36900506,CDM,58345,CPT,369,RC,,,outpatient,,,6900,4830,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3218.7,,,3218.7,399.86,5299.2,fee schedule,,,
HC Fetal Non-Stress Test,PX-92000003,CDM,59025,CPT,920,RC,,,outpatient,,,490,343,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,226.18,,,226.18,110.005,416.02,fee schedule,,,
HC PR Vaginal Delivery Only,PX-96000044,CDM,59409,CPT,960,RC,,,outpatient,,,3062,2143.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3218.7,,,3218.7,399.86,4777.053449,fee schedule,,,
HC PR Delivery Placenta Separate Procedure,PX-96000045,CDM,59414,CPT,960,RC,,,outpatient,,,7176,5023.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3218.7,,,3218.7,399.86,5511.168,fee schedule,,,
HC Biopsy of Thyroid-Percut,PX-36900512,CDM,60100,CPT,369,RC,,,outpatient,,,1514,1059.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,789.71,,,789.71,339.893,2141,fee schedule,,,
HC Endocrine Surgery Proc Unlisted,PX-36900513,CDM,60699,CPT,369,RC,,,outpatient,,,6035,4224.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,11413.04,other,Unlisted Codes,,
HC Brain Shunt Tube/Reserv Injectn,PX-36900514,CDM,61070,CPT,369,RC,,,outpatient,,,1885,1319.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,816.25,,,816.25,399.86,2141,fee schedule,,,
HC Endovasc Temp Balloon Occlus-Head/Nck,PX-36900515,CDM,61623,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13180.06,,,13180.06,399.86,20286.72,fee schedule,,,
HC Perm Occlusion/Embolization-Percut-Cns,PX-36900516,CDM,61624,CPT,369,RC,,,outpatient,,,533,373.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2346.02,,,2346.02,119.6585,5756,fee schedule,,,
HC Percut Cath Occlusn Non Cns Lesn,PX-36900517,CDM,61626,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13180.06,,,13180.06,399.86,20286.72,fee schedule,,,
HC Percut Aspiration Vertebral Disc,PX-36900518,CDM,62267,CPT,369,RC,,,outpatient,,,1637,1145.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,789.71,,,789.71,367.5065,2141,fee schedule,,,
HC Spinal Puncture-Lumbar-Diagnostic,PX-36100025,CDM,62270,CPT,361,RC,,,outpatient,,,915,640.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,816.25,,,816.25,205.4175,2141,fee schedule,,,
HC Spinal Puncture-Lumbar-Diagnostic,PX-36900519,CDM,62270,CPT,369,RC,,,outpatient,,,915,640.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,816.25,,,816.25,205.4175,2141,fee schedule,,,
HC PR Spinal Puncture Lumbar Diagnostic,PX-96000051,CDM,62270,CPT,960,RC,,,outpatient,,,915,640.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,816.25,,,816.25,205.4175,2141,fee schedule,,,
HC Spinal Puncture-Therapeutic Drainage,PX-36100026,CDM,62272,CPT,361,RC,,,outpatient,,,1256,879.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,816.25,,,816.25,281.972,2141,fee schedule,,,
HC Spinal Puncture-Therapeutic Drainage,PX-36900520,CDM,62272,CPT,369,RC,,,outpatient,,,1256,879.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,816.25,,,816.25,281.972,2141,fee schedule,,,
HC Inj-Lumb Epidur-Blood/Clot Patch,PX-36900521,CDM,62273,CPT,369,RC,,,outpatient,,,915,640.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,816.25,,,816.25,205.4175,2141,fee schedule,,,
HC Inject-Myelography &/or CT Scan-Spinal,PX-36900522,CDM,62284,CPT,369,RC,,,outpatient,,,1312,918.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,294.544,1592,other,SI=N Exclusions ,,
HC Diskectomy-Percutaneous Lumbar,PX-36900523,CDM,62287,CPT,369,RC,,,outpatient,,,6304,4412.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,6224.09,,,6224.09,399.86,6224.0876,fee schedule,,,
HC Inject Diskogram-Lumbar-Ea Level,PX-36900524,CDM,62290,CPT,369,RC,,,outpatient,,,1256,879.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,281.972,1592,other,SI=N Exclusions ,,
HC Inj-Cerv/Thorac-for Diskography,PX-36900525,CDM,62291,CPT,369,RC,,,outpatient,,,1107,774.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,248.5215,1592,other,SI=N Exclusions ,,
HC Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/O Img Gdn,PX-36900884,CDM,62322,CPT,369,RC,,,outpatient,,,2586,1810.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,816.25,,,816.25,399.86,2141,fee schedule,,,
HC Elec Anlys Implt Ithcl/Edrl Pmp W/Repr Phys/Qhp,PX-36900526,CDM,62370,CPT,369,RC,,,outpatient,,,821,574.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,382.23,,,382.23,155.844464,1592,fee schedule,,,
HC Inject Nerv Blck-Trigeminal,PX-36900609,CDM,64400,CPT,369,RC,,,outpatient,,,891,623.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,337.35,,,337.35,200.0295,1592,fee schedule,,,
HC Inject Nerv Blck-Great Occiptl,PX-36900611,CDM,64405,CPT,369,RC,,,outpatient,,,1634,1143.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,337.35,,,337.35,323.2601,1592,fee schedule,,,
HC Inject Nerv Blck-Vagus Nerve,PX-36900612,CDM,64408,CPT,369,RC,,,outpatient,,,877,613.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,337.35,,,337.35,196.8865,1592,fee schedule,,,
HC Inj-Anes Agent-Brachial Plexus-Single,PX-36900616,CDM,64415,CPT,369,RC,,,outpatient,,,1544,1080.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1042.57,,,1042.57,346.628,2141,fee schedule,,,
HC Inj-Anes Agent-Brachial Plexus-Cont Inf,PX-36900617,CDM,64416,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1042.57,,,1042.57,399.86,2141,fee schedule,,,
HC Inject Nerv Blck-Axillary Nerv,PX-36900618,CDM,64417,CPT,369,RC,,,outpatient,,,1544,1080.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1042.57,,,1042.57,346.628,2141,fee schedule,,,
HC Inject Nerv Blck-Suprascap N.,PX-36900619,CDM,64418,CPT,369,RC,,,outpatient,,,1544,1080.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,816.25,,,816.25,346.628,2141,fee schedule,,,
HC Inject Nerv Blck-Intercostal-One,PX-36900620,CDM,64420,CPT,369,RC,,,outpatient,,,1382,967.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,816.25,,,816.25,310.259,2141,fee schedule,,,
HC Inject Nerv Blck-Intercost-Multpl,PX-36900621,CDM,64421,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1042.57,,,1042.57,399.86,2141,fee schedule,,,
HC Inject Nerv Blck-Ilioingu/Iliohyp,PX-36900622,CDM,64425,CPT,369,RC,,,outpatient,,,1544,1080.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,816.25,,,816.25,346.628,2141,fee schedule,,,
HC Inject Nerv Blck-Pudendal,PX-36100029,CDM,64430,CPT,361,RC,,,outpatient,,,2785,1949.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1042.57,,,1042.57,399.86,2141,fee schedule,,,
HC Inject Nerv Blck-Pudendal,PX-36900623,CDM,64430,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1042.57,,,1042.57,399.86,2141,fee schedule,,,
HC Inject Nerv Blck-Paracervical,PX-36900624,CDM,64435,CPT,369,RC,,,outpatient,,,1544,1080.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,816.25,,,816.25,346.628,2141,fee schedule,,,
HC Inj-Anes Agent-Sciatic Nerve-Single,PX-36900625,CDM,64445,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,816.25,,,816.25,399.86,2141,fee schedule,,,
HC Inj-Anes Agent-Sciatic Nerve-Cont Inf,PX-36900626,CDM,64446,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1042.57,,,1042.57,399.86,2141,fee schedule,,,
HC Inj-Anes Agent-Femoral Nerve-Single,PX-36900627,CDM,64447,CPT,369,RC,,,outpatient,,,1544,1080.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,816.25,,,816.25,346.628,2141,fee schedule,,,
HC Inj-Anes Agent-Femoral Nerve-Cont Inf,PX-36900628,CDM,64448,CPT,369,RC,,,outpatient,,,6090,4263,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1042.57,,,1042.57,399.86,4677.12,fee schedule,,,
HC N Block Inj- Lumbar Plexus,PX-36900629,CDM,64449,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1042.57,,,1042.57,399.86,2141,fee schedule,,,
HC Inject Nerv Blck-Othr Periph Nerv,PX-36900630,CDM,64450,CPT,369,RC,,,outpatient,,,1634,1143.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,816.25,,,816.25,366.833,2141,fee schedule,,,
HC Njx Aa&/Strd Plantar Common Digital Nerves,PX-36900835,CDM,64455,CPT,369,RC,,,outpatient,,,825,577.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,337.35,,,337.35,185.2125,1592,fee schedule,,,
HC Inject Anes/Steroid Foramen Cerv/Thoracic W Img Guide -1 Level,PX-36900631,CDM,64479,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1042.57,,,1042.57,399.86,2141,fee schedule,,,
HC Inject Anes/Steroid Foramen Cerv/Thoracic W Img Guide -Ea Add Level,PX-36900632,CDM,64480,CPT,369,RC,,,outpatient,,,230,161,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.635,1592,other,SI=N Exclusions ,,
HC Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level,PX-36100027,CDM,64483,CPT,361,RC,,,outpatient,,,1693,1185.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1042.57,,,1042.57,380.0785,2141,fee schedule,,,
HC Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level,PX-36900531,CDM,64483,CPT,369,RC,,,outpatient,,,1693,1185.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1042.57,,,1042.57,380.0785,2141,fee schedule,,,
HC Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl,PX-36900532,CDM,64484,CPT,369,RC,,,outpatient,,,416,291.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,93.392,1592,other,SI=N Exclusions ,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- 1st Level,PX-36100028,CDM,64490,CPT,361,RC,,,outpatient,,,1693,1185.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1042.57,,,1042.57,380.0785,2141,fee schedule,,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- 1st Level,PX-36900533,CDM,64490,CPT,369,RC,,,outpatient,,,1693,1185.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1042.57,,,1042.57,380.0785,2141,fee schedule,,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- 2nd Level,PX-36900633,CDM,64491,CPT,369,RC,,,outpatient,,,221,154.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,49.6145,1592,other,SI=N Exclusions ,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- Add Level,PX-36900634,CDM,64492,CPT,369,RC,,,outpatient,,,224,156.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,50.288,1592,other,SI=N Exclusions ,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Lumbar/Sac- 1st Level,PX-36900536,CDM,64493,CPT,369,RC,,,outpatient,,,1693,1185.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1042.57,,,1042.57,380.0785,2141,fee schedule,,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Lumbar/Sac- 2nd Level,PX-36900537,CDM,64494,CPT,369,RC,,,outpatient,,,1693,1185.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,380.0785,1592,other,SI=N Exclusions ,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Lumbar/Sac- Add Level,PX-36900538,CDM,64495,CPT,369,RC,,,outpatient,,,54,37.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.123,1592,other,SI=N Exclusions ,,
HC Inject Nerv Blck-Celiac Plexus,PX-36900539,CDM,64530,CPT,369,RC,,,outpatient,,,2165,1515.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1042.57,,,1042.57,399.86,2141,fee schedule,,,
HC Unlisted Procedure Nervous System,PX-36100035,CDM,64999,CPT,361,RC,,,outpatient,,,687,480.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,154.2315,1592,other,Unlisted Codes,,
HC Unlisted Procedure Nervous System,PX-36900829,CDM,64999,CPT,369,RC,,,outpatient,,,687,480.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,154.2315,1592,other,Unlisted Codes,,
HC Removal Impacted Cerumen Using Irrigation/Lavage- Unilateral,PX-36900636,CDM,69209,CPT,761,RC,,,outpatient,,,205,143.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,76.19,,,76.19,46.0225,1592,fee schedule,,,
HC Removal Impacted Cerumen Instrumentation Unilat,PX-36900540,CDM,69210,CPT,761,RC,,,outpatient,,,305,213.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,76.19,,,76.19,66.75974,1592,fee schedule,,,
HC X-Ray Eye for Foreign Body,PX-32000004,CDM,70030,CPT,320,RC,,,outpatient,,,271,189.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,60.8395,416.02,fee schedule,,,
HC X-Ray Jaw <4 Vw,PX-32000005,CDM,70100,CPT,320,RC,,,outpatient,,,595,416.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,71.24,456.96,fee schedule,,,
HC X-Ray Jaw 4+ Vw,PX-32000006,CDM,70110,CPT,320,RC,,,outpatient,,,489,342.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,76.026473,416.02,fee schedule,,,
HC X-Ray Mastoids <3 Vw,PX-32000007,CDM,70120,CPT,320,RC,,,outpatient,,,384,268.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,86.208,416.02,fee schedule,,,
HC X-Ray Mastoids 3+ Vw,PX-32000008,CDM,70130,CPT,320,RC,,,outpatient,,,295,206.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,66.2275,416.02,fee schedule,,,
HC X-Ray Facial Bones <3 Vw,PX-32000009,CDM,70140,CPT,320,RC,,,outpatient,,,336,235.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,71.24,416.02,fee schedule,,,
HC X-Ray Facial Bones 3+ Vw,PX-32000010,CDM,70150,CPT,320,RC,,,outpatient,,,252,176.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,56.574,416.02,fee schedule,,,
HC X-Ray Nasal Bones,PX-32000011,CDM,70160,CPT,320,RC,,,outpatient,,,319,223.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,71.24,416.02,fee schedule,,,
HC X-Ray Orbits,PX-32000012,CDM,70200,CPT,320,RC,,,outpatient,,,328,229.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,73.636,416.02,fee schedule,,,
HC X-Ray Sinuses <3 Vw,PX-32000013,CDM,70210,CPT,320,RC,,,outpatient,,,328,229.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,71.24,416.02,fee schedule,,,
HC X-Ray Sinuses 3+ Vw,PX-32000014,CDM,70220,CPT,320,RC,,,outpatient,,,444,310.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,71.24,416.02,fee schedule,,,
HC X-Ray Exam Sella,PX-32000015,CDM,70240,CPT,320,RC,,,outpatient,,,262,183.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,58.819,416.02,fee schedule,,,
HC X-Ray Skull <4 Vw,PX-32000016,CDM,70250,CPT,320,RC,,,outpatient,,,352,246.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,76.026473,416.02,fee schedule,,,
HC X-Ray Skull 4+ Vw,PX-32000017,CDM,70260,CPT,320,RC,,,outpatient,,,419,293.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,76.026473,416.02,fee schedule,,,
HC X-Ray Teeth Single,PX-32000018,CDM,70300,CPT,320,RC,,,outpatient,,,241,168.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,54.1045,416.02,fee schedule,,,
HC X-Ray Tmj Unilat,PX-32000019,CDM,70328,CPT,320,RC,,,outpatient,,,241,168.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,54.1045,416.02,fee schedule,,,
HC X-Ray Tmj Bilat,PX-32000020,CDM,70330,CPT,320,RC,,,outpatient,,,716,501.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,71.24,549.888,fee schedule,,,
HC MRI- Tmj,PX-61000008,CDM,70336,CPT,610,RC,,,outpatient,,,2588,1811.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,622.5,,,622.5,267.439885,1987.584,fee schedule,,,
HC Panoramic X-Ray of Jaws,PX-32000022,CDM,70355,CPT,320,RC,,,outpatient,,,241,168.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,54.1045,416.02,fee schedule,,,
HC X-Ray Neck Soft Tissue,PX-32000023,CDM,70360,CPT,320,RC,,,outpatient,,,232,162.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,52.084,416.02,fee schedule,,,
HC X-Ray Salivary Gland,PX-32000025,CDM,70380,CPT,320,RC,,,outpatient,,,262,183.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,58.819,416.02,fee schedule,,,
HC X-Ray Sialogram,PX-32000026,CDM,70390,CPT,320,RC,,,outpatient,,,537,375.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,263.66,,,263.66,120.5565,646.6965,fee schedule,,,
HC CT Scan-Head/Brain-W/O Contrast Matl,PX-35000002,CDM,70450,CPT,350,RC,,,outpatient,,,1070,749,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,303.77,,,303.77,89.81,821.76,fee schedule,,,
HC CT Scan Head Contrast,PX-35000003,CDM,70460,CPT,350,RC,,,outpatient,,,1333,933.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,124.33,1023.744,fee schedule,,,
CT Head/Brain W/O & W/Contrast Material,PX-35000004,CDM,70470,CPT,350,RC,,,outpatient,,,1615,1130.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,153.75,1240.32,fee schedule,,,
HC CT Scan-Orbit/Sella/Post Fossa/Ear-W/O,PX-35000005,CDM,70480,CPT,350,RC,,,outpatient,,,657,459.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,303.77,,,303.77,96.160741,575,fee schedule,,,
HC CT Scan Skull Contrast,PX-35000006,CDM,70481,CPT,350,RC,,,outpatient,,,774,541.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,173.763,667.43,fee schedule,,,
CT Orbit Sella/Post Fossa/Ear W/O & W/Contr Matr,PX-35000007,CDM,70482,CPT,350,RC,,,outpatient,,,1619,1133.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,200.53123,1243.392,fee schedule,,,
HC CT Scan-Maxillofacial Area-W/O Contrast,PX-35000008,CDM,70486,CPT,350,RC,,,outpatient,,,1200,840,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,303.77,,,303.77,96.160741,921.6,fee schedule,,,
HC CT Scan- Face/Jaw Contrast,PX-35000009,CDM,70487,CPT,350,RC,,,outpatient,,,1321,924.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,200.53123,1014.528,fee schedule,,,
CT Maxillofacial W/O & W/Contrast Material,PX-35000010,CDM,70488,CPT,350,RC,,,outpatient,,,1158,810.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,200.53123,889.344,fee schedule,,,
HC CT Scan-Soft Tissue Neck-W/O Contrast,PX-35000011,CDM,70490,CPT,350,RC,,,outpatient,,,514,359.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,303.77,,,303.77,96.160741,575,fee schedule,,,
HC CT Neck Tissue Contrast,PX-35000012,CDM,70491,CPT,350,RC,,,outpatient,,,1482,1037.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,194.55,1138.176,fee schedule,,,
CT Soft Tissue Neck W/O & W/Contrast Material,PX-35000014,CDM,70492,CPT,350,RC,,,outpatient,,,1755,1228.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,200.53123,1347.84,fee schedule,,,
CT Angiography Head W/Contrast/Noncontrast,PX-35000013,CDM,70496,CPT,350,RC,,,outpatient,,,1330,931,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,200.53123,1021.44,fee schedule,,,
CT Angiography Neck W/Contrast/Noncontrast,PX-35000015,CDM,70498,CPT,350,RC,,,outpatient,,,1157,809.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,200.53123,888.576,fee schedule,,,
HC MRI- Face- Neck,PX-61000009,CDM,70540,CPT,610,RC,,,outpatient,,,5081,3556.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,622.5,,,622.5,237.688956,3902.208,fee schedule,,,
HC MRI- Face- Neck W/Contrast,PX-61000010,CDM,70542,CPT,610,RC,,,outpatient,,,2710,1897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,365.99,2081.28,fee schedule,,,
MRI Orbit Face & Neck W/O & W/Contrast Matrl,PX-61000011,CDM,70543,CPT,610,RC,,,outpatient,,,1692,1184.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,379.854,1299.456,fee schedule,,,
HC MR Angio- Head,PX-61000012,CDM,70544,CPT,610,RC,,,outpatient,,,2279,1595.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,622.5,,,622.5,267.439885,1750.272,fee schedule,,,
HC MR Angio- Head W/Contrast,PX-61000013,CDM,70545,CPT,610,RC,,,outpatient,,,2279,1595.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,374.62,1750.272,fee schedule,,,
Mra Head W/O & W/Contrast Material,PX-61000014,CDM,70546,CPT,610,RC,,,outpatient,,,2279,1595.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,301.425681,1750.272,fee schedule,,,
HC MR Angio- Neck,PX-61000015,CDM,70547,CPT,610,RC,,,outpatient,,,2182,1527.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,622.5,,,622.5,267.439885,1675.776,fee schedule,,,
HC MR Angio- Neck W/Contrast,PX-61000016,CDM,70548,CPT,610,RC,,,outpatient,,,2469,1728.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,399.86,1896.192,fee schedule,,,
Mra Neck W/O &W/Contrast Material,PX-61000017,CDM,70549,CPT,610,RC,,,outpatient,,,2534,1773.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,301.425681,1946.112,fee schedule,,,
HC MRI Brain,PX-61000018,CDM,70551,CPT,610,RC,,,outpatient,,,2090,1463,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,622.5,,,622.5,188.66,1605.12,fee schedule,,,
HC MRI Brain Contrast,PX-61000019,CDM,70552,CPT,610,RC,,,outpatient,,,5255,3678.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,268.7,4035.84,fee schedule,,,
MRI Brain Brain Stem W/O W/Contrast Material,PX-61000020,CDM,70553,CPT,610,RC,,,outpatient,,,2668,1867.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,307.14,2049.024,fee schedule,,,
HC X-Ray Exam Chest 1 View,PX-32000245,CDM,71045,CPT,320,RC,,,outpatient,,,214,149.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,48.043,416.02,fee schedule,,,
HC X-Ray Exam Chest 2 Views,PX-32000246,CDM,71046,CPT,320,RC,,,outpatient,,,232,162.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,52.084,416.02,fee schedule,,,
HC X-Ray Exam Chest 3 Views,PX-32000247,CDM,71047,CPT,320,RC,,,outpatient,,,245,171.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,55.0025,416.02,fee schedule,,,
HC X-Ray Exam Chest 4+ Views,PX-32000248,CDM,71048,CPT,320,RC,,,outpatient,,,410,287,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,76.026473,416.02,fee schedule,,,
HC X-Ray Ribs- Chest 3+ Vw,PX-32000036,CDM,71101,CPT,320,RC,,,outpatient,,,484,338.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,76.026473,416.02,fee schedule,,,
HC X-Ray Ribs- Chest 4+ Vw,PX-32000038,CDM,71111,CPT,320,RC,,,outpatient,,,562,393.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,76.026473,431.616,fee schedule,,,
HC X-Ray Sternum 2+ Vw,PX-32000039,CDM,71120,CPT,320,RC,,,outpatient,,,358,250.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,71.24,416.02,fee schedule,,,
HC X-Ray Sterno-Clavicluar Jt,PX-32000040,CDM,71130,CPT,320,RC,,,outpatient,,,250,175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,56.125,416.02,fee schedule,,,
HC Diagnostic Computed Tomography Thorax W/O Cntrst,PX-35000016,CDM,71250,CPT,350,RC,,,outpatient,,,1388,971.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,303.77,,,303.77,96.160741,1065.984,fee schedule,,,
HC Diagnostic Computed Tomography Thorax W/Contrast,PX-35000017,CDM,71260,CPT,350,RC,,,outpatient,,,1624,1136.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,195.34,1247.232,fee schedule,,,
HC Diagnostic Computed Tomography Thorax C-/C+,PX-35000018,CDM,71270,CPT,350,RC,,,outpatient,,,1982,1387.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,200.53123,1522.176,fee schedule,,,
HC Computed Tomography Thorax Lw Dose Lng Ca Scr C-,PX-35000070,CDM,71271,CPT,350,RC,,,outpatient,,,264,184.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,217.12,,,217.12,59.268,575,fee schedule,,,
CT Angiography Chest W/Contrast/Noncontrast,PX-35000019,CDM,71275,CPT,350,RC,,,outpatient,,,1592,1114.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,200.53123,1222.656,fee schedule,,,
HC MRI- Chest,PX-61000023,CDM,71550,CPT,610,RC,,,outpatient,,,1979,1385.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,622.5,,,622.5,237.688956,1519.872,fee schedule,,,
HC MRI- Chest- W/Contrast,PX-61000024,CDM,71551,CPT,610,RC,,,outpatient,,,3128,2189.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1867.69,,,1867.69,399.86,2402.304,fee schedule,,,
MRI Chest W/O & W/Contrast Material,PX-61000025,CDM,71552,CPT,610,RC,,,outpatient,,,1547,1082.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,347.3015,1288.93,fee schedule,,,
HC MR Angio Chest (Mra) W/Contrast,PX-61000026,CDM,71555,CPT,610,RC,,,outpatient,,,2367,1656.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1286.6,,,1286.6,301.425681,1817.856,fee schedule,,,
HC MR Angio Chest (Mra) Without Contrast,PX-61000071,CDM,71555,CPT,610,RC,,,outpatient,,,2367,1656.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1286.6,,,1286.6,301.425681,1817.856,fee schedule,,,
HC MR Angio Chest (Mra) W/Without Contrast,PX-61000072,CDM,71555,CPT,610,RC,,,outpatient,,,2367,1656.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1286.6,,,1286.6,301.425681,1817.856,fee schedule,,,
HC X-Ray Spine One View,PX-32000042,CDM,72020,CPT,320,RC,,,outpatient,,,251,175.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,56.3495,416.02,fee schedule,,,
HC Radex Spine Cervical 2 or 3 Views,PX-32000043,CDM,72040,CPT,320,RC,,,outpatient,,,296,207.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,66.452,416.02,fee schedule,,,
HC Radex Spine Cervical 4 or 5 Views,PX-32000044,CDM,72050,CPT,320,RC,,,outpatient,,,300,210,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,67.35,416.02,fee schedule,,,
HC Radex Spine Cervical 6 or More Views,PX-32000045,CDM,72052,CPT,320,RC,,,outpatient,,,300,210,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,67.35,416.02,fee schedule,,,
HC X-Ray Thoracic Spine 2 Vw,PX-32000046,CDM,72070,CPT,320,RC,,,outpatient,,,252,176.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,56.574,416.02,fee schedule,,,
HC X-Ray Thoracic Spine+Swim 3 Vw,PX-32000047,CDM,72072,CPT,320,RC,,,outpatient,,,283,198.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,63.5335,416.02,fee schedule,,,
HC X-Ray Thoracic Spine 4 Vw,PX-32000048,CDM,72074,CPT,320,RC,,,outpatient,,,306,214.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,68.697,416.02,fee schedule,,,
HC X-Ray Thor-Lumb Sp 2 Vw,PX-32000049,CDM,72080,CPT,320,RC,,,outpatient,,,357,249.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,71.24,416.02,fee schedule,,,
HC X-Ray Exam Entire Spi 1 Vw,PX-32000233,CDM,72081,CPT,320,RC,,,outpatient,,,241,168.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,54.1045,416.02,fee schedule,,,
HC X-Ray Exam Entire Spi 2/3 Vw,PX-32000234,CDM,72082,CPT,320,RC,,,outpatient,,,385,269.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,86.4325,416.02,fee schedule,,,
HC X-Ray Exam Entire Spi 4/5 Vw,PX-32000235,CDM,72083,CPT,320,RC,,,outpatient,,,757,529.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,119.991125,581.376,fee schedule,,,
HC X-Ray Exam Entire Spi 6/> Vw,PX-32000236,CDM,72084,CPT,320,RC,,,outpatient,,,757,529.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,76.026473,581.376,fee schedule,,,
HC X-Ray Lumbar Spine 2/3 Vw,PX-32000051,CDM,72100,CPT,320,RC,,,outpatient,,,235,164.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,52.7575,416.02,fee schedule,,,
HC X-Ray Lumbar Spine 4 Vw,PX-32000052,CDM,72110,CPT,320,RC,,,outpatient,,,323,226.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,72.5135,416.02,fee schedule,,,
HC X-Ray Lumbar Spine 6+ Vw,PX-32000053,CDM,72114,CPT,320,RC,,,outpatient,,,602,421.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,76.026473,462.336,fee schedule,,,
HC X-Ray Lumbar Spine Flex/Exten,PX-32000232,CDM,72120,CPT,320,RC,,,outpatient,,,411,287.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,92.2695,416.02,fee schedule,,,
HC CT Scan-Cervical Spine-W/O Contrast,PX-35000020,CDM,72125,CPT,350,RC,,,outpatient,,,1359,951.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,303.77,,,303.77,96.160741,1043.712,fee schedule,,,
HC CT Scan Cerv Spine Contrast,PX-35000021,CDM,72126,CPT,350,RC,,,outpatient,,,1556,1089.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,196.52,1195.008,fee schedule,,,
CT Cervical Spine W/O &W/Contrast Material,PX-35000022,CDM,72127,CPT,350,RC,,,outpatient,,,2239,1567.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,200.53123,1719.552,fee schedule,,,
HC CT Scan-Thoracic Spine-W/O Contrast,PX-35000023,CDM,72128,CPT,350,RC,,,outpatient,,,909,636.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,303.77,,,303.77,96.160741,698.112,fee schedule,,,
HC CT Scan Dorsal Sp Contrast,PX-35000024,CDM,72129,CPT,350,RC,,,outpatient,,,1037,725.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,196.52,796.416,fee schedule,,,
CT Thoracic Spine W/O & W/Contrast Material,PX-35000025,CDM,72130,CPT,350,RC,,,outpatient,,,2219,1553.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,200.53123,1704.192,fee schedule,,,
HC CT Scan-Lumbar Spine-W/O Contrast,PX-35000026,CDM,72131,CPT,350,RC,,,outpatient,,,688,481.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,303.77,,,303.77,96.160741,575,fee schedule,,,
HC CT Scan Lumbar Sp Contrast,PX-35000027,CDM,72132,CPT,350,RC,,,outpatient,,,1427,998.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,195.73,1095.936,fee schedule,,,
CT Lumbar Spine W/O & W/Contrast Material,PX-35000028,CDM,72133,CPT,350,RC,,,outpatient,,,1377,963.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,200.53123,1057.536,fee schedule,,,
HC MRI- Cerv Spine,PX-61000027,CDM,72141,CPT,610,RC,,,outpatient,,,2115,1480.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,622.5,,,622.5,185.92,1624.32,fee schedule,,,
HC MRI- Cerv Spine Contrast,PX-61000028,CDM,72142,CPT,610,RC,,,outpatient,,,3043,2130.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,270.27,2337.024,fee schedule,,,
HC MRI- Dorsal Spine,PX-61000029,CDM,72146,CPT,610,RC,,,outpatient,,,2222,1555.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,622.5,,,622.5,185.92,1706.496,fee schedule,,,
HC MRI- Dorsal Spine Contrast,PX-61000030,CDM,72147,CPT,610,RC,,,outpatient,,,2843,1990.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,266.73,2183.424,fee schedule,,,
HC MRI- Lumbar Spine,PX-61000031,CDM,72148,CPT,610,RC,,,outpatient,,,2651,1855.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,622.5,,,622.5,185.92,2035.968,fee schedule,,,
HC MRI- Lumbar Spine Contrast,PX-61000032,CDM,72149,CPT,610,RC,,,outpatient,,,2645,1851.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,265.17,2031.36,fee schedule,,,
MRI Spinal Canal Cervical W/O & W/Contr Matrl,PX-61000033,CDM,72156,CPT,610,RC,,,outpatient,,,3124,2186.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,307.53,2399.232,fee schedule,,,
MRI Spinal Canal Thoracic W/O & W/Contr Matrl,PX-61000034,CDM,72157,CPT,610,RC,,,outpatient,,,2833,1983.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,307.93,2175.744,fee schedule,,,
MRI Spinal Canal Lumbar W/O & W/Contr Matrl,PX-61000035,CDM,72158,CPT,610,RC,,,outpatient,,,3181,2226.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,305.58,2443.008,fee schedule,,,
HC X-Ray Pelvis 1/2 Vw,PX-32000054,CDM,72170,CPT,320,RC,,,outpatient,,,287,200.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,64.4315,416.02,fee schedule,,,
CT Angiography Pelvis W/Contrast/Noncontrast,PX-35000029,CDM,72191,CPT,350,RC,,,outpatient,,,1269,888.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,200.53123,974.592,fee schedule,,,
HC CT Scan-Pelvis-W/O Contrast,PX-35000030,CDM,72192,CPT,350,RC,,,outpatient,,,1368,957.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,303.77,,,303.77,96.160741,1050.624,fee schedule,,,
HC CT Scan of Pelvis Contrast,PX-35000031,CDM,72193,CPT,350,RC,,,outpatient,,,1561,1092.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,195.33,1198.848,fee schedule,,,
CT Pelvis W/O & W/Contrast Material,PX-35000032,CDM,72194,CPT,350,RC,,,outpatient,,,1902,1331.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,200.53123,1460.736,fee schedule,,,
HC MRI- Pelvis- W/O Contrast,PX-61000036,CDM,72195,CPT,610,RC,,,outpatient,,,2241,1568.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,622.5,,,622.5,237.688956,1721.088,fee schedule,,,
HC MRI- Pelvis W/Contrast,PX-61000037,CDM,72196,CPT,610,RC,,,outpatient,,,2850,1995,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,372.27,2188.8,fee schedule,,,
MRI Pelvis W/O & W/Contrast Material,PX-61000038,CDM,72197,CPT,610,RC,,,outpatient,,,2753,1927.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,399.547552,2114.304,fee schedule,,,
HC MR Angio Pelvis(Mra) W/Contrast,PX-61000039,CDM,72198,CPT,610,RC,,,outpatient,,,2908,2035.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1297.2,,,1297.2,399.86,2233.344,fee schedule,,,
HC MR Angio Pelvis(Mra) Without Contrast,PX-61000073,CDM,72198,CPT,610,RC,,,outpatient,,,2710,1897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1297.2,,,1297.2,399.86,2233.344,fee schedule,,,
HC MR Angio Pelvis(Mra) W/Without Contrast,PX-61000074,CDM,72198,CPT,610,RC,,,outpatient,,,1826,1278.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1297.2,,,1297.2,399.86,2233.344,fee schedule,,,
HC X-Ray Sacroiliac Jts 3+ Vw,PX-32000056,CDM,72202,CPT,320,RC,,,outpatient,,,443,310.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,76.026473,416.02,fee schedule,,,
HC X-Ray Sacrum/Coccyx 2+ Vw,PX-32000057,CDM,72220,CPT,320,RC,,,outpatient,,,336,235.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,71.24,416.02,fee schedule,,,
HC Myelography Cerv Spine,PX-32000058,CDM,72240,CPT,320,RC,,,outpatient,,,1478,1034.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,791.06,,,791.06,331.811,2051.3855,fee schedule,,,
HC Myelography Thorax Spine,PX-32000059,CDM,72255,CPT,320,RC,,,outpatient,,,1823,1276.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,791.06,,,791.06,399.86,2051.3855,fee schedule,,,
HC Myelography Lumbar Spine,PX-32000060,CDM,72265,CPT,320,RC,,,outpatient,,,1760,1232,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,791.06,,,791.06,395.12,2051.3855,fee schedule,,,
HC Myelography of Entire Spine,PX-32000061,CDM,72270,CPT,320,RC,,,outpatient,,,1823,1276.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,791.06,,,791.06,399.86,2051.3855,fee schedule,,,
HC X-Ray-C/T-Disk-Superv/Interpret,PX-32000062,CDM,72285,CPT,320,RC,,,outpatient,,,4306,3014.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1865.69,,,1865.69,399.86,4977.9345,fee schedule,,,
HC Discography Lumbar Spine,PX-32000064,CDM,72295,CPT,320,RC,,,outpatient,,,4306,3014.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1865.69,,,1865.69,399.86,4977.9345,fee schedule,,,
HC X-Ray Clavicle,PX-32000065,CDM,73000,CPT,320,RC,,,outpatient,,,170,119,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,38.165,416.02,fee schedule,,,
HC X-Ray Scapula,PX-32000066,CDM,73010,CPT,320,RC,,,outpatient,,,306,214.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,68.697,416.02,fee schedule,,,
HC X-Ray Shoulder 1 Vw,PX-32000067,CDM,73020,CPT,320,RC,,,outpatient,,,256,179.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,57.472,416.02,fee schedule,,,
HC X-Ray Shoulder 2+ Vw,PX-32000068,CDM,73030,CPT,320,RC,,,outpatient,,,139,97.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,31.2055,416.02,fee schedule,,,
HC Arthrogram of Shoulder,PX-32000069,CDM,73040,CPT,320,RC,,,outpatient,,,1690,1183,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,441.28,,,441.28,379.405,1297.92,fee schedule,,,
HC X-Ray Ac Jts,PX-32000070,CDM,73050,CPT,320,RC,,,outpatient,,,323,226.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,71.24,416.02,fee schedule,,,
HC X-Ray Humerus,PX-32000071,CDM,73060,CPT,320,RC,,,outpatient,,,178,124.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,39.961,416.02,fee schedule,,,
HC X-Ray Elbow 2 Vw,PX-32000072,CDM,73070,CPT,320,RC,,,outpatient,,,171,119.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,38.3895,416.02,fee schedule,,,
HC X-Ray Elbow 3+ Vw,PX-32000073,CDM,73080,CPT,320,RC,,,outpatient,,,129,90.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,28.9605,416.02,fee schedule,,,
HC Arthrogram of Elbow,PX-32000074,CDM,73085,CPT,320,RC,,,outpatient,,,1331,931.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,441.28,,,441.28,298.8095,1022.208,fee schedule,,,
HC X-Ray Forearm 2 Vw,PX-32000075,CDM,73090,CPT,320,RC,,,outpatient,,,225,157.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,50.5125,416.02,fee schedule,,,
HC X-Ray Arm- Infant,PX-32000076,CDM,73092,CPT,320,RC,,,outpatient,,,368,257.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,76.026473,416.02,fee schedule,,,
HC X-Ray Wrist 2 Vw,PX-32000077,CDM,73100,CPT,320,RC,,,outpatient,,,190,133,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,42.655,416.02,fee schedule,,,
HC X-Ray Wrist 3+ Vw,PX-32000078,CDM,73110,CPT,320,RC,,,outpatient,,,241,168.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,54.1045,416.02,fee schedule,,,
HC Arthrogram of Wrist,PX-32000079,CDM,73115,CPT,320,RC,,,outpatient,,,1722,1205.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,441.28,,,441.28,237.819698,1322.496,fee schedule,,,
HC X-Ray Hand 2 Vw,PX-32000080,CDM,73120,CPT,320,RC,,,outpatient,,,306,214.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,68.697,416.02,fee schedule,,,
HC X-Ray Hand 3+ Vw,PX-32000081,CDM,73130,CPT,320,RC,,,outpatient,,,236,165.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,52.982,416.02,fee schedule,,,
HC X-Ray Exam of Finger(S),PX-32000082,CDM,73140,CPT,320,RC,,,outpatient,,,129,90.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,28.9605,416.02,fee schedule,,,
HC CT Scan-Upper Extremity-W/O Contrast,PX-35000034,CDM,73200,CPT,350,RC,,,outpatient,,,959,671.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,303.77,,,303.77,96.160741,736.512,fee schedule,,,
HC CT Scan of Arm Contrast,PX-35000035,CDM,73201,CPT,350,RC,,,outpatient,,,1388,971.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,193.37,1065.984,fee schedule,,,
CT Upper Extremity W/O & W/Contrast Material,PX-35000036,CDM,73202,CPT,350,RC,,,outpatient,,,1961,1372.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,200.53123,1506.048,fee schedule,,,
CT Angiography Upper Extremity,PX-35000037,CDM,73206,CPT,350,RC,,,outpatient,,,1345,941.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,200.53123,1032.96,fee schedule,,,
HC MRI- Upper Extremity W/O Contrast,PX-61000040,CDM,73218,CPT,610,RC,,,outpatient,,,2888,2021.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,622.5,,,622.5,237.688956,2217.984,fee schedule,,,
HC MRI- Upper Extremity W/Contrast,PX-61000041,CDM,73219,CPT,610,RC,,,outpatient,,,2936,2055.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,371.09,2254.848,fee schedule,,,
HC MRI Ext Upp No Jnt W-W/O,PX-61000042,CDM,73220,CPT,610,RC,,,outpatient,,,3144,2200.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,399.547552,2414.592,fee schedule,,,
MRI Any Jt Upper Extremity W/O Contrast Matrl,PX-61000043,CDM,73221,CPT,610,RC,,,outpatient,,,3039,2127.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,622.5,,,622.5,204.76,2333.952,fee schedule,,,
HC MRI- Joint Upper Extrem W/Contrast,PX-61000044,CDM,73222,CPT,610,RC,,,outpatient,,,3144,2200.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1867.69,,,1867.69,340.49,2414.592,fee schedule,,,
MRI Any Jt Upper Extremity W/O & W/Contr Matrl,PX-61000045,CDM,73223,CPT,610,RC,,,outpatient,,,3060,2142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,399.547552,2350.08,fee schedule,,,
HC X-Ray Exam Hip Uni 1 View,PX-32000237,CDM,73501,CPT,320,RC,,,outpatient,,,222,155.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,49.839,416.02,fee schedule,,,
HC X-Ray Exam Hip Uni 2-3 Views,PX-32000238,CDM,73502,CPT,320,RC,,,outpatient,,,222,155.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,49.839,416.02,fee schedule,,,
HC X-Ray Exam Hip Uni 4/> Views,PX-32000239,CDM,73503,CPT,320,RC,,,outpatient,,,385,269.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,86.4325,416.02,fee schedule,,,
HC X-Ray Exam Hips Bi 2 Views,PX-32000240,CDM,73521,CPT,320,RC,,,outpatient,,,385,269.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,86.4325,416.02,fee schedule,,,
HC X-Ray Exam Hips Bi 5/> Views,PX-32000242,CDM,73523,CPT,320,RC,,,outpatient,,,757,529.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,76.026473,581.376,fee schedule,,,
HC Arthrogram of Hip,PX-32000086,CDM,73525,CPT,320,RC,,,outpatient,,,1616,1131.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,441.28,,,441.28,237.819698,1241.088,fee schedule,,,
HC X-Ray Exam of Femur 1,PX-32000243,CDM,73551,CPT,320,RC,,,outpatient,,,213,149.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,47.8185,416.02,fee schedule,,,
HC X-Ray Exam of Femur 2/>,PX-32000244,CDM,73552,CPT,320,RC,,,outpatient,,,241,168.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,54.1045,416.02,fee schedule,,,
HC X-Ray Knee 1 or 2 View,PX-32000090,CDM,73560,CPT,320,RC,,,outpatient,,,213,149.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,47.8185,416.02,fee schedule,,,
HC X-Ray Knee 3 View,PX-32000091,CDM,73562,CPT,320,RC,,,outpatient,,,232,162.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,52.084,416.02,fee schedule,,,
HC X-Ray Knee 4+ View,PX-32000092,CDM,73564,CPT,320,RC,,,outpatient,,,260,182,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,58.37,416.02,fee schedule,,,
HC X-Ray Knee Bilat Standing,PX-32000093,CDM,73565,CPT,320,RC,,,outpatient,,,394,275.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,71.24,416.02,fee schedule,,,
HC Arthrogram of Knee Joint,PX-32000094,CDM,73580,CPT,320,RC,,,outpatient,,,1704,1192.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,441.28,,,441.28,382.548,1308.672,fee schedule,,,
HC X-Ray Tib + Fib- 2vw,PX-32000095,CDM,73590,CPT,320,RC,,,outpatient,,,199,139.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,44.6755,416.02,fee schedule,,,
HC X-Ray Leg- Infant,PX-32000096,CDM,73592,CPT,320,RC,,,outpatient,,,231,161.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,51.8595,416.02,fee schedule,,,
HC X-Ray Ankle 2 Vw,PX-32000097,CDM,73600,CPT,320,RC,,,outpatient,,,137,95.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,30.7565,416.02,fee schedule,,,
HC X-Ray Ankle 3+ Vw,PX-32000098,CDM,73610,CPT,320,RC,,,outpatient,,,130,91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,29.185,416.02,fee schedule,,,
HC Arthrogram of Ankle,PX-32000099,CDM,73615,CPT,320,RC,,,outpatient,,,1221,854.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,441.28,,,441.28,237.819698,1020.2995,fee schedule,,,
HC X-Ray Foot 2 Vw,PX-32000100,CDM,73620,CPT,320,RC,,,outpatient,,,158,110.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,35.471,416.02,fee schedule,,,
HC X-Ray Foot 3+ Vw,PX-32000101,CDM,73630,CPT,320,RC,,,outpatient,,,164,114.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,36.818,416.02,fee schedule,,,
HC X-Ray Heel,PX-32000102,CDM,73650,CPT,320,RC,,,outpatient,,,234,163.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,52.533,416.02,fee schedule,,,
HC X-Ray Toe(S),PX-32000103,CDM,73660,CPT,320,RC,,,outpatient,,,192,134.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,43.104,416.02,fee schedule,,,
HC CT Scan-Lower Extremity-W/O Contrast,PX-35000038,CDM,73700,CPT,350,RC,,,outpatient,,,968,677.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,303.77,,,303.77,96.160741,743.424,fee schedule,,,
HC CT Scan of Leg Contrast,PX-35000039,CDM,73701,CPT,350,RC,,,outpatient,,,987,690.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,196.51,758.016,fee schedule,,,
CT Lower Extremity W/O & W/Contrast Matrl,PX-35000040,CDM,73702,CPT,350,RC,,,outpatient,,,1903,1332.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,200.53123,1461.504,fee schedule,,,
CT Angiography Lower Extremity,PX-35000041,CDM,73706,CPT,350,RC,,,outpatient,,,1176,823.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,200.53123,903.168,fee schedule,,,
HC MRI- Lower Extrem,PX-61000046,CDM,73718,CPT,610,RC,,,outpatient,,,2836,1985.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,622.5,,,622.5,237.688956,2178.048,fee schedule,,,
HC MRI- Lower Extrem W/Contrast,PX-61000047,CDM,73719,CPT,610,RC,,,outpatient,,,2396,1677.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,372.66,1840.128,fee schedule,,,
HC MRI- Lower Extr- W/O Contrast F/U by Contrast,PX-61000048,CDM,73720,CPT,610,RC,,,outpatient,,,3060,2142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,399.547552,2350.08,fee schedule,,,
HC MRI Lower Extrem Jt- W/O Contrast,PX-61000049,CDM,73721,CPT,610,RC,,,outpatient,,,3008,2105.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,622.5,,,622.5,205.15,2310.144,fee schedule,,,
HC MRI- Joint of Leg W/Contrast,PX-61000050,CDM,73722,CPT,610,RC,,,outpatient,,,3018,2112.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1867.69,,,1867.69,345.98,2317.824,fee schedule,,,
MRI Any Jt Lower Extrem W/O & W/Contrast Matrl,PX-61000051,CDM,73723,CPT,610,RC,,,outpatient,,,3098,2168.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,399.547552,2379.264,fee schedule,,,
HC MR Angio Lower Extrem (Mra) W/Contrast,PX-61000052,CDM,73725,CPT,610,RC,,,outpatient,,,2710,1897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1295.69,,,1295.69,399.86,2290.176,fee schedule,,,
HC MR Angio Lower Extrem (Mra) Without Contrast,PX-61000075,CDM,73725,CPT,610,RC,,,outpatient,,,2710,1897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1295.69,,,1295.69,399.86,2290.176,fee schedule,,,
HC MR Angio Lower Extrem (Mra) W/Without Contrast,PX-61000076,CDM,73725,CPT,610,RC,,,outpatient,,,2982,2087.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1295.69,,,1295.69,399.86,2290.176,fee schedule,,,
HC X-Ray Exam Abdomen 1 View,PX-32000249,CDM,74018,CPT,320,RC,,,outpatient,,,232,162.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,52.084,416.02,fee schedule,,,
HC X-Ray Exam Abdomen 2 Views,PX-32000250,CDM,74019,CPT,320,RC,,,outpatient,,,443,310.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,76.026473,416.02,fee schedule,,,
HC X-Ray Exam Abdomen 3+ Views,PX-32000251,CDM,74021,CPT,320,RC,,,outpatient,,,410,287,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,92.045,416.02,fee schedule,,,
HC CT Scan-Abdomen-W/O Contrast,PX-35000042,CDM,74150,CPT,350,RC,,,outpatient,,,1449,1014.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,303.77,,,303.77,96.160741,1112.832,fee schedule,,,
HC CT Scan of Abdomen Contrast,PX-35000043,CDM,74160,CPT,350,RC,,,outpatient,,,1586,1110.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,194.55,1218.048,fee schedule,,,
CT Abdomen W/O & W/Contrast Material,PX-35000044,CDM,74170,CPT,350,RC,,,outpatient,,,2058,1440.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,200.53123,1580.544,fee schedule,,,
HC CT Angio Abd&Plvis Cntrst Mtrl W/WO Cntrst Imges,PX-35000045,CDM,74174,CPT,350,RC,,,outpatient,,,2581,1806.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,329.339098,1982.208,fee schedule,,,
CT Angiography Abdomen W/Contrast/Noncontrast,PX-35000046,CDM,74175,CPT,350,RC,,,outpatient,,,1355,948.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,200.53123,1040.64,fee schedule,,,
HC CT Scan-Abdoment and Pelvis-W/O Contrast,PX-35000047,CDM,74176,CPT,350,RC,,,outpatient,,,1368,957.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,622.5,,,622.5,142.38,1050.624,fee schedule,,,
HC CT Scan-Abdoment and Pelvis-W Contrast,PX-35000048,CDM,74177,CPT,350,RC,,,outpatient,,,1971,1379.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,204.61123,1513.728,fee schedule,,,
CT Abdomen & Pelvis W/O Contrst 1/> Body Re,PX-35000049,CDM,74178,CPT,350,RC,,,outpatient,,,2122,1485.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,204.61123,1629.696,fee schedule,,,
HC MRI- Abdomen (MRI),PX-61000053,CDM,74181,CPT,610,RC,,,outpatient,,,2357,1649.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,622.5,,,622.5,237.688956,1810.176,fee schedule,,,
HC MRI- Abdomen W/Contrast,PX-61000054,CDM,74182,CPT,610,RC,,,outpatient,,,5081,3556.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,399.547552,3902.208,fee schedule,,,
MRI Abdomen W/O & W/Contrast Material,PX-61000055,CDM,74183,CPT,610,RC,,,outpatient,,,2698,1888.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,399.547552,2072.064,fee schedule,,,
HC MR Angio Abdomen (Mra) W/Contrast,PX-61000056,CDM,74185,CPT,610,RC,,,outpatient,,,2446,1712.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1301.76,,,1301.76,301.425681,1878.528,fee schedule,,,
HC MR Angio Abdomen (Mra) Without Contrast,PX-61000077,CDM,74185,CPT,610,RC,,,outpatient,,,2446,1712.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1301.76,,,1301.76,301.425681,1878.528,fee schedule,,,
HC MR Angio Abdomen (Mra) W/Without Contrast,PX-61000078,CDM,74185,CPT,610,RC,,,outpatient,,,2446,1712.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1301.76,,,1301.76,301.425681,1878.528,fee schedule,,,
HC Esophagram,PX-32000107,CDM,74220,CPT,320,RC,,,outpatient,,,981,686.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,230.7,,,230.7,76.026473,753.408,fee schedule,,,
HC Swallowing Fcn-W/Cine &/or Video,PX-32000108,CDM,74230,CPT,320,RC,,,outpatient,,,874,611.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,128.66,671.232,fee schedule,,,
HC Remove Esophagus Obstruction,PX-32000109,CDM,74235,CPT,320,RC,,,outpatient,,,1157,809.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,259.7465,888.576,other,SI=N Exclusions ,,
HC Xray Upper GI Tract,PX-32000110,CDM,74240,CPT,320,RC,,,outpatient,,,916,641.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,230.7,,,230.7,200.53123,703.488,fee schedule,,,
HC Xray Upper GI Air Contrast,PX-32000113,CDM,74246,CPT,320,RC,,,outpatient,,,865,605.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,230.7,,,230.7,194.1925,664.32,fee schedule,,,
HC X-Ray-Small Bowel-W/Mult Serial Films,PX-32000116,CDM,74250,CPT,320,RC,,,outpatient,,,2949,2064.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,128.66,2264.832,fee schedule,,,
HC X-Ray Small Bowel Enteroclysis,PX-32000117,CDM,74251,CPT,320,RC,,,outpatient,,,1182,827.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,263.66,,,263.66,183.14,907.776,fee schedule,,,
HC X-Ray Colon Contrast,PX-32000118,CDM,74270,CPT,320,RC,,,outpatient,,,1071,749.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,230.7,,,230.7,200.53123,822.528,fee schedule,,,
HC X-Ray Colon Air Contrast,PX-32000119,CDM,74280,CPT,320,RC,,,outpatient,,,1758,1230.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,230.7,,,230.7,200.53123,1350.144,fee schedule,,,
HC X-Ray Oper Cholangiogram,PX-32000123,CDM,74300,CPT,320,RC,,,outpatient,,,1336,935.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,145.12362,1026.048,other,SI=N Exclusions ,,
HC X-Ray Oper Cholangio Addnl Set,PX-32000124,CDM,74301,CPT,320,RC,,,outpatient,,,289,202.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,64.8805,416.02,other,SI=N Exclusions ,,
HC X-Ray Bile/Pancreas Endoscopy,PX-32000129,CDM,74330,CPT,320,RC,,,outpatient,,,1038,726.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,145.12362,797.184,other,SI=N Exclusions ,,
HC X-Ray Introductn GI Tube,PX-32000130,CDM,74340,CPT,320,RC,,,outpatient,,,872,610.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,195.08,669.696,other,SI=N Exclusions ,,
HC X-Ray Guide Enteroclysis Tube,PX-32000131,CDM,74355,CPT,320,RC,,,outpatient,,,2913,2039.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,260.23,2237.184,other,SI=N Exclusions ,,
HC X-Ray Guide- GI Dilation,PX-32000132,CDM,74360,CPT,320,RC,,,outpatient,,,631,441.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,141.6595,484.608,other,SI=N Exclusions ,,
HC Percut Transhepat Dilat-Bile Duct Strict,PX-32000133,CDM,74363,CPT,320,RC,,,outpatient,,,2462,1723.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,1890.816,other,SI=N Exclusions ,,
HC X-Ray IV Pyelogram (Ivp),PX-32000134,CDM,74400,CPT,320,RC,,,outpatient,,,599,419.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,230.7,,,230.7,134.4755,499.422,fee schedule,,,
HC X-Ray IV Pyelogram+Tomography,PX-32000136,CDM,74415,CPT,320,RC,,,outpatient,,,2078,1454.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,230.7,,,230.7,200.53123,1595.904,fee schedule,,,
HC X-Ray Retrograde Pyelogram,PX-32000137,CDM,74420,CPT,320,RC,,,outpatient,,,1189,832.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,441.28,,,441.28,237.819698,1020.2995,fee schedule,,,
HC Antegrade Urography Radiological Supvj & Interpj,PX-32000138,CDM,74425,CPT,320,RC,,,outpatient,,,2829,1980.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,441.28,,,441.28,399.86,2172.672,fee schedule,,,
HC X-Ray Cystogram- Min 3 View,PX-32000139,CDM,74430,CPT,320,RC,,,outpatient,,,1189,832.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,441.28,,,441.28,237.819698,1020.2995,fee schedule,,,
HC X-Ray Urethrocystogram,PX-32000140,CDM,74450,CPT,320,RC,,,outpatient,,,762,533.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,263.66,,,263.66,171.069,646.6965,fee schedule,,,
HC X-Ray Urethrocystogram+Voiding,PX-32000141,CDM,74455,CPT,320,RC,,,outpatient,,,762,533.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,263.66,,,263.66,171.069,646.6965,fee schedule,,,
HC X-Ray Renal Cyst Xlumbar+Contrst,PX-32000142,CDM,74470,CPT,320,RC,,,outpatient,,,542,379.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,568.91,,,568.91,121.679,1393.3385,fee schedule,,,
HC X-Ray Guide- Gu Dilation,PX-32000145,CDM,74485,CPT,320,RC,,,outpatient,,,3417,2391.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1989.5,,,1989.5,399.86,5136.771,fee schedule,,,
HC X-Ray Hysterosalpingogram,PX-32000146,CDM,74740,CPT,320,RC,,,outpatient,,,1695,1186.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,263.66,,,263.66,237.819698,1301.76,fee schedule,,,
HC X-Ray Xcerv Cath Fallopian Tube,PX-32000147,CDM,74742,CPT,320,RC,,,outpatient,,,1270,889,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,285.115,975.36,other,SI=N Exclusions ,,
HC Cardiac MRI Morphology & Function W/O Contrast,PX-61000057,CDM,75557,CPT,610,RC,,,outpatient,,,2222,1555.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,622.5,,,622.5,88.902,1706.496,fee schedule,,,
HC PR Cardiac MRI Morphology & Function W/O Contrast,PX-97200020,CDM,75557,CPT,972,RC,,,outpatient,,,396,277.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,622.5,,,622.5,88.902,1706.496,fee schedule,,,
HC Cardiac MRI W/W/O Contrast & Further Seq,PX-61000059,CDM,75561,CPT,610,RC,,,outpatient,,,2644,1850.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,102.5965,2030.592,fee schedule,,,
HC PR Cardiac MRI W/W/O Contrast & Further Seq,PX-97200021,CDM,75561,CPT,972,RC,,,outpatient,,,457,319.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1041.86,,,1041.86,102.5965,2030.592,fee schedule,,,
HC Cardiac MRI for Velocity Flow Mapping,PX-61000061,CDM,75565,CPT,610,RC,,,outpatient,,,222,155.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.2045,836,other,SI=N Exclusions ,,
HC PR Cardiac MRI for Velocity Flow Mapping,PX-97200022,CDM,75565,CPT,972,RC,,,outpatient,,,41,28.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.2045,836,other,SI=N Exclusions ,,
HC CT Heart W/O Contrast Quant Eval Coronary Calcium,PX-35000052,CDM,75571,CPT,350,RC,,,outpatient,,,264,184.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,168.2,,,168.2,19.0825,575,fee schedule,,,
HC PR CT Heart W/O Contrast Quant Eval Coronary Calcium,PX-97200023,CDM,75571,CPT,972,RC,,,outpatient,,,85,59.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,168.2,,,168.2,19.0825,575,fee schedule,,,
HC CT Heart Contrast Eval Cardiac Struct/Morph,PX-35000053,CDM,75572,CPT,350,RC,,,outpatient,,,872,610.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,58.819,669.696,fee schedule,,,
HC PR CT Heart Contrast Eval Cardiac Struct/Morph,PX-97200024,CDM,75572,CPT,972,RC,,,outpatient,,,262,183.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,58.819,669.696,fee schedule,,,
HC CT Heart Contrast Eval Cardiac Struct/Morph- Congen Heart Disease,PX-35000054,CDM,75573,CPT,350,RC,,,outpatient,,,1016,711.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,58.819,780.288,fee schedule,,,
HC PR CT Heart Contrast Eval Cardiac Struct/Morph- Congen Heart Disease,PX-97200025,CDM,75573,CPT,972,RC,,,outpatient,,,262,183.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,58.819,780.288,fee schedule,,,
HC CT Angio Hrt Cornry Art/Bypass Grfts Contrst 3d Post,PX-35000055,CDM,75574,CPT,350,RC,,,outpatient,,,1073,751.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,57.921,824.064,fee schedule,,,
HC PR CT Angio Hrt Cornry Art/Bypass Grfts Contrst 3d Post,PX-97200026,CDM,75574,CPT,972,RC,,,outpatient,,,258,180.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,544.68,,,544.68,57.921,824.064,fee schedule,,,
HC N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp,PX-48000097,CDM,75580,CPT,480,RC,,,outpatient,,,2856,1999.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2536.61,,,2536.61,399.86,2536.61118,fee schedule,,,
HC Angio Aortogram Thoracic,PX-32000148,CDM,75600,CPT,320,RC,,,outpatient,,,3155,2208.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3020.73,,,3020.73,399.86,8249.769,fee schedule,,,
HC Angio Aortogram Thor Serial,PX-32000149,CDM,75605,CPT,320,RC,,,outpatient,,,12541,8778.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5004.8,,,5004.8,399.86,14233.715,fee schedule,,,
HC Angio Aortogram Abd Serial,PX-32000150,CDM,75625,CPT,320,RC,,,outpatient,,,5654,3957.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3020.73,,,3020.73,399.86,8249.769,fee schedule,,,
HC Angio Aortobifemoral W Cath,PX-32000151,CDM,75630,CPT,320,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3020.73,,,3020.73,399.86,8249.769,fee schedule,,,
Cta Abdl Aorta&Bi Iliofem W/Contrast&Postp,PX-35000056,CDM,75635,CPT,350,RC,,,outpatient,,,1721,1204.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,230.7,,,230.7,200.53123,1321.728,fee schedule,,,
HC Angio Spinal Selectv,PX-32000153,CDM,75705,CPT,320,RC,,,outpatient,,,11403,7982.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5004.8,,,5004.8,399.86,14233.715,fee schedule,,,
HC Angio Extremity Unilat,PX-32000154,CDM,75710,CPT,320,RC,,,outpatient,,,6489,4542.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3020.73,,,3020.73,399.86,8249.769,fee schedule,,,
HC Angio Extermity Bilat,PX-32000155,CDM,75716,CPT,320,RC,,,outpatient,,,7162,5013.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3020.73,,,3020.73,399.86,8249.769,fee schedule,,,
HC Angio Visceral Selectv/Subselec,PX-32000156,CDM,75726,CPT,320,RC,,,outpatient,,,9831,6881.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5004.8,,,5004.8,399.86,14233.715,fee schedule,,,
HC Angio Adrenal Unilat Select,PX-32000157,CDM,75731,CPT,320,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1250.63,,,1250.63,399.86,8249.769,fee schedule,,,
HC Angio Adrenal Bilat Select,PX-32000158,CDM,75733,CPT,320,RC,,,outpatient,,,6665,4665.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3020.73,,,3020.73,399.86,8249.769,fee schedule,,,
HC Angio Pelvis,PX-32000159,CDM,75736,CPT,320,RC,,,outpatient,,,11403,7982.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5004.8,,,5004.8,399.86,14233.715,fee schedule,,,
HC Angio Pulmon Unilat Select,PX-32000160,CDM,75741,CPT,320,RC,,,outpatient,,,6665,4665.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3020.73,,,3020.73,399.86,8249.769,fee schedule,,,
HC Angio Pulmon Bilat Select,PX-32000161,CDM,75743,CPT,320,RC,,,outpatient,,,7162,5013.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3020.73,,,3020.73,399.86,8249.769,fee schedule,,,
HC Angio Pulmon Bilat Nonselec,PX-32000162,CDM,75746,CPT,320,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1250.63,,,1250.63,399.86,8249.769,fee schedule,,,
HC Angio Intern Mammary,PX-32000163,CDM,75756,CPT,320,RC,,,outpatient,,,6665,4665.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3020.73,,,3020.73,399.86,8249.769,fee schedule,,,
HC Angio Ea Addnl Selectv Vessel,PX-32000164,CDM,75774,CPT,320,RC,,,outpatient,,,3538,2476.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,2717.184,other,SI=N Exclusions ,,
HC Nonvascular Shuntogram,PX-32000166,CDM,75809,CPT,320,RC,,,outpatient,,,411,287.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,92.2695,416.02,fee schedule,,,
HC Venogram Splenoportogram,PX-32000167,CDM,75810,CPT,320,RC,,,outpatient,,,7698,5388.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1250.63,,,1250.63,399.86,8249.769,fee schedule,,,
HC Venogram Extrem Unilat,PX-32000168,CDM,75820,CPT,320,RC,,,outpatient,,,3212,2248.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,709.02,,,709.02,399.86,4120.349,fee schedule,,,
HC Venogram Extrem Bilat,PX-32000169,CDM,75822,CPT,320,RC,,,outpatient,,,2940,2058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1250.63,,,1250.63,399.86,4120.349,fee schedule,,,
HC Venogram Infer Vena Cava,PX-32000170,CDM,75825,CPT,320,RC,,,outpatient,,,5987,4190.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3020.73,,,3020.73,399.86,8249.769,fee schedule,,,
HC Venogram Super Vena Cava,PX-32000171,CDM,75827,CPT,320,RC,,,outpatient,,,2874,2011.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,709.02,,,709.02,399.86,4120.349,fee schedule,,,
HC Venogram Renal Unilat,PX-32000172,CDM,75831,CPT,320,RC,,,outpatient,,,6489,4542.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3020.73,,,3020.73,399.86,8249.769,fee schedule,,,
HC Venogram Renal Bilat,PX-32000173,CDM,75833,CPT,320,RC,,,outpatient,,,6665,4665.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3020.73,,,3020.73,399.86,8249.769,fee schedule,,,
HC Venogram Adrenal Unilat,PX-32000174,CDM,75840,CPT,320,RC,,,outpatient,,,7698,5388.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3020.73,,,3020.73,399.86,8249.769,fee schedule,,,
HC Venogram Adrenal Bilat,PX-32000175,CDM,75842,CPT,320,RC,,,outpatient,,,11403,7982.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5004.8,,,5004.8,399.86,14233.715,fee schedule,,,
HC Venogram Sinus/Jugular,PX-32000176,CDM,75860,CPT,320,RC,,,outpatient,,,6665,4665.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3020.73,,,3020.73,399.86,8249.769,fee schedule,,,
HC Venogram Super Sag Sinus,PX-32000177,CDM,75870,CPT,320,RC,,,outpatient,,,4428,3099.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1250.63,,,1250.63,399.86,8249.769,fee schedule,,,
HC Venogram Epidural,PX-32000178,CDM,75872,CPT,320,RC,,,outpatient,,,4428,3099.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,709.02,,,709.02,399.86,3400.704,fee schedule,,,
HC Venogram Orbital,PX-32000179,CDM,75880,CPT,320,RC,,,outpatient,,,1638,1146.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,709.02,,,709.02,367.731,1602.0655,fee schedule,,,
HC Percut Xhepatic Porto+Dynamic,PX-32000180,CDM,75885,CPT,320,RC,,,outpatient,,,7698,5388.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3020.73,,,3020.73,399.86,8249.769,fee schedule,,,
HC Percut Xhepatic Portogram,PX-32000181,CDM,75887,CPT,320,RC,,,outpatient,,,7528,5269.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1250.63,,,1250.63,399.86,8249.769,fee schedule,,,
HC Venogram Hepatic W Hemodynamics,PX-32000182,CDM,75889,CPT,320,RC,,,outpatient,,,5272,3690.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3020.73,,,3020.73,399.86,8249.769,fee schedule,,,
HC Venogram Hepatic,PX-32000183,CDM,75891,CPT,320,RC,,,outpatient,,,6665,4665.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3020.73,,,3020.73,399.86,8249.769,fee schedule,,,
HC Venous Sampling by Catheter,PX-32000184,CDM,75893,CPT,320,RC,,,outpatient,,,11403,7982.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5004.8,,,5004.8,399.86,14233.715,fee schedule,,,
HC Transcatheter Rx Embolizatn,PX-32000185,CDM,75894,CPT,320,RC,,,outpatient,,,2536,1775.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,145.12362,1947.648,other,SI=N Exclusions ,,
HC Angrph Cath F-Up Std Tcat Other Than Thrombylsis,PX-32000187,CDM,75898,CPT,320,RC,,,outpatient,,,3747,2622.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1250.63,,,1250.63,260.23,8249.769,fee schedule,,,
HC Remove-Obst Matl-Cva Dev via Sep Ven Acc,PX-32000188,CDM,75901,CPT,320,RC,,,outpatient,,,4773,3341.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,260.23,3665.664,other,SI=N Exclusions ,,
HC Remove-Obst Matl-Cva Device via Lumen,PX-32000189,CDM,75902,CPT,320,RC,,,outpatient,,,471,329.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,105.7395,416.02,other,SI=N Exclusions ,,
HC Endovasc Repair Thor Aorta Incl Subclavian,PX-32000195,CDM,75956,CPT,320,RC,,,outpatient,,,1446,1012.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,505.64,,,505.64,324.627,1110.528,fee schedule,,,
HC Endovasc Repair Thor Aorta Excl Subclavian,PX-32000196,CDM,75957,CPT,320,RC,,,outpatient,,,1312,918.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,434.03,,,434.03,294.544,1007.616,fee schedule,,,
HC Proximal Extens Durng Endovasc Rethor Aorta,PX-32000197,CDM,75958,CPT,320,RC,,,outpatient,,,845,591.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,288.34,,,288.34,189.7025,648.96,fee schedule,,,
HC Delayed Prox Extens Endovasc Rethor Aorta,PX-32000198,CDM,75959,CPT,320,RC,,,outpatient,,,744,520.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,251.22,,,251.22,167.028,571.392,fee schedule,,,
HC Vascular Biopsy,PX-32000203,CDM,75970,CPT,320,RC,,,outpatient,,,2918,2042.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,145.12362,2241.024,other,SI=N Exclusions ,,
HC Change Percut Tube/Drain Cath W Contrast Monit,PX-32000207,CDM,75984,CPT,320,RC,,,outpatient,,,2885,2019.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,145.12362,2215.68,other,SI=N Exclusions ,,
HC Rad Guided-Percut Drainage-W/Cath Place,PX-32000208,CDM,75989,CPT,320,RC,,,outpatient,,,888,621.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,145.12362,681.984,other,SI=N Exclusions ,,
HC Rad Guided-Percut Drainage-W/Cath Place,PX-35000057,CDM,75989,CPT,350,RC,,,outpatient,,,888,621.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,145.12362,681.984,other,SI=N Exclusions ,,
HC Fluoroscopy Spx Up to 1 Hour Phys/Qhp Time,PX-32000209,CDM,76000,CPT,320,RC,,,outpatient,,,997,697.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,263.66,,,263.66,195.08,765.696,fee schedule,,,
HC X-Ray Nose-Rectum Child F.B.,PX-32000210,CDM,76010,CPT,320,RC,,,outpatient,,,340,238,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,71.24,416.02,fee schedule,,,
HC X-Ray Fistula-Abscess-Sinus Tract,PX-32000211,CDM,76080,CPT,320,RC,,,outpatient,,,1950,1365,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,568.91,,,568.91,237.819698,1497.6,fee schedule,,,
HC X-Ray Exam- Breast Specimen,PX-32000212,CDM,76098,CPT,320,RC,,,outpatient,,,984,688.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,568.91,,,568.91,220.908,1393.3385,fee schedule,,,
HC Cine/Videoradiology-Exc Where Spec Incl,PX-32000214,CDM,76120,CPT,320,RC,,,outpatient,,,382,267.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,85.759,416.02,fee schedule,,,
HC 3d Rendering W/Interp & Postprocess Supervision,PX-35000058,CDM,76376,CPT,350,RC,,,outpatient,,,352,246.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,79.024,836,other,SI=N Exclusions ,,
HC 3d Rendering W/Interp & Postprocess Supervision,PX-40200003,CDM,76376,CPT,402,RC,,,outpatient,,,352,246.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,79.024,836,other,SI=N Exclusions ,,
HC 3d Rendering W/Interp & Postprocess Supervision,PX-61000062,CDM,76376,CPT,610,RC,,,outpatient,,,352,246.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,79.024,836,other,SI=N Exclusions ,,
HC 3d Rendering W/Interp&Postproc Diff Work Station,PX-35000059,CDM,76377,CPT,350,RC,,,outpatient,,,422,295.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,94.739,836,other,SI=N Exclusions ,,
HC 3d Rendering W/Interp&Postproc Diff Work Station,PX-40200004,CDM,76377,CPT,402,RC,,,outpatient,,,422,295.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,94.739,836,other,SI=N Exclusions ,,
HC 3d Rendering W/Interp&Postproc Diff Work Station,PX-61000063,CDM,76377,CPT,610,RC,,,outpatient,,,422,295.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,94.739,836,other,SI=N Exclusions ,,
HC CT Scan-Limited/Localized F/U Study,PX-35000060,CDM,76380,CPT,350,RC,,,outpatient,,,928,649.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,71.24,712.704,fee schedule,,,
HC MRI Spectroscopy,PX-61000064,CDM,76390,CPT,610,RC,,,outpatient,,,2218,1552.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1565.65,,,1565.65,81.08,1703.424,fee schedule,,,
HC Magnetic Resonance Elastography,PX-61000090,CDM,76391,CPT,610,RC,,,outpatient,,,842,589.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,602.98,,,602.98,189.029,836,fee schedule,,,
HC Unlisted CT Procedure,PX-35000061,CDM,76497,CPT,350,RC,,,outpatient,,,229,160.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.4105,575,other,Unlisted Codes,,
HC US- Head- Real Time,PX-40200005,CDM,76506,CPT,402,RC,,,outpatient,,,433,303.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,97.2085,416.02,fee schedule,,,
HC US- Head/Neck Tissues-Real Time,PX-40200006,CDM,76536,CPT,402,RC,,,outpatient,,,444,310.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,99.678,416.02,fee schedule,,,
HC US- Chest-Real Time,PX-40200007,CDM,76604,CPT,402,RC,,,outpatient,,,417,291.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,93.6165,416.02,fee schedule,,,
HC US Breast Uni Real Time With Image Complete,PX-40200056,CDM,76641,CPT,402,RC,,,outpatient,,,385,269.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,86.4325,416.02,fee schedule,,,
HC US Breast Uni Real Time With Image Limited,PX-40200055,CDM,76642,CPT,402,RC,,,outpatient,,,353,247.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,71.24,416.02,fee schedule,,,
HC US- Abdom-B-Scan &/or Real Time-Complete,PX-40200009,CDM,76700,CPT,402,RC,,,outpatient,,,461,322.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,103.4945,416.02,fee schedule,,,
HC US- Abdomen Limited,PX-40200010,CDM,76705,CPT,402,RC,,,outpatient,,,341,238.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,76.5545,416.02,fee schedule,,,
HC Ultrasound Exam Aaa Screen,PX-40200002,CDM,76706,CPT,402,RC,,,outpatient,,,261,182.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,58.5945,416.02,fee schedule,,,
HC US-Retroperit- B-Scan/Real Time-Complete,PX-40200011,CDM,76770,CPT,402,RC,,,outpatient,,,368,257.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,82.616,416.02,fee schedule,,,
HC US- Retroperitnl Abd- Ltd,PX-40200012,CDM,76775,CPT,402,RC,,,outpatient,,,345,241.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,77.4525,416.02,fee schedule,,,
HC US- Spinal Canal & Contents,PX-40200014,CDM,76800,CPT,402,RC,,,outpatient,,,595,416.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,119.991125,456.96,fee schedule,,,
HC US- OB < 14 Wks- Single Fetus,PX-40200015,CDM,76801,CPT,402,RC,,,outpatient,,,289,202.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,64.8805,416.02,fee schedule,,,
HC US- OB < 14 Wks- Add'l Fetus,PX-40200016,CDM,76802,CPT,402,RC,,,outpatient,,,224,156.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,50.288,416.02,other,SI=N Exclusions ,,
HC US- OB >/= 14 Wks- Sngl Fetus,PX-40200017,CDM,76805,CPT,402,RC,,,outpatient,,,421,294.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,94.5145,416.02,fee schedule,,,
HC US- OB >/= 14 Wks- Addl Fetus,PX-40200018,CDM,76810,CPT,402,RC,,,outpatient,,,713,499.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,157.086513,547.584,other,SI=N Exclusions ,,
HC US-Preg Uter-Fet & Mat-+ Detl Fet Exm,PX-40200019,CDM,76811,CPT,402,RC,,,outpatient,,,725,507.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,263.66,,,263.66,162.7625,646.6965,fee schedule,,,
HC US-Preg Uter-Fet & Mat-+ Detl Fet-Addl,PX-40200020,CDM,76812,CPT,402,RC,,,outpatient,,,240,168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,53.88,416.02,other,SI=N Exclusions ,,
HC US-Pregnant Uterus-Limited- 1/> Fetuses,PX-40200021,CDM,76815,CPT,402,RC,,,outpatient,,,303,212.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,68.0235,416.02,fee schedule,,,
HC US-Pregnant Uterus-F/U-Transabd App,PX-40200022,CDM,76816,CPT,402,RC,,,outpatient,,,600,420,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,119.991125,460.8,fee schedule,,,
HC US-Pregnant Uterus-Transvaginal,PX-40200023,CDM,76817,CPT,402,RC,,,outpatient,,,355,248.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,79.6975,416.02,fee schedule,,,
HC Fetal Biophysical Profile,PX-40200024,CDM,76818,CPT,402,RC,,,outpatient,,,439,307.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,98.5555,416.02,fee schedule,,,
HC Fetal Biophys Prof-W/O Nst,PX-40200025,CDM,76819,CPT,402,RC,,,outpatient,,,358,250.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,80.371,416.02,fee schedule,,,
HC Doppler Fetal Umbilical Artery,PX-40200026,CDM,76820,CPT,402,RC,,,outpatient,,,290,203,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,65.105,416.02,fee schedule,,,
HC US-Pregnant Uterus-Limited- 1/> Fetuses,PX-40200028,CDM,76827,CPT,402,RC,,,outpatient,,,578,404.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,119.991125,443.904,fee schedule,,,
HC Sono Fetal Hrt Doppl F/U,PX-40200029,CDM,76828,CPT,402,RC,,,outpatient,,,146,102.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,32.777,416.02,fee schedule,,,
HC Echography-Transvaginal,PX-40200030,CDM,76830,CPT,402,RC,,,outpatient,,,365,255.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,81.9425,416.02,fee schedule,,,
HC Sono Exam- Hysterosonography,PX-40200031,CDM,76831,CPT,402,RC,,,outpatient,,,1006,704.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,263.66,,,263.66,199.512292,772.608,fee schedule,,,
HC Echo-Pelvic (Nonobstetric),PX-40200032,CDM,76856,CPT,402,RC,,,outpatient,,,361,252.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,81.0445,416.02,fee schedule,,,
HC Sono Pelvis Limited,PX-40200033,CDM,76857,CPT,402,RC,,,outpatient,,,332,232.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,74.534,416.02,fee schedule,,,
HC Echo-Scrotum & Contents,PX-40200034,CDM,76870,CPT,402,RC,,,outpatient,,,457,319.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,102.5965,416.02,fee schedule,,,
HC Echo-Transrectal,PX-40200035,CDM,76872,CPT,402,RC,,,outpatient,,,401,280.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,90.0245,416.02,fee schedule,,,
HC Echo-Transrectal-Prostate Vol,PX-40200036,CDM,76873,CPT,402,RC,,,outpatient,,,273,191.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,61.2885,416.02,fee schedule,,,
HC US-Extremity-Nonvascular-Real-Time Image-Complete,PX-40200037,CDM,76881,CPT,402,RC,,,outpatient,,,400,280,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,89.8,416.02,fee schedule,,,
HC US-Extremity-Nonvascular-Real-Time Image-Limited,PX-40200038,CDM,76882,CPT,402,RC,,,outpatient,,,253,177.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,56.7985,416.02,fee schedule,,,
HC US Inft Hips R-T Img Dynamic Req Phys/Qhp Manj,PX-40200039,CDM,76885,CPT,402,RC,,,outpatient,,,412,288.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,71.24,416.02,fee schedule,,,
HC US Inft Hips R-T Img Lmtd Static Phys/Qhp Manj,PX-40200040,CDM,76886,CPT,402,RC,,,outpatient,,,412,288.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,71.24,416.02,fee schedule,,,
HC US Guid-Comp Repair-Pseudo-Aneur/Av Fist,PX-40200041,CDM,76936,CPT,402,RC,,,outpatient,,,681,476.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,288.53,,,288.53,152.8845,775.5705,fee schedule,,,
HC US Guide- Vascular Access,PX-40200042,CDM,76937,CPT,402,RC,,,outpatient,,,251,175.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,56.3495,416.02,other,SI=N Exclusions ,,
HC US Guide- Tissue Ablation,PX-40200043,CDM,76940,CPT,402,RC,,,outpatient,,,460,322,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,103.27,416.02,other,SI=N Exclusions ,,
HC Sono Guide Needle Biopsy,PX-40200044,CDM,76942,CPT,402,RC,,,outpatient,,,868,607.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,166.37,666.624,other,SI=N Exclusions ,,
HC Sono Guide Amniocentesis,PX-40200045,CDM,76946,CPT,402,RC,,,outpatient,,,354,247.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,79.473,416.02,other,SI=N Exclusions ,,
HC US Guid-Comp Repair-Pseudo-Aneur/Av Fist,PX-40200048,CDM,76998,CPT,402,RC,,,outpatient,,,604,422.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,135.598,463.872,other,SI=N Exclusions ,,
HC Fluoroguide Cntrl Ven Access-Place-Replace-Remove,PX-32000217,CDM,77001,CPT,320,RC,,,outpatient,,,521,364.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,116.9645,416.02,other,SI=N Exclusions ,,
HC Fluoroscopic Guidance Needle Placement,PX-32000218,CDM,77002,CPT,320,RC,,,outpatient,,,318,222.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,71.391,416.02,other,SI=N Exclusions ,,
HC Fluorscopic Guidance Spinal Injection,PX-32000219,CDM,77003,CPT,320,RC,,,outpatient,,,518,362.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,116.291,416.02,other,SI=N Exclusions ,,
HC CT Guidance Stereotactic Localization,PX-35000062,CDM,77011,CPT,350,RC,,,outpatient,,,1801,1260.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,1383.168,other,SI=N Exclusions ,,
HC CT Guidance Needle Placement,PX-35000063,CDM,77012,CPT,350,RC,,,outpatient,,,1747,1222.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,63.344499,1341.696,other,SI=N Exclusions ,,
HC CT Guidance Tissue Ablation,PX-35000064,CDM,77013,CPT,350,RC,,,outpatient,,,1755,1228.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,63.344499,1347.84,other,SI=N Exclusions ,,
HC CT Guidance Placement Rad Therapy Fields,PX-35000065,CDM,77014,CPT,350,RC,,,outpatient,,,623,436.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,139.8635,575,other,SI=N Exclusions ,,
HC MRI Guidance Needle Placement,PX-61000066,CDM,77021,CPT,610,RC,,,outpatient,,,3092,2164.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,2374.656,other,SI=N Exclusions ,,
HC MRI Breast Without Contrast Material Unilateral,PX-61000083,CDM,77046,CPT,610,RC,,,outpatient,,,842,589.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,622.5,,,622.5,189.029,836,fee schedule,,,
HC MRI Breast Without Contrast Material Bilateral,PX-61000086,CDM,77047,CPT,610,RC,,,outpatient,,,842,589.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,622.5,,,622.5,189.029,836,fee schedule,,,
HC MRI Breast With Contrast W/Cad Unilateral,PX-61000084,CDM,77048,CPT,610,RC,,,outpatient,,,2118,1482.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1238.08,,,1238.08,399.547552,1936.896,fee schedule,,,
HC MRI Breast W/Out&With Contrast W/Cad Unilateral,PX-61000085,CDM,77048,CPT,610,RC,,,outpatient,,,2522,1765.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1238.08,,,1238.08,399.547552,1936.896,fee schedule,,,
HC MRI Breast With Contrast W/Cad Bilateral,PX-61000087,CDM,77049,CPT,610,RC,,,outpatient,,,2788,1951.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1232.02,,,1232.02,399.547552,2548.224,fee schedule,,,
HC MRI Breast W/Out&With Contrast W/Cad Bilateral,PX-61000088,CDM,77049,CPT,610,RC,,,outpatient,,,3318,2322.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1232.02,,,1232.02,399.547552,2548.224,fee schedule,,,
HC Digital Breast Tomosynthesis Unilateral,PX-40100006,CDM,77061,CPT,401,RC,,,outpatient,,,321,224.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,72.0645,416.02,other,Non Reimbursable Rates,,
HC Digital Breast Tomosynthesis Bilateral,PX-40100007,CDM,77062,CPT,401,RC,,,outpatient,,,393,275.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,88.2285,416.02,other,Non Reimbursable Rates,,
HC Screening Digital Breast Tomosynthesis Bi,PX-40300004,CDM,77063,CPT,403,RC,,,outpatient,,,202,141.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,44.94,,,44.94,22.99364,416.02,fee schedule,,,
HC Dx Mammo Incl Cad Uni,PX-40100008,CDM,77065,CPT,401,RC,,,outpatient,,,393,275.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,167.5,,,167.5,88.2285,416.02,fee schedule,,,
HC Dx Mammo Incl Cad Bi,PX-40100009,CDM,77066,CPT,401,RC,,,outpatient,,,466,326.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,214.37,,,214.37,90.800319,416.02,fee schedule,,,
HC Scr Mammo Bi Incl Cad,PX-40300005,CDM,77067,CPT,403,RC,,,outpatient,,,466,326.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,177.13,,,177.13,90.800319,416.02,fee schedule,,,
HC Manual Appl Stress Pfrmd Phys/Qhp Joint Films,PX-32000222,CDM,77071,CPT,320,RC,,,outpatient,,,262,183.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,58.819,416.02,fee schedule,,,
HC X-Rays for Bone Age,PX-32000223,CDM,77072,CPT,320,RC,,,outpatient,,,218,152.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,48.941,416.02,fee schedule,,,
HC X-Rays- Bone Length Studies,PX-32000224,CDM,77073,CPT,320,RC,,,outpatient,,,502,351.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,76.026473,416.02,fee schedule,,,
HC X-Rays- Bone Survey- Limited,PX-32000225,CDM,77074,CPT,320,RC,,,outpatient,,,502,351.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,112.699,416.02,fee schedule,,,
HC X-Rays- Bone Survey Complete,PX-32000226,CDM,77075,CPT,320,RC,,,outpatient,,,502,351.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,112.699,416.02,fee schedule,,,
HC X-Rays- Bone Survey- Infant,PX-32000227,CDM,77076,CPT,320,RC,,,outpatient,,,502,351.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,76.026473,416.02,fee schedule,,,
HC Dexa-Bone Density- 1 + Site- Axial Skeleton,PX-32000228,CDM,77080,CPT,320,RC,,,outpatient,,,575,402.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,128.66,,,128.66,119.991125,441.6,fee schedule,,,
HC Dexa-Bone Density- 1 + Site- Appendiculr Skeltn,PX-32000229,CDM,77081,CPT,320,RC,,,outpatient,,,114,79.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.24,,,71.24,25.593,416.02,fee schedule,,,
HC MRI- Bone Marrow,PX-61000070,CDM,77084,CPT,610,RC,,,outpatient,,,2406,1684.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,622.5,,,622.5,267.439885,1847.808,fee schedule,,,
HC Tbs Techl Prep&Transmis Data Alys Pfrmd Elsewhr,PX-32000262,CDM,77090,CPT,320,RC,,,outpatient,,,248,173.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,210.2,55.676,416.02,percent of total billed charges,,,
HC Tbs Technical Calculation Only,PX-32000263,CDM,77091,CPT,320,RC,,,outpatient,,,248,173.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,210.2,55.676,416.02,percent of total billed charges,,,
HC Thyroid Uptake Single/Multiple Quant Measurement,PX-34100001,CDM,78012,CPT,341,RC,,,outpatient,,,935,654.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,209.9075,1076.394,fee schedule,,,
HC Thyroid Imaging With Vascular Flow,PX-34100002,CDM,78013,CPT,341,RC,,,outpatient,,,633,443.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,142.1085,1076.394,fee schedule,,,
HC Thyroid Uptake W/Blood Flow Sngle/Mult Quan Meas,PX-34100003,CDM,78014,CPT,341,RC,,,outpatient,,,982,687.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,220.459,1076.394,fee schedule,,,
HC Thyroid Met Imaging Body,PX-34100005,CDM,78018,CPT,341,RC,,,outpatient,,,1049,734.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,520.91,,,520.91,235.5005,1397.122,fee schedule,,,
HC Thyroid Met Uptake,PX-34100006,CDM,78020,CPT,341,RC,,,outpatient,,,171,119.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,38.3895,416.02,other,SI=N Exclusions ,,
HC Parathyroid Planar Imaging,PX-34100007,CDM,78070,CPT,341,RC,,,outpatient,,,1575,1102.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,353.5875,1209.6,fee schedule,,,
HC Parathyroid Planar Imaging W/WO Subtraction,PX-34100008,CDM,78071,CPT,341,RC,,,outpatient,,,1357,949.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,304.6465,1076.394,fee schedule,,,
HC Parathyroid Imaging W/Tomographic Spect & CT,PX-34100009,CDM,78072,CPT,341,RC,,,outpatient,,,1898,1328.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,520.91,,,520.91,358.69,1457.664,fee schedule,,,
HC Adrenal Nuclear Imaging,PX-34100010,CDM,78075,CPT,341,RC,,,outpatient,,,2974,2081.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1405.87,,,1405.87,399.86,3675.6585,fee schedule,,,
HC Bone Marrow Imaging- Ltd,PX-34100011,CDM,78102,CPT,341,RC,,,outpatient,,,1403,982.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,314.9735,1077.504,fee schedule,,,
HC Bone Marrow Imaging- Mult,PX-34100012,CDM,78103,CPT,341,RC,,,outpatient,,,1403,982.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,314.9735,1077.504,fee schedule,,,
HC Bone Marrow Imaging- Body,PX-34100013,CDM,78104,CPT,341,RC,,,outpatient,,,659,461.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,147.9455,1076.394,fee schedule,,,
HC Spleen Imaging,PX-34100015,CDM,78185,CPT,341,RC,,,outpatient,,,971,679.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,217.9895,1076.394,fee schedule,,,
HC Lymphatics & Lymph Glands Imaging,PX-34100016,CDM,78195,CPT,341,RC,,,outpatient,,,1071,749.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,520.91,,,520.91,240.4395,1397.122,fee schedule,,,
HC Liver Imaging,PX-34100017,CDM,78201,CPT,341,RC,,,outpatient,,,2228,1559.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1405.87,,,1405.87,399.86,2239.93036,fee schedule,,,
HC Liver and Spleen Imaging,PX-34100021,CDM,78215,CPT,341,RC,,,outpatient,,,1205,843.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,270.5225,1076.394,fee schedule,,,
HC Hepatobiliary Syst Imaging Including Gallbladder,PX-34100023,CDM,78226,CPT,341,RC,,,outpatient,,,1384,968.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,310.708,1076.394,fee schedule,,,
HC Hepatobil Syst Imag Inc Gb W/Pharma Intervenj,PX-34100024,CDM,78227,CPT,341,RC,,,outpatient,,,1384,968.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,520.91,,,520.91,310.708,1397.122,fee schedule,,,
HC Serial Salivary Imaging,PX-34100025,CDM,78231,CPT,341,RC,,,outpatient,,,788,551.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,176.906,1076.394,fee schedule,,,
HC Gastroesophageal Reflux Exam,PX-34100027,CDM,78262,CPT,341,RC,,,outpatient,,,1043,730.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,234.1535,1076.394,fee schedule,,,
HC Gastric Emptying Study,PX-34100028,CDM,78264,CPT,341,RC,,,outpatient,,,838,586.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,188.131,1076.394,fee schedule,,,
HC Acute GI Blood Loss Imaging,PX-34100031,CDM,78278,CPT,341,RC,,,outpatient,,,2079,1455.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,399.86,1596.672,fee schedule,,,
HC Bowel Imaging,PX-34100032,CDM,78290,CPT,341,RC,,,outpatient,,,893,625.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,200.4785,1076.394,fee schedule,,,
HC Leveen/Shunt Patency Exam,PX-34100033,CDM,78291,CPT,341,RC,,,outpatient,,,954,667.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,214.173,1076.394,fee schedule,,,
HC Bone Imaging- Limited Area,PX-34100034,CDM,78300,CPT,341,RC,,,outpatient,,,962,673.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,215.969,1076.394,fee schedule,,,
HC Bone Imaging- Multiple Areas,PX-34100035,CDM,78305,CPT,341,RC,,,outpatient,,,1098,768.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,246.501,1076.394,fee schedule,,,
HC Bone Imaging- Whole Body,PX-34100036,CDM,78306,CPT,341,RC,,,outpatient,,,893,625.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,200.4785,1076.394,fee schedule,,,
HC Bone Imaging- 3 Phase,PX-34100037,CDM,78315,CPT,341,RC,,,outpatient,,,956,669.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,214.622,1076.394,fee schedule,,,
HC Myocardial Spect Single Study at Rest or Stress,PX-34100040,CDM,78451,CPT,341,RC,,,outpatient,,,4510,3157,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3319.26,,,3319.26,399.86,3675.6585,fee schedule,,,
HC Myocardial Spect Multiple Studies,PX-34100041,CDM,78452,CPT,341,RC,,,outpatient,,,4510,3157,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3319.26,,,3319.26,399.86,3675.6585,fee schedule,,,
HC Myocardial Perfusion Planar 1 Study Rest/Stress,PX-34100042,CDM,78453,CPT,341,RC,,,outpatient,,,3900,2730,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3319.26,,,3319.26,399.86,3675.6585,fee schedule,,,
HC Myocardial Perfusion Planar Multiple Studies,PX-34100043,CDM,78454,CPT,341,RC,,,outpatient,,,3900,2730,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3319.26,,,3319.26,399.86,3675.6585,fee schedule,,,
HC Gated Heart- Planar Single,PX-34100048,CDM,78472,CPT,341,RC,,,outpatient,,,1586,1110.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,954.41,,,954.41,356.057,1218.048,fee schedule,,,
HC Heart Image- Spect,PX-34100050,CDM,78494,CPT,341,RC,,,outpatient,,,1671,1169.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,954.41,,,954.41,375.1395,1283.328,fee schedule,,,
HC Pulmonary Ventilation Imaging,PX-34100052,CDM,78579,CPT,341,RC,,,outpatient,,,767,536.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,172.1915,1076.394,fee schedule,,,
HC Lung Perfusion Imaging,PX-34100053,CDM,78580,CPT,341,RC,,,outpatient,,,640,448,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,143.68,1076.394,fee schedule,,,
HC Pulmonary Ventilation & Perfusion Imaging,PX-34100054,CDM,78582,CPT,341,RC,,,outpatient,,,946,662.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,520.91,,,520.91,212.377,1397.122,fee schedule,,,
HC Quant Differential Pulm Perfusion W/WO Imaging,PX-34100055,CDM,78597,CPT,341,RC,,,outpatient,,,902,631.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,202.499,1076.394,fee schedule,,,
HC Quant Diff Pulm Prfusion & Ventlaj W/WO Imaging,PX-34100056,CDM,78598,CPT,341,RC,,,outpatient,,,1499,1049.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,520.91,,,520.91,336.5255,1397.122,fee schedule,,,
HC Brain Imaging < 4 Static Views W Vascular Flow,PX-34100058,CDM,78601,CPT,341,RC,,,outpatient,,,2704,1892.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,399.86,2076.672,fee schedule,,,
HC Brain Imaging Min 4 Static Views W Vascular Flow,PX-34100059,CDM,78606,CPT,341,RC,,,outpatient,,,1589,1112.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,520.91,,,520.91,356.7305,1397.122,fee schedule,,,
HC Brain Imaging Pet Metabolic,PX-40400003,CDM,78608,CPT,404,RC,,,outpatient,,,4890,3423,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3713.88,,,3713.88,399.86,3755.52,fee schedule,,,
HC CSF Fluid Scan Cisternography,PX-34100061,CDM,78630,CPT,341,RC,,,outpatient,,,2570,1799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,520.91,,,520.91,399.86,1973.76,fee schedule,,,
HC CSF Shunt Evaluation,PX-34100062,CDM,78645,CPT,341,RC,,,outpatient,,,916,641.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,520.91,,,520.91,205.642,1397.122,fee schedule,,,
HC CSF Leakage Detection & Localization,PX-34100063,CDM,78650,CPT,341,RC,,,outpatient,,,3215,2250.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1405.87,,,1405.87,399.86,3675.6585,fee schedule,,,
HC Renal Imaging- Static,PX-34100064,CDM,78700,CPT,341,RC,,,outpatient,,,1292,904.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,290.054,1076.394,fee schedule,,,
HC Renal Flow/Funct Imaging,PX-34100065,CDM,78707,CPT,341,RC,,,outpatient,,,1210,847,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,520.91,,,520.91,271.645,1397.122,fee schedule,,,
HC Renal Flow/Funct Image-Pharm Rx,PX-34100066,CDM,78708,CPT,341,RC,,,outpatient,,,899,629.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,520.91,,,520.91,201.8255,1397.122,fee schedule,,,
HC Testicular Imaging & Flow,PX-34100069,CDM,78761,CPT,341,RC,,,outpatient,,,845,591.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,189.7025,1076.394,fee schedule,,,
HC Tumor Imaging- Limited Area,PX-34100070,CDM,78800,CPT,341,RC,,,outpatient,,,867,606.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,194.6415,1076.394,fee schedule,,,
HC Tumor Imaging- Whole Body- Single Day,PX-34100072,CDM,78802,CPT,341,RC,,,outpatient,,,3124,2186.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1405.87,,,1405.87,399.86,3675.6585,fee schedule,,,
HC Tumor Imaging Spect,PX-34100073,CDM,78803,CPT,341,RC,,,outpatient,,,2419,1693.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,520.91,,,520.91,399.86,3675.6585,fee schedule,,,
HC Tumor Imaging- Whole Body- 2 or More Days,PX-34100074,CDM,78804,CPT,341,RC,,,outpatient,,,2916,2041.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1405.87,,,1405.87,399.86,3675.6585,fee schedule,,,
HC Inject Radiopharm Non-Imaging Localization- IV,PX-34100080,CDM,78808,CPT,341,RC,,,outpatient,,,1227,858.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,404.24,,,404.24,275.4615,1076.394,fee schedule,,,
HC Pet Imaging CT for Attenuation Limited Area,PX-40400004,CDM,78814,CPT,404,RC,,,outpatient,,,5186,3630.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3713.88,,,3713.88,399.86,3982.848,fee schedule,,,
HC Pet Imaging CT Attenuation Skull Base Mid-Thigh,PX-40400005,CDM,78815,CPT,404,RC,,,outpatient,,,6904,4832.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3713.88,,,3713.88,399.86,5302.272,fee schedule,,,
HC Pet Imaging for CT Attenuation Whole Body,PX-40400006,CDM,78816,CPT,404,RC,,,outpatient,,,7705,5393.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3713.88,,,3713.88,399.86,5917.44,fee schedule,,,
HC Rp Loclzj Tum Spect W/CT 1 Area 1 Day Imaging,PX-34100081,CDM,78830,CPT,341,RC,,,outpatient,,,4318,3022.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3291.82,,,3291.82,399.86,3675.6585,fee schedule,,,
HC Rp Loclzj Tum Spect 2 Area 1d Img/1 Area Img>2+D,PX-34100082,CDM,78831,CPT,341,RC,,,outpatient,,,4318,3022.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3291.82,,,3291.82,399.86,3675.6585,fee schedule,,,
HC Rp Loclzj Tum Spect CT 2area 1d Img/1 AR Img>2+D,PX-34100083,CDM,78832,CPT,341,RC,,,outpatient,,,4899,3429.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3734.2,,,3734.2,399.86,4124.5085,fee schedule,,,
HC Radiopharmaceutical Quantification Meas 1 Area,PX-34100084,CDM,78835,CPT,341,RC,,,outpatient,,,203,142.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,45.5735,416.02,other,SI=N Exclusions ,,
HC Nuclear Therapy- Oral,PX-34200001,CDM,79005,CPT,342,RC,,,outpatient,,,782,547.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,264.04,,,264.04,175.559,691.5815,fee schedule,,,
HC Urinalysis- Auto- W/O Scope,PX-30000067,CDM,81003,CPT,300,RC,,,outpatient,,,32,22.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4.58,,,4.58,2.29,24.576,fee schedule,,,
HC Urine Pregnancy Test,PX-30000713,CDM,81025,CPT,300,RC,,,outpatient,,,28,19.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13.75,,,13.75,6.286,21.504,fee schedule,,,
HC Molecular Pathology Procedure Level 4,PX-30000097,CDM,81403,CPT,300,RC,,,outpatient,,,716,501.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,294.44,,,294.44,160.742,549.888,fee schedule,,,
HC Blood Occult-by Peroxid- Feces- 1-3 Simult- Non Ca Screen,PX-30000715,CDM,82272,CPT,300,RC,,,outpatient,,,24,16.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,6.87,,,6.87,3.33,18.432,fee schedule,,,
HC Glucose Blood Test,PX-30000221,CDM,82962,CPT,300,RC,,,outpatient,,,45,31.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5.16,,,5.16,2.4,34.56,fee schedule,,,
HC Bone Marrow-Smear Interpretation,PX-31000012,CDM,85097,CPT,310,RC,,,outpatient,,,1038,726.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,638.24,,,638.24,39.73,1313.895373,fee schedule,,,
HC Coagulation Time- Activated,PX-30000417,CDM,85347,CPT,300,RC,,,outpatient,,,80,56,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,8.59,,,8.59,4.35,61.44,fee schedule,,,
HC Hgb/Rbcs Fetal Fetomaternal Hemrrg Rosette,PX-30000732,CDM,85461,CPT,300,RC,,,outpatient,,,32,22.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14.89,,,14.89,6.78,24.576,fee schedule,,,
HC Sickling RBC Reduction,PX-30000730,CDM,85660,CPT,300,RC,,,outpatient,,,25,17.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10.88,,,10.88,5.6125,19.2,fee schedule,,,
HC Platelet Antibodies,PX-30000453,CDM,86022,CPT,300,RC,,,outpatient,,,128,89.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36.09,,,36.09,18.77,98.304,fee schedule,,,
HC Cold Agglutinin Screen,PX-30000465,CDM,86156,CPT,300,RC,,,outpatient,,,158,110.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13.18,,,13.18,6.51,121.344,fee schedule,,,
HC Cold Agglutinin- Titer,PX-30000466,CDM,86157,CPT,300,RC,,,outpatient,,,29,20.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16.04,,,16.04,6.5105,24.43,fee schedule,,,
HC Leukocyte Phagocytosis,PX-30000866,CDM,86344,CPT,300,RC,,,outpatient,,,33,23.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16.61,,,16.61,7.4085,25.344,fee schedule,,,
HC Cmv Antibody,PX-30000526,CDM,86644,CPT,300,RC,,,outpatient,,,155,108.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28.07,,,28.07,14.71,119.04,fee schedule,,,
HC Hla Typing- a-B-or C /Single,PX-30000582,CDM,86812,CPT,300,RC,,,outpatient,,,252,176.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,50.41,,,50.41,26.37,193.536,fee schedule,,,
HC Hla Typing Dr/Dq Single Antigen,PX-30000731,CDM,86816,CPT,300,RC,,,outpatient,,,124,86.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,54.42,,,54.42,27.838,95.232,fee schedule,,,
HC Hla Typing- Dr/Dq-Multi Antgn,PX-30000584,CDM,86817,CPT,300,RC,,,outpatient,,,287,200.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,168.99,,,168.99,64.4315,241.472,fee schedule,,,
HC RBC Antibody Screen,PX-30000585,CDM,86850,CPT,300,RC,,,outpatient,,,99,69.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,58.3,,,58.3,6.25,92.88556,fee schedule,,,
HC RBC Antibody Elution,PX-30000586,CDM,86860,CPT,300,RC,,,outpatient,,,358,250.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,165.51,,,165.51,2.072,274.944,fee schedule,,,
HC RBC Antibody Identification,PX-30000587,CDM,86870,CPT,300,RC,,,outpatient,,,501,350.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,313.59,,,313.59,2.842,549.235176,fee schedule,,,
HC Antihuman Globulin Dir Ea Antiserum,PX-30000588,CDM,86880,CPT,300,RC,,,outpatient,,,117,81.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36.73,,,36.73,5.5,93.463636,fee schedule,,,
HC Antihuman Globulin Indir Qual Ea Reagent Cell,PX-30000589,CDM,86885,CPT,300,RC,,,outpatient,,,357,249.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,165.51,,,165.51,5.85,274.176,fee schedule,,,
HC Antihuman Globulin Indirect Ea Antibody Titer,PX-30000590,CDM,86886,CPT,300,RC,,,outpatient,,,357,249.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,165.51,,,165.51,5.29,274.176,fee schedule,,,
HC Blood Typing- Abo,PX-30000592,CDM,86900,CPT,300,RC,,,outpatient,,,208,145.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,121.77,,,121.77,3.05,195.186327,fee schedule,,,
HC Blood Typing- Rh (D),PX-30000593,CDM,86901,CPT,300,RC,,,outpatient,,,85,59.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36.73,,,36.73,3.05,65.28,fee schedule,,,
HC Blood Type Antigen Donor Reagent Serum- Ea Antigen,PX-30000594,CDM,86902,CPT,300,RC,,,outpatient,,,628,439.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,313.59,,,313.59,3.91,549.235176,fee schedule,,,
HC Blood Typing Antigen Screen Patient Serum/Unit,PX-30000718,CDM,86904,CPT,300,RC,,,outpatient,,,311,217.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36.73,,,36.73,9.71,238.848,fee schedule,,,
HC Blood Typing- RBC Antigens,PX-30000595,CDM,86905,CPT,300,RC,,,outpatient,,,628,439.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,313.59,,,313.59,3.91,549.235176,fee schedule,,,
HC Blood Typing Serologic Rh Phenotyping Complete,PX-30000719,CDM,86906,CPT,300,RC,,,outpatient,,,284,198.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36.73,,,36.73,7.91,218.112,fee schedule,,,
HC Compatibility Test-Spin Tech,PX-30000596,CDM,86920,CPT,300,RC,,,outpatient,,,355,248.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,165.51,,,165.51,2.31,272.64,fee schedule,,,
HC Compatibility Test-Incub Tech,PX-30000597,CDM,86921,CPT,300,RC,,,outpatient,,,357,249.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,165.51,,,165.51,2.072,274.176,fee schedule,,,
HC Compatibility Test-Antiglob Tech,PX-30000598,CDM,86922,CPT,300,RC,,,outpatient,,,357,249.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,165.51,,,165.51,2.45,274.176,fee schedule,,,
HC Compatibility Test- Electronic,PX-30000599,CDM,86923,CPT,300,RC,,,outpatient,,,357,249.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,165.51,,,165.51,1.862,274.176,fee schedule,,,
HC Plasma- Fresh Frozen,PX-30000600,CDM,86927,CPT,300,RC,,,outpatient,,,312,218.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,165.51,,,165.51,1.302,263.69806,fee schedule,,,
HC Blood Product/Irradiation,PX-39100002,CDM,86945,CPT,391,RC,,,outpatient,,,116,81.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36.73,,,36.73,1.932,416.02,fee schedule,,,
HC Pretx RBC Antibody Incubat W/Chem Agnts/Drugs Ea,PX-30000729,CDM,86970,CPT,300,RC,,,outpatient,,,110,77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36.73,,,36.73,1.932,93.463636,fee schedule,,,
HC Pretx RBC Antibody Incubat W/Enzymes Each,PX-30000726,CDM,86971,CPT,300,RC,,,outpatient,,,560,392,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,313.59,,,313.59,1.54,499.62884,fee schedule,,,
HC Pretx RBC Antibody Incubat W/Density Grad Sep,PX-30000727,CDM,86972,CPT,300,RC,,,outpatient,,,358,250.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,171.41,,,171.41,2.702,274.944,fee schedule,,,
HC Pretx Serum RBC Antibody Incubation Drugs Each,PX-30000725,CDM,86975,CPT,300,RC,,,outpatient,,,358,250.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36.73,,,36.73,2.072,608.812631,fee schedule,,,
HC Pretx Serum RBC Antibody Identification Dilution,PX-30000724,CDM,86976,CPT,300,RC,,,outpatient,,,311,217.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19.63,,,19.63,2.31,238.848,fee schedule,,,
HC Pretx Serum RBC Antb ID Incubation Inhibitors Ea,PX-30000734,CDM,86977,CPT,300,RC,,,outpatient,,,509,356.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,165.51,,,165.51,2.31,416.02,fee schedule,,,
HC RBC Pretreatment-Serum Inhib,PX-39100003,CDM,86977,CPT,391,RC,,,outpatient,,,509,356.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,165.51,,,165.51,2.31,416.02,fee schedule,,,
HC Pretx Serum RBC Antibody ID Diffial Each Absrpj,PX-30000723,CDM,86978,CPT,300,RC,,,outpatient,,,311,217.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36.73,,,36.73,2.31,238.848,fee schedule,,,
HC Unlisted Transfusion Medicine Procedure,PX-30000728,CDM,86999,CPT,300,RC,,,outpatient,,,299,209.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.68,229.632,other,Unlisted Codes,,
HC Strep a Assay W/Optic,PX-30000714,CDM,87880,CPT,300,RC,,,outpatient,,,52,36.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26.35,,,26.35,11.674,39.936,fee schedule,,,
HC Sperm Isolation- Simple,PX-31000079,CDM,89260,CPT,310,RC,,,outpatient,,,210,147,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,58.3,,,58.3,47.145,416.02,fee schedule,,,
HC Sperm Isolation- Complex,PX-30000709,CDM,89261,CPT,300,RC,,,outpatient,,,152,106.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,58.3,,,58.3,34.124,116.736,fee schedule,,,
HC Semen Analysis-Volume- Count- Motility- Diff,PX-30000711,CDM,89320,CPT,300,RC,,,outpatient,,,58,40.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23.49,,,23.49,12.32,44.544,fee schedule,,,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4203-02,NDC,outpatient,5,ML,2200.75,1540.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,139.93,,,139.93,139.93,1690.176,fee schedule,,,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4202-01,NDC,outpatient,1,ML,650.46,455.322,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,139.93,,,139.93,139.93,1690.176,fee schedule,,,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4202-02,NDC,outpatient,1,ML,650.46,455.322,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,139.93,,,139.93,139.93,1690.176,fee schedule,,,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4203-01,NDC,outpatient,5,ML,2200.75,1540.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,139.93,,,139.93,139.93,1690.176,fee schedule,,,
RABIES IMMUNE GLOBULIN 300 UNIT/ML IJ SOLN,RX-142826,CDM,90375,HCPCS,636,RC,13533-0318-10,NDC,outpatient,1,ML,1554.22,1087.954,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,287.71,,,287.71,287.71,7105.5744,fee schedule,,,
RABIES IMMUNE GLOBULIN 300 UNIT/ML IJ SOLN,RX-142826,CDM,90375,HCPCS,636,RC,13533-0318-01,NDC,outpatient,1,ML,1554.22,1087.954,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,287.71,,,287.71,287.71,7105.5744,fee schedule,,,
RABIES IMMUNE GLOBULIN 1500 UNIT/5ML IJ SOLN,RX-142827,CDM,90375,HCPCS,636,RC,13533-0318-05,NDC,outpatient,5,ML,7771.09,5439.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,287.71,,,287.71,287.71,7105.5744,fee schedule,,,
RABIES IMMUNE GLOBULIN 1500 UNIT/5ML IJ SOLN,RX-142827,CDM,90375,HCPCS,636,RC,13533-0318-50,NDC,outpatient,5,ML,7771.09,5439.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,287.71,,,287.71,287.71,7105.5744,fee schedule,,,
RABIES IMMUNE GLOBULIN 900 UNIT/3ML IJ SOLN,RX-150138,CDM,90375,HCPCS,636,RC,13533-0318-03,NDC,outpatient,3,ML,4662.66,3263.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,287.71,,,287.71,287.71,7105.5744,fee schedule,,,
RABIES IMMUNE GLOBULIN 900 UNIT/3ML IJ SOLN,RX-150138,CDM,90375,HCPCS,636,RC,13533-0318-30,NDC,outpatient,3,ML,4662.66,3263.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,287.71,,,287.71,287.71,7105.5744,fee schedule,,,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-10,NDC,outpatient,10,ML,9252.05,6476.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,287.71,,,287.71,287.71,7105.5744,fee schedule,,,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-11,NDC,outpatient,10,ML,9252.05,6476.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,287.71,,,287.71,287.71,7105.5744,fee schedule,,,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-02,NDC,outpatient,2,ML,1850.42,1295.294,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,287.71,,,287.71,287.71,7105.5744,fee schedule,,,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-20,NDC,outpatient,2,ML,1850.42,1295.294,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,287.71,,,287.71,287.71,7105.5744,fee schedule,,,
PALIVIZUMAB 50 MG/0.5ML IM SOLN,RX-108060,CDM,90378,HCPCS,636,RC,66658-0230-01,NDC,outpatient,0.5,ML,5025.03,3517.521,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2075.55,,,2075.55,389.10344,4791.979,fee schedule,,,
RHO D IMMUNE GLOBULIN 1500 UNIT/2ML IJ SOSY,RX-129748,CDM,90384,HCPCS,636,RC,44206-0300-10,NDC,outpatient,2,ML,207.1,144.97,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,94.43,,,94.43,0.5,416.02,fee schedule,,,
RHO D IMMUNE GLOBULIN 1500 UNIT/2ML IJ SOSY,RX-129748,CDM,90384,HCPCS,636,RC,44206-0300-90,NDC,outpatient,2,ML,78.48,54.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,94.43,,,94.43,0.5,416.02,fee schedule,,,
RHO D IMMUNE GLOBULIN 1500 UNIT/2ML IJ SOSY,RX-129748,CDM,90384,HCPCS,636,RC,44206-0300-01,NDC,outpatient,2,ML,207.1,144.97,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,94.43,,,94.43,0.5,416.02,fee schedule,,,
HC Immuniz Admin-1 Single/Comb Vac/Toxoid,PX-77100004,CDM,90471,CPT,771,RC,,,outpatient,,,193,135.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,72.39,,,72.39,43.3285,416.02,fee schedule,,,
HC Immuniz-Admin-Each Addl,PX-77100008,CDM,90472,CPT,771,RC,,,outpatient,,,73,51.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,16.3885,416.02,other,SI=N Exclusions ,,
HC Admn Sarscov2 Vacc 1 Dose,PX-77100044,CDM,90480,CPT,771,RC,,,outpatient,,,111,77.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,94.08,24.9195,416.02,percent of total billed charges,,,
MENINGOCOCCAL B RECOMB OMV ADJ IM SUSY,RX-129389,CDM,90620,HCPCS,636,RC,58160-0976-02,NDC,outpatient,0.5,ML,874.41,612.087,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,268.35,,,268.35,0.5,671.54688,fee schedule,,,
MENINGOCOCCAL B RECOMB OMV ADJ IM SUSY,RX-129389,CDM,90620,HCPCS,636,RC,58160-0976-20,NDC,outpatient,0.5,ML,874.41,612.087,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,268.35,,,268.35,0.5,671.54688,fee schedule,,,
HEPATITIS A VACCINE 1440 EL U/ML IM SUSP,RX-91034,CDM,90632,HCPCS,636,RC,58160-0826-52,NDC,outpatient,1,ML,337.61,236.327,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,70.48,416.02,other,SI=N Exclusions ,,
HEPATITIS A VACCINE 1440 EL U/ML IM SUSP,RX-91034,CDM,90632,HCPCS,636,RC,58160-0826-43,NDC,outpatient,1,ML,337.61,236.327,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,70.48,416.02,other,SI=N Exclusions ,,
HEPATITIS A VACCINE 720 EL U/0.5ML IM SUSP,RX-91033,CDM,90633,HCPCS,636,RC,58160-0825-43,NDC,outpatient,0.5,ML,155.01,108.507,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,34.799745,416.02,other,SI=N Exclusions ,,
HEPATITIS A VACCINE 720 EL U/0.5ML IM SUSP,RX-91033,CDM,90633,HCPCS,636,RC,58160-0825-52,NDC,outpatient,0.5,ML,155.01,108.507,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,34.799745,416.02,other,SI=N Exclusions ,,
HAEMOPHILUS B POLYSAC CONJ VAC IM SOLR,RX-11931,CDM,90648,HCPCS,636,RC,49281-0545-03,NDC,outpatient,1,UN,49.34,34.538,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,11.07683,416.02,other,SI=N Exclusions ,,
HAEMOPHILUS B POLYSAC CONJ VAC IM SOLR,RX-11931,CDM,90648,HCPCS,636,RC,49281-0547-58,NDC,outpatient,1,UN,49.34,34.538,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,11.07683,416.02,other,SI=N Exclusions ,,
HPV 9-VALENT RECOMB VACCINE IM SUSY,RX-129114,CDM,90651,HCPCS,636,RC,00006-4121-02,NDC,outpatient,0.5,ML,1147.17,803.019,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,368.98,,,368.98,0.5,881.02656,fee schedule,,,
HPV 9-VALENT RECOMB VACCINE IM SUSY,RX-129114,CDM,90651,HCPCS,636,RC,00006-4121-01,NDC,outpatient,0.5,ML,1147.17,803.019,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,368.98,,,368.98,0.5,881.02656,fee schedule,,,
INFLUENZA VAC SUBUNIT QUAD 0.5 ML IM SUSY,RX-135284,CDM,90674,HCPCS,636,RC,70461-0323-03,NDC,outpatient,0.5,ML,94.26,65.982,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,35.97,,,35.97,0.5,416.02,fee schedule,,,
INFLUENZA VAC SUBUNIT QUAD 0.5 ML IM SUSY,RX-135284,CDM,90674,HCPCS,636,RC,70461-0323-04,NDC,outpatient,0.5,ML,94.26,65.982,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,35.97,,,35.97,0.5,416.02,fee schedule,,,
RABIES VACCINE WRAPPER,RX-4080220,CDM,90675,HCPCS,636,RC,50632-0010-01,NDC,outpatient,1,UN,1460.49,1022.343,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,350.14,,,350.14,91.911626,1316.02176,fee schedule,,,
RABIES VACCINE WRAPPER,RX-4080220,CDM,90675,HCPCS,636,RC,49281-0252-51,NDC,outpatient,1,UN,1713.57,1199.499,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,350.14,,,350.14,91.911626,1316.02176,fee schedule,,,
RABIES VACCINE WRAPPER,RX-4080220,CDM,90675,HCPCS,636,RC,50632-0013-01,NDC,outpatient,1,UN,1460.49,1022.343,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,350.14,,,350.14,91.911626,1316.02176,fee schedule,,,
PNEUMOCOCCAL 20-VAL CONJ VACC 0.5 ML IM SUSY,RX-156044,CDM,90677,HCPCS,636,RC,00005-2000-02,NDC,outpatient,0.5,ML,1098.4,768.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,298.04,,,298.04,0.5,843.5712,fee schedule,,,
INFLUENZA VAC A&B SA ADJ QUAD 0.5 ML IM PRSY,RX-150230,CDM,90694,HCPCS,636,RC,70461-0123-04,NDC,outpatient,0.5,ML,241.68,169.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,81.43,,,81.43,0.5,416.02,fee schedule,,,
INFLUENZA VAC A&B SA ADJ QUAD 0.5 ML IM PRSY,RX-150230,CDM,90694,HCPCS,636,RC,70461-0123-03,NDC,outpatient,0.5,ML,241.68,169.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,81.43,,,81.43,0.5,416.02,fee schedule,,,
DIPHTH-ACELL PERTUSSIS-TETANUS 15-23-5 LF-MCG/0.5 IM SUSP,RX-140528,CDM,90700,HCPCS,636,RC,49281-0286-10,NDC,outpatient,0.5,ML,107.51,75.257,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,24.135995,416.02,other,SI=N Exclusions ,,
DIPHTH-ACELL PERTUSSIS-TETANUS 15-23-5 LF-MCG/0.5 IM SUSP,RX-140528,CDM,90700,HCPCS,636,RC,49281-0286-58,NDC,outpatient,0.5,ML,107.51,75.257,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,24.135995,416.02,other,SI=N Exclusions ,,
MEASLES- MUMPS & RUBELLA VAC IJ SOLR,RX-148019,CDM,90707,HCPCS,636,RC,00006-4681-01,NDC,outpatient,1,UN,362.53,253.771,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,54.47,416.02,other,SI=N Exclusions ,,
MEASLES- MUMPS & RUBELLA VAC IJ SOLR,RX-148019,CDM,90707,HCPCS,636,RC,00006-4681-00,NDC,outpatient,1,UN,362.53,253.771,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,54.47,416.02,other,SI=N Exclusions ,,
POLIOVIRUS VACCINE INACTIVATED IJ INJ,RX-108127,CDM,90713,HCPCS,636,RC,49281-0860-10,NDC,outpatient,0.5,ML,163.66,114.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,25.298577,416.02,other,SI=N Exclusions ,,
POLIOVIRUS VACCINE INACTIVATED IJ INJ,RX-108127,CDM,90713,HCPCS,636,RC,49281-0860-78,NDC,outpatient,0.5,ML,163.66,114.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,25.298577,416.02,other,SI=N Exclusions ,,
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,58160-0842-01,NDC,outpatient,0.5,ML,193.78,135.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,25.298577,416.02,other,SI=N Exclusions ,,
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,49281-0400-10,NDC,outpatient,0.5,ML,187.93,131.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,25.298577,416.02,other,SI=N Exclusions ,,
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,49281-0400-58,NDC,outpatient,0.5,ML,187.93,131.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,25.298577,416.02,other,SI=N Exclusions ,,
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,58160-0842-11,NDC,outpatient,0.5,ML,193.78,135.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,25.298577,416.02,other,SI=N Exclusions ,,
VARICELLA VIRUS VACCINE LIVE 1350 PFU/0.5ML SC INJ,RX-113088,CDM,90716,HCPCS,636,RC,00006-4827-01,NDC,outpatient,1,UN,737.12,515.984,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,219.45,,,219.45,0.5,566.10816,fee schedule,,,
VARICELLA VIRUS VACCINE LIVE 1350 PFU/0.5ML SC INJ,RX-113088,CDM,90716,HCPCS,636,RC,00006-4827-00,NDC,outpatient,1,UN,737.12,515.984,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,219.45,,,219.45,0.5,566.10816,fee schedule,,,
DTAP-HEPATITIS B RECOMB-IPV IM SUSY,RX-158218,CDM,90723,HCPCS,636,RC,58160-0811-43,NDC,outpatient,0.5,ML,392.47,274.729,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,116.81,,,116.81,0.5,416.02,fee schedule,,,
DTAP-HEPATITIS B RECOMB-IPV IM SUSY,RX-158218,CDM,90723,HCPCS,636,RC,58160-0811-52,NDC,outpatient,0.5,ML,392.47,274.729,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,116.81,,,116.81,0.5,416.02,fee schedule,,,
MENINGOCOCCAL A C Y&W-135 OLIG IM SOLN,RX-161800,CDM,90734,HCPCS,636,RC,58160-0827-03,NDC,outpatient,0.5,ML,640.81,448.567,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,188.67,,,188.67,0.5,492.14208,fee schedule,,,
MENINGOCOCCAL A C Y&W-135 OLIG IM SOLN,RX-161800,CDM,90734,HCPCS,636,RC,58160-0827-30,NDC,outpatient,0.5,ML,640.81,448.567,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,188.67,,,188.67,0.5,492.14208,fee schedule,,,
HEPATITIS B VAC RECOMB ADJ 20 MCG/0.5ML IM SOSY,RX-143904,CDM,90739,HCPCS,636,RC,43528-0003-01,NDC,outpatient,0.5,ML,537.53,376.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,168.3,,,168.3,0.5,416.02,fee schedule,,,
HEPATITIS B VAC RECOMB ADJ 20 MCG/0.5ML IM SOSY,RX-143904,CDM,90739,HCPCS,636,RC,43528-0003-05,NDC,outpatient,0.5,ML,537.53,376.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,168.3,,,168.3,0.5,416.02,fee schedule,,,
HC Esophageal Motility Study- Manometry,PX-92000004,CDM,91010,CPT,920,RC,,,outpatient,,,1126,788.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,620.59,,,620.59,252.787,1055.807021,fee schedule,,,
HC Gerd Tst W/ Mucos Ph Electrod,PX-92000007,CDM,91035,CPT,920,RC,,,outpatient,,,1775,1242.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,620.59,,,620.59,398.4875,1363.2,fee schedule,,,
HC GI Trc Img Intraluminal Esophagus-Ileum W/I&R,PX-75000005,CDM,91110,CPT,750,RC,,,outpatient,,,3922,2745.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1038.09,,,1038.09,399.86,3012.096,fee schedule,,,
HC GI Imag Intraluminal Esophagus-Ileum W/I&R,PX-92000008,CDM,91110,CPT,920,RC,,,outpatient,,,3922,2745.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1038.09,,,1038.09,399.86,3012.096,fee schedule,,,
HC Rectal Sesation Tone & Compliance Test,PX-36900666,CDM,91120,CPT,369,RC,,,outpatient,,,752,526.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,185.32,,,185.32,168.824,1592,fee schedule,,,
HC Anal Pressure Record,PX-36900541,CDM,91122,CPT,920,RC,,,outpatient,,,1360,952,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,315.45,,,315.45,305.32,1592,fee schedule,,,
COVID-19 MRNA VACC (MODERNA) 50 MCG/0.5ML IM SUSY,RX-165852,CDM,91322,HCPCS,636,RC,80777-0102-01,NDC,outpatient,0.5,ML,492.72,344.904,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,417.63,0.5,417.629472,percent of total billed charges,,,
COVID-19 MRNA VACC (MODERNA) 50 MCG/0.5ML IM SUSY,RX-165852,CDM,91322,HCPCS,636,RC,80777-0102-93,NDC,outpatient,0.5,ML,492.72,344.904,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,417.63,0.5,417.629472,percent of total billed charges,,,
HC Eye Photography,PX-92000009,CDM,92285,CPT,920,RC,,,outpatient,,,80,56,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,76.19,,,76.19,17.96,416.02,fee schedule,,,
HC Caloric Vestibular Test Bilateral- Bithermal,PX-47100041,CDM,92537,CPT,471,RC,,,outpatient,,,1270,889,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,185.32,,,185.32,163,975.36,fee schedule,,,
HC Caloric Vestibular Test Bilateral- Monothermal,PX-47100042,CDM,92538,CPT,471,RC,,,outpatient,,,882,617.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,185.32,,,185.32,163,677.376,fee schedule,,,
HC Vestibular Eval Nystag Fovl&Perph Stim Oscil Tracking,PX-47000010,CDM,92540,CPT,470,RC,,,outpatient,,,550,385,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,185.32,,,185.32,123.475,422.4,fee schedule,,,
HC Spontaneous Nystagmus Test,PX-47000011,CDM,92541,CPT,470,RC,,,outpatient,,,155,108.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,34.7975,416.02,fee schedule,,,
HC Positional Nystagmus Test,PX-47000012,CDM,92542,CPT,470,RC,,,outpatient,,,155,108.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,34.7975,416.02,fee schedule,,,
HC Optokinetic Nystagmus Test- Bidirec- Foveal- Periph- W Record,PX-47000014,CDM,92544,CPT,470,RC,,,outpatient,,,155,108.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,185.32,,,185.32,34.7975,416.02,fee schedule,,,
HC Oscillating Tracking Test,PX-47000015,CDM,92545,CPT,470,RC,,,outpatient,,,696,487.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,185.32,,,185.32,142.97,534.528,fee schedule,,,
HC Supplemental Electrical Test,PX-47100012,CDM,92547,CPT,471,RC,,,outpatient,,,225,157.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,50.5125,416.02,other,SI=N Exclusions ,,
HC Tympanometry and Reflex Threshold Measurements,PX-47100013,CDM,92550,CPT,471,RC,,,outpatient,,,269,188.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,185.32,,,185.32,60.3905,416.02,fee schedule,,,
HC Pure Tone Audiometry- Air,PX-47100014,CDM,92552,CPT,471,RC,,,outpatient,,,230,161,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,51.635,416.02,fee schedule,,,
HC Audiometry- Air & Bone,PX-47100015,CDM,92553,CPT,471,RC,,,outpatient,,,295,206.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,185.32,,,185.32,61.17,416.02,fee schedule,,,
HC Speech Threshold Audiometry,PX-47100016,CDM,92555,CPT,471,RC,,,outpatient,,,144,100.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,43.78,,,43.78,32.328,416.02,fee schedule,,,
HC Speech Audiometry- Complete,PX-47100017,CDM,92556,CPT,471,RC,,,outpatient,,,132,92.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,43.78,,,43.78,29.634,416.02,fee schedule,,,
HC Comprehensive Hearing Test,PX-47100018,CDM,92557,CPT,471,RC,,,outpatient,,,519,363.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,185.32,,,185.32,116.5155,416.02,fee schedule,,,
HC Evoked Otoacoustic Emissions Screen Auto Analys,PX-47100047,CDM,92558,CPT,471,RC,,,outpatient,,,35,24.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17.44,,,17.44,7.8575,416.02,fee schedule,,,
HC Stenger Test- Pure Tone,PX-47100020,CDM,92565,CPT,471,RC,,,outpatient,,,95,66.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,43.78,,,43.78,21.3275,416.02,fee schedule,,,
HC Tympanometry,PX-47100021,CDM,92567,CPT,471,RC,,,outpatient,,,125,87.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,43.78,,,43.78,28.0625,416.02,fee schedule,,,
HC Acoustic Immit Test Tympanometry/Acoust Reflex/Decay,PX-47100023,CDM,92570,CPT,471,RC,,,outpatient,,,359,251.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,185.32,,,185.32,80.5955,416.02,fee schedule,,,
HC Visual Audiometry (Vra),PX-47100027,CDM,92579,CPT,471,RC,,,outpatient,,,500,350,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,185.32,,,185.32,112.25,416.02,fee schedule,,,
HC Conditioning Play Audiometry,PX-47100028,CDM,92582,CPT,471,RC,,,outpatient,,,511,357.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,185.32,,,185.32,114.7195,416.02,fee schedule,,,
HC Select Picture Audiometry,PX-47100029,CDM,92583,CPT,471,RC,,,outpatient,,,114,79.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,43.78,,,43.78,25.593,416.02,fee schedule,,,
HC Evoked Auditory Test-Limited,PX-47100032,CDM,92587,CPT,471,RC,,,outpatient,,,624,436.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,343.93,,,343.93,128.12716,479.602522,fee schedule,,,
HC Hearing Aid Check- One Ear,PX-47100036,CDM,92592,CPT,471,RC,,,outpatient,,,116,81.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,40.5,,,40.5,26.042,416.02,fee schedule,,,
HC Hearing Aid Check- Both Ears,PX-47100038,CDM,92593,CPT,471,RC,,,outpatient,,,162,113.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,66.67,,,66.67,36.369,416.02,fee schedule,,,
HC Auditory Function- 60 Min,PX-47100039,CDM,92620,CPT,471,RC,,,outpatient,,,729,510.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,185.32,,,185.32,84.99,559.872,fee schedule,,,
HC Auditory Function- + 15 Min,PX-47100040,CDM,92621,CPT,471,RC,,,outpatient,,,122,85.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.01,416.02,other,SI=N Exclusions ,,
HC Aep Threshold Estimation Mlt Frequencies I&R,PX-47100043,CDM,92652,CPT,471,RC,,,outpatient,,,863,604.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,358.32,,,358.32,128.12716,662.784,fee schedule,,,
HC Aep Neurodiagnostic Interpretation and Report,PX-47100044,CDM,92653,CPT,471,RC,,,outpatient,,,863,604.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,358.32,,,358.32,128.12716,662.784,fee schedule,,,
HC Prq Trluml Coronary Angioplasty One Art/Branch,PX-48100012,CDM,92920,CPT,481,RC,,,outpatient,,,17563,12294.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,6377.4,,,6377.4,399.86,13488.384,fee schedule,,,
HC Prq Trluml Coronary Angioplasty Addl Branch,PX-48100013,CDM,92921,CPT,481,RC,,,outpatient,,,17563,12294.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13488.384,other,SI=N Exclusions ,,
HC Prq Trluml Coronary Angio/Atherect One Art/Brnch,PX-48100014,CDM,92924,CPT,481,RC,,,outpatient,,,33484,23438.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13180.06,,,13180.06,399.86,25715.712,fee schedule,,,
HC Prq Trluml Coronary Angio/Atherec Addl Art/Brnch,PX-48100015,CDM,92925,CPT,481,RC,,,outpatient,,,32854,22997.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,25231.872,other,SI=N Exclusions ,,
HC Prq Trluml Coronary Stent W/Angio One Art/Brnch,PX-48100016,CDM,92928,CPT,481,RC,,,outpatient,,,32584,22808.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13180.06,,,13180.06,399.86,25024.512,fee schedule,,,
HC Prq Trluml Coronary Stent W/Angio Addl Art/Brnch,PX-48100017,CDM,92929,CPT,481,RC,,,outpatient,,,26673,18671.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,20484.864,other,SI=N Exclusions ,,
HC Prq Trluml Coronry Stent/Ath/Angio One Art/Brnch,PX-48100018,CDM,92933,CPT,481,RC,,,outpatient,,,33887,23720.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20930.03,,,20930.03,399.86,26793.51305,fee schedule,,,
HC Prq Trluml Coronary Stent/Ath/Angio Addl Branch,PX-48100019,CDM,92934,CPT,481,RC,,,outpatient,,,26169,18318.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,20097.792,other,SI=N Exclusions ,,
HC Prq Trluml Coronary Byp Grft Revasc One Vessel,PX-48100020,CDM,92937,CPT,481,RC,,,outpatient,,,26673,18671.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13180.06,,,13180.06,399.86,20484.864,fee schedule,,,
HC Prq Trluml Coronary Byp Grft Revasc Addl Vessel,PX-48100021,CDM,92938,CPT,481,RC,,,outpatient,,,26169,18318.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,20097.792,other,SI=N Exclusions ,,
HC Prq Trluml Coronry Chronic Occlus Revasc One Vsl,PX-48100023,CDM,92943,CPT,481,RC,,,outpatient,,,25667,17966.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13180.06,,,13180.06,399.86,19712.256,fee schedule,,,
HC Prq Trluml Coronry Chrnic Occlus Revasc Addl Vsl,PX-48100024,CDM,92944,CPT,481,RC,,,outpatient,,,26169,18318.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,20097.792,other,SI=N Exclusions ,,
HC Heart/Lung Resuscitation (Cpr),PX-48000001,CDM,92950,CPT,480,RC,,,outpatient,,,1034,723.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,343.93,,,343.93,232.133,997.822944,fee schedule,,,
HC PR Cardiopulmonary Resuscitation,PX-96000048,CDM,92950,CPT,960,RC,,,outpatient,,,1034,723.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,343.93,,,343.93,232.133,997.822944,fee schedule,,,
HC Temporary External Pacing,PX-48000002,CDM,92953,CPT,480,RC,,,outpatient,,,1302,911.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,717.67,,,717.67,292.299,999.936,fee schedule,,,
HC Cardioversion- Elective;Extern,PX-48000003,CDM,92960,CPT,480,RC,,,outpatient,,,2006,1404.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,717.67,,,717.67,399.86,1540.608,fee schedule,,,
HC PR Cardioversion Elective Arrhythmia External,PX-96000049,CDM,92960,CPT,960,RC,,,outpatient,,,2006,1404.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,717.67,,,717.67,399.86,1540.608,fee schedule,,,
HC Prq Transluminal Coronary Mechanicl Thrombectomy,PX-48000005,CDM,92973,CPT,480,RC,,,outpatient,,,773,541.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,173.5385,593.664,other,SI=N Exclusions ,,
HC Intrav Optcl Chernce Tmgrphy W/S&I Intl Vesl,PX-36900031,CDM,92978,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,145.12362,2138.88,other,SI=N Exclusions ,,
HC Intravasc US-Heart-1st Vessel,PX-48100025,CDM,92978,CPT,481,RC,,,outpatient,,,2785,1949.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,145.12362,2138.88,other,SI=N Exclusions ,,
HC Intrav Optcal Cohrnce Tmgrphy W/S&I Adl Vesl,PX-36900032,CDM,92979,CPT,369,RC,,,outpatient,,,755,528.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,169.4975,1592,other,SI=N Exclusions ,,
HC Intravasc Coronary Sono-Addn Vessel,PX-48100026,CDM,92979,CPT,481,RC,,,outpatient,,,755,528.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,169.4975,1592,other,SI=N Exclusions ,,
HC Percut Aortic Valvuloplasty,PX-48100027,CDM,92986,CPT,481,RC,,,outpatient,,,17231,12061.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,6377.4,,,6377.4,399.86,13233.408,fee schedule,,,
HC Percut Mitral Valvuloplasty,PX-48100028,CDM,92987,CPT,481,RC,,,outpatient,,,17231,12061.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13180.06,,,13180.06,399.86,16809.6787,fee schedule,,,
HC Percut Pulmonary Valvuloplasty,PX-48100029,CDM,92990,CPT,481,RC,,,outpatient,,,17231,12061.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13180.06,,,13180.06,399.86,16809.6787,fee schedule,,,
HC Electrocardiogram- Tracing,PX-73000001,CDM,93005,CPT,730,RC,,,outpatient,,,157,109.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,76.19,,,76.19,25.49469,416.02,fee schedule,,,
HC PR Electrocardiogram Report,PX-98500001,CDM,93010,CPT,985,RC,,,outpatient,,,28,19.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16.68,,,16.68,6.286,416.02,fee schedule,,,
HC Cardiac Stress Tst-Tracing Only,PX-48200001,CDM,93017,CPT,482,RC,,,outpatient,,,485,339.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,343.93,,,343.93,108.8825,479.602522,fee schedule,,,
HC Rhythm Ecg- Tracing,PX-73000003,CDM,93041,CPT,730,RC,,,outpatient,,,120,84,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,76.19,,,76.19,25.49469,416.02,fee schedule,,,
HC PR Rhythm Ecg 1-3 Leads Interpretation & Reprt On,PX-98500004,CDM,93042,CPT,985,RC,,,outpatient,,,22,15.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13.8,,,13.8,4.939,416.02,fee schedule,,,
HC Ext Ecg Record Contin 48 Hr- Record,PX-73100001,CDM,93225,CPT,731,RC,,,outpatient,,,433,303.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,84.459332,416.02,fee schedule,,,
HC Ext Ecg Record Contin 48 Hr- Scan Analysis W Report,PX-73100002,CDM,93226,CPT,731,RC,,,outpatient,,,318,222.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,66.75974,416.02,fee schedule,,,
HC PR Xtrnl Ecg Continuous Rhythm W/I&R Up to 48 Hrs,PX-98500002,CDM,93227,CPT,985,RC,,,outpatient,,,63,44.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,52.32,,,52.32,14.1435,416.02,fee schedule,,,
HC Prgrmg Dev Eval 1 Lead Pm/Ldls Pm 1 Car Chmbr IP,PX-48000087,CDM,93279,CPT,480,RC,,,outpatient,,,118,82.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,50.65,,,50.65,26.491,416.02,fee schedule,,,
HC Program Eval Implantable in Persn Dual Ld Pacer,PX-92000010,CDM,93280,CPT,920,RC,,,outpatient,,,1217,851.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,50.65,,,50.65,41.157815,934.656,fee schedule,,,
HC Program Eval Implantable in Prsn Multi Ld Pacer,PX-48000088,CDM,93281,CPT,480,RC,,,outpatient,,,118,82.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,50.65,,,50.65,26.491,416.02,fee schedule,,,
HC Prgrmng Dev Eval Implantable in Persn 1 Ld Dfb,PX-48000089,CDM,93282,CPT,480,RC,,,outpatient,,,118,82.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,50.65,,,50.65,26.491,416.02,fee schedule,,,
HC Progrm Eval Implantable in Prsn Dual L Card/Dfb,PX-48000009,CDM,93283,CPT,480,RC,,,outpatient,,,1878,1314.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,50.65,,,50.65,41.157815,1442.304,fee schedule,,,
HC Prgrmg Eval Implantable in Person Multi Lead Dfb,PX-48000090,CDM,93284,CPT,480,RC,,,outpatient,,,118,82.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,50.65,,,50.65,26.491,416.02,fee schedule,,,
HC Prgrmg Dev Eval Scrms Phys/Qhp in Person,PX-48000091,CDM,93285,CPT,480,RC,,,outpatient,,,118,82.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,50.65,,,50.65,26.491,416.02,fee schedule,,,
HC Interrogation Eval in Person 1/Dual/Mlt Lead Pm,PX-48000010,CDM,93288,CPT,480,RC,,,outpatient,,,224,156.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,50.65,,,50.65,41.157815,416.02,fee schedule,,,
HC Interrog Eval F2f 1/Dual/Mlt Leads Impltbl Dfb,PX-48000086,CDM,93289,CPT,480,RC,,,outpatient,,,118,82.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,50.65,,,50.65,26.491,416.02,fee schedule,,,
HC Interrogation Evaluation in Person Ilr System,PX-92000011,CDM,93291,CPT,920,RC,,,outpatient,,,248,173.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23.4,,,23.4,23.39896,416.02,fee schedule,,,
Rem Interrog Pm/Ldls Pm/Ids <90 D Tech Review,PX-48000085,CDM,93296,CPT,480,RC,,,outpatient,,,118,82.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,50.65,,,50.65,26.491,416.02,fee schedule,,,
HC Echo Xthoracic-Cong Anom-Complete,PX-48000014,CDM,93303,CPT,480,RC,,,outpatient,,,1337,935.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,678.14,,,678.14,54.1045,1223.3,fee schedule,,,
HC PR Echo Xthoracic-Cong Anom-Complete,PX-96000009,CDM,93303,CPT,960,RC,,,outpatient,,,241,168.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,678.14,,,678.14,54.1045,1223.3,fee schedule,,,
HC Echo Xthoracic-Cong Anom-Limited,PX-48000015,CDM,93304,CPT,480,RC,,,outpatient,,,1303,912.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,678.14,,,678.14,281.81,1040.64,fee schedule,,,
HC PR Echo Xthoracic-Cong Anom-Limited,PX-96000010,CDM,93304,CPT,960,RC,,,outpatient,,,1355,948.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,678.14,,,678.14,281.81,1040.64,fee schedule,,,
HC Echo Heart Xthoracic-Complete W Doppler W/Contrast,PX-48000016,CDM,93306,CPT,480,RC,,,outpatient,,,1347,942.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,678.14,,,678.14,54.1045,1034.496,fee schedule,,,
HC Echo Heart Xthoracic-Complete W Doppler W/O Contrast,PX-48000068,CDM,93306,CPT,480,RC,,,outpatient,,,1347,942.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,678.14,,,678.14,54.1045,1034.496,fee schedule,,,
HC PR Echo Heart Xthoracic-Complete W Doppler,PX-96000036,CDM,93306,CPT,960,RC,,,outpatient,,,241,168.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,678.14,,,678.14,54.1045,1034.496,fee schedule,,,
HC Echo Heart Xthoracic-Complete- W/O Doppler W/Contrast,PX-48000017,CDM,93307,CPT,480,RC,,,outpatient,,,1228,859.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,314.28,,,314.28,267.439885,943.104,fee schedule,,,
HC Echo Heart Xthoracic-Complete- W/O Doppler W/O Contrast,PX-48000063,CDM,93307,CPT,480,RC,,,outpatient,,,1228,859.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,314.28,,,314.28,267.439885,943.104,fee schedule,,,
HC Echo Heart Xthoracic-Limited W/Contrast,PX-48000018,CDM,93308,CPT,480,RC,,,outpatient,,,561,392.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,314.28,,,314.28,125.9445,465.66,fee schedule,,,
HC Echo Heart Xthoracic-Limited W/O Contrast,PX-48000065,CDM,93308,CPT,480,RC,,,outpatient,,,561,392.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,314.28,,,314.28,125.9445,465.66,fee schedule,,,
HC PR Echo Heart Xthoracic-Limited,PX-96000037,CDM,93308,CPT,960,RC,,,outpatient,,,561,392.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,314.28,,,314.28,125.9445,465.66,fee schedule,,,
HC Echo Heart-Transesophageal-Complete W/Contrast,PX-48000019,CDM,93312,CPT,480,RC,,,outpatient,,,1764,1234.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,678.14,,,678.14,224.549385,1354.752,fee schedule,,,
HC Echo Heart-Transesophageal-Complete W/O Contrast,PX-48000064,CDM,93312,CPT,480,RC,,,outpatient,,,1764,1234.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,678.14,,,678.14,224.549385,1354.752,fee schedule,,,
HC Echo R-T 2d W/Probe Placement Only,PX-48000083,CDM,93313,CPT,480,RC,,,outpatient,,,1501,1050.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,678.14,,,678.14,336.9745,1152.768,fee schedule,,,
HC 3d Echo Img&Pst-Pxessing Tee/Tte Cgen Car Anomal,PX-48000084,CDM,93319,CPT,480,RC,,,outpatient,,,352,246.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,79.024,416.02,other,SI=N Exclusions ,,
HC Doppler Echo Heart-Complete,PX-48000020,CDM,93320,CPT,480,RC,,,outpatient,,,323,226.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,72.5135,416.02,other,SI=N Exclusions ,,
HC Doppler Echo Heart-Limited-F/U,PX-48000021,CDM,93321,CPT,480,RC,,,outpatient,,,384,268.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,86.208,416.02,other,SI=N Exclusions ,,
HC Doppler Color Flow Velocity Map,PX-48000022,CDM,93325,CPT,480,RC,,,outpatient,,,744,520.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,135.906309,571.392,other,SI=N Exclusions ,,
HC Echo Heart Xthoracic- Stress/Rest W/Contrast,PX-48000023,CDM,93350,CPT,480,RC,,,outpatient,,,1384,968.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,678.14,,,678.14,224.549385,1062.912,fee schedule,,,
HC Echo Heart Xthoracic- Stress/Rest W/O Contrast,PX-48000066,CDM,93350,CPT,480,RC,,,outpatient,,,1384,968.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,678.14,,,678.14,224.549385,1062.912,fee schedule,,,
HC Echo Tthrc R-T 2d W/WO M-Mode Rest&Strs Cont Ecg W/Contrast,PX-48000024,CDM,93351,CPT,480,RC,,,outpatient,,,1785,1249.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,678.14,,,678.14,224.549385,1370.88,fee schedule,,,
HC Echo Tthrc R-T 2d W/WO M-Mode Rest&Strs Cont Ecg W/O Contrast,PX-48000067,CDM,93351,CPT,480,RC,,,outpatient,,,1785,1249.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,678.14,,,678.14,224.549385,1370.88,fee schedule,,,
HC Echo Tee Guid Tcat Icar/Vessel Structural Intvn,PX-48000052,CDM,93355,CPT,480,RC,,,outpatient,,,778,544.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.661,597.504,other,SI=N Exclusions ,,
HC Myocrd Strain Img Speckle Trck Assmt Myocrd Mech,PX-48000480,CDM,93356,CPT,480,RC,,,outpatient,,,1077,753.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,241.7865,827.136,other,SI=N Exclusions ,,
HC Right Heart Cath O2 Saturation & Cardiac Output,PX-48100030,CDM,93451,CPT,481,RC,,,outpatient,,,9177,6423.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3830.92,,,3830.92,399.86,7870.4,fee schedule,,,
HC Cath Place/Coronary Angio- Img Super/Interp,PX-48100031,CDM,93454,CPT,481,RC,,,outpatient,,,10988,7691.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3830.92,,,3830.92,399.86,8438.784,fee schedule,,,
HC Cath Place/Coronary Angio- Img Super/Interp- Bypass Angio,PX-48100032,CDM,93455,CPT,481,RC,,,outpatient,,,10988,7691.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3830.92,,,3830.92,399.86,8438.784,fee schedule,,,
HC Cath Place/Coronary Angio- Img Super/Interp-W Right Heart Cath,PX-48100033,CDM,93456,CPT,481,RC,,,outpatient,,,10988,7691.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3830.92,,,3830.92,399.86,8438.784,fee schedule,,,
HC Cath Place/Coron Angio- Img Super/Interp- Bypass Angio-W R Heart Cath,PX-48100034,CDM,93457,CPT,481,RC,,,outpatient,,,9755,6828.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3830.92,,,3830.92,399.86,7870.4,fee schedule,,,
HC Cath Place/Coron Angio- Img Super/Interp-W Left Heart Ventriculography,PX-48100035,CDM,93458,CPT,481,RC,,,outpatient,,,9755,6828.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3830.92,,,3830.92,399.86,7870.4,fee schedule,,,
HC Cath Place/Coron Angio- Img Super/Interp- Bypass Angio-W L Hrt Ventric,PX-48100036,CDM,93459,CPT,481,RC,,,outpatient,,,10988,7691.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3830.92,,,3830.92,399.86,8438.784,fee schedule,,,
HC Cath Place/Coron Angio- Img Super/Interp-R&L Hrt Cath- L Hrt Ventric,PX-48100037,CDM,93460,CPT,481,RC,,,outpatient,,,10988,7691.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3830.92,,,3830.92,399.86,8438.784,fee schedule,,,
HC Cath Place/Cor Ang-Img Supr/Intrp-Bypass Ang- R&L Cath- L Hrt Ventric,PX-48100038,CDM,93461,CPT,481,RC,,,outpatient,,,10988,7691.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3830.92,,,3830.92,399.86,8438.784,fee schedule,,,
HC Left Heart Cath by Transeptal Puncture,PX-48100039,CDM,93462,CPT,481,RC,,,outpatient,,,10365,7255.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7960.32,other,SI=N Exclusions ,,
HC Insert/Place Flow Direct Cath,PX-36900885,CDM,93503,CPT,369,RC,,,outpatient,,,2998,2098.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1490.75,,,1490.75,399.86,2532.39,fee schedule,,,
HC Insert/Place Flow Direct Cath,PX-48000025,CDM,93503,CPT,480,RC,,,outpatient,,,2998,2098.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1490.75,,,1490.75,399.86,2532.39,fee schedule,,,
HC Inject Select Cor Angio During Congenital Heart Cath,PX-48100044,CDM,93563,CPT,481,RC,,,outpatient,,,2542,1779.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,1952.256,other,SI=N Exclusions ,,
HC Inject Select Cor/Graft Angio During Congenital Heart Cath,PX-48100045,CDM,93564,CPT,481,RC,,,outpatient,,,1018,712.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,228.541,1592,other,SI=N Exclusions ,,
HC Inject Select Left Vent/Atrial Angio During Heart Cath,PX-48100046,CDM,93565,CPT,481,RC,,,outpatient,,,510,357,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,114.495,1592,other,SI=N Exclusions ,,
HC Inject Select Right Vent/Atrial Angio During Heart Cath,PX-48100047,CDM,93566,CPT,481,RC,,,outpatient,,,1018,712.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,228.541,1592,other,SI=N Exclusions ,,
HC Inject Supravalvular Aortography During Heart Cath,PX-48100048,CDM,93567,CPT,481,RC,,,outpatient,,,1498,1048.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,235.074116,1592,other,SI=N Exclusions ,,
HC Heart Flow Reserv Measure-Init Vessl,PX-48000026,CDM,93571,CPT,480,RC,,,outpatient,,,6936,4855.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,5638.7,other,SI=N Exclusions ,,
HC Heart Flow Reserv Measure-Addn Vessl,PX-48000027,CDM,93572,CPT,480,RC,,,outpatient,,,2051,1435.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,1575.168,other,SI=N Exclusions ,,
HC Perc Clos-Cong Interatrial Commun W/Impl,PX-48100049,CDM,93580,CPT,481,RC,,,outpatient,,,53254,37277.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20930.03,,,20930.03,399.86,40899.072,fee schedule,,,
HC Perc Closure-Cong Vsd W/Implant,PX-48100050,CDM,93581,CPT,481,RC,,,outpatient,,,53254,37277.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20930.03,,,20930.03,399.86,40899.072,fee schedule,,,
HC Percutan Transcath Closure Pat Duct Arteriosus,PX-36900556,CDM,93582,CPT,369,RC,,,outpatient,,,52790,36953,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20930.03,,,20930.03,399.86,40542.72,fee schedule,,,
HC Percutan Transcath Closure Pat Duct Arteriosus,PX-48100051,CDM,93582,CPT,481,RC,,,outpatient,,,52790,36953,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20930.03,,,20930.03,399.86,40542.72,fee schedule,,,
HC Percutaneous Transcatheter Septal Reduction Ther,PX-48100055,CDM,93583,CPT,481,RC,,,outpatient,,,16899,11829.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1501.69,,,1501.69,399.86,12978.432,fee schedule,,,
HC Heart Pacing- Mapping,PX-48000042,CDM,93631,CPT,480,RC,,,outpatient,,,8496,5947.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6909.98,other,SI=N Exclusions ,,
HC Eval Cardiovert Leads-Initial,PX-48000043,CDM,93640,CPT,480,RC,,,outpatient,,,5892,4124.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,4525.056,other,SI=N Exclusions ,,
HC Eval Cardiovert Leads/Puls Gen,PX-48000044,CDM,93641,CPT,480,RC,,,outpatient,,,3075,2152.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,2361.6,other,SI=N Exclusions ,,
HC Electrophys Eval-Cardioverter,PX-48000045,CDM,93642,CPT,480,RC,,,outpatient,,,3083,2158.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1253.16,,,1253.16,399.86,2367.744,fee schedule,,,
HC Tilt Table Evaluation,PX-48000049,CDM,93660,CPT,480,RC,,,outpatient,,,3083,2158.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,620.59,,,620.59,399.86,2367.744,fee schedule,,,
HC Intracard Echo- Ther/Dx Intervent,PX-48000050,CDM,93662,CPT,480,RC,,,outpatient,,,7689,5382.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10671.09667,other,SI=N Exclusions ,,
HC Analyze Pacer Sys,PX-48000051,CDM,93724,CPT,480,RC,,,outpatient,,,1217,851.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,382.23,,,382.23,73.54,934.656,fee schedule,,,
HC Outpatient Cardiac Rehab W/O Cont Ecg Monitor,PX-94300002,CDM,93797,CPT,943,RC,,,outpatient,,,255,178.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,161.05,,,161.05,57.2475,416.02,fee schedule,,,
HC Outpatient Cardiac Rehab W/Cont Ecg Monitoring,PX-94300003,CDM,93798,CPT,943,RC,,,outpatient,,,271,189.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,161.05,,,161.05,60.8395,416.02,fee schedule,,,
HC Duplex Scan Extracranial-Bilat,PX-92100008,CDM,93880,CPT,921,RC,,,outpatient,,,915,640.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,314.28,,,314.28,199.512292,702.72,fee schedule,,,
HC Duplex Scan Extracranial-Limited,PX-92100010,CDM,93882,CPT,921,RC,,,outpatient,,,915,640.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,153.36,,,153.36,119.991125,702.72,fee schedule,,,
HC Transcran Doppler Intracran Art,PX-92100011,CDM,93886,CPT,921,RC,,,outpatient,,,1137,795.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,314.28,,,314.28,255.2565,873.216,fee schedule,,,
HC Transcran Doppler Intracran-Limited,PX-92100013,CDM,93888,CPT,921,RC,,,outpatient,,,428,299.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,153.36,,,153.36,96.086,686,fee schedule,,,
HC Transcran Doppl Intracran- Vasoreact,PX-92100015,CDM,93890,CPT,921,RC,,,outpatient,,,952,666.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,314.28,,,314.28,213.724,731.136,fee schedule,,,
HC Non-Invas Physiologic Std Extremity Art 1-2 Level,PX-92100017,CDM,93922,CPT,921,RC,,,outpatient,,,915,640.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,135.906309,702.72,fee schedule,,,
HC Non-Invasive Physiologic Study Extremity 3 Levels,PX-92100019,CDM,93923,CPT,921,RC,,,outpatient,,,701,490.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,185.32,,,185.32,121.132463,686,fee schedule,,,
HC Non-Invasive Lower Extrem Art Stress/Rest- Complete-Bilateral,PX-92100020,CDM,93924,CPT,921,RC,,,outpatient,,,915,640.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,185.32,,,185.32,135.906309,775.5705,fee schedule,,,
HC Duplex Lo Extrem Art Bilat,PX-92100022,CDM,93925,CPT,921,RC,,,outpatient,,,915,640.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,314.28,,,314.28,199.512292,702.72,fee schedule,,,
HC Duplex Lo Extrem Art Unilat/Ltd,PX-92100024,CDM,93926,CPT,921,RC,,,outpatient,,,441,308.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,153.36,,,153.36,99.0045,686,fee schedule,,,
HC Duplex Up Extrem Art Bilat,PX-92100025,CDM,93930,CPT,921,RC,,,outpatient,,,842,589.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,314.28,,,314.28,135.906309,686,fee schedule,,,
HC Duplex Up Extrem Art Bilat,PX-92100026,CDM,93930,CPT,921,RC,,,outpatient,,,842,589.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,314.28,,,314.28,135.906309,686,fee schedule,,,
HC Duplex Up Extrem Art Unilat/Ltd,PX-92100028,CDM,93931,CPT,921,RC,,,outpatient,,,915,640.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,153.36,,,153.36,119.991125,702.72,fee schedule,,,
HC Duplex Extrem Venous-Bilat,PX-92100031,CDM,93970,CPT,921,RC,,,outpatient,,,758,530.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,314.28,,,314.28,170.171,686,fee schedule,,,
HC Duplex Extrem Venous-Bilat,PX-92100032,CDM,93970,CPT,921,RC,,,outpatient,,,758,530.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,314.28,,,314.28,170.171,686,fee schedule,,,
HC Duplex Extrem Venous-Uni or Ltd,PX-92100034,CDM,93971,CPT,921,RC,,,outpatient,,,915,640.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,153.36,,,153.36,119.991125,702.72,fee schedule,,,
HC Duplex Abd/Pel Vasc Study-Complete,PX-92100036,CDM,93975,CPT,921,RC,,,outpatient,,,816,571.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,314.28,,,314.28,183.192,686,fee schedule,,,
HC Duplex Abd/Pel Vasc Study-Limitd,PX-92100037,CDM,93976,CPT,921,RC,,,outpatient,,,418,292.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,153.36,,,153.36,93.841,686,fee schedule,,,
HC Duplex Large Vessel(S)-Complete,PX-92100039,CDM,93978,CPT,921,RC,,,outpatient,,,915,640.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,314.28,,,314.28,199.512292,702.72,fee schedule,,,
HC Duplex Large Vessel(S)-Limited,PX-92100041,CDM,93979,CPT,921,RC,,,outpatient,,,387,270.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,153.36,,,153.36,86.8815,686,fee schedule,,,
HC Duplex Hemodialysis Access,PX-92100042,CDM,93990,CPT,921,RC,,,outpatient,,,614,429.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,153.36,,,153.36,119.991125,686,fee schedule,,,
HC Breathing Capacity Test,PX-46000002,CDM,94010,CPT,460,RC,,,outpatient,,,295,206.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,185.32,,,185.32,66.2275,416.02,fee schedule,,,
HC Eval of Bronchospasm,PX-46000003,CDM,94060,CPT,460,RC,,,outpatient,,,446,312.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,343.93,,,343.93,100.127,479.602522,fee schedule,,,
HC Eval of Bronchospasm-Prolonged,PX-46000004,CDM,94070,CPT,460,RC,,,outpatient,,,925,647.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,343.93,,,343.93,163,710.4,fee schedule,,,
HC Xers Tst Brncspsm Pre&Post Spmtry&Pls Ox W/Ecg,PX-46000023,CDM,94617,CPT,460,RC,,,outpatient,,,392,274.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,88.004,416.02,fee schedule,,,
HC Pulmonary Stress Testing,PX-46000022,CDM,94618,CPT,460,RC,,,outpatient,,,392,274.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,88.004,416.02,fee schedule,,,
HC Xers Tst Brncspsm Pre&Post Spmtry&Pls Ox WO /Ecg,PX-46000024,CDM,94619,CPT,460,RC,,,outpatient,,,182,127.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,75.42,,,75.42,40.859,416.02,fee schedule,,,
HC Inhal Rx- Airway Obst/Dx Sputum Induct,PX-41000006,CDM,94640,CPT,410,RC,,,outpatient,,,494,345.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,261.18,,,261.18,59.92,416.02,fee schedule,,,
HC Plethysmography Lung Volumes W/WO Airway Resist,PX-46000012,CDM,94726,CPT,460,RC,,,outpatient,,,446,312.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,343.93,,,343.93,98.67,479.602522,fee schedule,,,
HC Gas Dilut/Washout Lung Vol W/WO Distrib Vent&Vol,PX-46000013,CDM,94727,CPT,460,RC,,,outpatient,,,295,206.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,185.32,,,185.32,66.2275,416.02,fee schedule,,,
HC Diffusing Capacity,PX-46000014,CDM,94729,CPT,460,RC,,,outpatient,,,265,185.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,59.4925,416.02,other,SI=N Exclusions ,,
HC Noninvasv Oxygen Satur;Single,PX-46000015,CDM,94760,CPT,460,RC,,,outpatient,,,54,37.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.123,416.02,other,SI=N Exclusions ,,
HC Noninvasv Oxygen Satur-Multiple,PX-46000016,CDM,94761,CPT,460,RC,,,outpatient,,,90,63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.205,416.02,other,SI=N Exclusions ,,
HC Car Seat/Bed Test Initial 60 Mins,PX-46000019,CDM,94780,CPT,460,RC,,,outpatient,,,194,135.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,43.78,,,43.78,43.553,416.02,fee schedule,,,
HC Car Seat/Bed Test Each Addl 30 Min,PX-46000020,CDM,94781,CPT,460,RC,,,outpatient,,,194,135.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,43.553,416.02,other,SI=N Exclusions ,,
HC Pulmonary Service/Procedure,PX-41000002,CDM,94799,CPT,410,RC,,,outpatient,,,367,256.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.74,416.02,other,Unlisted Codes,,
HC Eeg W/O Video by Tech 2-12 Hr Unmonitored,PX-74000012,CDM,95705,CPT,740,RC,,,outpatient,,,827,578.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,330.64,,,330.64,185.6615,635.136,fee schedule,,,
HC Eeg W/O Video by Tech 2-12 Hr Intermittent Mntr,PX-74000013,CDM,95706,CPT,740,RC,,,outpatient,,,827,578.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,330.64,,,330.64,185.6615,635.136,fee schedule,,,
HC Eeg W/O Video by Tech 2-12hr Continuous R-T Mntr,PX-74000014,CDM,95707,CPT,740,RC,,,outpatient,,,827,578.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,330.64,,,330.64,185.6615,635.136,fee schedule,,,
HC Eeg W/O Vid by Tech Ea Incr 12-26hr Unmonitored,PX-74000011,CDM,95708,CPT,740,RC,,,outpatient,,,1649,1154.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,634.38,,,634.38,370.2005,1266.432,fee schedule,,,
HC Eeg W/O Vid by Tech Ea Incr 12-26 Hr Intmt Mntr,PX-74000015,CDM,95709,CPT,740,RC,,,outpatient,,,1585,1109.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,634.38,,,634.38,355.8325,1217.28,fee schedule,,,
HC Eeg W/O Vid Tech Ea Incr 12-26 Hr Cont R-T Mntr,PX-74000016,CDM,95710,CPT,740,RC,,,outpatient,,,1585,1109.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,634.38,,,634.38,355.8325,1217.28,fee schedule,,,
HC Electroencephalogram Extend Monitoring 41-60 Min,PX-74000008,CDM,95812,CPT,740,RC,,,outpatient,,,812,568.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,343.93,,,343.93,182.294,623.616,fee schedule,,,
HC Eeg >1 Hr,PX-74000002,CDM,95813,CPT,740,RC,,,outpatient,,,958,670.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,343.93,,,343.93,215.071,735.744,fee schedule,,,
HC Eeg-W/Awake & Drowsy Record,PX-74000003,CDM,95816,CPT,740,RC,,,outpatient,,,701,490.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,343.93,,,343.93,157.3745,538.368,fee schedule,,,
HC Eeg-W/Awake & Asleep Record,PX-74000004,CDM,95819,CPT,740,RC,,,outpatient,,,786,550.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,343.93,,,343.93,176.457,603.648,fee schedule,,,
HC Eeg-Coma/Sleep Record Only,PX-74000005,CDM,95822,CPT,740,RC,,,outpatient,,,675,472.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,343.93,,,343.93,151.5375,518.4,fee schedule,,,
HC Eeg Eval Cerebral Death,PX-74000006,CDM,95824,CPT,740,RC,,,outpatient,,,675,472.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,572.13,151.5375,829.50194,percent of total billed charges,,,
HC Needle Emg Ea Extremity W/Paraspinl Area Limited,PX-92200011,CDM,95885,CPT,922,RC,,,outpatient,,,332,232.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.817,570,other,SI=N Exclusions ,,
HC PR Needle Emg Ea Extremity W/Paraspinl Area Limited,PX-96000021,CDM,95885,CPT,960,RC,,,outpatient,,,66,46.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.817,570,other,SI=N Exclusions ,,
HC Needle Emg Ea Extremty W/Paraspinl Area Complete,PX-92200012,CDM,95886,CPT,922,RC,,,outpatient,,,332,232.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,30.083,570,other,SI=N Exclusions ,,
HC PR Needle Emg Ea Extremty W/Paraspinl Area Complete,PX-96000022,CDM,95886,CPT,960,RC,,,outpatient,,,134,93.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,30.083,570,other,SI=N Exclusions ,,
HC Needle Emg Nonextremty Mscles W/Nerve Conduction,PX-92200013,CDM,95887,CPT,922,RC,,,outpatient,,,180,126,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.4295,570,other,SI=N Exclusions ,,
HC PR Needle Emg Nonextremty Mscles W/Nerve Conduction,PX-96000023,CDM,95887,CPT,960,RC,,,outpatient,,,91,63.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.4295,570,other,SI=N Exclusions ,,
HC Nerve Conduction Studies 1-2 Studies,PX-92200028,CDM,95907,CPT,922,RC,,,outpatient,,,760,532,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,185.32,,,185.32,94.4,583.68,fee schedule,,,
HC Motor &/Sens 7-8 Nrv Cndj Preconf Eltrode Limb,PX-92200017,CDM,95910,CPT,922,RC,,,outpatient,,,696,487.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,343.93,,,343.93,94.4,570,fee schedule,,,
HC PR Motor &/Sens 7-8 Nrv Cndj Preconf Eltrode Limb,PX-96000027,CDM,95910,CPT,960,RC,,,outpatient,,,724,506.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,343.93,,,343.93,94.4,570,fee schedule,,,
HC Ionm Remote/Nearby/>1 Patient in or per Hour,PX-92000015,CDM,95941,CPT,920,RC,,,outpatient,,,879,615.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,197.3355,675.072,other,SI=N Exclusions ,,
HC Eeg Digital Anylysis,PX-74000010,CDM,95957,CPT,740,RC,,,outpatient,,,696,487.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,156.252,534.528,other,SI=N Exclusions ,,
HC IV Inf- Hydration- 31 Min to 1 Hr,PX-26000001,CDM,96360,CPT,260,RC,,,outpatient,,,334,233.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,255.15,,,255.15,74.983,416.02,fee schedule,,,
HC IV Inf- Hydration- Each Add'l Hr,PX-26000002,CDM,96361,CPT,260,RC,,,outpatient,,,89,62.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,51.64,,,51.64,19.9805,585.854902,fee schedule,,,
HC IV Inf- Therapy - Init to 1 Hr (Spec Drug),PX-26000003,CDM,96365,CPT,260,RC,,,outpatient,,,418,292.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,255.15,,,255.15,93.841,416.02,fee schedule,,,
HC IV Inf- Therapy- Each Add Hr (Spec Drug),PX-26000004,CDM,96366,CPT,260,RC,,,outpatient,,,132,92.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,51.64,,,51.64,29.634,585.854902,fee schedule,,,
HC IV Infusion- Therap/Proph/Diagnost-Add Infusion-1st Hour,PX-26000005,CDM,96367,CPT,260,RC,,,outpatient,,,183,128.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,81.45,,,81.45,41.0835,416.02,fee schedule,,,
HC IV Infusion- Therap/Proph/Diagnost-Concurrent Infusion,PX-26000006,CDM,96368,CPT,260,RC,,,outpatient,,,109,76.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,24.4705,416.02,other,SI=N Exclusions ,,
HC Therapeutic Prophylactic/Dx Injection Subq/Im,PX-26000007,CDM,96372,CPT,260,RC,,,outpatient,,,162,113.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,81.45,,,81.45,16.16,416.02,fee schedule,,,
HC Injection-Therap/Proph/Diagnost- Intra-Arterial,PX-26000008,CDM,96373,CPT,260,RC,,,outpatient,,,334,233.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,255.15,,,255.15,74.983,416.02,fee schedule,,,
HC IV Push- Initial,PX-26000009,CDM,96374,CPT,260,RC,,,outpatient,,,309,216.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,255.15,,,255.15,69.3705,416.02,fee schedule,,,
HC IV Push- Ea Add Seq- of New Sub Drug,PX-26000010,CDM,96375,CPT,260,RC,,,outpatient,,,105,73.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,51.64,,,51.64,23.5725,416.02,fee schedule,,,
HC Injection-Therap/Proph/Diagnost- IV Push- Ea Add- Same Drug,PX-26000011,CDM,96376,CPT,260,RC,,,outpatient,,,303,212.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,68.0235,416.02,other,SI=N Exclusions ,,
HC Chemother-Non-Hormone Anti-Neopl- Sub-Q/Im,PX-33100001,CDM,96401,CPT,331,RC,,,outpatient,,,222,155.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,81.45,,,81.45,49.839,416.02,fee schedule,,,
HC Chemother- IV Push- Sngl Drug,PX-33100003,CDM,96409,CPT,331,RC,,,outpatient,,,691,483.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,255.15,,,255.15,155.1295,530.688,fee schedule,,,
HC Chemother- IV Infusion- 1 Hr,PX-33500001,CDM,96413,CPT,335,RC,,,outpatient,,,724,506.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,393.1,,,393.1,162.538,556.032,fee schedule,,,
HC Chemother- IV Infusion- Ea Add Hr,PX-33500002,CDM,96415,CPT,335,RC,,,outpatient,,,187,130.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,81.45,,,81.45,41.9815,585.854902,fee schedule,,,
HC Chemother-Ia Push Technique,PX-33100006,CDM,96420,CPT,331,RC,,,outpatient,,,668,467.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,393.1,,,393.1,70.143083,517.481916,fee schedule,,,
HC Chemother-Cns-W/Lumbar Puncture,PX-33100005,CDM,96450,CPT,331,RC,,,outpatient,,,657,459.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,393.1,,,393.1,147.4965,585.854902,fee schedule,,,
HC Ultraviolet Light Therapy,PX-94000005,CDM,96900,CPT,940,RC,,,outpatient,,,530,371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,43.78,,,43.78,34.385146,416.02,fee schedule,,,
HC Mechanical Traction Therapy,PX-42100004,CDM,97012,CPT,421,RC,,,outpatient,,,245,171.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,144.61,,,144.61,14.38,416.02,per diem,,,
HC Electric Stimulation Therapy,PX-42100005,CDM,97014,CPT,421,RC,,,outpatient,,,123,86.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,144.61,,,144.61,27.6135,416.02,per diem,,,
HC Electrical Stimulation,PX-42100010,CDM,97032,CPT,421,RC,,,outpatient,,,123,86.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,144.61,,,144.61,14.73,416.02,per diem,,,
HC Electric Current Therapy,PX-42100011,CDM,97033,CPT,421,RC,,,outpatient,,,185,129.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,144.61,,,144.61,20.02,416.02,per diem,,,
HC Ultrasound Therapy,PX-42000005,CDM,97035,CPT,420,RC,,,outpatient,,,115,80.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27.77,,,27.77,14.44,416.02,fee schedule,,,
HC Ultrasound Therapy,PX-42100013,CDM,97035,CPT,421,RC,,,outpatient,,,115,80.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,144.61,,,144.61,14.44,416.02,per diem,,,
HC Therapeutic Exercises,PX-42000006,CDM,97110,CPT,420,RC,,,outpatient,,,197,137.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,62.16,,,62.16,30.33,416.02,fee schedule,,,
HC Therapeutic Exercises,PX-42100014,CDM,97110,CPT,421,RC,,,outpatient,,,197,137.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,144.61,,,144.61,30.33,416.02,per diem,,,
HC Neuromusc Reeducat-1+ Areas- Ea 15 Min,PX-42000007,CDM,97112,CPT,420,RC,,,outpatient,,,115,80.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,70.88,,,70.88,25.8175,416.02,fee schedule,,,
HC Neuromusc Reeducat-1+ Areas- Ea 15 Min,PX-42100015,CDM,97112,CPT,421,RC,,,outpatient,,,115,80.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,144.61,,,144.61,25.8175,416.02,per diem,,,
HC Gait Training Therapy,PX-42100017,CDM,97116,CPT,421,RC,,,outpatient,,,115,80.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,144.61,,,144.61,25.8175,416.02,per diem,,,
HC Manual Ther Tech-1+Regions-Ea 15 Min,PX-42000008,CDM,97140,CPT,420,RC,,,outpatient,,,140,98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,56.31,,,56.31,27.89,416.02,fee schedule,,,
HC Manual Ther Tech-1+Regions-Ea 15 Min,PX-42100018,CDM,97140,CPT,421,RC,,,outpatient,,,140,98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,144.61,,,144.61,27.89,416.02,per diem,,,
HC Group Therapeutic Procedures,PX-42000009,CDM,97150,CPT,420,RC,,,outpatient,,,130,91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36.96,,,36.96,18.56,416.02,fee schedule,,,
HC Group Therapeutic Procedures,PX-42300001,CDM,97150,CPT,423,RC,,,outpatient,,,130,91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,36.96,,,36.96,18.56,416.02,fee schedule,,,
HC Pt Eval Low Complex,PX-42400003,CDM,97161,CPT,424,RC,,,outpatient,,,260,182,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,171.91,,,171.91,58.37,416.02,fee schedule,,,
HC Pt Eval Mod Complex,PX-42400004,CDM,97162,CPT,424,RC,,,outpatient,,,260,182,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,171.91,,,171.91,58.37,416.02,fee schedule,,,
HC Pt Eval High Complex,PX-42400005,CDM,97163,CPT,424,RC,,,outpatient,,,260,182,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,171.91,,,171.91,58.37,416.02,fee schedule,,,
HC Pt Re-Eval Est Plan Care,PX-42400006,CDM,97164,CPT,424,RC,,,outpatient,,,231,161.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,117.4,,,117.4,51.8595,416.02,fee schedule,,,
HC Therapeut Actvity Direct Pt Contact Each 15 Min,PX-42100019,CDM,97530,CPT,421,RC,,,outpatient,,,115,80.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,144.61,,,144.61,25.8175,416.02,per diem,,,
HC Self-Care/Home Mgmt Training Each 15 Minutes,PX-42100020,CDM,97535,CPT,421,RC,,,outpatient,,,115,80.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,144.61,,,144.61,25.8175,416.02,per diem,,,
HC Orthotic Mgmt and Training- Each 15 Min,PX-42100027,CDM,97760,CPT,421,RC,,,outpatient,,,115,80.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,144.61,,,144.61,25.8175,416.02,per diem,,,
HC Prosthetic Training- Each 15 Min,PX-42100028,CDM,97761,CPT,421,RC,,,outpatient,,,104,72.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,144.61,,,144.61,23.348,416.02,per diem,,,
HC Med Nutr Ther- 1st- Indiv- Ea 15 Min,PX-94200006,CDM,97802,CPT,942,RC,,,outpatient,,,182,127.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,68.29,,,68.29,34.45,416.02,fee schedule,,,
HC Med Nutr Ther- Subsq- Indiv- Ea 15 Min,PX-94200007,CDM,97803,CPT,942,RC,,,outpatient,,,106,74.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,58.34,,,58.34,23.797,416.02,fee schedule,,,
HC Med Nutr Ther- Group- Ea 30 Min,PX-94200008,CDM,97804,CPT,942,RC,,,outpatient,,,52,36.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,31.99,,,31.99,11.674,416.02,fee schedule,,,
HC Mod Sed Same Phys/Qhp <5 Yrs,PX-37000019,CDM,99151,CPT,370,RC,,,outpatient,,,230,161,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.635,416.02,other,SI=N Exclusions ,,
HC Mod Sed Same Phys/Qhp 5/>Yrs,PX-37000020,CDM,99152,CPT,370,RC,,,outpatient,,,240,168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,53.88,416.02,other,SI=N Exclusions ,,
HC Mod Sed Same Phys/Qhp Ea,PX-37000021,CDM,99153,CPT,370,RC,,,outpatient,,,240,168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,53.88,416.02,other,SI=N Exclusions ,,
HC Mod Sed Oth Phys/Qhp <5 Yrs,PX-37000022,CDM,99155,CPT,370,RC,,,outpatient,,,361,252.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,81.0445,416.02,other,SI=N Exclusions ,,
HC Mod Sed Oth Phys/Qhp 5/>Yrs,PX-37000023,CDM,99156,CPT,370,RC,,,outpatient,,,240,168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,53.88,416.02,other,SI=N Exclusions ,,
HC Mod Sed Other Phys/Qhp Ea,PX-37000024,CDM,99157,CPT,370,RC,,,outpatient,,,330,231,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,74.085,416.02,other,SI=N Exclusions ,,
HC Phlebotomy,PX-94000006,CDM,99195,CPT,300,RC,,,outpatient,,,312,218.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,145.15,,,145.15,70.044,416.02,fee schedule,,,
HC Office/Outpatient New Sf Mdm 15-29 Minutes,PX-51000025,CDM,99202,CPT,510,RC,,,outpatient,,,387,270.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,100.01,,,100.01,82.56,416.02,fee schedule,,,
HC Office/Outpatient New Low Mdm 30-44 Minutes,PX-51000026,CDM,99203,CPT,510,RC,,,outpatient,,,573,401.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,150,,,150,126.37,473.871,fee schedule,,,
HC Office/Outpatient New Moderate Mdm 45-59 Minutes,PX-51000027,CDM,99204,CPT,510,RC,,,outpatient,,,838,586.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,253.92,,,253.92,179.35,693.026,fee schedule,,,
HC Office/Outpatient New High Mdm 60-74 Minutes,PX-51000028,CDM,99205,CPT,510,RC,,,outpatient,,,1192,834.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,331.4,,,331.4,146.954008,985.784,fee schedule,,,
HC Office/Outpatient Est Pt May Not Req Phys/Qhp,PX-51000029,CDM,99211,CPT,510,RC,,,outpatient,,,287,200.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18.12,,,18.12,18.1184,416.02,fee schedule,,,
HC Office/Outpatient Est Pt May Not Req Phys/Qhp,PX-76100002,CDM,99211,CPT,761,RC,,,outpatient,,,287,200.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18.12,,,18.12,18.1184,416.02,fee schedule,,,
HC Office/Outpatient Est Pt May Not Req Phys/Qhp,PX-94200014,CDM,99211,CPT,942,RC,,,outpatient,,,287,200.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,18.12,,,18.12,18.1184,416.02,fee schedule,,,
HC Office/Outpatient Established Sf Mdm 10-19 Min,PX-51000030,CDM,99212,CPT,761,RC,,,outpatient,,,394,275.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,50.24,,,50.24,50.2428,416.02,fee schedule,,,
HC Office/Outpatient Established Sf Mdm 10-19 Min,PX-94200015,CDM,99212,CPT,761,RC,,,outpatient,,,394,275.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,50.24,,,50.24,50.2428,416.02,fee schedule,,,
HC PR Office/Outpatient Established Sf Mdm 10-19 Min,PX-98800012,CDM,99212,CPT,761,RC,,,outpatient,,,373,261.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,50.24,,,50.24,50.2428,416.02,fee schedule,,,
HC Office/Outpatient Established Low Mdm 20-29 Min,PX-51000031,CDM,99213,CPT,510,RC,,,outpatient,,,431,301.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,100.47,,,100.47,90.68,416.02,fee schedule,,,
HC Office/Outpatient Established Low Mdm 20-29 Min,PX-94200016,CDM,99213,CPT,942,RC,,,outpatient,,,431,301.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,100.47,,,100.47,90.68,416.02,fee schedule,,,
HC Office/Outpatient Established Mod Mdm 30-39 Min,PX-51000032,CDM,99214,CPT,510,RC,,,outpatient,,,467,326.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,154.91,,,154.91,104.8415,416.02,fee schedule,,,
HC Office/Outpatient Established Mod Mdm 30-39 Min,PX-94200020,CDM,99214,CPT,942,RC,,,outpatient,,,467,326.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,154.91,,,154.91,104.8415,416.02,fee schedule,,,
HC Office/Outpatient Established High Mdm 40-54 Min,PX-51000033,CDM,99215,CPT,510,RC,,,outpatient,,,829,580.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,218.39,,,218.39,169.273,685.583,fee schedule,,,
HC Office/Outpatient Established High Mdm 40-54 Min,PX-94200021,CDM,99215,CPT,942,RC,,,outpatient,,,754,527.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,218.39,,,218.39,169.273,685.583,fee schedule,,,
HC Critical Care Ill/Injured Patient Init 30-74 Min,PX-76000001,CDM,99291,CPT,760,RC,,,outpatient,,,3157,2209.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1008.74,,,1008.74,318.748996,2424.576,fee schedule,,,
HC PR Critical Care Ill/Injured Patient Init 30-74 Min,PX-96000052,CDM,99291,CPT,960,RC,,,outpatient,,,3157,2209.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1008.74,,,1008.74,318.748996,2424.576,fee schedule,,,
HC Critical Care Ill/Injured Patient Addl 30 Min,PX-76000002,CDM,99292,CPT,760,RC,,,outpatient,,,911,637.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,204.5195,699.648,other,SI=N Exclusions ,,
HC PR Critical Care Ill/Injured Patient Addl 30 Min,PX-96000053,CDM,99292,CPT,960,RC,,,outpatient,,,911,637.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,204.5195,699.648,other,SI=N Exclusions ,,
HC Tobacco Use Cessation Intermediate 3-10 Minutes,PX-94200022,CDM,99406,CPT,942,RC,,,outpatient,,,214,149.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,45.5,,,45.5,31.31797,416.02,fee schedule,,,
HC Tobacco Use Cessation Intensive >10 Minutes,PX-94200025,CDM,99407,CPT,942,RC,,,outpatient,,,214,149.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,45.5,,,45.5,31.31797,416.02,fee schedule,,,
TPN ELECTROLYTES IV CONC,RX-110242,CDM,25000001,HCPCS,250,RC,00409-5779-01,NDC,outpatient,20,ML,32.85,22.995,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,27.84,0.74534,528.0548,percent of total billed charges,,,
PHENYLEPHRINE INTRACAVERNOSAL IN NS 100 MCG/ML SYRINGE,RX-141326,CDM,25000001,HCPCS,250,RC,70092-1046-46,NDC,outpatient,10,ML,24.79,17.353,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,21.01,0.74534,528.0548,percent of total billed charges,,,
PHENYLEPHRINE INTRACAVERNOSAL IN NS 100 MCG/ML SYRINGE,RX-141326,CDM,25000001,HCPCS,250,RC,99999-0003-10,NDC,outpatient,10,ML,15.37,10.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,13.03,0.74534,528.0548,percent of total billed charges,,,
PHENYLEPHRINE INTRACAVERNOSAL IN NS 100 MCG/ML SYRINGE,RX-141326,CDM,25000001,HCPCS,250,RC,70004-0810-11,NDC,outpatient,5,ML,23.81,16.667,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,20.18,0.74534,528.0548,percent of total billed charges,,,
TALC 4 G PL POWD,RX-142785,CDM,25000001,HCPCS,250,RC,62327-0444-44,NDC,outpatient,1,UN,623,436.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,528.05,0.74534,528.0548,percent of total billed charges,,,
TALC 4 G PL POWD,RX-142785,CDM,25000001,HCPCS,250,RC,62327-0444-04,NDC,outpatient,1,UN,623,436.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,528.05,0.74534,528.0548,percent of total billed charges,,,
HYPERLYTE-CR IV CONC,RX-150262,CDM,25000001,HCPCS,250,RC,00409-5779-11,NDC,outpatient,20,ML,32.85,22.995,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,27.84,0.74534,528.0548,percent of total billed charges,,,
HYPERLYTE-CR IV CONC,RX-150262,CDM,25000001,HCPCS,250,RC,00409-5779-01,NDC,outpatient,20,ML,32.85,22.995,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,27.84,0.74534,528.0548,percent of total billed charges,,,
CLINIMIX E/DEXTROSE (8/14) 8 % IV SOLN,RX-152282,CDM,25000001,HCPCS,250,RC,00338-0202-06,NDC,outpatient,1000,ML,162.85,113.995,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,138.03,0.74534,528.0548,percent of total billed charges,,,
CLINIMIX E/DEXTROSE (8/14) 8 % IV SOLN,RX-152282,CDM,25000001,HCPCS,250,RC,00338-0206-04,NDC,outpatient,2000,ML,283,198.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,239.87,0.74534,528.0548,percent of total billed charges,,,
CLINIMIX E/DEXTROSE (8/14) 8 % IV SOLN,RX-152282,CDM,25000001,HCPCS,250,RC,00338-0206-01,NDC,outpatient,2000,ML,283,198.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,239.87,0.74534,528.0548,percent of total billed charges,,,
CLINIMIX E/DEXTROSE (8/14) 8 % IV SOLN,RX-152282,CDM,25000001,HCPCS,250,RC,00338-0202-01,NDC,outpatient,1000,ML,162.85,113.995,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,138.03,0.74534,528.0548,percent of total billed charges,,,
CLINIMIX E/DEXTROSE (8/10) 8 % IV SOLN,RX-152283,CDM,25000001,HCPCS,250,RC,00338-0214-01,NDC,outpatient,2000,ML,238.5,166.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,202.15,0.74534,528.0548,percent of total billed charges,,,
CLINIMIX E/DEXTROSE (8/10) 8 % IV SOLN,RX-152283,CDM,25000001,HCPCS,250,RC,00338-0210-01,NDC,outpatient,1000,ML,153.95,107.765,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,130.49,0.74534,528.0548,percent of total billed charges,,,
CLINIMIX E/DEXTROSE (8/10) 8 % IV SOLN,RX-152283,CDM,25000001,HCPCS,250,RC,00338-0214-04,NDC,outpatient,2000,ML,238.5,166.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,202.15,0.74534,528.0548,percent of total billed charges,,,
CLINIMIX E/DEXTROSE (8/10) 8 % IV SOLN,RX-152283,CDM,25000001,HCPCS,250,RC,00338-0210-06,NDC,outpatient,1000,ML,153.95,107.765,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,130.49,0.74534,528.0548,percent of total billed charges,,,
CLINIMIX/DEXTROSE (8/14) 8 % IV SOLN,RX-152285,CDM,25000001,HCPCS,250,RC,00338-0184-04,NDC,outpatient,2000,ML,274.1,191.87,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,232.33,0.74534,528.0548,percent of total billed charges,,,
CLINIMIX/DEXTROSE (8/14) 8 % IV SOLN,RX-152285,CDM,25000001,HCPCS,250,RC,00338-0184-01,NDC,outpatient,2000,ML,274.1,191.87,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,232.33,0.74534,528.0548,percent of total billed charges,,,
CLINIMIX/DEXTROSE (8/10) 8 % IV SOLN,RX-152286,CDM,25000001,HCPCS,250,RC,00338-0194-04,NDC,outpatient,2000,ML,229.6,160.72,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,194.61,0.74534,528.0548,percent of total billed charges,,,
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML IV SOLN,RX-156196,CDM,25000001,HCPCS,250,RC,00517-9302-01,NDC,outpatient,1,ML,76.19,53.333,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,64.58,0.74534,528.0548,percent of total billed charges,,,
TRACE MINERALS CU-MN-SE-ZN 60-3-6-1000 MCG/ML IV SOLN,RX-156196,CDM,25000001,HCPCS,250,RC,00517-9302-25,NDC,outpatient,1,ML,76.19,53.333,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,64.58,0.74534,528.0548,percent of total billed charges,,,
FAT EMULS PLANT BASE(SOY/OLIV) 20 % IV EMUL,RX-156373,CDM,25000001,HCPCS,250,RC,00338-9540-02,NDC,outpatient,250,ML,57.17,40.019,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,48.46,0.74534,528.0548,percent of total billed charges,,,
FAT EMULS PLANT BASE(SOY/OLIV) 20 % IV EMUL,RX-156373,CDM,25000001,HCPCS,250,RC,00338-9540-03,NDC,outpatient,500,ML,69.4,48.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,58.82,0.74534,528.0548,percent of total billed charges,,,
FAT EMULS PLANT BASE(SOY/OLIV) 20 % IV EMUL,RX-156373,CDM,25000001,HCPCS,250,RC,00338-9540-06,NDC,outpatient,250,ML,57.17,40.019,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,48.46,0.74534,528.0548,percent of total billed charges,,,
FAT EMULS PLANT BASE(SOY/OLIV) 20 % IV EMUL,RX-156373,CDM,25000001,HCPCS,250,RC,00338-9540-07,NDC,outpatient,500,ML,69.4,48.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,58.82,0.74534,528.0548,percent of total billed charges,,,
PRISMASOL BGK 4/0/1.2 32-4-1.2 MEQ/L EC SOLN,RX-156745,CDM,25000001,HCPCS,250,RC,24571-0114-06,NDC,outpatient,5000,ML,294.88,206.416,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,249.94,0.74534,528.0548,percent of total billed charges,,,
MORPHINE SULFATE 100 MG IN D5W 100 ML PREMIX,RX-166979,CDM,25000001,HCPCS,250,RC,99999-0003-25,NDC,outpatient,100,ML,48.85,34.195,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,41.41,0.74534,528.0548,percent of total billed charges,,,
ALUMINUM POTASSIUM SULFATE POWD,RX-21429,CDM,25000001,HCPCS,250,RC,24357-0300-30,NDC,outpatient,10,GR,267.27,187.089,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,226.54,0.74534,528.0548,percent of total billed charges,,,
TROPHAMINE 10 % IV SOLN,RX-25798,CDM,25000001,HCPCS,250,RC,00264-1933-10,NDC,outpatient,500,ML,198.45,138.915,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,168.21,0.74534,528.0548,percent of total billed charges,,,
GENTAMICIN IV SYRINGE 4 MG/ML (PEDIATRIC),RX-400058,CDM,25000001,HCPCS,250,RC,99999-0000-52,NDC,outpatient,10,ML,50.94,35.658,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,43.18,0.74534,528.0548,percent of total billed charges,,,
GENTAMICIN IV SYRINGE 4 MG/ML (PEDIATRIC),RX-400058,CDM,25000001,HCPCS,250,RC,99999-0001-20,NDC,outpatient,5,ML,36.18,25.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,30.67,0.74534,528.0548,percent of total billed charges,,,
AMINOCAPROIC ACID INFUSION (OPEN HEART),RX-400081,CDM,25000001,HCPCS,250,RC,99999-0000-86,NDC,outpatient,150,ML,97.97,68.579,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,83.04,0.74534,528.0548,percent of total billed charges,,,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,25000001,HCPCS,250,RC,00338-0043-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,22.27,0.74534,528.0548,percent of total billed charges,,,
SODIUM CHLORIDE 0.45 % IV BOLUS,RX-400292,CDM,25000001,HCPCS,250,RC,00338-0043-03,NDC,outpatient,500,ML,23.71,16.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,20.1,0.74534,528.0548,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % IV SOLN FOR COMPOUNDING,RX-4080675,CDM,25000001,HCPCS,250,RC,00409-4888-02,NDC,outpatient,10,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2.81,0.74534,528.0548,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % IV SOLN FOR COMPOUNDING,RX-4080675,CDM,25000001,HCPCS,250,RC,00338-0049-31,NDC,outpatient,50,ML,6.43,4.501,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,5.45,0.74534,528.0548,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % IV SOLN FOR COMPOUNDING,RX-4080675,CDM,25000001,HCPCS,250,RC,00409-4888-10,NDC,outpatient,10,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2.81,0.74534,528.0548,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % IV SOLN FOR COMPOUNDING,RX-4080675,CDM,25000001,HCPCS,250,RC,00409-4888-12,NDC,outpatient,10,ML,9.82,6.874,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,8.32,0.74534,528.0548,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % IV SOLN FOR COMPOUNDING,RX-4080675,CDM,25000001,HCPCS,250,RC,63323-0186-10,NDC,outpatient,10,ML,3.71,2.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,3.14,0.74534,528.0548,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % IV SOLN FOR COMPOUNDING,RX-4080675,CDM,25000001,HCPCS,250,RC,00409-4888-01,NDC,outpatient,10,ML,9.82,6.874,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,8.32,0.74534,528.0548,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % IV SOLN FOR COMPOUNDING,RX-4080675,CDM,25000001,HCPCS,250,RC,63323-0186-01,NDC,outpatient,10,ML,3.71,2.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,3.14,0.74534,528.0548,percent of total billed charges,,,
STERILE WATER FOR INJECTION COMPOUNDING ONLY,RX-4080705,CDM,25000001,HCPCS,250,RC,00338-0013-04,NDC,outpatient,1000,ML,10.28,7.196,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,8.71,0.74534,528.0548,percent of total billed charges,,,
STERILE WATER FOR INJECTION COMPOUNDING ONLY,RX-4080705,CDM,25000001,HCPCS,250,RC,00409-4887-99,NDC,outpatient,100,ML,13.88,9.716,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,11.76,0.74534,528.0548,percent of total billed charges,,,
STERILE WATER FOR INJECTION COMPOUNDING ONLY,RX-4080705,CDM,25000001,HCPCS,250,RC,00409-4887-10,NDC,outpatient,10,ML,3.6,2.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,3.05,0.74534,528.0548,percent of total billed charges,,,
STERILE WATER FOR INJECTION COMPOUNDING ONLY,RX-4080705,CDM,25000001,HCPCS,250,RC,00409-4887-17,NDC,outpatient,10,ML,3.6,2.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,3.05,0.74534,528.0548,percent of total billed charges,,,
STERILE WATER FOR INJECTION COMPOUNDING ONLY,RX-4080705,CDM,25000001,HCPCS,250,RC,63323-0185-10,NDC,outpatient,10,ML,4.07,2.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,3.45,0.74534,528.0548,percent of total billed charges,,,
STERILE WATER FOR INJECTION COMPOUNDING ONLY,RX-4080705,CDM,25000001,HCPCS,250,RC,00409-4887-20,NDC,outpatient,20,ML,4.84,3.388,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,4.1,0.74534,528.0548,percent of total billed charges,,,
STERILE WATER FOR INJECTION COMPOUNDING ONLY,RX-4080705,CDM,25000001,HCPCS,250,RC,00409-4887-25,NDC,outpatient,100,ML,13.88,9.716,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,11.76,0.74534,528.0548,percent of total billed charges,,,
STERILE WATER FOR INJECTION COMPOUNDING ONLY,RX-4080705,CDM,25000001,HCPCS,250,RC,00409-4887-23,NDC,outpatient,20,ML,4.84,3.388,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,4.1,0.74534,528.0548,percent of total billed charges,,,
STERILE WATER FOR INJECTION COMPOUNDING ONLY,RX-4080705,CDM,25000001,HCPCS,250,RC,63323-0185-20,NDC,outpatient,20,ML,7,4.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,5.93,0.74534,528.0548,percent of total billed charges,,,
SUGAMMADEX SODIUM 100 MG/ML IV SOLN WRAPPER,RX-4080830,CDM,25000001,HCPCS,250,RC,00006-5423-02,NDC,outpatient,2,ML,533.12,373.184,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,451.87,0.74534,528.0548,percent of total billed charges,,,
SUGAMMADEX SODIUM 100 MG/ML IV SOLN WRAPPER,RX-4080830,CDM,25000001,HCPCS,250,RC,00006-5423-12,NDC,outpatient,2,ML,533.12,373.184,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,451.87,0.74534,528.0548,percent of total billed charges,,,
DEXMEDETOMIDINE HCL IN NACL 4 MCG/ML IV SOLN WRAPPER,RX-4080915,CDM,25000001,HCPCS,250,RC,00338-9557-12,NDC,outpatient,100,ML,89.43,62.601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,75.8,0.74534,528.0548,percent of total billed charges,,,
DILTIAZEM 100 MG IN 100 ML D5W BATCHED INFUSION,RX-4080938,CDM,25000001,HCPCS,250,RC,99999-0000-30,NDC,outpatient,100,ML,48.09,33.663,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,40.76,0.74534,528.0548,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % CRRT SOLN,RX-4081079,CDM,25000001,HCPCS,250,RC,00338-0049-04,NDC,outpatient,1000,ML,21.14,14.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,17.92,0.74534,528.0548,percent of total billed charges,,,
SODIUM CHLORIDE 0.9 % CRRT SOLN,RX-4081079,CDM,25000001,HCPCS,250,RC,00338-0049-03,NDC,outpatient,500,ML,23.71,16.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,20.1,0.74534,528.0548,percent of total billed charges,,,
FAMOTIDINE IN NS (NEO/PEDI) SYRINGE 0.4 MG/ML,RX-4081338,CDM,25000001,HCPCS,250,RC,00338-5197-41,NDC,outpatient,50,ML,24.23,16.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,20.54,0.74534,528.0548,percent of total billed charges,,,
PANTOPRAZOLE 80 MG/100 ML BOLUS/LOADING DOSE PREMIX,RX-4081495,CDM,25000001,HCPCS,250,RC,99999-0004-21,NDC,outpatient,100,ML,36.56,25.592,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,30.99,0.74534,528.0548,percent of total billed charges,,,
CARDIOPLEGIA SOLN HIGH POTASSIUM 60 MEQ + MG 65 MEQ IN 500 ML OF NS,RX-4081526,CDM,25000001,HCPCS,250,RC,99999-0004-32,NDC,outpatient,500,ML,78.75,55.125,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,66.75,0.74534,528.0548,percent of total billed charges,,,
VANCOMYCIN INTRAOSSEOUS 500 MG/50 ML NS SYR,RX-4081621,CDM,25000001,HCPCS,250,RC,99999-0004-52,NDC,outpatient,50,ML,33.99,23.793,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,28.81,0.74534,528.0548,percent of total billed charges,,,
TRAVASOL 10 % IV SOLN,RX-8074,CDM,25000001,HCPCS,250,RC,00338-0644-06,NDC,outpatient,2000,ML,122.8,85.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,104.09,0.74534,528.0548,percent of total billed charges,,,
TRAVASOL 10 % IV SOLN,RX-8074,CDM,25000001,HCPCS,250,RC,00338-0644-04,NDC,outpatient,1000,ML,78.3,54.81,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,66.37,0.74534,528.0548,percent of total billed charges,,,
ZINC OXIDE 16 % EX OINT,RX-109467,CDM,25900001,HCPCS,259,RC,62103-0333-04,NDC,outpatient,113,GR,20.62,14.434,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,17.48,0.222255,1203.778472,percent of total billed charges,,,
GLYCOPYRROLATE-FORMOTEROL 9-4.8 MCG/ACT IN AERO,RX-135283,CDM,25900001,HCPCS,259,RC,00310-4600-12,NDC,outpatient,10.7,GR,1420.22,994.154,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1203.78,0.222255,1203.778472,percent of total billed charges,,,
MULTIVITAMINS PLUS IRON CHILD 18 MG ORAL CHEW,RX-138485,CDM,25900001,HCPCS,259,RC,16500-0079-09,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,0.84,0.222255,1203.778472,percent of total billed charges,,,
MULTIVITAMINS PLUS IRON CHILD 18 MG ORAL CHEW,RX-138485,CDM,25900001,HCPCS,259,RC,16500-0599-20,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,0.84,0.222255,1203.778472,percent of total billed charges,,,
DAKINS (FULL STRENGTH) 0.5 % EX SOLN,RX-148710,CDM,25900001,HCPCS,259,RC,00436-0946-16,NDC,outpatient,473,ML,52.63,36.841,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,44.61,0.222255,1203.778472,percent of total billed charges,,,
DAKINS (FULL STRENGTH) 0.5 % EX SOLN,RX-148710,CDM,25900001,HCPCS,259,RC,39328-0062-50,NDC,outpatient,473,ML,44.21,30.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,37.47,0.222255,1203.778472,percent of total billed charges,,,
HYDROCORTISONE (PERIANAL) 2.5 % EX CREA,RX-150300,CDM,25900001,HCPCS,259,RC,62559-0431-30,NDC,outpatient,30,GR,76.9,53.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,65.18,0.222255,1203.778472,percent of total billed charges,,,
HYDROCORTISONE (PERIANAL) 2.5 % EX CREA,RX-150300,CDM,25900001,HCPCS,259,RC,69315-0312-28,NDC,outpatient,28,GR,33.65,23.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,28.52,0.222255,1203.778472,percent of total billed charges,,,
HYDROCORTISONE (PERIANAL) 2.5 % EX CREA,RX-150300,CDM,25900001,HCPCS,259,RC,10631-0407-01,NDC,outpatient,28.35,GR,38.36,26.852,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,32.51,0.222255,1203.778472,percent of total billed charges,,,
HYDROCORTISONE (PERIANAL) 2.5 % EX CREA,RX-150300,CDM,25900001,HCPCS,259,RC,64980-0324-30,NDC,outpatient,30,GR,25.77,18.039,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,21.84,0.222255,1203.778472,percent of total billed charges,,,
PRAMOXINE HCL (PERIANAL) 1 % EX FOAM,RX-150306,CDM,25900001,HCPCS,259,RC,51862-0180-15,NDC,outpatient,15,GR,166.95,116.865,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,141.51,0.222255,1203.778472,percent of total billed charges,,,
HYDROCORT-PRAMOXINE (PERIANAL) 1-1 % EX FOAM,RX-150328,CDM,25900001,HCPCS,259,RC,00037-6822-10,NDC,outpatient,10,GR,761.13,532.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,645.13,0.222255,1203.778472,percent of total billed charges,,,
PRIMAQUINE PHOSPHATE 26.3 (15 BASE) MG ORAL TABS,RX-155613,CDM,25900001,HCPCS,259,RC,76385-0102-01,NDC,outpatient,1,UN,5.96,4.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,5.05,0.222255,1203.778472,percent of total billed charges,,,
ZANAMIVIR 5 MG/ACT IN AEPB,RX-160595,CDM,25900001,HCPCS,259,RC,00173-0681-01,NDC,outpatient,20,UN,240.22,168.154,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,203.61,0.222255,1203.778472,percent of total billed charges,,,
DIPHENHYDRAMINE-ZINC ACETATE 2-0.1 % EX CREA,RX-16299,CDM,25900001,HCPCS,259,RC,45802-0358-03,NDC,outpatient,28,GR,4.62,3.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,3.92,0.222255,1203.778472,percent of total billed charges,,,
GLYCERIN (LIQUID) 2.8 G RE SUPP,RX-163739,CDM,25900001,HCPCS,259,RC,00132-0190-12,NDC,outpatient,4,ML,3,2.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2.54,0.222255,1203.778472,percent of total billed charges,,,
FERROUS SULFATE 300 (60 FE) MG/5ML ORAL SOLN,RX-165823,CDM,25900001,HCPCS,259,RC,00121-0530-05,NDC,outpatient,5,ML,13.51,9.457,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,11.45,0.222255,1203.778472,percent of total billed charges,,,
FERROUS SULFATE 300 (60 FE) MG/5ML ORAL SOLN,RX-165823,CDM,25900001,HCPCS,259,RC,63739-0157-70,NDC,outpatient,5,ML,6.5,4.55,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,5.51,0.222255,1203.778472,percent of total billed charges,,,
FERROUS SULFATE 300 (60 FE) MG/5ML ORAL SOLN,RX-165823,CDM,25900001,HCPCS,259,RC,63739-0157-10,NDC,outpatient,5,ML,6.5,4.55,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,5.51,0.222255,1203.778472,percent of total billed charges,,,
PSYLLIUM 25 % ORAL PACK,RX-166710,CDM,25900001,HCPCS,259,RC,37000-0023-04,NDC,outpatient,1,UN,2.18,1.526,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1.85,0.222255,1203.778472,percent of total billed charges,,,
PSYLLIUM 25 % ORAL PACK,RX-166710,CDM,25900001,HCPCS,259,RC,37000-0023-10,NDC,outpatient,1,UN,2.18,1.526,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1.85,0.222255,1203.778472,percent of total billed charges,,,
ASTROGLIDE EX GEL,RX-23759,CDM,25900001,HCPCS,259,RC,15594-0010-07,NDC,outpatient,66.5,GR,20.13,14.091,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,17.06,0.222255,1203.778472,percent of total billed charges,,,
CORN STARCH EX POWD,RX-28839,CDM,25900001,HCPCS,259,RC,00316-0233-25,NDC,outpatient,71,GR,13.91,9.737,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,11.79,0.222255,1203.778472,percent of total billed charges,,,
GLYCERIN (LAXATIVE) 5.4 GM/DOSE RE ENEM,RX-37495,CDM,25900001,HCPCS,259,RC,00132-0185-82,NDC,outpatient,7.5,ML,3.54,2.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,3,0.222255,1203.778472,percent of total billed charges,,,
GLYCERIN (LAXATIVE) 5.4 GM/DOSE RE ENEM,RX-37495,CDM,25900001,HCPCS,259,RC,00132-0185-01,NDC,outpatient,7.5,ML,3.54,2.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,3,0.222255,1203.778472,percent of total billed charges,,,
HYOSCYAMINE SULFATE 0.125 MG/ML ORAL SOLN,RX-3782,CDM,25900001,HCPCS,259,RC,39328-0047-15,NDC,outpatient,15,ML,86.71,60.697,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,73.5,0.222255,1203.778472,percent of total billed charges,,,
HYOSCYAMINE SULFATE 0.125 MG/ML ORAL SOLN,RX-3782,CDM,25900001,HCPCS,259,RC,54838-0506-15,NDC,outpatient,15,ML,121.96,85.372,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,103.37,0.222255,1203.778472,percent of total billed charges,,,
GENTAMICIN FORTIFIED EYE SOLUTION 14 MG/ML,RX-4080014,CDM,25900001,HCPCS,259,RC,99999-0001-32,NDC,outpatient,7,ML,17.67,12.369,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,14.98,0.222255,1203.778472,percent of total billed charges,,,
LACTULOSE ENEMA IN STERILE WATER 1000 ML,RX-4080406,CDM,25900001,HCPCS,259,RC,,,outpatient,1000,ML,16.47,11.529,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,13.96,0.222255,1203.778472,percent of total billed charges,,,
LACTULOSE ENEMA IN SODIUM CHLORIDE 0.9 % 1000 ML,RX-4080407,CDM,25900001,HCPCS,259,RC,99999-0001-00,NDC,outpatient,1000,ML,16.47,11.529,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,13.96,0.222255,1203.778472,percent of total billed charges,,,
WITCH HAZEL-GLYCERIN EX PADS WRAPPER,RX-4080503,CDM,25900001,HCPCS,259,RC,50289-3250-01,NDC,outpatient,40,UN,9.62,6.734,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,8.15,0.222255,1203.778472,percent of total billed charges,,,
LIDOCAINE HCL 2 % EX GEL UROJET,RX-4080776,CDM,25900001,HCPCS,259,RC,76329-3011-05,NDC,outpatient,5,ML,18.29,12.803,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,15.5,0.222255,1203.778472,percent of total billed charges,,,
LIDOCAINE HCL 2 % EX GEL UROJET,RX-4080776,CDM,25900001,HCPCS,259,RC,76329-3013-05,NDC,outpatient,10,ML,24.12,16.884,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,20.44,0.222255,1203.778472,percent of total billed charges,,,
LIDOCAINE HCL 2 % EX GEL UROJET,RX-4080776,CDM,25900001,HCPCS,259,RC,76329-3015-05,NDC,outpatient,20,ML,33.02,23.114,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,27.99,0.222255,1203.778472,percent of total billed charges,,,
LIDOCAINE HCL 2 % EX GEL UROJET,RX-4080776,CDM,25900001,HCPCS,259,RC,76329-3012-05,NDC,outpatient,5,ML,18.29,12.803,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,15.5,0.222255,1203.778472,percent of total billed charges,,,
CLONIDINE NEONATAL SUSPENSION 5 MCG/ML,RX-4080796,CDM,25900001,HCPCS,259,RC,99999-0001-04,NDC,outpatient,1,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,0.84,0.222255,1203.778472,percent of total billed charges,,,
VANCOMYCIN 50 MG/ML ORAL SOLN WRAPPER,RX-4081075,CDM,25900001,HCPCS,259,RC,99999-0000-64,NDC,outpatient,2.5,ML,10.08,7.056,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,8.54,0.222255,1203.778472,percent of total billed charges,,,
VANCOMYCIN 50 MG/ML ORAL SOLN WRAPPER,RX-4081075,CDM,25900001,HCPCS,259,RC,65628-0206-05,NDC,outpatient,2.5,ML,10.08,7.056,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,8.54,0.222255,1203.778472,percent of total billed charges,,,
OXYMETAZOLINE HCL 0.05 % NA SOLN,RX-5943,CDM,25900001,HCPCS,259,RC,41100-0015-11,NDC,outpatient,15,ML,31.71,22.197,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,26.88,0.222255,1203.778472,percent of total billed charges,,,
OXYMETAZOLINE HCL 0.05 % NA SOLN,RX-5943,CDM,25900001,HCPCS,259,RC,41100-0811-23,NDC,outpatient,15,ML,25.17,17.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,21.33,0.222255,1203.778472,percent of total billed charges,,,
OXYMETAZOLINE HCL 0.05 % NA SOLN,RX-5943,CDM,25900001,HCPCS,259,RC,49348-0130-27,NDC,outpatient,30,ML,16.69,11.683,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,14.15,0.222255,1203.778472,percent of total billed charges,,,
OXYMETAZOLINE HCL 0.05 % NA SOLN,RX-5943,CDM,25900001,HCPCS,259,RC,00904-7006-35,NDC,outpatient,15,ML,6.41,4.487,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,5.43,0.222255,1203.778472,percent of total billed charges,,,
SULFUR PRECIPITATED POWD,RX-7576,CDM,25900001,HCPCS,259,RC,38779-0098-08,NDC,outpatient,500,GR,142.38,99.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,120.68,0.222255,1203.778472,percent of total billed charges,,,
DISCONTINUED BRAND PRODUCT - PROAIR HFA 108 (90 BASE) MCG/ACT IN AERS (ALBUTEROL),RX-76821,CDM,25900001,HCPCS,259,RC,66993-0019-68,NDC,outpatient,18,GR,146.67,102.669,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,124.32,0.222255,1203.778472,percent of total billed charges,,,
DISCONTINUED BRAND PRODUCT - PROAIR HFA 108 (90 BASE) MCG/ACT IN AERS (ALBUTEROL),RX-76821,CDM,25900001,HCPCS,259,RC,00173-0682-24,NDC,outpatient,8,GR,92.49,64.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,78.39,0.222255,1203.778472,percent of total billed charges,,,
DISCONTINUED BRAND PRODUCT - PROAIR HFA 108 (90 BASE) MCG/ACT IN AERS (ALBUTEROL),RX-76821,CDM,25900001,HCPCS,259,RC,00093-3174-31,NDC,outpatient,8.5,GR,117.83,82.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,99.87,0.222255,1203.778472,percent of total billed charges,,,
DESMOPRESSIN ACE REFRIGERATED 0.01 % NA SOLN,RX-9749,CDM,25900001,HCPCS,259,RC,55566-2400-00,NDC,outpatient,2.5,ML,1134.27,793.989,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,961.41,0.222255,1203.778472,percent of total billed charges,,,
HC Onc. Vad Kit,PX-27000020,CDM,27000020,LOCAL,270,RC,,,outpatient,,,90,63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.205,72,other,SI=N Exclusions ,,
HC Imed Pump for Lvl II,PX-27000021,CDM,27000021,LOCAL,270,RC,,,outpatient,,,118,82.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.491,94.4,other,SI=N Exclusions ,,
HC Imed Pump,PX-27000022,CDM,27000022,LOCAL,270,RC,,,outpatient,,,113,79.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,25.3685,90.4,other,SI=N Exclusions ,,
HC Local Anesth Supplies,PX-27000023,CDM,27000023,LOCAL,270,RC,,,outpatient,,,80,56,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,17.96,64,other,SI=N Exclusions ,,
HC Periop O2,PX-27000044,CDM,27000044,LOCAL,270,RC,,,outpatient,,,79,55.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,17.7355,63.2,other,SI=N Exclusions ,,
HC Bone Bx Kit,PX-27000050,CDM,27000050,LOCAL,270,RC,,,outpatient,,,267,186.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,59.9415,213.6,other,SI=N Exclusions ,,
HC Kit Portex Nerve Block,PX-27000051,CDM,27000051,LOCAL,270,RC,,,outpatient,,,90,63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.205,72,other,SI=N Exclusions ,,
HC Cannister Vac W/O Gel Ats,PX-27000052,CDM,27000052,LOCAL,270,RC,,,outpatient,,,282,197.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,63.309,225.6,other,SI=N Exclusions ,,
HC Dressing Kci Small 5/Cs,PX-27000053,CDM,27000053,LOCAL,270,RC,,,outpatient,,,268,187.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.166,214.4,other,SI=N Exclusions ,,
HC Cannister W/Gel Ats,PX-27000054,CDM,27000054,LOCAL,270,RC,,,outpatient,,,283,198.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,63.5335,226.4,other,SI=N Exclusions ,,
HC Compression Stocking A6530,PX-27000055,CDM,27000055,LOCAL,270,RC,,,outpatient,,,285,199.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,63.9825,228,other,SI=N Exclusions ,,
HC Custom Molded Insert,PX-27000056,CDM,27000056,LOCAL,270,RC,,,outpatient,,,287,200.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,64.4315,229.6,other,SI=N Exclusions ,,
HC Dressing Kci Medium 10/Cs,PX-27000057,CDM,27000057,LOCAL,270,RC,,,outpatient,,,307,214.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,68.9215,245.6,other,SI=N Exclusions ,,
HC Surgical Boot/Shoe L3260,PX-27000058,CDM,27000058,LOCAL,270,RC,,,outpatient,,,423,296.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,94.9635,338.4,other,SI=N Exclusions ,,
HC Vaccum Assisted Closure Pump,PX-27000059,CDM,27000059,LOCAL,270,RC,,,outpatient,,,438,306.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,98.331,350.4,other,SI=N Exclusions ,,
HC Ortho Wedge Shoe,PX-27000060,CDM,27000060,LOCAL,270,RC,,,outpatient,,,529,370.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,118.7605,423.2,other,SI=N Exclusions ,,
HC Foot Pressure Support A9283,PX-27000061,CDM,27000061,LOCAL,270,RC,,,outpatient,,,529,370.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,118.7605,423.2,other,SI=N Exclusions ,,
HC Sensor Nicom,PX-27000062,CDM,27000062,LOCAL,270,RC,,,outpatient,,,816,571.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,183.192,652.8,other,SI=N Exclusions ,,
HC 6 Channel Pneumogram,PX-27000063,CDM,27000063,LOCAL,270,RC,,,outpatient,,,3884,2718.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,871.958,3107.2,other,SI=N Exclusions ,,
HC Pneumogram 4-Channel,PX-27000064,CDM,27000064,LOCAL,270,RC,,,outpatient,,,4891,3423.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1098.0295,3912.8,other,SI=N Exclusions ,,
HC Pad Artic Gel Large,PX-27000065,CDM,27000065,LOCAL,270,RC,,,outpatient,,,5242,3669.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1176.829,4193.6,other,SI=N Exclusions ,,
HC Pneumogram 6- Channel,PX-27000066,CDM,27000066,LOCAL,270,RC,,,outpatient,,,5466,3826.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1227.117,4372.8,other,SI=N Exclusions ,,
HC Therapy Polar Cooler,PX-27000068,CDM,27000068,LOCAL,270,RC,,,outpatient,,,667,466.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,149.7415,533.6,other,SI=N Exclusions ,,
HC Liner Foam Permanently Med,PX-27000069,CDM,27000069,LOCAL,270,RC,,,outpatient,,,353,247.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,79.2485,282.4,other,SI=N Exclusions ,,
HC Dressing Kci Vac Small,PX-27000070,CDM,27000070,LOCAL,270,RC,,,outpatient,,,327,228.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,73.4115,261.6,other,SI=N Exclusions ,,
HC Dressing Kci Vac Large,PX-27000071,CDM,27000071,LOCAL,270,RC,,,outpatient,,,390,273,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,87.555,312,other,SI=N Exclusions ,,
HC Developmental Aides,PX-27000072,CDM,27000072,LOCAL,270,RC,,,outpatient,,,707,494.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,158.7215,565.6,other,SI=N Exclusions ,,
"HC Ez Reacher 30"" Suction",PX-27100004,CDM,27100004,LOCAL,271,RC,,,outpatient,,,144,100.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,122.05,32.328,122.0544,percent of total billed charges,,,
HC Support Bra Ez-on Med 958,PX-27100005,CDM,27100005,LOCAL,271,RC,,,outpatient,,,262,183.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,222.07,58.819,222.0712,percent of total billed charges,,,
HC Support Bra Ez-on Lrg 958,PX-27100006,CDM,27100006,LOCAL,271,RC,,,outpatient,,,272,190.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,230.55,61.064,230.5472,percent of total billed charges,,,
HC Support Bra Ez-on X-Lrg 958,PX-27100007,CDM,27100007,LOCAL,271,RC,,,outpatient,,,306,214.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,259.37,68.697,259.3656,percent of total billed charges,,,
HC Support Bra Ez-on Queen,PX-27100008,CDM,27100008,LOCAL,271,RC,,,outpatient,,,377,263.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,319.55,84.6365,319.5452,percent of total billed charges,,,
HC Bra Ez-on Super Queen,PX-27100009,CDM,27100009,LOCAL,271,RC,,,outpatient,,,471,329.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,399.22,105.7395,399.2196,percent of total billed charges,,,
HC Gradient Com Stocking,PX-27100010,CDM,27100010,LOCAL,271,RC,,,outpatient,,,490,343,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,415.32,110.005,415.324,percent of total billed charges,,,
HC Kit Flexi Seal Fecal,PX-27100011,CDM,27100011,LOCAL,271,RC,,,outpatient,,,939,657.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,795.9,210.8055,795.8964,percent of total billed charges,,,
HC Port Power Loc Access Kit,PX-27200054,CDM,27200054,LOCAL,272,RC,,,outpatient,,,88,61.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,74.59,19.756,74.5888,percent of total billed charges,,,
HC Dressing Kci Vac White Lg,PX-27200055,CDM,27200055,LOCAL,272,RC,,,outpatient,,,95,66.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,80.52,21.3275,80.522,percent of total billed charges,,,
HC Sheath Brite Tip 11cm,PX-27200056,CDM,27200056,LOCAL,272,RC,,,outpatient,,,108,75.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,91.54,24.246,91.5408,percent of total billed charges,,,
HC Kit Refill Syncromed Sys. Pain,PX-27200057,CDM,27200057,LOCAL,272,RC,,,outpatient,,,128,89.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,108.49,28.736,108.4928,percent of total billed charges,,,
HC Sock Fracture,PX-27200058,CDM,27200058,LOCAL,272,RC,,,outpatient,,,193,135.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,163.59,43.3285,163.5868,percent of total billed charges,,,
HC Tube Gastrostomy Replacement,PX-27200059,CDM,27200059,LOCAL,272,RC,,,outpatient,,,195,136.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,165.28,43.7775,165.282,percent of total billed charges,,,
HC Mod of Depth Shoe,PX-27200060,CDM,27200060,LOCAL,272,RC,,,outpatient,,,225,157.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,190.71,50.5125,190.71,percent of total billed charges,,,
HC Catheter Broncho 39l,PX-27200061,CDM,27200061,LOCAL,272,RC,,,outpatient,,,349,244.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,295.81,78.3505,295.8124,percent of total billed charges,,,
HC Catheter Bronch 35 Left 95892,PX-27200062,CDM,27200062,LOCAL,272,RC,,,outpatient,,,349,244.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,295.81,78.3505,295.8124,percent of total billed charges,,,
HC Endo-Bronch Tube 37fr Left,PX-27200063,CDM,27200063,LOCAL,272,RC,,,outpatient,,,349,244.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,295.81,78.3505,295.8124,percent of total billed charges,,,
HC Tube Endo Bronch #35 Left,PX-27200064,CDM,27200064,LOCAL,272,RC,,,outpatient,,,349,244.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,295.81,78.3505,295.8124,percent of total billed charges,,,
HC Endo Bronch Tube #39,PX-27200065,CDM,27200065,LOCAL,272,RC,,,outpatient,,,349,244.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,295.81,78.3505,295.8124,percent of total billed charges,,,
HC Catheter Broncho 41l,PX-27200066,CDM,27200066,LOCAL,272,RC,,,outpatient,,,349,244.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,295.81,78.3505,295.8124,percent of total billed charges,,,
HC Kit Arterial Line Arrow,PX-27200067,CDM,27200067,LOCAL,272,RC,,,outpatient,,,349,244.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,295.81,78.3505,295.8124,percent of total billed charges,,,
HC Cassette Kci Veralink,PX-27200068,CDM,27200068,LOCAL,272,RC,,,outpatient,,,357,249.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,302.59,80.1465,302.5932,percent of total billed charges,,,
HC Shiley Trach Tube 6lpc,PX-27200069,CDM,27200069,LOCAL,272,RC,,,outpatient,,,357,249.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,302.59,80.1465,302.5932,percent of total billed charges,,,
HC Tube Trach Shiley 8lpc,PX-27200070,CDM,27200070,LOCAL,272,RC,,,outpatient,,,357,249.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,302.59,80.1465,302.5932,percent of total billed charges,,,
HC Catheter Single 4fr Bard,PX-27200071,CDM,27200071,LOCAL,272,RC,,,outpatient,,,374,261.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,317,83.963,317.0024,percent of total billed charges,,,
HC Bivona #7 Trach Uncuffed,PX-27200072,CDM,27200072,LOCAL,272,RC,,,outpatient,,,396,277.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,335.65,88.902,335.6496,percent of total billed charges,,,
HC Retractor C Section Large,PX-27200073,CDM,27200073,LOCAL,272,RC,,,outpatient,,,402,281.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,340.74,90.249,340.7352,percent of total billed charges,,,
HC Midline 4fr Bd#384308,PX-27200074,CDM,27200074,LOCAL,272,RC,,,outpatient,,,409,286.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,346.67,91.8205,346.6684,percent of total billed charges,,,
HC Transducer Triple W/Vamp Pls,PX-27200075,CDM,27200075,LOCAL,272,RC,,,outpatient,,,418,292.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,354.3,93.841,354.2968,percent of total billed charges,,,
HC B Pleurx Drainage Kit,PX-27200076,CDM,27200076,LOCAL,272,RC,,,outpatient,,,417,291.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,353.45,93.6165,353.4492,percent of total billed charges,,,
HC Catheter Swan Ganz J Pacing,PX-27200078,CDM,27200078,LOCAL,272,RC,,,outpatient,,,446,312.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,378.03,100.127,378.0296,percent of total billed charges,,,
HC Tube Trach Distal Xlt 5.0,PX-27200079,CDM,27200079,LOCAL,272,RC,,,outpatient,,,451,315.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,382.27,101.2495,382.2676,percent of total billed charges,,,
HC Tube Trach Distal Xlt 6.0,PX-27200080,CDM,27200080,LOCAL,272,RC,,,outpatient,,,466,326.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,394.98,104.617,394.9816,percent of total billed charges,,,
HC Tube Trach 8 Cuff Non X Long,PX-27200081,CDM,27200081,LOCAL,272,RC,,,outpatient,,,466,326.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,394.98,104.617,394.9816,percent of total billed charges,,,
HC Sling Sam Pelvic Medium,PX-27200082,CDM,27200082,LOCAL,272,RC,,,outpatient,,,470,329,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,398.37,105.515,398.372,percent of total billed charges,,,
HC Set Tube Kaci Veratrac Duo,PX-27200083,CDM,27200083,LOCAL,272,RC,,,outpatient,,,488,341.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,413.63,109.556,413.6288,percent of total billed charges,,,
HC Retractor C Section Xlarge,PX-27200084,CDM,27200084,LOCAL,272,RC,,,outpatient,,,516,361.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,437.36,115.842,437.3616,percent of total billed charges,,,
HC Kit Mini 4fr Single Lumen,PX-27200085,CDM,27200085,LOCAL,272,RC,,,outpatient,,,519,363.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,439.9,116.5155,439.9044,percent of total billed charges,,,
HC Trach Bivona Tis 6id,PX-27200086,CDM,27200086,LOCAL,272,RC,,,outpatient,,,523,366.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,443.29,117.4135,443.2948,percent of total billed charges,,,
HC Pack C Section Custom Disp,PX-27200087,CDM,27200087,LOCAL,272,RC,,,outpatient,,,541,378.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,458.55,121.4545,458.5516,percent of total billed charges,,,
HC Trach Bivona Tts 8mm,PX-27200088,CDM,27200088,LOCAL,272,RC,,,outpatient,,,541,378.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,458.55,121.4545,458.5516,percent of total billed charges,,,
HC Trach Bivona 7.5 X 10,PX-27200089,CDM,27200089,LOCAL,272,RC,,,outpatient,,,556,389.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,471.27,124.822,471.2656,percent of total billed charges,,,
HC Tube Feeding Mic Key 14f 1.7,PX-27200091,CDM,27200091,LOCAL,272,RC,,,outpatient,,,674,471.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,571.28,151.313,571.2824,percent of total billed charges,,,
HC Kit Mic-Key G Feeding 16-3.5,PX-27200092,CDM,27200092,LOCAL,272,RC,,,outpatient,,,694,485.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,588.23,155.803,588.2344,percent of total billed charges,,,
HC Kit Mic-Key G Feeding 24-3.5,PX-27200093,CDM,27200093,LOCAL,272,RC,,,outpatient,,,694,485.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,588.23,155.803,588.2344,percent of total billed charges,,,
HC Mic Key G Tube 20fr 3.5cm,PX-27200094,CDM,27200094,LOCAL,272,RC,,,outpatient,,,694,485.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,588.23,155.803,588.2344,percent of total billed charges,,,
HC Device Support Foot,PX-27200095,CDM,27200095,LOCAL,272,RC,,,outpatient,,,703,492.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,595.86,157.8235,595.8628,percent of total billed charges,,,
HC Catheter 4 Fr Mid Line,PX-27200096,CDM,27200096,LOCAL,272,RC,,,outpatient,,,719,503.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,609.42,161.4155,609.4244,percent of total billed charges,,,
HC Tcc Size 3,PX-27200097,CDM,27200097,LOCAL,272,RC,,,outpatient,,,722,505.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,611.97,162.089,611.9672,percent of total billed charges,,,
HC Femostop Gold Compress Sys,PX-27200098,CDM,27200098,LOCAL,272,RC,,,outpatient,,,731,511.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,619.6,164.1095,619.5956,percent of total billed charges,,,
HC Dot Poly Midline 4fr Sl Full,PX-27200099,CDM,27200099,LOCAL,272,RC,,,outpatient,,,765,535.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,648.41,171.7425,648.414,percent of total billed charges,,,
HC Powerwand 5fr 10cm,PX-27200100,CDM,27200100,LOCAL,272,RC,,,outpatient,,,776,543.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,657.74,174.212,657.7376,percent of total billed charges,,,
HC Powerwand Single Sterile 5fr,PX-27200101,CDM,27200101,LOCAL,272,RC,,,outpatient,,,776,543.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,657.74,174.212,657.7376,percent of total billed charges,,,
HC Needle Intraosseous Pd 15g,PX-27200102,CDM,27200102,LOCAL,272,RC,,,outpatient,,,845,591.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,716.22,189.7025,716.222,percent of total billed charges,,,
HC Needle Intraosseous Ad 15g,PX-27200103,CDM,27200103,LOCAL,272,RC,,,outpatient,,,845,591.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,716.22,189.7025,716.222,percent of total billed charges,,,
HC Needle Intraosseous,PX-27200104,CDM,27200104,LOCAL,272,RC,,,outpatient,,,845,591.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,716.22,189.7025,716.222,percent of total billed charges,,,
HC Kit Triple Lumen Cath 7 X 6,PX-27200105,CDM,27200105,LOCAL,272,RC,,,outpatient,,,895,626.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,758.6,200.9275,758.602,percent of total billed charges,,,
HC Multi Lumen Cvc Kit Toh Cust,PX-27200106,CDM,27200106,LOCAL,272,RC,,,outpatient,,,895,626.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,758.6,200.9275,758.602,percent of total billed charges,,,
HC Pad Zoll Aed Cprd Access Kit,PX-27200107,CDM,27200107,LOCAL,272,RC,,,outpatient,,,827,578.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,700.97,185.6615,700.9652,percent of total billed charges,,,
HC Kit Flexi Seal Fecal,PX-27200108,CDM,27200108,LOCAL,272,RC,,,outpatient,,,939,657.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,795.9,210.8055,795.8964,percent of total billed charges,,,
HC Powerwand Quick Kit 5fr,PX-27200109,CDM,27200109,LOCAL,272,RC,,,outpatient,,,979,685.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,829.8,219.7855,829.8004,percent of total billed charges,,,
HC Mahurkar Dual Lumen Subclav Ca,PX-27200110,CDM,27200110,LOCAL,272,RC,,,outpatient,,,1581,1106.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1340.06,354.9345,1340.0556,percent of total billed charges,,,
HC Catheter With Curved Extension,PX-27200111,CDM,27200111,LOCAL,272,RC,,,outpatient,,,1581,1106.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1340.06,354.9345,1340.0556,percent of total billed charges,,,
HC Set Cath Cricothyroidotomy,PX-27200112,CDM,27200112,LOCAL,272,RC,,,outpatient,,,1136,795.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,962.87,255.032,962.8736,percent of total billed charges,,,
HC Rusch Quick Trac Small 2.0,PX-27200113,CDM,27200113,LOCAL,272,RC,,,outpatient,,,1269,888.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1075.6,284.8905,1075.6044,percent of total billed charges,,,
HC Set Prism Prewarm M100'2,PX-27200114,CDM,27200114,LOCAL,272,RC,,,outpatient,,,1319,923.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1117.98,296.1155,1117.9844,percent of total billed charges,,,
HC Set Prismaflex M100's,PX-27200115,CDM,27200115,LOCAL,272,RC,,,outpatient,,,1399,979.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1185.79,314.0755,1185.7924,percent of total billed charges,,,
HC Bakri Postpartum Balloon,PX-27200116,CDM,27200116,LOCAL,272,RC,,,outpatient,,,1408,985.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1193.42,316.096,1193.4208,percent of total billed charges,,,
HC Flo Trac Sensor Mhd6,PX-27200117,CDM,27200117,LOCAL,272,RC,,,outpatient,,,2027,1418.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1718.09,455.0615,1718.0852,percent of total billed charges,,,
HC Pad Universal Artic Gel,PX-27200118,CDM,27200118,LOCAL,272,RC,,,outpatient,,,2219,1553.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1880.82,498.1655,1880.8244,percent of total billed charges,,,
HC Cath Presep 8.5 Oximetry,PX-27200119,CDM,27200119,LOCAL,272,RC,,,outpatient,,,2602,1821.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2205.46,584.149,2205.4552,percent of total billed charges,,,
HC Set Cricothyrotomy Cath,PX-27200120,CDM,27200120,LOCAL,272,RC,,,outpatient,,,2943,2060.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2494.49,660.7035,2494.4868,percent of total billed charges,,,
HC Pad Artic Gel Small,PX-27200121,CDM,27200121,LOCAL,272,RC,,,outpatient,,,5565,3895.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,4716.89,1249.3425,4716.894,percent of total billed charges,,,
HC Pad Gel Artic Medium,PX-27200122,CDM,27200122,LOCAL,272,RC,,,outpatient,,,5512,3858.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,4671.97,1237.444,4671.9712,percent of total billed charges,,,
HC Rhino G2 Blue,PX-27200123,CDM,27200123,LOCAL,272,RC,,,outpatient,,,4120,2884,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,3492.11,924.94,3492.112,percent of total billed charges,,,
HC Pad Artic Gel Lrg,PX-27200124,CDM,27200124,LOCAL,272,RC,,,outpatient,,,5512,3858.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,4671.97,1237.444,4671.9712,percent of total billed charges,,,
HC Bag External Drainage Collect,PX-27200125,CDM,27200125,LOCAL,272,RC,,,outpatient,,,1349,944.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1143.41,302.8505,1143.4124,percent of total billed charges,,,
HC Catheter Thoracic 28fr,PX-27200126,CDM,27200126,LOCAL,272,RC,,,outpatient,,,39,27.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,33.06,8.7555,33.0564,percent of total billed charges,,,
HC Tube Endo Bronch Left 37,PX-27200127,CDM,27200127,LOCAL,272,RC,,,outpatient,,,349,244.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,295.81,78.3505,295.8124,percent of total billed charges,,,
HC Electrode Temporary Pacing 6,PX-27200128,CDM,27200128,LOCAL,272,RC,,,outpatient,,,1238,866.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1049.33,277.931,1049.3288,percent of total billed charges,,,
HC Set Pneumothorax,PX-27200129,CDM,27200129,LOCAL,272,RC,,,outpatient,,,1113,779.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,943.38,249.8685,943.3788,percent of total billed charges,,,
HC System External Drainage III,PX-27200130,CDM,27200130,LOCAL,272,RC,,,outpatient,,,1887,1320.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1599.42,423.6315,1599.4212,percent of total billed charges,,,
HC Electrode Temporary Pacing 5,PX-27200131,CDM,27200131,LOCAL,272,RC,,,outpatient,,,1097,767.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,929.82,246.2765,929.8172,percent of total billed charges,,,
HC Tray Tru Close Thoracic Vent,PX-27200132,CDM,27200132,LOCAL,272,RC,,,outpatient,,,1504,1052.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1274.79,337.648,1274.7904,percent of total billed charges,,,
HC Tube Trach Flex Laser 6.0 Mm,PX-27200133,CDM,27200133,LOCAL,272,RC,,,outpatient,,,319,223.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,270.38,71.6155,270.3844,percent of total billed charges,,,
HC Pack Cesarean Custom,PX-27200134,CDM,27200134,LOCAL,272,RC,,,outpatient,,,462,323.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,391.59,103.719,391.5912,percent of total billed charges,,,
HC Hemostat Instat 1gm,PX-27200135,CDM,27200135,LOCAL,272,RC,,,outpatient,,,1077,753.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,912.87,241.7865,912.8652,percent of total billed charges,,,
HC Tube Trach Distal Xlt 7.0,PX-27200136,CDM,27200136,LOCAL,272,RC,,,outpatient,,,486,340.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,411.93,109.107,411.9336,percent of total billed charges,,,
HC Surgicel 2 X 14 #1951,PX-27200137,CDM,27200137,LOCAL,272,RC,,,outpatient,,,447,312.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,378.88,100.3515,378.8772,percent of total billed charges,,,
HC Ligator Saeed Sx Shoot,PX-27200138,CDM,27200138,LOCAL,272,RC,,,outpatient,,,1332,932.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1129,299.034,1129.0032,percent of total billed charges,,,
HC Cath Swan Ganz 7.5 Vip Port,PX-27200139,CDM,27200139,LOCAL,272,RC,,,outpatient,,,297,207.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,251.74,66.6765,251.7372,percent of total billed charges,,,
HC Cath Multilumen Access,PX-27200140,CDM,27200140,LOCAL,272,RC,,,outpatient,,,537,375.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,455.16,120.5565,455.1612,percent of total billed charges,,,
HC Trach Bivona Tts 7mm,PX-27200141,CDM,27200141,LOCAL,272,RC,,,outpatient,,,565,395.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,478.89,126.8425,478.894,percent of total billed charges,,,
HC Kit Pleurx Drainage W Bottle,PX-27200142,CDM,27200142,LOCAL,272,RC,,,outpatient,,,417,291.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,353.45,93.6165,353.4492,percent of total billed charges,,,
HC Retractor Wound Alexis Lrg,PX-27200143,CDM,27200143,LOCAL,272,RC,,,outpatient,,,412,288.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,349.21,92.494,349.2112,percent of total billed charges,,,
HC Unit Cold Therapy Deroyal,PX-27200144,CDM,27200144,LOCAL,272,RC,,,outpatient,,,691,483.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,585.69,155.1295,585.6916,percent of total billed charges,,,
HC Dressing Kci Vac Silver Med,PX-27200145,CDM,27200145,LOCAL,272,RC,,,outpatient,,,506,354.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,428.89,113.597,428.8856,percent of total billed charges,,,
HC Kit Midline Cath 20ga X 20cm,PX-27200146,CDM,27200146,LOCAL,272,RC,,,outpatient,,,424,296.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,359.38,95.188,359.3824,percent of total billed charges,,,
HC Cath Mahurkar 3 Lumen 12x20,PX-27200147,CDM,27200147,LOCAL,272,RC,,,outpatient,,,594,415.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,503.47,133.353,503.4744,percent of total billed charges,,,
HC Retractor Alexis Wound Xlg,PX-27200148,CDM,27200148,LOCAL,272,RC,,,outpatient,,,529,370.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,448.38,118.7605,448.3804,percent of total billed charges,,,
HC Surgiflo Hemostatic Matrix,PX-27200149,CDM,27200149,LOCAL,272,RC,,,outpatient,,,906,634.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,767.93,203.397,767.9256,percent of total billed charges,,,
HC Kit Monitoring Press Abviser,PX-27200150,CDM,27200150,LOCAL,272,RC,,,outpatient,,,648,453.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,549.24,145.476,549.2448,percent of total billed charges,,,
HC Tray Fuhrman Pleural Drain,PX-27200151,CDM,27200151,LOCAL,272,RC,,,outpatient,,,990,693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,839.12,222.255,839.124,percent of total billed charges,,,
HC Kit Cath Triple Lumen 20cm,PX-27200152,CDM,27200152,LOCAL,272,RC,,,outpatient,,,865,605.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,733.17,194.1925,733.174,percent of total billed charges,,,
HC Dressing Kci Simplace Med,PX-27200153,CDM,27200153,LOCAL,272,RC,,,outpatient,,,433,303.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,367.01,97.2085,367.0108,percent of total billed charges,,,
HC Tube Non Balloon Replace Peg,PX-27200154,CDM,27200154,LOCAL,272,RC,,,outpatient,,,394,275.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,333.95,88.453,333.9544,percent of total billed charges,,,
HC Cath 12fr Hp Triple Lumen,PX-27200155,CDM,27200155,LOCAL,272,RC,,,outpatient,,,606,424.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,513.65,136.047,513.6456,percent of total billed charges,,,
HC Cath Pneumothorax Ak01500,PX-27200156,CDM,27200156,LOCAL,272,RC,,,outpatient,,,700,490,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,593.32,157.15,593.32,percent of total billed charges,,,
HC Kit Cranial Access 826614,PX-27200158,CDM,27200158,LOCAL,272,RC,,,outpatient,,,2205,1543.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1868.96,495.0225,1868.958,percent of total billed charges,,,
"HC Sensor Flotrac W Vamp 60""",PX-27200159,CDM,27200159,LOCAL,272,RC,,,outpatient,,,1336,935.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1132.39,299.932,1132.3936,percent of total billed charges,,,
HC Trach Lg 4.0 Quick Rusch,PX-27200160,CDM,27200160,LOCAL,272,RC,,,outpatient,,,1094,765.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,927.27,245.603,927.2744,percent of total billed charges,,,
HC Tray Pericardiocentesis Stra,PX-27200161,CDM,27200161,LOCAL,272,RC,,,outpatient,,,1188,831.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1006.95,266.706,1006.9488,percent of total billed charges,,,
HC Trocar Endo Ethicon 12 512sd,PX-27200162,CDM,27200162,LOCAL,272,RC,,,outpatient,,,1154,807.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,978.13,259.073,978.1304,percent of total billed charges,,,
HC Tube Laryngectomy 12mm Metal,PX-27200163,CDM,27200163,LOCAL,272,RC,,,outpatient,,,1154,807.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,978.13,259.073,978.1304,percent of total billed charges,,,
HC Tray Midline CT 4f 20cm Single,PX-27200164,CDM,27200164,LOCAL,272,RC,,,outpatient,,,785,549.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,665.37,176.2325,665.366,percent of total billed charges,,,
HC Tray Midline CT 5f 20cm Dual,PX-27200165,CDM,27200165,LOCAL,272,RC,,,outpatient,,,779,545.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,660.28,174.8855,660.2804,percent of total billed charges,,,
HC Mahurkar Triple Lumen Cath Tray #16,PX-27200166,CDM,27200166,LOCAL,272,RC,,,outpatient,,,1191,833.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1009.49,267.3795,1009.4916,percent of total billed charges,,,
HC Mahurkar Triple Lumen Cath Tray #20,PX-27200167,CDM,27200167,LOCAL,272,RC,,,outpatient,,,983,688.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,833.19,220.6835,833.1908,percent of total billed charges,,,
HC Compartment Pressure Monitoring Kit,PX-27200168,CDM,27200168,LOCAL,272,RC,,,outpatient,,,457,319.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,387.35,102.5965,387.3532,percent of total billed charges,,,
HC Kit Perc Sheath Introducer 8.5,PX-27200169,CDM,27200169,LOCAL,272,RC,,,outpatient,,,471,329.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,399.22,105.7395,399.2196,percent of total billed charges,,,
HC Cath Arrow Cvc Kit Latex Free,PX-27200170,CDM,27200170,LOCAL,272,RC,,,outpatient,,,465,325.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,394.13,104.3925,394.134,percent of total billed charges,,,
HC Electrode Temporary Pacing 4,PX-27200171,CDM,27200171,LOCAL,272,RC,,,outpatient,,,823,576.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,697.57,184.7635,697.5748,percent of total billed charges,,,
HC Catheter Bipolar Pacing 5,PX-27200172,CDM,27200172,LOCAL,272,RC,,,outpatient,,,619,433.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,524.66,138.9655,524.6644,percent of total billed charges,,,
HC Set Emergency Pneumothorax,PX-27200173,CDM,27200173,LOCAL,272,RC,,,outpatient,,,795,556.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,673.84,178.4775,673.842,percent of total billed charges,,,
HC Kit Pneumothorax,PX-27200174,CDM,27200174,LOCAL,272,RC,,,outpatient,,,722,505.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,611.97,162.089,611.9672,percent of total billed charges,,,
HC Impella Purge Cassette,PX-27200175,CDM,27200175,LOCAL,272,RC,,,outpatient,,,245,171.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,207.66,55.0025,207.662,percent of total billed charges,,,
HC Tray Midline CT 4f 20cm Singl,PX-27200176,CDM,27200176,LOCAL,272,RC,,,outpatient,,,954,667.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,808.61,214.173,808.6104,percent of total billed charges,,,
HC Tray Midline CT 5f 20cm Dual F,PX-27200177,CDM,27200177,LOCAL,272,RC,,,outpatient,,,1154,807.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,978.13,259.073,978.1304,percent of total billed charges,,,
HC Kit Microez Mst Nitinol 4.5 7c,PX-27200178,CDM,27200178,LOCAL,272,RC,,,outpatient,,,497,347.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,421.26,111.5765,421.2572,percent of total billed charges,,,
HC Kit Microez Mst 5f Nsx,PX-27200179,CDM,27200179,LOCAL,272,RC,,,outpatient,,,251,175.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,212.75,56.3495,212.7476,percent of total billed charges,,,
HC Electrode One Step Cpr Adult,PX-27200180,CDM,27200180,LOCAL,272,RC,,,outpatient,,,408,285.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,345.82,91.596,345.8208,percent of total billed charges,,,
HC Electrode One Step Pediatric,PX-27200181,CDM,27200181,LOCAL,272,RC,,,outpatient,,,447,312.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,378.88,100.3515,378.8772,percent of total billed charges,,,
HC Ambu® Ascopetm 4 Broncho Large (5.8/2.8),PX-27200196,CDM,27200196,LOCAL,272,RC,,,outpatient,,,359,251.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,304.29,80.5955,304.2884,percent of total billed charges,,,
HC Ambu® Ascopetm 4 Broncho Regular (5.0/2.2),PX-27200197,CDM,27200197,LOCAL,272,RC,,,outpatient,,,312,218.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,264.45,70.044,264.4512,percent of total billed charges,,,
HC Ambu® Ascopetm 4 Broncho Slim (3.8/1.2),PX-27200198,CDM,27200198,LOCAL,272,RC,,,outpatient,,,312,218.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,264.45,70.044,264.4512,percent of total billed charges,,,
HC Tray Pneumothorax Turkel 9 Cm Sys,PX-27200199,CDM,27200199,LOCAL,272,RC,,,outpatient,,,622,435.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,527.21,139.639,527.2072,percent of total billed charges,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400003,CDM,27400003,LOCAL,274,RC,,,outpatient,,,552,386.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,467.88,123.924,467.8752,percent of total billed charges,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400005,CDM,27400005,LOCAL,274,RC,,,outpatient,,,1221,854.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1034.92,274.1145,1034.9196,percent of total billed charges,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400008,CDM,27400008,LOCAL,274,RC,,,outpatient,,,3772,2640.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,3197.15,846.814,3197.1472,percent of total billed charges,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400012,CDM,27400012,LOCAL,274,RC,,,outpatient,,,1954,1367.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1656.21,438.673,1656.2104,percent of total billed charges,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400015,CDM,27400015,LOCAL,274,RC,,,outpatient,,,3806,2664.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,3225.97,854.447,3225.9656,percent of total billed charges,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400030,CDM,27400030,LOCAL,274,RC,,,outpatient,,,661,462.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,560.26,148.3945,560.2636,percent of total billed charges,,,
HC Brace Knee Enhanced Trom,PX-27400038,CDM,27400038,LOCAL,274,RC,,,outpatient,,,570,399,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,483.13,127.965,483.132,percent of total billed charges,,,
HC Brace Enhanced Trom Donjoy,PX-27400039,CDM,27400039,LOCAL,274,RC,,,outpatient,,,570,399,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,483.13,127.965,483.132,percent of total billed charges,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400047,CDM,27400047,LOCAL,274,RC,,,outpatient,,,3385,2369.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2869.13,759.9325,2869.126,percent of total billed charges,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400050,CDM,27400050,LOCAL,274,RC,,,outpatient,,,3185,2229.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2699.61,715.0325,2699.606,percent of total billed charges,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400107,CDM,27400107,LOCAL,274,RC,,,outpatient,,,380,266,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,322.09,85.31,322.088,percent of total billed charges,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400117,CDM,27400117,LOCAL,274,RC,,,outpatient,,,779,545.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,660.28,174.8855,660.2804,percent of total billed charges,,,
HC Add. to Lower Extremity L2210,PX-27400184,CDM,27400184,LOCAL,274,RC,,,outpatient,,,330,231,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,279.71,74.085,279.708,percent of total billed charges,,,
HC Lift Elevation Heel & Sole,PX-27400185,CDM,27400185,LOCAL,274,RC,,,outpatient,,,382,267.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,323.78,85.759,323.7832,percent of total billed charges,,,
HC Add. Lower Extremity Orthosis,PX-27400186,CDM,27400186,LOCAL,274,RC,,,outpatient,,,448,313.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,379.72,100.576,379.7248,percent of total billed charges,,,
HC Depth Shoe A5500,PX-27400187,CDM,27400187,LOCAL,274,RC,,,outpatient,,,473,331.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,400.91,106.1885,400.9148,percent of total billed charges,,,
HC Compression Stocking A6533,PX-27400188,CDM,27400188,LOCAL,274,RC,,,outpatient,,,502,351.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,425.5,112.699,425.4952,percent of total billed charges,,,
HC Collar L0172,PX-27400189,CDM,27400189,LOCAL,274,RC,,,outpatient,,,658,460.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,557.72,147.721,557.7208,percent of total billed charges,,,
HC Ko Elastic Knee Joint L1820,PX-27400190,CDM,27400190,LOCAL,274,RC,,,outpatient,,,661,462.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,560.26,148.3945,560.2636,percent of total billed charges,,,
HC Procedure Ortho Shoe/L3649,PX-27400191,CDM,27400191,LOCAL,274,RC,,,outpatient,,,703,492.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,595.86,157.8235,595.8628,percent of total billed charges,,,
HC Air Cast Boot L4386,PX-27400192,CDM,27400192,LOCAL,274,RC,,,outpatient,,,745,521.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,631.46,167.2525,631.462,percent of total billed charges,,,
HC Static Afa L4396,PX-27400193,CDM,27400193,LOCAL,274,RC,,,outpatient,,,785,549.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,665.37,176.2325,665.366,percent of total billed charges,,,
HC Brace Tlso,PX-27400194,CDM,27400194,LOCAL,274,RC,,,outpatient,,,901,630.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,763.69,202.2745,763.6876,percent of total billed charges,,,
HC Lumbar Corsette L0450,PX-27400195,CDM,27400195,LOCAL,274,RC,,,outpatient,,,915,640.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,775.55,205.4175,775.554,percent of total billed charges,,,
HC Brace Warm and Form,PX-27400196,CDM,27400196,LOCAL,274,RC,,,outpatient,,,1117,781.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,946.77,250.7665,946.7692,percent of total billed charges,,,
HC Afo L1940,PX-27400197,CDM,27400197,LOCAL,274,RC,,,outpatient,,,2560,1792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2169.86,574.72,2169.856,percent of total billed charges,,,
HC Ankle Foot Orthosis L1940,PX-27400198,CDM,27400198,LOCAL,274,RC,,,outpatient,,,2560,1792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2169.86,574.72,2169.856,percent of total billed charges,,,
HC POS OP Knee Brace L1832,PX-27400199,CDM,27400199,LOCAL,274,RC,,,outpatient,,,2974,2081.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2520.76,667.663,2520.7624,percent of total billed charges,,,
HC Afo Plastic L1960,PX-27400200,CDM,27400200,LOCAL,274,RC,,,outpatient,,,3011,2107.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2552.12,675.9695,2552.1236,percent of total billed charges,,,
HC Ankle/Foot Orthosis Afo,PX-27400201,CDM,27400201,LOCAL,274,RC,,,outpatient,,,3011,2107.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2552.12,675.9695,2552.1236,percent of total billed charges,,,
HC Left Afo Brace/Atlantic Pros,PX-27400202,CDM,27400202,LOCAL,274,RC,,,outpatient,,,3165,2215.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2682.65,710.5425,2682.654,percent of total billed charges,,,
HC Afo L1932,PX-27400203,CDM,27400203,LOCAL,274,RC,,,outpatient,,,3418,2392.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2897.1,767.341,2897.0968,percent of total billed charges,,,
HC Ankle Foot Orthosis L1970,PX-27400204,CDM,27400204,LOCAL,274,RC,,,outpatient,,,3462,2423.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2934.39,777.219,2934.3912,percent of total billed charges,,,
HC Back Brace Tlso Lo486,PX-27400205,CDM,27400205,LOCAL,274,RC,,,outpatient,,,6597,4617.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,5591.62,1481.0265,5591.6172,percent of total billed charges,,,
HC Cervical Collar L0172,PX-27400206,CDM,27400206,LOCAL,274,RC,,,outpatient,,,658,460.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,557.72,147.721,557.7208,percent of total billed charges,,,
HC Philly Collar No Extension,PX-27400207,CDM,27400207,LOCAL,274,RC,,,outpatient,,,658,460.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,557.72,147.721,557.7208,percent of total billed charges,,,
HC Cervical Collar 2/Piece L0174,PX-27400208,CDM,27400208,LOCAL,274,RC,,,outpatient,,,1232,862.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1044.24,276.584,1044.2432,percent of total billed charges,,,
HC Lumbar Orthosis L0627,PX-27400209,CDM,27400209,LOCAL,274,RC,,,outpatient,,,1750,1225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1483.3,392.875,1483.3,percent of total billed charges,,,
HC Lso Sagoro Rigid Frame L0631,PX-27400210,CDM,27400210,LOCAL,274,RC,,,outpatient,,,3933,2753.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,3333.61,882.9585,3333.6108,percent of total billed charges,,,
HC Lso Sagittal Coronal L0637,PX-27400211,CDM,27400211,LOCAL,274,RC,,,outpatient,,,4114,2879.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,3487.03,923.593,3487.0264,percent of total billed charges,,,
HC Hip Abduction Orthosis L1686,PX-27400212,CDM,27400212,LOCAL,274,RC,,,outpatient,,,4461,3122.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,3781.14,1001.4945,3781.1436,percent of total billed charges,,,
HC Knee Orthosis L1830,PX-27400213,CDM,27400213,LOCAL,274,RC,,,outpatient,,,466,326.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,394.98,104.617,394.9816,percent of total billed charges,,,
HC Knee Orthosis L1832,PX-27400214,CDM,27400214,LOCAL,274,RC,,,outpatient,,,2974,2081.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2520.76,667.663,2520.7624,percent of total billed charges,,,
HC Knee Orthosis L1832,PX-27400215,CDM,27400215,LOCAL,274,RC,,,outpatient,,,2974,2081.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2520.76,667.663,2520.7624,percent of total billed charges,,,
HC Knee Osthosis L1832,PX-27400216,CDM,27400216,LOCAL,274,RC,,,outpatient,,,2974,2081.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2520.76,667.663,2520.7624,percent of total billed charges,,,
HC Afo L1930,PX-27400217,CDM,27400217,LOCAL,274,RC,,,outpatient,,,1062,743.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,900.15,238.419,900.1512,percent of total billed charges,,,
HC Adj. Dorsal Splint L1930,PX-27400218,CDM,27400218,LOCAL,274,RC,,,outpatient,,,1062,743.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,900.15,238.419,900.1512,percent of total billed charges,,,
HC L'nard Boot L1930,PX-27400219,CDM,27400219,LOCAL,274,RC,,,outpatient,,,1062,743.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,900.15,238.419,900.1512,percent of total billed charges,,,
HC Hip Adj Ext L2624,PX-27400220,CDM,27400220,LOCAL,274,RC,,,outpatient,,,1445,1011.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1224.78,324.4025,1224.782,percent of total billed charges,,,
HC Bk Soft Interface L2820,PX-27400221,CDM,27400221,LOCAL,274,RC,,,outpatient,,,448,313.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,379.72,100.576,379.7248,percent of total billed charges,,,
HC Lift Elevation L3332,PX-27400222,CDM,27400222,LOCAL,274,RC,,,outpatient,,,347,242.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,294.12,77.9015,294.1172,percent of total billed charges,,,
HC Wrist Hand/Finger Ortho L3807,PX-27400223,CDM,27400223,LOCAL,274,RC,,,outpatient,,,1065,745.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,902.69,239.0925,902.694,percent of total billed charges,,,
HC Wrist Cockup Nonmolded L3908,PX-27400224,CDM,27400224,LOCAL,274,RC,,,outpatient,,,353,247.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,299.2,79.2485,299.2028,percent of total billed charges,,,
HC Orthosis Upper Limb Hum. Frac,PX-27400225,CDM,27400225,LOCAL,274,RC,,,outpatient,,,1413,989.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1197.66,317.2185,1197.6588,percent of total billed charges,,,
HC Walking Boot L4360,PX-27400226,CDM,27400226,LOCAL,274,RC,,,outpatient,,,1290,903,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1093.4,289.605,1093.404,percent of total billed charges,,,
HC Walking Boot Prefab L4360,PX-27400227,CDM,27400227,LOCAL,274,RC,,,outpatient,,,1290,903,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1093.4,289.605,1093.404,percent of total billed charges,,,
HC Walking Boot L4360,PX-27400228,CDM,27400228,LOCAL,274,RC,,,outpatient,,,2135,1494.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1809.63,479.3075,1809.626,percent of total billed charges,,,
HC Cam Walker L4386,PX-27400229,CDM,27400229,LOCAL,274,RC,,,outpatient,,,745,521.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,631.46,167.2525,631.462,percent of total billed charges,,,
HC Bk Stump Shrinker L8440,PX-27400230,CDM,27400230,LOCAL,274,RC,,,outpatient,,,262,183.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,222.07,58.819,222.0712,percent of total billed charges,,,
HC Stump Shrinker L8440,PX-27400231,CDM,27400231,LOCAL,274,RC,,,outpatient,,,262,183.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,222.07,58.819,222.0712,percent of total billed charges,,,
HC Liner Foam Permanently Lg,PX-27400232,CDM,27400232,LOCAL,274,RC,,,outpatient,,,353,247.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,299.2,79.2485,299.2028,percent of total billed charges,,,
HC Kit Electrode Pacing,PX-27500027,CDM,27500027,LOCAL,275,RC,,,outpatient,,,1286,900.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1090.01,288.707,1090.0136,percent of total billed charges,,,
HC Medical/Surgical Supplies: Other Implants,PX-27800095,CDM,27800095,LOCAL,278,RC,,,outpatient,,,649,454.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,550.09,145.7005,550.0924,percent of total billed charges,,,
HC Leg Post Rigid Brace/Sc Ortho,PX-27800096,CDM,27800096,LOCAL,278,RC,,,outpatient,,,758,530.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,642.48,170.171,642.4808,percent of total billed charges,,,
HC Kit Picc 4fr per-Q Poly Cath,PX-27800097,CDM,27800097,LOCAL,278,RC,,,outpatient,,,1063,744.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,901,238.6435,900.9988,percent of total billed charges,,,
HC Floseal Matrix Hemostatic,PX-27800098,CDM,27800098,LOCAL,278,RC,,,outpatient,,,1093,765.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,926.43,245.3785,926.4268,percent of total billed charges,,,
HC Kit Picc 5fr per-Q Poly Cath,PX-27800099,CDM,27800099,LOCAL,278,RC,,,outpatient,,,1217,851.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1031.53,273.2165,1031.5292,percent of total billed charges,,,
HC Tray Power Picc Dual 5f,PX-27800100,CDM,27800100,LOCAL,278,RC,,,outpatient,,,1355,948.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1148.5,304.1975,1148.498,percent of total billed charges,,,
HC Tray Power Picc Single 4f,PX-27800101,CDM,27800101,LOCAL,278,RC,,,outpatient,,,1398,978.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1184.94,313.851,1184.9448,percent of total billed charges,,,
HC Tray Power Picc Triple 5fr,PX-27800102,CDM,27800102,LOCAL,278,RC,,,outpatient,,,1474,1031.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1249.36,330.913,1249.3624,percent of total billed charges,,,
HC Tray Power Picc Triple 6f,PX-27800103,CDM,27800103,LOCAL,278,RC,,,outpatient,,,1499,1049.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1270.55,336.5255,1270.5524,percent of total billed charges,,,
HC Sepafilm/5x6,PX-27800104,CDM,27800104,LOCAL,278,RC,,,outpatient,,,1773,1241.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1502.79,398.0385,1502.7948,percent of total billed charges,,,
HC 3cg Power Picc Max 4fr Sl,PX-27800105,CDM,27800105,LOCAL,278,RC,,,outpatient,,,1585,1109.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1343.45,355.8325,1343.446,percent of total billed charges,,,
HC 3cg Power Picc Max 5fr Dl,PX-27800106,CDM,27800106,LOCAL,278,RC,,,outpatient,,,1636,1145.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1386.67,367.282,1386.6736,percent of total billed charges,,,
HC 3cg Power Picc Max 6fr Tl,PX-27800107,CDM,27800107,LOCAL,278,RC,,,outpatient,,,1749,1224.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1482.45,392.6505,1482.4524,percent of total billed charges,,,
HC Valve Passy Muir Aqua,PX-27800108,CDM,27800108,LOCAL,278,RC,,,outpatient,,,474,331.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,401.76,106.413,401.7624,percent of total billed charges,,,
HC Passy Muir Valve - Clear,PX-27800113,CDM,27800113,LOCAL,278,RC,,,outpatient,,,474,331.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,401.76,106.413,401.7624,percent of total billed charges,,,
HC Valve Passy Muir Purple,PX-27800114,CDM,27800114,LOCAL,278,RC,,,outpatient,,,474,331.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,401.76,106.413,401.7624,percent of total billed charges,,,
HC Liner Foam Permanently X-Lg,PX-27800115,CDM,27800115,LOCAL,278,RC,,,outpatient,,,328,229.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,278.01,73.636,278.0128,percent of total billed charges,,,
HC Tube Trach Proximal Xlt 7.0,PX-27800117,CDM,27800117,LOCAL,278,RC,,,outpatient,,,486,340.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,411.93,109.107,411.9336,percent of total billed charges,,,
HC Barrier Seprafilm 3x5in,PX-27800118,CDM,27800118,LOCAL,278,RC,,,outpatient,,,1773,1241.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1502.79,398.0385,1502.7948,percent of total billed charges,,,
HC Tube Feeding Low Profile 20f,PX-27800119,CDM,27800119,LOCAL,278,RC,,,outpatient,,,694,485.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,588.23,155.803,588.2344,percent of total billed charges,,,
HC Valve Speaking White #005,PX-27800121,CDM,27800121,LOCAL,278,RC,,,outpatient,,,474,331.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,401.76,106.413,401.7624,percent of total billed charges,,,
HC Tray Percu Introducer 8.5fr,PX-27800122,CDM,27800122,LOCAL,278,RC,,,outpatient,,,475,332.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,402.61,106.6375,402.61,percent of total billed charges,,,
HC Basket Zerotip Airway Retriv,PX-27800125,CDM,27800125,LOCAL,278,RC,,,outpatient,,,1710,1197,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1449.4,383.895,1449.396,percent of total billed charges,,,
HC Indwelling Prosthesis 20fr 8mm,PX-27800126,CDM,27800126,LOCAL,278,RC,,,outpatient,,,1327,928.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1124.77,297.9115,1124.7652,percent of total billed charges,,,
HC Indwelling Prosthesis 2.0,PX-27800127,CDM,27800127,LOCAL,278,RC,,,outpatient,,,1327,928.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1124.77,297.9115,1124.7652,percent of total billed charges,,,
HC Prosthesis Blom - 8mm,PX-27800128,CDM,27800128,LOCAL,278,RC,,,outpatient,,,1300,910,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1101.88,291.85,1101.88,percent of total billed charges,,,
HC Drug Collection,PX-30000005,CDM,30000005,LOCAL,300,RC,,,outpatient,,,32,22.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,27.12,7.184,27.1232,percent of total billed charges,,,
HC Cardiac Mnr Thoracic Prcd,PX-36000003,CDM,36000003,LOCAL,360,RC,,,outpatient,,,142,99.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,120.36,31.879,120.3592,percent of total billed charges,,,
HC Non-Pump Open Heart Other,PX-36000004,CDM,36000004,LOCAL,360,RC,,,outpatient,,,157,109.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,133.07,35.2465,133.0732,percent of total billed charges,,,
HC Pump Procedure,PX-36000005,CDM,36000005,LOCAL,360,RC,,,outpatient,,,152,106.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,128.84,34.124,128.8352,percent of total billed charges,,,
HC Non Pump Procedure,PX-36000006,CDM,36000006,LOCAL,360,RC,,,outpatient,,,208,145.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,176.3,46.696,176.3008,percent of total billed charges,,,
HC Sub Minor Proc,PX-36000014,CDM,36000014,LOCAL,360,RC,,,outpatient,,,60,42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,50.86,13.47,50.856,percent of total billed charges,,,
HC Pain Mgmt Proc,PX-36000015,CDM,36000015,LOCAL,360,RC,,,outpatient,,,75,52.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,63.57,16.8375,63.57,percent of total billed charges,,,
HC Endoscopy,PX-36000016,CDM,36000016,LOCAL,360,RC,,,outpatient,,,60,42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,50.86,13.47,50.856,percent of total billed charges,,,
HC Minor Proc,PX-36000017,CDM,36000017,LOCAL,360,RC,,,outpatient,,,75,52.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,63.57,16.8375,63.57,percent of total billed charges,,,
HC Major Proc,PX-36000019,CDM,36000019,LOCAL,360,RC,,,outpatient,,,99,69.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,83.91,22.2255,83.9124,percent of total billed charges,,,
HC Intensive Major Procedure,PX-36000020,CDM,36000020,LOCAL,360,RC,,,outpatient,,,140,98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,118.66,31.43,118.664,percent of total billed charges,,,
HC Ercp,PX-36000021,CDM,36000021,LOCAL,360,RC,,,outpatient,,,138,96.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,116.97,30.981,116.9688,percent of total billed charges,,,
HC Cardiac Maj Thoracic Prcd,PX-36000022,CDM,36000022,LOCAL,360,RC,,,outpatient,,,159,111.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,134.77,35.6955,134.7684,percent of total billed charges,,,
HC Anesthesia Block,PX-37000001,CDM,37000001,LOCAL,370,RC,,,outpatient,,,700,490,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,593.32,157.15,593.32,percent of total billed charges,,,
HC Anesthesia Spinal,PX-37000002,CDM,37000002,LOCAL,370,RC,,,outpatient,,,850,595,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,720.46,190.825,720.46,percent of total billed charges,,,
HC Anesthesia General Minor,PX-37000003,CDM,37000003,LOCAL,370,RC,,,outpatient,,,1662,1163.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1408.71,373.119,1408.7112,percent of total billed charges,,,
HC Anesthesia Epidural,PX-37000004,CDM,37000004,LOCAL,370,RC,,,outpatient,,,950,665,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,805.22,213.275,805.22,percent of total billed charges,,,
HC Anesthesia General Major,PX-37000005,CDM,37000005,LOCAL,370,RC,,,outpatient,,,2924,2046.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2478.38,656.438,2478.3824,percent of total billed charges,,,
HC Anesthesia Gen/Epi,PX-37000006,CDM,37000006,LOCAL,370,RC,,,outpatient,,,1200,840,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1017.12,269.4,1017.12,percent of total billed charges,,,
HC Anesthesia General Intensive,PX-37000007,CDM,37000007,LOCAL,370,RC,,,outpatient,,,4262,2983.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,3612.47,956.819,3612.4712,percent of total billed charges,,,
HC Anesthesia General Cvs Bypass Pump,PX-37000008,CDM,37000008,LOCAL,370,RC,,,outpatient,,,9166,6416.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,7769.1,2057.767,7769.1016,percent of total billed charges,,,
HC Anesthesia Mac,PX-37000009,CDM,37000009,LOCAL,370,RC,,,outpatient,,,1200,840,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1017.12,269.4,1017.12,percent of total billed charges,,,
HC Endo Level I,PX-49000001,CDM,49000001,LOCAL,490,RC,,,outpatient,,,3749,2624.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,3177.65,841.6505,3177.6524,percent of total billed charges,,,
HC Endo Level II,PX-49000002,CDM,49000002,LOCAL,490,RC,,,outpatient,,,5356,3749.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,4539.75,1202.422,4539.7456,percent of total billed charges,,,
HC Endo Level III,PX-49000003,CDM,49000003,LOCAL,490,RC,,,outpatient,,,9641,6748.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,8171.71,2164.4045,8171.7116,percent of total billed charges,,,
HC Recovery Room,PX-71000001,CDM,71000001,LOCAL,710,RC,,,outpatient,,,25,17.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,21.19,5.6125,21.19,percent of total billed charges,,,
HC Second Stage Recovery per Minute,PX-71000002,CDM,71000002,LOCAL,710,RC,,,outpatient,,,22,15.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,18.65,4.939,18.6472,percent of total billed charges,,,
HC Recovery - Sub Minor Proc,PX-71000003,CDM,71000003,LOCAL,710,RC,,,outpatient,,,23,16.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,19.49,5.1635,19.4948,percent of total billed charges,,,
HC Recovery Rm - Minor Procedure,PX-71000004,CDM,71000004,LOCAL,710,RC,,,outpatient,,,28,19.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,23.73,6.286,23.7328,percent of total billed charges,,,
HC Recovery Rm,PX-71000005,CDM,71000005,LOCAL,710,RC,,,outpatient,,,29,20.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,24.58,6.5105,24.5804,percent of total billed charges,,,
HC Recovery Rm - Major Procedure,PX-71000006,CDM,71000006,LOCAL,710,RC,,,outpatient,,,33,23.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,27.97,7.4085,27.9708,percent of total billed charges,,,
HC Recovery Rm - Intensive Major,PX-71000007,CDM,71000007,LOCAL,710,RC,,,outpatient,,,38,26.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,32.21,8.531,32.2088,percent of total billed charges,,,
HC Extended Recovery Overnight,PX-71000009,CDM,71000009,LOCAL,710,RC,,,outpatient,,,1500,1050,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1271.4,336.75,1271.4,percent of total billed charges,,,
HC Observation Nursing Time,PX-76200006,CDM,76200006,LOCAL,762,RC,,,outpatient,,,101,70.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,85.61,22.6745,6652,percent of total billed charges,,,
HC Tandem Dialysis,PX-80100001,CDM,80100001,LOCAL,801,RC,,,outpatient,,,1142,799.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,967.96,256.379,967.9592,percent of total billed charges,,,
HC Single Dialysis,PX-80100002,CDM,80100002,LOCAL,801,RC,,,outpatient,,,1142,799.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,967.96,256.379,967.9592,percent of total billed charges,,,
HC Unscheduled/Emergent Dialysis,PX-80100003,CDM,80100003,LOCAL,801,RC,,,outpatient,,,1142,799.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,967.96,256.379,967.9592,percent of total billed charges,,,
HC Weekend/Holiday Dialysis,PX-80100004,CDM,80100004,LOCAL,801,RC,,,outpatient,,,1142,799.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,967.96,256.379,967.9592,percent of total billed charges,,,
HC Capd per:Exchange,PX-80300001,CDM,80300001,LOCAL,803,RC,,,outpatient,,,569,398.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,482.28,127.7405,482.2844,percent of total billed charges,,,
HC Ccpd ER,PX-80400001,CDM,80400001,LOCAL,804,RC,,,outpatient,,,569,398.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,482.28,127.7405,482.2844,percent of total billed charges,,,
HC Ccpd,PX-80400002,CDM,80400002,LOCAL,804,RC,,,outpatient,,,1142,799.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,967.96,256.379,967.9592,percent of total billed charges,,,
HC Dietary Services per 15 Mins,PX-99000006,CDM,99000006,LOCAL,990,RC,,,outpatient,,,29,20.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,24.58,6.5105,24.5804,percent of total billed charges,,,
HC Hearing Aid Batteries,PX-99000034,CDM,99000034,LOCAL,479,RC,,,outpatient,,,7,4.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,5.93,1.5715,163,percent of total billed charges,,,
HC Hearing Aid Tune Up,PX-99000037,CDM,99000037,LOCAL,479,RC,,,outpatient,,,43,30.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,36.45,9.6535,163,percent of total billed charges,,,
HC Hearing Aid Fit,PX-99000038,CDM,99000038,LOCAL,479,RC,,,outpatient,,,171,119.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,144.94,38.3895,163,percent of total billed charges,,,
HC Arterial Stent- Xcranial Vertebral/ Thoracic Carotid- 1st Vessel,PX-36900026,CDM,0075T,CPT,369,RC,,,outpatient,,,774,541.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,656.04,173.763,2998,percent of total billed charges,,,
HC Arterial Stent- Xcranial Vertebral/ Thoracic Carotid- Ea Add,PX-36900027,CDM,0076T,CPT,369,RC,,,outpatient,,,161,112.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,136.46,36.1445,2998,percent of total billed charges,,,
HC Transluminal Peripheral Atherectomy- Renal Artery,PX-36900028,CDM,0234T,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,22389.35,399.86,22389.354,percent of total billed charges,,,
HC Transluminal Peripheral Atherectomy- Visceral Artery- Each,PX-36900029,CDM,0235T,CPT,369,RC,,,outpatient,,,735,514.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,622.99,165.0075,2998,percent of total billed charges,,,
BONE BX OSTEO SITE 11G 10CM -,SUP-G36211,CDM,A4215,HCPCS,272,RC,,,outpatient,,,1924.08,1346.856,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,1477.69344,other,SI=N Exclusions ,,
CATHETER COUDE 24FR 5CC -,SUP-1524C,CDM,A4340,HCPCS,270,RC,,,outpatient,,,45.92,32.144,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.30904,416.02,other,SI=N Exclusions ,,
SILICONE CATHETER FOLEY 24FR 5CC -,SUP-8887605247,CDM,A4344,HCPCS,270,RC,,,outpatient,,,17.15,12.005,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.850175,416.02,other,SI=N Exclusions ,,
CATH FOLEY 18FR 5ML BLN 3W DOVER LTX 16IN LUB -,SUP-2718,CDM,A4346,HCPCS,272,RC,,,outpatient,,,39.16,27.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.025285,416.02,other,SI=N Exclusions ,,
CATHETER FOLEY 22FR 30CC 3-WAY -,SUP-2822,CDM,A4346,HCPCS,272,RC,,,outpatient,,,41.84,29.288,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.025285,416.02,other,SI=N Exclusions ,,
CATHETER FOLEY 24FR 30CC 3-WAY -,SUP-2824,CDM,A4346,HCPCS,272,RC,,,outpatient,,,17.93,12.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.025285,416.02,other,SI=N Exclusions ,,
CATH FOLEY SIL 3W 30CC 22FR -,SUP-8887665225,CDM,A4346,HCPCS,272,RC,,,outpatient,,,41.84,29.288,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.025285,416.02,other,SI=N Exclusions ,,
SLING ORTHO ARM SM -,SUP-8023-01,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.98585,416.02,other,SI=N Exclusions ,,
SLING DEROYAL ARM MEDIUM -,SUP-8023-02,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.98585,416.02,other,SI=N Exclusions ,,
SLING DEROYAL ARM LARGE -,SUP-8023-03,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.98585,416.02,other,SI=N Exclusions ,,
SLING ORTHO ARM XL -,SUP-8023-04,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.98585,416.02,other,SI=N Exclusions ,,
SLING ARM MED STRP -,SUP-TX9901-43,CDM,A4565,HCPCS,270,RC,,,outpatient,,,13.3,9.31,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.98585,416.02,other,SI=N Exclusions ,,
HC Tissue Marker,PX-27800092,CDM,A4648,HCPCS,278,RC,,,outpatient,,,418,292.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.325665,1791.14496,other,SI=N Exclusions ,,
NEEDLE BRST LOC 20GAX3CM CM MRKNG STD MRKNG CANN ON WIRE -,SUP-253030,CDM,A4648,HCPCS,278,RC,,,outpatient,,,271.33,189.931,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.325665,1791.14496,other,SI=N Exclusions ,,
MARKER BRSTBIO 3MM 17GA INCONEL 625 ULTRA CLP -,SUP-862017,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.325665,1791.14496,other,SI=N Exclusions ,,
MARKER BRSTBIO 17GA TI ULTRA CLP II US -,SUP-863017,CDM,A4648,HCPCS,278,RC,,,outpatient,,,1097.2,768.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.325665,1791.14496,other,SI=N Exclusions ,,
INSTRUMENT BX 18GA/17GA/INTRO ACHIEVE AUTO 11CM SFT TIS -,SUP-CA1811,CDM,A4648,HCPCS,278,RC,,,outpatient,,,497.49,348.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.325665,1791.14496,other,SI=N Exclusions ,,
IDENTIFIER BIOPSY SITE FOR CELERO 12 THIRD SHAPE -,SUP-CELEROMARK-2S,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.325665,1791.14496,other,SI=N Exclusions ,,
NEEDLE BRST LOC KOPANS 20GAX5CM BVL CUT TIP MOD REINF TIP -,SUP-DKBL-20-5.0-A,CDM,A4648,HCPCS,278,RC,,,outpatient,,,175.17,122.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.325665,1791.14496,other,SI=N Exclusions ,,
NEEDLE BRST LOC KOPANS 20GAX7CM BVL CUT TIP MOD REINF TIP -,SUP-DKBL-20-7.0-A,CDM,A4648,HCPCS,278,RC,,,outpatient,,,175.17,122.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.325665,1791.14496,other,SI=N Exclusions ,,
NEEDLE BRST LOC KOPANS 20GAX9CM BVL CUT TIP MOD REINF TIP -,SUP-DKBL-20-9.0-A,CDM,A4648,HCPCS,278,RC,,,outpatient,,,175.17,122.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.325665,1791.14496,other,SI=N Exclusions ,,
NEEDLE 18GA X 20CM FUSIONCOIL WITH 1 X 5MM FIDUCIAL MARKER -,SUP-MTCTXFC1051820,CDM,A4648,HCPCS,278,RC,,,outpatient,,,752.72,526.904,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.325665,1791.14496,other,SI=N Exclusions ,,
MARKERS CIVCO FIDUCIAL 30CM -,SUP-MTNW887835,CDM,A4648,HCPCS,278,RC,,,outpatient,,,1129.01,790.307,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.325665,1791.14496,other,SI=N Exclusions ,,
MARKER BRSTBIO TI SCUR MRK MINI CORK -,SUP-SMARK-CELERO,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.325665,1791.14496,other,SI=N Exclusions ,,
MARKER BRSTBIO TI SECURMARK TOP HAT SHP -,SUP-SMARK-CELERO-2S,CDM,A4648,HCPCS,278,RC,,,outpatient,,,481.1,336.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.325665,1791.14496,other,SI=N Exclusions ,,
MARKER BRSTBIO TI SCUR MRK MINI CORK -,SUP-SMARK-EVIVA-13,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.325665,1791.14496,other,SI=N Exclusions ,,
MARKER BRSTBIO TI SECURMARK -,SUP-SMARK-EVIVA-2S-13,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.325665,1791.14496,other,SI=N Exclusions ,,
SCOUT 5CM DELIVERY NEEDLE AND REFLECTOR SSR05-01 -,SUP-SSR05-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.325665,1791.14496,other,SI=N Exclusions ,,
SCOUT 10CM DELIVERY NEEDLE AND REFLECTOR -,SUP-SSR10-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.325665,1791.14496,other,SI=N Exclusions ,,
SCOUT 7.5CM DELIVERY NEEDLE AND REFLECTOR -,SUP-SSR75-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.325665,1791.14496,other,SI=N Exclusions ,,
REFLECTOR AND DELIVERY SYSTEM SINGLE HAND 16G 7.5 CM -,SUP-SSR75S-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.325665,1791.14496,other,SI=N Exclusions ,,
IDENTIFIER BIOPSY SITE ATEC TRIMARK INTRODUCER SHEATH MARKER -,SUP-TRIMARK TD-2S-13-MR,CDM,A4648,HCPCS,278,RC,,,outpatient,,,371.98,260.386,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.325665,1791.14496,other,SI=N Exclusions ,,
EXPANDER BRST 500ML BIOCELL RND NATRLL 13CMX13.5CM 5.7CM -,SUP-133FV-13,CDM,A4649,HCPCS,272,RC,,,outpatient,,,4986.7,3490.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions ,,
EXPANDER TISSUE SMOOTH 600CC NATRELLE FULL HEIGHT -,SUP-133S-FV-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions ,,
EXPANDER TISSUE NATRELLE SMOOTH 650CC -,SUP-133S-FX-14-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions ,,
NATRELLE INSPIRA TISSUE EXPANDER 800CC -,SUP-133S-FX-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions ,,
TISSUE EXPANDER 400CC NATRELLE SMOOTH MOD HEIGHT EXTRA PROT -,SUP-133S-MX-12-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions ,,
TISSUE EXPANDER 500CC NATRELLE SMOOTH MOD HEIGHT EXTRA PROT -,SUP-133S-MX-13-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions ,,
TISSUE EXPANDER 600CC NATRELLE -,SUP-133S-MX-14-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions ,,
EXPANDER TISSUE NATRELLE SMOOTH 700CC -,SUP-133S-MX-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions ,,
EXPANDER TISSUE SMOOTH 400CC SHORT HT EXTRA PROJ NATRELLE -,SUP-133S-SX-13-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5903.4,4132.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions ,,
EXPANDER TISSUE SMOOTH 650CC HEIGHT EXTRA PROJ NATRELLE -,SUP-133S-SX-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions ,,
EXPANDER TISS 250ML SHRT H -,SUP-133SV-12,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions ,,
EXPANDER BRST UNIV NATRLL -,SUP-30-000003,CDM,A4649,HCPCS,272,RC,,,outpatient,,,63.19,44.233,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions ,,
EXPANDER BREAST TISSUE CPX4 450CC -,SUP-350-9213,CDM,A4649,HCPCS,272,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions ,,
650CC CPX 4 BREAST TISSUE EXPANDER W/SUTURE TABS MED. HEIGHT -,SUP-350-9215,CDM,A4649,HCPCS,272,RC,,,outpatient,,,7745.3,5421.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions ,,
EXPANDER TISSUE SMOOTH 800CC CPX 4 W/SUTURE TABS MED HT -,SUP-350-9216,CDM,A4649,HCPCS,272,RC,,,outpatient,,,7745.3,5421.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions ,,
EXPANDER BRST 850ML BIOCELL RND NATRLL 16CMX16.5CM 6.8CM -,SUP-37-133800,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5835.5,4084.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions ,,
EXPANDER BRST 600ML BIOCELL RND NATRLL 14CMX14.5CM 6.2CM -,SUP-67-133FV14,CDM,A4649,HCPCS,272,RC,,,outpatient,,,4986.7,3490.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions ,,
SIZER IMPLANT NATRELLE INSPIRA 520CC FULL PROFILE -,SUP-MSZ-F520,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions ,,
SIZER IMPLANT NATRELLE INSPIRA 560CC FULL PROFILE -,SUP-MSZ-F560,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions ,,
SIZER IMPLANT NATRELLE INSPIRA 605CC FULL PROFILE -,SUP-MSZ-F605,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions ,,
SIZER IMPLANT NATRELLE INSPIRA 695CC FULL PROFILE -,SUP-MSZ-F695,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions ,,
SIZER IMPLANT NATRELLE INSPIRA 770CC FULL PROFILE -,SUP-MSZ-F770,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions ,,
SIZER IMPLANT NATRELLE INSPIRA 275CC MODERATE PROFILE -,SUP-MSZ-M275,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions ,,
SIZER IMPLANT NATRELLE INSPIRA 560CC MODERATE PROFILE -,SUP-MSZ-M560,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions ,,
SIZER IMPLANT NATRELLE INSPIRA 600CC MODERATE PROFILE -,SUP-MSZ-M600,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions ,,
SIZER IMPLANT NATRELLE INSPIRA 525CC EXTRA FULL PROFILE -,SUP-MSZ-X525,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions ,,
SIZER IMPLANT NATRELLE INSPIRA 545CC EXTRA FULL PROFILE -,SUP-MSZ-X545,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions ,,
SIZER IMPLANT NATRELLE INSPIRA 580CC EXTRA FULL PROFILE -,SUP-MSZ-X580,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions ,,
SIZER IMPLANT NATRELLE INSPIRA 750CC XFULL PROFILE -,SUP-MSZ-X750,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions ,,
SIZER IMPLANT NATRELLE INSPIRA 800CC EXTRA FULL PROFILE -,SUP-MSZ-X800,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions ,,
SIZER IMPLANT NATRELLE INSPIRA 745CC FULL PROFILE -,SUP-SCF-745,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.186155,5948.3904,other,SI=N Exclusions ,,
DRESSING WND 2X2IN PURACOL + HI GEL INTGRTY COLL LF -,SUP-MSC8622EP,CDM,A6021,HCPCS,270,RC,,,outpatient,,,32.97,23.079,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7.401765,416.02,other,SI=N Exclusions ,,
DRESSING BURN PURACOL PLUS 2X2 AG SILVER  COLLAGEN -,SUP-MSC8722EP,CDM,A6021,HCPCS,270,RC,,,outpatient,,,43.41,30.387,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7.401765,416.02,other,SI=N Exclusions ,,
SHEETING SILASTIC 4.625X5.625IN SIL GEL HYPAL SLFADH LPRO -,SUP-NC15462,CDM,A6025,HCPCS,272,RC,,,outpatient,,,180.14,126.098,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,11.99,416.02,other,SI=N Exclusions ,,
DRESSING KALTOSTAT CA ALGIN 3X4.75IN ABSB -,SUP-168212,CDM,A6196,HCPCS,270,RC,,,outpatient,,,14.44,10.108,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.708445,416.02,other,SI=N Exclusions ,,
DRESSING XTRA HYDROFIBER AQUACEL 2X2IN -,SUP-420671,CDM,A6196,HCPCS,270,RC,,,outpatient,,,8.66,6.062,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.708445,416.02,other,SI=N Exclusions ,,
DRESSING ALGIN 2X2IN SQ NADH HI ABSB F/MOD TO HVY DRN -,SUP-MSC7022EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,7.61,5.327,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.708445,416.02,other,SI=N Exclusions ,,
DRESSING MAXORB 4X4IN EXTRA -,SUP-MSC7044EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,14.23,9.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.708445,416.02,other,SI=N Exclusions ,,
DRESSING WND 1X12IN FLT ROPE HI ABSORBENT1 F/WND MAXORB XTR -,SUP-MSC7112EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,20.07,14.049,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.708445,416.02,other,SI=N Exclusions ,,
DRESSING MAXORB AG 2X2IN ALGIN SILVER -,SUP-MSC9422EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,18.37,12.859,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.708445,416.02,other,SI=N Exclusions ,,
DRESSING GERMC AQUACEL AG EXTRA 4X4IN SLVR STRL -,SUP-420674,CDM,A6197,HCPCS,270,RC,,,outpatient,,,18.13,12.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.070185,416.02,other,SI=N Exclusions ,,
DRESSING AQUACEL 4 X 5 -,SUP-420674,CDM,A6197,HCPCS,270,RC,,,outpatient,,,18.13,12.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.070185,416.02,other,SI=N Exclusions ,,
DRESSING AQUACEL AG  2X2IN SQ HYDROFIBER SILVER -,SUP-422297,CDM,A6197,HCPCS,270,RC,,,outpatient,,,27.75,19.425,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.070185,416.02,other,SI=N Exclusions ,,
DRESSING AQUACEL AG 6X6IN HYDROFIBER -,SUP-422298,CDM,A6197,HCPCS,270,RC,,,outpatient,,,112.45,78.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.070185,416.02,other,SI=N Exclusions ,,
DRESSING ALGINATE SILVER 4X4.75IN CA ANTMIC NADH NWVN FLT -,SUP-MSC9445EP,CDM,A6197,HCPCS,270,RC,,,outpatient,,,34.27,23.989,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.070185,416.02,other,SI=N Exclusions ,,
DRESSING MAXORB EXTRA AG 4X4 SILVER -,SUP-MSC9445EP,CDM,A6197,HCPCS,270,RC,,,outpatient,,,34.72,24.304,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.070185,416.02,other,SI=N Exclusions ,,
DRESSING ALGIN AQUACL HYDROFIBER 0.75X18IN NADH CONFRM NWVN -,SUP-403770,CDM,A6199,HCPCS,270,RC,,,outpatient,,,22.99,16.093,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.3553,416.02,other,SI=N Exclusions ,,
DRESSING ALGIN AQUACL HYDROFIBER 0.75X18IN NADH CONFRM NWVN -,SUP-403770,CDM,A6199,HCPCS,270,RC,,,outpatient,,,19.4,13.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.3553,416.02,other,SI=N Exclusions ,,
DRESSING AQUACEL AG ROPE .75X18 IN -,SUP-422300,CDM,A6199,HCPCS,270,RC,,,outpatient,,,59.94,41.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.3553,416.02,other,SI=N Exclusions ,,
DRESSING SILVERLON 4 X 10 -,SUP-ID-410,CDM,A6206,HCPCS,272,RC,,,outpatient,,,169.8,118.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.23,416.02,other,SI=N Exclusions ,,
DRESSING ACTICOAT 4X5 -,SUP-66800405,CDM,A6207,HCPCS,272,RC,,,outpatient,,,81.2,56.84,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.98576,416.02,other,SI=N Exclusions ,,
DRESSING ACTICOAT 4X4 -,SUP-66800406,CDM,A6207,HCPCS,272,RC,,,outpatient,,,44.48,31.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.98576,416.02,other,SI=N Exclusions ,,
DRESSING ALLEVYN NONADHESIVE 2X2 NO BORDER -,SUP-66027643,CDM,A6209,HCPCS,272,RC,,,outpatient,,,14.63,10.241,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.94544,416.02,other,SI=N Exclusions ,,
DRESSING FOAM 4x4 BORDERLESS -,SUP-66927637,CDM,A6209,HCPCS,272,RC,,,outpatient,,,13.12,9.184,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.94544,416.02,other,SI=N Exclusions ,,
"DRESSING HYDROFERA 2.5"" X 2.5"" -",SUP-HLST-HBRT2525,CDM,A6209,HCPCS,272,RC,,,outpatient,,,268.12,187.684,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.94544,416.02,other,SI=N Exclusions ,,
HYDROFERA BLUE READY TRANSFER 2.5 X 2.5 -,SUP-HLST-HRBS2214,CDM,A6209,HCPCS,272,RC,,,outpatient,,,26.78,18.746,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.94544,416.02,other,SI=N Exclusions ,,
HYDROFERA BLUE READY TRANSFER 4 X 5 -,SUP-HBRS4520,CDM,A6210,HCPCS,272,RC,,,outpatient,,,40.63,28.441,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.121435,416.02,other,SI=N Exclusions ,,
HYDROFERA BLUE READY TRANSFER 4 X 5 -,SUP-HLST-HRBT4050,CDM,A6210,HCPCS,272,RC,,,outpatient,,,416.5,291.55,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.121435,416.02,other,SI=N Exclusions ,,
HYDROFERA BLUE READY TRANSFER 8 X 8 -,SUP-HLST-HRBS8820,CDM,A6211,HCPCS,272,RC,,,outpatient,,,92.17,64.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.692165,416.02,other,SI=N Exclusions ,,
DRESSING OPTIFOAM AG 3.5 X 6 -,SUP-412010,CDM,A6212,HCPCS,270,RC,,,outpatient,,,109.06,76.342,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.79151,416.02,other,SI=N Exclusions ,,
DRESSING OPTIFOAM AG 3.5 X 10 -,SUP-412011,CDM,A6212,HCPCS,270,RC,,,outpatient,,,139.34,97.538,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.79151,416.02,other,SI=N Exclusions ,,
BANDAGE ADH 4X4IN ALLEVYN -,SUP-66800270,CDM,A6212,HCPCS,270,RC,,,outpatient,,,12.57,8.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.79151,416.02,other,SI=N Exclusions ,,
BANDAGE ADH 4X4IN ALLEVYN -,SUP-66800270,CDM,A6212,HCPCS,270,RC,,,outpatient,,,18.72,13.104,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.79151,416.02,other,SI=N Exclusions ,,
"DRESSING FOAMING ALLEYN GENTLE BORDER LITE 5.5CM X 12CM"" -",SUP-66800836,CDM,A6212,HCPCS,270,RC,,,outpatient,,,8.42,5.894,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.79151,416.02,other,SI=N Exclusions ,,
DRESSING FOAM VERSATILE 2 1/8IN X 4 3/4IN SILICONE ADHESIVE -,SUP-66800836,CDM,A6212,HCPCS,270,RC,,,outpatient,,,7.98,5.586,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.79151,416.02,other,SI=N Exclusions ,,
DRESSING ALLEVYN LIFE 5 1/16IN x 5 1/16IN -,SUP-66801068,CDM,A6212,HCPCS,270,RC,,,outpatient,,,14.24,9.968,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.79151,416.02,other,SI=N Exclusions ,,
DRESSING OPTIFOAM AG 3.5 X 14 -,SUP-412012,CDM,A6213,HCPCS,270,RC,,,outpatient,,,148.97,104.279,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.206745,416.02,other,SI=N Exclusions ,,
DRESSING FOAM SACRUM 9.4 X 8.4CM LRG -,SUP-423270,CDM,A6213,HCPCS,270,RC,,,outpatient,,,41.01,28.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.206745,416.02,other,SI=N Exclusions ,,
DRESSING MEPORE 2.5 X 3 -,SUP-670800,CDM,A6219,HCPCS,270,RC,,,outpatient,,,0.55,0.385,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.04041,416.02,other,SI=N Exclusions ,,
TOWEL ABSORBENT STER 7550 -,SUP-7550,CDM,A6219,HCPCS,270,RC,,,outpatient,,,4,2.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.04041,416.02,other,SI=N Exclusions ,,
DRESSING WND 2X2IN ADH ISLND NWVN BRDR WTRPRF BK STRL SQ LF -,SUP-MSC3222,CDM,A6219,HCPCS,270,RC,,,outpatient,,,0.18,0.126,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.04041,416.02,other,SI=N Exclusions ,,
DRESSING BORDERED 4X4IN ADH ISLAND NWVN -,SUP-MSC3244,CDM,A6219,HCPCS,270,RC,,,outpatient,,,2.39,1.673,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.04041,416.02,other,SI=N Exclusions ,,
DRESSING ADAPTIC 3INX3IN 7.6CMx7.6CM NON-ADHERING -,SUP-2012,CDM,A6222,HCPCS,272,RC,,,outpatient,,,14.03,9.821,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.52533,416.02,other,SI=N Exclusions ,,
DRESSING PETRO ADPTC 3X3IN OIL EMUL NADH GZE CELLU-ACET -,SUP-2012,CDM,A6222,HCPCS,272,RC,,,outpatient,,,14.03,9.821,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.52533,416.02,other,SI=N Exclusions ,,
DRESSING XEROFORM 1X8 -,SUP-212,CDM,A6222,HCPCS,272,RC,,,outpatient,,,3.03,2.121,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.52533,416.02,other,SI=N Exclusions ,,
DRESSING XEROFORM 2 X 2 -,SUP-214,CDM,A6222,HCPCS,272,RC,,,outpatient,,,2.34,1.638,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.52533,416.02,other,SI=N Exclusions ,,
DRESSING MESALT RIBBON 3/4x39 IN DEBRIDE 0.75x39 IN ABSB -,SUP-285299,CDM,A6222,HCPCS,272,RC,,,outpatient,,,10.93,7.651,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.52533,416.02,other,SI=N Exclusions ,,
DRESSING MESALT 3x3 IN GAUZE -,SUP-285780,CDM,A6222,HCPCS,272,RC,,,outpatient,,,4.67,3.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.52533,416.02,other,SI=N Exclusions ,,
DRESSING WND 1.6 X 2.4IN CUTIMED SORBACT SWB PRIM STRL LF -,SUP-7216412,CDM,A6222,HCPCS,272,RC,,,outpatient,,,21.89,15.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.52533,416.02,other,SI=N Exclusions ,,
DRESSING ADAPTIC 3X8 -,SUP-2013,CDM,A6223,HCPCS,272,RC,,,outpatient,,,4.43,3.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.698195,416.02,other,SI=N Exclusions ,,
DRESSING PETRO VASELINE 1X36IN STRL 1-PLY IMPREG NADH LPRO -,SUP-205-12-A,CDM,A6223,HCPCS,272,RC,,,outpatient,,,3.11,2.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.698195,416.02,other,SI=N Exclusions ,,
DRESSING XEROFORM 5IN X 9IN -,SUP-213,CDM,A6223,HCPCS,272,RC,,,outpatient,,,4.32,3.024,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.698195,416.02,other,SI=N Exclusions ,,
DRESSING XEROFORM 5IN X 9IN -,SUP-213,CDM,A6223,HCPCS,272,RC,,,outpatient,,,4.32,3.024,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.698195,416.02,other,SI=N Exclusions ,,
DRESSING PETRO VASELINE 1X36IN OCL NADH STRIP STRL IMPREG -,SUP-8884412600,CDM,A6223,HCPCS,272,RC,,,outpatient,,,3.15,2.205,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.698195,416.02,other,SI=N Exclusions ,,
GAUZE VASELINE 1 X 36 -,SUP-8884412600,CDM,A6223,HCPCS,272,RC,,,outpatient,,,3.15,2.205,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.698195,416.02,other,SI=N Exclusions ,,
DRESSING ADAPTIC 3X8 -,SUP-JOHN-2013,CDM,A6223,HCPCS,272,RC,,,outpatient,,,26.74,18.718,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.698195,416.02,other,SI=N Exclusions ,,
GAUZE VASELINE 3IN X 18IN -,SUP-207-12-A,CDM,A6224,HCPCS,272,RC,,,outpatient,,,5.13,3.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.801465,416.02,other,SI=N Exclusions ,,
GAUZE VASELINE 3IN X 18IN -,SUP-207-12-A,CDM,A6224,HCPCS,272,RC,,,outpatient,,,5.13,3.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.801465,416.02,other,SI=N Exclusions ,,
"GAUZE VASELINE 3"" X 36"" -",SUP-425600,CDM,A6224,HCPCS,272,RC,,,outpatient,,,7.26,5.082,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.801465,416.02,other,SI=N Exclusions ,,
GAUZE PETRO 3X36IN VASELINE -,SUP-8884415600,CDM,A6224,HCPCS,272,RC,,,outpatient,,,3.57,2.499,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.801465,416.02,other,SI=N Exclusions ,,
GAUZE VASELINE 1/2 X 72 -,SUP-8884421600,CDM,A6224,HCPCS,272,RC,,,outpatient,,,5.95,4.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.801465,416.02,other,SI=N Exclusions ,,
DRESSING HYDROCOLLOID DUODERM 2X4IN XTRA THIN -,SUP-187900,CDM,A6234,HCPCS,272,RC,,,outpatient,,,4.07,2.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.913715,416.02,other,SI=N Exclusions ,,
DRESSING DUODERM EXTRA THIN 4X4 -,SUP-187955,CDM,A6234,HCPCS,272,RC,,,outpatient,,,6.71,4.697,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.913715,416.02,other,SI=N Exclusions ,,
DRESSING HYDROCOLLOID DUODERM 4X4IN XTRA THIN -,SUP-187955,CDM,A6234,HCPCS,272,RC,,,outpatient,,,4.49,3.143,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.913715,416.02,other,SI=N Exclusions ,,
DRESSING WND XTHN 4X4IN DDRM STRL CONFRM NADH HYDRCL SQ -,SUP-187955,CDM,A6234,HCPCS,272,RC,,,outpatient,,,6.73,4.711,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.913715,416.02,other,SI=N Exclusions ,,
DRESSING HYDRCL XTHN 4X6IN DDRM CGF STRL XTHN CONFRM NADH -,SUP-187902,CDM,A6235,HCPCS,270,RC,,,outpatient,,,11.92,8.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.67604,416.02,other,SI=N Exclusions ,,
DRESSING DUODERM 4 X 4 THICK -,SUP-187660,CDM,A6237,HCPCS,272,RC,,,outpatient,,,9.64,6.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,416.02,other,SI=N Exclusions ,,
DRESSING WND 4X4IN DDRM SGNL STRL CONFRM ADH ABSB WTRPRF -,SUP-403326,CDM,A6237,HCPCS,272,RC,,,outpatient,,,11.11,7.777,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,416.02,other,SI=N Exclusions ,,
DRESSING HYDROCOLLOID DUODERM 4X4IN -,SUP-403326,CDM,A6237,HCPCS,272,RC,,,outpatient,,,7.39,5.173,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,416.02,other,SI=N Exclusions ,,
DRESSING HYDRCL 6X7IN DUADERM CGF STRL -,SUP-187974,CDM,A6238,HCPCS,270,RC,,,outpatient,,,42.72,29.904,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.600005,416.02,other,SI=N Exclusions ,,
DRESSING WND 14X14CM DDRM SGNL STRL CONFRM ADH ABSB WTRPRF -,SUP-403327,CDM,A6238,HCPCS,270,RC,,,outpatient,,,20.49,14.343,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.600005,416.02,other,SI=N Exclusions ,,
DRESSING WND 15X18CM DDRM SGNL STRL CONFRM ADH ABSB WTRPRF -,SUP-403332,CDM,A6238,HCPCS,270,RC,,,outpatient,,,21.79,15.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.600005,416.02,other,SI=N Exclusions ,,
CREAM TRIAD HYDROPHILLIC WOUND DRESSING -,SUP-1964-A,CDM,A6240,HCPCS,270,RC,,,outpatient,,,31.57,22.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7.087465,416.02,other,SI=N Exclusions ,,
DRESSING HYDRCL 1.6IN TENDRWT STRL ACT CVTY LF -,SUP-MSC8401,CDM,A6242,HCPCS,270,RC,,,outpatient,,,16.34,11.438,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.66833,416.02,other,SI=N Exclusions ,,
DRESSING DEBRIDE 3X3IN PLYACRL PLYMR GL CVTY PAD TENDRWT ACT -,SUP-MSC8403Z,CDM,A6242,HCPCS,270,RC,,,outpatient,,,22.7,15.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.66833,416.02,other,SI=N Exclusions ,,
DRESSING GEL 30GM DDRM HYDACTV NADH FIL HYDRCL HYDACTV -,SUP-187987,CDM,A6248,HCPCS,272,RC,,,outpatient,,,13.91,9.737,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.122795,416.02,other,SI=N Exclusions ,,
DRESSING SILVASORB GEL 0.25OZ  SILVER ABSB ANTMIC -,SUP-MSC93025EP,CDM,A6248,HCPCS,272,RC,,,outpatient,,,34.03,23.821,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.122795,416.02,other,SI=N Exclusions ,,
SURGICAL DRESSING SILK 6 X 8IN -,SUP-NON4313,CDM,A6255,HCPCS,270,RC,,,outpatient,,,8.82,6.174,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.98009,416.02,other,SI=N Exclusions ,,
DRESSING TEGADERM 1.75X1.75IN TRANPARENT FILM -,SUP-1622-W,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.17,0.819,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.262665,416.02,other,SI=N Exclusions ,,
DRESSING TEGADERM 3 X 3 -,SUP-1624-W,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.17,0.819,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.262665,416.02,other,SI=N Exclusions ,,
DRESSING TRANSP 2.375X2.75IN TEGADERM OCL PIC FRM STYL -,SUP-1624-W,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.17,0.819,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.262665,416.02,other,SI=N Exclusions ,,
DRESSING TEAGDERM IV 2.75X3.25IN -,SUP-1633,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.63,1.141,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.262665,416.02,other,SI=N Exclusions ,,
DRESSING TEGADERM IV 3.5X4.5IN TRANSPARENT -,SUP-1655,CDM,A6257,HCPCS,270,RC,,,outpatient,,,5.37,3.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.262665,416.02,other,SI=N Exclusions ,,
DRESSING TRANSP 4X4.75IN TEGADERM OCL ORIG FRM STYL PLYSTR -,SUP-1626,CDM,A6258,HCPCS,270,RC,,,outpatient,,,3.38,2.366,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.75881,416.02,other,SI=N Exclusions ,,
DRESSING TRANSPARENT 4IN X 4.25IN -,SUP-1626,CDM,A6258,HCPCS,270,RC,,,outpatient,,,3.38,2.366,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.75881,416.02,other,SI=N Exclusions ,,
DRESSING TEGADERM 4X5 -,SUP-1626-W,CDM,A6258,HCPCS,270,RC,,,outpatient,,,3.53,2.471,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.75881,416.02,other,SI=N Exclusions ,,
DRESSING TEGADERM 15X20CM -,SUP-1628,CDM,A6258,HCPCS,270,RC,,,outpatient,,,6.97,4.879,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.75881,416.02,other,SI=N Exclusions ,,
DRESSING TRANSP 4X6.125IN TEGADERM OCL WND FRM STYL ADLT -,SUP-1689,CDM,A6258,HCPCS,270,RC,,,outpatient,,,10.58,7.406,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.75881,416.02,other,SI=N Exclusions ,,
DRESSING TEGADERM 20CM X 30CM -,SUP-1629,CDM,A6259,HCPCS,272,RC,,,outpatient,,,9.86,6.902,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.21357,416.02,other,SI=N Exclusions ,,
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7020-38,NDC,outpatient,10,ML,102.5,71.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.17,416.02,other,SI=N Exclusions ,,
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7030-42,NDC,outpatient,10,ML,100.56,70.392,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.17,416.02,other,SI=N Exclusions ,,
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7015-48,NDC,outpatient,10,ML,100.56,70.392,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.17,416.02,other,SI=N Exclusions ,,
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7015-46,NDC,outpatient,10,ML,100.56,70.392,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.17,416.02,other,SI=N Exclusions ,,
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7025-40,NDC,outpatient,10,ML,100.57,70.399,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.17,416.02,other,SI=N Exclusions ,,
GADOTERATE MEGLUMINE 1 MMOL/2 ML IV SOLN WRAPPER,RX-4080731,CDM,A9575,HCPCS,636,RC,67684-2000-00,NDC,outpatient,20,ML,136.25,95.375,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.12,416.02,other,SI=N Exclusions ,,
7 HOLE SUPERIOR MIDSHAFT CLAVICLE RIGHT PLATE -,SUP-0000000215,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEADLESS 4.0 FIXOS X 26MM -,SUP-0000000215,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE ANCHORED APACHE 5MM -,SUP-0000006784,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CABLE ORTHO CBL-RDY COCR 635MM -,SUP-00022320418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2083.36,1458.352,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN IM 4.8X222MM RUSH SS -,SUP-00080200103,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.68,514.976,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN IM 3.2X127MM RUSH SS -,SUP-00080300104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN IM 3.2X140MM RUSH SS -,SUP-00080300105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN IM 3.2X165MM RUSH SS -,SUP-00080300107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN IM 3.2X191MM RUSH SS -,SUP-00080300109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN IM SZ 3L 3.2X241MM RUSH SS -,SUP-00080300113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN IM 3.2X254MM RUSH SS -,SUP-00080300114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X18MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS POR -,SUP-00104223018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X24MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS POR -,SUP-00104223024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X30MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-00104223030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN CANC 4.5X33MM PROTASUL-64 WF TM ANTMC SHLDR STRL -,SUP-00104223033,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN CANC 4.5X36MM PROTASUL-64 WF TM ANTMC SHLDR STRL -,SUP-00104223036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X42MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-00104223042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X48MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-00104223048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FILLER TY I COLL CA PHOS 5ML PST COPIOS DBASC -,SUP-00110302005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3752.36,2626.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FILLER TY I COLL CA PHOS 10ML PST COPIOS DBASC -,SUP-00110302010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6279,4395.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CEMENT BN PLYMTHL MTHCRYLT 40GM PLC R HVISC -,SUP-00111214001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 40X3MM ANCHR XLPE GLOBAL STRL -,SUP-00113640026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9421.68,6595.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX10MM CANN 7.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX10MM CANN 1/2 5MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX12MM CANN 9.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX12MM CANN 1/3 5MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3MMX16MM CANN 1/2 8MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114701631,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX16MM CANN 13.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3MMX19MM CANN 1/3 6.3MM THRD SD/ST HX REVCT FLUT -,SUP-00114701930,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANN 3.0MM X 20MM 1/3 TH -,SUP-00114702030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3MMX21MM CANN 1/3 7MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3MMX24MM CANN 1/2 12MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702431,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3MMX26MM CANN 1/2 13MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702631,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3MMX28MM CANN 1/2 14MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702831,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX28MM CANN 9.3MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114702835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX28MM CANN 1/3 9.3MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114702840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.27,795.389,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX28MM CANN 1/2 14MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114702841,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.27,795.389,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3MMX30MM CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX30MM CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX30MM CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT. -,SUP-00114703041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX34MM CANN 1/3 11.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX34MM CANN 1/3 11.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX34MM CANN 1/3 17MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703441,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.27,795.389,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX36MM CANN 1/3 12MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX36MM CANN 1/3 12MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX36MM CANN 1/3 18MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703641,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX38MM CANN 1/3 12.7MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX38MM CANN 1/3 19MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703841,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3MMX40MM CANN 1/3 13.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX40MM CANN 1/3 13.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X40MM CANN 1/3 13.3MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX40MM CANN 1/3 20MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX42MM CANN 1/3 39.5MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX44MM CANN 14.7MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX44MM CANN 1/3 14.7MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX44MM CANN 1/2 22MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704441,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5MMX45MM CANN 16MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114704555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5MMX45MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114704556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX46MM CANN 15.3MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX46MM CANN 43.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX46MM CANN 1/3 15.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX46MM CANN 1/2 23MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704641,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX48MM CANN 16MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX48MM CANN 1/3 16MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX50MM CANN 16.7MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114705035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX50MM CANN 1/3 16.7MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114705040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5MMX50MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5MMX50MM CANN 45.3MM FT SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705057,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MMX50MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114705065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5MMX55MM CANN 16MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5MMX55MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MMX55MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114705565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5MMX60MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114706056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MMX60MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MMX60MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5MMX65MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114706556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MMX65MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MMX65MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MMX70MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MMX70MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7.5MMX70MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7.5MMX70MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MMX75MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MMX75MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7.5MMX75MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7.5MMX75MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5MMX80MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114708056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MMX80MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MMX80MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7.5MMX80MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7.5MMX80MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7.5MMX80MM CANN 74.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114708077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEPIN ORTHO 1.6MMX6IN P/T TROC TIP -,SUP-00114708400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEPIN ORTHO 1.25MMX6IN P/T TROC TIP -,SUP-00114708500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5MMX85MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114708556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MMX85MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MMX85MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7.5MMX85MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7.5MMX85MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7.5MMX85MM CANN 79.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114708577,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEPIN ORTHO 2.4MMX9IN P/T TROC TIP -,SUP-00114708700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEPIN ORTHO 3.2MMX9IN P/T TROC TIP -,SUP-00114708800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEPIN ORTHO 1.6MMX9IN SMTH SHFT TROC TIP -,SUP-00114709000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,70.98,49.686,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MMX90MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7.5MMX90MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7.5MMX90MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7.5MMX90MM CANN 84.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114709077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEPIN ORTHO 2.4MMX9IN SMTH SHFT TROC TIP -,SUP-00114709100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,147.14,102.998,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEPIN ORTHO 3.2MMX9IN SMTH SHFT TROC TIP -,SUP-00114709200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,147.04,102.928,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEPIN ORTHO 1.6MMX6IN SMTH SHFT TROC TIP -,SUP-00114709400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,70.95,49.665,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WASHER ORTHO 3MM -,SUP-00114709500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MMX95MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MMX95MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7.5MMX95MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7.5MMX95MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7.5MMX95MM CANN 89.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114709577,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WASHER ORTHO F/3.5/4MM CANN SCR NS -,SUP-00114709600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WASHER ORTHO F/4.5MM CANN SCR SS NS -,SUP-00114709700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WASHER ORTHO F/5.5MM/7.5MM CANN SCR SS RND NS -,SUP-00114709800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEPIN ORTHO 3.2MMX12IN P/T TROC TIP -,SUP-00114709901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEPIN ORTHO 3.2MM 30CM -,SUP-00114709902,CDM,C1713,HCPCS,278,RC,,,outpatient,,,155.78,109.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEPIN ORTHO 3.2MMX12IN SMTH SHFT DRILL TIP -,SUP-00114709903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,155.74,109.018,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MMX100MM CANN 16MM THRD SD/ST 4.5MM HX REVCT FLUT -,SUP-00114710065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW Z CANN PT 32 6.5 X 100 -,SUP-00114710066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7.5MMX100MM CANN FT SD/ST 5MM HX REVCT FLUT BIODUR 108 -,SUP-00114710077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MMX105MM CANN 16MM THRD SD/ST 4.5MM HX REVCT FLUT -,SUP-00114710565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7.5MMX105MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114710575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1399.33,979.531,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7.5MMX105MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114710576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7.5MMX110MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7.5MMX110MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7.5MMX115MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7.5MMX115MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7.5MMX120MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114712075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.25MM 2.5MM THRD MINI 10MM HRBRT MINI TIV STRL -,SUP-00115001000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2142.36,1499.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.25MM 2.5MM THRD MINI 16MM HRBRT MINI TIV STRL -,SUP-00115001600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2142.36,1499.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5MM 2.1MM THRD 14MM CANN HRBRT/WPL TIV STRL -,SUP-00115201400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2555.05,1788.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3X5MM DIA THRD MINI 18MM CANN LAG HRBRT/WPL TIV STRL -,SUP-00115201800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2555.05,1788.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEPIN ORTHO 3.2MMX23CM THRD TROC TIP FRLCK STRL -,SUP-00118102000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.84,81.788,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 12.7MM THRD VFX2 LAG 17MM S/T SS 130MM -,SUP-00119300557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1749.27,1224.489,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEPIN ORTHO 3.2MM TM -,SUP-00119703200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.19,908.033,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD FEM HIP 10MM TM TIV 25MM THRD -,SUP-00119710010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14101.97,9871.379,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN NCB 80MM 4HL CONTR LCK PROTASUL-64 STRL -,SUP-00202262104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5884.73,4119.311,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN NCB 117MM 7HL CONTR LCK PROTASUL-64 STRL -,SUP-00202262107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7175.97,5023.179,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X24MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X26MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X30MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X32MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,605.85,424.095,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X36MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,605.85,424.095,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAP LCK NCB NS -,SUP-00203150300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,930.39,651.273,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X24MM NLCKG CORT NCB ST TMX NS -,SUP-00203155024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX26MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX28MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX30MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX32MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX34MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX36MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X38MM NLCKG CORT NCB ST TMX NS -,SUP-00203155038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX40MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX42MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX44MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX46MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX50MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X32MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,778.91,545.237,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X44MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,778.91,545.237,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X46MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,778.91,545.237,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X50MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.68,514.976,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN NCB 93MM 5HL LCK TI -,SUP-00203262005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5979.97,4185.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
STAPLE INTNL 19MMX15.9MM LF -,SUP-00222901300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,294.26,205.982,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DEVICE ORTHO 23MM LNG CBL-RDY GTR TROCH TIV 121MM STRL -,SUP-00223200205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9554.89,6688.423,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CABLE ORTHO 1.8MM CBL-RDY COCR 914MM STRL -,SUP-00223200228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2397.84,1678.488,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 305MM 4.5MM 10HL SS STRL -,SUP-00223200302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4354.7,3048.29,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CABLE PLATE 1.8MM CBL-RDY BN SS 610MM STRL -,SUP-00223200318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1493.73,1045.611,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CABLE SURG 1.8MM X 635MM CBL-RDY CRLGE SS -,SUP-00223200418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2083.36,1458.352,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CABLE FX 1.3MM CBL-RDY SS 889MM STRL -,SUP-00223201113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1788.55,1251.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ORTHOPEDIC CBL-RDY GRP 65MM PIN -,SUP-00223205021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2708.43,1895.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX12MM LCK CORT ST FA SS NS -,SUP-00234801235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX18MM LCK CORT ST FA SS NS -,SUP-00234801835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX20MM LCK CORT ST FA SS NS -,SUP-00234802035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX22MM LCK CORT ST FA SS NS -,SUP-00234802235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX26MM LCK CORT ST FA SS NS -,SUP-00234802635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX30MM LCK CORT ST FA SS NS -,SUP-00234803035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX34MM LCK CORT ST FA SS NS -,SUP-00234803435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX40MM LCK CORT ST FA SS NS -,SUP-00234804035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX100MM LCK CORT ST FA SS NS -,SUP-00234810035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 132MM 2.7/3.5MM 8HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235701708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3823.64,2676.548,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 80MM 2.7/3.5MM 4HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235701804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3310.29,2317.203,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 106MM 6HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235701806,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3540.4,2478.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 114MM 3.5MM 6HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235800104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6389.13,4472.391,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 129MM 7HL FX-ANG LCK NS -,SUP-00235800907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.68,2924.376,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 77MM 3HL LCK SS NS -,SUP-00235801203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3788.26,2651.782,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX12MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX14MM LCK NCANN P/T ST CNCL SS NS -,SUP-00235901426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,328.92,230.244,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX14MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX14MM LCK NCANN P/T ST SS NS -,SUP-00235901438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX16MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX16MM LCK NCANN P/T ST CNCL SS NS -,SUP-00235901638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X18MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X30MM LCK NCANN FT ST SS NS -,SUP-00235903035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X32MM LCK NCANN FT ST SS NS -,SUP-00235903235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X36MM LCK NCANN FT ST SS NS -,SUP-00235903635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X38MM LCK NCANN FT ST SS NS -,SUP-00235903835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X40MM LCK NCANN FT ST SS NS -,SUP-00235904035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X42MM LCK NCANN FT ST SS NS -,SUP-00235904235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X44MM LCK NCANN FT ST SS NS -,SUP-00235904435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X46MM LCK NCANN FT ST SS NS -,SUP-00235904635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X48MM LCK NCANN FT ST SS NS -,SUP-00235904835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X50MM LCK NCANN FT ST SS NS -,SUP-00235905035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCRW 14MM CASPAR PIN F/DSTRCT -,SUP-0024-LDR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEPIN ORTHO 3.2X444MM -,SUP-00281001175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
STAPLE INTNL 22MMX9.5MM COCR LF -,SUP-00406000100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.27,530.089,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
STAPLE INTNL 25MMX9.5MM COCR LF -,SUP-00406000200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.27,530.089,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN FX 3.2MM BGLNI/FLTW THRD TIP -,SUP-00430400800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,379.28,265.496,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.5MM THRD 7MM CORT FT ST HEX HEAD SS NS -,SUP-00481500701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.5MM THRD 8MM CORT FT ST HEX HEAD SS NS -,SUP-00481500801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.5MM THRD 9MM CORT FT ST HEX HEAD SS NS -,SUP-00481500901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.5MM THRD 14MM CORT FT ST HEX HEAD SS NS -,SUP-00481501401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.5MM THRD 16MM CORT FT ST HEX HEAD SS NS -,SUP-00481501601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.5MM THRD 20MM CORT FT ST HEX HEAD SS NS -,SUP-00481502001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2MM THRD 6MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482000603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2MM THRD 8MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482000803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2MM THRD 10MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2MM THRD 10MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2MM THRD 12MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2MM THRD 12MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2MM THRD 14MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2MM THRD 14MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2MM THRD 16MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2MM THRD 16MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2MM THRD 18MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2MM THRD 22MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482002201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MM THRD 6MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00482700601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MM THRD 8MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00482700801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MM THRD 10MM LCK CORT FT NON- ST 2.5MM SM HEX RCESS -,SUP-00482701000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,128.9,90.23,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MM THRD 10MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MM THRD 12MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MM THRD 14MM CORT FT ST 2.5MM SM HEX RCESS -,SUP-00482701401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MM THRD 16MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MM THRD 18MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,147.33,103.131,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MM THRD 20MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482702001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MM THRD 26MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482702601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MMX10MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482801002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MMX12MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482801202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MMX12MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482801202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MMX14MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482801402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MMX16MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482801602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MMX18MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482801802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MMX20MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482802002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MMX22MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482802202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MMX26MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482802602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MMX28MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482802802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MMX30MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482803002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX16MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483501601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX16MM LCK CORT 6MM P/T NON- ST 2.5MM SM HEX RCESS -,SUP-00483501604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX20MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX20MM LCK CORT 6MM P/T NON- ST 2.5MM SM HEX RCESS -,SUP-00483502004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX22MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX22MM LCK CORT 6MM P/T NON- ST 2.5MM SM HEX RCESS -,SUP-00483502204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX24MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483502404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX26MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX26MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483502604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX28MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX28MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483502804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX30MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483503001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX30MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483503004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN CORT 3.5MM 32MM SS NS FT S/T LOCK 2.5MM SM HEX -,SUP-00483503201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX34MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483503401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX34MM LCK CORT 12MM P/T NON- ST 2.5MM SM HEX -,SUP-00483503404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX45MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483504501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX45MM LCK CORT 12MM P/T NON- ST 2.5MM SM HEX -,SUP-00483504504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX50MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483505001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX55MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483505501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX12MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484001200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX12MM CANC 5MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX14MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484001400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX14MM CANC 5MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX16MM LCK CANC FT 2.5MM SM HEX RCESS SS NS -,SUP-00484001600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX16MM CANC 6MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX18MM LCK CANC FT 2.5MM SM HEX RCESS SS NS -,SUP-00484001800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX18MM CANC 7MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX20MM LCK CANC FT 2.5MM SM HEX RCESS SS NS -,SUP-00484002000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX22MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484002200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX24MM CANC 10MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484002401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX26MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484002600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX28MM CANC 14MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484002801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX30MM CANC 14MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484003001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX34MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484003400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX38MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484003800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX40MM CANC 14MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484004001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX50MM CANC 15MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484005001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MM THRD 36MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484503601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MM THRD 38MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484503801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MM THRD 40MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MM THRD 40MM CORT 20.5MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00484504008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,194.77,136.339,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MM THRD 42MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MM THRD 44MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MM THRD 46MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MM THRD 50MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484505001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MM THRD 50MM CORT 24.5MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00484505008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,194.77,136.339,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MM THRD 55MM CORT 26.5MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00484505508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,194.77,136.339,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MM THRD 58MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484505801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MM THRD 60MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484506001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MM THRD 45MM CANC 32MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486504502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MM THRD 50MM CANC 16MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486505001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MM THRD 50MM CANC 32MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486505002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MM THRD 55MM CANC 32MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486505502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MM THRD 60MM CANC FT 3.5MM LRG HEX RCESS SS NS -,SUP-00486506000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WASHER ORTHO 4X7MM SM 2.7/3.5/4.0MM SS RND FLT NS -,SUP-00490004051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WASHER ORTHO 13MM LRG 4.5/6.5MM RND FLT NS -,SUP-00490006551,CDM,C1713,HCPCS,278,RC,,,outpatient,,,207.73,145.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 21MM 2MM SS L-SHP OB R MINI FRAG NS -,SUP-00492000210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,386.57,270.599,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 23MM 4HL 2MM SS STR MINI FRAG NS -,SUP-00492000402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,389.49,272.643,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 32MM 2.7MM SS T-SHP MINI FRAG NS -,SUP-00492700304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.52,254.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 31MM 4HL 1MM SS 1/4 TBLR MINI FRAG NS CLLR -,SUP-00492700403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,432.72,302.904,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 104MM 3.5MM 4HL SS CLVRLF SM FRAG NS -,SUP-00493500416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1493.73,1045.611,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 61MM 5HL SS SM 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500503,CDM,C1713,HCPCS,278,RC,,,outpatient,,,406.82,284.774,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 73MM 3.5MM 6HL COMPR SS SM FRAG NS -,SUP-00493500600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,800.56,560.392,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 73MM 6HL SS SM 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.09,296.863,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 85MM 3.5MM 7HL COMPR SS SM FRAG NS -,SUP-00493500700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,822.21,575.547,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 85MM 7HL SS SM 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.09,296.863,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 97MM 3.5MM 8HL 1.1MM COMPR SS SM FRAG NS -,SUP-00493500800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 97MM 3.5MM 8HL SS 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,454.37,318.059,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 109MM 3.5MM 9HL 1.1MM COMPR SS SM FRAG NS -,SUP-00493500900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,887.1,620.97,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 121MM 3.5MM 10HL 1.1MM COMPR SS SM FRAG NS -,SUP-00493501000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,908.74,636.118,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 74MM 3.5MM HLX3/5 HD/SHFT 1.5MM SS T-SHP OBLQ SM -,SUP-00493503505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1100.65,770.455,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
"PLATE Z ""T"" 4 HOLE 3.5MM -",SUP-00493504404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,714.03,499.821,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 68MM 3.5MM UNIV LCK SYS 5HL LCK SS 1/3 TBLR NS -,SUP-00493600503,CDM,C1713,HCPCS,278,RC,,,outpatient,,,952.04,666.428,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 94MM 3.5MM UNIV LCK SYS 7HL LCK SS 1/3 TBLR NS -,SUP-00493600703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1016.92,711.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 107MM 3.5MM UNIV LCK SYS 8HL LCK SS 1/3 TBLR NS -,SUP-00493600803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.22,742.154,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 105MM 3.5MM UNIV LCK SYS 8HL CONTR LCK DL COMPR SS -,SUP-00493600807,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1867.15,1307.005,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 105MM 3.5MM UNIV LCK SYS 8HL RECON LCK SS NS -,SUP-00493600813,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2566.79,1796.753,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 133MM 3.5MM UNIV LCK SYS 10HL LCK SS 1/3 TBLR LRG -,SUP-00493601003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.81,757.267,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 116MM 4.5MM 6HL SHFT SS T-SHP LRG FRAG NS -,SUP-00494500604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1316.86,921.802,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE Z 4.5 COMP B 12 HOLE -,SUP-00494501201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1356.19,949.333,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
KT MIXER BNCMNT VAC MX 35ML LNG CQ/NOZ FNL CHRCL FLTR SUCT -,SUP-00504903501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,811.07,567.749,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
KT MIXER BNCMNT VAC MX 45ML LNG CQ/NOZ FNL CHRCL FLTR SUCT -,SUP-00504904501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,905.01,633.507,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WIRE PACK .028 SPADE TIP -,SUP-00505004100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,49.89,34.923,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GRAFT HUM TIS 11MM CHONDROFIX OSTCHND LF -,SUP-00560402011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15111.91,10578.337,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GRAFT BN 15MM CHONDROFIX LF -,SUP-00560402015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15891.64,11124.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 48MM HD UNICMPT SS F/HI FLEX SYS -,SUP-00579104100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.77,258.139,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 48MM HD UNICMPT SS F/HI FLEX SYS -,SUP-00579104100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
HOLDER IMPL HDLS 48MM SS GOLD F/UNICMPT HI FLEX KN SPCR BLCK -,SUP-00579104200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEX HEAD 3.5MM -,SUP-00-5901-035-27,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEX HEAD 3.5MM X 48MM -,SUP-00-5901-035-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW FLEX LCK -,SUP-00595409000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
EXTENSION STM MG2 PS TIV ALY PLG TAPR KN -,SUP-00596009900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDE SURG NEXGEN F/UNICMPT KN ARTHPL TIB PT SPEC INST HI.. -,SUP-00597000001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDE SURG NEXGEN F/UNICMPT KN ARTHPL TIB PT SPEC INST HI -,SUP-00597000002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEPIN ORTHO PERSONA CRUCIF RCESS -,SUP-00597000025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BASEPLATE TIB SZ1 58/40MM KN STM NEXGEN TIV ALY PMMA UHMWPE -,SUP-00598002701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COMP TIBPLT SZ2 62/41MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598002702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COMP TIBPLT SZ3 66/42MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598003701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COMP TIBPLT SZ3 66/42MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598003701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8452.1,5916.47,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COMP TIBPLT SZ4 66/46MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598003702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COMP TIBPLT SZ5 74/46MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598004701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COMP TIBPLT SZ6 74/50MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598004702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COMP TIBPLT SZ7 82/51MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598005701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW AUG 48MM TIV HX HD F/ARTHPL NEXGEN STRL DIST FEM KN -,SUP-00598304048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COMP TIBTRY SZ3 66/42MM KN CMNT STM WDG NEXGEN TIV PMMA CR -,SUP-00598800300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10515.22,7360.654,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COMP TIBTRY SZ4 66/46MM KN CMNT STM WDG NEXGEN TIV PMMA CR -,SUP-00598800400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10515.22,7360.654,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COMP TIBTRY SZ5 74/46MM KN CMNT STM WDG NEXGEN TIV PMMA CR -,SUP-00598800500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10515.22,7360.654,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DEVICE 11X4X11MM TM-S 7DG TM -,SUP-00610101041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10526.36,7368.452,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER 11X14X29MM VBR-11 TM -,SUP-00611100292,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15891.64,11124.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ACTB 6.5X15MM TRILOGY TIV CNTRSNK HEAD ST -,SUP-00625006515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE SELF TAPPED 6.5 X 20 -,SUP-00-6250-065-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BONE SCREW 6.5X25 SELF-TAP -,SUP-00-6250-065-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE SELF TAP 6.5 X 30 -,SUP-00-6250-065-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ACTB 6.5X35MM TRILOGY TIV CNTRSNK HEAD ST -,SUP-00625006535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE 6.5 X 40 SELF TAP -,SUP-00625006540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ACTB 6.5X40MM TRILOGY TIV CNTRSNK HEAD ST -,SUP-00625006540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE 6.5X40 SELF-TAP -,SUP-00-6250-065-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BONE SCREW 6.5 X 50MM SELF TAP -,SUP-00625006550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE 6.5 X 50 SELF-TAP -,SUP-00-6250-065-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LINER 56 X 32  TRILOGY LONGEVITY CONSTRAINED -,SUP-00-6334-056-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14191.09,9933.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HGP ACETABULAR CUP BONE SLF TP 6.5 X 20 -,SUP-00662406520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HGPAETABULAR CUP BONE SLF TP 6.5 X 30 -,SUP-00662406530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SUBSTITUTE BVN SPNG 1ML STRIP FIL COPIOS 10X20MM 5MM -,SUP-00700582001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1934.68,1354.276,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 2MMX45CM TRIMAX NANCY TI ALY E CAP -,SUP-00800620450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1462.94,1024.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLUG ACTB DOME HL HIP CONTIN -,SUP-00875700001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,379.28,265.496,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
HEAD BIOLOX OPT FEM 32MM/+3.5MM DELTA -,SUP-00-8777-032-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8566.51,5996.557,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SIDUS STEM-FREE SHOULDER HUMERAL ANCHOR M -,SUP-01.04555.120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19121.95,13385.365,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
G7 ACETABULAR SCREW 6.5MM / 20L -,SUP-010000997,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
G7 SCREW 6.5MM X 30MM -,SUP-010000999,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
G7 ACETABULAR SCREW 6.5MM / 35L -,SUP-010001000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
G7 SCREW 6.5MM X 40MM -,SUP-010001001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ENDOBUTTON 013186 -,SUP-013186,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.2,778.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BASE SLDR GFT F/ACL /PCL GRAFTMS II -,SUP-014950,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3100.9,2170.63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL FLEXIBLE PRE CURVED 1.50MM X 300MM -,SUP-0194-1500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL FLEXIBLE PRE CURVED 1.75MM X 300MM -,SUP-0194-1750S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.66,795.662,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL FLEXIBLE PRE CURVED 2.25MM X 300MM -,SUP-0194-2250S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1104.62,773.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL FLEXIBLE PRE CURVED 2.5MM X 450MM -,SUP-0194-2500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.59,822.213,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL FLEXIBLE PRE CURVED 3.5MM X 450MM -,SUP-0194-3500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1240.32,868.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL FLEXIBLE PRE CURVED 4.0MM X 450MM -,SUP-0194-4000S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1276.36,893.452,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL FLEXIBLE PRE-CURVED 2.25 X 300MM -,SUP-0195-2250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1104.62,773.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL FLEXIBLE PRE CURVED 2.5 X 450MM -,SUP-0195-2500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.59,822.213,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN LCP 158MM 3.5MM 6HL FA LC CONTR LCK COMPR SS TAPR -,SUP-02.104.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5487.49,3841.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN_VA-LCP 45MM 2.4MM HLX6/2 HD/SHFT CLMNX2 VAR ANG LCK -,SUP-02.111.621,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5084.31,3559.017,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.7/3.5 VA ANTEROLAT DSTL TIB PL/10 H/RT -,SUP-02.118.208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10401.04,7280.728,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7 METAPHYSEA SLF-TPNG T8 SD REC/48 -,SUP-02.118.548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7 METAPHYSEA SLF-TPNG T8 SD REC/50 -,SUP-02.118.550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.7 VA LOCKING ANT PATELLA PL SS CORE SILE -,SUP-02.137.003S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11077.74,7754.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7 VA LOCKING SLF-TPNG T8 SD REC 10 -,SUP-02.211.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 12 -,SUP-02.211.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 16 -,SUP-02.211.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 18 -,SUP-02.211.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.7 VA LCKNG SCR SLF-TPNG T8 SD REC 36 -,SUP-02.211.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.7 VA LCKING SCR SLF-TPNG T8 SD REC 38 -,SUP-02.211.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 40 -,SUP-02.211.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7 VA LCKING SLF-TPNG T8 SD REC 42 -,SUP-02.211.042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.7 VA LCKNG SCR SLF-TPING T8 SD REC 46 -,SUP-02.211.046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.7MM VA LCKNG SCREW SLF-TPNG WITH T8 60MM -,SUP-02.211.060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE FUSION CLOVERLEAF SHORT 2.4/2.7 VA-LCP -,SUP-02.211.250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8683.22,6078.254,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAP FEM NCB LCK -,SUP-0203150300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,930.39,651.273,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PRESSURIZER BNCMNT PROX FEM MED -,SUP-0206-545-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.66,71.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FEM PRESSURIZING SEAL - MED -,SUP-0206-546-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.66,71.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW INTFR CANN BIOSTEON 7X23MM FT BABSRB WDG SHP HAP PLLA -,SUP-0234-010-161,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW INTFR CANN BIOSTEON 8X28MM FT BABSRB WDG SHP HAP PLLA -,SUP-0234-010-167,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW INTFR BIOSTEON 10X35MM INTFR HAP PLLA -,SUP-0234-010-178,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CROSS TITANIUM 8MM X 60MM -,SUP-0234500160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,885.69,619.983,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SYNFLATE BALLOON MED -,SUP-03.804.701S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DEVICE TK TI KNOT 5MM -,SUP-030404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1161.17,812.819,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE FUSION 2.4/2.7MM TI VA-LCP TMT -,SUP-04.211.266,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7524.61,5267.227,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN MATRIXRIB 17HL PRCONT TI NS ROSE RD -,SUP-04.501.006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7312.41,5118.687,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN MATRIXRIB 18HL 1.5MM PRCONT LCK TI NS LBLU -,SUP-04.501.007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8297.02,5807.914,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN MATRIXRIB 18HL PRCONT LCK TI NS ROSE RD -,SUP-04.501.008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7312.41,5118.687,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN MATRIXRIB 8HL PRCONT TI UNIV NS GOLD -,SUP-04.501.009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5653.01,3957.107,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.9X10MM LCK MATRIXRIB ST TI NS GOLD.. -,SUP-04.501.020.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1309.22,916.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.9X10MM LCK MATRIXRIB ST TI NS GOLD. -,SUP-04.501.020.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1147.03,802.921,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.9X12MM LCK MATRIXRIB ST TI NS GOLD -,SUP-04.501.022.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1309.22,916.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.9X14MM LCK MATRIXRIB ST TI NS GOLD -,SUP-04.501.024.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1150.21,805.147,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
IMPLANT ZERO-P IMP 8MM LORDOTIC STERILE -,SUP-04.617.128S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11510.3,8057.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
IMPLANT ZERO-P IMP 9MM LORDOTIC STERILE -,SUP-04.617.129S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11510.3,8057.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 3.0MM X 14MM TI CERVICAL SPINE -,SUP-04.617.814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
KT BONE CMNT SPINEPLEX -,SUP-0406-202-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1455.25,1018.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CEMENT BN 20GM VERTAPLEX DMSTC DUEL -,SUP-0406-402-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1853.05,1297.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PCD SYSTEM-LONG 90DEG TUBE W/VERTAPLEX -,SUP-0507-486-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2470.55,1729.385,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PCD PREC SYS LONG TUBE W/VHV -,SUP-0507-586-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2470.55,1729.385,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 8X70MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-05080000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
KT BONE CMNT AUTOPLEX STRL -,SUP-0605-687-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3912.53,2738.771,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANNULATED TI 6.5X 110MM,SUP-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.94,757.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEPIN ORTHO 2MM -,SUP-1007-1200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SUSTAIN SPACE SMALL - 11MM -,SUP-101.111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SUSTAIN SPACER SMALL NARROW 11MM -,SUP-101.711,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE ROD 5.5 X 250MM -,SUP-10-1025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X14MM CORT/CANC SS NS F/DMD CRPL FUSION PLATE -,SUP-1011602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,651.19,455.833,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X16MM CORT/CANC SS NS F/DMD CRPL FUSION PLATE -,SUP-1011603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,651.19,455.833,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X18MM CORT/CANC SS NS F/DMD CRPL FUSION PLATE -,SUP-1011604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,651.19,455.833,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SET SCREW -,SUP-1020-00-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.0 PLY 3.5 X 24MM SYMPHONY -,SUP-1020-035-124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X100MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.0 PLY 3.5 X 14MM SYMPHONY -,SUP-1020-35-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.0 PLY 3.5 X 16MM SYMPHONY -,SUP-1020-35-116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.0 PLY 3.5 X 18MM SYMPHONY -,SUP-1020-35-118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
4.0 PLY SCREW 3.5 X 20 -,SUP-102035120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.0 PLY 4.0 X 14MM SYMPHONY -,SUP-102040114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD TI 4.0 X 070 LOR -,SUP-102064070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD TI 4.0 X 075 LOR -,SUP-102064075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TI 4.0 X 090 LOR ROD -,SUP-102064090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X65MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X75MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X85MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER 12X8X27MM LUCENT LRDTC CRV PEEK -,SUP-10227-008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER 12X9X27MM LUCENT LRDTC CRV PEEK -,SUP-10227-009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER 12X11X27MM LUCENT LRDTC CRV PEEK -,SUP-10227-011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11695.95,8187.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN F /FUSSION SS SM NS -,SUP-1024002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7238.14,5066.698,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUT ULFX MICROMITE SZ2-0 2.7MM BRD PLYSTR -,SUP-10301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1633.77,1143.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CHIP CANCELLOUS BONE 5CC 1-8 C -,SUP-103015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CREO AMP 5.5 X 50MM -,SUP-1067.1550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CREO AMP 5.5 X 45MM MOD CAN -,SUP-1067.4545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MODULAR CANNULATED 6.5 X 40MM CREO AMP -,SUP-1067.4640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD CURVED TIT ALLOY 4.75MM X 35MM -,SUP-1067.7035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD CURVED TIT ALLOY 4.75MM X 40MM -,SUP-1067.7040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ONLAY LYOPLANT 7.5 X 7.5CM -,SUP-1067040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4108.41,2875.887,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FILLER 10ML OSTEOSPONGE -,SUP-109510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4081.77,2857.239,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FILLER CANC TRBCLR DBM 15ML CHP OSTEOSPONGE ELAS OSTCONDC -,SUP-109515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FILLER DEMIN CANC BN 5ML CHP OSTEOSPONGE ELAS OSTCONDC -,SUP-109550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GRAFT DEMIN CANC BN BLCK 14MM OSTEOSPONGE ELAS OSTCONDC -,SUP-109614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3437.28,2406.096,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SUBSTITUTE CORT FBR 10CC 3DEMIN -,SUP-109760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW T15 LP CORT 3.5 X 20MM NS -,SUP-110017720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW T15 LP CORT 3.5 X 22MM NS -,SUP-110017722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW T15 LP CORT 3.5 X 24MM NS -,SUP-110017724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW T15 LP CORT 3.5 X 26MM NS -,SUP-110017726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW T15 LP CORT 3.5 X 30MM NS -,SUP-110017730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW T15 LP CORT 3.5 X 32MM NS -,SUP-110017732,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW T15 LP CORT 3.5 X 34MM NS -,SUP-110017734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW T15 LOW PROFILE CORT 3.5 X 36MM NS -,SUP-110017736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW T15 LOW PROFILE CORT 3.5  X 38MM NS -,SUP-110017738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW T15 LOW PROFILE CORT 3.5 X 40MM NS -,SUP-110017740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW T15 LP CORT 3.5 X 44 NS -,SUP-110017744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW T15 MD 3.5 X 28MM NS -,SUP-110018028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW T15 LOCK MULTIDIRECTIONAL 3.5 X 34MM NS -,SUP-110018034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW T15 MULTIDDIRECTIONAL 3.5 X 38MM NS SILVER -,SUP-110018038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW T15 MULTIDIRECTIONAL 3.5 X 40MM NS SILVER -,SUP-110018040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE T15 MULTIDIRECTIONAL 3.5 X 42MM NS SILVER -,SUP-110018042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW T15MD 3.5 X 46MM NS -,SUP-110018046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW T15 MD 3.5 X 52MM NS -,SUP-110018052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
3.2MM PEG 20MM -,SUP-110025320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
3.2MM PEG 24MM -,SUP-110025324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG FIXATION 3.2 X 26MM -,SUP-110025326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG FIXATION 3.2 X 28MM -,SUP-110025328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
3.2MM PEGS 30MM -,SUP-110025330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG 3.2 X 32 -,SUP-110025332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEGS 3.2MM X 34MM -,SUP-110025334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG 3.2 X 36MM -,SUP-110025336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG 3.2MM X 38MM -,SUP-110025338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG 3.5 X 40MM -,SUP-110025340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG 3.2 X 42 -,SUP-110025342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG 3.2MM X 44MM -,SUP-110025344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG 3.2 X 46MM -,SUP-110025346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG 3.2 X 50MM -,SUP-110025350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG 3.2 X 52MM -,SUP-110025352,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG 3.2MM X 54MM -,SUP-110025354,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG 3.2 X 56 -,SUP-110025356,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG 3.2 X 58MM -,SUP-110025358,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
3.2MM PEG 60MM -,SUP-110025360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG 3.2 X 65MM -,SUP-110025365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE PRX HUM LO LT 3H 73MM -,SUP-110030100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6671.57,4670.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PRX HUM LO PLT LT 7H 133MM -,SUP-110030102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8021.16,5614.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PRX HUM HI PLTLT 3H 80MM -,SUP-110030300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6569.71,4598.797,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PRX HUM HI PLT RT 3H 80MM -,SUP-110030400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6569.71,4598.797,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE PRX HUM HI RT 4H 90MM -,SUP-110030401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6824.35,4777.045,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
REFOBACIN BONE CEMENT R 1X14 US -,SUP-110034355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COMPR NANO 7IN STEINMANN PIN -,SUP-110045821,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3246.32,2272.424,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GRAFT PLATE CANOPY INLINE 7MM -,SUP-1102.1007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW FIXATION VARIABLE ANGLE -,SUP-111655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1457.21,1020.047,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAP SPIN CREO 5.5MM -,SUP-1119.0000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CREO THREADED LOCKING CAP -,SUP-1119.0010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CONNECTOR CROSS 38-50 LONG 5.5 CREO -,SUP-1119.0039,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CREO 5.5 CROSS CONNECTOR 48-60MM LONG -,SUP-1119.0046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TULIP HEAD FOR CORTICAL SCREW -,SUP-1119.0100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CONNECTOR CREO 5.5 LOW PROFILE CROSS  21.5-25MM LONG -,SUP-1119.0221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CREO 5.5 LOW PROFILE CROSS CONN- 24.5-31MM LONG -,SUP-1119.0224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL 5.5-4.5X25MM MOD CREO AMP -,SUP-1119.1325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
5.5-4.5 X 30MM CREO MCS SCREW -,SUP-1119.1330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5 4.5 X 35MM CORTICAL MODULAR CREO AMP -,SUP-1119.1335,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL 6.0-5.0 X 30ML -,SUP-1119.1430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
6.0-5.0 X 35MM CORTICAL SCREW -,SUP-1119.1435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL 6.5-5.5X35MM -,SUP-1119.1535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORITICAL 6.5-5.5X35MM -,SUP-1119.1535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD 5.5 X 35 TITANIUM ALLOY -,SUP-1119.5035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD STRAIGHT 5.5MM X 40 -,SUP-1119.5040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD TITANIUM ALLOY 5.5 X 45 STRAIGHT -,SUP-1119.5045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD 150MM -,SUP-1119.5150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN CREO 5.5X35MM CRV TI ALY THORLUM -,SUP-1119.7035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
5.5MM CURVED ROD TITANIUM ALLOY 40MM LENGTH -,SUP-1119.7040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD CREO 5.5X40MM -,SUP-1119.7040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD CURVED 5.5MM TITANIUM ALLOY 45MM LENGTH -,SUP-1119.7045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN CREO 5.5X50MM CRV TI ALY THORLUM -,SUP-1119.7050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN CREO 5.5X55MM CRV TI ALY THORLUM -,SUP-1119.7055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD CURVED 5.5MM TITANIUM ALLOY 60MM LENGTH -,SUP-1119.7060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD 5.5MM CURVED TIT ALLOY 65MM -,SUP-1119.7065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD CURVED 5.5MM TITANIUM ALLOY 70MM LENGTH -,SUP-1119.7070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD CURVED 5.5MM TITANIUM ALLOY 80MM LENGTH -,SUP-1119.7080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LCK EXPLOR TI ALY -,SUP-11-210099,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PELVIC ARRAY -,SUP-112230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5393.06,3775.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
STEM TPR DIST SPR 14 X 150MM ARCOS -,SUP-11-300814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
STEM TPR DIST SPR 16 X 150MM ARCOS -,SUP-11-300816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAP LOCKING CREO MIS -,SUP-1134.0010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TULIP MODULAR POLYAXIAL 30MM REDUCTION CREO MIS -,SUP-1134.0100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD CURVED 5.5MM X 50MM TITANIUM ALLOY CREO MIS -,SUP-1134.7050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
HEAD MOD 36MM COCR STD -,SUP-11-363662,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COMP 44MM GLOBAL AP SHLDR 3MM XLPE PG -,SUP-1136-41-026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8667.95,6067.565,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COMP 52MM GLOBAL AP SHLDR 3MM XLPE PG -,SUP-1136-43-026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10652.6,7456.82,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
MITRIS RESILIA MITRAL VALVE 25MM -,SUP-11400M25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
MITRIS RESILIA MITRAL VALVE 27MM -,SUP-11400M27,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
MITRIS RESILIA MITRAL VALVE 29MM -,SUP-11400M29,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
MITRIS RESILIA MITRAL VALVE 31MM -,SUP-11400M31,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
THUMBSCREW FOR C501 ROCHE CUVETTE -,SUP-11406701001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,140.74,98.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7.5MMX100MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUTNS.. -,SUP-1147-100-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7.5MMX100MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT NS. -,SUP-1147-100-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEPIN ORTHO 3.2X353MM THRD -,SUP-115163,CDM,C1713,HCPCS,278,RC,,,outpatient,,,307.85,215.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW COMP RVS CONTROL 6.5 X 20MM ST -,SUP-115380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW COMP RVS CONTROL 6.5 X 30MM ST -,SUP-115382,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X35MM CORT RVRS CNTRL 3.5MM HEX DRV HEX HEAD TI ALY -,SUP-115383,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COMP RVS CNTRL 6.5 X 20MM ST/RST -,SUP-115394,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COMP RVS CNTRL 6.5 X 25MM ST/RST -,SUP-115395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X25MM CORT RVRS CNTRL 3.5MM HEX DRV HEX HEAD TI ALY -,SUP-115395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
6.5 X 30MM CENTRAL SCREW -,SUP-115396,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
REVERSE CENTRAL SHOULDER SCREW 3.5MM X 35MM -,SUP-115397,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COMP RVS CNTRL 6.5 X 40MM ST/RST -,SUP-115398,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COMP RVS CNTRL 6.5 X 45MM ST/RST -,SUP-115399,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER ANT THORLUM VERT 14MMX15-18MMH XPAND 0DG SM 12MM OPN -,SUP-116.101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14881.7,10417.19,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER ANT THORLUM VERT 21X23MMX37-46MM XPAND 0DG MED OPN TI -,SUP-116.207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16864.45,11805.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER ANT THORLUM VERT 21X23MMX49-70MM XPAND 0DG MED OPN TI -,SUP-116.208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16864.45,11805.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CATH ANGIOPLASTIC MARINER BERENSTEIN 4FR 100CM -,SUP-11714016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SING HEAD OPEN LAT CONN 5.5-6.0 HEAD-5.5-6.35 OPEN 12MM WIDE -,SUP-1175.9214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7265.73,5086.011,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN MOUNTAINEER 3.5-5.5X420MM CRV TI OCT LVL1 NS -,SUP-1183-11-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR LD SWIFT- LOCK SPIN CRD MECH LCK -,SUP-1192,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM-THRD -,SUP-121107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM THRD_ -,SUP-121108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM THRD- -,SUP-121109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM THRD. -,SUP-121110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 19MM COMPR LAG AMBI CLASSIC IMHS 21MM THRD STD 3.5MM -,SUP-121116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,781.07,546.749,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
12MM ROD -,SUP-12-1120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X25MM CANN 19MM THRD SD/ST REVCT FLUT SS -,SUP-121625,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X30MM CANN 16MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X35MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121627,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X40MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X45MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121629,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X50MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X55MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121631,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X60MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X65MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121633,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X70MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X75MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X80MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X85MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121637,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X90MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5 CANNULATED 9.5 -,SUP-121639,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X100MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X105MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121641,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X110MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X115MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121643,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X120MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WASHER ORTHO 6.5X12.7MM F/7MM CANN BN SCR RND STRL -,SUP-121680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.23,451.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ACTB 6.5X30MM GRIFTON PINNCL LCK TI FOAM DOME ST -,SUP-1217-30-500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,537.46,376.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX10MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX12MM CANN 5MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX14MM CANN 5MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX16MM CANN 6MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX18MM CANN 7MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX22MM CANN 9MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX24MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX26MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX28MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX30MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121830,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX32MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX34MM CANN 14MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121834,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX36MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121836,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX38MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121838,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX40MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX42MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121842,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX44MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121844,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX46MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX48MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121848,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX50MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121850,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX52MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121852,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX54MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121854,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX56MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121856,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX58MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121858,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANNULATED 4.0M X 60M -,SUP-121860,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX65MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX70MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121870,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
30MM CROSSLINK -,SUP-12-2052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CATALYST R1 6.5MM CENTER SCREW AND CAP SIZE 30 -,SUP-1230-7508-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CATALYST R1 4.5MM LOCKING SCREW SIZE 20 -,SUP-1230-7511-003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CATALYST R1 4.5MM LOCKING SCREW SIZE 24 -,SUP-1230-7511-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CATALYST R1 GLENOSPHERE LOCKING SCREW IMPLANT -,SUP-1230-7515-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LINER INSERT MDM X3 22.2MM ID X 36MM OD X 36C -,SUP-1236-2-242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ENDCAP SPIN REVERE -,SUP-124.000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
REV LOW PROF ADJ T-CONN 29 X 34 -,SUP-124.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X25MM REVERE DBL LD THRD POLYAX F/5.5MM TI -,SUP-124.051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X30MM REVERE DL HEAD THRD POLYAX F/5.5MM TI -,SUP-124.052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI -,SUP-124.053,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X35MM REVERE DEFRM MONOAX -,SUP-124.263,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X40MM REVERE DEFRM MONOAX -,SUP-124.264,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7.5X35MM REVERE DEFRM MONOAX -,SUP-124.273,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X30MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.443,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
4.5MM REVERE PEDICLE SCREW 45MM -,SUP-124.445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5X30MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.452,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.453,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5X40MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.454,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5X45MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5X50MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.456,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5X55MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.457,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X30MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.462,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.463,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X40MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.464,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X45MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X50MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.466,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X55MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.467,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X60MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.468,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X65MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.469,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7.5X40MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.474,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN REVERE DEFRM 5.5X100MM STR TI LPRO THORLUM NTHRD -,SUP-124.510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
5.5MM STRAIGHT ROD 125MM -,SUP-124.512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN REVERE DEFRM 5.5X150MM STR TI LPRO THORLUM NTHRD -,SUP-124.515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
5.5MM STRAIGHT ROD 400MM -,SUP-124.520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD STRAIGHT 5.5 X 500 -,SUP-124.521,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN REVERE DEFRM 5.5X45MM STR TI LPRO THORLUM NTHRD LCK -,SUP-124.545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN REVERE DEFRM 5.5X85MM STR TI LPRO THORLUM NTHRD LCK -,SUP-124.585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
5.5MM CURVED ROD 125MM -,SUP-124.612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN REVERE DEFRM 5.5X35MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN REVERE DEFRM 5.5X40MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN REVERE DEFRM 5.5X45MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN REVERE DEFRM 5.5X50MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN REVERE DEFRM 5.5X55MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN REVERE DEFRM 5.5X60MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN REVERE DEFRM 5.5X65MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN REVERE DEFRM 5.5X75MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6MM DL OD 35MM REVERE POLYAX CORT/CANC F/5.5MM TI ALY -,SUP-124.762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6MM DL OD 40MM REVERE POLYAX CORT/CANC F/5.5MM TI ALY -,SUP-124.763,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CONNECTOR ROD REVERE 5.5MM VARIABLE CROSS 38MM-50MM -,SUP-124.984,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3327.48,2329.236,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
5.5MM CLOSED OFFSET CONNECTOR 5.5MM ROD 30MM -,SUP-124.993,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ELIMINATOR ACTB THRD POS STP F/CUP DURALOC -,SUP-1246-03-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
OSTEOAMP GRANULES 1CC -,SUP-12600201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2340.97,1638.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
OSTEOAMP GRANULES 5CC -,SUP-12600401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4725.27,3307.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
OSTEOAMP GRANULES 10CC -,SUP-12600501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7875.46,5512.822,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
OSTEOAMP GRANULES 2-4MM (5CC) -,SUP-12700401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4587.68,3211.376,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEPIN ORTHO 1.3MMX15CM THRD TROC TIP -,SUP-128047,CDM,C1713,HCPCS,278,RC,,,outpatient,,,305.64,213.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
STAPLE BN FX XS COCR -,SUP-128690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2676.59,1873.613,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
STAPLE BN FX SM COCR -,SUP-128692,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2676.59,1873.613,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
RESTRICTOR BNCMNT FMCNL 25MM BUCK -,SUP-129419,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1159.24,811.468,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
UNITED HIP SYSTEM FULL XPE CUP 36MM X 54MM -,SUP-1302-3654,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
STAPLE SPIN RSTRL SM TI -,SUP-131.001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4759.68,3331.776,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
STAPLE SPIN CDL SM TI -,SUP-131.002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4759.68,3331.776,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
STAPLE SPIN ANT VERT SM TI -,SUP-131.011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3413.41,2389.387,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CONNECTOR SPIN REVERE DL CX 15MM TI -,SUP-131.115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CONNECTOR SPIN CX TI -,SUP-131.116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.5X35MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.5X40MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.5X18MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.5X24MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN TMX 12.9MMX43.7MM COMPR HI STRGTH 2D CONTR LCK Y -,SUP-1312-17-003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2534.99,1774.493,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN F 3 13MMX42.7MM HI FLEX 3D CONTR LCK NS RT -,SUP-131217100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2778.47,1944.929,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN F 3 13MMX42.7MM HI FLEX 3D CONTR LCK NS LT -,SUP-131217101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2778.47,1944.929,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WASHER ORTHO 3.5MM ALPS F/ELB PLATE SYS NS -,SUP-131218000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X14MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X16MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X28MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X30MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X36MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X40MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X44MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X48MM NLCKG CORT ALPS TRNCT SQ DRV TMX NS -,SUP-131218048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X50MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X60MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X70MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN ALPS 10.7X85MM 9HL 2.4MM CONTR LCK TMX ANTMC -,SUP-131218203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN ALPS 17.5X29MM 1.5MM CONTR LCK TMX SM ANTMC NS -,SUP-131218400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3637.79,2546.453,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN SM -,SUP-1312-18-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4024.48,2817.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN ALPS 81X10IN 10HL CONTR LCK COMPR TMX SM ANTMC NS -,SUP-131218600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN ALPS 10.7X154MM 17HL 2.5MM CONTR LCK COMPR TMX LNG -,SUP-131218607,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4481.66,3137.162,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WASHER ORTHO 2.5MM ALPS THRD -,SUP-131220025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN ALPS 2.5MM PRCONT LCK COMPR TMX T-SHP ANTMC NS -,SUP-131220152,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2353.42,1647.394,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN ALPS 2.5MM PRCONT LCK COMPR TMX SM T-SHP ANTMC NS -,SUP-131220157,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2099,1469.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN ALPS 2.5MM PRCONT LCK COMPR TMX STR ANTMC NS -,SUP-131220251,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2448.83,1714.181,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN ALPS 27.6MMX73.8MM 2.5MM 1.65MM PRCONT LCK COMPR -,SUP-131220252,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2448.83,1714.181,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN ALPS 19.5MMX71.8MM 2.5MM 1.65MM PRCONT LCK COMPR -,SUP-131220253,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2448.83,1714.181,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.5X11MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.5X14MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.5X15MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220415,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.5X16MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.5X12MM NLCKG CORT ALPS ST MULDIR MODULAR SQ DRV TMX -,SUP-131220512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.5X14MM NLCKG CORT ALPS ST MULDIR MODULAR SQ DRV TMX -,SUP-131220514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.5X15MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.5X16MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.5X18MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.5X20MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.7X18MM LCK SMTH DVR -,SUP-131227118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X20MM LCK CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X22MM LCK CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X14MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X15MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227215,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X16MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X26MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227226,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN DVR 24X85MM F/CROSSLOCK DIST RAD PLATE SYS LNG LCK -,SUP-131812090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4558.06,3190.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN MARS 5.5X45MM CRV CONE TIP TI ANT LMBR -,SUP-132.145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4334.79,3034.353,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN MARS 5.5X50MM CRV CONE TIP TI ANT LMBR -,SUP-132.150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN MARS 5.5X55MM CRV CONE TIP TI ANT LMBR -,SUP-132.155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4334.79,3034.353,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN MARS 5.5X60MM CRV CONE TIP TI ANT LMBR -,SUP-132.160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW REVIEVE 2.2MM X 6MM SELF TAPPING -,SUP-136.506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1235.02,864.514,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FEMORAL HEAD BIOLOX 32MM +5 12 -,SUP-1365-32-720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5432.32,3802.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FEMORAL HEAD BIOLOX DELTA TS CERAMIC  36MM +1.5 12/14 TAPER -,SUP-1365-36-710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5432.32,3802.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CERAMIC FEMORAL HEAD 40MM X 1.5 BIOLOX DELTA TS -,SUP-1365-40-710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FORTIFY I 12MM UPPER ENDPLATE 12 X 14MM 0 DEG -,SUP-137.300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FORTIFY I 12MM UPPER ENDPLATE 12 X 14MM 3.5 DEG -,SUP-137.301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FORTIFY I 12MM LOWER ENDPLATE 12 X 14MM 0 DEG -,SUP-137.350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FORTIFY I 12MM LOWER ENDPLAE 12 X 14MM 3.5 DEG -,SUP-137.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FORTIFY I 12MM LOWER ENDPLATE 12 X 14MM 3.5 DEG -,SUP-137.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
KT BONE CMNT 2.5% GENT40 GM CEMEX GENTA RX STRL -,SUP-1400-AG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEPIN ORTHO 3.2MM STNMN 14IN THRD -,SUP-14012-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,213.27,149.289,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEPIN ORTHO 3.2MMX9IN THRD -,SUP-140129,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X52MM CORT VERSANAIL FT ST NON-DRV END SLD HEX HEAD -,SUP-14022-52,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW AUTOFIX 2.0 X 10MM -,SUP-141-2010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW  AUTOFIX 2.0 X 12MM -,SUP-141-2012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
AUTOFIX HEADLESS SCREW 2.0 X 13 -,SUP-141-2013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW AUTOFIX HEADLESS 2.0 X 13 -,SUP-141-2013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW AUTOFIX HEADLESS 2.0 X 14 -,SUP-141-2014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANNULATED 2.0 X 15MM -,SUP-141-2015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW AUTOFIX 2.0 X 16 -,SUP-141-2016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2X17MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD MOD -,SUP-1412017,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2X18MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD MOD -,SUP-141-2018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANNULATED 2.0 X 19MM -,SUP-141-2019,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW AUTOFIX COMPRESSION 2.0 X 20MM -,SUP-141-2020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW AUTOFIX 2.0 X 21MM -,SUP-141-2021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW AUTOFIX 2.5 X 23MM -,SUP-141-2023,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW AUTOFIX 2.5 X 24MM -,SUP-141-2024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
AUTOFIX SCREW 2.0 X 25MM -,SUP-141-2025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW AUTOFIX 2.0 X 26MM -,SUP-141-2026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW AUTOFIX 2.5 X 28MM -,SUP-141-2028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
AUTOFIX 2.0 X 29MM SCREW -,SUP-141-2029,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW AUTOFIX COMPRESSION 2.0 X 30MM -,SUP-141-2030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW AUTOFIX 2.5 X 10 -,SUP-141-2510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW AUTOFIX HEADLESS 2.5 X 14 -,SUP-141-2514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANNULATED 25 X 15MM -,SUP-141-2515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
AUTOFIX 2.0/2.5 16MM -,SUP-141-2516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEADLESS 2.5 X 17MM -,SUP-141-2517,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW AUTOFIX 2.5 X 18MM -,SUP-141-2518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW AUTOFIX 2.5 X 19 -,SUP-141-2519,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW AUTOFIX 2.5 X 21MM -,SUP-141-2521,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
AUTOFIX 2.0/2.5 23MM -,SUP-141-2523,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5X24MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD -,SUP-1412524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEADLESS 2.5 X 25MM -,SUP-141-2525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEADLESS 2.5 X 26MM -,SUP-141-2526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
AUTOFIX 2.5/2.5 27MM -,SUP-141-2527,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEADLESS 2.5 X 28MM -,SUP-141-2528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5X30MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD -,SUP-141-2529,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5X30MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD -,SUP-1412530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE 2.5MM 30MM AUTOFIX STAINLESS STEEL T7 FOOT ANKLE -,SUP-141-2530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WASHER ORTHO 8MM TI -,SUP-14191,CDM,C1713,HCPCS,278,RC,,,outpatient,,,175.05,122.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 8X100MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 8X105MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 8X110MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 8X40MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 8X45MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 8X50MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 8X55MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 8X60MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 8X65MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 8X70MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 8X75MM CANN LAG CANC ACE THRD SD/ST CUT FLUTX4 TMX NS -,SUP-14192-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 8X85MM CANN LAG CANC ACE 24MM THRD SD/ST CUT FLUTX4 -,SUP-14192-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 8X90MM CANN LAG CANC ACE 24MM THRD SD/ST CUT FLUTX4 -,SUP-14192-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 8X95MM CANN LAG CANC ACE 24MM THRD SD/ST CUT FLUTX4 -,SUP-14192-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X100MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X105MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X110MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X115MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X120MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X25MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X30MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X35MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X40MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X45MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X50MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X55MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X60MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X65MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X70MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X75MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X80MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X85MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X90MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X95MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X100MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X105MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT -,SUP-14197-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X110MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT -,SUP-14197-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X40MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X45MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X50MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X55MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X60MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X65MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X70MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X75MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X80MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X85MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X90MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X95MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PRECISION PIN TM TAPERED D3.2/3.9X450MM -,SUP-1420-0065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X20MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X22MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X24MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X26MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X28MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X30MM CANNULATEDLAG CORT FT TMX NS -,SUP-14200-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X32MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X34MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X36MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X38MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X40MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X42MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X44MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X46MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X48MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X50MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X55MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X60MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X65MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X70MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X36MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-14223036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X30MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14250-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X32MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X34MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X36MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X38MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X40MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X42MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X44MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X46MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14250-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X48MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14250-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X50MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X55MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X60MM CANN LAG CORT 20MM FT SD/ST BIOCMPT TMX NS -,SUP-14250-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X65MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X70MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WASHER ORTHO F/4.5-5.0MM CANN SCR SYS FLT -,SUP-14260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,504.67,353.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 10HL 100DG TBLR -,SUP-14355-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,557.3,390.11,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN ALPS 9.2X49MM 3.5MM 4HL 1.3MM LCK TI 100DG ANG TBLR -,SUP-143554,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN ALPS 9.2X73MM 3.5MM 6HL LCK COMPR TMX ANTMC THRD HL -,SUP-143556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN ALPS 9.2X85MM 3.5MM 7HL LCK TI ANTMC NS -,SUP-143557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN ALPS 9.2X97MM 3.5MM 8HL LCK TI 100DG ANG TBLR ANTMC -,SUP-143558,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X14MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X16MM CANC -,SUP-14376-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,977.89,684.523,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X24MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X34MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-1437634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X40MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X42MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X44MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X46MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X48MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X50MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X55MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X60MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X65MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X70MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BONE PIN- 4 x 110MM- STERILE (2 Pack) -,SUP-144110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BONE PIN- 4 x 140MM- STERILE (2 Pack) -,SUP-144140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BONE PIN- 4 x 170MM- STERILE (2 Pack) -,SUP-144170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER ANT CERV 14X6X12MM SOLITAIRE 12DG LRDTC S/MED -,SUP-14-520506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12505.38,8753.766,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER ANT CERV 14X7X12MM SOLITAIRE 12DG LRDTC S/MED -,SUP-14-520507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12505.38,8753.766,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER ANT CERV 14X9X12MM SOLITAIRE 12DG LRDTC S/MED -,SUP-14-520509,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12505.38,8753.766,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER 10X27X8MM ZYSTON 6DG LRDTC CRV TAPR -,SUP-14-533128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER 10X25X7MM ZYSTON STR CNVX -,SUP-14-534067,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE 3.5MM X46MM CANNULATED -,SUP-148.146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.2X13MM PROVIDENCE SD FX-ANG -,SUP-150.013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.2MM X 14MM -,SUP-150.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN PROVIDENCE 12MM 4HL LVL1 TI LCK -,SUP-150.112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN PROVIDENCE 14MM 4HL LVL1 TI LCK -,SUP-150.114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN PROVIDENCE 16MM 4HL LVL1 TI LCK -,SUP-150.116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN PROVIDENCE 18MM 4HL LVL1 TI LCK -,SUP-150.118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANTERIOR CERVICAL PLATE 1-LEVEL -,SUP-150.120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE ANTERIOR CERVICAL 1-LEVEL 22MM PROV -,SUP-150.122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE ANTERIOR CERVICAL 24MM 1 LEVEL PROVIDENCE -,SUP-150.124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANTERIOR CERVICAL PLATE 14MM LORD -,SUP-150.134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN PROVIDENCE 28MM 6HL LVL2 TI LCK -,SUP-150.228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN PROVIDENCE 30MM 6HL LVL2 TI LCK -,SUP-150.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN PROVIDENCE 32MM 6HL LVL2 TI LCK -,SUP-150.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN PROVIDENCE 34MM 6HL LVL2 TI LCK -,SUP-150.234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN PROVIDENCE 36MM 6HL LVL2 TI LCK -,SUP-150.236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE CERVICAL ANTERIOR 2-LEVEL 38MM -,SUP-150.238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN PROVIDENCE 45MM 8HL LVL3 TI LCK -,SUP-150.345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN PROVIDENCE 48MM 8HL LVL3 TI LCK -,SUP-150.348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN PROVIDENCE 51MM 8HL LVL3 TI LCK -,SUP-150.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN PROVIDENCE 54MM 8HL LVL3 TI LCK -,SUP-150.354,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN PROVIDENCE 57MM 8HL LVL3 TI LCK -,SUP-150.357,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PROVIDENCE ANTERIOR CERVICAL PLATE 3-LVL 60MM -,SUP-150.360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANTERIOR CERVICAL PLATE 4-LEVEL 69MM -,SUP-150.469,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW PROV 4.6MM FIXED ANGLE SELF DRILL 14MM -,SUP-150.514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.6X16MM PROVIDENCE ST FA TI ALY -,SUP-150.536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.6X18MM PROVIDENCE SD FA TI ALY -,SUP-150.538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.2X12MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.2X13MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.613,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.2X14MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.2X15MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.2X16MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SELF DRILLING 4.6MM X 12MM VAR ANGLE PROV -,SUP-150.712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.6X13MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.713,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.6X14MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.6X16MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SELF DRILLING 4.2MM X 12MM VAR ANGLE PROV -,SUP-150.812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PROVIDENCE 4.2MM VARIABLE ANGLE SCREW SELF-TAP 14MM -,SUP-150.814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW PROVIDENCE 4.6MM VARIABLE ANGLE 16MM SELF TAPPING -,SUP-150.816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW PROVIDENCE 4.2MM VARIABLE ANGLE - 20MM -,SUP-150.820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TRNSCONN 4.6X12MM PROVIDENCE ST VAR ANG TI ANT CERV -,SUP-150.912,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.6X14MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.914,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.6X15MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.915,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.6X16MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.916,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.6X18MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.918,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SELF TAPPING 4.6 X 20 VAR ANGLE PROV -,SUP-150.920,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
OSS POLY LOCK PIN -,SUP-150478,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1865.78,1306.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FORTIFY 12MM CORE HEIGHT 21-29MM -,SUP-151.052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FORTIFY 12MM CORE HEIGHT 25-37MM -,SUP-151.053,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CORE FORTIFY 012MM HEIGHT 33-53MM -,SUP-151.054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ENDPLATE UPPER 012MM 12X14 FOOTPRINT 3.5 DEG -,SUP-151.323,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ENDPLATE LOWER 012MM 12 X 14 FOOTPRINT 7 DEG FORTIFY -,SUP-151.374,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SYSTEM CLENCH STAPEL 9MM X 7MM -,SUP-152-30907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SYSTEM CLENCH STAPLE 15MM X 12MM -,SUP-152-31512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SYSTEM CLENCH STAPLE 18MM X 18MM -,SUP-152-31818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
STAPLE CLENCH 15MM X 12MM -,SUP-152-41512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BED F/PROC STRECHER UPR FRM ASMB -,SUP-16042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.68,1.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE OSS RS NON MOD LONG 59 -,SUP-161022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20050.2,14035.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN FX STNMN 2MMX9IN SMTH SGL END PLN DMD PT NS -,SUP-1620-609NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21.41,14.987,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN FX STNMN 2.4MMX9IN SMTH SGL END PLN DMD PT NS -,SUP-1624-609NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21.41,14.987,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN FX STNMN 4.8MMX9IN SMTH SGL END PLN DMD PT NS -,SUP-1648-609X,CDM,C1713,HCPCS,278,RC,,,outpatient,,,29.18,20.426,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TIBIAL INSERT PS SZ 6 13MM -,SUP-166-5613,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SHELL ACETABULAR ESCALADE 46MM -,SUP-170-0146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ESCALADE EXL LINER +1 28 X 46MM -,SUP-170-2846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
EXPANSION BOLT RECONSTRUCTION PROSTHESIS -,SUP-172-947/38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
MESH SURG 17X22X50MM OVL TI HARMS -,SUP-1741-48-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17992.27,12594.589,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
MESH SURG 17X22X70MM OVL TI HARMS -,SUP-1741-49,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20248.85,14174.195,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
MESH SURG 22X28X70MM OVL TI HARMS -,SUP-1741-52-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20248.85,14174.195,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
MESH SURG 22X28X90MM OVL TI HARMS -,SUP-1741-53-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,24291.37,17003.959,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
MESH SURG 26X33X50MM OVL TI HARMS -,SUP-1741-54-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17992.27,12594.589,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
MESH SURG 26X33X70MM OVL TI HARMS -,SUP-1741-55-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21889.99,15322.993,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WASHER SPIN TI POLY IEXP -,SUP-1754-91-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NUT SPIN TI BOLT SWVL LCK IEXP -,SUP-1754-91-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,543.24,380.268,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE 50MM RND 10MM SGL LVL TI -,SUP-1760-10-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17292.37,12104.659,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE 50MM RND 12MM SGL LVL TI -,SUP-1760-12-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17292.37,12104.659,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE 90MM RND 12MM SGL LVL TI -,SUP-1760-12-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18873.18,13211.226,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE 50MM RND 14MM SGL LVL TI -,SUP-1760-14-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17292.37,12104.659,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE 90MM RND 14MM SGL LVL TI -,SUP-1760-14-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19307.6,13515.32,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE 50MM RND 16MM SGL LVL TI -,SUP-1760-16-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16483.86,11538.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
MESH ROUND 16MM X 90MM SPN -,SUP-1760-16-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19754.09,13827.863,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
MESH SURG 12X23MM DIA 12X14MM OVL TRPZD TI HARMS -,SUP-1762-02-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10345.35,7241.745,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NUT ORTHO DOME TI SWVL F/MONARCH SPN SYS -,SUP-1770-91-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,481.97,337.379,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN SKNLC 47MM LVL2 TI LPRO -,SUP-1796-02-047,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6079.53,4255.671,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SET SCREW SPIN EXPEDIUM TI POST PDCL THORLUM SQ THRD -,SUP-1797-02-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SET SCREW SPIN EXPEDIUM TI POST PDCL THORLUM SQ THRD -,SUP-1797-02-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
VIPER TI SAI POLY 8X90MM -,SUP-179704890,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7.5X45MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7.5X50MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-179712050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7.5X65MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.35X20MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.35X25MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.35X30MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.35X35MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.35X40MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5 X 25MM POLYAXIAL SI -,SUP-179712525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X40MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X45MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X50MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6X30MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6X35MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6X55MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7X35MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-735,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7X45MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-745,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7X50MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7X55MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
EXP TI POLY SCREW 8 X 40MM -,SUP-179712840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW POLYAXIAL 8MM X 65MM -,SUP-179712865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN EXPEDIUM 5.5X480MM HEX END TI POST PDCL THORLUM -,SUP-179762480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN EXPEDIUM 5.5X35MM CRV TI POST PDCL THORLUM PRELRD -,SUP-1797-71-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN EXPEDIUM 5.5X40MM CRV TI POST PDCL THORLUM PRELRD -,SUP-1797-71-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD PRE-LODOSED W/LINE 65MM -,SUP-179771065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD PRE-LORDOSED 75MM W/LINE -,SUP-179771075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD PRE-LORDOSED W/LINE 85MM -,SUP-179771085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CONNECTOR 20MM EXPEDIUM LAT OFST OPN F/10MM TI -,SUP-1797-92-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CONNECTOR 50MM EXPEDIUM LAT OFST OPN F/5.5MM TI -,SUP-1797-92-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CONNECTOR 20MM EXPEDIUM OPN F/5.5MM TI ILC -,SUP-1797-97-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X42MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-49-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X46MM TMX CANN RDC HEAD -,SUP-1802-49-046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X30MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X32MM CANN -,SUP-1802-53-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X34MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X36MM CANN -,SUP-1802-53-036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X38MM CANN -,SUP-1802-53-038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X40MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X42MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X44MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X50MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COMP SCR 5MM CANN LAG P/T SD/ST TMX 55MM -,SUP-1802-53-055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X60MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X65MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X70MM CANN LAG CANC P/T SD/ST SM HEAD TMX -,SUP-1802-53-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X75MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X80MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5MMSMX85MM CANN LAG CANC PARTIALY THRD SD/ST RDC HEAD -,SUP-1802-53-085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X90MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5MMSMX95MM CANNULATEDLAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X100MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.75X15MM LCK CMPRHNSV RVRS FX TI ALY HAP CTD BLU -,SUP-180500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.75X20MM NLCKG CMPRHNSV RVRS FX TI ALY HAP CTD GOLD -,SUP-180508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.75X25MM NLCKG CMPRHNSV RVRS FX TI ALY HAP CTD GOLD -,SUP-180509,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.75X15MM LCK CORT FX 3.5MM HEX HEAD TI ALY HAP CTD -,SUP-180550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
4.75 X 20MM FIXED LOCKING SCREW 3.5MM HEX -,SUP-180551,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COMP LK SCR 3.5 HEX 4.75 X 25 ST -,SUP-180552,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW COMP LK 3.5 HEX 4.75 X 30 ST -,SUP-180553,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW COMP LK 3.5 HEX 4.75 X 35 ST -,SUP-180554,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COMP LK SCR 3.5 HEX 4.75 X 40 ST -,SUP-180555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.75X15MM NLCKG CORT VAR ANG 3.5MM HEX HEAD TI ALY HAP -,SUP-180557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.75X20MM NLCKG CORT VAR ANG 3.5MM HEX HEAD TI ALY HAP -,SUP-180558,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.75X25MM NLCKG CORT VAR ANG 3.5MM HEX HEAD TI ALY HAP -,SUP-180559,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COMP NLK SCREW 3.5 HEX 4.75 X 30 ST -,SUP-180560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.75X35MM NLCKG CMPRHNSV 3.5MM HX HEX HEAD TMX HAP CTD -,SUP-180561,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
K-WIRE- STERILE 3 x 285MM -,SUP-1806-0050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,459.86,321.902,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
STRYKER PLATE -,SUP-1806-0150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,793.85,555.695,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10X320MM VERSANAIL CANN FEM TI ALY -,SUP-1813-10-320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7410.02,5187.014,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 13X400MM VERSANAIL CANN RT TROCH FEM TI ALY -,SUP-1814-13-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10160.14,7112.098,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 7X220MM VERSANAIL CANN HUM TI ALY -,SUP-1817-07-221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 8X200MM VERSANAIL CANN HUM TI ALY -,SUP-1817-08-201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 9X260MM VERSANAIL CANN HUM TI ALY -,SUP-1817-09-261,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
T2 ANKLE COMPRESSION SCREW -,SUP-1818-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1161.6,813.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10X150MM VERSANAIL CANN PROX HUM SS -,SUP-1818-10-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7282.7,5097.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL T2 ANKLE ARTHRODESIS LEFT -,SUP-1818-1020S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
T2 ANKLE NAIL 11x200MM LEFT -,SUP-1818-1120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
T2 ANKLE ARTHRODESIS NAIL LEFT 11X300MM -,SUP-1818-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 12X200MM T2 CANN LT ANKL TI ALY BIOMECH -,SUP-1818-1220S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
T2 ANKLE ARTHRODESIS NAIL RIGHT 11 X 150MM -,SUP-1819-1115S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 12X200MM T2 CANN RT ANKL TI ALY BIOMECH -,SUP-1819-1220S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.8MMX20MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-35-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X24MM CORT 3.5MM HX NS F/2.9MM DRLBT -,SUP-1819-35-024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X30MM CORT 3.5MM HX NS F/2.9MM DRLBT -,SUP-1819-35-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.8MMX30MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.8MMX32MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 4.8MMX42MM 3.6MM HX NS -,SUP-1819-48-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.8MMX44MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.8MMX46MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.8MMX50MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X24MM ELLIPSE POLYAX TI -,SUP-182.224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MM X 26MM ELLIPSE POLYAXIAL SHOULDER -,SUP-182.226,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X28MM ELLIPSE POLYAX TI. -,SUP-182.228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X30MM ELLIPSE POLYAX TI. -,SUP-182.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X32MM ELLIPSE POLYAX TI -,SUP-182.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X34MM ELLIPSE POLYAX TI -,SUP-182.234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X10MM ELLIPSE POLYAX TI -,SUP-182.310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X12MM ELLIPSE POLYAX TI -,SUP-182.312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X14MM ELLIPSE POLYAX TI -,SUP-182.314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ELLIPSE POLYAXIAL 3.5MM X 16MM -,SUP-182.316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X18MM ELLIPSE POLYAX TI -,SUP-182.318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X20MM ELLIPSE POLYAX TI -,SUP-182.320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X22MM ELLIPSE POLYAX TI -,SUP-182.322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X26MM ELLIPSE POLYAX TI -,SUP-182.326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X28MM ELLIPSE POLYAX TI -,SUP-182.328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X30MM ELLIPSE POLYAX TI -,SUP-182.330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X10MM ELLIPSE POLYAX TI -,SUP-182.410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X12MM ELLIPSE POLYAX TI -,SUP-182.412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X14MM ELLIPSE POLYAX TI -,SUP-182.414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
4.0MM ELLIPSE POLYAXIAL SCREW 16MM -,SUP-182.416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X18MM ELLIPSE POLYAX TI -,SUP-182.418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X20MM ELLIPSE POLYAX TI -,SUP-182.420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X22MM ELLIPSE POLYAX TI -,SUP-182.422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X24MM ELLIPSE POLYAX TI -,SUP-182.424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X26MM ELLIPSE POLYAX TI -,SUP-182.426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ELLIPSE POLYAXIAL 4.0 X 28MM -,SUP-182.428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ELLIPSE LOCKING CAP -,SUP-182.500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
HOOK SPIN INLN ELLIPSE -,SUP-182.501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ELLIPSE POLYAXIAL 4.5 X 20 -,SUP-182.520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X22MM ELLIPSE POLYAX TI -,SUP-182.522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X24MM ELLIPSE POLYAX TI -,SUP-182.524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X26MM ELLIPSE POLYAX TI -,SUP-182.526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ELLIPSE POLYAXIAL 4.5 X 28 -,SUP-182.528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ELLIPSE POLYAXIAL 4.5 X 30 -,SUP-182.530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD TO ROD CLAMP CT TO CT 7MM -,SUP-182.741,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD TO ROD CLAMP CT TO CT 9MM -,SUP-182.770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN ELLIPSE 6.35X80MM TI POST OCT -,SUP-182.801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN ELLIPSE 6.35X120MM TI POST OCT -,SUP-182.802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN ELLIPSE 3.5X240MM TI POST OCT -,SUP-182.803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN ELLIPSE 3.5X40MM TI POST OCT -,SUP-182.804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ENDCAP SPIN ELLIPSE T-SHP HD-TO-HD -,SUP-182.900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NUT SPIN ELLIPSE F/HD-TO-HD TRANSV CONN T-SHP -,SUP-182.901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TRNSCONN 27-33MM ELLIPSE HD-TO-HD F/3.5MM T-SHP POST OCT -,SUP-182.912,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TRNSCONN 26-46MM ELLIPSE F/3.5MM CRV POST OCT -,SUP-182.924,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE OCPTL SM ELLIPSE -,SUP-182.950,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 8MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0828S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 8MMSTDX300MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0830S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 8MMSTDX315MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0831S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 8MMSTDX330MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0833S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 8MMSTDX360MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0836S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 8MMSTDX390MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0839S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1028S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TIBIAL NAIL 10 X 390MM -,SUP-1822-1039S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1128S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
T2 STD. TIBIAL NAIL 11MM X 300MM -,SUP-1822-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TIBIAL NAIL 11 X 375MM -,SUP-1822-1137S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
11 X 390MM TIBIA NAIL -,SUP-1822-1139S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 12MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1228S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 12MMSTDX315MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1231S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 12MMSTDX345MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 12MMSTDX360MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
T2 TIBIAL NAIL SYSTEM  12 X 390MM -,SUP-1822-1239S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 8MM COMPR T2 CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1825-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.67,530.369,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 8X5MM COMPR T2 CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1825-0005S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.67,530.369,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL SYS T2 FEMUR A/R 010 X 340MM -,SUP-1825-1034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10X360MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1038S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11X280MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1128S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11X320MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1132S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11X340MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11X400MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1140S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1144S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 12X280MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1228S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 12X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1230S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 12X360MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 12X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1238S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 12X420MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1242S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 12X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1244S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 13X180MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1318S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 13X240MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1324S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 13X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1330S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 13X340MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1334S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 13X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1338S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 13X400MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 13X420MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1342S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 13X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1344S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 14X240MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1424S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 14X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1430S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 14X320MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1432S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 14X340MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1434S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 14X360MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1436S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 14X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1438S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 14X400MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 14X420MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1442S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 14X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1444S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAP ORTHO 8X4MM TI E CAP PROT -,SUP-1826-0003S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,771.97,540.379,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
T2 SUPRACONDYLAR NAIL 9X340MM -,SUP-1826-0934S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
T2 SUPRACONDYLAR NAIL 9X380MM -,SUP-1826-0938S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1020S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SUPRACONDYLAR NAIL 10 X 320 -,SUP-1826-1032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10MMLNGX340MM T2 CANN SPRACON TI BIOMECH -,SUP-1826-1034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10MMLNGX360MM T2 CANN SPRACON TI BIOMECH -,SUP-1826-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL SUPRACONDYLAR 10MM X 400MM -,SUP-1826-1040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11MMLNGX240MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1124S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11MMLNGX320MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1132S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SUPRACONDYLAR NAIL 11 X 360MM -,SUP-1826-1136S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL SUPRACONDYLAR 11 X 380 -,SUP-1826-1138S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL SUPRACONDYLAR 11 X 420 -,SUP-1826-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 12MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1220S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 12MMLNGX280MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1228S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 12MMLNGX300MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1230S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 12MMLNGX320MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1232S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 12MM X 340MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL SUPRACONDYLAR 12 X 360 -,SUP-1826-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
T2 SUPRACONDYLAR NAIL 12X400MM -,SUP-1826-1240S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 13MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 13MMLNGX300MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1330S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 13MMLNGX340MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1334S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL SUPRACONDYLAR 13MM X 360MM -,SUP-1826-1336S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 13MMLNGX380MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1338S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 13MMLNGX400MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 13MMLNGX420MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1342S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL SUPRACONDYLAR 14 X 380 -,SUP-1826-1438S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL FEMORAL 10 X 360 -,SUP-1828-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5072.64,3550.848,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL FEMORAL 11 X 340MM -,SUP-1828-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5072.64,3550.848,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL FEMORAL 11 X 400 -,SUP-1828-1140S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5072.64,3550.848,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 13X740MM T2 CANN RT KN TI ALY BIOMECH -,SUP-1829-1374S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,28428.72,19900.104,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WASHER ORTHO 10MM TI ALY SQ STRL -,SUP-1830-0009S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,718.87,503.209,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 7X210MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0721S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 7X220MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0722S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 7X240MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0724S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 8X240MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0824S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 8X250MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0825S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 8X280MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0828S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 9X210MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0921S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 9X220MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0922S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 9X240MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0924S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 9X250MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0925S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ENDCAP ORTHO 6MM STD TI T2 STRL -,SUP-1832-0003S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,725,507.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 8MMLNGX150MM T2 CANN LT PROX HUM TI ALY -,SUP-1832-1035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6798.89,4759.223,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 8MMLNGX240MM T2 CANN LT PROX HUM TI ALY BIOMECH -,SUP-1832-2824S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 8MMLNGX260MM T2 CANN LT PROX HUM TI ALY BIOMECH -,SUP-1832-2826S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 8MMLNGX220MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3822S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11MMLNGX240MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3824S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 8MMLNGX260MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3826S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11MMLNGX280MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3828S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE 3.6MM VAR SELF-TAPPING 14MM -,SUP-184.114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE 3.6MM VAR SELF-TAPPING 16MM -,SUP-184.116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 9MM 1.5M RAD 340MM T2 RECON CANN LT FEM TI ALY RECON -,SUP-1843-0934S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
T2 RECON NAIL R1.5- RIGHT 9 X 360MM X 125DG -,SUP-1845-0936S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
T2 RECON NAIL R1.5- RIGHT 9 X 380MM X 125DG -,SUP-1845-0938S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10MM 1.5M RAD 360MM T2 RECON CANN RT FEM TI ALY -,SUP-1845-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL T2 RECON R1 11MM X 420MM X 125 -,SUP-1845-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ENDCAP SPIN REVERE THORLUM NTHRD REVOLVE -,SUP-185.000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN REVOLVE 5.5X80MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN REVOLVE 5.5X90MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN REVOLVE 5.5X100MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN REVOLVE 5.5X110MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5X30MM REVOLVE POLYAX TI -,SUP-185.452,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5X35MM REVOLVE POLYAX TI -,SUP-185.453,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5X40MM REVOLVE POLYAX TI -,SUP-185.454,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5X45MM REVOLVE POLYAX TI -,SUP-185.455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5X50MM REVOLVE POLYAX TI -,SUP-185.456,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5X55MM REVOLVE POLYAX TI -,SUP-185.457,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X30MM REVOLVE POLYAX TI -,SUP-185.462,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X35MM REVOLVE POLYAX TI -,SUP-185.463,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X40MM REVOLVE POLYAX TI -,SUP-185.464,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X45MM REVOLVE POLYAX TI -,SUP-185.465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X50MM REVOLVE POLYAX TI -,SUP-185.466,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FEMORAL NAIL RIGHT 9 X 360MM -,SUP-1851-0936S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6489.92,4542.944,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10X380MM T2 CANN RT GTR TROCH FEM TI ALY RECON -,SUP-1851-1038S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6489.92,4542.944,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CABLE SINGLE LOOP TITANIUM WITH CRIMP -,SUP-186.200S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2978.98,2085.286,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER 28X8MM LPRD 5DG LRDTC BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE 28X9MM LPRD 5DG LRDTC BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER 28X7MM LPRD PRLL BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER 28X9MM LPRD PRLL BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER 28X11MM LPRD PRLL BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SET INNER MIS -,SUP-186715000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SET SCREW SPIN VIPER 2 TI PDCL SQ THRD SGL INNIE -,SUP-1867-15-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6X35MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6X35MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6X40MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6X40MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6 X 45 POLYAXIAL CANNULA -,SUP-186715645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6X45MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6X50MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6X50MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6X55MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7X40MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7X50MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X55MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X40MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6X30MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6X40MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6X45MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW TI CORT FIX 6X50MM -,SUP-186731650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW TI CORT FIX 6X55MM -,SUP-186731655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6X35MM VIPER 2 DBL LD THRD CANN ULTRA TI -,SUP-1867-60-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6X40MM VIPER 2 DBL LD THRD CANN ULTRA TI -,SUP-1867-60-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN VIPER 5.5X35MM CRV PREBNT TI F/MN INV SURG NS -,SUP-1867-62-635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN VIPER 5.5X40MM CRV PREBNT TI F/MN INV SURG NS -,SUP-1867-62-640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN VIPER 2  - 5.5 X 35MM LORDOTIC -,SUP-186788035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN VIPER 2 5.5X35MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN VIPER 2 5.5X40MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN VIPER 2 5.5X45MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN VIPER 2 5.5X50MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TRNSCONN REVERE ADDITION RD-TO-RD F/5.5MM PRLL -,SUP-1867-88-055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN VIPER 2 5.5X65MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD VIPER 2 LORDOTIC 75MM -,SUP-186788075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD LORDOTIC 80MM VIPER2 -,SUP-186788080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD LORDOTIC 90MM VIPER2 -,SUP-186788090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN SKYLINE 16X12MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN SKYLINE 16X14MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN SKYLINE 16X16MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN SKYLINE 16X18MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN SKYLINE 16X20MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN SKYLINE 16X22MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN SKYLINE 16X24MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN SKYLINE 16X26MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SKY 1 LEVEL PLATE 28MM -,SUP-1868-01-028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN SKYLINE 16X30MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 28MM SKYLINE 2 LEVEL TI -,SUP-186802028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN SKYLINE 16X30MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN SKYLINE 16X32MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN SKYLINE 16X34MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN SKYLINE 16X36MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN SKYLINE 16X40MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN SKYLINE 16X42MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN SKYLINE 16X44MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN SKYLINE 16X45MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN SKYLINE 16X48MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN SKYLINE 16X51MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN SKYLINE 16X54MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN SKYLINE 16X57MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-057,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X12MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL BLU -,SUP-1868-50-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X14MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL GOLD -,SUP-1868-50-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X16MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL MAG -,SUP-1868-50-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X18MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL -,SUP-1868-50-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X12MM SKYLINE ST VAR ANG HX LOBE HEAD TI STRL BLU -,SUP-1868-52-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X14MM SKYLINE ST VAR ANG HX LOBE HEAD TI STRL GOLD -,SUP-1868-52-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X16MM SKYLINE ST VAR ANG HX LOBE HEAD TI STRL MAG -,SUP-1868-52-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SKY VARIABLE S-T 18MM TI -,SUP-186852018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X12MM SKYLINE ST VAR ANG OVSZ HX LOBE HEAD TI STRL -,SUP-1868-54-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X14MM SKYLINE ST VAR ANG OVSZ HX LOBE HEAD TI STRL -,SUP-1868-54-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X16MM SKYLINE ST VAR ANG OVSZ HX LOBE HEAD TI STRL -,SUP-1868-54-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X14MM SKYLINE ST FA CNSTRN OVSZ HX LOBE HEAD TI -,SUP-1868-64-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
IMPLANT COUGAR SM 12MM 5 DEG -,SUP-187105112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COUGAR IMPLANT MED 14MM 50DEG -,SUP-187105214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER 14MM COUGAR 10DG SM CFRP -,SUP-1871-10-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COUGAR IMPLANT MED 14MM 10DEG -,SUP-187110214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN EXPEDIUM 5.5X70MM STR TI ANT PCUT NS -,SUP-1877-03-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BULLETT CONCORD 9 X 7 X 23 -,SUP-187823107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE 9X8X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE 9X9X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE 9X10X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE 9X8X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE 9X9X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-187823409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE 9X9X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE 9X10X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE 9X11X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE 9X12X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE 11X12X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CONCORDE BUL LOR 11X13X23 5DG -,SUP-187823513,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE 9X7X27MM CONCORDE -,SUP-187827107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE 9X7X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE 9X8X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE 9X9X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE 9X10X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE 11X12X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE 9X8X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-27-408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE 9X9X27MM CONCORDE 5DG LRDTC BLLT NOSE STNT LPRO CFRP -,SUP-1878-27-409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE 9X10X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-27-410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CONCORDE BUL LOR 9 X 11 X 27 -,SUP-187827411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE 9X11X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-27-411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE 11X12X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-187827512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE 9X7X23MM CONCORDE PRLL CFRP -,SUP-1879-23-107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14828.79,10380.153,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE 11X13X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1879-27-513,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CONNECTOR SPIN MOUNTAINEER LAT OFST TI -,SUP-1883-12-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X10MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X12MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X18MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X26MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X12MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X22MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X24MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X26MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X12MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X16MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X20MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X22MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X26MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X22MM MOUNTAINEER MINI POLYAX TAPR TI STRL BLU SHNK -,SUP-1883-19-422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X26MM MOUNTAINEER MINI POLYAX TAPR TI STRL BLU SHNK -,SUP-1883-19-426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X50MM MOUNTAINEER MINI POLYAX TAPR TI STRL BLU SHNK -,SUP-1883-19-450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.35X20MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.35X25MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.35X30MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.35X35MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.35X40MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X20MM MOUNTAINEER MINI POLYAX SHNK TAPR TI STRL -,SUP-1883-20-320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X28MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X32MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X34MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X36MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X38MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X40MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
XCONN 21MM MOUNTAINEER HD-TO-HD TI OCT -,SUP-1883-41-021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X12MM MOUNTAINEER MINI POLYAX TI STRL -,SUP-188362012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE OC 37MM -,SUP-188362037,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
MNTR OC PLATE LARGE -,SUP-188362045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.25X8MM MOUNTAINEER MINI POLYAX TI STRL -,SUP-188362108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
MNTR OC PREBENT ROD 3.5X120 -,SUP-188363200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,921.93,645.351,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN SKYLINE 34MM LVL2 PRELRD TI VSBL GFT SITE -,SUP-1888-02-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5856.72,4099.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE ANTLAT 33-46MMH X-MESH 0DG MED TI -,SUP-1889-01-033,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20402.94,14282.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE 0DG ANTLAT 51-71MM X-MESH MED TI -,SUP-1889-01-051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22445.09,15711.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X35MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,820.98,574.686,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X40MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,812.82,568.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X45MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,812.82,568.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X55MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,812.82,568.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X60MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,820.98,574.686,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X65MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,820.98,574.686,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SFX-5.5 TI LAT SIZE F4 -,SUP-189401104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DEPUY SPINE SFX F5 CROSSLINK -,SUP-189401105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CONNECTOR SZ F6 EXPEDIUM SFX FX F/5.5MM TI MDL -,SUP-1894-01-206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CONNECTOR SZ F7 EXPEDIUM SFX FX F/5.5MM TI MDL -,SUP-1894-01-207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CONNECTOR SPIN EXPEDIUM CX TI -,SUP-1894-01-209,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SFX 5.5 TI LAT SIZE A2 -,SUP-189401302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CONNECTOR SZ A4 EXPEDIUM SFX F/5.5MM TI MDL NS -,SUP-1894-01-404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CONNECTOR SZ A5 EXPEDIUM SFX F/5.5MM TI MDL NS -,SUP-1894-01-405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CONNECTOR SZ A6 EXPEDIUM SFX F/5.5MM TI MDL NS -,SUP-1894-01-406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW T2 CONDYLE 5MM X 50MM -,SUP-1895-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X60MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X75MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X80MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X85MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X20MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4020S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X22MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4022S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X26MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X28MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4028S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X30MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
T2 F/T LOCKING SCREW 4MM X 32MM -,SUP-1896-4032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X36MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X38MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4038S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X45MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X55MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW T2 F/T LOCK 5 X 30 -,SUP-1896-5030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5MMX32.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW T2 F/T LOCK 5 X 35 -,SUP-1896-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5MMX37.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW T2 F/T LOCK 5 X 40 -,SUP-1896-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5MMX42.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW T2 F/T LOCK 5 X 45 -,SUP-1896-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5MMX47.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5047S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW T2 F/T LOCK 5 X 50 -,SUP-1896-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5MMX52.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5052S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW T2 F/T LOCK 5 X 55 -,SUP-1896-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5MMX57.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5057S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW T2 F/T LOCK 5 X 60 -,SUP-1896-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW T2 F/T LOCK 5 X 65 -,SUP-1896-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW T2 F/T LOCK 5 X 70 -,SUP-1896-5070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW T2 F/T LOCK 5 X 75 -,SUP-1896-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X80MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X85MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X90MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X100MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN UNIPLATE 2 36MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-02-036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN UNIPLATE 2 38MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-02-038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.6X12MM UNIPLATE ST CANC TI BLU -,SUP-1897-06-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.6X13MM UNIPLATE ST CANC TI BLU -,SUP-1897-06-013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.6X14MM UNIPLATE ST CANC TI GOLD -,SUP-189706014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE 14MM UNIPLATE SPINE CERVICAL ANTERIOR SELF -,SUP-1897-06-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1293.32,905.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.6X15MM UNIPLATE ST CANC TI LBLU -,SUP-1897-06-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.6X18MM UNIPLATE ST CANC TI LBLU -,SUP-1897-06-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.2MMX14MM UNIPLATE OVSZ CANC TI GOLD -,SUP-1897-06-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.2MMX18MM UNIPLATE ST CANC TI GOLD -,SUP-1897-06-118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.6X12MM UNIPLATE SD CANC TI BLU -,SUP-1897-07-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.6X13MM UNIPLATE SD CANC TI VIOL -,SUP-1897-07-013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.6X15MM UNIPLATE SD CANC TI LBLU -,SUP-1897-07-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN UNIPLATE 2 14MM LVL1 PRELRD TI NRW MDLN NO- BND -,SUP-189721014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN UNIPLATE 2 16MM LVL1 PRELRD TI NRW MDLN NO- BND -,SUP-189721016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN UNIPLATE 2 28MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-22-028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN UNIPLATE 2 32MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-22-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN UNIPLATE 2 34MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-22-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW T2 RECON LAG 6.5MM X 75MM -,SUP-1897-6075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW T2 RECON LAG 6.5MM X 80MM -,SUP-1897-6080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LAG T2 RECON SYSTEM 6.5 X 85 -,SUP-1897-6085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LAG BONE T2 RECON SYSTEM 6.5 X 90 -,SUP-1897-6090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LAG T2 RECON 6.5MM X 100MM -,SUP-1897-6100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LEVEL 1 PLATE 20MM -,SUP-19-0120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CALBIBER SPACER 10 X 22MM- 10-15MM -,SUP-194.222,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SEMI CONST DRILL 4.0 X 14 -,SUP-19-6514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2MMX6MM LCK COMPR CORT LCP FT STD CRUCIF RCESS SS NS -,SUP-201.006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,93.36,65.352,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.4MMX10MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CLIP ANEUR 2.4MMX12MM SS LCP ST -,SUP-201.762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.4MMX13MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.763,CDM,C1713,HCPCS,278,RC,,,outpatient,,,411.37,287.959,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.4MMX14MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.764,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.4MMX18MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.768,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.4MMX22MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.772,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2X10MM LCK COMPR LCP THRD ST FA T6 STRDRV RCESS SS NS -,SUP-201.880,CDM,C1713,HCPCS,278,RC,,,outpatient,,,830.26,581.182,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MMX10MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,328.22,229.754,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MMX12MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,328.22,229.754,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MMX26MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MMX28MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MMX30MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MMX32MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MMX34MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MMX36MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MMX38MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MMX40MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MMX45MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MMX50MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MMX55MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X10MM LCK COMPR LCP THRD ST T8 STRDRV RCESS SS NS -,SUP-202.210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,886.92,620.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X30MM LCK COMPR LCP THRD ST T8 STRDRV RCESS SS NS -,SUP-202.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.01,516.607,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X40MM LCK COMPR LCP THRD ST T8 STRDRV RCESS SS NS -,SUP-202.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.01,516.607,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3X14MM CANN LNG THRD SD/ST CRUCIF RCESS SS NS -,SUP-202.714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1530.52,1071.364,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X16MM LCK COMPR CORT LCP FT ST T8 STRDRV RCESS SS -,SUP-202.876,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X18MM LCK COMPR CORT LCP FT ST T8 STRDRV RCESS SS -,SUP-202.878,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTEX SLF TPNG 2.7 X 20MM T8 SD REC -,SUP-202.880,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X24MM LCK COMPR CORT LCP FT ST T8 STRDRV RCESS SS -,SUP-202.884,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTEX SLF TPNG 2.7 X 26MM T8 SD REC -,SUP-202.886,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTEX SLF TPNG 2.7 X 28MM T8 SD REC -,SUP-202.888,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTEX SLF TPNG 2.7 X 30MM T8 SD REC -,SUP-202.890,CDM,C1713,HCPCS,278,RC,,,outpatient,,,577.67,404.369,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BODY PHOENIX SHRT OPN BD -,SUP-20-2070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BODY STD PHOENIX OPN BD POST PDCL F/MN INV FX SYS -,SUP-20-2090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
6.5 X 40MM CANCELLOUS BONE SCREW -,SUP-2030-6540-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ACTB 6.5X55MM OMNIFIT -,SUP-2030-6555-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ACTB 6.5X60MM OMNIFIT -,SUP-2030-6560-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X10MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X12MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X14MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,192.56,134.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X16MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX18MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX20MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX22MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX24MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX26MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX28MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX32MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX34MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX36MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX38MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX40MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX45MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X50MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X28MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X30MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X32MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X34MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X36MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X38MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X14MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X20MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X22MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X24MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X26MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X28MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X32MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X34MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.834,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X48MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.848,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN PHOENIX 35MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN PHOENIX 40MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN PHOENIX 45MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN PHOENIX 50MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN PHOENIX 55MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN PHOENIX 70MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN PHOENIX 75MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX10MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX12MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX14MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.61,257.327,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX16MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.61,257.327,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX18MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.61,257.327,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX22MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX24MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX26MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX30MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX35MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX40MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX45MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX50MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX55MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX60MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FEM PRESSURIZING SEAL - SMALL -,SUP-206-545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,101.12,70.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X10MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X12MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X14MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X16MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X18MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X20MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X22MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X24MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X26MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X28MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X30MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,157.55,110.285,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X40MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X45MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X50MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX34MM LCK CANN LCP LNG THRD SD/ST 2.5MM SM HEX SCKT -,SUP-207.734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7MMX35MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7MMX40MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7MMX45MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7MMX50MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7MMX70MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7MMX75MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X95MM LCK CANN 32MM THRD SD/ST REVCT FLUT 4MM LRG -,SUP-208.441,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1770.37,1239.259,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7MMX45MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7MMX50MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7MMX55MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7MMX80MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7X32MM CANN -,SUP-209.750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7.3X75MM LCK CANN THRD SD/ST REVCT FLUT HEX SCKT -,SUP-209.875,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1710.52,1197.364,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUT SQA + THRDR TAB TI NTNL -,SUP-210.309,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2065.07,1445.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SUBSTITUTE TCP 1.2ML FOAM PK VITOSS RESRB COMPR RSIS -,SUP-2102-1401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1579.18,1105.426,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
VITOSS BIOACTIVE PACK 2.5CC -,SUP-2102-1602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3430.26,2401.182,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
VITOSS BA2X FOAM PACK 1.2CC -,SUP-2102-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2600.96,1820.672,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
VITOSS BA2X FOAM PK BONE GRAFT 1.2CC -,SUP-2102-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2600.96,1820.672,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
VITOSS BA2X BONE GRAFT 2.5CC -,SUP-2102-2102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4015.89,2811.123,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
VITOSS BA2X BONE GRAFT 5CC -,SUP-2102-2105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6693.85,4685.695,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
VITOSS BA2X BONE GRAFT 10CC -,SUP-2102-2110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10931.81,7652.267,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.4MMX12MM CANN 0.5IN LNG THRD SD/ST T8 STRDRV RCESS -,SUP-211.812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1577.85,1104.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CANNULATED SCREW 2.4mm X15mm -,SUP-211.815,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANNULATED 2.4MM X17MM L -,SUP-211.817,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1431.14,1001.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.4MM CANN SCREW LONG 19MM -,SUP-211.819,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1431.14,1001.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX55MM LCK COMPR LCP FT ST SS NS GRN -,SUP-212.123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,813.98,569.786,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BONE PIN- 3.2 x 110MM- STERILE (2 Pack) -,SUP-213524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BONE PIN- 3.2 x 140MM- STERILE (2 Pack) -,SUP-213527,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX16MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX28MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX30MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX32MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX36MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX38MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX40MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX46MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX50MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX52MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX56MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX34MM LCK CANN P/T SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1518.59,1063.013,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX42MM LCK CANN P/T SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1518.59,1063.013,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX44MM LCK CANN P/T SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1518.59,1063.013,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX40MM LCK CANN FT SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1562.32,1093.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX44MM LCK CANN FT SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1562.32,1093.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX50MM LCK CANN FT SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1562.32,1093.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MMX40MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-216.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MMX55MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MMX60MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MMX65MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MMX70MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MMX75MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 9MM SHRT FASTFLAP 2HL STR 1.6MM NEURO SYS STRL -,SUP-218-0022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.42,222.194,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE CRNL 22MM 5HL 0.5MM STR FAST FLAP 1.6MM NEURO SYS TI -,SUP-218-0030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,868.25,607.775,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE CRANFC MED FST-FLP MSH 5HL TI BUR HL GRV SHNT 1.6MM -,SUP-218-0069,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE CRNL LNG 2HL 0.25MM STR FAST FLAP 1.6MM NEURO SYS TI -,SUP-218-0093,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.8,316.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE CRNL 22MM LRG 0.25MM FAST FLAP BUR HL CVR 1.6MM NEURO -,SUP-218-0095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1077.06,753.942,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE CRANFC 90X90MM FST-FLP OSTFRM MSH TI PREFRM 1.6MM -,SUP-218-2006-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6545.95,4582.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WASHER ORTHO 10MM F/4.5MM CANN SCR RND NS -,SUP-219.910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,218.81,153.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WASHER ORTHO 13MM F/6.5MM CANC LRG BN SCR RND NS -,SUP-219.990,CDM,C1713,HCPCS,278,RC,,,outpatient,,,223.19,156.233,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ACCELFIX LUMBAR EXPANDABLE CAGE 8 22 X 11 X 8MM -,SUP-2211-0808S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19669.62,13768.734,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ACCELFIX EXPANDABLE LUMBAR CAGE 15 22 X 11 X 8 -,SUP-2211-0815S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19669.62,13768.734,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE ACCELFIX LUMB EXPAND 8 DEG 22 X 11 X 12 -,SUP-2211-1208S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUT HEALIX ADVANCE 4.5MM MUL-THRD BCRL RAPIDE -,SUP-222.295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1643.16,1150.212,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SUTURE ORTHOCORD #2 MO-7 36IN BRD BLU VIOL 223114 1/2CIR MPK -,SUP-223.114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.04,210.028,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN LC-DCP 11X77MM 3.5MM 6HL LC BSC LCK DCP SS SM NS -,SUP-223.560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2413.05,1689.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN LC-DCP 11X90MM 3.5MM 7HL LC BSC LCK DCP SS SM NS -,SUP-223.570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2504.49,1753.143,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN LC-DCP 11X103MM 3.5MM 8HL LC BSC DCP SS SM NS -,SUP-223.580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2631.7,1842.19,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN LC-DCP 11X116MM 3.5MM 9HL LC BSC LCK DCP SS SM NS -,SUP-223.590,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2466.96,1726.872,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN LC-DCP 11X129MM 3.5MM 10HL LC BSC LCK DCP SS SM NS -,SUP-223.600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2542.16,1779.512,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEPIN ORTHO BRKWY 2.5MM GLOBAL APG + -,SUP-2230-00-019,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1126.16,788.312,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN LC-DCP 13.5X155MM 12HL 4.2MM LC COMPR SS 3.5MM BRD -,SUP-225.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2321.62,1625.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SUBSTITUTE DEMIN CANC TISS 0.75ML G2 DIVERTED MRSL VOID FIL -,SUP-227005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1139.61,797.727,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SUBSTITUTE G2 TISS 0.5ML STRIP PREFL ATF STR TUBE -,SUP-227010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,846.08,592.256,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
KT ORTHO MILAGRO FEM -,SUP-232.300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2199.71,1539.797,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
END CAP LOWER EXTREMITY 8 +0MM -,SUP-2330-0000S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1195.26,836.682,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
T2 ALFPHA COMPRESSION SCREW FEMUR 5.5 -,SUP-2330-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1333.08,933.156,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
END CAP GT/PF T2 ALPHA 013 +10 -,SUP-2330-0010S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1195.26,836.682,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL FEMORAL GT LEFT 11 X 320MM -,SUP-2331-1132S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FEMORAL NAIL GT- LEFT Ã˜11X420MM -,SUP-2331-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9735.49,6814.843,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FEMORAL NAIL GT LEFT 13 X 400MM -,SUP-2331-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10095.65,7066.955,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FEMORAL NAIL GT RT 10 X 360 -,SUP-2333-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12776.73,8943.711,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FEMORAL NAIL GT RIGHT 10 X 420MM -,SUP-2333-1042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL INTRAMEDULLARY T2 ALPHA FEMUR ANTEGRADE SYSTEM 11 X 380 -,SUP-2333-1138S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FEMORAL NAIL GT RIGHT 11 X 420MM -,SUP-2333-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FEMORAL NAIL GT RIGHT 11 X 440MM -,SUP-2333-1144S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FEMORAL NAIL GT RIGHT 13MM X 400MM -,SUP-2333-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10095.65,7066.955,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FEMORAL NAIL RETROGRADE D10X360MM -,SUP-2339-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FEMORAL NAIL RETROGRADE D10X400MM -,SUP-2339-1040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SYS FEMUR RETROGRADE NAIL 11 X 200MM T2 ALPHA SHORT -,SUP-2339-1120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FEMORAL NAIL RETROGRADE 11 X 300MM -,SUP-2339-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL T2 FEMUR ALPHA RETROGRADE 11 X 340MM -,SUP-2339-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FEMORAL NAIL RETROGRADE D11X380MM -,SUP-2339-1138S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FEMORAL NAIL RETROGRADE 12 X 340MM -,SUP-2339-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10561.63,7393.141,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
T2 ALPA FEMUR NAIL RETROGRADE 12 X 360 -,SUP-2339-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10559.77,7391.839,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FEMORAL NAIL RETROGRADE 13X340MM -,SUP-2339-1334S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10561.63,7393.141,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FEMORAL NAIL RETROGRADE D13X360MM -,SUP-2339-1336S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10559.77,7391.839,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW INTFR CANN 8X23MM THRD BABSRB PLLA -,SUP-234-010-162,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW INTFR CANN BIOSTEON 7X28MM 1MM CANN FLLY BLNT THRD -,SUP-234-010-164,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW INTFR CANN BIOSTEON 8X28MM BABSRB WDG SHP HAP PLLA -,SUP-234-010-165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW INTFR CANN 9X28MM THRD BABSRB PLLA -,SUP-234-010-166,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW INTFR CANN BIOSTEON 11X35MM 1MM CANN FLLY BLNT THRD -,SUP-234-010-179,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW INTFR CANN BIOSTEON 12X35MM 1MM CANN FLLY BLNT THRD -,SUP-234-010-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2187.89,1531.523,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COMPRESSION SCREW TIBIA 5.5 -,SUP-2341-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1333.08,933.156,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
END CAP TIBIA T2 ALPHA 11.5 X +5MM -,SUP-2341-0005S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
END CAP TIBIA T2 ALPHA 11.5 X 10MM -,SUP-2341-0010S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
END CAP TIBIA T2 ALPHA 11.5 X 15MM -,SUP-2341-0015S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEPIN ENDO VERSITOMIC SHP MEM ALY TECH FLXB -,SUP-234-108-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2166.31,1516.417,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEPIN ENDO VERSITOMIC FLXB -,SUP-234-108-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2187.89,1531.523,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TIBIAL NAIL 9 X 285MM -,SUP-2341-0928S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TIBIAL NAIL T2 ALPHA 9 X 300 -,SUP-2341-0930S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TIBIAL NAIL T2 09 X 315MM -,SUP-2341-0931S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL TIBIAL 9 X 330 T2 ALPHA -,SUP-2341-0933S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TIBIAL NAIL 9 X 345 -,SUP-2341-0934S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TIBIAL NAIL 9 X 360 -,SUP-2341-0936S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TIBIAL NAIL 9 X 375 -,SUP-2341-0937S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TIBIAL NAIL 9 X 390MM -,SUP-2341-0939S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TIBIAL NAIL 10X285MM -,SUP-2341-1028S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10764.14,7534.898,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM 10 X 300 -,SUP-2341-1030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM 10 X 315 -,SUP-2341-1031S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM -,SUP-2341-1033S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
T2 ALPHA TIBIA NAIL 10X345MM SYS -,SUP-2341-1034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL TIBIAL 10 X 360 T2 ALPHA -,SUP-2341-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL TIBIAL 10 X 375MM T2 ALPHA -,SUP-2341-1037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL TIBIAL 10 X 390 T2 ALPHA -,SUP-2341-1039S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL TIBIAL T2 ALPHA 11 X 300MM -,SUP-2341-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL TIBIAL T2 11 X 315 -,SUP-2341-1131S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TIBIAL NAIL 11 X 330 -,SUP-2341-1133S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL SYSTEM T2 ALPHA TIBIA 11 X 345MM -,SUP-2341-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM -,SUP-2341-1136S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TIBIAL NAIL T2 ALPHA 11 X 375 -,SUP-2341-1137S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
T2 ALPHA TIBIA NAIL 11 X 390MM -,SUP-2341-1139S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL TIBIAL T2 ALPHA 12 X 315MM -,SUP-2341-1231S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL TIBIAL T2 ALPHA 12 X 330MM -,SUP-2341-1233S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
T2 ALPHA TIBIA SYSTEM TIBIAL NAIL -,SUP-2341-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
T2 ALPHA TIBIAL NAIL 12 X 380MM -,SUP-2341-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10764.1,7534.87,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TIBIAL NAIL 12 X 375MM -,SUP-2341-1237S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 8X50MM -,SUP-234500150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,885.69,619.983,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOCKING SCREW 5 X 25MM -,SUP-2360-5025S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOCKING SCREW 5 X 27.5MM -,SUP-2360-5027S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 5X32MM -,SUP-2360-5032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW IMN SYSTEM LOCKING SCREW 5 X 35 -,SUP-2360-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
IMN LOCKING SCREW 5 X 37.5MM -,SUP-2360-5037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
IMN SCREW SYSTEM LOCKING SCREW 5 X 40 -,SUP-2360-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 5X42MM -,SUP-2360-5042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOCKING SCREW 05 X 45MM -,SUP-2360-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
IMN LOCKING SCREW 5X47.5MM -,SUP-2360-5047S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
IMN LCK SCREW 5X50 -,SUP-2360-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
IMN LCK SCREW 5X52 -,SUP-2360-5052S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LCK STRYKER 5 X 55 -,SUP-2360-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
IMN LOCKING SCREW 5X57.5MM -,SUP-2360-5057S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
IMN LOCKING SCREW 0.5 X 60MM -,SUP-2360-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1836.62,1285.634,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING SYS IMN 5 X 60MM -,SUP-2360-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
IMN LOCKING SCREW 0.5 X 65MM -,SUP-2360-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 5 X 70MM -,SUP-2360-5070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE T2 ALPHA IMN LOCKING  0.5 X 75MM -,SUP-2360-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING SYS IMN 5 X 65MM -,SUP-2360-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 5 X 85 -,SUP-2360-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 5 X 90 -,SUP-2360-5090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW IMN T2 ALPHA LOCKING  5MM X 95MM -,SUP-2360-5095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING SYS IMN 5 X 100MM -,SUP-2360-5100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ADVANCED LOCKING SCREW 5X30MM -,SUP-2361-5030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ADVANCED LOCKING 5MM X 32.5MM -,SUP-2361-5032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ADVANCED LOCKING 5 X 35 -,SUP-2361-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING ADVANCED IMN 05 X 37.5MM -,SUP-2361-5037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING ADVANCED IMN 05 X 40MM -,SUP-2361-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ADVANCED LOCKING 5MM X 42.5MM -,SUP-2361-5042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ADVANCED LOCKING SCREW 5MM X 45MM -,SUP-2361-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW IMN LCK 5 X 45 -,SUP-2361-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ADVANCED LOCKING 5MM X 47.5MM -,SUP-2361-5047S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING ADVANCED 5X50MM -,SUP-2361-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ADVANCED LOCKING SCREW 5MM X 52.5MM -,SUP-2361-5052S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ADVANCED LOCKING 5MM X 55MM -,SUP-2361-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ADVANCED LOCKING SCREW 5 X 57.5MM -,SUP-2361-5057S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X60MM IMN ADVANCED LOCKING -,SUP-2361-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ADVANCED LOCKING 5MM X 65MM -,SUP-2361-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ADVANCED LOCKING 5MM X 70MM -,SUP-2361-5070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ADVANCED LOCKING SCREW 5 X 57MM -,SUP-2361-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ADVANCED LOCKING SCREW 5 X 80 -,SUP-2361-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
IMN ADVANCED LOCKING SCREW 5MM X 85MM -,SUP-2361-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ADVANCED LOCKING SCREW 5 X 90MM -,SUP-2361-5090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1553.05,1087.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW IMN LOCKING 5MM X 95MM -,SUP-2361-5095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN LCP 83MM 4/5MM 4HL BSC LCK COMPR SS LRG T-SHP NS -,SUP-240.141,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3467.5,2427.25,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN STERNAL TALON 14MM D FT PLATE LEGX2 SGL TI SM STRL -,SUP-24-009-14-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN STERNAL TALON SGL LEGX2 BIOCMPT TI SM STRL -,SUP-24-009-17-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FOOT PLATE BN STERNAL TALON SGL VRSN TI 17MM MED STRL LEGX2 -,SUP-24-010-17-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN STERNAL TALON 20MM D LEGX2 SGL TI MED STRL -,SUP-24-010-20-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FOOT PLATE XL 12X20MM STERNAL TALON SGL -,SUP-24-012-20-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
STERNAL SCREW 2.3 -,SUP-24-023-09-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X11MM LCK DRL-FR MAXDRIVE THREADLOCK TS SLF RET TI -,SUP-24-023-11-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X13MM LCK DRL-FR MAXDRIVE THREADLOCK TS SLF RET TI -,SUP-24-023-13-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
STERNAL SCREW 2.3 X 15MM -,SUP-24-023-15-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.3MM SELF DRILLING STERNAL SCREWS -,SUP-24-023-17-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE LEVEL 1 THORACIC STERNAL LKG STR 2.3MM SCRW 20 HL -,SUP-24-025-07-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3118.62,2183.034,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
STERNAL PLATE LOCK 6-HOLE 1.8 -,SUP-24-025-42-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2398.48,1678.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 8HL 1.8MM LCK TI X-SHP -,SUP-24-025-44-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2224.88,1557.416,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
4 HOLE STRAIGHT -,SUP-24-025-48-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2155.98,1509.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE LEVEL ONE THORACIC STERNAL LKG STR W/2.3MM SCREW -,SUP-24-025-50-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2580.02,1806.014,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
9 HOLE Y PLATE -,SUP-24-025-52-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2613.77,1829.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 4 HOLE ANGLE -,SUP-24-025-59-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1906.85,1334.795,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN LC-DCP 10X50MM 3.5MM 3HL HD/SHFT LC DCP SS T-SHP RT -,SUP-241.130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,781.42,546.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN LC-DCP 11X64MM 3.5MM HLX3/5 HD/SHFT LC DCP SS T-SHP -,SUP-241.150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,944.22,660.954,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN LC-DCP 10X53MM 3.5MM 3HL HD/SHFT LC LCK DCP SS -,SUP-241.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1176.71,823.697,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN LC-DCP 10X63MM 3.5MM 0.75HL HD/SHFT LC LCK DCP SS -,SUP-241.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1296.45,907.515,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN LC-DCP 10X75MM 3.5MM HLX3/5 HD/SHFT LC LCK DCP SS -,SUP-241.250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1282.72,897.904,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN LC-DCP 9X25MM 3.5MM 2HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN LC-DCP 9X49MM 3.5MM 4HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN LC-DCP 9X61MM 3.5MM 5HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN LCP 9X57MM 2.7/3.5MM 5HL CONTR LCK COMPR SS SM 1/3 -,SUP-241.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1594.13,1115.891,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN LC-DCP 9X85MM 3.5MM 7HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1268.14,887.698,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN LC-DCP 9X97MM 3.5MM 8HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1315.85,921.095,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN LC-DCP 9X121MM 3.5MM 10HL LC DCP SS SM MINI 1/3 -,SUP-241.400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN LCP 9X117MM 2.7/3.5MM 10HL CONTR LCK COMPR SS SM -,SUP-241.401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1745.19,1221.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN LCP 15MM D 3.5MM 5HL PRCONT LCK COMPR SS HOOK STRL -,SUP-241-085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4546.38,3182.466,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN LCP 6.3X49MM 2.4MM 0.75HL HD/SHFT FA CONTR LCK -,SUP-242.507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2479.52,1735.664,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER TNDN 6X24MM SILASTIC PLYSTR COR SWN-HNT STRL -,SUP-24270006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7240.26,5068.182,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 82MM 3.5MM 7HL RECON SS STR NS -,SUP-245.170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3397.89,2378.523,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN LC-DCP 94MM 3.5MM 8HL RECON DCP SS STR NS -,SUP-245.181,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3544.7,2481.29,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN LC-DCP 106MM 3.5MM 9HL RECON DCP SS STR NS -,SUP-245.190,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3738.04,2616.628,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 53MM 2MM HLX2/8 HD/SHFT 1.2MM RECON SS T-SHP NS -,SUP-247.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1616.65,1131.655,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN LCP 54MM 2MM 7HL RECON LCK COMPR SS NS -,SUP-247.349,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4745.36,3321.752,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN LCP 44MM 2.4MM 5HL RECON ADPR LCK COMPR SS STR NS -,SUP-247.375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2573.19,1801.233,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN LCP 36MM 2.4MM 4HL RECON LCK COMPR SS STR NS -,SUP-249.674,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2496.8,1747.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN LCP 59MM 2.4MM 7HL RECON LCK COMPR SS STR NS -,SUP-249.679,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3862.17,2703.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN LCP 58MM 2.7MM 6HL RECON LCK COMPR SS STR NS -,SUP-249.682,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3247.51,2273.257,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN LCP 67MM 2.7MM 7HL RECON LCK COMPR SS STR NS -,SUP-249.683,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2544.54,1781.178,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN LCP 32MM 2.7MM 0.66HL HD/SHFT RECON LCK COMPR SS -,SUP-249.685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCK -,SUP-250-1001-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 8.5MM SHTH INTRAFIX PEEK PP NS F/ACL FX -,SUP-254.683,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LCK CRNMXF 2.3X11MM CROSS-DRIVE TI ALY -,SUP-25-773-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE 7 MWX8MMX21MM TRAXIS PEEK/ TI -,SUP-2601070921,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE VERT 25MM VUE 7MM/9MM LD /TRAILING DIA SGL LVL PEEK -,SUP-2601070925,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE 9X21X9MM TRAXIS VUE 9MM/9MM DIA LD /TRAILING DIA SGL -,SUP-2601090921,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDE DRILL POR F/KN ARTHPL -,SUP-261-0060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
USTAR II KNEE CEMENTED STR STEM RHS 17X125 -,SUP-2715-3117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BLADE IM NAIL 12.5X105MM SS HLCL NS F /LCP DHS -,SUP-282.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2284.52,1599.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BLADE IM NAIL 12.5X120MM SS HLCL NS F /LCP DHS -,SUP-282.243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2277.41,1594.187,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ORTHOFIX CAGE 6.5 -,SUP-28-2180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ORTHOFIX CAGE 8.5 -,SUP-28-2182,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ORTHOFIX CAGE 6.5 X 24 XP -,SUP-28-3140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE XP LORDOTIC 8.5 -,SUP-28-3142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ORTHOFIX FORZA XP CAGE 10.5H X 10W X 24L -,SUP-28-3144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ORTHOFIX 12H EXPANDABLE CAGE -,SUP-28-3146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
EXPANDABLE CAGE 6.5MMX10MM WIDE X28MM -,SUP-28-3180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE FORZA XP ORTHOFIX 10.5MM -,SUP-28-3184,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ORTHOFIX HYPERLORDOTIC CAGE 8.5 -,SUP-28-4142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE 10.5HL HYPER XP -,SUP-28-4144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ORTHOFIX CAGE 12.5 X 24. HL -,SUP-28-4146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
USTAR II KNEE SEGMENT PART RHS 25MM -,SUP-2915-1025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22014.38,15410.066,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER VERT 22X8MM CAP STN VERTSTCK PEEK -,SUP-2960822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER VERT 26X8MM CAP STN VERTSTCK PEEK -,SUP-2960826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20245.95,14172.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER VERT 22X10MM CAP STN VERTSTCK 8DG PEEK -,SUP-2961022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X12MM LCK ACU-LOC 2 HXLB DRIVE F/VOLAR DIST RAD -,SUP-30-0234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,822.74,575.918,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X14MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X18MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0237,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X20MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X22MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0239,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X24MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X26MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0241,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X30MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X32MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X36MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0246,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X45MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0249,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X22MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0262,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X24MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0263,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X26MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0264,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X32MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0267,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X40MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0271,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X45MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0272,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X50MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0273,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X55MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0274,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3X40MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0294,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW Ti SET 8X17.5MM -,SUP-3003-0822S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,858.1,600.67,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X14MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0327,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X16MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X18MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0329,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X20MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X22MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0331,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAP END +10MM TI GAMMA3 -,SUP-3005-1110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,858.1,600.67,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.7X45MM ACUTRAK 2 NS -,SUP-30-0645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.7X50MM ACUTRAK 2 NS -,SUP-30-0650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.3X26MM LCK POLARUS 3 HXLB DRV TI STRL -,SUP-3011-43026-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.3X46MM HXLB -,SUP-3011-43046-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.6MM/4.5MM DIA TIP/BK END 20MM CANN HDLS BIOTRAK -,SUP-3017-0009-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3465.92,2426.144,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.6MM/4.6MM DIA TIP/BK END 22MM CANN HDLS BIOTRAK -,SUP-3017-0010-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3465.92,2426.144,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER THORLUM VERT 10X26X8MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER THORLUM VERT 10X26X9MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER THORLUM VERT 10X26X10MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER THORLUM VERT 10X26X11MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER THORLUM VERT 10X26X12MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER THORLUM VERT 8X22X8MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.078,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER THORLUM VERT 8X22X9MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.079,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER THORLUM VERT 8X22X10MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER THORLUM VERT 8X22X11MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.081,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER THORLUM VERT 8X22X12MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER THORLUM VERT 8X22X13MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.083,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER THORLUM VERT 10X22X8MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.088,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER THORLUM VERT 10X22X9MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.089,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER THORLUM VERT 10X22X10MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER THORLUM VERT 10X22X11MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.091,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER THORLUM VERT 10X22X12MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.092,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER THORLUM VERT 10X22X13MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.093,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER THORLUM VERT 10X22X15MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER THORLUM VERT 12X26X10MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.970,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER THORLUM VERT 12X26X17MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.977,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LAG SCREW TI 10.5 X 75mm -,SUP-3060-0075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW GAMMA3 LAG TI 10.5X80 -,SUP-3060-0080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW GAMMA3 LAG Ti 10.5X85 -,SUP-3060-0085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 90MM -,SUP-3060-0090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW GAMMA3 LAG Ti 10.5X95 -,SUP-3060-0095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GAMMA3 LAG SCREW TI 10.5X100 -,SUP-3060-0100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW GAMMA3 LAG T1 10.5X105 -,SUP-3060-0105S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 110MM -,SUP-3060-0110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 115MM -,SUP-3060-0115S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 120MM -,SUP-3060-0120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 125MM -,SUP-3060-0125S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 130MM -,SUP-3060-0130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
U-BLADE SET TI 10.5 X 95MM -,SUP-3066-0095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2850.17,1995.119,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GRAFT DBM 1ML PTTY OSTEOSELECT VOID FIL OSTCONDC -,SUP-309010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
OSTEOSELECT 2.5CC -,SUP-309025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1749.17,1224.419,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SUBSTITUTE DBM 5ML PTTY OSTEOSELECT VOID FIL OSTCONDC -,SUP-309050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SUBSTITUTE DBM 10ML PTTY OSTEOSELECT -,SUP-309100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER RADIOLUCENT 7MM CANOPY -,SUP-3102.6007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
5CC BIO4 VIABLE BONE MATRIX -,SUP-3102-2105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8594.1,6015.87,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 15.5/11X180MM GAMMA3 LT TROCH FEM TI BIOMECH STRGTH -,SUP-3120-1180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4598.63,3219.041,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TROCHANTERIC NAIL KIT 10X170MMX125DG -,SUP-3125-0170S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5413.56,3789.492,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL GAMMA3 TROCHANTARIC 180 -,SUP-3125-1180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4598.63,3219.041,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
KIT TROCHANTERIC KIT 11X180 SF -,SUP-3130-1180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4598.63,3219.041,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DRILL BIT RINGLOC + QUICK CONNECT 3.2MM X 20MM -,SUP-31-323220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
EQUINOXE SHLDR -,SUP-320-15-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LCK COMPR EQUINOXE F/RVRS BALL/SCKT SURG -,SUP-320-15-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SET SCREW INTNL FX EQUINOXE SHLDR RVRS TRQ DEFINING LCK -,SUP-320-20-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X22MM LCK COMPR EQUINOXE BLK F/RVRS BALL/SCKT SURG -,SUP-320-20-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X34MM LCK COMPR EQUINOXE RD F/RVRS BALL/SCKT SURG -,SUP-320-20-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LONG NAIL GAMMA KIT 11X300 RIG -,SUP-3225-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LONG GAMMA NAIL 11X320 RIGHT -,SUP-3225-0320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL KIT LONG R2.0 TI RT. GAMM -,SUP-3225-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LONG GAMMA NAIL 11X380 RIGHT -,SUP-3225-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LONG GAMMA NAIL 11X400 RIGHT -,SUP-3225-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LONG GAMMA NAIL 11X420 RIGHT -,SUP-3225-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL LONG RT GAMMA3 KIT 11MM X -,SUP-3225-0440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 15MM/13MM DIA P/D 2MM RAD LNG 340MM GAMMA3 RT TROCH -,SUP-3225-3340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX16MM CANN ASNIS III 8MM P/T SD/ST REVCT FLUT SS NS -,SUP-325016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX24MM CANN ASNIS III 8MM P/T SD/ST REVCT FLUT SS NS -,SUP-325024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW PT CANN ASNIS 4.0 X 28 -,SUP-325028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX30MM CANN ASNIS III 10MM P/T SD/ST REVCT FLUT SS -,SUP-325030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX32MM CANN ASNIS III 11MM P/T SD/ST REVCT FLUT SS -,SUP-325032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX34MM CANN ASNIS III 11.5MM P/T SD/ST REVCT FLUT SS -,SUP-325034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX34MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-325034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX36MM CANN ASNIS III 12MM P/T SD/ST REVCT FLUT SS -,SUP-325036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX38MM CANN ASNIS III 13MM P/T SD/ST REVCT FLUT SS -,SUP-325038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX40MM CANN ASNIS III 13.5MM P/T SD/ST REVCT FLUT SS -,SUP-325040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX42MM CANN ASNIS III 14MM P/T SD/ST REVCT FLUT SS -,SUP-325042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX44MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325044S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX46MM CANN ASNIS III 15.5MM P/T SD/ST REVCT FLUT SS -,SUP-325046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX46MM CANN ASNIS III 0.33IN P/T SD/ST REVCT FLUT SS -,SUP-325046S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX48MM CANN ASNIS III 16MM P/T SD/ST REVCT FLUT SS -,SUP-325048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX50MM CANN ASNIS III 17MM P/T SD/ST REVCT FLUT SS -,SUP-325050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX55MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-325060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX60MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX70MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANNULATED 4.0 X 32 -,SUP-325232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X42MM CANN FT -,SUP-325242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X44MM CANN FT -,SUP-325244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5MMX70MM CANN ASNIS III 23.5MM P/T SD/ST REVCT FLUT SS -,SUP-325470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANNULATED 5.0 X 60MM -,SUP-325660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ASNIS III SS CANNULATED SCR 5 X 70MM -,SUP-325670S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SS CANN 6.5 X 70MM ASNIS -,SUP-326070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X75MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X80MM CANN ASNIS III P/T SD/ST REVCT FLUT SS NS -,SUP-326080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X80MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X85MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X85MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X90MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X90MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS 6.5MM 95MM -,SUP-326095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X95MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS 6.5MM 100MM -,SUP-326100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X100MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X105MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326105S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS 6.5 X 110 -,SUP-326110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X110MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X115MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326115S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X120MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW S.S. TL40 6.5 X 55 -,SUP-326255,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
6.5MM PARTIALLY THREADED 40MM SCREW 60MM LENGTH -,SUP-326260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW S.S. TL40 6.5 X 70 -,SUP-326270,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MMX75MM CANN ASNIS III 40MM THRD SD/ST REVCT FLUT -,SUP-326275,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MMX80MM CANN ASNIS III 40MM THRD SD/ST REVCT FLUT -,SUP-326280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS CAN 6.5 X 85 -,SUP-326285,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS CAN 6.5 X 90 -,SUP-326290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS CAN 6.5 X 95 -,SUP-326295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS CAN 6.5 X 95 -,SUP-326295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.94,757.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS CAN 6.5 X 100 -,SUP-326300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW S.S. TL40 6.5 X 110 -,SUP-326310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW S.S. TL40 6.5 X 115 -,SUP-326315,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW S.S. TL40 6.5 X 120 -,SUP-326320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1196.43,837.501,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 80 -,SUP-326480S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 85 -,SUP-326485S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANNULATED FULLY THREADED 6.5 X 90MM -,SUP-326490S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS III SS CANNULATED 6.5X95MM -,SUP-326495S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS III SS CANNULATED 6.5X100MM -,SUP-326500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS III SS CANNULATED 6.5X105MM -,SUP-326505S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS III SS CANNULATED 6.5X110MM -,SUP-326510S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS III SS CANNULATED 6.5X115MM -,SUP-326515S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS III SS CANNULATED 6.5X120MM -,SUP-326520S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS III SS CANNULATED 6.5X125MM -,SUP-326525S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS III SS CANNULATED 6.5X130MM -,SUP-326530S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS III CANN 8.0 X 70MM -,SUP-326670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW S.S. TL25 8.0 X 75 -,SUP-326675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS 8.0 X 80MM -,SUP-326680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS CANNULATED 8.0 X 85MM -,SUP-326685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 8MMX90MM CANN ASNIS III 25MM P/T SD/ST REVCT FLUT SS -,SUP-326690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 8MMX95MM CANN ASNIS III 25MM P/T SD/ST REVCT FLUT SS -,SUP-326695,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANNULATED PARTIALLY THREADED 8MM X 95MM TL25MM -,SUP-326695S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 8MMX100MM CANN ASNIS III 25MM P/T SD/ST REVCT FLUT SS -,SUP-326700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
8 x 105MM ASNIS SCREW -,SUP-326705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
8 X 110MM ASNIS SCREW -,SUP-326710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
C/M 16MM & 25MM PLUG WITH NOZZLE -,SUP-32810503800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1313.46,919.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LONG NAIL KIT LEFT 300mm -,SUP-3325-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL LONG KIT 11X320MMX125 GAM -,SUP-3325-0320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL GAMMA LGN LEFT 11X360 -,SUP-3325-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL LONG GAMMA3 11X380 LFT -,SUP-3325-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LONG GAMMA NAIL 11X400 LEFT -,SUP-3325-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LONG GAMMA NAIL 11X420 LEFT -,SUP-3325-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LONG GAMMA NAIL 11X440 LEFT -,SUP-3325-0440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 13MMLNGX340MM GAMMA3 LT TROCH FEM TI BIOMECH STRGTH -,SUP-3325-3340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN OPLS 2HL STD BRL COMPR SDE 130DG ANG -,SUP-3362-1-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 130DG ANG -,SUP-3362-1-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN OPLS 2HL STD BRL COMPR SDE 135DG ANG KYLS -,SUP-3362-1-102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE HIP COMP 135-5-HOLE -,SUP-3362-1-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE HIP OMEGA 135 6 HOLE - OBSOLETE DO NOT USE -,SUP-3362-1-106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN OPLS SLOTX2 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN OPLS SLOTX5 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN OPLS SLOTX6 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN OPLS SLOTX8 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN OPLS SLOTX3 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-303,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN OPLS SLOTX5 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-305,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2896.15,2027.305,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN OPLS SLOTX6 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2896.15,2027.305,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN OPLS SLOTX8 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN OPLS SLOTX10 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 150DG ANG -,SUP-3362-1-404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN OPLS SLOTX8 STD BRL COMPR SDE 150DG ANG -,SUP-3362-1-408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN OPLS SLOTX10 STD BRL COMPR SDE 150DG ANG -,SUP-3362-1-410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3570.95,2499.665,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN OPLS SLOTX12 25.4MM BRL 98DG ANG PRE- KY -,SUP-3362-2-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4883.15,3418.205,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN OMG SLOTX4 STD BRL COMPR 130DG ANG KYLS -,SUP-3362-3-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN OMG SLOTX2 STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN OMG SLOTX3 STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-103,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN OPLS 4HL STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN OMG SLOTX6 STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN OMG SLOTX5 STD BRL COMPR 140DG ANG KYLS -,SUP-3362-3-205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 50MM -,SUP-3362-5-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 55MM -,SUP-3362-5-055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1205.86,844.102,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 60MM -,SUP-3362-5-060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1205.86,844.102,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 65MM -,SUP-3362-5-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 70MM -,SUP-3362-5-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 75MM -,SUP-3362-5-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 80MM -,SUP-3362-5-080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 90MM -,SUP-3362-5-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 95MM -,SUP-3362-5-095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 100MM -,SUP-3362-5-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 105MM -,SUP-3362-5-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X10MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X12MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X14MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X16MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X18MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X20MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X22MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X24MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X26MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X28MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X30MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X32MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X34MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X36MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X38MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X40MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X42MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X44MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X45MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X46MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X48MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X50MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X55MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X60MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X65MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X70MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5 X 75 CORTICAL -,SUP-338675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X80MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL 3.5MM X 85MM -,SUP-338685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SELF TAP CORTICAL 3.5 X 115MM -,SUP-338715,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SELF TAP CORTICAL 3.5 X 120MM -,SUP-338720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X14MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV CUT -,SUP-340614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX16MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX18MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX20MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX22MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX24MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX26MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX28MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX30MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX34MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX34MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX36MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX36MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX38MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX38MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX40MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX40MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX42MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX42MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX44MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX44MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX46MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX48MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX48MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX50MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL 4.5 X 52 -,SUP-340652,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL 4.5 X 54 -,SUP-340654,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX55MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX56MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340656,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX58MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340658,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL 4.5 X 60MM -,SUP-340660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX65MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX75MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MMX35MM MATTA CANC OMEGA3 SPS 16MM P/T 3.5MM HEX -,SUP-341035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MMX40MM MATTA CANC OMEGA3 SPS 16MM P/T 3.5MM HEX -,SUP-341040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER KIKO CORPECTOMY SMALL 12 X 14 0 DEG 21MM -,SUP-342.721,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11547.43,8083.201,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB. -,SUP-3420-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11MMX320MM RT TI BIOMECH STRGTH STAB 120DG ANG -,SUP-3420-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11MMX340MM RT TI BIOMECH STRGTH STAB 120DG ANG -,SUP-3420-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MMX80MM MATTA CANC OMEGA3 SPS 32MM P/T 3.5MM HEX -,SUP-342080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MMX85MM MATTA CANC OMEGA3 SPS 32MM P/T 3.5MM HEX -,SUP-342085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10MMX300MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10MMX320MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10MMX340MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10MMX360MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB. -,SUP-3425-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10MMX380MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10MMX400MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LONG NAIL 10MM X 420MM X 125 DEGREES -,SUP-3425-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11MMX300MM GAMMA3 RT HIP TI BIOMECH STRGTH STAB -,SUP-3425-1300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11MMX320MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11MMX340MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11MMX360MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11MMX380MM GAMMA3 RT TI BIOMECH STRGTH STAB -,SUP-3425-1380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11MMX400MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANCL FT 6.5 X 20 -,SUP-343020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANCL FT 6.5 X 25 -,SUP-343025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANCL FT 6.5 X 30 -,SUP-343030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANCL FT 6.5 X 40 -,SUP-343040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MMX85MM MATTA CANC OMEGA3 SPS FT 3.5MM HEX DRV CUT -,SUP-343085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX10MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX12MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX14MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX16MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX18MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX20MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX22MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX24MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX26MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX28MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX30MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX32MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX34MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX36MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX38MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CNCL LCK 4.0 X 40 -,SUP-345440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX45MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX50MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX55MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX60MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX65MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX75MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345475,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX80MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX90MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX10MM LCK CANC AXSOS SPS 5MM P/T ST 2.5MM HEX DRV -,SUP-345510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX14MM LCK CANC AXSOS SPS 6MM P/T ST 2.5MM HEX DRV -,SUP-345514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX18MM LCK CANC AXSOS SPS 6MM P/T ST 2.5MM HEX DRV -,SUP-345518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX34MM LCK CANC AXSOS SPS 14MM P/T ST 2.5MM HEX DRV -,SUP-345534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX36MM LCK CANC AXSOS SPS 14MM P/T ST 2.5MM HEX DRV -,SUP-345536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX38MM LCK CANC AXSOS SPS 14MM P/T ST 2.5MM HEX DRV -,SUP-345538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX40MM LCK CANC AXSOS SPS P/T ST 2.5MM HEX DRV CUT -,SUP-345540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX45MM LCK CANC AXSOS SPS 15MM P/T ST 2.5MM HEX DRV -,SUP-345545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX50MM LCK CANC AXSOS SPS 15MM P/T ST 2.5MM HEX DRV -,SUP-345550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX55MM LCK CANC AXSOS SPS 16MM P/T ST 2.5MM HEX DRV -,SUP-345555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX60MM LCK CANC AXSOS SPS 16MM P/T ST 2.5MM HEX DRV -,SUP-345560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX70MM LCK CANC AXSOS SPS P/T ST 2.5MM HEX DRV CUT -,SUP-345570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX80MM LCK CANC AXSOS SPS P/T ST 2.5MM HEX DRV CUT -,SUP-345580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MMX8MM CORT AXSOS ISO SPS FT ST 2.5MM HEX DRV CUT -,SUP-349608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL 2.7 X 14MM -,SUP-349614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MMX16MM CORT AXSOS ISO SPS FT ST 2.5MM HEX DRV CUT -,SUP-349616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MMX18MM CORT AXSOS ISO SPS FT ST 2.5MM HEX DRV CUT -,SUP-349618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CORTEX SCREW SELF TAPPING STEEL 2.7MM X 60MM -,SUP-349660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,127.9,89.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ASSEMBLY CBL CRLGE TI CBL LOCK SPRCBL ISO-ELAS -,SUP-35-100-1010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2597.25,1818.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CABLE ORTHO SUPERCABLE 1.5MM CERVICAL CERCLAGE -,SUP-35-100-1040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2477.71,1734.397,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE KINAMED 2 HOLE SUPERCABLE -,SUP-35-200-1020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8377.66,5864.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN SPRCBL 190MM 4HL TI TROCH GRP -,SUP-35-200-1030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10233.03,7163.121,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11MMX340MM GAMMA3 LT TI 120DG ANG -,SUP-3520-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11MMX360MM GAMMA3 LT TI 120DG ANG -,SUP-3520-1360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11MMX380MM GAMMA3 LT TI 120DG ANG -,SUP-3520-1380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CABLE ORTHO SUPER CBL TI PLATE 6HL -,SUP-35-220-1010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5831.26,4081.882,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CABLE-PLATE 8 HOLE STRAIGHT -,SUP-35-220-2010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7363.34,5154.338,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SUPERCABLE GRIP AND PLATE 10 HOLE STRAIGHT -,SUP-35-220-3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9661.23,6762.861,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN SPRCBL 290MM 10HL TI TROCH GRP -,SUP-35-220-3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10530.07,7371.049,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GRIP AND PLATE SYSTEM COMPRESSION BONE SCREW 4.5X12MM -,SUP-35-230-4512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,250.91,175.637,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SUPERCABLE GRIP AND PLATE SYS COP BONE SCREW 4.5 X 14MM -,SUP-35-230-4514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,250.91,175.637,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GRIP AND PLATE COMPRESSION BONE SCREW 4.5 X 16MM -,SUP-35-230-4516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,250.91,175.637,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SUPERCABLE BONE SCREW 4.5 X 30 -,SUP-35-230-4530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SUPERCABLE BONE SCREW 4.5 X 32 -,SUP-35-230-4532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE SUPERCABLE GRIP AND PLATE COMP  4.5 X 34 -,SUP-35-230-4534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X36MM COMPR SPRCBL F/GRP PLATE SYS -,SUP-35-230-4536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X38MM COMPR SPRCBL F/GRP PLATE SYS -,SUP-35-230-4538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X40MM COMPR SPRCBL F/GRP PLATE SYS -,SUP-35-230-4540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GRIP AND PLATE SYS COMP BONE SCREW 4.5MM X 45MM -,SUP-35-230-4545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
KINAMED SUPERCABLE SCREW -,SUP-35-230-4550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X12MM LCK SPRCBL F/GRP PLATE SYS -,SUP-35-234-5012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X16MM LCK SPRCBL F/GRP PLATE SYS -,SUP-35-234-5016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X18MM LCK SPRCBL F/GRP PLATE SYS -,SUP-35-234-5018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE SUPERCABLE GRIP AND PLATE LOCK 5 X 20 -,SUP-35-234-5020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10MMX300MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10MMX340MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10MMX380MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
"NAIL LONG KIT R1.5 TI LEFT 010 X 125"" -",SUP-3525-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11MMX420MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11MMX440MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11MMX300MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11MMX320MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11MMX340MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11MMX380MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11MMX400MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
"NAIL LONG KIT R15 TI 011 X 400MM X 125"" LEFT GAMMAX3 SYS -",SUP-3525-1400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL LONG KIT R1 5 TI LEFT -,SUP-3525-1420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GAMMA LONG NAIL KIT R1.5 LEFT 11X440MM -,SUP-3525-1440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB. -,SUP-3530-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DBM PUTTY - OSTEOSELECT 2.5CC -,SUP-359025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1749.17,1224.419,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DBM PUTTY - OSTEOSELECT 5CC -,SUP-359050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DBM PUTTY - OSTEOSELECT 10CC -,SUP-359100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN FX STNMN 2.8X230MM SMTH TROC PNT 3-SDE SHNK SS -,SUP-3611-3-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13.5,9.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SET SCREW -,SUP-36-2001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TULIP BODY -,SUP-36-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
REDUCTION HEAD -,SUP-36-2103,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW JANUS ORTHOFIX 4.5 X 30 -,SUP-36-2430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5MM X 35 ORTHOFIX -,SUP-36-2535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW JANUS ORTHOFIX 5.5 X 40 -,SUP-36-2540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SREW ORTHOFIX FIREBIRD 5.5 X 45MM -,SUP-36-2545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MM X 30MM ORTHOFIX -,SUP-36-2630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW JANUS 6.5X35MM ORTHOFIX -,SUP-36-2635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW JANUS ORTHOFIX 6.5 X 40 -,SUP-36-2640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW JANUS CANN 5.5 X 35 -,SUP-36-3535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW JANUS CANN 5.5 X 40 -,SUP-36-3540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW JANUS CANN 5.5 X 45 -,SUP-36-3545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW JANUS CANN 65 X 35 -,SUP-36-3635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW JANUS CANN 65 X 45 -,SUP-36-3645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5 X 25MM ORTHOFIX -,SUP-36-4425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW JANUS 4.5 X 30MM FENESTRATE ORTHOFIX -,SUP-36-4430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW JANUS 4.5 X 35MM FENESTRATE ORTHOFIX -,SUP-36-4435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW JANUS ORTHOFIX 6.5 X 30MM -,SUP-36-4630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW JANUS ORTHOFIX 6.5 X 35MM -,SUP-36-4635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER ACDF COLONIAL 12 X 14 X 6MM 7 DEGREE -,SUP-365.406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER ACDF COLONIAL 12 X 14 X 8MM 7 DEGREE -,SUP-365.408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X10MM LCK AXSOS ST T20 DRV SS NS -,SUP-370110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X12MM LCK AXSOS ST T20 DRV SS NS -,SUP-370112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X14MM LCK AXSOS ST.T20 DRV SS NS -,SUP-370114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X16MM LCK AXSOS ST T20 DRV SS NS -,SUP-370116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X14MM LCK AXSOS ST-T20 DRV SS NS -,SUP-370118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X14MM LCK AXSOS ST..T20 DRV SS NS -,SUP-370120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X14MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.17,457.219,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X26MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X28MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X30MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X32MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X34MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X36MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X40MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X44MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X65MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X70MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X75MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X80MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X85MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370385,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X90MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X95MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CABLE ORTHO 1.6MM DLMLS HIP SS BEAD SM SLV -,SUP-3704-0-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CABLE/SLEEVE FX 0.2MM DLMLS SS BEAD -,SUP-3704-0-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN DLMLS 165MM 4.5MM 5HL RECON SC SS BRD GROOVEX6 -,SUP-3704-3-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN DLMLS F/RECON TRMA 7HL GROOVEX8 RECON COMPR SS -,SUP-3704-3-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN DLMLS 254MM 4.5MM 9HL RECON SC SS BRD GROOVEX10 -,SUP-3704-3-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN DLMLS 305MM 4.5MM 11HL RECON SC SS GROOVEX12 -,SUP-3704-3-130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CABLE ORTHO 2MM HIP SS -,SUP-3704-8-240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS -,SUP-370528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS. -,SUP-370532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS- -,SUP-370538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS_ -,SUP-370540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS.NS -,SUP-370542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS.. -,SUP-370544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS -,SUP-370546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS__ -,SUP-370570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS-- -,SUP-370575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X28MM LCK AXSOS ST T15 DRV-SS NS -,SUP-370585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LCK ST 3.0 X 10 -,SUP-371010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,301.9,211.33,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3X16MM LCK AXSOS -,SUP-371016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,301.9,211.33,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X14MM LCK AXSOS ST.T20 DRV SS NS DIST LAT PERIART -,SUP-371314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCK 5.0 X 16 -,SUP-371316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X14MM LCK AXSOS ST_T20 DRV SS NS DIST LAT PERIART -,SUP-371318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X14MM LCK AXSOS ST T20 DRV SS NS DIST LAT PERIART -,SUP-371320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X22MM LCK AXSOS ST T20 DRV SS NS -,SUP-371322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X26MM LCK AXSOS ST T20 DRV SS NS -,SUP-371326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X28MM LCK AXSOS ST T20 DRV SS NS -,SUP-371328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCK 5.0 X 30 -,SUP-371330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X32MM LCK AXSOS ST T20 DRV SS NS -,SUP-371332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X34MM LCK AXSOS ST T20 DRV SS NS -,SUP-371334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X36MM LCK AXSOS ST T20 DRV SS NS -,SUP-371336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X38MM LCK AXSOS ST T20 DRV SS NS -,SUP-371338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X40MM LCK AXSOS ST T20 DRV SS NS -,SUP-371340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X42MM LCK AXSOS ST T20 DRV SS NS -,SUP-371342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X44MM LCK AXSOS ST T20 DRV SS NS -,SUP-371344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X46MM LCK AXSOS ST T20 DRV SS NS -,SUP-371346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X48MM LCK AXSOS ST T20 DRV SS NS -,SUP-371348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X50MM LCK AXSOS ST T20 DRV SS NS -,SUP-371350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X60MM LCK AXSOS ST T20 DRV SS NS -,SUP-371360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X70MM LCK AXSOS ST T20 DRV SS NS -,SUP-371370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X75MM LCK AXSOS ST T20 DRV SS NS -,SUP-371375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X80MM LCK AXSOS ST T20 DRV SS NS -,SUP-371380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X90MM LCK AXSOS ST T20 DRV SS NS -,SUP-371390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X95MM LCK AXSOS ST T20 DRV SS NS -,SUP-371395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LCK 4.0 X 14 -,SUP-371514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X16MM LCK AXSOS ST T15 DRV SS NS -,SUP-371516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X20MM LCK AXSOS ST T15 DRV SS NS -,SUP-371520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X22MM LCK AXSOS ST T15 DRV SS NS -,SUP-371522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X24MM LCK AXSOS ST T15 DRV SS NS -,SUP-371524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X26MM LCK AXSOS ST T15 DRV SS NS -,SUP-371526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X28MM LCK AXSOS ST_T15 DRV SS NS PERIART -,SUP-371528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X30MM LCK AXSOS ST T15 DRV SS NS -,SUP-371530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X28MM LCK AXSOS ST.T15 DRV SS NS PERIART -,SUP-371532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X34MM LCK AXSOS ST T15 DRV SS NS -,SUP-371534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X36MM LCK AXSOS ST T15 DRV SS NS -,SUP-371536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X28MM LCK AXSOS ST-T15 DRV SS NS PERIART -,SUP-371538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS.PERIART -,SUP-371542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS_PERIART -,SUP-371544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS-PERIART -,SUP-371546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X48MM LCK AXSOS ST T15 DRV SS NS -,SUP-371548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X50MM LCK AXSOS ST T15 DRV SS NS -,SUP-371550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X55MM LCK AXSOS ST T15 DRV SS NS -,SUP-371555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X60MM LCK AXSOS ST T15 DRV SS NS -,SUP-371560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X65MM LCK AXSOS ST T15 DRV SS NS -,SUP-371565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X28MM-LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X28MM.LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X80MM LCK AXSOS ST T15 DRV SS NS -,SUP-371580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X28MM_LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X95MM LCK AXSOS ST T15 DRV SS NS -,SUP-371595,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEPIN ORTHO 2.4MM -,SUP-373-0224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BIT DRILL 6MM BN -,SUP-3815-1-660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,371.28,259.896,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER THORLUM 12X14X6MM COALITION 0DG -,SUP-384.006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER THORLUM 12X14X8MM COALITION 0DG -,SUP-384.008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEPIN ORTHO 2.8MMX23CM THRD TIP -,SUP-3861-0-628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,82.92,58.044,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WASHER ORTHO 13MM ASNIS III 6.5/8.0MM SS RND NS -,SUP-390016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,182.99,128.093,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WASHER ORTHO 4MM ASNIS III F/4MM BN SCR SS RND NS -,SUP-390018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,132.57,92.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WASHER ORTHO 4.1MM ASNIS III F/9MM BN SCR SS RND NS -,SUP-390019,CDM,C1713,HCPCS,278,RC,,,outpatient,,,145.64,101.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
REDUCTION PIN 4.5MM DIA 150MM -,SUP-390082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,624.75,437.325,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUT 5.5MM ZIP PEEK #2 SUT FORCE FIB NDL -,SUP-3910-200-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUT 5.5MM ZIP PEEK #2 SUTX2 FORCE FIB -,SUP-3910-200-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUT 5.5MM ZIP PEEK #2 SUTX2 FORCE FIB -,SUP-3910-200-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUT 6.5MM ZIP PEEK #2 SUTX2 FORCE FIB 1/2CIR TAPR NDL -,SUP-3910-200-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUT 6.5MM ZIP PEEK #2 SUTX2 FORCE FIB -,SUP-3910-200-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUT INTRALINE 4.5MM HA/PLLA COMP BIOSTEON SUTX2 W/O -,SUP-3910-200-080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2648.5,1853.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUT TWINLOOP 3.5MM ZIP PEEK #2 SUT FORCE FIB -,SUP-3910-400-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1151.37,805.959,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUT TWINLOOP 3.5MM ZIP PEEK #2 SUTX2 FORCE FIB EYLT -,SUP-3910-400-235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2055.64,1438.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUT ICONIX 2.3MM PILOT HL 3 STRN #2 FORCE FIB PLYSTR -,SUP-3910-500-532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2376.27,1663.389,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAP PROT STRL F/2.5MM K-WR -,SUP-392.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5.72,4.004,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAP ORTHO -,SUP-393.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11.67,8.169,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAP PROT F/11MM CFBR EXTFIX ROD -,SUP-394.970,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5.02,3.514,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAP PROT F/4.0MM CRBN FIBRE BAR ROD BLK -,SUP-394.990,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5.43,3.801,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAP PROT NS F/4MM FX PIN YEL -,SUP-394.991,CDM,C1713,HCPCS,278,RC,,,outpatient,,,28.24,19.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
HYDROSET HA BONE SUB 3CC -,SUP-397003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4410.87,3087.609,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
HYDROSET BONE SUB 15CC -,SUP-397015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17072.08,11950.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 150MM POLARUS 3 PROX HUM LCK -,SUP-4001-1015R-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10270.16,7189.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3X90MM COMPR DL -TRAK CUT FLUT TI ALY NS -,SUP-40-0137,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6336.29,4435.403,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SUBSTITUTE CANC 30ML CHP FRZDR VOID FIL 1.7-10MM -,SUP-400150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1681.8,1177.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GRAFT HUM TIS WDG FRZDR 10-17 MMX14-20MM TRCORT ILC CRST -,SUP-400405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4361,3052.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTEX TI SLF TPNG 2.4 X 10 T8 SD REC -,SUP-401.760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,656.44,459.508,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTEX TI SLF TPNG 2.4 X 14 T8 SD REC -,SUP-401.764,CDM,C1713,HCPCS,278,RC,,,outpatient,,,656.44,459.508,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTEX TI SLF TPNG 2.4 X 30 T8 SD REC -,SUP-401.780,CDM,C1713,HCPCS,278,RC,,,outpatient,,,656.44,459.508,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SMALL CALCANEOUS FOOT -,SUP-40-10102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2915.48,2040.836,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE CALCANEUS SMALL STANDARD -,SUP-40-10112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2915.48,2040.836,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE CALCANEUS STANDARD LARGE -,SUP-40-10116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2915.48,2040.836,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 36MM 2.7MM 4HL RECON POLYAX LCK TI NS -,SUP-40-15011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2418.35,1692.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CURVED PLATE 5 HOLES RIGHT -,SUP-40-15012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.07,1837.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 49MM 2.7MM 6HL RECON POLYAX LCK TI NS -,SUP-40-15014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2657.78,1860.446,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
H-PLATE SMALL -,SUP-40-15021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2050.76,1435.532,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE MED-H -,SUP-40-15022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2610.76,1827.532,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE LARGE -,SUP-40-15023,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2451.75,1716.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
RECTANGLE PLATE SZ 1 -,SUP-40-15032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2451.75,1716.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 48MM 2.7/3.5MM 5HL 1MM RECON POLYAX LCK TI -,SUP-40-15041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2439.24,1707.468,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
VARIAX FOOT PLATE -,SUP-40-15042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2547.84,1783.488,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 51MM 2.7/3.5MM 6HL 1MM RECON POLYAX LCK TI -,SUP-40-15062,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2785.68,1949.976,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 35MM 2.7MM 4HL RECON POLYAX LCK TI NS -,SUP-40-15081,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1737.5,1216.25,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2MMX8MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2MMX9MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2MMX10MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2MMX11MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2MMX12MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2MMX13MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2MMX14MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2MMX15MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2MMX16MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2MMX18MM CANN ASNIS 5MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2MMX20MM CANN ASNIS 5MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2MMX22MM CANN ASNIS 5MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2MMX24MM CANN ASNIS 6MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2MMX26MM CANN ASNIS 6MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2MMX28MM CANN ASNIS 6MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 28.5MM 2MM 2HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 60MM 2MM 4HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1910.88,1337.616,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 72MM 2MM 5HL 2MM PRCONT POLYAX TI STR SMRTLC -,SUP-40-20805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 84MM 2MM 6HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20806,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 96MM 2MM 7HL 2MM PRCONT POLYAX TI STR SMRTLC -,SUP-40-20807,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 108MM 2MM 8HL 2MM PRCONT POLYAX TI STR -,SUP-40-20808,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 132MM 2MM 10HL 2MM PRCONT POLYAX TI STR -,SUP-40-20810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1812.72,1268.904,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 156MM 2MM 12HL 2MM PRCONT POLYAX TI STR -,SUP-40-20812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2549.91,1784.937,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WASHER ORTHO 2MM ASNIS MICRO F/CANN SCR SYS NS -,SUP-40-20900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,304.88,213.416,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 77MM 2MM 3HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.1,1787.87,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 89MM 2MM 4HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.1,1787.87,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 101MM 2MM 5HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.1,1787.87,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 113MM 2MM 6HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2388.81,1672.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 125MM 2MM 7HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2591.95,1814.365,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 137MM 2MM 8HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20908,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2591.95,1814.365,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 149MM 2MM 9HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20909,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2591.95,1814.365,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TOTAL JNT SUBCHONDROPLASTY -,SUP-402201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11788.78,8252.146,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X14MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X16MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X18MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NON-LOCKING 2.7 X 20MM -,SUP-40-27020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X22MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X24MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X26MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X28MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE T7 2.7 X 38MM -,SUP-40-27038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE T7 2.7 X 40 -,SUP-40-27040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE T7 2.7 X 45MM -,SUP-40-27045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X12MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-2761,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X10MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X16MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X18MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X20MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X22MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X24MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X26MM LCK -,SUP-4027626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X28MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3MMX8MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3MMX10MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3MMX12MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3MMX13MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3MMX14MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3MMX15MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3MMX16MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3MMX17MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3MMX18MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.48,659.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
MICRO ASNIS SCREW 3.0MM X 18MM -,SUP-40-30118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3MMX19MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30119,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3MMX20MM CANN ASNIS THRD REVCT FLUT TI NS PUR -,SUP-40-30120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3MMX22MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3MMX24MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3MMX26MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3MMX28MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3MMX30MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3MMX32MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3MMX34MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
3.0 MICRO ASNIS SCREW -,SUP-40-30134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3MMX36MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3MMX40MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WASHER ORTHO 3MM ASNIS MICRO F/CANN SCR SYS NS -,SUP-40-30900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,339.01,237.307,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X10MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X12MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X14MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X16MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X18MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X20MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X22MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X24MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X26MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X28MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X30MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X32MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X34MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X36MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X38MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X40MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X42MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X44MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X46MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X48MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X50MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X55MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X60MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X65MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X70MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X10MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X12MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X14MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X16MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X18MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X20MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X22MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X24MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X26MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
3.5MM LOCKING 28MM SCREW -,SUP-40-35628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
3.5MM LOCKING 34MM SCREW -,SUP-40-35634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X40MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WASHER ORTHO F/3.5MM BN SCR -,SUP-40-35900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,376.01,263.207,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX28MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX36MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.836,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX38MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.838,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX55MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.855,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW EXHAL SZ 8-32X.375 -,SUP-4-072623-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6.48,4.536,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEPIN ORTHO 2.4MMX23CM -,SUP-410236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,407.52,285.264,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SET SCREWS MARINER SPINE -,SUP-41-1010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
POLYAXIAL HEAD G2 -,SUP-41-3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
HEAD SCREW SEASPINE MARINER POLY EXTEND -,SUP-41-4010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
30MM OFFSET -,SUP-41-4130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLUG CEMENT SMALL DIA 10MM -,SUP-414994,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLUG CEMENT SMALL DIA 12MM -,SUP-414995,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE SCREW 5.5 X 30MM -,SUP-41-5530-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
MARINER SOLD SCREW 5.5 X35MM -,SUP-41-5535-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SEASPINE MARINER SOLID 5.5MM X 35MM -,SUP-41-5535-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE SCREW 5.5 X 40 -,SUP-41-5540-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5 X 45MM -,SUP-41-5545-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SEASPINE MARINER SOLID 6.5MM X 35MM -,SUP-41-6535-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE SCREW 6.5 X 45MM -,SUP-41-6545-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7.5 X 70MM -,SUP-41-7570-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEPIN ORTHO TRUMATCH RT -,SUP-420901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6242.92,4370.044,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEPIN ORTHO TRUMATCH LT -,SUP-420902,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4990.94,3493.658,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEPIN SZ5 ATTUNE TRUMATCH LT KN -,SUP-420945,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE CRANFC 100X100MM MATRIXNEURO LPRO MSH 0.6MM TI SQ -,SUP-421.534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8428.58,5900.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X26MM LCK CANN SD 3.5MM HEX RCESS CNCL HEAD TI NS -,SUP-422.392,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1537.15,1076.005,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X55MM LCK CANN SD 3.5MM HEX RCESS CNCL HEAD TI NS -,SUP-422.394,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1515.94,1061.158,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X65MM LCK CANN SD 3.5MM HEX RCESS CNCL HEAD TI NS -,SUP-422.395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1515.94,1061.158,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BEARING FIXED ASF UC 14MM PLY R 4-11 EF PERSONA -,SUP-42-5212-005-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SYSTEM KNEE PERSONA ASF UC 35MM PLY R 7-12 GH 9.0 THICKNESS -,SUP-42-5400-000-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE CURVED PELVIC R 108MM/L58.5MM/4HOLE -,SUP-425604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE CURV PELV R 108MM L74.5MM 5 HOLE -,SUP-425605,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 8 HOLE -,SUP-425608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
10 HOLE PLATE -,SUP-425610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE CURV. PELV 108MM/L186.5MM/12H -,SUP-425612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE PELV CURV R 108MM L218.5MM 14HOLE -,SUP-425614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE PELV CURV R 108MM L250.5MM 16 HOLE -,SUP-425616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5273.81,3691.667,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE PELV CURV R 108MM L282.5MM 18H -,SUP-425618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5273.81,3691.667,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE PELV CURV R 108MM L314.5MM 20H -,SUP-425620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5273.81,3691.667,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SYMPYSIS -,SUP-425654,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 10.5MMX74.5MM F/3.5MM/4.5MM SCR 4HL MATTA SS 88MM -,SUP-425655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 6 HOLE R88 PELVIS -,SUP-425656,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 8HOLE R88 -,SUP-425658,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE PELV CURVED R 88MM/L154.5MM/10H -,SUP-425660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE R88 12 HOLE -,SUP-425662,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE R88 CURVED 218.5 14 HOLE -,SUP-425664,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 16 HOLE R88 PELVIS -,SUP-425666,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE PELV CURV R 88MM L282.5 18H -,SUP-425668,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE PELV CURV R 88MM L314.5MM 20H -,SUP-425670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE PELV STRAIGHT L 26.5MM -,SUP-425702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4046.3,2832.41,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PELVIC PLATE -,SUP-425753,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4676.37,3273.459,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE STRT ACET L 46.5MM 14 HOLE -,SUP-425754,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4676.37,3273.459,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE STRAIGHT ACET L 70.5M 6 HOLE -,SUP-425756,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4571.81,3200.267,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 8HOLE FLEX -,SUP-425758,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4571.81,3200.267,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 10 HOLE FLEX -,SUP-425760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4571.81,3200.267,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE STRT ACET L 142.5MM 12 HOLE -,SUP-425762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5044.63,3531.241,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SYMPHYSIS 4 HOLE -,SUP-425794,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6110.34,4277.238,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE PRO SUPRAPECTINEAL QLS LEFT -,SUP-425912S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.77,7018.039,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
INFRAPECTINEAL PLATE SMALL QLS LEFT -,SUP-425932S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8017.17,5612.019,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN AXSOS 45MM 4MM 3HL LCK COMPR SS WAIST SM FRAG NS -,SUP-427003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,557.83,390.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN AXSOS 71MM 4MM 5HL LCK COMPR SS WAIST SM FRAG NS -,SUP-427005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,716.54,501.578,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN AXSOS 97MM 4MM 7HL LCK COMPR SS WAIST RND TAPR END -,SUP-427007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,716.54,501.578,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN AXSOS 110MM 4MM 8HL LCK COMPR SS WAIST RND TAPR END -,SUP-427008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,795.89,557.123,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN AXSOS 123MM 4MM 9HL LCK COMPR SS WAIST SM FRAG STRL -,SUP-427009S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,795.89,557.123,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN AXSOS 136MM 4MM 10HL LCK COMPR SS WAIST RND TAPR -,SUP-427010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,795.89,557.123,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN AXSOS 266MM 4MM 20HL LCK COMPR SS WAIST SM FRAG NS -,SUP-427020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.32,779.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN AXSOS 48MM 4MM 4HL RECON LCK COMPR SS SM FRAG NS -,SUP-427034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1836.09,1285.263,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN AXSOS 60MM 4MM 5HL RECON LCK COMPR SS SM FRAG NS -,SUP-427035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1836.09,1285.263,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN AXSOS 72MM 4MM 6HL RECON LCK COMPR SS ADLT SM FRAG -,SUP-427036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2071.44,1450.008,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN AXSOS 96MM 4MM 8HL RECON LCK COMPR SS ADLT SM FRAG -,SUP-427038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2298.3,1608.81,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN AXSOS 76MM 3MM 6HL LCK SS 1/3 TBLR SM FRAG NS -,SUP-427066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,669.86,468.902,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN AXSOS 89MM 3MM 8HL LCK SS 1/3 TBLR SM FRAG NS -,SUP-427068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,725.87,508.109,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN AXSOS 169MM 5MM 9HL LCK COMPR SS NRW WAIST BSC FRAG -,SUP-427109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,898.59,629.013,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN AXSOS 223MM 5MM 12HL LCK COMPR SS NRW WAIST BSC -,SUP-427112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1075.97,753.179,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN AXSOS 259MM 5MM 14HL LCK COMPR SS NRW WAIST BSC -,SUP-427114S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1075.97,753.179,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE WSTD CMP BRD HL8 -,SUP-427138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN AXSOS 173MM 5MM 9HL LCK COMPR SS BRD WAIST BSC FRAG -,SUP-427139S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN AXSOS 263MM 5MM 14HL LCK COMPR SS BRD WAIST BSC ST -,SUP-427144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1159.75,811.825,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GRAFT HUM TIS HEMI FRZN 10-10.5 MMX8-13CM PTLR TNDN 30-75MM -,SUP-430007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11007.78,7705.446,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 10X60MM F/3.5MM/4MM SCR 5HL SHFT 2.8MM RECON -,SUP-430105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.67,1007.769,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 25MM 3MM 2HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,234.51,164.157,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 38MM 3MM 3HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,234.51,164.157,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 64MM 3MM 5HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,289.01,202.307,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 77MM 3MM 6HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,289.01,202.307,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 90MM 3MM 7HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.42,222.194,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 103MM 3MM 8HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,355.35,248.745,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 129MM 3MM 10HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,355.35,248.745,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
MESH TITANIUM 6X6 - DISCONTINUED DO NOT USE -,SUP-43-1022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 10X49MM F/3.5MM/4.5MM SCR 0.75HL HD/SHFT 1.2MM SS -,SUP-431024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,634.85,444.395,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 10X66MM F/3.5MM/4.5MM SCR HLX3/6 HD/SHFT 1.2MM SS -,SUP-431026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,871.75,610.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
MOLD CMNT SPCR 48MM SIL SS STAGEONE STRL -,SUP-431181,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5199.96,3639.972,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
HIP HEAD CEMENT MOLD 52MM -,SUP-431182,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5199.96,3639.972,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SHOULDER MOLD 12STD 54 X 21 X 64 -,SUP-431412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11946.58,8362.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
60MM FEMORAL KNEE CEMENT MOLD -,SUP-432160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8413.73,5889.611,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
MOLD BNCMNT FEM 65MM SIL STAGEONE STRL -,SUP-432165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8413.73,5889.611,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 158MM 4.5MM 10HL RECON SS -,SUP-432210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1420.32,994.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE RECON HL 4.5 X 14 HOLE -,SUP-432214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.92,1168.944,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE T 6 HOLE L=111MM -,SUP-433106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.57,778.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
70MM TIBIAL KNEE CEMENT MOLD -,SUP-433170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4530.53,3171.371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
MOLD BNCMNT TIB 75MM SIL STAGEONE STRL -,SUP-433175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4530.53,3171.371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN AXSOS 86MM 4MM 3HL CONTR LCK SS NS 1STRN/PK -,SUP-437123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5167.49,3617.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN AXSOS 112MM 4MM 5HL CONTR LCK SS NS -,SUP-437125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5167.49,3617.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN AXSOS 95MM 4MM HLX2/5 SHFT/METPHYSL CONTR LCK SS NS -,SUP-437302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN AXSOS 121MM 4MM HLX4/5 SHFT/METPHYSL CONTR LT TIB -,SUP-437304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN AXSOS 147MM 4MM HLX6/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN AXSOS 121MM 4MM HLX4/5 SHFT/METPHYSL CONTR RT TIB -,SUP-437324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN AXSOS 173MM 4MM HLX8/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN AXSOS 97MM 4MM HLX4/3 SHFT/METPHYSL CONTR LCK SS -,SUP-437424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4738,3316.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN AXSOS 166MM 5MM HLX6/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5434.02,3803.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN AXSOS 202MM 5MM HLX8/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN AXSOS 238MM 5MM HLX10/5 SHFT/METPHYSL CONTR LCK SS. -,SUP-437510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN AXSOS 310MM 5MM HLX14/5 SHFT/METPHYSL CONTR LCK SS- -,SUP-437514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN AXSOS 238MM 5MM HLX10/5 SHFT/METPHYSL CONTR LCK SS- -,SUP-437530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN AXSOS 310MM 5MM HLX14/5 SHFT/METPHYSL CONTR LCK SS. -,SUP-437534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN AXSOS 343MM 5MM HLX16/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LINER 32X49MM EPSLN STD DRSUL PRIM HOOD -,SUP-4377-32-049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3174.71,2222.297,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SET SCREW SPIN STD FIREBIRD TI -,SUP-44-2001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FIREBIRD TOP LOADING HEAD -,SUP-44-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ORTHOFIX 4.5 X 30 SCREW -,SUP-44-5430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ORTHOFIX SCREW 4.5 X 35 -,SUP-44-5435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ORTHOFIX SCREW 4.5 X 40 -,SUP-44-5440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ORTHOFIX SCREW 4.5 X 45 -,SUP-44-5445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ORTHOFIX SCREW 5.5 X 30 -,SUP-44-5530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ORTHOFIX SCREW 5.5 X 35 -,SUP-44-5535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ORTHOFIX SCREW 5.5 X 40 -,SUP-44-5540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ORTHOFIX SCREW 5.5 X 45 -,SUP-44-5545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ORTHOFIX SCREW 6.5 X 30 -,SUP-44-5630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
6.5 X 35 SHANK -,SUP-44-5635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
6.5 X 40 SHANK -,SUP-44-5640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
6.5 X 45 SHANK -,SUP-44-5645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
7.5 X 40 SHANK -,SUP-44-5740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW FIREBIRD ORTHOFIX 7.5 X 45 -,SUP-44-5745,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ORTHOFIX SCREW 7.5 X 50 -,SUP-44-5750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ORTHOFIX SCREW 6.5 X 35 -,SUP-44-6535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ORTHOFIX SCREW 6.5 X 40 -,SUP-44-6540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WASHER 3.5 -,SUP-45-35900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,139.05,97.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
MICROCOIL EMBL 4MMX 5CML AZUR DTCH 18 -,SUP-45-480405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3570.95,2499.665,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
IMPLANT PHALANX 2MM PRO- TOE VO 13MM 10DG ANG -,SUP-45712010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
MINI STICK MAX 5FR X 10CM -,SUP-45-756,CDM,C1713,HCPCS,278,RC,,,outpatient,,,431.21,301.847,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COUNTERSINK FOR SCREWS 02.7/3.5mm AO FITTING -,SUP-45-80040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,516.4,361.48,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3X12MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115401200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3X16MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115401600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3X18MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115401800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3X20MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115402000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER SYSTEM CONSTRUX MINI PEEK -,SUP-47-3009SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2X10MM CORT SM HX DRV -,SUP-4820-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.04,88.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX24MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-48-3502-41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COUPLING DELTA ROD TO ROD MULTI 05/8/11 5MM PIN -,SUP-4922-1-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4759.25,3331.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CLAMP 5 HOLE PIN -,SUP-4922-2-020-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3516.77,2461.739,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD VECTRAN COATED 11MM X 100MM CARBON CONN -,SUP-4922-8-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1854.96,1298.472,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WIRE BOLT SHORT -,SUP-4933-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,750.96,525.672,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WIRE BOLT MEDIUM -,SUP-4933-1-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,750.96,525.672,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WIRE BOLT ADAPTER SHORT -,SUP-4933-1-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1798.46,1258.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
M8 CONNECTING NUT -,SUP-4933-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,199.56,139.692,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
POST EXTERNAL FIXATION SHORT L44 MM OD8 MM HOFFMANN -,SUP-4933-1-644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,819.23,573.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BOLT FOR RING -,SUP-4933-1-702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,220.56,154.392,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WASHER YELLOW 2MM -,SUP-4933-1-711,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.1,249.97,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CARBON FIBER FULL RING 210MM -,SUP-4933-5-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10863.87,7604.709,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CARBON FIBER OPEN RING 180MM -,SUP-4933-6-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9858.39,6900.873,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CARBON FIBER OPEN RING 210MM -,SUP-4933-6-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9316.66,6521.662,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WIRE WITH OLIVE 1.8 X 450 -,SUP-4933-8-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,850.74,595.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
K-WIRE 2.0 OLIVE -,SUP-4933-8-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,887.5,621.25,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
HII COMPACT MRI PERIARTICULAR PIN CLAMP -,SUP-4941-2-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1539.11,1077.377,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SYNMESH 15MM DIA 8MM HEIGHT ROUND CAGE -,SUP-495.361,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9527.78,6669.446,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
END RING 10MM DIAM / 0 DEG -,SUP-495.384,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1024.04,716.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SYNMESH 10MM DIAM 20MM HEIGHT -,SUP-495.603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9664.94,6765.458,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CRNMXF UPR FACE 1.2X5MM UNIVERSAL NEURO II ST TI NS -,SUP-50-12005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,372.97,261.079,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CRNMXF UPR FACE 1.2X10MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-12010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,372.97,261.079,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CRNMXF UPR FACE 1.2X12MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-12012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,372.97,261.079,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CRNMXF UPR FACE 1.2X3MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-12903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,417.55,292.285,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN WND CLSR 200MM -,SUP-5014-5-200S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,680.36,476.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CANC HALF-PIN 5MM SHAFT 6MM X 250 THREAD -,SUP-5015-7-250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CRNMXF MIDFC 1.7X6MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-17006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.31,222.117,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CRNMXF MIDFC 1.7X8MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-17008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.31,222.117,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CRNMXF MIDFC 1.7X10MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-17010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.31,222.117,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ER CRNMXF MIDFC 1.7X4MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-17304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,441.77,309.239,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LCK CRNMXF MIDFC 1.7X4MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-17504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,416.09,291.263,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LCK CRNMXF MIDFC 1.7X5MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-17505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,416.09,291.263,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
HALF PIN FX APEX 5MM SS HA CTD SD/TAP180MML 50MM THRD -,SUP-5017-5-180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,642.67,449.869,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CRNMXF MIDFC 1.7X3MM CX PIN HD UNIVERSAL NEURO II SD -,SUP-50-17903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,356.29,249.403,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CRNMXF MIDFC 1.7X4MM CX PIN HD UNIVERSAL NEURO II ST. -,SUP-50-17904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,356.29,249.403,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN EXTFIX 5X150MM SS APEX 40MM THRD SD/ST -,SUP-5018-5-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
HALFPIN EXTFIX 5X150MM SS APEX 50MM THRD SD/ST -,SUP-5018-6-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN EXTFIX 5X50MM HLF SS APEX 180MM THRD SD -,SUP-5018-6-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CRNMXF MIDFC 1.9X3MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-19003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,348.64,244.048,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CRNMXF MAND 2X4MM CX PIN HD UNIVERSAL NEURO II ST TI -,SUP-50-20404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.62,210.434,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CRNMXF MAND 2X6MM CX PIN HD UNIVERSAL NEURO II ST TI -,SUP-50-20406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.62,210.434,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CRNMXF MAND 2X8MM CX PIN HD UNIVERSAL NEURO II ST TI -,SUP-50-20408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.62,210.434,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LCK CRNMXF MAND 2X12MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-20512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,551.06,385.742,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LCK CRNMXF MAND 2X14MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-20514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,551.06,385.742,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LCK CRNMXF MAND 2X16MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-20516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,551.06,385.742,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SELF DRILLING LOCKING 2 X 6MM -,SUP-50-20596,CDM,C1713,HCPCS,278,RC,,,outpatient,,,830.96,581.672,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN EXTFIX 6X200MM HLF SS APEX 70MM THRD SD/ST -,SUP-5021-8-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN EXTFIX 4X120MM SS APEX 30MM THRD SD/ST -,SUP-5023-3-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CRNMXF MAND 2.3X16MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-23416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.43,257.201,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN EXTFIX 4X120MM HLF SS APEX 35MM THRD SD/ST -,SUP-5023-5-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN EXTFIX 4X150MM HLF SS APEX 50MM THRD SD/ST -,SUP-5023-6-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN EXTFIX 4X180MM SS HLF PIN APEX 50MM THRD SD/ST -,SUP-5023-6-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN HYBRID APEX -,SUP-5026-8-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,591.79,414.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAP EXTFIX 5MM HOFFMN XPRESS 40MM THRD F/PIN TIP -,SUP-5027-1-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17.15,12.005,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ER CRNMXF MAND 2.7X12MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-27412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,416.21,291.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LCK CRNMXF MAND 2.7X10MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-27510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,708.49,495.943,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD CONNECTING VECTRAN COATED CARBON 8MM X 400MM -,SUP-5028-8-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1100.81,770.567,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TRANSFIX PIN 4X300MM -,SUP-5030-4-300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
APEX TRANSFIX 4 X 250 PIN 5 X 50 THR -,SUP-5030-5-250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN EXTFIX 3X100MM TRNSFX SS APEX 25MM THRD SD/ST F/BILAT -,SUP-5038-2-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,329.79,230.853,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN EXTFIX 3X200MM TRNSFX SS APEX -,SUP-5045-5-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD HII COMPACT MRI CONNECTING 5MM X 65MM -,SUP-5048-5-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
HII COMPACT MRI CONNECTING ROD 5MM X 100MM -,SUP-5048-5-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
HII COMPACT MRI CONNECTING ROD 5MM X 150MM -,SUP-5048-5-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD HII COMPACT MRI CONNECTING 5MM X 200MM -,SUP-5048-5-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN TRANSFIXING 300MM 5/6 -,SUP-5050-4-300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN EXTFIX 5MM/4X300MM TRNSFX SS APEX 50MM THRD SD/ST -,SUP-5050-5-250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,623.82,436.674,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BLADE SAW 13X90MM OSCIL/SGTL 0.89MM -,SUP-506123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,460.97,322.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN EXTFIX 2X45MM SS APEX 20MM THRD ST -,SUP-5065-4-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,297.76,208.432,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CARBON CONNECTING ROD 3MMX120MM -,SUP-5079-6-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,290.23,203.161,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
HALFPIN EXTFIX 2X45MM SS U THRD DBL HLCL FLUT APEX 12MM P/T -,SUP-5080-2-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,346.77,242.739,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN 2MM X 45MM HALF HOFFMANN II APEX STAINLESS STEEL MICRO -,SUP-5080-2-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,346.77,242.739,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW POLY THRD 4.5X25MM CREO -,SUP-5119.1327,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW POLY THRD 5.5 4.5X30MM CREO -,SUP-5119.1330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CREO 5.5 4.5MM X 40MM POLYAXIAL SCREW -,SUP-5119.1340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CREO 5.5 4.5MM X 45MM POLYAXIAL -,SUP-5119.1345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5 X 40 POLYAXIAL CREO -,SUP-5119.1440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CREO THREADED 5.0 X 45MM POLYAXIAL SCREW -,SUP-5119.1447,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5 X 35 POLYAXIAL CREO -,SUP-5119.1535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5 X 40 POLYAXIAL CREO -,SUP-5119.1540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5X45MM CREO THRD PRASMB F/5.5MM TI STRL -,SUP-5119.1545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CREO THREADED 5.5 X 45MM POLYAXIAL SCREW -,SUP-5119.1547,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW POLYAXIAL 5.5 X 50 -,SUP-5119.1550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW POLYAXIAL 5.5 6.5 X 30 CREO -,SUP-5119.1630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X35MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.1635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X40MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.1640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X45MM CREO THRD PRASMB F/5.5MM TI STRL -,SUP-5119.1645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW POLYAXIAL CREO 6.5 X 50 -,SUP-5119.1650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CREO 5.5 6.5 X 60MM POLYAXIAL SCREW -,SUP-5119.1660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5-5.5X30MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5-5.5X35MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3337,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL CREO 5.5- 6.0-5.0X25MM -,SUP-5119.3427,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6-5X30MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.3432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6-5X35MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.3437,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5-6.5X30MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5-6.5X35MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3537,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CREO 5.5 5.5MM X 45MM CORTICAL -,SUP-5119.3547,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER CERV 14X6X12MM MOSAIC PEEK-OPTIMA -,SUP-51412-206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER CERV 14X7X12MM MOSAIC PEEK-OPTIMA -,SUP-51412-207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11436.04,8005.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
UNITED HIP CANCELLOUS LOCKING SCREW 6.5MM X 15MM -,SUP-5208-1015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
UNITED CANCELLOUS LOCKING SCREW 6.5 X 20 -,SUP-5208-1020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
UNITED CANCELLOUS LOCKING SCREW 6.5 X 25 -,SUP-5208-1025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
UNITED CANCELLOUS LOCKING SCREW 6.5 X 30 -,SUP-5208-1030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
UNITED HIP CANCELLOUS LOCKING SCREW 6.5MM X 35MM -,SUP-5208-1035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
UNITED CANCELLOUS LOCKING SCREW 6.5 X 45 -,SUP-5208-1045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD FIREBIRD 40MM ORTHOFIX -,SUP-52-2040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ORTHOFIX NXG 70 ROD -,SUP-52-2070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ORTHOFIX 80MM ROD -,SUP-52-2080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
90MM TI ROD STRAIGHT -,SUP-52-2090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
100MM TI ROD STRAIGHT -,SUP-52-2100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NXG 110MM ROD -,SUP-52-2110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD FIREBIRD 120MM TI STRAIGHT ORTHOFIX -,SUP-52-2120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD FIREBIRD STRAIGHT 140MM TI ORTHOFIX -,SUP-52-2140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD 160MM NXG DIA 5.5MM TI ORTHOFIX -,SUP-52-2160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ORTHOFIX ROD 180 -,SUP-52-2180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ORTHOFIX ROD 200MM -,SUP-52-2200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD HEX TITANIUM 400MM -,SUP-52-2450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD 35MM ORTHOFIX -,SUP-52-6035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
40MM ROD TI CURVED -,SUP-52-6040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD 45MM ORTHOFIX -,SUP-52-6045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ORTHOFIX ROD 50MM -,SUP-52-6050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ACTB 6.5X12MM OSTLOK -,SUP-5260-5-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ACTB 6.5X14MM OSTLOK -,SUP-5260-5-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ACTB 6.5X18MM OSTLOK -,SUP-5260-5-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ACTB 6.5X30MM OSTLOK -,SUP-5260-5-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ACTB 6.5X35MM OSTLOK -,SUP-5260-5-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ACTB 6.5X40MM OSTLOK -,SUP-5260-5-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ACTB 6.5 X 45MM OSTLOK -,SUP-5260-5-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ACTB 6.5X50MM OSTLOK -,SUP-5260-5-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ORTHOFIX ROD 55MM -,SUP-52-6055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ORTHOFIX NXG 60MM ROD -,SUP-52-6060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ORTHOFIX NXG 65MM ROD -,SUP-52-6065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ORTHOFIX 70MM ROD -,SUP-52-6070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ORTHOFIX 75MM ROD -,SUP-52-6075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ORTHOFIX 80 ROD -,SUP-52-6080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
OPEN CONNCETOR 5.5 - 5.5 -,SUP-52-6805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE CRANFC 12MM BAR UNIV NEURO III LPRO 2HL TI STR 1.5MM -,SUP-53-05212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,705.92,494.144,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE CRANFC 2HL 16MM BAR STR UNIV NEURO III 1.5MM TI NS -,SUP-53-05216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,844.97,591.479,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE CRANFC 4HL 28MM BAR 3D BX UNIV NEURO III 1.5MM TI NS -,SUP-53-05228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.88,735.616,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE CRANFC LRG 2HL 3D BX LEIBINGER UNIV NEURO 2 1.5MM TI -,SUP-53-05240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1443.7,1010.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE CRANFC 6MM BAR 4HL STR LEIBINGER UNIV NEURO 2 1.5MM TI -,SUP-53-05406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,702.42,491.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COVER CRANFC 7MM UNIV NEURO III LPRO TI -,SUP-53-05507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1211.85,848.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COVER CRANFC 10MM UNIVERSAL NEURO II LPRO TI NS -,SUP-53-05510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1211.85,848.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COVER CRANFC 14MM UNIVERSAL NEURO II LPRO TI NS -,SUP-53-05514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1211.85,848.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COVER CRANFC 20MM UNIVERSAL NEURO II LPRO TI NS -,SUP-53-05520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1338.06,936.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE CRANFC 8MM UNIV NEURO III LPRO 6HL TI DBL Y 1.5MM NS -,SUP-53-05608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1331.38,931.966,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE STR LP GAP SMALL -,SUP-53-05612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1587.66,1111.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE STR LP GAP LARGE -,SUP-53-05622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1748.42,1223.894,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE CRANFC 4HL X-SHP LEIBINGER UNIV NEURO 2 1.5MM TI NS -,SUP-53-05630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1344.26,940.982,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE CRANFC 8HL STR LEIBINGER UNIV NEURO 2 1.5MM TI NS W/O -,SUP-53-05804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.28,665.896,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE CRANFC 12MM 2HL UNIV NEURO III XTR RGD TI NS -,SUP-53-06212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,597.33,418.131,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL SFT TIS BIO- ABSB LPRO 1.5X20MM PLYLC ACD PLYMR KN -,SUP-531520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,798.11,558.677,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.7X5MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17005E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LCK 1.7 X 06 -,SUP-53-17006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,518.32,362.824,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.7X8MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.7X9MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LCK 1.7 X 10 -,SUP-53-17010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.83,308.581,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.7X12MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LCK 1.7 X 16 -,SUP-53-17016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.7X16MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX -,SUP-53-20616E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2X18MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX NS -,SUP-53-20618E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2X20MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX NS -,SUP-53-20620E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2X22MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX NS -,SUP-53-20622E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.7X24MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX -,SUP-53-20624E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.7X26MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX. -,SUP-53-20626E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X6MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X8MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X9MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X10MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X11MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23011E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X12MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X13MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23013E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X16MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X18MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23018E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 2.3MM X 20MM -,SUP-53-23020E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.88,310.016,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 2.3 X 24 -,SUP-53-23024E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 2.3 X 26 -,SUP-53-23026E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X10MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23210E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X14MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23214E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X16MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23216E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X18MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23218E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X20MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23220E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X22MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23222E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X24MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23224E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X26MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23226E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X28MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23228E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X30MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23230E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X32MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23232E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X34MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23234E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X36MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23236E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X38MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23238E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X10MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23610E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X12MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23612E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X14MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT. -,SUP-53-23614E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X16MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23616E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X18MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT. -,SUP-53-23618E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X20MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23620E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X22MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23622E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X24MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23624E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X26MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23626E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X28MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23628E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X30MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23630E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X32MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23632E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X34MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23634E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X36MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23636E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X38MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23638E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X16MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27116E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X18MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27118E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X20MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27120E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X22MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27122E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X24MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27124E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X26MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27126E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X10MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27210E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NON LOCK 2.7 X 12MM -,SUP-53-27212E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NON LOCK 2.7 X 14 -,SUP-53-27214E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X16MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27216E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X18MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27218E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X20MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27220E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X22MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27222E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X24MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27224E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X25MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27226E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X10MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27610E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X12MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27612E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X14MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27614E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X16MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27616E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X18MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27618E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X20MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27620E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 2.7 X 22 -,SUP-53-27622E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X24MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27624E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X26MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27626E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE MSH CRANFC MIDFC MICRO 60X120MM 0.1MM MLBL 1.2MM TI NS -,SUP-54-00261,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3755.99,2629.193,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
MICRO/MESH 120 X 120 X .2MM / GOLD -,SUP-54-00270,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8602.59,6021.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
MICRO/MESH 120 X 60 X .2MM / GOLD -,SUP-54-00271,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6438.15,4506.705,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BLUE DYNAMIC MESH  90X90MM 0.3MM MLBL 1.7MM TI NS -,SUP-54-00346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2066.2,1446.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOCKING SCREW 3.5MM T15 L40MM -,SUP-541540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1621.95,1135.365,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 60MMX1.5MM 2.7MM ANTMC POLYAX TI SMRTLC RT -,SUP-54-25290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 60MMX1.5MM 2.7MM ANTMC POLYAX TI SMRTLC LT -,SUP-54-25291,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE WIDE DORSAL RIGHT -,SUP-54-25292,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 60MMX1.5MM 2.7MM ANTMC POLYAX TI W SMRTLC -,SUP-54-25293,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 81MMX1.5MM 2.7MM ANTMC POLYAX TI XLNG SMRTLC -,SUP-54-25295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4270.06,2989.042,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 56MM 2.7MM 9HL 2MM ANTMC POLYAX TI SMRTLC -,SUP-54-25374,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 76MM 2.7MM 2MM ANTMC POLYAX TI LNG NRW LT -,SUP-54-25375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 56MM 2.7MM 11HL ANTMC POLYAX TI STD SMRTLC -,SUP-54-25376,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 76MM 2.7MM 13HL 2MM ANTMC POLYAX TI STD LNG -,SUP-54-25377,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 56MM 2.7MM 9HL ANTMC POLYAX TI STD SMRTLC -,SUP-54-25384,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 76MM 2.7MM 2MM ANTMC POLYAX TI LNG NRW RT -,SUP-54-25385,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 56MM 2.7MM STD ANTMC TI SMRTLC -,SUP-54-25386,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE VOLAR 76MM L 14 HOLE 2MM H STAN LONG RT -,SUP-54-25387,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 53MM 2.7MM 2MM POLYAX TI MED/SHRT UNIV XLN -,SUP-54-25394,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3450.36,2415.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 53MM 2.7MM 2MM POLYAX TI SHRT UNIV STD -,SUP-54-25396,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3450.36,2415.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 53MM 2.7MM 2MM POLYAX TI SHRT UNIV W SMRTLC -,SUP-54-25398,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3450.36,2415.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 44MM 2.7MM 1MM ANTMC POLYAX TI SHRT NRW CLMN -,SUP-54-25400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 57MM 2.7MM ANTMC POLYAX TI LNG CLMN SMRTLC -,SUP-54-25401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 40MMX1MM FRAG SPEC POLYAX TI SHRT SMRTLC -,SUP-54-25402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 40MMX1MM 2.7MM FRAG SPEC POLYAX TI SHRT -,SUP-54-25403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 53MMX1MM FRAG SPEC POLYAX TI LNG SMRTLC -,SUP-54-25405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 2.7 X 189 15 HOLE -,SUP-54-25420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7093.08,4965.156,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 2.7 145 11 HOLES -,SUP-54-25424S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7093.08,4965.156,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 2.7MM XXL VOLAR L100MM 8 HOLE -,SUP-54-25428S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6203.58,4342.506,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE VOLAR XXL 7MM -,SUP-54-25442S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7093.08,4965.156,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 2.7MM XXL VOLAR NARROW 8 HOLE -,SUP-54-25444S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6203.58,4342.506,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 8 HOLES / 100MM / 2.7MM XXL -,SUP-54-25446S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6203.58,4342.506,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 3HL XSH NRW -,SUP-54-25573,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 8HL XSH -,SUP-54-25583,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN XSH -,SUP-54-25673,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 2X56MM 11HL INTMD ANTMC SHRT NS -,SUP-54-25674,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE INT LNG LEFT 14 HOLE -,SUP-54-25677,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4468.42,3127.894,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX F/DIST RAD SYS 10HL INTMD XSH -,SUP-54-25683,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 11HL INTMD SHRT -,SUP-54-25684,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 14HL INTMD LNG -,SUP-54-25687,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4468.42,3127.894,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX F/DIST RAD SYS 10HL STD XSH -,SUP-54-25773,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 10HL STD XSH -,SUP-54-25783,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
RESTRICTOR BNCMNT FEM SZ3 13.25MM UHMWPE -,SUP-5460-14-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1026.96,718.872,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
RESTRICTOR BNCMNT FEM SZ3 15.75MM UHMWPE -,SUP-5460-16-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1150.21,805.147,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
RESTRICTOR FMCNL BNCMNT SZ5 18.25MM UHMWPE HIP -,SUP-5460-18-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1070.7,749.49,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE HYBRID MMP -,SUP-55-02950,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1731.83,1212.281,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE CRANFC UPR FACE 18HL 3D SHP UNIVERSAL NEURO II MLBL -,SUP-55-04218,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2608.27,1825.789,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE CRANFC UPR FACE HLX2X2 3D UNIVERSAL NEURO II MLBL -,SUP-55-04231,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.51,834.757,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE CRANFC UPR FACE HLX6X2 0.5MM 3D UNIV 2 MLBL 1.2MM TI -,SUP-55-04233,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2146.54,1502.578,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE UPR FACE 7HL 0.5MM DBL Y UNIVERSAL NEURO II MLBL 1.2MM -,SUP-55-04240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1128.37,789.859,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE CRANFC UPR FACE 24HL 0.5MM STR UNIV 2 MLBL 1.2MM TI NS -,SUP-55-04424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2500,1750,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE CRANFC MIDFC 20HL 0.55MM UNIV 2 MLBL 1.7MM TI NS BLU -,SUP-55-04720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2468.01,1727.607,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE CRANFC MIDFC 24HL 0.55MM STR UNIV 2 MLBL CNDSD 1.7MM -,SUP-55-04724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.85,1788.395,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE CRANFC MIDFC 7HL 0.6MM UNIVERSAL NEURO II STD 1.7MM TI -,SUP-55-05164,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.58,742.406,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE ORBT MIDFC 6HL CRV LEIBINGER UNIV 2 STD 1.7MM TI NS -,SUP-55-05188,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1255.9,879.13,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE LCK CRANFC MIDFC HL 2X2 0.8MM 3D SHP UNIVERSAL NEURO -,SUP-55-05731,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1390.43,973.301,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE CRANFC UPR FACE 8HL STR UNIVERSAL NEURO II STD 1.2MM -,SUP-55-06208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1389.47,972.629,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE CRANFC UPR FACE HLX2X2 3D SHP UNIVERSAL NEURO II STD -,SUP-55-06231,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.43,785.001,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
3D PLATE 6 X 2 HL UPPERFACE -,SUP-55-06233,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2014.51,1410.157,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
3D PLATE 6 X 6 HL UPPERFACE -,SUP-55-06235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4305.34,3013.738,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLT/7 HOLE DOUBLE Y UPPERFACE -,SUP-55-06240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1022.23,715.561,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE MIDFC 4HL STR UNIVERSAL NEURO II STD 1.7MM TI NS BAR -,SUP-55-06704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.58,457.506,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE CRANFC MIDFC 8HL STR UNIVERSAL NEURO II STD 1.7MM TI -,SUP-55-06708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1319.35,923.545,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE MIDFC 24HL STR UNIVERSAL NEURO II STD 1.7MM TI NS BAR -,SUP-55-06724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2527.07,1768.949,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE STR 2 X 2 3D -,SUP-55-06731,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1207.72,845.404,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE MIDFC 10HL UNIVERSAL NEURO II STD 1.7MM TI NS BAR GOLD -,SUP-55-06750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1390.43,973.301,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE MIDFC 4HL CRV UNIVERSAL NEURO II STD 1.7MM TI NS GOLD -,SUP-55-06754,CDM,C1713,HCPCS,278,RC,,,outpatient,,,804.35,563.045,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE RT CRANFC MIDFC 2MM 5HL 0.6MM LEIBINGER UNIVERSAL -,SUP-55-06761,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1100.48,770.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE RT CRANFC MIDFC 5MM 5HL 0.6MM UNIVERSAL NEURO II STD -,SUP-55-06763,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1133.97,793.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE LCK MAND MINI 4HL 1MM STR UNIVERSAL NEURO II 2MM TI NS -,SUP-55-10504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,513.89,359.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE LCK MAND MINI 6HL 8MM STR UNIVERSAL NEURO II 2MM TI NS -,SUP-55-10507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.51,834.757,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE 10MM VUSION TS -,SUP-551-5210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE CRANFC MAND 4HL STR UNIVERSAL NEURO II RECON FX 2MM TI -,SUP-55-15505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1918.09,1342.663,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLT/FRACTURE 6 HOLES W. BAR -,SUP-55-15507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2440.83,1708.581,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE 10 X 9 X 25 -,SUP-551-7410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
INSERT TIB BEARING SZ2 9MM TRIATHLON X3 CR ARTCSURF -,SUP-5530-C-209,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BEARING TIB INSERT CS 9MM SZ1 TRIATHLON X3 -,SUP-5531-G-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BEARING TIB INSERT CS 10MM SZ 1TRIATHLON X3 -,SUP-5531-G-110-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BEARING TIB INSERT CS 11MM SZ 1 TRIATHLON X3 -,SUP-5531-G-111-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
INSERT TIBIAL BEARING  SZ. 5 / 11MM TYPE CS -,SUP-5531-G-511-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TIBIAL BEARING INSERT SZ.7 / CS / 11MM -,SUP-5531-G-711-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TIBIAL BEARING INSERT SZ.8 CS 9MM TRIATHLON X3 -,SUP-5531-G-809-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
9MM INSERT TRIAL PS#3 -,SUP-5532-T-309,CDM,C1713,HCPCS,278,RC,,,outpatient,,,728.5,509.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COMPONENT TIBIAL TRITANIUM SZ 1 TRIATHLON -,SUP-5536-B-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ORTHOFIX CROSSLINK 25 -,SUP-55-5325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CONNECTOR ROD FIREBIRD 45MM CROSSLINK ORTHOFIX -,SUP-55-5345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
4.5MM PERIPHERAL SCREW 16MM -,SUP-5572-4516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
4.5MM PERIPHERAL SCREW 24MM -,SUP-5572-4524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
4.5MM PERIPHERAL SCREW 36MM -,SUP-5572-4536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
6.5MM CENTER SCREW 32MM -,SUP-5573-6532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4573.49,3201.443,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX MODULAR TRIATH -,SUP-5575-X-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BONESCREW AXS ST 1.2 X 3MM 5P -,SUP-56-12003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BONESCREW - AXS ST 1.2 X 4MM 5P -,SUP-56-12004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BONESCREW AXS SD 1.2 X 3MM 5P -,SUP-56-12903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,636.37,445.459,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BONESCREW AXS SD 1.2 X 4MM 5P -,SUP-56-12904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,636.37,445.459,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE ER AXS ST 1.4 3MM 5P -,SUP-56-14003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,593.3,415.31,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BONESCREW AXS SD 1.7 X 4MM 5P -,SUP-56-17904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BONESCREW AXS SD 1.7 X 6MM 5P -,SUP-56-17906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GRAFT HUM TIS PTTY 1ML OSTEOSPARX SYR LF -,SUP-562-100-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X30MM CORT FT ST HEX HEAD -,SUP-5645-1-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X32MM CORT FT ST HEX HEAD -,SUP-5645-1-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X44MM CORT FT ST HEX HEAD -,SUP-5645-1-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X48MM CORT FT ST HEX HEAD -,SUP-5645-1-048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X50MM CORT FT ST HEX HEAD -,SUP-5645-1-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X52MM CORT FT ST HEX HEAD -,SUP-5645-1-052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X54MM CORT FT ST HEX HEAD -,SUP-5645-1-054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
STEM EXTENSION CEMENTED 12X30MM -,SUP-565-1203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
MESH HYBRID MEDIUM MALL 90 X 90 X .3 BLUE -,SUP-56-90344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7015.12,4910.584,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PROFYLE 0.55MM 1.2MM 4HL STD PRCONT NLCKG TI XS STR -,SUP-57-05101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE PRF 1.7 X 4 HL -,SUP-57-05202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE PRF 1.7 X 6 HL LT L -,SUP-57-05221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE HAND -,SUP-57-05240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE PRF 1.7 X 7 HL T -,SUP-57-05260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1028.42,719.894,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PROFYLE 0.55MM 1.7MM 1HL PRX2 STD PRCONT NLCKG TI -,SUP-57-05285,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1307.9,915.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE PRF 1.7 X 3 X 2 3D -,SUP-57-05291,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1307.9,915.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE PRF 1.7 X 4X2 RP 3D -,SUP-57-05295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1307.9,915.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE PRF 2.3 6 HL LT L -,SUP-57-10121,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2457.66,1720.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE PRF 2.3 X 6 HL NRW T -,SUP-57-10140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2457.66,1720.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PROFYLE 1MM 2.3MM 7HL SHFT PRCONT VAR ANG NLCKG TI -,SUP-57-10170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2457.66,1720.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE PRF 2.3 X 5HL ROT -,SUP-57-10185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2395.78,1677.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 1.5MM 1.7MM 10HL PRCONT VAR ANG TI SM NRW -,SUP-57-10310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 1.7 X 6 HL LT L -,SUP-57-10321,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 1MM 1.7MM 6HL PRCONT VAR ANG TI SM NRW T-SHP -,SUP-57-10340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 1.7 X 7 HL T -,SUP-57-10360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 1MM 1.7MM 5HL ROT PRCONT VAR ANG TI SM -,SUP-57-10380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 1MM 1.7MM HLX3X2 PRCONT VAR ANG TI SM 3D SHP -,SUP-57-10391,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PROFYLE 1MM 2.3MM 6HL PRCONT NLCKG COMPR TI MED STR -,SUP-57-10407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2921.69,2045.183,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PROFYLE 1MM 2.3MM 7HL PRCONT NLCKG COMPR TI MED Y -,SUP-57-10470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2921.69,2045.183,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PROFYLE 1.3MM 2.3MM 6HL SHFT PRCONT NLCKG COMPR TI -,SUP-57-13150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.06,784.742,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE HAND 2.3 LP 4 HOLE -,SUP-57-13402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PROFYLE 1.3MM 2.3MM 5HL PRCONT NLCKG COMPR TI LRG -,SUP-57-13405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PROFYLE 1.3MM 2.3MM 6HL PRCONT NLCKG COMPR TI LRG -,SUP-57-13408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE T 1O HOLE NARROW COMPRESSION -,SUP-57-13442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 1.5MM 2.3MM 4HL PRCONT VAR ANG TI MED STR -,SUP-57-15301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 1.5MM 2.3MM 4HL_PRCONT VAR ANG TI MED STR -,SUP-57-15302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 1.5MM 2.3MM 16HL PRCONT VAR ANG TI MED -,SUP-57-15316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 1.5MM 2.3MM 4HL PRCONT VAR ANG TI MED SMRTLC -,SUP-57-15340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 1.5MM 2.3MM 7HL PRCONT VAR ANG TI MED SMRTLC -,SUP-57-15370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE PROFYLE 2.3 X 13 HL NRWZ -,SUP-57-15379,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 1.5MM 2.3MM 5HL PRCONT VAR ANG TI MED SMRTLC -,SUP-57-15385,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.2X5MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12005E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.2X6MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.2X7MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12007E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.2X8MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.2X14MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX -,SUP-58-12014E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
MIDFOOT FUSION U-PLATE MD LT ORTHOLOC -,SUP-5817002L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5793.06,4055.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.7X8MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.7X9MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.7X10MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.7X11MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17011E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.7X12MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BONE SCREW 1.7 X 16MM STRYKER -,SUP-58-17016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE 2.3 X 6 -,SUP-58-23006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X8MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X9MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X10MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X11MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23011E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X12MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X13MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23013E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X14MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23014E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NL 2.3 X 15MM -,SUP-58-23015E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X16MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X20MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23020E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X24MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23024E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW EMERGENCY 2.5 X 6 -,SUP-58-25006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW EMERGENCY 2.5 X 8MM CROSSPIN LEFT -,SUP-58-25008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
MTP FUSIOIN MEDIUM 0DG RT ORTHOLOC 3DI PLATING SYSTEM -,SUP-587220RT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5046.12,3532.284,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING LG HD 2.7 X 12MM ORTHOLOC 3DI PLATING SYS -,SUP-58802712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING LG HD 2.7 14MM ORTHOLOCK 3DI PLATING SYS -,SUP-58802714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING LG HD  2.7 X 16MM ORTHOLOCK 3DI PLATING SYS -,SUP-58802716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOW PRO CORT 2.7 X 12MM ORTHOLOC SYS -,SUP-58812712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOW PRO CORT SCREW 2.7 X 14MM ORTHOLOC SYSTEM -,SUP-58812714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOW PRO CORT SCREW 2.7 X 16MM ORTHOLOC SYSTEM -,SUP-58812716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOW PRO CORT 2.7 X 18MM ORTHOLOC SYS -,SUP-58812718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOW PRO CORT SCREW 3.5 X 12MM ORTHOLOC SYSTEM -,SUP-58813512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOW PRO CORT SCREW 3.5 X 14MM ORTHOLOC SYSTEM -,SUP-58813514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOW PRO CORT SCREW 3.5 X 16MM ORTHOLOC SYSTEM -,SUP-58813516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NON LOCKING 3.5 X 18 -,SUP-58813518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOW-PRO CORT SCREW 3.5X22MM ORTHOLOC -,SUP-58813522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOW-PRO CORT SCREW 3.5X28MM ORTHOLOC -,SUP-58813528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOW-PRO CORT SCREW 3.5X34MM ORTHOLOC -,SUP-58813534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOW-PRO CORT SCREW 3.5X38MM ORTHOLOC -,SUP-58813538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WASHER ORTHO F/1.2MM SCR TI RND FLT HEAD NS -,SUP-59-12049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.24,105.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WASHER ORTHO F/1.7MM/1.9MM TI RND BN SCR TITIANIUM FLT EDGE -,SUP-59-17049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.24,105.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X10MM CORT PROFYLE ST CX PIN HD TI GOLD -,SUP-59-23010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 16MM -,SUP-59-23016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 18MM -,SUP-59-23018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 20MM -,SUP-59-23020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WASHER ORTHO F/2.3MM SCR TI RND FLT HEAD NS -,SUP-59-23049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.24,105.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 32.3MM COMPR OMEGA3 SS STRL -,SUP-596001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,329.09,230.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
STANDARD BARRELL HIP PLATE- 130DEG- 2 HOLES -,SUP-597002S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2817.14,1971.998,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN OMG 3 63MM 3HL STD BRL LCK COMPR SS 135DG ANG KY -,SUP-597023S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE HIP STD BARREL 4 HOLE KEYED 135DEG -,SUP-597024S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
HIP PLATE OMEGA 3 STD BARREL KEYED 135 DEG 6 HOLES -,SUP-597026S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE HIP STD BARREL 3 HOLE KEYED 140DEG -,SUP-597043S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE HIP STD BARREL 4 HOLE KEYED 145DEG -,SUP-597064S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE EXTFIX STD 47MM SS HIP 135DG ANG OMEGA3 KYLS BRL -,SUP-597122S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN OMG 3 79MM 4HL STD BRL LCK COMPR SS 135DG ANG KYLS -,SUP-597124S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN OMG 3 95MM 5HL STD BRL LCK COMPR SS 150DG ANG KYLS -,SUP-597185S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN OMG 3 79MM 4HL SHRT BRL LCK COMPR SS 135DG ANG KYLS -,SUP-597264S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2470.03,1729.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE ANT CERV 12MM BAK HOL CHMFR EDGE 8MM TI -,SUP-6000-0812-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DEVICE ANT CERV 12MM BAK/ C HOL CHMFR EDGE 10MM TI -,SUP-6000-1012-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GW ORTHO 2MM TOEMOTION MRH AXLE -,SUP-6007-1200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN DSTRCT 12MM ASSURE -,SUP-601.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ASNIS III CANN SCREW 5 X 28MM -,SUP-601628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS TI 5.0 X 30MM -,SUP-601630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ASNIS III CANN SCREW 5 X 32MM -,SUP-601632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS III CANN P/T 5.0MM X 42MM -,SUP-601642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS III CANN 5.0 X 44MM -,SUP-601644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE ASNIS PT 5 X 46 -,SUP-601646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS PT 5.0 X 48 -,SUP-601648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5MMX50MM CANN ASNIS III 17MM P/T SD/ST REVCT FLUT TI -,SUP-601650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5MMX55MM CANN ASNIS III 18.5MM P/T SD/ST REVCT FLUT TI -,SUP-601655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5MMX75MM CANN ASNIS III 27MM P/T SD/ST REVCT FLUT TI -,SUP-601675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5MMX80MM CANN ASNIS III 27MM P/T SD/ST REVCT FLUT TI -,SUP-601680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW FULLY THREADED 5MM X 38MM -,SUP-601738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW FULLY THREADED 5MM X 40MM -,SUP-601740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW FT 5MM X 42MM TITANIUM CANNULATED -,SUP-601742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS FT 5 X 44 -,SUP-601744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANNULATED 5 X 50 -,SUP-601750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANNULATED 5 X 55 -,SUP-601755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW FULLY THREADED 5 X 60 -,SUP-601760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANN HEADED 5.0 X 65MM ASNIS -,SUP-601765,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANNULATED 5MM X 70MM -,SUP-601770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANN TI 6.5 X 60MM -,SUP-602660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS TI TL20 6.5 X 65MM -,SUP-602665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANN TI 6.5 X 70MM -,SUP-602670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MMX75MM CANN ASNIS III 20MM THRD SD/ST HEX DRV -,SUP-602675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANN TI 6.5 X 80MM -,SUP-602680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MMX80MM CANN ASNIS III 20MM THRD SD/ST HEX DRV -,SUP-602680S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANN ASNIS TI 6.5 X 85MM -,SUP-602685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MMX90MM CANN ASNIS III 20MM THRD SD/ST HEX DRV NS -,SUP-602690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MMX90MM CANN ASNIS III 20MM THRD SD/ST HEX DRV STRL -,SUP-602690S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MMX95MM CANN ASNIS III 20MM THRD SD/ST HEX DRV NS -,SUP-602695,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MMX95MM CANN ASNIS III 20MM THRD SD/ST HEX DRV STRL -,SUP-602695S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MMX100MM CANN ASNIS III 20MM THRD SD/ST HEX DRV -,SUP-602700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW TI CANNULATED 6.5 X 105MM ASNIS -,SUP-602705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANNULATED TI 6.5X 110MM -,SUP-602710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS TI TL20 6.5 X 115 -,SUP-602715,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS TI TL40 6.5 X 60 -,SUP-602860,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS TI TL40 6.5 X 65 -,SUP-602865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS 6.5 X 70MM -,SUP-602870,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS TI TL40 6.5 X 75MM -,SUP-602875,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS TI CANNULATED 6.5 X 80MM -,SUP-602880,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS TI TL40 6.5 X 85 -,SUP-602885,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW TI 6.5 X 90MM ASNIS TL40 CANNULATED -,SUP-602890,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS TI TL40 6.5 X 95 -,SUP-602895,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS TI TL40 6.5 X 100 -,SUP-602900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS TI CANNULATED 6.5 X 105MM -,SUP-602905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX28MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE CAN TI 4.0 X 30MM -,SUP-604630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX32MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
4.0 X 34MM ASNIS CANN SCREW -,SUP-604634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX34MM CANN ASNIS III 11.5MM P/T SD/ST REVCT FLUT TI -,SUP-604634S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE CAN PT 4.0 X 36 -,SUP-604636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX38MM CANN ASNIS III -,SUP-604638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX40MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX40MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY -,SUP-604640S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX42MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX44MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX46MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE CAN PT 4.0 X 48 -,SUP-604648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX50MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX50MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY -,SUP-604650S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX55MM CANN ASNIS III 18.5MM P/T SD/ST REVCT FLUT TI -,SUP-604655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX55MM CANN ASNIS III 18.5MM.P/T SD/ST REVCT FLUT TI -,SUP-604655S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT TI- -,SUP-604660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT TI- -,SUP-604660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT TI_ -,SUP-604660S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX65MM CANN ASNIS III 22MM P/T SD/ST REVCT FLUT TI -,SUP-604665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX65MM CANN ASNIS III 22MM P/T SD/ST REVCT FLUT TI -,SUP-604665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX70MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX70MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY -,SUP-604670S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX40MM CANN ASNIS III FT SD/ST REVCT FLUT TI ALY NS -,SUP-604740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS III TI 4.0 X 42MM -,SUP-604742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANN FT 4.0 X 44MM -,SUP-604744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MMX50MM CANN ASNIS III FT SD/ST REVCT FLUT TI ALY NS -,SUP-604750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW TI SELF TAP CORTICAL 2.7MM X 22MM -,SUP-605022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.06,81.242,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW TI SELF TAP CORTICAL 2.7MM X 26MM -,SUP-605026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.06,81.242,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW TI SELF TAP CORTICAL 2.7MM X 28MM -,SUP-605028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.06,81.242,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW TI ASNIS III CANNULATED 6.5 X 85MM -,SUP-606085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 90 -,SUP-606090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 95 -,SUP-606095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANNULATED FULLY THREADED 6.5 X 100 -,SUP-606100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANNULATED FULLY THREADED 6.5 X 110 -,SUP-606110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANCELLOUS FT 4 X 14 -,SUP-607314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANCELLOUS FT 4.0 X 16 -,SUP-607316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X18MM CANC FT TI -,SUP-607318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANCELLOUS 4.0 X 20 -,SUP-607320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X22MM CANC FT TI -,SUP-607322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X24MM CANC FT TI -,SUP-607324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANCELLOUS 4.0 X 26MM -,SUP-607326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANCELLOUS 4.0 X 28MM -,SUP-607328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANCELLOUS 4.0 X 32MM -,SUP-607332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X34MM CANC FT TI -,SUP-607334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X36MM CANC FT TI -,SUP-607336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X38MM CANC FT TI -,SUP-607338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X40MM CANC FT TI -,SUP-607340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.0 X 42MM CANC FT TI -,SUP-607342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANN TI 4.0 X 48MM FULL -,SUP-607348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
4.0 CANCELLOUS SCREW 50MM FULLY THREADED -,SUP-607350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANCELLOUS 4.0 X 50MM -,SUP-607350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.0 X 55MM CANC FT TI -,SUP-607355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X60MM CANC FT TI -,SUP-607360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X65MM CANC FT TI -,SUP-607365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X70MM CANC FT TI -,SUP-607370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANCELLOUS FT 4.0 X 14MM STRYKER -,SUP-607414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANCELLOUS PT 4 X 16 -,SUP-607416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANCELLOUS PT 4 X 20 -,SUP-607420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X36MM CANC 16MM THRD TI -,SUP-607436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X38MM CANC 16MM THRD TI -,SUP-607438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X44MM CANC 16MM THRD TI -,SUP-607444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X46MM CANC 16MM THRD TI -,SUP-607446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X50MM CANC 16MM THRD TI -,SUP-607450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X65MM CANC 16MM THRD TI -,SUP-607465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X70MM CANC 16MM THRD TI -,SUP-607470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANC 6.0MM X 20MM  FULL THREAD -,SUP-608020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANCELLOUS 6 X 25 -,SUP-608025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CAN FT 6.0 X 35 -,SUP-608035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANCELLOUS 6.0 X 40MM -,SUP-608040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6X45MM CANC FT TI -,SUP-608045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.0MM X 50MM CANCELLOUS FULL THREAD -,SUP-608050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6X60MM CANC FT TI -,SUP-608060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL 3.5 X 60 FT -,SUP-608070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6X75MM CANC FT TI -,SUP-608075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6X80MM CANC FT TI -,SUP-608080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANCELLOUS FT 6.0 X 85 -,SUP-608085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CAN TL 16 6.0 X 35 -,SUP-608235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CAN TL 16 6.0 X 75 -,SUP-608275,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CAN TL 16 6.0 X 80 -,SUP-608280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANCELLOUS 6.0MM 90MM -,SUP-608290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6X70MM CANC 32MM THRD TI -,SUP-608470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6X80MM CANC 32MM THRD TI -,SUP-608480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6X85MM CANC 32MM THRD TI -,SUP-608485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6MM CANCELLOUS TI 6.0MM L90 TL32MM -,SUP-608490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,304.82,213.374,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS TI TL25 8.0 X 70MM -,SUP-611070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CANNULATED SCREW 8.0 X 75MM TI -,SUP-611075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
8.0 X 80MM TI CANNULATED SCREW -,SUP-611080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS TI TL25 8.0 X 85MM -,SUP-611085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ANSIS TI TL25 8.0 X 90MM -,SUP-611090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X8MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X12MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X14MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X16MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X18MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.7 X 20MM LOCKING SCREW -,SUP-614520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X22MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING T10 2.7 X 24MM -,SUP-614524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X26MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7 LOCKING ST 28 -,SUP-614528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X30MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7 LOCKING ST 34 -,SUP-614534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X36MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X38MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X40MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X55MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X60MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X8MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X10MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X12MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X14MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X16MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X18MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X20MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X22MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X24MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X26MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 3.5 X 28MM -,SUP-614628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X30MM LOCKING -,SUP-614630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X32MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
36MM 3.5 LOCKING SCREW -,SUP-614636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5 LCK ST 38 -,SUP-614638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5 X 40MM LOCKING -,SUP-614640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X42MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X44MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5 LCK ST 48 -,SUP-614648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X50MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE OLECRANON LEFT 8 HOLE -,SUP-614655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 3.5 X 55MM T10 -,SUP-614655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X60MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 3.5 X 65MM -,SUP-614665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 3.5 X 70MM -,SUP-614670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X8MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X12MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X14MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X16MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X18MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X20MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X22MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X24MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7 NON LOCKING ST 26 -,SUP-614726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X32MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614732,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X34MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X36MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X38MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X40MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7 NONLCK ST 44 -,SUP-614744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7 NONLOCKING ST 46 -,SUP-614746,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X55MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE T10 2.7 X 60MM -,SUP-614760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X8MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614808,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X10MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X12MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X14MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X16MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X18MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X20MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X22MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X24MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X26MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X28MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X30MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614830,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X32MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X34MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614834,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X36MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614836,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5 NONLCK ST 38 -,SUP-614838,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X40MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X42MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614842,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5 X 44 NONLOCK -,SUP-614844,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
46MM 3.5 SCREW -,SUP-614846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5 NONLOCK ST 46 -,SUP-614846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE 3.5 X 48MM NON-LOCK -,SUP-614848,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X50MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614850,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X60MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614860,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5 NONLOCK ST 65 -,SUP-614865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X70MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614870,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BONE CEMENT SIMPLEX -,SUP-6191-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,431.79,302.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CEMENT BONE SIMPLEX P -,SUP-6191-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BONE CEMENT SPEEDSET SIMPLEX P FULL DOSE -,SUP-6192-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,431.79,302.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CEMENT SIMPLEX SPEED SET -,SUP-6192-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CEMENT BONE SIMPLEX HV -,SUP-6194-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CEMENT BONE SIMPLEX GENTAMICIN -,SUP-6195-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CEMENT BONE SIMPLEX TOBRAMYCIN -,SUP-6197-9-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WASHER ORTHO ASNIS III F/6.5/8MM BN SCR TI RND -,SUP-619904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,157.55,110.285,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WASHER ORTHO ASNIS III 4MM TI RND -,SUP-619905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,122.54,85.778,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WASHER ORTHO 5MM ASNIS III 5MM TI RND -,SUP-619906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.64,107.548,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WASHER FOR 2.3MM BONE SCREWS -,SUP-619915,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.91,88.837,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
Washer T8 & T10 Scrws 2.4/2.7/3.5 -,SUP-619920,CDM,C1713,HCPCS,278,RC,,,outpatient,,,124.4,87.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WASHER 19 FOR SCREWS 6.5/8.0MM -,SUP-619990,CDM,C1713,HCPCS,278,RC,,,outpatient,,,882.25,617.575,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
STIMULAN 5CC -,SUP-620-005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
STIMULAN 10CC -,SUP-620-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SPIN 12MM ASPEN -,SUP-6201-0012-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN ASPEN 14MM -,SUP-6211-0014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,26874.69,18812.283,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 10HL TI -,SUP-621410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7788.16,5451.712,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLUG BONE H MED 25 -,SUP-6215-5-011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
MIS CALCANEAL PLATE S7 7 HOLES -,SUP-622102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
MIS CALCANEAL PLATE M8 8 HOLE -,SUP-622104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
INSERT 10 DEG POLYETHYLENE 32MM D TRIDENT X3 -,SUP-623-10-32D,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BONE SCREW 6.5X30 SELF-TAP -,SUP-6250-65-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ONE-THIRD TUBULAR PLATE 2 HOLE / L23MM -,SUP-626672,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1523.42,1066.394,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TUBULAR PLATE ONE-THIRD 4 HOLE -,SUP-626674,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ONE-THIRD TUBULAR PLATE 5 HOLE / L59MM -,SUP-626675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ONE-THIRD TUBULAR PLATE 6 HOLE / L71MM -,SUP-626676,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TUBULAR PLATE ONE-THIRD 6 HOLE -,SUP-626676S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ONE-THIRD TUBULAR PLATE 7 HOLE L83MM -,SUP-626677,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 8 HOLE -,SUP-626678,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE TUBULAR HOLE 9 -,SUP-626679,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2203.63,1542.541,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE TUBULAR HOLE 12 -,SUP-626682,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2203.63,1542.541,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE TUBULAR 16HL -,SUP-626686,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2746.15,1922.305,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE POLYAXIAL LKG TALO-NAVICULAR LONG T10 -,SUP-626762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4305.48,3013.836,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
VARIAX NAVICULAR PLATE -,SUP-626881,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4186.99,2930.893,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
POLYAXIAL LOCKING PLATE CUBOID (T8) -,SUP-626885,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.24,2762.368,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 3 HOLE SLIM -,SUP-626963,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5843.99,4090.793,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 6 HOLE SLIM -,SUP-626966,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5843.99,4090.793,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SLIM STRAIGHT 7 HOLE T8 -,SUP-626967,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5843.99,4090.793,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2 HOLE FOREFOOT PLATE -,SUP-626972,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BROAD 3 HOLE -,SUP-626973,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BROAD STRAIGHT PLATE 4 HOLE -,SUP-626974,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
5 HOLE FOREFOOT PLATE -,SUP-626975,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
6 HOLE BROAD Y-PLATE -,SUP-626976,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BROAD STRAIGHT T10 7 HOLE -,SUP-626977,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SLIM -,SUP-626982,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
3-HOLE 4-PLATE- SLIM -,SUP-626983,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE-Y 4 HOLE SLIM -,SUP-626984,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 5 HOLE SLIM Y -,SUP-626985,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BROAD Y PLATE 2 SHAFT HOLES -,SUP-626992,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BROAD Y PLATE 3 HOLE -,SUP-626993,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BROAD Y-PLATE- 3 SHAFT -,SUP-626993,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
STRYKER PLATE -,SUP-626994,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
VARIAX 2 FOREFOOT 5 HOLE PLATE -,SUP-626995,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BONE VARIAX BROAD Y 6 SHAFT HOLES T10 -,SUP-626996,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BROAD Y PLATE - 7 HOLES -,SUP-626997,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BROAD Y-PLATE- 7 SHAFT HOLES (T10) -,SUP-626997,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 3HL TI -,SUP-627203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
4 HOLE PLATE HUMERUS -,SUP-627204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 5-HOLE -,SUP-627205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE PROX LAT HUMERUS LEFT 6 HOLE L125MM -,SUP-627206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8796.54,6157.578,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE PROXIMAL LATERAL HUMERUS 8 HOLE -,SUP-627208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9123.11,6386.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 12 HOLE LEFT PROX LAT HUMERAL -,SUP-627212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9529.9,6670.93,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PROXIMAL LATERAL HUMERUS PLATE -,SUP-627216S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10146.77,7102.739,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 3 HOLE PROXIMAL LATERAL HUMERUS -,SUP-627233,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
4 HOLE PLATE RIGHT -,SUP-627234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BONE AXSOS 3 TI 6 HOLE HUMERUS RIGHT PROXIMAL LATERAL -,SUP-627236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8796.54,6157.578,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
8 HOLE PLATE STRYKER -,SUP-627238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9123.11,6386.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
10 HOLE PROXIMAL HUMERUS PLATE - RIGHT -,SUP-627240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9123.11,6386.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE HUMERUS 12 HOLE RIGHT PR -,SUP-627242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9529.9,6670.93,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PROXIMAL LATERAL HUMERUS PLATE FOR RIGHT HUMERUS 14 HOLE -,SUP-627244S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10146.77,7102.739,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2 HOLE PLATE LEFT TIBIA -,SUP-627302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7207.59,5045.313,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 121MM 4HL -,SUP-627304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7356.55,5149.585,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 147MM 6HL -,SUP-627306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7509.33,5256.531,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 8 HOLE PROX LATERAL FOR LEFT TIBIA L173MM -,SUP-627308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7658.3,5360.81,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE PROXIMAL LATERAL TIBIA FOR LEFT TIBIA 10 HOLE -,SUP-627310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8099.46,5669.622,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
AXSOS 3 TI PROX LAT TIBIA LEFT 12 HOLE PLATE -,SUP-627312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8414.58,5890.206,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 95MM 2HL F-SHP RT TIB -,SUP-627332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7207.59,5045.313,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 4HL -,SUP-627334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7356.55,5149.585,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE RIGHT HOLE 6 -,SUP-627336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8887.66,6221.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE PROXIMAL MEDIAL TIBIA 8 HOLE RIGHT -,SUP-627338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7658.3,5360.81,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 10 HOLE RIGHT PROX LATERAL TIBIA -,SUP-627340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8099.46,5669.622,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE RIGHT HOLE 12 -,SUP-627342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8252.25,5776.575,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE RIGHT HOLE 14 -,SUP-627344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8414.58,5890.206,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 6HL LT DIST -,SUP-627406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7102.55,4971.785,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE DIST RAD TIB 12 HOLE LFT -,SUP-627412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7996.33,5597.431,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 14HL TI -,SUP-627414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8206.41,5744.487,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN MED DST -,SUP-627434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6900.11,4830.077,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 6HL MDL/DIST RIGHT -,SUP-627436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7102.55,4971.785,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE DIST MED TIB 8HOLE RIGHT -,SUP-627438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7304.99,5113.493,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE DIST MEDIAL 10 HOLE RT -,SUP-627440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7788.16,5451.712,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE DIST MED LKD 12 HOLE RT -,SUP-627442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7996.33,5597.431,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 14 HOLE RIGHT DISTAL MEDICAL PLATE -,SUP-627444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8206.41,5744.487,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 4HL TI RT DIST -,SUP-627454,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.44,5926.508,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BONE AXSOS 3 TITANIUM 127 MM TIBIAL LEFT DISTAL -,SUP-627456,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7802.17,5461.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 8 HOLE LEFT ANTEROLATERAL -,SUP-627458,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7975.32,5582.724,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW DIST ANTERIORLATERAL TIBIA LFT 10HL 178MM -,SUP-627460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8370.53,5859.371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE TIBIA  14 HOLE LEFT L229MM DISTAL ANTEROLATERAL -,SUP-627464,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8724.98,6107.486,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 4 HOLE -,SUP-627484,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7631.05,5341.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 6 HOLE RIGHT ANT-LAT -,SUP-627486,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7802.17,5461.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE TIBIA DISTAL ANTEROLATERAL RIGHT 8 HOLE L153MM -,SUP-627488,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7975.32,5582.724,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE DISTAL ANTEROLAT TIBIA RIGHT 10 HOLE 178MM -,SUP-627490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8370.53,5859.371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE LKG COMP 11 HOLD L149MM X 4.0MM -,SUP-627511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5647.28,3953.096,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 12HOLE COMPRESSION -,SUP-627512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5647.28,3953.096,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 14 HOLE AXSOS STRAIGHT -,SUP-627514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5809.61,4066.727,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE LOCKING COMPRESSION 18 HOLE L240MM 4.0MM -,SUP-627518S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6099.9,4269.93,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 7 HOLE NARROW COMPRESSION -,SUP-627537,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6619.37,4633.559,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 8 HOLE NARROW COMPRESSION -,SUP-627538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.27,4961.089,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 9 HOLE NARROW -,SUP-627539,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.27,4961.089,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 10 HOLE STRAIGHT -,SUP-627540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7348.91,5144.237,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE STRAIGHT BROAD 9 HOLE COMPR 173 LENGTH -,SUP-627569,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.27,4961.089,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE STRAIGHT BROAD 10 HOLE COMPRESSION -,SUP-627570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7348.91,5144.237,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE LOCKING COMPRESSION BROAD 12 HOLE -,SUP-627572,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7348.91,5144.237,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 13 HOLE 5.0 COMPRESSION PLATE -,SUP-627573,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7518.88,5263.216,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BROAD 14 HOLE -,SUP-627574,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7518.88,5263.216,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DISTAL LATERAL FEMUR PLATE FOR LEFT FEMUR 4 HOLE -,SUP-627604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7824.24,5476.968,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 166MM 6HL LT DIST LAT FEM -,SUP-627606,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9329.8,6530.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 8HL LT -,SUP-627608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8189.22,5732.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 238MM 10HL LT DIST LAT FEM -,SUP-627610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8683.22,6078.254,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 12HL -,SUP-627612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8871.66,6210.162,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 343MM 16HL LT -,SUP-627616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9250.22,6475.154,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE DISTAL FEMUR -,SUP-627618S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9623.69,6736.583,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DISTAL LATERAL FEMUR 4 HOLE -,SUP-627634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7824.24,5476.968,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 166MM 6HL DIST LAT FEM -,SUP-627636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8009.28,5606.496,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE DISTAL LATERAL FEMUR -,SUP-627638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8189.22,5732.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 238MM 10HL RT DIST LAT FEM -,SUP-627640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8683.22,6078.254,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 274MM 12HL -,SUP-627642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8871.66,6210.162,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 343MM 16HL 1STRN/PK RT -,SUP-627646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9250.22,6475.154,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE AXSOS 3 TI DISTAL LAT FEMUR RT 18 HOLE L379MM -,SUP-627648S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9623.69,6736.583,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE TIBAL 4 HOLE LEFT/L71MM -,SUP-627704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.9,4447.73,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE MEDIAL PROXIMAL TIBIAL 5 HOLES LEFT -,SUP-627705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6560.16,4592.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE MEDIAL 6 HOLES STRYKER -,SUP-627706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6764.51,4735.157,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE PROX MED TIBIA FOR LEFT TIBIA 8HOLE L-123MM -,SUP-627708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6966.95,4876.865,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 14 HOLE PROX MEDIAL FOR LEFT TIBIA L201MM -,SUP-627714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7866.47,5506.529,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE PROXIMAL MEDIAL TIBIA FOR LEFT TIBIA 16 HOLE -,SUP-627716S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8278.98,5795.286,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOCKED TIBIAL PLATE -,SUP-627734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.9,4447.73,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE TIBIAL LATERAL 5 HOLE -,SUP-627735,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6560.16,4592.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PROXIMAL MEDIA TIBIA 97MM LENGTH -,SUP-627736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6764.51,4735.157,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE PROX MED TIB RT 6 HL -,SUP-627736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6764.51,4735.157,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE PROXIMAL MEDIAL TIBIA 8 HOLE RIGHT -,SUP-627738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8247.49,5773.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN AXSOS 10HL RT PROX MDL TIB COMPR -,SUP-627740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7438.67,5207.069,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PROXIMAL MEDIAL TIBIA PLATE FOR RT TIBIA 12 HOLE 175MM -,SUP-627742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7654.48,5358.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
INTERPROSTHETIC FEMUR PLATE RIGHT 334MM -,SUP-627846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,27813.56,19469.492,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DISTAL FEMUR PLATE RIGHT 280MM -,SUP-627863,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19576.64,13703.648,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
6 HOLE PLATE - LEFT -,SUP-628006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 88MM 7HL STD PRCONT VAR ANG TI ALY DECREASED -,SUP-628007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 99MM 8HL STD PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 122MM 10HL STD PRCONT VAR ANG TI ALY -,SUP-628010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SUPERIOR 7 HOLE RIGHT DECREASED -,SUP-628027,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE VARIAX 99MM CLAVICLE RIGHT SUPERIOR DECREASED 8 HOLE -,SUP-628028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 99MM 8HL STD PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 99MM 6HL BRDG PRCONT VAR ANG TI ALY LT CLVCL -,SUP-628046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 122MM 8HL BRDG PRCONT VAR ANG TI ALY -,SUP-628048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 99MM 6HL BRDG PRCONT VAR ANG TI ALY RT CLCVL -,SUP-628066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BRIDGE 8 HOLE SUPERIOR D -,SUP-628068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 8 HOLE STRYKER -,SUP-628108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 10 HOLE STRYKER -,SUP-628110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE CLAVICLE INC CURVED 8 HOLE -,SUP-628128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE CLAVICLE IC 10 HOLE -,SUP-628130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 6 HOLE BRIDGE -,SUP-628166,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SUPERIOR LATERAL PLATE - 3 HOLE / LEFT -,SUP-628203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 98MM 5HL PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SUPERIOR LATERAL PLATES -,SUP-628207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4698.11,3288.677,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 86MM 4HL PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE RIGHT LATERAL 5-HOLE #628225 -,SUP-628225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 7 HOLE LATERAL -,SUP-628227,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4698.11,3288.677,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 86MM 7HL PRCONT VAR ANG TI ALY UNIV SMRTLC -,SUP-628307,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 16MMX68MM PRCONT VAR ANG TI ALY LAT -,SUP-628525S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4480.35,3136.245,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
HOOK PLATE 7 HOLE 16MM RIGHT -,SUP-628537S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4480.35,3136.245,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DISTAL LATERAL HUMERUS PLATE 4 HOLE 109MM -,SUP-629204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 8 HOLE LEFT LATERAL -,SUP-629208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 3HL RT DIST LAT HUM COMPR -,SUP-629223S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE DISTAL LATERAL 4 HOLE 109MM -,SUP-629224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 12 HOLE RIGHT HUMERUS L203MM VARIAX DIST LATERAL -,SUP-629232S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE HUMERUS DIST POST LATERAL LEFT 3 HOLE -,SUP-629243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 105MM 4HL PRCONT VAR ANG LCK TI ALY NS LT -,SUP-629244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 128MM 6HL SHFT PRCONT VAR ANG LCK TI ALY NS -,SUP-629246,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 150MM 8HL PRCONT VAR ANG LCK TI ALY NS LT -,SUP-629248,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE DIST POST LATERAL HUMERUS 10 HOLE L173MM -,SUP-629250S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 105MM 4HL PRCONT VAR ANG LCK TI ALY NS RT -,SUP-629264,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 150MM 8HL PRCONT VAR ANG LCK TI ALY NS RT -,SUP-629268,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE HUMERUS DISTAL POSTERIOR LATERAL 12 HOLE -,SUP-629272S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE EXTENDED MEDIAL LEFT 3 HOLE -,SUP-629283,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 96MM 4HL PRCONT VAR ANG LCK TI ALY -,SUP-629284,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE DISTAL MEDIAL HUMERUS 6 HOLE EXTEND -,SUP-629286,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 104MM 4HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 151MM 8HL SHFT PRCONT VAR ANG LCK TI ALY NS -,SUP-629308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE DIST POST MEDIAL HUMERUS 12 HOLE L199MM -,SUP-629312S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DISTAL POSTERIOR MEDIAL HUMERUS PLATE FOR RT HUM 3 HOLE -,SUP-629323,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE DIST POST MDL RIGHT 4 -,SUP-629324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE DISTAL POSTERIOR MEDIAL 8 HOLE -,SUP-629328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE DIST POST MEDIAL HUMERUS 12 HOLE L199MM -,SUP-629332S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE OLECRARON LEFT 3 HOLE -,SUP-629343,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 89MM 4HL PRCONT VAR ANG LCK TI ALY NS LT -,SUP-629344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
3 HOLE RIGHT PLATE -,SUP-629363,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 89MM 4HL PRCONT VAR ANG LCK TI ALY NS RT -,SUP-629364,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 113MM 6HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629366,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 137MM 8HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629368,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE MEDIAL 3 HOLE -,SUP-629383,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 92MM 4HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629384,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 116MM 6HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629386,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 139MM 8HL LCK TI ALY NS -,SUP-629388,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE DISTAL MEDIAL HUMERUS LEFT 10HOLE 163MM -,SUP-629390S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE DISTAL MEDIAL HUMERUS 12 HOLE -,SUP-629392S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE COMPRESSION NARROW STRAIGHT 4 HOLES -,SUP-629504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1289.93,902.951,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE COMPRESSION NARROW STRAIGHT 5 HOLES -,SUP-629505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 6 HOLE COM PR NRW STR -,SUP-629506S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 7HL COMPR NRW STR -,SUP-629507S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX COMPR TI ALY NRW STR 629508S STRL -,SUP-629508S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE COMP 9 HOLE NARROW STR -,SUP-629509S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 10HL COMPR NRW STR -,SUP-629510S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE COMPRESSION NARROW STRAIGHT 12 HOLES -,SUP-629512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
14 HOLE NARROW COMPRESSION PLATE VARIAX -,SUP-629514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX COMPR TI ALY NRW STR 629527S STRL -,SUP-629527S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 7HL COMPR BRD STR -,SUP-629537S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COMPRESSION PLATE BROAD STRAIGHT 6 HOLES -,SUP-629546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 8HL COMPR NRW STR -,SUP-629548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COMPRESSION PLATE BROAD STRAIGHT 9 HOLES/L115MM -,SUP-629549S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2509.57,1756.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
VARIAX COMPRESSION PLATE BROAD CURVED 9 HOLES -,SUP-629559,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN VARIAX 8HL COMPR BRD CRV -,SUP-629560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE COMPRESSION BROAD CURVED 11 HOLES -,SUP-629561,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE COMP VARIAX BROAD CURVED 10 HOLES -,SUP-629562,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SHORT BEND -,SUP-629589,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8642.06,6049.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE PROFILE 2.0 4HOLE -,SUP-629604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1944.22,1360.954,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE PROFILE 2.0 X L33MM 6 HOLE -,SUP-629606,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1944.22,1360.954,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PROFILE PLATE 2.0 54MM -,SUP-629610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1944.22,1360.954,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PROFILE PLATE 2.0 L108MM 20HOLES -,SUP-629620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE NARROW LOCKING 2.0 4 HOLE -,SUP-629624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2488.21,1741.747,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE NARROW LOCK 2.0 L34MM 6 HOLES -,SUP-629626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2488.21,1741.747,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 8 HOLE NARROW -,SUP-629628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2488.21,1741.747,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 2.0MM BROAD LOCKING 6 HOLES STRAIGHT -,SUP-629646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BROAD LOCKING 2.0 / 10 HOLE -,SUP-629650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE PROFILE 8 HOLE 2.4 -,SUP-629666,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE PROFILE 2.4 8HOLE -,SUP-629668,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE VARIAX LOW PROFILE 2.4 X L66MM 10 HOLES -,SUP-629670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE NARROW LOCK 2.4 X L28MM 4 HOLE -,SUP-629684,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
6 HOLE NARROW PLATE -,SUP-629686,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 2.4MM 8 HOLE -,SUP-629688,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BONE VARIAX NARROW LOCK 2.4 L69MM 10 HOLE -,SUP-629690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 4 HOLE -,SUP-629704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BROAD LOCKING 2.4 6 HOLE -,SUP-629706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 8 HOLE STRAIGHT 2.4 -,SUP-629708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BONE VARIAX BROAD LOCK 2.4 L80MM 10HOLES -,SUP-629710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BROAD LOCKING 2.4 12 HOLE -,SUP-629712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 4 HOLE NARROW -,SUP-629724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 2.7 6 HOLE STRAIGHT -,SUP-629726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 8 HOLE -,SUP-629728,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 10 HOLE -,SUP-629730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE STRAIGHT 10 HOLE -,SUP-629740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BROAD LOCK 2.7 L39MM 4 HOLE -,SUP-629744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 2.7 6 HOLE -,SUP-629746,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BROAD LOCK 2.7 X 73MM 8HL -,SUP-629748,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
T-PLATE 2.7MM 3 X 10 -,SUP-629748,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BROAD LOCKING 2.7 10HOLE -,SUP-629750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 12 HOLE BROAD STRAIGHT -,SUP-629752,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3870.76,2709.532,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
T-PLATE NARROW LOCKING 2.0 2 X 5 HOLE -,SUP-629770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NARROW LOCK T-PLATE 2.0 L62MM 2X10HOLES -,SUP-629771,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2716.41,1901.487,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE NARROW LCK T 2.0 3X5 HOLE -,SUP-629772,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
T-PLATE 2.4MM NARROW LOCKING 2 X 5 -,SUP-629776,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
T-PLATE -,SUP-629777,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BONE VARIAX NARROW LOCK T-PLATE 2.4 L41MM 3X5 HOLES -,SUP-629778,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE T 2.4 NARROW -,SUP-629779,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE NARROW T 2.4 X L76MM 5X10 HOLES LKG -,SUP-629781,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE NARROW LOCKING T 5 HOLE -,SUP-629782,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 10 HOLE -,SUP-629783,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE AXSOS TITANIUM 5 HOLE -,SUP-629784,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE NARROW LOCKING T  2.7 X 87MM 10HOLE -,SUP-629785,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE T NARROW LOCK 2.7 L8 7MM X 5 X 10 HOLES -,SUP-629787,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 2.7 Y- PLATE -,SUP-629788,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4103.73,2872.611,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 2.7MM TRIANGLE -,SUP-629789,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4103.73,2872.611,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE Y 2.4MM -,SUP-629790,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE NARROW LOCK TRIANGLE 2.4 X 81MM 10 HOLE -,SUP-629791,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANTERIOR TT PLATE LEFT -,SUP-630101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10381.67,7267.169,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANTERIOR TT PLATE RIGHT -,SUP-630102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10381.67,7267.169,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
IMPLANT FLEXBLOCK -,SUP-6314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7031.8,4922.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN FX 38MM TRIATH HD F/T/K SYS -,SUP-6541-4-515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ABC IM ROD TRIATHLON INSTRUMENTS -,SUP-6541-4-516E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2213.49,1549.443,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN FX 19MM TRIATH HD F/T/K SYS -,SUP-6541-4-575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,327.34,229.138,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING T8 FULL THREAD 2.4 X 6 -,SUP-656006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING T8 FULL THREAD 2.4 X 7 -,SUP-656007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LCK T8 FULL THREAD 2.4X8 -,SUP-656008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING T8 FULL THREAD 2.4 X 10 -,SUP-656010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 2.4 X 11 -,SUP-656011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LCK T8 FII THRD 2.4 X 12 -,SUP-656012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING T8 FULL THREAD 2.4MM L14 -,SUP-656014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.4MM X 16MM LOCKING -,SUP-656016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING T8 FULL TRHEAD 2.4MM L 18MM -,SUP-656018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING T8 FULL THREAD 2.4 X 22 -,SUP-656022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING T8 FULL THREAD 2.4MM X 24MM -,SUP-656024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOCKING SCREW T8 FULL THREAD 2.4MM X 26MM -,SUP-656026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING T8 FULL THREAD 2.4 X 28 -,SUP-656028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING T8 FULL THREAD 2.4 X 30 -,SUP-656030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING T8 FULL THREAD 2.4 X 32 -,SUP-656032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING T8 FULL THREAD 2.4 X 34 -,SUP-656034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING T8 FULL THREAD 2.4 X 36 -,SUP-656036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 2.4MM X 38MM -,SUP-656038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN T8 FULL THREAD 2.4X6 -,SUP-656106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN T8 FULL THREAD 2.4X7 -,SUP-656107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN T8 FULL THREAD 2.4X8 -,SUP-656108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN T8 FULL THREAD 2.4X9 -,SUP-656109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN T8 FULL THREAD 2.4X12 -,SUP-656112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN T8 FULL THREAD 2.4X14 -,SUP-656114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.4 X 15 NL -,SUP-656115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN T8 FULL THREAD 2.4X18 -,SUP-656118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN T8 FULL THREAD 2.4X20 -,SUP-656120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN T8 FULL THREAD 2.4X24 -,SUP-656124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN T8 FULL THREAD 2.4X26 -,SUP-656126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN T8 FULL THREAD 2.4X28 -,SUP-656128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN T8 FULL THREAD 2.4X30 -,SUP-656130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN T8 FULL THREAD 2.4X32 -,SUP-656132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN T8 FULL THREAD 2.4X34 -,SUP-656134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN T8 FULL THREAD 2.4X36 -,SUP-656136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN T8 FULL THREAD 2.4X38 -,SUP-656138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE T8  2.4MM X L40MM NL -,SUP-656140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NON LOCKING 3.5 X 42 -,SUP-656142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NON LOCKING 3.5 X 44 -,SUP-656144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN T8 FULL THREAD 2.4X48 -,SUP-656148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN T8 FULL THREAD 2.4X50 -,SUP-656150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE VARIAX T8 2.4MM L55MM -,SUP-656155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN T8 FULL THREAD 2.4X60 -,SUP-656160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 2.7MM X 6MM -,SUP-656306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING T8 FULL THREAD 2.7 X 7 -,SUP-656307,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1150.21,805.147,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING T8 FULL THREAD 2.7X8 -,SUP-656308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 2.7MM X 9MM -,SUP-656309,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LCK T8 FULL THREAD 2.7X10 -,SUP-656310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LCK T8 2.7 X 11MM -,SUP-656311,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 2.7MM X 12MM -,SUP-656312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7 X 13 LOCKING -,SUP-656313,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 2.7MM X 14MM -,SUP-656314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LCK T8 2.7 X 15MM -,SUP-656315,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 2.7MM X 16MM -,SUP-656316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 2.7MM X 18MM -,SUP-656318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 2.7MM X 20MM -,SUP-656320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 2.7MM X 22MM -,SUP-656322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 2.7MM X 24MM -,SUP-656324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 2.7MM X 26MM -,SUP-656326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 2.7MM X 22MM -,SUP-656328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7 X 3 LOCKING -,SUP-656330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 2.7MM X 32MM -,SUP-656332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 2.7 X 34 -,SUP-656334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 2.7MM X 36MM -,SUP-656336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 2.7MM X 38MM -,SUP-656338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 2.7MM X 40MM -,SUP-656340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 2.7 X 42 -,SUP-656342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 2.7MM X 44MM -,SUP-656344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 2.7 X 45 -,SUP-656345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 2.7MM X 50MM -,SUP-656350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.7MM X 55MM LOCKING SCREW -,SUP-656355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE VARIAX T8 2.7MM  X  L 60MM LOCKING -,SUP-656360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 2.7 X 70 -,SUP-656370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE VARIAX T8 2.7MM X L 75MM LOCKING SCREW -,SUP-656375S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,694.95,486.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE VARIAX T8 2.7MM X L 80MM LOCKING -,SUP-656380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,694.95,486.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW T8 FULL THREAD NON LCK 2.7 X 6 -,SUP-656406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE VARIAX T8  7MM X 2.7MM -,SUP-656407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE T8 FULL THREAD 2.7MM X 9 -,SUP-656409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MM X 10MM NON LOCKING -,SUP-656410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE T8 2.7 X11MM -,SUP-656411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW N/L 2.7MM X 12MM -,SUP-656412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7 X 13 NL -,SUP-656413,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW N/L 2.7MM X 14MM -,SUP-656414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NON LOCKING 2.7 X 15 -,SUP-656415,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW N/L 2.7MM X 16MM -,SUP-656416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW N/L 2.7MM X 18MM -,SUP-656418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7 X 20MM NLCKG FT T8 STRDRV RCESS -,SUP-656420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NON-LOCKING 2.7MM X 22MM -,SUP-656422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NON LOCKING 2.7 X 26MM -,SUP-656426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.7MM NON LOCKING BONE SCREW 28MM -,SUP-656428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN T8 FLL THRD 2.7 X 30 -,SUP-656430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN T8 FLL THRD 2.7 X 32 -,SUP-656432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN T8 FLL THRD 2.7 X 34 -,SUP-656434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN T8 FLL THRD 2.7 X 36 -,SUP-656436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NON LOCKING 2.7 X 38 -,SUP-656438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE T8 FULL THREAD 2.7 X 40 -,SUP-656440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NON LOCKING 2.7 X 40 -,SUP-656440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NON LOCKING 2.7MM X 42MM -,SUP-656442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NON LOCKING 2.7 X 45 -,SUP-656445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NON LOCKING 2.7 X 46 -,SUP-656446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN T8 FLL THRD 2.7 X 48MM -,SUP-656448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7 X 50 NL -,SUP-656450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7 X 55 NL -,SUP-656455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NON LOCKING 2.7MM X 60MM -,SUP-656460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NON LOCKING 2.7MM X 65MM -,SUP-656465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NL 2.7 X 70 -,SUP-656470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE 2.7MM X 75MM T8 -,SUP-656475S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE VAIRAX T8 2.7MM X L 80MM -,SUP-656480S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING T10 FULL THREAD 2.7 X 8 -,SUP-657008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X12MM LCK FT T10 HX DRV -,SUP-657012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X14MM LCK FT T10 HX DRV -,SUP-657014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X16MM LCK FT T10 HX DRV -,SUP-657016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X20MM LCK FT T10 HX DRV -,SUP-657020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING T10 FULL 2.7 X 22 -,SUP-657022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING T10 FULL 2.7MM  X 22MM VARIAX -,SUP-657024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7 X 26 LOCKING -,SUP-657026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7 X 28 LOCKING -,SUP-657028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7 X 30 LOCKING -,SUP-657030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING T10 FULL 2.7 X 32 -,SUP-657032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOCKING SCREW T10 FULL THREAD 2.7MM L34MM -,SUP-657034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING T10 FULL 2.7 X 36 -,SUP-657036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7 X 38 LOCKING -,SUP-657038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MM X 40MM LOCKING -,SUP-657040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING T10 2.7 X 50 -,SUP-657050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING T10 2.7 X 55 -,SUP-657055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOCKING SCREW T10 FULL THREAD 2.7MM X 60MM -,SUP-657060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING T10 FULL THREAD 2.7 X 65 -,SUP-657065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING T10 FULL THREAD 2.7 X 70 -,SUP-657070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE T10 FULL THREAD 2.7 X 8 -,SUP-657108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X12MM FT T10 HX DRV -,SUP-657112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X14MM FT T10 HX DRV -,SUP-657114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X16MM FT T10 HX DRV -,SUP-657116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X18MM FT T10 HX DRV -,SUP-657118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X20MM FT T10 HX DRV -,SUP-657120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X22MM FT T10 HX DRV -,SUP-657122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE T10 FULL THREAD 2.7 X 26 -,SUP-657126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE T10 FULL THREAD 2.7 X 28 -,SUP-657128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
30MM BONE SCREW NONLOCKING 2.7MM -,SUP-657130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NL 2.7 X 32 -,SUP-657132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NL 2.7 X 34 -,SUP-657134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE T10 FULL THREAD 2.7MM /L36MM -,SUP-657136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NL 2.7 X 38 -,SUP-657138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE T10 FULL THREAD 2.7MM /L40MM -,SUP-657140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE T10 FULL THREAD 2.7MM /L42MM -,SUP-657142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE T10 FULL THREAD 2.7mm / L44mm -,SUP-657144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE T10 FULL THREAD 2.7MM /L46MM -,SUP-657146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE T10 FULL THREAD 2.7mm / L48mm -,SUP-657148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE T10 FULL THREAD 2.7MM /L50MM -,SUP-657150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE T10 FULL THREAD 2.7MM /L55MM -,SUP-657155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE T10 FULL THREAD 2.7MM /L60MM -,SUP-657160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE T10 FULL THREAD 2.7 X 65 -,SUP-657165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE T10 FULL THREAD 2.7 X 70 -,SUP-657170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING T10 FULL THREAD 3.5 X 8 -,SUP-657308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X10MM LCK FT T10 HX DRV -,SUP-657310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE 3.5MM 12MM VARIAX T10 FULL THREAD LOCK NONSTERILE -,SUP-657312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X14MM LCK FT T10 HX DRV -,SUP-657314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X16MM LCK FT T10 HX DRV -,SUP-657316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X18MM LCK FT T10 HX DRV -,SUP-657318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING T10 3.5MM / L20MM FULL THREAD -,SUP-657320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING T10 3.5MM / L22MM FULL THREAD -,SUP-657322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 3.5 X 22 -,SUP-657322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 3.5 X 24 -,SUP-657324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 3.5 X 26 -,SUP-657326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 3.5 X 30 -,SUP-657330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 3.5 X 32 -,SUP-657332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 3.5 X 34 -,SUP-657334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 3.5 X 38 -,SUP-657338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING T10 FULL THREAD 3.5 X 40 -,SUP-657340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING T10 FULL THREAD 3.5 X 42 -,SUP-657342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 3.5 X 44 -,SUP-657344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 3.5 X 46 -,SUP-657346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING T10FULL THREAD 3.5MM X 48MM -,SUP-657348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING T10 FULL THREAD 3.5MM X 50MM -,SUP-657350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING T10 FULL THREAD 3.5 X 60 -,SUP-657360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING T10 FULL THREAD 3.5 X 65 -,SUP-657365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING T10 FULL THREAD 3.5 X 70 -,SUP-657370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE T10 FULL THREAD 3.5 X 8 -,SUP-657408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE T10 FULL THREAD 3.5 X 8 -,SUP-657408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE T10 FULL THREAD 3.5MM /L10MM -,SUP-657410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MM X12MM NON LOCKING -,SUP-657412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5 NON LOCKING 12MM -,SUP-657412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X14MM FT T10 HX DRV -,SUP-657414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X16MM FT T10 HX DRV -,SUP-657416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X18MM FT T10 HX DRV -,SUP-657418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X20MM FT T10 HX DRV -,SUP-657420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NON-LOCKING 3.5 MM X 22 -,SUP-657422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5 NON LOCK FT 24MM -,SUP-657424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5 NON LOCK FT 26MM -,SUP-657426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MM NONLOCKING FT 28MM -,SUP-657428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MM NONLOCKING FT 30MM -,SUP-657430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
VARIAX 305MM NON LOCKING SCREW  32MM -,SUP-657432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
3.5MM NON-LOCKING SCREW 34MM -,SUP-657434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
3.5MM NON-LOCKING SCREW 36MM -,SUP-657436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE T10 FULL THREAD 3.5 X 38 -,SUP-657438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW  BONE T10 FULL THREAD NON LOCKING 3.5 X 40 -,SUP-657440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE T10 FULL THREAD 3.5MM X 42MM -,SUP-657442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
VARIAX 3.5MM NON LOCKING SCREW 44MM -,SUP-657444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BONE SCREW T10 FULL THREAD 3.5MM / L46MM -,SUP-657446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE T10FULL THREAD 3.5 X 48 -,SUP-657448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MM NONLOCKING FT 50MM -,SUP-657450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE T10 FULL THREAD 3.5 X 55 -,SUP-657455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE T10 FULL THREAD 3.5 X 60 -,SUP-657460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE T10 FULL THREAD 3.5 X 65 -,SUP-657465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE T10 FULL THREAD 3.5 X 70 -,SUP-657470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW VARIAX LOCKING T6 2.0MM L8MM -,SUP-657608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING T6 2.0MM L9MM -,SUP-657609,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW VARIAX LOCKING T6 2.0MM L10MM -,SUP-657610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING T6 2.0MM L11MM -,SUP-657611,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.0MM  X 12MM LOCKING -,SUP-657612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING T6 2 X 14MM -,SUP-657614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LCK T6 2.0 X 16MM -,SUP-657616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LCK T6 2.0 X 18MM -,SUP-657618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2-0MM LOCKING 20MM LENGTH -,SUP-657620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LCK T6 2.0 X 22MM -,SUP-657622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING T6 2.0 X 26MM -,SUP-657626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING VARIAX T6 2.0MM X L30MM -,SUP-657630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE 2.0M X L6MM T6 -,SUP-657706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NONLCK 2.0 X 10MM -,SUP-657710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2 X 11 -,SUP-657711,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.0MM X 12MM NON LOCKING -,SUP-657712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.0MM X 14MM NON LOCKING -,SUP-657714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2 X 16 -,SUP-657716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW VARIAX 2.0 X 18 -,SUP-657718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.9 NON LOCKING 20MM LENGTH -,SUP-657720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NON LOCKING 2 X 22 -,SUP-657722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE T6 2.0MM X L 24MM NON-LOCKING -,SUP-657724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE T6 2.0MM L26MM -,SUP-657726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.0MM NON LOCKING 28MM LENGTH -,SUP-657728,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE T6 2.0MM L30MM -,SUP-657730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE VARIAX T6 2.0MM X L34MM -,SUP-657734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NON LOCKING 2 X 36 -,SUP-657736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE VARIAX T6 2.0MM X L38MM -,SUP-657738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW FIXOS 4.0 30MM -,SUP-658030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEADLESS 4.0 FIXOS 38MM -,SUP-658038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
4.0 FIXOS 46MM SCREW -,SUP-658046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
4.0 FIXOS 48MM SCREW -,SUP-658048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEADLESS COMP. 7.0MM 50M -,SUP-658050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
4.0 FIXOS 55MM SCREW -,SUP-658055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEADLESS LONG THREAD 7.0 X 70MM -,SUP-658070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEADLESS COMP. 7.0MM 75M -,SUP-658075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
4.0 FIXOS SCREW 80MM -,SUP-658080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEADLESS 5 X 32 -,SUP-658132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW FIXOS 5.0 X 34MM -,SUP-658134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW FIXOS 5.0 X 36MM -,SUP-658136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
HEADLESS COMPRESSION SCREW 5MM X 38MM -,SUP-658138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
5.0 HEADLESS SCREW 44 MM -,SUP-658144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANNULATED 5.0 X 46MM FIXOS -,SUP-658146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
5.0 FIXOS 48MM SCREW -,SUP-658148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANNULATED 5.0 X 55MM FI -,SUP-658155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
HEADLESS COMPRESSION SCREW 5.0mm / L65mm -,SUP-658165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
HEADLESS COMPRESSION SCREW 5.0mm / L70mm -,SUP-658170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2402.19,1681.533,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW FIXOS 5 X 70MM -,SUP-658170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE FIXOS 5 X 75 -,SUP-658175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW FIXOS 5 X 80 -,SUP-658180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
HEADLESS COMPRESSION SCREW 7MM / L40MM ST -,SUP-658340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEADLESS COMP. 7.0MM 6.5 FIXOS -,SUP-658365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEADLESS COMP. 7.0MM 70M -,SUP-658370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEADLESS SHORT THREAD 7.0 X 75MM -,SUP-658375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEADLESS SHORT THREAD 7.0 X 90MM -,SUP-658390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEADLESS COMP. 7.0MM 12.5 FIXOS -,SUP-658425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
HEADLESS COMPRESSION SCREW 7MM / L65MM ST -,SUP-658565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEADLESS LONG THREAD 7.0 X 70MM -,SUP-658570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
HEADLESS COMPRESSION SCREW Ã˜7.0MM / L75MM LONG THREAD -,SUP-658575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7.0 FIXOS 80MM -,SUP-658580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
HEADLESS COMPRESSION SCREW 7MM X 85MM LONG THREAD -,SUP-658585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
HEADLESS COMPRESSION SCREW 7MM X25MM -,SUP-658625,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 8X20MM -,SUP-660H0820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 9X35MM -,SUP-660H0935,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X14MM LCK -,SUP-661014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X18MM LCK -,SUP-661018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X20MM LCK -,SUP-661020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X22MM LCK -,SUP-661022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X24MM LCK -,SUP-661024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X26MM LCK -,SUP-661026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X28MM LCK -,SUP-661028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X30MM LCK -,SUP-661030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X32MM LCK -,SUP-661032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X34MM LCK -,SUP-661034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X36MM LCK -,SUP-661036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X38MM LCK -,SUP-661038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X40MM LCK -,SUP-661040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1154.51,808.157,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X42MM LCK -,SUP-661042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X44MM LCK -,SUP-661044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X46MM LCK -,SUP-661046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X48MM LCK -,SUP-661048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X50MM LCK -,SUP-661050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCK 4.0 X 55MM -,SUP-661055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X60MM LCK -,SUP-661060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X65MM LCK -,SUP-661065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X70MM LCK -,SUP-661070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X75MM LCK -,SUP-661075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X80MM LCK -,SUP-661080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X85MM LCK -,SUP-661085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X90MM LCK -,SUP-661090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X95MM LCK -,SUP-661095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X14MM LCK -,SUP-661114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X16MM LCK -,SUP-661116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X18MM LCK -,SUP-661118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X20MM LCK -,SUP-661120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X22MM LCK -,SUP-661122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X24MM LCK -,SUP-661124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X26MM LCK -,SUP-661126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X28MM LCK -,SUP-661128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X30MM LCK -,SUP-661130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X32MM LCK -,SUP-661132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X34MM LCK -,SUP-661134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X36MM LCK -,SUP-661136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X38MM LCK -,SUP-661138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X40MM LCK -,SUP-661140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X42MM LCK -,SUP-661142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X44MM LCK -,SUP-661144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X46MM LCK -,SUP-661146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5 X 48MM LCK -,SUP-661148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X55MM LCK -,SUP-661155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X60MM LCK -,SUP-661160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,854.24,597.968,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X65MM LCK -,SUP-661165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X70MM LCK -,SUP-661170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X75MM LCK -,SUP-661175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X80MM LCK -,SUP-661180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X85MM LCK -,SUP-661185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X90MM LCK -,SUP-661190,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X95MM LCK -,SUP-661195,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOCKING SCREW FLAT TIP 5.0MM T20 L10MM -,SUP-661210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2630.74,1841.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOCKING SCREW FLAT TIP 5.0MM /T20 /L20 -,SUP-661220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2630.74,1841.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X8MM LCK ST PRPRSTHTC -,SUP-661308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 5.0 X 10MM PERIP -,SUP-661310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 5.0 X 12MM PERIP -,SUP-661312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X14MM LCK ST PRPRSTHTC -,SUP-661314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X16MM LCK ST PRPRSTHTC -,SUP-661316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X16MM PERI- LCK AXSOS -,SUP-661316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X18MM LCK ST PRPRSTHTC -,SUP-661318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X20MM LCK ST PRPRSTHTC -,SUP-661320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NON LOCKING 3.5 X 14MM -,SUP-661414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X18MM CORT TI -,SUP-661418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NON LOCKING 3.5 X 20MM -,SUP-661420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X22MM CORT TI -,SUP-661422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X24MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X26MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X28MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X30MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X32MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X34MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X36MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X38MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X40MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X42MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X44MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X46MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL 3.5 X 46 -,SUP-661447,CDM,C1713,HCPCS,278,RC,,,outpatient,,,239.99,167.993,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X48MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X50MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X55MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X65MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X70MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X75MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661475,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X80MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X85MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X90MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTEX 3.5MM X 120MM -,SUP-661520S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTEX TI 4.5 X 14MM -,SUP-661714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTEX SELF TAPPING 4.5 X 16 -,SUP-661716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORT 4.5 X 18 -,SUP-661718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL 4.5 X 20MM -,SUP-661720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X22MM CORT TI -,SUP-661722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORT 4.5 X 24 -,SUP-661724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORT 4.5 X 26 -,SUP-661726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORITCAL 4.5MM X 28MM -,SUP-661728,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X30MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X32MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661732,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X34MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X36MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X38MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X38MM LCK CORT VARIAX SELF TAPPING -,SUP-661738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X40MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X42MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X44MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X46MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661746,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X48MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661748,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X50MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X55MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X60MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X65MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661765,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X70MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X75MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661775,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X80MM CORT TI -,SUP-661780,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL 4.5 X 85 -,SUP-661785,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3MMX8IN ER CANC CORT VARIAX FT POLYAX ST T7 STRDRV -,SUP-661795,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CABLE PLUG 5.0MM -,SUP-662202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1868.43,1307.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOCKING SCREW 5.0MM /T20 / L24MM -,SUP-662324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOCKING SCREW 5.0MM /T20 /L30MM -,SUP-662330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOCKING SCREW 5.0MM /T20 / L40MM -,SUP-662340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOCKING SCREW 5.0MM T20 L46MM -,SUP-662346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOCKING SCREW 5.0MM T20 L50MM -,SUP-662350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOCKING SCREW 5.0MM T20 L60MM -,SUP-662360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOCKING SCREW 5.0MM /T20 / L65MM -,SUP-662365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOCKING SCREW 5.0MM T20 L70MM -,SUP-662370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOCKING SCREW 5.0MM /T20 / L75MM -,SUP-662375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOCKING SCREW 5.0MM /T20 /L80MM -,SUP-662380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LCK 1.7 X 5 -,SUP-662505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,497.14,347.998,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING T5 1.7MM X 9MM -,SUP-662509,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOCKING SCREW T5 1.7MM X 22MM -,SUP-662522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,497.14,347.998,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE 1.7 X 6 -,SUP-662606,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BONE SCREW T5 1.7MM X 8MM -,SUP-662608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE 1.7 X 9 -,SUP-662609,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.7 X 11 NON LOCKING -,SUP-662611,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.7 X 15 -,SUP-662615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.7 X 16 NL -,SUP-662616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.7 X 18 NL -,SUP-662618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW EMERGENCY 1.9 X 5 -,SUP-662705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW EMERGENCY T5 1.9MM/L12MM 12 HOLE LEFT -,SUP-662712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANNULATED 4.0MM X 38MM COMP -,SUP-663038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WASHER 5MM -,SUP-663101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,202.42,141.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW JFX CANNULATED 5 X 46MM -,SUP-663146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IMPCTR HD XTRCT SHRT 3.2X19MM DURACN -,SUP-6633-7-615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,376.53,263.571,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SOLID COMPRESSION 4.0MM X 36MM L -,SUP-663436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SOLID COMPRESSION 4.0MM X 38MM -,SUP-663438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COMPRESSION SCREW SOLID A 4.0MM/ L40MM -,SUP-663440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SOLID COMPRESSION 4 X 22 -,SUP-663442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
4.0 SOLID COMPRESSION SCREW 48MM -,SUP-663448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SOLID COMPRESSION 4.0MM X L50MM -,SUP-663450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.32,2719.724,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SOLID COMPRESSION 5.0MM X 36MM L -,SUP-663536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SOLID COMP 5MM X 40MM -,SUP-663540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW COMPRESSION 5 X 42 -,SUP-663542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
5.0MM L 44MM COMPRESSION SCREW -,SUP-663544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COMPRESSION SCREW 5.0MM -,SUP-663546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5 X 48 MM SOLID -,SUP-663548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SOLID COMPRESSION 5.0MM X L50MM -,SUP-663550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 2.3MM X 16MM -,SUP-663716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,498.89,349.223,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 2.3MM X 18MM -,SUP-663718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,498.89,349.223,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE 2.3 X 8 -,SUP-663808,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE 2.3  X 9 -,SUP-663809,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE 2.3 X 10 -,SUP-663810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NON LOCKING 2.3MM X 13MM -,SUP-663813,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NON-LOCKING 2.3MM 16MM -,SUP-663816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE 2.3 X 20 -,SUP-663820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW EMERGENCY  2.5 X 6 -,SUP-663906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW EMERGENCY 2.5 X 8 -,SUP-663908,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CORTEX SCREW DIA 4.0MM L38MM -,SUP-666138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CANLTD SCRW 16MM THREAD DIA 6.5MM L45MM -,SUP-666445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CANLTD SCREW 16MM THREAD DIA 6.5MM L50MM -,SUP-666450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CANLTD SCREW 16MM THREAD DIA 6.5MM L65MM -,SUP-666465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANNULATED 6.5 X 70 -,SUP-666470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANNULATED 6.5 X 80 -,SUP-666480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANNULATED 6.5 X 85 -,SUP-666485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER MOLD LG FEMORAL 53A/P X 75M/L -,SUP-669-1075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6663.08,4664.156,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GRIP CBL 1.6MM DLMLS VITAL -,SUP-6704-0-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3931.1,2751.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CABLE ORTHO 1.6MM DLMLS VITAL MED GRP + 2 -,SUP-6704-0-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3931.1,2751.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GRIP LARGE W/2 CABLES DALL MIL -,SUP-6704-0-310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3931.1,2751.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CABLE ORTHO DLMLS 1.6MM VITAL BEAD SM SLV -,SUP-6704-0-420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CABLE ORTHO DLMLS 2MM VITAL MED SLV -,SUP-6704-0-510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DALL-MILES 2.0MM VIT BEADED CABLE/SLEEVE SET -,SUP-6704-0-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SET CABLE SLEEVE BEADED  2.0 D -,SUP-6704-0-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN DLMLS 100MM GRP VITAL MED 2MM CBLX2 -,SUP-6704-3-081,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4408.24,3085.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN DLMLS 150MM GRP VITAL MED 2MM CBLX2 -,SUP-6704-3-082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5744.68,4021.276,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE TROC DLMLS 110MM GRP LRG W/2 CBS -,SUP-6704-3-091,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4408.24,3085.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN DLMLS 160MM GRP VITAL LRG 2MM CBLX2 -,SUP-6704-3-092,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5744.68,4021.276,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CENTURION 3.5 X 12 -,SUP-69-3312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CENTURION 3.5 X 18 -,SUP-69-3318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CENTURION 3.5 X 12 -,SUP-69-3412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CENTURION 4.0 X 14 -,SUP-69-3414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CENTURION 4.0 X 30 -,SUP-69-3430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CENTURION 4.5 X 30 -,SUP-69-3530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CENTURION 5.0 X 30 -,SUP-69-3630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
STAPLE INTNL 12X23MM VITAL ELLISON LF -,SUP-6982-1-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1703.05,1192.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
STAPLE INTNL 14X23MM VITAL ELLISON LF -,SUP-6982-2-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1602.87,1122.009,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GRAFT BONE I FACTOR 2.5CC ALLOGRAFT PUTTY SYRINGE -,SUP-700-025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 8HL STR -,SUP-70-0095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 8HL STR -,SUP-70-0096,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 3.5MM 9HL LCK TI NS RT -,SUP-70-0116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.27,4447.289,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 3.5MM 9HL LCK TI NS LT -,SUP-70-0117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.27,4447.289,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 2.3MM 16HL LCK TI NS -,SUP-70-0124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6989.87,4892.909,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 2.3MM 13HL LCK TI NS -,SUP-70-0126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.27,4447.289,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 8HL LT CLAV LPRO TI STR NS -,SUP-70-0286,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 8HL RT CLAV LPRO TI STR NS -,SUP-70-0287,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN F/ELB PLATE SYS 8HL LCK TI LRG NS -,SUP-70-0289,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN F/ELB PLATE SYS 10HL LCK TI NS -,SUP-70-0294,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN F/ELB PLATE SYS 6HL LCK TI NS LT CLVCL -,SUP-70-0296,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN F/ELB PLATE SYS 6HL LCK TI NS RT CLVCL -,SUP-70-0297,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 8HL LT CLAV NRW-PRFL TI STR NS -,SUP-70-0298,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 8HL RT CLAV NRW-PRFL TI STR NS -,SUP-70-0299,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 8HL CONTR LCK TI LRG NS LT -,SUP-70-0300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 8HL CONTR LCK TI LRG NS RT -,SUP-70-0301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 65MM 3HL CONTR LCK TI STD NS -,SUP-70-0302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6535.76,4575.032,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 110MM 7HL CONTR LCK TI STD NS -,SUP-70-0306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7414.27,5189.989,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 90MM 5HL TAP-LCK TI EXTEND NS -,SUP-70-0313,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6535.76,4575.032,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEPIN ORTHO 2MM ASNIS III THRD -,SUP-7007-1300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
K-WIRE ASNIS III 3.2 -,SUP-702463S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,505.08,353.556,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
IRON BENDING -,SUP-702901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.85,795.795,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
AXSOS 5.0 ADAPTOR NUT -,SUP-702977,CDM,C1713,HCPCS,278,RC,,,outpatient,,,559.11,391.377,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOW PROFILE HEX 6.5 X 15 -,SUP-7030-6515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEX LOW PROFILE 6.5MM X 20MM -,SUP-7030-6520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MM LOW PROFILE HEX -,SUP-7030-6525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEX 6.5MM X 30MM LOW PROFILE -,SUP-7030-6530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEX 6.5MM X 35MM LOW PROFILE -,SUP-7030-6535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
6.5x40MM LOW PROFILE HEX SCREW -,SUP-7030-6540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
6.5X45MM LOW PROFILE HEX SCREW -,SUP-7030-6545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
6.5x50MM LOW PROFILE HEX SCREW -,SUP-7030-6550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOW PROFILE HEX 6.5MM x 55MM -,SUP-7030-6555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
IMPLANT HIP 7X35MM POR TI PLASM SPRY SCRILAC IFUSE STRL -,SUP-7035-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDE WIRE WITH CALIBRATION 3.2MM X 230MM QUICK RELEASE -,SUP-705237,CDM,C1713,HCPCS,278,RC,,,outpatient,,,606.84,424.788,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ELEVATOR PERIOSTEAL 6MM ROUND EDGE -,SUP-705294,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1361.01,952.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
IMPLANT HIP 7X65MM POR TI PLASM SPRY SCRILAC IFUSE STRL -,SUP-7065-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN EXTFIX 3X120MM 16MM THRD COVE PNT -,SUP-71022001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN EXTFIX 3X120MM 22MM THRD COVE PNT -,SUP-71022002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN EXTFIX 3X120MM 28MM THRD COVE PNT -,SUP-71022003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X70MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X80MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X85MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X95MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X110MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X130MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 58MM 3.5MM 5HL RECON STR -,SUP-71140105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4158.44,2910.908,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 70MM 3.5MM 6HL RECON STR -,SUP-71140106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4651.85,3256.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 82MM 3.5MM 7HL RECON STR -,SUP-71140107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4446.01,3112.207,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 94MM 3.5MM 8HL RECON STR -,SUP-71140108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5084.1,3558.87,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 75MM 3.5MM 6HL SM T-SHP RT ANG -,SUP-71140406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2349.66,1644.762,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WASHER ORTHO 3.7X7MM SS -,SUP-71143107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,441.48,309.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 87MM 9HL Y STRL TMPLT -,SUP-71144012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7101.27,4970.889,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TROCAR PIN GEN 1/8 X 3 -,SUP-71210002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.63,108.241,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEPIN ORTHO 3MM GENESIS 12.5CM TROC TIP -,SUP-71210003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.63,108.241,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MM MINI 16MM CORT TC-100 FT HEX HEAD SS -,SUP-71220016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,359.67,251.769,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 15MM REF SPHER HEAD -,SUP-71332515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,811.07,567.749,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 20MM REF SPER HEAD -,SUP-71332520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,811.07,567.749,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CABLE ORTHO 2MM ACCORD COCR -,SUP-71340020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,977.36,684.152,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
INSERT PS LGN XLPE SZ 3-4 11MM -,SUP-71453247,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4520.12,3164.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ENDCAP ORTHO 0MM TRIGEN STRL -,SUP-71634000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2293.1,1605.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ENDCAP PROT 5MM TI STRL TRIGEN F/OB GYNAECOLOGICAL PROC TIB -,SUP-71634005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2293.1,1605.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ENDCAP ORTHO 20MM TRIGEN STRL -,SUP-71634020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2293.1,1605.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX25MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2401.07,1680.749,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX30MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX35MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642135,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX40MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX45MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX55MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MMX65MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5MMX20MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5MMX25MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5MMX35MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5MMX50MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5MMX60MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5MMX65MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642265,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5MMX75MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642275,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X35MM TRIGEN -,SUP-71645035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X45MM TRIGEN -,SUP-71645045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10X380MM TRIGEN TAN CANN LT TROCH FEM TI ALY ANTGRD -,SUP-71647238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15450.91,10815.637,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11.5X380MM TRIGEN TAN CANN LT TROCH FEM TI ALY -,SUP-71647338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15450.91,10815.637,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10X320MM TRIGEN META-NAIL CANN DIST FEM TI ALY RTRGD -,SUP-71653032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14208.35,9945.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 8.5X330MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655033,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 8.5X340MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 8.5X350MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10X280MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10X290MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655129,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10MMX30CM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10X310MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655131,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10X320MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10X340MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10X350MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655135,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10MMX37CM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655137,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11.5X300MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11.5X360MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11.5X390MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655239,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11.5MMX40CM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEPIN ORTHO 3.2MM TRIGEN 343MM THRD BRAD TIP -,SUP-71674130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1491.03,1043.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10X180MM TRIGEN INTERTAN 1.5 CANN TROCH FEM TI 125DG -,SUP-71675201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11.5X180MM TRIGEN INTERTAN 1.5 CANN TROCH FEM TI -,SUP-71675202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 13X180MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11.5X200MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 13X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10X180MM TRIGEN INTERTAN 1.5 CANN TROCH FEM TI 130DG -,SUP-71675207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11.5MM 180MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP -,SUP-71675208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 13X180MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71675209,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71675210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10X320MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP -,SUP-71675219,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10MMX32CM TRIGEN INTERTAN 1.5 CANN INTST HIP TI -,SUP-71675220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675222,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CAN LT INTS HIP TI LIME -,SUP-71675223,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI125 -,SUP-71675224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10X380MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10X400MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP -,SUP-71675227,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11.5X320MM TRIGEN INTERTAN 1.5 CANN RT INTS HIP TI.. -,SUP-71675242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71675244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11.5X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675245,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71675246,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI_ -,SUP-71675250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11.5X420MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675251,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI130 -,SUP-71675268,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 13X280MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 13X320MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 13MMX32CM TRIGEN INTERTAN 1.5 CANN INTST HIP TI -,SUP-71675408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 13X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 13X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 13X180MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71675412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 13X380MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675413,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 13X400MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675415,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 13X400MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 13X440MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10X320MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71676507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TIRSE -,SUP-71676510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71676511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676513,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10X380MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11.5X320MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI- -,SUP-71676552,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTS HIP TI.. -,SUP-71676553,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI- -,SUP-71676554,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11.5MMX36CM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71676555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11.5X360MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11.5X380MM TRIGEN INTERTAN 1.5 CANN LT INTST TI -,SUP-71676557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11.5MMX38CM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71676558,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11.5X400MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 13X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71676598,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 13X360MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 13X380MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71676602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 70MM/75MM -,SUP-71677075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 75MM/80MM -,SUP-71677080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 80MM/85MM -,SUP-71677085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 85MM/90MM -,SUP-71677090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 90MM/95MM -,SUP-71677095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI_ -,SUP-71677100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI- -,SUP-71677105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI.. -,SUP-71677110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI. -,SUP-71677115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 11MM TRIGEN INTERTAN LAG 100MM -,SUP-71678010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 11X110MM LAG TRIGEN INTERTAN -,SUP-71678011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 11X115MM TRIGEN INTERTAN SBTRCHNTRC TI -,SUP-71678015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 11MM TRIGEN INTERTAN LAG 85MM -,SUP-71678085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 11MM TRIGEN INTERTAN LAG 90MM -,SUP-71678090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 11MM TRIGEN INTERTAN LAG 95MM -,SUP-71678095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEPIN ORTHO 3.2MMX24.8CM THRD DRILL TIP -,SUP-71751147,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X20MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X22MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X24MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X30MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X24MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X26MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X30MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X32MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X34MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X36MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X38MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X40MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X42MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X44MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X46MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 8/ 7MMLNGX260MM TRIGEN CANN PROX HUM TI ALY -,SUP-71770826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 9/ 7.5MMLNGX240MM TRIGEN CANN PROX HUM TI ALY -,SUP-71770924,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10/ 8.5MMLNGX220MM TRIGEN CANN PROX HUM TI ALY -,SUP-71771022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10/ 8.5MMLNGX240MM TRIGEN CANN PROX HUM TI ALY -,SUP-71771024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 10/ 8.5MMLNGX280MM TRIGEN CANN PROX HUM TI ALY -,SUP-71771028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC 193MM 4.5MM 8HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16207.25,11345.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC 286MM 4.5MM 13HL CONTR SCALLP LCK SS BVL LT -,SUP-71800013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17251.71,12076.197,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC 342MM 4.5MM 16HL CONTR SCALLP LCK SS BVL LT -,SUP-71800016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17575.86,12303.102,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC 193MM 4.5MM 8HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16207.25,11345.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC 342MM 4.5MM 16HL CONTR SCALLP LCK SS BVL RT -,SUP-71800116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17575.86,12303.102,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC 94MM 4.5MM 4HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17341.75,12139.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC 130MM 4.5MM 6HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17575.86,12303.102,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 93MM 4.5MM 3HL CONTR SCALLP LCK BVL TIP -,SUP-71801603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17053.62,11937.534,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X10MM CORT PERILOC ST SS -,SUP-71804010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X12MM CORT PERILOC ST SS -,SUP-71804012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X14MM CORT PERILOC ST SS -,SUP-71804014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X16MM CORT PERILOC ST SS -,SUP-71804016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X18MM CORT PERILOC ST SS -,SUP-71804018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X20MM CORT PERILOC ST SS -,SUP-71804020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X24MM CORT PERILOC ST SS -,SUP-71804024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X32MM CORT PERILOC ST SS -,SUP-71804032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X34MM CORT PERILOC ST SS -,SUP-71804034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X36MM CORT PERILOC ST SS -,SUP-71804036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X38MM CORT PERILOC ST SS -,SUP-71804038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X40MM CORT PERILOC ST SS -,SUP-71804040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X50MM CORT PERILOC ST SS -,SUP-71804050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X55MM CORT PERILOC ST SS -,SUP-71804055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X60MM CORT PERILOC ST SS -,SUP-71804060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X12MM LCK CORT PERILOC ST SS -,SUP-71805012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1866.36,1306.452,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X20MM LCK CORT PERILOC ST SS -,SUP-71805020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1866.36,1306.452,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X14MM CANC PERILOC FT SS -,SUP-71805214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,496.09,347.263,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X36MM CORT PERILOC ST SS -,SUP-71806036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X38MM CORT PERILOC ST SS -,SUP-71806038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X40MM CORT PERILOC ST SS -,SUP-71806040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X42MM NLCKG CORT PERILOC ST SS -,SUP-71806042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X46MM NLCKG CORT PERILOC ST SS -,SUP-71806046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X50MM NLCKG CORT PERILOC ST SS -,SUP-71806050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X70MM NLCKG CORT PERILOC ST SS -,SUP-71806070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X32MM LCK CORT PERILOC ST SS -,SUP-71807032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X34MM LCK CORT PERILOC ST SS PERIART -,SUP-71807034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X36MM LCK CORT PERILOC ST SS PERIART -,SUP-71807036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X38MM LCK CORT PERILOC ST SS -,SUP-71807038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X48MM LCK CORT PERILOC ST SS -,SUP-71807048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X56MM LCK CORT PERILOC ST SS -,SUP-71807056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X58MM LCK CORT PERILOC ST SS -,SUP-71807058,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X60MM LCK CORT PERILOC ST SS PERIART -,SUP-71807060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X74MM LCK CORT PERILOC ST SS -,SUP-71807074,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.7X65MM LCK CANN PERILOC FT SS -,SUP-71808065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC 193MM 4.5MM 13HL CONTR SCALLP LCK SS BVL -,SUP-71820008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12497.59,8748.313,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 230MM 4.5MM 10HL CONTR SCALLP LCK SS BVL TIP -,SUP-71820010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12767.71,8937.397,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC 98MM 3.5MM 6HL CONTR SCALLP LCK SS BVL TIP -,SUP-71820506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13524.05,9466.835,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 196MM 3.5MM 10HL CONTR SCALLP LCK BVL TIP -,SUP-71821010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15522.94,10866.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X34MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X36MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X40MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X50MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X55MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X60MM LCK PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG -,SUP-71821160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX6MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
RETRACTOR EYELID DSMRS 1.12MMX5.5IN STN FNSH LID V. MUELLER -,SUP-71821208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
RETRACTOR LNG ALLISON 12.25IN 2.125IN BLD SS F/CV V. MUELLER -,SUP-71821210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX12MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX14MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX16MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX18MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821218,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX22MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821222,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX24MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX26MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821226,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX28MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX30MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX34MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX36MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX40MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC 89MM 3.5MM 3HL CONTR LCK SS BVL TIP -,SUP-71821303,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14982.7,10487.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX6MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM STD -,SUP-71821306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX8MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM STD -,SUP-71821308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX10MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX12MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX14MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX16MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX18MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX20MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX22MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX24MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX26MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX28MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX32MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX34MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX36MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX38MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX40MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX44MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX46MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX50MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC 89MM 3.5MM 3HL CONTR LCK SS BVL TIP NS -,SUP-71821403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14982.7,10487.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC 115MM 3.5MM 5HL CONTR LCK SS BVL TIP -,SUP-71821405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15414.89,10790.423,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC 79MM 2.7/3.5MM 5HL CONTR LCK SS BVL TIP -,SUP-71821805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11921.33,8344.931,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5MMX10MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5MMX12MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5MMX14MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5MMX16MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX18MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5MMX20MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5MMX38MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX40MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X10MM LCK CORT PERILOC FT ST SS NS -,SUP-71822310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X12MM LCK CORT PERILOC FT ST SS NS -,SUP-71822312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X14MM LCK CORT PERILOC FT ST SS NS -,SUP-71822314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X16MM LCK CORT PERILOC FT ST SS NS -,SUP-71822316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X18MM LCK CORT PERILOC FT ST SS NS -,SUP-71822318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X20MM LCK CORT PERILOC FT ST SS NS -,SUP-71822320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X24MM LCK CORT PERILOC FT ST SS NS -,SUP-71822324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X28MM LCK CORT PERILOC FT ST SS NS -,SUP-71822328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X30MM LCK CORT PERILOC FT ST SS NS -,SUP-71822330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X36MM LCK CORT PERILOC FT ST SS NS -,SUP-71822336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X40MM LCK CORT PERILOC FT ST SS NS -,SUP-71822340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X45MM LCK CORT PERILOC FT ST SS NS -,SUP-71822345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X50MM LCK CORT PERILOC FT ST SS NS -,SUP-71822350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X60MM LCK CORT PERILOC FT ST SS NS -,SUP-71822360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1413.91,989.737,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5X10MM LCK CORT PERILOC FT ST SS -,SUP-71822410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5X12MM LCK CORT PERILOC FT ST SS -,SUP-71822412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5X14MM LCK CORT PERILOC FT ST SS -,SUP-71822414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5X16MM LCK CORT PERILOC FT ST SS -,SUP-71822416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5X18MM LCK CORT PERILOC FT ST SS -,SUP-71822418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5X20MM LCK CORT PERILOC FT ST SS -,SUP-71822420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5X22MM LCK CORT PERILOC FT ST SS -,SUP-71822422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5X24MM LCK CORT PERILOC FT ST SS -,SUP-71822424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5X26MM LCK CORT PERILOC FT ST SS -,SUP-71822426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 153MM 2.7MM 11HL CONTR SS BVL TIP -,SUP-71822511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14982.7,10487.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC 80MM 2.7/3.5MM 5HL CONTR LCK SS BVL TIP -,SUP-71822705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12245.47,8571.829,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC 81MM 6HL LCK SS CORNL BND -,SUP-71822906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14406.44,10084.508,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC 107MM 8HL LCK SS CORNL BND -,SUP-71822908,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15522.94,10866.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MMX10MM LCK CORT PERILOC VLP ST VAR ANG CP 2.5MM -,SUP-71823010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MMX12MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MMX14MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MMX16MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MMX18MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DIRECTOR ORAL NO. 2522 7.25IN V. MUELLER SS GZE LIG TUCKER -,SUP-71823020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MMX22MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MMX24MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MMX26MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MMX30MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MMX40MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MMX45MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MMX50MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MMX55MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7MMX60MM LCK CORT PERILOC VLP ST FLUTX3 2.5MM STD HX -,SUP-71823060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,611.27,427.889,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC 62MM 2.5MM 3HL STD HEAD LCK SS -,SUP-71823110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC 86MM 2.5MM 5HL STD HEAD LCK SS LT VOLAR -,SUP-71823112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9562.27,6693.589,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC 62MM 2.5MM 3HL HEAD LCK SS STD -,SUP-71823114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC 86MM 2.5MM 5HL STD HEAD LCK SS RT VOLAR -,SUP-71823116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9562.27,6693.589,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC 62MM 2.5MM 3HL W HEAD LCK SS LT VOLAR RADL -,SUP-71823118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC 62MM 2.5MM 3HL W HEAD LCK SS RT VOLAR RADL -,SUP-71823122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC 97MM 3.5MM 8HL LCK SS -,SUP-71823401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8830.28,6181.196,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC 109MM 3.5MM 6HL LCK SS LT CLVCL -,SUP-71823403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9036.11,6325.277,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC 109MM 3.5MM 6HL LCK SS RT CLVCL -,SUP-71823404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9036.11,6325.277,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC 81MM 2.7MM LCK SS -,SUP-71823407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9036.11,6325.277,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC 81MM 6HL LCK SS -,SUP-71823906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14406.44,10084.508,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X10MM NLCKG CORT PERILOC ST SS -,SUP-71824010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X16MM NLCKG CORT PERILOC ST SS -,SUP-71824016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X22MM NLCKG CORT PERILOC ST SS -,SUP-71824022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X24MM NLCKG CORT PERILOC ST SS -,SUP-71824024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X26MM NLCKG CORT PERILOC ST SS -,SUP-71824026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X28MM NLCKG CORT PERILOC ST SS -,SUP-71824028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X30MM NLCKG CORT PERILOC ST SS -,SUP-71824030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X50MM NLCKG CORT PERILOC ST SS -,SUP-71824050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X18MM LCK CORT PERILOC ST SS -,SUP-71825018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X22MM LCK CORT PERILOC ST SS -,SUP-71825022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X24MM LCK CORT PERILOC ST SS -,SUP-71825024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X26MM LCK CORT PERILOC ST SS -,SUP-71825026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X28MM LCK CORT PERILOC ST SS -,SUP-71825028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X30MM LCK CORT PERILOC ST SS -,SUP-71825030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X32MM LCK CORT PERILOC ST SS -,SUP-71825032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X34MM LCK CORT PERILOC ST SS -,SUP-71825034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X50MM LCK CORT PERILOC ST SS -,SUP-71825050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X55MM LCK CORT PERILOC ST SS -,SUP-71825055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X60MM LCK CORT PERILOC ST SS -,SUP-71825060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X65MM LCK CORT PERILOC ST SS -,SUP-71825065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X80MM LCK CORT PERILOC ST SS -,SUP-71825080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X10MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X12MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X16MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X18MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825218,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X36MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X45MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825245,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X50MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X60MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X65MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825265,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X35MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825335,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X40MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X45MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X55MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X60MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X26MM NLCKG CORT PERILOC ST SS -,SUP-71826026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X30MM NLCKG CORT PERILOC ST SS -,SUP-71826030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X34MM NLCKG CORT PERILOC ST SS -,SUP-71826034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X40MM NLCKG CORT PERILOC ST SS -,SUP-71826040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X44MM NLCKG CORT PERILOC ST SS -,SUP-71826044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X48MM NLCKG CORT PERILOC ST SS -,SUP-71826048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X52MM NLCKG CORT PERILOC ST SS -,SUP-71826052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X60MM NLCKG CORT PERILOC ST SS -,SUP-71826060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X68MM NLCKG CORT PERILOC ST SS -,SUP-71826068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X72MM NLCKG CORT PERILOC ST SS -,SUP-71826072,CDM,C1713,HCPCS,278,RC,,,outpatient,,,594.29,416.003,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X74MM NLCKG CORT PERILOC ST SS -,SUP-71826074,CDM,C1713,HCPCS,278,RC,,,outpatient,,,594.29,416.003,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X10MM LCK CORT PERILOC ST SS -,SUP-71827010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X12MM LCK CORT PERILOC ST BLNT TIP SS -,SUP-71827012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X18MM LCK CORT PERILOC ST SS -,SUP-71827018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X20MM LCK CORT PERILOC ST SS -,SUP-71827020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X24MM LCK CORT PERILOC ST SS -,SUP-71827024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X26MM LCK CORT PERILOC ST SS -,SUP-71827026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X28MM LCK CORT PERILOC ST SS -,SUP-71827028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X30MM LCK CORT PERILOC ST SS -,SUP-71827030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X32MM LCK CORT PERILOC ST SS -,SUP-71827032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X34MM LCK CORT PERILOC ST SS -,SUP-71827034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X36MM LCK CORT PERILOC ST SS PROX FEM -,SUP-71827036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X40MM LCK CORT PERILOC ST SS -,SUP-71827040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X42MM LCK CORT PERILOC ST SS -,SUP-71827042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X46MM LCK CORT PERILOC ST SS -,SUP-71827046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X50MM LCK CORT PERILOC ST SS -,SUP-71827050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X52MM LCK CORT PERILOC ST SS -,SUP-71827052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X60MM LCK CORT PERILOC ST SS PROX FEM -,SUP-71827060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X66MM LCK CORT PERILOC ST SS -,SUP-71827066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X68MM LCK CORT PERILOC ST SS -,SUP-71827068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X70MM LCK CORT PERILOC ST SS -,SUP-71827070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1924.08,1346.856,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X70MM LCK CORT PERILOC ST SS -,SUP-71827070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X72MM LCK CORT PERILOC ST SS -,SUP-71827072,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X76MM LCK CORT PERILOC ST SS -,SUP-71827076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X80MM LCK CORT PERILOC ST SS -,SUP-71827080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X85MM LCK CORT PERILOC ST SS -,SUP-71827085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X90MM LCK CORT PERILOC ST SS -,SUP-71827090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1979.47,1385.629,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.7MMX20MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.7MMX25MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.7MMX35MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.7MMX40MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.7MMX45MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.7MMX50MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.7MMX55MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
RETRACTOR UTR DE LEE UNIV 2INX2.75IN 9.5IN HNDL SS V.MUELLER -,SUP-71828060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.7MMX65MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.7MMX70MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.7MMX80MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.7MMX85MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC CONTR + 57MM 3.5MM 4HL LCK COMPR SS 1/3 -,SUP-71829004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2601.59,1821.113,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC CONTR + 82MM 3.5MM 6HL LCK COMPR SS 1/3 -,SUP-71829006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2601.59,1821.113,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC CONTR + 107MM 3.5MM 8HL LCK COMPR SS 1/3 -,SUP-71829008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2533.04,1773.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC 93MM F/3.5MM 6HL NLCKG COMPR SS 1/3 TBLR SM -,SUP-71829406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2395.93,1677.151,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 106MM 3.5MM 7HL NLCKG COMPR 1/3 TBLR SM FRAG -,SUP-71829407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2514.19,1759.933,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 50MM 4.33HL TBLR NS -,SUP-71829434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.31,800.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 62MM 5.33HL TBLR NS -,SUP-71829435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.31,800.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 74MM 6.33HL TBLR NS -,SUP-71829436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1064.29,745.003,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 86MM 7.33HL TBLR NS -,SUP-71829437,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1064.29,745.003,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 98MM 8.33HL TBLR NS -,SUP-71829438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1095.14,766.598,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 122MM 10.33HL TBLR NS -,SUP-71829440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1095.14,766.598,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 70MM 3.5MM 6HL RECON SM FRAG -,SUP-71829516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4693.02,3285.114,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 94MM 3.5MM 8HL RECON -,SUP-71829518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5145.85,3602.095,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC 96MM F/3.5MM SM MUL FRAG SYS 6HL LCK COMPR -,SUP-71829706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4528.9,3170.23,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCR- SFTSLK-2.0 PKG.7X20 STER -,SUP-7207256,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SOFTSILK 2.0 7 X 25 -,SUP-7207257,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCR- SFTSLK-2.0 PKG.8X20 STER -,SUP-7207259,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SOFTSILK 2.0 8 X 25 -,SUP-7207260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DEVICE SUT ARSCP ENDBTTN CL 30MM STRL LF -,SUP-7210082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DEVICE SUT ARSCP ENDBTTN CL 35MM STRL LF -,SUP-7210083,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DEVICE SUT ARSCP ENDBTTN CL 40MM STRL LF -,SUP-7210084,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BUTTONENDO CL BTB STER 45MM -,SUP-7210085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BUTTON ENDO 15MM CL -,SUP-7220-0146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.98,1373.386,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ULTRA FAST FIX CURVED -,SUP-7220-1494,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2143.15,1500.205,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUT FTPRNT 5.5MM ARSCP NABSB OUTR SHL INR PLG -,SUP-7220-1697,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2143.95,1500.765,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW INTFR CANN BIOSURE 9X25MM ABSB TAPR PLLA HAP KN -,SUP-72201781,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1574.57,1102.199,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SUT ANCHOR OSTEORAPTOR  2.9 -,SUP-72201995,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2049.44,1434.608,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FAST-FIX 360 STRAIGHT -,SUP-72202467,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2543.73,1780.611,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FAST FIX 360 CVD NEEDLE -,SUP-72202468,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2543.73,1780.611,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FAST-FIX 360 REVERSE CURVED -,SUP-72202469,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2543.73,1780.611,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDE DRILL SZ1.2 ENDBTTN CL ULTRA PAC -,SUP-7220-2799,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2118.19,1482.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUTURE 4.5MM HEALICOIL -,SUP-7220-3378,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2261.88,1583.316,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR HEALICOIL 4.75MM REGENE -,SUP-72203697,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3911.82,2738.274,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR HEALICOIL 4.75MM -,SUP-72203704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2249.43,1574.601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW EVOS 2.7MM X 17MM CTX -,SUP-72402717,CDM,C1713,HCPCS,278,RC,,,outpatient,,,400.46,280.322,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW EVOS 2.7MM X 24MM CTX -,SUP-72402724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,188.59,132.013,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW EVOS 3.5MM X 14MM CTX -,SUP-72403514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.9,95.13,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW EVOS 3.5MM X 15MM CTX -,SUP-72403515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW EVOS 3.5MM X 16MM CTX -,SUP-72403516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW EVOS 3.5MM X 17MM CTX -,SUP-72403517,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW EVOS 3.5MM X 18MM CTX -,SUP-72403518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW EVOS 2.7MM X 18MM LCK -,SUP-72412718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,598.38,418.866,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW EVOS 2.7MM X 19MM LCK -,SUP-72412719,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.55,802.585,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW EVOS 2.7MM X 20MM LCK -,SUP-72412720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.55,802.585,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE EVOS VOLAR 10H R STD 138MM -,SUP-72468210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8021.16,5614.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC VLP 64MM 3.5MM 4HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10840.85,7588.595,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC VLP 72MM 3.5MM 5HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8521.53,5965.071,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC VLP 47MM 3.5MM 3HL VAR ANG CONTR LCK SS -,SUP-7282-0303,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7945.19,5561.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC VLP 89MM 3.5MM 3HL VAR ANG CONTR LCK SS -,SUP-7282-0603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10840.85,7588.595,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC VLP 89MM 3.5MM 3HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10840.85,7588.595,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC VLP 62MM 3.5MM 5HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6051.52,4236.064,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC VLP 86MM 3.5MM 7HL 1.5-MM VAR ANG CONTR LCK -,SUP-7282-0807,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7163.02,5014.114,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC VLP 74MM 3.5MM 6HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6607.27,4625.089,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC VLP 86MM 3.5MM 7HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7163.02,5014.114,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC VLP 59MM 3.5MM 3HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-1003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7060.11,4942.077,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC VLP 71MM 3.5MM 4HL VAR ANG CONTR LCK SS LT -,SUP-7282-1004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7492.36,5244.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC VLP 83MM 3.5MM 5HL VAR ANG CONTR LCK SS LT -,SUP-7282-1005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7924.61,5547.227,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC VLP 107MM 3.5MM 7HL 2MM VAR ANG CONTR LCK -,SUP-7282-1007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8336.28,5835.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC VLP 131MM 3.5MM 9HL VAR ANG CONTR LCK SS LT -,SUP-7282-1009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8830.28,6181.196,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC VLP 59MM 3.5MM 3HL VAR ANG CONTR LCK SS -,SUP-7282-2003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6977.77,4884.439,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC VLP 71MM 3.5MM 4HL VAR ANG CONTR LCK SS -,SUP-7282-2004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7451.19,5215.833,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC VLP 83MM 3.5MM 5HL VAR ANG CONTR LCK SS RT -,SUP-7282-2005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7862.86,5504.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC VLP 131MM 3.5MM 9HL VAR ANG CONTR LCK SS RT -,SUP-7282-2009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8768.53,6137.971,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC VLP 62MM 3.5MM 5HL VAR ANG CONTR LCK SS -,SUP-7282-3005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2852.56,1996.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC VLP 74MM 3.5MM 6HL VAR ANG CONTR LCK SS -,SUP-7282-3006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3223.02,2256.114,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERILOC VLP 86MM 3.5MM 7HL VAR ANG CONTR LCK SS -,SUP-7282-3007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3570.33,2499.231,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LCK ORLMXLFCL 2.4X14MM STERNALOCK SD TI GOLD -,SUP-73-2414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LCK ORLMXLFCL 2.4X16MM STERNALOCK SD TI GOLD -,SUP-73-2416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LCK ORLMXLFCL 2.4X18MM STERNALOCK SD TI GOLD -,SUP-73-2418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,460.97,322.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LCK ORLMXLFCL 2.4X20MM STERNALOCK SD TI GOLD -,SUP-73-2420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,460.97,322.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE ORLMXLFCL 8HL STERNALOCK 4HL BX TI BLU -,SUP-73-2622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2835.76,1985.032,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE ORLMXLFCL 12HL STERNALOCK LDDR TI BLU -,SUP-73-2632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4401.63,3081.141,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE ORLMXLFCL 12HL STERNALOCK W LDDR TI BLU -,SUP-73-2634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4401.63,3081.141,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE STRNM 8HL JL SHP STERNALOCK BLU TI -,SUP-73-2645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4124.74,2887.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COMP JRNY II CR FEM OX NP LT SZ 6 -,SUP-74021166,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BASEPLATE TIBIA JOURNEY NP LT SZ 5 -,SUP-74022225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
INSERT JOURNEY II CR XLPE RT SZ 5-6 9MM -,SUP-74025661,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
MESH CAGE 30MM H -,SUP-74-1030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE NGAGE 16MM X 12MM CORPECT -,SUP-74-1216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE N-GAGE TI 16 X 50MM -,SUP-74-1650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TONIER HUMERAL NAIL DISTAL SCREW 4.3MM X 20MM -,SUP-7424520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TONIER HUMERAL NAIL DISTAL SCREW 4.3MM X 22MM -,SUP-7424522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAP END N-GAGE ZERO DEGREE -,SUP-74-5016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ENDCAP 2.5 DEG 10MM -,SUP-74-6010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAP NPLATE 7.5 DEGREE -,SUP-74-6012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NUT LCK F/C IN ADVANCED IMPL SYS -,SUP-7642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.87,143.409,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SET SCREW SPIN 6.35MM CD HORIZN LEGC SS -,SUP-7660000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,869.18,608.426,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5X35MM FIREBIRD DBL LD THRD ST CANN TI GRN -,SUP-77-8535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5X40MM FIREBIRD DBL LD THRD ST CANN TI GRN -,SUP-77-8540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5X45MM FIREBIRD DBL LD THRD ST CANN GRN -,SUP-77-8545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X35MM FIREBIRD DBL LD THRD ST CANN TI GOLD -,SUP-77-8635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X40MM FIREBIRD DBL LD THRD ST CANN GOLD -,SUP-77-8640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X45MM FIREBIRD DBL LD THRD ST CANN TI GOLD -,SUP-77-8645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X50MM FIREBIRD DBL LD THRD ST CANN TI GOLD -,SUP-77-8650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
3.5MM COCR ROD- 240MM -,SUP-782.803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SET -,SUP-79-2003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CABLE SPIN 1.2MM TI DBL LOP INTGR CRIMPX2 STRL -,SUP-7925011S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1755.53,1228.871,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SUBSTITUTE CA PHOS HAP 5ML PTTY CMNT INJ HYDR ST SYNTH -,SUP-79-43905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6318.89,4423.223,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CEMENT BN CA PHOS HAP 10ML HYDR ST -,SUP-79-43910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10521.16,7364.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SUBSTITUTE CA PHOS HAP 15ML PTTY CMNT INJ HYDR ST SLF-SET -,SUP-79-43915,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15098.17,10568.719,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEPIN ORTHO 2.5MM HEMICAP -,SUP-8007-1200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
IMPLANT SHT CRANFC 50X76MM 0.85MM MEDPOR EMBD TI MSH F/RECON -,SUP-81020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5562.27,3893.589,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
MESH TITAN SHEET MTB 76 X 50 X 1MM -,SUP-81027,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6586.43,4610.501,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
IMPLANT PE SHT EMBD TI MSH CRANFC 50X76MM -,SUP-81029,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6345.33,4441.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
IMPLANT SHT 76X100MM 1.5MM MEDPOR TITAN MAX F/CRANFC -,SUP-81040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10857.55,7600.285,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X12MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X14MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X16MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X18MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN SPIDER 20MM TMX -,SUP-814100003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERI 70.1MM 5HL COMPR TMX TBLR BLLT -,SUP-814123005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,980.28,686.196,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PE.R.I. 83.1MM 6HL COMP TIMEX 1/3 TBLR -,SUP-814123006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 95.5MM 7HL COMPR COMP TBLR BLLT-SHP -,SUP-814123007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PERI 109.2MM 30MM COMPR TMX TBLR BLLT -,SUP-814123008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PE.R.I. 122.2MM 9HL NLCKG PERMTR RDC COMP TBLR -,SUP-814123009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 179.4MM 6HL LCK SHFT STRL -,SUP-814130106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN POLYAX 233.5MM 9HL LCK TMX STRL -,SUP-814131109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 287.6MM 12HL LCK SHFT -,SUP-814131112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN POLYAX 99.6MM 2HL PRCONT LCK TMX STRL -,SUP-814133002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 13MMSHRTX180MM AFFIXUS TROCH ANTGRD AN-ROT 125DG ANG -,SUP-814313180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7282.7,5097.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 10.5MM AFFIXUS CANN LAG THRD ST TMX 80MM -,SUP-814510080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3265.42,2285.794,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 10.5MM AFFIXUS CANN LAG THRD ST TMX 105MM -,SUP-814510105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3265.42,2285.794,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 13MMSHRTX180MM AFFIXUS TROCH ANTGRD AN-ROT 130DG ANG -,SUP-814513180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7282.7,5097.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X34MM CORT AFFIXUS VERSANAIL FT ST 3.5MM HX DRV SCKT -,SUP-814550034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X40MM CORT AFFIXUS VERSANAIL FT ST 3.5MM HX DRV SCKT -,SUP-814550040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X20MM CORT ALPS FT ST HX DRV TMX -,SUP-8150-36-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,134.21,93.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X10MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X12MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X14MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X20MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X22MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X24MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X26MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X28MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X30MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X34MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X38MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X42MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X44MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X46MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X48MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X50MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X55MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X60MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X65MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X26MM LCK SHFT CORT POLYAX FT POLYAX ST FA TMX NS -,SUP-815045526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X28MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X30MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X32MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X34MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X36MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X40MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X45MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X55MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X60MM LCK CANC POLYAX FT POLYAX ST FA BLLT SHP TIP TI -,SUP-815304060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X75MM LCK CANC POLYAX FT POLYAX ST FA BLLT SHP TIP TI -,SUP-815304075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 8X70MM LCK DUAL CORE POLYAX FT POLYAX ST FA BLLT SHP -,SUP-815308070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 8X75MM LCK DUAL CORE POLYAX FT POLYAX ST FA BLLT SHP -,SUP-815308075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X10MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X14MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X16MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X18MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X20MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X24MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X26MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X28MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X34MM CANC FT -,SUP-8153-41-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,278.62,195.034,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X44MM LAG CANC FT -,SUP-8153-41-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,198.39,138.873,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X50MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X55MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5X30MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5X45MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5X60MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5X65MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5X70MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5X75MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5X65MM NLCKG CANC POLYAX P/T POLYAX TI NS -,SUP-815455065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X20MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X24MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X28MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X30MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X32MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X36MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X42MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X46MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LAG SCREW D10.5X85MM -,SUP-8160-0085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4287.05,3000.935,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X10MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X12MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X14MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X16MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X18MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X20MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORT LOCK 3.5 X 20MM NS -,SUP-816135020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW  CORT LOCK 3.5 X 22MM NS -,SUP-816135022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X22MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X24MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-8161-35-024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
3.5MM CORT LOCK SCREW 26MM NS -,SUP-816135026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X28MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
3.5MM CORTLOCK SCREW 30MM NS -,SUP-816135030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X30MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X32MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X34MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X36MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X38MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X40MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X42MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
3.5MM CORT LOCK SCREW 50MM NS -,SUP-816135050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORT LOCK 3.5 X 52MM NS -,SUP-816135052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 3.5 X 54 CORT NS -,SUP-816135054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X56MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X60MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X65MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X10MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X12MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X14MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X16MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X18MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X26MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X28MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X46MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X60MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X65MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X70MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN ALPS 199MM 12HL PRCONT LCK COMPR TMX W ANTMC FST -,SUP-816200012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6798.89,4759.223,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN ALPS 77MM 6HL THRD LCK TMX ANTMC NS BLU -,SUP-816204006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN ALPS 92MM 7HL THRD LCK TMX ANTMC NS BLU -,SUP-816204007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN ALPS 103MM 8HL THRD LCK TMX ANTMC NS BLU -,SUP-816204008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1526.54,1068.578,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN ALPS 3.5MM 5HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1208.51,845.957,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN ALPS 3.5MM 6HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1208.51,845.957,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN ALPS HCP 3.5MM 7HL HYBRID LCK COMPR TMX THN ANTMC -,SUP-816235007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN ALPS 3.5MM 8HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1335.73,935.011,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN ALPS 3.5MM 9HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1335.73,935.011,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN ALPS 3.5MM 12HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN ALPS 3HL PRCONT LCK TMX STD CRV ANTMC LT TIB -,SUP-816235703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5627.54,3939.278,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN ALPS 5HL PRCONT LCK TMX STD CRV ANTMC -,SUP-816235705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5678.47,3974.929,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN ALPS 3HL PRCONT LCK TMX STD CRV ANTMC RT TIB -,SUP-816235803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5627.54,3939.278,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X22MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X26MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X32MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X50MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X55MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X56MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X65MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER SPNL ANT CERV 13X15X6MM ALTA 5DG PEEK. -,SUP-8401-0506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN FX 1.3MM ABSB -,SUP-84-1052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1153.11,807.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER SPNL ANT CERV 13X15X6MM ALTA 5DG PEEK.. -,SUP-8411-0506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER ANT CERV 13X15X7MM ALTA 5DG PEEK -,SUP-8411-0507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COVER LOCKING SHORELINE 8-12 MM STANDALONE GRAY -,SUP-85-2008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TEMP FIX PIN -,SUP-85-2100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LONG NAIL LEFT 13X340MM X 125 DEG -,SUP-8525-3340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13986.87,9790.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5 X 12MM SELF DRILLING -,SUP-85-3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5 X 14MM SELF DRILLING -,SUP-85-3014SD,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GRAVITY SYNCHFIX SYNDESMOSIS #5 SUTURE -,SUP-86SYN005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4349.11,3044.377,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER TRNSFRMNL POST LMBR 9X23X6MM FORZA 0DG STR BLLT NOSE -,SUP-89-1006SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER TRNSFRMNL POST LMBR 9X23X8MM FORZA 0DG STR BLLT NOSE -,SUP-89-1008SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER TRNSFRMNL POST LMBR 9X27X7MM FORZA 0DG CRV BLLT NOSE -,SUP-89-1707SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER TRNSFRMNL POST LMBR 9X27X8MM FORZA 0DG CRV BLLT NOSE -,SUP-89-1708SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER TRNSFRMNL POST LMBR 9X27X9MM FORZA 0DG CRV BLLT NOSE -,SUP-89-1709SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
IMPLANT HUM TIS 9X27X7MM SZ0 FORZA STR -,SUP-89-3007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPACER TRNSFRMNL POST LMBR 9X27X10MM FORZA 0DG STR BLLT NOSE -,SUP-89-3010SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BONE CEMENT HYDROSET XT INJECTABLE HA -,SUP-897003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5310.31,3717.217,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CEMENT BONE HYDROSET XT HA 5CC -,SUP-897005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8517.71,5962.397,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CEMENT BONE HYDROSET XT HA 10CC -,SUP-897010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14367.75,10057.425,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
HYDROSET XT -,SUP-897015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20614.72,14430.304,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GRAFT BONE BIO4 VIABLE BONE MATRIX 2.5CC -,SUP-90174424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEADLESS COMPRESSION 2.5MM X 28MM TI -,SUP-90176298,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN FIXATION IJS 2.5MM X 50MM AXIS -,SUP-90176511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1918.78,1343.146,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW FREEFIX COMPRESSION 4.5MM X 18MM TI -,SUP-90176560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1009.46,706.622,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW FREEFIX LOCKING 4.5MM X 14MM TI -,SUP-90176561,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW FREEFIX LOCKING 4.5MM X 16MM TI -,SUP-90176562,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW FREEFIX LOCKING 4.5MM X 18MM TI -,SUP-90176563,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW FREEFIX LOCKING 4.5MM X 20MM TI -,SUP-90176564,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE MIDSHAFT HUMERUS NARROW 172MM -,SUP-90176565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5334.71,3734.297,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE FREEFIX 173MM ULNA MIDSHAFT -,SUP-90176755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE FREEFIX DISTAL HUMERUS 85MM ASSEMBLED LAT HELICAL LEFT -,SUP-90176827,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW FREEFIX COMPRESSION 3.5MM X 12MM TI -,SUP-90176828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW FREEFIX LOCKING 3.5MM X 10MM TI -,SUP-90176829,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.51,808.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW POLYAXIAL LOCKING 3.0MM X 34MM CANNULATED COCR -,SUP-90176830,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW POLYAXIAL LOCKING 3.0MM X 50MM CANNULATED COCR -,SUP-90176831,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW POLYAXIAL LOCKING 3.0MM X 60MM CANNULATED COCR -,SUP-90176832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW POLYAXIAL LOCKING 3.0MM X 65MM CANNULATED COCR -,SUP-90176833,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEADLESS COMPRESSION 2.5MM X 20MM TI -,SUP-90176987,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ASSEMBLED FREE FIX DISTAL HUM PLATE LAT DIRECT 85MM RIGHT -,SUP-90178750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ASSEMBLED FREE FIX DISTAL HUM PLATE MED DIRECT 75MM RIGHT -,SUP-90178751,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8504.98,5953.486,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW FREEFIX COMPRESSION 3.5MM X 16MM TI -,SUP-90178752,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW FREEFIX COMPRESSION 3.5MM X 28MM TI -,SUP-90178753,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW FREEFIX LOCKING 3.5MM X 30MM TI -,SUP-90178754,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MULTI-THREAD LOCKING 2.7MM X 16MM TI -,SUP-90178756,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MULTI-THREAD LOCKING 2.7MM X 24MM TI -,SUP-90178757,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ASSEMBLED FREEFIX DIST HUM PLATE LAT DIRECT 85MM LEFT -,SUP-90178787,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DISTAL TROCHLEA COMPRESSION SCREW 3.5MM X 40MM TI -,SUP-90178788,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MULTI-THREAD LOCKING 2.7MM X 26MM TI -,SUP-90178789,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MULTI-THREAD LOCKING 2.7MM X 42MM TI -,SUP-90178790,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
HIGH COMPRESSION LOCKING PEG 2.7MM X 24MM TI -,SUP-90178898,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DRILL CANNULATED 3.7MM X 30MM -,SUP-90178926,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ASSEMBLY DOUBLE IJS -,SUP-90178927,CDM,C1713,HCPCS,278,RC,,,outpatient,,,27394.51,19176.157,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
IJS-E AXIS PIN FEMALE 30MM COCR -,SUP-90178928,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
THREADED HAND NAIL 4.5MM X 45MM TI -,SUP-90178982,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4258.41,2980.887,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
KT SPINAL 4.5MMX30-40MM PEDICAL COMPR TRANSFACET W/SCREWX2 -,SUP-9045-02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
IMPLANT ELB JNT TOGGLELOC -,SUP-909854,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4344.34,3041.038,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PK VALVE F/INFECT FLD WST MGMT ULTRA QUAD CART -,SUP-91530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CRNL 1.5X4MM STRDRV RCESS SD TI -,SUP-92-15904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,413.82,289.674,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CRNL 1.5X5MM STRDRV RCESS SD TI -,SUP-92-15905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,82.76,57.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CRNL 1.5X5MM STRDRV RCESS SD TI -,SUP-92-15905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,413.82,289.674,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE INSERT LOCKING 2.7MM -,SUP-940372,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN FX STNMN 2.8MMX9IN SMTH STRL F /THE VUEPASS PORTAL -,SUP-94152,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2711.63,1898.141,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PFC SIGMA DISTAL AUG COM CEMT SIZE 5 X 4MM RIGHT -,SUP-960901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PFC SIGMA DISTAL AUG COM CEMT SIZE 5 X 8MM RIGHT -,SUP-960903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TIBAL INSERT ROTATING PLATFORM (STAB) 5- 10MM -,SUP-962151,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
INSERT TIBIAL ROTATING PLATFORM SZ 2.5MM X 20MM TCS -,SUP-96-2335,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
5.0MM VARIABLE ANGLE EXTENSION ARM -,SUP-991088S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2160.48,1512.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAP TOT JNT SM PLST -,SUP-9911186002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1043.01,730.107,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
IMPLANT HUM TIS CHP ALLOGRAFT CANC 15ML -,SUP-A00035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.87,918.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TEMPORARY TENSION BOLT -,SUP-A-2791.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.07,775.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DRILL BIT AO FIXATION 1.2MM X 25MM X L81MM -,SUP-A-3230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1173.53,821.471,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COUNTERSINK M 1.2/1.5 -,SUP-A-3310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1607.11,1124.977,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
3.0 CCS COUNTERSINK- AO -,SUP-A-3938,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1978.15,1384.705,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
HOOK PLATE1.5 2 HOLE 2 HOOKS T0.6 -,SUP-A-4200.40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2365.61,1655.927,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
HOOK PLATE 4 HOLE 4 HOOKS T0.6 -,SUP-A-4200.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2632.76,1842.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
IMPLANT HUM TIS STRIP 1X20CMX8MM H GRFTN MATRIX -,SUP-A42280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8571.82,6000.274,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE M FIX 4 HOLE STRAIGHT -,SUP-A-4300.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2106.42,1474.494,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE M FIX 6 HOLE STRAIGHT -,SUP-A-4300.03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.98,1080.086,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE M FIX 16 H STRAIGHT -,SUP-A-4300.04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2571.75,1800.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE M FIX 16 H CURVED -,SUP-A-4300.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2092.11,1464.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE M FIX16 HOLE OFF SET -,SUP-A-4300.06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2700.17,1890.119,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN APTUS 10X27MM F/1.2MM/1.5MM FX SCR HLX3X5 TI T-SHP -,SUP-A-4300.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1852.52,1296.764,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE M FIX 2/3 H RIGHT L -,SUP-A-4300.21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1852.52,1296.764,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE M GD FIX 2X2 RECT LEA -,SUP-A-4300.51,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2632.23,1842.561,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE FIXATION GOLD GRID 2 X 2-HOLE TAPAZOID -,SUP-A-4300.54,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2632.23,1842.561,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN APTUS 15MM F/1.2MM/1.5MM SCR HLX3X2 0.6MM GRID FX -,SUP-A-4300.55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2074.62,1452.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN HLX4X2 FA MED L-SHP GRID -,SUP-A-4300.64,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2156.24,1509.368,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GRID 5 X 2 HOLE TRAPAZOID -,SUP-A-4300.66,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.52,1855.364,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE M CONDYLE 5 H PIN L -,SUP-A-4340.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2542.12,1779.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN APTUS F/1.2-1.5MM SCR 1HL HOOKX2 COMPR TI TRILOCK -,SUP-A-4340.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3184.74,2229.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE APTUS TRILOCK PI 4 HOLE STRAIGHT IO 8 -,SUP-A-4350.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3757.14,2629.998,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE M TRILOCK STR 4 HOLE -,SUP-A-4350.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2752.69,1926.883,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE TRILOCK PI 3/5 HOLE T -,SUP-A-4350.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4001.57,2801.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN APTUS 11X25MM 0.8MM 8HL HND TRILOCK TI T-SHP -,SUP-A-4350.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4001.57,2801.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE TRILOCK ROTATING 3 HOLE 1.2/1.5 -,SUP-A-4350.23,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4080.82,2856.574,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN APTUS 9X23MM F/1.2MM/1.5MM SCR FX/ROT 6HL 0.8MM VAR -,SUP-A-4350.23,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.67,2999.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE M TRILOCK T 5/4 HL -,SUP-A-4350.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4152.43,2906.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOCKING PLATE 1.5 BLUE -,SUP-A-4350.56,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3415.8,2391.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE M TRILOCK GRID HL 4 X 2 -,SUP-A-4350.62,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4381.08,3066.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 1.2/1.5 TRILOCK GRID 5X2H TRAPZ T 0.8 -,SUP-A-4350.66,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4471.05,3129.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE LOCKING TRILOCK BLUE 1.5 TRAPEZ 10.8 -,SUP-A-4350.80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3868.85,2708.195,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
IMPLANT HUM TIS GRFTN DBM OTHBLND -,SUP-A44135,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5713.91,3999.737,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN APTUS 55MM F/2MM/2.3MM SCR 8HL COMPR TI STR TRILOCK -,SUP-A-4645.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2466.32,1726.424,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN APTUS 35MM F/2MM/2.3MM SCR HLX2X4 COMPR TI T-SHP -,SUP-A-4645.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2428.06,1699.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE M COMP L 2/8 HOLE RIGHT -,SUP-A-4645.23,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2405.14,1683.598,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE LOCKING 1.0MM THCK 2./2.3 STRAIGHT BLUE -,SUP-A-4650.03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7191.46,5034.022,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOCKING PLATE 2.0/2.3 BLUE T-2/4 HOLE -,SUP-A-4650.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3100.24,2170.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE TRILOCK 3/4 HOLE -,SUP-A-4650.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3100.24,2170.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
"PLATE M LK ""Y"" 2/5 H -",SUP-A-4650.13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3199.53,2239.671,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE L 2/4 HOLE RIGHT -,SUP-A-4650.21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3601.51,2521.057,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN APTUS 45MM F/2MM/2.3MM SCR 8HL 1MM GRID TI -,SUP-A-4650.67,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3910.86,2737.602,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BLUE LOCKING 2.0 /2.3 4 HOLE STRAIGHT -,SUP-A-4655.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4610.73,3227.511,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE LOCKING T1.3MM 4 HOLE STRAIGHT 2.0/2.3 -,SUP-A-4655.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3973.88,2781.716,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN APTUS 32MM F/2MM/2.3MM SCR 5HL 1.3MM GRID TI STR -,SUP-A-4655.02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4294.08,3005.856,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BLUE 2.0 / 2.23 5 HOLE STRAIGHT -,SUP-A-4655.02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4308.93,3016.251,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE TRILOCK 8 HOLE STRAIGHT 2 X 3 -,SUP-A-4655.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4971,3479.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE TRILOCK STRAIGHT 8 HOLE 2.0/2.3 -,SUP-A-4655.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4969.72,3478.804,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE M TRILOCK T 2/4 HL -,SUP-A-4655.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5024.05,3516.835,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE TRILOCK 2.0/2.3 T 2/4 HOLE T1.3 -,SUP-A-4655.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5024.05,3516.835,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN APTUS 56MM 2.0/2.3MM 10HL 1.3MM GRID TI T-SHP -,SUP-A-4655.16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5311.37,3717.959,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.0/2.3 TRILOCK PLATE 2/4 HOLE LEFT -,SUP-A-4655.20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4600.23,3220.161,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE M TRILOCK L RT 2/4 HL -,SUP-A-4655.21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5024.05,3516.835,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE M TRILOCK L LT 2/8 HL -,SUP-A-4655.22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4539.38,3177.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE ROTATION 3/3 HOLE T 1.3 -,SUP-A-4655.24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4738.2,3316.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE TRILOCK GRIDPI 4 X2H TRAPEZ -,SUP-A-4655.62,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5438.26,3806.782,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE TRILOCK GRIDPI 5 X2 H TRAPEZ -,SUP-A-4655.66,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5679.32,3975.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 2.0 TRILOCK RADIAL HEAD RIM -,SUP-A-4656.68,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7432.09,5202.463,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.0 TRILOCK RADIAL HEAD BUTTRESS -,SUP-A-4656.69,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7017.88,4912.516,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE TRILOCK 4CF 2 X 2.3 -,SUP-A-4660.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7727.9,5409.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE M BABYFOOT LONG RT -,SUP-A-4750.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5479,3835.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 2.5 ADAPT II TRILOCK DISTRAD L 10 H NARROW -,SUP-A-4750.101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5810.88,4067.616,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE M ADAPTIVE II NARROW RT -,SUP-A-4750.102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7626.89,5338.823,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DISTAL RADIUS LOCKING PLATE RIGHT 12 NARROW-LONG -,SUP-A-4750.104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 2.5 ADAPTIVE II TRILOCK DISTRAD NARR LONG -,SUP-A-4750.104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8591.98,6014.386,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE ADAPTIVE 2.5 X 12HL NRW LNG -,SUP-A-4750.104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6904.56,4833.192,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE M ADAPTIVE II LT -,SUP-A-4750.105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5810.88,4067.616,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE M ADAPTIVE II LT -,SUP-A-4750.105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7626.89,5338.823,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE STD WATERSHED RIGHT ADAP -,SUP-A-4750.106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8008.43,5605.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ADAPTIVE II TRILOCK 2.5 DISTRAD. PLATE 13 HOLE -,SUP-A-4750.107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DISTAL RADIUS LOCKING PLATE RIGHT 13 LONG -,SUP-A-4750.108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8591.98,6014.386,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE M ADAPTIVE II LONG RIGHT -,SUP-A-4750.108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN APTUS 28X52MM 2.5MM 14HL TI TRILOCK TECH -,SUP-A-4750.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 2.5 ADAPTIVE II DISTAL RADIUS LEFT WIDE LONG -,SUP-A-4750.111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 2.5 ADAPTIVE II TRILOCK DIST RAD 15H WIDE LONG -,SUP-A-4750.112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6234.44,4364.108,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DISTAL RADIUS CORRECTION PLATE WIDE -,SUP-A-4750.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE M FPL LT -,SUP-A-4750.123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8106.46,5674.522,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE MEDARTIS 14HL -,SUP-A-4750.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6904.56,4833.192,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE ADAPTIVE 2.5 X 15 HOLE -,SUP-A-4750.15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7057.35,4940.145,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE ADAPTIVE 2.5 X 16 HOLE -,SUP-A-4750.16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7057.35,4940.145,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN APTUS 22X62MM 2.5MM 12HL 1.6MM TI LNG NRW TRILOCK -,SUP-A-4750.19,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 2.5TRILOCK WR SPANNINGPI DOR. STRAIGHT 11 HOLE TL6-3.4 -,SUP-A-4750.193S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13227.56,9259.292,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN APTUS 23X44MM 2.5MM 10HL 1.6MM TI NRW TRILOCK TECH -,SUP-A-4750.31,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN APTUS 23X44MM 2.5MM 10HL TI SHRT NRW TRILOCK TECH -,SUP-A-4750.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN APTUS 30X64MM F/2.5MM FX 1.6MM LCK TI FRM -,SUP-A-4750.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5815.98,4071.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN APTUS 30X64MM F/2.5 TRILOCK SYS 1.6MM LCK TI -,SUP-A-4750.42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5815.98,4071.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN APTUS 49MM 2.5MM 6HL TI STR TRILOCK TECH -,SUP-A-4750.54,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4373.94,3061.758,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN APTUS 23X54MM 2.5MM 13HL TI TRILOCK TECH RT WRST -,SUP-A-4750.62,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN APTUS 23X68MM 2.5MM 15HL TI LNG TRILOCK TECH LT -,SUP-A-4750.64,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6307.43,4415.201,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WASHER BICONCAVE 2.5/2.8 -,SUP-A-4750.70/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,340.18,238.126,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN APTUS 46MM 2.5MM 7HL VAR ANG CONTR TI Y -,SUP-A-4750.91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4323.36,3026.352,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN APTUS 67MM 2.5MM 10HL 1.6MM VAR ANG CONTR LCK TI Y -,SUP-A-4750.92,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4557.21,3190.047,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.5 TRILOCK ULNA SHORTENING PLATE 10HL -,SUP-A-4750.95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9650.43,6755.301,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.5 TRILOCK ULNA SHORTENING PLATE -,SUP-A-4750.95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9650.43,6755.301,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 2.5 TRILOCK WRIST FUSION PI SHORT BEND -,SUP-A-4760.02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11734.57,8214.199,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN APTUS 2.5MM 15HL LCK TI STR MULDIR TRILOCK -,SUP-A-4760.03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9292.66,6504.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE STRAIGHT 2.5 TRILOCK TOTAL WRIST FUS -,SUP-A-4760.04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11159.79,7811.853,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.5 TRILOCK TOTAL WRIST FUS PL LONG BEND 16HL T1.8-2.6 DRSL -,SUP-A-4760.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11734.57,8214.199,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.5 TRILOCK TOTAL WRIST FUS PI SHORT BEND 16 HOLE T1.8-2.6 D -,SUP-A-4760.06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11734.57,8214.199,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 2.5 TRILOCK WRIST FUSION SHORT BEND 12 HOLE -,SUP-A-4760.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11462.03,8023.421,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE TENSION 2.8 TRILOCK 6 HOLE OLECRANON -,SUP-A-4856.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5373.33,3761.331,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE TRILOCK T1-6 OLECRANON 7H RIGHT -,SUP-A-4856.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5556.24,3889.368,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 2.8 TRILOC OLECRANON 7H LEFT -,SUP-A-4856.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5557.94,3890.558,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE TRILOCK OLECRANON 2.8 7H STRAIGHT -,SUP-A-4856.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5306.27,3714.389,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TRILOCK PLATE 2.8 - 10H- RIGHT -,SUP-A-4856.13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5674.23,3971.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TRILOCK PLATE 10H STRAIGHT -,SUP-A-4856.15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5576.62,3903.634,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.8 TRILOCK DIST HUM PL MEDIAL 17H L -,SUP-A-4856.29,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10465.7,7325.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 2.8 TRILOCK DIST HUM MEDIAL 12H R -,SUP-A-4856.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9692.45,6784.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TriLock Dist. Hum Pl. Medial- 10h- l -,SUP-A-4856.33,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9291.81,6504.267,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.8 TRILOCK DIST HUM PL LATERAL 18H L -,SUP-A-4856.39,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9432.88,6603.016,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 2.8 TRILCK DIST HUM MEDIAL 10H LFT -,SUP-A-4856.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9692.45,6784.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE M TRILOCK GRID H 2X2 -,SUP-A-4856.44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9291.81,6504.267,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 10HL 2.8MM TRILOCK TECH RT OLCRN -,SUP-A-4856-13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4323.36,3026.352,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 10HL 2.8MM TRILOCK TECH LT OLCRN -,SUP-A-4856-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5674.23,3971.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
K-WIRES LNCET 150MM 1.8MM -,SUP-A-5042.51/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,247.99,173.593,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
1.1 K-WIRE- TROCAR- 2-END. 100MM -,SUP-A-5043.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,297.59,208.313,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.2X4MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.2X5MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.2X6MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.2X7MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.2X8MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.2X9MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.2X10MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.2X11MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.2X12MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.2X14MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW M CORTEX 1.2 X 16MM -,SUP-A-5100.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.5X4MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.5X5MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.5X6MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW M CORTEX 1.5 X 07 -,SUP-A-5200.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW M CORTEX 1.5 X 07 -,SUP-A-5200.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW M CORTEX 1.5 X 08 -,SUP-A-5200.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.5X9MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.5X10MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.5X11MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.5X12MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.5X13MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.5X14MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.5X15MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.5X15MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI. -,SUP-A-5200.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTEX 1.5 X 16 MEDARTIS -,SUP-A-5200.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTEX 1.5 X 17MM CORTICAL HD4 -,SUP-A-5200.17/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.5X18MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.5X19MM CORT APTUS DBL THRD ST/RET HEXDRV 4 TI GOLD -,SUP-A-5200.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW M CORTEX 1.5 X 21 -,SUP-A-5200.21/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL 1.5 22MM HD4 -,SUP-A-5200.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW M CORTEX 1.5 X 24 -,SUP-A-5200.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE APTUS 1.5 SPEEDTIP 10MM HD4 PK/1 -,SUP-A-5210.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1076.56,753.592,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE 1.5MM SPEEDTIP 14MM HD4 PK/1 -,SUP-A-5210.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1076.56,753.592,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.5X4MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.5X5MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.5X6MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.5X7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.5 X 7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.5X8MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.5X9MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.5X10MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.5X11MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.5X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.5X13MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 1.5 X 16 -,SUP-A-5250.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.8,742.56,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE CANNULATED COMPRESSION 10/4MM -,SUP-A-5281.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.7 CCS LONG THREAD 15/06MM 1/PKG -,SUP-A-5281.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.7 CCS LONG THREAD 16/07MM 1/PKG -,SUP-A-5281.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
1.7 CCS LONG THREAD 18/07MM -,SUP-A-5281.18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.7CCS LONG THREAD 20/08MM -,SUP-A-5281.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.7 CCS FULLY THREADED 10MM 1/PKG -,SUP-A-5282.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.7CCS FULLY THREADED 13MM -,SUP-A-5282.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.7CCS FULLY THREADED 14MM -,SUP-A-5282.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CORTEX BONE SCREWS 1.8MM 06MM LENGTH GOLD -,SUP-A-5300.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,884,618.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW M CORTEX 1.8 X 10 -,SUP-A-5300.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,654.69,458.283,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2X4MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2X5MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2X6MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2X7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5400.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2X8MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2X9MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5400.09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2X10MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2X11MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2X13MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2X14MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5400.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2X15MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.0 CORTICAL SCREW 16MM -,SUP-A-5400.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.0 X 17MM MEDARTIS -,SUP-A-5400.17/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL 2.0 X 18MM HD6 -,SUP-A-5400.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW APTUS TI CORTEX BONE GOLD 2.0 X 19MM -,SUP-A-5400.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2X20MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.0 CORTICAL SCREW 24MM -,SUP-A-5400.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2X6MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5450.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2X7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2X8MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5450.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2X9MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2X10MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2X11MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,295.02,206.514,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2X12MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2X13MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2X14MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW TRILOCK 2.0 X 14MM HD6 -,SUP-A-5450.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2X16MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.0 TRILOCK SCREW 18MM -,SUP-A-5450.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.0 TRILOCK SCREW 20MM -,SUP-A-5450.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.0 TRILOCK 20MM HD6 -,SUP-A-5450.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X5MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X6MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X7MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X8MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X9MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X10MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X11MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X12MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X13MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X14MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X18MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X19MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW M CORTEX 2.3 X 20 -,SUP-A-5500.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW M CORTEX 2.3 X 18 -,SUP-A-5500.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORT MEDARTIS 2.5 8MM -,SUP-A-5700.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5X10MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORT MEDARTIS 2.5 11MM -,SUP-A-5700.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5X12MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5X13MM NLCKG CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5700.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORT MEDARTIS 2.5 14MM -,SUP-A-5700.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW M CORT 2.5 X 15 -,SUP-A-5700.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOCKING SCREW 16 MM BLUE 2.5MM -,SUP-A-5700.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NON LOCKING BONE SCREW 16MM -,SUP-A-5700.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORT MEDARTIS 2.5 16MM -,SUP-A-5700.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5X18MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOCKING SCREW 18MM BLUE 2.5MM -,SUP-A-5700.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOCKING SCREW 20MM BLUE 2.5 -,SUP-A-5700.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5X20MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5X22MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.85,662.095,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5X24MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5X30MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,623.76,436.632,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CORTEX GOLD NON LCK 2.5 32MM  SCREW -,SUP-A-5700.32/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW M CORT 2.5 X 34MM -,SUP-A-5700.34/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5X20MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5720.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5X22MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5720.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5X10MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TRILOCK SCREW 2.5 12MM -,SUP-A-5750.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5X14MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5X16MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5X18MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCK MEDARTIS 2.5 18MM -,SUP-A-5750.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5X24MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5X26MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BLUE 2.5 X 28 LOCKING -,SUP-A-5750.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW M LOCKING 2.5 X 30MM -,SUP-A-5750.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5X32MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.8,742.56,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.5 TRILOCK SCREW 34MM -,SUP-A-5750.34/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5 TRILOCK EXPRESS 14MM HD7 PK/1 -,SUP-A-5755.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1158.25,810.775,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SILVER LOCKING SCREW 18MM -,SUP-A-5755.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1158.25,810.775,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SILVER LOCKING SCREW 20MM -,SUP-A-5755.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1158.25,810.775,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE APTUS 2.2 CANN COMP 10MM HD7 DISTAL THREAD 4MM -,SUP-A-5780.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE APTUS 2.2 CANN COMP 11MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE APTUS 2.2 CANN COMP 14MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE APTUS 2.2 CANN COMP 15MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE APTUS 2.2 CANN COMP 16MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANULATED COPR 17MM -,SUP-A-5780.17/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE APTUS 2.2 CANN COMP 19MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.2 CANNULATED SCREW COMPRESSION 20MM -,SUP-A-5780.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.2 CANNULATED COMPR 26MM DISTAL THREAD 6MM -,SUP-A-5780.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANULATED COPR 27MM -,SUP-A-5780.27/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.2 CANNULATED COMPR 30MM DISTAL THREAD 6MM -,SUP-A-5780.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MEDART CANN CMPR 2.2 X 22 -,SUP-A-5781.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MEDART CANN CMPR 2.2 X 24MM -,SUP-A-5781.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANNULATED 2.2 COMPRESSION LONG THREAD 26MM -,SUP-A-5781.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW COMPR CANNULATED 2.2 X 28MM -,SUP-A-5781.28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW COMPR CANNULATED 2.2 X 30MM -,SUP-A-5781.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MEDART CANN COMPR 2.2 X 32 -,SUP-A-5781.32/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW COMPR CANNULATED 2.2 X 36MM -,SUP-A-5781.36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW COMPR CANNULATED 2.2 X 38MM -,SUP-A-5781.38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.8 CORTICAL SCREW 10MM HD7 -,SUP-A-5800.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.8 CORTICAL SCREW 12MM HD7 -,SUP-A-5800.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.8X16MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.8X18MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.8X20MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.8X22MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.8X24MM CORT -,SUP-A-5800.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,654.69,458.283,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.8 CORTICAL SCREW 26MM HD7 -,SUP-A-5800.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.8 CORTICAL SCREW 28MM -,SUP-A-5800.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.8 CORTICAL SCREW 30MM HD7 -,SUP-A-5800.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.8 CORTICAL SCREW 32MM HD7 -,SUP-A-5800.32/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.8  CORTICAL SCREW 38MM- HD7 -,SUP-A-5800.38/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.8 GOLD CORTEX BONE 40MM HD7 -,SUP-A-5800.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.8X45MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.45/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORITCAL 50MM HD7 2.8 -,SUP-A-5800.50/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.8X55MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.55/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LAG 2.8 X 40 HD7 -,SUP-A-5830.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,654.69,458.283,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.8X14MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW TRILOCK BLUE 2.8 LOCKING16MM HD7 -,SUP-A-5850.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.8X18MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.8X20MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.8X22MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW TRILOCK 2.8 X 24MM HD7 -,SUP-A-5850.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW TRILOCK BLUE 2.8 LOCKING 26MM HD7 -,SUP-A-5850.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.8 TRILOCK  SCREW 28MM HD7 -,SUP-A-5850.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW TRILOCK BLUE 2.8 LOCKING 30MM HD7 -,SUP-A-5850.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.8 TRILOCK SCREW 32MM- HD7 -,SUP-A-5850.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.8 TRILOCK SCREW 36MM- HD7 -,SUP-A-5850.36/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.8 TRILOCK SCREW 38MM HD7 -,SUP-A-5850.38/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.8 TRILOCK SCREW 40MM HD7 -,SUP-A-5850.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.8 TRILOCK SCREW 50MM- HD7 -,SUP-A-5850.50/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.8 TRILOCK SCREW 55MM- HD7 -,SUP-A-5850.55/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.8 TRILCK 55MM -,SUP-A-5850.55/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.8,742.56,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.8 TRILOCK SCREW 70MM HD7 -,SUP-A-5850.70/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANNULATED SPEED TIP 3MM X 15MM -,SUP-A-5880.15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2326.39,1628.473,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANN SPEED TIP 3MM X 20MM -,SUP-A-5880.20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2326.87,1628.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3X24MM CANN SPEEDTIP CCS S/T SD HEXDRIVE 10 TI -,SUP-A-5880.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3X26MM CANN SPEEDTIP CCS S/T SD HEXDRIVE 10 TI -,SUP-A-5880.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.0 CANN COMPR 40 -,SUP-A-5880.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3X26MM CANN SPEEDTIP CCS LNG THRD SD HEXDRIVE 10 TI -,SUP-A-5881.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
3.0 CANNULATED COMPRSCREW28MM-HD10- DISTAL THREAD 9MM -,SUP-A-5881.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2326.39,1628.473,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3 X 30 CANN COMPR DISTAL THREAD -,SUP-A-5881.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3 X 36 CANN COMPR DISTAL THREAD -,SUP-A-5881.36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW EXTFIX 6/5MM DIA 100/ 40MM CORT TAPR DYNFX THRD -,SUP-A6010040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW EXTFIX 6MM/5X150MM CORT TAPR DYNFX VISION 50MM THRD -,SUP-A6015050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW EXTFIX 6MM/5X180MM CORT TAPR DYNFX VISION 50MM THRD -,SUP-A6018050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANULATED COMPR 44MM -,SUP-A-8112.44/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1707.29,1195.103,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
"PLATE M LK ""L"" 2/4 H LEFT -",SUP-AÂ€4650.20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3601.51,2521.057,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SYS BONE CMNT BIOCARTILAGE 3ML STRL -,SUP-ABS-1000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BIOCARTILAGE KIT SMALL JOINT -,SUP-ABS-1000-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FUNNEL BNCMNT BIOCARTILAGE -,SUP-ABS-1003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,163.38,114.366,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BIOCARTILAGE 1CC -,SUP-ABS-1010-BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4678.52,3274.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TACKER ABSORBATACK 5MM 30X -,SUP-ABSTACK30X,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2266.08,1586.256,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WAVEFORM C INTERBODY 16 X 14 X 7MM 7 DEG 3D -,SUP-AC4-264077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE WAVEFORM C INTERBODY 16 X 14X 8MM 7 DEGREE 3D -,SUP-AC4-264087,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 24MM COMPR HDLS ACUTRAK ACUTWIST FLLY W THRD PTCH -,SUP-AI-0024-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 26MM COMPR HDLS ACUTRAK ACUTWIST FLLY W THRD PTCH -,SUP-AI-0026-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 28MM COMPR HDLS ACUTRAK ACUTWIST FLLY W THRD PTCH -,SUP-AI-0028-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4-5X25MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0025-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4-5X30MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0030-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4-5X35MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0035-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4-5X40MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0040-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 45MM ACUTRAK 4/5 -,SUP-AM-0045-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5-6.5X50MM CANN HDLS ACUTRAK + 3MM HX DRV TI ALY STRL -,SUP-AP-0050-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2410.87,1687.609,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5-6.5X60MM CANN HDLS ACUTRAK + 3MM HX DRV TI ALY STRL -,SUP-AP-0060-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2410.87,1687.609,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE PLATE 10MM -,SUP-AP1-110010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 12MM -,SUP-AP1-110012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE 13MM PLATE -,SUP-AP1-110013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE ADMIRAL 14MM PLATE -,SUP-AP1-110014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE ANTERIOR CERVICAL PLATE 16MM -,SUP-AP1-110016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 30MM -,SUP-AP1-200030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ADMIRAL PLATE 36MM -,SUP-AP1-200036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE PLATE 28MM -,SUP-AP1-210028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE ADMIRAL 32MM SEASPINE -,SUP-AP1-210032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE ADMIRAL 36MM SPINE CERVICAL 2 LEVEL SEASPINE -,SUP-AP1-210036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE PLATE 54MM -,SUP-AP1-310054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ST 4 X 14 -,SUP-AP1-604014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ADMIRAL SCREW 4X14 -,SUP-AP1-614014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE SCREW 4 X 10 -,SUP-AP1-704010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 12MM -,SUP-AP1-704012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ADMIRA 4 X 14MM SPINE SELF TAP VARIABLE ANGLE SEASPINE -,SUP-AP1-704014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ADMIRAL 4.3 X 12MM SEASPINE -,SUP-AP1-704312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ADMIRAL 4.3 X 14MM SPINE SELF TAP VARIABLE ANGLE -,SUP-AP1-704314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ADMIRAL 4 X 12MM SEASPINE -,SUP-AP1-714012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE SCREW 4MM X 14MM SD -,SUP-AP1-714014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ADMIRAL 4 X 16MM SEASPINE -,SUP-AP1-714016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
4.0 X 14 FIX SCREW -,SUP-AP1-724014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6-7.5X70MM CANN HDLS ACUTRAK 6/7 4MM HX DRV TI ALY -,SUP-AP-6770-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6-7.5X75MM CANN HDLS ACUTRACK 6/7 4MM HX DRV TI ALY -,SUP-AP-6775-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE PROXIMAL ULNA 73MM LEFT -,SUP-APL-PUP-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5428.08,3799.656,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE PROXIMAL ULNA 108MM / LEFT -,SUP-APL-PUP-6HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6175.02,4322.514,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE PROXIMAL ULNA 108MM / RIGHT -,SUP-APL-PUP-6HR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6175.02,4322.514,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BONE 151MM ULNA LEFT PROXIMAL -,SUP-APL-PUP-9HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6531.52,4572.064,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEPIN ARSCP 1.1MM BLNT TIP F/BIOINTF SCR -,SUP-AR-1249,CDM,C1713,HCPCS,278,RC,,,outpatient,,,122.54,85.778,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEPIN ARSCP 2.4MM DRILL TIP F/BIOINTF SCR -,SUP-AR-1250L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DRILL SYSTEM FIXATION TIGHTROPE BTBT IB W/FLIPCUTTER III -,SUP-AR-1288BTBIB-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4816.94,3371.858,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DRILL TIGHTROPE RT IB W/FLIPCUTTER III -,SUP-AR-1288RTIB-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4477.42,3134.194,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FIBERTAG TIGHTROPE II IMPLANT W/ FLIPCUTTER III DRILL -,SUP-AR-1288RTT2-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FIBER TAG TIGHTROPE WITH FLIPCUTTER III -,SUP-AR-1288RTT-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEPIN ARSCP 2.4MM SUT EYE -,SUP-AR-1297L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X10MM CORT FT SLD TI STRL F/OSTMY SYS -,SUP-AR-13120T-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X10MM CANN LAG CORT P/T ST SLD TI F/OSTMY SYS -,SUP-AR-13120T-10C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X12MM CANN LAG CORT P/T ST SLD TI F/OSTMY SYS -,SUP-AR-13120T-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X14MM CANN LAG CORT P/T ST SLD TI F/OSTMY SYS -,SUP-AR-13120T-14C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X16MM CANN LAG CORT P/T ST SLD TI STRL F/OSTMY SYS -,SUP-AR-13120T-16C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NANO CORKSCREW FT TI W3-0 FW -,SUP-AR-1317FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUTURE MICRO CORKSCREW FT 2.2 X 4MM -,SUP-AR-1318FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 12.5MM OPN WDG SS -,SUP-AR-13200-12.5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 12.5MM TI SLP STRL -,SUP-AR-13200ST-12.5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUTURE TAK MICRO 2.4 X 6.5 BIOCOMPOSITE -,SUP-AR-1320BCNF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BB-TAK THREADED -,SUP-AR-13226T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SUTURETAPE S-TAK ASSY 3.0 SINGLE LOADED -,SUP-AR-1322BCST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SUTURETAPE S-TAK ASSY 3.0 SINGLE LOADED -,SUP-AR-1322BCST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X45MM CANC HTO PLATE TI F/OSTMY SYS -,SUP-AR-13280-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5X50MM CANC HTO PLATE TI F/OSTMY SYS -,SUP-AR-13280-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEPIN ARSCP 2.4MM F/OSTM -,SUP-AR-13303-2.4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,215.9,151.13,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEPIN SURG 3MM -,SUP-AR-13303-3.0,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SUBSTITUTE B TCP OPN WDG OSFERION 7MM 30MM -,SUP-AR-13370-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SUBSTITUTE B TCP WDG OSFERION 15X35MM -,SUP-AR-13370-4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X40MM CORT HTO PLATE TI F/OSTMY SYS -,SUP-AR-13380-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X46MM CORT HTO PLATE TI F/OSTMY SYS -,SUP-AR-13380-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUT IBALANCE 6.5X24MM HI TIB OPN PEEK -,SUP-AR-13401-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUT IBALANCE 6.5X28MM HI TIB OPN PEEK -,SUP-AR-13401-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SFT TIS CORT 4.5X38MM IBALANCE HTO -,SUP-AR-13402-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUT IBALANCE 4.5X40MM HI TIB OPN PEEK -,SUP-AR-13402-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUT IBALANCE HTO 4.5X48MM HI TIB OPN NABSB PEEK -,SUP-AR-13402-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN ARSCP FX 5X40MM PLLA FEM ABSB TRNSFX II F/ACL RECON -,SUP-AR-1351B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN ARSCP FX 5X50MM PLLA FEM ABSB TRNSFX II F/ACL RECON -,SUP-AR-1351LB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW INTFR CANN 6X23MM RND HEAD STP TAPR BIOCMPS FEM DBL -,SUP-AR-1360C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SILK 7 X 20 NON SHEATHED -,SUP-AR-1370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.64,822.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW INTFR CANN 7X23MM ABSB SHTH RND HEAD STP TAPR BIOCMPS -,SUP-AR-1370B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 7X23 BIOCOMPOSITE -,SUP-AR-1370C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW INTFR CANN TIGHTROPE RT 7X28MM FT ABSB RND HEAD STP -,SUP-AR-1370TC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN CONTR LOCK HTO 12.5MM A/P SLP WDG -,SUP-AR-13725-12.5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 8X23MM BIO -,SUP-AR-1380C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW INTFR CANN 8X28MM FT ABSB TAPR PLLA TIB KN STRL -,SUP-AR-1380TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 8 X 25 -,SUP-AR-1381,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SILK 9 X 2O NON SHEATHED -,SUP-AR-1390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.64,822.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW INTFR CANN TIGHTROPE RT 9X23MM SHTH ABSB HEX HEAD PLLA -,SUP-AR-1390B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 9 X 23 BIOCOMPOSITE -,SUP-AR-1390C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW INTFR CANN 9X28MM FT ABSB TAPR BIOCMPS PLLA TIB KN -,SUP-AR-1390TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SILK 9 X 25 NON SHEATHED -,SUP-AR-1391,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.64,822.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN SUTUREPLATE 90MM 3HL POLYAX TI STRL -,SUP-AR-14003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW INTFR CANN 10X23MM ABSB SHTH PLLA TIB KN GRD STRL -,SUP-AR-1400B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 10 X 23 BIOCOMPOSITE -,SUP-AR-1400C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW INTFR CANN 10X28MM ABSB FT TAPR PLLA TIB KN STRL -,SUP-AR-1400TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X18MM NLCKG CORT SUTUREPLATE TI STRL F/ARTHPL -,SUP-AR-14118NL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,262.58,183.806,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X20MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X22MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X26MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X26MM NLCKG CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14126NL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,262.58,183.806,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X28MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X32MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X34MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X36MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X38MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X40MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X50MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X28MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X32MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X38MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X48MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14248,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
KIT TENODESIS SCREW 3X8 DISPOSABLE -,SUP-AR-1530DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FOREFOOT IB IMPLANT SYS PEEK -,SUP-AR-1530P-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5920.38,4144.266,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW TENODESIS PEEK 3.5 X 8 -,SUP-AR-1530PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2146.7,1502.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4 X 10MM BIOTENODESIS -,SUP-AR-1540BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW TENODESIS PEEK 4X10 -,SUP-AR-1540PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW INTFR BIO-TENODESIS 4.75X15MM BABSRB BIOCMPS ANKL/FT -,SUP-AR-1547BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW TENODESIS PEEK 4.75X15MM INTERFERENCE -,SUP-AR-1547PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW TENODESIS PEEK  5.5 X 15 -,SUP-AR-1555PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW INTFR CANN BIO-TENODESIS 6.25X15MM BABSRB PEEK HND -,SUP-AR-1562BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW TENODESIS PEEK 6.25X15 -,SUP-AR-1562PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW INTFR CANN BIO-TENODESIS 7X23MM BABSRB PLLA HND WRST -,SUP-AR-1570BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW INTFR CANN BIO-TENODESIS 8X23MM BABSRB PLLA HND WRST -,SUP-AR-1580BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 9X20MM CORT RETROSCREW FT RTRGD RND HEAD PLLA STRL -,SUP-AR-1586RB-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1131.99,792.393,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
RETRO BUTTON 15MM -,SUP-AR-1588-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
RETRO BUTTON 20mm -,SUP-AR-1588-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
RETRO BUTTON 12mm/25 -,SUP-AR-1588-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
RETRO BUTTON 12MM/30MM -,SUP-AR-1588-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SYS ARTHROSCOPIC FX BTB TIGHTROPE RT F/ACL RECON -,SUP-AR-1588BTB-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2358.72,1651.104,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TIGHTROPE II RT WITH DEPLOYING SUTURE -,SUP-AR-1588RT-2J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2464.73,1725.311,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FIXATION ACL TIGHTROPE RT -,SUP-AR-1588RT-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FIXATION TIGHTROPE RT DBL -,SUP-AR-1588RT-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ACL TIGHTROPE WITH FIBER TAG -,SUP-AR-1588RTT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FIXATION ACL FEM TIGHTROPE -,SUP-AR-1588T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TIGHTROPE ABS BUTTON 11MM -,SUP-AR-1588TB-3IB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TIGHTROPE ABS BUTTON 14MM -,SUP-AR-1588TB-4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TIGHTROPE ABS BUTTON ROUND CONCAVE 20MM -,SUP-AR-1588TB-5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TIGHTROPE ABS BUTTON 20MM -,SUP-AR-1588TB-5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
IMPLANT TIGHTROPE ABS -,SUP-AR-1588TN,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
OPEN TIGHTROPE ABS -,SUP-AR-1588TN-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1131.99,792.393,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
IMPLANT FIXATION TIGHTROPE II ABS -,SUP-AR-1588TN-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TIGHTROPE II ABS- IMPLANT OPEN -,SUP-AR-1588TN-21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ACL TIGHTROPE WITH FIBER TAG ABS -,SUP-AR-1588TNT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1775.67,1242.969,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TIGHTROPE BUTTON EXTENDER -,SUP-AR-1589RT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW INTFR CANN BIO-TENODESIS 9X23MM BABSRB PLLA HND WRST -,SUP-AR-1590BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW INTFR BIO-TENODESIS 5.5X10MM BABSRB PEEK ANKL/FT HND -,SUP-AR-1655PS-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW INTFR BIO-TENODESIS 5.5X12MM PEEK SHOLUDER ELB -,SUP-AR-1655PS-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SWIVELOCK  BIOCOMPOSITE 8MM X 19.5MM -,SUP-AR-1662BC-8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2305.72,1614.004,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SYSTEM LATERAL ANKLE RECON -,SUP-AR-1675BC-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW INTFR CANN BIO-TENODESIS 8X12MM BABSRB PLLA SFT TIS -,SUP-AR-1680BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
KIT IB BC W/CC FT AND JUMPSTART -,SUP-AR-1788J-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
KIT IB BC W/CC FT AND JUMPSTART IMPLANT SYSTEM -,SUP-AR-1788J-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SWIVEL LOCK INTERNAL BRACE -,SUP-AR-1788J-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOW PROFILE SCREW 1.0 X 6MM CORTICAL TI -,SUP-AR-18710-06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOW PROFILE SCREW 1.0 X 7MM CORTICAL TI -,SUP-AR-18710-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOW PROFILE 2.4 X 10 CORTICAL -,SUP-AR-18724-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOW PROFILE 2.4 X 26 CORTICAL -,SUP-AR-18724-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
T-PLATE 2.4MM 6 HOLE -,SUP-AR-18724P-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TISSUE TAK TENDON ANCHOR -,SUP-AR-19021TT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUTURE CORKSCREW FT 3.5X10MM -,SUP-AR-1915FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ARTHREX SUTURE ANCHCRKSCRW FT3.5X10MM -,SUP-AR-1915FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUT CRKSCR 3.5X12MM THRD TI #2 SUT -,SUP-AR-1915S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUT CRKSCR 5X15MM ABSB -,SUP-AR-1920BF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1378.13,964.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUTURE CORKSCREW 5.0 -,SUP-AR-1920S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUT PSHLK 4.5X24MM BIOCMPS -,SUP-AR-1922BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUT BIO-PSHLK 4.5MMX18.5MM ABSB SLF-PNCH PLLA TI TIP -,SUP-AR-1922BM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2067.2,1447.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR PUSHLOCK 2.9 X 15.5 BIO -,SUP-AR-1923BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR PUSHLOK PEEK 2.9X15.5 -,SUP-AR-1923PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUT CRKSCR 6.5MMX15.5MM THRD ST TI SZ2 GRN WHT SUT -,SUP-AR-1925S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR CORKSCREW 6.5 FIBER 2 2 -,SUP-AR-1925SF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BIO-PUSHLOCK COMPOSITE 3.5MM -,SUP-AR-1926BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUT PSHLK 3.5MMX19.5MM PEEK HNDL INSRTR DRIVER -,SUP-AR-1926PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUT CRKSCR FT 5.5MMX14.7MM ARSCP FT BABSRB BIOCMPS -,SUP-AR-1927BCF-3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1802.17,1261.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR 4.5 BIO-COMPOSITE -,SUP-AR-1927BCF-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
6.5 BIOCOMPOSITE ANCHORS -,SUP-AR-1927BCF-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1775.67,1242.969,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR BIO CORKSCREW 5.5 -,SUP-AR-1927BCT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1881.68,1317.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR CORKSCREW 5.5 PEEK (BOX OF 5) -,SUP-AR-1927PSF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUT SUTAK 3MMX14.5MM ARSCP BIOCMPS ABSB #2 -,SUP-AR-1934BCF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1616.65,1131.655,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR BIOCOMPOSITE 3MM DBL -,SUP-AR-1934BCF-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUT SUTAK 2.4X12MM ARSCP BIOCMPS FIBERWIREX2 -,SUP-AR-1934BCF-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1616.65,1131.655,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUT SUTAK 2.4X12MM ARSCP BIOCMPS FIBERWIRE -,SUP-AR-1934BCF-24-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR BIOCOMPOSITE 3MM SING -,SUP-AR-1934BCT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1802.17,1261.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BIO SUTURE TAK DISPOSABLE -,SUP-AR-1934DS-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
KIT SUTURE TAK 3MM PERCUTANEOUS INSERTION -,SUP-AR-1934PI-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR KNOTLESS SUT TAK 3MM BI -,SUP-AR-1938BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR PEEK SUT TAK 3MM KNOTLESS -,SUP-AR-1938PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
IMPLANT DISTAL BICEP REPAIR 7 X 10MM -,SUP-AR-2260BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BUTTON SUT 2.6MM TI 12MM LF -,SUP-AR-2261,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BUTTON SUT DOG BN LF -,SUP-AR-2270,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SWIVEL LOCK 5.5 -,SUP-AR-2323BCC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUT SWIVLK C 5.5MMX19.1MM ABSB CLSD EYLT PLLA -,SUP-AR-2323BSLC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1987.69,1391.383,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SWIVELOCK- SP BC KL 5.5MM -,SUP-AR-2323KBCSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUT SWIVLK 5.5MMX24.5MM SLF-PNCH PEEK -,SUP-AR2323PSLM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUT SWIVLK C 4.7MMX19.1MM CLSD EYLT BIOCMPS WHT/BLK -,SUP-AR-2324BCCTT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR BIO COMP SWIVELOCK SP 4 (MIN 5 EACH) -,SUP-AR-2324BCM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR BIOCOMPOSITE SWIVEL W\FIBERTAPE -,SUP-AR-2324BCT-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SWIVELOCK  BIOCOMPOSITE 4.75MM X  22MM DOUBLE LOADED -,SUP-AR-2324BCT-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR BIO-SWIVELLOCK 4.75 -,SUP-AR-2324BCT-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SWIVELOCK KNOTLESS 4.75MM BC -,SUP-AR-2324KBCC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
KNOTLESS SWIVELOK 4.75MM BC W/TAPE -,SUP-AR-2324KBCCTT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2530.22,1771.154,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SWIVELOCK- SP BC KL 4.75MM -,SUP-AR-2324KBCSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUT BIO- SWIVLK SP 4.75MMX24.5MM SLF-PNCH PEEK TI -,SUP-AR-2324PSLM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BC SWIVELOCK 3.9 X 17.9 MM -,SUP-AR-2326BCC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
KIT SPEEDBRIDGE SHOULDER -,SUP-AR-2600SBS-8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8106.04,5674.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE DISTAL CLAVICLE 22 DEG RIGHT -,SUP-AR-2622DR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 8HL PRCONT SS LT CLVCL -,SUP-AR-2651CL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PRCONT SS RT CNTRL CLVCL -,SUP-AR-2653CR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN PRCONT SS LT CNTRL CLVCL -,SUP-AR-2654CL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE CLAVICLE DISTAL SHOR LEFT SS -,SUP-AR-2656DL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE CLAVICLE DISTAL SHORT RIGHT SS -,SUP-AR-2656DR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 8HL PRCONT SS RT CLVCL -,SUP-AR-2657DR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE DISTAL CLAVICLE BUTTON -,SUP-AR-2658,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DISTAL CLAVICLE REPAIR ASSEMBLY -,SUP-AR-2658T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SUTURE ANCHOR- BIOCOMPOSITE- HIP PUSHLOCK- SHORT 2.9 x 12.5 -,SUP-AR-2923BCH,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
KIT DISPOSABLES FOR FIBERTAK SUTR ANCH -,SUP-AR-3600DC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FIBERTAK WITH SUTURETAPE -,SUP-AR-3602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1881.68,1317.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.6 FIBERTAK ANCHOR DOUBLE  LOADED -,SUP-AR-3632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FIBERTAK ANCHOR TRIPLE LOADED -,SUP-AR-3633,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SELF-PUNCHING TRIPLE LOADED FIBERTAK -,SUP-AR-3633SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR FIBERTAK KNOTLESS -,SUP-AR-3636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FIBERTAK SHOULDER 1.8 SELF BUNCHING -,SUP-AR-3636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FIBERTAK HIP 1.8 SELF BUNCHING -,SUP-AR-3636H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
KNOTLESS 1.8 FIBERTAK W/ #2 SUTURE -,SUP-AR-3638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
KNOTLESS HIP FIBERTAK SUTURE ANCHOR- CURVED -,SUP-AR-3638DHC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
KIT FIBERTAK KNOTLESS STRAIGHT DISPOSABLE -,SUP-AR-3638DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SP FBTAK RC TGRTPE WH/BLK & STTPE WH/BL -,SUP-AR-3652SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SP FBTAC RC RBRTPE BLU & STTPE WH/BLK -,SUP-AR-3652TSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SP FBTAC RC RBRTPE BLK/BLU & STTPE BLU -,SUP-AR-3652TTSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
KL FBTK RC (WH/BLK)TT & (BLU)#2 MTS -,SUP-AR-3653SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2530.22,1771.154,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
KL FBTK RC W/(BLU)FT & (W/BLK) #2 MTS -,SUP-AR-3653TSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2530.22,1771.154,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
KNOTLESS TENSIONABLE FIBERTAK BICEP -,SUP-AR-3687,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ARTHROSCOPIC FX CHNDR -,SUP-AR-4005B-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW VENTED BC IF 7 X 20MM -,SUP-AR-4020C-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW VENTED BC IF 8 X 20MM -,SUP-AR-4020C-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW VENTED BC IF 9 X 20MM -,SUP-AR-4020C-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW VENTED BC IF 10 X 20MM -,SUP-AR-4020C-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ARTHREX PEEK SCREW 7 X 20MM FAST THREAD -,SUP-AR-4020P-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ARTHREX PEEK 8 X 20MM FAST THREAD -,SUP-AR-4020P-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ARTHREX PEEK 9 X 20MM FAST THREAD -,SUP-AR-4020P-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ARTHREX PEEK 10 X 20MM FAST THREAD -,SUP-AR-4020P-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW VENTED BC IF 7 X 30MM -,SUP-AR-4030C-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW VENTED BC IF 8 X 30MM -,SUP-AR-4030C-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW VENTED BC IF 9 X 30MM -,SUP-AR-4030C-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW VENTED BC IF 10 X 30MM -,SUP-AR-4030C-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW VENTED BC IF 11 X 30MM -,SUP-AR-4030C-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ARTHREX PEEK SCREW 7 X 30MM FAST THREAD -,SUP-AR-4030P-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ARTHREX PEEK 8 X 20MM FAST THREAD -,SUP-AR-4030P-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ARTHREX PEEK 9 X 30MM FAST THREAD -,SUP-AR-4030P-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ARTHREX PEEK 10 X 30MM FAST THREAD -,SUP-AR-4030P-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DEVICE SUT 1.5X5MM CRV C IN MNSCL 2-0 FIBERWIRE NDLX2 MINI -,SUP-AR-4500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
KIT BIOCOMPOSITE MENISCAL ROOT REPAIR -,SUP-AR-4550BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FIBER STITCH CURVED -,SUP-AR-4570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUTURE FIBERSTITCH FIBERWIRE POLYESTER 24 D 2-0 CURVE -,SUP-AR-4570-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
KIT ARTHROSCOPIC FIXATION FIBERSTITCH REVERSE CURVE -,SUP-AR-4570R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUTURE FIBERSTITCH STRAIGHT -,SUP-AR-4570S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW INTFR BIOCMPRSN 3X18MM BABSRB HDLS PLLA KN TAPR STP -,SUP-AR-5025B-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW INTFR BIOCMPRSN 2.7X20MM BABSRB HDLS PLLA KN TAPR STP -,SUP-AR-5025B-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 8 X 28 BIOCOMPOSITE -,SUP-AR-5028C-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 9X28 DELTA -,SUP-AR-5028C-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 10 X 28 BIOCOMPOSITE -,SUP-AR-5028C-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 11 X 28 DELTA -,SUP-AR-5028C-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 9 X 35 DELTA -,SUP-AR-5035TC-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 10 X 35 BIOCOMPOSITE -,SUP-AR-5035TC-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 11 X 35 DELTA -,SUP-AR-5035TC-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 12 X 35 BIOCOMPOSITE -,SUP-AR-5035TC-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WIRE GUIDE 1.35MM DUAL TROCAR -,SUP-AR-5050-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,239.24,167.468,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GRAFTBOLT TIBIAL 7MM -,SUP-AR-5100-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GRAFTBOLT TIBIAL 8MM -,SUP-AR-5100-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GRAFTBOLT TIBIAL 9MM -,SUP-AR-5100-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GRAFTBOLT TIBIAL 10MM -,SUP-AR-5100-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SUTURE ANCHOR- SWIVELOCK TENODESIS- PEEK -,SUP-AR-7324PSL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2969.43,2078.601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOW PROFILE SCREW TI 4.5 X 26MM -,SUP-AR-8545-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOW PROFILE SCREW TI 4.5 X 34MM -,SUP-AR-8545-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOW PROFILE SCREW TI 4.5 X 36MM -,SUP-AR-8545-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LO-PRO LOCK SCREW TI 4.5 X 28MM -,SUP-AR-8545L-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X55MM LCK -,SUP-AR-8545L-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X60MM LCK -,SUP-AR-8545L-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
IMPLANT SYSTEM CPR MINI SCORPION DX -,SUP-AR-8690DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
STAPLE BN FX QUICKFIX SM SS -,SUP-AR-8710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NITINOL COMPRESSION STAPLE- 9WX7L -,SUP-AR-8717-0907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NITINOL COMPRESSION STAPLE- 9WX10L -,SUP-AR-8717-0910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DYNANITE NITI STAPLE W/INSTRS 9WX10L -,SUP-AR-8717DS-0910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DYNANITE NITI STAPLE W/INSTRS 10W X 11L -,SUP-AR-8717DS-1110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DYNANITE NITI STAPLE W/INSTRS 11W X 15\12L -,SUP-AR-8717DS-111512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NITINOL COMP STAPLE 15W X 12L -,SUP-AR-8718-1512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
STAPLER DYNAMITE NITI  W/INSTRS 13W X 10L -,SUP-AR-8718DS-1310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8042.38,5629.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DYN NITI STAPLE W/INSTRS 15W X 12L -,SUP-AR-8718DS-1512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8042.38,5629.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
STAPLE 15W X 15L DYNANITE NITI W/INSTRS -,SUP-AR-8719DS-1515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DYN NITI STAPLE W/INSTRS 18W X 15L -,SUP-AR-8719DS-1815,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
STAPLE DYNANITE NITI W/INSTRS 18W X 18L -,SUP-AR-8719DS-1818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DYNANITE NITI STAPLE WINSTRS 20W X 20L -,SUP-AR-8719DS-2020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
QCKFIX SCRW TI CANN PT 2.0 X 10MM -,SUP-AR-8720-10PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.4X12MM HD CORT QUICKFIX ST SLD STND ALONE TI STRL -,SUP-AR-8724-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOW PROFILE 2.4 X 14 CORTEX -,SUP-AR-8724-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOW PROFILE SCREW 2.4 X 18MM CORTEX -,SUP-AR-8724-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW QUICKFIX 2.4 X 18MM TI CANNULATED -,SUP-AR-8724-18PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,846.08,592.256,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW QUICKFIX 2.4 X 22MM TI CANNULATED -,SUP-AR-8724-22PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,846.08,592.256,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.4X24MM CANN QUICKFIX P/T T8 HXLB DRV TI F/CMPRHNSV -,SUP-AR-8724-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOW PROFILE SCREW 2.4 X 32MM CORTEX -,SUP-AR-8724-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOW PROFILE SCREW 2.4 X 36MM CORTEX -,SUP-AR-8724-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.4 X 8 VAL TI -,SUP-AR-8724V-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.4 X 12 VAL TI -,SUP-AR-8724V-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.4 X 16 VAL TI -,SUP-AR-8724V-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.4MM X 18MM V AL SCREW TI -,SUP-AR-8724V-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW VAL TI 2.4MM X 18MM -,SUP-AR-8724V-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.4MM X 22MMV AL SCREW TI -,SUP-AR-8724V-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW VAL KREULOCK TI 2.4X12 -,SUP-AR-8724VCL-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW VAL KREULOCK TI 2.4X16 -,SUP-AR-8724VCL-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW COMPRESSION FT 2.5MM MICRO X 8MM LGTH -,SUP-AR-8725-08H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5MMX14MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-14H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5MMX16MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-16H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5MMX18MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-18H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5MMX20MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-20H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW COMPR FT 2.5 MICRO 22MM -,SUP-AR-8725-22H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5MMX24MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-24H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5MMX26MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-26H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COMPR FT SCREW 2.5 MICRO 28MM LGTH -,SUP-AR-8725-28H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEADLESS MICRO 2.5X 30MM -,SUP-AR-8725-30H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COMPR FT SCREW 2.5 MICRO 32MM LGTH -,SUP-AR-8725-32H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW QUICKFIX TI CANC PT 3.0 X 12MM -,SUP-AR-8730-12PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX14MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8730-14H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3MMX14MM DUAL CORE QUICKFIX -,SUP-AR-8730-14PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COMPR FT SCREW 3.5 MINI 16MM -,SUP-AR-8730-16H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3MMX16MM DUAL CORE QUICKFIX -,SUP-AR-8730-16PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COMPR FT SCRW 3.5 MINI 18MM LGTH -,SUP-AR-8730-18H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3MMX18MM DUAL CORE QUICKFIX -,SUP-AR-8730-18PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COMP SCREW 3.5 MINI 20MM -,SUP-AR-8730-20H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3MM X 20MM DUAL CORE QUICKFIX -,SUP-AR-8730-20PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COMPR FT SCREW 3.5 MINI 22MM -,SUP-AR-8730-22H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3MMX22MM DUAL CORE QUICKFIX -,SUP-AR-8730-22PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW FT COMPR 3.5 X 24MM -,SUP-AR-8730-24H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3MMX24MM DUAL CORE QUICKFIX -,SUP-AR-8730-24PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW COMPR FT 3.5 X 26 MINI -,SUP-AR-8730-26H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3MMX26MM DUAL CORE QUICKFIX P/T SD/ST T10 HXLB DRV TI -,SUP-AR-8730-26PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW COMPR FT 3.5 MINI 28MM -,SUP-AR-8730-28H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW FT COMPR 3.5 X 30MM -,SUP-AR-8730-30H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.6MMX32MM COMPR HDLS QUICKFIX P/T SD/ST T10 HXLB DRV -,SUP-AR-8730-32H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COMPR FT SCREW 3.5 MINI 34MM LGTH -,SUP-AR-8730-34H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
QCKFIX SCREW TI CANC PT 3.0 X 38MM -,SUP-AR-8730-38PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOW PROFILE SCREW CORTICAL 3.5MM X 14MM DRP -,SUP-AR-8735-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOW PROFILE SCREW CORTICAL 3.5MM X 16MM DRP -,SUP-AR-8735-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOW PROFILE SCREW CORTICAL 3.5MM X 18MM DRP -,SUP-AR-8735-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
3.5X32MM BEVELED FT SCREW -,SUP-AR-8735BV-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BEVELED FT 3.5MM X40MM -,SUP-AR-8735BV-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5 X 44MM BEVELED FT -,SUP-AR-8735BV-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOW PROFILE SCREW LOCKING 3.5MM X 16MM DRP -,SUP-AR-8735L-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEWIRE 0.86MM W/ LASER LINE SS -,SUP-AR-8737-21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,87.53,61.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW COMPR FT 4.0 STD 20MM LGTH -,SUP-AR-8740-20H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW COMPR FT 4.0 STD 22MM LGTH -,SUP-AR-8740-22H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COMPRESSION SCREW 4.0 24MM LENGTH -,SUP-AR-8740-24H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COMPRESSION SCREW 4.0 26MM LENGTH -,SUP-AR-8740-26H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COMPRESSION SCREW 4.0 28MM LENGTH -,SUP-AR-8740-28H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW COMPR FT 4.0 STD 30MM LGTH -,SUP-AR-8740-30H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW QUICKFIX TI CANN ST 4.0 X 38MM CANC -,SUP-AR-8740-38PTS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW QUICKFIX TI CANN 4.0 X 40MM ST CANC -,SUP-AR-8740-40PTS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
4X46MM BEVELED FT SCREW -,SUP-AR-8740BV-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4 X 50MM BEVELED FT -,SUP-AR-8740BV-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4 X 52MM BEVELED FT -,SUP-AR-8740BV-52,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WASHER 7.0MM TI -,SUP-AR-8740W,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEWIRE 1.6MM- 4MM BEVELED FT -,SUP-AR-8741-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEWIRE 1.6X150MM CAPITAL FRAG -,SUP-AR-8741-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW COMPR FT 5.0 X 42MM -,SUP-AR-8750-42H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW COMPR FT 5.0 X 55MM -,SUP-AR-8750-55H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COMPR FT SCREW 7.0 XL 65MM LGTH -,SUP-AR-8770-65H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COMPR FT SCREW 7.0 XL 70MM LGTH -,SUP-AR-8770-70H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COMPR FT SCREW 7.0 XL 75MM LGTH -,SUP-AR-8770-75H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUT BIO-PSHLK 2.5X8MM KNTLS PLLA ABSB #2 FIBERWIRE -,SUP-AR-8825B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUTURE PEEK MINI PUSHLOCK -,SUP-AR-8825P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
KREULOCK COMPRESSION SCREW SS 2.7 X 12MM -,SUP-AR-8827CL-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
KREULOCK COMPRESSION SCREW SS 2.7 X 14MM -,SUP-AR-8827CL-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
KREULOCK COMPRESSION SCREW SS 2.7 X 16MM -,SUP-AR-8827CL-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
KREULOCK COMPRESSION SCREW SS 2.7 X 18MM -,SUP-AR-8827CL-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
KREULOCK COMPRESSION SCREW SS 2.7 X 20MM -,SUP-AR-8827CL-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X10MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X12MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X18MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X20MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LO-PRO LOCK SS 2.7 X 22 -,SUP-AR-8827L-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LO-PRO LOCK 2.7 X 24 -,SUP-AR-8827L-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CANCLUS SCREW FULLY THREADED SS 3 X 24MM -,SUP-AR-8830-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LO-PRO SCREW TM SS 3.5 X 12MM CORT -,SUP-AR-8835-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X14MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X16MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X18MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X22MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X26MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X28MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X30MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X35MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X45MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X10MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X14MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X16MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X18MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X20MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X14MM NLCKG CANC TIGHTROPE FT SD T15 HXLB DRV SS -,SUP-AR-8840-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X16MM NLCKG CANC TIGHTROPE FT SD T15 HXLB DRV SS -,SUP-AR-8840-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X30MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X40MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X45MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X60MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X30MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X35MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X50MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X60MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PARS Suture Implant Kit w/ SutureTape -,SUP-AR-8862DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TIGHTROPE MINI 1.1MM -,SUP-AR-8914DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
VOLAR DISTAL RAD PLT TI NARROW LT 3HOLE -,SUP-AR-8916VNL-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
VOLAR DISTAL RAD PLT TI NARROW RT 3H -,SUP-AR-8916VNR-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
IMPLANT MINI TIGHTROPE 1.1 - 0 -,SUP-AR-8919DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
KT ARTHROSCOPIC FX TIGHTROPE ANKL 6.5MM RND BTN 3.5X10MM -,SUP-AR-8920CDS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
KT ARTHROSCOPIC FX TIGHTROPE ANKL 3.5MM RND/10MM OBLNG BTN -,SUP-AR-8921CDS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TIGHTROPE XP KNOTLESS TITANIUM -,SUP-AR-8925T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TIGHTROPE KNOTLESS -,SUP-AR-8926SS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4986.7,3490.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BIO-COMP ACHILLE SPEEDBRIDGE -,SUP-AR-8928BCJ-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SYSTEM IMPLANT MPFL BIOCOMPOSITE -,SUP-AR-8929BC-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6310.83,4417.581,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2X10MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI COLR F -,SUP-AR-8930-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2X11MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI MAG F -,SUP-AR-8930-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2X12MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI BLU F -,SUP-AR-8930-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2X13MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI GRN F -,SUP-AR-8930-13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2X14MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI PUR F -,SUP-AR-8930-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2X16MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI PUR F -,SUP-AR8930-16PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2X20MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI PUR F -,SUP-AR-8930-20PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3X12MM CANN CORT P/T TI -,SUP-AR-8933-12PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3X14MM CANN CORT P/T TI -,SUP-AR-8933-14PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LP SCREW 3 X 16MM CORTICAL MTP TI -,SUP-AR-8933-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3X16MM CANN CORT P/T TI -,SUP-AR-8933-16PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LO-PRO SCREW TI 3.0MM X 18MM CORT -,SUP-AR-8933-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3X18MM CANN CORT P/T TI -,SUP-AR-8933-18PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LO-PRO SCREW TI 3.0MM X 20MM CORT -,SUP-AR-8933-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LO-PRO SCREW TI 3.0MM X 22MM CORT -,SUP-AR-8933-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LO-PRO SCREW TI 3.0MM X 36MM CORT -,SUP-AR-8933-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3X14MM LCK CORT P/T TI BLU -,SUP-AR-8933L-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3X16MM LCK CORT P/T TI BLU -,SUP-AR-8933L-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
VAL KREULOCK SCREW TI 3 X 16 -,SUP-AR-8933VCL-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
VAL KREULOCK SCREW TI 3 X 18 -,SUP-AR-8933VCL-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
VAL KREULOCK SCREW TI 3 X 20 -,SUP-AR-8933VCL-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW VAL KREULOCK 3.0 X 22MM TI -,SUP-AR-8933VCL-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW VAL KREULOCK 3.0 X 26MM TI -,SUP-AR-8933VCL-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SUTURETAPE S-TAK ASSY 3.0 DOUBLE LOADED -,SUP-AR-8934BCST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
3.0 DOUBLE LOADED SUTURETAPE S-TAK ASSY -,SUP-AR-8934BCST-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LO-PRO SCREW TI 3.5MM X 12MM -,SUP-AR-8935-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LO-PRO SCREW TI 3.5MM X 22MM -,SUP-AR-8935-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LO-PRO SCREW TI 3.5MM X 24MM -,SUP-AR-8935-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LO-PRO TI 3.5MM X 26MM -,SUP-AR-8935-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LO-PRO TI 3.5MM X 30MM -,SUP-AR-8935-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LO-PRO SCREW TI 3.5MM X 32MM -,SUP-AR-8935-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LO-PRO TI 3.5MM X 34MM -,SUP-AR-8935-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LO-PRO SCREW TI 3.5MM X 36MM -,SUP-AR-8935-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LO-PRO SCREW TI 3.5MM X 38MM -,SUP-AR-8935-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LO-PRO SCREW TI 3.5MM X 40MM -,SUP-AR-8935-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LO-PRO SCREW TI 3.5MM X 42MM -,SUP-AR-8935-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LO-PRO SCREW TI 3.5MM X 44MM -,SUP-AR-8935-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LO-PRO SCREW TI 3.5MM X 46MM -,SUP-AR-8935-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LO-PRO SCREW TI 3.5MM X 48MM -,SUP-AR-8935-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW KREULOCK TI 3.5 X 24MM -,SUP-AR-8935CL-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW KREULOCK TI 3.5 X 26 -,SUP-AR-8935CL-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
KREULOCK SCREW TI 3.5 X 28 -,SUP-AR-8935CL-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW KREULOCK TI 3.5 X 28MM -,SUP-AR-8935CL-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW KREULOCK TI 3.5 X 30 -,SUP-AR-8935CL-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW KREULOCK TI 3.5 X 32 -,SUP-AR-8935CL-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
KREULOCK SCREW TI 3.5 X 34 -,SUP-AR-8935CL-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
KREULOCK SCREW TI 3.5 X 36 -,SUP-AR-8935CL-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LO-PRO LOCK SCREW TI 3.5MM X 12MM -,SUP-AR-8935L-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOCKING SCREW  TI 3.5MM X 14MM -,SUP-AR-8935L-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X24MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X26MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOCKING SCREW TITANIUM 3.5MM X 28MM -,SUP-AR-8935L-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING TITANIUM 3.5MM X 28MM -,SUP-AR-8935L-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X30MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X32MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOCKING SCREW TITANIUM 3.5MM X 34MM -,SUP-AR-8935L-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOCKING SCREW TITANIUM 3.5MM X 44MM -,SUP-AR-8935L-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
KIT ENDOSCOPIC BOSTROM REPAIR IMPLANT SYS -,SUP-AR-8936BC-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X30MM CANC FT SD TI STRL F/H-PLATE LPDS SURG -,SUP-AR-8940-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LO-PRO TI 4.0MM X 36MM -,SUP-AR-8940-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X40MM CANC FT SD TI -,SUP-AR-8940-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN TIGHTROPE 79MM F/SYNDSMS RPR 4HL SS BTRSS LT -,SUP-AR-8943BL-04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN TIGHTROPE 79MM F/SYNDSMS RPR 4HL SS BTRSS RT -,SUP-AR-8943BR-04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN TIGHTROPE 91MM F/SYNDSMS RPR 5HL SS BTRSS -,SUP-AR-8943BR-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN TIGHTROPE 104MM F/SYNDSMS RPR 6HL SS BTRSS -,SUP-AR-8943BR-06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN TIGHTROPE 61MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943H-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN TIGHTROPE F/DLTD LGMNT ATTCH AVULSION FX SYNDSMS -,SUP-AR-8943H-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN TIGHTROPE 47MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943T-04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN TIGHTROPE 72MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943T-06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN TIGHTROPE 98MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943T-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1404.63,983.241,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN TIGHTROPE F/SYNDSMS AVULSION FX MGMT 10HL LCK SS -,SUP-AR-8943T-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1484.14,1038.898,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN TIGHTROPE 72MM F/SYNDSMS AVULSION FX MGMT 3HL SS -,SUP-AR-8943TH-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN TIGHTROPE F/SYNDSMS AVULSION FX MGMT 7HL LCK SS 1/3 -,SUP-AR-8943TH-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN TIGHTROPE 43MM TI BTRSS 3.5MM LPS SCR 2.4MM GW -,SUP-AR-8947DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.1,3045.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 7.5MM STP -,SUP-AR-8949-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LISFRANC PLATE MEDIUM LEFT TI -,SUP-AR-8951ML,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE MEDIUM RIGHT TITANIUM LISFRANC -,SUP-AR-8951MR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LISFRANC PLATE SMALL RIGHT TI -,SUP-AR-8951SR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.5MM 2HOLE L-PLATE TI 5H RT -,SUP-AR-8952ML-05R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 3MM 5HL TI STR -,SUP-AR-8952TS-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CALCFX PERCPLT STD ANTERIOR PROCESS L -,SUP-AR-8954ML-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE LONG CALCANEUS RIGHT TUBEROSITY 3.5/4 MM PERCUTANEOUS -,SUP-AR-8954YR-L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BONE TAP CANNULATED 6.0MM -,SUP-AR-8956C-60T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE LONG METATARSAL RIGHT HOOK -,SUP-AR-8956R-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 2 HOLE TITANIUM -,SUP-AR-8958-02S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANTEROLATERAL PILON FUSION PLATE 5 HOLE LT -,SUP-AR-8963ALF-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12624.2,8836.94,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANTEROLATERAL PILON FUSION PLATE 7H RT -,SUP-AR-8963ARF-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.7X65MM CANN 18MM THRD SD/ST TI -,SUP-AR-8967-1865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WASHER ORTHO 13MM TI -,SUP-AR-8967W,CDM,C1713,HCPCS,278,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
KIT DX SWIVELOCK SL 3.5X8.5MM -,SUP-AR-8978DS-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SWIVELOCK DX SL 3.5 X 8.5 -,SUP-AR-8978P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SYSTEM INTERNAL FIXATION FIBERLOCK SUSPENSION  3.5 X 8.5 -,SUP-AR-8988-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5889.19,4122.433,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUTURE FIBER TAK DX -,SUP-AR-8990ST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2464.73,1725.311,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR FIBERTAK DOUBLE-LOADED DX SUTURE -,SUP-AR-8990ST-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2878.72,2015.104,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DX FIBERTAK SUTURE ANCHOR #2 MTS W/NDL -,SUP-AR-8991,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SWIVELOCK DISP KIT NANO 2.5 X 7 -,SUP-AR-8998DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NANO SWIVELOCK 2.5 X 7 WITH FORK EYELET -,SUP-AR-8998T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X45MM P/T TI F /5TH MTRSL JONES FX SYS -,SUP-AR-9045-45PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X55MM P/T TI GRN -,SUP-AR-9045-55PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LO-PRO SCREW PT THREADED TI 5.5MM X 40MM -,SUP-AR-9055-40PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LO-PRO SCRW PT THD TI 6.0MM X 40MM -,SUP-AR-9060-40PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCK GLENOID PERIPH -,SUP-AR-9145-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CENTRAL NL 6.5 X 25MM -,SUP-AR-9165-25NL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BC ACHILLES SPDBRG W/KL DX CC 3.9MM -,SUP-AR-9928BCK-DX,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10749.14,7524.398,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LP SCREW 3 X 18MM CORTICAL MTP TI -,SUP-AR-9933-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LP SCREW 3 X 20MM CORTICAL MTP TI -,SUP-AR-9933-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LP 3.0 X 22MM CORTICAL MTP TI -,SUP-AR-9933-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LP 3.0 X 24MM CORTICAL MTP TI -,SUP-AR-9933-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LP SCREW 3 X 16MM CORTICAL HYBRID MTP TI -,SUP-AR-9933HY-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOCK MED HOOK PLATE TI 3H -,SUP-AR-9943H-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
MAXFORCE MTP PLATE PETITE 0-0 RIGHT -,SUP-AR-9944P-0R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE MAXFORCE STD 5-5 RIGHT MTP -,SUP-AR-9944S-5R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 12.5MM CANN HDLS ACUTRAK STD TI ALY -,SUP-AT-1125-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.3-3.8X15MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI -,SUP-AT-1150-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.3-3.9MM 17.5MM CANN HDLS ACUTRAK FT ST STD 2MM HX -,SUP-AT-1175-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 20MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI ALY -,SUP-AT-1200-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.3-4.2MM 22.5MM CANN HDLS ACUTRAK FT ST STD 2MM HX -,SUP-AT-1225-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.3-4.4X25MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI -,SUP-AT-1250-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.3-4.5MM 27.5MM CANN HDLS ACUTRAK FT ST STD 2MM HX -,SUP-AT-1275-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.3-4.6X30MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI -,SUP-AT-1300-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5-2.8 MMX8MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5-2.8 MMX9MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5-2.8 MMX12MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5-2.8 MMX14MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5-2.8 MMX16MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5-2.8 MMX18MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5-2.8 MMX20MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5-2.8 MMX26MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5-2.8 MMX28MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5-3.6 MMX16MM CANN HDLS ACUTRAK 2 FT SLF CT 2MM HX -,SUP-AT2-M16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5-3.6 MMX22MM CANN HDLS ACUTRAK 2 FT SLF CT 2MM HX -,SUP-AT2-M22-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5-3.6 MMX24MM CANN HDLS ACUTRAK 2 FT SLF CT 2MM HX -,SUP-AT2-M24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4-4.1X16MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT STD -,SUP-AT2-S16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4-4.1X26MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT STD -,SUP-AT2-S26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4-4.1X34MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST CUT STD -,SUP-AT2-S34-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3-2.5X24MM CANN HDLS ACUTRAK FUSION FT ST 1.5MM/2MM -,SUP-ATF-240-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1966.49,1376.543,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3-3.5X32MM CANN HDLS ACUTRAK FUSION FT ST 1.5MM/2MM -,SUP-ATF-320-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1966.49,1376.543,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.8-3.2 MMX10MM CANN HDLS ACUTRAK FT ST 1.5MM HX DRV -,SUP-ATM-100-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
UNIVERSAL CEMENT RESTRICOTR SM 18.5MM -,SUP-B000-0185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
RESTRICTOR CMNT UNIV 24MM OSTEONICS -,SUP-B000-0240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
RESTRICTOR CEMENT UNIVERSAL SMALL INSERTER -,SUP-B000-1185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
RESTRICTOR CMNT MED UNIV STRL -,SUP-B000-1240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
RESTRICTOR BNCMNT 11MM -,SUP-B0010110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
RESTRICTOR BNCMNT 15.5MM -,SUP-B0020125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
RESTRICTOR BNCMNT 14MM -,SUP-B0030140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5MMX110MM CANC DYNFX 50MM THRD TAPR -,SUP-B6011050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW EXTFIX 6/5MM DIA 130/ 60MM CORT/CANC TAPR DYNFX THRD -,SUP-B6013060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,485.47,339.829,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW TITAN REV SHOULDER LARGE -,SUP-BBS-0960-21LRG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
REVERSE BODY SMALL AND REVERSCE BODY SCREW -,SUP-BBS-0960-21SML,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BALLOON 6FR PTA 200CM X 3MM X 120MM METACROSS -,SUP-BD-P30150ER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
AFX2 BIFURCATED ENDOGRAFT SYSTEM -,SUP-BEA25-80/I13-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
STENT BIFURCATED ENDOGRAFT AFX2  28MM X 80MM -I16-40 -,SUP-BEA28-80/I16-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,37002.53,25901.771,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN TRIMED VOLAR BUTT 20 -,SUP-BP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
RSS BODY SCREW -,SUP-BSC-0960-021-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW TI F/TITAN MODLR SHLDR SYS -,SUP-BSW-0920-021-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,758.61,531.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
MIXER CEMENT KYPHON W  CEMENT -,SUP-C01B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,919.01,643.307,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
"K-WIRE PIN COVER .028"" -",SUP-C-028NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X12MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-C03120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X16MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-C03160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
"K-WIRE PIN COVER .035"" -",SUP-C-035NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
"K-WIRE PIN COVER .045"" -",SUP-C-045NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
"K-WIRE PIN COVER .054"" -",SUP-C-054NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
"K-WIRE PIN COVER .062"" -",SUP-C-062NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
EXTERNAL FX 0.375IN BALL COLR F/CAP VRS SZ K-WIRE -,SUP-C50-COL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.5,771.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4X14MM LCK CANC ACU-LOC 2 HEX HEAD TI NS F/MAYO -,SUP-CA-4140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,542.66,379.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GRAFT CANC 30ML CHP RDIGRF FRZDR CRSH VOID FIL 1-8MM -,SUP-CAN30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1984.24,1388.968,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
EXPERT KNEE CAPITATED REVISION SYSTEM -,SUP-CAP PRICE,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21164.1,14814.87,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CEMENT CARTRIDGE CC02A CDS -,SUP-CC02A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DISC CERVICAL SIZE 6MM LL M6 -,SUP-CDL-637L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CERVICAL DISC SIZE 6MM M6 ORTHOFIX -,SUP-CDM-625,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CERVICAL DISC 6 MEDIUM LONG ARTIFICIAL -,SUP-CDM-635L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CEMENT GUN AND BONE FILLER CDS2A SIZE 2 -,SUP-CDS2A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2361.37,1652.959,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
EXCLUDER ILIAC 23MM X 10MM X 10CM 16FR BRANCH ENDO -,SUP-CEB231010A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31520.86,22064.602,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
IMPLANT VARILIFT- C STND ALONE XPD -,SUP-CIC1-7.5-12-BP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5835.5,4084.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE VARILIFT- C ST -,SUP-CIC1-9.0-12-BP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5835.5,4084.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
KT SUTURE REM SUT PRB KNT PSHR/CTR INTRO CROSSFIX II DISP -,SUP-CM-8000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DEVICE MENISCOTOME UP CRV STRONGER STF NDL HI STRGTH SUT -,SUP-CM-8002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR JK 2.9 SL WT/BL NS BK JUGGERKNOT -,SUP-CM-99329B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2067.2,1447.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR JK 2.9 BDL WT/BL NS BKLU BB JUGGERKNOT -,SUP-CM-99429B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2067.2,1447.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X12MM NLCKG CORT ACU-LOK 2 TI NS F/MAYO -,SUP-CO-2712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X14MM NLCKG CORT ACU-LOK 2 TI NS F/MAYO -,SUP-CO-2714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X16MM NLCKG CORT ACU-LOK 2 TI NS F/MAYO -,SUP-CO-2716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X20MM NLCKG CORT ACU-LOC 2 TI NS F/MAYO -,SUP-CO-2720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X22MM NLCKG CORT ACU-LOC 2 TI NS F/MAYO -,SUP-CO-2722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X6MM NLCKG CORT ACU-LOK 2 TI NS -,SUP-CO-3060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X10MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X12MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X14MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X16MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X24MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X25MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X26MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X28MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X30MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X32MM NLCKG CORT ACU-LOC 2 POLARUS TI NS COLR -,SUP-CO-3320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X12MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X14MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X16MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.7X18MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X8MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X10MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X12MM LCK CORT -,SUP-COL-3120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X14MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X20MM LCK CORT FT TI F/MAYO PLATE/MODULAR/UNIV SYS -,SUP-COL-3200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X22MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORITICAL LOCKING TI 3.5 X 13MM -,SUP-COLS -35130-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW GEMINUS CORTICAL LOCKING 3.5MM X 8MM TI -,SUP-COLS-35080-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL LOCKING 3.5 X 9 -,SUP-COLS-35090-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL LOCKING 3.5 X 10 -,SUP-COLS-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL LOCKING 3.5MM X 11MM -,SUP-COLS-35110-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL LOCKING 3.5MM X 12MM -,SUP-COLS-35120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW- CORTICAL LOCKING 3.5MM X 12MM -,SUP-COLS-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORT LOCKING 3.5MM X 15MM -,SUP-COLS-35150-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL LOCKING 3.5MM X 16MM -,SUP-COLS-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL LOCKING 3.5 X 18 -,SUP-COLS-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL LOCKING 3.5MM X 20MM TI -,SUP-COLS-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL LOCKING 3.5 X 24 -,SUP-COLS-35240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL LOCKING 3.5 X 26 -,SUP-COLS-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X14MM CORT ACU-LOC 2 FT NTOGG TI NS F/UNIV SYS -,SUP-CO-N2314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X22MM CORT ACU-LOC 2 FT NTOGG TI NS F/UNIV SYS -,SUP-CO-N2322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X14MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X16MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X18MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.3X20MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
RTR CROSS CONNECTOR -,SUP-CPF-CR 26 32-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CROSS CONNECTOR 32-44 -,SUP-CPF-CR 32 44-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL 3.5 X 12 -,SUP-CPF-CS 35 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CC PREFERRED ANGLE 3.5 X 14 -,SUP-CPF-CS 35 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CC PREFERRED ANGLE 3.5 X 18 -,SUP-CPF-CS 35 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CC PREFERRED ANGLE 3.5 X 20 -,SUP-CPF-CS 35 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LARGE OFFSET -,SUP-CPF-LC 00 0L-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SPINEART ML PREFERRED ANGLE 4MM X 12MM -,SUP-CPF-MS 04 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ML PREFERRED ANGLE SCRE 4 X 16 -,SUP-CPF-MS 04 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ML PREFERRED ANGLE SCRE 4 X 18 -,SUP-CPF-MS 04 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ML PREFERRED ANGLE 4 X 20 -,SUP-CPF-MS 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ML PREFERRED ANGLE 4 X 24 -,SUP-CPF-MS 04 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPINEART PERLA ML PREFERRED ANGLE SCREW 4 X 28 -,SUP-CPF-MS 04 28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ML PREFERRED 3.5 X 12 -,SUP-CPF-MS 35 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ML 35 X 14 -,SUP-CPF-MS 35 14S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW PERLA ML PREFERRED ANGLE 3.5MM X 16MM -,SUP-CPF-MS 35 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ML PREFERRED 3.5 X 18 -,SUP-CPF-MS 35 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ML 35 X 20 -,SUP-CPF-MS 35 20S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ML 35 X 24 -,SUP-CPF-MS 35 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SPINEART ML PREFERRED ANGLE 4MM X 14MM -,SUP-CPF-MS-04 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CONNECTOR PARALLEL 3-3 -,SUP-CPF-PC 30 3C-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CONNECTOR PARALLEL 3-5 -,SUP-CPF-PC 3C 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD PERLA 90MM TI -,SUP-CPF-PF T0 90-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PREBENT ROD COBALT CHROMIUM 45MM -,SUP-CPF-PR C0 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD PREBENT TITANIUM 3.5 X 40MM -,SUP-CPF-PR T0 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD 50MM -,SUP-CPF-PR T0 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD 60MM PREBENT TITANIUM -,SUP-CPF-PR T0 60-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PERLA PREBENT ROD TITANIUM 3.5 X 65MM -,SUP-CPF-PR T0 65-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD 70MM -,SUP-CPF-PR T0 70-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PERLA PREBENT ROD TITANIUM 3.5 X 75MM -,SUP-CPF-PR T0 75-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD PREBENT TITANIUM 3.5 L80 -,SUP-CPF-PR T0 80-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD 85MM -,SUP-CPF-PR T0 85-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD 45MM -,SUP-CPF-PR TO 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PREBENT TITANIUM ROD 3.5 X L12 PERLA -,SUP-CPF-PR TO 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD PREBENT TITANIUM 55MM -,SUP-CPF-PR TO 55-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD 60MM -,SUP-CPF-PR TO 60-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PRE-BENT ROD 3.5 X 90MM -,SUP-CPF-PR TO 90-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW POLY PERLA 4 X 10MM -,SUP-CPF-PS 04 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PERLA SCREW 12MM -,SUP-CPF-PS 04 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW POLYAXIAL PERLA 4MM X 12MM -,SUP-CPF-PS 04 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW POLYAXIAL 4MM X 14MM -,SUP-CPF-PS 04 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW POLYAXIAL 4 X 16 -,SUP-CPF-PS 04 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW POLY 4 X 18MM -,SUP-CPF-PS 04 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW POLYAXIAL PERLA 4MM X 20MM -,SUP-CPF-PS 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW POLY PERLA 4.0 X 24MM -,SUP-CPF-PS 04 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE PERLA 4MM X 32MM SPINE POLYAXIAL -,SUP-CPF-PS 04 32-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PERLA POLYAXIAL SCREW 3.5 X 10MM -,SUP-CPF-PS 35 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW POLY 3.5 X 12MM PERLA -,SUP-CPF-PS 35 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW PERLA 3.5 X 14 -,SUP-CPF-PS 35 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
3.5 x 16MM POLY SCREW -,SUP-CPF-PS 35 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW POLY 3.5 X 18MM PERLA -,SUP-CPF-PS 35 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PERLA POLYAXIAL SCREW 3.5 X 20MM -,SUP-CPF-PS 35 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
POLYAXIAL SCREW 3.5 X 24 -,SUP-CPF-PS 35 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW POLY PERLA 3.5MM X 28MM -,SUP-CPF-PS 35 28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
POLYAXIAL SCREW 3.5 X 12 -,SUP-CPF-PS 3512-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
POLYAXIAL SCREW 4.0 X 28 -,SUP-CPF-PS-0428-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
3.5 X 28 POLY SCREW -,SUP-CPF-PS-3528-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREWS SET PERLA -,SUP-CPF-SC 00 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPINEART STRAIGHT ROD CHROMIUM 350MM -,SUP-CPF-SR C3 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD TITANIUM 40MM -,SUP-CPF-SR CO 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD TITANIUM 80MM -,SUP-CPF-SR T0 80-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PERLA STRAIGHT ROD TITANIUM 03.5 L100 -,SUP-CPF-SR T1 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD TI 120MM -,SUP-CPF-SR T1 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD 240 -,SUP-CPF-SR T2 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SMOOTH SHANK SCREW 4MM Z 20 -,SUP-CPF-SS 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SS 3.5 X 20 -,SUP-CPF-SS 35 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SS 3.5 X 22 -,SUP-CPF-SS 35 22-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SS 3.5 X 24 -,SUP-CPF-SS 35 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREWS SS 3.5 X 26 -,SUP-CPF-SS 35 26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
3.5 x 28MM SMOOTH SHANK -,SUP-CPF-SS 35 28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SS 3.5 X 34 -,SUP-CPF-SS 35 34-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
3.5 X 30MM POLY SCREW -,SUP-CPF-SS-35 30-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X12MM CORT DVR FT CRUCIF HEAD MAG -,SUP-CS12000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X16MM CORT DVR FT CRUCIF HEAD MAG -,SUP-CS16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X18MM CORT DVR FT CRUCIF HEAD MAG -,SUP-CS18000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GRAFT STRUT MATRGRF FRZDR 15X100MM -,SUP-CST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3457.04,2419.928,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BONE CEMENT CX01B XPEDE W MIXER US -,SUP-CX01B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1598.1,1118.67,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
HEADLESS 3.0X40 SCREW -,SUP-D2N30040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.61,678.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TORNIER LONG HUMERAL NAIL LEFT 7MM X 230MM -,SUP-DHN5796,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13273.98,9291.786,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE DISTAL HUMERUS MEDIAL DIRECT 105MM -,SUP-DHPF-MDL-5HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN SCREW DISTRACTION 12MM -,SUP-DP-12-TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,145.88,102.116,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN SCREW DISTRACTION 14MM -,SUP-DP-14-TY,CDM,C1713,HCPCS,278,RC,,,outpatient,,,145.88,102.116,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ULNAR STEM 6.0MM 2CM EXT STEM -,SUP-DRUJ-IS260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9932.28,6952.596,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOCKING RADIAL PLATE SZ 20-15MM ASSY -,SUP-DRUJ-LP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19433.84,13603.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
14MM 3.5 LOCKING SCREW -,SUP-DRUJ-LSC14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,799.4,559.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
20MM 3.5 LOCKING SCREW -,SUP-DRUJ-LSC20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,799.4,559.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
22MM 3.5 LOCKING SCREW -,SUP-DRUJ-LSC22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,799.4,559.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
20MM 3.5 CORTICAL SCREW -,SUP-DRUJ-SC20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,636.02,445.214,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW DISTAL TROCHLEA COMP 3.5 X 45 TI -,SUP-DTCS-35045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW DISTAL TROCHLEA COMP 3.5 X 50 -,SUP-DTCS-35050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN DVR 24.4MMX51.3MM 4HL STD SHRT NS LT -,SUP-DVRAL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN DVR ANTMC NRW -,SUP-DVRANR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3828.27,2679.789,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN DVR 21.6MMX48.9MM 4HL SHRT BTRSS NRW NS -,SUP-DVRANSL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN DVR 21.6MMX48.9MM 4HL SHRT NS -,SUP-DVRANSR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN DVR 24.4MMX51.3MM 4HL STD SHRT NS RT -,SUP-DVRAR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN DVR 24.4MMX51.3MM 4HL STD SHRT NS RT RADL -,SUP-DVRASR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN DVR 28.2MMX62.6MM 4HL W NS -,SUP-DVRAWL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN DVR 28.2MMX62.6MM 4HL W BTRSS NS -,SUP-DVRAWR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN DVR 24.4MMX89.5MM 4HL EXTEND XLNG BTRSS NS -,SUP-DVRAXL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN DVR 24.4MMX59.5MM 4HL NS LT -,SUP-DVR-L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TORNIER PERFORM REVERESED CTRSCREW 6.5MM X 25MM NON ST -,SUP-DWJ125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TORNIER PERFORM REVERSED PERIPSCREW 5.0MM X 14MM NON ST -,SUP-DWJ314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1144.91,801.437,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TORNIER PERFORM REVERSED PERIPSCREW 5.0MM X 18MM NON ST -,SUP-DWJ318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1144.91,801.437,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
RESTRICTOR HUM CMNT 24MM F/TOT ELB PROS LTD -,SUP-EB0101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1166.11,816.277,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
RESTRICTOR CMNT TORNIER -,SUP-EBO101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1293.32,905.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ROMEO POLYAXIAL 6 X 40 -,SUP-ELL-PS 06 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X25MM SIGNTR POLYAX FX F /ROMEO PDCL SYS TI ALY -,SUP-ELL-PS0525-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X30MM SIGNTR POLYAX FX F /ROMEO PDCL SYS TI ALY -,SUP-ELL-PS0530-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW POLYAXIAL 5 X 35 -,SUP-ELL-PS0535-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW POLYAXIAL 6 X 30 -,SUP-ELL-PS0630-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6X35MM SIGNTR POLYAX FX F /ROMEO PDCL SYS TI ALY -,SUP-ELL-PS0635-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD 30MM -,SUP-ELL-RD 00 30 S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD ROMEO STRAIGHT HEX TIP 0.54 L240 -,SUP-ELL-RD 22 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPIN ROMEO 5.4X50MM PREBNT TI LMBR SFT MLBL F/TRNSCONN -,SUP-ELL-RD0050-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SET SCREW SPIN ROMEO2 -,SUP-ELL-SC 00 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GRAFT STENT 49E X 36MM X 36MM ENDURANT II AO EXT -,SUP-ETCF3636C49E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18052.61,12636.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
STENT ENDURANT II GRAFT 16F X 16MM X 146MM LIMB -,SUP-ETLW1616C146E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GRAFT STENT ENDUR II LIMB ELTW1620C146E -,SUP-ETLW1620C146E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
INFRAME IMPLANT 2.0MM X 32MM -,SUP-EXINF922032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
INFRAME EXSOMED IMPLANT 2.0MM X 36MM -,SUP-EXINF922036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6972.89,4881.023,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
INNATE IMPLANT 3.6MM X 35MM -,SUP-EXINN923635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL INTRAMEDULLARY INNATE IMPLANT 3.6MM X 40MM -,SUP-EXINN923640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
INNATE IMPLANT 3.6MM X 50MM -,SUP-EXINN923650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL INTRAMEDULLARY INNATE IMPLANT 3.6MM X 55MM -,SUP-EXINN923655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL INTRAMEDULLARY INNATE IMPLANT 4.5MM X 45MM -,SUP-EXINN924545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL INNATE IMPLANT 4.5MM X 50MM -,SUP-EXINN924550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
INNATE IMPLANT 4.5 X 55 -,SUP-EXINN924555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
STRYKER EASY CLIP STAPLE -,SUP-EZ 20-20-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9747.74,6823.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
EASYCLIP 15 X 15 X 15 -,SUP-EZ15-15-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8823.28,6176.296,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
EASYCLIP FIXATION DEVICE 18 X 19 X 17 -,SUP-EZ18-19-17,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8823.28,6176.296,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
EASYCLIP FIXATION DEVICE 20 X 20 X 20 -,SUP-EZ20-20-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9747.74,6823.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
EASYCLIP 8 X 8 X 8MM -,SUP-EZM08-08-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6512.42,4558.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BONE FILLER DEVICE SIZE 3 -,SUP-F04B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,577.67,404.369,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DEVICE BN FIL FEM SZ2 KYPHX EXP STRL -,SUP-F06A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,577.67,404.369,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ORTHOFIX 8.5 CAGE -,SUP-F28-3182,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SHAFT FROZEN BISECTED FEM -,SUP-FBFS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4383.06,3068.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CLAMP CRANIAL 11MM CRANIOFIX -,SUP-FF490T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,695.9,487.13,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CLAMP CRANIAL 16MM TITANIUM CRANIOFIX 2 -,SUP-FF491T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,862.41,603.687,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CLAMP CRANIAL 20MM TITANIUM CRANIOFIX 2 -,SUP-FF492T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1035.56,724.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW FREEFIX  COMPRESSION 3.5MM X 20MM TI -,SUP-FFC-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW FREEFIX COMPRESSION 3.5MM X 22MM TI -,SUP-FFC-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW FREEFIX COMPRESSION 3.5MM X 24MM TI -,SUP-FFC-35240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW FREEFIX COMPRESSION 4.5MM X 20MM TI -,SUP-FFC-45200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1009.46,706.622,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW FREEFIX COMPRESSION 4.5MM X 20MM TI -,SUP-FFC-45240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1009.46,706.622,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GRAFT HUMAN TISSUE FEMORAL HEAD 43MM -,SUP-FFH,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4839.09,3387.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GRAFT HUMAN TISSUE FEMORAL HEAD 43MM -,SUP-FFH,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4839.09,3387.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WEDGE FIBULA 18MM FROZEN -,SUP-FFIBW8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2636.84,1845.788,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW FREEFIX LOCKING 3.5MM X 20MM TI -,SUP-FFL-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW FREEFIX LOCKING 3.5MM X 22MM TI -,SUP-FFL-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW FREEFIX LOCKING 3.5MM X 26MM TI -,SUP-FFL-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW FREEFIX LOCKING 4.5MM 22MM TI -,SUP-FFL-45220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PRESUTURED ALLOGRAFT -,SUP-FGL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9411.49,6588.043,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GRAFT HUM TIS SPCR FRZN FLEXIGRAFT MNSCS R/M LF -,SUP-FMNRM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14676.34,10273.438,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.5X8MM LCK FT TI ALPS -,SUP-FP08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.5X10MM LCK FT TI ALPS NS -,SUP-FP10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.5X11MM LCK FT TI ALPS NS -,SUP-FP11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.5X12MM LCK FT TI ALPS NS -,SUP-FP12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.5X13MM LCK FT TI ALPS NS -,SUP-FP13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.5X14MM LCK FT TI ALPS -,SUP-FP14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.5X15MM LCK FT TI ALPS -,SUP-FP15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.5X16MM LCK FT TI ALPS -,SUP-FP16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2X18MM LCK FT TI DVR NS -,SUP-FP18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.5X20MM LCK FT TI DVR NS -,SUP-FP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.5X22MM LCK FT TI F3 NS -,SUP-FP22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.5X24MM LCK FT TI ALPS -,SUP-FP24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.5X26MM LCK FT TI ALPS NS -,SUP-FP26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.5X28MM LCK FT TI ALPS -,SUP-FP28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.5X30MM LCK FT TI F3 NS -,SUP-FP30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GRAFT HUM TIS FRZN 230CM 7.5MM FLEXIGRAFT PRNS LONGUS TNDN -,SUP-FPLT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.1,4960.97,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD 120MM -,SUP-G100-5-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD 200MM -,SUP-G100-5-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD 400MM -,SUP-G100-5-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD 6.0MM STRAIGHT -,SUP-G100-5-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD 100MM -,SUP-G150-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TIROD 200MM STRAIGHT -,SUP-G150-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD 30MM -,SUP-G150-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD 35MM -,SUP-G150-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD CURVED 40MM -,SUP-G150-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD 40MM CURVED -,SUP-G150-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD 45MM -,SUP-G150-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD CURVED 50MM -,SUP-G150-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD 55MM -,SUP-G150-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD CURVED 60MM -,SUP-G150-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD 65MM GENESYS -,SUP-G15065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD 70MM GENESYS -,SUP-G150-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD 75MM -,SUP-G150-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD 80MM GENESYS -,SUP-G150-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD 85MM SPINAL -,SUP-G150-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD 90MM -,SUP-G150-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD 95MM -,SUP-G150-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD 300MM GENESYS -,SUP-G300-5-300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CONNECTOR CROSS LINK LARGE -,SUP-G301-LRG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CROSSLINK MED -,SUP-G301-MED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CROSS LINK -,SUP-G301-SM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
27-35MM CC -,SUP-G301-XSM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
COIL MICRONESTER EMBOLIZATION 0.018 X 7CM X 6MM -,SUP-G52738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,916.1,641.27,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEADLESS COMP. 4.0MM 36M -,SUP-G58036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL 5.5 X 30MM -,SUP-G700-55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL 6.5 X 35MM -,SUP-G700-65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5 X 30MM GENESYS -,SUP-G701-55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW PEDICLE 5.5 X 35MM TI LO -,SUP-G701-55-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW PEDICLE 5.5MM X 40MM -,SUP-G701-55-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW TI LOCK 5.5 X 45MM -,SUP-G701-55-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW PEDICLE 6.5 X 30MM -,SUP-G701-65-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW PEDICLE 6.5 X 35MM -,SUP-G701-65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW PEDICLE 6.5 X 40MM -,SUP-G701-65-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW TI LOCK 6.5 X 45MM -,SUP-G701-65-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
6.5 X 50MM PEDICLE SCREW -,SUP-G701-65-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW TI-LOCK 7.5 X 30MM -,SUP-G701-75-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW TI-LOCK 7.5 X 35MM -,SUP-G701-75-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW PEDICLE 7.5 X 40MM -,SUP-G701-75-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW TI-LOCK 7.5 X 45MM -,SUP-G701-75-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
7.5 X 50MM PEDICLE SCREW -,SUP-G701-75-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 8.5MM X 70MM -,SUP-G701-85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CROSSLINK -,SUP-G701-XSM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MM X 25MM -,SUP-G702-45-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5MM X 30MM -,SUP-G702-45-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL 5.0 X 25MM -,SUP-G702-50-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL 5.0 X 30MM NEW -,SUP-G702-50-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CORTICAL SCREW 25 X 5.5MM -,SUP-G7025525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL 5.5 X 25 -,SUP-G702-55-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5 X 45 GENESYS -,SUP-G702-55-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL 6.5 X 40MM -,SUP-G702-65-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL 7.5 X 45 -,SUP-G702-75-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 8.5MM X 45MM -,SUP-G710-85-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ILIAC 8.5 X 60 -,SUP-G710-85-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SPINE 8.5 X 70 -,SUP-G710-85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SPINE 8.5 X 80 -,SUP-G710-85-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HI TOP 6.5 X 35 -,SUP-G711-65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ILIAC 8.5 X 70 -,SUP-G741-85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
OFFSET -,SUP-G780-21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
OFFSET 61 -,SUP-G780-61,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAP CIRCULAR TI LOCKING -,SUP-G826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SET 8.5 -,SUP-G826-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAP LOCKING TI -,SUP-G828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SET CAPS -,SUP-G828-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE 5MM SMALL -,SUP-GAC-05-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR APACHE CAGE 7MM -,SUP-GAC-07-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
APACHE CAGE ANCHORED 8MM -,SUP-GAC-08 SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE H8 -,SUP-GAC-08-SC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
APACHE ANCHORED 8MM -,SUP-GAC-08-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE 9MM -,SUP-GAC-09-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE APACHE ANCHORED 10MM -,SUP-GAC-10SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
APACHE ANCHORED 6MM -,SUP-GAC3D06-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
APACHE ANCHOR LARGE -,SUP-GAC-LG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR MEDIUM -,SUP-GAC-MD,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SMALL -,SUP-GAC-SM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR GREEN XL -,SUP-GAC-XL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR XXL BROWN -,SUP-GAC-XXL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BUTTRES 22MM -,SUP-GBP1-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 22MM 5.5 -,SUP-GBP1-2255,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
9mm CERVICAL PECK CAGE APACHE -,SUP-GCL-09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE SMALL APACHE 11MM -,SUP-GCL-11-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 12MM -,SUP-GCP10012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 14MM -,SUP-GCP10014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 14MM RESCU -,SUP-GCP10014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 16MM -,SUP-GCP10016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 35MM -,SUP-GCP20035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BINARY 12MM -,SUP-GCP2-112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 14MM -,SUP-GCP2-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 16MM -,SUP-GCP2-116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE CERVICAL 49MM -,SUP-GCP2-349,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.75MM X 16MM BINARY AUGER TIP FIXED -,SUP-GCP2-AF316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREWS 3.75 X 14MM SCREWS -,SUP-GCP2-AV314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.75MM X 18MM BINARY AUGER TIP VAIABLE -,SUP-GCP2-AV318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREWS 4.25 X 12MM -,SUP-GCP2-AV412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW FIXED CERV 3.75 X 14MM -,SUP-GCSF37514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BN 14MM -,SUP-GCSV37514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW VA 16MM -,SUP-GCSV37516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW RESCUE 16MM -,SUP-GCSV42516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
APACHE ANCHOR 6MM -,SUP-GCV-06-SO,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE APACHE 6MM -,SUP-GCV-06-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE APACHE ANCHORED 8MM -,SUP-GCV-08-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE APACHE ANCHORED 9MM -,SUP-GCV-09-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR LARGE -,SUP-GCV-LG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDE PIN 2.0MM X 125MM -,SUP-GDW-890-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.44,297.108,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
6.5 X 40MM PEDICLE SCREW -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CERVICAL APACHE CAGE 8MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BINARY 2 LEVEL CERVICAL 30MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE CERVICAL 2 LEVEL 32MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW REDUCTION 6.5 X 30MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL 7.5 X 30MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE STANDARD 31MM -,SUP-GLP-131,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 22MM -,SUP-GLPV-55 22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPINE 60MM -,SUP-GM150-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SET SCREW -,SUP-GM520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
MODULAR CORT IMPLANT HEAD -,SUP-GM557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
MODULAR LOCK SCREW -,SUP-GM820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE DORSAL SPANNING SHORT -,SUP-GMN-DSP-160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6217.46,4352.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BONE GEMINUS TITANIUM DORSAL SPANNING LONG -,SUP-GMN-DSP-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6416.93,4491.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BONE GEMINUS TITANIUM RADIAL DISTAL DORSAL HOOK -,SUP-GMN-HP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2592.28,1814.596,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW PLATE BONE GEMINUS TITANIUM RADIAL DISTAL DORSAL HOOK -,SUP-GMN-HP-SCRW,CDM,C1713,HCPCS,278,RC,,,outpatient,,,566,396.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ASSEMBLED GEMINUS VOLAR DISTAL RADIUS PLATE NARR 120MM LEFT -,SUP-GMN-LTN-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9969.16,6978.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE DIST RAD NARR 3 HOLE LEFT GEMINUS VOLAR -,SUP-GMN-LTN-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE NARROW DIS RAD 4 HOLE LEFT -,SUP-GMN-LTN-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE VOLAR DIST RAD STANDARD 3 HL LEFT -,SUP-GMN-LTS-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE GEMINUS VOLAR DISTAL RADIUS STANDARD 4 HOLE LEFT -,SUP-GMN-LTS-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE ASSEMBLED GEMINUS VOLAR DIST RAD NARROW 120MM RIGHT -,SUP-GMN-RTN-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9969.16,6978.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE VOLAR DISTAL RADIUS NARROW 3 HOLE RIGHT -,SUP-GMN-RTN-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DISTAL RADIUS PLATE- NARROW 4 HOLE RT. -,SUP-GMN-RTN-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE VOLAR DIST RADIUS STD 3 HOLD RIGHTTI GEMINUS -,SUP-GMN-RTS-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE DISTAL RADIUS VOLAR GEMINUS WIDE 4HL RIGHT -,SUP-GMN-RTW-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4621.72,3235.204,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5 X 30 -,SUP-GMSD 55 30-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5 X 45 -,SUP-GMSD 55 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL 4.5 X 30MM -,SUP-GMSD45-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5 X 35 -,SUP-GMSD-50 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL 5.0 X 30MM -,SUP-GMSD50-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL 5.0 X 35MM NEW -,SUP-GMSD50-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.0 X 4.0 -,SUP-GMSD50-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 55 X 35 -,SUP-GMSD-55 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL 5.5 X 30 -,SUP-GMSD55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CORTICAL MODULAR SCREW 5.5 X 35 -,SUP-GMSD55-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL 5.5 X 35 -,SUP-GMSD55-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL SPINE 5.5 X 40 -,SUP-GMSD55-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL 5.5 X 45 -,SUP-GMSD55-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL 6 X 35 -,SUP-GMSD-60 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL 6 X 30 -,SUP-GMSD60-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CORTICAL SCREW 6 X 35 -,SUP-GMSD60-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GENESYS CORTICAL SCREW 6.5MM X 35MM -,SUP-GMSD60-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MODULAR 6.0 x 40 -,SUP-GMSD60-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 65 X 35 -,SUP-GMSD-65 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORITCAL SPINE 6.5 X 35 -,SUP-GMSD65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL SPINE 6.5 X 40 -,SUP-GMSD65-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL 6.5 X 45 -,SUP-GMSD65-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW GENESYS MODULAR 6.5 X 50MM -,SUP-GMSD65-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL 7.5 X 40 -,SUP-GMSD75-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL 75 X 45 -,SUP-GMSD75-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL 75 X 50 -,SUP-GMSD75-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL 8.5 X 70 -,SUP-GMSD85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5 X 30 -,SUP-GMSP55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.0 X 30 -,SUP-GMSP60-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2-PIECE PIN TIP SECTION-TROCAR TIP -,SUP-GSI209-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,571.83,400.281,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2-PIECE PIN-TAIL SECTION 750MM W/TIP -,SUP-GSI210-02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2P PIN TAIL -,SUP-GSI210-02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
350 TROCAR PIN -,SUP-GSI211-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 9.5 X 35 -,SUP-GSI-SDW09535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 9.5 X 40 -,SUP-GSI-SDW09540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 9.5 X 40 -,SUP-GSI-SDW09545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 9.5 X 60 SI SUAL THREAD WASHER HEAD -,SUP-GSI-SDW09560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
POSTERIOR ALLOGRAFT 20MM -,SUP-GSPA-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
APACHE ANCHOR 8MM -,SUP-GVC-08-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
APACHE ANCHORED 9MM -,SUP-GVC-09-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDE PIN 2.0MM X 150MM -,SUP-GW0920061501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,306.34,214.438,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE CAN PT TI 4.0 X 24MM -,SUP-H00693,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE CAN PT TI 4.0 X 26MM -,SUP-H00693,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X40MM CANC POLARUS FT CNTRSNK TI NS -,SUP-HCA-5140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5X45MM CANC POLARUS FT CNTRSNK TI NS -,SUP-HCA-5145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.3X35MM LCK CANC POLARUS FT TI STRL -,SUP-HCA-L5335-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.3X40MM LCK CANC POLARUS FT TI STRL -,SUP-HCA-L5340-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.3X45MM LCK CANC POLARUS FT TI STRL -,SUP-HCA-L5345-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG HIGH COMPRESSION LOCKING 2.7 X 18 -,SUP-HCLP-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG HIGH COMPRESSION LOCKING 2.7MM  X 19MM TI -,SUP-HCLP-27190-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG HIGH COMPRESSION LOCKING 2.7MM  X 20M TI -,SUP-HCLP-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG HIGH COMPRESSION LOCKING 2.7MM  X 21M TI -,SUP-HCLP-27210-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
HIGH COMP PEG LCK 2.7 X 22 -,SUP-HCLP-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
HIGH COMPRESSION LOCKING PEG 2.7MM X 28MM TI -,SUP-HCLP-27280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X20MM NLCKG CORT POLARUS TI STRL -,SUP-HCO3200-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X25MM NLCKG CORT POLARUS TI STRL -,SUP-HCO3250-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MMX32.5MM NLCKG CORT POLARUS TI STRL -,SUP-HCO3325-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEADLESS COMP 2.5 X 14 -,SUP-HCS-25014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEADLESS COMP 2.5 X 16 -,SUP-HCS-25016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEADLESS COMPRESSION 2.5MM X 18MM -,SUP-HCS-25018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEADLESS COMP 2.5MM X 22MM TI -,SUP-HCS-25022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEADLESS COMP 2.5MM X 24MM TI -,SUP-HCS-25024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEADLESS COMP 2.5MM X 26MM TI -,SUP-HCS-25026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEADLESS COMPRESSION 2.5MM X 30MM -,SUP-HCS-25030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD IM 8X240MM POLARUS + CANN TAPR PRFL HUM TI STAB -,SUP-HR-0824-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9312.2,6518.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD IM 11X150MM POLARUS PROX HUM -,SUP-HR-L1115-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10452.97,7317.079,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEADED 2.5 X 12MM -,SUP-IC2512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.5MM HEADED SCREW LENGTH 14MM -,SUP-IC2514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE MINI HEADED 2.5 X 18MM -,SUP-IC2518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5 HEADED 20MM LENGTH -,SUP-IC2520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEADED 2.5 X 22MM -,SUP-IC2522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.5 MM HEADED 26MM LENGTH MINI CANN SCREW -,SUP-IC2526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
MINI SET SCREW 2.5X28MM -,SUP-IC2528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.5 MM HEADED 30MM LENGTH MINI CANN SCREW -,SUP-IC2530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
3.0 X 10MM CANNULATED SCREW -,SUP-IC3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.0 HEADED 18MM -,SUP-IC3018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
3.0MM HEADED 22MM LENGTH CANN SCREW -,SUP-IC3022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
3.0MM HEADED 24MM LENGTH CANN SCREW -,SUP-IC3024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
3.0MM HEADED 26MM LENGTH MINI CANN SCREW -,SUP-IC3026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3MM X 30MM -,SUP-IC3030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.0 HEADED 32MM LENGTH -,SUP-IC3032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.0MM HEADED 34MM LENGTH -,SUP-IC3034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.0MM HEADED 38MM LENGTH -,SUP-IC3038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEADED 3.0 X 40MM -,SUP-IC3040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
4.0MM HEADED 20MM LENGTH MINI CANN SCREW -,SUP-IC4020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
4.0MM HEADED SCREW LENGTH 32MM -,SUP-IC4032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
4.0MM HEADED SCREW LENGTH 34MM -,SUP-IC4034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
4.0MM HEADED 36MM LENGTH MINI CANN SCREW -,SUP-IC4036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
4.0MM HEADED 38MM LENGTH MINI CANN SCREW -,SUP-IC4038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
4.0MM HEADED 40MM LENGTH MINI CANN SCREW -,SUP-IC4040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE MINI 46MM X 4MM HEAD NONSTERILE -,SUP-IC4046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
4.0MM HEADED SCREW LENGTH 48MM -,SUP-IC4048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE MINI 50MM X 4MM HEAD NONSTERILE -,SUP-IC4050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
INFLUX SPARC (IBM) 1CC -,SUP-IFLX-CM-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2597.25,1818.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
INFLUX SPARC (IBM) 5CC -,SUP-IFLX-CM-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8530.44,5971.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
HEADLESS SCREW 2.5X10MM -,SUP-IH2510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.5MM HEADLESS SCREW LENGTH 20MM -,SUP-IH2520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.5MM HEADLESS SCREW LENGTH 24MM -,SUP-IH2524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.5MM HEADLESS SCREW LENGTH 26MM -,SUP-IH2526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
2.5MM HEADLESS SCREW LENGTH  30MM -,SUP-IH2530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE MINI 2.5 X 36MM HEADLESS -,SUP-IH2536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
3.0 X 14MM HEADLESS SCREW -,SUP-IH3014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.0 X 22MM HEADLESS -,SUP-IH3022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.0 X 24MM HEADLESS -,SUP-IH3024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.0 X 26MM HEADLESS -,SUP-IH3026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEADLESS 3.0MM X 30MM -,SUP-IH3030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
3.0 X 32MM HEADLESS SCREW -,SUP-IH3032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
3.0 X 34MM HEADLESS SCREW -,SUP-IH3034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEADLESS 3.0MM X 36MM -,SUP-IH3036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEADLESS 3.0MM X 38MM -,SUP-IH3038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEADLESS 3.0MM X 40MM -,SUP-IH3040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
4.0MM HEADLESS SCREW LENGTH 32MM -,SUP-IH4032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEADLESS 4.0MM X 16MM X 36MM -,SUP-IH4036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEADLESS 4.0MM X 38MM -,SUP-IH4038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEADLESS 4.0MM X 40MM -,SUP-IH4040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEADLESS 4.0MM X 42MM -,SUP-IH4042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEADLESS 4.0MM X 46MM -,SUP-IH4046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEADLESS 4.0MM X 50MM -,SUP-IH4050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN AXIS 2.5MM X 40MM IJS-E -,SUP-IJS-EAP-25400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1727.96,1209.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN IJS-E AXIS 2.5MM X 45MM -,SUP-IJS-EAP-25450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1727.96,1209.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BLADE T10 DRIVER 4.0 SCREWS -,SUP-IS1108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,921.23,644.861,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PK SCREW INTNL FX STRL CONTR -,SUP-JG303R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21.15,14.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE 28MMX10MM JULIET OL LD SHARING ANTMC PEEK -,SUP-JUL-OL 28 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE 7X28MM STR -,SUP-JUL-OX2807-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE LUMBAR POSTERIOR TI L24 W8 H7 -,SUP-JUN-P6 24 07-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
8 X 24 PLIF TITANIUM CAGE -,SUP-JUN-P6 24 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE LUMBAR POSTERIOR TI L24 W8 H09 6 DEGREE NARROW JULIET -,SUP-JUN-P6 24 09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE PLIF TI 24 X 8.5 X 10 -,SUP-JUN-P6 24 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LUMBAR POSTERIOR TI CAGE L24 W9 H11 -,SUP-JUN-P6 24 11-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE 24 X 9 X 12 PLIF 6 DEGREE -,SUP-JUN-P6 24 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE LUMBAR POSTERIOR TI 14 X 9 X 24 6DEG -,SUP-JUN-P6 24 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LUMBAR POSTERIOR TI CAGE L24 X W8 X H07 6 DEGREE -,SUP-JUN-P62407-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LUMBAR POSTERIOR TI CAGE L24 W8.5 H10 -,SUP-JUN-P62410-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE POSTERIOR LUMBAR TI L24 X W9 X H11 6DEG JULIET -,SUP-JUN-P62411-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TITANIUM PLIF CAGE L24 X W9 X H12 6 DEGREE -,SUP-JUN-P62412-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LUMBAR POSTERIOR TI CAGE L24 W10.5 -,SUP-JUT PX 24 09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE TRANSORAMINLA LUMBAR TI L30 W 10.5 -,SUP-JUT-T6 30 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE LUMBAR TRANSFORAMINAL L30 W 10.5 -,SUP-JUT-T6 30 09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE TRANSFORAMINAL LUMBAR TI CAGE L30 W 10.5 H10 -,SUP-JUT-T6 30 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE TRANSFORAMINAL LUMBAR TI L30 W 10.5 H 11 -,SUP-JUT-T6 30 11-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE TRANSFORAMINAL LUMBAR TI L30 W10.5 H12 6 DEG -,SUP-JUT-T6 30 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE TRANSORAMINAL LUMBAR TI L 30 W 10.5 H 13 -,SUP-JUT-T6 30 13-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SYS BONE CMNT PARALLAX EZFLOW -,SUP-KP-CDS-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
KT DEVICE PARALLAX CONTR -,SUP-KP-CTR-1508C-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7002.6,4901.82,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
STENT ADVANIX BIL 10FR X 3CM DBL PIGTAIL -,SUP-M00532240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DISK SPIN MOBI- C COCR MLYBDNM EPLT UHMWPE INLAY 13X15X5MM -,SUP-MB3355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PROSTHESIS CERV DISC 13 X 17 H -,SUP-MB3375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DISC SPIN MOBI- C COCR MLYBDNM EPLT UHMWPE INLAY 15X15X5MM -,SUP-MB3555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DISC SPIN MOBI- C PROS COCR MLYBDNM EPLT UHMWPE INLAY -,SUP-MB3576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE 40MM ROD -,SUP-MC1-200040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
IMPLANT ROI-C 7MM 12 X 14MM LO -,SUP-MC1343P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE CERV 10MM/7.2MM H A/P ROI- C LRDTC -,SUP-MC1426P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE CERV 5MM/2.3MM H A/P ROI- C LRDTC -,SUP-MC1441P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE CERV 6MM/3.1MM H A/P ROI- C LRDTC -,SUP-MC1442P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE CERV 8MM/5.1MM H A/P ROI- C LRDTC -,SUP-MC1444P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE CERV 9MM/6.1MM H A/P ROI- C LRDTC -,SUP-MC1445P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
IMPLANT ROI-C LORDOSED 12X15.5 -,SUP-MC1454P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.8X22MM S3 MULDIR NS -,SUP-MD22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.8X24MM S3 MULDIR NS -,SUP-MD24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.8X26MM S3 MULDIR NS -,SUP-MD26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.8X28MM S3 MULDIR NS -,SUP-MD-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.8X28MM S3 MULDIR NS -,SUP-MD-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.8X30MM S3 MULDIR NS -,SUP-MD30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.8X32MM S3 MULDIR NS -,SUP-MD32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.8X34MM S3 MULDIR NS -,SUP-MD34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.8X36MM S3 MULDIR NS -,SUP-MD36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.8X38MM S3 MULDIR NS -,SUP-MD38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5MM X 40MM CANNULATED POLYAXIAL -,SUP-MPF-PX  55 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5MM X 35MM CANNULATED POLYAXIAL -,SUP-MPF-PX 55 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
MIDSHAFT RADIUS PLATE 112MM -,SUP-MRP-112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5996.77,4197.739,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE FREEFIX MIDSHAFT RADIUS 127MM -,SUP-MRP-127,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SIZER NATRELLE INSPIRA 325CC FULL -,SUP-MSZ-F325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SIZER NATRELLE INSPIRA 345CC FULL -,SUP-MSZ-F345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SIZER NATRELLE INSPIRA 450CC FULL -,SUP-MSZ-F450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SIZER NATRELLE INSPIRA 485CC FULL -,SUP-MSZ-F485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SIZER NATRELLE INSPIRA 330CC MODERATE -,SUP-MSZ-M330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SIZER NATRELLE INSPIRA 445CC MODERATE -,SUP-MSZ-M445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SIZER NATRELLE INSPIRA 485CC MODERATE -,SUP-MSZ-M485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MULTI-THREAD LOCKING 2.7MM X 18MM TI -,SUP-MTLS-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MULTI-THREAD LOCKING 2.7MM X 20MM -,SUP-MTLS-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MULTI-THREAD LOCKING 2.7 X 22 -,SUP-MTLS-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MULTI THREAD LOCKING 2.7MM X 32MM TI -,SUP-MTLS-27320-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MULTI THREADED LOCKING 3.0MM X 10MM TI -,SUP-MTLS-30100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MULTI THREADED LOCKING 3.0MM X 12MM TI -,SUP-MTLS-30120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MULTI THREADED LOCKING 3.0MM X 14MM TI -,SUP-MTLS-30140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MT LOCKING 3.5MM X 8MM TI -,SUP-MTLS-35080-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MT LOCKING 3.5MM X 10MM TI -,SUP-MTLS-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MT LOCKING 3.5MM X 12MM TI -,SUP-MTLS-35120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MT LOCKING 3.5MM X 14MM TI -,SUP-MTLS-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MT LOCKING 3.5MM X 16MM TI -,SUP-MTLS-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MT LOCKING 3.5MM X 18MM TI -,SUP-MTLS-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MT LOCKING 3.5MM X 20MM TI -,SUP-MTLS-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MT LOCKING 3.5MM X 22MM TI -,SUP-MTLS-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MT LOCKING 3.5MM X 24MM TI -,SUP-MTLS-35240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MT LOCKING 3.5MM X 26MM TI -,SUP-MTLS-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MT LOCKING 3.5MM X 28MM TI -,SUP-MTLS-35280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE LKG 3.5MM X 32MM MULTITHREAD TI -,SUP-MTLS-35320-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE TITANIUM MULTI-THREAD LOCKING 3.5 X 34 -,SUP-MTLS-35340-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MULTI-THREAD LOCKING 3.5MM X 36MM TI -,SUP-MTLS-35360-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MULTI-THREAD LOCKING 3.5MM X 38MM TI -,SUP-MTLS-35380-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE TITANIUM MULTI-THREAD LOCKING 3.5 X 40 -,SUP-MTLS-35400-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MULTI THREAD LOCKING 3.5MM X 42MM TI -,SUP-MTLS-35420-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MULTI-THREAD LOCKING 3.5MM X 55MM TI -,SUP-MTLS-35550-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MULTI-THREAD COMPRESSION 3 X 10 -,SUP-MTNL-30100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MULTI THREAD COMP 3.0MM X 12MM TI -,SUP-MTNL-30120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MULTI-THREAD COMPRESSION 3.0MM X 16MM TI -,SUP-MTNL-30160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE TITANIUM MULTI-THREAD LOCKING 3.5 X 10 -,SUP-MTNL-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MT COMP 3.5MM X 14MM TI -,SUP-MTNL-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MT COMP 3.5MM X 16MM TI -,SUP-MTNL-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MT COMP 3.5MM X 18MM TI -,SUP-MTNL-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MT COMP 3.5MM X 22MM TI -,SUP-MTNL-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MT COMP 3.5MM X 40MM TI -,SUP-MTNL-35400-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MULTI THREAD COMPRESSION 3.5MM X 42MM TI -,SUP-MTNL-35420-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MT COMP 3.5MM X 45MM TI -,SUP-MTNL-35450-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MT COMP 3.5MM X 50MM TI -,SUP-MTNL-35500-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW MT COMP 3.5MM X 60MM TI -,SUP-MTNL-35600-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
MIDSHAFT ULNA PLATE 97MM -,SUP-MUP-097,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5937.36,4156.152,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE MIDSHAFT ULNA 112MM -,SUP-MUP-112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5996.77,4197.739,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
MACROFORM NOVABONE 5CC -,SUP-NB1002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
MACROFORM 5CC -,SUP-NB4305,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.8X20MM LCK S3 90DG ANG TI NS -,SUP-NL20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.8X24MM LCK S3 90DG ANG TI NS -,SUP-NL24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.8X26MM LCK S3 90DG ANG TI NS -,SUP-NL-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.8X28MM LCK S3 90DG ANG TI NS -,SUP-NL28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.8X30MM LCK S3 90DG ANG TI NS -,SUP-NL30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.8X32MM LCK S3 90DG ANG TI NS -,SUP-NL32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LCK 90DG ST BN HND SHLDR -,SUP-NL-SS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,408.45,285.915,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LCK 90DG ST BN HND SHLDR -,SUP-NL-SS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN FX STNMN 18INX9IN DBL END TROC SMTH SS -,SUP-OM 71-0459,CDM,C1713,HCPCS,278,RC,,,outpatient,,,69.73,48.811,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ARTHROSCOPIC FX MAGNUM2 ACC F/SHLDR FT/ANKL RPR HALLUX -,SUP-OM-1502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1106.83,774.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUT MAG PI -,SUP-OM-4500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DEVICE SUT MAG 2 + SMARTSTITCH KNTLS -,SUP-OM-9026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SFT TIS 3.2MM KNTLS FX W/PERFECTPASSER MAGNUMWR SUT -,SUP-OM-9146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3079.23,2155.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SFT TIS 3.2MM PNCH MAG PI + -,SUP-OM-9147,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3079.23,2155.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2X14MM LCK SMTH TI DVR NS -,SUP-P14000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2X16MM LCK SMTH TI DVR NS -,SUP-P16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2X20MM LCK SMTH TI DVR NS -,SUP-P20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2X22MM LCK SMTH TI DVR NS -,SUP-P22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2X26MM LCK SMTH TI DVR NS -,SUP-P26000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW POLYAXIAL LCK 2.5 X 10 CANNULATED COCR -,SUP-PALS-25100-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW POLYAXIAL LCK 2.5 X 16 CANNULATED COCR -,SUP-PALS-25160-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW POLYAXIAL LCK 2.5 X 22MM CANNULATED COCR -,SUP-PALS-25220-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE GEMINUS POLY LOCKING 2.5MM X 24MM CANN COCR -,SUP-PALS-25240-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW POLYAXL LCK 2.5MM X 26MM CANN -,SUP-PALS-25260-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW POLYAXIAL LOCKING 3.0MM X 18MM CANNULATED -,SUP-PALS-30180-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW POLYAXIAL LOCKING 3.0MM X 22MM CANNULATED -,SUP-PALS-30220-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW POLYAXIAL LOCKING 3.0MM X 24MM CANN -,SUP-PALS-30240-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW POLYAXAIL LCK 3.0 X 34 -,SUP-PALS-30340-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW POLYAXIAL LOCKING 3.0MM X 55MM CANNULATED -,SUP-PALS-30550-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
THREADED PEG CORTICAL NON-LOCKING 2.7MM X 10MM TI -,SUP-PANL-27140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL NON LOCKING 2.7 X 16 -,SUP-PANL-27160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW PEG THREADED CORTICAL NON-LOCKING 2.7MM X 18MM TI -,SUP-PANL-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG THREADED CORTICAL NON-LOCKING 2.7MM X 20MM TI -,SUP-PANL-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG THREADED CORTICAL NON-LOCKING 2.7MM X 22MM TI -,SUP-PANL-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG THREADED CORTICAL NL 2.7MM X 26MM TI -,SUP-PANL-27260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL NON LOCKING 3.5 X 9 -,SUP-PANL-35090-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL NON LOCKING 3.5 X 10 -,SUP-PANL-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL NON LOCKING 3.5MM X 11MM -,SUP-PANL-35110-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW- CORTICAL NON-LOCKING 3.5MM X 12MM -,SUP-PANL-35120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NON-LOCK 3.5 X 13 POLY TI -,SUP-PANL-35130-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE ASSEMBLED PROTEAN FRAGMENT DOUBLE HOCKEY STICK -,SUP-PANL-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4596.25,3217.375,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NON-LOCK 3.5 X 14 POLY TI -,SUP-PANL-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NON-LOCK 3.5 X 15 POLY TI -,SUP-PANL-35150-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW POLYAXIAL NON LOCKING 3.5MM X 16MM TI -,SUP-PANL-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW POLYAXIAL NON LOCKING 3.5MM X 18MM TI -,SUP-PANL-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NON-LOCK 3.5 X 20 POLY TI -,SUP-PANL-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NON-LOCK 3.5 X 22 POLY TI -,SUP-PANL-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL NON LCK 3.5MM X 26MM TI -,SUP-PANL-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW POLYAXIAL NON LOCKING 3.5MM X 28MM TI -,SUP-PANL-35280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MM X 10MM -,SUP-PC1-003510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5MM X 12MM -,SUP-PC1-003512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NORTHSTAR 3.5 X 14 SCREW -,SUP-PC1-003514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE 3.5MM X 16MM SCREW -,SUP-PC1-003516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NORTHSTAR SCREW 3.5 X 18 -,SUP-PC1-003518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW POLY SEASPINE 3.5 MM X 20 MM -,SUP-PC1-003520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE SCREW 3.5MM X 22MM -,SUP-PC1-003522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE SCREW 35 X 24 -,SUP-PC1-003524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE SCREW 3.5 X 26 -,SUP-PC1-003526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE SCREW 4MM X 10MM -,SUP-PC1-004010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE NORTHSTAR 4MM X 12MM SCREW -,SUP-PC1-004012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MM X 14MM SPINE POLYAXIAL -,SUP-PC1-004014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4MM X 16MM SPINE POLYAXIAL -,SUP-PC1004016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3007.62,2105.334,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW POLYAXIAL 4.0 X 16 SEASPINE -,SUP-PC1-004016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SEASPINE 4.0 X 18 POLYAXIAL -,SUP-PC1-004018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NORTHSTAR SCREW 4 X 20 -,SUP-PC1-004020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SEASPINE 4.0 X 22 POLYAXIAL -,SUP-PC1-004022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SEASPINE 4.0 X 24 POLYAXIAL -,SUP-PC1-004024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE SCREW 4MM X 26MM -,SUP-PC1-004026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE SCREW 4MM X 28MM -,SUP-PC1-004028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4 X 30 -,SUP-PC1-004030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE SCREW 4.0 X 34 -,SUP-PC1-004034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CROSS LINK MED 3.5 -,SUP-PC1-013502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CROSSHOLE LARGE 3.5MM -,SUP-PC1-013503,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE MD CROSSLINK -,SUP-PC1-014002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE LARGE CROSSLINK -,SUP-PC1-014003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LATERAL OFFSET -,SUP-PC1-020015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE 0-0CONNECTOR -,SUP-PC1-023540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PARALLELL TOP LOADING 5.5 -,SUP-PC1-023560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE 0-C CONNECTOR -,SUP-PC1-063535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE SCREW 4.5MM X 24MM -,SUP-PC1-104524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE 4.5 X 26 NS#2 -,SUP-PC1-104526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE 5.5 X 26 NS#2 -,SUP-PC1-104526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE SCREW 4.5MM X 28MM -,SUP-PC1-104528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE SCREW 4.5 X 30 NS#2 -,SUP-PC1-104530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE SCREW 4.5 X 34 -,SUP-PC1-104534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE SCREW 3.5 X 24 SS -,SUP-PC1-203524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE SCREW 3.5 X 26 SS -,SUP-PC1-203526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE SCREW 3.5 X 18 -,SUP-PC1-203528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
3.5 X 30MM SMOOTH SHANK SCREW -,SUP-PC1-203530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE REDUCTION SCREW 3.5 X 14 -,SUP-PC1-303514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SET OCCIPITOCERVICOTHORACIC FIXATION SYSTEM -,SUP-PC1-400000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE ROD OCC 3.5 X 170 -,SUP-PC1-503177,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPINAL100MM TITANIUM CONTOUR -,SUP-PC1-503500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE ROD -,SUP-PC1-503502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE 30MM ROD -,SUP-PC1-503530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPINAL 40MM -,SUP-PC1-503540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD 50MM -,SUP-PC1-503550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD SPINAL 60MM TITANIUM CONTOUR -,SUP-PC1-503560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD 70MM -,SUP-PC1-503570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD 80MM -,SUP-PC1-503580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE NORTHSTAR 90MM ROD -,SUP-PC1-503590,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE ROD 4 X 120MM -,SUP-PC1-504002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE ROD 4X200MM -,SUP-PC1-504003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE ROD 80MM -,SUP-PC1-504080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE ROD 4 X 120 -,SUP-PC1-514012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE TRAN ROD 3.5 X 5.5 -,SUP-PC1-523555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1166.11,816.277,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE OCC PLATE -,SUP-PC1-700000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BONE CHIPS CANCELLOUS CRUSHED 1-8 MM 15 CC CHIP -,SUP-PCAN15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.36,804.552,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SUBSTITUTE CANC 30ML CUBE RDIGRF PRESERVON CRSH VOID FIL -,SUP-PCANCUBE30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2148.98,1504.286,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
0 PDS PLUS VIOLET 1 X 27 CT-1 -,SUP-PDP340H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18.26,12.782,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAVIO BONE PIN 4.0MM X 89 -,SUP-PFSD-01008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.46,508.522,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SUBSTITUTE WDG MATRGRF PRESERVON 18MM -,SUP-PICW8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3831.09,2681.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LEG CONTRA EXCLUDER AAA ENDO 16MM X 18MM X 11.5CM 12FR -,SUP-PLC181200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN F/ELB PLATE SYS 16HL LCK TI LNG NS -,SUP-PL-LEM16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6824.35,4777.045,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN 11X84MM 7HL LCK TI CONGR NS PNK -,SUP-PL-LEM7,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6017.99,4212.593,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN ANCHORAGE 6HL PRCONT LCK TI GRN LT -,SUP-PLP10341,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN ANCHORAGE 6HL PRCONT LCK TI GRN RT -,SUP-PLP10342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN ANCHORAGE F /HALLUX VALGUS V1 8HL PRCONT LCK TI LNG -,SUP-PLP10462,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE MTP 5-HOLE -,SUP-PLP11341,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN ANCHORAGE F /HALLUX VALGUS V2 5HL PRCONT LCK TI GRN -,SUP-PLP11342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN ANCHORAGE F/CX PLATE SYS 1.5MM TI THRD HL COLR -,SUP-PLP14341,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHORAGE MTP CP PLATE RIGHT -,SUP-PLP14342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN ANCHORAGE F/CX PLATE SYS TI THRD HL GRN -,SUP-PLP14342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN ANCHORAGE F/LPDS FUSION 0MM STP PRCONT LCK TI YEL -,SUP-PLP20342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN ANCHORAGE F/LPDS FUSION 0MM STP PRCONT LCK TI CP -,SUP-PLP29371,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN ANCHORAGE 28MM 4HL PRCONT SYM LCK UTIL TI PNK -,SUP-PLP40280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4564.66,3195.262,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN POLARUS 4HL SLOTX3 TI LRG NS -,SUP-PL-PHGR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5967.06,4176.942,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3X10MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3X12MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3X14MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3X16MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3X18MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3X20MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X16MM LCK ANCHORAGE T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3X10MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3X12MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3X14MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,657.84,460.488,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3X16MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,657.84,460.488,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3X18MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,657.84,460.488,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3X20MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3X22MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3X24MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X18MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 3.5X24MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHORAGE STANDARD SCREW 3.5 X 26MM -,SUP-PLSS3526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TROCAR CLOSURE SUTURE GRASPER -,SUP-PMI-TC-SG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,64.19,44.933,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TEMPORARY FIXATION PIN ADMIRAL -,SUP-PN AP2-100506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN FIXATION -,SUP-PN0920051001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,233.4,163.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE ASSEMBLED PROTEAN CENTRAL COLUMN LEFT -,SUP-PRT-CCP-LT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4681.13,3276.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PROTEAN CORONOID PLATE RIGHT -,SUP-PRT-CRD-RT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5237.1,3665.97,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE PROTEAN FRAG DIST ULNA -,SUP-PRT-FSP-DU,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5054.6,3538.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE Y PROTEAN FRAGMENT -,SUP-PRT-FSP-YS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4596.25,3217.375,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
DEVICE FIXATION SIZE 18 4FUSION -,SUP-QUA-4F-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11849.67,8294.769,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 12MM X 2.7MM FUCHSIA U PLUS LOCKING -,SUP-RBL1224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1070.7,749.49,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 14MM X 2.7MM GOLD U PLUS LOCKING -,SUP-RBL1225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1070.7,749.49,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 50MM UPLUS RIB -,SUP-RBL1301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6463.61,4524.527,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X50MM -,SUP-RFS-S4500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
TRUNK IPSI EXCLUDER AAA ENDO 26MM X 14.5MM X 12CM 16FR -,SUP-RLT261412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,32100.6,22470.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SIZER SMOOTH ROUND MODERATE GEL XTRA 755 CC -,SUP-RSZSHPX755S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SIZER SMOOTH ROUND MODERATE GEL HP XTRA 790 CC -,SUP-RSZSHPX790S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL IM 1.6MMX12.7MM SBFS SS -,SUP-SBFS062,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE CERVICAL LORDOTIC ANT D12 W15 H08 -,SUP-SCA-AC LS 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CERVICAL 3 X 14MM -,SUP-SCA-CS 3014-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
RSS 4.5MM STAR SCREW AND CAP 15MM L -,SUP-SCW-0961-046-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
RSS 4.5MM STAR SCREW AND CAP 20MM L -,SUP-SCW-0961-046-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
RSS 4.5MM STAR SCREW AND CAP 25MM L -,SUP-SCW-0961-046-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
RSS 4.5MM STAR SCREW AND CAP 30MM -,SUP-SCW-0961-046-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
KIT IMPLANT 10 X 9MM SPEED 1.5 X 1.5MM -,SUP-SE-0910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4623.62,3236.534,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPEED IMPLANT 11 X 08 X 08MM -,SUP-SE-1108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPEED IMPLANT 11X10X10MM -,SUP-SE-1110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPEED IMPLANT 15X15X15MM -,SUP-SE-1515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5690.99,3983.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
STAPLE -,SUP-SE-1815,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPEEDTITAM 18X15X15MM -,SUP-SE-1815TI,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7289.07,5102.349,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPEED IMPLANT TI 18X18X18MM -,SUP-SE-1818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5690.99,3983.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPEED COMPRESSION IMPLANT KIT 20X20X20 -,SUP-SE-2020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPEED TITAN IMPLANT 20 X 20 X 20MM -,SUP-SE-2020TI,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5644.52,3951.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WASHER ORTHO -,SUP-SFCW,CDM,C1713,HCPCS,278,RC,,,outpatient,,,379.28,265.496,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCARLET AL-T BONE SCREW 5 X 25MM -,SUP-SJT-LS 50 25-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5X20MM CORT/CANC DVR FT HEX HEAD TI -,SUP-SP 20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,545.51,381.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.5X10MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP10000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG 2.5X11MM NLCKG SCR CANC DVR FT ST HEX HEAD TI NS F/ANTMC -,SUP-SP11000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.5X12MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP12000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.5X13MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP13000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.5X14MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP14000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.5X15MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP15000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.5X16MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.5X16MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.5X18MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP18000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.5X20MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.5X20MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.5X22MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.5X22MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,534.37,374.059,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.5X22MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.5X24MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP24000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.5X26MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP26000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.5X34MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP34000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG SMOTH LOCKING 2 X 14 -,SUP-SPLS-20140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG SMOOTH LOCKING 2 X 16 -,SUP-SPLS-20160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG SMOOTH LOCKING TI GRAY 2.0MM X 17MM -,SUP-SPLS-20170-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG SMOOTH LOCKING 2 X 18 -,SUP-SPLS-20180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SMOOTH PEG LOCKING 2.0MM X 18MM TI -,SUP-SPLS-20180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG SMOOTH LOCKING TI GRAY 2.0MM X 19MM -,SUP-SPLS-20190-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG SMOOTH LOCKING 2 X 20 -,SUP-SPLS-20200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG SMOOTH LOCKING TI GRAY 2.0MM X 21MM -,SUP-SPLS-20210-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG SMOOTH LOCKING TI GRAY 2.0MM X 22MM -,SUP-SPLS-20220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN S3 16X71MM 16MM 3HL CONTR LCK SS SUT HL FST GUIDE -,SUP-SSPL3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5703.94,3992.758,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN S3 16X84MM 4HL CONTR LCK SS SUT HL FST GUIDE TECH -,SUP-SSPL4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5703.94,3992.758,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN S3 16X70MM 16MM 3HL CONTR LCK SS SUT HL FST GUIDE -,SUP-SSPR3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5703.94,3992.758,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN S3 16X150MM 8HL CONTR LCK SS SUT HL FST GUIDE TECH -,SUP-SSPR8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7359.1,5151.37,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SIZER IMPLANT NATR INSPIRA SIL 485CC SINGLE USE FULL PROFILE -,SUP-SSZ-F485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SIZER IMPLANT NATR INSPIRA SIL 605CC SINGLE USE FULL PROFILE -,SUP-SSZ-F605,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SIZER IMPLANT NATR INSPIRA SIL 650CC SINGLE USE FULL PROFILE -,SUP-SSZ-F650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SIZER IMPLANT NATR INSPIRA SIL 695CC SINGLE USE FULL PROFILE -,SUP-SSZ-F695,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SIZER IMPLANT NATR INSPIRA SIL 560CC SINGLE USE MOD PROFILE -,SUP-SSZ-M560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SIZER IMPLANT NATR INSPIRA SIL 600CC SINGLE USE MOD PROFILE -,SUP-SSZ-M600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 4MMSTDX20MM LCK SMTH TI S3 -,SUP-STP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 4MMSTDX25MM LCK SMTH TI S3 NS -,SUP-STP25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 4MMSTDX32.5MM LCK SMTH TI S3 -,SUP-STP325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 4MMSTDX37.5MM LCK SMTH TI S3 NS -,SUP-STP375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 4MMSTDX42.5MM LCK SMTH TI S3 NS -,SUP-STP425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 4MMSTDX45MM LCK SMTH TI S3 -,SUP-STP45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 4MMSTDX47.5MM LCK SMTH TI S3 NS -,SUP-STP475,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 4MMSTDX50MM LCK SMTH TI S3 NS -,SUP-STP50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 4MMSTDX40MM LCK THRD TI S3 NS -,SUP-STPT40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 4MMSTDX50MM LCK THRD TI S3 NS -,SUP-STPT50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ENDOSCOPIC FX SECURESTRAP W/12 ABSB STRP F/HRN RPR -,SUP-STRAP12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1878.06,1314.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SECURESTRAP 5MM ASORB STRAP -,SUP-STRAP25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2542.51,1779.757,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ASNIS III SS CANN SCREW 6.5 X 105MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BONE SCREW T8 FULLY THREADED 2.7 X 24MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BONE SCREW T10 NON-LOCKING 2.7 X 30MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BONE SCREW T8 FULLY THREADED 2.7 X 18MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
BONE SCREW T10 NON-LOCKING 2.7 X 70MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL LONG R2.0 TI LEFT 13 X 320MM GAMMA -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTEX 3.5 X 22MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 2.3 X 15MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.88,310.016,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING FULLY THREADED T10 3.5 X 20MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING FULLY THREADED T10 3.5 X 28MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING ST 3.5 X 46MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WRIST FUSION PLATE STANDARD BEND 120MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8642.06,6049.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WRIST FUSION PLATE STRAIGHT 120MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8642.06,6049.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5MMX16MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5MMX20MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5MMX26MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2.5MMX30MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
3-0 20CM STRATAFIX SPIRAL MONOCRYL PLUS UNDYED SH -,SUP-SXMP1B427,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.67,104.769,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
4-0 STRATAFIX SPIRAL MONOCRYL PLUS 45 X 45CM UNDYED PS-2 -,SUP-SXMP2B151,CDM,C1713,HCPCS,278,RC,,,outpatient,,,125.22,87.654,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SUTURE STRATAFIX 2-0 CT-1 PDS VIOL 45CM -,SUP-SXPP1A403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,117.01,81.907,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
0 STRATAFIX SYMMETRIC PDS PLUS 23CM CT-1 -,SUP-SXPP1A425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.1,107.87,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SUTURE STRATAFIX 0 CT-1 PDS VIOL 45CM -,SUP-SXPP1B407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.07,107.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SUTURE STRATAFIX 3-0 SH SPIRAL PDS VIOLET 15CM -,SUP-SXPP1B420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,183.51,128.457,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
"SUTURE STRATAFIX SPIRAL PDS PLUS 2-0 9"" 23CM VIOLET CT-2 -",SUP-SXPP1B432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,155.78,109.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SUT STRATAFIX 0 30CM SPIRAL PDS PLUS VIOLET CT-1 -,SUP-SXPP1B450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,157.03,109.921,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SET HERNIA KUMAR T ANCHORS -,SUP-TA-008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,46.32,32.424,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE REEF TA INTERBODY 9X28X8MM -,SUP-TA1-928088,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
REEF TA INTERBODY 9 X 28 X 10MM 15DEG -,SUP-TA1-928105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
REEF TA 9X 28 X 11MM INTERBODY -,SUP-TA1-928115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SEASPINE REEF TA INTERBODY 9X32X8MM -,SUP-TA1-932088,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
INTERBODY 9X32X11 15DEG -,SUP-TA1-932115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN 70MM TENSION BAND -,SUP-TB-1570K,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1219.12,853.384,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW TROCHLEAR COMPRESSION FEMALE -,SUP-TCS-F,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1833.97,1283.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW TROCHLEAR COMPRESSION LOCKING CAP -,SUP-TCS-LC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1303.92,912.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW TROCHLEAR COMPRESSION MALE 60MM -,SUP-TCS-M-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD 35MM -,SUP-TLF-5P T0 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD 40MM -,SUP-TLF-5P T0 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD 45MM -,SUP-TLF-5P T0 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD PREBENT TITANIUM 50MM -,SUP-TLF-5P T0 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PREBENT ROD TITANIUM 55MM -,SUP-TLF-5P T0 55-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD 60MM -,SUP-TLF-5P T0 60-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PERLA TL PREBENT ROD TITANIUM 90MM -,SUP-TLF-5P T0 90-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD 5.5 X  70 -,SUP-TLF-5P TO 70-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ROD PREBENT 6MM X 40MM -,SUP-TLF-6P T0 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5 X 35 -,SUP-TLF-CS 55 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 5.5MM X 40MM -,SUP-TLF-CS 55 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CORTICAL BONE SCREW 5.5 X 45 -,SUP-TLF-CS 55 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5MM X 30MM -,SUP-TLF-CS 65 30-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5 X 35 -,SUP-TLF-CS 65 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCEW 6.5 X 40 -,SUP-TLF-CS 65 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 6.5 X 45 -,SUP-TLF-CS 65 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEAD -,SUP-TLF-MH PL 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
REDUCTION HEAD -,SUP-TLF-MH RE 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SET -,SUP-TLF-SC 00 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.5X10MM LCK LAG P/T TI DVR NS -,SUP-TP10000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.5X14MM TI DVR NS -,SUP-TP14000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.5X16MM TI DVR NS -,SUP-TP16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.5X18MM TI DVR NS -,SUP-TP18000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.5X20MM P/T -,SUP-TP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,534.37,374.059,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.5X20MM TI DVR NS -,SUP-TP20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG BN FX 2.5X28MM TI DVR NS -,SUP-TP28000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
THREADED PEG FLUTED LCK 2.3 X 20 -,SUP-TPFL-23200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG FIXATION LOCKING 2.3 X 10 TI -,SUP-TPLS-23100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG THREADED LOCKING 2.3MM X 12MM TI -,SUP-TPLS-23120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
THREADED PEG- LOCKING- 2.3MM X 16MM -,SUP-TPLS-23160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LCK TRH PEG 2.3 X 17MM -,SUP-TPLS-23170-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
THREADED PEG- LOCKING- 2.3MM X 18MM -,SUP-TPLS-23180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG THREADED LOCKING 2.3MM X 19MM -,SUP-TPLS-23190-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LCK TRH PEG 2.3 X 20MM -,SUP-TPLS-23200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
THREADED PEG- LOCKING 2.3MM X 21MM -,SUP-TPLS-23210-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
THREADED PEG LOCKING 2.3MM X 22MM -,SUP-TPLS-23220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
THREADED PEG- LOCKING 2.3MM X 23MM -,SUP-TPLS-23230-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG THREADED LOCKING TI PINK 2.3MM X 24MM -,SUP-TPLS-23240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
THREADED PEG- LOCKING 2.3MM X 26MM -,SUP-TPLS-23260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG THREADED 2.3 X 28 LOCKING -,SUP-TPLS-23280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG TRHEADED NON-LOCKING 2.7MM X 10MM TI -,SUP-TPNL-27100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG THREADES NON LOCKING 2.7 X 12 -,SUP-TPNL-27120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG THREADED NON LOCKING 2.7MM X 14MM -,SUP-TPNL-27140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG THREADES NON LOCKING 2.7 X 16 -,SUP-TPNL-27160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG THREADED NON LOCKING 2.7 X 18 -,SUP-TPNL-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NON-LCK TRH PEG 2.7 X 20MM -,SUP-TPNL-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NON-LCK TRH PEG 2.7 X 22MM -,SUP-TPNL-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG THREADED NON-LOCKING 2.7MM X 24MM -,SUP-TPNL-27240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG THREADED NON-LOCKING 2.7MM X 26MM -,SUP-TPNL-27260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PEG THREADED NON LOCKING 2.7MM X 28MM -,SUP-TPNL-27280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SUBSTITUTE DBM 5ML PTTY OPTIUM FRZDR -,SUP-TPUT05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2696.31,1887.417,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CAGE CERVICAL LORDOTIC D12 W14 H07 -,SUP-TRY-CL 12 07-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
CERVICAL CAGE-LORDOTIC D12 W14 H08 -,SUP-TRY-CL 12 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BONE 20MM 1-LEVEL SPINE CERVICAL -,SUP-TRY-CP 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 22MM -,SUP-TRY-CP 04 22-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 24MM 1-LEVEL -,SUP-TRY-CP 04 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 26MM 1-LEVEL -,SUP-TRY-CP 04 26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 2 LEVEL 36MM -,SUP-TRY-CP 06 36-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 38MM 2-LEVEL -,SUP-TRY-CP 06 38-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 40MM 2 LEVEL -,SUP-TRY-CP 06 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 43MM 2-LEVEL -,SUP-TRY-CP 06 43-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 46MM 2-LEVEL -,SUP-TRY-CP 06 46-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SPINEART TRYPTIK 2- PLATE-52MM-3-LEVEL -,SUP-TRY-CP 08 52-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 55MM 3-LEVEL -,SUP-TRY-CP 08 55-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE TRYPTIK 58MM 3-LEVEL -,SUP-TRY-CP 08 58-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 61MM 3-LEVEL -,SUP-TRY-CP 08 61-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE TRYPTIK 72MM 3 LEVEL -,SUP-TRY-CP 08 72-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 12MM SELF DRILLING POLYAXIAL -,SUP-TRY-PD 40 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SELF-DRILLING POLYAXIAL 4 X 14 -,SUP-TRY-PD 40 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SELF-DRILLING POLYAXIAL 4 X 16 -,SUP-TRY-PD 40 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SELF DRILLING POLYAXIAL 4.5 X 16 -,SUP-TRY-PD 45 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW SELF TAPPING 4 X 14 -,SUP-TRY-PS 40 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW TRYPTIK SELF-TAPPING 4 X 16 -,SUP-TRY-PS 40 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
STENT GRAFT 28 X 14 X 140MM OVATION ILIAC LIMB -,SUP-TV-IL1428140-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEPIN ORTHO THRD DRILL TIP -,SUP-U000-0200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHOR SUT 2.3MM FIBERWIREX2 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHORAGE LAPIDUS PLATING LS 0 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ANCHORAGE LISFRANC PLATING MED -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
FEMORAL AUGMENT DISTAL SZ3 12M -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOCKING COMP BROAD 16 HOLE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.44,869.708,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 6 HOLE STRAIGHT -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE DIAMOND FUSION LARGE NON -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7238.14,5066.698,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE M ADAPTIVE II 2.5 TRI DI -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5810.88,4067.616,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE RT ANTERIOR ANKLE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8806.3,6164.41,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL FLEXIBLE 1.5MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL FLEXIBLE 2.0MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL FLEXIBLE 2.5MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.59,822.213,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL LONG LT TI 11X400 130 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LO-PRO MTP PLT TM CONTRDSHTLTI -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
LOCKING PLATE 6 HOLE 2.0/2.3 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4600.23,3220.161,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 6 HOLE CURVED -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE CERVICAL 2 LEVEL 30MM GE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE GRIP TRICHANTERIC W/2 CA -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7111.03,4977.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ANCHORAGE 3.5MM X 14MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ANCHORAGE 3.5MM X 16MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ANCHORAGE LOCK 3.5 X 14 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS 6.5MM X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.94,757.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE WSTD CMP BRD 16 HOLE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.44,869.708,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCK LP 4.5 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCK LP 4.5 X 46MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 2.3 X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NON LOCKING 2.3 X 21MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,408.04,285.628,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW PERIPH NL 4.5 X 30MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW S-FIX 2.5LG X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL LONG R1/5 RT 11 X 440MM X -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
NAIL TI LNG RT 15 X 440MM X1 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW T2 F/T LOCK 5 X 105MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW TRILOCK 2.8 X 34MM HD7 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 1.2 X 12MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SCREW GAP 6.5MM 30MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,663.67,464.569,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SUPERIOR 6H INCREASED -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE 10 HOLE LOCKING COMPR BR -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BROAD 7 HOLE VARIAX COMP -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE DIST POST LAT HUMERAL 6H -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE HUMERUS RT. 14 HOLE L218 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE SCREW GAP 6.5MM 20MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,663.67,464.569,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ANCHORAGE 3.5MM X 20MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS 5.0MM 60MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS III SS CANN 5 X 46 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS TI 5.0 X 36MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE 2.3 X 26 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE 3.5 X 46MM NON-LOCK -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANN ASNIS III 5.0X 65MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANN ASNIS III 5.0X 70MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL 5.5 X 30MM GENE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW EMERGENCY 1.4 X 3 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCK LP 4.5 X 32MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW M CORTEX 2.3 X 16MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NON LOCK LP 4.5 X 30MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NON LOCKING 2.3 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NON-LOCK LP 4.5 X 28MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW TRILOCK 2.8 X 10MM HD7 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ANCHORAGE LOCK 3.5 X 18 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ANSIS 4.0 X 44MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS CANN TI 5.0 X 60MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS III SS CANN 5 X 38 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ASNIS TI 5.0 X 40MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ANCHORAGE 3.0 X 28MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ANCHORAGE 3.5MM X 32MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW ANCHORAGE LOCK 3.5 X 12 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW AUTOFIX 2.5 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE 2.3 X 18MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE T10 2.7 X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW BONE T10 2.7 X 48MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTEX T8 2.4MM X 8MM SE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORTICAL 5.5 X 40MM HIGH -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CANN FT 4.0 X 40MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW CORT HI-TOP 5.5 X 35MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEADLESS 2.5 X 12MM MICR -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW HEADLESS COMP. 4.0MM 32M -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LO-PRO PT 5MM X 50MM THR -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCK LP 4.5 X 26MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING SILVER 2.5 X 16M -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING T10 2.7 X 48MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NON LOCKING 3.5 X 55MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NON-LOCK LP 4.5 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.5,297.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW NON-LOCK LP 4.5 X 24MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LCK ST 2.7 X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCK LP 4.5 X 24MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCK LP 4.5 X 44MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING 2.3 X 12MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LOCKING T10 2.7 X 20MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW TRILOCK 2.8 X 12MM HD7 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW VA 4.25 X 14MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW LP 5.5 X 55MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW TI LOCK 5.5 X 35MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WIRE TEMP KIRSCH 1X100MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.71,106.197,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WASHER ORTHO -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,158.48,110.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PLATE BN ULTRA PIN -,SUP-UPP3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X23MM COMPR AEQUALIS REVERSED II ST NS F/BSPLT -,SUP-VDV223,CDM,C1713,HCPCS,278,RC,,,outpatient,,,980.28,686.196,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 4.5X35MM COMPR AEQUALIS REVERSED II ST NS F/BSPLT -,SUP-VDV235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
"V-LOC 180 ABSORABLE RELOAD 2-0 6"" ES-9 TAPER -",SUP-VLOCA206L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,211.29,147.903,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SUTURE V-LOC ABSORBABLE 2-0 8 IN FOR ENDOSTITCH -,SUP-VLOCA208L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,249.42,174.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
"SUT V-LOC 180 2-0 P-12 12""CLEAR -",SUP-VLOCL0015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.68,88.676,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
"V-LOC 0 ABS 12"" GS-21 GREEN -",SUP-VLOCL0316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,125.34,87.738,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
"V-LOC 2-0 ABS 18"" GS-21 GREEN -",SUP-VLOCL0325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,125.34,87.738,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
"V-LOC 0 ABS 18"" GS-21 GREEN -",SUP-VLOCL0326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,130.1,91.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
"SUT V-LOC 180 0 GS-21 9"" GREEN -",SUP-VLOCL0346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,124.81,87.367,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
"V-LOC 3-0 ABS 6"" V-20 GREEN -",SUP-VLOCL0604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.66,927.962,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
"V-LOC 180 GREEN 12"" V-20 TAPER -",SUP-VLOCL0614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
"SUTURE VLOC 9"" 1/2 CIRCLE 26MM -",SUP-VLOCL0644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
"SUT V-LOC 180 3-0 CV-23 6"" GREEN -",SUP-VLOCL0804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
"SUT V-LOC 180 3-0 CV-23 12"" GREEN -",SUP-VLOCL0814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
"V-LOC 2-0 ABS 9"" GS-22 GREEN -",SUP-VLOCL2145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
"V-LOC 3-0 ABS 18"" P-14 UNDYED -",SUP-VLOCM0124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.68,88.676,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
"V-LOC 3-0 ABS  6"" CV-23 VIOLET -",SUP-VLOCM0804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
"V-LOC 3-0 ABS 18"" P-17 UNDYED -",SUP-VLOCM1824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.68,88.676,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SUT V-LOC 90 2-0 GS-22 TAPER 12IN VIOLET -,SUP-VLOCM2115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,136.19,95.333,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
"SUTURE V-LOC 0 NON-ABS 6"" GS-21 BLUE -",SUP-VLOCN0306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,90.79,63.553,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
"V-LOC 2-0 PBT NON-ABS 6"" V-20 BLUE -",SUP-VLOCN0605,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1309.01,916.307,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
"V-LOC 2-0 NON-ABS 12"" V-20 BLUE -",SUP-VLOCN0615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
VLOC PBT 1 BLU 12 GS-22 -,SUP-VLOCN2117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,131.58,92.106,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
VLOC PBT 0 BLU 9 GS-22 NON-ABS -,SUP-VLOCN2146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,131.58,92.106,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GRAFT VALLIANT STENT 20F 31 X 90 NACION THORACIC -,SUP-VNMC3131C90TU,CDM,C1713,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN BALL JURGAN .045 YELLOW -,SUP-W045-YL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PK CAP PROT 0.375IN PIN BALL W-SRS F/0.045IN K-WR XTRNFXTR -,SUP-W045-YL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,256.74,179.718,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PIN BALL JURGAN .062 GREEN -,SUP-W062-GN,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PK CAP PROT 0.375IN PIN HEAD JRGN PIN BALL W-SRS F/.0938IN -,SUP-W332-CR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PK CAP PROT 0.375IN PIN HEAD JRGN PIN BALL W-SRS F/.0781IN -,SUP-W564-BL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,256.74,179.718,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PK CAP PROT 0.375IN PIN HEAD JRGN PIN BALL W-SRS F/.0781IN -,SUP-W564-BL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WASHER INSIDE 2.7MM OUTSIDE 5MM -,SUP-WBTN-2750-T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.27,240.989,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WASHER BUTTON BRONZE -,SUP-WBTN-HCLP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.93,224.651,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2MMX12MM NCANN TWST-OFF W- FX FIXOS MICROTHREADED -,SUP-WS12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 13MM NCANN TWST-OFF W- FX FIXOS MICROTHREADED -,SUP-WS13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SNAP OFF SCREW DIAM 2.1 LG.14 -,SUP-WS14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2MMX15MM NCANN W- FX FIXOS MICROTHREADED SD/ST/RM -,SUP-WS15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SCREW 2MMX16MM NCANN W- FX FIXOS MICROTHREADED SD/ST/RM -,SUP-WS16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
ORTHO 0.35MM -,SUP-WSO906ST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.7,81.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
WOUND MATRIX 6 LAYER 10CM X 15CM 150SQCM -,SUP-WSX1015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16411.46,11488.022,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
PK PIN BALL PIN BALL PROT REFL 0.125IN 0.1094X.125IN F/3MM -,SUP-X003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SUTURE MONODERM QUILL 3-0 MONO CLR YA-1023Q 30CMX30CM L BARB -,SUP-YA-1023Q,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.56,90.692,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
SUTURE MONODERM QUILL #0 MONO CLR YA-1029Q 36CMX36CM L BARB -,SUP-YA-1029Q,CDM,C1713,HCPCS,278,RC,,,outpatient,,,136.04,95.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.518595,35041.66656,other,SI=N Exclusions ,,
GUIDEWIRE HI-TORQUE CONNECT 250FT -,SUP-1012595,CDM,C1714,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions ,,
EARLY ACCESSORY DROP OFF FEE -,SUP-10595-10169,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions ,,
K-WIRE GAMMA 3.2 X 450MM -,SUP-1210-6451S,CDM,C1714,HCPCS,272,RC,,,outpatient,,,478.7,335.09,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions ,,
SCREWDRIVER FLEXIBLE GAMMA -,SUP-1320-0233,CDM,C1714,HCPCS,272,RC,,,outpatient,,,2438.28,1706.796,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions ,,
LEE RT ANG BRONCHUS CLAMP 9 39MM JAW -,SUP-320200,CDM,C1714,HCPCS,272,RC,,,outpatient,,,779.26,545.482,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions ,,
PROBE BALL TIP 3MM TIP PEDICLE SCREW D344 -,SUP-3603-00-TE,CDM,C1714,HCPCS,272,RC,,,outpatient,,,601.01,420.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions ,,
"KWIRE SINGLE POINT STST 150MM X .045"" -",SUP-451-1045,CDM,C1714,HCPCS,272,RC,,,outpatient,,,152.76,106.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions ,,
10X30CM PICO14 DRESSING KIT -,SUP-66022043,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1562.06,1093.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions ,,
HOLDER/POSITIOINER PLATE 1.2/1.55 FOR INSTRUMENT -,SUP-A-2350,CDM,C1714,HCPCS,272,RC,,,outpatient,,,4147.65,2903.355,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions ,,
HOLDER/POSITIOINER PLATE 2.0/2.3 FOR INSTRUMENT -,SUP-A-2650,CDM,C1714,HCPCS,272,RC,,,outpatient,,,4147.65,2903.355,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions ,,
KIT FIBERTAK KNOTLESS CURVED DISPOSABLE -,SUP-AR-3638DC,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions ,,
B CROSSTELLAÂ® RX PTA Balloon Dilatation Cath 6mm x 150mm -,SUP-BD-F60150LR,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions ,,
BALLOON R2P CROSTELLA  RX- 200cm- 6mm x 150mm -,SUP-BD-Q60150ER,CDM,C1714,HCPCS,272,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions ,,
CATH BLNOCC 1.3MM 5FR SHTH 146CM 20CM LUM C RSSR 14S RX -,SUP-CRU14S,CDM,C1714,HCPCS,272,RC,,,outpatient,,,9315.58,6520.906,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions ,,
CATH BLNOCC 1.1MM 5FR SHTH 146CM C RSSR 14P OTW PERIPH -,SUP-CRUO14PA,CDM,C1714,HCPCS,272,RC,,,outpatient,,,9315.58,6520.906,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions ,,
CATH PTCA 0.05IN C RSSR S6 156CM RECANALIZATION PERIPH 5FR -,SUP-CRUS6A,CDM,C1714,HCPCS,272,RC,,,outpatient,,,9315.58,6520.906,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions ,,
DRILL KIT FOR CONTINUOUS COMPRESSION -,SUP-DK-265C,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1863.92,1304.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions ,,
INTERSTIM BELT FIXATION LARGE SCS PH -,SUP-FP9000L,CDM,C1714,HCPCS,272,RC,,,outpatient,,,233.4,163.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions ,,
DILATOR COONS -,SUP-G04051,CDM,C1714,HCPCS,272,RC,,,outpatient,,,102.05,71.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions ,,
CATH ANG 5FR DAV 100CM ADVANTG BRD VSCR -,SUP-G08581,CDM,C1714,HCPCS,272,RC,,,outpatient,,,151.7,106.19,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions ,,
BALLOON EXTRACTOR PRO XL RETREIVAL 9-12 -,SUP-M00547130,CDM,C1714,HCPCS,272,RC,,,outpatient,,,612.32,428.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions ,,
SET DELIVERY SIROS -,SUP-SIR-10300,CDM,C1714,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions ,,
BLADE HOOK DISSECTING SYNERGY HARMONIC -,SUP-SNGHK,CDM,C1714,HCPCS,272,RC,,,outpatient,,,2781.64,1947.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions ,,
SUTURE 3-0 MONO PLUS 16 X 16CM UNDYED -,SUP-SXMP2B402,CDM,C1714,HCPCS,272,RC,,,outpatient,,,166.17,116.319,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions ,,
DRESSING KCI VERAFLO CLEANSE CHOICE LARGE -,SUP-ULTVCC05LG,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1428.85,1000.195,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions ,,
DRESSING NEG PRSS SM 10X7.5X3.3CM VAC GRANUFOAM -,SUP-XF-DSMF1,CDM,C1714,HCPCS,272,RC,,,outpatient,,,163.38,114.366,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.910225,6679.27086,other,SI=N Exclusions ,,
NEEDLE BRCHTX 18GAX20CM ULTRA-SHRP TIP PLSH SURF PRELD BN -,SUP-818205,CDM,C1715,CPT,272,RC,,,outpatient,,,84.61,59.227,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,18.994945,416.02,other,SI=N Exclusions ,,
CURRENT DR RF 2207-36 AICD -,SUP-2207-36,CDM,C1721,HCPCS,275,RC,,,outpatient,,,44309.79,31016.853,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR LUMAX 740 DR-T 2CHMBR CARD IMPL W/HOME MNTR -,SUP-365606,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30837.5,21586.25,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR ILESTO DR-T DF-1 2CHMBR HI ENRG CARD IMPL W/TI -,SUP-383562,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25644.47,17951.129,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR ILESTO DR-T DF-4 2CHMBR HI ENRG CARD IMPL W/TI -,SUP-383564,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25644.47,17951.129,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR ITREVIA 7 DR-T DF-4 2CHMBR CARD IMPL W/TI -,SUP-392426,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25644.47,17951.129,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR CRNT + DR DF-4 2CHMBR RR V- PCNG RDC 50X74MM -,SUP-CD2211-36Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR FORTIFY DR DF-1 2CHMBR 40X74MM 14MM 35ML 76GM -,SUP-CD2231-40,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR FORTIFY DR DF-4 2CHMBR RR V- PCNG RDC 40X71MM -,SUP-CD2231-40Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR FORTIFY ASSURA DR DF-1 TELEM 2CHMBR 40X74MM -,SUP-CD2257-40,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR FORTIFY ASSURA DR DF-4 TELEM 2CHMBR 40X71MM -,SUP-CD2257-40Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR ELLIPSE DR DF-1 IS-1 CONN 2CHMBR DEFT RESPONSE -,SUP-CD2311-36,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR ELLIPSE DR DF-4 2CHMBR DEFT RESPONSE RF TELEM -,SUP-CD2311-36Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR FORTIFY ASSURA DR DF-4 2CHMBR CARD IMPL 40C -,SUP-CD2357-40C,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR FORTIFY ASSURA DR DF-4 2CHMBR CARD IMP 40Q -,SUP-CD2357-40Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR ELLIPSE VR IS-1 DF-1 2CHMBR 51X68MM 12MM 31ML -,SUP-CD2411-36C,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR ELLIPSE ASSURA DR DF-4 2CHMBR CARD IMPL -,SUP-CD2411-36Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
ENTRANT ICD CDDRA300Q -,SUP-CDDRA300Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37130,25991,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
ENTRANT DR ICD DF1 CONNECTOR REF: CDDRA300T -,SUP-CDDRA300T,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37130,25991,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
GALLANT ICD CDDRA500Q -,SUP-CDDRA500Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,26150.2,18305.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
GALLANT DR ICD DF1 CONNECTOR REF: CDDRA500T -,SUP-CDDRA500T,CDM,C1721,HCPCS,275,RC,,,outpatient,,,26150.2,18305.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR INOGEN DF-1 SGL-CHMBR 5.23X7.14X0.99 CM D -,SUP-D013,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25975.04,18182.528,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DYNAGEN MINI ICD DR D022 -,SUP-D022,CDM,C1721,HCPCS,275,RC,,,outpatient,,,36747.56,25723.292,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
ICD MOMENTUM EO DR D121 -,SUP-D121,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25903.5,18132.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR D142 INOGEN MUL PRGM OPTN EXTEND LNGVT DR DF-4 -,SUP-D142,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25091.86,17564.302,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DYNAGEN D153 EL ICD -DF-1 -,SUP-D153,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25091.86,17564.302,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR CONSULTA DF-4 CARD IMPL -,SUP-D204TRM,CDM,C1721,HCPCS,275,RC,,,outpatient,,,48626.05,34038.235,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR SECURA DR 2CHMBR RR V- PCNG RDC 51X64MM 15MM -,SUP-D224DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,35700.82,24990.574,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR SECURA VR SGL-CHMBR RR V- PCNG RDC 51X64MM -,SUP-D224VRC,CDM,C1721,HCPCS,275,RC,,,outpatient,,,31901.76,22331.232,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
ICD DUAL VIGILANT EL DR DF4 MRI CONDITIONAL -,SUP-D233,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25903.5,18132.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR MAXIMO II DR WRLS TELEM 2CHMBR RR V- PCNG RDC -,SUP-D284DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34217.29,23952.103,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR PROTECTA XT DR DF-1 IS-1 CONN 2CHMBR RR -,SUP-D314DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37579.81,26305.867,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR PROTECTA DR DF-1 IS-1 CONN 2CHMBR RR V- PCNG -,SUP-D334DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32749.43,22924.601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR PROTECTA DR DF-4 2CHMBR CARD IMPL -,SUP-D334DRM,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32749.43,22924.601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
ICD PERCIVA DR D401 -,SUP-D401,CDM,C1721,HCPCS,275,RC,,,outpatient,,,27894.37,19526.059,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
ICD PERCIVA DR DF4 D413 MRI CONDITIONAL -,SUP-D413,CDM,C1721,HCPCS,275,RC,,,outpatient,,,27894.37,19526.059,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR EVERA S DR DF-1 2CHMBR CARD IMPL -,SUP-DDBC3D1,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32071,22449.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR EVERA S DR DF-4 2CHMBR CARD IMPL -,SUP-DDBC3D4,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32071,22449.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR EVERA MRI XT DR SURSCN DF-4 CARD IMPL -,SUP-DDMB1D1,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37251.7,26076.19,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
EVERA MRI S DR SURESCAN MODEL DDMC3D1 -,SUP-DDMC3D1,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34784.7,24349.29,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR EVERA 2CHMBR CARD IMPL -,SUP-DDMC3D4,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34784.7,24349.29,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
ICD DUAL COBALT DR MRI REF: DDPB3D4 -,SUP-DDPB3D4,CDM,C1721,HCPCS,275,RC,,,outpatient,,,38485.2,26939.64,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR OVATIO CARD 6550 -,SUP-DR6550,CDM,C1721,HCPCS,275,RC,,,outpatient,,,45639.5,31947.65,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DYNAGEN CRT-D G151 -,SUP-G151,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32897.45,23028.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR VITALITY II DR IS-1 DF-1 2CHMBR V- PCNG RDC -,SUP-T167,CDM,C1721,HCPCS,275,RC,,,outpatient,,,43197.17,30238.019,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR VITALITY HE IS-1 DF-1 2CHMBR 66MMX82.6MM -,SUP-T180,CDM,C1721,HCPCS,275,RC,,,outpatient,,,41877.33,29314.131,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR PARADYM RF VR IMPL 9250 -,SUP-TDF011U,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25661.73,17963.211,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR SQ-RX DF-1 SGL-CHMBR 65.5MMX78.2MMX15.7MM D -,SUP-1010,CDM,C1722,HCPCS,275,RC,,,outpatient,,,46873,32811.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
DEFIBRILLATOR CRNT VR RF SGL-CHMBR VNTRC PCNG CARD IMPL -,SUP-1207/36,CDM,C1722,HCPCS,275,RC,,,outpatient,,,37656.29,26359.403,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
DEFIBRILLATOR LUMAX 540 VR-T IS-1 CONN SGL-CHMBR RR 55X66MM -,SUP-360348,CDM,C1722,HCPCS,275,RC,,,outpatient,,,30895.47,21626.829,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
DEFIBRILLATOR LUMAX 740 VR-T SGL-CHMBR CARD IMPL W/HOME MNTR -,SUP-365609,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28370.5,19859.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
DEFIBRILLATOR LUMAX 740 VR-T DX CARD IMPL CELL GSM HOME MNTR -,SUP-372419,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28370.5,19859.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
DEFIBRILLATOR ILESTO VR-T SGL-CHMBR CARD IMPL -,SUP-383578,CDM,C1722,HCPCS,275,RC,,,outpatient,,,30837.5,21586.25,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
DEFIBRILLATOR ILESTO VR SGL-CHMBR HI ENRG CARD IMPL W/TI -,SUP-383580,CDM,C1722,HCPCS,275,RC,,,outpatient,,,30837.5,21586.25,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
DEFIBRILLATOR ILESTO DX HI ENRG CARD IMPL W/TI LANDLINE HOME -,SUP-383594,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35737.63,25016.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
DEFIBRILLATOR ITREVIA 7 VR-T DX HI ENRG CARD IMPL -,SUP-393037,CDM,C1722,HCPCS,275,RC,,,outpatient,,,24694.67,17286.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
DEVICE HI ENRG CARD IMPL TI -,SUP-393041,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35737.63,25016.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
ICD INTICA NEO 7 VR-T DX REF:429559 -,SUP-429559,CDM,C1722,HCPCS,275,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
DEFIBRILLATOR EMBLEM S SQ-1 CONN 83.1MMX69.1MMX12.7MM D -,SUP-A209,CDM,C1722,HCPCS,275,RC,,,outpatient,,,46873,32811.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
S-ICD Emblem MRI A219 -,SUP-A219,CDM,C1722,HCPCS,275,RC,,,outpatient,,,44406,31084.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
DEFIBRILLATOR CRNT + VR SJ-4 CONN SGL-CHMBR 50X74MM 14MM -,SUP-CD1211-36Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
DEFIBRILLATOR FORTIFY VR DF-1 SGL-CHMBR 40X73MM 14MM 35ML -,SUP-CD1231-40,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
DEFIBRILLATOR FORTIFY VR DF-4 ATP TERM AUTOMATICITY -,SUP-CD1231-40Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
DEFIBRILLATOR FORTIFY ASSURA VR DF-1 TELEM SGL-CHMBR 40X73MM -,SUP-CD1257-40,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
DEFIBRILLATOR FORTIFY ASSURA VR DF-4 SGL-CHMBR RF TELEM -,SUP-CD1257-40Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
DEFIBRILLATOR ELLIPSE VR DF-1 IS-1 CONN SGL-CHMBR DEFT -,SUP-CD1311-36,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
DEFIBRILLATOR ELLIPSE VR DF-4 DF-1 IS-1 CONN SGL-CHMBR DEFT -,SUP-CD1311-36Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,25163.4,17614.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
DEFIBRILLATOR FORTIFY ASSURA VR DF-1 IS-1 CONN SGL-CHMBR -,SUP-CD1357-40C,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
DEFIBRILLATOR FORTIFY ASSURA VR DF-4 SGL-CHMBR 40X71MM 14MM -,SUP-CD1357-40Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
DEFIBRILLATOR ELLIPSE VR IS-1 DF-1 SGL-CHMBR 51X68MM 12MM -,SUP-CD1411-36C,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
DEFIBRILLATOR ELLIPSE VR-ICD MRLN DF-4 SGL-CHMBR -,SUP-CD1411-36Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
ENTRANT ICD CDVRA300Q -,SUP-CDVRA300Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35273.5,24691.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
ENTRANT VR ICD DF1 CONNECTOR REF: CDVRA300T -,SUP-CDVRA300T,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35273.5,24691.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
GALLANT ICD CDVRA500Q -,SUP-CDVRA500Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36201.75,25341.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
GALLANT VR ICD DF1 CONNECTOR REF: CDVRA500T -,SUP-CDVRA500T,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36201.75,25341.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
DEFIBRILLATOR INOGEN DF-1 SGL-CHMBR 5.23X7.14X0.99 CM D. -,SUP-D011,CDM,C1722,HCPCS,275,RC,,,outpatient,,,26643.6,18650.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
ICD MOMENTUM EL VR D120 -,SUP-D120,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36573.05,25601.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
DEFIBRILLATOR INOGEN EXTEND LNGVT 5.37X7.36X0.99IN 68.9G -,SUP-D140,CDM,C1722,HCPCS,275,RC,,,outpatient,,,34746.25,24322.375,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
DYNAGEN EL ICD VR MODEL D151 -,SUP-D151,CDM,C1722,HCPCS,275,RC,,,outpatient,,,34746.25,24322.375,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
DEFIBRILLATOR SECURA DR DF-4 2CHMBR CARD IMPL -,SUP-D204DRM,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35700.82,24990.574,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
DEFIBRILLATOR SECURA VR DF-4 SGL-CHMBR CARD IMPL -,SUP-D204VRM,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31901.76,22331.232,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
ICD VIGILANT EO VR DF4 D232 MRI CONDITIONAL -,SUP-D232,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36573.05,25601.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
DEFIBRILLATOR PROTECTA VR DF-1 IS-1 CONN SGL-CHMBR RR -,SUP-D334VRG,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28710.95,20097.665,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
DEFIBRILLATOR PROTECTA VR DF-4 SGL-CHMBR CARD IMPL -,SUP-D334VRM,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28710.95,20097.665,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
ICD SINGLE PERCIVA VR REF: D400 -,SUP-D400,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36573.05,25601.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
ICD PERCIVA VR DF4 D142 MRI CONDITIONAL -,SUP-D412,CDM,C1722,HCPCS,275,RC,,,outpatient,,,25827.02,18078.914,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
ICD RESONATE EL VR -,SUP-D432,CDM,C1722,HCPCS,275,RC,,,outpatient,,,29019.32,20313.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
COBALT XT DR MRI ICD REF: DDPA2D4 -,SUP-DDPA2D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,41837.85,29286.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
DEFIBRILLATOR EVERA S VR DF-1 SGL-CHMBR CARD IMPL -,SUP-DVBC3D1,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28617.2,20032.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
DEFIBRILLATOR EVERA S VR DF-4 SGL-CHMBR CARD IMPL -,SUP-DVBC3D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28617.2,20032.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
VISIA AF MRI VR ICD DVFB1D1 -,SUP-DVFB1D1,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
ICD VISIA AF MRI SURESCAN VR -,SUP-DVFB1D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
DEFIBRILLATOR CARDIAC VISIA AF MRI SURESCAN DVFC3D1 -,SUP-DVFC3D1,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
DEFIBRILLATOR EVERA MRI XT DR SURSCN DF-4 CARD IMPL -,SUP-DVMB1D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,35998.464,other,SI=N Exclusions ,,
EXPLANT TRUNCATED BLADE 56MM -,SUP-00-7053-056-10,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions ,,
C 0.9M .014IN OTW TURBO ELITE -,SUP-410-152,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions ,,
C 1.4M .014IN OTW TURBO ELITE -,SUP-414-151,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions ,,
"2.0mm .018"" TURBO ELITE LASER -",SUP-420-006,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions ,,
C 2.3M .018IN OTW TURBO ELITE -,SUP-423-001,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions ,,
C 7FR LASER GUIDE 2.0MM TURBO -,SUP-423-050,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12234.34,8564.038,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions ,,
DEVICE ATHRCMY STEALTH 360 1.5MM MICRO CRWN 145CM SHFT DMD -,SUP-DBE-150,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12605.64,8823.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions ,,
CATH ATHRCMY DIAMONDBACK 360 1.25MM CROWN 135CM SHAFT -,SUP-DBEC-125,CDM,C1724,HCPCS,272,RC,,,outpatient,,,14833.44,10383.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions ,,
DEVICE ATHRCMY PREDATOR 360 2MM CRWN DMD CTD SLD ART -,SUP-DBG-SCT30-200,CDM,C1724,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions ,,
DEVICE ARTHREC 1.25 SOLID -,SUP-DBP-125MICRO145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions ,,
SYSTEM ATHERECTOMY DBP-125MICRO145 -,SUP-DBP-125MICRO145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions ,,
DEVICE ARTHREC STEALTH 1.25S -,SUP-DBP-125SOLID145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions ,,
DEVICE ARTHREC STEALTH 1.50MM 5F -,SUP-DBP-150SOLID145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions ,,
DBP-200SOLID145 -,SUP-DBP-200SOLID145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions ,,
CATH ATHRCMY DIAMONDBACK 360 1.50MM X 145CM SOLID -,SUP-DBP-EX-150SOL145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,14462.14,10123.498,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions ,,
ROTAPRO ADVANCER 1.25MM -,SUP-H749394671250,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7999.94,5599.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions ,,
ROTAPRO ADVANCER 1.5MM -,SUP-H749394671500,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7999.94,5599.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions ,,
ROTAPRO ADVANCER 1.75MM -,SUP-H749394671750,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions ,,
ROTAPRO ADVANCER 2.0MM -,SUP-H749394672000,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions ,,
ROTAPRO ADVANCER 2.25MM -,SUP-H749394672250,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions ,,
ROTAPRO ADVANCER 2.38MM -,SUP-H749394672380,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions ,,
ROTAPRO ADVANCER 2.5MM -,SUP-H749394672500,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions ,,
ROTAPRO ADVANCER 2.15MM -,SUP-H7494672150,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions ,,
CATH ATHRCMY ROTLNK + 1.25MM BUR 0.58IN SHTH 135CM TFLN PTFE -,SUP-H802227680020,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4502.88,3152.016,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions ,,
BURR ROTALINK 1.50MM 0.58IN SHTH 135CM EXCHGL -,SUP-H802227680030,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4953.17,3467.219,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions ,,
CATH ATHRCMY ROTLNK + 1.75MM BUR 0.58IN SHTH 135CM EXCHGL -,SUP-H802227680040,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4953.17,3467.219,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions ,,
CATH ATHRCMY ROTLNK + 2MM BUR 0.58IN SHTH 135CM EXCHGL ROT -,SUP-H802227680050,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4502.88,3152.016,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions ,,
CATH ATHRCMY ROTLNK 2.15MM BUR 0.58IN SHTH 135CM TFLN PTFE -,SUP-H802227680150,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4502.88,3152.016,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions ,,
PHOENIX 1.8MM X130CM -,SUP-P18130,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions ,,
1.8MM PHOENIX 149CM -,SUP-P18149K,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions ,,
PHOENIX 2.2MM X 130CM -,SUP-P22130K,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions ,,
PHOENIX ARTHERECTOMY 2.4MM 7FR -,SUP-P22149K,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions ,,
ARTHERECTOMY JTSTRM 1.85MM -,SUP-PV3118F,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12754.16,8927.912,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions ,,
ARTHERECTOMY JTSTRM 2.1/3MM -,SUP-PV31300,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12624.2,8836.94,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions ,,
CATH ARTHERECTOMY JTSTRM 2.4/3.4MM LT -,SUP-PV41340,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12624.2,8836.94,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10635.57648,other,SI=N Exclusions ,,
CATHETER BALLOON VALVULOPLASTY  22MX4.5CMX110CM -,SUP-00224512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATHETER BALLOON VALAVULOPLASTY 20MMX4.5X110CM TRUE DILATION -,SUP-0204511,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATHETER BALLOON VALVULOPLASTY 21MMX4.5CMX110CM TRUE DILATIO -,SUP-0214512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATHETER BALLOON VALVULOPLASTY 23MMX4.5CMX120CM TRUE DILATIO -,SUP-0234512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATHETER BALLOON VALVULOPLASTY 24MMX4.5CMX110CM TRUE DILAT -,SUP-0244512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATHETER TRUE DILATATION 25MM X 4.5CM REF: 0254513 -,SUP-0254513,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATHETER TRUE DILATION 26MM -,SUP-0264513,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATHETER BALLOON VALVULOPLASTY 28MMX4.5CMX110CM TRUE DILAT -,SUP-0284514,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH IABP LINEAR 7.5FR 40CC -,SUP-0684-00-0480-01,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4203.6,2942.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATHETER IABP 7.5FR 40CC SENSATION PLUS -,SUP-0684-00-0568-01U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4524.1,3166.87,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATHETER IABP 8FR 50CC SENSATION PLUS -,SUP-0684-00-0576-01U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4524.1,3166.87,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
GAIA FIRST 190CM MICRO J,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
GAIA SECOND 190CM MICRO J,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
GAIA THIRD 190CM MICRO J,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
RG3 330CM,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X18MM PWRSL 143CM RX F/PTCA COR HYDRCT 0.024IN GW -,SUP-1005527-18,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1086.6,760.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X15MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008189-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
4MM X 20MM X 135CM VIATRAC 14 PLUS BALLOON -,SUP-1008189-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ABBOTT VIATRAC BALLOON 4.5 X 20 X 135 -,SUP-1008191-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5X20MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008193-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ABBOTT VIATRAC BALLOON 5.5 X 20 X 135 -,SUP-1008195-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6X20MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008197-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6X40MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008197-40,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH CV 4.5X20MM VIATRAC LF -,SUP-10081991-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ABBOTT VIATRAC BALLOON 6.5 X 20 X 135 -,SUP-1008199-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 7X20MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008201-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.2X6MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012268-06U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON MINI TREK RX 1.20MM X 08MM REF: 1012268-08U -,SUP-1012268-08U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.2X12MM MINI TREK II RX UL-LPRO NC COR HYDRCT -,SUP-1012268-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.2X12MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012268-12U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON MINI TREK RX 1.20MM X 15MM REF: 1012268-15U -,SUP-1012268-15U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.2X20MM MINI TREK II RX UL-LPRO NC COR HYDRCT -,SUP-1012268-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.2X20MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012268-20U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.5X8MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.5X12MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.5X15MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.5X20MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X8MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X12MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X15MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X20MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X25MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X30MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X30MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON TREK RX 2.75MM X 08MM REF: 1012273-08 -,SUP-1012273-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON TREK RX 2.75MM X 12MM REF: 1012273-12 -,SUP-1012273-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON TREK RX 2.75MM X 20MM REF: 1012273-20 -,SUP-1012273-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X30MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON TREK RX 4.0MM X 8MM REF: 1012278-08 -,SUP-1012278-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012278-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON TREK RX 4.0MM X 15MM REF: 1012278-15 -,SUP-1012278-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON TREK RX 4.0MM X 20MM REF: 1012278-20 -,SUP-1012278-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012278-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X30MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012278-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4.5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012279-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON TREK RX 4.5MM X 15MM REF: 1012279-15 -,SUP-1012279-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012280-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON TREK RX 5.0MM X 15MM REF: 1012280-15 -,SUP-1012280-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.2X6MM MINI TREK II OTW UL-LPRO NC COR HYDRCT CTD -,SUP-1012401-06Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.2X8MM MINI TREK II OTW UL-LPRO NC COR HYDRCT CTD -,SUP-1012401-08Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.2X12MM MINI TREK II OTW UL-LPRO NC COR HYDRCT -,SUP-1012401-12Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.2X15MM MINI TREK II OTW UL-LPRO NC COR HYDRCT -,SUP-1012401-15Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.2X20MM MINI TREK II OTW UL-LPRO NC COR HYDRCT -,SUP-1012401-20Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.5X8MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.5X12MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.5X15MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.5X20MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X8MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012403-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X12MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X15MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X20MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X30MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X30MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012407-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X30MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X12MM NC TREK OTW SM-PRFL NC COR RND TIP HYDRCT -,SUP-1012433-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.75X15MM NC TREK OTW SM-PRFL NC COR RND TIP -,SUP-1012436-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.5X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X25MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.75X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.75X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.75X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.75X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.75X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X25MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X12 MM NC TREK RX ULLPRO NC COR RND TIP HYDRCT -,SUP-1012450-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X25MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.75X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.75X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.75X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.75X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
2.0MM X 60 MM X 150CM ARMADA 18 BALLOON OTW -,SUP-1013463-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA BALLOON 2.5MM X 40MM X 150CM -,SUP-1013464-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 18 2.5 X 200 X 150 -,SUP-1013464-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA BALLOON 2.5MM X 80MM X 150CM -,SUP-1013464-80,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA BALLOON .018 3MM X 60MM X 150CM -,SUP-1013465-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1155.33,808.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA BALLOON .018 3.0MM X 80MM X 150CM -,SUP-1013465-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA BALLOON .018 3.0MM X 100MM X 150CM -,SUP-1013465-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATHETER ARMADA 18 3.0MM X 120MM X 150CM -,SUP-1013465-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATHETER ARMADA 18 PTA -,SUP-1013465-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA BALLOON .018 3 X 200 X 150 -,SUP-1013465-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 18 4 X 20MM -,SUP-1013466-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
4MM X 40MM X 150CM ARMADA 18 BALLOON -,SUP-1013466-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
4MM X 60MM X 150CM ARMADA 18 -,SUP-1013466-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 4MM X 80MM X 150CM 18 -,SUP-1013466-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON ARMADA 4 X 150 X 150MM -,SUP-1013466-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 18 BALLOON 5MM X 20MM -,SUP-1013468-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
5mm x 40mm armada 18 -,SUP-1013468-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
5mm x 60mm Armada 18 Balloon -,SUP-1013468-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 18 BALLOON 5MM X 80MM -,SUP-1013468-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B ARMADA .018 5MM X 100MM -,SUP-1013468-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA BALLOON 5 MM X 150MM -,SUP-1013468-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA BALLOON 5MM X 200MM -,SUP-1013468-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 18 BALLOON 6 X 20MM -,SUP-1013470-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
6MM X 40MM X 150CM ARMADA 18 BALLOON -,SUP-1013470-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 18 B 6MM X 60MM X 150CM -,SUP-1013470-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 018 6MM X 80 MM -,SUP-1013470-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 6MM X 100MM 18 BALLOON -,SUP-1013470-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 6MM X 150MM 0.018 -,SUP-1013470-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 6MM X 200MM 0.018 -,SUP-1013470-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON TREK RX 3.75MM X 8MM REF: 1012277-08 -,SUP-102277-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 1.50MM X 8MM REF: 1400150-08 -,SUP-1400150-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 1.50MM X 12MM REF: 1400150-12 -,SUP-1400150-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 1.50MM X 15MM REF: 1400150-15 -,SUP-1400150-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 1.50MM X 20MM REF: 1400150-20 -,SUP-1400150-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 2.00MM X 8MM REF: 1400200-08 -,SUP-1400200-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 2.00MM X 12MM REF: 1400200-12 -,SUP-1400200-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 2.00MM X 15MM REF: 1400200-15 -,SUP-1400200-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 2.00MM X 20MM REF: 1400200-20 -,SUP-1400200-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 2.25MM X 08MM REF: 1400225-08 -,SUP-1400225-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 2.25MM X 12MM REF: 1400225-12 -,SUP-1400225-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 2.25MM X 15MM REF: 1400225-15 -,SUP-1400225-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 2.25MM X 20MM REF: 1400225-20 -,SUP-1400225-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 2.50MM X 8MM REF: 1400250-08 -,SUP-1400250-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 2.50MM X 12MM REF: 1400250-12 -,SUP-1400250-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 2.50MM X 15MM REF: 1400250-15 -,SUP-1400250-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 2.50MM X 20MM REF: 1400250-20 -,SUP-1400250-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 2.75MM X 8MM REF: 1400275-08 -,SUP-1400275-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 2.75MM X 12MM REF: 1400275-12 -,SUP-1400275-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 2.75MM X 15MM REF: 1400275-15 -,SUP-1400275-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 2.75MM X 20MM REF: 1400275-20 -,SUP-1400275-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 3.00MM X 8MM REF: 1400300-08 -,SUP-1400300-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 3.00MM X 15MM REF: 1400300-15 -,SUP-1400300-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 3.00MM X 20MM REF: 1400300-20 -,SUP-1400300-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 3.25MM X 8MM REF: 1400325-08 -,SUP-1400325-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 3.25MM X 12MM REF: 1400325-12 -,SUP-1400325-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 3.25MM X 15MM REF: 1400325-15 -,SUP-1400325-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 3.25MM X 20MM REF: 1400325-20 -,SUP-1400325-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 3.50MM X 8MM REF: 1400350-08 -,SUP-1400350-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 3.50MM X 12MM REF: 1400350-12 -,SUP-1400350-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 3.50MM X 15MM REF: 1400350-15 -,SUP-1400350-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 3.50MM X 20MM REF: 1400350-20 -,SUP-1400350-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 3.75MM X 12MM REF: 1400375-12 -,SUP-1400375-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 3.75MM X 20MM REF: 1400375-20 -,SUP-1400375-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 4.00MM X 8MM REF: 1400400-08 -,SUP-1400400-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 4.00MM X 12MM REF: 1400400-12 -,SUP-1400400-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 4.00MM X 15MM REF: 1400400-15 -,SUP-1400400-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 4.00MM X 20MM REF: 1400400-20 -,SUP-1400400-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 4.50MM X 8MM REF: 1400450-08 -,SUP-1400450-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 4.50MM X 12MM REF: 1400450-12 -,SUP-1400450-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 4.50MM X 20MM REF: 1400450-20 -,SUP-1400450-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 5.00MM X 12MM REF: 1400500-12 -,SUP-1400500-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 5.00MM X 15MM REF: 1400500-15 -,SUP-1400500-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 5.50MM X 12MM REF: 1400550-12 -,SUP-1400550-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 5.50MM X 15MM REF: 1400550-15 -,SUP-1400550-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 6.00MM X 12MM REF: 1400600-12 -,SUP-1400600-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 6.00MM X 15MM REF: 1400600-15 -,SUP-1400600-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH BLNOCC 15MM LRG 23X71X2.5CM ENDOCATH LPRO PLYISPRN -,SUP-20-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X20MM 2.7CM ANGIOSCULPT XL 137CM OTW F/PTCA -,SUP-2039-2520,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X20MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2076-4020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X40MM ANGIOSCULPT XL 137CM OTW -,SUP-2076-4040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5X40MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2076-5040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6X40MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2076-6040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6X20MM ANGIOSCULPT XL 90CM OTW F/PTCA SEM-COM -,SUP-2092-6020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATHETER SAPPHIRE II PRO L5 MM 5F -,SUP-210-053-5UU,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATHETER SAPPHIRE II PRO L15 MM 5F -,SUP-210-153-5UU,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X40MM ANGIOSCULPT XL 155CM OTW F/PTCA SEM-COM -,SUP-2155-2540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR TAPR -,SUP-2200-2006-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X10MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2010-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2015-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.0X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2020-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2506-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X10MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2510-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2515-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2520-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR TAPR -,SUP-2200-3006-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X10MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3010-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3015-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.0X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3020-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3506-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X10MM ANGIOSCULPT 137CM RX F /PTCA SEM-COM COR -,SUP-2200-3510-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3515-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3520-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5X100MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2237-50100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6X100MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2237-60100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B ANGIOSCULPT 7MM X 40MM -,SUP-2333-7040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6X100MM STERLNG 135CM OTW COAX SEM-COM PERIPH TAPR -,SUP-39032-60101,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATHETER PCA 4MM X 30MM x 145CM COYOTE ES M -,SUP-39135-40301,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 14MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-1440L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATHETER DILATION16MM X 4MM -,SUP-417-1640L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 18MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-1840L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 20MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-2040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 22MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-2240L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 25MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-2540L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 12MMX4CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-2040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3MMX4CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-3040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3MMX8CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-3080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4MMX10CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-4000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4MMX2CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-4020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
MIRROR SURG 16.4MMX7.625IN LRYNG HEX HNDL V. MUELLER -,SUP-419-4040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4MMX6CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-4060L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5MMX10CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-5000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 8MMX8CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-8080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-5040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5MM 5FR SHFT 6CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-5060L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5MM 5FR SHFT 8CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-5080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6MM 5FR SHFT 6FR SHTH 10CM POWERFLX P3 110CM OTW -,SUP-420-6000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6MM 5FR SHFT 5FR SHTH 2CM POWERFLX P3 110CM OTW -,SUP-420-6020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-6040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6MM 5FR SHFT 6CM POWERFLX P3 80CM OTW F/PTA PERIPH -,SUP-420-6060S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6MM 5FR SHFT 8CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-6080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 7MM 5FR SHFT 10CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-7000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 7MM 5FR SHFT 2CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-7020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 7MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-7040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 8MM 5FR SHFT 6FR SHTH 2CM POWERFLX P3 110CM OTW -,SUP-420-8020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 8MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-8040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4MMX2CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-4020W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4MMX3CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-4030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
RETRACTOR RGNL 6IN DBL END STN FNSH SS DLCT V. MUELLER NS -,SUP-424-5030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6MMX3CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-6030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 7MMX3CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-7030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH DIL 3MM 4FR SHTH 4CM BLN 150CM F/PTA -,SUP-425-3004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3MMX4CM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-3004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X120MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X40MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-4004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5X40MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-5004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5X100MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-5010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5MMX28CM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-5028X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1696.16,1187.312,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5MMX6CM SAVVY 120CM OTW COAX MOD PRSS PERIPH TAPR -,SUP-435-506L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1155.51,808.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4MMX22CM SAVVY LONG 120CM OTW COAX MOD PRSS PERIPH -,SUP-436-4022L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1420.53,994.371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4MMX22CM SAVVY LONG 150CM OTW COAX MOD PRSS PERIPH -,SUP-436-4022X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1420.53,994.371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0302S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0402S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4MMX4CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0404S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X220MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0422X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5MMX2CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0502S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0504S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5X60MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5X100MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5X220MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0522X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6MMX2CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0602S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6MMX4CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0604S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6X100MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0610X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6X150MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0615X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,840.24,588.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 7X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0702S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 7X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0704S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 7X40MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0704X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 8X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0802S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 8X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0804S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 9X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0902S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 10X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-1004S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
TURNPIKE 150 CM MICRO CATH -,SUP-5643,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2859.63,2001.741,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 22MMX4CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-610462,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 25MMX4CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-610463,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 28MMX4CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-610465,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA BALLOON DILATAION 22X4X100 Z-MED II -,SUP-611761,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 30MMX2CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-611801,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 28MMX2CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-611803,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 25MMX3CM Z-MED 100CM LPRO COAX F/PTA HPRS PERIPH -,SUP-611816,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATHETER PTV 16MMX4CM TYSHAK II REF:611920 -,SUP-611920,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATHETER PTV 18MMX4CM TYSHAK II REF:611928 -,SUP-611928,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATHETER PTV 20MMX4CM TYSHAK II REF:611932 -,SUP-611932,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATHETER PTV 22MMX4CM TYSHAK II REF:611936 -,SUP-611936,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATHETER PTV 25MMX4CM TYSHAK II REF:611944 -,SUP-611944,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH GUID 0.07IN 6FR MPA-1 90CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-270-90,CDM,C1725,HCPCS,272,RC,,,outpatient,,,309.26,216.482,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X6MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R06350N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R10200N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10225N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10250N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10325N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10350N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R10400N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R12250N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R12300N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R12325N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.75X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R12350N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R12400N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R15250N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R15300N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R15325N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R15340N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R15400N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
C PIG 5FR 20/1CM MARKS -,SUP-7602-20M65SH,CDM,C1725,HCPCS,272,RC,,,outpatient,,,528.13,369.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X12MM EMPIRA 139CM RX F/PTCA SEM-COM -,SUP-85R12250S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X12MM EMPIRA 139CM RX F/PTCA SEM-COM DURALYN -,SUP-85R12300S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X12MM EMPIRA 139CM RX F/PTCA SEM-COM -,SUP-85R12325S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X15MM EMPIRA 139CM RX F/PTCA SEM-COM -,SUP-85R15250S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X15MM EMPIRA 139CM RX F/PTCA SEM-COM DURALYN -,SUP-85R15300S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 3.00MM X 12MM REF: 1400300-12 -,SUP-90176431,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 4.50MM X 15MM REF: 1400450-15 -,SUP-90176448,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON TREK RX 2.75MM X 15MM REF: 1012273-15 -,SUP-90176463,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON TREK RX 3.75MM X 12MM REF: 1012277-12 -,SUP-90176465,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON TREK RX 3.75MM X 15MM REF: 1012277-15 -,SUP-90176466,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC TREK NEO 3.75MM X 15MM REF: 1400375-15 -,SUP-90176697,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH ANG 6FR 18MM 70CM 3.5CM BLN AMPLATZER SZ LUMX3 FLXB -,SUP-9-SB-018,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH ANG 24MM 7FR 70CM 4.5CM BLN AMPLATZER SZ LUMX3 FLXB -,SUP-9-SB-024,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.5X20MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2015-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 14 1.5MM X 40MM X 150CM -,SUP-A2015-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X20MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X60MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X80MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X200MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2025-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND -,SUP-A2025-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X200MM ARMADA 14 150CM LPRO F/PTA PERIPH RND -,SUP-A2025-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X20MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X60MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X80MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B ARMADA 14 PTA C 3.0 X 200M -,SUP-A2030-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X60MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X80MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X200MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X40MM NANOCROSS ELITE 150CM OTW ULTRA LO XING -,SUP-AB14W030040150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2093.7,1465.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X80MM NANOCROSS ELITE 150CM OTW ULTRA LO XING -,SUP-AB14W030080150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2093.7,1465.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
4MM X 40MM STELLAREX DCB -,SUP-AB35SX040040135,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON ATLAS PTA CATHETER 16MMX 40MM X 120CM REF: AT120164 -,SUP-AT120164,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1966.49,1376.543,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B ATLAS 12MM X 4CM X 75CM -,SUP-AT-75124,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B ATLAS 14MM X 4CM X 75CM -,SUP-AT-75144,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B ATLAS 16MM X 4CM X 75CM -,SUP-AT-75164,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1966.49,1376.543,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B ATLAS 18MM X 4CM X 75CM -,SUP-AT75184,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1966.49,1376.543,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ATLAS BALLOON 20 X 40 -,SUP-AT75204,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2276.62,1593.634,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ATLAS BALLOON 24 X 40 -,SUP-AT75244,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2910.99,2037.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 26MMX4CM ATLAS 75CM OTW COAX ULTRA NC PERIPH 12FR -,SUP-AT-75264,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2826.21,1978.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ATLAS GOLD PTA DILATATION CATHETER 120CM -,SUP-ATG120164,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1913.48,1339.436,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH ATLAS GOLD PTA DILATATION 16 X 6 X 80MM - 8 FR -,SUP-ATG80166,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1913.48,1339.436,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 35  4.0MM X 20MM X 80CM -,SUP-B1040-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 35 4.0MM X 40MM X 80CM -,SUP-B1040-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
4MM X 80MM X 80CM ARMADA 35 BALLOON -,SUP-B1040-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON ARMADA 4MM X 80MM X 80CM -,SUP-B1040-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 5MM X 20MM X 80CM -,SUP-B1050-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B ARMADA 35 5MM X 40MM X 80CM -,SUP-B1050-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5X40MM ARMADA  .035 -,SUP-B1050-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 35 5MM X 60MM X 80CM -,SUP-B1050-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B ARMADA 35 5.0 X 80 X 80 PTA CATH -,SUP-B1050-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON ARMADA 5MM X 100MM X 80CM -,SUP-B1050-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 5MM X 120MM X 80CM -,SUP-B1050-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 6MMx40MMx80CM -,SUP-B1060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 35 6MM X 40MM X 80CM -,SUP-B1060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
6MM X 60MM X 80CM ARMADA 35 BALLOON -,SUP-B1060-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 35 6.0MM X 60MM X80CM -,SUP-B1060-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
6MM X 80MM X 80CM ARMADA 35 BALLOON -,SUP-B1060-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON ARMADA 6MM X 100MM X 80CM -,SUP-B1060-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 6 X 150 X 80 -,SUP-B1060-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON 35 ARMADA 7 X 20 X 80 PTA -,SUP-B1070-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA PTA 7MM X 40MM X 80CM -,SUP-B1070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA B  35  7.0X60X80 PTA -,SUP-B1070-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 35 7MM X 60MM X 80CM -,SUP-B1070-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 35 7 X 80MM X 80CM -,SUP-B1070-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B ARMADA 35 7MM X 80MM X 80CM -,SUP-B1070-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B ARMADA 35 7.0 X 100 X 80 PTA CATH -,SUP-B1070-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON ARMADA 7MM X 150MM X 80CM -,SUP-B1070-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 35 8MM X 20MM X 80CM -,SUP-B1080-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
8mm x 40mm x 80cm Armada 35 -,SUP-B1080-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
XARMADA 35 8.0MM X 40MM X 80C -,SUP-B1080-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 35 8mmx60mmX80cm -,SUP-B1080-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B ARMADA 35 8MM X 60MM ON 80MM -,SUP-B1080-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
8MM X 80MM X 80CM ARMADA 35 BALLOON -,SUP-B1080-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 35 8.0MM X 80MM X 80CM -,SUP-B1080-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
9MM X 20MM X 80CM ARMADA 35 BALLOON -,SUP-B1090-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 35 BALLOON 9 X 40MM X 80CM -,SUP-B1090-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
10MM X 20MM X 80CM ARMADA 35 BALLOON -,SUP-B1100-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
10.0MM X 40MM X 80 ARMADA 35 BALLOON -,SUP-B1100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 35 10.0MM X 40MM X 80CM -,SUP-B1100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
10MM X 60MM X 80CM ARMADA 35 BALLOON -,SUP-B1100-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 35 10MM 60MM X 80CM -,SUP-B1100-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
12MM X 20MM X 80CM ARMADA 35 BALLOON -,SUP-B1120-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 35 12.0MM X 40MM X 80CM -,SUP-B1120-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 35 12 X 60MM X 80CM -,SUP-B1120-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 35 12.0MM X 60MM X 80CM -,SUP-B1120-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 35 14.0MM X 20MM X 80CM -,SUP-B1140-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
14MM X 40MM X 80CM ARMADA 35 BALLOON -,SUP-B1140-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 35 14MM X 60MM X 80CM -,SUP-B1140-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
4MM X 20MM X 135CM ARMADA 35 BALLOON -,SUP-B2040-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
Armada 4 x 40 x 135 Balloon -,SUP-B2040-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 4MM X 60MM X 135CM -,SUP-B2040-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 35 4X100X135 -,SUP-B2040-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
5MM X 20MM X 135CM ARMADA 35 -,SUP-B2050-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
5MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2050-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
5MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2050-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA PTA 0.035MM X 5MM X 60MM X 135CM -,SUP-B2050-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA PTA .035  5MM X 80MM X 135CM -,SUP-B2050-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
5MMX100MMX135CM ARMADA 35 -,SUP-B2050-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
5MM X 200MM X 135CM ARMADA 35 BALLOON -,SUP-B2050-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
6MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA PTA 0.035 6MM X 40MM X 135CM -,SUP-B2060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
6MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2060-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 35 6MM 80MM 135CM -,SUP-B2060-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 35 6MM 100MM 135CM -,SUP-B2060-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
6mm x 150mm x 135cm ARMADA 35 -,SUP-B2060-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
6MM X 200MM X 135CM ARMADA 35 BALLOON -,SUP-B2060-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
7MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 35  BALLOON  7.0MM X 40MM X 135CM -,SUP-B2070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B ARMADA 35  7MM X 40MM X 135CM -,SUP-B2070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
7MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2070-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 35 7MM X 100MM BALLOON -,SUP-B2070-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
7MM X 200MM X 135CM ARMADA 35 BALLOON -,SUP-B2070-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 35 8MM X 20MM X 135CM -,SUP-B2080-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 35 8MM X 40MM X 135CM -,SUP-B2080-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 35  8MM X 60MM X 135CM -,SUP-B2080-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 8MM X 80MM 35 BALLOON -,SUP-B2080-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON 9MM X 20MM X 135CM CATH ARMADA 35 -,SUP-B2090-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
9MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2090-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA PTA CATHETER 9MM X 60MM X 135CM -,SUP-B2090-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA PTA 10MM X 20MM X 135CM -,SUP-B2100-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
10MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA PTA 10MM X 40MM X 135CM -,SUP-B2100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA PTA 10MM X 60MM X 135MM -,SUP-B2100-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 35 12MM X 40MM X 135CM -,SUP-B2120-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
12MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2120-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ARMADA 35 BALLOON DIAL CATH 14X20X135 -,SUP-B2140-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
14MM X 40MM X 135CM ARMADA 35 BALOON -,SUP-B2140-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH BALLOON DIL CROSPERIO RX 0.014 X 4.0MM X 150CM 4FR -,SUP-BD-B40150LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1229.72,860.804,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH BALLOON DILATION R2P PTA 4.0MM X 150MM CROSPERIO RX -,SUP-BD-B40150LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1229.72,860.804,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CROSTELLA RX PTA DIL CATH 3MM X 8MM X 150CM -,SUP-BD-F30080LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CROSSTELLA OTW 3MM X 200MM 150CM -,SUP-BD-F30200LW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH CROSTELLA BALLOON RX PTA 4.0MM X 40MM 150CM 4FR -,SUP-BD-F40040LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH CROSTELLA BALLOON RX PTA 5.0MM X 80MM 150CM 4FR -,SUP-BD-F50080LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CROSSTELLAÂ® RX PTA Balloon Dil Cath 5mm x 150mm -,SUP-BD-F50150LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON METACROS 5MM X 150 X .030 PTCA -,SUP-BD-P50150ER,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON R2P CROSTELLA RX 2MM X 40MM X 200CM -,SUP-BD-Q20040ER,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5X120MM CHOC 120CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CB1812050120OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X40MM CHOC 150CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CF1415025040OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X120MM CHOC 150CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CF1415025120OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X120MM CHOC 150CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CF1415030120OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 10MMX4CM CONQUST 75CM OTW COAX ULTRA NC PERIPH -,SUP-CQ-75104,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 12MMX4CM CONQUST 75CM OTW COAX ULTRA NC PERIPH -,SUP-CQ-75124,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1490.45,1043.315,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6MMX2CM CONQUST 75CM OTW COAX ULTRA NC PERIPH -,SUP-CQ-7562,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B CONQUEST 6 X 4 X 75 -,SUP-CQ-7564,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B CONQUEST 7 X 4 X 75 -,SUP-CQ-7574,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B CONQUEST 8 X 4 X 75 -,SUP-CQ-7584,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH BALLOON CHOLANGIOGRAPHY -,SUP-CS-01701,CDM,C1725,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON DILATATION CATH OTW TAKERU 1.5X6MM REF:DC-PY1506UA1 -,SUP-DC-PY1506UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU OTW 1.5X12MM REF: DC-PY1512UA1 -,SUP-DC-PY1512UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON DILATATION CATH OTW TAKERU 1.5X15MM REF:DC-PY1515UA1 -,SUP-DC-PY1515UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU OTW 1.5X20MM REF: DC-PY1520UA1 -,SUP-DC-PY1520UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU OTW 2.0X8MM REF: DC-PY2008UA2 -,SUP-DC-PY2008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU OTW 2.0X12MM REF: DC-PY2012UA2 -,SUP-DC-PY2012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON DILATATION CATH OTW TAKERU 2.0X15MM REF:DC-PY2015UA2 -,SUP-DC-PY2015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON DILATATION CATH OTW TAKERU 2.0X20MM REF:DC-PY2020UA2 -,SUP-DC-PY2020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU OTW 2.25X12MM REF: DC-PY2212UA2 -,SUP-DC-PY2212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU OTW 2.25X15MM REF: DC-PY2215UA2 -,SUP-DC-PY2215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU OTW 2.25X20MM REF: DC-PY2220UA2 -,SUP-DC-PY2220UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU OTW 2.5X8MM REF: DC-PY2508UA2 -,SUP-DC-PY2508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU OTW 2.5X15MM REF: DC-PY2515UA2 -,SUP-DC-PY2515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU OTW 2.5X20MM REF: DC-PY2520UA2 -,SUP-DC-PY2520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU OTW 3.0X8MM REF: DC-PY3008UA2 -,SUP-DC-PY3008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU OTW 3.0X12MM REF: DC-PY3012UA2 -,SUP-DC-PY3012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU OTW 3.0X15MM REF: DC-PY3015UA2 -,SUP-DC-PY3015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU OTW 3.0X20MM REF: DC-PY3020UA2 -,SUP-DC-PY3020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU OTW 3.5X8MM REF: DC-PY3508UA2 -,SUP-DC-PY3508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU OTW 3.5X12MM REF: DC-PY3512UA2 -,SUP-DC-PY3512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU OTW 3.5X15MM REF: DC-PY3515UA2 -,SUP-DC-PY3515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU OTW 3.5X20MM REF: DC-PY3520UA2 -,SUP-DC-PY3520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU OTW 4.0X8MM REF: DC-PY4008UA2 -,SUP-DC-PY4008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU OTW 4.0X12MM REF: DC-PY4012UA2 -,SUP-DC-PY4012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU OTW 4.0X20MM REF: DC-PY4020UA2 -,SUP-DC-PY4020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON DILATATION CATH RX TAKERU 1.5X6MM REF:DC-RY1506UA1 -,SUP-DC-RY1506UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX 1.5X12MM REF: DC-RY1512UA1 -,SUP-DC-RY1512UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON DILATATION CATH RX TAKERU 1.5X15MM REF:DC-RY1515UA1 -,SUP-DC-RY1515UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON DILATATION CATH RX TAKERU 1.5X20MM REF:DC-RY1520UA1 -,SUP-DC-RY1520UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX 2.0X8MM REF: DC-RY2008UA2 -,SUP-DC-RY2008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX 2.0X12MM REF: DC-RY2012UA2 -,SUP-DC-RY2012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON DILATATION CATH RX TAKERU 2.0X15MM REF:DC-RY2015UA2 -,SUP-DC-RY2015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON DILATATION CATH RX TAKERU 2.0X20MM REF:DC-RY2020UA2 -,SUP-DC-RY2020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX 2.25X12MM REF: DC-RY2212UA2 -,SUP-DC-RY2212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX 2.25X15MM REF: DC-RY2215UA2 -,SUP-DC-RY2215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX 2.5X8MM REF: DC-RY2508UA2 -,SUP-DC-RY2508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX 2.5X12MM REF: DC-RY2512UA2 -,SUP-DC-RY2512UA,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX 2.5X15MM REF: DC-RY2515UA2 -,SUP-DC-RY2515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX 2.5X20MM REF: DC-RY2520UA2 -,SUP-DC-RY2520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX 3.0X8MM REF: DC-RY3008UA2 -,SUP-DC-RY3008UA,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX 3.0X12MM REF: DC-RY3012UA2 -,SUP-DC-RY3012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX 3.0X15MM REF: DC-RY3015UA2 -,SUP-DC-RY3015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX 3.0X20MM REF: DC-RY3020UA2 -,SUP-DC-RY3020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX 3.5X8MM REF: DC-RY3508UA2 -,SUP-DC-RY3508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX 3.5X12MM REF: DC-RY3512UA2 -,SUP-DC-RY3512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX 3.5X15MM REF: DC-RY3515UA2 -,SUP-DC-RY3515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX 3.5X20MM REF: DC-RY3520UA2 -,SUP-DC-RY3520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX 4.0X8MM REF: DC-RY4008UA2 -,SUP-DC-RY4008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX 4.0X12MM REF: DC-RY4012UA2 -,SUP-DC-RY4012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX 4.0X15MM REF: DC-RY4015UA2 -,SUP-DC-RY4015UA,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX 4.0X20MM REF: DC-RY4020UA2 -,SUP-DC-RY4020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX NC 2.0X8MM REF: DC-RZ2008UA2 -,SUP-DC-RZ2008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX NC 2.0X12MM REF: DC-RZ2012UA2 -,SUP-DC-RZ2012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX NC 2.0X15MM REF: DC-RZ2015UA2 -,SUP-DC-RZ2015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX NC 2.0X21MM REF: DC-RZ2021UA2 -,SUP-DC-RZ2021UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX NC 2.25X8MM REF: DC-RZ2208UA2 -,SUP-DC-RZ2208UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX NC 2.25X12MM REF: DC-RZ2212UA2 -,SUP-DC-RZ2212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX NC 2.25X15MM REF: DC-RZ2215UA2 -,SUP-DC-RZ2215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX NC 2.25X21MM REF: DC-RZ2221UA2 -,SUP-DC-RZ2221UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX NC 2.5X8MM REF: DC-RZ2508UA2 -,SUP-DC-RZ2508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX NC 2.5X12MM REF: DC-RZ2512UA2 -,SUP-DC-RZ2512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX NC 2.5X15MM REF: DC-RZ2515UA2 -,SUP-DC-RZ2515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX NC 2.5X21MM REF: DC-RZ2521UA2 -,SUP-DC-RZ2521UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX NC 2.75X8MM REF: DC-RZ2708UA2 -,SUP-DC-RZ2708UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX NC 2.75X12MM REF: DC-RZ2712UA2 -,SUP-DC-RZ2712UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX NC 2.75X15MM REF: DC-RZ2715UA2 -,SUP-DC-RZ2715UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX NC 2.75X21MM REF: DC-RZ2721UA2 -,SUP-DC-RZ2721UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX NC 3.0X8MM REF: DC-RZ3008UA2 -,SUP-DC-RZ3008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX NC 3.0X12MM REF: DC-RZ3012UA2 -,SUP-DC-RZ3012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX NC 3.0X15MM REF: DC-RZ3015UA2 -,SUP-DC-RZ3015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX NC 3.0X21MM REF: DC-RZ3021UA2 -,SUP-DC-RZ3021UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX NC 3.25X8MM REF: DC-RZ3208UA2 -,SUP-DC-RZ3208UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX NC 3.25X12MM REF: DC-RZ3212UA2 -,SUP-DC-RZ3212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX NC 3.25X15MM REF: DC-RZ3215UA2 -,SUP-DC-RZ3215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX NC 3.25X21MM REF: DC-RZ3221UA2 -,SUP-DC-RZ3221UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX NC 3.5X08MM REF: DC-RZ3508UA2 -,SUP-DC-RZ3508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX NC 3.5X12MM REF: DC-RZ3512UA2 -,SUP-DC-RZ3512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX NC 3.5X15MM REF: DC-RZ3515UA2 -,SUP-DC-RZ3515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX NC 3.5X21MM REF: DC-RZ3521UA2 -,SUP-DC-RZ3521UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX NC 4.0X8MM REF: DC-RZ4008UA2 -,SUP-DC-RZ4008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX NC 4.0X12MM REF: DC-RZ4012UA2 -,SUP-DC-RZ4012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX NC 4.0X15MM REF: DC-RZ4015UA2 -,SUP-DC-RZ4015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU RX NC 4.0X21MM REF: DC-RZ4021UA2 -,SUP-DC-RZ4021UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATH TAKERU OTW 2.5X12MM REF: DC-PY2512UA2 -,SUP-D-PY2512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4MMX2CM DORADO 40CM OTW F/PTA ULTRA NC PERIPH 5FR -,SUP-DR4042,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1335.73,935.011,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 7MMX6CM DORADO 80CM OTW F/PTA ULTRA NC PERIPH 6FR -,SUP-DR8076,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1335.73,935.011,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP1506X EUPHORA RX -,SUP-EUP1506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP1512X EUPHORA RX -,SUP-EUP1512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP1515X EUPHORA RX -,SUP-EUP1515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP1520X EUPHORA RX -,SUP-EUP1520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP2006X EUPHORA RX -,SUP-EUP2006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP2010X EUPHORA RX -,SUP-EUP2010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP2012X EUPHORA RX -,SUP-EUP2012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP2015X EUPHORA RX -,SUP-EUP2015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP2020X EUPHORA RX -,SUP-EUP2020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP2025X EUPHORA RX -,SUP-EUP2025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP2030X EUPHORA RX -,SUP-EUP2030X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP22506X EUPHORA RX -,SUP-EUP22506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP22510X EUPHORA RX -,SUP-EUP22510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP22512X EUPHORA RX -,SUP-EUP22512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP22515X EUPHORA RX -,SUP-EUP22515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP22520X EUPHORA RX -,SUP-EUP22520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP22525X EUPHORA RX -,SUP-EUP22525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP2506X EUPHORA RX -,SUP-EUP2506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP2510X EUPHORA RX -,SUP-EUP2510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP2512X EUPHORA RX -,SUP-EUP2512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP2515X EUPHORA RX -,SUP-EUP2515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP2520X EUPHORA RX -,SUP-EUP2520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP2525X EUPHORA RX -,SUP-EUP2525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP2530X EUPHORA RX -,SUP-EUP2530X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP27506X EUPHORA RX -,SUP-EUP27506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP27510X EUPHORA RX -,SUP-EUP27510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP27512X EUPHORA RX -,SUP-EUP27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP27515X EUPHORA RX -,SUP-EUP27515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP27520X EUPHORA RX -,SUP-EUP27520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP27525X EUPHORA RX -,SUP-EUP27525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP3006X EUPHORA RX -,SUP-EUP3006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP3010X EUPHORA RX -,SUP-EUP3010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP3012X EUPHORA RX -,SUP-EUP3012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP3015X EUPHORA RX -,SUP-EUP3015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP3020X EUPHORA RX -,SUP-EUP3020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP3025X EUPHORA RX -,SUP-EUP3025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP3030X EUPHORA RX -,SUP-EUP3030X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP32506X EUPHORA RX -,SUP-EUP32506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP32510X EUPHORA RX -,SUP-EUP32510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP32512X EUPHORA RX -,SUP-EUP32512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP32515X EUPHORA RX -,SUP-EUP32515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP32520X EUPHORA RX -,SUP-EUP32520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP32525X EUPHORA RX -,SUP-EUP32525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP3506X EUPHORA RX -,SUP-EUP3506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP3510X EUPHORA RX -,SUP-EUP3510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP3512X EUPHORA RX -,SUP-EUP3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP3515X EUPHORA RX -,SUP-EUP3515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP3520X EUPHORA RX -,SUP-EUP3520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP3525X EUPHORA RX -,SUP-EUP3525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP3530X EUPHORA RX -,SUP-EUP3530X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP37506X EUPHORA RX -,SUP-EUP37506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP37510X EUPHORA RX -,SUP-EUP37510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP37512X EUPHORA RX -,SUP-EUP37512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP37515X EUPHORA RX -,SUP-EUP37515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP37520X EUPHORA RX -,SUP-EUP37520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP37525X EUPHORA RX -,SUP-EUP37525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP4006X EUPHORA RX -,SUP-EUP4006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP4010X EUPHORA RX -,SUP-EUP4010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP4012X EUPHORA RX -,SUP-EUP4012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP4015X EUPHORA RX -,SUP-EUP4015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP4020X EUPHORA RX -,SUP-EUP4020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP4025X EUPHORA RX -,SUP-EUP4025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EUP4030X EUPHORA RX -,SUP-EUP4030X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH BLNOCC 9FRX120CM CODA -,SUP-G03831,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2702.08,1891.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.5MMX4CM ADVANCE MICRO 14 150CM OTW UL-LPRO F/PTA -,SUP-G26614,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2289.76,1602.832,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2MMX12CM ADVANCE MICRO 14 150CM OTW UL-LPRO F/PTA -,SUP-G26641,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2289.76,1602.832,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6MMX2CM ADVANCE ATB 80CM OTW F/PTA MIN-CMPLNT -,SUP-G26895,CDM,C1725,HCPCS,272,RC,,,outpatient,,,705.98,494.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH DIL 4MMX12CM ADVANCE 18 LP 150CM LPRO F/PTA 4FR SHTH -,SUP-G30949,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30952,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5MMX15CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30955,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ANGIOPLASTY 5 - 15 PTA -,SUP-G30956,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B 18LP ADVANCE 5MM X 15CM -,SUP-G30956,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ANGIOPLASTY / PTA4-18-150-5-20 -,SUP-G30958,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30958,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH DIL 6MMX12CM ADVANCE 18 LP 150CM LPRO F/PTA 5FR SHTH -,SUP-G30961,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ANGIOPLASTY 6 - 15 PTA -,SUP-G30962,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30964,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 7MMX12CM ADVANCE 18 LP 150CM LPRO F/PTA 5FR SHTH -,SUP-G30967,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 7MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30970,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3MMX4CM ADVANCE 18LP 150CM LPRO F/PTA -,SUP-G34319,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
3X6X150 PTA ADVANCE CATH -,SUP-G34320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3MMX8CM ADVANCE 18LP -,SUP-G34321,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON ADVANCE .018 3MM X 10CM X 150CM -,SUP-G34322,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G34331,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G34336,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5MMX6CM ADVANCE 35LP 135CM LPRO PERIPH D-SHP -,SUP-G35532,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATHETER ADVANCED LOW PROFILE BALLOON 6MM X 20MM X 135CM -,SUP-G35536,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 7MMX20CM ADVANCE 35LP 135CM LPRO F/PTA -,SUP-G35540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 10MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G35546,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH ANG 5FRX80CM ADVANCE LPRO -,SUP-G35547,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
GW ENDO 0.035INX260CM ACROBAT CLBRT TIP -,SUP-G47614,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1038.63,727.041,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G49479,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50216,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50218,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50222,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50224,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5MMX10CM ADVANCE 18LP 135CM LUMX2 -,SUP-G50226,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4MMX4CM ADVANCE 18LP - USE 0141543 DISC. -,SUP-G50228,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50230,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50235,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50237,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50239,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50241,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 -,SUP-G50243,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50245,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50247,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50249,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50251,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50253,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 7MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50257,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 7MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50262,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 7MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50264,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2MMX2CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50313,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50314,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2MMX6CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50315,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50316,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50317,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50318,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50319,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50321,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1836.57,1285.599,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5MMX6CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50322,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50323,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50324,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50325,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ADVANCE 14 LP BALLOON CATHETER -,SUP-G50327,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50328,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3MMX4CM ADVANCE 14LP 60MM LPRO LUMX2 F/PTA SEM-COM -,SUP-G50329,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50330,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50332,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50333,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4MMX2CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50334,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50335,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4MMX6CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50336,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50337,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50338,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50339,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50340,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52251,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52253,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52254,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52257,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52258,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5MMX6CM ADVANCE 35LP 135CM LPRO PERIPH -,SUP-G52259,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52260,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52261,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5MMX14CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52263,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52265,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52266,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52267,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52268,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6MMX14CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 7MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52271,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 7MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52272,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 7MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52273,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 7MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52274,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 7MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52275,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 7MMX14CM ADVANCE 35LP 135CM LPRO F/PTA -,SUP-G52277,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 8MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52278,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 8MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52279,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 8MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52280,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 8MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52282,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 9MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52286,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 9MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52287,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 10MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52293,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 10MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52294,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 12MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52299,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 12MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
US PRE PP-CA-422 DIR BALLOON CATHER T3 20-23 -,SUP-G57885,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATHETER US PRE PP-CA-422 DIR BALLOON T3 20-23 -,SUP-G57887,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ADVANCE SERENITY 14 150-20-220 -,SUP-G57889,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATHETER BALLOON DILATATION ADVANCE SERENITY 14 2.5MM X10CM -,SUP-G57894,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CATHETER T3 20-23 -,SUP-G57896,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
DIRECT BALLOON CATHETERS T2 23-26 -,SUP-G57897,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATHETER US PRE PP-CA-422 DIR BALLOON  T3 20-23 -,SUP-G57900,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ADVANCE SERENITY 14 HYDROPHILIC PTA BALLOON DILA CATH 3 X 10 -,SUP-G57901,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ADVANCE SERENITY 14 HYDROPHILIC PTA BALLOON DILA CATH 3 X 22 -,SUP-G57903,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
US PRE PP-CA-422 DIR BALLOON CATHETER T3 20-23 150-40-20 -,SUP-G57911,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ADVANCE SERENITY 14 4MM x 100MM x 150CM -,SUP-G57915,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATHETER BALLOON DIR SERENITY 14 4MM X 15CM 150CM -,SUP-G57916,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATHETER US PRE PP-CA-422 DIR BALLOON  T3 20-23 -,SUP-G57917,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PIG 0.045IN 5FR PIG 125CM EXPO -,SUP-H749085262151,CDM,C1725,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.5X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP 0.014IN -,SUP-H7493895808200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.75X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP 0.014IN -,SUP-H7493895808300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP 0.014IN -,SUP-H7493895808400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.5X12MM APEX FLX UL-LPRO NC -,SUP-H7493895812150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.75X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.75X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.5X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.75X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.75X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.5X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.75X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.75X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X30MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895830250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,991.95,694.365,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.5X8MM APEX FLEX MONORAIL RX UL-LPRO NC -,SUP-H7493895908150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.75X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.5X12MM APEX FLEX MONORAIL RX UL-LPRO -,SUP-H7493895912150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.75X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.75X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.5X15MM APEX FLEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.75X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.75X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.5X20MM APEX FLEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.75X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.75X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B APEX MR  30MM X 2.50 MONORAIL RX -,SUP-H7493895930250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.0X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.5X8MM APEX OTW UL-LPRO F/PTCA OPTILEAP -,SUP-H7493896008150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.5X12MM APEX MONORAIL OTW UL-LPRO PSH -,SUP-H7493896012150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.5X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493896015150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.5X20MM APEX OTW UL-LPRO F/PTCA OPTILEAP -,SUP-H7493896020150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.5X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493896108150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.5X12MM APEX MONORAIL RX UL-LPRO PSH -,SUP-H7493896112150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.5X15MM APEX MONORAIL RX UL-LPRO -,SUP-H7493896115150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.5X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493896120150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
STERLING MONORAIL RAPID EXCHANGE 3 X 60 -,SUP-H74939031306010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON FG STERLING MR 4.5MM X 20MM X 135CM 4FR -,SUP-H74939031452010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2014.19,1409.933,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
STERLING MONORAIL .018 5X20X80CM 4F -,SUP-H74939031502080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6X20MM STERLNG MONORAIL 135CM RX LPRO COAX SEM-COM -,SUP-H74939031602010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH BALLOON STERLING 7.0MM X 40MM X 80CM 4FR FG MONORL -,SUP-H74939031704080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B STERLING OTW 10.0 X 60 135 -,SUP-H74939032106010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B STERLING OTW 10.0 X 80 135 -,SUP-H74939032108010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B STERLING OTW 4 X 10 X 135 39 -,SUP-H74939032401010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X220MM STERLNG 150CM OTW COAX SEM-COM PERIPH TAPR -,SUP-H74939032402210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B STERLING OTW 4.0 X 30 135 -,SUP-H74939032403010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B STERLING OTW 4 X 40 X 135 MA -,SUP-H74939032404010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B STERLING OTW 4.0 X 60 135 -,SUP-H74939032406010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1669.29,1168.503,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B STERLING OTW 4.0 X 80 135 -,SUP-H74939032408010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1669.29,1168.503,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B STERLING OTW 5 X 10 X 135 39 -,SUP-H74939032501010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B STERLING OTW 5.0 X 120 150 -,SUP-H74939032501210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B STERLING OTW 5.0 X 150 150 -,SUP-H74939032501510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B STERLING OTW 5.0 X 200 150 -,SUP-H74939032502110,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B STERLING OTW 5.0 X 220 150 -,SUP-H74939032502210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B STERLING OTW 5.0 X 30 135 -,SUP-H74939032503010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B STERLING OTW 5 X 4 X 135 390 -,SUP-H74939032504010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B STERLING OTW 5.0 X 60 135 -,SUP-H74939032506010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B STERLING OTW 5.0 X 80 135 -,SUP-H74939032508010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B STERLING OTW 6 X 10 X 135 39 -,SUP-H74939032601010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6X120MM 150CM -,SUP-H74939032601210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B STERLING OTW 6.0 X 150 150 -,SUP-H74939032601510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B STERLING OTW 6.0 X 200 150 -,SUP-H74939032602110,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B STERLING OTW 6.0 X 220 150 -,SUP-H7493903260221,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B STERLING OTW 6.0X30X135 -,SUP-H74939032603010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B STERLING OTW 6 X 4 X 135 390 -,SUP-H74939032604010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B STERLING OTW 6.0 X 80 135 -,SUP-H74939032608010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B STERLING OTW 7.0 X 100 135 -,SUP-H74939032701010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B STERLING OTW 7.0 X 120 150 -,SUP-H74939032701210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B STERLING OTW 7.0 X 150 150 -,SUP-H74939032701510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B STERLING OTW 7.0 X 200 150 -,SUP-H74939032702110,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B STERLING OTW 7.0 X 220 150 -,SUP-H74939032702210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B STERLING OTW 7.0 X 30 135 -,SUP-H74939032703010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B STERLING OTW 7.0 X 40 135 -,SUP-H74939032704010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B STERLING OTW 7.0 X 60 135 -,SUP-H74939032706010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B STERLING OTW 7.0 X 80 135 -,SUP-H74939032708010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B STERLING OTW 8.0 X 30 135 -,SUP-H74939032803010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B STERLING OTW 8.0 X 40 135 -,SUP-H74939032804010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B STERLING OTW 8.0 X 60 135 -,SUP-H74939032806010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B STERLING OTW 8.0 X 80 135 -,SUP-H74939032808010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B STERLING OTW 9.0 X 60 135 -,SUP-H74939032906010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B STERLING OTW 9.0 X 80 135 -,SUP-H74939032908010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.75X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.75X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4.5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912412200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.75X12MM NC QUANTM APEX MONORAIL UL-LPRO NC -,SUP-H7493912412270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X12MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912412320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.75X12MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912412370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X12MM NC QUANTM APEX MONORAIL RX UL -LPRO NC -,SUP-H7493912412400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4.5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912412450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912412500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.75X15MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912415270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X15MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912415320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.75X15MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912415370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4.5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912420200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.75X20MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912420270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X20MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912420320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.75X20MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912420370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4.5X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912420450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5 X 20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912430200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.75X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4732.06,3312.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.75X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.75X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.75X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4732.06,3312.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4.5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.75X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.75X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4.5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.75X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.75X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4.5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.75X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.75X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4.5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.75X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.75X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X40MM COYOTE ES MONORAIL 145CM RX SEM-COM PERIPH -,SUP-H74939134204010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON COYOTE 2.5MM X 40MM X 145CM  .014 -,SUP-H74939134254010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X20MM COYOTE ES 143CM OTW UL-LPRO SEM-COM PERIPH -,SUP-H74939134302010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X30MM COYOTE ES 144MM OTW UL-LPRO SEM-COM PERIPH -,SUP-H74939134303010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X40MM COYOTE ES 145CM OTW UL-LPRO SEM-COM PERIPH -,SUP-H74939134404010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.5X20MM COYOTE ES MONORAIL 143CM RX SEM-COM -,SUP-H74939135152010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X20MM COYOTE ES MONORAIL 143CM RX SEM-COM PERIPH -,SUP-H74939135202010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X20MM COYOTE ES MONORAIL 144CM RX SEM-COM PERIPH -,SUP-H74939135302010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X30MM COYOTE ES MONORAIL 145CM RX SEM-COM PERIPH -,SUP-H74939135303010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X40MM COYOTE ES MONORAIL 146CM RX SEM-COM PERIPH -,SUP-H74939135304010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X20MM COYOTE ES MONORAIL 144CM RX SEM-COM -,SUP-H74939135352010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X30MM COYOTE ES MONORAIL 145CM RX SEM-COM -,SUP-H74939135353010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X20MM COYOTE ES MONORAIL 144CM RX SEM-COM PERIPH -,SUP-H74939135402010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X30MM COYOTE ES MONORAIL 145CM RX SEM-COM PERIPH -,SUP-H74939135403010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X40MM COYOTE ES MONORAIL 146CM RX SEM-COM PERIPH -,SUP-H74939135404010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X100MM STERLNG SL 150CM OTW COAX SEM-COM PERIPH -,SUP-H74939148401510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 3.0 X 20 135CM -,SUP-H74939171030210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171030270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 3.0 X 40 135CM -,SUP-H74939171030410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
3MM X 40MM X 40CM MUSTANG -,SUP-H74939171030440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171030470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 3.0 X 60 135CM -,SUP-H74939171030610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
MUSTANG 3 X 60 X 75 -,SUP-H74939171030670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 3.0 X 80 135CM -,SUP-H74939171030810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 3.0 X 100 135C -,SUP-H74939171031010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 3.0 X 120 135C -,SUP-H74939171031210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 3.0 X 150 135C -,SUP-H74939171031510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 3.0 X 180 135C -,SUP-H74939171031810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 3.0 200 135CM -,SUP-H74939171032010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 4.0 X 20 135CM -,SUP-H74939171040210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171040270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 4.0 X 40 135CM -,SUP-H74939171040410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
MUSTANG 4MM X 40MM X 40CM -,SUP-H74939171040440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171040470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 4.0 X 60 135CM -,SUP-H74939171040610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171040670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 4.0 X 80 135CM -,SUP-H74939171040810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
MUSTANG 4MM X 80MM X 40CM -,SUP-H74939171040840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 4.0 X 100 135C -,SUP-H74939171041010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171041070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 4.0 X 120 135C -,SUP-H74939171041210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 4.0 X 150 135C -,SUP-H74939171041510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 4.0 X 180 135C -,SUP-H74939171041810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 4.0X200 135CM -,SUP-H74939171042010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 5.0 X 20 135CM -,SUP-H74939171050210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5X30MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 5.0 X 40 135CM -,SUP-H74939171050410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
MUSTANG 5MM X 40MM X 40 CM -,SUP-H74939171050440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 5.0 X 60 135CM -,SUP-H74939171050610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 5.0 X 80 135CM -,SUP-H74939171050810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
MUSTANG 5MM X 80MM X 40CM -,SUP-H74939171050840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 5.0 X 100 135C -,SUP-H74939171051010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171051070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 5.0 X 120 135C -,SUP-H74939171051210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 5.0 X 150 135C -,SUP-H74939171051510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 5.0 180 135CM -,SUP-H74939171051810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 5.0 200 135CM -,SUP-H74939171052010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 6.0 X 20 135CM -,SUP-H74939171060210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 6.0 X 40 135CM -,SUP-H74939171060410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6X40MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1079.48,755.636,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
MUSTANG 6MM X 40MM X 40CM -,SUP-H74939171060440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 6.0 X 60 135CM -,SUP-H74939171060610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 6.0 X 80 135CM -,SUP-H74939171060810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
6MM X 80MM X 40CM MUSTANG PTA -,SUP-H74939171060840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
MUSTANG 6MM X 80MM X 40CM -,SUP-H74939171060840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 6.0 X 100 135C -,SUP-H74939171061010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 6.0 X 120 135C -,SUP-H74939171061210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6X150MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171061510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6X150MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171061570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 6.0 180 135CM -,SUP-H74939171061810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6X200MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171062010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 7.0 X 20 135CM -,SUP-H74939171070210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 7X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 7.0 X 40 135cm -,SUP-H74939171070410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
7MM X 40MM X 40CM MUSTANG -,SUP-H74939171070440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 7X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 7.0 X 60 135CM -,SUP-H74939171070610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 7X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 7X80MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 7X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 7.0 X 100 135C -,SUP-H74939171071010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 7X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171071070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 7.0 X 120 135C -,SUP-H74939171071210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 7X150MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171071510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 7X150MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171071570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 7.0 180 135CM -,SUP-H74939171071810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 7X200MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171072010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 7X200MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171072070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 8.0 X 20 135CM -,SUP-H74939171080210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 8X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171080270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 8.0 X 40 135CM -,SUP-H74939171080410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
8MM X 40MM X 40CM MUSTANG -,SUP-H74939171080440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON MUSTANG 7.0MM X 80MM X 40CM -,SUP-H74939171080440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON MUSTANG 8MM X 40MM X 40CM -,SUP-H74939171080440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 8X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171080470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 8.0 X 60 135CM -,SUP-H74939171080610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 8.0 X 80 135CM -,SUP-H74939171080810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
8MM X 80MM X 40CM MUSTANG PTA -,SUP-H74939171080840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 8X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171080870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 8.0 X 100 135C -,SUP-H74939171081010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 8X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171081070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 8.0 X 120 135C -,SUP-H74939171081210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 8X150MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171081570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 8.0 180 135CM -,SUP-H74939171081810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 8X200MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171082010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 8X200MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171082070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 9.0 X 20 135CM -,SUP-H74939171090210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 9X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 9.0 X 40 135CM -,SUP-H74939171090410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 9X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 9X60MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 9X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 9.0 X 80 135CM -,SUP-H74939171090810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 9X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 10.0 X 20 135C -,SUP-H74939171100210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 10X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 10.0X40 135CM -,SUP-H74939171100410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
MUSTANG BALLOON 10MM X 40MM X 40CM -,SUP-H74939171100440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 10X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 10.0 X 60 135C -,SUP-H74939171100610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 10X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 10.0 X 80 135C -,SUP-H74939171100810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
MUSTANG 10MM X 80MM X 40CM -,SUP-H74939171100840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 10X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 12.0X20 135CM -,SUP-H74939171120210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 12X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171120270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 12.0X40 135CM -,SUP-H74939171120410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 12X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171120470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 12X60MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171120610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 12X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171120670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 12.0 X 80 135C -,SUP-H74939171120810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B MUSTANG PTA 12MM X 80MM 40CM -,SUP-H74939171120840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B CATH COYOTE OTW 1.5X40X150 -,SUP-H74939186150410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B CATH COYOTE OTW 2X60X150 -,SUP-H74939186200610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B CATH COYOTE OTW 2X80X150 -,SUP-H74939186200810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B CATH COYOTE OTW 2X100X150 -,SUP-H74939186201010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B CATH COYOTE OTW 2X120X150 -,SUP-H74939186201210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B CATH COYOTE OTW 2X220X150 -,SUP-H74939186202210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
COYOTE 2 X 220 -,SUP-H74939186202290,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B CATH COYOTE OTW 2.5X60X150 -,SUP-H74939186250610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B CATH COYOTE OTW 2.5X80X150 -,SUP-H74939186250810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B CATH COYOTE OW 2.5X100X150 -,SUP-H74939186251010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B CATH COYOTE OW 2.5X120X150 -,SUP-H74939186251210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B CATH COYOTE OW 2.5X220X150 -,SUP-H74939186252210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B CATH COYOTE OTW 3X60X150 -,SUP-H74939186300610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B CATH COYOTE OTW 3X80X150 -,SUP-H74939186300810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B CATH COYOTE OTW 3X100X150 -,SUP-H74939186301010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B CATH COYOTE OTW 3X120X150 -,SUP-H74939186301210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B CATH COYOTE OTW 3X150X150 -,SUP-H74939186301510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B CATH COYOTE OTW 3X220X150 -,SUP-H74939186302210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B CATH COYOTE OTW 3.5X60X150 -,SUP-H74939186350610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B CATH COYOTE OTW 3.5X80X150 -,SUP-H7493918635081,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1637.85,1146.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B CATH COYOTE OW 3.5X100X150 -,SUP-H74939186351010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B CATH COYOTE OW 3.5X120X150 -,SUP-H74939186351210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B CATH COYOTE OW 3.5X150X150 -,SUP-H74939186351510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B CATH COYOTE OW 3.5X220X150 -,SUP-H74939186352210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B CATH COYOTE OTW 4X60X150 -,SUP-H74939186400610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B CATH COYOTE OTW 4X80X150 -,SUP-H74939186400810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B CATH COYOTE OTW 4X100X150 -,SUP-H74939186401010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1637.85,1146.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B CATH COYOTE OTW 4X120X150 -,SUP-H74939186401210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1637.85,1146.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B CATH COYOTE OTW 4X150X150 -,SUP-H74939186401510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B CATH COYOTE OTW 4X220X150 -,SUP-H74939186402210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 1.20MM X 8MM -,SUP-H7493918908120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 1.50MM X 8MM -,SUP-H7493918908150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 2.00 MM X 8MM -,SUP-H7493918908200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 2.50 MM X 8MM -,SUP-H7493918908250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 2.75 MM X 8MM -,SUP-H7493918908270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 3.00 MM X 8MM -,SUP-H7493918908300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 3.25 MM X 8MM -,SUP-H7493918908320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 3.50 MM X 8MM -,SUP-H7493918908350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 3.75 MM X 8MM -,SUP-H7493918908370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 4.00MM X 8MM -,SUP-H7493918908400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 1.20MM X 12MM -,SUP-H7493918912120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 1.50MM X 12MM -,SUP-H7493918912150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 2.00 MM X 12 MM -,SUP-H7493918912200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 2.25 MM X 12MM -,SUP-H7493918912220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 2.50 MM X 12 MM -,SUP-H7493918912250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 2.75 MM X 12MM -,SUP-H7493918912270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 3.00 MM X 12MM -,SUP-H7493918912300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 3.25 MM X 12MM -,SUP-H7493918912320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 3.50 MM X 12MM -,SUP-H7493918912350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 3.75 MM X 12MM -,SUP-H7493918912370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 4.00MM X 12MM -,SUP-H7493918912400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 1.20MM X 15MM -,SUP-H7493918915120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 1.50MM X 15MM -,SUP-H7493918915150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 2.00 MM X 15 MM -,SUP-H7493918915200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 2.25 MM X 15MM -,SUP-H7493918915220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 2.50 MM X 15MM -,SUP-H7493918915250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 2.75 MM X 15MM -,SUP-H7493918915270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 3.00 MM X 15MM -,SUP-H7493918915300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 3.25 MM X 15MM -,SUP-H7493918915320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 3.50 MM X 15MM -,SUP-H7493918915350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 3.75 MM X 15MM -,SUP-H7493918915370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 4.00MM X 15MM -,SUP-H7493918915400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 1.20MM X 20MM -,SUP-H7493918920120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 1.50MM X 20MM -,SUP-H7493918920150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 2.00 MM X 20 MM -,SUP-H7493918920200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 2.25 MM X 20MM -,SUP-H7493918920220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 2.50 MM X 20 MM -,SUP-H7493918920250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 2.75 MM X 20MM -,SUP-H7493918920270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 3.00 MM X 20 MM -,SUP-H7493918920300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 3.25 MM X 20MM -,SUP-H7493918920320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 3.50 MM X 20MM -,SUP-H7493918920350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 3.75 MM X 20MM -,SUP-H7493918920370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 4.00MM X 20MM -,SUP-H7493918920400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 2.00 MM X 30MM -,SUP-H7493918930200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 2.25 MM X 30MM -,SUP-H7493918930220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 2.50 MM X 30MM -,SUP-H7493918930250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 2.75 MM X 30MM -,SUP-H7493918930270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 3.00 MM X 30MM -,SUP-H7493918930300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 3.25 MM X 30MM -,SUP-H7493918930320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 3.50 MM X 30MM -,SUP-H7493918930350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 3.75 MM X 30MM -,SUP-H7493918930370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE MR 4.00MM X 30MM -,SUP-H7493918930400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE PUSH MR 1.20MM X 8MM -,SUP-H7493919008120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE PUSH MR 1.50MM X 8MM -,SUP-H7493919008150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE PUSH MR 1.20MM X 12MM -,SUP-H7493919012120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE PUSH MR 1.50MM X 12MM -,SUP-H7493919012150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE PUSH MR 1.20MM X 15MM -,SUP-H7493919015120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE PUSH MR 1.50MM X 15MM -,SUP-H7493919015150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE PUSH MR 1.20MM X 20MM -,SUP-H7493919020120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE PUSH MR 1.50MM X 20MM -,SUP-H7493919020150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 1.20MM X 8MM -,SUP-H7493919108120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 1.50MM X 8MM -,SUP-H7493919108150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 2.00MM X 8MM -,SUP-H7493919108200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 2.25MM X 8MM -,SUP-H7493919108220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 2.50MM X 8MM -,SUP-H7493919108250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 2.75MM X 8MM -,SUP-H7493919108270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 3.00MM X 8MM -,SUP-H7493919108300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 3.25MM X 8MM -,SUP-H7493919108320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 3.50MM X 8MM -,SUP-H7493919108350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 3.75MM X 8MM -,SUP-H7493919108370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 4.00MM X 8MM -,SUP-H7493919108400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 1.20MM X 12MM -,SUP-H7493919112120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 1.50MM X 12MM -,SUP-H7493919112150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 2.00MM X 12MM -,SUP-H7493919112200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 2.25MM X 12MM -,SUP-H7493919112220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 2.50MM X 12MM -,SUP-H7493919112250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 2.75MM X 12MM -,SUP-H7493919112270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 3.00MM X 12MM -,SUP-H7493919112300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 3.25MM X 12MM -,SUP-H7493919112320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 3.50MM X 12MM -,SUP-H7493919112350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 3.75MM X 12MM -,SUP-H7493919112370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 4.00MM X 12MM -,SUP-H7493919112400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 1.20MM X 15MM -,SUP-H7493919115120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 1.50MM X 15MM -,SUP-H7493919115150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 2.00MM X 15MM -,SUP-H7493919115200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 2.25MM X 15MM -,SUP-H7493919115220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 2.50MM X 15MM -,SUP-H7493919115250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 2.75MM X 15MM -,SUP-H7493919115270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 3.00MM X 15MM -,SUP-H7493919115300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 3.25MM X 15MM -,SUP-H7493919115320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 3.50MM X 15MM -,SUP-H7493919115350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 3.75MM X 15MM -,SUP-H7493919115370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 4.00MM X 15MM -,SUP-H7493919115400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 1.20MM X 20MM -,SUP-H7493919120120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 1.50MM X 20MM -,SUP-H7493919120150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 2.25MM X 20MM -,SUP-H7493919120220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 2.50MM X 20MM -,SUP-H7493919120250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 2.75MM X 20MM -,SUP-H7493919120270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 3.00MM X 20MM -,SUP-H7493919120300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 3.25MM X 20MM -,SUP-H7493919120320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 3.50MM X 20MM -,SUP-H7493919120350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 3.75MM X 20MM -,SUP-H7493919120370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 4.00MM X 20MM -,SUP-H7493919120400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 2.00MM X 20MM -,SUP-H7493919130200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 2.00MM X 30MM -,SUP-H7493919130200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 2.25MM X 30MM -,SUP-H7493919130220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 2.50MM X 30MM -,SUP-H7493919130250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 2.75MM X 30MM -,SUP-H7493919130270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 3.00MM X 30MM -,SUP-H7493919130300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 3.25MM X 30MM -,SUP-H7493919130320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 3.50MM X 30MM -,SUP-H7493919130350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 3.75MM X 30MM -,SUP-H7493919130370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE OTW 4.00MM X 30MM -,SUP-H7493919130400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE PUSH OTW 1.20MM X 8MM -,SUP-H7493919208120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE PUSH OTW 1.50MM X 8MM -,SUP-H7493919208150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE PUSH OTW 1.20MM X 12MM -,SUP-H7493919212120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE PUSH OTW 1.50MM X 12MM -,SUP-H7493919212150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE PUSH OTW 1.20MM X 15MM -,SUP-H7493919215120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE PUSH OTW 1.50MM X 15MM -,SUP-H7493919215150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE PUSH OTW 1.20MM X 20MM -,SUP-H7493919220120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON EMERGE PUSH OTW 1.50MM X 20MM -,SUP-H7493919220150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CHARGER BALLOON 3 X 20 X 135 -,SUP-H74939206030210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CHARGER BALLOON 3 X 20 X 75 -,SUP-H74939206030270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CHARGER BALLOON 3MM X 40MM X 130CM -,SUP-H74939206030410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CHARGER BALLOON 3MM X 80MM X 135CM -,SUP-H74939206030810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
3MM X 100MM X 135CM CHARGER -,SUP-H74939206031010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CHARGER 3MM X 120MM -,SUP-H74939206031210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
3.0MM X 150MM X 135CM CHARGER BALLOON -,SUP-H74939206031510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CHARGER 3MM X 200MM X 135CM -,SUP-H74939206032010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CHARGER OTW 4 X 20MM X135CM BALLOON -,SUP-H74939206040210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
4MM X 20MM X 75CM CHARGER BALLOON -,SUP-H74939206040270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
PTA BALLOON 5F -,SUP-H74939206040670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CHARGER BALLOON 4MM X 80MM X 75CM -,SUP-H74939206040870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CHARGER 4MM X 100MM X 135CM -,SUP-H74939206041010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
4MM X 100MM X 75CM CHARGER BALLOON -,SUP-H74939206041070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CHARGER BALLOON 4MM X 150MM X 135CM -,SUP-H74939206041510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
5MM X 20MM X 75CM .035 CHARGER SHORT SHAFT -,SUP-H74939206050270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CHARGER 5MM X 40MM X 135CM -,SUP-H74939206050410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CHARGER BALLOON 5MM X 60MM X 135CM -,SUP-H74939206050610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CHARGER BALLOON 5MM X 80MM X 135CM -,SUP-H74939206050810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
5MM X 80MM X 75CM CHARGER BALLOON -,SUP-H74939206050870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CHARGER 5MM X 100MM X 135CM -,SUP-H74939206051010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CHARGER 5MM X 120MM X 135CM -,SUP-H74939206051210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CHARGER BALLOON 5 X 150MM -,SUP-H74939206051510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
5MM X 200MM X 135CM CHARGER -,SUP-H74939206052010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
6MM X 20MM X 135CM CHARGER -,SUP-H74939206060210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
6MM X 20MM X 75CM .035 CHARGER SHORT SHAFT -,SUP-H74939206060270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CHARGER BALLOON 6MM X 40MM X 135CM -,SUP-H74939206060410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CHARGER 6MM X 40MM X 75CM BALLOON -,SUP-H74939206060470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
6.0MM X 60MM X 75CM CHARGER -,SUP-H74939206060670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
6MM X 8MM X 135CM CHARGER -,SUP-H74939206060810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CHARGER 6.0MM X 80MM X 75CM -,SUP-H74939206060870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CHARGER BALLOON 6MM X 100MM X 135CM -,SUP-H74939206061010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CHARGER 6MM X 100MM X 75CM -,SUP-H74939206061070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CHARGER BALLOON 6MM X 150MM X 135CM -,SUP-H74939206061510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
7MM X 20MM X 135CM CHARGER -,SUP-H74939206070210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
7MM X 40MM X 135CM CHARGER BALLOON -,SUP-H74939206070410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
7MM X 40MM X 75CM CHARGER BALLOON -,SUP-H74939206070470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CHARGER 7MM X 80MM X 135CM -,SUP-H74939206070610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CHARGER BALLOON .035 7MM X 60MM X 75CM -,SUP-H74939206070670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
7MM X 80MM X 75CM CHARGER BALLOON -,SUP-H74939206070870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
7MM X 100MM X 135CM CHARGER BALLOON -,SUP-H74939206071010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
7MM X 100MM X 75CM CHARGER PTA -,SUP-H74939206071070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CHARGER BALLOON 8MM X 40MM X 135CM -,SUP-H74939206080410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CHARGER 8MM X 40MM X 75CM -,SUP-H74939206080470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
8MM X 60MM X 75CM CHARGER PTA -,SUP-H74939206080670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
8MM X 80MM X 135CM CHARGER BALLOON -,SUP-H74939206080810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
8.0MM X 80MM X 75CM CHARGER -,SUP-H74939206080870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CHARGER PTA 8MM X 100MM X 135CM -,SUP-H74939206081010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
8MM X 100MM X 75CM CHARGER PTA -,SUP-H74939206081070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CHARGER 8MM X 180MM X 135CM -,SUP-H74939206081810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
8.0MM X 200MM X 135XM CHARGER BALLOON -,SUP-H74939206082010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
9MM X 40MM X 135CM CHARGER BALLOON -,SUP-H74939206090410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
9MM X 40MM X 75CM CHARGER BALLOON -,SUP-H74939206090470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CHARGER 9MM X 60MM X 75CM -,SUP-H74939206090670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CHARGER OTW 10 X 20 BALLOON 135CM -,SUP-H74939206100210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CHARGER .035 10MM X 40MM X 135CM -,SUP-H74939206100410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
10MM X 40MM X 75CM CHARGER PTA -,SUP-H74939206100470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
10.0MM X 80MM X 75CM CHARGER BALLOON -,SUP-H74939206100870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
12MM X 20MM X 75CM CHARGER -,SUP-H74939206120270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
12MM X 40MM X 135CM CHARGER -,SUP-H74939206120410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
12MM X 40MM X 75CM CHARGER -,SUP-H74939206120470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CHARGER 12MM X 60MM X 75CM -,SUP-H74939206120670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CHARGER 12MM X 80MM X 75CM -,SUP-H74939206120870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 2.00MM x 6MM -,SUP-H7493926706200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 2.25MM x 6MM -,SUP-H7493926706220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 2.50MM x 6MM -,SUP-H7493926706250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 2.75MM x 6MM -,SUP-H7493926706270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 3.00MM x 6MM -,SUP-H7493926706300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 3.25MM x 6MM -,SUP-H7493926706320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 3.50MM x 6MM -,SUP-H7493926706350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 3.75MM x 6MM -,SUP-H7493926706370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 4.00MM X 6MM -,SUP-H7493926706400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 4.50MM x 6MM -,SUP-H7493926706450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 5.00MM x 6MM -,SUP-H7493926706500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 2.00MM x 8MM -,SUP-H7493926708200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 2.25MM x 8MM -,SUP-H7493926708220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 2.50MM x 8MM -,SUP-H7493926708250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 2.75MM x 8MM -,SUP-H7493926708270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 3.00MM x 8MM -,SUP-H7493926708300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 3.25MM x 8MM -,SUP-H7493926708320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 3.50MM x 8MM -,SUP-H7493926708350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 3.75MM x 8MM -,SUP-H7493926708370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 4.0 MM X 8 MM -,SUP-H7493926708400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 4.50MM x 8MM -,SUP-H7493926708450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 5.00MM x 8MM -,SUP-H7493926708500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 5.50MM x 8MM -,SUP-H7493926708550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 6.00MM x 8MM -,SUP-H7493926708600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 2.00MM X 12MM -,SUP-H7493926712200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 2.25MM x 12MM -,SUP-H7493926712220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 2.50 MM X 12 MM -,SUP-H7493926712250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 2.75MM x 12MM -,SUP-H7493926712270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 3.00MM x 12MM -,SUP-H7493926712300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 3.25MM x 12MM -,SUP-H7493926712320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 3.50MM x 12MM -,SUP-H7493926712350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 3.75MM x 12MM -,SUP-H7493926712370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 4.00MM x 12MM -,SUP-H7493926712400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 4.50MM x 12MM -,SUP-H7493926712450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 5.0 MM X 12 MM -,SUP-H7493926712500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 5.50MM x 12MM -,SUP-H7493926712550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 6.00MM x 12MM -,SUP-H7493926712600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 2.00MM x 15MM -,SUP-H7493926715200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 2.25MM x 15MM -,SUP-H7493926715220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 2.50 MM X 15 MM -,SUP-H7493926715250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 2.75MM x 15MM -,SUP-H7493926715270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 3.0 MM X 15 MM -,SUP-H7493926715300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 3.25MM x 15MM -,SUP-H7493926715320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 3.50MM x 15MM -,SUP-H7493926715350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 3.75MM x 15MM -,SUP-H7493926715370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 4.00MM X 15MM -,SUP-H7493926715400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 4.50MM x 15MM -,SUP-H7493926715450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 5.00MM x 15MM -,SUP-H7493926715500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 5.50MM x 15MM -,SUP-H7493926715550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 6.00MM x 15MM -,SUP-H7493926715600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 2.00MM x 20MM -,SUP-H7493926720200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 2.25MM x 20MM -,SUP-H7493926720220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 2.50 MM X 20 MM -,SUP-H7493926720250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 2.75MM x 20MM -,SUP-H7493926720270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 3.0 MM X 20 MM -,SUP-H7493926720300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 3.25MM x 20MM -,SUP-H7493926720320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 3.50MM x 20MM -,SUP-H7493926720350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 3.75MM x 20MM -,SUP-H7493926720370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 4.00MM x 20MM -,SUP-H7493926720400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 4.50MM x 20MM -,SUP-H7493926720450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 5.00MM x 20MM -,SUP-H7493926720500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 5.50MM x 20MM -,SUP-H7493926720550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 6.00MM x 20MM -,SUP-H7493926720600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 2.00MM x 30MM -,SUP-H7493926730200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 2.25MM x 30MM -,SUP-H7493926730220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 2.50MM x 30MM -,SUP-H7493926730250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 2.75MM x 30MM -,SUP-H7493926730270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 3.00MM x 30MM -,SUP-H7493926730300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 3.25MM x 30MM -,SUP-H7493926730320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 3.50MM x 30MM -,SUP-H7493926730350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 3.75MM x 30MM -,SUP-H7493926730370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE MR 4.00MM x 30MM -,SUP-H7493926730400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 2.00MM x 6MM -,SUP-H7493926806200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 2.25MM x 6MM -,SUP-H7493926806220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 2.50MM x 6MM -,SUP-H7493926806250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 2.75MM x 6MM -,SUP-H7493926806270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 3.00MM x 6MM -,SUP-H7493926806300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 3.25MM x 6MM -,SUP-H7493926806320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 3.50MM x 6MM -,SUP-H7493926806350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 3.75MM x 6MM -,SUP-H7493926806370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 4.00MM x 6MM -,SUP-H7493926806400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 4.50MM x 6MM -,SUP-H7493926806450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 5.00MM x 6MM -,SUP-H7493926806500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 2.00MM x 8MM -,SUP-H7493926808200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 2.25MM x 8MM -,SUP-H7493926808220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 2.50MM x 8MM -,SUP-H7493926808250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 2.75MM x 8MM -,SUP-H7493926808270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 3.00MM x 8MM -,SUP-H7493926808300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 3.25MM x 8MM -,SUP-H7493926808320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 3.50MM x 8MM -,SUP-H7493926808350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 3.75MM x 8MM -,SUP-H7493926808370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 4.00MM x 8MM -,SUP-H7493926808400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 4.50MM x 8MM -,SUP-H7493926808450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 5.00MM x 8MM -,SUP-H7493926808500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 5.50MM x 8MM -,SUP-H7493926808550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 6.00MM x 8MM -,SUP-H7493926808600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 2.00MM x 12MM -,SUP-H7493926812200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 2.25MM x 12MM -,SUP-H7493926812220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 2.50MM x 12MM -,SUP-H7493926812250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 2.75MM X 12MM -,SUP-H7493926812270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 3.00MM x 12MM -,SUP-H7493926812300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 3.25MM x 12MM -,SUP-H7493926812320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 3.50MM x 12MM -,SUP-H7493926812350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 3.75MM x 12MM -,SUP-H7493926812370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 4.00MM x 12MM -,SUP-H7493926812400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 4.50MM x 12MM -,SUP-H7493926812450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 5.00MM x 12MM -,SUP-H7493926812500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 5.50MM x 12MM -,SUP-H7493926812550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 6.00MM x 12MM -,SUP-H7493926812600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 2.00MM x 15MM -,SUP-H7493926815200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 2.25MM x 15MM -,SUP-H7493926815220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 2.50MM x 15MM -,SUP-H7493926815250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 2.75MM x 15MM -,SUP-H7493926815270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 3.00MM x 15MM -,SUP-H7493926815300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 3.25MM x 15MM -,SUP-H7493926815320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 3.50MM x 15MM -,SUP-H7493926815350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 3.75MM x 15MM -,SUP-H7493926815370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 4.00MM x 15MM -,SUP-H7493926815400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 4.50MM x 15MM -,SUP-H7493926815450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 5.00MM x 15MM -,SUP-H7493926815500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 5.50MM x 15MM -,SUP-H7493926815550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 6.00MM x 15MM -,SUP-H7493926815600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 2.00MM x 20MM -,SUP-H7493926820200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 2.25MM x 20MM -,SUP-H7493926820220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 2.50MM x 20MM -,SUP-H7493926820250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 2.75MM x 20MM -,SUP-H7493926820270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 3.00MM x 20MM -,SUP-H7493926820300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 3.25MM x 20MM -,SUP-H7493926820320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 3.50MM x 20MM -,SUP-H7493926820350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 3.75MM x 20MM -,SUP-H7493926820370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 4.00MM x 20MM -,SUP-H7493926820400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 4.50MM x 20MM -,SUP-H7493926820450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 5.00MM x 20MM -,SUP-H7493926820500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 5.50MM x 20MM -,SUP-H7493926820550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 6.00MM x 20MM -,SUP-H7493926820600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 2.00MM x 30MM -,SUP-H7493926830200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 2.25MM x 30MM -,SUP-H7493926830220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 2.50MM x 20MM -,SUP-H7493926830250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 2.75MM x 30MM -,SUP-H7493926830270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 3.00MM x 30MM -,SUP-H7493926830300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 3.25MM x 30MM -,SUP-H7493926830320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 3.50MM x 30MM -,SUP-H7493926830350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 3.75MM x 30MM -,SUP-H7493926830370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NC EMERGE OTW 4.00MM x 30MM -,SUP-H7493926830400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CUTTING 6MMX2.0MM WOLVERINE -,SUP-H74939401062000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CUTTING 6MMX2.5MM WOLVERINE -,SUP-H74939401062500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CUTTING 6MMX3.0MM WOLVERINE -,SUP-H74939401063000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CUTTING 6MMX3.5MM WOLVERINE -,SUP-H74939401063500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CUTTING 6MMX4.0MM WOLVERINE -,SUP-H74939401064000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CUTTING 10MMX2.0MM WOLVERINE -,SUP-H74939401102000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CUTTING 10MMX2.5MM WOLVERINE -,SUP-H74939401102500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CUTTING 10MMX3.0MM WOLVERINE -,SUP-H74939401103000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CUTTING 10MMX3.5MM WOLVERINE -,SUP-H74939401103500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CUTTING 10MMX4.0MM WOLVERINE -,SUP-H74939401104000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CUTTING 15MX2.00MM WOLVERINE -,SUP-H74939401152000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CUTTING 15MX2.50MM WOLVERINE -,SUP-H74939401152500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON CUTTING 15MMX3.0MM WOLVERINE -,SUP-H74939401153000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
RANGER GLOBAL DCB OTW 6.0 X 150MM 150CM -,SUP-H74939419601510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
RANGER DCB OTW  7.0MM x 40MM x 80CM -,SUP-H74939419700480,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT BLN -,SUP-H749CBM3200100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X6MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3225060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3225100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X6MM FLEXTOME CUT BLN MONORAIL 142CM RX -,SUP-H749CBM3250060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3250100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3250150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.75X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3275100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.75X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3275150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT BLN -,SUP-H749CBM3300100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT BLN -,SUP-H749CBM3300150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3325100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X15MM FLEXTOME CUT BLN MONORAIL 142CM RX -,SUP-H749CBM3325150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3350100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3350150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.75X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3375100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3200060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3200100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3225060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3225100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X15MM FLEXTOME BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3225150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3250060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3250100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X15MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3250150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.75X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3275100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.75X15MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3275150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3300060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X15MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3300150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3325100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X15MM FLEXTOME CUT BLN 142CM CUT BLN NC -,SUP-H749CBO3325150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN -,SUP-H749CBO3350100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH DX 2.4FR ID 3.4FR RND TIP 135CM CROSSBOSS XING MUL-WIRE -,SUP-H749M2000A0,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4648.07,3253.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH ANG 0.045IN 5FR FR4 125CM EXPO FUL-R WIRE BRD ROBST -,SUP-H759085262251,CDM,C1725,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATHETER IABP 7.5FR 40CC ULTRA FLEX REF: IAB-06840-U -,SUP-IAB-06840-U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATHETER IABP 8FR 40CC REDIGUARD REF: IAB-S840C -,SUP-IAB-S840C,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4010.16,2807.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
INFLATION KIT 30/30 BASIX -,SUP-IN4530,CDM,C1725,HCPCS,272,RC,,,outpatient,,,364.57,255.199,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5X220MM LUTONIX -,SUP-LX3513052205F,CDM,C1725,HCPCS,272,RC,,,outpatient,,,8063.6,5644.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
LUTONIX BALLOON 7MM X 80MM -,SUP-LX351307805F,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5305,3713.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
LUTONIX PTA 5MM X 60MM X 75CM -,SUP-LX3575560V,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
LUTONIX BALLOON 7 X 80 -,SUP-LX3575780V,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
LUTONIX 8 X 80 -,SUP-LX3575880V,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B XXL 14MM 4CM 75 14-514 -,SUP-M001145140,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B CATH XXL VASC 12 X 6 X 75CM -,SUP-M001145300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 14X60MM 2XL 75CM LPRO F/PTA PERIPH NYBAX LUB -,SUP-M001145320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON XXL 16 X 4  5.8/120 -,SUP-M001145530,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON XXL 16 X 4 X 75 -,SUP-M001145530,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 16X60MM 2XL 75CM LPRO PERIPH NYBAX LUB BIOSLD CTD -,SUP-M001145540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B CATH XXL 18MM X 4CM 120CM -,SUP-M001145580,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH DIL 18MM 8FR SHEA 0.037IN TIP 5.8FRX75CM 6CM BLN GALWAY -,SUP-M001145590,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X40MM ULTR-THN DMD 75CM F/PTA PERIPH 5FR SHTH -,SUP-M001164230,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6X20MM ULTR-THN DMD 75CM F/PTA PERIPH 5FR SHTH -,SUP-M001164570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 7X20MM ULTR-THN DMD 75CM F/PTA PERIPH 5FR SHTH -,SUP-M001164770,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B DUT 8MM 4CM 75CM  16-505 -,SUP-M001165050,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
AST-GN45 -,SUP-M001NC20000001,CDM,C1725,HCPCS,272,RC,,,outpatient,,,358.85,251.195,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 7X40MM POLAR 120CM COAX F/PTA CLD THRP PERIPH -,SUP-M001P740120010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2807.11,1964.977,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 7X60MM POLAR 120CM COAX F/PTA CLD THRP PERIPH -,SUP-M001P760120010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2807.11,1964.977,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 8X20MM POLAR 120CM COAX F/PTA CLD THRP PERIPH -,SUP-M001P820120010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
DEVICE INFL POLAR N2O -,SUP-M001PCIU400000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4927.28,3449.096,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X40MM POLAR 150CM COAX F/PTA CLD THRP PERIPH -,SUP-M001T3040150010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X40MM POLAR 150CM COAX F/PTA CLD THRP PERIPH -,SUP-M001T4040150010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
RETRACTOR ORTHO HHMN 18MMX9.25IN STN FNSH SS V. MUELLER -,SUP-M001T5040135010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6X40MM POLAR 135CM COAX F/PTA CLD THRP PERIPH -,SUP-M001T6040135010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATHETER  SHOCKWAVE M5+ IVL CATHETER 5.0X60MM -,SUP-M5PIVL5060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATHETER SHOCKWAVE 5.5 X 60 MM M5+ -,SUP-M5PIVL5560,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATHETER- SHOCKWAVE M5+ IVL CATHETER- 6.0X60MM -,SUP-M5PIVL6060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATHETER- SHOCKWAVE M5+ IVL CATHETER- 7.0X60MM -,SUP-M5PIVL7060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATHETER- SHOCKWAVE M5+ IVL CATHETER- 8.0X60MM -,SUP-M5PIVL8060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP2006X NCEUPHORA RX -,SUP-NCEUP2006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP2008X NCEUPHORA RX -,SUP-NCEUP2008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP2012X NCEUPHORA RX -,SUP-NCEUP2012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP2015X NCEUPHORA RX -,SUP-NCEUP2015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP2020X NCEUPHORA RX -,SUP-NCEUP2020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP22506X NCEUPHORA RX -,SUP-NCEUP22506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP22508X NCEUPHORA RX -,SUP-NCEUP22508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP22512X NCEUPHORA RX -,SUP-NCEUP22512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP22515X NCEUPHORA RX -,SUP-NCEUP22515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP22520X NCEUPHORA RX -,SUP-NCEUP22520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP2506X NCEUPHORA RX -,SUP-NCEUP2506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP2508X NCEUPHORA RX -,SUP-NCEUP2508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP2512X NCEUPHORA RX -,SUP-NCEUP2512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP2515X NCEUPHORA RX -,SUP-NCEUP2515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP2520X NCEUPHORA RX -,SUP-NCEUP2520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP2527X NCEUPHORA RX -,SUP-NCEUP2527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP27506X NCEUPHORA RX -,SUP-NCEUP27506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP27508X NCEUPHORA RX -,SUP-NCEUP27508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP27512X NCEUPHORA RX -,SUP-NCEUP27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP27515X NCEUPHORA RX -,SUP-NCEUP27515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP27520X NCEUPHORA RX -,SUP-NCEUP27520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP27527X NCEUPHORA RX -,SUP-NCEUP27527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP3006X NCEUPHORA RX -,SUP-NCEUP3006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP3008X NCEUPHORA RX -,SUP-NCEUP3008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP3012X NCEUPHORA RX -,SUP-NCEUP3012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP3015X NCEUPHORA RX -,SUP-NCEUP3015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP3020X NCEUPHORA RX -,SUP-NCEUP3020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP3027X NCEUPHORA RX -,SUP-NCEUP3027X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP32506X NCEUPHORA RX -,SUP-NCEUP32506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP32508X NCEUPHORA RX -,SUP-NCEUP32508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP32512X NCEUPHORA RX -,SUP-NCEUP32512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP32515X NCEUPHORA RX -,SUP-NCEUP32515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP32520X NCEUPHORA RX -,SUP-NCEUP32520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP32527X NCEUPHORA RX -,SUP-NCEUP32527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP3506X NCEUPHORA RX -,SUP-NCEUP3506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP3508X NCEUPHORA RX -,SUP-NCEUP3508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP3512X NCEUPHORA RX -,SUP-NCEUP3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP3515X NCEUPHORA RX -,SUP-NCEUP3515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP3520X NCEUPHORA RX -,SUP-NCEUP3520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP3527X NCEUPHORA RX -,SUP-NCEUP3527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP37506X NCEUPHORA RX -,SUP-NCEUP37506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP37508X NCEUPHORA RX -,SUP-NCEUP37508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP37512X NCEUPHORA RX -,SUP-NCEUP37512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP37515X NCEUPHORA RX -,SUP-NCEUP37515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP37520X NCEUPHORA RX -,SUP-NCEUP37520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP37527X NCEUPHORA RX -,SUP-NCEUP37527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP4006X NCEUPHORA RX -,SUP-NCEUP4006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP4008X NCEUPHORA RX -,SUP-NCEUP4008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP4012X NCEUPHORA RX -,SUP-NCEUP4012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP4015X NCEUPHORA RX -,SUP-NCEUP4015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP4020X NCEUPHORA RX -,SUP-NCEUP4020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP4027X NCEUPHORA RX -,SUP-NCEUP4027X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP4508X NCEUPHORA RX -,SUP-NCEUP4508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP4512X NCEUPHORA RX -,SUP-NCEUP4512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP4515X NCEUPHORA RX -,SUP-NCEUP4515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP4520X NCEUPHORA RX -,SUP-NCEUP4520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP5008X NCEUPHORA RX -,SUP-NCEUP5008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP5012X NCEUPHORA RX -,SUP-NCEUP5012,CDM,C1725,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
BALLOON NCEUP5015X NCEUPHORA RX -,SUP-NCEUP5015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X6MM NC STRMR 138CM OTW NC COR 3- FOLD FLCRM + -,SUP-NCS2506W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X11MM NC STRMR 138CM OTW NC COR 3- FOLD FLCRM + -,SUP-NCS2511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS2514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.75X6MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS27506W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.75X11MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM -,SUP-NCS27511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.75X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS27514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.75X16MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS27516W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X6MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS3006W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X11MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS3011W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS3014W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X16MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS3016W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X11MM NC STRMR 138CM OTW NC COR 5- FOLD FLCRM -,SUP-NCS32511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS32514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X11MM NC STRMR 138CM OTW NC COR 5- FOLD FLCRM + -,SUP-NCS3511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X16MM NC STRMR 138CM OTW NC COR 5- FOLD FLCRM + -,SUP-NCS3516W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.75X11MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS37511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.75X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS37514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X11MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS4011W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X16MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS4016W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X21MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS4021W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X6MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP2506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP2512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP2515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.75X6MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP27506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.75X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.75X21MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP27521X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X6MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT FLCRM -,SUP-NCSP3006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X21MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3021X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X12MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP32512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X15MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP32515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X27MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.75X12MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP37512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.75X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP37515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X21MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4021X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4.5X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5X15MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP5015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
PALADIN CAROTID PTA CATHETER WITH INTEGRATED EMB PRO -,SUP-PD-5520-140-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATHETER ADVANCE MICRO 14 ULTRA LOW PROFILE BALLOON -,SUP-PTA3-14-90-2.5-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2289.76,1602.832,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATHETER PTA BALLOON DILATION 18LP ADVANCE LP 2MM X 20CM -,SUP-PTA4-18-150-2-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4MMX10CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4MMX6CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-8,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
B CATH ADVANCE 18LP 5X10 150 -,SUP-PTA4-18-150-510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-5-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-5-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5MMX6CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-5-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6MMX10CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-6-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-6-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH ANG 4FR 0.018/ 150CM/6MM DIA 6CM ADVANCE RNL POPLT PTA -,SUP-PTA4-18-150-6-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 7MMX10CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-710,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 7MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 7MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 7MMX6CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 7MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-8,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 10MMX3CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-PTA5-35-135-103,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-PTA5-35-135-44,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-PTA5-35-13562.0,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 8MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-PTA5-35-135-8-8,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-PTAX4141702.520,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-PTAX414170312,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 26MM 12FRX2.5CM INOUE 70CM PVC 0.025IN GW COMP -,SUP-PTMC-26,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10025.1,7017.57,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 28MM 12FRX2.5CM INOUE 70CM PVC 0.025IN GW COMP -,SUP-PTMC-28,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10025.1,7017.57,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 30MM 12FRX2.5CM INOUE 70CM PVC 0.025IN GW COMP -,SUP-PTMC-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10025.1,7017.57,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
SHOCKWAVE 3.0 X 40MM IVL KIT -,SUP-S4IVLK3040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ADV SERENITY 14 HYDROPHILIC PTA BALL DIL CATH 2.5X60X150CM -,SUP-SER14-150-25-60,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ADVANCE SERENITY 14 HYDROPHILIC PTA BALLOON DIL CATH -,SUP-SER14-150-30-60,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.25X6MM SPRINTER LEGEND 152CM OTW SEM-COM COR -,SUP-SPL12506WL,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.25X6MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.25X10MM SPRINTER LEGEND 152CM OTW SEM-COM COR -,SUP-SPL12510WL,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.25X10MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.25X12MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.25X15MM SPRINTER LEGEND 152CM OTW SEM-COM COR -,SUP-SPL12515WL,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.25X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.5X6MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL15006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.5X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL15012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.5X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL15015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL20012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL20015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X20MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL20020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X6MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL22506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL22515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL25012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL25015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X20MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL25020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X25MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL25025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.75X12MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.75X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL27515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.75X20MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL27520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL30012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL30015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X20MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL30020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X12MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL40012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL40015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.5X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR1512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 1.5X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR1515W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2012W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2015W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X20MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2020W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X25MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2025W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.25X12MM SPRINTER 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR22512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X6MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2506W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2515W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5X20MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2520W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.75X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR27512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.75X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR27515W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3012W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3015W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3X20MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3020W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.25X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR32512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3.5X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR4015W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ENROUTE ENFLATE TRANSCAROTID RX BALLOON -,SUP-SR-4525-BC,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2008.89,1406.223,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
ENROUTE ENFLATE TRANSCAROTID RX BALLOON -,SUP-SR-5035-BC,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2008.89,1406.223,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH ANG 4FR STR 125CM TEMPO AQ SLCT BRD SHFT NO SH NYL -,SUP-SRD6667,CDM,C1725,HCPCS,272,RC,,,outpatient,,,269.58,188.706,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATHETER BALLOON TRUE FLOW 24 MM x 3.5CM REF: TF0243514 -,SUP-TF0243514,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6153.8,4307.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CABLE ADPTR IABP -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,344.79,241.353,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2X15MM 140CM OTW PERIPH -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4134.28,2893.996,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH SHEATH RITESITE C315H1802 -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4X15MM 140CM OTW PERIPH -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4134.28,2893.996,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2MMX2CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V142020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V142040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 2.5MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V142540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3MMX2CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V143020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3319.12,2323.384,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V143040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 3MMX6CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V143060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4MMX12CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V1840120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 4MMX8CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V184080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V185040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 5MMX6CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V185060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATH PTCA 6MMX12CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V1860120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
CATHETER PTV DILATATION 26MX4CM VIDA REF:VDA100264 -,SUP-VDA100264,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2802.82,1961.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.650485,9184.66245,other,SI=N Exclusions ,,
DILATOR 6-30FR DIA TIP 30CM PE/PTFE -,SUP-118768,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1395.36,976.752,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
LEAD DEFIB IMPL BIPLR PERMNT PCNG ETAK RELIANCE G_59CM -,SUP-5843,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
KT MNMTRY BLN ADLT RCTL BLN -,SUP-A86-1070,CDM,C1726,HCPCS,272,RC,,,outpatient,,,52.52,36.764,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CATH DIL 6MMX16MM RELIEVA ULTIRRA SIN 2LUM SHFT ENDO F/IRR -,SUP-BC0616RU,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3728.49,2609.943,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CATH DIL 6MMX16MM RELIEVA SOLO PRO SIN 2LUM SHFT ENDO F/IRR -,SUP-BC0616SP,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3265.42,2285.794,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
KIT CATHETER SURGILUBE VINYL PEDIATRIC FEMALE OD8 FR SOFT LF -,SUP-CKF105L,CDM,C1726,HCPCS,272,RC,,,outpatient,,,18.96,13.272,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
KIT CATHETER SURGILUBE VINYL PEDIATRIC FEMALE OD8 FR SOFT LF -,SUP-CKF105L,CDM,C1726,HCPCS,272,RC,,,outpatient,,,18.99,13.293,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
TRAY URETHRAL 8FR FEMALE VINYL PVP URINE COLLECTION DEVICE -,SUP-CKF105L,CDM,C1726,HCPCS,272,RC,,,outpatient,,,18.15,12.705,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
BALLOON CERVICAL RIPENING W/STYLET -,SUP-G19891,CDM,C1726,HCPCS,272,RC,,,outpatient,,,243.61,170.527,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
IMPLANT PIP MCP SZ5 SWNSN SIL -,SUP-G470-0005,CDM,C1726,HCPCS,272,RC,,,outpatient,,,4413.76,3089.632,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
HURRICANE RX 4 X 4 -,SUP-G49219,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
HURRICANE RX 6 X 4 -,SUP-G49220,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
HURRICANE RX 8 X 4 -,SUP-G49221,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
HURRICANE RX 10 X 4 -,SUP-G49222,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CATH DIL 7FR CATH 7-5FR TIP 200CM 2CM BLN FUSION BIL TAPR -,SUP-G49571,CDM,C1726,HCPCS,272,RC,,,outpatient,,,676.86,473.802,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CATH DIL 8.5FR CATH 8.5-6FR TAPR 200CM 2CM BLN FUSION BIL -,SUP-G49572,CDM,C1726,HCPCS,272,RC,,,outpatient,,,676.86,473.802,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CATH DIL 7FR TAPR 200CM 2CM BLN FUSION BIL DOME TIP ENDO -,SUP-G49573,CDM,C1726,HCPCS,272,RC,,,outpatient,,,676.86,473.802,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CATH PTCA 6X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171061070,CDM,C1726,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
B CUTTING 5 X 2 X 135 -,SUP-M001PCB50201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
BALLOON 2CM PERIPHERAL CUTTING -,SUP-M001PCB50201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CATH PTCA 5MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-M001PCB50201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
PERIPHERAL CUTTING BALLOON  5MM X 2CM  50CM -,SUP-M001PCB5020500,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
B 6 X 2 X 135 CUTTING BAL -,SUP-M001PCB60201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
B CUTTING 7 X 2 X 135 -,SUP-M001PCB70201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CATH PTCA 7MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-M001PCB70201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CATH PTCA 7X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-M001PCB7020900,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
B CUTTING 8 X 2 X 135 -,SUP-M001PCB80201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CATH PTCA 8MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-M001PCB80201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CATH PTCA 8X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-M001PCB8020900,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CATH PTCA 1.5X3MM CUT BLN 140CM OTW PERIPH 0.018IN GW COMP -,SUP-M001PCBO3015140,CDM,C1726,HCPCS,272,RC,,,outpatient,,,4134.28,2893.996,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
B PERIPHERAL 6F 3.0X15X140 M00 -,SUP-M001PCBO3015140F0,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
B PER CUT OTW FLEX 4X15X140 M0 -,SUP-M001PCBO4015140F0,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CUTTING BALLOON 4MM X 1.5CM  X 135CM -,SUP-M001PCBO4015140F0,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CATH DIL 5.8FR 6MM BLN 180CM 4CM BLN HURRCN SS BIL RX ENDO -,SUP-M00545920,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CATH DIL 5.8FR 8MM BLN 180CM 4CM BLN HURRCN SS BIL RX ENDO -,SUP-M00545940,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CATHETER CHOLANGIOGRAM SPYGLASS 65CM CHOLANGIOSCOPY -,SUP-M00546780,CDM,C1726,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
DILATOR BLN 36-40.5-45FR OD BLN 75CM 5.5CM CRE ESPH WG ENDO -,SUP-M00550300,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1649.04,1154.328,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
DILATOR BLN 24-27-30FR OD BLN 75CM 3CM CRE ESPH WG ENDO -,SUP-M00550330,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1649.04,1154.328,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
DILATOR BLN 30-33-36FR OD BLN 75CM 3CM CRE ESPH WG ENDO -,SUP-M00550340,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1649.04,1154.328,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
DILATOR BALLOON 35MM RIGIFLEX -,SUP-M00554510,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3112.17,2178.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
DILATOR BLN 7.5FR 6-7-8 MMX180CM 5.5CM BLN CRE PEBAX ESPH FX -,SUP-M00556860,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CRE 8-10MM 8CM F/G -,SUP-M00558340,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CRE 10-12MM 8CM F/G -,SUP-M00558350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CRE 12-15MM 8CM F/G -,SUP-M00558360,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
DILATOR BLN 6FR 12-13.5-15 MMX180CM 8CM BLN CRE PEBAX ESPH -,SUP-M00558360,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CRE 15-18MM 8CM F/G -,SUP-M00558370,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
DILATOR BLN 6FR 18-19-20 MMX180CM 8CM BLN CRE PEBAX ESPH FX -,SUP-M00558380,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CRE 18-20MM 8CM F/G -,SUP-M00558380,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
DILATOR WIREGUIDED CRE 15-18 180CM -,SUP-M00558430,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
DILATOR BLN 7.5FR 10-11-12 MMX240CM 5.5CM BLN CRE PEBAX ESPH -,SUP-M00558470,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
DILATOR BLN 7.5FR 12-13.5-15 MMX240CM 5.5CM BLN CRE PEBAX -,SUP-M00558480,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
DILATOR WIREGUIDED CRE 8-10 180CM -,SUP-M00558610,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
DILATOR WIREGUIDED CRE 10-12 180CM -,SUP-M00558620,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
DILATOR WIREGUIDED CRE 12-15 180CM -,SUP-M00558630,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CRE PRO WIREGUIDED 6-7-8MM 240CM -,SUP-M00558660,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CRE PRO WIREGUIDE 8-9-10MM 240 -,SUP-M00558670,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CRE PRO WIREGUIDE 10-11-12MM 240 -,SUP-M00558680,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CRE PRO WIREGUIDE 12-13.5-15MM 240 -,SUP-M00558690,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CRE PRO WIREGUIDE 15-16.5-18MM 240 -,SUP-M00558700,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
DILATOR BLN 7.5FR 15-16.5-18 MMX240CM 5.5CM BLN CRE PEBAX -,SUP-M00558700,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CRE PRO WIREGUIDE 18-19-20MM 240 -,SUP-M00558710,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CATH BILIARY BALLOON DILATATION CRE 8-10 3CM -,SUP-M00558920,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1517,1061.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CATH BILIARY BALLOON DILATATION CRE 10-12 3CM -,SUP-M00558930,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1517,1061.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CATH BILIARY BALLOON DILATATION CRE 12-15 3CM -,SUP-M00558940,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1517,1061.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CATH NEPH DIL 7FR 30FR BLN LPRO NPHRMX LF MRKR STPCK 17CM -,SUP-M0062101170,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1232.21,862.547,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CATH NEPH 7FR 10MM NPHRMX LF MRKR PTFE SHTH STPCK INFL DVC -,SUP-M0062101180,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1347.23,943.061,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CATH NEPH DIL 7FR 30FR BLN LPRO NPHRMX LF MRKR STPCK 20CM -,SUP-M0062101440,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1303.92,912.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CATH URET 4MM BLN 12FR INFL 3FR SHFT 150CM HYDRPLS CTD SS -,SUP-M0062181100,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1434.32,1004.024,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
PASSPORT BALLOON CATH 2CM -,SUP-M0062181200,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1540.27,1078.189,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CATH URET 5.8FRX4MM OD BLN 12FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251000,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1208.3,845.81,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
URO-MAX 2Q 4CM BALLOON KIT -,SUP-M0062251010,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1252.72,876.904,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CATH URET 5.8FRX10MM OD BLN 30FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251050,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1170.62,819.434,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
UROMAX 2/Q CATH 6CM 15FR SINGLE -,SUP-M0062251070,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1170.62,819.434,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CATH UROMAX U2Q\8-8 SINGLE -,SUP-M0062251100,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1170.62,819.434,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
UROMAX 2/Q CATH 10CM 15FR -,SUP-M0062251160,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1252.72,876.904,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CATH URET 5.8FRX6MM OD BLN 15FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251360,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1464.74,1025.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CATH URET 5.8FRX6MM OD BLN 18FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251370,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1384.17,968.919,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
APPLICATOR ENDO BLN US F /BF-UC16F-OL8 LTX STRL -,SUP-MAJ-1351,CDM,C1726,HCPCS,272,RC,,,outpatient,,,191.19,133.833,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CUFF BLN ADLT ENDO US F -,SUP-MAJ-249,CDM,C1726,HCPCS,272,RC,,,outpatient,,,157.36,110.152,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CATH ESPH 4.2MMX1CM SPC HI-RESOLTN CHNLX36 MANOSCAN -,SUP-MSC-1286,CDM,C1726,HCPCS,272,RC,,,outpatient,,,25903.5,18132.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CATHETER HEMOSTATIC BALLOON NEXPOWDER -,SUP-NHS03,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CATH ATHRCMY PERIPH CUT BLN 4MMX140MM OTW PERIPH -,SUP-PCB04015140F,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CATH PTCA 6MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-PCB6020135,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CATH PTCA 7X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-PCB702090,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
CATH PTCA 8X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-PCB802090,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.074675,18572.8095,other,SI=N Exclusions ,,
HERNIA BALLOON #OMS-PDBS2 -,SUP-OMS-PDBS2,CDM,C1727,HCPCS,272,RC,,,outpatient,,,1296.65,907.655,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,291.097925,929.69805,other,SI=N Exclusions ,,
CATH BRCHTX MULTLUM 4-5CM CONTURA STRL -,SUP-B01245,CDM,C1728,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,195.18479,8389.93965,other,SI=N Exclusions ,,
APPLICATOR BRCHTX MULTLUM 5-6CM BLN CONTURA STRL SUD -,SUP-B01256,CDM,C1728,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,195.18479,8389.93965,other,SI=N Exclusions ,,
CATH BRCHTX 5-6CM CONTURAFLEX LF -,SUP-B13256,CDM,C1728,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,195.18479,8389.93965,other,SI=N Exclusions ,,
CATH BRCHTX F/CVTY MNTN CONTURA -,SUP-B90012,CDM,C1728,HCPCS,272,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,195.18479,8389.93965,other,SI=N Exclusions ,,
TRY APPLICATOR BRCHTX SAVI 6-1 -,SUP-SAVI-06,CDM,C1728,HCPCS,272,RC,,,outpatient,,,9468.15,6627.705,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,195.18479,8389.93965,other,SI=N Exclusions ,,
APPLICATOR BRCHTX SGL-ENTRY MUL-CATH SAVI PREP -,SUP-SPC-01,CDM,C1728,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,195.18479,8389.93965,other,SI=N Exclusions ,,
CT/MR APPLICATOR W/BASE PLATE -,SUP-UNDEFINED,CDM,C1728,HCPCS,272,RC,,,outpatient,,,11701.45,8191.015,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,195.18479,8389.93965,other,SI=N Exclusions ,,
DRAIN PENROSE19MM 30CM 32MM FLAT -,SUP-00000,CDM,C1729,HCPCS,272,RC,,,outpatient,,,4.14,2.898,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH NEPH PEZ 28FR EYEX2 PRPRTN HEAD LTX MSHRM SHP -,SUP-064028,CDM,C1729,HCPCS,272,RC,,,outpatient,,,44.17,30.919,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH NEPH MLCT 14FR WNGX4 LTX -,SUP-086014,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.82,46.074,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH MALECOT 18FR BARD -,SUP-086018,CDM,C1729,HCPCS,272,RC,,,outpatient,,,49.29,34.503,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH MALECOT 20FR BARD -,SUP-086020,CDM,C1729,HCPCS,272,RC,,,outpatient,,,49.29,34.503,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH MALECOT 22FR BARD -,SUP-086022,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.06,45.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH MALECOT 24FR BARD -,SUP-086024,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.07,45.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH MALECOT 34FR PROPORTIONATE HEAD LATEX -,SUP-086034,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.07,45.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH NEPH MLCT 38FR WNGX4 LTX -,SUP-086038,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.06,45.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH NEPH MLCT 40FR WNGX4 LTX -,SUP-086040,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.89,45.423,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
24FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14024,CDM,C1729,HCPCS,272,RC,,,outpatient,,,123.9,86.73,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
28FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14028,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
32 FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14032,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
36FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14036,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH DRN 10.2FRX25CM SDPRTX6 COOK-COPE TY LCK LOOP -,SUP-192550,CDM,C1729,HCPCS,272,RC,,,outpatient,,,429.81,300.867,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH DRN 16FRX25CM SDPRTX6 COOK-COPE TY LCK LOOP -,SUP-193581,CDM,C1729,HCPCS,272,RC,,,outpatient,,,609.7,426.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH BIL DRN 12FRX40CM SDPRTX32 MA C -LOC LCK LOOP -,SUP-228702,CDM,C1729,HCPCS,272,RC,,,outpatient,,,545.51,381.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH DRN 12 FR X 25CM J-CRV THAL-QUICK PVC SDPRTX3 -,SUP-228707,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH DRN 14FRX25CM SDPRTX6 MA C -LOC LCK LOOP -,SUP-228709,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
TUBE VACUTNR 4ML GRN CAP NAHEP SAFTY PLST PPR LBL STRL HG-FR -,SUP-367871,CDM,C1729,HCPCS,272,RC,,,outpatient,,,0.94,0.658,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
THORACENTESIS TRAY/P4340A -,SUP-4340A,CDM,C1729,HCPCS,272,RC,,,outpatient,,,176.04,123.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
TRY THORCNTS 14GAX2IN L INTRO NDLX4 3WAY STP C LOCK BTRFLY -,SUP-4341B,CDM,C1729,HCPCS,272,RC,,,outpatient,,,228.45,159.915,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH VNTRC DRN 80CM TUOHY NDL FX TAB BLNT NDL STRN RLF OPN -,SUP-464-20,CDM,C1729,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
THORACENTESIS 30IN TUBING 4653 -,SUP-4653-48,CDM,C1729,HCPCS,272,RC,,,outpatient,,,23.96,16.772,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
SYS VNTRC DRN 35CM DUET W/ICP LN NDL-FR PRTX3 DRP CHMBR TBG -,SUP-469-13,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1120.58,784.406,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
SYS BAG VNTRC DRN REPL 35CM INTLNK NDL-FR INJ SITE -,SUP-469-14,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1120.58,784.406,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
KIT CSF DRAINAGE W CATH -,SUP-46916,CDM,C1729,HCPCS,272,RC,,,outpatient,,,2091.05,1463.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATHETER PLEURAL PLEURX KIT -,SUP-50-7000B,CDM,C1729,HCPCS,272,RC,,,outpatient,,,3841.3,2688.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH WORD BARTHOLIN GLAND 10FR 5CM -,SUP-564000,CDM,C1729,HCPCS,272,RC,,,outpatient,,,104.15,72.905,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATHETER THORACIC 28F STRAIGHT -,SUP-8028,CDM,C1729,HCPCS,272,RC,,,outpatient,,,35.56,24.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATHETER THORACIC 32FR STERILE -,SUP-8032,CDM,C1729,HCPCS,272,RC,,,outpatient,,,35.05,24.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATHETER THORACIC 36F STRAIGHT -,SUP-8036,CDM,C1729,HCPCS,272,RC,,,outpatient,,,35.88,25.116,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATHETER THORACIC 24FR RT ANGL -,SUP-8124,CDM,C1729,HCPCS,272,RC,,,outpatient,,,57.26,40.082,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATHETER THORACIC  32F RT ANGLE -,SUP-8132,CDM,C1729,HCPCS,272,RC,,,outpatient,,,54.52,38.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
DRAIN CATH LUMBAR KTXTRN DRN 0.76MM 1.65MMX46CM -,SUP-82-1706,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1526.54,1068.578,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH VNTRC DRN 1.5MM BCTSL EVD SIL 0.15% CLNDMCN -,SUP-82-1745,CDM,C1729,HCPCS,272,RC,,,outpatient,,,2522.1,1765.47,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
DRAIN PENROSE 5/8 WND 0.625X12IN GRVTY  FLT LTX -,SUP-8888515007,CDM,C1729,HCPCS,272,RC,,,outpatient,,,223.25,156.275,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH TROCAR 12FR ARGYLE -,SUP-8888561027,CDM,C1729,HCPCS,272,RC,,,outpatient,,,106.84,74.788,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH TROCAR 20FR X 16 ARGYLE -,SUP-8888561043,CDM,C1729,HCPCS,272,RC,,,outpatient,,,78.42,54.894,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH TROCAR 28FR X 16 ARGYLE -,SUP-8888561068,CDM,C1729,HCPCS,272,RC,,,outpatient,,,110.81,77.567,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
KT DRN 20FRX10IN ARGYLE PVC GLVX2 PREP SWB /CUPX2 FEN DRAPE -,SUP-8888565036,CDM,C1729,HCPCS,272,RC,,,outpatient,,,192.93,135.051,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATHETER TROCAR KIT 28 FR NSQ -,SUP-8888565044,CDM,C1729,HCPCS,272,RC,,,outpatient,,,199.28,139.496,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH THORACIC 12FR MAR -,SUP-8888570507,CDM,C1729,HCPCS,272,RC,,,outpatient,,,55.61,38.927,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATHETER THORACIC 16FR -,SUP-8888570515,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.3,26.81,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH THORACIC 16FR MAR -,SUP-8888570515,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.3,26.81,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH THORACIC 20FR MAR -,SUP-8888570523,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.68,27.076,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
"CATHETER THORACIC 20FR X 20"" RADIOPAQUE 5 EYELETS -",SUP-8888570523,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.69,27.083,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATHETER THORACIC 24FR -,SUP-8888570531,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.15,27.405,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH THORACIC 24FR MAR -,SUP-8888570531,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.18,27.426,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATHETER THORACIC 28FR -,SUP-8888570549,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.44,27.608,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH THORACIC 28FR MAR -,SUP-8888570549,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.44,27.608,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH THORACIC 32FR MAR -,SUP-8888570556,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.85,27.895,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATHETER THORACIC 32FR -,SUP-8888570556,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.85,27.895,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH THORACIC 36FR MAR -,SUP-8888570564,CDM,C1729,HCPCS,272,RC,,,outpatient,,,40.24,28.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATHETER THORACIC 36FR -,SUP-8888570564,CDM,C1729,HCPCS,272,RC,,,outpatient,,,40.26,28.182,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH THORACIC 40FR MAR -,SUP-8888570572,CDM,C1729,HCPCS,272,RC,,,outpatient,,,40.63,28.441,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
TUBE CHEST RIGHT ANGLE 28 -,SUP-8888571042,CDM,C1729,HCPCS,272,RC,,,outpatient,,,77.11,53.977,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH THORCNTS 18FRX20IN LT VNTRC -,SUP-8888590216,CDM,C1729,HCPCS,272,RC,,,outpatient,,,193.84,135.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
KIT LUMBAR DRAINAGE CATH -,SUP-910121,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1076.58,753.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH DISTAL ATRIAL PERITONEAL SOPHYSA -,SUP-B905S,CDM,C1729,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATHETER VENTRICULAR STR 1.3 X 2.5 MM (INCL IN ITEM 0154508) -,SUP-BO19-10,CDM,C1729,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
TRAY CHEST TUBE 10FR THAL QUICK LUMX1 SDPRTX3 18GA ECHOTIP -,SUP-C-TQTSY-1000,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1096.98,767.886,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH PERFUS 12FR STR PVC -,SUP-EM012,CDM,C1729,HCPCS,272,RC,,,outpatient,,,263.92,184.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
EVACUATOR TBG UNIV ELLIK -,SUP-ET,CDM,C1729,HCPCS,272,RC,,,outpatient,,,74.71,52.297,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
BILIARY DRAINAGE CATH 8.5FR. -,SUP-G09497,CDM,C1729,HCPCS,272,RC,,,outpatient,,,545.51,381.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH BIL DRN 10.2FRX40CM MAC-LOC SDPRTX32 MA C -LOC LCK LOOP -,SUP-G09498,CDM,C1729,HCPCS,272,RC,,,outpatient,,,545.51,381.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH DRN 8.5FRX25CM LCK LOOP -,SUP-G09501,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH DRN 10FR NEPHROSTOMY TUBE -,SUP-G09502,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH MP DRAINAGE 10.2F 45CM UL -,SUP-G09766,CDM,C1729,HCPCS,272,RC,,,outpatient,,,554.27,387.989,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH DRN 12FRX45CM BND SDPRTX6 MA C -LOC LCK LOOP -,SUP-G09767,CDM,C1729,HCPCS,272,RC,,,outpatient,,,554.27,387.989,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH DRN 6FR UNIV 25CM CRV SDPRTX3 -,SUP-G10956,CDM,C1729,HCPCS,272,RC,,,outpatient,,,539.68,377.776,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
SET COLON DECOMPRESION 14FR -,SUP-G22181,CDM,C1729,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
Set Fuhrman Pleural Pneumopericardial Drainage -,SUP-G55723,CDM,C1729,HCPCS,272,RC,,,outpatient,,,711.87,498.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
Tray Fuhrman Pleural Pneumopericardial Drainage -,SUP-G55724,CDM,C1729,HCPCS,272,RC,,,outpatient,,,968.61,678.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
UNIV. LOOP DRAINAGE SET 10FR -,SUP-G55802,CDM,C1729,HCPCS,272,RC,,,outpatient,,,887.5,621.25,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
UNIV.  LOOP DRAINAGE SET 14FR X 30 -,SUP-G55804,CDM,C1729,HCPCS,272,RC,,,outpatient,,,887.5,621.25,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
ST UNIVERSA MALEOCOT16FRX22CM BLN SS NDL OBTR CON TUBE 3ML -,SUP-G55825,CDM,C1729,HCPCS,272,RC,,,outpatient,,,307.21,215.047,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
TRAY WAYNE PNEUMOTHORAX CATHETER 14.0 FR 29 CM -,SUP-G56537,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1250.92,875.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH PERC DRN 8FRX25CM STD LOOP TIP EXODUS LF -,SUP-H965101431,CDM,C1729,HCPCS,272,RC,,,outpatient,,,511.85,358.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH DRN 10FRX20CM EXODUS LF -,SUP-H965101511,CDM,C1729,HCPCS,272,RC,,,outpatient,,,511.85,358.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATHETER DRN 8FRX25CM EXODUS TIGHT TIP LOOP -,SUP-H965104031,CDM,C1729,HCPCS,272,RC,,,outpatient,,,537.4,376.18,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH DRN 10FRX25CM EXODUS TIGHT TIP LOOP -,SUP-H965104111,CDM,C1729,HCPCS,272,RC,,,outpatient,,,537.4,376.18,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH MULTIPURPOSE 14FR  25CM STD ;OOP W/MARKER BAND -,SUP-H965105621,CDM,C1729,HCPCS,272,RC,,,outpatient,,,2440.88,1708.616,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
SYSTEM EXTERNAL DRAINAGE WITHOUT VENTRICULAR CATH ACCUDRAIN -,SUP-INS8401,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1401.56,981.092,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH NEPH 14FR VTC -,SUP-M001245290,CDM,C1729,HCPCS,272,RC,,,outpatient,,,570.95,399.665,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH DRN 6FRX25CM PIGTL FOGARTY LOOP -,SUP-M001271380,CDM,C1729,HCPCS,272,RC,,,outpatient,,,468.26,327.782,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH DRN MP 10FR UNIV 30CM LCK PIGTL HUB LOCK CANN NTNL NAVR -,SUP-NNU10LPT,CDM,C1729,HCPCS,272,RC,,,outpatient,,,661.69,463.183,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
DRAIN SURG 30CM 12FR UNIV NTNL PIGTL MP -,SUP-NNU12LPT,CDM,C1729,HCPCS,272,RC,,,outpatient,,,661.69,463.183,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATH DRN MP 8FR UNIV 30CM NTNL LCK PIGTL HUB LOCK CANN NAVR -,SUP-NNU8LPT,CDM,C1729,HCPCS,272,RC,,,outpatient,,,661.69,463.183,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
KIT PERICARDIOCENTESIS 6F PIGTAIL CATH -,SUP-PC101,CDM,C1729,HCPCS,272,RC,,,outpatient,,,542.95,380.065,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
KT PERICRDCTS PIGTL 8.3FRX40CM ACC LF -,SUP-PC801,CDM,C1729,HCPCS,272,RC,,,outpatient,,,676.86,473.802,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
VALVE POLARIS ADJ 30-200 SHUNT WITH ITEM BO19-10 INCL -,SUP-SPVA-2010,CDM,C1729,HCPCS,272,RC,,,outpatient,,,14425.01,10097.507,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
CATHETER FIXATION SYSTEM 8F -,SUP-TFK-08,CDM,C1729,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
TRAY THORACENTESIS PARACENTESIS -,SUP-TPT1000SP,CDM,C1729,HCPCS,272,RC,,,outpatient,,,195.82,137.074,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21103,10342.73217,other,SI=N Exclusions ,,
ELECTRODE PCNG 5FRX110CM BIPLR NON- HEP BND -,SUP-006173P,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1018.79,713.153,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions ,,
CATH QUAD  MARINR-MDT -,SUP-072322M,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1378.13,964.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions ,,
CATH EP P- TY CRV 5FR 2-8-2MM SPC 110CM DECAPL MP POLEX10 -,SUP-1085122RT,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1505.34,1053.738,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions ,,
CATH ACHIEVE ADVANCE 2ACH20 MAPPING -,SUP-2ACH20,CDM,C1730,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions ,,
CATH ACHIEVE ADVANCE 2ACH20 REPROCESS MAPPING -,SUP-2ACH20,CDM,C1730,HCPCS,272,RC,,,outpatient,,,2983.75,2088.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions ,,
CATH RESPONSE CRD -REPROC QUAD 6FR -,SUP-401226,CDM,C1730,HCPCS,272,RC,,,outpatient,,,185.14,129.598,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions ,,
CATH EP RESPONSE CRD-SJM QUAD 6FR -,SUP-401226,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions ,,
CATH EP RESPONSE JSN -SJM QUAD  6FR -,SUP-401227,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions ,,
CATH RESPONSE JSN-REPROC 6FR -,SUP-401227,CDM,C1730,HCPCS,272,RC,,,outpatient,,,185.14,129.598,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions ,,
CATH EP RESPONSE CRD-SJM  DECAPOLAR -,SUP-401305,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1081.3,756.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions ,,
CATH EP RESPONSE CSL-SJM 6FR  DECAPOLAR  STEER -,SUP-401381,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions ,,
CATH RESPONSE DEC CSL-REPROC -,SUP-401381,CDM,C1730,HCPCS,272,RC,,,outpatient,,,349.87,244.909,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions ,,
CATH EP SPRM JSPHSN CRV 6FR 2-5-2MM ELCTRD SPC 120CM FX QDPL -,SUP-401451,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions ,,
CATH EP LIVEWIRE MED SWEEP-REPROC DECAPOLAR -,SUP-401575,CDM,C1730,HCPCS,272,RC,,,outpatient,,,588.34,411.838,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions ,,
CATH EP LIVEWIRE MED SWEEP-SJM DECAPOLAR -,SUP-401575,CDM,C1730,HCPCS,272,RC,,,outpatient,,,2056.59,1439.613,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions ,,
CATH EP LIVEWIRE LRG SWP-SJM  QUAD STEERABLE  2-5-2 -,SUP-401606,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1876.38,1313.466,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions ,,
CATH LIVEWIRE QUAD STEERABLE REPROC -,SUP-401606,CDM,C1730,HCPCS,272,RC,,,outpatient,,,593.19,415.233,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions ,,
BIPOLAR PACING CATH BALLOON TIP 5 FR 110CM- PACEL REF:401763 -,SUP-401763,CDM,C1730,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions ,,
CATH  LIVEWIRE 7F DUO SUPER LRG CURL-REPROC 2/10 -,SUP-401904,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1154.02,807.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions ,,
CATH EP LIVEWIRE SUPER LRG CURL- SJM DECA 2-10-2 -,SUP-401904,CDM,C1730,HCPCS,272,RC,,,outpatient,,,4392.08,3074.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions ,,
CATH LIVEWIRE MED CRL-REPROC 2-2-2 NO SPACE -,SUP-401908,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1591.63,1114.141,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions ,,
CATH EP  LIVEWIRE EXTRA LGE CURL-SJM  DECAPL 2-5-2 -,SUP-401915,CDM,C1730,HCPCS,272,RC,,,outpatient,,,2258.01,1580.607,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions ,,
CATH EP LIVEWIRE EXTRA LGE CURL-REPROC  DECAPL 2-5-2 -,SUP-401915,CDM,C1730,HCPCS,272,RC,,,outpatient,,,612.91,429.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions ,,
CATH  LIVEWIRE DUO DEC SUPER LGE CURL-REPROC 2-8-2-60-2-8-2 -,SUP-401932,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1208.14,845.698,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions ,,
CATH EP LIVEWIRE LRG SWP -REPROC  QUAD STEER 5-5-5 NO SPACE -,SUP-401934,CDM,C1730,HCPCS,272,RC,,,outpatient,,,593.19,415.233,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions ,,
CATH EP LIVEWIRE LRG SWP -SJM  QUAD STEER 5-5-5 NO SPACE -,SUP-401934,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1876.38,1313.466,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions ,,
CATH RESPONSE CRD-2 REPROC 6FR -,SUP-402004,CDM,C1730,HCPCS,272,RC,,,outpatient,,,193.84,135.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions ,,
CATH EP SUPREME CRD-2 -SJM QUAD -,SUP-402004,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions ,,
INQUIRY STEERABLE  SJM EP CATH 6FR -,SUP-81102,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions ,,
CATH 20MM ACHIEVE MAPPING EP CRV 3.3FRX6MM SPC 165CM BIPLR -,SUP-990063020,CDM,C1730,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions ,,
MEDIGUIDE LV CATH MED SWEEP MODEL D402058 -,SUP-D402058,CDM,C1730,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions ,,
ADVISOR HD GRID MAPPING CATHETER D-AVHD-DF16 -,SUP-D-AVHD-DF-16,CDM,C1730,HCPCS,272,RC,,,outpatient,,,9090.65,6363.455,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions ,,
ADVISOR HD GRID MAPPING CATHETER D-AVHD-DF 16 REPRO -,SUP-D-AVHD-DF-16,CDM,C1730,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions ,,
EPSTAR CATHETER DCF-2-8-55-130 -,SUP-DCF-2-8-55-130,CDM,C1730,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions ,,
CATHETER INQUIRY STEER 4 FR DEC 1110-4-2-M IBI-81530 -,SUP-IBI-81530,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions ,,
CATH EP POLARISX270DG ANG 6FR 2.5-5-2.5MM SPC 105CM QDPL -,SUP-M0047003D0,CDM,C1730,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.56393,6517.99605,other,SI=N Exclusions ,,
BLAZER DX -20 CATHETER SUPERLARGE CURVE -,SUP-20SL2860,CDM,C1731,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,4619.19363,other,SI=N Exclusions ,,
CATH EP LIVEWIRE MED CURL-SJM  2-2-2 -,SUP-401908,CDM,C1731,HCPCS,272,RC,,,outpatient,,,4392.08,3074.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,4619.19363,other,SI=N Exclusions ,,
CATH EP LIVEWIRE SUPER LGE CURL-SJM 2-8-2-60-2-8-2 -,SUP-401932,CDM,C1731,HCPCS,272,RC,,,outpatient,,,4596.25,3217.375,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,4619.19363,other,SI=N Exclusions ,,
CATH EP REFLEXION SPIRAL SJM -,SUP-D402893,CDM,C1731,HCPCS,272,RC,,,outpatient,,,6442.39,4509.673,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,4619.19363,other,SI=N Exclusions ,,
CATH ABLT BLAZER D X-20 SUPER LRG 7FR SHFT 2-10-2MM SPC -,SUP-M00420SL21020,CDM,C1731,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,4619.19363,other,SI=N Exclusions ,,
CATH ACHIEVE ADVANCE 2ACH15 MAPPING -,SUP-2ACH15,CDM,C1732,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions ,,
CATH ACHIEVE ADVANCE 2ACH15 REPROCESS MAPPING -,SUP-2ACH15,CDM,C1732,HCPCS,272,RC,,,outpatient,,,2983.75,2088.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions ,,
CATH ACHIEVE ADVANCE 2ACH25  MAPPING -,SUP-2ACH25,CDM,C1732,HCPCS,272,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions ,,
SOFTWARE MED ENSITE FUSION REGST MOD XPD F/SEG CT -,SUP-75-05772-001,CDM,C1732,HCPCS,272,RC,,,outpatient,,,27847.5,19493.25,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions ,,
CATHETER PVAC GOLD - REF:990078 -,SUP-990078,CDM,C1732,HCPCS,272,RC,,,outpatient,,,25991,18193.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions ,,
CATH ABLT THERMOCOOL SF CARTO XP D-F CRV 8FR 2-5-2MM SPC -,SUP-BNI35DFH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,11324.65,7927.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions ,,
CATH ABLT THERMOCOOL SF NAV F-J CRV 8FR 2-5-2MM SPC 115CM -,SUP-BNI35FJH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,11324.65,7927.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions ,,
CATH EP LASSO NAV ECO D-TYP CRV 7FR 4FR LOOP 25-15MM 2-6-2MM -,SUP-D134301,CDM,C1732,HCPCS,272,RC,,,outpatient,,,7257.24,5080.068,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions ,,
CATH EP WEBSTER CS CS-D CRV 6FR 2-8-2MM SPC 115CM SGL-BRD -,SUP-D135303,CDM,C1732,HCPCS,272,RC,,,outpatient,,,2644.95,1851.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions ,,
CATH EP WEBSTER CS CS-F CRV 6FR2MM TIP 2-8-2MM SPC 115CM FX -,SUP-D135304,CDM,C1732,HCPCS,272,RC,,,outpatient,,,2014.19,1409.933,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions ,,
CATH ABLT NAVISTAR C F-TY CRV 7FR EP -,SUP-D17TCFLRT,CDM,C1732,HCPCS,272,RC,,,outpatient,,,7057.77,4940.439,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions ,,
POLARX FIT BALLOON CATHETER ST REF:M004CRBS2060 -,SUP-M004CRBS2060,CDM,C1732,HCPCS,272,RC,,,outpatient,,,14852,10396.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions ,,
POLARX FIT BALLOON CATHETER LT REF:M004CRBS2160 -,SUP-M004CRBS2160,CDM,C1732,HCPCS,272,RC,,,outpatient,,,14852,10396.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions ,,
CATH POLARMAP CIRCULAR DX MAPPING CATHETER REF:M004CRBS7210 -,SUP-M004CRBS7210,CDM,C1732,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions ,,
CATHETER INTELLANAV ST 7/110/2.5/7-4 QUAD STD -,SUP-M004R5031TH0,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions ,,
CATHETER INTELLANAV ST K2 7/110/2.5/7-4 QUAD -,SUP-M004R5031THK20,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions ,,
INTELLAMAP ORION CATHETER M004RC64S0 -,SUP-M004RC64S0,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions ,,
CATH ABLT NAVISTAR THERMOCOOL D-CRV 8FR 2-5-2MM SPC 115CM -,SUP-NI75TCDH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions ,,
CATH ABLT THERMOCOOL F-TY CRV 7.5FR 2-5-2MM SPC 115CM COOL -,SUP-NI75TCFH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions ,,
CATH ABLT NAVISTAR C D-TYP CRV 7FR 1-7-4MM SPC 4MM TIP 115CM -,SUP-NS7TCDL174HS,CDM,C1732,HCPCS,272,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions ,,
CATH ABLT NAVISTAR DS F-TY CRV 7FR 1-7-4MM SPC 8MM TIP 115CM -,SUP-NS7TCF8L174HS,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions ,,
CATH ABLT NAVISTAR F-TY CRV 7FR 1-7-4MM SPC 4MM TIP 115CM -,SUP-NS7TCFL174HS,CDM,C1732,HCPCS,272,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19966.6575,other,SI=N Exclusions ,,
CATH ABLT FREEZOR 4MM TIP MDT -,SUP-207F3,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
CATH CRYABL FREEZOR MAX CRV 9FR 3-5-2MM SPC 90CM STEER BIDIR -,SUP-209F3,CDM,C1733,HCPCS,272,RC,,,outpatient,,,9124.6,6387.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
CATH ABLT FREEZOR XTRA 6MM 7FR 2-5-2MM SPC 108CM -,SUP-217F3,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
CATH ABLT FREEZOR XTRA LG CURVE 6MM 7FR REF:217F5 -,SUP-217F5,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
CATH CRYABL ARCTIC FRN 23MM STEER BIDIR EP -,SUP-2AF234,CDM,C1733,HCPCS,272,RC,,,outpatient,,,16337.2,11436.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
CATH CRYABL ARCTIC FRN 28MM STEER BIDIR EP -,SUP-2AF284,CDM,C1733,HCPCS,272,RC,,,outpatient,,,16337.2,11436.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
CATH ESPH ABLT 18MM 360DG ELCTRD ARRAY 85CM BARRX RF -,SUP-32041-18,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8339.46,5837.622,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
CATH PCNG 5FRX2.5CM SPC 110CM PACEL TEMP BIPLR 60DG CRV RT -,SUP-401775,CDM,C1733,HCPCS,272,RC,,,outpatient,,,513.48,359.436,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
CATH ABLT SAFIRE MED SWP 7FR 2-5-2MM SPC 115CM QDPL BIDIR -,SUP-402807,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3010.01,2107.007,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
CATH ABL SAFIRE LRG SWP 7FR -,SUP-402808,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3208.13,2245.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
CATH SAFIRE 7F 4MM SM CRL US -,SUP-402809,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3010.01,2107.007,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
CATH ABLT SAFIRE MED CURL 7FR 2-5-2MM SPC 115CM 7MM BIDIR -,SUP-402810,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3208.13,2245.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
CATH ABLT SAFIRE LRG CRV 7FR 2-5-2MM SPC 115CM QDPL BIDIR -,SUP-402811,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3208.13,2245.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
CATH ABLT SAFIRE LRG CRV 7FR 2-5-2MM 115CM 5MM QDPL BIDIR -,SUP-402817,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3232,2262.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
CATH SAFIRE TX  MED 7F 8 MM BI-DIR -,SUP-402839,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4501.88,3151.316,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
CATH SAFIRE TX  LRG  BI-DIR  7F 8MM -,SUP-402840,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4501.88,3151.316,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
FARAWAVE PFA CATHETER REF:41C601 -,SUP-41C601,CDM,C1733,HCPCS,272,RC,,,outpatient,,,25062.75,17543.925,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
FARAWAVE PFA CATHETER 35MM REF:41C602 -,SUP-41C602,CDM,C1733,HCPCS,272,RC,,,outpatient,,,25062.75,17543.925,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
CATHETER BARRX RFA EXPRESS RFA BALLOON -,SUP-64082,CDM,C1733,HCPCS,272,RC,,,outpatient,,,10218.18,7152.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
CATH ABLT THRP 7FR 2-5-2 MMMEDX110CM 4MM -,SUP-83365,CDM,C1733,HCPCS,272,RC,,,outpatient,,,2491.24,1743.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
CATH ABLT THRP 7FR 2-5-2 MMX110CM 4MM -,SUP-83366,CDM,C1733,HCPCS,272,RC,,,outpatient,,,2634.35,1844.045,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
CATH ABLT THRP 2-5-2 MMMEDX110CM DL -8 -,SUP-83371,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
CATH ABLT THRP 7FR MED 8MM DL -,SUP-83372,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3542.31,2479.617,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
CATH ABLT THRP DL -8 EXTEND REACH CRV 7FR 2-5-2MM SPC 110CM -,SUP-83374,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
CATHETER BARRX FOCAL 90 RFA 20MMX 13MM -,SUP-90-9100,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8492.24,5944.568,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
CATHETER BARRX FOCAL 90 RFA 40MM X 13MM -,SUP-90-9500,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7469.44,5228.608,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
CATH ABLT SAFIRE BLU LRG CURL DIST REACH CRV 7FR 2-5-2MM SPC -,SUP-A088109,CDM,C1733,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
CATH CRYABL ARCTIC FRN ADVANCED PRO 28MM STEER BIDIR EP -,SUP-AFAPRO28,CDM,C1733,HCPCS,272,RC,,,outpatient,,,16337.2,11436.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
FLEXABILITY SENSOR ENABLED BI DIR IRR CATH FJ CURVE -,SUP-A-FASE-FJ,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8190.92,5733.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
CATH 7F D/F BI-DIRECT CS REPROC -,SUP-BD710DF282RTS,CDM,C1733,HCPCS,272,RC,,,outpatient,,,1132.05,792.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
CATH ABLT WEBSTER EZ STEER D-F ASYM CRV 7FR 2-8-2MM SPC -,SUP-BD710DF282RTS,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3547.08,2482.956,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
CATH CV 7FRX3CM SIL CLSR FST LF ACC -,SUP-CF7-3-60,CDM,C1733,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
CATH ELCSURG 7FRX60CM RF FLXB CLSR FST -,SUP-CF7-7-60,CDM,C1733,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
AGILLIS NXT STEERABLE INTRO DUAL-REACH REF: I-V2-MED -,SUP-I-V2-MED,CDM,C1733,HCPCS,624,RC,,,outpatient,,,5.89,4.123,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,4.99,1.322305,17969.99175,percent of total billed charges,,,
CATH ABLT BLAZER II STD CRV 7FRX2.5MM SPC 4MM TIP QDPL DIST -,SUP-M0045031TH0,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
CATH ABLT BLAZER II STD CRV 7FRX2.5MM SPC QDPL EXTEND DIST -,SUP-M0045086TL0,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
CATH ABLT BLAZER PRIM XP LRG CRV 8MM TIP QDPL EP -,SUP-M004P4500THK20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7427,5198.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
CATH ABLT BLAZER PRIM XP STD CRV STR 7FR 8FR TIP 2.5MM SPC -,SUP-M004P4790TH0,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7639.2,5347.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
CATH ABLT BLAZER PRIM XP LRG CRV 10mm  8FRX2.5MM SPC 110CM -,SUP-M004P4790THK20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7639.2,5347.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
CATH ABLT BLAZER PRIM HTD ASYM CRV 7FRX2.5MM SPC 110CM QDPL -,SUP-M004P5031THN40,CDM,C1733,HCPCS,272,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
CATH ABLT INTELLATIP MIFI XP STD CRV STR 7FR 8FR TIP 2.5MM -,SUP-M004PM45000,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
CATH ABLT INTELLATIP MIFI XP LRG CRV STR 7FR 8FR TIP 2.5MM -,SUP-M004PM4500K20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
CATHETER INTELLANAV MIFI OI 7.5/110/2.5.4.5 STD -,SUP-M004PMR96200,CDM,C1733,HCPCS,272,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
CATHETER INTELLANAV MIFI K2 OI 7.5/110/2.5/4.5 -,SUP-M004PMR9620K20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
PULSESELECT PFA LOOP CATHETER REF: PSCC100 -,SUP-PSCC100,CDM,C1733,HCPCS,272,RC,,,outpatient,,,23763.2,16634.24,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.322305,17969.99175,other,SI=N Exclusions ,,
VOLT PFA CATHETER REF: P-SPI-DF8 -,SUP-VOLT PFA CATHETER REF: P-SPI-DF8,CDM,C1733,HCPCS,624,RC,,,outpatient,,,5.89,4.123,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,4.99,1.322305,17969.99175,percent of total billed charges,,,
CATHETER 27CM GLIDEPATH LONG TERM HEMO -,SUP-5393270,CDM,C1750,HCPCS,278,RC,,,outpatient,,,2210.31,1547.217,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions ,,
CATH HMDLYS HEMOSPLIT 14.5FRX31CM -,SUP-5733310,CDM,C1750,HCPCS,278,RC,,,outpatient,,,2390.53,1673.371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions ,,
CATH SHNT 1.2X2.5MM HLTR 65CM SIL RBR T-SHP 1PC -,SUP-82-1699,CDM,C1750,HCPCS,278,RC,,,outpatient,,,2533.64,1773.548,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions ,,
CATH PERITONEALTENCKHOFF42CM -,SUP-8810888003,CDM,C1750,HCPCS,278,RC,,,outpatient,,,255.92,179.144,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions ,,
CATH TENCKHOFF 15FRX62CM -,SUP-8811313010,CDM,C1750,HCPCS,278,RC,,,outpatient,,,366.38,256.466,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions ,,
KIT CATHETER PERITONEAL DIALYSIS ARGYLE 62CM SILICONE CURLED -,SUP-8817278006,CDM,C1750,HCPCS,278,RC,,,outpatient,,,450.39,315.273,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions ,,
KT DLYS 60CM CURL STYL 60CM PREPERITONEIAL CUF CLMP ADPTR -,SUP-8817278010,CDM,C1750,HCPCS,278,RC,,,outpatient,,,537.58,376.306,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions ,,
KT HMDLYS PRMCTH 36CM SIL RBR LUMX2 -,SUP-8817748001,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1012.58,708.806,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions ,,
CATH HMDLYS MHRKR 11.5FRX16CM PU ACUTE LUMX2 ACC -,SUP-8817749001,CDM,C1750,HCPCS,278,RC,,,outpatient,,,923.47,646.429,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions ,,
CATH HMDLYS PALINDROME 14.5FRX19CM -,SUP-8888119360P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1259.4,881.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions ,,
KIT CATHETER PALINDROME 14.5FR X 19CM -,SUP-8888145014P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions ,,
KIT CATHETER PALINDROME 14.5FR X 23CM -,SUP-8888145015P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions ,,
KIT CATHETER PALINDROME 14.5FR X 28CM -,SUP-8888145016P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions ,,
KIT CATHETER PALINDROME 14.5FR X 33CM -,SUP-8888145042P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions ,,
STENCIL PERITONEAL DIALYSIS RITUS PRE-OPERATIVE -,SUP-8888412305,CDM,C1750,HCPCS,278,RC,,,outpatient,,,55.72,39.004,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions ,,
KIT CATHETER PERITONEAL DIALYSIS ARGYLE 62.5CM SILICONE -,SUP-8888413823,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1150.95,805.665,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions ,,
KT HMDLYS PALINDROME 15FRX43CM CRBTHN ACC -,SUP-8888541023P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1612.03,1128.421,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions ,,
KT HMDLYS PALINDROME 15FRX48CM CRBTHN ACC -,SUP-8888541028P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1612.03,1128.421,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions ,,
CATH TESIO LEFT BFL-6 -,SUP-BFL-6,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1595.45,1116.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions ,,
CATH HMDLYS BFL TSO 10FR 22CM/25CM CUF -,SUP-BFR-6,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1690.86,1183.602,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions ,,
ST HMDLYS TESIO 10FRX52CM PU LUMX2 INTRO NDL GW TUNNLER -,SUP-BFR-6E,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1881.68,1317.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions ,,
CATH ARROW NEXT STEP 23CM HEMODIALYSIS -,SUP-CS-15232-X,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1436.44,1005.508,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions ,,
CATH ARROW NEXT STEP 27CM HEMODIALSIS -,SUP-CS-15272-X,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1436.44,1005.508,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions ,,
CATHETER KIT DIALYSIS 15FR ARROW -,SUP-CS-15282-SPM,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.50914,1945.83552,other,SI=N Exclusions ,,
HC Try Cv Lumx3 5fr Triple Powerpicc Acc,PX-27200312,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1544,1080.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
HC Needle Provena 4fr Dl Picc 4fr Dl Max Barrier,PX-27200313,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1417,991.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
HC Needle Provena 4fr Dl Provena Midline Max Barrier,PX-27200314,CDM,C1751,HCPCS,272,RC,,,outpatient,,,967,676.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
HC Cath Cv Lumx2 4frx20 Cm Dual Mdln,PX-27200315,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1012,708.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
HC Needle Provena 3fr Sl Provena Midline Max Barrier,PX-27200316,CDM,C1751,CPT,272,RC,,,outpatient,,,831,581.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
KIT URETERAL IRIS INFRARED -,SUP-0220180518,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1863.01,1304.107,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
TRY CV LUMX2 9FRX90CM SIL PED HKMN LF ACC -,SUP-0600604,CDM,C1751,HCPCS,272,RC,,,outpatient,,,2291.14,1603.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH SWAN GANZ TD 6FR X 110 - 096F6P -,SUP-096F6P,CDM,C1751,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH GUIDE ECHELON 14 MICRO STR AIGHT REF:105-5092-150 -,SUP-105-5092-150,CDM,C1751,HCPCS,272,RC,,,outpatient,,,4838.16,3386.712,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
TRY CV LUMX1 4FR PU POWERPICC LF ACC SINGLE -,SUP-1174108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1252.61,876.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
5FR POWERPICC TRAY CV LUMX2 DBL PU  LF ACC -,SUP-1275108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1232.53,862.771,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH SWAN GANZ TD 7FR 131F7P -,SUP-131F7P,CDM,C1751,HCPCS,272,RC,,,outpatient,,,501.81,351.267,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATHETER IV JELCO PROTECTIV 24G X 3/4IN YELLOW -,SUP-305306,CDM,C1751,HCPCS,272,RC,,,outpatient,,,12.2,8.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATHETER IV WINGED HUB PEDI 24G X 5/8â€ PERIPHERAL RADIOPAQUE -,SUP-307300,CDM,C1751,HCPCS,272,RC,,,outpatient,,,11.94,8.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
TRY CV LUMX1 5FRX55CM PU POWERPICC LF ACC -,SUP-3175155,CDM,C1751,HCPCS,272,RC,,,outpatient,,,456.94,319.858,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH IV PROT 22GAX1IN FEP PLYMR SAFTY STR HUB WNG INDWL VPNT -,SUP-326010,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.66,7.462,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH IV PROTECTIVE 22 X 1 -,SUP-326010,CDM,C1751,HCPCS,272,RC,,,outpatient,,,12.05,8.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH IV PROTECTIVE 24 X 3/4 RA -,SUP-326310,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.68,7.476,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH IV PROT 24GAX.75IN FEP PLYMR SAFTY STR HUB WNG INDWL -,SUP-326310,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.68,7.476,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH IV PROT 20GAX1IN FEP PLYMR SAFTY STR HUB WNG INDWL VPNT -,SUP-326710,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.28,6.496,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH IV PROTECTIVE 20 X 1 -,SUP-326710,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.28,6.496,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH IV 14GA X 1.25 IN VIAVALVE -,SUP-3268,CDM,C1751,HCPCS,272,RC,,,outpatient,,,12.05,8.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
TRY CV LUMX2 5FRX55CM PU POWERPICC LF ACC -,SUP-3275335,CDM,C1751,HCPCS,272,RC,,,outpatient,,,602.11,421.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH IV ANGIOCATH 14 X 1.88 -,SUP-381167,CDM,C1751,HCPCS,272,RC,,,outpatient,,,22.71,15.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH IV 24G X .56 IN INSYTE BD -,SUP-381411,CDM,C1751,HCPCS,272,RC,,,outpatient,,,14.41,10.087,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH IV INSYT AUTOGRD 20GAX48MM VIALON SAFTY WNG INDWL BLD -,SUP-381437,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.86,6.902,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH IV 20G X 1.88 IN INSYTE BD -,SUP-381437,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.86,6.902,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH IV 14G X 1.75 IN INSYTE BD -,SUP-381467,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.87,6.909,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH IV 24G X .56 IN INSYTE BD -,SUP-381511,CDM,C1751,HCPCS,272,RC,,,outpatient,,,14.42,10.094,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH IV 22G x 1 IN INSYTE AUTOGUARD BC -,SUP-382523,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.12,7.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH IV 16G X 1.16 IN INSYTE BD -,SUP-382554,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.86,6.902,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH IV SAF-T-INTIMA 23GAX0.75IN VIALON SAFTY WNG INDWL -,SUP-383323,CDM,C1751,HCPCS,272,RC,,,outpatient,,,20.11,14.077,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH IV SAF-T-INTIMA 20GAX1IN VIALON SAFTY WNG INDWL SLFBNT -,SUP-383336,CDM,C1751,HCPCS,272,RC,,,outpatient,,,19.62,13.734,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH IV 24G X .75 IN NEXIVA BD -,SUP-383511,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH IV 22GA X 1 IN NEXIVA BD -,SUP-383512,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH IV 20GA X 1 IN NEXIVA BD -,SUP-383516,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH IV 18GA X 1.25 IN NEXIVA BD -,SUP-383519-A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
ST NEEDLE INFS 24GAX0.75IN NEXIVA SAFTY LRG BORE WNG DL PRT -,SUP-383531,CDM,C1751,HCPCS,272,RC,,,outpatient,,,31.28,21.896,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
KT ARTERIAL LN 20GAX20CM 1ST MI D CATH MDLN SFN -,SUP-384304,CDM,C1751,HCPCS,272,RC,,,outpatient,,,468.67,328.069,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATHETER IV 16 X 2 SFR -,SUP-4082,CDM,C1751,HCPCS,272,RC,,,outpatient,,,11.6,8.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH IV 14 X 2.25in JELCO -,SUP-4088,CDM,C1751,HCPCS,272,RC,,,outpatient,,,20.36,14.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
TRY MIDLINE CATH 4FR 18GA LUM LUMX1 LF -,SUP-4154108,CDM,C1751,HCPCS,272,RC,,,outpatient,,,526.32,368.424,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
TRY CV LUMX1 4FR PU LF ACC -,SUP-4154108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1151.36,805.952,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH IV INTROCAN SAFTY 20GAX1.75IN FEP POYMER SAFTY STR HUB -,SUP-4252527-02,CDM,C1751,HCPCS,272,RC,,,outpatient,,,7.39,5.173,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH IV INTROCAN SAFTY 18GAX2.5IN TFLN FEP PLYMR SAFTY STR -,SUP-4252561-02,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.22,6.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH CV 5FRX8CM POWERWAND PWR-INJ MDLN QCK CHRNFLX C -,SUP-72135,CDM,C1751,HCPCS,272,RC,,,outpatient,,,811.07,567.749,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
PICC LINE CHANGE KIT IVAD ACCE -,SUP-73240B,CDM,C1751,HCPCS,272,RC,,,outpatient,,,17.27,12.089,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
PORT INFS 8FR 1LUM -,SUP-7711802,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1505.34,1053.738,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH PA 8FRX110CM SWAN-GNZ C CMB VOL LUMX7 INJ PRT ANTMIC -,SUP-777HF8,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1446.77,1012.739,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
SWAN-GANZ VIP/ OXIMETRY THERMOD CATHETER -,SUP-782F75M,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1519.92,1063.944,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
KT IT F/LEGEND SYNCHROMED INFS PMP RPR -,SUP-8590-9,CDM,C1751,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
TRY CV LUMX1 4FRX60CM PU POLY P-Q-CTH LF ACC -,SUP-9154108,CDM,C1751,HCPCS,272,RC,,,outpatient,,,908.45,635.915,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
TRY CV LUMX1 4FR STD 55CM PU POWERPICC LF ACC -,SUP-9174108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1953.71,1367.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH CV 5FRX10CM POWERWAND PWR-INJ MDLN CHRNFLX C -,SUP-92006,CDM,C1751,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
TRY CV LUMX2 5FRX60CM PU POLY P-Q-CTH LF ACC -,SUP-9255108,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1040.96,728.672,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH PA 7.5FRX110CM SWAN-GNZ PCNG LUMX5 AMC THRMBSHLD HPCT -,SUP-931HF75,CDM,C1751,HCPCS,272,RC,,,outpatient,,,303.24,212.268,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
TRY CV LUMX3 6FR STD 55CM PU POWERPICC LF ACC -,SUP-9386108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,2085.78,1460.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH PA 8FRX110CM SWAN-GNZ A-V PCNG LUMX6 INJ PRT ANTMIC AMC -,SUP-991HF8,CDM,C1751,HCPCS,272,RC,,,outpatient,,,787.2,551.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
"ACCUCATH 22G 1.25"" BASIC KIT -",SUP-AC0221250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,133.27,93.289,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
KIT CATHETER ACCUCATH ACE 18G 2.25 BASIC -,SUP-AC1182250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,254.41,178.087,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
"ACCUCATH 20G 1.25"" BASIC KIT -",SUP-AC1201250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,133.27,93.289,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
ACCUCATH ACE 20G X 2.25IN BASIC KIT -,SUP-AC1202250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,254.41,178.087,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH PRSS MONTR BLN WDG 5FR -,SUP-AI-07124,CDM,C1751,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH A-LN BLN WDG LUMX2 6FRX110CM PA INDWL 1ML CTRL STRK SYR -,SUP-AI-07126,CDM,C1751,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH PA 6FRX110CM BLN -,SUP-AI-07365-NHL,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
ST ARTERIAL CATH 20GAX1.75IN SHRP SAFTY LF -,SUP-AK-04020-SPC,CDM,C1751,HCPCS,272,RC,,,outpatient,,,145.29,101.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
KT A-LN 20GAX5IN PA INDWL 0.25IN SPR STR SFT TIP JTP GW -,SUP-AK-04510-S,CDM,C1751,HCPCS,272,RC,,,outpatient,,,164.55,115.185,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
KIT CENTRAL VENOUS TWO LUMEN -,SUP-AK-11142-D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,568.91,398.237,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
KT CV LUMX2 4FRX8CM PU ARROW G+ARD LF ACC -,SUP-AK-25402,CDM,C1751,HCPCS,272,RC,,,outpatient,,,431.79,302.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
FEMORAL ARTERY CATH KIT  5FR REF: G58398 -,SUP-APM-5.0-35J-1-15-NY,CDM,C1751,HCPCS,272,RC,,,outpatient,,,259.07,181.349,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
KIT CATH TRIPLE LUMEN 20CM CEN -,SUP-ASK-45703-PSCH,CDM,C1751,HCPCS,272,RC,,,outpatient,,,847.94,593.558,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
KT CV MULTLUM 20CM ARROW G+ARD LF ACC -,SUP-ASK-45703-PSCH,CDM,C1751,HCPCS,272,RC,,,outpatient,,,847.94,593.558,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
KT CV LUMX3 7FRX16CM PU ARW HWS LF ACC -,SUP-CDC-12703-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,352.9,247.03,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
KT CV LUMX3 7FRX20CM PU ARW HWS LF ACC -,SUP-CDC-15703-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,408.63,286.041,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
KT CV LUMX1 16GAX20CM PU ARROW G+ARD LF ACC -,SUP-CDC-24301-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,395.61,276.927,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
KT CV LUMX1 16GAX20CM PU ARROW G+ARD LF ACC -,SUP-CDC-24301-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,395.61,276.927,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
ARROW PEDI CENTRAL LINE KIT 13CM -,SUP-CDC-24402-X1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,754.66,528.262,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
SWAN -GANZ TEMP PACR STR EDWARDS -,SUP-D97120F5,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1130.07,791.049,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
SWAN-GANZ BIPOLAR PACING CATH J-TIP 5 FR 90CM -,SUP-D97130F5,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1130.07,791.049,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH PERFUS 20FRX.25IN ACPT 6CM PRFX STR PVC -,SUP-E063,CDM,C1751,HCPCS,272,RC,,,outpatient,,,239.59,167.713,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
ST ARTERIAL CATH 18GAX4.25IN LF -,SUP-FA-04018,CDM,C1751,HCPCS,272,RC,,,outpatient,,,81.46,57.022,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CENTRAL VENOUS CATHETER TRAY 4.0FR -,SUP-G02138,CDM,C1751,HCPCS,272,RC,,,outpatient,,,245.65,171.955,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH INFS 3FR STR 135CM SLIP-CATH NYL SS HYDRCT 0.025IN GW -,SUP-G12044,CDM,C1751,HCPCS,272,RC,,,outpatient,,,283,198.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH INFS 3FR STR 150CM SLIP-CATH NYL SS HYDRCT 0.025IN GW -,SUP-G12045,CDM,C1751,HCPCS,272,RC,,,outpatient,,,283,198.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
KT BLOOD GS ART 182CM CHMBR IV SPK 3W STPCKX2 122IN PRESSMNT -,SUP-H965700361481,CDM,C1751,HCPCS,272,RC,,,outpatient,,,164.55,115.185,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH INFS 4FRX135CM 10CM INFS ACCESSPLUS VLV PEBAX OCL WIRE -,SUP-IS4-135-10,CDM,C1751,HCPCS,272,RC,,,outpatient,,,793.56,555.492,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH INFS 4FRX135CM 20CM INFS ACCESSPLUS VLV PEBAX OCL WIRE -,SUP-IS4-135-20,CDM,C1751,HCPCS,272,RC,,,outpatient,,,793.56,555.492,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
KT INTRAVENOUS CATH 20GAX8CM POWERGLIDE LF -,SUP-M020081,CDM,C1751,HCPCS,272,RC,,,outpatient,,,493.06,345.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
KT INTRAVENOUS CATH 20GAX10CM POWERGLIDE -,SUP-M020101,CDM,C1751,HCPCS,272,RC,,,outpatient,,,493.06,345.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH VASC ACCESS 3FR LUMX1 MDLN PU PRELD STYL INTRO GW SYR -,SUP-ML3S20FN,CDM,C1751,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH CV LUMX1 4FRX200CM SINGLE MDLN -,SUP-MLCT4S20FN,CDM,C1751,HCPCS,272,RC,,,outpatient,,,805.52,563.864,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH PICC LUMX1 6FR PWR PICC -,SUP-MR17036306MB,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1081.3,756.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
ARTERIAL CATHETERIZATION KIT 20G -,SUP-NA-04550-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,303.42,212.394,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH CV LUMX2 4FRX20 CM DUAL MDLN -,SUP-P4254108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,982.38,687.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH RADIAL ARTERY 20G -,SUP-RA-04020,CDM,C1751,HCPCS,272,RC,,,outpatient,,,55.96,39.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
CATH SET RADIAL ARTERY 20GX1.5 -,SUP-RA-04220,CDM,C1751,HCPCS,272,RC,,,outpatient,,,70.49,49.343,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
SET RAPID INFUSION 7FR CATHETER EXCHANGE -,SUP-RC-09700,CDM,C1751,HCPCS,272,RC,,,outpatient,,,61.73,43.211,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
SET RAPID INFUSION 8.5FR CATHETER EXCHANGE -,SUP-RC-09850,CDM,C1751,HCPCS,272,RC,,,outpatient,,,59.52,41.664,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
STYLET ELCSURG 6FRX12CM RF D MRKNG CLOSURERFS -,SUP-RFS2612,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1908.18,1335.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
TRY CV LUMX3 5FR TRIPLE  POWERPICC ACC -,SUP-S1385108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1499.41,1049.587,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
MULTI-LUMEN VENOUS CATH 8FR -,SUP-SS-14703,CDM,C1751,HCPCS,272,RC,,,outpatient,,,187.89,131.523,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
C 6FR TRIPLE LUMEN PICC -,SUP-UNDEFINED,CDM,C1751,HCPCS,272,RC,,,outpatient,,,669.86,468.902,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.659055,3468.96072,other,SI=N Exclusions ,,
KT HMDLYS PWR TRIALYSIS 13FRX20CM LUMX3 SHRT TERM -,SUP-5603200,CDM,C1752,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.92327,4457.91882,other,SI=N Exclusions ,,
TRY HMDLYS PWR TRIALYSIS 13FRX15CM PU ACUTE SHRT TERM LUMX3 -,SUP-5605150,CDM,C1752,HCPCS,272,RC,,,outpatient,,,6217.46,4352.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.92327,4457.91882,other,SI=N Exclusions ,,
KT HMDLYS PWR -TRIALYSIS 13FRX20CM SHRT TERM LUMX3 ACC -,SUP-5605200,CDM,C1752,HCPCS,272,RC,,,outpatient,,,6217.46,4352.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.92327,4457.91882,other,SI=N Exclusions ,,
KT HMDLYS PWR -TRIALYSIS 13FRX20CM SHRT TERM LUMX3 ACC -,SUP-5605200,CDM,C1752,HCPCS,272,RC,,,outpatient,,,1553.05,1087.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.92327,4457.91882,other,SI=N Exclusions ,,
KT HMDLYS PWR -TRIALYSIS 13FRX15CM SHRT TERM LUMX3 ACC -,SUP-5613150,CDM,C1752,HCPCS,272,RC,,,outpatient,,,1372.83,960.981,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.92327,4457.91882,other,SI=N Exclusions ,,
MAHUKAR CATH DUAL 19FR. -,SUP-8813793009,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.92327,4457.91882,other,SI=N Exclusions ,,
MAHUKUR CATH DUAL 10 FR. -,SUP-8817146007,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.92327,4457.91882,other,SI=N Exclusions ,,
KT HMDLYS MHRKR 11.5FR LNG EXTEND 16CM LUMX2 ACUTE ACC -,SUP-8830415001,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.92327,4457.91882,other,SI=N Exclusions ,,
TRY HMDLYS MHRKR 11.5FRX24CM PU 1% 5ML LIDOCN LUMX2 ACC -,SUP-8831663001,CDM,C1752,HCPCS,272,RC,,,outpatient,,,443.65,310.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.92327,4457.91882,other,SI=N Exclusions ,,
CATH MAHURKAR CURVED 12FR 16CM -,SUP-8888101002HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,553.17,387.219,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.92327,4457.91882,other,SI=N Exclusions ,,
MAHURKER CATH DUAL 13.5 FR. -,SUP-8888135192,CDM,C1752,HCPCS,272,RC,,,outpatient,,,415.92,291.144,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.92327,4457.91882,other,SI=N Exclusions ,,
MAHURKAR STRAIGHT CATH KIT 12FR -,SUP-8888221220,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.92327,4457.91882,other,SI=N Exclusions ,,
TRY MHRKR ELITE ACUTE 12FRX20CM -,SUP-8888233420,CDM,C1752,HCPCS,272,RC,,,outpatient,,,859.55,601.685,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.92327,4457.91882,other,SI=N Exclusions ,,
KT HMDLYS MHRKR 12FRX20CM PU LUMX3 ACUTE ACC -,SUP-8888340629HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,471.37,329.959,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.92327,4457.91882,other,SI=N Exclusions ,,
KIT HEMODIALYSIS MAHURKAR 12FRX24CM PU LUMX3 ACUTE ACC -,SUP-8888340637HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,489.29,342.503,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.92327,4457.91882,other,SI=N Exclusions ,,
KT HMDLYS MHRKR 12FRX16CM PU LUMX3 ACUTE ACC -,SUP-8888345611HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,471.37,329.959,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.92327,4457.91882,other,SI=N Exclusions ,,
KT HEMODIALYSIS MHRKR TLC- C E 12FRX20CM LF -,SUP-8888345637,CDM,C1752,HCPCS,272,RC,,,outpatient,,,499.18,349.426,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.92327,4457.91882,other,SI=N Exclusions ,,
KT HMDLYS 12FR PU LUMX3 ACUTE ACC CVD -,SUP-8888345637HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,471.37,329.959,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,80.92327,4457.91882,other,SI=N Exclusions ,,
IVUS 0.014P RX CATHETER -,SUP-014R,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7720.4409,other,SI=N Exclusions ,,
CATH US 8FRX90CM ACUNAV 4W STEER -,SUP-10135936,CDM,C1753,HCPCS,272,RC,,,outpatient,,,10767.7,7537.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7720.4409,other,SI=N Exclusions ,,
CATH DRAGONFLY OPSTAR REF: 1014651 -,SUP-1014651,CDM,C1753,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7720.4409,other,SI=N Exclusions ,,
CATH US 5FR20MM IMG TAPR 150CM EAGLE EYE GOLD OTW COR PERIPH -,SUP-85900,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7720.4409,other,SI=N Exclusions ,,
CATH US EAGLE EYE PLATINUM REF: 85900P -,SUP-85900P,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7720.4409,other,SI=N Exclusions ,,
CATH US 5FR ID 20MM STR 150CM EAGLE EYE RX COR GLYDX PLTNM -,SUP-85900P,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7720.4409,other,SI=N Exclusions ,,
CATH US EAGLE EYE PLTNM SHORT TIP -,SUP-85900PST,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7720.4409,other,SI=N Exclusions ,,
CATH VISIONS PV 0.018 -,SUP-86700,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7720.4409,other,SI=N Exclusions ,,
C VOLCANO IVUS PV035 -,SUP-88901,CDM,C1753,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7720.4409,other,SI=N Exclusions ,,
CATH DX VIEWFLEXX ICE 4W -,SUP-D087031,CDM,C1753,HCPCS,272,RC,,,outpatient,,,8496.49,5947.543,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7720.4409,other,SI=N Exclusions ,,
CATH DX VIEWFLEX ECO ICE CATHERTER REPROC REF: D087031-R -,SUP-D087031-R,CDM,C1753,HCPCS,272,RC,,,outpatient,,,5544.79,3881.353,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7720.4409,other,SI=N Exclusions ,,
ECHO ATLANTIS ICE -,SUP-H749389790,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7720.4409,other,SI=N Exclusions ,,
CATHETER OPTICROSS HD IVUS 5FR -,SUP-H74939352040,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3843.07,2690.149,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7720.4409,other,SI=N Exclusions ,,
CATHETER OPTICROSS HD IVUS 6FR -,SUP-H74939354080,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3843.07,2690.149,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7720.4409,other,SI=N Exclusions ,,
CATH US 9FR 9 MHZ 110CM ULTRA ICE IMG COR -,SUP-M00499000,CDM,C1753,HCPCS,272,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7720.4409,other,SI=N Exclusions ,,
CATH US 6FR CRV NDL 120CM PIONEER + TRPL BRD SHFT PERC -,SUP-PPLUS120,CDM,C1753,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7720.4409,other,SI=N Exclusions ,,
KIT EPIDURAL MINI BREVI-XL -,SUP-181-2340,CDM,C1755,HCPCS,278,RC,,,outpatient,,,481.1,336.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions ,,
ST NEEDLE NRV BLCK CONTIPLEX -,SUP-331686,CDM,C1755,HCPCS,278,RC,,,outpatient,,,209.88,146.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions ,,
TRAY EPIDURAL PERIFIX 17GA -,SUP-332079,CDM,C1755,HCPCS,278,RC,,,outpatient,,,140.22,98.154,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions ,,
TRAY EPIDURAL WITH DURAPREP -,SUP-332215,CDM,C1755,HCPCS,278,RC,,,outpatient,,,192.5,134.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions ,,
EPIDURAL CATHETER SET 20GA -,SUP-333540,CDM,C1755,HCPCS,278,RC,,,outpatient,,,46,32.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions ,,
TRY EPDRL/SPIN CONT TUOHY WHITACRE 18GA PERISAFE 1% LIDOCN -,SUP-406048,CDM,C1755,HCPCS,278,RC,,,outpatient,,,114.89,80.423,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions ,,
TRAY SPINAL LIDOCAINE 25GA X 3.5IN WHITACRE 0.75% HCL D8.25W -,SUP-406704,CDM,C1755,HCPCS,278,RC,,,outpatient,,,159.23,111.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions ,,
LUMBAR PUNCTURE TRAY PEDI 22GA 1.5IN -,SUP-646,CDM,C1755,HCPCS,278,RC,,,outpatient,,,75.04,52.528,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions ,,
TRAY LUMBAR PUNCTURE 20G -,SUP-648,CDM,C1755,HCPCS,278,RC,,,outpatient,,,92.06,64.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions ,,
PASSER SURG SS HOL OBTR STRL -,SUP-8591-38,CDM,C1755,HCPCS,278,RC,,,outpatient,,,571.83,400.281,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions ,,
KT IT 4FR CLSD TIP SIL MRKNG GW SPIN NDL ANCHR RLR -,SUP-8598A,CDM,C1755,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions ,,
KT IT SIL RBR CLSD TIP SIL MRKNG GW SPIN NDL ANCHR RLR -,SUP-8709SC,CDM,C1755,HCPCS,278,RC,,,outpatient,,,3150.84,2205.588,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions ,,
CATH IT 0.53MM 1.4MM/2.2MM SPIN/PMP SEG SIL RBR TRMBL CLSD -,SUP-8731SC,CDM,C1755,HCPCS,278,RC,,,outpatient,,,3150.84,2205.588,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions ,,
CATHETER INTRA MEDTRONIC -,SUP-8780,CDM,C1755,HCPCS,278,RC,,,outpatient,,,4430.74,3101.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions ,,
CATHETER INTRATHECAL  MEDTRONIC -,SUP-8781,CDM,C1755,HCPCS,278,RC,,,outpatient,,,4430.74,3101.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions ,,
PROCEDURE 20GA 3.5IN NDL SF-T + F/LP -,SUP-974,CDM,C1755,HCPCS,278,RC,,,outpatient,,,130.65,91.455,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions ,,
PROCEDURE 20GA 3.5IN NDL SF-T + F/LP -,SUP-974,CDM,C1755,HCPCS,278,RC,,,outpatient,,,130.65,91.455,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions ,,
KIT SINGLE SHOT EPIDURAL -,SUP-A4082-20,CDM,C1755,HCPCS,278,RC,,,outpatient,,,85.52,59.864,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions ,,
KT NEEDLE NRV BLCK 20GA STIMUCATH CONT INSL 4CM -,SUP-AB-20604-KS,CDM,C1755,HCPCS,278,RC,,,outpatient,,,518.08,362.656,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions ,,
ST NEEDLE NRV BLCK 20GA STIMUCATH CONT INSL -,SUP-AB-20604-S,CDM,C1755,HCPCS,278,RC,,,outpatient,,,369.64,258.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions ,,
KT NEEDLE NRV BLCK 20GA STIMUCATH CONT INSL 8CM -,SUP-AB-20608-KS,CDM,C1755,HCPCS,278,RC,,,outpatient,,,256.13,179.291,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions ,,
SPACEOAR KITS -,SUP-SO-2101,CDM,C1755,HCPCS,278,RC,,,outpatient,,,11779.68,8245.776,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions ,,
SPINAL -,SUP-UNDEFINED,CDM,C1755,HCPCS,278,RC,,,outpatient,,,80.87,56.609,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.327,9046.79424,other,SI=N Exclusions ,,
POWER PULSE KIT ANGIO JET Y SE -,SUP-104834-0020,CDM,C1757,HCPCS,272,RC,,,outpatient,,,214.56,150.192,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
SET POWER PULSE Y SPIKE ANGIO -,SUP-104834-0021,CDM,C1757,HCPCS,272,RC,,,outpatient,,,214.56,150.192,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
C ANGIOJET AVX -,SUP-105039-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,3746.49,2622.543,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
DISC INJ F/THRMB -,SUP-105040001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,5326.22,3728.354,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATH THRMB 5FRX140CM ANGIOJET XVG HYDRCT -,SUP-105042-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,6917.72,4842.404,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
THROMBECTOMY 16.5INX54INX25IN D ANGIOJET -,SUP-105650-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,85111.5,59578.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATH THRMB 4.2FR FETCH -,SUP-106127-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATH THRMB 4FRX135CM ANGIOJET SPIROFLEX RX CX-STRM TECH -,SUP-106553-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10062.52,7043.764,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATH THRMB 5FRX135CM ANGIOJET SPIROFLEXVG RX CX-STRM TECH -,SUP-106608-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10062.52,7043.764,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATH THRMB 6FRX90CM ANGIOJET SOLENT PROXI OTW SPRL CUT PROX -,SUP-109676-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10503.9,7352.73,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
6FR 120CM ANGIOJET SOLENT OMNI -,SUP-109681-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9202.73,6441.911,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
4FRX145CM ANGIOJET  SOLENT DISTA THROMBECTOMY SE -,SUP-111303-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11183.56,7828.492,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
ANGIOIJET ZELANTEDVT 8X105CM -,SUP-114610-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10452.1,7316.47,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATH FOGARTY 3FR EMB 3 / SHORT -,SUP-120403FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATH FOGARTY 4FR EMB 4 SHORT -,SUP-120404FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATH FOGARTY 2FR / EMB 2 SHORT -,SUP-120602FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,493.23,345.261,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATH FOGARTY 3FR / EMB 3 -,SUP-120803FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATH FOGARTY 4FR 9MM  EMB 4 -,SUP-120804F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATH EMBCMT 4FR 9MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120804FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATH EMBCMT 5FR 11MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120805FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATH EMBCMT 6FR 13MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120806FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATH EMBCMT 7FR 14MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120807FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
C FOGARTY 3FR 12TLW403F -,SUP-12TLW403F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
C FOGARTY 4FR 12TLW404F -,SUP-12TLW404F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
C FOGARTY 5F 40 CM -,SUP-12TLW405F35,CDM,C1757,HCPCS,272,RC,,,outpatient,,,567.98,397.586,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
C FOGARTY 6FR 40CM -,SUP-12TLW406F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATH FOGARTY THRU LUMEN 3 -,SUP-12TLW803F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
C FOGARTY 4 80CM -,SUP-12TLW804F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
C FOGARTY 5.5 80CM OTW -,SUP-12TLW805F35,CDM,C1757,HCPCS,272,RC,,,outpatient,,,567.98,397.586,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
C FOGARTY 6 80CM -,SUP-12TLW806F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,567.98,397.586,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATH EMBCMT 7FRX14MM/8FR INFL/DFLT BLN 80CM FOGARTY OTW -,SUP-12TLW807F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATH FOGARTY 6FR. ACC 6/10 -,SUP-1408010,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1347.12,942.984,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATH FOGARTY 6FR. / EMB 6 -,SUP-160246F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1992.72,1394.904,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATH THRMB 5.5FR 138CM PRONTO V4 LRG LUM LNGTDNL WIRE HYDRCT -,SUP-4005,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1765.07,1235.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATH PTCA 4MMX4CM SAVVY 120CM OTW COAX MOD PRSS PERIPH TAPR -,SUP-435-404L,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1155.51,808.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATH US 5.2FRX106CM 12CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-55112,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATH US 5.2FRX106CM 18CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-55118,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATH US 5.2FRX106CM 24CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-55124,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATH US 5.2FRX135CM 12CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56112,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATH US 5.2FRX135CM 30CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56130,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATH US 5.2FRX135CM 40CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56140,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATH US 5.2FRX135CM 50CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56150,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATH THRMB 0.066IN 6FRX140CM WKG PRONTO LP LPRO XTRCT HYDRCT -,SUP-5010,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1929.38,1350.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CLOT TRIEVER SHEATH -,SUP-50-101,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CLOTTRIEVER SHEATH 16FR X 15CM -,SUP-51-101,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
INDIGO CATHETER 5 + LARGE LUMEN ASPIRATION TUBING -,SUP-90178584,CDM,C1757,HCPCS,272,RC,,,outpatient,,,6599.42,4619.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
INDIGO CATHETER 6 + LARGE LUMEN ASPIRATION TUBING -,SUP-90178585,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9782.42,6847.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATH INFS 6FR 3-10 MMX80CM 10CM BLN TRELLIS OTW MULTLUM INFS -,SUP-BVT608010,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8891.18,6223.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATH THRMB 8FRX80CM 15CM TRELLIS INFS PTRN -,SUP-BVT808015,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8891.18,6223.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATH THRMB 8FRX80CM 30CM TRELLIS INFS PTRN -,SUP-BVT808030,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9145.82,6402.074,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATH INFS 8FR 5-16 MMX120CM 30CM BLN TRELLIS OTW MULTLUM -,SUP-BVT812030,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8891.18,6223.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATH THRMB 0.041IN/0.032IN ID 4.1FR/3.4FR P/D 150CM INDIGO -,SUP-CAT3,CDM,C1757,HCPCS,272,RC,,,outpatient,,,5114.02,3579.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATH THRMB 0.064IN/0.054IN ID 6FR/5FR P/D 132CM INDIGO -,SUP-CAT5,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4753.28,3327.296,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATH THRMB 6FRX135CM INDIGO -,SUP-CAT6,CDM,C1757,HCPCS,272,RC,,,outpatient,,,7936.28,5555.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
INDIGO CATHETER 7D PLUS DYNAMIC ASPIRATION TUBING -,SUP-CAT7DKIT,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9913.71,6939.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATH THRMB 8FRX115CM INDIGO -,SUP-CAT8XTORQ115,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10804.83,7563.381,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATHETER D + INDIGO LARGE LUMEN ASPIRATING TUBING -,SUP-CATD,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9913.71,6939.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
INDIGO CATHETER RX 140 CM + LG LUMEN ASPIRATION TUBING -,SUP-CATRXKIT,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8063.6,5644.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATHETER SILICONE EMBOLECTOMY 4FR 80CM -,SUP-E1801-48,CDM,C1757,HCPCS,272,RC,,,outpatient,,,811.07,567.749,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATHETER SILICONE EMBOLECTOMY 5FR 80CM -,SUP-E1801-58,CDM,C1757,HCPCS,272,RC,,,outpatient,,,811.07,567.749,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
EXCIPIO SV THROMBECTOMY DEVICE 8MM -,SUP-EXC-0940-165,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11101.87,7771.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATH EXPORT AP ASPIRATION 6F 0 -,SUP-EXPORTAP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATH PTCA 4MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50233,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATH EMBCMT 7FRX145CM EXPORT AP BRD ASPIR SFT TIP FLXB -,SUP-GEZ6200US7B,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
EKOS+ KIT 106CM 8 CM -,SUP-H74939605106080,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
DEVICE THROMBECTOMY EKOS+ 106CM X 2.62CM TREATMENT ZONE 12CM -,SUP-H74939605106120,CDM,C1757,HCPCS,272,RC,,,outpatient,,,13181.15,9226.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
EKOS+ KIT 106CM 16 CM -,SUP-H74939605106160,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
EKOS+ KIT 106CM 20 CM -,SUP-H74939605106200,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
EKOS+ KIT 135CM 20 CM -,SUP-H74939605135200,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
INDIGO CATHETER 12 115CM HTORQ -,SUP-LITNG12HTORQ115,CDM,C1757,HCPCS,272,RC,,,outpatient,,,25137.01,17595.907,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
INDIGO CATHETER 7 130CM XTORQ -,SUP-LITNG7XTORQ130,CDM,C1757,HCPCS,272,RC,,,outpatient,,,20681.41,14476.987,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
INDIGO CATHETER 8 115CM XTORQ -,SUP-LITNG8XTORQ115,CDM,C1757,HCPCS,272,RC,,,outpatient,,,21424.01,14996.807,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-5080-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-5120-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-6080-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-6120-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-6200-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
ACCESSORY KIT JETI NON STERILE DISPOSABLE -,SUP-WV1500,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
JETI CATHETER KIT 6FR -,SUP-WV6203A,CDM,C1757,HCPCS,272,RC,,,outpatient,,,12141.51,8499.057,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
JETI CATHETER KIT 8FR -,SUP-WV8803A,CDM,C1757,HCPCS,272,RC,,,outpatient,,,17109.5,11976.65,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.14178,61024.9455,other,SI=N Exclusions ,,
CATH URETH 5FR TIGTL PU LF 70CM NPRT EYE FLXB OPN TIP -,SUP-0139005,CDM,C1758,HCPCS,272,RC,,,outpatient,,,549.07,384.349,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,11.97932,751.60242,other,SI=N Exclusions ,,
CATH URETERAL POLLACK 5 70 -,SUP-021305,CDM,C1758,HCPCS,272,RC,,,outpatient,,,94.44,66.108,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,11.97932,751.60242,other,SI=N Exclusions ,,
CATH FOLEY 6FR 2W LUBRI-SIL SIL LF PED -,SUP-175806N,CDM,C1758,HCPCS,272,RC,,,outpatient,,,146.07,102.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,11.97932,751.60242,other,SI=N Exclusions ,,
CATH URET 6FRX70CM PVC OP-EN TIP LF PVC SOF-FLEX -,SUP-G15942,CDM,C1758,HCPCS,272,RC,,,outpatient,,,65.41,45.787,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,11.97932,751.60242,other,SI=N Exclusions ,,
CATH URET 5FRX80CM VNYL LUMX1 LF BUSH SL CATHX2 CMN L/S -,SUP-G16746,CDM,C1758,HCPCS,272,RC,,,outpatient,,,1048.26,733.782,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,11.97932,751.60242,other,SI=N Exclusions ,,
CATH ANG 5FR KMP 100CM SLIP-CATH BRD HYDRCT -,SUP-G28535,CDM,C1758,HCPCS,272,RC,,,outpatient,,,379.26,265.482,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,11.97932,751.60242,other,SI=N Exclusions ,,
CATHETER ACCESS 6FR AXXCESS -,SUP-M0064001161,CDM,C1758,HCPCS,272,RC,,,outpatient,,,61.04,42.728,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,11.97932,751.60242,other,SI=N Exclusions ,,
CATH 5FR X 70 CONE TIP BX/20 -,SUP-M0064002111,CDM,C1758,HCPCS,272,RC,,,outpatient,,,53.36,37.352,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,11.97932,751.60242,other,SI=N Exclusions ,,
CATH DUAL LUMEN URETERAL -,SUP-M0064051000,CDM,C1758,HCPCS,272,RC,,,outpatient,,,384.35,269.045,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,11.97932,751.60242,other,SI=N Exclusions ,,
CATHETER 5.5 S2 -,SUP-1000100,CDM,C1759,HCPCS,272,RC,,,outpatient,,,101147,70802.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,72522.399,other,SI=N Exclusions ,,
CATH US 10FRX90CM 5.5-10 MHZ SOUNDSTAR NAV COR -,SUP-SNDSTR10,CDM,C1759,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,72522.399,other,SI=N Exclusions ,,
DEVICE SUT -,SUP-123250101,CDM,C1760,HCPCS,278,RC,,,outpatient,,,116.7,81.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions ,,
CLOSURE PERCLOSE PROGLIDE 6F -,SUP-12673-03,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions ,,
PERCLOSE PROSTYLE -,SUP-12773-03,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions ,,
DEVICE VASC CLSR 56FR STARCLOSE SE -,SUP-14679-01,CDM,C1760,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions ,,
STAR CLOSE SELF -,SUP-14679-01,CDM,C1760,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions ,,
ANGIO SEAL STS VIP/PLUS 6FR -,SUP-610119,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions ,,
ANGIO SEAL STS VIP/PLUS 8FR -,SUP-610121,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions ,,
DEVICE VASC CLSR 6FR ANGIO-SEAL VIP -,SUP-610130,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions ,,
DEVICE VASC CLSR 8FR ANGIO-SE  70CM -,SUP-610131,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions ,,
VASCADE MVP - VENOUS VASCULAR CLOSURE SYSTEM 6-12F -,SUP-800-612C-10U,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions ,,
SYS ATRICLIP STD 40 -,SUP-ACH140,CDM,C1760,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions ,,
SYS ATRICLIP STD 45 -,SUP-ACH145,CDM,C1760,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions ,,
DEVICE VASC CLSR 5FR EXOSEAL -,SUP-EX500,CDM,C1760,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions ,,
DEVICE VASC CLSR 6FR EXOSEAL -,SUP-EX600,CDM,C1760,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions ,,
PAS-PORT PROXIMAL ANASTOMOSIS -,SUP-FG-000001-13,CDM,C1760,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions ,,
CELT ACD 5FR CLOSURE DEVICE -,SUP-KCLT-05,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions ,,
CELT ACD 6FR CLOSURE DEVICE -,SUP-KCLT-06,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions ,,
CELT ACD 7FR CLOSURE DEVICE -,SUP-KCLT-07,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions ,,
MYNX GRIP 5FR CLOSURE DEVICE M - MULTIPLES OF 10 ONLY -,SUP-M465MX50210C,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions ,,
DEVICE 6F/7F MYNX GRIP CLOSURE -,SUP-MX6721,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions ,,
DEVICE VASC CLSR 6FR MYNXGRIP -,SUP-MX6721,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions ,,
VENASEAL SYSTEM CLOSURE -,SUP-VS-404,CDM,C1760,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3585.3312,other,SI=N Exclusions ,,
BALLOON SHOCKWAVE C2 + IVL CATHETER 2.5X12 REF: C2PIVL2512 -,SUP-C2PIVL2512,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,14791.55,399.86,14791.55236,percent of total billed charges,,,
BALLOON SHOCKWAVE C2 + IVL CATHETER 3.0X12 REF: C2PIVL3012 -,SUP-C2PIVL3012,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,14791.55,399.86,14791.55236,percent of total billed charges,,,
BALLOON SHOCKWAVE C2 + IVL CATHETER 3.5X12 REF: C2PIVL3512 -,SUP-C2PIVL3512,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,14791.55,399.86,14791.55236,percent of total billed charges,,,
BALLOON SHOCKWAVE C2 + IVL CATHETER 4.0X12 REF: C2PIVL4012 -,SUP-C2PIVL4012,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,14791.55,399.86,14791.55236,percent of total billed charges,,,
CATHETER  SHOCKWAVE L6 1VL- 8.0 X 30 MM -,SUP-L6IVL080030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,10857.63,399.86,14791.55236,percent of total billed charges,,,
CATHETER  SHOCKWAVE L6 1VL- 9.0 X 30 MM -,SUP-L6IVL090030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,10857.63,399.86,14791.55236,percent of total billed charges,,,
CATHETER  SHOCKWAVE L6 1VL- 10.0 X 30 MM -,SUP-L6IVL100030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,10857.63,399.86,14791.55236,percent of total billed charges,,,
CATHETER  SHOCKWAVE L6 1VL- 12.0 X 30 MM -,SUP-L6IVL120030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,10857.63,399.86,14791.55236,percent of total billed charges,,,
CATHETER SHOCKWAVE 6.5 X 60 MM M5+ -,SUP-M5PIVL6560,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,10857.63,399.86,14791.55236,percent of total billed charges,,,
TENDON SEMITENINOSIS -,SUP-004023,CDM,C1762,HCPCS,278,RC,,,outpatient,,,5817.25,4072.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions ,,
GRAFT HUM TIS NAT DENOVO LF -,SUP-00560600010,CDM,C1762,HCPCS,278,RC,,,outpatient,,,17339.71,12137.797,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions ,,
ADVANCE NERVE GRAFT D 1-2MM X 15MM -,SUP-111215,CDM,C1762,HCPCS,278,RC,,,outpatient,,,8649.27,6054.489,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions ,,
ADVANCE NERVE ALLOGRAFT -,SUP-111230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions ,,
STRATTICE RECONSTRUCTIVE TISSUE MATRIX 16 X 20CM -,SUP-1620002,CDM,C1762,HCPCS,278,RC,,,outpatient,,,30012.18,21008.526,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions ,,
STRATTICE RECONSTRUCTIVE TISSUE MATRIX 20 X 20CM -,SUP-2020002,CDM,C1762,HCPCS,278,RC,,,outpatient,,,24926.57,17448.599,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions ,,
GRAFT HUM TIS SPORTSMED TIB IRRAD LF -,SUP-208002,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions ,,
GRAFT HUM TIS SPORTSMED TIB TNDN POST TIB IRRAD LF -,SUP-208003,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions ,,
AVANCE NERVE GRAFT 2MM DIAM / 30MM LENGTH -,SUP-211230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions ,,
ADVANCE NERVE GRAFT 3-4MM X 30MM -,SUP-311230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions ,,
AXOGEN ADVANCE NERVE GRAFT 3.4MM X 70MM -,SUP-311270,CDM,C1762,HCPCS,278,RC,,,outpatient,,,25322.66,17725.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions ,,
NERVE GRAFT ADVANCED 4-5MM X 30MM -,SUP-411230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions ,,
AXOGEN ADVANCE NERVE GRAFT 4.5MM X 70MM -,SUP-411270,CDM,C1762,HCPCS,278,RC,,,outpatient,,,25322.66,17725.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions ,,
GRAFT HUM TIS FRZN 6-12 MMX20-38CM ANT TIB TNDN LF -,SUP-430335,CDM,C1762,HCPCS,278,RC,,,outpatient,,,8376.38,5863.466,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions ,,
TENDON TIBIALIS POSTERIOR -,SUP-430343,CDM,C1762,HCPCS,278,RC,,,outpatient,,,8168.81,5718.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions ,,
GRAFT HUM TIS FRZN 3-10 MMX26-38CM SEMITNDS TNDN LF -,SUP-430350,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions ,,
GRAFT HUM TIS FRZN 3-10 MMX20-25.9CM ANT TIB TNDN LF -,SUP-430355,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions ,,
IMPLANT HUM TIS PS 10MM TNDN ACH -,SUP-450200,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10971.92,7680.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions ,,
GRAFT HUM TIS FRZDR 2X14CM IOPATCH TUTOPLAST FSCA LATA -,SUP-68021,CDM,C1762,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions ,,
GRAFT HUM TIS DHYDR 1.5X1.5CM IOPATCH TUTOPLAST PROC -,SUP-68250,CDM,C1762,HCPCS,278,RC,,,outpatient,,,1404.63,983.241,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions ,,
GRAFT HUM TIS PTCH DHYDR 1X3CM IOPATCH TUTOPLAST SCLR IRRAD -,SUP-68334,CDM,C1762,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions ,,
GRAFT HTM NMSH SFT REGEN 5X5CM STD GRAFTJACKET ACLR DERM 1MM -,SUP-8600-5X05,CDM,C1762,HCPCS,278,RC,,,outpatient,,,9761.2,6832.84,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions ,,
GRAFT HTM FRZDR SFT REGEN 2X4CM GRAFTJACKET COLL 1.5MM UND -,SUP-86MX-2X04,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10752.85,7526.995,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions ,,
PATELLA TENDON W/ EXTENSION MECHANISM -,SUP-92-3300,CDM,C1762,HCPCS,278,RC,,,outpatient,,,26622.21,18635.547,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions ,,
GRAFT HUM TIS SPLT THK VSNGRFT CRNA NON-IMMUNOGENIC XLNK -,SUP-C0301AL-90,CDM,C1762,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions ,,
CORNEA HUMAN -,SUP-CORNEA,CDM,C1762,HCPCS,278,RC,,,outpatient,,,16467.16,11527.012,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions ,,
IMPLANT HUM TIS BLCK AT -,SUP-FATB,CDM,C1762,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions ,,
IMPLANT HUM TIS ALLOGRAFT BIOCLEANSE GRCLS TNDN FRZN -,SUP-FGRACILIS,CDM,C1762,HCPCS,278,RC,,,outpatient,,,5267.78,3687.446,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions ,,
GRAFT HUM TIS FRZDR 30X150MM MED RDIGRF FSCA LATA LF -,SUP-FLM,CDM,C1762,HCPCS,278,RC,,,outpatient,,,4565.66,3195.962,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions ,,
GRAFT HUM TIS SFT 230MM 7.5MM FLEXIGRAFT POST TIB TNDN FRZN -,SUP-FPOST.TIBIAL,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7087.1,4960.97,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions ,,
FLEXIGRAFT QUADLINK-ZORC -,SUP-FQL,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10482.68,7337.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions ,,
GRAFT HUM TIS HAMSTRING FRZN >150MM4MM-5.5MM DIA FLEXIGRAFT -,SUP-FROPE,CDM,C1762,HCPCS,278,RC,,,outpatient,,,3719.57,2603.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions ,,
GRAFT HUM TIS HAMSTRING FRZN 160-250MM 4-6MM FLEXIGRAFT -,SUP-FSTP,CDM,C1762,HCPCS,278,RC,,,outpatient,,,3657.31,2560.117,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions ,,
SLING TRNVAG RPLFRM COLL 5X10CM NABSB FEM FRZDR SLF-ANCHR -,SUP-M0068202450,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7456.11,5219.277,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions ,,
SLING TRNVAG RPLFRM COLL 6X12CM NABSB FEM FRZDR SLF-ANCHR -,SUP-M0068202460,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7882.17,5517.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions ,,
MACROFORM COMPOSITE NOVABONE 10CC -,SUP-NB1003,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions ,,
NOVABONE BIOACTIVE BONE GRAFT 10CC LONG STRIP -,SUP-NB2310L,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions ,,
NOVABONE 10CC STRIP -,SUP-NB2310S,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions ,,
NOVABONE 2.5CC PUTTY -,SUP-NB2602,CDM,C1762,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions ,,
NOVABONE 5CC PUTTY -,SUP-NB2605,CDM,C1762,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions ,,
NOVABONE 10CC PUTTY SYRINGE -,SUP-NB2610,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions ,,
GRAFT HUM TIS FRZN >=150MM TIB POST TNDN LF -,SUP-X30820,CDM,C1762,HCPCS,278,RC,,,outpatient,,,6302.34,4411.638,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,315.339435,23049.35424,other,SI=N Exclusions ,,
IMPLANT BIO TISS 15X20CM RECT PRCN COLL MATRIX NXLNK XENMTRX -,SUP-1161520,CDM,C1763,HCPCS,278,RC,,,outpatient,,,31189.2,21832.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions ,,
EPIDISK -,SUP-1417100,CDM,C1763,HCPCS,278,RC,,,outpatient,,,1203.21,842.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions ,,
IMPLANT COLL MEMBR 50X40MM GEISTLICH BIO-GIDE BILAYER RESRB -,SUP-20153,CDM,C1763,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions ,,
SHEET MEDPOR 38 X 50 X 0.85 ORBITAL IMPLANT -,SUP-7210,CDM,C1763,HCPCS,278,RC,,,outpatient,,,2390.53,1673.371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions ,,
SUBSTITUTE CA SLPHT 5ML GRNL MIIGX3 RESRB SYNTH PREFL -,SUP-84XS-0405,CDM,C1763,HCPCS,278,RC,,,outpatient,,,7940.52,5558.364,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions ,,
SUBSTITUTE CA SLPHT 5ML GRNL MIIGX3 RESRB SYNTH PREFL -,SUP-84XS-0405,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9145.82,6402.074,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions ,,
GRID CRNL 106X97MM 6MM MEDPOR FLEXBLOCK -,SUP-9524,CDM,C1763,HCPCS,278,RC,,,outpatient,,,15136.27,10595.389,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions ,,
NERVE PROTECTOR WRAP 2MM X 20MM -,SUP-AG0220,CDM,C1763,HCPCS,278,RC,,,outpatient,,,8118.77,5683.139,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions ,,
NERVE PROTECTOR WRAP 3.5MM X 20MM -,SUP-AG0320,CDM,C1763,HCPCS,278,RC,,,outpatient,,,8118.77,5683.139,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions ,,
NERVE WRAP AVANCE 3.5MM X 40MM -,SUP-AG0340,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9921.14,6944.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions ,,
NERVE WRAP AVANCE 3.5MM X 40MM -,SUP-AG0340,CDM,C1763,HCPCS,278,RC,,,outpatient,,,10525.12,7367.584,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions ,,
NERVE PROTECTOR 7MM X 40MM - USE 0169678 -,SUP-AG0740,CDM,C1763,HCPCS,278,RC,,,outpatient,,,10121.64,7085.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions ,,
NERVE PROTECTOR 7MM X 40MM -,SUP-AG0740,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9442.16,6609.512,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions ,,
AXOGUARD NERVE PROTECTOR 40MM 10MM -,SUP-AG1040,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9442.16,6609.512,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions ,,
AXOGAURD NERVE CONNECTOR 2 X 15 -,SUP-AGX215,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions ,,
AXOGAURD NERVE CONNECTOR D 3MM L 15MM -,SUP-AGX315,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions ,,
AXOGAURD NERVE CONNECTOR D 4MM L 15MM -,SUP-AGX415,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions ,,
CONNECTOR AXOGUARD NERVE D 5MM L 15MM -,SUP-AGX515,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions ,,
PLUG ANAL FISTULA -,SUP-G53614,CDM,C1763,HCPCS,278,RC,,,outpatient,,,5071.58,3550.106,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions ,,
IMPLANT GYN 17X70CM SYNTH UPHOLD LT -,SUP-M0068317170,CDM,C1763,HCPCS,278,RC,,,outpatient,,,8668.37,6067.859,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions ,,
SURGICAL MATRIX THICK 10 X 20CM -,SUP-PSMT1020,CDM,C1763,HCPCS,278,RC,,,outpatient,,,20941.32,14658.924,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions ,,
5 X 5CM 6 LAYER GENTRIX SURGICAL MATRIX DRESSING -,SUP-PSMX0505,CDM,C1763,HCPCS,278,RC,,,outpatient,,,3471.65,2430.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions ,,
ROD TNDN 3X250MM PLYSTR COR SIL PSS KNOB END HNTR STRL STR -,SUP-PT300000,CDM,C1763,HCPCS,278,RC,,,outpatient,,,5254.07,3677.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions ,,
ROD TNDN 5X250MM PLYSTR COR SIL PSS KNOB END HNTR STRL STR -,SUP-PT500000,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6315.07,4420.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions ,,
ROD TNDN STD 4X245MM PLYSTR COR SIL PSS HNTR STRL STR -,SUP-TR400000,CDM,C1763,HCPCS,278,RC,,,outpatient,,,5254.07,3677.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions ,,
WOUND MATRIX 6 LAYER 10 X 15 -,SUP-WSX1015,CDM,C1763,HCPCS,278,RC,,,outpatient,,,16411.46,11488.022,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,270.120645,23953.3056,other,SI=N Exclusions ,,
RECORDER LOOP 2-AF BIOMONITOR -,SUP-398493,CDM,C1764,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,14243.66592,other,SI=N Exclusions ,,
MONITOR CARD IMPL REVEAL XT 19X62MM TI 9ML 15GM -,SUP-9529,CDM,C1764,HCPCS,278,RC,,,outpatient,,,13348.24,9343.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,14243.66592,other,SI=N Exclusions ,,
MONITOR CARD IMPL CNFRM 18.5MMX56.3MM 6.5ML 12GM FRZDR LRDTC -,SUP-DM2100,CDM,C1764,HCPCS,278,RC,,,outpatient,,,11346.93,7942.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,14243.66592,other,SI=N Exclusions ,,
LOOP RECORDER NEXT GEN JOT DX REF: DM4500 -,SUP-DM4500,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,14243.66592,other,SI=N Exclusions ,,
LOOP RECORDER ASSERT IQ3+ ICM REF: DM5300 -,SUP-DM5300,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,14243.66592,other,SI=N Exclusions ,,
LOOP RECORDER ASSERT IQ EL+ ICM REF: DM5500 -,SUP-DM5500,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17636.75,12345.725,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,14243.66592,other,SI=N Exclusions ,,
REVEAL LINQ ICM SYSTEM LOOP RECORDER MDT -,SUP-LINQSYS,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17246.89,12072.823,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,14243.66592,other,SI=N Exclusions ,,
LOOP RECORDER REVEAL LINQ II SYSTEM REF: LNQ22SYS -,SUP-LNQ22SYS,CDM,C1764,HCPCS,278,RC,,,outpatient,,,18546.44,12982.508,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,14243.66592,other,SI=N Exclusions ,,
LUX DX INSERTABLE CARDIAC MONITOR M301 -,SUP-M301,CDM,C1764,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,14243.66592,other,SI=N Exclusions ,,
LUX -DX II+ INSERTABLE CARDIAC MONITOR REF: M312 -,SUP-M312,CDM,C1764,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,14243.66592,other,SI=N Exclusions ,,
GELFILM OPTH -,SUP-0009-0297-03,CDM,C1765,HCPCS,278,RC,,,outpatient,,,1102.46,771.722,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,247.50227,1378.95936,other,SI=N Exclusions ,,
"BARRIER ADHESION SEPRAFILM 5 X 6"" -",SUP-430102,CDM,C1765,HCPCS,278,RC,,,outpatient,,,1691.39,1183.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,247.50227,1378.95936,other,SI=N Exclusions ,,
BARRIER INTERCEED 3X4 -,SUP-4350,CDM,C1765,HCPCS,278,RC,,,outpatient,,,1795.52,1256.864,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,247.50227,1378.95936,other,SI=N Exclusions ,,
FLEXCATH CONTOUR STERERABLE SHEATH REF:10FCC13 -,SUP-10FCC13,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,109.158635,4260.1272,other,SI=N Exclusions ,,
FLEXCATH CONTOUR STERRABLE SHEATH 10FRX20MM REF:10FCC20 -,SUP-10FCC20,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,109.158635,4260.1272,other,SI=N Exclusions ,,
FLEXCATH CONTOUR STEERABLE SHEATH 12FRx13MM REF:12FCC13 -,SUP-12FCC13,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,109.158635,4260.1272,other,SI=N Exclusions ,,
FLEXCATH CONTOUR STEERABLE SHEATH 12FRx20MM REF:12FCC20 -,SUP-12FCC20,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,109.158635,4260.1272,other,SI=N Exclusions ,,
FARADRIVE STEERABLE SHEATH REF: 21C602 -,SUP-21C602,CDM,C1766,HCPCS,272,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,109.158635,4260.1272,other,SI=N Exclusions ,,
AGILIS SHEATH SMALL -SJM  8.5FRX91CM -,SUP-408309,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4139.92,2897.944,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,109.158635,4260.1272,other,SI=N Exclusions ,,
SHEATH AGILIS SM- REPROC 8.5FR -,SUP-408309,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2639.83,1847.881,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,109.158635,4260.1272,other,SI=N Exclusions ,,
AGILIS SHEATH  MED - SJM 8.5FR X 91CM -,SUP-408310,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4267.96,2987.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,109.158635,4260.1272,other,SI=N Exclusions ,,
INTRO SHTH FLEXCATH ADVANCE 12FR -,SUP-4FC12,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,109.158635,4260.1272,other,SI=N Exclusions ,,
CATH ABLT CARTO 3 XTRN REF -,SUP-CREFP6,CDM,C1766,HCPCS,272,RC,,,outpatient,,,486.23,340.361,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,109.158635,4260.1272,other,SI=N Exclusions ,,
SHEATH AGILIS LGE- REPROC  8.5FR -,SUP-G408234,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2473.84,1731.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,109.158635,4260.1272,other,SI=N Exclusions ,,
AGILIS SHEATH LRG CURL SFT 3MM J FNGR SJM -,SUP-G408324,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4172.48,2920.736,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,109.158635,4260.1272,other,SI=N Exclusions ,,
SHEATH POLARSHEATH STEERABLE SHEATH REF:M004CRBS3150 -,SUP-M004CRBS3150,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,109.158635,4260.1272,other,SI=N Exclusions ,,
AMULET STEERABLE DELIVERY SHEATH REF: STRBL-14F-075 -,SUP-STRBL-14F-075,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,109.158635,4260.1272,other,SI=N Exclusions ,,
TOURGUIDE 7FR X 55CM -,SUP-TG0705509,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,109.158635,4260.1272,other,SI=N Exclusions ,,
SHEATH 6.5 FR. 55CM -,SUP-UNDEFINED,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,109.158635,4260.1272,other,SI=N Exclusions ,,
SHEATH GRAFT 7FR. 9MM 45CM -,SUP-UNDEFINED,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,109.158635,4260.1272,other,SI=N Exclusions ,,
GENERATOR NEURSTM INTSTM TI 60MMX55MM SCRL NRV MRI-COND -,SUP-3023,CDM,C1767,HCPCS,278,RC,,,outpatient,,,36758.7,25731.09,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,39874.22976,other,SI=N Exclusions ,,
INTERSTIM STIMULATOR EXTERNAL NEURO -,SUP-353101,CDM,C1767,HCPCS,278,RC,,,outpatient,,,1987.69,1391.383,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,39874.22976,other,SI=N Exclusions ,,
PROCLAIM 5 ELITE -,SUP-3660ANS,CDM,C1767,HCPCS,278,RC,,,outpatient,,,40409.46,28286.622,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,39874.22976,other,SI=N Exclusions ,,
NEUROSTIMULATOR PROCLAIM 5 -,SUP-3661,CDM,C1767,HCPCS,278,RC,,,outpatient,,,45984.88,32189.416,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,39874.22976,other,SI=N Exclusions ,,
PROCLAIM 7 PULSE GENERATOR -,SUP-3663,CDM,C1767,HCPCS,278,RC,,,outpatient,,,44998.08,31498.656,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,39874.22976,other,SI=N Exclusions ,,
PROCLAIM DRG IPG 5.3AHG MRI EIFU RED -,SUP-3664,CDM,C1767,HCPCS,278,RC,,,outpatient,,,51919.57,36343.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,39874.22976,other,SI=N Exclusions ,,
DEVICE NEURSTM PRIM ADVANCED 2.6INX1.9IN PERC MRI-COND -,SUP-377-02,CDM,C1767,HCPCS,278,RC,,,outpatient,,,29604,20722.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,39874.22976,other,SI=N Exclusions ,,
NEURSTM PRGM ITREL 60MMX55MM SPIN CRD PRIM CELL -,SUP-377-03,CDM,C1767,HCPCS,278,RC,,,outpatient,,,27012.08,18908.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,39874.22976,other,SI=N Exclusions ,,
INS 977006 PAIN PC M -,SUP-977006,CDM,C1767,HCPCS,278,RC,,,outpatient,,,50457.55,35320.285,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,39874.22976,other,SI=N Exclusions ,,
NEURSTM IMPL PRIM ADVANCED 65X49X15MM SPIN CRD MRI-COND -,SUP-9770-2,CDM,C1767,HCPCS,278,RC,,,outpatient,,,32564.4,22795.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,39874.22976,other,SI=N Exclusions ,,
INTELLIS BATTERY #97715 -,SUP-97715,CDM,C1767,HCPCS,278,RC,,,outpatient,,,44376.4,31063.48,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,39874.22976,other,SI=N Exclusions ,,
INTERSTIM X NEUROSTIMULATOR IMPLANT -,SUP-97800,CDM,C1767,HCPCS,278,RC,,,outpatient,,,26510.38,18557.266,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,39874.22976,other,SI=N Exclusions ,,
PLEDGET FELT PTFE BARD 6 X 6IN -,SUP-007837,CDM,C1768,HCPCS,278,RC,,,outpatient,,,589.34,412.538,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT HEMA MDV BIF 20 10 40 -,SUP-0085201,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT VASC 20MM 15CM HEMASHLD GOLD STR KNTD DBL VELR AOR BVN -,SUP-095120,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1996.38,1397.466,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT HEMA 16MM 30CM MDV -,SUP-095216,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2628.78,1840.146,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT HEMA 18MM 30CM MDV -,SUP-095218,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2628.78,1840.146,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT VASC 22MM 30CM HEMASHLD GOLD STR KNTD DBL VELR AOR BVN -,SUP-095222,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2628.78,1840.146,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT VASC 1X6CM GORE-TEX 0.6MM PTCH -,SUP-1702515006,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2581.34,1806.938,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT HEMASHIELD D:28MM L:30CM -,SUP-175428P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT VASC 32MM 32X30CM HEMASHLD PLTNM STR WVN AOR COLL -,SUP-175432P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT VASC 38MMX30CM HEMASHLD PLTNM FINESSE STR WVN AOR BVN -,SUP-175438P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT VASC 20MM THOR 10MM BRNCH 50CM HEMASHLD PLTNM STR 20CM -,SUP-175820P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5377.66,3764.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT VASC 26MM THOR 10MM/10MM/8MM/8MM ID BRNCH 50CM -,SUP-175926P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6299.92,4409.944,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT VASC 7X10CM GORE-HYBRID PRECLUDE 0.1MM MEMBR PERICARD -,SUP-1PCM001,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1812.77,1268.939,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT ATRIUM VXT 4 7 45CM  - DISCONTINUED DO NOT USE -,SUP-22115,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2091.84,1464.288,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
KT INFL 20/20 PRIORITY PACK -,SUP-22297,CDM,C1768,HCPCS,278,RC,,,outpatient,,,227.57,159.299,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT VASC 6MM 50CM FLIXENE STR GRAD WL REINF SFT WRP TNLR -,SUP-25058,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5114.4,3580.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT VASC 6MM 40CM FLIXENE STR GRAD WL REINF SFT WRP TNLR -,SUP-25061,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4720.98,3304.686,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT VASC 4-7MM 30CM FLIXENE STR REINF SFT-WRP TNLR ATTCH -,SUP-25098,CDM,C1768,HCPCS,278,RC,,,outpatient,,,9358.02,6550.614,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT FLIXENE GTW GW 4 7 35 -,SUP-25129,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6294.62,4406.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT VASC 8MM 80CM STR HEP FUSION BIOLINE CTD RNG SUPP -,SUP-503088B,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10403.74,7282.618,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
VALVE AOR 6-30MM CRYOVALVE CONDT -,SUP-AV00,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39965.4,27975.78,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT STENT BIFURCATED -,SUP-BEA22-70/I16-30,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
AFX2 BIFURCATED ENDOGRAFT SYSTEM -,SUP-BEA25-80/113-40,CDM,C1768,HCPCS,278,RC,,,outpatient,,,14944.83,10461.381,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT STENT BIFURCATED -,SUP-BEA25-80/I20-40,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT STENT 90MM 28MM 16MM AFX2 2 BRANCH MAIN BODY ILIAC LIM -,SUP-BEA28-90/I16-30,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT VASC 7X15CM CORMATRIX PERICARD COLL GRW FACT PRTN -,SUP-CMCV-003-402,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT DISTAFLO VASCULAR 6X70 -,SUP-DFM7006SC,CDM,C1768,HCPCS,278,RC,,,outpatient,,,30067.87,21047.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
PATCH BOVINE 0.8 X 8CM DURAVESS PERICARDIAL -,SUP-DP08X8,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1126.45,788.515,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
PATCH BOVINE 2 X 9 DURAVESS PERICARDIUM -,SUP-DP2X9,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1655.24,1158.668,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT VASC 4-7MM 45CM ACUSEAL -,SUP-ECH470045A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6675.81,4673.067,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT ZENITH FLEX LEG 20X56 -,SUP-G55241,CDM,C1768,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT GORE PROPATEN 6 X 40 -,SUP-H060040A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4766.01,3336.207,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT GORE H470045A -,SUP-H470045A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5661.5,3963.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
PROPATEN AXILLO BIFEMORAL VASC GRAFT -,SUP-HAX02A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,17306.29,12114.403,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT VASC 26X34MM SKRT 15CM CARDIOROOT 26MM SKRT 10MM CLLR -,SUP-HEWROOT0026,CDM,C1768,HCPCS,278,RC,,,outpatient,,,8640.74,6048.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT VASC 6MM 70CM HEMAGARD STR 0.49MM KNTD RVRS LOCKNIT -,SUP-HGK000670,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2112.2,1478.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT VASC PROPATEN 6 X 80 -,SUP-HT066080A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10957.06,7669.942,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
PROPATEN VASCULAR GRAFT 7MM X 80CM -,SUP-HT076080A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10957.06,7669.942,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT PROPATEN 8 X 70 -,SUP-HT087080A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,11287.52,7901.264,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT FUSION BIOLINE 6 X 80 RING SUPPORTED -,SUP-M00201503086B0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10403.74,7282.618,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT CARDIOVASCULAR HEMASHIELD GOLD MDV BIF 14X7 40CM -,SUP-M002020851470,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT 16X8 40CM HEMA BIF MDV -,SUP-M002020851680,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT HEMA MDV BIF 18X9 40CM -,SUP-M002020851890,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT HEMA MDV BIF 22X11X40 -,SUP-M002020852210,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT HEMASHIELD D:6MM L:15CM GOLD -,SUP-M002020951060,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1879.03,1315.321,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT HEMASHIELD D:8MM L:15CM GOLD -,SUP-M002020951080,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1879.03,1315.321,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT HEMASHIELD GOLD 10MM X 30CM -,SUP-M002020954100,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2538.41,1776.887,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT HEMASHIELD D:10MM L:30CM GOLD -,SUP-M002020954100,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2538.41,1776.887,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT VASC 8MM 30CM HEMASHLD PLTNM STR WVN DBL VELR AOR BVN -,SUP-M00202175208P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2473.41,1731.387,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT HEMASHIELD 22MM X 30CM -,SUP-M00202175422P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2644.27,1850.989,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT HEMASHIELD D:24MM L:30CM -,SUP-M00202175424P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2644.27,1850.989,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT HEMASHIELD D:26MM L:30CM -,SUP-M00202175426P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT HEMASHIELD D:30MM L:30CM -,SUP-M00202175430P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT HEMASHIELD D:32MM L:30CM -,SUP-M00202175432P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
PERICARDIUM PERIGUARD 6X8 -,SUP-PC0608SNBIO,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2602.81,1821.967,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
PERICARDIUM PEROGIARD 8X14 -,SUP-PC0814SNBIO,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3079.33,2155.531,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT VASC 6MM 40CM GORE-TEX STR 30CM RNG SECT THNWL STRCH -,SUP-RRT06030040L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3933.78,2753.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT VASC 6MM 70CM GORE-TEX STR 60CM RNG SECT THNWL STRCH -,SUP-RRT06060070L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5648.76,3954.132,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT VASC 8MM 40CM GORE-TEX STR 30CM RNG SECT THNWL STRCH -,SUP-RRT08030040L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3933.78,2753.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT VASC 6MM 50CM GORE-TEX STR STD WL STRCH EPTFE -,SUP-S0605,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3403.86,2382.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT VASC 14X7MM 40CM GORE-TEX BIFUR THNWL STRCH EPTFE -,SUP-SBT1401D,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4303.42,3012.394,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT VASC 16X8MM 40CM GORE-TEX BIFUR THNWL STRCH -,SUP-SBT1601,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4000.61,2800.427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
STRETCH THIN WALL BIFURCATED GRAFT 16-8MM X 50CM -,SUP-SBT1602D,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5377.15,3764.005,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT VASC 8MM 40CM GORE-TEX STR THNWL STRCH LN REM RNG AOR -,SUP-SRRT08030040L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4387.31,3071.117,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT VASC 8MM 80CM GORE-TEX STR 70CM RNG SECT THNWL -,SUP-SRRT08070080L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,7032.31,4922.617,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT VASC 6MM 40CM GORE-TEX STR THNWL STRCH AOR EPTFE -,SUP-ST0604,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3232,2262.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT VASC 6MM 80CM GORE-TEX -,SUP-ST0608,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5330.46,3731.322,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
AORTIC BODY ALTO TM ABDOMINAL STENT GRAFT -,SUP-TV-AB2080-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
ALTO ABDOMINAL STENT GRAFT SYSTEM 23MM -,SUP-TV-AB2380-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
ALTO ABDOMINAL STENT GRAFT SYSTEM 26MM -,SUP-TV-AB2680-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
OVATION IX ABDOMINAL STENT GRAFT SYSTEM 29MM ALTO -,SUP-TV-AB2980-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
ALTO ABDOMINAL STENT GRAFT SYSTEM 34MM -,SUP-TV-AB3480-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
ILIAC GRAFT OVATION IX 10 X 160MM -,SUP-TV-IL1410160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT STENT TRIVASCULAR OVATION IX 12 X 140 ILIAC LIMB -,SUP-TV-IL1412140-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
ILIAC GRAFT 14 X 100MM -,SUP-TV-IL1414100-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
OVATION IX ILAC STENT GRAFT 14 X 160MM -,SUP-TV-IL1414160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
OVATION IX ILIAC STENT GRAFT 18MM X 140MM -,SUP-TV-IL1418140-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT STENT OVATION IX ILIAC LIMB 18 X 160MM -,SUP-TV-IL1418160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
OVATION IX 22 X 100MM -,SUP-TV-IL1422100-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT STENT TRIVASCULAR OVATION IX 28 X 120 ILIAC LIMB -,SUP-TV-IL1428120-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT STENT TRIVASCULAR OVATION IX 28 X 160 ILIAC LIMB -,SUP-TV-IL1428160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT HUM TIS VEIN CRYPRSR CRYOVEIN SAPHENOUS -,SUP-V010,CDM,C1768,HCPCS,278,RC,,,outpatient,,,30011.06,21007.742,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT VASC 6MM 50CM VENAFLO II STR CRBN IMPREG EPTFE CUF -,SUP-VL5006C,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6999.2,4899.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GRAFT VASC 6MM 80CM GORE-TEX THNWL LN EPTFE -,SUP-VT06080L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4621.23,3234.861,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,51.089465,30693.4272,other,SI=N Exclusions ,,
GUIDEWIRE SPRING TIP REUSABLE MARKED -,SUP-000150,CDM,C1769,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.038INX260CM 3MM JTP TAPR FXCR STD PTFE-CTD 6CM -,SUP-00-8634,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.43,38.801,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW CATH 0.025IN GW LNR SS PTFE-CTD -,SUP-0684-00-0254-09,CDM,C1769,HCPCS,272,RC,,,outpatient,,,123.7,86.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX300CM HTORQ ALL STAR STR XTR SUPP INTMD -,SUP-1001741,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
HI-TORQUE SUPRACORE 35 (300cm) -,SUP-1002703-02,CDM,C1769,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.018INX190CM HTORQ STLCOR 18 STR FLXB SFT SS MICGLD -,SUP-1003281,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.018INX300CM HTORQ STLCOR 18 STR FLXB SFT SS MICGLD -,SUP-1003282,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX190CM HTORQ XIT 100XT STR SS/CTD 3CM 1.7GM -,SUP-1003309H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
SPARTA CORE 190CM ST -,SUP-1005202,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
SPARTACORE 14 WIRE (0.014IN- 300CM) -,SUP-1005203,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX190CM HTORQ SPARTACORE STR SFT SS SHFT -,SUP-1005205,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX300CM HTORQ SPARTACORE STR SFT SS SHFT -,SUP-1005206,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX190CM HTORQ  WHISPER MS STR SFT DURASTEEL -,SUP-1005357H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX300CM HTORQ WHISPER MS STR SFT DURASTEEL/ -,SUP-1005359H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX190CM HTORQ BAL MDWT UNIV STR RBN INTMD -,SUP-1009660,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDEWIRE HI-TORQUE BALANCE MIDDLEWEIGHT UNIVERSAL II 190CM -,SUP-1009664,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX190CM HTORQ PILOT 50 STR SFT DURASTEEL/ -,SUP-1010480-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX190CM HTORQ PILOT 150 STR STF DURASTEEL/ -,SUP-1010481-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX190CM HTORQ PILOT 200 STR DURASTEEL/ SS/CTD -,SUP-1010482-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX300CM HTORQ PILOT 50 STR SFT DURASTEEL/ -,SUP-1010483-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX300CM HTORQ PILOT 150 STR DURASTEEL/ SS/CTD -,SUP-1010484-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX300CM HTORQ PILOT 200 STR SFT DURASTEEL -,SUP-1010485-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
HI-TORQUE WHISPER GUIDE WIRE -,SUP-1011835H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX180CM ASAHI FIELDER F C STR XTR SUPP CTD 3CM -,SUP-1011895-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDEWIRE HI-TORQUE COMMAND 18 ST WORKHORSE 0.018IN x 210CM -,SUP-1013730,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.018INX300CM HTORQ COMMAND ES SS/NTNL/CTD 30CM -,SUP-1013731,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDEWIRE VERRATA 185 CM STRAIGHT TIP -,SUP-10185,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDEWIRE VERRATA 185 CM J-TIP -,SUP-10185J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDEWIRE VERRATA PLUS 185 CM J-TIP -,SUP-10185JP,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDEWIRE VERRATA 300 CM STRAIGHT TIP -,SUP-10300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDEWIRE VERRATA 300 CM J-TIP -,SUP-10300J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDEWIRE VERRATA PLUS 300 CM J-TIP -,SUP-10300JP,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDEWIRE VERRATA PLUS 300 CM STRAIGHT TIP -,SUP-10300P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
ST INTUB 11FRX110CM RTRGD 0.38IN STR/3MM J WG INTRO NDL SYR -,SUP-110-70-38J-110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1022.29,715.603,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INSHRTX182CM CHC STR SPR COIL HYDRCT SS -,SUP-12132-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,480.8,336.56,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDEWIRE ASAHI PROWATER 180 L -,SUP-12776-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX300CM ASAHI MIRACLEBROS 3 STR STEER FLXB SS -,SUP-14937-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW URO 0.38IN NTNL -,SUP-150NSA38,CDM,C1769,HCPCS,272,RC,,,outpatient,,,221.73,155.211,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW URO 0.038INX150CM NICORE NTNL HYDRCT STR STF COR -,SUP-150NSS38,CDM,C1769,HCPCS,272,RC,,,outpatient,,,221.73,155.211,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.009INX180CM ASAHI CONFIANZA PRO PTCA STR STEER -,SUP-20629-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDEWIRE VASCULAR HI-TORQUE COMMAND 0.014IN X 190CM -,SUP-2078174,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX300CM HTORQ COMMAND ES SS/NTNL/CTD 30CM -,SUP-2078175,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014IN/0.018IN DIA 145CM -,SUP-22260,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX190CM HTORQ FLPY II JTP RBN LGT SUPP SFT SS -,SUP-22339MJ,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX300CM HTORQ FLPY II STR RBN LGT SUPP SFT SS -,SUP-22359M,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX300CM HTORQ FLPY II JTP RBN LGT SUPP SFT SS -,SUP-22359MJ,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX300CM HTORQ WIGGLE STR RBN SS HYDRPHB -,SUP-22359M-W2,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX300CM HTORQ TRAV STR STD SHFT SS/CTD 3CM -,SUP-22379H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WIRE FLTR DLV BAREWIRE 0.014INX315CM SS COR PTFE-CTD -,SUP-22440-31,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX180CM RUNTHROUGH NS STR STEER EXTEND WIRE SS -,SUP-25-1011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX300CM RUNTHROUGH NS STR WIRE SS -,SUP-25-1013,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDE WIRE PTCA RUNTHROUGH NS HYPERCOAT 0.014X180CM -,SUP-25-3011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX150CM RUNTHROUGH NS STEER EXTEND WIRE SS -,SUP-25-9092,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.035INX260CM STR FXCR PTFE-CTD -,SUP-395369,CDM,C1769,HCPCS,272,RC,,,outpatient,,,218.81,153.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.035INX200CM STR FXCR PTFE-CTD -,SUP-395703,CDM,C1769,HCPCS,272,RC,,,outpatient,,,218.81,153.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC GUIDERIGHT 0.035INX150CM  3MM J REF:404570 -,SUP-404570,CDM,C1769,HCPCS,272,RC,,,outpatient,,,40.85,28.595,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDEWIRE GUIDERIGHT 3 MM J CURVE  L180 CM L5 CM OD.035 -,SUP-404571,CDM,C1769,HCPCS,272,RC,,,outpatient,,,43.76,30.632,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDEWIRE VASCULAR GUIDERIGHT J CURVE L260 CM L5 CM OD.35 -,SUP-404577,CDM,C1769,HCPCS,272,RC,,,outpatient,,,93.36,65.352,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDEWIRE VASCULAR GUIDERIGHT BENTSON L150 CM L15 CM OD.035 -,SUP-404843,CDM,C1769,HCPCS,272,RC,,,outpatient,,,54.27,37.989,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 190CM WHISPER VW HTORQ -,SUP-4483,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC WHISPER VW HTORQ -,SUP-4639,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDEWIRE EMERALD 0.35INx260CM J TIP  FLEX FIXED CORE PTFE -,SUP-502455,CDM,C1769,HCPCS,272,RC,,,outpatient,,,52.52,36.764,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.038INX150CM EMERLD 3MM JTP FXCR FLXB STD PTFE-CTD -,SUP-502-520,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.14,38.598,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.032INX150CM EMERLD 3MM JTP FXCR FLXB STD PTFE-CTD -,SUP-502-526,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.14,38.598,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.035INX150CM EMERLD STR FXCR FLXB STD PTFE-CTD 7CM -,SUP-502-542,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.14,38.598,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.035INX300CM STORQ ANG STEER 1PC COR SFT SGL OUTR -,SUP-503-356Y,CDM,C1769,HCPCS,272,RC,,,outpatient,,,404.37,283.059,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX300CM STBR + STR STEER S-SFT 3CM -,SUP-507-114X,CDM,C1769,HCPCS,272,RC,,,outpatient,,,349.22,244.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX300CM STBR XS STR STEER XTR SUPP SFT -,SUP-527-300E,CDM,C1769,HCPCS,272,RC,,,outpatient,,,560.16,392.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
PLATE LEFT ANTER LATERAL -,SUP-630111,CDM,C1769,HCPCS,272,RC,,,outpatient,,,10381.67,7267.169,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDEWIRE WARRIOR 200CM REF: 7388 -,SUP-7388,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1131.99,792.393,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDEWIRE R350 350CM REF: 7390 -,SUP-7390,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1367.53,957.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDEWIRE BANDIT 200CM REF: 7444 -,SUP-7444,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1131.99,792.393,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WIRE GUIDE .035X260 STIFF SUPER -,SUP-80129-406,CDM,C1769,HCPCS,272,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX300CM ASAHI PROWATER FLEX STR FLXB SPR COIL -,SUP-82358-02,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
"GUIDEWIRE 0.014"" X300CM PTCA STRAIGHT -",SUP-82902-02,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
PRESSURE GUIDEWIRE OMNIWIRE 185CM STRAIGHT TIP REF:89185 -,SUP-89185,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
PRESSURE GUIDEWIRE OMNIWIRE 185CM J-TIP REF:89185J -,SUP-89185J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.035INX260CM AMPLATZER MOD 1.5MM JTP NOODLEWIRE -,SUP-9-GW-002,CDM,C1769,HCPCS,272,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
EXTENSION GW ASAHI -,SUP-AG14900-0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDEWIRE VASCULAR MIRACLEBROS 6 L180 CM OD.014 IN STERILE L -,SUP-AG14M060,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDEWIRE ASAHI MIRACLEBROS 6 300CM DUPLICATE -,SUP-AG14M360,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
W VASC 0.014INX300CM ASAHI MIRACLEBROS 12 STR STEER FLXB SS -,SUP-AG14M370,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX300CM ASAHI CONFIANZA 9 STR XTR SUPP SPR -,SUP-AGH143390,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDEWIRE ASAHI PROWATER 300 CM .014 -,SUP-AGH146300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.009INX180CM ASAHI FIELDER F C PTCA JTP 1.2GM LD -,SUP-AGP1400-01J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.009INX190CM ASAHI FIELDER XT STR SPR COIL -,SUP-AGP140002,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.009INX300CM ASAHI FIELDER XT STR SPR COIL -,SUP-AGP140302,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDE WIRE ASAHI SION BLUE 180/190CM -,SUP-AHW14R004S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GAIA FIRST 190CM MICRO J -,SUP-AHW14R007P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GAIA SECOND 190CM MICRO J -,SUP-AHW14R008P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GAIA THIRD 190CM MICRO J -,SUP-AHW14R011P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX300CM ASAHI SOFT STR STEER COR-TO-TIP SS -,SUP-AHW14R304S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,490.14,343.098,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW GLADIUS MONGO190CM REF: AP14R023S -,SUP-AP14R023S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW FIELDER XT-A 190CM REF: APW14R009S -,SUP-APW14R009S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDE WIRE ASAHI SION BLACK 190CM STRAIGHT REF:APW14R010S -,SUP-APW14R010S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,566,396.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDE WIRE DOUBLE ENDED TROCAR .86MM -,SUP-AR-8737-39KD,CDM,C1769,HCPCS,272,RC,,,outpatient,,,175.05,122.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDE SPRING WIRE .018D 25CM -,SUP-AW-04018,CDM,C1769,HCPCS,272,RC,,,outpatient,,,53.92,37.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.018INX25CM 2FLX STR DBL END SPR WIRE SS -,SUP-AW-04018,CDM,C1769,HCPCS,272,RC,,,outpatient,,,53.92,37.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
"GUIDE SPRING WIRE .032"" -",SUP-AW-04432,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.08,38.556,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 175CM PRESSUREWIRE CERTUS SS NTNL PTFE-CTD -,SUP-C12008,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
PRESSUREWIRE X GUIDEWIRE 0.014INX175CM -,SUP-C12059,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 300CM PRESSUREWIRE CERTUS STEER CTD -,SUP-C12308,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
PRESSUREWIRE X GUIDEWIRE .014MMX300CM -,SUP-C12358,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.035INX260CM TIGRWRE ANG TAPR STEER FLXB FLPY SFT -,SUP-C405085,CDM,C1769,HCPCS,272,RC,,,outpatient,,,390.95,273.665,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.035INX180CM TIGRWRE ANG TAPR STEER FLXB FLPY SFT -,SUP-C405086,CDM,C1769,HCPCS,272,RC,,,outpatient,,,390.95,273.665,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
INTRO LAP 6MM SHTH 18GA 50CM -,SUP-C-LASS-6-10,CDM,C1769,HCPCS,272,RC,,,outpatient,,,431.79,302.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
ST CRICO MLKR 5MM PTFE XSTIF WG ENTRY NDLHLDR CUP GZE -,SUP-C-TCCSB-500-UNI,CDM,C1769,HCPCS,272,RC,,,outpatient,,,2450.49,1715.343,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
CPS EXCEL MEDIGUIDE MEDIUM GUIDEWIRE -,SUP-DS2M028,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
CPS EXCEL MEDIGUIDE STIFF GUIDEWIRE -,SUP-DS2M029,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
MEDIGUIDE GUIDEWIRE TORQUE CLIP -,SUP-DS2M030,CDM,C1769,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.035INX145CM STR 3MM JTP DBL END FLPY SS HEP -,SUP-G00362,CDM,C1769,HCPCS,272,RC,,,outpatient,,,93.3,65.31,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
W 15J .035 145CM x 15MM CURVE -,SUP-G00509,CDM,C1769,HCPCS,272,RC,,,outpatient,,,67.04,46.928,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.035INX145CM 3MM JTP CRV FXCR STD FLXB SS NO HEP -,SUP-G00511,CDM,C1769,HCPCS,272,RC,,,outpatient,,,67.04,46.928,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WIRE GUIDE .035 260 SAFE-T-J T -,SUP-G00517,CDM,C1769,HCPCS,272,RC,,,outpatient,,,104.97,73.479,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.035INX50CM 3MM NWTN JTP FNGR STR FXCR FLXB FLPY -,SUP-G00524,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.63,57.141,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WIRE GUIDE FIXED CORE 3MM J CURVED -,SUP-G00524,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.63,57.141,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.038INX145CM 3MM JTP FXCR FLXB SS HEP PTFE-CTD 6CM -,SUP-G00541,CDM,C1769,HCPCS,272,RC,,,outpatient,,,67.04,46.928,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WIRE GUIDE FIXED CORE STRAIGHT -,SUP-G00650,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.37,38.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
W BENTSON .035 145CM -,SUP-G00691,CDM,C1769,HCPCS,272,RC,,,outpatient,,,87.47,61.229,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.035INX180CM SAFE-T-J-TIP FXCR FLPY SS PTFE-CTD -,SUP-G00902,CDM,C1769,HCPCS,272,RC,,,outpatient,,,72.88,51.016,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
W .035 260 BENTSON TSFB-35-260 -,SUP-G01063,CDM,C1769,HCPCS,272,RC,,,outpatient,,,116.64,81.648,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.035INX260CM CRV RSN TIP FXCR FLPY W/OUT HEP -,SUP-G01253,CDM,C1769,HCPCS,272,RC,,,outpatient,,,104.97,73.479,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
THSCF 35 260 1.5 ROSEN 43700 -,SUP-G01253,CDM,C1769,HCPCS,272,RC,,,outpatient,,,104.97,73.479,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
W THSCF-35-180-1.5 ROSEN WIRE -,SUP-G01264,CDM,C1769,HCPCS,272,RC,,,outpatient,,,78.71,55.097,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WTSFB-35-180 BENTSON -,SUP-G01290,CDM,C1769,HCPCS,272,RC,,,outpatient,,,96.22,67.354,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.025INX180CM 3MM JTP FXCR STD FLXB SS HEP PTFE-CTD -,SUP-G01602,CDM,C1769,HCPCS,272,RC,,,outpatient,,,84.55,59.185,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WIRE GUIDE 0.032 IN X180CM SAFE T JTP PTFE-C  - G02335 -,SUP-G02335,CDM,C1769,HCPCS,272,RC,,,outpatient,,,84.55,59.185,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WIRE GUIDE 0.032 IN X260CM SAFE T J HEAVY DUTY - G03133 -,SUP-G03133,CDM,C1769,HCPCS,272,RC,,,outpatient,,,294.61,206.227,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WIRE AMPLATZ  0.035 INX145CM J CRV TIP XSTIF FLPY SS -,SUP-G03203,CDM,C1769,HCPCS,272,RC,,,outpatient,,,169.16,118.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WIRE AMPLATZ  0.025 IN X 145 OR 180 CM SAFE-T-J XTR-STF -,SUP-G03304,CDM,C1769,HCPCS,272,RC,,,outpatient,,,457.99,320.593,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.035INX180CM AMP STR XSTIF SS PTFE-CTD 7CM TAPR 3CM -,SUP-G03330,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.31,89.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WIRE AMPLATZ 0.032 IN X180CM JTP XSTIF FLPY SS PTFE-CTD -,SUP-G03584,CDM,C1769,HCPCS,272,RC,,,outpatient,,,125.39,87.773,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.038INX80CM AMP STR XSTIF FLPY SS PTFE-CTD 9.5CM -,SUP-G04003,CDM,C1769,HCPCS,272,RC,,,outpatient,,,148.73,104.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
SET CRIC MELKER 3.5MM 3.8CM -,SUP-G06245,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1139.28,797.496,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDEWIRE ROADRUNNER EXTRA SUP -,SUP-G07640,CDM,C1769,HCPCS,272,RC,,,outpatient,,,676.8,473.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 60CM NTNL -,SUP-G08427,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.18,167.426,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
W PMG-18SP-60-COPE-NT -,SUP-G08427,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.18,167.426,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
W PMG-18SP-COPE-NT -,SUP-G08733,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.18,167.426,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
COPE WIRE 60CM ST -,SUP-G09395,CDM,C1769,HCPCS,272,RC,,,outpatient,,,262.52,183.764,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.035INX180CM AMP STR ULTRA STF FLPY SS PTFE-CTD -,SUP-G09956,CDM,C1769,HCPCS,272,RC,,,outpatient,,,119.56,83.692,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
SHORT TAPER AMPLATZ WIRE 1CM -,SUP-G23639,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.31,89.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WIREGLIDE AMPLATZ EXTRA STIFF 0.035 X 180CM -,SUP-G23639,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.31,89.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WIRE UNIGLIDE ANG .018 260CM -,SUP-G30489,CDM,C1769,HCPCS,272,RC,,,outpatient,,,251.48,176.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WIRE UNIGLIDE ANG. .035 260CM -,SUP-G30492,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WIRE UNIGLIDE SIFF STR .035 260CM -,SUP-G30496,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.018INX260CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-G30500,CDM,C1769,HCPCS,272,RC,,,outpatient,,,269.57,188.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WIRE UNIGLIDE STR .018 260CM -,SUP-G30500,CDM,C1769,HCPCS,272,RC,,,outpatient,,,269.57,188.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WIRE UNIGLIDE STR .035 260CM -,SUP-G30502,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WIRE UNIGLIDE STIFF ANG .035 260CM -,SUP-G30506,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.035INX260CM LNDRQST STR XSTIF FLXB SS PTFE-CTD 4CM -,SUP-G31453,CDM,C1769,HCPCS,272,RC,,,outpatient,,,919.6,643.72,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW ENDO 0.035INX260CM TRACER METRO DRCT -,SUP-G31914,CDM,C1769,HCPCS,272,RC,,,outpatient,,,770.22,539.154,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
ACROBAT STR WIRE GUIDE 260 .03 -,SUP-G34265,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1042.19,729.533,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
SET GASTRONOMY ENTUIT START INIT PLCMT SM FOR 12/14FR -,SUP-G34442,CDM,C1769,HCPCS,272,RC,,,outpatient,,,551.35,385.945,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WIRE GUIDE HIWIRE HYDROPHILIC ANGLED 35 -,SUP-G36284,CDM,C1769,HCPCS,272,RC,,,outpatient,,,215.3,150.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WIRE HI .035 X 150CM STIFF ANGLED -,SUP-G36290,CDM,C1769,HCPCS,272,RC,,,outpatient,,,215.3,150.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WIRE HI .035 X 260CM STIFF STRAIGHT -,SUP-G36327,CDM,C1769,HCPCS,272,RC,,,outpatient,,,308.08,215.656,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WIRE GUIDE EX-STIFF 35-300 LUN -,SUP-G45408,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1025.79,718.053,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.035INX450CM ACROBAT 2 CTD -,SUP-G47616,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1038.63,727.041,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX190CM PRO-LT NTNL/PTFE-CTD/SS/PD 8CM TAPR -,SUP-G47736,CDM,C1769,HCPCS,272,RC,,,outpatient,,,339.6,237.72,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
LUNDERQUIST WIRE 0.035 x 180CM -,SUP-G49228,CDM,C1769,HCPCS,272,RC,,,outpatient,,,593.41,415.387,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WIRE METRO TRACER .035 X 600 -,SUP-G50660,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX190CM CTO MICROWIRE FLPY SS/PTFE-CTD/PLTNM -,SUP-G50788,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
CATH CTO 25 GRAM X 014 X 190CM -,SUP-G50789,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
W CTO 6G CMW-14-300-6G -,SUP-G50790,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
W CTO 12G CMW-14-300-12G -,SUP-G50791,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
W CTO 18G GUIDE WIRE -,SUP-G50792,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
W CTO 25G -,SUP-G50793,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX190CM HYDR ST MICRO FLPY SS/PTFE-CTD/PLTNM -,SUP-G52938,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1038.57,726.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX300CM HYDR ST MICRO FLPY SS/PTFE-CTD/PLTNM -,SUP-G52939,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1038.57,726.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.018INX180CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-G56141,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WIRE UNIGLIDE STR .018 180CM -,SUP-G56141,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WIRE UNIGLIDE STR .035 180CM -,SUP-G56150,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WIRE UNIGLIDE STIFF STR .035 180CM -,SUP-G56153,CDM,C1769,HCPCS,272,RC,,,outpatient,,,260.81,182.567,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
W GLIDE STIFF .035 180 STR -,SUP-G56153,CDM,C1769,HCPCS,272,RC,,,outpatient,,,308.15,215.705,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WIRE UNIGLIDE ANG .018 180CM -,SUP-G56160,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WIRE UNIGLIDE STR .035 260CM -,SUP-G56174,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WIRE UNIGLIDE STIFF ANG .035 180CM -,SUP-G56177,CDM,C1769,HCPCS,272,RC,,,outpatient,,,260.81,182.567,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GLIDEWIRE ADV .014 300CM ANG -,SUP-GA1430,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
W GLIDE ADVANTAGE 300 .018 -,SUP-GA1830,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1431.14,1001.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.035INX150CM GLIDEWIR ADVANTG ANG STF SHFT FLXB STD -,SUP-GA3501,CDM,C1769,HCPCS,272,RC,,,outpatient,,,933.6,653.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
W GLIDE ADVANTAGE 260 .035 -,SUP-GA3502,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.018INX300CM GLIDEWIR GOLD 45DG ANG FLXB -,SUP-GM1831,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1115.94,781.158,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.018INX300CM GLIDEWIR 70DG ANG GOLDBAND FLXB TIP -,SUP-GM1832,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1115.94,781.158,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDEWIRE .018/180 STRAIGHT -,SUP-GR1803,CDM,C1769,HCPCS,272,RC,,,outpatient,,,354.24,247.968,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GLIDEWIRE .018 150 ANGLED -,SUP-GR1805,CDM,C1769,HCPCS,272,RC,,,outpatient,,,354.24,247.968,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WIRE GLIDEWIRE 0.018INX180CM ANG STD FLXB -,SUP-GR1806,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.018INX260CM GLIDEWIR ANG STF SHFT STD FLXB -,SUP-GR1807,CDM,C1769,HCPCS,272,RC,,,outpatient,,,251.48,176.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
W GLIDE .035 180 STR -,SUP-GR3503,CDM,C1769,HCPCS,272,RC,,,outpatient,,,261.7,183.19,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WIRE GLIDE .035 260 STR -,SUP-GR3504,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.035INX150CM GLIDEWIR ANG STF SHFT STD FLXB -,SUP-GR3506,CDM,C1769,HCPCS,272,RC,,,outpatient,,,194.95,136.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WIRE GLIDE .035 180 ANG  GR3508 -,SUP-GR3508,CDM,C1769,HCPCS,272,RC,,,outpatient,,,261.7,183.19,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WIRE GLIDE .035 260 ANGLED -,SUP-GR3509,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.038INX180CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-GR3803,CDM,C1769,HCPCS,272,RC,,,outpatient,,,261.7,183.19,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.038INX260CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-GR3804,CDM,C1769,HCPCS,272,RC,,,outpatient,,,292.57,204.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDEWIRE VASCULAR GLIDEWIRE NITINOL STRAIGHT 260CM -,SUP-GS3504,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WIRE GLIDE 0.035 IN X 80 CM ANG STIFF -,SUP-GS3505,CDM,C1769,HCPCS,272,RC,,,outpatient,,,297.59,208.313,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WIRE GLIDE STIFF .035 180CM -,SUP-GS3508,CDM,C1769,HCPCS,272,RC,,,outpatient,,,260.81,182.567,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDEWIRE VASCULAR GLIDEWIRE NITINOL HYDROPHILIC ANGLE 260CM -,SUP-GS3509,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.035INX270CM LINEARGUIDEV ANG PTFE-CTD -,SUP-G-V210-3527A,CDM,C1769,HCPCS,272,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC VIPERWIRE .014IN TIP X 325CM -,SUP-GWC-12325LG-FLP,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC VIPERWIRE W/FLEX TIP .014IN TIP X 325CM -,SUP-GWC-12325LG-FT,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX300CM MLMN STR SUPER RAIL SUPP FLXB SPR COIL -,SUP-H74912120012,CDM,C1769,HCPCS,272,RC,,,outpatient,,,480.8,336.56,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDEWIRE MAILMAN 182CM STRAIGHT TIP 0.014 -,SUP-H74912136011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,480.8,336.56,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.14X190CM PLTNM + STR SUPER RAIL SUPP INTMD SPR -,SUP-H74917511,CDM,C1769,HCPCS,272,RC,,,outpatient,,,485.59,339.913,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.035INX300CM PLTNM + STR SUPER RAIL SUPP INTMD SPR -,SUP-H74917521,CDM,C1769,HCPCS,272,RC,,,outpatient,,,485.61,339.927,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.018INX300CM PLTNM + STR SUPER RAIL SUPP INTMD SPR -,SUP-H74917541,CDM,C1769,HCPCS,272,RC,,,outpatient,,,485.61,339.927,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX300CM VCT 14 CTRL WIRE STR SHRT TAPR ICE CTD -,SUP-H74939216730010,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
PRESSURE WIRE COMET II -,SUP-H74939359110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3926.81,2748.767,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDEWIRE SAFARI2  0.035 x 0275 CM XSMALL CURVE -,SUP-H74939406XS1,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3007.62,2105.334,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX330CM RTBLTR RTWR FLXB FLPY SS/CTD 2.2CM -,SUP-H74939462005,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1518.31,1062.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.009INX330CM RTWR 1.5MM RSN JTP CRV STF XTR SUPP -,SUP-H74939463005,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1518.31,1062.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX300CM VCT 14 12GM CTRL WIRE STR LNG TAPR -,SUP-H74939470300120,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1219.12,853.384,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX300CM VCT 14 18GM CTRL WIRE STR LNG TAPR -,SUP-H74939470300180,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1219.12,853.384,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX300CM VCT 14 25GM CTRL WIRE STR LNG TAPR -,SUP-H74939471300250,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX300CM VCT 14 30GM CTRL WIRE STR LNG TAPR -,SUP-H74939471300300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
COMET FFR WIRE 555111 -,SUP-H7495551110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3414.6,2390.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX300CM STINGRAY CTD CONN -,SUP-H749M3004A0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1625.29,1137.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX145CM STINGRAY CTD CONN -,SUP-H749M3010A0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,521.24,364.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX185CM STINGRAY CTD CONN -,SUP-H749M3012A0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1789.24,1252.468,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX180CM INTUITION STR SS SIL CTD -,SUP-INTU180SS,CDM,C1769,HCPCS,272,RC,,,outpatient,,,169.22,118.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WIRE GUIDE .035 260 INQWIRE REF: IQ35F260J3 -,SUP-IQ35F260J3,CDM,C1769,HCPCS,272,RC,,,outpatient,,,59.63,41.741,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDEWIRE AMPLATZ INQWIRE 0.035 X 71IN STRAIGHT SHORT TIP -,SUP-IQA511,CDM,C1769,HCPCS,272,RC,,,outpatient,,,255.63,178.941,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.035INX150CM ZIPWIRE STR STEER STF SHFT FLXB -,SUP-M00146306B1,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.24,167.468,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW AMPLATZ 0.035INX180CM J-TIP SUPER STIFF -,SUP-M001465011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
AMPLATZ WIRE SUPER STIFF  0.035 X 260 J -,SUP-M001465021,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.035IN X 260CM SUPER STIFF AMP STR SHRT TAPR FLXB -,SUP-M001465091,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
W AMPLATZ SS ST 35 145 BX/5 GU -,SUP-M001465231,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.035INX145CM SUPER STIFF AMP STR SHRT TAPR STD -,SUP-M001465241,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.035INX180CM SUPER STIFF AMP STR STD STEER SHFT -,SUP-M001465251,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
W AMPL SS EXCHANGE 260 STR -,SUP-M001465261,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
MAGIC TORQUE DLVR GW .035/315CM -,SUP-M001465301,CDM,C1769,HCPCS,272,RC,,,outpatient,,,805.23,563.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
W TORQUE 35 180 MAGIC 46-591 -,SUP-M001465911,CDM,C1769,HCPCS,272,RC,,,outpatient,,,443.46,310.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDEWIRE MAGIC TORQUE STRAIGHT 35-260 -,SUP-M001465921,CDM,C1769,HCPCS,272,RC,,,outpatient,,,443.46,310.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.018INX260CM PLTNM + SHRT TAPR STEER STF SHFT FLXB -,SUP-M001466050,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WIRE PLATINUM PLUS PTFE .014 X -,SUP-M001467120,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
W CON V18 8 200 46-852 -,SUP-M001468520,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDEWIRE V18 18 300    46-854 -,SUP-M001468540,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.018INX200CM 12CM V-18 CTRL WIRE STR STEER SFT SCTN -,SUP-M001468580,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.035INX150CM STRTR 3MM J FNGR STR FXCR STD SPR COIL -,SUP-M001491181,CDM,C1769,HCPCS,272,RC,,,outpatient,,,70.02,49.014,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
J WIRE 0.035 X 180CM -,SUP-M001491201,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.69,57.183,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.035INX260CM STRTR 3MM J FNGR STR FXCR STD SPR COIL -,SUP-M001491211,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.69,57.183,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.018INX190CM THRUWAY STR SHRT TAPR STEER SFT FLXB -,SUP-M001492791,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.018INX300CM THRUWAY STR SHRT TAPR STEER SFT FLXB -,SUP-M001492831,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
BSX THRUWAY 190CM 0.014 WIRE -,SUP-M001492921,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WIRE THRUWAY .014 X 300 STR -,SUP-M001492971,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.016INX180CM FATHOM 16 STR STEER NTNL ALY/PLTNM -,SUP-M001509100,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1563.65,1094.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW ENDO 0.035INX180CM JGWR -,SUP-M00515171,CDM,C1769,HCPCS,272,RC,,,outpatient,,,735.47,514.829,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
NOVAGOLD .018/260 -,SUP-M00552000,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1082.39,757.673,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW ENDO 0.035INX260CM HYD JGWR STF SHFT -,SUP-M00556061,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
DREAMWIRE .035/260 -,SUP-M00556100,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
DREAMWIRE .035/260 ANGLED -,SUP-M00556110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
DREAMWIRE .035/260 STIFF -,SUP-M00556120,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
DREAMWIRE .035/450 -,SUP-M00556140,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW ENDO 0.035IN STD 450CM DREAMWIRE HI-PRFRM DIST TIP -,SUP-M00556141,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
DREAMWIRE ANGLED 0.035 X 450CM -,SUP-M00556150,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW ENDO 0.035INX450CM DREAMWIRE HIPERF STF -,SUP-M00556161,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
JAGWIRE .038 / 260CM STRIAGHT -,SUP-M00556620,CDM,C1769,HCPCS,272,RC,,,outpatient,,,594.64,416.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
JAG-REVOLUTION WIRE .025/260 -,SUP-M00557000,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WIRE JAG REVOLUTION .025/450 -,SUP-M00557021,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
TUBE PEG 24FR ENDOVIVE LPRO PUL LF -,SUP-M00566480,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
"SPHINTEROTOME JAGTOME RX 44 0.35"" X 260CM -",SUP-M00573040,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1685.56,1179.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDEWIRE .038 -,SUP-M0066201010,CDM,C1769,HCPCS,272,RC,,,outpatient,,,65.06,45.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW URO 0.035INX150CM ZIPWIRE NTNL COR HYDRCT STR STD SHFT -,SUP-M006630205B1,CDM,C1769,HCPCS,272,RC,,,outpatient,,,219.51,153.657,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDEWIRE SENSOR .038 ANGLED -,SUP-M0066703021,CDM,C1769,HCPCS,272,RC,,,outpatient,,,241.45,169.015,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDEWIRE SENSOR -,SUP-M0066703091,CDM,C1769,HCPCS,272,RC,,,outpatient,,,230.6,161.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW URO 0.018IN X 150CM STD ZIPWIRE STRAIGHT -,SUP-M0066802001,CDM,C1769,HCPCS,272,RC,,,outpatient,,,298.43,208.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GLIDEWIRE STRAIGHT STIFF .035 SS -,SUP-M0066802221,CDM,C1769,HCPCS,272,RC,,,outpatient,,,302.94,212.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GLIDEWIRE STRAIGHT .038 SS -,SUP-M0066802251,CDM,C1769,HCPCS,272,RC,,,outpatient,,,302.94,212.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GLIDEWIRE ANGLED .038 SS STIFF -,SUP-M0066802261,CDM,C1769,HCPCS,272,RC,,,outpatient,,,302.94,212.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.018INX40CM SS -,SUP-MAK001,CDM,C1769,HCPCS,272,RC,,,outpatient,,,114.37,80.059,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.018INX40CM NTNL PLTNM -,SUP-MAK001N,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.37,89.859,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW METRO TRACER .035 X 480 -,SUP-METII-35-480,CDM,C1769,HCPCS,272,RC,,,outpatient,,,770.22,539.154,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDEWIRE W/NITREX .018 80CM STRAIGHT -,SUP-N180801,CDM,C1769,HCPCS,272,RC,,,outpatient,,,348.82,244.174,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014/ 0.008INX300CM ASTATO XS 20 STR TAPR PTFE-CTD -,SUP-PAGH143392,CDM,C1769,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.0180.0 13INX300CM ASTATO 30 STR PTFE-CTD 15CM 30GM -,SUP-PAGH18M371,CDM,C1769,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX300CM REGALIA XS 1 STR STF SHFT FLXB SPR -,SUP-PAGP140300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
TUBE JEJUNAL 12FR X 60CM PEG24 -,SUP-PEGJ-12-24,CDM,C1769,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
PHOENIX .014 FLOPPY TIP WIRE EXTRA SUPPORT -,SUP-PG14300XF,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
PIGTAIL WIRE PRO TRACK 175CM -,SUP-PTW-25-175,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1120.32,784.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WIRE DX 0.025IN BD PIGTL 230CM PROTRACK -,SUP-PTW-25-230,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1120.32,784.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
ILLUMINATION RELIEVA LUMA SENTRY -,SUP-SIS-100B,CDM,C1769,HCPCS,272,RC,,,outpatient,,,2273.91,1591.737,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDEWIRE 0.014 TCAR ENROUTE -,SUP-SR-014-GW,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WIRE SAFESEPT TRASEPTAL  0.014INX135CM -,SUP-SS-135,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1102.82,771.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
PK PROC CUST CARD CATHETERISATION LAB SLHSFR -,SUP-STLM004-13,CDM,C1769,HCPCS,272,RC,,,outpatient,,,288.66,202.062,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
DEVICE TRQ SGL HND F/0.010-0.038IN GW MUL-TRQ VISE STRL -,SUP-TD01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,38.34,26.838,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WIRE AMPLATZ 0.035 IN X 260CM CRV TIP XSTIF FLXB SS PTFE-CTD -,SUP-THSCF-025-260-3,CDM,C1769,HCPCS,272,RC,,,outpatient,,,166.24,116.368,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.032INX260CM AMP CRV JTP XSTIF FLPY SS PTFE-CTD 8CM -,SUP-THSCF322603AES,CDM,C1769,HCPCS,272,RC,,,outpatient,,,166.24,116.368,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.035INX145CM CRV RSN TIP FXCR FLXB FLPY SS PTFE-CTD -,SUP-THSCF351451.5R,CDM,C1769,HCPCS,272,RC,,,outpatient,,,78.71,55.097,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDE WIRE TORAY TRG-25230 -,SUP-TRG-25230,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.021INX180CM 3MM JTP FXCR FLXB SS PTFE-CTD 7CM TAPR -,SUP-TSCF-21-180-3BH,CDM,C1769,HCPCS,272,RC,,,outpatient,,,96.04,67.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.035INX180CM 3MM JTP FXCR FLXB SS HEP PTFE-CTD 6CM -,SUP-TSCF-35-180-3,CDM,C1769,HCPCS,272,RC,,,outpatient,,,72.88,51.016,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.035INX260CM LNDRQST FLXB LO SURF FRCTN EXTEND CRV -,SUP-TSCMG35260ELESD,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1025.79,718.053,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
WIRE GUIDE LUNDERQUIST .035 -,SUP-TSCMG35260LESDC,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1025.79,718.053,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC HTORQ WHISPER VW EDS -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
LOOP TIP WIRE GUIDE .035 X 480 -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1085.31,759.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
W MOVEABLE CORE 1.5J 035 145CM -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,151.71,106.197,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
W MOVEABLE CORE 3J 035 145CM -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,151.71,106.197,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDE WIRE VIPER .014 TIP -,SUP-VPR-GW-14,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GUIDE WIRE VIPER .017 335CM -,SUP-VPR-GW-FLEX18,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
GW VASC 0.014INX180CM ZINGER LS RSN JTP CRV LGT SUPP FRMG -,SUP-ZNGRLS180J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,169.22,118.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.60733,7443.65739,other,SI=N Exclusions ,,
COIL MRI ENDORECTAL DISP BPX15 -,SUP-BPX 15,CDM,C1770,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,144.095325,460.20645,other,SI=N Exclusions ,,
SYS SLING MALE VIRTUE -,SUP-50020,CDM,C1771,HCPCS,278,RC,,,outpatient,,,20164.56,14115.192,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,248.891925,15486.38208,other,SI=N Exclusions ,,
SLING SINGLE INCISION ALTIS -,SUP-519650,CDM,C1771,HCPCS,278,RC,,,outpatient,,,6206.85,4344.795,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,248.891925,15486.38208,other,SI=N Exclusions ,,
SYS SLING URETH ADVANCE MALE 3.55X36CM NABSB MSH NDLHLDRX2 -,SUP-720088-01,CDM,C1771,HCPCS,278,RC,,,outpatient,,,18026.62,12618.634,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,248.891925,15486.38208,other,SI=N Exclusions ,,
MESH SURG MINI ARC SLNG -,SUP-720095-01,CDM,C1771,HCPCS,278,RC,,,outpatient,,,5623.3,3936.31,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,248.891925,15486.38208,other,SI=N Exclusions ,,
MESH MINI ARC SLING PRECISE - DISCONTINUED -,SUP-720191-01,CDM,C1771,HCPCS,278,RC,,,outpatient,,,6578.45,4604.915,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,248.891925,15486.38208,other,SI=N Exclusions ,,
PROSTHESIS PENL MONARCH + 1.1CMX35CM SAL FIL CYL NABSB -,SUP-724041-93,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4807.35,3365.145,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,248.891925,15486.38208,other,SI=N Exclusions ,,
SLING GYN TVT PP 1.1X45CM URETH FEM MECH CUT -,SUP-810041B,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4965.48,3475.836,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,248.891925,15486.38208,other,SI=N Exclusions ,,
KIT TRANS OBTURATOR W TAPE INC -,SUP-93-4001,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4720.05,3304.035,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,248.891925,15486.38208,other,SI=N Exclusions ,,
ANCHORSURE SACROSPINOUS LIGAMENT FIXATION -,SUP-A-SURE,CDM,C1771,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,248.891925,15486.38208,other,SI=N Exclusions ,,
NEOMEDIC ANCHORSURE ANCHOR SYSTEM 2 ANCHORS -,SUP-A-SURE02,CDM,C1771,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,248.891925,15486.38208,other,SI=N Exclusions ,,
SLING URETH PP NABSB FEM -,SUP-M006850200051,CDM,C1771,HCPCS,278,RC,,,outpatient,,,3571.91,2500.337,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,248.891925,15486.38208,other,SI=N Exclusions ,,
SLING ADVANTAGE TRAN VAGINAL -,SUP-M0068502110,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4616.84,3231.788,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,248.891925,15486.38208,other,SI=N Exclusions ,,
SLING GYN ADVANTG FIT PP TRNVAG MI D URETH FEM -,SUP-M0068502110,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4616.84,3231.788,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,248.891925,15486.38208,other,SI=N Exclusions ,,
SLING LYNX MID URETHRAL SUPRAPUBIC BLUE SYSTEM -,SUP-M0068503010,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4439.29,3107.503,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,248.891925,15486.38208,other,SI=N Exclusions ,,
SLING GYN OBTRYX II -,SUP-M0068505110,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4420,3094,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,248.891925,15486.38208,other,SI=N Exclusions ,,
SLING GYN SOLYX SGL-INCS -,SUP-ML00001621,CDM,C1771,HCPCS,278,RC,,,outpatient,,,5030.63,3521.441,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,248.891925,15486.38208,other,SI=N Exclusions ,,
PUMP IT 87.5MM 19.5MM 20ML 165/185 GM EMTY/FUL 0.22UM FLTR -,SUP-8637-20,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29090.86,20363.602,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,23012.49024,other,SI=N Exclusions ,,
PUMP IT 87.5X26MM THK 40ML 175/215 GM EMTY/FUL 0.22UM FLTR -,SUP-8637-40,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29090.86,20363.602,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,23012.49024,other,SI=N Exclusions ,,
PUMP 8667-20 SYNCHROMEDIII INFUSION 20ML -,SUP-8667-20,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29964.18,20974.926,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,23012.49024,other,SI=N Exclusions ,,
PUMP 8667-40 SYNCHROMEDIII INFUSION 40ML -,SUP-8667-40,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29964.18,20974.926,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,23012.49024,other,SI=N Exclusions ,,
TIGHTRAIL SUB-C  9FR 560-009 -,SUP-560-009,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7193.58,5035.506,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions ,,
TIGHTRAIL SUB-C 11FR 560-011 -,SUP-560-011,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7830.18,5481.126,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions ,,
TIGHTRAIL SUB-C 13FR 560-013 -,SUP-560-013,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7830.18,5481.126,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions ,,
SHEATH CATH DLV 10FRX80CM AMPLATZER TORQVUE VASC 45DG ANG -,SUP-9-ATV10F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions ,,
SHEATH CATH DLV 9FRX80CM AMPLATZER TORQVUE VASC 45DG ANG SFT -,SUP-9-EITV09F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions ,,
SHEATH CATH DLV 12FRX80CM AMPLATZER TORQVUE VASC 45DG ANG -,SUP-9-EITV12F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions ,,
SYSTEM AMPLATZER DELIVERY TORQVUE 9-ITV06F 180/80 -,SUP-9-ITV06F 180/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,3909.91,2736.937,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions ,,
SHEATH CATH DLV 6FRX60CM AMPLATZER TORQVUE VASC 45DG ANG SFT -,SUP-9-ITV06F45/60,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions ,,
SHEATH CATH DLV 7FRX80CM AMPLATZER TORQVUE VASC 180DG ANG -,SUP-9-ITV07F180/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions ,,
SHEATH CATH DLV 7FRX80CM AMPLATZER TORQVUE VASC 45DG ANG SFT -,SUP-9-ITV07F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions ,,
SHEATH CATH DLV AMPLATZER TORQVUE/TREVISIO VASC 45DG ANG SFT -,SUP-9-ITV08F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions ,,
SHEATH CATH DLV 9FRX80CM AMPLATZER TORQVUE VASC 45DG ANG -,SUP-9-ITV09F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions ,,
SHEATH CATH DLV 12FRX80CM AMPLATZER TORQVUE VASC 45DG ANG- -,SUP-9-ITV12F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions ,,
AMPLATZER TALISMAN DELIVERY SHEATH 8F 80 -,SUP-9-TDS-08F45-80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions ,,
AMPLATZER TALISMAN DELIVERY SHEATH 9FR 80 -,SUP-9-TDS-09F45-80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions ,,
COMP LOADING SYS CLS-3000- 18F -,SUP-CLS-3000-18F-US,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2067.2,1447.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions ,,
VALVE DEL SYS COMM 26/29/31 -,SUP-DCS-C4-18F-US,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions ,,
CATH DELIVERY EVOLUT FX 23-29 REF: D-EVOLUTFX-2329 -,SUP-D-EVOLUTFX-2329,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions ,,
CATH DELIVERY EVOLUT FX 34 REF: D-EVOLUTFX-34 -,SUP-D-EVOLUTFX-34,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions ,,
CATH DELIVERY EVPROP2329US -,SUP-D-EVPROP2329US,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions ,,
SNARE ENSNARE SYSTEM 9-15 120 -,SUP-EN2006015,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1779.27,1245.489,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions ,,
SNARE ENSNARE 18 30 CM -,SUP-EN2007030,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions ,,
SNARE VASC EN SNR 27-45MM 7FR CATH 120CM 3 PREFRM LOOP NTNL -,SUP-EN2007045,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2644.95,1851.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions ,,
GTRS-200-RB RETREIVAL SET TULI -,SUP-G13287,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1590.1,1113.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions ,,
EXTRACTION TOOL 13FR MANUAL CONTROL ROTATION DILATOR SHEATH -,SUP-G23747,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7285.21,5099.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions ,,
SHEATH DILATOR 11FR EVOLUTION SHORTIE RL PERC -,SUP-G23749,CDM,C1773,HCPCS,272,RC,,,outpatient,,,5843.14,4090.198,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions ,,
SNARE VASC EYE SNR 13MMX94CM FLSH PRT NTNL 16FR WRKSTN -,SUP-G26517,CDM,C1773,HCPCS,272,RC,,,outpatient,,,5674.23,3971.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions ,,
SNARE VASC AMP GOOSENECK 15MM/6FR LOOP/CATH 120CM GOLD TUNG -,SUP-GN1500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions ,,
SNARE EV AMP GOOSENECK 20X120MM GOLD TUNG NTNL 6FRX102CM -,SUP-GN2000,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions ,,
SNARE VASC AMP GOOSENECK 25MM/6FR LOOP/CATH 120CM GOLD TUNG -,SUP-GN2500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions ,,
KIT GOOSE NECK SNARE 25MM LOOP -,SUP-GN3000,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions ,,
SNARE GOOSENECK GN3500 -,SUP-GN3500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions ,,
SNARE AMPLATZ GN 5MM -,SUP-GN500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions ,,
STYLET LD LIBERATOR 140CM -,SUP-LR-OFA01,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2639.4,1847.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions ,,
CATHETER INTRODUCER AVEIR 50CM REF:LSN25501 -,SUP-LSN25501,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions ,,
BASKET STONE SEGURA -,SUP-M0063801120,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1030.93,721.651,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions ,,
SNARE ONE700 175CM 7MM LOOP -,SUP-ONE700,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2851.99,1996.393,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions ,,
SNARE ONE701 200CM 7MM LOOP -,SUP-ONE701,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2959.88,2071.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions ,,
SNARE VASC AMP GOOSENECK 7X175MM GOLD TUNG NTNL -,SUP-SK700,CDM,C1773,HCPCS,272,RC,,,outpatient,,,3126.44,2188.508,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,231.443785,6420.62028,other,SI=N Exclusions ,,
HEAD FEM 12/ 1440MMX3.5MM NK TAPR -,SUP-00080184001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 40MM -,SUP-00080184002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 15X190MM WAGNER SL REVISN PROTASUL-100 POR CTD -,SUP-00100101915,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 18X225MM WAGNER SL REVISN PROTASUL-100 POR CTD -,SUP-00100102218,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 9MM PRFT ANTMC 110MM PROTASUL-100 UNCEM TAPR SHLDR -,SUP-00104201092,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 40X14MM -,SUP-00104212400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 44X16MM PROTASUL-21 WF ANTMCREM -,SUP-00104212440,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 46X16MM PROTASUL-21 WF ANTMC REM -,SUP-00104212460,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 48X17MM ANTMC SHLDR PROTASUL-21 REM -,SUP-00104212480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 50X18MM PROTASUL-21 WF ANTMC REM -,SUP-00104212500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP 24MM SM ANTMC SHLDR 16MM PE PG CMNT -,SUP-00104214340,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP 28MM MED ANTMC SHLDR 19MM PE PG CMNT -,SUP-00104214370,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ3 39.68MM OFST 141MM AVENIR MULLER STD 56.11MM NK -,SUP-00106010003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ4 40.22MM OFST 147MM AVENIR MULLER STD 56.88MM NK -,SUP-00106010004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM LAT AVENIR MUELLER SZ 4 -,SUP-00106010104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 12/14 TAPR M/L HIP -,SUP-00106010107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
WEDGE ANKL JNT OSSEOTI 15X15MM POR MTL -,SUP-00110003821,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8785.08,6149.556,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CEMENT BN PLYMTHL MTHCRYLT 40GM PLC R HVISC -,SUP-00111214001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INTEGRAL SHORT GTR W/2 CABLES 23 X 53 -,SUP-00223200204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6861.23,4802.861,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 46X18MM BGLNI/FLTW STD ZML MODULAR OFST -,SUP-00430004618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP 40MM BGLNI/FLTW SHLDR UHMWPE SS PG -,SUP-00430008500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP 46MM BGLNI/FLTW SHLDR UHMWPE SS PG -,SUP-00430008600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 40X18MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 40X21MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP 40MM 46MM ARTC SURF BGLNI/FLTW SHLDR UHMWPE SS PG -,SUP-00430204046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 46X15MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204615,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 46X17MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 46MM OFST MODULAR -,SUP-00430204618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 46X19MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 46X27MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204627,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP 46MM BGLNI/FLTW SHLDR W/52MM SS PG -,SUP-00430204652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BF OFFSET HUM HEAD 18MM X 52MM -,SUP-00430205218,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 52X19MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430205219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 52X21MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430205221,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 10MM INTOP FLXB 130MM TM 42DG ANG NK SHLDR -,SUP-00434211013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 11MM INTOP FLXB 130MM TM 42DG ANG NK SHLDR -,SUP-00434211113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 6MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434810613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 8MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434810813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 9MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434810913,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 10MM TM 130MM 48DG ANG SHLDR -,SUP-00434811013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 11MM TM 130MM 48DG ANG SHLDR -,SUP-00434811113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 12MM TM 130MM 48DG ANG SHLDR -,SUP-00434811213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 13MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434811313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 12MM RVRS 130MM TM LPRO SHLDR -,SUP-00434901213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18477.37,12934.159,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 32X53MM EPSLN STD DRSL UHMWPE PRIM HD -,SUP-00437732053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 42MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500104200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 43MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500104300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 28X47-49MM VERSYS BIPLR UHMWPE -,SUP-00500104728,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 49MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500104900,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 28X50-52MM VERSYS BIPLR UHMWPE -,SUP-00500105028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 51MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 52MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 28X53-55MM VERSYS BIPLR UHMWPE -,SUP-00500105328,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 54MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 55MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 60MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500106000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT LMRL KN SZ2 27MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800227,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HALF BLOCK TRABECULAR TIBIAL AUGMENT RT LATERAL/LT MEDIAL -,SUP-00-5448-002-28,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10465.7,7325.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT RM/LL KN SZ2 37MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800237,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HALF BLOCK TRABECULAR TIBIAL AUGMENT LT LATERAL/RT MEDIAL -,SUP-00-5448-002-38,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10465.7,7325.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT LMRL KN SZ3 27MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800327,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT LMRL KN SZ3 26MM NEXGEN 5MM WDG FUL BLCK TM TIV PMMA -,SUP-00544800337,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT LMRL KN SZ5 27MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800527,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT RM/LL KN SZ5 37MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT KN 31MMMEDX31MM TM -,SUP-00545001331,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15863.61,11104.527,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT KN 36MM MED 25MMX36MM TM -,SUP-00545001336,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CONE TIBIAL TM LARGE 51 X 34 RIGHT -,SUP-00-5450-013-52,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CONE FEMORAL LT SM 30MM -,SUP-00545001730,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT RT DPHSL KN SZ30 SM TM -,SUP-00545001731,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT RT DPHSL KN SZ30 MED TM -,SUP-00545001831,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TM FEM DIAPHYSEAL CONE- 30 LARGE- RIGHT -,SUP-00-5450-019-31,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT KN SZ48 XS NEXGEN 15MM TM -,SUP-00545004801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19404.14,13582.898,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT TRAB METALTIB SZ 52-51MM FULL SMALL -,SUP-00-5450-052-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19404.14,13582.898,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT DIST KN SZ-D NEXGEN 5MM BLCK REVISN TM TIV -,SUP-00549003401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT KN SZ-D NEXGEN 5MM DIST BLCK REVISN TM TIV -,SUP-00549003410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT KN SZ-D NEXGEN 10MM BLCK REVISN TM TIV -,SUP-00549003420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT POST 5MM BLCK SZ-E NEXGEN BLCK REVISN TM TIV -,SUP-00549003501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT DIST KN SZ-E NEXGEN 5MM BLCK REVISN TM TIV -,SUP-00549003510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT KN SZ-E NEXGEN 10MM DIST BLCK REVISN TM TIV -,SUP-00549003520,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT POST KN SZ-F NEXGEN 5MM DIST BLCK REVISN TM TIV -,SUP-00549003601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT KN SZ-F NEXGEN 10MM POST BLCK REVISN TM TIV -,SUP-00549003602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT DIST KN SZ-F NEXGEN 5MM DIST BLCK REVISN TM TIV -,SUP-00549003610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-E MINUS NEXGEN GENDR SOL LT KN CR CMNT ZML PMMA -,SUP-00575001505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-E MINUS NEXGEN GENDR SOL LT KN CR CMNT COCR FLEX -,SUP-00575201505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-E MINUS NEXGEN GENDR SOL RT KN CR CMNT COCR FLEX -,SUP-00575201506,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-D NEXGEN LEGC GENDR SOL LT KN PS CMNT ZML FLEX -,SUP-00576401451,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-E NEXGEN LEGC GENDR SOL LT KN PS CMNT ZML FLEX -,SUP-00576401551,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-E NEXGEN LEGC GENDR SOL RT KN PS CMNT ZML FLEX -,SUP-00576401552,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-F NEXGEN LEGC GENDR SOL LT KN PS CMNT ZML FLEX -,SUP-00576401651,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBPLT SZ2 44/25MM LMRL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBPLT SZ3 47/27MM LMRL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBPLT SZ4 50/29MM LL/RM KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBPLT SZ5 53/31MM LMRL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBPLT SZ5 53/31MM RM/LL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-D 23/48MM NEXGEN LMRL CONDL UNICMPT ZML HI FLEX -,SUP-00584201401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-E 24/51.5MM NEXGEN LMRL CONDL UNICMPT ZML HI -,SUP-00584201501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-F 25/55.5MM NEXGEN LMRL CONDL UNICMPT ZML HI -,SUP-00584201601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-F 25/55.5MM NEXGEN LL/RM KN UNICMPT ZML HI FLEX -,SUP-00584201602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL SIZE G RM/LL -,SUP-00584201702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ARTICULAR SURFACE SIZE 2 11MM -,SUP-00584202211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 8MM UNICMPT ARTCSURF NET SHP KN-HI FLEX MLD -,SUP-00584202308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ARTICULAR SURFACE SIZE 5 8MM -,SUP-00584202508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ2 9MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3229.61,2260.727,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 8MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ4 8MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ4 10MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4521.46,3165.022,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5 8MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 32MM MED 19.5MM TM PMMA NEXGEN -,SUP-00587601019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16244.38,11371.066,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 29MM MICRO 10MM PEGX3 POR -,SUP-00587806129,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 32X10MM THK TM PMMA NEXGEN PRIM POR -,SUP-00587806532,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
NEXGEN POROUS TM PATELLA 10MM X 32MM -,SUP-00-5878-065-32,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 38X10MM THK TM PMMA NEXGEN PRIM POR -,SUP-00-5878-065-41,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIB SZ C-H FEM 3 TIB 10X67/43MM NEXGEN PRFT CR MBLK -,SUP-00588604310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12109.95,8476.965,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIB SZ C-H FEM 5 TIB 10X75/47.5MM NEXGEN PRFT CR MBLK -,SUP-00588604510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10860.53,7602.371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SCREW HEADED HEX 3.5MM X -,SUP-00-5901-035-33,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ1 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ2 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT. -,SUP-00592601201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ2 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ3 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ3 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ4 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ4 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
NEXTGEN CR FLEX PROLONG ART SURF C-H/1-2 SPUR- 14MM -,SUP-00-5952.021-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
NEXGEN CR FLEX PROLONG  ART SURF -,SUP-00-5952-021-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ A-B/1-2 10MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596202010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ C-D/1-2 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596202212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ C-D SZ1-2 FEM 14MM NEXGEN PS ARTCSURF KN FLEX -,SUP-00596202214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ C-D/1-2 17MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596202217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ-E SZ1-2 FEM 10MM NEXGEN PS ARTCSURF KN FLEX FX -,SUP-00596202410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ E-F/3-4 10MM NEXGEN LEGACY ARTCSURF KN PS FLEX -,SUP-00596203210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ E-F/3-4 14MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596203214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ E-F/3-4 17MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596203217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
NEXTGEN LPS-FLEX FIXED PROLONG ART SUR EF 3-4- 20MM -,SUP-00-5962-032-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ E-F/5-6 10MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ E-F/5-6 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ E-F/5-6 17MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ G-H/5-6 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ G-H/5-6 14MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ E-F/7-10 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596205112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-E 68/62.5MM NEXGEN LEGC RT KN PS CMNT ZML FLEX -,SUP-00596401552,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-F 72/65.5MM NEXGEN LEGC R/L KN PS CMNT ZML FLEX -,SUP-00596401652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-G 76.5/71.5MM NEXGEN LEGC L/L KN PS CMNT ZML -,SUP-00596401751,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-G 76.5/71.5MM NEXGEN LEGC R/L KN PS CMNT ZML -,SUP-00596401752,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ C-D/3-4 14MM NEXGEN LPS ARTCSURF NET SHP KN -,SUP-00596403012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-D NEXGEN LEGC LT KN PS CMNT TIV NPOR FLEX FX -,SUP-00596801451,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-F NEXGEN LEGC LT KN PS CMNT TIV NPOR FLEX FX -,SUP-00596801651,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-G NEXGEN LEGC RT KN PS CMNT TIV NPOR FLEX FX -,SUP-00596801752,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 29MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206529,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 32MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206532,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 35MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 38MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206538,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 29MM PRLNG NEXGEN ON ST -,SUP-00597206629,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 32MM PRLNG NEXGEN ON ST -,SUP-00597206632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PATELLA NEXGEN PROLONG ALLPOLY 35MM -,SUP-00597206635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 38MM PRLNG NEXGEN ON ST -,SUP-00597206638,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
NEXGEN AC ART SURF 5-6 GREEN 12MM -,SUP-00597604012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT KN SZ3 NEXGEN 5MM CR PRCTD TIV PMMA -,SUP-00-5988-003-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5398.37,3778.859,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT L/R KN SZ4 NEXGEN 10MM HLF BLCK CR TIV PMMA -,SUP-00598800427,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5398.37,3778.859,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 11MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 12MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SCISSORS OPTH KNAPP 4IN SS CRV V. MUELLER MIRR FNSH S/S IRIS -,SUP-00-5988-010-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 16MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 18MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 20MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 16MM NEXGEN 155MM TIV ALY STR FEM/TBL KN -,SUP-00598801116,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 12.7MM NEXGEN 30MM TIV ALY STR FEM/TBL KN -,SUP-00598801212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 15MM NEXGEN 30MM TIV ALY STR FEM/TBL KN -,SUP-00598801215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SCISSORS OPTH STVNS 4IN SS STR V. MUELLER MIRR FNSH -,SUP-00598802011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SCOOP SURG SM 11IN SLVR PLT CMN DCT MLBL V. MUELLER -,SUP-00598802012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 13MM NEXGEN OFST 100MM TIV ALY FEM/TBL KN -,SUP-00598802013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 14MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 15MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 16MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 17MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 12MM NEXGEN OFST 155MM TIV ALY FEM/TBL KN -,SUP-00598802112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 11MM NEXGEN OFST 155MM TIV ALY FEM/TBL KN -,SUP-00598802115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT ANT KN SZ-D NEXGEN 5MM WDG BLCK TIV PMMA -,SUP-00599003431,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5398.37,3778.859,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-C 60/53.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401392,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-D 64/57.5MM NEXGEN LEGC LT CONDL KN CNSTRN -,SUP-00599401491,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-D 64/57.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401492,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-E 68/61.5MM NEXGEN LEGC LT CONDL KN CNSTRN -,SUP-00599401591,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-E 68/61.5MM NEXGEN LEGC RT KN REVISN CNSTRN -,SUP-00599401592,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-F 72/65.5MM NEXGEN LEGC LT KN REVISN CNSTRN -,SUP-00599401691,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-F 72/65.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401692,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-G 76.5/70.5MM NEXGEN LEGC LT KN REVISN CNSTRN -,SUP-00599401791,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-G 76.5/70.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401792,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ C-D/1-2 MICRO 10X58/40MM NEXGEN LEGC CNSTRN -,SUP-00599402210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ C-D/1-2 MICRO 12X58/40MM NEXGEN LEGC CNSTRN -,SUP-00599402212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ C-D/1-2 MICRO 14X58/40MM NEXGEN LEGC CNSTRN -,SUP-00599402214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB 0.5X20MM THK 58MM/40MM M/L A/P NEXGEN LEGC CNSTRN -,SUP-00599402220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ C-D/3-4 17X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ C-D/3-4 20X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ E-F/3-4 10X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ E-F/3-4 12X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ E-F/3-4 14X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ E-F SZ3-4 FEM 17MM 66MM/42MM M/L/A/P NEXGEN -,SUP-00599403217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
NEXGEN LCCK ART SURF EF 3-4/STR YELLOW 20MM -,SUP-00599403220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9695.93,6787.151,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ E-F/5-6 10X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ E-F/5-6 14X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ E-F/5-6 17X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ E-F/5-6 20X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ-G 5-6 17X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ G-H/7-10 14X82/50MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599405014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIA ALL POLY NEXGEN LPS SZ 8 BLUE 14MM FEM G H -,SUP-00599600814,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4638.69,3247.083,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 32X50MM TRILOGY 10DG TIV ALY UHMWPE 6.3MM PRIM -,SUP-00615405032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8097.55,5668.285,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 32X68MM TRILOGY 10DG TIV ALY UHMWPE 12.4MM PRIM -,SUP-00615406832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8097.55,5668.285,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 54MM TRILOGY PRIM MUL-HL TIV POR CTD SLD HMSPHR -,SUP-00620005420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6960.16,4872.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 44MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620204420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 48MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620204820,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 50MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620205020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 54MM PRIM MODULAR REVISN CLUS-HL TM TNTLM TIV SLD -,SUP-00620205422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 56MM PRIM MODULAR REVISN NO-HL TM TNTLM TIV SLD -,SUP-00620205620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 22X62MM TRILOGY PRIM MODULAR REVISN CLUS-HL TM -,SUP-00620206220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 68MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620206820,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 32X48MM XL TRILOGY 0DG STD LNGVT XLPE 5.3MM PRIM -,SUP-00630504832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 36X50MM TRILOGY 0DG STD LNGVT XLPE 6.8MM PRIM -,SUP-00630505036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 28X44MM TRILOGY 10DG ELEV RM LNGVT XLPE 5.2MM -,SUP-00631004428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 28X46MM TRILOGY 10DG ELEV RM LNGVT XLPE 6.3MM -,SUP-00631004628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 36X58MM XL TRILOGY 10DG STD LNGVT XLPE 8.9MM PRIM -,SUP-00631005836,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 32X62MM TRILOGY 10DG LNGVT XLPE 9.3MM PRIM -,SUP-00631006236,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 28X44MM TRILOGY 20DG ELEV RM LNGVT XLPE 5.2MM -,SUP-00632004428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 28X46MM TRILOGY 20DG ELEV RM LNGVT XLPE 6.3MM -,SUP-00632004628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 32X48MM TRILOGY 20DG ELEV RM LNGVT XLPE 5.3MM -,SUP-00632004832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 32X56MM TRILOGY 20DG ELEV RM LNGVT XLPE 6.4MM -,SUP-00632005632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 28X50MM TRILOGY LNGVT XLPE 7.2MM CNSTRN MODULAR -,SUP-00633405028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14191.09,9933.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 32X56MM TRILOGY LNGVT XLPE 6.4MM CNSTRN MODULAR -,SUP-00633405632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14191.09,9933.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRABECULAR METAL REVISION SHELL 56MM -,SUP-00700005620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16582.26,11607.582,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BLADE EXPLANT TRUNCATED 60MM -,SUP-00705306010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BLADE FULL EXPLANT 60MM -,SUP-00705306020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 6X111MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 TAPR -,SUP-00771100600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 10X119MM PRFT EXTEND OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 11X121MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 12.5X124MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 15X129MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM VERSYS 41MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM VERSYS 43MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM VERSYS 44MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM VERSYS 47MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM VERSYS 50MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781805000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM VERSYS 51MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781805100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM VERSYS 52MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781805200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ADAPTER HIP VERSYS ENPROS TIV TAPR. -,SUP-00781809901,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ11 120MM VERSYS LD/FX PRFT ZML CMNT HIP -,SUP-00783301100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ12 125MM VERSYS LD/FX PRFT ZML CMNT HIP -,SUP-00783301200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ14 135MM VERSYS LD/FX PRFT ZML CMNT HIP -,SUP-00783301400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
NECK FEM SZ K2 KINECTIV M/L HIP MODULAR COCR -,SUP-00784802001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
NECK FEM SZ S2 KINECTIV M/L HIP MODULAR COCR -,SUP-00784803001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
NECK FEM SZ P2 KINECTIV M/L HIP MODULAR COCR STR 12/14 TAPR -,SUP-00784803101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
KINECTIV MODULAR NECK G2 -,SUP-00784803201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4916.67,3441.669,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
NECK FEM SZ R2 KINECTIV M/L HIP MODULAR COCR STR 12/14 TAPR -,SUP-00784804201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ13 130MM VERSYS ADVCT PRIM STD OFST NON V-LIGN -,SUP-00785001300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM VERSYS CMTD STD 14X135 -,SUP-00785001400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CENTRALIZER DIST FEM HIP 11MM VERSYS PMMA CMNT -,SUP-00785901100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CENTRALIZER DIST FEM HIP 13MM VERSYS PMMA CMNT -,SUP-00785901300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 14X135MM VERSYS PRIM EXTEND OFST TIV POR CTD FM -,SUP-00786201420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 16X145MM VERSYS PRIM STD OFST TIV POR CTD FM TAPR -,SUP-00786201600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 16X145MM VERSYS PRIM EXTEND OFST TIV POR CTD FM -,SUP-00786201620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 18X155MM VERSYS PRIM STD LRG OFST TIV POR CTD FM -,SUP-00786201830,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 20X155MM VERSYS PRIM EXTEND LRG OFST TIV POR CTD FM -,SUP-00786202050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 13X170MM VERSYS REVISN ZML CMNT CLCR HIP -,SUP-00787101360,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21520.55,15064.385,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 13X210MM VERSYS REVISN ZML CMNT CLCR HIP -,SUP-00-7871-013-61,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21520.55,15064.385,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ15 220MM VERSYS REVISN ZML CMNT CLCR HIP -,SUP-00787101561,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21520.55,15064.385,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM VERSYS 28X0MM NK ZML 12/14 TAPR STRL -,SUP-00801802802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM VERSYS 28MM +3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801802803,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM VERSYS 28MM +7MM NK ZML 12/14 TAPR STRL -,SUP-00801802814,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM VERSYS 32MM-3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM VERSYS 32MM +3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM VERSYS 32MM +7MM NK ZML 12/14 TAPR STRL -,SUP-00801803214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM VERSYS 36MM-3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM VERSYS 36X0MM NK ZML 12/14 TAPR STRL -,SUP-00801803602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM VERSYS 36MM +3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803603,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ELEV RIM 32MM I.D. LONGE -,SUP-00875200832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 36X52MM II SHL CONTIN ELEV LNGVT XLPE 4.7MM F -,SUP-00875201036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RIM LINER 36MM SIZE JJ LONGEVITY HIGHLY CROSSLINKED POLY -,SUP-00-8752-011-36,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ EE 44MM CONTIN CLUS-HL TM TIV SNP FIT LCK GRV -,SUP-00875704401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ FF 46MM CONTIN MUL-HL TM TIV SNP FIT LCK GRV -,SUP-00875704602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ GG 48MM CONTIN CLUS-HL TM TIV SNP FIT LCK GRV -,SUP-00875704801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ HH 50MM CONTIN CLUS-HL TM TIV SNP FIT LCK GRV -,SUP-00875705001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ II LINER 52MM CONTIN CLUS-HL TM TIV SNP FIT -,SUP-00875705201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ II 52MM CONTIN MUL-HL TM TIV SNP FIT LCK GRV -,SUP-00875705202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ JJ LINER 54MM CONTIN MUL-HL TM TIV SNP FIT LCK -,SUP-00875705401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 28MMX-3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877502801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BIOLOX DELTA FEM HEAD 28MM +0MM -,SUP-00877502802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 32MM-3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 32MM +0MML NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 36MM-3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEMORAL 36MM CERAMIC -,SUP-00-8775-036-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 36MM +3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503603,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 36MM +7MM BIOLOX DELTA CER -,SUP-00-8775-036-04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BIOLOX DELTA OPTION FEM HEAD 28MM +0MM -,SUP-00-8777-028-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3150.84,2205.588,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BIOLOX OPTION HEAD 36/+3.5 TAPER 12/14 -,SUP-00-8777-036-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9780.3,6846.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BIOLOX OPTION HEAD XL 36/+7 TAPER 12/14 -,SUP-00-8777-036-04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9780.3,6846.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 28X44MM EE SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 28X46MM FF SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200728,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 32X48MM GG SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 32X50MM HH SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200932,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 36NN ID 52MM II SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885201036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 36X54MM JJ SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885201136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 22MMLNGX5.5MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902602300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 28MM SHRT +0MML NK ZML 6DG TAPR ANTMC STRL -,SUP-00902602800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 28MMMEDX+7MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902602900,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 28MMLNGX+14MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902603000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 32MMSHRTX3.5MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902603235,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD 6DEGREE COCR FEM 36MM +3.5 S+ -,SUP-00-9026-036-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD 6 DEGREE COCR FEM 36MM +7 M -,SUP-00-9026-036-07,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 15X185MM ZMR REVISN MODULAR TIV PLASM SPRY POR CTD -,SUP-00998201518,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14636.65,10245.655,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BODY HIP SZ A 17.7MM BD 40MM OFST ZMR REVISN MODULAR 45MM NK -,SUP-00999601745,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21253.21,14877.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM WAGNER REVISION 135 NK ANGLE 18MM X 265MM -,SUP-01.00102.618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB DURAM -,SUP-01.00214.152,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16626.81,11638.767,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CONE WAGNER 135 DEG X 21MM -,SUP-01.00561.321,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13856.92,9699.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SIDUS STEM-FREE SHOULDER HUMERAL HEAD 48-17 -,SUP-01.04555.480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM AVENIR STANDARD CEM 4 -,SUP-01.06010.204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM STD CEMENTED 7 TAPER 12/14 AVENIR -,SUP-01.06010.207,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AVENIR LATERAL STEM CEM 4 -,SUP-01.06010.304,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM AVENIR LATERAL CEM 8 -,SUP-01.06010.308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP RVRS 25MM BSPLT HA+ADPTR -,SUP-010000589,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL G7 ACETABULAR PPS LTD 46B -,SUP-010000660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 PPS LTD ACET SHELL 48C -,SUP-010000661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 PPS LTD ACET SHELL 50D -,SUP-010000662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL G7 ACETABULAR PPS LTD 52E -,SUP-010000663,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL G7 ACET PPS LTD SHELL 54F -,SUP-010000664,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 PPS LTD ACET SHELL 56F -,SUP-010000665,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 PPS LTD ACET SHELL 60G -,SUP-010000667,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL G7 PPS LTD ACET 46 B -,SUP-010000719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER G7 NEUTRAL ARCOMXL 32MM B -,SUP-010000729,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 NEUTRAL ARCOMXL LNR 36MM D -,SUP-010000739,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 NEUTRAL ARCOMXL LNR 36MM E -,SUP-010000740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ARCOMXL G7 NEUTRAL 36MM F -,SUP-010000741,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 ACETABULAR LINER 36MM / G -,SUP-010000742,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 NEUTRAL ARCOMXL LNR 40MM G -,SUP-010000748,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 NEUTRAL E1 LINER 28MM C -,SUP-010000837,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 NEUTRAL E1 LINER 32MM -,SUP-010000846,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 NEUTRAL E1 LINER 32MM C -,SUP-010000847,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 NEUTRAL E1 LINER 36MM D -,SUP-010000856,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 NEUTRAL E1 LINER 36MM F -,SUP-010000858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 FREEDOM CONST E1 LNR 36MM -,SUP-010000982,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 FREEDOM COSTR E1 LNR 36MM G -,SUP-010000985,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD COCR FEM 40MM TYPE 1 +9MM -,SUP-010001032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COCR FEM HD 40MM TYPE 1 +6MM -,SUP-010001033,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEMORAL COCR 40MM TYPE 1 STD -,SUP-010001035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COCR FEM HD 40MM TYPE 1-3MM -,SUP-010001036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
WAGNER SL REVISION STEM 135 NK ANGLE 15MM X 225MM -,SUP-0100102215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
WAGNER SL REV STEM 135 NK ANGLE 14 X 265 -,SUP-0100102614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CONE WAGNER 125 DEG X 19MM -,SUP-0100561219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13856.92,9699.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ADAPTER ANTMC BGLNI 42 -,SUP-0104250042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AS B/F ADAPTOR 48 DEG -,SUP-0104250048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AC-CONNECTOR -,SUP-0104440000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM AVENIR 5 TAPER 12/14 MULL -,SUP-0106010005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM AVENIR 6 TAPER 12/14 MULL -,SUP-0106010006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
MORSE TAPER HEAD +5 OFFSET WITH LFIT 32MM -,SUP-01-3205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PLATE 2.7/3.5 VA ANTLAT DSTL TIB PL/10 H/LFT -,SUP-02.118.209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10401.04,7280.728,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BONE PREP KIT 21-1000 SFN -,SUP-0206-710-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,740.32,518.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LOW FRICTION ION TREATMENT -,SUP-06-2200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
C-TAPER LFIT HEAD LOW FRI ION TREATMENT -,SUP-06-2205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 26X0MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-06-2600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEMORAL LFIT COCR +5 MM OFFSET C TAPER 26MM HIP -,SUP-06-2605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
C-TAPER LFIT HEAD LOW FRICTION SZ. 26MM / +10 -,SUP-06-2610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 28X0MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-062800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
C-TAPER LFIT HEAD LOW FRICTION SZ. 28MM / +10 -,SUP-06-2810,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 32X0MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-063200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 32MM-5MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-063299,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 36MM +0MML NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-063600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 40MM-2.5MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-064097,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM PLASMA SPRAY STD SIZE 2 TI6AI4V -,SUP-101-0002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HIP STEM PLASAM STD SZ 3 -,SUP-101-0003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ4 37MM OFST 110MM OVATN STD OFST 29MM 7MM M/L/A/P -,SUP-101-0004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ5 OVATN STD OFST TI PLASM SPRY CTD 12/14 TAPR -,SUP-101-0005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ6 38MM OFST 118MM OVATN STD OFST 31MM 9MM M/L/A/P -,SUP-101-0006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ7 32MM OFST 122MM OVATN STD OFST 32MM 10MM -,SUP-101-0007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ8 43MM OFST 126MM OVATN STD OFST 34MM 11MM -,SUP-101-0008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ9 44MM OFST 130MM OVATN STD OFST 36MM 13MM -,SUP-101-0009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ10 47MM OFST 134MM OVATN STD OFST 38MM 16MM -,SUP-101-0010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ5 44MM OFST 114MM OVATN EXTEND OFST 30MM 8MM -,SUP-101-1005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8233.36,5763.352,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ6 9/31X118MM OVATN EXTEND OFST 33MM LEG 44MM HZNT -,SUP-101-1006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ7 49MM OFST 122MM OVATN EXTEND OFST 32MM 10MM -,SUP-101-1007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ8 50MM OFST 126MM OVATN EXTEND OFST 34MM 11MM -,SUP-101-1008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ9 STD OVATN EXTEND OFST TI PLASM SPRY CTD 12/14 -,SUP-101-1009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ10 55MM OFST 134MM TI PLASM SPRY CTD HIP OVATN -,SUP-101-1010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SELF CENT HIP 41X28 RUST -,SUP-1035-41-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
WIRE EXTFIX 1.8MM BAYNT PNT -,SUP-104.690,CDM,C1776,HCPCS,278,RC,,,outpatient,,,367.02,256.914,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RING ACTB SZ23 TI HIP LCK LINER YEL RINGLOC STRL SUD -,SUP-1054-23,CDM,C1776,HCPCS,278,RC,,,outpatient,,,770.22,539.154,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SPACER DIST HIP 10MM ACCOLADE C SZ SMALL -,SUP-1059-2310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SPACER FEM CMNT RNG STYL MED 12MM DIST F/STM 4/5 ACCOLADE -,SUP-1059-4512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RINGLOC + HIP SYSTEM SZ 21 -,SUP-106021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SPACER DIST FEM HIP UNIV 8MM ACCOLADE CMNT -,SUP-1067-0008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SPACER DIST FEM HIP 9MM UNIV CMNT -,SUP-1067-0009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SPACER DIST FEM HIP 10MM UNIV CMNT -,SUP-1067-0010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SPACER DIST FEM HIP 11MM UNIV RECON CMNT -,SUP-1067-0011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SPACER DIST FEM HIP 12MM UNIV CMNT -,SUP-1067-0012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SPACER DIST FEM HIP 13MM UNIV CMNT -,SUP-1067-0013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SPACER DIST FEM HIP 14MM UNIV CMNT -,SUP-1067-0014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SPACER DIST FEM HIP 15MM UNIV CMNT -,SUP-1067-0015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OMNIFIT UNIVERSAL DISTAL CEMENT SPACER 16MM -,SUP-1067-0016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CEMENT SPACER UNIVERSAL DISTAL -,SUP-1067-0017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
VARIO CUP 28MM X 47MM -,SUP-107-220/47,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5160.7,3612.49,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
VARIO CUP 28MM X 48MM -,SUP-107-220/48,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5160.7,3612.49,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
VARIO-CUP SYSTEM OUTER 50MM HEAD 28MM -,SUP-107-220/50,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5160.7,3612.49,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 OSSEOTI 3 HOLE SHELL 50MM D -,SUP-110010243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 OSSEOTI MULTIHOLE 50MM D -,SUP-110010263,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 MULTIHOLE 52MM -,SUP-110010264,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 OSSEOTI MULTIHOLE 54MM F -,SUP-110010265,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 OSSEOTI MULTIHOLE 56MM F -,SUP-110010266,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 OSSEO TI ACETABULAR SHELL 58MM / G -,SUP-110010267,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 OSSEO TI MULTIHOLE 60MM G -,SUP-110010268,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL G7 OSSEO TI MULTIHOLE 62MM H -,SUP-110010269,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 OSSEO TI MULTIHOLE 64MM H -,SUP-110010270,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER G7 DUAL MOBILITY 38MM C -,SUP-110024461,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 DUAL MOBILITY LINER 42MM E -,SUP-110024463,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 DUAL MOBILITY LINER 44MM F -,SUP-110024464,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 DUAL MOBILITY LINER 50MM H -,SUP-110024466,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPR VRS GLEN PPS MIN TPR ADR -,SUP-110027734,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26395.72,18477.004,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PRX HUM LO PLT LT 4H 83MM -,SUP-110030101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6875.28,4812.696,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
40MM VERSA-DIAL GLEN STD -,SUP-110030776,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
40MM VERSA-DIAL GLEN +3 -,SUP-110030777,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BEARING VIVACIT-E DM 28 X 44MM -,SUP-110031012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BEARING VIVACIT-E DM 28 X 50MM -,SUP-110031015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
VERSA-DIAL TAPER ADAPTOR 25MM -,SUP-110031378,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HMRL TRAY STD STD -,SUP-110031399,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRAY HMRL STD SHOULDER REVERSE TI -,SUP-110031408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HMRLBEARING 36MM +3 PRLNG -,SUP-110031419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HMRL BEARING 40MM STD PRLNG -,SUP-110031421,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HMRL BEARING 36 MM STD VITE -,SUP-110031424,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HMRL BEARING 36 MM +3 VITE -,SUP-110031425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BEARING HUMERAL 40MM STD VITE -,SUP-110031427,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPR AUG BSPLT W ADP SM -,SUP-110032410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPR AUG BSPLT W ADP MD -,SUP-110032420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPR AUG BSPLT W ADP LG -,SUP-110032430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HMRL BEARING 36MM STD PRLNG -,SUP-11031418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FREEDOM CONSTR HD 36MM T1 -,SUP-11-107016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7259.36,5081.552,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FREEDOM CONSTR 36MM T1 +9MM -,SUP-11-107021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7259.36,5081.552,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 6MM MAC PRIM RVRS CMPRHNSV 140MM COCR PLASM CTD -,SUP-11-113556,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PROXIMAL FEMORAL OMPONENT RHS LEFT -,SUP-1115-9110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22682.72,15877.904,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL CHECKPOINT STERILE -,SUP-111651,CDM,C1776,HCPCS,278,RC,,,outpatient,,,260.65,182.455,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RINGLOC BIPOLAR 28X49MM -,SUP-11-165222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD RADL SZ12 22MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6332.05,4432.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD RADL SZ14 24MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM RADL SZ7 26MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7295.44,5106.808,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM RADL SZ8 28MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210063,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7507.64,5255.348,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM STR DIST ARCOS 23MM X 150MM TAPER -,SUP-11-300823,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STS DISTAL STEM 15 X 190MM -,SUP-11-300915,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
DIST ARCOS 19 X 190MM SPL TPR -,SUP-11-300919,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CON ARCOS SZ A STD 60MM -,SUP-11-301301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CON ARCOS SZ A STD HI 50MM -,SUP-11-301310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ARCOS CON SIZE E HI 70MM -,SUP-11-301335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STANDARD CONE PROX BODY 80MM -,SUP-11-301342,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ARCOS CON SIZE B HI 80MM -,SUP-11-301352,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
VERSA-DIAL 38 X 19 X 39 HUM HEAD -,SUP-113022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
VERSA-DIAL 38X21X38 HUM HEAD -,SUP-113024,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 42MM 46X18MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
VERSA DIAL 42 X 21 X 43 HUM HEAD -,SUP-113034,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 46X53MM 18MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 46X50MM 24MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 46X46MM 27MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 50MM 57X21MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 50X50MM 27MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113057,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
MODULAR HEAD 54MM 21MM 64MM -,SUP-113063,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TAPER ADAPTER 54MM X 24MM -,SUP-113065,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM VERSA-DIAL 54X27X55 -,SUP-113067,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HUM HEAD VERSA-DIAL 58 X 24 X 64 -,SUP-113075,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE COMP FX HUM POS 8MM -,SUP-113576,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE COMP FX HUM POS 9MM -,SUP-113577,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
POSTIONING SLEEVE COMP FX HUM 10MM -,SUP-113578,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE COMP FX HUM POS 11MM -,SUP-113579,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FX HUM POS SLEEVE 12MM -,SUP-113580,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FX HUM POS SLEEVE 13MM -,SUP-113581,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PRIMARY STEM 9MM MICRO -,SUP-113609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PRIMARY STEM 10MM MICRO -,SUP-113610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PRIMARY STEM 11MM MICRO -,SUP-113611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PRIMARY STEM 12MM MICRO -,SUP-113612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM COMP PRIMARY MICRO 13MM -,SUP-113613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM COMP PRIMARY MICRO 14MM -,SUP-113614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PRIMARY STEM 15MM MICRO -,SUP-113615,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PRIMARY STEM 17MM MICRO -,SUP-113617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PRIMARY STEM 19MM MICRO -,SUP-113619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM COMP PRIMARY 5MM MINI -,SUP-113625,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM COMP PRIMARY 6MM MINI -,SUP-113626,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PRIMARY STEM 7MM MINI -,SUP-113627,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM COMP PRIMARY 8MM MINI -,SUP-113628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPREHENSIVE HUMERAL STEM 9MM MINI -,SUP-113629,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
POROUS PLASMA 10MM 83MM LONG -,SUP-113630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PRIMARY STEM 11MM MINI -,SUP-113631,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPREHENSIVE HUMERAL STEM 12MM MINI -,SUP-113632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM COMP PRIMARY 13MM MINI -,SUP-113633,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM COMP PRIMARY 14MM MINI -,SUP-113634,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM COMP PRIMARY 15MM MINI -,SUP-113635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM COMP PRIMARY 16MM MINI -,SUP-113636,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD MOD 36MM COCR 3MM -,SUP-11-363661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD COCR MOD HD STD 36MM -,SUP-11-363662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD 36MM COCR MOD +36MM -,SUP-11-363663,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM COMP PRIMARY 17MM MINI -,SUP-113637,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 7MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113647,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 8MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113648,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 12MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 15MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113655,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 16MM STD PRIM PRFT RVRS CMPRHNSV 122MM COCR PLASM -,SUP-113656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP MODULAR HYBRID SHLDR POST 4MM UHMWPE PG -,SUP-113951,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP SM MODULAR HYBRID SHLDR BS 4MM UHMWPE PG -,SUP-113952,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP MED MODULAR HYBRID SHLDR BS 4MM UHMWPE PG -,SUP-113954,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SPHERE GLND 36MM STD CMPRHNSV VERSA-DIAL RVRS HAP POR CTD -,SUP-115310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SPHERE GLND +3MM 36MM CMPRHNSV VERSA-DIAL RVRS HAP POR CTD -,SUP-115313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE 28MM CMPRHNSV SHLDR RVRS -,SUP-115330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRY HUMERAL STD 44MM COCR SHLDR RVRS CMPRHNSV STRL SUD -,SUP-115370,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PIN INSRTR 24.5CM FRLCK F/VFX2 FEM FX SYS -,SUP-118001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
KT BONE CMNT PREP-IM -,SUP-121010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3685.53,2579.871,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM COMPR 6MM HUM FRACT PPS -,SUP-12-113556,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPR 8MM HUM FRACT STEM PPS -,SUP-12-113558,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPR 10MM HUM FRACT STEM PPS -,SUP-12-113560,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPR 12NN HUM FRACT STEM PPS -,SUP-12-113562,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD MODULAR CER BIOLOXD 28MM -3 NK -,SUP-12-115109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CER BIOLOXD MOD HD 28MM STD NK -,SUP-12-115110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CER BIOLOXD MOD HD 28MM +3 NK -,SUP-12-115111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CER BIOLOXD MOD HD 32MM-3NK -,SUP-12-115114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD CERAMIC BIOLOX STANDARD NECK -,SUP-12-115115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CER BIOLOXD MOD HD 36MM STD NK -,SUP-12-115121,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CER BIOLOXD MOD HD 36MM +3 NK -,SUP-12-115122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CER BIOLOXD MOD HD 36MM +6 NK -,SUP-12-115123,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD ENDO II MOD SIZE 49 -,SUP-12-139022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 54MM PINNCL NO-HL POR CTD LCK RNG SLD -,SUP-1217-01-054,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4847.45,3393.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 58MM PINNCL NO-HL POR CTD LCK RNG SLD -,SUP-1217-01-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4992.9,3495.03,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 60MM PINNCL NO-HL POR CTD LCK RNG SLD -,SUP-1217-01-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4992.9,3495.03,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 46MM PINNCL MUL-HL BANTAM POR CTD PLASM SPRY LCK -,SUP-1217-20-046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6137.89,4296.523,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 48MM PINNCL MUL-HL BANTAM PE POR CTD LCK RNG SLD -,SUP-1217-22-048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6215.13,4350.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 52MM PINNCL MUL-HL BANTAM SECT PE POR CTD LCK RNG -,SUP-1217-22-052,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4847.45,3393.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 54MM PINNCL MUL-HL BANTAM SECT PE POR CTD LCK RNG -,SUP-1217-22-054,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4706.3,3294.41,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 62MM PINNCL PRFT NO-HL GRIPTN -,SUP-1217-31-062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16040.16,11228.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 48MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CUP ACETABULAR 50MM -,SUP-1217-32-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 52MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-052,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10299.17,7209.419,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 54MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-054,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 56MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10299.17,7209.419,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 58MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10509.65,7356.755,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 60MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10299.17,7209.419,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 62MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACETABULAR PINNACLE 54 47 -,SUP-121854047,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13117.66,9182.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PINNACLE DM LINER 56 49 -,SUP-121856049,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13117.66,9182.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER DUR MAR +4 10D 36 X 54 -,SUP-122036554,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 32X50MM PINNCL NEUT ALTRX BLU -,SUP-1221-32-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 32X48MM PINNCL +4 10DG ALTRX BLU -,SUP-1221-32-148,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 32X50MM PINNCL +4 10DG ALTRX BLU -,SUP-1221-32-150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 36X58MM PINNCL NEUT ALTRX ORNG -,SUP-1221-36-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 36X52MM PINNCL +4 10DG ALTRX ORNG -,SUP-1221-36-152,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 36X54MM PINNCL +4 10DG ALTRX ORNG -,SUP-1221-36-154,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 36X56MM PINNCL +4 10DG ALTRX ORNG -,SUP-1221-36-156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 40X56MM PINNCL NEUT ALTRX -,SUP-1221-40-056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 40X58MM PINNCL NEUT ALTRX WHT -,SUP-1221-40-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 40X62MM PINNCL NEUT ALTRX -,SUP-1221-40-062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 40X56MM PINNCL LD +4 10DG ALTRX PNK -,SUP-1221-40-156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 40X58MM PINNCL LD +4 10DG ALTRX PNK -,SUP-1221-40-158,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ALTRX +4 10D 40IDX620D -,SUP-1221-40-162,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CATALYST R1 SHORT STEM HUMERAL SIZE 36S -,SUP-1230-7501-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CATALYST R1 POLY INSERT IMPLANT36 +0 -,SUP-1230-7504-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CATALYST R1 POLY INSERT SIZE 36 +4 -,SUP-1230-7504-002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CATALYST R1 STANDARD BASEPLATE IMPLANT -,SUP-1230-7506-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10674.88,7472.416,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CATALYST R1 GLENOSHERE SIZE 36 STD -,SUP-1230-7513-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9761.2,6832.84,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 52MM RESTOR ADM X3 PRFT MBL BRNG CMNTLS SLF-LCK -,SUP-1235-2-521,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 54MM RESTOR ADM X3 PRFT MBL BRNG CMNTLS SLF-LCK -,SUP-1235-2-541,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 60MM RESTOR ADM PRIM -,SUP-1235-2-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 28X48MM RESTOR ADM 0DG DURATION PE 6.9MM -,SUP-1235-2-848,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 28X54MM RESTOR ADM 0DG DURATION PE 9.9MM -,SUP-1235-2-854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 28X60MM RESTOR ADM 0DG DURATION PE 12.9MM -,SUP-1235-2-860,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 36X22.2MM RECON ADM MDM X3 UHMWPE PRIM ASYM -,SUP-1236-2-242,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 38X22.2MM RECON ADM MDM X3 UHMWPE PRIM ASYM -,SUP-1236-2-244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT RESTORATION ADM/MD/ 29MM X 28/48 SIZE 42E X3 -,SUP-1236-2-848,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 28X48MM RESTOR ADM X3 PE 6.9MM REVISN -,SUP-1236-2-848,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 28X52MM RESTOR ADM X3 PE 8.9MM REVISN -,SUP-1236-2-852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT RESTORATION ADM/MD/ 28MM X 28/52 SIZE 46F X3 -,SUP-1236-2-852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 28X54MM RESTOR ADM X3 PE 9.9MM REVISN -,SUP-1236-2-854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT RESTORATION ADM/MDM 28MM X 52H X3 SZ 28/58MM -,SUP-1236-2-858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RES INSERT ADM/MDM 28MM SZ54I -,SUP-1236-2-860,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PROSTHESIS HEAD A 28MM NECK L S +3.5 TAPER 12/14 -,SUP-128-791/03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PROSTHESIS HEAD A 32MM MED 12/14 -,SUP-128-792/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PROSTHESIS HEAD A 36MM NECK L S -4 TAPER 12/14 -,SUP-128-793/01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PROSTHESIS HEAD A 36MM NECK M NECK LEN 0 TAPER 12/14 -,SUP-128-793/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PROSTHESIS HEAD A 36MM NECK LARGE +4 TAPER 12/14 -,SUP-128-793/03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINK PROSTHESIS HEAD A CERAMIC 8MM -,SUP-128-793/04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PROSTHESIS HEAD A 40MM NECK M TAPER 12/14 -,SUP-128-794/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD PROSTESIS B 24MM 12/14 M -,SUP-128-824/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PROSTHESIS HEAD B 28MM M NEC L 0 12/14 -,SUP-128-828/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PROSTHESIS HEAD B NECK XL +10.5 -,SUP-128-828/04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINK PROSTHESIS HEAD B 36MM +4 -,SUP-128-836/03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ2.5 69.6/45.8MM KN CMNT STM SIGMA COCR PS -,SUP-1294-33-125,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ3 KN CMNT STM SIGMA COCR PS TCMPRTMNTL MBL -,SUP-1294-33-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ5 KN CMNT STM SIGMA COCR PS TCMPRTMNTL MBL -,SUP-1294-33-150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ6 KN CMNT STM SIGMA COCR PS TCMPRTMNTL MBL -,SUP-1294-33-160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ2.5 67/44MM KN CMNT SIGMA COCR PS REVISN MBL -,SUP-1294-35-125,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ3 70MM M/L 46MM A/P KN CMNT SIGMA COCR PS -,SUP-1294-35-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIB TRAY ROT PLAT MBT REV SZ 4 -,SUP-129435140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
REV MBT TIBIAL ROT PLAT TRAY SZ. 3 -,SUP-1294-35-315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
REVISION MBT TIBIAL TRAY SZ. 4 / 15MM -,SUP-1294-35-415,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRAY TIBIAL ROTATING PLAT MBT REV SZ 4 25MM THICK CEMENTED -,SUP-1294-35-425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE FEMORAL UNIV DISTAL PORUS 34MM -,SUP-1294-53-225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE UNIV FEMORAL 48MM FULL POROUS -,SUP-1294-53-246,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE TIB 29X29/26MM LCS COMPL MODULAR REVISN BEAR KN RP -,SUP-1294-54-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE TIB 37X37/27MM LCS COMPL MODULAR REVISN BEAR KN RP -,SUP-1294-54-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE TIB 45X45/27MM LCS COMPL MODULAR REVISN BEAR KN RP -,SUP-1294-54-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE METAPHYSEAL 53MM POUROUS MBT REV -,SUP-1294-54-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
METAPHYSEAL SLEEVE POROUS -,SUP-1294-54-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
METAPHYSEAL SLEEVE 29MM CEMENTED REV -,SUP-1294-54-140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
UNITED HIP FULL XPE CUP I.D. 32MM O.D. 48MM -,SUP-1302-3248,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
UNITED HIP FULL XPE CUP I.D. 32MM O.D. 50MM -,SUP-1302-3250,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
UNITED HIP FULL XPE CUP I.D. 28MM O.D. 46MM -,SUP-1302-3846,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
UNITED HIP LOCKING CAGE OD58MM LEFT -,SUP-1308-1158,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
UNITED HIP LOCKING CAGE OD54MM RIGHT -,SUP-1308-1254,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
UNITED HIP LOCKING CAGE OD 58MM RIGHT -,SUP-1308-1258,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
UNITED HIP SYS LOCKING CAGE 62MM RIGHT -,SUP-1308-1262,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
UNIPOLAR 42MM OD -,SUP-132-0042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD SOLITUDE UNIPOLAR 43MM -,SUP-132-0043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
UNIPOLAR 47MM -,SUP-132-0047,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
UNIPOLAR 53MM SOLITUDE -,SUP-132-0053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
UNIPOLAR SOLITUDE 55MM -,SUP-132-0055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
UNIPOLAR 57MM -,SUP-132-0057,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ADAPTER SOLITUDE UNIPOLAR +0MM -,SUP-132-1200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ADAPTER +6MM 12/14 -,SUP-132-1206,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ADAPTER OFFSET 9MM 12/14 -,SUP-132-1209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP 3MM SOLITUDE OFST ADPTR UNIPL COCR 12/14 TAPR -,SUP-132-1230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL BIPOLAR PIVOT 22 X 40 ACETABULAR -,SUP-133-2240,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PIVOT BIPOLAR 22 X 43MM BIPOLAR -,SUP-133-2243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM 22X44MM SHL OFST L CUP BIPLR TI COCR UHMWPE -,SUP-133-2244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM 28X46MM SHL OFST L CUP BIPLR TI COCR UHMWPE -,SUP-133-2846,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CUP BIPOLAR MOD COCR 28X47MM -,SUP-133-2847,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PIVOT BIPOLAR 28 X 49 -,SUP-133-2849,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PIVOT BIPOLAR 28 X 50MM -,SUP-133-2850,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BIPOLAR 28MM ID 51MM OD -,SUP-133-2851,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PIVOT BIPOLAR 28 X 52 BIPOLAR -,SUP-133-2852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL BIPOLAR PIVOT 28MM X 53MM -,SUP-133-2853,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL BIPOLAR PIVOT 28X54MM -,SUP-133-2854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PIVOT BIPOLAR 28 X 55 -,SUP-133-2855,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PIVOT BIPOLAR 28X56MM BIPOLAR -,SUP-133-2856,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PIVOT BIPOLAR 28MM X 57MM -,SUP-133-2857,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEMORAL CERAMIC 28MM -,SUP-136-2800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEMORAL CERAMIC DELTA 28MM 3 BIOLOX -,SUP-136-2830,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TAPERED SPACER ARTICUL/EZE -3 -,SUP-136308000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SPACER HIP ARTICL/EZ MODULAR CATHCART UNIPL +0MML NK 12/14 -,SUP-1363-10-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1144.83,801.381,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SPACER HIP ARTICL/EZ MODULAR CATHCART UNIPL +5MM NK 12/14 -,SUP-1363-12-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1144.83,801.381,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL HEAD 32MM -3 CERAMIC 12/14 TAPER -,SUP-136-3230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 51MM UNIPL MODLR CATHCART BALL ORTHCNTRC DSGN -,SUP-1363-51-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1933.62,1353.534,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
MODULAR CATHCART BALL 53MM OD -,SUP-136353000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD 36MM +0 BIOLOX DELTA CERAMIC FEMORAL -,SUP-136-3600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM BIOLOX DELTA 36MM XL MODULAR -,SUP-136-3604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEMORAL 36MM +3 BIOLOX DELTA CERAMIC -,SUP-136-3613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEMORAL 36MM +6 CERAMIC 12/14 TAPER -,SUP-136-3616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEMORAL BIOLOX DELTA CERAMIC 36MM -3 -,SUP-136-3630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FERMORAL HEAD BIOLOX DELTA CERAMIC 36MM -6 -,SUP-136-3660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD CERAMIC FEMORAL DELTA -,SUP-136-4000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 40MMMEDX-1MM NK BIOLOX DELTA 12/14 TAPR -,SUP-136-4002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2570.74,1799.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL HEAD CERAMIC 40MM +3 BIOLOX -,SUP-136-4013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL CERAMIC HEAD 40MM +9 -,SUP-136-4019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL HEAD CERAMIC 40MM -3 BIOLOX -,SUP-136-4030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ARTICUL/EZE BALL 28 +1.5 GR -,SUP-136511000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM ARTICL/EZ 28MMSTDX+8.5MM NK BIOLOX DELTA TS CERM -,SUP-1365-13-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ARTIUL/EZE BALL 28 +12 BLK -,SUP-136514000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4405.7,3083.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEMORAL BIOLOX DELTA 28MM +5 12/14 TAPER CERAMIC REV -,SUP-1365-28-720,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8563.54,5994.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ARTICUL/EZE BALL 22.225+4 NK -,SUP-136529000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4405.7,3083.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD S-ROM M 36MM +0 -,SUP-136531000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL HEAD M-SPEC METAL 36MM +3 11/13 -,SUP-1365-32-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CERAMIC FEMORAL HEAD 32MM +0 11/13 TAPER -,SUP-1365-32-210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12117,8481.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD BIOLOX DELTA CERAMIC FEMORAL 36MM -,SUP-1365-36-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4487.56,3141.292,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CERAMIC FEMORAL HEAD 40MM X +8.5 BIOLOX DELTA TS 12/14 TAPER -,SUP-1365-40-730,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CERAMIC FEMORAL HEAD 40MM +12 BIOLOX DELTA TS -,SUP-1365-40-740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM ARTICL/EZ 44MM +1.5MM NK COCR 12/14 TAPR CONTR -,SUP-1365-61-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CEMENTRALIZER 11.0 -,SUP-137620000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 22MM BIPLR COCR MODLR -,SUP-138-2200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL HEAD 22MM +3 COCR -,SUP-138-2203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL HEAD COCR 22MM -3 -,SUP-138-2230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM OVATN 28MM +0MML NK COCR 12/14 TAPR STRL -,SUP-138-2800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL HEAD 28MM +9 12/14 TAPER -,SUP-138-2809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEMORAL COCR 28MM -,SUP-138-2830,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM OVATN 36MM +0MML NK COCR 12/14 TAPR -,SUP-138-3600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL HEAD COCR 36MM +6 -,SUP-138-3606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL HEAD COCR 36MM +9 -,SUP-138-3609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM OVATN 36MM-3MM NK COCR 12/14 TAPR -,SUP-138-3630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL HEAD 40MM +3 -,SUP-138-4003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COCR FEMORAL HEAD -,SUP-138-4009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ENDO II TAPER STD 0MM T -,SUP-139247,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FRDM CNSTR 36MM T12/14 -6MM -,SUP-14-107016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7206.31,5044.417,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FRDM CNSTR HD 36MM T 12/14 - 14-107018 -,SUP-14-107018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7206.31,5044.417,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BAR ORTHO INTLOK TI ASCENT MAXIM L/R KN CR PRIM STRL -,SUP-141205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1136.02,795.214,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRAY TIBIAL ILOK PRI 79MM BIOMET -,SUP-141215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL PLATE 67MM -,SUP-141232,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRAY COCR CRUCIATE 71MM CC BIOMET -,SUP-141233,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HIP FINNED PRI 80 X 10MM BIOMET -,SUP-141316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PIN FX STNMN 2MMX6IN SMTH PLN BAYNT PNT FA KN -,SUP-141796,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7206.31,5044.417,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM BMT SPLINED KNEE V2 12 X 40 -,SUP-148287,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM BMT SPLINED KNEE V2 14 X 40 -,SUP-148289,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SPLINED KNEE STEM V2 -,SUP-148291,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM BMT SPLINED KNEE V2 10 X 80 -,SUP-148300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 7MM PRSRVN RM/LL KN -,SUP-1498-11-306,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5824.89,4077.423,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 9.5MM PRSRVN RM/LL KN -,SUP-1498-11-308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5824.89,4077.423,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM OSS CEMENTED IM 9MM X 90MM -,SUP-150358,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9594.39,6716.073,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM OSS CEMENTED IM 12MM X 90MM -,SUP-150361,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9594.39,6716.073,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OSS CEMENTED IM STEM 13MM X 90MM -,SUP-150362,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9594.39,6716.073,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OSS CEMENTED IM STEM 13X150 -,SUP-150367,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10426.1,7298.27,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM OSS POUROUS IM 11.5MM X 90MM -,SUP-150382,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ3 ATTUNE LT KN CR CMNT -,SUP-1504-00-103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ9 ATTUNE LT KN CR CMNT -,SUP-1504-00-109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OSS POROUS IM STEM 12.5 X 225 -,SUP-150402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OSS POROUS IM STEM 14.5 X 225 -,SUP-150403,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OSS POROUS IM STEM 18.5 X 225 -,SUP-150405,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OSS TIBAL POLY BEARING 14MM -,SUP-150411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7469.44,5228.608,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OSS TIBAL POLY BEARING 18MM -,SUP-150413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7469.44,5228.608,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PLATE OSS NON-MOD TIBAL SHORT 67MM -,SUP-150417,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19307.6,13515.32,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OSS MOD TIBAL BASEPLATE 71MM -,SUP-150422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20436.35,14305.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BLOCK OSS TIB 20 X 63/67 MR/LL -,SUP-150429,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BLOCK OSS TIB 20 X 63/67 MR/LR -,SUP-150430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
REVISION CRS FEMORAL SZ 7 LEFT CEMENTED -,SUP-1504-40-107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24255.17,16978.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OSS FINN MOD PROX FMRL RT 7CM -,SUP-150457,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26939.64,18857.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT OSS LETSON MOD PROX FMRL R 7CM -,SUP-150459,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26939.64,18857.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OSS 3CM ELLIP DIAPHYSEAL SEG -,SUP-150461,CDM,C1776,HCPCS,278,RC,,,outpatient,,,35466.58,24826.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OSS POLY TIBIAL BUSHING -,SUP-150476,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2501.84,1751.288,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OSS POLY FEMORAL BUSHINGS 2PK -,SUP-150477,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1738.56,1216.992,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OSS AXLE -,SUP-150480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3399.09,2379.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OSS REINFORCED YOKE -,SUP-150493,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6994.11,4895.877,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL BASE FIXED BEARING -,SUP-1506-40-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12048.69,8434.083,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASE TIBIAL REV RP SIZE 4 CEM -,SUP-1506-60-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18338.51,12836.957,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIA SLV M/L ATUNE 29MM FULL POR -,SUP-1511-11-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13490.44,9443.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
REVISED CEMENTED SYSTEM -,SUP-1512-14-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4423.31,3096.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM PRESSFIT STR ATUNE 16 X 60MM -,SUP-1513-16-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.93,4893.651,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 6MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-306,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5 10MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ6 6MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ9 7MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-907,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT FIXED BEARING POSTERIOR STABILIZED -,SUP-1516-40-412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBAL INSERT FIXED BEARING POST STAB 7X10MM -,SUP-1516-40-710,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT PS RP SZ 5 ATTUNE 16MM -,SUP-1516-50-516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 41MM ATTUNE MDL DOME -,SUP-1518-20-041,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2364.02,1654.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUG TIBIL UNIV ATUE SZ 3/4 X 5MM -,SUP-1523-03-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5835.5,4084.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ1 41MM OFST 120MM PROSTALAC HI OFST 26MM LEG COCR -,SUP-1541-06-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19493.25,13645.275,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CUP ACTB PROSTALAC CMNT PE 32X42MM -,SUP-1541-42-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3762.63,2633.841,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OXFORD PARTIAL KNEE SYM FIXED LATERAL TIBIAL LEFT -,SUP-154335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FIXED LATERAL TIBIAL COSTRUCT LEFT  (E3) -,SUP-154340,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OXF FIX LAT BRG E4 LEFT -,SUP-154341,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OXF FIX LAT BRG B3 RIGHT -,SUP-154355,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OXFORD FIX LAT BRG E5 RIGHT -,SUP-154372,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OXFORD FIX LAT BRG F3 RIGHT -,SUP-154375,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SM OXFORD KN UNICMPT COCR -,SUP-154600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM MED OXFORD KN UNICMPT COCR -,SUP-154601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9586.97,6710.879,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
REVISION DISTAL FEMORAL AUGMENT SZ 7X4MM CEMENTED -,SUP-1547-07-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5135.24,3594.668,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ A LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154718,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ A R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ B LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154720,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ B R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154721,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ-C LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154722,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ-C L/M PMA ARTC OXFORD TI NIOBM NTRD CTD UHMWP -,SUP-154722,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ-C R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154723,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ-D LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154724,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ-D R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154725,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ-E R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154727,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
REVISION POSTERIOR FEMORAL AUGMENT SZ 7X4MM -,SUP-1549-07-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5135.24,3594.668,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SUMMIT BASIC CEMENTED SZ 6 -,SUP-157006120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ4 OFST 12/14 TAPR W/ POROCOAT -,SUP-1570-11-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL STEM 12/14 TAPER / SZ 5 / 145MM -,SUP-1570-11-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ6 12/14 TAPER W/ PORCOAT -,SUP-1570-11-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL STEM 12/14 TAPER SZ7X155MM -,SUP-1570-11-135,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB XS OXFORD UNICMPT ANTMC BEAR LT FEM MNSCL KN -,SUP-159530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OXFORD KNEED RIGHT MEDIAL TIBIAL TRAY SZAA -,SUP-159532,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SM SZ4 PMA OXFORD UNICMPT ANTMC BRG LT MNSCL -,SUP-159541,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SM 5MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159542,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SM 6MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159543,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SM 9MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159546,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB MED 3MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159547,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB MED 4MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159548,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB MED 6MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159550,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB LRG 3MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159554,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB LRG 6MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159557,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB XL 4MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159562,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB XL 5MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159563,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SM 3MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159568,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SM 6MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159571,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SM 7MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159572,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SM 8MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159573,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SM 9MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159574,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB MED 3MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159575,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB MED 4MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159576,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OXF ANAT BRG RT MD SZ 5 PMA -,SUP-159577,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB MED 6MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159578,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB MED 7MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159579,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB MED 8MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159580,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB LRG 3MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159582,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB LRG 4MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159583,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB LRG 5MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159584,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB LRG 6MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159585,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB XL 3MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL KN -,SUP-159589,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB XL 4MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL KN -,SUP-159590,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB XS 4MM OXFORD UNICMPT ANTMC ARTC BEAR LT MNSCL KN -,SUP-159791,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ5 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-05132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ6 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD. -,SUP-1601-06127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ6 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-06132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ7 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD. -,SUP-1601-07127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ7 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-07132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ8 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD. -,SUP-1601-08127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ8 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-08132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8806.3,6164.41,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ9 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-09127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HIP STEM SZ.9 34MM 142MM V40 -,SUP-1601-09132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HIP STEM SZ.10 34MM / 148MM -,SUP-1601-10132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ11 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-11132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB XS 4MM OXFORD UNIV ANTMC ARTC BEAR RT KN -,SUP-160791,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OSS 3CM PROXIMAL TIBIAL SLEEVE -,SUP-161000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13099.46,9169.622,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OSS RS 3 CM RESURF FMRL-LT -,SUP-161006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26742.28,18719.596,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OSS RS 7 CM MOD SEG FMRL-RT -,SUP-161011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28518.52,19962.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE OSS RS 3 CM PROX TIBIAL -,SUP-161023,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13663.84,9564.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BUSHING OSS RS POLY FEM SET/2 -,SUP-161034,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3131.74,2192.218,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AXLE OSS RS -,SUP-161035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3399.09,2379.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SEGMENT OSS 3CM LG ELLIPT DIAPH -,SUP-161079,CDM,C1776,HCPCS,278,RC,,,outpatient,,,35466.58,24826.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
MOD BEARING TIBIAL OSS RS 63MM -,SUP-161088,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21683.92,15178.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BEARING TIBIAL OSS RS 12MM LS -,SUP-161094,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BEARING TIBIAL OSS RS 16MM LS -,SUP-161096,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BEARING TIBIAL OSS RS 18MM LS -,SUP-161097,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT LT SZ 2 FEMORAL PS NONPOROUS -,SUP-161-1201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL PS RIGHT SZ 2 NON-POROUS -,SUP-161-1202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SEG OSS RS 8.5CM FMRL LEFT -,SUP-161124,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29722.42,20805.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ3 BAL KN LT PS NPOR -,SUP-161-1301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ3 BAL KN RT KN PS NPOR -,SUP-161-1302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ4 BAL KN LT KN PS NPOR -,SUP-161-1401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ4 BAL KN RT KN PS NPOR -,SUP-161-1402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT FEMORAL BALANCED KNEE COCR NONPOROUS 4N KNEE LEFT -,SUP-161-1405,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL PS NARROW RIGHT SZ 4 NON-POROUS -,SUP-161-1406,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 BAL KN LT KN PS NPOR -,SUP-161-1501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 BAL KN RT KN PS NPOR -,SUP-161-1502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL PS NARROW LEFT SZ 5 NON-POROUS -,SUP-161-1505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL PS NARROW RIGHT SZ 5 NON-POROUS -,SUP-161-1506,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ6 BAL KN LT KN PS NPOR -,SUP-161-1601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ6 BAL KN RT KN PS NPOR -,SUP-161-1602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ7 BAL KN LT KN PS NPOR -,SUP-161-1701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ7 BAL KN RT KN PS NPOR -,SUP-161-1702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RT SIZE 2 FEMORAL CR NONPOROUS -,SUP-161-3202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ4 BAL KN LT KN CR NPOR -,SUP-161-3401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 BAL KN LT KN CR NPOR -,SUP-161-3501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 BAL KN RT KN CR NPOR -,SUP-161-3502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ6 BAL KN LT KN CR NPOR -,SUP-161-3601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ6 BAL KN RT KN CR NPOR -,SUP-161-3602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM XS OXFORD KN TWN PG PRT CMNT COCR MLYBDNM ALY -,SUP-161467,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SM OXFORD KN TWN PG PRT CMNT COCR MLYBDNM ALY -,SUP-161468,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM MED OXFORD KN TWN PG PRT CMNT COCR MLYBDNM ALY -,SUP-161469,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TWIN PEGGED FEMORAL LRG KNEE -,SUP-161470,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ2 BAL KN NPOR -,SUP-162-1200A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ3 BAL KN NPOR -,SUP-162-1300A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ4 BAL KN NPOR -,SUP-162-1400A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ5 BAL KN NPOR -,SUP-162-1500A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ6 BAL KN NPOR -,SUP-162-1600A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL TRAY NONPOROUS SIZE 7 -,SUP-162-1700A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 11MM PS KN -,SUP-163-1311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5 8MM PS KN -,SUP-163-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5 13MM PS KN -,SUP-163-1513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ6 12MM PS KN -,SUP-163-1612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ2 13MM UL CONG KN -,SUP-163-3213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 11MM UL CONG KN -,SUP-163-3311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 16MM UL CONG KN -,SUP-163-3316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ4 9MM UL CONG KN PE -,SUP-163-3409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5 14MM UL CONG KN -,SUP-163-3514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2726.14,1908.298,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ6 10MM UL CONG KN -,SUP-163-3610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ6 11MM UL CONG KN -,SUP-163-3611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ6 14MM UL CONG KN -,SUP-163-3614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
MODULAR HEAD COMPONENT 32MM DIA HD 3MM NK -,SUP-163661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
28MM DIA COCR MOD HD -,SUP-163665,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
MODULAR HEAD COMPONENT 32MM -,SUP-163674,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PATELLA  29MM VITAMIN 3 -,SUP-164-5029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PATELLA 32MM VITAMIN E -,SUP-164-5032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PATELLA 35MM VITAMIN E -,SUP-164-5035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PATELLA 38MM VITAMIN E -,SUP-164-5038,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
41MM PATELLA VITAMIN E -,SUP-164-5041,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL PS RIGHT SZ 4 NON-POROUS -,SUP-165-1402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL CR LEFT SZ 6 NON-POROUS -,SUP-165-3601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT PS SIZE 2 7MM VITAMIN E -,SUP-166-5207,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT BKS E-VITALIZE 9MM SZ 2 -,SUP-166-5209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT PS TIBIAL 10MM SIZE 2 V -,SUP-166-5210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT PS TIBIAL SIZE 2 11MM VITAMIN E -,SUP-166-5211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT PS VITAMIN E SIZE 2 12MM -,SUP-166-5212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT PS TIBIAL SIZE 3 7MM VITAMIN E -,SUP-166-5307,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL PS SIZE 3 8MM VITAMIN E -,SUP-166-5308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SIZE 3 9MM TIBIAL INSERT PS VITAMIN E -,SUP-166-5309,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT PS TIBIAL 10MM SIZE 3 V -,SUP-166-5310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL PS SIZE 3 10MM VITAMIN E -,SUP-166-5310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL PS 11MM SIZE 3 V -,SUP-166-5311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL PS 12MM SIZE 3 V -,SUP-166-5312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL PS 13MM SIZE 3 V -,SUP-166-5313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT PS TIBIAL 14MM SIZE 3 V -,SUP-166-5314,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL PS 16MM SIZE 3 V -,SUP-166-5316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SIZE 3 18MM VIT E -,SUP-166-5318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SIZE 3 20MM -,SUP-166-5320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT PS VITAMIN E SZ4 7MM -,SUP-166-5407,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL PS 8MM SIZE 4 VITAMIN E -,SUP-166-5408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT PS TIBIAL 9MM SIZE 4 HI -,SUP-166-5409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT PS TIBIAL 10MM SIZE 4 V -,SUP-166-5410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL PS SIZE 4 10MM VITAMIN E -,SUP-166-5410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT PS VITAMIN E SZ 4 10MM -,SUP-166-5410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL PS 11MM SIZE 4 V -,SUP-166-5411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL PS 11MM SIZE 4 VITAMIN E -,SUP-166-5411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL PS SIZE 4 12MM VITAMIN E -,SUP-166-5412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT PS TIBIAL 12MM SIZE 4 H -,SUP-166-5412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT PS TIBIAL 13MM SIZE 4 H -,SUP-166-5413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL 14MM SIZE 4 HIGH -,SUP-166-5414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SIZE 4 16MM VIT E -,SUP-166-5416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT PS SIZE 4 18MM -,SUP-166-5418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT PS VIT 3 SIZE 4 20MM -,SUP-166-5420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT PS SIZE 5 7 MM VIT E -,SUP-166-5507,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIIAL PS SIZE 5 8MM VITAMIN E -,SUP-166-5508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT PS SIZE 5 9MM TIBIAL VITAMIN E -,SUP-166-5509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL PS SIZE 5 10MM VITAMIN E -,SUP-166-5510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL PS 10MM SIZE 5 V -,SUP-166-5510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL 11MM PS SIZE 5 HIGH FLEX VITAMIN E -,SUP-166-5511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL NONPOROUS SIZE 5 -,SUP-166-5511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL PS 12MM SIZE 5 V -,SUP-166-5512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL PS SIZE 5 12MM VITAMIN E -,SUP-166-5512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL PS 14MM SIZE 5 H -,SUP-166-5514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SIZE 5 16MM VIT E -,SUP-166-5516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SIZE 5 20MM -,SUP-166-5520,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SIZE 6 7MM -,SUP-166-5607,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SIZE 6 8MM VIT E -,SUP-166-5608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SZ 6 9MM PS -,SUP-166-5609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL PS 10MM SIZE 6 H -,SUP-166-5610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SIZE 6 10MM TIBIAL INSERT PS VITAMIN E -,SUP-166-5610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL PS 11MM SIZE 6 VITAMIN E -,SUP-166-5611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SIZE 6 12MM VIT E -,SUP-166-5612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SIZE6 14MM VITAMIN E -,SUP-166-5614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT PS SZ 6 16MM VITAMN-E -,SUP-166-5616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT INSERT PS SIZE 7 10MM VIT E XLPE -,SUP-166-5710,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT CR SZ 5 10MM VITAMIN E -,SUP-166-6510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SZ 2 12MM VIT E -,SUP-166-7212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT UC SZ 3 9MM VIT-E -,SUP-166-7309,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SIZE 3 11MM VIT E XLPE -,SUP-166-7311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT UC SZ 4 8MM VIT E -,SUP-166-7408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SZ 4 9MM VIT E -,SUP-166-7409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT UC SIZE 4 10MM VIT E -,SUP-166-7410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SIZE 4 11MM VIT E -,SUP-166-7411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SIZE 4 12MM VIT E -,SUP-166-7412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SIZE 4 13MM -,SUP-166-7413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT UC SZ 4 14MM VIT E -,SUP-166-7414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SZ 5 7MM VIT E -,SUP-166-7507,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT UC SZ 5 8MM VITAMIN-E -,SUP-166-7508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL UC SZ 5 9MM E-VITALIZE KNEE -,SUP-166-7509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SIZE 5 10MM VIT E -,SUP-166-7510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT BKS E-VITALIZE 11MM SZ 5 -,SUP-166-7511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT UC SZ 5 12MM VIT-E -,SUP-166-7512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SIZE 5 13MM VITAMIN E -,SUP-166-7513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SIZE 5 14MM VIT E -,SUP-166-7514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT UC SIZE 5 16MM VIT-E -,SUP-166-7516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SIZE 6 10MM VIT E -,SUP-166-7610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SIZE 6 11MM VITAMIN E -,SUP-166-7611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SIZE 6 12MM VIT E -,SUP-166-7612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT UC SIZE 6 13MM VIT E -,SUP-166-7613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SIZE 6 14MM VIT E -,SUP-166-7614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SIZE 7 11MM VIT E -,SUP-166-7711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE HIP UNITRAX V40 UNIPL TI -,SUP-170000E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL THREE HOLE 44MM -,SUP-170-0144,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 48MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0148,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4630.78,3241.546,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 50MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 52MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0152,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 56MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 58MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0158,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 60MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 62MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0162,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ESCALADE 68MM THREE HOLE -,SUP-170-0168,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACETABULAR LEGEND OD50 MM 3 HOLE -,SUP-170-0550,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
POROUS ACET SHELL THREE HOLE 52MM OD -,SUP-170-0552,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
POROUS ACETABULAR SHELL THREE-HOLE 54MM OD -,SUP-170-0554,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
POROUS ACETABULAR SHELL THREE HOLE 56MM OD -,SUP-170-0556,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4630.78,3241.546,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 32MM X 52MM NEUTRAL HXLPE -,SUP-170-3252,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 36MM 52MM SHL ESCALADE +3 NEUT -,SUP-170-3652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 36MM 54MM SHL ESCALADE +1 NEUT -,SUP-170-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 36MM 56MM SHL ESCALADE +0 NEUT -,SUP-170-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 36MM 58MM SHL ESCALADE +0 NEUT -,SUP-170-3658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 36MM 60MM SHL ESCALADE +0 NEUT -,SUP-170-3660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 36X62MM ESCALDE +ODEG NEUT F/T/H ARTHPL -,SUP-170-3662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER +3 NEUTRAL 40 X 56MM HXL -,SUP-170-4056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER NEUTRAL +1 ESCALADE -,SUP-170-4058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 40X60MM ESCALDE +ODEG NEUT F/T/H ARTHPL -,SUP-170-4060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 40X62MM ESCALDE +ODEG NEUT F/T/H ARTHPL -,SUP-170-4062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ACETABULAR LINER 36 X 52 +3 HOODED HXLPE -,SUP-171-3652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACETABULAR 36 X 54 HOODED -,SUP-171-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 36X56MM ESCALDE +ODEG HD F/T/H ARTHPL -,SUP-171-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER 28MM ID 44MM OD NEUTRAL HXLPE -,SUP-172-2844,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER 32MM ID 46MM OD NEUTRAL HXLPE -,SUP-172-3246,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER 36MM ID 50MM OD NEUTRAL HXLPE -,SUP-172-3650,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER 36MM ID 52MM OD NEUTRAL HXLPE -,SUP-172-3652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER 36MM ID 54MM OD NEUTRAL HXLPE -,SUP-172-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER 36MM ID 56MM OD NEUTRAL HXLPE -,SUP-172-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER 36MM ID 58MM OD NEUTRAL HXLPE -,SUP-172-3658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER 36MM ID 60MM OD NEUTRAL HXLPE -,SUP-172-3660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER 36MM 64-70MM OD NEUTRAL -,SUP-172-3664,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER 40MM ID 56MM OD NEUTRAL HXLPE -,SUP-172-4056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER 40MM ID 58MM OD NEUTRAL HXLPE -,SUP-172-4058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER 40MM ID 60MM OD NEUTRAL HXLPE -,SUP-172-4060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM WITH MICROPOUROUS SUR 14MM X 12MM X 180CM -,SUP-172-918/14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM WITH MICROPOROUS SURGACE 14MM X 16MM L 180MM -,SUP-172-918/16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM WITH MICROPOROUS SURFACE 18MM X 16MM L180MM -,SUP-172-918/18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEMORAL LINK W/MICROPOROUS CEMTLESS 20MM X 18MM X 180MM -,SUP-172-918/20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINK STEM WITH MICROP SUR 14MM X 16MM -,SUP-172-921/16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM WITH MICROPOROUS SURFACE 16 X 18 X 210 -,SUP-172-921/18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINK STEM WITH MICROP SUR 14MM X 11MM X 120MM -,SUP-172-925/14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM WITH MICROPOROUS SURFACE 12.5MM X 16MM L 250MM -,SUP-172-925/16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM MICROPOROUS SURF 14.5MM X 18MM L 250MM CEMENTLESS -,SUP-172-925/18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SPACER PROXIMAL 20MM X 14MM COCRMO -,SUP-172-950/20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1484.14,1038.898,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINK NECK SEGMENT WITHOUT COLLAR CEMLESS 65MM 126CCD -,SUP-172-964/26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
NECK FEMORAL W/O COLLAR CEMENTLESS TILASTAN TI6AI-4V LINK -,SUP-172-964/35,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
NECK SEGMENT WITHOUT COLLAR CEMENTLESS -,SUP-172-965/26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
NECK SEGMENT XXL W/O COLLAR 65MM 12/14MM CEMENTLESS -,SUP-172-984/26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINK NECK SEG XXL WITHOUT COLLAR CEMENLESS 65MM -,SUP-172-984/35,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER 36MM ID 50MM OD HOODED HXLPE -,SUP-173-3650,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER 36MM ID 54MM OD HOODED HXLPE -,SUP-173-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER 36MM ID 56MM OD HOODED -,SUP-173-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER 36MM ID 58MM OD HOODED HXLPE -,SUP-173-3658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM ABC 36X0MM NK ALMN C-TAPR PRIM -,SUP-173600E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ASCENT ANT STBLZD TIBIAL BEARING 14 X 67 -,SUP-179822,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5551.15,3885.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP RESTORIS SZ 3 LEFT MAKO PATELLOFEMORAL COCRMO -,SUP-180403,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT RESTORIS MCK SIZE 4 LEFT PATELLOFEMORAL COCRMO -,SUP-180404,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP RESTORIS MCK PAT/FEM SZ 5 RIGHT COCRMO -,SUP-180415,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT FEMORAL RESTORIS MCK SIZE 1 LM/RL -,SUP-180501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT FEMORAL SZ 3 LM/RL RESTORIS MAKO COCRMO -,SUP-180503,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT FEMORAL SIZE 4 LM/RL RESTORIS MCK COCRMO -,SUP-180504,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT FEMORAL SZ 5 LM/RL RESTORIS MAKO COCRMO -,SUP-180505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT FEMORAL SZ 6 LM/RL RESTORIS MAKO COCRMO -,SUP-180506,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT FEMORAL SZ 1 RM/LL RESTORIS MAKO COCRMO -,SUP-180511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT FEM ONLAY SZ 3 RM/LL RESTORIS MAKO COCRMO -,SUP-180513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT FEMORAL SZ 4 RM/LL RESTORIS MAKO COCRMO -,SUP-180514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT FEMORAL RESTORIS MCK SZ 5 RM/LL COCRMO MAKO -,SUP-180515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT FEMORAL RESTORIS MCK SZ 6 RM/LL COCRMO MAKO -,SUP-180516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT FEM RESTORIS MCK SZ 7 RM/LL COCRMO -,SUP-180517,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIBIAL RESTORIS MCK ONLAY SIZE 2 LM/RL -,SUP-180602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIBIAL RESTORIS SZ 3 LM/RL T/6A/4V ONLAY MAKO -,SUP-180603,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE ONLAY TIBIAL SZ 4 LM/RL T/6A/4V RESTORIS MAKO -,SUP-180604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE ONLAY TIBIAL 5 LM/RL RESTORIS MCK -,SUP-180605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE ONLAY TIBIAL 6 LM/RL RESTORIS MCK -,SUP-180606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE ONLAY TIBIAL SZ 2 RM/LL Ti6AI4V RESTORIS MAKO -,SUP-180612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE ONLAY TIBIAL SIZE 3 RM/LL RESTORIS MCK TI6AI4V -,SUP-180613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE ONLAY TIBIAL SZ 4 RM/LL Ti6AI4V RESTORIS MAKO -,SUP-180614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIBIAL RESTORIS MCK SZ 5 RM/LL ONLAY MAKO TI6AI4V -,SUP-180615,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE ONLAY TIBIAL 6 RM/LL RESTORIS MCK -,SUP-180616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE ONLAY TIBIAL 7 RM/LL RESTORIS MCK TI6A14V -,SUP-180617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIBIAL RESTORIS MCK SZ 8 RM/LL TI6I4V -,SUP-180618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL SIZE 2 UNI X 8MM MAKO X3 ONLAY -,SUP-180732-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL MAKO X3 UNI ONLAY SIZE 2 X 8MM -,SUP-180732-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL MAKO X3 3 X 8 MM KNEE ONLAY -,SUP-180733-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ONLAY TIBIAL SZ 4 X 8MM MAKO X3 UNI -,SUP-180734-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL SIZE 4 X 8MM UNI ONLAY MAKO X3 -,SUP-180734-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL UNI ONLAY SIZE 4 X 9MM THKNS MAKO X3 -,SUP-180734-2,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL ONLAY SZ 5 X 8MM MAKO X3 UNI -,SUP-180735-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL ONLAY SZ 5 X 9MM MAKO X3 UNI -,SUP-180735-2,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ONLAY TIBIAL SZ 6 X 8MM MAKO X3 UNI -,SUP-180736-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL ONLAY SZ 6 X 8MM MAKO X3 UNI -,SUP-180736-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ONLAY TIBIAL SZ 7 X 8MM MAKO X3 UNI -,SUP-180737-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ONLAY TIBIAL MAKO X3 UNI SZ 8 X 8MM THKNS -,SUP-180738-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 28MM +0MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-18-2800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM 55MM VANGRD RT KN CR ANTMC CMNT COCR NPOR INTLOK -,SUP-183000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM 62.5MM VANGRD RT KN CR ANTMC CMNT COCR NPOR INTLOK -,SUP-183006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMUR CR INTERLOCK RIGHT 65MM VANGUARD -,SUP-183008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
VANGUARD CR ILOK FEM-LT 62.5 -,SUP-183026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM 57.5MM VANGRD LT KN CR ANTMC CMNTLS TI POR -,SUP-183062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM 62.5MM VANGRD LT KN CR ANTMC CMNTLS TI POR -,SUP-183066,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM 70MM VANGRD LT KN CR ANTMC CMNTLS TI POR -,SUP-183072,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM 57.5MM VANGRD RT FEM OPN BX CMNT COCR -,SUP-183102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM 60MM VANGRD RT KN PS OPN BX CMNT COCR NPOR INTLOK -,SUP-183104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PS OPEN BOX FEMORAL - LEFT 62.5MM -,SUP-183126,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PLATE VN PS OPEN INTL FEM-LT 70 -,SUP-183132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 32MM +0MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 32MM +5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB 10X63/67MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-183520,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB 16X63/67MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-183526,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 36MM +0MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 36MM +5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB 12X63/67MM VANGRD PS MODULAR ARTC BEAR 0DG SLP KN -,SUP-183622,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 36MM -5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-18365,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 36MM +7.5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183675,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL BEARING 14MM X 63/67 MM -,SUP-183724,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BRIDGE VANGUARD PS+TIB 20 X63/67MM -,SUP-183730,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL BEARING 14MM X 71/75MM -,SUP-183744,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BRIDGE VNGD PS+TIB 24 X79/83MM -,SUP-183774,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
VNGD SSK PSC TIB BRG 20 X 71/75 -,SUP-183890,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9735.49,6814.843,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 31MM STD 8MM TI SS UNMWPE PEGX3 VANGRD -,SUP-184764,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SERIES A ASYMMETRIC PAT 31X8 -,SUP-184792,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SERIES-A ASYMMETRICAL PATELLA 31MM / 8MM -,SUP-184792,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SERIES A ASYMMETRIC PAT 34X8.5 -,SUP-184793,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
DRILL HEADLESS TROCAR PIN 75MM -,SUP-185086,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9557.26,6690.082,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL TRAY WITH TI LCK BAR AND SCREW -,SUP-185203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11606.84,8124.788,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OFFSET ADAPTER WITH SCREWS -,SUP-185210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4611.68,3228.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ADAPTER OFFSET BMT 360 TIB 6.0 -,SUP-185211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4611.68,3228.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT BMT 360 TIBIAL 7 X 5MM -,SUP-185223,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5321.98,3725.386,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT BMT 360 TIBIAL 71 X 15MM RL/LM -,SUP-185243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5321.98,3725.386,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT BMT 360 TIBIAL 71 X 15MM LL/RM -,SUP-185253,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5321.98,3725.386,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
VNGD SSK 360 L FEMORAL R 67.5 -,SUP-185265,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29741.13,20818.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
VNGD SSK 360 L FEMORAL 65MM -,SUP-185284,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29741.13,20818.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT VG 360 DIST FM 67.5 X 5 RL/LM -,SUP-185305,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT VG 360 DIST FM 67.5 X 5 LL/RM -,SUP-185325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT VG 360 UNIV PST FM 65 X 10 -,SUP-185424,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT VG 360 UNIV PST FM 67.5 X 10 -,SUP-185425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
WING BMT 360 TIBIAL SM CRUCIATE -,SUP-185650,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
VANGUARD ANT STBLZD BRG 12X67 -,SUP-189042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BRIDGE VANGUARD ANT STBLZD 14 X 67 -,SUP-189044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BRIDGE ANT TIBIAL STABILIZED10 X 71MM VANGD -,SUP-189060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE HIP UNIV TRIDENT PRIM ADPTR +0MML NK OFST BIOLOX -,SUP-19-0000T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ADAPTER UNIV C-TAPER +5MM SLEE -,SUP-19-0005T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
UNIVERSAL C-TAPER +2.5MM ADAPTER SLEEVE -,SUP-19-0025T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
UNITED HIP SYSTEM ISCHIAL FLANGE -,SUP-1908-5401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6459.37,4521.559,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM ECHO POR FEMORAL LAT NC 28 X 44MM -,SUP-192114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BOLT LOCKING CONICAL PROX BODY CEMENTLESS 24 X 95 -,SUP-1975-24-095,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17895.36,12526.752,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM DISTAL TAPERED 15 X 190 STRAIGHT -,SUP-1976-15-190,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15238.52,10666.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ7 FNDTN LT KN CR TI NPOR -,SUP-201-01-107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 LONGEVITY NEUTRIAL 32MM C -,SUP-20103203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 LONGEVITY NEUTRIAL 32MM D -,SUP-20103204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3174.71,2222.297,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL G7 LONGEVITY NEUTRIAL 32MM D -,SUP-20103204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 LONGEVITY NEUTRIAL 32MM E -,SUP-20103205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 LONGEVITY NEUTRAL 36MM D -,SUP-20103604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 LONGEVITY NEUTRAL 36MM E -,SUP-20103605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 LONGEVITY NEUTRAL 36MM F -,SUP-20103606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 LONGEVITY NEUTRAL 36MM G -,SUP-20103607,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 LONGEVITY NEUTRAL 40MM F -,SUP-20104006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 LONGEVITY NEUTRAL 40MM G -,SUP-20104007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 FNDTN RT KN CR TI NPOR -,SUP-202-01-105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ7 FNDTN RT KN CR TI NPOR -,SUP-202-01-107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 28X58-60MM SHL OMNIFIT 10DG CROSSFIRE 13.1MM -,SUP-2041C-2858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4587.76,3211.432,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT OMNIFIT SERIES II 20 DEGREE 32MM -,SUP-2042-3250,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3800.96,2660.672,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
JIG TOT JNT RT TIB KN PERSONA ROT -,SUP-20-8070-002-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
JIG TOT JNT LT KN PERSONA PREF -,SUP-20-8070-010-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GW ORTHO TM PT SPEC INST -,SUP-20-8075-001-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 28X58MM OSTEONICS 0DG BIPLR PE 5.8-10.4MM THK -,SUP-2099-2858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9662.67,6763.869,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR KNEE SYS FEMORAL COMPONENT HINGED #3 LEFT -,SUP-2115-1330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR II KNEE SYSTEM FEMORAL COMPONENT HINGED #4 LEFT -,SUP-2115-1340,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR KNEE FEMORAL COMPONENT HINGED #5 LEFT -,SUP-2115-1350,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
UNITED II KNEE FEMORAL COMPONENT HINGED #6 HINGED -,SUP-2115-1360,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
URSTAR II KNEE SYSTEM FEMORAL COMPONENT HINGED #3 RIGHT -,SUP-2115-1430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR II KNEE FEMORAL COMPONENT HINGED #5 RIGHT -,SUP-2115-1450,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR II KNEE DISTAL FEMORAL COMPONENT RHS S LEFT -,SUP-2115-3310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30242.39,21169.673,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR II KNEE DISTAL FEMORAL COMP RHS S RIGHT -,SUP-2115-3410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30242.39,21169.673,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ4 FNDTN LT KN PS TI NPOR -,SUP-213-01-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ8 FNDTN LT KN PS TI NPOR -,SUP-213-01-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ8 FNDTN RT KN PS TI NPOR -,SUP-214-01-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ12 FNDTN RT KN PS TI NPOR -,SUP-214-01-012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
IMPLANT  CUSTOM PFR KINEMATCH -,SUP-22-100-1001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19864.55,13905.185,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR II TIBIAL BASEPLATE HINGED #1 -,SUP-2215-1410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIBIAL USTAR II HINGED 2 KNEE -,SUP-2215-1420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIBIAL SYSTEM USTAR II HINGED 3 -,SUP-2215-1430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIBIAL USTAR II HINGED 4 KNEE -,SUP-2215-1440,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT TIBIAL USTAR II KNEE PROXIMAL RHS S -,SUP-2215-3410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,34950.47,24465.329,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL KNEE USTAR II XPE SMALL 12MM -,SUP-2315-3211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL USTAR II KNEE XPE S 14MM -,SUP-2315-3212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL USTAR II KNEE XPE S 17MM -,SUP-2315-3213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL USTAR II XPE H20 SMALL 20MM -,SUP-2315-3214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR II KNEE XPE TIBIAL INSERT M 17MM -,SUP-2315-3243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR II KNEE XPE TIBIAL INSERT M 20MM -,SUP-2315-3244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL USTAR II KNEW XPE M 23MM -,SUP-2315-3245,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT FEMORAL U2 PSA COCR 5 4MM POSTERIOR SET -,SUP-2603-5051,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5852.48,4096.736,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AGUMENT FEMORAL U2 TOTAL KNEE SET DISTAL #5 12MM -,SUP-2603-5353,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5852.48,4096.736,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEADED PIN 17-4 PH S.S. -,SUP-262-0520A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PS Insert Trial Size 2  14mm -,SUP-263-1214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 40X17MM COCR -,SUP-265 108,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9253.24,6477.268,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
U2 TOTAL KNEE STRAIGHT STEM PSA 14MM X 75MM -,SUP-2703-5013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TIBIAL U2 PSA TI STRAIGHT 16MM X 75MM KNEE -,SUP-2703-5014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
U2 TOTAL KNEE SYSTEM STRAIGHT STEM PSA 22MM DIA 75MM STEM -,SUP-2703-5017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
U2 TOTAL  KNEE STRAIGHT STEM PSA 24MM DIA 75MM STEM LENGTH -,SUP-2703-5018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
U2 TOTAL KNEE STRAIGHT STEM PSA 12MM DIA 100MM STEM LENGTH -,SUP-2703-5022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TIBIAL U2 PSA STRAIGHT 20MM X 150MM TOTAL KNEE -,SUP-2703-5056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR II KNEE CEMENTED STRT STEM RHS NON COAT 9 X 100 -,SUP-2715-3009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR II KNEE SYS CEMENTED STR STEM RHS NON-COAT 11X100 -,SUP-2715-3011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR II KNEE CEMENTED STRAIGHT STEM RHS NON COATED 13 X 100 -,SUP-2715-3013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR II KNEE CEMENTED STRT STEM RHS NON COATED 15 X 100 -,SUP-2715-3015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR II KNEE CEMENTED STRAIGHT STEM RHS NON COAT 17X100 -,SUP-2715-3017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CEMENTED STRAIGHT STEM RHS COLLARLESS 9 X 125MM -,SUP-2715-3109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR II KNEE CEMENTED STRAIGHT STEM RHS NON COATED 11X125 -,SUP-2715-3111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR CEMENTED STRAIGHT STEM RHS NON COATED 13 X 125MM -,SUP-2715-3113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
KNEE SYSTEM CEMENTED STRAIGHT STEM RHS NON COATED 15 X 125MM -,SUP-2715-3115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR II KEE CEMENTED TIBIAL STEM 9MM X 20MM STEM LENG -,SUP-2715-5109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR II KNEE CEMENTED TIBIAL STEM 9MM X 45MM STEM -,SUP-2715-5209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TIBIAL USTAR II 9MM X 95MM KNEE CEMENT -,SUP-2715-5409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR II KNEE TIBIAL STEM 12.5MM X 70MM -,SUP-2715-7312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR II KNEE TIBIAL AUGMENT #2 10MM THICK -,SUP-2815-1022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5215.88,3651.116,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR SEGMENT PART RHS 50MM LENGTH -,SUP-2915-1050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22014.38,15410.066,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR II KNEE SEGMENT PART RHS 70MM LENGTH -,SUP-2915-1070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22014.38,15410.066,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 11MM 8.5MM MDL OFST PRIM PRFT EQUINOXE 110MM TI ALY -,SUP-300-01-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 15MM 9.5MM MDL OFST PRIM PRFT EQUINOXE 120MM TI ALY -,SUP-300-01-15,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PLATE BN EQUINOXE F/RVRS SYS ANTMC REPLICATOR TI ALY 4.5MM -,SUP-300-10-45,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4686.87,3280.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER G7 VIT E NEUTRAL 36MM E -,SUP-30103605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER G7 VIT E NEUTRAL 36MM F -,SUP-30103606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 VIT E HIGH WALL LNR 36MM D -,SUP-30123604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER G7 VIT E HIGH WALL 36MM F -,SUP-30123606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER G7 VIT E HIGH WALL 40MM H -,SUP-30124008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER G7 VIT E +5MM 40MM H -,SUP-30154008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8963.33,6274.331,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 47MM SHRT 18MM EQUINOXE 1.5MM OFST COCR -,SUP-310-01-47,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7808.96,5466.272,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 53MM SHRT EQUINOXE -,SUP-310-21-53,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6472.1,4530.47,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP B MED EQUINOXE SHLDR PG -,SUP-314-02-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4010.16,2807.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SPHERE GLND 38MM EQUINOXE RVRS -,SUP-320-01-38,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRY ADAPTER HUM WDG +0MM RVRS BALL SCKT EQUINOXE -,SUP-320-10-00,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 10MM FNDTN MODULAR REVISN 100MM TIB KN -,SUP-320-10-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER HUM 38MM STD EQUINOXE -,SUP-320-38-00,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4559.17,3191.419,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER HUM 38MM STD RVRS EQUINOXE -,SUP-320-38-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4559.17,3191.419,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BLOCK CUT SZ4 10MM RM/LL FNDTN KN REVISN F/SPCR -,SUP-321-101-04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ4 RT KN STM FNDTN REVISN MODULAR NPOR -,SUP-322-01-104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BLOCK CUT SZ4 5MM RL/LM FNDTN KN REVISN F/SPCR -,SUP-322-05-104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BLOCK CUT SZ4 10MM RL/LM FNDTN KN REVISN F/SPCR -,SUP-322-10-104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ2 10.9MM FNDTN PS ARTC CONGR KN COMPR MLD -,SUP-360-09-510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ2 11MM FNDTN PS ARTC CONGR KN COMPR MLD UHMWPE -,SUP-360-11-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ2 13MM FNDTN PS ARTC CONGR KN COMPR MLD UHMWPE -,SUP-360-13-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB 4MM AXSOS LCK -,SUP-370002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,240.4,168.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ORTHO 14X8.5MM DIA FEM LCK 5MM HL AXSOS NS -,SUP-370003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,274.83,192.381,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ2 13MM FNDTN CR PRIM CNSTRN ARTC CONGR L/R KN -,SUP-385-13-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CENTRALIZER DIST HIP TI ALY -,SUP-400-03-002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 36MM +4MM NK BIOLOX DELTA CERM -,SUP-400-03-363,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4487.56,3141.292,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM BIOLOX DELTA 40MM NEUT CERM -,SUP-400-03-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP REV SHLDER 9 IN STEINMANN -,SUP-405800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SEASPINE TULIP HEADS -,SUP-41-1000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE HIP NEUT OFST UNIPL ANG -,SUP-411-00-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 46MM UNIPL -,SUP-411-00-146,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PLUG SMALL DIA CEMENT 8MM -,SUP-414993,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
KT THR SZ3 FEM 3 TIB RT HIP TRUMATCH -,SUP-420859,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
KT TKR LT HIPERF 3T/3F -,SUP-420878,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
KT TKR RT HIPERF -,SUP-420890,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMUR PERSONA CEMENTED CCR NARROW SIZE 5 R -,SUP-42500005802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMUR PERSONA CEMENTED NARROW PS LT SZ 6 -,SUP-42500006001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMUR PERSONA CEMENTED CCR NARROW SIZE 8 R -,SUP-42-5000-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT PSN FEM PS CMT CCR SZ 7 R STD -,SUP-42-5006-062-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT PSN FEM PS CCR STD SIZE 10 L -,SUP-42500606801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ3 PERSONA RT KN CR CMNT COCR NRW -,SUP-42-5020-054-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ6 PERSONA LT KN CR CMNT COCR NRW -,SUP-42-5020-060-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ7 PERSONA LT KN CR CMNT COCR NRW -,SUP-42-5020-062-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ7 PERSONA RT KN CR CMNT COCR NRW -,SUP-42-5020-062-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMUR PERSONA CEMENTED CR NARROW RT SZ 9 -,SUP-42502006602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMUR PERSONA CEMENTED KNEE CR   RT SZ10 -,SUP-42-5020-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 PERSONA LT KN CR CMNT COCR POR NRW -,SUP-42-5022-058-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ6 PERSONA LT KN CR CMNT COCR POR NRW -,SUP-42-5022-060-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMUR FEMORAL CR POR CCR NRW SIZE 6 RIGHT PERSONA -,SUP-42-5022-060-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ7 PERSONA RT KN CR CMNT COCR POR NRW -,SUP-42-5022-062-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PSN FEM SZ 10 R CR CCR POR NRW -,SUP-42-5022-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ6 LEFT PERSONA KN CR STD CMNT CCR -,SUP-42-5026-060-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PERSONA FEMUR CMNT STD CCR SIZE 7 RIGHT -,SUP-42502606202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ8 PERSONA LT KN CR STD CMNT COCR NRW -,SUP-42-5026-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ8 RIGHT PERSONA KN CR STD CMNT COCR -,SUP-42-5026-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ10 PERSONA RT KN CR STD CMNT COCR NRW -,SUP-42-5026-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PSN FEM CR POR CCR STD SZ7 L -,SUP-42-5028-062-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ8 PERSONA LT KN CR STD COCR POR -,SUP-42-5028-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ8 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ9 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-066-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PERSONA KNEE SYSTEM FEMUR -,SUP-42-5028-068-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ10 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ11 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-070-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ12 R PERSONA RT KN CCR STD COCR POR -,SUP-42-5028-074-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PSN REV FEM CMT CCR STD SZ 5 R -,SUP-42-5046-058-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,33973.95,23781.765,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PSN REV FEM CMT CCR STD SZ 9 L -,SUP-42-5046-066-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,31746.15,22222.305,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PSN ASF CR 12MM PLY L 3-11 EF -,SUP-42-5110-005-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ8 139MM LNR PRFT LAT OFST CLLRLS 47.4MM NK TI POR -,SUP-425-11-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ13 148.5MM LNR PRFT LAT OFST CLLRLS 49.8MM NK TI -,SUP-425-11-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SYS PERSONA KNEE ASF UC 18MM PLY L-4-11 EF -,SUP-42-5112-005-18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PERSONA KNEE SYSTEM ARTICULAR SURFACE -,SUP-42-5112-006-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ C-D/3-9 10MM PERSONA CR ARTCSURF LT KN PE -,SUP-42-5120-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ C-D/3-9 11MM PERSONA CR ARTCSURF LT KN PE -,SUP-42-5120-004-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ C-D/3-9 12MM PERSONA CR ARTCSURF LT KN PE -,SUP-42-5120-004-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ E-F SZ3-11 FEM 10MM PERSONA ARTCSURF LT KN PE -,SUP-42-5120-005-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PSN ASF CR 12MM VE L 3-11EF -,SUP-42-5120-005-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PERSONA ARTICULAR SURFACE LEFT 11MM -,SUP-42-5121-007-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PSN MC VE ASF L 12MM 12/GH -,SUP-42-5121-010-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ C-D SZ3-7 FEM 12MM PERSONA CR ARTCSURF LT KN -,SUP-42-5122-004-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SURFACE ARTICULAR PERSONA VIVACIT-E 3-7 UC C-D 10MM KNEE LFT -,SUP-42512200410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PERSONA ARTICULAR FIXED BEARING LEFT 16MM -,SUP-42512200516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PERSONA ARTICULAR SURFACE 10MM -,SUP-42-5122-006-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ARTICULAR SURFACE PERSONA LT 16MM -,SUP-42512600516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PSN ASF CPS 14MM VE L 6-9 GH -,SUP-42-5126-009-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PSN PK VE PLY- LM- SZ E- 8MM -,SUP-42-5182-005-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ7 PERSONA LT KN CR STD COCR POR -,SUP-42-5208-062-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PSN FEMORALASF UC 10MM POLY R 4-11 EF -,SUP-42-5212-00-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BEARING FIXED ASF UC 12MM PLY 3-7CD PERSONA -,SUP-42-5212-004-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BEARING FIXED ASF UC 12MM PLY R 4-11 EF PERSONA -,SUP-42-5212-005-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BEARING PSN ASF UC 10MM PLY R 7-12 GH -,SUP-42521200610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PSN ASF UC 12MM PLY R 7-12 GH -,SUP-42-5212-006-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ C-D SZ3-9 FEM 10MM PERSONA CR ARTCSURF RT KN -,SUP-42-5220-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ C-D/3-9 11MM PERSONA CR ARTCSURF RT KN PE -,SUP-42-5220-004-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ E-F/3-11 11MM PERSONA CR ARTCSURF RT KN PE -,SUP-42-5220-005-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SURFACE ARTICULAR 10MM HEIGHT RIGHT -,SUP-42-5221-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ARTICULAR SURFACE PERSONA MC VE RT 13MM -,SUP-42522100513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ARTICULAR SURFACE PERSONA MC RT 10MM -,SUP-42522100810,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ARTICULAR SURFACE RIGHT 10MM /SIZES E-F/CR 8-11 -,SUP-42-5221-008-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ARTICULAR SURFACE PERSONA MC RT 11MM -,SUP-42-5221-008-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SURFACE ARTICULAR PERSONA RIGHT 10MM X 12/GH MC VE ASF -,SUP-42-5221-010-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ C-D/3-7 10MM PERSONA ARTCSURF UL CONG RT KN PE -,SUP-42-5222-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ E-F 10MM PERSONA UL CONG ARTCSURF RT KN PE -,SUP-42-5222-005-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HIGHLY CROSSLINKED POLY ARTICULAR FIXED BEARING -,SUP-42-5222-005-18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
VIVICIT-E PERSONA ASF UC 11MM 7 - 12GH -,SUP-42-5222-006-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CD PERSONA ASF PS 16MM VE R 3-5 -,SUP-42522400416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL PSN ASF PS 13MM VE R 6-9 CD -,SUP-42-5224-005-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PSN ASF CPS 14MM VE R 3-5CD -,SUP-42-5226-004-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PERSONA HIGHLY CROSSLINKED POLY 6-9EF VE R -,SUP-42-5226-007-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PERSONA HIGHLY CROSSLINKED POLYETHLENE 6-9EF -,SUP-42-5226-007-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PSN REV CCK ART SURF VE 12MM R 7-9+ CD -,SUP-42522800512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIB SZ-C PERSONA PEGX2 LT KN POR TM -,SUP-42-5300-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIB SZ-D PERSONA PEGX2 RT KN POR TM -,SUP-42-5300-067-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PSN TIB POR 2 PEG SZ E L -,SUP-42-5300-071-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIB SZ-F PERSONA PEGX2 RT KN POR TM -,SUP-42-5300-075-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PSN TIB POR 2 PEG SZ G L -,SUP-42-5300-079-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PSN TIB POR 2 PEG SZ G R -,SUP-42530007902,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PSN TIB POR 2 PEG SZ H R -,SUP-42-5300-083-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TIB SZ-C 5DG PERSONA LT KN -,SUP-42-5320-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM PERSONA ASF 16MM VE 3-5 R CD -,SUP-42532006402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TIB SZ-C 5DG PERSONA RT KN -,SUP-42-5320-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TIB 5DG SZ-D PERSONA LT KN -,SUP-42-5320-067-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TIB SZ-D 5DG PERSONA RT KN -,SUP-42-5320-067-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TIB 5DG SZ-E PERSONA LT KN -,SUP-42-5320-071-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIA PERSONA CEMENTED STEMMED RT SZ E -,SUP-42532007102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
NAT TIBIA CEME 5 DG SIZE F -,SUP-42-5320-075-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TIB SZ-F 5DG PERSONA RT KN -,SUP-42-5320-075-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PSN PK CMT TIB- LM- SZ E -,SUP-42-5380-005-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT PATELLAR PERSONA ALL POLY PAT PLY 41MM -,SUP-42540000041,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
DIA ALL POLY PAT PERSONA  29MM -,SUP-42540200029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 29MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-29,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 32MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-32,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 35MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-35,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 41MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-41,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ8 SHRT TAPR FIL TI POR CTD P-SQUARED HIP -,SUP-425-41-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ15 SHRT TAPR FIL TI POR CTD P-SQUARED HIP -,SUP-425-41-015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
KEEL PSN REV TIB FIXED CMT SIZE C R -,SUP-42-5420-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11361.78,7953.246,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PSN REV TIB FIXED KEEL CMT SZ G L -,SUP-42-5420-079-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11361.78,7953.246,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUG PSN REV FEM DISTAL SZ 5 5MM -,SUP-42-5566-058-05,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5602.08,3921.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTENSION PERSONA CEMETED TPRD 14MM X +30MM -,SUP-42557000114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PSN PK CMT FEM- LM- SZ 3 -,SUP-42-5580-003-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PSN PK CMT FEM- RM SZ.4 -,SUP-42558000402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PSN REV TAPERED SMOOTH STEM EXT 14 X 75MM -,SUP-42-5600-075-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8199.41,5739.587,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM PSN REV 6MM OFFSET EXT 10MM X 135MM -,SUP-42-5606-135-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11584.56,8109.192,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMUR PSN CR CMT TIN NRW SIZE 6R -,SUP-42-5720-060-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT FEMORAL PERSONA 7 KNEE -,SUP-42572606201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT PSN FEMORAL TIN STD SIZE 9L -,SUP-42-5726-066-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ8 109MM TAPR FIL PRFT LAT OFST 37MM NK TI POR CTD -,SUP-425-96-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ8 109MM TAPR FIL PRFT LAT OFST 42.5MM NK TI POR -,SUP-425-97-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ9 111MM TAPR FIL PRFT LAT OFST 42.5MM NK TI POR -,SUP-425-97-009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ12 LRG TAPR FIL PRFT LAT OFST TI POR COAT -,SUP-425-97-012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ13 117MM TAPR FIL PRFT LAT OFST 42.5MM NK TI POR -,SUP-425-97-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 13MM STD BGLNI/FLTW 130MM -,SUP-4300-13-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5470.69,3829.483,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 46X21MM BGLNI/FLTW ZML MODULAR OFST -,SUP-4302-46-21,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 48MM POR STRUCTURED TECH HMSPHR -,SUP-430-98-048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM STAGEONE SLCT 56MM SIL MODULAR SPCR STRL -,SUP-431183,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5199.96,3639.972,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ADAPTER STD STAGEONE CMNT MLD SPCR -,SUP-431186,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1636.53,1145.571,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HIP ADAPTER STD STAGEONE 6MM -,SUP-431188,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1428.48,999.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 15X155MM STG 1 HIP -,SUP-431193,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6510.3,4557.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HIP MOLD STEM W/REINF 13 X 200 -,SUP-431197,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6510.3,4557.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 12MM FNDTN CLLR FRG COCR CMNT 132DG ANG TAPR HIP -,SUP-450-01-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD RADL 26MM 10.5MM EVOLVE PROLINE COCR MODULAR -,SUP-496H026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7999.94,5599.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 28MM SHRT -3.5MM NK COCR MODULAR -,SUP-497-28-035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ-G 62MM RIM TRIDENT PRIM MODULAR HAP CTD -,SUP-500-01-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ-C 48MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-48C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ-D 50MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ-D 52MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-52D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ-E 54MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ-E 56MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-56E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ-F 58MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL SOLID BACK 60MM F -,SUP-500-03-60F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 48MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-5001-48,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ-C 46MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-01-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ-C 48MM RIM TRIDENT PRIM MODULAR CLUS-HL. -,SUP-502-03-48C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 50MM TRIDENT PRIM MODULAR CLUS-HL X3 TRTNM LCK -,SUP-502-03-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ-D 52MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-03-52D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL HEMISPHERICAL 54MM SZ-E RIM CLUSTER HOLE -,SUP-502-03-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ-E 56MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-03-56E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ-D 50MM RIM TRIDENT PRIM.MODULAR CLUS-HL -,SUP-502-03-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ-F 60MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-03-60F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ-D 50MM RIM TRIDENT PRIM MODULAR.CLUS-HL -,SUP-502-11-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ANATOMIC HEMISPHERICAL SHELL  56MM D RT -,SUP-504-02-56D-R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12514.18,8759.926,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEMISPHERICAL SHELL ANATOMIC RESTORATION -,SUP-504-02-58D-L,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12514.18,8759.926,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEMISPHERICAL SHELL 64MM -,SUP-504-02-64E-R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12514.18,8759.926,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT HUM 4MM 32MM STD PE RVRS SCKT F/RSP STRL -,SUP-508-00-432,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4559.17,3191.419,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL TRIDENT HEMISPHERICAL ACETABULAR 46MM C -,SUP-508-11-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL HEMI ACETABULAR 48MM -,SUP-508-11-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ-D 50MM RIM TRIDENT PRIM MODULAR MUL-HL -,SUP-508-11-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ACETABULAR SHELL 52MM -,SUP-508-11-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ-E 54MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL HEMISPHERICAL 56MM E TRI -,SUP-509-02-56E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ-F 58MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ-F 60MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-60F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ-G 62MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ-G 64MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-64G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ H LINER 66MM RIM TRIDENT REVISN MUL-HL -,SUP-509-02-66H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ H LINER 68MM RIM TRIDENT REVISN MUL-HL -,SUP-509-02-68H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIDENT TRITANIUM HEMI SHELL SZ 70MM -,SUP-509-02-70I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT ACTB 50MM RESTOR REVISN RECON HIP 15MM -,SUP-5096-5015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT ACTB 50MM RESTOR REVISN RECON HIP 20MM -,SUP-5096-5020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
WEDGE AUGMENT RESTORATION ACET 54MM X 56MM X 15MM -,SUP-5096-5415,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT ACTB 58MM RESTOR REVISN RECON HIP -,SUP-5096-5815,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 6MM PRIM MBLK RVRS RSP 101MM CMNT 150DG ANG NK CYL -,SUP-510-00-006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19030.28,13321.196,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TPRLC 133 FP TYPE 1 PPS SO 5.0 -,SUP-51-100050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TPRLC 133 FP TYPE 1 PPS SO 6.0 -,SUP-51-100060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TPRLC 133 FP TYPE1 PPS SO 7.0 -,SUP-51-100070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TPRLC 133 FP TYPE1 PPS SO 8.0 -,SUP-51-100080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEMORAL TPRLC 133 FP PPS TYPE 1  6.0 H -,SUP-51-101060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TPRLC 133 FP PPS TYPE 1 HO 7.0 -,SUP-51-101070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TPRLC 133 FP PPS TYPE 1 HO 8.0 -,SUP-51-101080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TPRLC XR FP TYPE 1 PPS 5 X 130MM -,SUP-51-102050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TPRLC XR FP TYPE 1 PPS 6 X 132MM -,SUP-51-102060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TPRLC XR FP TYPE 1 PPS 8 X 136MM -,SUP-51-102080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TPRLC 133 TYPE 1 PPS SO 9 X 137MM -,SUP-51-103090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TPRLC 133 TYPE 1 PPS SO 10 X 140MM -,SUP-51-103100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TPRLC 133 TYPE 1 PPS SO 11 X 142MM -,SUP-51-103110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TPRLC 133 T1 PPS SO 12 X 144MM -,SUP-51-103120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TPRLC 133 T1 PPS SO 13 X 146MM -,SUP-51-103130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TPRLC 133 T1 PPS SO 14 X 148MM -,SUP-51-103140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TPRLC 133 TYPE 1 PPS SO 15 X 150MM -,SUP-51-103150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TAPERLOC 133 T1 9 X 137MM -,SUP-51-104090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TPRLC 133 T1 PPS 11 X 142MM -,SUP-51-104110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TPRLC 133 T1 PPS HO 13 X 146MM -,SUP-51-104130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TPRLC TYPE 1 PPS HO 14 X 148MM FEM POR -,SUP-51-104140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TPRLC TYPE 1 PPS HO 15 X 150MM FEM POR -,SUP-51-104150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TPRLC 133 TYPE 1 PPS HO 16 X 152MM -,SUP-51-104160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TAPERLOC 133 T1 PPS HO 20 X 160MM -,SUP-51-104200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TAPERLOC 10 X 140MM COMP XR FEM POR T1 TAPER -,SUP-51-105100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TAPERLOC 11 X 142MM COMP XR 123 FEM POR T1 TAPER -,SUP-51-105110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TPRLC 133 MP TYPE 1 PPS SO 11.0 -,SUP-51-106110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TPRLC 133 MP TYPE1 PPS HO 9.0 -,SUP-51-107090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TPRLC 133 MP TYPE1 PPS HO 14.0 -,SUP-51-107140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TPRLC 133 MP TYPE1 PPS HO 16.0 -,SUP-51-107160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TPRLC 133 MP TYPE1 PPS HO 17.0 -,SUP-51-107170,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TPRL 133 MP TYPE1 PPS SO 4.0 -,SUP-51-108040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TPRLC 133 MP T1 PPS SO 5X95MM -,SUP-51-108050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TPRLC133 MP 6X97.5MM -,SUP-51-108060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TPRLC 133 MP T1 PPS SO 8X101MM -,SUP-51-108080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TLOC 133 MP SP T1 PPSHO 6X97.5 -,SUP-51-109060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TLOC 133 MP SP T1 PPS HO 8X101 -,SUP-51-109080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM S-ROM 28MMSTDX+6MM NK COCR 11/13 TAPR MODULAR -,SUP-52-2029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4824.58,3377.206,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SCREW 2.3X12MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23212E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 45X15MM -,SUP-5350-4515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6472.1,4530.47,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 12MM SOLAR 130MM TI SHLDR -,SUP-5351-4108,CDM,C1776,HCPCS,278,RC,,,outpatient,,,33064.27,23144.989,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 40X15MM OFST -,SUP-5352-4015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6472.1,4530.47,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ-D 46MM 47.8MM RIM TRIDENT PSL PRIM MODULAR HAP -,SUP-540-11-46D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ1 TRIATH LT KN CR CMNT -,SUP-5510-F-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ1 TRIATH RT KN CR CMNT -,SUP-5510-F-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ2 TRIATH LT KN CR CMNT -,SUP-5510-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ2 TRIATH RT KN CR CMNT -,SUP-5510-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ3 TRIATH LT KN CR CMNT -,SUP-5510-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ3 TRIATH RT KN CR CMNT -,SUP-5510-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ4 TRIATH LT KN CR CMNT -,SUP-5510-F-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ4 TRIATH RT KN CR CMNT -,SUP-5510-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 TRIATH LT KN CR CMNT -,SUP-5510-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 TRIATH RT KN CR CMNT -,SUP-5510-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ6 TRIATH LT KN CR CMNT -,SUP-5510-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ6 TRIATH RT KN CR CMNT -,SUP-5510-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ7 TRIATH LT KN CR CMNT -,SUP-5510-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ7 TRIATH RT KN CR CMNT -,SUP-5510-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ8 TRIATH LT KN CR CMNT -,SUP-5510-F-801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ1 59/53MM TRIATH RT KN TOTAL STABILIZED REVISN -,SUP-5512-F-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ2 62/56MM TRIATH LT KN TOTAL STABILIZED REVISN -,SUP-5512-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT FEMORAL TOTAL STABILIZER #2 RT TS -,SUP-5512-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ3 65/59MM TRIATH LT KN CRCTE STAB REVISN COCR -,SUP-5512-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ3 65/59MM TRIATH RT KN CRCTE STAB REVISN COCR -,SUP-5512-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ4 68/62MM TRIATH LT KN CRCTE STAB REVISN COCR -,SUP-5512-F-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ4 68/62MM TRIATH RT KN CRCTE STAB REVISN COCR -,SUP-5512-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 71/65MM TRIATH LT KN CRCTE STAB REVISN COCR -,SUP-5512-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 71/65MM TRIATH RT KN CRCTE STAB REVISN COCR -,SUP-5512-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ6 74/68MM TRIATH LT KN TOTAL STABILIZED REVISN -,SUP-5512-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TOTAL STABILIZER COMPONET FEMORAL -,SUP-5512-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ7 77/71MM TRIATH LT KN TOTAL STABILIZED REVISN -,SUP-5512-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STABILIZER TOTAL FEM COMP SZ 7 RIGHT TS TRIATHLON -,SUP-5512-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ8 80/75MM TRIATH RT KN TOTAL STABILIZED REVISN -,SUP-5512-F-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ1 TRIATH LT KN PS CMNT -,SUP-5515-F-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ2 TRIATH LT KN PS CMNT -,SUP-5515-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ2 TRIATH RT KN PS CMNT -,SUP-5515-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ3 TRIATH LT KN PS CMNT -,SUP-5515-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ3 TRIATH RT KN PS CMNT -,SUP-5515-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ4 TRIATH RT KN PS CMNT -,SUP-5515-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 TRIATH LT KN PS CMNT -,SUP-5515-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 TRIATH RT KN PS CMNT -,SUP-5515-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ6 TRIATH LT KN PS CMNT -,SUP-5515-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ6 TRIATH RT KN PS CMNT -,SUP-5515-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ7 TRIATH LT KN PS CMNT -,SUP-5515-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ7 TRIATH RT KN PS CMNT -,SUP-5515-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIATHLON PS FEM COMP SZ 8 CEMENTED -,SUP-5515-F-801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ8 TRIATH RT KN PS CMNT -,SUP-5515-F-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
POSTERIOR STABILIZED FEMORAL -,SUP-5516-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIATHLON CRUCLATE RETAINING FEMORAL SZ #1 LEFT CR -,SUP-5517-F-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIATHLON CRUCLATE RETAINING FEMORAL SZ #1 RIGHT CR -,SUP-5517-F-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIATHLON CR FEM COMPONENT - BEADED W/PA -,SUP-5517-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ2 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ3 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ3 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ4 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ4 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ6 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ6 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ7 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ7 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ8 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIATHLON CRUCIATE RETAINING FEMORAL -,SUP-5517-F-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ1 KN CMNT TRIATH PRIM -,SUP-5520-B-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ2 KN CMNT TRIATH PRIM -,SUP-5520-B-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ3 KN CMNT TRIATH PRIM -,SUP-5520-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ4 KN CMNT TRIATH PRIM -,SUP-5520-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ5 KN CMNT TRIATH PRIM -,SUP-5520-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ6 KN CMNT TRIATH PRIM -,SUP-5520-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ7 KN CMNT TRIATH PRIM -,SUP-5520-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ8 KN CMNT TRIATH PRIM -,SUP-5520-B-800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ1 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ2 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ3 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL BASEPLATE TRIATHLON UNIV SIZE 4 -,SUP-5521-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ5 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ6 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ7 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ8 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ3 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ4 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ5 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ6 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ7 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ1 9MM TRIATH CR ARTC KN X3 -,SUP-5530-G-109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ1 11MM TRIATH CR ARTC KN X3 -,SUP-5530-G-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ1 13MM TRIATH CR ARTC KN X3 -,SUP-5530-G-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ1 16MM TRIATH CR ARTC KN X3 -,SUP-5530-G-116,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ1 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-119,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL BEARING INSERT CR SZ2 9MM -,SUP-5530-G-209-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ2 13MM TRIATH CR ARTC KN X3 -,SUP-5530-G-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ2 16MM TRIATH CR ARTC KN X3 -,SUP-5530-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ2 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL BEARING SZ 3 X 10MM CR X3 TRIATHLON -,SUP-5530-G-310-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL BEARING CR SZ4 9MM -,SUP-5530-G-409-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL BEARING CR SZ4 10MM TRIATHLON X3 -,SUP-5530-G-410-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL BEARING INSERT CR SZ4 11MM -,SUP-5530-G-411-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ4 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5 10MM TRIATH CR ARTCSURF KN X3 UHMWPE -,SUP-5530-G-510-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-519,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL BEARING SZ6 10MM TRIATH X3 CR -,SUP-5530-G-610-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ6 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBAL BEARING CR SZ 7 X 9MM TRIATHLON X3 -,SUP-5530-G-709-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBAL BEARING CR SZ 7 X 10MM TRIATHLON X3 -,SUP-5530-G-710-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ7 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ8 13MM TRIATH CR ARTC KN X3 -,SUP-5530-G-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ8 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-819,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIATHALON INSERT CS #1 12MM X3 -,SUP-5531-G-112-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ2 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-209-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL BEARING CS SZ 2 X 10MM TRIATHLON X3 -,SUP-5531-G-210-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ2 11MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT BEARING TIBIAL CS SIZE 2 X 11MM TRIATHLON X3 -,SUP-5531-G-211-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL BEARING CS SZ 2 X 12MM TRIATHLON X3 -,SUP-5531-G-212-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ2 13MM TRIATH CS BEAR KN X3 -,SUP-5531-G-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TRIATHLON X3 TIBIAL BEARING SIZE 2 X 13MM CS -,SUP-5531-G-213-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ2 16MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-309-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 11MM TRIATH CS BEAR KN X3 -,SUP-5531-G-311-A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL BEARING INSERT  SZ.3 / CS / 12MM -,SUP-5531-G-312-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 13MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL BEARING CS SIZE 3 X 13MM TRIATHLON X3 -,SUP-5531-G-313-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 16MM TRIATH CS ARTCSURF KN X3 UHMWPE -,SUP-5531-G-316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 19MM TRIATH ARTCSURF KN X3 UHMWPE -,SUP-5531-G-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ4 9MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-409-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ4 11MM TRIATH CS BEAR X3 -,SUP-5531-G-411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ4 11MM TRIATH CS BEAR KN X3 -,SUP-5531-G-411-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ4 13MM TRIATH CS BEAR KN X3 -,SUP-5531-G-413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT BEARING TIBIAL CS SIZE 4 X 13MM TRIATHLON X3 -,SUP-5531-G-413-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ4 16MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ4 19MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL BEARING SZ 5 CS 9MM TRIATHLON X3 -,SUP-5531-G-509-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL BEARING INSERT  SZ. 5 / 10MM -,SUP-5531-G-510-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5 11MM TRIATH CS BEAR KN X3 -,SUP-5531-G-511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TRIATHLON X3 TIBIAL BEARING CS -,SUP-5531-G-512-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5 13MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
X3 TRIATHILON CS INS SIZE 5 13MM -,SUP-5531-G-513-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5 16MM TRIATH CS BEAR KN X3 -,SUP-5531-G-516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL BEARING CS SIZE 5 X 19MM TRIATHLON X3 -,SUP-5531-G-519-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ6 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-609-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ6 11MM TRIATH CONDL STAB BEAR KN -,SUP-5531-G-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ6 11MM TRIATH CONDL STAB BEAR CS X3 -,SUP-5531-G-611-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ6 13MM TRIATH CS BEAR KN X3 -,SUP-5531-G-613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ6 13MM TRIATH X3 CS BEAR X3 -,SUP-5531-G-613-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ6 16MM TRIATH ARTCSURF KN X3 UHMWPE -,SUP-5531-G-616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ6 19MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ7 9MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-709-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ7 11MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ7 13MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-713,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ7 16MM TRIATH CS BEAR KN X3 -,SUP-5531-G-716,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL TRIATHLON X3 SZ 7 16MM BEARING INSERT-CS -,SUP-5531-G-716-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ8 9MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIATHLON TIBIAL BEARING INSERT - CS SZ8 11MM -,SUP-5531-G-811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ1 13MM TRIATH PS ARTC KN X3 -,SUP-5532-G-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ2 9MM TRIATH PS ARTC KN X3 -,SUP-5532-G-209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIATHLON PS X3 TIBIAL INSERT -,SUP-5532-G-209-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ2 11MM TRIATH PS ARTCSURF KN X3 UHMWPE -,SUP-5532-G-211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB H TRTHLN PS 2-13MM -,SUP-5532-G-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ2 16MM TRIATH PS ARTC KN X3 -,SUP-5532-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ2 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL BEARING PS SZ 3 X 16MM TRIATHLON X3 -,SUP-5532-G-316-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL BEARING PS SZ 4 X 11MM TRIATHLON X3 -,SUP-5532-G-411-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ4 16MM TRIATH PS ARTCSURF KN X3 UHMWPE -,SUP-5532-G-416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ4 19MM TRIATH PS ARTC KN X3 -,SUP-5532-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ4 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5 22MM TRIATH PS ARTC KN X3 -,SUP-5532-G-522,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-525,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL BEARING INSERT TRI - PS SZ.6 / 9MM -,SUP-5532-G-609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ6 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-625,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ7 9MM TRIATH PS ARTC KN X3 -,SUP-5532-G-709,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ7 16MM TRIATH PS ARTC KN X3 -,SUP-5532-G-716,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL BEARING / SZ. 7  / 19MM -,SUP-5532-G-719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ7 22MM TRIATH PS ARTC KN X3 -,SUP-5532-G-722,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ7 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-725,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ8 9MM TRIATH PS ARTC KN X3 -,SUP-5532-G-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIATHLON PS X3 TIBIAL INSERT SZ 8 -,SUP-5532-G-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT TIBIAL SIZE 2 X 16MM PS TRIATHLON ALL POLY -,SUP-5535-A-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT TIBIAL SIZE 5 X 9MM PS TRIATHLON ALL POLY -,SUP-5535-A-509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT TRIATHLON ALL POLY TIBIAL PS SIZE 5 13MM -,SUP-5535-A-513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT TRIATHLON ALL POLY TIBIAL PS SIZE 6 16MM -,SUP-5535-A-616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL COMPONENT TRITANIUM #2 -,SUP-5536-B-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ3 KN TRIATH TRTNM -,SUP-5536-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ4 KN TRIATH TRTNM -,SUP-5536-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ5 KN TRIATH TRTNM -,SUP-5536-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ6 KN TRIATH TRTNM -,SUP-5536-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ7 KN TRIATH TRTNM -,SUP-5536-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIATHLON TIBIAL COMPONENT -,SUP-5536-B-800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ1 19MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-119,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ2 11MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ2 10MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT TOTAL STABILIZER #2 19MM TS -,SUP-5537-G-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ2 22MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
NO 3 TRIATHLON TS PLUS TIBIAL INSERT X3 POLY -,SUP-5537-G-309-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 19MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 22MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 25MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TOTAL STABILIZER+ TIBIAL INSERT -,SUP-5537-G-409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL TOTAL STABILIZER + SIZE 4 X 9MM TS TRIATH X3 -,SUP-5537-G-409-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT TRIATHLON X3 TOTAL STABILIZER SIZE F 11MM TS -,SUP-5537-G-411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ4 13MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ4 16MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
NO 4 TRIATHLON TS PLUS TIBIAL INSERT X3 POLY 16MM -,SUP-5537-G-416-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ4 19MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ4 22MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ4 25MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ4 28MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL TOTAL STAB SIZE 5 X 16MM TS TRIATHLON X3 -,SUP-5537-G-516-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL TOTAL STABILIZER+ SIZE 5 X 19MM TRIATHLON X3 -,SUP-5537-G-519-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5 22MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-522,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5 28MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-528,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5 31MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-531,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ6 9MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ6 11MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ6 16MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ6 19MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ6 25MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-625,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TOTAL STABILIZER TIBIAL INSERT SZ7 -,SUP-5537-G-711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ7 16MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-716,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ8 22MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-822,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT RT DIST KN SZ1 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT LT DIST KN SZ2 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL DISTAL AUGMENT - RIGHT -,SUP-5540-A-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT LT DIST KN SZ4 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT RT DIST KN SZ4 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL DISTAL AUGMENT - RIGHT -,SUP-5540-A-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT RT DIST KN SZ8 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL DISTAL AUGMENT RIGHT #2 10MM -,SUP-5541-A-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT FEMORAL DISTAL LEFT TRIATHLON SIZE 3 10MM -,SUP-5541-A-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT LT DIST KN SZ4 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5541-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT LT DIST KN SZ5 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5541-A-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT FEMORAL DISTAL RIGHT SZ 7 X 5MM TRIATHLON -,SUP-5541-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT FEMORAL DISTAL RIGHT SZ 7 X 10MM TRIATHLON -,SUP-5541-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIATHLON FEMORAL DISTAL SUGMENT 15MM SIZE 4 LEFT -,SUP-5542-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4581.78,3207.246,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT FEMORAL DISTAL RIGHT SZ 7 X 15MM TRIATHLON -,SUP-5542-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4581.78,3207.246,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP SZ48 7MM REUNION ALLOGRAFT SHOLUDER PG -,SUP-5542-P-0048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP SZ56 7MM REUNION ALLOGRAFT SHOLUDER PG -,SUP-5542-P-0056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT POST KN SZ1 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT POST KN SZ2 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT POST KN SZ3 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT POST KN SZ4 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT POST KN SZ5 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT POST KN SZ6 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT POST KN SZ7 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT POST KN SZ2 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT POST KN SZ3 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT POST KN SZ4 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT POST KN SZ5 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT POST KN SZ6 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HALF BLOCK TIBIAL AUGMENT SIZE 3 X 5MM TRIATHLON -,SUP-5545-A-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT RM/LL KN SZ3 TRIATH 5MM BLCK TOTAL STABILIZED AUG -,SUP-5545-A-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT LMRL KN SZ7 TRIATH 5MM BLCK TOTAL STABILIZED AUG -,SUP-5545-A-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT RM/LL KN SZ7 TRIATH 5MM BLCK TOTAL STABILIZED AUG -,SUP-5545-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT LMRL KN SZ1 TRIATH 10MM BLCK TOTAL STABILIZED AUG -,SUP-5546-A-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT RM/LL KN SZ1 TRIATH 10MM BLCK TOTAL STABILIZED AUG -,SUP-5546-A-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL AUGMENT HALF BLOCK -,SUP-5546-A-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL AUGMENT HALF BLOCK - 10MM -,SUP-5546-A-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT LMRL KN SZ3 TRIATH 10MM HLF BLCK TOTAL STABILIZED -,SUP-5546-A-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL AUGMENT HALF BLOCK / SZ.3 -,SUP-5546-A-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT LMRL KN SZ4 TRIATH 10MM HLF BLCK TOTAL STABILIZED -,SUP-5546-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT RM/LL KN SZ4 TRIATH 10MM HLF BLCK TOTAL STABILIZED -,SUP-5546-A-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL SYMMETRIC CONE AUGMENT SIZE A -,SUP-5549-A-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13500.17,9450.119,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL SYMMETRIC CONE AUGMENT -,SUP-5549-A-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13500.17,9450.119,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL SYMMETRIC CONE AUGMENT SIZE C -,SUP-5549-A-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13500.17,9450.119,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL CONE AUGMENT SZ 1&2 RT -,SUP-5549-A-322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15374.42,10762.094,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIATH TRITNUM CNTRLFEMCONE AUG SZ 3&4 LEFT -,SUP-5549-A-641,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15375.53,10762.871,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIATH TRITNUM CNTRLFEMCONE AUG SZ 3 & 4 RIGHT -,SUP-5549-A-642,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15375.53,10762.871,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT CENTRAL FEM CONE SZ 7&8 RIGHT TRIATHLON -,SUP-5549-A-672,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15375.53,10762.871,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PATELLA SYMMETRIC SZ S27MM X 8MM TRIATHLON X3 -,SUP-5550-G-278-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIATHLON SYMMETRIC X3 PATELLA -,SUP-5550-G-298-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIATHLON X3 SYMMETRIC PATELLA 31MM 9MM -,SUP-5550-G-319-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 33X9MM THK X3 TRIATH PRIM SYM -,SUP-5550-G-339,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 39X11MM THK X3 TRIATH PRIM SYM -,SUP-5550-G-391,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 29X9MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-299-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 32X10MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-320-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 35X10MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-350-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 38X11MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-381-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SINGLE RADIUS HUMERAL HEAD SIZE 44 19MM -,SUP-5552-E-4419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13563.59,9494.513,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 4MM OFST 52X17 REUNION -,SUP-5552-E-5217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 29X9MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-299,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 32X10MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 35X10MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-350,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 38X11MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-381,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PATELLA ASYMMETRIC A40/11MM -,SUP-5552-L-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 56MM STD REUNION SGL RAD -,SUP-5552-S-5622,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 32X10MM THK X3 PERIAPATITE TRIATH ASYM MTL BK -,SUP-5554-L-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 35X10MM THK X3 PERIAPATITE TRIATH ASYM MTL BK -,SUP-5554-L-350,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 38X11MM THK X3 PERIAPATITE ASYM BEADX3 MTL BK -,SUP-5554L381,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 40X11MM THK X3 PERIAPATITE ASYM BEADX3 MTL BK -,SUP-5554L401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND SZ1 12MM TRIATH TOTAL STABILIZED 50MM COCR FEM -,SUP-5560-S-112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TOTAL KNEE 9MM X 100MM -,SUP-5560-S-209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND SZ2 12MM TRIATH TOTAL STABILIZED 100MM COCR FEM -,SUP-5560-S-212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND SZ2 15MM TRIATH TOTAL STABILIZED 50MM COCR FEM -,SUP-5560-S-215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND SZ3 12MM TRIATH TOTAL STABILIZED 50MM COCR FEM -,SUP-5560-S-312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 10MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 11MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 12MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 13MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 14MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 15MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 16MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 17MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FLUTED STEM 18MM / 100MM / TS -,SUP-5565-S-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 18MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 19MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 20MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 21MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 22MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 13MM TRIATH PRFT REVISN TOTAL STABILIZED 150MM -,SUP-5566-S-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4789.23,3352.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FLUTED STEM 14MM / 150MM / TS -,SUP-5566-S-014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4789.23,3352.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HUMERAL FRATURE STEM 7 X 113 -,SUP-5568-0007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,32158.29,22510.803,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
REUNION RFX-HUMERAL FRACTURE STEM 9MM -,SUP-5568-0009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,31160.68,21812.476,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUMERAL FRACTURE 11MM X 123MM REUNION RFX -,SUP-5568-0011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,33766.02,23636.214,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HUMERAL CUP 36MM DIA X 4MM THK -,SUP-5570-3604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16968.41,11877.887,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ADAPTER FEM 2MM OFST TRIATH RECON KN REVISN TOTAL STABILIZED -,SUP-5570-S-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4348.4,3043.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ADAPTER FEM 4MM OFST TRIATH RECON KN REVISN TOTAL STABILIZED -,SUP-5570-S-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4348.4,3043.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ADAPTER FEM 6MM OFST TRIATH RECON KN REVISN TOTAL STABILIZED -,SUP-5570-S-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4348.4,3043.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
EXTENDER STEM TRIATHLON 25MM LENGTH -,SUP-5571-S-025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4512.24,3158.568,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
X3 HUMERAL INSERT 36MM X 4MM STANDARD -,SUP-5571-S-3604-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13571.02,9499.714,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE 28MM X 10.05MM -,SUP-5572-2802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18676.39,13073.473,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GLENOSPHERE 36MM DIA X 2MM THK CONCENTRIC -,SUP-5573-C-3602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16968.41,11877.887,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ2 TRIATH LMRL KN UNICMPT PRIM PRT RSRFC COCR -,SUP-5610-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ2 TRIATH RM/LL KN UNICMPT PRIM PRT RSRFC COCR -,SUP-5610-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL REVISION LEFT SZ 2 NON-POROUS -,SUP-561-1201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ3 BAL KN MODULAR REVISN RT KN -,SUP-561-1302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ4 BAL KN MODULAR REVISN LT KN -,SUP-561-1401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ4 BAL KN RT KN MODULAR REVISN SYS -,SUP-561-1402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 BAL KN LT KN MODULAR REVISN SYS -,SUP-561-1501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 BAL KN RT KN MODULAR REVISN SYS -,SUP-561-1502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ6 BAL KN LT KN MODULAR REVISN SYS -,SUP-561-1601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
MODULAR FEMORAL LEFT SIZE 7 -,SUP-561-1701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
MODULAR FEMORAL SIZE 7 -,SUP-561-1702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ3 27/47MM LMRL KN TRIATH COCR PRIM REVISN -,SUP-5620-B-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ3 27/47MM RM/LL KN TRIATH COCR PRIM REVISN -,SUP-5620-B-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ2 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRAY TIBIAL REVISION SZ 2 NEUTRAL NON-POROUS -,SUP-562-1200A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ3 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL TRAY REVISION SZ 3 NEUTRAL NON-POROUS -,SUP-562-1300A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ4 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL TRAY REVISION SZ 4 NEUTRAL NON-POROUS -,SUP-562-1400A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ5 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL TRAY REVISION SZ 5 NEUTRAL NON-POROUS -,SUP-562-1500A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ6 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL TRAY SLOPED SIZE 5 MODULAR -,SUP-562-2500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9431.02,6601.714,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CONE TIBIAL CENTRAL 31MM -,SUP-562-7031,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12705.89,8894.123,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CONE TIBIAL CENTRAL 34MM -,SUP-562-7034,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12705.89,8894.123,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CONE TIBIAL CENTRAL 36MM -,SUP-562-7036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12705.89,8894.123,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CONE TIBIAL 25MM M-L 35MM A-P -,SUP-562-7135,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12223.2,8556.24,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CONE TIBIAL LARGE 47MM M/L 31MM A/P -,SUP-562-7247,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15108.2,10575.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 8MM TRIATH BEAR LMRL KN X3 UHMWPE -,SUP-5630-G-308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 8MM TRIATH BEAR RM/LL KN X3 UHMWPE -,SUP-5630-G-328,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 8MM CNSTRN -,SUP-563-1308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 10MM CNSTRN -,SUP-563-1310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 12MM CNSTRN -,SUP-563-1312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 14MM CNSTRN -,SUP-563-1314,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 16MM CNSTRN -,SUP-563-1316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 18MM CNSTRN -,SUP-563-1318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 20MM CNSTRN -,SUP-563-1320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SROM*ST XL 36+8LINK 18 X 13 X 255L -,SUP-563138L,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27357.55,19150.285,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL CK SZ 4 8MM -,SUP-563-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT CK SIZE 4 18MM -,SUP-563-1418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT CK SIZE 4 24MM -,SUP-563-1424,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5 8MM CNSTRN -,SUP-563-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5 10MM CNSTRN -,SUP-563-1510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5 12MM CNSTRN -,SUP-563-1512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT CK SIZE 6 8MM -,SUP-563-1608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ6 10MM CNSTRN -,SUP-563-1610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT CK SIZE 6 14MM -,SUP-563-1614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SZ 2 10MM -,SUP-563-2210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SZ 2 12MM -,SUP-563-2212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL REVISION CK SZ 2 14MM -,SUP-563-2214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SZ 2 18MM -,SUP-563-2218,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SZ 2 20MM -,SUP-563-2220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SZ 2 22MM -,SUP-563-2222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SZ 3 8MM -,SUP-563-2308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SZ 3 12MM -,SUP-563-2312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SZ 3 14MM -,SUP-563-2314,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SZ 3 18MM -,SUP-563-2318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL REV CK SZ 3 20MM -,SUP-563-2320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SZ 3 24MM -,SUP-563-2324,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SZ 4 8MM -,SUP-563-2408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SZ 4 10MM -,SUP-563-2410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SZ 4 12MM -,SUP-563-2412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SZ 4 14MM -,SUP-563-2414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SZ 4 16MM -,SUP-563-2416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SZ 4 18MM -,SUP-563-2418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SZ 4 22MM -,SUP-563-2422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SZ 5 10MM -,SUP-563-2510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SZ 5 12MM -,SUP-563-2512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SZ5 14MM -,SUP-563-2514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SZ 5 16MM -,SUP-563-2516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL REVISION CK SZ 6.8MM -,SUP-563-2608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SIZE 6 14MM -,SUP-563-2614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM 12MM X 50MM CEMENTED -,SUP-565-1205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM 12 X 80 CEMENTED -,SUP-565-1208,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXT CEMENTED 12MM X 110MM -,SUP-565-1211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTENSION CEMENTED 14MM X 30MM -,SUP-565-1403,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4481.66,3137.162,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM 14MM X 50MM CEMENTED -,SUP-565-1405,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 14MM BAL KN 80MM CMNT -,SUP-565-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4481.66,3137.162,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 10MM BAL KN 80MM FEM/TBL -,SUP-566-1008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM 10 X 150MM EXT FLUTED -,SUP-566-1015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 12MM BAL KN 80MM FEM/TBL -,SUP-566-1208,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 13MM BAL KN 80MM FEM/TBL -,SUP-566-1308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 13MM BAL KN 150MM FEM/TBL -,SUP-566-1315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 14MM BAL KN 80MM FEM/TBL -,SUP-566-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTENSION FLUTED 14 X 110 -,SUP-566-1411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 15MM BAL KN 80MM FEM/TBL -,SUP-566-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 16MM BAL KN 80MM FEM/TBL -,SUP-566-1608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 17MM BAL KN 80MM FEM/TBL -,SUP-566-1708,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTENSION FLUTED 17MM X 110MM -,SUP-566-1711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 18MM BAL KN 80MM FEM/TBL -,SUP-566-1808,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM 18MM X 110MM FLUTED -,SUP-566-1811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 20MM BAL KN 80MM FEM/TBL -,SUP-566-2008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTENSION FLUTED 20 X 110 -,SUP-566-2011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTENSION FLUTED 24 X 80MM -,SUP-566-2408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTENSION FLUTED 24 X 110MM -,SUP-566-2411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT RM/LL KN SZ3 BAL KN 5MM BLCK REVISN -,SUP-567-5103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL AUGMENT BLOCK 5MM RT LAT LT MED SIZE 4 -,SUP-567-5104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT RM/LL KN SZ3 BAL KN BLCK REVISN -,SUP-567-5203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL AUGMENT SZ 3 15MM BLOCK LT LATERAL RT MEDIAL -,SUP-567-7203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT DIST KN SZ3 BAL KN 4MM REVISN -,SUP-568-1304,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL AUGMENT DISTAL SIZE 3 8MM -,SUP-568-1308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT DIST KN SZ4 BAL KN 4MM REVISN -,SUP-568-1404,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT FEMORAL SZ 4 4MM DISTAL -,SUP-568-1404A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT DIST KN SZ4 BAL KN 8MM REVISN -,SUP-568-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL AUGMENT SZ 4 8MM DISTAL -,SUP-568-1408A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT DIST KN SZ5 BAL KN 4MM REVISN -,SUP-568-1504,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL AUGMENT SZ 5 4MM DISTAL -,SUP-568-1504A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL AUGMENT DISTA SIZE 5 8MM -,SUP-568-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL AUGMENT DISTAL 12MM -,SUP-568-1512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT DISTAL 4MM SIZE 6 -,SUP-568-1604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL AUGMENT SZ 6 8MM DISTAL -,SUP-568-1608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT POST KN SZ4 BAL KN 4MM REVISN -,SUP-568-2404,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FERMORAL AUGMENT POSTERIOR 4MM SIZE 6 -,SUP-568-2604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 14MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-5988-10-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4394.75,3076.325,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 14MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-5988-10-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
EXTENSION STM 15X30MM -,SUP-5988-12-15,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4394.75,3076.325,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ0 33MM OFST 86MM ACCOLADE PRFT STD OFST 30MM NK -,SUP-6020-0030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ1 34MM OFST 110MM RECON ACCOLADE PRFT PRIM STD -,SUP-6020-0130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ2 35MM OFST 115MM ACCOLADE PRFT STD OFST 30MM NK -,SUP-6020-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ3 39MM OFST 120MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-0335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ4 40MM OFST 125MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ5 44MM OFST 130MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-0537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ2.5 36MM OFST 118MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-2530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ3.5 39MM OFST 124MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-3535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ4.5 41MM OFST 129MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-4535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ5.5 45MM OFST 133MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-5537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ0 +0MM 37MM OFST 86MM ACCOLADE PRFT EXTEND OFST -,SUP-6021-0030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ1 +0MM 38MM OFST 110MM ACCOLADE PRFT EXTEND OFST -,SUP-6021-0130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ2 39MM OFST 115MM ACCOLADE PRFT PRIM EXTEND OFST -,SUP-6021-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ3 43MM OFST 120MM ACCOLADE RECON PRFT PRIM HI -,SUP-6021-0335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ4 44MM OFST 125MM ACCOLADE RECON PRFT PRIM HI -,SUP-6021-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ5 48MM OFST 130MM ACCOLADE RECON PRFT PRIM EXTEND -,SUP-6021-0537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ2.5 40MM OFST 118MM ACCOLADE RECON PRFT PRIM -,SUP-6021-2530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ3.5 124MM RECON ACCOLADE PRFT PRIM EXTEND OFST -,SUP-6021-3535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ4.5 45MM OFST 130MM ACCOLADE RECON PRFT PRIM -,SUP-6021-4535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ5.5 49MM OFST 133MM ACCOLADE PRFT EXTEND OFST -,SUP-6021-5537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ4 OMNIFIT PRIM CLLR CMNT MDL CLCR HIP -,SUP-6034-0425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ6 30MM OFST 132MM SECUR-FIT PRFT PRIM 25MM -,SUP-6051-0625S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ7 35.1MM OFST 132MM SECUR-FIT MAX PRFT PRIM 30MM -,SUP-6051-0730S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ8 132MM RECON SECUR-FIT MAX PRFT PRIM TI HAP CTD -,SUP-6051-0830S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ9 40.8MM OFST 132MM SECUR-FIT MAX PRFT PRIM 35MM -,SUP-6051-0935S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ10 132MM RECON SECUR-FIT MAX PRFT PRIM TI HAP CTD -,SUP-6051-1035S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ11 132MM RECON SECUR-FIT MAX PRFT PRIM TI HAP CTD -,SUP-6051-1140S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ12 47.3MM OFST 132MM SECUR-FIT MAX PRFT PRIM 40MM -,SUP-6051-1240S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HIP STEM SIZE 6 25MM C-TPR -,SUP-6052-0625S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ7 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-0730S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ8 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-0830S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ9 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-0935S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ10 127 DEG SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-1035S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ13 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-1340S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HIP SECUR-FIT PLUS MAX SZ 11 C-TPR 40MM X 170MM -,SUP-6054-1115S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HIP 127 DEG NECK ANGLE SZ 12 C-TPR 40MM X 170MM -,SUP-6054-1216S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HIP STEM 127 DEG CEMENTED SZ 2 V40 TPR 30MM X 124MM ACCOLADE -,SUP-6057-0230D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HIP ACCOLADE 127 DEG CEM NK 35MM SZ 3 V40 131MM LGTH -,SUP-6057-0335D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HIP CEM SZ4 V40 TPR 35MM X 137MM 127 DEG -,SUP-6057-0435D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HIP ACCOLADE 127 DEC CEM NK 37MM SZ 5 V40 145MM LGTH -,SUP-6057-0537D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HIP ACCOLADE 127 DEG CEM NK 37MM SZ 6 V40 158MM LGTH -,SUP-6057-0637D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HIP 127 DEG CEMENTED SZ 7 V40 TPR 40MM X 158MM ACCOLADE -,SUP-6057-0740D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HIP 132 DEG SIZE 3 V40 X 35MM X 131MM CEM ACCOLADE C -,SUP-6058-0335D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HIP 132 DEG CEMENTED SZ 4 V40 35MM X 137MM ACCOLADE -,SUP-6058-0435D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HIP STEM 132 DEG CEMENTED SZ 5 V40 TPR 37MM X 145MM -,SUP-6058-0537D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ10 42MM OFST 160MM OMNIFIT HFX RECON PRIM 35MM NK -,SUP-6070-1035A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ11 132MM OMNIFIT HFX PRIM COCR CMNT HIP -,SUP-6070-1140A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ5 35MM OFST 110MM RECON OMNIFIT HFX PRIM 25MM NK -,SUP-6076-0525A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ6 36MM OFST 120MM OMNIFIT HFX PRIM 25MM NK COCR -,SUP-6076-0625A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ7 41MM OFST 130MM OMNIFIT HFX PRIM 30MM NK COCR -,SUP-6076-0730A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ8 42MM OFST 140MM RECON OMNIFIT HFX PRIM 30MM NK -,SUP-6076-0830A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ2 +0MM 43MM OFST 120MM ACCOLADE HFX PRFT PRIM -,SUP-6077-0335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ4 +0MM 44MM OFST 125MM ACCOLADE HFX PRFT PRIM -,SUP-6077-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ5 +0MM 48MM OFST 130MM ACCOLADE HFX PRFT PRIM -,SUP-6077-0537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OMNIFIT CEMENTED LONG STEM RIGHT -,SUP-6088-0730-200R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17512.18,12258.526,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ4 33MM OFST 100MM OMNIFIT EON PRIM EXTEND OFST -,SUP-6097-0425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ5 8.9MM DIST TIP 39MM OFST 110MM OMNIFIT EON PRIM -,SUP-6097-0530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ6 9.6MM DIST TIP 40MM OFST 120MM OMNIFIT EON PRIM -,SUP-6097-0630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ7 10.4MM DIST TIP 45MM OFST 130MM OMNIFIT EON -,SUP-6097-0735,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ8 46MM OFST 135MM OMNIFIT EON PRIM EXTEND OFST -,SUP-6097-0835,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HIP OMNIFIT EON PLUS SIZE 11 C-TPR 40MM X 150MM -,SUP-6097-1140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ5 8.9MM DIST TIP 35MM OFST 110MM OMNIFIT EON STD -,SUP-6098-0530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ6 9.6MM DIST TIP 36MM OFST 120MM OMNIFIT EON PRIM -,SUP-6098-0630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ7 9.6MM DIST TIP 41MM OFST 130MM OMNIFIT EON PRIM -,SUP-6098-0735,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ8 11.3MM DIST TIP 42MM OFST 135MM OMNIFIT EON STD -,SUP-6098-0835,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ9 46MM OFST 140MM OMNIFIT EON STD OFST 40MM NK -,SUP-6098-0940,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
MODULAR CUP REPLACEMTN LOCK RING 54MM -,SUP-6201-54,CDM,C1776,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRABECULAR METAL LOCKING RING -,SUP-6201-56,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL MULTI HOLE TRABECULAR METAL 54MM -,SUP-6202-54-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9990.38,6993.266,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 36X58-60MM G SHL TRIDENT 0DG CROSSFIRE PRIM -,SUP-621-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 28X46-48MM D SHL TRIDENT 0DG NEUT X3 7.9MM PRIM -,SUP-623-00-28D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT 00 DEG X3 32MM ID TRIDENT -,SUP-623-00-32C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 32X44MM C SHL TRIDENT 0DG NEUT X3 4.9MM PRIM -,SUP-623-00-32C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT POLYETHLENE 0 DEG 32MM CODE D TRIDENT X3 -,SUP-623-00-32D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 32X54-56MM F SHL TRIDENT 0DG NEUT X3 9.9MM PRIM -,SUP-623-00-32F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT POLYETHLENE 0 DEG 36MM CODE D TRIDENT X3 -,SUP-623-00-36D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT POLYETHLENE 0 DEG 36MM CODE E TRIDENT X3 -,SUP-623-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 36X54-56MM F SHL TRIDENT 0DG NEUT X3 7.9MM PRIM -,SUP-623-00-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT POLYETHLENE 0 DEG 36MM CODE F TRIDENT X3 -,SUP-623-00-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT POLY ZERO DEGREE 36MM X ALPHA G TRIDENT X3 -,SUP-623-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 36X58-60MM G SHL TRIDENT 0DG NEUT X3 9.4MM PRIM -,SUP-623-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACET TRIDENT X3 0 DEG POLY 36MM H -,SUP-623-00-36H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIDENT X3 0 DG  POLY INSERT 40MM SZ E -,SUP-623-00-40E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIDENT X3 0 DG POLYETTHYLENE INSERT 40MM SZ E RIM -,SUP-623-00-40E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT 0 DEG POLYETHYLENE 40MM ALPHA CODE F TRIDENT X3 -,SUP-623-00-40F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT POLY ZERO DEGREE 40MM X ALPHA G TRIDENT X3 -,SUP-623-00-40G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 40X58-60MM G SHL TRIDENT 0DG X3 7.4MM PRIM -,SUP-623-00-40G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 40X62-64MM H SHL TRIDENT 0DG X3 9.1MM PRIM -,SUP-623-00-40H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT POLY ZERO DEGREE 40MM X ALPHA H TRIDENT X3 -,SUP-623-00-40H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TRIDENT X3 0 D POLY 40MM ALPHA I -,SUP-623-00-40I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 44X54-56MM F SHL TRIDENT 0DG X3 3.8MM PRIM -,SUP-623-00-44F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 44X58-60MM G SHL TRIDENT 0DG X3 5.4MM PRIM -,SUP-623-00-44G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 44X62-64MM H SHL TRIDENT 0DG X3 7.1MM PRIM -,SUP-623-00-44H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TRIDENT X3 0 DEGREE POLY 44MM ALPHA I -,SUP-623-00-44I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 22X42MM B SHL TRIDENT 10DG X3 8.8MM PRIM -,SUP-623-10-22B,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 32X54-56MM F SHL TRIDENT 10DG X3 9.9MM PRIM -,SUP-623-10-32F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 36X50-52MM E SHL TRIDENT 10DG X3 5.9MM PRIM -,SUP-623-10-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT 10 DEG POLYETHYLENE 36MM E TRIDENT X3 -,SUP-623-10-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 36X54-56MM F SHL TRIDENT 10DG X3 7.9MM PRIM -,SUP-623-10-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT 10 DEG X3 36MM ID TRIDENT -,SUP-623-10-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT 10 DEGREE POLY 36MM G TRIDENT X3 -,SUP-623-10-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 36X58-60MM G SHL TRIDENT 10DG X3 9.4MM PRIM -,SUP-623-10-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 36X66-68MM I SHL TRIDENT 10DG X3 12.7MM PRIM -,SUP-623-10-36I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM DISTAL 19MM DIA CENTRALIZER-CEMENTED -,SUP-6259-8-180,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 32X50-52MM E SHL TRIDENT 0DG ALMN CERM PRIM -,SUP-625-OT-32E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 36MM D SHL RECON MDM CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-36C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 38MM D SHL MDM RECON CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-38D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 42MM E SHL RECON MDM CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-42E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 46MM F SHL RECON MDM CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-46F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 48MM G SHL MDM RECON CMNTLS COCR REVISN MODULAR -,SUP-626-00-48G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER MDM 52MM H CEMENTLESS -,SUP-626-00-52H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 22.2MMSTDX0MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-4-122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 26MM-3MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 26MM +4MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-226,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 26MM +8MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-326,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 26MM +12MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-426,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 26MM -3MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 40MM -4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 44MM -4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 22MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 26MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-126,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V40 28MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-128,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 36MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 40MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL HEAD LFIT V40 22.2MM +3MM -,SUP-6260-9-222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 26MM +4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-226,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 28MM +4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-228,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 40MM +4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-240,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 26MM +8MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-326,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 28MM +8MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-328,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 32MM +8MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-332,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 36MM +10MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-336,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 26MM +12MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-426,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V40 28MM +12MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL HEAD LFIT ANATOMIC V40 6.5MM X 16MM -,SUP-6260-9-440,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ15 47MM OFST 140MM PARTNERSHIP RELIANCE PF PRFT -,SUP-6265-2-005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ6 50MM OFST 150MM PARTNERSHIP RELIANCE PF PRFT -,SUP-6265-2-006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CENTRALIZER DIST HIP 13MM TY A -,SUP-6265-4-413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,601.24,420.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CENTRALIZER DIST HIP 14MM TY A -,SUP-6265-4-414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,601.24,420.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CENTRALIZER DIST HIP 15MM TY B -,SUP-6265-4-515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,601.24,420.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ1 10X34MM OFST 115MM PARTNERSHIP CITNN PRFT PRIM -,SUP-6265-5101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ2 36MM OFST 120MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ4 44MM OFST 130MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ5 47MM OFST 135MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ0 9X34MM OFST 110MM PARTNERSHIP CITNN PRFT PRIM -,SUP-6265-5110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ1 34MM OFST 118MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ2 36MM OFST 120MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ3 40MM OFST 133MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ4 44MM OFST 130MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ5 47MM OFST 135MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BODY PROX HIP 21MM STD RESTOR MODULAR REVISN BOLT CNCL -,SUP-6276-1-021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SYS HIP RESTORATION MODULAR SZ 21MM +0 HT V40 TPR -,SUP-6276-1-021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BODY PROX HIP 25MM STD RESTOR MODULAR REVISN BOLT CNCL -,SUP-6276-1-025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BODY PROX HIP 19MM RESTOR MODULAR REVISN BOLT +10MM NK CNCL -,SUP-6276-1-119,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BODY PROX HIP 21MM RESTOR MODULAR REVISN BOLT +11MM NK CNCL -,SUP-6276-1-121,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIP SUCT ACORN STD V. MUELLER 1.0625IN SIL RBR -,SUP-6276-1-123,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
MODULAR HIP SYSTEM RESTORATION 25MM X +10 X V40 TPR -,SUP-6276-1-125,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SYSTEM HIP MODULAR 27MM X +10 X V40 TPR RESTORAITON -,SUP-6276-1-127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BODY PROX HIP 19MM RESTOR MODULAR REVISN BOLT +20MM NK CNCL -,SUP-6276-1-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BODY PROX HIP 21MM RESTOR MODULAR REVISN BOLT +20MM NK CNCL -,SUP-6276-1-221,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BODY PROX HIP 25MM RESTOR MODULAR REVISN BOLT +10MM NK CNCL -,SUP-6276-1-225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BODY PROX HIP 19MM RESTOR MODULAR REVISN BOLT +30MM NK CNCL -,SUP-6276-1-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BODY PROX HIP 21MM RESTOR MODULAR REVISN BOLT +30MM NK CNCL -,SUP-6276-1-321,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BODY PROX HIP 23MM RESTOR MODULAR REVISN BOLT +30MM NK CNCL -,SUP-6276-1-323,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RESTORATION MODULAR HIP SYSTEM 25MM X 30 V40 -,SUP-6276-1-325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 14X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 15X155MM RESTOR REVISN MODULAR STR CNCL DIST HIP -,SUP-6276-7-015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 16X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 17X155MM RESTOR REVISN MODULAR STR CNCL DIST HIP -,SUP-6276-7-017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 18X155MM RESTOR REVISN MODULAR STR CNCL DIST HIP -,SUP-6276-7-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 19X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HIP RESTORATION MODULAR 20MM X 155MM -,SUP-6276-7-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RESTORATION MODULAR HIP SYS 22MM X 155MM -,SUP-6276-7-022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 23X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-023,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 14X195MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10547.44,7383.208,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 14X195MM RESTOR REVISN MODULAR HIP -,SUP-6276-7-214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 15X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 16X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 19X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 21X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RESTORATION MODULAR HIP SYSTEM 21MM X 195MM -,SUP-6276-7-221,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 24X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-224,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 15X235MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11716.67,8201.669,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RESTORATION HIP STEM 235MM X 19MM -,SUP-6276-7-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11716.67,8201.669,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 22X235MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11716.67,8201.669,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SYS RESTORATION MOD HIP 18MM X 115MM -,SUP-6276-7-418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24628.33,17239.831,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM PCA 28X0MM NK COCR REVISN -,SUP-6280-0-136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM PCA 32MM +5MM NK COCR REVISN -,SUP-6280-0-232,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM PCA 36MM +5MM NK COCR REVISN -,SUP-6280-0-236,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM PCA 32MM +10MM NK COCR REVISN -,SUP-6280-0-332,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM PCA 36MM +10MM NK COCR REVISN -,SUP-6280-0-336,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 32X52-55MM DURATION 10DG UHMWPE PCA -,SUP-6299-7-525,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4020.85,2814.595,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINEAR STANDARD TRILOGY ACETABULAR SYSTEM -,SUP-6305-50-36,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5260.44,3682.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB SZ P6 28X62-64MM SHL S12 +4 10DG CROSSFIRE CONGR -,SUP-6352-5-076,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4458.11,3120.677,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CROSSFIRE SYSTEM 12 POLYETHYLENE INSERT 10 -,SUP-6352-5-105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4458.11,3120.677,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR SM 9MM PE PEGX3 AVON RND DOME REVISN OFST -,SUP-6430-0-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4079.19,2855.433,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR MED 9.5MM PE PEGX3 AVON RND DOME REVISN OFST -,SUP-6430-0-030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4079.19,2855.433,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR LRG 10MM PE PEGX3 AVON RND DOME REVISN OFST -,SUP-6430-0-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4079.19,2855.433,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM XS 43.5MMX42.5MM AVON KN CMNT PEGX4 COCR -,SUP-6430-0-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14140.63,9898.441,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM MED 50.3MMX47.5MM AVON KN CMNT PEGX4 COCR -,SUP-6430-0-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14140.63,9898.441,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 36MM E SHL TRIDENT 0DG ELEV RM ECCT X3 PRIM -,SUP-643-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIDENT ELEVATED RIM INSERT 36MM G -,SUP-643-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND XS KINEMAX PLUS PRFT REVISN MODULAR 80MM COCR -,SUP-6476-8-260,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3594.54,2516.178,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 14MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 16MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 19MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-645,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 23MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-665,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TITANIUM FLUTED 16MM X 155MM -,SUP-6478-6-715,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 17MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-720,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 21MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 SM M LT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 SM M RT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 MED M LT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 LRG M RT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-131,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
MRH KNEE FEMORAL DISTAL BLOCK MED 10MM -,SUP-6481-1-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3438.71,2407.097,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIB STD XS XL KN GMRS COCR MRH -,SUP-6481-2-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11254.62,7878.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL BEARING COMPONENT MRH -,SUP-6481-2-103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11254.62,7878.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ7 STD GMRS KN MODULAR REVISN BUSHNG COCR ROT HNG -,SUP-6481-2-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1628.47,1139.929,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ7 STD GMRS KN MODULAR REVISN AXLE COCR ROT HNG -,SUP-6481-2-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4454.42,3118.094,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB BEAR KN PE -,SUP-6481-2-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3005.95,2104.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
MRH KNEE BUMPER INSERT 3 DEGREES -,SUP-6481-2-133,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3005.95,2104.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE TIB SZ4 MODULAR BMPR DIST KN ROT HNG DURATION -,SUP-6481-2-140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2514.7,1760.29,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ1 KN GMRS COCR MODULAR KLD ROT HNG -,SUP-6481-3-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12573.67,8801.569,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ2 SM KN GMRS COCR MODULAR KLD ROT HNG -,SUP-6481-3-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12573.67,8801.569,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ2 LRG KN GMRS COCR MODULAR KLD ROT HNG -,SUP-6481-3-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12573.67,8801.569,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ1-2 XS/SM 10MM PS ARTCSURF KN PE -,SUP-6481-3-210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ1-2 XS/SM 13MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ1-2 XS/SM 16MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ1-2 XS/SM 20MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB MED 2/ L2 13MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5011.74,3508.218,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB MED 2/ L2 24MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-324,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5011.74,3508.218,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
KINEMATIC ROTATING HINGE KNEE XSM 8MM -,SUP-6485-2-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HINGE KNEE ROTATING SIZE XSM 11MM THKNS KINEMATIC -,SUP-6485-2-011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
KINEMATIC ROTATING HINGE KNEE -,SUP-6485-2-016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
KINEMATIC ROTATING  HINGE KNEE SM 8MM -,SUP-6485-2-108,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
KINEMATIC ROTATING HINGE KNEE -,SUP-6485-2-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
KINEMATIC ROTATING HINGE KNEE 16MM MEDIUM -,SUP-6485-2-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
KINEMATIC ROTATING HINGE KNEE LARGE 21MM -,SUP-6485-2-321,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM STRAIGHT CEMENTED 10MM X 102MM -,SUP-6485-3-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM REPLACEMENT STRAIGHT CEMENTED 8MM X 102MM -,SUP-6485-3-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM REPLACEMENT STRAIGHT 9MM X 102MM -,SUP-6485-3-019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM CEMENTED STRAIGHT 11 X 127 -,SUP-6485-3-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM MRS STRAIGHT CEMENTED 13 X 127 -,SUP-6485-3-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM-REPLACEMENT CURVED CEMENTED 10MM X 102MM -,SUP-6485-3-310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM REPLACEMENT CURVED CEMENTED 8MM X 102MM -,SUP-6485-3-318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM REPLACEMENT CURVED CEMENTED -,SUP-6485-3-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 11MM LNG GMRS MODULAR 203MM TI HAP PLASM SPRY CTD -,SUP-6485-3-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14897,10427.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 17X203MM MRS MODULAR COCR POR CTD CMNT CRV DIST HIP -,SUP-6485-3-617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14897,10427.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
MRS CURVED CEMENTED STEM 11MM X 127MM -,SUP-6485-3-811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
MRS CURVED CEMENTED STEM 13MM X 127MM -,SUP-6485-3-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM CEMENTED STEM 15 X 127 -,SUP-6485-3-815,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM CEMENTED 17MM X 127MM CURVED -,SUP-6485-3-817,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GMRS PROXIMAL FEMORAL COMPONENT V40 -,SUP-6495-1-002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19014.24,13309.968,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT DISTAL FEMORAL SMALL LEFT 65MM -,SUP-6495-2-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27396.07,19177.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
DISTAL FEMORAL COMPONENT SMALL RT 65MM -,SUP-6495-2-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27396.07,19177.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM STD 65MM GMRS LT DIST KN MODULAR COCR ROT HNG -,SUP-6495-2-030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27152.28,19006.596,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM STD 65MM GMRS RT DIST KN MODULAR COCR ROT HNG -,SUP-6495-2-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27152.28,19006.596,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BUSHING FOR SMALL DISTAL FEMUR -,SUP-6495-2-105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1672.63,1170.841,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AXLE GMRS -,SUP-6495-2-115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4462.74,3123.918,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT FOR SMALL PROXIMAL TIBIAL COMPONENT 13MM -,SUP-6495-3-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT FOR SMALL PROXIMAL TIBIAL COMPONENT 24MM -,SUP-6495-3-024,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PROXIMAL TIBIA GMRS SM 80MM -,SUP-6495-3-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27343.31,19140.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIA PROXIMAL STD 80MM -,SUP-6495-3-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27343.31,19140.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL ROTATING COMPONENT SM -,SUP-6495-3-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11240.07,7868.049,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND GMRS REVISN MODULAR 30MM FEM KN -,SUP-6495-6-030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PIECE EXTENSION GMRS 40MM LENGTH -,SUP-6495-6-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GMRS EXTENSION PIECE 50MM -,SUP-6495-6-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
EXTENSION PIECE GMRS -,SUP-6495-6-070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GMRS EXTENSION PIECE 120MM -,SUP-6495-6-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GRAFT HUM TIS 6X10CM TISSUEMEND COLL -,SUP-6495-9-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10181.42,7126.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD DELTA CERAMIC FEMORAL 36/-3MM -,SUP-650-0660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD DELTA CERAMIC FEMORAL 36/0MM -,SUP-650-0661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD DELTA CERAMIC FEMORAL 36/+3MM -,SUP-650-0662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CERAMIC HEAD BIOLOX DELTA  OP HIP SYSTEM 28MM -,SUP-650-1055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD CER BIOLOX D OPTION 28MM -,SUP-650-1055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD CER BIOLOXD OPTION 36MM -,SUP-650-1057,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CER OPTION TYPE 1 TPR SLEEVE +3 -,SUP-650-1067,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
+6MM NECK BIOLOCK OPTION HIP SYSTEM -,SUP-650-1068,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEMORAL G7 BIOLOX DELTA -3 MM OFFSET OD28 MM HIP -,SUP-650-1159,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL HEAD UNIVERSAL TAPER 28MM OD BIOLOX DELTA -,SUP-6519-1-028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL HEAD UNIVERSAL TAPER BIOLOX DELTA -,SUP-6519-1-032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 36MM UNIV +0MML NK BIOLOX DELTA CERM TAPR PRIM -,SUP-6519-1-036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEMORAL 40MM BIOLOX DELTA -,SUP-6519-1-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
UNIVERSAL V40  -2.5MM ADAPTER SLEEVE (TI) -,SUP-6519-T-025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE HIP UNIV V-40 RECON PRIM ADPTR +0MML NK OFST TI TAPR -,SUP-6519-T-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE HIP +4MM OFST UNIV V-40 RECON PRIM ADPTR TI TAPR -,SUP-6519-T-204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
IMPACTOR SURG F/TIB INS TRIATH -,SUP-6541-4-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2125.24,1487.668,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 36MM-5MM NK ALMN PRIM -,SUP-6565-0-036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 32X0MM NK ALMN PRIM -,SUP-6565-0-132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 28MM -2.7MM OFST BIOLOX DELTA CERAMIC -,SUP-6570-0-028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 32MM -4MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 36MM -5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 28MM +0MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-128,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 32MM +0MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 36MM +0MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 28MM +4MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-228,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 32MM +4MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-232,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 36MM +5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-236,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 36MM -2.5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-436,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 36MM +2.5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-536,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 36MM +7.5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-736,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 36X54-56MM F SHL TRIDENT 0DG ECCT X3 PRIM -,SUP-663-00-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT KN SZ1 SM DURACN 10MM WDG BLCK REVISN VITAL -,SUP-6630-6-510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5255.98,3679.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
DURACON TOTAL KNEE FULL FLAT TIBIAL WEDGE SM-2 10MM -,SUP-6630-6-515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5255.98,3679.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 32X46-48MM D SHL TRIDENT 10DG ECCT X3 16.8MM -,SUP-663-10-32D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 36X58-60MM G SHL TRIDENT 10DG ECCT X3 18.8MM -,SUP-663-10-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 36X62-64MM H SHL TRIDENT 10DG ECCT X3 20.4MM -,SUP-663-10-36H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CK Insert Trial Sz 4 8mm -,SUP-663-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CK Insert Trial Sz 5 16mm -,SUP-663-1516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB LRG 9X77/53MM DURACN CR A/P LIP ARTC L/R KN -,SUP-6642-1-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3601.27,2520.889,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT A-P LIPPED DURACON XLGE 9MM -,SUP-6642-1-909,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3601.27,2520.889,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR XS PE DURACON DURATION ASYM -,SUP-6642-2-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR MED PE DURACON DURATION ASYM -,SUP-6642-2-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SM 11MMX45MM A/P DURACN CNSTRN ARTC L/R KN -,SUP-6642-9-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB LRG 9MMX55MM ARTCSURF L/R KN PE -,SUP-6642-9-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB LRG 11MMX55MM A/P DURACN CNSTRN ARTC L/R KN -,SUP-6642-9-811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB LRG 13MMX55MM A/P DURACN CNSTRN ARTC L/R KN -,SUP-6642-9-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TibAugSz1Trial20Â°WedgeLtLat/RtMed -,SUP-667-2201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TibAugSz2Trial20Â°WedgeLtLat/RtMed -,SUP-667-2202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ2 33MM OFST 99MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ3 35MM OFST 102MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ4 38MM OFST 105MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ5 35MM OFST 108MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ6 41MM OFST 111MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ7 46MM OFST 114MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0737,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HIP ACCOLADE 132 SZ 8 -,SUP-6720-0837,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HIP 132 DEG SZ #9 37MM X 120MM V40 ANGLE ACCOLADE II -,SUP-6720-0937,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
NECK ANGLE HIP STEM SZ# 0 / 27MM / 93MM / V40 -,SUP-6721-0027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ1 34MM OFST 96MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ2 37MM OFST 99MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ3 30MM OFST 102MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ4 42MM OFST 105MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ACCOLADE II SZ5 35MM NECK ANGLE HIP STEM 108MM V40 -,SUP-6721-0535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ6 35MM OFST 111MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ7 50MM OFST 114MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0737,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ8 51MM OFST 117MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0837,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ9 53MM OFST 120MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0937,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ10 57MM OFST 123MM ACCOLADE II V40 PRFT PRIM -,SUP-6721-1040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SM 9MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4186.89,2930.823,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SM 11MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4186.89,2930.823,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SM 16MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-116,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4186.89,2930.823,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ2 16MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB LRG 9MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-309,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 11MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB LRG 16MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 22X50-52MM D SHL TRIDENT 0DG ECCT UHMWPE CNSTRN -,SUP-690-00-22D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 22X50-52MM E SHL TRIDENT 0DG ECCT UHMWPE CNSTRN -,SUP-690-00-22E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 22X54-56MM F SHL TRIDENT 0DG ECCT UHMWPE CNSTRN -,SUP-690-00-28F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIDENT 0 DG ACETABULAR INSERT SZ H -,SUP-690-00-32H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIDENT ALL POLY CONSTRAINED ACETABULAR INSERT -,SUP-69-2244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10027.4,7019.18,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ALL POLY CONSTRAINED INSERT 46MM -,SUP-69-2246,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10027.4,7019.18,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM UNITRAX 40MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM UNITRAX 42MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM UNITRAX 43MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM UNITRAX 46MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM UNITRAX 47MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-047,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE HIP UNITRAX V40 PRIM MODULAR UNIPL -4MM NK TAPR -,SUP-6942-6-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE HIP UNITRAX V40 PRIM MODULAR UNIPL +0MML NK TAPR -,SUP-6942-6-065,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE HIP UNITRAX V40 PRIM MODULAR UNIPL +8MM NK TAPR -,SUP-6942-6-075,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE HIP UNITRAX C UNIPL -3MM NK C-TAPR -,SUP-6942-7-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE HIP UNITRAX C UNIPL +0MML NK C-TAPR -,SUP-6942-7-065,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE HIP UNITRAX C UNIPL +5MM NK C-TAPR -,SUP-6942-7-075,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE HIP UNITRAX C UNIPL +10MM NK C-TAPR -,SUP-6942-7-085,CDM,C1776,HCPCS,278,RC,,,outpatient,,,810.6,567.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HIP HIGH OFFSET INSIGNIA SZ 4 X 36MM X 103MM -,SUP-7000-6604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL CLUSTERHOLE ACET 46MM C TRIDENT TRITANIUM -,SUP-702-04-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIDENT IITRITANIUM CLUSTERHOLE 48MM D -,SUP-702-04-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL TRIDENT II TRITANIUM CLUSTERHOLE ACETABULAR 50MM D -,SUP-702-04-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIDENT II TRITANIUM CLUSTERHOLE ACETABULAR SHELL -,SUP-702-04-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIDENT II TRITANIUM CLUSTERHOLE ACET SHELL 54MM -,SUP-702-04-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIDENT II TRITANIUM CLUSTERHOLE ACE SHELL 56MM F -,SUP-702-04-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIDENT II TRITANIUM CLUSTERHOLE ACE SHELL 58MM F -,SUP-702-04-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIDENT II TRITANIUM CLUST ACE SHELL SZ 60MM G -,SUP-702-04-60G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL CLUSTERHOLE ACET SIZE 62MM G TRIDENT II TRITANIUM -,SUP-702-04-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACET 64MM H TRIDENT II TRIT CLUSTERHOLE -,SUP-702-04-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
44MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-44B,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
46MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
48MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
52MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
54MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
56MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
58MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
60MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-60G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
62MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
64MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
66MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-66H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIDENT II TRITANIUM MULTIHOLE ACE SHELL 48MM D -,SUP-709-04-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL TRIDENT II TITAN MLTHLE ACE SIZE 52MM E -,SUP-709-04-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL TRIDENT II TRITANIUM MLTHOLE ACE 54MM E -,SUP-709-04-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIDENT II TRITANIUM MULTHL SHELL 56MM F -,SUP-709-04-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL MULTIHOLE ACETABULAR 62MM X G TRIDENT II TRITANIUM -,SUP-709-04-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL TRIDENT II TITANIUM 64MM H MULTIHOLE -,SUP-709-04-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL MULTIHOLE ACET SZ 66MM H TRIDENT II TRITANIUM -,SUP-709-04-66H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACETABULAR 68MM ALPHA I MULTIHOLE TRIDENT II TRITANIUM -,SUP-709-04-68I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP ACTB 22X42MM SHL TANDEM AN-ROT BIPLR COCR UHMWPE MAX -,SUP-71322042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2755.51,1928.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
REF XLPE 36 20 DEG 54-56F -,SUP-7133-3345,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9094.89,6366.423,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ACET LINER 36 X 58 R3 20 DEG XLPE -,SUP-71335758,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6230.19,4361.133,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COVER SCR HL HIP THRD R3 REFLC STRL -,SUP-71336500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,407.81,285.467,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACETABULAR 58MM R3 MULTI HOLE -,SUP-71338668,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8734.15,6113.905,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OXINIUM HD 12/14 22MM +4 -,SUP-71342204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7011.09,4907.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 36MM +0MML NK OXNM 12/14 TAPR STRL -,SUP-71343600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8339.46,5837.622,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GNS II CMT TIB SIZE 2 LEFT -,SUP-71420162,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GNS II CMT TIBIAL SIZE 3 LEFT -,SUP-71420164,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GNS II CMT TIB SIZE 5 LEFT -,SUP-71420168,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ3 64/48MM RT KN CMNT GENESIS II NPOR -,SUP-71420182,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4286.44,3000.508,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GNS II CMT TIB SIZE 4 RIGHT -,SUP-71420184,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GNS II CMT TIB SIZE 6 RIGHT -,SUP-71420188,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GNSII CON INS SZ3-4 11MM -,SUP-71420524,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT GENESIS II SZ 3-4 13MM -,SUP-71420526,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3-4 15MM 68-71MM M/L 48-50MM A/P GENESIS II -,SUP-71420528,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GNS II CON INS SZ 3-4 18MM -,SUP-71420530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GNS II CON INS SZ5-6 15MM -,SUP-71420542,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GNS II RESUR PAT 29MM -,SUP-71420574,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RESURF PAT GEN II 32MM -,SUP-71420576,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 35X9MM THK UHMWPE PEGX3 RSRFC GENESIS II -,SUP-71420578,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GNS II RESURF PAT 26MM -,SUP-71420580,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5-6 13MM 74-77MM M/L 52-54MM A/P GENESIS II PS -,SUP-71420834,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2502.77,1751.939,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEGION CON ART INS 9MM SZ 1-2 -,SUP-71420959,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT G2 CONST SZ1-2 11MM -,SUP-71420960,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ARTICULAR G2 CONST SIZE 1-2 13MM -,SUP-71420962,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEMORAL SIZE 4 RIGHT LEGI -,SUP-71420964,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ1-2 18MM 60-64MM M/L 42-45MM A/P GENESIS II -,SUP-71420966,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LGN HM ST 3-4 5MM LTMD-RTLA -,SUP-71421142,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6854.06,4797.842,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ3 LEGION LT KN CNSTRN REVISN OXNM -,SUP-71421163,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LGN OX CONSTRAINED FEM 4 LT -,SUP-71421164,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LGN OX CONSTRAINED FEM 6 LT -,SUP-71421166,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT FEMORAL SIZE 4 RIGHT -,SUP-71421174,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29666.87,20766.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEGION OX CONSTRAINED FEM 5 RT -,SUP-71421175,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEGION PS OIN FEM SZ3 RT -,SUP-71421203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ4 LEGION RT KN PS OXNM POR -,SUP-71421204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10489.23,7342.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 LEGION RT KN PS OXNM POR -,SUP-71421205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ6 LEGION PS OXIN RIGHT -,SUP-71421206,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEGION PS OXIN FEM SZ4 LT -,SUP-71421214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEGION PS OXIN FEM SZ6 LT -,SUP-71421216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 LEGION RT KN CR REVISN OXNM POR -,SUP-71421225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9893.85,6925.695,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEGION CR OXIN FEM SZ6 RT -,SUP-71421226,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEGION NARROW PS OXIN SZ 4N LT -,SUP-71421264,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEGION NARROW PS OXIN SZ 6N LT -,SUP-71421266,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEGION NARROW PS OXIN SZ 5N RT -,SUP-71421275,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEGION NARROW PS OXIN SZ 6N RT -,SUP-71421276,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9574.46,6702.122,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3-4 13MM GENESIS II PS ARTC L/R KN-HI FLEX OXNM -,SUP-71421510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3539.59,2477.713,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GEN II PS HIGH FLEXION ARTICULAR INSERT SZ 5-6 13 -,SUP-71421517,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5975.55,4182.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT DIST KN SZ3 LEGION 10MM WDG BLCK -,SUP-71421658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
WEDGE FEM LGN SCRW DIS SZ4 5MM -,SUP-71421661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEGION SCREW DIS FEM WDG SZ5 5MM -,SUP-71421664,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6068.92,4248.244,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEGION SCW LWDG S5 5D X 5P -,SUP-71421741,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8891.18,6223.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
JUNI OX FB FEM SZ 3 LM RL -,SUP-71422343,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
JUNI OX FB FEM SZ 5 LM RL -,SUP-71422345,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
JUNI OX FB FEM SZ 7 LM RL -,SUP-71422347,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT FEMORAL JOURNEY OXINIUM SZ 5 RM LL -,SUP-71422355,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LGN RK/HK HEMI SZ 3-4 LL/RM 5MM -,SUP-71423420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8496.49,5947.543,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LGN RK/HK HEMI SZ 3-4 LM/RL 5MM -,SUP-71423432,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8496.49,5947.543,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEGION REVISION TIBIAL BASEPLATE -,SUP-71424001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE REVISION LONG TIBIA SIZE 2 LT -,SUP-71424002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIA BASE LGN REV SIZE 4 LT -,SUP-71424004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LGN REV TIBIA BASE SZ 5 LT -,SUP-71424005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIBIAL SIZE 2 RIGHT -,SUP-71424012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11863.04,8304.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ3 RT KN LEGION TI REVISN -,SUP-71424013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEGION REV TIBIA BASE SZ 5 RT -,SUP-71424015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM PRESSFIT LONG 10MM X 120MM -,SUP-71424023,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LGN PRESSFIT STEM 12MM X 120MM -,SUP-71424025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 13MM LEGION PRFT REVISN 120MM TI FEM KN -,SUP-71424026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM STRAIGHT 14MM X 120MM LEG -,SUP-71424027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM LGN PRESSFIT 15MM X 120MM -,SUP-71424028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LGN PRESSFIT STEM 16MM X 120MM -,SUP-71424029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTENSION LEGION TI PRESSFIT 18MM X 120MM -,SUP-71424031,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LGN PRESSFIT STEM 11MM X 160MM -,SUP-71424044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM LGN PRESSFIT 12MM X 160MM -,SUP-71424045,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM LGN PRESSFIT 13MM X 160MM -,SUP-71424046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LGN PRESSFIT STEM 15MM X 160MM -,SUP-71424048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 16MM LEGION PRFT REVISN 160MM TI FEM KN -,SUP-71424049,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM LGN CEMENT 14MM X 160MM STRT -,SUP-71424206,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6527.27,4569.089,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LGN OFFSET COUPLER 2MM -,SUP-71424223,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6132.58,4292.806,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LGN OFFSET COUPLER 4MM -,SUP-71424225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6132.58,4292.806,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LGN CR HIGH FLEX XLPE SZ 3-4 9MM -,SUP-71453111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT LEGION CR HIGH FLEX XLPE SZ 3-4 -,SUP-71453112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3-4 9MM LEGION CR KN XLPE -,SUP-71453146,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LGN PS HIGH FLEX XLPE SZ 1-2 10MM -,SUP-71453171,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LGN PS HIGH FLEX XLPE SZ 3-4 12MM -,SUP-71453174,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LGN PS HIGH FLEX XLPE SZ 1-2 15MM -,SUP-71453204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LGN PS HIGH FLEX XLPE SZ 3-4 9MM -,SUP-71453211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEGION PS HIGH FLEX XLPE SZ 3-4 11MM -,SUP-71453212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LGN PS HIGH FLEX SLPE SZ 3-4 13MM -,SUP-71453213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEGION PS HIGH FLEX XLPE SZ 3-4 15MM -,SUP-71453214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4308.51,3015.957,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LGN PS HIGH FLEX XLPE SZ 5-6 15MM -,SUP-71453224,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3-4 13MM PS KN LEGION XLPE -,SUP-71453248,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LGN XLPE DISHED ISRT SZ 5-6 15MM -,SUP-71453287,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
JOURNEY PFJ IMPLANT X-SM LT -,SUP-71461010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
JOURNEY PFJ IMPLANT X-SMALL RIGHT -,SUP-71461011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12604.89,8823.423,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
JOURNEY PFJ IMPLANT SM LT -,SUP-71461012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
JOURNEY PF IMPLANT SM RT -,SUP-71461013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SCREW 5MMX55MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642255,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
UNIPL -,SUP-71701035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14184.25,9928.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 38X9MM THK GENESIS II REVISN PS -,SUP-71926225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GEN II 7.5MM RESUR PAT 26MM -,SUP-71932634,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GEN II 7.5MM RESUR PAT 29MM -,SUP-71932635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3366.62,2356.634,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEGION REV TIB BASE W/JRNY LOCK SZ 5 -,SUP-71933571,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11863.04,8304.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CONE TIB LGN ID 18 SHORT -,SUP-71935386,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22278,15594.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
WEDGE TIB LEGION CONE ID 20 SHORT -,SUP-71935387,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21210.51,14847.357,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEGION TIB CONE ID 22 SHORT -,SUP-71935388,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21210.51,14847.357,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL CONE LEGION 18 LONG -,SUP-71935393,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22927.78,16049.446,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEGION TIB CONE ID 22 LONG -,SUP-71935395,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21210.51,14847.357,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEM CONE LGN ID 18MM LEFT -,SUP-71935400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22324.41,15627.087,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEGION FEM CONE ID 20MM LEFT -,SUP-71935401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22324.41,15627.087,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEGION FEM CONE ID 22MM LEFT -,SUP-71935402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22324.41,15627.087,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
WEDGE FEMORAL LEGION CONE ID 18MM KNEE RIGHT -,SUP-71935407,CDM,C1776,HCPCS,278,RC,,,outpatient,,,23447.6,16413.32,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEMORAL ANTHOLOGY AFIT SO POR PL HA SZ7 -,SUP-71935567,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6009.5,4206.65,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SCROPIO-FLEX X3 TIBIAL BEARING INSERT CR SZ11 -,SUP-72-26-1110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 36X46-48MM D SHL TRIDENT 0DG NEUT X3 3.9MM PRIM -,SUP-723-00-36D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 36X50-52MM E SHL TRIDENT 0DG NEUT X3 5.9MM PRIM -,SUP-723-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 40X54-56MM G SHL TRIDENT 0DG X3 5.8MM PRIM -,SUP-723-00-40F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 28MM X 54MM RESTOR ADM/MDM X3 48G -,SUP-7236-2-854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ7 24X71/47MM 18X27MM SCORP CNSTRN TOTAL -,SUP-72-4-0724,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5828.45,4079.915,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PIN NONRIM SPEED 65 STERILE -,SUP-74013480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,128.37,89.859,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PIN NONRIM SPEED 80 STERILE -,SUP-74013490,CDM,C1776,HCPCS,278,RC,,,outpatient,,,122.54,85.778,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
JOURNEY II CR FEM OX NP RT SZ. 4 -,SUP-74021154,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP JRNY II CR FEM OX NP LT SZ 4 -,SUP-74021164,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
JRNY II BCS FEMORAL OXIN RT SZ 3 -,SUP-74022113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
JOURNEY TIBIA BASE NP RT SZ 2 -,SUP-74022212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
JOURNEY TIBIA BASE NP RT SZ 3 -,SUP-74022213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
JOURNEY TIBA BASE NP RT SZ. 4 -,SUP-74022214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4218.31,2952.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
JOURNEY TIBIA BASE NP LT SZ3 -,SUP-74022223,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
JOURNEY BCS PAT RESRF RD 32 MM STD -,SUP-74024832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2017.9,1412.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
JOURNEY II CR ISRT XLPE RT SZ 3-4 9MM -,SUP-74025631,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
JRNY II ISRT XLPE DD LT SZ 3-4 9MM -,SUP-74025741,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
JRNY II BCS XLPE ART ISRT SZ 1-2 RT 12MM -,SUP-74027214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
JRNY II BCS XLPE ART ISRT SZ 5-6 LT 12MM -,SUP-74027264,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
44MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-44B,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
48MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
50MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
52MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
54MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
56MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
58MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
64MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
POLARCUP XLPE INSERT 43/22 NON-CEM -,SUP-75018942,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4478.01,3134.607,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
POLARCUP SHELL 43 CEMENTED -,SUP-75100451,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT DIST KN SZ7 SCORP 5MM WDG BLCK CMNT SPCR TOTAL -,SUP-75-1-0705,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4305.81,3014.067,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT POST KN SZ7 SCORP 5MM WDG BLCK SPCR TOTAL STABILIZED -,SUP-75-2-0705,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4305.81,3014.067,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL LEFT MEDIAL SZ 4 NON-POROUS -,SUP-761-1401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL LEFT MEDIAL SIZE 6 NON-POROUS -,SUP-761-1601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL TRAY LEFT MEDIAL SIZE 3 NON-POROUS -,SUP-762-3100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL TRAY LEFT MEDIAL SZ 4 NON-POROUS -,SUP-762-4100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TRIDENT X3 ECCENTRIC 0DEG 36MM -,SUP-763-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT LEFT MEDIAL SZ 4 7MM -,SUP-763-4071,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ7 66MM M/L 60-62MM A/P SCORP LT KN TOTAL -,SUP-76-4107L,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17711.12,12397.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL HEAD 12/14 COCR 36MM +3.5 -,SUP-8018-36-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD 12/14 COCR FRDM 36MM X +6 -,SUP-802403605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7259.36,5081.552,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
3.5MM CORT LOCK SCR 48MM NS -,SUP-816135048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,882.25,617.575,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SPACER NO PROFILE 16 X 14 X 8MM 7IN STERILE SHORELINE -,SUP-85-0208-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9039.72,6327.804,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ4 76/51MM L/R KN PFC TI CR MODULAR + NPOR -,SUP-86-0124,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11851.9,8296.33,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ2 64/43MM L/R KN PFC SIG KLD NPOR -,SUP-86-4180,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TAPER SIDMA 13 X 120 CEMENTED -,SUP-86-6498,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TAPER 13 X 150 -,SUP-86-6499,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 12MM UNIV PFC PRFT MODULAR 75MM CMNT TIB KN -,SUP-86-7412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 14MM UNIV PFC PRFT MODULAR 75MM CMNT TIB KN -,SUP-86-7414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM UNIVERSAL FLUTED 75MM X 18MM -,SUP-86-7418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM UNIVERSAL FLUTED 75MM X 24MM -,SUP-86-7421,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FLUTED 115 X 16MM -,SUP-86-7430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM UNIVERSAL FLUTED 115MM X 18MM -,SUP-86-7432,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM UNIVERSAL FLUTED 115MM X 20MM -,SUP-86-7433,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM RADIAL ALIGN TITANIUM 11MM X 0MM -,SUP-90176510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10481.8,7337.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 28X48-50MM X-ALT 0DG NEUT STD HXLPE 6MM NON- HD F -,SUP-931-28-248,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 36X52-54MM X-ALT 0DG NEUT STD HXLPE 6MM HD F /FMP -,SUP-932-36-252,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ2.5 63/59MM SIGMA FB RT KN CR CMNT COCR NPOR -,SUP-96-0018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7199.14,5039.398,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SIGMA TC3 FEM RT SZ2 -,SUP-96-0087,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL TC3 CEMENTED SIGMA SIZE 5 RIGHT -,SUP-96-0090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL TC3 CEMENTED SIGMA SIZE 2.5 RIGHT -,SUP-96-0092,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 32MM XS UHMWPE PEGX3 PFC SIG OVL DOME -,SUP-96-0100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 38MM STD UHMWPE PEGX3 PFC SIG OVL DOME -,SUP-96-0102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 41MM LRG UHMWPE PEGX3 PFC SIG OVL DOME -,SUP-96-0103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ADAPTER FEM 5DG PFC SIGMA TC3 KN REVISN CMNT TI -,SUP-96-0781,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8615.53,6030.871,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BOLT FEMORAL ADAPTER +2/-2 OFF -,SUP-96-0784,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1623.81,1136.667,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
DISTAL AUGMENT SIZE 2 4MM RIGHT -,SUP-96-0821,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
DISTAL AUGMENT SIZE 2 8MM RIGHT -,SUP-96-0823,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
DISTAL AUGMENT SIZE 2.5 8MM RIGHT -,SUP-96-0843,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
DISTAL  AUGMENT  COMBO  SIZE 2.5 16MM RIGHT -,SUP-96-0852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT FEM SZ4 PFC SIG POST KN WDG/BLCK 4MM COCR -,SUP-96-0886,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMBO PFC SIGMA POST AUG CEMENTED SIZE 5 X 8MM -,SUP-960908,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMBO PFC SIGMA DIST AUG CEMENTED SIZE 6 X 12MM LEFT -,SUP-96-0909,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMBO PFC SIGMA DIST AUG CEMENTED SIZE 6 X 16MM LEFT -,SUP-96-0911,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5 10MM 74MM/47MM M/L/A/P PFC SIG PS ARTCSURF -,SUP-96-2051,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT ROTATING PLTFRM SIZE 3 X 12.5MM -,SUP-96-2132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBAL INSERT ROT PLAT STAB SZ4 12.5MM -,SUP-96-2142,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBAL INSERT ROTATING PLATFORM (STAB) 4- 20MM -,SUP-96-2145,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT ROT PLTFRM TC3 SZ 2 12.5MM -,SUP-96-2322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT ROTATING PLATFORM SIZE 2 20MM -,SUP-96-2325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT ROTATING PLATFORM TC3 SZ 12.5 -,SUP-96-2332,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT ROTATING PLTFRM SZ3 30MM -,SUP-96-2348,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT TC3 RP S4 12.5 -,SUP-96-2352,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL PLATFORM TCS SZ 5 GVF 22.5MM -,SUP-96-2366,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ3 8MM KN PFC SIG UHMWPE CR POST LIP -,SUP-96-2540,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6645.51,4651.857,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5 15X89/55MM PFC SIG PS TCMPRTMNTL BEAR ARTC -,SUP-97-0473,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM UNIPL COCR POR -,SUP-98000100400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12559.22,8791.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
KT THR PRFT SUMMIT -,SUP-98-0001-006-00,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12559.22,8791.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB LRG VIVACIT VIT-E XLNK PE CNSTRN F/T/H ARTHPL -,SUP-98000125053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21605.69,15123.983,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
KT THR PRIM KINECTIV -,SUP-98000132001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21605.69,15123.983,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
KT THR PERSONA -,SUP-98-0002-415-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21605.69,15123.983,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SYS TKR PRIM CONSTRUT -,SUP-98000600000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20654.23,14457.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 10MM PFC SIG MODULAR CS STAB ANTMC KN POR CTD -,SUP-98-6061,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINK NECK SEGMENT WITHOUTH COLLAR 12/14MM 126 DEG 65MM -,SUP-99-0984/30,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19311.31,13517.917,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE HIP +5MM 12/14 TAPR ASR UNIPL -,SUP-9998-00-315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1022.29,715.603,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE HIP +8MM 12/14 TAPR ASR ADPR UNIPL -,SUP-9998-00-318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RADIAL HEAD 22MM -,SUP-ALN-RH1-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9803.64,6862.548,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD RADIAL 20MM -,SUP-ALN-RHI-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9803.64,6862.548,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RADIAL HEAD 24MM -,SUP-ALN-RHI-240,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9803.64,6862.548,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM 8MM X 0MM -,SUP-ALN-RST-0800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM 8MM X 2MM -,SUP-ALN-RST-0802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RADAIL STEM ALIGN 9MM X 0MM -,SUP-ALN-RST-0900,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM 10MM X 0MM -,SUP-ALN-RST-1000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PACKAGED RADIAL STEM 11MM X 2MM -,SUP-ALN-RST-1102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT KN 7DG 8DG XL LRG 9.83 MDL OPN 78-88MM 88-96 MM -,SUP-AR-13400L-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT KN 11DG 12DG XL LRG 14.13 MDL OPN 78-88MM 88-96 MM -,SUP-AR-13400L-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PIP DART PEEK 10 DEGREE 2.5X30MM -,SUP-AR-4154PS-3010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
IMPLANT PIP 3MM PEEK 30MM 10DG ANG -,SUP-AR-4155PS-3010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SCREW 7X12 PROSTOP ARTHROEREISIS -,SUP-AR-4207-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SCREW 8 X 14 MM PROSTOP SFT THRD -,SUP-AR-4208-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6154.44,4308.108,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SCREW 9X14 PROSTOP ARTHROEREISIS -,SUP-AR-4209-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SCREW 10X14MM PROSTOP SFT THRD CNCL TI F /ARTHROEREISIS -,SUP-AR-4210-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SCREW 11X16MM PROSTOP SFT THRD CNCL TI F /ARTHROEREISIS -,SUP-AR-4211-16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SCREW 12X16 PROSTOP ARTHROEREISI S -,SUP-AR-4212-16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
"GUIDE WIRE .045"" X 5.91"" -",SUP-AR-8933K,CDM,C1776,HCPCS,278,RC,,,outpatient,,,40.85,28.595,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUMERAL UNIVERS  SZ 6 -,SUP-AR-9100-06P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13645.28,9551.696,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 10MM UNIVERS II 148MM SHLDR -,SUP-AR-9100-10P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13645.28,9551.696,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GLENOID UNIV BASEPLATE SMALL -,SUP-AR-9120-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7278.46,5094.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 54X23MM UNIVERS II ECCT -,SUP-AR-9154-23P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ANATOEMIC PROSTHESIS 17MM -,SUP-AR-9500-170,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ANATOEMIC PROSTHESIS 18.5MM -,SUP-AR-9500-185,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ANATOEMIC PROSTHESIS 20MM -,SUP-AR-9500-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ANATOEMIC PROSTHESIS 21.5 MM -,SUP-AR-9500-215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RESTRICTOR CEMENT REV 30MM -,SUP-B000-0300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
REVERSE BODY STANDARD AND REVERSE BODY SCREW -,SUP-BBS-0960-21STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS PRIMARY PROXIMAL BODY 2.5 08STD -,SUP-BOD-0923-020-08STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BODY TSS PRIMARY PROXIMAL 10 LRG -,SUP-BOD-0923-020-10LRG,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BODY TSS PRIMARY PROXIMAL 10 STD -,SUP-BOD-0923-020-10STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BODY TSS PRIMARY PROXIMAL 2.5 X 12 STD -,SUP-BOD-0923-020-12STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BODY HUM LRG 40MM TI PROX GFT TITAN F/MODULAR SHLDR SYS -,SUP-BOD-0923-020-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6836.57,4785.599,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BODY TSS PRIMARY PROX 2.5 14 LRG -,SUP-BOD-0923-020-14LRG,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS PRIMARY PROXIMAL BODY 2.5 14STD -,SUP-BOD-0923-020-14STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS FRACTURE BODY 2.5 08LRG -,SUP-BOD-0923-021-08LRG,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS FRACTURE BODY 2.5 08STD -,SUP-BOD-0923-021-08STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ULNAR STEM 5.0MM 2CM EXT STEM -,SUP-DRUJ-IS250,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9932.28,6952.596,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AEQREVSD FX/ADAPTER LATRLZD HMRL INSRT 36MM 9MM -,SUP-DWD861,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8929.38,6250.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AEQUALIS REVERSED FX STEM 11MM X 130MM -,SUP-DWD903,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24223.61,16956.527,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TORNIER PERFORM REVERSED STANDARD GLENOSPHERE DIA 36MM -,SUP-DWJ012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15178.74,10625.118,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB SZ23 36MM MAX-ROM RINGLOC +3 HW E1 -,SUP-EP108323,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BEARING E1 44-36 STD HMRL -,SUP-EP-115393,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB 10X71/75MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-EP-183540,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB 12X71/75MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-EP-183542,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB 18MMX67MM M/L VANGRD ANT STAB MODULAR ARTC BEAR -,SUP-EP-189048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ACT ARTIC E1 HIP BRG 28X42MM -,SUP-EP-200148,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ACT ARTIC E1 HIP BRG 28X44MM -,SUP-EP-200150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ACT ARTIC E1 HIP BRG 28 X 50MM -,SUP-EP-200156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
IMPLANT TOE JOINT PRIMUS SIZE 40 -,SUP-FGT-40T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6915.85,4841.095,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RSS GLENOID BASEPLATE-S -,SUP-GBP-0961-094-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS PEGGED GLENOID XS -,SUP-GLN-0920-030-00P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9802.32,6861.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GLENOID TSS PEGGED S -,SUP-GLN-0920-030-01P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4010.16,2807.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS PEGGED GLENOID S -,SUP-GLN-0920-030-01P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9802.32,6861.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS PEGGED GLENOID -,SUP-GLN-0920-030-02P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9802.32,6861.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS PEGGED GLENOID L -,SUP-GLN-0920-030-03P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4010.16,2807.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GLENDOID S FIN-LOCK -,SUP-GLN-0926-030-01A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5882.18,4117.526,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RSS GLENOSPHERE CONCENTRIC -S 2MM -,SUP-GLS-0961-02C-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RSS GLENOSPHERE CONCENTRIC -S 5MM -,SUP-GLS-0961-05C-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS PEGGED GLENOID XS -,SUP-GN092003000P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10292.44,7204.708,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
KEY SURG 26MM F /UHR ACTB HEAD REM -,SUP-HIUHRK26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1195.26,836.682,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASE PLATE ASSEMBLY IJS-E -,SUP-IJS-ELB-BPA,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21316.33,14921.431,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STANDARD POLY LINER +0 -,SUP-LNR-0960-00S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RSS HXL LINER STANDARD +35 -,SUP-LNR-0960-191-3S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RSS HXL LINER STANDARD +65 -,SUP-LNR-0960-191-6S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RSS HXL LINER STANDARD +9S -,SUP-LNR-0960-191-9S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RSS HXL LINER STANDARD +OS -,SUP-LNR-0960-191-OS,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RSS HXL LINER RETENTIVE +6R -,SUP-LNR-0960-192-6R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SYSTEM GREAT TOE MOVEMENT PROX PHALANX HEMI -,SUP-MGT-890-20PPH,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10627.83,7439.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SYS MOVEMENT GREAT TOE SIZE 40 HEMI PROX PHALANX -,SUP-MGT89040PPH,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10627.83,7439.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 44X19MM TITAN 2.5 ECCT COCR -,SUP-MHH-0920-010-4419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6991.01,4893.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS COCR ECCENTRIC HEAD 2.5 40 X 15MM -,SUP-MHH-0923-010-4015E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS COCR CONCENTRIC HEAD 2.5 44 X 19MM -,SUP-MHH-0923-010-4419C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD TSS COCR ECCENTRIC 2.5 44 X 19MM -,SUP-MHH-0923-010-4419E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CONCENTRIC HEAD TSS COCR 2.5 46 X 14MM -,SUP-MHH-0923-010-4614C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS COCR ECCENTRIC HEAD 2.5 46 X 14MM -,SUP-MHH-0923-010-4614E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD CONCENTRIC TSS COCR 2.5 46MM X 17MM -,SUP-MHH-0923-010-4617C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD TSS COCR ECCENTRIC 2.5 46 X 17MM -,SUP-MHH-0923-010-4617E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS COCR CONCENTRIC HEAD 2.5 46 X 20MM -,SUP-MHH-0923-010-4620C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS COCR CONCENTRIC HEAD 2.5 48 X 18MM -,SUP-MHH-0923-010-4818C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM COCR CONC 2.5 X 48 X 21MM TSS -,SUP-MHH-0923-010-4821C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD TSS COCR ECCENTRIC 2.5 48 X 21MM -,SUP-MHH-0923-010-4821E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS COCR CONCENTRIC HEAD 2.5 50 X 19MM -,SUP-MHH-0923-010-5019C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS COCR CONCENTRIC HEAD 2.5 50 X 22MM -,SUP-MHH-0923-010-5022C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD TSS COCR CONCENTRIC 2.5 52 X 20MM -,SUP-MHH-0923-010-5220C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
IMPLANT SZ30 -,SUP-MHT-30,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6017.99,4212.593,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT LT SIZE 7 FEMORAL CR NONPOROUS COCR -,SUP-ORTHO DEV,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL PS 8MM SIZE 5 VITAMIN E -,SUP-ORTHO DEV,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEMORAL 36MM +3 BIOLOX DELTA -,SUP-ORTHO DEV,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM PLASMA SPRAY STD SIZE 11 -,SUP-ORTHO DEVELOPMENT,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIB SZ1 STRIDE LL/RM -,SUP-PFSI-00001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIB SZ2 STRIDE LL/RM -,SUP-PFSI-00003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIB SZ2 STRIDE RL/LM -,SUP-PFSI-00004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STRIDE TIBIA BASEPLATE SIZE 3 RM/LL -,SUP-PFSI00005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIB SZ3 STRIDE LL/RM -,SUP-PFSI-00005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIB SZ3 STRIDE RL/LM -,SUP-PFSI-00006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBIAL STRIDE SZ 4 RMLL -,SUP-PFSI00007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STRIDE TIBIA BASEPLATE SZ. 4 LM/RL -,SUP-PFSI00008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIB SZ4 STRIDE RL/LM -,SUP-PFSI-00008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIB SZ5 STRIDE LL/RM -,SUP-PFSI-00009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5156.46,3609.522,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL 8MM SIZE A -,SUP-PFSI00021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ A 9MM -,SUP-PFSI-00022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ B 8MM -,SUP-PFSI00027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STRIDE POLY INSERT SZ. B 8MM -,SUP-PFSI00027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STRIDE POLY INSERT TIB SZ-C 8MM -,SUP-PFSI00033,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ1 STRIDE LL/RM -,SUP-PFSI-00052,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STRIDE FEMUR SZ. 3 LM/RL -,SUP-PFSI00055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10492.44,7344.708,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ3 STRIDE LL/RM -,SUP-PFSI00056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10492.44,7344.708,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STRIDE FEMUR SIZE 4 RM/LL -,SUP-PFSI00058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10492.44,7344.708,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 STRIDE LL/RM -,SUP-PFSI-00060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP COMPREHESIVE MODULAR HYBRID REGNREX SHLDR POST -,SUP-PT-113950,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 9MM LNG REUNION COCR HAP CTD SHLDR -,SUP-R53514509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SPACER KN 46MM FEM MODHD ANTBTC REMEDY -,SUP-RHHDSM,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8093.31,5665.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM MED MODULAR -,SUP-RHSTMD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM REFLEX HYBRID 32MM +2.5MM NK COCR C-TAPR PRIM LFRIC -,SUP-S1400HH32,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
C-TAPER LFIT INTER HEAD 28MM +2.5 -,SUP-S-1400-HH82,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
C-TAPER HEAD +7.5 OFFSET LFIT SZ. 28MM / +7.5 -,SUP-S-1400-HH84,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PEG 4 MOD GLEN SZ 2 -,SUP-SAGL2042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
4 PEG MOD GLEN SZ 3 -,SUP-SAGL2043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PEG 4 MOD GLEN SZ 4 -,SUP-SAGL2044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PEG 4 MOD GLEN SZ5 -,SUP-SAGL2045,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT 4 PEG MOD GLEN LT AUG SZ 2 -,SUP-SAGL2142,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
4 PEG MOD GLEN LT AUG SZ 3 -,SUP-SAGL2143,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PEG 4 MOD GLEN LT AUG SZ 5 -,SUP-SAGL2145,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
4 PEG MOD GLEN RT AUG SZ 2 -,SUP-SAGL2242,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
4 PEG MOD GLEN RT AUG SZ 3 -,SUP-SAGL2243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
4 PEG MOD GLEN RT AUG SZ 4 -,SUP-SAGL2244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PEG 4 MOD GLEN RT AUG SZ 5 -,SUP-SAGL2245,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
MODULAR POST PPS -,SUP-SAGP0001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
MODULAR POST TM -,SUP-SAGP0002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 10MM SHLDR -,SUP-SEM092002510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OXINIUM LEGION PS-SPC FEMUR LEFT SIZE 5 -,SUP-SMITH & NE,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9155.58,6408.906,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 16.7MM PROX 10MM DIST SM 150MM INTSPC HI RELS 25MM -,SUP-SPC0022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12735.59,8914.913,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 10.5MM/21.9MM DIA P/D MED/SHRT 156MM INTSPC HI RELS -,SUP-SPC0122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12364.29,8655.003,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SPACER THR CMNT XL 54MM HIP REVISN INTSPC -,SUP-SPC0421,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11101.87,7771.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 10.5MM/21.9MM DIA P/D MED LNG 271MM INTSPC HI RELS -,SUP-SPC0422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SPACER THR CMNT LNG STM 60MM HIP REVISN INTSPC -,SUP-SPC0522,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SMART TOE INTRAMEDULLARY ARTHRODEAL 11MM -,SUP-ST0XS-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6409.29,4486.503,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS PRESS FIT STEM SZ. O7 -,SUP-STEM-0920-025-07,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS PRESS FIT STEM SIZE 08 -,SUP-STEM-0920-025-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS PRESS FIT HUM STEM SIZE 09 -,SUP-STEM-0920-025-09,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 12MM PRFT TITAN -,SUP-STEM-0920-025-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS PRESS FIT STEM SZ 10 -,SUP-STEM-0920-025-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 11MM PRFT TITAN -,SUP-STEM-0920-025-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM PRESS FIT TSS SZ 12 -,SUP-STEM-0920-025-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 13MM PRFT TITAN -,SUP-STEM-0920-025-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS PRESS FIT STEM SZ 14 -,SUP-STEM-0920-025-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM PRESS FIT TSS SZ 15 -,SUP-STEM-0920-025-15,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS PRESS FIT STEM SIZE 16 -,SUP-STEM-0920-025-16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS CEMENTED STEM SZ 08 -,SUP-STEM-0950-025-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ECCENTRIC CUP 10' X 36MM X3 CODE E TRIDENT -,SUP-STRYKER,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
WEDGE ACETABULAR AUGMENT 54MM X 56MM X 15MM -,SUP-STRYKER,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP VRSDL GLNSPR 36MM TI -,SUP-TI-115310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP ACTB 26X42MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-42-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP ACTB 26X43MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-43-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP ACTB 26X44MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-44-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP ACTB 26X45MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-45-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP ACTB 26X46MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-46-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP ACTB 26X47MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-47-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP ACTB 26X48MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-48-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP ACTB 26X50MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-50-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP ACTB 26X51MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-51-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP ACTB 26X52MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-52-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP ACTB 26X53MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-53-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP ACTB 26X54MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-54-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP ACTB 26X55MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-55-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP ACTB 26X56MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-56-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP ACTB 26X58MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-58-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT FEM DIST 12MM SIZE 4 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT TIBIAL HALF BLOCK #6 T -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE 3LT REV TIBIA LNG -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE MED GLENOID UNIVER -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7278.46,5094.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT LGN OX FEMORAL 5LT C -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT LT MOD FEM SIZE 3 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CUP PIVOT BIPOLAR 22 X 45MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CONE FEMORAL MEDIUM LEFT 30MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CUP UNIVERS REVERS 39 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7575.54,5302.878,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CONE PROX BODY SIZE 0 60MM TYP -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CONE TIBIAL 31 X 31 X 25MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL #5 13MM TS -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GLENOID POLY WITH PEG LG -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GLENOID POLY WITH PEG SMALL -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GLENOID REVERS 39 +4 LAT -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD 40 CER 16/18 TAPER BIOLOXD -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HUMERAL HEAD UNIVERS 44/17 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT HUMERAL M/39 +3 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HIP MODULAR 12MM X 127MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10941.84,7659.288,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM STR DIST 21MM X 90MM TAPE -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIB TRAY ROTATING REV  SZ 2 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIAL KNEE INSERT 3X12 PS ORTH -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
POSTERIOR FEM AUGMENT 8MM SZ 4 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM STR DIST 21MM X 150MM TAP -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HIP MODULAR 13MM X 127MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10941.84,7659.288,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM UNIVERS SZ10 CAP COATED -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10546.34,7382.438,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM DIST CONICAL 21MM X 155MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL HALF BLOCK #6 5MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIAL CONE MED 31 X 31 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2768.92,1938.244,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
WEDGE ACET AUGMENT 46MM X 15MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBAL INSERT TOTAL STAB SZ.3 9 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPR NANO HMRL PPS 36MM -,SUP-US-115736,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24134.5,16894.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPR NANO HMRL PPS 38MM -,SUP-US-115738,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24134.5,16894.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPR NANO HMRL PPS 40MM -,SUP-US-115740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24134.5,16894.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BEARING HUM 44-36MM XL STD RVRS CMPRHNSV ARCM -,SUP-XL115363,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ARCOM XL 44-36 STD HMRL BRNG -,SUP-XL-115363,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
44MM X 36MM CURV HUMERAL BEARING -,SUP-XL-115364,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PERSONA FEMUR CEMENTED STD CCR SIZE 7 LEFT -,SUP-ZIMMER,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEAD DEFIB IMPL BIPLR PERMNT PCNG ETAK RELIANCE 59CM 9FR -,SUP-0137,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions ,,
ENDOTAK RELIANCE S 64CM REF: 0138 -,SUP-0138,CDM,C1777,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions ,,
LEAD PCNG 64CM ETAK RELIANCE SG -,SUP-0181,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions ,,
ENDOTAK RELIANCE S 0272 59CM -,SUP-0272-59,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions ,,
ENDOTAK RELIANCE S 0273 64CM -,SUP-0273-64,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions ,,
LEAD ENDOTAK RELIANCE SINGLE C -,SUP-0292,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions ,,
LEAD DEFIB PCNG ETAK RELIANCE 59CM GORE-HYBRID ETFE CTD STRD -,SUP-0292-59,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions ,,
LEAD ICD RELIANCE 4-FRONT DEFIB -,SUP-0672-59,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions ,,
LEAD DEFIB IMPL LINOX SMRT S 65CM ECRD SIL INSL SGL COIL -,SUP-369818,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions ,,
LEAD DEFIB IMPL LINOX SMRT S 60CM ECRD SIL INSL SGL COIL -,SUP-375012,CDM,C1777,HCPCS,278,RC,,,outpatient,,,12976.94,9083.858,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions ,,
LEAD PCNG PROTEGO T FX -,SUP-379967,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions ,,
DEFIBRILLATOR PROTEGO S SGL COIL 75CM LD CARD IMPL -,SUP-379968,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions ,,
DEFIBRILLATOR PROTEGO S SGL COIL 60CM LD CARD IMPL -,SUP-379970,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions ,,
PLEXA PROMRI DF-1 S DS 65/15 -,SUP-414005,CDM,C1777,HCPCS,278,RC,,,outpatient,,,10734.28,7513.996,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions ,,
LEAD DEFIB TRIPLR SPRNT QUATTRO 58CM 8.6FRX12MM SPC RT ECRD -,SUP-6935-58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions ,,
LEAD DEFIB TRIPLR SPRNT QUATTRO 75CM 8.6FRX12MM SPC SIL -,SUP-6935M,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions ,,
LEAD DEFIB TRIPLR SPRNT QUATTRO 72CM 8.6FRX12MM SPC SIL -,SUP-6935M72,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions ,,
LEAD DEFIB UNIPL 58CM 7.5FR SUBQ SIL INSL SUT ON ANCHR SLV -,SUP-6996SQ58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions ,,
LEAD DEFIB TRUE BIPLR DURATA 60CM 7FR VNTRC OPTIM INSL STRD -,SUP-7122/60,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions ,,
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FR VNTRC OPTIM INSL STRD -,SUP-7122/65,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions ,,
LEAD DEFIB TRUE BIPLR DURATA 52CM 7FR VNTRC OPTIM INSL SGL. -,SUP-7122Q/52,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions ,,
LEAD DEFIB 7FRX58CM DURATA TRUE BIPLR HLCL TIP AV SGL SHOCK. -,SUP-7122Q/58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions ,,
LEAD DEFIB 7FRX65CM DURATA TRUE BIPLR HLCL TIP AV SGL SHOCK -,SUP-7122Q/65,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions ,,
LEAD DEFIB 8FR INTRO 58CM OPTISURE TRUE BIPLR SGL COIL -,SUP-LDA210Q/58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions ,,
LEAD DEFIB 8FR INTRO 65CM OPTISURE TRUE BIPLR SGL COIL -,SUP-LDA210Q-65,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9966.28992,other,SI=N Exclusions ,,
PK LEAD NEURSTM ACC -,SUP-30571SC,CDM,C1778,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions ,,
KT LEAD NEURSTM OCTRODE 60CM ACC -,SUP-3186,CDM,C1778,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions ,,
OCTRODE -,SUP-3189,CDM,C1778,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions ,,
LEAD NEURSTM PENTA 60CM PDL -,SUP-3228,CDM,C1778,HCPCS,278,RC,,,outpatient,,,14480.7,10136.49,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions ,,
KT LEAD NEURSTM LMTRD S-8 60CM ACC -,SUP-3286,CDM,C1778,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions ,,
KT 8MMX60CM LDX1 REVISN F/MDTRNC DEEP BRN STIM DBS -,SUP-3550-27,CDM,C1778,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions ,,
KT EXTENSION NEURSTM 40CM ACC -,SUP-3708140,CDM,C1778,HCPCS,278,RC,,,outpatient,,,3007.62,2105.334,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions ,,
KT LEAD NEURSTM PLTNM-IRDM ELCTRD 60CM STD ACC -,SUP-3777-60,CDM,C1778,HCPCS,278,RC,,,outpatient,,,7193.58,5035.506,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions ,,
KT LEAD NEURSTM 60CM PERC CMPCT ACC -,SUP-3778-60,CDM,C1778,HCPCS,278,RC,,,outpatient,,,7193.58,5035.506,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions ,,
KT LEAD NEURSTM PLTNM-IRDM ELCTRD PU SLVR COR 75CM PERC -,SUP-3778-75,CDM,C1778,HCPCS,278,RC,,,outpatient,,,7193.58,5035.506,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions ,,
LEAD PCNG 56CM TIP PISCES QUAD -,SUP-3887-56,CDM,C1778,HCPCS,278,RC,,,outpatient,,,4498.64,3149.048,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions ,,
KT LEAD NEURSTM SPEC FLRPLYMR PLTNM-IRDM SIL RBR PLYSTR PU -,SUP-3956530,CDM,C1778,HCPCS,278,RC,,,outpatient,,,17822.4,12475.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions ,,
KT LEAD NEURSTM SPEC 65CM SPIN CRD 5-6-5 LD ACC -,SUP-3956565,CDM,C1778,HCPCS,278,RC,,,outpatient,,,17822.4,12475.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions ,,
REACTIV8 IMPLANTABLE LEAD 45CM -,SUP-8145,CDM,C1778,HCPCS,278,RC,,,outpatient,,,11127.86,7789.502,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions ,,
STIMULATOR NERVE SPRINT ENDURA PNS SYSTEM -,SUP-9244-6001,CDM,C1778,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions ,,
STIMULATOR NERVE SPRINT EXTENSA PNS SYSTEM -,SUP-9288-6002,CDM,C1778,HCPCS,278,RC,,,outpatient,,,30075.3,21052.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions ,,
LEAD NEURSTM VECTRIS SURECAN 60CM PERC IMPL -,SUP-977A260,CDM,C1778,HCPCS,278,RC,,,outpatient,,,8347.95,5843.565,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions ,,
SYS PROGRAMMER NEURSTM VECTRIS SURSCN 75CM SPIN CRD CMPCT -,SUP-977A275,CDM,C1778,HCPCS,278,RC,,,outpatient,,,8347.95,5843.565,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions ,,
SURESCAN MRI -,SUP-977C165,CDM,C1778,HCPCS,278,RC,,,outpatient,,,20681.41,14476.987,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions ,,
LEAD SPECIFY SURESCAN MRI LEAD -,SUP-977C265,CDM,C1778,HCPCS,278,RC,,,outpatient,,,20681.41,14476.987,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions ,,
SURESCAN 2 X 8 PADDLE LEAD -,SUP-977C290,CDM,C1778,HCPCS,278,RC,,,outpatient,,,20681.41,14476.987,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions ,,
LEAD INTERSTIM MICRO 28CM SSMRI TINED -,SUP-978A128,CDM,C1778,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions ,,
INTERSTIM MRI LEAD KIT 2.16MM X 28CM -,SUP-978B128,CDM,C1778,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions ,,
LEAD NEUROSTIMULATOR INTERSTIM L41 CM TINE SSMRI -,SUP-978B133,CDM,C1778,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions ,,
FREEDOM 4A NEUROSTIMULATOR FR4A-TRL-A0 -,SUP-FR4A-TRL-A0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions ,,
FREEDOM 4A NEUROSTIMULATOR FR4A-TRL-B0 -,SUP-FR4A-TRL-B0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions ,,
FREEDOM-8A TRIAL KIT CH A US -,SUP-FR8A-TRL-A0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions ,,
FREEDOM 8A NEUROSTIMULATOR FR8A-TRL-B0 -,SUP-FR8A-TRL-B0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions ,,
KIT INTELLIS TRIAL LEAD 2 -,SUP-INTELTRIAL2,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions ,,
BLUE PERC LEAD KIT -,SUP-LEAD1058-70B,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions ,,
NEVRO 70CM SURGICAL LEAD KIT -,SUP-LEAD3005-70B,CDM,C1778,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions ,,
KT NEURSTM PRGMR PRECISN ACC -,SUP-M365SC550040,CDM,C1778,HCPCS,278,RC,,,outpatient,,,6196.24,4337.368,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions ,,
VECTRIS SURESCAN MRI COMPACT LEAD KIT 1 X 8 SC -,SUP-MEDTRONIC INC,CDM,C1778,HCPCS,278,RC,,,outpatient,,,8347.95,5843.565,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions ,,
SLIM TIP DRG -,SUP-MN10450-50A,CDM,C1778,HCPCS,278,RC,,,outpatient,,,9331.07,6531.749,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions ,,
SLIMTIP DRG 90A -,SUP-MN10450-90A,CDM,C1778,HCPCS,278,RC,,,outpatient,,,9509.36,6656.552,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions ,,
KIT NEUROSTIMULATOR TUNNEL TOOL -,SUP-MN15000,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2572.47,1800.729,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions ,,
FREEDOM -4A PNS SYSTEM -,SUP-Q4SP-1-US DW,CDM,C1778,HCPCS,278,RC,,,outpatient,,,40705.5,28493.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions ,,
FREEDOM -4A PNS SYSTEM -,SUP-Q4SP-2-US,CDM,C1778,HCPCS,278,RC,,,outpatient,,,44406,31084.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions ,,
COVEREDGE 32 MRI PADDLE LEAD 50CM -,SUP-SC-8436-50,CDM,C1778,HCPCS,278,RC,,,outpatient,,,29704,20792.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions ,,
TRIAL LEAD KIT -,SUP-TLEAD1058-70B,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,34103.808,other,SI=N Exclusions ,,
LEAD PCNG 9FRX12MM SPC AV + DX PERMNT BIPLR STRD ELUT TND FX -,SUP-1368,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,2035.392,other,SI=N Exclusions ,,
LEAD PCNG 9FRX12MM SPC 52CM AV + DX PERMNT BIPLR STRD ELUT -,SUP-1368/52,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,2035.392,other,SI=N Exclusions ,,
LEAD PCNG 9FRX12MM SPC 58CM AV + DX PERMNT BIPLR STRD ELUT -,SUP-1368/58,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,2035.392,other,SI=N Exclusions ,,
PACING  LEAD TENDRIL STS 2088TC-65 -,SUP-2088TC-65,CDM,C1779,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,2035.392,other,SI=N Exclusions ,,
LEAD PCNG 58CM SOLOX IMPL BIPLR ECRD SGL -PASS PSS FX -,SUP-333900,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,2035.392,other,SI=N Exclusions ,,
MESH SURG LRG 5.4X7IN OVL PP EPTFE CMPSX KL NABSB PTCH -,SUP-0010202,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5029.22,3520.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH SURG SM 3.1X4.7IN OVL MONO PP PDS EPTFE VENTRIO PRT -,SUP-0010211,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3818.72,2673.104,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH SURG LRG 5.4X7IN OVL MONO PP PDS EPTFE VENTRIO PRT ABSB -,SUP-0010212,CDM,C1781,HCPCS,278,RC,,,outpatient,,,7123.55,4986.485,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH SURG 4.5IN LRG CIR MONO PP PDS EPTFE VENTRIO PRT ABSB -,SUP-0010214,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4340.04,3038.028,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH SURG MED 4.3X5.5IN OVL MONO PP PDS EPTFE VENTRIO PRT -,SUP-0010215,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5013.01,3509.107,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH SURG 8CM LRG 3.2X3.2IN CIR PP EPTFE VENTRALEX NABSB -,SUP-0010303,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4167.7,2917.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH PERFIX PLUG MED -,SUP-0112760,CDM,C1781,HCPCS,278,RC,,,outpatient,,,984.1,688.87,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH PERFIX PLUG LRG -,SUP-0112770,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1660.12,1162.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH PLUG PERFIX X-LRG -,SUP-0112780,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1159.39,811.573,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH 3DMAX DAVOL LRG LEFT -,SUP-0115311,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH 3DMAX DAVOL X-LRG LEFT -,SUP-0115312,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1187.9,831.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH 3DMAX DAVOL LRG RIGHT -,SUP-0115321,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH 3DMAX DAVOL X-LRG RIGHT -,SUP-0115322,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1187.9,831.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH MOD KUGEL 3.5 X 5 -,SUP-0115816,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH SURG 4X6IN ELLIP MONO PP EPTFE COMPOSIX E /X NABSB -,SUP-0123460,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2954.63,2068.241,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH ATRIUM 1 X 4 - DISC DO NOT USE -,SUP-1000104-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,116.7,81.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH ATRIUM 2 X 4 -  DISC DO NOT USE -,SUP-1000204-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,128.37,89.859,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH ATRIUM 6X6 - DISCONTINUED DO NOT USE -,SUP-1000606-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,163.38,114.366,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH ATRIUM 6 X 6 - DO NOT USE DISCONTINUED -,SUP-1000606-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,163.38,114.366,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH SURG 10X14IN PP KNTD PROLITE NABSB SHT -,SUP-1001014-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,478.47,334.929,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH ATRIUM PRE SHAPED -,SUP-1010306-02,CDM,C1781,HCPCS,278,RC,,,outpatient,,,192.56,134.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH SURG 20X30CM RECT EPTFE GORE-TEX PTCH -,SUP-1320030020,CDM,C1781,HCPCS,278,RC,,,outpatient,,,18928.87,13250.209,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH SURG 5X10CM EPTFE GORE-TEX PTCH -,SUP-1405010010,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1754.47,1228.129,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH SURG 10X15CM OVL EPTFE GORE-TEX PLG -,SUP-1410015010,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4014.93,2810.451,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
IMPLANT ARTELON 0.3X16CM -,SUP-31052,CDM,C1781,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
IMPLANT ARTELON 0.7X16CM -,SUP-31056,CDM,C1781,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH PROLENE 3D PATCH LRG -,SUP-3DPL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3399.12,2379.384,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH PROLENE 3D PATCH MED -,SUP-3DPM,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3399.12,2379.384,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH RESTORELLE 24CM X 4CM -,SUP-501420,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4419.28,3093.496,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH VENTRALEX ST SM 4.3CM -,SUP-5950007,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2292.25,1604.575,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH VENTRALEX ST MD 6.4CM -,SUP-5950008,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2488.78,1742.146,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH VENTRALEX ST LRG 8.0CM -,SUP-5950009,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3167.55,2217.285,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH SURG 3IN SM CIR MONO PP CO-KNTD VENTRALEX ST ECHO PS -,SUP-5950010,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3765.73,2636.011,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH SURG SM 3.1X4.7IN OVL MONO PP CO-KNTD VENTRALEX ST ECHO -,SUP-5950030,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4634.12,3243.884,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH SURG MED 4.3.X5.5IN OVL MONO PP CO-KNTD VENTRALEX ST -,SUP-5950040,CDM,C1781,HCPCS,278,RC,,,outpatient,,,6128.34,4289.838,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH SURG XL 8.7X10.7IN OVL MONO PP PTFE HYDRGL CO-KNTD -,SUP-5950080,CDM,C1781,HCPCS,278,RC,,,outpatient,,,12018.24,8412.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH SURG 4X6IN ELLIP MONO PP PTFE HYDRGL CO-KNTD -,SUP-5954460,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3720.86,2604.602,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH SURG 15CM MED RND ACCUMESH PSTN -,SUP-AMPPCO15X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3904.18,2732.926,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH SURG 20CM MED RND ACCUMESH PSTN -,SUP-AMPPCO20X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4655.67,3258.969,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH PARIETEX 15CM X 10CM RT -,SUP-AUTO-VTX1510,CDM,C1781,HCPCS,278,RC,,,outpatient,,,465.28,325.696,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH DEXTILE MEDIUM LEFT 13 X 9CM ANATOMICAL -,SUP-DXT1309AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH DEXTILE MEDIUM RIGHT 13 X 9CM ANATOMICAL -,SUP-DXT1309AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH DEXTILE LARGE LEFT 15 X 10CM ANATOMICAL -,SUP-DXT1510AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,846.08,592.256,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH DEXTILE LARGE RIGHT 15 X 10CM ANATOMICAL -,SUP-DXT1510AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,846.08,592.256,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH DEXTILE XL LEFT 16 X 12CM ANATOMICAL -,SUP-DXT1612AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH DEXTILE XL RIGHT 16 X 12CM ANATOMICAL -,SUP-DXT1612AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
PATCH BOVINE 0.8 X 8CM -,SUP-E0.8P8,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1160.81,812.567,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
PATCH BOVINE 2.0 X 9CM -,SUP-E2P9,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2008.89,1406.223,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
GORE BIOABSORBABLE SYNTHETIC MESH 7CM X 10CM -,SUP-HH0710,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH LAP PROGRIP 15 X 10 -,SUP-LPG1510,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1664.57,1165.199,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH PROGRIP ANATOM 15x10 L -,SUP-LPG1510AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1878.87,1315.209,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH PROGRIP ANATOM 15x10 R -,SUP-LPG1510AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1878.87,1315.209,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH PROGRIP LAPAROSCOPIC SELF-FIX 16 X 12 -,SUP-LPG1612,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1888.04,1321.628,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH PROGRIP ANATOM 16X12 L -,SUP-LPG1612AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2098.94,1469.258,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH PROGRIP ANATOMICAL RIGHT 16CM X 12CM -,SUP-LPG1612AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2098.94,1469.258,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
UPSYLON TRADITIONAL Y MESH -,SUP-M0068318200,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4180.97,2926.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH PROCEED 6IN X 8IN -,SUP-PCDG1,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4886.8,3420.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH PROCEED 4IN X 6IN -,SUP-PCDN1,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2936.68,2055.676,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
IMPLANT BIO TISS 10X15CM 3D RND PLYSTR PRCN COLL OPN SKRT -,SUP-PCO1510OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2440.67,1708.469,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
IMPLANT PLYSTR PRCN COLL 10X15CM PRTX 1.7MM ABSB 3D RND KNTD -,SUP-PCO1510X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1920.48,1344.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
IMPLANT BIO TISS 15CM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCO15X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2513.71,1759.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
IMPLANT BIO TISS 15X20CM 3D RECT PLYSTR PRCN COLL KNTD PRTX -,SUP-PCO2015OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3387.39,2371.173,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
IMPLANT BIO TISS 15X20CM 3D RND PLYSTR PRCN COLL KNTD PRTX -,SUP-PCO2015X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3237.25,2266.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH PARIETEX HEART SHAPED -,SUP-PCO2H1,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1862.49,1303.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH PARIETEX HORSE SHOE -,SUP-PCO2H3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1999.72,1399.804,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
IMPLANT BIO TISS 20X30CM 3D RECT PLYSTR PRCN COLL KNTD PRTX -,SUP-PCO3020X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5125.65,3587.955,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
PATCH VENTRAL PARITEX 4.6CM -,SUP-PCO4VP,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1712.49,1198.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
PATCH VENTRAL PARITEX 6.6CM -,SUP-PCO6VP,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2052.19,1436.533,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
IMPLANT BIO TISS 8CM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCO8OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2365.35,1655.745,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
IMPLANT BIO TISS 8CM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCO8OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2128.52,1489.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
PATCH VENTRAL PARITEX 8.6CM -,SUP-PCO8VP,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2635.99,1845.193,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
IMPLANT BIO TISS 50MM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCOPM15H50,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2579.06,1805.342,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH PROLENE HERNIA SYSTEM LARGE -,SUP-PHSL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2038.93,1427.251,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH PROLENE HERNIA SYSTEM MEDIUM -,SUP-PHSM,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2038.93,1427.251,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH PARIENTENE PROGRIP 15CM X 9CM -,SUP-PP1509G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1083.58,758.506,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH PARITENE MACROPOROUS 15 X 10 -,SUP-PPM1510X3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,223.71,156.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH PARITENE MACROPOROUS 15 X 15 -,SUP-PPM1515X3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,259.54,181.678,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH PARIETENE 20 X 20 -,SUP-PPM2020,CDM,C1781,HCPCS,278,RC,,,outpatient,,,301.09,210.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH PARIETENE 30 X 30 -,SUP-PPM3030,CDM,C1781,HCPCS,278,RC,,,outpatient,,,563.14,394.198,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH PARIETENE 45 X 30 -,SUP-PPM4530,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1191.23,833.861,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
DURASORB PTM 0616 6 X 16 -,SUP-PTM 0616,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
DURASORB PTM1 025 10 X 25 -,SUP-PTM1025,CDM,C1781,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
DURASORB PTM 2025 -,SUP-PTM2025,CDM,C1781,HCPCS,278,RC,,,outpatient,,,20050.2,14035.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH SURG 6X11CM RECT PLYSTR KNTD MERSILN NABSB SHT -,SUP-RMS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,992.11,694.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH SYMBOTEX 25 X 20 0118362 -,SUP-SMY2520OS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,6454.57,4518.199,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH SYMBOTEX VENTRAL 12CM -,SUP-SYM12,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1989.6,1392.72,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH SYMBOTEX VENTRAL 15CM -,SUP-SYM15,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2490.4,1743.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH SYMBOTEX VENTRAL 15CM -,SUP-SYM15,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2571.48,1800.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH SYMBOTEX VENTRAL 15 X 10 NON SKIRTED -,SUP-SYM1510,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1808.74,1266.118,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH SYMBOTEX 15 X 10 -,SUP-SYM1510OS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2418.08,1692.656,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH SYMBOTEX 2012E -,SUP-SYM2012E,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2774.79,1942.353,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH SYMBOTEX 20 X 15 CM -,SUP-SYM2015,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2613.29,1829.303,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH SYMBOTEX 20 X 15 SKIRTED -,SUP-SYM2015OS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3726.15,2608.305,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH SURG 25X15CM ELLIP MONO PLYSTR COLL SYMBOTEX NABSB -,SUP-SYM2515E,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4592.69,3214.883,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH PARIETENE DS COMPOSITE 25CM X 20CM -,SUP-SYM2520,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4274.74,2992.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH SYMBOTEX 25 X 20 -,SUP-SYM2520,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4118.24,2882.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH SYMBOTEX 30 X 20 -,SUP-SYM3020,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5381.94,3767.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH SYMBOTEX COMPOSITE -,SUP-SYM3728,CDM,C1781,HCPCS,278,RC,,,outpatient,,,6391.04,4473.728,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
Symbotexâ„¢ Composite Mesh- 42 x 32 cm -,SUP-SYM4232,CDM,C1781,HCPCS,278,RC,,,outpatient,,,7515.87,5261.109,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH SYMBOTEX VENTRAL 9CM -,SUP-SYM9,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1450.75,1015.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH SURG 10X15CM PLYSTR KNTD PRTX SHT -,SUP-TECT1510ADPL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,734.63,514.241,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
"MESH PARIETEX ANATOMICAL LEFT 6X4"" -",SUP-TECT1510AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,648.04,453.628,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
"MESH PARIETEX ANATOMICAL RIGHT 6X4"" -",SUP-TECT1510AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,648.04,453.628,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH SURG 8X12CM MONO PLYSTR KNTD PRTX PROGRIP PRT -,SUP-TEM1208GL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1175.76,823.032,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH SURG 8X12CM MONO PLYSTR KNTD PRTX PROGRIP PRT ABSB -,SUP-TEM1208GR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1175.76,823.032,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH PARIETEX PROGRIP 15cm x 9cm -,SUP-TEM1509G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1083.58,758.506,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH PARIETEX PROGRIP 15 X 15CM -,SUP-TEM1515G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1131.55,792.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH PARIETEX PROGRIP 20X15 -,SUP-TEM2015G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1382.48,967.736,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH PARIETEX PROGRIP 30X15 -,SUP-TEM3015G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1925.62,1347.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH SURG 30X30CM 3D PLYSTR KNTD PRTX EASEGRIP SHT -,SUP-TET3030,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1054.85,738.395,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH SURG 3X6IN RECT MONO PLGCPRN-25 PP KNTD ULTRAPRO PRT -,SUP-UMR3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,908.96,636.272,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
GRAFT HEMASHIELD 10MM X100CM G -,SUP-UNDEFINED,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2550.8,1785.56,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH VENTRIO XL 10 X 13 -,SUP-UNDEFINED,CDM,C1781,HCPCS,278,RC,,,outpatient,,,8233.36,5763.352,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
MESH VICRYL WOVEN FLAT12IN x 12IN ABSORBABLE HERNIA REPAIR -,SUP-VWML,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4702.1,3291.47,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,15398.5536,other,SI=N Exclusions ,,
STENT DES 2.25X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332220,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,200.09685,4563.1488,other,SI=N Exclusions ,,
STENT DES 2.5X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332250,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,200.09685,4563.1488,other,SI=N Exclusions ,,
STENT DES 3X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332300,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,200.09685,4563.1488,other,SI=N Exclusions ,,
STENT DES 3.5X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332350,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,200.09685,4563.1488,other,SI=N Exclusions ,,
STENT DES 4X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332400,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,200.09685,4563.1488,other,SI=N Exclusions ,,
STENT DES 2.75X38MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902338270,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,200.09685,4563.1488,other,SI=N Exclusions ,,
STENT DES 3.5X38MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902338350,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,200.09685,4563.1488,other,SI=N Exclusions ,,
STENT DES 4X38MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902338400,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,200.09685,4563.1488,other,SI=N Exclusions ,,
IMPLANT BIO TISS 6.5CM 3D RND PLYSTR PRCN COLL KNTD PRTX -,SUP-PNP6X3,CDM,C1784,HCPCS,278,RC,,,outpatient,,,891.3,623.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,200.09685,4563.1488,other,SI=N Exclusions ,,
PACEMAKER UNIPL BIPLR INSGA I ULTRA 2CHMBR RR 10.8ML 25.4GM -,SUP-1290,CDM,C1785,HCPCS,275,RC,,,outpatient,,,21052.71,14736.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER UNIPL BIPLR EVIA 2CHMBR 44.5X53MM 6.5MM 12ML 25GM -,SUP-359529,CDM,C1785,HCPCS,275,RC,,,outpatient,,,11220.69,7854.483,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER UNIPL BIPLR EVIA 2CHMBR RR 44.5X53MM 6.5MM 12ML -,SUP-377848,CDM,C1785,HCPCS,275,RC,,,outpatient,,,14573.53,10201.471,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER IMPL ENTOVIS PROMRI 2CHMBR IS-1 CONN SR-T ACC -,SUP-404722,CDM,C1785,HCPCS,275,RC,,,outpatient,,,18565,12995.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER IMPL UNIPL VERITY ADX MS DR 2CHMBR RR 45X52MM 6MM -,SUP-5357M/S,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9332.85,6532.995,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
GENERATOR TEMP PLS 2CHMBR 5392 ACC -,SUP-5392KIT,CDM,C1785,HCPCS,275,RC,,,outpatient,,,27828.94,19480.258,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER IMPL UNIPL BIPLR VCT DR 2CHMBR RR V- PCNG RDC -,SUP-5810,CDM,C1785,HCPCS,275,RC,,,outpatient,,,13842.06,9689.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER IMPL UNIPL BIPLR VCT XL DR 2CHMBR RR V- PCNG RDC -,SUP-5816,CDM,C1785,HCPCS,275,RC,,,outpatient,,,13842.06,9689.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER IMPL UNIPL BIPLR ZPHR 2CHMBR RR 43X44MM 6MM 8.5ML -,SUP-5820,CDM,C1785,HCPCS,275,RC,,,outpatient,,,22278,15594.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER IMPL UNIPL BIPLR ZPHR 2CHMBR RR 43X44MM 6MM 8.5ML -,SUP-5820,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9332.85,6532.995,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER IMPL UNIPL BIPLR ZPHR DR 2CHMBR RR 44X52MM 6MM -,SUP-5826,CDM,C1785,HCPCS,275,RC,,,outpatient,,,18565,12995.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER IMPL SURSCN ADVISA 2CHMBR RR MUL-PRGM IS-1 CONN SR -,SUP-A2DR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16337.2,11436.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER IMPL UNIPL ADAPTA DR 2CHMBR RR 12ML 21GM IS-1 -,SUP-ADAPTADRK2,CDM,C1785,HCPCS,275,RC,,,outpatient,,,27828.94,19480.258,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER IMPL BIPLR ADAPT 2CHMBR RR 13.1ML 31.3GM IS-1 CONN -,SUP-ADDRL1,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16567.96,11597.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER IMPL UNIPL BIPLR ADAPTA 2CHMBR RR 42.9MMX44.7MM -,SUP-ADDRS1,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16567.96,11597.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
GENERATOR 2CHMBR -,SUP-DR2550,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16708.5,11695.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER ESSENTIO DR DYNMC ADJ TI ACC -,SUP-L101,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9341.91,6539.337,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER ESSENTIO DR MRI L111 -,SUP-L111,CDM,C1785,HCPCS,275,RC,,,outpatient,,,12460.83,8722.581,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER IMPL ESSENTIO EL DR 2CHMBR 4.45X5.88X0.75IN 29.1GM -,SUP-L121,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9341.91,6539.337,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER ACCOLADE DR -REF: L301 -,SUP-L301,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9442.9,6610.03,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER ACCOLADE MRI DR L311 -,SUP-L311,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10582.05,7407.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER IMPL UNIPL BIPLR ACCENT DR 2CHMBR RR WRLS TELEM -,SUP-PM2110,CDM,C1785,HCPCS,275,RC,,,outpatient,,,12438.55,8706.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER ENDURITY 2CHMBR 50X46MM 6MM 10.4ML 19GM IS-1 CONN -,SUP-PM2160,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10470.66,7329.462,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER IMPL ACCENT DR 2CHMBR RR 52X52MM 6MM 12.8ML 23GM -,SUP-PM2210,CDM,C1785,HCPCS,275,RC,,,outpatient,,,12438.55,8706.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER IMPL ASSURITY 2CHMBR RR 50X47MM 6MM 10.4ML 20GM -,SUP-PM2240,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10732.43,7512.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
ASSURITY MRI PACEMAKER DR-RF PM2272 -,SUP-PM2272,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10582.05,7407.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER IMPL BIPLR REVO 2CHMBR RR SURSCN PCNG -,SUP-REVOMRIPEEM,CDM,C1785,HCPCS,275,RC,,,outpatient,,,23622.66,16535.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER IMPL BIPLR REVO SURSCN 2CHMBR RR 45X51X8MM 12.7ML -,SUP-RVDR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,17439.96,12207.972,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER ALTRUA 20 DDDR MUL-PRGM 43X49X8MM 29.6GM 12.6ML -,SUP-S202,CDM,C1785,HCPCS,275,RC,,,outpatient,,,17451.1,12215.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER ALTRUA 20 MUL-PRGM 42X44X8MM 25.4GM 10.8ML IS-1 -,SUP-S203,CDM,C1785,HCPCS,275,RC,,,outpatient,,,14373.02,10061.114,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER BIPLR ALTRUA 60 2CHMBR RR 42X44MM 8MM 10.8ML -,SUP-S603,CDM,C1785,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER IMPL UNIPL BIPLR SENSIA 2CHMBR RR -,SUP-SEDR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10396.4,7277.48,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
GENERATOR VERSA DUAL CHAMBER -,SUP-UNDEFINED,CDM,C1785,HCPCS,275,RC,,,outpatient,,,20402.94,14282.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER ALTRUA 20 DR 2 LD -,SUP-UNDEFINED,CDM,C1785,HCPCS,275,RC,,,outpatient,,,19827.42,13879.194,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
VERSA DR VEDR01 -,SUP-VEDR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10396.4,7277.48,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER MRI AZURE XT DR SURESCAN -,SUP-W1DR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,18565,12995.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
Azure S DR MRI Surescan W3DR01 -,SUP-W3DR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16708.5,11695.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER BIPLR INSGA ULTRA SR SGL-CHMBR RR 10ML 23.4GM IS-1 -,SUP-1190,CDM,C1786,HCPCS,275,RC,,,outpatient,,,17451.1,12215.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
PACEMAKER RELAY INTMD UNIPL CARD 5MM -,SUP-293-03,CDM,C1786,HCPCS,275,RC,,,outpatient,,,16151.55,11306.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
PACEMAKER UNIPL BIPLR EVIA SR-T SGL-CHMBR RR 39X53MM 6.5MM -,SUP-359 533,CDM,C1786,HCPCS,275,RC,,,outpatient,,,10983.05,7688.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
PACEMAKER IMPL ENTOVIS SR-T PROMRI SGL-CHMBR ACC -,SUP-404723,CDM,C1786,HCPCS,275,RC,,,outpatient,,,10457.22,7320.054,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
GENERATOR IMPL VERF SGL-CHMBR -,SUP-5156,CDM,C1786,HCPCS,275,RC,,,outpatient,,,11792.49,8254.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
PACEMAKER IMPL UNIPL VERITY ADX MS DR SGL-CHMBR RR 42X52MM -,SUP-5157M/S,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8533.24,5973.268,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
PACEMAKER IMPL UNIPL BIPLR ZPHR SGL-CHMBR RR 41X44MM 6MM 8ML -,SUP-5620,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8533.24,5973.268,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
PACEMAKER IMPL UNIPL BIPLR ZPHR XL SR SGL-CHMBR RR 52X42MM -,SUP-5626,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8533.24,5973.268,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
PACEMAKER IMPL SURSCN ADVISA 1CHMBR IS-1 CONN SR -,SUP-A3SR01,CDM,C1786,HCPCS,275,RC,,,outpatient,,,14852,10396.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
PACEMAKER IMPL UNIPL ADAPTA SR SGL-CHMBR RR 7.5MM 11ML -,SUP-ADSR06,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9952.18,6966.526,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
GENERATOR PCMKR  SR SSIR -,SUP-ICV1122,CDM,C1786,HCPCS,275,RC,,,outpatient,,,12497.96,8748.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
ESSENTIO 4.45X4.81X0.75 CM D 13.2ML TI -,SUP-L100,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8899.67,6229.769,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
PACEMAKER ESSENTIO SR MRI -,SUP-L110,CDM,C1786,HCPCS,275,RC,,,outpatient,,,10901.37,7630.959,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
PACEMAKER ACCOLADE SR -REF: L300 -,SUP-L300,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
ACCOLADE MRI SR PACEMAKER L310 -,SUP-L310,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
PACEMAKER LEADLESS SINGLE AVEIR RV REF: LSP112V -,SUP-LSP112V,CDM,C1786,HCPCS,275,RC,,,outpatient,,,37130,25991,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
MICRA MDT TRANSCATHER PACING MICRA SYSTEM -,SUP-MC1VR01,CDM,C1786,HCPCS,275,RC,,,outpatient,,,26520.25,18564.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
MICRA AV TRANSCATHETER  MC1AVR1 -,SUP-MICRAAVTCPSYSTEM,CDM,C1786,HCPCS,275,RC,,,outpatient,,,38855.25,27198.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
TRANSCATHETER PACING SYSTEM INC:CAPSULEDELIV CATHINTROD -,SUP-MICRATCPSYSTEM,CDM,C1786,HCPCS,275,RC,,,outpatient,,,26520.25,18564.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
PACEMAKER IMPL UNIPL BIPLR ACCENT SR SGL-CHMBR RR WRLS TELEM -,SUP-PM1110,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9375.33,6562.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
PACEMAKER ENDURITY SGL-CHMBR 50X41X6MM 6MM 19GM 9.7ML IS-1 -,SUP-PM1160,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
PACEMAKER IMPL UNIPL BIPLR ACCENT SR SGL-CHMBR RR WRLS TELEM -,SUP-PM1210,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9375.33,6562.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
PACEMAKER IMPL ASSURITY SGL-CHMBR RR 50X47MM 6MM 10.4ML 20GM -,SUP-PM1240,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
ASSURITY MRI PACEMAKER SR-RF -,SUP-PM1272,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
PACEMAKER ALTRUA 40 SR SGL-CHMBR RR 42X42X8MM 10ML 23.4GM -,SUP-S401,CDM,C1786,HCPCS,275,RC,,,outpatient,,,12887.82,9021.474,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
SYS ADAPTER PCMKR F/SR -,SUP-UNDEFINED,CDM,C1786,HCPCS,275,RC,,,outpatient,,,23744.64,16621.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
DEFIBRILLATOR VIVA QUAD S CRTN -,SUP-VIVA QUAD S CRT-D,CDM,C1786,HCPCS,275,RC,,,outpatient,,,60532.78,42372.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
Azure S SR NRI SureScan W3SR01 -,SUP-W3SR01,CDM,C1786,HCPCS,275,RC,,,outpatient,,,16708.5,11695.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
GENERATOR PROCLAIM 7 ELITE -,SUP-3662,CDM,C1787,HCPCS,272,RC,,,outpatient,,,40409.46,28286.622,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,28973.58282,other,SI=N Exclusions ,,
PROGRAMMER NEURSTM MYSTIM HNDHLD DVC -,SUP-377-44,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4606.91,3224.837,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,28973.58282,other,SI=N Exclusions ,,
PROGRAMMER NEURSTM MYSTIM 2.2X3.7X1.1IN -,SUP-377-46,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4606.91,3224.837,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,28973.58282,other,SI=N Exclusions ,,
PROGRAMMER NEURSTM IMMG-LN -,SUP-3852,CDM,C1787,HCPCS,272,RC,,,outpatient,,,2517.74,1762.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,28973.58282,other,SI=N Exclusions ,,
PRODIGY 3856 -,SUP-3856,CDM,C1787,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,28973.58282,other,SI=N Exclusions ,,
PROCLAIM DRG CONTROLLER LEAD -,SUP-7883,CDM,C1787,HCPCS,272,RC,,,outpatient,,,6212.96,4349.072,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,28973.58282,other,SI=N Exclusions ,,
PROGRAMMER PATIENT 97740 -,SUP-97740,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4507.13,3154.991,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,28973.58282,other,SI=N Exclusions ,,
CONTROLLER 97745NT INTELLIS PTM NONTRIAL -,SUP-97745NT,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4507.13,3154.991,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,28973.58282,other,SI=N Exclusions ,,
INTERSTIM KIT COMM W/HANDSET GU US -,SUP-TH90Q01,CDM,C1787,HCPCS,272,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,28973.58282,other,SI=N Exclusions ,,
PORT IMPLINFN NPWR 8FRX1.6MM ID 12.7MM X- PRT ISP PU LF -,SUP-0607540,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1620.15,1134.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions ,,
PORT IMPLINFN NPWR 9.5FR CATH X- PRT PLST PRT LF MRI-COND -,SUP-0607675,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2417.77,1692.439,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions ,,
PORT POWER LOW PROFILE 8F -,SUP-1708060,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2318.07,1622.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions ,,
PORT IMPLINFN PWR INJ 6FR CATH PWR PRT TI LF 1LUM -,SUP-1716000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2242.11,1569.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions ,,
PORT POWER 8F #1808000 -,SUP-1808000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2243.33,1570.331,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions ,,
PORT IMPLINFN PWR INJ 8FR CATH PWR PRT M R I ISP PU LF 1LUM -,SUP-1808000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2243.33,1570.331,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions ,,
PORT INFS 9FR CATH PWR PRT DUO M R I PLST LF LUMX2 -,SUP-1829500,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2559.29,1791.503,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions ,,
KT NEEDLE INFS 20GAX1IN POWERLOC PRT ACCESS SAFTY YST NACL -,SUP-2672010,CDM,C1788,HCPCS,278,RC,,,outpatient,,,99.2,69.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions ,,
PORT INFS PWR INJ 8FR CATH PWR PRT VUE ISP PU CATH LF -,SUP-5608062,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1261.52,883.064,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions ,,
PORT INFS 8FR MRI-SF PWR SLIM -,SUP-5618000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1261.52,883.064,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions ,,
TRY CV LUMX2 9.5FRX60CM GRSHNG LF ACC -,SUP-7726952,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1902.88,1332.016,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions ,,
CATH INFS PRT 6.6FR SMRT PRT CT TI /CARBOTHAN/ PU LPRO INJ -,SUP-CT66LTPD,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions ,,
CATH INFS PRT 8FR SMRT PRT CT TI/SIL INJ -,SUP-CT75STSD,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions ,,
CATH INFS PRT 8FR SMRT PRT CT FLUOROMAX TI/PU INJ -,SUP-CT80STPD,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions ,,
CATH INFS PRT 6.6FR MINI SMRT PRT CT TI /CARBOTHAN/ PU INJ -,SUP-H787CT66PTPD0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions ,,
SMARTPORT PLASTIC W/VORTEX TECH IF FILLED DETATCHED -,SUP-H787CT80LPPDVI0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions ,,
CATH INFS PRT 9.6FR SMRT PRT CT FLUOROMAX TI/SIL INJ -,SUP-H787CT96STSD0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions ,,
CATH INFS PRT 12/11.4 FR DIA INTRO/CATH VORT LP TI SIL DL -,SUP-H787LVTX52130,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions ,,
PORT IMPLINFN 8FR INTRO 7.2FR CATH VORT VX TI SIL LF -,SUP-H787P12355K0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions ,,
PORT VORTEX VASC 9.6 -,SUP-H787P5455K0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions ,,
PORT XCELA PLUS POWER INDECTABLE 8F FILLED DETATCHED -,SUP-H965440320,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions ,,
PORT INFS 8FR MED DIGNITY -,SUP-MRDP80AMS,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1404.63,983.241,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,22.2704,1965.53472,other,SI=N Exclusions ,,
EXPANDER TISSUE SMOOTH 600CC NATRELLE FULL HT VAR -,SUP-133S-FV-14-T,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BRST 397ML 13.1CM NATRLL 4.2CM PRJCT -,SUP-15-397,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BRST 125ML SIL GEL MOD+ RND 8.9CM MEMORYGEL 2.8CM -,SUP-350-1251BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BRST SIL GEL MOD+ RND 150CC -,SUP-350-1501BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BRST 175ML SIL GEL MOD+ RND 10CM MEMORYGEL 3.1CM -,SUP-350-1751BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BRST 200ML SIL GEL MOD+ RND 10.5CM MEMORYGEL 3.2CM -,SUP-350-2001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BRST 350-420ML SAL MOD+ RND 12.1-11.7CM MENTOR -,SUP-350-2350,CDM,C1789,HCPCS,278,RC,,,outpatient,,,2597.25,1818.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BRST 250ML SIL GEL HPRO RND 10.5CM MEMORYGEL 4.3CM -,SUP-350-2504BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BRST 600ML SIL GEL MOD+ RND 15CM MEMORYGEL 4.6CM -,SUP-350-6001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4320.47,3024.329,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BRST 650ML SIL GEL MOD+ RND 15.4CM MEMORYGEL 4.7CM -,SUP-350-6501BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4320.47,3024.329,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BRST 650ML SIL GEL HPRO RND 14.4CM MEMORYGEL 5.7CM -,SUP-350-6504BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BRST 700ML SIL GEL MOD+ RND 15.8CM MEMORYGEL 4.9CM -,SUP-350-7001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4320.47,3024.329,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BRST 130ML SIL GEL MOD CLASS RND 9.6CM MEMORYGEL -,SUP-350-7130MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BRST 150ML SIL GEL MOD CLASS RND 10.3CM MEMORYGEL -,SUP-350-7150MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BRST SIL GEL MOD+ RND CLSSC 190CC -,SUP-350-7190MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BRST SIL GEL MOD+ RND CLSSC 215CC -,SUP-350-7215MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BRST 750ML SIL GEL MOD CLASS RND 16.1CM MEMORYGEL -,SUP-350-7501BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
BREAST IMPLANT SMOOTH ROUND MODERATE 750CC -,SUP-350-7750MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
BREAST IMPLANT SMOOTH ROUND MODERATE 800CC -,SUP-350-7800MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BRST 800ML SIL GEL HPRO RND 16.5CM MEMORYGEL 5.1CM -,SUP-350-8001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BRST 800ML SIL GEL HPRO RND 15.5CM MEMORYGEL 6CM -,SUP-350-8004BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BRST 330-350ML SIL SAL BIOCELL PTOTIC SHP NATRLL -,SUP-363LF-330,CDM,C1789,HCPCS,278,RC,,,outpatient,,,3628.24,2539.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
NATRELLE SALINE FILLED SMOOTH ROUND IMLANTS 640CC -,SUP-68HP-600,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1637.85,1146.495,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
NATRELLE SMOOTH ROUND SALINE IMPLANTS 68LP-225 -,SUP-68LP-225,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
NATRELLE SMOOTH ROUND SALINE IMPLANTS 250CC -,SUP-68LP-250,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
NATRELLE SMOOTH ROUND SALINE IMPLANTS 275CC -,SUP-68LP-275,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
SIZER IMPLANT NATRELLE INSPIRA 295CC FULL PROFILE -,SUP-MSZ-F295,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
SIZER NATRELLE INSPIRA 335CC FULL -,SUP-MSZ-F335,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
SIZER IMPLANT NATRELLE INSPIRA 650CC FULL PROFILE -,SUP-MSZ-F650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 200CC NATRELLE INSPIRA FULL -,SUP-SCF-200,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 240CC NATRELLE INSPIRA FULL -,SUP-SCF-240,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 265CC NATRELLE INSPIRA FULL -,SUP-SCF-265,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 295CC NATRELLE INSPIRA FULL -,SUP-SCF-295,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 335CC NATRELLE INSPIRA FULL -,SUP-SCF-335,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 345CC NATRELLE INSPIRA FULL -,SUP-SCF-345,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 365CC NATRELLE INSPIRA FULL -,SUP-SCF-365,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 385CC NATRELLE INSPIRA FULL -,SUP-SCF-385,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 415CC NATRELLE INSPIRA FULL -,SUP-SCF-415,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 450CC NATRELLE INSPIRA FULL -,SUP-SCF-450,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 485CC NATRELLE INSPIRA FULL -,SUP-SCF-485,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4787.23,3351.061,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 520CC NATRELLE INSPIRA FULL -,SUP-SCF-520,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 560CC NATRELLE INSPIRA FULL -,SUP-SCF-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 605CC NATRELLE INSPIRA FULL -,SUP-SCF-605,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5623.3,3936.31,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 650CC NATRELLE INSPIRA FULL -,SUP-SCF-650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHES GEL 695CC NATRELLE INSPIRA FULL -,SUP-SCF-695,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
NATRELLE INSPIRA COHESIVE IMPLANT 745 -,SUP-SCF-745,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
NATRELLE INSPIRA COHESIVE IMPLANT 770 -,SUP-SCF-770,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST 460CC NATRELLE SMOOTH ROUND -,SUP-SCL-460,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST 490CC SMOOTH COHESIVE LOW PLUS PROFILE -,SUP-SCLP-490,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST 540CC SMOOTH COHESIVE LOW PLUS PROFILE -,SUP-SCLP-540,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST 330CC NATRELLE SMOOTH ROUND -,SUP-SCM-330,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST 360CC NATRELLE SMOOTH ROUND -,SUP-SCM-360,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST 375CC NATRELLE SMOOTH ROUND -,SUP-SCM-375,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SILICONE 375CC NATRELLE INSPIRA STYLE MODERAT -,SUP-SCM-375,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST 405CC NATRELLE SMOOTH ROUND -,SUP-SCM-405,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHES 485CC NATRELLE INSPIRA MODERATE -,SUP-SCM-485,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 560CC NATRELLE INSPIRA MOD -,SUP-SCM-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 600CC NATRELLE INSPIRA MOD -,SUP-SCM-600,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 640CC NAT INSPIRA MOD -,SUP-SCM-640,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHES GEL 685CC NATRELLE INSPIRA MOD -,SUP-SCM-685,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHES GEL 755CC NATRELLE INSPIRA MOD -,SUP-SCM-755,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 340CC NATRELLE INSPIRA FULL -,SUP-SCX-340,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 375CC NATRELLE INSP EXTRA FUL -,SUP-SCX-375,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 525CC NATRELLE INSPIRA FULL -,SUP-SCX-525,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 545CC NATRELLE INSPIRA FULL -,SUP-SCX-545,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST 560CC SMOOTH COHESIVE NATRELLE INSPIRA FULL -,SUP-SCX-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST 580CC SMOOTH COHESIVE NATRELLE INSPIRA FULL -,SUP-SCX-580,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST 615CC SMOOTH COHESIVE NATRELLE INSPIRA FULL -,SUP-SCX-615,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 650CC NATRELLE INSP EX-FULL -,SUP-SCX-650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
NATRELLE INSPIRA COHESIVE IMPLANT 700 -,SUP-SCX-700,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
NATRELLE INSPIRA COHESIVE IMPLANT 750 -,SUP-SCX-750,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
NATRELLE INSPIRA COHESIVE IMPLANT 800CC -,SUP-SCX-800,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT SMOOTH HIGH PROFILE XTRA 755 CC -,SUP-SHPX755,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5211.63,3648.141,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT SMOOTH HIGH PROFILE XTRA 790 CC -,SUP-SHPX790,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5211.63,3648.141,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH FULL 450CC NATRELLE INSPIRA FULL -,SUP-SSF-450,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH FULL 520CC NATRELLE INSPIRA FULL -,SUP-SSF-520,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH FULL 560CC NATRELLE INSPIRA FULL -,SUP-SSF-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH FULL 650CC NATRELLE INSPIRA FULL -,SUP-SSF-650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH FULL 695CC NATRELLE INSPIRA FULL -,SUP-SSF-695,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH FULL 745CC NATRELLE INSPIRA FULL -,SUP-SSF-745,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH SOFT TOUCH 330CC NATRELLE INSPIRA MOD -,SUP-SSM-330,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH SOFT TOUCH 445CC NATRELLE INSPIRA MOD -,SUP-SSM-445,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH SOFT TOUCH 485CC NATRELLE INSPIRA MOD -,SUP-SSM-485,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH SOFT TOUCH 520CC NATRELLE INSPIRA MOD -,SUP-SSM-520,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST EXTRA FULL SOFT TOUCH 750CC -,SUP-SSX-750,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST EXTRA FULL SOFT TOUCH 800CC -,SUP-SSX-800,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
PROSTHESIS PENL CL SPCTR MALE 9.5MMX12CM CNCLBL SNP FIT TIP -,SUP-720054-01,CDM,C1813,HCPCS,278,RC,,,outpatient,,,20421.5,14295.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
PROSTHESIS PENL CL SPCTR MALE 9.5MMX16CM SIL PE TI SEG -,SUP-720054-02,CDM,C1813,HCPCS,278,RC,,,outpatient,,,21238.36,14866.852,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
PROSTHESIS PENL AMS SPCTR MALE 12MMX20CM SIL PE TI SEG CYL -,SUP-720074-03,CDM,C1813,HCPCS,278,RC,,,outpatient,,,28358.17,19850.719,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
PROSTHESIS PENL AMS 700 LGX 100CM SAL FIL INFL MOMNTRY SQZ -,SUP-720185-01,CDM,C1813,HCPCS,278,RC,,,outpatient,,,12122.95,8486.065,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
AMS 800 PRESSURE REGULATION BALLOON -,SUP-72400024,CDM,C1813,HCPCS,278,RC,,,outpatient,,,12791.29,8953.903,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
KT PROSTHESIS PENL URIN ARTF SPHNCR IMPL SAL FIL SCRT CYL -,SUP-724000-95,CDM,C1813,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
PUMP URIN SPHNCR AMS 800 MALE SIL CNCLD FLD-FIL W/O INHBZN -,SUP-724000-98,CDM,C1813,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
PROSTHESIS PENL AMBICOR 11MM/12.5MM DIA FIL PMP 16CM SAL FIL -,SUP-72401451,CDM,C1813,HCPCS,278,RC,,,outpatient,,,31752.76,22226.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
AMS AMBICOR PENILE PROTHESIS -,SUP-72401452,CDM,C1813,HCPCS,278,RC,,,outpatient,,,34352.98,24047.086,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
AMS AMBICOR PENILE PROTHESIS 18CM X 14 MM -,SUP-72401454,CDM,C1813,HCPCS,278,RC,,,outpatient,,,31752.76,22226.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
RESERVOIR PROS -,SUP-724014-77,CDM,C1813,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
PROSTHESIS PENL AMS 700 LGX 65CM SAL FIL INFL MOMNTRY SQZ -,SUP-724041-55,CDM,C1813,HCPCS,278,RC,,,outpatient,,,12122.95,8486.065,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
PROSTHESIS PENL AMS 700 CX MALE 100ML SAL FIL INFL CYL TIP -,SUP-72404156,CDM,C1813,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
PROSTHESIS PENL PMP AMS 700 CX MALE SAL FIL INFL STRL -,SUP-724042-09,CDM,C1813,HCPCS,278,RC,,,outpatient,,,15498.06,10848.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
18CM 700CX -,SUP-72404232,CDM,C1813,HCPCS,278,RC,,,outpatient,,,25200.41,17640.287,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
PUMP AMS 700 12MM X 18CM CX MS PENILE -,SUP-72404232-10,CDM,C1813,HCPCS,278,RC,,,outpatient,,,31466.59,22026.613,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
AMS 700 CX MS PUMP IZ 21CM -,SUP-72404233-12,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26705.28,18693.696,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
PROSTHESIS PENL AMS 700 LGX 15MM CL INFL PRECNCT W/MS PMP -,SUP-724042-51,CDM,C1813,HCPCS,278,RC,,,outpatient,,,28543.19,19980.233,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
PROSTHESIS PENL AMS 700 LGX 18CM SAL FIL INFL MOMNTRY SQZ -,SUP-72404252,CDM,C1813,HCPCS,278,RC,,,outpatient,,,36034.67,25224.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
AMS 700 LGX MS PUMP IZ 21CM X 12MM -,SUP-72404253-12,CDM,C1813,HCPCS,278,RC,,,outpatient,,,32354.71,22648.297,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
PROSTHESIS PENL AMS 700 CXR 14CM X 9.5MM -,SUP-72404262,CDM,C1813,HCPCS,278,RC,,,outpatient,,,25200.41,17640.287,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
AMS CXR MS PUMP IZ -,SUP-72404264,CDM,C1813,HCPCS,278,RC,,,outpatient,,,32749.43,22924.601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
EXTENDER PENL AMS SPCTR 12MM/14MM DIA CL 3CM REAR TIP -,SUP-724043-23,CDM,C1813,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
IMPLANT PENL RSVR CLPLST 75ML HYDRPHL CTD LKOUT VLV STRL -,SUP-90-9075K-LOC,CDM,C1813,HCPCS,278,RC,,,outpatient,,,5602.08,3921.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
PROSTHESIS PENL TITAN 16CM HYDRPHL RST CTD CYL 3 PRT REFL -,SUP-90-9916SC,CDM,C1813,HCPCS,278,RC,,,outpatient,,,24505.8,17154.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
PROSTHESIS PENL STD 18CM BIOFLEX/SIL MALE SCRT CL/PMP ST -,SUP-90-9918SNCOTR,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26752.17,18726.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
PROSTHESIS PENL STD 20CM BIOFLEX/SIL MALE SCRT CL/PMP ST -,SUP-90-9920SCOTR,CDM,C1813,HCPCS,278,RC,,,outpatient,,,24505.8,17154.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
KT PROSTHESIS PENL TITAN MALE NRW BS EXTEND ESSAY NDLX1 -,SUP-91-9480SNC,CDM,C1813,HCPCS,278,RC,,,outpatient,,,2507.14,1754.998,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
PROSTHESIS PENL RSVR TITAN 75ML BIOFLEX SIL INFL SLF-CNTN -,SUP-ER8075,CDM,C1813,HCPCS,278,RC,,,outpatient,,,6938.94,4857.258,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
ST PROSTHESIS PENL TITAN 18CM BIOFLEX SIL CYL INFL SLF-CNTN -,SUP-ES2918,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26956.38,18869.466,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
ST PROSTHESIS TITAN 22CM BIOFLEX SIL TCH ZERO DG CL PMP -,SUP-ES2922,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26956.38,18869.466,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
PROSTHESIS PENL TITAN 18CM 0DG ANG CYL INFL 1-TCH RELS -,SUP-ESR918,CDM,C1813,HCPCS,278,RC,,,outpatient,,,27550.46,19285.322,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
ST UROLOGICAL PMP/CL TITAN 20CM BIOFLEX SIL 0DG ANG PENL -,SUP-ESR920,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26752.17,18726.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
AMS AMBICOR 16CM X 14MM -,SUP-UNDEFINED,CDM,C1813,HCPCS,278,RC,,,outpatient,,,30531.59,21372.113,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
PROSTHESIS PENL 3.5CM INFL SCRT INHBZN CONTINENCE -,SUP-720157-01,CDM,C1815,HCPCS,278,RC,,,outpatient,,,16337.2,11436.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21443.91168,other,SI=N Exclusions ,,
PUMP CORTIAL 700 PROSTHESIS -,SUP-72404127,CDM,C1815,HCPCS,278,RC,,,outpatient,,,26900.69,18830.483,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21443.91168,other,SI=N Exclusions ,,
SYS UROLOGICAL AMS 800 4CM CUF BLT W/IZ -,SUP-724041-30,CDM,C1815,HCPCS,278,RC,,,outpatient,,,27921.76,19545.232,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21443.91168,other,SI=N Exclusions ,,
PROSTHESIS PENL AMS 800 4.5CM SAL FIL CNCLD CYL SCRT INHBZN -,SUP-72404131,CDM,C1815,HCPCS,278,RC,,,outpatient,,,27921.76,19545.232,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21443.91168,other,SI=N Exclusions ,,
PROSTHESIS PENL AMS 800 5.0CM SAL FIL CNCLD CYL SCRT INHBZN -,SUP-72404132,CDM,C1815,HCPCS,278,RC,,,outpatient,,,26585.08,18609.556,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21443.91168,other,SI=N Exclusions ,,
PROSTHESIS PENL AMS 800 6.0CM SAL FIL ARTIF URINARY SPHINCTR -,SUP-72404134,CDM,C1815,HCPCS,278,RC,,,outpatient,,,25935.31,18154.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,21443.91168,other,SI=N Exclusions ,,
OCCLUDERS FLO RESTER 1.5 -,SUP-50150,CDM,C1817,HCPCS,278,RC,,,outpatient,,,470.8,329.56,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDERS FLO RESTER 2.5 -,SUP-50250,CDM,C1817,HCPCS,278,RC,,,outpatient,,,470.8,329.56,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER VASC 2MM BLB 30MM INTNL VES FLO-RST DISP -,SUP-60200,CDM,C1817,HCPCS,278,RC,,,outpatient,,,443.78,310.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
AMPLATZER AMULET 16MM WW REF: 9-ACP2-007-016 -,SUP-9-ACP2-007-016,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
AMPLATZER AMULET 18MM WW REF: 9-ACP2-007-018 -,SUP-9-ACP2-007-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
AMPLATZER AMULET 20 MM WW REF: 9-ACP2-007-020 -,SUP-9-ACP2-007-020,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
AMPLATZER AMULET 22 MM WW REF: 9-ACP2-007-022 -,SUP-9-ACP2-007-022,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
AMPLATZER AMULET 25 MM WW REF: 9-ACP2-010-025 -,SUP-9-ACP2-010-025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
AMPLATZER AMULET 28 MM WW REF: 9-ACP2-010-028 -,SUP-9-ACP2-010-028,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
AMPLATZER AMULET 31 MM WW REF: 9-ACP2-010-031 -,SUP-9-ACP2-010-031,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
AMPLATZER AMULET 34 MM WW REF: 9-ACP2-010-034 -,SUP-9-ACP2-010-034,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER AMPLATZER SEPTAL 5MM  REF: 9-ASD-005 -,SUP-9-ASD-005,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER AMPLATZER SEPTAL 6MM  REF: 9-ASD-006 -,SUP-9-ASD-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 08MM WST 16MM/20MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-008,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 10MM WST 18MM/22MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-010,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 11MM WST 21MM/25MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-011,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 12MM WST 22MM/26MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-012,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 13MM WST 23MM/27MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-013,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 14MM WST 24MM/28MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-014,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 15MM WST 25MM/29MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-015,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 16MM WST 26MM/30MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-016,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 18MM WST 28MM/32MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 19MM WST 28MM/32MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-019,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 20MM WST 30MM/34MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-020,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 22MM WST 32MM/36MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-022,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 24MM WST 34MM/38MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-024,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 26MM WST 36MM/40MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-026,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 28MM WST 38MM/42MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-028,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 30MM WST 40MM/44MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-030,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 32MM WST 42MM/46MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-032,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 34MM WST 44MM/50MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-034,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 36MM WST 46MM/52MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-036,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 18MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 25MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 30MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-030,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 35MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-035,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
GRAFT VASC 5MMX12.5MM AMPLATZER OCLR SE FUL CX-SECT CVRGLS -,SUP-9-AVP038-005,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
GRAFT VASC 6X11MM AMPLATZER PLG SE FUL CX-SECT CVRGLS LT ATR -,SUP-9-AVP038-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
GRAFT VASC 7MMX12.5MM AMPLATZER PLG OCLR SE FUL CX-SECT -,SUP-9-AVP038-007,CDM,C1817,HCPCS,278,RC,,,outpatient,,,5177.68,3624.376,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
PLUG VASCULAR AMPLATZER 6MM REF:09-AVP2-006 -,SUP-9-AVP2-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
PLUG VASCULAR AMPLATZER 8 -,SUP-9-AVP2-008,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
PLUG VASCULAR AMPLATZER 10 011 -,SUP-9-AVP2-010,CDM,C1817,HCPCS,278,RC,,,outpatient,,,3971.97,2780.379,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
PLUG VASCULAR AMPLATZER 12 -,SUP-9-AVP2-012,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
PLUG VASCULAR AMPLATZER 16 -,SUP-9-AVP2-016,CDM,C1817,HCPCS,278,RC,,,outpatient,,,3971.97,2780.379,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
PLUG VASCULAR AMPLATZER 18 -,SUP-9-AVP2-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
GRAFT VASC 22X6MM AMPLATZER PLG SE MUL-LOBE LT ATR NTNL -,SUP-9-AVP2-022,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER DCT 5MM/4MM DIA DSCND AOR/PA AMPLATZER NTNL INTRWVN -,SUP-9-PDA-003,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER DCT 6MM/4MM DIA DSCND AOR/PA AMPLATZER NTNL INTRWVN -,SUP-9-PDA-004,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER DCT 8MM/6MM DIA DSCND AOR/PA AMPLATZER NTNL INTRWVN -,SUP-9-PDA-005,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
10/8 AMPLATZER DUCT OCCLUDER -,SUP-9-PDA-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER VASC DCT 12MM/10MM DIA/DSCND/PULM AOR 7FRX8MM NTNL -,SUP-9-PDA-007,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER DUCT II AMPLATZER 3MMX4MM -,SUP-9-PDA2-03-04,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER DCT 5MM/4MM DIA WST/DISC AMPLATZER NTNL DBL DISC -,SUP-9-PDA2-05-04,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER DCT 5MM/6MM DIA WST/DISC AMPLATZER NTNL DBL DISC. -,SUP-9-PDA2-05-06,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER DUCT II AMPLATZER 6MMX4MM -,SUP-9-PDA2-06-04,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER DCT 5MM/11MM DIA WST/DISC AMPLATZER NTNL DBL DISC.. -,SUP-9-PDA2-06-06,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER DUCT II AMPLATZER 6MMX6MM -,SUP-9-PDA2-06-06,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCULUDER AMPLATZER PFO 18MM -,SUP-9-PFO-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER AMPLATZER PFO 25MM -,SUP-9-PFO-025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER AMPLATZER PFO 35MM -,SUP-9-PFO-035,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
AMPLATZER TALISMAN PFO OCCLUDER 8FR 18MM REF:9-PFO-1818 -,SUP-9-PFO-1818,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
AMPLATZER TALISMAN PFO OCCLUDER 25-18MM -,SUP-9-PFO-2518,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
AMPLATZER TALISMAN PFO OCCLUDER 30-25MM -,SUP-9-PFO-3025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
TORQVUE SHEATH 12F 80CM 45X45 REF: 9-TV45X45-12F-080 -,SUP-9-TV45X45-12F-080,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4676.89,3273.823,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
CLOSURE DEVICE WATCHMAN FLEX 27MM -,SUP-M635WU0270,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
SHEATH WATCHMAN 21MM 12FR CLSR 75CM TRNSEPT -,SUP-M635WU21060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
SHEATH WATCHMAN 24MM 12FR CLSR 75CM  TRNSEPT -,SUP-M635WU24060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
SHEATH WATCHMAN 27MM 12FR CLSR 75CM  TRNSEPT -,SUP-M635WU27060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
SHEATH WATCHMAN 30MM 12FR CLSR 75CM TRNSEPT -,SUP-M635WU30060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
SHEATH WATCHMAN 33MM 12FR CLSR 75CM TRANSEPT -,SUP-M635WU33060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
CLOSURE DEVICE WATCHMAN FLEX 20MM -,SUP-M635WU50200,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
CLOSURE DEVICE WATCHMAN FLEX 31MM -,SUP-M635WU50310,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
CLOSURE DEVICE WATCHMAN FLEX 35MM -,SUP-M635WU50350,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
CLOSURE DEVICE WATCHMAN FLEX PRO 20MM REF:M635WU60200 -,SUP-M635WU60200,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
CLOSURE DEVICE WATCHMAN FLEX PRO 24MM REF:M635WU60240 -,SUP-M635WU60240,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
CLOSURE DEVICE WATCHMAN FLEX PRO 27MM REF:M635WU60270 -,SUP-M635WU60270,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
CLOSURE DEVICE WATCHMAN FLEX PRO 31MM REF:M635WU60310 -,SUP-M635WU60310,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
CLOSURE DEVICE WATCHMAN FLEX PRO 35MM REF:M635WU60350 -,SUP-M635WU60350,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
CLOSURE DEVICE WATCHMAN FLEX PRO 40MM REF:M635WU60400 -,SUP-M635WU60400,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
CLOSURE DEVICE WATCHMAN FLEX 24MM -,SUP-M63WU50240,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
TULOC LOCALIZATION WIRE 20G X 5CM -,SUP-271660,CDM,C1819,HCPCS,278,RC,,,outpatient,,,200.72,140.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,45.06164,416.02,other,SI=N Exclusions ,,
TULOC LOCALIZATION WIRE 20G X 9CM -,SUP-271661,CDM,C1819,HCPCS,278,RC,,,outpatient,,,200.72,140.504,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,45.06164,416.02,other,SI=N Exclusions ,,
TULOC PREMIUM LOCALIZATION WIRE 20G X 5CM -,SUP-271880,CDM,C1819,HCPCS,278,RC,,,outpatient,,,256.74,179.718,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,45.06164,416.02,other,SI=N Exclusions ,,
TULOC PREMIUM LOCALIZATION WIRE 20G X 9CM -,SUP-271881,CDM,C1819,HCPCS,278,RC,,,outpatient,,,256.74,179.718,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,45.06164,416.02,other,SI=N Exclusions ,,
ETERNA IMPLANTABLE PULSE GENERATOR -,SUP-32400,CDM,C1820,HCPCS,278,RC,,,outpatient,,,45639.5,31947.65,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,41625.59232,other,SI=N Exclusions ,,
PRODIGY 3730 -,SUP-3730,CDM,C1820,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,41625.59232,other,SI=N Exclusions ,,
SYS GENERATOR NEURSTM RSTOR ADVANCED PERC MUL-PRGM RCHG ACC -,SUP-377-13,CDM,C1820,HCPCS,278,RC,,,outpatient,,,31108.87,21776.209,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,41625.59232,other,SI=N Exclusions ,,
NEURSTM IMPL RESTORESENSOR 2.1INX2.1IN PERC SMALLEST -,SUP-377-14,CDM,C1820,HCPCS,278,RC,,,outpatient,,,38238.5,26766.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,41625.59232,other,SI=N Exclusions ,,
PRODIGY MRI -,SUP-3772,CDM,C1820,HCPCS,278,RC,,,outpatient,,,38929.26,27250.482,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,41625.59232,other,SI=N Exclusions ,,
NEURSTM IMPL RESTORESENSOR SURSCN 9X54X54MM SPIN CRD RCHG -,SUP-97714,CDM,C1820,HCPCS,278,RC,,,outpatient,,,38238.5,26766.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,41625.59232,other,SI=N Exclusions ,,
INTERSTIM MICRO MRI RECHARGEABLE NEUROSTIMULATOR -,SUP-97810,CDM,C1820,HCPCS,278,RC,,,outpatient,,,25644.47,17951.129,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,41625.59232,other,SI=N Exclusions ,,
MICROSTIMULATOR INS 97810 RECHARGEABLE -,SUP-97810,CDM,C1820,HCPCS,278,RC,,,outpatient,,,25644.47,17951.129,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,41625.59232,other,SI=N Exclusions ,,
KT GENERATOR NEURSTM PRECISN SPCTR -,SUP-M365SC1110020,CDM,C1820,HCPCS,278,RC,,,outpatient,,,54199.99,37939.993,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,41625.59232,other,SI=N Exclusions ,,
VERTIFLEX SUPERION IDS-10MM -,SUP-101-9810,CDM,C1821,HCPCS,278,RC,,,outpatient,,,25619.7,17933.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
VERTIFLEX SUPERION IDS-12MM -,SUP-101-9812,CDM,C1821,HCPCS,278,RC,,,outpatient,,,25619.7,17933.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
VERTIFLEX SUPERION IDS -14MM -,SUP-101-9814,CDM,C1821,HCPCS,278,RC,,,outpatient,,,25619.7,17933.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
SPACER CERV 8X27MMX0.016IN ZYSTON -,SUP-14-533108,CDM,C1821,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
SPACER ANT CERV 19-25MMH FORTIFY OPTMZ FIT TI -,SUP-151.051,CDM,C1821,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
SPACER ANT CERV 15X18MM FTPRNT FORTIFY 7DG OPTMZ FIT TI -,SUP-151.334,CDM,C1821,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
SPACER ANT CERV 15X18MM FTPRNT FORTIFY 7DG OPTMZ FIT TI. -,SUP-151.384,CDM,C1821,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
MESH 14MM ROUND 30MM HGT -,SUP-176014030,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11221.61,7855.127,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
MESH SURG 23X27MM DIA 12X14MM OBLNG TRPZD TI HARMS -,SUP-1763-02-012,CDM,C1821,HCPCS,278,RC,,,outpatient,,,14854.78,10398.346,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
RISE SPACER 8 X 22MM- 7-13MM -,SUP-193.001,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
SPACER RISE 8 X 22MM 8-14MM 10 DEG -,SUP-193.021,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
SPACER RISE 10 X 22 7-13 -,SUP-193.101,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
SPACER RISE 10 X 26MM 7-14MM -,SUP-193.102,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
SPACER RISE 10 X 26MM 10-17MM -,SUP-193.112,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
RISE SPACER 10X22MM 8-14MM 10 DEGREES -,SUP-193.121,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
RISE SPACER 10MM X 26MM 8-15MM 10 DEGREES -,SUP-193.122,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
SPACER SPINAL RISE 10MM X 30MM 8-15MM 10 DEG -,SUP-193.123,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
RISE SPACER 10 X 26MM 10-17MM -,SUP-193.142,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
RISER SPACER 10X22MM- 9-15MM -,SUP-193.151,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
NORMANDY 12X14 30MM 10DEGREES -,SUP-250-1214-30-10,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19597.21,13718.047,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
CAGE 12X14 44-76 10 DEGREE -,SUP-250-1214-4410,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19597.21,13718.047,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
SPACER THORLUM VERT 12X26X12MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.972,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
SPACER SMALL 12 X 14 ZERO DEG 19MM NIKO CORPECTOMY -,SUP-342.719,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11547.43,8083.201,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
SPACER SPINAL NIKO PEEK 7 D D12 MM SMALL 14X15MM CORPECTOMY -,SUP-342.815,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11547.43,8083.201,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
SEASPINE 7H CAGE -,SUP-AC4-143077,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9901.25,6930.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
SEASPINE CAGE 16X14X6MM 7 DEGREE 3D INTERBODY -,SUP-AC4-264067,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
GENESYS 6H CAGE -,SUP-ACC804-06S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
CAGE 9 X 26 X 12 6-20 DEGREES -,SUP-ET1-102612,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19678.9,13775.23,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
SEASPINE 9 X 26 0-14 DEGREE LORDOTIC CAGE -,SUP-ET1-142608,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
SEASPINE 10H 17 DEGREE CAGE -,SUP-ET1-172610,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
CAGE EXPANDABLE SEASPINE 10H 9W 30L -,SUP-ET1-173010,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
SEASPINE 10-14MM 8 DEGREE CAGE -,SUP-ET1-382810,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
APACHE SPACER 8MM -,SUP-GAC-08SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
TITANIUM APACHE CAGE 5MM -,SUP-GAC3D-05SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
TITANIUM APACHE CAGE 6MM -,SUP-GAC3D-06SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
7MM CAGE APACHE -,SUP-GAC3D-07SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
CAGE TLIF 7MM X 30MM -,SUP-GP-07-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
CAGE APACHE PEEK SPACER 8 X 30 -,SUP-GP-08-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
CAGE 25 STRAIGHT 9MM -,SUP-GP-09,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
CAGE 9 X 30 -,SUP-GP-09-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
CAGE 10MM STANDARD PLIF -,SUP-GP-10,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
CAGE PEEK 30 X 10MM -,SUP-GP-10-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
CAGE APACHE 11MM -,SUP-GP-11,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
CAGE 8MM BI-CONVEX PLIF -,SUP-GPC2-08,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
CAGE 9MM CONVEX PLIF -,SUP-GPC2-09,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
SPACER PEEK 10 X 24 CONVEX -,SUP-GPC2-10,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
CAGE PEEK APACHE 11MM -,SUP-GPC2-11,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
SPINEART LUMBAR POSTERIOR TI CAGE L24 W10.5 H08 12 DEG -,SUP-JUT-PX 24 08-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
JULIET TI PO LUMBAR POSTERIOR TI CAGE L24 W10.5 H10 12DEG -,SUP-JUT-PX 24 10-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
CAGE LUMBAR POSTERIOR TI L24 W10.5 H11 12 DEG -,SUP-JUT-PX 24 11-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
CAGE LUMBAR POSTERIOR TI L24 W10.5 H12 -,SUP-JUT-PX 24 12-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
CAGE TRANSORAMINAL LUMBAR TI L 30 W 10.5 H 14 -,SUP-JUT-T6 30 14-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
TRANSFORMATIONAL LUMBAR TI CAGE L34 W10.5 H12 06 DEG -,SUP-JUT-T6 34 12-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
CAGE CERV 7MM/4.1MM H A/P ROI- C LRDTC -,SUP-MC1443P,CDM,C1821,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
CAGE CERV 10MM/7.1MM H A/P ROI- C LRDTC -,SUP-MC1446P,CDM,C1821,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
PATHLOC LUMBAR INTERBODY FUSION CAGE 12MM 15 DEGREES -,SUP-PT2211-0815S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19678.9,13775.23,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
SCARLET AL-T SECURED ANTERIOR CAGE SMALL H12 15' -,SUP-SCA-LS 15 12-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
CAGE 11MM LUCENT STR -,SUP-UNDEFINED,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11695.95,8187.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
NPG IMPLANT AND CHARGER -,SUP-HFX-D,CDM,C1822,HCPCS,278,RC,,,outpatient,,,60441.5,42309.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46419.072,other,SI=N Exclusions ,,
KIT BLUE LEAD 90CM WITH 5MM SPACING -,SUP-LEAD1058-90B,CDM,C1822,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46419.072,other,SI=N Exclusions ,,
IPG KIT -,SUP-NIPG2500,CDM,C1822,HCPCS,278,RC,,,outpatient,,,60441.5,42309.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46419.072,other,SI=N Exclusions ,,
NEVRO IPG KIT WITH NEW BATTERY -,SUP-NIPG3000,CDM,C1822,HCPCS,278,RC,,,outpatient,,,60441.5,42309.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,46419.072,other,SI=N Exclusions ,,
STENT DES 4X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-10074400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3X15MM XIENCE V RX BE PRMNT 143CM EVEROL CMPLNT -,SUP-1009541-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT 2.8X16MM GRAFTMS RX 143CM SEM-COM HYDRCT -,SUP-1012580-16,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT 4X16MM GRAFTMS RX 143CM SEM-COM HYDRCT -,SUP-1012582-16,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT 4X26MM GRAFTMS RX 143CM SEM-COM HYDRCT -,SUP-1012582-26,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.25X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.25X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.25X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.25X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.25X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.25X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.25X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.25X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.25X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.25X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.25X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.25X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.25X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.25X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.5X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.5X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.5X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.5X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.5X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.5X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.5X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.5X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.25X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125225-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.25X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.25X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.25X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.25X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.25X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125275-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.25X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.25X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.25X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35644.8,24951.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.25X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.25X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT 3X19MM JOST GRAFTMS OTW BE 143CM SEM-COM HYDREX CTD -,SUP-12744-19,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT 4X19MM JOST GRAFTMS OTW BE 143CM SEM-COM HYDREX CTD -,SUP-12746-19,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.25X8MM XIENCE SKYPOINT -,SUP-1804225-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.25X12MM XIENCE SKYPOINT -,SUP-1804225-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.25X15MM XIENCE SKYPOINT -,SUP-1804225-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.25X18MM XIENCE SKYPOINT -,SUP-1804225-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.25X23MM XIENCE SKYPOINT -,SUP-1804225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.25X28MM XIENCE SKYPOINT -,SUP-1804225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.25X33MM XIENCE SKYPOINT -,SUP-1804225-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.25X38MM XIENCE SKYPOINT -,SUP-1804225-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X8MM XIENCE SKYPOINT -,SUP-1804250-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X12MM XIENCE SKYPOINT -,SUP-1804250-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X15MM XIENCE SKYPOINT -,SUP-1804250-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X18MM XIENCE SKYPOINT -,SUP-1804250-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X23MM XIENCE SKYPOINT -,SUP-1804250-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X28MM XIENCE SKYPOINT -,SUP-1804250-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X33MM XIENCE SKYPOINT -,SUP-1804250-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X38MM XIENCE SKYPOINT -,SUP-1804250-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X8MM XIENCE SKYPOINT -,SUP-1804275-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X12MM XIENCE SKYPOINT -,SUP-1804275-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X15MM XIENCE SKYPOINT -,SUP-1804275-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X18MM XIENCE SKYPOINT -,SUP-1804275-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X23MM XIENCE SKYPOINT -,SUP-1804275-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X28MM XIENCE SKYPOINT -,SUP-1804275-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X33MM XIENCE SKYPOINT -,SUP-1804275-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X38MM XIENCE SKYPOINT -,SUP-1804275-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.0X8MM XIENCE SKYPOINT -,SUP-1804300-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.0X12MM XIENCE SKYPOINT -,SUP-1804300-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.0X15MM XIENCE SKYPOINT -,SUP-1804300-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.0X18MM XIENCE SKYPOINT -,SUP-1804300-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.0X23MM XIENCE SKYPOINT -,SUP-1804300-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.0X28MM XIENCE SKYPOINT -,SUP-1804300-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.0X33MM XIENCE SKYPOINT -,SUP-1804300-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.0X38MM XIENCE SKYPOINT -,SUP-1804300-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.25X8MM XIENCE SKYPOINT -,SUP-1804325-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.25X12MM XIENCE SKYPOINT -,SUP-1804325-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.25X15MM XIENCE SKYPOINT -,SUP-1804325-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.25X18MM XIENCE SKYPOINT -,SUP-1804325-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.25X23MM XIENCE SKYPOINT -,SUP-1804325-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.25X28MM XIENCE SKYPOINT -,SUP-1804325-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.25X33MM XIENCE SKYPOINT -,SUP-1804325-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.25X38MM XIENCE SKYPOINT -,SUP-1804325-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.5X8MM XIENCE SKYPOINT -,SUP-1804350-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.5X12MM XIENCE SKYPOINT -,SUP-1804350-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.5X15MM XIENCE SKYPOINT -,SUP-1804350-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.5X18MM XIENCE SKYPOINT -,SUP-1804350-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.5X23MM XIENCE SKYPOINT -,SUP-1804350-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.5X28MM XIENCE SKYPOINT -,SUP-1804350-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.5X33MM XIENCE SKYPOINT -,SUP-1804350-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.5X38MM XIENCE SKYPOINT -,SUP-1804350-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4.0X8MM XIENCE SKYPOINT -,SUP-1804400-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4.0X12MM XIENCE SKYPOINT -,SUP-1804400-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4.0X15MM XIENCE SKYPOINT -,SUP-1804400-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4.0X18MM XIENCE SKYPOINT -,SUP-1804400-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4.0X23MM XIENCE SKYPOINT -,SUP-1804400-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4.0X28MM XIENCE SKYPOINT -,SUP-1804400-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4.0X33MM XIENCE SKYPOINT -,SUP-1804400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4.0X38MM XIENCE SKYPOINT -,SUP-1804400-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4.5 X12MM XIENCE SKYPOINT -,SUP-1804450-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4.5 X15MM XIENCE SKYPOINT -,SUP-1804450-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4.5 X18MM XIENCE SKYPOINT -,SUP-1804450-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4.5 X23MM XIENCE SKYPOINT -,SUP-1804450-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4.5 X28MM XIENCE SKYPOINT -,SUP-1804450-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4.5 X33MM XIENCE SKYPOINT -,SUP-1804450-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 5.0 X12MM XIENCE SKYPOINT -,SUP-1804500-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 5.0 X15MM XIENCE SKYPOINT -,SUP-1804500-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 5.0 X18MM XIENCE SKYPOINT -,SUP-1804500-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 5.0 X23MM XIENCE SKYPOINT -,SUP-1804500-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 5.0 X28MM XIENCE SKYPOINT -,SUP-1804500-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 5.0 X33MM XIENCE SKYPOINT -,SUP-1804500-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 30MM PROX 30MM DIST 25-27MM OD AOR 140MM ZENITH TX2 -,SUP-2TEG-2P-30-140-,CDM,C1874,HCPCS,278,RC,,,outpatient,,,29835.9,20885.13,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
DETACHABLE COIL 4MM X 8MM -,SUP-36-152,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT PK PAPYRUS 2.5/15 -,SUP-434887,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT PK PAPYRUS 3.0/15 -,SUP-434888,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT PK PAPYRUS 3.5/15 -,SUP-434889,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT PK PAPYRUS 4.0/15 -,SUP-434890,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT PK PAPYRUS 4.5/15 -,SUP-434891,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT PK PAPYRUS 5.0/15 -,SUP-434892,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT PK PAPYRUS 2.5/20 -,SUP-434893,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT PK PAPYRUS 3.0/20 -,SUP-434894,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT PK PAPYRUS 3.5/20 -,SUP-434895,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT PK PAPYRUS 4.0/20 -,SUP-434896,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT PK PAPYRUS 4.5/20 -,SUP-434897,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT PK PAPYRUS 5.0/20 -,SUP-434898,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT PK PAPYRUS 3.0/26 -,SUP-434899,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT PK PAPYRUS 3.5/26 -,SUP-434900,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT PK PAPYRUS 4.0/26 -,SUP-434901,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT PK PAPYRUS 4.5/26 -,SUP-434902,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT PK PAPYRUS 5.0/26 -,SUP-434903,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
COVERA VASCULAR COVERED STENT 6 x 60 Ref: AVFM06060 -,SUP-AVFM06060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
COVERA VASCULAR COVERED STENT 7 X 80 8F -,SUP-AVFM07080,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
COVERA 8MM X 40MM FLARED -,SUP-AVFM08040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
COVERA 8MM X 60MM FLARED -,SUP-AVFM08060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT VASCULAR COVERA FLARE 8MM X 80MM -,SUP-AVFM08080,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
COVERA STENT GRAFT 10 X 40 -,SUP-AVFM10040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
COVERA VASCULAR COVERED STENT 6 x 40 Ref: AVSM06040 -,SUP-AVSM06040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
COVERA AV STENT GRAFT 8MM X 60MM X 80MM -,SUP-AVSM08060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT COVERA AV GRAFT 8MM X 80MM X 80MM -,SUP-AVSM08080,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT COVERA AV GRAFT 10MM X 60MM 80CM STRAIGHT -,SUP-AVSM10060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
VIABAHN BALLOON EXPANDABLE 7MM X 29MM STENT -,SUP-BXA072902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12468.25,8727.775,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
BALLOON EXPANDABLE ENDOPROSTHESIS VIABAHN 8-11 7FR 29LGTH -,SUP-BXA082902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13199.72,9239.804,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
BALLOON EXPANDABLE ENDOPROSTHESIS VIABAHN 8-11 7FR 39LGTH -,SUP-BXA083902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
BALLOON EXPANDABLE ENDOPROSTHESIS VIABAHN 8-11 7FR 59 LGTH -,SUP-BXA085902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12468.25,8727.775,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT VIABAHN 11MM X 39CM GORE -,SUP-BXA113902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11844.47,8291.129,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
VIABAHN BALLOON EXPANDABLE 1MM X 59MM STENT -,SUP-BXA115902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT VIABAHN VBX BALLOON EXPANDABLE ENDOPROSTHESIS 2 -,SUP-BXAL082901A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
VIABAHN VBX BALLOON EXPANDABLE ENDOPROSTHESIS -,SUP-BXAL082902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT VIABAHN VBX 8MM X 39MM BALLOON EXPANDABLE -,SUP-BXAL083901A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
VIABAHN VBX 8MM X 59MM BALLOON AXPANDABLE STENT -,SUP-BXAL085901A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
VIABAHN VBX BALLOON EXPANDABLE ENDOPROSTHESIS -,SUP-BXAL085902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
EXCLUDER CONFORM AAA EXT ENDO 26MM X 4.5CM 15FR -,SUP-CXA260005,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19511.82,13658.274,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT 3.5X15MM DRIVER OTW BE  143CM 0.014IN GW COMP -,SUP-DRV35015W,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 22X39MM ZENITH FLEX BIFUR MAIN BD EXTEND Z-TRAK -,SUP-ESBE-22-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 24X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-24-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 26X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-26-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 28MM DI 39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK -,SUP-ESBE-28-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 30X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-30-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 32X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-32-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 36X50MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-36-50-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT STENT ENDURANT 23MM -,SUP-ESBF2314C103E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 28/14X103MM ENDURANT IIS BIFUR STNT PRELD PROX -,SUP-ESBF2814C103E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,36592.73,25614.911,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 32/14X103MM ENDURANT IIS BIFUR STNT PRELD PROX -,SUP-ESBF3214C103E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
CONVERTER EV 12MM DIST 24MM PROX 80MM ZENITH FLEX Z-TRAK -,SUP-ESC-24-12-80-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
CONVERTER EV 28MMX12MMX80MM ZENITH FLEX Z-TRAK INTRO SYS -,SUP-ESC-28-12-80ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
CONVERTER EV 32MMX12MMX80MM ZENITH FLEX Z-TRAK INTRO SYS -,SUP-ESC-32-12-80-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
CONVERTER EV 36MMX12MMX82MM ZENITH FLEX Z-TRAK INTRO SYS -,SUP-ESC-36-12-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 18X55MM ZENITH AOR -,SUP-ESLE-18-55-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8246.09,5772.263,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
SYS STENT ENDURANT II GRAFT BI -,SUP-ETBF2316C145E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT GRAFT ENDURANT II AORTIC EXTENSION 49E -,SUP-ETCF2323C49E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14726.69,10308.683,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT GRAFT ENDURANT II AO EXT -,SUP-ETCF2828C49E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15079.42,10555.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STEN GRAFT ENDURANT II AORTIC EXT 49E -,SUP-ETCF3232C49E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16783.13,11748.191,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT GRAFT ENDURANTII ILEXT -,SUP-ETEW1313C82E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16402.18,11481.526,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT GRAFT ENDUR II LIMB -,SUP-ETLW1610C156E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT STENT ENDUR II LIMB -,SUP-ETLW1610C199E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,22910.14,16037.098,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT STENT ENDUR IIS LIMB -,SUP-ETLW1610C93E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17372.2,12160.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 16/13X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1613C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17548.57,12283.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 16/13X156MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1613C156E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,24713.73,17299.611,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 16/16X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1616C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,18067.09,12646.963,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 16/16X82MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1616C82E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17280.3,12096.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 16/20X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1620C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,18250.51,12775.357,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 16/20X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1620C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17548.57,12283.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT GRAFT ENDUR II LIMB -,SUP-ETLW1624C156E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT GRAFT CONTRAL ENDURANT -,SUP-ETLW1624C93E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17372.2,12160.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT GRAFT ENDURANT II AUI -,SUP-ETUF2314C102E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 28/14X102MM ENDURANT II BIFUR STNT AOR ILC PRELD -,SUP-ETUF2814C102E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT STENT ENDURANT II 14MM X 36 X102MM -,SUP-ETUF3614C102E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 7MM 9FR CATH 50MM 120CM TOT 80CM DLV SYS FLAIR FLR -,SUP-FAF07050,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 8MM 9FR CATH 40MM 800CM TOT 80CM DLV SYS FLAIR FLR -,SUP-FAF08040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 7MM 9FR CATH 40MM 120CM TOT 80CM DLV SYS FLAIR STR -,SUP-FAS07040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9995.4,6996.78,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ENPROS 10MM 9FR CATH 40MM FLUENCY+ 117CM TRACHBR SE -,SUP-FTL10040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9825.92,6878.144,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ENPROS 7MM 8FR CATH 60MM FLUENCY+ 80CM TRACHBR SE -,SUP-FTM07060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10077.08,7053.956,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ENPROS 8MM 9FR CATH 40MM FLUENCY+ 80CM TRACHBR SE -,SUP-FTM08040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10077.08,7053.956,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ENPROS 12X54MM ZENITH AAA CNTRLAT ILC LEG WVN PLYSTR -,SUP-G12446,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 12MM IPSI LEG DIA 106MM DIST LEG 28MM DIST BD -,SUP-G32500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 30MM PROX 24-26MM OD AOR 94MM PROX BD ZENITH FEN -,SUP-G32533,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
ZENITH FENESTRATED PROXIMAL BODY -,SUP-G32537,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7045.04,4931.528,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT CUST ZFEN-P 2-24-124-R -,SUP-G32540,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 28MM PROX 23-24MM OD AOR 124MM PROX BD ZENITH FEN -,SUP-G32542,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 30MM PROX 24-26MM OD AOR 124MM PROX BD ZENITH FEN -,SUP-G32543,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT ZENITH FEN PROXIMAL BODY - ZFEN-P-2-32-124-R -,SUP-G32544,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 36MM PROX 29-31MM OD AOR 122MM PROX BD ZENITH FEN -,SUP-G32548,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT ZENITH DISTAL BODY - ZFEN-12-28-91 -,SUP-G32554,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 24/12X113MM ZENITH RENU ANCLRY CNVTR H&L-B 1-SHOT -,SUP-G36155,CDM,C1874,HCPCS,278,RC,,,outpatient,,,24186.48,16930.536,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
DRUG ELUTING STENT 80 PTX -,SUP-G38480,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
S ZILVER PTX 6 X 120 X 125 DRU -,SUP-G38482,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9315.54,6520.878,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT PTX 7MM X 40MM -,SUP-G38486,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5487.45,3841.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
DRUG ELUTING STENT 7 - 60 PTX -,SUP-G38487,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6981.34,4886.938,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
DRUG ELUTING STENT 7 - 100 PTX -,SUP-G38489,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ZILVER PTX 7MM X 120MM P -,SUP-G38490,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9315.54,6520.878,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT 8mm x 40mm PTX ZILVER -,SUP-G38495,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5487.45,3841.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ZILVER 8MM X 80MM PTX DRUG ELUTING PERIP -,SUP-G38518,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ZIV6-35-125-8-120-PTX -,SUP-G38532,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9315.54,6520.878,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 20X30MM ZENITH FLEX BIFUR ILC PLG H&L-B 1-SHOT -,SUP-G43055,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7775.01,5442.507,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 36MMX11.3CM ZENITH FLEX AAA BIFUR STNT 20FR DLV SYS -,SUP-G43357,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30491.16,21343.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 36MMX12MMX127MM ZENITH RENU ANCLRY CNVTR H&L-B -,SUP-G43366,CDM,C1874,HCPCS,278,RC,,,outpatient,,,23484.73,16439.311,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
ZENITH TX2 DISSECTION ENDOVASCULAR GRAFT STRAIGHT COMPONENT -,SUP-G47454,CDM,C1874,HCPCS,278,RC,,,outpatient,,,49547.23,34683.061,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
COMPONENT STRAIGHT ENDO GRAFT ZENITH TX2 DISSECTION -,SUP-G47457,CDM,C1874,HCPCS,278,RC,,,outpatient,,,43823.79,30676.653,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
ZENITH FLEX AAA ENDOVASC GRAFT MAIN BODY -,SUP-G48403,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 24MM BD 20-21MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-G48408,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT ZENITH FLEX AAA ENDOVASCULAR BIFURC MAIN BODY -,SUP-G48409,CDM,C1874,HCPCS,278,RC,,,outpatient,,,34530.9,24171.63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
ENDOGRAFT 32-82 ZENITH FLEX -,SUP-G48427,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 36MM BD 29-32MM OD AOR 95MM ZENITH FLEX BIFUR MAIN -,SUP-G48428,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
ZENITH FLEX AAA ENDOVASCULAR GRAFT 20FR -,SUP-G48429,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT ZEINTH 36X95MM ENDOVAS A -,SUP-G48432,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 36MM BD 29-32MM OD AOR 113MM ZENITH FLEX BIFUR MAIN -,SUP-G48433,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 14MM MAIN BD 37MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-G48454,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 22MM MAIN BD 39MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-G48472,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11454.61,8018.227,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 24MM MAIN BD 39MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-G48476,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11454.61,8018.227,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT COLONIC 18MM X 23MM X 12 -,SUP-G51183,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ESOPHAGEAL EVOLUTION FULLY COVERED 20-25-8 -,SUP-G52225,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 38MM PROX 38MM DIST 33-34MM OD AOR 202MM ZENITH TX2 -,SUP-G53435,CDM,C1874,HCPCS,278,RC,,,outpatient,,,29835.9,20885.13,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT ZENITH FLES Z-TRAK AAA ENDOVASC MAIN BODY EXT -,SUP-G55213,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9273.14,6491.198,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
ZENITH FLEX WITH SPIRAL Z ENDOVASCULAR GRAFT -,SUP-G55221,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT ZENITH FLEX LEG 13X56 -,SUP-G55231,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 16MM DIST 56MM ZENITH SPRL-Z CNTRLAT IPSI ILC LEG -,SUP-G55237,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT ZENITH FLEX LEG 16X74 14FR -,SUP-G55238,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT ZENITH FLEX LEG 20MM X 39MM -,SUP-G55240,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 24MM DIST 90MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-G55247,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT ZENITH 22 X 113 -,SUP-G55357,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30944.14,21660.898,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
ZENITH RENU AAA ANCILLARY GRAFT CON 12MM X 28MM X 113MM -,SUP-G55376,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30944.14,21660.898,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
ICAST COVERED STENT- 9MMX38MMX120CM -,SUP-G60511,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9841.79,6889.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
SYNERGY II US MR 2.5X8 -,SUP-H493926008250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
SYNERGY II US MR 2.75X8 -,SUP-H493926008270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
SYNERGY II US MR 3.5X8 -,SUP-H7433926008350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X24MM TAXUS EXPR2 OTW BE PRMNT 135CM PACLIT -,SUP-H7493896824250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.5X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.25X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.5X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X16MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902316250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4X16MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902316400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X20MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902320270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3X20MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902320300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4X20MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902320400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.25X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.5X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.25X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.25X16MM ION MONORAIL RX BE PRMNT 144CM PACLIT -,SUP-H7493902416220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X16MM ION MONORAIL RX BE PRMNT 144CM PACLIT -,SUP-H7493902416270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3X20MM ION MONORAIL RX BE PRMNT 144CM PACLIT THN -,SUP-H7493902420300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3X28MM ION MONORAIL RX BE PRMNT 144CM PACLIT THN -,SUP-H7493902428300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X32MM ION MONORAIL RX BE PRMNT 144CM PACLIT THN -,SUP-H7493902432250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X32MM ION MONORAIL RX BE PRMNT 144CM PACLIT -,SUP-H7493902432270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.25X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.5X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.25X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.5X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.25X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.5X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.25X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.5X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.25X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.5X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.25X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.5X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.25X32MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911432220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X32MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911432250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.5X32MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911432350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.5X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.25X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SV -,SUP-H7493911608220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911608250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911608270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL WKHRS -,SUP-H7493911608300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911608400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.25X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911612250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.5X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911612400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.25X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.5X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911616400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.5X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911620400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.25X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.5X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911624400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.25X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911628250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.5X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911628400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.25X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911632250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.5X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911632400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.5X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911638250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911638270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911638300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3.5X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911638350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911638400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 2.25 X 8 -,SUP-H7493926008220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
SYNERGY II US MR 2.25X8 -,SUP-H7493926008220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 2.50 X 8 -,SUP-H7493926008250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 2.75 X 8 -,SUP-H7493926008270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 3.00 X 8 -,SUP-H7493926008300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
SYNERGY II US MR 3.00X8 -,SUP-H7493926008300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 3.50 X 8 -,SUP-H7493926008350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 4.00 X 8 -,SUP-H7493926008400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
SYNERGY II US MR 4.0X8 -,SUP-H7493926008400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 2.25 X 12 -,SUP-H7493926012220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 2.50 X 12 -,SUP-H7493926012250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 2.75 X 12 -,SUP-H7493926012270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 3.00 X 12 -,SUP-H7493926012300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 3.50 X 12 -,SUP-H7493926012350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 4.00 X 12 -,SUP-H7493926012400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 2.25 X 16 -,SUP-H7493926016220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 2.50 X 16 -,SUP-H7493926016250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 2.75 X 16 -,SUP-H7493926016270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 3.00 X 16 -,SUP-H7493926016300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 3.50 X 16 -,SUP-H7493926016350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 4.00 X 16 -,SUP-H7493926016400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 2.25 X 20 -,SUP-H7493926020220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 2.50 X 20 -,SUP-H7493926020250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 2.50 X 28 -,SUP-H7493926020250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 2.50 X 24 -,SUP-H7493926020250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 2.75 X 20 -,SUP-H7493926020270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 3.00 X 20 -,SUP-H749392602030,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 3.50 X 20 -,SUP-H7493926020350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 4.00 X 20 -,SUP-H7493926020400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 2.25 X 24 -,SUP-H7493926024220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 2.75 X 24 -,SUP-H7493926024270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 3.00 X 24 -,SUP-H7493926024300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 3.50 X 24 -,SUP-H7493926024350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 4.00 X 24 -,SUP-H7493926024400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 2.25 X 28 -,SUP-H7493926028220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 2.75 X 28 -,SUP-H7493926028270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 3.00 X 28 -,SUP-H7493926028300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 3.50 X 28 -,SUP-H7493926028350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 4.00 X 28 -,SUP-H7493926028400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 2.50 X 32 -,SUP-H7493926032250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 2.75 X 32 -,SUP-H7493926032270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 3.00 X 32 -,SUP-H7493926032300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 3.50 X 32 -,SUP-H7493926032350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 4.00 X 32 -,SUP-H7493926032400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 2.25 X 38 -,SUP-H7493926038220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 2.50 X 38 -,SUP-H7493926038250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 2.75 X 38 -,SUP-H7493926038270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 3.00 X 38 -,SUP-H7493926038300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 3.50 X 38 -,SUP-H7493926038350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES MR 4.00 X 38 -,SUP-H7493926038400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 2.25 X 8 -,SUP-H7493926108220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 2.50 X 8 -,SUP-H7493926108250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 2.75 X 8 -,SUP-H7493926108270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 3.00 X 8 -,SUP-H7493926108300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 3.50 X 8 -,SUP-H7493926108350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 4.00 X 8 -,SUP-H7493926108400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 2.25 X 12 -,SUP-H7493926112220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 2.50 X 12 -,SUP-H7493926112250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 2.75 X 12 -,SUP-H7493926112270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 3.00 X 12 -,SUP-H7493926112300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 3.50 X 12 -,SUP-H7493926112350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 4.00 X 12 -,SUP-H7493926112400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 2.25 X 16 -,SUP-H7493926116220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 2.50 X 16 -,SUP-H7493926116250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 2.75 X 16 -,SUP-H7493926116270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 3.00 X 16 -,SUP-H7493926116300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 3.50 X 16 -,SUP-H7493926116350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 4.00 X 16 -,SUP-H7493926116400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 2.25 X 20 -,SUP-H7493926120220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 2.50 X 20 -,SUP-H7493926120250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 2.75 X 20 -,SUP-H7493926120270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 3.00 X 20 -,SUP-H7493926120300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 3.50 X 20 -,SUP-H7493926120350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 4.00 X 20 -,SUP-H7493926120400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 2.25 X 24 -,SUP-H7493926124220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 2.50 X 24 -,SUP-H7493926124250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 2.75 X 24 -,SUP-H7493926124270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 3.00 X 24 -,SUP-H7493926124300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 3.50 X 24 -,SUP-H7493926124350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 4.00 X 24 -,SUP-H7493926124400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 2.25 X 28 -,SUP-H7493926128220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 2.50 X 28 -,SUP-H7493926128250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 2.75 X 28 -,SUP-H7493926128270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 3.00 X 28 -,SUP-H7493926128300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 3.50 X 28 -,SUP-H7493926128350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 4.00 X 28 -,SUP-H7493926128400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 2.25 X 32 -,SUP-H7493926132220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 2.50 X 32 -,SUP-H7493926132250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 2.75 X 32 -,SUP-H7493926132270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 3.00 X 32 -,SUP-H7493926132300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 3.50 X 32 -,SUP-H7493926132350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 4.00 X 32 -,SUP-H7493926132400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 2.25 X 38 -,SUP-H7493926138220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 2.50 X 38 -,SUP-H7493926138250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 2.75 X 38 -,SUP-H7493926138270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 3.00 X 38 -,SUP-H7493926138300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 3.50 X 38 -,SUP-H7493926138350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY DES OTW 4.00 X 38 -,SUP-H7493926138400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
ELUVIA US 6MM X 40MM X 130CM -,SUP-H74939294600410,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
ELUVIA US 6MM X 60MM X 130CM -,SUP-H74939294600610,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
ELUVIA US 6MM X 80MM X 130CM -,SUP-H74939294600810,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
ELUVIA US 6MM X 100MM X 130CM -,SUP-H74939294601010,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
ELUVIA US 6MM X 120MM X 130CM -,SUP-H74939294601210,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10749.14,7524.398,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
ELUVIA US 6X150 130 cm -,SUP-H74939294601510,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13719.54,9603.678,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
ELUVIA 7MM x 40MM x 130CM -,SUP-H74939294700410,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
ELUVIA 7MM x 60MM x 130CM -,SUP-H74939294700610,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
ELUVIA DRUG-ELUTING VASCULAR STENT SYSTEM 7MM X 80MM X 130CM -,SUP-H74939294700810,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
ELUVIA 7MM x 100MM x 130CM -,SUP-H74939294701010,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
ELUVIA 7MM x 120MM x 130CM -,SUP-H74939294701210,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10749.14,7524.398,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
ELUVIA US 7X150 130 cm -,SUP-H74939294701510,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13719.54,9603.678,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT PROMUS ELITE US MR 4.0 X 8MM -,SUP-H7493941208400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT PROMUS ELITE US MR 4.0 X 12MM -,SUP-H7493941212400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT PROMUS ELITE US MR 2.50 X 32MM -,SUP-H7493941232250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT PROMUS ELITE US MR 3.50 X 32MM -,SUP-H7493941232350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT PROMUS ELITE US MR 3.50 X 38MM -,SUP-H7493941238350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 2.25 X 8 -,SUP-H7493941808220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 2.50 X 8 -,SUP-H7493941808250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 2.75 X 8 -,SUP-H7493941808270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 3.0 X 8 -,SUP-H7493941808300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 3.5 X 8 -,SUP-H7493941808350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 4.0 X 8 -,SUP-H7493941808400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 2.25 X 12 -,SUP-H7493941812220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 2.50 X 12 -,SUP-H7493941812250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 2.75 X 12 -,SUP-H7493941812270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 3.0 X 12 -,SUP-H7493941812300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 3.5 X 12 -,SUP-H7493941812350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 4.0 X 12 -,SUP-H7493941812400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 4.5 X 12 -,SUP-H7493941812450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 5.0 X 12 -,SUP-H7493941812500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 2.25 X 16 -,SUP-H7493941816220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 2.50 X 16 -,SUP-H7493941816250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 2.75 X 16 -,SUP-H7493941816270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 3.0 X 16 -,SUP-H7493941816300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 3.5 X 16 -,SUP-H7493941816350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 4.0 X 16 -,SUP-H7493941816400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 4.5 X 16 -,SUP-H7493941816450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 5.0 X 16 -,SUP-H7493941816500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 2.25 X 20 -,SUP-H7493941820220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 2.50 X 20 -,SUP-H7493941820250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 2.75 X 20 -,SUP-H7493941820270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 3.0 X 20 -,SUP-H7493941820300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 3.5 X 20 -,SUP-H7493941820350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 4.0 X 20 -,SUP-H7493941820400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 4.5 X 20 -,SUP-H7493941820450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 5.0 X 20 -,SUP-H7493941820500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 2.25 X 24 -,SUP-H7493941824220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 2.50 X 24 -,SUP-H7493941824250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 2.75 X 24 -,SUP-H7493941824270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 3.0 X 24 -,SUP-H7493941824300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 3.5 X 24 -,SUP-H7493941824350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 4.0 X 24 -,SUP-H7493941824400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 4.5 X 24 -,SUP-H7493941824450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 5.0 X 24 -,SUP-H7493941824500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 2.25 X 28 -,SUP-H7493941828220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 2.50 X 28 -,SUP-H7493941828250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 2.75 X 28 -,SUP-H7493941828270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 3.0 X 28 -,SUP-H7493941828300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 3.5 X 28 -,SUP-H7493941828350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 4.0 X 28 -,SUP-H7493941828400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 4.5 X 28 -,SUP-H7493941828450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 5.0 X 28 -,SUP-H7493941828500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 2.25 X 32 -,SUP-H7493941832220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 2.50 X 32 -,SUP-H7493941832250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 2.75 X 32 -,SUP-H7493941832270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 3.0 X 32 -,SUP-H7493941832300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 3.5 X 32 -,SUP-H7493941832350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 4.0 X 32 -,SUP-H7493941832400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 4.5 X 32 -,SUP-H7493941832450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 5.0 X 32 -,SUP-H7493941832500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 2.25 X 38 -,SUP-H7493941838220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 2.50 X 38 -,SUP-H7493941838250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 2.75 X 38 -,SUP-H7493941838270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 3.0 X 38 -,SUP-H7493941838300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 3.5 X 38 -,SUP-H7493941838350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR 4.0 X 38 -,SUP-H7493941838400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR US 2.5 X 48MM REF:H7493941848250 -,SUP-H7493941848250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR US 2.75 X 48MM REF:H7493941848270 -,SUP-H7493941848270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR US 3 X 48MM REF:H7493941848300 -,SUP-H7493941848300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR US 3.5 X 48MM REF:H7493941848350 -,SUP-H7493941848350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT SYNERGY XD DES MR US 4 X 48MM REF:H7493941848400 -,SUP-H7493941848400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT S MEGATRON DES US MR 3.5 X 16MM REF:H7493942816350 -,SUP-H7493942816350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT S MEGATRON DES US MR 3.5 X 20MM REF:H7493942820350 -,SUP-H7493942820350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT S MEGATRON DES US MR 4 X 20MM REF:H7493942820400 -,SUP-H7493942820400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT S MEGATRON DES US MR 4.5 X 20MM REF:H7493942820450 -,SUP-H7493942820450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT S MEGATRON DES US MR 5 X 20MM REF:H7493942820500 -,SUP-H7493942820500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT S MEGATRON DES US MR 3.5 X 24MM REF:H7493942824350 -,SUP-H7493942824350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT S MEGATRON DES US MR 4 X 24MM REF:H7493942824400 -,SUP-H7493942824400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT S MEGATRON DES US MR 4.5 X 24MM REF:H7493942824450 -,SUP-H7493942824450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT S MEGATRON DES US MR 5 X 24MM REF:H7493942824500 -,SUP-H7493942824500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT S MEGATRON DES US MR 3.5 X 28MM REF:H7493942828350 -,SUP-H7493942828350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT S MEGATRON DES US MR 4.0 X 28MM REF:H7493942828400 -,SUP-H7493942828400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT S MEGATRON DES US MR 4.5 X 28MM REF:H7493942828450 -,SUP-H7493942828450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT S MEGATRON DES US MR 5.0 X 28MM REF:H7493942828500 -,SUP-H7493942828500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT S MEGATRON DES US MR 3.5 X 32MM REF:H7493942832350 -,SUP-H7493942832350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT S MEGATRON DES US MR 4.0 X 32MM REF:H7493942832400 -,SUP-H7493942832400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT S MEGATRON DES US MR 4.5 X 32MM REF:H7493942832450 -,SUP-H7493942832450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT S MEGATRON DES US MR 5.0 X 32MM REF:H7493942832500 -,SUP-H7493942832500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
SYNERGY II US MR 2.25X12 -,SUP-H749396012220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT BIL 10X60MM 194CM CATH WALLSTNT SE UNCNTSTR CVR ENPROS -,SUP-H965431100,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7116.04,4981.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT BALLOON EXPANDABLE VASC COVERED -,SUP-LSMU0800737,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT LIFESTREAM 7MM X 58MM BALLOON EXP -,SUP-LSMU0800758,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
LIFESTREAM BALLOON EP VASC COVERED STENT 80CM X 26MM -,SUP-LSMU0800826,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
12MM X 38MM LIFE STREAM -,SUP-LSMU0801238,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT LIFESTREAM 5MM X 26MM -,SUP-LSMU1350526,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
LIFESTREAM 12MM X 38MM X 80CM -,SUP-LSMU1350626,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
FIBERED PLATINUM COIL 2 X 5MM -,SUP-M0013120211,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2243.7,1570.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
FIBERED PLATNUM COIL 4 X 4MM -,SUP-M0013120221,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2243.7,1570.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
DETACHABLE COIL 3MM X 6MM -,SUP-M001361500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2622.16,1835.512,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
DETACHABLE COIL 6MM X 10MM -,SUP-M001361560,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
PUSHER SURG ARSCP 0.016INX177CM VASC COIL 16 -,SUP-M0014012160,CDM,C1874,HCPCS,278,RC,,,outpatient,,,1036.3,725.41,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ESPH 18MM BD 13MM BD 23MM FLR 15CM POLYFLEX SE SIL LF -,SUP-M00514320,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8623.21,6036.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ESPH 18MM 25/23MM OD P/D FLR 18.5FR CATH 10CM WALLFLX -,SUP-M00516700,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ESPH 18MM 25/23MM OD P/D FLR 12CM WALLFLX SE BRD FLLY -,SUP-M00516710,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
WALLFLEX ESOPHAGEAL FULLY COVERED 18 X 15 -,SUP-M00516720,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ESPH 23MM 28/28MM OD P/D FLR 10CM WALLFLX SE BRD FLLY -,SUP-M00516730,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
WALLFLEX ESOPHAGEAL FULLY COVERED 23 X 10 -,SUP-M00516730,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ESPH 23MM 28/28MM OD P/D FLR 12CM WALLFLX SE BRD FLLY -,SUP-M00516740,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
WALLFLEX ESOPHAGEAL FULLY COVERED 23 X 12 -,SUP-M00516740,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
WALLFLEX ESOPHAGEAL FULLY COVERED 18 X 15 -,SUP-M00516750,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ESPH 18MM 23/23MM OD P/D FLR 10CM WALLFLX SE BRD FLLY -,SUP-M00516900,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9314.91,6520.437,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
WALLFLEX ESOPHAGEAL PARTIALLY COVERED 18 X 10 -,SUP-M00516900,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ESPH 18MM 23/23MM OD P/D FLR 123MM WALLFLX SE BRD FLLY -,SUP-M00516910,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
WALLFLEX ESOPHAGEAL PARTIALLY COVERED 18 X 12 -,SUP-M00516910,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
WALLFLEX PC ESOPH STENT 23/28MM X 105MM -,SUP-M00516930,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
WALLFLEX ESOPHAGEAL PARTIALLY COVERED 23 X 12 -,SUP-M00516940,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT AXIOS ELECTROCAUTERY-ENHANCED 15mm X 10mm -,SUP-M00553650,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17317.43,12122.201,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT CYST GASTROSTOMY AXIOS -,SUP-M00553650,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19659.22,13761.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT AXIOS 10 X 20 EE LO -,SUP-M00553660,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19659.22,13761.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT BIL 10X60MM WALLSTNT RX SE PRT CVR MTL 0.035IN GW COMP -,SUP-M00569710,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7266.24,5086.368,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT WALLFLEX BILIARY FULLY COVERED -,SUP-M00570350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
S WALLFLEX BILI 10X40 RX COV -,SUP-M00570360,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT BIL 10X60MM WALLFLX RX SE FLLY CVR PLATINOL 0.035IN GW -,SUP-M00570370,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT BIL 10X80MM WALLFLX RX SE FLLY CVR PLATINOL 0.035IN GW -,SUP-M00570380,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT PARTIALLY COVERED 8 X 100 -,SUP-M00570730,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9639.76,6747.832,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ULTRAFLEX 8 X 40 25MM TR -,SUP-M00576520,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT TRACHBR 10MM XPND 18FR COMPRESS 30MM ULFLX PRT CVR -,SUP-M00576530,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT RX COVRD 15 X 30 -,SUP-M00576550,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT RX COVRD 25 X 40 -,SUP-M00576560,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT CVRD ULTRAFLEX 14 X 40 -,SUP-M00576580,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT CVRD ULTRAFLEX 14 X 60 -,SUP-M00576590,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT TRACHBR 16MMX40MM ULFLX CVR DIST RELS SIL DIST RELS -,SUP-M00576610,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ULTRAFLEX 16X45 -,SUP-M00576620,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT CVRD ULTRAFLEX 18 X 40 -,SUP-M00576640,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT CVRD ULTRAFLEX 20 X 40 -,SUP-M00576670,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11747.93,8223.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT CVRD ULTRAFLEX 20 X 80 -,SUP-M00576690,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ESOPHAGEAL 23 X 150 ENDO -,SUP-MAXX-2315,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9175.53,6422.871,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  2.00 x 08MM -,SUP-ONYXNG20008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  2.00 x 12MM -,SUP-ONYXNG20012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  2.00 x 15MM -,SUP-ONYXNG20015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  2.00 x 18MM -,SUP-ONYXNG20018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  2.00 x 30MM -,SUP-ONYXNG20030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  2.25 x 08MM -,SUP-ONYXNG22508UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  2.25 x 12MM -,SUP-ONYXNG22512UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  2.25 x 15MM -,SUP-ONYXNG22515UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  2.25 x 18MM -,SUP-ONYXNG22518UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  2.25 x 22MM -,SUP-ONYXNG22522UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  2.25 x 26MM -,SUP-ONYXNG22526UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  2.25 x 30MM -,SUP-ONYXNG22530UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  2.25 x 34MM -,SUP-ONYXNG22534UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  2.25 x 38MM -,SUP-ONYXNG22538UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  2.50 x 08MM -,SUP-ONYXNG25008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  2.50 x 12MM -,SUP-ONYXNG25012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  2.50 x 15MM -,SUP-ONYXNG25015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  2.50 x 18MM -,SUP-ONYXNG25018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  2.50 x 22MM -,SUP-ONYXNG25022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  2.50 x 26MM -,SUP-ONYXNG25026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  2.50 x 30MM -,SUP-ONYXNG25030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  2.50 x 34MM -,SUP-ONYXNG25034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  2.50 x 38MM -,SUP-ONYXNG25038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  2.75 x 08MM -,SUP-ONYXNG27508UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  2.75 x 12MM -,SUP-ONYXNG27512UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  2.75 x 15MM -,SUP-ONYXNG27515UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  2.75 x 18MM -,SUP-ONYXNG27518UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  2.75 x 22MM -,SUP-ONYXNG27522UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  2.75 x 26MM -,SUP-ONYXNG27526UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  2.75 x 30MM -,SUP-ONYXNG27530UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  2.75 x 34MM -,SUP-ONYXNG27534UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  2.75 x 38MM -,SUP-ONYXNG27538UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  3.0 x 08MM -,SUP-ONYXNG30008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  3.0 x 12MM -,SUP-ONYXNG30012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  3.0 x 15MM -,SUP-ONYXNG30015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  3.0 x 18MM -,SUP-ONYXNG30018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  3.0 x 22MM -,SUP-ONYXNG30022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  3.0 x 26MM -,SUP-ONYXNG30026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  3.0 x 30MM -,SUP-ONYXNG30030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  3.0 x 34MM -,SUP-ONYXNG30034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  3.0 x 38MM -,SUP-ONYXNG30038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  3.5 x 08MM -,SUP-ONYXNG35008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  3.5 x 12MM -,SUP-ONYXNG35012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  3.5 x 15MM -,SUP-ONYXNG35015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  3.5 x 18MM -,SUP-ONYXNG35018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  3.5 x 22MM -,SUP-ONYXNG35022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  3.5 x 26MM -,SUP-ONYXNG35026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  3.5 x 30MM -,SUP-ONYXNG35030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  3.5 x 34MM -,SUP-ONYXNG35034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  3.5 x 38MM -,SUP-ONYXNG35038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  4.0 x 12MM -,SUP-ONYXNG40012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  4.0 x 15MM -,SUP-ONYXNG40015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  4.0 x 18MM -,SUP-ONYXNG40018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  4.0 x 22MM -,SUP-ONYXNG40022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  4.0 x 26MM -,SUP-ONYXNG40026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  4.0 x 30MM -,SUP-ONYXNG40030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  4.0 x 34MM -,SUP-ONYXNG40034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  4.0 x 38MM -,SUP-ONYXNG40038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  4.5 x 12MM -,SUP-ONYXNG45012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  4.5 x 15MM -,SUP-ONYXNG45015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  4.5 x 18MM -,SUP-ONYXNG45018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  4.5 x 22MM -,SUP-ONYXNG45022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  4.5 x 26MM -,SUP-ONYXNG45026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  4.5 x 30MM -,SUP-ONYXNG45030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  5.0 x 18MM -,SUP-ONYXNG50018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  5.0 x 22MM -,SUP-ONYXNG50022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ONYX DES  5.0 x 30MM -,SUP-ONYXNG50030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT BIL 5X18MM 135CM PALMZ GENESIS RX BE TRNSHEP SS -,SUP-PG1850BAX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4882.72,3417.904,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
EXCLUDER AAA ENDO EXTENDER 26MMX3.3CM 16FR -,SUP-PLA260300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13934.89,9754.423,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 32MM 27-29MM AOR 4.5CM EXCLDR AOR EXTEND LPRO SULS -,SUP-PLA320400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13934.89,9754.423,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
EXCLUDER AAA ENDO EXTENDER 36MM X 4.5CM 18FR -,SUP-PLA360400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13934.89,9754.423,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
EXCLUDER AAA ENDOPROSTHESIS L 16MM X 12MM X 14CM 12F -,SUP-PLC121400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
EXCLUDER CONTRALATERAL LEG 16MM X 14.5MM X 10CM 12F -,SUP-PLC141000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GORE EXCLUDER AAA ENDOPROSTHESIS -,SUP-PLC141200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 13.5-14.5MM 16MM ILC 9.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PLC161000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 13.5-14.5MM 16MM ILC 11.5CM EXCLDR CNTRLAT LEG ILC -,SUP-PLC161200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 13.5-14.5MM 16MM ILC 13.5CM EXCLDR CNTRLAT LEG ILC -,SUP-PLC161400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EXCLUDER AAA ENDO CONTRA LEG 16 X 18 X 9.5CM 12FR -,SUP-PLC181000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
EXCLUDER AAA ENDO CONTRA LEG 16MM X 20MM X 11.5CM 12FR -,SUP-PLC201200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
EXCLUDER AAA ENDO CONTRA LEG 16 X 23 X 12 14FR -,SUP-PLC231200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
EXCLUDER AAA ENDO CONTRA LEG 16MM X 23MM X 14CM 14FR -,SUP-PLC231400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GORE EXCLUDER AAA CONTRALATERAL LEG 16 X 27 X 100MM -,SUP-PLK271000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GORE VIATORR 10MM X 6CM -,SUP-PTB8106275,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17651.6,12356.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GORE VIATORR 10MM X 7CM -,SUP-PTB8107275,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17651.6,12356.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 10-11MM 12MM ILC 10CM EXCLDR CNTRLAT LEG LPRO SULS -,SUP-PXC121000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 12-13.5MM 14.5MM ILC 12CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC141200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 13.5-14.5 MM 6MMX11.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC161200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 16.5-18.5 MM 20MMX11.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC201200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 16.5-18.5 MM 20MMX13.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC201400-L,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 10MMX7CM EXCLDR ILC EXTEND LPRO SULS CNSTRCT SEAL -,SUP-PXL161007,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11510.3,8057.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 12MMX7CM EXCLDR ILC EXTEND LPRO SULS CNSTRCT SEAL -,SUP-PXL161207,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10953.35,7667.345,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 27-29/12-13.5MM 31/14.5MM DIA AOR/ILC 18CM EXCLDR -,SUP-RLT311413,CDM,C1874,HCPCS,278,RC,,,outpatient,,,32100.6,22470.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 2.75X18MM RESOLUT IN RX BE PRMNT 140CM ZOTARO -,SUP-RSINT27518UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30022W,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30026W,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 3X38MM RESOLUT IN RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT30038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT DES 4X38MM RESOLUT IN RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT40038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 22MM 18FR SHTH 8.2CM BIFUR -,SUP-TFFB-22-82,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30491.16,21343.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT 22X82 ZENITH ENDOVASC AA -,SUP-TFFB-22-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 22MM BD 18-19MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-22-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT ZENITH 24X82 ENDOVASC -,SUP-TFFB-24-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 26MM BD 22MM AOR 111MM ZENITH FLEX BIFUR MAIN BD -,SUP-TFFB-26-111-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT 26X82 ZEINTH ENDOV AAA -,SUP-TFFB-26-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 26MM BD 22MM AOR 96MM ZENITH FLEX BIFUR MAIN BD -,SUP-TFFB-26-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 28MM BD 23-24MM OD AOR 111MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-28-111-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 28MM BD 23-24MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-28-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 30MM BD 25-26MM OD AOR 11.1CM ZENITH FLEX BIFUR -,SUP-TFFB-30-111,CDM,C1874,HCPCS,278,RC,,,outpatient,,,31404.55,21983.185,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 30MM BD 25-26MM OD AOR 111MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-30-111-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT 30X82 ZEINTH ENDOVASC AB -,SUP-TFFB-30-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV ZENITH FLEX 30MM 20FRX9.6MM BIFUR MAIN BD EXTEND -,SUP-TFFB-30-96,CDM,C1874,HCPCS,278,RC,,,outpatient,,,29150.76,20405.532,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 30MM BD 25-26MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-30-96-2T,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
COOK GRAFT TFFB-30-96-ZT -,SUP-TFFB-30-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ENPROS 12X71MM ZENITH AAA CNTRLAT ILC LEG WVN PLYSTR -,SUP-TFLE-12-71,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ENPROS 14X54MM ZENITH AAA CNTRLAT ILC LEG WVN PLYSTR -,SUP-TFLE-14-54,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 14MM MAIN 56MM LEG ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-TFLE-14-56-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11454.61,8018.227,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 14MM MAIN BD 73MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-TFLE-14-73,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 14X56MM ZENITH FLEX AAA Z-TRAK BIFUR ILC CNTRLAT -,SUP-TFLE-15-56,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ENPROS 18MM 16FR SHTH 54MM ZENITH AAA CNTRLAT ILC LEG -,SUP-TFLE-18-54,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT ZENITH FLEX AAA 28X82M -,SUP-TTFB-28-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT STENT ENDUR IIS BIF BODY -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GORE VIATORR 10MM X 8CM -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16385.47,11469.829,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
S VIABAHN 7MM X 7CM VIA VAS -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ESOPHAGEAL 21X150 -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9175.53,6422.871,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT POLYFLEX AIRWAY 16X40 -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8267.48,5787.236,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
VALIANT THORACIC CAPTIVA STENT GRAFT 26MM X 112MM 22FR -,SUP-VAMF2626C100TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,40668.87,28468.209,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT GRAFT VALIANT CAPTIVA WITH DELIVERY SYSTEM -,SUP-VAMF2828C100TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,40668.5,28467.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ENPROS 5MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART. -,SUP-VBH051002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12063.54,8444.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ENPROS 6MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART. -,SUP-VBH061002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12152.65,8506.855,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ENPROS 6MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC_ART. -,SUP-VBH061502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13968.31,9777.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ENPROS 7MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBH071002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12152.65,8506.855,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ENPROS 8MMX10CM 120CM VIABAHN SE LPRO TIP TO HUB DPLY -,SUP-VBH081002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12152.65,8506.855,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ENPROS 9MMX15CM 120CM VIABAHN SE LPRO TIP TO HUB DPLY -,SUP-VBH091502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13968.31,9777.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
S 10MMX 5.0CM VIA VASC 120CM -,SUP-VBH100502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11785.06,8249.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ENPROS 10MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBH101502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14495.55,10146.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GORE VIABAHN ENDOPROSTHESIS- 7MMX5CM 8FR 120CMCATH -,SUP-VBHR070502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12910.1,9037.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ENPROS 8MM 8FR DVC 5CM GORE-HYBRID VIABAHN 120CM NTNL -,SUP-VBHR080502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12910.1,9037.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ENPROS 6MMX5CM 120CM VIABAHN FEM ILC ART TIP TO HUB -,SUP-VBJ060502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11268.96,7888.272,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ENPROS 6MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART. -,SUP-VBJ061502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14347.03,10042.921,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ENPROS 6MMX25CM 120CM GORE-HYBRID VIABAHN SUPRFC FEM -,SUP-VBJ062502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,23555.27,16488.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ENPROS 7MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJ071502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14347.03,10042.921,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ENPROS 8MMX5CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJ080502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10923.65,7646.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ENPROS 8MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJ081002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12445.98,8712.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ENPROS 5MM 6FRX5CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR050502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11669.96,8168.972,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ENPROS 5MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR051002A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12761.58,8933.106,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ENPROS 5MMX15CM VIABAHN 120MM CATH -,SUP-VBJR051502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14885.42,10419.794,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ENPROS 5MM 6FRX25CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR052502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,24297.87,17008.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ENPROS 6MMX5CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR060502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13403.93,9382.751,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ENPROS 6MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR061002A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ENPROS 6MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR061502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14224.5,9957.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ENPROS 6MM 6FRX25CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR062502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,23351.06,16345.742,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ENPROS 7MM 7FRX5CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR070502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12226.91,8558.837,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ENPROS 7MM 7FRX10CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR071002A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT ENPROS 7MMX25CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR072502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26414.28,18489.996,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
VALIANT NAVION THORACIC STENT GRAFT SYSTEM -,SUP-VNMC2020C94TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
THORACIC STENT GRAFT 94MM 25MM -,SUP-VNMC2525C94TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT GRAFT VALION NAVION THORACIC -,SUP-VNMC4040C55TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT GORE VIABIL 10MM X 6CM BILIARY -,SUP-VSWVN1006,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT GORE VIABIL 10MM X 8CM BILIARY -,SUP-VSWVN1008,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 28MM PROX BD DIA 94MM PROX BD ZENITH FEN INTNL -,SUP-ZFEN-9-2-28-94R,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 12MM IPSI LEG DIA 121MM DIST LEG 28MM DIST BD -,SUP-ZFEN-D-1228121C,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
FENESTRATED DISTAL BODY -,SUP-ZFEN-D-12-2876C,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT HUM TIS FEN 26MM ZENITH EV PROX BD LF -,SUP-ZFEN-P-226124-R,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 36MM PROX 29-31MM OD AOR 107MM PROX BD ZENITH FEN -,SUP-ZFEN-P-2-36107R,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT VASC DES ZILVER PTX 6X100MM 125CM OTW SE PRELD -,SUP-ZISV6351256100,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT VASC DES ZILVER PTX 6X60MM 125CM OTW SE PRELD -,SUP-ZIV6-35-125660,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6981.34,4886.938,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT VASC DES ZILVER PTX 7X100MM 125CM OTW SE PRELD -,SUP-ZIV6351257100PT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7617.98,5332.586,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT VASC DES ZILVER PTX 7X80MM 125CM OTW SE PRELD -,SUP-ZIV635125780PTX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7617.98,5332.586,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 11MM DIST 56MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-ZSLE-11-56-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14387.88,10071.516,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 11MM DIST 74MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-ZSLE-11-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT ZENITH FLEX LEG 13X74 -,SUP-ZSLE-13-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT ZENITH AAA LEG 13X90MM -,SUP-ZSLE-13-90-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 16MMX90MM ZENITH SPRL -Z BIFUR CNTRLAT IPSI -,SUP-ZSLE-16-16-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 16MM DIST 39MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-ZSLE-16-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT ZENITH AAA LEG 20X74MM -,SUP-ZSLE-20-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT ZENITH AAA 24 X 56MM LEG -,SUP-ZSLE-24-56-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
GRAFT EV 24MM 16FR ID 6MM INTRO SHTH 74MM ZENITH SPRL -Z -,SUP-ZSLE-24-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,232.64935,38052.27264,other,SI=N Exclusions ,,
STENT 4.5X13MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003381-13,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 4.5X18MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003381-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 4.5X28MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003381-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 5X13MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003382-13,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2X8MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2X12MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2X15MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2X18MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2X23MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2X28MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.25X8MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.25X12MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.25X15MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.25X18MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.25X23MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.25X28MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.5X8MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.5X12MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.5X15MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.5X18MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.5X23MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.5X28MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.75X8MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007847-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.75X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007847-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.75X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007847-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3X8MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3X23MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3.5X8MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3.5X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3.5X23MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3.5X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 4X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007850-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 4X23MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007850-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 4X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007850-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.75X15MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010142-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.75X23MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010142-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3X8MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010143-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3X15MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010143-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VISION OTW 3.5 X 15 -,SUP-1010144-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VISION OTW 3.5 X 23 -,SUP-1010144-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3.5X28MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010144-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 4X18MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010145-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 4X23MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010145-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2X8MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3.5X12MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2X15MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3.5X18MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2X23MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2X28MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.25X8MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.25X12MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.25X15MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.25X18MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.25X23MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.25X28MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.5X8MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.5X12MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.5X15MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.5X18MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.5X23MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC ACCULINK 5X20MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011337-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC ACCULINK 5X30MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011337-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC ACCULINK 5X40MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011337-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S RX ACCULINK 7.0MM X 30MM X 132CM -,SUP-1011339-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC ACCULINK 7X40MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011339-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
6-8 mm X 30mm RX ACCULINK STENT -,SUP-1011343-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC ACCULINK 6-8X40MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011343-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
ACCULINK STENT 7-10 X 40MM -,SUP-1011344-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 4X12MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011487-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 4X18MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011487-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 4.5X15MM 135CM DLV CATH HERCULINK ELITE RX BE -,SUP-1011490-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 5X15MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011493-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 5X18MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011493-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR SELF-EXPANDING 6.0MM X 100MM X 80CM -,SUP-1012528-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR SELF-EXPANDING 6.0MM X 20MM X 80CM -,SUP-1012528-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR SELF-EXPANDING 6.0MM X 30MM X 80CM -,SUP-1012528-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR SELF-EXPANDING 6.0MM X 40MM X 80CM -,SUP-1012528-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR SEL-EXPANDING 6.0MM X 60MM X 80CM -,SUP-1012528-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAT SELF-EXPANDING 6.0MM X 80MM X 80CM -,SUP-1012528-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 100MM X 80CM -,SUP-1012529-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 20MM X 80CM -,SUP-1012529-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 30MM X 80CM -,SUP-1012529-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 40MM X 80CM -,SUP-1012529-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 60MM X 80CM -,SUP-1012529-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 80MM X 80CM -,SUP-1012529-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
ABSOLUTE PRO 8 X 100MM X 80CM -,SUP-1012530-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCUALR SELF-EXPANDING 8.0MM X 20MM X 80CM -,SUP-1012530-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR SELF-EXPANDING 8.0MM X 30MM X 80CM -,SUP-1012530-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
ABSOLUTE PRO VASCULAR SELF-EXPANDING STENT SYS 8 X 40 -,SUP-1012530-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
ABSOLUTE PRO 8 X 60MM X 80CM -,SUP-1012530-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
ABSOLUTE PRO 8 X 80MM X 80CM -,SUP-1012530-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR SELF-EXPANDING 9.0MM X 100MM X 80CM -,SUP-1012531-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR SELF-EXPANDING 9.0MM 20MM X 80CM -,SUP-1012531-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR SELF-EXPANDING 9.0MM X 30MM X 80CM -,SUP-1012531-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR SELF-EXPANDING 9.0MM X 40MM X 80CM -,SUP-1012531-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR SELF-EXPANDING 9.0MM X 60MM X 80CM -,SUP-1012531-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR SELF-EXPANDING 9.0MM X 80MM X 80CM -,SUP-1012531-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 100MM X 80CM -,SUP-1012532-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 20MM X 80CM -,SUP-1012532-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 30MM X 80CM -,SUP-1012532-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT ABSOLUTE PRO 10 X 40MM X 80CM -,SUP-1012532-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC ABSOLUTE PRO 10X60CM -,SUP-1012532-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
ABSOLUTE PRO SELF EXPANDING STENT 10MM X 80MM C 80CM -,SUP-1012532-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC ABSOLUTE PRO 6X100MM 135CM OTW SE PRMNT -,SUP-1012534-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC ABSOLUTE PRO 6X40MM 135CM OTW SE PRMNT -,SUP-1012534-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC ABSOLUTE PRO 7.0X100MM 135CM -,SUP-1012535-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 20MM X 135CM -,SUP-1012535-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 30MM X 135CM -,SUP-1012535-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC ABSOLUTE PRO 7X40MM 135CM OTW SE PRMNT -,SUP-1012535-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC ABSOLUTE PRO 7X60MM 135CM OTW SE PRMNT -,SUP-1012535-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 80MM X 135CM -,SUP-1012535-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR SELF-EXPANDING 8.0MM X 100MM X 135CM -,SUP-1012536-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR SELF-EXPANDING 8.0MM X 20MM X 135CM -,SUP-1012536-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR SELF-EXPANDING 8.0MM X 30MM X 135CM -,SUP-1012536-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR SELF-EXPANDING 8.0MM X 40MM X 135CM -,SUP-1012536-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC ABSOLUTE PRO 8.0 X 60MM X 135CM -,SUP-1012536-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR SELF-EXPANDING 9.0MM X 100MM X 135CM -,SUP-1012537-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR SELF-EXPANDED 9.0MM X 40MM X 135CM -,SUP-1012537-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR SELF-EXPANDING 9.0MM X 80MM X 135CM -,SUP-1012537-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 100MM X 135CM -,SUP-1012538-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 20MM X 135CM -,SUP-1012538-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 30MM X 135CM -,SUP-1012538-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 40MM X 135CM -,SUP-1012538-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 60MM X 135CM -,SUP-1012538-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 80MM X 135CM -,SUP-1012538-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR BALLOON-EXPANDABLE 6.0MM X 16MM X 80CM -,SUP-1012622-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC OMNILINK ELITE 6X19MM 80CM OTW BE PRMNT -,SUP-1012622-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC OMNILINK ELITE 6X29MM 80CM OTW BE PRMNT -,SUP-1012622-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC OMNILINK ELITE 6X39MM 80CM OTW BE PRMNT -,SUP-1012622-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC OMNILINK ELITE 6X59MM 80CM OTW BE PRMNT -,SUP-1012622-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 12MM X 80CM -,SUP-1012623-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 16MM X 80CM -,SUP-1012623-16,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC OMNILINK ELITE 7X19MM 80CM OTW BE PRMNT -,SUP-1012623-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC OMNILINK ELITE 7X29MM 80CM OTW BE PRMNT -,SUP-1012623-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC OMNILINK ELITE 7X39MM 80CM OTW BE PRMNT -,SUP-1012623-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC OMNILINK ELITE 7X59MM 80CM OTW BE PRMNT -,SUP-1012623-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC OMNILINK ELITE 8X19MM 80CM OTW BE PRMNT -,SUP-1012624-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC OMNILINK ELITE 8X29MM 80CM OTW BE PRMNT -,SUP-1012624-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC OMNILINK ELITE 8X39MM 80CM OTW BE PRMNT -,SUP-1012624-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC OMNILINK ELITE 8X59MM 80CM OTW BE PRMNT -,SUP-1012624-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC OMNILINK ELITE 9X19MM 80CM OTW BE PRMNT -,SUP-1012625-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC OMNILINK ELITE 9X29MM 80CM OTW BE PRMNT -,SUP-1012625-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC OMNILINK ELITE 9X39MM 80CM OTW BE PRMNT -,SUP-1012625-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC OMNILINK ELITE 9X59MM 80CM OTW BE PRMNT -,SUP-1012625-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC OMNILINK ELITE 10X19MM 80CM OTW BE PRMNT -,SUP-1012626-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC OMNILINK ELITE 10X29MM 80CM OTW BE PRMNT -,SUP-1012626-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC OMNILINK ELITE 10X39MM 80CM OTW BE PRMNT -,SUP-1012626-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC OMNILINK ELITE 10X59MM 80CM OTW BE PRMNT -,SUP-1012626-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR BALLOON-EXPANDABLE 6.0MM X 16MM X 135 -,SUP-1012629-16,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC OMNILINK ELITE 6X19MM 135CM OTW BE PRMNT -,SUP-1012629-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC OMNILINK ELITE 6X29MM 135CM OTW BE PRMNT -,SUP-1012629-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC OMNILINK ELITE 6X39MM 135CM OTW BE PRMNT -,SUP-1012629-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC OMNILINK ELITE 6X59MM 135CM OTW BE PRMNT -,SUP-1012629-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 12MM X 135CM -,SUP-1012630-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 16MM X 135CM -,SUP-1012630-16,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC OMNILINK ELITE 7X19MM 135CM OTW BE PRMNT -,SUP-1012630-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC OMNILINK ELITE 7X29MM 135CM OTW BE PRMNT -,SUP-1012630-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC OMNILINK ELITE 7X39MM 135CM OTW BE PRMNT -,SUP-1012630-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC OMNILINK ELITE 7X59MM 135CM OTW BE PRMNT -,SUP-1012630-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC OMNILINK ELITE 8X19MM 135CM OTW BE PRMNT -,SUP-1012631-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC OMNILINK ELITE 8X29MM 135CM OTW BE PRMNT -,SUP-1012631-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC OMNILINK ELITE 8X39MM 135CM OTW BE PRMNT -,SUP-1012631-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC OMNILINK ELITE 8X59MM 135CM OTW BE PRMNT -,SUP-1012631-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC OMNILINK ELITE 9X19MM 135CM OTW BE PRMNT -,SUP-1012632-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC OMNILINK ELITE 9X29MM 135CM OTW BE PRMNT -,SUP-1012632-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC OMNILINK ELITE 9X39MM 135CM OTW BE PRMNT -,SUP-1012632-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC OMNILINK ELITE 9X59MM 135CM OTW BE PRMNT -,SUP-1012632-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC OMNILINK ELITE 10X19MM 135CM OTW BE PRMNT -,SUP-1012633-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC OMNILINK ELITE 10X29MM 135CM OTW BE PRMNT -,SUP-1012633-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC OMNILINK ELITE 10X39MM 135CM OTW BE PRMNT -,SUP-1012633-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC OMNILINK ELITE 10X59MM 135CM OTW BE PRMNT -,SUP-1012633-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 4X12MM JOST GRAFTMS OTW BE 143CM SEM-COM HYDREX CTD -,SUP-12746-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
BIOMIMICS 3-D STENT 5MM X 60MM -,SUP-142122-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
BIOMIMICS 3-D STENT 6MM X 60MM -,SUP-142122-02,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
BIOMIMICS 3-D STENT 7MM X 60MM -,SUP-142122-03,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
BIOMIMICS 3-D STENT 5MM X 80MM -,SUP-142122-05,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
BIOMIMICS 3-D STENT 6MM X 80MM -,SUP-142122-06,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
BIOMIMICS 3-D STENT 7MM X 80MM -,SUP-142122-07,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
BIOMIMICS 3-D STENT 5MM X 100MM -,SUP-142122-09,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
BIOMIMICS 3-D STENT 6MM X 100MM -,SUP-142122-10,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
BIOMIMICS 3-D STENT 7MM X 100MM -,SUP-142122-11,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
BIOMIMICS 3-D STENT 5MM X 125MM -,SUP-142122-13,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
BIOMIMICS 3-D STENT 6MM X 125MM -,SUP-142122-14,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
BIOMIMICS 3-D STENT 7MM X 125MM -,SUP-142122-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
BIOMIMICS 3-D STENT 5MM X 150MM -,SUP-144700-05,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
BIOMIMICS 3-D STENT 6MM X 150MM -,SUP-144700-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
BIOMIMICS 3-D STENT 7MM X 150MM -,SUP-144700-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S BILIARY LD PMTD 8 X 37 X75 6 -,SUP-38046-84075,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 8X37MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38046-84075,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 9 X 25MM 75CM EXP LD -,SUP-38046-92075,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 10X25MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-12013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 10X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-16013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 6X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-63013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 7X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-76013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S BILIARY EXPRESS 8X37X135CM L -,SUP-38047-84013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 8X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-38047-84013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
PULSAR 18 - 6 X 40 X 135 -,SUP-390724,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
PULSAR 18 - 6 X 120 X 135 -,SUP-390728,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
PULSAR 18 - 6 X 150 X 135 -,SUP-390729,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
PULSAR 18  7X40X135  .018 -,SUP-390734,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC EPIC 6X120MM 120CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-39200-06122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC OTW 6 X 120 X 120 -,SUP-39200-06122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-XPD 7X118X120 -,SUP-39200-07122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC EPIC 7X120MM 163CM/120CM WKG CATH SE MTLC ILC -,SUP-39200-07122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-XPD 7X79X120 -,SUP-39200-07802,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC EPIC 7X80MM 120CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-39200-07802,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-XPD 9X40X120 -,SUP-39200-09402,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
EPIC STENT 10MM X 40MM X 120CM -,SUP-39200-10402,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
EPIC STENT 10MM X 60MM X 120CM -,SUP-39200-10602,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
EPIC STENT 12MM X 60MM X 120CM -,SUP-39200-12602,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT ENPROS 24MM 11FR CATH 70MM WALLSTNT RP 100CM TOT 75CM -,SUP-40512,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT PULSAR - 18 T3 4/20/135 -,SUP-430477,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT PULSAR - 18 T3 4/40/135 -,SUP-430479,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT PULSAR - 18 T3 4/80/135 -,SUP-430481,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT PULSAR - 18 T3  5/80/135 -,SUP-430491,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT PULSAR - 18 T3 5/120/135 -,SUP-430493,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT PULSAR - 18 T3 5/200/135 -,SUP-430496,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT PULSAR - 18 T3 6/40/135 -,SUP-430499,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT PULSAR - 18 T3 6/80/135 -,SUP-430501,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT PULSAR - 18 T3 6/120/135 -,SUP-430503,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT PULSAR - 18 T3 6/150/135 -,SUP-430504,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT PULSAR - 18 T3 6/200/135 -,SUP-430506,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT PULSAR - 18 T3 7/120/135 -,SUP-430513,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT PULSAR - 18 T3 7/150/135 -,SUP-430514,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
WRENCH SPLTY HX F /CPI -,SUP-6563,CDM,C1876,HCPCS,278,RC,,,outpatient,,,175.05,122.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT URET 6FR 22-32CM INLAY OPTM PLYMR BLND DBL PIGTL TAPR -,SUP-788600,CDM,C1876,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC XACT 7-9X40MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82086-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC XACT 7-9X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82087-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC XACT 9X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82088-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC XACT 9X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82089-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC XACT 6-8X40MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82090-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC XACT 6-8X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82091-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC XACT 8X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82092-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC XACT 8X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82093-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC XACT 7X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82094-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC XACT 7X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82095-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC XACT 10.8MM X 40MM X 136CM -,SUP-82096-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC XACT 10X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82098-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC XACT 10X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82099-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
ABRE STENTS 16MM X 80MM -,SUP-AB9U16080090,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6896.5,4827.55,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
ABRE STENTS 18MM X 100MM -,SUP-AB9U18100090,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6896.5,4827.55,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
ABRE STENTS 18MM X 120MM -,SUP-AB9U18120090,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6896.5,4827.55,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
COVERA AV STENT GRAFT 7MM X 60MM X 80MM -,SUP-AVSM07060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC SMART CONT 6X30MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06030ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC SMART CONT 6X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC SMART CONT 6X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC SMART CONT 6X80MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06080ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC SMART CONT 6X100MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06100ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC SMART CONT 6X120MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06120ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC SMART CONT 6X150MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06150ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC SMART CONT 7X30MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07030ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC SMART CONT 7X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC SMART CONT 7X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC SMART CONT 7X80MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07080ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC SMART CONT 7X100MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07100ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC SMART CONT 7X120MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07120ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC SMART CONT 7X150MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07150ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC SMART CONT 8X30MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08030ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC SMART CONT 8X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC SMART CONT 8X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC SMART CONT 8X80MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08080ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC SMART CONT 8X100MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08100ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC SMART CONT 8X120MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08120ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC SMART CONT 8X150MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08150ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC SMART CONT 10X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C10040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC SMART CONT 10X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C10060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 12X40MM 120CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-C12040MB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 12X60MM 120CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-C12060MB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 12X60MM 80CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-C12060SB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 6X100MM 130CM LIFESTENT SE HLCL NTNL 0.035IN GW -,SUP-EX061003CD,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9230.7,6461.49,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC LIFESTENT 6X150MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX061503CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC LIFESTENT 6X170MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX061703CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC LIFESTENT 6X200MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX062003CL,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC LIFESTENT 7X60MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX070603CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
GRAFT EV 8MM 9FR CATH 40MM 120CM TOT 80CM DLV SYS FLAIR STR -,SUP-FAS08040,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11020.18,7714.126,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
COIL MICRONESTER EMBOLIZATION 0.018 X 5CM X 3MM -,SUP-G23520,CDM,C1876,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 5MM 7FR GUID CATH 30MM 125CM ZILVER 518 OTW SE -,SUP-G31351,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S ZILVER 518 5X40 125CM S-E ZI -,SUP-G31352,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 4X40MM 125CM ZILVER 518 OTW SE PRELD FLXB SLT TUBE -,SUP-G31439,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 8MM 6FRX40MM 80CM SE PRELD MTL NTNL 5FR SHTH MUL -,SUP-G32020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S ZILVER .035 125CM 5 X 60 -,SUP-G32033,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 8X80MM MTL SE 6FRX125CM PRELD DLV SYS NTNL 6FR -,SUP-G36025,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S ZILVER 518 5X80 125CM S-E -,SUP-G36048,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 14X30MM 80CM ZILVER 635 OTW SE PRELD FLXB SLT TUBE -,SUP-G36233,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 12MM 8FR GUID CATH 40MM 125CM ZILVER 635 OTW SE -,SUP-G36239,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
12MM X 8CM ZILVER 635 STENT -,SUP-G36241,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 14MM 8FR GUID CATH 40MM 125CM ZILVER 635 OTW SE -,SUP-G36244,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 14X60MM 125CM ZILVER 635 OTW SE PRELD 0.035IN GW -,SUP-G36245,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 5X20MM 135CM FRMLA 418 BLN-XPD GUID CATH 5/6 FR -,SUP-G42956,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4034.03,2823.821,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 6X24MM 135CM FRMLA 418 OTW BE U STRUT TAPR 0.018IN -,SUP-G42962,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S ZILVER 518 VASC 6X40 125CM S -,SUP-G43771,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S ZILVER518 VASC 6X60 125CM -,SUP-G43772,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S ZILVER 518 VASC 6X80 125CM S -,SUP-G43773,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
7x40x125 ZILVER STENT 0.018 -,SUP-G43776,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC ZILVER 518 7X80MM 125CM OTW SE 0.018IN/5FR -,SUP-G43778,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC ZILVER 518 8X60MM 125CM OTW SE 0.018IN/5FR -,SUP-G43782,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S ZILVER .035 125CM 6 X 60 012 -,SUP-G43822,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S ZILVER .035 125CM 6 X 80 012 -,SUP-G43823,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC ZILVER 635 7X30MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43825,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC ZILVER 635 7X40MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43826,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC ZILVER 635 7X60MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43827,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC ZILVER 635 7X80MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43828,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC ZILVER 635 8X30MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC ZILVER 635 8X40MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43831,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC ZILVER 635 8X60MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43832,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC ZILVER 635 8X80MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43833,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC ZILVER 635 10X40MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43841,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC ZILVER 635 10X60MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43842,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC ZILVER 635 10X80MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43843,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
COIL NESTOR 3 X 5 -,SUP-G47334,CDM,C1876,HCPCS,278,RC,,,outpatient,,,577.61,404.327,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
COIL MICRONESTOR EMBOLIZATION .018 X 7CM X 4MM PLAT -,SUP-G47339,CDM,C1876,HCPCS,278,RC,,,outpatient,,,638.87,447.209,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
ZENITH DISSECTION ENDOVASCULAR STENT -,SUP-G47492,CDM,C1876,HCPCS,278,RC,,,outpatient,,,41924.2,29346.94,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
ZENITH DISSECTION ENDOVASCULAR STENT -,SUP-G47493,CDM,C1876,HCPCS,278,RC,,,outpatient,,,41924.2,29346.94,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT ENDOVASCULAR DISSECTION ZENITH -,SUP-G47496,CDM,C1876,HCPCS,278,RC,,,outpatient,,,37318.31,26122.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT DUODENAL EVOLUTION CONTROL RELEASE 22-27-9 -,SUP-G48026,CDM,C1876,HCPCS,278,RC,,,outpatient,,,8886.94,6220.858,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S ZILVER .035 125CM 5 X 100 -,SUP-G50162,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 7MM 8FR GUID CATH LNG 100MM 125CM ZILVER FLEX 35 -,SUP-G50168,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 7MM 8FR GUID CATH LNG 120MM 125CM ZILVER FLEX 35 -,SUP-G50169,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 7X140MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-G50170,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 8X100MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-G50171,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 8MM 8FR GUID CATH LNG 140MM 125CM ZILVER FLEX 35 -,SUP-G50173,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 10X100MM 80CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-G50177,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
Z STENT BILIARY 8 X 8 -,SUP-G50623,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC FRMLA 418 5X16MM 80CM OTW BE PRMNT -,SUP-G56609,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC FRMLA 418 5X20MM 80CM OTW BE PRMNT -,SUP-G56610,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC FRMLA 418 6X12MM 80CM OTW BE PRMNT -,SUP-G56611,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC FRMLA 418 6X16MM 80CM OTW BE PRMNT -,SUP-G56613,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC FRMLA 418 6X20MM 80CM OTW BE PRMNT -,SUP-G56614,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC FRMLA 418 7X16MM 80CM -,SUP-G56617,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC FRMLA 418 5X12MM 80CM OTW BE PRMNT -,SUP-G56631,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC FRMLA 414 5X20MM 80CM RX BE PRMNT 0.014IN/5FR/6FR -,SUP-G56950,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC FRMLA 414 5X16MM 135CM RX BE PRMNT -,SUP-G56958,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
0.14 ZILVER 5MM X 120MM X 135CM -,SUP-G56966,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC FRMLA 414 5X20MM 135CM RX BE PRMNT -,SUP-G56969,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC FRMLA 414 6X12MM 135CM RX BE PRMNT -,SUP-G56970,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC FRMLA 414 6X16MM 135CM RX BE PRMNT -,SUP-G56971,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC FRMLA 414 6X20MM 135CM RX BE PRMNT -,SUP-G56972,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
0.14 ZILVER 7MM X 160MM X 135CM -,SUP-G56974,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC FRMLA 414 7X20MM 135CM RX BE PRMNT -,SUP-G56975,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
US PRE PP-CA-397 P&B BARE METAL STENT ZVT7-35-120-16-60 -,SUP-G57453,CDM,C1876,HCPCS,278,RC,,,outpatient,,,8016.87,5611.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
SYS STENT VASCULAR ZILVER VENA 16MM 100MM 120CM VEIN OTW -,SUP-G57454,CDM,C1876,HCPCS,278,RC,,,outpatient,,,8016.87,5611.809,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
VENOUS WALLSTENT 10X94X75CM -,SUP-H74912044109470,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
VENOUS WALLSTENT 12X60X75CM -,SUP-H74912044126070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
VENOUS WALLSTENT 12X90X75CM -,SUP-H74912044129070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
VENOUS WALLSTENT 14X60X75CM -,SUP-H74912044146070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
VENOUS WALLSTENT 14X90X75CM -,SUP-H74912044149070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
VENOUS WALLSTENT 16X40X75CM -,SUP-H74912044164070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
VENOUS WALLSTENT 16X60X75CM -,SUP-H74912044166070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
VENOUS WALLSTENT 16X90X75CM -,SUP-H74912044169070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
VENOUS WALLSTENT 18X40X75CM -,SUP-H74912044184070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
VENOUS WALLSTENT 18X60X75CM -,SUP-H74912044186070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
VENOUS WALLSTENT 18X90X75CM -,SUP-H74912044189070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
VENOUS WALLSTENT 20X40X75CM -,SUP-H74912044204070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
VENOUS WALLSTENT 20X55X75CM -,SUP-H74912044205570,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
VENOUS WALLSTENT 20X80X75CM -,SUP-H74912044208070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
VICI VENOUS STENT 12MM X60MM X 100CM -,SUP-H74912060100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
VICI VENOUS STENT 14MM X 60MM X 100CM -,SUP-H74914060100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
VICI VENOUS STENT 14MM X 90MM X 100CM -,SUP-H74914090100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
VICI VENOUS STENT 16MM X 60MM X 100CM -,SUP-H74916060100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
VICI VENOUS STENT 16MM X90MM X 100CM -,SUP-H74916090100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 6X14MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937911614150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
FG EXP SD RENAL-BILIARY 7.0mmX15mmX150cm -,SUP-H74937911715150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 4X19MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912419150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 5X19MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912519150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 6X18MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912618150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 7X19MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912719150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 10X37MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046104070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 10X57MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046106070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 6X27MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046630750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S BIL EXPRESS PMTD  6X27X75 -,SUP-H74938046630750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S BILIARY LD PMTD 6X37X75 6FR -,SUP-H74938046640750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 6X37MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046640750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S BILI LD PMTD 6 X 57 X 75 EXP -,SUP-H74938046660750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 6X57MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046660750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 7X27MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046730750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S BILIARY LD PMTD 7X37X75 40CM -,SUP-H74938046740750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S  BILI LD PMTD 7 X 57 X 75 EX -,SUP-H74938046760750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EXPRESS B-I LD 8 X 27 X 75 P -,SUP-H74938046830750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 8X27MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046830750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
BEACON 8MM X 37MM X 75CM  ILIAC STENT -,SUP-H74938046840750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
8 X 57 X 75CM EXPRESS STENT -,SUP-H74938046860750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S BILI LD PMTD 8 X 57 X 75 EXP -,SUP-H74938046860750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 9X57MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046960750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 10X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047140130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 5X17MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047520130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 5X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047530130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 5X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047540130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 5X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047560130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 6X17MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047620130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 6X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047640130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 6X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047660130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 7X17MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047720130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 7X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047730130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 7X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047740130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
7 X 57MM EXPRESS ILIAC / BILIARY STENT 135CM -,SUP-H74938047760130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 8X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047830130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 8X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047860130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 9X25MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047920130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 9X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047940130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 9X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047960130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3X16MM VERIFLEX OTW BE PRMNT LO XING THN STRUT HYDRCT -,SUP-H7493893516300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3294.06,2305.842,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-XPD 6X100X120 -,SUP-H74939200061020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-XPD 6X19X120 -,SUP-H74939200062020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-XPD 6X29X120 -,SUP-H74939200063020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-XPD 6X40X120 -,SUP-H74939200064020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-XPD 6X51X120 -,SUP-H74939200065020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-XPD 6X61X120 -,SUP-H74939200066020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-XPD 6X71X120 -,SUP-H74939200067020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-XPD 6X80X120 -,SUP-H74939200068020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-XPD 7X99X120 -,SUP-H74939200071020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-XPD 7X19X120 -,SUP-H74939200072020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-XPD 7X29X120 -,SUP-H74939200073020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-XPD 7X41X120 -,SUP-H74939200074020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-XPD 7X50X120 -,SUP-H74939200075020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-XPD 7X60X120 -,SUP-H74939200076020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-XPD 7X70X120 -,SUP-H74939200077020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-XPD 8X100X120 -,SUP-H74939200081020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-XPD 8X120X120 -,SUP-H74939200081220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-XPD 8X20X120 -,SUP-H74939200082020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-XPD 8X31X120 -,SUP-H74939200083020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-XPD 8X41X120 -,SUP-H74939200084020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-XPD 8X51X120 -,SUP-H74939200085020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-XPD 8X61X120 -,SUP-H74939200086020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-XPD 8X72X120 -,SUP-H74939200087020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-XPD 8X82X120 -,SUP-H74939200088020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-XPD 9X99X120 -,SUP-H74939200091020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-XPD 9X21X120 -,SUP-H74939200092020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-XPD 9X30X120 -,SUP-H74939200093020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-XPD 9X51X120 -,SUP-H74939200095020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-XPD 9X61X120 -,SUP-H74939200096020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-XPD 9X81X120 -,SUP-H74939200098020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-XPD 10X98X120 -,SUP-H74939200101020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-EXP 10X20X120 -,SUP-H74939200102020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-EXP 10X30X120 -,SUP-H74939200103020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-XPD 10X40X120 -,SUP-H74939200104020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-XPD 10X50X120 -,SUP-H74939200105020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC EPIC 10X60MM 120CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939200106020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-XPD 10X71X120 -,SUP-H74939200107020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-XPD 10X80X120 -,SUP-H74939200108020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-EXP 12X32X120 -,SUP-H74939200123020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-XPD 12X42X120 -,SUP-H74939200124020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-XPD 12X52X120 -,SUP-H74939200125020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S EPIC ILIAC S-XPD 12X61X120 -,SUP-H74939200126020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.2X8MM REBEL MR RX BE -,SUP-H7493927408220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.5X8MM REBEL MR RX BE -,SUP-H7493927408250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.75X8MM REBEL MR RX BE -,SUP-H7493927408270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3X8MM REBEL MR RX BE -,SUP-H7493927408300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3.5X8MM REBEL MR RX BE -,SUP-H7493927408350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 4X8MM REBEL MR RX BE -,SUP-H7493927408400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.25X12MM REBEL MR RX BE -,SUP-H7493927412220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.5X12MM REBEL MR RX BE -,SUP-H7493927412250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.75X12MM REBEL MR RX BE -,SUP-H7493927412270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3X12MM REBEL MR RX BE -,SUP-H7493927412300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3.5X12MM REBEL MR RX BE -,SUP-H7493927412350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 4X12MM REBEL MR RX BE -,SUP-H7493927412400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 4.5X12MM REBEL MR RX BE -,SUP-H7493927412450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.25X16MM REBEL MR RX BE -,SUP-H7493927416220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.5X16MM REBEL MR RX BE -,SUP-H7493927416250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.75X16MM REBEL MR RX BE -,SUP-H7493927416270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3X16MM REBEL MR RX BE -,SUP-H7493927416300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3.5X16MM REBEL MR RX BE -,SUP-H7493927416350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 4X16MM REBEL MR RX BE -,SUP-H7493927416400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 4.5X16MM REBEL MR RX BE -,SUP-H7493927416450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.25X20MM REBEL MR RX BE -,SUP-H7493927420220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.5X20MM REBEL MR RX BE -,SUP-H7493927420250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.75X20MM REBEL MR RX BE -,SUP-H7493927420270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3X20MM REBEL MR RX BE -,SUP-H7493927420300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3.5X20MM REBEL MR RX BE -,SUP-H7493927420350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 4X20MM REBEL MR RX BE -,SUP-H7493927420400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 4.5X20MM REBEL MR RX BE -,SUP-H7493927420450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.25X24MM REBEL MR RX BE -,SUP-H7493927424220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.5X24MM REBEL MR RX BE -,SUP-H7493927424250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.75X24MM REBEL MR RX BE -,SUP-H7493927424270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3X24MM REBEL MR RX BE -,SUP-H7493927424300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3.5X24MM REBEL MR RX BE -,SUP-H7493927424350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 4X24MM REBEL MR RX BE -,SUP-H7493927424400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 4.5X24MM REBEL MR RX BE -,SUP-H7493927424450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.25X28MM REBEL MR RX BE -,SUP-H7493927428220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.5X28MM REBEL MR RX BE -,SUP-H7493927428250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.75X28MM REBEL MR RX BE -,SUP-H7493927428270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3X28MM REBEL MR RX BE -,SUP-H7493927428300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3.5X28MM REBEL MR RX BE -,SUP-H7493927428350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 4X28MM REBEL MR RX BE -,SUP-H7493927428400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 4.5X28MM REBEL MR RX BE -,SUP-H7493927428450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.75X32MM REBEL MR RX BE -,SUP-H7493927432270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3X32MM REBEL MR RX BE -,SUP-H7493927432300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3.5X32MM REBEL MR RX BE -,SUP-H7493927432350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 4X32MM REBEL MR RX BE -,SUP-H7493927432400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 4.5X32MM REBEL MR RX BE -,SUP-H7493927432450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.25X8MM REBEL OTW BE -,SUP-H7493927508220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.5X8MM REBEL OTW BE -,SUP-H7493927508250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.75X8MM REBEL OTW BE -,SUP-H7493927508270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3X8MM REBEL OTW BE -,SUP-H7493927508300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3.5X8MM REBEL OTW BE -,SUP-H7493927508350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 4X8MM REBEL OTW BE -,SUP-H7493927508400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.25X12MM REBEL OTW BE -,SUP-H7493927512220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.5X12MM REBEL OTW BE -,SUP-H7493927512250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.75X12MM REBEL OTW BE -,SUP-H7493927512270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3X12MM REBEL OTW BE -,SUP-H7493927512300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3.5X12MM REBEL OTW BE -,SUP-H7493927512350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 4X12MM REBEL OTW BE -,SUP-H7493927512400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 4.5X12MM REBEL OTW BE -,SUP-H7493927512450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.25X16MM REBEL OTW BE -,SUP-H7493927516220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.5X16MM REBEL OTW BE -,SUP-H7493927516250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.75X16MM REBEL OTW BE -,SUP-H7493927516270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3X16MM REBEL OTW BE -,SUP-H7493927516300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3.5X16MM REBEL OTW BE -,SUP-H7493927516350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 4X16MM REBEL OTW BE -,SUP-H7493927516400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 4.5X16MM REBEL OTW BE -,SUP-H7493927516450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.25X20MM REBEL OTW BE -,SUP-H7493927520220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.5X20MM REBEL OTW BE -,SUP-H7493927520250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.75X20MM REBEL OTW BE -,SUP-H7493927520270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3X20MM REBEL OTW BE -,SUP-H7493927520300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3.5X20MM REBEL OTW BE -,SUP-H7493927520350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 4X20MM REBEL OTW BE -,SUP-H7493927520400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 4.5X20MM REBEL OTW BE -,SUP-H7493927520450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.25X24MM REBEL OTW BE -,SUP-H7493927524220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.5X24MM REBEL OTW BE -,SUP-H7493927524250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.75X24MM REBEL OTW BE -,SUP-H7493927524270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3X24MM REBEL OTW BE -,SUP-H7493927524300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3.5X24MM REBEL OTW BE -,SUP-H7493927524350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 4X24MM REBEL OTW BE -,SUP-H7493927524400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 4.5X24MM REBEL OTW BE -,SUP-H7493927524450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.25X28MM REBEL OTW BE -,SUP-H7493927528220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.5X28MM REBEL OTW BE -,SUP-H7493927528250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.75X28MM REBEL OTW BE -,SUP-H7493927528270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3X28MM REBEL OTW BE -,SUP-H7493927528300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3.5X28MM REBEL OTW BE -,SUP-H7493927528350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 4X28MM REBEL OTW BE -,SUP-H7493927528400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 4.5X28MM REBEL OTW BE -,SUP-H7493927528450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 2.75X32MM REBEL OTW BE -,SUP-H7493927532270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3X32MM REBEL OTW BE -,SUP-H7493927532300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3.5X32MM REBEL OTW BE -,SUP-H7493927532350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 4X32MM REBEL OTW BE -,SUP-H7493927532400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 4.5X32MM REBEL OTW BE -,SUP-H7493927532450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC INNOVA 5X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293050230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC INNOVA 5X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC INNOVA 5X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC INNOVA 5X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC INNOVA 5X180MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC INNOVA 5X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293052030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9018.5,6312.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC INNOVA 5X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293054030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC INNOVA 5X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293056030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC INNOVA 5X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293058030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC INNOVA 6X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293060230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC INNOVA 6X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC INNOVA 6X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC INNOVA 6X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC INNOVA 6X180MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC INNOVA 6X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293062030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC INNOVA 6X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293064030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC INNOVA 6X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293066030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC INNOVA 6X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293068030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC INNOVA 7X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293070230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC INNOVA 7X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293071030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC INNOVA 7X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293071230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC INNOVA 7X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293071530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC INNOVA 7X180X130 SE ILC -,SUP-H74939293071830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC INNOVA 7X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293072030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC INNOVA 7X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293074030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC INNOVA 7X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293076030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC INNOVA 7X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293078030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC INNOVA 8X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293080230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC INNOVA 8X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293081030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC INNOVA 8X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293081230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC INNOVA 8X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293081530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC INNOVA 8X180X130 SE ILC -,SUP-H74939293081830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC INNOVA 8X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293082030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC INNOVA 8X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293084030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC INNOVA 8X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293086030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC INNOVA 8X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293088030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT ENPROS 22MM 10FR CATH 45MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965404510,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT ENPROS 22MM 10FR CATH 70MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965404520,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT ENPROS 24MM 11FR CATH 35MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965405100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT ENPROS 24MM 11FR CATH 45MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965405110,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
WALLSTENT 24X70 X 75CM/11F UNI PLUS 1 -,SUP-H965405120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 2.25X8MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22508UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 2.25X8MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 2.25X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22512UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 2.25X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 2.25X14MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22514UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 2.25X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22518UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 2.25X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 2.25X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22522UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 2.25X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 2.25X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22526UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 2.25X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 2.5X8MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25008UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 2.5X8MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25008W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 2.5X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 2.5X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 2.5X14MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25014UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS #1 27IN INTGRTY MO-4 DTCH 140CM MONO GUT TAPR PNT -,SUP-INT25014W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 2.5X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 2.5X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 2.5X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 2.5X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 2.5X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 2.5X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 2.75X8MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27508UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 2.75X8MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 2.75X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27512UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 2.75X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 2.75X14MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27514UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 2.75X14MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27514W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 2.75X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27518UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 2.75X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 2.75X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27522UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 2.75X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 2.75X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27526UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 2.75X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 3X9MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30009UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 3X9MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 3X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 3X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 3X15MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30015UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 3X15MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 3X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 3X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 3X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 3X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 3X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 3X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 3X30MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30030UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 3X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 3.5X9MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35009UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 3.5X9MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 3.5X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 3.5X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 3.5X15MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35015UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 3.5X15MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 3.5X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 3.5X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 3.5X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 3.5X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 3.5X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 3.5X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 3.5X30MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35030UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 3.5X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 4X9MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40009UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 4X9MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 4X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 4X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 4X15MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40015UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 4X15MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 4X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 4X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 4X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 4X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 4X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 4X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 4X30MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40030UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 4X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT LIFESTREAM 7MM X 26MM X 80MM -,SUP-LSMU0800726,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT ENPROS 8MM 6FR CATH 80MM WALLSTNT RP 100CM TOT 75CM -,SUP-M001711300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7320.9,5124.63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT ESPH 18MM BD 23MMX7CM ULFLX NON- CVR FLR END MTL LF -,SUP-M00514070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT DUOD 22MMX6CM WALLFLX 230CM DLV SYS TTS/ OTW NTNL FLR -,SUP-M00565010,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT WALLFLEX DUODENAL 22 X 60 -,SUP-M00565010,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT DUOD 22MMX9CM WALLFLX 230CM NON- CVR NTNL LF -,SUP-M00565020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT WALLFLEX DUODENAL 22 X 90 -,SUP-M00565020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT WALLFLEX DUODENAL 22 X 120 -,SUP-M00565030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT WALLFLEX COLONIC 25 X 60 -,SUP-M00565040,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT WALLFLEX COLONIC 25 X 90 -,SUP-M00565050,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT WALLFLEX COLONIC 25 X 120 -,SUP-M00565060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT WALLFLEX COLONIC 22 X 60 -,SUP-M00565100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT WALLFLEX COLONIC 22 X 90 -,SUP-M00565110,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT WALLFLEX COLONIC 22 X 120 -,SUP-M00565120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT ENPROS 10FR 20X60MM WALLSTNT 135CM HRP -,SUP-M00565620,CDM,C1876,HCPCS,278,RC,,,outpatient,,,116.7,81.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT COLN 22MM BD 10FR CATH 6CM WALLSTNT 135CM CATH 160CM -,SUP-M00565640,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7434.26,5203.982,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 10X80MM WALLSTNT RX SE UNCVR MTL 0.035IN GW COMP -,SUP-M00569660,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6340.15,4438.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 8X80MM WALLFLX RX SE UNCVR PLATINOL 0.035IN GW -,SUP-M00570620,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 8X100MM WALLFLX RX SE NON- CVR PLATINOL 0.035IN GW -,SUP-M00570630,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 10X60MM WALLFLX RX SE NON- CVR PLATINOL 0.035IN GW -,SUP-M00570640,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
CATH GUID 6FRX68CM ACUITY BREAK-AWAY COR CS-IC 130 -,SUP-M00570650,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
WALLFLEX BILIARY RX UNCOVERED 10 X 80 -,SUP-M00570650,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
WALLFLEX RX UNCOVERED BILIARY STENT 10MM X 100MM -,SUP-M00570660,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
WALLFLEX BILIARY RX UNCOVERED 10 X 40 -,SUP-M00570890,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 14X60MM 120CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-N1460BB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT PULSAR - 18 T3 5/40/135 -,SUP-NO MANUFACTURE IN DICTIONARY,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 10X30MM PALMZ XL BE UNMT TRNSHEP CLSD CELLFLEX SEG -,SUP-P3110,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 5X15MM 135CM PALMZ BLU RX BE TRNSHEP COCR 0.014IN -,SUP-PB1550BAX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4882.72,3417.904,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 5X15MM 135CM PALMZ BLU OTW BE TRNSHEP COCR 0.018IN -,SUP-PB1550BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 6X18MM 80CM PALMZ BLU OTW BE TRNSHEP COCR 0.014IN -,SUP-PB1860BSS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 6X18MM 135CM PALMZ BLU OTW BE TRNSHEP COCR 0.018IN -,SUP-PB1860BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 6X24MM 135CM PALMZ BLU OTW BE TRNSHEP COCR 0.018IN -,SUP-PB2460BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 6X18MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG1860BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 6X18MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG1860BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 9X19MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG1990BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 6X24MM 135CM PALMZ GENESIS RX BE TRNSHEP SS -,SUP-PG2460BAX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4948.93,3464.251,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 6X24MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2460BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 8X24MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG2480BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 10X29MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2910BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 5X29MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG2950BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 5X30MM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW COMP -,SUP-PG2950BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 6X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2960BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 7X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2970BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 7X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN. -,SUP-PG2970BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 8X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN. -,SUP-PG2980BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 8X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN- -,SUP-PG2980BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 10X39MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3910BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 6X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3960BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 7X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3970BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 8X29MM 135CM PALMZ_GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3980BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 8X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3980BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 7X59MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG5970BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 7X59MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG5970BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 8X59MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG5980BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 6X79MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG7960BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 6X20MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506020120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 6X40MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 6X60MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 6X80MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506080120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 6X100MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506100120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 6X120MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506120120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 6X150MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506150120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 6X200MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506200120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,12141.51,8499.057,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 7X20MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507020120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 7X40MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 7X60MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 7X80MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507080120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 7X120MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507120120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 7X150MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507150120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 8X40MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3508040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 8X60MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3508060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 8X80MM 120CM EVERFLX SE SUPRFC FEM/PROX POPLT ART -,SUP-PRB3508080120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC EVERFLX 10X120MM 120CM SE 3-WV PEAK DSGN PRECISN -,SUP-PRB3508100120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 12X120MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT -,SUP-PRB3508120120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 8X150MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3508150120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 7X37MM 135CM VISI-PRO BE MNT SS 0.035IN/6FR -,SUP-PXB350737135,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 8X27MM 135CM VISI-PRO BE MNT SS 0.035IN/6FR -,SUP-PXB350827135,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 8X37MM 135CM VISI-PRO BE MNT SS 0.035IN/6FR -,SUP-PXB350837135,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT DES 2.25X8MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT DES 2.25X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT DES 2.25X14MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22514W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT DES 2.25X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT DES 2.25X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT DES 2.25X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BMS 2.25X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22530W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT DES 2.5X8MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25008W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT DES 2.5X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT DES 2.5X14MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25014W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT DES 2.5X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT DES 2.5X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT DES 2.5X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT DES 2.5X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT DES 2.75X8MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT DES 2.75X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT DES 2.75X14MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27514W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT DES 2.75X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT DES 2.75X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT DES 2.75X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT DES 2.75X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27530W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT DES 3X9MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT30009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT DES 3X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT DES 3X15MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT DES 3X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT DES 3X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT DES 3.5X9MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT DES 3.5X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT DES 3.5X15MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT DES 3.5X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT DES 3.5X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT DES 3.5X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT DES 3.5X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT DES 4X9MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT40009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT DES 4X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT DES 4X15MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT DES 4X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT DES 4X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT DES 4X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT DES 4X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 4MM 6FR CATH 60MM 120CM SUPERA TRNSHEP -,SUP-S-04-060-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 5MM 6FR CATH 40MM 120CM SUPERA TRNSHEP -,SUP-S-05-040-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 5MM 6FR CATH 80MM 120CM SUPERA TRNSHEP -,SUP-S-05-080-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6599.42,4619.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 5MM 6FR CATH 100MM 120CM SUPERA TRNSHEP -,SUP-S-05-100-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6599.42,4619.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 6MM 6FR CATH 40MM 120CM SUPERA TRNSHEP -,SUP-S-06-040-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7617.98,5332.586,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 7MM 6FR CATH 60MM 120CM SUPERA TRNSHEP -,SUP-S-07-060-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 8X100MM 120CM SUPERA TRNSHEP -,SUP-S-08-100-120-G3,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6599.42,4619.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT PERIPHERAL 4.5MM X 20MM X 120CM  6F -,SUP-S-45-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT PERIPHERAL 4.5MM X 30MM X 120CM  6F -,SUP-S-45-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC SUPERA 4.5X40MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-45-040-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC SUPERA 4.5X60MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-45-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT PERIPHERAL 4.5MM X 80MM X 120CM  6F -,SUP-S-45-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT PERIPHERAL 4.5MM X 100MM X 120CM  6F -,SUP-S-45-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC SUPERA 4.5X120MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-45-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT PERIPHERAL 5MM X 20MM X 120CM  6F -,SUP-S-50-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT PERIPHERAL 5MM X 30MM X 120CM  6F -,SUP-S-50-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC SUPERA 5 X 60MM 120 -,SUP-S-50-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT  VASC SUPERA 5 X 80MM x 120 -,SUP-S-50-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
5MM X 100MM X 120CM SUPERA STENT -,SUP-S-50-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
5MM x 120MM x 120CM SUPERA STENT -,SUP-S-50-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC SUPERA 5.5X40MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-040-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC SUPERA 5.5X60MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC SUPERA 5.5X80MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
SUPERA PERIPHERAL STENT SYSTEM 5.5MM X 100MM X 120CM -,SUP-S-55-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5495.98,3847.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC SUPERA 5.5X120MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC SUPERA 5.5X150MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-150-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT PERIPHERAL 6MM X 30MM X 120CM  6F -,SUP-S-60-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT SUPERA 6.0MM X 80 X 120CM -,SUP-S-60-080-120-P,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5920.38,4144.266,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT SUPERA 6MM X 80 X 120CM -,SUP-S-60-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S SUPERA 6.0MM X 100 X 120CM -,SUP-S-60-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S SUPERA 6.0MM X 120 X 120CM -,SUP-S-60-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S SUPERA 6.0MM X 150 X 120CM -,SUP-S-60-150-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT PERIPHERAL  6.5MM X 20MM X 120CM 6F -,SUP-S-65-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT PERIPHERAL 6.5MM X 30MM X 120CM  6F -,SUP-S-65-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC SUPERA 6.5X40MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-040-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC SUPERA 6.5X60MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC SUPERA 6.5X80MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC SUPERA 6.5X100MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC SUPERA 6.5X120MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC SUPERA 6.5X150MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-150-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT PERIPHERAL 7.0MM X 020MM X 120CM  6F -,SUP-S-70-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT PERIPHERAL 7.0MM X 030MM X 120CM  6F -,SUP-S-70-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 10X40MM 120CM PROTEGE GPS OTW SE PRMNT OPN LATTICE -,SUP-SERB651040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 10X60MM 120CM PROTEGE GPS OTW SE PRMNT OPN LATTICE -,SUP-SERB651060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 12X20MM 120CM PROTEGE GPS OTW SE PRMNT OPN LATTICE -,SUP-SERB651220120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
7MM X 30MM TCAR STENT ENROUTE -,SUP-SR-0730-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
7MM X 40MM STENT TCAR ENROUTE -,SUP-SR-0740-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
8MM X 30MM STENT TCAR ENROUTE -,SUP-SR-0830-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
8MM X 40MM STENT TCAR ENROUTE -,SUP-SR-0840-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
9MM X 30MM STENT TCAR ENROUTE -,SUP-SR-0930-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
9MM X 40MM STENT TCAR ENROUTE -,SUP-SR-0940-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
ENROUTE TANSCAROTID STENT SYSTEM SR-1030-CS -,SUP-SR-1030-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
ENROUTE TANSCAROTID STENT -,SUP-SR-1040-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC MISAGO 6MM X120MM X 200CM RX R -,SUP-SXR06120R,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC MISAGO 6X150MM 135CM SELF EXPANDING -,SUP-SXR06150R,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
GRAFT EV 14X40 ILC -,SUP-UNDEFINED,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S BILI EXPRESS 5X15X150 -,SUP-UNDEFINED,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 5X18 GENESIS AVIATOR -,SUP-UNDEFINED,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
VENOUS 8F 10mm x 80 mm 120cm CATHETER LENGTH -,SUP-VENUM10080,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
VENOVO VENOUS STENT 12MM X 60MM -,SUP-VENUM12060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
16MM x 60MM x 80CM VENOVO STENT -,SUP-VENUM16060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
VENOUS STENT 14MM x 100MM 120CM CATHETER LENGTH -,SUP-VENUM16080,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
VENOVO VENOUS STENT 18MM X 100MM X 80CM -,SUP-VENUM18100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
VENOUS STENT SYSTEM 18X 120MM 80CM CATH LENGTH -,SUP-VENUM18120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
VENOVO 10FR 20MM X 60MM- 80CM CATHETER LENGTH -,SUP-VENUM20060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 4MMX6CM 125CM ZILVER 518 OTW SE PRELD SLT TUBE -,SUP-ZIB5-125-4.0-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 4MMX8CM 125CM ZILVER 518 OTW SE PRELD SLT TUBE -,SUP-ZIB5-125-4.0-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S ZILVER 518 5X60 125CM S-E -,SUP-ZIB5-125-5.0-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 12MM 8FR GUID CATH 60MM 125CM ZILVER 635 OTW SE -,SUP-ZIB6-125-12.060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S ZILVER .035 120CM 5 X 40 -,SUP-ZIB6-125-5.0-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S ZILVER .035 125CM 5 X 80 -,SUP-ZIB6-125-5.0-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 6X100MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-ZIB6-35-1256100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT BIL 6X140MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-ZIB6-35-1256140,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT ZILVER 6MM X 60MM X 125MM -,SUP-ZIV5-18-125-6-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC ZILVER 518 8X40MM 125CM OTW SE 0.018IN/5FR -,SUP-ZIV5-18-125-840,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC ZILVER 518 8X80MM 125CM OTW SE 0.018IN/5FR -,SUP-ZIV5-18-125-880,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
S ZILVER 6 X 30 -,SUP-ZIV6-35-125-630,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT ZILVER 6 X 40 -,SUP-ZIV6-35-125-640,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT VASC DES ZILVER PTX 6X40MM 125CM OTW SE PRELD -,SUP-ZIV635125640PTX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5487.45,3841.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,32197.7856,other,SI=N Exclusions ,,
STENT 3.5X18MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010144-18,CDM,C1877,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,198.065125,7007.6928,other,SI=N Exclusions ,,
CATH GUID 7FR AL 0.75 SH 100CM -,SUP-G782AL75,CDM,C1877,HCPCS,278,RC,,,outpatient,,,882.25,617.575,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,198.065125,7007.6928,other,SI=N Exclusions ,,
STENT ESPH 18MM 23/23MM OD P/D FLR 153MM WALLFLX SE BRD FLLY -,SUP-M00516920,CDM,C1877,HCPCS,278,RC,,,outpatient,,,9124.6,6387.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,198.065125,7007.6928,other,SI=N Exclusions ,,
PALMAZ UNMOUNTED STENT DIA 1 -,SUP-P4010,CDM,C1877,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,198.065125,7007.6928,other,SI=N Exclusions ,,
STENT BIL 10X59MM PALMZ GENESIS BE UNMT TRNSHEP SS 0.035IN -,SUP-PG5910B,CDM,C1877,HCPCS,278,RC,,,outpatient,,,3986.29,2790.403,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,198.065125,7007.6928,other,SI=N Exclusions ,,
IMPLANT VOCAL CRD PST PROLARYN PLUS 1ML SYR -,SUP-8044M0K5,CDM,C1878,HCPCS,278,RC,,,outpatient,,,3246.32,2272.424,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,2621.49888,other,SI=N Exclusions ,,
IMPLANT VOCAL CORD PROLARYN GEL 1CC NEEDLE -,SUP-8602M0K5,CDM,C1878,HCPCS,278,RC,,,outpatient,,,3413.41,2389.387,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,2621.49888,other,SI=N Exclusions ,,
IMPLANT THYRPL MONT SZ9 SIL EAR FEM STRL -,SUP-MTF.09,CDM,C1878,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,2621.49888,other,SI=N Exclusions ,,
KIT THYROPLASTY MALE -,SUP-MT-SPM,CDM,C1878,HCPCS,278,RC,,,outpatient,,,3308.38,2315.866,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,2621.49888,other,SI=N Exclusions ,,
FILTER VASC BIRDS NEST 40MMX40CM SS VC MRKR -,SUP-178242,CDM,C1880,HCPCS,278,RC,,,outpatient,,,9467.05,6626.935,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.22547,6153.5825,other,SI=N Exclusions ,,
FILTER EMBL PROT OPTEASE 6FR ID 8FR INTRO SHTH 55CM SLF CNTR -,SUP-466-F220A,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3189.03,2232.321,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.22547,6153.5825,other,SI=N Exclusions ,,
FILTER OPTEASE FEMORAL 55CM -,SUP-466-F230AF,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3189.03,2232.321,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.22547,6153.5825,other,SI=N Exclusions ,,
FILTER VASC BIRD S NEST 40MM 11FR CATH 12FR INTRO 75CM SS VC -,SUP-BNF-75-PB,CDM,C1880,HCPCS,278,RC,,,outpatient,,,9467.05,6626.935,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.22547,6153.5825,other,SI=N Exclusions ,,
FILTER EMBL NAVALIGN CELECT 30X48MM FEM VC -,SUP-G03767,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.22547,6153.5825,other,SI=N Exclusions ,,
FILTER CELECT VENA CAVA UNI -,SUP-G34505,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4773.95,3341.765,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.22547,6153.5825,other,SI=N Exclusions ,,
VENA CAVA FILTER FEMORAL & JUG -,SUP-G34505,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4773.95,3341.765,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.22547,6153.5825,other,SI=N Exclusions ,,
FILTER EMBL CELECT 30MM 7FR INTRO SHTH 48MM UNISET VC -,SUP-G52915,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.22547,6153.5825,other,SI=N Exclusions ,,
FILTER EMBL GUNTHER TULIP 30X50MM FEM VC -,SUP-G52917,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3819.15,2673.405,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.22547,6153.5825,other,SI=N Exclusions ,,
FILTER VASC NAVALIGN CELECT 30MM 7FR CATH UNIV 49MM UNISET -,SUP-IGTCFS651UNICEL,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4773.95,3341.765,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.22547,6153.5825,other,SI=N Exclusions ,,
FILTER VASC GUNTHER TULIP 30MM 8.5FR INTRO SHTH 50MM PRELD -,SUP-IGTCFS-65-FEM,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.22547,6153.5825,other,SI=N Exclusions ,,
FILTER VASC GUNTHER TULIP 30MM 8.5FR INTRO SHTH 50MM- -,SUP-IGTCFS-65-UNI,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.22547,6153.5825,other,SI=N Exclusions ,,
FILTER VENA CAVA TULIP UNI GUNTHER -,SUP-IGTCFS-65-UNI,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3819.15,2673.405,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.22547,6153.5825,other,SI=N Exclusions ,,
FILTER GREENFIELD JUG -,SUP-M001503000,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4249.67,2974.769,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.22547,6153.5825,other,SI=N Exclusions ,,
FILTER GREENFIELD FEM -,SUP-M001503010,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4249.67,2974.769,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.22547,6153.5825,other,SI=N Exclusions ,,
DILATOR VASC 18GA GW 0.038IN DILATOR 8/10/12 FR DIA SYR -,SUP-M001503500,CDM,C1880,HCPCS,278,RC,,,outpatient,,,776.06,543.242,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.22547,6153.5825,other,SI=N Exclusions ,,
FILTER VASC MERIDIAN NTNL VC -,SUP-MD800F,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.22547,6153.5825,other,SI=N Exclusions ,,
FILTER VASC MERIDIAN NTNL SBCLVN VC -,SUP-MD800J,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.22547,6153.5825,other,SI=N Exclusions ,,
FILTER OPTEASE JUGULAR 90CM -,SUP-UNDEFINED,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.22547,6153.5825,other,SI=N Exclusions ,,
FILTER OPTEASE JUGULAR 55CM -,SUP-UNDEFINED,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3189.03,2232.321,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,174.22547,6153.5825,other,SI=N Exclusions ,,
DEFIBRILLATOR PRMT RF DF-1 2CHMBR 50X81MM 14MM 43ML 82GM -,SUP-3207-36,CDM,C1882,HCPCS,275,RC,,,outpatient,,,59022.98,41316.086,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
DEFIBRILLATOR LUMAX 540 HF-T DF-1 IS-1 CONN 3 CHMBR RR. -,SUP-360347,CDM,C1882,HCPCS,275,RC,,,outpatient,,,38238.5,26766.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
DEFIBRILLATOR LUMAX 740 HF-T BIVEN PCNG CARD IMPL W/HOME -,SUP-365608,CDM,C1882,HCPCS,275,RC,,,outpatient,,,40705.5,28493.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
DEFIBRILLATOR ILESTO HF-T DF-1 BIVEN PCNG RDC HI ENRG CARD -,SUP-383547,CDM,C1882,HCPCS,275,RC,,,outpatient,,,40705.5,28493.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
DEFIBRILLATOR ILESTO HF-T DF-4 BIVEN PCNG HI ENRG CARD IMPL -,SUP-383549,CDM,C1882,HCPCS,275,RC,,,outpatient,,,32036.46,22425.522,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
DEFIBRILLATOR LUMAX 740 HF-T CARD IMPL W/HOME MNTR MBL -,SUP-393803,CDM,C1882,HCPCS,275,RC,,,outpatient,,,39472,27630.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
DEFIB HI ENRG BIVEN CARD IMPL TI -,SUP-401662,CDM,C1882,HCPCS,275,RC,,,outpatient,,,34503.46,24152.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
DEFIBRILLATOR PRMT + DF-4 RR V- PCNG RDC 50X75MM 14MM 42ML -,SUP-CD3211-36Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
DEFIBRILLATOR UNIFY IS-1 CONN 40X79MM 14MM 36ML 78GM CARD -,SUP-CD3231-40,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
DEFIBRILLATOR UNIFY QUADRA DF-4 IS-4 IS-1 CONN 41X75MM 14MM -,SUP-CD3249-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43251.44,30276.008,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
DEFIBRILLATOR UNIFY ASSURA DF-1 IS-1 DF-4 BIVEN PCNG 40X79MM -,SUP-CD3257-40,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
DEFIBRILLATOR UNIFY ASSURA DF-4 TELEM 2CHMBR 40X73MM 14MM -,SUP-CD3257-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
DEFIBRILLATOR QUADRA ASSURA DF-1 BIVEN PCNG 41X83MM 14MM -,SUP-CD3265-40,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43251.44,30276.008,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
DEFIBRILLATOR QUADRA ASSURA DF-4 IS-4 IS-1 CONN BIVEN PCNG -,SUP-CD3265-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43251.44,30276.008,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
DEFIBRILLATOR UNIFY ASSURA CARD IMPL PARYLENE CTD -,SUP-CD3357-40C,CDM,C1882,HCPCS,275,RC,,,outpatient,,,29974.05,20981.835,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
UNIFY ASSURA NXGEN CRT-D 40 MEDIGUIDE -,SUP-CD3357-40C,CDM,C1882,HCPCS,275,RC,,,outpatient,,,47726.58,33408.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
DEFIBRILLATOR UNIFY ASSURA DF-4 CARD IMPL PARYLENE CTD CD -,SUP-CD3357-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,29974.05,20981.835,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
CRT-D 40 QUADRA ASSURA -,SUP-CD3365-40C CELL,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35225.31,24657.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
DEFIBRILLATOR QUADRA ASSURA DF-4 SGL/2CHMBR 41X75MM 14MM -,SUP-CD3365-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35225.31,24657.717,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
CRT-D QUADRA ASSURA MP CD3369-40C -,SUP-CD3369-40C,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
CRT-D QUADRA ASSURA MP DFR CON -,SUP-CD3369-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
ENTRANT CRT-D CDHFA300Q -,SUP-CDHFA300Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35771.5,25040.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
ENTRANT HF CRT-D DF1 CONNECTOR REF: CDHFA300T -,SUP-CDHFA300T,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35771.5,25040.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
GALLANT CRT-D CDHFA500Q -,SUP-CDHFA500Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,38238.5,26766.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
GALLANT HF CRT-D DF1 CONNECTOR REF: CDHFA500T -,SUP-CDHFA500T,CDM,C1882,HCPCS,275,RC,,,outpatient,,,38238.5,26766.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
DEFIBRILLATOR INOGEN MUL PRGM OPTN EXTEND LNGVT VR -,SUP-D141,CDM,C1882,HCPCS,275,RC,,,outpatient,,,28370.5,19859.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
DEFIBRILLATOR CONSULTA DF-1 IS-1 CONN WRLS TELEM 2CHMBR RR -,SUP-D224TRK,CDM,C1882,HCPCS,275,RC,,,outpatient,,,48626.05,34038.235,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
DEFIBRILLATOR PROTECTA DF-4 CARD IMPL -,SUP-D334TRM,CDM,C1882,HCPCS,275,RC,,,outpatient,,,39911.13,27937.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
EVERA MRI MRT XT DR DDMB1D4 -,SUP-DDMB1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,37251.7,26076.19,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
VIVA CARD IMPL -,SUP-DTBA1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50599.65,35419.755,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
DEFIBRILLATOR VIVA XT IS-1 DF-1 ADPTVCRT PHYCRV SMRTSHCK -,SUP-DTBA1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50599.65,35419.755,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
DEFIBRILLATOR VIVA S DF-4 IS-1 CONN SGL-CHMBR CARD IMPL -,SUP-DTBB1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,42839.46,29987.622,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
DEFIBRILLATOR VIVA S DF-4 IS-1 CONN SGL-CHMBR CARD IMPL. -,SUP-DTBB1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,42839.46,29987.622,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
DEFIB  VIVA QUAD S CRT-D DF-1 IS-4 CONN CARD IMPL -,SUP-DTBB1Q1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43172.5,30220.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
DEFIBRILLATOR VIVA QUAD S DF-4 IS-4 CONN CARD IMPL -,SUP-DTBB1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,42839.46,29987.622,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
CLARIA MRI CRT-D DTMA1D1 -,SUP-DTMA1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49006.96,34304.872,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
CLARIA MRI CRT-D MODEL DTMA1D1 -,SUP-DTMA1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49006.96,34304.872,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
CLARIA MRI CRT-D DTMA1D4 -,SUP-DTMA1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49006.96,34304.872,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
CLARIA MRI QUAD CRT-D Model DTMA1QQ -,SUP-DTMA1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50326.8,35228.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
CLARIA MRI QUAD CRT-D DTMA1QQ -,SUP-DTMA1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50326.8,35228.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
AMPLIA MRI CRT-D DTMB1D1 -,SUP-DTMB1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,47773.46,33441.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
CRTD DTMB1D1 AMPLIA MRI US DF1 -,SUP-DTMB1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,47773.46,33441.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
AMPLIA CRT-D MRI DEVICE -,SUP-DTMB1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,54249.33,37974.531,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
AMPLIA MRI QUAD CRT-D SURESCAN DTMB1Q1 -,SUP-DTMB1Q1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
AMPLIA MRI QUAD CRT-D -,SUP-DTMB1Q1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
AMPLIA CRT-D DTMB 1 QQ -,SUP-DTMB1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
ICD COBALT HF CRT-D MRI SURESCAN REF: DTPB2D1 -,SUP-DTPB2D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,48237.25,33766.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
COBALT HF QUAD CRTD REF: DTPB2QQ -,SUP-DTPB2QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,52793.8,36955.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
CROME MRI CRTD REF: DTPC2D4 -,SUP-DTPC2D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50240.46,35168.322,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
CRT-D MOMENTUM IS1 DF4 G124 -,SUP-G124,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
CRT-D MOMENTUM IS1 DF1 G125 -,SUP-G125,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
CRT-D MOMENTUM LV-1 G126 -,SUP-G126,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
CRT-D MOMENTUM X4 IS4-DF1 G138 -,SUP-G138,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
PACEMAKER INOGEN CARD -,SUP-G140,CDM,C1882,HCPCS,275,RC,,,outpatient,,,39225.3,27457.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
DEFIBRILLATOR INOGEN CARD -,SUP-G141,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
DEFIBRILLATOR INOGEN DF-1 SGL-CHMBR 5.37CMX8.08CMX0.99CM D -,SUP-G146,CDM,C1882,HCPCS,275,RC,,,outpatient,,,41692.3,29184.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
DEFIBRILLATOR INOGEN DF-4 5.37CMX8.08CMX0.99CM D 32ML CARD -,SUP-G148,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
DYNAGEN CRT-D MODEL G150 -,SUP-G150,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
DYNAGEN CRT-D G-154 DEFIBRILLATOR -,SUP-G154,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
CRT-D DYNAGEN X4 G156 -,SUP-G156,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33218.16,23252.712,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
CRT-D VIGILANT X4 IS4 DF4 MRI CONDITIONAL -,SUP-G247,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
COMPIA CRT-D MRI QUAD -,SUP-UNDEFINED,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,45329.64864,other,SI=N Exclusions ,,
ANCHOR LD C IN 94IN LF ACC -,SUP-1194,CDM,C1883,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3519.77472,other,SI=N Exclusions ,,
KIT EXTENSION INTERSTIM 10CM S  - DISCONTINUED DO NOT USE -,SUP-3095-10,CDM,C1883,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3519.77472,other,SI=N Exclusions ,,
KIT REVISION INTERSTIM -,SUP-3550-05,CDM,C1883,HCPCS,278,RC,,,outpatient,,,1079.48,755.636,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3519.77472,other,SI=N Exclusions ,,
KT EXTENSION NEURSTM INTSTM 60CM PERC MRI-COND INSL MULI- -,SUP-3708160,CDM,C1883,HCPCS,278,RC,,,outpatient,,,3007.62,2105.334,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3519.77472,other,SI=N Exclusions ,,
LEAD ADPTR -,SUP-5866,CDM,C1883,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3519.77472,other,SI=N Exclusions ,,
CABLE PCNG -,SUP-5867AS,CDM,C1883,HCPCS,278,RC,,,outpatient,,,116.7,81.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3519.77472,other,SI=N Exclusions ,,
EXTENDER LD UNIPL -,SUP-6981M,CDM,C1883,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3519.77472,other,SI=N Exclusions ,,
EXTENDER LD BIPLR MRI-COND -,SUP-6984M,CDM,C1883,HCPCS,278,RC,,,outpatient,,,1079.48,755.636,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3519.77472,other,SI=N Exclusions ,,
ADAPTER NEURSTM 27.4CM SPIN CRD 2X4 PCKT -,SUP-740-02,CDM,C1883,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,26.19915,3519.77472,other,SI=N Exclusions ,,
FILTER EMBL PROT EMBOSHIELD NAV6 5MMX190CM WIRE UNCNTSTR -,SUP-22437-19,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,5331.24633,other,SI=N Exclusions ,,
FILTER EMBL PROT EMBOSHIELD NAV6 7.2MMSMX190CM WIRE UNCNTSTR -,SUP-22438-19,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,5331.24633,other,SI=N Exclusions ,,
FILTER EMBL PROT FLTWR EZ 3.2FRX190CM WIRE NTNL LOOP CRTD -,SUP-H749201001900,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6875.28,4812.696,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,5331.24633,other,SI=N Exclusions ,,
FILTER EMBL PROT FLTWR EZ 3.2FRX300CM WIRE NTNL LOOP CRTD -,SUP-H749201003000,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7078.99,4955.293,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,5331.24633,other,SI=N Exclusions ,,
EMBOLIC PROT FLTWR EZ 0.042IN 0.014 DIA GW 110U FLTR 190CM -,SUP-H749390711900,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7435.49,5204.843,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,5331.24633,other,SI=N Exclusions ,,
FILTERWIRE EMBL EZ 2.25MM 3.5MMX300CM FEM VC -,SUP-H74939071300,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6457.03,4519.921,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,5331.24633,other,SI=N Exclusions ,,
DEVICE EMBL PROT SPIDERFX 3MM FLTR BSKT 0.014IN GW 0.066IN -,SUP-SPD2US030320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,5331.24633,other,SI=N Exclusions ,,
DEVICE EMBL PROT SPIDERFX 4MM FLTR BSKT 0.014IN GW 0.066IN -,SUP-SPD2US040320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,5331.24633,other,SI=N Exclusions ,,
SPIDER FX 5MM 320 .014 EMBOLIC -,SUP-SPD2US050320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,5331.24633,other,SI=N Exclusions ,,
SPIDER FX 6MM 320 .014 EMBOLIC -,SUP-SPD2US060320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,5331.24633,other,SI=N Exclusions ,,
DEVICE EMBL PROT SPIDERFX 7MM FLTR BSKT 0.014IN GW 0.066IN -,SUP-SPD2US070320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,5331.24633,other,SI=N Exclusions ,,
CATHETER LASER CORONARY ATHETECTOMY 0.9X80 ELACX-80 -,SUP-110-004,CDM,C1885,HCPCS,272,RC,,,outpatient,,,10588.78,7412.146,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7592.15526,other,SI=N Exclusions ,,
CATHETER 1.4MM ELCA CORONARY LASER ATHE -,SUP-114-009,CDM,C1885,HCPCS,272,RC,,,outpatient,,,10588.78,7412.146,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7592.15526,other,SI=N Exclusions ,,
C 1.7M .018IN OTW TURBO ELITE -,SUP-417-152,CDM,C1885,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7592.15526,other,SI=N Exclusions ,,
CATH ABLT 4MM 90DG 160CM BARRX ULTRA LNG LF -,SUP-90-9200,CDM,C1886,HCPCS,272,RC,,,outpatient,,,9419.88,6593.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7607.37,other,SI=N Exclusions ,,
CATHETER BRONCHIAL THERMOPLAST -,SUP-M005ATS25010,CDM,C1886,HCPCS,272,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7607.37,other,SI=N Exclusions ,,
CATH SHEATH RITESITE C315H40,SUP-,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
GUIDE 8F MARK 1 AL 2 -,SUP-34358-20,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
GUIDE 8F MARK 1 IM -,SUP-34358-26,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
LEAD PCNG 6.6FR 7FR INTRO 53CM TILDA HELIX ELECTRICALLY -,SUP-382889,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
LEAD PCNG 6.6FR 7FR INTRO 60CM TILDA HELIX ELECTRICALLY -,SUP-382895,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATHETER GUIDE 6FR X 85CM INTERNAL MAMMARY -,SUP-38969-122/H749389691220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 5FR IL-3.5 HEARTRAIL III NO SH COR SS FLTWR PTFE -,SUP-40-5370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 5FR IKARI RT 2 HEARTRAIL III NO SH COR SS FLTWR -,SUP-40-5382,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 6FR ID 0.081IN IL-3.5 100CM HEARTRAIL III LRG LUM -,SUP-40-6370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 6FR ID 0.081IN IL-4.5 100CM HEARTRAIL III LRG LUM -,SUP-40-6375,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
MICRO GUIDE CATH NHANCER RX REF: 451669 -,SUP-451669,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATHETER GUIDE -,SUP-490107,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH DX 0.039/0.026IN DIA P/D 45DG ANG TAPR 135CM QCK-CX -,SUP-518-032,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH DX 0.044/0.030IN DIA P/D 15MM SPC 45DG ANG TAPR 90CM -,SUP-518-033,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
C QUICKCROSS .018 150CM -,SUP-518-035,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH DX 0.063/0.050IN DIA P/D 15MM SPC 45DG ANG TAPR 90CM -,SUP-518-036,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
C QUICKCROSS .035 135CM -,SUP-518-037,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
C QUICKCROSS .035 150CM -,SUP-518-038,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
C 0.014-150CM QUICK CROSS -,SUP-518-065,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH DX 0.052/0.059IN DIA P/D 15MM SPC 45DG ANG TAPR 135CM -,SUP-518-081,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
C QUICK CROSS SEL .035 150CM -,SUP-518-083,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
C QUICK CROSS SEL .014 150 -,SUP-518-087,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
C QUICK CROSS SEL .018 150 -,SUP-518-093,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH DX 3FR ID 1.9FRX140CM TWN PASS RX LPRO LUMX2 COR PERIPH -,SUP-5200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2003.59,1402.513,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATHETER SUPERCROSS 45 ANGLED 0.014 X 130CM -,SUP-5302,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
SUPERCROSS 90 ANGLED TIP CATH -,SUP-5305,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2279.22,1595.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
MICRO GUIDE CATH SUPERCROSS 120 ANGLED TIP REF: 5306 -,SUP-5306,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2472.93,1731.051,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH ANG INFINITI 5FR JR4 REF: 534521T -,SUP-534521T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH ANG 5FR 145 PIGTL 110CM INFINITI REF: 534-552S -,SUP-534552S,CDM,C1887,HCPCS,272,RC,,,outpatient,,,43.47,30.429,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH ANG 5FR IMA CRV 100CM INFIN SLCT 3 STG BRD NBRD PROX -,SUP-534-560T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH ANG INFINITI 6FR JL4 REF: 534620T -,SUP-534620T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH ANG INFINITI 6FR JR4 REF: 534-621T -,SUP-534-621T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH ANG INFINITI 6FR AR MOD REF: 534648T -,SUP-534648T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH ANG INFINITI 6FR RCB REF: 534670T -,SUP-534670T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH ANG INFINITI 6FR LCB REF: 534672T -,SUP-534672T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
SHEATH GUID 5FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-54-54501,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH DX 6FR 145DG PIGTL 110CM LANGSTON BRD LUMX2 LO XING -,SUP-5540,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1088.81,762.167,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.056IN 5FRX100CM 2.5MM VISTA BRITE TIP SS PTFE -,SUP-556-002-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.056IN 5FR JL3.5 100CM VISTA BRITE TIP BRD -,SUP-556-002-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.056IN 5FR LT COR EBU 3.5 100CM 2.5MM VISTA BRITE -,SUP-556-054-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.056IN 5FR  XBLAD 3.5 LBT 100CM 2.5MM VISTA -,SUP-556-060-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.056IN 5FR BARB 100CM VISTA BRITE TIP BRD MUL-SEG -,SUP-556-174-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATHETER 6FRX150CM TRAPLINER REF:5566 -,SUP-5566,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3652.11,2556.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATHETER 7FRX150CM TRAPLINER REF:5567 -,SUP-5567,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3652.11,2556.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH DX 6FRX150CM GUIDELINER V2 RX COAX PERIPH -,SUP-5571,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2183.81,1528.667,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH DX 7FRX150CM GUIDELINER V2 RX COAX PERIPH -,SUP-5572,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2183.81,1528.667,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH DX 8FRX150CM GUIDELINER V2 RX COAX PERIPH -,SUP-5573,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2173.21,1521.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
TURNPIKE GOLD 135CM MICRO CATH -,SUP-5621,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3294.06,2305.842,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
TURNPIKE LP 135 ON MICRO CATHETER -,SUP-5638,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3771.46,2640.022,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
TURNPIKE LP 150CM MICRO CATH -,SUP-5639,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2931.24,2051.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATHETER TURNPIKE SPIRAL 135CM -,SUP-5640,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3771.46,2640.022,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.018IN 3.5FR SHFT 70CM 8MM VENTURE OTW CS PED -,SUP-5822,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3146.07,2202.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.088IN 8FR JL4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-588-823,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.088IN 8FR LT COR EBU3 100CM 2.5MM VISTA BRITE -,SUP-588-829,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.088IN 8FR JR4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-588-830,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.088IN 8FR JL3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-588-851,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID VISTA 8FR XB 3.5 -,SUP-588-882,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.088IN 8FR LT COR EBU 4 100CM 2.5MM VISTA BRIT -,SUP-588-894,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH DX 0.054IN 6FRX100CM 2CM PERFORM ULTMT 2 -,SUP-610038ULT2,CDM,C1887,HCPCS,272,RC,,,outpatient,,,140.74,98.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 130DG CRV ATTAIN SELECT COR STR 5.5FR INR CATH -,SUP-6248DEL,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATHETER ATTAIN SELECT REF: 6248V-130 -,SUP-6248V-130,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1284.84,899.388,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH 6248V-90 ATTAIN SELECT II -,SUP-6248V-90,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1284.84,899.388,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATHETER  CRDM Adaptor 6250V-EH -,SUP-6250V-EH,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATHETER ATTAIN COMMAND REF: 6250V-MPR -,SUP-6250V-MPR,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.96MM/MIN 2.4MM/MAX MPX COR 50CM ATTAIN COMMAND -,SUP-6250VMPX,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.07IN 6FR JL3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-002-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.07IN 6FR JL4 100CM VISTA BRITE TIP BRD -,SUP-670-004-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.07IN 6FR JL4 SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-005-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.07IN 6FR JL4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-014-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.07IN 6FR AL1 100CM .75MM SH VISTA BRITE TIP -,SUP-67003500,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.07IN 6FR ALC1 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-036-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.07IN 6FR ALC2 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-040-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.07IN 6FR  XB3 100CM 1.8MM VISTA BRITE TIP -,SUP-670-052-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.07IN 6FR XB 3 SH 100CM VISTA BRITE TIP -,SUP-670-053-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUIDING 6FR XB 3.5 VISTA -,SUP-670-054-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUIDING 6FR XB 3.5 VISTA LBT -,SUP-670-054-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,253.82,177.674,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.07IN 6FR LT COR EBU3.5 SH 100CM 2.5MM VISTA -,SUP-670-055-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.07IN 6FR XB4 100CM 2.5MM VISTA BRITE TIP -,SUP-670-056-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.07IN 6FR XB4.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-67005800,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.07IN 6FR XBLAD 3.5 100CM  VISTA BRITE -,SUP-670-060-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.07IN 6FR XBLAD 4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-062-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 6FR XBLAD 4.5 100CM VISTA BRITE TIP -,SUP-67006400,CDM,C1887,HCPCS,272,RC,,,outpatient,,,198.39,138.873,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.07IN 6FR XBLAD 3 100CM VISTA BRITE TIP -,SUP-670-066-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.07IN 6FR JR3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-080-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.07IN 6FR JR4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-67008200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.07IN 6FR JR4 55CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-082-55,CDM,C1887,HCPCS,272,RC,,,outpatient,,,355.35,248.745,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.07IN 6FR JR4 SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-083-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.07IN 6FR ARC1 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-67011000,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.07IN 6FR XBRCA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-126-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.07IN 6FR JEAN- FJL 100CM 2.5MM VISTA BRITE TIP -,SUP-670-166-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 6FR JFL LT REF: 670-166-00 -,SUP-670-166-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.07IN 6FR BARB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-174-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.07IN 6FR LCB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-180-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.07IN 6FR LCB 90CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-180-90,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.07IN 6FR RCB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-182-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.07IN 6FR RCB 90CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-182-90,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.07IN 6FR IMA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-190-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.07IN 6FR VERT 55CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-190-55,CDM,C1887,HCPCS,272,RC,,,outpatient,,,355.35,248.745,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.07IN 6FR IM SH REF: 670-191-00 -,SUP-670-191-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 6FR IM VB-1 100CM VISTA BRITE TIP -,SUP-67019200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,198.39,138.873,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.07IN 6FR RNL CRV 55CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-212-55,CDM,C1887,HCPCS,272,RC,,,outpatient,,,355.35,248.745,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.07IN 6FR HS 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-278-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.07IN 6FR HS SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-279-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.078IN 7FR JL4 100CM 2.5MM VISTA BRITE TIP BD -,SUP-778-004-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATHETER GUIDING 7FR JL 5 SH JUDKINS -,SUP-77800900,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUIDE 7FR AL2 REF: 778704000 -,SUP-77804000,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.078IN 7FR LT EBU LAD 3 100CM 2.5MM VISTA BRITE -,SUP-778-052-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.078IN 7FR XB 3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-054-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUIDING  7FR XB3.5 SH VIS -,SUP-778-055-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.078IN 7FR XB4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-056-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.078IN 7FR LT EBU LAD 4.5 100CM 2.5MM VISTA BRITE -,SUP-778-058-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUIDING 7FR XBLAD 3.5 100CM 2.5MM VISTA -,SUP-778-060-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.078IN 7FR LT COR EBU LAD 4 100CM 2.5MM VISTA -,SUP-778-062-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.078IN 7FR JR4 100CM 2.5MM VISTA BRITE BRD -,SUP-778-082-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.078IN 7FR JR4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-083-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.078IN 7FR ARC1 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-110-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.078IN 7FR ARC2 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-112-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.078IN 7FR RCB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-182-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.078IN 7FR IMA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-190-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.078IN 7FR MPA-1 COR 100CM 2.5MM VISTA BRITE TIP -,SUP-778-270-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.078IN 7FR HS 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-278-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.078IN 7FR HS SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-279-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH BLN OCCULSION 2.1FRX135CM ASAHI TORNUS SUPP CHRNC OTW -,SUP-82380-01,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH DX 2.6FRX135CM ASAHI TORNUS SUPP OTW THRD COR SS -,SUP-82381-01,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3795.33,2656.731,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATHETER CENTER POINT REF:9181 -,SUP-9181,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATHETER CENTER POINT REF:9182 -,SUP-9182,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATHETER CENTER POINT REF:9183 -,SUP-9183,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATHETER CENTER POINT REF:9184 -,SUP-9184,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH SHEATH RITESITE C315H2002 -,SUP-C315H2002,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH SHEATH RITESITE C315H4002 -,SUP-C315H4002,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH SHEATH C315HIS02 -,SUP-C315HIS02,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
HIS SHEATH DELIVERY SYSTEM C315HIS02 -,SUP-C315HIS02,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH SHEATH RITESITE C315J02 -,SUP-C315J02,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH SHEATH RITESITE C315S1002 -,SUP-C315S1002,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH SHEATH RITESITE C315S402 -,SUP-C315S402,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH SHEATH RITESITE C315S502 -,SUP-C315S502,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH ELCSURG 7FRX100CM RF FLXB CLSR FST -,SUP-CF7-7-100,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
GLIDECATH MG1 4F 125CM  LONG -,SUP-CG440,CDM,C1887,HCPCS,272,RC,,,outpatient,,,295.54,206.878,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
GLIDECATH MG2 4F 135CM  LONG -,SUP-CG441,CDM,C1887,HCPCS,272,RC,,,outpatient,,,295.54,206.878,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH ABLT CLSR FST 65CM PROC KT MIS-7F11 INTRO -,SUP-CPK6511,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1908.18,1335.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH ABLT CLSR FST 73CM PROC KT MIS-7F11 INTRO -,SUP-CPK8511,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1908.18,1335.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
ASAHI CARAVEL MICROCATHETER 150 CM -,SUP-CRV150-19P,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATHETER CORSAIR PRO XS 150CM REF: CSR150-21S -,SUP-CSR150-21S,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATHETER CORSAIR PRO 150CM CSR150-26P ASAHI -,SUP-CSR150-26P,CDM,C1887,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
"CATHETER CXI SUPPORT 4.OFR X 135CM STR TIP .035"" MAX GUIDEWR -",SUP-CXI-4.0-35-135-P-NS-O,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATHETER CPS LOCATOR 3D- SMALL REF:DS2C100-42 -,SUP-DS2C100-42,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATHETER CPS LOCATOR 3D- MEDIUM REF:DS2C200-42 -,SUP-DS2C200-42,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATHETER CPS LOCATOR 3D- LAGE REF:DS2C300-42 -,SUP-DS2C300-42,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATHETER AGILIS HISPRO DS3H010-38 -,SUP-DS3H010-38,CDM,C1887,HCPCS,272,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATHETER AGILIS HISPRO DS3H010-38  BUNDLE -,SUP-DS3H010-38,CDM,C1887,HCPCS,272,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH ANG 0.056IN 6FR AR1 100CM DXTERITY REF: DXT6AR10 -,SUP-DXT6AR10,CDM,C1887,HCPCS,272,RC,,,outpatient,,,9.92,6.944,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
RING TRANS-JUG ACCESS SET WITH 10fr -,SUP-G06541,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2542.11,1779.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
TRANSJUGLAR LIVER ACCESS SET R -,SUP-G06929,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2558.82,1791.174,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
BEACON TIP 5.0 FR ANGIOGRAPHIC CATHETER - C2 -,SUP-G08442,CDM,C1887,HCPCS,272,RC,,,outpatient,,,151.7,106.19,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATHETER RIM 5FR X 100CM -,SUP-G12870,CDM,C1887,HCPCS,272,RC,,,outpatient,,,758.49,530.943,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH DX 2.6FR STR 65CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G18367,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1051.93,736.351,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATHETER CXI SUPPORT -,SUP-G18368,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1051.93,736.351,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CXI-2.3-14-65-0 -,SUP-G18369,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH CXI 2.3FR X 65CM X 014 SU -,SUP-G18370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH CXI 2.3FR X 90CM X 014 SU -,SUP-G18371,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CXI-2.3-14-90-ANG -,SUP-G18372,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CXI-2.3-14-150-ANG -,SUP-G18376,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH DX 2.6FR ANG 150CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G50003,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH DX 2.6FR STR 90CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G50004,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH DX 3FR/1.9FR P/D STR 135CM CROSSCATH SUPP LUMX1 PERIPH -,SUP-G51573,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH DX 4.8FR/3.7FR P/D STR 90CM CROSSCATH SUPP LUMX1 PERIPH -,SUP-G51580,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH DX 4.8FR/3.7FR P/D STR 135CM CROSSCATH SUPP LUMX1 -,SUP-G51581,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH DX 3.4FR/2.2FR P/D STR 135CM CROSSCATH SUPP LUMX1 -,SUP-G51583,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH DX 4FR DAV 135CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G52543,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
C NAVICROSS ANG 150CM .035 -,SUP-G52545,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH DX 4FR DAV 150CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G52545,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATHETER CXI SUPPORT 4FR X 90CM STR TIP .035 MAX GUIDEWRE -,SUP-G52546,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH DX 4FR DAV 90CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G52547,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH ANG 90CM NAVICROSS -,SUP-G52547,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.07IN 7FR XBRCA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-G778126,CDM,C1887,HCPCS,272,RC,,,outpatient,,,882.25,617.575,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID RELIEVA FLEX SIN S-0 SFT DIST TIP ENDO -,SUP-GC000RF,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1961.19,1372.833,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID RELIEVA FLEX SIN F-70 C SFT DIST TIP ENDO -,SUP-GC070CRF,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1961.19,1372.833,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID RELIEVA FLEX SIN M-110 SFT DIST TIP ENDO -,SUP-GC110RF,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1961.19,1372.833,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH ANGIO IMPULSE 5FR FL3.5 REF:H74916391212 -,SUP-H74916391212,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATHETER 5FR FL4 IMPULSE REF:H74916391222 -,SUP-H74916391222,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH ANGIO IMPULSE 5FR AR1 REF:H74916391842 -,SUP-H74916391842,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH ANG 0.045IN 5FR AL1 100CM IMPULSE REF:H74916391962 -,SUP-H74916391962,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATHETER 5FR AL2 IMPULSE REF:H74916391982 -,SUP-H74916391982,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
ANGIO CATH PIG 6F IMPULSE -,SUP-H74916599412,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.070IN 6FR AL3 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934356210,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATHETER GUIDING 6FR Mach 1 AL .75 -,SUP-H74934356220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 6FR MACH 1 ML 3.5 REF: H749343565370 -,SUP-H749343565370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.081IN 7FR FL3 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934357050,CDM,C1887,HCPCS,272,RC,,,outpatient,,,306.51,214.557,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.081IN 7FR FL3.5 100CM MACH1 4X2 RND BRD LRG LUM -,SUP-H74934357060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 7FR IM 85CM MACH1 -,SUP-H749343571220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 7FR AL.75 100CM MACH1 REF:H74934357220 -,SUP-H74934357220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.081IN 7FR RCB 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934357240,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.081IN 7FR Q- TY CRV 4 100CM MACH1 4X2 RND BRD -,SUP-H749343572940,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.070IN 7FR Q4.5 MACH 1 -,SUP-H749343572950,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.081IN 7FR MP1 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934357380,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUIDE 7FR MP2 REF: H74934357390 -,SUP-H74934357390,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.081IN 7FR FR3.5 SH 100CM MACH1 2X2 RND BRD -,SUP-H74934357470,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.081IN 7FR FL4.5 100CM MACH1 2X2 RND BRD LRG LUM -,SUP-H74934357540,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.081IN 7FR CNTRLAT 3 100CM MACH1 2X2 RND BRD LRG -,SUP-H749343575730,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.081IN 7FR CLS 3.5 100CM MACH1 4X2 RND BRD LRG -,SUP-H749343575740,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.081IN 7FR VL3 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934357710,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.081IN 7FR VL3.5 100CM MACH1 4X2 RND BRD LRG LUM -,SUP-H74934357720,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.081IN 7FR FR4 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934357920,CDM,C1887,HCPCS,272,RC,,,outpatient,,,306.51,214.557,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.091IN 8FR FR3.5 100CM MACH1 2X2 RND BRD SD HOL -,SUP-H74934358010,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.091IN 8FR FR4 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934358020,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.091IN 8FR FL3.5 100CM MACH1 4X2 RND BRD LRG LUM -,SUP-H74934358060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.091IN 8FR FL4.5 100CM MACH1 2X2 RND BRD LRG LUM -,SUP-H74934358080,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID MACH1 8FR AL.75 SH  90CM - H749343581920 -,SUP-H749343581920,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.091IN 8FR LCB 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934358250,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.091IN 8FR FR4 100CM MACH1 4X2 RND BRD LRG LUM SH -,SUP-H74934358480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.070IN 6FR FR3.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969010,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.070IN 6FR FR4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969020,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.07IN 6FR FL3 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969050,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.07IN 6FR FL3.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.07IN 6FR FL4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969070,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.070IN 6FR FL4.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969080,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.070IN 6FR FEM HS 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H749389691410,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.070IN 6FR AR2 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969180,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.070IN 6FR AL1 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969190,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.070IN 6FR AL2 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.07IN 6FR FRC BYPS 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H74938969240,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.070IN 6FR LCB RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969250,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.070IN 6FR IMA RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969260,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.070IN 6FR FL4 ST RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H74938969290,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.070IN 6FR Q3.5 -,SUP-H749389692930,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.070IN 6FR Q4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389692940,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.070IN 6FR Q4.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389692950,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.07IN 6FR MP1 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969380,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.070IN 6FR FEM MP 2 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H74938969390,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.070IN 6FR HS RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969410,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.070IN 6FR IMA 90CM RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389694460,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.070IN 6FR RC 4 SC RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389694480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.070IN 6FR RC 3.5 SC RUNWAY 2X2 RND BRD LRG LUM -,SUP-H74938969460,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.070IN 6FR FR3.5 RUNWAY 2X2 RND BRD LRG LUM SH -,SUP-H74938969470,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.070IN 6FR FR4 RUNWAY 2X2 RND BRD LRG LUM SH FEM -,SUP-H74938969480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.070IN 6FR ART3 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389694960,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.070IN 6FR ART3.5 RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389694980,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.070IN 6FR ART3.5 RUNWAY 2X2 RND BRD LRG LUM SH -,SUP-H749389694990,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.070IN 6FR ART4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389695000,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.070IN 6FR FL 3.5 SH RUNWAY 2X2 RND BRD LRG -,SUP-H74938969520,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.070IN 6FR MUTA LT 3 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695360,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.070IN 6FR MUTA LT 3.5 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.070IN 6FR MUTA LT 4 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695380,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.070IN 6FR MUTA LT 4.5 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695390,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.07IN 6FR FEM CLS 3 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H749389695730,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.070IN 6FR CLS 3.5 RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389695740,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.070IN 6FR CLS 4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389695750,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.070IN 6FR CLS 3.5 RUNWAY 2X2 RND BRD LRG LUM SH -,SUP-H749389695780,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUIDE RUNWAY 6F CLS4 SH -,SUP-H749389695790,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.070IN 6FR KRT HZNT 3H RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389696480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.081IN 7FR VL3.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389696620,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.070IN 6FR FEM JL5 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H749389696640,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.07IN 6FR FEM AL1 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H74938969680,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.070IN 6FR VL3 RUNWAY -,SUP-H74938969710,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.070IN 6FR FL BK -UP 4 100CM RUNWAY 2X2 RND BRD -,SUP-H749389697160,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.070IN 6FR FR4 ST RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H74938969920,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.070IN 6FR MP1 125CM RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389699530,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
MICRO GUIDE CATH MAMBA FLEX 135 REF: H7493928713540 -,SUP-H7493928713540,CDM,C1887,HCPCS,272,RC,,,outpatient,,,5071.58,3550.106,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
STINGRAY LP BALLOON 3.2FR -,SUP-H749393120SR0,CDM,C1887,HCPCS,272,RC,,,outpatient,,,6490.48,4543.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
GUIDE EXTENSION CATHETER GUIDEZILLA II 6F -,SUP-H7493933515060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
GUIDE EXTENSION CATHETER GUIDEZILLA II 6F LONG -,SUP-H74939335150610,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
GUIDE EXTENSION CATHETER GUIDEZILLA II 7F -,SUP-H7493933515070,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
GUIDE EXTENSION CATHETER GUIDEZILLA II 8F -,SUP-H7493933515080,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH PTCA 135CM CROSSBOSS STINGRAY F/COR CTO -,SUP-H749M1000A0,CDM,C1887,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH ANG 4FR STR 65CM RADIFOCUS GLIDECATH DBL BRD SM-PRFL -,SUP-H787117140155,CDM,C1887,HCPCS,272,RC,,,outpatient,,,388.61,272.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
4FR GLIDECATH LONG 100CM STRAIGHT -,SUP-H787117140225,CDM,C1887,HCPCS,272,RC,,,outpatient,,,295.54,206.878,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH ANG 5FR ANG TAPR 65CM RADIFOCUS GLIDECATH SGL-BRD LRG -,SUP-H787117221045,CDM,C1887,HCPCS,272,RC,,,outpatient,,,388.61,272.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH ANG 5FR STR TAPR 65CM RADIFOCUS GLIDECATH SGL-BRD LRG -,SUP-H787117315025,CDM,C1887,HCPCS,272,RC,,,outpatient,,,388.61,272.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH ANG 4FR JB3 TIP 100CM TORCONNB ADVANTG BEACN BRD PERIPH -,SUP-HNBR4.0-35-100-P-NS-JB3,CDM,C1887,HCPCS,272,RC,,,outpatient,,,227.57,159.299,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.071IN 5FR EBU3.5 100CM LAUNCHR BRD LRG LUM DIST -,SUP-LA5EBU35,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 6FR 3D RIGHT LAUNCHR REF: LA63DRIGHT -,SUP-LA63DRIGHT,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.071IN 6FR AL1 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6AL10,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 6FR AL75 100CM LAUNCHR REF: LA6AL75 -,SUP-LA6AL75,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.071IN 6FR AR1 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6AR10,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.071IN 6FR BU LT EBU 3 100CM LAUNCHR BRD LRG LUM -,SUP-LA6EBU30,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.071IN 6FR BU LT EBU 3.5 100CM LAUNCHR BRD LRG -,SUP-LA6EBU35,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.071IN 6FR BU LT EBU 3.75 100CM LAUNCHR BRD LRG -,SUP-LA6EBU375,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.071IN 6FR BU LT EBU 4 100CM LAUNCHR BRD LRG LUM -,SUP-LA6EBU40,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.071IN 6FR EBU 4.5 100CM LAUNCHR -,SUP-LA6EBU45,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.071IN 6FR BYPS IMA 90CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6IMAD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.071IN 6FR STD JR4 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6JR40,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 7FR 3D RIGHT LAUNCHR REF: LA73DRIGHT -,SUP-LA73DRIGHT,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUIDE 7 FR AL.75 SH D REF: LA7AL75SHD -,SUP-LA7AL75SHD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.081IN 7FR COR EBU3.5 100CM LAUNCHR BRD LRG LUM -,SUP-LA7EBU35,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.081IN 7FR COR EBU4 100CM LAUNCHR BRD LRG LUM -,SUP-LA7EBU40,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.081IN 7FR EBU4.5 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA7EBU45,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 7FR JR4 90CM LAUNCHR -,SUP-LA7JR40D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,256.74,179.718,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
GUIDE 8F AL 1.0 SH 90CM -,SUP-LA8AL10D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
GUIDE 8F AL 2.0 90CM MICR CATH -,SUP-LA8AL20D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
GUIDE 8F AL .75 90CM CATH -,SUP-LA8AL75D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
GUIDE 8F EBU 3.5 90CM -,SUP-LA8EBU35D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
GUIDE 8F EBU 3.5 SH 90CM -,SUP-LA8EBU35D SHD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
GUIDE 8F EBU 4.0 90CM -,SUP-LA8EBU40D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
GUIDE 8F JL 4.0 90CM -,SUP-LA8JL40D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
GUIDE 8F JL 4.0 SH 90CM -,SUP-LA8JL40D SHD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 105CM 20CM -,SUP-M001181250,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2497.81,1748.467,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D C 1 130CM 20CM -,SUP-M001181310,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2497.81,1748.467,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 150CM 20CM STC-18 -,SUP-M001181370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2497.81,1748.467,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 130CM 20CM -,SUP-M001182520,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1981.8,1387.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 150CM 20CM -,SUP-M001182530,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2297.77,1608.439,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
C RENEGADE HI-FLO MICROCATH -,SUP-M001183030,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2589.9,1812.93,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
MICROCATH INTVN 0.021IN SWAN 130CM DIREXION HI-FLO -,SUP-M001195300,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3221.16,2254.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH MICRO DREXION HI FLO J TO -,SUP-M001195470,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2566.03,1796.221,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.081IN 7FR LIMA 55CM MACH1 4X2 RND BRD LRG LUM -,SUP-M001197620,CDM,C1887,HCPCS,272,RC,,,outpatient,,,560.22,392.154,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH GUID 0.091IN 8FR LIMA 55CM MACH1 RND BRD LRG LUM PERIPH -,SUP-M001198620,CDM,C1887,HCPCS,272,RC,,,outpatient,,,560.22,392.154,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH ANG 4FR PIGTL 65CM IMAGER II SLCT FLSH BRD TRQ TUNG -,SUP-M001315091,CDM,C1887,HCPCS,272,RC,,,outpatient,,,58.24,40.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH ANG 4FR PIGTL 90CM IMAGER II FLSH BRD TRQ MED-GLD CTD -,SUP-M001315111,CDM,C1887,HCPCS,272,RC,,,outpatient,,,58.24,40.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH ANG 4FR CNTRLAT 2 CRV 65CM IMAGER II SLCT BRD TRQ SDE -,SUP-M001316581,CDM,C1887,HCPCS,272,RC,,,outpatient,,,58.24,40.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
MICRO GUIDE CATH FINECROSS M3 2.5 Fr 130 CM REF: M3-1430 -,SUP-M3-1430,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
MICRO GUIDE CATH FINECROSS M3 2.5 Fr 150 CM REF: M3-1450 -,SUP-M3-1450,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
PROGREAT 2.0 70 DEGREE ANGLE  150CM -,SUP-MC*PC2015ZRA,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3652.11,2556.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
PROGREAT COAXIAL MICROCATHETER2.4 FR  150CM   DEGREE ANGLE -,SUP-MC*PE24151YV,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2673.44,1871.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
PROGREAT COAXIAL 2.8 FR  150CM   RO MARKER BAND -,SUP-MC*PE28151YV,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2673.44,1871.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
PROGREAT 2.4  70 DEGREE ANGLE  150CM -,SUP-MC*PV2415ZRA,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2061.89,1443.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
PROGREAT MICROCATHETER 2.4x150CM -,SUP-MCPV2415Y,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1749.17,1224.419,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATHETER NAVICROSS 018 65CM ANGLED STAINLESS STEEL -,SUP-NC18651,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATHETER NAVICROSS 018 90CM ANGLED STAINLESS STEEL -,SUP-NC18901,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
C NAVICROSS 135CM .035 STR T -,SUP-NC35130,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
C NAVICROSS 135CM .035 ANGLE -,SUP-NC35131,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH INTVN 12MM TIP STR TAPR 150CM NAVICROSS SUPP DBL BRD -,SUP-NC35150,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATHETER SUPPORT NAVICROSS 0.035 150CM ANGLED -,SUP-NC35151,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
SHEATH GUID 6FRX90CM PINNACLE -,SUP-RSC03,CDM,C1887,HCPCS,272,RC,,,outpatient,,,743.96,520.772,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
SHEATH GUID 6FRX90CM PINNCL DSTNTN VASC STR CRV GOLD COIL. -,SUP-RSC05,CDM,C1887,HCPCS,272,RC,,,outpatient,,,743.96,520.772,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
SHEATH GUID 6FRX90CM PINNCL DSTNTN VASC MP CRV GOLD COIL -,SUP-RSC07,CDM,C1887,HCPCS,272,RC,,,outpatient,,,743.96,520.772,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
SHEATH GUID 6FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL- -,SUP-RSR01,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
SHEATH GUID 7FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-RSR04,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
SHEATH GUID 7FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-RSR04,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
TIP GUIDE CATH RELIEVA SPIN SPND SIN S-0 SHP TIP BLN WND ORT -,SUP-RSS0,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1696.16,1187.312,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH DX TAPR 65CM TRAILBLAZER SUPP HYDRCT -,SUP-SC035065,CDM,C1887,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATHETER GUIDING 6FR X 125 JL 5 JUDKINS -,SUP-SM7361,CDM,C1887,HCPCS,272,RC,,,outpatient,,,882.25,617.575,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
SHEATH 6.5 FR X 55CM X 17MM -,SUP-TG0655517,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH SHEATH RITESITE C315H20 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH SHEATH RITESITE C315H2001 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH SHEATH RITESITE C315H40 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH SHEATH RITESITE C315H4001 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH SHEATH RITESITE C315J -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH SHEATH RITESITE C315S4 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH SHEATH RITESITE C315S401 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH SHEATH RITESITE C315G -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH SHEATH RITESITE C315S5 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH SHEATH RITESITE C315J01 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH SHEATH RITESITE C315S10 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH SHEATH RITESITE C315S1001 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH SHEATH RITESITE C315S501 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
COIL MICRO RENEGADE STR FIBER -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2297.77,1608.439,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH OCL 0.97MM 6FR SHTH 110CM WILDCAT FLSH OTW 2MM XING -,SUP-W400,CDM,C1887,HCPCS,272,RC,,,outpatient,,,6769.18,4738.426,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
CATH OCL 0.43MM 5FR SHTH 150CM KITTYCAT 2 OTW 1.7MM XING -,SUP-W550,CDM,C1887,HCPCS,272,RC,,,outpatient,,,6769.18,4738.426,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.22704,7607.37,other,SI=N Exclusions ,,
TUBE PEG 20FR PONSKY NBR NON BALLOON REPLACEMENT -,SUP-000700,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1250.92,875.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
TUBE JJUNO 16FRX108IN PVC/PLST 15ML BLN LUMX2 -,SUP-0042510,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1602.34,1121.638,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
TUBE GASTROSTOMY 14 FR -,SUP-0100-14LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
TUBE GASTROSTOMY FEEDING 16 FR -,SUP-010016LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,220.33,154.231,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
TUBE GASTROSTOMY 16FR -,SUP-0100-16LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
TUBE GASTROSTOMY FEEDING 18FR -,SUP-0100-18,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
MIC GASTROSTOMY TUBE 20 FR -,SUP-0100-20,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
TUBE GASTROSTOMY FEEDING 20 FR -,SUP-0100-20,CDM,C1889,HCPCS,278,RC,,,outpatient,,,45.16,31.612,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
TUBE GASTROSTOMY FEEDING 22 FR -,SUP-0100-22,CDM,C1889,HCPCS,278,RC,,,outpatient,,,225.87,158.109,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
MIC GASTROSTOMY TUBE 24 FR -,SUP-0100-24,CDM,C1889,HCPCS,278,RC,,,outpatient,,,43.52,30.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
TUBE GASTROSTOMY 26 FR -,SUP-0100-26,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
TUBE JJUNO 12FR SIL MI C SECUR-LOK XTRN RETEN RNG -,SUP-0200-12LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
TUBE JJUNO 14FR SIL 7-10ML BLN MI C SECUR-LOK XTRN RETEN RNG -,SUP-0200-14,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
TUBE FEEDING JEJUNAL 16F -,SUP-0200-16,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
TUBE JJUNO 18FR SIL 7-10ML BLN MIC-KEY SECUR-LOK XTRN RETEN -,SUP-0200-18,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
TUBE JEJUNOSTOMY 22FR MIC SECUR-LOK SILICONE -,SUP-0200-22,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
TUBE JJUNO 22FRX45CM SIL 7-10ML BLN MIC-KEY LPRO -,SUP-0250-22,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1221.18,854.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
TUBE MIC JEJUNOSTOMY 14FR / DR. GLEESON -,SUP-0301-14,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1113.49,779.443,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
TUBE NG 6FR SALEM SMP 60CM VYGON -,SUP-1340.06,CDM,C1889,HCPCS,278,RC,,,outpatient,,,79.12,55.384,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
CONNECTOR CATHETER NYLON STRAIGHT 1.5 X 1.0 X 1.9 -,SUP-45103,CDM,C1889,HCPCS,278,RC,,,outpatient,,,481.1,336.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
CONNECTOR CSF CATH STRAIGHT 3 WAY IMP 2 X 1.5 X 1.8 X 1.0 -,SUP-45105,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1359.53,951.671,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
AZUR 18D SYSTEM 4MM X 5CM -,SUP-45-480405,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3570.95,2499.665,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
AZUR CX 35D 4MM X 7C3 DETACHABLE -,SUP-45-750407,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
AZUR CX .035 5MM X 11CM DETACH -,SUP-45-750511,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
AZUR CX DETACH 035 6MMX17CM -,SUP-45-750617,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
AZUR CK DETACHABLE 035 8MM X 12CM -,SUP-45-750812,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
AZUR CX DETACH 035 8MMX24CM -,SUP-45-750824,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
AZUR CX DETACH 035 10MMX19CM -,SUP-45-751019,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
AZUR CX 35 DETACH 13MMX24CM CX COIL -,SUP-45-751324,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
AZUR CX 35D 16MM X 32 CM -,SUP-45-751632,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
AZUR CX 35D 20MM X 39 CM -,SUP-45-752039,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
AZUR CX DETACHABLE 018 6MM X 20CM -,SUP-45-780620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
AZUR CX DETACHABLE 018 7MM X 24CM -,SUP-45-780724,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
AZUR CX DETACHABLE 018 8MM X 28CM -,SUP-45-780828,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
COIL EMBOLIZATION POD 0.020IN 4MM 30CM FULLY DETACHABLE RESH -,SUP-90178538,CDM,C1889,HCPCS,278,RC,,,outpatient,,,8190.92,5733.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
KIT INTRO GASTROSTOMY FEED -,SUP-98432,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1149.84,804.888,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
SENTINEL CEREBRAL PROTECTION SYSTEM REF: CMS15-10C-US -,SUP-CMS15-10C-US,CDM,C1889,HCPCS,278,RC,,,outpatient,,,14852,10396.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
COIL EMBOLIZATION NESTER MICROCOIL PLATINUM L3 CM OD2 MM . -,SUP-G47331,CDM,C1889,HCPCS,278,RC,,,outpatient,,,577.61,404.327,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
14X14 NESTER COIL 0.035 -,SUP-G47347,CDM,C1889,HCPCS,278,RC,,,outpatient,,,705.98,494.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
CATH COOK AIRWAY EXCHANGE 14FR 83CM. -,SUP-G57622,CDM,C1889,HCPCS,278,RC,,,outpatient,,,374.02,261.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
SPACER BONE CERVICAL LOR 6MM -,SUP-LGAL906,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
SPACER BONE CERVICAL LOR 7MM -,SUP-LGAL907,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
SPACER BONE CERVICAL LOR 8MM -,SUP-LGAL908,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
SPACER BONE CERVICAL PAR 6MM -,SUP-LGAP906-P,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
SPACER BONE CERVICAL PAR 7MM -,SUP-LGAP907-P,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
SPACER BONE CERVICAL PAR 8MM -,SUP-LGAP908-P,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
CATHETER DELIVERY AVEIR REF:LSCD111 -,SUP-LSCD111,CDM,C1889,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
BASKET SPECIMEN RETRIEVAL ZERO TIP 0.8MM 12MM ENDOSCOPIC -,SUP-M00513200,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1398.8,979.16,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
PROBE BILIARY EHL -,SUP-M00546620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2273.91,1591.737,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
TUBE PEG 16FR ENDOVIVE LPRO PUL LF -,SUP-M00582060,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
TUBE PEG 18FR ENDOVIVE LPRO PUL LF -,SUP-M00582070,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
KIT BALLOON REPLACEMENT STRAIGHT BOLSTER 20FR -,SUP-M00582080,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
KT TUBE PEG 24FR ENDOVIVE LPRO PUL LF -,SUP-M00582090,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
KIT BALLOON REPLACEMENT RIGHT ANGLE BOLSTER 20FR -,SUP-M00582150,CDM,C1889,HCPCS,278,RC,,,outpatient,,,192.44,134.708,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
TUBE PEG 24FR 3ML BLN SIL ENDOVIVE RT ANG LF -,SUP-M00582160,CDM,C1889,HCPCS,278,RC,,,outpatient,,,192.44,134.708,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
WATCHMAN FXD CURVE ACCESS SYSTEM SGL US REF: M635TU80010 -,SUP-M635TU80010,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
WATCHMAN FXD CURVE ACCESS SYSTEM DBL US REF: M635TU80020 -,SUP-M635TU80020,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
TUBE PEG 14FR 5ML BALLON TRITON LTX -,SUP-PEG-14-BRT-TR1,CDM,C1889,HCPCS,278,RC,,,outpatient,,,233.4,163.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
COIL EMBL 3MMX5CM RUBY MICRO CMPLX STD FRM FLLY DTCH RSHEATH -,SUP-RBY2C0305,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
COIL EMBL 3MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0320,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4769.23,3338.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
COIL EMBL 4MMX10CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0410,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
COIL EMBL 4MMX15CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0415,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
COIL EMBL 4MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0420,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
COIL EMBL 4MMX35CM RUBY CMPLX STD FRM FLLY DTCH RSHEATH -,SUP-RBY2C0435,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
COIL EMBL 5MMX12CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0512,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
COIL EMBL 5MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0520,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
COIL EMBL 5MMX30CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0530,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
COIL EMBL 6MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4769.23,3338.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
COIL EMBL 6MMX30CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0630,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
COIL EMBL 7MMX25CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0725,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
COIL EMBL 8MMX25CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0825,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
COIL EMBL 8MMX40CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0840,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
COIL EMBL 9MMX30CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0930,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
COIL EMBL 10MMX35CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1035,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
COIL EMBL 12MMX40CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1240,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
COIL EMBL 12MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1260,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
COIL EMBL 14MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1460,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
COIL EMBL 16MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1660,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
COIL EMBL 18MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1857,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
COIL EMBL 20MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C2060,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
COIL EMBL 24MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C2457,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
COIL EMBL 28MMX60CM RUBY MICRO CMPLX STD FRM FLLY -,SUP-RBY2C2860,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
COIL EMBL 32MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C3260,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
RUBYCOIL 36MM X 60MM STANDARD -,SUP-RBY2C3660,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
RUBYCOIL 40MM X 60MM STANDARD -,SUP-RBY2C4060,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
COIL EMBL 2MMX4CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH PLTNM -,SUP-RBY4C0204,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3814.43,2670.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
COIL EMBL 3MMX5CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH PLTNM -,SUP-RBY4C0305,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
COIL EMBL 3MMX15CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0315,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
COIL EMBL 4MMX6CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH PLTNM -,SUP-RBY4C0406,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
COIL EMBL 4MMX15CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0415,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
COIL EMBL 6MMX20CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
COIL EMBL 6MMX30CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0630,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
COIL EMBL 8MMX35CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0835,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
COIL EMBL 8MMX60CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0860,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
COIL EMBL 16MMX50CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C1650,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
RUBY COIL LP- 1 MM x 5 CM PERIPHERAL EMBOLIZATION COILS -,SUP-RBYLP0105,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
RUBY COIL LP- 2 MM x 10 CM PERIPHERAL EMBOLIZATION COILS -,SUP-RBYLP0210,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
RUBY COIL LP- 3 MM x 4 CM PERIPHERAL EMBOLIZATION COILS -,SUP-RBYLP0304,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
PENUMBRA RUBY POD 6MM X 50CM -,SUP-RBYPOD6,CDM,C1889,HCPCS,278,RC,,,outpatient,,,8190.92,5733.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
SPACE OAR VUE HYDROGEL -,SUP-SV-2101,CDM,C1889,HCPCS,278,RC,,,outpatient,,,12791.29,8953.903,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.77024,11406.336,other,SI=N Exclusions ,,
INTRO SHTH 6FRX14CM J SHP TIP 12ML SYR DI-LOK DILATOR 18GA -,SUP-405104,CDM,C1892,HCPCS,272,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.121935,3080.6622,other,SI=N Exclusions ,,
INTRO SHTH 7FRX14CM 0.038INX50CM JTP GW 18GA XTW NDL 12ML -,SUP-405108,CDM,C1892,HCPCS,272,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.121935,3080.6622,other,SI=N Exclusions ,,
KT 12FR 18GAX14CM 0.38INX50CM GW CV 3MM JTP PEEL-AWAY -,SUP-405120,CDM,C1892,HCPCS,272,RC,,,outpatient,,,186.72,130.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.121935,3080.6622,other,SI=N Exclusions ,,
INTRO SHTH 10.5FRX14CM 0.038INX50CM JTP GW 18GA XTW NDL 12ML -,SUP-405122,CDM,C1892,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.121935,3080.6622,other,SI=N Exclusions ,,
INTRO SHTH 8T-TW FR DIA 14CM 0.038INX50CM JTP GW 18GA XTW -,SUP-405129,CDM,C1892,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.121935,3080.6622,other,SI=N Exclusions ,,
INTRO SHTH 8FRX14CM J SHP TIP 12ML SYR DI-LOK DILATOR 18GA -,SUP-405145,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.121935,3080.6622,other,SI=N Exclusions ,,
INTRO LD 9FR PEEL-AWAY SHTH SGL-CHMBR -,SUP-405147,CDM,C1892,HCPCS,272,RC,,,outpatient,,,320.93,224.651,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.121935,3080.6622,other,SI=N Exclusions ,,
INTRO SHTH 8FRX14CM 0.038IN GW DI- LOCK DILATOR -,SUP-405412,CDM,C1892,HCPCS,272,RC,,,outpatient,,,90.56,63.392,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.121935,3080.6622,other,SI=N Exclusions ,,
INTRO SHTH 9FRX14CM 0.038IN GW DI- LOCK DILATOR -,SUP-405416,CDM,C1892,HCPCS,272,RC,,,outpatient,,,89.63,62.741,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.121935,3080.6622,other,SI=N Exclusions ,,
TRANSDC TRANSTHORACIC BTRY PK VIEWMATE -,SUP-405422,CDM,C1892,HCPCS,272,RC,,,outpatient,,,175.05,122.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.121935,3080.6622,other,SI=N Exclusions ,,
INTRO SHTH 11FRX14CM 0.038INX50CM JTP GW 18GA XTW NDL 12ML -,SUP-405424,CDM,C1892,HCPCS,272,RC,,,outpatient,,,175.05,122.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.121935,3080.6622,other,SI=N Exclusions ,,
INTRO VASC 8FR SUPER SHTH INFS SDPRT -,SUP-CLS-1008,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.121935,3080.6622,other,SI=N Exclusions ,,
INTRO VASC 8.5FR SUPER SHTH INFS SDPRT -,SUP-CLS-1008.5,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.121935,3080.6622,other,SI=N Exclusions ,,
INTRO VASC 10.5FR SUPER SHTH INFS SDPRT -,SUP-CLS-1010.5,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.121935,3080.6622,other,SI=N Exclusions ,,
INTRO VASC 8FR LNG SUPER SHTH INFS SDPRT -,SUP-CLS-2508,CDM,C1892,HCPCS,272,RC,,,outpatient,,,301.67,211.169,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.121935,3080.6622,other,SI=N Exclusions ,,
CPS DIRECT MEDI GUIDE ENABLED OUT CATH  RIGHT -,SUP-DS2M044,CDM,C1892,HCPCS,272,RC,,,outpatient,,,4296.6,3007.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.121935,3080.6622,other,SI=N Exclusions ,,
SET INTRODUCER PEEL-AWAY SAFE-T-J -,SUP-G04496,CDM,C1892,HCPCS,272,RC,,,outpatient,,,397.66,278.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.121935,3080.6622,other,SI=N Exclusions ,,
SHEATH SAFE PRELUDE 6F 13CM LN -,SUP-PLS-1006,CDM,C1892,HCPCS,272,RC,,,outpatient,,,274.25,191.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.121935,3080.6622,other,SI=N Exclusions ,,
INTRODUCER MERIT PRELUDE 9F 25CM -,SUP-PLS-2509,CDM,C1892,HCPCS,272,RC,,,outpatient,,,301.67,211.169,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.121935,3080.6622,other,SI=N Exclusions ,,
INTRODUCER 9FR OPTISEAL -,SUP-UNDEFINED,CDM,C1892,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,20.121935,3080.6622,other,SI=N Exclusions ,,
CATH GUID 7FR COR -,SUP-358735,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2448.83,1714.181,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,165.054645,2224.9227,other,SI=N Exclusions ,,
INTRO  SL1  CURVE - SJM 8.5FRX 63CM -,SUP-406849,CDM,C1893,HCPCS,272,RC,,,outpatient,,,892.76,624.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,165.054645,2224.9227,other,SI=N Exclusions ,,
INTRO GUID 8.5FRX60CM FAST-CATH SWARTZ TRNSEPT SAFL CRV -,SUP-406868,CDM,C1893,HCPCS,272,RC,,,outpatient,,,898.59,629.013,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,165.054645,2224.9227,other,SI=N Exclusions ,,
INTRO GUID 8FRX60CM FAST-CATH SWARTZ TRNSEPT SAFL CRV -,SUP-406871,CDM,C1893,HCPCS,272,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,165.054645,2224.9227,other,SI=N Exclusions ,,
INTRO GUID 8FRX60CM FAST-CATH SWARTZ TRNSEPT SEPT CRV -,SUP-406885,CDM,C1893,HCPCS,272,RC,,,outpatient,,,904.43,633.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,165.054645,2224.9227,other,SI=N Exclusions ,,
INTRO SEPT CURVE-SJM  8.5FRX60CM -,SUP-406894,CDM,C1893,HCPCS,272,RC,,,outpatient,,,898.59,629.013,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,165.054645,2224.9227,other,SI=N Exclusions ,,
INTRO  RAMP  CURVE - SJM 8.5FRX 63CM -,SUP-406965,CDM,C1893,HCPCS,272,RC,,,outpatient,,,735.21,514.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,165.054645,2224.9227,other,SI=N Exclusions ,,
SHEATH GUIDE LAMP 45 407363 -,SUP-407363,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1015.29,710.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,165.054645,2224.9227,other,SI=N Exclusions ,,
INTRODUCER CATHETER BRITE TIP RADIANZ GUIDING 6FR 110CM -,SUP-687280110,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1363.55,954.485,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,165.054645,2224.9227,other,SI=N Exclusions ,,
INTRODUCER CATHETER BRITE TIP RADIANZ GUIDING 6FR 135CM -,SUP-687280135,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1363.55,954.485,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,165.054645,2224.9227,other,SI=N Exclusions ,,
TRANSSEPTAL ACCESS STYSTEM ACQCROSS QX AG 71 CM REF: 900301 -,SUP-900301,CDM,C1893,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,165.054645,2224.9227,other,SI=N Exclusions ,,
TRANSSEPTAL ACCESS STYSTEM ACQCROSS QX - FC 65CM REF: 900304 -,SUP-900304,CDM,C1893,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,165.054645,2224.9227,other,SI=N Exclusions ,,
TRANSSEPTAL ACCESS STYSTEM ACQCROSS  WT 75CM REF: 900308 -,SUP-900308,CDM,C1893,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,165.054645,2224.9227,other,SI=N Exclusions ,,
FLEXCATH CROSS FCC 65CM 10FR REF:900310 -,SUP-900310,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,165.054645,2224.9227,other,SI=N Exclusions ,,
FLEXCATH CROSS FCC 65CM 12FR REF:900311 -,SUP-900311,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,165.054645,2224.9227,other,SI=N Exclusions ,,
CATHETER CPS LOCATOR 3D- LAGE EXTRA LONG REF:DS2C300-45 -,SUP-DS2C300-45,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,165.054645,2224.9227,other,SI=N Exclusions ,,
SHEATH GUID WORLEY RNL TLSCP GUIDE -,SUP-LVI7556207RE,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2464.73,1725.311,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,165.054645,2224.9227,other,SI=N Exclusions ,,
TORFLEX TRANSSEPTAL GUIDING SH -,SUP-TF85-32-63-45,CDM,C1893,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,165.054645,2224.9227,other,SI=N Exclusions ,,
DILATOR VESSEL 5 FR 35 -,SUP-040037A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,23.34,16.338,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
MICINTRO VASC 4.5FRX50CM MICRO EZ FNL DSGN SMTH DILATOR PTFE -,SUP-0928945,CDM,C1894,HCPCS,272,RC,,,outpatient,,,205.74,144.018,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
MICINTRO VASC 5FRX50CM MICRO EZ FNL DSGN SMTH DILATOR PTFE -,SUP-0928950,CDM,C1894,HCPCS,272,RC,,,outpatient,,,213.56,149.492,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
MICINTRO VASC 6FRX50CM MICRO EZ SMTH DILATOR PTFE 7CM A BVL -,SUP-0928960,CDM,C1894,HCPCS,272,RC,,,outpatient,,,189.64,132.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH INTRO 6FRX10CM PINNCL TIF TIP PERIPH 0.038INX45CM SS -,SUP-10-2032,CDM,C1894,HCPCS,272,RC,,,outpatient,,,72.94,51.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO INFS 7FR PEEL-AWAY -,SUP-120089,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.83,253.281,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH INTRO 5FRX10CM GLIDESHEATH RADL STR GOLD COIL MRKR -,SUP-20 -1050,CDM,C1894,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH INTRO 6FRX10CM GLIDESHEATH RADL STR GOLD COIL MRKR -,SUP-20 -1060,CDM,C1894,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
S COOK 7FR X 6CM -,SUP-242381,CDM,C1894,HCPCS,272,RC,,,outpatient,,,170.73,119.511,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH INTRO 5FRX10CM GLIDESHEATH RADL STR CRV GOLD COIL -,SUP-30-1050,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.48,364.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH INTRO 6FRX10CM GLIDESHEATH RADL STR CRV GOLD COIL -,SUP-30-1060,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.48,364.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH INTRO 6FRX10CM GLIDESHEATH RADL  STR CRV GOLD COIL -,SUP-30-1065,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.48,364.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH GUID 0.110IN 8FRX62CM PREFACE MP ST TAPR PRFL -,SUP-301803MS,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO CATH 4FRX3.2CM INTRSYT-N PERC SHLD -,SUP-384011,CDM,C1894,HCPCS,272,RC,,,outpatient,,,234.57,164.199,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO CATH 1.9FRX1.9CM INTRSYT-N PERC SHLD -,SUP-384021,CDM,C1894,HCPCS,272,RC,,,outpatient,,,280.08,196.056,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
FORTRESS SHEATH 5FR x 45CM -,SUP-386591,CDM,C1894,HCPCS,272,RC,,,outpatient,,,102.7,71.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
FORTRESS SHEALTH 5FRx45CM -,SUP-386591,CDM,C1894,HCPCS,272,RC,,,outpatient,,,102.7,71.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 10FRX11CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-011M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
S BRITE TIP 10FR 11CM  RB -,SUP-401-011M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH BRITE TIP 4F 11CM -,SUP-401411M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH 5FR 11CM BRITE TIP -,SUP-401511M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH 5FR BRITE TIP 23CM -,SUP-401-523M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 5FRX55CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-555M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 6FRX5.5CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401605M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 6FRX5.5CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-605M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH 6FR 11CM BRITE TIP -,SUP-401-611M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 6FRX5.5CM X 23CM CANN BRT TIP PERC TAPR SMTH -,SUP-401-623M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH 6F 23CM BRITE TIP -,SUP-401-623M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 6FRX55CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-655M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH 7 FR 11CM BRITE TIP -,SUP-401-711M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH 7FR X 23CM BRITE TIP -,SUP-401-723M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 7FRX45CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-745M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH 8FR 11CM BRITE TIP -,SUP-401-811M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
S BRITE TIP 8FR 23CM RB -,SUP-401-823M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 8FRX45CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-845M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
S BRITE TIP 9FR X 11CM RB -,SUP-401-911M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHTH INTRO 11FR X 11CM CANN BRT -,SUP-402611X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,43.18,30.226,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 6FR STD L 11CM REF: 402656X -,SUP-402656X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,43.18,30.226,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 2MM ANCURE -,SUP-40320,CDM,C1894,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
HEMOSTASIS INTRODUCER FAST CATH 10FRX30CM REF: 406180 -,SUP-406180,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.77,253.239,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
HEMOSTASIS INTRODUCER FAST CATH 14FRX30CM REF: 406188 -,SUP-406188,CDM,C1894,HCPCS,272,RC,,,outpatient,,,385.11,269.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
FAST CATH DUO SHEATH 12F  12CM -,SUP-406301,CDM,C1894,HCPCS,272,RC,,,outpatient,,,140.04,98.028,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 7FRX12CM FAST-CATH CATH-LOCK PERC JTP STR SNP -,SUP-406702,CDM,C1894,HCPCS,272,RC,,,outpatient,,,62.26,43.582,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 8FRX12CM FAST-CATH CATH-LOCK PERC JTP STR SNP -,SUP-406706,CDM,C1894,HCPCS,272,RC,,,outpatient,,,105.03,73.521,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 4FRX12CM FAST-CATH CATH-LOCK PERC JTP STR SNP -,SUP-406709,CDM,C1894,HCPCS,272,RC,,,outpatient,,,105.03,73.521,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 8FRX60CM FAST-CATH TRNSEPT MLNS CRV SNP LOCK -,SUP-406805,CDM,C1894,HCPCS,272,RC,,,outpatient,,,501.81,351.267,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SR0 CURVE-SJM -,SUP-406853,CDM,C1894,HCPCS,272,RC,,,outpatient,,,898.59,629.013,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH AGILIS MED-REPROC  8.5X 71CM -,SUP-408310,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2473.84,1731.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 4FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-604X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 6FR MI D L 23CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-606D,CDM,C1894,HCPCS,272,RC,,,outpatient,,,93.36,65.352,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 7FR MI D L 23CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-607T,CDM,C1894,HCPCS,272,RC,,,outpatient,,,93.36,65.352,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH INTRODUCER AVANTI 7FR X 11 CM -,SUP-504-607X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 8FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-608X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 9FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-609X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 10FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504610X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 11FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-611X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 5MS FR DIA MI D L 23CM CANN AVANTI + PERC TAPR SS -,SUP-504-655T,CDM,C1894,HCPCS,272,RC,,,outpatient,,,103.57,72.499,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 5MS DIA STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-655X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 5MS DIA STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-655X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 6MS FR DIA MI D L 23CM CANN AVANTI + PERC TAPR SS -,SUP-504-656T,CDM,C1894,HCPCS,272,RC,,,outpatient,,,93.36,65.352,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 6FR STD L 11CM CANN AVANTI  PERC TAPR SS W/O -,SUP-504-656X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 6FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-656X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
MONITORING SHEATH 7 FR INTRO -,SUP-504-657X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 8MS DIA STD L 11CM CANN AVANTI PERC TAPR SS W/O -,SUP-504-658X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
TIGHTRAIL MINI 11FR 545-011 -,SUP-540-011,CDM,C1894,HCPCS,272,RC,,,outpatient,,,7193.58,5035.506,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
TIGHTRAIL MINI  9FR 545-009 -,SUP-545-009,CDM,C1894,HCPCS,272,RC,,,outpatient,,,7193.58,5035.506,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
TIGHTRAIL LONG  9FR 545-509 -,SUP-545-509,CDM,C1894,HCPCS,272,RC,,,outpatient,,,10121.94,7085.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
TIGHTRAIL LONG 11FR 545-511 -,SUP-545-511,CDM,C1894,HCPCS,272,RC,,,outpatient,,,10121.94,7085.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
TIGHTRAIL LONG 13FR 545-513 -,SUP-545-513,CDM,C1894,HCPCS,272,RC,,,outpatient,,,10121.94,7085.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH GUID 8FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-54-84501,CDM,C1894,HCPCS,272,RC,,,outpatient,,,609.76,426.832,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
GLIDESHEATH SLENDER 6FR X 10CM X .021CM SS GLIDEWIRE -,SUP-60-1060,CDM,C1894,HCPCS,272,RC,,,outpatient,,,353.02,247.114,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
GLIDESHEATH SLENDER A KIT 0.025 GW 6FR 10CM -,SUP-60-1065,CDM,C1894,HCPCS,272,RC,,,outpatient,,,619.97,433.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
GLIDESHEATH SLENDER A KIT 0.025 GW 7FR 10CM -,SUP-60-1075,CDM,C1894,HCPCS,272,RC,,,outpatient,,,619.97,433.979,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 7FRX11CM INPUT PS PERC 0.038IN GW COMP VES -,SUP-700-11,CDM,C1894,HCPCS,272,RC,,,outpatient,,,56.02,39.214,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRODUCER SET 11 FR - DISCONTINUED DO NOT USE -,SUP-7097,CDM,C1894,HCPCS,272,RC,,,outpatient,,,320.93,224.651,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
GLIDESHEATH SLENDER SS KIT 0.025 GW 6FR 10CM -,SUP-80-1065,CDM,C1894,HCPCS,272,RC,,,outpatient,,,353.02,247.114,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
GLIDESHEATH SLENDER SS KIT 0.025 GW 7FR 10CM -,SUP-80-1075,CDM,C1894,HCPCS,272,RC,,,outpatient,,,353.02,247.114,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
AMPLATZER DELIVERY SHEATH TORQVUE 2 5FR REF: 9-TV2-05F120 -,SUP-90176109,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
AMPLATZER DELIVERY SHEATH TORQVUE 2 6FR REF: 9-TV2-06F120 -,SUP-9-TV2-06F120,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
TORQVUE SHEATH 14F 80CM 45X45 REF: 9-TV45X45-14F-080 -,SUP-9-TV45X45-14F-080,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4676.89,3273.823,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
OBTURATOR VASC 8FR SHRT -,SUP-AO-09000,CDM,C1894,HCPCS,272,RC,,,outpatient,,,13.65,9.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
CATH PA 7FR X 110CM SWAN-GNZ LUMX4 PLYMR BLND -,SUP-C146F7,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2531.31,1771.917,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRODUCER SHEATH 8.5FR CATH-GARD PERC ARROW KIT -,SUP-CDC-09803-1A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,430.62,301.434,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
9FR. PERC SHEATH INTRO KIT -,SUP-CDC-09903-1A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,418.37,292.859,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 10FRX35CM SUPER ARROW-FLEX PERC SNP-LOCK MIN -,SUP-CL-07035,CDM,C1894,HCPCS,272,RC,,,outpatient,,,547.82,383.474,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 5FR SHTH 4.375IN SHTH 0.035-0.038IN GW HEMSTS VLV -,SUP-CL-07511,CDM,C1894,HCPCS,272,RC,,,outpatient,,,182.55,127.785,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 6FRX24CM SUPER ARROW-FLEX PERC 0.038IN GW COMP -,SUP-CL-07624,CDM,C1894,HCPCS,272,RC,,,outpatient,,,431.79,302.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 6FRX45CM SUPER ARROW-FLEX PERC ANTMIC SURF PU -,SUP-CL-07645,CDM,C1894,HCPCS,272,RC,,,outpatient,,,553.38,387.366,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 7FRX24CM SUPER ARROW-FLEX PERC INTGR HEMSTS -,SUP-CL-07724,CDM,C1894,HCPCS,272,RC,,,outpatient,,,379.08,265.356,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 7FRX45CM SUPER ARROW-FLEX PERC ANTMIC SURF PU -,SUP-CL-07745,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.82,364.574,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH CLASSICSHEATH 6FR STD 13CM CRV GRN CAP -,SUP-CLS-1006,CDM,C1894,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO VASC 7FR SAFESHEATH INFS SDPRT -,SUP-CLS-1007,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.77,253.239,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO VASC 10FR SUPER SHTH INFS SDPRT -,SUP-CLS-1010,CDM,C1894,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 5FRX11CM SUPER ARROW-FLEX PERC 0.035IN GW COMP -,SUP-CP-07511,CDM,C1894,HCPCS,272,RC,,,outpatient,,,148.79,104.153,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
DRYSEAL FLEX INTRODUCER SHEATH - 1233 -,SUP-DSF1233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3695.08,2586.556,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH INTRO 12FRX28CM DRYSEAL HYDRCT -,SUP-DSF1233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3695.08,2586.556,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH DRYSEAL INTRODUCER -,SUP-DSF1245,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4821.18,3374.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
DRYSEAL FLEX INTRODUCER SHEATH 14FR REF: DSF1433 -,SUP-DSF1433,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
GORE INTRODUCER SHEATH 16 -,SUP-DSF1633,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3695.08,2586.556,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
DRYSEAL SHEATH--16 FR X 65CM -,SUP-DSF1665,CDM,C1894,HCPCS,272,RC,,,outpatient,,,5780.33,4046.231,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
GORE INTRODUCER SHEATH 18 -,SUP-DSF1833,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
22FR X 33CM DRYSEAL SHEATH -,SUP-DSF2233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
GORE DRY SEAL SHEATH 22F X 33CM -,SUP-DSF2233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
22FR X 65CM DRYSEAL SHEATH -,SUP-DSF2265,CDM,C1894,HCPCS,272,RC,,,outpatient,,,5780.33,4046.231,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
GORE DRY SEAL SHEATH 26F X 33CM -,SUP-DSF2633,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH INTRO 18FRX28CM DRYSEAL HYDRCT -,SUP-DSL1828,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
URETHRAL ACCESS SHTH 9.5FR ID AQ HYDRCT TAPR LUMX1 DILATOR -,SUP-FUS-095045,CDM,C1894,HCPCS,272,RC,,,outpatient,,,774.6,542.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
URETHRAL ACCESS SHTH 14FRX28CM AQ HYDRCT FLEXOR TAPR LUMX1 -,SUP-FUS-120028,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
URETHRAL ACCESS SHTH 12FR ID HYDRCT LUMX1 DILATOR -,SUP-FUS-120035,CDM,C1894,HCPCS,272,RC,,,outpatient,,,762.34,533.638,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
URETHRAL ACCESS SHTH 12FRX45CM HYDRCT TAPR LUMX1 DILATOR -,SUP-FUS-120045,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
DILATOR VASCULAR 16FR 20CM REF G01212 -,SUP-G01212,CDM,C1894,HCPCS,272,RC,,,outpatient,,,49.54,34.678,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH MICROPUN TRANSTLS TIP 0.018INX40CM GW PEDAL -,SUP-G02972,CDM,C1894,HCPCS,272,RC,,,outpatient,,,349.52,244.664,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 16FRX30CM PEEL-AWAY 0.038IN GW COMP -,SUP-G02997,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO CATH 22FRX13CM PEEL-AWAY LNG COONS TAPR STR 0.038IN GW -,SUP-G04096,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.57,194.299,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 18FRX15.5CM PEEL-AWAY LNG COONS TAPR STR 20CM VES -,SUP-G06444,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 20FRX13CM PEEL-AWAY PERC STR 20CM VES DILATOR W/O -,SUP-G06445,CDM,C1894,HCPCS,272,RC,,,outpatient,,,273.6,191.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 24FRX13CM PEEL-AWAY PERC STR 20CM VES DILATOR W/O -,SUP-G06446,CDM,C1894,HCPCS,272,RC,,,outpatient,,,273.6,191.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 12FRX15.5CM PEEL-AWAY PERC STR 0.038IN GW COMP -,SUP-G06492,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 14FRX15.5CM PEEL-AWAY PERC STR 0.038IN GW COMP -,SUP-G06496,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SET INTRODUCER PEEL-AWAY .038IN 15.5CM 15FR -,SUP-G06497,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
RING TRANS-JUG ACCESS SET WITH 9Fr -,SUP-G06541,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2759.32,1931.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 4MM 12FRX13CM PERFORM JTP 0.038IN GW COMP -,SUP-G07369,CDM,C1894,HCPCS,272,RC,,,outpatient,,,293.56,205.492,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 2.9MM 8FRX13CM FLEXOR 0.038IN GW SM CHECK-FLO VLV -,SUP-G07856,CDM,C1894,HCPCS,272,RC,,,outpatient,,,243.44,170.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH CHECKFLO PERFORMA 10FRX30CM -,SUP-G08686,CDM,C1894,HCPCS,272,RC,,,outpatient,,,419.77,293.839,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRODUCER CHECK-FLO PERFORMER 12FR 30CM -,SUP-G08956,CDM,C1894,HCPCS,272,RC,,,outpatient,,,419.77,293.839,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRODUCER CHECK-FLO PERFORMER 14FR 30CM -,SUP-G08957,CDM,C1894,HCPCS,272,RC,,,outpatient,,,419.77,293.839,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
CHECK FLOW PERFORMER INTRODUCER 16FR 70CM REF:G09582 -,SUP-G09582,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRODUCER CHECK-FLO PERFORMER 16FR 30CM -,SUP-G09691,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SET INTRODUCER CHECK-FLO EXTRA LARGE 18FR 40CM -,SUP-G10626,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH GUID 2.2MM 6FRX45CM FLEXOR CHECK-FLO BLKN UP/ OVR -,SUP-G10634,CDM,C1894,HCPCS,272,RC,,,outpatient,,,313.51,219.457,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
S COOK 6FR X 6CM -,SUP-G10675,CDM,C1894,HCPCS,272,RC,,,outpatient,,,170.73,119.511,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SET INTRODUCER CATHETER NEFF 4/6FR -,SUP-G10797,CDM,C1894,HCPCS,272,RC,,,outpatient,,,513.42,359.394,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 5FRX9CM PEEL-AWAY MICROPUNCTURE DENNY MOD LCK -,SUP-G11566,CDM,C1894,HCPCS,272,RC,,,outpatient,,,465.11,325.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 6FRX9CM PEEL-AWAY PERC DENNY MOD 0.018IN GW COMP -,SUP-G11568,CDM,C1894,HCPCS,272,RC,,,outpatient,,,465.11,325.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 8FRX9CM PEEL-AWAY PERC DENNY MOD 0.038IN GW COMP -,SUP-G11570,CDM,C1894,HCPCS,272,RC,,,outpatient,,,375.77,263.039,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
VALVE CHECK-FLO 7F 55C RAABE K -,SUP-G11633,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH RAABE FLEXOR 7FR X 90CM -,SUP-G11634,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH GUID 7FRX70CM FLEXOR CHECK-FLO RAABE MOD STR 0.038IN -,SUP-G11635,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH GUID 6FRX70CM FLEXOR CHECK-FLO RAABE MOD STR 0.038IN -,SUP-G11636,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH GUID 2.9MM 8FRX70CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G11637,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH 6FR STRAIGHT FLEXOR -,SUP-G11638,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH GUID 2.2MM 6FRX55CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G11638,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
CHECK FLOW PERFORMER INTRODUCER 18FR X 30CM -,SUP-G11672,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
VALVE CHECK-FLO 8F 55C RAABE K -,SUP-G12242,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH 6FR 90CM RAABE KCFW-6.0 -,SUP-G12266,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH GUID 3.2MM 9FRX70CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G12606,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRODUCER CHECK-FLO PERFORMER 22FR 25CM -,SUP-G12831,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2364.02,1654.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH GUID 2.5MM 7FRX90CM FLEXOR SHTL SFT TIP HYDRCT -,SUP-G12835,CDM,C1894,HCPCS,272,RC,,,outpatient,,,611.39,427.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH GUID 1.9MM 5FRX55CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G13009,CDM,C1894,HCPCS,272,RC,,,outpatient,,,268.41,187.887,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH GUID 1.9MM 5FRX90CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G13069,CDM,C1894,HCPCS,272,RC,,,outpatient,,,348.58,244.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 5FRX70CM FLEXOR CHECK-FLO RAABE MOD STR 0.038IN -,SUP-G13091,CDM,C1894,HCPCS,272,RC,,,outpatient,,,268.41,187.887,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH 6FR. 80CM -,SUP-G13539,CDM,C1894,HCPCS,272,RC,,,outpatient,,,611.39,427.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
URETHRAL ACCESS SHTH 9.5FR ID HYDRCT TAPR LUMX1 DILATOR -,SUP-G19174,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
URETHRAL ACCESS SHTH 9.5FRX28CM AQ HYDRCT FLEXOR TAPR LUMX1 -,SUP-G19176,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH 20F X 25CM COOK -,SUP-G28999,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2364.02,1654.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 12FRX24CM PEEL-AWAY PERC CRV 0.038IN GW COMP 34CM -,SUP-G29839,CDM,C1894,HCPCS,272,RC,,,outpatient,,,689.99,482.993,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 14FRX24CM PEEL-AWAY CRV 0.038IN GW COMP 18GA 12ML -,SUP-G29840,CDM,C1894,HCPCS,272,RC,,,outpatient,,,689.99,482.993,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH GUID 2.5MM 7FRX45CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29885,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
5Fr. 45cm ANSEL SHEATH WITH ANGLE KCFW-5.0-18/38/45-RB-ANL1- -,SUP-G29981,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH GUID 1.9MM 5FRX45CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29981,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH GUID 1.9MM 5FRX90MM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29988,CDM,C1894,HCPCS,272,RC,,,outpatient,,,586.83,410.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH 6F ANSEL 90CM FLEXOR KC -,SUP-G29989,CDM,C1894,HCPCS,272,RC,,,outpatient,,,586.83,410.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH GUID 2.2MM 6FRX55MM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29996,CDM,C1894,HCPCS,272,RC,,,outpatient,,,420.18,294.126,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH GUID 2.2MM 6FRX55MM FLEXOR CHECK-FLO ANSEL MOD RNL -,SUP-G29997,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHUTTLE SELECT GUIDE SHEATH KS -,SUP-G31138,CDM,C1894,HCPCS,272,RC,,,outpatient,,,617.11,431.977,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH CHECKFLOW 3.4MM 10FRX40CM FLEXOR -,SUP-G32233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,385.81,270.067,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH GUID 4.1MM 12FRX40CM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-G32373,CDM,C1894,HCPCS,272,RC,,,outpatient,,,444.22,310.954,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SET MICROPUNCTURE 5.0F 10CM -,SUP-G36333,CDM,C1894,HCPCS,272,RC,,,outpatient,,,159.7,111.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH GUID 3.2MM 9FRX55CM FLEXOR CHECK-FLO RAABE MOD -,SUP-G36393,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
MICRO PUNCTURE  5FR X 10CM  0.018INX40CM -,SUP-G43870,CDM,C1894,HCPCS,272,RC,,,outpatient,,,191.21,133.847,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH 5F ANSEL 45CM ANLO -,SUP-G44153,CDM,C1894,HCPCS,272,RC,,,outpatient,,,300.62,210.434,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH 6F ANSEL 45CM -,SUP-G44154,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH MICROPUNCTURE TRANSTLS TIP 0.018INX40CM PLTNM TIP -,SUP-G47942,CDM,C1894,HCPCS,272,RC,,,outpatient,,,190.1,133.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
MICROPUNCTURE STIFF 4F NIT -,SUP-G48003,CDM,C1894,HCPCS,272,RC,,,outpatient,,,281.36,196.952,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
MICROPUNCTURE TRANSITIONLESS STIFFENED CANNULA ACCESS SET -,SUP-G48005,CDM,C1894,HCPCS,272,RC,,,outpatient,,,281.36,196.952,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
WIRE FOR  MICROPUNCTURE 0.018 IN X 40 CM PLTNM TIP -,SUP-G48007,CDM,C1894,HCPCS,272,RC,,,outpatient,,,281.36,196.952,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH GUID 1.5MM 4FRX45MM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-G48186,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH 4F ANSEL 90CM -,SUP-G48188,CDM,C1894,HCPCS,272,RC,,,outpatient,,,620.26,434.182,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH 5F 90 RB ANSEL KCF-5.0- -,SUP-G48189,CDM,C1894,HCPCS,272,RC,,,outpatient,,,620.26,434.182,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH 7F X 55CM ANSEL 1 -,SUP-G49043,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH GUID 2.9MM 8FRX45CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G49100,CDM,C1894,HCPCS,272,RC,,,outpatient,,,356.11,249.277,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH GUID 3.2MM 9FRX45MM FLEXOR CHECK-FLO ANSEL MOD ANL1 -,SUP-G49102,CDM,C1894,HCPCS,272,RC,,,outpatient,,,356.11,249.277,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH GUID 6FRX70CM FLEXOR 0.038IN GW COMP HYDRCT -,SUP-G56221,CDM,C1894,HCPCS,272,RC,,,outpatient,,,452.45,316.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH GUIDING 7FR x 70CM STRAIGHT -,SUP-G56222,CDM,C1894,HCPCS,272,RC,,,outpatient,,,452.45,316.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH GUID 2.2MM 6FRX70CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G56226,CDM,C1894,HCPCS,272,RC,,,outpatient,,,452.45,316.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH GUID 1.9MM 5FRX55CM FLEXOR CHECK-FLO ANSEL MOD STR. -,SUP-G56230,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH GUID 1.9MM 5FRX55CM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-G56235,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH 6F X 55 ANSEL 1 -,SUP-G56236,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH FLEXOR PARALLEL 9.5CM x 28CM - URETERAL -,SUP-G56429,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1012.66,708.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH FLEXOR PARALLEL 9.5FR x 45CM URETERAL -,SUP-G56431,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1012.66,708.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SET MICROPUNCTURE INTRODUCER 21G -,SUP-G84006,CDM,C1894,HCPCS,272,RC,,,outpatient,,,252.07,176.449,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH GUIDING DESTINATION SLENDER 105CM 6FR STRAIGHT -,SUP-GS-R6ST1C10W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1599.43,1119.601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SYS SHEATH RTRVL 4FR BNTP EMBL PROT FLTWR EZ -,SUP-H749501001500,CDM,C1894,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
COAXIAL MICROINTRODUCER KIT 4FR -,SUP-H965457531,CDM,C1894,HCPCS,272,RC,,,outpatient,,,175.05,122.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO PERC 6FR SHTH INTROFLEX -,SUP-I500-F6,CDM,C1894,HCPCS,272,RC,,,outpatient,,,288.25,201.775,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 9FR STD INTROFLEX PERC W/O LIDOCN -,SUP-I505BF9C,CDM,C1894,HCPCS,272,RC,,,outpatient,,,243.32,170.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 5FRX10CM MICROPUNCTURE STF CANN COAX CATH PR -,SUP-JCD5.01810.0MPI,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.06,81.242,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
10fr 0.035 Flexer Guiding Sheath -,SUP-KCFW-10.0-35-RB-RTPS-100,CDM,C1894,HCPCS,272,RC,,,outpatient,,,641.79,449.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 2.2MM 6FRX30CM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-KCFW6.0-38-30RB,CDM,C1894,HCPCS,272,RC,,,outpatient,,,268.35,187.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO CATH 6FRX13CM SHTH FLEXOR NTPR 0.038IN GW VES DILATOR -,SUP-KCFW-6.0-38-RB,CDM,C1894,HCPCS,272,RC,,,outpatient,,,243.44,170.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO 4.5FRX5CM MICRO-ACCESS TEARAWAY 0.018INX4.CM MRK NTNL -,SUP-KIT-010-03,CDM,C1894,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
CATHETER RETRIEVAL AVEIR REF:LSCR111 -,SUP-LSCR111,CDM,C1894,HCPCS,272,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
LOADING SYSTEM ENVEO R  LS-MDT2-2629-US -,SUP-LS-MDT2-2629-US,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2067.2,1447.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
CATHETER INTRODUCER AVEIR 30CM REF:LSN25301 -,SUP-LSN25301,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 21GA ACCUSTICK II STF CANN -,SUP-M001207020,CDM,C1894,HCPCS,272,RC,,,outpatient,,,416.39,291.473,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH INTRO 8.5FRX60CM HEARTSPAN TRNSEPT 55DG CRV TAPR -,SUP-M0045660550,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1108.65,776.055,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH URET 11/13FRX36CM NAVIGATOR -,SUP-M0062502021,CDM,C1894,HCPCS,272,RC,,,outpatient,,,567.91,397.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH NAVIGATOR HD 11/13 X 28 -,SUP-M0062502210,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH NAVIGATOR HD 11 13 36 -,SUP-M0062502220,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH NAVIGATOR HD 11 13 46 -,SUP-M0062502230,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH NAVIGATOR HD 12 14 36 -,SUP-M0062502250,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH NAVIGATOR 12F/14F X 46CM -,SUP-M0062502260,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
ST DILATOR URETH 8-30FR OD 35CM 30CM SHTH TFLN-CT TAPR GRAD -,SUP-M0062601000,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1208.3,845.81,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
ST DILATOR URETH SHTH 8FR/10FR 70CM/35CM L PTFE TAPR LF -,SUP-M0062601200,CDM,C1894,HCPCS,272,RC,,,outpatient,,,280.31,196.217,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
URETHRAL ACCESS SHTH 34FR TAPR -,SUP-M0062601600,CDM,C1894,HCPCS,272,RC,,,outpatient,,,344.5,241.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
MICRO PUNCTURE 4FR X 10 CM NTNL 0.018X 40 -,SUP-MAK401NPD,CDM,C1894,HCPCS,272,RC,,,outpatient,,,91.84,64.288,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
MICRO PUNCTURE  5FR X 10CM  0.018INX40CM - MAK501N -,SUP-MAK501N,CDM,C1894,HCPCS,272,RC,,,outpatient,,,151.42,105.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
MICRA INTRO SHEATH HYDRO COAT -,SUP-MI2355A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
MICINTRO SHTH 7FRX7CM VENEFIT ECHGNC TIP 21GA -,SUP-MIS7F07,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
MICRO INTRO SHEATH 7F 11CM -,SUP-MIS-7F11,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH MICROPUNCTURE TRANSTLS TIP 0.018INX40CM PLTNM TIP -,SUP-MPIS-401-NT,CDM,C1894,HCPCS,272,RC,,,outpatient,,,190.1,133.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 4FR MICROPUNCTURE TRANSTLS TIP 0.018INX40CM PLTNM -,SUP-MPIS401PEDNTSST,CDM,C1894,HCPCS,272,RC,,,outpatient,,,197.05,137.935,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 5FRX10CM MICROPUNCTURE TRANSTLS TIP 0.018INX40CM -,SUP-MPIS-501-NT,CDM,C1894,HCPCS,272,RC,,,outpatient,,,191.21,133.847,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO ORTHO 4FR MICRO-STK NTNL WIRE -,SUP-MR190421,CDM,C1894,HCPCS,272,RC,,,outpatient,,,105.03,73.521,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 18FRX85CM PERFORM 0.038IN GW 97CM VES DILATOR -,SUP-RCFW18.0P3885RB,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 2.6MM 8FRX63CM PERFORM MLNS CRV 0.038IN GW COMP -,SUP-RCFW8.0-38-63,CDM,C1894,HCPCS,272,RC,,,outpatient,,,433.42,303.394,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH INTRO 6FRX10CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB602,CDM,C1894,HCPCS,272,RC,,,outpatient,,,152.29,106.603,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH INTRO 7FR X 10CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB702,CDM,C1894,HCPCS,272,RC,,,outpatient,,,152.29,106.603,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH INTRO 8FRX25CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB803,CDM,C1894,HCPCS,272,RC,,,outpatient,,,193.72,135.604,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH INTRO 9FRX10CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB902,CDM,C1894,HCPCS,272,RC,,,outpatient,,,152.29,106.603,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH INTRO 9FRX25CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB903,CDM,C1894,HCPCS,272,RC,,,outpatient,,,193.72,135.604,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH INTRO 5FRX10CM PINNCL PERIPH STR CRV 0.035IN GW COMP -,SUP-RSS501,CDM,C1894,HCPCS,272,RC,,,outpatient,,,63.43,44.401,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH 8FR 10CM PINNACLE -,SUP-RSS802,CDM,C1894,HCPCS,272,RC,,,outpatient,,,60.68,42.476,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH 9FR 10CM PINNACLE -,SUP-RSS901,CDM,C1894,HCPCS,272,RC,,,outpatient,,,63.43,44.401,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 14FRX28CM SENTRANT 0.035IN GW HYDRCT -,SUP-SENSH1428W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1108.65,776.055,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
INTRO SHTH 16FRX28CM SENTRANT 0.035IN GW COMP HYDRCT -,SUP-SENSH1628W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1123.71,786.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH 18FR MEDTRONIC -,SUP-SENSH1828W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1123.71,786.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH 20FR X 28CM MEDTRONIC -,SUP-SENSH2028W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1258.87,881.209,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
MICRO PUNCTURE  5FR X 10CM  0.018INX40CM STIFF- S-MAK501N -,SUP-S-MAK501N,CDM,C1894,HCPCS,272,RC,,,outpatient,,,210.06,147.042,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH NAVIGATOR 12F/14F X 28CM -,SUP-STRYKER INSTRUMENTS,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
9.5F SAFESHEATH PEEL AWAY HEMO -,SUP-UNDEFINED,CDM,C1894,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SHEATH INTRO 6FR BRT TIP -,SUP-UNDEFINED,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
CATAPULT US 5F 15CM STRAIGHT 5PK -,SUP-US-35015-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,519.32,363.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
CATAPULT US 5F 45CM STRAIGHT 5PK -,SUP-US-35045-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,636.02,445.214,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
CATAPULT US 5F 60CM STRAIGHT 5PK -,SUP-US-35060-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,694.37,486.059,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
CATAPULT US 5F 90CM STRAIGHT 5PK -,SUP-US-35090-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
TRANSEPTAL ACCESS SET VERSACROSS REF: VXSK0032 -,SUP-VXSK0032,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4630.78,3241.546,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
SET INTRODUCER CHECK-FLO EXTRA LARGE 20FR 40CM -,SUP-XVCFW-20.0-35-40,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2364.02,1654.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.064425,7986.663,other,SI=N Exclusions ,,
LEAD DEFIB IMPL BIPLR PERMNT PCNG ETAK RELIANCE 59CM 8FR -,SUP-0157,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions ,,
LEAD DEFIB ETAK RELIANCE 59CM -,SUP-0275-59,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions ,,
LEAD DEFIB ETAK RELIANCE 64CM -,SUP-0276-64,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions ,,
LEAD DEFIB ENDOTAK RELIANCE G 64CM -,SUP-0286,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions ,,
LEAD DEFIB PCNG ETAK RELIANCE 64CM GORE-HYBRID ETFE CTD STRD -,SUP-0293-64,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10470.66,7329.462,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions ,,
LEAD DEFIB IMPL BIPLR ETAK RELIANCE 4- SITE 59CM RT ECRD -,SUP-0295,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions ,,
LEAD DEFIB IMPL BIPLR ETAK RELIANCE 4- SITE 64CM RT ECRD -,SUP-0296,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions ,,
LEAD RELIANCE 4-FRONT 0673 64 CM -,SUP-0673-64,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions ,,
LEAD DEFIB BIPLR PERMNT PCNG KENTROX SL 65CM 7.8FRX180MM SPC -,SUP-350054,CDM,C1895,HCPCS,278,RC,,,outpatient,,,14265.35,9985.745,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions ,,
LEAD DEFIB IMPL LINOX SMRT SD 65CM 18CM ECRD SIL INSL DL -,SUP-359067,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions ,,
LEAD PCNG 60MM LINOX SD IMPL BIPLR RV STRD ELUT ACT -,SUP-363303,CDM,C1895,HCPCS,278,RC,,,outpatient,,,14265.35,9985.745,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions ,,
LEAD DEFIB TRIPLR SPRNT QUATTRO 65CM 8.6FRX12MM SPC RT ECRD -,SUP-6935-65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions ,,
LEAD DEFIB 8.6FRX12MM SPC 55CM SPRNT QUATTRO TRIPLR STRD -,SUP-6935M55,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions ,,
LEAD DEFIB TRIPLR SPRNT QUATTRO 62CM 8.6FRX12MM SPC SIL -,SUP-6935M62,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions ,,
LEAD PCNG 8.6FRX12MM SPC 58CM SPRNT QUATTRO PERMNT QDPL -,SUP-6947-58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions ,,
LEAD PCNG 8.6FRX12MM SPC 65CM SPRNT QUATTRO PERMNT QDPL -,SUP-6947-65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions ,,
LEAD DEFIB QDPL SPRNT QUATTRO 55CM 8.6FRX12MM SPC RT ECRD -,SUP-6947M55,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions ,,
LEAD DEFIB QDPL SPRNT QUATTRO 62CM 8.6FRX12MM SPC RT ECRD -,SUP-6947M62,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions ,,
LEAD DEFIB QDPL SPRNT QUATTRO 72CM 8.6FRX12MM SPC RT ECRD -,SUP-6947M72,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions ,,
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FRX170MM SPC VNTRC OPTIM -,SUP-7120/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions ,,
LEAD DEFIB TRUE BIPLR DURATA 52CM 7FRX170MM SPC VNTRC OPTIM -,SUP-7120Q/52,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions ,,
LEAD DEFIB TRUE BIPLR DURATA 58CM 7FR VNTRC OPTIM INSL SGL -,SUP-7120Q/58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions ,,
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FR VNTRC OPTIM INSL SGL -,SUP-7120Q/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions ,,
LEAD DEFIBRILLATOR DURATA OPTIM L21 CM OD7 FR 2 COIL -,SUP-7121,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11031.32,7721.924,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions ,,
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FRX210MM SPC VNTRC OPTIM -,SUP-7121/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions ,,
LEAD DEFIB TRUE BIPLR DURATA 52CM 7FR VNTRC OPTIM INSL SGL -,SUP-7121Q/52,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions ,,
LEAD DEFIB DURATA IMPL -,SUP-7131,CDM,C1895,HCPCS,278,RC,,,outpatient,,,17543.93,12280.751,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions ,,
LEAD DEFIB TRUE BIPLR DURATA 58CM 17CM-TO-PROX COIL 7FR -,SUP-7170Q/58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions ,,
LEAD DEFIB TRUE BIPLR DURATA 58CM 21CM-TO-PROX COIL 7FR -,SUP-7171Q/58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions ,,
LEAD DEFIB 8FR INTRO 65CM OPTISURE TRUE BIPLR XTD-RETRAC -,SUP-LDA230Q/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,13473.73824,other,SI=N Exclusions ,,
ELECTRODE DEFIB 12FR DIST TIP 9FR COIL 45CM Q-TRAK TRIPLR -,SUP-3400,CDM,C1896,HCPCS,278,RC,,,outpatient,,,14852,10396.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,11406.336,other,SI=N Exclusions ,,
ELECTRODE DEFIB 12FR DIST TIP 45CM EMBLEM TRIPLR SUBQ DIST -,SUP-3401,CDM,C1896,HCPCS,278,RC,,,outpatient,,,14852,10396.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,11406.336,other,SI=N Exclusions ,,
EMBLEM S-ICD LEAD 3501-45CM -,SUP-3501-45,CDM,C1896,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,11406.336,other,SI=N Exclusions ,,
LEAD EPICARDIAC 5071 -,SUP-5071,CDM,C1896,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,11406.336,other,SI=N Exclusions ,,
LEAD PCNG 58CM TRANSVENE IMPL UNIPL ECRD CS SVC -,SUP-6937A58,CDM,C1896,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,11406.336,other,SI=N Exclusions ,,
OPTISURE DEFIBRILLATION LEAD DF1 SINGLE COIL LDA210-65 -,SUP-LDA210-65,CDM,C1896,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,11406.336,other,SI=N Exclusions ,,
KT LEAD NEURSTM OCTRODE 60CM PERC ACC -,SUP-3086ANS,CDM,C1897,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,196.493625,28414.1568,other,SI=N Exclusions ,,
KT LEAD NEURSTM 60CM PERC ACC 6MM -,SUP-3873-60,CDM,C1897,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,196.493625,28414.1568,other,SI=N Exclusions ,,
KT LEAD NEURSTM 60CM PERC SUBCOMPACT ACC -,SUP-3875-60,CDM,C1897,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,196.493625,28414.1568,other,SI=N Exclusions ,,
REACTIV8 IMPLANTABLE PULSE GENERATOR -,SUP-5100,CDM,C1897,HCPCS,278,RC,,,outpatient,,,36997.6,25898.32,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,196.493625,28414.1568,other,SI=N Exclusions ,,
KT IT REVISN INTFC TRANSP STRN RLF SLVX2 NS RLR F/SULS PMP -,SUP-8578,CDM,C1897,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,196.493625,28414.1568,other,SI=N Exclusions ,,
LEAD NEURSTM VECTRIS SURSCN 60CM PERC SPIN CRD MRI-COND -,SUP-977D260,CDM,C1897,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,196.493625,28414.1568,other,SI=N Exclusions ,,
SLIM TIP DRG TRIAL LEAD KIT -,SUP-MN10350-50A,CDM,C1897,HCPCS,278,RC,,,outpatient,,,4874.15,3411.905,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,196.493625,28414.1568,other,SI=N Exclusions ,,
SLIP TIP DRG -,SUP-MN10350-90A,CDM,C1897,HCPCS,278,RC,,,outpatient,,,4909.5,3436.65,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,196.493625,28414.1568,other,SI=N Exclusions ,,
STIMWAVE NEUROSTIMULATOR RECEIVER KIT -,SUP-STQ4-RCV-A0,CDM,C1897,HCPCS,278,RC,,,outpatient,,,32936.92,23055.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,196.493625,28414.1568,other,SI=N Exclusions ,,
PNS PERMANENT TINED RECEIVER KIT CHANNEL B -,SUP-STQ4-RCV-B0,CDM,C1897,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,196.493625,28414.1568,other,SI=N Exclusions ,,
LEAD NRV STIM 50CM F/TRL -,SUP-UNDEFINED,CDM,C1897,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,196.493625,28414.1568,other,SI=N Exclusions ,,
LEAD PCNG 8FR INTRO 58CM TENDRIL DX PERMNT BIPLR AV -,SUP-1388TC/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 1642T X 46 -,SUP-1642T/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 7FR INTRO 10MM SPC 52CM ISFLX PERMNT BIPLR STR AV -,SUP-1646T/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 1646T-58 ISFLX PERMNT BIPLR_STR AV -,SUP-1646T/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 46CM TENDRIL -,SUP-1688TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
TENDRIL SDX 1688TC/46 -,SUP-1688TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD TENDRIL 1688 TC/58 -,SUP-1688TC-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 6FR INTRO 10MM SPC 52CM TENDRILL SDX PERMNT BIPLR -,SUP-1788TC/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 6FR INTRO 10MM SPC 58CM TENDRILL SDX PERMNT BIPLR -,SUP-1788TC/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 7FR INTRO 10MM SPC 46CM TENDRILL ST PERMNT BIPLR -,SUP-1882TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 7FR INTRO 10MM SPC 52CM TENDRILL ST PERMNT BIPLR -,SUP-1882TC/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 6FR INTRO 10MM SPC 46CM TENDRILL ST PERMNT BIPLR -,SUP-1888TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 6FR INTRO 10MM SPC 52CM TENDRILL ST PERMNT BIPLR -,SUP-1888TC/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 6FR INTRO 10MM SPC 58CM TENDRILL ST PERMNT BIPLR -,SUP-1888TC/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD ISOFLEX OPTIM J 1944-46CM -,SUP-1944/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 7FR INTRO 10MM SPC 52CM ISFLX PERMNT BIPLR J-SHP -,SUP-1944/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG ISOFLEX 1948-52 ISFLX PERMNT BIPLR STR AV. -,SUP-1948/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 7FR INTRO 10MM SPC 58CM ISFLX PERMNT BIPLR STR AV -,SUP-1948/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD OPINSENSE  MODEL 1999-52 -,SUP-1999/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD CATH DELIVERED 3830 69CM,SUP-2,CDM,C1898,HCPCS,275,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 6FRX46CM TENDRIL STS IMPL BIPLR RAV ACT SCR IN FX -,SUP-2088TC-46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 6FRX52CM TENDRIL STS IMPL BIPLR RAV ACT SCR IN FX -,SUP-2088TC-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 6FRX58CM TENDRIL STS IMPL BIPLR RAV ACT SCR IN FX -,SUP-2088TC-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 6.6FRX15MM SPC 60CM SELOX ST 60 PERMNT IMPL BIPLR -,SUP-346367,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 6.6FRX15MM SPC 53CM SELOX JT 53 PERMNT IMPL BIPLR -,SUP-346368,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 6.6FRX10MM SPC 45CM SETROX DX PERMNT IMPL BIPLR -,SUP-350973,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 7FRX10MM SPC 53CM SETROX DX PERMNT IMPL BIPLR HLCL -,SUP-350974,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 6.6FRX10MM SPC 60CM SETROX DX PERMNT IMPL BIPLR -,SUP-350975,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 6.6FR 7FR INTRO 53CM TILDA STR PSS FX -,SUP-382872,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD CATH DELIVERED 3830 69 CM -,SUP-383069,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 52CM SELUTE PICOTIP COMPLIANCE PRACTITIONERS -,SUP-4064,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 5.7FRX10MM SPC 35CM CAP NOV PERMNT BIPLR AV STRD -,SUP-4076-35,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2570.74,1799.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 5.7FRX10MM SPC 45CM CAP NOV IMPL BIPLR AV STRD -,SUP-4076-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PPM 45CM CAPSURE FIX NOVUS 4076-45 -,SUP-4076-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 5.3FRX9MM SPC 52CM CPSR SP NOVUS PERMNT BIPLR AV -,SUP-4092-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 5.3FRX9MM SPC 58CM CPSR SP NOVUS PERMNT BIPLR AV -,SUP-4092-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 6.7FRX10MM SPC 53CM DEXTRUS PERMNT BIPLR HLCL TIP -,SUP-4136-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 6.7FRX10MM SPC 60CM DEXTRUS PERMNT BIPLR HLCL TIP -,SUP-4137,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 5.7FRX16MM SPC 58CM FNLN STRX PERMNT BIPLR STR -,SUP-4457,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 1.7X16MM SPC_45CM FINELINE II EZ STEROX PERMNT -,SUP-4469,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 1.7X16MM SPC 45CM FINELINE II EZ STEROX PERMNT -,SUP-4469-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 1.7X16MM SPC 52CM FINELINE II EZ STEROX PERMNT -,SUP-4470-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 1.7X16MM SPC 58CM FINELINE II EZ STEROX PERMNT -,SUP-4471,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 5.7FRX45CM FNLN STRX AJ PERMNT BIPLR JTP RA ECRD -,SUP-4479,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 5.7FRX52CM FNLN STRX AJ PERMNT BIPLR JTP RA ECRD -,SUP-4480-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 5.3FRX9MM SPC 45CM CPSR SP NOVUS PERMNT BIPLR JTP -,SUP-4592-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 5.3FR CPSR SP NOVUS J-SHP ATR BIPLR -,SUP-4592-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD MEDTRONIC CAPSURE VDD-2 5038S-52 -,SUP-5038S-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD MEDTRONIC CAPSURE VDD-2 5038S-58 -,SUP-5038S-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG EPCRD -,SUP-5071-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PPM 45CM CAPSUREFIX SURSCN NOVUS 5076-45 -,SUP-5076-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 6.2FRX10MM SPC 52CM CAPSUREFIX SURSCN NOVUS IMPL -,SUP-5076-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 6.2FR X10MM SPC 58CM CAPSUREFIX SURSCN NOVUS IMPL -,SUP-5076-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 6.2FRX10MM SPC 65CM CAPSUREFIX SURSCN NOVUS IMPL -,SUP-5076-65,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 7FRX45CM CPSR FX MRI BIPLR STR AV ACT SCR IN FX -,SUP-5086MRI-45CM,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 7FRX52CM CPSR FX MRI BIPLR STR AV ACT SCR IN FX -,SUP-5086MRI-52CM,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 7FRX58CM CAPSUREFIX BIPLR STR AV ACT SCR IN FX -,SUP-5086MRI-58CM,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 35MM MYOPORE IMPL BIPLR EPCRD AV STRD ELUT ACT SCR -,SUP-511211,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD MYOPORE BIPOLAR 511211 -,SUP-511211,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 54CM MYOPORE IMPL BIPLR EPCRD AV STRD ELUT ACT SCR -,SUP-511212,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 7.2FRX53CM CAPSUREFIX PERMNT BIPLR J-SHP TIP ATR -,SUP-5568-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
BIPOLAR TEMPORARY MYOCARDIAL PACING LEAD -,SUP-6495F,CDM,C1898,HCPCS,278,RC,,,outpatient,,,408.45,285.915,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
OIL MNRL F/EZ INS STYL -,SUP-6529,CDM,C1898,HCPCS,278,RC,,,outpatient,,,175.05,122.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD INGEVITY MRI 7731 52 CM P -,SUP-7731,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD INGEVITY MRI 7732-59 ( PASSIVE ) -,SUP-7732,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD INGEVITY MRI 7732 59 -,SUP-7732-59,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
INGEVITY MRI  MODEL 7735-45 -,SUP-7735,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD INGEVITY MRI 7736-52 ( PASSIVE J ) -,SUP-7736,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD INGEVITY MRI 7740 -,SUP-7740,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD INGEVITY MRI 7741 52CM -,SUP-7741,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD INGEVITY MRI 7742 59CM -,SUP-7742,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
INGEVITY + 7840-45cm -,SUP-7840,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
INGEVITY + 7841/52 -,SUP-7841/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
INGEVITY + 7842/59 LEAD -,SUP-7842/59,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG ELAFIX ATR -,SUP-ELAFIX P2 752,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2549.32,1784.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 7FRX52CM BIPLR ECRD THN TND -,SUP-ELAPASSP752,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 7FRX58CM BIPLR ECRD THN TND -,SUP-ELAPASSP758,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2549.32,1784.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 7FRX52CM BIPLR J-SHP ECRD THN TND -,SUP-ELAPASSPJ752,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
TENDRIL MRI LEAD 46CM -,SUP-LPA1200M/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
TENDRIL MRI LEAD- 52CM -,SUP-LPA1200M/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
TENDRIL MRI LEAD- 58CM -,SUP-LPA1200M/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD CATH DELIVERED 3830 49CM -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD CATH DELIVERED 3830 59CM -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD CATH DELIVERED 3830 74CM -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD GENTR -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,39.298725,2053.20192,other,SI=N Exclusions ,,
LEAD PCNG 7FR INTRO 20MM SPC 86CM QUICKFLEX PERMNT BIPLR -,SUP-1156T/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions ,,
LEAD PCNG 5FRX20MM SPC 75CM QUICKFLEX U BIPLR STYP CRV LH -,SUP-1258T/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions ,,
LEAD PCNG 5FRX20MM SPC 86CM QUICKFLEX U BIPLR STYP CRV LH -,SUP-1258T/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions ,,
LEAD PCNG 5FRX20MM SPC 92CM QUICKFLEX U BIPLR STYP CRV LH -,SUP-1258T/92,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions ,,
Lead Quartet 1456/75Q LV Lead -,SUP-1456/75Q,CDM,C1900,HCPCS,278,RC,,,outpatient,,,8445.56,5911.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions ,,
LEAD QUARTET 1456Q/86 LV LEAD -,SUP-1456/86Q,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions ,,
QUARTET LEAD DOUBLE BEND- 75 CM MODEL 1457Q/75 -,SUP-1457Q/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions ,,
QUARTET LEAD DOUBLE BEND-86CM MODEL 1457Q/86 -,SUP-1457Q/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions ,,
LEAD PCNG 7FR INTRO 75CMX16MM QRTT CRT STYP CRV LH LPRO -,SUP-1458Q/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions ,,
LEAD PCNG 7FR INTRO 86CMX16MM QRTT CRT STYP CRV LH LPRO -,SUP-1458Q/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions ,,
LEAD QUARTET 75 WIDE SPACING -,SUP-1458QL/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions ,,
LEAD QUARTET 1458QL 86 WIDE SPACING -,SUP-1458QL/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions ,,
LEAD PCNG 5.4FRX18MM SPC 77CM COROX PERMNT IMPL BIPLR HMSPHR -,SUP-355148,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5228.61,3660.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions ,,
LEAD SENTUS OTW QP L-75 -,SUP-386835,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions ,,
LEAD SENTUS OTW QP S-75 -,SUP-400719,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions ,,
LV LEAD SENTUS OTW QP L 75/49 -,SUP-408718,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions ,,
LV LEAD SENTUS OTW QP L 85/49 -,SUP-408719,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions ,,
LEAD PCNG 5FRX88CM ATTAIN PERMNT UNIPL CANTED LT VNTRC OTW -,SUP-4195-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions ,,
LEAD PCNG 4FRX21MM SPC 88CM ATTAIN PERMNT BIPLR ANG LT VNTRC -,SUP-4196-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions ,,
LEAD PCNG 5.3FRX21MM SPC 88CM ATTAIN ABILITY + IMPL BIPLR -,SUP-4296-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions ,,
LEAD ATTAIN PERFORMA LV REF:429878 -,SUP-429878,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions ,,
LEAD PCNG 5.3FRX21MM SPC 78CM ATTAIN PERFORM QDPL DBL CRV LT -,SUP-4298-78,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions ,,
LEAD ATTAIN PERFORM 4298-88 CM QDPL DBL CRV LT -,SUP-4298-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions ,,
LEAD ATTAIN PERFORMA QUAD LV  88 -,SUP-439888,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions ,,
LEAD PCNG 6FRX11MM SPC 80CM EASYTRAK 2 IMPL UNIPL BIPLR LT -,SUP-4542,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5585.1,3909.57,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions ,,
LEAD PCNG 6FRX11MM SPC 90CM EASYTRAK 2 IMPL UNIPL BIPLR LT -,SUP-4543,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5585.1,3909.57,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions ,,
LEAD PCNG 6FRX11MM SPC 90CM EASYTRAK 3 IMPL UNIPL BIPLR LT -,SUP-4549,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5585.1,3909.57,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions ,,
LEAD PCNG 4.5FRX90CM ACUITY IMPL UNIPL LT ECRD VNTRC SPRL FX -,SUP-4592,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions ,,
LEAD ATTAIN PERFORMA LV 4598-78 -,SUP-4598-78,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions ,,
LEAD ATTAIN PERFORMA LV 4598-88 -,SUP-4598-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions ,,
LEAD ACUITY X4 86CM STRAIGHT -,SUP-4671,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions ,,
LEAD ACUITY X4 95CM STRAIGHT -,SUP-4672-95,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions ,,
LV LEAD ACUTIY SPIRAL S MODEL 4674-86 -,SUP-4674,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions ,,
LEAD ACUITY X4 95CM SPIRAL S -,SUP-4675-95,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions ,,
LEAD ACUITY X4 86CM SPIRAL L -,SUP-4677,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions ,,
LEAD ACUITY X4 95CM SPIRAL L -,SUP-4678-95,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions ,,
LEAD ATTAIN STABILITY QUAD MRI SURESCAN LV LEAD REF:4798-88 -,SUP-4798-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10247.88,7173.516,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions ,,
LV LEAD SENTUS OTW QP S 75/49 MODEL 406081 -,SUP-706081,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions ,,
LEAD COROX OTW-L 75-BP -,SUP-UNDEFINED,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5228.61,3660.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions ,,
LEAD COROX OTW-L 85-BP -,SUP-UNDEFINED,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5228.61,3660.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,9410.2272,other,SI=N Exclusions ,,
PROBE PERC SPIN 17GAX6IN -,SUP-0407-250-000,CDM,C2614,HCPCS,270,RC,,,outpatient,,,8309.75,5816.825,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6381.888,other,SI=N Exclusions ,,
SIR-SPHERES Y-90 RESIN MICROSPHERES -,SUP-SIR-Y001,CDM,C2616,HCPCS,278,RC,,,outpatient,,,44393.67,31075.569,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42246.09,,,42246.09,399.86,42246.08608,fee schedule,,,
STENT BLDR 14F/7FRX24CM RETROMAX + PERCUFLEX HYDRPLS CTD -,SUP-145-148,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1085.19,759.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT 6FR OPEN END -,SUP-160205,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT URET 8FRX80CM PERCUFLEX STR OPEN TIP -,SUP-160215,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
URINARY STENT 7FR CLOSED TIP -,SUP-160230,CDM,C2617,HCPCS,278,RC,,,outpatient,,,535.8,375.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT PANC 7FR PSHR CATH 5CM FREEMN -ALIPERT FLEX-STNT -,SUP-6521,CDM,C2617,HCPCS,278,RC,,,outpatient,,,320.93,224.651,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT PANC 7FRX9CM FREEMN FLX-STNT SGL PIGTL DBL XTRN FLNG -,SUP-6575,CDM,C2617,HCPCS,278,RC,,,outpatient,,,268.41,187.887,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT URET 4.7FRX26CM INLAY DBL PIGTL TAPR -,SUP-778426,CDM,C2617,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT BIL 10FRX5CM COTTON-LEUNG CRV TAPR PE -,SUP-CLSO 10-5,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT BIL 7FRX7CM COTTON-LEUNG CRV TAPR PE P/D FLP -,SUP-CLSO 7-7,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT BILIARY ZIMMON 8FR 12CM 0.035IN GW 3.2MM -,SUP-G21404,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT BIL 10FRX7CM COTTON-LEUNG CRV TAPR PE -,SUP-G21469,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT BIL 10FRX8CM COTTON-LEUNG CRV TAPR PE P/D FLP -,SUP-G21472,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT BIL 10FRX10CM COTTON-LEUNG CRV TAPR PE P/D FLP -,SUP-G21807,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT BILIARY ZIMMON 10-5 -,SUP-G21975,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT PANC 5FRX5CM ZIMMON SPRL SH PE PIGTL TAPR FLP LF MRI -,SUP-G22980,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT PANC 3FRX4CM ZIMMON SPRL SH PE PIGTL TAPR OPTN DCT FLP -,SUP-G24566,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT PANC 5FRX9CM GEENEN SPRL SH SOF-FLEX OFST PROX FLP LF -,SUP-G49666,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT PANC 5FR 7CM GEENEN SOF-FLEX NO INTERNAL FLAP -,SUP-G49670,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT PANC 5FR 9CM GEENEN SOF-FLEX NO INTERNAL FLAP -,SUP-G49671,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT BIL 7FRX5CM COMPASS BDS DBL PIGTL TAPR PLST 0.035IN GW -,SUP-G55519,CDM,C2617,HCPCS,278,RC,,,outpatient,,,414.29,290.003,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT PANC 5FR 3CM GEENEN SOF-FLEX NO INTERNAL FLAP -,SUP-GPSOS-SF-5-3,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT PANC 5FR 5CM GEENEN SOF-FLEX NO INTERNAL PLAP -,SUP-GPSOS-SF-5-5,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT URET 8FRX22CM PERCUFLEX DBL PIGTL FLXB STF -,SUP-M001245500,CDM,C2617,HCPCS,278,RC,,,outpatient,,,826.41,578.487,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT URET 6FRX22CM PERCUFLEX DBL PIGTL -,SUP-M001245730,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT URET 6FRX24CM PERCUFLEX DBL PIGTL -,SUP-M001245740,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT URET 6FRX26CM PERCUFLEX DBL PIGTL -,SUP-M001245750,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT URET 6FRX28CM PERCUFLEX DBL PIGTL -,SUP-M001245760,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT URET 8FRX26CM FLEXIMA DBL PIGTL -,SUP-M001274030,CDM,C2617,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT ADVANIX 7FR X 3CM DOUBLE PIGTAIL -,SUP-M00532160,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
ADVANIX DOUBLE PIGTAIL 7FR X 5CM -,SUP-M00532180,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
ADVANIX DOUBLE PIGTAIL 7FR X 7CM -,SUP-M00532190,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
ADVANIX DOUBLE PIGTAIL 7FR X 10CM -,SUP-M00532210,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
ADVANIX DOUBLE PIGTAIL 10FR X 5CM -,SUP-M00532260,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT BIL 10FRX5CM ADVANIX RX SGL DBL PIGTL PLST 4.2MM WKG -,SUP-M00532260,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
ADVANIX DOUBLE PIGTAIL 10FR X 7CM -,SUP-M00532270,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT BIL 10FRX15CM WALLSTNT DUOD BND PERCUFLEX -,SUP-M00533700,CDM,C2617,HCPCS,278,RC,,,outpatient,,,290.87,203.609,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT URET 8FRX22CM PERCUFLEX DBL PIGTL PSTNR -,SUP-M0061453800,CDM,C2617,HCPCS,278,RC,,,outpatient,,,441.13,308.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
SCISSORS SURG KAYE CRV 7.5IN SERR DSCT V. MUELLER LF -,SUP-M0061552310,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT URET 6FRX24CM POLARIS LOOP PERCUFLEX -,SUP-M0061552320,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT URET 6FRX26CM POLARIS LOOP PERCUFLEX -,SUP-M0061552330,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT URET 6FRX28CM POLARIS LOOP PERCUFLEX -,SUP-M0061552340,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT URET 8FRX26CM POLARIS LOOP PERCUFLEX -,SUP-M0061552530,CDM,C2617,HCPCS,278,RC,,,outpatient,,,836.51,585.557,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT URET 7FRX80CM PERCUFLEX STR LF -,SUP-M006160210,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT PERC PLUS 4.8 X 24 -,SUP-M0061752520,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT PERC PLUS 4.8 X 26 -,SUP-M0061752530,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT PERC PLUS 4.8 X 28 -,SUP-M0061752540,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT PERCUFLEX PLUS 6 X 22 -,SUP-M0061752610,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT PERCUFLEX PLUS 6 X 24 -,SUP-M0061752620,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT PERCUFLEX PLUS 6 X 26 -,SUP-M0061752630,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT PERCUFLEX PLUS 6 X 28 -,SUP-M0061752640,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT PERCUFLEX PLUS 6 X 30 -,SUP-M0061752650,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT PERCUFLEX PLUS 7FR X 24CM -,SUP-M0061752720,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT PERCUFLEX PLUS 7FR X 26CM -,SUP-M0061752730,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT PERCUFLEX PLUS 8 X 26 -,SUP-M0061752830,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT PERCUFLEX PLUS 8 X 28 NO -,SUP-M0061752840,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT URET 8FRX30CM PERCUFLEX DBL PIGTL TAPR -,SUP-M0061752850,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT URET 4.8FR 22-30CM CONTR VL PERCUFLEX DBL PIGTL TAPR -,SUP-M0061801550,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT URET 6FR 22-30CM CONTR VL PERCUFLEX DBL PIGTL TAPR -,SUP-M0061801560,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT URET CONTOUR 6 X 22 -,SUP-M0061802210,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT URET CONTOUR 6 X 28 -,SUP-M0061802240,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT URET 8FRX28CM PERCUFLEX TAPR LF -,SUP-M00618022440,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT URET CONTOUR 8 X 24 -,SUP-M0061802420,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT URET 6FRX22CM NTNL/PTFE DBL PIGTL -,SUP-M006190131090,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1073.17,751.219,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT URET 6FRX24CM NTNL/PTFE DBL PIGTL -,SUP-M006190132090,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1073.17,751.219,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT URET 6FRX22CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921310,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT URET 6FRX24CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921320,CDM,C2617,HCPCS,278,RC,,,outpatient,,,791.28,553.896,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT URET 6FRX26CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921330,CDM,C2617,HCPCS,278,RC,,,outpatient,,,791.28,553.896,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT URET 6FRX28CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921340,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT URET 8FRX22CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921510,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT URET 8FRX26CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921530,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT PANC 5FRX5CM ZIMMON SPRL SH PE PIGTL TAPR OPTN DCT FLP -,SUP-SPSOF-5-5,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT BIL 7FRX10CM ZIMMON DBL PIGTL TAPR PE -,SUP-ZSO-7-10,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
STENT BIL 7FRX7CM ZIMMON DBL PIGTL TAPR PE -,SUP-ZSO-7-7,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,734.3115,other,SI=N Exclusions ,,
PROBE CRYOSPHERE 11IN -,SUP-CRYOS,CDM,C2618,HCPCS,272,RC,,,outpatient,,,10397.8,7278.46,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7607.37,other,SI=N Exclusions ,,
PROBE CRYOSPHERE 18IN -,SUP-CRYOS-L,CDM,C2618,HCPCS,272,RC,,,outpatient,,,9468.15,6627.705,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7607.37,other,SI=N Exclusions ,,
ICEROD 1.5C X 90 NEEDLE -,SUP-FPRPR3533,CDM,C2618,HCPCS,272,RC,,,outpatient,,,8042.38,5629.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7607.37,other,SI=N Exclusions ,,
NEEDLE ICEROD CX 90 VL -,SUP-FPRPR3533,CDM,C2618,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7607.37,other,SI=N Exclusions ,,
NEEDLE ICEPEARL  2.1C X 90 -,SUP-FPRPR3601,CDM,C2618,HCPCS,272,RC,,,outpatient,,,8042.38,5629.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7607.37,other,SI=N Exclusions ,,
NEEDLE ICEFORCE 2.1 X 90 -,SUP-FPRPR3602,CDM,C2618,HCPCS,272,RC,,,outpatient,,,10610,7427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,7607.37,other,SI=N Exclusions ,,
PACEMAKER IMPL BIPLR ADAPTA VDD SGL-CHMBR RR 11.1ML 23.6GM -,SUP-ADVDD01,CDM,C2619,HCPCS,275,RC,,,outpatient,,,16567.96,11597.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,12724.19328,other,SI=N Exclusions ,,
PACEMAKER IMPL EVIA HF-T TRI CHMBR 14ML 27GM IS-1 CONN -,SUP-377208,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25991,18193.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24381.0432,other,SI=N Exclusions ,,
PACEMAKER IMPL SYNCRA 15ML 26GM DR -,SUP-C2TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24381.0432,other,SI=N Exclusions ,,
PACEMAKER IMPL CONSULTA CRT-P SGL-CHMBR 15ML 26GM IS-1 CONN -,SUP-C4TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24381.0432,other,SI=N Exclusions ,,
PACEMAKER IMPL ANTHEM 2CHMBR RR 52X58MM 6MM 13.7ML 25GM IS-1 -,SUP-PM3210,CDM,C2621,HCPCS,275,RC,,,outpatient,,,19897.97,13928.579,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24381.0432,other,SI=N Exclusions ,,
PACEMAKER IMPL ALLURE RF 59X55MM 6MM 14ML 24GM IS-1 CONN -,SUP-PM3222,CDM,C2621,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24381.0432,other,SI=N Exclusions ,,
PACEMAKER IMPL QDPL ALLURE QUADRA RF 2CHMBR RR 59X56MM 6MM -,SUP-PM3242,CDM,C2621,HCPCS,275,RC,,,outpatient,,,20792.8,14554.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24381.0432,other,SI=N Exclusions ,,
CRT-PACER QUADRA ALLURE MP  RF -,SUP-PM3262,CDM,C2621,HCPCS,275,RC,,,outpatient,,,21813.88,15269.716,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24381.0432,other,SI=N Exclusions ,,
QUADRA ALLURE MP MRI PM3562 -,SUP-PM3562,CDM,C2621,HCPCS,275,RC,,,outpatient,,,20792.8,14554.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24381.0432,other,SI=N Exclusions ,,
PACEMAKER ALTRUA 60 49MMX43X8MM 12.1ML TI -,SUP-S606 DR EL,CDM,C2621,HCPCS,275,RC,,,outpatient,,,18193.7,12735.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24381.0432,other,SI=N Exclusions ,,
VALITUDE CRT-P U125 -,SUP-U125,CDM,C2621,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24381.0432,other,SI=N Exclusions ,,
CRT-P VALITUDE MODEL - U128 -,SUP-U128,CDM,C2621,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24381.0432,other,SI=N Exclusions ,,
VISIONIST CRT-P MODEL U226 BI-V PACEMAKER -,SUP-U226,CDM,C2621,HCPCS,275,RC,,,outpatient,,,27736.11,19415.277,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24381.0432,other,SI=N Exclusions ,,
CRT-P VISIONIST X4 - U228 -,SUP-U228,CDM,C2621,HCPCS,275,RC,,,outpatient,,,20313.82,14219.674,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24381.0432,other,SI=N Exclusions ,,
PACEMAKER IMPL INVIVE CRT-PS SMARTDELAY ALGORITHM RPM -,SUP-V172,CDM,C2621,HCPCS,275,RC,,,outpatient,,,31746.15,22222.305,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24381.0432,other,SI=N Exclusions ,,
PACEMAKER INTUA CARD -,SUP-V272,CDM,C2621,HCPCS,275,RC,,,outpatient,,,28590.1,20013.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24381.0432,other,SI=N Exclusions ,,
PACEMAKER PERCEPTA CRT-P MRI W1TR01 -,SUP-W1TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25991,18193.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24381.0432,other,SI=N Exclusions ,,
SOLARA CRT-P MRI W1TR03 -,SUP-W1TR03,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24381.0432,other,SI=N Exclusions ,,
PACEMAKER PERCEPTA QUAD CRT-P MRI W4TR01 -,SUP-W4TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25991,18193.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24381.0432,other,SI=N Exclusions ,,
PACEMAKER SERENA QUAD CRT-P MRI W4TR02 -,SUP-W4TR02,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25248.4,17673.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24381.0432,other,SI=N Exclusions ,,
SOLARA QUAD CRT-P MRI W4TR03 -,SUP-W4TR03,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24381.0432,other,SI=N Exclusions ,,
PROSTHESIS PENL CNCLBL 14MMX16CM ANG RGD CONN MIN SPR BK -,SUP-720056-02,CDM,C2622,HCPCS,278,RC,,,outpatient,,,24383.27,17068.289,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,23086.3872,other,SI=N Exclusions ,,
IMPLANT PENL CL 12MMX12CM SIL PE TI SEG MALE CNCLBL SNP FIT -,SUP-720074-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,20421.5,14295.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,23086.3872,other,SI=N Exclusions ,,
PROSTHESIS TACTRA 9.5MM X 14CM-23CM MALLEABLE -,SUP-720080-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,30060.4,21042.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,23086.3872,other,SI=N Exclusions ,,
TACTRA 11CM MALLEABLE PROSTHESIS -,SUP-720081-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,30060.4,21042.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,23086.3872,other,SI=N Exclusions ,,
TACTRA 13MM X 18CM-27CM MALLEABLE PROSTHESIS -,SUP-720082-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,28358.17,19850.719,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,23086.3872,other,SI=N Exclusions ,,
IMPLANT PENL DURA 11 10MMX14CM CL HX WRNCH STRL -,SUP-720093-10,CDM,C2622,HCPCS,278,RC,,,outpatient,,,15579.75,10905.825,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,23086.3872,other,SI=N Exclusions ,,
TIP PROS DURA II 10MMX1CM UNIV PENL STRL -,SUP-720093-12,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,23086.3872,other,SI=N Exclusions ,,
TIP PROS DURA II 10MMX5CM PROX PENL STRL -,SUP-720093-16,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,23086.3872,other,SI=N Exclusions ,,
TIP PROS DURA II 10MMX4CM DIST PENL STRL -,SUP-720093-23,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,23086.3872,other,SI=N Exclusions ,,
TIP PROS DURA II 10MMX2CM UNIV PENL STRL -,SUP-720093-60,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,23086.3872,other,SI=N Exclusions ,,
KT PROSTHESIS PENL 11MMX25CM MALE CYL MLBL TRMBL ADPR W/TAIL -,SUP-91-9511SC,CDM,C2622,HCPCS,278,RC,,,outpatient,,,20291.55,14204.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,23086.3872,other,SI=N Exclusions ,,
BARD BALLOON LUTONIX .035 4.0 X 150MM -,SUP-BSLX3513041505F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8912.4,6238.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
CATH PTCA 6MMX130CM LUTONIX 60MM DRG CTD 0.035IN GW COMP -,SUP-BSLX351306605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
LUTONIX BALLOON 6MM X 80MM -,SUP-BSLX351306805F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,7214.8,5050.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
RANGER DCB OTW  4.0MM x 40MM x 135CM -,SUP-H74939419400410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
RANGER GLOBAL DCB OTW 4.0 X 80MM 135CM -,SUP-H74939419400810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
RANGER GLOBAL DCB OTW 4.0 X 100MM 135CM -,SUP-H74939419401010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
RANGER GLOBAL DCB OTW 4.0 X 150MM 150CM -,SUP-H74939419401510,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
RANGER GLOBAL DCB OTW 4.0 X 200MM 150CM -,SUP-H74939419402010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
RANGER GLOBAL DCB OTW 4.0 X 200MM 150CM -,SUP-H74939419500410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
RANGER GLOBAL DCB OTW 5.0 X 60MM 135CM -,SUP-H74939419500610,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
CATH BALLOON RANGER GLOBAL 5.0 X 80MM X 135CM GLOBAL DCB OTW -,SUP-H74939419500810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
RANGER GLOBAL DCB OTW 5.0 X 100MM 135CM -,SUP-H74939419501010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
RANGER GLOBAL DCB OTW 5.0 X 120MM 150CM -,SUP-H74939419501210,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5708.18,3995.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
RANGER GLOBAL DCB OTW 5.0 X 150MM 150CM -,SUP-H74939419501510,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
RANGER DCB OTW 5.0MM x 200MM x 150CM -,SUP-H74939419502010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
RANGER GLOBAL DCB OTW 5.0 X 200MM 90CM -,SUP-H74939419502090,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
RANGER GLOBAL DCB OTW 6.0 X 40MM 135CM -,SUP-H74939419600410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
RANGER GLOBAL DCB OTW 6.0 X 60MM 135CM -,SUP-H74939419600610,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
CATH BALLOON RANGER GLOBAL 6.0 X 80MM X 135CM GLOBAL DCB OTW -,SUP-H74939419600810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
RANGER GLOBAL DCB OTW 6.0 X 100MM 135CM -,SUP-H74939419601010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
RANGER GLOBAL DCB OTW 6.0 X 200MM 150CM -,SUP-H74939419602010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
RANGER GLOBAL DCB OTW 7.0 X 40MM 135CM -,SUP-H74939419700410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
RANGER GLOBAL DCB OTW 7.0 X 60MM 135CM -,SUP-H74939419700610,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
RANGER GLOBAL DCB OTW 7.0 X 80MM 135CM -,SUP-H74939419700810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
RANGER GLOBAL DCB OTW 7.0 X 100MM 135CM -,SUP-H74939419701010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
RANGER GLOBAL DCB OTW 7.0 X 150MM 150CM -,SUP-H74939419701510,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
RANGER GLOBAL DCB OTW 7.0 X 200MM 150CM -,SUP-H74939419702010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
LUTONIX 018 6 X 80MM -,SUP-LX181306805F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
CATH PTCA 4MMX130CM LUTONIX 40MM DRG CTD 0.035IN GW COMP -,SUP-LX351304405F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
CATH PTCA 4MMX130CM LUTONIX 60MM DRG CTD 0.035IN GW COMP -,SUP-LX351304605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
CATH PTCA 5MMX130CM LUTONIX 100MM DRG CTD 0.035IN GW COMP -,SUP-LX3513051005F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
CATH PTCA 5X150MM LUTONIX 130CM -,SUP-LX3513051505F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
CATH PTCA 5MMX130CM LUTONIX 60MM DRG CTD 0.035IN GW COMP -,SUP-LX351305605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
B LUTONIX 6MM X 100MM X 130 -,SUP-LX3513061005F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
CATH PTCA 6X150MM LUTONIX 130CM -,SUP-LX3513061505F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
LUTONIX BALLOON -,SUP-LX3513062205F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8700.2,6090.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
CATH PTCA LUTONIX 0.035 X 6.0MM X 130CM 6FR DRG CTD GW GROUP -,SUP-LX351306605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
CATH PTCA 6MMX130CM LUTONIX 80MM DRG CTD 0.035IN GW COMP -,SUP-LX351306805F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
LUTONIX BALLOON 7MM X 100MM X 130M -,SUP-LX3513071005F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
S LUTONIX 7 X 40 X 130 -,SUP-LX351307405F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
S LUTONIX 7 X 60 X 130 -,SUP-LX351307605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
BALLOON LUTONIX .035 X 10MM X 40MM -,SUP-LX35751040V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
BALLOON LUTONIX .035 X 10MM X 60MM -,SUP-LX35751060V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
LUTONIX 12MM X 40MMX 75CM -,SUP-LX35751240V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6896.5,4827.55,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
BALLOON LUTONIX .035  4.0MM X 40MM -,SUP-LX3575440V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
CATH LUTONIX BALLOON DILATATION 6MM 75CM 40MM PACLITAXEL LF -,SUP-LX3575640V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
CATH LUTONIX BALLOON DILATATION 6MM 75CM 60MM PACLITAXEL LF -,SUP-LX3575660V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
LUTONIX DCB BALLOON 6 X 80 X 75 -,SUP-LX3575680V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
BALLOON LUTONIX .035  7.0MM X 40MM -,SUP-LX3575740V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
BALLOON LUTONIX .035  4 X 60 X 75 -,SUP-LX3575760V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
BALLOON LUTONIX .035 X 8MM X 40MM X 75CM -,SUP-LX3575840V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
BALLOON LUTONIX  .035 8 X 60 X 75 -,SUP-LX3575860V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
BALLOON LUTONIX .035 9.0MM X 40MM X 75CM -,SUP-LX3575940V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,6390.1908,other,SI=N Exclusions ,,
STENT NEPHURET 8.5FRX22CM ULTRATHANE COPE DBL PIGTL BND -,SUP-240735,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT NEPHURET 8.5FRX24CM ULTRATHANE COPE DBL PIGTL BND -,SUP-240736,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT NEPHURET 8.5FRX28 CM ULTRATHANE COPE DBL PIGTL BND -,SUP-244806,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT URET 4.7FRX24CM INLAY DBL PIGTL TAPR -,SUP-778424,CDM,C2625,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
8FR X 22 BARD OPTIMA INLAY URETERAL STENT -,SUP-778822,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
8FR X 24 BARD OPTIMA INLAY URETERAL STENT -,SUP-778824,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
8FR X 26 BARD OPTIMA INLAY URETERAL STENT -,SUP-778826,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
8FR X 28 BARD OPTIMA INLAY URETERAL STENT -,SUP-778828,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT URETERAL INLAY 6F 20 OPT -,SUP-788620,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT URETERAL INLAY 6F 22 OPT -,SUP-788622,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT URETERAL INLAY 6F 24 -,SUP-788624,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT URETERAL INLAY 6F 26 -,SUP-788626,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT URETERAL INLAY 6F 28 -,SUP-788628,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT URETERAL INLAY 6F 30 -,SUP-788630,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
BARD OPTIMA INLAY STENT 7 X 24 -,SUP-788724,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
BARD OPTIMA INLAY STENT 7 X 26 -,SUP-788726,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
BARD OPTIMA INLAY STENT 7 X 28 -,SUP-788728,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT BIL 7FRX5CM COTTON-LEUNG CRV TAPR PE P/D FLP PSH CATH -,SUP-CLBS-7-5,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT FANELLI BILIARY -,SUP-G13699,CDM,C2625,HCPCS,278,RC,,,outpatient,,,2999.5,2099.65,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT URET 7FRX75CM BNDR RT SOF-FLEX -,SUP-G14779,CDM,C2625,HCPCS,278,RC,,,outpatient,,,446.79,312.753,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT URET 7FRX75CM BNDR PTFE -,SUP-G14780,CDM,C2625,HCPCS,278,RC,,,outpatient,,,451.1,315.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT BILIARY DOUBLE PIGTAIL 7 X 7 -,SUP-G21396,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT BILIARY DOUBLE PIGTAIL 7 X 9 -,SUP-G21398,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT GEENAN PANCREATIC 7X7 -,SUP-G21479,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT GEENAN PANCREATIC 7X9 -,SUP-G21480,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT SET ZIMMON BILIARY 7-12 -,SUP-G21526,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT ZIMON BILIARY 7 X 15 -,SUP-G21529,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT ZIMMON DBL PIGTAIL 10X4 -,SUP-G21781,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT BIL 10MMX5CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN -,SUP-G25379,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT BIL 10MMX7CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN -,SUP-G25380,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT BIL 7MMX5CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN GW -,SUP-G25656,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT BIL 7MMX7CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN GW -,SUP-G25657,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT SOLUS DOUBLE PIGTAIL 10FR 3CM -,SUP-G25670,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT SOLUS DBL PIGTAIL 10 X 4 -,SUP-G25671,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT SOLUS DBL PIGTAIL 10 X 5 -,SUP-G25672,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT DBLE PIGTAIL 10F 1CM -,SUP-G26829,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT SOLUS DOUBLE PIGTAIL 10FR 1CM -,SUP-G26829,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT NEPHURET 10.2FRX22CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48162,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT NEPHURET 8.5FRX24CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48176,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT NEPHURET 8.5FRX26CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48180,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT NEPHURET 8.5FRX26CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48180,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
COMPASS BDS BILIARY STENT 7FR 15CM -,SUP-G58990,CDM,C2625,HCPCS,278,RC,,,outpatient,,,408.45,285.915,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT PANC 3FRX4CM GEENEN 170CM/320CM PSH/GUID CATH SPRL SH -,SUP-GEPD3-4,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
TUBE LRNCMY JCKSN SZ8 12MMX7CM OSDE V. MUELLER CRV MIRR FNSH -,SUP-GEPD3-5,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
CATH DRN 10FR NAVIFLEX RX -,SUP-M00533580,CDM,C2625,HCPCS,278,RC,,,outpatient,,,512.08,358.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT ADVANIX RX 7FR X 5CM PRELOADED -,SUP-M00534200,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT ADVANIX RX 7FR X 7CM PRELOADED -,SUP-M00534210,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT ADVANIX RX 7FR X 9CM PRELOADED -,SUP-M00534220,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT BIL 2.3MMX9CM ADVANIX RX PRELD DUOD BND PLST 3.2MM WKG -,SUP-M00534220,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT ADVANIX RX 7FR X 12CM PRELOADED -,SUP-M00534230,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT ADVANIX RX 10FR X 5CM PRELOADED -,SUP-M00534320,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT ADVANIX RX 10FR X 5CM PRELOADED -,SUP-M00534330,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT BIL 10FRX9CM ADVANIX RX PRELD DUOD BND PLST 4.2MM WKG -,SUP-M00534340,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT ADVANIX RX 10FR X 9CM PRELOADED -,SUP-M00534340,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT ADVANIX RX 10FR X 12CM PRELOADED -,SUP-M00534350,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT BIL 10FRX12CM ADVANIX RX PRELD DUOD BND PLST 4.2MM WKG -,SUP-M00534350,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT ADVANIX RX 10FR X 15CM -,SUP-M00534360,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT BIL 10FRX15CM ADVANIX RX PRELD DUOD BND PLST 4.2MM WKG -,SUP-M00534360,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT BIL 8.5FRX7CM ADVANIX RX PRELD CTR BND PLST 3.2MM WKG -,SUP-M00534630,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT BIL 8.5FRX9CM ADVANIX RX PRELD CTR BND PLST 3.2MM WKG -,SUP-M00534640,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT BIL 10FRX7CM ADVANIX RX PRELD CTR BND PLST 4.2MM WKG -,SUP-M00534690,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT BIL 10FRX12CM ADVANIX RX PRELD CTR BND PLST 4.2MM WKG -,SUP-M00534710,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT ADVANTIX 5X3 PANCREATIC NO LEADING BARB SINGLE PIGTAIL -,SUP-M00537390,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT ADVANTIX 5 X 4 PANCREATIC - NO LEADING BARB -,SUP-M00537400,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT ADVANTIX 5X5 PANCREATIC NO LEADING BARB SINGLE PIGTAIL -,SUP-M00537410,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT ADVANTIX 5 X 3 PANCREATIC -LEADING BARB -,SUP-M00537430,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT ADVANTIX 5 X 4 PANCREATIC -LEADING BARB -,SUP-M00537440,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT ADVANTIX 5X3 PANCREATIC NO LEADING BARB STRAIGHT -,SUP-M00537500,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT ADVANTIX 5X5 PANCREATIC NO LEADING BARB STRAIGHT -,SUP-M00537520,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT KIT PANCREATIC 5FR X 3CM -,SUP-M00537540,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
STENT BIL 7FRX4CM ZIMMON DBL PIGTL TAPR PE 170CM PSH CATH -,SUP-ZEBD-7-4,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,89.07711,1949.675,other,SI=N Exclusions ,,
PAIN CONTROL DEVICE BEELINE -,SUP-UNDEFINED,CDM,C2626,HCPCS,278,RC,,,outpatient,,,758.55,530.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,170.294475,582.5664,other,SI=N Exclusions ,,
HC Cath Stamey Suprapubic 14,PX-27200045,CDM,C2627,HCPCS,272,RC,,,outpatient,,,306,214.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,24.890315,416.02,other,SI=N Exclusions ,,
ST SUPRAPUBIC 12FRX25CM CONN TUBEX1/NDL OBTURATORX1/ 1W -,SUP-G14313,CDM,C2627,HCPCS,272,RC,,,outpatient,,,357.1,249.97,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,24.890315,416.02,other,SI=N Exclusions ,,
CATHETER MALECOT DRAINAGE 14FR 30CM -,SUP-G55824,CDM,C2627,HCPCS,272,RC,,,outpatient,,,307.21,215.047,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,24.890315,416.02,other,SI=N Exclusions ,,
LAWRENCE SUPRA-FOLEY 16F -,SUP-SF-S16-851,CDM,C2627,HCPCS,272,RC,,,outpatient,,,110.87,77.609,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,24.890315,416.02,other,SI=N Exclusions ,,
OCCULSION BALLOON CATH 90CM BR -,SUP-590-001,CDM,C2628,HCPCS,272,RC,,,outpatient,,,4415.95,3091.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,23.64434,10635.57648,other,SI=N Exclusions ,,
CATH OCL 6FRX10MM BLN ATTAIN COR -,SUP-6215,CDM,C2628,HCPCS,272,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,23.64434,10635.57648,other,SI=N Exclusions ,,
CATHETER PRUITT OCCLUSION 3F 7MM 27CM -,SUP-E2103-36,CDM,C2628,HCPCS,272,RC,,,outpatient,,,1743.86,1220.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,23.64434,10635.57648,other,SI=N Exclusions ,,
CATH ANG 5FR SHTH 135CM 3.75X20X1.5MM BLN ENTEER PERIPH -,SUP-ENB37520135,CDM,C2628,HCPCS,272,RC,,,outpatient,,,10273.24,7191.268,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,23.64434,10635.57648,other,SI=N Exclusions ,,
CATHETER OCCLUSION ER-REBOA PLUS -,SUP-ER7232PLUS,CDM,C2628,HCPCS,272,RC,,,outpatient,,,14833.44,10383.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,23.64434,10635.57648,other,SI=N Exclusions ,,
CATH HSG 5FRX30CM SIL 1ML BLN/SYR OPN TIP MRI-COND STRL SUD -,SUP-G17147,CDM,C2628,HCPCS,272,RC,,,outpatient,,,171.9,120.33,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,23.64434,10635.57648,other,SI=N Exclusions ,,
B CODA-2-10.0-35-140-46 -,SUP-G23773,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2702.08,1891.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,23.64434,10635.57648,other,SI=N Exclusions ,,
CODA BALLOON 46MM -,SUP-G23773,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2702.08,1891.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,23.64434,10635.57648,other,SI=N Exclusions ,,
CATH URET 6.2FRX26CM LF W/HSG/SHG MLBL STYL -,SUP-J-UHSG-062026,CDM,C2628,HCPCS,272,RC,,,outpatient,,,105.32,73.724,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,23.64434,10635.57648,other,SI=N Exclusions ,,
KIT CATHETER REBOA CONVENIENCE -,SUP-KT1835C,CDM,C2628,HCPCS,272,RC,,,outpatient,,,1192.61,834.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,23.64434,10635.57648,other,SI=N Exclusions ,,
CATHETER BALLOON MOLDING OCCLUSION 10MM X 37MM 10FR -,SUP-MOB37,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2740.28,1918.196,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,23.64434,10635.57648,other,SI=N Exclusions ,,
CATH OUTBACK RE-ENTRY 120CM -,SUP-OTB59120A,CDM,C2628,HCPCS,272,RC,,,outpatient,,,8021.16,5614.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,23.64434,10635.57648,other,SI=N Exclusions ,,
Q50X STENT GRAFT BALLOON CATHETER -,SUP-Q50-100-X,CDM,C2628,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,23.64434,10635.57648,other,SI=N Exclusions ,,
CATH GUID 8FR 10-46MM INFL 100CM RELIANT PU 12FR SHTH -,SUP-REL46,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2500.25,1750.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,23.64434,10635.57648,other,SI=N Exclusions ,,
MICRO INTRO KIT 21G 4FR 7CM TCAR - MULT'S OF 10EA -,SUP-SR-4F21G7D-MP,CDM,C2628,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,23.64434,10635.57648,other,SI=N Exclusions ,,
HSG CATHETER -,SUP-UNDEFINED,CDM,C2628,HCPCS,272,RC,,,outpatient,,,207.35,145.145,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,23.64434,10635.57648,other,SI=N Exclusions ,,
CATH ABLT THRP COOL PATH MED CURL 7FR 2-5-2MM SPC 110CM QDPL -,SUP-A088047,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions ,,
CATH ABLT THRP COOL PATH LRG CURL 7FR 2-5-2MM SPC 110CM QDPL -,SUP-A088049,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions ,,
CATH ABLT SAFIRE BLU MED SWP DIST REACH CRV 7FR 2-5-2MM SPC -,SUP-A088106,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions ,,
CATH ABLT SAFIRE BLU MED CURL DIST REACH CRV 7FR 2-5-2MM SPC -,SUP-A088107,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions ,,
CATH ABLT SAFIRE BLU LRG SWP 7FR 2-5-2MM SPC LRG SWP 110CM -,SUP-A088108,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions ,,
CATH ABLT SAFIRE BLU MED CURL DIST REACH CRV 7FR HGH TRQ -,SUP-A402871,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions ,,
CATH ABLT SAFIRE BLU LRG CURL DIST REACH CRV HGH TRQ SHFT -,SUP-A402872,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions ,,
CATH ABLT SAFIRE BLU MED CURL CRV EP DUO -,SUP-A700455,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions ,,
CATH ABLT TACTICATH SE BI-D DF -,SUP-A-TCSE-DF,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10440.96,7308.672,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions ,,
CATH ABLT TACTI SE BI-D FJ -,SUP-A-TCSE-FJ,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10440.96,7308.672,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions ,,
CATH ABLT TACTIFLEX SE BID DF REF: A-TFSE-DF -,SUP-A-TFSE-DF,CDM,C2630,HCPCS,272,RC,,,outpatient,,,14387.88,10071.516,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions ,,
CATH ABLT TACTIFLEX SE BID FJ REF: A-TFSE-FJ -,SUP-A-TFSE-FJ,CDM,C2630,HCPCS,272,RC,,,outpatient,,,14387.88,10071.516,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions ,,
CATH ABLT THERMOCOOL SF F-J CRV 8FR 2-5-2MM SPC 115CM BIDIR -,SUP-BDI35FJRT,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7957.5,5570.25,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions ,,
CATH ABLT THERMOCOOL SF B- CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131601,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions ,,
CATH ABLT THERMOCOOL SF D-CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131602,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions ,,
CATH ABLT THERMOCOOL SF F-CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131603,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions ,,
CATH ABLT THERMOCOOL SF J-CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131604,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions ,,
CATH ABLT THERMOCOOL SF CARTO XP F-TY CRV STEER UNI- DRCT -,SUP-D131803,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions ,,
CATH ABLT THERMOCOOL SF CARTO XP J CRV STEER UNI- DRCT HTORQ -,SUP-D131804,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions ,,
CATH ABLT CHILLI II STD CRV 7.5FRX2.5MM SPC 4MM TIP 110CM -,SUP-M00490310,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7151.14,5005.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions ,,
CATH ABLT THRMCPL CRV 7.5FR LRG 110CM 2.5/2.5MM SPC -,SUP-M0049031K20,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7151.14,5005.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions ,,
CATH ABLT TACTICATH 65 MM -,SUP-PN-004 065,CDM,C2630,HCPCS,272,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions ,,
CATH ABLT TACTICATH 75MM -,SUP-PN-004075,CDM,C2630,HCPCS,272,RC,,,outpatient,,,11139,7797.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10316.10996,other,SI=N Exclusions ,,
DEVICE SUTCAP 12MM OPN ACCESS -,SUP-M0068311251,CDM,C2631,HCPCS,272,RC,,,outpatient,,,2073.95,1451.765,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,1487.02215,other,SI=N Exclusions ,,
HC Mra- W/Dye- Upper Extremity,PX-61000005,CDM,C8934,CPT,610,RC,,,outpatient,,,2034,1423.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1724.02,399.86,1724.0184,percent of total billed charges,,,
HC Mra- W/O Dye- Upper Extr,PX-61000006,CDM,C8935,CPT,610,RC,,,outpatient,,,1745,1221.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1479.06,267.439885,1479.062,percent of total billed charges,,,
HC Mra- W/O&W/Dye- Upper Extr,PX-61000007,CDM,C8936,CPT,610,RC,,,outpatient,,,3036,2125.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2573.31,399.86,2573.3136,percent of total billed charges,,,
HC Cad Breast MRI,PX-61000089,CDM,C8937,HCPCS,610,RC,,,outpatient,,,344,240.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,77.228,836,other,SI=N Exclusions ,,
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML IJ SOLN,RX-155306,CDM,C9088,HCPCS,636,RC,47426-0301-02,NDC,outpatient,14,ML,1200.46,840.322,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.84,,,0.84,0.71,921.95328,fee schedule,,,
PANTOPRAZOLE SODIUM 40 MG IV SOLR,RX-26226,CDM,C9113,HCPCS,636,RC,00008-0923-51,NDC,outpatient,1,UN,8.55,5.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.69273,416.02,other,SI=N Exclusions ,,
PANTOPRAZOLE SODIUM 40 MG IV SOLR,RX-26226,CDM,C9113,HCPCS,636,RC,00008-0923-60,NDC,outpatient,1,UN,8.55,5.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.69273,416.02,other,SI=N Exclusions ,,
PANTOPRAZOLE SODIUM 40 MG IV SOLR,RX-26226,CDM,C9113,HCPCS,636,RC,55150-0202-00,NDC,outpatient,1,UN,7.54,5.278,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.69273,416.02,other,SI=N Exclusions ,,
PANTOPRAZOLE SODIUM 40 MG IV SOLR,RX-26226,CDM,C9113,HCPCS,636,RC,00008-0923-55,NDC,outpatient,1,UN,8.55,5.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.69273,416.02,other,SI=N Exclusions ,,
PANTOPRAZOLE SODIUM 40 MG IV SOLR,RX-26226,CDM,C9113,HCPCS,636,RC,55150-0202-10,NDC,outpatient,1,UN,7.54,5.278,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.69273,416.02,other,SI=N Exclusions ,,
COCAINE HCL 4 % EX SOLN,RX-1792,CDM,C9143,HCPCS,636,RC,70839-0362-04,NDC,outpatient,4,ML,1089.63,762.741,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.4,836.83584,other,SI=N Exclusions ,,
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-01,NDC,outpatient,50,ML,360.88,252.616,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.39,416.02,other,SI=N Exclusions ,,
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-01,NDC,outpatient,50,ML,344.88,241.416,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,,,,,3.39,416.02,other,SI=N Exclusions ,,
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-10,NDC,outpatient,50,ML,360.88,252.616,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.39,416.02,other,SI=N Exclusions ,,
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-10,NDC,outpatient,50,ML,344.88,241.416,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,,,,,3.39,416.02,other,SI=N Exclusions ,,
LACOSAMIDE 200 MG/20ML IV SOLN,RX-96972,CDM,C9254,HCPCS,636,RC,72603-0140-01,NDC,outpatient,20,ML,100.4,70.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.31,416.02,other,SI=N Exclusions ,,
LACOSAMIDE 200 MG/20ML IV SOLN,RX-96972,CDM,C9254,HCPCS,636,RC,72603-0140-02,NDC,outpatient,20,ML,100.4,70.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.31,416.02,other,SI=N Exclusions ,,
LACOSAMIDE 200 MG/20ML IV SOLN,RX-96972,CDM,C9254,HCPCS,636,RC,00131-1810-67,NDC,outpatient,20,ML,278.22,194.754,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.31,416.02,other,SI=N Exclusions ,,
BUPIVACAINE LIPOSOME 1.3 % IJ SUSP,RX-112781,CDM,C9290,HCPCS,636,RC,65250-0266-09,NDC,outpatient,20,ML,1495.03,1046.521,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.36,1148.18304,other,SI=N Exclusions ,,
BUPIVACAINE LIPOSOME 1.3 % IJ SUSP,RX-112781,CDM,C9290,HCPCS,636,RC,65250-0266-20,NDC,outpatient,20,ML,1495.03,1046.521,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.36,1148.18304,other,SI=N Exclusions ,,
CAP NERVE AXOGEN 2MM X 15MM -,SUP-AGT215,CDM,C9353,HCPCS,278,RC,,,outpatient,,,6688.54,4681.978,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,5136.79872,other,SI=N Exclusions ,,
CAP NERVE AXOGEN 3MM X 15MM -,SUP-AGT315,CDM,C9353,HCPCS,278,RC,,,outpatient,,,6688.54,4681.978,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,5136.79872,other,SI=N Exclusions ,,
CAP NERVE AXOGEN 4 X 15 -,SUP-AGT415,CDM,C9353,HCPCS,278,RC,,,outpatient,,,6688.54,4681.978,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,5136.79872,other,SI=N Exclusions ,,
NEUROMATRIX 6.0MM DIAMETER 2.5CM LENGTH -,SUP-CNC6025,CDM,C9355,HCPCS,278,RC,,,outpatient,,,5756.22,4029.354,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,182.24,5164.04736,other,SI=N Exclusions ,,
NEUROFLEX NERVE 4MM X 2.5CM -,SUP-CNCF4025,CDM,C9355,HCPCS,278,RC,,,outpatient,,,6724.02,4706.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,182.24,5164.04736,other,SI=N Exclusions ,,
NEUROFLEX NERVE 6MM X 2.5CM -,SUP-CNCF6025,CDM,C9355,HCPCS,278,RC,,,outpatient,,,6724.02,4706.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,182.24,5164.04736,other,SI=N Exclusions ,,
MESH SURGIMEND 5X6CM 1.0MM -,SUP-606-001-002,CDM,C9358,HCPCS,636,RC,,,outpatient,,,2525.06,1767.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24858.15552,other,SI=N Exclusions ,,
MESH SURGIMEND 5X6CM 1.0MM - C -,SUP-606-001-002,CDM,C9358,HCPCS,636,RC,,,outpatient,,,2525.06,1767.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24858.15552,other,SI=N Exclusions ,,
MESH SURGIMEND BOVINE 10 X 15CM -,SUP-606-001-006,CDM,C9358,HCPCS,636,RC,,,outpatient,,,9819.33,6873.531,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24858.15552,other,SI=N Exclusions ,,
IMPLANT NDNTR COLL 4X7CM SRGMND RECT -,SUP-606-001-013,CDM,C9358,HCPCS,636,RC,,,outpatient,,,2616.64,1831.648,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24858.15552,other,SI=N Exclusions ,,
SURGIMEND PRS 10CM X 20CM RECT -,SUP-606-004-102,CDM,C9358,HCPCS,636,RC,,,outpatient,,,16238.36,11366.852,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24858.15552,other,SI=N Exclusions ,,
MESH SURGIMEND 8CM X 16CM SEMI OVAL FENESTRAED -,SUP-606-004-103,CDM,C9358,HCPCS,636,RC,,,outpatient,,,10392.54,7274.778,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24858.15552,other,SI=N Exclusions ,,
GRAFT FTL BVN NDNTR COLL MATRIX 20X30CM SRGMND 2MM SHT RECT -,SUP-606-200-017,CDM,C9358,HCPCS,636,RC,,,outpatient,,,27546.57,19282.599,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24858.15552,other,SI=N Exclusions ,,
MESH SURGIMEND 3.0 13 X 25CM -,SUP-606-300-009,CDM,C9358,HCPCS,636,RC,,,outpatient,,,26387.33,18471.131,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24858.15552,other,SI=N Exclusions ,,
MESH SURGIMEND 20 X 30 X 3MM -,SUP-606-300-017,CDM,C9358,HCPCS,636,RC,,,outpatient,,,32367.39,22657.173,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24858.15552,other,SI=N Exclusions ,,
GENTRIX SURGICAL MATRIX HIATAL 7.5 X 6CM -,SUP-HIAT0706,CDM,C9358,HCPCS,636,RC,,,outpatient,,,4704.78,3293.346,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,24858.15552,other,SI=N Exclusions ,,
MESH SURGIMEND 3.0 10 X 15CM -,SUP-603-300-006,CDM,C9360,HCPCS,636,RC,,,outpatient,,,12178.79,8525.153,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,41430.25152,other,SI=N Exclusions ,,
MESH SURGIMEND 10 X 15CM 2.0 -,SUP-606-200-006,CDM,C9360,HCPCS,636,RC,,,outpatient,,,10364.84,7255.388,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,41430.25152,other,SI=N Exclusions ,,
IMPLANT NDNTR COLL 13X20CM SRGMND RECT -,SUP-606-200-009,CDM,C9360,HCPCS,636,RC,,,outpatient,,,22457.19,15720.033,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,41430.25152,other,SI=N Exclusions ,,
MESH SURGIMEND 25X40 X 3.0MM -,SUP-606-300-016,CDM,C9360,HCPCS,636,RC,,,outpatient,,,53945.64,37761.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,41430.25152,other,SI=N Exclusions ,,
NEUROMEND12MM X 2.5CM -,SUP-CNW12025,CDM,C9361,HCPCS,636,RC,,,outpatient,,,6724.07,4706.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,177.26,5164.08576,other,SI=N Exclusions ,,
NEUROMEND 4MM X 2.25CM -,SUP-CNW4025,CDM,C9361,HCPCS,636,RC,,,outpatient,,,6464.93,4525.451,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,177.26,5164.08576,other,SI=N Exclusions ,,
IMPLANT BIO TISS 3X8CM 3D HYDR PRCN COLL MATRIX PERMACOL SHT -,SUP-P100308,CDM,C9364,HCPCS,636,RC,,,outpatient,,,2987.95,2091.565,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,18.39,18739.8144,other,SI=N Exclusions ,,
MESH PERMACOL 5X10CM 1.0MM -,SUP-P100510,CDM,C9364,HCPCS,636,RC,,,outpatient,,,4648.41,3253.887,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,18.39,18739.8144,other,SI=N Exclusions ,,
IMPLANT BIO TISS 10X10CM 3D HYDR PRCN DERM COLL PERMACOL SHT -,SUP-P101010,CDM,C9364,HCPCS,636,RC,,,outpatient,,,9294.36,6506.052,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,18.39,18739.8144,other,SI=N Exclusions ,,
IMPLANT BIO TISS 15X20CM 3D HYDR PRCN COLL MATRIX PERMACOL -,SUP-P151520,CDM,C9364,HCPCS,636,RC,,,outpatient,,,24400.8,17080.56,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,18.39,18739.8144,other,SI=N Exclusions ,,
SARILUMAB 200 MG/1.14ML SC SOAJ,RX-143091,CDM,C9399,HCPCS,636,RC,00024-5922-01,NDC,outpatient,1.14,ML,5813.71,4069.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,4927.7,399.86,4927.700596,percent of total billed charges,,,
CANGRELOR TETRASODIUM 50 MG IV SOLR,RX-131579,CDM,C9460,HCPCS,636,RC,10122-0620-01,NDC,outpatient,1,UN,2428.93,1700.251,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21.76,,,21.76,18.2,1865.41824,fee schedule,,,
CANGRELOR TETRASODIUM 50 MG IV SOLR,RX-131579,CDM,C9460,HCPCS,636,RC,10122-0620-10,NDC,outpatient,1,UN,2428.93,1700.251,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21.76,,,21.76,18.2,1865.41824,fee schedule,,,
HC Perc Drug-El Cor Stent Sing,PX-48100003,CDM,C9600,CPT,481,RC,,,outpatient,,,32584,22808.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13180.06,,,13180.06,399.86,25024.512,fee schedule,,,
HC Perc Drug-El Cor Stent Bran,PX-48100004,CDM,C9601,CPT,481,RC,,,outpatient,,,33887,23720.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,26025.216,other,SI=N Exclusions ,,
HC Perc D-E Cor Stent Ather S,PX-48100005,CDM,C9602,CPT,481,RC,,,outpatient,,,33887,23720.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20930.03,,,20930.03,399.86,26793.51305,fee schedule,,,
HC Perc D-E Cor Revasc T Cabg S,PX-48100007,CDM,C9604,CPT,481,RC,,,outpatient,,,33887,23720.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13180.06,,,13180.06,399.86,26025.216,fee schedule,,,
HC Perc D-E Cor Revasc T Cabg B,PX-48100008,CDM,C9605,CPT,481,RC,,,outpatient,,,33887,23720.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,26025.216,other,SI=N Exclusions ,,
HC Perc D-E Cor Revasc Chro Sin,PX-48100010,CDM,C9607,CPT,481,RC,,,outpatient,,,33887,23720.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,20930.03,,,20930.03,399.86,26793.51305,fee schedule,,,
HC Perc D-E Cor Revasc Chro Add,PX-48100011,CDM,C9608,CPT,481,RC,,,outpatient,,,33887,23720.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,26025.216,other,SI=N Exclusions ,,
HC Admin Influenza Virus Vac,PX-77100001,CDM,G0008,CPT,771,RC,,,outpatient,,,193,135.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48.81,,,48.81,19.95,416.02,fee schedule,,,
HC Immuniz-Admin-Each Addl,PX-77100005,CDM,G0008,CPT,771,RC,,,outpatient,,,215,150.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48.81,,,48.81,19.95,416.02,fee schedule,,,
HC Admin Pneumococcal Vaccine,PX-77100002,CDM,G0009,CPT,771,RC,,,outpatient,,,193,135.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48.81,,,48.81,19.95,416.02,fee schedule,,,
HC Immuniz-Admin-Each Addl,PX-77100006,CDM,G0009,CPT,771,RC,,,outpatient,,,215,150.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48.81,,,48.81,19.95,416.02,fee schedule,,,
HC Admin Hepatitis B Vaccine,PX-77100003,CDM,G0010,CPT,771,RC,,,outpatient,,,193,135.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48.81,,,48.81,19.95,416.02,fee schedule,,,
HC Immuniz-Admin-Each Addl,PX-77100007,CDM,G0010,CPT,771,RC,,,outpatient,,,215,150.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48.81,,,48.81,19.95,416.02,fee schedule,,,
HC Inject for Sacroiliac Joint,PX-36900022,CDM,G0259,CPT,369,RC,,,outpatient,,,827,578.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,185.6615,1592,other,SI=N Exclusions ,,
HC Inj for Sacroiliac Jt Anesth,PX-36900023,CDM,G0260,CPT,369,RC,,,outpatient,,,1722,1205.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,816.25,,,816.25,386.589,2141,fee schedule,,,
HC Occlusive Device in Vein Art,PX-48100001,CDM,G0269,CPT,481,RC,,,outpatient,,,202,141.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,45.349,1592,other,SI=N Exclusions ,,
HC Iliac Art Angio-Cardiac Cath,PX-32000003,CDM,G0278,CPT,320,RC,,,outpatient,,,113,79.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,25.3685,416.02,other,SI=N Exclusions ,,
HC Elec Stim Other Than Wound,PX-42000003,CDM,G0283,CPT,420,RC,,,outpatient,,,123,86.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,28.83,,,28.83,12.01,416.02,fee schedule,,,
HC Observation Time,PX-76200003,CDM,G0378,CPT,762,RC,,,outpatient,,,101,70.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4585,,,4585,22.6745,6652,per diem,,,
HC Observation Carve-Out,PX-76200004,CDM,G0378,CPT,762,RC,,,outpatient,,,101,70.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4585,,,4585,22.6745,6652,per diem,,,
HC Direct Refer Hospital Observ,PX-76200001,CDM,G0379,CPT,762,RC,,,outpatient,,,1442,1009.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4585,,,4585,104.83,6652,per diem,,,
HC PR Trauma Respons W/Hosp Criti,PX-68200001,CDM,G0390,HCPCS,682,RC,,,outpatient,,,10370,7259,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1288.62,,,1288.62,399.86,7964.16,fee schedule,,,
HC Full Trauma,PX-68200002,CDM,G0390,HCPCS,682,RC,,,outpatient,,,10370,7259,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1288.62,,,1288.62,399.86,7964.16,fee schedule,,,
HC Partial Trauma,PX-68200003,CDM,G0390,HCPCS,682,RC,,,outpatient,,,7029,4920.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1288.62,,,1288.62,399.86,7964.16,fee schedule,,,
HC Mod Sedat Endo Service >5yrs,PX-37000025,CDM,G0500,HCPCS,370,RC,,,outpatient,,,240,168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,53.88,416.02,other,SI=N Exclusions ,,
HC Inter Devc Remote 30d,PX-48000092,CDM,G2066,HCPCS,480,RC,,,outpatient,,,118,82.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,100.02,26.491,416.02,percent of total billed charges,,,
ABATACEPT 250 MG IV SOLR,RX-70287,CDM,J0129,HCPCS,636,RC,00003-2187-13,NDC,outpatient,1,UN,3823.57,2676.499,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,43.44,,,43.44,43.27,2936.50176,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0131,HCPCS,636,RC,36000-0306-60,NDC,outpatient,100,ML,53.83,37.681,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.04,416.02,other,SI=N Exclusions ,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0131,HCPCS,636,RC,67457-0940-10,NDC,outpatient,100,ML,44.93,31.451,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.04,416.02,other,SI=N Exclusions ,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0131,HCPCS,636,RC,67457-0940-10,NDC,outpatient,100,ML,44.93,31.451,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.04,416.02,other,SI=N Exclusions ,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0131,HCPCS,636,RC,67457-0940-10,NDC,outpatient,100,ML,44.93,31.451,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.04,416.02,other,SI=N Exclusions ,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0131,HCPCS,636,RC,36000-0306-60,NDC,outpatient,100,ML,53.83,37.681,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.04,416.02,other,SI=N Exclusions ,,
ACETYLCYSTEINE 200 MG/ML IV SOLN,RX-38303,CDM,J0132,HCPCS,636,RC,00574-0805-00,NDC,outpatient,30,ML,278.49,194.943,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.57,416.02,other,SI=N Exclusions ,,
ACETYLCYSTEINE 200 MG/ML IV SOLN,RX-38303,CDM,J0132,HCPCS,636,RC,00574-0805-30,NDC,outpatient,30,ML,278.49,194.943,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.57,416.02,other,SI=N Exclusions ,,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,55150-0155-20,NDC,outpatient,20,ML,19.14,13.398,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.02,416.02,other,SI=N Exclusions ,,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-09,NDC,outpatient,20,ML,18.52,12.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.02,416.02,other,SI=N Exclusions ,,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-20,NDC,outpatient,20,ML,18.52,12.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.02,416.02,other,SI=N Exclusions ,,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,55150-0154-10,NDC,outpatient,10,ML,11.47,8.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.02,416.02,other,SI=N Exclusions ,,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-03,NDC,outpatient,10,ML,8.9,6.23,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.02,416.02,other,SI=N Exclusions ,,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-10,NDC,outpatient,10,ML,8.9,6.23,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.02,416.02,other,SI=N Exclusions ,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,40.48,28.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.04,,,0.04,0.04,416.02,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,24.48,17.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.04,,,0.04,0.04,416.02,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,40.48,28.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.04,,,0.04,0.04,416.02,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,24.48,17.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.04,,,0.04,0.04,416.02,fee schedule,,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,40.48,28.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.04,,,0.04,0.04,416.02,fee schedule,,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,24.48,17.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.04,,,0.04,0.04,416.02,fee schedule,,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,40.48,28.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.04,,,0.04,0.04,416.02,fee schedule,,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,24.48,17.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.04,,,0.04,0.04,416.02,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,40.48,28.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.04,,,0.04,0.04,416.02,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,24.48,17.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.04,,,0.04,0.04,416.02,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,40.48,28.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.04,,,0.04,0.04,416.02,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,24.48,17.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.04,,,0.04,0.04,416.02,fee schedule,,,
ADALIMUMAB 40 MG/0.8ML SC PSKT,RX-129739,CDM,J0135,HCPCS,636,RC,00074-3799-02,NDC,outpatient,1,UN,9266.62,6486.634,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1705.16,,,1705.16,336.23,7116.76416,fee schedule,,,
ADALIMUMAB 40 MG/0.8ML SC PNKT,RX-129742,CDM,J0135,HCPCS,636,RC,00074-4339-02,NDC,outpatient,1,UN,9266.62,6486.634,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1705.16,,,1705.16,336.23,7116.76416,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0136,HCPCS,636,RC,00264-4100-95,NDC,outpatient,100,ML,39.59,27.713,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.05,,,0.05,0.05,416.02,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,23.59,16.513,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.05,,,0.05,0.05,416.02,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,39.59,27.713,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.05,,,0.05,0.05,416.02,fee schedule,,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,39.59,27.713,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.05,,,0.05,0.05,416.02,fee schedule,,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,23.59,16.513,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.05,,,0.05,0.05,416.02,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0136,HCPCS,636,RC,00264-4100-95,NDC,outpatient,100,ML,39.59,27.713,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.05,,,0.05,0.05,416.02,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,39.59,27.713,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.05,,,0.05,0.05,416.02,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,23.59,16.513,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.05,,,0.05,0.05,416.02,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,34.69,24.283,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.05,,,0.05,0.05,416.02,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,34.69,24.283,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.05,,,0.05,0.05,416.02,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,18.69,13.083,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.05,,,0.05,0.05,416.02,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,18.69,13.083,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.05,,,0.05,0.05,416.02,fee schedule,,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,34.69,24.283,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.05,,,0.05,0.05,416.02,fee schedule,,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,34.69,24.283,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.05,,,0.05,0.05,416.02,fee schedule,,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,18.69,13.083,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.05,,,0.05,0.05,416.02,fee schedule,,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,18.69,13.083,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.05,,,0.05,0.05,416.02,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,34.69,24.283,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.05,,,0.05,0.05,416.02,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,18.69,13.083,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.05,,,0.05,0.05,416.02,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,34.69,24.283,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.05,,,0.05,0.05,416.02,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,18.69,13.083,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.05,,,0.05,0.05,416.02,fee schedule,,,
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,RX-15330,CDM,J0153,HCPCS,636,RC,55150-0193-01,NDC,outpatient,30,ML,91.83,64.281,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,631.24992,other,SI=N Exclusions ,,
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,RX-15330,CDM,J0153,HCPCS,636,RC,67457-0857-30,NDC,outpatient,30,ML,821.94,575.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,631.24992,other,SI=N Exclusions ,,
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,RX-15330,CDM,J0153,HCPCS,636,RC,16714-0997-01,NDC,outpatient,30,ML,109.72,76.804,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,631.24992,other,SI=N Exclusions ,,
ADENOSINE 6 MG/2ML IV SOLN,RX-38703,CDM,J0153,HCPCS,636,RC,67457-0855-02,NDC,outpatient,2,ML,24.68,17.276,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,631.24992,other,SI=N Exclusions ,,
ADENOSINE 6 MG/2ML IV SOLN,RX-38703,CDM,J0153,HCPCS,636,RC,67457-0855-00,NDC,outpatient,2,ML,24.68,17.276,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,631.24992,other,SI=N Exclusions ,,
EPINEPHRINE 0.15 MG/0.3ML IJ SOAJ,RX-124855,CDM,J0171,HCPCS,636,RC,49502-0101-02,NDC,outpatient,1,UN,616.75,431.725,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.73,960.94464,other,SI=N Exclusions ,,
EPINEPHRINE 0.15 MG/0.3ML IJ SOAJ,RX-124855,CDM,J0171,HCPCS,636,RC,49502-0501-02,NDC,outpatient,1,UN,1251.23,875.861,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.73,960.94464,other,SI=N Exclusions ,,
EPINEPHRINE 0.15 MG/0.3ML IJ SOAJ,RX-124855,CDM,J0171,HCPCS,636,RC,49502-0101-01,NDC,outpatient,1,UN,616.75,431.725,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.73,960.94464,other,SI=N Exclusions ,,
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,49502-0102-02,NDC,outpatient,1,UN,616.75,431.725,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.73,960.94464,other,SI=N Exclusions ,,
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,00115-1694-30,NDC,outpatient,1,UN,506.88,354.816,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.73,960.94464,other,SI=N Exclusions ,,
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,49502-0500-02,NDC,outpatient,1,UN,1251.23,875.861,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.73,960.94464,other,SI=N Exclusions ,,
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,00115-1694-49,NDC,outpatient,1,UN,506.88,354.816,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.73,960.94464,other,SI=N Exclusions ,,
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,49502-0102-01,NDC,outpatient,1,UN,616.75,431.725,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.73,960.94464,other,SI=N Exclusions ,,
EPINEPHRINE INFUSION PREMIX 1 MG IN 250 ML,RX-4080061,CDM,J0171,HCPCS,636,RC,99999-0001-65,NDC,outpatient,250,ML,83.79,58.653,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.73,960.94464,other,SI=N Exclusions ,,
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER,RX-4080099,CDM,J0171,HCPCS,636,RC,42023-0159-01,NDC,outpatient,1,ML,57.57,40.299,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.73,960.94464,other,SI=N Exclusions ,,
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER,RX-4080099,CDM,J0171,HCPCS,636,RC,42023-0159-25,NDC,outpatient,1,ML,57.57,40.299,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.73,960.94464,other,SI=N Exclusions ,,
EPINEPHRINE HCL 0.1 MG/ML IJ WRAPPER,RX-4080103,CDM,J0171,HCPCS,636,RC,76329-3318-01,NDC,outpatient,10,ML,42.5,29.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.73,960.94464,other,SI=N Exclusions ,,
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER FOR CODE NARRATOR,RX-4081384,CDM,J0171,HCPCS,636,RC,42023-0159-01,NDC,outpatient,1,ML,57.57,40.299,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.73,960.94464,other,SI=N Exclusions ,,
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER FOR CODE NARRATOR,RX-4081384,CDM,J0171,HCPCS,636,RC,42023-0159-25,NDC,outpatient,1,ML,57.57,40.299,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.73,960.94464,other,SI=N Exclusions ,,
EPINEPHRINE PF 1 MG/ML IJ SOLN,RX-140555,CDM,J0173,HCPCS,636,RC,54288-0103-01,NDC,outpatient,1,ML,35.98,25.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.01,,,2.01,1.61,416.02,fee schedule,,,
EPINEPHRINE PF 1 MG/ML IJ SOLN,RX-140555,CDM,J0173,HCPCS,636,RC,54288-0103-10,NDC,outpatient,1,ML,35.98,25.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.01,,,2.01,1.61,416.02,fee schedule,,,
AGALSIDASE BETA 35 MG IV SOLR,RX-35775,CDM,J0180,HCPCS,636,RC,58468-0040-01,NDC,outpatient,1,UN,20575.06,14402.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,223.52,,,223.52,215.38,15801.64608,fee schedule,,,
AGALSIDASE BETA 5 MG IV SOLR,RX-38494,CDM,J0180,HCPCS,636,RC,58468-0041-01,NDC,outpatient,1,UN,2938.8,2057.16,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,223.52,,,223.52,215.38,15801.64608,fee schedule,,,
ALGLUCOSIDASE ALFA 50 MG IV SOLR,RX-76353,CDM,J0221,HCPCS,636,RC,58468-0160-01,NDC,outpatient,1,UN,2661.83,1863.281,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,201.97,,,201.97,194.92,2044.28544,fee schedule,,,
REMDESIVIR 100 MG IV SOLR,RX-150611,CDM,J0248,HCPCS,636,RC,61958-2901-02,NDC,outpatient,1,UN,1654.57,1158.199,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5.51,,,5.51,5.51,1270.70976,fee schedule,,,
ALPHA1-PROTEINASE INHIBITOR 1000 MG/20ML IV SOLN,RX-141646,CDM,J0256,HCPCS,636,RC,13533-0705-01,NDC,outpatient,1,UN,1462.8,1023.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4.94,,,4.94,4.88,1606.272,fee schedule,,,
ALPHA1-PROTEINASE INHIBITOR 1000 MG/20ML IV SOLN,RX-141646,CDM,J0256,HCPCS,636,RC,13533-0705-11,NDC,outpatient,1,UN,1462.8,1023.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4.94,,,4.94,4.88,1606.272,fee schedule,,,
ZEMAIRA 1000 MG IV SOLR,RX-36564,CDM,J0256,HCPCS,636,RC,00053-7201-02,NDC,outpatient,1,UN,2091.5,1464.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4.94,,,4.94,4.88,1606.272,fee schedule,,,
ALPROSTADIL 500 MCG/ML IJ SOLN,RX-9001,CDM,J0270,HCPCS,636,RC,00009-3169-01,NDC,outpatient,1,ML,564.52,395.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11.71,,,11.71,2.98,4260,fee schedule,,,
ALPROSTADIL 500 MCG/ML IJ SOLN,RX-9001,CDM,J0270,HCPCS,636,RC,00009-3169-06,NDC,outpatient,1,ML,564.52,395.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11.71,,,11.71,2.98,4260,fee schedule,,,
AMIKACIN SULFATE 500 MG/2ML IJ SOLN,RX-108131,CDM,J0278,HCPCS,636,RC,23155-0290-31,NDC,outpatient,2,ML,17.6,12.32,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.77,416.02,other,SI=N Exclusions ,,
AMIKACIN SULFATE 500 MG/2ML IJ SOLN,RX-108131,CDM,J0278,HCPCS,636,RC,23155-0290-41,NDC,outpatient,2,ML,17.6,12.32,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.77,416.02,other,SI=N Exclusions ,,
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5922-16,NDC,outpatient,20,ML,38.54,26.978,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.51,416.02,other,SI=N Exclusions ,,
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5921-01,NDC,outpatient,10,ML,61.06,42.742,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.51,416.02,other,SI=N Exclusions ,,
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5921-16,NDC,outpatient,10,ML,61.06,42.742,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.51,416.02,other,SI=N Exclusions ,,
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5922-01,NDC,outpatient,20,ML,38.54,26.978,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.51,416.02,other,SI=N Exclusions ,,
AMIODARONE HCL IN DEXTROSE 900-5 MG/500ML-% IV SOLN,RX-135815,CDM,J0282,HCPCS,636,RC,70092-1005-38,NDC,outpatient,500,ML,218.97,153.279,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.46,416.02,other,SI=N Exclusions ,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-03,NDC,outpatient,3,ML,9.41,6.587,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.46,416.02,other,SI=N Exclusions ,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-09,NDC,outpatient,9,ML,22.43,15.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.46,416.02,other,SI=N Exclusions ,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-01,NDC,outpatient,3,ML,9.41,6.587,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.46,416.02,other,SI=N Exclusions ,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-02,NDC,outpatient,9,ML,22.43,15.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.46,416.02,other,SI=N Exclusions ,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,00143-9875-01,NDC,outpatient,3,ML,3.58,2.506,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.46,416.02,other,SI=N Exclusions ,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,00143-9875-25,NDC,outpatient,3,ML,3.58,2.506,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.46,416.02,other,SI=N Exclusions ,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,67457-0153-00,NDC,outpatient,3,ML,16.55,11.585,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.46,416.02,other,SI=N Exclusions ,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,67457-0153-03,NDC,outpatient,3,ML,16.55,11.585,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.46,416.02,other,SI=N Exclusions ,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,67457-0153-18,NDC,outpatient,18,ML,55.43,38.801,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.46,416.02,other,SI=N Exclusions ,,
AMPHOTERICIN B 50 MG IV SOLR,RX-464,CDM,J0285,HCPCS,636,RC,39822-1055-05,NDC,outpatient,1,UN,155.22,108.654,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,34.84689,416.02,other,SI=N Exclusions ,,
AMPHOTERICIN B LIPID 5 MG/ML IV SUSP,RX-22981,CDM,J0287,HCPCS,636,RC,57665-0101-41,NDC,outpatient,20,ML,431.74,302.218,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11.97,,,11.97,11.13,416.02,fee schedule,,,
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,RX-21900,CDM,J0289,HCPCS,636,RC,62756-0233-01,NDC,outpatient,1,UN,328.95,230.265,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23.33,,,23.33,23.33,974.33088,fee schedule,,,
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,RX-21900,CDM,J0289,HCPCS,636,RC,00469-3051-30,NDC,outpatient,1,UN,1268.66,888.062,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23.33,,,23.33,23.33,974.33088,fee schedule,,,
AMPICILLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080940,CDM,J0290,HCPCS,636,RC,25021-0136-10,NDC,outpatient,1,UN,10.62,7.434,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions ,,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,65219-0016-01,NDC,outpatient,1,UN,5.52,3.864,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions ,,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,67850-0024-10,NDC,outpatient,1,UN,8.62,6.034,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions ,,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,00781-3407-95,NDC,outpatient,1,UN,4.29,3.003,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions ,,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,67850-0024-00,NDC,outpatient,1,UN,8.62,6.034,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions ,,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,00781-3407-78,NDC,outpatient,1,UN,4.29,3.003,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions ,,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,65219-0016-10,NDC,outpatient,1,UN,5.52,3.864,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions ,,
AMPICILLIN SODIUM 1 G IJ SOLR,RX-469,CDM,J0290,HCPCS,636,RC,25021-0136-10,NDC,outpatient,1,UN,10.62,7.434,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions ,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,55150-0114-20,NDC,outpatient,1,UN,13.5,9.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions ,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,65219-0020-03,NDC,outpatient,1,UN,32.57,22.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions ,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,25021-0137-20,NDC,outpatient,1,UN,16.54,11.578,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions ,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,72485-0422-01,NDC,outpatient,1,UN,18.51,12.957,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions ,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,72485-0422-10,NDC,outpatient,1,UN,18.51,12.957,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions ,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,44567-0103-10,NDC,outpatient,1,UN,45.23,31.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions ,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,65219-0020-23,NDC,outpatient,1,UN,32.57,22.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions ,,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,00781-3407-95,NDC,outpatient,1,UN,4.29,3.003,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions ,,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,65219-0016-10,NDC,outpatient,1,UN,5.52,3.864,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions ,,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,00781-3407-78,NDC,outpatient,1,UN,4.29,3.003,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions ,,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,65219-0016-01,NDC,outpatient,1,UN,5.52,3.864,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions ,,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,67850-0024-10,NDC,outpatient,1,UN,8.62,6.034,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions ,,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,67850-0024-00,NDC,outpatient,1,UN,8.62,6.034,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions ,,
AMPICILLIN-SULBACTAM SODIUM 15 (10-5) G IV SOLR,RX-105616,CDM,J0295,HCPCS,636,RC,00049-0024-28,NDC,outpatient,1,UN,84.11,58.877,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.600685,416.02,other,SI=N Exclusions ,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IV SOLR,RX-27283,CDM,J0295,HCPCS,636,RC,00409-2987-23,NDC,outpatient,1,UN,24.87,17.409,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.600685,416.02,other,SI=N Exclusions ,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IV SOLR,RX-27283,CDM,J0295,HCPCS,636,RC,00409-2987-03,NDC,outpatient,1,UN,24.87,17.409,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.600685,416.02,other,SI=N Exclusions ,,
AMPICILLIN-SULBACTAM 3 G 100 ML ADD-VANTAGE BAG,RX-400006,CDM,J0295,HCPCS,636,RC,99999-0003-15,NDC,outpatient,100,ML,43.51,30.457,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.600685,416.02,other,SI=N Exclusions ,,
AMPICILLIN-SULBACTAM 3 G 100 ML IVPB BATCHED,RX-4081206,CDM,J0295,HCPCS,636,RC,99999-0003-29,NDC,outpatient,100,ML,29.73,20.811,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.600685,416.02,other,SI=N Exclusions ,,
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR,RX-9083,CDM,J0295,HCPCS,636,RC,55150-0116-20,NDC,outpatient,1,UN,7.13,4.991,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.600685,416.02,other,SI=N Exclusions ,,
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR,RX-9083,CDM,J0295,HCPCS,636,RC,71288-0031-20,NDC,outpatient,1,UN,21.1,14.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.600685,416.02,other,SI=N Exclusions ,,
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR,RX-9083,CDM,J0295,HCPCS,636,RC,71288-0031-21,NDC,outpatient,1,UN,21.1,14.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.600685,416.02,other,SI=N Exclusions ,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,00641-6117-10,NDC,outpatient,1,UN,28.2,19.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.600685,416.02,other,SI=N Exclusions ,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,70594-0082-01,NDC,outpatient,1,UN,37.01,25.907,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.600685,416.02,other,SI=N Exclusions ,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,71288-0032-20,NDC,outpatient,1,UN,33.6,23.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.600685,416.02,other,SI=N Exclusions ,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,71288-0032-21,NDC,outpatient,1,UN,33.6,23.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.600685,416.02,other,SI=N Exclusions ,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,00641-6117-01,NDC,outpatient,1,UN,28.2,19.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.600685,416.02,other,SI=N Exclusions ,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,25021-0143-30,NDC,outpatient,1,UN,36.19,25.333,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.600685,416.02,other,SI=N Exclusions ,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,70594-0082-02,NDC,outpatient,1,UN,37.01,25.907,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.600685,416.02,other,SI=N Exclusions ,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,72485-0417-01,NDC,outpatient,1,UN,18.05,12.635,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.600685,416.02,other,SI=N Exclusions ,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,55150-0117-01,NDC,outpatient,1,UN,13.78,9.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.600685,416.02,other,SI=N Exclusions ,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,55150-0117-10,NDC,outpatient,1,UN,13.78,9.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.600685,416.02,other,SI=N Exclusions ,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,55150-0117-20,NDC,outpatient,1,UN,13.78,9.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.600685,416.02,other,SI=N Exclusions ,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,72485-0417-10,NDC,outpatient,1,UN,18.05,12.635,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.600685,416.02,other,SI=N Exclusions ,,
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,70004-0908-09,NDC,outpatient,5,ML,95.5,66.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.82,416.02,other,SI=N Exclusions ,,
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,70004-0910-09,NDC,outpatient,5,ML,31.6,22.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.82,416.02,other,SI=N Exclusions ,,
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,70092-1086-44,NDC,outpatient,5,ML,84.42,59.094,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.82,416.02,other,SI=N Exclusions ,,
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,69374-0920-05,NDC,outpatient,5,ML,14.14,9.898,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.82,416.02,other,SI=N Exclusions ,,
ANIDULAFUNGIN 100 MG IV SOLR,RX-88093,CDM,J0348,HCPCS,636,RC,00049-0116-28,NDC,outpatient,1,UN,139.38,97.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.46,416.02,other,SI=N Exclusions ,,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,55150-0400-01,NDC,outpatient,1,ML,14.72,10.304,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.732165,416.02,other,SI=N Exclusions ,,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,63323-0614-00,NDC,outpatient,1,ML,14.49,10.143,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.732165,416.02,other,SI=N Exclusions ,,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,00641-6231-25,NDC,outpatient,1,ML,12.17,8.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.732165,416.02,other,SI=N Exclusions ,,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,63323-0614-01,NDC,outpatient,1,ML,14.49,10.143,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.732165,416.02,other,SI=N Exclusions ,,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,00641-6231-01,NDC,outpatient,1,ML,12.17,8.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.732165,416.02,other,SI=N Exclusions ,,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,55150-0400-25,NDC,outpatient,1,ML,14.72,10.304,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.732165,416.02,other,SI=N Exclusions ,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,00069-3150-84,NDC,outpatient,1,UN,24.39,17.073,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.834165,416.02,other,SI=N Exclusions ,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,63323-0398-01,NDC,outpatient,1,UN,8.17,5.719,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.834165,416.02,other,SI=N Exclusions ,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,00069-3150-83,NDC,outpatient,1,UN,24.39,17.073,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.834165,416.02,other,SI=N Exclusions ,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,55150-0174-10,NDC,outpatient,1,UN,9.22,6.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.834165,416.02,other,SI=N Exclusions ,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,63323-0398-10,NDC,outpatient,1,UN,8.17,5.719,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.834165,416.02,other,SI=N Exclusions ,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70095-0025-02,NDC,outpatient,1,UN,8.79,6.153,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.834165,416.02,other,SI=N Exclusions ,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70095-0025-01,NDC,outpatient,1,UN,8.79,6.153,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.834165,416.02,other,SI=N Exclusions ,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70436-0019-82,NDC,outpatient,1,UN,12.13,8.491,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.834165,416.02,other,SI=N Exclusions ,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70860-0100-41,NDC,outpatient,1,UN,13.9,9.73,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.834165,416.02,other,SI=N Exclusions ,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70860-0100-10,NDC,outpatient,1,UN,13.9,9.73,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.834165,416.02,other,SI=N Exclusions ,,
AZITHROMYCIN 500 MG IN 250 ML NS PREMIX,RX-4080917,CDM,J0456,HCPCS,636,RC,99999-0001-37,NDC,outpatient,255,ML,46.12,32.284,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.834165,416.02,other,SI=N Exclusions ,,
AZTREONAM 1 G IJ SOLR 100 MG/ML,RX-4081004,CDM,J0457,HCPCS,636,RC,00409-0829-11,NDC,outpatient,1,UN,98.69,69.083,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.97,,,1.97,1.97,416.02,fee schedule,,,
AZTREONAM 1 G IJ SOLR 100 MG/ML,RX-4081004,CDM,J0457,HCPCS,636,RC,00409-0829-01,NDC,outpatient,1,UN,98.69,69.083,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.97,,,1.97,1.97,416.02,fee schedule,,,
AZTREONAM 1 G IJ SOLR 100 MG/ML,RX-4081004,CDM,J0457,HCPCS,636,RC,00003-2560-16,NDC,outpatient,1,UN,122.23,85.561,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.97,,,1.97,1.97,416.02,fee schedule,,,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,00409-0830-01,NDC,outpatient,1,UN,201.48,141.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.97,,,1.97,1.97,416.02,fee schedule,,,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,63323-0402-20,NDC,outpatient,1,UN,201.48,141.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.97,,,1.97,1.97,416.02,fee schedule,,,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,00003-2570-16,NDC,outpatient,1,UN,244.45,171.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.97,,,1.97,1.97,416.02,fee schedule,,,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,00409-0830-11,NDC,outpatient,1,UN,201.48,141.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.97,,,1.97,1.97,416.02,fee schedule,,,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,63323-0402-01,NDC,outpatient,1,UN,201.48,141.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.97,,,1.97,1.97,416.02,fee schedule,,,
AZTREONAM 1 G IJ SOLR,RX-9185,CDM,J0457,HCPCS,636,RC,00409-0829-11,NDC,outpatient,1,UN,98.69,69.083,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.97,,,1.97,1.97,416.02,fee schedule,,,
AZTREONAM 1 G IJ SOLR,RX-9185,CDM,J0457,HCPCS,636,RC,00003-2560-16,NDC,outpatient,1,UN,122.23,85.561,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.97,,,1.97,1.97,416.02,fee schedule,,,
AZTREONAM 1 G IJ SOLR,RX-9185,CDM,J0457,HCPCS,636,RC,00409-0829-01,NDC,outpatient,1,UN,98.69,69.083,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.97,,,1.97,1.97,416.02,fee schedule,,,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,00409-0830-01,NDC,outpatient,1,UN,201.48,141.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.97,,,1.97,1.97,416.02,fee schedule,,,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,63323-0402-20,NDC,outpatient,1,UN,201.48,141.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.97,,,1.97,1.97,416.02,fee schedule,,,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,00409-0830-11,NDC,outpatient,1,UN,201.48,141.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.97,,,1.97,1.97,416.02,fee schedule,,,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,00003-2570-16,NDC,outpatient,1,UN,244.45,171.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.97,,,1.97,1.97,416.02,fee schedule,,,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,63323-0402-01,NDC,outpatient,1,UN,201.48,141.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.97,,,1.97,1.97,416.02,fee schedule,,,
ATROPINE SULFATE 0.1 MG/ML IJ SOLN WRAPPER,RX-4080930,CDM,J0461,HCPCS,636,RC,76329-3340-01,NDC,outpatient,10,ML,42.72,29.904,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
ATROPINE SULFATE 0.4 MG/ML IJ SOLN WRAPPER,RX-4080931,CDM,J0461,HCPCS,636,RC,00517-1004-01,NDC,outpatient,1,ML,19.31,13.517,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
ATROPINE SULFATE 0.4 MG/ML IJ SOLN WRAPPER,RX-4080931,CDM,J0461,HCPCS,636,RC,00517-1004-25,NDC,outpatient,1,ML,19.31,13.517,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
ATROPINE SULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4081335,CDM,J0461,HCPCS,636,RC,00517-1001-25,NDC,outpatient,1,ML,30.76,21.532,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
ATROPINE SULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4081335,CDM,J0461,HCPCS,636,RC,00517-1001-01,NDC,outpatient,1,ML,30.76,21.532,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
ATROPINE SULFATE 0.25 MG/5ML IJ SOSY,RX-729,CDM,J0461,HCPCS,636,RC,00409-9630-15,NDC,outpatient,5,ML,87.58,61.306,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
ATROPINE SULFATE 0.25 MG/5ML IJ SOSY,RX-729,CDM,J0461,HCPCS,636,RC,00409-9630-05,NDC,outpatient,5,ML,87.58,61.306,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
BACLOFEN 10000 MCG/20ML IT WRAPPER,RX-4081072,CDM,J0475,HCPCS,636,RC,66794-0155-01,NDC,outpatient,20,ML,794.33,556.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,174.58,,,174.58,174.58,1359.95136,fee schedule,,,
BACLOFEN 20000 MCG/20ML IT WRAPPER,RX-4081073,CDM,J0475,HCPCS,636,RC,66794-0156-02,NDC,outpatient,20,ML,1497.87,1048.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,174.58,,,174.58,174.58,1359.95136,fee schedule,,,
BACLOFEN 40000 MCG/20ML IT WRAPPER,RX-4081074,CDM,J0475,HCPCS,636,RC,66794-0157-02,NDC,outpatient,20,ML,1770.77,1239.539,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,174.58,,,174.58,174.58,1359.95136,fee schedule,,,
BACLOFEN 50 MCG/ML IT SOSY,RX-107798,CDM,J0476,HCPCS,636,RC,66794-0151-01,NDC,outpatient,1,ML,326.81,228.767,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,40.38,416.02,other,SI=N Exclusions ,,
BELIMUMAB 120 MG IV SOLR,RX-108842,CDM,J0490,HCPCS,636,RC,49401-0101-01,NDC,outpatient,1,UN,1753.47,1227.429,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,54.15,,,54.15,50.93,4488.66816,fee schedule,,,
BELIMUMAB 400 MG IV SOLR,RX-108843,CDM,J0490,HCPCS,636,RC,49401-0102-01,NDC,outpatient,1,UN,5844.62,4091.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,54.15,,,54.15,50.93,4488.66816,fee schedule,,,
DICYCLOMINE HCL 10 MG/ML IM SOLN,RX-2417,CDM,J0500,HCPCS,636,RC,14789-0010-02,NDC,outpatient,2,ML,41.12,28.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.23144,416.02,other,SI=N Exclusions ,,
DICYCLOMINE HCL 10 MG/ML IM SOLN,RX-2417,CDM,J0500,HCPCS,636,RC,14789-0010-07,NDC,outpatient,2,ML,41.12,28.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.23144,416.02,other,SI=N Exclusions ,,
DICYCLOMINE HCL 10 MG/ML IM SOLN,RX-2417,CDM,J0500,HCPCS,636,RC,58914-0080-52,NDC,outpatient,2,ML,345.64,241.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.23144,416.02,other,SI=N Exclusions ,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9233-05,NDC,outpatient,2,ML,97.73,68.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,16.21,416.02,other,SI=N Exclusions ,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,68382-0860-10,NDC,outpatient,2,ML,102.98,72.086,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,16.21,416.02,other,SI=N Exclusions ,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9729-05,NDC,outpatient,2,ML,114.01,79.807,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,16.21,416.02,other,SI=N Exclusions ,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,68382-0860-02,NDC,outpatient,2,ML,102.98,72.086,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,16.21,416.02,other,SI=N Exclusions ,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9729-01,NDC,outpatient,2,ML,114.01,79.807,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,16.21,416.02,other,SI=N Exclusions ,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9233-01,NDC,outpatient,2,ML,97.73,68.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,16.21,416.02,other,SI=N Exclusions ,,
PENICILLIN G BENZATHINE & PROC 1200000 UNIT/2ML IM SUSP,RX-108051,CDM,J0558,HCPCS,636,RC,60793-0600-02,NDC,outpatient,2,ML,908.68,636.076,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19.52,,,19.52,15.67,697.86624,fee schedule,,,
PENICILLIN G BENZATHINE & PROC 1200000 UNIT/2ML IM SUSP,RX-108051,CDM,J0558,HCPCS,636,RC,60793-0600-10,NDC,outpatient,2,ML,908.68,636.076,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,19.52,,,19.52,15.67,697.86624,fee schedule,,,
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SUSY,RX-158171,CDM,J0561,HCPCS,636,RC,60793-0700-01,NDC,outpatient,1,ML,595.58,416.906,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24.37,,,24.37,20.17,1623.552,fee schedule,,,
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SUSY,RX-158171,CDM,J0561,HCPCS,636,RC,60793-0700-10,NDC,outpatient,1,ML,595.58,416.906,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24.37,,,24.37,20.17,1623.552,fee schedule,,,
PENICILLIN G BENZATHINE 1200000 UNIT/2ML IM SUSY,RX-158172,CDM,J0561,HCPCS,636,RC,60793-0701-10,NDC,outpatient,2,ML,1139.95,797.965,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24.37,,,24.37,20.17,1623.552,fee schedule,,,
PENICILLIN G BENZATHINE 1200000 UNIT/2ML IM SUSY,RX-158172,CDM,J0561,HCPCS,636,RC,60793-0701-02,NDC,outpatient,2,ML,1139.95,797.965,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24.37,,,24.37,20.17,1623.552,fee schedule,,,
PENICILLIN G BENZATHINE 2400000 UNIT/4ML IM SUSY,RX-162947,CDM,J0561,HCPCS,636,RC,60793-0702-04,NDC,outpatient,4,ML,2114,1479.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24.37,,,24.37,20.17,1623.552,fee schedule,,,
PENICILLIN G BENZATHINE 2400000 UNIT/4ML IM SUSY,RX-162947,CDM,J0561,HCPCS,636,RC,60793-0702-10,NDC,outpatient,4,ML,2114,1479.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,24.37,,,24.37,20.17,1623.552,fee schedule,,,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,00781-3158-95,NDC,outpatient,1,UN,308.39,215.873,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.17,416.02,other,SI=N Exclusions ,,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,16729-0275-03,NDC,outpatient,1,UN,294.51,206.157,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.17,416.02,other,SI=N Exclusions ,,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,55150-0210-10,NDC,outpatient,1,UN,189.45,132.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.17,416.02,other,SI=N Exclusions ,,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,00781-3158-94,NDC,outpatient,1,UN,308.39,215.873,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.17,416.02,other,SI=N Exclusions ,,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,16729-0275-67,NDC,outpatient,1,UN,294.51,206.157,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.17,416.02,other,SI=N Exclusions ,,
ONABOTULINUMTOXINA 100 UNITS IJ SOLR,RX-100610,CDM,J0585,HCPCS,636,RC,00023-1145-01,NDC,outpatient,1,UN,1749.84,1224.888,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,6.41,,,6.41,6.15,1343.87712,fee schedule,,,
BUPRENORPHINE HCL 0.3 MG/ML IJ SOLN,RX-9320,CDM,J0592,HCPCS,636,RC,42023-0179-05,NDC,outpatient,1,ML,53.16,37.212,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.03,416.02,other,SI=N Exclusions ,,
BUPRENORPHINE HCL 0.3 MG/ML IJ SOLN,RX-9320,CDM,J0592,HCPCS,636,RC,42023-0179-01,NDC,outpatient,1,ML,53.16,37.212,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.03,416.02,other,SI=N Exclusions ,,
BUTORPHANOL TARTRATE 2 MG/ML IJ SOLN,RX-9334,CDM,J0595,HCPCS,636,RC,00409-1626-21,NDC,outpatient,1,ML,29.94,20.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.06,416.02,other,SI=N Exclusions ,,
BUTORPHANOL TARTRATE 2 MG/ML IJ SOLN,RX-9334,CDM,J0595,HCPCS,636,RC,00409-1626-01,NDC,outpatient,1,ML,29.94,20.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.06,416.02,other,SI=N Exclusions ,,
EDETATE CALCIUM DISODIUM 1 GM/5ML IJ SOLN,RX-108094,CDM,J0600,HCPCS,250,RC,64980-0588-05,NDC,outpatient,5,ML,16465.83,11526.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7403.87,,,7403.87,60.43,12645.75744,fee schedule,,,
EDETATE CALCIUM DISODIUM 1 GM/5ML IJ SOLN,RX-108094,CDM,J0600,HCPCS,250,RC,64980-0588-51,NDC,outpatient,5,ML,16465.83,11526.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7403.87,,,7403.87,60.43,12645.75744,fee schedule,,,
CALCIUM GLUCONATE 10 % IV SOLN,RX-1312,CDM,J0612,HCPCS,636,RC,63323-0360-01,NDC,outpatient,10,ML,36.54,25.578,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.04,,,0.04,0.04,416.02,fee schedule,,,
CALCIUM GLUCONATE 10 % IV SOLN,RX-1312,CDM,J0612,HCPCS,636,RC,63323-0360-19,NDC,outpatient,10,ML,36.54,25.578,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.04,,,0.04,0.04,416.02,fee schedule,,,
CALCIUM GLUCONATE-NACL 1-0.8 GM/100ML-% IV SOLN,RX-156703,CDM,J0613,HCPCS,636,RC,44567-0622-24,NDC,outpatient,100,ML,37.38,26.166,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.09,,,0.09,0.08,416.02,fee schedule,,,
CALCIUM GLUCONATE-NACL 1-0.8 GM/100ML-% IV SOLN,RX-156703,CDM,J0613,HCPCS,636,RC,44567-0622-01,NDC,outpatient,100,ML,37.38,26.166,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.09,,,0.09,0.08,416.02,fee schedule,,,
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-01,NDC,outpatient,100,ML,53.38,37.366,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.09,,,0.09,0.08,416.02,fee schedule,,,
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-24,NDC,outpatient,100,ML,37.38,26.166,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.09,,,0.09,0.08,416.02,fee schedule,,,
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-24,NDC,outpatient,100,ML,53.38,37.366,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.09,,,0.09,0.08,416.02,fee schedule,,,
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-01,NDC,outpatient,100,ML,37.38,26.166,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.09,,,0.09,0.08,416.02,fee schedule,,,
CALCITONIN (SALMON) 200 UNIT/ML IJ SOLN,RX-9347,CDM,J0630,HCPCS,636,RC,42023-0205-01,NDC,outpatient,2,ML,2193.21,1535.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1173.06,,,1173.06,399.86,2155.44576,fee schedule,,,
CALCITONIN (SALMON) 200 UNIT/ML IJ SOLN,RX-9347,CDM,J0630,HCPCS,636,RC,67457-0675-02,NDC,outpatient,2,ML,2806.57,1964.599,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1173.06,,,1173.06,399.86,2155.44576,fee schedule,,,
LEUCOVORIN CALCIUM IM INJECTION,RX-4080923,CDM,J0640,HCPCS,636,RC,25021-0813-10,NDC,outpatient,50,ME,16.97,11.879,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.68951,416.02,other,SI=N Exclusions ,,
LEUCOVORIN CALCIUM 350 MG IJ SOLR,RX-4393,CDM,J0640,HCPCS,636,RC,00143-9552-01,NDC,outpatient,1,UN,106.72,74.704,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.68951,416.02,other,SI=N Exclusions ,,
LEUCOVORIN CALCIUM 50 MG IJ SOLR,RX-4394,CDM,J0640,HCPCS,636,RC,25021-0813-10,NDC,outpatient,50,ME,11.98,8.386,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.68951,416.02,other,SI=N Exclusions ,,
LEVOTHYROXINE SODIUM 100 MCG IV SOLR,RX-113060,CDM,J0651,HCPCS,250,RC,63323-0649-07,NDC,outpatient,1,UN,279.46,195.622,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10.11,,,10.11,4.2921885,416.02,fee schedule,,,
LEVOTHYROXINE SODIUM 100 MCG IV SOLR,RX-113060,CDM,J0651,HCPCS,250,RC,63323-0885-12,NDC,outpatient,5,ML,293.44,205.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10.11,,,10.11,4.2921885,416.02,fee schedule,,,
LEVOTHYROXINE SODIUM 100 MCG IV SOLR,RX-113060,CDM,J0651,HCPCS,250,RC,63323-0885-10,NDC,outpatient,5,ML,293.44,205.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10.11,,,10.11,4.2921885,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1559-19,NDC,outpatient,30,ML,19.59,13.713,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,63323-0464-01,NDC,outpatient,10,ML,6.48,4.536,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-02,NDC,outpatient,30,ML,8.79,6.153,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-19,NDC,outpatient,30,ML,8.79,6.153,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,55150-0168-30,NDC,outpatient,30,ML,11.11,7.777,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00143-9330-10,NDC,outpatient,10,ML,7.82,5.474,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-01,NDC,outpatient,10,ML,8.79,6.153,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,55150-0167-10,NDC,outpatient,10,ML,10.85,7.595,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00143-9330-01,NDC,outpatient,10,ML,7.82,5.474,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-18,NDC,outpatient,10,ML,8.79,6.153,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1559-30,NDC,outpatient,30,ML,19.59,13.713,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,63323-0464-17,NDC,outpatient,10,ML,6.48,4.536,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1162-02,NDC,outpatient,30,ML,9.72,6.804,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,63323-0466-37,NDC,outpatient,30,ML,9.57,6.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1162-01,NDC,outpatient,10,ML,10.08,7.056,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1560-18,NDC,outpatient,10,ML,19.43,13.601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,63323-0466-01,NDC,outpatient,30,ML,9.57,6.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1560-19,NDC,outpatient,30,ML,17.89,12.523,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,55150-0170-30,NDC,outpatient,30,ML,12.34,8.638,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,00409-1165-19,NDC,outpatient,30,ML,16.97,11.879,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,63323-0472-01,NDC,outpatient,30,ML,12.8,8.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,63323-0472-37,NDC,outpatient,30,ML,12.8,8.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,00409-1165-02,NDC,outpatient,30,ML,16.97,11.879,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL 0.25 % IJ SOLN,RX-1222,CDM,J0665,HCPCS,636,RC,63323-0465-57,NDC,outpatient,5,ML,5.5,3.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL 0.25 % IJ SOLN,RX-1222,CDM,J0665,HCPCS,636,RC,63323-0465-01,NDC,outpatient,5,ML,5.5,3.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL 0.5 % IJ SOLN,RX-1223,CDM,J0665,HCPCS,636,RC,00409-1163-01,NDC,outpatient,5,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL 0.5 % IJ SOLN,RX-1223,CDM,J0665,HCPCS,636,RC,00409-1163-18,NDC,outpatient,5,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,,,
BUPIVACAINE IN DEXTROSE 0.75-8.25 % IT SOLN,RX-9316,CDM,J0665,HCPCS,636,RC,00409-1761-18,NDC,outpatient,2,ML,20.36,14.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,,,
BUPIVACAINE IN DEXTROSE 0.75-8.25 % IT SOLN,RX-9316,CDM,J0665,HCPCS,636,RC,00409-1761-10,NDC,outpatient,2,ML,20.36,14.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.01,,,0.01,0.01,416.02,fee schedule,,,
MEPIVACAINE HCL (PF) 2 % IJ SOLN,RX-105638,CDM,J0670,HCPCS,636,RC,63323-0294-27,NDC,outpatient,20,ML,27.95,19.565,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.08,416.02,other,SI=N Exclusions ,,
MEPIVACAINE HCL (PF) 2 % IJ SOLN,RX-105638,CDM,J0670,HCPCS,636,RC,63323-0294-01,NDC,outpatient,20,ML,27.95,19.565,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.08,416.02,other,SI=N Exclusions ,,
CEFAZOLIN IVPB 2 G IN 100 ML D4W PREMIX|DISCARDED DRUG NOT ADMINISTERED,RX-4080727,CDM,J0689,HCPCS,636,RC,00338-3508-41,NDC,outpatient,100,ML,26.74,18.718,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,1.26,,,1.26,1.22,416.02,fee schedule,,,
CEFAZOLIN IVPB 2 G IN 100 ML D4W PREMIX,RX-4080727,CDM,J0689,HCPCS,636,RC,00338-3508-41,NDC,outpatient,100,ML,42.74,29.918,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.26,,,1.26,1.22,416.02,fee schedule,,,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,44567-0707-25,NDC,outpatient,1,UN,7.84,5.488,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,25021-0101-10,NDC,outpatient,1,UN,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,00143-9924-90,NDC,outpatient,1,UN,5.85,4.095,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,60505-6142-00,NDC,outpatient,1,UN,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,60505-6142-05,NDC,outpatient,1,UN,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 10 G IJ SOLR,RX-1446,CDM,J0690,HCPCS,636,RC,00143-9983-91,NDC,outpatient,1,UN,40.9,28.63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 10 G IJ SOLR,RX-1446,CDM,J0690,HCPCS,636,RC,00143-9983-03,NDC,outpatient,1,UN,40.9,28.63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 500 MG IJ SOLR,RX-1448,CDM,J0690,HCPCS,636,RC,44567-0706-25,NDC,outpatient,1,UN,4.28,2.996,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 2 G IJ SOLR,RX-158156,CDM,J0690,HCPCS,636,RC,60505-6231-05,NDC,outpatient,1,UN,18.74,13.118,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 2 G IJ SOLR,RX-158156,CDM,J0690,HCPCS,636,RC,60505-6231-00,NDC,outpatient,1,UN,18.74,13.118,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 1 G IV SOLR ADD-VANTAGE,RX-27297,CDM,J0690,HCPCS,636,RC,00409-2585-01,NDC,outpatient,1,UN,12.17,8.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 1 G IV SOLR ADD-VANTAGE,RX-27297,CDM,J0690,HCPCS,636,RC,00409-2585-11,NDC,outpatient,1,UN,12.17,8.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,44567-0707-25,NDC,outpatient,1,UN,7.84,5.488,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,60505-6142-00,NDC,outpatient,1,UN,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,60505-6142-05,NDC,outpatient,1,UN,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,25021-0101-10,NDC,outpatient,1,UN,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,00143-9924-90,NDC,outpatient,1,UN,5.85,4.095,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,00143-9924-90,NDC,outpatient,1,UN,5.85,4.095,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,60505-6142-00,NDC,outpatient,1,UN,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,60505-6142-05,NDC,outpatient,1,UN,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,44567-0707-25,NDC,outpatient,1,UN,7.84,5.488,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,25021-0101-10,NDC,outpatient,1,UN,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 1 G 100 ML ADD-VANTAGE BAG,RX-4081138,CDM,J0690,HCPCS,636,RC,99999-0003-01,NDC,outpatient,100,ML,32.9,23.03,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,00409-9566-10,NDC,outpatient,1,UN,16.63,11.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,00409-9566-01,NDC,outpatient,1,UN,16.63,11.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,60505-6146-04,NDC,outpatient,1,UN,12,8.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,44567-0240-10,NDC,outpatient,1,UN,23.44,16.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,60505-6146-00,NDC,outpatient,1,UN,12,8.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,25021-0121-20,NDC,outpatient,1,UN,17.97,12.579,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,60505-6246-04,NDC,outpatient,1,UN,19.47,13.629,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,70594-0090-01,NDC,outpatient,1,UN,40.3,28.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,44567-0241-10,NDC,outpatient,1,UN,40.3,28.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,60505-6246-00,NDC,outpatient,1,UN,19.47,13.629,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,00409-9735-10,NDC,outpatient,1,UN,25.5,17.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,70594-0090-02,NDC,outpatient,1,UN,40.3,28.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,00409-9735-01,NDC,outpatient,1,UN,25.5,17.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,25021-0122-50,NDC,outpatient,1,UN,32.22,22.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME IVPB 1 G IN 100 ML NS COMPOUNDED,RX-4080828,CDM,J0692,HCPCS,636,RC,99999-0001-09,NDC,outpatient,100,ML,48.93,34.251,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,00409-9735-01,NDC,outpatient,1,UN,25.5,17.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,60505-6147-00,NDC,outpatient,1,UN,34.31,24.017,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,00409-9735-10,NDC,outpatient,1,UN,25.5,17.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,44567-0241-10,NDC,outpatient,1,UN,40.3,28.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,60505-6147-04,NDC,outpatient,1,UN,19.47,13.629,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,70594-0090-01,NDC,outpatient,1,UN,40.3,28.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,70594-0090-02,NDC,outpatient,1,UN,40.3,28.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,60505-6146-04,NDC,outpatient,1,UN,12,8.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,00409-9566-10,NDC,outpatient,1,UN,16.63,11.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,25021-0121-20,NDC,outpatient,1,UN,17.97,12.579,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,60505-6146-00,NDC,outpatient,1,UN,12,8.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,00409-9566-01,NDC,outpatient,1,UN,16.63,11.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,44567-0240-10,NDC,outpatient,1,UN,23.44,16.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFOXITIN SODIUM-DEXTROSE 2-2.2 GM-%(50ML) IV SOLR,RX-144407,CDM,J0694,HCPCS,636,RC,00264-3125-11,NDC,outpatient,1,UN,147.33,103.131,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.679555,416.02,other,SI=N Exclusions ,,
CEFOXITIN IVPB 2 G IN 100 ML NS COMPOUNDED,RX-4080864,CDM,J0694,HCPCS,636,RC,99999-0001-16,NDC,outpatient,100,ML,46.14,32.298,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.679555,416.02,other,SI=N Exclusions ,,
CEFOXITIN SODIUM 1 G IV SOLR 1000 MG/10.5 ML,RX-4080998,CDM,J0694,HCPCS,636,RC,44567-0245-25,NDC,outpatient,1,UN,40.92,28.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.679555,416.02,other,SI=N Exclusions ,,
CEFOXITIN SODIUM 1 G IV SOLR 1000 MG/10.5 ML,RX-4080998,CDM,J0694,HCPCS,636,RC,25021-0109-10,NDC,outpatient,1,UN,16.39,11.473,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.679555,416.02,other,SI=N Exclusions ,,
CEFOXITIN SODIUM 2 G IV SOLR 2000 MG/11.1 ML,RX-4081009,CDM,J0694,HCPCS,636,RC,25021-0110-20,NDC,outpatient,1,UN,30.34,21.238,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.679555,416.02,other,SI=N Exclusions ,,
CEFOXITIN SODIUM 2 G IV SOLR 2000 MG/11.1 ML,RX-4081009,CDM,J0694,HCPCS,636,RC,44567-0246-25,NDC,outpatient,1,UN,82.04,57.428,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.679555,416.02,other,SI=N Exclusions ,,
CEFOXITIN SODIUM 1 G IV SOLR,RX-9461,CDM,J0694,HCPCS,636,RC,44567-0245-25,NDC,outpatient,1,UN,40.92,28.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.679555,416.02,other,SI=N Exclusions ,,
CEFOXITIN SODIUM 1 G IV SOLR,RX-9461,CDM,J0694,HCPCS,636,RC,25021-0109-10,NDC,outpatient,1,UN,16.39,11.473,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.679555,416.02,other,SI=N Exclusions ,,
CEFOXITIN SODIUM 2 G IV SOLR,RX-9463,CDM,J0694,HCPCS,636,RC,25021-0110-20,NDC,outpatient,1,UN,30.34,21.238,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.679555,416.02,other,SI=N Exclusions ,,
CEFOXITIN SODIUM 2 G IV SOLR,RX-9463,CDM,J0694,HCPCS,636,RC,44567-0246-25,NDC,outpatient,1,UN,82.04,57.428,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.679555,416.02,other,SI=N Exclusions ,,
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G IV SOLR,RX-129169,CDM,J0695,HCPCS,636,RC,67919-0030-01,NDC,outpatient,1,UN,652.32,456.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,8.23,,,8.23,7.54,500.98176,fee schedule,,,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00781-3208-85,NDC,outpatient,1,UN,17.99,12.593,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,44567-0701-25,NDC,outpatient,1,UN,4.75,3.325,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00143-9857-01,NDC,outpatient,1,UN,5.23,3.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00143-9857-25,NDC,outpatient,1,UN,5.23,3.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,25021-0106-10,NDC,outpatient,1,UN,9.22,6.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00781-3208-95,NDC,outpatient,1,UN,17.99,12.593,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00143-9856-01,NDC,outpatient,1,UN,9.12,6.384,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00143-9856-25,NDC,outpatient,1,UN,9.12,6.384,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,25021-0107-20,NDC,outpatient,1,UN,18.72,13.104,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,44567-0702-25,NDC,outpatient,1,UN,9.03,6.321,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00781-3209-95,NDC,outpatient,1,UN,11.14,7.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00781-3209-90,NDC,outpatient,1,UN,11.14,7.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00143-9857-25,NDC,outpatient,1,UN,5.23,3.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00409-7332-11,NDC,outpatient,1,UN,6.94,4.858,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00143-9857-01,NDC,outpatient,1,UN,5.23,3.661,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00409-7332-01,NDC,outpatient,1,UN,6.94,4.858,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00781-3208-85,NDC,outpatient,1,UN,17.99,12.593,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,25021-0106-10,NDC,outpatient,1,UN,9.22,6.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,44567-0701-25,NDC,outpatient,1,UN,4.75,3.325,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00781-3208-95,NDC,outpatient,1,UN,17.99,12.593,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00143-9856-25,NDC,outpatient,1,UN,9.12,6.384,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,44567-0702-25,NDC,outpatient,1,UN,9.03,6.321,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00143-9856-01,NDC,outpatient,1,UN,9.12,6.384,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00781-3209-90,NDC,outpatient,1,UN,11.14,7.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00781-3209-95,NDC,outpatient,1,UN,11.14,7.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,25021-0107-20,NDC,outpatient,1,UN,18.72,13.104,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00409-7337-01,NDC,outpatient,1,UN,3.47,2.429,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00781-3206-95,NDC,outpatient,1,UN,6.33,4.431,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00143-9859-25,NDC,outpatient,1,UN,4.32,3.024,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00143-9859-01,NDC,outpatient,1,UN,4.32,3.024,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00409-7337-11,NDC,outpatient,1,UN,3.47,2.429,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00781-3206-85,NDC,outpatient,1,UN,6.33,4.431,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFUROXIME SODIUM 750 MG IJ SOLR,RX-1465,CDM,J0697,HCPCS,636,RC,00143-9979-22,NDC,outpatient,1,UN,12.5,8.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.88,416.02,other,SI=N Exclusions ,,
CEFUROXIME SODIUM 750 MG IJ SOLR,RX-1465,CDM,J0697,HCPCS,636,RC,00143-9979-90,NDC,outpatient,1,UN,12.5,8.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.88,416.02,other,SI=N Exclusions ,,
CEFUROXIME SODIUM 750 MG IJ SOLR,RX-1465,CDM,J0697,HCPCS,636,RC,25021-0118-10,NDC,outpatient,1,UN,9.6,6.72,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.88,416.02,other,SI=N Exclusions ,,
CEFUROXIME SODIUM 1.5 G IV SOLR,RX-27299,CDM,J0697,HCPCS,636,RC,00143-9977-90,NDC,outpatient,1,UN,21.64,15.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.88,416.02,other,SI=N Exclusions ,,
CEFUROXIME SODIUM 1.5 G IV SOLR,RX-27299,CDM,J0697,HCPCS,636,RC,00143-9977-22,NDC,outpatient,1,UN,21.64,15.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.88,416.02,other,SI=N Exclusions ,,
CEFUROXIME SODIUM 750 MG IJ SOLR 750 MG/8.3 ML,RX-4080994,CDM,J0697,HCPCS,636,RC,00143-9979-22,NDC,outpatient,1,UN,12.5,8.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.88,416.02,other,SI=N Exclusions ,,
CEFUROXIME SODIUM 750 MG IJ SOLR 750 MG/8.3 ML,RX-4080994,CDM,J0697,HCPCS,636,RC,00143-9979-90,NDC,outpatient,1,UN,12.5,8.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.88,416.02,other,SI=N Exclusions ,,
CEFUROXIME SODIUM 750 MG IJ SOLR 750 MG/8.3 ML,RX-4080994,CDM,J0697,HCPCS,636,RC,25021-0118-10,NDC,outpatient,1,UN,9.6,6.72,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.88,416.02,other,SI=N Exclusions ,,
CEFUROXIME SODIUM 1.5 G IJ SOLR IN 16 ML,RX-4081008,CDM,J0697,HCPCS,636,RC,00143-9977-22,NDC,outpatient,1,UN,21.64,15.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.88,416.02,other,SI=N Exclusions ,,
CEFUROXIME SODIUM 1.5 G IJ SOLR IN 16 ML,RX-4081008,CDM,J0697,HCPCS,636,RC,00143-9977-90,NDC,outpatient,1,UN,21.64,15.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.88,416.02,other,SI=N Exclusions ,,
BETAMETHASONE SOD PHOS & ACET 6 (3-3) MG/ML IJ SUSP,RX-9266,CDM,J0702,HCPCS,636,RC,00517-0720-01,NDC,outpatient,5,ML,143.92,100.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6.96,416.02,other,SI=N Exclusions ,,
BETAMETHASONE SOD PHOS & ACET 6 (3-3) MG/ML IJ SUSP,RX-9266,CDM,J0702,HCPCS,636,RC,78206-0118-01,NDC,outpatient,5,ML,170.75,119.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6.96,416.02,other,SI=N Exclusions ,,
CAFFEINE CITRATE 60 MG/3ML IV SOLN,RX-109034,CDM,J0706,HCPCS,636,RC,51754-0500-01,NDC,outpatient,3,ML,26.75,18.725,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.65,416.02,other,SI=N Exclusions ,,
CEFTAROLINE FOSAMIL 400 MG IV SOLR,RX-107670,CDM,J0712,HCPCS,636,RC,00456-0400-01,NDC,outpatient,1,UN,806.58,564.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3.94,,,3.94,3.89,619.45344,fee schedule,,,
CEFTAROLINE FOSAMIL 400 MG IV SOLR,RX-107670,CDM,J0712,HCPCS,636,RC,00456-0400-10,NDC,outpatient,1,UN,806.58,564.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3.94,,,3.94,3.89,619.45344,fee schedule,,,
CEFTAROLINE FOSAMIL 600 MG IV SOLR,RX-107671,CDM,J0712,HCPCS,636,RC,00456-0600-01,NDC,outpatient,1,UN,806.58,564.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3.94,,,3.94,3.89,619.45344,fee schedule,,,
CEFTAROLINE FOSAMIL 600 MG IV SOLR,RX-107671,CDM,J0712,HCPCS,636,RC,00456-0600-10,NDC,outpatient,1,UN,806.58,564.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3.94,,,3.94,3.89,619.45344,fee schedule,,,
CEFTAZIDIME 2 G IV SOLR,RX-27291,CDM,J0713,HCPCS,636,RC,44567-0236-10,NDC,outpatient,1,UN,23.52,16.464,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.66,416.02,other,SI=N Exclusions ,,
CEFTAZIDIME 2 G IV SOLR,RX-27291,CDM,J0713,HCPCS,636,RC,25021-0128-50,NDC,outpatient,1,UN,37.01,25.907,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.66,416.02,other,SI=N Exclusions ,,
CEFTAZIDIME 1 MG/ML IJ SOLR,RX-4080666,CDM,J0713,HCPCS,636,RC,00409-5082-16,NDC,outpatient,1,UN,14.25,9.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.66,416.02,other,SI=N Exclusions ,,
CEFTAZIDIME 1 G IJ SOLR 1000 MG/10.8 ML,RX-4081001,CDM,J0713,HCPCS,636,RC,00409-5082-16,NDC,outpatient,1,UN,14.25,9.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.66,416.02,other,SI=N Exclusions ,,
CEFTAZIDIME 2 G IJ SOLR 2000 MG/11.5 ML,RX-4081002,CDM,J0713,HCPCS,636,RC,25021-0128-50,NDC,outpatient,1,UN,37.01,25.907,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.66,416.02,other,SI=N Exclusions ,,
CEFTAZIDIME 1 G IJ SOLR,RX-9474,CDM,J0713,HCPCS,636,RC,44567-0235-25,NDC,outpatient,1,UN,13.87,9.709,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.66,416.02,other,SI=N Exclusions ,,
CEFTAZIDIME 1 G IJ SOLR,RX-9474,CDM,J0713,HCPCS,636,RC,00409-5082-11,NDC,outpatient,1,UN,14.25,9.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.66,416.02,other,SI=N Exclusions ,,
CEFTAZIDIME 1 G IJ SOLR,RX-9474,CDM,J0713,HCPCS,636,RC,00409-5082-16,NDC,outpatient,1,UN,14.25,9.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.66,416.02,other,SI=N Exclusions ,,
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G IV SOLR,RX-130403,CDM,J0714,HCPCS,636,RC,00456-2700-01,NDC,outpatient,1,UN,1625.76,1138.032,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,100.58,,,100.58,92.48,1248.58368,fee schedule,,,
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G IV SOLR,RX-130403,CDM,J0714,HCPCS,636,RC,00456-2700-10,NDC,outpatient,1,UN,1625.76,1138.032,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,100.58,,,100.58,92.48,1248.58368,fee schedule,,,
CLONIDINE HCL (ANALGESIA) 100 MCG/ML EP SOLN,RX-19333,CDM,J0735,HCPCS,636,RC,67457-0218-10,NDC,outpatient,10,ML,45.22,31.654,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.15189,416.02,other,SI=N Exclusions ,,
CLONIDINE HCL (ANALGESIA) 500 MCG/ML EP SOLN,RX-27113,CDM,J0735,HCPCS,636,RC,39822-2010-01,NDC,outpatient,10,ML,402.95,282.065,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.15189,416.02,other,SI=N Exclusions ,,
CLINDAMYCIN PHOSPHATE 150 MG/ML IJ WRAPPER,RX-4080195,CDM,J0736,HCPCS,636,RC,00009-0775-26,NDC,outpatient,4,ML,13.99,9.793,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.47,,,2.47,1.61,416.02,fee schedule,,,
CLINDAMYCIN PHOSPHATE 150 MG/ML IJ WRAPPER,RX-4080195,CDM,J0736,HCPCS,636,RC,00009-0775-20,NDC,outpatient,4,ML,13.99,9.793,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.47,,,2.47,1.61,416.02,fee schedule,,,
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0736,HCPCS,636,RC,00781-3288-09,NDC,outpatient,50,ML,48.27,33.789,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.47,,,2.47,1.61,416.02,fee schedule,,,
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0736,HCPCS,636,RC,00781-3288-91,NDC,outpatient,50,ML,48.27,33.789,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.47,,,2.47,1.61,416.02,fee schedule,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-09,NDC,outpatient,50,ML,64.73,45.311,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.47,,,2.47,1.61,416.02,fee schedule,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-91,NDC,outpatient,50,ML,48.73,34.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,2.47,,,2.47,1.61,416.02,fee schedule,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-91,NDC,outpatient,50,ML,64.73,45.311,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.47,,,2.47,1.61,416.02,fee schedule,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-09,NDC,outpatient,50,ML,48.73,34.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,2.47,,,2.47,1.61,416.02,fee schedule,,,
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0737,HCPCS,636,RC,00338-3410-50,NDC,outpatient,50,ML,30.91,21.637,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.82,,,2.82,2.59,416.02,fee schedule,,,
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0737,HCPCS,636,RC,00338-3410-24,NDC,outpatient,50,ML,30.91,21.637,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.82,,,2.82,2.59,416.02,fee schedule,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-50,NDC,outpatient,50,ML,34.25,23.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.82,,,2.82,2.59,416.02,fee schedule,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-24,NDC,outpatient,50,ML,34.25,23.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.82,,,2.82,2.59,416.02,fee schedule,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-50,NDC,outpatient,50,ML,34.25,23.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.82,,,2.82,2.59,416.02,fee schedule,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-50,NDC,outpatient,50,ML,18.25,12.775,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,2.82,,,2.82,2.59,416.02,fee schedule,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-24,NDC,outpatient,50,ML,34.25,23.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.82,,,2.82,2.59,416.02,fee schedule,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-24,NDC,outpatient,50,ML,18.25,12.775,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,2.82,,,2.82,2.59,416.02,fee schedule,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-50,NDC,outpatient,50,ML,18.25,12.775,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,2.82,,,2.82,2.59,416.02,fee schedule,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-24,NDC,outpatient,50,ML,18.25,12.775,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,2.82,,,2.82,2.59,416.02,fee schedule,,,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-24,NDC,outpatient,50,ML,38.7,27.09,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.82,,,2.82,2.59,416.02,fee schedule,,,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-50,NDC,outpatient,50,ML,38.7,27.09,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.82,,,2.82,2.59,416.02,fee schedule,,,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-24,NDC,outpatient,50,ML,22.7,15.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,2.82,,,2.82,2.59,416.02,fee schedule,,,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-50,NDC,outpatient,50,ML,22.7,15.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,2.82,,,2.82,2.59,416.02,fee schedule,,,
IMIPENEM-CILASTATIN 250 MG IV SOLR,RX-9602,CDM,J0743,HCPCS,636,RC,63323-0349-25,NDC,outpatient,1,UN,25.58,17.906,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.74271,416.02,other,SI=N Exclusions ,,
IMIPENEM-CILASTATIN 500 MG IV SOLR,RX-9603,CDM,J0743,HCPCS,636,RC,63323-0322-01,NDC,outpatient,1,UN,43.92,30.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.74271,416.02,other,SI=N Exclusions ,,
IMIPENEM-CILASTATIN 500 MG IV SOLR,RX-9603,CDM,J0743,HCPCS,636,RC,63323-0322-25,NDC,outpatient,1,UN,43.92,30.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.74271,416.02,other,SI=N Exclusions ,,
CIPROFLOXACIN IN D5W 200 MG/100ML IV SOLN,RX-108130,CDM,J0744,HCPCS,636,RC,00409-2300-24,NDC,outpatient,100,ML,26.8,18.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.86,416.02,other,SI=N Exclusions ,,
CIPROFLOXACIN IN D5W 200 MG/100ML IV SOLN,RX-108130,CDM,J0744,HCPCS,636,RC,00409-2300-01,NDC,outpatient,100,ML,26.8,18.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.86,416.02,other,SI=N Exclusions ,,
CIPROFLOXACIN IN D5W 400 MG/200ML IV SOLN,RX-108132,CDM,J0744,HCPCS,636,RC,25021-0114-87,NDC,outpatient,200,ML,42.7,29.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.86,416.02,other,SI=N Exclusions ,,
COLISTIMETHATE SODIUM (CBA) 150 MG IJ SOLR,RX-142413,CDM,J0770,HCPCS,636,RC,70594-0023-04,NDC,outpatient,1,UN,46.34,32.438,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.40333,416.02,other,SI=N Exclusions ,,
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,00713-0351-02,NDC,outpatient,2,ML,13.73,9.611,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.01,416.02,other,SI=N Exclusions ,,
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,00713-0351-09,NDC,outpatient,2,ML,15.66,10.962,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.01,416.02,other,SI=N Exclusions ,,
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,00713-0351-25,NDC,outpatient,2,ML,13.73,9.611,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.01,416.02,other,SI=N Exclusions ,,
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,14789-0700-07,NDC,outpatient,2,ML,14.97,10.479,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.01,416.02,other,SI=N Exclusions ,,
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,14789-0700-02,NDC,outpatient,2,ML,14.97,10.479,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.01,416.02,other,SI=N Exclusions ,,
COSYNTROPIN 0.25 MG IJ SOLR,RX-9686,CDM,J0834,HCPCS,636,RC,00548-5900-00,NDC,outpatient,1,UN,74.02,51.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,16.61749,416.02,other,SI=N Exclusions ,,
COSYNTROPIN 0.25 MG IJ SOLR,RX-9686,CDM,J0834,HCPCS,636,RC,00781-3440-71,NDC,outpatient,1,UN,356.89,249.823,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,16.61749,416.02,other,SI=N Exclusions ,,
COSYNTROPIN 0.25 MG IJ SOLR,RX-9686,CDM,J0834,HCPCS,636,RC,00781-3440-95,NDC,outpatient,1,UN,356.89,249.823,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,16.61749,416.02,other,SI=N Exclusions ,,
DAPTOMYCIN 500 MG IV SOLR,RX-36989,CDM,J0873,HCPCS,636,RC,70594-0034-01,NDC,outpatient,1,UN,65.78,46.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.04,416.02,other,SI=N Exclusions ,,
DALBAVANCIN HCL 500 MG IV SOLR,RX-125774,CDM,J0875,HCPCS,636,RC,57970-0100-01,NDC,outpatient,1,UN,2550.24,1785.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,15.61,,,15.61,14.7,4668.927562,fee schedule,,,
DAPTOMYCIN 350 MG IV SOLR,RX-143414,CDM,J0878,HCPCS,636,RC,16729-0434-05,NDC,outpatient,1,UN,201.5,141.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.03,416.02,other,SI=N Exclusions ,,
DAPTOMYCIN 350 MG IV SOLR,RX-143414,CDM,J0878,HCPCS,636,RC,16729-0434-45,NDC,outpatient,1,UN,201.59,141.113,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.03,416.02,other,SI=N Exclusions ,,
DAPTOMYCIN 500 MG IV SOLR,RX-36989,CDM,J0878,HCPCS,636,RC,00143-9378-01,NDC,outpatient,1,UN,57.59,40.313,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.03,416.02,other,SI=N Exclusions ,,
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0883,HCPCS,636,RC,00143-9559-01,NDC,outpatient,50,ML,438.53,306.971,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3.99,,,3.99,1.35,1059.84,fee schedule,,,
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0883,HCPCS,636,RC,25021-0414-50,NDC,outpatient,50,ML,333.29,233.303,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3.99,,,3.99,1.35,1059.84,fee schedule,,,
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0883,HCPCS,636,RC,00143-9559-01,NDC,outpatient,50,ML,422.53,295.771,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,3.99,,,3.99,1.35,1059.84,fee schedule,,,
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0883,HCPCS,636,RC,25021-0414-50,NDC,outpatient,50,ML,317.29,222.103,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,3.99,,,3.99,1.35,1059.84,fee schedule,,,
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0883,HCPCS,636,RC,16729-0430-43,NDC,outpatient,50,ML,358.65,251.055,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3.99,,,3.99,1.35,1059.84,fee schedule,,,
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0883,HCPCS,636,RC,16729-0430-43,NDC,outpatient,50,ML,342.65,239.855,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,3.99,,,3.99,1.35,1059.84,fee schedule,,,
ARGATROBAN 250 MG/2.5ML IV SOLN,RX-28947,CDM,J0883,HCPCS,636,RC,63323-0526-03,NDC,outpatient,2.5,ML,1328.82,930.174,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3.99,,,3.99,1.35,1059.84,fee schedule,,,
ARGATROBAN 250 MG/2.5ML IV SOLN,RX-28947,CDM,J0883,HCPCS,636,RC,00143-9674-01,NDC,outpatient,2.5,ML,1380,966,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3.99,,,3.99,1.35,1059.84,fee schedule,,,
ARGATROBAN 250 MG/2.5ML IV SOLN,RX-28947,CDM,J0883,HCPCS,636,RC,00409-1140-01,NDC,outpatient,2.5,ML,226.15,158.305,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3.99,,,3.99,1.35,1059.84,fee schedule,,,
EPOETIN ALFA 10000 UNIT/ML IJ SOLN,RX-9938,CDM,J0885,HCPCS,636,RC,59676-0310-00,NDC,outpatient,1,ML,622.94,436.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7.53,,,7.53,6.88,478.41792,fee schedule,,,
EPOETIN ALFA 10000 UNIT/ML IJ SOLN,RX-9938,CDM,J0885,HCPCS,636,RC,59676-0310-01,NDC,outpatient,1,ML,622.94,436.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7.53,,,7.53,6.88,478.41792,fee schedule,,,
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,55513-0148-10,NDC,outpatient,1,ML,283.41,198.387,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7.53,,,7.53,6.88,478.41792,fee schedule,,,
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,59676-0304-00,NDC,outpatient,1,ML,456.83,319.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7.53,,,7.53,6.88,478.41792,fee schedule,,,
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,55513-0148-01,NDC,outpatient,1,ML,283.41,198.387,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7.53,,,7.53,6.88,478.41792,fee schedule,,,
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,59676-0304-01,NDC,outpatient,1,ML,456.83,319.781,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7.53,,,7.53,6.88,478.41792,fee schedule,,,
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0891,HCPCS,636,RC,16729-0430-11,NDC,outpatient,50,ML,342.65,239.855,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,4.51,,,4.51,0.46,416.02,fee schedule,,,
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0891,HCPCS,636,RC,16729-0430-11,NDC,outpatient,50,ML,358.65,251.055,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4.51,,,4.51,0.46,416.02,fee schedule,,,
DECITABINE 50 MG IV SOLR,RX-76364,CDM,J0894,HCPCS,636,RC,16729-0224-05,NDC,outpatient,1,UN,335.38,234.766,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.63,416.02,other,SI=N Exclusions ,,
DEFEROXAMINE MESYLATE 500 MG IJ SOLR,RX-9723,CDM,J0895,HCPCS,636,RC,60505-6236-00,NDC,outpatient,1,UN,46.34,32.438,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6.78,416.02,other,SI=N Exclusions ,,
DEFEROXAMINE MESYLATE 500 MG IJ SOLR,RX-9723,CDM,J0895,HCPCS,636,RC,60505-6236-06,NDC,outpatient,1,UN,46.34,32.438,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6.78,416.02,other,SI=N Exclusions ,,
DENOSUMAB 120 MG/1.7ML SC SOLN,RX-106804,CDM,J0897,HCPCS,636,RC,55513-0730-01,NDC,outpatient,1.7,ML,8861.12,6202.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26.96,,,26.96,24.19,6805.34016,fee schedule,,,
DENOSUMAB 60 MG/ML SC SOSY,RX-146195,CDM,J0897,HCPCS,636,RC,55513-0710-01,NDC,outpatient,1,ML,4649.31,3254.517,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,26.96,,,26.96,24.19,6805.34016,fee schedule,,,
METHYLPREDNISOLONE ACETATE 40 MG/ML IJ SUSP,RX-4995,CDM,J1030,HCPCS,636,RC,00009-3073-03,NDC,outpatient,1,ML,22.62,15.834,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.07819,416.02,other,SI=N Exclusions ,,
METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP,RX-4996,CDM,J1040,HCPCS,636,RC,70121-1574-01,NDC,outpatient,1,ML,25.95,18.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.82353,416.02,other,SI=N Exclusions ,,
METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP,RX-4996,CDM,J1040,HCPCS,636,RC,00009-3475-03,NDC,outpatient,1,ML,34.96,24.472,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.82353,416.02,other,SI=N Exclusions ,,
METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP,RX-4996,CDM,J1040,HCPCS,636,RC,70121-1574-05,NDC,outpatient,1,ML,25.94,18.158,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.82353,416.02,other,SI=N Exclusions ,,
TESTOSTERONE CYPIONATE 200 MG/ML IM SOLN,RX-7784,CDM,J1071,HCPCS,636,RC,00009-0417-01,NDC,outpatient,1,ML,41.92,29.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.03,416.02,other,SI=N Exclusions ,,
DEXAMETHASONE SOD PHOSPHATE PF 10 MG/ML IJ SOLN,RX-116345,CDM,J1100,HCPCS,636,RC,99999-0003-18,NDC,outpatient,1,ML,8.17,5.719,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.11,416.02,other,SI=N Exclusions ,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,63323-0165-01,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.11,416.02,other,SI=N Exclusions ,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,67457-0423-00,NDC,outpatient,1,ML,3.69,2.583,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.11,416.02,other,SI=N Exclusions ,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,00641-6145-01,NDC,outpatient,1,ML,4.14,2.898,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.11,416.02,other,SI=N Exclusions ,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,00641-6145-25,NDC,outpatient,1,ML,4.14,2.898,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.11,416.02,other,SI=N Exclusions ,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,55150-0237-01,NDC,outpatient,1,ML,4.01,2.807,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.11,416.02,other,SI=N Exclusions ,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,63323-0165-02,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.11,416.02,other,SI=N Exclusions ,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,67457-0423-12,NDC,outpatient,1,ML,3.69,2.583,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.11,416.02,other,SI=N Exclusions ,,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,00641-0367-21,NDC,outpatient,1,ML,6.11,4.277,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.11,416.02,other,SI=N Exclusions ,,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,63323-0506-01,NDC,outpatient,1,ML,6.99,4.893,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.11,416.02,other,SI=N Exclusions ,,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,00641-0367-25,NDC,outpatient,1,ML,6.11,4.277,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.11,416.02,other,SI=N Exclusions ,,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,70069-0021-01,NDC,outpatient,1,ML,8.17,5.719,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.11,416.02,other,SI=N Exclusions ,,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,70069-0021-25,NDC,outpatient,1,ML,8.17,5.719,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.11,416.02,other,SI=N Exclusions ,,
DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN,RX-9859,CDM,J1110,HCPCS,636,RC,81284-0411-05,NDC,outpatient,1,ML,220.97,154.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,40.295505,416.02,other,SI=N Exclusions ,,
DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN,RX-9859,CDM,J1110,HCPCS,636,RC,81284-0411-00,NDC,outpatient,1,ML,179.49,125.643,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,40.295505,416.02,other,SI=N Exclusions ,,
DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN,RX-9859,CDM,J1110,HCPCS,636,RC,81284-0411-10,NDC,outpatient,1,ML,179.49,125.643,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,40.295505,416.02,other,SI=N Exclusions ,,
ACETAZOLAMIDE SODIUM 500 MG IJ SOLR,RX-114,CDM,J1120,HCPCS,636,RC,23155-0313-31,NDC,outpatient,1,UN,45.84,32.088,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.29108,416.02,other,SI=N Exclusions ,,
ACETAZOLAMIDE SODIUM 500 MG IJ SOLR,RX-114,CDM,J1120,HCPCS,636,RC,00143-9503-01,NDC,outpatient,1,UN,178.94,125.258,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.29108,416.02,other,SI=N Exclusions ,,
ACETAZOLAMIDE SODIUM 500 MG IJ SOLR,RX-114,CDM,J1120,HCPCS,636,RC,67457-0853-50,NDC,outpatient,1,UN,164.43,115.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.29108,416.02,other,SI=N Exclusions ,,
DIGOXIN 0.25 MG/ML IJ SOLN,RX-2442,CDM,J1160,HCPCS,636,RC,00641-1410-31,NDC,outpatient,2,ML,14.62,10.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.28219,416.02,other,SI=N Exclusions ,,
DIGOXIN 0.25 MG/ML IJ SOLN,RX-2442,CDM,J1160,HCPCS,636,RC,00641-1410-35,NDC,outpatient,2,ML,14.62,10.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.28219,416.02,other,SI=N Exclusions ,,
DIGOXIN 0.1 MG/ML IJ SOLN,RX-9853,CDM,J1160,HCPCS,636,RC,70515-0263-10,NDC,outpatient,1,ML,449.39,314.573,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.28219,416.02,other,SI=N Exclusions ,,
DIGOXIN IMMUNE FAB 40 MG IV SOLR,RX-31432,CDM,J1162,HCPCS,636,RC,50633-0120-11,NDC,outpatient,1,UN,12197.8,8538.46,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4888.1,,,4888.1,399.86,9367.9104,fee schedule,,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,00641-0493-25,NDC,outpatient,2,ML,5.82,4.074,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions ,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-30,NDC,outpatient,5,ML,10.7,7.49,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions ,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-02,NDC,outpatient,2,ML,10.45,7.315,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions ,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-05,NDC,outpatient,5,ML,10.7,7.49,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions ,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,00641-0493-21,NDC,outpatient,2,ML,5.82,4.074,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions ,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-10,NDC,outpatient,2,ML,10.45,7.315,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.44,416.02,other,SI=N Exclusions ,,
HYDROMORPHONE HCL PF 10 MG/ML IJ SOLN,RX-116809,CDM,J1170,HCPCS,636,RC,00703-0113-01,NDC,outpatient,10,ML,44.91,31.437,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.507665,416.02,other,SI=N Exclusions ,,
HYDROMORPHONE HCL PF 10 MG/ML IJ SOLN,RX-116809,CDM,J1170,HCPCS,636,RC,00409-2634-25,NDC,outpatient,10,ML,71.61,50.127,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.507665,416.02,other,SI=N Exclusions ,,
HYDROMORPHONE HCL PF 10 MG/ML IJ SOLN,RX-116809,CDM,J1170,HCPCS,636,RC,00703-0113-03,NDC,outpatient,10,ML,44.91,31.437,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.507665,416.02,other,SI=N Exclusions ,,
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,76045-0009-06,NDC,outpatient,0.5,ML,12.4,8.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.507665,416.02,other,SI=N Exclusions ,,
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,76045-0009-11,NDC,outpatient,1,ML,11.73,8.211,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.507665,416.02,other,SI=N Exclusions ,,
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,76045-0009-01,NDC,outpatient,1,ML,11.73,8.211,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.507665,416.02,other,SI=N Exclusions ,,
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,76045-0009-96,NDC,outpatient,0.5,ML,12.4,8.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.507665,416.02,other,SI=N Exclusions ,,
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,00409-1283-03,NDC,outpatient,1,ML,11.43,8.001,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.507665,416.02,other,SI=N Exclusions ,,
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,00409-1283-31,NDC,outpatient,1,ML,11.43,8.001,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.507665,416.02,other,SI=N Exclusions ,,
HYDROMORPHONE HCL 2 MG/ML IJ SOLN,RX-3758,CDM,J1170,HCPCS,636,RC,00641-6151-25,NDC,outpatient,1,ML,11.17,7.819,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.507665,416.02,other,SI=N Exclusions ,,
HYDROMORPHONE HCL 2 MG/ML IJ SOLN,RX-3758,CDM,J1170,HCPCS,636,RC,00641-6151-01,NDC,outpatient,1,ML,11.17,7.819,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.507665,416.02,other,SI=N Exclusions ,,
CONC DILAUDID 10 MG/ML PCA,RX-4080160,CDM,J1170,HCPCS,636,RC,99999-0000-95,NDC,outpatient,50,ML,267.65,187.355,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.507665,416.02,other,SI=N Exclusions ,,
DEXRAZOXANE HCL 500 MG IV SOLR,RX-146172,CDM,J1190,HCPCS,636,RC,51991-0942-98,NDC,outpatient,1,UN,575.66,402.962,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,87.49,,,87.49,87.49,442.10688,fee schedule,,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,72485-0101-01,NDC,outpatient,1,ML,4.75,3.325,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,00641-0376-21,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-00,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-16,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,00641-0376-25,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,72485-0101-25,NDC,outpatient,1,ML,4.75,3.325,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-01,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-41,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CHLOROTHIAZIDE SODIUM 500 MG IV SOLR,RX-9526,CDM,J1205,HCPCS,636,RC,25021-0305-20,NDC,outpatient,1,UN,139.6,97.72,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,31.3402,416.02,other,SI=N Exclusions ,,
DIMETHYL SULFOXIDE 50 % IS SOLN,RX-9873,CDM,J1212,HCPCS,636,RC,67457-0177-50,NDC,outpatient,50,ML,1852.55,1296.785,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,715.9,,,715.9,399.86,1422.7584,fee schedule,,,
METHADONE HCL 10 MG/ML IJ SOLN,RX-10546,CDM,J1230,HCPCS,636,RC,67457-0217-20,NDC,outpatient,20,ML,869.71,608.797,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.763505,945.2928,other,SI=N Exclusions ,,
METHADONE HCL 10 MG/ML IJ SOLN,RX-10546,CDM,J1230,HCPCS,636,RC,99999-0000-89,NDC,outpatient,1,ML,43.49,30.443,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.763505,945.2928,other,SI=N Exclusions ,,
METHADONE 10 MG/ML PCA,RX-4080162,CDM,J1230,HCPCS,636,RC,99999-0000-13,NDC,outpatient,50,ML,1230.85,861.595,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.763505,945.2928,other,SI=N Exclusions ,,
METHADONE 1 MG/ML IV INFUSION PREMIX,RX-4080178,CDM,J1230,HCPCS,636,RC,99999-0000-27,NDC,outpatient,200,ML,874.19,611.933,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.763505,945.2928,other,SI=N Exclusions ,,
DIPYRIDAMOLE 5 MG/ML IV SOLN,RX-9891,CDM,J1245,HCPCS,636,RC,00641-2569-41,NDC,outpatient,10,ML,75.79,53.053,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.78,416.02,other,SI=N Exclusions ,,
DIPYRIDAMOLE 5 MG/ML IV SOLN,RX-9891,CDM,J1245,HCPCS,636,RC,00641-2569-44,NDC,outpatient,10,ML,75.79,53.053,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.78,416.02,other,SI=N Exclusions ,,
DOBUTAMINE-DEXTROSE 1-5 MG/ML-% IV SOLN,RX-18314,CDM,J1250,HCPCS,636,RC,00338-1073-02,NDC,outpatient,250,ML,38.25,26.775,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.15774,416.02,other,SI=N Exclusions ,,
DOBUTAMINE-DEXTROSE 1-5 MG/ML-% IV SOLN,RX-18314,CDM,J1250,HCPCS,636,RC,00409-2346-32,NDC,outpatient,250,ML,52.72,36.904,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.15774,416.02,other,SI=N Exclusions ,,
DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN,RX-18315,CDM,J1250,HCPCS,636,RC,00409-2347-31,NDC,outpatient,250,ML,72.74,50.918,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.15774,416.02,other,SI=N Exclusions ,,
DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN,RX-18315,CDM,J1250,HCPCS,636,RC,00409-2347-32,NDC,outpatient,250,ML,72.74,50.918,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.15774,416.02,other,SI=N Exclusions ,,
DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN,RX-18315,CDM,J1250,HCPCS,636,RC,00338-1075-02,NDC,outpatient,250,ML,52.72,36.904,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.15774,416.02,other,SI=N Exclusions ,,
DOBUTAMINE 50 MG IN D5W 50 ML SYRINGE FROM PREMIX BAG (NEO/PED),RX-4081532,CDM,J1250,HCPCS,636,RC,99999-0004-34,NDC,outpatient,50,ML,24.49,17.143,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.15774,416.02,other,SI=N Exclusions ,,
DOBUTAMINE HCL 250 MG/20ML IV SOLN,RX-77318,CDM,J1250,HCPCS,636,RC,00143-9141-10,NDC,outpatient,20,ML,18.52,12.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.15774,416.02,other,SI=N Exclusions ,,
DOBUTAMINE HCL 250 MG/20ML IV SOLN,RX-77318,CDM,J1250,HCPCS,636,RC,00409-2344-01,NDC,outpatient,20,ML,27.59,19.313,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.15774,416.02,other,SI=N Exclusions ,,
DOBUTAMINE HCL 250 MG/20ML IV SOLN,RX-77318,CDM,J1250,HCPCS,636,RC,00143-9141-01,NDC,outpatient,20,ML,18.52,12.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.15774,416.02,other,SI=N Exclusions ,,
DOPAMINE-DEXTROSE 0.8-5 MG/ML-% IV SOLN,RX-14844,CDM,J1265,HCPCS,636,RC,00338-1005-02,NDC,outpatient,250,ML,41.59,29.113,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.7,416.02,other,SI=N Exclusions ,,
DOPAMINE-DEXTROSE 1.6-5 MG/ML-% IV SOLN,RX-14845,CDM,J1265,HCPCS,636,RC,00338-1007-02,NDC,outpatient,250,ML,48.27,33.789,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.7,416.02,other,SI=N Exclusions ,,
DOPAMINE-DEXTROSE 1.6-5 MG/ML-% IV SOLN,RX-14845,CDM,J1265,HCPCS,636,RC,00409-7809-11,NDC,outpatient,250,ML,50.49,35.343,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.7,416.02,other,SI=N Exclusions ,,
DOPAMINE-DEXTROSE 1.6-5 MG/ML-% IV SOLN,RX-14845,CDM,J1265,HCPCS,636,RC,00409-7809-22,NDC,outpatient,250,ML,50.49,35.343,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.7,416.02,other,SI=N Exclusions ,,
DOPAMINE HCL 40 MG/ML IV SOLN,RX-2595,CDM,J1265,HCPCS,636,RC,00409-9104-21,NDC,outpatient,10,ML,13.16,9.212,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.7,416.02,other,SI=N Exclusions ,,
DOPAMINE HCL 40 MG/ML IV SOLN,RX-2595,CDM,J1265,HCPCS,636,RC,00409-9104-20,NDC,outpatient,10,ML,13.16,9.212,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.7,416.02,other,SI=N Exclusions ,,
DOPAMINE 40 MG IN D5W 50 ML SYRINGE FROM PREMIX BAG (NEO/PED),RX-4081531,CDM,J1265,HCPCS,636,RC,99999-0004-33,NDC,outpatient,50,ML,21.92,15.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.7,416.02,other,SI=N Exclusions ,,
ECULIZUMAB 300 MG/30ML IV SOLN,RX-81696,CDM,J1300,HCPCS,636,RC,25682-0001-01,NDC,outpatient,30,ML,18003.46,12602.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,224.63,,,224.63,224.63,13826.65728,fee schedule,,,
VELETRI 1.5 MG IV SOLR,RX-106514,CDM,J1325,HCPCS,636,RC,66215-0402-01,NDC,outpatient,1,UN,260.55,182.385,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,15.86,416.02,other,SI=N Exclusions ,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00409-3510-22,NDC,outpatient,1,UN,135.69,94.983,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,55150-0282-20,NDC,outpatient,1,UN,111.68,78.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00143-9398-01,NDC,outpatient,1,UN,100.74,70.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,16714-0889-10,NDC,outpatient,1,UN,129.15,90.405,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,42023-0221-01,NDC,outpatient,1,UN,95.49,66.843,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,60505-6196-00,NDC,outpatient,1,UN,127.17,89.019,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00143-9398-10,NDC,outpatient,1,UN,100.74,70.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,16714-0889-01,NDC,outpatient,1,UN,129.15,90.405,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,42023-0221-10,NDC,outpatient,1,UN,95.49,66.843,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00409-3510-21,NDC,outpatient,1,UN,135.69,94.983,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,60505-6196-04,NDC,outpatient,1,UN,127.17,89.019,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,60505-6196-04,NDC,outpatient,1,UN,127.17,89.019,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00409-3510-21,NDC,outpatient,1,UN,135.69,94.983,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,16714-0889-01,NDC,outpatient,1,UN,129.15,90.405,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,55150-0282-20,NDC,outpatient,1,UN,111.68,78.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00143-9398-01,NDC,outpatient,1,UN,100.74,70.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00143-9398-10,NDC,outpatient,1,UN,100.74,70.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00409-3510-22,NDC,outpatient,1,UN,135.69,94.983,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,16714-0889-10,NDC,outpatient,1,UN,129.15,90.405,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,42023-0221-01,NDC,outpatient,1,UN,95.49,66.843,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,42023-0221-10,NDC,outpatient,1,UN,95.49,66.843,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,60505-6196-00,NDC,outpatient,1,UN,127.17,89.019,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERYTHROMYCIN LACTOBIONATE 500 MG IV SOLR,RX-2903,CDM,J1364,HCPCS,636,RC,00409-6482-01,NDC,outpatient,1,UN,236.03,165.221,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,65.38,,,65.38,52.988735,416.02,fee schedule,,,
ERYTHROMYCIN LACTOBIONATE 500 MG IV SOLR,RX-2903,CDM,J1364,HCPCS,636,RC,00409-6482-11,NDC,outpatient,1,UN,236.03,165.221,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,65.38,,,65.38,52.988735,416.02,fee schedule,,,
ESTROGENS CONJUGATED 25 MG IJ SOLR,RX-9972,CDM,J1410,HCPCS,636,RC,00046-0749-05,NDC,outpatient,1,UN,1513.36,1059.352,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,382.79,,,382.79,339.74932,1162.26048,fee schedule,,,
FERRIC CARBOXYMALTOSE 750 MG/15ML IV SOLN,RX-122648,CDM,J1439,HCPCS,636,RC,00517-0650-01,NDC,outpatient,15,ML,2478.29,1734.803,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.1,,,1.1,1.1,1903.32672,fee schedule,,,
FLUCONAZOLE IN SODIUM CHLORIDE 200-0.9 MG/100ML-% IV SOLN,RX-10049,CDM,J1450,HCPCS,636,RC,25021-0184-82,NDC,outpatient,100,ML,36.03,25.221,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.61,416.02,other,SI=N Exclusions ,,
FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN,RX-10050,CDM,J1450,HCPCS,636,RC,00409-4688-16,NDC,outpatient,200,ML,35.54,24.878,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.61,416.02,other,SI=N Exclusions ,,
FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN,RX-10050,CDM,J1450,HCPCS,636,RC,69784-0003-06,NDC,outpatient,200,ML,35.58,24.906,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.61,416.02,other,SI=N Exclusions ,,
FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN,RX-10050,CDM,J1450,HCPCS,636,RC,00409-4688-12,NDC,outpatient,200,ML,35.54,24.878,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.61,416.02,other,SI=N Exclusions ,,
FLUCONAZOLE IVPB,RX-4080630,CDM,J1450,HCPCS,636,RC,99999-0001-23,NDC,outpatient,50,ML,23.46,16.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.61,416.02,other,SI=N Exclusions ,,
FOMEPIZOLE 1 GM/ML IV SOLN,RX-22185,CDM,J1451,HCPCS,636,RC,67457-0211-02,NDC,outpatient,1.5,ML,1680.9,1176.63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14.4,,,14.4,7.3781655,1590,fee schedule,,,
FOMEPIZOLE 1 GM/ML IV SOLN,RX-22185,CDM,J1451,HCPCS,636,RC,70710-1478-01,NDC,outpatient,1.5,ML,2014.79,1410.353,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14.4,,,14.4,7.3781655,1590,fee schedule,,,
FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR,RX-106783,CDM,J1453,HCPCS,636,RC,00006-3061-00,NDC,outpatient,1,UN,1375.94,963.158,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.14,1056.72192,other,SI=N Exclusions ,,
FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR,RX-106783,CDM,J1453,HCPCS,636,RC,00006-3061-01,NDC,outpatient,1,UN,1375.94,963.158,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.14,1056.72192,other,SI=N Exclusions ,,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0437-10,NDC,outpatient,100,ML,2692.38,1884.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48.58,,,48.58,47.99,8270.99136,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0437-91,NDC,outpatient,100,ML,2692.38,1884.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48.58,,,48.58,47.99,8270.99136,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0438-20,NDC,outpatient,200,ML,5384.76,3769.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48.58,,,48.58,47.99,8270.99136,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0439-93,NDC,outpatient,400,ML,10769.52,7538.664,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48.58,,,48.58,47.99,8270.99136,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0439-40,NDC,outpatient,400,ML,10769.52,7538.664,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48.58,,,48.58,47.99,8270.99136,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0436-05,NDC,outpatient,100,ML,2692.38,1884.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48.58,,,48.58,47.99,8270.99136,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0436-90,NDC,outpatient,100,ML,2692.38,1884.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48.58,,,48.58,47.99,8270.99136,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) IM INJ,RX-15342,CDM,J1460,HCPCS,636,RC,13533-0335-40,NDC,outpatient,2,ML,422.8,295.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49.85,,,49.85,48.47,416.02,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) IM INJ,RX-15342,CDM,J1460,HCPCS,636,RC,13533-0335-04,NDC,outpatient,2,ML,422.8,295.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49.85,,,49.85,48.47,416.02,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-25,NDC,outpatient,200,ML,4199.62,2939.734,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48.81,,,48.81,48.81,6450.61632,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-41,NDC,outpatient,400,ML,8399.24,5879.468,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48.81,,,48.81,48.81,6450.61632,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-71,NDC,outpatient,100,ML,2099.81,1469.867,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48.81,,,48.81,48.81,6450.61632,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-24,NDC,outpatient,200,ML,4199.62,2939.734,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48.81,,,48.81,48.81,6450.61632,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-40,NDC,outpatient,400,ML,8399.24,5879.468,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48.81,,,48.81,48.81,6450.61632,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-72,NDC,outpatient,100,ML,2099.81,1469.867,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48.81,,,48.81,48.81,6450.61632,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-21,NDC,outpatient,100,ML,2099.81,1469.867,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48.81,,,48.81,48.81,6450.61632,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-20,NDC,outpatient,100,ML,2099.81,1469.867,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,48.81,,,48.81,48.81,6450.61632,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD S/D  5 % IGA <=2.2,RX-4080223,CDM,J1566,HCPCS,636,RC,00944-2620-03,NDC,outpatient,5,GR,934.5,654.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,82.19,,,82.19,77.77,1531.4,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD S/D  5 % IGA <= 1,RX-4080224,CDM,J1566,HCPCS,636,RC,00944-2658-04,NDC,outpatient,10,GR,1154.96,808.472,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,82.19,,,82.19,77.77,1531.4,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD S/D  5 % IGA <= 1,RX-4080224,CDM,J1566,HCPCS,636,RC,00944-2656-03,NDC,outpatient,5,GR,577.48,404.236,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,82.19,,,82.19,77.77,1531.4,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) OCTAGAM 5 % IV SOLN,RX-4080225,CDM,J1568,HCPCS,636,RC,68209-0843-03,NDC,outpatient,200,ML,1884.53,1319.171,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49,,,49,44.12,1447.31904,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) OCTAGAM 5 % IV SOLN,RX-4080225,CDM,J1568,HCPCS,636,RC,68209-0843-04,NDC,outpatient,200,ML,1884.53,1319.171,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49,,,49,44.12,1447.31904,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-04,NDC,outpatient,100,ML,2726.33,1908.431,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49.69,,,49.69,46.03,6281.46432,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-06,NDC,outpatient,200,ML,5452.66,3816.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49.69,,,49.69,46.03,6281.46432,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-10,NDC,outpatient,100,ML,2726.33,1908.431,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49.69,,,49.69,46.03,6281.46432,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-02,NDC,outpatient,100,ML,2726.33,1908.431,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49.69,,,49.69,46.03,6281.46432,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-05,NDC,outpatient,100,ML,2726.33,1908.431,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49.69,,,49.69,46.03,6281.46432,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-07,NDC,outpatient,300,ML,8178.99,5725.293,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49.69,,,49.69,46.03,6281.46432,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-11,NDC,outpatient,100,ML,2726.33,1908.431,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49.69,,,49.69,46.03,6281.46432,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-12,NDC,outpatient,200,ML,5452.66,3816.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49.69,,,49.69,46.03,6281.46432,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-08,NDC,outpatient,100,ML,2726.33,1908.431,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49.69,,,49.69,46.03,6281.46432,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-03,NDC,outpatient,100,ML,2726.33,1908.431,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49.69,,,49.69,46.03,6281.46432,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-09,NDC,outpatient,100,ML,2726.33,1908.431,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49.69,,,49.69,46.03,6281.46432,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-13,NDC,outpatient,300,ML,8178.99,5725.293,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49.69,,,49.69,46.03,6281.46432,fee schedule,,,
GANCICLOVIR SODIUM 500 MG IV SOLR,RX-10101,CDM,J1570,HCPCS,636,RC,70436-0089-55,NDC,outpatient,1,UN,165.87,116.109,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,36.41,416.02,other,SI=N Exclusions ,,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-04,NDC,outpatient,200,ML,2125.2,1487.64,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,60.35,,,60.35,48.52,3264.3072,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-03,NDC,outpatient,200,ML,2125.2,1487.64,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,60.35,,,60.35,48.52,3264.3072,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-05,NDC,outpatient,400,ML,4250.4,2975.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,60.35,,,60.35,48.52,3264.3072,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-00,NDC,outpatient,400,ML,4250.4,2975.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,60.35,,,60.35,48.52,3264.3072,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-08,NDC,outpatient,200,ML,2125.2,1487.64,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,60.35,,,60.35,48.52,3264.3072,fee schedule,,,
GENTAMICIN 80 MG IN NS 50 ML IV SOLN PREMIX,RX-15911,CDM,J1580,HCPCS,636,RC,99999-0002-93,NDC,outpatient,50,ML,25.25,17.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.23924,416.02,other,SI=N Exclusions ,,
GENTAMICIN 80 MG IN NS 50 ML IV SOLN PREMIX,RX-15911,CDM,J1580,HCPCS,636,RC,00338-0509-41,NDC,outpatient,50,ML,25,17.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.23924,416.02,other,SI=N Exclusions ,,
GENTAMICIN SULFATE 10 MG/ML IJ SOLN,RX-3425,CDM,J1580,HCPCS,636,RC,63323-0173-01,NDC,outpatient,2,ML,9.88,6.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.23924,416.02,other,SI=N Exclusions ,,
GENTAMICIN SULFATE 10 MG/ML IJ SOLN,RX-3425,CDM,J1580,HCPCS,636,RC,63323-0173-02,NDC,outpatient,2,ML,9.88,6.916,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.23924,416.02,other,SI=N Exclusions ,,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,00409-1207-03,NDC,outpatient,2,ML,12.55,8.785,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.23924,416.02,other,SI=N Exclusions ,,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-02,NDC,outpatient,2,ML,5.52,3.864,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.23924,416.02,other,SI=N Exclusions ,,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-20,NDC,outpatient,20,ML,102.62,71.834,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.23924,416.02,other,SI=N Exclusions ,,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-01,NDC,outpatient,2,ML,5.52,3.864,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.23924,416.02,other,SI=N Exclusions ,,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,00409-1207-13,NDC,outpatient,2,ML,12.55,8.785,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.23924,416.02,other,SI=N Exclusions ,,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-03,NDC,outpatient,20,ML,102.62,71.834,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.23924,416.02,other,SI=N Exclusions ,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,00143-9682-25,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.51,416.02,other,SI=N Exclusions ,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,70121-1394-05,NDC,outpatient,1,ML,17.13,11.991,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.51,416.02,other,SI=N Exclusions ,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,71288-0414-03,NDC,outpatient,1,ML,4.37,3.059,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.51,416.02,other,SI=N Exclusions ,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,00143-9682-01,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.51,416.02,other,SI=N Exclusions ,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,00517-4601-25,NDC,outpatient,1,ML,7.56,5.292,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.51,416.02,other,SI=N Exclusions ,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,16714-0536-01,NDC,outpatient,1,ML,5.69,3.983,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.51,416.02,other,SI=N Exclusions ,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,16714-0536-25,NDC,outpatient,1,ML,5.69,3.983,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.51,416.02,other,SI=N Exclusions ,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,71288-0414-01,NDC,outpatient,1,ML,4.37,3.059,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.51,416.02,other,SI=N Exclusions ,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,70121-1394-01,NDC,outpatient,1,ML,17.13,11.991,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.51,416.02,other,SI=N Exclusions ,,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00597-0053-01,NDC,outpatient,1,UN,403.75,282.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,192.3,,,192.3,90.641875,579.456,fee schedule,,,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00597-0053-45,NDC,outpatient,1,UN,403.75,282.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,192.3,,,192.3,90.641875,579.456,fee schedule,,,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00597-0260-10,NDC,outpatient,1,UN,403.75,282.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,192.3,,,192.3,90.641875,579.456,fee schedule,,,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00548-5850-00,NDC,outpatient,1,UN,754.5,528.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,192.3,,,192.3,90.641875,579.456,fee schedule,,,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1611,HCPCS,636,RC,63323-0593-03,NDC,outpatient,1,UN,610.59,427.413,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,108.93,,,108.93,101.41,468.94848,fee schedule,,,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1611,HCPCS,636,RC,63323-0596-11,NDC,outpatient,1,UN,610.61,427.427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,108.93,,,108.93,101.41,468.94848,fee schedule,,,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1611,HCPCS,636,RC,63323-0596-13,NDC,outpatient,1,UN,610.61,427.427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,108.93,,,108.93,101.41,468.94848,fee schedule,,,
GRANISETRON HCL 1 MG/ML IV SOLN,RX-12552,CDM,J1626,HCPCS,636,RC,00143-9744-01,NDC,outpatient,1,ML,11.46,8.022,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.28,416.02,other,SI=N Exclusions ,,
GRANISETRON HCL 1 MG/ML IV SOLN,RX-12552,CDM,J1626,HCPCS,636,RC,00143-9744-10,NDC,outpatient,1,ML,11.46,8.022,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.28,416.02,other,SI=N Exclusions ,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,67457-0426-00,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,76045-0737-10,NDC,outpatient,1,ML,15.64,10.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,00143-9501-01,NDC,outpatient,1,ML,7.22,5.054,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,00143-9501-25,NDC,outpatient,1,ML,7.22,5.054,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,63323-0474-00,NDC,outpatient,1,ML,3.76,2.632,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,76045-0737-01,NDC,outpatient,1,ML,15.64,10.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,63323-0474-01,NDC,outpatient,1,ML,3.76,2.632,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,67457-0426-12,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
HEPARIN LOCK FLUSH 100 UNIT/ML IV SOLN WRAPPER,RX-4080200,CDM,J1642,HCPCS,636,RC,64253-0333-35,NDC,outpatient,5,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.02,416.02,other,SI=N Exclusions ,,
HEPARIN LOCK FLUSH 100 UNIT/ML IV SOLN WRAPPER,RX-4080200,CDM,J1642,HCPCS,636,RC,08290-3064-24,NDC,outpatient,5,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.02,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,00409-2720-31,NDC,outpatient,10,ML,15.99,11.193,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,25021-0400-10,NDC,outpatient,10,ML,16.81,11.767,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-05,NDC,outpatient,10,ML,18.71,13.097,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-33,NDC,outpatient,30,ML,21.77,15.239,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-36,NDC,outpatient,30,ML,21.77,15.239,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0931-28,NDC,outpatient,10,ML,10.28,7.196,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0372-12,NDC,outpatient,1,ML,13.11,9.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,25021-0400-01,NDC,outpatient,1,ML,5.04,3.528,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0276-02,NDC,outpatient,2,ML,21.8,15.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-15,NDC,outpatient,10,ML,18.71,13.097,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0385-99,NDC,outpatient,10,ML,19.64,13.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,71288-0400-03,NDC,outpatient,2,ML,19.86,13.902,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0276-01,NDC,outpatient,2,ML,21.8,15.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0920-11,NDC,outpatient,1,ML,3.83,2.681,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0920-25,NDC,outpatient,1,ML,3.83,2.681,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,71288-0400-02,NDC,outpatient,2,ML,19.86,13.902,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,00409-2720-02,NDC,outpatient,10,ML,15.99,11.193,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0931-14,NDC,outpatient,10,ML,10.28,7.196,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0372-99,NDC,outpatient,1,ML,13.11,9.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0385-10,NDC,outpatient,10,ML,19.64,13.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 20000 UNIT/ML IJ SOLN,RX-10178,CDM,J1644,HCPCS,636,RC,63739-0986-11,NDC,outpatient,1,ML,33.86,23.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 20000 UNIT/ML IJ SOLN,RX-10178,CDM,J1644,HCPCS,636,RC,63739-0986-25,NDC,outpatient,1,ML,33.86,23.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,00409-2723-02,NDC,outpatient,1,ML,3.99,2.793,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,63739-0953-11,NDC,outpatient,1,ML,6.36,4.452,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,71288-0403-02,NDC,outpatient,1,ML,3.33,2.331,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,00409-2723-31,NDC,outpatient,1,ML,3.99,2.793,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,71288-0403-01,NDC,outpatient,1,ML,3.33,2.331,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,63739-0953-25,NDC,outpatient,1,ML,6.36,4.452,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN (PORCINE) IN NACL 25000-0.45 UT/250ML-% IV SOLN,RX-135728,CDM,J1644,HCPCS,636,RC,00409-7650-52,NDC,outpatient,250,ML,63.84,44.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN (PORCINE) IN NACL 25000-0.45 UT/250ML-% IV SOLN,RX-135728,CDM,J1644,HCPCS,636,RC,00409-7650-62,NDC,outpatient,250,ML,63.84,44.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SOD (PORCINE) IN D5W 100 UNIT/ML IV SOLN,RX-24329,CDM,J1644,HCPCS,636,RC,63323-0523-74,NDC,outpatient,250,ML,44.93,31.451,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SOD (PORCINE) IN D5W 100 UNIT/ML IV SOLN,RX-24329,CDM,J1644,HCPCS,636,RC,63323-0523-01,NDC,outpatient,250,ML,44.93,31.451,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SOD (PORCINE) IN D5W 100 UNIT/ML IV SOLN,RX-24329,CDM,J1644,HCPCS,636,RC,00264-9587-20,NDC,outpatient,250,ML,77.19,54.033,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SOD (PORCINE) PREMIX 30000 UNITS IN 1L NS,RX-4080227,CDM,J1644,HCPCS,636,RC,70092-1281-08,NDC,outpatient,1000,ML,120.09,84.063,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SOD (PORCINE) PREMIX 30000 UNITS IN 1L NS,RX-4080227,CDM,J1644,HCPCS,636,RC,99999-0921-33,NDC,outpatient,1000,ML,91.43,64.001,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00338-0424-18,NDC,outpatient,500,ML,28.85,20.195,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-1005-20,NDC,outpatient,500,ML,33.99,23.793,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-7620-03,NDC,outpatient,500,ML,33.99,23.793,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,99999-0002-94,NDC,outpatient,5,ML,16.13,11.291,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,63323-0519-77,NDC,outpatient,500,ML,31.42,21.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00264-9872-10,NDC,outpatient,500,ML,33.8,23.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-1005-01,NDC,outpatient,500,ML,33.99,23.793,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-7620-13,NDC,outpatient,500,ML,33.99,23.793,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,99999-0001-71,NDC,outpatient,500,ML,22,15.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,99999-0001-81,NDC,outpatient,1000,ML,22.86,16.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,63323-0519-02,NDC,outpatient,500,ML,31.42,21.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN (PORCINE) IN NACL 25000-0.9 UT/250ML-% IV SOLN,RX-4081544,CDM,J1644,HCPCS,636,RC,99999-0003-31,NDC,outpatient,250,ML,42.73,29.911,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN (PORCINE) IN NACL 25000-0.9 UT/250ML-% IV SOLN,RX-4081544,CDM,J1644,HCPCS,636,RC,99999-0003-32,NDC,outpatient,250,ML,30.4,21.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
ENOXAPARIN SODIUM 30 MG/0.3ML IJ SOSY,RX-158184,CDM,J1650,HCPCS,636,RC,00548-5601-00,NDC,outpatient,0.3,ML,20.03,14.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.57,416.02,other,SI=N Exclusions ,,
ENOXAPARIN SODIUM 40 MG/0.4ML IJ SOSY,RX-158185,CDM,J1650,HCPCS,636,RC,00548-5602-00,NDC,outpatient,0.4,ML,26.7,18.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.57,416.02,other,SI=N Exclusions ,,
ENOXAPARIN SODIUM 60 MG/0.6ML IJ SOSY,RX-158186,CDM,J1650,HCPCS,636,RC,00548-5603-00,NDC,outpatient,0.6,ML,40.05,28.035,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.57,416.02,other,SI=N Exclusions ,,
ENOXAPARIN SODIUM 80 MG/0.8ML IJ SOSY,RX-158187,CDM,J1650,HCPCS,636,RC,00548-5604-00,NDC,outpatient,0.8,ML,53.4,37.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.57,416.02,other,SI=N Exclusions ,,
ENOXAPARIN SODIUM 100 MG/ML IJ SOSY,RX-158188,CDM,J1650,HCPCS,636,RC,00548-5605-00,NDC,outpatient,1,ML,66.75,46.725,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.57,416.02,other,SI=N Exclusions ,,
ENOXAPARIN SODIUM 120 MG/0.8ML IJ SOSY,RX-158189,CDM,J1650,HCPCS,636,RC,00548-5606-00,NDC,outpatient,0.8,ML,80.1,56.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.57,416.02,other,SI=N Exclusions ,,
ENOXAPARIN SODIUM 150 MG/ML IJ SOSY,RX-158190,CDM,J1650,HCPCS,636,RC,00548-5607-00,NDC,outpatient,1,ML,100.13,70.091,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.57,416.02,other,SI=N Exclusions ,,
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,67457-0583-00,NDC,outpatient,0.4,ML,146.14,102.298,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions ,,
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,55150-0231-00,NDC,outpatient,0.4,ML,58.52,40.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions ,,
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,55150-0231-10,NDC,outpatient,0.4,ML,58.52,40.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions ,,
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,67457-0583-04,NDC,outpatient,0.4,ML,146.14,102.298,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions ,,
FONDAPARINUX SODIUM 7.5 MG/0.6ML SC SOLN,RX-108028,CDM,J1652,HCPCS,636,RC,55111-0680-11,NDC,outpatient,0.6,ML,45.65,31.955,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions ,,
FONDAPARINUX SODIUM 7.5 MG/0.6ML SC SOLN,RX-108028,CDM,J1652,HCPCS,636,RC,55111-0680-10,NDC,outpatient,0.6,ML,45.65,31.955,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions ,,
FONDAPARINUX SODIUM 10 MG/0.8ML SC SOLN,RX-108029,CDM,J1652,HCPCS,636,RC,67457-0585-00,NDC,outpatient,0.8,ML,146.14,102.298,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions ,,
FONDAPARINUX SODIUM 10 MG/0.8ML SC SOLN,RX-108029,CDM,J1652,HCPCS,636,RC,67457-0585-08,NDC,outpatient,0.8,ML,146.14,102.298,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions ,,
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55111-0678-11,NDC,outpatient,0.5,ML,21,14.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions ,,
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55150-0230-00,NDC,outpatient,0.5,ML,20.75,14.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions ,,
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55150-0230-10,NDC,outpatient,0.5,ML,20.75,14.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions ,,
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55111-0678-10,NDC,outpatient,0.5,ML,21,14.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions ,,
TETANUS IMMUNE GLOBULIN 250 UNIT/ML IM SOSY,RX-156399,CDM,J1670,HCPCS,636,RC,13533-0634-02,NDC,outpatient,1,ML,1484.53,1039.171,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,581.78,,,581.78,333.276985,1140.11904,fee schedule,,,
TETANUS IMMUNE GLOBULIN 250 UNIT/ML IM SOSY,RX-156399,CDM,J1670,HCPCS,636,RC,13533-0634-20,NDC,outpatient,1,ML,1484.53,1039.171,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,581.78,,,581.78,333.276985,1140.11904,fee schedule,,,
HYDROCORTISONE SOD SUC (PF) 250 MG IJ SOLR,RX-160127,CDM,J1720,HCPCS,636,RC,00009-0013-05,NDC,outpatient,1,UN,153.4,107.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,13.56878,416.02,other,SI=N Exclusions ,,
HYDROCORTISONE SOD SUC (PF) 500 MG IJ SOLR,RX-160129,CDM,J1720,HCPCS,636,RC,00009-0016-12,NDC,outpatient,1,UN,308.7,216.09,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,13.56878,416.02,other,SI=N Exclusions ,,
HYDROCORTISONE NA SUCCINATE PF 100 MG IJ WRAPPER,RX-4080176,CDM,J1720,HCPCS,636,RC,00009-0011-04,NDC,outpatient,1,UN,83.69,58.583,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,13.56878,416.02,other,SI=N Exclusions ,,
HYDROCORTISONE NA SUCCINATE PF 100 MG IJ WRAPPER,RX-4080176,CDM,J1720,HCPCS,636,RC,00009-0825-01,NDC,outpatient,1,UN,60.44,42.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,13.56878,416.02,other,SI=N Exclusions ,,
IBANDRONATE SODIUM 3 MG/3ML IV SOLN,RX-110306,CDM,J1740,HCPCS,636,RC,60505-6097-00,NDC,outpatient,3,ML,291.8,204.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,27.14,416.02,other,SI=N Exclusions ,,
IBUTILIDE FUMARATE 1 MG/10ML IV SOLN,RX-100740,CDM,J1742,HCPCS,636,RC,00009-3794-01,NDC,outpatient,10,ML,380.26,266.182,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,347.15,,,347.15,85.36837,416.02,fee schedule,,,
INFLIXIMAB 100 MG IV SOLR,RX-23796,CDM,J1745,HCPCS,636,RC,57894-0030-01,NDC,outpatient,1,UN,3124.93,2187.451,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,32.22,,,32.22,32.22,2399.94624,fee schedule,,,
IRON DEXTRAN 50 MG/ML IJ SOLN,RX-3990,CDM,J1750,HCPCS,636,RC,00023-6082-10,NDC,outpatient,2,ML,145.94,102.158,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17.67,,,17.67,17.18,416.02,fee schedule,,,
IRON DEXTRAN 50 MG/ML IJ SOLN,RX-3990,CDM,J1750,HCPCS,636,RC,00023-6082-01,NDC,outpatient,2,ML,145.94,102.158,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,17.67,,,17.67,17.18,416.02,fee schedule,,,
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2310-05,NDC,outpatient,10,ML,278.93,195.251,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21,416.02,other,SI=N Exclusions ,,
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2340-10,NDC,outpatient,5,ML,131.72,92.204,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21,416.02,other,SI=N Exclusions ,,
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2340-01,NDC,outpatient,5,ML,137.29,96.103,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21,416.02,other,SI=N Exclusions ,,
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2310-01,NDC,outpatient,10,ML,278.93,195.251,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.21,416.02,other,SI=N Exclusions ,,
DROPERIDOL 2.5 MG/ML IJ SOLN,RX-2654,CDM,J1790,HCPCS,636,RC,00517-9702-01,NDC,outpatient,2,ML,31.33,21.931,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.83,416.02,other,SI=N Exclusions ,,
DROPERIDOL 2.5 MG/ML IJ SOLN,RX-2654,CDM,J1790,HCPCS,636,RC,00517-9702-25,NDC,outpatient,2,ML,31.33,21.931,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.83,416.02,other,SI=N Exclusions ,,
PROPRANOLOL HCL 1 MG/ML IV SOLN,RX-29335,CDM,J1800,HCPCS,636,RC,63323-0604-01,NDC,outpatient,1,ML,8.17,5.719,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.834165,416.02,other,SI=N Exclusions ,,
PROPRANOLOL HCL 1 MG/ML IV SOLN,RX-29335,CDM,J1800,HCPCS,636,RC,63323-0604-00,NDC,outpatient,1,ML,8.17,5.719,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.834165,416.02,other,SI=N Exclusions ,,
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN,RX-29805,CDM,J1805,HCPCS,636,RC,25021-0308-84,NDC,outpatient,250,ML,336.4,235.48,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.19,,,0.19,0.19,416.02,fee schedule,,,
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-29805,CDM,J1805,HCPCS,636,RC,25021-0308-84,NDC,outpatient,250,ML,320.4,224.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.19,,,0.19,0.19,416.02,fee schedule,,,
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN,RX-29805,CDM,J1805,HCPCS,636,RC,67457-0657-25,NDC,outpatient,250,ML,426.52,298.564,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.19,,,0.19,0.19,416.02,fee schedule,,,
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-29805,CDM,J1805,HCPCS,636,RC,67457-0657-25,NDC,outpatient,250,ML,410.52,287.364,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.19,,,0.19,0.19,416.02,fee schedule,,,
ESMOLOL HCL 100 MG/10ML IV SOLN,RX-82085,CDM,J1805,HCPCS,636,RC,67457-0182-10,NDC,outpatient,10,ML,17.12,11.984,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.19,,,0.19,0.19,416.02,fee schedule,,,
ESMOLOL HCL 100 MG/10ML IV SOLN,RX-82085,CDM,J1805,HCPCS,636,RC,67457-0182-00,NDC,outpatient,10,ML,17.12,11.984,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.19,,,0.19,0.19,416.02,fee schedule,,,
ESMOLOL HCL 100 MG/10ML IV SOLN,RX-82085,CDM,J1805,HCPCS,636,RC,55150-0194-10,NDC,outpatient,10,ML,10.39,7.273,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.19,,,0.19,0.19,416.02,fee schedule,,,
ESMOLOL HCL 2500 MG/250ML IV SOLN,RX-142051,CDM,J1806,HCPCS,636,RC,44567-0811-10,NDC,outpatient,250,ML,430.97,301.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.36,,,0.36,0.36,416.02,fee schedule,,,
ESMOLOL HCL 2500 MG/250ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-142051,CDM,J1806,HCPCS,636,RC,44567-0811-10,NDC,outpatient,250,ML,414.97,290.479,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.36,,,0.36,0.36,416.02,fee schedule,,,
INTERFERON BETA-1B 0.3 MG SC KIT,RX-124318,CDM,J1830,HCPCS,636,RC,50419-0524-35,NDC,outpatient,1,UN,1865.02,1305.514,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,794.16,,,794.16,114.43,1432.33536,fee schedule,,,
INTERFERON BETA-1B 0.3 MG SC KIT,RX-124318,CDM,J1830,HCPCS,636,RC,50419-0524-01,NDC,outpatient,1,UN,1865.02,1305.514,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,794.16,,,794.16,114.43,1432.33536,fee schedule,,,
ISAVUCONAZONIUM SULFATE 372 MG IV SOLR,RX-130407,CDM,J1833,HCPCS,636,RC,00469-0420-01,NDC,outpatient,1,UN,1572.32,1100.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.18,,,1.18,1,1207.54176,fee schedule,,,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-24,NDC,outpatient,100,ML,24.23,16.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.03,,,0.03,0.02,416.02,fee schedule,,,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,47335-0993-01,NDC,outpatient,100,ML,23.2,16.24,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.03,,,0.03,0.02,416.02,fee schedule,,,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,00338-1055-48,NDC,outpatient,100,ML,5.14,3.598,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.03,,,0.03,0.02,416.02,fee schedule,,,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,47335-0993-01,NDC,outpatient,100,ML,7.2,5.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.03,,,0.03,0.02,416.02,fee schedule,,,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-01,NDC,outpatient,100,ML,24.23,16.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.03,,,0.03,0.02,416.02,fee schedule,,,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,25021-0131-82,NDC,outpatient,100,ML,25.77,18.039,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.03,,,0.03,0.02,416.02,fee schedule,,,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,25021-0131-82,NDC,outpatient,100,ML,9.77,6.839,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.03,,,0.03,0.02,416.02,fee schedule,,,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-01,NDC,outpatient,100,ML,8.23,5.761,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.03,,,0.03,0.02,416.02,fee schedule,,,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,00338-1055-48,NDC,outpatient,100,ML,21.14,14.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.03,,,0.03,0.02,416.02,fee schedule,,,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-24,NDC,outpatient,100,ML,8.23,5.761,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,0.03,,,0.03,0.02,416.02,fee schedule,,,
METRONIDAZOLE IN NACL IVPB,RX-4080369,CDM,J1836,HCPCS,636,RC,99999-0001-74,NDC,outpatient,50,ML,20.37,14.259,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.03,,,0.03,0.02,416.02,fee schedule,,,
METRONIDAZOLE IV SYRINGE (PEDIATRIC),RX-40840043,CDM,J1836,HCPCS,636,RC,99999-0001-74,NDC,outpatient,50,ML,20.37,14.259,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.03,,,0.03,0.02,416.02,fee schedule,,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,63323-0162-00,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.55,416.02,other,SI=N Exclusions ,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,72266-0118-25,NDC,outpatient,1,ML,4.8,3.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.55,416.02,other,SI=N Exclusions ,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,00338-0072-25,NDC,outpatient,1,ML,3.57,2.499,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.55,416.02,other,SI=N Exclusions ,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,62332-0600-25,NDC,outpatient,1,ML,9.77,6.839,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.55,416.02,other,SI=N Exclusions ,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,00409-3795-01,NDC,outpatient,1,ML,18.43,12.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.55,416.02,other,SI=N Exclusions ,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,00409-3795-19,NDC,outpatient,1,ML,18.43,12.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.55,416.02,other,SI=N Exclusions ,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,62332-0600-01,NDC,outpatient,1,ML,9.77,6.839,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.55,416.02,other,SI=N Exclusions ,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,72266-0118-01,NDC,outpatient,1,ML,4.8,3.36,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.55,416.02,other,SI=N Exclusions ,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,63323-0162-01,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.55,416.02,other,SI=N Exclusions ,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,00409-2339-24,NDC,outpatient,4,ML,35.3,24.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.27,,,0.27,0.24,416.02,fee schedule,,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,25021-0317-20,NDC,outpatient,20,ML,9.98,6.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.27,,,0.27,0.24,416.02,fee schedule,,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,36000-0320-10,NDC,outpatient,4,ML,16.17,11.319,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.27,,,0.27,0.24,416.02,fee schedule,,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,72266-0102-01,NDC,outpatient,20,ML,12.14,8.498,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.27,,,0.27,0.24,416.02,fee schedule,,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,00409-2267-54,NDC,outpatient,40,ML,40.77,28.539,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.27,,,0.27,0.24,416.02,fee schedule,,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,00409-2339-34,NDC,outpatient,4,ML,35.3,24.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.27,,,0.27,0.24,416.02,fee schedule,,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,36000-0320-01,NDC,outpatient,4,ML,16.17,11.319,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.27,,,0.27,0.24,416.02,fee schedule,,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1921,HCPCS,636,RC,00143-9623-01,NDC,outpatient,40,ML,18.87,13.209,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.63,,,1.63,1.24,416.02,fee schedule,,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1921,HCPCS,636,RC,00143-9622-01,NDC,outpatient,20,ML,8.85,6.195,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.63,,,1.63,1.24,416.02,fee schedule,,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6007-01,NDC,outpatient,10,ML,15.42,10.794,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.62,416.02,other,SI=N Exclusions ,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0572-10,NDC,outpatient,10,ML,8.64,6.048,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.62,416.02,other,SI=N Exclusions ,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6008-10,NDC,outpatient,4,ML,14.21,9.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.62,416.02,other,SI=N Exclusions ,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0570-04,NDC,outpatient,4,ML,8.04,5.628,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.62,416.02,other,SI=N Exclusions ,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6007-10,NDC,outpatient,10,ML,15.42,10.794,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.62,416.02,other,SI=N Exclusions ,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6008-01,NDC,outpatient,4,ML,14.21,9.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.62,416.02,other,SI=N Exclusions ,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0572-01,NDC,outpatient,10,ML,8.64,6.048,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.62,416.02,other,SI=N Exclusions ,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,72205-0101-07,NDC,outpatient,4,ML,12.36,8.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.62,416.02,other,SI=N Exclusions ,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0570-01,NDC,outpatient,4,ML,8.04,5.628,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.62,416.02,other,SI=N Exclusions ,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,72205-0101-01,NDC,outpatient,4,ML,12.36,8.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.62,416.02,other,SI=N Exclusions ,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,00409-6102-04,NDC,outpatient,4,ML,9.24,6.468,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,416.02,other,SI=N Exclusions ,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-44,NDC,outpatient,10,ML,7.2,5.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,416.02,other,SI=N Exclusions ,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,36000-0283-25,NDC,outpatient,4,ML,5.41,3.787,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,416.02,other,SI=N Exclusions ,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,36000-0284-25,NDC,outpatient,10,ML,8.33,5.831,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,416.02,other,SI=N Exclusions ,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,71288-0203-05,NDC,outpatient,4,ML,3.66,2.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,416.02,other,SI=N Exclusions ,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,72603-0251-01,NDC,outpatient,4,ML,3.79,2.653,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,416.02,other,SI=N Exclusions ,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,72603-0251-25,NDC,outpatient,4,ML,3.79,2.653,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,416.02,other,SI=N Exclusions ,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,63323-0280-03,NDC,outpatient,4,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,416.02,other,SI=N Exclusions ,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,63323-0280-26,NDC,outpatient,4,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,416.02,other,SI=N Exclusions ,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,70860-0302-04,NDC,outpatient,4,ML,4.94,3.458,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,416.02,other,SI=N Exclusions ,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-32,NDC,outpatient,4,ML,4.75,3.325,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,416.02,other,SI=N Exclusions ,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,25021-0311-10,NDC,outpatient,10,ML,7.25,5.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,416.02,other,SI=N Exclusions ,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,71288-0203-04,NDC,outpatient,4,ML,3.66,2.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,416.02,other,SI=N Exclusions ,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,00409-6102-18,NDC,outpatient,4,ML,9.24,6.468,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,416.02,other,SI=N Exclusions ,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-33,NDC,outpatient,10,ML,7.2,5.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,416.02,other,SI=N Exclusions ,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-42,NDC,outpatient,4,ML,4.75,3.325,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,416.02,other,SI=N Exclusions ,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,63323-0280-04,NDC,outpatient,4,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,416.02,other,SI=N Exclusions ,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,70860-0302-42,NDC,outpatient,4,ML,4.94,3.458,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.4,416.02,other,SI=N Exclusions ,,
LEUPROLIDE ACETATE 3.75 MG IM KIT,RX-13691,CDM,J1950,HCPCS,636,RC,00074-3641-03,NDC,outpatient,1,UN,4758.7,3331.09,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1617.65,,,1617.65,399.86,10964.15232,fee schedule,,,
LEUPROLIDE ACETATE (3 MONTH) 11.25 MG IM KIT,RX-21044,CDM,J1950,HCPCS,636,RC,00074-3663-03,NDC,outpatient,1,UN,14276.24,9993.368,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1617.65,,,1617.65,399.86,10964.15232,fee schedule,,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,00264-1009-90,NDC,outpatient,100,ML,43.15,30.205,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions ,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,44567-0502-01,NDC,outpatient,100,ML,49.38,34.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions ,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,14789-0220-10,NDC,outpatient,100,ML,48.49,33.943,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions ,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,44567-0502-10,NDC,outpatient,100,ML,49.38,34.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions ,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,67457-0265-00,NDC,outpatient,100,ML,64.06,44.842,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions ,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,70860-0603-41,NDC,outpatient,100,ML,63.62,44.534,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions ,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,14789-0220-08,NDC,outpatient,100,ML,48.49,33.943,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions ,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,43598-0636-10,NDC,outpatient,100,ML,87.65,61.355,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions ,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,43598-0636-52,NDC,outpatient,100,ML,87.65,61.355,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions ,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,67457-0265-10,NDC,outpatient,100,ML,64.06,44.842,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions ,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,70860-0603-82,NDC,outpatient,100,ML,63.62,44.534,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions ,,
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,44567-0503-10,NDC,outpatient,100,ML,60.06,42.042,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions ,,
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,70860-0604-41,NDC,outpatient,100,ML,79.64,55.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions ,,
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,44567-0503-01,NDC,outpatient,100,ML,60.06,42.042,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions ,,
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,70860-0604-82,NDC,outpatient,100,ML,79.64,55.748,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions ,,
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,55150-0177-05,NDC,outpatient,5,ML,5.07,3.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions ,,
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,67457-0790-05,NDC,outpatient,5,ML,10.7,7.49,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions ,,
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,00409-1886-22,NDC,outpatient,5,ML,6.38,4.466,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions ,,
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,00409-1886-02,NDC,outpatient,5,ML,6.38,4.466,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions ,,
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,67457-0790-00,NDC,outpatient,5,ML,10.7,7.49,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions ,,
LEVOFLOXACIN IN D5W 250 MG/50ML IV SOLN,RX-108118,CDM,J1956,HCPCS,636,RC,25021-0132-81,NDC,outpatient,50,ML,25.26,17.682,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions ,,
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00143-9721-01,NDC,outpatient,100,ML,25.77,18.039,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions ,,
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00143-9721-24,NDC,outpatient,100,ML,25.77,18.039,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions ,,
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00409-0528-23,NDC,outpatient,100,ML,28.85,20.195,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions ,,
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,25021-0132-82,NDC,outpatient,100,ML,26.28,18.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions ,,
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00409-0528-25,NDC,outpatient,100,ML,28.85,20.195,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions ,,
LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN,RX-108120,CDM,J1956,HCPCS,636,RC,00409-0528-31,NDC,outpatient,150,ML,32.2,22.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions ,,
LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN,RX-108120,CDM,J1956,HCPCS,636,RC,25021-0132-83,NDC,outpatient,150,ML,33.74,23.618,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions ,,
LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN,RX-108120,CDM,J1956,HCPCS,636,RC,00409-0528-35,NDC,outpatient,150,ML,32.2,22.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions ,,
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,36000-0046-24,NDC,outpatient,50,ML,26.54,18.578,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions ,,
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,63323-0355-50,NDC,outpatient,50,ML,45.6,31.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions ,,
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,25021-0132-81,NDC,outpatient,50,ML,25.26,17.682,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions ,,
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,00143-9722-24,NDC,outpatient,50,ML,23.97,16.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92,416.02,other,SI=N Exclusions ,,
LIDOCAINE IN D5W 4-5 MG/ML-% IV SOLN,RX-14868,CDM,J2001,HCPCS,636,RC,00338-0409-03,NDC,outpatient,500,ML,42.7,29.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.02,416.02,other,SI=N Exclusions ,,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,00781-3433-46,NDC,outpatient,300,ML,100.11,70.077,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.08,416.02,other,SI=N Exclusions ,,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,00781-3433-95,NDC,outpatient,300,ML,100.11,70.077,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.08,416.02,other,SI=N Exclusions ,,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,57664-0683-57,NDC,outpatient,300,ML,46.71,32.697,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.08,416.02,other,SI=N Exclusions ,,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,63323-0713-03,NDC,outpatient,300,ML,49.38,34.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.08,416.02,other,SI=N Exclusions ,,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,63323-0713-13,NDC,outpatient,300,ML,49.38,34.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.08,416.02,other,SI=N Exclusions ,,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,55150-0242-51,NDC,outpatient,300,ML,53.38,37.366,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.08,416.02,other,SI=N Exclusions ,,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,57664-0683-31,NDC,outpatient,300,ML,46.71,32.697,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.08,416.02,other,SI=N Exclusions ,,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,57664-0683-31,NDC,outpatient,300,ML,46.71,32.697,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.08,416.02,other,SI=N Exclusions ,,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,00781-3433-95,NDC,outpatient,300,ML,100.11,70.077,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.08,416.02,other,SI=N Exclusions ,,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,57664-0683-57,NDC,outpatient,300,ML,46.71,32.697,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.08,416.02,other,SI=N Exclusions ,,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,63323-0713-03,NDC,outpatient,300,ML,49.38,34.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.08,416.02,other,SI=N Exclusions ,,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,55150-0242-51,NDC,outpatient,300,ML,53.38,37.366,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.08,416.02,other,SI=N Exclusions ,,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,00781-3433-46,NDC,outpatient,300,ML,100.11,70.077,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.08,416.02,other,SI=N Exclusions ,,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,63323-0713-13,NDC,outpatient,300,ML,49.38,34.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.08,416.02,other,SI=N Exclusions ,,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00409-1985-30,NDC,outpatient,1,ML,16.06,11.242,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.85,416.02,other,SI=N Exclusions ,,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6044-25,NDC,outpatient,1,ML,4.94,3.458,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.85,416.02,other,SI=N Exclusions ,,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6207-25,NDC,outpatient,1,ML,5.04,3.528,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.85,416.02,other,SI=N Exclusions ,,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00409-1985-03,NDC,outpatient,1,ML,16.06,11.242,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.85,416.02,other,SI=N Exclusions ,,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6044-01,NDC,outpatient,1,ML,4.94,3.458,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.85,416.02,other,SI=N Exclusions ,,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6207-01,NDC,outpatient,1,ML,5.04,3.528,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.85,416.02,other,SI=N Exclusions ,,
LORAZEPAM INFUSION PREMIX,RX-4080084,CDM,J2060,HCPCS,636,RC,SH408-0084-01,NDC,outpatient,100,ML,126.59,88.613,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.85,416.02,other,SI=N Exclusions ,,
MANNITOL 25 % IV SOLN,RX-4750,CDM,J2150,HCPCS,636,RC,00409-4031-01,NDC,outpatient,50,ML,10.28,7.196,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.30786,416.02,other,SI=N Exclusions ,,
MANNITOL 25 % IV SOLN,RX-4750,CDM,J2150,HCPCS,636,RC,00409-4031-16,NDC,outpatient,50,ML,10.28,7.196,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.30786,416.02,other,SI=N Exclusions ,,
MEPERIDINE 10 MG/ML PCA,RX-400415,CDM,J2175,HCPCS,636,RC,99999-0000-09,NDC,outpatient,50,ML,59.93,41.951,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.386435,416.02,other,SI=N Exclusions ,,
MEPERIDINE HCL 25 MG/ML IJ SOLN,RX-4903,CDM,J2175,HCPCS,636,RC,00641-6052-01,NDC,outpatient,1,ML,10.63,7.441,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.386435,416.02,other,SI=N Exclusions ,,
MEPERIDINE HCL 25 MG/ML IJ SOLN,RX-4903,CDM,J2175,HCPCS,636,RC,00641-6052-25,NDC,outpatient,1,ML,10.63,7.441,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.386435,416.02,other,SI=N Exclusions ,,
MEPERIDINE HCL 50 MG/ML IJ SOLN,RX-4904,CDM,J2175,HCPCS,636,RC,00641-6053-01,NDC,outpatient,1,ML,11.08,7.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.386435,416.02,other,SI=N Exclusions ,,
MEPERIDINE HCL 50 MG/ML IJ SOLN,RX-4904,CDM,J2175,HCPCS,636,RC,00641-6053-25,NDC,outpatient,1,ML,11.08,7.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.386435,416.02,other,SI=N Exclusions ,,
MEPOLIZUMAB 100 MG SC SOLR,RX-131231,CDM,J2182,HCPCS,636,RC,00173-0881-01,NDC,outpatient,1,UN,8145.21,5701.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,30.44,,,30.44,29.75,6255.52128,fee schedule,,,
MEROPENEM 500 MG IV SOLR,RX-17379,CDM,J2185,HCPCS,636,RC,55150-0207-20,NDC,outpatient,1,UN,7.45,5.215,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.35,416.02,other,SI=N Exclusions ,,
MEROPENEM 500 MG IV SOLR,RX-17379,CDM,J2185,HCPCS,636,RC,63323-0507-20,NDC,outpatient,1,UN,14.25,9.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.35,416.02,other,SI=N Exclusions ,,
MEROPENEM 500 MG IV SOLR,RX-17379,CDM,J2185,HCPCS,636,RC,63323-0507-01,NDC,outpatient,1,UN,14.25,9.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.35,416.02,other,SI=N Exclusions ,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00781-3098-94,NDC,outpatient,1,UN,48.95,34.265,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.35,416.02,other,SI=N Exclusions ,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00409-1391-22,NDC,outpatient,1,UN,20.02,14.014,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.35,416.02,other,SI=N Exclusions ,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00781-3098-95,NDC,outpatient,1,UN,48.95,34.265,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.35,416.02,other,SI=N Exclusions ,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,55150-0208-30,NDC,outpatient,1,UN,17.23,12.061,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.35,416.02,other,SI=N Exclusions ,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,70121-1453-01,NDC,outpatient,1,UN,45.95,32.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.35,416.02,other,SI=N Exclusions ,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,70121-1453-07,NDC,outpatient,1,UN,45.95,32.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.35,416.02,other,SI=N Exclusions ,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00409-1391-21,NDC,outpatient,1,UN,20.02,14.014,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.35,416.02,other,SI=N Exclusions ,,
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,00517-0740-01,NDC,outpatient,1,ML,89.19,62.433,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,15.18518,416.02,other,SI=N Exclusions ,,
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,51991-0144-17,NDC,outpatient,1,ML,67.64,47.348,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,15.18518,416.02,other,SI=N Exclusions ,,
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,51991-0144-99,NDC,outpatient,1,ML,67.64,47.348,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,15.18518,416.02,other,SI=N Exclusions ,,
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,00517-0740-20,NDC,outpatient,1,ML,89.19,62.433,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,15.18518,416.02,other,SI=N Exclusions ,,
METHYLNALTREXONE BROMIDE 12 MG/0.6ML SC SOLN,RX-91651,CDM,J2212,HCPCS,636,RC,65649-0551-02,NDC,outpatient,0.6,ML,659.14,461.398,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.52,,,1.52,1.07677,506.21952,fee schedule,,,
MICAFUNGIN SODIUM 50 MG IV SOLR,RX-41144,CDM,J2248,HCPCS,636,RC,00469-3250-10,NDC,outpatient,1,UN,384.44,269.108,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.29,590.53056,other,SI=N Exclusions ,,
MICAFUNGIN SODIUM 50 MG IV SOLR,RX-41144,CDM,J2248,HCPCS,636,RC,70710-1724-06,NDC,outpatient,1,UN,160.37,112.259,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.29,590.53056,other,SI=N Exclusions ,,
MICAFUNGIN SODIUM 50 MG IV SOLR,RX-41144,CDM,J2248,HCPCS,636,RC,70710-1724-01,NDC,outpatient,1,UN,160.37,112.259,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.29,590.53056,other,SI=N Exclusions ,,
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,00469-3211-10,NDC,outpatient,1,UN,768.92,538.244,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.29,590.53056,other,SI=N Exclusions ,,
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,25021-0191-10,NDC,outpatient,1,UN,136.09,95.263,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.29,590.53056,other,SI=N Exclusions ,,
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,70710-1725-01,NDC,outpatient,1,UN,320.73,224.511,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.29,590.53056,other,SI=N Exclusions ,,
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,70710-1725-06,NDC,outpatient,1,UN,320.73,224.511,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.29,590.53056,other,SI=N Exclusions ,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,00409-2305-16,NDC,outpatient,2,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.13,416.02,other,SI=N Exclusions ,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,23155-0600-31,NDC,outpatient,2,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.13,416.02,other,SI=N Exclusions ,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-18,NDC,outpatient,5,ML,13.45,9.415,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.13,416.02,other,SI=N Exclusions ,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-12,NDC,outpatient,2,ML,6.08,4.256,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.13,416.02,other,SI=N Exclusions ,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-15,NDC,outpatient,2,ML,6.08,4.256,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.13,416.02,other,SI=N Exclusions ,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,00409-2305-17,NDC,outpatient,2,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.13,416.02,other,SI=N Exclusions ,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,23155-0600-41,NDC,outpatient,2,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.13,416.02,other,SI=N Exclusions ,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-25,NDC,outpatient,5,ML,13.45,9.415,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.13,416.02,other,SI=N Exclusions ,,
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2250,HCPCS,636,RC,99999-0001-46,NDC,outpatient,100,ML,75.72,53.004,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.13,416.02,other,SI=N Exclusions ,,
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2250,HCPCS,636,RC,70004-0411-59,NDC,outpatient,100,ML,159.16,111.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.13,416.02,other,SI=N Exclusions ,,
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00641-6060-01,NDC,outpatient,10,ML,8.07,5.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.13,416.02,other,SI=N Exclusions ,,
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00409-2308-01,NDC,outpatient,1,ML,3.95,2.765,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.13,416.02,other,SI=N Exclusions ,,
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00409-2308-21,NDC,outpatient,1,ML,3.95,2.765,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.13,416.02,other,SI=N Exclusions ,,
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00641-6060-10,NDC,outpatient,10,ML,8.07,5.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.13,416.02,other,SI=N Exclusions ,,
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2251,HCPCS,636,RC,44567-0611-01,NDC,outpatient,100,ML,77.41,54.187,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.18,,,0.18,0.18,416.02,fee schedule,,,
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2251,HCPCS,636,RC,44567-0611-10,NDC,outpatient,100,ML,77.41,54.187,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.18,,,0.18,0.18,416.02,fee schedule,,,
MILRINONE IN DEXTROSE 20 MG/100ML IV SOLN,RX-122186,CDM,J2260,HCPCS,636,RC,00143-9719-10,NDC,outpatient,100,ML,44.93,31.451,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.41,416.02,other,SI=N Exclusions ,,
MILRINONE IN DEXTROSE 20 MG/100ML IV SOLN,RX-122186,CDM,J2260,HCPCS,636,RC,00143-9719-01,NDC,outpatient,100,ML,44.93,31.451,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.41,416.02,other,SI=N Exclusions ,,
MILRINONE IN DEXTROSE 20 MG/100ML IV SOLN,RX-122186,CDM,J2260,HCPCS,636,RC,25021-0313-82,NDC,outpatient,100,ML,50.27,35.189,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.41,416.02,other,SI=N Exclusions ,,
MILRINONE LACTATE 10 MG/10ML IV SOLN,RX-122188,CDM,J2260,HCPCS,636,RC,00143-9710-10,NDC,outpatient,10,ML,16.45,11.515,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.41,416.02,other,SI=N Exclusions ,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00641-6125-01,NDC,outpatient,1,ML,10.46,7.322,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.02948,416.02,other,SI=N Exclusions ,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00409-1891-01,NDC,outpatient,1,ML,9.04,6.328,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.02948,416.02,other,SI=N Exclusions ,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00409-1891-03,NDC,outpatient,1,ML,9.04,6.328,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.02948,416.02,other,SI=N Exclusions ,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00641-6125-25,NDC,outpatient,1,ML,10.46,7.322,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.02948,416.02,other,SI=N Exclusions ,,
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2270,HCPCS,636,RC,00641-6127-25,NDC,outpatient,1,ML,10.68,7.476,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.02948,416.02,other,SI=N Exclusions ,,
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2270,HCPCS,636,RC,00641-6127-01,NDC,outpatient,1,ML,10.68,7.476,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.02948,416.02,other,SI=N Exclusions ,,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2270,HCPCS,636,RC,52533-0161-45,NDC,outpatient,1,ML,33.38,23.366,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.02948,416.02,other,SI=N Exclusions ,,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2270,HCPCS,636,RC,00409-1890-01,NDC,outpatient,1,ML,9.93,6.951,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.02948,416.02,other,SI=N Exclusions ,,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2270,HCPCS,636,RC,00409-1890-03,NDC,outpatient,1,ML,9.93,6.951,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.02948,416.02,other,SI=N Exclusions ,,
MORPHINE SULFATE 50 MG/ML IV SOLN,RX-27393,CDM,J2270,HCPCS,636,RC,00409-1134-05,NDC,outpatient,50,ML,115.7,80.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.02948,416.02,other,SI=N Exclusions ,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2272,HCPCS,636,RC,76045-0005-10,NDC,outpatient,1,ML,8.79,6.153,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5.07,,,5.07,1.816205,416.02,fee schedule,,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2272,HCPCS,636,RC,63323-0454-01,NDC,outpatient,1,ML,8.51,5.957,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5.07,,,5.07,1.816205,416.02,fee schedule,,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2272,HCPCS,636,RC,63323-0454-00,NDC,outpatient,1,ML,8.51,5.957,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5.07,,,5.07,1.816205,416.02,fee schedule,,,
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2272,HCPCS,636,RC,63323-0451-00,NDC,outpatient,1,ML,9.36,6.552,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5.07,,,5.07,1.816205,416.02,fee schedule,,,
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2272,HCPCS,636,RC,63323-0451-01,NDC,outpatient,1,ML,9.36,6.552,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5.07,,,5.07,1.816205,416.02,fee schedule,,,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2272,HCPCS,636,RC,63323-0452-01,NDC,outpatient,1,ML,8.27,5.789,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5.07,,,5.07,1.816205,416.02,fee schedule,,,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2272,HCPCS,636,RC,63323-0452-00,NDC,outpatient,1,ML,8.27,5.789,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5.07,,,5.07,1.816205,416.02,fee schedule,,,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2272,HCPCS,636,RC,76045-0004-10,NDC,outpatient,1,ML,8.09,5.663,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5.07,,,5.07,1.816205,416.02,fee schedule,,,
MORPHINE SULFATE (PF) 1 MG/ML IJ SOLN,RX-15852,CDM,J2274,HCPCS,636,RC,00641-6019-01,NDC,outpatient,10,ML,82.11,57.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.46,1022.48448,other,SI=N Exclusions ,,
MORPHINE SULFATE (PF) 1 MG/ML IJ SOLN,RX-15852,CDM,J2274,HCPCS,636,RC,00641-6019-10,NDC,outpatient,10,ML,82.11,57.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.46,1022.48448,other,SI=N Exclusions ,,
MORPHINE SULF MICROINFUSION PF 200 MG/20ML (10 MG/ML) IJ SOLN,RX-77009,CDM,J2274,HCPCS,636,RC,00641-6039-01,NDC,outpatient,20,ML,695.45,486.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.46,1022.48448,other,SI=N Exclusions ,,
MORPHINE SULF MICROINFUSION PF 500 MG/20ML (25 MG/ML) IJ SOLN,RX-77010,CDM,J2274,HCPCS,636,RC,00641-6040-01,NDC,outpatient,20,ML,1331.36,931.952,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,10.46,1022.48448,other,SI=N Exclusions ,,
NALBUPHINE HCL 10 MG/ML IJ SOLN,RX-5339,CDM,J2300,HCPCS,636,RC,00409-1463-71,NDC,outpatient,1,ML,17.79,12.453,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.72,416.02,other,SI=N Exclusions ,,
NALBUPHINE HCL 10 MG/ML IJ SOLN,RX-5339,CDM,J2300,HCPCS,636,RC,00409-1463-01,NDC,outpatient,1,ML,17.79,12.453,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.72,416.02,other,SI=N Exclusions ,,
NITROGLYCERIN IN D5W 400-5 MCG/ML-% IV SOLN,RX-14895,CDM,J2305,HCPCS,636,RC,00338-1051-02,NDC,outpatient,250,ML,62.73,43.911,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.41,,,1.41,1.3,416.02,fee schedule,,,
NITROGLYCERIN IN D5W 400-5 MCG/ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-14895,CDM,J2305,HCPCS,636,RC,00338-1051-02,NDC,outpatient,250,ML,46.73,32.711,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,1.41,,,1.41,1.3,416.02,fee schedule,,,
NITROGLYCERIN IN D5W 100-5 MCG/ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-15858,CDM,J2305,HCPCS,636,RC,00338-1047-02,NDC,outpatient,250,ML,40.05,28.035,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,1.41,,,1.41,1.3,416.02,fee schedule,,,
NITROGLYCERIN IN D5W 100-5 MCG/ML-% IV SOLN,RX-15858,CDM,J2305,HCPCS,636,RC,00338-1047-02,NDC,outpatient,250,ML,56.05,39.235,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.41,,,1.41,1.3,416.02,fee schedule,,,
NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN,RX-15859,CDM,J2305,HCPCS,636,RC,00338-1049-02,NDC,outpatient,250,ML,58.28,40.796,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.41,,,1.41,1.3,416.02,fee schedule,,,
NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-15859,CDM,J2305,HCPCS,636,RC,00338-1049-02,NDC,outpatient,250,ML,42.28,29.596,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,1.41,,,1.41,1.3,416.02,fee schedule,,,
NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN,RX-15859,CDM,J2305,HCPCS,636,RC,99999-0004-40,NDC,outpatient,250,ML,45.49,31.843,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.41,,,1.41,1.3,416.02,fee schedule,,,
NITROGLYCERIN 5 MG/ML IV SOLN,RX-5599,CDM,J2305,HCPCS,636,RC,00517-4810-01,NDC,outpatient,10,ML,51.4,35.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.41,,,1.41,1.3,416.02,fee schedule,,,
NITROGLYCERIN 5 MG/ML IV SOLN,RX-5599,CDM,J2305,HCPCS,636,RC,00517-4810-25,NDC,outpatient,10,ML,51.4,35.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.41,,,1.41,1.3,416.02,fee schedule,,,
NALOXONE HCL 2 MG/2ML IJ SOSY,RX-136113,CDM,J2310,HCPCS,636,RC,76329-3369-01,NDC,outpatient,2,ML,42.08,29.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.03075,416.02,other,SI=N Exclusions ,,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,00409-1215-01,NDC,outpatient,1,ML,63.16,44.212,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.03075,416.02,other,SI=N Exclusions ,,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,00409-1215-21,NDC,outpatient,1,ML,63.16,44.212,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.03075,416.02,other,SI=N Exclusions ,,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,36000-0308-10,NDC,outpatient,1,ML,13.5,9.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.03075,416.02,other,SI=N Exclusions ,,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,36000-0308-01,NDC,outpatient,1,ML,13.5,9.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.03075,416.02,other,SI=N Exclusions ,,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,67457-0292-00,NDC,outpatient,1,ML,15.44,10.808,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.03075,416.02,other,SI=N Exclusions ,,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,67457-0292-02,NDC,outpatient,1,ML,15.44,10.808,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.03075,416.02,other,SI=N Exclusions ,,
OCTREOTIDE ACETATE 50 MCG/ML IJ SOLN,RX-91278,CDM,J2354,HCPCS,636,RC,67457-0239-00,NDC,outpatient,1,ML,17.58,12.306,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.86,416.02,other,SI=N Exclusions ,,
OCTREOTIDE ACETATE 50 MCG/ML IJ SOLN,RX-91278,CDM,J2354,HCPCS,636,RC,67457-0239-01,NDC,outpatient,1,ML,17.58,12.306,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.86,416.02,other,SI=N Exclusions ,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,00641-6175-01,NDC,outpatient,1,ML,7.84,5.488,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.86,416.02,other,SI=N Exclusions ,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,23155-0688-31,NDC,outpatient,1,ML,11.88,8.316,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.86,416.02,other,SI=N Exclusions ,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,23155-0688-41,NDC,outpatient,1,ML,11.88,8.316,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.86,416.02,other,SI=N Exclusions ,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,63323-0376-00,NDC,outpatient,1,ML,11.92,8.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.86,416.02,other,SI=N Exclusions ,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,63323-0376-01,NDC,outpatient,1,ML,11.92,8.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.86,416.02,other,SI=N Exclusions ,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,00641-6175-10,NDC,outpatient,1,ML,7.84,5.488,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.86,416.02,other,SI=N Exclusions ,,
OCTREOTIDE ACETATE 200 MCG/ML IJ SOLN,RX-91280,CDM,J2354,HCPCS,636,RC,00641-6177-01,NDC,outpatient,0.5,ML,25.17,17.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.86,416.02,other,SI=N Exclusions ,,
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,00641-6176-10,NDC,outpatient,1,ML,46.52,32.564,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.86,416.02,other,SI=N Exclusions ,,
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,00641-6176-01,NDC,outpatient,1,ML,46.52,32.564,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.86,416.02,other,SI=N Exclusions ,,
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,63323-0377-00,NDC,outpatient,1,ML,41.91,29.337,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.86,416.02,other,SI=N Exclusions ,,
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,63323-0377-01,NDC,outpatient,1,ML,41.91,29.337,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.86,416.02,other,SI=N Exclusions ,,
OMALIZUMAB 150 MG/ML SC SOSY,RX-144954,CDM,J2357,HCPCS,636,RC,50242-0215-01,NDC,outpatient,1,ML,3822.49,2675.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38.29,,,38.29,38.29,2935.67232,fee schedule,,,
OMALIZUMAB 75 MG/0.5ML SC SOSY,RX-144955,CDM,J2357,HCPCS,636,RC,50242-0214-01,NDC,outpatient,0.5,ML,1911.25,1337.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38.29,,,38.29,38.29,2935.67232,fee schedule,,,
OMALIZUMAB 150 MG SC SOLR,RX-36151,CDM,J2357,HCPCS,636,RC,50242-0040-62,NDC,outpatient,1,UN,3822.49,2675.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,38.29,,,38.29,38.29,2935.67232,fee schedule,,,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00781-3159-72,NDC,outpatient,1,UN,62.44,43.708,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.92,,,0.92,0.92,416.02,fee schedule,,,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00517-0955-01,NDC,outpatient,1,UN,115.66,80.962,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.92,,,0.92,0.92,416.02,fee schedule,,,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00781-9105-72,NDC,outpatient,1,UN,62.44,43.708,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.92,,,0.92,0.92,416.02,fee schedule,,,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,55150-0308-01,NDC,outpatient,1,UN,77.39,54.173,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.92,,,0.92,0.92,416.02,fee schedule,,,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00002-7597-01,NDC,outpatient,1,UN,206.8,144.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.92,,,0.92,0.92,416.02,fee schedule,,,
ORPHENADRINE CITRATE 30 MG/ML IJ SOLN,RX-5886,CDM,J2360,HCPCS,636,RC,00641-6182-01,NDC,outpatient,2,ML,19.23,13.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.317135,416.02,other,SI=N Exclusions ,,
ORPHENADRINE CITRATE 30 MG/ML IJ SOLN,RX-5886,CDM,J2360,HCPCS,636,RC,00641-6182-10,NDC,outpatient,2,ML,19.23,13.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.317135,416.02,other,SI=N Exclusions ,,
PHENYLEPHRINE HCL 100 MCG/ML SYRINGE,RX-4080501,CDM,J2371,HCPCS,636,RC,70004-0810-11,NDC,outpatient,5,ML,23.81,16.667,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.01,416.02,other,SI=N Exclusions ,,
PHENYLEPHRINE HCL 100 MCG/ML SYRINGE,RX-4080501,CDM,J2371,HCPCS,636,RC,70004-0810-12,NDC,outpatient,10,ML,25.28,17.696,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.01,416.02,other,SI=N Exclusions ,,
PHENYLEPHRINE HCL 100 MCG/ML SYRINGE,RX-4080501,CDM,J2371,HCPCS,636,RC,70092-1046-46,NDC,outpatient,10,ML,24.79,17.353,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.01,416.02,other,SI=N Exclusions ,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70069-0801-01,NDC,outpatient,1,ML,6.49,4.543,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.01,416.02,other,SI=N Exclusions ,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1577-01,NDC,outpatient,1,ML,9.89,6.923,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.01,416.02,other,SI=N Exclusions ,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,00781-3422-71,NDC,outpatient,1,ML,12.34,8.638,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.01,416.02,other,SI=N Exclusions ,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,00781-3422-92,NDC,outpatient,1,ML,12.34,8.638,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.01,416.02,other,SI=N Exclusions ,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,25021-0315-01,NDC,outpatient,1,ML,3.42,2.394,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.01,416.02,other,SI=N Exclusions ,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70069-0801-25,NDC,outpatient,1,ML,6.49,4.543,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.01,416.02,other,SI=N Exclusions ,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1577-05,NDC,outpatient,1,ML,9.89,6.923,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.01,416.02,other,SI=N Exclusions ,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1578-01,NDC,outpatient,5,ML,19.7,13.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.01,416.02,other,SI=N Exclusions ,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1578-07,NDC,outpatient,5,ML,19.7,13.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.01,416.02,other,SI=N Exclusions ,,
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,63323-0477-01,NDC,outpatient,20,ML,78.86,55.202,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.03,,,0.03,0.03,416.02,fee schedule,,,
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,00143-9209-01,NDC,outpatient,20,ML,51.18,35.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.03,,,0.03,0.03,416.02,fee schedule,,,
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,00143-9209-10,NDC,outpatient,20,ML,51.18,35.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.03,,,0.03,0.03,416.02,fee schedule,,,
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,63323-0477-27,NDC,outpatient,20,ML,78.86,55.202,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.03,,,0.03,0.03,416.02,fee schedule,,,
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,63323-0478-01,NDC,outpatient,20,ML,82.77,57.939,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.03,,,0.03,0.03,416.02,fee schedule,,,
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,00143-9210-01,NDC,outpatient,20,ML,54.03,37.821,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.03,,,0.03,0.03,416.02,fee schedule,,,
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,63323-0478-27,NDC,outpatient,20,ML,82.77,57.939,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.03,,,0.03,0.03,416.02,fee schedule,,,
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,00143-9210-10,NDC,outpatient,20,ML,54.03,37.821,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.03,,,0.03,0.03,416.02,fee schedule,,,
NICARDIPINE HCL 2.5 MG/ML IV SOLN,RX-12370,CDM,J2404,HCPCS,636,RC,00143-9689-01,NDC,outpatient,10,ML,41.12,28.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.54,416.02,other,SI=N Exclusions ,,
NICARDIPINE HCL 2.5 MG/ML IV SOLN,RX-12370,CDM,J2404,HCPCS,636,RC,00143-9689-10,NDC,outpatient,10,ML,41.12,28.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.54,416.02,other,SI=N Exclusions ,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00641-6078-01,NDC,outpatient,2,ML,3.61,2.527,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,60505-6130-00,NDC,outpatient,2,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00409-4755-18,NDC,outpatient,2,ML,6.09,4.263,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,23155-0547-31,NDC,outpatient,2,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,23155-0547-42,NDC,outpatient,2,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,60505-6130-05,NDC,outpatient,2,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00409-4755-03,NDC,outpatient,2,ML,6.09,4.263,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00641-6078-25,NDC,outpatient,2,ML,3.61,2.527,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,23155-0549-31,NDC,outpatient,20,ML,18.1,12.67,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,36000-0012-25,NDC,outpatient,2,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
PAMIDRONATE DISODIUM 30 MG/10ML IV SOLN,RX-32589,CDM,J2430,HCPCS,636,RC,67457-0430-10,NDC,outpatient,10,ML,36.81,25.767,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.263845,416.02,other,SI=N Exclusions ,,
PAMIDRONATE DISODIUM 30 MG/10ML IV SOLN,RX-32589,CDM,J2430,HCPCS,636,RC,61703-0324-18,NDC,outpatient,10,ML,46.42,32.494,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,8.263845,416.02,other,SI=N Exclusions ,,
PALONOSETRON HCL 0.25 MG/5ML IV SOLN,RX-36591,CDM,J2469,HCPCS,636,RC,55111-0694-07,NDC,outpatient,5,ML,25.1,17.57,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.62,416.02,other,SI=N Exclusions ,,
PALONOSETRON HCL 0.25 MG/5ML IV SOLN,RX-36591,CDM,J2469,HCPCS,636,RC,60505-6193-01,NDC,outpatient,5,ML,13.32,9.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.62,416.02,other,SI=N Exclusions ,,
PARICALCITOL 5 MCG/ML IV SOLN,RX-22960,CDM,J2501,HCPCS,636,RC,00074-1658-01,NDC,outpatient,1,ML,40.71,28.497,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.5,416.02,other,SI=N Exclusions ,,
PEGLOTICASE 8 MG/ML IV SOLN,RX-107664,CDM,J2507,HCPCS,636,RC,75987-0080-10,NDC,outpatient,1,ML,59467.57,41627.299,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3482.15,,,3482.15,399.86,45671.09376,fee schedule,,,
PENICILLIN G POT IN DEXTROSE 60000 UNIT/ML IV WRAPPER,RX-4080111,CDM,J2540,HCPCS,636,RC,00338-1025-41,NDC,outpatient,50,ML,55.67,38.969,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.01,416.02,other,SI=N Exclusions ,,
PENICILLIN G POTASSIUM 5000000 UNITS IJ SOLR,RX-6086,CDM,J2540,HCPCS,636,RC,44567-0311-10,NDC,outpatient,1,UN,17.93,12.551,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.01,416.02,other,SI=N Exclusions ,,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,55150-0121-50,NDC,outpatient,1,UN,18.43,12.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.1,416.02,other,SI=N Exclusions ,,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,72485-0404-01,NDC,outpatient,1,UN,18.51,12.957,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.1,416.02,other,SI=N Exclusions ,,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,72485-0404-10,NDC,outpatient,1,UN,18.51,12.957,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.1,416.02,other,SI=N Exclusions ,,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,00781-3114-95,NDC,outpatient,1,UN,30.55,21.385,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.1,416.02,other,SI=N Exclusions ,,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,00781-3114-91,NDC,outpatient,1,UN,30.55,21.385,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.1,416.02,other,SI=N Exclusions ,,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,44567-0803-10,NDC,outpatient,1,UN,27.96,19.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.1,416.02,other,SI=N Exclusions ,,
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,55150-0120-30,NDC,outpatient,1,UN,12.91,9.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.1,416.02,other,SI=N Exclusions ,,
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,64679-0056-01,NDC,outpatient,1,UN,13.78,9.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.1,416.02,other,SI=N Exclusions ,,
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,60505-6157-04,NDC,outpatient,1,UN,9.79,6.853,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.1,416.02,other,SI=N Exclusions ,,
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,60505-6157-00,NDC,outpatient,1,UN,9.79,6.853,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.1,416.02,other,SI=N Exclusions ,,
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,64679-0056-02,NDC,outpatient,1,UN,13.78,9.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.1,416.02,other,SI=N Exclusions ,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00409-3383-02,NDC,outpatient,1,UN,25.13,17.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.1,416.02,other,SI=N Exclusions ,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00409-3383-11,NDC,outpatient,1,UN,25.13,17.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.1,416.02,other,SI=N Exclusions ,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,44567-0801-10,NDC,outpatient,1,UN,14.21,9.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.1,416.02,other,SI=N Exclusions ,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,55150-0119-30,NDC,outpatient,1,UN,8.76,6.132,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.1,416.02,other,SI=N Exclusions ,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,60505-6156-00,NDC,outpatient,1,UN,7.94,5.558,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.1,416.02,other,SI=N Exclusions ,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00781-3110-90,NDC,outpatient,1,UN,17.66,12.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.1,416.02,other,SI=N Exclusions ,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,60505-6156-04,NDC,outpatient,1,UN,7.94,5.558,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.1,416.02,other,SI=N Exclusions ,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00781-3110-95,NDC,outpatient,1,UN,17.66,12.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.1,416.02,other,SI=N Exclusions ,,
PROMETHAZINE HCL 25 MG/ML IJ SOLN,RX-6618,CDM,J2550,HCPCS,636,RC,00641-1495-31,NDC,outpatient,1,ML,7.75,5.425,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.739875,416.02,other,SI=N Exclusions ,,
PROMETHAZINE HCL 25 MG/ML IJ SOLN,RX-6618,CDM,J2550,HCPCS,636,RC,00641-1495-35,NDC,outpatient,1,ML,7.75,5.425,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.739875,416.02,other,SI=N Exclusions ,,
PHENOBARBITAL SODIUM 130 MG/ML IJ SOLN,RX-6221,CDM,J2560,HCPCS,636,RC,00641-0477-21,NDC,outpatient,1,ML,155.87,109.109,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,13.89655,416.02,other,SI=N Exclusions ,,
PHENOBARBITAL SODIUM 130 MG/ML IJ SOLN,RX-6221,CDM,J2560,HCPCS,636,RC,00641-0477-25,NDC,outpatient,1,ML,155.87,109.109,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,13.89655,416.02,other,SI=N Exclusions ,,
PHENOBARBITAL SODIUM 65 MG/ML IJ SOLN,RX-6224,CDM,J2560,HCPCS,636,RC,00641-0476-25,NDC,outpatient,1,ML,61.9,43.33,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,13.89655,416.02,other,SI=N Exclusions ,,
PHENOBARBITAL SODIUM 65 MG/ML IJ SOLN,RX-6224,CDM,J2560,HCPCS,636,RC,00641-0476-21,NDC,outpatient,1,ML,61.9,43.33,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,13.89655,416.02,other,SI=N Exclusions ,,
OXYTOCIN 10 UNIT/ML IJ SOLN,RX-5944,CDM,J2590,HCPCS,636,RC,63323-0012-10,NDC,outpatient,0.3,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
OXYTOCIN 10 UNIT/ML IJ SOLN,RX-5944,CDM,J2590,HCPCS,636,RC,42023-0116-25,NDC,outpatient,1,ML,7.42,5.194,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
OXYTOCIN 10 UNIT/ML IJ SOLN,RX-5944,CDM,J2590,HCPCS,636,RC,63323-0012-06,NDC,outpatient,0.3,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
DESMOPRESSIN ACETATE 4 MCG/ML IJ SOLN WRAPPER,RX-4081353,CDM,J2597,HCPCS,636,RC,69918-0899-01,NDC,outpatient,1,ML,91.9,64.33,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5.42,,,5.42,5.42,416.02,fee schedule,,,
DESMOPRESSIN ACETATE 4 MCG/ML IJ SOLN WRAPPER,RX-4081353,CDM,J2597,HCPCS,636,RC,69918-0899-10,NDC,outpatient,1,ML,91.9,64.33,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5.42,,,5.42,5.42,416.02,fee schedule,,,
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-01,NDC,outpatient,100,ML,534.45,374.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,1.62,,,1.62,1.62,422.7456,fee schedule,,,
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-01,NDC,outpatient,100,ML,550.45,385.315,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.62,,,1.62,1.62,422.7456,fee schedule,,,
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-10,NDC,outpatient,100,ML,534.45,374.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,1.62,,,1.62,1.62,422.7456,fee schedule,,,
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-10,NDC,outpatient,100,ML,550.45,385.315,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.62,,,1.62,1.62,422.7456,fee schedule,,,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42023-0164-25,NDC,outpatient,1,ML,50.82,35.574,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.62,,,1.62,1.62,422.7456,fee schedule,,,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42367-0570-87,NDC,outpatient,0.25,ML,175.83,123.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.62,,,1.62,1.62,422.7456,fee schedule,,,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42367-0570-22,NDC,outpatient,0.25,ML,175.83,123.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.62,,,1.62,1.62,422.7456,fee schedule,,,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,55150-0370-25,NDC,outpatient,0.25,ML,21.94,15.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.62,,,1.62,1.62,422.7456,fee schedule,,,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42023-0164-01,NDC,outpatient,1,ML,50.82,35.574,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.62,,,1.62,1.62,422.7456,fee schedule,,,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,55150-0370-01,NDC,outpatient,0.25,ML,21.94,15.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.62,,,1.62,1.62,422.7456,fee schedule,,,
FLUPHENAZINE HCL 2.5 MG/ML IJ SOLN,RX-3216,CDM,J2679,HCPCS,636,RC,63323-0281-10,NDC,outpatient,0.5,ML,19.62,13.734,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.40469,416.02,other,SI=N Exclusions ,,
FLUPHENAZINE DECANOATE 25 MG/ML IJ SOLN,RX-3215,CDM,J2680,HCPCS,636,RC,42023-0129-01,NDC,outpatient,0.5,ML,20.43,14.301,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.586535,416.02,other,SI=N Exclusions ,,
FLUPHENAZINE DECANOATE 25 MG/ML IJ SOLN,RX-3215,CDM,J2680,HCPCS,636,RC,63323-0272-05,NDC,outpatient,0.5,ML,32.89,23.023,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.586535,416.02,other,SI=N Exclusions ,,
PROCAINAMIDE HCL 100 MG/ML IJ SOLN,RX-6562,CDM,J2690,HCPCS,636,RC,00409-1902-11,NDC,outpatient,1,ML,24.43,17.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,546.07,,,546.07,5.484535,1082.90304,fee schedule,,,
PROCAINAMIDE HCL 100 MG/ML IJ SOLN,RX-6562,CDM,J2690,HCPCS,636,RC,00409-1902-01,NDC,outpatient,1,ML,24.43,17.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,546.07,,,546.07,5.484535,1082.90304,fee schedule,,,
PROCAINAMIDE HCL 500 MG/ML IJ SOLN,RX-6563,CDM,J2690,HCPCS,636,RC,14789-0900-07,NDC,outpatient,2,ML,1410.03,987.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,546.07,,,546.07,5.484535,1082.90304,fee schedule,,,
PROCAINAMIDE HCL 500 MG/ML IJ SOLN,RX-6563,CDM,J2690,HCPCS,636,RC,14789-0900-02,NDC,outpatient,2,ML,1410.03,987.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,546.07,,,546.07,5.484535,1082.90304,fee schedule,,,
OXACILLIN SODIUM 10 G IV SOLR,RX-150085,CDM,J2700,HCPCS,636,RC,25021-0163-99,NDC,outpatient,1,UN,489.5,342.65,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.87,416.02,other,SI=N Exclusions ,,
OXACILLIN SODIUM 10 G IV SOLR,RX-150085,CDM,J2700,HCPCS,636,RC,63323-0811-00,NDC,outpatient,1,UN,137.38,96.166,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.87,416.02,other,SI=N Exclusions ,,
OXACILLIN SODIUM 10 G IV SOLR,RX-150085,CDM,J2700,HCPCS,636,RC,55150-0129-99,NDC,outpatient,1,UN,150.46,105.322,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.87,416.02,other,SI=N Exclusions ,,
OXACILLIN SODIUM 1 G IJ SOLR,RX-5924,CDM,J2700,HCPCS,636,RC,64679-0698-02,NDC,outpatient,1,UN,20.97,14.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.87,416.02,other,SI=N Exclusions ,,
OXACILLIN SODIUM 1 G IJ SOLR,RX-5924,CDM,J2700,HCPCS,636,RC,64679-0698-01,NDC,outpatient,1,UN,20.97,14.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.87,416.02,other,SI=N Exclusions ,,
OXACILLIN SODIUM 1 G IJ SOLR,RX-5924,CDM,J2700,HCPCS,636,RC,55150-0127-15,NDC,outpatient,1,UN,19.11,13.377,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.87,416.02,other,SI=N Exclusions ,,
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,64679-0699-01,NDC,outpatient,1,UN,38.24,26.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.87,416.02,other,SI=N Exclusions ,,
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,63323-0812-01,NDC,outpatient,1,UN,25.17,17.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.87,416.02,other,SI=N Exclusions ,,
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,63323-0812-20,NDC,outpatient,1,UN,25.17,17.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.87,416.02,other,SI=N Exclusions ,,
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,64679-0699-02,NDC,outpatient,1,UN,38.24,26.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.87,416.02,other,SI=N Exclusions ,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0248-01,NDC,outpatient,100,ML,43.17,30.219,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0248-10,NDC,outpatient,100,ML,43.17,30.219,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0528-01,NDC,outpatient,20,ML,8.95,6.265,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0528-10,NDC,outpatient,20,ML,9.98,6.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0977-20,NDC,outpatient,50,ML,18.69,13.083,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,43598-0548-50,NDC,outpatient,50,ML,20.47,14.329,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-54,NDC,outpatient,100,ML,36.94,25.858,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,25021-0608-20,NDC,outpatient,20,ML,10.49,7.343,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,43598-0548-21,NDC,outpatient,50,ML,20.47,14.329,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,63323-0269-29,NDC,outpatient,20,ML,9.57,6.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0209-10,NDC,outpatient,20,ML,9.98,6.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-24,NDC,outpatient,100,ML,36.94,25.858,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-33,NDC,outpatient,50,ML,18.47,12.929,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0690-01,NDC,outpatient,100,ML,32.93,23.051,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,25021-0608-51,NDC,outpatient,100,ML,57.41,40.187,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0209-01,NDC,outpatient,20,ML,9.98,6.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0234-01,NDC,outpatient,50,ML,21.59,15.113,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0234-20,NDC,outpatient,50,ML,21.59,15.113,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-53,NDC,outpatient,50,ML,18.47,12.929,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0690-10,NDC,outpatient,100,ML,32.93,23.051,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0977-01,NDC,outpatient,50,ML,18.69,13.083,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,25021-0608-50,NDC,outpatient,50,ML,28.71,20.097,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,63323-0269-22,NDC,outpatient,20,ML,9.57,6.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0234-01,NDC,outpatient,50,ML,37.59,26.313,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0234-20,NDC,outpatient,50,ML,37.59,26.313,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-54,NDC,outpatient,100,ML,52.94,37.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0690-10,NDC,outpatient,100,ML,48.93,34.251,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-33,NDC,outpatient,50,ML,34.47,24.129,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,25021-0608-50,NDC,outpatient,50,ML,44.71,31.297,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,43598-0548-21,NDC,outpatient,50,ML,36.47,25.529,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,43598-0548-50,NDC,outpatient,50,ML,36.47,25.529,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0690-01,NDC,outpatient,100,ML,48.93,34.251,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,25021-0608-51,NDC,outpatient,100,ML,73.41,51.387,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0248-01,NDC,outpatient,100,ML,59.17,41.419,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0248-10,NDC,outpatient,100,ML,59.17,41.419,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-24,NDC,outpatient,100,ML,52.94,37.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-53,NDC,outpatient,50,ML,34.47,24.129,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0977-01,NDC,outpatient,50,ML,34.69,24.283,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0977-20,NDC,outpatient,50,ML,34.69,24.283,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
NEOSTIGMINE METHYLSULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4080613,CDM,J2710,HCPCS,636,RC,70121-1479-01,NDC,outpatient,10,ML,34.98,24.486,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.43,416.02,other,SI=N Exclusions ,,
NEOSTIGMINE METHYLSULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4080613,CDM,J2710,HCPCS,636,RC,70121-1479-07,NDC,outpatient,10,ML,34.98,24.486,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.43,416.02,other,SI=N Exclusions ,,
PROTAMINE SULFATE 10 MG/ML IV SOLN,RX-6677,CDM,J2720,HCPCS,636,RC,63323-0229-05,NDC,outpatient,5,ML,44.82,31.374,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.95,416.02,other,SI=N Exclusions ,,
PROTAMINE SULFATE 10 MG/ML IV SOLN,RX-6677,CDM,J2720,HCPCS,636,RC,63323-0229-30,NDC,outpatient,25,ML,134.62,94.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.95,416.02,other,SI=N Exclusions ,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-3414-18,NDC,outpatient,2,ML,4.14,2.898,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92943,416.02,other,SI=N Exclusions ,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00703-4502-01,NDC,outpatient,2,ML,17.23,12.061,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92943,416.02,other,SI=N Exclusions ,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,76045-0101-20,NDC,outpatient,2,ML,9.08,6.356,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92943,416.02,other,SI=N Exclusions ,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-3414-01,NDC,outpatient,2,ML,4.14,2.898,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92943,416.02,other,SI=N Exclusions ,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00703-4502-04,NDC,outpatient,2,ML,17.23,12.061,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92943,416.02,other,SI=N Exclusions ,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-5255-25,NDC,outpatient,2,ML,4.14,2.898,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92943,416.02,other,SI=N Exclusions ,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-5255-02,NDC,outpatient,2,ML,4.14,2.898,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.92943,416.02,other,SI=N Exclusions ,,
QUINUPRISTIN-DALFOPRISTIN 500 MG IV SOLR,RX-26335,CDM,J2770,HCPCS,636,RC,61570-0260-01,NDC,outpatient,1,UN,1916.14,1341.298,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,531.25,,,531.25,7.136465,1471.59552,fee schedule,,,
QUINUPRISTIN-DALFOPRISTIN 500 MG IV SOLR,RX-26335,CDM,J2770,HCPCS,636,RC,61570-0260-10,NDC,outpatient,1,UN,1916.14,1341.298,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,531.25,,,531.25,7.136465,1471.59552,fee schedule,,,
RASBURICASE 1.5 MG IV SOLR,RX-33591,CDM,J2783,HCPCS,636,RC,00024-5150-10,NDC,outpatient,1,UN,3073.12,2151.184,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,371.29,,,371.29,357.36,11800.75008,fee schedule,,,
RASBURICASE 7.5 MG IV SOLR,RX-76868,CDM,J2783,HCPCS,636,RC,00024-5151-75,NDC,outpatient,1,UN,15365.56,10755.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,371.29,,,371.29,357.36,11800.75008,fee schedule,,,
REGADENOSON 0.4 MG/5ML IV SOLN,RX-91408,CDM,J2785,HCPCS,636,RC,00469-6501-89,NDC,outpatient,5,ML,593.55,415.485,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.88,455.8464,other,SI=N Exclusions ,,
REGADENOSON 0.4 MG/5ML IV SOLN,RX-91408,CDM,J2785,HCPCS,636,RC,67457-0994-05,NDC,outpatient,5,ML,26.97,18.879,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.88,455.8464,other,SI=N Exclusions ,,
REGADENOSON 0.4 MG/5ML IV SOLN,RX-91408,CDM,J2785,HCPCS,636,RC,71288-0201-85,NDC,outpatient,5,ML,30.71,21.497,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.88,455.8464,other,SI=N Exclusions ,,
RHO D IMMUNE GLOBULIN 5000 UNIT/4.4ML IJ SOLN,RX-70574,CDM,J2792,HCPCS,636,RC,70257-0310-04,NDC,outpatient,4.4,ML,3912.94,2739.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,34.34,,,34.34,33.71,3005.13792,fee schedule,,,
RHO D IMMUNE GLOBULIN 5000 UNIT/4.4ML IJ SOLN,RX-70574,CDM,J2792,HCPCS,636,RC,70257-0310-51,NDC,outpatient,4.4,ML,3912.94,2739.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,34.34,,,34.34,33.71,3005.13792,fee schedule,,,
RISPERIDONE MICROSPHERES ER 37.5 MG IM SRER,RX-148032,CDM,J2794,HCPCS,636,RC,50458-0307-11,NDC,outpatient,1,UN,2304,1612.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11.3,,,11.3,10.7,2359.38048,fee schedule,,,
RISPERIDONE MICROSPHERES ER 50 MG IM SRER,RX-148033,CDM,J2794,HCPCS,636,RC,50458-0308-11,NDC,outpatient,1,UN,3072.11,2150.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,11.3,,,11.3,10.7,2359.38048,fee schedule,,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,43066-0023-10,NDC,outpatient,30,ML,15.73,11.011,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions ,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,70069-0064-01,NDC,outpatient,30,ML,20.21,14.147,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions ,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-11,NDC,outpatient,30,ML,20.56,14.392,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions ,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,43066-0023-01,NDC,outpatient,30,ML,15.73,11.011,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions ,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-20,NDC,outpatient,20,ML,59.55,41.685,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions ,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-35,NDC,outpatient,30,ML,20.56,14.392,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions ,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,55150-0198-30,NDC,outpatient,30,ML,20.21,14.147,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions ,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-01,NDC,outpatient,20,ML,59.55,41.685,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions ,,
ROMIPLOSTIM 125 MCG SC SOLR,RX-148858,CDM,J2796,HCPCS,636,RC,55513-0223-01,NDC,outpatient,1,UN,3455.52,2418.864,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,101.05,,,101.05,95.47,5307.61728,fee schedule,,,
ROMIPLOSTIM 125 MCG SC SOLR|DISCARDED DRUG NOT ADMINISTERED,RX-148858,CDM,J2796,HCPCS,636,RC,55513-0223-01,NDC,outpatient,1,UN,3455.52,2418.864,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,101.05,,,101.05,95.47,5307.61728,fee schedule,,,
ROMIPLOSTIM 250 MCG SC SOLR,RX-93566,CDM,J2796,HCPCS,636,RC,55513-0221-01,NDC,outpatient,1,UN,6910.96,4837.672,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,101.05,,,101.05,95.47,5307.61728,fee schedule,,,
SILTUXIMAB 100 MG IV SOLR,RX-125552,CDM,J2860,HCPCS,636,RC,73090-0420-01,NDC,outpatient,1,UN,4143.92,2900.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,157.07,,,157.07,139.22,12730.14528,fee schedule,,,
SILTUXIMAB 400 MG IV SOLR,RX-125553,CDM,J2860,HCPCS,636,RC,73090-0421-01,NDC,outpatient,1,UN,16575.71,11602.997,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,157.07,,,157.07,139.22,12730.14528,fee schedule,,,
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00024-2792-10,NDC,outpatient,5,ML,35.83,25.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.12,416.02,other,SI=N Exclusions ,,
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00024-2792-01,NDC,outpatient,5,ML,35.83,25.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.12,416.02,other,SI=N Exclusions ,,
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00143-9570-01,NDC,outpatient,5,ML,61.68,43.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.12,416.02,other,SI=N Exclusions ,,
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00143-9570-10,NDC,outpatient,5,ML,61.68,43.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.12,416.02,other,SI=N Exclusions ,,
METHYLPREDNISOLONE SODIUM SUCC 40 MG IJ SOLR,RX-10580,CDM,J2920,HCPCS,636,RC,00009-0039-28,NDC,outpatient,1,UN,20.03,14.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.24,416.02,other,SI=N Exclusions ,,
METHYLPREDNISOLONE SODIUM SUCC 40 MG IJ SOLR,RX-10580,CDM,J2920,HCPCS,636,RC,00009-0039-30,NDC,outpatient,1,UN,20.03,14.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.24,416.02,other,SI=N Exclusions ,,
METHYLPREDNISOLONE SODIUM SUCC 1000 MG IJ SOLR,RX-10577,CDM,J2930,HCPCS,636,RC,00009-0698-01,NDC,outpatient,1,UN,79.04,55.328,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.73,565.07136,other,SI=N Exclusions ,,
METHYLPREDNISOLONE SODIUM SUCC 125 MG IJ SOLR,RX-10578,CDM,J2930,HCPCS,636,RC,00009-0047-22,NDC,outpatient,1,UN,31.87,22.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.73,565.07136,other,SI=N Exclusions ,,
METHYLPREDNISOLONE SODIUM SUCC 125 MG IJ SOLR,RX-10578,CDM,J2930,HCPCS,636,RC,00009-0047-25,NDC,outpatient,1,UN,31.87,22.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.73,565.07136,other,SI=N Exclusions ,,
METHYLPREDNISOLONE SODIUM SUCC 2000 MG IJ SOLR,RX-10579,CDM,J2930,HCPCS,636,RC,00009-0850-01,NDC,outpatient,1,UN,735.77,515.039,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.73,565.07136,other,SI=N Exclusions ,,
METHYLPREDNISOLONE SODIUM SUCC 500 MG IJ SOLR,RX-10581,CDM,J2930,HCPCS,636,RC,00009-0758-01,NDC,outpatient,1,UN,87,60.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.73,565.07136,other,SI=N Exclusions ,,
METHYLPREDNISOLONE SODIUM SUCC 1000 MG IJ ACT-O-VIAL,RX-4081056,CDM,J2930,HCPCS,636,RC,00009-0018-20,NDC,outpatient,1,UN,235.14,164.598,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.73,565.07136,other,SI=N Exclusions ,,
METHYLPREDNISOLONE SODIUM SUCC 500 MG IJ ACT-O-VIAL,RX-4081057,CDM,J2930,HCPCS,636,RC,00009-0003-02,NDC,outpatient,1,UN,180.85,126.595,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.73,565.07136,other,SI=N Exclusions ,,
ALTEPLASE 2 MG IJ SOLR,RX-31310,CDM,J2997,HCPCS,636,RC,50242-0041-64,NDC,outpatient,1,UN,725.13,507.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,91.47,,,91.47,89.15,17236.24704,fee schedule,,,
ALTEPLASE 2 MG IJ SOLR,RX-31310,CDM,J2997,HCPCS,636,RC,99999-0000-50,NDC,outpatient,2,ML,723.71,506.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,91.47,,,91.47,89.15,17236.24704,fee schedule,,,
ALTEPLASE 100 MG IV SOLR,RX-9002,CDM,J2997,HCPCS,636,RC,50242-0085-27,NDC,outpatient,1,UN,22443.03,15710.121,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,91.47,,,91.47,89.15,17236.24704,fee schedule,,,
ALTEPLASE 50 MG IV SOLR,RX-9003,CDM,J2997,HCPCS,636,RC,50242-0044-13,NDC,outpatient,1,UN,11221.53,7855.071,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,91.47,,,91.47,89.15,17236.24704,fee schedule,,,
STREPTOMYCIN SULFATE 1 G IM SOLR,RX-7508,CDM,J3000,HCPCS,636,RC,39822-0706-02,NDC,outpatient,1,UN,186.61,130.627,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,31.57,416.02,other,SI=N Exclusions ,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-12,NDC,outpatient,2,ML,7.31,5.117,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.84,416.02,other,SI=N Exclusions ,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-02,NDC,outpatient,2,ML,7.42,5.194,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.84,416.02,other,SI=N Exclusions ,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-05,NDC,outpatient,5,ML,9.41,6.587,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.84,416.02,other,SI=N Exclusions ,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-41,NDC,outpatient,50,ML,40.05,28.035,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.84,416.02,other,SI=N Exclusions ,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-12,NDC,outpatient,2,ML,7.42,5.194,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.84,416.02,other,SI=N Exclusions ,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-22,NDC,outpatient,2,ML,7.31,5.117,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.84,416.02,other,SI=N Exclusions ,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-61,NDC,outpatient,50,ML,40.05,28.035,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.84,416.02,other,SI=N Exclusions ,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00641-6027-01,NDC,outpatient,2,ML,6.08,4.256,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.84,416.02,other,SI=N Exclusions ,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00641-6027-25,NDC,outpatient,2,ML,6.08,4.256,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.84,416.02,other,SI=N Exclusions ,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-13,NDC,outpatient,5,ML,9.41,6.587,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.84,416.02,other,SI=N Exclusions ,,
TENECTEPLASE 50 MG IV KIT,RX-28530,CDM,J3101,HCPCS,636,RC,50242-0120-47,NDC,outpatient,1,UN,19380.84,13566.588,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,157.72,,,157.72,152.7,14884.48512,fee schedule,,,
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,00143-9746-10,NDC,outpatient,1,ML,6.05,4.235,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.358225,416.02,other,SI=N Exclusions ,,
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,63323-0665-00,NDC,outpatient,1,ML,6.42,4.494,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.358225,416.02,other,SI=N Exclusions ,,
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,00143-9746-01,NDC,outpatient,1,ML,6.05,4.235,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.358225,416.02,other,SI=N Exclusions ,,
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,63323-0665-01,NDC,outpatient,1,ML,6.42,4.494,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.358225,416.02,other,SI=N Exclusions ,,
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,00641-1398-35,NDC,outpatient,2,ML,108.05,75.635,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.63291,416.02,other,SI=N Exclusions ,,
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,55150-0318-01,NDC,outpatient,1,ML,65.18,45.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.63291,416.02,other,SI=N Exclusions ,,
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,00641-1398-31,NDC,outpatient,2,ML,108.05,75.635,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.63291,416.02,other,SI=N Exclusions ,,
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,55150-0318-25,NDC,outpatient,1,ML,65.18,45.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.63291,416.02,other,SI=N Exclusions ,,
THYROTROPIN ALFA 0.9 MG IM SOLR,RX-156409,CDM,J3240,HCPCS,636,RC,58468-0030-02,NDC,outpatient,1,UN,5457.19,3820.033,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2073.34,,,2073.34,399.86,4191.12192,fee schedule,,,
TIGECYCLINE 50 MG IV SOLR,RX-41652,CDM,J3243,HCPCS,636,RC,55150-0228-10,NDC,outpatient,1,UN,119.66,83.762,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.52,416.02,other,SI=N Exclusions ,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-01,NDC,outpatient,100,ML,301.69,211.183,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3.83,,,3.83,3.83,567.65184,fee schedule,,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-03,NDC,outpatient,100,ML,198.47,138.929,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,3.83,,,3.83,3.83,567.65184,fee schedule,,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-01,NDC,outpatient,100,ML,285.69,199.983,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,3.83,,,3.83,3.83,567.65184,fee schedule,,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0429-01,NDC,outpatient,100,ML,219.39,153.573,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,3.83,,,3.83,3.83,567.65184,fee schedule,,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-02,NDC,outpatient,250,ML,739.13,517.391,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3.83,,,3.83,3.83,567.65184,fee schedule,,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0429-01,NDC,outpatient,100,ML,235.39,164.773,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3.83,,,3.83,3.83,567.65184,fee schedule,,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0430-01,NDC,outpatient,250,ML,513.98,359.786,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,3.83,,,3.83,3.83,567.65184,fee schedule,,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-03,NDC,outpatient,100,ML,214.47,150.129,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3.83,,,3.83,3.83,567.65184,fee schedule,,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0430-01,NDC,outpatient,250,ML,529.98,370.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3.83,,,3.83,3.83,567.65184,fee schedule,,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-02,NDC,outpatient,250,ML,723.13,506.191,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,3.83,,,3.83,3.83,567.65184,fee schedule,,,
TRIMETHOBENZAMIDE HCL 100 MG/ML IM SOLN,RX-8178,CDM,J3250,HCPCS,636,RC,42023-0119-25,NDC,outpatient,2,ML,199.22,139.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,44.72489,416.02,other,SI=N Exclusions ,,
TOBRAMYCIN SULFATE 1.2 G IJ SOLR,RX-11565,CDM,J3260,HCPCS,636,RC,39822-0412-01,NDC,outpatient,1,UN,217.92,152.544,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.882285,416.02,other,SI=N Exclusions ,,
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,00409-3578-11,NDC,outpatient,2,ML,13.74,9.618,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.882285,416.02,other,SI=N Exclusions ,,
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,63323-0306-02,NDC,outpatient,2,ML,16.01,11.207,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.882285,416.02,other,SI=N Exclusions ,,
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,67457-0473-00,NDC,outpatient,2,ML,3.93,2.751,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.882285,416.02,other,SI=N Exclusions ,,
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,00409-3578-01,NDC,outpatient,2,ML,13.74,9.618,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.882285,416.02,other,SI=N Exclusions ,,
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,67457-0473-22,NDC,outpatient,2,ML,3.93,2.751,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.882285,416.02,other,SI=N Exclusions ,,
TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN,RX-97790,CDM,J3260,HCPCS,636,RC,67457-0428-30,NDC,outpatient,30,ML,45.26,31.682,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.882285,416.02,other,SI=N Exclusions ,,
TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN,RX-97790,CDM,J3260,HCPCS,636,RC,67457-0428-00,NDC,outpatient,30,ML,45.26,31.682,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.882285,416.02,other,SI=N Exclusions ,,
TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN,RX-97790,CDM,J3260,HCPCS,636,RC,63323-0306-30,NDC,outpatient,30,ML,60.48,42.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.882285,416.02,other,SI=N Exclusions ,,
TOCILIZUMAB 20 MG/ML IV WRAPPER,RX-4080174,CDM,J3262,HCPCS,636,RC,50242-0137-01,NDC,outpatient,20,ML,7110.21,4977.147,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5.96,,,5.96,5.91,5460.64128,fee schedule,,,
TOCILIZUMAB 20 MG/ML IV WRAPPER,RX-4080174,CDM,J3262,HCPCS,636,RC,50242-0135-01,NDC,outpatient,4,ML,1422.05,995.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5.96,,,5.96,5.91,5460.64128,fee schedule,,,
TOCILIZUMAB 20 MG/ML IV WRAPPER,RX-4080174,CDM,J3262,HCPCS,636,RC,50242-0136-01,NDC,outpatient,10,ML,3555.08,2488.556,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5.96,,,5.96,5.91,5460.64128,fee schedule,,,
TRIAMCINOLONE ACETONIDE 10 MG/ML IJ SUSP,RX-11584,CDM,J3301,HCPCS,636,RC,00003-0494-20,NDC,outpatient,5,ML,49.71,34.797,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.9,416.02,other,SI=N Exclusions ,,
TRIAMCINOLONE ACETONIDE 40 MG/ML IJ SUSP,RX-8120,CDM,J3301,HCPCS,636,RC,00003-0293-05,NDC,outpatient,1,ML,38.5,26.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.9,416.02,other,SI=N Exclusions ,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00409-1273-03,NDC,outpatient,2,ML,106.04,74.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.25,416.02,other,SI=N Exclusions ,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,69339-0136-34,NDC,outpatient,2,ML,63.74,44.618,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.25,416.02,other,SI=N Exclusions ,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,76045-0204-20,NDC,outpatient,2,ML,59.63,41.741,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.25,416.02,other,SI=N Exclusions ,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00409-1273-32,NDC,outpatient,2,ML,106.04,74.228,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.25,416.02,other,SI=N Exclusions ,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,69339-0136-03,NDC,outpatient,2,ML,63.74,44.618,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.25,416.02,other,SI=N Exclusions ,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,76045-0204-00,NDC,outpatient,2,ML,59.63,41.741,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.25,416.02,other,SI=N Exclusions ,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00641-6244-01,NDC,outpatient,2,ML,60.45,42.315,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.25,416.02,other,SI=N Exclusions ,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00641-6244-10,NDC,outpatient,2,ML,60.45,42.315,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.25,416.02,other,SI=N Exclusions ,,
VANCOMYCIN HCL IN DEXTROSE 750 MG/150ML IV SOLN,RX-108740,CDM,J3370,HCPCS,636,RC,00338-3580-48,NDC,outpatient,150,ML,49.93,34.951,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VANCOMYCIN HCL IN DEXTROSE 750 MG/150ML IV SOLN,RX-108740,CDM,J3370,HCPCS,636,RC,99999-0000-88,NDC,outpatient,150,ML,35.17,24.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,63323-0314-61,NDC,outpatient,10,GR,107.34,75.138,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,25021-0158-99,NDC,outpatient,10,GR,205.59,143.913,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,67457-0342-10,NDC,outpatient,10,GR,875.85,613.095,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,70594-0048-01,NDC,outpatient,10,GR,267,186.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VANCOMYCIN HCL IN DEXTROSE 500 MG/100ML IV SOLN,RX-11632,CDM,J3370,HCPCS,636,RC,00338-3551-48,NDC,outpatient,100,ML,52.94,37.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VANCOMYCIN HCL IN NACL 750-0.9 MG/150ML-% IV SOLN,RX-134904,CDM,J3370,HCPCS,636,RC,00338-3582-01,NDC,outpatient,150,ML,73.41,51.387,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,67457-0340-01,NDC,outpatient,1,UN,16.63,11.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,00143-9357-10,NDC,outpatient,1,UN,12.35,8.645,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,16714-0309-01,NDC,outpatient,1,UN,11.19,7.833,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,16714-0309-10,NDC,outpatient,1,UN,11.19,7.833,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,00143-9357-01,NDC,outpatient,1,UN,12.35,8.645,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,67457-0340-00,NDC,outpatient,1,UN,16.63,11.641,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VANCOMYCIN HCL 5 G IV SOLR,RX-144290,CDM,J3370,HCPCS,636,RC,25021-0157-99,NDC,outpatient,5,GR,81.22,56.854,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VANCOMYCIN HCL 5 G IV SOLR,RX-144290,CDM,J3370,HCPCS,636,RC,00409-6509-01,NDC,outpatient,5,GR,364.64,255.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VANCOMYCIN HCL 5 G IV SOLR,RX-144290,CDM,J3370,HCPCS,636,RC,67457-0341-05,NDC,outpatient,5,GR,361.57,253.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VANCOMYCIN HCL 1.5 G IV SOLR,RX-145320,CDM,J3370,HCPCS,636,RC,00409-3515-11,NDC,outpatient,1,UN,51.81,36.267,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VANCOMYCIN HCL 1.5 G IV SOLR,RX-145320,CDM,J3370,HCPCS,636,RC,00409-3515-01,NDC,outpatient,1,UN,51.81,36.267,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VANCOMYCIN HCL 500 MG IV SOLR,RX-8443,CDM,J3370,HCPCS,636,RC,72611-0761-01,NDC,outpatient,1,UN,15.42,10.794,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VANCOMYCIN HCL 500 MG IV SOLR,RX-8443,CDM,J3370,HCPCS,636,RC,72611-0761-10,NDC,outpatient,1,UN,15.42,10.794,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VANCOMYCIN HCL IN DEXTROSE 1 GM/200ML IV SOLN,RX-92895,CDM,J3370,HCPCS,636,RC,00338-3552-48,NDC,outpatient,200,ML,52.27,36.589,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VEDOLIZUMAB 300 MG IV SOLR,RX-125757,CDM,J3380,HCPCS,636,RC,64764-0300-20,NDC,outpatient,1,UN,23919.77,16743.839,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,22.26,,,22.26,22.26,18370.38336,fee schedule,,,
HYDROXYZINE HCL 50 MG/ML IM SOLN,RX-3770,CDM,J3410,HCPCS,636,RC,00517-5601-25,NDC,outpatient,1,ML,82.29,57.603,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.41,416.02,other,SI=N Exclusions ,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,25021-0500-02,NDC,outpatient,0.5,ML,4.68,3.276,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.88453,416.02,other,SI=N Exclusions ,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,55150-0273-01,NDC,outpatient,0.5,ML,4.61,3.227,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.88453,416.02,other,SI=N Exclusions ,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,67457-0196-02,NDC,outpatient,0.5,ML,3.94,2.758,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.88453,416.02,other,SI=N Exclusions ,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,00641-6228-25,NDC,outpatient,0.5,ML,4.75,3.325,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.88453,416.02,other,SI=N Exclusions ,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,55150-0273-25,NDC,outpatient,0.5,ML,4.61,3.227,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.88453,416.02,other,SI=N Exclusions ,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,67457-0196-00,NDC,outpatient,0.5,ML,3.94,2.758,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.88453,416.02,other,SI=N Exclusions ,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,00641-6228-01,NDC,outpatient,0.5,ML,4.75,3.325,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.88453,416.02,other,SI=N Exclusions ,,
PYRIDOXINE HCL 100 MG/ML IJ SOLN,RX-6744,CDM,J3415,HCPCS,636,RC,63323-0180-00,NDC,outpatient,0.5,ML,20.17,14.119,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.528165,416.02,other,SI=N Exclusions ,,
PYRIDOXINE HCL 100 MG/ML IJ SOLN,RX-6744,CDM,J3415,HCPCS,636,RC,63323-0180-01,NDC,outpatient,0.5,ML,20.17,14.119,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,4.528165,416.02,other,SI=N Exclusions ,,
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,63323-0044-00,NDC,outpatient,1,ML,6.18,4.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.15,416.02,other,SI=N Exclusions ,,
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,00143-9621-25,NDC,outpatient,1,ML,10.83,7.581,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.15,416.02,other,SI=N Exclusions ,,
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,63323-0044-01,NDC,outpatient,1,ML,6.18,4.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.15,416.02,other,SI=N Exclusions ,,
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,00143-9621-01,NDC,outpatient,1,ML,10.83,7.581,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.15,416.02,other,SI=N Exclusions ,,
HYDROXOCOBALAMIN 5 G IV SOLR,RX-111437,CDM,J3424,HCPCS,250,RC,50633-0310-11,NDC,outpatient,1,UN,2471.2,1729.84,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5.69,,,5.69,5.69,1897.8816,fee schedule,,,
PHYTONADIONE 1 MG/0.5ML IJ SOLN WRAPPER,RX-4080206,CDM,J3430,HCPCS,636,RC,76329-1240-01,NDC,outpatient,0.5,ML,98.15,68.705,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.51,416.02,other,SI=N Exclusions ,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,43598-0405-11,NDC,outpatient,1,ML,78.97,55.279,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.51,416.02,other,SI=N Exclusions ,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,69097-0708-31,NDC,outpatient,1,ML,82.7,57.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.51,416.02,other,SI=N Exclusions ,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,69097-0708-96,NDC,outpatient,1,ML,82.7,57.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.51,416.02,other,SI=N Exclusions ,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,00409-9158-01,NDC,outpatient,1,ML,85.53,59.871,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.51,416.02,other,SI=N Exclusions ,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,00409-9158-31,NDC,outpatient,1,ML,85.53,59.871,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.51,416.02,other,SI=N Exclusions ,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,00409-9158-50,NDC,outpatient,1,ML,85.53,59.871,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.51,416.02,other,SI=N Exclusions ,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,43598-0405-16,NDC,outpatient,1,ML,78.97,55.279,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.51,416.02,other,SI=N Exclusions ,,
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,00781-3416-94,NDC,outpatient,1,UN,325.92,228.144,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions ,,
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,39822-1077-01,NDC,outpatient,1,UN,89.45,62.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions ,,
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,00049-3190-28,NDC,outpatient,1,UN,59.15,41.405,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions ,,
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,70436-0029-80,NDC,outpatient,1,UN,78.41,54.887,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.78,416.02,other,SI=N Exclusions ,,
HYALURONIDASE HUMAN 15 UNIT/ML INJECTION SYRINGE,RX-4081350,CDM,J3473,HCPCS,636,RC,99999-0004-00,NDC,outpatient,1,ML,164.85,115.395,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.36,416.02,other,SI=N Exclusions ,,
HYALURONIDASE HUMAN 150 UNIT/ML IJ SOLN,RX-76338,CDM,J3473,HCPCS,636,RC,18657-0117-01,NDC,outpatient,1,ML,164.85,115.395,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.36,416.02,other,SI=N Exclusions ,,
HYALURONIDASE HUMAN 150 UNIT/ML IJ SOLN,RX-76338,CDM,J3473,HCPCS,636,RC,18657-0117-04,NDC,outpatient,1,ML,164.85,115.395,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.36,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00338-1709-40,NDC,outpatient,100,ML,22.17,15.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00409-6727-11,NDC,outpatient,100,ML,46.71,32.697,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,63323-0108-00,NDC,outpatient,100,ML,26.28,18.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00264-4400-54,NDC,outpatient,100,ML,30.4,21.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,63323-0108-01,NDC,outpatient,100,ML,26.28,18.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,67457-0567-00,NDC,outpatient,100,ML,30.4,21.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00409-6727-23,NDC,outpatient,100,ML,46.71,32.697,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,00338-1708-40,NDC,outpatient,50,ML,28.6,20.02,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,00409-6729-11,NDC,outpatient,50,ML,36.31,25.417,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,00409-6729-24,NDC,outpatient,50,ML,36.31,25.417,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,25021-0612-81,NDC,outpatient,50,ML,24.74,17.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,44567-0420-00,NDC,outpatient,50,ML,43.82,30.674,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,44567-0420-24,NDC,outpatient,50,ML,43.82,30.674,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,47335-0992-01,NDC,outpatient,50,ML,28.85,20.195,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,63323-0106-02,NDC,outpatient,50,ML,32.45,22.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,63323-0106-05,NDC,outpatient,50,ML,32.45,22.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,67457-0553-00,NDC,outpatient,50,ML,33.74,23.618,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 40 MG/ML SOLN WRAPPER,RX-4080721,CDM,J3475,HCPCS,636,RC,00409-2050-01,NDC,outpatient,500,ML,38.25,26.775,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 40 MG/ML SOLN WRAPPER,RX-4080721,CDM,J3475,HCPCS,636,RC,00409-2050-20,NDC,outpatient,500,ML,38.25,26.775,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 40 MG/ML SOLN WRAPPER,RX-4080721,CDM,J3475,HCPCS,636,RC,63323-0106-15,NDC,outpatient,500,ML,33.99,23.793,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-03,NDC,outpatient,2,ML,5.46,3.822,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-04,NDC,outpatient,10,ML,6.53,4.571,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0642-02,NDC,outpatient,50,ML,55.41,38.787,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0642-50,NDC,outpatient,2,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-01,NDC,outpatient,2,ML,5.46,3.822,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-11,NDC,outpatient,10,ML,6.53,4.571,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,99999-0002-95,NDC,outpatient,2,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.47,416.02,other,SI=N Exclusions ,,
POTASSIUM CHLORIDE 10 MEQ/100ML IV SOLN,RX-11074,CDM,J3480,HCPCS,636,RC,00338-0709-48,NDC,outpatient,100,ML,26.8,18.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions ,,
POTASSIUM CHLORIDE 10 MEQ/100ML IV SOLN,RX-11074,CDM,J3480,HCPCS,636,RC,00990-7074-26,NDC,outpatient,100,ML,36.92,25.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions ,,
POTASSIUM CHLORIDE 20 MEQ/100ML IV SOLN,RX-11076,CDM,J3480,HCPCS,636,RC,00990-7075-26,NDC,outpatient,100,ML,37.81,26.467,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions ,,
POTASSIUM CHLORIDE 20 MEQ/100ML IV SOLN,RX-11076,CDM,J3480,HCPCS,636,RC,00338-0705-48,NDC,outpatient,100,ML,26.8,18.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions ,,
POTASSIUM CHLORIDE 20 MEQ/50ML IV SOLN,RX-11077,CDM,J3480,HCPCS,636,RC,00990-7077-14,NDC,outpatient,50,ML,37.59,26.313,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions ,,
POTASSIUM CHLORIDE 20 MEQ/50ML IV SOLN,RX-11077,CDM,J3480,HCPCS,636,RC,00338-0703-41,NDC,outpatient,50,ML,26.28,18.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions ,,
POTASSIUM CHLORIDE IN NACL 20-0.9 MEQ/L-% IV SOLN,RX-11081,CDM,J3480,HCPCS,636,RC,00338-0691-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions ,,
POTASSIUM CHLORIDE IN NACL 40-0.9 MEQ/L-% IV SOLN,RX-11082,CDM,J3480,HCPCS,636,RC,00338-0695-04,NDC,outpatient,1000,ML,31.42,21.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions ,,
KCL IN NACL 0.9% 10 MEQ/100ML IV SOLN,RX-166975,CDM,J3480,HCPCS,636,RC,99999-0001-77,NDC,outpatient,100,ML,26.28,18.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions ,,
POTASSIUM CHLORIDE IN NACL 20-0.45 MEQ/L-% IV SOLN,RX-36046,CDM,J3480,HCPCS,636,RC,00338-0704-34,NDC,outpatient,1000,ML,26.28,18.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions ,,
POTASSIUM CHLORIDE IN NACL 20 MEQ/50ML IV SOLN,RX-4081006,CDM,J3480,HCPCS,636,RC,99999-0001-79,NDC,outpatient,50,ML,31.17,21.819,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions ,,
POTASSIUM CHLORIDE IN NACL 20 MEQ/100ML IV SOLN,RX-4081007,CDM,J3480,HCPCS,636,RC,99999-0001-78,NDC,outpatient,100,ML,30.91,21.637,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions ,,
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN,RX-6429,CDM,J3480,HCPCS,636,RC,63323-0965-02,NDC,outpatient,20,ML,6.48,4.536,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions ,,
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN,RX-6429,CDM,J3480,HCPCS,636,RC,63323-0965-20,NDC,outpatient,20,ML,6.48,4.536,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions ,,
POTASSIUM CL IN DEXTROSE 5% 20 MEQ/L IV SOLN,RX-9791,CDM,J3480,HCPCS,636,RC,00338-0683-04,NDC,outpatient,1000,ML,31.42,21.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions ,,
KCL IN DEXTROSE-NACL 20-5-0.9 MEQ/L-%-% IV SOLN,RX-9795,CDM,J3480,HCPCS,636,RC,00338-0803-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions ,,
KCL IN DEXTROSE-NACL 20-5-0.9 MEQ/L-%-% IV SOLN,RX-9795,CDM,J3480,HCPCS,636,RC,00264-7652-00,NDC,outpatient,1000,ML,38.25,26.775,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions ,,
KCL IN DEXTROSE-NACL 10-5-0.45 MEQ/L-%-% IV SOLN,RX-9799,CDM,J3480,HCPCS,636,RC,00990-7993-09,NDC,outpatient,1000,ML,47.15,33.005,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions ,,
KCL IN DEXTROSE-NACL 10-5-0.45 MEQ/L-%-% IV SOLN,RX-9799,CDM,J3480,HCPCS,636,RC,00338-0669-04,NDC,outpatient,1000,ML,31.42,21.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions ,,
KCL IN DEXTROSE-NACL 20-5-0.2 MEQ/L-%-% IV SOLN,RX-9800,CDM,J3480,HCPCS,636,RC,00264-7645-00,NDC,outpatient,1000,ML,47.15,33.005,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions ,,
KCL IN DEXTROSE-NACL 20-5-0.2 MEQ/L-%-% IV SOLN,RX-9800,CDM,J3480,HCPCS,636,RC,00338-0663-04,NDC,outpatient,1000,ML,31.42,21.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions ,,
KCL IN DEXTROSE-NACL 20-5-0.45 MEQ/L-%-% IV SOLN,RX-9801,CDM,J3480,HCPCS,636,RC,00338-0671-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions ,,
KCL IN DEXTROSE-NACL 40-5-0.45 MEQ/L-%-% IV SOLN,RX-9807,CDM,J3480,HCPCS,636,RC,00338-0675-04,NDC,outpatient,1000,ML,31.42,21.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions ,,
ZIDOVUDINE 10 MG/ML IV SOLN,RX-11691,CDM,J3485,HCPCS,636,RC,49702-0213-01,NDC,outpatient,20,ML,126.03,88.221,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.51,416.02,other,SI=N Exclusions ,,
ZIDOVUDINE 10 MG/ML IV SOLN,RX-11691,CDM,J3485,HCPCS,636,RC,49702-0213-26,NDC,outpatient,20,ML,126.03,88.221,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.51,416.02,other,SI=N Exclusions ,,
ZIPRASIDONE MESYLATE 20 MG IM SOLR,RX-33175,CDM,J3486,HCPCS,636,RC,00049-3920-83,NDC,outpatient,1,UN,264.92,185.444,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7.43,416.02,other,SI=N Exclusions ,,
ZIPRASIDONE MESYLATE 20 MG IM SOLR,RX-33175,CDM,J3486,HCPCS,636,RC,00049-3920-20,NDC,outpatient,1,UN,264.92,185.444,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7.43,416.02,other,SI=N Exclusions ,,
ZOLEDRONIC ACID 4 MG/5ML IV CONC,RX-35640,CDM,J3489,HCPCS,636,RC,67457-0390-54,NDC,outpatient,5,ML,30.53,21.371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6.47,416.02,other,SI=N Exclusions ,,
ZOLEDRONIC ACID 5 MG/100ML IV SOLN,RX-81434,CDM,J3489,HCPCS,636,RC,67457-0619-10,NDC,outpatient,100,ML,182.43,127.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6.47,416.02,other,SI=N Exclusions ,,
ZOLEDRONIC ACID 5 MG/100ML IV SOLN,RX-81434,CDM,J3489,HCPCS,636,RC,55111-0688-52,NDC,outpatient,100,ML,126.81,88.767,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,6.47,416.02,other,SI=N Exclusions ,,
IDARUCIZUMAB 2.5 GM/50ML IV SOLN,RX-132721,CDM,J3590,HCPCS,636,RC,00597-0197-05,NDC,outpatient,100,ML,13473.22,9431.254,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,10347.43296,other,SI=N Exclusions ,,
SODIUM CHLORIDE 0.45 % IV SOLN,RX-7318,CDM,J7030,HCPCS,250,RC,00338-0043-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.54,416.02,other,SI=N Exclusions ,,
SODIUM CHLORIDE 0.45 % IV SOLN,RX-7318,CDM,J7030,HCPCS,250,RC,00338-0043-03,NDC,outpatient,500,ML,23.71,16.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.54,416.02,other,SI=N Exclusions ,,
DEXTROSE-SODIUM CHLORIDE 5-0.9 % IV SOLN,RX-9815,CDM,J7042,HCPCS,636,RC,00338-0089-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.14,416.02,other,SI=N Exclusions ,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-02,NDC,outpatient,250,ML,22.43,15.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.81,416.02,other,SI=N Exclusions ,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-31,NDC,outpatient,50,ML,22.43,15.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.81,416.02,other,SI=N Exclusions ,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-41,NDC,outpatient,50,ML,22.94,16.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.81,416.02,other,SI=N Exclusions ,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-48,NDC,outpatient,100,ML,22.69,15.883,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.81,416.02,other,SI=N Exclusions ,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00409-7100-04,NDC,outpatient,250,ML,30.14,21.098,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.81,416.02,other,SI=N Exclusions ,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,63323-0624-04,NDC,outpatient,250,ML,25,17.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.81,416.02,other,SI=N Exclusions ,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-03,NDC,outpatient,500,ML,23.71,16.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.81,416.02,other,SI=N Exclusions ,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,63323-0624-74,NDC,outpatient,250,ML,25,17.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.81,416.02,other,SI=N Exclusions ,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-38,NDC,outpatient,100,ML,22.17,15.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.81,416.02,other,SI=N Exclusions ,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00409-7100-02,NDC,outpatient,250,ML,30.14,21.098,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.81,416.02,other,SI=N Exclusions ,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-11,NDC,outpatient,50,ML,22.43,15.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.81,416.02,other,SI=N Exclusions ,,
DEXTROSE 5 % IV PVC FREE SOLN,RX-4080550,CDM,J7060,HCPCS,636,RC,00338-6346-03,NDC,outpatient,500,ML,42.7,29.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.81,416.02,other,SI=N Exclusions ,,
DEXTROSE 5 % IV PVC FREE SOLN,RX-4080550,CDM,J7060,HCPCS,636,RC,00264-7510-10,NDC,outpatient,500,ML,33.99,23.793,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.81,416.02,other,SI=N Exclusions ,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7070,HCPCS,636,RC,00338-0017-04,NDC,outpatient,1000,ML,21.14,14.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.62,416.02,other,SI=N Exclusions ,,
DEXTRAN 40 IN D5W 10 % IV SOLN,RX-9759,CDM,J7100,HCPCS,636,RC,00409-7418-03,NDC,outpatient,500,ML,116.13,81.291,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.23,416.02,other,SI=N Exclusions ,,
DEXTRAN 40 IN D5W 10 % IV SOLN,RX-9759,CDM,J7100,HCPCS,636,RC,00409-7418-13,NDC,outpatient,500,ML,116.13,81.291,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,19.23,416.02,other,SI=N Exclusions ,,
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00338-0117-02,NDC,outpatient,250,ML,22.43,15.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.39,416.02,other,SI=N Exclusions ,,
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00338-0117-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.39,416.02,other,SI=N Exclusions ,,
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00264-7750-20,NDC,outpatient,250,ML,33.8,23.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.39,416.02,other,SI=N Exclusions ,,
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00338-0117-03,NDC,outpatient,500,ML,23.71,16.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.39,416.02,other,SI=N Exclusions ,,
DEXTROSE IN LACTATED RINGERS 5 % IV SOLN,RX-9788,CDM,J7121,HCPCS,636,RC,00338-0125-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,5.89986,416.02,other,SI=N Exclusions ,,
PROTHROMBIN COMPLEX CONC HUMAN 500 UNITS IV KIT,RX-122122,CDM,J7168,HCPCS,636,RC,63833-0386-02,NDC,outpatient,1,UN,3022.2,2115.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3.4,,,3.4,2.568211,4642.0992,fee schedule,,,
PROTHROMBIN COMPLEX CONC HUMAN 1000 UNITS IV KIT,RX-125272,CDM,J7168,HCPCS,636,RC,63833-0387-02,NDC,outpatient,1,UN,6044.4,4231.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3.4,,,3.4,2.568211,4642.0992,fee schedule,,,
ANTIHEMOPHILIC FACTOR-VWF 500-500 UNITS IV KIT,RX-134441,CDM,J7183,HCPCS,636,RC,68982-0182-01,NDC,outpatient,1,UN,1449,1014.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.28,,,1.28,1.26,2225.664,fee schedule,,,
ANTIHEMOPHILIC FACTOR-VWF 1000-1000 UNITS IV KIT,RX-134442,CDM,J7183,HCPCS,636,RC,68982-0182-02,NDC,outpatient,1,UN,2898,2028.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.28,,,1.28,1.26,2225.664,fee schedule,,,
ANTIHEMOPHILIC FACTOR-VWF 250-600 UNITS IV SOLR,RX-70404,CDM,J7187,HCPCS,636,RC,63833-0625-01,NDC,outpatient,1,UN,1821.6,1275.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.4,,,1.4,1.23,3240,fee schedule,,,
ANTIHEMOPHILIC FACTOR-VWF 250-600 UNITS IV SOLR,RX-70404,CDM,J7187,HCPCS,636,RC,63833-0615-02,NDC,outpatient,1,UN,1821.6,1275.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.4,,,1.4,1.23,3240,fee schedule,,,
ANTIHEMOPHILIC FACTOR-VWF 500-1200 UNITS IV SOLR,RX-70405,CDM,J7187,HCPCS,636,RC,63833-0616-02,NDC,outpatient,1,UN,3643.2,2550.24,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.4,,,1.4,1.23,3240,fee schedule,,,
ANTIHEMOPHILIC FACTOR-VWF 500-1200 UNITS IV SOLR,RX-70405,CDM,J7187,HCPCS,636,RC,63833-0626-01,NDC,outpatient,1,UN,3643.2,2550.24,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.4,,,1.4,1.23,3240,fee schedule,,,
ANTIHEMOPHILIC FACTOR-VWF 1000-2400 UNITS IV SOLR,RX-70406,CDM,J7187,HCPCS,636,RC,63833-0617-02,NDC,outpatient,1,UN,3036,2125.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.4,,,1.4,1.23,3240,fee schedule,,,
ANTIHEMOPHILIC FACTOR-VWF 1000-2400 UNITS IV SOLR,RX-70406,CDM,J7187,HCPCS,636,RC,63833-0627-01,NDC,outpatient,1,UN,3036,2125.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.4,,,1.4,1.23,3240,fee schedule,,,
COAGULATION FACTOR VIIA RECOMB 1 MG IV SOLR,RX-92853,CDM,J7189,HCPCS,636,RC,00169-7201-01,NDC,outpatient,1,UN,6342.76,4439.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.52,,,2.52,2.13,24356.18304,fee schedule,,,
COAGULATION FACTOR VIIA RECOMB 1 MG IV SOLR,RX-92853,CDM,J7189,HCPCS,636,RC,00169-7211-11,NDC,outpatient,1,UN,6342.76,4439.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.52,,,2.52,2.13,24356.18304,fee schedule,,,
COAGULATION FACTOR VIIA RECOMB 2 MG IV SOLR,RX-92854,CDM,J7189,HCPCS,636,RC,00169-7212-11,NDC,outpatient,1,UN,12685.52,8879.864,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.52,,,2.52,2.13,24356.18304,fee schedule,,,
COAGULATION FACTOR VIIA RECOMB 2 MG IV SOLR,RX-92854,CDM,J7189,HCPCS,636,RC,00169-7202-01,NDC,outpatient,1,UN,12685.52,8879.864,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.52,,,2.52,2.13,24356.18304,fee schedule,,,
COAGULATION FACTOR VIIA RECOMB 5 MG IV SOLR,RX-92855,CDM,J7189,HCPCS,636,RC,00169-7205-01,NDC,outpatient,1,UN,31713.78,22199.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.52,,,2.52,2.13,24356.18304,fee schedule,,,
ANTIHEMOPHILIC FACTOR VIII RAHF-PFM 500 UNITS IV SOLR,RX-76366,CDM,J7192,HCPCS,636,RC,00944-3052-02,NDC,outpatient,1,UN,1863,1304.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.55,,,1.55,1.25,2861.568,fee schedule,,,
ANTIHEMOPHILIC FACTOR VIII RAHF-PFM 1000 UNITS IV SOLR,RX-76367,CDM,J7192,HCPCS,636,RC,00944-3053-02,NDC,outpatient,1,UN,3726,2608.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.55,,,1.55,1.25,2861.568,fee schedule,,,
ANTITHROMBIN III (HUMAN) 500 UNITS IV SOLR,RX-9116,CDM,J7197,HCPCS,636,RC,13533-0602-50,NDC,outpatient,1,UN,4954.2,3467.94,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3.85,,,3.85,3.35,3804.8256,fee schedule,,,
ANTITHROMBIN III (HUMAN) 500 UNITS IV SOLR,RX-9116,CDM,J7197,HCPCS,636,RC,13533-0606-12,NDC,outpatient,1,UN,4954.2,3467.94,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,3.85,,,3.85,3.35,3804.8256,fee schedule,,,
ANTIINHIBITOR COAGULANT CMPLX 2500 UNITS IV SOLR,RX-146201,CDM,J7198,HCPCS,636,RC,64193-0425-02,NDC,outpatient,1,UN,13869,9708.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.34,,,2.34,1.94,10651.392,fee schedule,,,
SODIUM HYALURONATE (VISCOSUP) 25 MG/2.5ML IX SOSY,RX-127543,CDM,J7321,HCPCS,636,RC,89130-4444-01,NDC,outpatient,2.5,ML,1023.91,716.737,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,73.22,786.36288,other,SI=N Exclusions ,,
AZATHIOPRINE 50 MG ORAL TABS,RX-9183,CDM,J7500,HCPCS,259,RC,68084-0229-01,NDC,outpatient,1,UN,2.39,1.673,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.536555,416.02,other,SI=N Exclusions ,,
AZATHIOPRINE 50 MG ORAL TABS,RX-9183,CDM,J7500,HCPCS,259,RC,68084-0229-11,NDC,outpatient,1,UN,2.39,1.673,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.536555,416.02,other,SI=N Exclusions ,,
CYCLOSPORINE 50 MG/ML IV SOLN,RX-9705,CDM,J7516,HCPCS,636,RC,00574-0866-10,NDC,outpatient,5,ML,142.85,99.995,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,15.32,416.02,other,SI=N Exclusions ,,
MYCOPHENOLATE MOFETIL HCL 500 MG IV SOLR,RX-23968,CDM,J7519,HCPCS,636,RC,00004-0298-09,NDC,outpatient,1,UN,298.3,208.81,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.52,,,0.52,0.52,416.02,fee schedule,,,
MYCOPHENOLATE MOFETIL HCL 500 MG IV SOLR,RX-23968,CDM,J7519,HCPCS,636,RC,71288-0803-20,NDC,outpatient,1,UN,89.27,62.489,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.52,,,0.52,0.52,416.02,fee schedule,,,
METHACHOLINE CHLORIDE 100 MG IN SOLR,RX-27032,CDM,J7674,HCPCS,636,RC,64281-0100-00,NDC,outpatient,1,UN,341.28,238.896,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.86,416.02,other,SI=N Exclusions ,,
METHACHOLINE CHLORIDE 100 MG IN SOLR,RX-27032,CDM,J7674,HCPCS,636,RC,64281-0100-06,NDC,outpatient,1,UN,341.28,238.896,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.86,416.02,other,SI=N Exclusions ,,
ETOPOSIDE 50 MG ORAL CAPS,RX-10001,CDM,J8560,HCPCS,636,RC,00378-3266-32,NDC,outpatient,1,UN,309.74,216.818,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,76.66,,,76.66,69.53663,416.02,fee schedule,,,
ETOPOSIDE 50 MG ORAL CAPS,RX-10001,CDM,J8560,HCPCS,636,RC,00378-3266-94,NDC,outpatient,1,UN,309.74,216.818,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,76.66,,,76.66,69.53663,416.02,fee schedule,,,
MERCAPTOPURINE 50 MG ORAL TABS,RX-10531,CDM,J8999,HCPCS,259,RC,00378-3547-52,NDC,outpatient,1,UN,4.39,3.073,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,3.72,0.370425,416.02,percent of total billed charges,,,
MERCAPTOPURINE 50 MG ORAL TABS,RX-10531,CDM,J8999,HCPCS,259,RC,00054-4581-11,NDC,outpatient,1,UN,14.11,9.877,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,11.96,0.370425,416.02,percent of total billed charges,,,
BICALUTAMIDE 50 MG ORAL TABS,RX-15746,CDM,J8999,HCPCS,259,RC,16729-0023-10,NDC,outpatient,1,UN,2.86,2.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2.42,0.370425,416.02,percent of total billed charges,,,
ANASTROZOLE 1 MG ORAL TABS,RX-16205,CDM,J8999,HCPCS,259,RC,60687-0112-21,NDC,outpatient,1,UN,3.22,2.254,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2.73,0.370425,416.02,percent of total billed charges,,,
ANASTROZOLE 1 MG ORAL TABS,RX-16205,CDM,J8999,HCPCS,259,RC,60687-0112-11,NDC,outpatient,1,UN,3.22,2.254,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2.73,0.370425,416.02,percent of total billed charges,,,
MEGESTROL ACETATE 40 MG ORAL TABS,RX-4871,CDM,J8999,HCPCS,259,RC,64380-0159-01,NDC,outpatient,1,UN,1.65,1.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1.4,0.370425,416.02,percent of total billed charges,,,
MEGESTROL ACETATE 400 MG/10ML ORAL SUSP,RX-76824,CDM,J8999,HCPCS,259,RC,00121-0945-40,NDC,outpatient,10,ML,15.58,10.906,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,13.21,0.370425,416.02,percent of total billed charges,,,
MEGESTROL ACETATE 400 MG/10ML ORAL SUSP,RX-76824,CDM,J8999,HCPCS,259,RC,99999-0003-95,NDC,outpatient,10,ML,8.73,6.111,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,7.4,0.370425,416.02,percent of total billed charges,,,
MEGESTROL ACETATE 400 MG/10ML ORAL SUSP,RX-76824,CDM,J8999,HCPCS,259,RC,00121-0945-10,NDC,outpatient,10,ML,15.58,10.906,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,13.21,0.370425,416.02,percent of total billed charges,,,
TAMOXIFEN CITRATE 10 MG ORAL TABS,RX-7711,CDM,J8999,HCPCS,259,RC,63739-0143-10,NDC,outpatient,1,UN,1.98,1.386,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1.68,0.370425,416.02,percent of total billed charges,,,
DOXORUBICIN HCL 2 MG/ML IV PUSH SOLN,RX-2616,CDM,J9000,HCPCS,636,RC,00069-3030-20,NDC,outpatient,5,ML,19.68,13.776,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.5,525.12,other,SI=N Exclusions ,,
DOXORUBICIN HCL 2 MG/ML IV PUSH SOLN,RX-2616,CDM,J9000,HCPCS,636,RC,00069-3031-20,NDC,outpatient,10,ML,34.71,24.297,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.5,525.12,other,SI=N Exclusions ,,
DOXORUBICIN HCL 2 MG/ML IV PUSH SOLN,RX-2616,CDM,J9000,HCPCS,636,RC,00069-3032-20,NDC,outpatient,25,ML,44.02,30.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.5,525.12,other,SI=N Exclusions ,,
DOXORUBICIN HCL 10 MG IV SOLR,RX-2617,CDM,J9000,HCPCS,636,RC,00143-9092-01,NDC,outpatient,1,UN,143.64,100.548,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.5,525.12,other,SI=N Exclusions ,,
DOXORUBICIN HCL 50 MG IV SOLR,RX-2619,CDM,J9000,HCPCS,636,RC,00143-9277-01,NDC,outpatient,1,UN,683.75,478.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.5,525.12,other,SI=N Exclusions ,,
ARSENIC TRIOXIDE 12 MG/6ML IV SOLN,RX-141420,CDM,J9017,HCPCS,636,RC,63459-0601-06,NDC,outpatient,6,ML,3082.97,2158.079,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7.2,,,7.2,7.2,2367.72096,fee schedule,,,
ARSENIC TRIOXIDE 12 MG/6ML IV SOLN,RX-141420,CDM,J9017,HCPCS,636,RC,63459-0601-11,NDC,outpatient,6,ML,3082.97,2158.079,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7.2,,,7.2,7.2,2367.72096,fee schedule,,,
AZACITIDINE 100 MG IJ SUSR,RX-78420,CDM,J9025,HCPCS,636,RC,63323-0771-39,NDC,outpatient,1,UN,117.36,82.152,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.32,416.02,other,SI=N Exclusions ,,
AZACITIDINE 100 MG IJ SUSR,RX-78420,CDM,J9025,HCPCS,636,RC,43598-0305-62,NDC,outpatient,1,UN,83.86,58.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.32,416.02,other,SI=N Exclusions ,,
BENDAMUSTINE HCL 5 MG/ML IV SOLR WRAPPER,RX-4080211,CDM,J9033,HCPCS,636,RC,63459-0390-08,NDC,outpatient,5,ML,889.43,622.601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5.43,,,5.43,5.43,2152.77312,fee schedule,,,
BENDAMUSTINE HCL 5 MG/ML IV SOLR WRAPPER,RX-4080211,CDM,J9033,HCPCS,636,RC,63459-0391-20,NDC,outpatient,20,ML,2803.09,1962.163,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,5.43,,,5.43,5.43,2152.77312,fee schedule,,,
BENDAMUSTINE HCL 100 MG/4ML IV SOLN,RX-133070,CDM,J9034,HCPCS,636,RC,63459-0348-04,NDC,outpatient,4,ML,5078.48,3554.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,12.95,,,12.95,12.95,3900.27264,fee schedule,,,
BEVACIZUMAB 25 MG/ML IV WRAPPER,RX-4080193,CDM,J9035,HCPCS,636,RC,50242-0061-01,NDC,outpatient,16,ML,9117,6381.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,72.7,,,72.7,72.7,7001.856,fee schedule,,,
BEVACIZUMAB 25 MG/ML IV WRAPPER,RX-4080193,CDM,J9035,HCPCS,636,RC,50242-0060-01,NDC,outpatient,4,ML,2279.25,1595.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,72.7,,,72.7,72.7,7001.856,fee schedule,,,
BLEOMYCIN SULFATE 30 UNITS IJ SOLR,RX-17012,CDM,J9040,HCPCS,636,RC,63323-0137-20,NDC,outpatient,1,UN,120.16,84.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.931495,416.02,other,SI=N Exclusions ,,
BLEOMYCIN SULFATE 15 UNITS IJ SOLR *TEST DOSE*,RX-9289,CDM,J9040,HCPCS,636,RC,16714-0886-01,NDC,outpatient,1,UN,66.51,46.557,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,14.931495,416.02,other,SI=N Exclusions ,,
BORTEZOMIB 3.5 MG IJ SOLR,RX-123070,CDM,J9041,HCPCS,636,RC,10019-0991-01,NDC,outpatient,1,UN,147.6,103.32,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.57,,,1.57,1.57,905.322979,fee schedule,,,
BORTEZOMIB 3.5 MG IJ SOLR,RX-123070,CDM,J9041,HCPCS,636,RC,00143-9098-01,NDC,outpatient,1,UN,58.7,41.09,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,1.57,,,1.57,1.57,905.322979,fee schedule,,,
BRENTUXIMAB VEDOTIN 50 MG IV SOLR,RX-111348,CDM,J9042,HCPCS,636,RC,51144-0050-01,NDC,outpatient,1,UN,32323.72,22626.604,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,239.86,,,239.86,221.96,24824.61696,fee schedule,,,
CABAZITAXEL 60 MG/1.5ML IV SOLN,RX-105644,CDM,J9043,HCPCS,636,RC,00024-5824-11,NDC,outpatient,6,ML,39665.77,27766.039,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,216.46,,,216.46,206.03,30463.31136,fee schedule,,,
CARBOPLATIN 10 MG/ML IV SOLN WRAPPER,RX-4080212,CDM,J9045,HCPCS,636,RC,00703-4248-01,NDC,outpatient,45,ML,63.71,44.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.41,416.02,other,SI=N Exclusions ,,
CARBOPLATIN 10 MG/ML IV SOLN WRAPPER,RX-4080212,CDM,J9045,HCPCS,636,RC,61703-0339-50,NDC,outpatient,45,ML,157.96,110.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.41,416.02,other,SI=N Exclusions ,,
CARFILZOMIB 60 MG IV SOLR,RX-117047,CDM,J9047,HCPCS,636,RC,76075-0101-01,NDC,outpatient,1,UN,8945.66,6261.962,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,49.58,,,49.58,47.04,6870.26688,fee schedule,,,
CETUXIMAB 200 MG/100ML IV SOLN,RX-108072,CDM,J9055,HCPCS,636,RC,66733-0958-23,NDC,outpatient,100,ML,4373.8,3061.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,75.48,,,75.48,72.08,3359.0784,fee schedule,,,
CETUXIMAB 100 MG/50ML IV SOLN,RX-37989,CDM,J9055,HCPCS,636,RC,66733-0948-23,NDC,outpatient,50,ML,2186.9,1530.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,75.48,,,75.48,72.08,3359.0784,fee schedule,,,
CISPLATIN 1 MG/ML IV WRAPPER,RX-4080194,CDM,J9060,HCPCS,636,RC,00703-5748-11,NDC,outpatient,100,ML,67.89,47.523,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.37,416.02,other,SI=N Exclusions ,,
CLADRIBINE 1 MG/ML IV SOLN WRAPPER,RX-4080791,CDM,J9065,HCPCS,636,RC,63323-0140-10,NDC,outpatient,10,ML,347.72,243.404,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,14.25,,,14.25,14.25,416.02,fee schedule,,,
CYCLOPHOSPHAMIDE 1 G IJ SOLR,RX-38270,CDM,J9070,HCPCS,636,RC,00781-3244-94,NDC,outpatient,1,UN,1602.63,1121.841,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.03,,,53.03,17.09,1230.81984,fee schedule,,,
CYCLOPHOSPHAMIDE 500 MG IJ SOLR,RX-38271,CDM,J9070,HCPCS,636,RC,00781-3233-94,NDC,outpatient,1,UN,1017.09,711.963,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.03,,,53.03,17.09,1230.81984,fee schedule,,,
CYCLOPHOSPHAMIDE 2 G IJ SOLR,RX-38280,CDM,J9070,HCPCS,636,RC,10019-0957-01,NDC,outpatient,1,UN,1524.13,1066.891,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.03,,,53.03,17.09,1230.81984,fee schedule,,,
CYTARABINE (PF) 100 MG/ML IJ SOLN,RX-20156,CDM,J9100,HCPCS,636,RC,63323-0120-20,NDC,outpatient,20,ML,40.95,28.665,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.77,416.02,other,SI=N Exclusions ,,
CYTARABINE (PF) 100 MG/ML IJ SOLN,RX-20156,CDM,J9100,HCPCS,636,RC,61703-0319-22,NDC,outpatient,20,ML,53.29,37.303,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.77,416.02,other,SI=N Exclusions ,,
CYTARABINE (PF) 20 MG/ML IJ SOLN,RX-96982,CDM,J9100,HCPCS,636,RC,61703-0305-58,NDC,outpatient,5,ML,16.81,11.767,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.77,416.02,other,SI=N Exclusions ,,
CYTARABINE (PF) 20 MG/ML IJ SOLN,RX-96982,CDM,J9100,HCPCS,636,RC,61703-0303-46,NDC,outpatient,50,ML,62.44,43.708,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.77,416.02,other,SI=N Exclusions ,,
CYTARABINE (PF) 20 MG/ML IJ SOLN,RX-96982,CDM,J9100,HCPCS,636,RC,61703-0305-38,NDC,outpatient,5,ML,16.81,11.767,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.77,416.02,other,SI=N Exclusions ,,
CYTARABINE 20 MG/ML IJ SOLN,RX-9709,CDM,J9100,HCPCS,636,RC,61703-0304-36,NDC,outpatient,25,ML,34.67,24.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.77,416.02,other,SI=N Exclusions ,,
DACARBAZINE 200 MG IV SOLR,RX-2091,CDM,J9130,HCPCS,636,RC,00143-9245-10,NDC,outpatient,1,UN,16.44,11.508,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.69078,416.02,other,SI=N Exclusions ,,
DACARBAZINE 200 MG IV SOLR,RX-2091,CDM,J9130,HCPCS,636,RC,00143-9245-01,NDC,outpatient,1,UN,16.44,11.508,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.69078,416.02,other,SI=N Exclusions ,,
DEGARELIX ACETATE(240 MG DOSE) 120 MG/VIAL SC SOLR,RX-150086,CDM,J9155,HCPCS,636,RC,55566-8403-01,NDC,outpatient,1,UN,1744.22,1220.954,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4.18,,,4.18,4.18,1339.56096,fee schedule,,,
DEGARELIX ACETATE 80 MG SC SOLR,RX-96986,CDM,J9155,HCPCS,636,RC,55566-8303-01,NDC,outpatient,1,UN,1117.94,782.558,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4.18,,,4.18,4.18,1339.56096,fee schedule,,,
DOCETAXEL 20 MG/ML IV CONC WRAPPER,RX-4080197,CDM,J9171,HCPCS,636,RC,16729-0267-65,NDC,outpatient,8,ML,615.8,431.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.79,1115.136,other,SI=N Exclusions ,,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,43066-0006-01,NDC,outpatient,8,ML,120.55,84.385,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.79,1115.136,other,SI=N Exclusions ,,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,66758-0050-01,NDC,outpatient,2,ML,181.5,127.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.79,1115.136,other,SI=N Exclusions ,,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,00409-0201-20,NDC,outpatient,16,ML,345.35,241.745,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.79,1115.136,other,SI=N Exclusions ,,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,66758-0050-02,NDC,outpatient,8,ML,726,508.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.79,1115.136,other,SI=N Exclusions ,,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,66758-0050-03,NDC,outpatient,16,ML,1452,1016.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.79,1115.136,other,SI=N Exclusions ,,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,00409-0201-02,NDC,outpatient,2,ML,45.67,31.969,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.79,1115.136,other,SI=N Exclusions ,,
EPIRUBICIN HCL 2 MG/ML IV SOLN WRAPPER,RX-4080365,CDM,J9178,HCPCS,636,RC,00009-5091-01,NDC,outpatient,25,ML,112.35,78.645,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.34,416.02,other,SI=N Exclusions ,,
ERIBULIN MESYLATE 1 MG/2ML IV PUSH SOLN,RX-106773,CDM,J9179,HCPCS,636,RC,62856-0389-01,NDC,outpatient,2,ML,4032.6,2822.82,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,135.79,,,135.79,128.78,3097.0368,fee schedule,,,
ETOPOSIDE 100 MG/5ML IV SOLN,RX-124543,CDM,J9181,HCPCS,636,RC,16729-0114-31,NDC,outpatient,5,ML,33.84,23.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.7,416.02,other,SI=N Exclusions ,,
ETOPOSIDE 100 MG/5ML IV SOLN,RX-124543,CDM,J9181,HCPCS,636,RC,16729-0114-08,NDC,outpatient,25,ML,169.25,118.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.7,416.02,other,SI=N Exclusions ,,
FLUDARABINE PHOSPHATE 25 MG/ML IV WRAPPER,RX-4080526,CDM,J9185,HCPCS,636,RC,25021-0242-02,NDC,outpatient,2,ML,278.39,194.873,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,134.15,,,134.15,62.498555,604.75,fee schedule,,,
FLUOROURACIL 50 MG/ML IV SOLN WRAPPER,RX-4080199,CDM,J9190,HCPCS,636,RC,16729-0276-11,NDC,outpatient,50,ML,99.65,69.755,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.83,416.02,other,SI=N Exclusions ,,
FLUOROURACIL 500 MG/10ML IV PUSH SOLN,RX-82200,CDM,J9190,HCPCS,636,RC,63323-0117-00,NDC,outpatient,10,ML,8.43,5.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.83,416.02,other,SI=N Exclusions ,,
FLUOROURACIL 500 MG/10ML IV PUSH SOLN,RX-82200,CDM,J9190,HCPCS,636,RC,63323-0117-10,NDC,outpatient,10,ML,8.43,5.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.83,416.02,other,SI=N Exclusions ,,
GEMCITABINE HCL 200 MG/5.26ML IV SOLN,RX-112786,CDM,J9201,HCPCS,636,RC,00409-0183-01,NDC,outpatient,5.26,ML,31.43,22.001,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.79,416.02,other,SI=N Exclusions ,,
GEMCITABINE HCL 1 GM/26.3ML IV SOLN,RX-112787,CDM,J9201,HCPCS,636,RC,00409-0181-01,NDC,outpatient,26.3,ML,133.66,93.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.79,416.02,other,SI=N Exclusions ,,
GEMCITABINE HCL 200 MG IV SOLR,RX-17121,CDM,J9201,HCPCS,636,RC,25021-0234-10,NDC,outpatient,1,UN,27.81,19.467,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.79,416.02,other,SI=N Exclusions ,,
GEMCITABINE HCL 1 G IV SOLR,RX-17122,CDM,J9201,HCPCS,636,RC,16714-0930-01,NDC,outpatient,1,UN,63.54,44.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.79,416.02,other,SI=N Exclusions ,,
GOSERELIN ACETATE 3.6 MG SC IMPL,RX-10137,CDM,J9202,HCPCS,636,RC,70720-0950-36,NDC,outpatient,1,UN,2706.82,1894.774,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,674.77,,,674.77,399.86,5828.5824,fee schedule,,,
GOSERELIN ACETATE 10.8 MG SC IMPL,RX-16254,CDM,J9202,HCPCS,636,RC,70720-0951-30,NDC,outpatient,1,UN,7589.3,5312.51,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,674.77,,,674.77,399.86,5828.5824,fee schedule,,,
IRINOTECAN HCL 20 MG/ML IV SOLN WRAPPER,RX-4080202,CDM,J9206,HCPCS,636,RC,61703-0349-09,NDC,outpatient,5,ML,56.89,39.823,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.5,416.02,other,SI=N Exclusions ,,
IRINOTECAN HCL 20 MG/ML IV SOLN WRAPPER,RX-4080202,CDM,J9206,HCPCS,636,RC,61703-0349-16,NDC,outpatient,2,ML,43.49,30.443,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.5,416.02,other,SI=N Exclusions ,,
IRINOTECAN HCL 20 MG/ML IV SOLN WRAPPER,RX-4080202,CDM,J9206,HCPCS,636,RC,60505-6128-01,NDC,outpatient,5,ML,26.29,18.403,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.5,416.02,other,SI=N Exclusions ,,
IXABEPILONE 15 MG IV SOLR,RX-88652,CDM,J9207,HCPCS,636,RC,70020-1910-01,NDC,outpatient,1,UN,5537.91,3876.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,134.06,,,134.06,122.55,12759.31392,fee schedule,,,
IXABEPILONE 45 MG IV SOLR,RX-88653,CDM,J9207,HCPCS,636,RC,70020-1911-01,NDC,outpatient,1,UN,16613.69,11629.583,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,134.06,,,134.06,122.55,12759.31392,fee schedule,,,
IFOSFAMIDE 1 G IV SOLR,RX-10248,CDM,J9208,HCPCS,636,RC,10019-0925-82,NDC,outpatient,1,UN,94.35,66.045,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,21.181575,416.02,other,SI=N Exclusions ,,
IFOSFAMIDE 1 G IV SOLR,RX-10248,CDM,J9208,HCPCS,636,RC,10019-0925-01,NDC,outpatient,1,UN,94.35,66.045,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,21.181575,416.02,other,SI=N Exclusions ,,
IFOSFAMIDE 3 G IV SOLR,RX-10249,CDM,J9208,HCPCS,636,RC,00338-3993-01,NDC,outpatient,1,UN,350.95,245.665,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,21.181575,416.02,other,SI=N Exclusions ,,
IFOSFAMIDE 3 G IV SOLR,RX-10249,CDM,J9208,HCPCS,636,RC,10019-0926-02,NDC,outpatient,1,UN,288.44,201.908,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,21.181575,416.02,other,SI=N Exclusions ,,
IFOSFAMIDE 3 G IV SOLR,RX-10249,CDM,J9208,HCPCS,636,RC,10019-0926-16,NDC,outpatient,1,UN,288.44,201.908,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,21.181575,416.02,other,SI=N Exclusions ,,
MESNA 100 MG/ML IV SOLN,RX-10537,CDM,J9209,HCPCS,636,RC,00338-1305-01,NDC,outpatient,10,ML,28.36,19.852,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.67,416.02,other,SI=N Exclusions ,,
MESNA 100 MG/ML IV SOLN,RX-10537,CDM,J9209,HCPCS,636,RC,63323-0733-11,NDC,outpatient,10,ML,222.31,155.617,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.67,416.02,other,SI=N Exclusions ,,
IDARUBICIN HCL 1 MG/ML IV SOLN WRAPPER,RX-4080583,CDM,J9211,HCPCS,636,RC,00013-2576-91,NDC,outpatient,5,ML,121.76,85.232,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,27.33512,416.02,other,SI=N Exclusions ,,
LEUPROLIDE ACETATE 7.5 MG IM KIT,RX-10392,CDM,J9217,HCPCS,636,RC,00074-3642-03,NDC,outpatient,1,UN,5670.76,3969.532,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,176.51,,,176.51,165.86,17420.48256,fee schedule,,,
LEUPROLIDE ACETATE (3 MONTH) 22.5 MG IM KIT,RX-21045,CDM,J9217,HCPCS,636,RC,00074-3346-03,NDC,outpatient,1,UN,17012.14,11908.498,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,176.51,,,176.51,165.86,17420.48256,fee schedule,,,
LEUPROLIDE ACETATE (4 MONTH) 30 MG IM KIT,RX-21108,CDM,J9217,HCPCS,636,RC,00074-3683-03,NDC,outpatient,1,UN,22682.92,15878.044,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,176.51,,,176.51,165.86,17420.48256,fee schedule,,,
LEUPROLIDE ACETATE (4 MONTH) 30 MG SC KIT,RX-35236,CDM,J9217,HCPCS,636,RC,62935-0303-30,NDC,outpatient,1,UN,1549.29,1084.503,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,176.51,,,176.51,165.86,17420.48256,fee schedule,,,
IPILIMUMAB 5 MG/ML IV SOLN WRAPPER,RX-4080201,CDM,J9228,HCPCS,636,RC,00003-2328-22,NDC,outpatient,40,ML,97611.46,68328.022,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,176.88,,,176.88,167.93,74965.60128,fee schedule,,,
IPILIMUMAB 5 MG/ML IV SOLN WRAPPER,RX-4080201,CDM,J9228,HCPCS,636,RC,00003-2327-11,NDC,outpatient,10,ML,24402.93,17082.051,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,176.88,,,176.88,167.93,74965.60128,fee schedule,,,
METHOTREXATE SODIUM 25 MG/ML IJ SOLN WRAPPER,RX-4080788,CDM,J9250,HCPCS,636,RC,61703-0350-37,NDC,outpatient,0.5,ML,3.4,2.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.27,416.02,other,SI=N Exclusions ,,
METHOTREXATE SODIUM 25 MG/ML IJ SOLN WRAPPER,RX-4080788,CDM,J9250,HCPCS,636,RC,61703-0350-38,NDC,outpatient,0.5,ML,3.4,2.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.27,416.02,other,SI=N Exclusions ,,
METHOTREXATE SODIUM (PF) 25 MG/ML IJ SOLN WRAPPER,RX-4080789,CDM,J9260,HCPCS,636,RC,00143-9519-10,NDC,outpatient,2,ML,6.58,4.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.47721,416.02,other,SI=N Exclusions ,,
METHOTREXATE SODIUM (PF) 25 MG/ML IJ SOLN WRAPPER,RX-4080789,CDM,J9260,HCPCS,636,RC,00143-9519-01,NDC,outpatient,2,ML,6.58,4.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.47721,416.02,other,SI=N Exclusions ,,
NELARABINE 5 MG/ML IV SOLN,RX-70267,CDM,J9261,HCPCS,636,RC,00078-0683-61,NDC,outpatient,50,ML,2241.96,1569.372,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,72.53,,,72.53,72.53,1721.82528,fee schedule,,,
OXALIPLATIN 5 MG/ML IV SOLR WRAPPER,RX-4080205,CDM,J9263,HCPCS,636,RC,00703-3986-01,NDC,outpatient,20,ML,216.64,151.648,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions ,,
OXALIPLATIN 5 MG/ML IV SOLR WRAPPER,RX-4080205,CDM,J9263,HCPCS,636,RC,67457-0469-10,NDC,outpatient,10,ML,50.32,35.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.06,416.02,other,SI=N Exclusions ,,
PACLITAXEL PROTEIN-BOUND PART 100 MG IV SUSR,RX-40475,CDM,J9264,HCPCS,636,RC,68817-0134-50,NDC,outpatient,1,UN,4383.41,3068.387,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13.34,,,13.34,12.06,3366.45888,fee schedule,,,
PACLITAXEL 6 MG/ML IV CONC WRAPPER,RX-4080637,CDM,J9267,HCPCS,636,RC,61703-0342-50,NDC,outpatient,50,ML,238.31,166.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions ,,
PACLITAXEL 6 MG/ML IV CONC WRAPPER,RX-4080637,CDM,J9267,HCPCS,636,RC,63323-0763-50,NDC,outpatient,50,ML,433.61,303.527,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.1,416.02,other,SI=N Exclusions ,,
PENTOSTATIN 10 MG IV SOLR,RX-10910,CDM,J9268,HCPCS,636,RC,00409-0801-01,NDC,outpatient,1,UN,6377.89,4464.523,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2541.77,,,2541.77,399.86,4898.21952,fee schedule,,,
PEMBROLIZUMAB 25 MG/ML IV SOLN WRAPPER,RX-4080564,CDM,J9271,HCPCS,636,RC,00006-3026-02,NDC,outpatient,4,ML,16212.43,11348.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,58.22,,,58.22,54.81,12451.14624,fee schedule,,,
MITOMYCIN 20 MG IV SOLR,RX-10630,CDM,J9280,HCPCS,636,RC,16729-0108-11,NDC,outpatient,1,UN,505.56,353.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42.51,,,42.51,42.51,2565.35808,fee schedule,,,
MITOMYCIN 40 MG IV SOLR,RX-10631,CDM,J9280,HCPCS,636,RC,00143-9280-01,NDC,outpatient,1,UN,3340.31,2338.217,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42.51,,,42.51,42.51,2565.35808,fee schedule,,,
MITOMYCIN 40 MG IV SOLR,RX-10631,CDM,J9280,HCPCS,636,RC,16729-0116-38,NDC,outpatient,1,UN,3340.2,2338.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42.51,,,42.51,42.51,2565.35808,fee schedule,,,
MITOMYCIN 5 MG IV SOLR,RX-10632,CDM,J9280,HCPCS,636,RC,16729-0115-05,NDC,outpatient,1,UN,734.35,514.045,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,42.51,,,42.51,42.51,2565.35808,fee schedule,,,
MITOXANTRONE HCL 20 MG/10ML IV CONC,RX-93748,CDM,J9293,HCPCS,636,RC,61703-0343-18,NDC,outpatient,10,ML,279.99,195.993,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,54.65,,,54.65,29.06,416.02,fee schedule,,,
NIVOLUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080562,CDM,J9299,HCPCS,636,RC,00003-3734-13,NDC,outpatient,24,ML,21406.97,14984.879,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,31.75,,,31.75,30.46,16440.55296,fee schedule,,,
NIVOLUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080562,CDM,J9299,HCPCS,636,RC,00003-3772-11,NDC,outpatient,4,ML,3567.83,2497.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,31.75,,,31.75,30.46,16440.55296,fee schedule,,,
NIVOLUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080562,CDM,J9299,HCPCS,636,RC,00003-3774-12,NDC,outpatient,10,ML,8919.54,6243.678,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,31.75,,,31.75,30.46,16440.55296,fee schedule,,,
OBINUTUZUMAB 1000 MG/40ML IV SOLN,RX-124650,CDM,J9301,HCPCS,636,RC,50242-0070-01,NDC,outpatient,40,ML,23571.67,16500.169,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,74.59,,,74.59,70.55,18103.04256,fee schedule,,,
PANITUMUMAB 20 MG/ML IV SOLN WRAPPER,RX-4080216,CDM,J9303,HCPCS,636,RC,55513-0954-01,NDC,outpatient,5,ML,4571.26,3199.882,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,159.33,,,159.33,149.71,14042.8032,fee schedule,,,
PANITUMUMAB 20 MG/ML IV SOLN WRAPPER,RX-4080216,CDM,J9303,HCPCS,636,RC,55513-0956-01,NDC,outpatient,20,ML,18284.9,12799.43,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,159.33,,,159.33,149.71,14042.8032,fee schedule,,,
PEMETREXED DISODIUM 500 MG IV SOLR,RX-37894,CDM,J9305,HCPCS,636,RC,00002-7623-01,NDC,outpatient,1,UN,11216.1,7851.27,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4.18,,,4.18,4.18,8613.9648,fee schedule,,,
PEMETREXED DISODIUM 100 MG IV SOLR,RX-89350,CDM,J9305,HCPCS,636,RC,00002-7640-01,NDC,outpatient,1,UN,2243.22,1570.254,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,4.18,,,4.18,4.18,8613.9648,fee schedule,,,
PERTUZUMAB 420 MG/14ML IV SOLN,RX-116596,CDM,J9306,HCPCS,636,RC,50242-0145-01,NDC,outpatient,14,ML,18666.61,13066.627,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,16.12,,,16.12,15.37,14335.95648,fee schedule,,,
PRALATREXATE 20 MG/ML IV SOLN WRAPPER,RX-4080207,CDM,J9307,HCPCS,636,RC,72893-0003-01,NDC,outpatient,1,ML,20371.07,14259.749,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,373.77,,,373.77,356.51,15644.98176,fee schedule,,,
RAMUCIRUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080567,CDM,J9308,HCPCS,636,RC,00002-7678-01,NDC,outpatient,50,ML,20423.69,14296.583,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.07,,,71.07,68.87,15685.39392,fee schedule,,,
RAMUCIRUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080567,CDM,J9308,HCPCS,636,RC,00002-7669-01,NDC,outpatient,10,ML,4084.74,2859.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,71.07,,,71.07,68.87,15685.39392,fee schedule,,,
RITUXIMAB 10 MG/ML IV SOLN WRAPPER,RX-4080719,CDM,J9312,HCPCS,636,RC,50242-0053-06,NDC,outpatient,50,ML,13435.14,9404.598,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,77.31,,,77.31,77.31,10318.18752,fee schedule,,,
RITUXIMAB 10 MG/ML IV SOLN WRAPPER,RX-4080719,CDM,J9312,HCPCS,636,RC,50242-0051-21,NDC,outpatient,10,ML,2687.03,1880.921,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,77.31,,,77.31,77.31,10318.18752,fee schedule,,,
STREPTOZOCIN 1 G IV SOLR,RX-11436,CDM,J9320,HCPCS,636,RC,00703-4636-01,NDC,outpatient,1,UN,1171.99,820.393,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,398.13,,,398.13,223.44,900.08832,fee schedule,,,
TEMSIROLIMUS 25 MG/ML IV SOLN,RX-82228,CDM,J9330,HCPCS,636,RC,00008-1179-01,NDC,outpatient,2.5,ML,5549.29,3884.503,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,32.21,,,32.21,32.21,4261.85472,fee schedule,,,
TOPOTECAN HCL 1 MG/ML IV SOLN WRAPPER,RX-4080561,CDM,J9351,HCPCS,636,RC,16729-0151-31,NDC,outpatient,1,UN,263.29,184.303,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.5,416.02,other,SI=N Exclusions ,,
ADO-TRASTUZUMAB EMTANSINE 100 MG IV SOLR,RX-120086,CDM,J9354,HCPCS,636,RC,50242-0088-01,NDC,outpatient,1,UN,11130.41,7791.287,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,40.45,,,40.45,38.33,13677.02016,fee schedule,,,
ADO-TRASTUZUMAB EMTANSINE 160 MG IV SOLR,RX-120087,CDM,J9354,HCPCS,636,RC,50242-0087-01,NDC,outpatient,1,UN,17808.62,12466.034,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,40.45,,,40.45,38.33,13677.02016,fee schedule,,,
TRASTUZUMAB 21 MG/ML IV SOLR WRAPPER,RX-4080954,CDM,J9355,HCPCS,636,RC,50242-0132-01,NDC,outpatient,150,ME,4754.01,3327.807,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,77.94,,,77.94,77.94,3651.07968,fee schedule,,,
TRASTUZUMAB 21 MG/ML IV SOLR WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080954,CDM,J9355,HCPCS,636,RC,50242-0132-01,NDC,outpatient,150,ME,4456.89,3119.823,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,77.94,,,77.94,77.94,3651.07968,fee schedule,,,
VINBLASTINE SULFATE 1 MG/ML IV SOLN IV PUSH,RX-8594,CDM,J9360,HCPCS,636,RC,63323-0278-10,NDC,outpatient,10,ML,173.56,121.492,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.95,416.02,other,SI=N Exclusions ,,
VINCRISTINE SULFATE 1 MG/ML IV SOLN,RX-8597,CDM,J9370,HCPCS,636,RC,61703-0309-06,NDC,outpatient,2,ML,92.35,64.645,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7.49,416.02,other,SI=N Exclusions ,,
VINCRISTINE SULFATE 1 MG/ML IV SOLN,RX-8597,CDM,J9370,HCPCS,636,RC,61703-0309-16,NDC,outpatient,2,ML,46.03,32.221,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7.49,416.02,other,SI=N Exclusions ,,
VINORELBINE TARTRATE 10 MG/ML IV SOLN WRAPPER,RX-4080209,CDM,J9390,HCPCS,636,RC,25021-0204-05,NDC,outpatient,5,ML,163.03,114.121,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,7.59,416.02,other,SI=N Exclusions ,,
FULVESTRANT 250 MG/5ML IM SOSY,RX-160451,CDM,J9394,HCPCS,636,RC,63323-0715-05,NDC,outpatient,10,ML,518.07,362.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53,,,53,1.65,1060,fee schedule,,,
FULVESTRANT 250 MG/5ML IM SOSY,RX-160451,CDM,J9394,HCPCS,636,RC,63323-0715-01,NDC,outpatient,10,ML,518.07,362.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53,,,53,1.65,1060,fee schedule,,,
COLLAR CERV FOAM LARGE -,SUP-00273900400,CDM,L0120,HCPCS,274,RC,,,outpatient,,,175.05,122.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,29.37,,,29.37,4.41367,416.02,fee schedule,,,
COLLAR SM 20.5INX3.5IN SFT DENS BRTHBL STCKNT CVR FOAM/CTTN -,SUP-1018-02,CDM,L0120,HCPCS,274,RC,,,outpatient,,,22.99,16.093,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,29.37,,,29.37,4.41367,416.02,fee schedule,,,
COLLAR CERVICAL STAT MEDIUM -,SUP-1018-03,CDM,L0120,HCPCS,274,RC,,,outpatient,,,19.66,13.762,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,29.37,,,29.37,4.41367,416.02,fee schedule,,,
CERVICAL COLLAR XL SOFT 22x3.5 -,SUP-1050-24,CDM,L0120,HCPCS,274,RC,,,outpatient,,,23.75,16.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,29.37,,,29.37,4.41367,416.02,fee schedule,,,
COLLAR PHILADELPHIA CERVICAL SM TRACH 2PC 4.25IN X 10-13IN -,SUP-1044-11,CDM,L0172,HCPCS,274,RC,,,outpatient,,,126.85,88.795,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,140.5,,,140.5,12.10504,416.02,fee schedule,,,
COLLAR PHILADELPHIA CERVICAL MD TRACH 2PC 4.25IN X 13-16IN -,SUP-1044-12,CDM,L0172,HCPCS,274,RC,,,outpatient,,,126.85,88.795,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,140.5,,,140.5,12.10504,416.02,fee schedule,,,
COLLAR PHILADELPHIA CERVICAL LRG TRACH 2PC 4.25IN X 16-19IN -,SUP-1044-13,CDM,L0172,HCPCS,274,RC,,,outpatient,,,126.85,88.795,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,140.5,,,140.5,12.10504,416.02,fee schedule,,,
COLLAR CERVICAL RIGID MED TRACH 2PC 3.25IN X 13-16IN -,SUP-1113MPP,CDM,L0172,HCPCS,274,RC,,,outpatient,,,53.92,37.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,140.5,,,140.5,12.10504,416.02,fee schedule,,,
COLLAR CERVICAL RIGID SM TRACH 2PC 3.25IN X 10-13IN -,SUP-1113SPP,CDM,L0172,HCPCS,274,RC,,,outpatient,,,53.92,37.744,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,140.5,,,140.5,12.10504,416.02,fee schedule,,,
COLLAR PHILADELPHIA SM 3.25IN 10-13 IN -,SUP-79-83133,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.23,46.361,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,140.5,,,140.5,12.10504,416.02,fee schedule,,,
COLLAR PHILADELPHIA MD 3.25IN x 13-16 IN -,SUP-79-83135,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.23,46.361,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,140.5,,,140.5,12.10504,416.02,fee schedule,,,
COLLAR PHILADELPHIA LG 3.25IN x 16-19IN -,SUP-79-83137,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.23,46.361,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,140.5,,,140.5,12.10504,416.02,fee schedule,,,
COLLAR PHILADELPHIA SM 4.25IN x 10-13IN -,SUP-79-83143,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.46,46.522,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,140.5,,,140.5,12.10504,416.02,fee schedule,,,
COLLAR PHILADELPHIA LG 4.25IN x 16-19IN -,SUP-79-83147,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.46,46.522,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,140.5,,,140.5,12.10504,416.02,fee schedule,,,
KNEE SUPPORT- HINGED PULL UP- MEDIUM -,SUP-NE7711-73,CDM,L1820,HCPCS,274,RC,,,outpatient,,,136.07,95.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,168.45,,,168.45,29.06826,416.02,fee schedule,,,
KNEE SUPPORT HINGED PULL UP- LRG -,SUP-NE7711-74,CDM,L1820,HCPCS,274,RC,,,outpatient,,,129.48,90.636,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,168.45,,,168.45,29.06826,416.02,fee schedule,,,
SUPPORT KNEE HINGED PULL UP LARGE -,SUP-NE7711-74,CDM,L1820,HCPCS,274,RC,,,outpatient,,,136.13,95.291,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,168.45,,,168.45,29.06826,416.02,fee schedule,,,
KNEE SUPPORT HINGED PULL UP X-LRG -,SUP-NE7711-75,CDM,L1820,HCPCS,274,RC,,,outpatient,,,136.07,95.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,168.45,,,168.45,29.06826,416.02,fee schedule,,,
SUPPORT KNEE HINGED PULL UP X-LARGE -,SUP-NE7711-75,CDM,L1820,HCPCS,274,RC,,,outpatient,,,129.48,90.636,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,168.45,,,168.45,29.06826,416.02,fee schedule,,,
BRACE KNEE ENHANCED TROM - DONJOY -,SUP-11-9114-9,CDM,L1832,HCPCS,274,RC,,,outpatient,,,544.99,381.493,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,878.46,,,878.46,110.03643,1222.676,fee schedule,,,
KNEE BRACE HINGED TROM DONJOY -,SUP-11-9114-9,CDM,L1832,HCPCS,274,RC,,,outpatient,,,544.99,381.493,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,878.46,,,878.46,110.03643,1222.676,fee schedule,,,
BRACE KN POSTOP 18-26IN FIT UPTO 34IN THG 6IN ABV MI D PTLR -,SUP-75-7500-000,CDM,L1832,HCPCS,274,RC,,,outpatient,,,490.14,343.098,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,878.46,,,878.46,110.03643,1222.676,fee schedule,,,
ANKLE BRACE SPORTS ORTHOSIS LACE UP BOA SMALL -,SUP-AB3000-12,CDM,L1902,HCPCS,274,RC,,,outpatient,,,105.56,73.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,101.76,,,101.76,23.579235,416.02,fee schedule,,,
ANKLE BRACE SPORTS ORTHOSIS LACE UP BOA MEDIUM -,SUP-AB3000-14,CDM,L1902,HCPCS,274,RC,,,outpatient,,,105.03,73.521,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,101.76,,,101.76,23.579235,416.02,fee schedule,,,
BRACE ANKLE SPORTS ORTHOSIS LACE UP BOA LARGE -,SUP-AB3000-16,CDM,L1902,HCPCS,274,RC,,,outpatient,,,105.56,73.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,101.76,,,101.76,23.579235,416.02,fee schedule,,,
BRACE ANKLE- SPORTS ORTHOSIS LACE UP BOA- XL -,SUP-AB3000-18,CDM,L1902,HCPCS,274,RC,,,outpatient,,,111.45,78.015,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,101.76,,,101.76,23.579235,416.02,fee schedule,,,
SPLINT ORTHO LT ANKL/FT LRG SZ8-10 PLST CLSD HL MLD HK/LOP -,SUP-A508LL,CDM,L1930,HCPCS,274,RC,,,outpatient,,,180.48,126.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,302.12,,,302.12,34.77954,420.504,fee schedule,,,
SPLINT ORTHO LT ANKL/FT MED SZ8-10 PLST CLSD HL MLD HK/LOP -,SUP-A508LM,CDM,L1930,HCPCS,274,RC,,,outpatient,,,179.78,125.846,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,302.12,,,302.12,34.77954,420.504,fee schedule,,,
SPLINT ORTHO RT ANKL/FT LRG SZ8-10 MALE PLST CLSD HL MLD -,SUP-A508RL,CDM,L1930,HCPCS,274,RC,,,outpatient,,,180.48,126.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,302.12,,,302.12,34.77954,420.504,fee schedule,,,
SPLINT ORTHO RT ANKL/FT LRG SZ8-10 PLST CLSD HL MLD HK/LOP -,SUP-A508RM,CDM,L1930,HCPCS,274,RC,,,outpatient,,,175.28,122.696,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,302.12,,,302.12,34.77954,420.504,fee schedule,,,
SPLINT ORTHO RT ANKL/FT SM SZ3-6 FEM PLST CLSD HL MLD HK/LOP -,SUP-A508RS,CDM,L1930,HCPCS,274,RC,,,outpatient,,,226.22,158.354,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,302.12,,,302.12,34.77954,420.504,fee schedule,,,
AFO FOR FOOT AND ANKLE -,SUP-XEE64330,CDM,L1930,HCPCS,274,RC,,,outpatient,,,154.92,108.444,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,302.12,,,302.12,34.77954,420.504,fee schedule,,,
AFO FOR FOOT AND ANKLE -,SUP-XEE64331,CDM,L1930,HCPCS,274,RC,,,outpatient,,,154.92,108.444,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,302.12,,,302.12,34.77954,420.504,fee schedule,,,
SYS FOOT OTHTC SM PEGASSIST DARCO -,SUP-PW1,CDM,L3002,HCPCS,274,RC,,,outpatient,,,73.46,51.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,62.26,16.49177,416.02,percent of total billed charges,,,
SYS FOOT OTHTC MED PEGASSIST DARCO -,SUP-PW2,CDM,L3002,HCPCS,274,RC,,,outpatient,,,73.46,51.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,62.26,16.49177,416.02,percent of total billed charges,,,
SYS FOOT OTHTC XL PEGASSIST DARCO -,SUP-PW4,CDM,L3002,HCPCS,274,RC,,,outpatient,,,73.46,51.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,62.26,16.49177,416.02,percent of total billed charges,,,
SHOE POSTOP SZ5-6.5 SM MALE RT/LT LACE-UP CLSR -,SUP-2020-01,CDM,L3260,HCPCS,274,RC,,,outpatient,,,31.86,22.302,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,,,
SHOE POSTOP SZ7-8.5 MED MALE RT/LT LACE-UP CLSR -,SUP-2020-02,CDM,L3260,HCPCS,274,RC,,,outpatient,,,31.86,22.302,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,,,
SHOE POSTOP SZ9-11 LRG MALE RT/LT LACE-UP CLSR -,SUP-2020-03,CDM,L3260,HCPCS,274,RC,,,outpatient,,,31.86,22.302,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,,,
SHOE POSTOP SZ4-6 SM FEM RT/LT LACE-UP CLSR -,SUP-2021-01,CDM,L3260,HCPCS,274,RC,,,outpatient,,,30.87,21.609,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,,,
SHOE POSTOP SZ6.5-8 MED FEM RT/LT LACE-UP CLSR -,SUP-2021-02,CDM,L3260,HCPCS,274,RC,,,outpatient,,,30.87,21.609,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,,,
SHOE POSTOP SZ8.5-10 LRG L/R ANKL OPN TOE CLSD HL CNVS RBR -,SUP-2021-03,CDM,L3260,HCPCS,274,RC,,,outpatient,,,30.87,21.609,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,,,
BOOT CAST SM 4.5X8.5IN CNVS FT RCKR SOLE NSLIP HK/LOP CLSR -,SUP-2035-02,CDM,L3260,HCPCS,274,RC,,,outpatient,,,27.25,19.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,,,
CAST SHOE MED CANVAS ROCKER -,SUP-2035-03,CDM,L3260,HCPCS,274,RC,,,outpatient,,,27.6,19.32,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,,,
SHOE CAST LRG 5.25X11.5IN CNVS FT RCKR SOLE NSLIP HK/LOP -,SUP-2035-04,CDM,L3260,HCPCS,274,RC,,,outpatient,,,27.25,19.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,,,
SURGICAL SHOE MENS XL -,SUP-5701024,CDM,L3260,HCPCS,274,RC,,,outpatient,,,39.56,27.692,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,,,
SHOE ORTHO ANKL SM SZ7.5-10 MSH CLSD HL CLSD TOE HK/LOP STRP -,SUP-92732502,CDM,L3260,HCPCS,274,RC,,,outpatient,,,221.73,155.211,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,,,
SHOE ORTHO ANKL MED SZ8.5-10 MALE MSH CLSD HL CLSD TOE -,SUP-92732503,CDM,L3260,HCPCS,274,RC,,,outpatient,,,214.44,150.108,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,,,
SHOE ORTHO ANKL LRG SZ10.5-12 MSH CLSD HL CLSD TOE HK/LOP -,SUP-92732504,CDM,L3260,HCPCS,274,RC,,,outpatient,,,214.44,150.108,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,,,
SHOE CAST SZ6-8 MALE SZ7.5-10 FEM SM FT DARCO HEELWEDGE -,SUP-92732602,CDM,L3260,HCPCS,274,RC,,,outpatient,,,116.41,81.487,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,,,
SHOE CAST SZ8.5-10 MALE 10.5-13 FEM MED FT DARCO HEELWEDGE -,SUP-92732603,CDM,L3260,HCPCS,274,RC,,,outpatient,,,124.52,87.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,,,
SHOE POST-OP NYLON RUBBER HOOK/LOOP MALE SMALL -,SUP-A152305,CDM,L3260,HCPCS,274,RC,,,outpatient,,,20.66,14.462,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,,,
POST OP SHOE NYLON RUBBER HOOK/LOOP MALE LRG -,SUP-A152307,CDM,L3260,HCPCS,274,RC,,,outpatient,,,22.29,15.603,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,,,
SHOE POSTOP MENS SM SIZES 6-8 MEDSURG -,SUP-MQM1B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,,,
SHOE POSTOP MENS MED SIZES 8.5-10 MEDSURG -,SUP-MQM2B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,,,
SHOE POSTOP MENS LG SIZES 10.5-12 MEDSURG -,SUP-MQM3B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,,,
SHOE POSTOP MENS XL SIZES 12.5-14 MEDSURG -,SUP-MQM4B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,,,
SHOE POSTOP WOMENS SM SIZES 4-6 MEDSURG -,SUP-MQW1B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,,,
SHOE POSTOP SZ6.5-8 FEM MED MEDSURG OPN TOE CLSD HL RCKR BTM -,SUP-MQW2B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,110.4,77.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,,,
SHOE POSTOP WOMENS MED SIZES 6.5- 8 MEDSURG -,SUP-MQW2B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,,,
SHOE POSTOP WOMENS LG SIZES  8.5 -10 MEDSURG -,SUP-MQW3B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,,,
SHOE DARCO SURGICAL MENS SMALL -,SUP-MSM1N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,28.47,19.929,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,,,
SHOES DARCO MENS MEDIUM -,SUP-MSM2N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,47.21,33.047,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,,,
SHOES DARCO MENS LARGE -,SUP-MSM3N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,48.55,33.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,,,
SHOES DARCO WOMENS SMALL -,SUP-MSW1N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,48.55,33.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,,,
SHOES DARCO WOMENS MEDIUM -,SUP-MSW2N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,28.47,19.929,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,,,
SHOES DARCO WOMENS LARGE -,SUP-MSW3N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,45.63,31.941,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,,,
BOOT CAST REG FT PD WVN TCC-EZ -,SUP-TCC21100,CDM,L3260,HCPCS,274,RC,,,outpatient,,,393.57,275.499,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,,,
BOOT CAST LRG FT PD WVN TCC-EZ -,SUP-TCC21114,CDM,L3260,HCPCS,274,RC,,,outpatient,,,444.34,311.038,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,,,
BOOT CAST LRG FT CHARCOT PD WVN TCC-EZ -,SUP-TCC21116,CDM,L3260,HCPCS,274,RC,,,outpatient,,,538.28,376.796,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,,,
SYS CAST 3IN FT CHARCOT PD WVN W/REGULARX2 BT TCC-EZ -,SUP-TCC23000,CDM,L3260,HCPCS,274,RC,,,outpatient,,,627.97,439.579,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,,,
SYS CAST SZ4 IN FT PD WVN W/2 REG BT TCC-EZ -,SUP-TCC24000,CDM,L3260,HCPCS,274,RC,,,outpatient,,,627.97,439.579,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,25.26,,,25.26,4.63817,482.28096,fee schedule,,,
IMMOBILIZER SHLDR LRG ELAS HUM CUF RB WRP -,SUP-00078300300,CDM,L3670,HCPCS,274,RC,,,outpatient,,,291.75,204.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122.45,,,122.45,3.81201,416.02,fee schedule,,,
IMMOBILIZER SHLDR LRG ELAS HUM CUF CONTR RB WRP -,SUP-00078400300,CDM,L3670,HCPCS,274,RC,,,outpatient,,,233.4,163.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122.45,,,122.45,3.81201,416.02,fee schedule,,,
IMMOBILIZER SHLDR SMALL ULTRASLING III BLACK -,SUP-11-0449-2,CDM,L3670,HCPCS,274,RC,,,outpatient,,,305.46,213.822,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122.45,,,122.45,3.81201,416.02,fee schedule,,,
IMMOBILIZER SHLDR MED ULTRASLING III BLACK -,SUP-11-0449-3,CDM,L3670,HCPCS,274,RC,,,outpatient,,,305.46,213.822,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122.45,,,122.45,3.81201,416.02,fee schedule,,,
SUPPORT RT SHLDR SM 11IN MSH FBRC ULSNG ER HUM CUF 15DEG -,SUP-11-1343-2-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122.45,,,122.45,3.81201,416.02,fee schedule,,,
SUPPORT LT SHLDR ARM SM UPTO 11IN MSH FBRC ULSNG ER BRTHBL -,SUP-11-1344-2-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122.45,,,122.45,3.81201,416.02,fee schedule,,,
SUPPORT LT SHLDR ARM LRG ABV 13IN MSH FBRC ULSNG ER BRTHBL -,SUP-11-1344-4-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122.45,,,122.45,3.81201,416.02,fee schedule,,,
SUPPORT RT SHLDR SM 11IN MSH FBRC ULSNG ER HUM CUF 30DEG -,SUP-11-1345-2,CDM,L3670,HCPCS,274,RC,,,outpatient,,,371.22,259.854,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122.45,,,122.45,3.81201,416.02,fee schedule,,,
SUPPORT RT SHLDR LRG 13-15IN MSH FBRC ULSNG ER HUM 30DEG -,SUP-11-1345-4-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122.45,,,122.45,3.81201,416.02,fee schedule,,,
SUPPORT LT SHLDR LRG 13-15IN MSH FBRC ULSNG ER BRTHBL HUM -,SUP-11-1346-4-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122.45,,,122.45,3.81201,416.02,fee schedule,,,
IMMOBILIZER SHLDR SLING MED 7IN X 17IN -,SUP-11630006,CDM,L3670,HCPCS,274,RC,,,outpatient,,,243.14,170.198,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122.45,,,122.45,3.81201,416.02,fee schedule,,,
IMMOBILIZER SHLDR SLING LRG 7IN X 18IN -,SUP-11630007,CDM,L3670,HCPCS,274,RC,,,outpatient,,,243.14,170.198,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122.45,,,122.45,3.81201,416.02,fee schedule,,,
IIMMOBILIZER SHOULDER VELPEAU M -,SUP-23-1872,CDM,L3670,HCPCS,274,RC,,,outpatient,,,29.7,20.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122.45,,,122.45,3.81201,416.02,fee schedule,,,
IMMOBILIZER SHOULDER VELPEAU L -,SUP-23-1873-000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,29.7,20.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122.45,,,122.45,3.81201,416.02,fee schedule,,,
IMMOBILIZER SHLDR SM PD WRST/HUM CUF SHLDR/WST STRP -,SUP-667110,CDM,L3670,HCPCS,274,RC,,,outpatient,,,343.1,240.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122.45,,,122.45,3.81201,416.02,fee schedule,,,
IMMOBILIZER RT/LT SHLDR XS CTTN CLTH 6X12.5IN PCH CLSD/OPN -,SUP-9002-01,CDM,L3670,HCPCS,274,RC,,,outpatient,,,29.12,20.384,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122.45,,,122.45,3.81201,416.02,fee schedule,,,
IMMOBILIZER SHOULDER UNIVERSAL -,SUP-9013-00,CDM,L3670,HCPCS,274,RC,,,outpatient,,,56.25,39.375,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122.45,,,122.45,3.81201,416.02,fee schedule,,,
SHOULDER IMMOBILIZER W/FOAM SMALL -,SUP-A111015,CDM,L3670,HCPCS,274,RC,,,outpatient,,,19.02,13.314,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122.45,,,122.45,3.81201,416.02,fee schedule,,,
SHOULDER IMMOBILIZER W/FOAM WAIST STRAP M -,SUP-A111016,CDM,L3670,HCPCS,274,RC,,,outpatient,,,19.02,13.314,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122.45,,,122.45,3.81201,416.02,fee schedule,,,
IMMOBILIZER SHLDR X-LRG 9IN X 22.5IN -,SUP-A111018,CDM,L3670,HCPCS,274,RC,,,outpatient,,,16.98,11.886,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122.45,,,122.45,3.81201,416.02,fee schedule,,,
IMMOBILIZER SHOULDER VELP XLG -,SUP-TX9023-04,CDM,L3670,HCPCS,274,RC,,,outpatient,,,31.1,21.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,122.45,,,122.45,3.81201,416.02,fee schedule,,,
SPLINT RT HND SM 6.5-7.25IN ALIFLEECE LINER THRMPLST DLX FIG -,SUP-5183,CDM,L3807,HCPCS,274,RC,,,outpatient,,,286.27,200.389,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,262.88,,,262.88,31.76675,416.02,fee schedule,,,
SPLINT RT HND LRG 8.25-9.25IN ALIFLEECE LINER THRMPLST DLX -,SUP-5187,CDM,L3807,HCPCS,274,RC,,,outpatient,,,284.4,199.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,262.88,,,262.88,31.76675,416.02,fee schedule,,,
SPLINT LT SM RST -,SUP-5812,CDM,L3807,HCPCS,274,RC,,,outpatient,,,273.08,191.156,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,262.88,,,262.88,31.76675,416.02,fee schedule,,,
SPLINT WRST MED POLY FOAM CCKUP -,SUP-A1601P,CDM,L3807,HCPCS,274,RC,,,outpatient,,,141.5,99.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,262.88,,,262.88,31.76675,416.02,fee schedule,,,
EXTERNAL FIX DIGIT WIDGET -,SUP-DWD-232,CDM,L3921,HCPCS,274,RC,,,outpatient,,,7002.6,4901.82,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,337.68,,,337.68,335.72,5377.9968,fee schedule,,,
SPLINT THUMB SPICA RIGHT MED/LRG 3.5IN - 4.25IN -,SUP-340M/LR,CDM,L3924,HCPCS,274,RC,,,outpatient,,,68.27,47.789,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,57.87,15.326615,416.02,percent of total billed charges,,,
THUMB SPLINT COMFORT COOL CMC LT MEDIUM -,SUP-348ML,CDM,L3924,HCPCS,274,RC,,,outpatient,,,92.66,64.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,78.54,15.326615,416.02,percent of total billed charges,,,
THUMB SPLINT COMFORT COOL CMC RT MEDIUM -,SUP-348MR,CDM,L3924,HCPCS,274,RC,,,outpatient,,,92.66,64.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,78.54,15.326615,416.02,percent of total billed charges,,,
LMB SPRING PIP EXTENSION ASSIST -,SUP-704103,CDM,L3925,HCPCS,274,RC,,,outpatient,,,89.16,62.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,56.51,,,56.51,17.225885,416.02,fee schedule,,,
SPLINT FINGER EXTENSION LMB SPRING SIZE A -,SUP-704200,CDM,L3925,HCPCS,274,RC,,,outpatient,,,76.73,53.711,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,56.51,,,56.51,17.225885,416.02,fee schedule,,,
SPLINT FINGER EXTENSION SPRING LMB SIZE C -,SUP-704202,CDM,L3925,HCPCS,274,RC,,,outpatient,,,76.79,53.753,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,56.51,,,56.51,17.225885,416.02,fee schedule,,,
BOOT WALKER LRG AIRCAST SZ10-13 MALE SZ11-15 FEM PED -,SUP-01EF-L,CDM,L4361,HCPCS,274,RC,,,outpatient,,,269.52,188.664,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,228.45,50.613525,568.638,percent of total billed charges,,,
BOOT WALKER MED AIRCAST SZ7-10 MALE SZ8-11 FEM -,SUP-01EF-M,CDM,L4361,HCPCS,274,RC,,,outpatient,,,269.52,188.664,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,228.45,50.613525,568.638,percent of total billed charges,,,
BOOT WALKER SM AIRCAST SZ4-7 MALE SZ5-8 FEM -,SUP-01F-S,CDM,L4361,HCPCS,274,RC,,,outpatient,,,263.86,184.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,223.65,50.613525,568.638,percent of total billed charges,,,
BOOT WALKER XL AIRCAST SZ 13+ MALE SZ 15+ FEM -,SUP-01F-XL,CDM,L4361,HCPCS,274,RC,,,outpatient,,,263.86,184.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,223.65,50.613525,568.638,percent of total billed charges,,,
BOOT WALKER LRG SHELL 10-13M/11-15F -,SUP-1175LPP,CDM,L4361,HCPCS,274,RC,,,outpatient,,,225.45,157.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,191.09,50.613525,568.638,percent of total billed charges,,,
WALKER FULL SHELL 2 SHORT- SMALL -,SUP-15500047,CDM,L4361,HCPCS,274,RC,,,outpatient,,,274.6,192.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,232.75,50.613525,568.638,percent of total billed charges,,,
WALKER- FULL SHELL 2 SHORT- MEDIUM -,SUP-15500048,CDM,L4361,HCPCS,274,RC,,,outpatient,,,249.74,174.818,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,211.68,50.613525,568.638,percent of total billed charges,,,
WALKER FULL SHELL 2 SHORT LARGE -,SUP-1550049,CDM,L4361,HCPCS,274,RC,,,outpatient,,,234.33,164.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,198.62,50.613525,568.638,percent of total billed charges,,,
BOOT ORTHO FT MED/L FLEECE LINER OPN TOE SEMI- FLXB SHL -,SUP-6963,CDM,L4394,HCPCS,274,RC,,,outpatient,,,127.09,88.963,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,23.95,,,23.95,20.61,416.02,fee schedule,,,
VALVE SPK 15X23MM PASSY-MUIR WHITE -,SUP-PMV 005,CDM,L8501,HCPCS,274,RC,,,outpatient,,,429.46,300.622,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,364.01,52.37136,418.655068,percent of total billed charges,,,
VALVE SPK PASSY-MUIR PMV 15X22MM LPRO REUS FLEX AQUA -,SUP-PMV 007,CDM,L8501,HCPCS,274,RC,,,outpatient,,,493.93,345.751,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,418.66,52.37136,418.655068,percent of total billed charges,,,
VALVE SPK/SWALW IN G 15X23MM PASSY-MUIR PMV 1W  CLEAR -,SUP-PMV 2000,CDM,L8501,HCPCS,274,RC,,,outpatient,,,429.46,300.622,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,364.01,52.37136,418.655068,percent of total billed charges,,,
VALVE PASSY MUIR PURPLE SPEAK SWALLOW IN G 15X23MM PMV -,SUP-PMV 2001,CDM,L8501,HCPCS,274,RC,,,outpatient,,,429.46,300.622,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,364.01,52.37136,418.655068,percent of total billed charges,,,
VALVE SPK SHILEY 0.66MM MINI STRL MONOKA PHONATE W/O O2 PRT -,SUP-SSV,CDM,L8501,HCPCS,274,RC,,,outpatient,,,233.28,163.296,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,197.73,52.37136,418.655068,percent of total billed charges,,,
PROSTHESIS VOCAL CRD BLOM-SINGER CLASSIC 20FRX8MM INDWL STRL -,SUP-IN 2008-SO,CDM,L8509,HCPCS,274,RC,,,outpatient,,,1378.13,964.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,126.4,,,126.4,125.65,1058.40384,fee schedule,,,
PROSTHESIS VOCAL CRD BLOM-SINGER 20FRX14MM INDWL STRL -,SUP-IN2014-SO,CDM,L8509,HCPCS,274,RC,,,outpatient,,,1378.13,964.691,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,126.4,,,126.4,125.65,1058.40384,fee schedule,,,
IMPLANT BRST 600ML SIL GEL HPRO RND 14CM MEMORYGEL 5.6CM -,SUP-350-6004BC,CDM,L8600,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,3409.78176,other,SI=N Exclusions ,,
BULKAMID URETHRAL BULKING SYSTEM -,SUP-50050,CDM,L8606,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,252.25,3748.3008,other,SI=N Exclusions ,,
COAPTITE SYRINGE 1ML -,SUP-M0068903000,CDM,L8606,HCPCS,278,RC,,,outpatient,,,1975.44,1382.808,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,252.25,3748.3008,other,SI=N Exclusions ,,
SPHERE EYE 18MM -,SUP-14254,CDM,L8610,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,70.737705,686.06,other,SI=N Exclusions ,,
IMPLANT OSS PRT WIET 1.14MM SHFT 3.25MMX5MM OFF-CTR HAP FLEX -,SUP-0516,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions ,,
PROSTHESIS OSS PRT 4X5MM CTR HAP FLEX TI MLBL -,SUP-0550,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2565.44,1795.808,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions ,,
MNP TOTAL TITANIUM .2 X 3.00MM -,SUP-1004434,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions ,,
MNP TOTAL TITANIUM .2 X 3.5MM -,SUP-1004436,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions ,,
OMEGA CONNECTOR 1.5MM X 8MMX0.5 -,SUP-1004930,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1219.12,853.384,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions ,,
PROSTHESIS OSS ASTN PLAS-PR MOD PORP 3MM FLNG DIA 1MM SHFT -,SUP-14-0063,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1300.05,910.035,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions ,,
PISTON OTO SCHKNT 0.8MMX4.25MM WIRE LOOP FLPLS SS -,SUP-14-0105,CDM,L8613,HCPCS,278,RC,,,outpatient,,,628.66,440.062,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions ,,
LOOP WIRE HOUSE TYPE .12 X 4.0 -,SUP-140184,CDM,L8613,HCPCS,278,RC,,,outpatient,,,268.41,187.887,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions ,,
LOOP WIRE HOUSE TYPE .12 X 4.25 -,SUP-140184,CDM,L8613,HCPCS,278,RC,,,outpatient,,,346.6,242.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions ,,
PISTON OTO RCHRD 0.6MMX3.50MM RBN LOOP FLPLS PLTNM -,SUP-14-0781,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions ,,
PISTON OTO RCHRD 0.6X4MM RBN LOOP FLPLS PLTNM -,SUP-14-0783,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions ,,
PISTON OTO RCHRD 0.6MMX4.25MM RBN LOOP FLPLS PLTNM -,SUP-14-0784,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions ,,
PISTON OTO RCHRD 0.8X4MM RBN LOOP FLPLS PLTNM -,SUP-14-0792,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1024.74,717.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions ,,
PISTON OTO RCHRD 0.8MMX4.5MM RBN LOOP FLPLS PLTNM -,SUP-14-0794,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions ,,
PLATE OSS MED 10MM POR HAP ATTIC DFCT -,SUP-14-0863,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1063.14,744.198,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions ,,
PLATE OSS 14MM LRG POR HAP ATTIC DFCT -,SUP-14-0864,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1072.41,750.687,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions ,,
PROSTHESIS OSS APLBM SM 2X2MM 1MM CANN HAP INCSTP -,SUP-14-0956,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2182.32,1527.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions ,,
PROSTHESIS OSS PRT GLDNBRG 1.5MM 1.14MM FLLY CANN HAP EAR -,SUP-14-0963,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2038.36,1426.852,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions ,,
PROSTHESIS OSS APLBM 2.5X3MM HAP INCUS -,SUP-14-0973,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2205.54,1543.878,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions ,,
PROSTHESIS OSS RCHRD 0.4MM PSTN 1MM WELL 4.50MM CUP PED -,SUP-142152,CDM,L8613,HCPCS,278,RC,,,outpatient,,,761.58,533.106,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions ,,
Eclipse Flat Ribbon Piston .6MM X 4.50MM -,SUP-472-450,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1863.34,1304.338,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions ,,
Eclipse Flat Ribbon Piston .6MM X 4.75MM -,SUP-472-475,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1863.34,1304.338,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions ,,
Eclipse Flat Ribbon Piston .6MM X 5.00MM -,SUP-472-500,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1863.34,1304.338,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions ,,
PROSTHESIS OSS UM TORP 2X10MM CTR TI ADJ -,SUP-7014-1044,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1852.68,1296.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions ,,
PROSTHESIS OSS UM TORP 2X5MM CTR TI ADJ -,SUP-7014-1046,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1852.68,1296.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions ,,
PISTON OSS SMRT 0.6X4MM WIRE LOOP FLPLS NTNL STPS ADLT -,SUP-70145926,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1601.92,1121.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions ,,
PISTON OSS SMRT 0.6MMX4.25MM WIRE LOOP FLPLS NTNL STPS ADLT -,SUP-70145927,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1601.92,1121.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions ,,
PISTON OSS SMRT 0.6MMX4.50MM WIRE LOOP FLPLS NTNL STPS ADLT -,SUP-70145928,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1601.92,1121.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions ,,
DISTANCE PLATES REPLACEMENT 0.1 /0.2 /0.3 -,SUP-8000140,CDM,L8613,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,60.258045,2016.5376,other,SI=N Exclusions ,,
JOINT FINGER SWANSON 1 MCP FLEXIBLE STERILE W/O GROMMETS SIL -,SUP-4700001,CDM,L8630,HCPCS,278,RC,,,outpatient,,,4602.62,3221.834,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,3534.81216,other,SI=N Exclusions ,,
IMPLANT PIP MCP SZ4 SWNSN SIL -,SUP-G470-0004,CDM,L8630,HCPCS,278,RC,,,outpatient,,,4413.76,3089.632,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,3534.81216,other,SI=N Exclusions ,,
PROSTHESIS PENL TOROSA LRG SAL FIL CYL INFL PRECNCT SCRT -,SUP-450-1329,CDM,L8699,HCPCS,278,RC,,,outpatient,,,8471.02,5929.714,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,163.74581,6505.74336,other,SI=N Exclusions ,,
PROSTHESIS TSTCLR 2.9CMX4.5IN -,SUP-96-450-1329,CDM,L8699,HCPCS,278,RC,,,outpatient,,,7002.6,4901.82,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,163.74581,6505.74336,other,SI=N Exclusions ,,
LEAD ANCHOR KIT -,SUP-ACCK5300,CDM,L8699,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,163.74581,6505.74336,other,SI=N Exclusions ,,
WEIGHT EYELID THN 0.6MM PLTNM 0.6GM SPHRCL CRV TAPR EDGE RND -,SUP-LL 6006,CDM,L8699,HCPCS,278,RC,,,outpatient,,,1749.17,1224.419,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,163.74581,6505.74336,other,SI=N Exclusions ,,
UROLIFT ATC IMPLANT CARTRIDGE -,SUP-UL2ATC-C,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4986.7,3490.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,163.74581,6505.74336,other,SI=N Exclusions ,,
IMPLANT UROLOGICAL UROLIFT 2 CARTRIDGE -,SUP-UL2-C,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,163.74581,6505.74336,other,SI=N Exclusions ,,
IMPLANT CARTRIDGE UROLIFT -,SUP-UL2-C,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4350.1,3045.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,163.74581,6505.74336,other,SI=N Exclusions ,,
KIT HANDLE UROLIFT DELIVERY HANDLE IMPLANT CARTRIDGE -,SUP-UL2-CHK,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,163.74581,6505.74336,other,SI=N Exclusions ,,
IMPLANT HANDLE CARTRIDGE UROLIFT -,SUP-UL2-CHK,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,163.74581,6505.74336,other,SI=N Exclusions ,,
HC Bebtelovimab Injection,PX-26000018,CDM,M0222,HCPCS,260,RC,,,outpatient,,,1455,1018.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,394.43,,,394.43,326.6475,1117.44,fee schedule,,,
HC Cryoprecipitate Each Unit,PX-39000006,CDM,P9012,CPT,390,RC,,,outpatient,,,1227,858.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,56.49,,,56.49,49.4,942.336,fee schedule,,,
HC RBC Leukocytes Reduced,PX-39000007,CDM,P9016,CPT,390,RC,,,outpatient,,,551,385.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,211.31,,,211.31,123.6995,423.168,fee schedule,,,
HC Plasma 1 Donor Frz W/in 8 Hr,PX-39000008,CDM,P9017,CPT,390,RC,,,outpatient,,,379,265.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,81.8,,,81.8,71.53,416.02,fee schedule,,,
HC Red Blood Cells Unit,PX-39000009,CDM,P9021,CPT,390,RC,,,outpatient,,,471,329.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,160.24,,,160.24,105.7395,416.02,fee schedule,,,
HC Washed Red Blood Cells Unit,PX-39000010,CDM,P9022,CPT,390,RC,,,outpatient,,,1028,719.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,871.33,163,871.3328,percent of total billed charges,,,
HC Platelets Leukocytes Reduced,PX-39000011,CDM,P9031,CPT,390,RC,,,outpatient,,,1397,977.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,172.26,,,172.26,136.61,1072.896,fee schedule,,,
HC Platelets Leukoreduced Irrad,PX-39000012,CDM,P9033,CPT,390,RC,,,outpatient,,,1633,1143.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1384.13,163,1384.1308,percent of total billed charges,,,
HC Platelet Pheres Leukoreduced,PX-39000013,CDM,P9035,CPT,390,RC,,,outpatient,,,1233,863.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,556.11,,,556.11,163,1119.53,fee schedule,,,
HC Plate Pheres Leukoredu Irrad,PX-39000014,CDM,P9037,CPT,390,RC,,,outpatient,,,1624,1136.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,714.64,,,714.64,163,1476.21,fee schedule,,,
HC RBC Deglycerolized,PX-39000015,CDM,P9039,CPT,390,RC,,,outpatient,,,2586,1810.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2191.89,163,2191.8936,percent of total billed charges,,,
HC RBC Leukoreduced Irradiated,PX-39000016,CDM,P9040,CPT,390,RC,,,outpatient,,,636,445.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,292.27,,,292.27,142.782,598.2,fee schedule,,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,00944-0495-06,NDC,outpatient,250,ML,112.79,78.953,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.08,,,53.08,25.321355,416.02,fee schedule,,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,68516-5214-03,NDC,outpatient,250,ML,168.42,117.894,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.08,,,53.08,25.321355,416.02,fee schedule,,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,00944-0495-05,NDC,outpatient,250,ML,112.79,78.953,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.08,,,53.08,25.321355,416.02,fee schedule,,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,68516-5214-01,NDC,outpatient,250,ML,168.42,117.894,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.08,,,53.08,25.321355,416.02,fee schedule,,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,76125-0790-25,NDC,outpatient,250,ML,171.75,120.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.08,,,53.08,25.321355,416.02,fee schedule,,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,44206-0310-25,NDC,outpatient,250,ML,199.57,139.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.08,,,53.08,25.321355,416.02,fee schedule,,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,44206-0310-90,NDC,outpatient,250,ML,199.57,139.699,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.08,,,53.08,25.321355,416.02,fee schedule,,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,68982-0623-03,NDC,outpatient,500,ML,363.1,254.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.08,,,53.08,25.321355,416.02,fee schedule,,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,76125-0790-26,NDC,outpatient,250,ML,171.75,120.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.08,,,53.08,25.321355,416.02,fee schedule,,,
ALBUMIN HUMAN 5 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8982,CDM,P9045,HCPCS,636,RC,68982-0623-03,NDC,outpatient,500,ML,347.1,242.97,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,53.08,,,53.08,25.321355,416.02,fee schedule,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-01,NDC,outpatient,50,ML,209.58,146.706,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.08,,,53.08,7.294005,416.02,fee schedule,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-02,NDC,outpatient,100,ML,48.49,33.943,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.08,,,53.08,7.294005,416.02,fee schedule,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,64208-2512-07,NDC,outpatient,100,ML,309.7,216.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.08,,,53.08,7.294005,416.02,fee schedule,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-00,NDC,outpatient,100,ML,309.7,216.79,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.08,,,53.08,7.294005,416.02,fee schedule,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-01,NDC,outpatient,50,ML,168.42,117.894,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.08,,,53.08,7.294005,416.02,fee schedule,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-02,NDC,outpatient,100,ML,320.83,224.581,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.08,,,53.08,7.294005,416.02,fee schedule,,,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-04,NDC,outpatient,100,ML,32.49,22.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,53.08,,,53.08,7.294005,416.02,fee schedule,,,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-00,NDC,outpatient,100,ML,293.7,205.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,53.08,,,53.08,7.294005,416.02,fee schedule,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-03,NDC,outpatient,50,ML,209.58,146.706,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.08,,,53.08,7.294005,416.02,fee schedule,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-04,NDC,outpatient,100,ML,320.83,224.581,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.08,,,53.08,7.294005,416.02,fee schedule,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-08,NDC,outpatient,100,ML,430.3,301.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.08,,,53.08,7.294005,416.02,fee schedule,,,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,64208-2512-07,NDC,outpatient,100,ML,293.7,205.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,53.08,,,53.08,7.294005,416.02,fee schedule,,,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-08,NDC,outpatient,100,ML,414.3,290.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,53.08,,,53.08,7.294005,416.02,fee schedule,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-04,NDC,outpatient,100,ML,48.49,33.943,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.08,,,53.08,7.294005,416.02,fee schedule,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-03,NDC,outpatient,50,ML,168.42,117.894,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,53.08,,,53.08,7.294005,416.02,fee schedule,,,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-02,NDC,outpatient,100,ML,32.49,22.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,53.08,,,53.08,7.294005,416.02,fee schedule,,,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-04,NDC,outpatient,100,ML,304.83,213.381,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,53.08,,,53.08,7.294005,416.02,fee schedule,,,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-02,NDC,outpatient,100,ML,304.83,213.381,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],JW,53.08,,,53.08,7.294005,416.02,fee schedule,,,
HC Platelets- Hla-M- L/R- Unit,PX-39000026,CDM,P9052,HCPCS,390,RC,,,outpatient,,,1807,1264.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,925.16,,,925.16,163,1698,fee schedule,,,
HC RBC- Frz/Deg/Wsh- L/R- Irrad,PX-39000023,CDM,P9057,CPT,390,RC,,,outpatient,,,2062,1443.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1747.75,163,1747.7512,percent of total billed charges,,,
HC RBC- L/R- Cmv-Neg- Irrad,PX-39000024,CDM,P9058,CPT,390,RC,,,outpatient,,,1235,864.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1046.79,163,1046.786,percent of total billed charges,,,
HC Plasma- Frz Between 8-24hour,PX-39000025,CDM,P9059,CPT,390,RC,,,outpatient,,,222,155.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,87.67,,,87.67,49.839,416.02,fee schedule,,,
HC Platelets- Pheresis- Pathogen-Reduced- Each Unit,PX-39000028,CDM,P9073,HCPCS,390,RC,,,outpatient,,,1626,1138.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,714.64,,,714.64,163,1265.41,fee schedule,,,
HC Pathogen Test for Platelets,PX-30000897,CDM,P9100,HCPCS,300,RC,,,outpatient,,,89,62.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,29.16,,,29.16,19.9805,416.02,fee schedule,,,
FERUMOXYTOL 510 MG/17ML IV SOLN,RX-98312,CDM,Q0138,HCPCS,636,RC,59338-0775-01,NDC,outpatient,17,ML,945.71,661.997,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.34,,,0.34,0.34,726.30528,fee schedule,,,
ONDANSETRON HCL 4 MG ORAL TABS,RX-10778,CDM,Q0162,HCPCS,259,RC,00904-6551-61,NDC,outpatient,1,UN,1.57,1.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.01,416.02,other,SI=N Exclusions ,,
ONDANSETRON 4 MG ORAL TBDP,RX-27697,CDM,Q0162,HCPCS,259,RC,65862-0390-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.01,416.02,other,SI=N Exclusions ,,
ONDANSETRON 4 MG ORAL TBDP,RX-27697,CDM,Q0162,HCPCS,259,RC,68462-0157-40,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.01,416.02,other,SI=N Exclusions ,,
ONDANSETRON 4 MG ORAL TBDP,RX-27697,CDM,Q0162,HCPCS,259,RC,68462-0157-13,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.01,416.02,other,SI=N Exclusions ,,
PROCHLORPERAZINE MALEATE 5 MG ORAL TABS,RX-6583,CDM,Q0164,HCPCS,259,RC,50268-0684-11,NDC,outpatient,1,UN,3.56,2.492,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.35,416.02,other,SI=N Exclusions ,,
PROCHLORPERAZINE MALEATE 5 MG ORAL TABS,RX-6583,CDM,Q0164,HCPCS,259,RC,50268-0684-15,NDC,outpatient,1,UN,3.56,2.492,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.35,416.02,other,SI=N Exclusions ,,
DRONABINOL 2.5 MG ORAL CAPS,RX-9904,CDM,Q0167,HCPCS,259,RC,60687-0375-11,NDC,outpatient,1,UN,18.82,13.174,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.73,416.02,other,SI=N Exclusions ,,
DRONABINOL 2.5 MG ORAL CAPS,RX-9904,CDM,Q0167,HCPCS,259,RC,60687-0375-21,NDC,outpatient,1,UN,18.82,13.174,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.73,416.02,other,SI=N Exclusions ,,
PROMETHAZINE HCL 25 MG ORAL TABS,RX-6622,CDM,Q0169,HCPCS,259,RC,00904-7304-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
PROMETHAZINE HCL 25 MG ORAL TABS,RX-6622,CDM,Q0169,HCPCS,259,RC,68382-0041-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.09,416.02,other,SI=N Exclusions ,,
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,63323-0403-01,NDC,outpatient,2,ML,19.75,13.825,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.85,,,2.85,2.55,416.02,fee schedule,,,
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,00069-6001-21,NDC,outpatient,10,ML,77.92,54.544,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.85,,,2.85,2.55,416.02,fee schedule,,,
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,63323-0403-02,NDC,outpatient,2,ML,19.75,13.825,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.85,,,2.85,2.55,416.02,fee schedule,,,
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,00069-6001-10,NDC,outpatient,10,ML,77.92,54.544,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,2.85,,,2.85,2.55,416.02,fee schedule,,,
DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ,RX-27431,CDM,Q2050,HCPCS,636,RC,47335-0050-40,NDC,outpatient,25,ML,1589.76,1112.832,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,133.08,,,133.08,87.98,1653.428703,fee schedule,,,
DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ,RX-27431,CDM,Q2050,HCPCS,636,RC,00338-0067-01,NDC,outpatient,25,ML,1408.44,985.908,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,133.08,,,133.08,87.98,1653.428703,fee schedule,,,
HC Telehealth Originating Site Facility Fee,PX-78000001,CDM,Q3014,HCPCS,983,RC,,,outpatient,,,373,261.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,316.15,83.7385,416.02,percent of total billed charges,,,
IMPLANT TY I COLL 1X1IN DURAMATRIX-ONLAY -,SUP-CDSLM11,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,1553.95,1087.765,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,348.861775,3862.93248,other,SI=N Exclusions ,,
DURAMATRIX SUTURABLE 2 X 2 -,SUP-DMS22,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,2490.5,1743.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,348.861775,3862.93248,other,SI=N Exclusions ,,
DURAMATRIX SUTURABLE  3x3 -,SUP-DMS33,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,4042.29,2829.603,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,348.861775,3862.93248,other,SI=N Exclusions ,,
DURAMATRIX SUTURABLE 4 X 5 -,SUP-DMS45,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,5029.86,3520.902,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,348.861775,3862.93248,other,SI=N Exclusions ,,
HC Skin Apligraf,PX-63600004,CDM,Q4101,HCPCS,636,RC,,,outpatient,,,8745,6121.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,30.42,6716.16,other,SI=N Exclusions ,,
HC Matrix Wound Oasis by Sq Cm,PX-63600006,CDM,Q4102,HCPCS,636,RC,,,outpatient,,,65,45.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.25,659.42016,other,SI=N Exclusions ,,
DRESSING WND 3 X 3.5CM OASIS WND MATRIX -,SUP-8213-1000-33,CDM,Q4102,CPT,278,RC,,,outpatient,,,858.62,601.034,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,12.25,659.42016,other,SI=N Exclusions ,,
INTEGRA BILAYER MATRIX WOUND DRESSING 4 x 5 -,SUP-BMW4051,CDM,Q4104,HCPCS,278,RC,,,outpatient,,,24698.88,17289.216,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.96,24594.91584,other,SI=N Exclusions ,,
MATRIX MESHED BILAYER 2X2 INTE -,SUP-MWM2021,CDM,Q4104,HCPCS,278,RC,,,outpatient,,,20440.07,14308.049,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.96,24594.91584,other,SI=N Exclusions ,,
MATRIX MESH BILAYER 4 X 5 -,SUP-MWM4051,CDM,Q4104,HCPCS,278,RC,,,outpatient,,,32024.63,22417.241,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,48.96,24594.91584,other,SI=N Exclusions ,,
HC Primatrix Mesh by Sq Cm,PX-63600008,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,186,130.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.757,4074.24,other,SI=N Exclusions ,,
PRIMATRIX 0.2 x 26.5 ROPE 3 UNITS/BOX -,SUP-607-001-009,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,2157.3,1510.11,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.757,4074.24,other,SI=N Exclusions ,,
PRIMATRIX 2X2 MESHED -,SUP-607-005-220,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,2364.02,1654.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.757,4074.24,other,SI=N Exclusions ,,
PRIMATRIX 3X3 MESHED -,SUP-607-005-330,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,2506.35,1754.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.757,4074.24,other,SI=N Exclusions ,,
PRIMATRIX 4 X 4CM  MESH -,SUP-607-005-440,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,3074.46,2152.122,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.757,4074.24,other,SI=N Exclusions ,,
PRIMATRIX 6 X 6 MESH -,SUP-607-005-660,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,5305,3713.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.757,4074.24,other,SI=N Exclusions ,,
PRIMATRIX 4X4 AG -,SUP-UNDEFINED,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,41.757,4074.24,other,SI=N Exclusions ,,
ALLODERM LARGE THK1.04-2.28 MM THICK L12 CM X W4 CM 48CM2 -,SUP-102050,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,5700.37,3990.259,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,31.11,14996.48256,other,SI=N Exclusions ,,
ALLODERM LARGE THK2-2.8 MM THICK L12CM X W6CM 72CM2 -,SUP-151972,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,4655.67,3258.969,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,31.11,14996.48256,other,SI=N Exclusions ,,
GRAFT SOFT TISSUE AXIS TUTOPLAST DERMIS 12CM X 8CM ALLODERM -,SUP-939812,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,10961.89,7673.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,31.11,14996.48256,other,SI=N Exclusions ,,
ALLODERM CONTOUR LARGE PERF L21.5 CM X W10 230.05CM2 -,SUP-CL1519P,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,19526.67,13668.669,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,31.11,14996.48256,other,SI=N Exclusions ,,
ALLODERM CONTOUR MED PERF THICK 19.3 CM X 9.6 CM 185.28CM2 -,SUP-CM1519P,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,15267.86,10687.502,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,31.11,14996.48256,other,SI=N Exclusions ,,
ACELL MICROMATRIX POWDER 200MG -,SUP-MM0200,CDM,Q4118,HCPCS,278,RC,,,outpatient,,,2929.8,2050.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.5,8051.0208,other,SI=N Exclusions ,,
ACELL MICRO MATRIX 500 MG -,SUP-MM0500,CDM,Q4118,HCPCS,278,RC,,,outpatient,,,5728.55,4009.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.5,8051.0208,other,SI=N Exclusions ,,
ACELL MICRO MATRIX 1000 MG -,SUP-MM1000,CDM,Q4118,HCPCS,278,RC,,,outpatient,,,10483.1,7338.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,2.5,8051.0208,other,SI=N Exclusions ,,
SURGICLOSE MICRO 38CM2 -,SUP-50205P04D0D,CDM,Q4121,HCPCS,636,RC,,,outpatient,,,8488,5941.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,46.98,6518.784,other,SI=N Exclusions ,,
HC Matrix Wound Oasis Ultra by Sq Cm,PX-63600010,CDM,Q4124,HCPCS,636,RC,,,outpatient,,,61,42.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.16,4034.304,other,SI=N Exclusions ,,
HC Matrix Oasis Ultra 7 X 10,PX-63600014,CDM,Q4124,HCPCS,636,RC,,,outpatient,,,5253,3677.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,9.16,4034.304,other,SI=N Exclusions ,,
GRAFT ARTHROFLEX DERMIS THK1.5MM 35MM X 35MM 12.25CM2 -,SUP-AFLEX100,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,7779.25,5445.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,209.5932,10851.38688,other,SI=N Exclusions ,,
DERMIS DECELLULARIZED 35MM X 35MM X 2.0MM 12.25SQCM -,SUP-AFLEX200,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,11781.35,8246.945,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,209.5932,10851.38688,other,SI=N Exclusions ,,
ARTHROFLEX 40MM X 70MM X 3.0 DERMIS DECELLULARIZED 28SQCM -,SUP-AFLEX301,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,14129.41,9890.587,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,209.5932,10851.38688,other,SI=N Exclusions ,,
ARTHROFLEX 25 X 30 X 1MM 7.5SQCM -,SUP-AFLEX403,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,209.5932,10851.38688,other,SI=N Exclusions ,,
CONNECT PRE-SUTURED TENDON-ZORC 4.5 x 160MM -,SUP-FCON,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,5187.44,3631.208,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,209.5932,10851.38688,other,SI=N Exclusions ,,
SURGICLOSE 7 X 10CM- 70SQCM -,SUP-50205N03D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,16121.85,11285.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.06,20434.45248,other,SI=N Exclusions ,,
SURGICLOSE 6 X 8 MESHED 2:1 UP TO 86CM2 -,SUP-50205N18D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,10804.83,7563.381,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.06,20434.45248,other,SI=N Exclusions ,,
SURGICLOSE MESHED 2:1 4X6 CM- 24SQCM -,SUP-50205N20D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,6934.7,4854.29,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.06,20434.45248,other,SI=N Exclusions ,,
SURGICLOSE MESHED 7 X 20 -,SUP-50205N21D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,26607.36,18625.152,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.06,20434.45248,other,SI=N Exclusions ,,
SURGICLOSE MICRO 95 CM2 -,SUP-50205P31D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,15965.9,11176.13,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,3.06,20434.45248,other,SI=N Exclusions ,,
ACELL WOUND/BURN MATRIX 2 LAYER -,SUP-BMM0710,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,4509.25,3156.475,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,18.9,9453.0048,other,SI=N Exclusions ,,
CYTAL BURN MATRIX -,SUP-BMM1015,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,8116.65,5681.655,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,18.9,9453.0048,other,SI=N Exclusions ,,
CYTAL WOUND MATRIX 1 LAYER 3 X 7CM -,SUP-WS0307,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,853.08,597.156,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,18.9,9453.0048,other,SI=N Exclusions ,,
MATRIX WOUND ACELL GENTRIX 5M X 5CM 25CM2 3 LAYERS -,SUP-WSR0505,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,4118.77,2883.139,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,18.9,9453.0048,other,SI=N Exclusions ,,
WOUND MATRIX CYTEL 3 LAYER 7 X 10CM -,SUP-WSR0710,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,8206.84,5744.788,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,18.9,9453.0048,other,SI=N Exclusions ,,
WOUND MATRIX 3 LAYER 10 X 15CM -,SUP-WSR1015,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,12308.6,8616.02,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,18.9,9453.0048,other,SI=N Exclusions ,,
ACELL WOUND MATRIX 6-LAYER MESH -,SUP-WSX0505,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,4869.99,3408.993,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,18.9,9453.0048,other,SI=N Exclusions ,,
CYTAL WOUND MATRIX 6 LAYER 7 X 10CM -,SUP-WSX0710,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,9562.83,6693.981,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,18.9,9453.0048,other,SI=N Exclusions ,,
HC Epifix- per Square Centimeter,PX-63600024,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,501,350.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,112.4745,3643.99872,other,SI=N Exclusions ,,
EPIFIX DISK 14MM -,SUP-GS-5140,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,1746.51,1222.557,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,112.4745,3643.99872,other,SI=N Exclusions ,,
EPIFIX DISK 18MM -,SUP-GS-5180,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,3733.27,2613.289,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,112.4745,3643.99872,other,SI=N Exclusions ,,
EPIFIX 2 X 2 CM -,SUP-GS-5220,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,4744.79,3321.353,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,112.4745,3643.99872,other,SI=N Exclusions ,,
PURAPLY AM 2CMX2CM -,SUP-00000000000000000000000000000,CDM,Q4196,HCPCS,636,RC,,,outpatient,,,4057.9,2840.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,102.28,3422.3616,other,SI=N Exclusions ,,
PURAPLY AM 2CMX4CM -,SUP-PURAPLYAM-COM 2X4,CDM,Q4196,HCPCS,636,RC,,,outpatient,,,4456.2,3119.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,102.28,3422.3616,other,SI=N Exclusions ,,
FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY,RX-132201,CDM,Q5101,HCPCS,636,RC,61314-0318-01,NDC,outpatient,0.5,ML,603.11,422.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.36,,,0.36,0.18,741.12768,fee schedule,,,
FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY,RX-132201,CDM,Q5101,HCPCS,636,RC,61314-0318-10,NDC,outpatient,0.5,ML,603.14,422.198,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.36,,,0.36,0.18,741.12768,fee schedule,,,
FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY,RX-132201,CDM,Q5101,HCPCS,636,RC,61314-0318-05,NDC,outpatient,0.5,ML,603.14,422.198,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.36,,,0.36,0.18,741.12768,fee schedule,,,
FILGRASTIM-SNDZ 480 MCG/0.8ML IJ SOSY,RX-132202,CDM,Q5101,HCPCS,636,RC,61314-0326-05,NDC,outpatient,0.8,ML,965.01,675.507,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.36,,,0.36,0.18,741.12768,fee schedule,,,
FILGRASTIM-SNDZ 480 MCG/0.8ML IJ SOSY,RX-132202,CDM,Q5101,HCPCS,636,RC,61314-0326-10,NDC,outpatient,0.8,ML,965.01,675.507,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,0.36,,,0.36,0.18,741.12768,fee schedule,,,
INFLIXIMAB-DYYB 100 MG IV SOLR,RX-136637,CDM,Q5103,HCPCS,636,RC,00069-0809-01,NDC,outpatient,1,UN,1389.66,972.762,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,13.62,,,13.62,13.62,1653.428703,fee schedule,,,
INFLIXIMAB-ABDA 100 MG IV SOLR,RX-139995,CDM,Q5104,HCPCS,636,RC,00006-4305-01,NDC,outpatient,1,UN,1902.38,1331.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27.18,,,27.18,27.18,1653.428703,fee schedule,,,
INFLIXIMAB-ABDA 100 MG IV SOLR,RX-139995,CDM,Q5104,HCPCS,636,RC,00006-4305-02,NDC,outpatient,1,UN,1902.38,1331.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,27.18,,,27.18,27.18,1653.428703,fee schedule,,,
EPOETIN ALFA-EPBX 2000 UNIT/ML IJ SOLN,RX-143174,CDM,Q5106,HCPCS,636,RC,00069-1305-10,NDC,outpatient,1,ML,79.46,55.622,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7.62,,,7.62,7.5,416.02,fee schedule,,,
EPOETIN ALFA-EPBX 2000 UNIT/ML IJ SOLN,RX-143174,CDM,Q5106,HCPCS,636,RC,00069-1305-01,NDC,outpatient,1,ML,79.46,55.622,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7.62,,,7.62,7.5,416.02,fee schedule,,,
EPOETIN ALFA-EPBX 3000 UNIT/ML IJ SOLN,RX-143175,CDM,Q5106,HCPCS,636,RC,00069-1306-01,NDC,outpatient,1,ML,119.19,83.433,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7.62,,,7.62,7.5,416.02,fee schedule,,,
EPOETIN ALFA-EPBX 3000 UNIT/ML IJ SOLN,RX-143175,CDM,Q5106,HCPCS,636,RC,00069-1306-10,NDC,outpatient,1,ML,119.19,83.433,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7.62,,,7.62,7.5,416.02,fee schedule,,,
EPOETIN ALFA-EPBX 4000 UNIT/ML IJ SOLN,RX-143176,CDM,Q5106,HCPCS,636,RC,00069-1307-01,NDC,outpatient,1,ML,158.92,111.244,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7.62,,,7.62,7.5,416.02,fee schedule,,,
EPOETIN ALFA-EPBX 4000 UNIT/ML IJ SOLN,RX-143176,CDM,Q5106,HCPCS,636,RC,00069-1307-10,NDC,outpatient,1,ML,158.92,111.244,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7.62,,,7.62,7.5,416.02,fee schedule,,,
EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN,RX-143177,CDM,Q5106,HCPCS,636,RC,00069-1308-01,NDC,outpatient,1,ML,377.7,264.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7.62,,,7.62,7.5,416.02,fee schedule,,,
EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN,RX-143177,CDM,Q5106,HCPCS,636,RC,00069-1308-10,NDC,outpatient,1,ML,377.7,264.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7.62,,,7.62,7.5,416.02,fee schedule,,,
EPOETIN ALFA-EPBX 40000 UNIT/ML IJ SOLN,RX-143178,CDM,Q5106,HCPCS,636,RC,00069-1309-01,NDC,outpatient,0.05,ML,75.54,52.878,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7.62,,,7.62,7.5,416.02,fee schedule,,,
EPOETIN ALFA-EPBX 40000 UNIT/ML IJ SOLN,RX-143178,CDM,Q5106,HCPCS,636,RC,00069-1309-04,NDC,outpatient,0.05,ML,75.54,52.878,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,7.62,,,7.62,7.5,416.02,fee schedule,,,
RITUXIMAB-ABBS 10 MG/ML IV SOLN WRAPPER,RX-4081244,CDM,Q5115,HCPCS,636,RC,63459-0104-50,NDC,outpatient,50,ML,6662.37,4663.659,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,33.59,,,33.59,33.59,7269.974281,fee schedule,,,
RITUXIMAB-ABBS 10 MG/ML IV SOLN WRAPPER,RX-4081244,CDM,Q5115,HCPCS,636,RC,63459-0103-10,NDC,outpatient,10,ML,1691.22,1183.854,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,33.59,,,33.59,33.59,7269.974281,fee schedule,,,
INFLIXIMAB-AXXQ 100 MG IV SOLR,RX-150921,CDM,Q5121,HCPCS,636,RC,55513-0670-01,NDC,outpatient,1,UN,2071.48,1450.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,21.29,,,21.29,21.29,1590.89664,fee schedule,,,
MEDIA CONTR PRFLTRN LPD MICSPHR INJ SUSP VL DEFINITY -,SUP-DE16,CDM,Q9957,CPT,636,RC,,,outpatient,,,554.33,388.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,40.92,438.4896,other,SI=N Exclusions ,,
DEFINITY DE-4 -,SUP-DE4,CDM,Q9957,CPT,636,RC,,,outpatient,,,570.95,399.665,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,40.92,438.4896,other,SI=N Exclusions ,,
DIATRIZOATE MEGLUMINE & SODIUM 66-10 % ORAL SOLN,RX-9828,CDM,Q9963,HCPCS,636,RC,00270-0445-40,NDC,outpatient,7.5,ML,3.71,2.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.22,416.02,other,SI=N Exclusions ,,
IOHEXOL 180 MG/ML IJ SOLN,RX-10319,CDM,Q9965,HCPCS,636,RC,99999-0004-10,NDC,outpatient,3,ML,16.35,11.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.56,416.02,other,SI=N Exclusions ,,
IOHEXOL 180 MG/ML IJ SOLN,RX-10319,CDM,Q9965,HCPCS,636,RC,00407-1411-10,NDC,outpatient,3,ML,16.35,11.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,1.56,416.02,other,SI=N Exclusions ,,
IOPAMIDOL 41 % IJ SOLN,RX-10325,CDM,Q9966,HCPCS,636,RC,00270-1411-11,NDC,outpatient,10,ML,98.1,68.67,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.38,416.02,other,SI=N Exclusions ,,
IOHEXOL 240 MG/ML IJ SOLN,RX-119843,CDM,Q9966,HCPCS,636,RC,00407-1412-33,NDC,outpatient,10,ML,32.7,22.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.38,416.02,other,SI=N Exclusions ,,
IOHEXOL 240 MG/ML IJ SOLN,RX-119843,CDM,Q9966,HCPCS,636,RC,99999-0004-07,NDC,outpatient,10,ML,32.7,22.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.38,416.02,other,SI=N Exclusions ,,
IOHEXOL 240 MG/ML IJ SOLN,RX-119843,CDM,Q9966,HCPCS,636,RC,00407-1412-30,NDC,outpatient,10,ML,32.7,22.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.38,416.02,other,SI=N Exclusions ,,
IOPAMIDOL 61 % IJ SOLN,RX-10327,CDM,Q9967,HCPCS,636,RC,00270-1412-15,NDC,outpatient,15,ML,81.75,57.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.14,416.02,other,SI=N Exclusions ,,
IOPAMIDOL 76 % IV SOLN,RX-10328,CDM,Q9967,HCPCS,636,RC,00270-1316-35,NDC,outpatient,50,ML,272.5,190.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.14,416.02,other,SI=N Exclusions ,,
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-10,NDC,outpatient,5,ML,10.9,7.63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.14,416.02,other,SI=N Exclusions ,,
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-61,NDC,outpatient,5,ML,10.9,7.63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.14,416.02,other,SI=N Exclusions ,,
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-63,NDC,outpatient,5,ML,10.9,7.63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.14,416.02,other,SI=N Exclusions ,,
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-58,NDC,outpatient,5,ML,10.9,7.63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.14,416.02,other,SI=N Exclusions ,,
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-59,NDC,outpatient,5,ML,10.9,7.63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.14,416.02,other,SI=N Exclusions ,,
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,99999-0004-09,NDC,outpatient,5,ML,10.9,7.63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.14,416.02,other,SI=N Exclusions ,,
IOPAMIDOL 61 % IV SOLN,RX-27737,CDM,Q9967,HCPCS,636,RC,00270-1315-25,NDC,outpatient,30,ML,163.5,114.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.14,416.02,other,SI=N Exclusions ,,
IOVERSOL 68 % IJ SOLN,RX-39700,CDM,Q9967,HCPCS,636,RC,00019-1323-02,NDC,outpatient,20,ML,109,76.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.14,416.02,other,SI=N Exclusions ,,
ISOSULFAN BLUE 1 % SC SOLN,RX-10358,CDM,Q9968,HCPCS,636,RC,67457-0220-00,NDC,outpatient,5,ML,2840.8,1988.56,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10.65,,,10.65,9.53,2181.7344,fee schedule,,,
ISOSULFAN BLUE 1 % SC SOLN,RX-10358,CDM,Q9968,HCPCS,636,RC,67457-0220-05,NDC,outpatient,5,ML,2840.8,1988.56,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,10.65,,,10.65,9.53,2181.7344,fee schedule,,,
ACETAMINOPHEN 160 MG/5ML ORAL SOLN,RX-100,CDM,S5000,HCPCS,259,RC,00121-1971-00,NDC,outpatient,650,ME,11.57,8.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACETAMINOPHEN 160 MG/5ML ORAL SOLN,RX-100,CDM,S5000,HCPCS,259,RC,81033-0002-20,NDC,outpatient,650,ME,11.57,8.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACETAMINOPHEN 160 MG/5ML ORAL SOLN,RX-100,CDM,S5000,HCPCS,259,RC,00121-1971-21,NDC,outpatient,650,ME,11.57,8.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACETAMINOPHEN 160 MG/5ML ORAL SOLN,RX-100,CDM,S5000,HCPCS,259,RC,81033-0002-30,NDC,outpatient,650,ME,11.57,8.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FAMOTIDINE 40 MG/5ML ORAL SUSR,RX-10010,CDM,S5000,HCPCS,259,RC,99999-0004-18,NDC,outpatient,2.5,ML,4.86,3.402,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FAMOTIDINE 40 MG/5ML ORAL SUSR,RX-10010,CDM,S5000,HCPCS,259,RC,70954-0316-10,NDC,outpatient,50,ML,117.71,82.397,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FAMOTIDINE 20 MG ORAL TABS,RX-10011,CDM,S5000,HCPCS,259,RC,00904-7193-06,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FAMOTIDINE 20 MG ORAL TABS,RX-10011,CDM,S5000,HCPCS,259,RC,50268-0299-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FAMOTIDINE 20 MG ORAL TABS,RX-10011,CDM,S5000,HCPCS,259,RC,63739-0645-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FAMOTIDINE 20 MG ORAL TABS,RX-10011,CDM,S5000,HCPCS,259,RC,62332-0001-31,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FAMOTIDINE 20 MG ORAL TABS,RX-10011,CDM,S5000,HCPCS,259,RC,50268-0299-15,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FELBAMATE 600 MG ORAL TABS,RX-10025,CDM,S5000,HCPCS,259,RC,72578-0057-16,NDC,outpatient,1,UN,5.99,4.193,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FINASTERIDE 5 MG ORAL TABS,RX-10037,CDM,S5000,HCPCS,259,RC,00904-6830-61,NDC,outpatient,1,UN,2.18,1.526,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FINASTERIDE 5 MG ORAL TABS,RX-10037,CDM,S5000,HCPCS,259,RC,00904-6830-06,NDC,outpatient,1,UN,1.66,1.162,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FINASTERIDE 5 MG ORAL TABS,RX-10037,CDM,S5000,HCPCS,259,RC,60687-0428-01,NDC,outpatient,1,UN,2.29,1.603,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FINASTERIDE 5 MG ORAL TABS,RX-10037,CDM,S5000,HCPCS,259,RC,60687-0428-11,NDC,outpatient,1,UN,2.29,1.603,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLECAINIDE ACETATE 100 MG ORAL TABS,RX-10041,CDM,S5000,HCPCS,259,RC,50268-0321-11,NDC,outpatient,1,UN,2.86,2.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLECAINIDE ACETATE 100 MG ORAL TABS,RX-10041,CDM,S5000,HCPCS,259,RC,00054-0011-21,NDC,outpatient,1,UN,2.98,2.086,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLECAINIDE ACETATE 100 MG ORAL TABS,RX-10041,CDM,S5000,HCPCS,259,RC,50268-0321-15,NDC,outpatient,1,UN,2.86,2.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLECAINIDE ACETATE 50 MG ORAL TABS,RX-10043,CDM,S5000,HCPCS,259,RC,50268-0320-11,NDC,outpatient,1,UN,3.66,2.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLECAINIDE ACETATE 50 MG ORAL TABS,RX-10043,CDM,S5000,HCPCS,259,RC,00054-0010-20,NDC,outpatient,1,UN,2.45,1.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLECAINIDE ACETATE 50 MG ORAL TABS,RX-10043,CDM,S5000,HCPCS,259,RC,50268-0320-15,NDC,outpatient,1,UN,3.66,2.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLUCONAZOLE 100 MG ORAL TABS,RX-10044,CDM,S5000,HCPCS,259,RC,68084-0728-11,NDC,outpatient,1,UN,4.94,3.458,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLUCONAZOLE 100 MG ORAL TABS,RX-10044,CDM,S5000,HCPCS,259,RC,00904-6500-61,NDC,outpatient,1,UN,4.03,2.821,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLUCONAZOLE 100 MG ORAL TABS,RX-10044,CDM,S5000,HCPCS,259,RC,68084-0728-01,NDC,outpatient,1,UN,4.94,3.458,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLUCONAZOLE 200 MG ORAL TABS,RX-10045,CDM,S5000,HCPCS,259,RC,00904-6501-61,NDC,outpatient,1,UN,6.68,4.676,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VITAMIN D2 (ERGOCALCIFEROL) 1.25 MG (50000 UNITS) ORAL CAPS,RX-100493,CDM,S5000,HCPCS,259,RC,64380-0737-06,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VITAMIN D2 (ERGOCALCIFEROL) 1.25 MG (50000 UNITS) ORAL CAPS,RX-100493,CDM,S5000,HCPCS,259,RC,50268-0297-11,NDC,outpatient,1,UN,3.93,2.751,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VITAMIN D2 (ERGOCALCIFEROL) 1.25 MG (50000 UNITS) ORAL CAPS,RX-100493,CDM,S5000,HCPCS,259,RC,50268-0297-15,NDC,outpatient,1,UN,3.93,2.751,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLUCYTOSINE 500 MG ORAL CAPS,RX-10052,CDM,S5000,HCPCS,259,RC,42794-0010-08,NDC,outpatient,1,UN,233.01,163.107,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLUDROCORTISONE ACETATE 0.1 MG ORAL TABS,RX-10054,CDM,S5000,HCPCS,259,RC,00115-7033-01,NDC,outpatient,1,UN,2.43,1.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLUDROCORTISONE ACETATE 0.1 MG ORAL TABS,RX-10054,CDM,S5000,HCPCS,259,RC,50268-0330-11,NDC,outpatient,1,UN,2.26,1.582,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLUDROCORTISONE ACETATE 0.1 MG ORAL TABS,RX-10054,CDM,S5000,HCPCS,259,RC,50268-0330-15,NDC,outpatient,1,UN,2.26,1.582,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLUOROURACIL 5 % EX CREA,RX-10065,CDM,S5000,HCPCS,259,RC,16729-0542-35,NDC,outpatient,40,GR,458.18,320.726,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLUOROURACIL 5 % EX CREA,RX-10065,CDM,S5000,HCPCS,259,RC,51672-4118-06,NDC,outpatient,40,GR,108.41,75.887,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLUOXETINE HCL 10 MG ORAL CAPS,RX-10069,CDM,S5000,HCPCS,259,RC,16714-0720-02,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLUOXETINE HCL 20 MG ORAL CAPS,RX-10070,CDM,S5000,HCPCS,259,RC,00904-7346-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLURBIPROFEN SODIUM 0.03 % OP SOLN,RX-10080,CDM,S5000,HCPCS,259,RC,69292-0722-25,NDC,outpatient,2.5,ML,140.89,98.623,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLUVOXAMINE MALEATE 50 MG ORAL TABS,RX-10085,CDM,S5000,HCPCS,259,RC,60505-0165-01,NDC,outpatient,1,UN,1.63,1.141,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FOSINOPRIL SODIUM 10 MG ORAL TABS,RX-10094,CDM,S5000,HCPCS,259,RC,69097-0856-05,NDC,outpatient,1,UN,1.76,1.232,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RITONAVIR 100 MG ORAL TABS,RX-100995,CDM,S5000,HCPCS,259,RC,00074-2340-30,NDC,outpatient,1,UN,37.01,25.907,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GLIPIZIDE 5 MG ORAL TABS,RX-10117,CDM,S5000,HCPCS,259,RC,60505-0141-00,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GLIPIZIDE 5 MG ORAL TABS,RX-10117,CDM,S5000,HCPCS,259,RC,00904-6637-61,NDC,outpatient,1,UN,1.21,0.847,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GLYBURIDE 2.5 MG ORAL TABS,RX-10126,CDM,S5000,HCPCS,259,RC,00093-8343-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GLYCOPYRROLATE 1 MG ORAL TABS,RX-10130,CDM,S5000,HCPCS,259,RC,23155-0606-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GUANFACINE HCL 1 MG ORAL TABS,RX-10149,CDM,S5000,HCPCS,259,RC,68094-0065-59,NDC,outpatient,1,UN,8.9,6.23,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GUANFACINE HCL 1 MG ORAL TABS,RX-10149,CDM,S5000,HCPCS,259,RC,68094-0065-62,NDC,outpatient,1,UN,8.9,6.23,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACETAMINOPHEN 500 MG ORAL TABS,RX-102,CDM,S5000,HCPCS,259,RC,00904-6730-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROCORTISONE 5 MG ORAL TABS,RX-10209,CDM,S5000,HCPCS,259,RC,59762-0073-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROCORTISONE 5 MG ORAL TABS,RX-10209,CDM,S5000,HCPCS,259,RC,64380-0970-25,NDC,outpatient,1,UN,1.23,0.861,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROCORTISONE 100 MG/60ML RE ENEM,RX-10210,CDM,S5000,HCPCS,259,RC,62559-0138-11,NDC,outpatient,60,ML,88.11,61.677,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROCORTISONE 100 MG/60ML RE ENEM,RX-10210,CDM,S5000,HCPCS,259,RC,62559-0138-07,NDC,outpatient,60,ML,88.11,61.677,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROCORTISONE MICRONIZED POWD,RX-10217,CDM,S5000,HCPCS,259,RC,51552-0020-05,NDC,outpatient,100,GR,1580.42,1106.294,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROXYCHLOROQUINE SULFATE 200 MG ORAL TABS,RX-10235,CDM,S5000,HCPCS,259,RC,00904-7046-61,NDC,outpatient,1,UN,3.27,2.289,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROXYCHLOROQUINE SULFATE 200 MG ORAL TABS,RX-10235,CDM,S5000,HCPCS,259,RC,68084-0269-01,NDC,outpatient,1,UN,4.87,3.409,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROXYCHLOROQUINE SULFATE 200 MG ORAL TABS,RX-10235,CDM,S5000,HCPCS,259,RC,68084-0269-11,NDC,outpatient,1,UN,4.87,3.409,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROXYUREA 500 MG ORAL CAPS,RX-10236,CDM,S5000,HCPCS,259,RC,68084-0284-01,NDC,outpatient,1,UN,3.02,2.114,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROXYUREA 500 MG ORAL CAPS,RX-10236,CDM,S5000,HCPCS,259,RC,68084-0284-11,NDC,outpatient,1,UN,3.02,2.114,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,68094-0494-61,NDC,outpatient,5,ML,2.54,1.778,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,00121-0914-05,NDC,outpatient,5,ML,2.5,1.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,00121-0914-00,NDC,outpatient,5,ML,2.5,1.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,51672-2130-08,NDC,outpatient,120,ML,11.22,7.854,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,59651-0032-47,NDC,outpatient,473,ML,67.36,47.152,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,68094-0494-59,NDC,outpatient,5,ML,2.54,1.778,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,99999-0004-24,NDC,outpatient,5,ML,1.37,0.959,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,59651-0032-05,NDC,outpatient,5,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,68094-0494-62,NDC,outpatient,5,ML,2.59,1.813,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
INDIGOTINDISULFONATE SODIUM 8 MG/ML IJ SOLN,RX-10265,CDM,S5000,HCPCS,250,RC,81284-0315-05,NDC,outpatient,5,ML,1398.02,978.614,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
INDIGOTINDISULFONATE SODIUM 8 MG/ML IJ SOLN,RX-10265,CDM,S5000,HCPCS,250,RC,81284-0315-00,NDC,outpatient,5,ML,1398.02,978.614,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
INDOCYANINE GREEN 25 MG IV SOLR,RX-10266,CDM,S5000,HCPCS,250,RC,70100-0424-02,NDC,outpatient,1,UN,501.97,351.379,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
INDOCYANINE GREEN 25 MG IV SOLR,RX-10266,CDM,S5000,HCPCS,250,RC,70100-0424-01,NDC,outpatient,1,UN,501.97,351.379,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
INDOMETHACIN SODIUM 1 MG IV SOLR,RX-10267,CDM,S5000,HCPCS,250,RC,63323-0659-03,NDC,outpatient,1,UN,1192.43,834.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
INSULIN NPH (HUMAN) (ISOPHANE) 100 UNIT/ML SC SUSP,RX-10284,CDM,S5000,HCPCS,259,RC,00002-8315-01,NDC,outpatient,10,ML,61.5,43.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
INSULIN REGULAR HUMAN 100 UNIT/ML IJ SOLN,RX-10289,CDM,S5000,HCPCS,259,RC,00002-8215-01,NDC,outpatient,10,ML,61.5,43.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACETAMINOPHEN 120 MG RE SUPP,RX-103,CDM,S5000,HCPCS,259,RC,45802-0732-30,NDC,outpatient,1,UN,1.69,1.183,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BETAMETHASONE VALERATE 0.1 % EX CREA,RX-1031,CDM,S5000,HCPCS,259,RC,00713-0326-15,NDC,outpatient,15,GR,50.4,35.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BETAMETHASONE VALERATE 0.1 % EX CREA,RX-1031,CDM,S5000,HCPCS,259,RC,00472-0370-15,NDC,outpatient,15,GR,93.12,65.184,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BETAMETHASONE VALERATE 0.1 % EX LOTN,RX-1032,CDM,S5000,HCPCS,259,RC,00168-0041-60,NDC,outpatient,60,ML,267,186.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ISOSORBIDE MONONITRATE 20 MG ORAL TABS,RX-10357,CDM,S5000,HCPCS,259,RC,00228-2620-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ISRADIPINE 5 MG ORAL CAPS,RX-10363,CDM,S5000,HCPCS,259,RC,16252-0540-01,NDC,outpatient,1,UN,8.59,6.013,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ITRACONAZOLE 100 MG ORAL CAPS,RX-10364,CDM,S5000,HCPCS,259,RC,16714-0743-02,NDC,outpatient,1,UN,5.65,3.955,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
KETOCONAZOLE 2 % EX CREA,RX-10368,CDM,S5000,HCPCS,259,RC,00168-0099-15,NDC,outpatient,15,GR,22.57,15.799,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
KETOROLAC TROMETHAMINE 10 MG ORAL TABS,RX-10371,CDM,S5000,HCPCS,259,RC,00093-0314-01,NDC,outpatient,1,UN,4.33,3.031,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
KETOROLAC TROMETHAMINE 10 MG ORAL TABS,RX-10371,CDM,S5000,HCPCS,259,RC,70710-1710-01,NDC,outpatient,1,UN,3.63,2.541,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LABETALOL HCL 100 MG ORAL TABS,RX-10373,CDM,S5000,HCPCS,259,RC,60687-0439-01,NDC,outpatient,1,UN,1.32,0.924,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LABETALOL HCL 100 MG ORAL TABS,RX-10373,CDM,S5000,HCPCS,259,RC,60687-0439-11,NDC,outpatient,1,UN,1.32,0.924,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LABETALOL HCL 200 MG ORAL TABS,RX-10374,CDM,S5000,HCPCS,259,RC,60687-0450-01,NDC,outpatient,1,UN,1.81,1.267,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LABETALOL HCL 200 MG ORAL TABS,RX-10374,CDM,S5000,HCPCS,259,RC,60687-0450-11,NDC,outpatient,1,UN,1.81,1.267,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMMONIUM LACTATE 12 % EX LOTN,RX-10380,CDM,S5000,HCPCS,259,RC,16864-0000-18,NDC,outpatient,225,GR,41.06,28.742,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMMONIUM LACTATE 12 % EX LOTN,RX-10380,CDM,S5000,HCPCS,259,RC,30781-7098-79,NDC,outpatient,225,GR,41.06,28.742,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMMONIUM LACTATE 12 % EX LOTN,RX-10380,CDM,S5000,HCPCS,259,RC,00904-5984-26,NDC,outpatient,226,GR,13.08,9.156,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMMONIUM LACTATE 12 % EX LOTN,RX-10380,CDM,S5000,HCPCS,259,RC,51672-1300-05,NDC,outpatient,225,GR,61.08,42.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMMONIUM LACTATE 12 % EX LOTN,RX-10380,CDM,S5000,HCPCS,259,RC,63044-0484-09,NDC,outpatient,225,GR,29.04,20.328,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TAMSULOSIN HCL 0.4 MG ORAL CAPS,RX-103890,CDM,S5000,HCPCS,259,RC,68084-0299-01,NDC,outpatient,1,UN,1.04,0.728,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TAMSULOSIN HCL 0.4 MG ORAL CAPS,RX-103890,CDM,S5000,HCPCS,259,RC,72603-0115-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TAMSULOSIN HCL 0.4 MG ORAL CAPS,RX-103890,CDM,S5000,HCPCS,259,RC,68084-0299-11,NDC,outpatient,1,UN,1.04,0.728,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TAMSULOSIN HCL 0.4 MG ORAL CAPS,RX-103890,CDM,S5000,HCPCS,259,RC,57237-0014-01,NDC,outpatient,1,UN,1.24,0.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TAMSULOSIN HCL 0.4 MG ORAL CAPS,RX-103890,CDM,S5000,HCPCS,259,RC,63739-0567-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACETAMINOPHEN 325 MG RE SUPP,RX-104,CDM,S5000,HCPCS,259,RC,51672-2116-02,NDC,outpatient,1,UN,2.7,1.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACETAMINOPHEN 325 MG RE SUPP,RX-104,CDM,S5000,HCPCS,259,RC,51672-2116-04,NDC,outpatient,1,UN,1.99,1.393,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVOTHYROXINE SODIUM 88 MCG ORAL TABS,RX-10403,CDM,S5000,HCPCS,259,RC,42292-0038-20,NDC,outpatient,1,UN,2.39,1.673,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVOTHYROXINE SODIUM 88 MCG ORAL TABS,RX-10403,CDM,S5000,HCPCS,259,RC,60687-0486-01,NDC,outpatient,1,UN,2.07,1.449,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVOTHYROXINE SODIUM 88 MCG ORAL TABS,RX-10403,CDM,S5000,HCPCS,259,RC,60687-0486-11,NDC,outpatient,1,UN,2.07,1.449,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVOTHYROXINE SODIUM 88 MCG ORAL TABS,RX-10403,CDM,S5000,HCPCS,259,RC,42292-0038-01,NDC,outpatient,1,UN,2.39,1.673,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVOTHYROXINE SODIUM 112 MCG ORAL TABS,RX-10404,CDM,S5000,HCPCS,259,RC,69238-1835-01,NDC,outpatient,1,UN,1.64,1.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVOTHYROXINE SODIUM 112 MCG ORAL TABS,RX-10404,CDM,S5000,HCPCS,259,RC,42292-0039-01,NDC,outpatient,1,UN,2.79,1.953,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVOTHYROXINE SODIUM 112 MCG ORAL TABS,RX-10404,CDM,S5000,HCPCS,259,RC,42292-0039-20,NDC,outpatient,1,UN,2.79,1.953,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVOTHYROXINE SODIUM 137 MCG ORAL TABS,RX-10405,CDM,S5000,HCPCS,259,RC,00527-3287-46,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVOTHYROXINE SODIUM 137 MCG ORAL TABS,RX-10405,CDM,S5000,HCPCS,259,RC,00378-1823-77,NDC,outpatient,1,UN,2.29,1.603,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVOTHYROXINE SODIUM 137 MCG ORAL TABS,RX-10405,CDM,S5000,HCPCS,259,RC,00074-3727-90,NDC,outpatient,1,UN,6.49,4.543,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVOTHYROXINE SODIUM 175 MCG ORAL TABS,RX-10406,CDM,S5000,HCPCS,259,RC,42292-0040-01,NDC,outpatient,1,UN,3.47,2.429,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVOTHYROXINE SODIUM 175 MCG ORAL TABS,RX-10406,CDM,S5000,HCPCS,259,RC,42292-0040-20,NDC,outpatient,1,UN,3.47,2.429,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00143-9595-25,NDC,outpatient,5,ML,7.61,5.327,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00409-4279-16,NDC,outpatient,30,ML,13.42,9.394,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00409-4713-02,NDC,outpatient,5,ML,4.55,3.185,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,55150-0163-30,NDC,outpatient,30,ML,6.17,4.319,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-27,NDC,outpatient,2,ML,4.85,3.395,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00143-9595-01,NDC,outpatient,5,ML,7.61,5.327,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00409-4713-26,NDC,outpatient,5,ML,4.55,3.185,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,55150-0159-74,NDC,outpatient,5,ML,3.68,2.576,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00409-4713-12,NDC,outpatient,5,ML,4.55,3.185,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-97,NDC,outpatient,10,ML,24.48,17.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00409-4279-02,NDC,outpatient,30,ML,13.42,9.394,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-04,NDC,outpatient,2,ML,4.85,3.395,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-08,NDC,outpatient,10,ML,24.48,17.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-09,NDC,outpatient,5,ML,6.46,4.522,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-57,NDC,outpatient,5,ML,6.46,4.522,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-2066-05,NDC,outpatient,5,ML,11.34,7.938,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-4282-25,NDC,outpatient,2,ML,4.57,3.199,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,55150-0164-02,NDC,outpatient,2,ML,4.16,2.912,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0495-07,NDC,outpatient,5,ML,6.46,4.522,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0495-09,NDC,outpatient,2,ML,8.69,6.083,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00143-9594-25,NDC,outpatient,5,ML,7.61,5.327,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-4282-01,NDC,outpatient,2,ML,4.57,3.199,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0495-04,NDC,outpatient,5,ML,6.46,4.522,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0496-97,NDC,outpatient,10,ML,28.48,19.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-4282-11,NDC,outpatient,2,ML,4.57,3.199,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-4282-12,NDC,outpatient,10,ML,10.34,7.238,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,55150-0165-05,NDC,outpatient,5,ML,4.63,3.241,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00143-9594-01,NDC,outpatient,5,ML,7.61,5.327,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-2066-10,NDC,outpatient,5,ML,11.34,7.938,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-4282-02,NDC,outpatient,10,ML,10.34,7.238,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0495-27,NDC,outpatient,2,ML,8.69,6.083,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0496-03,NDC,outpatient,10,ML,28.48,19.936,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE-EPINEPHRINE 0.5 %-1:200000 IJ SOLN,RX-10426,CDM,S5000,HCPCS,250,RC,63323-0481-01,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE-EPINEPHRINE 0.5 %-1:200000 IJ SOLN,RX-10426,CDM,S5000,HCPCS,250,RC,63323-0481-57,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE-EPINEPHRINE 0.5 %-1:200000 IJ SOLN,RX-10426,CDM,S5000,HCPCS,250,RC,00409-3177-16,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE-EPINEPHRINE 0.5 %-1:200000 IJ SOLN,RX-10426,CDM,S5000,HCPCS,250,RC,00409-3177-01,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,00409-3178-16,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,00409-3178-17,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,63323-0482-03,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,00409-3178-02,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,63323-0482-17,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,00409-3178-01,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,63323-0482-01,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,63323-0482-27,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE-EPINEPHRINE 1.5 %-1:200000 IJ SOLN,RX-10429,CDM,S5000,HCPCS,250,RC,63323-0488-07,NDC,outpatient,30,ML,30.31,21.217,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE-EPINEPHRINE 1.5 %-1:200000 IJ SOLN,RX-10429,CDM,S5000,HCPCS,250,RC,63323-0488-37,NDC,outpatient,30,ML,30.31,21.217,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BETHANECHOL CHLORIDE 10 MG ORAL TABS,RX-1043,CDM,S5000,HCPCS,259,RC,00832-0511-01,NDC,outpatient,1,UN,1.83,1.281,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BETHANECHOL CHLORIDE 10 MG ORAL TABS,RX-1043,CDM,S5000,HCPCS,259,RC,00832-0511-89,NDC,outpatient,1,UN,1.83,1.281,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN,RX-10430,CDM,S5000,HCPCS,250,RC,00409-3182-01,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN,RX-10430,CDM,S5000,HCPCS,250,RC,63323-0483-03,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN,RX-10430,CDM,S5000,HCPCS,250,RC,00409-3182-11,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN,RX-10430,CDM,S5000,HCPCS,250,RC,63323-0483-27,NDC,outpatient,1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN,RX-10431,CDM,S5000,HCPCS,250,RC,00409-3183-01,NDC,outpatient,20,ML,16.35,11.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN,RX-10431,CDM,S5000,HCPCS,250,RC,63323-0489-02,NDC,outpatient,20,ML,30.18,21.126,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN,RX-10431,CDM,S5000,HCPCS,250,RC,63323-0489-17,NDC,outpatient,10,ML,19.13,13.391,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN,RX-10431,CDM,S5000,HCPCS,250,RC,63323-0489-27,NDC,outpatient,20,ML,30.18,21.126,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN,RX-10431,CDM,S5000,HCPCS,250,RC,00409-3183-11,NDC,outpatient,20,ML,16.35,11.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BETHANECHOL CHLORIDE 25 MG ORAL TABS,RX-1044,CDM,S5000,HCPCS,259,RC,00832-0512-01,NDC,outpatient,1,UN,2.51,1.757,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BETHANECHOL CHLORIDE 25 MG ORAL TABS,RX-1044,CDM,S5000,HCPCS,259,RC,00832-0512-89,NDC,outpatient,1,UN,2.51,1.757,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIOTHYRONINE SODIUM 10 MCG/ML IV SOLN,RX-10442,CDM,S5000,HCPCS,250,RC,39822-0151-01,NDC,outpatient,1,ML,1739.29,1217.503,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIOTHYRONINE SODIUM 5 MCG ORAL TABS,RX-10443,CDM,S5000,HCPCS,259,RC,68382-0582-01,NDC,outpatient,1,UN,2.45,1.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIOTHYRONINE SODIUM 5 MCG ORAL TABS,RX-10443,CDM,S5000,HCPCS,259,RC,00093-2179-01,NDC,outpatient,1,UN,2.45,1.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LISINOPRIL 10 MG ORAL TABS,RX-10449,CDM,S5000,HCPCS,259,RC,00904-6798-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LISINOPRIL 10 MG ORAL TABS,RX-10449,CDM,S5000,HCPCS,259,RC,68180-0980-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LISINOPRIL 10 MG ORAL TABS,RX-10449,CDM,S5000,HCPCS,259,RC,68180-0980-03,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LISINOPRIL 5 MG ORAL TABS,RX-10451,CDM,S5000,HCPCS,259,RC,00904-6797-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LITHIUM CARBONATE ER 300 MG ORAL TBCR,RX-10454,CDM,S5000,HCPCS,259,RC,68084-0640-01,NDC,outpatient,1,UN,1.52,1.064,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LITHIUM CARBONATE ER 300 MG ORAL TBCR,RX-10454,CDM,S5000,HCPCS,259,RC,68084-0640-11,NDC,outpatient,1,UN,1.52,1.064,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LITHIUM CARBONATE ER 450 MG ORAL TBCR,RX-10455,CDM,S5000,HCPCS,259,RC,68462-0224-01,NDC,outpatient,1,UN,1,0.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LITHIUM CARBONATE ER 450 MG ORAL TBCR,RX-10455,CDM,S5000,HCPCS,259,RC,68084-0655-11,NDC,outpatient,1,UN,2.55,1.785,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LITHIUM CARBONATE ER 450 MG ORAL TBCR,RX-10455,CDM,S5000,HCPCS,259,RC,68084-0655-01,NDC,outpatient,1,UN,2.55,1.785,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRANEXAMIC ACID 650 MG ORAL TABS,RX-104576,CDM,S5000,HCPCS,259,RC,50268-0772-11,NDC,outpatient,1,UN,11.87,8.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRANEXAMIC ACID 650 MG ORAL TABS,RX-104576,CDM,S5000,HCPCS,259,RC,50268-0772-13,NDC,outpatient,1,UN,11.87,8.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRANEXAMIC ACID 650 MG ORAL TABS,RX-104576,CDM,S5000,HCPCS,259,RC,62559-0265-30,NDC,outpatient,1,UN,10.97,7.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRANEXAMIC ACID 650 MG ORAL TABS,RX-104576,CDM,S5000,HCPCS,259,RC,69918-0301-30,NDC,outpatient,1,UN,6.2,4.34,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RIFAXIMIN 550 MG ORAL TABS,RX-104604,CDM,S5000,HCPCS,259,RC,65649-0303-03,NDC,outpatient,1,UN,223.91,156.737,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RIFAXIMIN 550 MG ORAL TABS,RX-104604,CDM,S5000,HCPCS,259,RC,65649-0303-02,NDC,outpatient,1,UN,223.91,156.737,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LORATADINE 10 MG ORAL TABS,RX-10466,CDM,S5000,HCPCS,259,RC,00904-6852-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LORATADINE 10 MG ORAL TABS,RX-10466,CDM,S5000,HCPCS,259,RC,51079-0246-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LORATADINE 10 MG ORAL TABS,RX-10466,CDM,S5000,HCPCS,259,RC,51079-0246-20,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SIROLIMUS 0.5 MG ORAL TABS,RX-104764,CDM,S5000,HCPCS,259,RC,68382-0520-01,NDC,outpatient,1,UN,18.05,12.635,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SIROLIMUS 0.5 MG ORAL TABS,RX-104764,CDM,S5000,HCPCS,259,RC,59762-1001-01,NDC,outpatient,1,UN,20.25,14.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MAFENIDE ACETATE 85 MG/GM EX CREA,RX-10478,CDM,S5000,HCPCS,259,RC,16571-0723-60,NDC,outpatient,56.7,GR,282.85,197.995,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CAFFEINE CITRATE 60 MG/3ML ORAL SOLN,RX-104787,CDM,S5000,HCPCS,259,RC,25021-0602-03,NDC,outpatient,3,ML,26.44,18.508,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CAFFEINE CITRATE 60 MG/3ML ORAL SOLN,RX-104787,CDM,S5000,HCPCS,259,RC,63323-0406-03,NDC,outpatient,3,ML,31.83,22.281,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CAFFEINE CITRATE 60 MG/3ML ORAL SOLN,RX-104787,CDM,S5000,HCPCS,259,RC,51754-0501-03,NDC,outpatient,3,ML,27.32,19.124,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CAFFEINE CITRATE 60 MG/3ML ORAL SOLN,RX-104787,CDM,S5000,HCPCS,259,RC,63323-0406-01,NDC,outpatient,3,ML,31.83,22.281,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MAGNESIUM OXIDE 140 MG ORAL CAPS,RX-10490,CDM,S5000,HCPCS,259,RC,60569-0495-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACETAMINOPHEN 650 MG RE SUPP,RX-105,CDM,S5000,HCPCS,259,RC,45802-0730-30,NDC,outpatient,1,UN,1.95,1.365,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACETAMINOPHEN 650 MG RE SUPP,RX-105,CDM,S5000,HCPCS,259,RC,45802-0730-33,NDC,outpatient,1,UN,1.05,0.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MEDIUM CHAIN TRIGLYCERIDES ORAL OIL,RX-10518,CDM,S5000,HCPCS,259,RC,41679-0365-03,NDC,outpatient,946,ML,46.31,32.417,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MEDIUM CHAIN TRIGLYCERIDES ORAL OIL,RX-10518,CDM,S5000,HCPCS,259,RC,99999-0003-05,NDC,outpatient,15,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MEDIUM CHAIN TRIGLYCERIDES ORAL OIL,RX-10518,CDM,S5000,HCPCS,259,RC,41679-0365-13,NDC,outpatient,946,ML,46.31,32.417,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MEDIUM CHAIN TRIGLYCERIDES ORAL OIL,RX-10518,CDM,S5000,HCPCS,259,RC,99999-0003-04,NDC,outpatient,1,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MESALAMINE ER 250 MG ORAL CPCR,RX-10533,CDM,S5000,HCPCS,259,RC,54092-0189-81,NDC,outpatient,1,UN,12.49,8.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BROMOCRIPTINE MESYLATE 0.8 MG ORAL TABS,RX-105409,CDM,S5000,HCPCS,259,RC,68012-0258-20,NDC,outpatient,1,UN,23.23,16.261,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METFORMIN HCL 500 MG ORAL TABS,RX-10544,CDM,S5000,HCPCS,259,RC,60687-0155-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METFORMIN HCL 500 MG ORAL TABS,RX-10544,CDM,S5000,HCPCS,259,RC,60687-0155-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METFORMIN HCL 500 MG ORAL TABS,RX-10544,CDM,S5000,HCPCS,259,RC,00904-7162-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LACOSAMIDE 10 MG/ML ORAL SOLN,RX-105482,CDM,S5000,HCPCS,259,RC,00131-5410-72,NDC,outpatient,5,ML,47,32.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LACOSAMIDE 10 MG/ML ORAL SOLN,RX-105482,CDM,S5000,HCPCS,259,RC,99999-0001-42,NDC,outpatient,20,ML,187.97,131.579,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METHENAMINE HIPPURATE 1 G ORAL TABS,RX-10549,CDM,S5000,HCPCS,259,RC,60687-0694-11,NDC,outpatient,1,UN,7.92,5.544,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METHENAMINE HIPPURATE 1 G ORAL TABS,RX-10549,CDM,S5000,HCPCS,259,RC,60687-0694-21,NDC,outpatient,1,UN,7.92,5.544,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METHIMAZOLE 5 MG ORAL TABS,RX-10553,CDM,S5000,HCPCS,259,RC,23155-0070-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METHIMAZOLE 5 MG ORAL TABS,RX-10553,CDM,S5000,HCPCS,259,RC,60687-0669-01,NDC,outpatient,1,UN,2.25,1.575,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METHIMAZOLE 5 MG ORAL TABS,RX-10553,CDM,S5000,HCPCS,259,RC,60687-0669-11,NDC,outpatient,1,UN,2.25,1.575,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-1746-10,NDC,outpatient,10,ML,17.38,12.166,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-1746-71,NDC,outpatient,30,ML,36.85,25.795,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-9042-11,NDC,outpatient,10,ML,18.15,12.705,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,63323-0468-02,NDC,outpatient,30,ML,28.84,20.188,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-9042-01,NDC,outpatient,10,ML,18.15,12.705,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-1746-30,NDC,outpatient,30,ML,36.85,25.795,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-1746-70,NDC,outpatient,10,ML,17.38,12.166,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,63323-0468-01,NDC,outpatient,10,ML,18.16,12.712,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,63323-0468-37,NDC,outpatient,30,ML,28.84,20.188,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,63323-0468-17,NDC,outpatient,10,ML,18.16,12.712,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-31,NDC,outpatient,30,ML,25.5,17.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-37,NDC,outpatient,30,ML,30.98,21.686,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,00409-9045-11,NDC,outpatient,10,ML,11.21,7.847,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,00409-9045-16,NDC,outpatient,30,ML,11.88,8.316,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-01,NDC,outpatient,30,ML,30.98,21.686,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-02,NDC,outpatient,30,ML,25.5,17.85,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-04,NDC,outpatient,10,ML,18.61,13.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,00409-9045-01,NDC,outpatient,10,ML,11.21,7.847,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,00409-9045-17,NDC,outpatient,30,ML,11.88,8.316,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-17,NDC,outpatient,10,ML,18.61,13.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METHYLERGONOVINE MALEATE 0.2 MG ORAL TABS,RX-10572,CDM,S5000,HCPCS,259,RC,69238-1605-02,NDC,outpatient,1,UN,78.51,54.957,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METHYLERGONOVINE MALEATE 0.2 MG ORAL TABS,RX-10572,CDM,S5000,HCPCS,259,RC,60687-0813-94,NDC,outpatient,1,UN,190.6,133.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METHYLERGONOVINE MALEATE 0.2 MG ORAL TABS,RX-10572,CDM,S5000,HCPCS,259,RC,69238-1605-08,NDC,outpatient,1,UN,71.96,50.372,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METHYLERGONOVINE MALEATE 0.2 MG ORAL TABS,RX-10572,CDM,S5000,HCPCS,259,RC,60687-0813-11,NDC,outpatient,1,UN,190.6,133.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METOLAZONE 2.5 MG ORAL TABS,RX-10587,CDM,S5000,HCPCS,259,RC,51079-0023-20,NDC,outpatient,1,UN,11.25,7.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METOLAZONE 2.5 MG ORAL TABS,RX-10587,CDM,S5000,HCPCS,259,RC,51079-0023-01,NDC,outpatient,1,UN,11.25,7.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METOLAZONE 5 MG ORAL TABS,RX-10588,CDM,S5000,HCPCS,259,RC,51079-0024-01,NDC,outpatient,1,UN,12.79,8.953,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METOLAZONE 5 MG ORAL TABS,RX-10588,CDM,S5000,HCPCS,259,RC,51079-0024-20,NDC,outpatient,1,UN,12.79,8.953,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METRONIDAZOLE 0.75 % VA GEL,RX-10592,CDM,S5000,HCPCS,259,RC,16714-0557-01,NDC,outpatient,70,GR,66.67,46.669,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MEXILETINE HCL 150 MG ORAL CAPS,RX-10595,CDM,S5000,HCPCS,259,RC,62559-0820-01,NDC,outpatient,1,UN,1.38,0.966,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MEXILETINE HCL 150 MG ORAL CAPS,RX-10595,CDM,S5000,HCPCS,259,RC,00093-8739-01,NDC,outpatient,1,UN,2.26,1.582,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MEXILETINE HCL 150 MG ORAL CAPS,RX-10595,CDM,S5000,HCPCS,259,RC,50742-0239-01,NDC,outpatient,1,UN,1.39,0.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MEXILETINE HCL 200 MG ORAL CAPS,RX-10596,CDM,S5000,HCPCS,259,RC,00093-8740-01,NDC,outpatient,1,UN,3.1,2.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MICONAZOLE NITRATE 2 % EX POWD,RX-10599,CDM,S5000,HCPCS,259,RC,11701-0038-16,NDC,outpatient,85,GR,25.73,18.011,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MICONAZOLE NITRATE 2 % EX POWD,RX-10599,CDM,S5000,HCPCS,259,RC,53329-0169-79,NDC,outpatient,85,GR,16.27,11.389,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MICROFIBRILLAR COLL HEMOSTAT EX PADS,RX-10605,CDM,S5000,HCPCS,259,RC,53276-1010-08,NDC,outpatient,1,UN,496.85,347.795,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MICROFIBRILLAR COLL HEMOSTAT EX POWD,RX-10606,CDM,S5000,HCPCS,250,RC,53276-1010-02,NDC,outpatient,1,GR,993.69,695.583,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ULIPRISTAL ACETATE 30 MG ORAL TABS,RX-106079,CDM,S5000,HCPCS,259,RC,73302-0456-01,NDC,outpatient,1,UN,159.36,111.552,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MIDODRINE HCL 2.5 MG ORAL TABS,RX-10609,CDM,S5000,HCPCS,259,RC,00245-0211-11,NDC,outpatient,1,UN,1.99,1.393,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MIDODRINE HCL 2.5 MG ORAL TABS,RX-10609,CDM,S5000,HCPCS,259,RC,00378-1901-01,NDC,outpatient,1,UN,2.12,1.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,51079-0453-20,NDC,outpatient,1,UN,1.17,0.819,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,63739-0145-10,NDC,outpatient,1,UN,1.05,0.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,00245-0212-01,NDC,outpatient,1,UN,2.4,1.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,00904-6818-61,NDC,outpatient,1,UN,2.24,1.568,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,00245-0212-89,NDC,outpatient,1,UN,2.4,1.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,51079-0453-01,NDC,outpatient,1,UN,1.17,0.819,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NEOMYCIN-POLYMYXIN-DEXAMETH 3.5-10000-0.1 OP SUSP,RX-106248,CDM,S5000,HCPCS,259,RC,24208-0830-60,NDC,outpatient,5,ML,59.63,41.741,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NEOMYCIN-POLYMYXIN-DEXAMETH 3.5-10000-0.1 OP OINT,RX-106249,CDM,S5000,HCPCS,259,RC,61314-0631-36,NDC,outpatient,3.5,GR,69.78,48.846,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MISOPROSTOL 100 MCG ORAL TABS,RX-10628,CDM,S5000,HCPCS,259,RC,60687-0735-01,NDC,outpatient,1,UN,9.27,6.489,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MISOPROSTOL 100 MCG ORAL TABS,RX-10628,CDM,S5000,HCPCS,259,RC,00025-1451-34,NDC,outpatient,1,UN,17.24,12.068,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MISOPROSTOL 100 MCG ORAL TABS,RX-10628,CDM,S5000,HCPCS,259,RC,59762-5007-01,NDC,outpatient,1,UN,2.08,1.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MISOPROSTOL 100 MCG ORAL TABS,RX-10628,CDM,S5000,HCPCS,259,RC,60687-0735-11,NDC,outpatient,1,UN,9.27,6.489,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MISOPROSTOL 200 MCG ORAL TABS,RX-10629,CDM,S5000,HCPCS,259,RC,60687-0746-11,NDC,outpatient,1,UN,7.19,5.033,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MISOPROSTOL 200 MCG ORAL TABS,RX-10629,CDM,S5000,HCPCS,259,RC,60687-0746-01,NDC,outpatient,1,UN,7.19,5.033,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL (PF) 0.5 % IJ SOLN,RX-106363,CDM,S5000,HCPCS,250,RC,00409-4278-16,NDC,outpatient,50,ML,10.28,7.196,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL (PF) 0.5 % IJ SOLN,RX-106363,CDM,S5000,HCPCS,250,RC,00409-4278-01,NDC,outpatient,50,ML,10.28,7.196,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DABIGATRAN ETEXILATE MESYLATE 75 MG ORAL CAPS,RX-106490,CDM,S5000,HCPCS,259,RC,00597-0355-56,NDC,outpatient,1,UN,12.92,9.044,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DABIGATRAN ETEXILATE MESYLATE 75 MG ORAL CAPS,RX-106490,CDM,S5000,HCPCS,259,RC,00597-0355-61,NDC,outpatient,1,UN,12.92,9.044,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DABIGATRAN ETEXILATE MESYLATE 150 MG ORAL CAPS,RX-106491,CDM,S5000,HCPCS,259,RC,00597-0360-82,NDC,outpatient,1,UN,12.92,9.044,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DABIGATRAN ETEXILATE MESYLATE 150 MG ORAL CAPS,RX-106491,CDM,S5000,HCPCS,259,RC,00597-0360-55,NDC,outpatient,1,UN,12.92,9.044,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MORPHINE SULFATE (CONCENTRATE) 20 MG/ML ORAL SOLN,RX-10655,CDM,S5000,HCPCS,259,RC,00406-8003-30,NDC,outpatient,0.25,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MORPHINE SULFATE (CONCENTRATE) 20 MG/ML ORAL SOLN,RX-10655,CDM,S5000,HCPCS,259,RC,99999-0002-18,NDC,outpatient,1,ML,2.33,1.631,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MUPIROCIN 2 % EX OINT,RX-10674,CDM,S5000,HCPCS,259,RC,68462-0180-22,NDC,outpatient,22,GR,18.61,13.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MUPIROCIN 2 % EX OINT,RX-10674,CDM,S5000,HCPCS,259,RC,45802-0112-22,NDC,outpatient,22,GR,13.61,9.527,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MUPIROCIN 2 % EX OINT,RX-10674,CDM,S5000,HCPCS,259,RC,51672-1312-00,NDC,outpatient,22,GR,11.07,7.749,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NABUMETONE 500 MG ORAL TABS,RX-10676,CDM,S5000,HCPCS,259,RC,00591-3670-01,NDC,outpatient,1,UN,1.2,0.84,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NABUMETONE 500 MG ORAL TABS,RX-10676,CDM,S5000,HCPCS,259,RC,60687-0630-11,NDC,outpatient,1,UN,3.85,2.695,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NABUMETONE 500 MG ORAL TABS,RX-10676,CDM,S5000,HCPCS,259,RC,60687-0630-21,NDC,outpatient,1,UN,3.85,2.695,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NALTREXONE HCL 50 MG ORAL TABS,RX-10685,CDM,S5000,HCPCS,259,RC,00904-7036-04,NDC,outpatient,1,UN,7.95,5.565,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NALTREXONE HCL 50 MG ORAL TABS,RX-10685,CDM,S5000,HCPCS,259,RC,68084-0291-21,NDC,outpatient,1,UN,8.68,6.076,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NALTREXONE HCL 50 MG ORAL TABS,RX-10685,CDM,S5000,HCPCS,259,RC,68084-0291-11,NDC,outpatient,1,UN,8.68,6.076,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NALTREXONE HCL 50 MG ORAL TABS,RX-10685,CDM,S5000,HCPCS,259,RC,00406-1170-03,NDC,outpatient,1,UN,4.49,3.143,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NICARDIPINE HCL 20 MG ORAL CAPS,RX-10712,CDM,S5000,HCPCS,259,RC,62559-0205-90,NDC,outpatient,1,UN,35.49,24.843,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NICARDIPINE HCL 20 MG ORAL CAPS,RX-10712,CDM,S5000,HCPCS,259,RC,68462-0120-90,NDC,outpatient,1,UN,18.98,13.286,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NICARDIPINE HCL 30 MG ORAL CAPS,RX-10713,CDM,S5000,HCPCS,259,RC,68462-0121-90,NDC,outpatient,1,UN,27.58,19.306,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NICARDIPINE HCL 30 MG ORAL CAPS,RX-10713,CDM,S5000,HCPCS,259,RC,42806-0502-09,NDC,outpatient,1,UN,24.73,17.311,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NICOTINE POLACRILEX 2 MG MT GUM,RX-10717,CDM,S5000,HCPCS,259,RC,00536-1362-23,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NICOTINE POLACRILEX 2 MG MT GUM,RX-10717,CDM,S5000,HCPCS,259,RC,00536-3029-23,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NICOTINE POLACRILEX 4 MG MT GUM,RX-10718,CDM,S5000,HCPCS,259,RC,00536-1372-23,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NICOTINE POLACRILEX 4 MG MT GUM,RX-10718,CDM,S5000,HCPCS,259,RC,00135-0242-08,NDC,outpatient,1,UN,2.37,1.659,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NIMODIPINE 30 MG ORAL CAPS,RX-10722,CDM,S5000,HCPCS,259,RC,23155-0512-00,NDC,outpatient,1,UN,5.11,3.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NIMODIPINE 30 MG ORAL CAPS,RX-10722,CDM,S5000,HCPCS,259,RC,23155-0512-11,NDC,outpatient,1,UN,5.11,3.577,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,00904-7137-61,NDC,outpatient,1,UN,6.96,4.872,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,50268-0625-15,NDC,outpatient,1,UN,7.34,5.138,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,16714-0439-01,NDC,outpatient,1,UN,7.17,5.019,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,60687-0633-01,NDC,outpatient,1,UN,9.67,6.769,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,60687-0633-11,NDC,outpatient,1,UN,9.67,6.769,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,50268-0625-11,NDC,outpatient,1,UN,7.34,5.138,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPRENORPHINE 5 MCG/HR TD PTWK,RX-107660,CDM,S5000,HCPCS,259,RC,42858-0750-40,NDC,outpatient,1,UN,220.77,154.539,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPRENORPHINE 5 MCG/HR TD PTWK,RX-107660,CDM,S5000,HCPCS,259,RC,50742-0372-01,NDC,outpatient,1,UN,146.92,102.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPRENORPHINE 5 MCG/HR TD PTWK,RX-107660,CDM,S5000,HCPCS,259,RC,50742-0372-04,NDC,outpatient,1,UN,146.92,102.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPRENORPHINE 10 MCG/HR TD PTWK,RX-107661,CDM,S5000,HCPCS,259,RC,00093-3657-40,NDC,outpatient,1,UN,232.52,162.764,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPRENORPHINE 10 MCG/HR TD PTWK,RX-107661,CDM,S5000,HCPCS,259,RC,00093-3657-21,NDC,outpatient,1,UN,232.52,162.764,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OLSALAZINE SODIUM 250 MG ORAL CAPS,RX-10773,CDM,S5000,HCPCS,259,RC,00037-6860-10,NDC,outpatient,1,UN,61.39,42.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VALPROIC ACID 250 MG/5ML ORAL SOLN,RX-107838,CDM,S5000,HCPCS,259,RC,00121-4675-05,NDC,outpatient,5,ML,7.15,5.005,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VALPROIC ACID 250 MG/5ML ORAL SOLN,RX-107838,CDM,S5000,HCPCS,259,RC,00121-4675-40,NDC,outpatient,5,ML,7.15,5.005,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VALPROIC ACID 250 MG/5ML ORAL SOLN,RX-107838,CDM,S5000,HCPCS,259,RC,99999-0001-41,NDC,outpatient,5,ML,2.27,1.589,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VALPROIC ACID 250 MG/5ML ORAL SOLN,RX-107838,CDM,S5000,HCPCS,259,RC,00121-4675-00,NDC,outpatient,5,ML,4.92,3.444,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BISACODYL 5 MG ORAL TBEC,RX-1079,CDM,S5000,HCPCS,259,RC,00904-6407-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BISACODYL 10 MG RE SUPP,RX-1080,CDM,S5000,HCPCS,259,RC,00574-7050-12,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BISACODYL 10 MG RE SUPP,RX-1080,CDM,S5000,HCPCS,259,RC,81421-0021-03,NDC,outpatient,1,UN,3.38,2.366,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BISACODYL 10 MG RE SUPP,RX-1080,CDM,S5000,HCPCS,259,RC,58980-0415-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BISACODYL 10 MG RE SUPP,RX-1080,CDM,S5000,HCPCS,259,RC,58980-0415-50,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BISACODYL 10 MG RE SUPP,RX-1080,CDM,S5000,HCPCS,259,RC,00574-7050-50,NDC,outpatient,1,UN,1.02,0.714,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TESTOSTERONE 25 MG/2.5GM (1%) TD GEL,RX-108038,CDM,S5000,HCPCS,259,RC,64380-0151-02,NDC,outpatient,2.5,GR,13.58,9.506,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TESTOSTERONE 25 MG/2.5GM (1%) TD GEL,RX-108038,CDM,S5000,HCPCS,259,RC,64380-0151-01,NDC,outpatient,2.5,GR,13.58,9.506,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TESTOSTERONE 50 MG/5GM (1%) TD GEL,RX-108039,CDM,S5000,HCPCS,259,RC,00591-3524-30,NDC,outpatient,5,GR,13.67,9.569,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TESTOSTERONE 50 MG/5GM (1%) TD GEL,RX-108039,CDM,S5000,HCPCS,259,RC,00591-3524-26,NDC,outpatient,5,GR,13.67,9.569,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXYCODONE HCL 100 MG/5ML ORAL CONC,RX-10812,CDM,S5000,HCPCS,259,RC,00406-8557-30,NDC,outpatient,30,ML,133.24,93.268,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXYCODONE HCL 100 MG/5ML ORAL CONC,RX-10812,CDM,S5000,HCPCS,259,RC,99999-0002-27,NDC,outpatient,1,ML,7.21,5.047,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXYCODONE HCL 5 MG/5ML ORAL SOLN,RX-10813,CDM,S5000,HCPCS,259,RC,64950-0354-05,NDC,outpatient,5,ML,8.79,6.153,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXYCODONE HCL 5 MG/5ML ORAL SOLN,RX-10813,CDM,S5000,HCPCS,259,RC,64950-0354-55,NDC,outpatient,5,ML,8.79,6.153,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,00406-0552-23,NDC,outpatient,1,UN,1.17,0.819,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,42858-0001-10,NDC,outpatient,1,UN,1,0.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,68084-0354-01,NDC,outpatient,1,UN,1.65,1.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,00406-0552-62,NDC,outpatient,1,UN,1.17,0.819,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,10702-0018-50,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,00406-0552-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,68084-0354-11,NDC,outpatient,1,UN,1.65,1.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,00904-6966-61,NDC,outpatient,1,UN,1.01,0.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PAROXETINE HCL 20 MG ORAL TABS,RX-10855,CDM,S5000,HCPCS,259,RC,63739-0963-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BISMUTH SUBCARBONATE POWD,RX-1086,CDM,S5000,HCPCS,259,RC,62991-2844-02,NDC,outpatient,100,GR,276.06,193.242,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BISMUTH SUBSALICYLATE 262 MG/15ML ORAL SUSP,RX-1090,CDM,S5000,HCPCS,259,RC,99999-0001-91,NDC,outpatient,30,ML,2.01,1.407,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BISMUTH SUBSALICYLATE 262 MG/15ML ORAL SUSP,RX-1090,CDM,S5000,HCPCS,259,RC,37000-0475-08,NDC,outpatient,10,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PERMETHRIN 5 % EX CREA,RX-10917,CDM,S5000,HCPCS,259,RC,00472-0242-60,NDC,outpatient,60,GR,76.37,53.459,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,00378-1905-77,NDC,outpatient,1,UN,17.44,12.208,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,42571-0259-30,NDC,outpatient,1,UN,4.47,3.129,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,60687-0786-11,NDC,outpatient,1,UN,7.84,5.488,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,31722-0623-90,NDC,outpatient,1,UN,7.15,5.005,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,60687-0786-21,NDC,outpatient,1,UN,7.84,5.488,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,00310-0095-30,NDC,outpatient,1,UN,54.75,38.325,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PHENOXYBENZAMINE HCL 10 MG ORAL CAPS,RX-10945,CDM,S5000,HCPCS,259,RC,66993-0066-02,NDC,outpatient,1,UN,73.53,51.471,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PHENTOLAMINE MESYLATE 5 MG IJ SOLR,RX-10947,CDM,S5000,HCPCS,259,RC,00143-9564-01,NDC,outpatient,1,UN,1208.89,846.223,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PHENTOLAMINE MESYLATE 5 MG IJ SOLR,RX-10947,CDM,S5000,HCPCS,259,RC,00143-9564-10,NDC,outpatient,1,UN,1233.54,863.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LINAGLIPTIN 5 MG ORAL TABS,RX-109773,CDM,S5000,HCPCS,259,RC,00597-0140-61,NDC,outpatient,1,UN,56.14,39.298,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RILPIVIRINE HCL 25 MG ORAL TABS,RX-109909,CDM,S5000,HCPCS,259,RC,59676-0278-01,NDC,outpatient,1,UN,209.04,146.328,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PHENYTOIN 50 MG ORAL CHEW,RX-11018,CDM,S5000,HCPCS,259,RC,60687-0156-25,NDC,outpatient,1,UN,4.05,2.835,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PHENYTOIN 50 MG ORAL CHEW,RX-11018,CDM,S5000,HCPCS,259,RC,60687-0156-95,NDC,outpatient,1,UN,4.05,2.835,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PHENYTOIN 50 MG ORAL CHEW,RX-11018,CDM,S5000,HCPCS,259,RC,00904-7199-07,NDC,outpatient,1,UN,3.73,2.611,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PHENYTOIN SODIUM EXTENDED 30 MG ORAL CAPS,RX-11019,CDM,S5000,HCPCS,259,RC,00071-3740-66,NDC,outpatient,1,UN,5.97,4.179,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PHYTONADIONE 5 MG ORAL TABS,RX-11024,CDM,S5000,HCPCS,259,RC,60687-0381-94,NDC,outpatient,1,UN,227.6,159.32,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PHYTONADIONE 5 MG ORAL TABS,RX-11024,CDM,S5000,HCPCS,259,RC,60687-0381-11,NDC,outpatient,1,UN,227.6,159.32,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RIVAROXABAN 10 MG ORAL TABS,RX-110250,CDM,S5000,HCPCS,259,RC,50458-0580-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RIVAROXABAN 10 MG ORAL TABS,RX-110250,CDM,S5000,HCPCS,259,RC,50458-0580-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FIDAXOMICIN 200 MG ORAL TABS,RX-110360,CDM,S5000,HCPCS,259,RC,52015-0080-01,NDC,outpatient,1,UN,501.77,351.239,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TICAGRELOR 90 MG ORAL TABS,RX-110427,CDM,S5000,HCPCS,259,RC,00186-0777-39,NDC,outpatient,1,UN,30.77,21.539,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CALCIUM POLYCARBOPHIL 625 MG ORAL TABS,RX-11046,CDM,S5000,HCPCS,259,RC,00904-2500-91,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CALCIUM POLYCARBOPHIL 625 MG ORAL TABS,RX-11046,CDM,S5000,HCPCS,259,RC,00536-4306-05,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POLYSACCHARIDE IRON COMPLEX 150 MG ORAL CAPS,RX-11050,CDM,S5000,HCPCS,259,RC,00904-5395-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POTASSIUM CITRATE ER 10 MEQ (1080 MG) ORAL TBCR,RX-11083,CDM,S5000,HCPCS,259,RC,00178-0610-01,NDC,outpatient,1,UN,7.92,5.544,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POTASSIUM CITRATE ER 10 MEQ (1080 MG) ORAL TBCR,RX-11083,CDM,S5000,HCPCS,259,RC,68084-0850-32,NDC,outpatient,1,UN,8.47,5.929,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POTASSIUM CITRATE ER 10 MEQ (1080 MG) ORAL TBCR,RX-11083,CDM,S5000,HCPCS,259,RC,68084-0850-33,NDC,outpatient,1,UN,8.47,5.929,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OSELTAMIVIR PHOSPHATE 6 MG/ML ORAL SUSR,RX-110998,CDM,S5000,HCPCS,259,RC,27241-0139-09,NDC,outpatient,60,ML,35.52,24.864,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OSELTAMIVIR PHOSPHATE 6 MG/ML ORAL SUSR,RX-110998,CDM,S5000,HCPCS,259,RC,68180-0678-01,NDC,outpatient,60,ML,26.7,18.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OSELTAMIVIR PHOSPHATE 6 MG/ML ORAL SUSR,RX-110998,CDM,S5000,HCPCS,259,RC,00004-0822-05,NDC,outpatient,60,ML,624.52,437.164,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OSELTAMIVIR PHOSPHATE 6 MG/ML ORAL SUSR,RX-110998,CDM,S5000,HCPCS,259,RC,99999-0000-41,NDC,outpatient,5,ML,52.63,36.841,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PRAVASTATIN SODIUM 10 MG ORAL TABS,RX-11110,CDM,S5000,HCPCS,259,RC,00904-5891-61,NDC,outpatient,1,UN,1.35,0.945,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PRAVASTATIN SODIUM 20 MG ORAL TABS,RX-11111,CDM,S5000,HCPCS,259,RC,00904-5892-61,NDC,outpatient,1,UN,2.3,1.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PRAVASTATIN SODIUM 20 MG ORAL TABS,RX-11111,CDM,S5000,HCPCS,259,RC,51079-0458-01,NDC,outpatient,1,UN,2.39,1.673,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PRAVASTATIN SODIUM 20 MG ORAL TABS,RX-11111,CDM,S5000,HCPCS,259,RC,51079-0458-20,NDC,outpatient,1,UN,2.39,1.673,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PRIMIDONE 50 MG ORAL TABS,RX-11129,CDM,S5000,HCPCS,259,RC,68084-0202-11,NDC,outpatient,1,UN,2.64,1.848,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PRIMIDONE 50 MG ORAL TABS,RX-11129,CDM,S5000,HCPCS,259,RC,68084-0202-01,NDC,outpatient,1,UN,2.64,1.848,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PROCHLORPERAZINE 25 MG RE SUPP,RX-11138,CDM,S5000,HCPCS,259,RC,00574-7226-12,NDC,outpatient,1,UN,26.18,18.326,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PROMETHAZINE HCL 12.5 MG RE SUPP,RX-11143,CDM,S5000,HCPCS,259,RC,00713-0536-12,NDC,outpatient,1,UN,43.38,30.366,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PROMETHAZINE HCL 12.5 MG RE SUPP,RX-11143,CDM,S5000,HCPCS,259,RC,00713-0536-06,NDC,outpatient,1,UN,43.38,30.366,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PROMETHAZINE HCL 25 MG RE SUPP,RX-11144,CDM,S5000,HCPCS,259,RC,00713-0526-12,NDC,outpatient,1,UN,43.38,30.366,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PROPAFENONE HCL 150 MG ORAL TABS,RX-11146,CDM,S5000,HCPCS,259,RC,00591-0582-01,NDC,outpatient,1,UN,1.95,1.365,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PROPAFENONE HCL 225 MG ORAL TABS,RX-11147,CDM,S5000,HCPCS,259,RC,00591-0583-01,NDC,outpatient,1,UN,1.32,0.924,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PYRIDOSTIGMINE BROMIDE 60 MG ORAL TABS,RX-11239,CDM,S5000,HCPCS,259,RC,00904-6622-61,NDC,outpatient,1,UN,3.64,2.548,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PYRIDOSTIGMINE BROMIDE 60 MG ORAL TABS,RX-11239,CDM,S5000,HCPCS,259,RC,68382-0659-06,NDC,outpatient,1,UN,1.59,1.113,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PYRIDOSTIGMINE BROMIDE ER 180 MG ORAL TBCR,RX-11240,CDM,S5000,HCPCS,259,RC,47781-0335-30,NDC,outpatient,1,UN,71.76,50.232,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PYRIMETHAMINE 25 MG ORAL TABS,RX-11246,CDM,S5000,HCPCS,259,RC,43598-0672-01,NDC,outpatient,1,UN,1019.51,713.657,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POLIDOCANOL 1 % IV SOLN,RX-112481,CDM,S5000,HCPCS,250,RC,67850-0141-00,NDC,outpatient,2,ML,92.93,65.051,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POLIDOCANOL 1 % IV SOLN,RX-112481,CDM,S5000,HCPCS,250,RC,67850-0141-05,NDC,outpatient,2,ML,92.93,65.051,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RAMIPRIL 1.25 MG ORAL CAPS,RX-11258,CDM,S5000,HCPCS,259,RC,68382-0144-06,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RAMIPRIL 5 MG ORAL CAPS,RX-11261,CDM,S5000,HCPCS,259,RC,57237-0224-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RAMIPRIL 5 MG ORAL CAPS,RX-11261,CDM,S5000,HCPCS,259,RC,68382-0146-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLOBAZAM 10 MG ORAL TABS,RX-112703,CDM,S5000,HCPCS,259,RC,60687-0423-11,NDC,outpatient,1,UN,9.33,6.531,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLOBAZAM 10 MG ORAL TABS,RX-112703,CDM,S5000,HCPCS,259,RC,60687-0423-21,NDC,outpatient,1,UN,9.33,6.531,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLOBAZAM 10 MG ORAL TABS,RX-112703,CDM,S5000,HCPCS,259,RC,68180-0157-01,NDC,outpatient,1,UN,2.47,1.729,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RIVAROXABAN 15 MG ORAL TABS,RX-112834,CDM,S5000,HCPCS,259,RC,50458-0578-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RIVAROXABAN 15 MG ORAL TABS,RX-112834,CDM,S5000,HCPCS,259,RC,50458-0578-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RIBAVIRIN 200 MG ORAL CAPS,RX-11286,CDM,S5000,HCPCS,259,RC,65862-0290-84,NDC,outpatient,1,UN,5.94,4.158,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RIFABUTIN 150 MG ORAL CAPS,RX-11290,CDM,S5000,HCPCS,259,RC,59762-1350-01,NDC,outpatient,1,UN,47.58,33.306,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RIFAMPIN 600 MG IV SOLR,RX-11291,CDM,S5000,HCPCS,250,RC,67457-0445-60,NDC,outpatient,1,UN,242,169.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RIFAMPIN 600 MG IV SOLR,RX-11291,CDM,S5000,HCPCS,250,RC,00068-0597-01,NDC,outpatient,1,UN,360.5,252.35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RIFAMPIN 600 MG IV SOLR,RX-11291,CDM,S5000,HCPCS,250,RC,63323-0351-20,NDC,outpatient,1,UN,246.71,172.697,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RIFAMPIN 150 MG ORAL CAPS,RX-11292,CDM,S5000,HCPCS,259,RC,60687-0575-11,NDC,outpatient,1,UN,10.17,7.119,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RIFAMPIN 150 MG ORAL CAPS,RX-11292,CDM,S5000,HCPCS,259,RC,60687-0575-21,NDC,outpatient,1,UN,10.17,7.119,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RIFAMPIN 300 MG ORAL CAPS,RX-11293,CDM,S5000,HCPCS,259,RC,60687-0586-01,NDC,outpatient,1,UN,6.25,4.375,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RIFAMPIN 300 MG ORAL CAPS,RX-11293,CDM,S5000,HCPCS,259,RC,60687-0586-11,NDC,outpatient,1,UN,6.25,4.375,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACETAZOLAMIDE 250 MG ORAL TABS,RX-113,CDM,S5000,HCPCS,259,RC,60687-0619-01,NDC,outpatient,1,UN,9.15,6.405,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACETAZOLAMIDE 250 MG ORAL TABS,RX-113,CDM,S5000,HCPCS,259,RC,60687-0619-11,NDC,outpatient,1,UN,9.15,6.405,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RACEPINEPHRINE HCL 2.25 % IN NEBU,RX-113082,CDM,S5000,HCPCS,259,RC,00487-5901-99,NDC,outpatient,1,UN,5.79,4.053,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FIRST-OMEPRAZOLE 2 MG/ML ORAL SUSP,RX-113272,CDM,S5000,HCPCS,259,RC,65628-0070-03,NDC,outpatient,5,ML,27.75,19.425,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FIRST-OMEPRAZOLE 2 MG/ML ORAL SUSP,RX-113272,CDM,S5000,HCPCS,259,RC,99999-9003-64,NDC,outpatient,5,ML,27.75,19.425,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,16714-0612-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,76282-0213-18,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,16714-0612-04,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,60687-0242-01,NDC,outpatient,1,UN,1.35,0.945,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,60687-0242-11,NDC,outpatient,1,UN,1.35,0.945,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,00904-6925-61,NDC,outpatient,1,UN,1.38,0.966,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,68180-0352-09,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LURASIDONE HCL 20 MG ORAL TABS,RX-113587,CDM,S5000,HCPCS,259,RC,16729-0346-10,NDC,outpatient,1,UN,5,3.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LURASIDONE HCL 20 MG ORAL TABS,RX-113587,CDM,S5000,HCPCS,259,RC,67877-0638-30,NDC,outpatient,1,UN,1.86,1.302,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LURASIDONE HCL 20 MG ORAL TABS,RX-113587,CDM,S5000,HCPCS,259,RC,63402-0302-30,NDC,outpatient,1,UN,165.29,115.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SILVER NITRATE-POT NITRATE 75-25 % EX MISC,RX-11359,CDM,S5000,HCPCS,259,RC,12870-0001-01,NDC,outpatient,10,UN,28.31,19.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SOD CITRATE-CITRIC ACID 500-334 MG/5ML ORAL SOLN,RX-11394,CDM,S5000,HCPCS,259,RC,00121-1190-30,NDC,outpatient,30,ML,19.63,13.741,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SOD CITRATE-CITRIC ACID 500-334 MG/5ML ORAL SOLN,RX-11394,CDM,S5000,HCPCS,259,RC,00121-1190-00,NDC,outpatient,30,ML,19.63,13.741,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE 0.9 % IR SOLN,RX-11403,CDM,S5000,HCPCS,250,RC,00338-0048-03,NDC,outpatient,500,ML,11.87,8.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE 0.9 % IR SOLN,RX-11403,CDM,S5000,HCPCS,250,RC,00338-0048-04,NDC,outpatient,1000,ML,15.82,11.074,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE (HYPERTONIC) 2 % OP SOLN,RX-11404,CDM,S5000,HCPCS,259,RC,24208-0276-15,NDC,outpatient,15,ML,65.35,45.745,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SOTALOL HCL 80 MG ORAL TABS,RX-11421,CDM,S5000,HCPCS,259,RC,68084-0654-01,NDC,outpatient,1,UN,4.36,3.052,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SOTALOL HCL 80 MG ORAL TABS,RX-11421,CDM,S5000,HCPCS,259,RC,68084-0654-11,NDC,outpatient,1,UN,4.36,3.052,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,51079-0753-01,NDC,outpatient,1,UN,1.48,1.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,51079-0753-20,NDC,outpatient,1,UN,1.48,1.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,29033-0003-05,NDC,outpatient,1,UN,1.06,0.742,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,00093-2210-01,NDC,outpatient,1,UN,1.34,0.938,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,59762-0401-05,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,62135-0436-90,NDC,outpatient,1,UN,16.45,11.515,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TERBUTALINE SULFATE 2.5 MG ORAL TABS,RX-11508,CDM,S5000,HCPCS,259,RC,00527-1318-01,NDC,outpatient,1,UN,19.38,13.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TERBUTALINE SULFATE 2.5 MG ORAL TABS,RX-11508,CDM,S5000,HCPCS,259,RC,62559-0721-01,NDC,outpatient,1,UN,4.45,3.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TETRACAINE HCL 1 % IJ SOLN,RX-11517,CDM,S5000,HCPCS,250,RC,54288-0127-01,NDC,outpatient,2,ML,164.48,115.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TETRACAINE HCL 1 % IJ SOLN,RX-11517,CDM,S5000,HCPCS,250,RC,54288-0127-10,NDC,outpatient,2,ML,164.48,115.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
THROMBIN 20000 UNITS EX KIT,RX-11544,CDM,S5000,HCPCS,250,RC,60793-0217-22,NDC,outpatient,1,UN,883.55,618.485,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
THROMBIN 20000 UNITS EX KIT,RX-11544,CDM,S5000,HCPCS,250,RC,60793-0217-21,NDC,outpatient,1,UN,883.55,618.485,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
THROMBIN 5000 UNITS EX SOLR,RX-11548,CDM,S5000,HCPCS,250,RC,60793-0215-05,NDC,outpatient,1,UN,195.76,137.032,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TIMOLOL MALEATE 0.25 % OP SOLN,RX-11561,CDM,S5000,HCPCS,259,RC,60758-0802-05,NDC,outpatient,5,ML,11.17,7.819,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TIMOLOL MALEATE 0.25 % OP SOLN,RX-11561,CDM,S5000,HCPCS,259,RC,64980-0513-05,NDC,outpatient,5,ML,10.28,7.196,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TIMOLOL MALEATE 0.5 % OP SOLN,RX-11562,CDM,S5000,HCPCS,259,RC,60758-0801-05,NDC,outpatient,5,ML,22.48,15.736,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TIMOLOL MALEATE 0.5 % OP SOLN,RX-11562,CDM,S5000,HCPCS,259,RC,64980-0514-05,NDC,outpatient,5,ML,21.94,15.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OP OINT,RX-11566,CDM,S5000,HCPCS,259,RC,00078-0876-01,NDC,outpatient,3.5,GR,1115.32,780.724,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OP SUSP,RX-11567,CDM,S5000,HCPCS,259,RC,24208-0295-25,NDC,outpatient,2.5,ML,173.64,121.548,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRIAMTERENE 50 MG ORAL CAPS,RX-11588,CDM,S5000,HCPCS,259,RC,66993-0831-02,NDC,outpatient,1,UN,36.58,25.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRIAMTERENE 50 MG ORAL CAPS,RX-11588,CDM,S5000,HCPCS,259,RC,59212-0002-01,NDC,outpatient,1,UN,60.49,42.343,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRIFLURIDINE 1 % OP SOLN,RX-11595,CDM,S5000,HCPCS,259,RC,61314-0044-75,NDC,outpatient,7.5,ML,948.02,663.614,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POLYMYXIN B-TRIMETHOPRIM 10000-0.1 UNIT/ML-% OP SOLN,RX-11596,CDM,S5000,HCPCS,259,RC,24208-0315-10,NDC,outpatient,10,ML,47.84,33.488,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POLYMYXIN B-TRIMETHOPRIM 10000-0.1 UNIT/ML-% OP SOLN,RX-11596,CDM,S5000,HCPCS,259,RC,61314-0628-10,NDC,outpatient,10,ML,43.88,30.716,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG ORAL TABS,RX-11599,CDM,S5000,HCPCS,259,RC,00904-2725-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
URSODIOL 300 MG ORAL CAPS,RX-11624,CDM,S5000,HCPCS,259,RC,60687-0100-01,NDC,outpatient,1,UN,15.37,10.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
URSODIOL 300 MG ORAL CAPS,RX-11624,CDM,S5000,HCPCS,259,RC,60687-0100-11,NDC,outpatient,1,UN,15.37,10.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VECURONIUM BROMIDE 10 MG IV SOLR,RX-11634,CDM,S5000,HCPCS,250,RC,55150-0235-01,NDC,outpatient,1,UN,11.52,8.064,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VECURONIUM BROMIDE 10 MG IV SOLR,RX-11634,CDM,S5000,HCPCS,250,RC,55150-0235-10,NDC,outpatient,1,UN,11.52,8.064,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VECURONIUM BROMIDE 20 MG IV SOLR,RX-11635,CDM,S5000,HCPCS,250,RC,00143-9232-01,NDC,outpatient,1,UN,41.49,29.043,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VECURONIUM BROMIDE 20 MG IV SOLR,RX-11635,CDM,S5000,HCPCS,250,RC,00143-9232-10,NDC,outpatient,1,UN,41.49,29.043,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
WARFARIN SODIUM 1 MG ORAL TABS,RX-11664,CDM,S5000,HCPCS,259,RC,00832-1211-89,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
WARFARIN SODIUM 1 MG ORAL TABS,RX-11664,CDM,S5000,HCPCS,259,RC,00832-1211-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IPRATROPIUM-ALBUTEROL 20-100 MCG/ACT IN AERS,RX-116728,CDM,S5000,HCPCS,259,RC,00597-0024-02,NDC,outpatient,4,GR,2012.08,1408.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ZIDOVUDINE 100 MG ORAL CAPS,RX-11692,CDM,S5000,HCPCS,259,RC,65862-0107-01,NDC,outpatient,1,UN,6.23,4.361,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ZIDOVUDINE 10 MG/ML ORAL SYRP,RX-11693,CDM,S5000,HCPCS,259,RC,,,outpatient,5,ML,3.1,2.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ZOLPIDEM TARTRATE 5 MG ORAL TABS,RX-11701,CDM,S5000,HCPCS,259,RC,00904-6082-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LINACLOTIDE 145 MCG ORAL CAPS,RX-117352,CDM,S5000,HCPCS,259,RC,00456-1201-30,NDC,outpatient,1,UN,74.11,51.877,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RIVASTIGMINE 13.3 MG/24HR TD PT24,RX-117356,CDM,S5000,HCPCS,259,RC,00378-9072-93,NDC,outpatient,1,UN,6.86,4.802,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RIVASTIGMINE 13.3 MG/24HR TD PT24,RX-117356,CDM,S5000,HCPCS,259,RC,70710-1198-07,NDC,outpatient,1,UN,8.83,6.181,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RIVASTIGMINE 13.3 MG/24HR TD PT24,RX-117356,CDM,S5000,HCPCS,259,RC,00378-9072-16,NDC,outpatient,1,UN,6.86,4.802,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RIVASTIGMINE 13.3 MG/24HR TD PT24,RX-117356,CDM,S5000,HCPCS,259,RC,70710-1198-01,NDC,outpatient,1,UN,8.83,6.181,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MORPHINE SULFATE ER 30 MG ORAL TBCR,RX-119007,CDM,S5000,HCPCS,259,RC,00406-8330-01,NDC,outpatient,1,UN,1.46,1.022,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MORPHINE SULFATE ER 30 MG ORAL TBCR,RX-119007,CDM,S5000,HCPCS,259,RC,00406-8330-23,NDC,outpatient,1,UN,4.35,3.045,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MORPHINE SULFATE ER 30 MG ORAL TBCR,RX-119007,CDM,S5000,HCPCS,259,RC,00904-6558-61,NDC,outpatient,1,UN,5.15,3.605,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MORPHINE SULFATE ER 30 MG ORAL TBCR,RX-119007,CDM,S5000,HCPCS,259,RC,00406-8330-62,NDC,outpatient,1,UN,4.35,3.045,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
APIXABAN 2.5 MG ORAL TABS,RX-119040,CDM,S5000,HCPCS,259,RC,00003-0893-21,NDC,outpatient,1,UN,6.17,4.319,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
APIXABAN 2.5 MG ORAL TABS,RX-119040,CDM,S5000,HCPCS,259,RC,00003-0893-31,NDC,outpatient,1,UN,6.17,4.319,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,00703-2056-03,NDC,outpatient,10,ML,102.35,71.645,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,70069-0161-01,NDC,outpatient,10,ML,30.13,21.091,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,70069-0161-10,NDC,outpatient,10,ML,30.13,21.091,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,71288-0714-10,NDC,outpatient,10,ML,30.26,21.182,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,00703-2056-01,NDC,outpatient,10,ML,102.35,71.645,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,71288-0714-11,NDC,outpatient,10,ML,30.26,21.182,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MORPHINE SULFATE ER 15 MG ORAL TBCR,RX-119246,CDM,S5000,HCPCS,259,RC,00406-8315-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MORPHINE SULFATE ER 15 MG ORAL TBCR,RX-119246,CDM,S5000,HCPCS,259,RC,63304-0450-01,NDC,outpatient,1,UN,1.05,0.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MORPHINE SULFATE ER 15 MG ORAL TBCR,RX-119246,CDM,S5000,HCPCS,259,RC,00406-8315-62,NDC,outpatient,1,UN,2.2,1.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MORPHINE SULFATE ER 15 MG ORAL TBCR,RX-119246,CDM,S5000,HCPCS,259,RC,00228-4270-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MORPHINE SULFATE ER 15 MG ORAL TBCR,RX-119246,CDM,S5000,HCPCS,259,RC,00406-8315-23,NDC,outpatient,1,UN,2.2,1.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MORPHINE SULFATE ER 100 MG ORAL TBCR,RX-119248,CDM,S5000,HCPCS,259,RC,00406-8390-23,NDC,outpatient,1,UN,12.34,8.638,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MORPHINE SULFATE ER 100 MG ORAL TBCR,RX-119248,CDM,S5000,HCPCS,259,RC,00406-8390-62,NDC,outpatient,1,UN,12.34,8.638,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
INFUVITE ADULT IV INJ,RX-119571,CDM,S5000,HCPCS,250,RC,54643-5650-02,NDC,outpatient,10,ML,3.96,2.772,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
INFUVITE ADULT IV INJ,RX-119571,CDM,S5000,HCPCS,250,RC,54643-5650-28,NDC,outpatient,10,ML,3.96,2.772,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
INFUVITE ADULT IV INJ,RX-119571,CDM,S5000,HCPCS,250,RC,54643-5649-01,NDC,outpatient,10,ML,39.65,27.755,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
INFUVITE ADULT IV INJ,RX-119571,CDM,S5000,HCPCS,250,RC,54643-5650-09,NDC,outpatient,10,ML,3.96,2.772,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
APIXABAN 5 MG ORAL TABS,RX-119614,CDM,S5000,HCPCS,259,RC,00003-0894-31,NDC,outpatient,1,UN,6.17,4.319,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MESALAMINE 400 MG ORAL CPDR,RX-119913,CDM,S5000,HCPCS,259,RC,60687-0556-32,NDC,outpatient,1,UN,23.14,16.198,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MESALAMINE 400 MG ORAL CPDR,RX-119913,CDM,S5000,HCPCS,259,RC,00023-5853-18,NDC,outpatient,1,UN,15.96,11.172,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MESALAMINE 400 MG ORAL CPDR,RX-119913,CDM,S5000,HCPCS,259,RC,59762-0117-01,NDC,outpatient,1,UN,10.4,7.28,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MESALAMINE 400 MG ORAL CPDR,RX-119913,CDM,S5000,HCPCS,259,RC,60687-0556-33,NDC,outpatient,1,UN,23.14,16.198,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MECLIZINE HCL 12.5 MG ORAL TABS,RX-12024,CDM,S5000,HCPCS,259,RC,60687-0775-01,NDC,outpatient,1,UN,1.73,1.211,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MECLIZINE HCL 12.5 MG ORAL TABS,RX-12024,CDM,S5000,HCPCS,259,RC,60687-0775-11,NDC,outpatient,1,UN,1.73,1.211,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
THEOPHYLLINE ER 300 MG ORAL TB12,RX-12098,CDM,S5000,HCPCS,259,RC,68462-0721-01,NDC,outpatient,1,UN,5.92,4.144,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
THEOPHYLLINE ER 300 MG ORAL TB12,RX-12098,CDM,S5000,HCPCS,259,RC,62332-0025-31,NDC,outpatient,1,UN,11.73,8.211,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MEMANTINE HCL ER 14 MG ORAL CP24,RX-121474,CDM,S5000,HCPCS,259,RC,00456-3414-33,NDC,outpatient,1,UN,7.56,5.292,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MEMANTINE HCL ER 21 MG ORAL CP24,RX-121475,CDM,S5000,HCPCS,259,RC,00456-3421-33,NDC,outpatient,1,UN,7.56,5.292,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MEMANTINE HCL ER 28 MG ORAL CP24,RX-121476,CDM,S5000,HCPCS,259,RC,00456-3428-33,NDC,outpatient,1,UN,63.71,44.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOXYLAMINE-PYRIDOXINE 10-10 MG ORAL TBEC,RX-121504,CDM,S5000,HCPCS,259,RC,55494-0100-10,NDC,outpatient,1,UN,13.41,9.387,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOXYLAMINE-PYRIDOXINE 10-10 MG ORAL TBEC,RX-121504,CDM,S5000,HCPCS,259,RC,70505-0100-10,NDC,outpatient,1,UN,13.18,9.226,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
QUINIDINE GLUCONATE ER 324 MG ORAL TBCR,RX-12197,CDM,S5000,HCPCS,259,RC,53489-0141-01,NDC,outpatient,1,UN,24.15,16.905,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VENLAFAXINE HCL 25 MG ORAL TABS,RX-12203,CDM,S5000,HCPCS,259,RC,68084-0896-25,NDC,outpatient,1,UN,3.98,2.786,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VENLAFAXINE HCL 25 MG ORAL TABS,RX-12203,CDM,S5000,HCPCS,259,RC,68084-0896-95,NDC,outpatient,1,UN,3.98,2.786,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VENLAFAXINE HCL 75 MG ORAL TABS,RX-12206,CDM,S5000,HCPCS,259,RC,57664-0395-88,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VENLAFAXINE HCL 75 MG ORAL TABS,RX-12206,CDM,S5000,HCPCS,259,RC,68084-0856-01,NDC,outpatient,1,UN,3.02,2.114,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VENLAFAXINE HCL 75 MG ORAL TABS,RX-12206,CDM,S5000,HCPCS,259,RC,68084-0856-11,NDC,outpatient,1,UN,3.02,2.114,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VENLAFAXINE HCL 37.5 MG ORAL TABS,RX-12207,CDM,S5000,HCPCS,259,RC,68084-0844-11,NDC,outpatient,1,UN,2.34,1.638,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VENLAFAXINE HCL 37.5 MG ORAL TABS,RX-12207,CDM,S5000,HCPCS,259,RC,68084-0844-01,NDC,outpatient,1,UN,2.34,1.638,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DORNASE ALFA 2.5 MG/2.5ML IN SOLN,RX-12211,CDM,S5000,HCPCS,259,RC,50242-0100-39,NDC,outpatient,2.5,ML,560.63,392.441,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DORNASE ALFA 2.5 MG/2.5ML IN SOLN,RX-12211,CDM,S5000,HCPCS,259,RC,50242-0100-40,NDC,outpatient,2.5,ML,560.63,392.441,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IRON-VITAMIN C 65-125 MG ORAL TABS,RX-122332,CDM,S5000,HCPCS,259,RC,63736-0123-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXYCODONE HCL ER 10 MG ORAL T12A,RX-122363,CDM,S5000,HCPCS,259,RC,59011-0410-20,NDC,outpatient,1,UN,22.52,15.764,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXYCODONE HCL ER 20 MG ORAL T12A,RX-122366,CDM,S5000,HCPCS,259,RC,59011-0420-10,NDC,outpatient,1,UN,40.9,28.63,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXYCODONE HCL ER 20 MG ORAL T12A,RX-122366,CDM,S5000,HCPCS,259,RC,59011-0420-20,NDC,outpatient,1,UN,41.94,29.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXYCODONE HCL ER 40 MG ORAL T12A,RX-122368,CDM,S5000,HCPCS,259,RC,59011-0440-20,NDC,outpatient,1,UN,71.8,50.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOLUTEGRAVIR SODIUM 50 MG ORAL TABS,RX-122784,CDM,S5000,HCPCS,259,RC,49702-0228-13,NDC,outpatient,1,UN,324.81,227.367,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LURASIDONE HCL 60 MG ORAL TABS,RX-122968,CDM,S5000,HCPCS,259,RC,16729-0348-10,NDC,outpatient,1,UN,5,3.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LURASIDONE HCL 60 MG ORAL TABS,RX-122968,CDM,S5000,HCPCS,259,RC,65162-0082-03,NDC,outpatient,1,UN,1.48,1.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,00517-7604-25,NDC,outpatient,4,ML,26.92,18.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,63323-0694-04,NDC,outpatient,4,ML,17.02,11.914,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,63323-0694-22,NDC,outpatient,4,ML,17.02,11.914,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,00517-7604-01,NDC,outpatient,4,ML,26.92,18.844,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,63323-0690-22,NDC,outpatient,30,ML,25.77,18.039,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,63323-0690-30,NDC,outpatient,30,ML,25.77,18.039,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,00409-3308-03,NDC,outpatient,30,ML,57.68,40.376,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,00409-3308-11,NDC,outpatient,30,ML,57.68,40.376,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,99999-0002-61,NDC,outpatient,3,ML,9.75,6.825,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,99999-0002-60,NDC,outpatient,3,ML,9.75,6.825,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,70860-0605-03,NDC,outpatient,2,ML,9.94,6.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,71288-0505-03,NDC,outpatient,2,ML,11.79,8.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,66794-0230-02,NDC,outpatient,2,ML,21.6,15.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,66794-0230-42,NDC,outpatient,2,ML,21.6,15.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,71288-0505-02,NDC,outpatient,2,ML,11.79,8.253,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,70860-0605-41,NDC,outpatient,2,ML,9.94,6.958,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CETIRIZINE HCL 5 MG/5ML ORAL SOLN,RX-124298,CDM,S5000,HCPCS,259,RC,99999-0004-13,NDC,outpatient,5,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CETIRIZINE HCL 5 MG/5ML ORAL SOLN,RX-124298,CDM,S5000,HCPCS,259,RC,51672-4070-08,NDC,outpatient,2.5,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TOBRAMYCIN 0.3 % OP SOLN,RX-124312,CDM,S5000,HCPCS,259,RC,61314-0643-05,NDC,outpatient,5,ML,42.15,29.505,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TOBRAMYCIN 0.3 % OP SOLN,RX-124312,CDM,S5000,HCPCS,259,RC,70069-0131-01,NDC,outpatient,5,ML,22.25,15.575,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
EXENATIDE 5 MCG/0.02ML SC SOPN,RX-124738,CDM,S5000,HCPCS,259,RC,00310-6512-01,NDC,outpatient,1.2,ML,2102.55,1471.785,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
EXENATIDE 10 MCG/0.04ML SC SOPN,RX-124739,CDM,S5000,HCPCS,259,RC,00310-6524-01,NDC,outpatient,2.4,ML,2102.55,1471.785,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIRAGLUTIDE 18 MG/3ML SC SOPN,RX-124740,CDM,S5000,HCPCS,250,RC,00169-4060-12,NDC,outpatient,3,ML,1117.4,782.18,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIRAGLUTIDE 18 MG/3ML SC SOPN,RX-124740,CDM,S5000,HCPCS,250,RC,00169-4060-13,NDC,outpatient,3,ML,1117.41,782.187,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ESTRADIOL 0.5 MG ORAL TABS,RX-12491,CDM,S5000,HCPCS,259,RC,00555-0899-02,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ESTRADIOL 0.5 MG ORAL TABS,RX-12491,CDM,S5000,HCPCS,259,RC,42806-0087-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TOBRAMYCIN 0.3 % OP OINT,RX-125351,CDM,S5000,HCPCS,259,RC,00078-0813-01,NDC,outpatient,3.5,GR,1047.63,733.341,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DIPHENHYDRAMINE HCL 12.5 MG/5ML ORAL LIQD,RX-12556,CDM,S5000,HCPCS,259,RC,00904-6985-20,NDC,outpatient,2.5,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,60687-0394-79,NDC,outpatient,2.5,ML,1.05,0.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,76204-0100-01,NDC,outpatient,2.5,ML,1.24,0.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,60687-0394-83,NDC,outpatient,2.5,ML,1.05,0.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,00378-7970-93,NDC,outpatient,2.5,ML,1.02,0.714,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,00487-9801-01,NDC,outpatient,2.5,ML,1.51,1.057,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,00487-9801-60,NDC,outpatient,2.5,ML,1.12,0.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PHENYLEPHRINE-COCOA BUTTER 0.25-88.44 % RE SUPP,RX-125849,CDM,S5000,HCPCS,259,RC,00536-1186-12,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CAFFEINE 200 MG ORAL TABS,RX-1259,CDM,S5000,HCPCS,259,RC,46017-0018-40,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DANTROLENE SODIUM 250 MG IV SUSR,RX-126042,CDM,S5000,HCPCS,250,RC,42367-0540-32,NDC,outpatient,1,UN,5868.29,4107.803,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
EMPAGLIFLOZIN 10 MG ORAL TABS,RX-126076,CDM,S5000,HCPCS,259,RC,00597-0152-30,NDC,outpatient,1,UN,55.29,38.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
EMPAGLIFLOZIN 10 MG ORAL TABS,RX-126076,CDM,S5000,HCPCS,259,RC,00597-0152-37,NDC,outpatient,1,UN,55.29,38.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
EMPAGLIFLOZIN 25 MG ORAL TABS,RX-126078,CDM,S5000,HCPCS,259,RC,00597-0153-37,NDC,outpatient,1,UN,55.29,38.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML IJ SOLN,RX-1262,CDM,S5000,HCPCS,250,RC,00517-2502-01,NDC,outpatient,2,ML,107.33,75.131,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML IJ SOLN,RX-1262,CDM,S5000,HCPCS,250,RC,00517-2502-10,NDC,outpatient,2,ML,107.33,75.131,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TERBINAFINE HCL 250 MG ORAL TABS,RX-12724,CDM,S5000,HCPCS,259,RC,65862-0079-30,NDC,outpatient,1,UN,1.29,0.903,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRIAMTERENE-HCTZ 37.5-25 MG ORAL CAPS,RX-12729,CDM,S5000,HCPCS,259,RC,00781-2074-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FAMOTIDINE IN NACL 20-0.9 MG/50ML-% IV SOLN,RX-12735,CDM,S5000,HCPCS,250,RC,00338-5197-41,NDC,outpatient,50,ML,24.23,16.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML ORAL ELIX,RX-127530,CDM,S5000,HCPCS,259,RC,75826-0127-04,NDC,outpatient,5,ML,13.49,9.443,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML ORAL ELIX,RX-127530,CDM,S5000,HCPCS,259,RC,75826-0128-04,NDC,outpatient,5,ML,45.71,31.997,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML ORAL ELIX,RX-127530,CDM,S5000,HCPCS,259,RC,99999-0002-29,NDC,outpatient,5,ML,70.67,49.469,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML ORAL ELIX,RX-127530,CDM,S5000,HCPCS,259,RC,75826-0127-05,NDC,outpatient,5,ML,13.49,9.443,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML ORAL ELIX,RX-127530,CDM,S5000,HCPCS,259,RC,75826-0128-05,NDC,outpatient,5,ML,45.71,31.997,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPRENORPHINE 7.5 MCG/HR TD PTWK,RX-127562,CDM,S5000,HCPCS,259,RC,42858-0353-40,NDC,outpatient,1,UN,309.07,216.349,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PILOCARPINE HCL 5 MG ORAL TABS,RX-12803,CDM,S5000,HCPCS,259,RC,68084-0928-25,NDC,outpatient,1,UN,10.51,7.357,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PILOCARPINE HCL 5 MG ORAL TABS,RX-12803,CDM,S5000,HCPCS,259,RC,00527-1313-01,NDC,outpatient,1,UN,4.2,2.94,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PILOCARPINE HCL 5 MG ORAL TABS,RX-12803,CDM,S5000,HCPCS,259,RC,68084-0928-95,NDC,outpatient,1,UN,10.51,7.357,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TIOTROPIUM BROMIDE MONOHYDRATE 2.5 MCG/ACT IN AERS,RX-128423,CDM,S5000,HCPCS,259,RC,00597-0100-51,NDC,outpatient,4,GR,308.39,215.873,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PENTOSAN POLYSULFATE SODIUM 100 MG ORAL CAPS,RX-12912,CDM,S5000,HCPCS,259,RC,50458-0098-01,NDC,outpatient,1,UN,46.46,32.522,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TACROLIMUS 1 MG ORAL CAPS,RX-12933,CDM,S5000,HCPCS,259,RC,00904-7097-61,NDC,outpatient,1,UN,4.43,3.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TACROLIMUS 1 MG ORAL CAPS,RX-12933,CDM,S5000,HCPCS,259,RC,51079-0818-20,NDC,outpatient,1,UN,4.95,3.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TACROLIMUS 1 MG ORAL CAPS,RX-12933,CDM,S5000,HCPCS,259,RC,51079-0818-01,NDC,outpatient,1,UN,4.95,3.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOMEBORO EX PACK,RX-129475,CDM,S5000,HCPCS,259,RC,57074-0001-77,NDC,outpatient,1,UN,2.6,1.82,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DARUNAVIR-COBICISTAT 800-150 MG ORAL TABS,RX-129730,CDM,S5000,HCPCS,259,RC,59676-0575-30,NDC,outpatient,1,UN,354.92,248.444,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PYRIDOSTIGMINE BROMIDE 10 MG/2ML IV SOLN,RX-129741,CDM,S5000,HCPCS,250,RC,00781-3040-95,NDC,outpatient,2,ML,130.52,91.364,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PYRIDOSTIGMINE BROMIDE 10 MG/2ML IV SOLN,RX-129741,CDM,S5000,HCPCS,250,RC,00781-3040-72,NDC,outpatient,2,ML,130.52,91.364,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SCOPOLAMINE 1 MG/3DAYS TD PT72,RX-129902,CDM,S5000,HCPCS,259,RC,50742-0505-01,NDC,outpatient,1,UN,42.28,29.596,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SCOPOLAMINE 1 MG/3DAYS TD PT72,RX-129902,CDM,S5000,HCPCS,259,RC,50742-0505-24,NDC,outpatient,1,UN,23.2,16.24,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SCOPOLAMINE 1 MG/3DAYS TD PT72,RX-129902,CDM,S5000,HCPCS,259,RC,10019-0553-04,NDC,outpatient,1,UN,23.54,16.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SCOPOLAMINE 1 MG/3DAYS TD PT72,RX-129902,CDM,S5000,HCPCS,259,RC,10019-0553-90,NDC,outpatient,1,UN,23.54,16.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,00409-3375-14,NDC,outpatient,4,ML,23.45,16.415,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,70121-1576-07,NDC,outpatient,4,ML,19.72,13.804,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,00143-9318-01,NDC,outpatient,4,ML,15.67,10.969,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,25021-0316-04,NDC,outpatient,4,ML,19.53,13.671,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,67457-0852-04,NDC,outpatient,4,ML,24.37,17.059,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,00143-9318-10,NDC,outpatient,4,ML,15.67,10.969,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,00409-3375-04,NDC,outpatient,4,ML,23.45,16.415,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,67457-0852-00,NDC,outpatient,4,ML,24.37,17.059,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,70121-1576-01,NDC,outpatient,4,ML,19.72,13.804,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CALCIUM CARBONATE 600 MG ORAL TABS,RX-1302,CDM,S5000,HCPCS,259,RC,20555-0005-00,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CALCIUM CARBONATE 600 MG ORAL TABS,RX-1302,CDM,S5000,HCPCS,259,RC,00904-3232-92,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE 4 % EX PTCH,RX-130376,CDM,S5000,HCPCS,259,RC,00536-1202-07,NDC,outpatient,1,UN,3.11,2.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE 4 % EX PTCH,RX-130376,CDM,S5000,HCPCS,259,RC,70512-0812-30,NDC,outpatient,1,UN,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE 4 % EX PTCH,RX-130376,CDM,S5000,HCPCS,259,RC,41167-0058-40,NDC,outpatient,1,UN,6.13,4.291,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DESVENLAFAXINE SUCCINATE ER 25 MG ORAL TB24,RX-130484,CDM,S5000,HCPCS,259,RC,59762-1210-03,NDC,outpatient,1,UN,2.76,1.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DESVENLAFAXINE SUCCINATE ER 25 MG ORAL TB24,RX-130484,CDM,S5000,HCPCS,259,RC,68180-0604-06,NDC,outpatient,1,UN,2.56,1.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CALCIUM CHLORIDE 10 % IV SOLN,RX-1306,CDM,S5000,HCPCS,250,RC,00409-4928-11,NDC,outpatient,10,ML,55.67,38.969,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CALCIUM CHLORIDE 10 % IV SOLN,RX-1306,CDM,S5000,HCPCS,250,RC,00409-1631-40,NDC,outpatient,10,ML,41.92,29.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CALCIUM CHLORIDE 10 % IV SOLN,RX-1306,CDM,S5000,HCPCS,250,RC,00409-1631-10,NDC,outpatient,10,ML,41.92,29.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CALCIUM CHLORIDE 10 % IV SOLN,RX-1306,CDM,S5000,HCPCS,250,RC,00409-4928-34,NDC,outpatient,10,ML,55.67,38.969,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CALCIUM CHLORIDE 10 % IV SOLN,RX-1306,CDM,S5000,HCPCS,250,RC,76329-3304-01,NDC,outpatient,10,ML,39.08,27.356,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VERAPAMIL HCL ER 240 MG ORAL TBCR,RX-13073,CDM,S5000,HCPCS,259,RC,60687-0515-11,NDC,outpatient,1,UN,5.2,3.64,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VERAPAMIL HCL ER 240 MG ORAL TBCR,RX-13073,CDM,S5000,HCPCS,259,RC,60687-0515-01,NDC,outpatient,1,UN,5.2,3.64,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VERAPAMIL HCL ER 240 MG ORAL TBCR,RX-13073,CDM,S5000,HCPCS,259,RC,68462-0260-01,NDC,outpatient,1,UN,1.48,1.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TIOTROPIUM BROMIDE-OLODATEROL 2.5-2.5 MCG/ACT IN AERS,RX-131078,CDM,S5000,HCPCS,259,RC,00597-0155-70,NDC,outpatient,4,GR,308.39,215.873,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VITAMIN D3 10 MCG (400 UNIT) ORAL TABS,RX-13108,CDM,S5000,HCPCS,259,RC,00904-5823-60,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VITAMIN D3 10 MCG (400 UNIT) ORAL TABS,RX-13108,CDM,S5000,HCPCS,259,RC,50268-0863-15,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VITAMIN D3 10 MCG (400 UNIT) ORAL TABS,RX-13108,CDM,S5000,HCPCS,259,RC,50268-0863-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ELVITEG-COBIC-EMTRICIT-TENOFAF 150-150-200-10 MG ORAL TABS,RX-131233,CDM,S5000,HCPCS,259,RC,61958-1901-01,NDC,outpatient,1,UN,572.84,400.988,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VALACYCLOVIR HCL 500 MG ORAL TABS,RX-13133,CDM,S5000,HCPCS,259,RC,00904-6565-61,NDC,outpatient,1,UN,4.32,3.024,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VALACYCLOVIR HCL 500 MG ORAL TABS,RX-13133,CDM,S5000,HCPCS,259,RC,63739-0077-10,NDC,outpatient,1,UN,4,2.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VALACYCLOVIR HCL 500 MG ORAL TABS,RX-13133,CDM,S5000,HCPCS,259,RC,68084-0215-11,NDC,outpatient,1,UN,4.3,3.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VALACYCLOVIR HCL 500 MG ORAL TABS,RX-13133,CDM,S5000,HCPCS,259,RC,68084-0215-01,NDC,outpatient,1,UN,4.3,3.01,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SACUBITRIL-VALSARTAN 24-26 MG ORAL TABS,RX-131630,CDM,S5000,HCPCS,259,RC,00078-0659-20,NDC,outpatient,1,UN,46.68,32.676,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SACUBITRIL-VALSARTAN 49-51 MG ORAL TABS,RX-131631,CDM,S5000,HCPCS,259,RC,00078-0777-20,NDC,outpatient,1,UN,46.68,32.676,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SACUBITRIL-VALSARTAN 97-103 MG ORAL TABS,RX-131632,CDM,S5000,HCPCS,259,RC,00078-0696-20,NDC,outpatient,1,UN,46.68,32.676,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMINOCAPROIC ACID 0.25 GM/ML ORAL SOLN,RX-131645,CDM,S5000,HCPCS,259,RC,99999-0001-90,NDC,outpatient,5,ML,202.39,141.673,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VERAPAMIL HCL ER 120 MG ORAL TBCR,RX-13184,CDM,S5000,HCPCS,259,RC,68462-0292-01,NDC,outpatient,1,UN,1.05,0.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPIVACAINE-EPINEPHRINE (PF) 0.75% -1:200000 IJ SOLN,RX-132205,CDM,S5000,HCPCS,250,RC,63323-0460-37,NDC,outpatient,30,ML,34.71,24.297,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TICAGRELOR 60 MG ORAL TABS,RX-132286,CDM,S5000,HCPCS,259,RC,00186-0776-60,NDC,outpatient,1,UN,30.77,21.539,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
KETAMINE HCL 10 MG/ML IN NS IV SYRINGE,RX-132334,CDM,S5000,HCPCS,250,RC,69374-0982-55,NDC,outpatient,5,ML,26.7,18.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
KETAMINE HCL 10 MG/ML IN NS IV SYRINGE,RX-132334,CDM,S5000,HCPCS,250,RC,70092-1119-44,NDC,outpatient,5,ML,20.39,14.273,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
KETAMINE HCL 10 MG/ML IN NS IV SYRINGE,RX-132334,CDM,S5000,HCPCS,250,RC,70004-0430-09,NDC,outpatient,5,ML,28.93,20.251,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
KETAMINE HCL 10 MG/ML IN NS IV SYRINGE,RX-132334,CDM,S5000,HCPCS,250,RC,70092-9119-44,NDC,outpatient,5,ML,27.82,19.474,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CALCIUM ACETATE (PHOS BINDER) 667 MG ORAL CAPS,RX-132734,CDM,S5000,HCPCS,259,RC,00904-7119-06,NDC,outpatient,1,UN,3.29,2.303,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CALCIUM ACETATE (PHOS BINDER) 667 MG ORAL CAPS,RX-132734,CDM,S5000,HCPCS,259,RC,68084-0479-01,NDC,outpatient,1,UN,5.45,3.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CALCIUM ACETATE (PHOS BINDER) 667 MG ORAL CAPS,RX-132734,CDM,S5000,HCPCS,259,RC,68084-0479-11,NDC,outpatient,1,UN,5.45,3.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPRENORPHINE HCL 75 MCG BU FILM,RX-132950,CDM,S5000,HCPCS,259,RC,59385-0021-60,NDC,outpatient,1,UN,29.34,20.538,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPRENORPHINE HCL 75 MCG BU FILM,RX-132950,CDM,S5000,HCPCS,259,RC,59385-0021-01,NDC,outpatient,1,UN,29.34,20.538,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPRENORPHINE HCL 300 MCG BU FILM,RX-132952,CDM,S5000,HCPCS,259,RC,59385-0023-60,NDC,outpatient,1,UN,46.07,32.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPRENORPHINE HCL 300 MCG BU FILM,RX-132952,CDM,S5000,HCPCS,259,RC,59385-0023-01,NDC,outpatient,1,UN,46.07,32.249,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPRENORPHINE HCL 750 MCG BU FILM,RX-132955,CDM,S5000,HCPCS,259,RC,59385-0026-01,NDC,outpatient,1,UN,70.24,49.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPRENORPHINE HCL 750 MCG BU FILM,RX-132955,CDM,S5000,HCPCS,259,RC,59385-0026-60,NDC,outpatient,1,UN,70.24,49.168,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPRENORPHINE HCL 900 MCG BU FILM,RX-132956,CDM,S5000,HCPCS,259,RC,59385-0027-01,NDC,outpatient,1,UN,72.31,50.617,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPRENORPHINE HCL 900 MCG BU FILM,RX-132956,CDM,S5000,HCPCS,259,RC,59385-0027-60,NDC,outpatient,1,UN,72.31,50.617,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NALOXONE HCL 4 MG/0.1ML NA LIQD,RX-132964,CDM,S5000,HCPCS,259,RC,00093-2165-68,NDC,outpatient,1,UN,146.88,102.816,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NALOXONE HCL 4 MG/0.1ML NA LIQD,RX-132964,CDM,S5000,HCPCS,259,RC,00093-2165-19,NDC,outpatient,1,UN,146.88,102.816,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PRENATAL VITAMIN PLUS LOW IRON 27-1 MG ORAL TABS,RX-133380,CDM,S5000,HCPCS,259,RC,39328-0106-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FAMCICLOVIR 500 MG ORAL TABS,RX-13358,CDM,S5000,HCPCS,259,RC,60505-3247-03,NDC,outpatient,1,UN,1.93,1.351,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRANEXAMIC ACID 1000 MG/10ML IV SOLN,RX-133831,CDM,S5000,HCPCS,250,RC,39822-1000-01,NDC,outpatient,10,ML,23.86,16.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRANEXAMIC ACID 1000 MG/10ML IV SOLN,RX-133831,CDM,S5000,HCPCS,250,RC,72485-0510-01,NDC,outpatient,10,ML,14.6,10.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRANEXAMIC ACID 1000 MG/10ML IV SOLN,RX-133831,CDM,S5000,HCPCS,250,RC,72485-0510-10,NDC,outpatient,10,ML,14.6,10.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRANEXAMIC ACID 1000 MG/10ML IV SOLN,RX-133831,CDM,S5000,HCPCS,250,RC,81284-0611-00,NDC,outpatient,10,ML,24.48,17.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRANEXAMIC ACID 1000 MG/10ML IV SOLN,RX-133831,CDM,S5000,HCPCS,250,RC,81284-0611-10,NDC,outpatient,10,ML,24.48,17.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
INSULIN REGULAR HUMAN (CONC) 500 UNIT/ML SC SOPN,RX-134373,CDM,S5000,HCPCS,259,RC,00002-8824-01,NDC,outpatient,3,ML,1168.7,818.09,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
INSULIN REGULAR HUMAN (CONC) 500 UNIT/ML SC SOPN,RX-134373,CDM,S5000,HCPCS,259,RC,00002-8824-27,NDC,outpatient,3,ML,1168.7,818.09,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
EMTRICITABINE-TENOFOVIR AF 200-25 MG ORAL TABS,RX-134420,CDM,S5000,HCPCS,259,RC,61958-2002-01,NDC,outpatient,1,UN,316.88,221.816,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DILTIAZEM HCL-DEXTROSE 125-5 MG/125ML-% IV SOLN,RX-134429,CDM,S5000,HCPCS,250,RC,70004-0540-35,NDC,outpatient,125,ML,123.38,86.366,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DILTIAZEM HCL-DEXTROSE 125-5 MG/125ML-% IV SOLN,RX-134429,CDM,S5000,HCPCS,250,RC,70092-1007-36,NDC,outpatient,125,ML,77.9,54.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DILTIAZEM HCL-DEXTROSE 125-5 MG/125ML-% IV SOLN,RX-134429,CDM,S5000,HCPCS,250,RC,70092-1575-36,NDC,outpatient,125,ML,81.02,56.714,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PSYLLIUM 400 MG ORAL CAPS,RX-134482,CDM,S5000,HCPCS,259,RC,37000-0405-14,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CARBAMAZEPINE 100 MG ORAL CHEW,RX-1355,CDM,S5000,HCPCS,259,RC,60687-0479-01,NDC,outpatient,1,UN,1.69,1.183,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CARBAMAZEPINE 100 MG ORAL CHEW,RX-1355,CDM,S5000,HCPCS,259,RC,60687-0479-11,NDC,outpatient,1,UN,1.69,1.183,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CARBAMAZEPINE 100 MG ORAL CHEW,RX-1355,CDM,S5000,HCPCS,259,RC,00904-3854-61,NDC,outpatient,1,UN,1.65,1.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CARBAMAZEPINE 100 MG/5ML ORAL SUSP,RX-1356,CDM,S5000,HCPCS,259,RC,99999-0001-92,NDC,outpatient,10,ML,6.06,4.242,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METHYLENE BLUE (ANTIDOTE) 50 MG/10ML IV SOLN,RX-135699,CDM,S5000,HCPCS,250,RC,00517-0374-01,NDC,outpatient,10,ML,411.18,287.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METHYLENE BLUE (ANTIDOTE) 50 MG/10ML IV SOLN,RX-135699,CDM,S5000,HCPCS,250,RC,00517-0374-05,NDC,outpatient,10,ML,411.18,287.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CARBAMAZEPINE 200 MG ORAL TABS,RX-1357,CDM,S5000,HCPCS,259,RC,00904-6172-61,NDC,outpatient,1,UN,2.42,1.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE-SODIUM BICARBONATE 1-8.4 % IJ SOSY,RX-135806,CDM,S5000,HCPCS,250,RC,70004-0725-05,NDC,outpatient,1,ML,19.02,13.314,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE-SODIUM BICARBONATE 1-8.4 % IJ SOSY,RX-135806,CDM,S5000,HCPCS,250,RC,99999-0003-11,NDC,outpatient,1.1,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE-SODIUM BICARBONATE 1-8.4 % IJ SOSY,RX-135806,CDM,S5000,HCPCS,250,RC,70092-1443-43,NDC,outpatient,1,ML,22.08,15.456,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VANCOMYCIN HCL IN NACL 0.9 % 1500 MG/250ML IV SOLN,RX-135845,CDM,S5000,HCPCS,250,RC,70004-0924-59,NDC,outpatient,280,ML,189.24,132.468,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VANCOMYCIN HCL IN NACL 0.9 % 1500 MG/250ML IV SOLN,RX-135845,CDM,S5000,HCPCS,250,RC,99999-0001-84,NDC,outpatient,280,ML,33.42,23.394,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VANCOMYCIN HCL IN NACL 0.9 % 1500 MG/250ML IV SOLN,RX-135845,CDM,S5000,HCPCS,250,RC,70092-9056-05,NDC,outpatient,280,ML,121.34,84.938,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CARBAMIDE PEROXIDE 6.5 % OT SOLN,RX-1359,CDM,S5000,HCPCS,259,RC,00904-6627-35,NDC,outpatient,15,ML,6.35,4.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CARBAMIDE PEROXIDE 6.5 % OT SOLN,RX-1359,CDM,S5000,HCPCS,259,RC,78112-0736-23,NDC,outpatient,15,ML,15.56,10.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CARBAMIDE PEROXIDE 6.5 % OT SOLN,RX-1359,CDM,S5000,HCPCS,259,RC,78112-0736-21,NDC,outpatient,15,ML,17.89,12.523,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METHOTREXATE SODIUM 2.5 MG ORAL TABS,RX-13594,CDM,S5000,HCPCS,259,RC,50268-0527-11,NDC,outpatient,1,UN,5.12,3.584,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METHOTREXATE SODIUM 2.5 MG ORAL TABS,RX-13594,CDM,S5000,HCPCS,259,RC,00054-8550-25,NDC,outpatient,1,UN,5.49,3.843,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METHOTREXATE SODIUM 2.5 MG ORAL TABS,RX-13594,CDM,S5000,HCPCS,259,RC,50268-0527-15,NDC,outpatient,1,UN,5.12,3.584,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DEXMEDETOMIDINE HCL 1000 MCG/10ML IV SOLN,RX-136367,CDM,S5000,HCPCS,250,RC,44567-0601-04,NDC,outpatient,10,ML,205.59,143.913,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MICONAZOLE NITRATE 2 % EX OINT,RX-13651,CDM,S5000,HCPCS,259,RC,11701-0067-23,NDC,outpatient,57,GR,25.88,18.116,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MICONAZOLE NITRATE 2 % EX OINT,RX-13651,CDM,S5000,HCPCS,259,RC,53329-0172-10,NDC,outpatient,71,GR,15.17,10.619,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VANCOMYCIN HCL IN NACL 0.9 % 1250 MG/250ML IV SOLN,RX-136649,CDM,S5000,HCPCS,250,RC,70004-0923-59,NDC,outpatient,275,ML,170.02,119.014,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VANCOMYCIN HCL IN NACL 0.9 % 1250 MG/250ML IV SOLN,RX-136649,CDM,S5000,HCPCS,250,RC,99999-0001-85,NDC,outpatient,275,ML,59.61,41.727,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VANCOMYCIN HCL IN NACL 0.9 % 1250 MG/250ML IV SOLN,RX-136649,CDM,S5000,HCPCS,250,RC,70092-9054-05,NDC,outpatient,275,ML,111.55,78.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VANCOMYCIN HCL IN NACL 0.9 % 1250 MG/250ML IV SOLN,RX-136649,CDM,S5000,HCPCS,250,RC,71506-0015-58,NDC,outpatient,275,ML,93.39,65.373,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GUAIFENESIN 100 MG/5ML ORAL LIQD,RX-13748,CDM,S5000,HCPCS,259,RC,00121-2232-15,NDC,outpatient,15,ML,6.68,4.676,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GUAIFENESIN 100 MG/5ML ORAL LIQD,RX-13748,CDM,S5000,HCPCS,259,RC,00121-2232-00,NDC,outpatient,15,ML,6.68,4.676,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DILTIAZEM HCL-SODIUM CHLORIDE 125-0.9 MG/125ML-% IV SOLN,RX-137908,CDM,S5000,HCPCS,250,RC,76154-0818-05,NDC,outpatient,125,ML,82.75,57.925,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DILTIAZEM HCL-SODIUM CHLORIDE 125-0.9 MG/125ML-% IV SOLN,RX-137908,CDM,S5000,HCPCS,250,RC,99999-0003-40,NDC,outpatient,125,ML,51.6,36.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXYTOCIN-SODIUM CHLORIDE 30-0.9 UT/500ML-% IV SOLN,RX-137935,CDM,S5000,HCPCS,250,RC,70092-1068-07,NDC,outpatient,500,ML,106.3,74.41,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXYTOCIN-SODIUM CHLORIDE 30-0.9 UT/500ML-% IV SOLN,RX-137935,CDM,S5000,HCPCS,250,RC,70092-1552-07,NDC,outpatient,500,ML,97.53,68.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LINACLOTIDE 72 MCG ORAL CAPS,RX-138008,CDM,S5000,HCPCS,259,RC,00456-1203-30,NDC,outpatient,1,UN,74.11,51.877,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BACITRACIN ZINC 500 UNIT/GM EX OINT,RX-13818,CDM,S5000,HCPCS,259,RC,57896-0145-14,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BACITRACIN ZINC 500 UNIT/GM EX OINT,RX-13818,CDM,S5000,HCPCS,259,RC,58980-0011-10,NDC,outpatient,28.35,GR,10.1,7.07,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BACITRACIN ZINC 500 UNIT/GM EX OINT,RX-13818,CDM,S5000,HCPCS,259,RC,00536-1263-28,NDC,outpatient,28,GR,4.99,3.493,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VANCOMYCIN HCL IN NACL 2-0.9 GM/500ML-% IV SOLN,RX-138299,CDM,S5000,HCPCS,250,RC,71506-0019-59,NDC,outpatient,540,ML,128.46,89.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VANCOMYCIN HCL IN NACL 2-0.9 GM/500ML-% IV SOLN,RX-138299,CDM,S5000,HCPCS,250,RC,99999-0002-01,NDC,outpatient,540,ML,36.84,25.788,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VANCOMYCIN HCL IN NACL 1.75-0.9 GM/500ML-% IV SOLN,RX-138322,CDM,S5000,HCPCS,250,RC,71506-0017-59,NDC,outpatient,535,ML,119.16,83.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VANCOMYCIN HCL IN NACL 1.75-0.9 GM/500ML-% IV SOLN,RX-138322,CDM,S5000,HCPCS,250,RC,99999-0002-00,NDC,outpatient,535,ML,35.39,24.773,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BENZOCAINE 20 % MT AERO,RX-138339,CDM,S5000,HCPCS,259,RC,00283-0679-02,NDC,outpatient,57,GR,120.74,84.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PORACTANT ALFA 120 MG/1.5ML INTRATRACHEA SUSP,RX-138354,CDM,S5000,HCPCS,250,RC,10122-0510-01,NDC,outpatient,1.5,ML,1807.78,1265.446,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PORACTANT ALFA 240 MG/3ML INTRATRACHEA SUSP,RX-138355,CDM,S5000,HCPCS,250,RC,10122-0510-03,NDC,outpatient,3,ML,2153.49,1507.443,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
COLESTIPOL HCL 1 G ORAL TABS,RX-13884,CDM,S5000,HCPCS,259,RC,00115-5211-16,NDC,outpatient,1,UN,4.6,3.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
COLESTIPOL HCL 1 G ORAL TABS,RX-13884,CDM,S5000,HCPCS,259,RC,60687-0715-11,NDC,outpatient,1,UN,12.93,9.051,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
COLESTIPOL HCL 1 G ORAL TABS,RX-13884,CDM,S5000,HCPCS,259,RC,00009-0450-03,NDC,outpatient,1,UN,9.24,6.468,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
COLESTIPOL HCL 1 G ORAL TABS,RX-13884,CDM,S5000,HCPCS,259,RC,59762-0450-01,NDC,outpatient,1,UN,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
COLESTIPOL HCL 1 G ORAL TABS,RX-13884,CDM,S5000,HCPCS,259,RC,60687-0715-21,NDC,outpatient,1,UN,12.93,9.051,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MORPHINE SULFATE 100 MG IN NACL 0.9 % 100 ML IV PREMIX,RX-138903,CDM,S5000,HCPCS,250,RC,70092-1380-36,NDC,outpatient,100,ML,69.27,48.489,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MORPHINE SULFATE 100 MG IN NACL 0.9 % 100 ML IV PREMIX,RX-138903,CDM,S5000,HCPCS,250,RC,70092-1130-36,NDC,outpatient,100,ML,83.73,58.611,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MORPHINE SULFATE 100 MG IN NACL 0.9 % 100 ML IV PREMIX,RX-138903,CDM,S5000,HCPCS,250,RC,99999-0003-24,NDC,outpatient,100,ML,48.85,34.195,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DAPAGLIFLOZIN PROPANEDIOL 5 MG ORAL TABS,RX-138997,CDM,S5000,HCPCS,259,RC,66993-0456-30,NDC,outpatient,1,UN,54.61,38.227,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DAPAGLIFLOZIN PROPANEDIOL 5 MG ORAL TABS,RX-138997,CDM,S5000,HCPCS,259,RC,00310-6205-30,NDC,outpatient,1,UN,54.15,37.905,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DAPAGLIFLOZIN PROPANEDIOL 10 MG ORAL TABS,RX-138998,CDM,S5000,HCPCS,259,RC,00310-6210-39,NDC,outpatient,1,UN,54.15,37.905,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DAPAGLIFLOZIN PROPANEDIOL 10 MG ORAL TABS,RX-138998,CDM,S5000,HCPCS,259,RC,66993-0457-30,NDC,outpatient,1,UN,57.77,40.439,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OCUVITE-LUTEIN ORAL TABS,RX-139063,CDM,S5000,HCPCS,259,RC,24208-0387-62,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OCUVITE-LUTEIN ORAL TABS,RX-139063,CDM,S5000,HCPCS,259,RC,00536-5090-08,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SARILUMAB 200 MG/1.14ML SC SOSY,RX-139347,CDM,S5000,HCPCS,250,RC,00024-5910-01,NDC,outpatient,1.14,ML,5813.71,4069.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SARILUMAB 200 MG/1.14ML SC SOSY,RX-139347,CDM,S5000,HCPCS,250,RC,00024-5910-00,NDC,outpatient,1.14,ML,5813.71,4069.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CARISOPRODOL 350 MG ORAL TABS,RX-1395,CDM,S5000,HCPCS,259,RC,50228-0109-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LAMOTRIGINE 25 MG ORAL TABS,RX-13981,CDM,S5000,HCPCS,259,RC,68084-0318-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LAMOTRIGINE 25 MG ORAL TABS,RX-13981,CDM,S5000,HCPCS,259,RC,68084-0318-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LAMOTRIGINE 25 MG ORAL TABS,RX-13981,CDM,S5000,HCPCS,259,RC,00904-7007-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LAMOTRIGINE 25 MG ORAL TABS,RX-13981,CDM,S5000,HCPCS,259,RC,51672-4130-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LAMOTRIGINE 100 MG ORAL TABS,RX-13982,CDM,S5000,HCPCS,259,RC,68084-0319-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LAMOTRIGINE 100 MG ORAL TABS,RX-13982,CDM,S5000,HCPCS,259,RC,00904-7008-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LAMOTRIGINE 100 MG ORAL TABS,RX-13982,CDM,S5000,HCPCS,259,RC,51672-4131-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LAMOTRIGINE 100 MG ORAL TABS,RX-13982,CDM,S5000,HCPCS,259,RC,68084-0319-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CALCIUM CARBONATE ANTACID 1250 MG/5ML ORAL SUSP,RX-140541,CDM,S5000,HCPCS,259,RC,00121-4766-05,NDC,outpatient,5,ML,9.19,6.433,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DILTIAZEM HCL ER 60 MG ORAL CP12,RX-14100,CDM,S5000,HCPCS,259,RC,51079-0924-01,NDC,outpatient,1,UN,13.61,9.527,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DILTIAZEM HCL ER 60 MG ORAL CP12,RX-14100,CDM,S5000,HCPCS,259,RC,51079-0924-20,NDC,outpatient,1,UN,13.61,9.527,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DILTIAZEM HCL ER 90 MG ORAL CP12,RX-14101,CDM,S5000,HCPCS,259,RC,51079-0925-20,NDC,outpatient,1,UN,16,11.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DILTIAZEM HCL ER 90 MG ORAL CP12,RX-14101,CDM,S5000,HCPCS,259,RC,51079-0925-01,NDC,outpatient,1,UN,16,11.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
KETOCONAZOLE 2 % EX SHAM,RX-14132,CDM,S5000,HCPCS,259,RC,45802-0465-64,NDC,outpatient,120,ML,53.4,37.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BECLOMETHASONE DIPROP HFA 40 MCG/ACT IN AERB,RX-141345,CDM,S5000,HCPCS,259,RC,59310-0302-40,NDC,outpatient,10.6,GR,878.5,614.95,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BECLOMETHASONE DIPROP HFA 80 MCG/ACT IN AERB,RX-141346,CDM,S5000,HCPCS,259,RC,59310-0304-80,NDC,outpatient,10.6,GR,1176.28,823.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BICTEGRAVIR-EMTRICITAB-TENOFOV 50-200-25 MG ORAL TABS,RX-142007,CDM,S5000,HCPCS,259,RC,61958-2501-01,NDC,outpatient,1,UN,572.84,400.988,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLUCONAZOLE 40 MG/ML ORAL SUSR,RX-14233,CDM,S5000,HCPCS,259,RC,16714-0696-01,NDC,outpatient,35,ML,43.77,30.639,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLUCONAZOLE 40 MG/ML ORAL SUSR,RX-14233,CDM,S5000,HCPCS,259,RC,99999-0002-78,NDC,outpatient,5,ML,12.62,8.834,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLUCONAZOLE 40 MG/ML ORAL SUSR,RX-14233,CDM,S5000,HCPCS,259,RC,59762-5030-01,NDC,outpatient,35,ML,84.73,59.311,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MAGNESIUM CHLORIDE 64 MG ORAL TBEC,RX-142395,CDM,S5000,HCPCS,259,RC,57896-0635-06,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MAGNESIUM CHLORIDE 64 MG ORAL TBEC,RX-142395,CDM,S5000,HCPCS,259,RC,68585-0005-75,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MAGNESIUM CHLORIDE 64 MG ORAL TBEC,RX-142395,CDM,S5000,HCPCS,259,RC,10006-0700-13,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POTASSIUM IODIDE (EXPECTORANT) 1 GM/ML ORAL SOLN,RX-142406,CDM,S5000,HCPCS,259,RC,71740-0112-30,NDC,outpatient,0.25,ML,14.74,10.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POTASSIUM IODIDE (EXPECTORANT) 1 GM/ML ORAL SOLN,RX-142406,CDM,S5000,HCPCS,259,RC,99999-0003-49,NDC,outpatient,1,ML,58.94,41.258,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DARUN-COBIC-EMTRICIT-TENOFAF 800-150-200-10 MG ORAL TABS,RX-143657,CDM,S5000,HCPCS,259,RC,59676-0800-30,NDC,outpatient,1,UN,678.69,475.083,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PIMAVANSERIN TARTRATE 34 MG ORAL CAPS,RX-143683,CDM,S5000,HCPCS,259,RC,63090-0340-30,NDC,outpatient,1,UN,740.93,518.651,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM ZIRCONIUM CYCLOSILICATE 10 G ORAL PACK,RX-143885,CDM,S5000,HCPCS,259,RC,00310-1110-01,NDC,outpatient,1,UN,69.73,48.811,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM ZIRCONIUM CYCLOSILICATE 10 G ORAL PACK,RX-143885,CDM,S5000,HCPCS,259,RC,00310-1110-39,NDC,outpatient,1,UN,69.73,48.811,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLONIDINE 0.1 MG/24HR TD PTWK,RX-144285,CDM,S5000,HCPCS,259,RC,00378-0871-16,NDC,outpatient,1,UN,58.96,41.272,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLONIDINE 0.1 MG/24HR TD PTWK,RX-144285,CDM,S5000,HCPCS,259,RC,00378-0871-99,NDC,outpatient,1,UN,58.96,41.272,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLONIDINE 0.1 MG/24HR TD PTWK,RX-144285,CDM,S5000,HCPCS,259,RC,52817-0610-04,NDC,outpatient,1,UN,36.6,25.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLONIDINE 0.2 MG/24HR TD PTWK,RX-144286,CDM,S5000,HCPCS,259,RC,82089-0102-34,NDC,outpatient,1,UN,502.38,351.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLONIDINE 0.2 MG/24HR TD PTWK,RX-144286,CDM,S5000,HCPCS,259,RC,00591-3509-54,NDC,outpatient,1,UN,89.34,62.538,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLONIDINE 0.2 MG/24HR TD PTWK,RX-144286,CDM,S5000,HCPCS,259,RC,51862-0454-04,NDC,outpatient,1,UN,43.76,30.632,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLONIDINE 0.2 MG/24HR TD PTWK,RX-144286,CDM,S5000,HCPCS,259,RC,00591-3509-04,NDC,outpatient,1,UN,89.34,62.538,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLONIDINE 0.2 MG/24HR TD PTWK,RX-144286,CDM,S5000,HCPCS,259,RC,51862-0454-01,NDC,outpatient,1,UN,43.76,30.632,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLONIDINE 0.3 MG/24HR TD PTWK,RX-144287,CDM,S5000,HCPCS,259,RC,00591-3510-04,NDC,outpatient,1,UN,122.13,85.491,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLONIDINE 0.3 MG/24HR TD PTWK,RX-144287,CDM,S5000,HCPCS,259,RC,00591-3510-54,NDC,outpatient,1,UN,122.13,85.491,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RIVAROXABAN 2.5 MG ORAL TABS,RX-144544,CDM,S5000,HCPCS,259,RC,50458-0577-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RIVAROXABAN 2.5 MG ORAL TABS,RX-144544,CDM,S5000,HCPCS,259,RC,50458-0577-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DORZOLAMIDE HCL 2 % OP SOLN,RX-14471,CDM,S5000,HCPCS,259,RC,24208-0485-10,NDC,outpatient,10,ML,36.09,25.263,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DORZOLAMIDE HCL 2 % OP SOLN,RX-14471,CDM,S5000,HCPCS,259,RC,42571-0141-26,NDC,outpatient,10,ML,151.26,105.882,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DORZOLAMIDE HCL 2 % OP SOLN,RX-14471,CDM,S5000,HCPCS,259,RC,61314-0019-10,NDC,outpatient,10,ML,71.78,50.246,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
REVEFENACIN 175 MCG/3ML IN SOLN,RX-145104,CDM,S5000,HCPCS,259,RC,49502-0806-32,NDC,outpatient,3,ML,93.63,65.541,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
REVEFENACIN 175 MCG/3ML IN SOLN,RX-145104,CDM,S5000,HCPCS,259,RC,49502-0806-93,NDC,outpatient,3,ML,93.63,65.541,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TERAZOSIN HCL 1 MG ORAL CAPS,RX-14550,CDM,S5000,HCPCS,259,RC,50268-0764-15,NDC,outpatient,1,UN,2.5,1.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TERAZOSIN HCL 1 MG ORAL CAPS,RX-14550,CDM,S5000,HCPCS,259,RC,50268-0764-11,NDC,outpatient,1,UN,2.5,1.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TERAZOSIN HCL 5 MG ORAL CAPS,RX-14553,CDM,S5000,HCPCS,259,RC,50268-0766-15,NDC,outpatient,1,UN,2.67,1.869,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TERAZOSIN HCL 5 MG ORAL CAPS,RX-14553,CDM,S5000,HCPCS,259,RC,50268-0766-11,NDC,outpatient,1,UN,2.67,1.869,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ABLYSINOL IA SOLN,RX-145979,CDM,S5000,HCPCS,250,RC,54288-0105-02,NDC,outpatient,5,ML,2091.2,1463.84,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ABLYSINOL IA SOLN,RX-145979,CDM,S5000,HCPCS,250,RC,54288-0105-15,NDC,outpatient,5,ML,2091.2,1463.84,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PYRIDOSTIGMINE BROMIDE 60 MG/5ML ORAL SOLN,RX-146239,CDM,S5000,HCPCS,259,RC,99999-0002-40,NDC,outpatient,5,ML,47,32.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PYRIDOSTIGMINE BROMIDE 60 MG/5ML ORAL SOLN,RX-146239,CDM,S5000,HCPCS,259,RC,69238-1731-02,NDC,outpatient,473,ML,2201.68,1541.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VERAPAMIL HCL ER 180 MG ORAL TBCR,RX-14626,CDM,S5000,HCPCS,259,RC,75834-0158-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
INDOMETHACIN ER 75 MG ORAL CPCR,RX-14628,CDM,S5000,HCPCS,259,RC,68084-0411-11,NDC,outpatient,1,UN,9.29,6.503,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
INDOMETHACIN ER 75 MG ORAL CPCR,RX-14628,CDM,S5000,HCPCS,259,RC,68084-0411-21,NDC,outpatient,1,UN,9.29,6.503,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRAMADOL HCL 50 MG ORAL TABS,RX-14632,CDM,S5000,HCPCS,259,RC,00904-7179-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRAMADOL HCL 50 MG ORAL TABS,RX-14632,CDM,S5000,HCPCS,259,RC,60687-0795-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRAMADOL HCL 50 MG ORAL TABS,RX-14632,CDM,S5000,HCPCS,259,RC,00093-0058-05,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRAMADOL HCL 50 MG ORAL TABS,RX-14632,CDM,S5000,HCPCS,259,RC,29300-0355-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRAMADOL HCL 50 MG ORAL TABS,RX-14632,CDM,S5000,HCPCS,259,RC,60687-0795-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACETIC ACID 5 % SOLN,RX-14702,CDM,S5000,HCPCS,259,RC,99999-0000-92,NDC,outpatient,60,ML,12.55,8.785,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METFORMIN HCL 850 MG ORAL TABS,RX-14719,CDM,S5000,HCPCS,259,RC,60687-0143-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METFORMIN HCL 850 MG ORAL TABS,RX-14719,CDM,S5000,HCPCS,259,RC,00904-7163-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METFORMIN HCL 850 MG ORAL TABS,RX-14719,CDM,S5000,HCPCS,259,RC,60687-0143-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GLYBURIDE MICRONIZED 1.5 MG ORAL TABS,RX-14777,CDM,S5000,HCPCS,259,RC,00093-8034-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
INSULIN REGULAR(HUMAN) IN NACL 100-0.9 UT/100ML-% IV SOLN,RX-147794,CDM,S5000,HCPCS,250,RC,00338-0126-12,NDC,outpatient,100,ML,98.33,68.831,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRANEXAMIC ACID-NACL 1000-0.7 MG/100ML-% IV SOLN,RX-147865,CDM,S5000,HCPCS,250,RC,51754-0108-03,NDC,outpatient,100,ML,46.71,32.697,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRANEXAMIC ACID-NACL 1000-0.7 MG/100ML-% IV SOLN,RX-147865,CDM,S5000,HCPCS,250,RC,51754-0108-01,NDC,outpatient,100,ML,46.71,32.697,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DORZOLAMIDE HCL-TIMOLOL MAL PF 2-0.5 % OP SOLN,RX-147878,CDM,S5000,HCPCS,259,RC,82584-0604-01,NDC,outpatient,1,UN,14.17,9.919,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DORZOLAMIDE HCL-TIMOLOL MAL PF 2-0.5 % OP SOLN,RX-147878,CDM,S5000,HCPCS,259,RC,82584-0604-30,NDC,outpatient,1,UN,14.17,9.919,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TIZANIDINE HCL 2 MG ORAL TABS,RX-14792,CDM,S5000,HCPCS,259,RC,50268-0759-11,NDC,outpatient,1,UN,2.93,2.051,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TIZANIDINE HCL 2 MG ORAL TABS,RX-14792,CDM,S5000,HCPCS,259,RC,50268-0759-15,NDC,outpatient,1,UN,2.93,2.051,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TIZANIDINE HCL 4 MG ORAL TABS,RX-14793,CDM,S5000,HCPCS,259,RC,00904-6418-61,NDC,outpatient,1,UN,1.85,1.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LANSOPRAZOLE 30 MG ORAL TBDD,RX-148035,CDM,S5000,HCPCS,259,RC,00378-6982-88,NDC,outpatient,1,UN,22.99,16.093,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LANSOPRAZOLE 30 MG ORAL TBDD,RX-148035,CDM,S5000,HCPCS,259,RC,68382-0772-77,NDC,outpatient,1,UN,20.73,14.511,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LANSOPRAZOLE 30 MG ORAL TBDD,RX-148035,CDM,S5000,HCPCS,259,RC,00378-6982-32,NDC,outpatient,1,UN,22.99,16.093,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LANSOPRAZOLE 30 MG ORAL TBDD,RX-148035,CDM,S5000,HCPCS,259,RC,64764-0544-11,NDC,outpatient,1,UN,56.9,39.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LANSOPRAZOLE 30 MG ORAL TBDD,RX-148035,CDM,S5000,HCPCS,259,RC,68382-0772-30,NDC,outpatient,1,UN,20.73,14.511,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LOSARTAN POTASSIUM 25 MG ORAL TABS,RX-14823,CDM,S5000,HCPCS,259,RC,68084-0346-01,NDC,outpatient,1,UN,1.75,1.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LOSARTAN POTASSIUM 25 MG ORAL TABS,RX-14823,CDM,S5000,HCPCS,259,RC,68084-0346-11,NDC,outpatient,1,UN,1.75,1.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LOSARTAN POTASSIUM 50 MG ORAL TABS,RX-14824,CDM,S5000,HCPCS,259,RC,00904-7048-61,NDC,outpatient,1,UN,1.68,1.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LOSARTAN POTASSIUM 50 MG ORAL TABS,RX-14824,CDM,S5000,HCPCS,259,RC,50268-0505-15,NDC,outpatient,1,UN,1.24,0.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LOSARTAN POTASSIUM 50 MG ORAL TABS,RX-14824,CDM,S5000,HCPCS,259,RC,31722-0701-30,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LOSARTAN POTASSIUM 50 MG ORAL TABS,RX-14824,CDM,S5000,HCPCS,259,RC,50268-0505-11,NDC,outpatient,1,UN,1.24,0.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LOSARTAN POTASSIUM 50 MG ORAL TABS,RX-14824,CDM,S5000,HCPCS,259,RC,31722-0701-90,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FOSFOMYCIN TROMETHAMINE 3 G ORAL PACK,RX-14825,CDM,S5000,HCPCS,259,RC,69097-0579-67,NDC,outpatient,1,UN,204.35,143.045,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FOSFOMYCIN TROMETHAMINE 3 G ORAL PACK,RX-14825,CDM,S5000,HCPCS,259,RC,70700-0268-94,NDC,outpatient,1,UN,214.58,150.206,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FOSFOMYCIN TROMETHAMINE 3 G ORAL PACK,RX-14825,CDM,S5000,HCPCS,259,RC,70700-0268-99,NDC,outpatient,1,UN,214.58,150.206,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ATOVAQUONE 750 MG/5ML ORAL SUSP,RX-14953,CDM,S5000,HCPCS,259,RC,70748-0299-01,NDC,outpatient,210,ML,615.84,431.088,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ATOVAQUONE 750 MG/5ML ORAL SUSP,RX-14953,CDM,S5000,HCPCS,259,RC,99999-0004-54,NDC,outpatient,5,ML,14.67,10.269,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BACTERIOSTATIC WATER(BENZ ALC) IJ SOLN,RX-14979,CDM,S5000,HCPCS,250,RC,00409-3977-03,NDC,outpatient,30,ML,8.02,5.614,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BACTERIOSTATIC WATER(BENZ ALC) IJ SOLN,RX-14979,CDM,S5000,HCPCS,250,RC,00409-3977-01,NDC,outpatient,30,ML,8.02,5.614,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MOEXIPRIL HCL 7.5 MG ORAL TABS,RX-15025,CDM,S5000,HCPCS,259,RC,68462-0209-01,NDC,outpatient,1,UN,3.46,2.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VITAMIN A 3 MG (10000 UT) ORAL CAPS,RX-150260,CDM,S5000,HCPCS,259,RC,40093-0140-03,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VITAMIN A 3 MG (10000 UT) ORAL CAPS,RX-150260,CDM,S5000,HCPCS,259,RC,00904-2085-60,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VITAMIN A 3 MG (10000 UT) ORAL CAPS,RX-150260,CDM,S5000,HCPCS,259,RC,40093-0101-44,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROCORT-PRAMOXINE (PERIANAL) 2.5-1 % EX CREA,RX-150325,CDM,S5000,HCPCS,259,RC,45802-0472-64,NDC,outpatient,30,GR,583,408.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACETIC ACID 3 % SOLN,RX-15091,CDM,S5000,HCPCS,259,RC,99999-0001-49,NDC,outpatient,60,ML,11.75,8.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACETIC ACID 3 % SOLN,RX-15091,CDM,S5000,HCPCS,259,RC,51552-0051-06,NDC,outpatient,500,ML,97.9,68.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LOPERAMIDE HCL 1 MG/7.5ML ORAL SOLN,RX-150997,CDM,S5000,HCPCS,259,RC,68094-0129-59,NDC,outpatient,15,ML,10.55,7.385,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LOPERAMIDE HCL 1 MG/7.5ML ORAL SOLN,RX-150997,CDM,S5000,HCPCS,259,RC,68094-0129-62,NDC,outpatient,15,ML,10.55,7.385,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MYCOPHENOLATE MOFETIL 250 MG ORAL CAPS,RX-15113,CDM,S5000,HCPCS,259,RC,51079-0721-01,NDC,outpatient,1,UN,2.18,1.526,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MYCOPHENOLATE MOFETIL 250 MG ORAL CAPS,RX-15113,CDM,S5000,HCPCS,259,RC,51079-0721-20,NDC,outpatient,1,UN,2.18,1.526,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MYCOPHENOLATE MOFETIL 250 MG ORAL CAPS,RX-15113,CDM,S5000,HCPCS,259,RC,60687-0494-01,NDC,outpatient,1,UN,2.25,1.575,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MYCOPHENOLATE MOFETIL 250 MG ORAL CAPS,RX-15113,CDM,S5000,HCPCS,259,RC,60687-0494-11,NDC,outpatient,1,UN,2.25,1.575,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POLY-VI-SOL/IRON 11 MG/ML ORAL SOLN,RX-151638,CDM,S5000,HCPCS,259,RC,99999-0001-69,NDC,outpatient,0.5,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POLY-VI-SOL/IRON 11 MG/ML ORAL SOLN,RX-151638,CDM,S5000,HCPCS,259,RC,00087-0405-01,NDC,outpatient,0.5,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TACROLIMUS ER 1 MG ORAL TB24,RX-151676,CDM,S5000,HCPCS,259,RC,68992-3010-03,NDC,outpatient,1,UN,3.04,2.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TACROLIMUS ER 0.75 MG ORAL TB24,RX-151678,CDM,S5000,HCPCS,259,RC,68992-3075-03,NDC,outpatient,1,UN,2.28,1.596,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TACROLIMUS ER 4 MG ORAL TB24,RX-151679,CDM,S5000,HCPCS,259,RC,68992-3040-03,NDC,outpatient,1,UN,12.17,8.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SENNOSIDES 8.8 MG/5ML ORAL SYRP,RX-15168,CDM,S5000,HCPCS,259,RC,00536-1266-10,NDC,outpatient,10,ML,1.5,1.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SENNOSIDES 8.8 MG/5ML ORAL SYRP,RX-15168,CDM,S5000,HCPCS,259,RC,99999-0002-42,NDC,outpatient,10,ML,1.6,1.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SENNOSIDES 8.8 MG/5ML ORAL SYRP,RX-15168,CDM,S5000,HCPCS,259,RC,00536-1266-59,NDC,outpatient,10,ML,1.5,1.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SENNOSIDES 8.8 MG/5ML ORAL SYRP,RX-15168,CDM,S5000,HCPCS,259,RC,57896-0472-08,NDC,outpatient,5,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SENNOSIDES 8.8 MG/5ML ORAL SYRP,RX-15168,CDM,S5000,HCPCS,259,RC,57896-0472-10,NDC,outpatient,10,ML,1.39,0.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRACE MINERALS CU-MN-SE-ZN 300-55-60-3000 MCG/ML IV SOLN,RX-151858,CDM,S5000,HCPCS,250,RC,00517-9305-01,NDC,outpatient,1,ML,93.05,65.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRACE MINERALS CU-MN-SE-ZN 300-55-60-3000 MCG/ML IV SOLN,RX-151858,CDM,S5000,HCPCS,250,RC,00517-9305-25,NDC,outpatient,1,ML,93.05,65.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METHACHOLINE CHLORIDE IN KIT,RX-151916,CDM,S5000,HCPCS,259,RC,69374-0542-06,NDC,outpatient,18,ML,600.75,420.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DICLOFENAC SODIUM 1 % EX GEL,RX-152701,CDM,S5000,HCPCS,259,RC,00536-1294-97,NDC,outpatient,100,GR,33.38,23.366,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DICLOFENAC SODIUM 1 % EX GEL,RX-152701,CDM,S5000,HCPCS,259,RC,69097-0524-44,NDC,outpatient,100,GR,59.63,41.741,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DICLOFENAC SODIUM 1 % EX GEL,RX-152701,CDM,S5000,HCPCS,259,RC,43598-0977-10,NDC,outpatient,100,GR,59.19,41.433,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SUMATRIPTAN SUCCINATE 25 MG ORAL TABS,RX-15327,CDM,S5000,HCPCS,259,RC,65862-0146-36,NDC,outpatient,1,UN,1.72,1.204,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DICLOFENAC SODIUM 50 MG ORAL TBEC,RX-15340,CDM,S5000,HCPCS,259,RC,00228-2550-11,NDC,outpatient,1,UN,1.63,1.141,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DICLOFENAC SODIUM 50 MG ORAL TBEC,RX-15340,CDM,S5000,HCPCS,259,RC,60687-0606-11,NDC,outpatient,1,UN,2.07,1.449,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DICLOFENAC SODIUM 50 MG ORAL TBEC,RX-15340,CDM,S5000,HCPCS,259,RC,16571-0202-10,NDC,outpatient,1,UN,1.23,0.861,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DICLOFENAC SODIUM 50 MG ORAL TBEC,RX-15340,CDM,S5000,HCPCS,259,RC,61442-0102-01,NDC,outpatient,1,UN,1.24,0.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DICLOFENAC SODIUM 50 MG ORAL TBEC,RX-15340,CDM,S5000,HCPCS,259,RC,60687-0606-01,NDC,outpatient,1,UN,2.07,1.449,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DICLOFENAC SODIUM 75 MG ORAL TBEC,RX-15341,CDM,S5000,HCPCS,259,RC,16571-0201-06,NDC,outpatient,1,UN,1.46,1.022,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AYR SALINE NASAL NA GEL,RX-15372,CDM,S5000,HCPCS,259,RC,00225-0525-47,NDC,outpatient,14.1,GR,10.92,7.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AYR SALINE NASAL NA GEL,RX-15372,CDM,S5000,HCPCS,259,RC,05928-0000-99,NDC,outpatient,28.4,GR,22.75,15.925,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RIMANTADINE HCL 100 MG ORAL TABS,RX-15440,CDM,S5000,HCPCS,259,RC,00115-1911-01,NDC,outpatient,1,UN,10.21,7.147,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CHERRY ORAL SYRP,RX-1562,CDM,S5000,HCPCS,259,RC,00395-2662-16,NDC,outpatient,473,ML,78.58,55.006,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FAT EMULSION PLANT BASED (SOY) 20 % IV EMUL,RX-156372,CDM,S5000,HCPCS,250,RC,00338-0519-09,NDC,outpatient,250,ML,59.39,41.573,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FAT EMULSION PLANT BASED (SOY) 20 % IV EMUL,RX-156372,CDM,S5000,HCPCS,250,RC,00338-0519-13,NDC,outpatient,500,ML,73.85,51.695,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMANTADINE HCL 50 MG/5ML ORAL SOLN,RX-156382,CDM,S5000,HCPCS,259,RC,00121-0646-10,NDC,outpatient,10,ML,13.67,9.569,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALENDRONATE SODIUM 10 MG ORAL TABS,RX-15661,CDM,S5000,HCPCS,259,RC,16714-0631-01,NDC,outpatient,1,UN,1.72,1.204,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM THIOSULFATE 250 MG/ML IV SOLN,RX-156724,CDM,S5000,HCPCS,250,RC,60267-0705-50,NDC,outpatient,50,ML,431.65,302.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PRISMASOL BGK 0/2.5 32-2.5 MEQ/L EC SOLN,RX-156740,CDM,S5000,HCPCS,250,RC,24571-0108-06,NDC,outpatient,5000,ML,294.88,206.416,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PRISMASOL BGK 4/2.5 32-4-2.5 MEQ/L EC SOLN,RX-156741,CDM,S5000,HCPCS,250,RC,24571-0105-06,NDC,outpatient,5000,ML,294.88,206.416,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PRISMASOL BGK 2/0 32-2 MEQ/L EC SOLN,RX-156742,CDM,S5000,HCPCS,250,RC,24571-0102-06,NDC,outpatient,5000,ML,294.88,206.416,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PRISMASOL BGK 2/3.5 32-2-3.5 MEQ/L EC SOLN,RX-156743,CDM,S5000,HCPCS,250,RC,24571-0103-06,NDC,outpatient,5000,ML,325.06,227.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SOTALOL HCL 120 MG ORAL TABS,RX-15723,CDM,S5000,HCPCS,259,RC,00093-1060-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SOTALOL HCL 120 MG ORAL TABS,RX-15723,CDM,S5000,HCPCS,259,RC,60505-0159-00,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CALCITONIN (SALMON) 200 UNIT/ACT NA SOLN,RX-15738,CDM,S5000,HCPCS,259,RC,60505-0823-06,NDC,outpatient,3.7,ML,230.15,161.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CALCITONIN (SALMON) 200 UNIT/ACT NA SOLN,RX-15738,CDM,S5000,HCPCS,259,RC,49884-0161-11,NDC,outpatient,3.7,ML,207.33,145.131,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CARVEDILOL 6.25 MG ORAL TABS,RX-15747,CDM,S5000,HCPCS,259,RC,00904-6301-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CARVEDILOL 12.5 MG ORAL TABS,RX-15749,CDM,S5000,HCPCS,259,RC,00904-6302-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CARVEDILOL 12.5 MG ORAL TABS,RX-15749,CDM,S5000,HCPCS,259,RC,68382-0094-05,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AZITHROMYCIN 200 MG/5ML ORAL SUSR,RX-15797,CDM,S5000,HCPCS,259,RC,59762-3120-01,NDC,outpatient,18.75,ML,76.85,53.795,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AZITHROMYCIN 200 MG/5ML ORAL SUSR,RX-15797,CDM,S5000,HCPCS,259,RC,00093-2026-23,NDC,outpatient,18.75,ML,62.17,43.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AZITHROMYCIN 200 MG/5ML ORAL SUSR,RX-15797,CDM,S5000,HCPCS,259,RC,99999-0002-81,NDC,outpatient,6.25,ML,21.03,14.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DARUNAVIR 800 MG ORAL TABS,RX-158170,CDM,S5000,HCPCS,259,RC,59676-0566-30,NDC,outpatient,1,UN,310.53,217.371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
INSULIN LISPRO 100 UNIT/ML IJ SOLN,RX-158181,CDM,S5000,HCPCS,259,RC,00002-7533-01,NDC,outpatient,3,ML,80.06,56.042,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
INSULIN LISPRO 100 UNIT/ML IJ SOLN,RX-158181,CDM,S5000,HCPCS,259,RC,00024-5924-10,NDC,outpatient,10,ML,322.63,225.841,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
INSULIN LISPRO 100 UNIT/ML IJ SOLN,RX-158181,CDM,S5000,HCPCS,259,RC,00024-5926-05,NDC,outpatient,3,ML,50.03,35.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LAMIVUDINE 150 MG ORAL TABS,RX-15880,CDM,S5000,HCPCS,259,RC,00904-6583-04,NDC,outpatient,1,UN,21.27,14.889,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LAMIVUDINE 150 MG ORAL TABS,RX-15880,CDM,S5000,HCPCS,259,RC,64380-0710-03,NDC,outpatient,1,UN,2.38,1.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LAMIVUDINE 10 MG/ML ORAL SOLN,RX-15881,CDM,S5000,HCPCS,259,RC,54838-0566-70,NDC,outpatient,15,ML,23.1,16.17,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACARBOSE 50 MG ORAL TABS,RX-15895,CDM,S5000,HCPCS,259,RC,64380-0759-06,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DAKINS (1/2 STRENGTH) 0.25 % EX SOLN,RX-15950,CDM,S5000,HCPCS,259,RC,00436-0936-16,NDC,outpatient,473,ML,52.63,36.841,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NIRMATRELVIR&RITONAVIR 150/100 10 X 150 MG & 10 X 100MG ORAL TBPK,RX-159847,CDM,S5000,HCPCS,259,RC,00069-5317-02,NDC,outpatient,1,UN,571.55,400.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NIRMATRELVIR&RITONAVIR 150/100 10 X 150 MG & 10 X 100MG ORAL TBPK,RX-159847,CDM,S5000,HCPCS,259,RC,00069-5317-20,NDC,outpatient,1,UN,3544.84,2481.388,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NIRMATRELVIR&RITONAVIR 300/100 20 X 150 MG & 10 X 100MG ORAL TBPK,RX-159848,CDM,S5000,HCPCS,259,RC,00069-5321-30,NDC,outpatient,1,UN,3544.84,2481.388,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NIRMATRELVIR&RITONAVIR 300/100 20 X 150 MG & 10 X 100MG ORAL TBPK,RX-159848,CDM,S5000,HCPCS,259,RC,00069-5321-03,NDC,outpatient,1,UN,571.55,400.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METHADONE HCL 10 MG/ML ORAL CONC,RX-15996,CDM,S5000,HCPCS,259,RC,00406-0527-10,NDC,outpatient,0.5,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METHADONE HCL 10 MG/ML ORAL CONC,RX-15996,CDM,S5000,HCPCS,259,RC,99999-0002-10,NDC,outpatient,10,ML,27.28,19.096,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ESTROGENS CONJUGATED 0.625 MG/GM VA CREA,RX-160113,CDM,S5000,HCPCS,259,RC,00046-0872-21,NDC,outpatient,30,GR,1850.58,1295.406,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CALCIPOTRIENE 0.005 % EX CREA,RX-16034,CDM,S5000,HCPCS,259,RC,16714-0763-01,NDC,outpatient,60,GR,327.35,229.145,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GLUCOSE 4 G ORAL CHEW,RX-16050,CDM,S5000,HCPCS,259,RC,56151-1610-11,NDC,outpatient,1,UN,3.58,2.506,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GLUCOSE 4 G ORAL CHEW,RX-16050,CDM,S5000,HCPCS,259,RC,80681-0100-00,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GLUCOSE 4 G ORAL CHEW,RX-16050,CDM,S5000,HCPCS,259,RC,56151-1610-51,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DESMOPRESSIN ACETATE 0.2 MG ORAL TABS,RX-16053,CDM,S5000,HCPCS,259,RC,60687-0732-11,NDC,outpatient,1,UN,7.9,5.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DESMOPRESSIN ACETATE 0.2 MG ORAL TABS,RX-16053,CDM,S5000,HCPCS,259,RC,60687-0732-21,NDC,outpatient,1,UN,7.9,5.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DESMOPRESSIN ACETATE 0.2 MG ORAL TABS,RX-16053,CDM,S5000,HCPCS,259,RC,23155-0490-01,NDC,outpatient,1,UN,1.27,0.889,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METHYLENE BLUE 1 % IV SOLN,RX-160649,CDM,S5000,HCPCS,250,RC,54288-0147-01,NDC,outpatient,10,ML,616.77,431.739,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACTIDOSE WITH SORBITOL 25 GM/120ML ORAL SUSP,RX-160655,CDM,S5000,HCPCS,259,RC,00574-0520-74,NDC,outpatient,120,ML,51.8,36.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACTIDOSE WITH SORBITOL 25 GM/120ML ORAL SUSP,RX-160655,CDM,S5000,HCPCS,259,RC,66689-0203-04,NDC,outpatient,120,ML,73.16,51.212,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IPRATROPIUM BROMIDE 0.03 % NA SOLN,RX-16070,CDM,S5000,HCPCS,259,RC,00054-0045-44,NDC,outpatient,30,ML,160.2,112.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IPRATROPIUM BROMIDE 0.03 % NA SOLN,RX-16070,CDM,S5000,HCPCS,259,RC,24208-0398-30,NDC,outpatient,30,ML,45.66,31.962,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CALCIUM CARB-CHOLECALCIFEROL 600-5 MG-MCG ORAL TABS,RX-160700,CDM,S5000,HCPCS,259,RC,80681-0138-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IPRATROPIUM BROMIDE 0.06 % NA SOLN,RX-16071,CDM,S5000,HCPCS,259,RC,00054-0046-41,NDC,outpatient,15,ML,147.99,103.593,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IPRATROPIUM BROMIDE 0.06 % NA SOLN,RX-16071,CDM,S5000,HCPCS,259,RC,60505-0827-01,NDC,outpatient,15,ML,69.49,48.643,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FAMCICLOVIR 250 MG ORAL TABS,RX-16081,CDM,S5000,HCPCS,259,RC,60505-3246-03,NDC,outpatient,1,UN,1.06,0.742,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CALCIUM CITRATE-VITAMIN D 200-6.25 MG-MCG ORAL TABS,RX-160846,CDM,S5000,HCPCS,259,RC,00536-3223-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CALCIUM CITRATE-VITAMIN D 200-6.25 MG-MCG ORAL TABS,RX-160846,CDM,S5000,HCPCS,259,RC,16500-0535-02,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CALCIUM CITRATE-VITAMIN D 200-6.25 MG-MCG ORAL TABS,RX-160846,CDM,S5000,HCPCS,259,RC,16500-0535-03,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RILUZOLE 50 MG ORAL TABS,RX-16124,CDM,S5000,HCPCS,259,RC,67877-0286-60,NDC,outpatient,1,UN,2.96,2.072,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CALCITRIOL 1 MCG/ML ORAL SOLN,RX-16218,CDM,S5000,HCPCS,259,RC,00054-3120-41,NDC,outpatient,1,ML,24.45,17.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CALCITRIOL 1 MCG/ML ORAL SOLN,RX-16218,CDM,S5000,HCPCS,259,RC,99999-0002-71,NDC,outpatient,1,ML,19.3,13.51,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CALCITRIOL 1 MCG/ML ORAL SOLN,RX-16218,CDM,S5000,HCPCS,259,RC,63304-0241-59,NDC,outpatient,1,ML,19.3,13.51,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CHLORDIAZEPOXIDE HCL 25 MG ORAL CAPS,RX-1623,CDM,S5000,HCPCS,259,RC,51079-0141-20,NDC,outpatient,1,UN,2.52,1.764,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CHLORDIAZEPOXIDE HCL 25 MG ORAL CAPS,RX-1623,CDM,S5000,HCPCS,259,RC,00555-0159-02,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CHLORDIAZEPOXIDE HCL 25 MG ORAL CAPS,RX-1623,CDM,S5000,HCPCS,259,RC,51079-0141-01,NDC,outpatient,1,UN,2.52,1.764,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CHLORDIAZEPOXIDE HCL 5 MG ORAL CAPS,RX-1624,CDM,S5000,HCPCS,259,RC,51079-0374-20,NDC,outpatient,1,UN,2.65,1.855,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CHLORDIAZEPOXIDE HCL 5 MG ORAL CAPS,RX-1624,CDM,S5000,HCPCS,259,RC,51079-0374-01,NDC,outpatient,1,UN,2.65,1.855,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
EUCERIN ORIGINAL HEALING EX CREA,RX-162713,CDM,S5000,HCPCS,259,RC,72140-0038-68,NDC,outpatient,57,GR,20.04,14.028,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GLIMEPIRIDE 2 MG ORAL TABS,RX-16356,CDM,S5000,HCPCS,259,RC,68084-0326-01,NDC,outpatient,1,UN,2.06,1.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GLIMEPIRIDE 2 MG ORAL TABS,RX-16356,CDM,S5000,HCPCS,259,RC,55111-0321-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GLIMEPIRIDE 2 MG ORAL TABS,RX-16356,CDM,S5000,HCPCS,259,RC,68084-0326-11,NDC,outpatient,1,UN,2.06,1.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CHLORPHENIRAMINE MALEATE 4 MG ORAL TABS,RX-1645,CDM,S5000,HCPCS,259,RC,00904-0012-59,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CHLORPHENIRAMINE MALEATE 4 MG ORAL TABS,RX-1645,CDM,S5000,HCPCS,259,RC,00904-0012-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PHENYLEPH-SHARK LIV OIL-MO-PET 0.25-3-14-71.9 % RE OINT,RX-16462,CDM,S5000,HCPCS,259,RC,00573-2871-93,NDC,outpatient,28,GR,25.8,18.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CHLORPROMAZINE HCL 10 MG ORAL TABS,RX-1653,CDM,S5000,HCPCS,259,RC,50268-0162-11,NDC,outpatient,1,UN,4.66,3.262,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CHLORPROMAZINE HCL 10 MG ORAL TABS,RX-1653,CDM,S5000,HCPCS,259,RC,00904-7129-61,NDC,outpatient,1,UN,10.41,7.287,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CHLORPROMAZINE HCL 10 MG ORAL TABS,RX-1653,CDM,S5000,HCPCS,259,RC,50268-0162-15,NDC,outpatient,1,UN,4.66,3.262,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CHLORPROMAZINE HCL 100 MG ORAL TABS,RX-1654,CDM,S5000,HCPCS,259,RC,69238-1060-01,NDC,outpatient,1,UN,6.98,4.886,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CHLORPROMAZINE HCL 100 MG ORAL TABS,RX-1654,CDM,S5000,HCPCS,259,RC,00904-7132-61,NDC,outpatient,1,UN,20.86,14.602,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CHLORPROMAZINE HCL 25 MG ORAL TABS,RX-1656,CDM,S5000,HCPCS,259,RC,50268-0163-11,NDC,outpatient,1,UN,7.19,5.033,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CHLORPROMAZINE HCL 25 MG ORAL TABS,RX-1656,CDM,S5000,HCPCS,259,RC,69238-1056-01,NDC,outpatient,1,UN,2.88,2.016,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CHLORPROMAZINE HCL 25 MG ORAL TABS,RX-1656,CDM,S5000,HCPCS,259,RC,50268-0163-15,NDC,outpatient,1,UN,7.19,5.033,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
KETOTIFEN FUMARATE 0.035 % OP SOLN,RX-165824,CDM,S5000,HCPCS,259,RC,00065-4011-05,NDC,outpatient,5,ML,42.77,29.939,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
KETOTIFEN FUMARATE 0.035 % OP SOLN,RX-165824,CDM,S5000,HCPCS,259,RC,00536-1252-40,NDC,outpatient,5,ML,30.09,21.063,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
KETOTIFEN FUMARATE 0.035 % OP SOLN,RX-165824,CDM,S5000,HCPCS,259,RC,72485-0617-10,NDC,outpatient,5,ML,28.93,20.251,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CHLORTHALIDONE 25 MG ORAL TABS,RX-1661,CDM,S5000,HCPCS,259,RC,51079-0058-01,NDC,outpatient,1,UN,7.86,5.502,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CHLORTHALIDONE 25 MG ORAL TABS,RX-1661,CDM,S5000,HCPCS,259,RC,51079-0058-20,NDC,outpatient,1,UN,7.86,5.502,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PAROXETINE HCL 10 MG ORAL TABS,RX-16632,CDM,S5000,HCPCS,259,RC,68084-0044-01,NDC,outpatient,1,UN,2.56,1.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PAROXETINE HCL 10 MG ORAL TABS,RX-16632,CDM,S5000,HCPCS,259,RC,63739-0888-10,NDC,outpatient,1,UN,2.7,1.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PAROXETINE HCL 10 MG ORAL TABS,RX-16632,CDM,S5000,HCPCS,259,RC,68084-0044-11,NDC,outpatient,1,UN,2.56,1.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FERROUS SULFATE ER 45 MG ORAL TBCR,RX-167735,CDM,S5000,HCPCS,259,RC,10006-0730-13,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACD FORMULA A 0.73-2.45-2.2 GM/100ML VI SOLN,RX-16825,CDM,S5000,HCPCS,250,RC,00942-0641-04,NDC,outpatient,1000,ML,60.15,42.105,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,68094-0110-59,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,77333-0516-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,77333-0516-25,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,50268-0524-15,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,20555-0036-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,50268-0524-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,68094-0110-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYOSCYAMINE SULFATE ER 0.375 MG ORAL TB12,RX-17010,CDM,S5000,HCPCS,259,RC,51525-0115-01,NDC,outpatient,1,UN,1.16,0.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRANDOLAPRIL 1 MG ORAL TABS,RX-17017,CDM,S5000,HCPCS,259,RC,68180-0566-01,NDC,outpatient,1,UN,2.46,1.722,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SELEGILINE HCL 5 MG ORAL CAPS,RX-17280,CDM,S5000,HCPCS,259,RC,60505-0055-01,NDC,outpatient,1,UN,2.47,1.729,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DERMAPHOR EX OINT,RX-17369,CDM,S5000,HCPCS,259,RC,61924-0184-04,NDC,outpatient,106,GR,13.68,9.576,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DERMAPHOR EX OINT,RX-17369,CDM,S5000,HCPCS,259,RC,72140-0031-47,NDC,outpatient,396,GR,61.68,43.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DERMAPHOR EX OINT,RX-17369,CDM,S5000,HCPCS,259,RC,72140-0452-31,NDC,outpatient,50,GR,20.25,14.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RISPERIDONE 1 MG/ML ORAL SOLN,RX-17377,CDM,S5000,HCPCS,259,RC,27808-0002-01,NDC,outpatient,0.25,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RISPERIDONE 1 MG/ML ORAL SOLN,RX-17377,CDM,S5000,HCPCS,259,RC,99999-0003-81,NDC,outpatient,1,ML,4.12,2.884,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RISPERIDONE 1 MG/ML ORAL SOLN,RX-17377,CDM,S5000,HCPCS,259,RC,65162-0673-84,NDC,outpatient,0.25,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AZITHROMYCIN 600 MG ORAL TABS,RX-17387,CDM,S5000,HCPCS,259,RC,62332-0253-30,NDC,outpatient,1,UN,1.72,1.204,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLINDAMYCIN HCL 150 MG ORAL CAPS,RX-1740,CDM,S5000,HCPCS,259,RC,00904-5959-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NEVIRAPINE 200 MG ORAL TABS,RX-17403,CDM,S5000,HCPCS,259,RC,31722-0505-60,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLINDAMYCIN PHOSPHATE 1 % EX SOLN,RX-1742,CDM,S5000,HCPCS,259,RC,45802-0562-02,NDC,outpatient,60,ML,48.6,34.02,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLINDAMYCIN PHOSPHATE 1 % EX SOLN,RX-1742,CDM,S5000,HCPCS,259,RC,00168-0201-60,NDC,outpatient,60,ML,139.11,97.377,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MIRTAZAPINE 15 MG ORAL TABS,RX-17466,CDM,S5000,HCPCS,259,RC,00904-6519-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MIRTAZAPINE 15 MG ORAL TABS,RX-17466,CDM,S5000,HCPCS,259,RC,51079-0086-20,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MIRTAZAPINE 15 MG ORAL TABS,RX-17466,CDM,S5000,HCPCS,259,RC,51079-0086-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CANDIDA ALBICANS SKN TST ANTGN ID SOLN,RX-17524,CDM,S5000,HCPCS,250,RC,59584-0138-01,NDC,outpatient,0.1,ML,121.71,85.197,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLONIDINE HCL 0.1 MG ORAL TABS,RX-1755,CDM,S5000,HCPCS,259,RC,60687-0113-01,NDC,outpatient,1,UN,1.25,0.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLONIDINE HCL 0.1 MG ORAL TABS,RX-1755,CDM,S5000,HCPCS,259,RC,60687-0113-11,NDC,outpatient,1,UN,1.25,0.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLORAZEPATE DIPOTASSIUM 3.75 MG ORAL TABS,RX-1759,CDM,S5000,HCPCS,259,RC,13107-0319-01,NDC,outpatient,1,UN,4.43,3.101,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLOTRIMAZOLE 1 % EX CREA,RX-1767,CDM,S5000,HCPCS,259,RC,51672-2002-02,NDC,outpatient,30,GR,6.01,4.207,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLOTRIMAZOLE 1 % EX CREA,RX-1767,CDM,S5000,HCPCS,259,RC,45802-0434-11,NDC,outpatient,30,GR,10.42,7.294,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLOTRIMAZOLE 1 % EX SOLN,RX-1768,CDM,S5000,HCPCS,259,RC,51672-1260-03,NDC,outpatient,30,ML,97.86,68.502,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLOTRIMAZOLE 1 % VA CREA,RX-1769,CDM,S5000,HCPCS,259,RC,51672-2003-06,NDC,outpatient,45,GR,11.82,8.274,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS,RX-17837,CDM,S5000,HCPCS,259,RC,00173-0682-24,NDC,outpatient,8,GR,92.49,64.743,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS,RX-17837,CDM,S5000,HCPCS,259,RC,66993-0019-68,NDC,outpatient,18,GR,146.67,102.669,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS,RX-17837,CDM,S5000,HCPCS,259,RC,00093-3174-31,NDC,outpatient,8.5,GR,117.83,82.481,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BRIMONIDINE TARTRATE 0.2 % OP SOLN,RX-17881,CDM,S5000,HCPCS,259,RC,24208-0411-05,NDC,outpatient,5,ML,61.95,43.365,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BRIMONIDINE TARTRATE 0.2 % OP SOLN,RX-17881,CDM,S5000,HCPCS,259,RC,61314-0143-05,NDC,outpatient,5,ML,13.04,9.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BRIMONIDINE TARTRATE 0.2 % OP SOLN,RX-17881,CDM,S5000,HCPCS,259,RC,70069-0231-01,NDC,outpatient,5,ML,7.26,5.082,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BRIMONIDINE TARTRATE 0.2 % OP SOLN,RX-17881,CDM,S5000,HCPCS,259,RC,71921-0185-05,NDC,outpatient,5,ML,41.12,28.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
B COMPLEX ORAL CAPS,RX-17882,CDM,S5000,HCPCS,259,RC,54629-0560-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OLANZAPINE 5 MG ORAL TABS,RX-17936,CDM,S5000,HCPCS,259,RC,00904-6377-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DEXAMETHASONE 1 MG/ML ORAL CONC,RX-17946,CDM,S5000,HCPCS,259,RC,00054-3176-44,NDC,outpatient,30,ML,90.92,63.644,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ZAFIRLUKAST 20 MG ORAL TABS,RX-17960,CDM,S5000,HCPCS,259,RC,68084-0059-11,NDC,outpatient,1,UN,10.83,7.581,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ZAFIRLUKAST 20 MG ORAL TABS,RX-17960,CDM,S5000,HCPCS,259,RC,68084-0059-21,NDC,outpatient,1,UN,10.83,7.581,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMMONIUM LACTATE 12 % EX CREA,RX-17997,CDM,S5000,HCPCS,259,RC,45802-0513-77,NDC,outpatient,140,GR,35.52,24.864,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CODEINE SULFATE 15 MG ORAL TABS,RX-1801,CDM,S5000,HCPCS,259,RC,00054-0243-24,NDC,outpatient,1,UN,2.94,2.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SENNA 8.6 MG ORAL TABS,RX-18138,CDM,S5000,HCPCS,259,RC,00904-7252-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
COLCHICINE 0.6 MG ORAL TABS,RX-1821,CDM,S5000,HCPCS,259,RC,42292-0054-03,NDC,outpatient,1,UN,13.56,9.492,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
COLCHICINE 0.6 MG ORAL TABS,RX-1821,CDM,S5000,HCPCS,259,RC,65162-0710-09,NDC,outpatient,1,UN,2.83,1.981,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
COLCHICINE 0.6 MG ORAL TABS,RX-1821,CDM,S5000,HCPCS,259,RC,42292-0054-01,NDC,outpatient,1,UN,13.56,9.492,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BISOPROLOL FUMARATE 5 MG ORAL TABS,RX-18288,CDM,S5000,HCPCS,259,RC,29300-0126-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BISOPROLOL-HYDROCHLOROTHIAZIDE 10-6.25 MG ORAL TABS,RX-18289,CDM,S5000,HCPCS,259,RC,29300-0189-01,NDC,outpatient,1,UN,2.16,1.512,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BISOPROLOL-HYDROCHLOROTHIAZIDE 10-6.25 MG ORAL TABS,RX-18289,CDM,S5000,HCPCS,259,RC,10135-0742-30,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BISOPROLOL-HYDROCHLOROTHIAZIDE 5-6.25 MG ORAL TABS,RX-18290,CDM,S5000,HCPCS,259,RC,29300-0188-01,NDC,outpatient,1,UN,2.18,1.526,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BISOPROLOL-HYDROCHLOROTHIAZIDE 2.5-6.25 MG ORAL TABS,RX-18291,CDM,S5000,HCPCS,259,RC,68462-0878-30,NDC,outpatient,1,UN,1.61,1.127,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BISOPROLOL-HYDROCHLOROTHIAZIDE 2.5-6.25 MG ORAL TABS,RX-18291,CDM,S5000,HCPCS,259,RC,29300-0187-01,NDC,outpatient,1,UN,2.03,1.421,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TORSEMIDE 10 MG ORAL TABS,RX-18292,CDM,S5000,HCPCS,259,RC,50268-0755-11,NDC,outpatient,1,UN,1.14,0.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TORSEMIDE 10 MG ORAL TABS,RX-18292,CDM,S5000,HCPCS,259,RC,50268-0755-15,NDC,outpatient,1,UN,1.14,0.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,50268-0756-11,NDC,outpatient,1,UN,1.5,1.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,68084-0539-11,NDC,outpatient,1,UN,1.28,0.896,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,68084-0539-01,NDC,outpatient,1,UN,1.28,0.896,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,00054-0077-25,NDC,outpatient,1,UN,1.1,0.77,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,00054-0077-29,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,50268-0756-15,NDC,outpatient,1,UN,1.5,1.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TORSEMIDE 100 MG ORAL TABS,RX-18294,CDM,S5000,HCPCS,259,RC,50268-0757-11,NDC,outpatient,1,UN,1.64,1.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TORSEMIDE 100 MG ORAL TABS,RX-18294,CDM,S5000,HCPCS,259,RC,31722-0532-01,NDC,outpatient,1,UN,2.32,1.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TORSEMIDE 100 MG ORAL TABS,RX-18294,CDM,S5000,HCPCS,259,RC,50268-0757-15,NDC,outpatient,1,UN,1.64,1.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GABAPENTIN 400 MG ORAL CAPS,RX-18307,CDM,S5000,HCPCS,259,RC,00904-6667-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GABAPENTIN 400 MG ORAL CAPS,RX-18307,CDM,S5000,HCPCS,259,RC,63739-0904-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,16714-0662-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,60687-0591-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,00904-6666-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,45963-0556-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,60687-0591-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,63739-0903-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GABAPENTIN 100 MG ORAL CAPS,RX-18309,CDM,S5000,HCPCS,259,RC,60687-0580-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GABAPENTIN 100 MG ORAL CAPS,RX-18309,CDM,S5000,HCPCS,259,RC,60687-0580-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GABAPENTIN 100 MG ORAL CAPS,RX-18309,CDM,S5000,HCPCS,259,RC,00904-6665-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GABAPENTIN 100 MG ORAL CAPS,RX-18309,CDM,S5000,HCPCS,259,RC,63739-0902-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RISPERIDONE 2 MG ORAL TABS,RX-18311,CDM,S5000,HCPCS,259,RC,00904-7363-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RISPERIDONE 1 MG ORAL TABS,RX-18313,CDM,S5000,HCPCS,259,RC,00904-7362-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RISPERIDONE 1 MG ORAL TABS,RX-18313,CDM,S5000,HCPCS,259,RC,42291-0910-60,NDC,outpatient,1,UN,11.7,8.19,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPROPION HCL ER (SR) 100 MG ORAL TB12,RX-18385,CDM,S5000,HCPCS,259,RC,68084-0697-11,NDC,outpatient,1,UN,2.72,1.904,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPROPION HCL ER (SR) 100 MG ORAL TB12,RX-18385,CDM,S5000,HCPCS,259,RC,68084-0697-01,NDC,outpatient,1,UN,2.72,1.904,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPROPION HCL ER (SR) 150 MG ORAL TB12,RX-18386,CDM,S5000,HCPCS,259,RC,68084-0708-25,NDC,outpatient,1,UN,2.27,1.589,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPROPION HCL ER (SR) 150 MG ORAL TB12,RX-18386,CDM,S5000,HCPCS,259,RC,68084-0708-95,NDC,outpatient,1,UN,2.27,1.589,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
REMIFENTANIL HCL 1 MG IV SOLR,RX-18398,CDM,S5000,HCPCS,250,RC,00143-9391-01,NDC,outpatient,1,UN,164.07,114.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
REMIFENTANIL HCL 1 MG IV SOLR,RX-18398,CDM,S5000,HCPCS,250,RC,63323-0723-03,NDC,outpatient,1,UN,164.48,115.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
REMIFENTANIL HCL 1 MG IV SOLR,RX-18398,CDM,S5000,HCPCS,250,RC,00143-9391-10,NDC,outpatient,1,UN,164.07,114.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
REMIFENTANIL HCL 1 MG IV SOLR,RX-18398,CDM,S5000,HCPCS,250,RC,63323-0723-01,NDC,outpatient,1,UN,164.48,115.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CARVEDILOL 3.125 MG ORAL TABS,RX-18551,CDM,S5000,HCPCS,259,RC,00904-6300-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LATANOPROST 0.005 % OP SOLN,RX-18621,CDM,S5000,HCPCS,259,RC,61314-0547-01,NDC,outpatient,2.5,ML,19.1,13.37,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LATANOPROST 0.005 % OP SOLN,RX-18621,CDM,S5000,HCPCS,259,RC,59762-0333-02,NDC,outpatient,2.5,ML,18.92,13.244,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LATANOPROST 0.005 % OP SOLN,RX-18621,CDM,S5000,HCPCS,259,RC,24208-0463-25,NDC,outpatient,2.5,ML,46.77,32.739,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LATANOPROST 0.005 % OP SOLN,RX-18621,CDM,S5000,HCPCS,259,RC,70069-0421-01,NDC,outpatient,2.5,ML,19.9,13.93,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DONEPEZIL HCL 5 MG ORAL TABS,RX-18786,CDM,S5000,HCPCS,259,RC,00904-6477-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NITROPRUSSIDE SODIUM 25 MG/ML IV SOLN,RX-18908,CDM,S5000,HCPCS,250,RC,67457-0839-02,NDC,outpatient,2,ML,53.45,37.415,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NITROPRUSSIDE SODIUM 25 MG/ML IV SOLN,RX-18908,CDM,S5000,HCPCS,250,RC,72485-0105-01,NDC,outpatient,2,ML,69.91,48.937,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NITROPRUSSIDE SODIUM 25 MG/ML IV SOLN,RX-18908,CDM,S5000,HCPCS,250,RC,43598-0587-23,NDC,outpatient,2,ML,87.58,61.306,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVOFLOXACIN 250 MG ORAL TABS,RX-18918,CDM,S5000,HCPCS,259,RC,00904-6351-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVOFLOXACIN 500 MG ORAL TABS,RX-18919,CDM,S5000,HCPCS,259,RC,00904-6352-61,NDC,outpatient,1,UN,1.04,0.728,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TOPIRAMATE 25 MG ORAL TABS,RX-18920,CDM,S5000,HCPCS,259,RC,68084-0342-11,NDC,outpatient,1,UN,1.38,0.966,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TOPIRAMATE 25 MG ORAL TABS,RX-18920,CDM,S5000,HCPCS,259,RC,68084-0342-01,NDC,outpatient,1,UN,1.38,0.966,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TOPIRAMATE 100 MG ORAL TABS,RX-18922,CDM,S5000,HCPCS,259,RC,68084-0344-01,NDC,outpatient,1,UN,2.19,1.533,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TOPIRAMATE 100 MG ORAL TABS,RX-18922,CDM,S5000,HCPCS,259,RC,68084-0344-11,NDC,outpatient,1,UN,2.19,1.533,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ATORVASTATIN CALCIUM 10 MG ORAL TABS,RX-19176,CDM,S5000,HCPCS,259,RC,00904-6290-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ATORVASTATIN CALCIUM 20 MG ORAL TABS,RX-19178,CDM,S5000,HCPCS,259,RC,00904-6291-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AZELASTINE HCL 0.1 % NA SOLN,RX-19179,CDM,S5000,HCPCS,259,RC,60505-0833-05,NDC,outpatient,30,ML,24.97,17.479,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CABERGOLINE 0.5 MG ORAL TABS,RX-19226,CDM,S5000,HCPCS,259,RC,50742-0118-08,NDC,outpatient,1,UN,13.91,9.737,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CABERGOLINE 0.5 MG ORAL TABS,RX-19226,CDM,S5000,HCPCS,259,RC,23155-0823-73,NDC,outpatient,1,UN,8.36,5.852,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CABERGOLINE 0.5 MG ORAL TABS,RX-19226,CDM,S5000,HCPCS,259,RC,59762-1005-01,NDC,outpatient,1,UN,22.17,15.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PHENYLEPHRINE HCL 10 % OP SOLN,RX-19636,CDM,S5000,HCPCS,259,RC,70756-0614-30,NDC,outpatient,5,ML,178,124.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BENZOCAINE 20 % MT GEL,RX-19691,CDM,S5000,HCPCS,259,RC,10310-0566-20,NDC,outpatient,11.9,GR,20.34,14.238,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CARBACHOL 0.01 % IO SOLN,RX-19704,CDM,S5000,HCPCS,259,RC,00065-0023-15,NDC,outpatient,1.5,ML,66,46.2,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DIAZOXIDE 50 MG/ML ORAL SUSP,RX-19713,CDM,S5000,HCPCS,259,RC,00254-1010-19,NDC,outpatient,30,ML,1132.89,793.023,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DIAZOXIDE 50 MG/ML ORAL SUSP,RX-19713,CDM,S5000,HCPCS,259,RC,99999-0003-50,NDC,outpatient,1,ML,37.77,26.439,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DICLOFENAC SODIUM 0.1 % OP SOLN,RX-19714,CDM,S5000,HCPCS,259,RC,24208-0457-05,NDC,outpatient,5,ML,46.46,32.522,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DICLOFENAC SODIUM 0.1 % OP SOLN,RX-19714,CDM,S5000,HCPCS,259,RC,61314-0014-25,NDC,outpatient,2.5,ML,39.79,27.853,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLUOROMETHOLONE 0.25 % OP SUSP,RX-19722,CDM,S5000,HCPCS,259,RC,11980-0228-05,NDC,outpatient,5,ML,692.51,484.757,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP,RX-19736,CDM,S5000,HCPCS,250,RC,00009-0746-30,NDC,outpatient,1,ML,216.41,151.487,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP,RX-19736,CDM,S5000,HCPCS,250,RC,00548-5400-00,NDC,outpatient,1,ML,75.65,52.955,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METHYLCELLULOSE (LAXATIVE) 500 MG ORAL TABS,RX-19740,CDM,S5000,HCPCS,259,RC,49348-0541-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METHYLCELLULOSE (LAXATIVE) 500 MG ORAL TABS,RX-19740,CDM,S5000,HCPCS,259,RC,00135-0199-02,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OFLOXACIN 0.3 % OP SOLN,RX-19746,CDM,S5000,HCPCS,259,RC,60505-0560-00,NDC,outpatient,5,ML,32.22,22.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OFLOXACIN 0.3 % OP SOLN,RX-19746,CDM,S5000,HCPCS,259,RC,64980-0515-05,NDC,outpatient,5,ML,58.61,41.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POVIDONE-IODINE 5 % OP SOLN,RX-19791,CDM,S5000,HCPCS,259,RC,00065-0411-30,NDC,outpatient,30,ML,45.26,31.682,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NEOMYCIN-POLYMYXIN-PRAMOXINE 1 % EX CREA,RX-19880,CDM,S5000,HCPCS,259,RC,12547-0407-40,NDC,outpatient,14.2,GR,19.03,13.321,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SERTRALINE HCL 25 MG ORAL TABS,RX-19882,CDM,S5000,HCPCS,259,RC,60687-0231-01,NDC,outpatient,1,UN,1.26,0.882,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SERTRALINE HCL 25 MG ORAL TABS,RX-19882,CDM,S5000,HCPCS,259,RC,60687-0231-11,NDC,outpatient,1,UN,1.26,0.882,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NELFINAVIR MESYLATE 250 MG ORAL TABS,RX-20032,CDM,S5000,HCPCS,259,RC,63010-0010-30,NDC,outpatient,1,UN,17.47,12.229,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MESNA 400 MG ORAL TABS,RX-20077,CDM,S5000,HCPCS,259,RC,67108-3565-09,NDC,outpatient,1,UN,287.17,201.019,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CYANOCOBALAMIN 100 MCG ORAL TABS,RX-2008,CDM,S5000,HCPCS,259,RC,50268-0852-15,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CYANOCOBALAMIN 100 MCG ORAL TABS,RX-2008,CDM,S5000,HCPCS,259,RC,50268-0852-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CYCLOBENZAPRINE HCL 10 MG ORAL TABS,RX-2017,CDM,S5000,HCPCS,259,RC,60687-0558-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CYCLOBENZAPRINE HCL 10 MG ORAL TABS,RX-2017,CDM,S5000,HCPCS,259,RC,60687-0558-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CYCLOPENTOLATE HCL 1 % OP SOLN,RX-2025,CDM,S5000,HCPCS,259,RC,24208-0735-01,NDC,outpatient,2,ML,47.31,33.117,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CYCLOPENTOLATE HCL 1 % OP SOLN,RX-2025,CDM,S5000,HCPCS,259,RC,24208-0735-06,NDC,outpatient,15,ML,121.82,85.274,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CYPROHEPTADINE HCL 4 MG ORAL TABS,RX-2033,CDM,S5000,HCPCS,259,RC,50268-0189-11,NDC,outpatient,1,UN,2.94,2.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CYPROHEPTADINE HCL 4 MG ORAL TABS,RX-2033,CDM,S5000,HCPCS,259,RC,50268-0189-15,NDC,outpatient,1,UN,2.94,2.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CYSTEINE HCL 50 MG/ML IV SOLN,RX-2034,CDM,S5000,HCPCS,250,RC,51754-1007-01,NDC,outpatient,10,ML,375.94,263.158,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CYSTEINE HCL 50 MG/ML IV SOLN,RX-2034,CDM,S5000,HCPCS,250,RC,51754-1007-03,NDC,outpatient,10,ML,375.94,263.158,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ANAGRELIDE HCL 0.5 MG ORAL CAPS,RX-20446,CDM,S5000,HCPCS,259,RC,00172-5241-60,NDC,outpatient,1,UN,3.43,2.401,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ANAGRELIDE HCL 0.5 MG ORAL CAPS,RX-20446,CDM,S5000,HCPCS,259,RC,13668-0453-01,NDC,outpatient,1,UN,2.97,2.079,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,00143-9506-10,NDC,outpatient,10,ML,25.46,17.822,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,55150-0221-10,NDC,outpatient,10,ML,12.44,8.708,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,72266-0146-10,NDC,outpatient,10,ML,13.73,9.611,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,00143-9507-01,NDC,outpatient,20,ML,27.51,19.257,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,00143-9507-10,NDC,outpatient,20,ML,27.51,19.257,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,72266-0146-01,NDC,outpatient,10,ML,13.73,9.611,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,00143-9506-01,NDC,outpatient,10,ML,25.46,17.822,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MELOXICAM 7.5 MG ORAL TABS,RX-20566,CDM,S5000,HCPCS,259,RC,50268-0525-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MELOXICAM 7.5 MG ORAL TABS,RX-20566,CDM,S5000,HCPCS,259,RC,50268-0525-15,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PYRETHRINS-PIPERONYL BUTOXIDE 0.33-4 % EX LIQD,RX-20781,CDM,S5000,HCPCS,259,RC,49348-0443-34,NDC,outpatient,118,ML,21.53,15.071,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MIGLITOL 25 MG ORAL TABS,RX-20799,CDM,S5000,HCPCS,259,RC,69367-0303-01,NDC,outpatient,1,UN,7.35,5.145,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,63323-0494-01,NDC,outpatient,5,ML,9.31,6.517,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,00143-9785-01,NDC,outpatient,5,ML,20.56,14.392,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,00143-9785-10,NDC,outpatient,5,ML,20.56,14.392,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,63323-0494-05,NDC,outpatient,5,ML,9.31,6.517,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,70860-0784-05,NDC,outpatient,5,ML,10.16,7.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,70860-0784-41,NDC,outpatient,5,ML,10.16,7.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AZITHROMYCIN 250 MG ORAL TABS,RX-20943,CDM,S5000,HCPCS,259,RC,60687-0742-11,NDC,outpatient,1,UN,3.5,2.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AZITHROMYCIN 250 MG ORAL TABS,RX-20943,CDM,S5000,HCPCS,259,RC,65862-0641-63,NDC,outpatient,1,UN,1.45,1.015,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AZITHROMYCIN 250 MG ORAL TABS,RX-20943,CDM,S5000,HCPCS,259,RC,60687-0742-01,NDC,outpatient,1,UN,3.5,2.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVOCARNITINE 200 MG/ML IV SOLN,RX-20954,CDM,S5000,HCPCS,250,RC,00143-9852-01,NDC,outpatient,5,ML,94.7,66.29,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVOCARNITINE 200 MG/ML IV SOLN,RX-20954,CDM,S5000,HCPCS,250,RC,00143-9852-10,NDC,outpatient,5,ML,94.7,66.29,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVOCARNITINE 200 MG/ML IV SOLN,RX-20954,CDM,S5000,HCPCS,250,RC,54482-0147-01,NDC,outpatient,5,ML,99.51,69.657,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OLANZAPINE 2.5 MG ORAL TABS,RX-21057,CDM,S5000,HCPCS,259,RC,00904-6283-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXCARBAZEPINE 300 MG ORAL TABS,RX-21061,CDM,S5000,HCPCS,259,RC,60687-0722-01,NDC,outpatient,1,UN,2.53,1.771,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXCARBAZEPINE 300 MG ORAL TABS,RX-21061,CDM,S5000,HCPCS,259,RC,60687-0722-11,NDC,outpatient,1,UN,2.53,1.771,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXCARBAZEPINE 300 MG ORAL TABS,RX-21061,CDM,S5000,HCPCS,259,RC,62756-0184-88,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CITALOPRAM HYDROBROMIDE 20 MG ORAL TABS,RX-21062,CDM,S5000,HCPCS,259,RC,00904-6085-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMPHETAMINE-DEXTROAMPHETAMINE 5 MG ORAL TABS,RX-21284,CDM,S5000,HCPCS,259,RC,42806-0339-01,NDC,outpatient,1,UN,1.83,1.281,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PRAMIPEXOLE DIHYDROCHLORIDE 1 MG ORAL TABS,RX-21288,CDM,S5000,HCPCS,259,RC,60687-0592-11,NDC,outpatient,1,UN,3.34,2.338,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PRAMIPEXOLE DIHYDROCHLORIDE 1 MG ORAL TABS,RX-21288,CDM,S5000,HCPCS,259,RC,60687-0592-21,NDC,outpatient,1,UN,3.34,2.338,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PRAMIPEXOLE DIHYDROCHLORIDE 1.5 MG ORAL TABS,RX-21289,CDM,S5000,HCPCS,259,RC,68462-0334-90,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PRAMIPEXOLE DIHYDROCHLORIDE 0.25 MG ORAL TABS,RX-21290,CDM,S5000,HCPCS,259,RC,00904-6704-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PENTOXIFYLLINE ER 400 MG ORAL TBCR,RX-21300,CDM,S5000,HCPCS,259,RC,60505-0033-06,NDC,outpatient,1,UN,2.18,1.526,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PENTOXIFYLLINE ER 400 MG ORAL TBCR,RX-21300,CDM,S5000,HCPCS,259,RC,00904-5448-61,NDC,outpatient,1,UN,1.11,0.777,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DAPSONE 100 MG ORAL TABS,RX-2131,CDM,S5000,HCPCS,259,RC,70954-0136-10,NDC,outpatient,1,UN,5.05,3.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DAPSONE 25 MG ORAL TABS,RX-2132,CDM,S5000,HCPCS,259,RC,70954-0135-10,NDC,outpatient,1,UN,4.35,3.045,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LETROZOLE 2.5 MG ORAL TABS,RX-21509,CDM,S5000,HCPCS,259,RC,00078-0249-15,NDC,outpatient,1,UN,108.93,76.251,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LETROZOLE 2.5 MG ORAL TABS,RX-21509,CDM,S5000,HCPCS,259,RC,59651-0180-30,NDC,outpatient,1,UN,1.55,1.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CARMUSTINE IN POLIFEPROSAN 7.7 MG IL WAFR,RX-21672,CDM,S5000,HCPCS,250,RC,24338-0050-08,NDC,outpatient,8,UN,110831.48,77582.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ROPINIROLE HCL 0.25 MG ORAL TABS,RX-21688,CDM,S5000,HCPCS,259,RC,00904-6373-61,NDC,outpatient,1,UN,1.51,1.057,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ROPINIROLE HCL 1 MG ORAL TABS,RX-21689,CDM,S5000,HCPCS,259,RC,00904-6374-61,NDC,outpatient,1,UN,1.76,1.232,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ROPINIROLE HCL 2 MG ORAL TABS,RX-21690,CDM,S5000,HCPCS,259,RC,50268-0744-11,NDC,outpatient,1,UN,2.46,1.722,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ROPINIROLE HCL 2 MG ORAL TABS,RX-21690,CDM,S5000,HCPCS,259,RC,50268-0744-15,NDC,outpatient,1,UN,2.46,1.722,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
QUETIAPINE FUMARATE 25 MG ORAL TABS,RX-21823,CDM,S5000,HCPCS,259,RC,60687-0327-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
QUETIAPINE FUMARATE 25 MG ORAL TABS,RX-21823,CDM,S5000,HCPCS,259,RC,00904-6638-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
QUETIAPINE FUMARATE 25 MG ORAL TABS,RX-21823,CDM,S5000,HCPCS,259,RC,60687-0327-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
QUETIAPINE FUMARATE 100 MG ORAL TABS,RX-21824,CDM,S5000,HCPCS,259,RC,00904-6640-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TIAGABINE HCL 4 MG ORAL TABS,RX-21827,CDM,S5000,HCPCS,259,RC,62756-0224-83,NDC,outpatient,1,UN,16.11,11.277,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IRBESARTAN 150 MG ORAL TABS,RX-21848,CDM,S5000,HCPCS,259,RC,33342-0048-10,NDC,outpatient,1,UN,1.15,0.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IRBESARTAN 150 MG ORAL TABS,RX-21848,CDM,S5000,HCPCS,259,RC,31722-0730-90,NDC,outpatient,1,UN,1.91,1.337,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLOPIDOGREL BISULFATE 75 MG ORAL TABS,RX-22142,CDM,S5000,HCPCS,259,RC,00904-6294-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RALOXIFENE HCL 60 MG ORAL TABS,RX-22143,CDM,S5000,HCPCS,259,RC,60687-0266-11,NDC,outpatient,1,UN,23.4,16.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RALOXIFENE HCL 60 MG ORAL TABS,RX-22143,CDM,S5000,HCPCS,259,RC,60687-0266-21,NDC,outpatient,1,UN,23.4,16.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DILTIAZEM HCL 100 MG IV SOLR,RX-22156,CDM,S5000,HCPCS,250,RC,00409-4350-03,NDC,outpatient,1,UN,40.12,28.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DILTIAZEM HCL 100 MG IV SOLR,RX-22156,CDM,S5000,HCPCS,250,RC,00409-4350-13,NDC,outpatient,1,UN,40.12,28.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TOBRAMYCIN 300 MG/5ML IN NEBU,RX-22240,CDM,S5000,HCPCS,259,RC,70756-0604-44,NDC,outpatient,5,ML,19.47,13.629,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TOBRAMYCIN 300 MG/5ML IN NEBU,RX-22240,CDM,S5000,HCPCS,259,RC,68180-0962-56,NDC,outpatient,5,ML,27.71,19.397,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TOBRAMYCIN 300 MG/5ML IN NEBU,RX-22240,CDM,S5000,HCPCS,259,RC,70756-0604-56,NDC,outpatient,5,ML,19.47,13.629,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TOBRAMYCIN 300 MG/5ML IN NEBU,RX-22240,CDM,S5000,HCPCS,259,RC,68180-0962-04,NDC,outpatient,5,ML,27.71,19.397,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MUPIROCIN CALCIUM 2 % EX CREA,RX-22251,CDM,S5000,HCPCS,259,RC,68462-0564-17,NDC,outpatient,15,GR,861.28,602.896,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MUPIROCIN CALCIUM 2 % EX CREA,RX-22251,CDM,S5000,HCPCS,259,RC,51672-1370-01,NDC,outpatient,15,GR,62.62,43.834,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OFLOXACIN 0.3 % OT SOLN,RX-22257,CDM,S5000,HCPCS,259,RC,24208-0410-05,NDC,outpatient,5,ML,214.49,150.143,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OFLOXACIN 0.3 % OT SOLN,RX-22257,CDM,S5000,HCPCS,259,RC,70756-0609-15,NDC,outpatient,5,ML,31.29,21.903,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LACTASE 3000 UNITS ORAL TABS,RX-22469,CDM,S5000,HCPCS,259,RC,77333-0430-50,NDC,outpatient,1,UN,1.55,1.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LACTASE 3000 UNITS ORAL TABS,RX-22469,CDM,S5000,HCPCS,259,RC,00904-5224-52,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LACTASE 3000 UNITS ORAL TABS,RX-22469,CDM,S5000,HCPCS,259,RC,77333-0430-25,NDC,outpatient,1,UN,1.55,1.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MONTELUKAST SODIUM 10 MG ORAL TABS,RX-22509,CDM,S5000,HCPCS,259,RC,00904-6808-61,NDC,outpatient,1,UN,1.44,1.008,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MONTELUKAST SODIUM 10 MG ORAL TABS,RX-22509,CDM,S5000,HCPCS,259,RC,00904-6808-06,NDC,outpatient,1,UN,1.19,0.833,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MONTELUKAST SODIUM 5 MG ORAL CHEW,RX-22510,CDM,S5000,HCPCS,259,RC,50268-0574-11,NDC,outpatient,1,UN,2.8,1.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MONTELUKAST SODIUM 5 MG ORAL CHEW,RX-22510,CDM,S5000,HCPCS,259,RC,50268-0574-15,NDC,outpatient,1,UN,2.8,1.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML ORAL SUSP,RX-22560,CDM,S5000,HCPCS,259,RC,00121-0853-20,NDC,outpatient,20,ML,60.61,42.427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML ORAL SUSP,RX-22560,CDM,S5000,HCPCS,259,RC,00121-0853-40,NDC,outpatient,20,ML,60.61,42.427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML ORAL SUSP,RX-22560,CDM,S5000,HCPCS,259,RC,99999-0002-45,NDC,outpatient,20,ML,22.52,15.764,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
REPAGLINIDE 2 MG ORAL TABS,RX-22585,CDM,S5000,HCPCS,259,RC,65862-0672-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
REPAGLINIDE 1 MG ORAL TABS,RX-22586,CDM,S5000,HCPCS,259,RC,65862-0671-01,NDC,outpatient,1,UN,1.06,0.742,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POTASSIUM CITRATE-CITRIC ACID 1100-334 MG/5ML ORAL SOLN,RX-22646,CDM,S5000,HCPCS,259,RC,60258-0003-16,NDC,outpatient,10,ML,5.88,4.116,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POTASSIUM CITRATE-CITRIC ACID 1100-334 MG/5ML ORAL SOLN,RX-22646,CDM,S5000,HCPCS,259,RC,00121-0676-16,NDC,outpatient,15,ML,3.61,2.527,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POTASSIUM CITRATE-CITRIC ACID 1100-334 MG/5ML ORAL SOLN,RX-22646,CDM,S5000,HCPCS,259,RC,99999-0002-34,NDC,outpatient,15,ML,3.14,2.198,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
URSODIOL 250 MG ORAL TABS,RX-22660,CDM,S5000,HCPCS,259,RC,68462-0473-01,NDC,outpatient,1,UN,2.31,1.617,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
URSODIOL 250 MG ORAL TABS,RX-22660,CDM,S5000,HCPCS,259,RC,60687-0527-11,NDC,outpatient,1,UN,6.99,4.893,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
URSODIOL 250 MG ORAL TABS,RX-22660,CDM,S5000,HCPCS,259,RC,00904-6890-04,NDC,outpatient,1,UN,10.99,7.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
URSODIOL 250 MG ORAL TABS,RX-22660,CDM,S5000,HCPCS,259,RC,60687-0527-21,NDC,outpatient,1,UN,6.99,4.893,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DESIPRAMINE HCL 25 MG ORAL TABS,RX-2286,CDM,S5000,HCPCS,259,RC,50742-0113-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PAROXETINE HCL 10 MG/5ML ORAL SUSP,RX-22959,CDM,S5000,HCPCS,259,RC,70954-0319-10,NDC,outpatient,5,ML,32.69,22.883,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PAROXETINE HCL 10 MG/5ML ORAL SUSP,RX-22959,CDM,S5000,HCPCS,259,RC,99999-0001-34,NDC,outpatient,10,ML,72.98,51.086,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN,RX-22982,CDM,S5000,HCPCS,259,RC,65862-0946-01,NDC,outpatient,10,ML,89,62.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN,RX-22982,CDM,S5000,HCPCS,259,RC,71921-0226-10,NDC,outpatient,10,ML,45.39,31.773,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN,RX-22982,CDM,S5000,HCPCS,259,RC,82584-0605-10,NDC,outpatient,10,ML,996.05,697.235,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN,RX-22982,CDM,S5000,HCPCS,259,RC,70069-0051-01,NDC,outpatient,10,ML,38.99,27.293,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN,RX-22982,CDM,S5000,HCPCS,259,RC,24208-0486-10,NDC,outpatient,10,ML,45.62,31.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMOXICILLIN-POT CLAVULANATE 250-125 MG ORAL TABS,RX-22992,CDM,S5000,HCPCS,259,RC,00781-1874-31,NDC,outpatient,1,UN,6.58,4.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMOXICILLIN-POT CLAVULANATE 250-125 MG ORAL TABS,RX-22992,CDM,S5000,HCPCS,259,RC,42571-0160-30,NDC,outpatient,1,UN,9.65,6.755,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CAPECITABINE 500 MG ORAL TABS,RX-22994,CDM,S5000,HCPCS,259,RC,16729-0073-29,NDC,outpatient,1,UN,1.65,1.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CAPECITABINE 500 MG ORAL TABS,RX-22994,CDM,S5000,HCPCS,259,RC,00004-1101-50,NDC,outpatient,1,UN,195.05,136.535,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RISEDRONATE SODIUM 30 MG ORAL TABS,RX-23015,CDM,S5000,HCPCS,259,RC,00093-3100-56,NDC,outpatient,1,UN,220.55,154.385,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CAMPHOR-MENTHOL 0.5-0.5 % EX LOTN,RX-23063,CDM,S5000,HCPCS,259,RC,00536-1268-12,NDC,outpatient,222,ML,16.8,11.76,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CAMPHOR-MENTHOL 0.5-0.5 % EX LOTN,RX-23063,CDM,S5000,HCPCS,259,RC,46122-0573-10,NDC,outpatient,222,ML,11.13,7.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLINISOL SF 15 % IV SOLN,RX-23068,CDM,S5000,HCPCS,250,RC,00338-0502-06,NDC,outpatient,2000,ML,211.8,148.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLINIMIX E/DEXTROSE (5/15) 5 % IV SOLN,RX-23165,CDM,S5000,HCPCS,250,RC,00338-1123-04,NDC,outpatient,2000,ML,211.8,148.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLINIMIX E/DEXTROSE (5/15) 5 % IV SOLN,RX-23165,CDM,S5000,HCPCS,250,RC,00338-1147-03,NDC,outpatient,1000,ML,122.8,85.96,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DEXAMETHASONE 0.5 MG ORAL TABS,RX-2322,CDM,S5000,HCPCS,259,RC,00054-8179-25,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CANDESARTAN CILEXETIL 4 MG ORAL TABS,RX-23229,CDM,S5000,HCPCS,259,RC,33342-0114-07,NDC,outpatient,1,UN,5.64,3.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CANDESARTAN CILEXETIL 4 MG ORAL TABS,RX-23229,CDM,S5000,HCPCS,259,RC,62332-0341-90,NDC,outpatient,1,UN,4.08,2.856,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CANDESARTAN CILEXETIL 16 MG ORAL TABS,RX-23231,CDM,S5000,HCPCS,259,RC,33342-0116-07,NDC,outpatient,1,UN,4.6,3.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DEXAMETHASONE 1 MG ORAL TABS,RX-2324,CDM,S5000,HCPCS,259,RC,00054-8174-25,NDC,outpatient,1,UN,1.46,1.022,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DEXAMETHASONE 4 MG ORAL TABS,RX-2327,CDM,S5000,HCPCS,259,RC,66993-0730-51,NDC,outpatient,1,UN,4.47,3.129,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DEXAMETHASONE 4 MG ORAL TABS,RX-2327,CDM,S5000,HCPCS,259,RC,66993-0730-80,NDC,outpatient,1,UN,4.47,3.129,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DEXAMETHASONE 4 MG ORAL TABS,RX-2327,CDM,S5000,HCPCS,259,RC,00054-8175-25,NDC,outpatient,1,UN,4.2,2.94,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DEXAMETHASONE 6 MG ORAL TABS,RX-2328,CDM,S5000,HCPCS,259,RC,00054-8183-25,NDC,outpatient,1,UN,6.68,4.676,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DEXAMETHASONE SODIUM PHOSPHATE 0.1 % OP SOLN,RX-2335,CDM,S5000,HCPCS,259,RC,24208-0720-02,NDC,outpatient,5,ML,228.82,160.174,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE 4 % EX CREA,RX-23461,CDM,S5000,HCPCS,259,RC,00496-0882-05,NDC,outpatient,5,GR,12.51,8.757,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE 4 % EX CREA,RX-23461,CDM,S5000,HCPCS,259,RC,00496-0882-06,NDC,outpatient,5,GR,12.51,8.757,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE 4 % EX CREA,RX-23461,CDM,S5000,HCPCS,259,RC,39328-0024-30,NDC,outpatient,30,GR,40.32,28.224,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DEXTROSE 10 % IV SOLN,RX-2357,CDM,S5000,HCPCS,250,RC,00338-0023-02,NDC,outpatient,250,ML,25,17.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DEXTROSE 10 % IV SOLN,RX-2357,CDM,S5000,HCPCS,250,RC,00338-0023-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DEXTROSE 20 % IV SOLN,RX-2359,CDM,S5000,HCPCS,250,RC,00990-7935-19,NDC,outpatient,500,ML,62.73,43.911,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DEXTROSE 250 MG/ML IV SOLN,RX-2361,CDM,S5000,HCPCS,250,RC,00409-1775-10,NDC,outpatient,10,ML,57.77,40.439,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-6648-16,NDC,outpatient,50,ML,19.02,13.314,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,69374-0953-50,NDC,outpatient,50,ML,66.75,46.725,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,76329-3302-01,NDC,outpatient,50,ML,66.31,46.417,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-4902-64,NDC,outpatient,50,ML,59.41,41.587,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-6648-02,NDC,outpatient,50,ML,19.02,13.314,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-7517-16,NDC,outpatient,50,ML,31.82,22.274,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-4902-34,NDC,outpatient,50,ML,59.41,41.587,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-7517-66,NDC,outpatient,50,ML,58.08,40.656,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,69623-0201-39,NDC,outpatient,50,ML,93.45,65.415,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
EFAVIRENZ 200 MG ORAL CAPS,RX-23900,CDM,S5000,HCPCS,259,RC,64980-0407-09,NDC,outpatient,1,UN,33.64,23.548,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DIAZEPAM 2 MG ORAL TABS,RX-2404,CDM,S5000,HCPCS,259,RC,51079-0284-20,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DIAZEPAM 2 MG ORAL TABS,RX-2404,CDM,S5000,HCPCS,259,RC,00172-3925-60,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DIAZEPAM 2 MG ORAL TABS,RX-2404,CDM,S5000,HCPCS,259,RC,51079-0284-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DIAZEPAM 5 MG ORAL TABS,RX-2405,CDM,S5000,HCPCS,259,RC,51079-0285-20,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DIAZEPAM 5 MG ORAL TABS,RX-2405,CDM,S5000,HCPCS,259,RC,51079-0285-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MICONAZOLE NITRATE 4 % VA CREA,RX-24050,CDM,S5000,HCPCS,259,RC,63736-0442-01,NDC,outpatient,15,GR,44.73,31.311,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DICLOXACILLIN SODIUM 250 MG ORAL CAPS,RX-2414,CDM,S5000,HCPCS,259,RC,59651-0565-01,NDC,outpatient,1,UN,2.33,1.631,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DICLOXACILLIN SODIUM 250 MG ORAL CAPS,RX-2414,CDM,S5000,HCPCS,259,RC,00093-3123-01,NDC,outpatient,1,UN,2.5,1.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MIDAZOLAM HCL 2 MG/ML ORAL SYRP,RX-24176,CDM,S5000,HCPCS,259,RC,68094-0764-59,NDC,outpatient,5,ML,21.65,15.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MIDAZOLAM HCL 2 MG/ML ORAL SYRP,RX-24176,CDM,S5000,HCPCS,259,RC,68094-0764-62,NDC,outpatient,5,ML,21.65,15.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DICYCLOMINE HCL 10 MG ORAL CAPS,RX-2418,CDM,S5000,HCPCS,259,RC,60687-0369-01,NDC,outpatient,1,UN,1.75,1.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DICYCLOMINE HCL 10 MG ORAL CAPS,RX-2418,CDM,S5000,HCPCS,259,RC,60687-0369-11,NDC,outpatient,1,UN,1.75,1.225,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DICYCLOMINE HCL 20 MG ORAL TABS,RX-2420,CDM,S5000,HCPCS,259,RC,60687-0380-01,NDC,outpatient,1,UN,1.8,1.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DICYCLOMINE HCL 20 MG ORAL TABS,RX-2420,CDM,S5000,HCPCS,259,RC,60687-0380-11,NDC,outpatient,1,UN,1.8,1.26,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG ORAL TABS,RX-24216,CDM,S5000,HCPCS,259,RC,00536-1248-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG ORAL TABS,RX-24216,CDM,S5000,HCPCS,259,RC,60687-0622-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG ORAL TABS,RX-24216,CDM,S5000,HCPCS,259,RC,60687-0622-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG ORAL TABS,RX-24216,CDM,S5000,HCPCS,259,RC,63739-0432-02,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ISOSORBIDE MONONITRATE ER 60 MG ORAL TAB,RX-24268,CDM,S5000,HCPCS,259,RC,00904-6450-61,NDC,outpatient,1,UN,1.31,0.917,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TELMISARTAN 40 MG ORAL TABS,RX-24335,CDM,S5000,HCPCS,259,RC,00597-0040-37,NDC,outpatient,1,UN,19.23,13.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROCORTISONE-ACETIC ACID 1-2 % OT SOLN,RX-24385,CDM,S5000,HCPCS,259,RC,51672-3007-01,NDC,outpatient,10,ML,303.14,212.198,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ABACAVIR SULFATE 300 MG ORAL TABS,RX-24438,CDM,S5000,HCPCS,259,RC,00378-4105-91,NDC,outpatient,1,UN,13.01,9.107,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ABACAVIR SULFATE 300 MG ORAL TABS,RX-24438,CDM,S5000,HCPCS,259,RC,68084-0021-21,NDC,outpatient,1,UN,26.71,18.697,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ABACAVIR SULFATE 300 MG ORAL TABS,RX-24438,CDM,S5000,HCPCS,259,RC,68084-0021-11,NDC,outpatient,1,UN,26.71,18.697,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DIGOXIN 125 MCG ORAL TABS,RX-2444,CDM,S5000,HCPCS,259,RC,00904-5921-61,NDC,outpatient,1,UN,3.14,2.198,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXYBUTYNIN CHLORIDE ER 5 MG ORAL TB24,RX-24470,CDM,S5000,HCPCS,259,RC,68084-0480-11,NDC,outpatient,1,UN,4.79,3.353,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXYBUTYNIN CHLORIDE ER 5 MG ORAL TB24,RX-24470,CDM,S5000,HCPCS,259,RC,63739-0548-33,NDC,outpatient,1,UN,5.24,3.668,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXYBUTYNIN CHLORIDE ER 5 MG ORAL TB24,RX-24470,CDM,S5000,HCPCS,259,RC,00904-6570-61,NDC,outpatient,1,UN,5.08,3.556,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXYBUTYNIN CHLORIDE ER 5 MG ORAL TB24,RX-24470,CDM,S5000,HCPCS,259,RC,68084-0480-01,NDC,outpatient,1,UN,4.79,3.353,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXYBUTYNIN CHLORIDE ER 5 MG ORAL TB24,RX-24470,CDM,S5000,HCPCS,259,RC,00904-6570-04,NDC,outpatient,1,UN,7.7,5.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CILOSTAZOL 100 MG ORAL TABS,RX-24474,CDM,S5000,HCPCS,259,RC,50268-0177-15,NDC,outpatient,1,UN,3.18,2.226,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CILOSTAZOL 100 MG ORAL TABS,RX-24474,CDM,S5000,HCPCS,259,RC,50268-0177-11,NDC,outpatient,1,UN,3.18,2.226,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CELECOXIB 100 MG ORAL CAPS,RX-24500,CDM,S5000,HCPCS,259,RC,00904-6502-61,NDC,outpatient,1,UN,3.56,2.492,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CELECOXIB 100 MG ORAL CAPS,RX-24500,CDM,S5000,HCPCS,259,RC,60687-0436-11,NDC,outpatient,1,UN,3.16,2.212,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CELECOXIB 100 MG ORAL CAPS,RX-24500,CDM,S5000,HCPCS,259,RC,60687-0436-01,NDC,outpatient,1,UN,3.16,2.212,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CELECOXIB 200 MG ORAL CAPS,RX-24501,CDM,S5000,HCPCS,259,RC,00904-6503-61,NDC,outpatient,1,UN,5.49,3.843,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CELECOXIB 200 MG ORAL CAPS,RX-24501,CDM,S5000,HCPCS,259,RC,60505-3849-01,NDC,outpatient,1,UN,2.67,1.869,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ISOSORBIDE MONONITRATE ER 30 MG ORAL TB24,RX-24521,CDM,S5000,HCPCS,259,RC,00904-6449-61,NDC,outpatient,1,UN,1.08,0.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MODAFINIL 100 MG ORAL TABS,RX-24702,CDM,S5000,HCPCS,259,RC,50268-0570-11,NDC,outpatient,1,UN,25.83,18.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MODAFINIL 100 MG ORAL TABS,RX-24702,CDM,S5000,HCPCS,259,RC,50268-0570-12,NDC,outpatient,1,UN,25.83,18.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MODAFINIL 100 MG ORAL TABS,RX-24702,CDM,S5000,HCPCS,259,RC,68084-0621-11,NDC,outpatient,1,UN,21.38,14.966,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MODAFINIL 100 MG ORAL TABS,RX-24702,CDM,S5000,HCPCS,259,RC,68084-0621-21,NDC,outpatient,1,UN,21.38,14.966,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MODAFINIL 100 MG ORAL TABS,RX-24702,CDM,S5000,HCPCS,259,RC,00904-6791-04,NDC,outpatient,1,UN,21.38,14.966,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BELLADONNA ALKALOIDS-OPIUM 16.2-60 MG RE SUPP,RX-24731,CDM,S5000,HCPCS,259,RC,00574-7040-12,NDC,outpatient,1,UN,104.53,73.171,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DILTIAZEM HCL 30 MG ORAL TABS,RX-2475,CDM,S5000,HCPCS,259,RC,00093-0318-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DILTIAZEM HCL 30 MG ORAL TABS,RX-2475,CDM,S5000,HCPCS,259,RC,60687-0717-01,NDC,outpatient,1,UN,1.81,1.267,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DILTIAZEM HCL 30 MG ORAL TABS,RX-2475,CDM,S5000,HCPCS,259,RC,60687-0717-11,NDC,outpatient,1,UN,1.81,1.267,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DIMENHYDRINATE 50 MG ORAL TABS,RX-2485,CDM,S5000,HCPCS,259,RC,00904-2051-59,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TACROLIMUS 0.5 MG ORAL CAPS,RX-24914,CDM,S5000,HCPCS,259,RC,00904-6623-61,NDC,outpatient,1,UN,2.82,1.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU,RX-24915,CDM,S5000,HCPCS,259,RC,76204-0800-11,NDC,outpatient,3,ML,5.32,3.724,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU,RX-24915,CDM,S5000,HCPCS,259,RC,00093-4146-45,NDC,outpatient,3,ML,7.12,4.984,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU,RX-24915,CDM,S5000,HCPCS,259,RC,00093-4146-56,NDC,outpatient,3,ML,7.12,4.984,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU,RX-24915,CDM,S5000,HCPCS,259,RC,76204-0800-01,NDC,outpatient,3,ML,5.32,3.724,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVALBUTEROL HCL 1.25 MG/3ML IN NEBU,RX-24916,CDM,S5000,HCPCS,259,RC,76204-0900-11,NDC,outpatient,3,ML,5.47,3.829,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVALBUTEROL HCL 1.25 MG/3ML IN NEBU,RX-24916,CDM,S5000,HCPCS,259,RC,76204-0900-01,NDC,outpatient,3,ML,5.47,3.829,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,00378-8270-31,NDC,outpatient,3,ML,1.22,0.854,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,00487-9501-01,NDC,outpatient,3,ML,1.41,0.987,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,47335-0703-49,NDC,outpatient,3,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,47335-0703-52,NDC,outpatient,3,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,60687-0395-83,NDC,outpatient,3,ML,1.02,0.714,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,47335-0703-48,NDC,outpatient,3,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,00378-8270-55,NDC,outpatient,3,ML,1.22,0.854,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,60687-0395-79,NDC,outpatient,3,ML,1.02,0.714,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,76204-0200-01,NDC,outpatient,3,ML,1.18,0.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,76204-0200-60,NDC,outpatient,3,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL SUSR,RX-25005,CDM,S5000,HCPCS,259,RC,66689-0307-08,NDC,outpatient,160,ML,1111.44,778.008,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL SUSR,RX-25005,CDM,S5000,HCPCS,259,RC,99999-0002-21,NDC,outpatient,2.5,ML,69.2,48.44,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DIPHENHYDRAMINE HCL 25 MG ORAL CAPS,RX-2509,CDM,S5000,HCPCS,259,RC,00904-7237-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DIPHENHYDRAMINE HCL 12.5 MG/5ML ORAL SOLN,RX-2511,CDM,S5000,HCPCS,259,RC,00121-0489-00,NDC,outpatient,5,ML,15.4,10.78,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DIPHENHYDRAMINE HCL 12.5 MG/5ML ORAL SOLN,RX-2511,CDM,S5000,HCPCS,259,RC,00121-0489-05,NDC,outpatient,5,ML,15.4,10.78,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CIPROFLOXACIN HCL 250 MG ORAL TABS,RX-25118,CDM,S5000,HCPCS,259,RC,00143-9927-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CIPROFLOXACIN HCL 250 MG ORAL TABS,RX-25118,CDM,S5000,HCPCS,259,RC,62135-0308-01,NDC,outpatient,1,UN,12.1,8.47,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CIPROFLOXACIN HCL 250 MG ORAL TABS,RX-25118,CDM,S5000,HCPCS,259,RC,65862-0076-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DIPHENOXYLATE-ATROPINE 2.5-0.025 MG ORAL TABS,RX-2516,CDM,S5000,HCPCS,259,RC,00406-1236-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DIPHENOXYLATE-ATROPINE 2.5-0.025 MG ORAL TABS,RX-2516,CDM,S5000,HCPCS,259,RC,69315-0910-01,NDC,outpatient,1,UN,2.4,1.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALBUTEROL SULFATE 2 MG/5ML ORAL SYRP,RX-252,CDM,S5000,HCPCS,259,RC,00472-0825-16,NDC,outpatient,5,ML,1.24,0.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALBUTEROL SULFATE 2 MG/5ML ORAL SYRP,RX-252,CDM,S5000,HCPCS,259,RC,70752-0102-12,NDC,outpatient,5,ML,1.91,1.337,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALBUTEROL SULFATE 2 MG/5ML ORAL SYRP,RX-252,CDM,S5000,HCPCS,259,RC,99999-0003-98,NDC,outpatient,5,ML,1.34,0.938,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DIPYRIDAMOLE 25 MG ORAL TABS,RX-2528,CDM,S5000,HCPCS,259,RC,64980-0133-01,NDC,outpatient,1,UN,5.27,3.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALBUTEROL SULFATE 2 MG ORAL TABS,RX-253,CDM,S5000,HCPCS,259,RC,68084-0949-95,NDC,outpatient,1,UN,27.72,19.404,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALBUTEROL SULFATE 2 MG ORAL TABS,RX-253,CDM,S5000,HCPCS,259,RC,68084-0949-25,NDC,outpatient,1,UN,27.72,19.404,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DISOPYRAMIDE PHOSPHATE 100 MG ORAL CAPS,RX-2535,CDM,S5000,HCPCS,259,RC,00093-3127-01,NDC,outpatient,1,UN,5.28,3.696,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DISULFIRAM 250 MG ORAL TABS,RX-2540,CDM,S5000,HCPCS,259,RC,47781-0607-30,NDC,outpatient,1,UN,7.69,5.383,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POLYETHYLENE GLYCOL 3350 17 G ORAL PACK,RX-25424,CDM,S5000,HCPCS,259,RC,00904-6931-81,NDC,outpatient,1,UN,3.67,2.569,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POLYETHYLENE GLYCOL 3350 17 G ORAL PACK,RX-25424,CDM,S5000,HCPCS,259,RC,00904-6931-86,NDC,outpatient,1,UN,3.67,2.569,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POLYETHYLENE GLYCOL 3350 17 G ORAL PACK,RX-25424,CDM,S5000,HCPCS,259,RC,62559-0157-17,NDC,outpatient,1,UN,3.43,2.401,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POLYETHYLENE GLYCOL 3350 17 G ORAL PACK,RX-25424,CDM,S5000,HCPCS,259,RC,62559-0157-10,NDC,outpatient,1,UN,3.43,2.401,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DIVALPROEX SODIUM 125 MG ORAL TBEC,RX-2551,CDM,S5000,HCPCS,259,RC,60687-0211-21,NDC,outpatient,1,UN,3.46,2.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DIVALPROEX SODIUM 125 MG ORAL TBEC,RX-2551,CDM,S5000,HCPCS,259,RC,60687-0211-11,NDC,outpatient,1,UN,3.46,2.422,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RISPERIDONE 0.25 MG ORAL TABS,RX-25519,CDM,S5000,HCPCS,259,RC,68382-0112-14,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RISPERIDONE 0.25 MG ORAL TABS,RX-25519,CDM,S5000,HCPCS,259,RC,68084-0270-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RISPERIDONE 0.25 MG ORAL TABS,RX-25519,CDM,S5000,HCPCS,259,RC,68084-0270-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DIVALPROEX SODIUM 250 MG ORAL TBEC,RX-2552,CDM,S5000,HCPCS,259,RC,68084-0776-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DIVALPROEX SODIUM 250 MG ORAL TBEC,RX-2552,CDM,S5000,HCPCS,259,RC,68084-0776-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RISPERIDONE 0.5 MG ORAL TABS,RX-25520,CDM,S5000,HCPCS,259,RC,00904-7361-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PIOGLITAZONE HCL 15 MG ORAL TABS,RX-25528,CDM,S5000,HCPCS,259,RC,60687-0391-11,NDC,outpatient,1,UN,3.42,2.394,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PIOGLITAZONE HCL 15 MG ORAL TABS,RX-25528,CDM,S5000,HCPCS,259,RC,60687-0391-01,NDC,outpatient,1,UN,3.42,2.394,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DIVALPROEX SODIUM 500 MG ORAL TBEC,RX-2553,CDM,S5000,HCPCS,259,RC,00904-6861-90,NDC,outpatient,1,UN,1.2,0.84,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DIVALPROEX SODIUM 500 MG ORAL TBEC,RX-2553,CDM,S5000,HCPCS,259,RC,68084-0782-61,NDC,outpatient,1,UN,1.16,0.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DIVALPROEX SODIUM 500 MG ORAL TBEC,RX-2553,CDM,S5000,HCPCS,259,RC,68084-0782-11,NDC,outpatient,1,UN,1.16,0.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOCUSATE SODIUM 100 MG ORAL CAPS,RX-2566,CDM,S5000,HCPCS,259,RC,00904-7183-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOCUSATE SODIUM 100 MG ORAL CAPS,RX-2566,CDM,S5000,HCPCS,259,RC,00904-7280-60,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOCUSATE SODIUM 100 MG ORAL CAPS,RX-2566,CDM,S5000,HCPCS,259,RC,00904-7280-80,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IVERMECTIN 3 MG ORAL TABS,RX-25820,CDM,S5000,HCPCS,259,RC,42799-0806-01,NDC,outpatient,1,UN,14.59,10.213,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IVERMECTIN 3 MG ORAL TABS,RX-25820,CDM,S5000,HCPCS,259,RC,00006-0032-20,NDC,outpatient,1,UN,19.14,13.398,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOXEPIN HCL 10 MG ORAL CAPS,RX-2608,CDM,S5000,HCPCS,259,RC,00904-7052-61,NDC,outpatient,1,UN,2.19,1.533,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOXEPIN HCL 10 MG ORAL CAPS,RX-2608,CDM,S5000,HCPCS,259,RC,51079-0436-20,NDC,outpatient,1,UN,2.53,1.771,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOXEPIN HCL 10 MG ORAL CAPS,RX-2608,CDM,S5000,HCPCS,259,RC,51079-0436-01,NDC,outpatient,1,UN,2.53,1.771,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOXEPIN HCL 100 MG ORAL CAPS,RX-2609,CDM,S5000,HCPCS,259,RC,51079-0651-01,NDC,outpatient,1,UN,6.84,4.788,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOXEPIN HCL 100 MG ORAL CAPS,RX-2609,CDM,S5000,HCPCS,259,RC,00378-6410-01,NDC,outpatient,1,UN,5.48,3.836,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOXEPIN HCL 100 MG ORAL CAPS,RX-2609,CDM,S5000,HCPCS,259,RC,51079-0651-20,NDC,outpatient,1,UN,6.84,4.788,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOXEPIN HCL 25 MG ORAL CAPS,RX-2611,CDM,S5000,HCPCS,259,RC,51079-0437-01,NDC,outpatient,1,UN,2.89,2.023,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOXEPIN HCL 25 MG ORAL CAPS,RX-2611,CDM,S5000,HCPCS,259,RC,00378-3125-01,NDC,outpatient,1,UN,2.29,1.603,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOXEPIN HCL 25 MG ORAL CAPS,RX-2611,CDM,S5000,HCPCS,259,RC,51079-0437-20,NDC,outpatient,1,UN,2.89,2.023,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MUSCLE RUB 10-15 % EX CREA,RX-26210,CDM,S5000,HCPCS,259,RC,00536-1101-45,NDC,outpatient,85,GR,10.6,7.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MUSCLE RUB 10-15 % EX CREA,RX-26210,CDM,S5000,HCPCS,259,RC,57896-0116-03,NDC,outpatient,85,GR,10.97,7.679,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MUSCLE RUB 10-15 % EX CREA,RX-26210,CDM,S5000,HCPCS,259,RC,00536-1349-57,NDC,outpatient,85,GR,9.08,6.356,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,00143-9381-01,NDC,outpatient,1,UN,49.76,34.832,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,63323-0130-11,NDC,outpatient,1,UN,45.64,31.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,67457-0437-00,NDC,outpatient,1,UN,68.55,47.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,63323-0130-02,NDC,outpatient,1,UN,45.64,31.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,67457-0437-10,NDC,outpatient,1,UN,68.55,47.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,00143-9381-10,NDC,outpatient,1,UN,49.76,34.832,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,68382-0910-01,NDC,outpatient,1,UN,107.52,75.264,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,68382-0910-10,NDC,outpatient,1,UN,107.52,75.264,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PANTOPRAZOLE SODIUM 40 MG ORAL TBEC,RX-26225,CDM,S5000,HCPCS,259,RC,00904-6474-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PANTOPRAZOLE SODIUM 40 MG ORAL TBEC,RX-26225,CDM,S5000,HCPCS,259,RC,51079-0051-20,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PANTOPRAZOLE SODIUM 40 MG ORAL TBEC,RX-26225,CDM,S5000,HCPCS,259,RC,35573-0428-51,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PANTOPRAZOLE SODIUM 40 MG ORAL TBEC,RX-26225,CDM,S5000,HCPCS,259,RC,51079-0051-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PANTOPRAZOLE SODIUM 40 MG ORAL TBEC,RX-26225,CDM,S5000,HCPCS,259,RC,35573-0428-80,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOXYCYCLINE HYCLATE 100 MG ORAL TABS,RX-2625,CDM,S5000,HCPCS,259,RC,00904-0430-06,NDC,outpatient,1,UN,5.29,3.703,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOXYCYCLINE HYCLATE 100 MG ORAL TABS,RX-2625,CDM,S5000,HCPCS,259,RC,62584-0693-21,NDC,outpatient,1,UN,4.84,3.388,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOXYCYCLINE HYCLATE 100 MG ORAL TABS,RX-2625,CDM,S5000,HCPCS,259,RC,00143-2112-50,NDC,outpatient,1,UN,1.07,0.749,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOXYCYCLINE HYCLATE 100 MG ORAL TABS,RX-2625,CDM,S5000,HCPCS,259,RC,62584-0693-11,NDC,outpatient,1,UN,4.84,3.388,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CARBIDOPA-LEVODOPA ER 50-200 MG ORAL TBCR,RX-26371,CDM,S5000,HCPCS,259,RC,68084-0282-11,NDC,outpatient,1,UN,4.16,2.912,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CARBIDOPA-LEVODOPA ER 50-200 MG ORAL TBCR,RX-26371,CDM,S5000,HCPCS,259,RC,68084-0282-01,NDC,outpatient,1,UN,4.16,2.912,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAPS,RX-26546,CDM,S5000,HCPCS,259,RC,64380-0799-01,NDC,outpatient,1,UN,8.24,5.768,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAPS,RX-26546,CDM,S5000,HCPCS,259,RC,31722-0632-31,NDC,outpatient,1,UN,4.28,2.996,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ENTACAPONE 200 MG ORAL TABS,RX-26547,CDM,S5000,HCPCS,259,RC,60687-0188-11,NDC,outpatient,1,UN,18.43,12.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ENTACAPONE 200 MG ORAL TABS,RX-26547,CDM,S5000,HCPCS,259,RC,27241-0049-10,NDC,outpatient,1,UN,2.4,1.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ENTACAPONE 200 MG ORAL TABS,RX-26547,CDM,S5000,HCPCS,259,RC,60687-0188-21,NDC,outpatient,1,UN,18.43,12.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
EXEMESTANE 25 MG ORAL TABS,RX-26551,CDM,S5000,HCPCS,259,RC,59762-2858-01,NDC,outpatient,1,UN,6.65,4.655,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVETIRACETAM 500 MG ORAL TABS,RX-26817,CDM,S5000,HCPCS,259,RC,65862-0246-08,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVETIRACETAM 500 MG ORAL TABS,RX-26817,CDM,S5000,HCPCS,259,RC,00904-7124-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MOXIFLOXACIN HCL 400 MG ORAL TABS,RX-26854,CDM,S5000,HCPCS,259,RC,65862-0603-30,NDC,outpatient,1,UN,13.67,9.569,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOFETILIDE 125 MCG ORAL CAPS,RX-26965,CDM,S5000,HCPCS,259,RC,16729-0490-12,NDC,outpatient,1,UN,6.58,4.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOFETILIDE 125 MCG ORAL CAPS,RX-26965,CDM,S5000,HCPCS,259,RC,69452-0131-17,NDC,outpatient,1,UN,2.23,1.561,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOFETILIDE 125 MCG ORAL CAPS,RX-26965,CDM,S5000,HCPCS,259,RC,72205-0039-60,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOFETILIDE 250 MCG ORAL CAPS,RX-26966,CDM,S5000,HCPCS,259,RC,00904-6682-08,NDC,outpatient,1,UN,13.18,9.226,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOFETILIDE 250 MCG ORAL CAPS,RX-26966,CDM,S5000,HCPCS,259,RC,42291-0412-60,NDC,outpatient,1,UN,1.48,1.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOFETILIDE 250 MCG ORAL CAPS,RX-26966,CDM,S5000,HCPCS,259,RC,69452-0132-17,NDC,outpatient,1,UN,2.23,1.561,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOFETILIDE 500 MCG ORAL CAPS,RX-26967,CDM,S5000,HCPCS,259,RC,42291-0413-60,NDC,outpatient,1,UN,1.4,0.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOFETILIDE 500 MCG ORAL CAPS,RX-26967,CDM,S5000,HCPCS,259,RC,00904-6683-08,NDC,outpatient,1,UN,13.31,9.317,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TERBINAFINE HCL 1 % EX CREA,RX-27023,CDM,S5000,HCPCS,259,RC,51672-2080-01,NDC,outpatient,15,GR,24.57,17.199,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREDNISOLONE ACETATE 0.12 % OP SUSP,RX-27038,CDM,S5000,HCPCS,259,RC,11980-0174-05,NDC,outpatient,5,ML,659.54,461.678,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXCARBAZEPINE 150 MG ORAL TABS,RX-27049,CDM,S5000,HCPCS,259,RC,60687-0711-11,NDC,outpatient,1,UN,1.81,1.267,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXCARBAZEPINE 150 MG ORAL TABS,RX-27049,CDM,S5000,HCPCS,259,RC,60687-0711-01,NDC,outpatient,1,UN,1.81,1.267,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CHARCOAL ACTIVATED ORAL LIQD,RX-27099,CDM,S5000,HCPCS,259,RC,66689-0202-04,NDC,outpatient,120,ML,82.77,57.939,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RISEDRONATE SODIUM 5 MG ORAL TABS,RX-27112,CDM,S5000,HCPCS,259,RC,33342-0107-07,NDC,outpatient,1,UN,11.13,7.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NIACIN ER (ANTIHYPERLIPIDEMIC) 500 MG ORAL TBCR,RX-27181,CDM,S5000,HCPCS,259,RC,59651-0018-90,NDC,outpatient,1,UN,1.7,1.19,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NIACIN ER (ANTIHYPERLIPIDEMIC) 500 MG ORAL TBCR,RX-27181,CDM,S5000,HCPCS,259,RC,47335-0539-81,NDC,outpatient,1,UN,1.02,0.714,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MAGNESIUM SULFATE (LAXATIVE) ORAL GRAN,RX-27322,CDM,S5000,HCPCS,259,RC,70677-1210-01,NDC,outpatient,454,GR,8.09,5.663,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MAGNESIUM SULFATE (LAXATIVE) ORAL GRAN,RX-27322,CDM,S5000,HCPCS,259,RC,49580-0394-04,NDC,outpatient,1814,GR,16.15,11.305,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MAGNESIUM SULFATE (LAXATIVE) ORAL GRAN,RX-27322,CDM,S5000,HCPCS,259,RC,70677-0038-01,NDC,outpatient,454,GR,8.09,5.663,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MINERAL OIL LIGHT OIL,RX-27386,CDM,S5000,HCPCS,259,RC,63323-0254-10,NDC,outpatient,10,ML,39.03,27.321,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MINERAL OIL LIGHT OIL,RX-27386,CDM,S5000,HCPCS,259,RC,63323-0254-02,NDC,outpatient,2,ML,34.38,24.066,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
THEOPHYLLINE ER 100 MG ORAL CP24,RX-27418,CDM,S5000,HCPCS,259,RC,52244-0100-10,NDC,outpatient,1,UN,14.48,10.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PENTAMIDINE ISETHIONATE 300 MG IJ SOLR,RX-27430,CDM,S5000,HCPCS,250,RC,63323-0113-10,NDC,outpatient,1,UN,686.14,480.298,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DINOPROSTONE 10 MG VA INST,RX-27467,CDM,S5000,HCPCS,259,RC,55566-2800-01,NDC,outpatient,1,UN,2100.63,1470.441,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NITROGLYCERIN 0.1 MG/HR TD PT24,RX-27471,CDM,S5000,HCPCS,259,RC,00378-9102-16,NDC,outpatient,1,UN,2.47,1.729,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NITROGLYCERIN 0.1 MG/HR TD PT24,RX-27471,CDM,S5000,HCPCS,259,RC,00378-9102-93,NDC,outpatient,1,UN,2.47,1.729,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NITROGLYCERIN 0.2 MG/HR TD PT24,RX-27472,CDM,S5000,HCPCS,259,RC,00378-9104-16,NDC,outpatient,1,UN,2.2,1.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NITROGLYCERIN 0.2 MG/HR TD PT24,RX-27472,CDM,S5000,HCPCS,259,RC,00378-9104-93,NDC,outpatient,1,UN,2.2,1.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NITROGLYCERIN 0.3 MG/HR TD PT24,RX-27473,CDM,S5000,HCPCS,259,RC,50742-0515-01,NDC,outpatient,1,UN,217.89,152.523,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NITROGLYCERIN 0.3 MG/HR TD PT24,RX-27473,CDM,S5000,HCPCS,259,RC,50742-0515-30,NDC,outpatient,1,UN,217.89,152.523,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NITROGLYCERIN 0.4 MG/HR TD PT24,RX-27474,CDM,S5000,HCPCS,259,RC,00378-9112-93,NDC,outpatient,1,UN,2.77,1.939,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NITROGLYCERIN 0.4 MG/HR TD PT24,RX-27474,CDM,S5000,HCPCS,259,RC,43598-0894-30,NDC,outpatient,1,UN,9.32,6.524,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NITROGLYCERIN 0.4 MG/HR TD PT24,RX-27474,CDM,S5000,HCPCS,259,RC,00378-9112-16,NDC,outpatient,1,UN,2.77,1.939,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NITROGLYCERIN 0.6 MG/HR TD PT24,RX-27475,CDM,S5000,HCPCS,259,RC,00378-9116-93,NDC,outpatient,1,UN,3.17,2.219,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NITROGLYCERIN 0.6 MG/HR TD PT24,RX-27475,CDM,S5000,HCPCS,259,RC,00378-9116-16,NDC,outpatient,1,UN,3.17,2.219,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FELODIPINE ER 2.5 MG ORAL TB24,RX-27489,CDM,S5000,HCPCS,259,RC,00603-3581-21,NDC,outpatient,1,UN,1.73,1.211,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FELODIPINE ER 2.5 MG ORAL TB24,RX-27489,CDM,S5000,HCPCS,259,RC,68462-0233-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FELODIPINE ER 2.5 MG ORAL TB24,RX-27489,CDM,S5000,HCPCS,259,RC,13668-0132-01,NDC,outpatient,1,UN,1.96,1.372,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DM-GUAIFENESIN ER 30-600 MG ORAL TB12,RX-27543,CDM,S5000,HCPCS,259,RC,63824-0056-34,NDC,outpatient,1,UN,1.93,1.351,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DM-GUAIFENESIN ER 30-600 MG ORAL TB12,RX-27543,CDM,S5000,HCPCS,259,RC,00536-1161-37,NDC,outpatient,1,UN,1.77,1.239,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DIVALPROEX SODIUM 125 MG ORAL CSDR,RX-27631,CDM,S5000,HCPCS,259,RC,68382-0106-01,NDC,outpatient,1,UN,1.55,1.085,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DIVALPROEX SODIUM 125 MG ORAL CSDR,RX-27631,CDM,S5000,HCPCS,259,RC,68084-0313-11,NDC,outpatient,1,UN,3.24,2.268,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DIVALPROEX SODIUM 125 MG ORAL CSDR,RX-27631,CDM,S5000,HCPCS,259,RC,68084-0313-01,NDC,outpatient,1,UN,3.24,2.268,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CARBAMAZEPINE ER 200 MG ORAL CP12,RX-27632,CDM,S5000,HCPCS,259,RC,50268-0171-13,NDC,outpatient,1,UN,7.06,4.942,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CARBAMAZEPINE ER 200 MG ORAL CP12,RX-27632,CDM,S5000,HCPCS,259,RC,50268-0171-11,NDC,outpatient,1,UN,7.06,4.942,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CARBAMAZEPINE ER 300 MG ORAL CP12,RX-27633,CDM,S5000,HCPCS,259,RC,66993-0409-32,NDC,outpatient,1,UN,5.66,3.962,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CARBAMAZEPINE ER 100 MG ORAL TB12,RX-27634,CDM,S5000,HCPCS,259,RC,51672-4123-01,NDC,outpatient,1,UN,1.04,0.728,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CARBAMAZEPINE ER 400 MG ORAL TB12,RX-27636,CDM,S5000,HCPCS,259,RC,51672-4125-01,NDC,outpatient,1,UN,2.24,1.568,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ASPIRIN-DIPYRIDAMOLE ER 25-200 MG ORAL CP12,RX-27644,CDM,S5000,HCPCS,259,RC,49884-0007-02,NDC,outpatient,1,UN,22.19,15.533,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ASPIRIN-DIPYRIDAMOLE ER 25-200 MG ORAL CP12,RX-27644,CDM,S5000,HCPCS,259,RC,68462-0405-60,NDC,outpatient,1,UN,2.36,1.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NIFEDIPINE ER OSMOTIC RELEASE 60 MG ORAL TB24,RX-27659,CDM,S5000,HCPCS,259,RC,68084-0598-01,NDC,outpatient,1,UN,8.9,6.23,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NIFEDIPINE ER OSMOTIC RELEASE 60 MG ORAL TB24,RX-27659,CDM,S5000,HCPCS,259,RC,68084-0598-11,NDC,outpatient,1,UN,8.9,6.23,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NIFEDIPINE ER OSMOTIC RELEASE 90 MG ORAL TB24,RX-27660,CDM,S5000,HCPCS,259,RC,68084-0603-21,NDC,outpatient,1,UN,11.24,7.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NIFEDIPINE ER OSMOTIC RELEASE 90 MG ORAL TB24,RX-27660,CDM,S5000,HCPCS,259,RC,62175-0262-37,NDC,outpatient,1,UN,9.51,6.657,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NIFEDIPINE ER OSMOTIC RELEASE 90 MG ORAL TB24,RX-27660,CDM,S5000,HCPCS,259,RC,68084-0603-11,NDC,outpatient,1,UN,11.24,7.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLUORESCEIN SODIUM 1 MG OP STRP,RX-27663,CDM,S5000,HCPCS,259,RC,17238-0900-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TROLAMINE SALICYLATE 10 % EX CREA,RX-27680,CDM,S5000,HCPCS,259,RC,41167-0057-24,NDC,outpatient,141,GR,30.75,21.525,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DESMOPRESSIN ACE SPRAY REFRIG 0.01 % NA SOLN,RX-27770,CDM,S5000,HCPCS,259,RC,24208-0342-05,NDC,outpatient,5,ML,655.13,458.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ZONISAMIDE 100 MG ORAL CAPS,RX-27780,CDM,S5000,HCPCS,259,RC,50268-0816-15,NDC,outpatient,1,UN,2.24,1.568,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ZONISAMIDE 100 MG ORAL CAPS,RX-27780,CDM,S5000,HCPCS,259,RC,50268-0816-11,NDC,outpatient,1,UN,2.24,1.568,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00264-1800-32,NDC,outpatient,100,ML,28.85,20.195,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-9543-02,NDC,outpatient,250,ML,25,17.5,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-9543-04,NDC,outpatient,500,ML,26.7,18.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-02,NDC,outpatient,250,ML,22.43,15.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-48,NDC,outpatient,100,ML,22.69,15.883,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00487-4301-10,NDC,outpatient,100,ML,28.85,20.195,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-03,NDC,outpatient,500,ML,23.71,16.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-04,NDC,outpatient,1000,ML,21.14,14.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-38,NDC,outpatient,100,ML,22.17,15.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-41,NDC,outpatient,50,ML,22.94,16.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,,,outpatient,500,ML,21.14,14.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-31,NDC,outpatient,50,ML,22.43,15.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00409-7101-67,NDC,outpatient,100,ML,25.77,18.039,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VENLAFAXINE HCL ER 37.5 MG ORAL CP24,RX-27857,CDM,S5000,HCPCS,259,RC,68084-0698-01,NDC,outpatient,1,UN,2.07,1.449,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VENLAFAXINE HCL ER 37.5 MG ORAL CP24,RX-27857,CDM,S5000,HCPCS,259,RC,68084-0698-11,NDC,outpatient,1,UN,2.07,1.449,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VENLAFAXINE HCL ER 75 MG ORAL CP24,RX-27858,CDM,S5000,HCPCS,259,RC,00904-7077-61,NDC,outpatient,1,UN,1.54,1.078,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VENLAFAXINE HCL ER 75 MG ORAL CP24,RX-27858,CDM,S5000,HCPCS,259,RC,68084-0709-01,NDC,outpatient,1,UN,2.26,1.582,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VENLAFAXINE HCL ER 75 MG ORAL CP24,RX-27858,CDM,S5000,HCPCS,259,RC,68084-0709-11,NDC,outpatient,1,UN,2.26,1.582,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NICOTINE 7 MG/24HR TD PT24,RX-27860,CDM,S5000,HCPCS,259,RC,43598-0446-74,NDC,outpatient,1,UN,4.78,3.346,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NICOTINE 14 MG/24HR TD PT24,RX-27862,CDM,S5000,HCPCS,259,RC,43598-0447-74,NDC,outpatient,1,UN,5.28,3.696,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NICOTINE 21 MG/24HR TD PT24,RX-27863,CDM,S5000,HCPCS,259,RC,43598-0448-28,NDC,outpatient,1,UN,5.25,3.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NICOTINE 21 MG/24HR TD PT24,RX-27863,CDM,S5000,HCPCS,259,RC,43598-0448-74,NDC,outpatient,1,UN,4.94,3.458,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NICOTINE 21 MG/24HR TD PT24,RX-27863,CDM,S5000,HCPCS,259,RC,00536-5896-88,NDC,outpatient,1,UN,7.5,5.25,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NICOTINE 21 MG/24HR TD PT24,RX-27863,CDM,S5000,HCPCS,259,RC,00536-5896-33,NDC,outpatient,1,UN,7.5,5.25,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE VISCOUS HCL 2 % MT SOLN,RX-27898,CDM,S5000,HCPCS,259,RC,99999-0002-05,NDC,outpatient,15,ML,60.48,42.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE VISCOUS HCL 2 % MT SOLN,RX-27898,CDM,S5000,HCPCS,259,RC,62135-0712-42,NDC,outpatient,5,ML,20.16,14.112,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE VISCOUS HCL 2 % MT SOLN,RX-27898,CDM,S5000,HCPCS,259,RC,00054-3500-49,NDC,outpatient,5,ML,2.23,1.561,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE VISCOUS HCL 2 % MT SOLN,RX-27898,CDM,S5000,HCPCS,259,RC,72888-0125-26,NDC,outpatient,5,ML,2.5,1.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FENTANYL 25 MCG/HR TD PT72,RX-27905,CDM,S5000,HCPCS,259,RC,47781-0424-11,NDC,outpatient,1,UN,17.49,12.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FENTANYL 25 MCG/HR TD PT72,RX-27905,CDM,S5000,HCPCS,259,RC,47781-0424-47,NDC,outpatient,1,UN,17.49,12.243,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FENTANYL 50 MCG/HR TD PT72,RX-27906,CDM,S5000,HCPCS,259,RC,00378-9122-98,NDC,outpatient,1,UN,37.78,26.446,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FENTANYL 50 MCG/HR TD PT72,RX-27906,CDM,S5000,HCPCS,259,RC,47781-0426-47,NDC,outpatient,1,UN,25.49,17.843,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FENTANYL 50 MCG/HR TD PT72,RX-27906,CDM,S5000,HCPCS,259,RC,00378-9122-16,NDC,outpatient,1,UN,37.78,26.446,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FENTANYL 50 MCG/HR TD PT72,RX-27906,CDM,S5000,HCPCS,259,RC,47781-0426-11,NDC,outpatient,1,UN,25.49,17.843,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FENTANYL 75 MCG/HR TD PT72,RX-27907,CDM,S5000,HCPCS,259,RC,47781-0427-11,NDC,outpatient,1,UN,37.66,26.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FENTANYL 75 MCG/HR TD PT72,RX-27907,CDM,S5000,HCPCS,259,RC,47781-0427-47,NDC,outpatient,1,UN,37.66,26.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FENTANYL 100 MCG/HR TD PT72,RX-27908,CDM,S5000,HCPCS,259,RC,00378-9124-16,NDC,outpatient,1,UN,93.74,65.618,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FENTANYL 100 MCG/HR TD PT72,RX-27908,CDM,S5000,HCPCS,259,RC,00378-9124-98,NDC,outpatient,1,UN,93.74,65.618,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
EMPTY STERILIZED CONTAINER,RX-2795,CDM,S5000,HCPCS,250,RC,63323-0001-10,NDC,outpatient,1,UN,3.99,2.793,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
EMPTY STERILIZED CONTAINER,RX-2795,CDM,S5000,HCPCS,250,RC,63323-0001-30,NDC,outpatient,1,UN,4.71,3.297,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM POLYSTYRENE SULFONATE 15 GM/60ML ORAL SUSP,RX-27999,CDM,S5000,HCPCS,259,RC,46287-0006-60,NDC,outpatient,60,ML,91.85,64.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SERTRALINE HCL 20 MG/ML ORAL CONC,RX-28011,CDM,S5000,HCPCS,259,RC,16714-0601-02,NDC,outpatient,2.5,ML,10.37,7.259,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SERTRALINE HCL 20 MG/ML ORAL CONC,RX-28011,CDM,S5000,HCPCS,259,RC,99999-0003-51,NDC,outpatient,2.5,ML,10.37,7.259,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FE FUMARATE-B12-VIT C-FA-IFC ORAL CAPS,RX-28030,CDM,S5000,HCPCS,259,RC,51991-0635-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BENZOCAINE-MENTHOL 20-0.5 % EX AERO,RX-28048,CDM,S5000,HCPCS,259,RC,16864-0680-01,NDC,outpatient,78,GR,22.91,16.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BENZOCAINE-MENTHOL 20-0.5 % EX AERO,RX-28048,CDM,S5000,HCPCS,259,RC,16864-0680-02,NDC,outpatient,56,GR,17.7,12.39,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ASPIRIN BUF(CACARB-MGCARB-MGO) 325 MG ORAL TABS,RX-28122,CDM,S5000,HCPCS,259,RC,00904-2015-59,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,55111-0262-79,NDC,outpatient,1,UN,3.06,2.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,60505-3275-00,NDC,outpatient,1,UN,1.9,1.33,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,00093-5245-65,NDC,outpatient,1,UN,2.89,2.023,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,33342-0083-07,NDC,outpatient,1,UN,3.81,2.667,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,55111-0262-81,NDC,outpatient,1,UN,3.06,2.142,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,00093-5245-19,NDC,outpatient,1,UN,2.89,2.023,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OLANZAPINE 10 MG ORAL TBDP,RX-28160,CDM,S5000,HCPCS,259,RC,49884-0321-55,NDC,outpatient,1,UN,2.45,1.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OLANZAPINE 10 MG ORAL TBDP,RX-28160,CDM,S5000,HCPCS,259,RC,49884-0321-52,NDC,outpatient,1,UN,2.45,1.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LINEZOLID 600 MG ORAL TABS,RX-28224,CDM,S5000,HCPCS,259,RC,00904-6553-04,NDC,outpatient,1,UN,7.73,5.411,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LINEZOLID 600 MG ORAL TABS,RX-28224,CDM,S5000,HCPCS,259,RC,67877-0419-33,NDC,outpatient,1,UN,7.42,5.194,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LINEZOLID 600 MG ORAL TABS,RX-28224,CDM,S5000,HCPCS,259,RC,67877-0419-84,NDC,outpatient,1,UN,7.42,5.194,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LINEZOLID 100 MG/5ML ORAL SUSR,RX-28225,CDM,S5000,HCPCS,259,RC,59762-1308-04,NDC,outpatient,150,ML,1694.12,1185.884,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LINEZOLID 100 MG/5ML ORAL SUSR,RX-28225,CDM,S5000,HCPCS,259,RC,99999-0002-85,NDC,outpatient,30,ML,340.43,238.301,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PENTAMIDINE ISETHIONATE 300 MG IN SOLR,RX-28235,CDM,S5000,HCPCS,259,RC,63323-0877-15,NDC,outpatient,1,UN,686.24,480.368,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RIVASTIGMINE TARTRATE 1.5 MG ORAL CAPS,RX-28278,CDM,S5000,HCPCS,259,RC,00904-7107-61,NDC,outpatient,1,UN,10.27,7.189,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RIVASTIGMINE TARTRATE 3 MG ORAL CAPS,RX-28279,CDM,S5000,HCPCS,259,RC,55111-0353-60,NDC,outpatient,1,UN,2.6,1.82,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
INSULIN GLARGINE 100 UNIT/ML SC SOLN,RX-28282,CDM,S5000,HCPCS,259,RC,00088-2220-33,NDC,outpatient,10,ML,252.19,176.533,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
COLESEVELAM HCL 625 MG ORAL TABS,RX-28372,CDM,S5000,HCPCS,259,RC,60687-0385-95,NDC,outpatient,1,UN,13.08,9.156,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
COLESEVELAM HCL 625 MG ORAL TABS,RX-28372,CDM,S5000,HCPCS,259,RC,60687-0385-25,NDC,outpatient,1,UN,13.08,9.156,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROCODONE-ACETAMINOPHEN 10-325 MG ORAL TABS,RX-28384,CDM,S5000,HCPCS,259,RC,00406-0125-62,NDC,outpatient,1,UN,2,1.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROCODONE-ACETAMINOPHEN 10-325 MG ORAL TABS,RX-28384,CDM,S5000,HCPCS,259,RC,00406-0125-23,NDC,outpatient,1,UN,2,1.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ESTRADIOL 0.05 MG/24HR TD PTWK,RX-28408,CDM,S5000,HCPCS,259,RC,00378-3350-99,NDC,outpatient,1,UN,65.95,46.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ESTRADIOL 0.05 MG/24HR TD PTWK,RX-28408,CDM,S5000,HCPCS,259,RC,00378-3350-16,NDC,outpatient,1,UN,65.95,46.165,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ESTRADIOL 0.1 MG/24HR TD PTWK,RX-28409,CDM,S5000,HCPCS,259,RC,00378-3352-16,NDC,outpatient,1,UN,65.26,45.682,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ESTRADIOL 0.1 MG/24HR TD PTWK,RX-28409,CDM,S5000,HCPCS,259,RC,00378-3352-99,NDC,outpatient,1,UN,65.26,45.682,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NIFEDIPINE ER OSMOTIC RELEASE 30 MG ORAL TB24,RX-28643,CDM,S5000,HCPCS,259,RC,68084-0597-01,NDC,outpatient,1,UN,5.37,3.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NIFEDIPINE ER OSMOTIC RELEASE 30 MG ORAL TB24,RX-28643,CDM,S5000,HCPCS,259,RC,68084-0597-11,NDC,outpatient,1,UN,5.37,3.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METHYLPHENIDATE HCL ER (OSM) 18 MG ORAL TBCR,RX-28750,CDM,S5000,HCPCS,259,RC,13811-0706-10,NDC,outpatient,1,UN,3.22,2.254,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METHYLPHENIDATE HCL ER (OSM) 18 MG ORAL TBCR,RX-28750,CDM,S5000,HCPCS,259,RC,50458-0585-01,NDC,outpatient,1,UN,53.04,37.128,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUDESONIDE 0.25 MG/2ML IN SUSP,RX-28774,CDM,S5000,HCPCS,259,RC,00186-1988-04,NDC,outpatient,2,ML,35.8,25.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUDESONIDE 0.25 MG/2ML IN SUSP,RX-28774,CDM,S5000,HCPCS,259,RC,00487-9601-01,NDC,outpatient,2,ML,17.76,12.432,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,68180-0984-05,NDC,outpatient,2,ML,5.21,3.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,69097-0319-53,NDC,outpatient,2,ML,12.55,8.785,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,69097-0319-86,NDC,outpatient,2,ML,8.61,6.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,00487-9701-01,NDC,outpatient,2,ML,14.93,10.451,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,68180-0984-30,NDC,outpatient,2,ML,5.21,3.647,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,00093-6816-45,NDC,outpatient,2,ML,39.45,27.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,00093-6816-73,NDC,outpatient,2,ML,39.45,27.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,47335-0632-49,NDC,outpatient,1,ML,6.14,4.298,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,69097-0319-32,NDC,outpatient,2,ML,12.55,8.785,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,69097-0319-87,NDC,outpatient,2,ML,8.61,6.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,00168-0053-16,NDC,outpatient,453.6,GR,58.59,41.013,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,08080-4302-01,NDC,outpatient,30,ML,5.88,4.116,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,00168-0053-21,NDC,outpatient,28.35,GR,7.2,5.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,00521-2311-00,NDC,outpatient,52.5,GR,7.25,5.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,00521-2335-00,NDC,outpatient,390,GR,19.1,13.37,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,53329-0993-04,NDC,outpatient,113,GR,5.26,3.682,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,38779-3068-00,NDC,outpatient,30,GR,75.03,52.521,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SUSP,RX-28810,CDM,S5000,HCPCS,259,RC,24208-0635-62,NDC,outpatient,10,ML,221.08,154.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SUSP,RX-28810,CDM,S5000,HCPCS,259,RC,61314-0645-11,NDC,outpatient,10,ML,217.88,152.516,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GLYCERIN LIQD,RX-28815,CDM,S5000,HCPCS,259,RC,00395-1031-96,NDC,outpatient,177,ML,23.63,16.541,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MAGNESIUM HYDROXIDE 400 MG/5ML ORAL SUSP,RX-28836,CDM,S5000,HCPCS,259,RC,00121-0431-30,NDC,outpatient,30,ML,4.14,2.898,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CYCLOSPORINE MODIFIED 25 MG ORAL CAPS,RX-28842,CDM,S5000,HCPCS,259,RC,00093-9018-19,NDC,outpatient,1,UN,1.84,1.288,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CYCLOSPORINE MODIFIED 25 MG ORAL CAPS,RX-28842,CDM,S5000,HCPCS,259,RC,00093-9018-65,NDC,outpatient,1,UN,1.84,1.288,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CYCLOSPORINE MODIFIED 100 MG ORAL CAPS,RX-28843,CDM,S5000,HCPCS,259,RC,00078-0248-15,NDC,outpatient,1,UN,46.19,32.333,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CYCLOSPORINE MODIFIED 100 MG ORAL CAPS,RX-28843,CDM,S5000,HCPCS,259,RC,00078-0248-61,NDC,outpatient,1,UN,46.19,32.333,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CYCLOSPORINE MODIFIED 100 MG/ML ORAL SOLN,RX-28844,CDM,S5000,HCPCS,259,RC,00172-7313-20,NDC,outpatient,50,ML,396.5,277.55,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ERYTHROMYCIN 2 % EX SOLN,RX-2887,CDM,S5000,HCPCS,259,RC,45802-0038-46,NDC,outpatient,60,ML,71.56,50.092,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ERYTHROMYCIN 5 MG/GM OP OINT,RX-2888,CDM,S5000,HCPCS,259,RC,00574-4024-50,NDC,outpatient,1,GR,31.37,21.959,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ERYTHROMYCIN 5 MG/GM OP OINT,RX-2888,CDM,S5000,HCPCS,259,RC,24208-0910-19,NDC,outpatient,1,GR,31.03,21.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ERYTHROMYCIN 5 MG/GM OP OINT,RX-2888,CDM,S5000,HCPCS,259,RC,48102-0057-11,NDC,outpatient,1,GR,40.3,28.21,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ERYTHROMYCIN 5 MG/GM OP OINT,RX-2888,CDM,S5000,HCPCS,259,RC,00574-4024-11,NDC,outpatient,1,GR,31.37,21.959,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,68084-0975-11,NDC,outpatient,1,UN,4.25,2.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,68094-0005-59,NDC,outpatient,1,UN,2.33,1.631,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,68084-0975-01,NDC,outpatient,1,UN,4.25,2.975,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,68094-0005-61,NDC,outpatient,1,UN,2.33,1.631,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,00406-8515-23,NDC,outpatient,1,UN,2.43,1.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,00406-8515-62,NDC,outpatient,1,UN,2.43,1.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ERYTHROMYCIN BASE 250 MG ORAL TBEC,RX-2891,CDM,S5000,HCPCS,259,RC,13668-0586-30,NDC,outpatient,1,UN,21.71,15.197,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ERYTHROMYCIN BASE 250 MG ORAL TBEC,RX-2891,CDM,S5000,HCPCS,259,RC,24338-0122-03,NDC,outpatient,1,UN,24.57,17.199,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NA HYALUR & NA CHOND-NA HYALUR 0.4-0.35 ML IO KIT,RX-28916,CDM,S5000,HCPCS,250,RC,08065-1831-35,NDC,outpatient,0.75,ML,867.31,607.117,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVOFLOXACIN 750 MG ORAL TABS,RX-28964,CDM,S5000,HCPCS,259,RC,00904-6353-61,NDC,outpatient,1,UN,2.17,1.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5ML ORAL SUSR,RX-2899,CDM,S5000,HCPCS,259,RC,99999-0002-77,NDC,outpatient,5,ML,50.87,35.609,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5ML ORAL SUSR,RX-2899,CDM,S5000,HCPCS,259,RC,24338-0134-02,NDC,outpatient,100,ML,1005.7,703.99,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5ML ORAL SUSR,RX-2899,CDM,S5000,HCPCS,259,RC,75834-0295-01,NDC,outpatient,100,ML,494.4,346.08,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METFORMIN HCL ER 500 MG ORAL TB24,RX-28995,CDM,S5000,HCPCS,259,RC,51224-0007-50,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METFORMIN HCL ER 500 MG ORAL TB24,RX-28995,CDM,S5000,HCPCS,259,RC,70010-0491-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALENDRONATE SODIUM 70 MG ORAL TABS,RX-29048,CDM,S5000,HCPCS,259,RC,16714-0633-01,NDC,outpatient,1,UN,2.67,1.869,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALENDRONATE SODIUM 35 MG ORAL TABS,RX-29072,CDM,S5000,HCPCS,259,RC,16714-0632-01,NDC,outpatient,1,UN,5.43,3.801,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,42192-0608-06,NDC,outpatient,6,ML,15.62,10.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,99999-0003-42,NDC,outpatient,6,ML,2.43,1.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,42192-0608-16,NDC,outpatient,470,ML,144.32,101.024,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,65162-0698-06,NDC,outpatient,6,ML,2.47,1.729,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,42192-0608-40,NDC,outpatient,6,ML,15.62,10.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,59762-5050-07,NDC,outpatient,470,ML,154.78,108.346,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,59762-5050-06,NDC,outpatient,6,ML,2.26,1.582,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,65162-0698-90,NDC,outpatient,473,ML,168.39,117.873,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DILTIAZEM HCL ER COATED BEADS 120 MG ORAL CP24,RX-29270,CDM,S5000,HCPCS,259,RC,50742-0248-30,NDC,outpatient,1,UN,1.44,1.008,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DILTIAZEM HCL ER COATED BEADS 120 MG ORAL CP24,RX-29270,CDM,S5000,HCPCS,259,RC,60687-0195-01,NDC,outpatient,1,UN,1.87,1.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DILTIAZEM HCL ER COATED BEADS 120 MG ORAL CP24,RX-29270,CDM,S5000,HCPCS,259,RC,60687-0195-11,NDC,outpatient,1,UN,1.87,1.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DILTIAZEM HCL ER COATED BEADS 120 MG ORAL CP24,RX-29270,CDM,S5000,HCPCS,259,RC,50742-0248-90,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DILTIAZEM HCL ER COATED BEADS 120 MG ORAL CP24,RX-29270,CDM,S5000,HCPCS,259,RC,68682-0993-98,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DILTIAZEM HCL ER COATED BEADS 180 MG ORAL CP24,RX-29272,CDM,S5000,HCPCS,259,RC,00904-7218-61,NDC,outpatient,1,UN,1.28,0.896,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DILTIAZEM HCL ER COATED BEADS 180 MG ORAL CP24,RX-29272,CDM,S5000,HCPCS,259,RC,62037-0598-90,NDC,outpatient,1,UN,2.27,1.589,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DILTIAZEM HCL ER COATED BEADS 180 MG ORAL CP24,RX-29272,CDM,S5000,HCPCS,259,RC,60687-0206-11,NDC,outpatient,1,UN,1.65,1.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DILTIAZEM HCL ER COATED BEADS 180 MG ORAL CP24,RX-29272,CDM,S5000,HCPCS,259,RC,60687-0206-01,NDC,outpatient,1,UN,1.65,1.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DILTIAZEM HCL ER COATED BEADS 240 MG ORAL CP24,RX-29274,CDM,S5000,HCPCS,259,RC,00904-7219-61,NDC,outpatient,1,UN,1.59,1.113,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DILTIAZEM HCL ER COATED BEADS 240 MG ORAL CP24,RX-29274,CDM,S5000,HCPCS,259,RC,60687-0217-11,NDC,outpatient,1,UN,2.46,1.722,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DILTIAZEM HCL ER COATED BEADS 240 MG ORAL CP24,RX-29274,CDM,S5000,HCPCS,259,RC,60687-0217-01,NDC,outpatient,1,UN,2.46,1.722,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DILTIAZEM HCL ER COATED BEADS 300 MG ORAL CP24,RX-29276,CDM,S5000,HCPCS,259,RC,60687-0228-01,NDC,outpatient,1,UN,6.23,4.361,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DILTIAZEM HCL ER COATED BEADS 300 MG ORAL CP24,RX-29276,CDM,S5000,HCPCS,259,RC,60687-0228-11,NDC,outpatient,1,UN,6.23,4.361,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DILTIAZEM HCL ER COATED BEADS 300 MG ORAL CP24,RX-29276,CDM,S5000,HCPCS,259,RC,24979-0029-07,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOCOSANOL 10 % EX CREA,RX-29287,CDM,S5000,HCPCS,259,RC,00135-0300-01,NDC,outpatient,2,GR,72.76,50.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,00054-0079-28,NDC,outpatient,1,UN,1.72,1.204,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,50268-0102-13,NDC,outpatient,1,UN,5.8,4.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,50268-0102-11,NDC,outpatient,1,UN,5.8,4.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,65649-0101-02,NDC,outpatient,1,UN,26.86,18.802,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,72789-0149-69,NDC,outpatient,1,UN,1.89,1.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,60505-2575-07,NDC,outpatient,1,UN,1.09,0.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % EX CREA,RX-29424,CDM,S5000,HCPCS,259,RC,16714-0496-01,NDC,outpatient,15,GR,55.61,38.927,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % EX CREA,RX-29424,CDM,S5000,HCPCS,259,RC,00168-0258-15,NDC,outpatient,15,GR,71.29,49.903,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NATEGLINIDE 60 MG ORAL TABS,RX-29437,CDM,S5000,HCPCS,259,RC,60687-0673-21,NDC,outpatient,1,UN,7.98,5.586,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NATEGLINIDE 60 MG ORAL TABS,RX-29437,CDM,S5000,HCPCS,259,RC,60687-0673-11,NDC,outpatient,1,UN,7.98,5.586,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MIRTAZAPINE 15 MG ORAL TBDP,RX-29531,CDM,S5000,HCPCS,259,RC,65862-0021-06,NDC,outpatient,1,UN,1.96,1.372,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ZIPRASIDONE HCL 20 MG ORAL CAPS,RX-29778,CDM,S5000,HCPCS,259,RC,00904-6269-08,NDC,outpatient,1,UN,11.99,8.393,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ZIPRASIDONE HCL 60 MG ORAL CAPS,RX-29780,CDM,S5000,HCPCS,259,RC,68084-0105-11,NDC,outpatient,1,UN,7.81,5.467,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ZIPRASIDONE HCL 60 MG ORAL CAPS,RX-29780,CDM,S5000,HCPCS,259,RC,50268-0813-12,NDC,outpatient,1,UN,7.96,5.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ZIPRASIDONE HCL 60 MG ORAL CAPS,RX-29780,CDM,S5000,HCPCS,259,RC,50268-0813-11,NDC,outpatient,1,UN,7.96,5.572,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ZIPRASIDONE HCL 60 MG ORAL CAPS,RX-29780,CDM,S5000,HCPCS,259,RC,68084-0105-09,NDC,outpatient,1,UN,7.81,5.467,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ZIPRASIDONE HCL 80 MG ORAL CAPS,RX-29781,CDM,S5000,HCPCS,259,RC,00781-2168-60,NDC,outpatient,1,UN,1.24,0.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ZIPRASIDONE HCL 80 MG ORAL CAPS,RX-29781,CDM,S5000,HCPCS,259,RC,68084-0106-09,NDC,outpatient,1,UN,7.81,5.467,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ZIPRASIDONE HCL 80 MG ORAL CAPS,RX-29781,CDM,S5000,HCPCS,259,RC,68084-0106-11,NDC,outpatient,1,UN,7.81,5.467,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GALANTAMINE HYDROBROMIDE 4 MG ORAL TABS,RX-29806,CDM,S5000,HCPCS,259,RC,70436-0004-06,NDC,outpatient,1,UN,1.21,0.847,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GALANTAMINE HYDROBROMIDE 4 MG ORAL TABS,RX-29806,CDM,S5000,HCPCS,259,RC,68084-0729-11,NDC,outpatient,1,UN,14.03,9.821,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GALANTAMINE HYDROBROMIDE 4 MG ORAL TABS,RX-29806,CDM,S5000,HCPCS,259,RC,68084-0729-21,NDC,outpatient,1,UN,14.03,9.821,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,00904-6322-06,NDC,outpatient,1,UN,1.21,0.847,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,45963-0709-11,NDC,outpatient,1,UN,1.28,0.896,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,50742-0615-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,51079-0169-01,NDC,outpatient,1,UN,2.11,1.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,51079-0169-20,NDC,outpatient,1,UN,2.11,1.477,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,00904-6322-61,NDC,outpatient,1,UN,2.19,1.533,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
EYE STREAM OP SOLN,RX-2999,CDM,S5000,HCPCS,259,RC,00065-0530-01,NDC,outpatient,30,ML,81.97,57.379,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METOPROLOL SUCCINATE ER 50 MG ORAL TAB,RX-30070,CDM,S5000,HCPCS,259,RC,51079-0170-20,NDC,outpatient,1,UN,1.9,1.33,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METOPROLOL SUCCINATE ER 50 MG ORAL TAB,RX-30070,CDM,S5000,HCPCS,259,RC,00904-6323-61,NDC,outpatient,1,UN,2.29,1.603,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METOPROLOL SUCCINATE ER 50 MG ORAL TAB,RX-30070,CDM,S5000,HCPCS,259,RC,68382-0565-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METOPROLOL SUCCINATE ER 50 MG ORAL TAB,RX-30070,CDM,S5000,HCPCS,259,RC,50742-0616-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METOPROLOL SUCCINATE ER 50 MG ORAL TAB,RX-30070,CDM,S5000,HCPCS,259,RC,51079-0170-01,NDC,outpatient,1,UN,1.9,1.33,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,00904-6324-61,NDC,outpatient,1,UN,2.66,1.862,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,50268-0542-15,NDC,outpatient,1,UN,2.35,1.645,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,51079-0171-01,NDC,outpatient,1,UN,5.81,4.067,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,50268-0542-11,NDC,outpatient,1,UN,2.35,1.645,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,51079-0171-03,NDC,outpatient,1,UN,5.81,4.067,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,60687-0413-01,NDC,outpatient,1,UN,3.08,2.156,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,60687-0413-11,NDC,outpatient,1,UN,3.08,2.156,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VALGANCICLOVIR HCL 450 MG ORAL TABS,RX-30148,CDM,S5000,HCPCS,259,RC,63739-0357-33,NDC,outpatient,1,UN,93.6,65.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VALGANCICLOVIR HCL 450 MG ORAL TABS,RX-30148,CDM,S5000,HCPCS,259,RC,68084-0965-25,NDC,outpatient,1,UN,121.31,84.917,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VALGANCICLOVIR HCL 450 MG ORAL TABS,RX-30148,CDM,S5000,HCPCS,259,RC,68084-0965-95,NDC,outpatient,1,UN,121.31,84.917,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CITALOPRAM HYDROBROMIDE 10 MG ORAL TABS,RX-30264,CDM,S5000,HCPCS,259,RC,00904-6084-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXCARBAZEPINE 300 MG/5ML ORAL SUSP,RX-30479,CDM,S5000,HCPCS,259,RC,00078-0357-52,NDC,outpatient,5,ML,39.3,27.51,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXCARBAZEPINE 300 MG/5ML ORAL SUSP,RX-30479,CDM,S5000,HCPCS,259,RC,99999-0002-25,NDC,outpatient,5,ML,33.09,23.163,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXCARBAZEPINE 300 MG/5ML ORAL SUSP,RX-30479,CDM,S5000,HCPCS,259,RC,68094-0123-59,NDC,outpatient,5,ML,23.66,16.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXCARBAZEPINE 300 MG/5ML ORAL SUSP,RX-30479,CDM,S5000,HCPCS,259,RC,68094-0123-62,NDC,outpatient,5,ML,23.66,16.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MELATONIN 5 MG SL SUBL,RX-30511,CDM,S5000,HCPCS,259,RC,54629-0615-00,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FERROUS SULFATE 325 (65 FE) MG ORAL TABS,RX-3074,CDM,S5000,HCPCS,259,RC,00904-7590-60,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FERROUS SULFATE 325 (65 FE) MG ORAL TABS,RX-3074,CDM,S5000,HCPCS,259,RC,20555-0021-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FERROUS SULFATE 325 (65 FE) MG ORAL TABS,RX-3074,CDM,S5000,HCPCS,259,RC,00904-7591-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,60687-0677-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,51079-0205-20,NDC,outpatient,1,UN,1.23,0.861,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,60687-0677-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,00904-7041-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,51079-0205-01,NDC,outpatient,1,UN,1.23,0.861,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,16714-0576-02,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,55111-0729-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALLOPURINOL 300 MG ORAL TABS,RX-311,CDM,S5000,HCPCS,259,RC,00904-6572-61,NDC,outpatient,1,UN,1.71,1.197,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALLOPURINOL 300 MG ORAL TABS,RX-311,CDM,S5000,HCPCS,259,RC,51079-0206-01,NDC,outpatient,1,UN,1.68,1.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALLOPURINOL 300 MG ORAL TABS,RX-311,CDM,S5000,HCPCS,259,RC,51079-0206-20,NDC,outpatient,1,UN,1.68,1.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FISH OIL 1000 MG ORAL CAPS,RX-3113,CDM,S5000,HCPCS,259,RC,77333-0308-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FISH OIL 1000 MG ORAL CAPS,RX-3113,CDM,S5000,HCPCS,259,RC,77333-0308-25,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMOXICILLIN-POT CLAVULANATE 600-42.9 MG/5ML ORAL SUSR,RX-31177,CDM,S5000,HCPCS,259,RC,00143-9853-75,NDC,outpatient,75,ML,63.42,44.394,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMOXICILLIN-POT CLAVULANATE 600-42.9 MG/5ML ORAL SUSR,RX-31177,CDM,S5000,HCPCS,259,RC,99999-0002-82,NDC,outpatient,5,ML,8.55,5.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VALSARTAN 160 MG ORAL TABS,RX-31210,CDM,S5000,HCPCS,259,RC,60687-0634-11,NDC,outpatient,1,UN,4.62,3.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VALSARTAN 160 MG ORAL TABS,RX-31210,CDM,S5000,HCPCS,259,RC,31722-0153-90,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VALSARTAN 160 MG ORAL TABS,RX-31210,CDM,S5000,HCPCS,259,RC,33342-0064-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VALSARTAN 160 MG ORAL TABS,RX-31210,CDM,S5000,HCPCS,259,RC,60687-0634-01,NDC,outpatient,1,UN,4.62,3.234,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUDESONIDE 3 MG ORAL CPEP,RX-31576,CDM,S5000,HCPCS,259,RC,00574-9855-10,NDC,outpatient,1,UN,2.52,1.764,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUDESONIDE 3 MG ORAL CPEP,RX-31576,CDM,S5000,HCPCS,259,RC,65162-0778-10,NDC,outpatient,1,UN,2.47,1.729,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALBUTEROL SULFATE 0.63 MG/3ML IN NEBU,RX-31577,CDM,S5000,HCPCS,259,RC,00487-0301-01,NDC,outpatient,3,ML,2.43,1.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALBUTEROL SULFATE 0.63 MG/3ML IN NEBU,RX-31577,CDM,S5000,HCPCS,259,RC,76204-0010-55,NDC,outpatient,3,ML,1.98,1.386,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALBUTEROL SULFATE 1.25 MG/3ML IN NEBU,RX-31578,CDM,S5000,HCPCS,259,RC,00487-9904-25,NDC,outpatient,3,ML,2.43,1.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALBUTEROL SULFATE 1.25 MG/3ML IN NEBU,RX-31578,CDM,S5000,HCPCS,259,RC,00487-9904-01,NDC,outpatient,3,ML,2.43,1.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMPHETAMINE-DEXTROAMPHET ER 10 MG ORAL CP24,RX-31587,CDM,S5000,HCPCS,259,RC,00228-3059-11,NDC,outpatient,1,UN,12.55,8.785,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMPHETAMINE-DEXTROAMPHET ER 10 MG ORAL CP24,RX-31587,CDM,S5000,HCPCS,259,RC,70010-0030-01,NDC,outpatient,1,UN,3.45,2.415,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMPHETAMINE-DEXTROAMPHET ER 10 MG ORAL CP24,RX-31587,CDM,S5000,HCPCS,259,RC,64850-0511-01,NDC,outpatient,1,UN,2,1.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
UREA 40 % EX LOTN,RX-31683,CDM,S5000,HCPCS,259,RC,54295-0312-18,NDC,outpatient,226.8,GR,419.86,293.902,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
UREA 40 % EX LOTN,RX-31683,CDM,S5000,HCPCS,259,RC,81542-0201-08,NDC,outpatient,226.8,GR,454.17,317.919,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TENOFOVIR DISOPROXIL FUMARATE 300 MG ORAL TABS,RX-31684,CDM,S5000,HCPCS,259,RC,61958-0401-01,NDC,outpatient,1,UN,180.36,126.252,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLUOCINONIDE 0.05 % EX CREA,RX-3187,CDM,S5000,HCPCS,259,RC,00093-0262-15,NDC,outpatient,15,GR,162.14,113.498,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLUOCINONIDE 0.05 % EX CREA,RX-3187,CDM,S5000,HCPCS,259,RC,51672-1386-01,NDC,outpatient,15,GR,35.32,24.724,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLUOCINONIDE 0.05 % EX OINT,RX-3189,CDM,S5000,HCPCS,259,RC,51672-1264-01,NDC,outpatient,15,GR,55.01,38.507,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLUOCINONIDE 0.05 % EX SOLN,RX-3190,CDM,S5000,HCPCS,259,RC,51672-1273-02,NDC,outpatient,20,ML,137.87,96.509,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLUOROMETHOLONE 0.1 % OP SUSP,RX-3208,CDM,S5000,HCPCS,259,RC,60758-0880-05,NDC,outpatient,5,ML,308.83,216.181,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLUPHENAZINE HCL 1 MG ORAL TABS,RX-3218,CDM,S5000,HCPCS,259,RC,00527-1788-01,NDC,outpatient,1,UN,6.6,4.62,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLUPHENAZINE HCL 2.5 MG ORAL TABS,RX-3220,CDM,S5000,HCPCS,259,RC,00527-1789-01,NDC,outpatient,1,UN,10.2,7.14,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLUPHENAZINE HCL 2.5 MG ORAL TABS,RX-3220,CDM,S5000,HCPCS,259,RC,70954-0274-10,NDC,outpatient,1,UN,2.47,1.729,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLUPHENAZINE HCL 5 MG ORAL TABS,RX-3221,CDM,S5000,HCPCS,259,RC,00527-1790-01,NDC,outpatient,1,UN,13.8,9.66,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLUPHENAZINE HCL 5 MG ORAL TABS,RX-3221,CDM,S5000,HCPCS,259,RC,69238-1680-01,NDC,outpatient,1,UN,6.45,4.515,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FOLIC ACID 5 MG/ML IJ SOLN,RX-3232,CDM,S5000,HCPCS,250,RC,39822-1100-01,NDC,outpatient,0.2,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FOLIC ACID 5 MG/ML IJ SOLN,RX-3232,CDM,S5000,HCPCS,250,RC,63323-0184-10,NDC,outpatient,0.2,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FOLIC ACID 1 MG ORAL TABS,RX-3233,CDM,S5000,HCPCS,259,RC,60687-0681-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FOLIC ACID 1 MG ORAL TABS,RX-3233,CDM,S5000,HCPCS,259,RC,60687-0681-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FOLIC ACID 1 MG ORAL TABS,RX-3233,CDM,S5000,HCPCS,259,RC,00904-7224-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALPRAZOLAM 0.25 MG ORAL TABS,RX-324,CDM,S5000,HCPCS,259,RC,00781-1061-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALPRAZOLAM 0.25 MG ORAL TABS,RX-324,CDM,S5000,HCPCS,259,RC,65862-0676-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALPRAZOLAM 0.5 MG ORAL TABS,RX-325,CDM,S5000,HCPCS,259,RC,00781-1077-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PAROXETINE HCL ER 12.5 MG ORAL TB24,RX-32631,CDM,S5000,HCPCS,259,RC,62175-0470-32,NDC,outpatient,1,UN,4.97,3.479,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METHYLPHENIDATE HCL ER (OSM) 27 MG ORAL TBCR,RX-32654,CDM,S5000,HCPCS,259,RC,13811-0707-10,NDC,outpatient,1,UN,3.33,2.331,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OLMESARTAN MEDOXOMIL 20 MG ORAL TABS,RX-32762,CDM,S5000,HCPCS,259,RC,33342-0179-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OLMESARTAN MEDOXOMIL 20 MG ORAL TABS,RX-32762,CDM,S5000,HCPCS,259,RC,00713-0861-30,NDC,outpatient,1,UN,39.98,27.986,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OLMESARTAN MEDOXOMIL 20 MG ORAL TABS,RX-32762,CDM,S5000,HCPCS,259,RC,68462-0437-30,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RISEDRONATE SODIUM 35 MG ORAL TABS,RX-32895,CDM,S5000,HCPCS,259,RC,33342-0109-50,NDC,outpatient,1,UN,18.52,12.964,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FUROSEMIDE 10 MG/ML ORAL SOLN,RX-3292,CDM,S5000,HCPCS,259,RC,68094-0756-62,NDC,outpatient,4,ML,7.04,4.928,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FUROSEMIDE 10 MG/ML ORAL SOLN,RX-3292,CDM,S5000,HCPCS,259,RC,68094-0756-59,NDC,outpatient,4,ML,7.04,4.928,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FUROSEMIDE 8 MG/ML ORAL SOLN,RX-3293,CDM,S5000,HCPCS,259,RC,68094-0867-62,NDC,outpatient,5,ML,7.04,4.928,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FUROSEMIDE 8 MG/ML ORAL SOLN,RX-3293,CDM,S5000,HCPCS,259,RC,68094-0867-59,NDC,outpatient,5,ML,7.04,4.928,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FUROSEMIDE 20 MG ORAL TABS,RX-3294,CDM,S5000,HCPCS,259,RC,00054-8297-25,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FUROSEMIDE 20 MG ORAL TABS,RX-3294,CDM,S5000,HCPCS,259,RC,00904-7177-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FUROSEMIDE 40 MG ORAL TABS,RX-3295,CDM,S5000,HCPCS,259,RC,51079-0073-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FUROSEMIDE 40 MG ORAL TABS,RX-3295,CDM,S5000,HCPCS,259,RC,51079-0073-20,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FUROSEMIDE 80 MG ORAL TABS,RX-3296,CDM,S5000,HCPCS,259,RC,51079-0527-20,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FUROSEMIDE 80 MG ORAL TABS,RX-3296,CDM,S5000,HCPCS,259,RC,00054-8301-25,NDC,outpatient,1,UN,2.07,1.449,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FUROSEMIDE 80 MG ORAL TABS,RX-3296,CDM,S5000,HCPCS,259,RC,51079-0527-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMPHETAMINE-DEXTROAMPHET ER 5 MG ORAL CP24,RX-33005,CDM,S5000,HCPCS,259,RC,54092-0381-01,NDC,outpatient,1,UN,29.29,20.503,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VORICONAZOLE 200 MG ORAL TABS,RX-33009,CDM,S5000,HCPCS,259,RC,00904-7024-04,NDC,outpatient,1,UN,43.81,30.667,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMOXICILLIN-POT CLAVULANATE 500-125 MG ORAL TABS,RX-33227,CDM,S5000,HCPCS,259,RC,00781-1831-01,NDC,outpatient,1,UN,1.59,1.113,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMOXICILLIN-POT CLAVULANATE 875-125 MG ORAL TABS,RX-33228,CDM,S5000,HCPCS,259,RC,42571-0162-01,NDC,outpatient,1,UN,2.67,1.869,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMOXICILLIN-POT CLAVULANATE 875-125 MG ORAL TABS,RX-33228,CDM,S5000,HCPCS,259,RC,65862-0503-01,NDC,outpatient,1,UN,2.34,1.638,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMOXICILLIN-POT CLAVULANATE 875-125 MG ORAL TABS,RX-33228,CDM,S5000,HCPCS,259,RC,65862-0503-20,NDC,outpatient,1,UN,1.87,1.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMOXICILLIN-POT CLAVULANATE 875-125 MG ORAL TABS,RX-33228,CDM,S5000,HCPCS,259,RC,00143-9249-20,NDC,outpatient,1,UN,5.26,3.682,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ESCITALOPRAM OXALATE 10 MG ORAL TABS,RX-33512,CDM,S5000,HCPCS,259,RC,00904-6426-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ESCITALOPRAM OXALATE 10 MG ORAL TABS,RX-33512,CDM,S5000,HCPCS,259,RC,68084-0617-11,NDC,outpatient,1,UN,1.04,0.728,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ESCITALOPRAM OXALATE 10 MG ORAL TABS,RX-33512,CDM,S5000,HCPCS,259,RC,68084-0617-01,NDC,outpatient,1,UN,1.04,0.728,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VALSARTAN 40 MG ORAL TABS,RX-33541,CDM,S5000,HCPCS,259,RC,60687-0612-11,NDC,outpatient,1,UN,3.18,2.226,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VALSARTAN 40 MG ORAL TABS,RX-33541,CDM,S5000,HCPCS,259,RC,60687-0612-21,NDC,outpatient,1,UN,3.18,2.226,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VALSARTAN 40 MG ORAL TABS,RX-33541,CDM,S5000,HCPCS,259,RC,31722-0151-30,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GEMFIBROZIL 600 MG ORAL TABS,RX-3378,CDM,S5000,HCPCS,259,RC,60687-0224-11,NDC,outpatient,1,UN,1.15,0.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GEMFIBROZIL 600 MG ORAL TABS,RX-3378,CDM,S5000,HCPCS,259,RC,60687-0224-01,NDC,outpatient,1,UN,1.15,0.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METAXALONE 800 MG ORAL TABS,RX-33963,CDM,S5000,HCPCS,259,RC,00527-1435-01,NDC,outpatient,1,UN,2.54,1.778,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DUTASTERIDE 0.5 MG ORAL CAPS,RX-34089,CDM,S5000,HCPCS,259,RC,42806-0549-09,NDC,outpatient,1,UN,1.7,1.19,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
EZETIMIBE 10 MG ORAL TABS,RX-34153,CDM,S5000,HCPCS,259,RC,51660-0200-90,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
EZETIMIBE 10 MG ORAL TABS,RX-34153,CDM,S5000,HCPCS,259,RC,60687-0373-21,NDC,outpatient,1,UN,18.75,13.125,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
EZETIMIBE 10 MG ORAL TABS,RX-34153,CDM,S5000,HCPCS,259,RC,00904-7103-04,NDC,outpatient,1,UN,18.36,12.852,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
EZETIMIBE 10 MG ORAL TABS,RX-34153,CDM,S5000,HCPCS,259,RC,60687-0373-11,NDC,outpatient,1,UN,18.75,13.125,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GENTAMICIN SULFATE 0.1 % EX CREA,RX-3423,CDM,S5000,HCPCS,259,RC,45802-0056-35,NDC,outpatient,15,GR,170.02,119.014,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GENTAMICIN SULFATE 0.1 % EX OINT,RX-3424,CDM,S5000,HCPCS,259,RC,45802-0046-35,NDC,outpatient,15,GR,132.44,92.708,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GENTAMICIN SULFATE 0.3 % OP SOLN,RX-3428,CDM,S5000,HCPCS,259,RC,24208-0580-60,NDC,outpatient,5,ML,23.41,16.387,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GENTAMICIN SULFATE 0.3 % OP SOLN,RX-3428,CDM,S5000,HCPCS,259,RC,61314-0633-05,NDC,outpatient,5,ML,21.99,15.393,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ARIPIPRAZOLE 10 MG ORAL TABS,RX-34369,CDM,S5000,HCPCS,259,RC,60687-0179-11,NDC,outpatient,1,UN,22.5,15.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ARIPIPRAZOLE 10 MG ORAL TABS,RX-34369,CDM,S5000,HCPCS,259,RC,60687-0179-01,NDC,outpatient,1,UN,22.5,15.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ARIPIPRAZOLE 15 MG ORAL TABS,RX-34370,CDM,S5000,HCPCS,259,RC,27241-0054-03,NDC,outpatient,1,UN,2.88,2.016,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ARIPIPRAZOLE 15 MG ORAL TABS,RX-34370,CDM,S5000,HCPCS,259,RC,60687-0191-11,NDC,outpatient,1,UN,27.24,19.068,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ARIPIPRAZOLE 15 MG ORAL TABS,RX-34370,CDM,S5000,HCPCS,259,RC,60687-0191-21,NDC,outpatient,1,UN,27.24,19.068,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ARIPIPRAZOLE 15 MG ORAL TABS,RX-34370,CDM,S5000,HCPCS,259,RC,63739-0078-33,NDC,outpatient,1,UN,22.38,15.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DIVALPROEX SODIUM ER 250 MG ORAL TB24,RX-34418,CDM,S5000,HCPCS,259,RC,68084-0310-11,NDC,outpatient,1,UN,2.75,1.925,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DIVALPROEX SODIUM ER 250 MG ORAL TB24,RX-34418,CDM,S5000,HCPCS,259,RC,68084-0310-01,NDC,outpatient,1,UN,2.75,1.925,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ATOMOXETINE HCL 10 MG ORAL CAPS,RX-34444,CDM,S5000,HCPCS,259,RC,35573-0415-30,NDC,outpatient,1,UN,14,9.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ATOMOXETINE HCL 10 MG ORAL CAPS,RX-34444,CDM,S5000,HCPCS,259,RC,55111-0519-30,NDC,outpatient,1,UN,7.25,5.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ATOMOXETINE HCL 10 MG ORAL CAPS,RX-34444,CDM,S5000,HCPCS,259,RC,31722-0714-30,NDC,outpatient,1,UN,8.16,5.712,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ATOMOXETINE HCL 10 MG ORAL CAPS,RX-34444,CDM,S5000,HCPCS,259,RC,68462-0265-30,NDC,outpatient,1,UN,4.5,3.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ATOMOXETINE HCL 25 MG ORAL CAPS,RX-34446,CDM,S5000,HCPCS,259,RC,16714-0757-01,NDC,outpatient,1,UN,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ATOMOXETINE HCL 25 MG ORAL CAPS,RX-34446,CDM,S5000,HCPCS,259,RC,64980-0375-03,NDC,outpatient,1,UN,7.25,5.075,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ATOMOXETINE HCL 40 MG ORAL CAPS,RX-34447,CDM,S5000,HCPCS,259,RC,00093-3545-56,NDC,outpatient,1,UN,17.9,12.53,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ATOMOXETINE HCL 40 MG ORAL CAPS,RX-34447,CDM,S5000,HCPCS,259,RC,60687-0326-25,NDC,outpatient,1,UN,14.68,10.276,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ATOMOXETINE HCL 40 MG ORAL CAPS,RX-34447,CDM,S5000,HCPCS,259,RC,68462-0268-30,NDC,outpatient,1,UN,2.91,2.037,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ATOMOXETINE HCL 40 MG ORAL CAPS,RX-34447,CDM,S5000,HCPCS,259,RC,60687-0326-95,NDC,outpatient,1,UN,14.68,10.276,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROCODONE-ACETAMINOPHEN 5-325 MG ORAL TABS,RX-34505,CDM,S5000,HCPCS,259,RC,00406-0123-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROCODONE-ACETAMINOPHEN 5-325 MG ORAL TABS,RX-34505,CDM,S5000,HCPCS,259,RC,00406-0123-62,NDC,outpatient,1,UN,1.5,1.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROCODONE-ACETAMINOPHEN 5-325 MG ORAL TABS,RX-34505,CDM,S5000,HCPCS,259,RC,00406-0123-23,NDC,outpatient,1,UN,1.5,1.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPRENORPHINE HCL 2 MG SL SUBL,RX-34711,CDM,S5000,HCPCS,259,RC,60687-0481-11,NDC,outpatient,1,UN,6.96,4.872,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPRENORPHINE HCL 2 MG SL SUBL,RX-34711,CDM,S5000,HCPCS,259,RC,60687-0481-21,NDC,outpatient,1,UN,6.96,4.872,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPRENORPHINE HCL 8 MG SL SUBL,RX-34712,CDM,S5000,HCPCS,259,RC,42858-0502-03,NDC,outpatient,1,UN,2.47,1.729,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPRENORPHINE HCL 8 MG SL SUBL,RX-34712,CDM,S5000,HCPCS,259,RC,60687-0492-21,NDC,outpatient,1,UN,11.98,8.386,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPRENORPHINE HCL 8 MG SL SUBL,RX-34712,CDM,S5000,HCPCS,259,RC,60687-0492-11,NDC,outpatient,1,UN,11.98,8.386,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPRENORPHINE HCL-NALOXONE HCL 2-0.5 MG SL SUBL,RX-34713,CDM,S5000,HCPCS,259,RC,00054-0188-13,NDC,outpatient,1,UN,2.47,1.729,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPRENORPHINE HCL-NALOXONE HCL 2-0.5 MG SL SUBL,RX-34713,CDM,S5000,HCPCS,259,RC,65162-0416-03,NDC,outpatient,1,UN,2.45,1.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPRENORPHINE HCL-NALOXONE HCL 8-2 MG SL SUBL,RX-34714,CDM,S5000,HCPCS,259,RC,50268-0145-11,NDC,outpatient,1,UN,14.96,10.472,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPRENORPHINE HCL-NALOXONE HCL 8-2 MG SL SUBL,RX-34714,CDM,S5000,HCPCS,259,RC,42858-0602-03,NDC,outpatient,1,UN,27,18.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPRENORPHINE HCL-NALOXONE HCL 8-2 MG SL SUBL,RX-34714,CDM,S5000,HCPCS,259,RC,50268-0145-15,NDC,outpatient,1,UN,14.96,10.472,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SOLN,RX-34814,CDM,S5000,HCPCS,259,RC,24208-0631-10,NDC,outpatient,10,ML,205.06,143.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SOLN,RX-34814,CDM,S5000,HCPCS,259,RC,61314-0646-10,NDC,outpatient,10,ML,188.28,131.796,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ROSUVASTATIN CALCIUM 10 MG ORAL TABS,RX-35134,CDM,S5000,HCPCS,259,RC,60687-0245-01,NDC,outpatient,1,UN,4.01,2.807,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ROSUVASTATIN CALCIUM 10 MG ORAL TABS,RX-35134,CDM,S5000,HCPCS,259,RC,00904-6779-61,NDC,outpatient,1,UN,3.97,2.779,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ROSUVASTATIN CALCIUM 10 MG ORAL TABS,RX-35134,CDM,S5000,HCPCS,259,RC,60687-0245-11,NDC,outpatient,1,UN,4.01,2.807,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,16714-0990-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,50268-0710-11,NDC,outpatient,1,UN,2.29,1.603,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,60687-0256-01,NDC,outpatient,1,UN,5.36,3.752,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,60687-0256-11,NDC,outpatient,1,UN,5.36,3.752,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,00904-6780-61,NDC,outpatient,1,UN,3.57,2.499,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,50268-0710-15,NDC,outpatient,1,UN,2.29,1.603,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CYCLOSPORINE 0.05 % OP EMUL,RX-35209,CDM,S5000,HCPCS,259,RC,00023-9163-30,NDC,outpatient,1,UN,44.22,30.954,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALUMINUM HYDROXIDE GEL 320 MG/5ML ORAL SUSP,RX-353,CDM,S5000,HCPCS,259,RC,99999-0002-48,NDC,outpatient,30,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALUMINUM HYDROXIDE GEL 320 MG/5ML ORAL SUSP,RX-353,CDM,S5000,HCPCS,259,RC,00536-0091-85,NDC,outpatient,5,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GRISEOFULVIN ULTRAMICROSIZE 250 MG ORAL TABS,RX-3536,CDM,S5000,HCPCS,259,RC,00115-1725-01,NDC,outpatient,1,UN,20.98,14.686,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXYBUTYNIN 3.9 MG/24HR TD PTTW,RX-35495,CDM,S5000,HCPCS,259,RC,00023-6153-01,NDC,outpatient,1,UN,349.43,244.601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXYBUTYNIN 3.9 MG/24HR TD PTTW,RX-35495,CDM,S5000,HCPCS,259,RC,00023-9637-08,NDC,outpatient,1,UN,10.21,7.147,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXYBUTYNIN 3.9 MG/24HR TD PTTW,RX-35495,CDM,S5000,HCPCS,259,RC,00023-6153-08,NDC,outpatient,1,UN,349.43,244.601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXYBUTYNIN 3.9 MG/24HR TD PTTW,RX-35495,CDM,S5000,HCPCS,259,RC,00023-9637-01,NDC,outpatient,1,UN,10.21,7.147,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RISPERIDONE 0.5 MG ORAL TBDP,RX-35686,CDM,S5000,HCPCS,259,RC,49884-0311-52,NDC,outpatient,1,UN,2.41,1.687,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RISPERIDONE 0.5 MG ORAL TBDP,RX-35686,CDM,S5000,HCPCS,259,RC,49884-0311-55,NDC,outpatient,1,UN,2.41,1.687,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RISPERIDONE 1 MG ORAL TBDP,RX-35687,CDM,S5000,HCPCS,259,RC,49884-0315-55,NDC,outpatient,1,UN,2.77,1.939,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RISPERIDONE 1 MG ORAL TBDP,RX-35687,CDM,S5000,HCPCS,259,RC,49884-0315-52,NDC,outpatient,1,UN,2.77,1.939,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MOXIFLOXACIN HCL 0.5 % OP SOLN,RX-35699,CDM,S5000,HCPCS,259,RC,00832-1410-03,NDC,outpatient,3,ML,113.88,79.716,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MOXIFLOXACIN HCL 0.5 % OP SOLN,RX-35699,CDM,S5000,HCPCS,259,RC,72266-0158-01,NDC,outpatient,3,ML,45.03,31.521,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METFORMIN HCL ER 750 MG ORAL TB24,RX-35771,CDM,S5000,HCPCS,259,RC,70010-0492-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METFORMIN HCL ER 750 MG ORAL TB24,RX-35771,CDM,S5000,HCPCS,259,RC,62756-0143-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METFORMIN HCL ER 750 MG ORAL TB24,RX-35771,CDM,S5000,HCPCS,259,RC,67877-0414-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HALOPERIDOL 0.5 MG ORAL TABS,RX-3578,CDM,S5000,HCPCS,259,RC,51079-0733-20,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HALOPERIDOL 0.5 MG ORAL TABS,RX-3578,CDM,S5000,HCPCS,259,RC,51079-0733-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HALOPERIDOL 2 MG ORAL TABS,RX-3581,CDM,S5000,HCPCS,259,RC,00832-1530-11,NDC,outpatient,1,UN,1.81,1.267,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HALOPERIDOL 2 MG ORAL TABS,RX-3581,CDM,S5000,HCPCS,259,RC,00378-0214-01,NDC,outpatient,1,UN,2.45,1.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HALOPERIDOL 5 MG ORAL TABS,RX-3583,CDM,S5000,HCPCS,259,RC,51079-0736-01,NDC,outpatient,1,UN,1.41,0.987,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HALOPERIDOL 5 MG ORAL TABS,RX-3583,CDM,S5000,HCPCS,259,RC,51079-0736-20,NDC,outpatient,1,UN,1.41,0.987,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONC,RX-3585,CDM,S5000,HCPCS,259,RC,54838-0501-15,NDC,outpatient,0.5,ML,2.5,1.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONC,RX-3585,CDM,S5000,HCPCS,259,RC,99999-0003-09,NDC,outpatient,0.5,ML,2.5,1.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POTASSIUM CHLORIDE CRYS ER 10 MEQ ORAL TBCR,RX-35942,CDM,S5000,HCPCS,259,RC,00245-5317-89,NDC,outpatient,1,UN,1.08,0.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POTASSIUM CHLORIDE CRYS ER 10 MEQ ORAL TBCR,RX-35942,CDM,S5000,HCPCS,259,RC,00245-5317-01,NDC,outpatient,1,UN,1.08,0.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POTASSIUM CHLORIDE CRYS ER 10 MEQ ORAL TBCR,RX-35942,CDM,S5000,HCPCS,259,RC,63739-0972-10,NDC,outpatient,1,UN,1.14,0.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POTASSIUM CHLORIDE CRYS ER 20 MEQ ORAL TBCR,RX-35943,CDM,S5000,HCPCS,259,RC,00245-5319-01,NDC,outpatient,1,UN,1.25,0.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POTASSIUM CHLORIDE CRYS ER 20 MEQ ORAL TBCR,RX-35943,CDM,S5000,HCPCS,259,RC,00245-5319-89,NDC,outpatient,1,UN,1.25,0.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POTASSIUM CHLORIDE CRYS ER 20 MEQ ORAL TBCR,RX-35943,CDM,S5000,HCPCS,259,RC,00832-5325-11,NDC,outpatient,1,UN,1.25,0.875,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ATAZANAVIR SULFATE 150 MG ORAL CAPS,RX-36149,CDM,S5000,HCPCS,259,RC,42385-0920-60,NDC,outpatient,1,UN,11.33,7.931,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ATAZANAVIR SULFATE 200 MG ORAL CAPS,RX-36150,CDM,S5000,HCPCS,259,RC,65862-0712-60,NDC,outpatient,1,UN,13.22,9.254,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREMASOL 10 % IV SOLN,RX-36160,CDM,S5000,HCPCS,250,RC,00338-1130-03,NDC,outpatient,500,ML,98.33,68.831,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
EMTRICITABINE 200 MG ORAL CAPS,RX-36252,CDM,S5000,HCPCS,259,RC,61958-0601-01,NDC,outpatient,1,UN,77.2,54.04,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMANTADINE HCL 100 MG ORAL CAPS,RX-364,CDM,S5000,HCPCS,259,RC,50268-0069-15,NDC,outpatient,1,UN,4.75,3.325,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMANTADINE HCL 100 MG ORAL CAPS,RX-364,CDM,S5000,HCPCS,259,RC,50268-0069-11,NDC,outpatient,1,UN,4.75,3.325,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ARIPIPRAZOLE 5 MG ORAL TABS,RX-36438,CDM,S5000,HCPCS,259,RC,60687-0168-01,NDC,outpatient,1,UN,15.64,10.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ARIPIPRAZOLE 5 MG ORAL TABS,RX-36438,CDM,S5000,HCPCS,259,RC,60687-0168-11,NDC,outpatient,1,UN,15.64,10.948,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % OT SUSP,RX-36576,CDM,S5000,HCPCS,259,RC,43598-0326-75,NDC,outpatient,7.5,ML,438.69,307.083,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % OT SUSP,RX-36576,CDM,S5000,HCPCS,259,RC,16714-0628-01,NDC,outpatient,7.5,ML,422.83,295.981,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % OT SUSP,RX-36576,CDM,S5000,HCPCS,259,RC,62756-0427-90,NDC,outpatient,7.5,ML,336.96,235.872,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVETIRACETAM 100 MG/ML ORAL SOLN,RX-36590,CDM,S5000,HCPCS,259,RC,60687-0249-40,NDC,outpatient,5,ML,12.02,8.414,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVETIRACETAM 100 MG/ML ORAL SOLN,RX-36590,CDM,S5000,HCPCS,259,RC,00121-4799-05,NDC,outpatient,5,ML,9.93,6.951,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVETIRACETAM 100 MG/ML ORAL SOLN,RX-36590,CDM,S5000,HCPCS,259,RC,00121-4799-40,NDC,outpatient,5,ML,9.93,6.951,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVETIRACETAM 100 MG/ML ORAL SOLN,RX-36590,CDM,S5000,HCPCS,259,RC,60687-0249-67,NDC,outpatient,5,ML,12.02,8.414,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ROSUVASTATIN CALCIUM 5 MG ORAL TABS,RX-36612,CDM,S5000,HCPCS,259,RC,00904-6778-61,NDC,outpatient,1,UN,2.9,2.03,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
KETOROLAC TROMETHAMINE 0.4 % OP SOLN,RX-36631,CDM,S5000,HCPCS,259,RC,60758-0773-05,NDC,outpatient,5,ML,248.94,174.258,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPROPION HCL ER (XL) 150 MG ORAL TB24,RX-36775,CDM,S5000,HCPCS,259,RC,00904-7084-04,NDC,outpatient,1,UN,5.27,3.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPROPION HCL ER (XL) 150 MG ORAL TB24,RX-36775,CDM,S5000,HCPCS,259,RC,00904-7084-61,NDC,outpatient,1,UN,6.35,4.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPROPION HCL ER (XL) 150 MG ORAL TB24,RX-36775,CDM,S5000,HCPCS,259,RC,16729-0443-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOCUSATE SODIUM 50 MG/5ML ORAL LIQD,RX-36962,CDM,S5000,HCPCS,259,RC,00121-1870-10,NDC,outpatient,10,ML,6.46,4.522,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOCUSATE SODIUM 50 MG/5ML ORAL LIQD,RX-36962,CDM,S5000,HCPCS,259,RC,63739-0976-01,NDC,outpatient,10,ML,3.61,2.527,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOCUSATE SODIUM 50 MG/5ML ORAL LIQD,RX-36962,CDM,S5000,HCPCS,259,RC,00121-1870-00,NDC,outpatient,10,ML,6.46,4.522,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOCUSATE SODIUM 50 MG/5ML ORAL LIQD,RX-36962,CDM,S5000,HCPCS,259,RC,99999-0001-96,NDC,outpatient,10,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOCUSATE SODIUM 50 MG/5ML ORAL LIQD,RX-36962,CDM,S5000,HCPCS,259,RC,63739-0976-10,NDC,outpatient,10,ML,3.61,2.527,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
THEOPHYLLINE ER 400 MG ORAL TB24,RX-36973,CDM,S5000,HCPCS,259,RC,29033-0001-01,NDC,outpatient,1,UN,5.44,3.808,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
THEOPHYLLINE ER 400 MG ORAL TB24,RX-36973,CDM,S5000,HCPCS,259,RC,42858-0701-01,NDC,outpatient,1,UN,3.89,2.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PHENOL 1.4 % MT LIQD,RX-36976,CDM,S5000,HCPCS,259,RC,49348-0991-36,NDC,outpatient,177,ML,7.88,5.516,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PHENOL 1.4 % MT LIQD,RX-36976,CDM,S5000,HCPCS,259,RC,78112-0011-03,NDC,outpatient,177,ML,17.33,12.131,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PHENOL 1.4 % MT LIQD,RX-36976,CDM,S5000,HCPCS,259,RC,00904-6305-21,NDC,outpatient,177,ML,7.09,4.963,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDRALAZINE HCL 10 MG ORAL TABS,RX-3698,CDM,S5000,HCPCS,259,RC,51079-0074-20,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDRALAZINE HCL 10 MG ORAL TABS,RX-3698,CDM,S5000,HCPCS,259,RC,51079-0074-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALFUZOSIN HCL ER 10 MG ORAL TB24,RX-36982,CDM,S5000,HCPCS,259,RC,29300-0155-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALFUZOSIN HCL ER 10 MG ORAL TB24,RX-36982,CDM,S5000,HCPCS,259,RC,57237-0114-90,NDC,outpatient,1,UN,2,1.4,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
EPLERENONE 25 MG ORAL TABS,RX-36983,CDM,S5000,HCPCS,259,RC,59762-1710-02,NDC,outpatient,1,UN,5.59,3.913,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
EPLERENONE 25 MG ORAL TABS,RX-36983,CDM,S5000,HCPCS,259,RC,60687-0451-11,NDC,outpatient,1,UN,18.55,12.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
EPLERENONE 25 MG ORAL TABS,RX-36983,CDM,S5000,HCPCS,259,RC,60687-0451-21,NDC,outpatient,1,UN,18.55,12.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
EPLERENONE 25 MG ORAL TABS,RX-36983,CDM,S5000,HCPCS,259,RC,51991-0877-33,NDC,outpatient,1,UN,1.68,1.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ZONISAMIDE 25 MG ORAL CAPS,RX-36987,CDM,S5000,HCPCS,259,RC,68462-0128-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,31722-0520-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,51079-0075-01,NDC,outpatient,1,UN,1.14,0.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,60687-0822-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,60687-0822-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,63739-0327-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,23155-0833-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,51079-0075-20,NDC,outpatient,1,UN,1.14,0.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
THERA M PLUS ORAL TABS,RX-37053,CDM,S5000,HCPCS,259,RC,00536-3445-08,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
THERA M PLUS ORAL TABS,RX-37053,CDM,S5000,HCPCS,259,RC,57896-0621-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,00591-3870-45,NDC,outpatient,1,UN,1.42,0.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,00832-1112-60,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,60687-0173-57,NDC,outpatient,1,UN,2.01,1.407,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,00591-3870-44,NDC,outpatient,1,UN,1.42,0.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,00904-6505-61,NDC,outpatient,1,UN,1.34,0.938,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,60687-0173-11,NDC,outpatient,1,UN,2.01,1.407,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROCHLOROTHIAZIDE 25 MG ORAL TABS,RX-3720,CDM,S5000,HCPCS,259,RC,60687-0593-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROCHLOROTHIAZIDE 25 MG ORAL TABS,RX-3720,CDM,S5000,HCPCS,259,RC,60687-0593-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROCORTISONE 1 % EX CREA,RX-3726,CDM,S5000,HCPCS,259,RC,00536-1277-80,NDC,outpatient,28,GR,5.24,3.668,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROCORTISONE 1 % EX CREA,RX-3726,CDM,S5000,HCPCS,259,RC,49348-0521-72,NDC,outpatient,28.4,GR,6.32,4.424,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROCORTISONE 1 % EX LOTN,RX-3728,CDM,S5000,HCPCS,259,RC,00394-0859-32,NDC,outpatient,114,ML,22.83,15.981,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROCORTISONE 1 % EX LOTN,RX-3728,CDM,S5000,HCPCS,259,RC,00096-0732-04,NDC,outpatient,120,ML,56.61,39.627,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROCORTISONE 1 % EX OINT,RX-3731,CDM,S5000,HCPCS,259,RC,00168-0020-31,NDC,outpatient,28.35,GR,18.05,12.635,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROCORTISONE 10 MG ORAL TABS,RX-3733,CDM,S5000,HCPCS,259,RC,60687-0582-11,NDC,outpatient,1,UN,6.08,4.256,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROCORTISONE 10 MG ORAL TABS,RX-3733,CDM,S5000,HCPCS,259,RC,60687-0582-01,NDC,outpatient,1,UN,6.08,4.256,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROCORTISONE 10 MG ORAL TABS,RX-3733,CDM,S5000,HCPCS,259,RC,59762-0074-01,NDC,outpatient,1,UN,1.14,0.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROCORTISONE ACETATE 25 MG RE SUPP,RX-3738,CDM,S5000,HCPCS,259,RC,00574-7090-12,NDC,outpatient,1,UN,5.54,3.878,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROCORTISONE ACETATE 25 MG RE SUPP,RX-3738,CDM,S5000,HCPCS,259,RC,10135-0751-12,NDC,outpatient,1,UN,7.8,5.46,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,49884-0466-63,NDC,outpatient,1,UN,2.84,1.988,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,00245-0036-60,NDC,outpatient,1,UN,3.71,2.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,00245-0036-89,NDC,outpatient,1,UN,3.71,2.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,42806-0270-95,NDC,outpatient,1,UN,3.48,2.436,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,42806-0270-98,NDC,outpatient,1,UN,3.48,2.436,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,49884-0466-65,NDC,outpatient,1,UN,2.84,1.988,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CARBAMAZEPINE ER 100 MG ORAL CP12,RX-37567,CDM,S5000,HCPCS,259,RC,50268-0170-11,NDC,outpatient,1,UN,7.06,4.942,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CARBAMAZEPINE ER 100 MG ORAL CP12,RX-37567,CDM,S5000,HCPCS,259,RC,50268-0170-13,NDC,outpatient,1,UN,7.06,4.942,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BSS IO SOLN,RX-37579,CDM,S5000,HCPCS,259,RC,00065-0795-15,NDC,outpatient,15,ML,24.7,17.29,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROMORPHONE HCL 2 MG ORAL TABS,RX-3760,CDM,S5000,HCPCS,259,RC,00406-3243-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROMORPHONE HCL 2 MG ORAL TABS,RX-3760,CDM,S5000,HCPCS,259,RC,60687-0579-11,NDC,outpatient,1,UN,1.27,0.889,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROMORPHONE HCL 2 MG ORAL TABS,RX-3760,CDM,S5000,HCPCS,259,RC,60687-0579-01,NDC,outpatient,1,UN,1.27,0.889,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROMORPHONE HCL 2 MG ORAL TABS,RX-3760,CDM,S5000,HCPCS,259,RC,42858-0301-01,NDC,outpatient,1,UN,1.14,0.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROMORPHONE HCL 2 MG ORAL TABS,RX-3760,CDM,S5000,HCPCS,259,RC,42858-0301-25,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROMORPHONE HCL 4 MG ORAL TABS,RX-3761,CDM,S5000,HCPCS,259,RC,00406-3244-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROMORPHONE HCL 4 MG ORAL TABS,RX-3761,CDM,S5000,HCPCS,259,RC,42858-0234-01,NDC,outpatient,1,UN,17.03,11.921,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROMORPHONE HCL 4 MG ORAL TABS,RX-3761,CDM,S5000,HCPCS,259,RC,60687-0590-01,NDC,outpatient,1,UN,1.06,0.742,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROMORPHONE HCL 4 MG ORAL TABS,RX-3761,CDM,S5000,HCPCS,259,RC,60687-0590-11,NDC,outpatient,1,UN,1.06,0.742,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METOPROLOL TARTRATE 25 MG ORAL TABS,RX-37637,CDM,S5000,HCPCS,259,RC,51079-0255-20,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METOPROLOL TARTRATE 25 MG ORAL TABS,RX-37637,CDM,S5000,HCPCS,259,RC,62584-0265-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METOPROLOL TARTRATE 25 MG ORAL TABS,RX-37637,CDM,S5000,HCPCS,259,RC,51079-0255-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METOPROLOL TARTRATE 25 MG ORAL TABS,RX-37637,CDM,S5000,HCPCS,259,RC,00378-0018-05,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METOPROLOL TARTRATE 25 MG ORAL TABS,RX-37637,CDM,S5000,HCPCS,259,RC,62584-0265-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLINDAMYCIN PALMITATE HCL 75 MG/5ML ORAL SOLR,RX-37642,CDM,S5000,HCPCS,259,RC,59762-0016-01,NDC,outpatient,100,ML,170.44,119.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLINDAMYCIN PALMITATE HCL 75 MG/5ML ORAL SOLR,RX-37642,CDM,S5000,HCPCS,259,RC,23155-0603-51,NDC,outpatient,100,ML,170.44,119.308,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLINDAMYCIN PALMITATE HCL 75 MG/5ML ORAL SOLR,RX-37642,CDM,S5000,HCPCS,259,RC,99999-0002-90,NDC,outpatient,10,ML,18.43,12.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GLIPIZIDE ER 2.5 MG ORAL TB24,RX-37648,CDM,S5000,HCPCS,259,RC,60687-0768-11,NDC,outpatient,1,UN,4.6,3.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GLIPIZIDE ER 2.5 MG ORAL TB24,RX-37648,CDM,S5000,HCPCS,259,RC,60687-0768-21,NDC,outpatient,1,UN,4.6,3.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GLIPIZIDE ER 5 MG ORAL TB24,RX-37649,CDM,S5000,HCPCS,259,RC,68084-0111-11,NDC,outpatient,1,UN,2.4,1.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GLIPIZIDE ER 5 MG ORAL TB24,RX-37649,CDM,S5000,HCPCS,259,RC,68084-0111-01,NDC,outpatient,1,UN,2.4,1.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GUAIFENESIN ER 600 MG ORAL TB12,RX-37651,CDM,S5000,HCPCS,259,RC,63824-0008-50,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GUAIFENESIN ER 600 MG ORAL TB12,RX-37651,CDM,S5000,HCPCS,259,RC,68084-0572-01,NDC,outpatient,1,UN,2.76,1.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GUAIFENESIN ER 600 MG ORAL TB12,RX-37651,CDM,S5000,HCPCS,259,RC,00904-6718-39,NDC,outpatient,1,UN,2.32,1.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GUAIFENESIN ER 600 MG ORAL TB12,RX-37651,CDM,S5000,HCPCS,259,RC,68084-0572-11,NDC,outpatient,1,UN,2.76,1.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROXYZINE HCL 10 MG/5ML ORAL SYRP,RX-3771,CDM,S5000,HCPCS,259,RC,54838-0502-80,NDC,outpatient,5,ML,2.88,2.016,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROXYZINE HCL 10 MG/5ML ORAL SYRP,RX-3771,CDM,S5000,HCPCS,259,RC,62135-0750-47,NDC,outpatient,5,ML,21.74,15.218,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROXYZINE HCL 10 MG/5ML ORAL SYRP,RX-3771,CDM,S5000,HCPCS,259,RC,99999-0002-50,NDC,outpatient,5,ML,1.16,0.812,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROXYZINE HCL 10 MG ORAL TABS,RX-3772,CDM,S5000,HCPCS,259,RC,63739-0483-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROXYZINE HCL 25 MG ORAL TABS,RX-3774,CDM,S5000,HCPCS,259,RC,00904-6617-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROXYZINE HCL 25 MG ORAL TABS,RX-3774,CDM,S5000,HCPCS,259,RC,60687-0675-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROXYZINE HCL 25 MG ORAL TABS,RX-3774,CDM,S5000,HCPCS,259,RC,60687-0675-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROXYZINE HCL 25 MG ORAL TABS,RX-3774,CDM,S5000,HCPCS,259,RC,63739-0486-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TALC 5 G PL SUSR,RX-37812,CDM,S5000,HCPCS,259,RC,63256-0200-05,NDC,outpatient,1,UN,458.35,320.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CINACALCET HCL 30 MG ORAL TABS,RX-38100,CDM,S5000,HCPCS,259,RC,55513-0073-30,NDC,outpatient,1,UN,75.45,52.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CINACALCET HCL 30 MG ORAL TABS,RX-38100,CDM,S5000,HCPCS,259,RC,70436-0007-04,NDC,outpatient,1,UN,1.94,1.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CINACALCET HCL 30 MG ORAL TABS,RX-38100,CDM,S5000,HCPCS,259,RC,60687-0525-11,NDC,outpatient,1,UN,64.87,45.409,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CINACALCET HCL 30 MG ORAL TABS,RX-38100,CDM,S5000,HCPCS,259,RC,00904-7067-04,NDC,outpatient,1,UN,76.53,53.571,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CINACALCET HCL 30 MG ORAL TABS,RX-38100,CDM,S5000,HCPCS,259,RC,60687-0525-21,NDC,outpatient,1,UN,64.87,45.409,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ORPHENADRINE CITRATE ER 100 MG ORAL TB12,RX-38213,CDM,S5000,HCPCS,259,RC,43386-0480-24,NDC,outpatient,1,UN,2.27,1.589,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PROPRANOLOL HCL ER 60 MG ORAL CP24,RX-38224,CDM,S5000,HCPCS,259,RC,00228-2778-11,NDC,outpatient,1,UN,6.75,4.725,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PROPRANOLOL HCL ER 60 MG ORAL CP24,RX-38224,CDM,S5000,HCPCS,259,RC,42291-0522-01,NDC,outpatient,1,UN,1.68,1.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PROPRANOLOL HCL ER 60 MG ORAL CP24,RX-38224,CDM,S5000,HCPCS,259,RC,62559-0530-01,NDC,outpatient,1,UN,2.1,1.47,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PROPRANOLOL HCL ER 80 MG ORAL CP24,RX-38225,CDM,S5000,HCPCS,259,RC,00228-2779-11,NDC,outpatient,1,UN,8.57,5.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PROPRANOLOL HCL ER 80 MG ORAL CP24,RX-38225,CDM,S5000,HCPCS,259,RC,00527-4117-37,NDC,outpatient,1,UN,1.14,0.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PROPRANOLOL HCL ER 120 MG ORAL CP24,RX-38226,CDM,S5000,HCPCS,259,RC,00228-2780-11,NDC,outpatient,1,UN,10.29,7.203,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PROPRANOLOL HCL ER 120 MG ORAL CP24,RX-38226,CDM,S5000,HCPCS,259,RC,42291-0524-01,NDC,outpatient,1,UN,2.42,1.694,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LACTULOSE 10 GM/15ML ORAL SOLN,RX-38245,CDM,S5000,HCPCS,259,RC,00121-1154-00,NDC,outpatient,30,ML,4.94,3.458,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LACTULOSE 10 GM/15ML ORAL SOLN,RX-38245,CDM,S5000,HCPCS,259,RC,45963-0439-30,NDC,outpatient,30,ML,2.01,1.407,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LACTULOSE 10 GM/15ML ORAL SOLN,RX-38245,CDM,S5000,HCPCS,259,RC,45963-0439-65,NDC,outpatient,15,ML,1.01,0.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LACTULOSE 10 GM/15ML ORAL SOLN,RX-38245,CDM,S5000,HCPCS,259,RC,99999-0001-83,NDC,outpatient,30,ML,2.16,1.512,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LACTULOSE 10 GM/15ML ORAL SOLN,RX-38245,CDM,S5000,HCPCS,259,RC,00121-1154-30,NDC,outpatient,30,ML,4.94,3.458,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CETIRIZINE HCL 5 MG ORAL CHEW,RX-38402,CDM,S5000,HCPCS,259,RC,00781-5283-06,NDC,outpatient,1,UN,12.96,9.072,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CETIRIZINE HCL 5 MG ORAL CHEW,RX-38402,CDM,S5000,HCPCS,259,RC,00781-5283-64,NDC,outpatient,1,UN,12.96,9.072,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IBUPROFEN 200 MG ORAL TABS,RX-3841,CDM,S5000,HCPCS,259,RC,00904-7914-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,60687-0446-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,00904-5853-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,67877-0319-05,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,60687-0446-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,67877-0319-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,00904-5853-60,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IBUPROFEN 600 MG ORAL TABS,RX-3844,CDM,S5000,HCPCS,259,RC,00904-5854-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
INFUVITE PEDIATRIC IV SOLN,RX-38445,CDM,S5000,HCPCS,250,RC,54643-5646-09,NDC,outpatient,1,ML,15.58,10.906,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
INFUVITE PEDIATRIC IV SOLN,RX-38445,CDM,S5000,HCPCS,250,RC,54643-5646-01,NDC,outpatient,4,ML,53.96,37.772,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IBUPROFEN 800 MG ORAL TABS,RX-3845,CDM,S5000,HCPCS,259,RC,00904-5855-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLUOXETINE HCL 20 MG/5ML ORAL SOLN,RX-38488,CDM,S5000,HCPCS,259,RC,00121-4721-05,NDC,outpatient,5,ML,14.38,10.066,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IMIPRAMINE HCL 10 MG ORAL TABS,RX-3860,CDM,S5000,HCPCS,259,RC,69584-0425-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IMIPRAMINE HCL 25 MG ORAL TABS,RX-3861,CDM,S5000,HCPCS,259,RC,69584-0426-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NEOMYCIN-BACITRACIN ZN-POLYMYX 5-400-10000 OP OINT,RX-38701,CDM,S5000,HCPCS,259,RC,24208-0780-55,NDC,outpatient,3.5,GR,57.59,40.313,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
INDAPAMIDE 2.5 MG ORAL TABS,RX-3879,CDM,S5000,HCPCS,259,RC,00228-2571-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
INDAPAMIDE 2.5 MG ORAL TABS,RX-3879,CDM,S5000,HCPCS,259,RC,62559-0511-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SELENIUM SULFIDE 1 % EX SHAM,RX-38961,CDM,S5000,HCPCS,259,RC,00536-1995-53,NDC,outpatient,207,ML,9.22,6.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PEG 3350-KCL-NABCB-NACL-NASULF 240 G ORAL SOLR,RX-38965,CDM,S5000,HCPCS,259,RC,43386-0060-19,NDC,outpatient,4000,ML,53.4,37.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
INDOMETHACIN 25 MG ORAL CAPS,RX-3897,CDM,S5000,HCPCS,259,RC,50268-0430-15,NDC,outpatient,1,UN,1.4,0.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
INDOMETHACIN 25 MG ORAL CAPS,RX-3897,CDM,S5000,HCPCS,259,RC,50268-0430-11,NDC,outpatient,1,UN,1.4,0.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
INDOMETHACIN 50 MG RE SUPP,RX-3901,CDM,S5000,HCPCS,259,RC,69344-0102-33,NDC,outpatient,1,UN,1095.8,767.06,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RIFAXIMIN 200 MG ORAL TABS,RX-39063,CDM,S5000,HCPCS,259,RC,65649-0301-03,NDC,outpatient,1,UN,43.55,30.485,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMILORIDE HCL 5 MG ORAL TABS,RX-391,CDM,S5000,HCPCS,259,RC,00574-0292-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NYSTATIN 100000 UNIT/GM EX POWD,RX-39136,CDM,S5000,HCPCS,259,RC,00832-0465-15,NDC,outpatient,15,GR,37.52,26.264,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NYSTATIN 100000 UNIT/GM EX POWD,RX-39136,CDM,S5000,HCPCS,259,RC,68382-0370-01,NDC,outpatient,15,GR,31.18,21.826,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NYSTATIN 100000 UNIT/GM EX POWD,RX-39136,CDM,S5000,HCPCS,259,RC,16714-0769-01,NDC,outpatient,15,GR,25.04,17.528,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NYSTATIN 100000 UNIT/GM EX POWD,RX-39136,CDM,S5000,HCPCS,259,RC,68308-0152-15,NDC,outpatient,15,GR,27.84,19.488,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NYSTATIN 100000 UNIT/GM EX POWD,RX-39136,CDM,S5000,HCPCS,259,RC,69315-0306-15,NDC,outpatient,15,GR,24.5,17.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
EMTRICITABINE-TENOFOVIR DF 200-300 MG ORAL TABS,RX-39255,CDM,S5000,HCPCS,259,RC,61958-0701-01,NDC,outpatient,1,UN,265.08,185.556,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DULOXETINE HCL 20 MG ORAL CPEP,RX-39275,CDM,S5000,HCPCS,259,RC,00904-7043-04,NDC,outpatient,1,UN,3.3,2.31,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DULOXETINE HCL 20 MG ORAL CPEP,RX-39275,CDM,S5000,HCPCS,259,RC,60687-0723-21,NDC,outpatient,1,UN,3.39,2.373,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DULOXETINE HCL 20 MG ORAL CPEP,RX-39275,CDM,S5000,HCPCS,259,RC,60687-0723-11,NDC,outpatient,1,UN,3.39,2.373,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DULOXETINE HCL 30 MG ORAL CPEP,RX-39276,CDM,S5000,HCPCS,259,RC,60687-0734-01,NDC,outpatient,1,UN,3.41,2.387,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DULOXETINE HCL 30 MG ORAL CPEP,RX-39276,CDM,S5000,HCPCS,259,RC,57237-0018-90,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DULOXETINE HCL 30 MG ORAL CPEP,RX-39276,CDM,S5000,HCPCS,259,RC,00904-7044-61,NDC,outpatient,1,UN,3.08,2.156,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DULOXETINE HCL 30 MG ORAL CPEP,RX-39276,CDM,S5000,HCPCS,259,RC,60687-0734-11,NDC,outpatient,1,UN,3.41,2.387,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVALBUTEROL HCL 1.25 MG/0.5ML IN NEBU,RX-39278,CDM,S5000,HCPCS,259,RC,00378-6993-93,NDC,outpatient,1,UN,20.14,14.098,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVALBUTEROL HCL 1.25 MG/0.5ML IN NEBU,RX-39278,CDM,S5000,HCPCS,259,RC,00378-6993-31,NDC,outpatient,1,UN,20.14,14.098,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CEFDINIR 250 MG/5ML ORAL SUSR,RX-39522,CDM,S5000,HCPCS,259,RC,65862-0219-60,NDC,outpatient,60,ML,88.92,62.244,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CEFDINIR 250 MG/5ML ORAL SUSR,RX-39522,CDM,S5000,HCPCS,259,RC,68180-0723-04,NDC,outpatient,60,ML,87.31,61.117,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CEFDINIR 250 MG/5ML ORAL SUSR,RX-39522,CDM,S5000,HCPCS,259,RC,99999-0002-80,NDC,outpatient,6,ML,3.93,2.751,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MESALAMINE ER 500 MG ORAL CPCR,RX-39575,CDM,S5000,HCPCS,259,RC,54092-0191-12,NDC,outpatient,1,UN,24.97,17.479,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IODINE STRONG 5 % ORAL SOLN,RX-3961,CDM,S5000,HCPCS,259,RC,48433-0230-15,NDC,outpatient,14,ML,132.64,92.848,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IODINE STRONG 5 % ORAL SOLN,RX-3961,CDM,S5000,HCPCS,259,RC,51552-0019-44,NDC,outpatient,14,ML,5.44,3.808,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACAMPROSATE CALCIUM 333 MG ORAL TBEC,RX-39720,CDM,S5000,HCPCS,259,RC,60687-0121-95,NDC,outpatient,1,UN,6.9,4.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACAMPROSATE CALCIUM 333 MG ORAL TBEC,RX-39720,CDM,S5000,HCPCS,259,RC,60687-0121-25,NDC,outpatient,1,UN,6.9,4.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLUMAZENIL 0.5 MG/5ML IV SOLN,RX-39744,CDM,S5000,HCPCS,250,RC,36000-0148-01,NDC,outpatient,5,ML,12.98,9.086,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLUMAZENIL 0.5 MG/5ML IV SOLN,RX-39744,CDM,S5000,HCPCS,250,RC,00143-9784-01,NDC,outpatient,5,ML,13.42,9.394,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLUMAZENIL 0.5 MG/5ML IV SOLN,RX-39744,CDM,S5000,HCPCS,250,RC,36000-0148-10,NDC,outpatient,5,ML,12.98,9.086,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLUMAZENIL 0.5 MG/5ML IV SOLN,RX-39744,CDM,S5000,HCPCS,250,RC,00143-9784-10,NDC,outpatient,5,ML,13.42,9.394,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLUMAZENIL 0.5 MG/5ML IV SOLN,RX-39744,CDM,S5000,HCPCS,250,RC,63323-0424-05,NDC,outpatient,5,ML,15.68,10.976,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVOFLOXACIN 25 MG/ML ORAL SOLN,RX-39970,CDM,S5000,HCPCS,259,RC,00527-1948-68,NDC,outpatient,10,ML,85.98,60.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVOFLOXACIN 25 MG/ML ORAL SOLN,RX-39970,CDM,S5000,HCPCS,259,RC,99999-0002-53,NDC,outpatient,10,ML,37.07,25.949,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LANTHANUM CARBONATE 500 MG ORAL CHEW,RX-39975,CDM,S5000,HCPCS,259,RC,54092-0252-45,NDC,outpatient,1,UN,49.37,34.559,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LANTHANUM CARBONATE 500 MG ORAL CHEW,RX-39975,CDM,S5000,HCPCS,259,RC,54092-0252-90,NDC,outpatient,1,UN,49.37,34.559,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LANTHANUM CARBONATE 500 MG ORAL CHEW,RX-39975,CDM,S5000,HCPCS,259,RC,68180-0819-42,NDC,outpatient,1,UN,24.73,17.311,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LANTHANUM CARBONATE 500 MG ORAL CHEW,RX-39975,CDM,S5000,HCPCS,259,RC,68180-0819-52,NDC,outpatient,1,UN,24.73,17.311,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FENOFIBRATE 48 MG ORAL TABS,RX-40009,CDM,S5000,HCPCS,259,RC,51079-0599-20,NDC,outpatient,1,UN,4.01,2.807,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FENOFIBRATE 48 MG ORAL TABS,RX-40009,CDM,S5000,HCPCS,259,RC,51079-0599-01,NDC,outpatient,1,UN,4.01,2.807,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FENOFIBRATE 145 MG ORAL TABS,RX-40010,CDM,S5000,HCPCS,259,RC,60687-0629-21,NDC,outpatient,1,UN,4.19,2.933,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FENOFIBRATE 145 MG ORAL TABS,RX-40010,CDM,S5000,HCPCS,259,RC,51079-0608-20,NDC,outpatient,1,UN,10.74,7.518,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MAGIC MOUTHWASH ORAL SUSPENSION *HOSPITAL USE ONLY*,RX-400477,CDM,S5000,HCPCS,259,RC,65628-0050-01,NDC,outpatient,10,ML,19.54,13.678,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MAGIC MOUTHWASH ORAL SUSPENSION *HOSPITAL USE ONLY*,RX-400477,CDM,S5000,HCPCS,259,RC,99999-0000-61,NDC,outpatient,180,ML,12.46,8.722,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MAGIC MOUTHWASH ORAL SUSPENSION *HOSPITAL USE ONLY*,RX-400477,CDM,S5000,HCPCS,259,RC,65628-0050-04,NDC,outpatient,5,ML,14,9.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MAGIC MOUTHWASH ORAL SUSPENSION *HOSPITAL USE ONLY*,RX-400477,CDM,S5000,HCPCS,259,RC,99999-0000-82,NDC,outpatient,10,ML,19.54,13.678,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RIFAMPIN 10 MG/ML ORAL SUSPENSION,RX-400484,CDM,S5000,HCPCS,259,RC,99999-0001-44,NDC,outpatient,120,ML,34,23.8,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METOPROLOL TARTRATE 12.5 MG ORAL SPLIT TABLET,RX-400503,CDM,S5000,HCPCS,259,RC,,,outpatient,12.5,ME,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METOPROLOL TARTRATE 12.5 MG ORAL SPLIT TABLET,RX-400503,CDM,S5000,HCPCS,259,RC,99999-0002-12,NDC,outpatient,12.5,ME,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METOPROLOL TARTRATE 12.5 MG ORAL SPLIT TABLET,RX-400503,CDM,S5000,HCPCS,259,RC,SH040-0403-01,NDC,outpatient,12.5,ME,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CEFAZOLIN EYE DROPS 50 MG/ML 20 ML BOTTLE,RX-400598,CDM,S5000,HCPCS,259,RC,SH408-0378-01,NDC,outpatient,20,ML,18.41,12.887,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MISOPROSTOL 25 MCG ORAL SPLIT TABS,RX-400620,CDM,S5000,HCPCS,259,RC,SH040-0620-01,NDC,outpatient,1,UN,1.69,1.183,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MISOPROSTOL 25 MCG ORAL SPLIT TABS,RX-400620,CDM,S5000,HCPCS,259,RC,,,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ISONIAZID 100 MG ORAL TABS,RX-4026,CDM,S5000,HCPCS,259,RC,00555-0066-02,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMINOCAPROIC ACID 250 MG/ML IV SOLN,RX-403,CDM,S5000,HCPCS,250,RC,00409-4346-73,NDC,outpatient,20,ML,18.34,12.838,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMINOCAPROIC ACID 250 MG/ML IV SOLN,RX-403,CDM,S5000,HCPCS,250,RC,00517-9120-25,NDC,outpatient,4,ML,8,5.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMINOCAPROIC ACID 250 MG/ML IV SOLN,RX-403,CDM,S5000,HCPCS,250,RC,00409-4346-16,NDC,outpatient,20,ML,18.34,12.838,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMINOCAPROIC ACID 250 MG/ML IV SOLN,RX-403,CDM,S5000,HCPCS,250,RC,00517-9120-01,NDC,outpatient,4,ML,8,5.6,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN,RX-4034,CDM,S5000,HCPCS,250,RC,00548-9502-00,NDC,outpatient,5,ML,246.51,172.557,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN,RX-4034,CDM,S5000,HCPCS,250,RC,14789-0015-05,NDC,outpatient,5,ML,1453.64,1017.548,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN,RX-4034,CDM,S5000,HCPCS,250,RC,14789-0015-07,NDC,outpatient,5,ML,1453.64,1017.548,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MESALAMINE 1000 MG RE SUPP,RX-40369,CDM,S5000,HCPCS,259,RC,59762-0118-03,NDC,outpatient,1,UN,22.5,15.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MESALAMINE 1000 MG RE SUPP,RX-40369,CDM,S5000,HCPCS,259,RC,69918-0560-30,NDC,outpatient,1,UN,7.56,5.292,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SOLIFENACIN SUCCINATE 5 MG ORAL TABS,RX-40392,CDM,S5000,HCPCS,259,RC,51248-0150-01,NDC,outpatient,1,UN,52.84,36.988,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CYANOCOBALAMIN 500 MCG SL SUBL,RX-40518,CDM,S5000,HCPCS,259,RC,74312-0035-95,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CYANOCOBALAMIN 500 MCG SL SUBL,RX-40518,CDM,S5000,HCPCS,259,RC,00743-1203-59,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ISOSORBIDE DINITRATE 10 MG ORAL TABS,RX-4064,CDM,S5000,HCPCS,259,RC,68084-0082-11,NDC,outpatient,1,UN,2.67,1.869,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ISOSORBIDE DINITRATE 10 MG ORAL TABS,RX-4064,CDM,S5000,HCPCS,259,RC,68084-0082-01,NDC,outpatient,1,UN,2.67,1.869,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ISOSORBIDE DINITRATE 20 MG ORAL TABS,RX-4065,CDM,S5000,HCPCS,259,RC,00904-6620-61,NDC,outpatient,1,UN,2.27,1.589,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE 0.9 % IV PVC FREE SOLN,RX-4080010,CDM,S5000,HCPCS,250,RC,00264-1800-32,NDC,outpatient,100,ML,28.85,20.195,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE 0.9 % IV PVC FREE SOLN,RX-4080010,CDM,S5000,HCPCS,250,RC,00264-7800-20,NDC,outpatient,250,ML,30.14,21.098,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE 0.9 % IV PVC FREE SOLN,RX-4080010,CDM,S5000,HCPCS,250,RC,00264-7800-10,NDC,outpatient,500,ML,31.42,21.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROMORPHONE 100 MG/100 ML INFUSION,RX-4080055,CDM,S5000,HCPCS,250,RC,99999-0000-26,NDC,outpatient,100,ML,168.65,118.055,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DILTIAZEM ADDVANTAGE INFUSION IN NS,RX-4080056,CDM,S5000,HCPCS,250,RC,99999-0000-00,NDC,outpatient,100,ML,54.5,38.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FENTANYL INFUSION PREMIX 10 MCG/ML 250 ML,RX-4080065,CDM,S5000,HCPCS,250,RC,70092-1093-37,NDC,outpatient,250,ML,130.86,91.602,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FENTANYL INFUSION PREMIX 10 MCG/ML 250 ML,RX-4080065,CDM,S5000,HCPCS,250,RC,70004-0202-40,NDC,outpatient,250,ML,236.1,165.27,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FENTANYL INFUSION PREMIX 10 MCG/ML 250 ML,RX-4080065,CDM,S5000,HCPCS,250,RC,70004-0229-40,NDC,outpatient,250,ML,277.66,194.362,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FENTANYL INFUSION PREMIX 10 MCG/ML 250 ML,RX-4080065,CDM,S5000,HCPCS,250,RC,99999-0001-54,NDC,outpatient,250,ML,37.36,26.152,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
KETAMINE INFUSION 500 MG IN 250 ML INFUSION,RX-4080078,CDM,S5000,HCPCS,250,RC,70004-0442-40,NDC,outpatient,250,ML,112.79,78.953,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
KETAMINE INFUSION 500 MG IN 250 ML INFUSION,RX-4080078,CDM,S5000,HCPCS,250,RC,99999-9990-03,NDC,outpatient,250,ML,37.81,26.467,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MORPHINE INFUSION 250 MG IN D5W 250 ML PREMIX,RX-4080096,CDM,S5000,HCPCS,250,RC,99999-0001-61,NDC,outpatient,250,ML,35.02,24.514,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FAMOTIDINE 10 MG/ML IJ WRAPPER,RX-4080100,CDM,S5000,HCPCS,250,RC,00641-6022-01,NDC,outpatient,2,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FAMOTIDINE 10 MG/ML IJ WRAPPER,RX-4080100,CDM,S5000,HCPCS,250,RC,67457-0433-00,NDC,outpatient,2,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FAMOTIDINE 10 MG/ML IJ WRAPPER,RX-4080100,CDM,S5000,HCPCS,250,RC,00641-6022-25,NDC,outpatient,2,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FAMOTIDINE 10 MG/ML IJ WRAPPER,RX-4080100,CDM,S5000,HCPCS,250,RC,67457-0433-22,NDC,outpatient,2,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ARTIFICIAL TEARS EYE SOLN WRAPPER,RX-4080101,CDM,S5000,HCPCS,259,RC,00065-0426-36,NDC,outpatient,15,ML,27.17,19.019,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ARTIFICIAL TEARS EYE SOLN WRAPPER,RX-4080101,CDM,S5000,HCPCS,259,RC,57896-0181-05,NDC,outpatient,15,ML,5.55,3.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NAFCILLIN SODIUM 1 G IJ WRAPPER,RX-4080106,CDM,S5000,HCPCS,250,RC,63323-0327-10,NDC,outpatient,1,UN,15.49,10.843,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NAFCILLIN SODIUM 2 G IJ WRAPPER,RX-4080107,CDM,S5000,HCPCS,250,RC,44567-0222-10,NDC,outpatient,1,UN,90.46,63.322,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NAFCILLIN SODIUM 2 G IJ WRAPPER,RX-4080107,CDM,S5000,HCPCS,250,RC,63323-0328-20,NDC,outpatient,1,UN,24.64,17.248,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NAFCILLIN SODIUM 2 G IJ WRAPPER,RX-4080107,CDM,S5000,HCPCS,250,RC,55150-0123-15,NDC,outpatient,1,UN,30.45,21.315,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NOREPINEPHRINE PREMIX 4 MG IN 250 ML NS,RX-4080110,CDM,S5000,HCPCS,250,RC,70092-1650-05,NDC,outpatient,250,ML,102.2,71.54,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NOREPINEPHRINE PREMIX 4 MG IN 250 ML NS,RX-4080110,CDM,S5000,HCPCS,250,RC,70004-0781-40,NDC,outpatient,250,ML,123.78,86.646,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NOREPINEPHRINE PREMIX 4 MG IN 250 ML NS,RX-4080110,CDM,S5000,HCPCS,250,RC,71266-5020-02,NDC,outpatient,250,ML,112.97,79.079,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PHENYLEPHRINE IV PREMIX 40 MG IN 250 ML NS,RX-4080112,CDM,S5000,HCPCS,250,RC,42852-0838-25,NDC,outpatient,250,ML,158.85,111.195,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PHENYLEPHRINE IV PREMIX 40 MG IN 250 ML NS,RX-4080112,CDM,S5000,HCPCS,250,RC,70004-0812-40,NDC,outpatient,250,ML,93.12,65.184,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PHENYLEPHRINE IV PREMIX 40 MG IN 250 ML NS,RX-4080112,CDM,S5000,HCPCS,250,RC,70092-9170-05,NDC,outpatient,250,ML,146.26,102.382,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PHENYLEPHRINE IV PREMIX 10 MG IN 250 ML NS,RX-4080113,CDM,S5000,HCPCS,250,RC,70004-0811-40,NDC,outpatient,250,ML,109.23,76.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PHENYLEPHRINE IV PREMIX 10 MG IN 250 ML NS,RX-4080113,CDM,S5000,HCPCS,250,RC,71506-0010-58,NDC,outpatient,250,ML,88.76,62.132,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VANCOMYCIN HCL IN DEXTROSE 1250 MG/250 ML IV SOLN,RX-4080122,CDM,S5000,HCPCS,250,RC,99999-0000-46,NDC,outpatient,275,ML,64.38,45.066,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VANCOMYCIN HCL IN DEXTROSE 1500 MG/250 ML IV SOLN,RX-4080123,CDM,S5000,HCPCS,250,RC,99999-0000-47,NDC,outpatient,280,ML,80.8,56.56,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CARDIOPLEGIA SOLN HIGH POTASSIUM 4:1 INDUCTION,RX-4080154,CDM,S5000,HCPCS,250,RC,72196-0101-01,NDC,outpatient,500,ML,673.36,471.352,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CARDIOPLEGIA SOLN LOW POTASSION 4:1 REPERFUSATE,RX-4080155,CDM,S5000,HCPCS,250,RC,71285-0007-01,NDC,outpatient,238.75,ML,1537.64,1076.348,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CARDIOPLEGIA SOLN LOW POTASSIUM 4:1 MAINTENANCE,RX-4080156,CDM,S5000,HCPCS,250,RC,72196-0104-01,NDC,outpatient,1000,ML,1042.09,729.463,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CONCENTRATED DILAUDID 1 MG/ML PCA,RX-4080157,CDM,S5000,HCPCS,250,RC,70004-0303-62,NDC,outpatient,50,ML,212.25,148.575,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DILAUDID 0.2 MG/ML PCA (HYDROMORPHONE),RX-4080159,CDM,S5000,HCPCS,250,RC,70004-0300-62,NDC,outpatient,50,ML,69.63,48.741,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PRISMASATE K 0/CA 3.5 CRRT SOLUTION,RX-4080163,CDM,S5000,HCPCS,250,RC,00000-1053-53,NDC,outpatient,5000,ML,188.44,131.908,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FENTANYL 2 MCG/ML WITH BUPIVACAINE 0.125 % EPIDURAL,RX-4080168,CDM,S5000,HCPCS,250,RC,70092-1202-75,NDC,outpatient,100,ML,258.44,180.908,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FENTANYL 2 MCG/ML WITH BUPIVACAINE 0.125 % EPIDURAL,RX-4080168,CDM,S5000,HCPCS,250,RC,70004-0231-64,NDC,outpatient,100,ML,109.23,76.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FENTANYL 2 MCG/ML WITH BUPIVACAINE 0.125 % EPIDURAL,RX-4080168,CDM,S5000,HCPCS,250,RC,70092-9202-75,NDC,outpatient,100,ML,251.94,176.358,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FENTANYL 2 MCG/ML WITH BUPIVACAINE 0.125 % EPIDURAL,RX-4080168,CDM,S5000,HCPCS,250,RC,99999-0001-52,NDC,outpatient,100,ML,30.84,21.588,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FENTANYL 5 MCG/ML WITH BUPIVACAINE 0.075 % EPIDURAL,RX-4080169,CDM,S5000,HCPCS,250,RC,99999-0001-55,NDC,outpatient,100,ML,34.55,24.185,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FENTANYL 3 MCG/ML WITH BUPIVACAINE 0.075 % EPIDURAL,RX-4080170,CDM,S5000,HCPCS,250,RC,99999-0000-03,NDC,outpatient,100,ML,67.18,47.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FENTANYL CITRATE (PF) 0.05 MG/ML NASAL SOLUTION,RX-4080181,CDM,S5000,HCPCS,259,RC,00409-9094-22,NDC,outpatient,2,ML,6.33,4.431,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FENTANYL CITRATE (PF) 0.05 MG/ML NASAL SOLUTION,RX-4080181,CDM,S5000,HCPCS,259,RC,00409-9094-12,NDC,outpatient,2,ML,6.33,4.431,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MIDAZOLAM HCL 5 MG/ML NASAL SOLUTION,RX-4080183,CDM,S5000,HCPCS,250,RC,00409-2308-21,NDC,outpatient,1,ML,3.42,2.394,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MIDAZOLAM HCL 5 MG/ML NASAL SOLUTION,RX-4080183,CDM,S5000,HCPCS,250,RC,00409-2308-01,NDC,outpatient,1,ML,3.42,2.394,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NICARDIPINE HCL IN NACL 1 MG/10 ML IV SYRINGE,RX-4080192,CDM,S5000,HCPCS,250,RC,70004-0756-12,NDC,outpatient,10,ML,39.83,27.881,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NICARDIPINE HCL IN NACL 1 MG/10 ML IV SYRINGE,RX-4080192,CDM,S5000,HCPCS,250,RC,99999-0001-50,NDC,outpatient,10,ML,10.7,7.49,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DILTIAZEM HCL 5 MG/ML IV WRAPPER,RX-4080196,CDM,S5000,HCPCS,250,RC,00641-6014-01,NDC,outpatient,10,ML,22.61,15.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DILTIAZEM HCL 5 MG/ML IV WRAPPER,RX-4080196,CDM,S5000,HCPCS,250,RC,00641-6013-01,NDC,outpatient,5,ML,14.35,10.045,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DILTIAZEM HCL 5 MG/ML IV WRAPPER,RX-4080196,CDM,S5000,HCPCS,250,RC,00641-6013-10,NDC,outpatient,5,ML,14.35,10.045,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DILTIAZEM HCL 5 MG/ML IV WRAPPER,RX-4080196,CDM,S5000,HCPCS,250,RC,00641-6014-10,NDC,outpatient,10,ML,22.61,15.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NIFEDIPINE-LIDOCAINE 0.3%-1.5% OINT,RX-408020,CDM,S5000,HCPCS,259,RC,00000-0000-03,NDC,outpatient,30,GR,333.75,233.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METOPROLOL TARTRATE 1 MG/ML IV SOLN WRAPPER,RX-4080203,CDM,S5000,HCPCS,250,RC,00409-1778-05,NDC,outpatient,5,ML,3.47,2.429,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METOPROLOL TARTRATE 1 MG/ML IV SOLN WRAPPER,RX-4080203,CDM,S5000,HCPCS,250,RC,00409-1778-15,NDC,outpatient,5,ML,3.47,2.429,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DIBUCAINE 1 % EX OINT WRAPPER,RX-4080210,CDM,S5000,HCPCS,259,RC,71399-2829-01,NDC,outpatient,28,GR,14.21,9.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DIBUCAINE 1 % EX OINT WRAPPER,RX-4080210,CDM,S5000,HCPCS,259,RC,00536-1211-95,NDC,outpatient,28,GR,13.84,9.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
COCOA BUTTER STICK,RX-4080278,CDM,S5000,HCPCS,259,RC,07570-7011-00,NDC,outpatient,30,ML,4.41,3.087,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CAPSAICIN 0.025 % EX CREAM WRAPPER,RX-4080289,CDM,S5000,HCPCS,259,RC,00536-2525-25,NDC,outpatient,60,GR,10.95,7.665,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE-PRILOCAINE 2.5-2.5 % EX CREAM WRAPPER,RX-4080290,CDM,S5000,HCPCS,259,RC,62332-0582-04,NDC,outpatient,5,GR,24.68,17.276,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE-PRILOCAINE 2.5-2.5 % EX CREAM WRAPPER,RX-4080290,CDM,S5000,HCPCS,259,RC,62332-0582-31,NDC,outpatient,30,GR,87.18,61.026,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE-PRILOCAINE 2.5-2.5 % EX CREAM WRAPPER,RX-4080290,CDM,S5000,HCPCS,259,RC,00168-0357-55,NDC,outpatient,5,GR,29.95,20.965,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NITROGLYCERIN IN D5W 2000 MCG/20 ML IV SYRINGE,RX-4080358,CDM,S5000,HCPCS,250,RC,99999-0000-54,NDC,outpatient,20,ML,3.71,2.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NITROGLYCERIN IN D5W 2000 MCG/20 ML IV SYRINGE,RX-4080358,CDM,S5000,HCPCS,250,RC,SH408-0358-01,NDC,outpatient,20,ML,3.71,2.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MULTIVITAMIN CHILDRENS ORAL CHEW WRAPPER,RX-4080360,CDM,S5000,HCPCS,259,RC,80681-0049-00,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMPHOTERICIN B EYE DROPS 0.2 MG/ML 10 ML BOTTLE,RX-4080376,CDM,S5000,HCPCS,259,RC,SH408-0376-01,NDC,outpatient,10,ML,61.86,43.302,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ASPIRIN 1 MG/ML ORAL SUSPENSION 81 ML FOR ASA DESENSITIZATION,RX-4080380,CDM,S5000,HCPCS,259,RC,SH408-0380-01,NDC,outpatient,81,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CEFTAZIDIME EYE DROPS 22.5 MG/ML SYRINGE,RX-4080386,CDM,S5000,HCPCS,259,RC,99999-0000-32,NDC,outpatient,1,ML,37.46,26.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLINDAMYCIN MOUTH WASH 3 MG/ML,RX-4080388,CDM,S5000,HCPCS,259,RC,99999-0000-33,NDC,outpatient,250,ML,10.02,7.014,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDO 4%-EPI 0.05%-TETRACAINE 0.5% (LET) GEL 3 ML,RX-4080408,CDM,S5000,HCPCS,259,RC,99999-0003-19,NDC,outpatient,3,ML,14.57,10.199,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDO 4%-EPI 0.05%-TETRACAINE 0.5% (LET) GEL 3 ML,RX-4080408,CDM,S5000,HCPCS,259,RC,69623-0801-14,NDC,outpatient,3,ML,35.6,24.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDO 4%-EPI 0.05%-TETRACAINE 0.5% (LET) GEL 3 ML,RX-4080408,CDM,S5000,HCPCS,259,RC,70092-1135-44,NDC,outpatient,3,ML,49.22,34.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDO 4%-EPI 0.05%-TETRACAINE 0.5% (LET) GEL 3 ML,RX-4080408,CDM,S5000,HCPCS,259,RC,88888-0926-28,NDC,outpatient,3,ML,22.25,15.575,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MAG SULFATE-GLYCERIN-WATER ENEMA 180 ML,RX-4080412,CDM,S5000,HCPCS,259,RC,00000-0000-02,NDC,outpatient,180,ML,28.04,19.628,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METOPROLOL TARTRATE ORAL SUSPENSION 1 MG/ML,RX-4080416,CDM,S5000,HCPCS,259,RC,99999-0003-46,NDC,outpatient,12.5,ML,1.93,1.351,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,00121-0759-08,NDC,outpatient,237,ML,159.26,111.482,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,62135-0250-20,NDC,outpatient,20,ML,98.71,69.097,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,99999-0002-36,NDC,outpatient,5,ML,2.94,2.058,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,69238-2122-20,NDC,outpatient,20,ML,14.96,10.472,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,00121-0885-16,NDC,outpatient,480,ML,1149.17,804.419,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,62135-0250-37,NDC,outpatient,240,ML,1184.42,829.094,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,00121-0759-20,NDC,outpatient,20,ML,13.44,9.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,42799-0815-01,NDC,outpatient,237,ML,151.87,106.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,99999-0002-35,NDC,outpatient,20,ML,13.44,9.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MORPHINE 0.4 MG/ML 1 ML NEONATAL ORAL SYRINGE,RX-4080423,CDM,S5000,HCPCS,259,RC,SH408-0423-01,NDC,outpatient,1,ML,1.09,0.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MORPHINE 0.4 MG/ML 1 ML NEONATAL ORAL SYRINGE,RX-4080423,CDM,S5000,HCPCS,259,RC,99999-0001-12,NDC,outpatient,1,ML,1.09,0.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE 1 MEQ/ML 1 ML ORAL SYRINGE,RX-4080424,CDM,S5000,HCPCS,259,RC,99999-0001-25,NDC,outpatient,1,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE-MINERAL OIL-GLYCERIN ENEMA,RX-4080430,CDM,S5000,HCPCS,259,RC,SH408-0430-01,NDC,outpatient,135,ML,9.22,6.454,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POTASSIUM CHLORIDE 2 MEQ/1.5 ML ORAL SYRINGE,RX-4080432,CDM,S5000,HCPCS,259,RC,99999-0001-26,NDC,outpatient,1.5,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POTASSIUM CHLORIDE 2 MEQ/1.5 ML ORAL SYRINGE,RX-4080432,CDM,S5000,HCPCS,259,RC,,,outpatient,1.5,ML,1.92,1.344,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SPIRONOLACTONE 6 MG/3 ML ORAL SYRINGE,RX-4080435,CDM,S5000,HCPCS,259,RC,99999-0000-28,NDC,outpatient,3,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CEFAZOLIN IVPB 2 G IN 100 ML NS PREMIX,RX-4080437,CDM,S5000,HCPCS,250,RC,99999-0000-45,NDC,outpatient,100,ML,47.78,33.446,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VANCOMYCIN INTRACAMERAL INJECTION 10 MG/ML,RX-4080449,CDM,S5000,HCPCS,259,RC,SH408-0450-01,NDC,outpatient,0.1,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VANCOMYCIN INTRACAMERAL INJECTION 10 MG/ML,RX-4080449,CDM,S5000,HCPCS,259,RC,SH408-0449-01,NDC,outpatient,2,ML,22.21,15.547,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VANCOMYCIN EYE SOLUTION 25 MG/ML,RX-4080451,CDM,S5000,HCPCS,259,RC,SH408-0451-01,NDC,outpatient,20,ML,54.07,37.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VANCOMYCIN EYE SOLUTION 50 MG/ML ,RX-4080452,CDM,S5000,HCPCS,259,RC,SH408-0452-01,NDC,outpatient,20,ML,54.07,37.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
WARFARIN SODIUM 0.5 MG ORAL SPLIT TABS,RX-4080479,CDM,S5000,HCPCS,259,RC,76282-0327-01,NDC,outpatient,1,UN,1.15,0.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
WARFARIN SODIUM 0.5 MG ORAL SPLIT TABS,RX-4080479,CDM,S5000,HCPCS,259,RC,51672-4027-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
WARFARIN SODIUM 0.5 MG ORAL SPLIT TABS,RX-4080479,CDM,S5000,HCPCS,259,RC,99999-0002-46,NDC,outpatient,0.5,ME,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
WARFARIN SODIUM 1.25 MG ORAL SPLIT TABS,RX-4080485,CDM,S5000,HCPCS,259,RC,51672-4029-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
WARFARIN SODIUM 1.25 MG ORAL SPLIT TABS,RX-4080485,CDM,S5000,HCPCS,259,RC,99999-0002-47,NDC,outpatient,1.25,ME,4.53,3.171,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,69374-0315-25,NDC,outpatient,250,ML,118.35,82.845,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,69374-0533-25,NDC,outpatient,250,ML,140.6,98.42,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,70004-0785-40,NDC,outpatient,250,ML,301.03,210.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,81298-9658-01,NDC,outpatient,250,ML,261.87,183.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,70004-0775-40,NDC,outpatient,250,ML,320.83,224.581,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,70092-1468-05,NDC,outpatient,250,ML,192.22,134.554,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,70092-1652-05,NDC,outpatient,250,ML,216.97,151.879,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,81298-9658-03,NDC,outpatient,250,ML,261.87,183.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
THIAMINE HCL 100 MG ORAL TABS WRAPPER,RX-4080502,CDM,S5000,HCPCS,259,RC,48433-0108-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
THIAMINE HCL 100 MG ORAL TABS WRAPPER,RX-4080502,CDM,S5000,HCPCS,259,RC,77333-0934-25,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
THIAMINE HCL 100 MG ORAL TABS WRAPPER,RX-4080502,CDM,S5000,HCPCS,259,RC,77333-0934-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
THIAMINE HCL 100 MG ORAL TABS WRAPPER,RX-4080502,CDM,S5000,HCPCS,259,RC,00904-7191-06,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NEOSTIGMINE METHYLSULFATE 1 MG/ML SYRINGE,RX-4080506,CDM,S5000,HCPCS,250,RC,70004-0750-09,NDC,outpatient,5,ML,78.06,54.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NEOSTIGMINE METHYLSULFATE 1 MG/ML SYRINGE,RX-4080506,CDM,S5000,HCPCS,250,RC,69374-0932-03,NDC,outpatient,3,ML,45.62,31.934,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NEOSTIGMINE METHYLSULFATE 1 MG/ML SYRINGE,RX-4080506,CDM,S5000,HCPCS,250,RC,76045-0383-30,NDC,outpatient,3,ML,51.74,36.218,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NEOSTIGMINE METHYLSULFATE 1 MG/ML SYRINGE,RX-4080506,CDM,S5000,HCPCS,250,RC,76045-0383-13,NDC,outpatient,3,ML,51.74,36.218,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NEOSTIGMINE METHYLSULFATE 1 MG/ML SYRINGE,RX-4080506,CDM,S5000,HCPCS,250,RC,70092-1084-44,NDC,outpatient,5,ML,61.01,42.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FERROUS GLUCONATE 324 MG ORAL TABS WRAPPER,RX-4080542,CDM,S5000,HCPCS,259,RC,20555-0019-00,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FERROUS GLUCONATE 324 MG ORAL TABS WRAPPER,RX-4080542,CDM,S5000,HCPCS,259,RC,00574-0508-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ARTIFICIAL TEARS OP OINT WRAPPER,RX-4080546,CDM,S5000,HCPCS,259,RC,00065-0518-01,NDC,outpatient,3.5,GR,29.43,20.601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ARTIFICIAL TEARS OP OINT WRAPPER,RX-4080546,CDM,S5000,HCPCS,259,RC,10119-0022-39,NDC,outpatient,3.5,GR,30.17,21.119,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE 1 % FOR PLEURODESIS,RX-4080551,CDM,S5000,HCPCS,250,RC,99999-0003-43,NDC,outpatient,50,ML,13.37,9.359,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POTASSIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080554,CDM,S5000,HCPCS,250,RC,65219-0052-09,NDC,outpatient,5,ML,93.68,65.576,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POTASSIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080554,CDM,S5000,HCPCS,250,RC,65219-0052-29,NDC,outpatient,5,ML,93.68,65.576,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POTASSIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080554,CDM,S5000,HCPCS,250,RC,00409-7295-01,NDC,outpatient,15,ML,59.41,41.587,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POTASSIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080554,CDM,S5000,HCPCS,250,RC,00409-7295-11,NDC,outpatient,15,ML,59.41,41.587,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,00409-4888-01,NDC,outpatient,10,ML,9.82,6.874,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,00409-4888-10,NDC,outpatient,10,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,63323-0186-10,NDC,outpatient,10,ML,3.71,2.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,00409-4888-02,NDC,outpatient,10,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,63323-0186-01,NDC,outpatient,10,ML,3.71,2.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,00409-4888-12,NDC,outpatient,10,ML,9.82,6.874,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MENTHOL-ZINC OXIDE 0.44-20.625 % EX OINT WRAPPER,RX-4080556,CDM,S5000,HCPCS,259,RC,00799-0001-04,NDC,outpatient,113,GR,20.12,14.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MENTHOL-ZINC OXIDE 0.44-20.625 % EX OINT WRAPPER,RX-4080556,CDM,S5000,HCPCS,259,RC,10135-0701-04,NDC,outpatient,113,GR,13.58,9.506,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DILTIAZEM 100 MG ADDVANTAGE INFUSION IN D5W 100 ML,RX-4080558,CDM,S5000,HCPCS,250,RC,99999-0000-01,NDC,outpatient,100,ML,48.09,33.663,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HIV POST EXPOSURE KIT,RX-4080559,CDM,S5000,HCPCS,259,RC,SH408-0559-01,NDC,outpatient,1,UN,1178.97,825.279,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPIVACAINE 0.125 % IN 100 ML NS NERVE BLOCK CASSETTE,RX-4080570,CDM,S5000,HCPCS,250,RC,61553-0829-48,NDC,outpatient,100,ML,76.93,53.851,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FENTANYL 3 MCG/ML WITH BUPIVACAINE 0.125 % EPIDURAL,RX-4080589,CDM,S5000,HCPCS,250,RC,99999-0000-04,NDC,outpatient,100,ML,79.95,55.965,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VEIN GRAFT SOLUTION,RX-4080591,CDM,S5000,HCPCS,250,RC,99999-0000-07,NDC,outpatient,505.67,ML,73.5,51.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLECAINIDE ACETATE 20 MG/ML ORAL SUSP,RX-4080607,CDM,S5000,HCPCS,259,RC,99999-0003-52,NDC,outpatient,2.5,ML,2.45,1.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYOSCYAMINE SULFATE 0.125 MG SL SUBL WRAPPER,RX-4080632,CDM,S5000,HCPCS,259,RC,42192-0338-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MESALAMINE 4 G RE ENEM WRAPPER,RX-4080640,CDM,S5000,HCPCS,259,RC,45802-0098-46,NDC,outpatient,60,ML,33.11,23.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MESALAMINE 4 G RE ENEM WRAPPER,RX-4080640,CDM,S5000,HCPCS,259,RC,45802-0098-51,NDC,outpatient,60,ML,33.11,23.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MESALAMINE 4 G RE ENEM WRAPPER,RX-4080640,CDM,S5000,HCPCS,259,RC,45802-0923-41,NDC,outpatient,60,ML,80.91,56.637,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MAGNESIUM OXIDE 400 MG ORAL TABS WRAPPER,RX-4080641,CDM,S5000,HCPCS,259,RC,10006-0700-28,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MAGNESIUM OXIDE 400 MG ORAL TABS WRAPPER,RX-4080641,CDM,S5000,HCPCS,259,RC,64980-0339-90,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MAGNESIUM OXIDE 400 MG ORAL TABS WRAPPER,RX-4080641,CDM,S5000,HCPCS,259,RC,64980-0339-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MAGNESIUM GLUCONATE 500 MG ORAL TABS WRAPPER,RX-4080642,CDM,S5000,HCPCS,259,RC,60258-0172-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GI COCKTAIL SUSPENSION,RX-4080647,CDM,S5000,HCPCS,259,RC,99999-0000-39,NDC,outpatient,55,ML,82.33,57.631,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CARDIOPLEGIA SOLN DEL NIDO,RX-4080676,CDM,S5000,HCPCS,250,RC,99999-0004-39,NDC,outpatient,1052.8,ML,113.01,79.107,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
EPINEPHRINE PF 10 MCG/ML 10 ML SYRINGE,RX-4080700,CDM,S5000,HCPCS,250,RC,70092-1617-46,NDC,outpatient,10,ML,31.42,21.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
EPINEPHRINE PF 10 MCG/ML 10 ML SYRINGE,RX-4080700,CDM,S5000,HCPCS,250,RC,70092-1512-46,NDC,outpatient,10,ML,20.96,14.672,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE 0.9 % IV SOLN MINI-BAG 100 ML,RX-4080711,CDM,S5000,HCPCS,250,RC,00338-0553-18,NDC,outpatient,100,ML,29.37,20.559,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HYDROCORTISONE ORAL SUSPENSION 2.5 MG/ML COMPOUNDED PRODUCT,RX-4080716,CDM,S5000,HCPCS,259,RC,99999-0000-80,NDC,outpatient,1,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLUDROCORTISONE ACETATE SUSP 0.2 MG/ML,RX-4080718,CDM,S5000,HCPCS,259,RC,99999-0000-81,NDC,outpatient,1,ML,4.96,3.472,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ZINC OXIDE 40 % (BOUDREAUX'S) PASTE,RX-4080754,CDM,S5000,HCPCS,259,RC,74300-0000-71,NDC,outpatient,113,GR,26.15,18.305,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ZINC OXIDE 40 % (BOUDREAUX'S) PASTE,RX-4080754,CDM,S5000,HCPCS,259,RC,62103-0323-02,NDC,outpatient,57,GR,14.72,10.304,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NALOXONE INHALATION KIT - HOSPITAL USE ONLY,RX-4080774,CDM,S5000,HCPCS,259,RC,99999-0000-90,NDC,outpatient,1,UN,110.81,77.567,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CISATRACURIUM BESYLATE 10 MG/ML IV SOLN WRAPPER,RX-4080786,CDM,S5000,HCPCS,250,RC,00409-1103-11,NDC,outpatient,20,ML,230.78,161.546,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CISATRACURIUM BESYLATE 10 MG/ML IV SOLN WRAPPER,RX-4080786,CDM,S5000,HCPCS,250,RC,00409-1103-01,NDC,outpatient,20,ML,230.78,161.546,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CEFAZOLIN IVPB 3 G IN 100 ML NS PREMIX,RX-4080801,CDM,S5000,HCPCS,250,RC,99999-0001-10,NDC,outpatient,130,ML,33.43,23.401,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PERICAPSULAR MIXTURE INJECTION,RX-4080804,CDM,S5000,HCPCS,250,RC,99999-0000-98,NDC,outpatient,50,ML,59.06,41.342,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PERICAPSULAR MIXTURE INJECTION,RX-4080804,CDM,S5000,HCPCS,250,RC,70092-1433-50,NDC,outpatient,50,ML,216.36,151.452,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRANEXAMIC ACID 5 % MOUTHWASH ORAL SUSPENSION,RX-4080811,CDM,S5000,HCPCS,259,RC,99999-0001-06,NDC,outpatient,169,ML,77.47,54.229,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP *DYE FREE*,RX-4080831,CDM,S5000,HCPCS,259,RC,50580-0170-05,NDC,outpatient,5,ML,1.37,0.959,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP *DYE FREE*,RX-4080831,CDM,S5000,HCPCS,259,RC,99999-0001-17,NDC,outpatient,5,ML,1.37,0.959,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP *DYE FREE*,RX-4080831,CDM,S5000,HCPCS,259,RC,00045-0166-04,NDC,outpatient,120,ML,28.31,19.817,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BABY BUTT BALM,RX-4080852,CDM,S5000,HCPCS,259,RC,99999-0001-13,NDC,outpatient,118.7,GR,70.96,49.672,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACETAZOLAMIDE 25 MG/ML SUSPENSION,RX-4080874,CDM,S5000,HCPCS,259,RC,99999-0001-21,NDC,outpatient,5,ML,10.93,7.651,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,00573-0513-15,NDC,outpatient,15,ML,2.32,1.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,68094-0120-59,NDC,outpatient,15,ML,7.68,5.376,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,00573-0513-30,NDC,outpatient,15,ML,2.32,1.624,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,68094-0120-61,NDC,outpatient,15,ML,7.68,5.376,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,69618-0008-58,NDC,outpatient,15,ML,2.55,1.785,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,99999-0002-20,NDC,outpatient,15,ML,2.01,1.407,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,00005-4344-62,NDC,outpatient,15,ML,2.09,1.463,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FERRIC SUBSULFATE SOLN WRAPPER,RX-4080921,CDM,S5000,HCPCS,250,RC,10481-0112-02,NDC,outpatient,8,ML,9.33,6.531,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FERRIC SUBSULFATE SOLN WRAPPER,RX-4080921,CDM,S5000,HCPCS,250,RC,10481-0112-08,NDC,outpatient,8,ML,47.67,33.369,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FERRIC SUBSULFATE SOLN WRAPPER,RX-4080921,CDM,S5000,HCPCS,250,RC,38779-1284-08,NDC,outpatient,8,ML,2.35,1.645,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FERRIC SUBSULFATE SOLN WRAPPER,RX-4080921,CDM,S5000,HCPCS,250,RC,49452-3081-02,NDC,outpatient,8,ML,2.35,1.645,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080937,CDM,S5000,HCPCS,250,RC,63323-0881-01,NDC,outpatient,15,ML,169.35,118.545,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080937,CDM,S5000,HCPCS,250,RC,63323-0170-05,NDC,outpatient,5,ML,35.56,24.892,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080937,CDM,S5000,HCPCS,250,RC,63323-0881-16,NDC,outpatient,15,ML,169.35,118.545,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080937,CDM,S5000,HCPCS,250,RC,63323-0884-01,NDC,outpatient,5,ML,79.73,55.811,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080937,CDM,S5000,HCPCS,250,RC,63323-0884-06,NDC,outpatient,5,ML,79.73,55.811,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,66794-0228-41,NDC,outpatient,5,ML,6.84,4.788,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,55150-0225-05,NDC,outpatient,5,ML,9.23,6.461,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,55150-0226-10,NDC,outpatient,10,ML,18.46,12.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,72611-0756-10,NDC,outpatient,5,ML,24.17,16.919,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,00143-9250-10,NDC,outpatient,5,ML,10.46,7.322,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,39822-4200-05,NDC,outpatient,10,ML,22.61,15.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,39822-4200-06,NDC,outpatient,10,ML,22.61,15.827,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,43066-0007-10,NDC,outpatient,5,ML,8.46,5.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,63323-0426-05,NDC,outpatient,5,ML,7.05,4.935,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,67457-0228-02,NDC,outpatient,5,ML,6.84,4.788,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,00143-9250-01,NDC,outpatient,5,ML,10.46,7.322,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,25021-0662-05,NDC,outpatient,5,ML,11.88,8.316,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,63323-0426-02,NDC,outpatient,5,ML,7.05,4.935,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,72611-0756-01,NDC,outpatient,5,ML,24.17,16.919,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMIODARONE ORAL SUSPENSION 40 MG/ML,RX-4080970,CDM,S5000,HCPCS,259,RC,99999-0001-63,NDC,outpatient,10,ML,2.04,1.428,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MORPHINE SULFATE 100 MG/100 ML IN D5W PF PREMIX,RX-4081012,CDM,S5000,HCPCS,250,RC,99999-0000-99,NDC,outpatient,100,ML,312.37,218.659,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
EPHEDRINE SULFATE 5 MG/ML IJ WRAPPER,RX-4081019,CDM,S5000,HCPCS,250,RC,14789-0250-07,NDC,outpatient,10,ML,61.68,43.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
EPHEDRINE SULFATE 5 MG/ML IJ WRAPPER,RX-4081019,CDM,S5000,HCPCS,250,RC,14789-0250-10,NDC,outpatient,10,ML,61.68,43.176,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
EPHEDRINE SULFATE 5 MG/ML IJ WRAPPER,RX-4081019,CDM,S5000,HCPCS,250,RC,42023-0243-01,NDC,outpatient,10,ML,42.55,29.785,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
INSULIN REGULAR 1 UNIT/ML INFUSION PREMIX,RX-4081020,CDM,S5000,HCPCS,250,RC,00338-0126-12,NDC,outpatient,100,ML,98.33,68.831,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
INSULIN REGULAR 1 UNIT/ML INFUSION PREMIX,RX-4081020,CDM,S5000,HCPCS,250,RC,99999-0000-87,NDC,outpatient,100,ML,34.01,23.807,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DILTIAZEM 100 MG IN 100 ML NS BATCHED INFUSION,RX-4081050,CDM,S5000,HCPCS,250,RC,99999-0002-64,NDC,outpatient,100,ML,56.68,39.676,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
URSODIOL 50 MG/ML ORAL SUSPENSION,RX-4081064,CDM,S5000,HCPCS,259,RC,99999-0002-69,NDC,outpatient,1,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPRENORPHINE-NALOXONE (SUBOXONE) SL FILM 8 MG-2 MG KIT,RX-4081171,CDM,S5000,HCPCS,259,RC,99999-0003-16,NDC,outpatient,1,UN,142.33,99.631,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,00409-1323-05,NDC,outpatient,5,ML,19.63,13.741,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,00409-1323-15,NDC,outpatient,5,ML,19.63,13.741,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,00409-4903-11,NDC,outpatient,5,ML,17.92,12.544,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,63323-0208-05,NDC,outpatient,5,ML,7.41,5.187,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,76329-3390-01,NDC,outpatient,5,ML,27.15,19.005,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,00409-4903-34,NDC,outpatient,5,ML,17.92,12.544,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRANEXAMIC ACID 100 MG/ML FOR INHALATION,RX-4081187,CDM,S5000,HCPCS,250,RC,39822-1000-01,NDC,outpatient,10,ML,23.86,16.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRANEXAMIC ACID 100 MG/ML FOR INHALATION,RX-4081187,CDM,S5000,HCPCS,250,RC,72485-0510-01,NDC,outpatient,10,ML,12.64,8.848,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRANEXAMIC ACID 100 MG/ML FOR INHALATION,RX-4081187,CDM,S5000,HCPCS,250,RC,81284-0611-00,NDC,outpatient,10,ML,24.48,17.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRANEXAMIC ACID 100 MG/ML FOR INHALATION,RX-4081187,CDM,S5000,HCPCS,250,RC,72485-0510-10,NDC,outpatient,10,ML,12.64,8.848,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRANEXAMIC ACID 100 MG/ML FOR INHALATION,RX-4081187,CDM,S5000,HCPCS,250,RC,81284-0611-10,NDC,outpatient,10,ML,24.48,17.136,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MORPHINE SULFATE 100 MG/100 ML IN NS PF PREMIX,RX-4081195,CDM,S5000,HCPCS,250,RC,99999-0003-26,NDC,outpatient,100,ML,312.37,218.659,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PANTOPRAZOLE 80 MG/100 ML INFUSION PREMIX,RX-4081208,CDM,S5000,HCPCS,250,RC,99999-0000-77,NDC,outpatient,100,ML,36.56,25.592,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NICARDIPINE HCL 40 MG IN NACL 200 ML IV SOLN WRAPPER,RX-4081293,CDM,S5000,HCPCS,250,RC,00143-9633-10,NDC,outpatient,200,ML,242.06,169.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NICARDIPINE HCL 40 MG IN NACL 200 ML IV SOLN WRAPPER,RX-4081293,CDM,S5000,HCPCS,250,RC,00143-9633-01,NDC,outpatient,200,ML,242.06,169.442,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE 3 % IV ONCE,RX-4081432,CDM,S5000,HCPCS,250,RC,99999-0003-86,NDC,outpatient,100,ML,18.06,12.642,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FAMOTIDINE IN NACL 20-0.9 MG/10 ML-% IV SOSY,RX-4081444,CDM,S5000,HCPCS,250,RC,99999-0003-96,NDC,outpatient,5,ML,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM HYALURONATE 10 MG/ML IO SOLN WRAPPER,RX-4081458,CDM,S5000,HCPCS,250,RC,05047-4508-38,NDC,outpatient,0.4,ML,397.92,278.544,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV *BATCHED*,RX-4081542,CDM,S5000,HCPCS,250,RC,99999-0004-35,NDC,outpatient,50,ML,157.29,110.103,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NALOXONE HCL 4 MG/0.1ML NA LIQD FOR CODE NARRATOR,RX-4081549,CDM,S5000,HCPCS,259,RC,00093-2165-19,NDC,outpatient,1,UN,146.88,102.816,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NALOXONE HCL 4 MG/0.1ML NA LIQD FOR CODE NARRATOR,RX-4081549,CDM,S5000,HCPCS,259,RC,00093-2165-68,NDC,outpatient,1,UN,146.88,102.816,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MORPHINE SULFATE 1 MG/ML 100 ML PCA,RX-4081551,CDM,S5000,HCPCS,250,RC,99999-0004-53,NDC,outpatient,100,ML,48.85,34.195,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MORPHINE SULFATE 1 MG/ML 100 ML PCA,RX-4081551,CDM,S5000,HCPCS,250,RC,70092-1518-75,NDC,outpatient,100,ML,209.09,146.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PRASUGREL HCL 10 MG TABS - OMNICELL CATH LAB USE ONLY,RX-4081602,CDM,S5000,HCPCS,259,RC,00378-5186-93,NDC,outpatient,0.5,UN,4.12,2.884,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PRASUGREL HCL 10 MG TABS - OMNICELL CATH LAB USE ONLY,RX-4081602,CDM,S5000,HCPCS,259,RC,65162-0002-03,NDC,outpatient,0.5,UN,2.9,2.03,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PRASUGREL HCL 10 MG TABS - OMNICELL CATH LAB USE ONLY,RX-4081602,CDM,S5000,HCPCS,259,RC,65862-0830-30,NDC,outpatient,0.5,UN,1,0.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METHADONE 10 MG TABLET DISCHARGE KIT,RX-4081610,CDM,S5000,HCPCS,259,RC,99999-0004-50,NDC,outpatient,1,UN,6.15,4.305,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PRISMASATE K 4/CA 2.5 CRRT SOLUTION,RX-40840045,CDM,S5000,HCPCS,250,RC,SH408-4045-01,NDC,outpatient,5000,ML,188.44,131.908,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PRISMASATE K 2/CA 0 CRRT SOLUTION,RX-40840046,CDM,S5000,HCPCS,250,RC,SH408-4046-01,NDC,outpatient,5000,ML,188.44,131.908,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BENZOCAINE-MENTHOL 6-10 MG MT LOZG,RX-41085,CDM,S5000,HCPCS,259,RC,78112-0011-06,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BENZOCAINE-MENTHOL 6-10 MG MT LOZG,RX-41085,CDM,S5000,HCPCS,259,RC,78112-0012-66,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GALANTAMINE HYDROBROMIDE ER 8 MG ORAL CP24,RX-41138,CDM,S5000,HCPCS,259,RC,47335-0835-83,NDC,outpatient,1,UN,5.27,3.689,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GALANTAMINE HYDROBROMIDE ER 8 MG ORAL CP24,RX-41138,CDM,S5000,HCPCS,259,RC,63629-2364-01,NDC,outpatient,1,UN,6.03,4.221,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IPRATROPIUM BROMIDE HFA 17 MCG/ACT IN AERS,RX-41142,CDM,S5000,HCPCS,259,RC,00597-0087-17,NDC,outpatient,12.9,GR,1940.98,1358.686,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ENTECAVIR 0.5 MG ORAL TABS,RX-41147,CDM,S5000,HCPCS,259,RC,00003-1611-12,NDC,outpatient,1,UN,197.48,138.236,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ENTECAVIR 1 MG ORAL TABS,RX-41148,CDM,S5000,HCPCS,259,RC,65862-0842-30,NDC,outpatient,1,UN,8.95,6.265,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FENTANYL 12 MCG/HR TD PT72,RX-41382,CDM,S5000,HCPCS,259,RC,00378-9119-98,NDC,outpatient,1,UN,50.62,35.434,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FENTANYL 12 MCG/HR TD PT72,RX-41382,CDM,S5000,HCPCS,259,RC,00378-9119-16,NDC,outpatient,1,UN,50.62,35.434,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FENTANYL 12 MCG/HR TD PT72,RX-41382,CDM,S5000,HCPCS,259,RC,47781-0423-11,NDC,outpatient,1,UN,21.37,14.959,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FENTANYL 12 MCG/HR TD PT72,RX-41382,CDM,S5000,HCPCS,259,RC,47781-0423-47,NDC,outpatient,1,UN,21.37,14.959,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PARICALCITOL 1 MCG ORAL CAPS,RX-41497,CDM,S5000,HCPCS,259,RC,49483-0687-03,NDC,outpatient,1,UN,4.45,3.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PARICALCITOL 1 MCG ORAL CAPS,RX-41497,CDM,S5000,HCPCS,259,RC,65862-0936-30,NDC,outpatient,1,UN,5.24,3.668,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVOCARNITINE 1 GM/10ML ORAL SOLN,RX-41623,CDM,S5000,HCPCS,259,RC,99999-0002-52,NDC,outpatient,10,ML,6.37,4.459,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVOCARNITINE 1 GM/10ML ORAL SOLN,RX-41623,CDM,S5000,HCPCS,259,RC,52817-0830-04,NDC,outpatient,1,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM TETRADECYL SULFATE 3 % IV SOLN,RX-41793,CDM,S5000,HCPCS,250,RC,24201-0201-05,NDC,outpatient,0.5,ML,58.03,40.621,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM TETRADECYL SULFATE 3 % IV SOLN,RX-41793,CDM,S5000,HCPCS,250,RC,67457-0163-00,NDC,outpatient,0.5,ML,58.19,40.733,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM TETRADECYL SULFATE 3 % IV SOLN,RX-41793,CDM,S5000,HCPCS,250,RC,67457-0163-02,NDC,outpatient,0.5,ML,64.31,45.017,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM TETRADECYL SULFATE 3 % IV SOLN,RX-41793,CDM,S5000,HCPCS,250,RC,24201-0201-01,NDC,outpatient,0.5,ML,58.03,40.621,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OMEGA-3-ACID ETHYL ESTERS 1 G ORAL CAPS,RX-41822,CDM,S5000,HCPCS,259,RC,64380-0761-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE 5 % EX OINT,RX-41831,CDM,S5000,HCPCS,259,RC,65162-0918-38,NDC,outpatient,35.44,GR,50,35,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE 5 % EX OINT,RX-41831,CDM,S5000,HCPCS,259,RC,64380-0789-32,NDC,outpatient,35.44,GR,61.67,43.169,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SILDENAFIL CITRATE 20 MG ORAL TABS,RX-41832,CDM,S5000,HCPCS,259,RC,63739-0072-33,NDC,outpatient,1,UN,2.21,1.547,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SILDENAFIL CITRATE 20 MG ORAL TABS,RX-41832,CDM,S5000,HCPCS,259,RC,00904-6671-04,NDC,outpatient,1,UN,2.21,1.547,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METRONIDAZOLE 1 % EX GEL,RX-41899,CDM,S5000,HCPCS,259,RC,51672-4215-03,NDC,outpatient,60,GR,258.99,181.293,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AVEENO SOOTHING BATH TREATMENT EX PACK,RX-41904,CDM,S5000,HCPCS,259,RC,08137-0036-40,NDC,outpatient,1,UN,2.74,1.918,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RAMELTEON 8 MG ORAL TABS,RX-42064,CDM,S5000,HCPCS,259,RC,50268-0708-11,NDC,outpatient,1,UN,11.47,8.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RAMELTEON 8 MG ORAL TABS,RX-42064,CDM,S5000,HCPCS,259,RC,70010-0028-03,NDC,outpatient,1,UN,6.31,4.417,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RAMELTEON 8 MG ORAL TABS,RX-42064,CDM,S5000,HCPCS,259,RC,50268-0708-15,NDC,outpatient,1,UN,11.47,8.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DICYCLOMINE HCL 10 MG/5ML ORAL SOLN,RX-42119,CDM,S5000,HCPCS,259,RC,00054-0622-63,NDC,outpatient,5,ML,3.5,2.45,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DICYCLOMINE HCL 10 MG/5ML ORAL SOLN,RX-42119,CDM,S5000,HCPCS,259,RC,99999-0003-12,NDC,outpatient,5,ML,5.06,3.542,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREGABALIN 25 MG ORAL CAPS,RX-42162,CDM,S5000,HCPCS,259,RC,60687-0473-11,NDC,outpatient,1,UN,1.96,1.372,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREGABALIN 25 MG ORAL CAPS,RX-42162,CDM,S5000,HCPCS,259,RC,50228-0350-90,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREGABALIN 25 MG ORAL CAPS,RX-42162,CDM,S5000,HCPCS,259,RC,60687-0473-01,NDC,outpatient,1,UN,1.96,1.372,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREGABALIN 50 MG ORAL CAPS,RX-42163,CDM,S5000,HCPCS,259,RC,00071-1013-41,NDC,outpatient,1,UN,45.77,32.039,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREGABALIN 50 MG ORAL CAPS,RX-42163,CDM,S5000,HCPCS,259,RC,72205-0012-90,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREGABALIN 50 MG ORAL CAPS,RX-42163,CDM,S5000,HCPCS,259,RC,00904-6992-61,NDC,outpatient,1,UN,2.3,1.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREGABALIN 75 MG ORAL CAPS,RX-42164,CDM,S5000,HCPCS,259,RC,00071-1014-41,NDC,outpatient,1,UN,45.77,32.039,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREGABALIN 75 MG ORAL CAPS,RX-42164,CDM,S5000,HCPCS,259,RC,60687-0495-01,NDC,outpatient,1,UN,1.87,1.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREGABALIN 75 MG ORAL CAPS,RX-42164,CDM,S5000,HCPCS,259,RC,60687-0495-11,NDC,outpatient,1,UN,1.87,1.309,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREGABALIN 75 MG ORAL CAPS,RX-42164,CDM,S5000,HCPCS,259,RC,62332-0121-90,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREGABALIN 75 MG ORAL CAPS,RX-42164,CDM,S5000,HCPCS,259,RC,00904-7000-61,NDC,outpatient,1,UN,2.47,1.729,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREGABALIN 100 MG ORAL CAPS,RX-42165,CDM,S5000,HCPCS,259,RC,62332-0122-90,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREGABALIN 100 MG ORAL CAPS,RX-42165,CDM,S5000,HCPCS,259,RC,00904-7001-61,NDC,outpatient,1,UN,2.38,1.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREGABALIN 100 MG ORAL CAPS,RX-42165,CDM,S5000,HCPCS,259,RC,69238-1313-09,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREGABALIN 150 MG ORAL CAPS,RX-42166,CDM,S5000,HCPCS,259,RC,00071-1016-41,NDC,outpatient,1,UN,45.77,32.039,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREGABALIN 150 MG ORAL CAPS,RX-42166,CDM,S5000,HCPCS,259,RC,00904-7002-61,NDC,outpatient,1,UN,2.56,1.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
KETAMINE HCL 10 MG/ML IJ SOLN,RX-4236,CDM,S5000,HCPCS,250,RC,42023-0113-10,NDC,outpatient,20,ML,41.57,29.099,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
KETAMINE HCL 100 MG/ML IJ SOLN,RX-4237,CDM,S5000,HCPCS,250,RC,42023-0115-10,NDC,outpatient,5,ML,53.45,37.415,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
KETAMINE HCL 50 MG/ML IJ SOLN,RX-4238,CDM,S5000,HCPCS,250,RC,00143-9508-10,NDC,outpatient,10,ML,23.23,16.261,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
KETAMINE HCL 50 MG/ML IJ SOLN,RX-4238,CDM,S5000,HCPCS,250,RC,00143-9508-01,NDC,outpatient,10,ML,23.23,16.261,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMITRIPTYLINE HCL 10 MG ORAL TABS,RX-432,CDM,S5000,HCPCS,259,RC,50268-0037-15,NDC,outpatient,1,UN,1.35,0.945,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMITRIPTYLINE HCL 10 MG ORAL TABS,RX-432,CDM,S5000,HCPCS,259,RC,50268-0037-11,NDC,outpatient,1,UN,1.35,0.945,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMITRIPTYLINE HCL 10 MG ORAL TABS,RX-432,CDM,S5000,HCPCS,259,RC,70756-0201-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMITRIPTYLINE HCL 25 MG ORAL TABS,RX-435,CDM,S5000,HCPCS,259,RC,00781-1487-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMITRIPTYLINE HCL 25 MG ORAL TABS,RX-435,CDM,S5000,HCPCS,259,RC,60687-0433-01,NDC,outpatient,1,UN,1.4,0.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMITRIPTYLINE HCL 25 MG ORAL TABS,RX-435,CDM,S5000,HCPCS,259,RC,60687-0433-11,NDC,outpatient,1,UN,1.4,0.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DIGOXIN 0.05 MG/ML ORAL SOLN,RX-43556,CDM,S5000,HCPCS,259,RC,99999-0004-03,NDC,outpatient,2.5,ML,25.53,17.871,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DIGOXIN 0.05 MG/ML ORAL SOLN,RX-43556,CDM,S5000,HCPCS,259,RC,00054-0057-46,NDC,outpatient,60,ML,612.5,428.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMITRIPTYLINE HCL 50 MG ORAL TABS,RX-436,CDM,S5000,HCPCS,259,RC,60687-0444-01,NDC,outpatient,1,UN,1.83,1.281,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMITRIPTYLINE HCL 50 MG ORAL TABS,RX-436,CDM,S5000,HCPCS,259,RC,60687-0444-11,NDC,outpatient,1,UN,1.83,1.281,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL 4 % MT SOLN,RX-43717,CDM,S5000,HCPCS,259,RC,76329-6300-05,NDC,outpatient,4,ML,116.7,81.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMMONIA AROMATIC IN INHA,RX-439,CDM,S5000,HCPCS,259,RC,67777-0251-01,NDC,outpatient,1,UN,1.04,0.728,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEUCOVORIN CALCIUM 5 MG ORAL TABS,RX-4398,CDM,S5000,HCPCS,259,RC,00555-0484-02,NDC,outpatient,1,UN,5.35,3.745,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEUCOVORIN CALCIUM 5 MG ORAL TABS,RX-4398,CDM,S5000,HCPCS,259,RC,00054-8496-19,NDC,outpatient,1,UN,7.46,5.222,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVOTHYROXINE SODIUM 25 MCG ORAL TABS,RX-4420,CDM,S5000,HCPCS,259,RC,51079-0444-01,NDC,outpatient,1,UN,2.38,1.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVOTHYROXINE SODIUM 25 MCG ORAL TABS,RX-4420,CDM,S5000,HCPCS,259,RC,51079-0444-20,NDC,outpatient,1,UN,2.38,1.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVOTHYROXINE SODIUM 25 MCG ORAL TABS,RX-4420,CDM,S5000,HCPCS,259,RC,60687-0453-01,NDC,outpatient,1,UN,1.54,1.078,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVOTHYROXINE SODIUM 25 MCG ORAL TABS,RX-4420,CDM,S5000,HCPCS,259,RC,60687-0453-11,NDC,outpatient,1,UN,1.54,1.078,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVOTHYROXINE SODIUM 50 MCG ORAL TABS,RX-4421,CDM,S5000,HCPCS,259,RC,51079-0440-20,NDC,outpatient,1,UN,2.52,1.764,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVOTHYROXINE SODIUM 50 MCG ORAL TABS,RX-4421,CDM,S5000,HCPCS,259,RC,00074-4552-11,NDC,outpatient,1,UN,6.49,4.543,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVOTHYROXINE SODIUM 50 MCG ORAL TABS,RX-4421,CDM,S5000,HCPCS,259,RC,51079-0440-01,NDC,outpatient,1,UN,2.52,1.764,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVOTHYROXINE SODIUM 50 MCG ORAL TABS,RX-4421,CDM,S5000,HCPCS,259,RC,60687-0464-11,NDC,outpatient,1,UN,1.67,1.169,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVOTHYROXINE SODIUM 50 MCG ORAL TABS,RX-4421,CDM,S5000,HCPCS,259,RC,60687-0464-01,NDC,outpatient,1,UN,1.67,1.169,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVOTHYROXINE SODIUM 75 MCG ORAL TABS,RX-4422,CDM,S5000,HCPCS,259,RC,60687-0475-11,NDC,outpatient,1,UN,2.04,1.428,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVOTHYROXINE SODIUM 75 MCG ORAL TABS,RX-4422,CDM,S5000,HCPCS,259,RC,51079-0441-20,NDC,outpatient,1,UN,2.6,1.82,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVOTHYROXINE SODIUM 75 MCG ORAL TABS,RX-4422,CDM,S5000,HCPCS,259,RC,51079-0441-01,NDC,outpatient,1,UN,2.6,1.82,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVOTHYROXINE SODIUM 75 MCG ORAL TABS,RX-4422,CDM,S5000,HCPCS,259,RC,60687-0475-01,NDC,outpatient,1,UN,2.04,1.428,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVOTHYROXINE SODIUM 100 MCG ORAL TABS,RX-4423,CDM,S5000,HCPCS,259,RC,51079-0442-20,NDC,outpatient,1,UN,2.67,1.869,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVOTHYROXINE SODIUM 100 MCG ORAL TABS,RX-4423,CDM,S5000,HCPCS,259,RC,00074-6624-11,NDC,outpatient,1,UN,6.49,4.543,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVOTHYROXINE SODIUM 100 MCG ORAL TABS,RX-4423,CDM,S5000,HCPCS,259,RC,51079-0442-01,NDC,outpatient,1,UN,2.67,1.869,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVOTHYROXINE SODIUM 125 MCG ORAL TABS,RX-4424,CDM,S5000,HCPCS,259,RC,51079-0443-20,NDC,outpatient,1,UN,3.14,2.198,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVOTHYROXINE SODIUM 125 MCG ORAL TABS,RX-4424,CDM,S5000,HCPCS,259,RC,51079-0443-01,NDC,outpatient,1,UN,3.14,2.198,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVOTHYROXINE SODIUM 150 MCG ORAL TABS,RX-4425,CDM,S5000,HCPCS,259,RC,00074-7069-11,NDC,outpatient,1,UN,6.49,4.543,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVOTHYROXINE SODIUM 150 MCG ORAL TABS,RX-4425,CDM,S5000,HCPCS,259,RC,60687-0530-01,NDC,outpatient,1,UN,2.51,1.757,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL 4 % EX SOLN,RX-4450,CDM,S5000,HCPCS,259,RC,00054-3505-47,NDC,outpatient,50,ML,107.03,74.921,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL 4 % EX SOLN,RX-4450,CDM,S5000,HCPCS,259,RC,00527-6004-80,NDC,outpatient,50,ML,75.88,53.116,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL 4 % EX SOLN,RX-4450,CDM,S5000,HCPCS,259,RC,60432-0465-51,NDC,outpatient,50,ML,131.72,92.204,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL 0.5 % IJ SOLN,RX-4451,CDM,S5000,HCPCS,250,RC,63323-0484-57,NDC,outpatient,50,ML,22.7,15.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL 1 % IJ SOLN,RX-4452,CDM,S5000,HCPCS,250,RC,00409-4276-02,NDC,outpatient,50,ML,8.23,5.761,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL 1 % IJ SOLN,RX-4452,CDM,S5000,HCPCS,250,RC,00409-4276-16,NDC,outpatient,20,ML,4.63,3.241,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL 1 % IJ SOLN,RX-4452,CDM,S5000,HCPCS,250,RC,00409-4276-01,NDC,outpatient,20,ML,4.63,3.241,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL 1 % IJ SOLN,RX-4452,CDM,S5000,HCPCS,250,RC,00409-4276-17,NDC,outpatient,50,ML,8.23,5.761,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,00409-4277-16,NDC,outpatient,20,ML,5.14,3.598,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,55150-0255-20,NDC,outpatient,20,ML,4.22,2.954,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0486-17,NDC,outpatient,10,ML,16.35,11.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0202-02,NDC,outpatient,2,ML,11.73,8.211,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0486-01,NDC,outpatient,10,ML,16.35,11.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0486-26,NDC,outpatient,20,ML,8.02,5.614,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0486-27,NDC,outpatient,20,ML,18.2,12.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,00409-4277-01,NDC,outpatient,20,ML,5.14,3.598,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,55150-0254-10,NDC,outpatient,10,ML,3.76,2.632,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0202-01,NDC,outpatient,2,ML,11.73,8.211,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0486-02,NDC,outpatient,20,ML,18.2,12.74,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMOXICILLIN 250 MG ORAL CAPS,RX-450,CDM,S5000,HCPCS,259,RC,16714-0298-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMOXICILLIN 250 MG ORAL CAPS,RX-450,CDM,S5000,HCPCS,259,RC,65862-0016-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIOTHYRONINE SODIUM 25 MCG ORAL TABS,RX-4504,CDM,S5000,HCPCS,259,RC,00093-2178-01,NDC,outpatient,1,UN,3.21,2.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIOTHYRONINE SODIUM 25 MCG ORAL TABS,RX-4504,CDM,S5000,HCPCS,259,RC,51862-0321-01,NDC,outpatient,1,UN,3.45,2.415,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LIOTHYRONINE SODIUM 25 MCG ORAL TABS,RX-4504,CDM,S5000,HCPCS,259,RC,59762-1207-01,NDC,outpatient,1,UN,3.28,2.296,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMOXICILLIN 500 MG ORAL CAPS,RX-451,CDM,S5000,HCPCS,259,RC,16714-0299-03,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LITHIUM CARBONATE 150 MG ORAL CAPS,RX-4528,CDM,S5000,HCPCS,259,RC,00054-8526-25,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LITHIUM CARBONATE 300 MG ORAL CAPS,RX-4529,CDM,S5000,HCPCS,259,RC,31722-0545-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LITHIUM CARBONATE 300 MG ORAL CAPS,RX-4529,CDM,S5000,HCPCS,259,RC,00054-8527-25,NDC,outpatient,1,UN,1.04,0.728,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMOXICILLIN 250 MG/5ML ORAL SUSR,RX-454,CDM,S5000,HCPCS,259,RC,00143-9889-15,NDC,outpatient,150,ML,20.7,14.49,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMOXICILLIN 250 MG/5ML ORAL SUSR,RX-454,CDM,S5000,HCPCS,259,RC,00093-4155-79,NDC,outpatient,80,ML,14.6,10.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMOXICILLIN 250 MG/5ML ORAL SUSR,RX-454,CDM,S5000,HCPCS,259,RC,99999-0002-83,NDC,outpatient,10,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LOPERAMIDE HCL 2 MG ORAL CAPS,RX-4560,CDM,S5000,HCPCS,259,RC,51079-0690-01,NDC,outpatient,1,UN,3,2.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LOPERAMIDE HCL 2 MG ORAL CAPS,RX-4560,CDM,S5000,HCPCS,259,RC,51079-0690-20,NDC,outpatient,1,UN,3,2.1,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LOPERAMIDE HCL 2 MG ORAL CAPS,RX-4560,CDM,S5000,HCPCS,259,RC,60687-0229-01,NDC,outpatient,1,UN,2.63,1.841,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LOPERAMIDE HCL 2 MG ORAL CAPS,RX-4560,CDM,S5000,HCPCS,259,RC,60687-0229-11,NDC,outpatient,1,UN,2.63,1.841,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LORAZEPAM 2 MG/ML ORAL CONC,RX-4571,CDM,S5000,HCPCS,259,RC,00054-3532-44,NDC,outpatient,30,ML,100.26,70.182,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LORAZEPAM 2 MG/ML ORAL CONC,RX-4571,CDM,S5000,HCPCS,259,RC,99999-0001-38,NDC,outpatient,1,ML,3.55,2.485,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LORAZEPAM 2 MG/ML ORAL CONC,RX-4571,CDM,S5000,HCPCS,259,RC,00121-0770-01,NDC,outpatient,30,ML,33.11,23.177,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LORAZEPAM 0.5 MG ORAL TABS,RX-4572,CDM,S5000,HCPCS,259,RC,00904-6007-60,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LORAZEPAM 0.5 MG ORAL TABS,RX-4572,CDM,S5000,HCPCS,259,RC,13107-0083-05,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LORAZEPAM 0.5 MG ORAL TABS,RX-4572,CDM,S5000,HCPCS,259,RC,69315-0904-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LORAZEPAM 0.5 MG ORAL TABS,RX-4572,CDM,S5000,HCPCS,259,RC,00093-3425-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LORAZEPAM 0.5 MG ORAL TABS,RX-4572,CDM,S5000,HCPCS,259,RC,00904-6007-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LORAZEPAM 1 MG ORAL TABS,RX-4573,CDM,S5000,HCPCS,259,RC,00904-6008-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LORAZEPAM 1 MG ORAL TABS,RX-4573,CDM,S5000,HCPCS,259,RC,69315-0905-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LORAZEPAM 1 MG ORAL TABS,RX-4573,CDM,S5000,HCPCS,259,RC,00093-3426-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LORAZEPAM 1 MG ORAL TABS,RX-4573,CDM,S5000,HCPCS,259,RC,69315-0905-05,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LOXAPINE SUCCINATE 25 MG ORAL CAPS,RX-4600,CDM,S5000,HCPCS,259,RC,00591-0371-01,NDC,outpatient,1,UN,2.33,1.631,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LOXAPINE SUCCINATE 5 MG ORAL CAPS,RX-4601,CDM,S5000,HCPCS,259,RC,00591-0369-01,NDC,outpatient,1,UN,1.31,0.917,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MAGNESIUM CITRATE 1.745 GM/30ML ORAL SOLN,RX-4711,CDM,S5000,HCPCS,259,RC,70677-1111-01,NDC,outpatient,296,ML,7.91,5.537,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MANNITOL 20 % IV SOLN,RX-4749,CDM,S5000,HCPCS,250,RC,00338-0357-02,NDC,outpatient,250,ML,79.42,55.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MANNITOL 20 % IV SOLN,RX-4749,CDM,S5000,HCPCS,250,RC,00990-7715-03,NDC,outpatient,500,ML,93.88,65.716,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MANNITOL 20 % IV SOLN,RX-4749,CDM,S5000,HCPCS,250,RC,00338-0357-03,NDC,outpatient,500,ML,80.53,56.371,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MANNITOL 20 % IV SOLN,RX-4749,CDM,S5000,HCPCS,250,RC,00990-7715-13,NDC,outpatient,500,ML,93.88,65.716,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MEDROXYPROGESTERONE ACETATE 10 MG ORAL TABS,RX-4854,CDM,S5000,HCPCS,259,RC,00555-0779-02,NDC,outpatient,1,UN,1.07,0.749,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MEDROXYPROGESTERONE ACETATE 2.5 MG ORAL TABS,RX-4855,CDM,S5000,HCPCS,259,RC,00555-0872-02,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METHADONE HCL 10 MG ORAL TABS,RX-4953,CDM,S5000,HCPCS,259,RC,00054-0710-20,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METHADONE HCL 10 MG ORAL TABS,RX-4953,CDM,S5000,HCPCS,259,RC,00406-5771-23,NDC,outpatient,1,UN,1.39,0.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METHADONE HCL 10 MG ORAL TABS,RX-4953,CDM,S5000,HCPCS,259,RC,00406-5771-62,NDC,outpatient,1,UN,1.39,0.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METHADONE HCL 5 MG ORAL TABS,RX-4954,CDM,S5000,HCPCS,259,RC,00406-5755-23,NDC,outpatient,1,UN,1.17,0.819,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METHADONE HCL 5 MG ORAL TABS,RX-4954,CDM,S5000,HCPCS,259,RC,00406-5755-62,NDC,outpatient,1,UN,1.17,0.819,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METHAZOLAMIDE 50 MG ORAL TABS,RX-4962,CDM,S5000,HCPCS,259,RC,00574-0791-01,NDC,outpatient,1,UN,6.49,4.543,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METHOCARBAMOL 500 MG ORAL TABS,RX-4971,CDM,S5000,HCPCS,259,RC,00904-7057-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METHOCARBAMOL 500 MG ORAL TABS,RX-4971,CDM,S5000,HCPCS,259,RC,31722-0533-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METHOCARBAMOL 500 MG ORAL TABS,RX-4971,CDM,S5000,HCPCS,259,RC,76385-0123-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METHYLPHENIDATE HCL 10 MG ORAL TABS,RX-4986,CDM,S5000,HCPCS,259,RC,68084-0823-21,NDC,outpatient,1,UN,5.13,3.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METHYLPHENIDATE HCL 10 MG ORAL TABS,RX-4986,CDM,S5000,HCPCS,259,RC,68084-0823-11,NDC,outpatient,1,UN,5.13,3.591,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METHYLPHENIDATE HCL 10 MG ORAL TABS,RX-4986,CDM,S5000,HCPCS,259,RC,00406-1144-01,NDC,outpatient,1,UN,1.43,1.001,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METHYLPREDNISOLONE 16 MG ORAL TABS,RX-4992,CDM,S5000,HCPCS,259,RC,59762-0050-01,NDC,outpatient,1,UN,8.54,5.978,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METHYLPREDNISOLONE 4 MG ORAL TABS,RX-4993,CDM,S5000,HCPCS,259,RC,00904-6914-61,NDC,outpatient,1,UN,4.37,3.059,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METHYLPREDNISOLONE 4 MG ORAL TABS,RX-4993,CDM,S5000,HCPCS,259,RC,68084-0149-11,NDC,outpatient,1,UN,4.95,3.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METHYLPREDNISOLONE 4 MG ORAL TABS,RX-4993,CDM,S5000,HCPCS,259,RC,68084-0149-01,NDC,outpatient,1,UN,4.95,3.465,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METOCLOPRAMIDE HCL 10 MG ORAL TABS,RX-5005,CDM,S5000,HCPCS,259,RC,60687-0631-01,NDC,outpatient,1,UN,2.56,1.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METOCLOPRAMIDE HCL 10 MG ORAL TABS,RX-5005,CDM,S5000,HCPCS,259,RC,60687-0631-11,NDC,outpatient,1,UN,2.56,1.792,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METOPROLOL TARTRATE 50 MG ORAL TABS,RX-5009,CDM,S5000,HCPCS,259,RC,51079-0801-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METOPROLOL TARTRATE 50 MG ORAL TABS,RX-5009,CDM,S5000,HCPCS,259,RC,51079-0801-20,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METOPROLOL TARTRATE 50 MG ORAL TABS,RX-5009,CDM,S5000,HCPCS,259,RC,62584-0266-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METOPROLOL TARTRATE 50 MG ORAL TABS,RX-5009,CDM,S5000,HCPCS,259,RC,62584-0266-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METRONIDAZOLE 250 MG ORAL TABS,RX-5015,CDM,S5000,HCPCS,259,RC,00904-7156-61,NDC,outpatient,1,UN,1.09,0.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METRONIDAZOLE 500 MG ORAL TABS,RX-5016,CDM,S5000,HCPCS,259,RC,60687-0550-01,NDC,outpatient,1,UN,2.17,1.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METRONIDAZOLE 500 MG ORAL TABS,RX-5016,CDM,S5000,HCPCS,259,RC,60687-0550-11,NDC,outpatient,1,UN,2.17,1.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METRONIDAZOLE 500 MG ORAL TABS,RX-5016,CDM,S5000,HCPCS,259,RC,29300-0227-01,NDC,outpatient,1,UN,1.76,1.232,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MICONAZOLE NITRATE 2 % EX CREA,RX-5039,CDM,S5000,HCPCS,259,RC,61269-0735-14,NDC,outpatient,14,GR,7.54,5.278,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MINERAL OIL ORAL OIL,RX-5086,CDM,S5000,HCPCS,259,RC,99999-0002-15,NDC,outpatient,30,ML,1.39,0.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MINERAL OIL ORAL OIL,RX-5086,CDM,S5000,HCPCS,259,RC,48433-0202-30,NDC,outpatient,30,ML,5.08,3.556,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MINOCYCLINE HCL 50 MG ORAL CAPS,RX-5111,CDM,S5000,HCPCS,259,RC,00591-5694-60,NDC,outpatient,1,UN,1.26,0.882,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MINOXIDIL 10 MG ORAL TABS,RX-5114,CDM,S5000,HCPCS,259,RC,68084-0205-01,NDC,outpatient,1,UN,2.48,1.736,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MINOXIDIL 10 MG ORAL TABS,RX-5114,CDM,S5000,HCPCS,259,RC,68084-0205-11,NDC,outpatient,1,UN,2.48,1.736,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MINOXIDIL 2.5 MG ORAL TABS,RX-5115,CDM,S5000,HCPCS,259,RC,00591-5642-01,NDC,outpatient,1,UN,1.01,0.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MINOXIDIL 2.5 MG ORAL TABS,RX-5115,CDM,S5000,HCPCS,259,RC,68084-0204-11,NDC,outpatient,1,UN,2.25,1.575,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MINOXIDIL 2.5 MG ORAL TABS,RX-5115,CDM,S5000,HCPCS,259,RC,68084-0204-01,NDC,outpatient,1,UN,2.25,1.575,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,00054-0237-49,NDC,outpatient,100,ML,37.38,26.166,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,68094-0001-59,NDC,outpatient,5,ML,4.7,3.29,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,68094-0001-62,NDC,outpatient,5,ML,4.7,3.29,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,00121-0904-05,NDC,outpatient,5,ML,4.01,2.807,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,00121-0904-94,NDC,outpatient,5,ML,4.01,2.807,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,99999-0002-19,NDC,outpatient,5,ML,2.14,1.498,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MORPHINE SULFATE 15 MG ORAL TABS,RX-5178,CDM,S5000,HCPCS,259,RC,00054-0235-24,NDC,outpatient,1,UN,3.2,2.24,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MORPHINE SULFATE 15 MG ORAL TABS,RX-5178,CDM,S5000,HCPCS,259,RC,00054-0235-25,NDC,outpatient,1,UN,2.1,1.47,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MORPHINE SULFATE 10 MG RE SUPP,RX-5180,CDM,S5000,HCPCS,259,RC,00574-7112-12,NDC,outpatient,1,UN,19.66,13.762,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NADOLOL 20 MG ORAL TABS,RX-5330,CDM,S5000,HCPCS,259,RC,60687-0302-25,NDC,outpatient,1,UN,11.38,7.966,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NADOLOL 20 MG ORAL TABS,RX-5330,CDM,S5000,HCPCS,259,RC,60687-0302-95,NDC,outpatient,1,UN,11.38,7.966,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NADOLOL 40 MG ORAL TABS,RX-5331,CDM,S5000,HCPCS,259,RC,00904-7071-07,NDC,outpatient,1,UN,9.11,6.377,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NADOLOL 40 MG ORAL TABS,RX-5331,CDM,S5000,HCPCS,259,RC,69097-0868-07,NDC,outpatient,1,UN,1.13,0.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NAPROXEN 250 MG ORAL TABS,RX-5391,CDM,S5000,HCPCS,259,RC,50268-0594-15,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NAPROXEN 250 MG ORAL TABS,RX-5391,CDM,S5000,HCPCS,259,RC,50268-0594-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NAPROXEN 250 MG ORAL TABS,RX-5391,CDM,S5000,HCPCS,259,RC,65162-0188-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NAPROXEN 375 MG ORAL TABS,RX-5392,CDM,S5000,HCPCS,259,RC,50268-0595-15,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NAPROXEN 375 MG ORAL TABS,RX-5392,CDM,S5000,HCPCS,259,RC,50268-0595-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NAPROXEN 375 MG ORAL TABS,RX-5392,CDM,S5000,HCPCS,259,RC,65162-0189-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NAPROXEN 500 MG ORAL TABS,RX-5393,CDM,S5000,HCPCS,259,RC,65162-0190-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NAPROXEN 500 MG ORAL TABS,RX-5393,CDM,S5000,HCPCS,259,RC,63739-0403-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NAPROXEN 500 MG ORAL TABS,RX-5393,CDM,S5000,HCPCS,259,RC,65862-0522-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NEOMYCIN SULFATE 500 MG ORAL TABS,RX-5472,CDM,S5000,HCPCS,259,RC,39822-0310-05,NDC,outpatient,1,UN,3.09,2.163,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NEOMYCIN SULFATE 500 MG ORAL TABS,RX-5472,CDM,S5000,HCPCS,259,RC,39822-0310-07,NDC,outpatient,1,UN,3.09,2.163,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NEOMYCIN-POLYMYXIN-GRAMICIDIN 1.75-10000-.025 OP SOLN,RX-5474,CDM,S5000,HCPCS,259,RC,24208-0790-62,NDC,outpatient,10,ML,150.86,105.602,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NIACIN 100 MG ORAL TABS,RX-5539,CDM,S5000,HCPCS,259,RC,80681-0057-00,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NIFEDIPINE 10 MG ORAL CAPS,RX-5558,CDM,S5000,HCPCS,259,RC,23155-0194-01,NDC,outpatient,1,UN,1.98,1.386,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NITROFURANTOIN MACROCRYSTAL 50 MG ORAL CAPS,RX-5595,CDM,S5000,HCPCS,259,RC,57664-0232-88,NDC,outpatient,1,UN,3.41,2.387,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NITROGLYCERIN 0.3 MG SL SUBL,RX-5603,CDM,S5000,HCPCS,259,RC,68462-0638-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NITROGLYCERIN 0.3 MG SL SUBL,RX-5603,CDM,S5000,HCPCS,259,RC,72888-0138-01,NDC,outpatient,1,UN,1.43,1.001,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NITROGLYCERIN 0.3 MG SL SUBL,RX-5603,CDM,S5000,HCPCS,259,RC,00071-0417-24,NDC,outpatient,1,UN,3.05,2.135,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NITROGLYCERIN 0.4 MG SL SUBL,RX-5604,CDM,S5000,HCPCS,259,RC,43598-0436-11,NDC,outpatient,0.75,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NITROGLYCERIN 0.4 MG SL SUBL,RX-5604,CDM,S5000,HCPCS,259,RC,43598-0436-35,NDC,outpatient,0.75,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NITROGLYCERIN 0.4 MG SL SUBL,RX-5604,CDM,S5000,HCPCS,259,RC,68462-0639-45,NDC,outpatient,0.75,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NITROGLYCERIN 0.4 MG SL SUBL,RX-5604,CDM,S5000,HCPCS,259,RC,68462-0639-25,NDC,outpatient,0.75,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NITROGLYCERIN 2 % TD OINT,RX-5606,CDM,S5000,HCPCS,259,RC,00281-0326-08,NDC,outpatient,1,GR,9.96,6.972,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NORTRIPTYLINE HCL 25 MG ORAL CAPS,RX-5675,CDM,S5000,HCPCS,259,RC,60687-0293-11,NDC,outpatient,1,UN,1.89,1.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NORTRIPTYLINE HCL 25 MG ORAL CAPS,RX-5675,CDM,S5000,HCPCS,259,RC,60687-0293-01,NDC,outpatient,1,UN,1.89,1.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NYSTATIN 100000 UNIT/GM EX CREA,RX-5749,CDM,S5000,HCPCS,259,RC,00713-0678-15,NDC,outpatient,15,GR,53.4,37.38,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NYSTATIN 100000 UNIT/GM EX CREA,RX-5749,CDM,S5000,HCPCS,259,RC,45802-0059-35,NDC,outpatient,15,GR,17.03,11.921,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NYSTATIN 100000 UNIT/GM EX CREA,RX-5749,CDM,S5000,HCPCS,259,RC,51672-1289-01,NDC,outpatient,15,GR,18.83,13.181,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NYSTATIN 100000 UNIT/GM EX OINT,RX-5750,CDM,S5000,HCPCS,259,RC,45802-0048-35,NDC,outpatient,15,GR,13.29,9.303,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NYSTATIN 100000 UNIT/GM EX OINT,RX-5750,CDM,S5000,HCPCS,259,RC,00472-0166-15,NDC,outpatient,15,GR,61.35,42.945,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,00121-0868-00,NDC,outpatient,5,ML,4.74,3.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,00121-1045-16,NDC,outpatient,5,ML,4.21,2.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,63739-0160-10,NDC,outpatient,5,ML,2.63,1.841,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,99999-0003-91,NDC,outpatient,5,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,00121-0868-05,NDC,outpatient,5,ML,4.74,3.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,63739-0160-70,NDC,outpatient,5,ML,2.63,1.841,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NYSTATIN-TRIAMCINOLONE 100000-0.1 UNIT/GM-% EX CREA,RX-5754,CDM,S5000,HCPCS,259,RC,51672-1263-01,NDC,outpatient,15,GR,15.02,10.514,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NYSTATIN-TRIAMCINOLONE 100000-0.1 UNIT/GM-% EX OINT,RX-5755,CDM,S5000,HCPCS,259,RC,51672-1272-01,NDC,outpatient,15,GR,22.37,15.659,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ORA-PLUS ORAL LIQD,RX-5851,CDM,S5000,HCPCS,259,RC,00574-0303-16,NDC,outpatient,473,ML,130.96,91.672,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ORA-SWEET SF ORAL SYRP,RX-5853,CDM,S5000,HCPCS,259,RC,00574-0302-16,NDC,outpatient,473,ML,130.96,91.672,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXAZEPAM 10 MG ORAL CAPS,RX-5930,CDM,S5000,HCPCS,259,RC,00228-2067-10,NDC,outpatient,1,UN,3.24,2.268,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXAZEPAM 10 MG ORAL CAPS,RX-5930,CDM,S5000,HCPCS,259,RC,62584-0812-11,NDC,outpatient,1,UN,8.63,6.041,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXAZEPAM 10 MG ORAL CAPS,RX-5930,CDM,S5000,HCPCS,259,RC,62584-0812-01,NDC,outpatient,1,UN,8.63,6.041,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXAZEPAM 15 MG ORAL CAPS,RX-5931,CDM,S5000,HCPCS,259,RC,62584-0813-01,NDC,outpatient,1,UN,9.09,6.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXAZEPAM 15 MG ORAL CAPS,RX-5931,CDM,S5000,HCPCS,259,RC,62584-0813-11,NDC,outpatient,1,UN,9.09,6.363,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXYBUTYNIN CHLORIDE 5 MG ORAL TABS,RX-5938,CDM,S5000,HCPCS,259,RC,00904-7027-61,NDC,outpatient,1,UN,1.69,1.183,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXYBUTYNIN CHLORIDE 5 MG ORAL TABS,RX-5938,CDM,S5000,HCPCS,259,RC,60687-0670-11,NDC,outpatient,1,UN,1.85,1.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXYBUTYNIN CHLORIDE 5 MG ORAL TABS,RX-5938,CDM,S5000,HCPCS,259,RC,60687-0670-01,NDC,outpatient,1,UN,1.85,1.295,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXYCODONE-ACETAMINOPHEN 5-325 MG ORAL TABS,RX-5940,CDM,S5000,HCPCS,259,RC,00406-0512-23,NDC,outpatient,1,UN,1.65,1.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OXYCODONE-ACETAMINOPHEN 5-325 MG ORAL TABS,RX-5940,CDM,S5000,HCPCS,259,RC,00406-0512-62,NDC,outpatient,1,UN,1.65,1.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PAPAVERINE HCL 30 MG/ML IJ SOLN,RX-6030,CDM,S5000,HCPCS,250,RC,54288-0142-01,NDC,outpatient,2,ML,69.91,48.937,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PAPAVERINE HCL 30 MG/ML IJ SOLN,RX-6030,CDM,S5000,HCPCS,250,RC,54288-0142-10,NDC,outpatient,2,ML,69.91,48.937,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PAPAVERINE HCL 30 MG/ML IJ SOLN,RX-6030,CDM,S5000,HCPCS,250,RC,00517-4002-25,NDC,outpatient,2,ML,103.84,72.688,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PAPAVERINE HCL 30 MG/ML IJ SOLN,RX-6030,CDM,S5000,HCPCS,250,RC,14789-0121-07,NDC,outpatient,2,ML,78.96,55.272,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PAPAVERINE HCL 30 MG/ML IJ SOLN,RX-6030,CDM,S5000,HCPCS,250,RC,14789-0121-05,NDC,outpatient,2,ML,78.96,55.272,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PENICILLIN G SODIUM 5000000 UNITS IJ SOLR,RX-6087,CDM,S5000,HCPCS,250,RC,00781-6153-95,NDC,outpatient,1,UN,142.02,99.414,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PENICILLIN G SODIUM 5000000 UNITS IJ SOLR,RX-6087,CDM,S5000,HCPCS,250,RC,00781-6153-94,NDC,outpatient,1,UN,142.02,99.414,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PENICILLIN V POTASSIUM 250 MG/5ML ORAL SOLR,RX-6091,CDM,S5000,HCPCS,259,RC,99999-0002-88,NDC,outpatient,10,ML,2.67,1.869,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PENICILLIN V POTASSIUM 250 MG/5ML ORAL SOLR,RX-6091,CDM,S5000,HCPCS,259,RC,00093-4127-73,NDC,outpatient,100,ML,26.7,18.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PENICILLIN V POTASSIUM 250 MG ORAL TABS,RX-6092,CDM,S5000,HCPCS,259,RC,57237-0040-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PENICILLIN V POTASSIUM 500 MG ORAL TABS,RX-6093,CDM,S5000,HCPCS,259,RC,00093-1174-01,NDC,outpatient,1,UN,1.67,1.169,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PENICILLIN V POTASSIUM 500 MG ORAL TABS,RX-6093,CDM,S5000,HCPCS,259,RC,00143-9836-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PERPHENAZINE 2 MG ORAL TABS,RX-6157,CDM,S5000,HCPCS,259,RC,00904-6599-61,NDC,outpatient,1,UN,2.75,1.925,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PERPHENAZINE 8 MG ORAL TABS,RX-6159,CDM,S5000,HCPCS,259,RC,00904-6601-61,NDC,outpatient,1,UN,5.02,3.514,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PHENAZOPYRIDINE HCL 100 MG ORAL TABS,RX-6193,CDM,S5000,HCPCS,259,RC,65162-0681-10,NDC,outpatient,1,UN,1.61,1.127,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,00121-0942-05,NDC,outpatient,5,ML,7.01,4.907,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,00121-0942-50,NDC,outpatient,5,ML,7.01,4.907,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,13517-0107-16,NDC,outpatient,473,ML,307.31,215.117,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,16571-0675-16,NDC,outpatient,473,ML,82.09,57.463,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,99999-0002-30,NDC,outpatient,5,ML,2.5,1.75,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,54932-0501-81,NDC,outpatient,473,ML,75.78,53.046,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PHENOBARBITAL 32.4 MG ORAL TABS,RX-6217,CDM,S5000,HCPCS,259,RC,00904-6575-61,NDC,outpatient,1,UN,1.34,0.938,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PHENOBARBITAL 32.4 MG ORAL TABS,RX-6217,CDM,S5000,HCPCS,259,RC,16571-0673-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PHENYLEPHRINE HCL 0.25 % NA SOLN,RX-6243,CDM,S5000,HCPCS,259,RC,00225-0800-47,NDC,outpatient,15,ML,13.42,9.394,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PHENYLEPHRINE HCL 0.5 % NA SOLN,RX-6244,CDM,S5000,HCPCS,259,RC,00225-0805-47,NDC,outpatient,15,ML,13.42,9.394,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PHENYLEPHRINE HCL 1 % NA SOLN,RX-6245,CDM,S5000,HCPCS,259,RC,00225-0810-47,NDC,outpatient,15,ML,15.09,10.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PHENYLEPHRINE HCL 2.5 % OP SOLN,RX-6246,CDM,S5000,HCPCS,259,RC,70756-0629-25,NDC,outpatient,2,ML,146.94,102.858,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PHENYTOIN 125 MG/5ML ORAL SUSP,RX-6255,CDM,S5000,HCPCS,259,RC,60687-0275-62,NDC,outpatient,4,ML,13.48,9.436,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PHENYTOIN 125 MG/5ML ORAL SUSP,RX-6255,CDM,S5000,HCPCS,259,RC,60687-0275-66,NDC,outpatient,4,ML,13.48,9.436,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAPS,RX-6257,CDM,S5000,HCPCS,259,RC,57664-0808-88,NDC,outpatient,1,UN,1.19,0.833,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAPS,RX-6257,CDM,S5000,HCPCS,259,RC,65862-0692-01,NDC,outpatient,1,UN,1.74,1.218,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PILOCARPINE HCL 1 % OP SOLN,RX-6279,CDM,S5000,HCPCS,259,RC,61314-0203-15,NDC,outpatient,15,ML,342.03,239.421,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PILOCARPINE HCL 2 % OP SOLN,RX-6280,CDM,S5000,HCPCS,259,RC,70069-0191-01,NDC,outpatient,15,ML,140.98,98.686,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PILOCARPINE HCL 2 % OP SOLN,RX-6280,CDM,S5000,HCPCS,259,RC,61314-0204-15,NDC,outpatient,15,ML,351.44,246.008,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PILOCARPINE HCL 4 % OP SOLN,RX-6282,CDM,S5000,HCPCS,259,RC,61314-0206-15,NDC,outpatient,15,ML,326.81,228.767,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PIROXICAM 10 MG ORAL CAPS,RX-6310,CDM,S5000,HCPCS,259,RC,42571-0176-01,NDC,outpatient,1,UN,3.12,2.184,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POLY-VI-SOL ORAL SOLN,RX-6374,CDM,S5000,HCPCS,259,RC,00087-0402-03,NDC,outpatient,1,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POLY-VI-SOL ORAL SOLN,RX-6374,CDM,S5000,HCPCS,259,RC,99999-0001-68,NDC,outpatient,1,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POLYMYXIN B SULFATE 500000 UNITS IJ SOLR,RX-6393,CDM,S5000,HCPCS,250,RC,55150-0234-10,NDC,outpatient,1,UN,16.13,11.291,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POTASSIUM ACETATE 2 MEQ/ML IV SOLN,RX-6420,CDM,S5000,HCPCS,250,RC,51754-2001-04,NDC,outpatient,20,ML,18.07,12.649,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POTASSIUM ACETATE 2 MEQ/ML IV SOLN,RX-6420,CDM,S5000,HCPCS,250,RC,00409-8183-01,NDC,outpatient,20,ML,16.35,11.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POTASSIUM ACETATE 2 MEQ/ML IV SOLN,RX-6420,CDM,S5000,HCPCS,250,RC,00409-8183-11,NDC,outpatient,20,ML,16.35,11.445,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POVIDONE-IODINE 10 % EX SOLN,RX-6458,CDM,S5000,HCPCS,259,RC,52380-1905-00,NDC,outpatient,59,ML,4.73,3.311,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PRAZOSIN HCL 1 MG ORAL CAPS,RX-6468,CDM,S5000,HCPCS,259,RC,51079-0630-01,NDC,outpatient,1,UN,6.21,4.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PRAZOSIN HCL 1 MG ORAL CAPS,RX-6468,CDM,S5000,HCPCS,259,RC,68084-0996-11,NDC,outpatient,1,UN,5.34,3.738,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PRAZOSIN HCL 1 MG ORAL CAPS,RX-6468,CDM,S5000,HCPCS,259,RC,51079-0630-20,NDC,outpatient,1,UN,6.21,4.347,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PRAZOSIN HCL 1 MG ORAL CAPS,RX-6468,CDM,S5000,HCPCS,259,RC,68084-0996-01,NDC,outpatient,1,UN,5.34,3.738,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PRAZOSIN HCL 5 MG ORAL CAPS,RX-6470,CDM,S5000,HCPCS,259,RC,51079-0632-20,NDC,outpatient,1,UN,14.76,10.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PRAZOSIN HCL 5 MG ORAL CAPS,RX-6470,CDM,S5000,HCPCS,259,RC,51079-0632-01,NDC,outpatient,1,UN,14.76,10.332,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREDNISOLONE ACETATE 1 % OP SUSP,RX-6487,CDM,S5000,HCPCS,259,RC,60758-0119-05,NDC,outpatient,5,ML,106.58,74.606,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREDNISOLONE ACETATE 1 % OP SUSP,RX-6487,CDM,S5000,HCPCS,259,RC,61314-0637-05,NDC,outpatient,5,ML,113.48,79.436,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREDNISOLONE ACETATE 1 % OP SUSP,RX-6487,CDM,S5000,HCPCS,259,RC,11980-0180-05,NDC,outpatient,5,ML,534.23,373.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREDNISONE 1 MG ORAL TABS,RX-6493,CDM,S5000,HCPCS,259,RC,00054-8739-25,NDC,outpatient,1,UN,1.06,0.742,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREDNISONE 1 MG ORAL TABS,RX-6493,CDM,S5000,HCPCS,259,RC,59651-0484-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREDNISONE 1 MG ORAL TABS,RX-6493,CDM,S5000,HCPCS,259,RC,00054-4741-25,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREDNISONE 10 MG ORAL TABS,RX-6494,CDM,S5000,HCPCS,259,RC,00054-0017-20,NDC,outpatient,1,UN,1.02,0.714,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREDNISONE 10 MG ORAL TABS,RX-6494,CDM,S5000,HCPCS,259,RC,00603-5338-21,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREDNISONE 10 MG ORAL TABS,RX-6494,CDM,S5000,HCPCS,259,RC,60687-0134-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREDNISONE 10 MG ORAL TABS,RX-6494,CDM,S5000,HCPCS,259,RC,60687-0134-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREDNISONE 10 MG ORAL TABS,RX-6494,CDM,S5000,HCPCS,259,RC,00904-6923-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREDNISONE 2.5 MG ORAL TABS,RX-6495,CDM,S5000,HCPCS,259,RC,00054-8740-25,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREDNISONE 2.5 MG ORAL TABS,RX-6495,CDM,S5000,HCPCS,259,RC,00054-4742-25,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,00904-7127-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,60687-0145-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,00054-0018-20,NDC,outpatient,1,UN,1.09,0.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,59746-0175-06,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,60687-0145-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,64380-0785-07,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREDNISONE 5 MG ORAL TABS,RX-6497,CDM,S5000,HCPCS,259,RC,60687-0122-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREDNISONE 5 MG ORAL TABS,RX-6497,CDM,S5000,HCPCS,259,RC,60687-0122-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREDNISONE 5 MG ORAL TABS,RX-6497,CDM,S5000,HCPCS,259,RC,00054-8724-25,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREDNISONE 50 MG ORAL TABS,RX-6498,CDM,S5000,HCPCS,259,RC,10135-0779-01,NDC,outpatient,1,UN,1.24,0.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREDNISONE 50 MG ORAL TABS,RX-6498,CDM,S5000,HCPCS,259,RC,59651-0489-01,NDC,outpatient,1,UN,1.61,1.127,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREDNISONE 50 MG ORAL TABS,RX-6498,CDM,S5000,HCPCS,259,RC,00054-0019-20,NDC,outpatient,1,UN,1.23,0.861,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PREDNISONE 50 MG ORAL TABS,RX-6498,CDM,S5000,HCPCS,259,RC,00054-0019-25,NDC,outpatient,1,UN,1.08,0.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ASCORBIC ACID 500 MG/ML IJ SOLN,RX-654,CDM,S5000,HCPCS,250,RC,67157-0101-51,NDC,outpatient,50,ML,1099.15,769.405,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PRIMIDONE 250 MG ORAL TABS,RX-6544,CDM,S5000,HCPCS,259,RC,50268-0687-11,NDC,outpatient,1,UN,2.53,1.771,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PRIMIDONE 250 MG ORAL TABS,RX-6544,CDM,S5000,HCPCS,259,RC,50268-0687-15,NDC,outpatient,1,UN,2.53,1.771,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PROBENECID 500 MG ORAL TABS,RX-6561,CDM,S5000,HCPCS,259,RC,00591-5347-01,NDC,outpatient,1,UN,2.65,1.855,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PROMETHAZINE-CODEINE 6.25-10 MG/5ML ORAL SYRP,RX-6627,CDM,S5000,HCPCS,259,RC,99999-0002-39,NDC,outpatient,5,ML,1.21,0.847,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PROMETHAZINE-CODEINE 6.25-10 MG/5ML ORAL SYRP,RX-6627,CDM,S5000,HCPCS,259,RC,27808-0065-02,NDC,outpatient,2.5,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ASCORBIC ACID 500 MG ORAL TABS,RX-664,CDM,S5000,HCPCS,259,RC,00904-0523-60,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ASCORBIC ACID 500 MG ORAL TABS,RX-664,CDM,S5000,HCPCS,259,RC,00904-0523-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PROPARACAINE HCL 0.5 % OP SOLN,RX-6644,CDM,S5000,HCPCS,259,RC,24208-0730-06,NDC,outpatient,15,ML,110.61,77.427,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PROPARACAINE HCL 0.5 % OP SOLN,RX-6644,CDM,S5000,HCPCS,259,RC,61314-0016-01,NDC,outpatient,15,ML,111.21,77.847,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PROPRANOLOL HCL 20 MG/5ML ORAL SOLN,RX-6654,CDM,S5000,HCPCS,259,RC,00121-0908-05,NDC,outpatient,5,ML,10.08,7.056,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PROPRANOLOL HCL 20 MG/5ML ORAL SOLN,RX-6654,CDM,S5000,HCPCS,259,RC,00121-0908-40,NDC,outpatient,5,ML,10.08,7.056,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PROPRANOLOL HCL 20 MG/5ML ORAL SOLN,RX-6654,CDM,S5000,HCPCS,259,RC,00054-3727-63,NDC,outpatient,500,ML,209.15,146.405,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PROPRANOLOL HCL 10 MG ORAL TABS,RX-6656,CDM,S5000,HCPCS,259,RC,69238-2077-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PROPRANOLOL HCL 10 MG ORAL TABS,RX-6656,CDM,S5000,HCPCS,259,RC,00378-0182-01,NDC,outpatient,1,UN,1.22,0.854,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PROPRANOLOL HCL 10 MG ORAL TABS,RX-6656,CDM,S5000,HCPCS,259,RC,60687-0587-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PROPRANOLOL HCL 10 MG ORAL TABS,RX-6656,CDM,S5000,HCPCS,259,RC,60687-0587-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PROPRANOLOL HCL 40 MG ORAL TABS,RX-6658,CDM,S5000,HCPCS,259,RC,60687-0609-01,NDC,outpatient,1,UN,2.26,1.582,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PROPRANOLOL HCL 40 MG ORAL TABS,RX-6658,CDM,S5000,HCPCS,259,RC,00603-5484-21,NDC,outpatient,1,UN,1.21,0.847,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PROPRANOLOL HCL 40 MG ORAL TABS,RX-6658,CDM,S5000,HCPCS,259,RC,60687-0609-11,NDC,outpatient,1,UN,2.26,1.582,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PROPYLTHIOURACIL 50 MG ORAL TABS,RX-6662,CDM,S5000,HCPCS,259,RC,67253-0651-10,NDC,outpatient,1,UN,2.63,1.841,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PROPYLTHIOURACIL 50 MG ORAL TABS,RX-6662,CDM,S5000,HCPCS,259,RC,00228-2348-10,NDC,outpatient,1,UN,3.18,2.226,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PSEUDOEPHEDRINE HCL 30 MG ORAL TABS,RX-6714,CDM,S5000,HCPCS,259,RC,00904-6990-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PSEUDOEPHEDRINE HCL 30 MG ORAL TABS,RX-6714,CDM,S5000,HCPCS,259,RC,00904-5053-59,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PYRAZINAMIDE 500 MG ORAL TABS,RX-6738,CDM,S5000,HCPCS,259,RC,10135-0735-60,NDC,outpatient,1,UN,15.09,10.563,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PYRAZINAMIDE 500 MG ORAL TABS,RX-6738,CDM,S5000,HCPCS,259,RC,33342-0447-11,NDC,outpatient,1,UN,19.28,13.496,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PYRAZINAMIDE 500 MG ORAL TABS,RX-6738,CDM,S5000,HCPCS,259,RC,70954-0484-10,NDC,outpatient,1,UN,17.43,12.201,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PYRIDOXINE HCL 50 MG ORAL TABS,RX-6748,CDM,S5000,HCPCS,259,RC,50268-0858-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PYRIDOXINE HCL 50 MG ORAL TABS,RX-6748,CDM,S5000,HCPCS,259,RC,77333-0940-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PYRIDOXINE HCL 50 MG ORAL TABS,RX-6748,CDM,S5000,HCPCS,259,RC,77333-0940-25,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PYRIDOXINE HCL 50 MG ORAL TABS,RX-6748,CDM,S5000,HCPCS,259,RC,50268-0858-15,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
QUININE SULFATE 324 MG ORAL CAPS,RX-6781,CDM,S5000,HCPCS,259,RC,50742-0238-30,NDC,outpatient,1,UN,2.82,1.974,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ASPIRIN 81 MG ORAL CHEW,RX-680,CDM,S5000,HCPCS,259,RC,63739-0434-02,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ASPIRIN 81 MG ORAL CHEW,RX-680,CDM,S5000,HCPCS,259,RC,00904-6794-80,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ASPIRIN 81 MG ORAL CHEW,RX-680,CDM,S5000,HCPCS,259,RC,66553-0002-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ASPIRIN 81 MG ORAL CHEW,RX-680,CDM,S5000,HCPCS,259,RC,00904-6794-30,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ASPIRIN 325 MG ORAL TABS,RX-681,CDM,S5000,HCPCS,259,RC,57896-0901-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ASPIRIN 325 MG ORAL TABS,RX-681,CDM,S5000,HCPCS,259,RC,66553-0001-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ASPIRIN 325 MG ORAL TBEC,RX-685,CDM,S5000,HCPCS,259,RC,57896-0921-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ASPIRIN 81 MG ORAL TBEC,RX-688,CDM,S5000,HCPCS,259,RC,00904-6783-70,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ASPIRIN 81 MG ORAL TBEC,RX-688,CDM,S5000,HCPCS,259,RC,63739-0212-02,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ASPIRIN 81 MG ORAL TBEC,RX-688,CDM,S5000,HCPCS,259,RC,00536-1234-41,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ASPIRIN 300 MG RE SUPP,RX-693,CDM,S5000,HCPCS,259,RC,00574-7034-12,NDC,outpatient,1,UN,4.58,3.206,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
INSULIN DETEMIR 100 UNIT/ML SC SOLN,RX-70261,CDM,S5000,HCPCS,259,RC,00169-3687-12,NDC,outpatient,10,ML,388.27,271.789,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PACK,RX-70284,CDM,S5000,HCPCS,259,RC,71351-0010-01,NDC,outpatient,1,UN,1.65,1.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PACK,RX-70284,CDM,S5000,HCPCS,259,RC,71351-0010-99,NDC,outpatient,1,UN,1.65,1.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PACK,RX-70284,CDM,S5000,HCPCS,259,RC,60258-0006-15,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PACK,RX-70284,CDM,S5000,HCPCS,259,RC,60258-0006-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SALINE NASAL SPRAY 0.65 % NA SOLN,RX-7030,CDM,S5000,HCPCS,259,RC,00904-3865-75,NDC,outpatient,44,ML,3.33,2.331,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SALINE NASAL SPRAY 0.65 % NA SOLN,RX-7030,CDM,S5000,HCPCS,259,RC,49348-0356-25,NDC,outpatient,44,ML,5.88,4.116,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRAMADOL HCL ER 200 MG ORAL TB24,RX-70353,CDM,S5000,HCPCS,259,RC,68180-0698-06,NDC,outpatient,1,UN,19.84,13.888,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RANOLAZINE ER 500 MG ORAL TB12,RX-70434,CDM,S5000,HCPCS,259,RC,50268-0722-11,NDC,outpatient,1,UN,5.07,3.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RANOLAZINE ER 500 MG ORAL TB12,RX-70434,CDM,S5000,HCPCS,259,RC,60687-0549-21,NDC,outpatient,1,UN,5.08,3.556,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RANOLAZINE ER 500 MG ORAL TB12,RX-70434,CDM,S5000,HCPCS,259,RC,50268-0722-15,NDC,outpatient,1,UN,5.07,3.549,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RANOLAZINE ER 500 MG ORAL TB12,RX-70434,CDM,S5000,HCPCS,259,RC,60687-0549-11,NDC,outpatient,1,UN,5.08,3.556,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RANOLAZINE ER 500 MG ORAL TB12,RX-70434,CDM,S5000,HCPCS,259,RC,68462-0319-60,NDC,outpatient,1,UN,1.05,0.735,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LUBIPROSTONE 24 MCG ORAL CAPS,RX-70472,CDM,S5000,HCPCS,259,RC,00254-3029-02,NDC,outpatient,1,UN,4.45,3.115,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLUTICASONE PROPIONATE 50 MCG/ACT NA SUSP,RX-70536,CDM,S5000,HCPCS,259,RC,00536-1183-99,NDC,outpatient,9.9,ML,45.6,31.92,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FLUTICASONE PROPIONATE 50 MCG/ACT NA SUSP,RX-70536,CDM,S5000,HCPCS,259,RC,00054-3270-99,NDC,outpatient,16,GR,32.12,22.484,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
INSULIN LISPRO PROT & LISPRO (75-25) 100 UNIT/ML SC SUSP,RX-70693,CDM,S5000,HCPCS,259,RC,00002-7511-01,NDC,outpatient,10,ML,211.82,148.274,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ATENOLOL 25 MG ORAL TABS,RX-717,CDM,S5000,HCPCS,259,RC,51079-0759-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ATENOLOL 25 MG ORAL TABS,RX-717,CDM,S5000,HCPCS,259,RC,51079-0759-20,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ATENOLOL 50 MG ORAL TABS,RX-718,CDM,S5000,HCPCS,259,RC,51079-0684-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ATENOLOL 50 MG ORAL TABS,RX-718,CDM,S5000,HCPCS,259,RC,51079-0684-20,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SILVER SULFADIAZINE 1 % EX CREA,RX-7224,CDM,S5000,HCPCS,259,RC,43598-0210-40,NDC,outpatient,400,GR,153.08,107.156,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SILVER SULFADIAZINE 1 % EX CREA,RX-7224,CDM,S5000,HCPCS,259,RC,43598-0210-50,NDC,outpatient,50,GR,55.18,38.626,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SILVER SULFADIAZINE 1 % EX CREA,RX-7224,CDM,S5000,HCPCS,259,RC,61570-0131-55,NDC,outpatient,50,GR,30.49,21.343,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SIMETHICONE 80 MG ORAL CHEW,RX-7227,CDM,S5000,HCPCS,259,RC,00904-7206-60,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SIMETHICONE 80 MG ORAL CHEW,RX-7227,CDM,S5000,HCPCS,259,RC,69618-0033-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SIMETHICONE 80 MG ORAL CHEW,RX-7227,CDM,S5000,HCPCS,259,RC,49348-0188-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SIMETHICONE 80 MG ORAL CHEW,RX-7227,CDM,S5000,HCPCS,259,RC,77333-0812-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SIMETHICONE 80 MG ORAL CHEW,RX-7227,CDM,S5000,HCPCS,259,RC,77333-0812-25,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SIMETHICONE 40 MG/0.6ML ORAL SUSP,RX-7228,CDM,S5000,HCPCS,259,RC,00536-1303-75,NDC,outpatient,0.3,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SIMETHICONE 40 MG/0.6ML ORAL SUSP,RX-7228,CDM,S5000,HCPCS,259,RC,49348-0740-27,NDC,outpatient,0.6,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SIMETHICONE 40 MG/0.6ML ORAL SUSP,RX-7228,CDM,S5000,HCPCS,259,RC,99999-0003-45,NDC,outpatient,0.6,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM ACETATE 2 MEQ/ML IV SOLN,RX-7301,CDM,S5000,HCPCS,250,RC,00409-7299-73,NDC,outpatient,20,ML,14.91,10.437,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM ACETATE 2 MEQ/ML IV SOLN,RX-7301,CDM,S5000,HCPCS,250,RC,00409-7299-83,NDC,outpatient,20,ML,14.91,10.437,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM ACETATE 4 MEQ/ML IV SOLN,RX-7302,CDM,S5000,HCPCS,250,RC,63323-0032-00,NDC,outpatient,100,ML,36.05,25.235,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM ACETATE 4 MEQ/ML IV SOLN,RX-7302,CDM,S5000,HCPCS,250,RC,63323-0032-04,NDC,outpatient,100,ML,36.05,25.235,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM BICARBONATE 4.2 % IV SOLN,RX-7306,CDM,S5000,HCPCS,250,RC,00409-5555-02,NDC,outpatient,5,ML,19.45,13.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM BICARBONATE 4.2 % IV SOLN,RX-7306,CDM,S5000,HCPCS,250,RC,63323-0083-05,NDC,outpatient,5,ML,33.6,23.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM BICARBONATE 4.2 % IV SOLN,RX-7306,CDM,S5000,HCPCS,250,RC,00409-5534-14,NDC,outpatient,10,ML,57.94,40.558,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM BICARBONATE 4.2 % IV SOLN,RX-7306,CDM,S5000,HCPCS,250,RC,00409-5534-24,NDC,outpatient,10,ML,57.94,40.558,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM BICARBONATE 4.2 % IV SOLN,RX-7306,CDM,S5000,HCPCS,250,RC,00409-5555-12,NDC,outpatient,5,ML,19.45,13.615,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM BICARBONATE 7.5 % IV SOLN,RX-7308,CDM,S5000,HCPCS,250,RC,00409-4916-14,NDC,outpatient,50,ML,85.67,59.969,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM BICARBONATE 7.5 % IV SOLN,RX-7308,CDM,S5000,HCPCS,250,RC,00409-4916-24,NDC,outpatient,50,ML,85.67,59.969,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-6625-14,NDC,outpatient,50,ML,35.83,25.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-6637-14,NDC,outpatient,50,ML,54.74,38.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,51754-5001-04,NDC,outpatient,50,ML,22.7,15.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,63323-0089-50,NDC,outpatient,50,ML,24.7,17.29,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-4900-24,NDC,outpatient,10,ML,71.78,50.246,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-6625-22,NDC,outpatient,50,ML,35.83,25.081,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-4900-14,NDC,outpatient,10,ML,71.78,50.246,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,69374-0214-50,NDC,outpatient,50,ML,48.95,34.265,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-6637-24,NDC,outpatient,50,ML,54.74,38.318,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,51754-5001-01,NDC,outpatient,50,ML,22.7,15.89,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,76329-3352-01,NDC,outpatient,50,ML,66.31,46.417,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM BICARBONATE 650 MG ORAL TABS,RX-7313,CDM,S5000,HCPCS,259,RC,66553-0008-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE 3 % IV SOLN,RX-7321,CDM,S5000,HCPCS,250,RC,00338-0054-03,NDC,outpatient,500,ML,26.28,18.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE 3 % IV SOLN,RX-7321,CDM,S5000,HCPCS,250,RC,99999-0004-11,NDC,outpatient,250,ML,21.14,14.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE 4 MEQ/ML IV SOLN,RX-7322,CDM,S5000,HCPCS,250,RC,63323-0095-02,NDC,outpatient,100,ML,55.63,38.941,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE 4 MEQ/ML IV SOLN,RX-7322,CDM,S5000,HCPCS,250,RC,63323-0095-61,NDC,outpatient,100,ML,55.63,38.941,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE 0.9 % IN NEBU,RX-7325,CDM,S5000,HCPCS,259,RC,00487-9301-03,NDC,outpatient,3,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE 0.9 % IN NEBU,RX-7325,CDM,S5000,HCPCS,259,RC,00487-9301-33,NDC,outpatient,3,ML,1.13,0.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE 0.9 % IN NEBU,RX-7325,CDM,S5000,HCPCS,259,RC,76204-0300-03,NDC,outpatient,3,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE 3 % IN NEBU,RX-7327,CDM,S5000,HCPCS,259,RC,50190-0142-63,NDC,outpatient,4,ML,2.6,1.82,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE 3 % IN NEBU,RX-7327,CDM,S5000,HCPCS,259,RC,00487-9003-30,NDC,outpatient,4,ML,2.44,1.708,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE 1 G ORAL TABS,RX-7328,CDM,S5000,HCPCS,259,RC,77333-0835-25,NDC,outpatient,1,UN,1.03,0.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE 1 G ORAL TABS,RX-7328,CDM,S5000,HCPCS,259,RC,00223-1760-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE 1 G ORAL TABS,RX-7328,CDM,S5000,HCPCS,259,RC,77333-0835-10,NDC,outpatient,1,UN,1.03,0.721,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE (HYPERTONIC) 5 % OP OINT,RX-7331,CDM,S5000,HCPCS,259,RC,24208-0385-55,NDC,outpatient,3.5,GR,68.8,48.16,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE (HYPERTONIC) 5 % OP SOLN,RX-7332,CDM,S5000,HCPCS,259,RC,00536-1254-94,NDC,outpatient,15,ML,15.76,11.032,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM HYPOCHLORITE 5 % SOLN,RX-7343,CDM,S5000,HCPCS,259,RC,SH000-4343-01,NDC,outpatient,4000,ML,17.8,12.46,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM POLYSTYRENE SULFONATE ORAL POWD,RX-7356,CDM,S5000,HCPCS,259,RC,11534-0166-15,NDC,outpatient,15,GR,55.61,38.927,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SULFACETAMIDE SODIUM 10 % OP SOLN,RX-7359,CDM,S5000,HCPCS,259,RC,24208-0670-04,NDC,outpatient,15,ML,213.67,149.569,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ATROPINE SULFATE 1 % OP SOLN,RX-736,CDM,S5000,HCPCS,259,RC,60219-1749-03,NDC,outpatient,5,ML,103.02,72.114,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SPIRONOLACTONE 25 MG ORAL TABS,RX-7437,CDM,S5000,HCPCS,259,RC,00904-6927-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SPIRONOLACTONE 25 MG ORAL TABS,RX-7437,CDM,S5000,HCPCS,259,RC,51079-0103-20,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SPIRONOLACTONE 25 MG ORAL TABS,RX-7437,CDM,S5000,HCPCS,259,RC,63629-1061-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SPIRONOLACTONE 25 MG ORAL TABS,RX-7437,CDM,S5000,HCPCS,259,RC,51079-0103-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-24,NDC,outpatient,50,ML,8.74,6.118,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-99,NDC,outpatient,100,ML,13.88,9.716,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00641-6147-01,NDC,outpatient,10,ML,4.79,3.353,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,63323-0185-10,NDC,outpatient,10,ML,4.07,2.849,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-17,NDC,outpatient,10,ML,3.6,2.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-25,NDC,outpatient,100,ML,13.88,9.716,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00641-6147-10,NDC,outpatient,10,ML,4.22,2.954,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-10,NDC,outpatient,10,ML,3.6,2.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-50,NDC,outpatient,50,ML,8.74,6.118,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00641-6147-25,NDC,outpatient,10,ML,4.79,3.353,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,63323-0185-20,NDC,outpatient,20,ML,7,4.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
STERILE WATER FOR IRRIGATION IR SOLN,RX-7485,CDM,S5000,HCPCS,250,RC,00338-0003-47,NDC,outpatient,3000,ML,26.7,18.69,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
STERILE WATER FOR IRRIGATION IR SOLN,RX-7485,CDM,S5000,HCPCS,250,RC,00338-0004-04,NDC,outpatient,1000,ML,8.9,6.23,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
STOMAHESIVE PASTE PSTE,RX-7493,CDM,S5000,HCPCS,259,RC,68455-0106-90,NDC,outpatient,56.7,GR,38.61,27.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SULFADIAZINE 500 MG ORAL TABS,RX-7554,CDM,S5000,HCPCS,259,RC,42806-0757-60,NDC,outpatient,1,UN,65.91,46.137,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN,RX-7556,CDM,S5000,HCPCS,250,RC,70069-0362-01,NDC,outpatient,10,ML,27.51,19.257,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN,RX-7556,CDM,S5000,HCPCS,250,RC,70069-0362-10,NDC,outpatient,10,ML,27.51,19.257,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN,RX-7556,CDM,S5000,HCPCS,250,RC,00703-9514-03,NDC,outpatient,10,ML,28.26,19.782,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN,RX-7556,CDM,S5000,HCPCS,250,RC,00703-9514-01,NDC,outpatient,10,ML,28.26,19.782,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG ORAL TABS,RX-7557,CDM,S5000,HCPCS,259,RC,50268-0728-15,NDC,outpatient,1,UN,1.12,0.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG ORAL TABS,RX-7557,CDM,S5000,HCPCS,259,RC,50268-0728-11,NDC,outpatient,1,UN,1.12,0.784,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG ORAL TABS,RX-7557,CDM,S5000,HCPCS,259,RC,60687-0603-65,NDC,outpatient,1,UN,1.41,0.987,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG ORAL TABS,RX-7557,CDM,S5000,HCPCS,259,RC,60687-0603-11,NDC,outpatient,1,UN,1.41,0.987,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SULFASALAZINE 500 MG ORAL TABS,RX-7562,CDM,S5000,HCPCS,259,RC,59762-5000-05,NDC,outpatient,1,UN,1.02,0.714,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SULFASALAZINE 500 MG ORAL TBEC,RX-7563,CDM,S5000,HCPCS,259,RC,00013-0102-50,NDC,outpatient,1,UN,8.65,6.055,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SULFASALAZINE 500 MG ORAL TBEC,RX-7563,CDM,S5000,HCPCS,259,RC,59762-0104-05,NDC,outpatient,1,UN,1.47,1.029,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VARENICLINE TARTRATE 0.5 MG ORAL TABS,RX-76444,CDM,S5000,HCPCS,259,RC,49884-0155-76,NDC,outpatient,1,UN,6.79,4.753,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VARENICLINE TARTRATE 1 MG ORAL TABS,RX-76445,CDM,S5000,HCPCS,259,RC,60687-0648-21,NDC,outpatient,1,UN,43.68,30.576,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VARENICLINE TARTRATE 1 MG ORAL TABS,RX-76445,CDM,S5000,HCPCS,259,RC,60687-0648-11,NDC,outpatient,1,UN,43.68,30.576,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACETYLCHOLINE CHLORIDE 20 MG IO SOLR,RX-76641,CDM,S5000,HCPCS,259,RC,24208-0539-20,NDC,outpatient,1,UN,349.11,244.377,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DAKINS (1/4 STRENGTH) 0.125 % EX SOLN,RX-76724,CDM,S5000,HCPCS,259,RC,00436-0672-16,NDC,outpatient,473,ML,52.63,36.841,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DAKINS (1/4 STRENGTH) 0.125 % EX SOLN,RX-76724,CDM,S5000,HCPCS,259,RC,39328-0064-12,NDC,outpatient,473,ML,44.21,30.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,00121-4948-40,NDC,outpatient,15,ML,19.43,13.601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,63739-0724-50,NDC,outpatient,15,ML,8.75,6.125,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,00121-0948-15,NDC,outpatient,15,ML,3.54,2.478,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,00121-0948-16,NDC,outpatient,7.5,ML,2.05,1.435,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,00121-4948-15,NDC,outpatient,15,ML,19.43,13.601,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,63739-0724-01,NDC,outpatient,15,ML,8.75,6.125,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VITAMIN D3 25 MCG (1000 UT) ORAL TABS,RX-76997,CDM,S5000,HCPCS,259,RC,20555-0033-00,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TANNIC ACID POWD,RX-7715,CDM,S5000,HCPCS,259,RC,,,outpatient,20,GR,9.26,6.482,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SELENIUM 40 MCG/ML IV SOLN,RX-77308,CDM,S5000,HCPCS,250,RC,69784-0840-05,NDC,outpatient,10,ML,230.25,161.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SELENIUM 40 MCG/ML IV SOLN,RX-77308,CDM,S5000,HCPCS,250,RC,69784-0840-01,NDC,outpatient,10,ML,230.25,161.175,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SITAGLIPTIN PHOSPHATE 25 MG ORAL TABS,RX-77615,CDM,S5000,HCPCS,259,RC,00006-0221-01,NDC,outpatient,1,UN,78.54,54.978,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SITAGLIPTIN PHOSPHATE 25 MG ORAL TABS,RX-77615,CDM,S5000,HCPCS,259,RC,00006-0221-28,NDC,outpatient,1,UN,78.54,54.978,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SITAGLIPTIN PHOSPHATE 100 MG ORAL TABS,RX-77617,CDM,S5000,HCPCS,259,RC,00006-0277-28,NDC,outpatient,1,UN,78.54,54.978,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SITAGLIPTIN PHOSPHATE 100 MG ORAL TABS,RX-77617,CDM,S5000,HCPCS,259,RC,00006-0277-01,NDC,outpatient,1,UN,78.54,54.978,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SITAGLIPTIN PHOSPHATE 100 MG ORAL TABS,RX-77617,CDM,S5000,HCPCS,259,RC,00006-0277-31,NDC,outpatient,1,UN,78.53,54.971,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METOCLOPRAMIDE HCL 10 MG/10ML ORAL SOLN,RX-77710,CDM,S5000,HCPCS,259,RC,00121-1576-10,NDC,outpatient,10,ML,13.35,9.345,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
METOCLOPRAMIDE HCL 10 MG/10ML ORAL SOLN,RX-77710,CDM,S5000,HCPCS,259,RC,99999-0001-27,NDC,outpatient,1,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TETRACAINE HCL 0.5 % OP SOLN,RX-7795,CDM,S5000,HCPCS,259,RC,00065-0741-14,NDC,outpatient,4,ML,54.08,37.856,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TETRACAINE HCL 0.5 % OP SOLN,RX-7795,CDM,S5000,HCPCS,259,RC,68682-0920-64,NDC,outpatient,15,ML,325.88,228.116,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TETRACYCLINE HCL 250 MG ORAL CAPS,RX-7796,CDM,S5000,HCPCS,259,RC,23155-0766-01,NDC,outpatient,1,UN,2.97,2.079,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
THEOPHYLLINE 80 MG/15ML ORAL ELIX,RX-7820,CDM,S5000,HCPCS,259,RC,00121-4820-40,NDC,outpatient,15,ML,35.25,24.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
THEOPHYLLINE 80 MG/15ML ORAL ELIX,RX-7820,CDM,S5000,HCPCS,259,RC,60687-0258-44,NDC,outpatient,15,ML,40.12,28.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
THEOPHYLLINE 80 MG/15ML ORAL ELIX,RX-7820,CDM,S5000,HCPCS,259,RC,60687-0258-71,NDC,outpatient,15,ML,40.12,28.084,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
THEOPHYLLINE 80 MG/15ML ORAL ELIX,RX-7820,CDM,S5000,HCPCS,259,RC,00121-4820-15,NDC,outpatient,15,ML,35.25,24.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
THERA ORAL TABS,RX-7825,CDM,S5000,HCPCS,259,RC,00904-0539-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
THERA-DERM EX LOTN,RX-7831,CDM,S5000,HCPCS,259,RC,00904-4299-09,NDC,outpatient,236,ML,8.41,5.887,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MESALAMINE 1.2 G ORAL TBEC,RX-78310,CDM,S5000,HCPCS,259,RC,00527-3012-48,NDC,outpatient,1,UN,7.61,5.327,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CALAMINE 8-8 % EX LOTN,RX-78879,CDM,S5000,HCPCS,259,RC,49348-0011-34,NDC,outpatient,177,ML,6.31,4.417,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CALAMINE 8-8 % EX LOTN,RX-78879,CDM,S5000,HCPCS,259,RC,00395-0413-96,NDC,outpatient,177,ML,11.82,8.274,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CALAMINE 8-8 % EX LOTN,RX-78879,CDM,S5000,HCPCS,259,RC,00904-2533-21,NDC,outpatient,177,ML,5.52,3.864,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GUAIFENESIN-CODEINE 100-10 MG/5ML ORAL SOLN,RX-79088,CDM,S5000,HCPCS,259,RC,00121-1775-05,NDC,outpatient,5,ML,11.06,7.742,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GUAIFENESIN-CODEINE 100-10 MG/5ML ORAL SOLN,RX-79088,CDM,S5000,HCPCS,259,RC,00121-1775-40,NDC,outpatient,5,ML,11.06,7.742,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GUAIFENESIN-CODEINE 100-10 MG/5ML ORAL SOLN,RX-79088,CDM,S5000,HCPCS,259,RC,99999-0002-04,NDC,outpatient,5,ML,1.78,1.246,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
THYROID 30 MG ORAL TABS,RX-7944,CDM,S5000,HCPCS,259,RC,62559-0741-01,NDC,outpatient,1,UN,2.88,2.016,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TOLNAFTATE 1 % EX CREA,RX-8020,CDM,S5000,HCPCS,259,RC,49348-0155-29,NDC,outpatient,15,GR,8.88,6.216,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TOLNAFTATE 1 % EX CREA,RX-8020,CDM,S5000,HCPCS,259,RC,00904-0722-36,NDC,outpatient,14.18,GR,4.36,3.052,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TOLNAFTATE 1 % EX POWD,RX-8021,CDM,S5000,HCPCS,259,RC,00536-1329-26,NDC,outpatient,45,GR,7.41,5.187,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRAZODONE HCL 150 MG ORAL TABS,RX-8084,CDM,S5000,HCPCS,259,RC,50268-0776-11,NDC,outpatient,1,UN,1.77,1.239,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRAZODONE HCL 150 MG ORAL TABS,RX-8084,CDM,S5000,HCPCS,259,RC,50268-0776-15,NDC,outpatient,1,UN,1.77,1.239,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRAZODONE HCL 150 MG ORAL TABS,RX-8084,CDM,S5000,HCPCS,259,RC,68382-0807-01,NDC,outpatient,1,UN,1.31,0.917,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,42291-0868-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,50111-0560-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,60505-2653-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,00904-6868-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,68382-0805-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,42291-0868-90,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRIAMCINOLONE ACETONIDE 0.025 % EX CREA,RX-8112,CDM,S5000,HCPCS,259,RC,00168-0003-80,NDC,outpatient,80,GR,21.72,15.204,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRIAMCINOLONE ACETONIDE 0.1 % EX CREA,RX-8113,CDM,S5000,HCPCS,259,RC,45802-0064-36,NDC,outpatient,80,GR,11.04,7.728,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRIAMCINOLONE ACETONIDE 0.1 % EX CREA,RX-8113,CDM,S5000,HCPCS,259,RC,67877-0251-80,NDC,outpatient,80,GR,39.16,27.412,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRIAMCINOLONE ACETONIDE 0.5 % EX CREA,RX-8114,CDM,S5000,HCPCS,259,RC,45802-0065-35,NDC,outpatient,15,GR,20.23,14.161,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRIAMCINOLONE ACETONIDE 0.025 % EX LOTN,RX-8115,CDM,S5000,HCPCS,259,RC,70752-0129-05,NDC,outpatient,60,ML,126.03,88.221,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRIAMCINOLONE ACETONIDE 0.1 % EX LOTN,RX-8116,CDM,S5000,HCPCS,259,RC,00713-0676-53,NDC,outpatient,60,ML,73.43,51.401,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRIAMCINOLONE ACETONIDE 0.1 % EX LOTN,RX-8116,CDM,S5000,HCPCS,259,RC,60432-0561-61,NDC,outpatient,60,ML,66.75,46.725,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRIAMCINOLONE ACETONIDE 0.025 % EX OINT,RX-8117,CDM,S5000,HCPCS,259,RC,00168-0005-80,NDC,outpatient,80,GR,21.01,14.707,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRIAMCINOLONE ACETONIDE 0.1 % EX OINT,RX-8118,CDM,S5000,HCPCS,259,RC,51672-1284-08,NDC,outpatient,80,GR,43.44,30.408,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRIAMCINOLONE ACETONIDE 0.1 % EX OINT,RX-8118,CDM,S5000,HCPCS,259,RC,00713-0228-80,NDC,outpatient,80,GR,37.03,25.921,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRIAMCINOLONE ACETONIDE 0.1 % EX OINT,RX-8118,CDM,S5000,HCPCS,259,RC,00168-0006-80,NDC,outpatient,80,GR,22.79,15.953,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRIAMCINOLONE ACETONIDE 0.1 % EX OINT,RX-8118,CDM,S5000,HCPCS,259,RC,45802-0055-36,NDC,outpatient,80,GR,19.58,13.706,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRIAMCINOLONE ACETONIDE 0.5 % EX OINT,RX-8119,CDM,S5000,HCPCS,259,RC,33342-0332-15,NDC,outpatient,15,GR,28.77,20.139,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRIAMCINOLONE ACETONIDE 0.1 % MT PSTE,RX-8121,CDM,S5000,HCPCS,259,RC,64980-0320-05,NDC,outpatient,5,GR,139.78,97.846,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DIVALPROEX SODIUM ER 500 MG ORAL TB24,RX-81426,CDM,S5000,HCPCS,259,RC,00904-7182-45,NDC,outpatient,1,UN,11.3,7.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUDESONIDE-FORMOTEROL FUMARATE 80-4.5 MCG/ACT IN AERO,RX-81453,CDM,S5000,HCPCS,259,RC,00186-0372-28,NDC,outpatient,6.9,GR,250.86,175.602,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUDESONIDE-FORMOTEROL FUMARATE 80-4.5 MCG/ACT IN AERO,RX-81453,CDM,S5000,HCPCS,259,RC,00310-7372-20,NDC,outpatient,10.2,GR,973.53,681.471,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUDESONIDE-FORMOTEROL FUMARATE 160-4.5 MCG/ACT IN AERO,RX-81454,CDM,S5000,HCPCS,259,RC,00186-0370-28,NDC,outpatient,6,GR,250.85,175.595,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUDESONIDE-FORMOTEROL FUMARATE 160-4.5 MCG/ACT IN AERO,RX-81454,CDM,S5000,HCPCS,259,RC,00310-7370-20,NDC,outpatient,10.2,GR,1011.48,708.036,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRIFLUOPERAZINE HCL 1 MG ORAL TABS,RX-8161,CDM,S5000,HCPCS,259,RC,00781-8028-01,NDC,outpatient,1,UN,2.52,1.764,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRIFLUOPERAZINE HCL 5 MG ORAL TABS,RX-8164,CDM,S5000,HCPCS,259,RC,00781-8034-01,NDC,outpatient,1,UN,4.68,3.276,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRIHEXYPHENIDYL HCL 2 MG ORAL TABS,RX-8166,CDM,S5000,HCPCS,259,RC,00591-5335-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRIHEXYPHENIDYL HCL 2 MG ORAL TABS,RX-8166,CDM,S5000,HCPCS,259,RC,69452-0241-20,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TRIHEXYPHENIDYL HCL 5 MG ORAL TABS,RX-8167,CDM,S5000,HCPCS,259,RC,70954-0211-10,NDC,outpatient,1,UN,1.15,0.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CEFIXIME 200 MG/5ML ORAL SUSR,RX-81816,CDM,S5000,HCPCS,259,RC,68180-0407-03,NDC,outpatient,6.25,ML,50.07,35.049,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CEFIXIME 200 MG/5ML ORAL SUSR,RX-81816,CDM,S5000,HCPCS,259,RC,99999-0002-91,NDC,outpatient,6.25,ML,120.07,84.049,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GLUCOSE 40 % ORAL GEL,RX-81823,CDM,S5000,HCPCS,259,RC,00574-0070-30,NDC,outpatient,37.5,GR,12.35,8.645,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GLUCOSE 40 % ORAL GEL,RX-81823,CDM,S5000,HCPCS,259,RC,00574-0069-30,NDC,outpatient,37.5,GR,12.35,8.645,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GLUCOSE 40 % ORAL GEL,RX-81823,CDM,S5000,HCPCS,259,RC,00574-0069-15,NDC,outpatient,37.5,GR,12.35,8.645,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GLUCOSE 40 % ORAL GEL,RX-81823,CDM,S5000,HCPCS,259,RC,19962-0626-53,NDC,outpatient,31,GR,6.68,4.676,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GLUCOSE 40 % ORAL GEL,RX-81823,CDM,S5000,HCPCS,259,RC,19962-0627-63,NDC,outpatient,31,GR,6.68,4.676,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE 7 % IN NEBU,RX-82134,CDM,S5000,HCPCS,259,RC,83490-0207-60,NDC,outpatient,4,ML,3.01,2.107,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE 7 % IN NEBU,RX-82134,CDM,S5000,HCPCS,259,RC,83490-0307-60,NDC,outpatient,4,ML,1.2,0.84,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SODIUM CHLORIDE 7 % IN NEBU,RX-82134,CDM,S5000,HCPCS,259,RC,50190-0141-23,NDC,outpatient,4,ML,2.6,1.82,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
THROMBI-GEL 40 EX PADS,RX-82259,CDM,S5000,HCPCS,259,RC,60793-0908-04,NDC,outpatient,1,UN,254.02,177.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TROPICAMIDE 1 % OP SOLN,RX-8250,CDM,S5000,HCPCS,259,RC,70069-0121-01,NDC,outpatient,15,ML,25.3,17.71,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RIVASTIGMINE 4.6 MG/24HR TD PT24,RX-82504,CDM,S5000,HCPCS,259,RC,00078-0501-15,NDC,outpatient,1,UN,93.94,65.758,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RIVASTIGMINE 4.6 MG/24HR TD PT24,RX-82504,CDM,S5000,HCPCS,259,RC,00078-0501-61,NDC,outpatient,1,UN,93.94,65.758,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RIVASTIGMINE 9.5 MG/24HR TD PT24,RX-82505,CDM,S5000,HCPCS,259,RC,47781-0305-11,NDC,outpatient,1,UN,24.46,17.122,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RIVASTIGMINE 9.5 MG/24HR TD PT24,RX-82505,CDM,S5000,HCPCS,259,RC,47781-0305-03,NDC,outpatient,1,UN,24.46,17.122,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TUBERCULIN PPD 5 UNIT/0.1ML ID SOLN,RX-8259,CDM,S5000,HCPCS,250,RC,49281-0752-21,NDC,outpatient,0.1,ML,35.98,25.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TUBERCULIN PPD 5 UNIT/0.1ML ID SOLN,RX-8259,CDM,S5000,HCPCS,250,RC,49281-0752-78,NDC,outpatient,0.1,ML,35.98,25.186,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
UNNA-FLEX ELASTIC UNNA BOOT EX MISC,RX-8371,CDM,S5000,HCPCS,250,RC,68455-0107-63,NDC,outpatient,1,UN,44.16,30.912,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VALPROIC ACID 250 MG ORAL CAPS,RX-8429,CDM,S5000,HCPCS,259,RC,69452-0150-20,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VALPROIC ACID 250 MG ORAL CAPS,RX-8429,CDM,S5000,HCPCS,259,RC,00832-0310-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VALPROIC ACID 250 MG ORAL CAPS,RX-8429,CDM,S5000,HCPCS,259,RC,00591-4012-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BACITRA-NEOMYCIN-POLYMYXIN-HC 1 % OP OINT,RX-849,CDM,S5000,HCPCS,259,RC,24208-0785-55,NDC,outpatient,3.5,GR,70.76,49.532,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VERAPAMIL HCL 2.5 MG/ML IV SOLN,RX-8527,CDM,S5000,HCPCS,250,RC,51754-0203-01,NDC,outpatient,2,ML,15.45,10.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VERAPAMIL HCL 2.5 MG/ML IV SOLN,RX-8527,CDM,S5000,HCPCS,250,RC,51754-0203-02,NDC,outpatient,2,ML,15.45,10.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VERAPAMIL HCL 2.5 MG/ML IV SOLN,RX-8527,CDM,S5000,HCPCS,250,RC,51754-0203-04,NDC,outpatient,2,ML,15.45,10.815,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VERAPAMIL HCL 2.5 MG/ML IV SOLN,RX-8527,CDM,S5000,HCPCS,250,RC,70710-1643-07,NDC,outpatient,2,ML,44.5,31.15,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VERAPAMIL HCL 120 MG ORAL TABS,RX-8528,CDM,S5000,HCPCS,259,RC,23155-0486-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VERAPAMIL HCL 40 MG ORAL TABS,RX-8529,CDM,S5000,HCPCS,259,RC,23155-0059-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VERAPAMIL HCL 80 MG ORAL TABS,RX-8530,CDM,S5000,HCPCS,259,RC,23155-0026-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BACITRACIN-NEOMYCIN-POLYMYXIN 400-3.5-5000 EX OINT,RX-854,CDM,S5000,HCPCS,259,RC,49348-0029-72,NDC,outpatient,30,GR,11.49,8.043,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BACITRACIN-NEOMYCIN-POLYMYXIN 400-3.5-5000 EX OINT,RX-854,CDM,S5000,HCPCS,259,RC,70677-0013-01,NDC,outpatient,28.4,GR,10.49,7.343,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BACITRACIN-POLYMYXIN B 500-10000 UNIT/GM EX OINT,RX-855,CDM,S5000,HCPCS,259,RC,00501-3798-05,NDC,outpatient,14.2,GR,20.67,14.469,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BACITRACIN-POLYMYXIN B 500-10000 UNIT/GM OP OINT,RX-856,CDM,S5000,HCPCS,259,RC,24208-0555-55,NDC,outpatient,3.5,GR,22.88,16.016,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BACLOFEN 10 MG ORAL TABS,RX-860,CDM,S5000,HCPCS,259,RC,00527-1330-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BACLOFEN 10 MG ORAL TABS,RX-860,CDM,S5000,HCPCS,259,RC,63739-0479-10,NDC,outpatient,1,UN,1.74,1.218,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BACLOFEN 10 MG ORAL TABS,RX-860,CDM,S5000,HCPCS,259,RC,00904-6475-61,NDC,outpatient,1,UN,1.6,1.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VITAMIN C 250 MG ORAL TABS,RX-8679,CDM,S5000,HCPCS,259,RC,50268-0860-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VITAMIN C 250 MG ORAL TABS,RX-8679,CDM,S5000,HCPCS,259,RC,50268-0860-15,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VITAMIN E 100 UNITS ORAL CAPS,RX-8698,CDM,S5000,HCPCS,259,RC,80681-0134-00,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VITAMIN E 400 UNITS ORAL CAPS,RX-8701,CDM,S5000,HCPCS,259,RC,77333-0951-25,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VITAMIN E 400 UNITS ORAL CAPS,RX-8701,CDM,S5000,HCPCS,259,RC,00536-1352-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VITAMIN E 400 UNITS ORAL CAPS,RX-8701,CDM,S5000,HCPCS,259,RC,77333-0951-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VITAMINS A & D EX OINT,RX-8723,CDM,S5000,HCPCS,259,RC,57896-0110-05,NDC,outpatient,5,GR,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
VITAMINS A & D EX OINT,RX-8723,CDM,S5000,HCPCS,259,RC,57896-0110-14,NDC,outpatient,5,GR,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
WARFARIN SODIUM 2 MG ORAL TABS,RX-8749,CDM,S5000,HCPCS,259,RC,62584-0984-01,NDC,outpatient,1,UN,1.22,0.854,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
WARFARIN SODIUM 2 MG ORAL TABS,RX-8749,CDM,S5000,HCPCS,259,RC,62584-0984-11,NDC,outpatient,1,UN,1.22,0.854,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
WARFARIN SODIUM 2.5 MG ORAL TABS,RX-8750,CDM,S5000,HCPCS,259,RC,00832-1213-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
WARFARIN SODIUM 2.5 MG ORAL TABS,RX-8750,CDM,S5000,HCPCS,259,RC,68084-0027-01,NDC,outpatient,1,UN,1.29,0.903,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
WARFARIN SODIUM 2.5 MG ORAL TABS,RX-8750,CDM,S5000,HCPCS,259,RC,68084-0027-11,NDC,outpatient,1,UN,1.29,0.903,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
WARFARIN SODIUM 2.5 MG ORAL TABS,RX-8750,CDM,S5000,HCPCS,259,RC,00832-1213-89,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
WARFARIN SODIUM 5 MG ORAL TABS,RX-8751,CDM,S5000,HCPCS,259,RC,00832-1216-89,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
WARFARIN SODIUM 5 MG ORAL TABS,RX-8751,CDM,S5000,HCPCS,259,RC,00832-1216-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
WARFARIN SODIUM 7.5 MG ORAL TABS,RX-8752,CDM,S5000,HCPCS,259,RC,00832-1218-89,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
WARFARIN SODIUM 7.5 MG ORAL TABS,RX-8752,CDM,S5000,HCPCS,259,RC,00832-1218-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
THROMBIN 5000 UNITS EX KIT,RX-87798,CDM,S5000,HCPCS,250,RC,60793-0205-05,NDC,outpatient,1,UN,228.51,159.957,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
THROMBIN 5000 UNITS EX KIT,RX-87798,CDM,S5000,HCPCS,250,RC,60793-0705-05,NDC,outpatient,1,UN,217.65,152.355,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CALCIUM GLUCONATE (ANTIDOTE) 2.5 % EX GEL,RX-87801,CDM,S5000,HCPCS,259,RC,35181-7303-32,NDC,outpatient,25,GR,146.52,102.564,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BRIMONIDINE TARTRATE-TIMOLOL 0.2-0.5 % OP SOLN,RX-87834,CDM,S5000,HCPCS,259,RC,82182-0455-05,NDC,outpatient,5,ML,356.54,249.578,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BRIMONIDINE TARTRATE-TIMOLOL 0.2-0.5 % OP SOLN,RX-87834,CDM,S5000,HCPCS,259,RC,00023-9211-05,NDC,outpatient,5,ML,838.92,587.244,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DIAZEPAM 2.5 MG RE GEL,RX-87865,CDM,S5000,HCPCS,259,RC,68682-0650-20,NDC,outpatient,1,UN,430.63,301.441,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DIAZEPAM 10 MG RE GEL,RX-87867,CDM,S5000,HCPCS,259,RC,68682-0652-20,NDC,outpatient,1,UN,622.96,436.072,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DIAZEPAM 20 MG RE GEL,RX-87869,CDM,S5000,HCPCS,259,RC,68682-0655-20,NDC,outpatient,1,UN,601.24,420.868,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,00093-4061-06,NDC,outpatient,2,ML,64.19,44.933,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,62332-0655-01,NDC,outpatient,2,ML,18.21,12.747,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,00093-4061-19,NDC,outpatient,2,ML,64.19,44.933,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,00378-1631-32,NDC,outpatient,2,ML,38.15,26.705,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,49502-0605-61,NDC,outpatient,2,ML,20.29,14.203,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,00378-1631-93,NDC,outpatient,2,ML,38.15,26.705,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,62332-0655-60,NDC,outpatient,2,ML,18.21,12.747,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,70756-0608-44,NDC,outpatient,2,ML,11.64,8.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,70756-0608-60,NDC,outpatient,2,ML,11.64,8.148,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RALTEGRAVIR POTASSIUM 400 MG ORAL TABS,RX-88608,CDM,S5000,HCPCS,259,RC,00006-0227-61,NDC,outpatient,1,UN,143.66,100.562,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ZINC CHLORIDE 1 MG/ML IV SOLN,RX-8865,CDM,S5000,HCPCS,250,RC,00409-4090-11,NDC,outpatient,10,ML,63.68,44.576,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ZINC CHLORIDE 1 MG/ML IV SOLN,RX-8865,CDM,S5000,HCPCS,250,RC,00409-4090-01,NDC,outpatient,10,ML,63.68,44.576,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAPS,RX-88704,CDM,S5000,HCPCS,259,RC,00004-0802-85,NDC,outpatient,1,UN,57.3,40.11,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAPS,RX-88704,CDM,S5000,HCPCS,259,RC,31722-0630-31,NDC,outpatient,1,UN,3.93,2.751,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OSELTAMIVIR PHOSPHATE 45 MG ORAL CAPS,RX-88705,CDM,S5000,HCPCS,259,RC,00004-0801-85,NDC,outpatient,1,UN,57.3,40.11,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ZINC OXIDE 20 % EX OINT,RX-8874,CDM,S5000,HCPCS,259,RC,00536-1316-98,NDC,outpatient,454,GR,22.23,15.561,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ZINC OXIDE 20 % EX OINT,RX-8874,CDM,S5000,HCPCS,259,RC,75834-0170-01,NDC,outpatient,28.4,GR,13.53,9.471,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ZINC SULFATE 1 MG/ML IV SOLN,RX-8878,CDM,S5000,HCPCS,250,RC,00517-6101-01,NDC,outpatient,10,ML,75.92,53.144,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ZINC SULFATE 1 MG/ML IV SOLN,RX-8878,CDM,S5000,HCPCS,250,RC,00517-6101-25,NDC,outpatient,10,ML,75.92,53.144,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ZINC SULFATE 5 MG/ML IV SOLN,RX-8879,CDM,S5000,HCPCS,250,RC,00517-8005-01,NDC,outpatient,5,ML,189.8,132.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ZINC SULFATE 5 MG/ML IV SOLN,RX-8879,CDM,S5000,HCPCS,250,RC,00517-8005-25,NDC,outpatient,5,ML,189.8,132.86,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ZINC SULFATE 220 (50 ZN) MG ORAL CAPS,RX-8880,CDM,S5000,HCPCS,259,RC,77333-0983-25,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ZINC SULFATE 220 (50 ZN) MG ORAL CAPS,RX-8880,CDM,S5000,HCPCS,259,RC,77333-0983-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SEVELAMER CARBONATE 800 MG ORAL TABS,RX-89201,CDM,S5000,HCPCS,259,RC,68094-0034-59,NDC,outpatient,1,UN,6.38,4.466,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SEVELAMER CARBONATE 800 MG ORAL TABS,RX-89201,CDM,S5000,HCPCS,259,RC,00904-6707-82,NDC,outpatient,1,UN,11.14,7.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SEVELAMER CARBONATE 800 MG ORAL TABS,RX-89201,CDM,S5000,HCPCS,259,RC,68094-0034-64,NDC,outpatient,1,UN,6.38,4.466,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
NEBIVOLOL HCL 5 MG ORAL TABS,RX-89284,CDM,S5000,HCPCS,259,RC,00904-7189-04,NDC,outpatient,1,UN,7.99,5.593,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLOPIDOGREL BISULFATE 300 MG ORAL TABS,RX-89346,CDM,S5000,HCPCS,259,RC,00904-6467-07,NDC,outpatient,1,UN,32.67,22.869,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLOPIDOGREL BISULFATE 300 MG ORAL TABS,RX-89346,CDM,S5000,HCPCS,259,RC,00904-6467-10,NDC,outpatient,1,UN,22.14,15.498,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACEBUTOLOL HCL 200 MG ORAL CAPS,RX-8939,CDM,S5000,HCPCS,259,RC,50268-0050-15,NDC,outpatient,1,UN,5.16,3.612,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACEBUTOLOL HCL 200 MG ORAL CAPS,RX-8939,CDM,S5000,HCPCS,259,RC,50268-0050-11,NDC,outpatient,1,UN,5.16,3.612,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ZINC OXIDE 11.3 % EX CREA,RX-89412,CDM,S5000,HCPCS,259,RC,57074-0001-86,NDC,outpatient,60,GR,9.35,6.545,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ZINC OXIDE 11.3 % EX CREA,RX-89412,CDM,S5000,HCPCS,259,RC,30103-0040-00,NDC,outpatient,60,GR,12.55,8.785,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,68094-0231-61,NDC,outpatient,5,ML,2.67,1.869,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,00121-1781-00,NDC,outpatient,5,ML,4.72,3.304,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,00121-1781-05,NDC,outpatient,5,ML,4.72,3.304,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,68094-0231-59,NDC,outpatient,5,ML,2.67,1.869,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,68094-0231-62,NDC,outpatient,5,ML,2.76,1.932,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,99999-0004-23,NDC,outpatient,5,ML,2.67,1.869,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ETRAVIRINE 100 MG ORAL TABS,RX-89432,CDM,S5000,HCPCS,259,RC,60219-1721-07,NDC,outpatient,1,UN,36.43,25.501,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ETRAVIRINE 100 MG ORAL TABS,RX-89432,CDM,S5000,HCPCS,259,RC,59676-0570-01,NDC,outpatient,1,UN,53.89,37.723,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACETAMINOPHEN-CODEINE 300-30 MG ORAL TABS,RX-8949,CDM,S5000,HCPCS,259,RC,00406-0484-23,NDC,outpatient,1,UN,1.51,1.057,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACETAMINOPHEN-CODEINE 300-30 MG ORAL TABS,RX-8949,CDM,S5000,HCPCS,259,RC,00406-0484-62,NDC,outpatient,1,UN,1.51,1.057,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
THROMBIN (RECOMBINANT) 5000 UNITS EX SOLR,RX-89570,CDM,S5000,HCPCS,250,RC,00338-0322-01,NDC,outpatient,1,UN,281.38,196.966,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUTALBITAL-APAP-CAFFEINE 50-325-40 MG ORAL TABS,RX-8958,CDM,S5000,HCPCS,259,RC,00527-1695-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUTALBITAL-APAP-CAFFEINE 50-325-40 MG ORAL TABS,RX-8958,CDM,S5000,HCPCS,259,RC,00904-6938-06,NDC,outpatient,1,UN,4.29,3.003,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUTALBITAL-APAP-CAFFEINE 50-325-40 MG ORAL TABS,RX-8958,CDM,S5000,HCPCS,259,RC,60687-0672-65,NDC,outpatient,1,UN,4.66,3.262,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUTALBITAL-APAP-CAFFEINE 50-325-40 MG ORAL TABS,RX-8958,CDM,S5000,HCPCS,259,RC,10702-0253-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUTALBITAL-APAP-CAFFEINE 50-325-40 MG ORAL TABS,RX-8958,CDM,S5000,HCPCS,259,RC,60687-0672-11,NDC,outpatient,1,UN,4.66,3.262,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACETIC ACID 0.25 % IR SOLN,RX-8963,CDM,S5000,HCPCS,250,RC,00338-0656-04,NDC,outpatient,1000,ML,13.35,9.345,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACYCLOVIR 5 % EX CREA,RX-8967,CDM,S5000,HCPCS,259,RC,00187-0994-45,NDC,outpatient,5,GR,822.36,575.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACYCLOVIR 5 % EX CREA,RX-8967,CDM,S5000,HCPCS,259,RC,45802-0044-75,NDC,outpatient,5,GR,210.13,147.091,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACYCLOVIR 200 MG ORAL CAPS,RX-8969,CDM,S5000,HCPCS,259,RC,00904-5789-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACYCLOVIR 200 MG ORAL CAPS,RX-8969,CDM,S5000,HCPCS,259,RC,60505-0042-06,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACYCLOVIR 200 MG/5ML ORAL SUSP,RX-8970,CDM,S5000,HCPCS,259,RC,31722-0681-47,NDC,outpatient,473,ML,244.17,170.919,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACYCLOVIR 200 MG/5ML ORAL SUSP,RX-8970,CDM,S5000,HCPCS,259,RC,99999-0004-02,NDC,outpatient,5,ML,4.94,3.458,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACYCLOVIR 200 MG/5ML ORAL SUSP,RX-8970,CDM,S5000,HCPCS,259,RC,00472-0082-16,NDC,outpatient,473,ML,1582.85,1107.995,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACYCLOVIR 800 MG ORAL TABS,RX-8972,CDM,S5000,HCPCS,259,RC,68084-0109-11,NDC,outpatient,1,UN,3.08,2.156,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ACYCLOVIR 800 MG ORAL TABS,RX-8972,CDM,S5000,HCPCS,259,RC,68084-0109-01,NDC,outpatient,1,UN,3.08,2.156,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,57896-0629-12,NDC,outpatient,10,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,70677-1063-30,NDC,outpatient,30,ML,1.7,1.19,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,99999-0002-58,NDC,outpatient,30,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,00121-1761-30,NDC,outpatient,30,ML,7.21,5.047,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,00904-7325-73,NDC,outpatient,30,ML,11.09,7.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,00904-7325-62,NDC,outpatient,30,ML,11.09,7.763,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,70677-1063-01,NDC,outpatient,10,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMINOCAPROIC ACID 500 MG ORAL TABS,RX-9063,CDM,S5000,HCPCS,259,RC,69680-0115-30,NDC,outpatient,1,UN,26.56,18.592,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMIODARONE HCL 200 MG ORAL TABS,RX-9066,CDM,S5000,HCPCS,259,RC,63739-0051-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMIODARONE HCL 200 MG ORAL TABS,RX-9066,CDM,S5000,HCPCS,259,RC,00245-0147-89,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMIODARONE HCL 200 MG ORAL TABS,RX-9066,CDM,S5000,HCPCS,259,RC,00904-6993-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMIODARONE HCL 200 MG ORAL TABS,RX-9066,CDM,S5000,HCPCS,259,RC,00245-0147-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMLODIPINE BESYLATE 2.5 MG ORAL TABS,RX-9070,CDM,S5000,HCPCS,259,RC,00904-6369-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMLODIPINE BESYLATE 5 MG ORAL TABS,RX-9071,CDM,S5000,HCPCS,259,RC,68382-0122-16,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMLODIPINE BESYLATE 5 MG ORAL TABS,RX-9071,CDM,S5000,HCPCS,259,RC,00904-6370-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TABS,RX-9081,CDM,S5000,HCPCS,259,RC,64850-0502-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TABS,RX-9081,CDM,S5000,HCPCS,259,RC,42806-0341-01,NDC,outpatient,1,UN,1.52,1.064,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DESVENLAFAXINE SUCCINATE ER 50 MG ORAL TB24,RX-91073,CDM,S5000,HCPCS,259,RC,00591-3659-30,NDC,outpatient,1,UN,2.77,1.939,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DESVENLAFAXINE SUCCINATE ER 50 MG ORAL TB24,RX-91073,CDM,S5000,HCPCS,259,RC,00008-1211-14,NDC,outpatient,1,UN,5.76,4.032,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DESVENLAFAXINE SUCCINATE ER 50 MG ORAL TB24,RX-91073,CDM,S5000,HCPCS,259,RC,51991-0311-90,NDC,outpatient,1,UN,2.38,1.666,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ROPINIROLE HCL ER 2 MG ORAL TB24,RX-92015,CDM,S5000,HCPCS,259,RC,55111-0659-30,NDC,outpatient,1,UN,2.69,1.883,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BENAZEPRIL HCL 10 MG ORAL TABS,RX-9220,CDM,S5000,HCPCS,259,RC,50268-0110-11,NDC,outpatient,1,UN,2.09,1.463,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BENAZEPRIL HCL 10 MG ORAL TABS,RX-9220,CDM,S5000,HCPCS,259,RC,50268-0110-15,NDC,outpatient,1,UN,2.09,1.463,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BETAXOLOL HCL 0.5 % OP SOLN,RX-9268,CDM,S5000,HCPCS,259,RC,61314-0245-01,NDC,outpatient,5,ML,147.74,103.418,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BETAXOLOL HCL 10 MG ORAL TABS,RX-9269,CDM,S5000,HCPCS,259,RC,10135-0623-01,NDC,outpatient,1,UN,2.28,1.596,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BETAXOLOL HCL 10 MG ORAL TABS,RX-9269,CDM,S5000,HCPCS,259,RC,10702-0013-01,NDC,outpatient,1,UN,1.58,1.106,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
MOUTH KOTE MT SOLN,RX-92764,CDM,S5000,HCPCS,259,RC,50930-0098-02,NDC,outpatient,59,ML,21.53,15.071,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BROMOCRIPTINE MESYLATE 2.5 MG ORAL TABS,RX-9297,CDM,S5000,HCPCS,259,RC,00574-0106-03,NDC,outpatient,1,UN,3.28,2.296,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUMETANIDE 0.5 MG ORAL TABS,RX-9309,CDM,S5000,HCPCS,259,RC,50268-0130-11,NDC,outpatient,1,UN,5.55,3.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUMETANIDE 0.5 MG ORAL TABS,RX-9309,CDM,S5000,HCPCS,259,RC,42799-0119-01,NDC,outpatient,1,UN,1.43,1.001,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUMETANIDE 0.5 MG ORAL TABS,RX-9309,CDM,S5000,HCPCS,259,RC,50268-0130-15,NDC,outpatient,1,UN,5.55,3.885,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,00185-0129-01,NDC,outpatient,1,UN,1.65,1.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,60687-0384-11,NDC,outpatient,1,UN,3.38,2.366,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,00185-0129-05,NDC,outpatient,1,UN,1.38,0.966,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,50268-0131-11,NDC,outpatient,1,UN,3.09,2.163,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,60687-0384-01,NDC,outpatient,1,UN,3.38,2.366,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,69238-1490-01,NDC,outpatient,1,UN,1.61,1.127,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,50268-0131-15,NDC,outpatient,1,UN,3.09,2.163,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 IJ SOLN,RX-9318,CDM,S5000,HCPCS,250,RC,63323-0463-57,NDC,outpatient,50,ML,49.4,34.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 IJ SOLN,RX-9318,CDM,S5000,HCPCS,250,RC,63323-0463-01,NDC,outpatient,50,ML,49.4,34.58,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPROPION HCL 100 MG ORAL TABS,RX-9321,CDM,S5000,HCPCS,259,RC,00904-6636-61,NDC,outpatient,1,UN,4.6,3.22,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPROPION HCL 75 MG ORAL TABS,RX-9322,CDM,S5000,HCPCS,259,RC,50268-0142-11,NDC,outpatient,1,UN,2.99,2.093,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPROPION HCL 75 MG ORAL TABS,RX-9322,CDM,S5000,HCPCS,259,RC,50268-0142-15,NDC,outpatient,1,UN,2.99,2.093,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPROPION HCL 75 MG ORAL TABS,RX-9322,CDM,S5000,HCPCS,259,RC,60687-0340-01,NDC,outpatient,1,UN,3.85,2.695,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUPROPION HCL 75 MG ORAL TABS,RX-9322,CDM,S5000,HCPCS,259,RC,60687-0340-11,NDC,outpatient,1,UN,3.85,2.695,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUSPIRONE HCL 5 MG ORAL TABS,RX-9324,CDM,S5000,HCPCS,259,RC,00904-7122-61,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUSPIRONE HCL 5 MG ORAL TABS,RX-9324,CDM,S5000,HCPCS,259,RC,51079-0985-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUSPIRONE HCL 5 MG ORAL TABS,RX-9324,CDM,S5000,HCPCS,259,RC,51079-0985-20,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BUSPIRONE HCL 5 MG ORAL TABS,RX-9324,CDM,S5000,HCPCS,259,RC,00093-0053-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CALCITRIOL 0.25 MCG ORAL CAPS,RX-9350,CDM,S5000,HCPCS,259,RC,69452-0207-20,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CALCITRIOL 0.25 MCG ORAL CAPS,RX-9350,CDM,S5000,HCPCS,259,RC,23155-0662-01,NDC,outpatient,1,UN,1.4,0.98,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CALCIUM CARBONATE ANTACID 500 MG ORAL CHEW,RX-9385,CDM,S5000,HCPCS,259,RC,66553-0004-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CALCIUM CARBONATE ANTACID 500 MG ORAL CHEW,RX-9385,CDM,S5000,HCPCS,259,RC,00904-6412-92,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CALCIUM CARBONATE ANTACID 500 MG ORAL CHEW,RX-9385,CDM,S5000,HCPCS,259,RC,68084-0988-32,NDC,outpatient,1,UN,2.86,2.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CALCIUM CARBONATE ANTACID 500 MG ORAL CHEW,RX-9385,CDM,S5000,HCPCS,259,RC,68084-0988-33,NDC,outpatient,1,UN,2.86,2.002,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SORBITOL 70 % SOLN,RX-93927,CDM,S5000,HCPCS,259,RC,46287-0500-30,NDC,outpatient,30,ML,9.48,6.636,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00378-9671-93,NDC,outpatient,3,ML,2.4,1.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00487-0201-03,NDC,outpatient,3,ML,1.13,0.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,76204-0600-01,NDC,outpatient,3,ML,1.22,0.854,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00378-9671-31,NDC,outpatient,3,ML,2.4,1.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00487-0201-01,NDC,outpatient,3,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,47335-0756-48,NDC,outpatient,3,ML,1.42,0.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,47335-0756-49,NDC,outpatient,3,ML,1.42,0.994,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00378-9671-30,NDC,outpatient,3,ML,2.4,1.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00378-9671-60,NDC,outpatient,3,ML,2.4,1.68,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CAPTOPRIL 12.5 MG ORAL TABS,RX-9401,CDM,S5000,HCPCS,259,RC,00904-7105-61,NDC,outpatient,1,UN,6.29,4.403,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CAPTOPRIL 25 MG ORAL TABS,RX-9402,CDM,S5000,HCPCS,259,RC,00904-7106-61,NDC,outpatient,1,UN,5.2,3.64,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CARBIDOPA-LEVODOPA 10-100 MG ORAL TABS,RX-9406,CDM,S5000,HCPCS,259,RC,00093-9701-01,NDC,outpatient,1,UN,1.15,0.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CARBIDOPA-LEVODOPA 25-100 MG ORAL TABS,RX-9407,CDM,S5000,HCPCS,259,RC,00093-9702-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CARBIDOPA-LEVODOPA 25-100 MG ORAL TABS,RX-9407,CDM,S5000,HCPCS,259,RC,60687-0661-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CARBIDOPA-LEVODOPA 25-100 MG ORAL TABS,RX-9407,CDM,S5000,HCPCS,259,RC,60687-0661-11,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN,RX-9413,CDM,S5000,HCPCS,250,RC,00009-0856-05,NDC,outpatient,1,ML,319.49,223.643,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN,RX-9413,CDM,S5000,HCPCS,250,RC,00009-0856-08,NDC,outpatient,1,ML,319.49,223.643,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BENZOCAINE-MENTHOL 15-3.6 MG MT LOZG,RX-94141,CDM,S5000,HCPCS,259,RC,00904-6255-49,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RENO CAPS 1 MG ORAL CAPS,RX-94178,CDM,S5000,HCPCS,259,RC,60258-0162-01,NDC,outpatient,1,UN,2.43,1.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
RENO CAPS 1 MG ORAL CAPS,RX-94178,CDM,S5000,HCPCS,259,RC,63044-0622-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CEFACLOR 250 MG ORAL CAPS,RX-9430,CDM,S5000,HCPCS,259,RC,61442-0171-30,NDC,outpatient,1,UN,8.1,5.67,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CEFADROXIL 500 MG ORAL CAPS,RX-9436,CDM,S5000,HCPCS,259,RC,68180-0180-01,NDC,outpatient,1,UN,2.36,1.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CEFADROXIL 500 MG ORAL CAPS,RX-9436,CDM,S5000,HCPCS,259,RC,16714-0388-01,NDC,outpatient,1,UN,1.08,0.756,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CEFADROXIL 500 MG ORAL CAPS,RX-9436,CDM,S5000,HCPCS,259,RC,65862-0085-50,NDC,outpatient,1,UN,2.45,1.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CEFADROXIL 500 MG ORAL CAPS,RX-9436,CDM,S5000,HCPCS,259,RC,68180-0180-08,NDC,outpatient,1,UN,2.65,1.855,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CEFPODOXIME PROXETIL 200 MG ORAL TABS,RX-9469,CDM,S5000,HCPCS,259,RC,00781-5439-20,NDC,outpatient,1,UN,12.33,8.631,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CEFPODOXIME PROXETIL 200 MG ORAL TABS,RX-9469,CDM,S5000,HCPCS,259,RC,65862-0096-20,NDC,outpatient,1,UN,14.53,10.171,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CEFUROXIME AXETIL 250 MG ORAL TABS,RX-9495,CDM,S5000,HCPCS,259,RC,16714-0400-02,NDC,outpatient,1,UN,3.64,2.548,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CEFUROXIME AXETIL 250 MG ORAL TABS,RX-9495,CDM,S5000,HCPCS,259,RC,67877-0215-60,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CEFUROXIME AXETIL 250 MG ORAL TABS,RX-9495,CDM,S5000,HCPCS,259,RC,65862-0699-60,NDC,outpatient,1,UN,2.34,1.638,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CEPHALEXIN 250 MG ORAL CAPS,RX-9499,CDM,S5000,HCPCS,259,RC,50268-0151-15,NDC,outpatient,1,UN,1.49,1.043,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CEPHALEXIN 250 MG ORAL CAPS,RX-9499,CDM,S5000,HCPCS,259,RC,60687-0152-01,NDC,outpatient,1,UN,1.3,0.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CEPHALEXIN 250 MG ORAL CAPS,RX-9499,CDM,S5000,HCPCS,259,RC,50268-0151-11,NDC,outpatient,1,UN,1.49,1.043,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CEPHALEXIN 250 MG ORAL CAPS,RX-9499,CDM,S5000,HCPCS,259,RC,60687-0152-11,NDC,outpatient,1,UN,1.3,0.91,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CEPHALEXIN 250 MG ORAL CAPS,RX-9499,CDM,S5000,HCPCS,259,RC,67877-0220-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CHLORHEXIDINE GLUCONATE 0.12 % MT SOLN,RX-9516,CDM,S5000,HCPCS,259,RC,69339-0138-15,NDC,outpatient,15,ML,6.55,4.585,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CHLORHEXIDINE GLUCONATE 0.12 % MT SOLN,RX-9516,CDM,S5000,HCPCS,259,RC,69339-0138-19,NDC,outpatient,15,ML,6.15,4.305,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CHLOROTHIAZIDE 250 MG/5ML ORAL SUSP,RX-9525,CDM,S5000,HCPCS,259,RC,,,outpatient,1,ML,1.39,0.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CHLOROTHIAZIDE 250 MG/5ML ORAL SUSP,RX-9525,CDM,S5000,HCPCS,259,RC,,,outpatient,5,ML,5.99,4.193,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FERROUS SULFATE 75 (15 FE) MG/ML ORAL SOLN,RX-95693,CDM,S5000,HCPCS,259,RC,99999-0003-94,NDC,outpatient,1,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
FERROUS SULFATE 75 (15 FE) MG/ML ORAL SOLN,RX-95693,CDM,S5000,HCPCS,259,RC,54838-0011-50,NDC,outpatient,50,ML,14.02,9.814,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CIPROFLOXACIN HCL 0.3 % OP SOLN,RX-9610,CDM,S5000,HCPCS,259,RC,69315-0308-05,NDC,outpatient,5,ML,62.3,43.61,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CIPROFLOXACIN HCL 0.3 % OP SOLN,RX-9610,CDM,S5000,HCPCS,259,RC,61314-0656-05,NDC,outpatient,5,ML,15.4,10.78,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLARITHROMYCIN 250 MG ORAL TABS,RX-9616,CDM,S5000,HCPCS,259,RC,00527-1931-06,NDC,outpatient,1,UN,1.14,0.798,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLARITHROMYCIN 250 MG ORAL TABS,RX-9616,CDM,S5000,HCPCS,259,RC,65862-0225-60,NDC,outpatient,1,UN,1.39,0.973,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLINDAMYCIN PHOSPHATE 1 % EX GEL,RX-9623,CDM,S5000,HCPCS,259,RC,00168-0202-30,NDC,outpatient,30,GR,207.33,145.131,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLINDAMYCIN PHOSPHATE 1 % EX GEL,RX-9623,CDM,S5000,HCPCS,259,RC,59762-3743-01,NDC,outpatient,30,GR,208.26,145.782,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLOBETASOL PROPIONATE 0.05 % EX CREA,RX-9630,CDM,S5000,HCPCS,259,RC,51672-1258-02,NDC,outpatient,30,GR,31.11,21.777,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLOBETASOL PROPIONATE 0.05 % EX CREA,RX-9630,CDM,S5000,HCPCS,259,RC,69238-1532-05,NDC,outpatient,15,GR,19.83,13.881,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLOBETASOL PROPIONATE 0.05 % EX OINT,RX-9631,CDM,S5000,HCPCS,259,RC,51672-1259-02,NDC,outpatient,30,GR,43.53,30.471,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLOBETASOL PROPIONATE 0.05 % EX OINT,RX-9631,CDM,S5000,HCPCS,259,RC,21922-0017-05,NDC,outpatient,30,GR,42.19,29.533,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLOMIPRAMINE HCL 25 MG ORAL CAPS,RX-9635,CDM,S5000,HCPCS,259,RC,68084-0790-25,NDC,outpatient,1,UN,36.81,25.767,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLOMIPRAMINE HCL 25 MG ORAL CAPS,RX-9635,CDM,S5000,HCPCS,259,RC,68084-0790-95,NDC,outpatient,1,UN,36.81,25.767,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLONAZEPAM 0.5 MG ORAL TABS,RX-9637,CDM,S5000,HCPCS,259,RC,60687-0544-11,NDC,outpatient,1,UN,1.65,1.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLONAZEPAM 0.5 MG ORAL TABS,RX-9637,CDM,S5000,HCPCS,259,RC,60687-0544-01,NDC,outpatient,1,UN,1.65,1.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLONAZEPAM 1 MG ORAL TABS,RX-9638,CDM,S5000,HCPCS,259,RC,16729-0137-00,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLONAZEPAM 1 MG ORAL TABS,RX-9638,CDM,S5000,HCPCS,259,RC,60687-0555-11,NDC,outpatient,1,UN,1.65,1.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLONAZEPAM 1 MG ORAL TABS,RX-9638,CDM,S5000,HCPCS,259,RC,43547-0407-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLONAZEPAM 1 MG ORAL TABS,RX-9638,CDM,S5000,HCPCS,259,RC,60687-0555-01,NDC,outpatient,1,UN,1.65,1.155,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLOTRIMAZOLE 10 MG MT TROC,RX-9644,CDM,S5000,HCPCS,259,RC,00054-4146-22,NDC,outpatient,1,UN,1.41,0.987,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLOTRIMAZOLE 10 MG MT TROC,RX-9644,CDM,S5000,HCPCS,259,RC,00574-0107-70,NDC,outpatient,1,UN,1.34,0.938,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLOZAPINE 100 MG ORAL TABS,RX-9647,CDM,S5000,HCPCS,259,RC,60687-0415-01,NDC,outpatient,1,UN,2.55,1.785,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLOZAPINE 100 MG ORAL TABS,RX-9647,CDM,S5000,HCPCS,259,RC,51079-0922-01,NDC,outpatient,1,UN,4.21,2.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLOZAPINE 100 MG ORAL TABS,RX-9647,CDM,S5000,HCPCS,259,RC,60687-0415-11,NDC,outpatient,1,UN,2.55,1.785,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLOZAPINE 100 MG ORAL TABS,RX-9647,CDM,S5000,HCPCS,259,RC,51079-0922-20,NDC,outpatient,1,UN,4.21,2.947,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLOZAPINE 25 MG ORAL TABS,RX-9648,CDM,S5000,HCPCS,259,RC,51079-0921-20,NDC,outpatient,1,UN,2.14,1.498,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CLOZAPINE 25 MG ORAL TABS,RX-9648,CDM,S5000,HCPCS,259,RC,51079-0921-01,NDC,outpatient,1,UN,2.14,1.498,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
COLLAGENASE 250 UNIT/GM EX OINT,RX-9682,CDM,S5000,HCPCS,259,RC,50484-0010-30,NDC,outpatient,30,GR,1218.46,852.922,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CROMOLYN SODIUM 4 % OP SOLN,RX-9691,CDM,S5000,HCPCS,259,RC,61314-0237-10,NDC,outpatient,10,ML,27.77,19.439,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LACOSAMIDE 50 MG ORAL TABS,RX-96968,CDM,S5000,HCPCS,259,RC,00131-2477-60,NDC,outpatient,1,UN,53.28,37.296,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LACOSAMIDE 50 MG ORAL TABS,RX-96968,CDM,S5000,HCPCS,259,RC,00131-2477-35,NDC,outpatient,1,UN,48.43,33.901,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LACOSAMIDE 50 MG ORAL TABS,RX-96968,CDM,S5000,HCPCS,259,RC,68462-0678-60,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LACOSAMIDE 100 MG ORAL TABS,RX-96969,CDM,S5000,HCPCS,259,RC,00131-2478-60,NDC,outpatient,1,UN,83.29,58.303,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LACOSAMIDE 100 MG ORAL TABS,RX-96969,CDM,S5000,HCPCS,259,RC,31722-0813-60,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LACOSAMIDE 100 MG ORAL TABS,RX-96969,CDM,S5000,HCPCS,259,RC,60687-0687-57,NDC,outpatient,1,UN,5.37,3.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LACOSAMIDE 100 MG ORAL TABS,RX-96969,CDM,S5000,HCPCS,259,RC,51991-0349-06,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LACOSAMIDE 100 MG ORAL TABS,RX-96969,CDM,S5000,HCPCS,259,RC,60687-0687-11,NDC,outpatient,1,UN,5.37,3.759,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CYCLOPENTOLATE HCL 2 % OP SOLN,RX-9700,CDM,S5000,HCPCS,259,RC,00065-0397-02,NDC,outpatient,2,ML,180.67,126.469,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % OP SOLN,RX-9701,CDM,S5000,HCPCS,259,RC,00065-0359-02,NDC,outpatient,2,ML,144.23,100.961,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CYCLOSPORINE 100 MG ORAL CAPS,RX-9706,CDM,S5000,HCPCS,259,RC,00078-0241-61,NDC,outpatient,1,UN,74.28,51.996,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CYCLOSPORINE 100 MG ORAL CAPS,RX-9706,CDM,S5000,HCPCS,259,RC,00078-0241-15,NDC,outpatient,1,UN,74.28,51.996,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CYCLOSPORINE 100 MG ORAL CAPS,RX-9706,CDM,S5000,HCPCS,259,RC,60505-0134-00,NDC,outpatient,1,UN,46.97,32.879,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CYCLOSPORINE 25 MG ORAL CAPS,RX-9707,CDM,S5000,HCPCS,259,RC,68084-0879-25,NDC,outpatient,1,UN,18.44,12.908,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CYCLOSPORINE 25 MG ORAL CAPS,RX-9707,CDM,S5000,HCPCS,259,RC,68084-0879-95,NDC,outpatient,1,UN,18.44,12.908,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CYCLOSPORINE 25 MG ORAL CAPS,RX-9707,CDM,S5000,HCPCS,259,RC,00078-0240-61,NDC,outpatient,1,UN,18.61,13.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
CYCLOSPORINE 25 MG ORAL CAPS,RX-9707,CDM,S5000,HCPCS,259,RC,00078-0240-15,NDC,outpatient,1,UN,18.61,13.027,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DANTROLENE SODIUM 20 MG IV SOLR,RX-9716,CDM,S5000,HCPCS,250,RC,42023-0123-06,NDC,outpatient,1,UN,288.51,201.957,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DANTROLENE SODIUM 25 MG ORAL CAPS,RX-9718,CDM,S5000,HCPCS,259,RC,00115-4411-01,NDC,outpatient,1,UN,2.65,1.855,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DANTROLENE SODIUM 25 MG ORAL CAPS,RX-9718,CDM,S5000,HCPCS,259,RC,00904-7211-04,NDC,outpatient,1,UN,4.53,3.171,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SUMATRIPTAN SUCCINATE 6 MG/0.5ML SC SOLN,RX-97343,CDM,S5000,HCPCS,250,RC,55150-0173-01,NDC,outpatient,0.5,ML,17.69,12.383,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
SUMATRIPTAN SUCCINATE 6 MG/0.5ML SC SOLN,RX-97343,CDM,S5000,HCPCS,250,RC,63323-0273-01,NDC,outpatient,0.5,ML,24.66,17.262,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PROMETHAZINE HCL 6.25 MG/5ML ORAL SOLN,RX-97609,CDM,S5000,HCPCS,259,RC,99999-0002-38,NDC,outpatient,10,ML,1.5,1.05,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PROMETHAZINE HCL 6.25 MG/5ML ORAL SOLN,RX-97609,CDM,S5000,HCPCS,259,RC,60432-0608-16,NDC,outpatient,10,ML,3.48,2.436,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,00121-1276-10,NDC,outpatient,10,ML,7.53,5.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,00904-7135-72,NDC,outpatient,10,ML,6.5,4.55,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,49348-0861-34,NDC,outpatient,118,ML,8.93,6.251,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,00121-1276-00,NDC,outpatient,10,ML,7.53,5.271,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,49348-0861-10,NDC,outpatient,10,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,61787-0513-04,NDC,outpatient,118,ML,17.33,12.131,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,61787-0513-10,NDC,outpatient,10,ML,1.7,1.19,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,99999-0001-87,NDC,outpatient,10,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
TOLVAPTAN 15 MG ORAL TABS,RX-97893,CDM,S5000,HCPCS,259,RC,59148-0020-50,NDC,outpatient,1,UN,1428.57,999.999,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PANCRELIPASE (LIP-PROT-AMYL) 6000-19000 UNITS ORAL CPEP,RX-98034,CDM,S5000,HCPCS,259,RC,00032-0046-70,NDC,outpatient,1,UN,8.55,5.985,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PANCRELIPASE (LIP-PROT-AMYL) 24000-76000 UNITS ORAL CPEP,RX-98036,CDM,S5000,HCPCS,259,RC,00032-2636-01,NDC,outpatient,1,UN,33.86,23.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PANCRELIPASE (LIP-PROT-AMYL) 24000-76000 UNITS ORAL CPEP,RX-98036,CDM,S5000,HCPCS,259,RC,00032-1224-01,NDC,outpatient,1,UN,33.86,23.702,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DEXTROSE-SODIUM CHLORIDE 10-0.45 % IV SOLN,RX-9809,CDM,S5000,HCPCS,250,RC,00264-7622-00,NDC,outpatient,1000,ML,51.6,36.12,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DEXTROSE-SODIUM CHLORIDE 5-0.2 % IV SOLN,RX-9812,CDM,S5000,HCPCS,250,RC,00338-0077-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DEXTROSE-SODIUM CHLORIDE 5-0.33 % IV SOLN,RX-9813,CDM,S5000,HCPCS,250,RC,00264-7614-10,NDC,outpatient,500,ML,40.48,28.336,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DEXTROSE-SODIUM CHLORIDE 5-0.45 % IV SOLN,RX-9814,CDM,S5000,HCPCS,250,RC,00338-0085-03,NDC,outpatient,500,ML,23.71,16.597,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DEXTROSE-SODIUM CHLORIDE 5-0.45 % IV SOLN,RX-9814,CDM,S5000,HCPCS,250,RC,00338-0085-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DRONEDARONE HCL 400 MG ORAL TABS,RX-98329,CDM,S5000,HCPCS,259,RC,00024-4142-60,NDC,outpatient,1,UN,53.6,37.52,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PRASUGREL HCL 5 MG ORAL TABS,RX-98372,CDM,S5000,HCPCS,259,RC,60505-4642-03,NDC,outpatient,1,UN,1.06,0.742,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PRASUGREL HCL 10 MG ORAL TABS,RX-98373,CDM,S5000,HCPCS,259,RC,00378-5186-93,NDC,outpatient,1,UN,4.12,2.884,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PRASUGREL HCL 10 MG ORAL TABS,RX-98373,CDM,S5000,HCPCS,259,RC,65162-0002-03,NDC,outpatient,1,UN,2.9,2.03,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
PRASUGREL HCL 10 MG ORAL TABS,RX-98373,CDM,S5000,HCPCS,259,RC,65862-0830-30,NDC,outpatient,1,UN,1,0.7,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BENZOIN COMPOUND EX TINC,RX-987,CDM,S5000,HCPCS,259,RC,00395-0243-92,NDC,outpatient,1,ML,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DINOPROSTONE 0.5 MG/3GM VA GEL,RX-9874,CDM,S5000,HCPCS,259,RC,00009-3359-01,NDC,outpatient,3,GR,1932.45,1352.715,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BENZONATATE 100 MG ORAL CAPS,RX-988,CDM,S5000,HCPCS,259,RC,00904-7153-61,NDC,outpatient,1,UN,1.32,0.924,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BENZONATATE 100 MG ORAL CAPS,RX-988,CDM,S5000,HCPCS,259,RC,64380-0712-06,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BENZONATATE 100 MG ORAL CAPS,RX-988,CDM,S5000,HCPCS,259,RC,42806-0714-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BENZONATATE 100 MG ORAL CAPS,RX-988,CDM,S5000,HCPCS,259,RC,69452-0143-20,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOXAZOSIN MESYLATE 1 MG ORAL TABS,RX-9894,CDM,S5000,HCPCS,259,RC,00904-5522-61,NDC,outpatient,1,UN,2.36,1.652,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOXAZOSIN MESYLATE 1 MG ORAL TABS,RX-9894,CDM,S5000,HCPCS,259,RC,68084-0836-95,NDC,outpatient,1,UN,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOXAZOSIN MESYLATE 1 MG ORAL TABS,RX-9894,CDM,S5000,HCPCS,259,RC,68084-0836-25,NDC,outpatient,1,UN,3.32,2.324,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOXAZOSIN MESYLATE 4 MG ORAL TABS,RX-9896,CDM,S5000,HCPCS,259,RC,00904-5524-61,NDC,outpatient,1,UN,2.28,1.596,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOXAZOSIN MESYLATE 4 MG ORAL TABS,RX-9896,CDM,S5000,HCPCS,259,RC,16729-0213-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOXAZOSIN MESYLATE 4 MG ORAL TABS,RX-9896,CDM,S5000,HCPCS,259,RC,60505-0095-00,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOXYCYCLINE MONOHYDRATE 25 MG/5ML ORAL SUSR,RX-9902,CDM,S5000,HCPCS,259,RC,68180-0657-01,NDC,outpatient,20,ML,27.06,18.942,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
DOXYCYCLINE MONOHYDRATE 25 MG/5ML ORAL SUSR,RX-9902,CDM,S5000,HCPCS,259,RC,99999-0002-89,NDC,outpatient,20,ML,27.06,18.942,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ECONAZOLE NITRATE 1 % EX CREA,RX-9915,CDM,S5000,HCPCS,259,RC,51672-1303-01,NDC,outpatient,15,GR,32.65,22.855,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ENALAPRIL MALEATE 10 MG ORAL TABS,RX-9924,CDM,S5000,HCPCS,259,RC,23155-0772-01,NDC,outpatient,1,UN,1.15,0.805,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ENALAPRIL MALEATE 10 MG ORAL TABS,RX-9924,CDM,S5000,HCPCS,259,RC,43547-0547-10,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ENALAPRIL MALEATE 2.5 MG ORAL TABS,RX-9925,CDM,S5000,HCPCS,259,RC,16714-0442-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ENALAPRILAT 1.25 MG/ML IV INJ,RX-9929,CDM,S5000,HCPCS,250,RC,00143-9786-10,NDC,outpatient,2,ML,34.39,24.073,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ENALAPRILAT 1.25 MG/ML IV INJ,RX-9929,CDM,S5000,HCPCS,250,RC,00143-9786-01,NDC,outpatient,2,ML,34.39,24.073,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OPIUM 10 MG/ML (1%) ORAL TINC,RX-99405,CDM,S5000,HCPCS,259,RC,99999-0002-24,NDC,outpatient,0.6,ML,13.98,9.786,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
OPIUM 10 MG/ML (1%) ORAL TINC,RX-99405,CDM,S5000,HCPCS,259,RC,42799-0217-01,NDC,outpatient,0.6,ML,13.98,9.786,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GLYCERIN (LAXATIVE) 1 G RE SUPP,RX-99417,CDM,S5000,HCPCS,259,RC,58980-0409-12,NDC,outpatient,1,UN,2.17,1.519,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVONORGESTREL 1.5 MG ORAL TABS,RX-99445,CDM,S5000,HCPCS,259,RC,69536-0162-88,NDC,outpatient,1,UN,133.64,93.548,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
LEVONORGESTREL 1.5 MG ORAL TABS,RX-99445,CDM,S5000,HCPCS,259,RC,69536-0146-19,NDC,outpatient,1,UN,133.73,93.611,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ESTROGENS CONJUGATED 0.3 MG ORAL TABS,RX-9973,CDM,S5000,HCPCS,259,RC,00046-1100-81,NDC,outpatient,1,UN,28.4,19.88,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ETHACRYNATE SODIUM 50 MG IV SOLR,RX-9979,CDM,S5000,HCPCS,250,RC,42023-0157-01,NDC,outpatient,1,UN,1563.3,1094.31,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ETHACRYNATE SODIUM 50 MG IV SOLR,RX-9979,CDM,S5000,HCPCS,250,RC,67457-0297-50,NDC,outpatient,1,UN,2098.98,1469.286,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BENZTROPINE MESYLATE 0.5 MG ORAL TABS,RX-998,CDM,S5000,HCPCS,259,RC,68084-0381-11,NDC,outpatient,1,UN,1.82,1.274,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BENZTROPINE MESYLATE 0.5 MG ORAL TABS,RX-998,CDM,S5000,HCPCS,259,RC,68084-0381-01,NDC,outpatient,1,UN,1.82,1.274,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ETHACRYNIC ACID 25 MG ORAL TABS,RX-9980,CDM,S5000,HCPCS,259,RC,69238-1126-01,NDC,outpatient,1,UN,8.7,6.09,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ETHAMBUTOL HCL 400 MG ORAL TABS,RX-9983,CDM,S5000,HCPCS,259,RC,68850-0012-02,NDC,outpatient,1,UN,3.21,2.247,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GUANFACINE HCL ER 1 MG ORAL TB24,RX-99835,CDM,S5000,HCPCS,259,RC,24979-0533-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GUANFACINE HCL ER 1 MG ORAL TB24,RX-99835,CDM,S5000,HCPCS,259,RC,60505-3927-01,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
GUANFACINE HCL ER 2 MG ORAL TB24,RX-99836,CDM,S5000,HCPCS,259,RC,62332-0746-31,NDC,outpatient,1,UN,0.99,0.693,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ETHOSUXIMIDE 250 MG ORAL CAPS,RX-9989,CDM,S5000,HCPCS,259,RC,23155-0532-01,NDC,outpatient,1,UN,5.34,3.738,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ETHOSUXIMIDE 250 MG ORAL CAPS,RX-9989,CDM,S5000,HCPCS,259,RC,64380-0878-06,NDC,outpatient,1,UN,1.63,1.141,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BENZTROPINE MESYLATE 1 MG ORAL TABS,RX-999,CDM,S5000,HCPCS,259,RC,68084-0388-01,NDC,outpatient,1,UN,1.62,1.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
BENZTROPINE MESYLATE 1 MG ORAL TABS,RX-999,CDM,S5000,HCPCS,259,RC,68084-0388-11,NDC,outpatient,1,UN,1.62,1.134,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ETODOLAC 200 MG ORAL CAPS,RX-9997,CDM,S5000,HCPCS,259,RC,60505-0039-01,NDC,outpatient,1,UN,1.83,1.281,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ETODOLAC 200 MG ORAL CAPS,RX-9997,CDM,S5000,HCPCS,259,RC,62559-0250-01,NDC,outpatient,1,UN,1.72,1.204,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
ETODOLAC 300 MG ORAL CAPS,RX-9998,CDM,S5000,HCPCS,259,RC,62559-0251-01,NDC,outpatient,1,UN,2.43,1.701,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,0.222255,85118.57664,other,Non Reimbursable Rates,,
HC Crisis Intervention Mental Health Services- per Diem,PX-90000001,CDM,S9485,HCPCS,900,RC,,,outpatient,,,1627,1138.9,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,741.66,,,741.66,365.2615,1249.536,fee schedule,,,
HC Full Trauma No Notification,PX-45000633,CDM,TR450,LOCAL,450,RC,,,outpatient,,,10370,7259,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,8789.61,399.86,9291.52,percent of total billed charges,,,
HC Partial Trauma No Notification,PX-45000634,CDM,TR450,LOCAL,450,RC,,,outpatient,,,7029,4920.3,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,5957.78,399.86,9291.52,percent of total billed charges,,,
IOL 16D 5.5X12.5MM PMMA AC CNVXPLN ACRYSOF MTA3U0 -,SUP-MTA3U0.160,CDM,V2630,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,129.686915,921.62304,other,SI=N Exclusions ,,
IOL 9.5D 5.5MMX12.5MM AC CNVXPLN -,SUP-MTA3UO.095,CDM,V2630,HCPCS,276,RC,,,outpatient,,,577.67,404.369,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,129.686915,921.62304,other,SI=N Exclusions ,,
IOL 10.5D 5.5MMX12.5MM AC CNVXPLN -,SUP-MTA3UO.105,CDM,V2630,HCPCS,276,RC,,,outpatient,,,577.67,404.369,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,129.686915,921.62304,other,SI=N Exclusions ,,
IOL 20D 5.5MMX12.5MM AC CNVXPLN -,SUP-MTA3UO.200,CDM,V2630,HCPCS,276,RC,,,outpatient,,,1200.03,840.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,129.686915,921.62304,other,SI=N Exclusions ,,
IOL 22D 5.5X13MM AC CNVXPLN -,SUP-MTA4UO.220,CDM,V2630,HCPCS,276,RC,,,outpatient,,,1200.03,840.021,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,129.686915,921.62304,other,SI=N Exclusions ,,
IOL 12.5D 5.5MMX13.5MM AC CNVXPLN -,SUP-MTA5U0.125,CDM,V2630,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,129.686915,921.62304,other,SI=N Exclusions ,,
IOL 10.5D X 13.5OP AC CNVXPLN -,SUP-MTA5UO.105,CDM,V2630,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,129.686915,921.62304,other,SI=N Exclusions ,,
IOL 8.5D PC -,SUP-AR40MN085,CDM,V2632,HCPCS,276,RC,,,outpatient,,,1021.13,714.791,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 23D 6X13MM CLARIFLEX CLRFLXC 3PC PC BICNVX SIL BLU COR -,SUP-CLRFLXC.230,CDM,V2632,HCPCS,276,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 26.5D CLARIFLEX PC -,SUP-CLRFLXC.265,CDM,V2632,HCPCS,276,RC,,,outpatient,,,612.68,428.876,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 16.5D 6X13MM ACRYSF MA60AC 3PC PC BICNVX BLU ACRYLT -,SUP-MA60AC.165,CDM,V2632,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL +1D 6X13MM ACRYSF MA60MA MULPC PC MNSCS BLU ACRYLT -,SUP-MA60MA.010,CDM,V2632,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 3D 6X13MM ACRYSF MA60MA MULPC PC MNSCS BLU ACRYLT -,SUP-MA60MA.030,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL -4D 6X13MM ACRYSF XPD SRS MULPC PC BICNVX BLU ACRYLT -,SUP-MA60MA-4.0,CDM,V2632,HCPCS,276,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
LENS I/O X.010 NEGATIVE D -,SUP-MA60MAN010,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 4D 6X13MM ACRYSF XPD SRS MULPC PC BICNVX BLU ACRYLT -,SUP-MA60MAN040,CDM,V2632,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
LENS I/O MN60AC X 8.0 -,SUP-MN60AC.080,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 28D 6X13MM ACRYSF MN60AC MULPC PC BICNVX NAT YEL ACRYLT -,SUP-MN60AC.280,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 2.0 DIA 6X13MM ACRYSF XPD SRS MULPC PC MNSCS NAT -,SUP-MN60MA.020,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 3D 6X13MM ACRYSF XPD SRS MULPC PC MNSCS NAT -,SUP-MN60MA.030,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
LENS IOL 5.0D MN60MA 6X13MM ACRYSF MULPC PC MNSCS BLU ACRYLT -,SUP-MN60MA.050,CDM,V2632,HCPCS,276,RC,,,outpatient,,,875.25,612.675,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 9D 6X13MM ACRYSF SA60AT 1-PC PC BICNVX CLR ACRYLT -,SUP-SA60AT.090,CDM,V2632,HCPCS,276,RC,,,outpatient,,,781.89,547.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 30D 6X13MM ACRYSF 1-PC PC BICNVX NAT ANT ASYM -,SUP-SN60AT.300,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 31D 6X13MM 31  ACRYSF SA60AT 1-PC PC BICNVX CLR ACRYLT -,SUP-SN60AT.310,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 34D 6X13MM ACRYSF SA60AT 1-PC PC BICNVX CLR ACRYLT -,SUP-SN60AT.340,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 6.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.065,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 7D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.070,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 9D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.090,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 9.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.095,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 10D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.100,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 10.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.105,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 11D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.110,CDM,V2632,HCPCS,276,RC,,,outpatient,,,781.89,547.323,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 11.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.115,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 12D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.120,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 13D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.130,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 13.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.135,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 14D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.140,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 14.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.145,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 16D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.160,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 16.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.165,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 17D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.170,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 17.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.175,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 18D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.180,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 19D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.190,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 20D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.200,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 21D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.210,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 21.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.215,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 22D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.220,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 22.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.225,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 23D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.230,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 24D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.240,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 24.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.245,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 25D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.250,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 26D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.260,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 26.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.265,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 19D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.190,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 20D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.200,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 20.5D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.205,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 21D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.210,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 21.5D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.215,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
LENS I/O MA60MA x 1.0 -,SUP-UNDEFINED,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
IOL 24.5D 6X13MM TECNIS ZA9003 3PC PC BICNVX HYDRPHB ACRL -,SUP-ZA9003.245,CDM,V2632,HCPCS,276,RC,,,outpatient,,,816.9,571.83,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,137.54666,3281.45664,other,SI=N Exclusions ,,
LENS ACRYSOF TORIC IQ  SN6AT3 X 9.5D -,SUP-SN6AT3.095,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,,,
IOL TORIC LENS  SN6AT3  12.0 -,SUP-SN6AT3.120,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,,,
IOL 15.5D 6X13MM ACRYSF SN6AT3 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT3.155,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,,,
IOL 16.0D  6X13MM ACRYSF  SN6AT3 -,SUP-SN6AT3.160,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,,,
IOL 17.0D  6X13MM ACRYSF  SN6AT3 -,SUP-SN6AT3.170,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,,,
IOL 18.0 D 6X13MM ACRYSF SN6AT3 -,SUP-SN6AT3.180,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,,,
IOL 19.5D 6X13MM ACRYSF SN6AT3 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT3.195,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,,,
IOL 24D 6X13MM ACRYSF  SN6 -,SUP-SN6AT3.240,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,,,
IOL 13.5D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.135,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,,,
IOL 19D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.190,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,,,
IOL 19.5D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.195,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,,,
IOL 21D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.210,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,,,
IOL 16D 6X13MM ACRYSF SN6AT5 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT5.160,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,,,
LENS ACRYSOF IQ  SN6AT5.180 -,SUP-SN6AT5.180,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,,,
IOL 21D 6X13MM ACRYSF SN6AT5 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT5.210,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,,,
IOL 23D 6X13MM ACRYSF SN6AT5 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT5.230,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,,,
IOL 11D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT6.110,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,,,
IOL 13.5D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT -,SUP-SN6AT6.135,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,,,
IOL 14D 6X13MM  ACRYSF  SN6AT6 -,SUP-SN6AT6.140,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,,,
IOL LENS SN6AT6 X 18.0 D -,SUP-SN6AT6.180,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,,,
IOL 20D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT6.200,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,,,
IOL 20.5D 6X13MM ACRYSF SN6AT6 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT6.205,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2093.7,1465.59,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,1774.62,399.86,2223.8905,percent of total billed charges,,,
IOL TORIC LENS 23.5 DIOPTER -,SUP-SN6AT6.235,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,,,
IOL 22D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT6U220,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,,,
IOL 20D 6X13MM  ACRYSF -,SUP-SN6AT7.200,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,,,
IOL 23.5D  6X13MM  ACRYSF   SN6AT7 -,SUP-SN6AT7.235,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,84.76,,2223.89,399.86,2223.8905,percent of total billed charges,,,
AMNIOGRAFT AMNIO MEMBR HUM TIS FRZN 3.5X3.5CM SZ-C -,SUP-AG-3535,CDM,V2790,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,3992.7552,other,SI=N Exclusions ,,
GRAFT HUM TIS 3.5X3.5CM SZ-C AMNIOGRFT AMNIO MEMBR 50-100U -,SUP-AG-3535F,CDM,V2790,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],,,,,,399.86,3992.7552,other,SI=N Exclusions ,,
Bilateral procedure,,,,,,,,,,,,,,BCBS MASSACHUSETTS [1010401],BCBS MASSACHUSETTS HMO [101040122],50,,150,,,,,,150% payment adjustment for the item or service to which the modifier is appended.,,
HC Semi-Private Unit,PX-12100001,CDM,12100001,LOCAL,121,RC,,,inpatient,,,1577,1103.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,525.9295,1261.6,,,,
HC Med/Surg Stepdown,PX-12100003,CDM,12100003,LOCAL,121,RC,,,inpatient,,,2423,1696.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,808.0705,1938.4,,,,
HC Maternity Unit,PX-12200001,CDM,12200001,LOCAL,122,RC,,,inpatient,,,2193,1535.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,731.3655,1754.4,,,,
HC Pediatric Semi-Private Unit,PX-12300001,CDM,12300001,LOCAL,123,RC,,,inpatient,,,3323,2326.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1108.2205,2658.4,,,,
HC S.E. Rehab Semi-Private Unit,PX-12800001,CDM,12800001,LOCAL,128,RC,,,inpatient,,,1783,1248.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2425.01,,,2425.01,594.6305,2483,per diem,,,
HC Nursery,PX-17000001,CDM,17000001,LOCAL,170,RC,,,inpatient,,,1333,933.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,444.5555,1066.4,,,,
HC Nursery Boarder,PX-17900001,CDM,17900001,LOCAL,179,RC,,,inpatient,,,1195,836.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,398.5325,956,,,,
HC Icu/Ccu Unit,PX-20000001,CDM,20000001,LOCAL,200,RC,,,inpatient,,,4009,2806.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1337.0015,3207.2,,,,
HC Icu Surgical Unit,PX-20100001,CDM,20100001,LOCAL,201,RC,,,inpatient,,,3646,2552.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1215.941,2916.8,,,,
HC Telemetry Unit,PX-20600001,CDM,20600001,LOCAL,206,RC,,,inpatient,,,2015,1410.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,672.0025,1612,,,,
HC Trauma,PX-20800001,CDM,20800001,LOCAL,208,RC,,,inpatient,,,4810,3367,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1604.135,3848,,,,
HC Onc. Vad Kit,PX-27000020,CDM,27000020,LOCAL,270,RC,,,inpatient,,,90,63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.205,72,,,,
HC Imed Pump for Lvl II,PX-27000021,CDM,27000021,LOCAL,270,RC,,,inpatient,,,118,82.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.491,94.4,,,,
HC Imed Pump,PX-27000022,CDM,27000022,LOCAL,270,RC,,,inpatient,,,113,79.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,25.3685,90.4,,,,
HC Local Anesth Supplies,PX-27000023,CDM,27000023,LOCAL,270,RC,,,inpatient,,,80,56,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,17.96,64,,,,
HC Periop O2,PX-27000044,CDM,27000044,LOCAL,270,RC,,,inpatient,,,79,55.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,17.7355,63.2,,,,
HC Bone Bx Kit,PX-27000050,CDM,27000050,LOCAL,270,RC,,,inpatient,,,267,186.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,59.9415,213.6,,,,
HC Kit Portex Nerve Block,PX-27000051,CDM,27000051,LOCAL,270,RC,,,inpatient,,,90,63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.205,72,,,,
HC Cannister Vac W/O Gel Ats,PX-27000052,CDM,27000052,LOCAL,270,RC,,,inpatient,,,282,197.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,63.309,225.6,,,,
HC Dressing Kci Small 5/Cs,PX-27000053,CDM,27000053,LOCAL,270,RC,,,inpatient,,,268,187.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.166,214.4,,,,
HC Cannister W/Gel Ats,PX-27000054,CDM,27000054,LOCAL,270,RC,,,inpatient,,,283,198.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,63.5335,226.4,,,,
HC Compression Stocking A6530,PX-27000055,CDM,27000055,LOCAL,270,RC,,,inpatient,,,285,199.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,63.9825,228,,,,
HC Custom Molded Insert,PX-27000056,CDM,27000056,LOCAL,270,RC,,,inpatient,,,287,200.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,64.4315,229.6,,,,
HC Dressing Kci Medium 10/Cs,PX-27000057,CDM,27000057,LOCAL,270,RC,,,inpatient,,,307,214.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,68.9215,245.6,,,,
HC Surgical Boot/Shoe L3260,PX-27000058,CDM,27000058,LOCAL,270,RC,,,inpatient,,,423,296.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,94.9635,338.4,,,,
HC Vaccum Assisted Closure Pump,PX-27000059,CDM,27000059,LOCAL,270,RC,,,inpatient,,,438,306.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,98.331,350.4,,,,
HC Ortho Wedge Shoe,PX-27000060,CDM,27000060,LOCAL,270,RC,,,inpatient,,,529,370.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,118.7605,423.2,,,,
HC Foot Pressure Support A9283,PX-27000061,CDM,27000061,LOCAL,270,RC,,,inpatient,,,529,370.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,118.7605,423.2,,,,
HC Sensor Nicom,PX-27000062,CDM,27000062,LOCAL,270,RC,,,inpatient,,,816,571.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,183.192,652.8,,,,
HC 6 Channel Pneumogram,PX-27000063,CDM,27000063,LOCAL,270,RC,,,inpatient,,,3884,2718.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,871.958,3107.2,,,,
HC Pneumogram 4-Channel,PX-27000064,CDM,27000064,LOCAL,270,RC,,,inpatient,,,4891,3423.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1098.0295,3912.8,,,,
HC Pad Artic Gel Large,PX-27000065,CDM,27000065,LOCAL,270,RC,,,inpatient,,,5242,3669.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1176.829,4193.6,,,,
HC Pneumogram 6- Channel,PX-27000066,CDM,27000066,LOCAL,270,RC,,,inpatient,,,5466,3826.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1227.117,4372.8,,,,
HC Therapy Polar Cooler,PX-27000068,CDM,27000068,LOCAL,270,RC,,,inpatient,,,667,466.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,149.7415,533.6,,,,
HC Liner Foam Permanently Med,PX-27000069,CDM,27000069,LOCAL,270,RC,,,inpatient,,,353,247.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,79.2485,282.4,,,,
HC Dressing Kci Vac Small,PX-27000070,CDM,27000070,LOCAL,270,RC,,,inpatient,,,327,228.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,73.4115,261.6,,,,
HC Dressing Kci Vac Large,PX-27000071,CDM,27000071,LOCAL,270,RC,,,inpatient,,,390,273,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,87.555,312,,,,
HC Developmental Aides,PX-27000072,CDM,27000072,LOCAL,270,RC,,,inpatient,,,707,494.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,158.7215,565.6,,,,
"HC Ez Reacher 30"" Suction",PX-27100004,CDM,27100004,LOCAL,271,RC,,,inpatient,,,144,100.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,32.328,122.0544,,,,
HC Support Bra Ez-on Med 958,PX-27100005,CDM,27100005,LOCAL,271,RC,,,inpatient,,,262,183.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,58.819,222.0712,,,,
HC Support Bra Ez-on Lrg 958,PX-27100006,CDM,27100006,LOCAL,271,RC,,,inpatient,,,272,190.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,61.064,230.5472,,,,
HC Support Bra Ez-on X-Lrg 958,PX-27100007,CDM,27100007,LOCAL,271,RC,,,inpatient,,,306,214.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,68.697,259.3656,,,,
HC Support Bra Ez-on Queen,PX-27100008,CDM,27100008,LOCAL,271,RC,,,inpatient,,,377,263.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,84.6365,319.5452,,,,
HC Bra Ez-on Super Queen,PX-27100009,CDM,27100009,LOCAL,271,RC,,,inpatient,,,471,329.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,105.7395,399.2196,,,,
HC Gradient Com Stocking,PX-27100010,CDM,27100010,LOCAL,271,RC,,,inpatient,,,490,343,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,110.005,415.324,,,,
HC Kit Flexi Seal Fecal,PX-27100011,CDM,27100011,LOCAL,271,RC,,,inpatient,,,939,657.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,210.8055,795.8964,,,,
HC Port Power Loc Access Kit,PX-27200054,CDM,27200054,LOCAL,272,RC,,,inpatient,,,88,61.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.756,74.5888,,,,
HC Dressing Kci Vac White Lg,PX-27200055,CDM,27200055,LOCAL,272,RC,,,inpatient,,,95,66.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,21.3275,80.522,,,,
HC Sheath Brite Tip 11cm,PX-27200056,CDM,27200056,LOCAL,272,RC,,,inpatient,,,108,75.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,24.246,91.5408,,,,
HC Kit Refill Syncromed Sys. Pain,PX-27200057,CDM,27200057,LOCAL,272,RC,,,inpatient,,,128,89.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,28.736,108.4928,,,,
HC Sock Fracture,PX-27200058,CDM,27200058,LOCAL,272,RC,,,inpatient,,,193,135.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,43.3285,163.5868,,,,
HC Tube Gastrostomy Replacement,PX-27200059,CDM,27200059,LOCAL,272,RC,,,inpatient,,,195,136.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,43.7775,165.282,,,,
HC Mod of Depth Shoe,PX-27200060,CDM,27200060,LOCAL,272,RC,,,inpatient,,,225,157.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,50.5125,190.71,,,,
HC Catheter Broncho 39l,PX-27200061,CDM,27200061,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,78.3505,295.8124,,,,
HC Catheter Bronch 35 Left 95892,PX-27200062,CDM,27200062,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,78.3505,295.8124,,,,
HC Endo-Bronch Tube 37fr Left,PX-27200063,CDM,27200063,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,78.3505,295.8124,,,,
HC Tube Endo Bronch #35 Left,PX-27200064,CDM,27200064,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,78.3505,295.8124,,,,
HC Endo Bronch Tube #39,PX-27200065,CDM,27200065,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,78.3505,295.8124,,,,
HC Catheter Broncho 41l,PX-27200066,CDM,27200066,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,78.3505,295.8124,,,,
HC Kit Arterial Line Arrow,PX-27200067,CDM,27200067,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,78.3505,295.8124,,,,
HC Cassette Kci Veralink,PX-27200068,CDM,27200068,LOCAL,272,RC,,,inpatient,,,357,249.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.1465,302.5932,,,,
HC Shiley Trach Tube 6lpc,PX-27200069,CDM,27200069,LOCAL,272,RC,,,inpatient,,,357,249.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.1465,302.5932,,,,
HC Tube Trach Shiley 8lpc,PX-27200070,CDM,27200070,LOCAL,272,RC,,,inpatient,,,357,249.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.1465,302.5932,,,,
HC Catheter Single 4fr Bard,PX-27200071,CDM,27200071,LOCAL,272,RC,,,inpatient,,,374,261.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,83.963,317.0024,,,,
HC Bivona #7 Trach Uncuffed,PX-27200072,CDM,27200072,LOCAL,272,RC,,,inpatient,,,396,277.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,88.902,335.6496,,,,
HC Retractor C Section Large,PX-27200073,CDM,27200073,LOCAL,272,RC,,,inpatient,,,402,281.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,90.249,340.7352,,,,
HC Midline 4fr Bd#384308,PX-27200074,CDM,27200074,LOCAL,272,RC,,,inpatient,,,409,286.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,91.8205,346.6684,,,,
HC Transducer Triple W/Vamp Pls,PX-27200075,CDM,27200075,LOCAL,272,RC,,,inpatient,,,418,292.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,93.841,354.2968,,,,
HC B Pleurx Drainage Kit,PX-27200076,CDM,27200076,LOCAL,272,RC,,,inpatient,,,417,291.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,93.6165,353.4492,,,,
HC Catheter Swan Ganz J Pacing,PX-27200078,CDM,27200078,LOCAL,272,RC,,,inpatient,,,446,312.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,100.127,378.0296,,,,
HC Tube Trach Distal Xlt 5.0,PX-27200079,CDM,27200079,LOCAL,272,RC,,,inpatient,,,451,315.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,101.2495,382.2676,,,,
HC Tube Trach Distal Xlt 6.0,PX-27200080,CDM,27200080,LOCAL,272,RC,,,inpatient,,,466,326.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,104.617,394.9816,,,,
HC Tube Trach 8 Cuff Non X Long,PX-27200081,CDM,27200081,LOCAL,272,RC,,,inpatient,,,466,326.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,104.617,394.9816,,,,
HC Sling Sam Pelvic Medium,PX-27200082,CDM,27200082,LOCAL,272,RC,,,inpatient,,,470,329,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,105.515,398.372,,,,
HC Set Tube Kaci Veratrac Duo,PX-27200083,CDM,27200083,LOCAL,272,RC,,,inpatient,,,488,341.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,109.556,413.6288,,,,
HC Retractor C Section Xlarge,PX-27200084,CDM,27200084,LOCAL,272,RC,,,inpatient,,,516,361.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,115.842,437.3616,,,,
HC Kit Mini 4fr Single Lumen,PX-27200085,CDM,27200085,LOCAL,272,RC,,,inpatient,,,519,363.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,116.5155,439.9044,,,,
HC Trach Bivona Tis 6id,PX-27200086,CDM,27200086,LOCAL,272,RC,,,inpatient,,,523,366.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,117.4135,443.2948,,,,
HC Pack C Section Custom Disp,PX-27200087,CDM,27200087,LOCAL,272,RC,,,inpatient,,,541,378.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,121.4545,458.5516,,,,
HC Trach Bivona Tts 8mm,PX-27200088,CDM,27200088,LOCAL,272,RC,,,inpatient,,,541,378.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,121.4545,458.5516,,,,
HC Trach Bivona 7.5 X 10,PX-27200089,CDM,27200089,LOCAL,272,RC,,,inpatient,,,556,389.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,124.822,471.2656,,,,
HC Tube Feeding Mic Key 14f 1.7,PX-27200091,CDM,27200091,LOCAL,272,RC,,,inpatient,,,674,471.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,151.313,571.2824,,,,
HC Kit Mic-Key G Feeding 16-3.5,PX-27200092,CDM,27200092,LOCAL,272,RC,,,inpatient,,,694,485.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,155.803,588.2344,,,,
HC Kit Mic-Key G Feeding 24-3.5,PX-27200093,CDM,27200093,LOCAL,272,RC,,,inpatient,,,694,485.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,155.803,588.2344,,,,
HC Mic Key G Tube 20fr 3.5cm,PX-27200094,CDM,27200094,LOCAL,272,RC,,,inpatient,,,694,485.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,155.803,588.2344,,,,
HC Device Support Foot,PX-27200095,CDM,27200095,LOCAL,272,RC,,,inpatient,,,703,492.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,157.8235,595.8628,,,,
HC Catheter 4 Fr Mid Line,PX-27200096,CDM,27200096,LOCAL,272,RC,,,inpatient,,,719,503.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,161.4155,609.4244,,,,
HC Tcc Size 3,PX-27200097,CDM,27200097,LOCAL,272,RC,,,inpatient,,,722,505.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,162.089,611.9672,,,,
HC Femostop Gold Compress Sys,PX-27200098,CDM,27200098,LOCAL,272,RC,,,inpatient,,,731,511.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,164.1095,619.5956,,,,
HC Dot Poly Midline 4fr Sl Full,PX-27200099,CDM,27200099,LOCAL,272,RC,,,inpatient,,,765,535.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,171.7425,648.414,,,,
HC Powerwand 5fr 10cm,PX-27200100,CDM,27200100,LOCAL,272,RC,,,inpatient,,,776,543.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.212,657.7376,,,,
HC Powerwand Single Sterile 5fr,PX-27200101,CDM,27200101,LOCAL,272,RC,,,inpatient,,,776,543.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.212,657.7376,,,,
HC Needle Intraosseous Pd 15g,PX-27200102,CDM,27200102,LOCAL,272,RC,,,inpatient,,,845,591.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,189.7025,716.222,,,,
HC Needle Intraosseous Ad 15g,PX-27200103,CDM,27200103,LOCAL,272,RC,,,inpatient,,,845,591.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,189.7025,716.222,,,,
HC Needle Intraosseous,PX-27200104,CDM,27200104,LOCAL,272,RC,,,inpatient,,,845,591.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,189.7025,716.222,,,,
HC Kit Triple Lumen Cath 7 X 6,PX-27200105,CDM,27200105,LOCAL,272,RC,,,inpatient,,,895,626.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,200.9275,758.602,,,,
HC Multi Lumen Cvc Kit Toh Cust,PX-27200106,CDM,27200106,LOCAL,272,RC,,,inpatient,,,895,626.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,200.9275,758.602,,,,
HC Pad Zoll Aed Cprd Access Kit,PX-27200107,CDM,27200107,LOCAL,272,RC,,,inpatient,,,827,578.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,185.6615,700.9652,,,,
HC Kit Flexi Seal Fecal,PX-27200108,CDM,27200108,LOCAL,272,RC,,,inpatient,,,939,657.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,210.8055,795.8964,,,,
HC Powerwand Quick Kit 5fr,PX-27200109,CDM,27200109,LOCAL,272,RC,,,inpatient,,,979,685.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,219.7855,829.8004,,,,
HC Mahurkar Dual Lumen Subclav Ca,PX-27200110,CDM,27200110,LOCAL,272,RC,,,inpatient,,,1581,1106.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,354.9345,1340.0556,,,,
HC Catheter With Curved Extension,PX-27200111,CDM,27200111,LOCAL,272,RC,,,inpatient,,,1581,1106.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,354.9345,1340.0556,,,,
HC Set Cath Cricothyroidotomy,PX-27200112,CDM,27200112,LOCAL,272,RC,,,inpatient,,,1136,795.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,255.032,962.8736,,,,
HC Rusch Quick Trac Small 2.0,PX-27200113,CDM,27200113,LOCAL,272,RC,,,inpatient,,,1269,888.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,284.8905,1075.6044,,,,
HC Set Prism Prewarm M100'2,PX-27200114,CDM,27200114,LOCAL,272,RC,,,inpatient,,,1319,923.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,296.1155,1117.9844,,,,
HC Set Prismaflex M100's,PX-27200115,CDM,27200115,LOCAL,272,RC,,,inpatient,,,1399,979.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,314.0755,1185.7924,,,,
HC Bakri Postpartum Balloon,PX-27200116,CDM,27200116,LOCAL,272,RC,,,inpatient,,,1408,985.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,316.096,1193.4208,,,,
HC Flo Trac Sensor Mhd6,PX-27200117,CDM,27200117,LOCAL,272,RC,,,inpatient,,,2027,1418.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,455.0615,1718.0852,,,,
HC Pad Universal Artic Gel,PX-27200118,CDM,27200118,LOCAL,272,RC,,,inpatient,,,2219,1553.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,498.1655,1880.8244,,,,
HC Cath Presep 8.5 Oximetry,PX-27200119,CDM,27200119,LOCAL,272,RC,,,inpatient,,,2602,1821.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,584.149,2205.4552,,,,
HC Set Cricothyrotomy Cath,PX-27200120,CDM,27200120,LOCAL,272,RC,,,inpatient,,,2943,2060.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,660.7035,2494.4868,,,,
HC Pad Artic Gel Small,PX-27200121,CDM,27200121,LOCAL,272,RC,,,inpatient,,,5565,3895.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1249.3425,4716.894,,,,
HC Pad Gel Artic Medium,PX-27200122,CDM,27200122,LOCAL,272,RC,,,inpatient,,,5512,3858.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1237.444,4671.9712,,,,
HC Rhino G2 Blue,PX-27200123,CDM,27200123,LOCAL,272,RC,,,inpatient,,,4120,2884,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,924.94,3492.112,,,,
HC Pad Artic Gel Lrg,PX-27200124,CDM,27200124,LOCAL,272,RC,,,inpatient,,,5512,3858.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1237.444,4671.9712,,,,
HC Bag External Drainage Collect,PX-27200125,CDM,27200125,LOCAL,272,RC,,,inpatient,,,1349,944.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,302.8505,1143.4124,,,,
HC Catheter Thoracic 28fr,PX-27200126,CDM,27200126,LOCAL,272,RC,,,inpatient,,,39,27.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.7555,33.0564,,,,
HC Tube Endo Bronch Left 37,PX-27200127,CDM,27200127,LOCAL,272,RC,,,inpatient,,,349,244.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,78.3505,295.8124,,,,
HC Electrode Temporary Pacing 6,PX-27200128,CDM,27200128,LOCAL,272,RC,,,inpatient,,,1238,866.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,277.931,1049.3288,,,,
HC Set Pneumothorax,PX-27200129,CDM,27200129,LOCAL,272,RC,,,inpatient,,,1113,779.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,249.8685,943.3788,,,,
HC System External Drainage III,PX-27200130,CDM,27200130,LOCAL,272,RC,,,inpatient,,,1887,1320.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,423.6315,1599.4212,,,,
HC Electrode Temporary Pacing 5,PX-27200131,CDM,27200131,LOCAL,272,RC,,,inpatient,,,1097,767.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,246.2765,929.8172,,,,
HC Tray Tru Close Thoracic Vent,PX-27200132,CDM,27200132,LOCAL,272,RC,,,inpatient,,,1504,1052.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,337.648,1274.7904,,,,
HC Tube Trach Flex Laser 6.0 Mm,PX-27200133,CDM,27200133,LOCAL,272,RC,,,inpatient,,,319,223.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,71.6155,270.3844,,,,
HC Pack Cesarean Custom,PX-27200134,CDM,27200134,LOCAL,272,RC,,,inpatient,,,462,323.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,103.719,391.5912,,,,
HC Hemostat Instat 1gm,PX-27200135,CDM,27200135,LOCAL,272,RC,,,inpatient,,,1077,753.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,241.7865,912.8652,,,,
HC Tube Trach Distal Xlt 7.0,PX-27200136,CDM,27200136,LOCAL,272,RC,,,inpatient,,,486,340.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,109.107,411.9336,,,,
HC Surgicel 2 X 14 #1951,PX-27200137,CDM,27200137,LOCAL,272,RC,,,inpatient,,,447,312.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,100.3515,378.8772,,,,
HC Ligator Saeed Sx Shoot,PX-27200138,CDM,27200138,LOCAL,272,RC,,,inpatient,,,1332,932.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,299.034,1129.0032,,,,
HC Cath Swan Ganz 7.5 Vip Port,PX-27200139,CDM,27200139,LOCAL,272,RC,,,inpatient,,,297,207.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,66.6765,251.7372,,,,
HC Cath Multilumen Access,PX-27200140,CDM,27200140,LOCAL,272,RC,,,inpatient,,,537,375.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,120.5565,455.1612,,,,
HC Trach Bivona Tts 7mm,PX-27200141,CDM,27200141,LOCAL,272,RC,,,inpatient,,,565,395.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,126.8425,478.894,,,,
HC Kit Pleurx Drainage W Bottle,PX-27200142,CDM,27200142,LOCAL,272,RC,,,inpatient,,,417,291.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,93.6165,353.4492,,,,
HC Retractor Wound Alexis Lrg,PX-27200143,CDM,27200143,LOCAL,272,RC,,,inpatient,,,412,288.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,92.494,349.2112,,,,
HC Unit Cold Therapy Deroyal,PX-27200144,CDM,27200144,LOCAL,272,RC,,,inpatient,,,691,483.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,155.1295,585.6916,,,,
HC Dressing Kci Vac Silver Med,PX-27200145,CDM,27200145,LOCAL,272,RC,,,inpatient,,,506,354.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,113.597,428.8856,,,,
HC Kit Midline Cath 20ga X 20cm,PX-27200146,CDM,27200146,LOCAL,272,RC,,,inpatient,,,424,296.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,95.188,359.3824,,,,
HC Cath Mahurkar 3 Lumen 12x20,PX-27200147,CDM,27200147,LOCAL,272,RC,,,inpatient,,,594,415.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,133.353,503.4744,,,,
HC Retractor Alexis Wound Xlg,PX-27200148,CDM,27200148,LOCAL,272,RC,,,inpatient,,,529,370.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,118.7605,448.3804,,,,
HC Surgiflo Hemostatic Matrix,PX-27200149,CDM,27200149,LOCAL,272,RC,,,inpatient,,,906,634.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,203.397,767.9256,,,,
HC Kit Monitoring Press Abviser,PX-27200150,CDM,27200150,LOCAL,272,RC,,,inpatient,,,648,453.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,145.476,549.2448,,,,
HC Tray Fuhrman Pleural Drain,PX-27200151,CDM,27200151,LOCAL,272,RC,,,inpatient,,,990,693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,222.255,839.124,,,,
HC Kit Cath Triple Lumen 20cm,PX-27200152,CDM,27200152,LOCAL,272,RC,,,inpatient,,,865,605.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,194.1925,733.174,,,,
HC Dressing Kci Simplace Med,PX-27200153,CDM,27200153,LOCAL,272,RC,,,inpatient,,,433,303.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,97.2085,367.0108,,,,
HC Tube Non Balloon Replace Peg,PX-27200154,CDM,27200154,LOCAL,272,RC,,,inpatient,,,394,275.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,88.453,333.9544,,,,
HC Cath 12fr Hp Triple Lumen,PX-27200155,CDM,27200155,LOCAL,272,RC,,,inpatient,,,606,424.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,136.047,513.6456,,,,
HC Cath Pneumothorax Ak01500,PX-27200156,CDM,27200156,LOCAL,272,RC,,,inpatient,,,700,490,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,157.15,593.32,,,,
HC Kit Cranial Access 826614,PX-27200158,CDM,27200158,LOCAL,272,RC,,,inpatient,,,2205,1543.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,495.0225,1868.958,,,,
"HC Sensor Flotrac W Vamp 60""",PX-27200159,CDM,27200159,LOCAL,272,RC,,,inpatient,,,1336,935.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,299.932,1132.3936,,,,
HC Trach Lg 4.0 Quick Rusch,PX-27200160,CDM,27200160,LOCAL,272,RC,,,inpatient,,,1094,765.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,245.603,927.2744,,,,
HC Tray Pericardiocentesis Stra,PX-27200161,CDM,27200161,LOCAL,272,RC,,,inpatient,,,1188,831.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,266.706,1006.9488,,,,
HC Trocar Endo Ethicon 12 512sd,PX-27200162,CDM,27200162,LOCAL,272,RC,,,inpatient,,,1154,807.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,259.073,978.1304,,,,
HC Tube Laryngectomy 12mm Metal,PX-27200163,CDM,27200163,LOCAL,272,RC,,,inpatient,,,1154,807.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,259.073,978.1304,,,,
HC Tray Midline CT 4f 20cm Single,PX-27200164,CDM,27200164,LOCAL,272,RC,,,inpatient,,,785,549.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,176.2325,665.366,,,,
HC Tray Midline CT 5f 20cm Dual,PX-27200165,CDM,27200165,LOCAL,272,RC,,,inpatient,,,779,545.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.8855,660.2804,,,,
HC Mahurkar Triple Lumen Cath Tray #16,PX-27200166,CDM,27200166,LOCAL,272,RC,,,inpatient,,,1191,833.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,267.3795,1009.4916,,,,
HC Mahurkar Triple Lumen Cath Tray #20,PX-27200167,CDM,27200167,LOCAL,272,RC,,,inpatient,,,983,688.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,220.6835,833.1908,,,,
HC Compartment Pressure Monitoring Kit,PX-27200168,CDM,27200168,LOCAL,272,RC,,,inpatient,,,457,319.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,102.5965,387.3532,,,,
HC Kit Perc Sheath Introducer 8.5,PX-27200169,CDM,27200169,LOCAL,272,RC,,,inpatient,,,471,329.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,105.7395,399.2196,,,,
HC Cath Arrow Cvc Kit Latex Free,PX-27200170,CDM,27200170,LOCAL,272,RC,,,inpatient,,,465,325.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,104.3925,394.134,,,,
HC Electrode Temporary Pacing 4,PX-27200171,CDM,27200171,LOCAL,272,RC,,,inpatient,,,823,576.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,184.7635,697.5748,,,,
HC Catheter Bipolar Pacing 5,PX-27200172,CDM,27200172,LOCAL,272,RC,,,inpatient,,,619,433.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,138.9655,524.6644,,,,
HC Set Emergency Pneumothorax,PX-27200173,CDM,27200173,LOCAL,272,RC,,,inpatient,,,795,556.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,178.4775,673.842,,,,
HC Kit Pneumothorax,PX-27200174,CDM,27200174,LOCAL,272,RC,,,inpatient,,,722,505.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,162.089,611.9672,,,,
HC Impella Purge Cassette,PX-27200175,CDM,27200175,LOCAL,272,RC,,,inpatient,,,245,171.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,55.0025,207.662,,,,
HC Tray Midline CT 4f 20cm Singl,PX-27200176,CDM,27200176,LOCAL,272,RC,,,inpatient,,,954,667.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,214.173,808.6104,,,,
HC Tray Midline CT 5f 20cm Dual F,PX-27200177,CDM,27200177,LOCAL,272,RC,,,inpatient,,,1154,807.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,259.073,978.1304,,,,
HC Kit Microez Mst Nitinol 4.5 7c,PX-27200178,CDM,27200178,LOCAL,272,RC,,,inpatient,,,497,347.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,111.5765,421.2572,,,,
HC Kit Microez Mst 5f Nsx,PX-27200179,CDM,27200179,LOCAL,272,RC,,,inpatient,,,251,175.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,56.3495,212.7476,,,,
HC Electrode One Step Cpr Adult,PX-27200180,CDM,27200180,LOCAL,272,RC,,,inpatient,,,408,285.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,91.596,345.8208,,,,
HC Electrode One Step Pediatric,PX-27200181,CDM,27200181,LOCAL,272,RC,,,inpatient,,,447,312.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,100.3515,378.8772,,,,
HC Ambu® Ascopetm 4 Broncho Large (5.8/2.8),PX-27200196,CDM,27200196,LOCAL,272,RC,,,inpatient,,,359,251.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.5955,304.2884,,,,
HC Ambu® Ascopetm 4 Broncho Regular (5.0/2.2),PX-27200197,CDM,27200197,LOCAL,272,RC,,,inpatient,,,312,218.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,70.044,264.4512,,,,
HC Ambu® Ascopetm 4 Broncho Slim (3.8/1.2),PX-27200198,CDM,27200198,LOCAL,272,RC,,,inpatient,,,312,218.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,70.044,264.4512,,,,
HC Tray Pneumothorax Turkel 9 Cm Sys,PX-27200199,CDM,27200199,LOCAL,272,RC,,,inpatient,,,622,435.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,139.639,527.2072,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400003,CDM,27400003,LOCAL,274,RC,,,inpatient,,,552,386.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,123.924,467.8752,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400005,CDM,27400005,LOCAL,274,RC,,,inpatient,,,1221,854.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,274.1145,1034.9196,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400008,CDM,27400008,LOCAL,274,RC,,,inpatient,,,3772,2640.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,846.814,3197.1472,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400012,CDM,27400012,LOCAL,274,RC,,,inpatient,,,1954,1367.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,438.673,1656.2104,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400015,CDM,27400015,LOCAL,274,RC,,,inpatient,,,3806,2664.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,854.447,3225.9656,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400030,CDM,27400030,LOCAL,274,RC,,,inpatient,,,661,462.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,148.3945,560.2636,,,,
HC Brace Knee Enhanced Trom,PX-27400038,CDM,27400038,LOCAL,274,RC,,,inpatient,,,570,399,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,127.965,483.132,,,,
HC Brace Enhanced Trom Donjoy,PX-27400039,CDM,27400039,LOCAL,274,RC,,,inpatient,,,570,399,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,127.965,483.132,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400047,CDM,27400047,LOCAL,274,RC,,,inpatient,,,3385,2369.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,759.9325,2869.126,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400050,CDM,27400050,LOCAL,274,RC,,,inpatient,,,3185,2229.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,715.0325,2699.606,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400107,CDM,27400107,LOCAL,274,RC,,,inpatient,,,380,266,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,85.31,322.088,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400117,CDM,27400117,LOCAL,274,RC,,,inpatient,,,779,545.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.8855,660.2804,,,,
HC Add. to Lower Extremity L2210,PX-27400184,CDM,27400184,LOCAL,274,RC,,,inpatient,,,330,231,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,74.085,279.708,,,,
HC Lift Elevation Heel & Sole,PX-27400185,CDM,27400185,LOCAL,274,RC,,,inpatient,,,382,267.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,85.759,323.7832,,,,
HC Add. Lower Extremity Orthosis,PX-27400186,CDM,27400186,LOCAL,274,RC,,,inpatient,,,448,313.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,100.576,379.7248,,,,
HC Depth Shoe A5500,PX-27400187,CDM,27400187,LOCAL,274,RC,,,inpatient,,,473,331.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,106.1885,400.9148,,,,
HC Compression Stocking A6533,PX-27400188,CDM,27400188,LOCAL,274,RC,,,inpatient,,,502,351.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,112.699,425.4952,,,,
HC Collar L0172,PX-27400189,CDM,27400189,LOCAL,274,RC,,,inpatient,,,658,460.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,147.721,557.7208,,,,
HC Ko Elastic Knee Joint L1820,PX-27400190,CDM,27400190,LOCAL,274,RC,,,inpatient,,,661,462.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,148.3945,560.2636,,,,
HC Procedure Ortho Shoe/L3649,PX-27400191,CDM,27400191,LOCAL,274,RC,,,inpatient,,,703,492.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,157.8235,595.8628,,,,
HC Air Cast Boot L4386,PX-27400192,CDM,27400192,LOCAL,274,RC,,,inpatient,,,745,521.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,167.2525,631.462,,,,
HC Static Afa L4396,PX-27400193,CDM,27400193,LOCAL,274,RC,,,inpatient,,,785,549.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,176.2325,665.366,,,,
HC Brace Tlso,PX-27400194,CDM,27400194,LOCAL,274,RC,,,inpatient,,,901,630.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,202.2745,763.6876,,,,
HC Lumbar Corsette L0450,PX-27400195,CDM,27400195,LOCAL,274,RC,,,inpatient,,,915,640.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,205.4175,775.554,,,,
HC Brace Warm and Form,PX-27400196,CDM,27400196,LOCAL,274,RC,,,inpatient,,,1117,781.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,250.7665,946.7692,,,,
HC Afo L1940,PX-27400197,CDM,27400197,LOCAL,274,RC,,,inpatient,,,2560,1792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,574.72,2169.856,,,,
HC Ankle Foot Orthosis L1940,PX-27400198,CDM,27400198,LOCAL,274,RC,,,inpatient,,,2560,1792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,574.72,2169.856,,,,
HC POS OP Knee Brace L1832,PX-27400199,CDM,27400199,LOCAL,274,RC,,,inpatient,,,2974,2081.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,667.663,2520.7624,,,,
HC Afo Plastic L1960,PX-27400200,CDM,27400200,LOCAL,274,RC,,,inpatient,,,3011,2107.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,675.9695,2552.1236,,,,
HC Ankle/Foot Orthosis Afo,PX-27400201,CDM,27400201,LOCAL,274,RC,,,inpatient,,,3011,2107.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,675.9695,2552.1236,,,,
HC Left Afo Brace/Atlantic Pros,PX-27400202,CDM,27400202,LOCAL,274,RC,,,inpatient,,,3165,2215.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,710.5425,2682.654,,,,
HC Afo L1932,PX-27400203,CDM,27400203,LOCAL,274,RC,,,inpatient,,,3418,2392.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,767.341,2897.0968,,,,
HC Ankle Foot Orthosis L1970,PX-27400204,CDM,27400204,LOCAL,274,RC,,,inpatient,,,3462,2423.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,777.219,2934.3912,,,,
HC Back Brace Tlso Lo486,PX-27400205,CDM,27400205,LOCAL,274,RC,,,inpatient,,,6597,4617.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1481.0265,5591.6172,,,,
HC Cervical Collar L0172,PX-27400206,CDM,27400206,LOCAL,274,RC,,,inpatient,,,658,460.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,147.721,557.7208,,,,
HC Philly Collar No Extension,PX-27400207,CDM,27400207,LOCAL,274,RC,,,inpatient,,,658,460.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,147.721,557.7208,,,,
HC Cervical Collar 2/Piece L0174,PX-27400208,CDM,27400208,LOCAL,274,RC,,,inpatient,,,1232,862.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,276.584,1044.2432,,,,
HC Lumbar Orthosis L0627,PX-27400209,CDM,27400209,LOCAL,274,RC,,,inpatient,,,1750,1225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,392.875,1483.3,,,,
HC Lso Sagoro Rigid Frame L0631,PX-27400210,CDM,27400210,LOCAL,274,RC,,,inpatient,,,3933,2753.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,882.9585,3333.6108,,,,
HC Lso Sagittal Coronal L0637,PX-27400211,CDM,27400211,LOCAL,274,RC,,,inpatient,,,4114,2879.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,923.593,3487.0264,,,,
HC Hip Abduction Orthosis L1686,PX-27400212,CDM,27400212,LOCAL,274,RC,,,inpatient,,,4461,3122.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1001.4945,3781.1436,,,,
HC Knee Orthosis L1830,PX-27400213,CDM,27400213,LOCAL,274,RC,,,inpatient,,,466,326.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,104.617,394.9816,,,,
HC Knee Orthosis L1832,PX-27400214,CDM,27400214,LOCAL,274,RC,,,inpatient,,,2974,2081.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,667.663,2520.7624,,,,
HC Knee Orthosis L1832,PX-27400215,CDM,27400215,LOCAL,274,RC,,,inpatient,,,2974,2081.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,667.663,2520.7624,,,,
HC Knee Osthosis L1832,PX-27400216,CDM,27400216,LOCAL,274,RC,,,inpatient,,,2974,2081.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,667.663,2520.7624,,,,
HC Afo L1930,PX-27400217,CDM,27400217,LOCAL,274,RC,,,inpatient,,,1062,743.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,238.419,900.1512,,,,
HC Adj. Dorsal Splint L1930,PX-27400218,CDM,27400218,LOCAL,274,RC,,,inpatient,,,1062,743.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,238.419,900.1512,,,,
HC L'nard Boot L1930,PX-27400219,CDM,27400219,LOCAL,274,RC,,,inpatient,,,1062,743.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,238.419,900.1512,,,,
HC Hip Adj Ext L2624,PX-27400220,CDM,27400220,LOCAL,274,RC,,,inpatient,,,1445,1011.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,324.4025,1224.782,,,,
HC Bk Soft Interface L2820,PX-27400221,CDM,27400221,LOCAL,274,RC,,,inpatient,,,448,313.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,100.576,379.7248,,,,
HC Lift Elevation L3332,PX-27400222,CDM,27400222,LOCAL,274,RC,,,inpatient,,,347,242.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,77.9015,294.1172,,,,
HC Wrist Hand/Finger Ortho L3807,PX-27400223,CDM,27400223,LOCAL,274,RC,,,inpatient,,,1065,745.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,239.0925,902.694,,,,
HC Wrist Cockup Nonmolded L3908,PX-27400224,CDM,27400224,LOCAL,274,RC,,,inpatient,,,353,247.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,79.2485,299.2028,,,,
HC Orthosis Upper Limb Hum. Frac,PX-27400225,CDM,27400225,LOCAL,274,RC,,,inpatient,,,1413,989.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,317.2185,1197.6588,,,,
HC Walking Boot L4360,PX-27400226,CDM,27400226,LOCAL,274,RC,,,inpatient,,,1290,903,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,289.605,1093.404,,,,
HC Walking Boot Prefab L4360,PX-27400227,CDM,27400227,LOCAL,274,RC,,,inpatient,,,1290,903,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,289.605,1093.404,,,,
HC Walking Boot L4360,PX-27400228,CDM,27400228,LOCAL,274,RC,,,inpatient,,,2135,1494.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,479.3075,1809.626,,,,
HC Cam Walker L4386,PX-27400229,CDM,27400229,LOCAL,274,RC,,,inpatient,,,745,521.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,167.2525,631.462,,,,
HC Bk Stump Shrinker L8440,PX-27400230,CDM,27400230,LOCAL,274,RC,,,inpatient,,,262,183.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,58.819,222.0712,,,,
HC Stump Shrinker L8440,PX-27400231,CDM,27400231,LOCAL,274,RC,,,inpatient,,,262,183.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,58.819,222.0712,,,,
HC Liner Foam Permanently Lg,PX-27400232,CDM,27400232,LOCAL,274,RC,,,inpatient,,,353,247.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,79.2485,299.2028,,,,
HC Kit Electrode Pacing,PX-27500027,CDM,27500027,LOCAL,275,RC,,,inpatient,,,1286,900.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,288.707,1090.0136,,,,
HC Medical/Surgical Supplies: Other Implants,PX-27800095,CDM,27800095,LOCAL,278,RC,,,inpatient,,,649,454.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,145.7005,550.0924,,,,
HC Leg Post Rigid Brace/Sc Ortho,PX-27800096,CDM,27800096,LOCAL,278,RC,,,inpatient,,,758,530.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,170.171,642.4808,,,,
HC Kit Picc 4fr per-Q Poly Cath,PX-27800097,CDM,27800097,LOCAL,278,RC,,,inpatient,,,1063,744.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,238.6435,900.9988,,,,
HC Floseal Matrix Hemostatic,PX-27800098,CDM,27800098,LOCAL,278,RC,,,inpatient,,,1093,765.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,245.3785,926.4268,,,,
HC Kit Picc 5fr per-Q Poly Cath,PX-27800099,CDM,27800099,LOCAL,278,RC,,,inpatient,,,1217,851.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,273.2165,1031.5292,,,,
HC Tray Power Picc Dual 5f,PX-27800100,CDM,27800100,LOCAL,278,RC,,,inpatient,,,1355,948.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,304.1975,1148.498,,,,
HC Tray Power Picc Single 4f,PX-27800101,CDM,27800101,LOCAL,278,RC,,,inpatient,,,1398,978.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,313.851,1184.9448,,,,
HC Tray Power Picc Triple 5fr,PX-27800102,CDM,27800102,LOCAL,278,RC,,,inpatient,,,1474,1031.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,330.913,1249.3624,,,,
HC Tray Power Picc Triple 6f,PX-27800103,CDM,27800103,LOCAL,278,RC,,,inpatient,,,1499,1049.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,336.5255,1270.5524,,,,
HC Sepafilm/5x6,PX-27800104,CDM,27800104,LOCAL,278,RC,,,inpatient,,,1773,1241.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,398.0385,1502.7948,,,,
HC 3cg Power Picc Max 4fr Sl,PX-27800105,CDM,27800105,LOCAL,278,RC,,,inpatient,,,1585,1109.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,355.8325,1343.446,,,,
HC 3cg Power Picc Max 5fr Dl,PX-27800106,CDM,27800106,LOCAL,278,RC,,,inpatient,,,1636,1145.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,367.282,1386.6736,,,,
HC 3cg Power Picc Max 6fr Tl,PX-27800107,CDM,27800107,LOCAL,278,RC,,,inpatient,,,1749,1224.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,392.6505,1482.4524,,,,
HC Valve Passy Muir Aqua,PX-27800108,CDM,27800108,LOCAL,278,RC,,,inpatient,,,474,331.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,106.413,401.7624,,,,
HC Passy Muir Valve - Clear,PX-27800113,CDM,27800113,LOCAL,278,RC,,,inpatient,,,474,331.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,106.413,401.7624,,,,
HC Valve Passy Muir Purple,PX-27800114,CDM,27800114,LOCAL,278,RC,,,inpatient,,,474,331.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,106.413,401.7624,,,,
HC Liner Foam Permanently X-Lg,PX-27800115,CDM,27800115,LOCAL,278,RC,,,inpatient,,,328,229.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,73.636,278.0128,,,,
HC Tube Trach Proximal Xlt 7.0,PX-27800117,CDM,27800117,LOCAL,278,RC,,,inpatient,,,486,340.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,109.107,411.9336,,,,
HC Barrier Seprafilm 3x5in,PX-27800118,CDM,27800118,LOCAL,278,RC,,,inpatient,,,1773,1241.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,398.0385,1502.7948,,,,
HC Tube Feeding Low Profile 20f,PX-27800119,CDM,27800119,LOCAL,278,RC,,,inpatient,,,694,485.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,155.803,588.2344,,,,
HC Valve Speaking White #005,PX-27800121,CDM,27800121,LOCAL,278,RC,,,inpatient,,,474,331.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,106.413,401.7624,,,,
HC Tray Percu Introducer 8.5fr,PX-27800122,CDM,27800122,LOCAL,278,RC,,,inpatient,,,475,332.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,106.6375,402.61,,,,
HC Basket Zerotip Airway Retriv,PX-27800125,CDM,27800125,LOCAL,278,RC,,,inpatient,,,1710,1197,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,383.895,1449.396,,,,
HC Indwelling Prosthesis 20fr 8mm,PX-27800126,CDM,27800126,LOCAL,278,RC,,,inpatient,,,1327,928.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,297.9115,1124.7652,,,,
HC Indwelling Prosthesis 2.0,PX-27800127,CDM,27800127,LOCAL,278,RC,,,inpatient,,,1327,928.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,297.9115,1124.7652,,,,
HC Prosthesis Blom - 8mm,PX-27800128,CDM,27800128,LOCAL,278,RC,,,inpatient,,,1300,910,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,291.85,1101.88,,,,
HC Drug Collection,PX-30000005,CDM,30000005,LOCAL,300,RC,,,inpatient,,,32,22.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7.184,27.1232,,,,
HC Cardiac Mnr Thoracic Prcd,PX-36000003,CDM,36000003,LOCAL,360,RC,,,inpatient,,,142,99.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,31.879,120.3592,,,,
HC Non-Pump Open Heart Other,PX-36000004,CDM,36000004,LOCAL,360,RC,,,inpatient,,,157,109.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,35.2465,133.0732,,,,
HC Pump Procedure,PX-36000005,CDM,36000005,LOCAL,360,RC,,,inpatient,,,152,106.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,34.124,128.8352,,,,
HC Non Pump Procedure,PX-36000006,CDM,36000006,LOCAL,360,RC,,,inpatient,,,208,145.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,46.696,176.3008,,,,
HC Sub Minor Proc,PX-36000014,CDM,36000014,LOCAL,360,RC,,,inpatient,,,60,42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,13.47,50.856,,,,
HC Pain Mgmt Proc,PX-36000015,CDM,36000015,LOCAL,360,RC,,,inpatient,,,75,52.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,16.8375,63.57,,,,
HC Endoscopy,PX-36000016,CDM,36000016,LOCAL,360,RC,,,inpatient,,,60,42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,13.47,50.856,,,,
HC Minor Proc,PX-36000017,CDM,36000017,LOCAL,360,RC,,,inpatient,,,75,52.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,16.8375,63.57,,,,
HC Major Proc,PX-36000019,CDM,36000019,LOCAL,360,RC,,,inpatient,,,99,69.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2255,83.9124,,,,
HC Intensive Major Procedure,PX-36000020,CDM,36000020,LOCAL,360,RC,,,inpatient,,,140,98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,31.43,118.664,,,,
HC Ercp,PX-36000021,CDM,36000021,LOCAL,360,RC,,,inpatient,,,138,96.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,30.981,116.9688,,,,
HC Cardiac Maj Thoracic Prcd,PX-36000022,CDM,36000022,LOCAL,360,RC,,,inpatient,,,159,111.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,35.6955,134.7684,,,,
HC Anesthesia Block,PX-37000001,CDM,37000001,LOCAL,370,RC,,,inpatient,,,700,490,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,157.15,593.32,,,,
HC Anesthesia Spinal,PX-37000002,CDM,37000002,LOCAL,370,RC,,,inpatient,,,850,595,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,190.825,720.46,,,,
HC Anesthesia General Minor,PX-37000003,CDM,37000003,LOCAL,370,RC,,,inpatient,,,1662,1163.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,373.119,1408.7112,,,,
HC Anesthesia Epidural,PX-37000004,CDM,37000004,LOCAL,370,RC,,,inpatient,,,950,665,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,213.275,805.22,,,,
HC Anesthesia General Major,PX-37000005,CDM,37000005,LOCAL,370,RC,,,inpatient,,,2924,2046.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,656.438,2478.3824,,,,
HC Anesthesia Gen/Epi,PX-37000006,CDM,37000006,LOCAL,370,RC,,,inpatient,,,1200,840,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,269.4,1017.12,,,,
HC Anesthesia General Intensive,PX-37000007,CDM,37000007,LOCAL,370,RC,,,inpatient,,,4262,2983.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,956.819,3612.4712,,,,
HC Anesthesia General Cvs Bypass Pump,PX-37000008,CDM,37000008,LOCAL,370,RC,,,inpatient,,,9166,6416.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2057.767,7769.1016,,,,
HC Anesthesia Mac,PX-37000009,CDM,37000009,LOCAL,370,RC,,,inpatient,,,1200,840,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,269.4,1017.12,,,,
HC Endo Level I,PX-49000001,CDM,49000001,LOCAL,490,RC,,,inpatient,,,3749,2624.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,841.6505,3177.6524,,,,
HC Endo Level II,PX-49000002,CDM,49000002,LOCAL,490,RC,,,inpatient,,,5356,3749.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1202.422,4539.7456,,,,
HC Endo Level III,PX-49000003,CDM,49000003,LOCAL,490,RC,,,inpatient,,,9641,6748.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2164.4045,8171.7116,,,,
HC Recovery Room,PX-71000001,CDM,71000001,LOCAL,710,RC,,,inpatient,,,25,17.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.6125,21.19,,,,
HC Second Stage Recovery per Minute,PX-71000002,CDM,71000002,LOCAL,710,RC,,,inpatient,,,22,15.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.939,18.6472,,,,
HC Recovery - Sub Minor Proc,PX-71000003,CDM,71000003,LOCAL,710,RC,,,inpatient,,,23,16.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.1635,19.4948,,,,
HC Recovery Rm - Minor Procedure,PX-71000004,CDM,71000004,LOCAL,710,RC,,,inpatient,,,28,19.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6.286,23.7328,,,,
HC Recovery Rm,PX-71000005,CDM,71000005,LOCAL,710,RC,,,inpatient,,,29,20.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6.5105,24.5804,,,,
HC Recovery Rm - Major Procedure,PX-71000006,CDM,71000006,LOCAL,710,RC,,,inpatient,,,33,23.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7.4085,27.9708,,,,
HC Recovery Rm - Intensive Major,PX-71000007,CDM,71000007,LOCAL,710,RC,,,inpatient,,,38,26.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.531,32.2088,,,,
HC Extended Recovery Overnight,PX-71000009,CDM,71000009,LOCAL,710,RC,,,inpatient,,,1500,1050,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,336.75,1271.4,,,,
HC Observation Nursing Time,PX-76200006,CDM,76200006,LOCAL,762,RC,,,inpatient,,,101,70.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,104.83,,,104.83,22.6745,6652,per diem,,,
HC Tandem Dialysis,PX-80100001,CDM,80100001,LOCAL,801,RC,,,inpatient,,,1142,799.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,256.379,967.9592,,,,
HC Single Dialysis,PX-80100002,CDM,80100002,LOCAL,801,RC,,,inpatient,,,1142,799.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,256.379,967.9592,,,,
HC Unscheduled/Emergent Dialysis,PX-80100003,CDM,80100003,LOCAL,801,RC,,,inpatient,,,1142,799.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,256.379,967.9592,,,,
HC Weekend/Holiday Dialysis,PX-80100004,CDM,80100004,LOCAL,801,RC,,,inpatient,,,1142,799.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,256.379,967.9592,,,,
HC Capd per:Exchange,PX-80300001,CDM,80300001,LOCAL,803,RC,,,inpatient,,,569,398.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,127.7405,482.2844,,,,
HC Ccpd ER,PX-80400001,CDM,80400001,LOCAL,804,RC,,,inpatient,,,569,398.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,127.7405,482.2844,,,,
HC Ccpd,PX-80400002,CDM,80400002,LOCAL,804,RC,,,inpatient,,,1142,799.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,256.379,967.9592,,,,
HC Dietary Services per 15 Mins,PX-99000006,CDM,99000006,LOCAL,990,RC,,,inpatient,,,29,20.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6.5105,24.5804,,,,
HC Hearing Aid Batteries,PX-99000034,CDM,99000034,LOCAL,479,RC,,,inpatient,,,7,4.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.5715,163,,,,
HC Hearing Aid Tune Up,PX-99000037,CDM,99000037,LOCAL,479,RC,,,inpatient,,,43,30.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.6535,163,,,,
HC Hearing Aid Fit,PX-99000038,CDM,99000038,LOCAL,479,RC,,,inpatient,,,171,119.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,38.3895,163,,,,
HC Full Trauma No Notification,PX-45000633,CDM,TR450,LOCAL,450,RC,,,inpatient,,,10370,7259,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9291.52,,,,
HC Partial Trauma No Notification,PX-45000634,CDM,TR450,LOCAL,450,RC,,,inpatient,,,7029,4920.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6297.984,,,,
Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face- Mouth And Neck With Major O.R. Procedures,3,MS-DRG,,,,,,,inpatient,,,404600.26,283220.182,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,434261.5728,,,,
Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face- Mouth And Neck Without Major O.R. Procedures,4,MS-DRG,,,,,,,inpatient,,,379341.67,265539.169,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,303473.336,,,,
Tracheostomy For Face- Mouth And Neck Diagnoses Or Laryngectomy With McC,11,MS-DRG,,,,,,,inpatient,,,57485.95,40240.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,109336.4384,,,,
Tracheostomy For Face- Mouth And Neck Diagnoses Or Laryngectomy With Cc,12,MS-DRG,,,,,,,inpatient,,,82266.47,57586.529,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,83151.2976,,,,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With McC Or Chemotherapy Implant Or Epilepsy With Neurostimulator,23,MS-DRG,,,,,,,inpatient,,,82526.76,57768.732,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,115600.0408,,,,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without McC,24,MS-DRG,,,,,,,inpatient,,,54359.41,38051.587,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,77031.5696,,,,
Craniotomy And Endovascular Intracranial Procedures With McC,25,MS-DRG,,,,,,,inpatient,,,91861.46,64303.022,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,90620.608,,,,
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,,,inpatient,,,74058,51840.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,61975.4176,,,,
Craniotomy And Endovascular Intracranial Procedures Without Cc/McC,27,MS-DRG,,,,,,,inpatient,,,61484.65,43039.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,50003.4464,,,,
Spinal Procedures With McC,28,MS-DRG,,,,,,,inpatient,,,148126.56,103688.592,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,123186.8824,,,,
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,inpatient,,,74991.36,52493.952,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,68016.116,,,,
Spinal Procedures Without Cc/McC,30,MS-DRG,,,,,,,inpatient,,,28580.9,20006.63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,45091.4528,,,,
Ventricular Shunt Procedures With McC,31,MS-DRG,,,,,,,inpatient,,,61588.79,43112.153,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,84912.2392,,,,
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,,,inpatient,,,117340.84,82138.588,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,93872.672,,,,
Ventricular Shunt Procedures Without Cc/McC,33,MS-DRG,,,,,,,inpatient,,,50092.67,35064.869,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,40074.136,,,,
Carotid Artery Stent Procedures With McC,34,MS-DRG,,,,,,,inpatient,,,80412.35,56288.645,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,78796.564,,,,
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,inpatient,,,59060.84,41342.588,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,47248.672,,,,
Carotid Artery Stent Procedures Without Cc/McC,36,MS-DRG,,,,,,,inpatient,,,55590.26,38913.182,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,44472.208,,,,
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,inpatient,,,47239.38,33067.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,37791.504,,,,
Extracranial Procedures Without Cc/McC,39,MS-DRG,,,,,,,inpatient,,,40302.61,28211.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,32242.088,,,,
Peripheral- Cranial Nerve And Other Nervous System Procedures With McC,40,MS-DRG,,,,,,,inpatient,,,42423.5,29696.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,76431.7552,,,,
Peripheral- Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator,41,MS-DRG,,,,,,,inpatient,,,29478.8,20635.16,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,45768.2704,,,,
Peripheral- Cranial Nerve And Other Nervous System Procedures Without Cc/McC,42,MS-DRG,,,,,,,inpatient,,,40958.56,28670.992,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,35613.98,,,,
Spinal Disorders And Injuries With Cc/McC,52,MS-DRG,,,,,,,inpatient,,,14188.67,9932.069,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4731.921445,40779.2736,,,,
Spinal Disorders And Injuries Without Cc/McC,53,MS-DRG,,,,,,,inpatient,,,42918.11,30042.677,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,34334.488,,,,
Nervous System Neoplasms With McC,54,MS-DRG,,,,,,,inpatient,,,16507.92,11555.544,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5505.39132,30377.7624,,,,
Nervous System Neoplasms Without McC,55,MS-DRG,,,,,,,inpatient,,,15148.1,10603.67,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5051.89135,22105.9976,,,,
Degenerative Nervous System Disorders With McC,56,MS-DRG,,,,,,,inpatient,,,32807.03,22964.921,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,50741.056,,,,
Degenerative Nervous System Disorders Without McC,57,MS-DRG,,,,,,,inpatient,,,21955.44,15368.808,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7322.13924,27046.3608,,,,
Multiple Sclerosis And Cerebellar Ataxia With McC,58,MS-DRG,,,,,,,inpatient,,,18732.22,13112.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6247.19537,37401.2648,,,,
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,inpatient,,,30559.84,21391.888,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,24793.004,,,,
Multiple Sclerosis And Cerebellar Ataxia Without Cc/McC,60,MS-DRG,,,,,,,inpatient,,,18686.21,13080.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6231.851035,18083.5936,,,,
Ischemic Stroke- Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With McC,61,MS-DRG,,,,,,,inpatient,,,81185.85,56830.095,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,64948.68,,,,
Ischemic Stroke- Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc,62,MS-DRG,,,,,,,inpatient,,,55465.6,38825.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,44372.48,,,,
Ischemic Stroke- Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/McC,63,MS-DRG,,,,,,,inpatient,,,65826.61,46078.627,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,52661.288,,,,
Intracranial Hemorrhage Or Cerebral Infarction With McC,64,MS-DRG,,,,,,,inpatient,,,31988.78,22392.146,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,40307.1224,,,,
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,inpatient,,,20095.65,14066.955,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6701.899275,20608.488,,,,
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/McC,66,MS-DRG,,,,,,,inpatient,,,17438.35,12206.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5143.64,13950.68,,,,
Nonspecific Cva And Precerebral Occlusion Without Infarction With McC,67,MS-DRG,,,,,,,inpatient,,,38053.25,26637.275,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,30442.6,,,,
Nonspecific Cva And Precerebral Occlusion Without Infarction Without McC,68,MS-DRG,,,,,,,inpatient,,,27888.66,19522.062,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6429.37,22310.928,,,,
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,inpatient,,,17825.05,12477.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5687.74,16215.2528,,,,
Nonspecific Cerebrovascular Disorders With McC,70,MS-DRG,,,,,,,inpatient,,,36237.19,25366.033,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,35233.0168,,,,
Nonspecific Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,inpatient,,,26346.94,18442.858,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7313.53,21354.2032,,,,
Cranial And Peripheral Nerve Disorders With McC,73,MS-DRG,,,,,,,inpatient,,,24367.12,17056.984,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,31318.012,,,,
Cranial And Peripheral Nerve Disorders Without McC,74,MS-DRG,,,,,,,inpatient,,,24431.87,17102.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7368.52,21123.1936,,,,
Viral Meningitis With Cc/McC,75,MS-DRG,,,,,,,inpatient,,,38318.52,26822.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,34902.7136,,,,
Viral Meningitis Without Cc/McC,76,MS-DRG,,,,,,,inpatient,,,18360.72,12852.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6123.30012,18580.0616,,,,
Hypertensive Encephalopathy With McC,77,MS-DRG,,,,,,,inpatient,,,24086.79,16860.753,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,31332.1968,,,,
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,,,inpatient,,,18407.7,12885.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6138.96795,20219.4192,,,,
Nontraumatic Stupor And Coma With McC,80,MS-DRG,,,,,,,inpatient,,,17643.44,12350.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5884.08724,40280.7792,,,,
Traumatic Stupor And Coma >1 Hour With McC,82,MS-DRG,,,,,,,inpatient,,,45789.39,32052.573,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,47014.5064,,,,
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,inpatient,,,24521.38,17164.966,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,28173.0392,,,,
Traumatic Stupor And Coma >1 Hour Without Cc/McC,84,MS-DRG,,,,,,,inpatient,,,12382.21,8667.547,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4129.467035,19372.384,,,,
Traumatic Stupor And Coma <1 Hour With McC,85,MS-DRG,,,,,,,inpatient,,,44820.5,31374.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,45916.1976,,,,
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,inpatient,,,22755.94,15929.158,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7589.10599,26578.2624,,,,
Traumatic Stupor And Coma <1 Hour Without Cc/McC,87,MS-DRG,,,,,,,inpatient,,,19756.53,13829.571,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6241.25,17913.376,,,,
Concussion With McC,88,MS-DRG,,,,,,,inpatient,,,61939.59,43357.713,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,49551.672,,,,
Concussion With Cc,89,MS-DRG,,,,,,,inpatient,,,38694.98,27086.486,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7678.2,30955.984,,,,
Other Disorders Of Nervous System With McC,91,MS-DRG,,,,,,,inpatient,,,27946.92,19562.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,36937.2192,,,,
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,inpatient,,,23877.59,16714.313,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7134.82,21455.5232,,,,
Other Disorders Of Nervous System Without Cc/McC,93,MS-DRG,,,,,,,inpatient,,,19087.94,13361.558,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5653.01,15994.3752,,,,
Bacterial And Tuberculous Infections Of Nervous System With McC,94,MS-DRG,,,,,,,inpatient,,,86655,60658.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,73931.1776,,,,
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,,,inpatient,,,61521.3,43064.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,49217.04,,,,
Bacterial And Tuberculous Infections Of Nervous System Without Cc/McC,96,MS-DRG,,,,,,,inpatient,,,33095.5,23166.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,48572.808,,,,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With McC,97,MS-DRG,,,,,,,inpatient,,,90065.06,63045.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,72642.3872,,,,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,inpatient,,,23740.04,16618.028,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,43954.6424,,,,
Seizures With McC,100,MS-DRG,,,,,,,inpatient,,,22104.14,15472.898,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7371.73069,40228.0928,,,,
Seizures Without McC,101,MS-DRG,,,,,,,inpatient,,,15944.38,11161.066,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5317.45073,18675.3024,,,,
Headaches With McC,102,MS-DRG,,,,,,,inpatient,,,25624.62,17937.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,23494.0816,,,,
Headaches Without McC,103,MS-DRG,,,,,,,inpatient,,,20277.76,14194.432,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5992.35,17228.4528,,,,
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,,,inpatient,,,26970.92,18879.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,31022.1576,,,,
Neurological Eye Disorders,123,MS-DRG,,,,,,,inpatient,,,18842.87,13190.009,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5537.24,16276.0448,,,,
Sinus And Mastoid Procedures With Cc/McC,135,MS-DRG,,,,,,,inpatient,,,60852.06,42596.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,48854.4776,,,,
Mouth Procedures Without Cc/McC,138,MS-DRG,,,,,,,inpatient,,,12689.7,8882.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4232.01495,16484.764,,,,
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,inpatient,,,50999.49,35699.643,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,43533.1512,,,,
Major Head And Neck Procedures Without Cc/McC,142,MS-DRG,,,,,,,inpatient,,,31036.34,21725.438,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,31861.0872,,,,
Other Ear- Nose- Mouth And Throat O.R. Procedures With McC,143,MS-DRG,,,,,,,inpatient,,,146130.64,102291.448,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,116904.512,,,,
Other Ear- Nose- Mouth And Throat O.R. Procedures With Cc,144,MS-DRG,,,,,,,inpatient,,,29177.65,20424.355,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,35595.7424,,,,
Ear- Nose- Mouth And Throat Malignancy With Cc,147,MS-DRG,,,,,,,inpatient,,,20455.22,14318.654,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6821.81587,25222.6008,,,,
Ear- Nose- Mouth And Throat Malignancy Without Cc/McC,148,MS-DRG,,,,,,,inpatient,,,18282.89,12798.023,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5689.187157,16225.3848,,,,
Dysequilibrium,149,MS-DRG,,,,,,,inpatient,,,21458.09,15020.663,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5321.63,17166.472,,,,
Epistaxis With McC,150,MS-DRG,,,,,,,inpatient,,,36459.7,25521.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,29167.76,,,,
Epistaxis Without McC,151,MS-DRG,,,,,,,inpatient,,,17762.28,12433.596,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5332.48243,15360.112,,,,
Otitis Media And Uri With McC,152,MS-DRG,,,,,,,inpatient,,,22895.06,16026.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7635.50251,22993.5608,,,,
Otitis Media And Uri Without McC,153,MS-DRG,,,,,,,inpatient,,,11257.92,7880.544,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3754.51632,14421.8888,,,,
Other Ear- Nose- Mouth And Throat Diagnoses With McC,154,MS-DRG,,,,,,,inpatient,,,33108.79,23176.153,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,32953.3168,,,,
Other Ear- Nose- Mouth And Throat Diagnoses With Cc,155,MS-DRG,,,,,,,inpatient,,,14149.33,9904.531,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4718.801555,18918.4704,,,,
Other Ear- Nose- Mouth And Throat Diagnoses Without Cc/McC,156,MS-DRG,,,,,,,inpatient,,,3168.14,2217.698,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1056.57469,13625.5136,,,,
Dental And Oral Diseases With McC,157,MS-DRG,,,,,,,inpatient,,,25823.75,18076.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,33180.2736,,,,
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,inpatient,,,17794.61,12456.227,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5934.502435,19058.292,,,,
Dental And Oral Diseases Without Cc/McC,159,MS-DRG,,,,,,,inpatient,,,15217,10651.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4744.97,13366.1344,,,,
Major Chest Procedures With McC,163,MS-DRG,,,,,,,inpatient,,,128830.68,90181.476,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,103064.544,,,,
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,inpatient,,,83811.85,58668.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,67049.48,,,,
Major Chest Procedures Without Cc/McC,165,MS-DRG,,,,,,,inpatient,,,63087.07,44160.949,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,50469.656,,,,
Other Respiratory System O.R. Procedures With McC,166,MS-DRG,,,,,,,inpatient,,,68518.66,47963.062,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,78036.664,,,,
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,inpatient,,,50504.64,35353.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,40403.712,,,,
Other Respiratory System O.R. Procedures Without Cc/McC,168,MS-DRG,,,,,,,inpatient,,,36816.23,25771.361,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,29452.984,,,,
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,inpatient,,,76600.57,53620.399,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,62178.0576,,,,
Pulmonary Embolism With McC Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,inpatient,,,27323.68,19126.576,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,28554.0024,,,,
Pulmonary Embolism Without McC,176,MS-DRG,,,,,,,inpatient,,,16280.09,11396.063,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5429.410015,16505.028,,,,
Respiratory Infections And Inflammations With McC,177,MS-DRG,,,,,,,inpatient,,,30316.04,21221.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,32756.756,,,,
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,inpatient,,,21346.77,14942.739,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7119.147795,20103.9144,,,,
Respiratory Infections And Inflammations Without Cc/McC,179,MS-DRG,,,,,,,inpatient,,,20533.98,14373.786,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6302.75,16427.184,,,,
Respiratory Neoplasms With McC,180,MS-DRG,,,,,,,inpatient,,,24678.76,17275.132,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,35415.3928,,,,
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,inpatient,,,15915.05,11140.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5307.669175,22497.0928,,,,
Major Chest Trauma With McC,183,MS-DRG,,,,,,,inpatient,,,30366.68,21256.676,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,32163.0208,,,,
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,inpatient,,,23252.15,16276.505,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7520.46,21641.952,,,,
Major Chest Trauma Without Cc/McC,185,MS-DRG,,,,,,,inpatient,,,26254.04,18377.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5597.297704,21003.232,,,,
Pleural Effusion With McC,186,MS-DRG,,,,,,,inpatient,,,23322.86,16326.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,32017.12,,,,
Pleural Effusion With Cc,187,MS-DRG,,,,,,,inpatient,,,25224.41,17657.087,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7468.37,20343.0296,,,,
Pleural Effusion Without Cc/McC,188,MS-DRG,,,,,,,inpatient,,,14227.72,9959.404,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4744.94462,14875.8024,,,,
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,inpatient,,,23597.45,16518.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,25076.7,,,,
Chronic Obstructive Pulmonary Disease With McC,190,MS-DRG,,,,,,,inpatient,,,20380.17,14266.119,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6796.786695,22762.5512,,,,
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,inpatient,,,18415.04,12890.528,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6141.41584,17408.8024,,,,
Chronic Obstructive Pulmonary Disease Without Cc/McC,192,MS-DRG,,,,,,,inpatient,,,15021,10514.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5009.5035,13114.8608,,,,
Simple Pneumonia And Pleurisy With McC,193,MS-DRG,,,,,,,inpatient,,,24854.58,17398.206,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,26703.8992,,,,
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,inpatient,,,16852.25,11796.575,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5620.225375,16616.48,,,,
Simple Pneumonia And Pleurisy Without Cc/McC,195,MS-DRG,,,,,,,inpatient,,,11327.34,7929.138,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3777.66789,12620.4192,,,,
Interstitial Lung Disease With McC,196,MS-DRG,,,,,,,inpatient,,,25824.88,18077.416,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,38181.4288,,,,
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,inpatient,,,14747.43,10323.201,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4918.267905,20059.3336,,,,
Interstitial Lung Disease Without Cc/McC,198,MS-DRG,,,,,,,inpatient,,,102750.94,71925.658,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5370.829997,82200.752,,,,
Pneumothorax With McC,199,MS-DRG,,,,,,,inpatient,,,30942.21,21659.547,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,35770.0128,,,,
Pneumothorax With Cc,200,MS-DRG,,,,,,,inpatient,,,23899.07,16729.349,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,22440.3536,,,,
Pneumothorax Without Cc/McC,201,MS-DRG,,,,,,,inpatient,,,14142.03,9899.421,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4716.367005,13716.7016,,,,
Bronchitis And Asthma With Cc/McC,202,MS-DRG,,,,,,,inpatient,,,14008.78,9806.146,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4671.92813,19589.2088,,,,
Bronchitis And Asthma Without Cc/McC,203,MS-DRG,,,,,,,inpatient,,,8434.66,5904.262,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2812.95911,14109.8232,,,,
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,inpatient,,,19382.31,13567.617,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5734.05,16432.0776,,,,
Other Respiratory System Diagnoses With McC,205,MS-DRG,,,,,,,inpatient,,,29471.66,20630.162,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,38252.3528,,,,
Other Respiratory System Diagnoses Without McC,206,MS-DRG,,,,,,,inpatient,,,18289.13,12802.391,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6099.424855,18355.1312,,,,
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,inpatient,,,153413.76,107389.632,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,131061.4728,,,,
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,inpatient,,,60056.19,42039.333,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,54390.6024,,,,
Other Heart Assist System Implant,215,MS-DRG,,,,,,,inpatient,,,163000.7,114100.49,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,214680.8688,,,,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/McC,218,MS-DRG,,,,,,,inpatient,,,144438.6,101107.02,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,120552.5624,,,,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/McC,221,MS-DRG,,,,,,,inpatient,,,282573.82,197801.674,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,226059.056,,,,
Other Cardiothoracic Procedures With McC,228,MS-DRG,,,,,,,inpatient,,,215439.26,150807.482,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,172351.408,,,,
Coronary Bypass With Cardiac Catheterization Or Open Ablation With McC,233,MS-DRG,,,,,,,inpatient,,,335724.2,235006.94,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,268579.36,,,,
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without McC,234,MS-DRG,,,,,,,inpatient,,,168474.77,117932.339,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,134779.816,,,,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With McC,239,MS-DRG,,,,,,,inpatient,,,57370.89,40159.623,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,102059.636,,,,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,inpatient,,,51903.54,36332.478,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,59008.768,,,,
Permanent Cardiac Pacemaker Implant With McC,242,MS-DRG,,,,,,,inpatient,,,86942.73,60859.911,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,69554.184,,,,
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,inpatient,,,65531.01,45871.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,52424.808,,,,
Permanent Cardiac Pacemaker Implant Without Cc/McC,244,MS-DRG,,,,,,,inpatient,,,63411.07,44387.749,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,50728.856,,,,
Aicd Generator Procedures,245,MS-DRG,,,,,,,inpatient,,,15907.12,11134.984,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5305.02452,99020.036,,,,
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without McC,251,MS-DRG,,,,,,,inpatient,,,55424.98,38797.486,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,44339.984,,,,
Other Vascular Procedures With McC,252,MS-DRG,,,,,,,inpatient,,,85181.97,59627.379,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,69509.5728,,,,
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,inpatient,,,82797.33,57958.131,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,66237.864,,,,
Other Vascular Procedures Without Cc/McC,254,MS-DRG,,,,,,,inpatient,,,61488.65,43042.055,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,49190.92,,,,
Upper Limb And Toe Amputation For Circulatory System Disorders With McC,255,MS-DRG,,,,,,,inpatient,,,163135.56,114194.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,130508.448,,,,
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,inpatient,,,13744.76,9621.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4583.87746,34319.1104,,,,
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/McC,257,MS-DRG,,,,,,,inpatient,,,13802.75,9661.925,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4603.217125,18073.4616,,,,
Cardiac Pacemaker Device Replacement Without McC,259,MS-DRG,,,,,,,inpatient,,,51584.98,36109.486,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,41267.984,,,,
Cardiac Pacemaker Revision Except Device Replacement With McC,260,MS-DRG,,,,,,,inpatient,,,218275.68,152792.976,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,174620.544,,,,
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,inpatient,,,57651.04,40355.728,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,46120.832,,,,
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,inpatient,,,28475.53,19932.871,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,70820.6536,,,,
Aortic And Heart Assist Procedures Except Pulsation Balloon With McC,268,MS-DRG,,,,,,,inpatient,,,101907.56,71335.292,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,135104.1408,,,,
Aortic And Heart Assist Procedures Except Pulsation Balloon Without McC,269,MS-DRG,,,,,,,inpatient,,,145888.49,102121.943,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,116710.792,,,,
Other Major Cardiovascular Procedures With McC,270,MS-DRG,,,,,,,inpatient,,,185659.89,129961.923,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,148527.912,,,,
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,inpatient,,,127626.27,89338.389,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,102101.016,,,,
Other Major Cardiovascular Procedures Without Cc/McC,272,MS-DRG,,,,,,,inpatient,,,104134.1,72893.87,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,83307.28,,,,
Percutaneous And Other Intracardiac Procedures Without McC,274,MS-DRG,,,,,,,inpatient,,,98959.28,69271.496,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,79167.424,,,,
Cardiac Defibrillator Implant With Cardiac Catheterization And McC,275,MS-DRG,,,,,,,inpatient,,,167450.04,117215.028,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,143195.556,,,,
Cardiac Defibrillator Implant Without McC,277,MS-DRG,,,,,,,inpatient,,,278318.05,194822.635,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,222654.44,,,,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With McC,278,MS-DRG,,,,,,,inpatient,,,130044.83,91031.381,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,104035.864,,,,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without McC,279,MS-DRG,,,,,,,inpatient,,,135336.66,94735.662,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,108269.328,,,,
Acute Myocardial Infarction- Discharged Alive With McC,280,MS-DRG,,,,,,,inpatient,,,31571.18,22099.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,33263.356,,,,
Acute Myocardial Infarction- Discharged Alive With Cc,281,MS-DRG,,,,,,,inpatient,,,22298.62,15609.034,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6744.11,18679.3552,,,,
Acute Myocardial Infarction- Discharged Alive Without Cc/McC,282,MS-DRG,,,,,,,inpatient,,,15726.17,11008.319,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5244.677695,14693.4264,,,,
Acute Myocardial Infarction- Expired With McC,283,MS-DRG,,,,,,,inpatient,,,47695.81,33387.067,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,39624.2256,,,,
Acute Myocardial Infarction- Expired With Cc,284,MS-DRG,,,,,,,inpatient,,,30935.67,21654.969,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5312.22,24748.536,,,,
Circulatory Disorders Except Ami- With Cardiac Catheterization With McC,286,MS-DRG,,,,,,,inpatient,,,48769.97,34138.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,44850.3112,,,,
Circulatory Disorders Except Ami- With Cardiac Catheterization Without McC,287,MS-DRG,,,,,,,inpatient,,,33854.25,23697.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,27083.4,,,,
Acute And Subacute Endocarditis With McC,288,MS-DRG,,,,,,,inpatient,,,36276.49,25393.543,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,55347.0632,,,,
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,inpatient,,,34648,24253.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,31948.2224,,,,
Heart Failure And Shock With McC,291,MS-DRG,,,,,,,inpatient,,,22051.33,15435.931,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7354.118555,26442.4936,,,,
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,inpatient,,,17435.09,12204.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5814.602515,17453.3832,,,,
Cardiac Arrest- Unexplained With McC,296,MS-DRG,,,,,,,inpatient,,,34260.06,23982.042,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,33198.5112,,,,
Peripheral Vascular Disorders With McC,299,MS-DRG,,,,,,,inpatient,,,30642.24,21449.568,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,32781.0728,,,,
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,inpatient,,,19909.9,13936.93,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6639.95165,21692.612,,,,
Peripheral Vascular Disorders Without Cc/McC,301,MS-DRG,,,,,,,inpatient,,,15022.69,10515.883,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5010.067115,14454.3112,,,,
Atherosclerosis With McC,302,MS-DRG,,,,,,,inpatient,,,19965.6,13975.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6658.5276,23571.0848,,,,
Atherosclerosis Without McC,303,MS-DRG,,,,,,,inpatient,,,16291.73,11404.211,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4894.02,13625.5136,,,,
Hypertension With McC,304,MS-DRG,,,,,,,inpatient,,,26689.62,18682.734,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,23806.1472,,,,
Hypertension Without McC,305,MS-DRG,,,,,,,inpatient,,,17122.11,11985.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5343.34,15212.1848,,,,
Cardiac Congenital And Valvular Disorders With McC,306,MS-DRG,,,,,,,inpatient,,,18809.29,13166.503,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6272.898215,30343.3136,,,,
Cardiac Congenital And Valvular Disorders Without McC,307,MS-DRG,,,,,,,inpatient,,,16249.07,11374.349,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5419.064845,18770.5432,,,,
Cardiac Arrhythmia And Conduction Disorders With McC,308,MS-DRG,,,,,,,inpatient,,,21486.31,15040.417,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7165.684385,24438.384,,,,
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,inpatient,,,15843.59,11090.513,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5283.837265,14981.1752,,,,
Cardiac Arrhythmia And Conduction Disorders Without Cc/McC,310,MS-DRG,,,,,,,inpatient,,,13559.61,9491.727,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4040.24,11337.708,,,,
Angina Pectoris,311,MS-DRG,,,,,,,inpatient,,,18298.95,12809.265,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5043.07,14639.16,,,,
Syncope And Collapse,312,MS-DRG,,,,,,,inpatient,,,18654.24,13057.968,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6057.47,17656.0232,,,,
Chest Pain,313,MS-DRG,,,,,,,inpatient,,,18746.43,13122.501,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5215.27,14997.144,,,,
Other Circulatory System Diagnoses With McC,314,MS-DRG,,,,,,,inpatient,,,33351.93,23346.351,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,43636.4976,,,,
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,inpatient,,,17192.63,12034.841,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5733.742105,19500.0472,,,,
Other Circulatory System Diagnoses Without Cc/McC,316,MS-DRG,,,,,,,inpatient,,,16812.59,11768.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5422.92,13832.2064,,,,
Percutaneous Cardiovascular Procedures With Intraluminal Device With McC Or 4+ Arteries/Intraluminal Devices,321,MS-DRG,,,,,,,inpatient,,,107897.8,75528.46,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,86318.24,,,,
Percutaneous Cardiovascular Procedures With Intraluminal Device Without McC,322,MS-DRG,,,,,,,inpatient,,,85234.32,59664.024,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,68187.456,,,,
Coronary Intravascular Lithotripsy With Intraluminal Device With McC,323,MS-DRG,,,,,,,inpatient,,,110878.49,77614.943,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,88702.792,,,,
Coronary Intravascular Lithotripsy With Intraluminal Device Without McC,324,MS-DRG,,,,,,,inpatient,,,99829.51,69880.657,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,79863.608,,,,
Stomach- Esophageal And Duodenal Procedures With McC,326,MS-DRG,,,,,,,inpatient,,,70344.55,49241.185,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,102914.7768,,,,
Stomach- Esophageal And Duodenal Procedures With Cc,327,MS-DRG,,,,,,,inpatient,,,76692.68,53684.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,61354.144,,,,
Stomach- Esophageal And Duodenal Procedures Without Cc/McC,328,MS-DRG,,,,,,,inpatient,,,58306.69,40814.683,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,46645.352,,,,
Major Small And Large Bowel Procedures With McC,329,MS-DRG,,,,,,,inpatient,,,92091.01,64463.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,93046.2088,,,,
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,inpatient,,,66292.87,46405.009,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,53034.296,,,,
Major Small And Large Bowel Procedures Without Cc/McC,331,MS-DRG,,,,,,,inpatient,,,44944.36,31461.052,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,35955.488,,,,
Rectal Resection With McC,332,MS-DRG,,,,,,,inpatient,,,65516.56,45861.592,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,70285.684,,,,
Rectal Resection With Cc,333,MS-DRG,,,,,,,inpatient,,,51060.47,35742.329,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,43063.0264,,,,
Peritoneal Adhesiolysis With McC,335,MS-DRG,,,,,,,inpatient,,,76073.75,53251.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,73434.7096,,,,
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,inpatient,,,39391.39,27573.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,42805.6736,,,,
Peritoneal Adhesiolysis Without Cc/McC,337,MS-DRG,,,,,,,inpatient,,,43856.45,30699.515,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,35085.16,,,,
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,inpatient,,,22777.13,15943.991,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7596.172855,30177.1488,,,,
Minor Small And Large Bowel Procedures Without Cc/McC,346,MS-DRG,,,,,,,inpatient,,,25360.83,17752.581,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,25232.7328,,,,
Anal And Stomal Procedures With McC,347,MS-DRG,,,,,,,inpatient,,,33046.94,23132.858,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,47956.7824,,,,
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,inpatient,,,21678.05,15174.635,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7229.629675,25508.3232,,,,
Anal And Stomal Procedures Without Cc/McC,349,MS-DRG,,,,,,,inpatient,,,20851.83,14596.281,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6954.085305,17850.5576,,,,
Inguinal And Femoral Hernia Procedures With McC,350,MS-DRG,,,,,,,inpatient,,,123839.74,86687.818,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,99071.792,,,,
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,inpatient,,,41444.06,29010.842,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,33155.248,,,,
Inguinal And Femoral Hernia Procedures Without Cc/McC,352,MS-DRG,,,,,,,inpatient,,,27314.17,19119.919,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,22341.06,,,,
Hernia Procedures Except Inguinal And Femoral With McC,353,MS-DRG,,,,,,,inpatient,,,60356.38,42249.466,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,59430.2592,,,,
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,inpatient,,,30185.36,21129.752,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,34471.0904,,,,
Hernia Procedures Except Inguinal And Femoral Without Cc/McC,355,MS-DRG,,,,,,,inpatient,,,34745.89,24322.123,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,27796.712,,,,
Other Digestive System O.R. Procedures With McC,356,MS-DRG,,,,,,,inpatient,,,122041.99,85429.393,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,97633.592,,,,
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,inpatient,,,40025.14,28017.598,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,45632.5016,,,,
Other Digestive System O.R. Procedures Without Cc/McC,358,MS-DRG,,,,,,,inpatient,,,22899.78,16029.846,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7637.07663,27457.72,,,,
Major Esophageal Disorders With McC,368,MS-DRG,,,,,,,inpatient,,,52357.14,36649.998,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,41885.712,,,,
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,inpatient,,,25013.89,17509.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,20620.6464,,,,
Major Gastrointestinal Disorders And Peritoneal Infections With McC,371,MS-DRG,,,,,,,inpatient,,,31663.98,22164.786,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,35427.5512,,,,
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,inpatient,,,22657.22,15860.054,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7435.09,20857.7352,,,,
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/McC,373,MS-DRG,,,,,,,inpatient,,,16862.96,11804.072,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5379.51,14697.4792,,,,
Digestive Malignancy With McC,374,MS-DRG,,,,,,,inpatient,,,35452.33,24816.631,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,42787.436,,,,
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,inpatient,,,28899.99,20229.993,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,24898.3768,,,,
Digestive Malignancy Without Cc/McC,376,MS-DRG,,,,,,,inpatient,,,13461.5,9423.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4489.41025,17891.0856,,,,
Gastrointestinal Hemorrhage With McC,377,MS-DRG,,,,,,,inpatient,,,36368.06,25457.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,36841.9784,,,,
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,inpatient,,,26039.38,18227.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7186.19,20831.504,,,,
Gastrointestinal Hemorrhage Without Cc/McC,379,MS-DRG,,,,,,,inpatient,,,12685.62,8879.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4230.65427,12900.0624,,,,
Complicated Peptic Ulcer With McC,380,MS-DRG,,,,,,,inpatient,,,33309.68,23316.776,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,38994.0152,,,,
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,inpatient,,,25551.79,17886.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7667.34,22069.5224,,,,
Uncomplicated Peptic Ulcer With McC,383,MS-DRG,,,,,,,inpatient,,,17337.01,12135.907,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5781.892835,25617.7488,,,,
Uncomplicated Peptic Ulcer Without McC,384,MS-DRG,,,,,,,inpatient,,,17367.77,12157.439,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5792.151295,17621.5744,,,,
Inflammatory Bowel Disease With McC,385,MS-DRG,,,,,,,inpatient,,,26393.7,18475.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,32922.9208,,,,
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,inpatient,,,16705.38,11693.766,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5571.24423,20109.9936,,,,
Inflammatory Bowel Disease Without Cc/McC,387,MS-DRG,,,,,,,inpatient,,,12511.84,8758.288,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4172.69864,13582.9592,,,,
Gastrointestinal Obstruction With McC,388,MS-DRG,,,,,,,inpatient,,,25855.59,18098.913,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,29788.08,,,,
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,inpatient,,,16977.78,11884.446,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5662.08963,16245.6488,,,,
Gastrointestinal Obstruction Without Cc/McC,390,MS-DRG,,,,,,,inpatient,,,12959.35,9071.545,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4215.34,11086.4344,,,,
Esophagitis- Gastroenteritis And Miscellaneous Digestive Disorders With McC,391,MS-DRG,,,,,,,inpatient,,,20838.16,14586.712,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6949.52636,26037.2136,,,,
Esophagitis- Gastroenteritis And Miscellaneous Digestive Disorders Without McC,392,MS-DRG,,,,,,,inpatient,,,16987.8,11891.46,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5530.73,15811.9992,,,,
Other Digestive System Diagnoses With McC,393,MS-DRG,,,,,,,inpatient,,,37534.54,26274.178,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,33555.1576,,,,
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,inpatient,,,23011.57,16108.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6791.14,19074.5032,,,,
Other Digestive System Diagnoses Without Cc/McC,395,MS-DRG,,,,,,,inpatient,,,17300.89,12110.623,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4700.83,13840.712,,,,
Appendix Procedures With McC,397,MS-DRG,,,,,,,inpatient,,,61991.24,43393.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,50206.0864,,,,
Appendix Procedures With Cc,398,MS-DRG,,,,,,,inpatient,,,56760.43,39732.301,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,45408.344,,,,
Appendix Procedures Without Cc/McC,399,MS-DRG,,,,,,,inpatient,,,27586.47,19310.529,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,22778.7624,,,,
Pancreas- Liver And Shunt Procedures With McC,405,MS-DRG,,,,,,,inpatient,,,46019.16,32213.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,110001.0976,,,,
Pancreas- Liver And Shunt Procedures With Cc,406,MS-DRG,,,,,,,inpatient,,,55926.32,39148.424,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,56905.3648,,,,
Pancreas- Liver And Shunt Procedures Without Cc/McC,407,MS-DRG,,,,,,,inpatient,,,51764.06,36234.842,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,43275.7984,,,,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,inpatient,,,23884.65,16719.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,42479.4232,,,,
Laparoscopic Cholecystectomy Without C.D.E. With McC,417,MS-DRG,,,,,,,inpatient,,,63968.01,44777.607,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,51174.408,,,,
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,inpatient,,,44129.12,30890.384,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,35303.296,,,,
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/McC,419,MS-DRG,,,,,,,inpatient,,,36100.79,25270.553,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,28880.632,,,,
Hepatobiliary Diagnostic Procedures With McC,420,MS-DRG,,,,,,,inpatient,,,75254.61,52678.227,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,71515.7088,,,,
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,,,inpatient,,,37061.98,25943.386,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,33182.3,,,,
Hepatobiliary Diagnostic Procedures Without Cc/McC,422,MS-DRG,,,,,,,inpatient,,,34064.62,23845.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,29773.8952,,,,
Other Hepatobiliary Or Pancreas O.R. Procedures With McC,423,MS-DRG,,,,,,,inpatient,,,81747.41,57223.187,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,82415.7144,,,,
Cirrhosis And Alcoholic Hepatitis With McC,432,MS-DRG,,,,,,,inpatient,,,29574.59,20702.213,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,39699.2024,,,,
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,inpatient,,,21623.94,15136.758,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7211.58399,21676.4008,,,,
Cirrhosis And Alcoholic Hepatitis Without Cc/McC,434,MS-DRG,,,,,,,inpatient,,,14349.7,10044.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4483.05,14111.8496,,,,
Malignancy Of Hepatobiliary System Or Pancreas With McC,435,MS-DRG,,,,,,,inpatient,,,41847.14,29292.998,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,36971.668,,,,
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,inpatient,,,20489.14,14342.398,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6833.12819,22849.6864,,,,
Disorders Of Pancreas Except Malignancy With McC,438,MS-DRG,,,,,,,inpatient,,,28902.5,20231.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,33715.2432,,,,
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,inpatient,,,16481.74,11537.218,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5496.66029,17431.0928,,,,
Disorders Of Pancreas Except Malignancy Without Cc/McC,440,MS-DRG,,,,,,,inpatient,,,15295.1,10706.57,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4383.92,12464.3864,,,,
Disorders Of Liver Except Malignancy- Cirrhosis Or Alcoholic Hepatitis With McC,441,MS-DRG,,,,,,,inpatient,,,34043.85,23830.695,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,38305.0392,,,,
Disorders Of Liver Except Malignancy- Cirrhosis Or Alcoholic Hepatitis With Cc,442,MS-DRG,,,,,,,inpatient,,,21274.77,14892.339,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6740.49,19579.0768,,,,
Disorders Of Liver Except Malignancy- Cirrhosis Or Alcoholic Hepatitis Without Cc/McC,443,MS-DRG,,,,,,,inpatient,,,11297.88,7908.516,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3767.84298,14237.4864,,,,
Disorders Of The Biliary Tract With McC,444,MS-DRG,,,,,,,inpatient,,,39694.28,27785.996,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,34134.708,,,,
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,inpatient,,,32558.38,22790.866,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,26046.704,,,,
Disorders Of The Biliary Tract Without Cc/McC,446,MS-DRG,,,,,,,inpatient,,,33146.93,23202.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5905.53,26517.544,,,,
Combined Anterior And Posterior Spinal Fusion With McC,453,MS-DRG,,,,,,,inpatient,,,126551.26,88585.882,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,101241.008,,,,
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,,,inpatient,,,108469.17,75928.419,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,86775.336,,,,
Combined Anterior And Posterior Spinal Fusion Without Cc/McC,455,MS-DRG,,,,,,,inpatient,,,115580.93,80906.651,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,92464.744,,,,
Spinal Fusion Except Cervical With Spinal Curvature- Malignancy- Infection Or Extensive Fusions With Cc,457,MS-DRG,,,,,,,inpatient,,,143333.97,100333.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,116295.096,,,,
Spinal Fusion Except Cervical With McC,459,MS-DRG,,,,,,,inpatient,,,98009.72,68606.804,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,78407.776,,,,
Spinal Fusion Except Cervical Without McC,460,MS-DRG,,,,,,,inpatient,,,99867.86,69907.502,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,79894.288,,,,
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With McC,461,MS-DRG,,,,,,,inpatient,,,327456.17,229219.319,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,261964.936,,,,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With McC,463,MS-DRG,,,,,,,inpatient,,,128878.42,90214.894,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,109439.7848,,,,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With Cc,464,MS-DRG,,,,,,,inpatient,,,40970.26,28679.182,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,59750.4304,,,,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Without Cc/McC,465,MS-DRG,,,,,,,inpatient,,,35885.97,25120.179,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,35176.2776,,,,
Revision Of Hip Or Knee Replacement With McC,466,MS-DRG,,,,,,,inpatient,,,84828.36,59379.852,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,103230.8952,,,,
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,inpatient,,,72170.88,50519.616,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,69402.1736,,,,
Revision Of Hip Or Knee Replacement Without Cc/McC,468,MS-DRG,,,,,,,inpatient,,,88973.4,62281.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,71178.72,,,,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With McC Or Total Ankle Replacement,469,MS-DRG,,,,,,,inpatient,,,112079.98,78455.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,89663.984,,,,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without McC,470,MS-DRG,,,,,,,inpatient,,,49135.63,34394.941,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,39308.504,,,,
Cervical Spinal Fusion With McC,471,MS-DRG,,,,,,,inpatient,,,68213.66,47749.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,98422.248,,,,
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,inpatient,,,62194.58,43536.206,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,58704.808,,,,
Cervical Spinal Fusion Without Cc/McC,473,MS-DRG,,,,,,,inpatient,,,60389.67,42272.769,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,48311.736,,,,
Amputation For Musculoskeletal System And Connective Tissue Disorders With McC,474,MS-DRG,,,,,,,inpatient,,,118369.6,82858.72,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,94695.68,,,,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,inpatient,,,42743.34,29920.338,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,43711.4744,,,,
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/McC,476,MS-DRG,,,,,,,inpatient,,,10865.65,7605.955,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3623.694275,23567.032,,,,
Biopsies Of Musculoskeletal System And Connective Tissue With McC,477,MS-DRG,,,,,,,inpatient,,,79298.26,55508.782,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,69683.8432,,,,
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,inpatient,,,43683.25,30578.275,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,47385.3376,,,,
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/McC,479,MS-DRG,,,,,,,inpatient,,,48180.79,33726.553,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,38544.632,,,,
Hip And Femur Procedures Except Major Joint With McC,480,MS-DRG,,,,,,,inpatient,,,63845.68,44691.976,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,59596.424,,,,
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,inpatient,,,51147.69,35803.383,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,42045.7736,,,,
Hip And Femur Procedures Except Major Joint Without Cc/McC,482,MS-DRG,,,,,,,inpatient,,,37492.92,26245.044,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,32146.8096,,,,
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,inpatient,,,82685.37,57879.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,66148.296,,,,
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,inpatient,,,54953.11,38467.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,43962.488,,,,
Knee Procedures With Principal Diagnosis Of Infection Without Cc/McC,487,MS-DRG,,,,,,,inpatient,,,28558.04,19990.628,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,32019.1464,,,,
Knee Procedures Without Principal Diagnosis Of Infection With Cc/McC,488,MS-DRG,,,,,,,inpatient,,,29907.22,20935.054,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,39824.8392,,,,
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/McC,489,MS-DRG,,,,,,,inpatient,,,28726.07,20108.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,25098.9904,,,,
Lower Extremity And Humerus Procedures Except Hip- Foot And Femur With McC,492,MS-DRG,,,,,,,inpatient,,,73476.69,51433.683,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,71957.464,,,,
Lower Extremity And Humerus Procedures Except Hip- Foot And Femur With Cc,493,MS-DRG,,,,,,,inpatient,,,59232.47,41462.729,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,48653.864,,,,
Lower Extremity And Humerus Procedures Except Hip- Foot And Femur Without Cc/McC,494,MS-DRG,,,,,,,inpatient,,,55024.26,38516.982,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,44019.408,,,,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/McC,497,MS-DRG,,,,,,,inpatient,,,25582.79,17907.953,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,27214.552,,,,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/McC,498,MS-DRG,,,,,,,inpatient,,,53889.53,37722.671,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,51160.5208,,,,
Soft Tissue Procedures With McC,500,MS-DRG,,,,,,,inpatient,,,39746.36,27822.452,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,64206.484,,,,
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,inpatient,,,35413.37,24789.359,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,36169.2136,,,,
Soft Tissue Procedures Without Cc/McC,502,MS-DRG,,,,,,,inpatient,,,46820.44,32774.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,37456.352,,,,
Foot Procedures With McC,503,MS-DRG,,,,,,,inpatient,,,139085.96,97360.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,111268.768,,,,
Foot Procedures With Cc,504,MS-DRG,,,,,,,inpatient,,,58509.52,40956.664,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,46807.616,,,,
Foot Procedures Without Cc/McC,505,MS-DRG,,,,,,,inpatient,,,18215.65,12750.955,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6074.919275,35575.4784,,,,
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,inpatient,,,34935.4,24454.78,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,30375.736,,,,
Major Shoulder Or Elbow Joint Procedures With Cc/McC,507,MS-DRG,,,,,,,inpatient,,,46308.19,32415.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,39273.6584,,,,
Major Shoulder Or Elbow Joint Procedures Without Cc/McC,508,MS-DRG,,,,,,,inpatient,,,21924.51,15347.157,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7311.824085,26152.7184,,,,
Arthroscopy,509,MS-DRG,,,,,,,inpatient,,,27294.99,19106.493,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,35593.716,,,,
Shoulder- Elbow Or Forearm Procedures- Except Major Joint Procedures With McC,510,MS-DRG,,,,,,,inpatient,,,62572,43800.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,57914.512,,,,
Shoulder- Elbow Or Forearm Procedures- Except Major Joint Procedures With Cc,511,MS-DRG,,,,,,,inpatient,,,55415.55,38790.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,44332.44,,,,
Shoulder- Elbow Or Forearm Procedures- Except Major Joint Procedures Without Cc/McC,512,MS-DRG,,,,,,,inpatient,,,47238.2,33066.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,37790.56,,,,
Hand Or Wrist Procedures- Except Major Thumb Or Joint Procedures With Cc/McC,513,MS-DRG,,,,,,,inpatient,,,43600.38,30520.266,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,34880.304,,,,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With McC,515,MS-DRG,,,,,,,inpatient,,,49277.7,34494.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,62660.3408,,,,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,inpatient,,,53176.69,37223.683,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,42541.352,,,,
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/McC,517,MS-DRG,,,,,,,inpatient,,,52111.68,36478.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,41689.344,,,,
Back And Neck Procedures Except Spinal Fusion With McC Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,inpatient,,,37618.21,26332.747,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,72622.1232,,,,
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,inpatient,,,45454.66,31818.262,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,39954.5288,,,,
Back And Neck Procedures Except Spinal Fusion Without Cc/McC,520,MS-DRG,,,,,,,inpatient,,,30414.64,21290.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,29040.3384,,,,
Hip Replacement With Principal Diagnosis Of Hip Fracture With McC,521,MS-DRG,,,,,,,inpatient,,,66299.82,46409.874,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,59061.4544,,,,
Hip Replacement With Principal Diagnosis Of Hip Fracture Without McC,522,MS-DRG,,,,,,,inpatient,,,59172.56,41420.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,47338.048,,,,
Fractures Of Femur With McC,533,MS-DRG,,,,,,,inpatient,,,15534.08,10873.856,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5180.61568,30898.5472,,,,
Fractures Of Femur Without McC,534,MS-DRG,,,,,,,inpatient,,,23461.3,16422.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5705.828554,18769.04,,,,
Fractures Of Hip And Pelvis With McC,535,MS-DRG,,,,,,,inpatient,,,19899.42,13929.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6636.45657,26949.0936,,,,
Fractures Of Hip And Pelvis Without McC,536,MS-DRG,,,,,,,inpatient,,,17540.07,12278.049,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5582.83,16432.0776,,,,
Sprains- Strains- And Dislocations Of Hip- Pelvis And Thigh With Cc/McC,537,MS-DRG,,,,,,,inpatient,,,18243.05,12770.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6084.057175,18620.5896,,,,
Sprains- Strains- And Dislocations Of Hip- Pelvis And Thigh Without Cc/McC,538,MS-DRG,,,,,,,inpatient,,,12750.59,8925.413,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4252.321765,13607.276,,,,
Osteomyelitis With McC,539,MS-DRG,,,,,,,inpatient,,,15126.14,10588.298,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5044.56769,40987.9928,,,,
Osteomyelitis With Cc,540,MS-DRG,,,,,,,inpatient,,,18734.75,13114.325,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6248.039125,26229.7216,,,,
Osteomyelitis Without Cc/McC,541,MS-DRG,,,,,,,inpatient,,,13958.41,9770.887,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4655.129735,17726.9472,,,,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With McC,542,MS-DRG,,,,,,,inpatient,,,18971.85,13280.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6327.111975,37790.3336,,,,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,inpatient,,,20157.83,14110.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6722.636305,21496.0512,,,,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/McC,544,MS-DRG,,,,,,,inpatient,,,15770.25,11039.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5259.378375,15313.5048,,,,
Connective Tissue Disorders With McC,545,MS-DRG,,,,,,,inpatient,,,29219.27,20453.489,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,51201.0488,,,,
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,inpatient,,,19656.15,13759.305,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6555.326025,23459.6328,,,,
Connective Tissue Disorders Without Cc/McC,547,MS-DRG,,,,,,,inpatient,,,8610.08,6027.056,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2871.46168,15120.9968,,,,
Septic Arthritis With Cc,549,MS-DRG,,,,,,,inpatient,,,46061.25,32242.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,36849,,,,
Medical Back Problems With McC,551,MS-DRG,,,,,,,inpatient,,,27883.52,19518.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,34576.4632,,,,
Medical Back Problems Without McC,552,MS-DRG,,,,,,,inpatient,,,22361.84,15653.288,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6815.74,19530.4432,,,,
Bone Diseases And Arthropathies With McC,553,MS-DRG,,,,,,,inpatient,,,13901.34,9730.938,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4636.09689,26470.8632,,,,
Bone Diseases And Arthropathies Without McC,554,MS-DRG,,,,,,,inpatient,,,18962.8,13273.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5718.85,16912.3344,,,,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without McC,556,MS-DRG,,,,,,,inpatient,,,20178.82,14125.174,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5833.89,16545.556,,,,
Tendonitis- Myositis And Bursitis With McC,557,MS-DRG,,,,,,,inpatient,,,32769.21,22938.447,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,31403.1208,,,,
Tendonitis- Myositis And Bursitis Without McC,558,MS-DRG,,,,,,,inpatient,,,15272.59,10690.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5093.408765,17504.0432,,,,
Aftercare- Musculoskeletal System And Connective Tissue With McC,559,MS-DRG,,,,,,,inpatient,,,16267.53,11387.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5425.221255,37612.0104,,,,
Aftercare- Musculoskeletal System And Connective Tissue With Cc,560,MS-DRG,,,,,,,inpatient,,,15449.56,10814.692,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5152.42826,23076.6432,,,,
Aftercare- Musculoskeletal System And Connective Tissue Without Cc/McC,561,MS-DRG,,,,,,,inpatient,,,9300.65,6510.455,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3101.766775,16567.8464,,,,
Fracture- Sprain- Strain And Dislocation Except Femur- Hip- Pelvis And Thigh With McC,562,MS-DRG,,,,,,,inpatient,,,32385.67,22669.969,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,29660.4168,,,,
Fracture- Sprain- Strain And Dislocation Except Femur- Hip- Pelvis And Thigh Without McC,563,MS-DRG,,,,,,,inpatient,,,24167.6,16917.32,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6300.58,19334.08,,,,
Other Musculoskeletal System And Connective Tissue Diagnoses With McC,564,MS-DRG,,,,,,,inpatient,,,25802.93,18062.051,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,31798.2688,,,,
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,inpatient,,,22006.13,15404.291,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7280.97,20661.1744,,,,
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/McC,566,MS-DRG,,,,,,,inpatient,,,6764.1,4734.87,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2255.82735,15157.472,,,,
Skin Debridement With McC,570,MS-DRG,,,,,,,inpatient,,,33594.41,23516.087,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,61002.7456,,,,
Skin Debridement With Cc,571,MS-DRG,,,,,,,inpatient,,,26173.08,18321.156,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,33938.1472,,,,
Skin Graft For Skin Ulcer Or Cellulitis With McC,573,MS-DRG,,,,,,,inpatient,,,229287.37,160501.159,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,183429.896,,,,
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,inpatient,,,76990.64,53893.448,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,70208.6808,,,,
Other Skin- Subcutaneous Tissue And Breast Procedures With McC,579,MS-DRG,,,,,,,inpatient,,,44370,31059,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,66042.4024,,,,
Other Skin- Subcutaneous Tissue And Breast Procedures With Cc,580,MS-DRG,,,,,,,inpatient,,,32530.15,22771.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,35926.0456,,,,
Other Skin- Subcutaneous Tissue And Breast Procedures Without Cc/McC,581,MS-DRG,,,,,,,inpatient,,,34001.93,23801.351,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,29161.9224,,,,
Mastectomy For Malignancy Without Cc/McC,583,MS-DRG,,,,,,,inpatient,,,26986.11,18890.277,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,33283.62,,,,
Breast Biopsy- Local Excision And Other Breast Procedures With Cc/McC,584,MS-DRG,,,,,,,inpatient,,,15783.7,11048.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5263.86395,41486.4872,,,,
Skin Ulcers With McC,592,MS-DRG,,,,,,,inpatient,,,11607.65,8125.355,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3871.151275,41666.8368,,,,
Skin Ulcers With Cc,593,MS-DRG,,,,,,,inpatient,,,11196.69,7837.683,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3734.096115,24774.7664,,,,
Skin Ulcers Without Cc/McC,594,MS-DRG,,,,,,,inpatient,,,9029.64,6320.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3011.38494,17196.0304,,,,
Major Skin Disorders With McC,595,MS-DRG,,,,,,,inpatient,,,27847.46,19493.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,42858.36,,,,
Major Skin Disorders Without McC,596,MS-DRG,,,,,,,inpatient,,,30386.11,21270.277,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7157.25,24308.888,,,,
Malignant Breast Disorders With McC,597,MS-DRG,,,,,,,inpatient,,,49956.04,34969.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,39964.832,,,,
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,inpatient,,,27430.15,19201.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,21944.12,,,,
Non-Malignant Breast Disorders With Cc/McC,600,MS-DRG,,,,,,,inpatient,,,13956.43,9769.501,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4654.469405,19396.7008,,,,
Non-Malignant Breast Disorders Without Cc/McC,601,MS-DRG,,,,,,,inpatient,,,9383.02,6568.114,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3129.23717,12148.268,,,,
Cellulitis With McC,602,MS-DRG,,,,,,,inpatient,,,27986.19,19590.333,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,29775.9216,,,,
Cellulitis Without McC,603,MS-DRG,,,,,,,inpatient,,,16886.67,11820.669,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5631.704445,17850.5576,,,,
Trauma To The Skin- Subcutaneous Tissue And Breast With McC,604,MS-DRG,,,,,,,inpatient,,,38556.84,26989.788,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,30845.472,,,,
Trauma To The Skin- Subcutaneous Tissue And Breast Without McC,605,MS-DRG,,,,,,,inpatient,,,21359.36,14951.552,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6578.42,18717.8568,,,,
Minor Skin Disorders With McC,606,MS-DRG,,,,,,,inpatient,,,6185.67,4329.969,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2062.920945,32627.0664,,,,
Minor Skin Disorders Without McC,607,MS-DRG,,,,,,,inpatient,,,19860.65,13902.455,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5973.54,17514.1752,,,,
Adrenal And Pituitary Procedures With Cc/McC,614,MS-DRG,,,,,,,inpatient,,,37769.13,26438.391,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,46177.6032,,,,
Adrenal And Pituitary Procedures Without Cc/McC,615,MS-DRG,,,,,,,inpatient,,,58015.91,40611.137,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,46412.728,,,,
Amputation Of Lower Limb For Endocrine- Nutritional And Metabolic Disorders With McC,616,MS-DRG,,,,,,,inpatient,,,66449.27,46514.489,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,78318.3336,,,,
Amputation Of Lower Limb For Endocrine- Nutritional And Metabolic Disorders With Cc,617,MS-DRG,,,,,,,inpatient,,,29882.58,20917.806,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,39154.1008,,,,
Amputation Of Lower Limb For Endocrine- Nutritional And Metabolic Disorders Without Cc/McC,618,MS-DRG,,,,,,,inpatient,,,10245.69,7171.983,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3416.937615,25228.68,,,,
Skin Grafts And Wound Debridement For Endocrine- Nutritional And Metabolic Disorders With McC,622,MS-DRG,,,,,,,inpatient,,,103303.17,72312.219,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,82642.536,,,,
Skin Grafts And Wound Debridement For Endocrine- Nutritional And Metabolic Disorders With Cc,623,MS-DRG,,,,,,,inpatient,,,20666.05,14466.235,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6892.127675,38785.296,,,,
Thyroid- Parathyroid And Thyroglossal Procedures With Cc,626,MS-DRG,,,,,,,inpatient,,,27302.86,19112.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,30582.4288,,,,
Thyroid- Parathyroid And Thyroglossal Procedures Without Cc/McC,627,MS-DRG,,,,,,,inpatient,,,31328.53,21929.971,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,25670.4352,,,,
Other Endocrine- Nutritional And Metabolic O.R. Procedures With McC,628,MS-DRG,,,,,,,inpatient,,,48752.32,34126.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,79967.8232,,,,
Other Endocrine- Nutritional And Metabolic O.R. Procedures With Cc,629,MS-DRG,,,,,,,inpatient,,,41481.26,29036.882,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,45596.0264,,,,
Diabetes With McC,637,MS-DRG,,,,,,,inpatient,,,33585.6,23509.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,29510.4632,,,,
Diabetes With Cc,638,MS-DRG,,,,,,,inpatient,,,16607.1,11624.97,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5538.46785,18586.1408,,,,
Diabetes Without Cc/McC,639,MS-DRG,,,,,,,inpatient,,,15715.82,11001.074,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4408.52,12697.4224,,,,
Miscellaneous Disorders Of Nutrition- Metabolism- Fluids And Electrolytes With McC,640,MS-DRG,,,,,,,inpatient,,,19706.61,13794.627,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6572.154435,26912.6184,,,,
Miscellaneous Disorders Of Nutrition- Metabolism- Fluids And Electrolytes Without McC,641,MS-DRG,,,,,,,inpatient,,,15211.2,10647.84,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5072.9352,15836.316,,,,
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,inpatient,,,44600.9,31220.63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,35680.72,,,,
Endocrine Disorders With McC,643,MS-DRG,,,,,,,inpatient,,,24319.36,17023.552,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,33583.5272,,,,
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,inpatient,,,18127.98,12689.586,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6045.68133,20942.844,,,,
Endocrine Disorders Without Cc/McC,645,MS-DRG,,,,,,,inpatient,,,13087.48,9161.236,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4364.67458,15785.656,,,,
Major Bladder Procedures With McC,653,MS-DRG,,,,,,,inpatient,,,74103.71,51872.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,112955.5888,,,,
Major Bladder Procedures With Cc,654,MS-DRG,,,,,,,inpatient,,,32847.58,22993.306,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,57182.9816,,,,
Kidney And Ureter Procedures For Neoplasm With McC,656,MS-DRG,,,,,,,inpatient,,,74882.24,52417.568,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,66014.0328,,,,
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,inpatient,,,35825.52,25077.864,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,37042.592,,,,
Kidney And Ureter Procedures For Neoplasm Without Cc/McC,658,MS-DRG,,,,,,,inpatient,,,45531.4,31871.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,36425.12,,,,
Kidney And Ureter Procedures For Non-Neoplasm With McC,659,MS-DRG,,,,,,,inpatient,,,43577.66,30504.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,52366.2288,,,,
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,inpatient,,,27744.56,19421.192,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,27151.7336,,,,
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/McC,661,MS-DRG,,,,,,,inpatient,,,23214.29,16250.003,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7701.35,20803.0224,,,,
Minor Bladder Procedures With McC,662,MS-DRG,,,,,,,inpatient,,,26200.57,18340.399,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,63211.5216,,,,
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,inpatient,,,51470.37,36029.259,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,41176.296,,,,
Minor Bladder Procedures Without Cc/McC,664,MS-DRG,,,,,,,inpatient,,,21663.46,15164.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7224.76391,21881.0672,,,,
Prostatectomy With McC,665,MS-DRG,,,,,,,inpatient,,,440302,308211.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,352241.6,,,,
Prostatectomy With Cc,666,MS-DRG,,,,,,,inpatient,,,21861.75,15303.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7290.893625,33378.8608,,,,
Prostatectomy Without Cc/McC,667,MS-DRG,,,,,,,inpatient,,,16201.02,11340.714,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5403.04017,20825.3128,,,,
Transurethral Procedures With McC,668,MS-DRG,,,,,,,inpatient,,,48931.22,34251.854,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,59091.8504,,,,
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,inpatient,,,33035.66,23124.962,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,31358.54,,,,
Transurethral Procedures Without Cc/McC,670,MS-DRG,,,,,,,inpatient,,,33732.79,23612.953,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7065.36,26986.232,,,,
Other Kidney And Urinary Tract Procedures With McC,673,MS-DRG,,,,,,,inpatient,,,60478,42334.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,84906.16,,,,
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,inpatient,,,73440.29,51408.203,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,58752.232,,,,
Renal Failure With McC,682,MS-DRG,,,,,,,inpatient,,,25189.25,17632.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,30436.528,,,,
Renal Failure With Cc,683,MS-DRG,,,,,,,inpatient,,,17753.72,12427.604,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5920.86562,18012.6696,,,,
Renal Failure Without Cc/McC,684,MS-DRG,,,,,,,inpatient,,,9135.38,6394.766,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3046.64923,12310.38,,,,
Kidney And Urinary Tract Neoplasms With McC,686,MS-DRG,,,,,,,inpatient,,,27497.1,19247.97,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,38209.7984,,,,
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,inpatient,,,25492.34,17844.638,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7581.24,21329.8864,,,,
Kidney And Urinary Tract Infections With McC,689,MS-DRG,,,,,,,inpatient,,,20757.97,14530.579,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6922.782995,23716.9856,,,,
Kidney And Urinary Tract Infections Without McC,690,MS-DRG,,,,,,,inpatient,,,16632.65,11642.855,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5546.988775,16263.8864,,,,
Urinary Stones With McC,693,MS-DRG,,,,,,,inpatient,,,4007.39,2805.173,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1336.464565,29794.1592,,,,
Urinary Stones Without McC,694,MS-DRG,,,,,,,inpatient,,,15019.62,10513.734,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5009.04327,15834.2896,,,,
Kidney And Urinary Tract Signs And Symptoms With McC,695,MS-DRG,,,,,,,inpatient,,,29850.37,20895.259,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,23880.296,,,,
Kidney And Urinary Tract Signs And Symptoms Without McC,696,MS-DRG,,,,,,,inpatient,,,12055.26,8438.682,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4020.42921,14016.6088,,,,
Other Kidney And Urinary Tract Diagnoses With McC,698,MS-DRG,,,,,,,inpatient,,,25421.96,17795.372,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,34061.7576,,,,
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,inpatient,,,18359.1,12851.37,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6122.75985,20665.2272,,,,
Other Kidney And Urinary Tract Diagnoses Without Cc/McC,700,MS-DRG,,,,,,,inpatient,,,8380.95,5866.665,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2795.046825,14065.2424,,,,
Major Male Pelvic Procedures Without Cc/McC,708,MS-DRG,,,,,,,inpatient,,,55574.17,38901.919,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,44459.336,,,,
Penis Procedures With Cc/McC,709,MS-DRG,,,,,,,inpatient,,,18738.26,13116.782,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6249.20971,45533.208,,,,
Transurethral Prostatectomy With Cc/McC,713,MS-DRG,,,,,,,inpatient,,,28299.1,19809.37,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,29299.7176,,,,
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/McC,717,MS-DRG,,,,,,,inpatient,,,29999.37,20999.559,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,37597.8256,,,,
Malignancy- Male Reproductive System With Cc,723,MS-DRG,,,,,,,inpatient,,,3972.81,2780.967,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1324.932135,22754.4456,,,,
Benign Prostatic Hypertrophy Without McC,726,MS-DRG,,,,,,,inpatient,,,40258.34,28180.838,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5378.07,32206.672,,,,
Inflammation Of The Male Reproductive System With McC,727,MS-DRG,,,,,,,inpatient,,,22656.48,15859.536,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7555.93608,29773.8952,,,,
Inflammation Of The Male Reproductive System Without McC,728,MS-DRG,,,,,,,inpatient,,,13639.47,9547.629,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4548.763245,16557.7144,,,,
Other Male Reproductive System Diagnoses With Cc/McC,729,MS-DRG,,,,,,,inpatient,,,16117.99,11282.593,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5375.349665,22306.6112,,,,
Other Male Reproductive System Diagnoses Without Cc/McC,730,MS-DRG,,,,,,,inpatient,,,5959.58,4171.706,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1987.51993,12298.2216,,,,
Uterine And Adnexa Procedures For Non-Malignancy With Cc/McC,742,MS-DRG,,,,,,,inpatient,,,28503.79,19952.653,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,37014.2224,,,,
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/McC,743,MS-DRG,,,,,,,inpatient,,,26776.68,18743.676,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,24288.4304,,,,
D&C- Conization- Laparoscopy And Tubal Interruption With Cc/McC,744,MS-DRG,,,,,,,inpatient,,,42207.27,29545.089,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,39593.8296,,,,
D&C- Conization- Laparoscopy And Tubal Interruption Without Cc/McC,745,MS-DRG,,,,,,,inpatient,,,41300.62,28910.434,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,33040.496,,,,
Vagina- Cervix And Vulva Procedures With Cc/McC,746,MS-DRG,,,,,,,inpatient,,,54026.22,37818.354,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,43220.976,,,,
Vagina- Cervix And Vulva Procedures Without Cc/McC,747,MS-DRG,,,,,,,inpatient,,,14150.78,9905.546,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4719.28513,19354.1464,,,,
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,,,inpatient,,,71661.69,50163.183,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,57329.352,,,,
Other Female Reproductive System O.R. Procedures With Cc/McC,749,MS-DRG,,,,,,,inpatient,,,40397.2,28278.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,52451.3376,,,,
Malignancy- Female Reproductive System With McC,754,MS-DRG,,,,,,,inpatient,,,31179.58,21825.706,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,36661.6288,,,,
Malignancy- Female Reproductive System With Cc,755,MS-DRG,,,,,,,inpatient,,,7660.86,5362.602,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2554.89681,22495.0664,,,,
Malignancy- Female Reproductive System Without Cc/McC,756,MS-DRG,,,,,,,inpatient,,,11168.92,7818.244,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3724.83482,19350.0936,,,,
Infections- Female Reproductive System With Cc,758,MS-DRG,,,,,,,inpatient,,,20130.99,14091.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6713.685165,20655.0952,,,,
Infections- Female Reproductive System Without Cc/McC,759,MS-DRG,,,,,,,inpatient,,,18187.49,12731.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4943.22,14549.992,,,,
Menstrual And Other Female Reproductive System Disorders With Cc/McC,760,MS-DRG,,,,,,,inpatient,,,19375.46,13562.822,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6461.71591,19970.172,,,,
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,inpatient,,,14024.34,9817.038,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4677.11739,22215.4232,,,,
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,inpatient,,,9265.92,6486.144,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3090.18432,28156.828,,,,
Abortion With D&C- Aspiration Curettage Or Hysterotomy,770,MS-DRG,,,,,,,inpatient,,,25214.53,17650.171,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6425.75,21802.0376,,,,
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,inpatient,,,8836.34,6185.438,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2946.91939,14456.3376,,,,
Cesarean Section With Sterilization With McC,783,MS-DRG,,,,,,,inpatient,,,17734.56,12414.192,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5914.47576,37326.288,,,,
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,inpatient,,,18719.59,13103.713,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6242.983265,21945.912,,,,
Cesarean Section With Sterilization Without Cc/McC,785,MS-DRG,,,,,,,inpatient,,,17648.18,12353.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5885.66803,17728.9736,,,,
Cesarean Section Without Sterilization With McC,786,MS-DRG,,,,,,,inpatient,,,21072.73,14750.911,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7027.755455,32742.5712,,,,
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,inpatient,,,18455.52,12918.864,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6154.91592,21516.3152,,,,
Cesarean Section Without Sterilization Without Cc/McC,788,MS-DRG,,,,,,,inpatient,,,17822.26,12475.582,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5943.72371,18338.92,,,,
Neonates- Died Or Transferred To Another Acute Care Facility,789,MS-DRG,,,,,,,inpatient,,,6500.45,4550.315,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2167.900075,36529.9128,,,,
Extreme Immaturity Or Respiratory Distress Syndrome- Neonate,790,MS-DRG,,,,,,,inpatient,,,71335.38,49934.766,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,120469.48,,,,
Prematurity With Major Problems,791,MS-DRG,,,,,,,inpatient,,,39411.64,27588.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,82273.8664,,,,
Prematurity Without Major Problems,792,MS-DRG,,,,,,,inpatient,,,10975.85,7683.095,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3660.445975,49642.7472,,,,
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,inpatient,,,8093.71,5665.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2699.252285,84513.0384,,,,
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,inpatient,,,5349.51,3744.657,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1784.061585,29913.7168,,,,
Normal Newborn,795,MS-DRG,,,,,,,inpatient,,,4927.51,3449.257,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1378.34,7947.23,,,,
Vaginal Delivery With Sterilization And/Or D&C With McC,796,MS-DRG,,,,,,,inpatient,,,17976.19,12583.333,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5995.059365,25869.0224,,,,
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,inpatient,,,23001.33,16100.931,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6655.835261,19619.6048,,,,
Vaginal Delivery With Sterilization And/Or D&C Without Cc/McC,798,MS-DRG,,,,,,,inpatient,,,14819.75,10373.825,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4942.386625,19619.6048,,,,
Splenic Procedures With McC,799,MS-DRG,,,,,,,inpatient,,,81427.43,56999.201,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,96345.188,,,,
Splenic Procedures Without Cc/McC,801,MS-DRG,,,,,,,inpatient,,,60652.11,42456.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,48521.688,,,,
Other O.R. Procedures Of The Blood And Blood Forming Organs With McC,802,MS-DRG,,,,,,,inpatient,,,94944.09,66460.863,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,75955.272,,,,
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/McC,804,MS-DRG,,,,,,,inpatient,,,22075,15452.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7362.0125,22401.852,,,,
Vaginal Delivery Without Sterilization Or D&C With McC,805,MS-DRG,,,,,,,inpatient,,,13956.78,9769.746,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4654.58613,20221.4456,,,,
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,inpatient,,,13483.61,9438.527,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4496.783935,14661.004,,,,
Vaginal Delivery Without Sterilization Or D&C Without Cc/McC,807,MS-DRG,,,,,,,inpatient,,,13157.23,9210.061,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4387.936205,12912.2208,,,,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With McC,808,MS-DRG,,,,,,,inpatient,,,31882.27,22317.589,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,46412.6656,,,,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With Cc,809,MS-DRG,,,,,,,inpatient,,,26642.66,18649.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,25096.964,,,,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders Without Cc/McC,810,MS-DRG,,,,,,,inpatient,,,85706.42,59994.494,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6951.04,68565.136,,,,
Red Blood Cell Disorders With McC,811,MS-DRG,,,,,,,inpatient,,,33080.94,23156.658,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,28507.3952,,,,
Red Blood Cell Disorders Without McC,812,MS-DRG,,,,,,,inpatient,,,21914.25,15339.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6364.97,18701.6456,,,,
Coagulation Disorders,813,MS-DRG,,,,,,,inpatient,,,31592.62,22114.834,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,31366.6456,,,,
Reticuloendothelial And Immunity Disorders With McC,814,MS-DRG,,,,,,,inpatient,,,15313.53,10719.471,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5107.062255,42357.8392,,,,
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,inpatient,,,14949.63,10464.741,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4985.701605,20590.2504,,,,
Other Antepartum Diagnoses With O.R. Procedures With McC,817,MS-DRG,,,,,,,inpatient,,,35079.77,24555.839,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,51371.2664,,,,
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,inpatient,,,56068.99,39248.293,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,44855.192,,,,
Other Antepartum Diagnoses With O.R. Procedures Without Cc/McC,819,MS-DRG,,,,,,,inpatient,,,15513.53,10859.471,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5173.762255,16545.556,,,,
Lymphoma And Leukemia With Major O.R. Procedures With McC,820,MS-DRG,,,,,,,inpatient,,,86514.51,60560.157,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,117974.9816,,,,
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,inpatient,,,70253.02,49177.114,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,56202.416,,,,
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/McC,822,MS-DRG,,,,,,,inpatient,,,27823.59,19476.513,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,23173.9104,,,,
Lymphoma And Non-Acute Leukemia With Other Procedures With McC,823,MS-DRG,,,,,,,inpatient,,,49236.57,34465.599,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,94819.3088,,,,
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/McC,825,MS-DRG,,,,,,,inpatient,,,56788.87,39752.209,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,45431.096,,,,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With McC,826,MS-DRG,,,,,,,inpatient,,,115032.85,80522.995,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,96764.6528,,,,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without Cc/McC,828,MS-DRG,,,,,,,inpatient,,,37373.35,26161.345,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,32479.1392,,,,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/McC,829,MS-DRG,,,,,,,inpatient,,,26899.5,18829.65,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,62486.0704,,,,
Other Antepartum Diagnoses Without O.R. Procedures With McC,831,MS-DRG,,,,,,,inpatient,,,8108.51,5675.957,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2704.188085,23321.8376,,,,
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,inpatient,,,9811.14,6867.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3272.01519,15143.2872,,,,
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/McC,833,MS-DRG,,,,,,,inpatient,,,8494.15,5945.905,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2832.799025,10533.2272,,,,
Acute Leukemia Without Major O.R. Procedures With McC,834,MS-DRG,,,,,,,inpatient,,,33540.42,23478.294,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,111997.1016,,,,
Acute Leukemia Without Major O.R. Procedures With Cc,835,MS-DRG,,,,,,,inpatient,,,15922.85,11145.995,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5310.270475,43279.8512,,,,
Lymphoma And Non-Acute Leukemia With McC,840,MS-DRG,,,,,,,inpatient,,,35119.86,24583.902,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,64630.0016,,,,
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,inpatient,,,17465.46,12225.822,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5824.73091,31771.9256,,,,
Lymphoma And Non-Acute Leukemia Without Cc/McC,842,MS-DRG,,,,,,,inpatient,,,22518.92,15763.244,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7510.05982,21313.6752,,,,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With McC,843,MS-DRG,,,,,,,inpatient,,,21080.37,14756.259,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7030.303395,38361.7784,,,,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,inpatient,,,11557.79,8090.453,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3854.522965,24217.5064,,,,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/McC,845,MS-DRG,,,,,,,inpatient,,,13919.38,9743.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4642.11323,16954.8888,,,,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With McC,846,MS-DRG,,,,,,,inpatient,,,22506.34,15754.438,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7505.86439,51746.1504,,,,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,inpatient,,,14849.65,10394.755,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4952.358275,25747.4384,,,,
Infectious And Parasitic Diseases With O.R. Procedures With McC,853,MS-DRG,,,,,,,inpatient,,,91139.43,63797.601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,101350.396,,,,
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,inpatient,,,41334.13,28933.891,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,40491.5248,,,,
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/McC,855,MS-DRG,,,,,,,inpatient,,,41292.75,28904.925,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,33034.2,,,,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With McC,856,MS-DRG,,,,,,,inpatient,,,65177.47,45624.229,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,91416.9832,,,,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,inpatient,,,33908.27,23735.789,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,44153.2296,,,,
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/McC,858,MS-DRG,,,,,,,inpatient,,,18266.15,12786.305,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6091.761025,26108.1376,,,,
Postoperative And Post-Traumatic Infections With McC,862,MS-DRG,,,,,,,inpatient,,,32409.02,22686.314,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,37257.3904,,,,
Postoperative And Post-Traumatic Infections Without McC,863,MS-DRG,,,,,,,inpatient,,,26972.96,18881.072,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7071.87,21578.368,,,,
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,inpatient,,,18759.94,13131.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6256.43999,18195.0456,,,,
Viral Illness With McC,865,MS-DRG,,,,,,,inpatient,,,22475.35,15732.745,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7495.529225,29907.6376,,,,
Viral Illness Without McC,866,MS-DRG,,,,,,,inpatient,,,13589.18,9512.426,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4531.99153,17927.5608,,,,
Other Infectious And Parasitic Diseases Diagnoses With McC,867,MS-DRG,,,,,,,inpatient,,,29124.07,20386.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,43450.0688,,,,
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,inpatient,,,22783.92,15948.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7598.43732,21277.2,,,,
Other Infectious And Parasitic Diseases Diagnoses Without Cc/McC,869,MS-DRG,,,,,,,inpatient,,,6491.58,4544.106,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2164.94193,14579.948,,,,
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,inpatient,,,165811.55,116068.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,140966.516,,,,
Septicemia Or Severe Sepsis Without Mv >96 Hours With McC,871,MS-DRG,,,,,,,inpatient,,,32860.99,23002.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,39764.0472,,,,
Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC,872,MS-DRG,,,,,,,inpatient,,,22133.41,15493.387,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7381.492235,20892.184,,,,
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,,,inpatient,,,167914.64,117540.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,134331.712,,,,
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,inpatient,,,22889.31,16022.517,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6248.48,19425.0704,,,,
Depressive Neuroses,881,MS-DRG,,,,,,,inpatient,,,44762.95,31334.065,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5798.441546,35810.36,,,,
Neuroses Except Depressive,882,MS-DRG,,,,,,,inpatient,,,10863.25,7604.275,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3622.893875,19491.9416,,,,
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,inpatient,,,35747.4,25023.18,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,33842.9064,,,,
Psychoses,885,MS-DRG,,,,,,,inpatient,,,20082.8,14057.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6697.6138,28562.108,,,,
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,inpatient,,,10508,7355.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3504.418,36402.2496,,,,
Alcohol- Drug Abuse Or Dependence- Left Ama,894,MS-DRG,,,,,,,inpatient,,,15836.23,11085.361,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3961.38,12668.984,,,,
Alcohol- Drug Abuse Or Dependence Without Rehabilitation Therapy With McC,896,MS-DRG,,,,,,,inpatient,,,35553.78,24887.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,36086.1312,,,,
Alcohol- Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC,897,MS-DRG,,,,,,,inpatient,,,18541.81,12979.267,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5972.81,17876.9008,,,,
Wound Debridements For Injuries With McC,901,MS-DRG,,,,,,,inpatient,,,46387.19,32471.033,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,89773.5728,,,,
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,inpatient,,,59864.86,41905.402,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,47891.888,,,,
Wound Debridements For Injuries Without Cc/McC,903,MS-DRG,,,,,,,inpatient,,,13693.85,9585.695,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4566.898975,24701.816,,,,
Skin Grafts For Injuries With Cc/McC,904,MS-DRG,,,,,,,inpatient,,,114417.1,80091.97,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,91533.68,,,,
Hand Procedures For Injuries,906,MS-DRG,,,,,,,inpatient,,,51389.12,35972.384,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,44224.1536,,,,
Other O.R. Procedures For Injuries With McC,907,MS-DRG,,,,,,,inpatient,,,48914.02,34239.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,80721.644,,,,
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,inpatient,,,44494.39,31146.073,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,40872.488,,,,
Other O.R. Procedures For Injuries Without Cc/McC,909,MS-DRG,,,,,,,inpatient,,,14125.93,9888.151,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4710.997655,25698.8048,,,,
Traumatic Injury With McC,913,MS-DRG,,,,,,,inpatient,,,57017.38,39912.166,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,45613.904,,,,
Traumatic Injury Without McC,914,MS-DRG,,,,,,,inpatient,,,28970.93,20279.651,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6429.37,23176.744,,,,
Allergic Reactions With McC,915,MS-DRG,,,,,,,inpatient,,,42664.44,29865.108,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,35214.7792,,,,
Allergic Reactions Without McC,916,MS-DRG,,,,,,,inpatient,,,12818.09,8972.663,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4274.833015,13455.296,,,,
Poisoning And Toxic Effects Of Drugs With McC,917,MS-DRG,,,,,,,inpatient,,,41573.69,29101.583,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,33258.952,,,,
Poisoning And Toxic Effects Of Drugs Without McC,918,MS-DRG,,,,,,,inpatient,,,19845.67,13891.969,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5723.92,17921.4816,,,,
Complications Of Treatment With McC,919,MS-DRG,,,,,,,inpatient,,,48229.35,33760.545,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,38583.48,,,,
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,inpatient,,,20650.21,14455.147,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6886.845035,20584.1712,,,,
Complications Of Treatment Without Cc/McC,921,MS-DRG,,,,,,,inpatient,,,18737.44,13116.208,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5002.55,14989.952,,,,
Other Injury- Poisoning And Toxic Effect Diagnoses With McC,922,MS-DRG,,,,,,,inpatient,,,42436.37,29705.459,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,34229.9488,,,,
Other Injury- Poisoning And Toxic Effect Diagnoses Without McC,923,MS-DRG,,,,,,,inpatient,,,18119.88,12683.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6042.97998,20665.2272,,,,
Non-Extensive Burns,935,MS-DRG,,,,,,,inpatient,,,6946.99,4862.893,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2316.821165,44505.8232,,,,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,inpatient,,,22686.24,15880.368,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7565.86104,42783.3832,,,,
Signs And Symptoms With McC,947,MS-DRG,,,,,,,inpatient,,,29399.47,20579.629,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,26061.5304,,,,
Signs And Symptoms Without McC,948,MS-DRG,,,,,,,inpatient,,,16042.18,11229.526,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5350.06703,16099.748,,,,
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,inpatient,,,5109.91,3576.937,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1704.154985,11487.6616,,,,
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,,,inpatient,,,149455.54,104618.878,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,138360.5656,,,,
Limb Reattachment- Hip And Femur Procedures For Multiple Significant Trauma,956,MS-DRG,,,,,,,inpatient,,,64530.82,45171.574,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,77453.0608,,,,
Other O.R. Procedures For Multiple Significant Trauma With McC,957,MS-DRG,,,,,,,inpatient,,,104697.23,73288.061,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,151244.4168,,,,
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,inpatient,,,68495.96,47947.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,83274.908,,,,
Other Multiple Significant Trauma With McC,963,MS-DRG,,,,,,,inpatient,,,43017.73,30112.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,55049.1824,,,,
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,inpatient,,,32958.94,23071.258,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,30400.0528,,,,
Hiv With Major Related Condition With McC,974,MS-DRG,,,,,,,inpatient,,,42445.87,29712.109,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,60508.304,,,,
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,,,inpatient,,,19415.36,13590.752,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6475.02256,28801.2232,,,,
Hiv With Major Related Condition Without Cc/McC,976,MS-DRG,,,,,,,inpatient,,,36673.45,25671.415,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6867.108649,29338.76,,,,
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,inpatient,,,53209.61,37246.727,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,42567.688,,,,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC,981,MS-DRG,,,,,,,inpatient,,,96543.58,67580.506,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,96341.1352,,,,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,inpatient,,,54470.12,38129.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,49616.404,,,,
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/McC,983,MS-DRG,,,,,,,inpatient,,,18703.75,13092.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6237.700625,33802.3784,,,,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC,987,MS-DRG,,,,,,,inpatient,,,51141.58,35799.106,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,70984.792,,,,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,inpatient,,,31104,21772.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,34773.024,,,,
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,,,inpatient,,,13700.33,9590.231,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4569.060055,10960.264,,,,
Ungroupable,999,MS-DRG,,,,,,,inpatient,,,28509.33,19956.531,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7771.48,22807.464,,,,
LIVER TRANSPLANT &/OR INTESTINAL TRANSPLANT,1-Jan,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,133764.1397,,,133764.1397,103405.0931,149414.3361,case rate,,,
LIVER TRANSPLANT &/OR INTESTINAL TRANSPLANT,2-Jan,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,146420.7796,,,146420.7796,119539.9493,155243.7215,case rate,,,
LIVER TRANSPLANT &/OR INTESTINAL TRANSPLANT,3-Jan,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,182462.9492,,,182462.9492,142112.4189,182462.9492,case rate,,,
LIVER TRANSPLANT &/OR INTESTINAL TRANSPLANT,4-Jan,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,356163.0583,,,356163.0583,226313.5322,358242.4353,case rate,,,
HEART &/OR LUNG TRANSPLANT,1-Feb,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,181680.7104,,,181680.7104,142837.3308,196067.4461,case rate,,,
HEART &/OR LUNG TRANSPLANT,2-Feb,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,202322.9873,,,202322.9873,166618.3992,253130.9776,case rate,,,
HEART &/OR LUNG TRANSPLANT,3-Feb,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,260985.9824,,,260985.9824,234168.8061,315100.0259,case rate,,,
HEART &/OR LUNG TRANSPLANT,4-Feb,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,425881.9225,,,425881.9225,425881.9225,555938.1417,case rate,,,
BONE MARROW TRANSPLANT,1-Mar,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,92529.88267,,,92529.88267,92529.88267,92529.88267,case rate,,,
BONE MARROW TRANSPLANT,2-Mar,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,128648.651,,,128648.651,128648.651,128648.651,case rate,,,
BONE MARROW TRANSPLANT,3-Mar,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,211522.2079,,,211522.2079,211522.2079,211522.2079,case rate,,,
BONE MARROW TRANSPLANT,4-Mar,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,401490.6372,,,401490.6372,401490.6372,401490.6372,case rate,,,
TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE OR ECMO,1-Apr,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,132148.001,,,132148.001,79313.52487,138057.5126,case rate,,,
TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE OR ECMO,2-Apr,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,146832.9447,,,146832.9447,114964.0976,168236.4684,case rate,,,
TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE OR ECMO,3-Apr,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,201018.099,,,201018.099,152444.2688,229698.5157,case rate,,,
TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE OR ECMO,4-Apr,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,303583.269,,,303583.269,229192.1499,327380.718,case rate,,,
TRACHEOSTOMY W MV 96+ HOURS W/O EXTENSIVE PROCEDURE,1-May,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,97435.7779,,,97435.7779,74467.9961,103545.3878,case rate,,,
TRACHEOSTOMY W MV 96+ HOURS W/O EXTENSIVE PROCEDURE,2-May,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,108263.6562,,,108263.6562,82840.35727,126757.0225,case rate,,,
TRACHEOSTOMY W MV 96+ HOURS W/O EXTENSIVE PROCEDURE,3-May,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,140374.1479,,,140374.1479,100813.4712,159926.1579,case rate,,,
TRACHEOSTOMY W MV 96+ HOURS W/O EXTENSIVE PROCEDURE,4-May,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,210366.6853,,,210366.6853,147899.3435,217638.6507,case rate,,,
PANCREAS TRANSPLANT,1-Jun,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,127154.4325,,,127154.4325,98346.79155,172141.5032,case rate,,,
PANCREAS TRANSPLANT,2-Jun,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,166559.7875,,,166559.7875,122912.1503,174392.5878,case rate,,,
PANCREAS TRANSPLANT,3-Jun,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,171673.7113,,,171673.7113,142933.8207,192809.1193,case rate,,,
PANCREAS TRANSPLANT,4-Jun,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,266151.9885,,,266151.9885,214875.7587,298355.4712,case rate,,,
"EAR, NOSE, MOUTH, THROAT, CRANIAL/FACIAL MALIGNANCIES",110-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11983.24044,,,11983.24044,7804.554759,17174.7516,case rate,,,
"EAR, NOSE, MOUTH, THROAT, CRANIAL/FACIAL MALIGNANCIES",110-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16137.63269,,,16137.63269,10054.75053,19969.08136,case rate,,,
"EAR, NOSE, MOUTH, THROAT, CRANIAL/FACIAL MALIGNANCIES",110-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24032.64717,,,24032.64717,18364.0221,36768.202,case rate,,,
"EAR, NOSE, MOUTH, THROAT, CRANIAL/FACIAL MALIGNANCIES",110-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,51808.26389,,,51808.26389,29642.21606,75209.4764,case rate,,,
VERTIGO & OTHER LABYRINTH DISORDERS,111-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9912.323894,,,9912.323894,4173.810074,13335.366,case rate,,,
VERTIGO & OTHER LABYRINTH DISORDERS,111-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11053.94315,,,11053.94315,5069.434998,15320.0484,case rate,,,
VERTIGO & OTHER LABYRINTH DISORDERS,111-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14226.4341,,,14226.4341,7409.93549,18497.04,case rate,,,
VERTIGO & OTHER LABYRINTH DISORDERS,111-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26795.70161,,,26795.70161,16098.398,32429.8104,case rate,,,
INFECTIONS OF UPPER RESPIRATORY TRACT,113-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5418.112181,,,5418.112181,3541.677013,8046.0892,case rate,,,
INFECTIONS OF UPPER RESPIRATORY TRACT,113-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8064.36246,,,8064.36246,5316.845198,11833.1064,case rate,,,
INFECTIONS OF UPPER RESPIRATORY TRACT,113-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13989.95683,,,13989.95683,9272.934296,17242.2408,case rate,,,
INFECTIONS OF UPPER RESPIRATORY TRACT,113-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,31672.92746,,,31672.92746,20706.99669,43255.2448,case rate,,,
DENTAL & ORAL DISEASES & INJURIES,114-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8316.72927,,,8316.72927,4800.994931,9924.4084,case rate,,,
DENTAL & ORAL DISEASES & INJURIES,114-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12258.43843,,,12258.43843,5801.76919,13095.4044,case rate,,,
DENTAL & ORAL DISEASES & INJURIES,114-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20430.87785,,,20430.87785,12922.23475,24874.2536,case rate,,,
DENTAL & ORAL DISEASES & INJURIES,114-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,46078.94144,,,46078.94144,22504.43179,51689.32038,case rate,,,
"OTHER EAR, NOSE, MOUTH,THROAT & CRANIAL/FACIAL DIAGNOSES",115-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8763.080871,,,8763.080871,5154.791517,11040.7332,case rate,,,
"OTHER EAR, NOSE, MOUTH,THROAT & CRANIAL/FACIAL DIAGNOSES",115-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12607.98823,,,12607.98823,7210.770279,15257.5584,case rate,,,
"OTHER EAR, NOSE, MOUTH,THROAT & CRANIAL/FACIAL DIAGNOSES",115-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18056.39486,,,18056.39486,11860.84499,23439.22188,case rate,,,
"OTHER EAR, NOSE, MOUTH,THROAT & CRANIAL/FACIAL DIAGNOSES",115-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,40837.39976,,,40837.39976,23846.63213,54355.1576,case rate,,,
MAJOR RESPIRATORY & CHEST PROCEDURES,120-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,33493.64395,,,33493.64395,16750.90759,44865.3204,case rate,,,
MAJOR RESPIRATORY & CHEST PROCEDURES,120-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,41466.07981,,,41466.07981,22197.64314,55086.1848,case rate,,,
MAJOR RESPIRATORY & CHEST PROCEDURES,120-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,63315.25953,,,63315.25953,35911.59053,74813.028,case rate,,,
MAJOR RESPIRATORY & CHEST PROCEDURES,120-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,119694.5145,,,119694.5145,76282.74992,130499.1168,case rate,,,
OTHER RESPIRATORY & CHEST PROCEDURES,121-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22882.50133,,,22882.50133,12586.99393,32674.7712,case rate,,,
OTHER RESPIRATORY & CHEST PROCEDURES,121-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29728.46516,,,29728.46516,16524.52726,42243.24,case rate,,,
OTHER RESPIRATORY & CHEST PROCEDURES,121-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50804.15335,,,50804.15335,32257.34188,64252.218,case rate,,,
OTHER RESPIRATORY & CHEST PROCEDURES,121-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,111072.2727,,,111072.2727,50793.31406,125575.7972,case rate,,,
RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS,130-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,59760.3162,,,59760.3162,44137.97968,78087.504,case rate,,,
RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS,130-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,66401.02008,,,66401.02008,44144.16494,78105.0012,case rate,,,
RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS,130-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,73780.68785,,,73780.68785,50414.77645,95607.2004,case rate,,,
RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS,130-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,105318.0928,,,105318.0928,64377.37109,125901.2896,case rate,,,
CYSTIC FIBROSIS - PULMONARY DISEASE,131-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,25363.77727,,,25363.77727,18351.65159,28610.16,case rate,,,
CYSTIC FIBROSIS - PULMONARY DISEASE,131-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,30660.06965,,,30660.06965,30617.01225,37344.57067,case rate,,,
CYSTIC FIBROSIS - PULMONARY DISEASE,131-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,40575.76405,,,40575.76405,33589.6458,52937.0888,case rate,,,
CYSTIC FIBROSIS - PULMONARY DISEASE,131-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,57086.01847,,,57086.01847,47173.70283,71140.134,case rate,,,
BPD & OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,132-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8412.10663,,,8412.10663,6492.043648,12236.0264,case rate,,,
BPD & OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,132-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11399.84156,,,11399.84156,9144.280992,16260.1076,case rate,,,
BPD & OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,132-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18082.29561,,,18082.29561,18082.29561,27318.5564,case rate,,,
BPD & OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,132-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,36102.79858,,,36102.79858,27233.67777,49773.3856,case rate,,,
PULMONARY EDEMA & RESPIRATORY FAILURE,133-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10705.87798,,,10705.87798,6645.437972,19104.538,case rate,,,
PULMONARY EDEMA & RESPIRATORY FAILURE,133-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13948.58785,,,13948.58785,7074.694669,19143.9288,case rate,,,
PULMONARY EDEMA & RESPIRATORY FAILURE,133-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21337.36402,,,21337.36402,12283.91643,28336.4976,case rate,,,
PULMONARY EDEMA & RESPIRATORY FAILURE,133-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,36411.80196,,,36411.80196,20103.3158,44045.4516,case rate,,,
PULMONARY EMBOLISM,134-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13023.10244,,,13023.10244,4556.058833,14609.8404,case rate,,,
PULMONARY EMBOLISM,134-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16925.34857,,,16925.34857,6642.96387,19386.4932,case rate,,,
PULMONARY EMBOLISM,134-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24680.86814,,,24680.86814,10252.67869,31292.8808,case rate,,,
PULMONARY EMBOLISM,134-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,43757.78471,,,43757.78471,17673.74764,52999.2848,case rate,,,
MAJOR CHEST & RESPIRATORY TRAUMA,135-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13136.51604,,,13136.51604,6071.446308,16967.2848,case rate,,,
MAJOR CHEST & RESPIRATORY TRAUMA,135-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16566.85088,,,16566.85088,7148.917729,19744.3404,case rate,,,
MAJOR CHEST & RESPIRATORY TRAUMA,135-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24477.35364,,,24477.35364,10658.43142,28322.9676,case rate,,,
MAJOR CHEST & RESPIRATORY TRAUMA,135-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45321.31938,,,45321.31938,19730.96345,47714.8644,case rate,,,
RESPIRATORY MALIGNANCY,136-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11995.4786,,,11995.4786,6234.73704,16070.80662,case rate,,,
RESPIRATORY MALIGNANCY,136-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15684.19901,,,15684.19901,8144.743784,20394.2364,case rate,,,
RESPIRATORY MALIGNANCY,136-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,25303.89056,,,25303.89056,12849.24874,32335.7004,case rate,,,
RESPIRATORY MALIGNANCY,136-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,41580.2959,,,41580.2959,20995.22957,47550.9152,case rate,,,
MAJOR RESPIRATORY INFECTIONS & INFLAMMATIONS,137-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13163.46004,,,13163.46004,5451.683757,15065.0892,case rate,,,
MAJOR RESPIRATORY INFECTIONS & INFLAMMATIONS,137-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15996.31209,,,15996.31209,7466.839836,21370.5456,case rate,,,
MAJOR RESPIRATORY INFECTIONS & INFLAMMATIONS,137-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24869.97774,,,24869.97774,9037.894606,34763.4176,case rate,,,
MAJOR RESPIRATORY INFECTIONS & INFLAMMATIONS,137-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,43009.15068,,,43009.15068,15549.73107,54154.0572,case rate,,,
BRONCHIOLITIS & RSV PNEUMONIA,138-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5479.844645,,,5479.844645,3455.083443,10110.9964,case rate,,,
BRONCHIOLITIS & RSV PNEUMONIA,138-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7681.629203,,,7681.629203,5805.480343,13067.3796,case rate,,,
BRONCHIOLITIS & RSV PNEUMONIA,138-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16451.21034,,,16451.21034,7324.578971,28295.0336,case rate,,,
BRONCHIOLITIS & RSV PNEUMONIA,138-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,40297.37611,,,40297.37611,13445.50732,62687.3484,case rate,,,
OTHER PNEUMONIA,139-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7853.605377,,,7853.605377,4274.011205,11010.738,case rate,,,
OTHER PNEUMONIA,139-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11315.33811,,,11315.33811,5524.669766,15272.556,case rate,,,
OTHER PNEUMONIA,139-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18846.77906,,,18846.77906,8252.367221,23595.0892,case rate,,,
OTHER PNEUMONIA,139-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,37611.5023,,,37611.5023,13963.83169,44984.2936,case rate,,,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE,140-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9536.411904,,,9536.411904,4930.885286,13080.4068,case rate,,,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE,140-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12064.27308,,,12064.27308,6179.069745,16109.922,case rate,,,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE,140-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17107.83752,,,17107.83752,7526.218284,20987.0036,case rate,,,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE,140-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,35693.84357,,,35693.84357,12126.81095,40850.3328,case rate,,,
ASTHMA,141-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6921.59964,,,6921.59964,4437.301937,9818.6752,case rate,,,
ASTHMA,141-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10231.77987,,,10231.77987,5702.80511,13912.7736,case rate,,,
ASTHMA,141-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15603.58769,,,15603.58769,7042.531343,19440.3964,case rate,,,
ASTHMA,141-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,28336.68598,,,28336.68598,11905.37882,34247.1908,case rate,,,
INTERSTITIAL & ALVEOLAR LUNG DISEASES,142-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12477.30079,,,12477.30079,6514.310566,15147.576,case rate,,,
INTERSTITIAL & ALVEOLAR LUNG DISEASES,142-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14974.84745,,,14974.84745,8622.24547,17837.1456,case rate,,,
INTERSTITIAL & ALVEOLAR LUNG DISEASES,142-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21937.97656,,,21937.97656,11563.95275,27590.1456,case rate,,,
INTERSTITIAL & ALVEOLAR LUNG DISEASES,142-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,43126.57678,,,43126.57678,17954.55821,57668.1312,case rate,,,
"OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS, SYMPTOMS & MINOR DIAGNOSES",143-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8723.577711,,,8723.577711,5546.936684,12253.0392,case rate,,,
"OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS, SYMPTOMS & MINOR DIAGNOSES",143-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13473.28599,,,13473.28599,7136.547219,17362.2216,case rate,,,
"OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS, SYMPTOMS & MINOR DIAGNOSES",143-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21890.52864,,,21890.52864,11880.6378,26595.0096,case rate,,,
"OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS, SYMPTOMS & MINOR DIAGNOSES",143-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,38264.05678,,,38264.05678,18578.03192,42660.2364,case rate,,,
"RESPIRATORY SIGNS, SYMPTOMS & MINOR DIAGNOSES",144-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8588.155502,,,8588.155502,5226.540475,11890.5972,case rate,,,
"RESPIRATORY SIGNS, SYMPTOMS & MINOR DIAGNOSES",144-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10771.40226,,,10771.40226,6706.053471,15649.9956,case rate,,,
"RESPIRATORY SIGNS, SYMPTOMS & MINOR DIAGNOSES",144-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15710.32045,,,15710.32045,10366.48738,22108.962,case rate,,,
"RESPIRATORY SIGNS, SYMPTOMS & MINOR DIAGNOSES",144-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29959.76629,,,29959.76629,14954.70954,38556.33,case rate,,,
MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,160-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,56987.81229,,,56987.81229,32815.25188,74752.23481,case rate,,,
MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,160-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,64958.44252,,,64958.44252,47755.1168,87402.47434,case rate,,,
MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,160-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,91863.36465,,,91863.36465,80727.47416,132108.8592,case rate,,,
MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,160-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,208329.5943,,,208329.5943,206156.9348,247472.8459,case rate,,,
CARDIAC DEFIBRILLATOR & HEART ASSIST IMPLANT,161-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,79731.80178,,,79731.80178,79731.80178,339865.6128,case rate,,,
CARDIAC DEFIBRILLATOR & HEART ASSIST IMPLANT,161-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,105224.0396,,,105224.0396,105224.0396,357755.25,case rate,,,
CARDIAC DEFIBRILLATOR & HEART ASSIST IMPLANT,161-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,172491.9223,,,172491.9223,172491.9223,445571.1972,case rate,,,
CARDIAC DEFIBRILLATOR & HEART ASSIST IMPLANT,161-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,424790.8809,,,424790.8809,352820.5528,581606.928,case rate,,,
CARDIAC VALVE PROCEDURES W CARDIAC CATHETERIZATION,162-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,82152.32832,,,82152.32832,40249.92839,107445.306,case rate,,,
CARDIAC VALVE PROCEDURES W CARDIAC CATHETERIZATION,162-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95116.88824,,,95116.88824,46683.83064,125907.3516,case rate,,,
CARDIAC VALVE PROCEDURES W CARDIAC CATHETERIZATION,162-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,129195.1148,,,129195.1148,60055.1149,158864.5776,case rate,,,
CARDIAC VALVE PROCEDURES W CARDIAC CATHETERIZATION,162-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,205671.3466,,,205671.3466,91535.58875,231947.8824,case rate,,,
CARDIAC VALVE PROCEDURES W/O CARDIAC CATHETERIZATION,163-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,72797.7433,,,72797.7433,36385.38106,93974.9616,case rate,,,
CARDIAC VALVE PROCEDURES W/O CARDIAC CATHETERIZATION,163-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,79988.98361,,,79988.98361,36882.67557,103988.3592,case rate,,,
CARDIAC VALVE PROCEDURES W/O CARDIAC CATHETERIZATION,163-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,106225.6623,,,106225.6623,50725.27626,131396.4732,case rate,,,
CARDIAC VALVE PROCEDURES W/O CARDIAC CATHETERIZATION,163-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,191399.1097,,,191399.1097,83557.84685,197373.4152,case rate,,,
CORONARY BYPASS W CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE,165-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,67721.03552,,,67721.03552,44446.00538,91047.93,case rate,,,
CORONARY BYPASS W CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE,165-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,78082.01821,,,78082.01821,45162.25791,110872.2576,case rate,,,
CORONARY BYPASS W CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE,165-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,98883.47141,,,98883.47141,45972.52631,133306.1676,case rate,,,
CORONARY BYPASS W CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE,165-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,159236.9569,,,159236.9569,66108.00544,180493.6164,case rate,,,
CORONARY BYPASS W/O CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE,166-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,53046.80532,,,53046.80532,24844.93228,83816.5872,case rate,,,
CORONARY BYPASS W/O CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE,166-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,61224.42087,,,61224.42087,29920.55254,93327.5652,case rate,,,
CORONARY BYPASS W/O CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE,166-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,80640.27415,,,80640.27415,37668.20295,110829.7644,case rate,,,
CORONARY BYPASS W/O CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE,166-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,140876.8351,,,140876.8351,61902.03204,162698.964,case rate,,,
OTHER CARDIOTHORACIC PROCEDURES,167-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,54643.90463,,,54643.90463,32102.7105,70466.2236,case rate,,,
OTHER CARDIOTHORACIC PROCEDURES,167-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,63653.23324,,,63653.23324,33589.6458,73245.7788,case rate,,,
OTHER CARDIOTHORACIC PROCEDURES,167-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,84324.05918,,,84324.05918,53570.49356,110579.8044,case rate,,,
OTHER CARDIOTHORACIC PROCEDURES,167-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,158187.7257,,,158187.7257,99594.97601,177539.0892,case rate,,,
MAJOR THORACIC & ABDOMINAL VASCULAR PROCEDURES,169-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,32646.08148,,,32646.08148,25621.80031,70681.1892,case rate,,,
MAJOR THORACIC & ABDOMINAL VASCULAR PROCEDURES,169-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,44466.91559,,,44466.91559,33672.52822,71633.5368,case rate,,,
MAJOR THORACIC & ABDOMINAL VASCULAR PROCEDURES,169-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,74364.26729,,,74364.26729,40465.17526,93605.0208,case rate,,,
MAJOR THORACIC & ABDOMINAL VASCULAR PROCEDURES,169-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,143843.2235,,,143843.2235,68057.59782,152280.6312,case rate,,,
"PERMANENT CARDIAC PACEMAKER IMPLANT W AMI, HEART FAILURE OR SHOCK",170-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,43824.09144,,,43824.09144,34434.55164,56092.4992,case rate,,,
"PERMANENT CARDIAC PACEMAKER IMPLANT W AMI, HEART FAILURE OR SHOCK",170-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45671.19018,,,45671.19018,37556.86836,60215.364,case rate,,,
"PERMANENT CARDIAC PACEMAKER IMPLANT W AMI, HEART FAILURE OR SHOCK",170-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,56578.83722,,,56578.83722,44554.86587,76367.7792,case rate,,,
"PERMANENT CARDIAC PACEMAKER IMPLANT W AMI, HEART FAILURE OR SHOCK",170-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95002.55177,,,95002.55177,59987.07709,107377.8168,case rate,,,
"PERM CARDIAC PACEMAKER IMPLANT W/O AMI, HEART FAILURE OR SHOCK",171-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,30166.53093,,,30166.53093,15793.43012,39288.7128,case rate,,,
"PERM CARDIAC PACEMAKER IMPLANT W/O AMI, HEART FAILURE OR SHOCK",171-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,35250.80229,,,35250.80229,17834.56427,45050.2908,case rate,,,
"PERM CARDIAC PACEMAKER IMPLANT W/O AMI, HEART FAILURE OR SHOCK",171-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,46552.61823,,,46552.61823,22882.9694,61945.1428,case rate,,,
"PERM CARDIAC PACEMAKER IMPLANT W/O AMI, HEART FAILURE OR SHOCK",171-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,87035.09143,,,87035.09143,39432.23768,123641.5016,case rate,,,
OTHER VASCULAR PROCEDURES,173-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,34336.37134,,,34336.37134,34336.37134,34336.37134,case rate,,,
OTHER VASCULAR PROCEDURES,173-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,41618.29437,,,41618.29437,41618.29437,41618.29437,case rate,,,
OTHER VASCULAR PROCEDURES,173-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,59056.46177,,,59056.46177,59056.46177,59056.46177,case rate,,,
OTHER VASCULAR PROCEDURES,173-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,115277.042,,,115277.042,115277.042,115277.042,case rate,,,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES W AMI,174-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,37727.04252,,,37727.04252,13742.39956,48872.1792,case rate,,,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES W AMI,174-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,40824.3591,,,40824.3591,16797.91553,53031.5136,case rate,,,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES W AMI,174-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,52773.23239,,,52773.23239,22014.5596,65057.0892,case rate,,,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES W AMI,174-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,87926.43038,,,87926.43038,33365.73957,90917.9508,case rate,,,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES W/O AMI,175-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,34692.98316,,,34692.98316,18256.39866,49214.6244,case rate,,,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES W/O AMI,175-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,39419.27845,,,39419.27845,22254.54749,55626.0984,case rate,,,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES W/O AMI,175-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50881.75529,,,50881.75529,29002.6607,68651.514,case rate,,,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES W/O AMI,175-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,88783.26174,,,88783.26174,51064.22823,101808.6324,case rate,,,
CARDIAC PACEMAKER & DEFIBRILLATOR DEVICE REPLACEMENT,176-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26979.51469,,,26979.51469,10411.02122,40633.4976,case rate,,,
CARDIAC PACEMAKER & DEFIBRILLATOR DEVICE REPLACEMENT,176-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,52041.85215,,,52041.85215,17778.89697,54740.7728,case rate,,,
CARDIAC PACEMAKER & DEFIBRILLATOR DEVICE REPLACEMENT,176-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,57509.29814,,,57509.29814,31694.48367,74680.5492,case rate,,,
CARDIAC PACEMAKER & DEFIBRILLATOR DEVICE REPLACEMENT,176-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,102401.4194,,,102401.4194,71004.2533,123690.2064,case rate,,,
CARDIAC PACEMAKER & DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,177-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22642.83412,,,22642.83412,10907.07867,29112.8412,case rate,,,
CARDIAC PACEMAKER & DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,177-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29048.06386,,,29048.06386,15745.18513,42025.7748,case rate,,,
CARDIAC PACEMAKER & DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,177-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45631.28577,,,45631.28577,21154.80915,56468.4636,case rate,,,
CARDIAC PACEMAKER & DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,177-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,93471.09712,,,93471.09712,29189.4554,131328.9272,case rate,,,
OTHER CIRCULATORY SYSTEM PROCEDURES,180-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21970.43777,,,21970.43777,12224.53798,28537.9332,case rate,,,
OTHER CIRCULATORY SYSTEM PROCEDURES,180-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29824.68515,,,29824.68515,14166.70805,35626.7988,case rate,,,
OTHER CIRCULATORY SYSTEM PROCEDURES,180-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,46583.45437,,,46583.45437,23586.85142,50161.074,case rate,,,
OTHER CIRCULATORY SYSTEM PROCEDURES,180-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,91790.59779,,,91790.59779,48915.47064,99909.5812,case rate,,,
ACUTE MYOCARDIAL INFARCTION,190-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13490.41941,,,13490.41941,4908.618368,18979.4628,case rate,,,
ACUTE MYOCARDIAL INFARCTION,190-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16059.10787,,,16059.10787,6489.569546,20691.6888,case rate,,,
ACUTE MYOCARDIAL INFARCTION,190-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22754.70289,,,22754.70289,9506.736935,30077.9856,case rate,,,
ACUTE MYOCARDIAL INFARCTION,190-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,46216.06897,,,46216.06897,15969.09136,58323.2624,case rate,,,
CARDIAC CATHETERIZATION W CIRC DISORD EXC ISCHEMIC HEART DISEASE,191-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19667.05646,,,19667.05646,6754.29846,22648.8756,case rate,,,
CARDIAC CATHETERIZATION W CIRC DISORD EXC ISCHEMIC HEART DISEASE,191-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,23431.75375,,,23431.75375,8429.265514,26550.7512,case rate,,,
CARDIAC CATHETERIZATION W CIRC DISORD EXC ISCHEMIC HEART DISEASE,191-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,30840.31159,,,30840.31159,11964.75727,34479.4824,case rate,,,
CARDIAC CATHETERIZATION W CIRC DISORD EXC ISCHEMIC HEART DISEASE,191-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,70774.2145,,,70774.2145,23082.13461,70774.2145,case rate,,,
CARDIAC CATHETERIZATION FOR ISCHEMIC HEART DISEASE,192-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16744.02325,,,16744.02325,7564.566865,24296.112,case rate,,,
CARDIAC CATHETERIZATION FOR ISCHEMIC HEART DISEASE,192-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19347.07886,,,19347.07886,11895.48242,30232.662,case rate,,,
CARDIAC CATHETERIZATION FOR ISCHEMIC HEART DISEASE,192-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26635.48209,,,26635.48209,20402.68214,42398.2152,case rate,,,
CARDIAC CATHETERIZATION FOR ISCHEMIC HEART DISEASE,192-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,53728.81163,,,53728.81163,34344.24691,85359.8636,case rate,,,
ACUTE & SUBACUTE ENDOCARDITIS,193-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17413.39015,,,17413.39015,7518.795978,21391.2776,case rate,,,
ACUTE & SUBACUTE ENDOCARDITIS,193-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21827.4921,,,21827.4921,11648.07222,28570.7692,case rate,,,
ACUTE & SUBACUTE ENDOCARDITIS,193-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,35752.8074,,,35752.8074,15821.88229,44640.1424,case rate,,,
ACUTE & SUBACUTE ENDOCARDITIS,193-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,62225.62234,,,62225.62234,19017.18502,92551.7944,case rate,,,
HEART FAILURE,194-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9765.867283,,,9765.867283,5170.87318,12637.9776,case rate,,,
HEART FAILURE,194-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12292.28395,,,12292.28395,7424.780102,16587.3456,case rate,,,
HEART FAILURE,194-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19241.36929,,,19241.36929,10382.56904,26820.9884,case rate,,,
HEART FAILURE,194-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,40318.46185,,,40318.46185,16741.01118,59882.3088,case rate,,,
CARDIAC ARREST,196-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7495.769744,,,7495.769744,5052.116284,12142.7324,case rate,,,
CARDIAC ARREST,196-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9873.482798,,,9873.482798,6543.99979,13425.3516,case rate,,,
CARDIAC ARREST,196-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15218.2463,,,15218.2463,9109.643564,20909.154,case rate,,,
CARDIAC ARREST,196-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,35343.19033,,,35343.19033,18825.44212,43346.4656,case rate,,,
PERIPHERAL & OTHER VASCULAR DISORDERS,197-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9402.093135,,,9402.093135,5903.207372,12148.952,case rate,,,
PERIPHERAL & OTHER VASCULAR DISORDERS,197-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12953.04402,,,12953.04402,6915.11509,16425.9636,case rate,,,
PERIPHERAL & OTHER VASCULAR DISORDERS,197-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19607.51081,,,19607.51081,9851.874164,24482.4188,case rate,,,
PERIPHERAL & OTHER VASCULAR DISORDERS,197-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,46150.82555,,,46150.82555,22813.69454,59374.3748,case rate,,,
ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS,198-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8357.095119,,,8357.095119,4095.875861,11513.1576,case rate,,,
ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS,198-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9809.142202,,,9809.142202,4888.825552,13757.7984,case rate,,,
ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS,198-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13942.72959,,,13942.72959,6854.499591,18152.0952,case rate,,,
ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS,198-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,33022.9966,,,33022.9966,17462.21192,50185.9524,case rate,,,
HYPERTENSION,199-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8973.25614,,,8973.25614,4050.104974,12285.534,case rate,,,
HYPERTENSION,199-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10629.07854,,,10629.07854,5675.589988,15012.5976,case rate,,,
HYPERTENSION,199-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15425.89369,,,15425.89369,10229.17472,20679.1908,case rate,,,
HYPERTENSION,199-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,35452.73185,,,35452.73185,16997.08074,50924.0116,case rate,,,
CARDIAC STRUCTURAL & VALVULAR DISORDERS,200-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10476.80379,,,10476.80379,4220.818012,12210.83862,case rate,,,
CARDIAC STRUCTURAL & VALVULAR DISORDERS,200-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12137.16032,,,12137.16032,6976.96764,15610.002,case rate,,,
CARDIAC STRUCTURAL & VALVULAR DISORDERS,200-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17982.72518,,,17982.72518,11180.46694,25948.1712,case rate,,,
CARDIAC STRUCTURAL & VALVULAR DISORDERS,200-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45696.99062,,,45696.99062,20948.22163,81673.714,case rate,,,
CRANIOTOMY FOR TRAUMA,20-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,36238.9631,,,36238.9631,19805.18651,46704.93673,case rate,,,
CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS,201-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8299.194601,,,8299.194601,4022.889852,10910.754,case rate,,,
CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS,201-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10761.71205,,,10761.71205,5311.896994,14145.2364,case rate,,,
CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS,201-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16761.53786,,,16761.53786,9129.43638,22492.1468,case rate,,,
CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS,201-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,39591.43518,,,39591.43518,15520.04185,52659.28,case rate,,,
CRANIOTOMY FOR TRAUMA,20-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50079.97556,,,50079.97556,23978.99658,58278.08069,case rate,,,
CRANIOTOMY FOR TRAUMA,20-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,72299.22907,,,72299.22907,36220.85328,75333.59602,case rate,,,
CHEST PAIN,203-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8757.242669,,,8757.242669,3613.425971,11899.87798,case rate,,,
CHEST PAIN,203-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10316.10277,,,10316.10277,4734.194177,13795.2924,case rate,,,
CHEST PAIN,203-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13975.27104,,,13975.27104,7037.583139,17194.7484,case rate,,,
CHEST PAIN,203-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,31244.27103,,,31244.27103,16674.21043,48828.0064,case rate,,,
CRANIOTOMY FOR TRAUMA,20-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,138336.3145,,,138336.3145,62844.6649,138336.3145,case rate,,,
SYNCOPE & COLLAPSE,204-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10025.95817,,,10025.95817,4154.017258,13440.3492,case rate,,,
SYNCOPE & COLLAPSE,204-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11534.68196,,,11534.68196,5446.735553,15799.9716,case rate,,,
SYNCOPE & COLLAPSE,204-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15011.04029,,,15011.04029,7779.813739,20356.7424,case rate,,,
SYNCOPE & COLLAPSE,204-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,33717.34138,,,33717.34138,14922.54621,43966.3524,case rate,,,
CARDIOMYOPATHY,205-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8950.525271,,,8950.525271,5577.862959,12182.1232,case rate,,,
CARDIOMYOPATHY,205-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11805.22544,,,11805.22544,7204.585024,15472.2916,case rate,,,
CARDIOMYOPATHY,205-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18105.86911,,,18105.86911,9117.06587,30131.8888,case rate,,,
CARDIOMYOPATHY,205-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,51079.15071,,,51079.15071,20627.82543,51189.07935,case rate,,,
"MALFUNCTION,REACTION,COMPLICATION OF CARDIAC/VASC DEVICE OR PROCEDURE",206-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10403.71592,,,10403.71592,8209.070436,16381.76726,case rate,,,
"MALFUNCTION,REACTION,COMPLICATION OF CARDIAC/VASC DEVICE OR PROCEDURE",206-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13037.5876,,,13037.5876,8331.538485,16672.44786,case rate,,,
"MALFUNCTION,REACTION,COMPLICATION OF CARDIAC/VASC DEVICE OR PROCEDURE",206-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21621.69047,,,21621.69047,13368.81016,25794.7544,case rate,,,
"MALFUNCTION,REACTION,COMPLICATION OF CARDIAC/VASC DEVICE OR PROCEDURE",206-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50071.08785,,,50071.08785,21965.07756,70582.094,case rate,,,
OTHER CIRCULATORY SYSTEM DIAGNOSES,207-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9729.152817,,,9729.152817,4987.789632,12897.936,case rate,,,
OTHER CIRCULATORY SYSTEM DIAGNOSES,207-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13037.30673,,,13037.30673,7229.326044,16159.914,case rate,,,
OTHER CIRCULATORY SYSTEM DIAGNOSES,207-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19028.98714,,,19028.98714,10315.76829,24938.5228,case rate,,,
OTHER CIRCULATORY SYSTEM DIAGNOSES,207-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,39119.18283,,,39119.18283,19013.47387,52389.764,case rate,,,
CRANIOTOMY EXCEPT FOR TRAUMA,21-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,39480.1081,,,39480.1081,20275.26589,42930.59558,case rate,,,
CRANIOTOMY EXCEPT FOR TRAUMA,21-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,52692.52076,,,52692.52076,25641.59313,57433.07894,case rate,,,
CRANIOTOMY EXCEPT FOR TRAUMA,21-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,80728.16818,,,80728.16818,40677.94803,86872.93991,case rate,,,
CRANIOTOMY EXCEPT FOR TRAUMA,21-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,150116.9232,,,150116.9232,77535.88258,150116.9232,case rate,,,
"MAJOR STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES",220-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,25027.36844,,,25027.36844,11795.28129,34484.4816,case rate,,,
"MAJOR STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES",220-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,39501.87596,,,39501.87596,20573.39518,49487.0808,case rate,,,
"MAJOR STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES",220-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,66731.39008,,,66731.39008,39021.53674,75362.94,case rate,,,
"MAJOR STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES",220-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,133173.9998,,,133173.9998,106277.5255,146942.1964,case rate,,,
VENTRICULAR SHUNT PROCEDURES,22-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,23772.93747,,,23772.93747,13846.31184,27305.94988,case rate,,,
MAJOR SMALL & LARGE BOWEL PROCEDURES,221-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,25651.23348,,,25651.23348,25651.23348,30820.1912,case rate,,,
MAJOR SMALL & LARGE BOWEL PROCEDURES,221-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,33855.57234,,,33855.57234,33855.57234,39032.1364,case rate,,,
MAJOR SMALL & LARGE BOWEL PROCEDURES,221-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,56883.62747,,,56883.62747,56883.62747,64298.2248,case rate,,,
MAJOR SMALL & LARGE BOWEL PROCEDURES,221-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,120144.999,,,120144.999,120144.999,137003.2756,case rate,,,
VENTRICULAR SHUNT PROCEDURES,22-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,34540.42753,,,34540.42753,18145.06407,34540.42753,case rate,,,
"OTHER STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES",222-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15798.23454,,,15798.23454,9287.778908,18402.0552,case rate,,,
"OTHER STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES",222-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,23514.47164,,,23514.47164,15192.22333,31047.5316,case rate,,,
"OTHER STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES",222-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,41695.3145,,,41695.3145,25201.20297,46377.5784,case rate,,,
"OTHER STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES",222-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,100536.7258,,,100536.7258,58294.79132,114730.888,case rate,,,
VENTRICULAR SHUNT PROCEDURES,22-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,72268.15218,,,72268.15218,29328.00511,72268.15218,case rate,,,
OTHER SMALL & LARGE BOWEL PROCEDURES,223-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20441.33043,,,20441.33043,10002.79439,25325.9472,case rate,,,
OTHER SMALL & LARGE BOWEL PROCEDURES,223-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,27848.74471,,,27848.74471,15392.62559,38313.8688,case rate,,,
OTHER SMALL & LARGE BOWEL PROCEDURES,223-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,48413.62033,,,48413.62033,20923.48061,55153.3396,case rate,,,
OTHER SMALL & LARGE BOWEL PROCEDURES,223-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,105247.5127,,,105247.5127,37913.13905,115653.462,case rate,,,
VENTRICULAR SHUNT PROCEDURES,22-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,144481.9148,,,144481.9148,65519.16916,144481.9148,case rate,,,
PERITONEAL ADHESIOLYSIS,224-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22133.66667,,,22133.66667,11619.62004,30657.594,case rate,,,
PERITONEAL ADHESIOLYSIS,224-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,30581.92602,,,30581.92602,15476.74506,37911.4332,case rate,,,
PERITONEAL ADHESIOLYSIS,224-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,47808.03227,,,47808.03227,20085.99709,55018.5816,case rate,,,
PERITONEAL ADHESIOLYSIS,224-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,91264.63799,,,91264.63799,39683.35903,115448.2152,case rate,,,
APPENDECTOMY,225-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15077.02601,,,15077.02601,14927.04,15077.02601,case rate,,,
APPENDECTOMY,225-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20544.65256,,,20544.65256,20544.65256,22896.4208,case rate,,,
APPENDECTOMY,225-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,36466.5326,,,36466.5326,36466.5326,42061.0816,case rate,,,
APPENDECTOMY,225-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,74809.47533,,,74809.47533,74809.47533,84217.5304,case rate,,,
ANAL PROCEDURES,226-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12284.49968,,,12284.49968,8456.480636,20286.7536,case rate,,,
ANAL PROCEDURES,226-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17215.65366,,,17215.65366,12622.8684,26843.2044,case rate,,,
ANAL PROCEDURES,226-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29488.27632,,,29488.27632,16980.99908,39381.198,case rate,,,
ANAL PROCEDURES,226-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,60013.26482,,,60013.26482,40645.78471,80996.23441,case rate,,,
"HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL & UMBILICAL",227-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19097.54087,,,19097.54087,10607.71233,28880.3784,case rate,,,
"HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL & UMBILICAL",227-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24804.71426,,,24804.71426,14005.89142,36129.2184,case rate,,,
"HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL & UMBILICAL",227-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,42883.09768,,,42883.09768,21309.44053,51061.8288,case rate,,,
"HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL & UMBILICAL",227-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,90406.26181,,,90406.26181,45345.34146,109334.3484,case rate,,,
"INGUINAL, FEMORAL & UMBILICAL HERNIA PROCEDURES",228-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14305.52067,,,14305.52067,7252.830013,21943.9884,case rate,,,
"INGUINAL, FEMORAL & UMBILICAL HERNIA PROCEDURES",228-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18916.47636,,,18916.47636,9181.392522,28295.472,case rate,,,
"INGUINAL, FEMORAL & UMBILICAL HERNIA PROCEDURES",228-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,30302.07351,,,30302.07351,13930.43131,38531.334,case rate,,,
"INGUINAL, FEMORAL & UMBILICAL HERNIA PROCEDURES",228-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,70896.5158,,,70896.5158,31251.61941,92377.6456,case rate,,,
OTHER DIGESTIVE SYSTEM & ABDOMINAL PROCEDURES,229-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21059.91902,,,21059.91902,11359.83933,27510.5976,case rate,,,
OTHER DIGESTIVE SYSTEM & ABDOMINAL PROCEDURES,229-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,28861.04077,,,28861.04077,16394.6369,37928.9304,case rate,,,
OTHER DIGESTIVE SYSTEM & ABDOMINAL PROCEDURES,229-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,48100.66462,,,48100.66462,27792.82482,57270.8352,case rate,,,
OTHER DIGESTIVE SYSTEM & ABDOMINAL PROCEDURES,229-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,103640.4825,,,103640.4825,51088.96925,119971.9376,case rate,,,
SPINAL PROCEDURES,23-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,28462.03679,,,28462.03679,18366.4962,32752.26783,case rate,,,
SPINAL PROCEDURES,23-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,40147.91012,,,40147.91012,24527.01018,44471.87877,case rate,,,
SPINAL PROCEDURES,23-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,81964.34223,,,81964.34223,41133.1828,81964.34223,case rate,,,
SPINAL PROCEDURES,23-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,141447.2536,,,141447.2536,55129.17782,141447.2536,case rate,,,
DIGESTIVE MALIGNANCY,240-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13399.59625,,,13399.59625,8009.905225,17452.2072,case rate,,,
DIGESTIVE MALIGNANCY,240-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15778.57324,,,15778.57324,9018.10179,20171.772,case rate,,,
DIGESTIVE MALIGNANCY,240-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24439.7163,,,24439.7163,13940.32772,32827.0488,case rate,,,
DIGESTIVE MALIGNANCY,240-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,51030.88022,,,51030.88022,27582.52615,61654.8948,case rate,,,
EXTRACRANIAL VASCULAR PROCEDURES,24-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20879.97802,,,20879.97802,9246.956225,20879.97802,case rate,,,
PEPTIC ULCER & GASTRITIS,241-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10788.39524,,,10788.39524,5443.0244,14755.1388,case rate,,,
PEPTIC ULCER & GASTRITIS,241-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13575.54481,,,13575.54481,7158.814137,18367.0608,case rate,,,
PEPTIC ULCER & GASTRITIS,241-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20403.1514,,,20403.1514,11687.65785,26773.2156,case rate,,,
PEPTIC ULCER & GASTRITIS,241-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,51201.41189,,,51201.41189,26657.212,64884.9404,case rate,,,
EXTRACRANIAL VASCULAR PROCEDURES,24-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29326.31136,,,29326.31136,11849.71153,29326.31136,case rate,,,
MAJOR ESOPHAGEAL DISORDERS,242-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10136.34232,,,10136.34232,4658.734066,13460.346,case rate,,,
MAJOR ESOPHAGEAL DISORDERS,242-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13426.781,,,13426.781,6976.96764,17412.2136,case rate,,,
MAJOR ESOPHAGEAL DISORDERS,242-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20127.03053,,,20127.03053,10997.38339,25879.7556,case rate,,,
MAJOR ESOPHAGEAL DISORDERS,242-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,52692.70132,,,52692.70132,26074.56098,65413.6064,case rate,,,
EXTRACRANIAL VASCULAR PROCEDURES,24-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,58659.38379,,,58659.38379,21997.24088,58659.38379,case rate,,,
OTHER ESOPHAGEAL DISORDERS,243-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9138.43111,,,9138.43111,5304.474688,12677.9712,case rate,,,
OTHER ESOPHAGEAL DISORDERS,243-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11861.40058,,,11861.40058,6915.11509,16302.3912,case rate,,,
OTHER ESOPHAGEAL DISORDERS,243-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17940.57376,,,17940.57376,11024.59851,23763.6972,case rate,,,
OTHER ESOPHAGEAL DISORDERS,243-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,43395.43501,,,43395.43501,22461.13501,47656.6484,case rate,,,
EXTRACRANIAL VASCULAR PROCEDURES,24-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,122463.5476,,,122463.5476,47518.84006,122463.5476,case rate,,,
DIVERTICULITIS & DIVERTICULOSIS,244-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9754.913131,,,9754.913131,4678.526882,12745.4604,case rate,,,
DIVERTICULITIS & DIVERTICULOSIS,244-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12391.4732,,,12391.4732,6540.288637,16652.3352,case rate,,,
DIVERTICULITIS & DIVERTICULOSIS,244-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19424.60055,,,19424.60055,10845.22612,25178.4708,case rate,,,
DIVERTICULITIS & DIVERTICULOSIS,244-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45101.63447,,,45101.63447,19779.20844,63707.3628,case rate,,,
INFLAMMATORY BOWEL DISEASE,245-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11371.79412,,,11371.79412,6521.732872,13647.816,case rate,,,
INFLAMMATORY BOWEL DISEASE,245-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13693.89379,,,13693.89379,8877.077976,17404.7148,case rate,,,
INFLAMMATORY BOWEL DISEASE,245-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20953.50726,,,20953.50726,13804.25211,25253.6492,case rate,,,
INFLAMMATORY BOWEL DISEASE,245-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,41845.48268,,,41845.48268,24630.92246,50686.58497,case rate,,,
GASTROINTESTINAL VASCULAR INSUFFICIENCY,246-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12188.74114,,,12188.74114,4878.929144,14457.6864,case rate,,,
GASTROINTESTINAL VASCULAR INSUFFICIENCY,246-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14813.24361,,,14813.24361,6376.997905,18297.072,case rate,,,
GASTROINTESTINAL VASCULAR INSUFFICIENCY,246-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22282.37029,,,22282.37029,9554.981924,26800.2564,case rate,,,
GASTROINTESTINAL VASCULAR INSUFFICIENCY,246-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50018.98541,,,50018.98541,21514.79099,59117.298,case rate,,,
INTESTINAL OBSTRUCTION,247-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9249.035945,,,9249.035945,4421.220274,11575.6476,case rate,,,
INTESTINAL OBSTRUCTION,247-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11732.6592,,,11732.6592,6002.171452,14997.6,case rate,,,
INTESTINAL OBSTRUCTION,247-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18964.68667,,,18964.68667,10741.31383,24967.5476,case rate,,,
INTESTINAL OBSTRUCTION,247-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45704.75483,,,45704.75483,21418.30101,52984.7724,case rate,,,
MAJOR GASTROINTESTINAL & PERITONEAL INFECTIONS,248-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9776.560622,,,9776.560622,5063.249743,12750.4596,case rate,,,
MAJOR GASTROINTESTINAL & PERITONEAL INFECTIONS,248-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14060.11557,,,14060.11557,7340.660634,17547.5648,case rate,,,
MAJOR GASTROINTESTINAL & PERITONEAL INFECTIONS,248-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22381.07803,,,22381.07803,11489.72969,27343.4348,case rate,,,
MAJOR GASTROINTESTINAL & PERITONEAL INFECTIONS,248-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,48411.6542,,,48411.6542,19904.15059,67099.118,case rate,,,
"NON-BACTERIAL GASTROENTERITIS, NAUSEA & VOMITING",249-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7411.326473,,,7411.326473,4322.256194,10815.7692,case rate,,,
"NON-BACTERIAL GASTROENTERITIS, NAUSEA & VOMITING",249-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9603.119881,,,9603.119881,5654.560121,13520.3364,case rate,,,
"NON-BACTERIAL GASTROENTERITIS, NAUSEA & VOMITING",249-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14297.49565,,,14297.49565,9362.001968,19554.3708,case rate,,,
"NON-BACTERIAL GASTROENTERITIS, NAUSEA & VOMITING",249-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,37183.70856,,,37183.70856,19865.80201,41934.6164,case rate,,,
ABDOMINAL PAIN,251-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9168.063495,,,9168.063495,5001.397193,11383.1784,case rate,,,
ABDOMINAL PAIN,251-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11331.64896,,,11331.64896,5901.970321,14700.1476,case rate,,,
ABDOMINAL PAIN,251-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15888.51601,,,15888.51601,8885.737333,19404.3948,case rate,,,
ABDOMINAL PAIN,251-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,34293.35724,,,34293.35724,13706.52508,40143.3716,case rate,,,
"MALFUNCTION, REACTION & COMPLICATION OF GI DEVICE OR PROCEDURE",252-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10085.6242,,,10085.6242,7087.065179,13850.2836,case rate,,,
"MALFUNCTION, REACTION & COMPLICATION OF GI DEVICE OR PROCEDURE",252-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13478.48219,,,13478.48219,8288.2417,17144.7564,case rate,,,
"MALFUNCTION, REACTION & COMPLICATION OF GI DEVICE OR PROCEDURE",252-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22149.49602,,,22149.49602,13444.27027,25749.144,case rate,,,
"MALFUNCTION, REACTION & COMPLICATION OF GI DEVICE OR PROCEDURE",252-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50998.59958,,,50998.59958,33788.81101,58758.6344,case rate,,,
OTHER & UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,253-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10144.80872,,,10144.80872,5614.974489,13917.7728,case rate,,,
OTHER & UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,253-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13251.05313,,,13251.05313,7647.449282,17984.622,case rate,,,
OTHER & UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,253-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20298.04371,,,20298.04371,11075.3176,27712.4644,case rate,,,
OTHER & UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,253-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,44880.84611,,,44880.84611,20257.94718,49049.8388,case rate,,,
OTHER DIGESTIVE SYSTEM DIAGNOSES,254-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9275.418198,,,9275.418198,5711.464467,11923.092,case rate,,,
OTHER DIGESTIVE SYSTEM DIAGNOSES,254-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12567.8832,,,12567.8832,7617.760058,16644.8364,case rate,,,
OTHER DIGESTIVE SYSTEM DIAGNOSES,254-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18925.12332,,,18925.12332,12753.99581,25139.6232,case rate,,,
OTHER DIGESTIVE SYSTEM DIAGNOSES,254-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,44011.0744,,,44011.0744,23382.738,54071.1292,case rate,,,
"MAJOR PANCREAS, LIVER & SHUNT PROCEDURES",260-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,32748.8218,,,32748.8218,18315.77711,42770.6556,case rate,,,
"MAJOR PANCREAS, LIVER & SHUNT PROCEDURES",260-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,41179.9076,,,41179.9076,22749.36789,54218.8236,case rate,,,
"MAJOR PANCREAS, LIVER & SHUNT PROCEDURES",260-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,66199.65227,,,66199.65227,33478.31121,74310.6084,case rate,,,
"MAJOR PANCREAS, LIVER & SHUNT PROCEDURES",260-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,152399.9811,,,152399.9811,68009.35283,153966.198,case rate,,,
OTHER NERVOUS SYSTEM & RELATED PROCEDURES,26-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,25211.46239,,,25211.46239,14776.5742,29410.56758,case rate,,,
MAJOR BILIARY TRACT PROCEDURES,261-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24939.13334,,,24939.13334,17556.22779,35706.786,case rate,,,
MAJOR BILIARY TRACT PROCEDURES,261-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,36159.75615,,,36159.75615,20447.21598,46730.022,case rate,,,
MAJOR BILIARY TRACT PROCEDURES,261-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,53765.82703,,,53765.82703,28839.36996,64744.6392,case rate,,,
MAJOR BILIARY TRACT PROCEDURES,261-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,108923.5737,,,108923.5737,56363.75471,127306.9192,case rate,,,
OTHER NERVOUS SYSTEM & RELATED PROCEDURES,26-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,34042.51518,,,34042.51518,18644.83267,38218.86582,case rate,,,
CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC,262-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21620.58703,,,21620.58703,21620.58703,27235.6284,case rate,,,
CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC,262-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,28710.69202,,,28710.69202,28710.69202,33285.226,case rate,,,
CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC,262-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45464.62617,,,45464.62617,45464.62617,56743.484,case rate,,,
CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC,262-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,97548.58962,,,97548.58962,97548.58962,125503.2352,case rate,,,
OTHER NERVOUS SYSTEM & RELATED PROCEDURES,26-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50389.15951,,,50389.15951,30984.4164,54039.55192,case rate,,,
LAPAROSCOPIC CHOLECYSTECTOMY,263-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18050.11528,,,18050.11528,9202.422389,26193.3084,case rate,,,
LAPAROSCOPIC CHOLECYSTECTOMY,263-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,23258.35313,,,23258.35313,11789.09603,33202.1868,case rate,,,
LAPAROSCOPIC CHOLECYSTECTOMY,263-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,33681.04823,,,33681.04823,16421.85203,42120.7596,case rate,,,
LAPAROSCOPIC CHOLECYSTECTOMY,263-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,74727.27906,,,74727.27906,34638.66505,77732.5608,case rate,,,
OTHER NERVOUS SYSTEM & RELATED PROCEDURES,26-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,117561.0831,,,117561.0831,68867.86622,117561.0831,case rate,,,
"OTHER HEPATOBILIARY, PANCREAS & ABDOMINAL PROCEDURES",264-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26979.57488,,,26979.57488,14046.71411,32412.3132,case rate,,,
"OTHER HEPATOBILIARY, PANCREAS & ABDOMINAL PROCEDURES",264-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29636.29781,,,29636.29781,16510.9197,35461.8252,case rate,,,
"OTHER HEPATOBILIARY, PANCREAS & ABDOMINAL PROCEDURES",264-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50553.17085,,,50553.17085,23031.41552,59220.958,case rate,,,
"OTHER HEPATOBILIARY, PANCREAS & ABDOMINAL PROCEDURES",264-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,124541.8472,,,124541.8472,61248.86911,127597.1672,case rate,,,
HEPATIC COMA & OTHER MAJOR ACUTE LIVER DISORDERS,279-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9743.316977,,,9743.316977,5034.79757,12178.0512,case rate,,,
HEPATIC COMA & OTHER MAJOR ACUTE LIVER DISORDERS,279-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12877.54865,,,12877.54865,7568.278018,16218.6436,case rate,,,
HEPATIC COMA & OTHER MAJOR ACUTE LIVER DISORDERS,279-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21604.39655,,,21604.39655,11967.23137,28147.8364,case rate,,,
HEPATIC COMA & OTHER MAJOR ACUTE LIVER DISORDERS,279-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,62602.25658,,,62602.25658,27713.65355,76812.06,case rate,,,
ALCOHOLIC LIVER DISEASE,280-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10448.55572,,,10448.55572,5038.508723,12535.494,case rate,,,
ALCOHOLIC LIVER DISEASE,280-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12686.01149,,,12686.01149,6806.254602,16174.9116,case rate,,,
ALCOHOLIC LIVER DISEASE,280-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20242.06919,,,20242.06919,12098.35878,26271.5904,case rate,,,
ALCOHOLIC LIVER DISEASE,280-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,52937.46442,,,52937.46442,27156.9806,70743.8036,case rate,,,
MALIGNANCY OF HEPATOBILIARY SYSTEM & PANCREAS,281-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13305.86402,,,13305.86402,7709.301832,15295.65834,case rate,,,
MALIGNANCY OF HEPATOBILIARY SYSTEM & PANCREAS,281-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16906.40953,,,16906.40953,9416.432212,20184.27,case rate,,,
MALIGNANCY OF HEPATOBILIARY SYSTEM & PANCREAS,281-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24067.77669,,,24067.77669,13007.59127,28570.7692,case rate,,,
MALIGNANCY OF HEPATOBILIARY SYSTEM & PANCREAS,281-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,44115.19903,,,44115.19903,20094.65644,50140.342,case rate,,,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY,282-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10492.75351,,,10492.75351,4971.707969,12850.4436,case rate,,,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY,282-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13418.65567,,,13418.65567,7026.44968,16732.3224,case rate,,,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY,282-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,23224.32705,,,23224.32705,11528.07827,28234.9108,case rate,,,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY,282-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,65602.63092,,,65602.63092,29874.78165,71666.3776,case rate,,,
OTHER DISORDERS OF THE LIVER,283-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10595.17283,,,10595.17283,6150.617572,12145.5564,case rate,,,
OTHER DISORDERS OF THE LIVER,283-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13223.68781,,,13223.68781,7450.758173,15542.5128,case rate,,,
OTHER DISORDERS OF THE LIVER,283-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19832.83331,,,19832.83331,10999.85749,24971.694,case rate,,,
OTHER DISORDERS OF THE LIVER,283-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,46176.70624,,,46176.70624,23408.71607,53689.6604,case rate,,,
DISORDERS OF GALLBLADDER & BILIARY TRACT,284-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10999.67395,,,10999.67395,6745.639103,15552.5112,case rate,,,
DISORDERS OF GALLBLADDER & BILIARY TRACT,284-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14787.0018,,,14787.0018,9157.888553,20541.7128,case rate,,,
DISORDERS OF GALLBLADDER & BILIARY TRACT,284-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22102.00797,,,22102.00797,13476.43359,28450.4472,case rate,,,
DISORDERS OF GALLBLADDER & BILIARY TRACT,284-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,49937.91265,,,49937.91265,24994.61546,61453.7944,case rate,,,
HIP JOINT REPLACEMENT,301-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,30783.51451,,,30783.51451,30783.51451,38258.8328,case rate,,,
HIP JOINT REPLACEMENT,301-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,34094.31668,,,34094.31668,34094.31668,39761.9028,case rate,,,
HIP JOINT REPLACEMENT,301-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,47100.00483,,,47100.00483,47100.00483,52590.8644,case rate,,,
HIP JOINT REPLACEMENT,301-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,79491.27188,,,79491.27188,79491.27188,125505.3084,case rate,,,
KNEE JOINT REPLACEMENT,302-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,28871.83442,,,28871.83442,28871.83442,36759.9092,case rate,,,
KNEE JOINT REPLACEMENT,302-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,32754.07819,,,32754.07819,32754.07819,41476.4392,case rate,,,
KNEE JOINT REPLACEMENT,302-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,42988.16525,,,42988.16525,42988.16525,55843.7152,case rate,,,
KNEE JOINT REPLACEMENT,302-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,86380.10937,,,86380.10937,86380.10937,112840.1296,case rate,,,
DORSAL & LUMBAR FUSION PROC FOR CURVATURE OF BACK,303-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,89811.92884,,,89811.92884,46210.04011,101563.7472,case rate,,,
DORSAL & LUMBAR FUSION PROC FOR CURVATURE OF BACK,303-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,107486.2324,,,107486.2324,74849.00781,121987.9788,case rate,,,
DORSAL & LUMBAR FUSION PROC FOR CURVATURE OF BACK,303-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,153275.7716,,,153275.7716,89785.16158,167900.6316,case rate,,,
DORSAL & LUMBAR FUSION PROC FOR CURVATURE OF BACK,303-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,211667.6815,,,211667.6815,132386.7239,225864.774,case rate,,,
DORSAL & LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK,304-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,55619.56648,,,55619.56648,30469.80318,68644.0152,case rate,,,
DORSAL & LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK,304-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,66765.87761,,,66765.87761,37658.30654,81546.9504,case rate,,,
DORSAL & LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK,304-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,99400.82438,,,99400.82438,49603.271,115024.0932,case rate,,,
DORSAL & LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK,304-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,177041.6671,,,177041.6671,73919.98251,190365.3704,case rate,,,
AMPUTATION OF LOWER LIMB EXCEPT TOES,305-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20173.8164,,,20173.8164,12742.86235,28220.3984,case rate,,,
AMPUTATION OF LOWER LIMB EXCEPT TOES,305-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26898.32155,,,26898.32155,15330.77304,39745.3172,case rate,,,
AMPUTATION OF LOWER LIMB EXCEPT TOES,305-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,44668.6044,,,44668.6044,23719.21587,70113.5508,case rate,,,
AMPUTATION OF LOWER LIMB EXCEPT TOES,305-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,96438.95007,,,96438.95007,48347.66423,130648.9176,case rate,,,
HIP & FEMUR PROCEDURES FOR TRAUMA EXCEPT JOINT REPLACEMENT,308-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,23127.22431,,,23127.22431,12426.1773,34324.5072,case rate,,,
HIP & FEMUR PROCEDURES FOR TRAUMA EXCEPT JOINT REPLACEMENT,308-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,28365.61617,,,28365.61617,15106.86681,40488.5208,case rate,,,
HIP & FEMUR PROCEDURES FOR TRAUMA EXCEPT JOINT REPLACEMENT,308-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,40017.1023,,,40017.1023,19182.94986,56923.8524,case rate,,,
HIP & FEMUR PROCEDURES FOR TRAUMA EXCEPT JOINT REPLACEMENT,308-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,75417.65145,,,75417.65145,29528.40737,119598.7616,case rate,,,
HIP & FEMUR PROCEDURES FOR NON-TRAUMA EXCEPT JOINT REPLACEMENT,309-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22449.79227,,,22449.79227,16540.60892,33297.1716,case rate,,,
HIP & FEMUR PROCEDURES FOR NON-TRAUMA EXCEPT JOINT REPLACEMENT,309-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,31419.31677,,,31419.31677,21734.98607,44285.4132,case rate,,,
HIP & FEMUR PROCEDURES FOR NON-TRAUMA EXCEPT JOINT REPLACEMENT,309-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,47903.02844,,,47903.02844,28908.64482,62982.4212,case rate,,,
HIP & FEMUR PROCEDURES FOR NON-TRAUMA EXCEPT JOINT REPLACEMENT,309-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,94595.40239,,,94595.40239,56593.8462,119107.4132,case rate,,,
INTERVERTEBRAL DISC EXCISION & DECOMPRESSION,310-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17783.3235,,,17783.3235,10533.48927,27105.6624,case rate,,,
INTERVERTEBRAL DISC EXCISION & DECOMPRESSION,310-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,23724.72716,,,23724.72716,15069.75528,36544.152,case rate,,,
INTERVERTEBRAL DISC EXCISION & DECOMPRESSION,310-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,34049.19601,,,34049.19601,23419.84953,52762.94,case rate,,,
INTERVERTEBRAL DISC EXCISION & DECOMPRESSION,310-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,91566.19817,,,91566.19817,48989.6937,141852.4904,case rate,,,
"SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL & CONNECTIVE TISSUE DIAGNOSES",312-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,30354.69758,,,30354.69758,18913.27274,30354.69758,case rate,,,
"SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL & CONNECTIVE TISSUE DIAGNOSES",312-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,42281.06069,,,42281.06069,26360.31976,46715.4156,case rate,,,
"SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL & CONNECTIVE TISSUE DIAGNOSES",312-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,82679.87306,,,82679.87306,37950.25058,93868.2764,case rate,,,
"SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL & CONNECTIVE TISSUE DIAGNOSES",312-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,183380.53,,,183380.53,93185.81478,186635.6836,case rate,,,
KNEE & LOWER LEG PROCEDURES EXCEPT FOOT,313-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20598.84151,,,20598.84151,13044.7028,31992.3804,case rate,,,
KNEE & LOWER LEG PROCEDURES EXCEPT FOOT,313-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29376.68842,,,29376.68842,19132.23077,42118.26,case rate,,,
KNEE & LOWER LEG PROCEDURES EXCEPT FOOT,313-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,46836.403,,,46836.403,26401.14244,61450.1664,case rate,,,
KNEE & LOWER LEG PROCEDURES EXCEPT FOOT,313-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,96823.85008,,,96823.85008,49239.578,134162.9916,case rate,,,
FOOT & TOE PROCEDURES,314-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18144.46946,,,18144.46946,11925.17164,27115.6608,case rate,,,
FOOT & TOE PROCEDURES,314-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21889.82645,,,21889.82645,12198.55991,28865.3808,case rate,,,
FOOT & TOE PROCEDURES,314-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,32047.21438,,,32047.21438,16163.30837,42139.8632,case rate,,,
FOOT & TOE PROCEDURES,314-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,73780.46716,,,73780.46716,30921.3268,79714.54,case rate,,,
"SHOULDER, UPPER ARM & FOREARM PROCEDURES",315-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16914.33423,,,16914.33423,11076.55465,23488.7412,case rate,,,
"SHOULDER, UPPER ARM & FOREARM PROCEDURES",315-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29485.08637,,,29485.08637,15271.3946,37593.984,case rate,,,
"SHOULDER, UPPER ARM & FOREARM PROCEDURES",315-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,44437.14276,,,44437.14276,26054.76816,56016.036,case rate,,,
"SHOULDER, UPPER ARM & FOREARM PROCEDURES",315-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,94925.01002,,,94925.01002,41354.61493,106425.6488,case rate,,,
HAND & WRIST PROCEDURES,316-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15496.63423,,,15496.63423,10506.27414,19796.832,case rate,,,
HAND & WRIST PROCEDURES,316-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,23061.8204,,,23061.8204,13457.87783,26730.7224,case rate,,,
HAND & WRIST PROCEDURES,316-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,36801.27624,,,36801.27624,21581.59175,44223.4292,case rate,,,
HAND & WRIST PROCEDURES,316-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,76379.85133,,,76379.85133,43606.04775,78407.14905,case rate,,,
"TENDON, MUSCLE & OTHER SOFT TISSUE PROCEDURES",317-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15855.81406,,,15855.81406,11239.84539,23246.28,case rate,,,
"TENDON, MUSCLE & OTHER SOFT TISSUE PROCEDURES",317-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,23570.28565,,,23570.28565,13519.73038,30067.6884,case rate,,,
"TENDON, MUSCLE & OTHER SOFT TISSUE PROCEDURES",317-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,42332.46095,,,42332.46095,21681.79288,54064.9096,case rate,,,
"TENDON, MUSCLE & OTHER SOFT TISSUE PROCEDURES",317-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,101663.7195,,,101663.7195,56003.77287,130984.776,case rate,,,
OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE PROCEDURES,320-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19715.10627,,,19715.10627,11227.47488,25820.868,case rate,,,
OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE PROCEDURES,320-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,28326.91552,,,28326.91552,13892.08273,35774.2752,case rate,,,
OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE PROCEDURES,320-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,44687.24251,,,44687.24251,22818.64275,52138.9068,case rate,,,
OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE PROCEDURES,320-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,91047.46089,,,91047.46089,40027.25921,103734.6352,case rate,,,
CERVICAL SPINAL FUSION & OTHER BACK/NECK PROC EXC DISC EXCIS/DECOMP,321-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,32269.02593,,,32269.02593,19325.21072,42785.6532,case rate,,,
CERVICAL SPINAL FUSION & OTHER BACK/NECK PROC EXC DISC EXCIS/DECOMP,321-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,42760.87663,,,42760.87663,22260.73275,51899.1948,case rate,,,
CERVICAL SPINAL FUSION & OTHER BACK/NECK PROC EXC DISC EXCIS/DECOMP,321-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,75205.65049,,,75205.65049,30257.03041,76762.3032,case rate,,,
CERVICAL SPINAL FUSION & OTHER BACK/NECK PROC EXC DISC EXCIS/DECOMP,321-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,144667.1523,,,144667.1523,44892.58079,146454.9944,case rate,,,
FRACTURE OF FEMUR,340-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8026.04299,,,8026.04299,5316.845198,11410.674,case rate,,,
FRACTURE OF FEMUR,340-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10175.24361,,,10175.24361,6034.334778,14680.3292,case rate,,,
FRACTURE OF FEMUR,340-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15817.45446,,,15817.45446,8849.862854,35316.962,case rate,,,
FRACTURE OF FEMUR,340-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,32665.60235,,,32665.60235,16870.90154,48058.8492,case rate,,,
FRACTURE OF PELVIS OR DISLOCATION OF HIP,341-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9050.898206,,,9050.898206,4732.957126,12260.538,case rate,,,
FRACTURE OF PELVIS OR DISLOCATION OF HIP,341-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10767.32957,,,10767.32957,5737.442538,15037.5936,case rate,,,
FRACTURE OF PELVIS OR DISLOCATION OF HIP,341-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15314.16535,,,15314.16535,7997.534715,19946.2572,case rate,,,
FRACTURE OF PELVIS OR DISLOCATION OF HIP,341-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45123.20171,,,45123.20171,15281.291,45123.20171,case rate,,,
"FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK",342-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8952.290775,,,8952.290775,4844.291716,12295.5324,case rate,,,
"FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK",342-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11889.04677,,,11889.04677,5866.095842,16562.3496,case rate,,,
"FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK",342-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17773.27216,,,17773.27216,9358.290815,23083.806,case rate,,,
"FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK",342-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,46538.57445,,,46538.57445,15367.88457,54869.3112,case rate,,,
MUSCULOSKELETAL MALIGNANCY & PATHOL FRACTURE D/T MUSCSKEL MALIG,343-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13843.60053,,,13843.60053,7009.130966,18679.5108,case rate,,,
MUSCULOSKELETAL MALIGNANCY & PATHOL FRACTURE D/T MUSCSKEL MALIG,343-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17133.79846,,,17133.79846,8775.639794,21953.9868,case rate,,,
MUSCULOSKELETAL MALIGNANCY & PATHOL FRACTURE D/T MUSCSKEL MALIG,343-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,27749.87647,,,27749.87647,17239.54274,44503.3112,case rate,,,
MUSCULOSKELETAL MALIGNANCY & PATHOL FRACTURE D/T MUSCSKEL MALIG,343-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,52131.23081,,,52131.23081,21617.46623,79855.5176,case rate,,,
"OSTEOMYELITIS, SEPTIC ARTHRITIS & OTHER MUSCULOSKELETAL INFECTIONS",344-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13003.01983,,,13003.01983,7847.851544,16670.6012,case rate,,,
"OSTEOMYELITIS, SEPTIC ARTHRITIS & OTHER MUSCULOSKELETAL INFECTIONS",344-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17007.02321,,,17007.02321,9243.245072,23837.6536,case rate,,,
"OSTEOMYELITIS, SEPTIC ARTHRITIS & OTHER MUSCULOSKELETAL INFECTIONS",344-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29181.17887,,,29181.17887,13350.25439,36973.4488,case rate,,,
"OSTEOMYELITIS, SEPTIC ARTHRITIS & OTHER MUSCULOSKELETAL INFECTIONS",344-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,56004.20568,,,56004.20568,25700.97158,71168.8096,case rate,,,
CONNECTIVE TISSUE DISORDERS,346-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11318.96943,,,11318.96943,7701.879526,15165.458,case rate,,,
CONNECTIVE TISSUE DISORDERS,346-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15390.14222,,,15390.14222,9745.487778,19948.3304,case rate,,,
CONNECTIVE TISSUE DISORDERS,346-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,27661.74169,,,27661.74169,16054.44788,34475.2428,case rate,,,
CONNECTIVE TISSUE DISORDERS,346-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,80639.79265,,,80639.79265,31037.60959,101058.134,case rate,,,
"OTHER BACK & NECK DISORDERS, FRACTURES & INJURIES",347-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10887.02274,,,10887.02274,5435.602094,14497.68,case rate,,,
"OTHER BACK & NECK DISORDERS, FRACTURES & INJURIES",347-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14005.82631,,,14005.82631,6772.854225,18282.0744,case rate,,,
"OTHER BACK & NECK DISORDERS, FRACTURES & INJURIES",347-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20300.09009,,,20300.09009,9911.252612,24741.0408,case rate,,,
"OTHER BACK & NECK DISORDERS, FRACTURES & INJURIES",347-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,51751.56712,,,51751.56712,17676.22174,65415.6796,case rate,,,
"MALFUNCTION, REACTION, COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE",349-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8887.348303,,,8887.348303,5452.920808,12840.4452,case rate,,,
"MALFUNCTION, REACTION, COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE",349-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13547.6378,,,13547.6378,7583.12263,18227.5744,case rate,,,
"MALFUNCTION, REACTION, COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE",349-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22767.88399,,,22767.88399,12562.25291,32300.456,case rate,,,
"MALFUNCTION, REACTION, COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE",349-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50333.52606,,,50333.52606,18529.78693,74042.2648,case rate,,,
OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE DIAGNOSES,351-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8903.217779,,,8903.217779,5078.094355,11600.6436,case rate,,,
OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE DIAGNOSES,351-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11203.71008,,,11203.71008,6184.017949,14707.6464,case rate,,,
OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE DIAGNOSES,351-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18402.53403,,,18402.53403,10279.89381,23939.2404,case rate,,,
OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE DIAGNOSES,351-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,44236.63764,,,44236.63764,17155.42327,63864.926,case rate,,,
SKIN GRAFT FOR SKIN & SUBCUTANEOUS TISSUE DIAGNOSES,361-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24162.33149,,,24162.33149,14186.50087,33619.62,case rate,,,
SKIN GRAFT FOR SKIN & SUBCUTANEOUS TISSUE DIAGNOSES,361-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,32600.11818,,,32600.11818,18065.8928,41758.3176,case rate,,,
SKIN GRAFT FOR SKIN & SUBCUTANEOUS TISSUE DIAGNOSES,361-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50195.1346,,,50195.1346,39833.0422,69240.7336,case rate,,,
SKIN GRAFT FOR SKIN & SUBCUTANEOUS TISSUE DIAGNOSES,361-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,113823.3498,,,113823.3498,86944.89248,199037.566,case rate,,,
MASTECTOMY PROCEDURES,362-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20851.4892,,,20851.4892,13186.96366,31032.534,case rate,,,
MASTECTOMY PROCEDURES,362-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,27884.39586,,,27884.39586,21263.66964,44682.8496,case rate,,,
MASTECTOMY PROCEDURES,362-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,39053.61842,,,39053.61842,31751.38802,57599.7156,case rate,,,
MASTECTOMY PROCEDURES,362-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,98228.30879,,,98228.30879,60199.5084,98228.30879,case rate,,,
BREAST PROCEDURES EXCEPT MASTECTOMY,363-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18594.85363,,,18594.85363,12076.09186,25605.9024,case rate,,,
BREAST PROCEDURES EXCEPT MASTECTOMY,363-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,32003.01659,,,32003.01659,22093.73086,47132.4576,case rate,,,
BREAST PROCEDURES EXCEPT MASTECTOMY,363-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,39029.92455,,,39029.92455,24995.85251,59822.9268,case rate,,,
BREAST PROCEDURES EXCEPT MASTECTOMY,363-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,86414.37621,,,86414.37621,47162.56938,86414.37621,case rate,,,
"OTHER SKIN, SUBCUTANEOUS TISSUE & RELATED PROCEDURES",364-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15539.28721,,,15539.28721,7727.857597,18327.0672,case rate,,,
"OTHER SKIN, SUBCUTANEOUS TISSUE & RELATED PROCEDURES",364-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21946.64359,,,21946.64359,10091.86206,25320.948,case rate,,,
"OTHER SKIN, SUBCUTANEOUS TISSUE & RELATED PROCEDURES",364-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,36214.00529,,,36214.00529,19288.09919,41942.9092,case rate,,,
"OTHER SKIN, SUBCUTANEOUS TISSUE & RELATED PROCEDURES",364-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,77952.73514,,,77952.73514,30685.05006,110072.4076,case rate,,,
SKIN ULCERS,380-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10643.20257,,,10643.20257,5143.658058,14232.518,case rate,,,
SKIN ULCERS,380-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12785.30104,,,12785.30104,7255.304115,17296.7076,case rate,,,
SKIN ULCERS,380-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19707.18156,,,19707.18156,10987.48698,26905.9896,case rate,,,
SKIN ULCERS,380-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45491.69055,,,45491.69055,22432.68283,51670.3636,case rate,,,
MAJOR SKIN DISORDERS,381-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8606.733423,,,8606.733423,5139.946905,12325.174,case rate,,,
MAJOR SKIN DISORDERS,381-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12399.49822,,,12399.49822,10814.29984,18256.5992,case rate,,,
MAJOR SKIN DISORDERS,381-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22498.0427,,,22498.0427,16178.15298,39952.6372,case rate,,,
MAJOR SKIN DISORDERS,381-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,82134.83377,,,82134.83377,46947.3225,122376.8496,case rate,,,
MALIGNANT BREAST DISORDERS,382-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9556.474454,,,9556.474454,7409.93549,14382.6984,case rate,,,
MALIGNANT BREAST DISORDERS,382-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13336.35909,,,13336.35909,8736.054162,17551.24968,case rate,,,
MALIGNANT BREAST DISORDERS,382-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22360.09261,,,22360.09261,12394.01397,31224.4652,case rate,,,
MALIGNANT BREAST DISORDERS,382-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,42350.43699,,,42350.43699,22958.42951,59992.1884,case rate,,,
CELLULITIS & OTHER BACTERIAL SKIN INFECTIONS,383-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8194.548343,,,8194.548343,4840.580563,10528.3152,case rate,,,
CELLULITIS & OTHER BACTERIAL SKIN INFECTIONS,383-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11460.93203,,,11460.93203,6415.346486,14430.1908,case rate,,,
CELLULITIS & OTHER BACTERIAL SKIN INFECTIONS,383-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18461.91918,,,18461.91918,9314.99403,24503.1508,case rate,,,
CELLULITIS & OTHER BACTERIAL SKIN INFECTIONS,383-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45547.92588,,,45547.92588,19870.75021,57916.9152,case rate,,,
"CONTUSION, OPEN WOUND & OTHER TRAUMA TO SKIN & SUBCUTANEOUS TISSUE",384-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10747.74852,,,10747.74852,4469.465263,13467.8448,case rate,,,
"CONTUSION, OPEN WOUND & OTHER TRAUMA TO SKIN & SUBCUTANEOUS TISSUE",384-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12661.7358,,,12661.7358,5931.659545,16879.7988,case rate,,,
"CONTUSION, OPEN WOUND & OTHER TRAUMA TO SKIN & SUBCUTANEOUS TISSUE",384-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18458.74929,,,18458.74929,9802.392124,24593.5644,case rate,,,
"CONTUSION, OPEN WOUND & OTHER TRAUMA TO SKIN & SUBCUTANEOUS TISSUE",384-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,46957.76136,,,46957.76136,23002.96335,46957.76136,case rate,,,
"OTHER SKIN, SUBCUTANEOUS TISSUE & BREAST DISORDERS",385-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7533.988901,,,7533.988901,5467.76542,10365.8412,case rate,,,
"OTHER SKIN, SUBCUTANEOUS TISSUE & BREAST DISORDERS",385-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10466.05026,,,10466.05026,6529.155178,13672.812,case rate,,,
"OTHER SKIN, SUBCUTANEOUS TISSUE & BREAST DISORDERS",385-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17352.62069,,,17352.62069,11117.37734,22452.756,case rate,,,
"OTHER SKIN, SUBCUTANEOUS TISSUE & BREAST DISORDERS",385-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,55304.48414,,,55304.48414,21545.71727,60012.9204,case rate,,,
SPINAL DISORDERS & INJURIES,40-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17842.08671,,,17842.08671,10988.72403,20241.73525,case rate,,,
PITUITARY & ADRENAL PROCEDURES,401-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,27998.71227,,,27998.71227,12116.91455,31822.4076,case rate,,,
PITUITARY & ADRENAL PROCEDURES,401-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,37083.01462,,,37083.01462,35069.1588,56076.0264,case rate,,,
PITUITARY & ADRENAL PROCEDURES,401-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,62558.82116,,,62558.82116,42096.84553,70371.2388,case rate,,,
PITUITARY & ADRENAL PROCEDURES,401-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,152983.7211,,,152983.7211,73754.21767,152983.7211,case rate,,,
SPINAL DISORDERS & INJURIES,40-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22116.99469,,,22116.99469,13329.22453,26192.80091,case rate,,,
SPINAL DISORDERS & INJURIES,40-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29592.12007,,,29592.12007,16477.51932,41182.00529,case rate,,,
PROCEDURES FOR OBESITY,403-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,25862.79306,,,25862.79306,9434.987977,27653.0748,case rate,,,
PROCEDURES FOR OBESITY,403-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,27646.77502,,,27646.77502,10330.6129,32104.8624,case rate,,,
PROCEDURES FOR OBESITY,403-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,42857.1568,,,42857.1568,21879.72104,45797.6712,case rate,,,
PROCEDURES FOR OBESITY,403-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,133223.3938,,,133223.3938,52066.23954,136348.1444,case rate,,,
SPINAL DISORDERS & INJURIES,40-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,68979.90032,,,68979.90032,39208.33145,68979.90032,case rate,,,
"THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES",404-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15028.4947,,,15028.4947,8439.161922,22673.8716,case rate,,,
"THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES",404-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19434.09014,,,19434.09014,13549.4196,33262.1772,case rate,,,
"THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES",404-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,41269.54707,,,41269.54707,24232.59204,55818.5676,case rate,,,
"THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES",404-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,91224.03139,,,91224.03139,55286.0244,116111.4192,case rate,,,
"OTHER PROCEDURES FOR ENDOCRINE, NUTRITIONAL & METABOLIC DISORDERS",405-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,25339.20064,,,25339.20064,14101.14435,31882.398,case rate,,,
"OTHER PROCEDURES FOR ENDOCRINE, NUTRITIONAL & METABOLIC DISORDERS",405-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29805.00379,,,29805.00379,17777.65992,35949.2472,case rate,,,
"OTHER PROCEDURES FOR ENDOCRINE, NUTRITIONAL & METABOLIC DISORDERS",405-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45671.67168,,,45671.67168,34643.61326,61057.8132,case rate,,,
"OTHER PROCEDURES FOR ENDOCRINE, NUTRITIONAL & METABOLIC DISORDERS",405-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,113634.4409,,,113634.4409,64833.84291,173902.0892,case rate,,,
NERVOUS SYSTEM MALIGNANCY,41-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15256.36514,,,15256.36514,7717.961189,17041.99529,case rate,,,
NERVOUS SYSTEM MALIGNANCY,41-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16208.37324,,,16208.37324,9082.428442,18903.25248,case rate,,,
NERVOUS SYSTEM MALIGNANCY,41-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22952.96101,,,22952.96101,13337.88388,25176.54547,case rate,,,
NERVOUS SYSTEM MALIGNANCY,41-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,43462.98561,,,43462.98561,21511.07984,43462.98561,case rate,,,
DIABETES,420-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7780.316884,,,7780.316884,5450.446706,10585.806,case rate,,,
DIABETES,420-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10122.55935,,,10122.55935,6132.061807,13602.8232,case rate,,,
DIABETES,420-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15829.19106,,,15829.19106,9246.956225,20261.3836,case rate,,,
DIABETES,420-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,44471.61022,,,44471.61022,19479.8421,52659.28,case rate,,,
DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS,42-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11035.26491,,,11035.26491,11035.26491,14139.69595,case rate,,,
"MALNUTRITION, FAILURE TO THRIVE & OTHER NUTRITIONAL DISORDERS",421-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6843.636573,,,6843.636573,6843.636573,12957.5,case rate,,,
"MALNUTRITION, FAILURE TO THRIVE & OTHER NUTRITIONAL DISORDERS",421-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10558.47843,,,10558.47843,10073.30629,18934.5356,case rate,,,
"MALNUTRITION, FAILURE TO THRIVE & OTHER NUTRITIONAL DISORDERS",421-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17142.46548,,,17142.46548,16778.12271,28767.7232,case rate,,,
"MALNUTRITION, FAILURE TO THRIVE & OTHER NUTRITIONAL DISORDERS",421-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,43857.63602,,,43857.63602,28107.03577,66369.3516,case rate,,,
DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS,42-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13719.63404,,,13719.63404,13719.63404,17410.25577,case rate,,,
HYPOVOLEMIA & RELATED ELECTROLYTE DISORDERS,422-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5615.62798,,,5615.62798,4104.535218,8221.1844,case rate,,,
HYPOVOLEMIA & RELATED ELECTROLYTE DISORDERS,422-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8734.210862,,,8734.210862,5026.138213,12235.542,case rate,,,
HYPOVOLEMIA & RELATED ELECTROLYTE DISORDERS,422-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13384.8904,,,13384.8904,8599.978552,18700.264,case rate,,,
HYPOVOLEMIA & RELATED ELECTROLYTE DISORDERS,422-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,33604.89079,,,33604.89079,13498.70051,47067.8596,case rate,,,
DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS,42-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20318.88869,,,20318.88869,20318.88869,25809.73345,case rate,,,
INBORN ERRORS OF METABOLISM,423-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11010.66823,,,11010.66823,7505.188417,17938.82382,case rate,,,
INBORN ERRORS OF METABOLISM,423-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13720.99829,,,13720.99829,12073.61776,22501.83327,case rate,,,
INBORN ERRORS OF METABOLISM,423-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21091.5376,,,21091.5376,21091.5376,33626.56297,case rate,,,
INBORN ERRORS OF METABOLISM,423-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,75339.08651,,,75339.08651,55516.116,112746.8356,case rate,,,
DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS,42-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,56663.98268,,,56663.98268,33323.67984,58237.52061,case rate,,,
OTHER ENDOCRINE DISORDERS,424-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9278.387455,,,9278.387455,5590.233469,11885.598,case rate,,,
OTHER ENDOCRINE DISORDERS,424-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13400.67963,,,13400.67963,7811.977065,16539.8532,case rate,,,
OTHER ENDOCRINE DISORDERS,424-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20028.92467,,,20028.92467,13841.36364,24573.6396,case rate,,,
OTHER ENDOCRINE DISORDERS,424-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,48011.54677,,,48011.54677,17585.91702,57699.2292,case rate,,,
ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED,425-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7841.628035,,,7841.628035,4443.487192,10568.3088,case rate,,,
ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED,425-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9931.864817,,,9931.864817,5879.703403,12940.4292,case rate,,,
ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED,425-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15711.64458,,,15711.64458,9494.366425,20698.8288,case rate,,,
ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED,425-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,38531.67113,,,38531.67113,16985.94728,51643.412,case rate,,,
MULTIPLE SCLEROSIS & OTHER DEMYELINATING DISEASES,43-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15568.03685,,,15568.03685,9343.446203,18083.03745,case rate,,,
MULTIPLE SCLEROSIS & OTHER DEMYELINATING DISEASES,43-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19892.96077,,,19892.96077,11349.94293,24550.11751,case rate,,,
MULTIPLE SCLEROSIS & OTHER DEMYELINATING DISEASES,43-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,30096.29194,,,30096.29194,17613.13214,39363.56152,case rate,,,
MULTIPLE SCLEROSIS & OTHER DEMYELINATING DISEASES,43-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,68791.15185,,,68791.15185,47495.33609,79098.92381,case rate,,,
KIDNEY TRANSPLANT,440-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,89616.49955,,,89616.49955,76832.792,106417.9704,case rate,,,
KIDNEY TRANSPLANT,440-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,99290.31985,,,99290.31985,85811.75377,119178.4284,case rate,,,
KIDNEY TRANSPLANT,440-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,118326.0279,,,118326.0279,90276.27083,138957.7632,case rate,,,
KIDNEY TRANSPLANT,440-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,205291.3619,,,205291.3619,116025.4874,215283.1612,case rate,,,
INTRACRANIAL HEMORRHAGE,44-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15276.22707,,,15276.22707,7552.196355,17220.009,case rate,,,
MAJOR BLADDER PROCEDURES,441-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,27757.44005,,,27757.44005,23355.52288,36241.7004,case rate,,,
MAJOR BLADDER PROCEDURES,441-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,43203.85772,,,43203.85772,24085.38297,55153.674,case rate,,,
MAJOR BLADDER PROCEDURES,441-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,57886.9957,,,57886.9957,29608.81569,72115.9596,case rate,,,
MAJOR BLADDER PROCEDURES,441-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,124938.885,,,124938.885,79176.2122,142082.2632,case rate,,,
INTRACRANIAL HEMORRHAGE,44-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20152.7106,,,20152.7106,11254.69,22242.6994,case rate,,,
KIDNEY & URINARY TRACT PROCEDURES FOR MALIGNANCY,442-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24814.18379,,,24814.18379,11636.93876,33899.5752,case rate,,,
KIDNEY & URINARY TRACT PROCEDURES FOR MALIGNANCY,442-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29164.90815,,,29164.90815,13346.54324,39366.2004,case rate,,,
KIDNEY & URINARY TRACT PROCEDURES FOR MALIGNANCY,442-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,46621.3124,,,46621.3124,22750.60494,58375.0924,case rate,,,
KIDNEY & URINARY TRACT PROCEDURES FOR MALIGNANCY,442-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,111753.8778,,,111753.8778,44083.54944,132185.1588,case rate,,,
INTRACRANIAL HEMORRHAGE,44-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,27569.77496,,,27569.77496,16736.06298,31028.46426,case rate,,,
KIDNEY & URINARY TRACT PROCEDURES FOR NONMALIGNANCY,443-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20967.25011,,,20967.25011,11062.94709,28535.4336,case rate,,,
KIDNEY & URINARY TRACT PROCEDURES FOR NONMALIGNANCY,443-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,25532.80425,,,25532.80425,12123.0998,33039.7128,case rate,,,
KIDNEY & URINARY TRACT PROCEDURES FOR NONMALIGNANCY,443-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,39350.82503,,,39350.82503,22086.30855,48587.2248,case rate,,,
KIDNEY & URINARY TRACT PROCEDURES FOR NONMALIGNANCY,443-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,93921.08004,,,93921.08004,37955.19878,105065.6296,case rate,,,
INTRACRANIAL HEMORRHAGE,44-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50911.5883,,,50911.5883,25780.14284,50911.5883,case rate,,,
RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY,444-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21281.04844,,,21281.04844,11144.59246,23252.19482,case rate,,,
RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY,444-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,27619.99152,,,27619.99152,17159.13442,36216.7308,case rate,,,
RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY,444-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45638.56848,,,45638.56848,25838.28424,67018.2632,case rate,,,
RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY,444-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,84629.09018,,,84629.09018,48597.54854,128246.0788,case rate,,,
OTHER BLADDER PROCEDURES,445-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16907.45278,,,16907.45278,8854.811058,23348.7636,case rate,,,
OTHER BLADDER PROCEDURES,445-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,23370.34229,,,23370.34229,12878.93796,29707.746,case rate,,,
OTHER BLADDER PROCEDURES,445-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,34196.03381,,,34196.03381,21110.27532,41720.8236,case rate,,,
OTHER BLADDER PROCEDURES,445-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,69451.10942,,,69451.10942,50785.1072,79405.37778,case rate,,,
URETHRAL & TRANSURETHRAL PROCEDURES,446-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12745.53707,,,12745.53707,6557.607351,20209.266,case rate,,,
URETHRAL & TRANSURETHRAL PROCEDURES,446-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16645.43588,,,16645.43588,8358.753607,24608.562,case rate,,,
URETHRAL & TRANSURETHRAL PROCEDURES,446-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,28222.44982,,,28222.44982,15461.90045,38683.8096,case rate,,,
URETHRAL & TRANSURETHRAL PROCEDURES,446-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,59926.83536,,,59926.83536,25928.58896,68185.4748,case rate,,,
"OTHER KIDNEY, URINARY TRACT & RELATED PROCEDURES",447-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22163.7605,,,22163.7605,17965.69167,30457.626,case rate,,,
"OTHER KIDNEY, URINARY TRACT & RELATED PROCEDURES",447-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,28347.86082,,,28347.86082,19581.28028,36876.5988,case rate,,,
"OTHER KIDNEY, URINARY TRACT & RELATED PROCEDURES",447-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,42820.26177,,,42820.26177,23259.0329,60769.6384,case rate,,,
"OTHER KIDNEY, URINARY TRACT & RELATED PROCEDURES",447-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,107754.8299,,,107754.8299,52201.0781,158197.5992,case rate,,,
CVA & PRECEREBRAL OCCLUSION W INFARCT,45-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14284.45499,,,14284.45499,5539.514378,15426.35195,case rate,,,
CVA & PRECEREBRAL OCCLUSION W INFARCT,45-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17200.24563,,,17200.24563,7630.130568,19464.33364,case rate,,,
CVA & PRECEREBRAL OCCLUSION W INFARCT,45-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,25261.31783,,,25261.31783,12318.55386,28245.59183,case rate,,,
CVA & PRECEREBRAL OCCLUSION W INFARCT,45-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,55255.59171,,,55255.59171,23074.7123,55255.59171,case rate,,,
RENAL FAILURE,460-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10597.29946,,,10597.29946,10597.29946,10597.29946,case rate,,,
RENAL FAILURE,460-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13119.86412,,,13119.86412,13119.86412,13119.86412,case rate,,,
RENAL FAILURE,460-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16509.35161,,,16509.35161,16509.35161,16509.35161,case rate,,,
RENAL FAILURE,460-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,47530.72771,,,47530.72771,47530.72771,47530.72771,case rate,,,
NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT,46-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13916.78871,,,13916.78871,5274.785464,15721.53923,case rate,,,
KIDNEY & URINARY TRACT MALIGNANCY,461-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10777.18028,,,10777.18028,6963.360079,16296.14042,case rate,,,
KIDNEY & URINARY TRACT MALIGNANCY,461-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12919.90069,,,12919.90069,8693.994428,18328.65129,case rate,,,
KIDNEY & URINARY TRACT MALIGNANCY,461-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20327.4554,,,20327.4554,13224.07519,31158.1228,case rate,,,
KIDNEY & URINARY TRACT MALIGNANCY,461-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,44131.06851,,,44131.06851,23208.31381,48266.1692,case rate,,,
NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT,46-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15819.05947,,,15819.05947,5449.209655,18355.69135,case rate,,,
NEPHRITIS & NEPHROSIS,462-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8225.163794,,,8225.163794,6113.506042,12236.0264,case rate,,,
NEPHRITIS & NEPHROSIS,462-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11288.43423,,,11288.43423,8983.464362,15020.0964,case rate,,,
NEPHRITIS & NEPHROSIS,462-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20529.58559,,,20529.58559,17557.46484,29937.84867,case rate,,,
NEPHRITIS & NEPHROSIS,462-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,51256.04221,,,51256.04221,42597.85119,83303.2492,case rate,,,
NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT,46-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21583.71207,,,21583.71207,7928.259859,23858.34274,case rate,,,
KIDNEY & URINARY TRACT INFECTIONS,463-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8023.13392,,,8023.13392,4507.813844,11468.1648,case rate,,,
KIDNEY & URINARY TRACT INFECTIONS,463-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10498.53153,,,10498.53153,5660.745376,14412.6936,case rate,,,
KIDNEY & URINARY TRACT INFECTIONS,463-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15159.50315,,,15159.50315,8570.289328,20464.5572,case rate,,,
KIDNEY & URINARY TRACT INFECTIONS,463-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,31581.9438,,,31581.9438,15012.85094,45216.492,case rate,,,
NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT,46-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,46957.48048,,,46957.48048,27606.03012,46957.48048,case rate,,,
URINARY STONES & ACQUIRED UPPER URINARY TRACT OBSTRUCTION,465-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8543.436079,,,8543.436079,4434.827835,12080.5668,case rate,,,
URINARY STONES & ACQUIRED UPPER URINARY TRACT OBSTRUCTION,465-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10813.63393,,,10813.63393,4939.544643,14842.6248,case rate,,,
URINARY STONES & ACQUIRED UPPER URINARY TRACT OBSTRUCTION,465-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17468.36154,,,17468.36154,10142.58115,24563.5692,case rate,,,
URINARY STONES & ACQUIRED UPPER URINARY TRACT OBSTRUCTION,465-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,38074.48575,,,38074.48575,14394.32544,44967.708,case rate,,,
"MALFUNCTION, REACTION, COMPLIC OF GENITOURINARY DEVICE OR PROC",466-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8157.232001,,,8157.232001,4913.566572,10413.6836,case rate,,,
"MALFUNCTION, REACTION, COMPLIC OF GENITOURINARY DEVICE OR PROC",466-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12214.48139,,,12214.48139,5910.629678,14847.624,case rate,,,
"MALFUNCTION, REACTION, COMPLIC OF GENITOURINARY DEVICE OR PROC",466-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20093.30539,,,20093.30539,9423.854518,24121.682,case rate,,,
"MALFUNCTION, REACTION, COMPLIC OF GENITOURINARY DEVICE OR PROC",466-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,40767.86296,,,40767.86296,16039.60327,48257.8764,case rate,,,
"OTHER KIDNEY & URINARY TRACT DIAGNOSES, SIGNS & SYMPTOMS",468-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8959.733981,,,8959.733981,5075.620253,11188.2096,case rate,,,
"OTHER KIDNEY & URINARY TRACT DIAGNOSES, SIGNS & SYMPTOMS",468-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12179.51236,,,12179.51236,6367.101497,15387.5376,case rate,,,
"OTHER KIDNEY & URINARY TRACT DIAGNOSES, SIGNS & SYMPTOMS",468-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18104.32429,,,18104.32429,11291.80153,24658.6408,case rate,,,
"OTHER KIDNEY & URINARY TRACT DIAGNOSES, SIGNS & SYMPTOMS",468-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,42080.99695,,,42080.99695,28734.22063,58229.9684,case rate,,,
TRANSIENT ISCHEMIA,47-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11542.78723,,,11542.78723,4323.493245,13745.3618,case rate,,,
TRANSIENT ISCHEMIA,47-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12503.10122,,,12503.10122,5094.176018,15273.12496,case rate,,,
TRANSIENT ISCHEMIA,47-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16456.68742,,,16456.68742,7476.736244,19761.77426,case rate,,,
TRANSIENT ISCHEMIA,47-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,37947.229,,,37947.229,19202.74267,37947.229,case rate,,,
MAJOR MALE PELVIC PROCEDURES,480-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22764.59373,,,22764.59373,10733.89153,31872.3996,case rate,,,
MAJOR MALE PELVIC PROCEDURES,480-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24858.98346,,,24858.98346,11931.3569,36631.638,case rate,,,
MAJOR MALE PELVIC PROCEDURES,480-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,40972.94234,,,40972.94234,28808.44369,54628.758,case rate,,,
MAJOR MALE PELVIC PROCEDURES,480-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,94684.39986,,,94684.39986,53851.37,99928.78029,case rate,,,
"PERIPHERAL, CRANIAL & AUTONOMIC NERVE DISORDERS",48-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11736.59146,,,11736.59146,5361.379034,13876.0554,case rate,,,
PENIS PROCEDURES,481-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14237.97007,,,14237.97007,14237.97007,15385.2172,case rate,,,
PENIS PROCEDURES,481-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24707.69177,,,24707.69177,24707.69177,25282.674,case rate,,,
PENIS PROCEDURES,481-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,38096.21349,,,38096.21349,38096.21349,40522.7672,case rate,,,
PENIS PROCEDURES,481-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,94993.78444,,,94993.78444,42840.6048,94993.78444,case rate,,,
"PERIPHERAL, CRANIAL & AUTONOMIC NERVE DISORDERS",48-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13216.7863,,,13216.7863,7298.6009,15581.83227,case rate,,,
TRANSURETHRAL PROSTATECTOMY,482-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11340.05517,,,11340.05517,6333.70112,17547.192,case rate,,,
TRANSURETHRAL PROSTATECTOMY,482-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14777.99371,,,14777.99371,7856.510901,21459.066,case rate,,,
TRANSURETHRAL PROSTATECTOMY,482-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29767.14576,,,29767.14576,15105.62976,48801.0548,case rate,,,
TRANSURETHRAL PROSTATECTOMY,482-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,60010.53631,,,60010.53631,40045.81497,67897.58062,case rate,,,
"PERIPHERAL, CRANIAL & AUTONOMIC NERVE DISORDERS",48-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18065.90451,,,18065.90451,11413.03253,22003.84557,case rate,,,
TESTES & SCROTAL PROCEDURES,483-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12625.92415,,,12625.92415,10968.93122,23008.83432,case rate,,,
TESTES & SCROTAL PROCEDURES,483-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,23392.25059,,,23392.25059,13637.25022,30185.1696,case rate,,,
TESTES & SCROTAL PROCEDURES,483-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45127.33459,,,45127.33459,29367.59074,65958.858,case rate,,,
TESTES & SCROTAL PROCEDURES,483-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,102854.6324,,,102854.6324,61402.26344,102854.6324,case rate,,,
"PERIPHERAL, CRANIAL & AUTONOMIC NERVE DISORDERS",48-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,52223.91979,,,52223.91979,33365.73957,52223.91979,case rate,,,
OTHER MALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES,484-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16516.31331,,,16516.31331,9928.571326,26938.1892,case rate,,,
OTHER MALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES,484-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,23051.9095,,,23051.9095,10566.88964,34426.9908,case rate,,,
OTHER MALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES,484-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,30404.4527,,,30404.4527,14999.24338,41285.8932,case rate,,,
OTHER MALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES,484-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,75878.58853,,,75878.58853,44530.2628,93312.97992,case rate,,,
BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,49-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17685.19757,,,17685.19757,14547.71976,21605.00474,case rate,,,
BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,49-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,36691.01246,,,36691.01246,15626.42823,40686.27093,case rate,,,
BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,49-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,48513.15063,,,48513.15063,21618.70328,50639.26487,case rate,,,
BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,49-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,89058.94123,,,89058.94123,49668.8347,89437.23856,case rate,,,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM",500-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10441.39339,,,10441.39339,6494.51775,13909.85547,case rate,,,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM",500-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13647.18817,,,13647.18817,9042.84281,19544.0564,case rate,,,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM",500-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20311.5458,,,20311.5458,14146.91524,32750.3404,case rate,,,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM",500-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,40852.76767,,,40852.76767,30680.10185,45340.2444,case rate,,,
NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS,50-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12733.80048,,,12733.80048,9092.32485,14141.94929,case rate,,,
MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,501-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8396.959405,,,8396.959405,4676.05278,10988.2416,case rate,,,
MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,501-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11221.52562,,,11221.52562,6501.940056,14745.1404,case rate,,,
MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,501-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17159.23777,,,17159.23777,9456.017844,23275.8164,case rate,,,
MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,501-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,40599.35761,,,40599.35761,24962.45213,44213.0632,case rate,,,
NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS,50-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21984.88281,,,21984.88281,13511.07102,27459.17687,case rate,,,
NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS,50-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,36206.94327,,,36206.94327,22689.98944,46443.54952,case rate,,,
NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS,50-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,92389.06364,,,92389.06364,48152.21018,95431.11764,case rate,,,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY & OTHER RADICAL GYN PROCS",510-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22791.73836,,,22791.73836,14689.98063,32867.2404,case rate,,,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY & OTHER RADICAL GYN PROCS",510-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,28759.84527,,,28759.84527,18325.67351,38461.3452,case rate,,,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY & OTHER RADICAL GYN PROCS",510-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,56199.6751,,,56199.6751,39320.90309,58620.6192,case rate,,,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY & OTHER RADICAL GYN PROCS",510-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,126587.9062,,,126587.9062,83533.10583,132877.6076,case rate,,,
VIRAL MENINGITIS,51-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9700.984998,,,9700.984998,5958.874667,9700.984998,case rate,,,
UTERINE & ADNEXA PROCEDURES FOR OVARIAN & ADNEXAL MALIGNANCY,511-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,23299.52149,,,23299.52149,13689.20637,33049.7112,case rate,,,
UTERINE & ADNEXA PROCEDURES FOR OVARIAN & ADNEXAL MALIGNANCY,511-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29107.68975,,,29107.68975,16269.69475,40136.0772,case rate,,,
UTERINE & ADNEXA PROCEDURES FOR OVARIAN & ADNEXAL MALIGNANCY,511-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,44953.37223,,,44953.37223,24194.24346,59110.5408,case rate,,,
UTERINE & ADNEXA PROCEDURES FOR OVARIAN & ADNEXAL MALIGNANCY,511-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,100675.1373,,,100675.1373,70245.94104,129085.7248,case rate,,,
VIRAL MENINGITIS,51-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14247.23896,,,14247.23896,7971.556644,14971.17767,case rate,,,
UTERINE & ADNEXA PROCEDURES FOR NON-OVARIAN & NON-ADNEXAL MALIG,512-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21379.45525,,,21379.45525,11993.20945,30305.1504,case rate,,,
UTERINE & ADNEXA PROCEDURES FOR NON-OVARIAN & NON-ADNEXAL MALIG,512-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24250.70702,,,24250.70702,14775.33714,35854.2624,case rate,,,
UTERINE & ADNEXA PROCEDURES FOR NON-OVARIAN & NON-ADNEXAL MALIG,512-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,39945.39874,,,39945.39874,20139.19028,56425.9704,case rate,,,
UTERINE & ADNEXA PROCEDURES FOR NON-OVARIAN & NON-ADNEXAL MALIG,512-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,98123.16097,,,98123.16097,66543.44739,155560.4888,case rate,,,
VIRAL MENINGITIS,51-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26314.18036,,,26314.18036,12687.19506,28606.12591,case rate,,,
UTERINE & ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA,513-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15479.38044,,,15479.38044,8623.482521,23416.2528,case rate,,,
UTERINE & ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA,513-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18292.67151,,,18292.67151,11237.37128,28187.9892,case rate,,,
UTERINE & ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA,513-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,31694.25395,,,31694.25395,17451.07846,44782.8336,case rate,,,
UTERINE & ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA,513-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,87886.60622,,,87886.60622,48770.73568,99546.7712,case rate,,,
VIRAL MENINGITIS,51-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,66604.57471,,,66604.57471,38400.53714,66604.57471,case rate,,,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,514-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13284.35696,,,13284.35696,8475.036401,20611.7544,case rate,,,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,514-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18463.72481,,,18463.72481,13920.5349,28765.3968,case rate,,,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,514-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,31396.62603,,,31396.62603,20611.7544,55523.6148,case rate,,,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,514-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,99535.28358,,,99535.28358,64279.64406,99535.28358,case rate,,,
DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES,517-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12553.05697,,,12553.05697,8457.717687,16377.3792,case rate,,,
DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES,517-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16054.65399,,,16054.65399,10204.4337,20789.1732,case rate,,,
DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES,517-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,28108.6751,,,28108.6751,17614.36919,42208.2788,case rate,,,
DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES,517-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,54112.30726,,,54112.30726,40275.90646,74713.92807,case rate,,,
OTHER FEMALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES,518-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14612.3573,,,14612.3573,8877.077976,19889.3172,case rate,,,
OTHER FEMALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES,518-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20146.23039,,,20146.23039,11375.921,28867.8804,case rate,,,
OTHER FEMALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES,518-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,39090.19245,,,39090.19245,24019.81927,48604.50066,case rate,,,
OTHER FEMALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES,518-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,98865.69599,,,98865.69599,53627.3979,123933.8228,case rate,,,
UTERINE & ADNEXA PROCEDURES FOR LEIOMYOMA,519-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16294.62214,,,16294.62214,8666.779306,22143.9564,case rate,,,
UTERINE & ADNEXA PROCEDURES FOR LEIOMYOMA,519-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18835.96535,,,18835.96535,11551.58224,28140.4968,case rate,,,
UTERINE & ADNEXA PROCEDURES FOR LEIOMYOMA,519-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,34243.22093,,,34243.22093,24517.11377,45487.7208,case rate,,,
UTERINE & ADNEXA PROCEDURES FOR LEIOMYOMA,519-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,90668.07808,,,90668.07808,55004.23566,125403.7216,case rate,,,
NONTRAUMATIC STUPOR & COMA,52-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10816.864,,,10816.864,4157.728411,12904.86673,case rate,,,
NONTRAUMATIC STUPOR & COMA,52-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12564.7735,,,12564.7735,6290.404335,14583.60354,case rate,,,
NONTRAUMATIC STUPOR & COMA,52-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17904.76211,,,17904.76211,9645.286647,18982.11931,case rate,,,
NONTRAUMATIC STUPOR & COMA,52-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,49467.56624,,,49467.56624,25354.5973,49467.56624,case rate,,,
FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,530-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9848.504924,,,9848.504924,6657.808482,13587.62814,case rate,,,
FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,530-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13116.63405,,,13116.63405,9229.637511,17554.6908,case rate,,,
FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,530-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22144.19951,,,22144.19951,12299.99809,30100.7908,case rate,,,
FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,530-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,46753.00298,,,46753.00298,16086.6112,51977.1972,case rate,,,
SEIZURE,53-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9711.096523,,,9711.096523,5759.709456,11613.70405,case rate,,,
FEMALE REPRODUCTIVE SYSTEM INFECTIONS,531-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8983.748853,,,8983.748853,4797.283778,11913.0936,case rate,,,
FEMALE REPRODUCTIVE SYSTEM INFECTIONS,531-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12507.83599,,,12507.83599,6639.252717,15552.5112,case rate,,,
FEMALE REPRODUCTIVE SYSTEM INFECTIONS,531-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21100.8065,,,21100.8065,9031.709351,24028.388,case rate,,,
FEMALE REPRODUCTIVE SYSTEM INFECTIONS,531-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45870.35111,,,45870.35111,26913.28156,45870.35111,case rate,,,
SEIZURE,53-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11832.61082,,,11832.61082,6668.941941,14387.56313,case rate,,,
MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,532-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8462.002191,,,8462.002191,4301.226327,9995.807368,case rate,,,
MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,532-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10191.59458,,,10191.59458,5490.032338,12453.0072,case rate,,,
MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,532-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16657.5336,,,16657.5336,8175.670059,20124.5524,case rate,,,
MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,532-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,37029.06642,,,37029.06642,21329.0816,41303.68554,case rate,,,
SEIZURE,53-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17613.43383,,,17613.43383,10600.29002,19211.95979,case rate,,,
SEIZURE,53-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,48383.72713,,,48383.72713,28097.13936,49100.23502,case rate,,,
CESAREAN DELIVERY,540-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14674.8,,,14674.8,8545.548308,16608.4052,case rate,,,
CESAREAN DELIVERY,540-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14674.8,,,14674.8,10912.02687,19136.9376,case rate,,,
CESAREAN DELIVERY,540-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14674.8,,,14674.8,14180.31561,24389.1248,case rate,,,
CESAREAN DELIVERY,540-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14674.8,,,14674.8,14674.8,56092.4992,case rate,,,
MIGRAINE & OTHER HEADACHES,54-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10128.71855,,,10128.71855,4755.224044,12057.61164,case rate,,,
VAGINAL DELIVERY W STERILIZATION &/OR D&C,541-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9564.96,,,9564.96,8247.419017,16309.89,case rate,,,
VAGINAL DELIVERY W STERILIZATION &/OR D&C,541-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9564.96,,,9564.96,9564.96,16997.28,case rate,,,
VAGINAL DELIVERY W STERILIZATION &/OR D&C,541-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9564.96,,,9564.96,9564.96,20924.1516,case rate,,,
VAGINAL DELIVERY W STERILIZATION &/OR D&C,541-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9564.96,,,9564.96,9564.96,28137.9972,case rate,,,
MIGRAINE & OTHER HEADACHES,54-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12032.11281,,,12032.11281,6539.051586,14419.10986,case rate,,,
VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION &/OR D&C,542-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9564.96,,,9564.96,7415.735358,12337.6132,case rate,,,
VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION &/OR D&C,542-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9564.96,,,9564.96,8497.303319,14060.4424,case rate,,,
VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION &/OR D&C,542-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9564.96,,,9564.96,9564.96,25326.2112,case rate,,,
VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION &/OR D&C,542-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9564.96,,,9564.96,9564.96,41235.9012,case rate,,,
MIGRAINE & OTHER HEADACHES,54-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15929.96524,,,15929.96524,9390.454141,18346.678,case rate,,,
MIGRAINE & OTHER HEADACHES,54-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,36686.71908,,,36686.71908,21545.71727,37326.54397,case rate,,,
"D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES",544-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9955.25775,,,9955.25775,9949.2868,9955.25775,case rate,,,
"D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES",544-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11827.33437,,,11827.33437,11827.33437,12831.0348,case rate,,,
"D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES",544-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22509.83948,,,22509.83948,22509.83948,22792.7608,case rate,,,
"D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES",544-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,55482.90039,,,55482.90039,55482.90039,59513.2792,case rate,,,
ECTOPIC PREGNANCY PROCEDURE,545-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14081.62262,,,14081.62262,14081.62262,14410.8132,case rate,,,
ECTOPIC PREGNANCY PROCEDURE,545-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16112.01282,,,16112.01282,16112.01282,16274.62,case rate,,,
ECTOPIC PREGNANCY PROCEDURE,545-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20079.82336,,,20079.82336,20079.82336,22832.1516,case rate,,,
ECTOPIC PREGNANCY PROCEDURE,545-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,30491.08279,,,30491.08279,24362.1732,30491.08279,case rate,,,
OTHER O.R. PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES,546-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10886.94249,,,10886.94249,10886.94249,11929.1928,case rate,,,
OTHER O.R. PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES,546-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15506.98651,,,15506.98651,15506.98651,16160.594,case rate,,,
OTHER O.R. PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES,546-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,30759.09839,,,30759.09839,30759.09839,34703.2948,case rate,,,
OTHER O.R. PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES,546-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,89227.98828,,,89227.98828,89227.98828,89307.2364,case rate,,,
HEAD TRAUMA W COMA >1 HR OR HEMORRHAGE,55-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12770.29426,,,12770.29426,5866.095842,15117.64464,case rate,,,
HEAD TRAUMA W COMA >1 HR OR HEMORRHAGE,55-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17506.72113,,,17506.72113,8598.741501,20645.08276,case rate,,,
HEAD TRAUMA W COMA >1 HR OR HEMORRHAGE,55-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,27519.95965,,,27519.95965,14370.82147,30954.10411,case rate,,,
HEAD TRAUMA W COMA >1 HR OR HEMORRHAGE,55-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,67919.11308,,,67919.11308,31019.05383,67919.11308,case rate,,,
VAGINAL DELIVERY,560-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9564.96,,,9564.96,6405.450078,10977.594,case rate,,,
VAGINAL DELIVERY,560-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9564.96,,,9564.96,7140.828122,12132.3664,case rate,,,
VAGINAL DELIVERY,560-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9564.96,,,9564.96,9198.711236,15059.7248,case rate,,,
VAGINAL DELIVERY,560-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9564.96,,,9564.96,9564.96,35173.9112,case rate,,,
"BRAIN CONTUSION/LACERATION & COMPLICATED SKULL FX, COMA < 1 HR OR NO COMA",56-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13228.48276,,,13228.48276,8596.267399,14094.62919,case rate,,,
POSTPARTUM & POST ABORTION DIAGNOSES W/O PROCEDURE,561-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5427.682017,,,5427.682017,3781.664907,7857.428,case rate,,,
POSTPARTUM & POST ABORTION DIAGNOSES W/O PROCEDURE,561-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8121.480538,,,8121.480538,4975.419122,9898.416,case rate,,,
POSTPARTUM & POST ABORTION DIAGNOSES W/O PROCEDURE,561-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12979.74727,,,12979.74727,6473.487883,15482.5224,case rate,,,
POSTPARTUM & POST ABORTION DIAGNOSES W/O PROCEDURE,561-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,34523.97624,,,34523.97624,14762.96663,34523.97624,case rate,,,
"BRAIN CONTUSION/LACERATION & COMPLICATED SKULL FX, COMA < 1 HR OR NO COMA",56-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18815.28086,,,18815.28086,10099.28436,19876.6945,case rate,,,
"BRAIN CONTUSION/LACERATION & COMPLICATED SKULL FX, COMA < 1 HR OR NO COMA",56-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29532.0528,,,29532.0528,15516.33069,30363.72955,case rate,,,
PRETERM LABOR,563-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5608.586025,,,5608.586025,5608.586025,7214.736,case rate,,,
PRETERM LABOR,563-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7528.39145,,,7528.39145,7528.39145,8682.5616,case rate,,,
PRETERM LABOR,563-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13947.44429,,,13947.44429,12327.2472,13947.44429,case rate,,,
PRETERM LABOR,563-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21166.09004,,,21166.09004,12327.2472,21166.09004,case rate,,,
"BRAIN CONTUSION/LACERATION & COMPLICATED SKULL FX, COMA < 1 HR OR NO COMA",56-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,74596.21043,,,74596.21043,31626.44587,74596.21043,case rate,,,
"ABORTION W/O D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",564-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5782.127079,,,5782.127079,4097.112912,7981.2228,case rate,,,
"ABORTION W/O D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",564-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6760.136242,,,6760.136242,4789.861472,10675.7916,case rate,,,
"ABORTION W/O D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",564-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9790.102842,,,9790.102842,9176.444318,14905.1148,case rate,,,
"ABORTION W/O D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",564-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,49092.57713,,,49092.57713,15036.9196,49092.57713,case rate,,,
FALSE LABOR,565-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2649.48035,,,2649.48035,2649.48035,4718.6032,case rate,,,
FALSE LABOR,565-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3976.818624,,,3976.818624,3976.818624,5854.7168,case rate,,,
FALSE LABOR,565-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6322.67235,,,6322.67235,5958.3768,6322.67235,case rate,,,
FALSE LABOR,565-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6954.943597,,,6954.943597,5958.3768,6954.943597,case rate,,,
OTHER ANTEPARTUM DIAGNOSES,566-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5303.635273,,,5303.635273,3870.732579,7063.3924,case rate,,,
OTHER ANTEPARTUM DIAGNOSES,566-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7089.081803,,,7089.081803,5616.21154,9244.3988,case rate,,,
OTHER ANTEPARTUM DIAGNOSES,566-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11190.18792,,,11190.18792,7637.552874,13602.2652,case rate,,,
OTHER ANTEPARTUM DIAGNOSES,566-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,35116.00202,,,35116.00202,13598.90164,35116.00202,case rate,,,
"CONCUSSION, CLOSED SKULL FX NOS,UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HR OR NO COMA",57-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12841.2555,,,12841.2555,4092.164708,12841.2555,case rate,,,
"CONCUSSION, CLOSED SKULL FX NOS,UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HR OR NO COMA",57-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16916.36055,,,16916.36055,6427.716996,18427.79816,case rate,,,
"CONCUSSION, CLOSED SKULL FX NOS,UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HR OR NO COMA",57-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24974.44343,,,24974.44343,11096.34747,26134.21412,case rate,,,
"CONCUSSION, CLOSED SKULL FX NOS,UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HR OR NO COMA",57-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,63082.27314,,,63082.27314,22070.22689,63082.27314,case rate,,,
"NEONATE, TRANSFERRED <5 DAYS OLD, NOT BORN HERE",580-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,7308.8304,per diem,,,
"NEONATE, TRANSFERRED <5 DAYS OLD, NOT BORN HERE",580-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,9346.0044,per diem,,,
"NEONATE, TRANSFERRED <5 DAYS OLD, NOT BORN HERE",580-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,15332.5464,per diem,,,
"NEONATE, TRANSFERRED <5 DAYS OLD, NOT BORN HERE",580-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,25158.51877,per diem,,,
OTHER DISORDERS OF NERVOUS SYSTEM,58-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11983.36082,,,11983.36082,6548.947994,16023.48652,case rate,,,
"NEONATE, TRANSFERRED < 5 DAYS OLD, BORN HERE",581-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,2088.142088,3106.94,per diem,,,
"NEONATE, TRANSFERRED < 5 DAYS OLD, BORN HERE",581-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,2351.633951,3852.0056,per diem,,,
"NEONATE, TRANSFERRED < 5 DAYS OLD, BORN HERE",581-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,2710.378741,5844.0648,per diem,,,
"NEONATE, TRANSFERRED < 5 DAYS OLD, BORN HERE",581-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,10254.0472,per diem,,,
OTHER DISORDERS OF NERVOUS SYSTEM,58-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14680.04834,,,14680.04834,10462.97736,20723.94959,case rate,,,
OTHER DISORDERS OF NERVOUS SYSTEM,58-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20733.86247,,,20733.86247,15280.05395,28038.28473,case rate,,,
NEONATE W ECMO,583-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,374287.6044,per diem,,,
NEONATE W ECMO,583-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,433113.1908,per diem,,,
NEONATE W ECMO,583-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,602569.6213,per diem,,,
NEONATE W ECMO,583-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,741583.8276,per diem,,,
OTHER DISORDERS OF NERVOUS SYSTEM,58-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,47556.34758,,,47556.34758,27114.92087,48663.08745,case rate,,,
NEONATE BWT <1500G W MAJOR PROCEDURE,588-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,400220.894,per diem,,,
NEONATE BWT <1500G W MAJOR PROCEDURE,588-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,400220.894,per diem,,,
NEONATE BWT <1500G W MAJOR PROCEDURE,588-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,523155.4344,per diem,,,
NEONATE BWT <1500G W MAJOR PROCEDURE,588-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,608300.1564,per diem,,,
NEONATE BWT <500G OR GA <24 WEEKS,589-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,284033.2549,per diem,,,
NEONATE BWT <500G OR GA <24 WEEKS,589-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,275285.7968,per diem,,,
NEONATE BWT <500G OR GA <24 WEEKS,589-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,250260.225,per diem,,,
NEONATE BWT <500G OR GA <24 WEEKS,589-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,1664.7336,47416.99153,per diem,,,
NEONATE BIRTHWT 500-749G W/O MAJOR PROCEDURE,591-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,2247.721667,214623.6845,per diem,,,
NEONATE BIRTHWT 500-749G W/O MAJOR PROCEDURE,591-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,297672.7098,per diem,,,
NEONATE BIRTHWT 500-749G W/O MAJOR PROCEDURE,591-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,316172.6148,per diem,,,
NEONATE BIRTHWT 500-749G W/O MAJOR PROCEDURE,591-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,453416.6724,per diem,,,
NEONATE BIRTHWT 750-999G W/O MAJOR PROCEDURE,593-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,2595.332998,223963.6496,per diem,,,
NEONATE BIRTHWT 750-999G W/O MAJOR PROCEDURE,593-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,243214.037,per diem,,,
NEONATE BIRTHWT 750-999G W/O MAJOR PROCEDURE,593-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,282328.376,per diem,,,
NEONATE BIRTHWT 750-999G W/O MAJOR PROCEDURE,593-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,396726.5136,per diem,,,
NEONATE BWT 1000-1249G W RESP DIST SYND/OTH MAJ RESP OR MAJ ANOM,602-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,134606.6564,per diem,,,
NEONATE BWT 1000-1249G W RESP DIST SYND/OTH MAJ RESP OR MAJ ANOM,602-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,196622.288,per diem,,,
NEONATE BWT 1000-1249G W RESP DIST SYND/OTH MAJ RESP OR MAJ ANOM,602-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,231412.6572,per diem,,,
NEONATE BWT 1000-1249G W RESP DIST SYND/OTH MAJ RESP OR MAJ ANOM,602-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,313501.0112,per diem,,,
NEONATE BIRTHWT 1000-1249G W OR W/O OTHER SIGNIFICANT CONDITION,603-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3035.723154,107271.5144,per diem,,,
NEONATE BIRTHWT 1000-1249G W OR W/O OTHER SIGNIFICANT CONDITION,603-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,143019.702,per diem,,,
NEONATE BIRTHWT 1000-1249G W OR W/O OTHER SIGNIFICANT CONDITION,603-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,186808.4802,per diem,,,
NEONATE BIRTHWT 1000-1249G W OR W/O OTHER SIGNIFICANT CONDITION,603-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,318901.4676,per diem,,,
NEONATE BWT 1250-1499G W RESP DIST SYND/OTH MAJ RESP OR MAJ ANOM,607-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,125246.1584,per diem,,,
NEONATE BWT 1250-1499G W RESP DIST SYND/OTH MAJ RESP OR MAJ ANOM,607-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,155042.1888,per diem,,,
NEONATE BWT 1250-1499G W RESP DIST SYND/OTH MAJ RESP OR MAJ ANOM,607-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,189679.1412,per diem,,,
NEONATE BWT 1250-1499G W RESP DIST SYND/OTH MAJ RESP OR MAJ ANOM,607-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,256779.1318,per diem,,,
NEONATE BWT 1250-1499G W OR W/O OTHER SIGNIFICANT CONDITION,608-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,87994.9008,per diem,,,
NEONATE BWT 1250-1499G W OR W/O OTHER SIGNIFICANT CONDITION,608-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,117882.152,per diem,,,
NEONATE BWT 1250-1499G W OR W/O OTHER SIGNIFICANT CONDITION,608-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,141466.8752,per diem,,,
NEONATE BWT 1250-1499G W OR W/O OTHER SIGNIFICANT CONDITION,608-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,235257.5006,per diem,,,
NEONATE BWT 1500-2499G W MAJOR PROCEDURE,609-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,115776.5064,per diem,,,
NEONATE BWT 1500-2499G W MAJOR PROCEDURE,609-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,119983.4885,per diem,,,
NEONATE BWT 1500-2499G W MAJOR PROCEDURE,609-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,191851.4507,per diem,,,
NEONATE BWT 1500-2499G W MAJOR PROCEDURE,609-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,430881.039,per diem,,,
NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY,611-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,51933.66,per diem,,,
NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY,611-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,83651.5468,per diem,,,
NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY,611-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,129902.5656,per diem,,,
NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY,611-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,216541.2751,per diem,,,
NEONATE BWT 1500-1999G W RESP DIST SYND/OTH MAJ RESP COND,612-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,72939.3224,per diem,,,
NEONATE BWT 1500-1999G W RESP DIST SYND/OTH MAJ RESP COND,612-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,94332.6732,per diem,,,
NEONATE BWT 1500-1999G W RESP DIST SYND/OTH MAJ RESP COND,612-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,131503.076,per diem,,,
NEONATE BWT 1500-1999G W RESP DIST SYND/OTH MAJ RESP COND,612-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,175674.6752,per diem,,,
NEONATE BIRTHWT 1500-1999G W CONGENITAL/PERINATAL INFECTION,613-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,55232.1212,per diem,,,
NEONATE BIRTHWT 1500-1999G W CONGENITAL/PERINATAL INFECTION,613-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,83500.2032,per diem,,,
NEONATE BIRTHWT 1500-1999G W CONGENITAL/PERINATAL INFECTION,613-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,109408.5733,per diem,,,
NEONATE BIRTHWT 1500-1999G W CONGENITAL/PERINATAL INFECTION,613-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,182804.2986,per diem,,,
NEONATE BWT 1500-1999G W OR W/O OTHER SIGNIFICANT CONDITION,614-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,41352.0472,per diem,,,
NEONATE BWT 1500-1999G W OR W/O OTHER SIGNIFICANT CONDITION,614-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,68380.3556,per diem,,,
NEONATE BWT 1500-1999G W OR W/O OTHER SIGNIFICANT CONDITION,614-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,104408.4252,per diem,,,
NEONATE BWT 1500-1999G W OR W/O OTHER SIGNIFICANT CONDITION,614-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,156676.8445,per diem,,,
NEONATE BWT 2000-2499G W MAJOR ANOMALY,621-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,22326.0729,per diem,,,
NEONATE BWT 2000-2499G W MAJOR ANOMALY,621-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,53971.95178,per diem,,,
NEONATE BWT 2000-2499G W MAJOR ANOMALY,621-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,99259.5389,per diem,,,
NEONATE BWT 2000-2499G W MAJOR ANOMALY,621-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,182153.0839,per diem,,,
NEONATE BWT 2000-2499G W RESP DIST SYND/OTH MAJ RESP COND,622-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,40164.1036,per diem,,,
NEONATE BWT 2000-2499G W RESP DIST SYND/OTH MAJ RESP COND,622-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,54533.4528,per diem,,,
NEONATE BWT 2000-2499G W RESP DIST SYND/OTH MAJ RESP COND,622-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,74755.4456,per diem,,,
NEONATE BWT 2000-2499G W RESP DIST SYND/OTH MAJ RESP COND,622-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,128510.1195,per diem,,,
NEONATE BWT 2000-2499G W CONGENITAL/PERINATAL INFECTION,623-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,30162.9868,per diem,,,
NEONATE BWT 2000-2499G W CONGENITAL/PERINATAL INFECTION,623-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,45294.34714,per diem,,,
NEONATE BWT 2000-2499G W CONGENITAL/PERINATAL INFECTION,623-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,81926.863,per diem,,,
NEONATE BWT 2000-2499G W CONGENITAL/PERINATAL INFECTION,623-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,128086.4919,per diem,,,
NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION,625-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,33167.0536,per diem,,,
NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION,625-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,53639.9036,per diem,,,
NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION,625-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,72902.24431,per diem,,,
NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION,625-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,136351.7357,per diem,,,
"NEONATE BWT 2000-2499G, NORMAL NEWBORN OR NEONATE W OTHER PROBLEM",626-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,2371.426767,4318.4756,per diem,,,
"NEONATE BWT 2000-2499G, NORMAL NEWBORN OR NEONATE W OTHER PROBLEM",626-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,8636.9512,per diem,,,
"NEONATE BWT 2000-2499G, NORMAL NEWBORN OR NEONATE W OTHER PROBLEM",626-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,27737.3428,per diem,,,
"NEONATE BWT 2000-2499G, NORMAL NEWBORN OR NEONATE W OTHER PROBLEM",626-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,63318.7978,per diem,,,
NEONATE BIRTHWT >2499G W MAJOR CARDIOVASCULAR PROCEDURE,630-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,71500.5216,per diem,,,
NEONATE BIRTHWT >2499G W MAJOR CARDIOVASCULAR PROCEDURE,630-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,135353.34,per diem,,,
NEONATE BIRTHWT >2499G W MAJOR CARDIOVASCULAR PROCEDURE,630-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,213335.8608,per diem,,,
NEONATE BIRTHWT >2499G W MAJOR CARDIOVASCULAR PROCEDURE,630-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,441526.8444,per diem,,,
NEONATE BIRTHWT >2499G W OTHER MAJOR PROCEDURE,631-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,37594.69119,per diem,,,
NEONATE BIRTHWT >2499G W OTHER MAJOR PROCEDURE,631-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,86071.2264,per diem,,,
NEONATE BIRTHWT >2499G W OTHER MAJOR PROCEDURE,631-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,140342.5416,per diem,,,
NEONATE BIRTHWT >2499G W OTHER MAJOR PROCEDURE,631-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,365451.5184,per diem,,,
NEONATE BIRTHWT >2499G W MAJOR ANOMALY,633-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,8596.48447,per diem,,,
NEONATE BIRTHWT >2499G W MAJOR ANOMALY,633-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,28784.13961,per diem,,,
NEONATE BIRTHWT >2499G W MAJOR ANOMALY,633-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,70693.97307,per diem,,,
NEONATE BIRTHWT >2499G W MAJOR ANOMALY,633-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,165647.3831,per diem,,,
"NEONATE, BIRTHWT >2499G W RESP DIST SYND/OTH MAJ RESP COND",634-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,16670.6012,per diem,,,
"NEONATE, BIRTHWT >2499G W RESP DIST SYND/OTH MAJ RESP COND",634-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,30082.0623,per diem,,,
"NEONATE, BIRTHWT >2499G W RESP DIST SYND/OTH MAJ RESP COND",634-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,46692.6104,per diem,,,
"NEONATE, BIRTHWT >2499G W RESP DIST SYND/OTH MAJ RESP COND",634-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,111116.6035,per diem,,,
NEONATE BIRTHWT >2499G W CONGENITAL/PERINATAL INFECTION,636-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,20470.7768,per diem,,,
NEONATE BIRTHWT >2499G W CONGENITAL/PERINATAL INFECTION,636-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,27780.88,per diem,,,
NEONATE BIRTHWT >2499G W CONGENITAL/PERINATAL INFECTION,636-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,53190.04349,per diem,,,
NEONATE BIRTHWT >2499G W CONGENITAL/PERINATAL INFECTION,636-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,95108.8903,per diem,,,
NEONATE BIRTHWT >2499G W OTHER SIGNIFICANT CONDITION,639-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,14743.59053,per diem,,,
NEONATE BIRTHWT >2499G W OTHER SIGNIFICANT CONDITION,639-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,27456.92353,per diem,,,
NEONATE BIRTHWT >2499G W OTHER SIGNIFICANT CONDITION,639-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,45195.20027,per diem,,,
NEONATE BIRTHWT >2499G W OTHER SIGNIFICANT CONDITION,639-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3106.94,,,3106.94,3106.94,79492.7076,per diem,,,
"NEONATE BIRTHWT >2499G, NORMAL NEWBORN OR NEONATE W OTHER PROBLEM",640-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3283.28,,,3283.28,1692.285768,3626.0268,case rate,,,
"NEONATE BIRTHWT >2499G, NORMAL NEWBORN OR NEONATE W OTHER PROBLEM",640-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3283.28,,,3283.28,2154.942842,5037.876,case rate,,,
"NEONATE BIRTHWT >2499G, NORMAL NEWBORN OR NEONATE W OTHER PROBLEM",640-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3283.28,,,3283.28,3283.28,11197.3532,case rate,,,
"NEONATE BIRTHWT >2499G, NORMAL NEWBORN OR NEONATE W OTHER PROBLEM",640-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3283.28,,,3283.28,3283.28,71164.92072,case rate,,,
SPLENECTOMY,650-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24474.84582,,,24474.84582,17516.64216,33414.6528,case rate,,,
SPLENECTOMY,650-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,33982.90935,,,33982.90935,22954.71836,44220.4236,case rate,,,
SPLENECTOMY,650-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,51075.39902,,,51075.39902,35121.11494,65164.572,case rate,,,
SPLENECTOMY,650-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,110425.7972,,,110425.7972,55417.4107,118234.596,case rate,,,
OTHER PROCEDURES OF BLOOD & BLOOD-FORMING ORGANS,651-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19476.1613,,,19476.1613,10462.97736,25815.8688,case rate,,,
OTHER PROCEDURES OF BLOOD & BLOOD-FORMING ORGANS,651-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,27535.36769,,,27535.36769,16851.10872,37791.4524,case rate,,,
OTHER PROCEDURES OF BLOOD & BLOOD-FORMING ORGANS,651-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,44404.92231,,,44404.92231,32278.37174,54677.24657,case rate,,,
OTHER PROCEDURES OF BLOOD & BLOOD-FORMING ORGANS,651-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,121197.701,,,121197.701,78199.0308,158835.5423,case rate,,,
MAJOR HEMATOLOGIC/IMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS & COAGUL,660-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12374.46016,,,12374.46016,9472.099507,15356.49847,case rate,,,
MAJOR HEMATOLOGIC/IMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS & COAGUL,660-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15196.83956,,,15196.83956,10841.51496,18656.7268,case rate,,,
MAJOR HEMATOLOGIC/IMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS & COAGUL,660-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24988.62765,,,24988.62765,15981.46187,31547.8844,case rate,,,
MAJOR HEMATOLOGIC/IMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS & COAGUL,660-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,76904.10581,,,76904.10581,45934.17773,103203.896,case rate,,,
COAGULATION & PLATELET DISORDERS,661-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16654.66465,,,16654.66465,10362.77623,20931.0272,case rate,,,
COAGULATION & PLATELET DISORDERS,661-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20397.61414,,,20397.61414,12003.10585,24584.0056,case rate,,,
COAGULATION & PLATELET DISORDERS,661-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,37329.6636,,,37329.6636,17730.65198,40547.6456,case rate,,,
COAGULATION & PLATELET DISORDERS,661-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,76971.11472,,,76971.11472,41091.12307,94664.3852,case rate,,,
SICKLE CELL ANEMIA CRISIS,662-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10640.49413,,,10640.49413,7726.620546,13865.5616,case rate,,,
SICKLE CELL ANEMIA CRISIS,662-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14397.24665,,,14397.24665,11199.0227,20010.5264,case rate,,,
SICKLE CELL ANEMIA CRISIS,662-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22826.30613,,,22826.30613,14193.92317,31941.7924,case rate,,,
SICKLE CELL ANEMIA CRISIS,662-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,58402.92422,,,58402.92422,19756.94152,68670.6036,case rate,,,
OTHER ANEMIA & DISORDERS OF BLOOD & BLOOD-FORMING ORGANS,663-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8942.038813,,,8942.038813,5320.556351,11645.6364,case rate,,,
OTHER ANEMIA & DISORDERS OF BLOOD & BLOOD-FORMING ORGANS,663-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11587.08534,,,11587.08534,7001.70866,16472.364,case rate,,,
OTHER ANEMIA & DISORDERS OF BLOOD & BLOOD-FORMING ORGANS,663-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17183.37302,,,17183.37302,9911.252612,23020.8128,case rate,,,
OTHER ANEMIA & DISORDERS OF BLOOD & BLOOD-FORMING ORGANS,663-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,37636.1993,,,37636.1993,20617.92902,48832.1528,case rate,,,
MAJOR O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/OTHER NEOPLASMS,680-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,28082.39316,,,28082.39316,15089.5481,38263.8768,case rate,,,
MAJOR O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/OTHER NEOPLASMS,680-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,39077.07154,,,39077.07154,20636.48478,50486.9208,case rate,,,
MAJOR O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/OTHER NEOPLASMS,680-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,68573.79419,,,68573.79419,38646.71029,83031.7128,case rate,,,
MAJOR O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/OTHER NEOPLASMS,680-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,154900.6776,,,154900.6776,98899.75335,185474.6916,case rate,,,
OTHER O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/OTHER NEOPLASMS,681-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20629.77796,,,20629.77796,11471.17392,28300.4712,case rate,,,
OTHER O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/OTHER NEOPLASMS,681-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,28953.0075,,,28953.0075,16049.49967,37141.5564,case rate,,,
OTHER O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/OTHER NEOPLASMS,681-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,52482.18499,,,52482.18499,29709.01682,79181.7276,case rate,,,
OTHER O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/OTHER NEOPLASMS,681-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,140315.3847,,,140315.3847,68121.92447,185990.9184,case rate,,,
ACUTE LEUKEMIA,690-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20685.75248,,,20685.75248,20674.1916,32434.54717,case rate,,,
ACUTE LEUKEMIA,690-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,31863.76243,,,31863.76243,31812.00352,56364.0884,case rate,,,
ACUTE LEUKEMIA,690-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,65733.49893,,,65733.49893,57289.06886,125696.0428,case rate,,,
ACUTE LEUKEMIA,690-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,146223.8055,,,146223.8055,97509.30802,181469.2692,case rate,,,
"LYMPHOMA, MYELOMA & NON-ACUTE LEUKEMIA",691-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17553.86812,,,17553.86812,11648.07222,23067.42111,case rate,,,
"LYMPHOMA, MYELOMA & NON-ACUTE LEUKEMIA",691-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22931.55427,,,22931.55427,15364.17342,30766.288,case rate,,,
"LYMPHOMA, MYELOMA & NON-ACUTE LEUKEMIA",691-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,35632.01079,,,35632.01079,23463.14632,52093.2964,case rate,,,
"LYMPHOMA, MYELOMA & NON-ACUTE LEUKEMIA",691-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,81875.68582,,,81875.68582,43705.01183,131291.6096,case rate,,,
RADIOTHERAPY,692-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16832.05772,,,16832.05772,12354.1988,19865.42781,case rate,,,
RADIOTHERAPY,692-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,31897.32707,,,31897.32707,15810.74883,34570.7116,case rate,,,
RADIOTHERAPY,692-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45424.56126,,,45424.56126,28178.78473,57713.7416,case rate,,,
RADIOTHERAPY,692-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,81233.3833,,,81233.3833,47680.89374,94797.92966,case rate,,,
CHEMOTHERAPY,693-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14789.91087,,,14789.91087,14789.91087,14789.91087,case rate,,,
CHEMOTHERAPY,693-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17344.39504,,,17344.39504,17344.39504,17344.39504,case rate,,,
CHEMOTHERAPY,693-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,33891.82537,,,33891.82537,33891.82537,33891.82537,case rate,,,
CHEMOTHERAPY,693-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,118665.065,,,118665.065,118665.065,118665.065,case rate,,,
LYMPHATIC & OTHER MALIGNANCIES & NEOPLASMS OF UNCERTAIN BEHAVIOR,694-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11535.7854,,,11535.7854,6308.9601,14902.6152,case rate,,,
LYMPHATIC & OTHER MALIGNANCIES & NEOPLASMS OF UNCERTAIN BEHAVIOR,694-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14964.45505,,,14964.45505,8468.851146,20348.458,case rate,,,
LYMPHATIC & OTHER MALIGNANCIES & NEOPLASMS OF UNCERTAIN BEHAVIOR,694-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24597.92957,,,24597.92957,13250.05326,33604.4988,case rate,,,
LYMPHATIC & OTHER MALIGNANCIES & NEOPLASMS OF UNCERTAIN BEHAVIOR,694-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,53247.08975,,,53247.08975,24004.97466,70103.1848,case rate,,,
ORBITAL PROCEDURES,70-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17171.69662,,,17171.69662,17171.69662,17171.69662,case rate,,,
ORBITAL PROCEDURES,70-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24603.64739,,,24603.64739,24603.64739,24603.64739,case rate,,,
ORBITAL PROCEDURES,70-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,44276.02043,,,44276.02043,44276.02043,44276.02043,case rate,,,
ORBITAL PROCEDURES,70-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,85525.86608,,,85525.86608,85525.86608,85525.86608,case rate,,,
INFECTIOUS & PARASITIC DISEASES INCLUDING HIV W O.R. PROCEDURE,710-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21338.40727,,,21338.40727,8477.510503,24978.5028,case rate,,,
INFECTIOUS & PARASITIC DISEASES INCLUDING HIV W O.R. PROCEDURE,710-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,31491.54195,,,31491.54195,13063.25856,36136.7172,case rate,,,
INFECTIOUS & PARASITIC DISEASES INCLUDING HIV W O.R. PROCEDURE,710-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,51836.69252,,,51836.69252,22055.38228,61690.1392,case rate,,,
INFECTIOUS & PARASITIC DISEASES INCLUDING HIV W O.R. PROCEDURE,710-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,116497.8682,,,116497.8682,54399.31773,131034.5328,case rate,,,
"POST-OP, POST-TRAUMA, OTHER DEVICE INFECTIONS W O.R. PROCEDURE",711-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20219.65933,,,20219.65933,11346.23177,25383.438,case rate,,,
"POST-OP, POST-TRAUMA, OTHER DEVICE INFECTIONS W O.R. PROCEDURE",711-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29039.21627,,,29039.21627,15597.97606,33192.1884,case rate,,,
"POST-OP, POST-TRAUMA, OTHER DEVICE INFECTIONS W O.R. PROCEDURE",711-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,51068.91881,,,51068.91881,27400.67965,59602.4268,case rate,,,
"POST-OP, POST-TRAUMA, OTHER DEVICE INFECTIONS W O.R. PROCEDURE",711-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,121608.7827,,,121608.7827,59994.4994,125136.2788,case rate,,,
SEPTICEMIA & DISSEMINATED INFECTIONS,720-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10626.08922,,,10626.08922,4986.552581,13955.2668,case rate,,,
SEPTICEMIA & DISSEMINATED INFECTIONS,720-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14338.022,,,14338.022,6671.416043,17947.128,case rate,,,
SEPTICEMIA & DISSEMINATED INFECTIONS,720-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24576.90401,,,24576.90401,10689.35769,30849.216,case rate,,,
SEPTICEMIA & DISSEMINATED INFECTIONS,720-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,56429.07029,,,56429.07029,22367.11913,66348.6196,case rate,,,
"POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS",721-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11103.03621,,,11103.03621,6469.77673,13525.3356,case rate,,,
"POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS",721-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14833.26604,,,14833.26604,8070.520724,17827.1472,case rate,,,
"POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS",721-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24920.25449,,,24920.25449,14030.63244,29679.9312,case rate,,,
"POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS",721-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50938.69281,,,50938.69281,27841.06981,58692.292,case rate,,,
FEVER,722-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6893.792946,,,6893.792946,4348.234265,10643.8088,case rate,,,
FEVER,722-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10609.4373,,,10609.4373,6099.898481,13842.7848,case rate,,,
FEVER,722-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15842.83359,,,15842.83359,8863.470415,18866.9808,case rate,,,
FEVER,722-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,30130.55878,,,30130.55878,15852.80857,37151.744,case rate,,,
VIRAL ILLNESS,723-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6550.141536,,,6550.141536,4109.483422,9532.5736,case rate,,,
VIRAL ILLNESS,723-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9585.40465,,,9585.40465,6531.62928,12627.9792,case rate,,,
VIRAL ILLNESS,723-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16109.22412,,,16109.22412,9405.298753,19313.36,case rate,,,
VIRAL ILLNESS,723-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,58763.36799,,,58763.36799,23387.68621,58763.36799,case rate,,,
OTHER INFECTIOUS & PARASITIC DISEASES,724-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11775.21187,,,11775.21187,6918.826243,13605.3228,case rate,,,
OTHER INFECTIOUS & PARASITIC DISEASES,724-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14322.25284,,,14322.25284,7115.517352,16299.8916,case rate,,,
OTHER INFECTIOUS & PARASITIC DISEASES,724-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,23459.05888,,,23459.05888,10074.54334,28255.6428,case rate,,,
OTHER INFECTIOUS & PARASITIC DISEASES,724-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,60298.21321,,,60298.21321,20912.34716,75062.2792,case rate,,,
EYE PROCEDURES EXCEPT ORBIT,73-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14537.08262,,,14537.08262,10326.90175,20336.37545,case rate,,,
EYE PROCEDURES EXCEPT ORBIT,73-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18247.4104,,,18247.4104,14159.28575,28132.92493,case rate,,,
EYE PROCEDURES EXCEPT ORBIT,73-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29582.30949,,,29582.30949,28636.4936,47349.39139,case rate,,,
EYE PROCEDURES EXCEPT ORBIT,73-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,61405.64588,,,61405.64588,53497.50755,97375.74833,case rate,,,
MENTAL ILLNESS DIAGNOSIS W O.R. PROCEDURE,740-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,27109.86108,,,27109.86108,4163,62735.032,case rate,,,
MENTAL ILLNESS DIAGNOSIS W O.R. PROCEDURE,740-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,27651.65022,,,27651.65022,4163,62735.032,case rate,,,
MENTAL ILLNESS DIAGNOSIS W O.R. PROCEDURE,740-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,51990.43184,,,51990.43184,4163,62735.032,case rate,,,
MENTAL ILLNESS DIAGNOSIS W O.R. PROCEDURE,740-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,75876.70265,,,75876.70265,4163,102414.2121,case rate,,,
SCHIZOPHRENIA,750-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13011.2856,,,13011.2856,4163,30820.1912,case rate,,,
SCHIZOPHRENIA,750-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14401.25916,,,14401.25916,4163,35922.3364,case rate,,,
SCHIZOPHRENIA,750-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20815.19604,,,20815.19604,4163,44998.806,case rate,,,
SCHIZOPHRENIA,750-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,38378.53369,,,38378.53369,4163,67191.66212,case rate,,,
MAJOR DEPRESSIVE DISORDERS & OTHER/UNSPECIFIED PSYCHOSES,751-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7159.059976,,,7159.059976,4163,17790.1292,case rate,,,
MAJOR DEPRESSIVE DISORDERS & OTHER/UNSPECIFIED PSYCHOSES,751-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10103.35949,,,10103.35949,4163,21897.1384,case rate,,,
MAJOR DEPRESSIVE DISORDERS & OTHER/UNSPECIFIED PSYCHOSES,751-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16409.21942,,,16409.21942,4163,37218.0864,case rate,,,
MAJOR DEPRESSIVE DISORDERS & OTHER/UNSPECIFIED PSYCHOSES,751-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,32216.3818,,,32216.3818,4163,47849.456,case rate,,,
DISORDERS OF PERSONALITY & IMPULSE CONTROL,752-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6510.096687,,,6510.096687,4163,19658.0824,case rate,,,
DISORDERS OF PERSONALITY & IMPULSE CONTROL,752-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8708.871862,,,8708.871862,4163,19658.0824,case rate,,,
DISORDERS OF PERSONALITY & IMPULSE CONTROL,752-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18661.82242,,,18661.82242,4163,39719.23351,case rate,,,
DISORDERS OF PERSONALITY & IMPULSE CONTROL,752-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20025.29335,,,20025.29335,4163,62910.22861,case rate,,,
BIPOLAR DISORDERS,753-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7943.88685,,,7943.88685,4163,17174.3888,case rate,,,
BIPOLAR DISORDERS,753-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10679.2951,,,10679.2951,4163,21279.3248,case rate,,,
BIPOLAR DISORDERS,753-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17282.92339,,,17282.92339,4163,34187.068,case rate,,,
BIPOLAR DISORDERS,753-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29351.18892,,,29351.18892,4163,44570.94753,case rate,,,
DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,754-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5731.388891,,,5731.388891,4163,14365.2028,case rate,,,
DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,754-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7636.087215,,,7636.087215,4163,14365.2028,case rate,,,
DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,754-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11410.25403,,,11410.25403,4163,17667.8104,case rate,,,
DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,754-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,25196.51579,,,25196.51579,4163,36008.34124,case rate,,,
ADJUSTMENT DISORDERS & NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,755-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5134.748731,,,5134.748731,4163,10579.5396,case rate,,,
ADJUSTMENT DISORDERS & NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,755-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8160.221321,,,8160.221321,4163,16724.5044,case rate,,,
ADJUSTMENT DISORDERS & NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,755-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12505.10748,,,12505.10748,4163,19860.85381,case rate,,,
ADJUSTMENT DISORDERS & NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,755-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18869.22906,,,18869.22906,4163,32470.60058,case rate,,,
ACUTE ANXIETY & DELIRIUM STATES,756-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8111.730139,,,8111.730139,4163,10119.74096,case rate,,,
ACUTE ANXIETY & DELIRIUM STATES,756-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10261.13138,,,10261.13138,4163,12528.55928,case rate,,,
ACUTE ANXIETY & DELIRIUM STATES,756-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12845.64919,,,12845.64919,4163,18559.2864,case rate,,,
ACUTE ANXIETY & DELIRIUM STATES,756-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29601.60966,,,29601.60966,4163,34512.12481,case rate,,,
ORGANIC MENTAL HEALTH DISTURBANCES,757-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11523.52718,,,11523.52718,4163,16728.6508,case rate,,,
ORGANIC MENTAL HEALTH DISTURBANCES,757-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12920.34207,,,12920.34207,4163,20286.39935,case rate,,,
ORGANIC MENTAL HEALTH DISTURBANCES,757-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16792.79531,,,16792.79531,4163,26792.18882,case rate,,,
ORGANIC MENTAL HEALTH DISTURBANCES,757-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,31596.30858,,,31596.30858,4163,60416.49846,case rate,,,
CHILDHOOD BEHAVIORAL DISORDERS,758-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8645.454143,,,8645.454143,4163,11153.816,case rate,,,
CHILDHOOD BEHAVIORAL DISORDERS,758-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11084.49841,,,11084.49841,4163,23445.8188,case rate,,,
CHILDHOOD BEHAVIORAL DISORDERS,758-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15984.43506,,,15984.43506,4163,23445.8188,case rate,,,
CHILDHOOD BEHAVIORAL DISORDERS,758-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21123.13612,,,21123.13612,4163,30255.56933,case rate,,,
EATING DISORDERS,759-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16547.8717,,,16547.8717,4163,26874.8916,case rate,,,
EATING DISORDERS,759-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17552.88506,,,17552.88506,4163,27017.52262,case rate,,,
EATING DISORDERS,759-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24736.50159,,,24736.50159,4163,43860.6192,case rate,,,
EATING DISORDERS,759-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,42174.40818,,,42174.40818,4163,81708.4556,case rate,,,
OTHER MENTAL HEALTH DISORDERS,760-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10899.94302,,,10899.94302,4163,12464.52588,case rate,,,
OTHER MENTAL HEALTH DISORDERS,760-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12859.53248,,,12859.53248,4163,16861.3356,case rate,,,
OTHER MENTAL HEALTH DISORDERS,760-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16764.76793,,,16764.76793,4163,28750.30229,case rate,,,
OTHER MENTAL HEALTH DISORDERS,760-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,28714.34341,,,28714.34341,4163,36459.00884,case rate,,,
"DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE",770-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4321.252474,,,4321.252474,2690.585925,6198.868,case rate,,,
"DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE",770-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5204.586466,,,5204.586466,3943.718588,7857.428,case rate,,,
"DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE",770-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11854.82006,,,11854.82006,4163,16311.9376,case rate,,,
"DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE",770-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,43554.27021,,,43554.27021,4163,43554.27021,case rate,,,
ALCOHOL & DRUG DEPENDENCE W REHAB OR REHAB/DETOX THERAPY,772-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12128.73405,,,12128.73405,4163,20526.7532,case rate,,,
ALCOHOL & DRUG DEPENDENCE W REHAB OR REHAB/DETOX THERAPY,772-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14071.81203,,,14071.81203,4163,20526.7532,case rate,,,
ALCOHOL & DRUG DEPENDENCE W REHAB OR REHAB/DETOX THERAPY,772-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14682.79691,,,14682.79691,4163,20526.7532,case rate,,,
ALCOHOL & DRUG DEPENDENCE W REHAB OR REHAB/DETOX THERAPY,772-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50558.74824,,,50558.74824,4163,50558.74824,case rate,,,
OPIOID ABUSE & DEPENDENCE,773-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4923.690711,,,4923.690711,4163,7596.2048,case rate,,,
OPIOID ABUSE & DEPENDENCE,773-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6301.225484,,,6301.225484,4163,10334.902,case rate,,,
OPIOID ABUSE & DEPENDENCE,773-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12550.93034,,,12550.93034,4163,23483.1364,case rate,,,
OPIOID ABUSE & DEPENDENCE,773-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,36938.72476,,,36938.72476,4163,41123.4185,case rate,,,
COCAINE ABUSE & DEPENDENCE,774-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6416.565081,,,6416.565081,3928.873976,10274.7792,case rate,,,
COCAINE ABUSE & DEPENDENCE,774-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6720.191706,,,6720.191706,4163,10378.4392,case rate,,,
COCAINE ABUSE & DEPENDENCE,774-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13367.27548,,,13367.27548,4163,16765.9684,case rate,,,
COCAINE ABUSE & DEPENDENCE,774-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45820.27499,,,45820.27499,4163,45820.27499,case rate,,,
ALCOHOL ABUSE & DEPENDENCE,775-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6123.431171,,,6123.431171,4163,9460.0116,case rate,,,
ALCOHOL ABUSE & DEPENDENCE,775-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9149.906888,,,9149.906888,4163,13477.8732,case rate,,,
ALCOHOL ABUSE & DEPENDENCE,775-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17622.52217,,,17622.52217,4163,25550.1168,case rate,,,
ALCOHOL ABUSE & DEPENDENCE,775-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,52331.17418,,,52331.17418,4163,81254.9276,case rate,,,
OTHER DRUG ABUSE & DEPENDENCE,776-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6497.758219,,,6497.758219,4163,10842.836,case rate,,,
OTHER DRUG ABUSE & DEPENDENCE,776-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8611.869435,,,8611.869435,4163,11475.162,case rate,,,
OTHER DRUG ABUSE & DEPENDENCE,776-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15007.75003,,,15007.75003,4163,18763.54553,case rate,,,
OTHER DRUG ABUSE & DEPENDENCE,776-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,34820.09947,,,34820.09947,4163,34820.09947,case rate,,,
O.R. PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT,791-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18173.74071,,,18173.74071,17580.736,18173.74071,case rate,,,
O.R. PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT,791-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,27112.81027,,,27112.81027,27112.81027,29507.8556,case rate,,,
O.R. PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT,791-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,47893.83979,,,47893.83979,47893.83979,55439.4412,case rate,,,
O.R. PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT,791-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,113485.5768,,,113485.5768,113485.5768,137053.0324,case rate,,,
ACUTE MAJOR EYE INFECTIONS,80-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7669.451235,,,7669.451235,7669.451235,7669.451235,case rate,,,
ACUTE MAJOR EYE INFECTIONS,80-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11247.96806,,,11247.96806,11247.96806,11247.96806,case rate,,,
ACUTE MAJOR EYE INFECTIONS,80-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19088.45253,,,19088.45253,19088.45253,19088.45253,case rate,,,
ACUTE MAJOR EYE INFECTIONS,80-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,52142.56615,,,52142.56615,52142.56615,52142.56615,case rate,,,
ALLERGIC REACTIONS,811-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5676.618131,,,5676.618131,3623.322379,7813.7496,case rate,,,
ALLERGIC REACTIONS,811-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7911.184894,,,7911.184894,5976.193381,11623.14,case rate,,,
ALLERGIC REACTIONS,811-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17531.69901,,,17531.69901,10055.98758,22351.4232,case rate,,,
ALLERGIC REACTIONS,811-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,49700.37206,,,49700.37206,22568.75844,49700.37206,case rate,,,
POISONING OF MEDICINAL AGENTS,812-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6580.195235,,,6580.195235,4079.794198,8626.1196,case rate,,,
POISONING OF MEDICINAL AGENTS,812-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8277.968424,,,8277.968424,5519.721562,12308.0304,case rate,,,
POISONING OF MEDICINAL AGENTS,812-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15212.78928,,,15212.78928,7542.299947,19073.44,case rate,,,
POISONING OF MEDICINAL AGENTS,812-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,37989.92211,,,37989.92211,16447.8301,45328.4448,case rate,,,
OTHER COMPLICATIONS OF TREATMENT,813-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9406.246083,,,9406.246083,5669.404733,13412.8536,case rate,,,
OTHER COMPLICATIONS OF TREATMENT,813-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12655.4161,,,12655.4161,7962.897287,16522.356,case rate,,,
OTHER COMPLICATIONS OF TREATMENT,813-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21217.7511,,,21217.7511,12449.68126,23961.1656,case rate,,,
OTHER COMPLICATIONS OF TREATMENT,813-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,49353.14952,,,49353.14952,22671.43368,54185.1552,case rate,,,
"OTHER INJURY, POISONING & TOXIC EFFECT DIAGNOSES",815-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9248.654757,,,9248.654757,4531.317813,9506.833022,case rate,,,
"OTHER INJURY, POISONING & TOXIC EFFECT DIAGNOSES",815-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10119.48978,,,10119.48978,6949.752518,13352.8632,case rate,,,
"OTHER INJURY, POISONING & TOXIC EFFECT DIAGNOSES",815-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17479.47619,,,17479.47619,11911.56408,22497.32659,case rate,,,
"OTHER INJURY, POISONING & TOXIC EFFECT DIAGNOSES",815-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,51452.15363,,,51452.15363,21705.29685,60952.7929,case rate,,,
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES,816-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10822.28089,,,10822.28089,4087.216504,12685.47,case rate,,,
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES,816-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11903.11062,,,11903.11062,5840.117771,13430.3508,case rate,,,
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES,816-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16453.47741,,,16453.47741,7023.975578,18266.9652,case rate,,,
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES,816-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,40797.19441,,,40797.19441,15849.09741,43412.808,case rate,,,
EYE DISORDERS EXCEPT MAJOR INFECTIONS,82-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9417.501173,,,9417.501173,6026.912472,11866.07791,case rate,,,
EYE DISORDERS EXCEPT MAJOR INFECTIONS,82-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12129.81743,,,12129.81743,7631.367619,15052.29784,case rate,,,
EYE DISORDERS EXCEPT MAJOR INFECTIONS,82-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16802.14446,,,16802.14446,11573.84916,23193.60803,case rate,,,
EYE DISORDERS EXCEPT MAJOR INFECTIONS,82-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,62488.26118,,,62488.26118,31991.37591,62488.26118,case rate,,,
EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT,841-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,88007.0417,,,88007.0417,26814.31748,111264.4976,case rate,,,
EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT,841-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,89501.92233,,,89501.92233,30521.75932,146821.9508,case rate,,,
EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT,841-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,120840.7883,,,120840.7883,109203.1511,303576.6028,case rate,,,
EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT,841-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,358403.2626,,,358403.2626,225396.8775,410151.8652,case rate,,,
FULL THICKNESS BURNS W SKIN GRAFT,842-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29103.79762,,,29103.79762,19083.98578,44681.6064,case rate,,,
FULL THICKNESS BURNS W SKIN GRAFT,842-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,42910.12193,,,42910.12193,24716.27898,58762.7808,case rate,,,
FULL THICKNESS BURNS W SKIN GRAFT,842-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,79926.02733,,,79926.02733,42663.41489,93889.83445,case rate,,,
FULL THICKNESS BURNS W SKIN GRAFT,842-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,197817.4202,,,197817.4202,123239.9688,216388.0481,case rate,,,
EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS W/O SKIN GRAFT,843-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11056.99266,,,11056.99266,6250.818703,40871.0648,case rate,,,
EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS W/O SKIN GRAFT,843-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15253.55638,,,15253.55638,7184.792208,40871.0648,case rate,,,
EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS W/O SKIN GRAFT,843-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,27857.05061,,,27857.05061,11055.52479,40871.0648,case rate,,,
EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS W/O SKIN GRAFT,843-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,75152.58505,,,75152.58505,27429.13182,92760.91211,case rate,,,
PARTIAL THICKNESS BURNS W OR W/O SKIN GRAFT,844-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10244.41928,,,10244.41928,3558.995727,13461.2876,case rate,,,
PARTIAL THICKNESS BURNS W OR W/O SKIN GRAFT,844-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16760.37423,,,16760.37423,7095.724536,22050.5552,case rate,,,
PARTIAL THICKNESS BURNS W OR W/O SKIN GRAFT,844-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29521.05852,,,29521.05852,13734.97725,39019.6972,case rate,,,
PARTIAL THICKNESS BURNS W OR W/O SKIN GRAFT,844-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,119309.2333,,,119309.2333,37509.86042,119309.2333,case rate,,,
"PROCEDURE W DIAG OF REHAB, AFTERCARE OR OTH CONTACT W HEALTH SERVICE",850-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26651.39169,,,26651.39169,16233.82027,40893.456,case rate,,,
"PROCEDURE W DIAG OF REHAB, AFTERCARE OR OTH CONTACT W HEALTH SERVICE",850-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,30216.48668,,,30216.48668,26437.01692,55463.6244,case rate,,,
"PROCEDURE W DIAG OF REHAB, AFTERCARE OR OTH CONTACT W HEALTH SERVICE",850-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,57264.7156,,,57264.7156,33009.46888,67991.6196,case rate,,,
"PROCEDURE W DIAG OF REHAB, AFTERCARE OR OTH CONTACT W HEALTH SERVICE",850-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,121786.2961,,,121786.2961,65129.4981,158116.7444,case rate,,,
REHABILITATION,860-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15236.40291,,,15236.40291,14210.00484,31767.6436,case rate,,,
REHABILITATION,860-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21014.77829,,,21014.77829,17966.92872,37191.1348,case rate,,,
REHABILITATION,860-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,31144.11878,,,31144.11878,20564.73582,49180.4504,case rate,,,
REHABILITATION,860-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,44282.58088,,,44282.58088,22327.5335,49180.4504,case rate,,,
"SIGNS, SYMPTOMS & OTHER FACTORS INFLUENCING HEALTH STATUS",861-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7653.962947,,,7653.962947,5162.213823,10782.22233,case rate,,,
"SIGNS, SYMPTOMS & OTHER FACTORS INFLUENCING HEALTH STATUS",861-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10339.05432,,,10339.05432,6654.097329,14677.6512,case rate,,,
"SIGNS, SYMPTOMS & OTHER FACTORS INFLUENCING HEALTH STATUS",861-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15477.39425,,,15477.39425,10072.06924,21930.3096,case rate,,,
"SIGNS, SYMPTOMS & OTHER FACTORS INFLUENCING HEALTH STATUS",861-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,35599.56965,,,35599.56965,20888.84319,43334.0264,case rate,,,
OTHER AFTERCARE & CONVALESCENCE,862-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7142.668873,,,7142.668873,4630.281893,12895.85337,case rate,,,
OTHER AFTERCARE & CONVALESCENCE,862-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12527.71797,,,12527.71797,6746.876154,17745.03675,case rate,,,
OTHER AFTERCARE & CONVALESCENCE,862-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19669.34359,,,19669.34359,7539.825845,26528.54827,case rate,,,
OTHER AFTERCARE & CONVALESCENCE,862-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,35179.54011,,,35179.54011,7915.889349,44418.31,case rate,,,
NEONATAL AFTERCARE,863-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15421.15892,,,15421.15892,12751.52171,21059.13,case rate,,,
NEONATAL AFTERCARE,863-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,43591.20536,,,43591.20536,18800.7011,53571.4272,case rate,,,
NEONATAL AFTERCARE,863-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,78036.81729,,,78036.81729,43645.63338,104410.7916,case rate,,,
NEONATAL AFTERCARE,863-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,186439.3666,,,186439.3666,109858.868,225297.7466,case rate,,,
HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS,890-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21700.19523,,,21700.19523,10628.74219,23085.082,case rate,,,
HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS,890-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,25146.31929,,,25146.31929,11189.1263,25146.31929,case rate,,,
HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS,890-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,35815.3223,,,35815.3223,16691.52914,39929.832,case rate,,,
HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS,890-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,80427.67131,,,80427.67131,31893.64888,80427.67131,case rate,,,
MAJOR CRANIAL/FACIAL BONE PROCEDURES,89-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29447.18822,,,29447.18822,15622.71708,36434.22212,case rate,,,
MAJOR CRANIAL/FACIAL BONE PROCEDURES,89-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,38745.09653,,,38745.09653,27834.88455,48165.09975,case rate,,,
HIV W MAJOR HIV RELATED CONDITION,892-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12938.41842,,,12938.41842,8930.271169,16769.8164,case rate,,,
HIV W MAJOR HIV RELATED CONDITION,892-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18339.05612,,,18339.05612,9432.513875,19345.0292,case rate,,,
HIV W MAJOR HIV RELATED CONDITION,892-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24817.61448,,,24817.61448,12723.06954,27148.554,case rate,,,
HIV W MAJOR HIV RELATED CONDITION,892-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,48052.71512,,,48052.71512,24712.56783,48398.854,case rate,,,
MAJOR CRANIAL/FACIAL BONE PROCEDURES,89-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,69570.04021,,,69570.04021,45277.30365,80847.5141,case rate,,,
HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,893-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17568.27303,,,17568.27303,10636.1645,18472.044,case rate,,,
HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,893-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,18809.98435,,,18809.98435,11138.4072,20009.298,case rate,,,
HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,893-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,28900.70443,,,28900.70443,13720.13264,30111.1568,case rate,,,
HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,893-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50292.65865,,,50292.65865,28810.91779,50292.65865,case rate,,,
MAJOR CRANIAL/FACIAL BONE PROCEDURES,89-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,135133.2683,,,135133.2683,73853.18175,138501.4202,case rate,,,
HIV W ONE SIGNIF HIV COND OR W/O SIGNIF RELATED COND,894-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11760.50602,,,11760.50602,6723.372185,13617.8208,case rate,,,
HIV W ONE SIGNIF HIV COND OR W/O SIGNIF RELATED COND,894-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14461.14587,,,14461.14587,8786.773253,17042.2728,case rate,,,
HIV W ONE SIGNIF HIV COND OR W/O SIGNIF RELATED COND,894-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20782.45396,,,20782.45396,13374.99541,24656.0544,case rate,,,
HIV W ONE SIGNIF HIV COND OR W/O SIGNIF RELATED COND,894-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,41338.26131,,,41338.26131,24032.5344,41338.26131,case rate,,,
MAJOR LARYNX & TRACHEA PROCEDURES,90-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13630.15507,,,13630.15507,13630.15507,13630.15507,case rate,,,
MAJOR LARYNX & TRACHEA PROCEDURES,90-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45805.46883,,,45805.46883,45805.46883,45805.46883,case rate,,,
MAJOR LARYNX & TRACHEA PROCEDURES,90-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,72769.27454,,,72769.27454,72769.27454,72769.27454,case rate,,,
MAJOR LARYNX & TRACHEA PROCEDURES,90-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,144932.5999,,,144932.5999,144932.5999,144932.5999,case rate,,,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,910-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,58900.37514,,,58900.37514,41677.48524,77939.8808,case rate,,,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,910-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,65295.51342,,,65295.51342,47677.18259,85066.3872,case rate,,,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,910-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,92318.66415,,,92318.66415,53675.64289,95769.6744,case rate,,,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,910-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,189232.1738,,,189232.1738,90084.52792,189232.1738,case rate,,,
OTHER MAJOR HEAD & NECK PROCEDURES,91-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,27449.07866,,,27449.07866,14823.58213,29640.40805,case rate,,,
EXTENSIVE ABDOMINAL/THORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA,911-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26156.06741,,,26156.06741,26156.06741,40947.65814,case rate,,,
EXTENSIVE ABDOMINAL/THORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA,911-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,41135.79006,,,41135.79006,30735.76915,52459.1052,case rate,,,
EXTENSIVE ABDOMINAL/THORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA,911-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,59554.4945,,,59554.4945,31043.79485,71461.0644,case rate,,,
EXTENSIVE ABDOMINAL/THORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA,911-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,158230.479,,,158230.479,67139.70597,158230.479,case rate,,,
OTHER MAJOR HEAD & NECK PROCEDURES,91-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,41541.11374,,,41541.11374,25589.63699,45965.84186,case rate,,,
MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,912-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,41332.86448,,,41332.86448,27601.08191,51666.732,case rate,,,
MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,912-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45925.72375,,,45925.72375,27690.14958,52399.1148,case rate,,,
MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,912-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,77245.99171,,,77245.99171,31402.53964,83091.7032,case rate,,,
MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,912-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,154215.8425,,,154215.8425,62592.3065,157078.0712,case rate,,,
OTHER MAJOR HEAD & NECK PROCEDURES,91-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,77244.30646,,,77244.30646,51338.85355,80313.473,case rate,,,
OTHER MAJOR HEAD & NECK PROCEDURES,91-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,125726.5407,,,125726.5407,112767.0951,143844.0846,case rate,,,
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL/FACIAL BONE PROCEDURES,92-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20930.05414,,,20930.05414,16195.47169,27186.52297,case rate,,,
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL/FACIAL BONE PROCEDURES,92-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29289.07526,,,29289.07526,24432.9943,36580.68909,case rate,,,
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL/FACIAL BONE PROCEDURES,92-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50147.94748,,,50147.94748,29467.79187,59995.12425,case rate,,,
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL/FACIAL BONE PROCEDURES,92-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,109717.7898,,,109717.7898,83676.60374,120508.5162,case rate,,,
MULTIPLE SIGNIFICANT TRAUMA W/O O.R. PROCEDURE,930-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16691.80043,,,16691.80043,8180.618263,18694.5084,case rate,,,
MULTIPLE SIGNIFICANT TRAUMA W/O O.R. PROCEDURE,930-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20587.78705,,,20587.78705,9733.117268,22506.3984,case rate,,,
MULTIPLE SIGNIFICANT TRAUMA W/O O.R. PROCEDURE,930-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,33201.67367,,,33201.67367,14993.05812,35419.332,case rate,,,
MULTIPLE SIGNIFICANT TRAUMA W/O O.R. PROCEDURE,930-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,88840.39988,,,88840.39988,30959.67538,88840.39988,case rate,,,
SINUS & MASTOID PROCEDURES,93-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20642.35718,,,20642.35718,20642.35718,20642.35718,case rate,,,
SINUS & MASTOID PROCEDURES,93-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,27301.81955,,,27301.81955,27301.81955,27301.81955,case rate,,,
SINUS & MASTOID PROCEDURES,93-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,41976.77201,,,41976.77201,41976.77201,41976.77201,case rate,,,
SINUS & MASTOID PROCEDURES,93-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,62534.60567,,,62534.60567,62534.60567,62534.60567,case rate,,,
EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,950-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,28505.55246,,,28505.55246,14584.83129,35254.3584,case rate,,,
EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,950-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,43003.59335,,,43003.59335,20831.93884,47919.8316,case rate,,,
EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,950-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,68188.23211,,,68188.23211,33165.33731,82811.9008,case rate,,,
EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,950-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,136897.2278,,,136897.2278,71562.1633,168225.6676,case rate,,,
CLEFT LIP & PALATE REPAIR,95-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11973.85117,,,11973.85117,11973.85117,17041.99529,case rate,,,
MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,951-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20193.59807,,,20193.59807,11862.08204,26835.7056,case rate,,,
MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,951-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29978.64515,,,29978.64515,15976.51367,36514.1568,case rate,,,
MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,951-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50729.64104,,,50729.64104,26771.02069,56221.0376,case rate,,,
MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,951-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,105118.651,,,105118.651,52603.11967,130095.3732,case rate,,,
CLEFT LIP & PALATE REPAIR,95-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14362.25756,,,14362.25756,14362.25756,19308.85332,case rate,,,
NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,952-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15496.77467,,,15496.77467,9786.310461,21918.9924,case rate,,,
NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,952-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,23715.41814,,,23715.41814,13476.43359,30187.6692,case rate,,,
NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,952-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,41961.80534,,,41961.80534,25246.97386,50666.9348,case rate,,,
NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,952-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,89974.67624,,,89974.67624,49125.76931,122973.9312,case rate,,,
CLEFT LIP & PALATE REPAIR,95-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24552.56814,,,24552.56814,24436.70545,31037.47761,case rate,,,
CLEFT LIP & PALATE REPAIR,95-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,51750.86493,,,51750.86493,36149.10432,69531.25067,case rate,,,
TONSIL & ADENOID PROCEDURES,97-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7670.133362,,,7670.133362,7292.415645,12192.81192,case rate,,,
TONSIL & ADENOID PROCEDURES,97-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12826.00796,,,12826.00796,8903.056047,17609.83647,case rate,,,
TONSIL & ADENOID PROCEDURES,97-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,28329.1224,,,28329.1224,19357.37405,30780.59708,case rate,,,
TONSIL & ADENOID PROCEDURES,97-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,81191.09145,,,81191.09145,45078.13844,81191.09145,case rate,,,
"OTHER EAR, NOSE, MOUTH & THROAT PROCEDURES",98-1,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14806.34209,,,14806.34209,9798.680971,20198.92183,case rate,,,
"OTHER EAR, NOSE, MOUTH & THROAT PROCEDURES",98-2,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,20253.72553,,,20253.72553,14894.09404,27970.68459,case rate,,,
"OTHER EAR, NOSE, MOUTH & THROAT PROCEDURES",98-3,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,34496.55074,,,34496.55074,26093.11674,48198.89982,case rate,,,
"OTHER EAR, NOSE, MOUTH & THROAT PROCEDURES",98-4,APR-DRG,,,,,,,inpatient,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,77028.2328,,,77028.2328,50136.43998,90331.81374,case rate,,,
HC Fine Needle Aspiration Bx W/O Img Gdn Ea Addl,PX-36900722,CDM,10004,CPT,369,RC,,,outpatient,,,79,55.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,17.7355,1592,other,SI=N Exclusions ,,
HC Fine Needle Aspiration Bx W/US Gdn 1st Lesion,PX-36900723,CDM,10005,CPT,369,RC,,,outpatient,,,2116,1481.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1338.33,,,1268.58,399.86,2141,fee schedule,,,
HC Fine Needle Aspiration Bx W/US Gdn Ea Addl,PX-36900724,CDM,10006,CPT,369,RC,,,outpatient,,,258,180.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,57.921,1592,other,SI=N Exclusions ,,
HC Fine Needle Aspiration W/O Imaging Guidance,PX-36900674,CDM,10021,CPT,369,RC,,,outpatient,,,871,609.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,283.26,,,268.5,195.5395,1592,fee schedule,,,
HC Image-Guided Catheter Fluid Collection Drainage,PX-36900043,CDM,10030,CPT,369,RC,,,outpatient,,,692,484.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,289.8,,,274.7,155.354,2141,fee schedule,,,
HC Plcmt of Soft Tissue Loc Device(S)- Perc- First Lesion,PX-36900637,CDM,10035,CPT,369,RC,,,outpatient,,,1860,1302,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1110.33,,,1052.46,291.227805,2141,fee schedule,,,
HC Plmt Sft Tiss Loclzj Dev Perq Each Addl Lesion,PX-36900889,CDM,10036,CPT,369,RC,,,outpatient,,,130,91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,29.185,1592,other,SI=N Exclusions ,,
HC Drain Skin Abscess Simple,PX-36900044,CDM,10060,CPT,369,RC,,,outpatient,,,922,645.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,289.8,,,274.7,206.989,1592,fee schedule,,,
HC Drain Skin Abscess Complic,PX-36900045,CDM,10061,CPT,369,RC,,,outpatient,,,922,645.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,289.8,,,274.7,206.989,1592,fee schedule,,,
HC Drainage of Hematoma/Fluid,PX-36900048,CDM,10140,CPT,369,RC,,,outpatient,,,4838,3386.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1676.16,,,1588.8,399.86,3715.584,fee schedule,,,
HC Puncture Drainage of Lesion,PX-36100003,CDM,10160,CPT,361,RC,,,outpatient,,,916,641.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,289.8,,,274.7,205.642,1592,fee schedule,,,
HC Puncture Drainage of Lesion,PX-36900049,CDM,10160,CPT,369,RC,,,outpatient,,,916,641.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,289.8,,,274.7,205.642,1592,fee schedule,,,
HC Complex Drainage- Wound,PX-36900050,CDM,10180,CPT,369,RC,,,outpatient,,,8640,6048,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3047.3,,,2888.48,399.86,6635.52,fee schedule,,,
HC Debridement- Infected Skin- Up to 10% Bsa,PX-36900606,CDM,11000,CPT,369,RC,,,outpatient,,,1174,821.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,484.31,,,459.07,263.563,1592,fee schedule,,,
HC Debridement- Infected Skin- Ea Add 10% Bsa,PX-36900607,CDM,11001,CPT,369,RC,,,outpatient,,,53,37.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,11.8985,1592,other,SI=N Exclusions ,,
HC Debride Necrotic Skin/ Tissue- Genit & Perinm,PX-36900608,CDM,11004,CPT,369,RC,,,outpatient,,,2036,1425.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,815.8252,399.86,2998,percent of total billed charges,,,
HC Dbrdmt Skn Subq T/M/F Necro Infctj Abdl Wall,PX-36900876,CDM,11005,CPT,369,RC,,,outpatient,,,2001,1400.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,801.8007,399.86,2998,percent of total billed charges,,,
HC Dbrdmt Skn Subq T/M/F Necro Infctj Gent/Abdl,PX-36900877,CDM,11006,CPT,369,RC,,,outpatient,,,1815,1270.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,727.2705,399.86,2998,percent of total billed charges,,,
HC Removal Prosthetic Matrl Abdl Wall for Infection,PX-36900878,CDM,11008,CPT,369,RC,,,outpatient,,,706,494.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,282.8942,158.497,3914,percent of total billed charges,,,
HC Dbrdmt W/Rmvl Fm Fx&/Dislc Skin&Subq Tissus,PX-36900743,CDM,11010,CPT,369,RC,,,outpatient,,,2113,1479.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,777.07,,,736.57,399.86,2141,fee schedule,,,
HC Dbrdmt W/Rmvl Fm Fx&/Dislc Skn Subq T/M/F Musc,PX-36900773,CDM,11011,CPT,369,RC,,,outpatient,,,2197,1537.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,777.07,,,736.57,399.86,2141,fee schedule,,,
HC Dbrdmt Fx&/Dislc Subq T/M/F Bone,PX-36900744,CDM,11012,CPT,369,RC,,,outpatient,,,9022,6315.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,777.07,,,736.57,399.86,6928.896,fee schedule,,,
HC Debridement- Skin- Sub-Q Tissue-=<20 Sq Cm,PX-36900052,CDM,11042,CPT,369,RC,,,outpatient,,,1018,712.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,484.31,,,459.07,228.541,1592,fee schedule,,,
HC Debridement- Skin- Sub-Q Tissue-Muscle-=<20 Sq Cm,PX-36900053,CDM,11043,CPT,369,RC,,,outpatient,,,1065,745.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,484.31,,,459.07,239.0925,1592,fee schedule,,,
HC Debridement- Skin- Sub-Q Tissue-Muscle-Bone-=<20 Sq Cm,PX-36900054,CDM,11044,CPT,369,RC,,,outpatient,,,2829,1980.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1348.2,,,1277.93,399.86,2477.315575,fee schedule,,,
HC Debridement- Skin- Sub-Q Tissue-Each Add 20 Sq Cm,PX-36900055,CDM,11045,CPT,369,RC,,,outpatient,,,1203,842.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.0735,1592,other,SI=N Exclusions ,,
HC Debridement- Skin- Sub-Q Tissue-Muscle-Each Add 20 Sq Cm,PX-36900056,CDM,11046,CPT,369,RC,,,outpatient,,,1203,842.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.0735,1592,other,SI=N Exclusions ,,
HC Debridement- Skin- Sub-Q Tissue-Muscle-Bone-Each Add 20 Sq Cm,PX-36900057,CDM,11047,CPT,369,RC,,,outpatient,,,1910,1337,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,1592,other,SI=N Exclusions ,,
HC Trim Nail(S),PX-36900064,CDM,11719,CPT,369,RC,,,outpatient,,,347,242.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,65.61,,,62.19,62.19,1592,fee schedule,,,
HC Debridement of Nail(S)- 1-5,PX-36900065,CDM,11720,CPT,369,RC,,,outpatient,,,347,242.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,165.26,,,156.65,66.75974,1592,fee schedule,,,
HC Debridement Nail Any Method 6/>,PX-36900791,CDM,11721,CPT,369,RC,,,outpatient,,,212,148.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,165.26,,,156.65,47.594,1592,fee schedule,,,
HC Removal of Nail Plate,PX-36900067,CDM,11730,CPT,369,RC,,,outpatient,,,431,301.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,165.26,,,156.65,96.7595,1592,fee schedule,,,
HC Avulsion Nail Plate Partial/Comp Simple Ea Addl,PX-36900831,CDM,11732,CPT,369,RC,,,outpatient,,,139,97.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,31.2055,1592,other,SI=N Exclusions ,,
HC Evacuation Subungual Hematoma,PX-36900832,CDM,11740,CPT,369,RC,,,outpatient,,,159,111.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,65.61,,,62.19,35.6955,1592,fee schedule,,,
HC Removal of Nail Bed,PX-36900069,CDM,11750,CPT,369,RC,,,outpatient,,,1914,1339.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,777.07,,,736.57,399.86,1592,fee schedule,,,
HC Biopsy Nail Unit Separate Procedure,PX-36900763,CDM,11755,CPT,369,RC,,,outpatient,,,2197,1537.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,777.07,,,736.57,399.86,2141,fee schedule,,,
HC Repair Nail Bed,PX-36900833,CDM,11760,CPT,369,RC,,,outpatient,,,909,636.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,198.09,,,187.77,113.876282,1592,fee schedule,,,
HC Wedge Excision Skin Nail Fold,PX-36900834,CDM,11765,CPT,369,RC,,,outpatient,,,1377,963.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,165.26,,,156.65,156.65,1592,fee schedule,,,
HC Resuperf Wnd Body <2.5cm,PX-36900070,CDM,12001,CPT,369,RC,,,outpatient,,,505,353.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,198.09,,,187.77,113.3725,1592,fee schedule,,,
HC Resup Npterf Wnd Body 2.6-7.5 Cm,PX-36900071,CDM,12002,CPT,369,RC,,,outpatient,,,505,353.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,198.09,,,187.77,113.3725,1592,fee schedule,,,
HC Resuperf Wnd Body 7.6-12.5 Cm,PX-36900072,CDM,12004,CPT,369,RC,,,outpatient,,,445,311.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,198.09,,,187.77,99.9025,1592,fee schedule,,,
HC Resuperf Wnd Body 12.6-20 Cm,PX-36900839,CDM,12005,CPT,369,RC,,,outpatient,,,513,359.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,198.09,,,187.77,115.1685,1592,fee schedule,,,
HC Resuperf Wnd Body 20.1-30 Cm,PX-36900840,CDM,12006,CPT,369,RC,,,outpatient,,,648,453.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,198.09,,,187.77,145.476,1592,fee schedule,,,
HC Resuperf Wnd Body >30 Cm,PX-36900841,CDM,12007,CPT,369,RC,,,outpatient,,,425,297.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,198.09,,,187.77,95.4125,1592,fee schedule,,,
HC Simple Repair F/E/E/N/L/M 2.5cm/<,PX-36900758,CDM,12011,CPT,369,RC,,,outpatient,,,329,230.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,198.09,,,187.77,73.8605,1592,fee schedule,,,
HC Resuperf Wnd Face 2.6-5 Cm,PX-36900842,CDM,12013,CPT,369,RC,,,outpatient,,,400,280,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,198.09,,,187.77,89.8,1592,fee schedule,,,
HC Resuperf Wnd Face 5.1-7.5 Cm,PX-36900843,CDM,12014,CPT,369,RC,,,outpatient,,,479,335.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,198.09,,,187.77,107.5355,1592,fee schedule,,,
HC Resuperf Wnd Face 7.6-12.5 Cm,PX-36900844,CDM,12015,CPT,369,RC,,,outpatient,,,633,443.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,198.09,,,187.77,142.1085,1592,fee schedule,,,
HC Resuperf Wnd Face 12.6-20 Cm,PX-36900845,CDM,12016,CPT,369,RC,,,outpatient,,,779,545.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,198.09,,,187.77,174.8855,1592,fee schedule,,,
HC Simple Repair Suprfcl Wnds F/E/E/N/L/Mucs Membrnes;20.1-30.0 Cm,PX-36900846,CDM,12017,CPT,369,RC,,,outpatient,,,555,388.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,198.09,,,187.77,124.5975,1592,fee schedule,,,
HC Simple Repair Suprfcl Wnds F/E/E/N/L/Mucs Membrnes;Over 30.0 Cm,PX-36900847,CDM,12018,CPT,369,RC,,,outpatient,,,448,313.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,100.576,1592,fee schedule,,,
HC Closure Superf Wnd Dehis Simple,PX-36900848,CDM,12020,CPT,369,RC,,,outpatient,,,1377,963.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,908.75,,,861.38,309.1365,1592,fee schedule,,,
HC Closure Superf Wnd Dehis W Packing,PX-36900849,CDM,12021,CPT,369,RC,,,outpatient,,,809,566.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,181.6205,1592,fee schedule,,,
HC Repair Intermediate S/a/T/E 2.5 Cm/<,PX-36900757,CDM,12031,CPT,369,RC,,,outpatient,,,891,623.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,200.0295,1592,fee schedule,,,
HC Layr Clos Wnd Trunk-Arm-Leg 2.6-7.5 Cm,PX-36900850,CDM,12032,CPT,369,RC,,,outpatient,,,505,353.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,113.3725,1592,fee schedule,,,
HC Layr Clos Wnd Trunk-Arm-Leg 7.6-12.5 Cm,PX-36900851,CDM,12034,CPT,369,RC,,,outpatient,,,685,479.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,153.7825,1592,fee schedule,,,
HC Layr Clos Wnd Trunk-Arm-Leg 12.6-20 Cm,PX-36900852,CDM,12035,CPT,369,RC,,,outpatient,,,685,479.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,153.7825,1592,fee schedule,,,
HC Layr Clos Wnd Trunk-Arm-Leg 20.1-30 Cm,PX-36900853,CDM,12036,CPT,369,RC,,,outpatient,,,649,454.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,145.7005,1592,fee schedule,,,
HC Layr Clos Wnd Trunk-Arm-Leg >30 Cm,PX-36900854,CDM,12037,CPT,369,RC,,,outpatient,,,4504,3152.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,399.86,3459.072,fee schedule,,,
HC Repair Intermediate N/H/F/Xtrnl Gent 2.5cm/<,PX-36900756,CDM,12041,CPT,369,RC,,,outpatient,,,634,443.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,198.09,,,187.77,142.333,1592,fee schedule,,,
HC Repair Intermediate Neck/Hand/Feet/Xtrnl Gent 2.6-7.5 Cm,PX-36900806,CDM,12042,CPT,369,RC,,,outpatient,,,633,443.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,142.1085,1592,fee schedule,,,
HC Layr Clos Wnd Rest Body 7.6-12.5 Cm,PX-36900855,CDM,12044,CPT,369,RC,,,outpatient,,,623,436.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,139.8635,1592,fee schedule,,,
HC Layr Clos Wnd Rest Body 12.6-20 Cm,PX-36900856,CDM,12045,CPT,369,RC,,,outpatient,,,627,438.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,140.7615,1592,fee schedule,,,
HC Layr Clos Wnd Rest Body 20.1-30 Cm,PX-36900857,CDM,12046,CPT,369,RC,,,outpatient,,,1056,739.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,237.072,2141,fee schedule,,,
HC Repair Intermediate N/H/F/Xtrnl Gent >30.0 Cm,PX-36900858,CDM,12047,CPT,369,RC,,,outpatient,,,5238,3666.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,399.86,4022.784,fee schedule,,,
HC Repair Intermediate F/E/E/N/L&/Muc 2.5 Cm/<,PX-36900755,CDM,12051,CPT,369,RC,,,outpatient,,,891,623.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,200.0295,1592,fee schedule,,,
HC Layr Clos Wnd Face-Facial 2.5-5 Cm,PX-36900859,CDM,12052,CPT,369,RC,,,outpatient,,,596,417.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,133.802,1592,fee schedule,,,
HC Layr Clos Wnd Face-Facial 5.1-7.5 Cm,PX-36900860,CDM,12053,CPT,369,RC,,,outpatient,,,663,464.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,148.8435,1592,fee schedule,,,
HC Layr Clos Wnd Face-Facial 7.6-12.5 Cm,PX-36900861,CDM,12054,CPT,369,RC,,,outpatient,,,652,456.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,198.09,,,187.77,146.374,1592,fee schedule,,,
HC Layr Clos Wnd Face-Facial 12.6-20 Cm,PX-36900862,CDM,12055,CPT,369,RC,,,outpatient,,,749,524.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,168.1505,1592,fee schedule,,,
HC Layr Clos Wnd Face-Facial 20.1-30 Cm,PX-36900863,CDM,12056,CPT,369,RC,,,outpatient,,,1419,993.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,318.5655,1592,fee schedule,,,
HC Repair Intermediate F/E/E/N/L&/Muc >30.0 Cm,PX-36900864,CDM,12057,CPT,369,RC,,,outpatient,,,1132,792.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,254.134,1592,fee schedule,,,
HC Repair Complex Trunk 1.1-2.5 Cm,PX-36900788,CDM,13100,CPT,369,RC,,,outpatient,,,1831,1281.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,908.75,,,861.38,399.86,1592,fee schedule,,,
HC Recmpl Wnd Trunk 2.6-7.5 Cm,PX-36900865,CDM,13101,CPT,369,RC,,,outpatient,,,1090,763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,908.75,,,861.38,244.705,1592,fee schedule,,,
HC Rep-Skin-Trunk-Cmplx-+5 Cm/<,PX-36900866,CDM,13102,CPT,369,RC,,,outpatient,,,250,175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,56.125,1592,other,SI=N Exclusions ,,
HC Repair Complex Scalp/Arm/Leg 1.1-2.5 Cm,PX-36900754,CDM,13120,CPT,369,RC,,,outpatient,,,1761,1232.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,395.3445,1592,fee schedule,,,
HC Recmpl Wnd Scalp-Extr 2.6-7.5 Cm,PX-36900867,CDM,13121,CPT,369,RC,,,outpatient,,,735,514.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,165.0075,1592,fee schedule,,,
HC Rep-Skin-Scalp/Extrem+5 Cm/<,PX-36900868,CDM,13122,CPT,369,RC,,,outpatient,,,305,213.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,68.4725,1592,other,SI=N Exclusions ,,
HC Repair Complex F/C/C/M/N/Ax/G/H/F 1.1-2.5 Cm,PX-36900753,CDM,13131,CPT,369,RC,,,outpatient,,,1145,801.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,580.94,,,550.67,257.0525,1592,fee schedule,,,
HC Recmpl Wnd Head-Fac-Hand 2.6-7.5 Cm,PX-36900869,CDM,13132,CPT,369,RC,,,outpatient,,,723,506.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,908.75,,,861.38,162.3135,1592,fee schedule,,,
HC Repr-Face-Genital-Hand-Ft+5 Cmcm/<,PX-36900870,CDM,13133,CPT,369,RC,,,outpatient,,,578,404.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,129.761,1592,other,SI=N Exclusions ,,
HC Repair Complex Eyelid/Nose/Ear/Lip 1.1-2.5 Cm,PX-36900752,CDM,13151,CPT,369,RC,,,outpatient,,,1761,1232.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,908.75,,,861.38,395.3445,1592,fee schedule,,,
HC Recmpl Wnd Lid-Nos-Ear 2.5-7.5 Cm,PX-36900871,CDM,13152,CPT,369,RC,,,outpatient,,,743,520.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,908.75,,,861.38,166.8035,1592,fee schedule,,,
HC Repr-Eyelid-Nose-Ear-Lip+5 Cm,PX-36900872,CDM,13153,CPT,369,RC,,,outpatient,,,462,323.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,103.719,1592,other,SI=N Exclusions ,,
HC Secd Clos Surg Wnd Exten/Complic,PX-36900873,CDM,13160,CPT,369,RC,,,outpatient,,,4504,3152.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3488.41,,,3306.6,399.86,3459.072,fee schedule,,,
HC Dressing Change Under Anesthesia,PX-36900774,CDM,15852,CPT,369,RC,,,outpatient,,,1831,1281.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,114.67,,,108.7,108.7,1592,fee schedule,,,
HC Exc Coccyx/Ulcer W Suture,PX-36900598,CDM,15920,CPT,369,RC,,,outpatient,,,3425,2397.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,777.07,,,736.57,399.86,4341.777195,fee schedule,,,
HC Exc Sacr Press Ulc W Pri Suture,PX-36900599,CDM,15931,CPT,369,RC,,,outpatient,,,7558,5290.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3837.26,,,3637.27,399.86,5804.544,fee schedule,,,
HC Exc Sacr Press Ulc W Flap Clos,PX-36900600,CDM,15934,CPT,369,RC,,,outpatient,,,9536,6675.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3488.41,,,3306.6,399.86,7323.648,fee schedule,,,
HC Exc Sacr Press Ulc W Musc Flap Clo,PX-36900601,CDM,15936,CPT,369,RC,,,outpatient,,,5831,4081.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2567.93,,,2434.09,399.86,4478.208,fee schedule,,,
HC Exc Isch Pres Ulc W Prim Clos,PX-36900602,CDM,15940,CPT,369,RC,,,outpatient,,,7558,5290.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3837.26,,,3637.27,399.86,5804.544,fee schedule,,,
HC Exc Isch Pres Ulc W Flap Clos,PX-36900603,CDM,15944,CPT,369,RC,,,outpatient,,,5831,4081.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3488.41,,,3306.6,399.86,5481.863562,fee schedule,,,
HC Exc Isch Pres Ulc Bone Myocut Flap,PX-36900604,CDM,15946,CPT,369,RC,,,outpatient,,,9536,6675.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3488.41,,,3306.6,399.86,7323.648,fee schedule,,,
HC Exc Troc Pres Ulc W Prim Clos,PX-36900605,CDM,15950,CPT,369,RC,,,outpatient,,,7558,5290.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3837.26,,,3637.27,399.86,5804.544,fee schedule,,,
HC Initial Tx 1st Degree Burn Local Tx,PX-36900591,CDM,16000,CPT,369,RC,,,outpatient,,,393,275.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,165.26,,,156.65,88.2285,1592,fee schedule,,,
HC Dress/Debrid Small Burn No Anes,PX-36900090,CDM,16020,CPT,369,RC,,,outpatient,,,812,568.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,247.09,,,234.21,182.294,1592,fee schedule,,,
HC Dress/Debrid Med Burn No Anesth,PX-36900091,CDM,16025,CPT,369,RC,,,outpatient,,,812,568.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,247.09,,,234.21,182.294,1592,fee schedule,,,
HC Dress/Debrid Large Burn No Anesth,PX-36900092,CDM,16030,CPT,369,RC,,,outpatient,,,845,591.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,247.09,,,234.21,189.7025,1592,fee schedule,,,
HC Escharotomy Each Additional Incision,PX-36900883,CDM,16036,CPT,369,RC,,,outpatient,,,670,469,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,268.469,150.415,2998,percent of total billed charges,,,
HC Destruc Cut/Vasc 10-50 Sqcm,PX-36900094,CDM,17107,CPT,369,RC,,,outpatient,,,1763,1234.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,484.31,,,459.07,395.7935,1592,fee schedule,,,
HC Punc/Aspir Breast Cyst,PX-36900096,CDM,19000,CPT,369,RC,,,outpatient,,,1637,1145.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,798.19,,,756.59,367.5065,2141,fee schedule,,,
HC Puct/Aspir Breast Cyst-Each Addn,PX-36900097,CDM,19001,CPT,369,RC,,,outpatient,,,60,42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,13.47,1592,other,Non-Reimbursable List,,
HC Bx Breast W Device 1st Lesion Stereotactic Guide,PX-36900099,CDM,19081,CPT,369,RC,,,outpatient,,,4317,3021.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1444.37,,,1369.09,399.86,3315.456,fee schedule,,,
HC Bx Breast W Device Addl Lesion Stereotact Guide,PX-36900100,CDM,19082,CPT,369,RC,,,outpatient,,,3998,2798.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,3070.464,other,Non-Reimbursable List,,
HC Bx Breast W Device 1st Lesion Ultrasound Guide,PX-36900101,CDM,19083,CPT,369,RC,,,outpatient,,,3271,2289.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1444.37,,,1369.09,399.86,2998,fee schedule,,,
HC Bx Breast W Device Addl Lesion Ultrasound Guide,PX-36900102,CDM,19084,CPT,369,RC,,,outpatient,,,2336,1635.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,1794.048,other,Non-Reimbursable List,,
HC Bx Breast W Device 1st Lesion Magnetic Res Guide,PX-36900103,CDM,19085,CPT,369,RC,,,outpatient,,,5120,3584,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1444.37,,,1369.09,399.86,3932.16,fee schedule,,,
HC Bx Breast W Device Addl Lesion Magnet Res Guide,PX-36900104,CDM,19086,CPT,369,RC,,,outpatient,,,2232,1562.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,1714.176,other,Non-Reimbursable List,,
HC Perq Device Placemt Breast Loc 1st Les W Guidnce,PX-36900106,CDM,19281,CPT,369,RC,,,outpatient,,,915,640.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,114.67,,,108.7,108.7,2998,fee schedule,,,
HC Perq Device Placemt Breast Loc Ea Les W Guidnce,PX-36900107,CDM,19282,CPT,369,RC,,,outpatient,,,880,616,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,197.56,1592,other,Non-Reimbursable List,,
HC Perq Breast Loc Device Placemt 1st Strtctc Guid,PX-36900108,CDM,19283,CPT,369,RC,,,outpatient,,,2116,1481.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,114.67,,,108.7,108.7,2141,fee schedule,,,
HC Perq Breast Loc Device Placemt Ea Lesion Strtctc,PX-36900109,CDM,19284,CPT,369,RC,,,outpatient,,,84,58.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,18.858,1592,other,Non-Reimbursable List,,
HC Perq Breast Loc Device Placemt 1st Lesio US Imag,PX-36900110,CDM,19285,CPT,369,RC,,,outpatient,,,1175,822.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,114.67,,,108.7,108.7,2141,fee schedule,,,
HC Perq Breast Loc Device Placemt Each Les US Image,PX-36900111,CDM,19286,CPT,369,RC,,,outpatient,,,274,191.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,61.513,1592,other,Non-Reimbursable List,,
HC Perq Breast Loc Device Placemt 1st Lesio MR Guid,PX-36900112,CDM,19287,CPT,369,RC,,,outpatient,,,2116,1481.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,114.67,,,108.7,108.7,2141,fee schedule,,,
HC Place Postop Breast Cath for Rad,PX-36900114,CDM,19296,CPT,369,RC,,,outpatient,,,14045,9831.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10538.68,,,9989.41,399.86,14403.82399,fee schedule,,,
HC Muscle Biopsy,PX-36900115,CDM,20200,CPT,369,RC,,,outpatient,,,3700,2590,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2591.35,,,2456.3,399.86,2998,fee schedule,,,
HC Biopsy Muscle Deep,PX-36900764,CDM,20205,CPT,369,RC,,,outpatient,,,9022,6315.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2591.35,,,2456.3,399.86,6928.896,fee schedule,,,
HC Needle Biopsy-Muscle,PX-36900116,CDM,20206,CPT,369,RC,,,outpatient,,,3700,2590,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1444.37,,,1369.09,399.86,2998,fee schedule,,,
HC Bone Biopsy-Trocar/Needle Superf,PX-36900117,CDM,20220,CPT,369,RC,,,outpatient,,,3847,2692.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1348.2,,,1277.93,399.86,2954.496,fee schedule,,,
HC Bone Biopsy-Trocar/Needle Deep,PX-36900118,CDM,20225,CPT,369,RC,,,outpatient,,,3700,2590,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2591.35,,,2456.3,399.86,2998,fee schedule,,,
HC Biopsy Bone Open Superficial,PX-36900770,CDM,20240,CPT,369,RC,,,outpatient,,,9022,6315.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3837.26,,,3637.27,399.86,6928.896,fee schedule,,,
HC Biopsy Bone Open Deep,PX-36900769,CDM,20245,CPT,369,RC,,,outpatient,,,9022,6315.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3837.26,,,3637.27,399.86,6928.896,fee schedule,,,
HC Inject Sinus Tract for Dx W Xray,PX-36900120,CDM,20501,CPT,369,RC,,,outpatient,,,1451,1015.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,235.074116,1592,other,Non-Reimbursable List,,
HC Removal Foreign Body Muscle/Tendon Sheath Simple,PX-36900749,CDM,20520,CPT,369,RC,,,outpatient,,,5218,3652.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,777.07,,,736.57,399.86,4007.424,fee schedule,,,
HC Rmvl Foreign Body Muscle/Tendon Sheath Deep/Comp,PX-36900748,CDM,20525,CPT,369,RC,,,outpatient,,,5793,4055.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3837.26,,,3637.27,399.86,4449.024,fee schedule,,,
HC Injection of Tendon Sheath,PX-36900693,CDM,20550,CPT,369,RC,,,outpatient,,,823,576.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,421.85,,,399.86,184.7635,1592,fee schedule,,,
HC Injection Single Tendon Origin/Insertion,PX-36900793,CDM,20551,CPT,369,RC,,,outpatient,,,903,632.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,421.85,,,399.86,202.7235,1592,fee schedule,,,
HC Inject Trigger Point- 1 or 2,PX-36900123,CDM,20552,CPT,369,RC,,,outpatient,,,658,460.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,421.85,,,399.86,147.721,1592,fee schedule,,,
HC Drain/Inject Small Joint/Bursa,PX-36100004,CDM,20600,CPT,361,RC,,,outpatient,,,714,499.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,421.85,,,399.86,160.293,1592,fee schedule,,,
HC Drain/Inject Small Joint/Bursa,PX-36900125,CDM,20600,CPT,369,RC,,,outpatient,,,714,499.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,421.85,,,399.86,160.293,1592,fee schedule,,,
HC Arthrocnt Aspir&/Inj Small Jt/Bursaw/US Rec Rprt,PX-36900787,CDM,20604,CPT,369,RC,,,outpatient,,,938,656.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,628.09,,,595.36,210.581,1592,fee schedule,,,
HC Drain/Inject Intermediate Joint/Bursa,PX-36100005,CDM,20605,CPT,361,RC,,,outpatient,,,753,527.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,421.85,,,399.86,169.0485,1592,fee schedule,,,
HC Drain/Inject Intermediate Joint/Bursa,PX-36900126,CDM,20605,CPT,369,RC,,,outpatient,,,753,527.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,421.85,,,399.86,169.0485,1592,fee schedule,,,
HC Arthrocentesis Aspir&/Inj Interm Jt/Burs W/US,PX-36100030,CDM,20606,CPT,361,RC,,,outpatient,,,1844,1290.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1488.49,,,1410.91,399.86,2141,fee schedule,,,
HC Drain/Inject Large Joint/Bursa,PX-36100006,CDM,20610,CPT,361,RC,,,outpatient,,,658,460.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,421.85,,,399.86,147.721,1592,fee schedule,,,
HC Drain/Inject Large Joint/Bursa,PX-36900127,CDM,20610,CPT,369,RC,,,outpatient,,,658,460.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,421.85,,,399.86,147.721,1592,fee schedule,,,
HC Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US,PX-36100031,CDM,20611,CPT,361,RC,,,outpatient,,,784,548.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,628.09,,,595.36,176.008,1592,fee schedule,,,
HC Ablate- Bone Tumor(S) Perq,PX-36900128,CDM,20982,CPT,369,RC,,,outpatient,,,16473,11531.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7941.18,,,7527.29,399.86,20110.10933,fee schedule,,,
HC Biopsy Soft Tissue Neck/Chest,PX-36900130,CDM,21550,CPT,369,RC,,,outpatient,,,4796,3357.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2591.35,,,2456.3,399.86,3683.328,fee schedule,,,
HC Vertebroplasty Each Addl Cervicothor/Lumbosacral,PX-36900134,CDM,22512,CPT,369,RC,,,outpatient,,,1695,1186.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,380.5275,1592,other,Non-Reimbursable List,,
HC Biopsy Soft Tissue Shoulder Superficial,PX-36900138,CDM,23065,CPT,369,RC,,,outpatient,,,2502,1751.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1348.2,,,1277.93,399.86,2477.315575,fee schedule,,,
HC Inj Proc Shoulder Arthrography/CT/MRI,PX-36900139,CDM,23350,CPT,369,RC,,,outpatient,,,1114,779.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,235.074116,1592,other,Non-Reimbursable List,,
HC Clsd Tx Shoulder Dislc W/Manipulation W/O Anes,PX-36900581,CDM,23650,CPT,369,RC,,,outpatient,,,735,514.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,308.74,,,292.65,165.0075,1592,fee schedule,,,
HC Clsd Tx Shoulder Dislc W/Manipulation Req Anes,PX-36900582,CDM,23655,CPT,369,RC,,,outpatient,,,3604,2522.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2400.36,,,2275.25,399.86,2998,fee schedule,,,
HC I&D Upper Arm/Elbow Deep Abscess/Hematoma,PX-36900784,CDM,23930,CPT,369,RC,,,outpatient,,,5218,3652.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3047.3,,,2888.48,399.86,4341.777195,fee schedule,,,
HC Incision&Drainage Upper Arm/Elbow Bursa,PX-36900751,CDM,23931,CPT,369,RC,,,outpatient,,,3342,2339.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1676.16,,,1588.8,399.86,2998,fee schedule,,,
HC Biopsy Soft Tissue Upper Arm/Elbow Superficial,PX-36900768,CDM,24065,CPT,369,RC,,,outpatient,,,5218,3652.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2591.35,,,2456.3,399.86,4007.424,fee schedule,,,
HC Biopsy Soft Tissue Upper Arm/Elbow Area Deep,PX-36900767,CDM,24066,CPT,369,RC,,,outpatient,,,9022,6315.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2591.35,,,2456.3,399.86,6928.896,fee schedule,,,
HC Injection for Elbow Arthrogram,PX-36900143,CDM,24220,CPT,369,RC,,,outpatient,,,1224,856.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,274.788,1592,other,Non-Reimbursable List,,
HC I&D Forearm&/Wrist Deep Abscess/Hematoma,PX-36900782,CDM,25028,CPT,369,RC,,,outpatient,,,9952,6966.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3592.92,,,3405.66,399.86,7643.136,fee schedule,,,
HC Incision & Drainage Forearm&/Wrist Bursa,PX-36900783,CDM,25031,CPT,369,RC,,,outpatient,,,4983,3488.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3592.92,,,3405.66,399.86,3826.944,fee schedule,,,
HC Incision Deep Bone Cortex Forearm&/Wrist,PX-36900785,CDM,25035,CPT,369,RC,,,outpatient,,,21621,15134.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3592.92,,,3405.66,399.86,16604.928,fee schedule,,,
HC Arthrt Rdcrpl/Midcarpl Jt W/Expl Drg/Rmvl FB,PX-36900778,CDM,25040,CPT,369,RC,,,outpatient,,,9952,6966.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5328.87,,,5051.13,399.86,7643.136,fee schedule,,,
HC Biopsy Soft Tissue Forearm&/Wrist Superficial,PX-36900766,CDM,25065,CPT,369,RC,,,outpatient,,,5218,3652.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1348.2,,,1277.93,399.86,4007.424,fee schedule,,,
HC Biopsy Soft Tissue Forearm&/Wrist Deep,PX-36900765,CDM,25066,CPT,369,RC,,,outpatient,,,9022,6315.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3837.26,,,3637.27,399.86,6928.896,fee schedule,,,
HC Injection for Wrist Arthrogram,PX-36900149,CDM,25246,CPT,369,RC,,,outpatient,,,1660,1162,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,235.074116,1592,other,Non-Reimbursable List,,
HC Cltx Dstl Rdl Fx/Epiphysl Sep W/Manj When Perf,PX-36900792,CDM,25605,CPT,369,RC,,,outpatient,,,2563,1794.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,921.41,,,873.38,399.86,2455.793921,fee schedule,,,
HC Drainage Finger Abscess Complicated,PX-36900750,CDM,26011,CPT,369,RC,,,outpatient,,,2563,1794.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1676.16,,,1588.8,399.86,2998,fee schedule,,,
HC Drainage Tendon Sheath Digit&/Palm Each,PX-36900781,CDM,26020,CPT,369,RC,,,outpatient,,,9952,6966.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2738.48,,,2595.76,399.86,7643.136,fee schedule,,,
HC Drainage of Palmar Bursa Single Bursa,PX-36900780,CDM,26025,CPT,369,RC,,,outpatient,,,9952,6966.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2738.48,,,2595.76,399.86,7643.136,fee schedule,,,
HC Drainage of Palmar Bursa Multiple Bursa,PX-36900779,CDM,26030,CPT,369,RC,,,outpatient,,,9952,6966.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2738.48,,,2595.76,399.86,7643.136,fee schedule,,,
HC Incision Bone Cortex Hand/Finger,PX-36900786,CDM,26034,CPT,369,RC,,,outpatient,,,4983,3488.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2738.48,,,2595.76,399.86,3826.944,fee schedule,,,
HC Arthrt Expl Drg/Rmvl Loose/FB Carp/Mtcrpl Jt,PX-36900775,CDM,26070,CPT,369,RC,,,outpatient,,,4983,3488.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2738.48,,,2595.76,399.86,3826.944,fee schedule,,,
HC Arthrt Expl Drg/Rmvl Loose/FB Mtcarphlngl Jt Ea,PX-36900777,CDM,26075,CPT,369,RC,,,outpatient,,,9952,6966.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2738.48,,,2595.76,399.86,7643.136,fee schedule,,,
HC Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea,PX-36900776,CDM,26080,CPT,369,RC,,,outpatient,,,4983,3488.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2738.48,,,2595.76,399.86,3826.944,fee schedule,,,
HC Bx Soft Tissues-Pelv/Hip-Superficl,PX-36900160,CDM,27040,CPT,369,RC,,,outpatient,,,3700,2590,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1348.2,,,1277.93,399.86,2841.6,fee schedule,,,
HC Bx Soft Tissues-Pelv/Hip-Deep,PX-36900161,CDM,27041,CPT,369,RC,,,outpatient,,,3700,2590,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1348.2,,,1277.93,399.86,2841.6,fee schedule,,,
HC Injection Hip Arthrogram,PX-36900162,CDM,27093,CPT,369,RC,,,outpatient,,,1589,1112.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,235.074116,1592,other,Non-Reimbursable List,,
HC Closed Rx Prox/Neck Femur Fx-Manip,PX-36900886,CDM,27232,CPT,369,RC,,,outpatient,,,3499,2449.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1402.0493,399.86,2998,percent of total billed charges,,,
HC Cltx Hip Dislocation Traumatic W/O Anesthesia,PX-36900583,CDM,27250,CPT,369,RC,,,outpatient,,,902,631.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,308.74,,,292.65,202.499,1592,fee schedule,,,
HC Cltx Hip Dislocation Traumatic Req Anesthesia,PX-36900584,CDM,27252,CPT,369,RC,,,outpatient,,,2848,1993.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2400.36,,,2275.25,399.86,2455.793921,fee schedule,,,
HC Cltx Post Hip Arthrp Dislc W/O Anes,PX-36900585,CDM,27265,CPT,369,RC,,,outpatient,,,671,469.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,308.74,,,292.65,150.6395,1592,fee schedule,,,
HC Cltx Post Hip Arthrp Dislc Req Anes,PX-36900586,CDM,27266,CPT,369,RC,,,outpatient,,,2045,1431.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2400.36,,,2275.25,399.86,2998,fee schedule,,,
HC Unlisted Procedure Pelvis/Hip Joint,PX-36900700,CDM,27299,CPT,369,RC,,,outpatient,,,715,500.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,478.21,,,453.29,160.5175,1592,fee schedule,,,
HC I&D Deep Absc Bursa/Hematoma Thigh/Knee Region,PX-36900814,CDM,27301,CPT,369,RC,,,outpatient,,,7663,5364.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3047.3,,,2888.48,399.86,5885.184,fee schedule,,,
HC Injection Knee Arthrography,PX-36900731,CDM,27369,CPT,369,RC,,,outpatient,,,1446,1012.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,324.627,1592,other,Non-Reimbursable List,,
HC Injection for Ankle Arthrogram,PX-36900167,CDM,27648,CPT,369,RC,,,outpatient,,,834,583.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,187.233,1592,other,Non-Reimbursable List,,
HC Closed Tx Bimalleolar Ankle Fracture W/Manj,PX-36900880,CDM,27810,CPT,369,RC,,,outpatient,,,3663,2564.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,308.74,,,292.65,292.65,2813.184,fee schedule,,,
HC Application Cast Shoulder Hand Long Arm,PX-36900741,CDM,29065,CPT,369,RC,,,outpatient,,,664,464.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,436.93,,,414.16,149.068,1592,fee schedule,,,
HC Application Cast Elbow Finger Short Arm,PX-36900739,CDM,29075,CPT,369,RC,,,outpatient,,,893,625.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,436.93,,,414.16,200.4785,1592,fee schedule,,,
HC Application Cast Hand & Lower Forearm Gauntlet,PX-36900740,CDM,29085,CPT,369,RC,,,outpatient,,,491,343.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,218.4,,,207.01,110.2295,1592,fee schedule,,,
HC Application Cast Finger,PX-36900771,CDM,29086,CPT,369,RC,,,outpatient,,,511,357.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,218.4,,,207.01,114.7195,1592,fee schedule,,,
HC Application Long Arm Splint Shoulder Hand,PX-36900759,CDM,29105,CPT,369,RC,,,outpatient,,,453,317.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,218.4,,,207.01,101.6985,1592,fee schedule,,,
HC Application Short Arm Splint Forearm-Hand Static,PX-36900576,CDM,29125,CPT,369,RC,,,outpatient,,,354,247.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,218.4,,,207.01,79.473,1592,fee schedule,,,
HC Application Short Arm Splint Dynamic,PX-36900577,CDM,29126,CPT,369,RC,,,outpatient,,,354,247.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,218.4,,,207.01,79.473,1592,fee schedule,,,
HC Application Finger Splint Static,PX-36900579,CDM,29130,CPT,369,RC,,,outpatient,,,221,154.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,124.58,,,118.09,49.6145,1592,fee schedule,,,
HC Application Finger Splint Dynamic,PX-36900580,CDM,29131,CPT,369,RC,,,outpatient,,,218,152.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,124.58,,,118.09,48.941,1592,fee schedule,,,
HC Strapping Shoulder,PX-36900761,CDM,29240,CPT,369,RC,,,outpatient,,,405,283.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,124.58,,,118.09,90.9225,1592,fee schedule,,,
HC Strapping Elbow/Wrist,PX-36900760,CDM,29260,CPT,369,RC,,,outpatient,,,122,85.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,124.58,,,118.09,27.389,1592,fee schedule,,,
HC Strapping Hand/Finger,PX-36900790,CDM,29280,CPT,369,RC,,,outpatient,,,122,85.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,124.58,,,118.09,27.389,1592,fee schedule,,,
HC Application Short Leg Cast Below Knee-Toe,PX-36900818,CDM,29405,CPT,369,RC,,,outpatient,,,699,489.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,436.93,,,414.16,156.9255,1592,fee schedule,,,
HC Application Long Leg Splint Thigh Ankle/Toes,PX-36900737,CDM,29505,CPT,369,RC,,,outpatient,,,554,387.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,218.4,,,207.01,124.373,1592,fee schedule,,,
HC Application Short Leg Splint Calf Foot,PX-36900578,CDM,29515,CPT,369,RC,,,outpatient,,,354,247.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,218.4,,,207.01,79.473,1592,fee schedule,,,
HC Ctrl Nosebleed-Anter-Simple,PX-36900181,CDM,30901,CPT,369,RC,,,outpatient,,,347,242.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,180.4,,,170.99,77.9015,1592,fee schedule,,,
HC PR Control Nasal Hemorrhage Anterior Simple,PX-96000041,CDM,30901,CPT,960,RC,,,outpatient,,,347,242.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,180.4,,,170.99,77.9015,1592,fee schedule,,,
HC Control Nasal Hemorrhage Anterior Complex,PX-36900745,CDM,30903,CPT,369,RC,,,outpatient,,,289,202.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,180.4,,,170.99,64.8805,1592,fee schedule,,,
HC PR Control Nasal Hemorrhage Anterior Complex,PX-96000042,CDM,30903,CPT,960,RC,,,outpatient,,,289,202.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,180.4,,,170.99,64.8805,1592,fee schedule,,,
HC Ctrl Nsl Hemrrg Pst Nasal Packs&/Cautery 1st,PX-36900746,CDM,30905,CPT,369,RC,,,outpatient,,,486,340.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,180.4,,,170.99,109.107,1592,fee schedule,,,
HC Ctrl Nsl Hemrrg Pst Nasal Packs&/Cautery Subsq,PX-36900747,CDM,30906,CPT,369,RC,,,outpatient,,,510,357,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,180.4,,,170.99,114.495,1592,fee schedule,,,
HC Insert Emergency Endotrach Airway,PX-36100007,CDM,31500,CPT,361,RC,,,outpatient,,,544,380.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,371.53,,,352.17,122.128,1592,fee schedule,,,
HC Insert Emergency Endotrach Airway,PX-36900182,CDM,31500,CPT,369,RC,,,outpatient,,,544,380.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,371.53,,,352.17,122.128,1592,fee schedule,,,
HC PR Intubation Endotracheal Emergency Procedure,PX-96000038,CDM,31500,CPT,960,RC,,,outpatient,,,544,380.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,371.53,,,352.17,122.128,1592,fee schedule,,,
HC Trach Tube Change,PX-36900183,CDM,31502,CPT,369,RC,,,outpatient,,,615,430.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,233.18,,,221.03,138.0675,1592,fee schedule,,,
HC Laryngoscopy-Flex Fiber-Diagnostic,PX-36900185,CDM,31575,CPT,369,RC,,,outpatient,,,371,259.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,330.07,,,312.86,83.2895,1592,fee schedule,,,
HC Bronchoscopy-Diagnostic,PX-36900187,CDM,31622,CPT,369,RC,,,outpatient,,,3151,2205.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1764.64,,,1672.67,399.86,2998,fee schedule,,,
HC Bronchoscopy-Diagnostic W Brush,PX-36900188,CDM,31623,CPT,369,RC,,,outpatient,,,3150,2205,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1764.64,,,1672.67,399.86,2998,fee schedule,,,
HC Brnchsc W/Brncl Alveolar Lavage,PX-36900896,CDM,31624,CPT,369,RC,,,outpatient,,,3935,2754.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1764.64,,,1672.67,399.86,3022.08,fee schedule,,,
HC Bronchoscopy-Biopsy,PX-36900189,CDM,31625,CPT,369,RC,,,outpatient,,,3271,2289.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1764.64,,,1672.67,399.86,2998,fee schedule,,,
HC Needle Biopsy Pleura,PX-36900190,CDM,32400,CPT,369,RC,,,outpatient,,,3700,2590,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1648.39,,,1562.48,399.86,2998,fee schedule,,,
HC Core Needle Bx Lung/Mediastinum Perq W/Img,PX-36900808,CDM,32408,CPT,369,RC,,,outpatient,,,4594,3215.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3250.31,,,3080.91,399.86,3528.192,fee schedule,,,
HC Insertion Indwelling Tunneled Pleural Catheter,PX-36900192,CDM,32550,CPT,369,RC,,,outpatient,,,8367,5856.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5218.7,,,4946.71,399.86,6425.856,fee schedule,,,
HC Tube Thoracostomy Includes Water Seal,PX-36100008,CDM,32551,CPT,361,RC,,,outpatient,,,1951,1365.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,952.66,,,903.01,399.86,2447.133941,fee schedule,,,
HC Tube Thoracostomy Includes Water Seal,PX-36900193,CDM,32551,CPT,369,RC,,,outpatient,,,1951,1365.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,952.66,,,903.01,399.86,2447.133941,fee schedule,,,
HC Tube Thoracostomy Includes Water Seal,PX-36900573,CDM,32551,CPT,369,RC,,,outpatient,,,1951,1365.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,952.66,,,903.01,399.86,2447.133941,fee schedule,,,
HC PR Tube Thoracostomy Includes Water Seal,PX-96000039,CDM,32551,CPT,960,RC,,,outpatient,,,1951,1365.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,952.66,,,903.01,399.86,2447.133941,fee schedule,,,
HC Removal of Indwelling Tunneled Pleural Catheter With Cuff,PX-36900194,CDM,32552,CPT,369,RC,,,outpatient,,,2265,1585.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,952.66,,,903.01,399.86,2141,fee schedule,,,
HC Perc Place Intra-Thoracic Interstit Rad Therapy Guide- 1/Mult,PX-36900195,CDM,32553,CPT,369,RC,,,outpatient,,,4198,2938.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2274.27,,,2155.74,399.86,3224.064,fee schedule,,,
HC Thoracentesis Needle/Cath Pleura W/O Imaging,PX-36900196,CDM,32554,CPT,369,RC,,,outpatient,,,1874,1311.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,952.66,,,903.01,399.86,2141,fee schedule,,,
HC Thoracentesis Needle/Cath Pleura W/Imaging,PX-36100001,CDM,32555,CPT,361,RC,,,outpatient,,,1636,1145.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,952.66,,,903.01,367.282,2141,fee schedule,,,
HC Thoracentesis Needle/Cath Pleura W/Imaging,PX-36900197,CDM,32555,CPT,369,RC,,,outpatient,,,1636,1145.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,952.66,,,903.01,367.282,2141,fee schedule,,,
HC Perq Drainage Pleura Insert Cath W/O Imaging,PX-36900742,CDM,32556,CPT,369,RC,,,outpatient,,,2896,2027.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,952.66,,,903.01,399.86,2998,fee schedule,,,
HC Perq Drainage Pleura Insert Cath W/Imaging,PX-36900198,CDM,32557,CPT,369,RC,,,outpatient,,,1882,1317.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,952.66,,,903.01,399.86,2447.133941,fee schedule,,,
HC PR Instlj via Chest Tube/Cath Agent for Pleurodesis,PX-96000040,CDM,32560,CPT,960,RC,,,outpatient,,,2265,1585.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,952.66,,,903.01,399.86,1739.52,fee schedule,,,
HC Instlj via Ch Tube/Cath Agent Fbrnlysis 1st Day,PX-36900826,CDM,32561,CPT,369,RC,,,outpatient,,,1421,994.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,952.66,,,903.01,319.0145,2141,fee schedule,,,
HC Instlj Ch Tube/Cath Agent Fbrnlysis Sbsq Day,PX-36900827,CDM,32562,CPT,369,RC,,,outpatient,,,1421,994.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,952.66,,,903.01,319.0145,2141,fee schedule,,,
HC Pericardiocentesis W/Img Guidance When Performed,PX-36100034,CDM,33016,CPT,361,RC,,,outpatient,,,5537,3875.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3437.08,,,3257.95,399.86,4252.416,fee schedule,,,
HC Pericardiocentesis W/Img Guidance When Performed,PX-36900797,CDM,33016,CPT,369,RC,,,outpatient,,,5537,3875.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3437.08,,,3257.95,399.86,4252.416,fee schedule,,,
HC Inser Hart Pacer Xvenous Atrial,PX-36900204,CDM,33206,CPT,369,RC,,,outpatient,,,27344,19140.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12358.09,,,11714,399.86,21000.192,fee schedule,,,
HC Inser Hart Pacer Xvenous Ventr,PX-36900205,CDM,33207,CPT,369,RC,,,outpatient,,,36767,25736.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12358.09,,,11714,399.86,28237.056,fee schedule,,,
HC Inser Hart Pacer Xvenous Atr/Ventr,PX-36900206,CDM,33208,CPT,369,RC,,,outpatient,,,27344,19140.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15295.82,,,14498.62,399.86,21000.192,fee schedule,,,
HC Inser Heart Temp Pacer One Chmbr,PX-36900207,CDM,33210,CPT,369,RC,,,outpatient,,,21456,15019.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8699.95,,,8246.52,399.86,16478.208,fee schedule,,,
HC Insert Pulse Gener One Chmbr,PX-36900209,CDM,33212,CPT,369,RC,,,outpatient,,,21456,15019.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9928.88,,,9411.4,399.86,16478.208,fee schedule,,,
HC Insert Pulse Gener Dual Chmbr,PX-36900210,CDM,33213,CPT,369,RC,,,outpatient,,,27344,19140.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11584.14,,,10980.38,399.86,21000.192,fee schedule,,,
HC Upgrade of Pacemaker System,PX-36900211,CDM,33214,CPT,369,RC,,,outpatient,,,27344,19140.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15295.82,,,14498.62,399.86,21000.192,fee schedule,,,
HC Reposition Transvenous Electrode,PX-36900212,CDM,33215,CPT,369,RC,,,outpatient,,,4029,2820.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3888.2,,,3685.55,399.86,4870.452937,fee schedule,,,
HC Revise Electrode-Pacing-Dual,PX-36900215,CDM,33217,CPT,369,RC,,,outpatient,,,21456,15019.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8699.95,,,8246.52,399.86,16478.208,fee schedule,,,
HC Reeletrode-Pacing-Single,PX-36900216,CDM,33218,CPT,369,RC,,,outpatient,,,9056,6339.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3888.2,,,3685.55,399.86,6955.008,fee schedule,,,
HC Reelectrode-Pacing-Dual,PX-36900217,CDM,33220,CPT,369,RC,,,outpatient,,,9056,6339.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3888.2,,,3685.55,399.86,6955.008,fee schedule,,,
HC Ins Pacemaker Pulse Gen Only W/Exist Mult Leads,PX-36900218,CDM,33221,CPT,369,RC,,,outpatient,,,48979,34285.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11584.14,,,10980.38,399.86,37615.872,fee schedule,,,
HC Relocation of Skin Pocket for Pacemaker,PX-36900219,CDM,33222,CPT,369,RC,,,outpatient,,,4504,3152.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2567.93,,,2434.09,399.86,3459.072,fee schedule,,,
HC Relocate Skin Pocket Cardioverter-Defibrillator,PX-36900220,CDM,33223,CPT,369,RC,,,outpatient,,,2716,1901.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2567.93,,,2434.09,399.86,2998,fee schedule,,,
HC Insrt Pacing Elect-W/Attach Prev Device,PX-36900221,CDM,33224,CPT,369,RC,,,outpatient,,,27344,19140.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15295.82,,,14498.62,399.86,21000.192,fee schedule,,,
HC Insj Eltrd Car Ven Sys Tm Insj Cvdfb/Pm Pls Gen,PX-36900222,CDM,33225,CPT,369,RC,,,outpatient,,,7571,5299.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6364,other,Non-Reimbursable List,,
HC Reposit Prev Implanted Cardiac Electrode,PX-36900223,CDM,33226,CPT,369,RC,,,outpatient,,,3644,2550.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3888.2,,,3685.55,399.86,4870.452937,fee schedule,,,
HC Remvl Perm Pm Plse Gen W/Repl Plse Gen Sngl Lead,PX-36900224,CDM,33227,CPT,369,RC,,,outpatient,,,17786,12450.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9928.88,,,9411.4,399.86,13659.648,fee schedule,,,
HC Remvl Perm Pm Pls Gen W/Repl Plse Gen 2 Lead Sys,PX-36900225,CDM,33228,CPT,369,RC,,,outpatient,,,19652,13756.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11584.14,,,10980.38,399.86,16316.30039,fee schedule,,,
HC Remvl Perm Pm Pls Gen W/Repl Plse Gen Mult Lead,PX-36900226,CDM,33229,CPT,369,RC,,,outpatient,,,22582,15807.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11584.14,,,10980.38,399.86,29773.2518,fee schedule,,,
HC Ins Pacng Cvdfb Pls Gen Only W/Exist Dual Leads,PX-36900227,CDM,33230,CPT,369,RC,,,outpatient,,,67496,47247.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,33803.3,,,32041.51,399.86,51836.928,fee schedule,,,
HC Ins Pacng Cvdfb Pls Gen Only W/Exist Multi Leads,PX-36900228,CDM,33231,CPT,369,RC,,,outpatient,,,64998,45498.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,33803.3,,,32041.51,399.86,50269.54813,fee schedule,,,
HC Remv Perm Pacer Generator,PX-36900229,CDM,33233,CPT,369,RC,,,outpatient,,,21456,15019.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3888.2,,,3685.55,399.86,16478.208,fee schedule,,,
HC Remv Transven Pacer Electrode-1 Lead,PX-36900230,CDM,33234,CPT,369,RC,,,outpatient,,,9056,6339.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3888.2,,,3685.55,399.86,6955.008,fee schedule,,,
HC Remv Transven Pacer Electrode-2 Lead,PX-36900231,CDM,33235,CPT,369,RC,,,outpatient,,,9056,6339.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3888.2,,,3685.55,399.86,6955.008,fee schedule,,,
HC Rmv Pulse Generator-Sngl/Dual,PX-36900233,CDM,33241,CPT,369,RC,,,outpatient,,,9028,6319.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3888.2,,,3685.55,399.86,6933.504,fee schedule,,,
HC Rmv Pacer/Electrd-Transven Extrct,PX-36900234,CDM,33244,CPT,369,RC,,,outpatient,,,9056,6339.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3888.2,,,3685.55,399.86,6955.008,fee schedule,,,
HC Insert Electrd Leads/Repostion,PX-36900235,CDM,33249,CPT,369,RC,,,outpatient,,,86384,60468.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,46068.04,,,43667.02,399.86,66342.912,fee schedule,,,
HC Rem Pac Cvdfb Plse Gen &Repl Plse Gen Sngl Lead,PX-36900236,CDM,33262,CPT,369,RC,,,outpatient,,,63006,44104.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,33803.3,,,32041.51,399.86,48388.608,fee schedule,,,
HC Rem Pac Cvdfb Plse Gen &Repl Plse Gen Dual Lead,PX-36900237,CDM,33263,CPT,369,RC,,,outpatient,,,65752,46026.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,33803.3,,,32041.51,399.86,50497.536,fee schedule,,,
HC Rem Pac Cvdfb Pls Gen &Repl Plse Gen Multi Lead,PX-36900238,CDM,33264,CPT,369,RC,,,outpatient,,,65752,46026.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,33803.3,,,32041.51,399.86,50497.536,fee schedule,,,
HC Replace Aortic Valve Perq Femoral Artry Approach,PX-36900544,CDM,33361,CPT,369,RC,,,outpatient,,,27728,19409.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,11110.6096,399.86,21295.104,percent of total billed charges,,,
HC Replace Aortic Valve Openfemoral Artery Approach,PX-36900545,CDM,33362,CPT,369,RC,,,outpatient,,,29393,20575.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,11777.7751,399.86,24913.5068,percent of total billed charges,,,
HC Replace Aortic Valve Open Axillry Artry Approach,PX-36900546,CDM,33363,CPT,369,RC,,,outpatient,,,27728,19409.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,11110.6096,399.86,21295.104,percent of total billed charges,,,
HC Replace Aortic Valve Open Iliac Artery Approach,PX-36900547,CDM,33364,CPT,369,RC,,,outpatient,,,29393,20575.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,11777.7751,399.86,22573.824,percent of total billed charges,,,
HC Replace Aortic Valve Open Transaortic Approach,PX-36900548,CDM,33365,CPT,369,RC,,,outpatient,,,29393,20575.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,11777.7751,399.86,22573.824,percent of total billed charges,,,
HC Transcatheter Transapical Replacemt Aortic Valve,PX-36900549,CDM,33366,CPT,369,RC,,,outpatient,,,29393,20575.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,11777.7751,399.86,24913.5068,percent of total billed charges,,,
HC Replace Aortic Valve W/Byp Prq Art/Venous Apprch,PX-36900550,CDM,33367,CPT,369,RC,,,outpatient,,,27728,19409.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,11110.6096,399.86,23502.2528,percent of total billed charges,,,
HC Replace Aortic Valve W/Byp Open Art/Venous Aprch,PX-36900551,CDM,33368,CPT,369,RC,,,outpatient,,,29393,20575.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,11777.7751,399.86,24913.5068,percent of total billed charges,,,
HC Replace Aorta Valve W/Byp Cntrl Art/Venous Aprch,PX-36900552,CDM,33369,CPT,369,RC,,,outpatient,,,29393,20575.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,11777.7751,399.86,24913.5068,percent of total billed charges,,,
HC Endovasc Taa Reincl Subcl,PX-36900241,CDM,33880,CPT,369,RC,,,outpatient,,,6951,4865.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,2785.2657,399.86,5338.368,percent of total billed charges,,,
HC Endovasc Taa Rew/O Subcl,PX-36900242,CDM,33881,CPT,369,RC,,,outpatient,,,5970,4179,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,2392.179,399.86,4584.96,percent of total billed charges,,,
HC Insert Endovasc Prosth- Taa,PX-36900243,CDM,33883,CPT,369,RC,,,outpatient,,,4420,3094,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1771.094,399.86,3746.392,percent of total billed charges,,,
HC Endovasc Prosth- Taa- Ea Add,PX-36900244,CDM,33884,CPT,369,RC,,,outpatient,,,1649,1154.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,660.7543,370.2005,2998,percent of total billed charges,,,
HC Endovasc Dist Extens Taa Prosth- Delayed,PX-36900245,CDM,33886,CPT,369,RC,,,outpatient,,,3820,2674,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1530.674,399.86,3237.832,percent of total billed charges,,,
HC Car-Car Bypass Grft W/ Endovas Taa Repair,PX-36900247,CDM,33891,CPT,369,RC,,,outpatient,,,4194,2935.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1680.5358,399.86,3220.992,percent of total billed charges,,,
HC Remove Pul Art Emboli No Bypass,PX-36900248,CDM,33915,CPT,369,RC,,,outpatient,,,1800,1260,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,721.26,399.86,2998,percent of total billed charges,,,
HC Insert Intra-Aortic Balloon Asst Device,PX-36900249,CDM,33967,CPT,369,RC,,,outpatient,,,2513,1759.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1006.9591,399.86,6913,percent of total billed charges,,,
HC Rmv Aortic Balloon Device,PX-36900250,CDM,33968,CPT,369,RC,,,outpatient,,,139,97.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,55.6973,31.2055,6913,percent of total billed charges,,,
HC Insj Perq Vad W/Rs&I L Hrt Arterial Access Only,PX-36900251,CDM,33990,CPT,369,RC,,,outpatient,,,4109,2876.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1646.4763,399.86,3155.712,percent of total billed charges,,,
HC Removal Perq Left Hrt Vad Artl/Artl&Ven Sep Insj,PX-36900252,CDM,33992,CPT,369,RC,,,outpatient,,,4188,2931.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1678.1316,399.86,3549.7488,percent of total billed charges,,,
HC Repositioning Perq R/L Vad W/Img Gdn Sep Insj,PX-36900253,CDM,33993,CPT,369,RC,,,outpatient,,,4188,2931.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1678.1316,399.86,3549.7488,percent of total billed charges,,,
HC Insj Perq Vad W/Rs&I R Heart Venous Access Only,PX-36900809,CDM,33995,CPT,369,RC,,,outpatient,,,4109,2876.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1646.4763,399.86,3155.712,percent of total billed charges,,,
HC Removal Perq R Heart Vad Venous Cannula Sep Insj,PX-36900810,CDM,33997,CPT,369,RC,,,outpatient,,,4188,2931.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1678.1316,293.5896,3216.384,percent of total billed charges,,,
HC Cardiac Surg Procedure Unlist,PX-36900254,CDM,33999,CPT,369,RC,,,outpatient,,,1770,1239,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1336.39,,,1266.74,397.365,2141,fee schedule,,,
HC Cardiac Surg Procedure Unlist,PX-36900635,CDM,33999,CPT,369,RC,,,outpatient,,,1770,1239,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1336.39,,,1266.74,397.365,2141,fee schedule,,,
HC Remv Art Clot Axill-Brach-Arm Incis,PX-36900255,CDM,34101,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7161.84,,,6788.57,399.86,9631.488,fee schedule,,,
HC Remv Art Clot Arm-Arm Incis,PX-36900256,CDM,34111,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7161.84,,,6788.57,399.86,9631.488,fee schedule,,,
HC Remv Art Clot Iliac-Pop-Leg Incis,PX-36900257,CDM,34201,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7161.84,,,6788.57,399.86,9631.488,fee schedule,,,
HC Remv Art Clot Low Leg-Leg Incis,PX-36900258,CDM,34203,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7161.84,,,6788.57,399.86,9631.488,fee schedule,,,
HC Aaa Repair-Iliac Artery Occlsn Device,PX-36900264,CDM,34808,CPT,369,RC,,,outpatient,,,152,106.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,60.9064,34.124,2998,percent of total billed charges,,,
HC Aaa Repr-Expose Femoral Art-Groin Incis,PX-36900265,CDM,34812,CPT,369,RC,,,outpatient,,,238,166.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,95.3666,53.431,2998,percent of total billed charges,,,
HC Aaa Repair- Femoral-Femoral Graft,PX-36900266,CDM,34813,CPT,369,RC,,,outpatient,,,167,116.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,66.9169,37.4915,2998,percent of total billed charges,,,
HC Aaa Repr-Expose Iliac Art-Abd Incis- Unilat,PX-36900267,CDM,34820,CPT,369,RC,,,outpatient,,,337,235.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,135.0359,75.6565,2998,percent of total billed charges,,,
HC Open Iliac Art Exp W/Conduit-Unilat,PX-36900270,CDM,34833,CPT,369,RC,,,outpatient,,,447,312.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,179.1129,100.3515,2998,percent of total billed charges,,,
HC Open Brach Art Exp-Endovas Pros-Unilat,PX-36900271,CDM,34834,CPT,369,RC,,,outpatient,,,218,152.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,87.3526,48.941,2998,percent of total billed charges,,,
HC Thrombectomy a-V Graft- Exc Hemodialysis,PX-36900278,CDM,35875,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7161.84,,,6788.57,399.86,9631.488,fee schedule,,,
HC Place Needle in Vein,PX-36900279,CDM,36000,CPT,369,RC,,,outpatient,,,343,240.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,77.0035,1592,other,Non-Reimbursable List,,
HC Injection Rx Extremity Pseudoaneurysm,PX-36900280,CDM,36002,CPT,369,RC,,,outpatient,,,775,542.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,357.46,,,338.83,173.9875,2141,fee schedule,,,
HC Injection Proc-Extremity-Venography,PX-36900281,CDM,36005,CPT,369,RC,,,outpatient,,,258,180.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,57.921,1592,other,Non-Reimbursable List,,
HC Place Cath in Vein-Svc-Ivc,PX-36900282,CDM,36010,CPT,369,RC,,,outpatient,,,541,378.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,121.4545,1592,other,Non-Reimbursable List,,
HC Place Cath in Vein-Select,PX-36900283,CDM,36011,CPT,369,RC,,,outpatient,,,773,541.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,173.5385,1592,other,Non-Reimbursable List,,
HC Place Cath in Vein-Subselect,PX-36900284,CDM,36012,CPT,369,RC,,,outpatient,,,909,636.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,204.0705,1592,other,Non-Reimbursable List,,
HC Place Cath in Rt Hrt-Main Pulm Art,PX-36900285,CDM,36013,CPT,369,RC,,,outpatient,,,8331,5831.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6398.208,other,Non-Reimbursable List,,
HC Place Cath in Lt/Rt Pulm Art,PX-36900286,CDM,36014,CPT,369,RC,,,outpatient,,,721,504.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,161.8645,1592,other,Non-Reimbursable List,,
HC Place Cath in Subsegmt Pulm Art,PX-36900287,CDM,36015,CPT,369,RC,,,outpatient,,,1662,1163.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,373.119,1592,other,Non-Reimbursable List,,
HC Place Cath Carot/Vert Art,PX-36900288,CDM,36100,CPT,369,RC,,,outpatient,,,628,439.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,140.986,1592,other,Non-Reimbursable List,,
HC Place Cath Extrem Artery,PX-36900290,CDM,36140,CPT,369,RC,,,outpatient,,,340,238,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,76.33,1592,other,Non-Reimbursable List,,
HC Place Cath Aorta via Translumbar,PX-36900293,CDM,36160,CPT,369,RC,,,outpatient,,,2609,1826.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,2003.712,other,Non-Reimbursable List,,
HC Place Cath Aorta,PX-36900294,CDM,36200,CPT,369,RC,,,outpatient,,,721,504.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,161.8645,1592,other,Non-Reimbursable List,,
HC Place Cath Selective Art-Neck,PX-36900295,CDM,36215,CPT,369,RC,,,outpatient,,,1030,721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.235,1592,other,Non-Reimbursable List,,
HC Place Cath Subselect Art-Neck,PX-36900296,CDM,36216,CPT,369,RC,,,outpatient,,,568,397.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,127.516,1592,other,Non-Reimbursable List,,
HC Place Cath Subsubselect Art-Neck,PX-36900297,CDM,36217,CPT,369,RC,,,outpatient,,,1545,1081.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,346.8525,1592,other,Non-Reimbursable List,,
HC Place Cath Addn Subselec Art-Neck,PX-36900298,CDM,36218,CPT,369,RC,,,outpatient,,,109,76.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,24.4705,1592,other,Non-Reimbursable List,,
HC Nonslctv Cath Thor Aorta Angio Intr/Xtrcranl Art,PX-36900299,CDM,36221,CPT,369,RC,,,outpatient,,,9691,6783.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5128.01,,,4860.74,399.86,7442.688,fee schedule,,,
HC Slctv Cath Carotid/Innom Art Angio Xtrcranl Art,PX-36900300,CDM,36222,CPT,369,RC,,,outpatient,,,9691,6783.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5128.01,,,4860.74,399.86,7442.688,fee schedule,,,
HC Slctv Cath Carotid/Innom Art Angio Intrcranl Art,PX-36900301,CDM,36223,CPT,369,RC,,,outpatient,,,9141,6398.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5128.01,,,4860.74,399.86,8396.844904,fee schedule,,,
HC Slctv Cath Intrnl Carotid Art Angio Intrcrnl Art,PX-36900302,CDM,36224,CPT,369,RC,,,outpatient,,,15847,11092.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8386.59,,,7949.49,399.86,12170.496,fee schedule,,,
HC Slctv Cath Subclavian Art Angio Vertebral Artery,PX-36900303,CDM,36225,CPT,369,RC,,,outpatient,,,9141,6398.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5128.01,,,4860.74,399.86,7020.288,fee schedule,,,
HC Slctv Cath Vertebral Art Angio Vertebral Artery,PX-36900304,CDM,36226,CPT,369,RC,,,outpatient,,,15847,11092.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8386.59,,,7949.49,399.86,12170.496,fee schedule,,,
HC Slctv Cath Xtrnl Carotid Angio Xtrnl Carotd Circ,PX-36900305,CDM,36227,CPT,369,RC,,,outpatient,,,515,360.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,115.6175,1592,other,Non-Reimbursable List,,
HC Slctv Cath Intrcrnl Brnch Angio Intrl Carot/Vert,PX-36900306,CDM,36228,CPT,369,RC,,,outpatient,,,612,428.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.394,1592,other,Non-Reimbursable List,,
HC Place Cath Select Art-Abd/Pel,PX-36900307,CDM,36245,CPT,369,RC,,,outpatient,,,1107,774.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,248.5215,1592,other,Non-Reimbursable List,,
HC Place Cath Subselect Art-Abd/Pel,PX-36900308,CDM,36246,CPT,369,RC,,,outpatient,,,1236,865.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,277.482,1592,other,Non-Reimbursable List,,
HC Place Cath Subsubselect Art-Abd/Pel,PX-36900309,CDM,36247,CPT,369,RC,,,outpatient,,,1442,1009.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,323.729,1592,other,Non-Reimbursable List,,
HC Place Cath Addn Subsel Art-Abd/Pel,PX-36900310,CDM,36248,CPT,369,RC,,,outpatient,,,258,180.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,57.921,1592,other,Non-Reimbursable List,,
HC Slctv Cath 1stord W/WO Art Punct/Fluoro/S&I Uni,PX-36900311,CDM,36251,CPT,369,RC,,,outpatient,,,9430,6601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5128.01,,,4860.74,399.86,7242.24,fee schedule,,,
HC Slctv Cath 1stord W/WO Art Punct/Fluor/S&I Bilat,PX-36900312,CDM,36252,CPT,369,RC,,,outpatient,,,9430,6601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5128.01,,,4860.74,399.86,7242.24,fee schedule,,,
HC Supslctv Cath 2nd+Ord Renl&Acces Artery/S&I Uni,PX-36900313,CDM,36253,CPT,369,RC,,,outpatient,,,9430,6601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5128.01,,,4860.74,399.86,8396.844904,fee schedule,,,
HC Supslctv Cath 2nd+Ord Renl&Acces Arter/S&I Bilat,PX-36900314,CDM,36254,CPT,369,RC,,,outpatient,,,9430,6601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5128.01,,,4860.74,399.86,7242.24,fee schedule,,,
Vnpnxr <3 Years Phys/Qhp Skill Other Vein,PX-36900875,CDM,36406,CPT,369,RC,,,outpatient,,,24,16.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.388,416.02,other,Non-Reimbursable List,,
HC Blood Transfusion Service,PX-39100001,CDM,36430,CPT,391,RC,,,outpatient,,,923,646.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,601.64,,,570.29,207.2135,1592,fee schedule,,,
HC Injection; Spider Veins-Limb/Trunk,PX-36900315,CDM,36468,CPT,369,RC,,,outpatient,,,909,636.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,165.26,,,156.65,156.65,1592,fee schedule,,,
HC Injection Therapy Vein-One Vein,PX-36900316,CDM,36470,CPT,369,RC,,,outpatient,,,909,636.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,247.09,,,234.21,204.0705,1592,fee schedule,,,
HC Injection Therapy Vein-Mult Veins,PX-36900317,CDM,36471,CPT,369,RC,,,outpatient,,,383,268.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,247.09,,,234.21,85.9835,1592,fee schedule,,,
HC Endovenous Rf- 1st Vein,PX-36900318,CDM,36475,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6987.24,,,6623.08,399.86,6623.08,fee schedule,,,
HC Endovenous Rf- Vein Add-On,PX-36900319,CDM,36476,CPT,369,RC,,,outpatient,,,1797,1257.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,1592,other,Non-Reimbursable List,,
HC Endovenous Laser- 1st Vein,PX-36900320,CDM,36478,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4524.72,,,4288.9,399.86,5781.504,fee schedule,,,
HC Endovenous Laser Vein Addon,PX-36900321,CDM,36479,CPT,369,RC,,,outpatient,,,1797,1257.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,1592,other,Non-Reimbursable List,,
HC Percut Portal Vein Cath,PX-36900322,CDM,36481,CPT,369,RC,,,outpatient,,,915,640.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,205.4175,1592,other,Non-Reimbursable List,,
HC Venous Select Sampling W Cath,PX-36900323,CDM,36500,CPT,369,RC,,,outpatient,,,412,288.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,92.494,1592,other,Non-Reimbursable List,,
HC Cathj Umbilical Vein Dx/Ther Nb,PX-36900588,CDM,36510,CPT,369,RC,,,outpatient,,,773,541.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,173.5385,1592,other,Non-Reimbursable List,,
HC Ther Apheresis-Platelets,PX-36900553,CDM,36513,CPT,369,RC,,,outpatient,,,1337,935.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2196.1,,,2081.64,300.1565,2081.64,fee schedule,,,
HC Ther Apheresis-Plasma Pheresis,PX-36900324,CDM,36514,CPT,369,RC,,,outpatient,,,4919,3443.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2196.1,,,2081.64,399.86,3777.792,fee schedule,,,
HC Insert Non-Tunnel Cv Cath < 5 Y/O,PX-36100009,CDM,36555,CPT,361,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1815.92,,,1721.28,399.86,5781.504,fee schedule,,,
HC Insert Non-Tunnel Cv Cath < 5 Y/O,PX-36900325,CDM,36555,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1815.92,,,1721.28,399.86,5781.504,fee schedule,,,
HC Insert Non-Tunnel Cv Cath,PX-36100010,CDM,36556,CPT,361,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1815.92,,,1721.28,399.86,6012.672,fee schedule,,,
HC Insert Non-Tunnel Cv Cath,PX-36900326,CDM,36556,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1815.92,,,1721.28,399.86,6012.672,fee schedule,,,
HC PR Insj Non-Tunneled Central Venous Cath Age 5 Yr/>,PX-96000046,CDM,36556,CPT,960,RC,,,outpatient,,,7829,5480.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1815.92,,,1721.28,399.86,6012.672,fee schedule,,,
HC Insert Tunneled Cv Cath W/O Port or Pump < 5 Y/O,PX-36100011,CDM,36557,CPT,361,RC,,,outpatient,,,12541,8778.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4052.15,,,3840.95,399.86,9631.488,fee schedule,,,
HC Insert Tunneled Cv Cath W/O Port or Pump < 5 Y/O,PX-36900327,CDM,36557,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4052.15,,,3840.95,399.86,9631.488,fee schedule,,,
HC Insert Tunneled Cv Cath W/O Port or Pump,PX-36100012,CDM,36558,CPT,361,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4052.15,,,3840.95,399.86,5781.504,fee schedule,,,
HC Insert Tunneled Cv Cath W/O Port or Pump,PX-36900328,CDM,36558,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4052.15,,,3840.95,399.86,5781.504,fee schedule,,,
HC Insert Tunneled Cv Cath With Port <5 Y/O,PX-36100013,CDM,36560,CPT,361,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5146.9,,,4878.65,399.86,5781.504,fee schedule,,,
HC Insert Tunneled Cv Cath With Port <5 Y/O,PX-36900329,CDM,36560,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5146.9,,,4878.65,399.86,5781.504,fee schedule,,,
HC Insert Tunneled Cv Cath With Port,PX-36100014,CDM,36561,CPT,361,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5146.9,,,4878.65,399.86,5781.504,fee schedule,,,
HC Insert Tunneled Cv Cath With Port,PX-36900330,CDM,36561,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5146.9,,,4878.65,399.86,5781.504,fee schedule,,,
HC Insert Tunneled Cv Cath With Pump,PX-36100015,CDM,36563,CPT,361,RC,,,outpatient,,,12541,8778.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5146.9,,,4878.65,399.86,9631.488,fee schedule,,,
HC Insert Tunneled Cv Cath With Pump,PX-36900331,CDM,36563,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5146.9,,,4878.65,399.86,9631.488,fee schedule,,,
HC Insert Tunneled Cv Cath W 2 Access Sites- W/O Pump or Port,PX-36900332,CDM,36565,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5146.9,,,4878.65,399.86,5781.504,fee schedule,,,
HC Insert Tunneled Cv Cath W 2 Access Sites- W/ Pump or Port,PX-36900333,CDM,36566,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5146.9,,,4878.65,399.86,9631.488,fee schedule,,,
HC Insert Picc W/O Sub-Q Port <5 Y/O,PX-36900334,CDM,36568,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1815.92,,,1721.28,399.86,2840.064,fee schedule,,,
HC Insert Picc W/O Sub-Q Port,PX-36900335,CDM,36569,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1815.92,,,1721.28,399.86,2953.728,fee schedule,,,
HC PR Insj Prph Cvc W/O Subq Port/Pmp Age 5 Yr/>,PX-96000047,CDM,36569,CPT,960,RC,,,outpatient,,,3846,2692.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1815.92,,,1721.28,399.86,2953.728,fee schedule,,,
HC Insert Picc W/ Sub-Q Port <5 Y/O,PX-36900336,CDM,36570,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4052.15,,,3840.95,399.86,5781.504,fee schedule,,,
HC Insert Picc W/ Sub-Q Port,PX-36900337,CDM,36571,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4052.15,,,3840.95,399.86,5781.504,fee schedule,,,
HC Repair Cv Cath W/O Subq Port or Pump,PX-36900338,CDM,36575,CPT,369,RC,,,outpatient,,,1421,994.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1015.59,,,962.66,319.0145,2141,fee schedule,,,
HC Repair Cv Cath W Subq Port or Pump,PX-36900339,CDM,36576,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1815.92,,,1721.28,399.86,2840.064,fee schedule,,,
HC Replace Cv Cath- Catheter Only W Subq Pump or Port,PX-36900340,CDM,36578,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4052.15,,,3840.95,399.86,5781.504,fee schedule,,,
HC Replace Cv Cath- Complete- Non-Tunneled- W/O Subq Port or Pump,PX-36900341,CDM,36580,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1815.92,,,1721.28,399.86,2840.064,fee schedule,,,
HC Replace Cv Cath- Complete- Tunneled- W/O Subq Port or Pump,PX-36900342,CDM,36581,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4052.15,,,3840.95,399.86,5781.504,fee schedule,,,
HC Replace Cv Cath- Complete- Non-Tunneled- W Subq Port or Pump,PX-36900343,CDM,36582,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5146.9,,,4878.65,399.86,5781.504,fee schedule,,,
HC Replace Cv Cath- Complete- Tunneled- W Subq Port or Pump,PX-36900344,CDM,36583,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5146.9,,,4878.65,399.86,9631.488,fee schedule,,,
HC Replace Picc W/O Port or Pump,PX-36900345,CDM,36584,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1815.92,,,1721.28,399.86,2840.064,fee schedule,,,
HC Replace Picc W Port or Pump,PX-36900346,CDM,36585,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4052.15,,,3840.95,399.86,5781.504,fee schedule,,,
HC Removal Tunneled Cv Cath W/O Subq Port or Pump,PX-36900347,CDM,36589,CPT,369,RC,,,outpatient,,,1421,994.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1015.59,,,962.66,319.0145,2141,fee schedule,,,
HC Removal Tunneled Cv Cath W Subq Port or Pump,PX-36900348,CDM,36590,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1815.92,,,1721.28,399.86,2998,fee schedule,,,
HC Collect Blood From Implant Venous Access Device,PX-76100001,CDM,36591,CPT,761,RC,,,outpatient,,,160,112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,35.92,1592,other,Non-Reimbursable List,,
HC Collect Blood From Catheter Venous Nos,PX-36900349,CDM,36592,CPT,369,RC,,,outpatient,,,125,87.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,28.0625,1592,other,Non-Reimbursable List,,
HC Declot of Cent Venous Catheter,PX-36900350,CDM,36593,CPT,369,RC,,,outpatient,,,806,564.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,398.86,,,378.07,180.947,1592,fee schedule,,,
HC Mech Remov Pericath Obstr Cv Dev via Ven Access,PX-36900351,CDM,36595,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4052.15,,,3840.95,399.86,5781.504,fee schedule,,,
HC Mech Remov Intralum Obstr Cv Dev Thru Lumen,PX-36900352,CDM,36596,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1815.92,,,1721.28,399.86,2840.064,fee schedule,,,
HC Reposition Venous Catheter,PX-36900353,CDM,36597,CPT,369,RC,,,outpatient,,,3698,2588.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1815.92,,,1721.28,399.86,2840.064,fee schedule,,,
HC Contrast Inj Cent Ven Cath- Inc Flouro,PX-36900354,CDM,36598,CPT,369,RC,,,outpatient,,,406,284.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,398.86,,,378.07,91.147,1592,fee schedule,,,
HC Withdrawal of Arterial Blood,PX-36900355,CDM,36600,CPT,369,RC,,,outpatient,,,297,207.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,66.6765,1592,other,Non-Reimbursable List,,
HC Insert Cath-Art-Percut-Shortterm,PX-36900356,CDM,36620,CPT,369,RC,,,outpatient,,,309,216.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,69.3705,1592,other,Non-Reimbursable List,,
HC Catheterization Umbilical Newborn Art Dx/Therapy,PX-36900836,CDM,36660,CPT,369,RC,,,outpatient,,,10702,7491.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,4288.2914,399.86,9071.0152,percent of total billed charges,,,
HC Placement Needle Intraosseous Infusion,PX-36900592,CDM,36680,CPT,369,RC,,,outpatient,,,568,397.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,283.26,,,268.5,127.516,1592,fee schedule,,,
HC PR Placement Needle Intraosseous Infusion,PX-96000050,CDM,36680,CPT,960,RC,,,outpatient,,,568,397.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,283.26,,,268.5,127.516,1592,fee schedule,,,
HC Insert Cannula-Vein-Vein,PX-36900358,CDM,36800,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6190.44,,,5867.8,399.86,9631.488,fee schedule,,,
HC Revise Av Fistula-W/O Thrombectomy,PX-36900359,CDM,36832,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7161.84,,,6788.57,399.86,9631.488,fee schedule,,,
HC Insert Transven Intrahep Portosys Shunt,PX-36900361,CDM,37182,CPT,369,RC,,,outpatient,,,4120,2884,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1650.884,399.86,5756,percent of total billed charges,,,
HC Revis Transven Intrahep Portosys Shunt,PX-36900362,CDM,37183,CPT,369,RC,,,outpatient,,,13035,9124.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19998.12,,,18955.84,399.86,18955.84,fee schedule,,,
HC Prim Perc Mech Thrombectomy- Arterial,PX-36900363,CDM,37184,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7161.84,,,6788.57,399.86,26793.51305,fee schedule,,,
HC Prim Perc Mech Thrombectomy- Arterial Ea Add,PX-36900364,CDM,37185,CPT,369,RC,,,outpatient,,,824,576.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,184.988,4800.911611,other,Non-Reimbursable List,,
HC Sec Perc Mech Thrombect- Arterial- W Other Proc,PX-36900365,CDM,37186,CPT,369,RC,,,outpatient,,,1236,865.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,277.482,8164.18419,other,Non-Reimbursable List,,
HC Percut Mech Thrombectomy- Venous,PX-36900366,CDM,37187,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7161.84,,,6788.57,399.86,20286.72,fee schedule,,,
HC Percut Mech Thrombectomy- Venous- Repeat,PX-36900367,CDM,37188,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7161.84,,,6788.57,399.86,6788.57,fee schedule,,,
HC Ins Intrvas Vc Filtr W/WO Vas Acs Vsl Selxn Rs&I,PX-36900368,CDM,37191,CPT,369,RC,,,outpatient,,,14030,9821,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6987.24,,,6623.08,399.86,10775.04,fee schedule,,,
HC Repsng Intrvas Vc Filtr W/WO Acs Vsl Selxn Rs&I,PX-36900369,CDM,37192,CPT,369,RC,,,outpatient,,,9628,6739.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5146.9,,,4878.65,399.86,7394.304,fee schedule,,,
HC Rtrvl Intrvas Vc Filtr W/WO Acs Vsl Selxn Rs&I,PX-36900370,CDM,37193,CPT,369,RC,,,outpatient,,,9998,6998.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5146.9,,,4878.65,399.86,7678.464,fee schedule,,,
HC Thrombolysis Cerebral IV Infusion,PX-36900762,CDM,37195,CPT,369,RC,,,outpatient,,,613,429.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,398.86,,,378.07,137.6185,1592,fee schedule,,,
HC Prq Transcatheter Rtrvl Intrvas FB With Imaging,PX-36900371,CDM,37197,CPT,369,RC,,,outpatient,,,8825,6177.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5146.9,,,4878.65,399.86,6777.6,fee schedule,,,
HC Transcatheter Biopsy,PX-36900372,CDM,37200,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5146.9,,,4878.65,399.86,9631.488,fee schedule,,,
HC Thrombolysis Arterial Infusion W/Imaging Init Tx,PX-36900374,CDM,37211,CPT,369,RC,,,outpatient,,,12541,8778.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1815.92,,,1721.28,399.86,9631.488,fee schedule,,,
HC Thrombolysis Venous Infusion W/Imaging Init Tx,PX-36900375,CDM,37212,CPT,369,RC,,,outpatient,,,3239,2267.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1815.92,,,1721.28,399.86,4870.452937,fee schedule,,,
HC Thrombolysis Art/Venous Infsn W/Image Subsq Tx,PX-36900376,CDM,37213,CPT,369,RC,,,outpatient,,,7224,5056.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4052.15,,,3840.95,399.86,5548.032,fee schedule,,,
HC Cessation Thrombolytic Thrpy W/Catheter Removal,PX-36900377,CDM,37214,CPT,369,RC,,,outpatient,,,7224,5056.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4052.15,,,3840.95,399.86,5548.032,fee schedule,,,
HC Transcath Stent- Cca W/Eps,PX-36900378,CDM,37215,CPT,369,RC,,,outpatient,,,553,387.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,221.5871,124.1485,2998,percent of total billed charges,,,
HC Revascularize Iliac Artery-Angioplasty- Initial Vessel,PX-36900379,CDM,37220,CPT,369,RC,,,outpatient,,,15994,11195.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9293.65,,,8809.27,399.86,12283.392,fee schedule,,,
HC Revascularize Iliac Artery-Angioplasty/Stent- Initial Vessel,PX-36900380,CDM,37221,CPT,369,RC,,,outpatient,,,16597,11617.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19998.12,,,18955.84,399.86,18955.84,fee schedule,,,
HC Revascularize Iliac Artery-Angioplasty- Ea Add Vessel,PX-36900381,CDM,37222,CPT,369,RC,,,outpatient,,,15818,11072.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,12148.224,other,Non-Reimbursable List,,
HC Revascularize Iliac Artery-Angioplasty/Stent- Ea Add Vessel,PX-36900382,CDM,37223,CPT,369,RC,,,outpatient,,,16216,11351.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,12453.888,other,Non-Reimbursable List,,
HC Revascularize Fem/Pop Artery-Angioplasty,PX-36900383,CDM,37224,CPT,369,RC,,,outpatient,,,16599,11619.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9293.65,,,8809.27,399.86,12748.032,fee schedule,,,
HC Revascularize Fem/Pop Artery-Angioplasty/Atherectomy,PX-36900384,CDM,37225,CPT,369,RC,,,outpatient,,,34070,23849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19998.12,,,18955.84,399.86,26793.51305,fee schedule,,,
HC Revascularize Fem/Pop Artery-Angioplasty/Stent,PX-36900385,CDM,37226,CPT,369,RC,,,outpatient,,,32579,22805.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19998.12,,,18955.84,399.86,25020.672,fee schedule,,,
HC Revascularize Fem/Pop Artery-Angioplasty/Stent/Atherectomy,PX-36900386,CDM,37227,CPT,369,RC,,,outpatient,,,59005,41303.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,33718.77,,,31961.39,399.86,45315.84,fee schedule,,,
HC Revascularize Tibial/Peron Artery-Angioplasty Initial,PX-36900387,CDM,37228,CPT,369,RC,,,outpatient,,,15999,11199.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9293.65,,,8809.27,399.86,16809.6787,fee schedule,,,
HC Revascularize Tibial/Peron Artery-Angioplasty/Atherectomy Initial,PX-36900388,CDM,37229,CPT,369,RC,,,outpatient,,,34866,24406.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19998.12,,,18955.84,399.86,26793.51305,fee schedule,,,
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent Initial,PX-36900389,CDM,37230,CPT,369,RC,,,outpatient,,,34070,23849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19998.12,,,18955.84,399.86,26793.51305,fee schedule,,,
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent/Atherectomy Init,PX-36900390,CDM,37231,CPT,369,RC,,,outpatient,,,58146,40702.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,33718.77,,,31961.39,399.86,44656.128,fee schedule,,,
HC Revascularize Tibial/Peron Artery-Angioplasty Ea Add,PX-36900391,CDM,37232,CPT,369,RC,,,outpatient,,,16052,11236.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,12327.936,other,Non-Reimbursable List,,
HC Revascularize Tibial/Peron Artery-Angioplasty/Atherectomy Ea Add,PX-36900392,CDM,37233,CPT,369,RC,,,outpatient,,,33576,23503.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,25786.368,other,Non-Reimbursable List,,
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent Ea Add,PX-36900393,CDM,37234,CPT,369,RC,,,outpatient,,,16052,11236.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,12327.936,other,Non-Reimbursable List,,
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent/Atherectomy Ea Add,PX-36900394,CDM,37235,CPT,369,RC,,,outpatient,,,15818,11072.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,12148.224,other,Non-Reimbursable List,,
HC Open/Perq Placement Intravascular Stent Initial,PX-36900395,CDM,37236,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19998.12,,,18955.84,399.86,20286.72,fee schedule,,,
HC Open/Perq Placement Intravascular Stent Ea Addl,PX-36900396,CDM,37237,CPT,369,RC,,,outpatient,,,3978,2784.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,4532,other,Non-Reimbursable List,,
HC Open/Perq Placement Intravascular Stent Same 1st,PX-36900397,CDM,37238,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19998.12,,,18955.84,399.86,20286.72,fee schedule,,,
HC Open/Perq Placemt Intravasc Stent Same Ea Addl,PX-36900398,CDM,37239,CPT,369,RC,,,outpatient,,,3978,2784.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,4532,other,Non-Reimbursable List,,
HC Vascular Embolization or Occlusion Venous Rs&I,PX-36900399,CDM,37241,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17721.19,,,16797.58,399.86,20286.72,fee schedule,,,
HC Vascular Embolization or Occlusion Arterial Rs&I,PX-36900400,CDM,37242,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17721.19,,,16797.58,399.86,26793.51305,fee schedule,,,
HC Vascular Embolize/Occlude Organ Tumor Infarct,PX-36900401,CDM,37243,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17721.19,,,16797.58,399.86,20286.72,fee schedule,,,
HC Vascular Embolization or Occlusion Hemorrhage,PX-36100016,CDM,37244,CPT,361,RC,,,outpatient,,,26415,18490.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17721.19,,,16797.58,399.86,20286.72,fee schedule,,,
HC Vascular Embolization or Occlusion Hemorrhage,PX-36900402,CDM,37244,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17721.19,,,16797.58,399.86,20286.72,fee schedule,,,
HC Temporal Artery Ligatn or Bx,PX-36900554,CDM,37609,CPT,369,RC,,,outpatient,,,4643,3250.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2591.35,,,2456.3,399.86,3565.824,fee schedule,,,
HC Phleb Veins - Extrem - to 20,PX-36900405,CDM,37765,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4524.72,,,4288.9,399.86,5781.504,fee schedule,,,
HC Phleb Veins - Extrem 20+,PX-36900406,CDM,37766,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4524.72,,,4288.9,399.86,5781.504,fee schedule,,,
HC Injection for Spleen X-Ray,PX-36900408,CDM,38200,CPT,369,RC,,,outpatient,,,381,266.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,85.5345,1592,other,SI=N Exclusions ,,
HC Bone Marrow; Aspiration Only,PX-36100017,CDM,38220,CPT,361,RC,,,outpatient,,,1973,1381.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,624.65,,,592.09,399.86,2477.315575,fee schedule,,,
HC Bone Marrow; Aspiration Only,PX-36900409,CDM,38220,CPT,369,RC,,,outpatient,,,1973,1381.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,624.65,,,592.09,399.86,2477.315575,fee schedule,,,
HC Bone Marrow Bx- Needle/Trocar,PX-36100018,CDM,38221,CPT,361,RC,,,outpatient,,,1972,1380.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,624.65,,,592.09,399.86,2477.315575,fee schedule,,,
HC Bone Marrow Bx- Needle/Trocar,PX-36900410,CDM,38221,CPT,369,RC,,,outpatient,,,1972,1380.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,624.65,,,592.09,399.86,2477.315575,fee schedule,,,
HC Dx Bone Marrow Bx & Aspir,PX-36100032,CDM,38222,CPT,361,RC,,,outpatient,,,4653,3257.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3114.08,,,2951.78,399.86,4341.777195,fee schedule,,,
HC Dx Bone Marrow Bx & Aspir,PX-36900703,CDM,38222,CPT,369,RC,,,outpatient,,,4653,3257.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3114.08,,,2951.78,399.86,4341.777195,fee schedule,,,
HC Needle Biopsy- Lymph Node(S),PX-36900411,CDM,38505,CPT,369,RC,,,outpatient,,,1973,1381.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1444.37,,,1369.09,399.86,2998,fee schedule,,,
HC Injection for Lymphatic Xray,PX-36900412,CDM,38790,CPT,369,RC,,,outpatient,,,500,350,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,112.25,1592,other,SI=N Exclusions ,,
HC Identify Sentinel Node,PX-36900413,CDM,38792,CPT,369,RC,,,outpatient,,,540,378,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,216.378,121.23,1592,percent of total billed charges,,,
HC Biopsy of Floor of Mouth,PX-36900555,CDM,41108,CPT,369,RC,,,outpatient,,,2598,1818.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,777.07,,,736.57,399.86,2477.315575,fee schedule,,,
HC Biopsy Salivary Gland-Needle,PX-36900414,CDM,42400,CPT,369,RC,,,outpatient,,,1637,1145.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1444.37,,,1369.09,367.5065,2141,fee schedule,,,
HC Injection for Salivary X-Ray,PX-36900415,CDM,42550,CPT,369,RC,,,outpatient,,,424,296.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,95.188,1592,other,Non-Reimbursable List,,
HC Dilation/Cath of Salivary Duct,PX-36900416,CDM,42660,CPT,369,RC,,,outpatient,,,533,373.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,530.88,,,503.21,119.6585,1592,fee schedule,,,
HC Inc/Drain Peritonsil Abscess,PX-36900812,CDM,42700,CPT,369,RC,,,outpatient,,,685,479.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,530.88,,,503.21,153.7825,1592,fee schedule,,,
HC Placement Ng/Og Tube by Physician,PX-36900423,CDM,43752,CPT,369,RC,,,outpatient,,,325,227.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,263.95,,,250.2,72.9625,1592,fee schedule,,,
HC PR Naso/Oro-Gastric Tube Plmt Req Phys&Fluor Gdnce,PX-96000043,CDM,43752,CPT,960,RC,,,outpatient,,,325,227.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,263.95,,,250.2,72.9625,1592,fee schedule,,,
HC Gastric Intubatj & Aspiraj W/Phys Skill/Lavage,PX-36900575,CDM,43753,CPT,369,RC,,,outpatient,,,579,405.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,129.9855,1592,other,Non-Reimbursable List,,
HC Reposition Gastric Feeding Tube Thru Duodenum,PX-36900425,CDM,43761,CPT,369,RC,,,outpatient,,,496,347.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1440.23,,,1365.17,111.352,1592,fee schedule,,,
HC Perq Replacement Gtube Not Req Revj Gstrst Trc,PX-36100033,CDM,43762,CPT,361,RC,,,outpatient,,,879,615.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,496.37,,,470.5,197.3355,1592,fee schedule,,,
HC Perq Replacement Gtube Not Req Revj Gstrst Trc,PX-36900727,CDM,43762,CPT,369,RC,,,outpatient,,,879,615.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,496.37,,,470.5,197.3355,1592,fee schedule,,,
HC Intro Long GI Tube,PX-36900427,CDM,44500,CPT,369,RC,,,outpatient,,,1673,1171.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1015.59,,,962.66,375.5885,2998,fee schedule,,,
HC Drainage of Pelvic Abscess,PX-36900428,CDM,45000,CPT,369,RC,,,outpatient,,,2727,1908.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4226.17,,,4005.9,399.86,4005.9,fee schedule,,,
HC Drainage of Deep Rectal Abscess,PX-36900429,CDM,45020,CPT,369,RC,,,outpatient,,,6425,4497.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2954.27,,,2800.3,399.86,4934.4,fee schedule,,,
HC I&D Ischiorectal&/Perirectal Abscess Spx,PX-36900738,CDM,46040,CPT,369,RC,,,outpatient,,,3716,2601.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2954.27,,,2800.3,399.86,2998,fee schedule,,,
HC Needle Biopsy Liver,PX-36900430,CDM,47000,CPT,369,RC,,,outpatient,,,3700,2590,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1648.39,,,1562.48,399.86,2998,fee schedule,,,
HC Needle Biopsy Liver-W Othr Proc,PX-36900431,CDM,47001,CPT,369,RC,,,outpatient,,,972,680.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,218.214,1592,other,Non-Reimbursable List,,
HC Ablat-Open-1+ Liver Tumor(S)-Percut Rf,PX-36900433,CDM,47382,CPT,369,RC,,,outpatient,,,13307,9314.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9348.07,,,8860.86,399.86,10219.776,fee schedule,,,
HC Cholecystostomy-Percutaneous- Complete,PX-36900434,CDM,47490,CPT,369,RC,,,outpatient,,,8367,5856.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4684.33,,,4440.19,399.86,6425.856,fee schedule,,,
HC Biliary Endoscopy Percut-Dil Strict,PX-36900443,CDM,47555,CPT,369,RC,,,outpatient,,,8367,5856.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4684.33,,,4440.19,399.86,6425.856,fee schedule,,,
HC Biliary Endoscopy Percut-Dil+Stent,PX-36900444,CDM,47556,CPT,369,RC,,,outpatient,,,13307,9314.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9348.07,,,8860.86,399.86,15728.70471,fee schedule,,,
HC Needle Biopsy of Pancreas,PX-36900446,CDM,48102,CPT,369,RC,,,outpatient,,,3700,2590,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1648.39,,,1562.48,399.86,2998,fee schedule,,,
HC Anast Panc Cyst-Bowel-Direct,PX-36900447,CDM,48520,CPT,369,RC,,,outpatient,,,1740,1218,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,697.218,390.63,2998,percent of total billed charges,,,
HC Exploratory Laparotomy Celiotomy W/WO Biopsy Spx,PX-36900881,CDM,49000,CPT,369,RC,,,outpatient,,,8564,5994.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,3431.5948,399.86,6577.152,percent of total billed charges,,,
HC Reopening Recent Laparotomy,PX-36900882,CDM,49002,CPT,369,RC,,,outpatient,,,8564,5994.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,3431.5948,399.86,6577.152,percent of total billed charges,,,
HC Abdom Paracentesis Dx/Ther W/O Imaging Guidance,PX-36900448,CDM,49082,CPT,369,RC,,,outpatient,,,925,647.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,952.66,,,903.01,207.6625,2998,fee schedule,,,
HC Abdom Paracentesis Dx/Ther W Imaging Guidance,PX-36100002,CDM,49083,CPT,361,RC,,,outpatient,,,1635,1144.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,952.66,,,903.01,367.0575,2998,fee schedule,,,
HC Abdom Paracentesis Dx/Ther W Imaging Guidance,PX-36900449,CDM,49083,CPT,369,RC,,,outpatient,,,1635,1144.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,952.66,,,903.01,367.0575,2998,fee schedule,,,
HC Percut Biopsy- Abdominal Mass,PX-36900450,CDM,49180,CPT,369,RC,,,outpatient,,,3700,2590,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1648.39,,,1562.48,399.86,2998,fee schedule,,,
HC Remove Peritoneal Foreign Body,PX-36900451,CDM,49402,CPT,369,RC,,,outpatient,,,8367,5856.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4279.65,,,4056.59,399.86,6425.856,fee schedule,,,
HC Image-Guide Fluid Collxn Drainage Cath Visc Perq,PX-36900452,CDM,49405,CPT,369,RC,,,outpatient,,,2870,2009,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2583.94,,,2449.27,399.86,2998,fee schedule,,,
HC Img-Guide Fluid Collxn Drainag Cath Periton Perq,PX-36900453,CDM,49406,CPT,369,RC,,,outpatient,,,2647,1852.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2583.94,,,2449.27,399.86,2998,fee schedule,,,
HC Insertion Tunnel Intraperitoneal Cath W Image Guidance,PX-36900455,CDM,49418,CPT,369,RC,,,outpatient,,,7964,5574.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5218.7,,,4946.71,399.86,6116.352,fee schedule,,,
HC Removal Tunneled Intraperitoneal Catheter,PX-36900456,CDM,49422,CPT,369,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3888.2,,,3685.55,399.86,5781.504,fee schedule,,,
HC Drainage Catheter Exchange,PX-36900457,CDM,49423,CPT,369,RC,,,outpatient,,,4271,2989.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2775.82,,,2631.14,399.86,3280.128,fee schedule,,,
HC Contrast Inj-Abscess/Cyst via Cath Tube,PX-36900458,CDM,49424,CPT,369,RC,,,outpatient,,,491,343.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,110.2295,1592,other,Non-Reimbursable List,,
HC Insert Gastrostomy Tube Percutaneous,PX-36900460,CDM,49440,CPT,369,RC,,,outpatient,,,4271,2989.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2140.95,,,2029.37,399.86,3280.128,fee schedule,,,
HC Convert Gastrostomy-Gastro-Jejunostomy Tube Percutaneous,PX-36900461,CDM,49446,CPT,369,RC,,,outpatient,,,4271,2989.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2140.95,,,2029.37,399.86,3280.128,fee schedule,,,
HC Replace Gastrostomy/Cecostomy Tube Percutaneous,PX-36100019,CDM,49450,CPT,361,RC,,,outpatient,,,1644,1150.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1015.59,,,962.66,369.078,2998,fee schedule,,,
HC Replace Gastrostomy/Cecostomy Tube Percutaneous,PX-36900462,CDM,49450,CPT,369,RC,,,outpatient,,,1644,1150.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1015.59,,,962.66,369.078,2998,fee schedule,,,
HC Replace Duodenostomy/Jejunostomy Tube Percutaneous,PX-36100020,CDM,49451,CPT,361,RC,,,outpatient,,,1692,1184.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1015.59,,,962.66,379.854,2998,fee schedule,,,
HC Replace Duodenostomy/Jejunostomy Tube Percutaneous,PX-36900463,CDM,49451,CPT,369,RC,,,outpatient,,,1692,1184.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1015.59,,,962.66,379.854,2998,fee schedule,,,
HC Replacement Gastro-Jejunostomy Tube Percutaneous,PX-36100021,CDM,49452,CPT,361,RC,,,outpatient,,,2617,1831.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1015.59,,,962.66,399.86,2998,fee schedule,,,
HC Replacement Gastro-Jejunostomy Tube Percutaneous,PX-36900464,CDM,49452,CPT,369,RC,,,outpatient,,,2617,1831.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1015.59,,,962.66,399.86,2998,fee schedule,,,
HC Obstructive Material Removal From GI Tube,PX-36900465,CDM,49460,CPT,369,RC,,,outpatient,,,2128,1489.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1015.59,,,962.66,399.86,2998,fee schedule,,,
HC Contrast Injection Percutaneouos Radiologic Eval GI Tube,PX-36900466,CDM,49465,CPT,369,RC,,,outpatient,,,606,424.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,242.8242,136.047,1592,percent of total billed charges,,,
CEPHALEXIN 250 MG/5ML ORAL SUSR,RX-9502,CDM,50000,HCPCS,259,RC,99999-0002-84,NDC,outpatient,10,ML,5.17,3.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,2.071619,1.160665,416.02,percent of total billed charges,,,
CEPHALEXIN 250 MG/5ML ORAL SUSR,RX-9502,CDM,50000,HCPCS,259,RC,68180-0441-01,NDC,outpatient,100,ML,50.29,35.203,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,20.151203,1.160665,416.02,percent of total billed charges,,,
HC Biopsy of Kidney-Percutaneous,PX-36900467,CDM,50200,CPT,369,RC,,,outpatient,,,3700,2590,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1648.39,,,1562.48,399.86,2998,fee schedule,,,
HC Change Ureter Stent- Percut,PX-36900468,CDM,50382,CPT,369,RC,,,outpatient,,,4709,3296.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4409.66,,,4179.83,399.86,4179.83,fee schedule,,,
HC Remove Ureter Stent- Percut,PX-36900469,CDM,50384,CPT,369,RC,,,outpatient,,,4709,3296.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2613.35,,,2477.14,399.86,3616.512,fee schedule,,,
HC Change Ext Transneph Ureter Stent W/ Fluoro,PX-36900470,CDM,50387,CPT,369,RC,,,outpatient,,,4709,3296.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2775.82,,,2631.14,399.86,3616.512,fee schedule,,,
HC Remove Renal Tube W/Fluoro,PX-36900471,CDM,50389,CPT,369,RC,,,outpatient,,,1513,1059.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1177.6,,,1116.22,339.6685,2141,fee schedule,,,
HC Percut Drain/Inject Renal Cyst,PX-36900472,CDM,50390,CPT,369,RC,,,outpatient,,,726,508.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1648.39,,,1562.48,162.987,2141,fee schedule,,,
HC Instll Rx Agnt Into Rnal Tub,PX-36900473,CDM,50391,CPT,369,RC,,,outpatient,,,533,373.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,189.41,,,179.53,119.6585,1592,fee schedule,,,
HC Measure Kidney Pressure Thru Tube,PX-36900478,CDM,50396,CPT,369,RC,,,outpatient,,,1513,1059.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,352.87,,,334.48,334.48,2141,fee schedule,,,
HC Plmt Nephrostomy Cath Prq New Access Rs&I,PX-36900659,CDM,50432,CPT,369,RC,,,outpatient,,,5502,3851.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3479.98,,,3298.61,399.86,4225.536,fee schedule,,,
HC Renal Endoscopy-Remv FB/Stone,PX-36900480,CDM,50561,CPT,369,RC,,,outpatient,,,11603,8122.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4409.66,,,4179.83,399.86,8911.104,fee schedule,,,
HC Perc Radiofreq Ablate Renal Tumor,PX-36900481,CDM,50592,CPT,369,RC,,,outpatient,,,13307,9314.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9348.07,,,8860.86,399.86,10219.776,fee schedule,,,
HC Inject Indwell Cath-Ureter X-Ray,PX-36900482,CDM,50684,CPT,369,RC,,,outpatient,,,374,261.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,83.963,1592,other,Non-Reimbursable List,,
HC Change of Ureterostomy Tube via Ileal Conduit,PX-36900483,CDM,50688,CPT,369,RC,,,outpatient,,,4709,3296.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2775.82,,,2631.14,399.86,3616.512,fee schedule,,,
HC Inject Retrograde/Conduit X-Ray,PX-36900484,CDM,50690,CPT,369,RC,,,outpatient,,,533,373.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,119.6585,1592,other,Non-Reimbursable List,,
HC Ureter Endoscopy Thru Ureterostomy W Biopsy,PX-36900485,CDM,50955,CPT,369,RC,,,outpatient,,,11603,8122.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4409.66,,,4179.83,399.86,8911.104,fee schedule,,,
HC Ureter Endoscopy Thru Ureterostomy Remv FB or Calculus,PX-36900486,CDM,50961,CPT,369,RC,,,outpatient,,,11603,8122.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4409.66,,,4179.83,399.86,8911.104,fee schedule,,,
HC Aspiration Bladder Needle,PX-36100022,CDM,51100,CPT,361,RC,,,outpatient,,,699,489.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,352.87,,,334.48,156.9255,1592,fee schedule,,,
HC Aspiration Bladder Needle,PX-36900488,CDM,51100,CPT,369,RC,,,outpatient,,,699,489.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,352.87,,,334.48,156.9255,1592,fee schedule,,,
HC Aspiration Bladder Trocar/Intracatheter,PX-36100023,CDM,51101,CPT,361,RC,,,outpatient,,,2419,1693.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,189.41,,,179.53,179.53,2998,fee schedule,,,
HC Aspiration Bladder Trocar/Intracatheter,PX-36900489,CDM,51101,CPT,369,RC,,,outpatient,,,2419,1693.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,189.41,,,179.53,179.53,2998,fee schedule,,,
HC Aspiration Bladder Insert Suprapubic Catheter,PX-36100024,CDM,51102,CPT,361,RC,,,outpatient,,,4709,3296.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3256.18,,,3086.47,399.86,3616.512,fee schedule,,,
HC Aspiration Bladder Insert Suprapubic Catheter,PX-36900490,CDM,51102,CPT,369,RC,,,outpatient,,,4709,3296.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3256.18,,,3086.47,399.86,3616.512,fee schedule,,,
HC Injection for Bladder X-Ray,PX-36900491,CDM,51600,CPT,369,RC,,,outpatient,,,1455,1018.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,235.074116,1592,other,Non-Reimbursable List,,
HC Inject for Retrograde Urethocysto,PX-36900492,CDM,51610,CPT,369,RC,,,outpatient,,,976,683.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,219.112,1592,other,Non-Reimbursable List,,
HC Bldr Irrigation Smpl Lavage &/Instlj,PX-36900732,CDM,51700,CPT,369,RC,,,outpatient,,,879,615.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,352.87,,,334.48,197.3355,1592,fee schedule,,,
HC Insert-Non-Indwelling Bladder Catheter,PX-36900494,CDM,51701,CPT,369,RC,,,outpatient,,,389,272.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,114.67,,,108.7,87.3305,1592,fee schedule,,,
HC Insert-Temp Indwelling Blad Cath-Simple,PX-36900495,CDM,51702,CPT,369,RC,,,outpatient,,,391,273.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,114.67,,,108.7,87.7795,1592,fee schedule,,,
HC Insert-Temp Indwelling Blad Cath-Comp,PX-36900496,CDM,51703,CPT,369,RC,,,outpatient,,,354,247.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,189.41,,,179.53,79.473,1592,fee schedule,,,
HC Change of Bladder Tube-Simple,PX-36900497,CDM,51705,CPT,369,RC,,,outpatient,,,456,319.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,352.87,,,334.48,102.372,1592,fee schedule,,,
HC Emg Stds Anal/Urtl Sphnctr Oth/Thn Ndl,PX-36900667,CDM,51784,CPT,369,RC,,,outpatient,,,475,332.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,189.41,,,179.53,106.6375,1592,fee schedule,,,
HC Meas Post-Voiding Residual Urine&/Bladder Cap,PX-36900733,CDM,51798,CPT,369,RC,,,outpatient,,,212,148.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,114.67,,,108.7,47.594,1592,fee schedule,,,
HC Cysto/Ureteroscopy-Tx Ureter Strict,PX-36900500,CDM,52344,CPT,369,RC,,,outpatient,,,8086,5660.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4409.66,,,4179.83,399.86,6210.048,fee schedule,,,
HC Circumcision Age >28 Days,PX-36900772,CDM,54161,CPT,369,RC,,,outpatient,,,6599,4619.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3919.87,,,3715.57,399.86,5068.032,fee schedule,,,
HC Irrigation Corpora Cavernosa Priapism,PX-36900736,CDM,54220,CPT,369,RC,,,outpatient,,,591,413.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,352.87,,,334.48,120.28264,1592,fee schedule,,,
HC Biopsy of Prostate-Needle/Punch,PX-36900501,CDM,55700,CPT,369,RC,,,outpatient,,,4709,3296.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2234.37,,,2117.92,399.86,3616.512,fee schedule,,,
HC I&D of Vulva/Perineum Abscess,PX-36900502,CDM,56405,CPT,369,RC,,,outpatient,,,829,580.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,273.89,,,259.61,186.1105,1592,fee schedule,,,
HC PR Colporrhaphy- Suture Vaginal Injury- Non-OB,PX-36900795,CDM,57200,CPT,369,RC,,,outpatient,,,5013,3509.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3360.16,,,3185.03,399.86,4777.053449,fee schedule,,,
HC Cath/Inject Hysterosalpingogram,PX-36900505,CDM,58340,CPT,369,RC,,,outpatient,,,1092,764.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,235.074116,1592,other,Non-Reimbursable List,,
HC Reopen Fallopian Tube-Transcerv Cath,PX-36900506,CDM,58345,CPT,369,RC,,,outpatient,,,6900,4830,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3360.16,,,3185.03,399.86,5299.2,fee schedule,,,
HC Fetal Non-Stress Test,PX-92000003,CDM,59025,CPT,920,RC,,,outpatient,,,490,343,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,273.89,,,259.61,110.005,416.02,fee schedule,,,
HC PR Vaginal Delivery Only,PX-96000044,CDM,59409,CPT,960,RC,,,outpatient,,,3062,2143.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3360.16,,,3185.03,399.86,4777.053449,fee schedule,,,
HC PR Delivery Placenta Separate Procedure,PX-96000045,CDM,59414,CPT,960,RC,,,outpatient,,,7176,5023.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3360.16,,,3185.03,399.86,5511.168,fee schedule,,,
HC Biopsy of Thyroid-Percut,PX-36900512,CDM,60100,CPT,369,RC,,,outpatient,,,1514,1059.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,798.19,,,756.59,339.893,2141,fee schedule,,,
HC Endocrine Surgery Proc Unlisted,PX-36900513,CDM,60699,CPT,369,RC,,,outpatient,,,6035,4224.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12040.59,,,11413.04,399.86,11413.04,fee schedule,,,
HC Brain Shunt Tube/Reserv Injectn,PX-36900514,CDM,61070,CPT,369,RC,,,outpatient,,,1885,1319.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1015.59,,,962.66,399.86,2141,fee schedule,,,
HC Endovasc Temp Balloon Occlus-Head/Nck,PX-36900515,CDM,61623,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17721.19,,,16797.58,399.86,20286.72,fee schedule,,,
HC Perm Occlusion/Embolization-Percut-Cns,PX-36900516,CDM,61624,CPT,369,RC,,,outpatient,,,533,373.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,213.5731,119.6585,5756,percent of total billed charges,,,
HC Percut Cath Occlusn Non Cns Lesn,PX-36900517,CDM,61626,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17721.19,,,16797.58,399.86,20286.72,fee schedule,,,
HC Percut Aspiration Vertebral Disc,PX-36900518,CDM,62267,CPT,369,RC,,,outpatient,,,1637,1145.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,798.19,,,756.59,367.5065,2141,fee schedule,,,
HC Spinal Puncture-Lumbar-Diagnostic,PX-36100025,CDM,62270,CPT,361,RC,,,outpatient,,,915,640.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,673.95,,,638.82,205.4175,2141,fee schedule,,,
HC Spinal Puncture-Lumbar-Diagnostic,PX-36900519,CDM,62270,CPT,369,RC,,,outpatient,,,915,640.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,673.95,,,638.82,205.4175,2141,fee schedule,,,
HC PR Spinal Puncture Lumbar Diagnostic,PX-96000051,CDM,62270,CPT,960,RC,,,outpatient,,,915,640.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,673.95,,,638.82,205.4175,2141,fee schedule,,,
HC Spinal Puncture-Therapeutic Drainage,PX-36100026,CDM,62272,CPT,361,RC,,,outpatient,,,1256,879.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,673.95,,,638.82,281.972,2141,fee schedule,,,
HC Spinal Puncture-Therapeutic Drainage,PX-36900520,CDM,62272,CPT,369,RC,,,outpatient,,,1256,879.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,673.95,,,638.82,281.972,2141,fee schedule,,,
HC Inj-Lumb Epidur-Blood/Clot Patch,PX-36900521,CDM,62273,CPT,369,RC,,,outpatient,,,915,640.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1306.94,,,1238.82,205.4175,2141,fee schedule,,,
HC Inject-Myelography &/or CT Scan-Spinal,PX-36900522,CDM,62284,CPT,369,RC,,,outpatient,,,1312,918.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,294.544,1592,other,Non-Reimbursable List,,
HC Diskectomy-Percutaneous Lumbar,PX-36900523,CDM,62287,CPT,369,RC,,,outpatient,,,6304,4412.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5732.7,,,5433.92,399.86,6224.0876,fee schedule,,,
HC Inject Diskogram-Lumbar-Ea Level,PX-36900524,CDM,62290,CPT,369,RC,,,outpatient,,,1256,879.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,281.972,1592,other,Non-Reimbursable List,,
HC Inj-Cerv/Thorac-for Diskography,PX-36900525,CDM,62291,CPT,369,RC,,,outpatient,,,1107,774.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,248.5215,1592,other,Non-Reimbursable List,,
HC Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/O Img Gdn,PX-36900884,CDM,62322,CPT,369,RC,,,outpatient,,,2586,1810.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1171.66,,,1110.59,399.86,2141,fee schedule,,,
HC Elec Anlys Implt Ithcl/Edrl Pmp W/Repr Phys/Qhp,PX-36900526,CDM,62370,CPT,369,RC,,,outpatient,,,821,574.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,442.8,,,419.72,155.844464,1592,fee schedule,,,
HC Inject Nerv Blck-Trigeminal,PX-36900609,CDM,64400,CPT,369,RC,,,outpatient,,,891,623.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,421.85,,,399.86,200.0295,1592,fee schedule,,,
HC Inject Nerv Blck-Great Occiptl,PX-36900611,CDM,64405,CPT,369,RC,,,outpatient,,,1634,1143.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,673.95,,,638.82,323.2601,1592,fee schedule,,,
HC Inject Nerv Blck-Vagus Nerve,PX-36900612,CDM,64408,CPT,369,RC,,,outpatient,,,877,613.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,421.85,,,399.86,196.8865,1592,fee schedule,,,
HC Inj-Anes Agent-Brachial Plexus-Single,PX-36900616,CDM,64415,CPT,369,RC,,,outpatient,,,1544,1080.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,673.95,,,638.82,346.628,2141,fee schedule,,,
HC Inj-Anes Agent-Brachial Plexus-Cont Inf,PX-36900617,CDM,64416,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1306.94,,,1238.82,399.86,2141,fee schedule,,,
HC Inject Nerv Blck-Axillary Nerv,PX-36900618,CDM,64417,CPT,369,RC,,,outpatient,,,1544,1080.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,673.95,,,638.82,346.628,2141,fee schedule,,,
HC Inject Nerv Blck-Suprascap N.,PX-36900619,CDM,64418,CPT,369,RC,,,outpatient,,,1544,1080.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,673.95,,,638.82,346.628,2141,fee schedule,,,
HC Inject Nerv Blck-Intercostal-One,PX-36900620,CDM,64420,CPT,369,RC,,,outpatient,,,1382,967.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,673.95,,,638.82,310.259,2141,fee schedule,,,
HC Inject Nerv Blck-Intercost-Multpl,PX-36900621,CDM,64421,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1306.94,,,1238.82,399.86,2141,fee schedule,,,
HC Inject Nerv Blck-Ilioingu/Iliohyp,PX-36900622,CDM,64425,CPT,369,RC,,,outpatient,,,1544,1080.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,673.95,,,638.82,346.628,2141,fee schedule,,,
HC Inject Nerv Blck-Pudendal,PX-36100029,CDM,64430,CPT,361,RC,,,outpatient,,,2785,1949.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1306.94,,,1238.82,399.86,2141,fee schedule,,,
HC Inject Nerv Blck-Pudendal,PX-36900623,CDM,64430,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1306.94,,,1238.82,399.86,2141,fee schedule,,,
HC Inject Nerv Blck-Paracervical,PX-36900624,CDM,64435,CPT,369,RC,,,outpatient,,,1544,1080.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,673.95,,,638.82,346.628,2141,fee schedule,,,
HC Inj-Anes Agent-Sciatic Nerve-Single,PX-36900625,CDM,64445,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1306.94,,,1238.82,399.86,2141,fee schedule,,,
HC Inj-Anes Agent-Sciatic Nerve-Cont Inf,PX-36900626,CDM,64446,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1306.94,,,1238.82,399.86,2141,fee schedule,,,
HC Inj-Anes Agent-Femoral Nerve-Single,PX-36900627,CDM,64447,CPT,369,RC,,,outpatient,,,1544,1080.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,673.95,,,638.82,346.628,2141,fee schedule,,,
HC Inj-Anes Agent-Femoral Nerve-Cont Inf,PX-36900628,CDM,64448,CPT,369,RC,,,outpatient,,,6090,4263,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1306.94,,,1238.82,399.86,4677.12,fee schedule,,,
HC N Block Inj- Lumbar Plexus,PX-36900629,CDM,64449,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1306.94,,,1238.82,399.86,2141,fee schedule,,,
HC Inject Nerv Blck-Othr Periph Nerv,PX-36900630,CDM,64450,CPT,369,RC,,,outpatient,,,1634,1143.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,673.95,,,638.82,366.833,2141,fee schedule,,,
HC Njx Aa&/Strd Plantar Common Digital Nerves,PX-36900835,CDM,64455,CPT,369,RC,,,outpatient,,,825,577.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,421.85,,,399.86,185.2125,1592,fee schedule,,,
HC Inject Anes/Steroid Foramen Cerv/Thoracic W Img Guide -1 Level,PX-36900631,CDM,64479,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1306.94,,,1238.82,399.86,2141,fee schedule,,,
HC Inject Anes/Steroid Foramen Cerv/Thoracic W Img Guide -Ea Add Level,PX-36900632,CDM,64480,CPT,369,RC,,,outpatient,,,230,161,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.635,1592,other,Non-Reimbursable List,,
HC Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level,PX-36100027,CDM,64483,CPT,361,RC,,,outpatient,,,1693,1185.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1306.94,,,1238.82,380.0785,2141,fee schedule,,,
HC Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level,PX-36900531,CDM,64483,CPT,369,RC,,,outpatient,,,1693,1185.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1306.94,,,1238.82,380.0785,2141,fee schedule,,,
HC Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl,PX-36900532,CDM,64484,CPT,369,RC,,,outpatient,,,416,291.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,93.392,1592,other,Non-Reimbursable List,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- 1st Level,PX-36100028,CDM,64490,CPT,361,RC,,,outpatient,,,1693,1185.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1306.94,,,1238.82,380.0785,2141,fee schedule,,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- 1st Level,PX-36900533,CDM,64490,CPT,369,RC,,,outpatient,,,1693,1185.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1306.94,,,1238.82,380.0785,2141,fee schedule,,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- 2nd Level,PX-36900633,CDM,64491,CPT,369,RC,,,outpatient,,,221,154.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,49.6145,1592,other,SI=N Exclusions ,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- Add Level,PX-36900634,CDM,64492,CPT,369,RC,,,outpatient,,,224,156.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,50.288,1592,other,SI=N Exclusions ,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Lumbar/Sac- 1st Level,PX-36900536,CDM,64493,CPT,369,RC,,,outpatient,,,1693,1185.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1306.94,,,1238.82,380.0785,2141,fee schedule,,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Lumbar/Sac- 2nd Level,PX-36900537,CDM,64494,CPT,369,RC,,,outpatient,,,1693,1185.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,380.0785,1592,other,SI=N Exclusions ,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Lumbar/Sac- Add Level,PX-36900538,CDM,64495,CPT,369,RC,,,outpatient,,,54,37.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.123,1592,other,SI=N Exclusions ,,
HC Inject Nerv Blck-Celiac Plexus,PX-36900539,CDM,64530,CPT,369,RC,,,outpatient,,,2165,1515.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1306.94,,,1238.82,399.86,2141,fee schedule,,,
HC Unlisted Procedure Nervous System,PX-36100035,CDM,64999,CPT,361,RC,,,outpatient,,,687,480.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,628.09,,,595.36,154.2315,1592,fee schedule,,,
HC Unlisted Procedure Nervous System,PX-36900829,CDM,64999,CPT,369,RC,,,outpatient,,,687,480.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,628.09,,,595.36,154.2315,1592,fee schedule,,,
HC Removal Impacted Cerumen Using Irrigation/Lavage- Unilateral,PX-36900636,CDM,69209,CPT,369,RC,,,outpatient,,,205,143.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,46.0225,1592,other,Non-Reimbursable List,,
HC Removal Impacted Cerumen Instrumentation Unilat,PX-36900540,CDM,69210,CPT,369,RC,,,outpatient,,,305,213.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,66.75974,1592,other,Non-Reimbursable List,,
HC X-Ray Eye for Foreign Body,PX-32000004,CDM,70030,CPT,320,RC,,,outpatient,,,271,189.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,60.8395,416.02,fee schedule,,,
HC X-Ray Jaw <4 Vw,PX-32000005,CDM,70100,CPT,320,RC,,,outpatient,,,595,416.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,71.24,456.96,fee schedule,,,
HC X-Ray Jaw 4+ Vw,PX-32000006,CDM,70110,CPT,320,RC,,,outpatient,,,489,342.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,147.03,,,147.03,76.026473,416.02,fee schedule,,,
HC X-Ray Mastoids <3 Vw,PX-32000007,CDM,70120,CPT,320,RC,,,outpatient,,,384,268.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,147.03,,,147.03,86.208,416.02,fee schedule,,,
HC X-Ray Mastoids 3+ Vw,PX-32000008,CDM,70130,CPT,320,RC,,,outpatient,,,295,206.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,66.2275,416.02,fee schedule,,,
HC X-Ray Facial Bones <3 Vw,PX-32000009,CDM,70140,CPT,320,RC,,,outpatient,,,336,235.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,71.24,416.02,fee schedule,,,
HC X-Ray Facial Bones 3+ Vw,PX-32000010,CDM,70150,CPT,320,RC,,,outpatient,,,252,176.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,147.03,,,147.03,56.574,416.02,fee schedule,,,
HC X-Ray Nasal Bones,PX-32000011,CDM,70160,CPT,320,RC,,,outpatient,,,319,223.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,71.24,416.02,fee schedule,,,
HC X-Ray Orbits,PX-32000012,CDM,70200,CPT,320,RC,,,outpatient,,,328,229.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,147.03,,,147.03,73.636,416.02,fee schedule,,,
HC X-Ray Sinuses <3 Vw,PX-32000013,CDM,70210,CPT,320,RC,,,outpatient,,,328,229.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,71.24,416.02,fee schedule,,,
HC X-Ray Sinuses 3+ Vw,PX-32000014,CDM,70220,CPT,320,RC,,,outpatient,,,444,310.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,147.03,,,147.03,71.24,416.02,fee schedule,,,
HC X-Ray Exam Sella,PX-32000015,CDM,70240,CPT,320,RC,,,outpatient,,,262,183.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,58.819,416.02,fee schedule,,,
HC X-Ray Skull <4 Vw,PX-32000016,CDM,70250,CPT,320,RC,,,outpatient,,,352,246.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,76.026473,416.02,fee schedule,,,
HC X-Ray Skull 4+ Vw,PX-32000017,CDM,70260,CPT,320,RC,,,outpatient,,,419,293.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,147.03,,,147.03,76.026473,416.02,fee schedule,,,
HC X-Ray Teeth Single,PX-32000018,CDM,70300,CPT,320,RC,,,outpatient,,,241,168.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,74.47,,,74.47,54.1045,416.02,fee schedule,,,
HC X-Ray Tmj Unilat,PX-32000019,CDM,70328,CPT,320,RC,,,outpatient,,,241,168.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,54.1045,416.02,fee schedule,,,
HC X-Ray Tmj Bilat,PX-32000020,CDM,70330,CPT,320,RC,,,outpatient,,,716,501.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,71.24,549.888,fee schedule,,,
HC MRI- Tmj,PX-61000008,CDM,70336,CPT,610,RC,,,outpatient,,,2588,1811.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,360.21,,,360.21,267.439885,1987.584,fee schedule,,,
HC Panoramic X-Ray of Jaws,PX-32000022,CDM,70355,CPT,320,RC,,,outpatient,,,241,168.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,74.47,,,74.47,54.1045,416.02,fee schedule,,,
HC X-Ray Neck Soft Tissue,PX-32000023,CDM,70360,CPT,320,RC,,,outpatient,,,232,162.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,52.084,416.02,fee schedule,,,
HC X-Ray Salivary Gland,PX-32000025,CDM,70380,CPT,320,RC,,,outpatient,,,262,183.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,58.819,416.02,fee schedule,,,
HC X-Ray Sialogram,PX-32000026,CDM,70390,CPT,320,RC,,,outpatient,,,537,375.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,120.5565,646.6965,other,Non-Reimbursable List,,
HC CT Scan-Head/Brain-W/O Contrast Matl,PX-35000002,CDM,70450,CPT,350,RC,,,outpatient,,,1070,749,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,154.41,,,154.41,89.81,821.76,fee schedule,,,
HC CT Scan Head Contrast,PX-35000003,CDM,70460,CPT,350,RC,,,outpatient,,,1333,933.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,201.75,,,201.75,124.33,1023.744,fee schedule,,,
CT Head/Brain W/O & W/Contrast Material,PX-35000004,CDM,70470,CPT,350,RC,,,outpatient,,,1615,1130.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,195.57,,,195.57,153.75,1240.32,fee schedule,,,
HC CT Scan-Orbit/Sella/Post Fossa/Ear-W/O,PX-35000005,CDM,70480,CPT,350,RC,,,outpatient,,,657,459.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,267.19,,,267.19,96.160741,575,fee schedule,,,
HC CT Scan Skull Contrast,PX-35000006,CDM,70481,CPT,350,RC,,,outpatient,,,774,541.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,316.17,,,316.17,173.763,667.43,fee schedule,,,
CT Orbit Sella/Post Fossa/Ear W/O & W/Contr Matr,PX-35000007,CDM,70482,CPT,350,RC,,,outpatient,,,1619,1133.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,355.27,,,355.27,200.53123,1243.392,fee schedule,,,
HC CT Scan-Maxillofacial Area-W/O Contrast,PX-35000008,CDM,70486,CPT,350,RC,,,outpatient,,,1200,840,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,214.92,,,214.92,96.160741,921.6,fee schedule,,,
HC CT Scan- Face/Jaw Contrast,PX-35000009,CDM,70487,CPT,350,RC,,,outpatient,,,1321,924.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,263.48,,,263.48,200.53123,1014.528,fee schedule,,,
CT Maxillofacial W/O & W/Contrast Material,PX-35000010,CDM,70488,CPT,350,RC,,,outpatient,,,1158,810.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,325.64,,,325.64,200.53123,889.344,fee schedule,,,
HC CT Scan-Soft Tissue Neck-W/O Contrast,PX-35000011,CDM,70490,CPT,350,RC,,,outpatient,,,514,359.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,199.27,,,199.27,96.160741,575,fee schedule,,,
HC CT Neck Tissue Contrast,PX-35000012,CDM,70491,CPT,350,RC,,,outpatient,,,1482,1037.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,249.9,,,249.9,194.55,1138.176,fee schedule,,,
CT Soft Tissue Neck W/O & W/Contrast Material,PX-35000014,CDM,70492,CPT,350,RC,,,outpatient,,,1755,1228.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,310.41,,,310.41,200.53123,1347.84,fee schedule,,,
CT Angiography Head W/Contrast/Noncontrast,PX-35000013,CDM,70496,CPT,350,RC,,,outpatient,,,1330,931,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,517.04,,,517.04,200.53123,1021.44,fee schedule,,,
CT Angiography Neck W/Contrast/Noncontrast,PX-35000015,CDM,70498,CPT,350,RC,,,outpatient,,,1157,809.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,537.62,,,537.62,200.53123,888.576,fee schedule,,,
HC MRI- Face- Neck,PX-61000009,CDM,70540,CPT,610,RC,,,outpatient,,,5081,3556.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,425.25,,,425.25,237.688956,3902.208,fee schedule,,,
HC MRI- Face- Neck W/Contrast,PX-61000010,CDM,70542,CPT,610,RC,,,outpatient,,,2710,1897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,472.58,,,472.58,365.99,2081.28,fee schedule,,,
MRI Orbit Face & Neck W/O & W/Contrast Matrl,PX-61000011,CDM,70543,CPT,610,RC,,,outpatient,,,1692,1184.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,571.78,,,571.78,379.854,1299.456,fee schedule,,,
HC MR Angio- Head,PX-61000012,CDM,70544,CPT,610,RC,,,outpatient,,,2279,1595.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,498.1,,,498.1,267.439885,1750.272,fee schedule,,,
HC MR Angio- Head W/Contrast,PX-61000013,CDM,70545,CPT,610,RC,,,outpatient,,,2279,1595.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,489.05,,,489.05,374.62,1750.272,fee schedule,,,
Mra Head W/O & W/Contrast Material,PX-61000014,CDM,70546,CPT,610,RC,,,outpatient,,,2279,1595.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,753.3,,,753.3,301.425681,1750.272,fee schedule,,,
HC MR Angio- Neck,PX-61000015,CDM,70547,CPT,610,RC,,,outpatient,,,2182,1527.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,498.51,,,498.51,267.439885,1675.776,fee schedule,,,
HC MR Angio- Neck W/Contrast,PX-61000016,CDM,70548,CPT,610,RC,,,outpatient,,,2469,1728.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,531.44,,,531.44,399.86,1896.192,fee schedule,,,
Mra Neck W/O &W/Contrast Material,PX-61000017,CDM,70549,CPT,610,RC,,,outpatient,,,2534,1773.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,755.35,,,755.35,301.425681,1946.112,fee schedule,,,
HC MRI Brain,PX-61000018,CDM,70551,CPT,610,RC,,,outpatient,,,2090,1463,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,445.83,,,445.83,188.66,1605.12,fee schedule,,,
HC MRI Brain Contrast,PX-61000019,CDM,70552,CPT,610,RC,,,outpatient,,,5255,3678.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,490.28,,,490.28,268.7,4035.84,fee schedule,,,
MRI Brain Brain Stem W/O W/Contrast Material,PX-61000020,CDM,70553,CPT,610,RC,,,outpatient,,,2668,1867.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,558.2,,,558.2,307.14,2049.024,fee schedule,,,
HC X-Ray Exam Chest 1 View,PX-32000245,CDM,71045,CPT,320,RC,,,outpatient,,,214,149.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,128.93,,,128.93,48.043,416.02,fee schedule,,,
HC X-Ray Exam Chest 2 Views,PX-32000246,CDM,71046,CPT,320,RC,,,outpatient,,,232,162.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,128.93,,,128.93,52.084,416.02,fee schedule,,,
HC X-Ray Exam Chest 3 Views,PX-32000247,CDM,71047,CPT,320,RC,,,outpatient,,,245,171.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,128.93,,,128.93,55.0025,416.02,fee schedule,,,
HC X-Ray Exam Chest 4+ Views,PX-32000248,CDM,71048,CPT,320,RC,,,outpatient,,,410,287,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,237.56,,,237.56,76.026473,416.02,fee schedule,,,
HC X-Ray Ribs- Chest 3+ Vw,PX-32000036,CDM,71101,CPT,320,RC,,,outpatient,,,484,338.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,147.03,,,147.03,76.026473,416.02,fee schedule,,,
HC X-Ray Ribs- Chest 4+ Vw,PX-32000038,CDM,71111,CPT,320,RC,,,outpatient,,,562,393.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,147.03,,,147.03,76.026473,431.616,fee schedule,,,
HC X-Ray Sternum 2+ Vw,PX-32000039,CDM,71120,CPT,320,RC,,,outpatient,,,358,250.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,71.24,416.02,fee schedule,,,
HC X-Ray Sterno-Clavicluar Jt,PX-32000040,CDM,71130,CPT,320,RC,,,outpatient,,,250,175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,56.125,416.02,fee schedule,,,
HC Diagnostic Computed Tomography Thorax W/O Cntrst,PX-35000016,CDM,71250,CPT,350,RC,,,outpatient,,,1388,971.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,200.09,,,200.09,96.160741,1065.984,fee schedule,,,
HC Diagnostic Computed Tomography Thorax W/Contrast,PX-35000017,CDM,71260,CPT,350,RC,,,outpatient,,,1624,1136.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,251.54,,,251.54,195.34,1247.232,fee schedule,,,
HC Diagnostic Computed Tomography Thorax C-/C+,PX-35000018,CDM,71270,CPT,350,RC,,,outpatient,,,1982,1387.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,312.88,,,312.88,200.53123,1522.176,fee schedule,,,
HC Computed Tomography Thorax Lw Dose Lng Ca Scr C-,PX-35000070,CDM,71271,CPT,350,RC,,,outpatient,,,264,184.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,167.91,,,167.91,59.268,575,fee schedule,,,
CT Angiography Chest W/Contrast/Noncontrast,PX-35000019,CDM,71275,CPT,350,RC,,,outpatient,,,1592,1114.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,386.97,,,386.97,200.53123,1222.656,fee schedule,,,
HC MRI- Chest,PX-61000023,CDM,71550,CPT,610,RC,,,outpatient,,,1979,1385.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,496.45,,,496.45,237.688956,1519.872,fee schedule,,,
HC MRI- Chest- W/Contrast,PX-61000024,CDM,71551,CPT,610,RC,,,outpatient,,,3128,2189.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,544.61,,,544.61,399.86,2402.304,fee schedule,,,
MRI Chest W/O & W/Contrast Material,PX-61000025,CDM,71552,CPT,610,RC,,,outpatient,,,1547,1082.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,690.74,,,690.74,347.3015,1288.93,fee schedule,,,
HC MR Angio Chest (Mra) W/Contrast,PX-61000026,CDM,71555,CPT,610,RC,,,outpatient,,,2367,1656.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,466.82,,,466.82,301.425681,1817.856,fee schedule,,,
HC MR Angio Chest (Mra) Without Contrast,PX-61000071,CDM,71555,CPT,610,RC,,,outpatient,,,2367,1656.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,466.82,,,466.82,301.425681,1817.856,fee schedule,,,
HC MR Angio Chest (Mra) W/Without Contrast,PX-61000072,CDM,71555,CPT,610,RC,,,outpatient,,,2367,1656.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,466.82,,,466.82,301.425681,1817.856,fee schedule,,,
HC X-Ray Spine One View,PX-32000042,CDM,72020,CPT,320,RC,,,outpatient,,,251,175.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,56.3495,416.02,fee schedule,,,
HC Radex Spine Cervical 2 or 3 Views,PX-32000043,CDM,72040,CPT,320,RC,,,outpatient,,,296,207.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,66.452,416.02,fee schedule,,,
HC Radex Spine Cervical 4 or 5 Views,PX-32000044,CDM,72050,CPT,320,RC,,,outpatient,,,300,210,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,147.03,,,147.03,67.35,416.02,fee schedule,,,
HC Radex Spine Cervical 6 or More Views,PX-32000045,CDM,72052,CPT,320,RC,,,outpatient,,,300,210,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,147.03,,,147.03,67.35,416.02,fee schedule,,,
HC X-Ray Thoracic Spine 2 Vw,PX-32000046,CDM,72070,CPT,320,RC,,,outpatient,,,252,176.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,56.574,416.02,fee schedule,,,
HC X-Ray Thoracic Spine+Swim 3 Vw,PX-32000047,CDM,72072,CPT,320,RC,,,outpatient,,,283,198.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,147.03,,,147.03,63.5335,416.02,fee schedule,,,
HC X-Ray Thoracic Spine 4 Vw,PX-32000048,CDM,72074,CPT,320,RC,,,outpatient,,,306,214.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,68.697,416.02,fee schedule,,,
HC X-Ray Thor-Lumb Sp 2 Vw,PX-32000049,CDM,72080,CPT,320,RC,,,outpatient,,,357,249.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,71.24,416.02,fee schedule,,,
HC X-Ray Exam Entire Spi 1 Vw,PX-32000233,CDM,72081,CPT,320,RC,,,outpatient,,,241,168.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,126.19,,,126.19,54.1045,416.02,fee schedule,,,
HC X-Ray Exam Entire Spi 2/3 Vw,PX-32000234,CDM,72082,CPT,320,RC,,,outpatient,,,385,269.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,208.98,,,208.98,86.4325,416.02,fee schedule,,,
HC X-Ray Exam Entire Spi 4/5 Vw,PX-32000235,CDM,72083,CPT,320,RC,,,outpatient,,,757,529.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,398.43,,,398.43,119.991125,581.376,fee schedule,,,
HC X-Ray Exam Entire Spi 6/> Vw,PX-32000236,CDM,72084,CPT,320,RC,,,outpatient,,,757,529.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,398.43,,,398.43,76.026473,581.376,fee schedule,,,
HC X-Ray Lumbar Spine 2/3 Vw,PX-32000051,CDM,72100,CPT,320,RC,,,outpatient,,,235,164.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,52.7575,416.02,fee schedule,,,
HC X-Ray Lumbar Spine 4 Vw,PX-32000052,CDM,72110,CPT,320,RC,,,outpatient,,,323,226.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,147.03,,,147.03,72.5135,416.02,fee schedule,,,
HC X-Ray Lumbar Spine 6+ Vw,PX-32000053,CDM,72114,CPT,320,RC,,,outpatient,,,602,421.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,147.03,,,147.03,76.026473,462.336,fee schedule,,,
HC X-Ray Lumbar Spine Flex/Exten,PX-32000232,CDM,72120,CPT,320,RC,,,outpatient,,,411,287.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,147.03,,,147.03,92.2695,416.02,fee schedule,,,
HC CT Scan-Cervical Spine-W/O Contrast,PX-35000020,CDM,72125,CPT,350,RC,,,outpatient,,,1359,951.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,202.98,,,202.98,96.160741,1043.712,fee schedule,,,
HC CT Scan Cerv Spine Contrast,PX-35000021,CDM,72126,CPT,350,RC,,,outpatient,,,1556,1089.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,252.78,,,252.78,196.52,1195.008,fee schedule,,,
CT Cervical Spine W/O &W/Contrast Material,PX-35000022,CDM,72127,CPT,350,RC,,,outpatient,,,2239,1567.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,313.29,,,313.29,200.53123,1719.552,fee schedule,,,
HC CT Scan-Thoracic Spine-W/O Contrast,PX-35000023,CDM,72128,CPT,350,RC,,,outpatient,,,909,636.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,201.75,,,201.75,96.160741,698.112,fee schedule,,,
HC CT Scan Dorsal Sp Contrast,PX-35000024,CDM,72129,CPT,350,RC,,,outpatient,,,1037,725.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,254.02,,,254.02,196.52,796.416,fee schedule,,,
CT Thoracic Spine W/O & W/Contrast Material,PX-35000025,CDM,72130,CPT,350,RC,,,outpatient,,,2219,1553.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,315.76,,,315.76,200.53123,1704.192,fee schedule,,,
HC CT Scan-Lumbar Spine-W/O Contrast,PX-35000026,CDM,72131,CPT,350,RC,,,outpatient,,,688,481.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,200.51,,,200.51,96.160741,575,fee schedule,,,
HC CT Scan Lumbar Sp Contrast,PX-35000027,CDM,72132,CPT,350,RC,,,outpatient,,,1427,998.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,253.19,,,253.19,195.73,1095.936,fee schedule,,,
CT Lumbar Spine W/O & W/Contrast Material,PX-35000028,CDM,72133,CPT,350,RC,,,outpatient,,,1377,963.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,313.7,,,313.7,200.53123,1057.536,fee schedule,,,
HC MRI- Cerv Spine,PX-61000027,CDM,72141,CPT,610,RC,,,outpatient,,,2115,1480.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,377.08,,,377.08,185.92,1624.32,fee schedule,,,
HC MRI- Cerv Spine Contrast,PX-61000028,CDM,72142,CPT,610,RC,,,outpatient,,,3043,2130.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,493.17,,,493.17,270.27,2337.024,fee schedule,,,
HC MRI- Dorsal Spine,PX-61000029,CDM,72146,CPT,610,RC,,,outpatient,,,2222,1555.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,377.91,,,377.91,185.92,1706.496,fee schedule,,,
HC MRI- Dorsal Spine Contrast,PX-61000030,CDM,72147,CPT,610,RC,,,outpatient,,,2843,1990.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,423.19,,,423.19,266.73,2183.424,fee schedule,,,
HC MRI- Lumbar Spine,PX-61000031,CDM,72148,CPT,610,RC,,,outpatient,,,2651,1855.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,377.5,,,377.5,185.92,2035.968,fee schedule,,,
HC MRI- Lumbar Spine Contrast,PX-61000032,CDM,72149,CPT,610,RC,,,outpatient,,,2645,1851.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,481.23,,,481.23,265.17,2031.36,fee schedule,,,
MRI Spinal Canal Cervical W/O & W/Contr Matrl,PX-61000033,CDM,72156,CPT,610,RC,,,outpatient,,,3124,2186.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,545.84,,,545.84,307.53,2399.232,fee schedule,,,
MRI Spinal Canal Thoracic W/O & W/Contr Matrl,PX-61000034,CDM,72157,CPT,610,RC,,,outpatient,,,2833,1983.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,496.86,,,496.86,307.93,2175.744,fee schedule,,,
MRI Spinal Canal Lumbar W/O & W/Contr Matrl,PX-61000035,CDM,72158,CPT,610,RC,,,outpatient,,,3181,2226.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,542.55,,,542.55,305.58,2443.008,fee schedule,,,
HC X-Ray Pelvis 1/2 Vw,PX-32000054,CDM,72170,CPT,320,RC,,,outpatient,,,287,200.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,64.4315,416.02,fee schedule,,,
CT Angiography Pelvis W/Contrast/Noncontrast,PX-35000029,CDM,72191,CPT,350,RC,,,outpatient,,,1269,888.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,389.85,,,389.85,200.53123,974.592,fee schedule,,,
HC CT Scan-Pelvis-W/O Contrast,PX-35000030,CDM,72192,CPT,350,RC,,,outpatient,,,1368,957.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,151.52,,,151.52,96.160741,1050.624,fee schedule,,,
HC CT Scan of Pelvis Contrast,PX-35000031,CDM,72193,CPT,350,RC,,,outpatient,,,1561,1092.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,257.72,,,257.72,195.33,1198.848,fee schedule,,,
CT Pelvis W/O & W/Contrast Material,PX-35000032,CDM,72194,CPT,350,RC,,,outpatient,,,1902,1331.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,301.76,,,301.76,200.53123,1460.736,fee schedule,,,
HC MRI- Pelvis- W/O Contrast,PX-61000036,CDM,72195,CPT,610,RC,,,outpatient,,,2241,1568.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,439.65,,,439.65,237.688956,1721.088,fee schedule,,,
HC MRI- Pelvis W/Contrast,PX-61000037,CDM,72196,CPT,610,RC,,,outpatient,,,2850,1995,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,483.28,,,483.28,372.27,2188.8,fee schedule,,,
MRI Pelvis W/O & W/Contrast Material,PX-61000038,CDM,72197,CPT,610,RC,,,outpatient,,,2753,1927.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,582.07,,,582.07,399.547552,2114.304,fee schedule,,,
HC MR Angio Pelvis(Mra) W/Contrast,PX-61000039,CDM,72198,CPT,610,RC,,,outpatient,,,2908,2035.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,473.82,,,473.82,399.86,2233.344,fee schedule,,,
HC MR Angio Pelvis(Mra) Without Contrast,PX-61000073,CDM,72198,CPT,610,RC,,,outpatient,,,2710,1897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,473.82,,,473.82,399.86,2233.344,fee schedule,,,
HC MR Angio Pelvis(Mra) W/Without Contrast,PX-61000074,CDM,72198,CPT,610,RC,,,outpatient,,,1826,1278.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,473.82,,,473.82,399.86,2233.344,fee schedule,,,
HC X-Ray Sacroiliac Jts 3+ Vw,PX-32000056,CDM,72202,CPT,320,RC,,,outpatient,,,443,310.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,76.026473,416.02,fee schedule,,,
HC X-Ray Sacrum/Coccyx 2+ Vw,PX-32000057,CDM,72220,CPT,320,RC,,,outpatient,,,336,235.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,71.24,416.02,fee schedule,,,
HC Myelography Cerv Spine,PX-32000058,CDM,72240,CPT,320,RC,,,outpatient,,,1478,1034.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,331.811,2051.3855,other,Non-Reimbursable List,,
HC Myelography Thorax Spine,PX-32000059,CDM,72255,CPT,320,RC,,,outpatient,,,1823,1276.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,2051.3855,other,Non-Reimbursable List,,
HC Myelography Lumbar Spine,PX-32000060,CDM,72265,CPT,320,RC,,,outpatient,,,1760,1232,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,395.12,2051.3855,other,Non-Reimbursable List,,
HC Myelography of Entire Spine,PX-32000061,CDM,72270,CPT,320,RC,,,outpatient,,,1823,1276.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,2051.3855,other,Non-Reimbursable List,,
HC X-Ray-C/T-Disk-Superv/Interpret,PX-32000062,CDM,72285,CPT,320,RC,,,outpatient,,,4306,3014.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,4977.9345,other,Non-Reimbursable List,,
HC Discography Lumbar Spine,PX-32000064,CDM,72295,CPT,320,RC,,,outpatient,,,4306,3014.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,4977.9345,other,Non-Reimbursable List,,
HC X-Ray Clavicle,PX-32000065,CDM,73000,CPT,320,RC,,,outpatient,,,170,119,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,38.165,416.02,fee schedule,,,
HC X-Ray Scapula,PX-32000066,CDM,73010,CPT,320,RC,,,outpatient,,,306,214.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,68.697,416.02,fee schedule,,,
HC X-Ray Shoulder 1 Vw,PX-32000067,CDM,73020,CPT,320,RC,,,outpatient,,,256,179.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,57.472,416.02,fee schedule,,,
HC X-Ray Shoulder 2+ Vw,PX-32000068,CDM,73030,CPT,320,RC,,,outpatient,,,139,97.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,31.2055,416.02,fee schedule,,,
HC Arthrogram of Shoulder,PX-32000069,CDM,73040,CPT,320,RC,,,outpatient,,,1690,1183,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,379.405,1297.92,other,Non-Reimbursable List,,
HC X-Ray Ac Jts,PX-32000070,CDM,73050,CPT,320,RC,,,outpatient,,,323,226.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,71.24,416.02,fee schedule,,,
HC X-Ray Humerus,PX-32000071,CDM,73060,CPT,320,RC,,,outpatient,,,178,124.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,39.961,416.02,fee schedule,,,
HC X-Ray Elbow 2 Vw,PX-32000072,CDM,73070,CPT,320,RC,,,outpatient,,,171,119.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,38.3895,416.02,fee schedule,,,
HC X-Ray Elbow 3+ Vw,PX-32000073,CDM,73080,CPT,320,RC,,,outpatient,,,129,90.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,28.9605,416.02,fee schedule,,,
HC Arthrogram of Elbow,PX-32000074,CDM,73085,CPT,320,RC,,,outpatient,,,1331,931.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,298.8095,1022.208,other,Non-Reimbursable List,,
HC X-Ray Forearm 2 Vw,PX-32000075,CDM,73090,CPT,320,RC,,,outpatient,,,225,157.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,50.5125,416.02,fee schedule,,,
HC X-Ray Arm- Infant,PX-32000076,CDM,73092,CPT,320,RC,,,outpatient,,,368,257.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,76.026473,416.02,fee schedule,,,
HC X-Ray Wrist 2 Vw,PX-32000077,CDM,73100,CPT,320,RC,,,outpatient,,,190,133,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,42.655,416.02,fee schedule,,,
HC X-Ray Wrist 3+ Vw,PX-32000078,CDM,73110,CPT,320,RC,,,outpatient,,,241,168.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,54.1045,416.02,fee schedule,,,
HC Arthrogram of Wrist,PX-32000079,CDM,73115,CPT,320,RC,,,outpatient,,,1722,1205.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,237.819698,1322.496,other,Non-Reimbursable List,,
HC X-Ray Hand 2 Vw,PX-32000080,CDM,73120,CPT,320,RC,,,outpatient,,,306,214.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,68.697,416.02,fee schedule,,,
HC X-Ray Hand 3+ Vw,PX-32000081,CDM,73130,CPT,320,RC,,,outpatient,,,236,165.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,52.982,416.02,fee schedule,,,
HC X-Ray Exam of Finger(S),PX-32000082,CDM,73140,CPT,320,RC,,,outpatient,,,129,90.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,28.9605,416.02,fee schedule,,,
HC CT Scan-Upper Extremity-W/O Contrast,PX-35000034,CDM,73200,CPT,350,RC,,,outpatient,,,959,671.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,199.27,,,199.27,96.160741,736.512,fee schedule,,,
HC CT Scan of Arm Contrast,PX-35000035,CDM,73201,CPT,350,RC,,,outpatient,,,1388,971.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,249.07,,,249.07,193.37,1065.984,fee schedule,,,
CT Upper Extremity W/O & W/Contrast Material,PX-35000036,CDM,73202,CPT,350,RC,,,outpatient,,,1961,1372.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,332.22,,,332.22,200.53123,1506.048,fee schedule,,,
CT Angiography Upper Extremity,PX-35000037,CDM,73206,CPT,350,RC,,,outpatient,,,1345,941.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,347.46,,,347.46,200.53123,1032.96,fee schedule,,,
HC MRI- Upper Extremity W/O Contrast,PX-61000040,CDM,73218,CPT,610,RC,,,outpatient,,,2888,2021.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,437.59,,,437.59,237.688956,2217.984,fee schedule,,,
HC MRI- Upper Extremity W/Contrast,PX-61000041,CDM,73219,CPT,610,RC,,,outpatient,,,2936,2055.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,478.76,,,478.76,371.09,2254.848,fee schedule,,,
HC MRI Ext Upp No Jnt W-W/O,PX-61000042,CDM,73220,CPT,610,RC,,,outpatient,,,3144,2200.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,581.66,,,581.66,399.547552,2414.592,fee schedule,,,
MRI Any Jt Upper Extremity W/O Contrast Matrl,PX-61000043,CDM,73221,CPT,610,RC,,,outpatient,,,3039,2127.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,262.24,,,262.24,204.76,2333.952,fee schedule,,,
HC MRI- Joint Upper Extrem W/Contrast,PX-61000044,CDM,73222,CPT,610,RC,,,outpatient,,,3144,2200.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,443.77,,,443.77,340.49,2414.592,fee schedule,,,
MRI Any Jt Upper Extremity W/O & W/Contr Matrl,PX-61000045,CDM,73223,CPT,610,RC,,,outpatient,,,3060,2142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,540.91,,,540.91,399.547552,2350.08,fee schedule,,,
HC X-Ray Exam Hip Uni 1 View,PX-32000237,CDM,73501,CPT,320,RC,,,outpatient,,,222,155.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,49.839,416.02,fee schedule,,,
HC X-Ray Exam Hip Uni 2-3 Views,PX-32000238,CDM,73502,CPT,320,RC,,,outpatient,,,222,155.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,126.19,,,126.19,49.839,416.02,fee schedule,,,
HC X-Ray Exam Hip Uni 4/> Views,PX-32000239,CDM,73503,CPT,320,RC,,,outpatient,,,385,269.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,208.98,,,208.98,86.4325,416.02,fee schedule,,,
HC X-Ray Exam Hips Bi 2 Views,PX-32000240,CDM,73521,CPT,320,RC,,,outpatient,,,385,269.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,208.98,,,208.98,86.4325,416.02,fee schedule,,,
HC X-Ray Exam Hips Bi 5/> Views,PX-32000242,CDM,73523,CPT,320,RC,,,outpatient,,,757,529.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,398.43,,,398.43,76.026473,581.376,fee schedule,,,
HC Arthrogram of Hip,PX-32000086,CDM,73525,CPT,320,RC,,,outpatient,,,1616,1131.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,237.819698,1241.088,other,Non-Reimbursable List,,
HC X-Ray Exam of Femur 1,PX-32000243,CDM,73551,CPT,320,RC,,,outpatient,,,213,149.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,126.19,,,126.19,47.8185,416.02,fee schedule,,,
HC X-Ray Exam of Femur 2/>,PX-32000244,CDM,73552,CPT,320,RC,,,outpatient,,,241,168.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,126.19,,,126.19,54.1045,416.02,fee schedule,,,
HC X-Ray Knee 1 or 2 View,PX-32000090,CDM,73560,CPT,320,RC,,,outpatient,,,213,149.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,47.8185,416.02,fee schedule,,,
HC X-Ray Knee 3 View,PX-32000091,CDM,73562,CPT,320,RC,,,outpatient,,,232,162.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,52.084,416.02,fee schedule,,,
HC X-Ray Knee 4+ View,PX-32000092,CDM,73564,CPT,320,RC,,,outpatient,,,260,182,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,147.03,,,147.03,58.37,416.02,fee schedule,,,
HC X-Ray Knee Bilat Standing,PX-32000093,CDM,73565,CPT,320,RC,,,outpatient,,,394,275.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,71.24,416.02,fee schedule,,,
HC Arthrogram of Knee Joint,PX-32000094,CDM,73580,CPT,320,RC,,,outpatient,,,1704,1192.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,382.548,1308.672,other,Non-Reimbursable List,,
HC X-Ray Tib + Fib- 2vw,PX-32000095,CDM,73590,CPT,320,RC,,,outpatient,,,199,139.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,44.6755,416.02,fee schedule,,,
HC X-Ray Leg- Infant,PX-32000096,CDM,73592,CPT,320,RC,,,outpatient,,,231,161.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,51.8595,416.02,fee schedule,,,
HC X-Ray Ankle 2 Vw,PX-32000097,CDM,73600,CPT,320,RC,,,outpatient,,,137,95.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,30.7565,416.02,fee schedule,,,
HC X-Ray Ankle 3+ Vw,PX-32000098,CDM,73610,CPT,320,RC,,,outpatient,,,130,91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,29.185,416.02,fee schedule,,,
HC Arthrogram of Ankle,PX-32000099,CDM,73615,CPT,320,RC,,,outpatient,,,1221,854.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,237.819698,1020.2995,other,Non-Reimbursable List,,
HC X-Ray Foot 2 Vw,PX-32000100,CDM,73620,CPT,320,RC,,,outpatient,,,158,110.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,35.471,416.02,fee schedule,,,
HC X-Ray Foot 3+ Vw,PX-32000101,CDM,73630,CPT,320,RC,,,outpatient,,,164,114.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,36.818,416.02,fee schedule,,,
HC X-Ray Heel,PX-32000102,CDM,73650,CPT,320,RC,,,outpatient,,,234,163.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,52.533,416.02,fee schedule,,,
HC X-Ray Toe(S),PX-32000103,CDM,73660,CPT,320,RC,,,outpatient,,,192,134.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,43.104,416.02,fee schedule,,,
HC CT Scan-Lower Extremity-W/O Contrast,PX-35000038,CDM,73700,CPT,350,RC,,,outpatient,,,968,677.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,200.1,,,200.1,96.160741,743.424,fee schedule,,,
HC CT Scan of Leg Contrast,PX-35000039,CDM,73701,CPT,350,RC,,,outpatient,,,987,690.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,253.6,,,253.6,196.51,758.016,fee schedule,,,
CT Lower Extremity W/O & W/Contrast Matrl,PX-35000040,CDM,73702,CPT,350,RC,,,outpatient,,,1903,1332.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,330.99,,,330.99,200.53123,1461.504,fee schedule,,,
CT Angiography Lower Extremity,PX-35000041,CDM,73706,CPT,350,RC,,,outpatient,,,1176,823.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,389.44,,,389.44,200.53123,903.168,fee schedule,,,
HC MRI- Lower Extrem,PX-61000046,CDM,73718,CPT,610,RC,,,outpatient,,,2836,1985.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,434.72,,,434.72,237.688956,2178.048,fee schedule,,,
HC MRI- Lower Extrem W/Contrast,PX-61000047,CDM,73719,CPT,610,RC,,,outpatient,,,2396,1677.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,488.64,,,488.64,372.66,1840.128,fee schedule,,,
HC MRI- Lower Extr- W/O Contrast F/U by Contrast,PX-61000048,CDM,73720,CPT,610,RC,,,outpatient,,,3060,2142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,587.42,,,587.42,399.547552,2350.08,fee schedule,,,
HC MRI Lower Extrem Jt- W/O Contrast,PX-61000049,CDM,73721,CPT,610,RC,,,outpatient,,,3008,2105.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,262.24,,,262.24,205.15,2310.144,fee schedule,,,
HC MRI- Joint of Leg W/Contrast,PX-61000050,CDM,73722,CPT,610,RC,,,outpatient,,,3018,2112.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,450.35,,,450.35,345.98,2317.824,fee schedule,,,
MRI Any Jt Lower Extrem W/O & W/Contrast Matrl,PX-61000051,CDM,73723,CPT,610,RC,,,outpatient,,,3098,2168.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,541.32,,,541.32,399.547552,2379.264,fee schedule,,,
HC MR Angio Lower Extrem (Mra) W/Contrast,PX-61000052,CDM,73725,CPT,610,RC,,,outpatient,,,2710,1897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,476.29,,,476.29,399.86,2290.176,fee schedule,,,
HC MR Angio Lower Extrem (Mra) Without Contrast,PX-61000075,CDM,73725,CPT,610,RC,,,outpatient,,,2710,1897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,476.29,,,476.29,399.86,2290.176,fee schedule,,,
HC MR Angio Lower Extrem (Mra) W/Without Contrast,PX-61000076,CDM,73725,CPT,610,RC,,,outpatient,,,2982,2087.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,476.29,,,476.29,399.86,2290.176,fee schedule,,,
HC X-Ray Exam Abdomen 1 View,PX-32000249,CDM,74018,CPT,320,RC,,,outpatient,,,232,162.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,128.93,,,128.93,52.084,416.02,fee schedule,,,
HC X-Ray Exam Abdomen 2 Views,PX-32000250,CDM,74019,CPT,320,RC,,,outpatient,,,443,310.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,237.56,,,237.56,76.026473,416.02,fee schedule,,,
HC X-Ray Exam Abdomen 3+ Views,PX-32000251,CDM,74021,CPT,320,RC,,,outpatient,,,410,287,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,237.56,,,237.56,92.045,416.02,fee schedule,,,
HC CT Scan-Abdomen-W/O Contrast,PX-35000042,CDM,74150,CPT,350,RC,,,outpatient,,,1449,1014.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,149.47,,,149.47,96.160741,1112.832,fee schedule,,,
HC CT Scan of Abdomen Contrast,PX-35000043,CDM,74160,CPT,350,RC,,,outpatient,,,1586,1110.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,256.9,,,256.9,194.55,1218.048,fee schedule,,,
CT Abdomen W/O & W/Contrast Material,PX-35000044,CDM,74170,CPT,350,RC,,,outpatient,,,2058,1440.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,301.35,,,301.35,200.53123,1580.544,fee schedule,,,
HC CT Angio Abd&Plvis Cntrst Mtrl W/WO Cntrst Imges,PX-35000045,CDM,74174,CPT,350,RC,,,outpatient,,,2581,1806.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,488.63,,,488.63,329.339098,1982.208,fee schedule,,,
CT Angiography Abdomen W/Contrast/Noncontrast,PX-35000046,CDM,74175,CPT,350,RC,,,outpatient,,,1355,948.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,390.26,,,390.26,200.53123,1040.64,fee schedule,,,
HC CT Scan-Abdoment and Pelvis-W/O Contrast,PX-35000047,CDM,74176,CPT,350,RC,,,outpatient,,,1368,957.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,181.17,,,181.17,142.38,1050.624,fee schedule,,,
HC CT Scan-Abdoment and Pelvis-W Contrast,PX-35000048,CDM,74177,CPT,350,RC,,,outpatient,,,1971,1379.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,306.29,,,306.29,204.61123,1513.728,fee schedule,,,
CT Abdomen & Pelvis W/O Contrst 1/> Body Re,PX-35000049,CDM,74178,CPT,350,RC,,,outpatient,,,2122,1485.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,367.62,,,367.62,204.61123,1629.696,fee schedule,,,
HC MRI- Abdomen (MRI),PX-61000053,CDM,74181,CPT,610,RC,,,outpatient,,,2357,1649.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,380.79,,,380.79,237.688956,1810.176,fee schedule,,,
HC MRI- Abdomen W/Contrast,PX-61000054,CDM,74182,CPT,610,RC,,,outpatient,,,5081,3556.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,542.14,,,542.14,399.547552,3902.208,fee schedule,,,
MRI Abdomen W/O & W/Contrast Material,PX-61000055,CDM,74183,CPT,610,RC,,,outpatient,,,2698,1888.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,584.54,,,584.54,399.547552,2072.064,fee schedule,,,
HC MR Angio Abdomen (Mra) W/Contrast,PX-61000056,CDM,74185,CPT,610,RC,,,outpatient,,,2446,1712.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,473.41,,,473.41,301.425681,1878.528,fee schedule,,,
HC MR Angio Abdomen (Mra) Without Contrast,PX-61000077,CDM,74185,CPT,610,RC,,,outpatient,,,2446,1712.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,473.41,,,473.41,301.425681,1878.528,fee schedule,,,
HC MR Angio Abdomen (Mra) W/Without Contrast,PX-61000078,CDM,74185,CPT,610,RC,,,outpatient,,,2446,1712.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,473.41,,,473.41,301.425681,1878.528,fee schedule,,,
HC Esophagram,PX-32000107,CDM,74220,CPT,320,RC,,,outpatient,,,981,686.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,171.69,,,171.69,76.026473,753.408,fee schedule,,,
HC Swallowing Fcn-W/Cine &/or Video,PX-32000108,CDM,74230,CPT,320,RC,,,outpatient,,,874,611.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,171.69,,,171.69,128.66,671.232,fee schedule,,,
HC Remove Esophagus Obstruction,PX-32000109,CDM,74235,CPT,320,RC,,,outpatient,,,1157,809.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,259.7465,888.576,other,Non-Reimbursable List,,
HC Xray Upper GI Tract,PX-32000110,CDM,74240,CPT,320,RC,,,outpatient,,,916,641.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,254.91,,,254.91,200.53123,703.488,fee schedule,,,
HC Xray Upper GI Air Contrast,PX-32000113,CDM,74246,CPT,320,RC,,,outpatient,,,865,605.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,254.91,,,254.91,194.1925,664.32,fee schedule,,,
HC X-Ray-Small Bowel-W/Mult Serial Films,PX-32000116,CDM,74250,CPT,320,RC,,,outpatient,,,2949,2064.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,171.69,,,171.69,128.66,2264.832,fee schedule,,,
HC X-Ray Small Bowel Enteroclysis,PX-32000117,CDM,74251,CPT,320,RC,,,outpatient,,,1182,827.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,254.91,,,254.91,183.14,907.776,fee schedule,,,
HC X-Ray Colon Contrast,PX-32000118,CDM,74270,CPT,320,RC,,,outpatient,,,1071,749.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,254.91,,,254.91,200.53123,822.528,fee schedule,,,
HC X-Ray Colon Air Contrast,PX-32000119,CDM,74280,CPT,320,RC,,,outpatient,,,1758,1230.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,254.91,,,254.91,200.53123,1350.144,fee schedule,,,
HC X-Ray Oper Cholangiogram,PX-32000123,CDM,74300,CPT,320,RC,,,outpatient,,,1336,935.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,145.12362,1026.048,other,Non-Reimbursable List,,
HC X-Ray Oper Cholangio Addnl Set,PX-32000124,CDM,74301,CPT,320,RC,,,outpatient,,,289,202.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,64.8805,416.02,other,Non-Reimbursable List,,
HC X-Ray Bile/Pancreas Endoscopy,PX-32000129,CDM,74330,CPT,320,RC,,,outpatient,,,1038,726.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,145.12362,797.184,other,Non-Reimbursable List,,
HC X-Ray Introductn GI Tube,PX-32000130,CDM,74340,CPT,320,RC,,,outpatient,,,872,610.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,195.08,669.696,other,Non-Reimbursable List,,
HC X-Ray Guide Enteroclysis Tube,PX-32000131,CDM,74355,CPT,320,RC,,,outpatient,,,2913,2039.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,260.23,2237.184,other,Non-Reimbursable List,,
HC X-Ray Guide- GI Dilation,PX-32000132,CDM,74360,CPT,320,RC,,,outpatient,,,631,441.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,141.6595,484.608,other,Non-Reimbursable List,,
HC Percut Transhepat Dilat-Bile Duct Strict,PX-32000133,CDM,74363,CPT,320,RC,,,outpatient,,,2462,1723.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,1890.816,other,Non-Reimbursable List,,
HC X-Ray IV Pyelogram (Ivp),PX-32000134,CDM,74400,CPT,320,RC,,,outpatient,,,599,419.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,434.92,,,434.92,134.4755,499.422,fee schedule,,,
HC X-Ray IV Pyelogram+Tomography,PX-32000136,CDM,74415,CPT,320,RC,,,outpatient,,,2078,1454.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,434.92,,,434.92,200.53123,1595.904,fee schedule,,,
HC X-Ray Retrograde Pyelogram,PX-32000137,CDM,74420,CPT,320,RC,,,outpatient,,,1189,832.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,434.92,,,434.92,237.819698,1020.2995,fee schedule,,,
HC Antegrade Urography Radiological Supvj & Interpj,PX-32000138,CDM,74425,CPT,320,RC,,,outpatient,,,2829,1980.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,2172.672,other,Non-Reimbursable List,,
HC X-Ray Cystogram- Min 3 View,PX-32000139,CDM,74430,CPT,320,RC,,,outpatient,,,1189,832.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,237.819698,1020.2995,other,Non-Reimbursable List,,
HC X-Ray Urethrocystogram,PX-32000140,CDM,74450,CPT,320,RC,,,outpatient,,,762,533.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,171.069,646.6965,other,Non-Reimbursable List,,
HC X-Ray Urethrocystogram+Voiding,PX-32000141,CDM,74455,CPT,320,RC,,,outpatient,,,762,533.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,171.069,646.6965,other,Non-Reimbursable List,,
HC X-Ray Renal Cyst Xlumbar+Contrst,PX-32000142,CDM,74470,CPT,320,RC,,,outpatient,,,542,379.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,121.679,1393.3385,other,Non-Reimbursable List,,
HC X-Ray Guide- Gu Dilation,PX-32000145,CDM,74485,CPT,320,RC,,,outpatient,,,3417,2391.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,5136.771,other,Non-Reimbursable List,,
HC X-Ray Hysterosalpingogram,PX-32000146,CDM,74740,CPT,320,RC,,,outpatient,,,1695,1186.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,237.819698,1301.76,other,Non-Reimbursable List,,
HC X-Ray Xcerv Cath Fallopian Tube,PX-32000147,CDM,74742,CPT,320,RC,,,outpatient,,,1270,889,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,285.115,975.36,other,Non-Reimbursable List,,
HC Cardiac MRI Morphology & Function W/O Contrast,PX-61000057,CDM,75557,CPT,610,RC,,,outpatient,,,2222,1555.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,308.76,,,308.76,88.902,1706.496,fee schedule,,,
HC PR Cardiac MRI Morphology & Function W/O Contrast,PX-97200020,CDM,75557,CPT,972,RC,,,outpatient,,,396,277.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,308.76,,,308.76,88.902,1706.496,fee schedule,,,
HC Cardiac MRI W/W/O Contrast & Further Seq,PX-61000059,CDM,75561,CPT,610,RC,,,outpatient,,,2644,1850.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,443.77,,,443.77,102.5965,2030.592,fee schedule,,,
HC PR Cardiac MRI W/W/O Contrast & Further Seq,PX-97200021,CDM,75561,CPT,972,RC,,,outpatient,,,457,319.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,443.77,,,443.77,102.5965,2030.592,fee schedule,,,
HC Cardiac MRI for Velocity Flow Mapping,PX-61000061,CDM,75565,CPT,610,RC,,,outpatient,,,222,155.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.2045,836,other,SI=N Exclusions ,,
HC PR Cardiac MRI for Velocity Flow Mapping,PX-97200022,CDM,75565,CPT,972,RC,,,outpatient,,,41,28.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.2045,836,other,SI=N Exclusions ,,
HC CT Heart W/O Contrast Quant Eval Coronary Calcium,PX-35000052,CDM,75571,CPT,350,RC,,,outpatient,,,264,184.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,81.96,,,81.96,19.0825,575,fee schedule,,,
HC PR CT Heart W/O Contrast Quant Eval Coronary Calcium,PX-97200023,CDM,75571,CPT,972,RC,,,outpatient,,,85,59.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,81.96,,,81.96,19.0825,575,fee schedule,,,
HC CT Heart Contrast Eval Cardiac Struct/Morph,PX-35000053,CDM,75572,CPT,350,RC,,,outpatient,,,872,610.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,280.36,,,280.36,58.819,669.696,fee schedule,,,
HC PR CT Heart Contrast Eval Cardiac Struct/Morph,PX-97200024,CDM,75572,CPT,972,RC,,,outpatient,,,262,183.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,280.36,,,280.36,58.819,669.696,fee schedule,,,
HC CT Heart Contrast Eval Cardiac Struct/Morph- Congen Heart Disease,PX-35000054,CDM,75573,CPT,350,RC,,,outpatient,,,1016,711.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,374.21,,,374.21,58.819,780.288,fee schedule,,,
HC PR CT Heart Contrast Eval Cardiac Struct/Morph- Congen Heart Disease,PX-97200025,CDM,75573,CPT,972,RC,,,outpatient,,,262,183.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,374.21,,,374.21,58.819,780.288,fee schedule,,,
HC CT Angio Hrt Cornry Art/Bypass Grfts Contrst 3d Post,PX-35000055,CDM,75574,CPT,350,RC,,,outpatient,,,1073,751.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,423.6,,,423.6,57.921,824.064,fee schedule,,,
HC PR CT Angio Hrt Cornry Art/Bypass Grfts Contrst 3d Post,PX-97200026,CDM,75574,CPT,972,RC,,,outpatient,,,258,180.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,423.6,,,423.6,57.921,824.064,fee schedule,,,
HC N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp,PX-48000097,CDM,75580,CPT,480,RC,,,outpatient,,,2856,1999.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,996.18,39.5,,1128.12,399.86,2536.61118,percent of total billed charges,,,
HC Angio Aortogram Thoracic,PX-32000148,CDM,75600,CPT,320,RC,,,outpatient,,,3155,2208.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,8249.769,other,Non-Reimbursable List,,
HC Angio Aortogram Thor Serial,PX-32000149,CDM,75605,CPT,320,RC,,,outpatient,,,12541,8778.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,14233.715,other,Non-Reimbursable List,,
HC Angio Aortogram Abd Serial,PX-32000150,CDM,75625,CPT,320,RC,,,outpatient,,,5654,3957.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,8249.769,other,Non-Reimbursable List,,
HC Angio Aortobifemoral W Cath,PX-32000151,CDM,75630,CPT,320,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,8249.769,other,Non-Reimbursable List,,
Cta Abdl Aorta&Bi Iliofem W/Contrast&Postp,PX-35000056,CDM,75635,CPT,350,RC,,,outpatient,,,1721,1204.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,415.06,,,415.06,200.53123,1321.728,fee schedule,,,
HC Angio Spinal Selectv,PX-32000153,CDM,75705,CPT,320,RC,,,outpatient,,,11403,7982.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,14233.715,other,Non-Reimbursable List,,
HC Angio Extremity Unilat,PX-32000154,CDM,75710,CPT,320,RC,,,outpatient,,,6489,4542.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,8249.769,other,Non-Reimbursable List,,
HC Angio Extermity Bilat,PX-32000155,CDM,75716,CPT,320,RC,,,outpatient,,,7162,5013.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,8249.769,other,Non-Reimbursable List,,
HC Angio Visceral Selectv/Subselec,PX-32000156,CDM,75726,CPT,320,RC,,,outpatient,,,9831,6881.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4607.24,,,4607.24,399.86,14233.715,fee schedule,,,
HC Angio Adrenal Unilat Select,PX-32000157,CDM,75731,CPT,320,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,8249.769,other,Non-Reimbursable List,,
HC Angio Adrenal Bilat Select,PX-32000158,CDM,75733,CPT,320,RC,,,outpatient,,,6665,4665.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,8249.769,other,Non-Reimbursable List,,
HC Angio Pelvis,PX-32000159,CDM,75736,CPT,320,RC,,,outpatient,,,11403,7982.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,14233.715,other,Non-Reimbursable List,,
HC Angio Pulmon Unilat Select,PX-32000160,CDM,75741,CPT,320,RC,,,outpatient,,,6665,4665.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,8249.769,other,Non-Reimbursable List,,
HC Angio Pulmon Bilat Select,PX-32000161,CDM,75743,CPT,320,RC,,,outpatient,,,7162,5013.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,8249.769,other,Non-Reimbursable List,,
HC Angio Pulmon Bilat Nonselec,PX-32000162,CDM,75746,CPT,320,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,8249.769,other,Non-Reimbursable List,,
HC Angio Intern Mammary,PX-32000163,CDM,75756,CPT,320,RC,,,outpatient,,,6665,4665.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,8249.769,other,Non-Reimbursable List,,
HC Angio Ea Addnl Selectv Vessel,PX-32000164,CDM,75774,CPT,320,RC,,,outpatient,,,3538,2476.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,2717.184,other,Non-Reimbursable List,,
HC Nonvascular Shuntogram,PX-32000166,CDM,75809,CPT,320,RC,,,outpatient,,,411,287.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,92.2695,416.02,other,Non-Reimbursable List,,
HC Venogram Splenoportogram,PX-32000167,CDM,75810,CPT,320,RC,,,outpatient,,,7698,5388.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4607.24,,,4607.24,399.86,8249.769,fee schedule,,,
HC Venogram Extrem Unilat,PX-32000168,CDM,75820,CPT,320,RC,,,outpatient,,,3212,2248.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,4120.349,other,Non-Reimbursable List,,
HC Venogram Extrem Bilat,PX-32000169,CDM,75822,CPT,320,RC,,,outpatient,,,2940,2058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,4120.349,other,Non-Reimbursable List,,
HC Venogram Infer Vena Cava,PX-32000170,CDM,75825,CPT,320,RC,,,outpatient,,,5987,4190.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,8249.769,other,Non-Reimbursable List,,
HC Venogram Super Vena Cava,PX-32000171,CDM,75827,CPT,320,RC,,,outpatient,,,2874,2011.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,4120.349,other,Non-Reimbursable List,,
HC Venogram Renal Unilat,PX-32000172,CDM,75831,CPT,320,RC,,,outpatient,,,6489,4542.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,8249.769,other,Non-Reimbursable List,,
HC Venogram Renal Bilat,PX-32000173,CDM,75833,CPT,320,RC,,,outpatient,,,6665,4665.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,8249.769,other,Non-Reimbursable List,,
HC Venogram Adrenal Unilat,PX-32000174,CDM,75840,CPT,320,RC,,,outpatient,,,7698,5388.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,8249.769,other,Non-Reimbursable List,,
HC Venogram Adrenal Bilat,PX-32000175,CDM,75842,CPT,320,RC,,,outpatient,,,11403,7982.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,14233.715,other,Non-Reimbursable List,,
HC Venogram Sinus/Jugular,PX-32000176,CDM,75860,CPT,320,RC,,,outpatient,,,6665,4665.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,8249.769,other,Non-Reimbursable List,,
HC Venogram Super Sag Sinus,PX-32000177,CDM,75870,CPT,320,RC,,,outpatient,,,4428,3099.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,8249.769,other,Non-Reimbursable List,,
HC Venogram Epidural,PX-32000178,CDM,75872,CPT,320,RC,,,outpatient,,,4428,3099.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,3400.704,other,Non-Reimbursable List,,
HC Venogram Orbital,PX-32000179,CDM,75880,CPT,320,RC,,,outpatient,,,1638,1146.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,367.731,1602.0655,other,Non-Reimbursable List,,
HC Percut Xhepatic Porto+Dynamic,PX-32000180,CDM,75885,CPT,320,RC,,,outpatient,,,7698,5388.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,8249.769,other,Non-Reimbursable List,,
HC Percut Xhepatic Portogram,PX-32000181,CDM,75887,CPT,320,RC,,,outpatient,,,7528,5269.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,8249.769,other,Non-Reimbursable List,,
HC Venogram Hepatic W Hemodynamics,PX-32000182,CDM,75889,CPT,320,RC,,,outpatient,,,5272,3690.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,8249.769,other,Non-Reimbursable List,,
HC Venogram Hepatic,PX-32000183,CDM,75891,CPT,320,RC,,,outpatient,,,6665,4665.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,8249.769,other,Non-Reimbursable List,,
HC Venous Sampling by Catheter,PX-32000184,CDM,75893,CPT,320,RC,,,outpatient,,,11403,7982.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,14233.715,other,Non-Reimbursable List,,
HC Transcatheter Rx Embolizatn,PX-32000185,CDM,75894,CPT,320,RC,,,outpatient,,,2536,1775.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,145.12362,1947.648,other,Non-Reimbursable List,,
HC Angrph Cath F-Up Std Tcat Other Than Thrombylsis,PX-32000187,CDM,75898,CPT,320,RC,,,outpatient,,,3747,2622.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,260.23,8249.769,other,Non-Reimbursable List,,
HC Remove-Obst Matl-Cva Dev via Sep Ven Acc,PX-32000188,CDM,75901,CPT,320,RC,,,outpatient,,,4773,3341.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,260.23,3665.664,other,Non-Reimbursable List,,
HC Remove-Obst Matl-Cva Device via Lumen,PX-32000189,CDM,75902,CPT,320,RC,,,outpatient,,,471,329.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,105.7395,416.02,other,Non-Reimbursable List,,
HC Endovasc Repair Thor Aorta Incl Subclavian,PX-32000195,CDM,75956,CPT,320,RC,,,outpatient,,,1446,1012.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,324.627,1110.528,other,Non-Reimbursable List,,
HC Endovasc Repair Thor Aorta Excl Subclavian,PX-32000196,CDM,75957,CPT,320,RC,,,outpatient,,,1312,918.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,294.544,1007.616,other,Non-Reimbursable List,,
HC Proximal Extens Durng Endovasc Rethor Aorta,PX-32000197,CDM,75958,CPT,320,RC,,,outpatient,,,845,591.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,189.7025,648.96,other,Non-Reimbursable List,,
HC Delayed Prox Extens Endovasc Rethor Aorta,PX-32000198,CDM,75959,CPT,320,RC,,,outpatient,,,744,520.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,167.028,571.392,other,Non-Reimbursable List,,
HC Vascular Biopsy,PX-32000203,CDM,75970,CPT,320,RC,,,outpatient,,,2918,2042.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,145.12362,2241.024,other,Non-Reimbursable List,,
HC Change Percut Tube/Drain Cath W Contrast Monit,PX-32000207,CDM,75984,CPT,320,RC,,,outpatient,,,2885,2019.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,145.12362,2215.68,other,Non-Reimbursable List,,
HC Rad Guided-Percut Drainage-W/Cath Place,PX-32000208,CDM,75989,CPT,320,RC,,,outpatient,,,888,621.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,145.12362,681.984,other,Non-Reimbursable List,,
HC Rad Guided-Percut Drainage-W/Cath Place,PX-35000057,CDM,75989,CPT,350,RC,,,outpatient,,,888,621.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,145.12362,681.984,other,Non-Reimbursable List,,
HC Fluoroscopy Spx Up to 1 Hour Phys/Qhp Time,PX-32000209,CDM,76000,CPT,320,RC,,,outpatient,,,997,697.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,195.08,765.696,other,Non-Reimbursable List,,
HC X-Ray Nose-Rectum Child F.B.,PX-32000210,CDM,76010,CPT,320,RC,,,outpatient,,,340,238,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,71.24,416.02,fee schedule,,,
HC X-Ray Fistula-Abscess-Sinus Tract,PX-32000211,CDM,76080,CPT,320,RC,,,outpatient,,,1950,1365,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,237.819698,1497.6,other,Non-Reimbursable List,,
HC X-Ray Exam- Breast Specimen,PX-32000212,CDM,76098,CPT,320,RC,,,outpatient,,,984,688.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,668.39,,,668.39,220.908,1393.3385,fee schedule,,,
HC Cine/Videoradiology-Exc Where Spec Incl,PX-32000214,CDM,76120,CPT,320,RC,,,outpatient,,,382,267.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,237.15,,,237.15,85.759,416.02,fee schedule,,,
HC 3d Rendering W/Interp & Postprocess Supervision,PX-35000058,CDM,76376,CPT,350,RC,,,outpatient,,,352,246.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,79.024,836,other,Non-Reimbursable List,,
HC 3d Rendering W/Interp & Postprocess Supervision,PX-40200003,CDM,76376,CPT,402,RC,,,outpatient,,,352,246.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,79.024,836,other,Non-Reimbursable List,,
HC 3d Rendering W/Interp & Postprocess Supervision,PX-61000062,CDM,76376,CPT,610,RC,,,outpatient,,,352,246.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,79.024,836,other,Non-Reimbursable List,,
HC 3d Rendering W/Interp&Postproc Diff Work Station,PX-35000059,CDM,76377,CPT,350,RC,,,outpatient,,,422,295.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,94.739,836,other,Non-Reimbursable List,,
HC 3d Rendering W/Interp&Postproc Diff Work Station,PX-40200004,CDM,76377,CPT,402,RC,,,outpatient,,,422,295.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,94.739,836,other,Non-Reimbursable List,,
HC 3d Rendering W/Interp&Postproc Diff Work Station,PX-61000063,CDM,76377,CPT,610,RC,,,outpatient,,,422,295.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,94.739,836,other,Non-Reimbursable List,,
HC CT Scan-Limited/Localized F/U Study,PX-35000060,CDM,76380,CPT,350,RC,,,outpatient,,,928,649.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,147.41,,,147.41,71.24,712.704,fee schedule,,,
HC MRI Spectroscopy,PX-61000064,CDM,76390,CPT,610,RC,,,outpatient,,,2218,1552.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,81.08,,,81.08,81.08,1703.424,fee schedule,,,
HC Magnetic Resonance Elastography,PX-61000090,CDM,76391,CPT,610,RC,,,outpatient,,,842,589.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,484.67,,,484.67,189.029,836,fee schedule,,,
HC Unlisted CT Procedure,PX-35000061,CDM,76497,CPT,350,RC,,,outpatient,,,229,160.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,180.32,,,180.32,51.4105,575,fee schedule,,,
HC US- Head- Real Time,PX-40200005,CDM,76506,CPT,402,RC,,,outpatient,,,433,303.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,134.02,,,134.02,97.2085,416.02,fee schedule,,,
HC US- Head/Neck Tissues-Real Time,PX-40200006,CDM,76536,CPT,402,RC,,,outpatient,,,444,310.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,206.14,,,206.14,99.678,416.02,fee schedule,,,
HC US- Chest-Real Time,PX-40200007,CDM,76604,CPT,402,RC,,,outpatient,,,417,291.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,134.02,,,134.02,93.6165,416.02,fee schedule,,,
HC US Breast Uni Real Time With Image Complete,PX-40200056,CDM,76641,CPT,402,RC,,,outpatient,,,385,269.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,221.83,,,221.83,86.4325,416.02,fee schedule,,,
HC US Breast Uni Real Time With Image Limited,PX-40200055,CDM,76642,CPT,402,RC,,,outpatient,,,353,247.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,180.32,,,180.32,71.24,416.02,fee schedule,,,
HC US- Abdom-B-Scan &/or Real Time-Complete,PX-40200009,CDM,76700,CPT,402,RC,,,outpatient,,,461,322.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,206.14,,,206.14,103.4945,416.02,fee schedule,,,
HC US- Abdomen Limited,PX-40200010,CDM,76705,CPT,402,RC,,,outpatient,,,341,238.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,206.14,,,206.14,76.5545,416.02,fee schedule,,,
HC Ultrasound Exam Aaa Screen,PX-40200002,CDM,76706,CPT,402,RC,,,outpatient,,,261,182.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,233.97,,,233.97,58.5945,416.02,fee schedule,,,
HC US-Retroperit- B-Scan/Real Time-Complete,PX-40200011,CDM,76770,CPT,402,RC,,,outpatient,,,368,257.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,206.14,,,206.14,82.616,416.02,fee schedule,,,
HC US- Retroperitnl Abd- Ltd,PX-40200012,CDM,76775,CPT,402,RC,,,outpatient,,,345,241.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,206.14,,,206.14,77.4525,416.02,fee schedule,,,
HC US- Spinal Canal & Contents,PX-40200014,CDM,76800,CPT,402,RC,,,outpatient,,,595,416.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,206.14,,,206.14,119.991125,456.96,fee schedule,,,
HC US- OB < 14 Wks- Single Fetus,PX-40200015,CDM,76801,CPT,402,RC,,,outpatient,,,289,202.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,206.14,,,206.14,64.8805,416.02,fee schedule,,,
HC US- OB < 14 Wks- Add'l Fetus,PX-40200016,CDM,76802,CPT,402,RC,,,outpatient,,,224,156.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,50.288,416.02,other,SI=N Exclusions ,,
HC US- OB >/= 14 Wks- Sngl Fetus,PX-40200017,CDM,76805,CPT,402,RC,,,outpatient,,,421,294.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,206.14,,,206.14,94.5145,416.02,fee schedule,,,
HC US- OB >/= 14 Wks- Addl Fetus,PX-40200018,CDM,76810,CPT,402,RC,,,outpatient,,,713,499.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,157.086513,547.584,other,SI=N Exclusions ,,
HC US-Preg Uter-Fet & Mat-+ Detl Fet Exm,PX-40200019,CDM,76811,CPT,402,RC,,,outpatient,,,725,507.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,321.16,,,321.16,162.7625,646.6965,fee schedule,,,
HC US-Preg Uter-Fet & Mat-+ Detl Fet-Addl,PX-40200020,CDM,76812,CPT,402,RC,,,outpatient,,,240,168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,53.88,416.02,other,SI=N Exclusions ,,
HC US-Pregnant Uterus-Limited- 1/> Fetuses,PX-40200021,CDM,76815,CPT,402,RC,,,outpatient,,,303,212.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,134.02,,,134.02,68.0235,416.02,fee schedule,,,
HC US-Pregnant Uterus-F/U-Transabd App,PX-40200022,CDM,76816,CPT,402,RC,,,outpatient,,,600,420,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,134.02,,,134.02,119.991125,460.8,fee schedule,,,
HC US-Pregnant Uterus-Transvaginal,PX-40200023,CDM,76817,CPT,402,RC,,,outpatient,,,355,248.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,134.02,,,134.02,79.6975,416.02,fee schedule,,,
HC Fetal Biophysical Profile,PX-40200024,CDM,76818,CPT,402,RC,,,outpatient,,,439,307.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,206.14,,,206.14,98.5555,416.02,fee schedule,,,
HC Fetal Biophys Prof-W/O Nst,PX-40200025,CDM,76819,CPT,402,RC,,,outpatient,,,358,250.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,206.14,,,206.14,80.371,416.02,fee schedule,,,
HC Doppler Fetal Umbilical Artery,PX-40200026,CDM,76820,CPT,402,RC,,,outpatient,,,290,203,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,134.02,,,134.02,65.105,416.02,fee schedule,,,
HC US-Pregnant Uterus-Limited- 1/> Fetuses,PX-40200028,CDM,76827,CPT,402,RC,,,outpatient,,,578,404.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,134.02,,,134.02,119.991125,443.904,fee schedule,,,
HC Sono Fetal Hrt Doppl F/U,PX-40200029,CDM,76828,CPT,402,RC,,,outpatient,,,146,102.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,134.02,,,134.02,32.777,416.02,fee schedule,,,
HC Echography-Transvaginal,PX-40200030,CDM,76830,CPT,402,RC,,,outpatient,,,365,255.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,206.14,,,206.14,81.9425,416.02,fee schedule,,,
HC Sono Exam- Hysterosonography,PX-40200031,CDM,76831,CPT,402,RC,,,outpatient,,,1006,704.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,321.16,,,321.16,199.512292,772.608,fee schedule,,,
HC Echo-Pelvic (Nonobstetric),PX-40200032,CDM,76856,CPT,402,RC,,,outpatient,,,361,252.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,206.14,,,206.14,81.0445,416.02,fee schedule,,,
HC Sono Pelvis Limited,PX-40200033,CDM,76857,CPT,402,RC,,,outpatient,,,332,232.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,134.02,,,134.02,74.534,416.02,fee schedule,,,
HC Echo-Scrotum & Contents,PX-40200034,CDM,76870,CPT,402,RC,,,outpatient,,,457,319.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,206.14,,,206.14,102.5965,416.02,fee schedule,,,
HC Echo-Transrectal,PX-40200035,CDM,76872,CPT,402,RC,,,outpatient,,,401,280.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,206.14,,,206.14,90.0245,416.02,fee schedule,,,
HC Echo-Transrectal-Prostate Vol,PX-40200036,CDM,76873,CPT,402,RC,,,outpatient,,,273,191.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,321.16,,,321.16,61.2885,416.02,fee schedule,,,
HC US-Extremity-Nonvascular-Real-Time Image-Complete,PX-40200037,CDM,76881,CPT,402,RC,,,outpatient,,,400,280,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,206.14,,,206.14,89.8,416.02,fee schedule,,,
HC US-Extremity-Nonvascular-Real-Time Image-Limited,PX-40200038,CDM,76882,CPT,402,RC,,,outpatient,,,253,177.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,134.02,,,134.02,56.7985,416.02,fee schedule,,,
HC US Inft Hips R-T Img Dynamic Req Phys/Qhp Manj,PX-40200039,CDM,76885,CPT,402,RC,,,outpatient,,,412,288.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,134.02,,,134.02,71.24,416.02,fee schedule,,,
HC US Inft Hips R-T Img Lmtd Static Phys/Qhp Manj,PX-40200040,CDM,76886,CPT,402,RC,,,outpatient,,,412,288.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,134.02,,,134.02,71.24,416.02,fee schedule,,,
HC US Guid-Comp Repair-Pseudo-Aneur/Av Fist,PX-40200041,CDM,76936,CPT,402,RC,,,outpatient,,,681,476.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,225.42,,,225.42,152.8845,775.5705,fee schedule,,,
HC US Guide- Vascular Access,PX-40200042,CDM,76937,CPT,402,RC,,,outpatient,,,251,175.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,56.3495,416.02,other,Non-Reimbursable List,,
HC US Guide- Tissue Ablation,PX-40200043,CDM,76940,CPT,402,RC,,,outpatient,,,460,322,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,103.27,416.02,other,Non-Reimbursable List,,
HC Sono Guide Needle Biopsy,PX-40200044,CDM,76942,CPT,402,RC,,,outpatient,,,868,607.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,166.37,666.624,other,Non-Reimbursable List,,
HC Sono Guide Amniocentesis,PX-40200045,CDM,76946,CPT,402,RC,,,outpatient,,,354,247.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,79.473,416.02,other,Non-Reimbursable List,,
HC US Guid-Comp Repair-Pseudo-Aneur/Av Fist,PX-40200048,CDM,76998,CPT,402,RC,,,outpatient,,,604,422.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,135.598,463.872,other,Non-Reimbursable List,,
HC Fluoroguide Cntrl Ven Access-Place-Replace-Remove,PX-32000217,CDM,77001,CPT,320,RC,,,outpatient,,,521,364.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,116.9645,416.02,other,Non-Reimbursable List,,
HC Fluoroscopic Guidance Needle Placement,PX-32000218,CDM,77002,CPT,320,RC,,,outpatient,,,318,222.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,71.391,416.02,other,Non-Reimbursable List,,
HC Fluorscopic Guidance Spinal Injection,PX-32000219,CDM,77003,CPT,320,RC,,,outpatient,,,518,362.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,116.291,416.02,other,Non-Reimbursable List,,
HC CT Guidance Stereotactic Localization,PX-35000062,CDM,77011,CPT,350,RC,,,outpatient,,,1801,1260.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,1383.168,other,Non-Reimbursable List,,
HC CT Guidance Needle Placement,PX-35000063,CDM,77012,CPT,350,RC,,,outpatient,,,1747,1222.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,63.344499,1341.696,other,Non-Reimbursable List,,
HC CT Guidance Tissue Ablation,PX-35000064,CDM,77013,CPT,350,RC,,,outpatient,,,1755,1228.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,63.344499,1347.84,other,Non-Reimbursable List,,
HC CT Guidance Placement Rad Therapy Fields,PX-35000065,CDM,77014,CPT,350,RC,,,outpatient,,,623,436.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,139.8635,575,other,Non-Reimbursable List,,
HC MRI Guidance Needle Placement,PX-61000066,CDM,77021,CPT,610,RC,,,outpatient,,,3092,2164.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,2374.656,other,Non-Reimbursable List,,
HC MRI Breast Without Contrast Material Unilateral,PX-61000083,CDM,77046,CPT,610,RC,,,outpatient,,,842,589.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,484.67,,,484.67,189.029,836,fee schedule,,,
HC MRI Breast Without Contrast Material Bilateral,PX-61000086,CDM,77047,CPT,610,RC,,,outpatient,,,842,589.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,484.67,,,484.67,189.029,836,fee schedule,,,
HC MRI Breast With Contrast W/Cad Unilateral,PX-61000084,CDM,77048,CPT,610,RC,,,outpatient,,,2118,1482.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,848.6826,399.547552,1936.896,percent of total billed charges,,,
HC MRI Breast W/Out&With Contrast W/Cad Unilateral,PX-61000085,CDM,77048,CPT,610,RC,,,outpatient,,,2522,1765.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1010.5654,399.547552,1936.896,percent of total billed charges,,,
HC MRI Breast With Contrast W/Cad Bilateral,PX-61000087,CDM,77049,CPT,610,RC,,,outpatient,,,2788,1951.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1117.1516,399.547552,2548.224,percent of total billed charges,,,
HC MRI Breast W/Out&With Contrast W/Cad Bilateral,PX-61000088,CDM,77049,CPT,610,RC,,,outpatient,,,3318,2322.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1329.5226,399.547552,2548.224,percent of total billed charges,,,
HC Digital Breast Tomosynthesis Unilateral,PX-40100006,CDM,77061,CPT,401,RC,,,outpatient,,,321,224.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,72.0645,416.02,other,Non-Reimbursable List,,
HC Digital Breast Tomosynthesis Bilateral,PX-40100007,CDM,77062,CPT,401,RC,,,outpatient,,,393,275.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,88.2285,416.02,other,Non-Reimbursable List,,
HC Screening Digital Breast Tomosynthesis Bi,PX-40300004,CDM,77063,CPT,403,RC,,,outpatient,,,202,141.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.99364,416.02,other,Non-Reimbursable List,,
HC Dx Mammo Incl Cad Uni,PX-40100008,CDM,77065,CPT,401,RC,,,outpatient,,,393,275.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,157.4751,88.2285,416.02,percent of total billed charges,,,
HC Dx Mammo Incl Cad Bi,PX-40100009,CDM,77066,CPT,401,RC,,,outpatient,,,466,326.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,186.7262,90.800319,416.02,percent of total billed charges,,,
HC Scr Mammo Bi Incl Cad,PX-40300005,CDM,77067,CPT,403,RC,,,outpatient,,,466,326.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,186.7262,90.800319,416.02,percent of total billed charges,,,
HC Manual Appl Stress Pfrmd Phys/Qhp Joint Films,PX-32000222,CDM,77071,CPT,320,RC,,,outpatient,,,262,183.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,58.819,416.02,fee schedule,,,
HC X-Rays for Bone Age,PX-32000223,CDM,77072,CPT,320,RC,,,outpatient,,,218,152.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.37,,,95.37,48.941,416.02,fee schedule,,,
HC X-Rays- Bone Length Studies,PX-32000224,CDM,77073,CPT,320,RC,,,outpatient,,,502,351.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,147.03,,,147.03,76.026473,416.02,fee schedule,,,
HC X-Rays- Bone Survey- Limited,PX-32000225,CDM,77074,CPT,320,RC,,,outpatient,,,502,351.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,147.03,,,147.03,112.699,416.02,fee schedule,,,
HC X-Rays- Bone Survey Complete,PX-32000226,CDM,77075,CPT,320,RC,,,outpatient,,,502,351.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,147.03,,,147.03,112.699,416.02,fee schedule,,,
HC X-Rays- Bone Survey- Infant,PX-32000227,CDM,77076,CPT,320,RC,,,outpatient,,,502,351.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,147.03,,,147.03,76.026473,416.02,fee schedule,,,
HC Dexa-Bone Density- 1 + Site- Axial Skeleton,PX-32000228,CDM,77080,CPT,320,RC,,,outpatient,,,575,402.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,230.77,,,230.77,119.991125,441.6,fee schedule,,,
HC Dexa-Bone Density- 1 + Site- Appendiculr Skeltn,PX-32000229,CDM,77081,CPT,320,RC,,,outpatient,,,114,79.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,73.14,,,73.14,25.593,416.02,fee schedule,,,
HC MRI- Bone Marrow,PX-61000070,CDM,77084,CPT,610,RC,,,outpatient,,,2406,1684.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,450.35,,,450.35,267.439885,1847.808,fee schedule,,,
HC Tbs Techl Prep&Transmis Data Alys Pfrmd Elsewhr,PX-32000262,CDM,77090,CPT,320,RC,,,outpatient,,,248,173.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,55.676,416.02,other,Non-Reimbursable List,,
HC Tbs Technical Calculation Only,PX-32000263,CDM,77091,CPT,320,RC,,,outpatient,,,248,173.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,55.676,416.02,other,Non-Reimbursable List,,
HC Thyroid Uptake Single/Multiple Quant Measurement,PX-34100001,CDM,78012,CPT,341,RC,,,outpatient,,,935,654.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,236.67,,,236.67,209.9075,1076.394,fee schedule,,,
HC Thyroid Imaging With Vascular Flow,PX-34100002,CDM,78013,CPT,341,RC,,,outpatient,,,633,443.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,311.41,,,311.41,142.1085,1076.394,fee schedule,,,
HC Thyroid Uptake W/Blood Flow Sngle/Mult Quan Meas,PX-34100003,CDM,78014,CPT,341,RC,,,outpatient,,,982,687.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,483.47,,,483.47,220.459,1076.394,fee schedule,,,
HC Thyroid Met Imaging Body,PX-34100005,CDM,78018,CPT,341,RC,,,outpatient,,,1049,734.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,622.84,,,622.84,235.5005,1397.122,fee schedule,,,
HC Thyroid Met Uptake,PX-34100006,CDM,78020,CPT,341,RC,,,outpatient,,,171,119.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,38.3895,416.02,other,SI=N Exclusions ,,
HC Parathyroid Planar Imaging,PX-34100007,CDM,78070,CPT,341,RC,,,outpatient,,,1575,1102.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,483.47,,,483.47,353.5875,1209.6,fee schedule,,,
HC Parathyroid Planar Imaging W/WO Subtraction,PX-34100008,CDM,78071,CPT,341,RC,,,outpatient,,,1357,949.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,668.39,,,668.39,304.6465,1076.394,fee schedule,,,
HC Parathyroid Imaging W/Tomographic Spect & CT,PX-34100009,CDM,78072,CPT,341,RC,,,outpatient,,,1898,1328.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,668.39,,,668.39,358.69,1457.664,fee schedule,,,
HC Adrenal Nuclear Imaging,PX-34100010,CDM,78075,CPT,341,RC,,,outpatient,,,2974,2081.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1983.35,,,1983.35,399.86,3675.6585,fee schedule,,,
HC Bone Marrow Imaging- Ltd,PX-34100011,CDM,78102,CPT,341,RC,,,outpatient,,,1403,982.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,581.04,,,581.04,314.9735,1077.504,fee schedule,,,
HC Bone Marrow Imaging- Mult,PX-34100012,CDM,78103,CPT,341,RC,,,outpatient,,,1403,982.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,581.04,,,581.04,314.9735,1077.504,fee schedule,,,
HC Bone Marrow Imaging- Body,PX-34100013,CDM,78104,CPT,341,RC,,,outpatient,,,659,461.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,581.04,,,581.04,147.9455,1076.394,fee schedule,,,
HC Spleen Imaging,PX-34100015,CDM,78185,CPT,341,RC,,,outpatient,,,971,679.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,581.04,,,581.04,217.9895,1076.394,fee schedule,,,
HC Lymphatics & Lymph Glands Imaging,PX-34100016,CDM,78195,CPT,341,RC,,,outpatient,,,1071,749.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,581.04,,,581.04,240.4395,1397.122,fee schedule,,,
HC Liver Imaging,PX-34100017,CDM,78201,CPT,341,RC,,,outpatient,,,2228,1559.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,652.52,,,652.52,399.86,2239.93036,fee schedule,,,
HC Liver and Spleen Imaging,PX-34100021,CDM,78215,CPT,341,RC,,,outpatient,,,1205,843.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,652.52,,,652.52,270.5225,1076.394,fee schedule,,,
HC Hepatobiliary Syst Imaging Including Gallbladder,PX-34100023,CDM,78226,CPT,341,RC,,,outpatient,,,1384,968.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,652.52,,,652.52,310.708,1076.394,fee schedule,,,
HC Hepatobil Syst Imag Inc Gb W/Pharma Intervenj,PX-34100024,CDM,78227,CPT,341,RC,,,outpatient,,,1384,968.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,652.52,,,652.52,310.708,1397.122,fee schedule,,,
HC Serial Salivary Imaging,PX-34100025,CDM,78231,CPT,341,RC,,,outpatient,,,788,551.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,532.91,,,532.91,176.906,1076.394,fee schedule,,,
HC Gastroesophageal Reflux Exam,PX-34100027,CDM,78262,CPT,341,RC,,,outpatient,,,1043,730.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,532.91,,,532.91,234.1535,1076.394,fee schedule,,,
HC Gastric Emptying Study,PX-34100028,CDM,78264,CPT,341,RC,,,outpatient,,,838,586.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,532.91,,,532.91,188.131,1076.394,fee schedule,,,
HC Acute GI Blood Loss Imaging,PX-34100031,CDM,78278,CPT,341,RC,,,outpatient,,,2079,1455.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,532.91,,,532.91,399.86,1596.672,fee schedule,,,
HC Bowel Imaging,PX-34100032,CDM,78290,CPT,341,RC,,,outpatient,,,893,625.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,532.91,,,532.91,200.4785,1076.394,fee schedule,,,
HC Leveen/Shunt Patency Exam,PX-34100033,CDM,78291,CPT,341,RC,,,outpatient,,,954,667.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,532.91,,,532.91,214.173,1076.394,fee schedule,,,
HC Bone Imaging- Limited Area,PX-34100034,CDM,78300,CPT,341,RC,,,outpatient,,,962,673.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,543.12,,,543.12,215.969,1076.394,fee schedule,,,
HC Bone Imaging- Multiple Areas,PX-34100035,CDM,78305,CPT,341,RC,,,outpatient,,,1098,768.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,543.12,,,543.12,246.501,1076.394,fee schedule,,,
HC Bone Imaging- Whole Body,PX-34100036,CDM,78306,CPT,341,RC,,,outpatient,,,893,625.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,543.12,,,543.12,200.4785,1076.394,fee schedule,,,
HC Bone Imaging- 3 Phase,PX-34100037,CDM,78315,CPT,341,RC,,,outpatient,,,956,669.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,543.12,,,543.12,214.622,1076.394,fee schedule,,,
HC Myocardial Spect Single Study at Rest or Stress,PX-34100040,CDM,78451,CPT,341,RC,,,outpatient,,,4510,3157,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1410.68,,,1410.68,399.86,3675.6585,fee schedule,,,
HC Myocardial Spect Multiple Studies,PX-34100041,CDM,78452,CPT,341,RC,,,outpatient,,,4510,3157,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1410.68,,,1410.68,399.86,3675.6585,fee schedule,,,
HC Myocardial Perfusion Planar 1 Study Rest/Stress,PX-34100042,CDM,78453,CPT,341,RC,,,outpatient,,,3900,2730,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1410.68,,,1410.68,399.86,3675.6585,fee schedule,,,
HC Myocardial Perfusion Planar Multiple Studies,PX-34100043,CDM,78454,CPT,341,RC,,,outpatient,,,3900,2730,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1410.68,,,1410.68,399.86,3675.6585,fee schedule,,,
HC Gated Heart- Planar Single,PX-34100048,CDM,78472,CPT,341,RC,,,outpatient,,,1586,1110.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,641.31,,,641.31,356.057,1218.048,fee schedule,,,
HC Heart Image- Spect,PX-34100050,CDM,78494,CPT,341,RC,,,outpatient,,,1671,1169.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,641.31,,,641.31,375.1395,1283.328,fee schedule,,,
HC Pulmonary Ventilation Imaging,PX-34100052,CDM,78579,CPT,341,RC,,,outpatient,,,767,536.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,458.6,,,458.6,172.1915,1076.394,fee schedule,,,
HC Lung Perfusion Imaging,PX-34100053,CDM,78580,CPT,341,RC,,,outpatient,,,640,448,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,458.6,,,458.6,143.68,1076.394,fee schedule,,,
HC Pulmonary Ventilation & Perfusion Imaging,PX-34100054,CDM,78582,CPT,341,RC,,,outpatient,,,946,662.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,698.2,,,698.2,212.377,1397.122,fee schedule,,,
HC Quant Differential Pulm Perfusion W/WO Imaging,PX-34100055,CDM,78597,CPT,341,RC,,,outpatient,,,902,631.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,458.6,,,458.6,202.499,1076.394,fee schedule,,,
HC Quant Diff Pulm Prfusion & Ventlaj W/WO Imaging,PX-34100056,CDM,78598,CPT,341,RC,,,outpatient,,,1499,1049.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,698.2,,,698.2,336.5255,1397.122,fee schedule,,,
HC Brain Imaging < 4 Static Views W Vascular Flow,PX-34100058,CDM,78601,CPT,341,RC,,,outpatient,,,2704,1892.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,951.28,,,951.28,399.86,2076.672,fee schedule,,,
HC Brain Imaging Min 4 Static Views W Vascular Flow,PX-34100059,CDM,78606,CPT,341,RC,,,outpatient,,,1589,1112.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,951.28,,,951.28,356.7305,1397.122,fee schedule,,,
HC Brain Imaging Pet Metabolic,PX-40400003,CDM,78608,CPT,404,RC,,,outpatient,,,4890,3423,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2191.98,,,2191.98,399.86,3755.52,fee schedule,,,
HC CSF Fluid Scan Cisternography,PX-34100061,CDM,78630,CPT,341,RC,,,outpatient,,,2570,1799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,951.28,,,951.28,399.86,1973.76,fee schedule,,,
HC CSF Shunt Evaluation,PX-34100062,CDM,78645,CPT,341,RC,,,outpatient,,,916,641.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,548.12,,,548.12,205.642,1397.122,fee schedule,,,
HC CSF Leakage Detection & Localization,PX-34100063,CDM,78650,CPT,341,RC,,,outpatient,,,3215,2250.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,951.28,,,951.28,399.86,3675.6585,fee schedule,,,
HC Renal Imaging- Static,PX-34100064,CDM,78700,CPT,341,RC,,,outpatient,,,1292,904.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,690.95,,,690.95,290.054,1076.394,fee schedule,,,
HC Renal Flow/Funct Imaging,PX-34100065,CDM,78707,CPT,341,RC,,,outpatient,,,1210,847,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,690.95,,,690.95,271.645,1397.122,fee schedule,,,
HC Renal Flow/Funct Image-Pharm Rx,PX-34100066,CDM,78708,CPT,341,RC,,,outpatient,,,899,629.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,690.95,,,690.95,201.8255,1397.122,fee schedule,,,
HC Testicular Imaging & Flow,PX-34100069,CDM,78761,CPT,341,RC,,,outpatient,,,845,591.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,690.95,,,690.95,189.7025,1076.394,fee schedule,,,
HC Tumor Imaging- Limited Area,PX-34100070,CDM,78800,CPT,341,RC,,,outpatient,,,867,606.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,622.84,,,622.84,194.6415,1076.394,fee schedule,,,
HC Tumor Imaging- Whole Body- Single Day,PX-34100072,CDM,78802,CPT,341,RC,,,outpatient,,,3124,2186.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1043.02,,,1043.02,399.86,3675.6585,fee schedule,,,
HC Tumor Imaging Spect,PX-34100073,CDM,78803,CPT,341,RC,,,outpatient,,,2419,1693.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1043.02,,,1043.02,399.86,3675.6585,fee schedule,,,
HC Tumor Imaging- Whole Body- 2 or More Days,PX-34100074,CDM,78804,CPT,341,RC,,,outpatient,,,2916,2041.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1983.35,,,1983.35,399.86,3675.6585,fee schedule,,,
HC Inject Radiopharm Non-Imaging Localization- IV,PX-34100080,CDM,78808,CPT,341,RC,,,outpatient,,,1227,858.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,491.6589,275.4615,1076.394,percent of total billed charges,,,
HC Pet Imaging CT for Attenuation Limited Area,PX-40400004,CDM,78814,CPT,404,RC,,,outpatient,,,5186,3630.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2191.98,,,2191.98,399.86,3982.848,fee schedule,,,
HC Pet Imaging CT Attenuation Skull Base Mid-Thigh,PX-40400005,CDM,78815,CPT,404,RC,,,outpatient,,,6904,4832.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2191.98,,,2191.98,399.86,5302.272,fee schedule,,,
HC Pet Imaging for CT Attenuation Whole Body,PX-40400006,CDM,78816,CPT,404,RC,,,outpatient,,,7705,5393.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2191.98,,,2191.98,399.86,5917.44,fee schedule,,,
HC Rp Loclzj Tum Spect W/CT 1 Area 1 Day Imaging,PX-34100081,CDM,78830,CPT,341,RC,,,outpatient,,,4318,3022.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2754.75,,,2754.75,399.86,3675.6585,fee schedule,,,
HC Rp Loclzj Tum Spect 2 Area 1d Img/1 Area Img>2+D,PX-34100082,CDM,78831,CPT,341,RC,,,outpatient,,,4318,3022.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2754.75,,,2754.75,399.86,3675.6585,fee schedule,,,
HC Rp Loclzj Tum Spect CT 2area 1d Img/1 AR Img>2+D,PX-34100083,CDM,78832,CPT,341,RC,,,outpatient,,,4899,3429.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3091.15,,,3091.15,399.86,4124.5085,fee schedule,,,
HC Radiopharmaceutical Quantification Meas 1 Area,PX-34100084,CDM,78835,CPT,341,RC,,,outpatient,,,203,142.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,45.5735,416.02,other,SI=N Exclusions ,,
HC Nuclear Therapy- Oral,PX-34200001,CDM,79005,CPT,342,RC,,,outpatient,,,782,547.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,491.29,,,491.29,175.559,691.5815,fee schedule,,,
HC Urinalysis- Auto- W/O Scope,PX-30000067,CDM,81003,CPT,300,RC,,,outpatient,,,32,22.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.52,,,5.02,2.29,24.576,fee schedule,,,
HC Urine Pregnancy Test,PX-30000713,CDM,81025,CPT,300,RC,,,outpatient,,,28,19.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12.72,,,14.13,6.286,21.504,fee schedule,,,
HC Molecular Pathology Procedure Level 4,PX-30000097,CDM,81403,CPT,300,RC,,,outpatient,,,716,501.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,343.5,,,381.66,160.742,549.888,fee schedule,,,
HC Blood Occult-by Peroxid- Feces- 1-3 Simult- Non Ca Screen,PX-30000715,CDM,82272,CPT,300,RC,,,outpatient,,,24,16.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6.55,,,7.28,3.33,18.432,fee schedule,,,
HC Glucose Blood Test,PX-30000221,CDM,82962,CPT,300,RC,,,outpatient,,,45,31.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.71,,,5.23,2.4,34.56,fee schedule,,,
HC Bone Marrow-Smear Interpretation,PX-31000012,CDM,85097,CPT,310,RC,,,outpatient,,,1038,726.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,55.69,,,61.88,39.73,1313.895373,fee schedule,,,
HC Coagulation Time- Activated,PX-30000417,CDM,85347,CPT,300,RC,,,outpatient,,,80,56,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8.55,,,9.5,4.35,61.44,fee schedule,,,
HC Hgb/Rbcs Fetal Fetomaternal Hemrrg Rosette,PX-30000732,CDM,85461,CPT,300,RC,,,outpatient,,,32,22.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13.33,,,14.81,6.78,24.576,fee schedule,,,
HC Sickling RBC Reduction,PX-30000730,CDM,85660,CPT,300,RC,,,outpatient,,,25,17.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11.09,,,12.33,5.6125,19.2,fee schedule,,,
HC Platelet Antibodies,PX-30000453,CDM,86022,CPT,300,RC,,,outpatient,,,128,89.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,36.91,,,41.01,18.77,98.304,fee schedule,,,
HC Cold Agglutinin Screen,PX-30000465,CDM,86156,CPT,300,RC,,,outpatient,,,158,110.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13.46,,,14.96,6.51,121.344,fee schedule,,,
HC Cold Agglutinin- Titer,PX-30000466,CDM,86157,CPT,300,RC,,,outpatient,,,29,20.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16.21,,,18.01,6.5105,24.43,fee schedule,,,
HC Leukocyte Phagocytosis,PX-30000866,CDM,86344,CPT,300,RC,,,outpatient,,,33,23.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,16.05,,,17.83,7.4085,25.344,fee schedule,,,
HC Cmv Antibody,PX-30000526,CDM,86644,CPT,300,RC,,,outpatient,,,155,108.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,28.93,,,32.14,14.71,119.04,fee schedule,,,
HC Hla Typing- a-B-or C /Single,PX-30000582,CDM,86812,CPT,300,RC,,,outpatient,,,252,176.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,51.86,,,57.62,26.37,193.536,fee schedule,,,
HC Hla Typing Dr/Dq Single Antigen,PX-30000731,CDM,86816,CPT,300,RC,,,outpatient,,,124,86.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,55.98,,,62.2,27.838,95.232,fee schedule,,,
HC Hla Typing- Dr/Dq-Multi Antgn,PX-30000584,CDM,86817,CPT,300,RC,,,outpatient,,,287,200.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,129.36,,,143.73,64.4315,241.472,fee schedule,,,
HC RBC Antibody Screen,PX-30000585,CDM,86850,CPT,300,RC,,,outpatient,,,99,69.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26.25,,,29.17,6.25,92.88556,fee schedule,,,
HC RBC Antibody Elution,PX-30000586,CDM,86860,CPT,300,RC,,,outpatient,,,358,250.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,36.53,,,40.59,2.072,274.944,fee schedule,,,
HC RBC Antibody Identification,PX-30000587,CDM,86870,CPT,300,RC,,,outpatient,,,501,350.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50.14,,,55.71,2.842,549.235176,fee schedule,,,
HC Antihuman Globulin Dir Ea Antiserum,PX-30000588,CDM,86880,CPT,300,RC,,,outpatient,,,117,81.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14.13,,,15.71,5.5,93.463636,fee schedule,,,
HC Antihuman Globulin Indir Qual Ea Reagent Cell,PX-30000589,CDM,86885,CPT,300,RC,,,outpatient,,,357,249.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14.13,,,15.71,5.85,274.176,fee schedule,,,
HC Antihuman Globulin Indirect Ea Antibody Titer,PX-30000590,CDM,86886,CPT,300,RC,,,outpatient,,,357,249.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14.13,,,15.71,5.29,274.176,fee schedule,,,
HC Blood Typing- Abo,PX-30000592,CDM,86900,CPT,300,RC,,,outpatient,,,208,145.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14.13,,,15.71,3.05,195.186327,fee schedule,,,
HC Blood Typing- Rh (D),PX-30000593,CDM,86901,CPT,300,RC,,,outpatient,,,85,59.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14.13,,,15.71,3.05,65.28,fee schedule,,,
HC Blood Type Antigen Donor Reagent Serum- Ea Antigen,PX-30000594,CDM,86902,CPT,300,RC,,,outpatient,,,628,439.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26.25,,,29.17,3.91,549.235176,fee schedule,,,
HC Blood Typing Antigen Screen Patient Serum/Unit,PX-30000718,CDM,86904,CPT,300,RC,,,outpatient,,,311,217.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26.25,,,29.17,9.71,238.848,fee schedule,,,
HC Blood Typing- RBC Antigens,PX-30000595,CDM,86905,CPT,300,RC,,,outpatient,,,628,439.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26.25,,,29.17,3.91,549.235176,fee schedule,,,
HC Blood Typing Serologic Rh Phenotyping Complete,PX-30000719,CDM,86906,CPT,300,RC,,,outpatient,,,284,198.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26.25,,,29.17,7.91,218.112,fee schedule,,,
HC Compatibility Test-Spin Tech,PX-30000596,CDM,86920,CPT,300,RC,,,outpatient,,,355,248.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26.25,,,29.17,2.31,272.64,fee schedule,,,
HC Compatibility Test-Incub Tech,PX-30000597,CDM,86921,CPT,300,RC,,,outpatient,,,357,249.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26.25,,,29.17,2.072,274.176,fee schedule,,,
HC Compatibility Test-Antiglob Tech,PX-30000598,CDM,86922,CPT,300,RC,,,outpatient,,,357,249.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,36.53,,,40.59,2.45,274.176,fee schedule,,,
HC Compatibility Test- Electronic,PX-30000599,CDM,86923,CPT,300,RC,,,outpatient,,,357,249.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.862,274.176,other,Non-Reimbursable List,,
HC Plasma- Fresh Frozen,PX-30000600,CDM,86927,CPT,300,RC,,,outpatient,,,312,218.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26.25,,,29.17,1.302,263.69806,fee schedule,,,
HC Blood Product/Irradiation,PX-39100002,CDM,86945,CPT,391,RC,,,outpatient,,,116,81.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26.25,,,29.17,1.932,416.02,fee schedule,,,
HC Pretx RBC Antibody Incubat W/Chem Agnts/Drugs Ea,PX-30000729,CDM,86970,CPT,300,RC,,,outpatient,,,110,77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26.25,,,29.17,1.932,93.463636,fee schedule,,,
HC Pretx RBC Antibody Incubat W/Enzymes Each,PX-30000726,CDM,86971,CPT,300,RC,,,outpatient,,,560,392,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26.25,,,29.17,1.54,499.62884,fee schedule,,,
HC Pretx RBC Antibody Incubat W/Density Grad Sep,PX-30000727,CDM,86972,CPT,300,RC,,,outpatient,,,358,250.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26.25,,,29.17,2.702,274.944,fee schedule,,,
HC Pretx Serum RBC Antibody Incubation Drugs Each,PX-30000725,CDM,86975,CPT,300,RC,,,outpatient,,,358,250.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50.14,,,55.71,2.072,608.812631,fee schedule,,,
HC Pretx Serum RBC Antibody Identification Dilution,PX-30000724,CDM,86976,CPT,300,RC,,,outpatient,,,311,217.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26.25,,,29.17,2.31,238.848,fee schedule,,,
HC Pretx Serum RBC Antb ID Incubation Inhibitors Ea,PX-30000734,CDM,86977,CPT,300,RC,,,outpatient,,,509,356.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50.14,,,55.71,2.31,416.02,fee schedule,,,
HC RBC Pretreatment-Serum Inhib,PX-39100003,CDM,86977,CPT,391,RC,,,outpatient,,,509,356.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50.14,,,55.71,2.31,416.02,fee schedule,,,
HC Pretx Serum RBC Antibody ID Diffial Each Absrpj,PX-30000723,CDM,86978,CPT,300,RC,,,outpatient,,,311,217.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,36.53,,,40.59,2.31,238.848,fee schedule,,,
HC Unlisted Transfusion Medicine Procedure,PX-30000728,CDM,86999,CPT,300,RC,,,outpatient,,,299,209.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26.25,,,29.17,1.68,229.632,fee schedule,,,
HC Strep a Assay W/Optic,PX-30000714,CDM,87880,CPT,300,RC,,,outpatient,,,52,36.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21.88,,,24.31,11.674,39.936,fee schedule,,,
HC Sperm Isolation- Simple,PX-31000079,CDM,89260,CPT,310,RC,,,outpatient,,,210,147,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,55.69,,,61.88,47.145,416.02,fee schedule,,,
HC Sperm Isolation- Complex,PX-30000709,CDM,89261,CPT,300,RC,,,outpatient,,,152,106.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,55.69,,,61.88,34.124,116.736,fee schedule,,,
HC Semen Analysis-Volume- Count- Motility- Diff,PX-30000711,CDM,89320,CPT,300,RC,,,outpatient,,,58,40.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24.22,,,26.91,12.32,44.544,fee schedule,,,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4203-01,NDC,outpatient,5,ML,2200.75,1540.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,313.9,,,1487.7,139.93,1690.176,fee schedule,,,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4202-01,NDC,outpatient,1,ML,650.46,455.322,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,313.9,,,297.54,139.93,1690.176,fee schedule,,,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4202-02,NDC,outpatient,1,ML,650.46,455.322,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,313.9,,,297.54,139.93,1690.176,fee schedule,,,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4203-02,NDC,outpatient,5,ML,2200.75,1540.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,313.9,,,1487.7,139.93,1690.176,fee schedule,,,
RABIES IMMUNE GLOBULIN 300 UNIT/ML IJ SOLN,RX-142826,CDM,90375,HCPCS,636,RC,13533-0318-10,NDC,outpatient,1,ML,1554.22,1087.954,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,492.61,,,933.86,287.71,7105.5744,fee schedule,,,
RABIES IMMUNE GLOBULIN 300 UNIT/ML IJ SOLN,RX-142826,CDM,90375,HCPCS,636,RC,13533-0318-01,NDC,outpatient,1,ML,1554.22,1087.954,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,492.61,,,933.86,287.71,7105.5744,fee schedule,,,
RABIES IMMUNE GLOBULIN 1500 UNIT/5ML IJ SOLN,RX-142827,CDM,90375,HCPCS,636,RC,13533-0318-50,NDC,outpatient,5,ML,7771.09,5439.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,492.61,,,4669.3,287.71,7105.5744,fee schedule,,,
RABIES IMMUNE GLOBULIN 1500 UNIT/5ML IJ SOLN,RX-142827,CDM,90375,HCPCS,636,RC,13533-0318-05,NDC,outpatient,5,ML,7771.09,5439.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,492.61,,,4669.3,287.71,7105.5744,fee schedule,,,
RABIES IMMUNE GLOBULIN 900 UNIT/3ML IJ SOLN,RX-150138,CDM,90375,HCPCS,636,RC,13533-0318-30,NDC,outpatient,3,ML,4662.66,3263.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,492.61,,,2801.58,287.71,7105.5744,fee schedule,,,
RABIES IMMUNE GLOBULIN 900 UNIT/3ML IJ SOLN,RX-150138,CDM,90375,HCPCS,636,RC,13533-0318-03,NDC,outpatient,3,ML,4662.66,3263.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,492.61,,,2801.58,287.71,7105.5744,fee schedule,,,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-02,NDC,outpatient,2,ML,1850.42,1295.294,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,492.61,,,933.86,287.71,7105.5744,fee schedule,,,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-10,NDC,outpatient,10,ML,9252.05,6476.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,492.61,,,4669.3,287.71,7105.5744,fee schedule,,,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-11,NDC,outpatient,10,ML,9252.05,6476.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,492.61,,,4669.3,287.71,7105.5744,fee schedule,,,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-20,NDC,outpatient,2,ML,1850.42,1295.294,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,492.61,,,933.86,287.71,7105.5744,fee schedule,,,
PALIVIZUMAB 50 MG/0.5ML IM SOLN,RX-108060,CDM,90378,HCPCS,636,RC,66658-0230-01,NDC,outpatient,0.5,ML,5025.03,3517.521,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2739.02,,,2596.26,389.10344,4791.979,fee schedule,,,
RHO D IMMUNE GLOBULIN 1500 UNIT/2ML IJ SOSY,RX-129748,CDM,90384,HCPCS,636,RC,44206-0300-10,NDC,outpatient,2,ML,207.1,144.97,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,416.02,fee schedule,,,
RHO D IMMUNE GLOBULIN 1500 UNIT/2ML IJ SOSY,RX-129748,CDM,90384,HCPCS,636,RC,44206-0300-01,NDC,outpatient,2,ML,207.1,144.97,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,416.02,fee schedule,,,
RHO D IMMUNE GLOBULIN 1500 UNIT/2ML IJ SOSY,RX-129748,CDM,90384,HCPCS,636,RC,44206-0300-90,NDC,outpatient,2,ML,78.48,54.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,416.02,fee schedule,,,
HC Immuniz Admin-1 Single/Comb Vac/Toxoid,PX-77100004,CDM,90471,CPT,771,RC,,,outpatient,,,193,135.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,90.39,,,85.68,43.3285,416.02,fee schedule,,,
HC Immuniz-Admin-Each Addl,PX-77100008,CDM,90472,CPT,771,RC,,,outpatient,,,73,51.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,16.3885,416.02,other,SI=N Exclusions ,,
HC Admn Sarscov2 Vacc 1 Dose,PX-77100044,CDM,90480,CPT,771,RC,,,outpatient,,,111,77.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,44.4777,24.9195,416.02,percent of total billed charges,,,
MENINGOCOCCAL B RECOMB OMV ADJ IM SUSY,RX-129389,CDM,90620,HCPCS,636,RC,58160-0976-02,NDC,outpatient,0.5,ML,874.41,612.087,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,671.54688,fee schedule,,,
MENINGOCOCCAL B RECOMB OMV ADJ IM SUSY,RX-129389,CDM,90620,HCPCS,636,RC,58160-0976-20,NDC,outpatient,0.5,ML,874.41,612.087,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,671.54688,fee schedule,,,
HEPATITIS A VACCINE 1440 EL U/ML IM SUSP,RX-91034,CDM,90632,HCPCS,636,RC,58160-0826-43,NDC,outpatient,1,ML,337.61,236.327,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,70.48,416.02,other,SI=N Exclusions ,,
HEPATITIS A VACCINE 1440 EL U/ML IM SUSP,RX-91034,CDM,90632,HCPCS,636,RC,58160-0826-52,NDC,outpatient,1,ML,337.61,236.327,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,70.48,416.02,other,SI=N Exclusions ,,
HEPATITIS A VACCINE 720 EL U/0.5ML IM SUSP,RX-91033,CDM,90633,HCPCS,636,RC,58160-0825-43,NDC,outpatient,0.5,ML,155.01,108.507,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,34.799745,416.02,other,SI=N Exclusions ,,
HEPATITIS A VACCINE 720 EL U/0.5ML IM SUSP,RX-91033,CDM,90633,HCPCS,636,RC,58160-0825-52,NDC,outpatient,0.5,ML,155.01,108.507,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,34.799745,416.02,other,SI=N Exclusions ,,
HAEMOPHILUS B POLYSAC CONJ VAC IM SOLR,RX-11931,CDM,90648,HCPCS,636,RC,49281-0545-03,NDC,outpatient,1,UN,49.34,34.538,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,11.07683,416.02,other,SI=N Exclusions ,,
HAEMOPHILUS B POLYSAC CONJ VAC IM SOLR,RX-11931,CDM,90648,HCPCS,636,RC,49281-0547-58,NDC,outpatient,1,UN,49.34,34.538,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,11.07683,416.02,other,SI=N Exclusions ,,
HPV 9-VALENT RECOMB VACCINE IM SUSY,RX-129114,CDM,90651,HCPCS,636,RC,00006-4121-02,NDC,outpatient,0.5,ML,1147.17,803.019,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,881.02656,fee schedule,,,
HPV 9-VALENT RECOMB VACCINE IM SUSY,RX-129114,CDM,90651,HCPCS,636,RC,00006-4121-01,NDC,outpatient,0.5,ML,1147.17,803.019,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,881.02656,fee schedule,,,
INFLUENZA VAC SUBUNIT QUAD 0.5 ML IM SUSY,RX-135284,CDM,90674,HCPCS,636,RC,70461-0323-03,NDC,outpatient,0.5,ML,94.26,65.982,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,416.02,fee schedule,,,
INFLUENZA VAC SUBUNIT QUAD 0.5 ML IM SUSY,RX-135284,CDM,90674,HCPCS,636,RC,70461-0323-04,NDC,outpatient,0.5,ML,94.26,65.982,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,416.02,fee schedule,,,
RABIES VACCINE WRAPPER,RX-4080220,CDM,90675,HCPCS,636,RC,50632-0013-01,NDC,outpatient,1,UN,1460.49,1022.343,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,805.14,,,763.18,91.911626,1316.02176,fee schedule,,,
RABIES VACCINE WRAPPER,RX-4080220,CDM,90675,HCPCS,636,RC,49281-0252-51,NDC,outpatient,1,UN,1713.57,1199.499,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,805.14,,,763.18,91.911626,1316.02176,fee schedule,,,
RABIES VACCINE WRAPPER,RX-4080220,CDM,90675,HCPCS,636,RC,50632-0010-01,NDC,outpatient,1,UN,1460.49,1022.343,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,805.14,,,763.18,91.911626,1316.02176,fee schedule,,,
PNEUMOCOCCAL 20-VAL CONJ VACC 0.5 ML IM SUSY,RX-156044,CDM,90677,HCPCS,636,RC,00005-2000-02,NDC,outpatient,0.5,ML,1098.4,768.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,843.5712,fee schedule,,,
INFLUENZA VAC A&B SA ADJ QUAD 0.5 ML IM PRSY,RX-150230,CDM,90694,HCPCS,636,RC,70461-0123-04,NDC,outpatient,0.5,ML,241.68,169.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,416.02,fee schedule,,,
INFLUENZA VAC A&B SA ADJ QUAD 0.5 ML IM PRSY,RX-150230,CDM,90694,HCPCS,636,RC,70461-0123-03,NDC,outpatient,0.5,ML,241.68,169.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,416.02,fee schedule,,,
DIPHTH-ACELL PERTUSSIS-TETANUS 15-23-5 LF-MCG/0.5 IM SUSP,RX-140528,CDM,90700,HCPCS,636,RC,49281-0286-10,NDC,outpatient,0.5,ML,107.51,75.257,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,24.135995,416.02,other,SI=N Exclusions ,,
DIPHTH-ACELL PERTUSSIS-TETANUS 15-23-5 LF-MCG/0.5 IM SUSP,RX-140528,CDM,90700,HCPCS,636,RC,49281-0286-58,NDC,outpatient,0.5,ML,107.51,75.257,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,24.135995,416.02,other,SI=N Exclusions ,,
MEASLES- MUMPS & RUBELLA VAC IJ SOLR,RX-148019,CDM,90707,HCPCS,636,RC,00006-4681-01,NDC,outpatient,1,UN,362.53,253.771,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,54.47,416.02,other,SI=N Exclusions ,,
MEASLES- MUMPS & RUBELLA VAC IJ SOLR,RX-148019,CDM,90707,HCPCS,636,RC,00006-4681-00,NDC,outpatient,1,UN,362.53,253.771,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,54.47,416.02,other,SI=N Exclusions ,,
POLIOVIRUS VACCINE INACTIVATED IJ INJ,RX-108127,CDM,90713,HCPCS,636,RC,49281-0860-78,NDC,outpatient,0.5,ML,163.66,114.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,25.298577,416.02,other,SI=N Exclusions ,,
POLIOVIRUS VACCINE INACTIVATED IJ INJ,RX-108127,CDM,90713,HCPCS,636,RC,49281-0860-10,NDC,outpatient,0.5,ML,163.66,114.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,25.298577,416.02,other,SI=N Exclusions ,,
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,58160-0842-01,NDC,outpatient,0.5,ML,193.78,135.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,25.298577,416.02,other,SI=N Exclusions ,,
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,49281-0400-58,NDC,outpatient,0.5,ML,187.93,131.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,25.298577,416.02,other,SI=N Exclusions ,,
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,58160-0842-11,NDC,outpatient,0.5,ML,193.78,135.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,25.298577,416.02,other,SI=N Exclusions ,,
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,49281-0400-10,NDC,outpatient,0.5,ML,187.93,131.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,25.298577,416.02,other,SI=N Exclusions ,,
VARICELLA VIRUS VACCINE LIVE 1350 PFU/0.5ML SC INJ,RX-113088,CDM,90716,HCPCS,636,RC,00006-4827-01,NDC,outpatient,1,UN,737.12,515.984,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,566.10816,fee schedule,,,
VARICELLA VIRUS VACCINE LIVE 1350 PFU/0.5ML SC INJ,RX-113088,CDM,90716,HCPCS,636,RC,00006-4827-00,NDC,outpatient,1,UN,737.12,515.984,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,566.10816,fee schedule,,,
DTAP-HEPATITIS B RECOMB-IPV IM SUSY,RX-158218,CDM,90723,HCPCS,636,RC,58160-0811-43,NDC,outpatient,0.5,ML,392.47,274.729,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,416.02,fee schedule,,,
DTAP-HEPATITIS B RECOMB-IPV IM SUSY,RX-158218,CDM,90723,HCPCS,636,RC,58160-0811-52,NDC,outpatient,0.5,ML,392.47,274.729,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,416.02,fee schedule,,,
MENINGOCOCCAL A C Y&W-135 OLIG IM SOLN,RX-161800,CDM,90734,HCPCS,636,RC,58160-0827-30,NDC,outpatient,0.5,ML,640.81,448.567,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,492.14208,fee schedule,,,
MENINGOCOCCAL A C Y&W-135 OLIG IM SOLN,RX-161800,CDM,90734,HCPCS,636,RC,58160-0827-03,NDC,outpatient,0.5,ML,640.81,448.567,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,492.14208,fee schedule,,,
HEPATITIS B VAC RECOMB ADJ 20 MCG/0.5ML IM SOSY,RX-143904,CDM,90739,HCPCS,636,RC,43528-0003-05,NDC,outpatient,0.5,ML,537.53,376.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,416.02,fee schedule,,,
HEPATITIS B VAC RECOMB ADJ 20 MCG/0.5ML IM SOSY,RX-143904,CDM,90739,HCPCS,636,RC,43528-0003-01,NDC,outpatient,0.5,ML,537.53,376.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,416.02,fee schedule,,,
HC Esophageal Motility Study- Manometry,PX-92000004,CDM,91010,CPT,920,RC,,,outpatient,,,1126,788.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,699.04,,,662.6,252.787,1055.807021,fee schedule,,,
HC Gerd Tst W/ Mucos Ph Electrod,PX-92000007,CDM,91035,CPT,920,RC,,,outpatient,,,1775,1242.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,699.04,,,662.6,398.4875,1363.2,fee schedule,,,
HC GI Trc Img Intraluminal Esophagus-Ileum W/I&R,PX-75000005,CDM,91110,CPT,750,RC,,,outpatient,,,3922,2745.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1734.15,,,1643.76,399.86,3012.096,fee schedule,,,
HC GI Imag Intraluminal Esophagus-Ileum W/I&R,PX-92000008,CDM,91110,CPT,920,RC,,,outpatient,,,3922,2745.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1734.15,,,1643.76,399.86,3012.096,fee schedule,,,
HC Rectal Sesation Tone & Compliance Test,PX-36900666,CDM,91120,CPT,369,RC,,,outpatient,,,752,526.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,189.41,,,179.53,168.824,1592,fee schedule,,,
HC Anal Pressure Record,PX-36900541,CDM,91122,CPT,920,RC,,,outpatient,,,1360,952,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,536.68,,,508.71,305.32,1592,fee schedule,,,
COVID-19 MRNA VACC (MODERNA) 50 MCG/0.5ML IM SUSY,RX-165852,CDM,91322,HCPCS,636,RC,80777-0102-01,NDC,outpatient,0.5,ML,492.72,344.904,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,417.629472,fee schedule,,,
COVID-19 MRNA VACC (MODERNA) 50 MCG/0.5ML IM SUSY,RX-165852,CDM,91322,HCPCS,636,RC,80777-0102-93,NDC,outpatient,0.5,ML,492.72,344.904,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,0.5,0.5,417.629472,fee schedule,,,
HC Eye Photography,PX-92000009,CDM,92285,CPT,920,RC,,,outpatient,,,80,56,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,17.96,416.02,other,Non-Reimbursable List,,
HC Caloric Vestibular Test Bilateral- Bithermal,PX-47100041,CDM,92537,CPT,471,RC,,,outpatient,,,1270,889,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,509.03,,,482.5,163,975.36,fee schedule,,,
HC Caloric Vestibular Test Bilateral- Monothermal,PX-47100042,CDM,92538,CPT,471,RC,,,outpatient,,,882,617.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,509.03,,,482.5,163,677.376,fee schedule,,,
HC Vestibular Eval Nystag Fovl&Perph Stim Oscil Tracking,PX-47000010,CDM,92540,CPT,470,RC,,,outpatient,,,550,385,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,305.07,,,289.17,123.475,422.4,fee schedule,,,
HC Spontaneous Nystagmus Test,PX-47000011,CDM,92541,CPT,470,RC,,,outpatient,,,155,108.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,150.83,,,142.97,34.7975,416.02,fee schedule,,,
HC Positional Nystagmus Test,PX-47000012,CDM,92542,CPT,470,RC,,,outpatient,,,155,108.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,150.83,,,142.97,34.7975,416.02,fee schedule,,,
HC Optokinetic Nystagmus Test- Bidirec- Foveal- Periph- W Record,PX-47000014,CDM,92544,CPT,470,RC,,,outpatient,,,155,108.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,150.83,,,142.97,34.7975,416.02,fee schedule,,,
HC Oscillating Tracking Test,PX-47000015,CDM,92545,CPT,470,RC,,,outpatient,,,696,487.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,150.83,,,142.97,142.97,534.528,fee schedule,,,
HC Supplemental Electrical Test,PX-47100012,CDM,92547,CPT,471,RC,,,outpatient,,,225,157.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,50.5125,416.02,other,SI=N Exclusions ,,
HC Tympanometry and Reflex Threshold Measurements,PX-47100013,CDM,92550,CPT,471,RC,,,outpatient,,,269,188.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,82.89,,,78.57,60.3905,416.02,fee schedule,,,
HC Pure Tone Audiometry- Air,PX-47100014,CDM,92552,CPT,471,RC,,,outpatient,,,230,161,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,82.89,,,78.57,51.635,416.02,fee schedule,,,
HC Audiometry- Air & Bone,PX-47100015,CDM,92553,CPT,471,RC,,,outpatient,,,295,206.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,204.67,,,194.01,61.17,416.02,fee schedule,,,
HC Speech Threshold Audiometry,PX-47100016,CDM,92555,CPT,471,RC,,,outpatient,,,144,100.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,82.89,,,78.57,32.328,416.02,fee schedule,,,
HC Speech Audiometry- Complete,PX-47100017,CDM,92556,CPT,471,RC,,,outpatient,,,132,92.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,82.89,,,78.57,29.634,416.02,fee schedule,,,
HC Comprehensive Hearing Test,PX-47100018,CDM,92557,CPT,471,RC,,,outpatient,,,519,363.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,204.67,,,194.01,116.5155,416.02,fee schedule,,,
HC Evoked Otoacoustic Emissions Screen Auto Analys,PX-47100047,CDM,92558,CPT,471,RC,,,outpatient,,,35,24.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,14.0245,7.8575,416.02,percent of total billed charges,,,
HC Stenger Test- Pure Tone,PX-47100020,CDM,92565,CPT,471,RC,,,outpatient,,,95,66.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,82.89,,,78.57,21.3275,416.02,fee schedule,,,
HC Tympanometry,PX-47100021,CDM,92567,CPT,471,RC,,,outpatient,,,125,87.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,82.89,,,78.57,28.0625,416.02,fee schedule,,,
HC Acoustic Immit Test Tympanometry/Acoust Reflex/Decay,PX-47100023,CDM,92570,CPT,471,RC,,,outpatient,,,359,251.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,204.67,,,194.01,80.5955,416.02,fee schedule,,,
HC Visual Audiometry (Vra),PX-47100027,CDM,92579,CPT,471,RC,,,outpatient,,,500,350,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,204.67,,,194.01,112.25,416.02,fee schedule,,,
HC Conditioning Play Audiometry,PX-47100028,CDM,92582,CPT,471,RC,,,outpatient,,,511,357.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,204.67,,,194.01,114.7195,416.02,fee schedule,,,
HC Select Picture Audiometry,PX-47100029,CDM,92583,CPT,471,RC,,,outpatient,,,114,79.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,82.89,,,78.57,25.593,416.02,fee schedule,,,
HC Evoked Auditory Test-Limited,PX-47100032,CDM,92587,CPT,471,RC,,,outpatient,,,624,436.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,150.83,,,142.97,128.12716,479.602522,fee schedule,,,
HC Hearing Aid Check- One Ear,PX-47100036,CDM,92592,CPT,471,RC,,,outpatient,,,116,81.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,46.4812,26.042,416.02,percent of total billed charges,,,
HC Hearing Aid Check- Both Ears,PX-47100038,CDM,92593,CPT,471,RC,,,outpatient,,,162,113.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,64.9134,36.369,416.02,percent of total billed charges,,,
HC Auditory Function- 60 Min,PX-47100039,CDM,92620,CPT,471,RC,,,outpatient,,,729,510.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,204.67,,,194.01,84.99,559.872,fee schedule,,,
HC Auditory Function- + 15 Min,PX-47100040,CDM,92621,CPT,471,RC,,,outpatient,,,122,85.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.01,416.02,other,SI=N Exclusions ,,
HC Aep Threshold Estimation Mlt Frequencies I&R,PX-47100043,CDM,92652,CPT,471,RC,,,outpatient,,,863,604.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,610.91,,,579.07,128.12716,662.784,fee schedule,,,
HC Aep Neurodiagnostic Interpretation and Report,PX-47100044,CDM,92653,CPT,471,RC,,,outpatient,,,863,604.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,610.91,,,579.07,128.12716,662.784,fee schedule,,,
HC Prq Trluml Coronary Angioplasty One Art/Branch,PX-48100012,CDM,92920,CPT,481,RC,,,outpatient,,,17563,12294.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9293.65,,,8809.27,399.86,13488.384,fee schedule,,,
HC Prq Trluml Coronary Angioplasty Addl Branch,PX-48100013,CDM,92921,CPT,481,RC,,,outpatient,,,17563,12294.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13488.384,other,Non-Reimbursable List,,
HC Prq Trluml Coronary Angio/Atherect One Art/Brnch,PX-48100014,CDM,92924,CPT,481,RC,,,outpatient,,,33484,23438.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17721.19,,,16797.58,399.86,25715.712,fee schedule,,,
HC Prq Trluml Coronary Angio/Atherec Addl Art/Brnch,PX-48100015,CDM,92925,CPT,481,RC,,,outpatient,,,32854,22997.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,25231.872,other,Non-Reimbursable List,,
HC Prq Trluml Coronary Stent W/Angio One Art/Brnch,PX-48100016,CDM,92928,CPT,481,RC,,,outpatient,,,32584,22808.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14115.73,,,13380.03,399.86,25024.512,fee schedule,,,
HC Prq Trluml Coronary Stent W/Angio Addl Art/Brnch,PX-48100017,CDM,92929,CPT,481,RC,,,outpatient,,,26673,18671.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,20484.864,other,Non-Reimbursable List,,
HC Prq Trluml Coronry Stent/Ath/Angio One Art/Brnch,PX-48100018,CDM,92933,CPT,481,RC,,,outpatient,,,33887,23720.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14115.73,,,13380.03,399.86,26793.51305,fee schedule,,,
HC Prq Trluml Coronary Stent/Ath/Angio Addl Branch,PX-48100019,CDM,92934,CPT,481,RC,,,outpatient,,,26169,18318.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,20097.792,other,SI=N Exclusions ,,
HC Prq Trluml Coronary Byp Grft Revasc One Vessel,PX-48100020,CDM,92937,CPT,481,RC,,,outpatient,,,26673,18671.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14115.73,,,13380.03,399.86,20484.864,fee schedule,,,
HC Prq Trluml Coronary Byp Grft Revasc Addl Vessel,PX-48100021,CDM,92938,CPT,481,RC,,,outpatient,,,26169,18318.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,20097.792,other,Non-Reimbursable List,,
HC Prq Trluml Coronry Chronic Occlus Revasc One Vsl,PX-48100023,CDM,92943,CPT,481,RC,,,outpatient,,,25667,17966.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,14115.73,,,13380.03,399.86,19712.256,fee schedule,,,
HC Prq Trluml Coronry Chrnic Occlus Revasc Addl Vsl,PX-48100024,CDM,92944,CPT,481,RC,,,outpatient,,,26169,18318.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,20097.792,other,Non-Reimbursable List,,
HC Heart/Lung Resuscitation (Cpr),PX-48000001,CDM,92950,CPT,480,RC,,,outpatient,,,1034,723.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.133,997.822944,other,Non-Reimbursable List,,
HC PR Cardiopulmonary Resuscitation,PX-96000048,CDM,92950,CPT,960,RC,,,outpatient,,,1034,723.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.133,997.822944,other,Non-Reimbursable List,,
HC Temporary External Pacing,PX-48000002,CDM,92953,CPT,480,RC,,,outpatient,,,1302,911.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,371.53,,,352.17,292.299,999.936,fee schedule,,,
HC Cardioversion- Elective;Extern,PX-48000003,CDM,92960,CPT,480,RC,,,outpatient,,,2006,1404.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,923.32,,,875.2,399.86,1540.608,fee schedule,,,
HC PR Cardioversion Elective Arrhythmia External,PX-96000049,CDM,92960,CPT,960,RC,,,outpatient,,,2006,1404.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,923.32,,,875.2,399.86,1540.608,fee schedule,,,
HC Prq Transluminal Coronary Mechanicl Thrombectomy,PX-48000005,CDM,92973,CPT,480,RC,,,outpatient,,,773,541.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,173.5385,593.664,other,SI=N Exclusions ,,
HC Intrav Optcl Chernce Tmgrphy W/S&I Intl Vesl,PX-36900031,CDM,92978,CPT,369,RC,,,outpatient,,,2785,1949.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,145.12362,2138.88,other,Non-Reimbursable List,,
HC Intravasc US-Heart-1st Vessel,PX-48100025,CDM,92978,CPT,481,RC,,,outpatient,,,2785,1949.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,145.12362,2138.88,other,Non-Reimbursable List,,
HC Intrav Optcal Cohrnce Tmgrphy W/S&I Adl Vesl,PX-36900032,CDM,92979,CPT,369,RC,,,outpatient,,,755,528.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,169.4975,1592,other,Non-Reimbursable List,,
HC Intravasc Coronary Sono-Addn Vessel,PX-48100026,CDM,92979,CPT,481,RC,,,outpatient,,,755,528.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,169.4975,1592,other,Non-Reimbursable List,,
HC Percut Aortic Valvuloplasty,PX-48100027,CDM,92986,CPT,481,RC,,,outpatient,,,17231,12061.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9293.65,,,8809.27,399.86,13233.408,fee schedule,,,
HC Percut Mitral Valvuloplasty,PX-48100028,CDM,92987,CPT,481,RC,,,outpatient,,,17231,12061.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9293.65,,,8809.27,399.86,16809.6787,fee schedule,,,
HC Percut Pulmonary Valvuloplasty,PX-48100029,CDM,92990,CPT,481,RC,,,outpatient,,,17231,12061.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9293.65,,,8809.27,399.86,16809.6787,fee schedule,,,
HC Electrocardiogram- Tracing,PX-73000001,CDM,93005,CPT,730,RC,,,outpatient,,,157,109.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,61.61,,,58.4,25.49469,416.02,fee schedule,,,
HC PR Electrocardiogram Report,PX-98500001,CDM,93010,CPT,985,RC,,,outpatient,,,28,19.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6.286,416.02,other,Non-Reimbursable List,,
HC Cardiac Stress Tst-Tracing Only,PX-48200001,CDM,93017,CPT,482,RC,,,outpatient,,,485,339.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,366.99,,,366.99,108.8825,479.602522,fee schedule,,,
HC Rhythm Ecg- Tracing,PX-73000003,CDM,93041,CPT,730,RC,,,outpatient,,,120,84,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,48.63,,,48.63,25.49469,416.02,fee schedule,,,
HC PR Rhythm Ecg 1-3 Leads Interpretation & Reprt On,PX-98500004,CDM,93042,CPT,985,RC,,,outpatient,,,22,15.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.939,416.02,other,Non-Reimbursable List,,
HC Ext Ecg Record Contin 48 Hr- Record,PX-73100001,CDM,93225,CPT,731,RC,,,outpatient,,,433,303.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,138.06,,,138.06,84.459332,416.02,fee schedule,,,
HC Ext Ecg Record Contin 48 Hr- Scan Analysis W Report,PX-73100002,CDM,93226,CPT,731,RC,,,outpatient,,,318,222.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,153.67,,,145.66,66.75974,416.02,fee schedule,,,
HC PR Xtrnl Ecg Continuous Rhythm W/I&R Up to 48 Hrs,PX-98500002,CDM,93227,CPT,985,RC,,,outpatient,,,63,44.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.1435,416.02,other,Non-Reimbursable List,,
HC Prgrmg Dev Eval 1 Lead Pm/Ldls Pm 1 Car Chmbr IP,PX-48000087,CDM,93279,CPT,480,RC,,,outpatient,,,118,82.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,78.43,,,74.34,26.491,416.02,fee schedule,,,
HC Program Eval Implantable in Persn Dual Ld Pacer,PX-92000010,CDM,93280,CPT,920,RC,,,outpatient,,,1217,851.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,78.43,,,74.34,41.157815,934.656,fee schedule,,,
HC Program Eval Implantable in Prsn Multi Ld Pacer,PX-48000088,CDM,93281,CPT,480,RC,,,outpatient,,,118,82.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,78.43,,,74.34,26.491,416.02,fee schedule,,,
HC Prgrmng Dev Eval Implantable in Persn 1 Ld Dfb,PX-48000089,CDM,93282,CPT,480,RC,,,outpatient,,,118,82.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,78.43,,,74.34,26.491,416.02,fee schedule,,,
HC Progrm Eval Implantable in Prsn Dual L Card/Dfb,PX-48000009,CDM,93283,CPT,480,RC,,,outpatient,,,1878,1314.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,78.43,,,74.34,41.157815,1442.304,fee schedule,,,
HC Prgrmg Eval Implantable in Person Multi Lead Dfb,PX-48000090,CDM,93284,CPT,480,RC,,,outpatient,,,118,82.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,78.43,,,74.34,26.491,416.02,fee schedule,,,
HC Prgrmg Dev Eval Scrms Phys/Qhp in Person,PX-48000091,CDM,93285,CPT,480,RC,,,outpatient,,,118,82.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,78.43,,,74.34,26.491,416.02,fee schedule,,,
HC Interrogation Eval in Person 1/Dual/Mlt Lead Pm,PX-48000010,CDM,93288,CPT,480,RC,,,outpatient,,,224,156.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,78.43,,,74.34,41.157815,416.02,fee schedule,,,
HC Interrog Eval F2f 1/Dual/Mlt Leads Impltbl Dfb,PX-48000086,CDM,93289,CPT,480,RC,,,outpatient,,,118,82.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,78.43,,,74.34,26.491,416.02,fee schedule,,,
HC Interrogation Evaluation in Person Ilr System,PX-92000011,CDM,93291,CPT,920,RC,,,outpatient,,,248,173.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,78.43,,,74.34,23.39896,416.02,fee schedule,,,
Rem Interrog Pm/Ldls Pm/Ids <90 D Tech Review,PX-48000085,CDM,93296,CPT,480,RC,,,outpatient,,,118,82.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,78.43,,,74.34,26.491,416.02,fee schedule,,,
HC Echo Xthoracic-Cong Anom-Complete,PX-48000014,CDM,93303,CPT,480,RC,,,outpatient,,,1337,935.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1290.56,,,1223.3,54.1045,1223.3,fee schedule,,,
HC PR Echo Xthoracic-Cong Anom-Complete,PX-96000009,CDM,93303,CPT,960,RC,,,outpatient,,,241,168.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1290.56,,,1223.3,54.1045,1223.3,fee schedule,,,
HC Echo Xthoracic-Cong Anom-Limited,PX-48000015,CDM,93304,CPT,480,RC,,,outpatient,,,1303,912.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,902.07,,,855.06,281.81,1040.64,fee schedule,,,
HC PR Echo Xthoracic-Cong Anom-Limited,PX-96000010,CDM,93304,CPT,960,RC,,,outpatient,,,1355,948.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,902.07,,,855.06,281.81,1040.64,fee schedule,,,
HC Echo Heart Xthoracic-Complete W Doppler W/Contrast,PX-48000016,CDM,93306,CPT,480,RC,,,outpatient,,,1347,942.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,902.07,,,855.06,54.1045,1034.496,fee schedule,,,
HC Echo Heart Xthoracic-Complete W Doppler W/O Contrast,PX-48000068,CDM,93306,CPT,480,RC,,,outpatient,,,1347,942.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,902.07,,,855.06,54.1045,1034.496,fee schedule,,,
HC PR Echo Heart Xthoracic-Complete W Doppler,PX-96000036,CDM,93306,CPT,960,RC,,,outpatient,,,241,168.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,902.07,,,855.06,54.1045,1034.496,fee schedule,,,
HC Echo Heart Xthoracic-Complete- W/O Doppler W/Contrast,PX-48000017,CDM,93307,CPT,480,RC,,,outpatient,,,1228,859.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,902.07,,,855.06,267.439885,943.104,fee schedule,,,
HC Echo Heart Xthoracic-Complete- W/O Doppler W/O Contrast,PX-48000063,CDM,93307,CPT,480,RC,,,outpatient,,,1228,859.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,902.07,,,855.06,267.439885,943.104,fee schedule,,,
HC Echo Heart Xthoracic-Limited W/Contrast,PX-48000018,CDM,93308,CPT,480,RC,,,outpatient,,,561,392.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,491.27,,,465.66,125.9445,465.66,fee schedule,,,
HC Echo Heart Xthoracic-Limited W/O Contrast,PX-48000065,CDM,93308,CPT,480,RC,,,outpatient,,,561,392.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,491.27,,,465.66,125.9445,465.66,fee schedule,,,
HC PR Echo Heart Xthoracic-Limited,PX-96000037,CDM,93308,CPT,960,RC,,,outpatient,,,561,392.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,491.27,,,465.66,125.9445,465.66,fee schedule,,,
HC Echo Heart-Transesophageal-Complete W/Contrast,PX-48000019,CDM,93312,CPT,480,RC,,,outpatient,,,1764,1234.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1290.56,,,1223.3,224.549385,1354.752,fee schedule,,,
HC Echo Heart-Transesophageal-Complete W/O Contrast,PX-48000064,CDM,93312,CPT,480,RC,,,outpatient,,,1764,1234.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1290.56,,,1223.3,224.549385,1354.752,fee schedule,,,
HC Echo R-T 2d W/Probe Placement Only,PX-48000083,CDM,93313,CPT,480,RC,,,outpatient,,,1501,1050.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,902.07,,,855.06,336.9745,1152.768,fee schedule,,,
HC 3d Echo Img&Pst-Pxessing Tee/Tte Cgen Car Anomal,PX-48000084,CDM,93319,CPT,480,RC,,,outpatient,,,352,246.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,79.024,416.02,other,Non-Reimbursable List,,
HC Doppler Echo Heart-Complete,PX-48000020,CDM,93320,CPT,480,RC,,,outpatient,,,323,226.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,72.5135,416.02,other,Non-Reimbursable List,,
HC Doppler Echo Heart-Limited-F/U,PX-48000021,CDM,93321,CPT,480,RC,,,outpatient,,,384,268.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,86.208,416.02,other,Non-Reimbursable List,,
HC Doppler Color Flow Velocity Map,PX-48000022,CDM,93325,CPT,480,RC,,,outpatient,,,744,520.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,135.906309,571.392,other,Non-Reimbursable List,,
HC Echo Heart Xthoracic- Stress/Rest W/Contrast,PX-48000023,CDM,93350,CPT,480,RC,,,outpatient,,,1384,968.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,902.07,,,855.06,224.549385,1062.912,fee schedule,,,
HC Echo Heart Xthoracic- Stress/Rest W/O Contrast,PX-48000066,CDM,93350,CPT,480,RC,,,outpatient,,,1384,968.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,902.07,,,855.06,224.549385,1062.912,fee schedule,,,
HC Echo Tthrc R-T 2d W/WO M-Mode Rest&Strs Cont Ecg W/Contrast,PX-48000024,CDM,93351,CPT,480,RC,,,outpatient,,,1785,1249.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1290.56,,,1223.3,224.549385,1370.88,fee schedule,,,
HC Echo Tthrc R-T 2d W/WO M-Mode Rest&Strs Cont Ecg W/O Contrast,PX-48000067,CDM,93351,CPT,480,RC,,,outpatient,,,1785,1249.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1290.56,,,1223.3,224.549385,1370.88,fee schedule,,,
HC Echo Tee Guid Tcat Icar/Vessel Structural Intvn,PX-48000052,CDM,93355,CPT,480,RC,,,outpatient,,,778,544.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.661,597.504,other,SI=N Exclusions ,,
HC Myocrd Strain Img Speckle Trck Assmt Myocrd Mech,PX-48000480,CDM,93356,CPT,480,RC,,,outpatient,,,1077,753.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,241.7865,827.136,other,SI=N Exclusions ,,
HC Right Heart Cath O2 Saturation & Cardiac Output,PX-48100030,CDM,93451,CPT,481,RC,,,outpatient,,,9177,6423.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8303.33,,,7870.4,399.86,7870.4,fee schedule,,,
HC Cath Place/Coronary Angio- Img Super/Interp,PX-48100031,CDM,93454,CPT,481,RC,,,outpatient,,,10988,7691.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8303.33,,,7870.4,399.86,8438.784,fee schedule,,,
HC Cath Place/Coronary Angio- Img Super/Interp- Bypass Angio,PX-48100032,CDM,93455,CPT,481,RC,,,outpatient,,,10988,7691.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8303.33,,,7870.4,399.86,8438.784,fee schedule,,,
HC Cath Place/Coronary Angio- Img Super/Interp-W Right Heart Cath,PX-48100033,CDM,93456,CPT,481,RC,,,outpatient,,,10988,7691.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8303.33,,,7870.4,399.86,8438.784,fee schedule,,,
HC Cath Place/Coron Angio- Img Super/Interp- Bypass Angio-W R Heart Cath,PX-48100034,CDM,93457,CPT,481,RC,,,outpatient,,,9755,6828.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8303.33,,,7870.4,399.86,7870.4,fee schedule,,,
HC Cath Place/Coron Angio- Img Super/Interp-W Left Heart Ventriculography,PX-48100035,CDM,93458,CPT,481,RC,,,outpatient,,,9755,6828.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8303.33,,,7870.4,399.86,7870.4,fee schedule,,,
HC Cath Place/Coron Angio- Img Super/Interp- Bypass Angio-W L Hrt Ventric,PX-48100036,CDM,93459,CPT,481,RC,,,outpatient,,,10988,7691.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8303.33,,,7870.4,399.86,8438.784,fee schedule,,,
HC Cath Place/Coron Angio- Img Super/Interp-R&L Hrt Cath- L Hrt Ventric,PX-48100037,CDM,93460,CPT,481,RC,,,outpatient,,,10988,7691.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8303.33,,,7870.4,399.86,8438.784,fee schedule,,,
HC Cath Place/Cor Ang-Img Supr/Intrp-Bypass Ang- R&L Cath- L Hrt Ventric,PX-48100038,CDM,93461,CPT,481,RC,,,outpatient,,,10988,7691.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8303.33,,,7870.4,399.86,8438.784,fee schedule,,,
HC Left Heart Cath by Transeptal Puncture,PX-48100039,CDM,93462,CPT,481,RC,,,outpatient,,,10365,7255.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7960.32,other,SI=N Exclusions ,,
HC Insert/Place Flow Direct Cath,PX-36900885,CDM,93503,CPT,369,RC,,,outpatient,,,2998,2098.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2671.63,,,2532.39,399.86,2532.39,fee schedule,,,
HC Insert/Place Flow Direct Cath,PX-48000025,CDM,93503,CPT,480,RC,,,outpatient,,,2998,2098.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2671.63,,,2532.39,399.86,2532.39,fee schedule,,,
HC Inject Select Cor Angio During Congenital Heart Cath,PX-48100044,CDM,93563,CPT,481,RC,,,outpatient,,,2542,1779.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,1952.256,other,SI=N Exclusions ,,
HC Inject Select Cor/Graft Angio During Congenital Heart Cath,PX-48100045,CDM,93564,CPT,481,RC,,,outpatient,,,1018,712.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,228.541,1592,other,SI=N Exclusions ,,
HC Inject Select Left Vent/Atrial Angio During Heart Cath,PX-48100046,CDM,93565,CPT,481,RC,,,outpatient,,,510,357,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,114.495,1592,other,SI=N Exclusions ,,
HC Inject Select Right Vent/Atrial Angio During Heart Cath,PX-48100047,CDM,93566,CPT,481,RC,,,outpatient,,,1018,712.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,228.541,1592,other,SI=N Exclusions ,,
HC Inject Supravalvular Aortography During Heart Cath,PX-48100048,CDM,93567,CPT,481,RC,,,outpatient,,,1498,1048.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,235.074116,1592,other,SI=N Exclusions ,,
HC Heart Flow Reserv Measure-Init Vessl,PX-48000026,CDM,93571,CPT,480,RC,,,outpatient,,,6936,4855.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,5638.7,other,Non-Reimbursable List,,
HC Heart Flow Reserv Measure-Addn Vessl,PX-48000027,CDM,93572,CPT,480,RC,,,outpatient,,,2051,1435.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,1575.168,other,Non-Reimbursable List,,
HC Perc Clos-Cong Interatrial Commun W/Impl,PX-48100049,CDM,93580,CPT,481,RC,,,outpatient,,,53254,37277.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17980.76,,,17043.62,399.86,40899.072,fee schedule,,,
HC Perc Closure-Cong Vsd W/Implant,PX-48100050,CDM,93581,CPT,481,RC,,,outpatient,,,53254,37277.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17980.76,,,17043.62,399.86,40899.072,fee schedule,,,
HC Percutan Transcath Closure Pat Duct Arteriosus,PX-36900556,CDM,93582,CPT,369,RC,,,outpatient,,,52790,36953,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,27662.69,,,26220.93,399.86,40542.72,fee schedule,,,
HC Percutan Transcath Closure Pat Duct Arteriosus,PX-48100051,CDM,93582,CPT,481,RC,,,outpatient,,,52790,36953,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,27662.69,,,26220.93,399.86,40542.72,fee schedule,,,
HC Percutaneous Transcatheter Septal Reduction Ther,PX-48100055,CDM,93583,CPT,481,RC,,,outpatient,,,16899,11829.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,6771.4293,399.86,12978.432,percent of total billed charges,,,
HC Heart Pacing- Mapping,PX-48000042,CDM,93631,CPT,480,RC,,,outpatient,,,8496,5947.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6909.98,other,Non-Reimbursable List,,
HC Eval Cardiovert Leads-Initial,PX-48000043,CDM,93640,CPT,480,RC,,,outpatient,,,5892,4124.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,4525.056,other,Non-Reimbursable List,,
HC Eval Cardiovert Leads/Puls Gen,PX-48000044,CDM,93641,CPT,480,RC,,,outpatient,,,3075,2152.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,2361.6,other,Non-Reimbursable List,,
HC Electrophys Eval-Cardioverter,PX-48000045,CDM,93642,CPT,480,RC,,,outpatient,,,3083,2158.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1629.45,,,1544.53,399.86,2367.744,fee schedule,,,
HC Tilt Table Evaluation,PX-48000049,CDM,93660,CPT,480,RC,,,outpatient,,,3083,2158.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,701.16,,,664.62,399.86,2367.744,fee schedule,,,
HC Intracard Echo- Ther/Dx Intervent,PX-48000050,CDM,93662,CPT,480,RC,,,outpatient,,,7689,5382.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10671.09667,other,Non-Reimbursable List,,
HC Analyze Pacer Sys,PX-48000051,CDM,93724,CPT,480,RC,,,outpatient,,,1217,851.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,78.43,,,74.34,73.54,934.656,fee schedule,,,
HC Outpatient Cardiac Rehab W/O Cont Ecg Monitor,PX-94300002,CDM,93797,CPT,943,RC,,,outpatient,,,255,178.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,184.6,,,174.98,57.2475,416.02,fee schedule,,,
HC Outpatient Cardiac Rehab W/Cont Ecg Monitoring,PX-94300003,CDM,93798,CPT,943,RC,,,outpatient,,,271,189.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,184.6,,,174.98,60.8395,416.02,fee schedule,,,
HC Duplex Scan Extracranial-Bilat,PX-92100008,CDM,93880,CPT,921,RC,,,outpatient,,,915,640.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,357.46,,,338.83,199.512292,702.72,fee schedule,,,
HC Duplex Scan Extracranial-Limited,PX-92100010,CDM,93882,CPT,921,RC,,,outpatient,,,915,640.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,357.46,,,338.83,119.991125,702.72,fee schedule,,,
HC Transcran Doppler Intracran Art,PX-92100011,CDM,93886,CPT,921,RC,,,outpatient,,,1137,795.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,357.46,,,338.83,255.2565,873.216,fee schedule,,,
HC Transcran Doppler Intracran-Limited,PX-92100013,CDM,93888,CPT,921,RC,,,outpatient,,,428,299.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,149.16,,,141.39,96.086,686,fee schedule,,,
HC Transcran Doppl Intracran- Vasoreact,PX-92100015,CDM,93890,CPT,921,RC,,,outpatient,,,952,666.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,229.44,,,217.48,213.724,731.136,fee schedule,,,
HC Non-Invas Physiologic Std Extremity Art 1-2 Level,PX-92100017,CDM,93922,CPT,921,RC,,,outpatient,,,915,640.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,153.67,,,145.66,135.906309,702.72,fee schedule,,,
HC Non-Invasive Physiologic Study Extremity 3 Levels,PX-92100019,CDM,93923,CPT,921,RC,,,outpatient,,,701,490.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,250.9,,,237.82,121.132463,686,fee schedule,,,
HC Non-Invasive Lower Extrem Art Stress/Rest- Complete-Bilateral,PX-92100020,CDM,93924,CPT,921,RC,,,outpatient,,,915,640.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,250.9,,,237.82,135.906309,775.5705,fee schedule,,,
HC Duplex Lo Extrem Art Bilat,PX-92100022,CDM,93925,CPT,921,RC,,,outpatient,,,915,640.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,357.46,,,338.83,199.512292,702.72,fee schedule,,,
HC Duplex Lo Extrem Art Unilat/Ltd,PX-92100024,CDM,93926,CPT,921,RC,,,outpatient,,,441,308.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,229.44,,,217.48,99.0045,686,fee schedule,,,
HC Duplex Up Extrem Art Bilat,PX-92100025,CDM,93930,CPT,921,RC,,,outpatient,,,842,589.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,357.46,,,338.83,135.906309,686,fee schedule,,,
HC Duplex Up Extrem Art Bilat,PX-92100026,CDM,93930,CPT,921,RC,,,outpatient,,,842,589.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,357.46,,,338.83,135.906309,686,fee schedule,,,
HC Duplex Up Extrem Art Unilat/Ltd,PX-92100028,CDM,93931,CPT,921,RC,,,outpatient,,,915,640.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,229.44,,,217.48,119.991125,702.72,fee schedule,,,
HC Duplex Extrem Venous-Bilat,PX-92100031,CDM,93970,CPT,921,RC,,,outpatient,,,758,530.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,357.46,,,338.83,170.171,686,fee schedule,,,
HC Duplex Extrem Venous-Bilat,PX-92100032,CDM,93970,CPT,921,RC,,,outpatient,,,758,530.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,357.46,,,338.83,170.171,686,fee schedule,,,
HC Duplex Extrem Venous-Uni or Ltd,PX-92100034,CDM,93971,CPT,921,RC,,,outpatient,,,915,640.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,229.44,,,217.48,119.991125,702.72,fee schedule,,,
HC Duplex Abd/Pel Vasc Study-Complete,PX-92100036,CDM,93975,CPT,921,RC,,,outpatient,,,816,571.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,357.46,,,338.83,183.192,686,fee schedule,,,
HC Duplex Abd/Pel Vasc Study-Limitd,PX-92100037,CDM,93976,CPT,921,RC,,,outpatient,,,418,292.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,357.46,,,338.83,93.841,686,fee schedule,,,
HC Duplex Large Vessel(S)-Complete,PX-92100039,CDM,93978,CPT,921,RC,,,outpatient,,,915,640.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,357.46,,,338.83,199.512292,702.72,fee schedule,,,
HC Duplex Large Vessel(S)-Limited,PX-92100041,CDM,93979,CPT,921,RC,,,outpatient,,,387,270.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,229.44,,,217.48,86.8815,686,fee schedule,,,
HC Duplex Hemodialysis Access,PX-92100042,CDM,93990,CPT,921,RC,,,outpatient,,,614,429.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,229.44,,,217.48,119.991125,686,fee schedule,,,
HC Breathing Capacity Test,PX-46000002,CDM,94010,CPT,460,RC,,,outpatient,,,295,206.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,145.24,,,137.67,66.2275,416.02,fee schedule,,,
HC Eval of Bronchospasm,PX-46000003,CDM,94060,CPT,460,RC,,,outpatient,,,446,312.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,233.18,,,221.03,100.127,479.602522,fee schedule,,,
HC Eval of Bronchospasm-Prolonged,PX-46000004,CDM,94070,CPT,460,RC,,,outpatient,,,925,647.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,415.49,,,393.84,163,710.4,fee schedule,,,
HC Xers Tst Brncspsm Pre&Post Spmtry&Pls Ox W/Ecg,PX-46000023,CDM,94617,CPT,460,RC,,,outpatient,,,392,274.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,242.65,,,230.01,88.004,416.02,fee schedule,,,
HC Pulmonary Stress Testing,PX-46000022,CDM,94618,CPT,460,RC,,,outpatient,,,392,274.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,242.65,,,230.01,88.004,416.02,fee schedule,,,
HC Xers Tst Brncspsm Pre&Post Spmtry&Pls Ox WO /Ecg,PX-46000024,CDM,94619,CPT,460,RC,,,outpatient,,,182,127.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,128.58,,,121.88,40.859,416.02,fee schedule,,,
HC Inhal Rx- Airway Obst/Dx Sputum Induct,PX-41000006,CDM,94640,CPT,410,RC,,,outpatient,,,494,345.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,81.06,,,76.84,59.92,416.02,fee schedule,,,
HC Plethysmography Lung Volumes W/WO Airway Resist,PX-46000012,CDM,94726,CPT,460,RC,,,outpatient,,,446,312.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,104.09,,,98.67,98.67,479.602522,fee schedule,,,
HC Gas Dilut/Washout Lung Vol W/WO Distrib Vent&Vol,PX-46000013,CDM,94727,CPT,460,RC,,,outpatient,,,295,206.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,104.09,,,98.67,66.2275,416.02,fee schedule,,,
HC Diffusing Capacity,PX-46000014,CDM,94729,CPT,460,RC,,,outpatient,,,265,185.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,145.24,,,137.67,59.4925,416.02,fee schedule,,,
HC Noninvasv Oxygen Satur;Single,PX-46000015,CDM,94760,CPT,460,RC,,,outpatient,,,54,37.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.123,416.02,other,Non-Reimbursable List,,
HC Noninvasv Oxygen Satur-Multiple,PX-46000016,CDM,94761,CPT,460,RC,,,outpatient,,,90,63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.205,416.02,other,Non-Reimbursable List,,
HC Car Seat/Bed Test Initial 60 Mins,PX-46000019,CDM,94780,CPT,460,RC,,,outpatient,,,194,135.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,114.67,,,108.7,43.553,416.02,fee schedule,,,
HC Car Seat/Bed Test Each Addl 30 Min,PX-46000020,CDM,94781,CPT,460,RC,,,outpatient,,,194,135.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,43.553,416.02,other,Non-Reimbursable List,,
HC Pulmonary Service/Procedure,PX-41000002,CDM,94799,CPT,410,RC,,,outpatient,,,367,256.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,335.96,,,22.74,22.74,416.02,fee schedule,,,
HC Eeg W/O Video by Tech 2-12 Hr Unmonitored,PX-74000012,CDM,95705,CPT,740,RC,,,outpatient,,,827,578.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,335.96,,,318.45,185.6615,635.136,fee schedule,,,
HC Eeg W/O Video by Tech 2-12 Hr Intermittent Mntr,PX-74000013,CDM,95706,CPT,740,RC,,,outpatient,,,827,578.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,646.97,,,613.25,185.6615,635.136,fee schedule,,,
HC Eeg W/O Video by Tech 2-12hr Continuous R-T Mntr,PX-74000014,CDM,95707,CPT,740,RC,,,outpatient,,,827,578.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,646.97,,,613.25,185.6615,635.136,fee schedule,,,
HC Eeg W/O Vid by Tech Ea Incr 12-26hr Unmonitored,PX-74000011,CDM,95708,CPT,740,RC,,,outpatient,,,1649,1154.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1116.77,,,1058.57,370.2005,1266.432,fee schedule,,,
HC Eeg W/O Vid by Tech Ea Incr 12-26 Hr Intmt Mntr,PX-74000015,CDM,95709,CPT,740,RC,,,outpatient,,,1585,1109.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1116.77,,,1058.57,355.8325,1217.28,fee schedule,,,
HC Eeg W/O Vid Tech Ea Incr 12-26 Hr Cont R-T Mntr,PX-74000016,CDM,95710,CPT,740,RC,,,outpatient,,,1585,1109.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1116.77,,,1058.57,355.8325,1217.28,fee schedule,,,
HC Electroencephalogram Extend Monitoring 41-60 Min,PX-74000008,CDM,95812,CPT,740,RC,,,outpatient,,,812,568.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,358.25,,,358.25,182.294,623.616,fee schedule,,,
HC Eeg >1 Hr,PX-74000002,CDM,95813,CPT,740,RC,,,outpatient,,,958,670.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,358.25,,,358.25,215.071,735.744,fee schedule,,,
HC Eeg-W/Awake & Drowsy Record,PX-74000003,CDM,95816,CPT,740,RC,,,outpatient,,,701,490.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,358.25,,,358.25,157.3745,538.368,fee schedule,,,
HC Eeg-W/Awake & Asleep Record,PX-74000004,CDM,95819,CPT,740,RC,,,outpatient,,,786,550.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,358.25,,,358.25,176.457,603.648,fee schedule,,,
HC Eeg-Coma/Sleep Record Only,PX-74000005,CDM,95822,CPT,740,RC,,,outpatient,,,675,472.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,358.25,,,358.25,151.5375,518.4,fee schedule,,,
HC Eeg Eval Cerebral Death,PX-74000006,CDM,95824,CPT,740,RC,,,outpatient,,,675,472.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,381.93,,,381.93,151.5375,829.50194,fee schedule,,,
HC Needle Emg Ea Extremity W/Paraspinl Area Limited,PX-92200011,CDM,95885,CPT,922,RC,,,outpatient,,,332,232.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.817,570,other,SI=N Exclusions ,,
HC PR Needle Emg Ea Extremity W/Paraspinl Area Limited,PX-96000021,CDM,95885,CPT,960,RC,,,outpatient,,,66,46.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.817,570,other,SI=N Exclusions ,,
HC Needle Emg Ea Extremty W/Paraspinl Area Complete,PX-92200012,CDM,95886,CPT,922,RC,,,outpatient,,,332,232.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,30.083,570,other,SI=N Exclusions ,,
HC PR Needle Emg Ea Extremty W/Paraspinl Area Complete,PX-96000022,CDM,95886,CPT,960,RC,,,outpatient,,,134,93.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,30.083,570,other,SI=N Exclusions ,,
HC Needle Emg Nonextremty Mscles W/Nerve Conduction,PX-92200013,CDM,95887,CPT,922,RC,,,outpatient,,,180,126,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.4295,570,other,SI=N Exclusions ,,
HC PR Needle Emg Nonextremty Mscles W/Nerve Conduction,PX-96000023,CDM,95887,CPT,960,RC,,,outpatient,,,91,63.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.4295,570,other,SI=N Exclusions ,,
HC Nerve Conduction Studies 1-2 Studies,PX-92200028,CDM,95907,CPT,922,RC,,,outpatient,,,760,532,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,99.59,,,94.4,94.4,583.68,fee schedule,,,
HC Motor &/Sens 7-8 Nrv Cndj Preconf Eltrode Limb,PX-92200017,CDM,95910,CPT,922,RC,,,outpatient,,,696,487.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,99.59,,,94.4,94.4,570,fee schedule,,,
HC PR Motor &/Sens 7-8 Nrv Cndj Preconf Eltrode Limb,PX-96000027,CDM,95910,CPT,960,RC,,,outpatient,,,724,506.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,99.59,,,94.4,94.4,570,fee schedule,,,
HC Ionm Remote/Nearby/>1 Patient in or per Hour,PX-92000015,CDM,95941,CPT,920,RC,,,outpatient,,,879,615.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,197.3355,675.072,other,SI=N Exclusions ,,
HC Eeg Digital Anylysis,PX-74000010,CDM,95957,CPT,740,RC,,,outpatient,,,696,487.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,156.252,534.528,other,Non-Reimbursable List,,
HC IV Inf- Hydration- 31 Min to 1 Hr,PX-26000001,CDM,96360,CPT,260,RC,,,outpatient,,,334,233.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,172.54,,,163.55,74.983,416.02,fee schedule,,,
HC IV Inf- Hydration- Each Add'l Hr,PX-26000002,CDM,96361,CPT,260,RC,,,outpatient,,,89,62.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,62.4,,,59.14,19.9805,585.854902,fee schedule,,,
HC IV Inf- Therapy - Init to 1 Hr (Spec Drug),PX-26000003,CDM,96365,CPT,260,RC,,,outpatient,,,418,292.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,337.83,,,320.22,93.841,416.02,fee schedule,,,
HC IV Inf- Therapy- Each Add Hr (Spec Drug),PX-26000004,CDM,96366,CPT,260,RC,,,outpatient,,,132,92.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,62.4,,,59.14,29.634,585.854902,fee schedule,,,
HC IV Infusion- Therap/Proph/Diagnost-Add Infusion-1st Hour,PX-26000005,CDM,96367,CPT,260,RC,,,outpatient,,,183,128.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,90.39,,,85.68,41.0835,416.02,fee schedule,,,
HC IV Infusion- Therap/Proph/Diagnost-Concurrent Infusion,PX-26000006,CDM,96368,CPT,260,RC,,,outpatient,,,109,76.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,24.4705,416.02,other,Non-Reimbursable List,,
HC Therapeutic Prophylactic/Dx Injection Subq/Im,PX-26000007,CDM,96372,CPT,260,RC,,,outpatient,,,162,113.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,90.39,,,85.68,16.16,416.02,fee schedule,,,
HC Injection-Therap/Proph/Diagnost- Intra-Arterial,PX-26000008,CDM,96373,CPT,260,RC,,,outpatient,,,334,233.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,90.39,,,85.68,74.983,416.02,fee schedule,,,
HC IV Push- Initial,PX-26000009,CDM,96374,CPT,260,RC,,,outpatient,,,309,216.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,90.39,,,85.68,69.3705,416.02,fee schedule,,,
HC IV Push- Ea Add Seq- of New Sub Drug,PX-26000010,CDM,96375,CPT,260,RC,,,outpatient,,,105,73.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,90.39,,,85.68,23.5725,416.02,fee schedule,,,
HC Injection-Therap/Proph/Diagnost- IV Push- Ea Add- Same Drug,PX-26000011,CDM,96376,CPT,260,RC,,,outpatient,,,303,212.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,68.0235,416.02,other,Non-Reimbursable List,,
HC Chemother-Non-Hormone Anti-Neopl- Sub-Q/Im,PX-33100001,CDM,96401,CPT,331,RC,,,outpatient,,,222,155.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,90.39,,,85.68,49.839,416.02,fee schedule,,,
HC Chemother- IV Push- Sngl Drug,PX-33100003,CDM,96409,CPT,331,RC,,,outpatient,,,691,483.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,337.83,,,320.22,155.1295,530.688,fee schedule,,,
HC Chemother- IV Infusion- 1 Hr,PX-33500001,CDM,96413,CPT,335,RC,,,outpatient,,,724,506.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,532.48,,,504.73,162.538,556.032,fee schedule,,,
HC Chemother- IV Infusion- Ea Add Hr,PX-33500002,CDM,96415,CPT,335,RC,,,outpatient,,,187,130.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,90.39,,,85.68,41.9815,585.854902,fee schedule,,,
HC Chemother-Ia Push Technique,PX-33100006,CDM,96420,CPT,331,RC,,,outpatient,,,668,467.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,172.54,,,163.55,70.143083,517.481916,fee schedule,,,
HC Chemother-Cns-W/Lumbar Puncture,PX-33100005,CDM,96450,CPT,331,RC,,,outpatient,,,657,459.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,532.48,,,504.73,147.4965,585.854902,fee schedule,,,
HC Ultraviolet Light Therapy,PX-94000005,CDM,96900,CPT,940,RC,,,outpatient,,,530,371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,85.82,,,81.35,34.385146,416.02,fee schedule,,,
HC Mechanical Traction Therapy,PX-42100004,CDM,97012,CPT,421,RC,,,outpatient,,,245,171.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,36.94,,,35.01,14.38,416.02,fee schedule,,,
HC Electric Stimulation Therapy,PX-42100005,CDM,97014,CPT,421,RC,,,outpatient,,,123,86.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,49.2861,27.6135,416.02,percent of total billed charges,,,
HC Electrical Stimulation,PX-42100010,CDM,97032,CPT,421,RC,,,outpatient,,,123,86.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,44.01,,,41.71,14.73,416.02,fee schedule,,,
HC Electric Current Therapy,PX-42100011,CDM,97033,CPT,421,RC,,,outpatient,,,185,129.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,76.23,,,72.26,20.02,416.02,fee schedule,,,
HC Ultrasound Therapy,PX-42000005,CDM,97035,CPT,420,RC,,,outpatient,,,115,80.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29.08,,,27.57,14.44,416.02,fee schedule,,,
HC Ultrasound Therapy,PX-42100013,CDM,97035,CPT,421,RC,,,outpatient,,,115,80.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29.08,,,27.57,14.44,416.02,fee schedule,,,
HC Therapeutic Exercises,PX-42000006,CDM,97110,CPT,420,RC,,,outpatient,,,197,137.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,73.88,,,70.03,30.33,416.02,fee schedule,,,
HC Therapeutic Exercises,PX-42100014,CDM,97110,CPT,421,RC,,,outpatient,,,197,137.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,73.88,,,70.03,30.33,416.02,fee schedule,,,
HC Neuromusc Reeducat-1+ Areas- Ea 15 Min,PX-42000007,CDM,97112,CPT,420,RC,,,outpatient,,,115,80.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,77.02,,,73,25.8175,416.02,fee schedule,,,
HC Neuromusc Reeducat-1+ Areas- Ea 15 Min,PX-42100015,CDM,97112,CPT,421,RC,,,outpatient,,,115,80.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,77.02,,,73,25.8175,416.02,fee schedule,,,
HC Gait Training Therapy,PX-42100017,CDM,97116,CPT,421,RC,,,outpatient,,,115,80.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,25.8175,416.02,other,Non-Reimbursable List,,
HC Manual Ther Tech-1+Regions-Ea 15 Min,PX-42000008,CDM,97140,CPT,420,RC,,,outpatient,,,140,98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,69.16,,,65.56,27.89,416.02,fee schedule,,,
HC Manual Ther Tech-1+Regions-Ea 15 Min,PX-42100018,CDM,97140,CPT,421,RC,,,outpatient,,,140,98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,69.16,,,65.56,27.89,416.02,fee schedule,,,
HC Group Therapeutic Procedures,PX-42000009,CDM,97150,CPT,420,RC,,,outpatient,,,130,91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,40.08,,,37.99,18.56,416.02,fee schedule,,,
HC Group Therapeutic Procedures,PX-42300001,CDM,97150,CPT,423,RC,,,outpatient,,,130,91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,40.08,,,37.99,18.56,416.02,fee schedule,,,
HC Pt Eval Low Complex,PX-42400003,CDM,97161,CPT,424,RC,,,outpatient,,,260,182,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,104.182,58.37,416.02,percent of total billed charges,,,
HC Pt Eval Mod Complex,PX-42400004,CDM,97162,CPT,424,RC,,,outpatient,,,260,182,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,104.182,58.37,416.02,percent of total billed charges,,,
HC Pt Eval High Complex,PX-42400005,CDM,97163,CPT,424,RC,,,outpatient,,,260,182,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,104.182,58.37,416.02,percent of total billed charges,,,
HC Pt Re-Eval Est Plan Care,PX-42400006,CDM,97164,CPT,424,RC,,,outpatient,,,231,161.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.8595,416.02,other,Non-Reimbursable List,,
HC Therapeut Actvity Direct Pt Contact Each 15 Min,PX-42100019,CDM,97530,CPT,421,RC,,,outpatient,,,115,80.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,80.95,,,76.73,25.8175,416.02,fee schedule,,,
HC Self-Care/Home Mgmt Training Each 15 Minutes,PX-42100020,CDM,97535,CPT,421,RC,,,outpatient,,,115,80.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,80.16,,,75.98,25.8175,416.02,fee schedule,,,
HC Orthotic Mgmt and Training- Each 15 Min,PX-42100027,CDM,97760,CPT,421,RC,,,outpatient,,,115,80.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,88.82,,,84.19,25.8175,416.02,fee schedule,,,
HC Prosthetic Training- Each 15 Min,PX-42100028,CDM,97761,CPT,421,RC,,,outpatient,,,104,72.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,77.02,,,73,23.348,416.02,fee schedule,,,
HC Med Nutr Ther- 1st- Indiv- Ea 15 Min,PX-94200006,CDM,97802,CPT,942,RC,,,outpatient,,,182,127.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,81.73,,,77.47,34.45,416.02,fee schedule,,,
HC Med Nutr Ther- Subsq- Indiv- Ea 15 Min,PX-94200007,CDM,97803,CPT,942,RC,,,outpatient,,,106,74.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,70.74,,,67.05,23.797,416.02,fee schedule,,,
HC Med Nutr Ther- Group- Ea 30 Min,PX-94200008,CDM,97804,CPT,942,RC,,,outpatient,,,52,36.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,36.15,,,34.27,11.674,416.02,fee schedule,,,
HC Mod Sed Same Phys/Qhp <5 Yrs,PX-37000019,CDM,99151,CPT,370,RC,,,outpatient,,,230,161,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.635,416.02,other,Non-Reimbursable List,,
HC Mod Sed Same Phys/Qhp 5/>Yrs,PX-37000020,CDM,99152,CPT,370,RC,,,outpatient,,,240,168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,53.88,416.02,other,Non-Reimbursable List,,
HC Mod Sed Same Phys/Qhp Ea,PX-37000021,CDM,99153,CPT,370,RC,,,outpatient,,,240,168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,53.88,416.02,other,Non-Reimbursable List,,
HC Mod Sed Oth Phys/Qhp <5 Yrs,PX-37000022,CDM,99155,CPT,370,RC,,,outpatient,,,361,252.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,81.0445,416.02,other,Non-Reimbursable List,,
HC Mod Sed Oth Phys/Qhp 5/>Yrs,PX-37000023,CDM,99156,CPT,370,RC,,,outpatient,,,240,168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,53.88,416.02,other,Non-Reimbursable List,,
HC Mod Sed Other Phys/Qhp Ea,PX-37000024,CDM,99157,CPT,370,RC,,,outpatient,,,330,231,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,74.085,416.02,other,Non-Reimbursable List,,
HC Phlebotomy,PX-94000006,CDM,99195,CPT,940,RC,,,outpatient,,,312,218.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,113.5,,,107.58,70.044,416.02,fee schedule,,,
HC Office/Outpatient New Sf Mdm 15-29 Minutes,PX-51000025,CDM,99202,CPT,510,RC,,,outpatient,,,387,270.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,83.42,,,82.56,82.56,416.02,fee schedule,,,
HC Office/Outpatient New Low Mdm 30-44 Minutes,PX-51000026,CDM,99203,CPT,510,RC,,,outpatient,,,573,401.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,128,,,126.74,126.37,473.871,fee schedule,,,
HC Office/Outpatient New Moderate Mdm 45-59 Minutes,PX-51000027,CDM,99204,CPT,510,RC,,,outpatient,,,838,586.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,190.44,,,189.11,179.35,693.026,fee schedule,,,
HC Office/Outpatient New High Mdm 60-74 Minutes,PX-51000028,CDM,99205,CPT,510,RC,,,outpatient,,,1192,834.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,251.79,,,249.6,146.954008,985.784,fee schedule,,,
HC Office/Outpatient Est Pt May Not Req Phys/Qhp,PX-51000029,CDM,99211,CPT,510,RC,,,outpatient,,,287,200.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24.71,,,22.74,18.1184,416.02,fee schedule,,,
HC Office/Outpatient Est Pt May Not Req Phys/Qhp,PX-76100002,CDM,99211,CPT,761,RC,,,outpatient,,,287,200.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24.71,,,22.74,18.1184,416.02,fee schedule,,,
HC Office/Outpatient Est Pt May Not Req Phys/Qhp,PX-94200014,CDM,99211,CPT,942,RC,,,outpatient,,,287,200.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,24.71,,,22.74,18.1184,416.02,fee schedule,,,
HC Office/Outpatient Established Sf Mdm 10-19 Min,PX-51000030,CDM,99212,CPT,510,RC,,,outpatient,,,394,275.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,59.98,,,55.89,50.2428,416.02,fee schedule,,,
HC Office/Outpatient Established Sf Mdm 10-19 Min,PX-94200015,CDM,99212,CPT,942,RC,,,outpatient,,,394,275.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,59.98,,,55.89,50.2428,416.02,fee schedule,,,
HC PR Office/Outpatient Established Sf Mdm 10-19 Min,PX-98800012,CDM,99212,CPT,988,RC,,,outpatient,,,373,261.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,59.98,,,55.89,50.2428,416.02,fee schedule,,,
HC Office/Outpatient Established Low Mdm 20-29 Min,PX-51000031,CDM,99213,CPT,510,RC,,,outpatient,,,431,301.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.97,,,90.68,90.68,416.02,fee schedule,,,
HC Office/Outpatient Established Low Mdm 20-29 Min,PX-94200016,CDM,99213,CPT,942,RC,,,outpatient,,,431,301.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,95.97,,,90.68,90.68,416.02,fee schedule,,,
HC Office/Outpatient Established Mod Mdm 30-39 Min,PX-51000032,CDM,99214,CPT,510,RC,,,outpatient,,,467,326.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,135.27,,,128.59,104.8415,416.02,fee schedule,,,
HC Office/Outpatient Established Mod Mdm 30-39 Min,PX-94200020,CDM,99214,CPT,942,RC,,,outpatient,,,467,326.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,135.27,,,128.59,104.8415,416.02,fee schedule,,,
HC Office/Outpatient Established High Mdm 40-54 Min,PX-51000033,CDM,99215,CPT,510,RC,,,outpatient,,,829,580.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,190.46,,,179.41,169.273,685.583,fee schedule,,,
HC Office/Outpatient Established High Mdm 40-54 Min,PX-94200021,CDM,99215,CPT,942,RC,,,outpatient,,,754,527.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,190.46,,,179.41,169.273,685.583,fee schedule,,,
HC Critical Care Ill/Injured Patient Init 30-74 Min,PX-76000001,CDM,99291,CPT,760,RC,,,outpatient,,,3157,2209.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1678.05,39.5,,1247.02,318.748996,2424.576,percent of total billed charges,,,
HC PR Critical Care Ill/Injured Patient Init 30-74 Min,PX-96000052,CDM,99291,CPT,960,RC,,,outpatient,,,3157,2209.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1678.05,39.5,,1247.02,318.748996,2424.576,percent of total billed charges,,,
HC Critical Care Ill/Injured Patient Addl 30 Min,PX-76000002,CDM,99292,CPT,760,RC,,,outpatient,,,911,637.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,204.5195,699.648,other,Non-Reimbursable List,,
HC PR Critical Care Ill/Injured Patient Addl 30 Min,PX-96000053,CDM,99292,CPT,960,RC,,,outpatient,,,911,637.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,204.5195,699.648,other,Non-Reimbursable List,,
HC Tobacco Use Cessation Intermediate 3-10 Minutes,PX-94200022,CDM,99406,CPT,942,RC,,,outpatient,,,214,149.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,31.31797,416.02,other,Non-Reimbursable List,,
HC Tobacco Use Cessation Intensive >10 Minutes,PX-94200025,CDM,99407,CPT,942,RC,,,outpatient,,,214,149.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,51.65,,,48.96,31.31797,416.02,fee schedule,,,
HC Arterial Stent- Xcranial Vertebral/ Thoracic Carotid- 1st Vessel,PX-36900026,CDM,0075T,CPT,369,RC,,,outpatient,,,774,541.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,310.1418,173.763,2998,percent of total billed charges,,,
HC Arterial Stent- Xcranial Vertebral/ Thoracic Carotid- Ea Add,PX-36900027,CDM,0076T,CPT,369,RC,,,outpatient,,,161,112.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,64.5127,36.1445,2998,percent of total billed charges,,,
HC Transluminal Peripheral Atherectomy- Renal Artery,PX-36900028,CDM,0234T,CPT,369,RC,,,outpatient,,,26415,18490.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17721.19,,,16797.58,399.86,22389.354,fee schedule,,,
HC Transluminal Peripheral Atherectomy- Visceral Artery- Each,PX-36900029,CDM,0235T,CPT,369,RC,,,outpatient,,,735,514.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,294.5145,165.0075,2998,percent of total billed charges,,,
BONE BX OSTEO SITE 11G 10CM -,SUP-G36211,CDM,A4215,HCPCS,272,RC,,,outpatient,,,1924.08,1346.856,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,1477.69344,other,Non-Reimbursable List,,
CATHETER COUDE 24FR 5CC -,SUP-1524C,CDM,A4340,HCPCS,270,RC,,,outpatient,,,45.92,32.144,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.30904,416.02,other,Non-Reimbursable List,,
SILICONE CATHETER FOLEY 24FR 5CC -,SUP-8887605247,CDM,A4344,HCPCS,270,RC,,,outpatient,,,17.15,12.005,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.850175,416.02,other,Non-Reimbursable List,,
CATH FOLEY 18FR 5ML BLN 3W DOVER LTX 16IN LUB -,SUP-2718,CDM,A4346,HCPCS,272,RC,,,outpatient,,,39.16,27.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.025285,416.02,other,Non-Reimbursable List,,
CATHETER FOLEY 22FR 30CC 3-WAY -,SUP-2822,CDM,A4346,HCPCS,272,RC,,,outpatient,,,41.84,29.288,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.025285,416.02,other,Non-Reimbursable List,,
CATHETER FOLEY 24FR 30CC 3-WAY -,SUP-2824,CDM,A4346,HCPCS,272,RC,,,outpatient,,,17.93,12.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.025285,416.02,other,Non-Reimbursable List,,
CATH FOLEY SIL 3W 30CC 22FR -,SUP-8887665225,CDM,A4346,HCPCS,272,RC,,,outpatient,,,41.84,29.288,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.025285,416.02,other,Non-Reimbursable List,,
SLING ORTHO ARM SM -,SUP-8023-01,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.98585,416.02,other,Non-Reimbursable List,,
SLING DEROYAL ARM MEDIUM -,SUP-8023-02,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.98585,416.02,other,Non-Reimbursable List,,
SLING DEROYAL ARM LARGE -,SUP-8023-03,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.98585,416.02,other,Non-Reimbursable List,,
SLING ORTHO ARM XL -,SUP-8023-04,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.98585,416.02,other,Non-Reimbursable List,,
SLING ARM MED STRP -,SUP-TX9901-43,CDM,A4565,HCPCS,270,RC,,,outpatient,,,13.3,9.31,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.98585,416.02,other,Non-Reimbursable List,,
HC Tissue Marker,PX-27800092,CDM,A4648,HCPCS,278,RC,,,outpatient,,,418,292.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.325665,1791.14496,other,Non-Reimbursable List,,
NEEDLE BRST LOC 20GAX3CM CM MRKNG STD MRKNG CANN ON WIRE -,SUP-253030,CDM,A4648,HCPCS,278,RC,,,outpatient,,,271.33,189.931,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.325665,1791.14496,other,Non-Reimbursable List,,
MARKER BRSTBIO 3MM 17GA INCONEL 625 ULTRA CLP -,SUP-862017,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.325665,1791.14496,other,Non-Reimbursable List,,
MARKER BRSTBIO 17GA TI ULTRA CLP II US -,SUP-863017,CDM,A4648,HCPCS,278,RC,,,outpatient,,,1097.2,768.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.325665,1791.14496,other,Non-Reimbursable List,,
INSTRUMENT BX 18GA/17GA/INTRO ACHIEVE AUTO 11CM SFT TIS -,SUP-CA1811,CDM,A4648,HCPCS,278,RC,,,outpatient,,,497.49,348.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.325665,1791.14496,other,Non-Reimbursable List,,
IDENTIFIER BIOPSY SITE FOR CELERO 12 THIRD SHAPE -,SUP-CELEROMARK-2S,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.325665,1791.14496,other,Non-Reimbursable List,,
NEEDLE BRST LOC KOPANS 20GAX5CM BVL CUT TIP MOD REINF TIP -,SUP-DKBL-20-5.0-A,CDM,A4648,HCPCS,278,RC,,,outpatient,,,175.17,122.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.325665,1791.14496,other,Non-Reimbursable List,,
NEEDLE BRST LOC KOPANS 20GAX7CM BVL CUT TIP MOD REINF TIP -,SUP-DKBL-20-7.0-A,CDM,A4648,HCPCS,278,RC,,,outpatient,,,175.17,122.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.325665,1791.14496,other,Non-Reimbursable List,,
NEEDLE BRST LOC KOPANS 20GAX9CM BVL CUT TIP MOD REINF TIP -,SUP-DKBL-20-9.0-A,CDM,A4648,HCPCS,278,RC,,,outpatient,,,175.17,122.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.325665,1791.14496,other,Non-Reimbursable List,,
NEEDLE 18GA X 20CM FUSIONCOIL WITH 1 X 5MM FIDUCIAL MARKER -,SUP-MTCTXFC1051820,CDM,A4648,HCPCS,278,RC,,,outpatient,,,752.72,526.904,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.325665,1791.14496,other,Non-Reimbursable List,,
MARKERS CIVCO FIDUCIAL 30CM -,SUP-MTNW887835,CDM,A4648,HCPCS,278,RC,,,outpatient,,,1129.01,790.307,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.325665,1791.14496,other,Non-Reimbursable List,,
MARKER BRSTBIO TI SCUR MRK MINI CORK -,SUP-SMARK-CELERO,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.325665,1791.14496,other,Non-Reimbursable List,,
MARKER BRSTBIO TI SECURMARK TOP HAT SHP -,SUP-SMARK-CELERO-2S,CDM,A4648,HCPCS,278,RC,,,outpatient,,,481.1,336.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.325665,1791.14496,other,Non-Reimbursable List,,
MARKER BRSTBIO TI SCUR MRK MINI CORK -,SUP-SMARK-EVIVA-13,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.325665,1791.14496,other,Non-Reimbursable List,,
MARKER BRSTBIO TI SECURMARK -,SUP-SMARK-EVIVA-2S-13,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.325665,1791.14496,other,Non-Reimbursable List,,
SCOUT 5CM DELIVERY NEEDLE AND REFLECTOR SSR05-01 -,SUP-SSR05-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.325665,1791.14496,other,Non-Reimbursable List,,
SCOUT 10CM DELIVERY NEEDLE AND REFLECTOR -,SUP-SSR10-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.325665,1791.14496,other,Non-Reimbursable List,,
SCOUT 7.5CM DELIVERY NEEDLE AND REFLECTOR -,SUP-SSR75-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.325665,1791.14496,other,Non-Reimbursable List,,
REFLECTOR AND DELIVERY SYSTEM SINGLE HAND 16G 7.5 CM -,SUP-SSR75S-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.325665,1791.14496,other,Non-Reimbursable List,,
IDENTIFIER BIOPSY SITE ATEC TRIMARK INTRODUCER SHEATH MARKER -,SUP-TRIMARK TD-2S-13-MR,CDM,A4648,HCPCS,278,RC,,,outpatient,,,371.98,260.386,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.325665,1791.14496,other,Non-Reimbursable List,,
EXPANDER BRST 500ML BIOCELL RND NATRLL 13CMX13.5CM 5.7CM -,SUP-133FV-13,CDM,A4649,HCPCS,272,RC,,,outpatient,,,4986.7,3490.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List,,
EXPANDER TISSUE SMOOTH 600CC NATRELLE FULL HEIGHT -,SUP-133S-FV-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List,,
EXPANDER TISSUE NATRELLE SMOOTH 650CC -,SUP-133S-FX-14-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List,,
NATRELLE INSPIRA TISSUE EXPANDER 800CC -,SUP-133S-FX-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List,,
TISSUE EXPANDER 400CC NATRELLE SMOOTH MOD HEIGHT EXTRA PROT -,SUP-133S-MX-12-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List,,
TISSUE EXPANDER 500CC NATRELLE SMOOTH MOD HEIGHT EXTRA PROT -,SUP-133S-MX-13-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List,,
TISSUE EXPANDER 600CC NATRELLE -,SUP-133S-MX-14-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List,,
EXPANDER TISSUE NATRELLE SMOOTH 700CC -,SUP-133S-MX-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List,,
EXPANDER TISSUE SMOOTH 400CC SHORT HT EXTRA PROJ NATRELLE -,SUP-133S-SX-13-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5903.4,4132.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List,,
EXPANDER TISSUE SMOOTH 650CC HEIGHT EXTRA PROJ NATRELLE -,SUP-133S-SX-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List,,
EXPANDER TISS 250ML SHRT H -,SUP-133SV-12,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List,,
EXPANDER BRST UNIV NATRLL -,SUP-30-000003,CDM,A4649,HCPCS,272,RC,,,outpatient,,,63.19,44.233,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List,,
EXPANDER BREAST TISSUE CPX4 450CC -,SUP-350-9213,CDM,A4649,HCPCS,272,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List,,
650CC CPX 4 BREAST TISSUE EXPANDER W/SUTURE TABS MED. HEIGHT -,SUP-350-9215,CDM,A4649,HCPCS,272,RC,,,outpatient,,,7745.3,5421.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List,,
EXPANDER TISSUE SMOOTH 800CC CPX 4 W/SUTURE TABS MED HT -,SUP-350-9216,CDM,A4649,HCPCS,272,RC,,,outpatient,,,7745.3,5421.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List,,
EXPANDER BRST 850ML BIOCELL RND NATRLL 16CMX16.5CM 6.8CM -,SUP-37-133800,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5835.5,4084.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List,,
EXPANDER BRST 600ML BIOCELL RND NATRLL 14CMX14.5CM 6.2CM -,SUP-67-133FV14,CDM,A4649,HCPCS,272,RC,,,outpatient,,,4986.7,3490.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List,,
SIZER IMPLANT NATRELLE INSPIRA 520CC FULL PROFILE -,SUP-MSZ-F520,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List,,
SIZER IMPLANT NATRELLE INSPIRA 560CC FULL PROFILE -,SUP-MSZ-F560,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List,,
SIZER IMPLANT NATRELLE INSPIRA 605CC FULL PROFILE -,SUP-MSZ-F605,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List,,
SIZER IMPLANT NATRELLE INSPIRA 695CC FULL PROFILE -,SUP-MSZ-F695,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List,,
SIZER IMPLANT NATRELLE INSPIRA 770CC FULL PROFILE -,SUP-MSZ-F770,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List,,
SIZER IMPLANT NATRELLE INSPIRA 275CC MODERATE PROFILE -,SUP-MSZ-M275,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List,,
SIZER IMPLANT NATRELLE INSPIRA 560CC MODERATE PROFILE -,SUP-MSZ-M560,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List,,
SIZER IMPLANT NATRELLE INSPIRA 600CC MODERATE PROFILE -,SUP-MSZ-M600,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List,,
SIZER IMPLANT NATRELLE INSPIRA 525CC EXTRA FULL PROFILE -,SUP-MSZ-X525,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List,,
SIZER IMPLANT NATRELLE INSPIRA 545CC EXTRA FULL PROFILE -,SUP-MSZ-X545,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List,,
SIZER IMPLANT NATRELLE INSPIRA 580CC EXTRA FULL PROFILE -,SUP-MSZ-X580,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List,,
SIZER IMPLANT NATRELLE INSPIRA 750CC XFULL PROFILE -,SUP-MSZ-X750,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List,,
SIZER IMPLANT NATRELLE INSPIRA 800CC EXTRA FULL PROFILE -,SUP-MSZ-X800,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List,,
SIZER IMPLANT NATRELLE INSPIRA 745CC FULL PROFILE -,SUP-SCF-745,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.186155,5948.3904,other,Non-Reimbursable List,,
DRESSING WND 2X2IN PURACOL + HI GEL INTGRTY COLL LF -,SUP-MSC8622EP,CDM,A6021,HCPCS,270,RC,,,outpatient,,,32.97,23.079,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7.401765,416.02,other,Non-Reimbursable List,,
DRESSING BURN PURACOL PLUS 2X2 AG SILVER  COLLAGEN -,SUP-MSC8722EP,CDM,A6021,HCPCS,270,RC,,,outpatient,,,43.41,30.387,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7.401765,416.02,other,Non-Reimbursable List,,
SHEETING SILASTIC 4.625X5.625IN SIL GEL HYPAL SLFADH LPRO -,SUP-NC15462,CDM,A6025,HCPCS,272,RC,,,outpatient,,,180.14,126.098,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,11.99,416.02,other,Non-Reimbursable List,,
DRESSING KALTOSTAT CA ALGIN 3X4.75IN ABSB -,SUP-168212,CDM,A6196,HCPCS,270,RC,,,outpatient,,,14.44,10.108,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.708445,416.02,other,Non-Reimbursable List,,
DRESSING XTRA HYDROFIBER AQUACEL 2X2IN -,SUP-420671,CDM,A6196,HCPCS,270,RC,,,outpatient,,,8.66,6.062,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.708445,416.02,other,Non-Reimbursable List,,
DRESSING ALGIN 2X2IN SQ NADH HI ABSB F/MOD TO HVY DRN -,SUP-MSC7022EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,7.61,5.327,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.708445,416.02,other,Non-Reimbursable List,,
DRESSING MAXORB 4X4IN EXTRA -,SUP-MSC7044EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,14.23,9.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.708445,416.02,other,Non-Reimbursable List,,
DRESSING WND 1X12IN FLT ROPE HI ABSORBENT1 F/WND MAXORB XTR -,SUP-MSC7112EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,20.07,14.049,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.708445,416.02,other,Non-Reimbursable List,,
DRESSING MAXORB AG 2X2IN ALGIN SILVER -,SUP-MSC9422EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,18.37,12.859,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.708445,416.02,other,Non-Reimbursable List,,
DRESSING GERMC AQUACEL AG EXTRA 4X4IN SLVR STRL -,SUP-420674,CDM,A6197,HCPCS,270,RC,,,outpatient,,,18.13,12.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.070185,416.02,other,Non-Reimbursable List,,
DRESSING AQUACEL 4 X 5 -,SUP-420674,CDM,A6197,HCPCS,270,RC,,,outpatient,,,18.13,12.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.070185,416.02,other,Non-Reimbursable List,,
DRESSING AQUACEL AG  2X2IN SQ HYDROFIBER SILVER -,SUP-422297,CDM,A6197,HCPCS,270,RC,,,outpatient,,,27.75,19.425,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.070185,416.02,other,Non-Reimbursable List,,
DRESSING AQUACEL AG 6X6IN HYDROFIBER -,SUP-422298,CDM,A6197,HCPCS,270,RC,,,outpatient,,,112.45,78.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.070185,416.02,other,Non-Reimbursable List,,
DRESSING MAXORB EXTRA AG 4X4 SILVER -,SUP-MSC9445EP,CDM,A6197,HCPCS,270,RC,,,outpatient,,,34.72,24.304,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.070185,416.02,other,Non-Reimbursable List,,
DRESSING ALGINATE SILVER 4X4.75IN CA ANTMIC NADH NWVN FLT -,SUP-MSC9445EP,CDM,A6197,HCPCS,270,RC,,,outpatient,,,34.27,23.989,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.070185,416.02,other,Non-Reimbursable List,,
DRESSING ALGIN AQUACL HYDROFIBER 0.75X18IN NADH CONFRM NWVN -,SUP-403770,CDM,A6199,HCPCS,270,RC,,,outpatient,,,22.99,16.093,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.3553,416.02,other,Non-Reimbursable List,,
DRESSING ALGIN AQUACL HYDROFIBER 0.75X18IN NADH CONFRM NWVN -,SUP-403770,CDM,A6199,HCPCS,270,RC,,,outpatient,,,19.4,13.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.3553,416.02,other,Non-Reimbursable List,,
DRESSING AQUACEL AG ROPE .75X18 IN -,SUP-422300,CDM,A6199,HCPCS,270,RC,,,outpatient,,,59.94,41.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.3553,416.02,other,Non-Reimbursable List,,
DRESSING SILVERLON 4 X 10 -,SUP-ID-410,CDM,A6206,HCPCS,272,RC,,,outpatient,,,169.8,118.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.23,416.02,other,Non-Reimbursable List,,
DRESSING ACTICOAT 4X5 -,SUP-66800405,CDM,A6207,HCPCS,272,RC,,,outpatient,,,81.2,56.84,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.98576,416.02,other,Non-Reimbursable List,,
DRESSING ACTICOAT 4X4 -,SUP-66800406,CDM,A6207,HCPCS,272,RC,,,outpatient,,,44.48,31.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.98576,416.02,other,Non-Reimbursable List,,
DRESSING ALLEVYN NONADHESIVE 2X2 NO BORDER -,SUP-66027643,CDM,A6209,HCPCS,272,RC,,,outpatient,,,14.63,10.241,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.94544,416.02,other,Non-Reimbursable List,,
DRESSING FOAM 4x4 BORDERLESS -,SUP-66927637,CDM,A6209,HCPCS,272,RC,,,outpatient,,,13.12,9.184,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.94544,416.02,other,Non-Reimbursable List,,
"DRESSING HYDROFERA 2.5"" X 2.5"" -",SUP-HLST-HBRT2525,CDM,A6209,HCPCS,272,RC,,,outpatient,,,268.12,187.684,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.94544,416.02,other,Non-Reimbursable List,,
HYDROFERA BLUE READY TRANSFER 2.5 X 2.5 -,SUP-HLST-HRBS2214,CDM,A6209,HCPCS,272,RC,,,outpatient,,,26.78,18.746,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.94544,416.02,other,Non-Reimbursable List,,
HYDROFERA BLUE READY TRANSFER 4 X 5 -,SUP-HBRS4520,CDM,A6210,HCPCS,272,RC,,,outpatient,,,40.63,28.441,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.121435,416.02,other,Non-Reimbursable List,,
HYDROFERA BLUE READY TRANSFER 4 X 5 -,SUP-HLST-HRBT4050,CDM,A6210,HCPCS,272,RC,,,outpatient,,,416.5,291.55,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.121435,416.02,other,Non-Reimbursable List,,
HYDROFERA BLUE READY TRANSFER 8 X 8 -,SUP-HLST-HRBS8820,CDM,A6211,HCPCS,272,RC,,,outpatient,,,92.17,64.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.692165,416.02,other,Non-Reimbursable List,,
DRESSING OPTIFOAM AG 3.5 X 6 -,SUP-412010,CDM,A6212,HCPCS,270,RC,,,outpatient,,,109.06,76.342,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.79151,416.02,other,Non-Reimbursable List,,
DRESSING OPTIFOAM AG 3.5 X 10 -,SUP-412011,CDM,A6212,HCPCS,270,RC,,,outpatient,,,139.34,97.538,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.79151,416.02,other,Non-Reimbursable List,,
BANDAGE ADH 4X4IN ALLEVYN -,SUP-66800270,CDM,A6212,HCPCS,270,RC,,,outpatient,,,12.57,8.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.79151,416.02,other,Non-Reimbursable List,,
BANDAGE ADH 4X4IN ALLEVYN -,SUP-66800270,CDM,A6212,HCPCS,270,RC,,,outpatient,,,18.72,13.104,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.79151,416.02,other,Non-Reimbursable List,,
"DRESSING FOAMING ALLEYN GENTLE BORDER LITE 5.5CM X 12CM"" -",SUP-66800836,CDM,A6212,HCPCS,270,RC,,,outpatient,,,8.42,5.894,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.79151,416.02,other,Non-Reimbursable List,,
DRESSING FOAM VERSATILE 2 1/8IN X 4 3/4IN SILICONE ADHESIVE -,SUP-66800836,CDM,A6212,HCPCS,270,RC,,,outpatient,,,7.98,5.586,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.79151,416.02,other,Non-Reimbursable List,,
DRESSING ALLEVYN LIFE 5 1/16IN x 5 1/16IN -,SUP-66801068,CDM,A6212,HCPCS,270,RC,,,outpatient,,,14.24,9.968,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.79151,416.02,other,Non-Reimbursable List,,
DRESSING OPTIFOAM AG 3.5 X 14 -,SUP-412012,CDM,A6213,HCPCS,270,RC,,,outpatient,,,148.97,104.279,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.206745,416.02,other,Non-Reimbursable List,,
DRESSING FOAM SACRUM 9.4 X 8.4CM LRG -,SUP-423270,CDM,A6213,HCPCS,270,RC,,,outpatient,,,41.01,28.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.206745,416.02,other,Non-Reimbursable List,,
DRESSING MEPORE 2.5 X 3 -,SUP-670800,CDM,A6219,HCPCS,270,RC,,,outpatient,,,0.55,0.385,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.04041,416.02,other,Non-Reimbursable List,,
TOWEL ABSORBENT STER 7550 -,SUP-7550,CDM,A6219,HCPCS,270,RC,,,outpatient,,,4,2.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.04041,416.02,other,Non-Reimbursable List,,
DRESSING WND 2X2IN ADH ISLND NWVN BRDR WTRPRF BK STRL SQ LF -,SUP-MSC3222,CDM,A6219,HCPCS,270,RC,,,outpatient,,,0.18,0.126,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.04041,416.02,other,Non-Reimbursable List,,
DRESSING BORDERED 4X4IN ADH ISLAND NWVN -,SUP-MSC3244,CDM,A6219,HCPCS,270,RC,,,outpatient,,,2.39,1.673,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.04041,416.02,other,Non-Reimbursable List,,
DRESSING PETRO ADPTC 3X3IN OIL EMUL NADH GZE CELLU-ACET -,SUP-2012,CDM,A6222,HCPCS,272,RC,,,outpatient,,,14.03,9.821,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.52533,416.02,other,Non-Reimbursable List,,
DRESSING ADAPTIC 3INX3IN 7.6CMx7.6CM NON-ADHERING -,SUP-2012,CDM,A6222,HCPCS,272,RC,,,outpatient,,,14.03,9.821,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.52533,416.02,other,Non-Reimbursable List,,
DRESSING XEROFORM 1X8 -,SUP-212,CDM,A6222,HCPCS,272,RC,,,outpatient,,,3.03,2.121,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.52533,416.02,other,Non-Reimbursable List,,
DRESSING XEROFORM 2 X 2 -,SUP-214,CDM,A6222,HCPCS,272,RC,,,outpatient,,,2.34,1.638,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.52533,416.02,other,Non-Reimbursable List,,
DRESSING MESALT RIBBON 3/4x39 IN DEBRIDE 0.75x39 IN ABSB -,SUP-285299,CDM,A6222,HCPCS,272,RC,,,outpatient,,,10.93,7.651,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.52533,416.02,other,Non-Reimbursable List,,
DRESSING MESALT 3x3 IN GAUZE -,SUP-285780,CDM,A6222,HCPCS,272,RC,,,outpatient,,,4.67,3.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.52533,416.02,other,Non-Reimbursable List,,
DRESSING WND 1.6 X 2.4IN CUTIMED SORBACT SWB PRIM STRL LF -,SUP-7216412,CDM,A6222,HCPCS,272,RC,,,outpatient,,,21.89,15.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.52533,416.02,other,Non-Reimbursable List,,
DRESSING ADAPTIC 3X8 -,SUP-2013,CDM,A6223,HCPCS,272,RC,,,outpatient,,,4.43,3.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.698195,416.02,other,Non-Reimbursable List,,
DRESSING PETRO VASELINE 1X36IN STRL 1-PLY IMPREG NADH LPRO -,SUP-205-12-A,CDM,A6223,HCPCS,272,RC,,,outpatient,,,3.11,2.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.698195,416.02,other,Non-Reimbursable List,,
DRESSING XEROFORM 5IN X 9IN -,SUP-213,CDM,A6223,HCPCS,272,RC,,,outpatient,,,4.32,3.024,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.698195,416.02,other,Non-Reimbursable List,,
DRESSING XEROFORM 5IN X 9IN -,SUP-213,CDM,A6223,HCPCS,272,RC,,,outpatient,,,4.32,3.024,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.698195,416.02,other,Non-Reimbursable List,,
DRESSING PETRO VASELINE 1X36IN OCL NADH STRIP STRL IMPREG -,SUP-8884412600,CDM,A6223,HCPCS,272,RC,,,outpatient,,,3.15,2.205,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.698195,416.02,other,Non-Reimbursable List,,
GAUZE VASELINE 1 X 36 -,SUP-8884412600,CDM,A6223,HCPCS,272,RC,,,outpatient,,,3.15,2.205,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.698195,416.02,other,Non-Reimbursable List,,
DRESSING ADAPTIC 3X8 -,SUP-JOHN-2013,CDM,A6223,HCPCS,272,RC,,,outpatient,,,26.74,18.718,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.698195,416.02,other,Non-Reimbursable List,,
GAUZE VASELINE 3IN X 18IN -,SUP-207-12-A,CDM,A6224,HCPCS,272,RC,,,outpatient,,,5.13,3.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.801465,416.02,other,Non-Reimbursable List,,
GAUZE VASELINE 3IN X 18IN -,SUP-207-12-A,CDM,A6224,HCPCS,272,RC,,,outpatient,,,5.13,3.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.801465,416.02,other,Non-Reimbursable List,,
"GAUZE VASELINE 3"" X 36"" -",SUP-425600,CDM,A6224,HCPCS,272,RC,,,outpatient,,,7.26,5.082,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.801465,416.02,other,Non-Reimbursable List,,
GAUZE PETRO 3X36IN VASELINE -,SUP-8884415600,CDM,A6224,HCPCS,272,RC,,,outpatient,,,3.57,2.499,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.801465,416.02,other,Non-Reimbursable List,,
GAUZE VASELINE 1/2 X 72 -,SUP-8884421600,CDM,A6224,HCPCS,272,RC,,,outpatient,,,5.95,4.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.801465,416.02,other,Non-Reimbursable List,,
DRESSING HYDROCOLLOID DUODERM 2X4IN XTRA THIN -,SUP-187900,CDM,A6234,HCPCS,272,RC,,,outpatient,,,4.07,2.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.913715,416.02,other,Non-Reimbursable List,,
DRESSING HYDROCOLLOID DUODERM 4X4IN XTRA THIN -,SUP-187955,CDM,A6234,HCPCS,272,RC,,,outpatient,,,4.49,3.143,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.913715,416.02,other,Non-Reimbursable List,,
DRESSING WND XTHN 4X4IN DDRM STRL CONFRM NADH HYDRCL SQ -,SUP-187955,CDM,A6234,HCPCS,272,RC,,,outpatient,,,6.73,4.711,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.913715,416.02,other,Non-Reimbursable List,,
DRESSING DUODERM EXTRA THIN 4X4 -,SUP-187955,CDM,A6234,HCPCS,272,RC,,,outpatient,,,6.71,4.697,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.913715,416.02,other,Non-Reimbursable List,,
DRESSING HYDRCL XTHN 4X6IN DDRM CGF STRL XTHN CONFRM NADH -,SUP-187902,CDM,A6235,HCPCS,270,RC,,,outpatient,,,11.92,8.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.67604,416.02,other,Non-Reimbursable List,,
DRESSING DUODERM 4 X 4 THICK -,SUP-187660,CDM,A6237,HCPCS,272,RC,,,outpatient,,,9.64,6.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,416.02,other,Non-Reimbursable List,,
DRESSING WND 4X4IN DDRM SGNL STRL CONFRM ADH ABSB WTRPRF -,SUP-403326,CDM,A6237,HCPCS,272,RC,,,outpatient,,,11.11,7.777,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,416.02,other,Non-Reimbursable List,,
DRESSING HYDROCOLLOID DUODERM 4X4IN -,SUP-403326,CDM,A6237,HCPCS,272,RC,,,outpatient,,,7.39,5.173,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,416.02,other,Non-Reimbursable List,,
DRESSING HYDRCL 6X7IN DUADERM CGF STRL -,SUP-187974,CDM,A6238,HCPCS,270,RC,,,outpatient,,,42.72,29.904,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.600005,416.02,other,Non-Reimbursable List,,
DRESSING WND 14X14CM DDRM SGNL STRL CONFRM ADH ABSB WTRPRF -,SUP-403327,CDM,A6238,HCPCS,270,RC,,,outpatient,,,20.49,14.343,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.600005,416.02,other,Non-Reimbursable List,,
DRESSING WND 15X18CM DDRM SGNL STRL CONFRM ADH ABSB WTRPRF -,SUP-403332,CDM,A6238,HCPCS,270,RC,,,outpatient,,,21.79,15.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.600005,416.02,other,Non-Reimbursable List,,
CREAM TRIAD HYDROPHILLIC WOUND DRESSING -,SUP-1964-A,CDM,A6240,HCPCS,270,RC,,,outpatient,,,31.57,22.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7.087465,416.02,other,Non-Reimbursable List,,
DRESSING HYDRCL 1.6IN TENDRWT STRL ACT CVTY LF -,SUP-MSC8401,CDM,A6242,HCPCS,270,RC,,,outpatient,,,16.34,11.438,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.66833,416.02,other,Non-Reimbursable List,,
DRESSING DEBRIDE 3X3IN PLYACRL PLYMR GL CVTY PAD TENDRWT ACT -,SUP-MSC8403Z,CDM,A6242,HCPCS,270,RC,,,outpatient,,,22.7,15.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.66833,416.02,other,Non-Reimbursable List,,
DRESSING GEL 30GM DDRM HYDACTV NADH FIL HYDRCL HYDACTV -,SUP-187987,CDM,A6248,HCPCS,272,RC,,,outpatient,,,13.91,9.737,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.122795,416.02,other,Non-Reimbursable List,,
DRESSING SILVASORB GEL 0.25OZ  SILVER ABSB ANTMIC -,SUP-MSC93025EP,CDM,A6248,HCPCS,272,RC,,,outpatient,,,34.03,23.821,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.122795,416.02,other,Non-Reimbursable List,,
SURGICAL DRESSING SILK 6 X 8IN -,SUP-NON4313,CDM,A6255,HCPCS,270,RC,,,outpatient,,,8.82,6.174,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.98009,416.02,other,Non-Reimbursable List,,
DRESSING TEGADERM 1.75X1.75IN TRANPARENT FILM -,SUP-1622-W,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.17,0.819,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.262665,416.02,other,Non-Reimbursable List,,
DRESSING TEGADERM 3 X 3 -,SUP-1624-W,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.17,0.819,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.262665,416.02,other,Non-Reimbursable List,,
DRESSING TRANSP 2.375X2.75IN TEGADERM OCL PIC FRM STYL -,SUP-1624-W,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.17,0.819,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.262665,416.02,other,Non-Reimbursable List,,
DRESSING TEAGDERM IV 2.75X3.25IN -,SUP-1633,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.63,1.141,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.262665,416.02,other,Non-Reimbursable List,,
DRESSING TEGADERM IV 3.5X4.5IN TRANSPARENT -,SUP-1655,CDM,A6257,HCPCS,270,RC,,,outpatient,,,5.37,3.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.262665,416.02,other,Non-Reimbursable List,,
DRESSING TRANSP 4X4.75IN TEGADERM OCL ORIG FRM STYL PLYSTR -,SUP-1626,CDM,A6258,HCPCS,270,RC,,,outpatient,,,3.38,2.366,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.75881,416.02,other,Non-Reimbursable List,,
DRESSING TRANSPARENT 4IN X 4.25IN -,SUP-1626,CDM,A6258,HCPCS,270,RC,,,outpatient,,,3.38,2.366,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.75881,416.02,other,Non-Reimbursable List,,
DRESSING TEGADERM 4X5 -,SUP-1626-W,CDM,A6258,HCPCS,270,RC,,,outpatient,,,3.53,2.471,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.75881,416.02,other,Non-Reimbursable List,,
DRESSING TEGADERM 15X20CM -,SUP-1628,CDM,A6258,HCPCS,270,RC,,,outpatient,,,6.97,4.879,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.75881,416.02,other,Non-Reimbursable List,,
DRESSING TRANSP 4X6.125IN TEGADERM OCL WND FRM STYL ADLT -,SUP-1689,CDM,A6258,HCPCS,270,RC,,,outpatient,,,10.58,7.406,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.75881,416.02,other,Non-Reimbursable List,,
DRESSING TEGADERM 20CM X 30CM -,SUP-1629,CDM,A6259,HCPCS,272,RC,,,outpatient,,,9.86,6.902,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.21357,416.02,other,Non-Reimbursable List,,
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7030-42,NDC,outpatient,10,ML,100.56,70.392,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.17,416.02,other,Non-Reimbursable List,,
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7015-46,NDC,outpatient,10,ML,100.56,70.392,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.17,416.02,other,Non-Reimbursable List,,
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7020-38,NDC,outpatient,10,ML,102.5,71.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.17,416.02,other,Non-Reimbursable List,,
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7025-40,NDC,outpatient,10,ML,100.57,70.399,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.17,416.02,other,Non-Reimbursable List,,
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7015-48,NDC,outpatient,10,ML,100.56,70.392,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.17,416.02,other,Non-Reimbursable List,,
GADOTERATE MEGLUMINE 1 MMOL/2 ML IV SOLN WRAPPER,RX-4080731,CDM,A9575,HCPCS,636,RC,67684-2000-00,NDC,outpatient,20,ML,136.25,95.375,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.12,416.02,other,Non-Reimbursable List,,
7 HOLE SUPERIOR MIDSHAFT CLAVICLE RIGHT PLATE -,SUP-0000000215,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEADLESS 4.0 FIXOS X 26MM -,SUP-0000000215,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE ANCHORED APACHE 5MM -,SUP-0000006784,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CABLE ORTHO CBL-RDY COCR 635MM -,SUP-00022320418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2083.36,1458.352,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN IM 4.8X222MM RUSH SS -,SUP-00080200103,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.68,514.976,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN IM 3.2X127MM RUSH SS -,SUP-00080300104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN IM 3.2X140MM RUSH SS -,SUP-00080300105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN IM 3.2X165MM RUSH SS -,SUP-00080300107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN IM 3.2X191MM RUSH SS -,SUP-00080300109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN IM SZ 3L 3.2X241MM RUSH SS -,SUP-00080300113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN IM 3.2X254MM RUSH SS -,SUP-00080300114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X18MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS POR -,SUP-00104223018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X24MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS POR -,SUP-00104223024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X30MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-00104223030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN CANC 4.5X33MM PROTASUL-64 WF TM ANTMC SHLDR STRL -,SUP-00104223033,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN CANC 4.5X36MM PROTASUL-64 WF TM ANTMC SHLDR STRL -,SUP-00104223036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X42MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-00104223042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X48MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-00104223048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FILLER TY I COLL CA PHOS 5ML PST COPIOS DBASC -,SUP-00110302005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3752.36,2626.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FILLER TY I COLL CA PHOS 10ML PST COPIOS DBASC -,SUP-00110302010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6279,4395.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CEMENT BN PLYMTHL MTHCRYLT 40GM PLC R HVISC -,SUP-00111214001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 40X3MM ANCHR XLPE GLOBAL STRL -,SUP-00113640026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9421.68,6595.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX10MM CANN 7.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX10MM CANN 1/2 5MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX12MM CANN 9.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX12MM CANN 1/3 5MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3MMX16MM CANN 1/2 8MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114701631,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX16MM CANN 13.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3MMX19MM CANN 1/3 6.3MM THRD SD/ST HX REVCT FLUT -,SUP-00114701930,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANN 3.0MM X 20MM 1/3 TH -,SUP-00114702030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3MMX21MM CANN 1/3 7MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3MMX24MM CANN 1/2 12MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702431,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3MMX26MM CANN 1/2 13MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702631,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3MMX28MM CANN 1/2 14MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702831,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX28MM CANN 9.3MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114702835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX28MM CANN 1/3 9.3MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114702840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.27,795.389,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX28MM CANN 1/2 14MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114702841,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.27,795.389,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3MMX30MM CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX30MM CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX30MM CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT. -,SUP-00114703041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX34MM CANN 1/3 11.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX34MM CANN 1/3 11.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX34MM CANN 1/3 17MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703441,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.27,795.389,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX36MM CANN 1/3 12MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX36MM CANN 1/3 12MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX36MM CANN 1/3 18MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703641,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX38MM CANN 1/3 12.7MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX38MM CANN 1/3 19MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703841,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3MMX40MM CANN 1/3 13.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX40MM CANN 1/3 13.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X40MM CANN 1/3 13.3MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX40MM CANN 1/3 20MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX42MM CANN 1/3 39.5MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX44MM CANN 14.7MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX44MM CANN 1/3 14.7MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX44MM CANN 1/2 22MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704441,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5MMX45MM CANN 16MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114704555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5MMX45MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114704556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX46MM CANN 15.3MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX46MM CANN 43.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX46MM CANN 1/3 15.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX46MM CANN 1/2 23MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704641,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX48MM CANN 16MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX48MM CANN 1/3 16MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX50MM CANN 16.7MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114705035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX50MM CANN 1/3 16.7MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114705040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5MMX50MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5MMX50MM CANN 45.3MM FT SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705057,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MMX50MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114705065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5MMX55MM CANN 16MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5MMX55MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MMX55MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114705565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5MMX60MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114706056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MMX60MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MMX60MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5MMX65MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114706556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MMX65MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MMX65MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MMX70MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MMX70MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7.5MMX70MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7.5MMX70MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MMX75MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MMX75MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7.5MMX75MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7.5MMX75MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5MMX80MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114708056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MMX80MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MMX80MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7.5MMX80MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7.5MMX80MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7.5MMX80MM CANN 74.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114708077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEPIN ORTHO 1.6MMX6IN P/T TROC TIP -,SUP-00114708400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEPIN ORTHO 1.25MMX6IN P/T TROC TIP -,SUP-00114708500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5MMX85MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114708556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MMX85MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MMX85MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7.5MMX85MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7.5MMX85MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7.5MMX85MM CANN 79.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114708577,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEPIN ORTHO 2.4MMX9IN P/T TROC TIP -,SUP-00114708700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEPIN ORTHO 3.2MMX9IN P/T TROC TIP -,SUP-00114708800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEPIN ORTHO 1.6MMX9IN SMTH SHFT TROC TIP -,SUP-00114709000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,70.98,49.686,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MMX90MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7.5MMX90MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7.5MMX90MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7.5MMX90MM CANN 84.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114709077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEPIN ORTHO 2.4MMX9IN SMTH SHFT TROC TIP -,SUP-00114709100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,147.14,102.998,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEPIN ORTHO 3.2MMX9IN SMTH SHFT TROC TIP -,SUP-00114709200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,147.04,102.928,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEPIN ORTHO 1.6MMX6IN SMTH SHFT TROC TIP -,SUP-00114709400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,70.95,49.665,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WASHER ORTHO 3MM -,SUP-00114709500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MMX95MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MMX95MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7.5MMX95MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7.5MMX95MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7.5MMX95MM CANN 89.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114709577,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WASHER ORTHO F/3.5/4MM CANN SCR NS -,SUP-00114709600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WASHER ORTHO F/4.5MM CANN SCR SS NS -,SUP-00114709700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WASHER ORTHO F/5.5MM/7.5MM CANN SCR SS RND NS -,SUP-00114709800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEPIN ORTHO 3.2MMX12IN P/T TROC TIP -,SUP-00114709901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEPIN ORTHO 3.2MM 30CM -,SUP-00114709902,CDM,C1713,HCPCS,278,RC,,,outpatient,,,155.78,109.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEPIN ORTHO 3.2MMX12IN SMTH SHFT DRILL TIP -,SUP-00114709903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,155.74,109.018,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MMX100MM CANN 16MM THRD SD/ST 4.5MM HX REVCT FLUT -,SUP-00114710065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW Z CANN PT 32 6.5 X 100 -,SUP-00114710066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7.5MMX100MM CANN FT SD/ST 5MM HX REVCT FLUT BIODUR 108 -,SUP-00114710077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MMX105MM CANN 16MM THRD SD/ST 4.5MM HX REVCT FLUT -,SUP-00114710565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7.5MMX105MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114710575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1399.33,979.531,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7.5MMX105MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114710576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7.5MMX110MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7.5MMX110MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7.5MMX115MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7.5MMX115MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7.5MMX120MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114712075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.25MM 2.5MM THRD MINI 10MM HRBRT MINI TIV STRL -,SUP-00115001000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2142.36,1499.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.25MM 2.5MM THRD MINI 16MM HRBRT MINI TIV STRL -,SUP-00115001600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2142.36,1499.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5MM 2.1MM THRD 14MM CANN HRBRT/WPL TIV STRL -,SUP-00115201400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2555.05,1788.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3X5MM DIA THRD MINI 18MM CANN LAG HRBRT/WPL TIV STRL -,SUP-00115201800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2555.05,1788.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEPIN ORTHO 3.2MMX23CM THRD TROC TIP FRLCK STRL -,SUP-00118102000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.84,81.788,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 12.7MM THRD VFX2 LAG 17MM S/T SS 130MM -,SUP-00119300557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1749.27,1224.489,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEPIN ORTHO 3.2MM TM -,SUP-00119703200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.19,908.033,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD FEM HIP 10MM TM TIV 25MM THRD -,SUP-00119710010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14101.97,9871.379,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN NCB 80MM 4HL CONTR LCK PROTASUL-64 STRL -,SUP-00202262104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5884.73,4119.311,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN NCB 117MM 7HL CONTR LCK PROTASUL-64 STRL -,SUP-00202262107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7175.97,5023.179,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X24MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X26MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X30MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X32MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,605.85,424.095,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X36MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,605.85,424.095,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAP LCK NCB NS -,SUP-00203150300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,930.39,651.273,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X24MM NLCKG CORT NCB ST TMX NS -,SUP-00203155024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX26MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX28MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX30MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX32MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX34MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX36MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X38MM NLCKG CORT NCB ST TMX NS -,SUP-00203155038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX40MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX42MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX44MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX46MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX50MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X32MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,778.91,545.237,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X44MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,778.91,545.237,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X46MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,778.91,545.237,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X50MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.68,514.976,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN NCB 93MM 5HL LCK TI -,SUP-00203262005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5979.97,4185.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
STAPLE INTNL 19MMX15.9MM LF -,SUP-00222901300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,294.26,205.982,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DEVICE ORTHO 23MM LNG CBL-RDY GTR TROCH TIV 121MM STRL -,SUP-00223200205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9554.89,6688.423,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CABLE ORTHO 1.8MM CBL-RDY COCR 914MM STRL -,SUP-00223200228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2397.84,1678.488,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 305MM 4.5MM 10HL SS STRL -,SUP-00223200302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4354.7,3048.29,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CABLE PLATE 1.8MM CBL-RDY BN SS 610MM STRL -,SUP-00223200318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1493.73,1045.611,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CABLE SURG 1.8MM X 635MM CBL-RDY CRLGE SS -,SUP-00223200418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2083.36,1458.352,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CABLE FX 1.3MM CBL-RDY SS 889MM STRL -,SUP-00223201113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1788.55,1251.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ORTHOPEDIC CBL-RDY GRP 65MM PIN -,SUP-00223205021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2708.43,1895.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX12MM LCK CORT ST FA SS NS -,SUP-00234801235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX18MM LCK CORT ST FA SS NS -,SUP-00234801835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX20MM LCK CORT ST FA SS NS -,SUP-00234802035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX22MM LCK CORT ST FA SS NS -,SUP-00234802235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX26MM LCK CORT ST FA SS NS -,SUP-00234802635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX30MM LCK CORT ST FA SS NS -,SUP-00234803035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX34MM LCK CORT ST FA SS NS -,SUP-00234803435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX40MM LCK CORT ST FA SS NS -,SUP-00234804035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX100MM LCK CORT ST FA SS NS -,SUP-00234810035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 132MM 2.7/3.5MM 8HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235701708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3823.64,2676.548,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 80MM 2.7/3.5MM 4HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235701804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3310.29,2317.203,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 106MM 6HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235701806,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3540.4,2478.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 114MM 3.5MM 6HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235800104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6389.13,4472.391,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 129MM 7HL FX-ANG LCK NS -,SUP-00235800907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.68,2924.376,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 77MM 3HL LCK SS NS -,SUP-00235801203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3788.26,2651.782,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX12MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX14MM LCK NCANN P/T ST CNCL SS NS -,SUP-00235901426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,328.92,230.244,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX14MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX14MM LCK NCANN P/T ST SS NS -,SUP-00235901438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX16MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX16MM LCK NCANN P/T ST CNCL SS NS -,SUP-00235901638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X18MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X30MM LCK NCANN FT ST SS NS -,SUP-00235903035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X32MM LCK NCANN FT ST SS NS -,SUP-00235903235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X36MM LCK NCANN FT ST SS NS -,SUP-00235903635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X38MM LCK NCANN FT ST SS NS -,SUP-00235903835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X40MM LCK NCANN FT ST SS NS -,SUP-00235904035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X42MM LCK NCANN FT ST SS NS -,SUP-00235904235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X44MM LCK NCANN FT ST SS NS -,SUP-00235904435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X46MM LCK NCANN FT ST SS NS -,SUP-00235904635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X48MM LCK NCANN FT ST SS NS -,SUP-00235904835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X50MM LCK NCANN FT ST SS NS -,SUP-00235905035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCRW 14MM CASPAR PIN F/DSTRCT -,SUP-0024-LDR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEPIN ORTHO 3.2X444MM -,SUP-00281001175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
STAPLE INTNL 22MMX9.5MM COCR LF -,SUP-00406000100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.27,530.089,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
STAPLE INTNL 25MMX9.5MM COCR LF -,SUP-00406000200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.27,530.089,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN FX 3.2MM BGLNI/FLTW THRD TIP -,SUP-00430400800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,379.28,265.496,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.5MM THRD 7MM CORT FT ST HEX HEAD SS NS -,SUP-00481500701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.5MM THRD 8MM CORT FT ST HEX HEAD SS NS -,SUP-00481500801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.5MM THRD 9MM CORT FT ST HEX HEAD SS NS -,SUP-00481500901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.5MM THRD 14MM CORT FT ST HEX HEAD SS NS -,SUP-00481501401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.5MM THRD 16MM CORT FT ST HEX HEAD SS NS -,SUP-00481501601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.5MM THRD 20MM CORT FT ST HEX HEAD SS NS -,SUP-00481502001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2MM THRD 6MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482000603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2MM THRD 8MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482000803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2MM THRD 10MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2MM THRD 10MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2MM THRD 12MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2MM THRD 12MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2MM THRD 14MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2MM THRD 14MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2MM THRD 16MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2MM THRD 16MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2MM THRD 18MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2MM THRD 22MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482002201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MM THRD 6MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00482700601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MM THRD 8MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00482700801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MM THRD 10MM LCK CORT FT NON- ST 2.5MM SM HEX RCESS -,SUP-00482701000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,128.9,90.23,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MM THRD 10MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MM THRD 12MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MM THRD 14MM CORT FT ST 2.5MM SM HEX RCESS -,SUP-00482701401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MM THRD 16MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MM THRD 18MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,147.33,103.131,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MM THRD 20MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482702001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MM THRD 26MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482702601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MMX10MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482801002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MMX12MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482801202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MMX12MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482801202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MMX14MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482801402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MMX16MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482801602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MMX18MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482801802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MMX20MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482802002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MMX22MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482802202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MMX26MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482802602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MMX28MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482802802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MMX30MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482803002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX16MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483501601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX16MM LCK CORT 6MM P/T NON- ST 2.5MM SM HEX RCESS -,SUP-00483501604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX20MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX20MM LCK CORT 6MM P/T NON- ST 2.5MM SM HEX RCESS -,SUP-00483502004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX22MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX22MM LCK CORT 6MM P/T NON- ST 2.5MM SM HEX RCESS -,SUP-00483502204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX24MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483502404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX26MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX26MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483502604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX28MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX28MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483502804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX30MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483503001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX30MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483503004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN CORT 3.5MM 32MM SS NS FT S/T LOCK 2.5MM SM HEX -,SUP-00483503201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX34MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483503401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX34MM LCK CORT 12MM P/T NON- ST 2.5MM SM HEX -,SUP-00483503404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX45MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483504501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX45MM LCK CORT 12MM P/T NON- ST 2.5MM SM HEX -,SUP-00483504504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX50MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483505001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX55MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483505501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX12MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484001200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX12MM CANC 5MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX14MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484001400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX14MM CANC 5MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX16MM LCK CANC FT 2.5MM SM HEX RCESS SS NS -,SUP-00484001600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX16MM CANC 6MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX18MM LCK CANC FT 2.5MM SM HEX RCESS SS NS -,SUP-00484001800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX18MM CANC 7MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX20MM LCK CANC FT 2.5MM SM HEX RCESS SS NS -,SUP-00484002000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX22MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484002200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX24MM CANC 10MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484002401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX26MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484002600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX28MM CANC 14MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484002801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX30MM CANC 14MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484003001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX34MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484003400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX38MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484003800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX40MM CANC 14MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484004001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX50MM CANC 15MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484005001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MM THRD 36MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484503601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MM THRD 38MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484503801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MM THRD 40MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MM THRD 40MM CORT 20.5MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00484504008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,194.77,136.339,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MM THRD 42MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MM THRD 44MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MM THRD 46MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MM THRD 50MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484505001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MM THRD 50MM CORT 24.5MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00484505008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,194.77,136.339,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MM THRD 55MM CORT 26.5MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00484505508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,194.77,136.339,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MM THRD 58MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484505801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MM THRD 60MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484506001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MM THRD 45MM CANC 32MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486504502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MM THRD 50MM CANC 16MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486505001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MM THRD 50MM CANC 32MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486505002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MM THRD 55MM CANC 32MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486505502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MM THRD 60MM CANC FT 3.5MM LRG HEX RCESS SS NS -,SUP-00486506000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WASHER ORTHO 4X7MM SM 2.7/3.5/4.0MM SS RND FLT NS -,SUP-00490004051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WASHER ORTHO 13MM LRG 4.5/6.5MM RND FLT NS -,SUP-00490006551,CDM,C1713,HCPCS,278,RC,,,outpatient,,,207.73,145.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 21MM 2MM SS L-SHP OB R MINI FRAG NS -,SUP-00492000210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,386.57,270.599,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 23MM 4HL 2MM SS STR MINI FRAG NS -,SUP-00492000402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,389.49,272.643,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 32MM 2.7MM SS T-SHP MINI FRAG NS -,SUP-00492700304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.52,254.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 31MM 4HL 1MM SS 1/4 TBLR MINI FRAG NS CLLR -,SUP-00492700403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,432.72,302.904,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 104MM 3.5MM 4HL SS CLVRLF SM FRAG NS -,SUP-00493500416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1493.73,1045.611,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 61MM 5HL SS SM 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500503,CDM,C1713,HCPCS,278,RC,,,outpatient,,,406.82,284.774,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 73MM 3.5MM 6HL COMPR SS SM FRAG NS -,SUP-00493500600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,800.56,560.392,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 73MM 6HL SS SM 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.09,296.863,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 85MM 3.5MM 7HL COMPR SS SM FRAG NS -,SUP-00493500700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,822.21,575.547,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 85MM 7HL SS SM 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.09,296.863,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 97MM 3.5MM 8HL 1.1MM COMPR SS SM FRAG NS -,SUP-00493500800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 97MM 3.5MM 8HL SS 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,454.37,318.059,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 109MM 3.5MM 9HL 1.1MM COMPR SS SM FRAG NS -,SUP-00493500900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,887.1,620.97,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 121MM 3.5MM 10HL 1.1MM COMPR SS SM FRAG NS -,SUP-00493501000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,908.74,636.118,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 74MM 3.5MM HLX3/5 HD/SHFT 1.5MM SS T-SHP OBLQ SM -,SUP-00493503505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1100.65,770.455,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
"PLATE Z ""T"" 4 HOLE 3.5MM -",SUP-00493504404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,714.03,499.821,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 68MM 3.5MM UNIV LCK SYS 5HL LCK SS 1/3 TBLR NS -,SUP-00493600503,CDM,C1713,HCPCS,278,RC,,,outpatient,,,952.04,666.428,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 94MM 3.5MM UNIV LCK SYS 7HL LCK SS 1/3 TBLR NS -,SUP-00493600703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1016.92,711.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 107MM 3.5MM UNIV LCK SYS 8HL LCK SS 1/3 TBLR NS -,SUP-00493600803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.22,742.154,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 105MM 3.5MM UNIV LCK SYS 8HL CONTR LCK DL COMPR SS -,SUP-00493600807,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1867.15,1307.005,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 105MM 3.5MM UNIV LCK SYS 8HL RECON LCK SS NS -,SUP-00493600813,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2566.79,1796.753,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 133MM 3.5MM UNIV LCK SYS 10HL LCK SS 1/3 TBLR LRG -,SUP-00493601003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.81,757.267,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 116MM 4.5MM 6HL SHFT SS T-SHP LRG FRAG NS -,SUP-00494500604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1316.86,921.802,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE Z 4.5 COMP B 12 HOLE -,SUP-00494501201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1356.19,949.333,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
KT MIXER BNCMNT VAC MX 35ML LNG CQ/NOZ FNL CHRCL FLTR SUCT -,SUP-00504903501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,811.07,567.749,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
KT MIXER BNCMNT VAC MX 45ML LNG CQ/NOZ FNL CHRCL FLTR SUCT -,SUP-00504904501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,905.01,633.507,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WIRE PACK .028 SPADE TIP -,SUP-00505004100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,49.89,34.923,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GRAFT HUM TIS 11MM CHONDROFIX OSTCHND LF -,SUP-00560402011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15111.91,10578.337,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GRAFT BN 15MM CHONDROFIX LF -,SUP-00560402015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15891.64,11124.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 48MM HD UNICMPT SS F/HI FLEX SYS -,SUP-00579104100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 48MM HD UNICMPT SS F/HI FLEX SYS -,SUP-00579104100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.77,258.139,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
HOLDER IMPL HDLS 48MM SS GOLD F/UNICMPT HI FLEX KN SPCR BLCK -,SUP-00579104200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEX HEAD 3.5MM -,SUP-00-5901-035-27,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEX HEAD 3.5MM X 48MM -,SUP-00-5901-035-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW FLEX LCK -,SUP-00595409000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
EXTENSION STM MG2 PS TIV ALY PLG TAPR KN -,SUP-00596009900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDE SURG NEXGEN F/UNICMPT KN ARTHPL TIB PT SPEC INST HI.. -,SUP-00597000001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDE SURG NEXGEN F/UNICMPT KN ARTHPL TIB PT SPEC INST HI -,SUP-00597000002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEPIN ORTHO PERSONA CRUCIF RCESS -,SUP-00597000025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BASEPLATE TIB SZ1 58/40MM KN STM NEXGEN TIV ALY PMMA UHMWPE -,SUP-00598002701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COMP TIBPLT SZ2 62/41MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598002702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COMP TIBPLT SZ3 66/42MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598003701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COMP TIBPLT SZ3 66/42MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598003701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8452.1,5916.47,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COMP TIBPLT SZ4 66/46MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598003702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COMP TIBPLT SZ5 74/46MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598004701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COMP TIBPLT SZ6 74/50MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598004702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COMP TIBPLT SZ7 82/51MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598005701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW AUG 48MM TIV HX HD F/ARTHPL NEXGEN STRL DIST FEM KN -,SUP-00598304048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COMP TIBTRY SZ3 66/42MM KN CMNT STM WDG NEXGEN TIV PMMA CR -,SUP-00598800300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10515.22,7360.654,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COMP TIBTRY SZ4 66/46MM KN CMNT STM WDG NEXGEN TIV PMMA CR -,SUP-00598800400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10515.22,7360.654,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COMP TIBTRY SZ5 74/46MM KN CMNT STM WDG NEXGEN TIV PMMA CR -,SUP-00598800500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10515.22,7360.654,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DEVICE 11X4X11MM TM-S 7DG TM -,SUP-00610101041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10526.36,7368.452,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER 11X14X29MM VBR-11 TM -,SUP-00611100292,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15891.64,11124.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ACTB 6.5X15MM TRILOGY TIV CNTRSNK HEAD ST -,SUP-00625006515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE SELF TAPPED 6.5 X 20 -,SUP-00-6250-065-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BONE SCREW 6.5X25 SELF-TAP -,SUP-00-6250-065-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE SELF TAP 6.5 X 30 -,SUP-00-6250-065-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ACTB 6.5X35MM TRILOGY TIV CNTRSNK HEAD ST -,SUP-00625006535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ACTB 6.5X40MM TRILOGY TIV CNTRSNK HEAD ST -,SUP-00625006540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE 6.5 X 40 SELF TAP -,SUP-00625006540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE 6.5X40 SELF-TAP -,SUP-00-6250-065-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BONE SCREW 6.5 X 50MM SELF TAP -,SUP-00625006550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE 6.5 X 50 SELF-TAP -,SUP-00-6250-065-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LINER 56 X 32  TRILOGY LONGEVITY CONSTRAINED -,SUP-00-6334-056-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14191.09,9933.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HGP ACETABULAR CUP BONE SLF TP 6.5 X 20 -,SUP-00662406520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HGPAETABULAR CUP BONE SLF TP 6.5 X 30 -,SUP-00662406530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SUBSTITUTE BVN SPNG 1ML STRIP FIL COPIOS 10X20MM 5MM -,SUP-00700582001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1934.68,1354.276,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 2MMX45CM TRIMAX NANCY TI ALY E CAP -,SUP-00800620450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1462.94,1024.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLUG ACTB DOME HL HIP CONTIN -,SUP-00875700001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,379.28,265.496,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
HEAD BIOLOX OPT FEM 32MM/+3.5MM DELTA -,SUP-00-8777-032-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8566.51,5996.557,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SIDUS STEM-FREE SHOULDER HUMERAL ANCHOR M -,SUP-01.04555.120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19121.95,13385.365,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
G7 ACETABULAR SCREW 6.5MM / 20L -,SUP-010000997,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
G7 SCREW 6.5MM X 30MM -,SUP-010000999,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
G7 ACETABULAR SCREW 6.5MM / 35L -,SUP-010001000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
G7 SCREW 6.5MM X 40MM -,SUP-010001001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ENDOBUTTON 013186 -,SUP-013186,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.2,778.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BASE SLDR GFT F/ACL /PCL GRAFTMS II -,SUP-014950,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3100.9,2170.63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL FLEXIBLE PRE CURVED 1.50MM X 300MM -,SUP-0194-1500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL FLEXIBLE PRE CURVED 1.75MM X 300MM -,SUP-0194-1750S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.66,795.662,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL FLEXIBLE PRE CURVED 2.25MM X 300MM -,SUP-0194-2250S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1104.62,773.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL FLEXIBLE PRE CURVED 2.5MM X 450MM -,SUP-0194-2500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.59,822.213,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL FLEXIBLE PRE CURVED 3.5MM X 450MM -,SUP-0194-3500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1240.32,868.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL FLEXIBLE PRE CURVED 4.0MM X 450MM -,SUP-0194-4000S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1276.36,893.452,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL FLEXIBLE PRE-CURVED 2.25 X 300MM -,SUP-0195-2250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1104.62,773.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL FLEXIBLE PRE CURVED 2.5 X 450MM -,SUP-0195-2500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.59,822.213,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN LCP 158MM 3.5MM 6HL FA LC CONTR LCK COMPR SS TAPR -,SUP-02.104.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5487.49,3841.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN_VA-LCP 45MM 2.4MM HLX6/2 HD/SHFT CLMNX2 VAR ANG LCK -,SUP-02.111.621,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5084.31,3559.017,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.7/3.5 VA ANTEROLAT DSTL TIB PL/10 H/RT -,SUP-02.118.208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10401.04,7280.728,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7 METAPHYSEA SLF-TPNG T8 SD REC/48 -,SUP-02.118.548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7 METAPHYSEA SLF-TPNG T8 SD REC/50 -,SUP-02.118.550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.7 VA LOCKING ANT PATELLA PL SS CORE SILE -,SUP-02.137.003S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11077.74,7754.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7 VA LOCKING SLF-TPNG T8 SD REC 10 -,SUP-02.211.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 12 -,SUP-02.211.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 16 -,SUP-02.211.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 18 -,SUP-02.211.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.7 VA LCKNG SCR SLF-TPNG T8 SD REC 36 -,SUP-02.211.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.7 VA LCKING SCR SLF-TPNG T8 SD REC 38 -,SUP-02.211.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 40 -,SUP-02.211.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7 VA LCKING SLF-TPNG T8 SD REC 42 -,SUP-02.211.042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.7 VA LCKNG SCR SLF-TPING T8 SD REC 46 -,SUP-02.211.046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.7MM VA LCKNG SCREW SLF-TPNG WITH T8 60MM -,SUP-02.211.060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE FUSION CLOVERLEAF SHORT 2.4/2.7 VA-LCP -,SUP-02.211.250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8683.22,6078.254,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAP FEM NCB LCK -,SUP-0203150300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,930.39,651.273,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PRESSURIZER BNCMNT PROX FEM MED -,SUP-0206-545-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.66,71.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FEM PRESSURIZING SEAL - MED -,SUP-0206-546-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.66,71.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW INTFR CANN BIOSTEON 7X23MM FT BABSRB WDG SHP HAP PLLA -,SUP-0234-010-161,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW INTFR CANN BIOSTEON 8X28MM FT BABSRB WDG SHP HAP PLLA -,SUP-0234-010-167,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW INTFR BIOSTEON 10X35MM INTFR HAP PLLA -,SUP-0234-010-178,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CROSS TITANIUM 8MM X 60MM -,SUP-0234500160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,885.69,619.983,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SYNFLATE BALLOON MED -,SUP-03.804.701S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DEVICE TK TI KNOT 5MM -,SUP-030404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1161.17,812.819,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE FUSION 2.4/2.7MM TI VA-LCP TMT -,SUP-04.211.266,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7524.61,5267.227,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN MATRIXRIB 17HL PRCONT TI NS ROSE RD -,SUP-04.501.006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7312.41,5118.687,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN MATRIXRIB 18HL 1.5MM PRCONT LCK TI NS LBLU -,SUP-04.501.007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8297.02,5807.914,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN MATRIXRIB 18HL PRCONT LCK TI NS ROSE RD -,SUP-04.501.008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7312.41,5118.687,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN MATRIXRIB 8HL PRCONT TI UNIV NS GOLD -,SUP-04.501.009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5653.01,3957.107,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.9X10MM LCK MATRIXRIB ST TI NS GOLD.. -,SUP-04.501.020.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1309.22,916.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.9X10MM LCK MATRIXRIB ST TI NS GOLD. -,SUP-04.501.020.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1147.03,802.921,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.9X12MM LCK MATRIXRIB ST TI NS GOLD -,SUP-04.501.022.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1309.22,916.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.9X14MM LCK MATRIXRIB ST TI NS GOLD -,SUP-04.501.024.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1150.21,805.147,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
IMPLANT ZERO-P IMP 8MM LORDOTIC STERILE -,SUP-04.617.128S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11510.3,8057.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
IMPLANT ZERO-P IMP 9MM LORDOTIC STERILE -,SUP-04.617.129S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11510.3,8057.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 3.0MM X 14MM TI CERVICAL SPINE -,SUP-04.617.814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
KT BONE CMNT SPINEPLEX -,SUP-0406-202-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1455.25,1018.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CEMENT BN 20GM VERTAPLEX DMSTC DUEL -,SUP-0406-402-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1853.05,1297.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PCD SYSTEM-LONG 90DEG TUBE W/VERTAPLEX -,SUP-0507-486-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2470.55,1729.385,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PCD PREC SYS LONG TUBE W/VHV -,SUP-0507-586-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2470.55,1729.385,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 8X70MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-05080000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
KT BONE CMNT AUTOPLEX STRL -,SUP-0605-687-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3912.53,2738.771,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANNULATED TI 6.5X 110MM,SUP-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.94,757.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEPIN ORTHO 2MM -,SUP-1007-1200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SUSTAIN SPACE SMALL - 11MM -,SUP-101.111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SUSTAIN SPACER SMALL NARROW 11MM -,SUP-101.711,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE ROD 5.5 X 250MM -,SUP-10-1025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X14MM CORT/CANC SS NS F/DMD CRPL FUSION PLATE -,SUP-1011602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,651.19,455.833,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X16MM CORT/CANC SS NS F/DMD CRPL FUSION PLATE -,SUP-1011603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,651.19,455.833,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X18MM CORT/CANC SS NS F/DMD CRPL FUSION PLATE -,SUP-1011604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,651.19,455.833,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SET SCREW -,SUP-1020-00-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.0 PLY 3.5 X 24MM SYMPHONY -,SUP-1020-035-124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X100MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.0 PLY 3.5 X 14MM SYMPHONY -,SUP-1020-35-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.0 PLY 3.5 X 16MM SYMPHONY -,SUP-1020-35-116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.0 PLY 3.5 X 18MM SYMPHONY -,SUP-1020-35-118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
4.0 PLY SCREW 3.5 X 20 -,SUP-102035120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.0 PLY 4.0 X 14MM SYMPHONY -,SUP-102040114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD TI 4.0 X 070 LOR -,SUP-102064070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD TI 4.0 X 075 LOR -,SUP-102064075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TI 4.0 X 090 LOR ROD -,SUP-102064090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X65MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X75MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X85MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER 12X8X27MM LUCENT LRDTC CRV PEEK -,SUP-10227-008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER 12X9X27MM LUCENT LRDTC CRV PEEK -,SUP-10227-009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER 12X11X27MM LUCENT LRDTC CRV PEEK -,SUP-10227-011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11695.95,8187.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN F /FUSSION SS SM NS -,SUP-1024002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7238.14,5066.698,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUT ULFX MICROMITE SZ2-0 2.7MM BRD PLYSTR -,SUP-10301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1633.77,1143.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CHIP CANCELLOUS BONE 5CC 1-8 C -,SUP-103015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CREO AMP 5.5 X 50MM -,SUP-1067.1550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CREO AMP 5.5 X 45MM MOD CAN -,SUP-1067.4545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MODULAR CANNULATED 6.5 X 40MM CREO AMP -,SUP-1067.4640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD CURVED TIT ALLOY 4.75MM X 35MM -,SUP-1067.7035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD CURVED TIT ALLOY 4.75MM X 40MM -,SUP-1067.7040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ONLAY LYOPLANT 7.5 X 7.5CM -,SUP-1067040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4108.41,2875.887,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FILLER 10ML OSTEOSPONGE -,SUP-109510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4081.77,2857.239,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FILLER CANC TRBCLR DBM 15ML CHP OSTEOSPONGE ELAS OSTCONDC -,SUP-109515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FILLER DEMIN CANC BN 5ML CHP OSTEOSPONGE ELAS OSTCONDC -,SUP-109550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GRAFT DEMIN CANC BN BLCK 14MM OSTEOSPONGE ELAS OSTCONDC -,SUP-109614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3437.28,2406.096,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SUBSTITUTE CORT FBR 10CC 3DEMIN -,SUP-109760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW T15 LP CORT 3.5 X 20MM NS -,SUP-110017720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW T15 LP CORT 3.5 X 22MM NS -,SUP-110017722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW T15 LP CORT 3.5 X 24MM NS -,SUP-110017724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW T15 LP CORT 3.5 X 26MM NS -,SUP-110017726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW T15 LP CORT 3.5 X 30MM NS -,SUP-110017730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW T15 LP CORT 3.5 X 32MM NS -,SUP-110017732,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW T15 LP CORT 3.5 X 34MM NS -,SUP-110017734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW T15 LOW PROFILE CORT 3.5 X 36MM NS -,SUP-110017736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW T15 LOW PROFILE CORT 3.5  X 38MM NS -,SUP-110017738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW T15 LOW PROFILE CORT 3.5 X 40MM NS -,SUP-110017740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW T15 LP CORT 3.5 X 44 NS -,SUP-110017744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW T15 MD 3.5 X 28MM NS -,SUP-110018028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW T15 LOCK MULTIDIRECTIONAL 3.5 X 34MM NS -,SUP-110018034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW T15 MULTIDDIRECTIONAL 3.5 X 38MM NS SILVER -,SUP-110018038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW T15 MULTIDIRECTIONAL 3.5 X 40MM NS SILVER -,SUP-110018040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE T15 MULTIDIRECTIONAL 3.5 X 42MM NS SILVER -,SUP-110018042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW T15MD 3.5 X 46MM NS -,SUP-110018046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW T15 MD 3.5 X 52MM NS -,SUP-110018052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
3.2MM PEG 20MM -,SUP-110025320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
3.2MM PEG 24MM -,SUP-110025324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG FIXATION 3.2 X 26MM -,SUP-110025326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG FIXATION 3.2 X 28MM -,SUP-110025328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
3.2MM PEGS 30MM -,SUP-110025330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG 3.2 X 32 -,SUP-110025332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEGS 3.2MM X 34MM -,SUP-110025334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG 3.2 X 36MM -,SUP-110025336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG 3.2MM X 38MM -,SUP-110025338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG 3.5 X 40MM -,SUP-110025340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG 3.2 X 42 -,SUP-110025342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG 3.2MM X 44MM -,SUP-110025344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG 3.2 X 46MM -,SUP-110025346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG 3.2 X 50MM -,SUP-110025350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG 3.2 X 52MM -,SUP-110025352,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG 3.2MM X 54MM -,SUP-110025354,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG 3.2 X 56 -,SUP-110025356,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG 3.2 X 58MM -,SUP-110025358,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
3.2MM PEG 60MM -,SUP-110025360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG 3.2 X 65MM -,SUP-110025365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE PRX HUM LO LT 3H 73MM -,SUP-110030100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6671.57,4670.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PRX HUM LO PLT LT 7H 133MM -,SUP-110030102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8021.16,5614.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PRX HUM HI PLTLT 3H 80MM -,SUP-110030300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6569.71,4598.797,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PRX HUM HI PLT RT 3H 80MM -,SUP-110030400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6569.71,4598.797,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE PRX HUM HI RT 4H 90MM -,SUP-110030401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6824.35,4777.045,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
REFOBACIN BONE CEMENT R 1X14 US -,SUP-110034355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COMPR NANO 7IN STEINMANN PIN -,SUP-110045821,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3246.32,2272.424,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GRAFT PLATE CANOPY INLINE 7MM -,SUP-1102.1007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW FIXATION VARIABLE ANGLE -,SUP-111655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1457.21,1020.047,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAP SPIN CREO 5.5MM -,SUP-1119.0000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CREO THREADED LOCKING CAP -,SUP-1119.0010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CONNECTOR CROSS 38-50 LONG 5.5 CREO -,SUP-1119.0039,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CREO 5.5 CROSS CONNECTOR 48-60MM LONG -,SUP-1119.0046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TULIP HEAD FOR CORTICAL SCREW -,SUP-1119.0100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CONNECTOR CREO 5.5 LOW PROFILE CROSS  21.5-25MM LONG -,SUP-1119.0221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CREO 5.5 LOW PROFILE CROSS CONN- 24.5-31MM LONG -,SUP-1119.0224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL 5.5-4.5X25MM MOD CREO AMP -,SUP-1119.1325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
5.5-4.5 X 30MM CREO MCS SCREW -,SUP-1119.1330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5 4.5 X 35MM CORTICAL MODULAR CREO AMP -,SUP-1119.1335,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL 6.0-5.0 X 30ML -,SUP-1119.1430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
6.0-5.0 X 35MM CORTICAL SCREW -,SUP-1119.1435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORITICAL 6.5-5.5X35MM -,SUP-1119.1535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL 6.5-5.5X35MM -,SUP-1119.1535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD 5.5 X 35 TITANIUM ALLOY -,SUP-1119.5035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD STRAIGHT 5.5MM X 40 -,SUP-1119.5040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD TITANIUM ALLOY 5.5 X 45 STRAIGHT -,SUP-1119.5045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD 150MM -,SUP-1119.5150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN CREO 5.5X35MM CRV TI ALY THORLUM -,SUP-1119.7035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
5.5MM CURVED ROD TITANIUM ALLOY 40MM LENGTH -,SUP-1119.7040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD CREO 5.5X40MM -,SUP-1119.7040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD CURVED 5.5MM TITANIUM ALLOY 45MM LENGTH -,SUP-1119.7045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN CREO 5.5X50MM CRV TI ALY THORLUM -,SUP-1119.7050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN CREO 5.5X55MM CRV TI ALY THORLUM -,SUP-1119.7055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD CURVED 5.5MM TITANIUM ALLOY 60MM LENGTH -,SUP-1119.7060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD 5.5MM CURVED TIT ALLOY 65MM -,SUP-1119.7065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD CURVED 5.5MM TITANIUM ALLOY 70MM LENGTH -,SUP-1119.7070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD CURVED 5.5MM TITANIUM ALLOY 80MM LENGTH -,SUP-1119.7080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LCK EXPLOR TI ALY -,SUP-11-210099,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PELVIC ARRAY -,SUP-112230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5393.06,3775.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
STEM TPR DIST SPR 14 X 150MM ARCOS -,SUP-11-300814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
STEM TPR DIST SPR 16 X 150MM ARCOS -,SUP-11-300816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAP LOCKING CREO MIS -,SUP-1134.0010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TULIP MODULAR POLYAXIAL 30MM REDUCTION CREO MIS -,SUP-1134.0100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD CURVED 5.5MM X 50MM TITANIUM ALLOY CREO MIS -,SUP-1134.7050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
HEAD MOD 36MM COCR STD -,SUP-11-363662,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COMP 44MM GLOBAL AP SHLDR 3MM XLPE PG -,SUP-1136-41-026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8667.95,6067.565,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COMP 52MM GLOBAL AP SHLDR 3MM XLPE PG -,SUP-1136-43-026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10652.6,7456.82,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
MITRIS RESILIA MITRAL VALVE 25MM -,SUP-11400M25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
MITRIS RESILIA MITRAL VALVE 27MM -,SUP-11400M27,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
MITRIS RESILIA MITRAL VALVE 29MM -,SUP-11400M29,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
MITRIS RESILIA MITRAL VALVE 31MM -,SUP-11400M31,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
THUMBSCREW FOR C501 ROCHE CUVETTE -,SUP-11406701001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,140.74,98.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7.5MMX100MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT NS. -,SUP-1147-100-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7.5MMX100MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUTNS.. -,SUP-1147-100-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEPIN ORTHO 3.2X353MM THRD -,SUP-115163,CDM,C1713,HCPCS,278,RC,,,outpatient,,,307.85,215.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW COMP RVS CONTROL 6.5 X 20MM ST -,SUP-115380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW COMP RVS CONTROL 6.5 X 30MM ST -,SUP-115382,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X35MM CORT RVRS CNTRL 3.5MM HEX DRV HEX HEAD TI ALY -,SUP-115383,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COMP RVS CNTRL 6.5 X 20MM ST/RST -,SUP-115394,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COMP RVS CNTRL 6.5 X 25MM ST/RST -,SUP-115395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X25MM CORT RVRS CNTRL 3.5MM HEX DRV HEX HEAD TI ALY -,SUP-115395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
6.5 X 30MM CENTRAL SCREW -,SUP-115396,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
REVERSE CENTRAL SHOULDER SCREW 3.5MM X 35MM -,SUP-115397,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COMP RVS CNTRL 6.5 X 40MM ST/RST -,SUP-115398,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COMP RVS CNTRL 6.5 X 45MM ST/RST -,SUP-115399,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER ANT THORLUM VERT 14MMX15-18MMH XPAND 0DG SM 12MM OPN -,SUP-116.101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14881.7,10417.19,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER ANT THORLUM VERT 21X23MMX37-46MM XPAND 0DG MED OPN TI -,SUP-116.207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16864.45,11805.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER ANT THORLUM VERT 21X23MMX49-70MM XPAND 0DG MED OPN TI -,SUP-116.208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16864.45,11805.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CATH ANGIOPLASTIC MARINER BERENSTEIN 4FR 100CM -,SUP-11714016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SING HEAD OPEN LAT CONN 5.5-6.0 HEAD-5.5-6.35 OPEN 12MM WIDE -,SUP-1175.9214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7265.73,5086.011,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN MOUNTAINEER 3.5-5.5X420MM CRV TI OCT LVL1 NS -,SUP-1183-11-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR LD SWIFT- LOCK SPIN CRD MECH LCK -,SUP-1192,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM-THRD -,SUP-121107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM THRD_ -,SUP-121108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM THRD- -,SUP-121109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM THRD. -,SUP-121110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 19MM COMPR LAG AMBI CLASSIC IMHS 21MM THRD STD 3.5MM -,SUP-121116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,781.07,546.749,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
12MM ROD -,SUP-12-1120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X25MM CANN 19MM THRD SD/ST REVCT FLUT SS -,SUP-121625,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X30MM CANN 16MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X35MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121627,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X40MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X45MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121629,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X50MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X55MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121631,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X60MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X65MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121633,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X70MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X75MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X80MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X85MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121637,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X90MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5 CANNULATED 9.5 -,SUP-121639,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X100MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X105MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121641,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X110MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X115MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121643,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X120MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WASHER ORTHO 6.5X12.7MM F/7MM CANN BN SCR RND STRL -,SUP-121680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.23,451.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ACTB 6.5X30MM GRIFTON PINNCL LCK TI FOAM DOME ST -,SUP-1217-30-500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,537.46,376.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX10MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX12MM CANN 5MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX14MM CANN 5MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX16MM CANN 6MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX18MM CANN 7MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX22MM CANN 9MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX24MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX26MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX28MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX30MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121830,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX32MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX34MM CANN 14MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121834,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX36MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121836,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX38MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121838,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX40MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX42MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121842,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX44MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121844,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX46MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX48MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121848,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX50MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121850,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX52MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121852,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX54MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121854,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX56MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121856,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX58MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121858,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANNULATED 4.0M X 60M -,SUP-121860,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX65MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX70MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121870,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
30MM CROSSLINK -,SUP-12-2052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CATALYST R1 6.5MM CENTER SCREW AND CAP SIZE 30 -,SUP-1230-7508-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CATALYST R1 4.5MM LOCKING SCREW SIZE 20 -,SUP-1230-7511-003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CATALYST R1 4.5MM LOCKING SCREW SIZE 24 -,SUP-1230-7511-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CATALYST R1 GLENOSPHERE LOCKING SCREW IMPLANT -,SUP-1230-7515-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LINER INSERT MDM X3 22.2MM ID X 36MM OD X 36C -,SUP-1236-2-242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ENDCAP SPIN REVERE -,SUP-124.000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
REV LOW PROF ADJ T-CONN 29 X 34 -,SUP-124.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X25MM REVERE DBL LD THRD POLYAX F/5.5MM TI -,SUP-124.051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X30MM REVERE DL HEAD THRD POLYAX F/5.5MM TI -,SUP-124.052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI -,SUP-124.053,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X35MM REVERE DEFRM MONOAX -,SUP-124.263,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X40MM REVERE DEFRM MONOAX -,SUP-124.264,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7.5X35MM REVERE DEFRM MONOAX -,SUP-124.273,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X30MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.443,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
4.5MM REVERE PEDICLE SCREW 45MM -,SUP-124.445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5X30MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.452,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.453,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5X40MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.454,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5X45MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5X50MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.456,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5X55MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.457,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X30MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.462,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.463,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X40MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.464,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X45MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X50MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.466,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X55MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.467,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X60MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.468,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X65MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.469,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7.5X40MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.474,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN REVERE DEFRM 5.5X100MM STR TI LPRO THORLUM NTHRD -,SUP-124.510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
5.5MM STRAIGHT ROD 125MM -,SUP-124.512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN REVERE DEFRM 5.5X150MM STR TI LPRO THORLUM NTHRD -,SUP-124.515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
5.5MM STRAIGHT ROD 400MM -,SUP-124.520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD STRAIGHT 5.5 X 500 -,SUP-124.521,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN REVERE DEFRM 5.5X45MM STR TI LPRO THORLUM NTHRD LCK -,SUP-124.545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN REVERE DEFRM 5.5X85MM STR TI LPRO THORLUM NTHRD LCK -,SUP-124.585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
5.5MM CURVED ROD 125MM -,SUP-124.612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN REVERE DEFRM 5.5X35MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN REVERE DEFRM 5.5X40MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN REVERE DEFRM 5.5X45MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN REVERE DEFRM 5.5X50MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN REVERE DEFRM 5.5X55MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN REVERE DEFRM 5.5X60MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN REVERE DEFRM 5.5X65MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN REVERE DEFRM 5.5X75MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6MM DL OD 35MM REVERE POLYAX CORT/CANC F/5.5MM TI ALY -,SUP-124.762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6MM DL OD 40MM REVERE POLYAX CORT/CANC F/5.5MM TI ALY -,SUP-124.763,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CONNECTOR ROD REVERE 5.5MM VARIABLE CROSS 38MM-50MM -,SUP-124.984,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3327.48,2329.236,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
5.5MM CLOSED OFFSET CONNECTOR 5.5MM ROD 30MM -,SUP-124.993,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ELIMINATOR ACTB THRD POS STP F/CUP DURALOC -,SUP-1246-03-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
OSTEOAMP GRANULES 1CC -,SUP-12600201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2340.97,1638.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
OSTEOAMP GRANULES 5CC -,SUP-12600401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4725.27,3307.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
OSTEOAMP GRANULES 10CC -,SUP-12600501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7875.46,5512.822,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
OSTEOAMP GRANULES 2-4MM (5CC) -,SUP-12700401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4587.68,3211.376,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEPIN ORTHO 1.3MMX15CM THRD TROC TIP -,SUP-128047,CDM,C1713,HCPCS,278,RC,,,outpatient,,,305.64,213.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
STAPLE BN FX XS COCR -,SUP-128690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2676.59,1873.613,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
STAPLE BN FX SM COCR -,SUP-128692,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2676.59,1873.613,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
RESTRICTOR BNCMNT FMCNL 25MM BUCK -,SUP-129419,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1159.24,811.468,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
UNITED HIP SYSTEM FULL XPE CUP 36MM X 54MM -,SUP-1302-3654,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
STAPLE SPIN RSTRL SM TI -,SUP-131.001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4759.68,3331.776,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
STAPLE SPIN CDL SM TI -,SUP-131.002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4759.68,3331.776,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
STAPLE SPIN ANT VERT SM TI -,SUP-131.011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3413.41,2389.387,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CONNECTOR SPIN REVERE DL CX 15MM TI -,SUP-131.115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CONNECTOR SPIN CX TI -,SUP-131.116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.5X35MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.5X40MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.5X18MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.5X24MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN TMX 12.9MMX43.7MM COMPR HI STRGTH 2D CONTR LCK Y -,SUP-1312-17-003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2534.99,1774.493,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN F 3 13MMX42.7MM HI FLEX 3D CONTR LCK NS RT -,SUP-131217100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2778.47,1944.929,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN F 3 13MMX42.7MM HI FLEX 3D CONTR LCK NS LT -,SUP-131217101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2778.47,1944.929,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WASHER ORTHO 3.5MM ALPS F/ELB PLATE SYS NS -,SUP-131218000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X14MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X16MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X28MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X30MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X36MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X40MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X44MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X48MM NLCKG CORT ALPS TRNCT SQ DRV TMX NS -,SUP-131218048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X50MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X60MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X70MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN ALPS 10.7X85MM 9HL 2.4MM CONTR LCK TMX ANTMC -,SUP-131218203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN ALPS 17.5X29MM 1.5MM CONTR LCK TMX SM ANTMC NS -,SUP-131218400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3637.79,2546.453,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN SM -,SUP-1312-18-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4024.48,2817.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN ALPS 81X10IN 10HL CONTR LCK COMPR TMX SM ANTMC NS -,SUP-131218600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN ALPS 10.7X154MM 17HL 2.5MM CONTR LCK COMPR TMX LNG -,SUP-131218607,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4481.66,3137.162,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WASHER ORTHO 2.5MM ALPS THRD -,SUP-131220025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN ALPS 2.5MM PRCONT LCK COMPR TMX T-SHP ANTMC NS -,SUP-131220152,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2353.42,1647.394,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN ALPS 2.5MM PRCONT LCK COMPR TMX SM T-SHP ANTMC NS -,SUP-131220157,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2099,1469.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN ALPS 2.5MM PRCONT LCK COMPR TMX STR ANTMC NS -,SUP-131220251,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2448.83,1714.181,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN ALPS 27.6MMX73.8MM 2.5MM 1.65MM PRCONT LCK COMPR -,SUP-131220252,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2448.83,1714.181,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN ALPS 19.5MMX71.8MM 2.5MM 1.65MM PRCONT LCK COMPR -,SUP-131220253,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2448.83,1714.181,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.5X11MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.5X14MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.5X15MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220415,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.5X16MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.5X12MM NLCKG CORT ALPS ST MULDIR MODULAR SQ DRV TMX -,SUP-131220512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.5X14MM NLCKG CORT ALPS ST MULDIR MODULAR SQ DRV TMX -,SUP-131220514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.5X15MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.5X16MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.5X18MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.5X20MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.7X18MM LCK SMTH DVR -,SUP-131227118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X20MM LCK CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X22MM LCK CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X14MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X15MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227215,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X16MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X26MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227226,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN DVR 24X85MM F/CROSSLOCK DIST RAD PLATE SYS LNG LCK -,SUP-131812090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4558.06,3190.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN MARS 5.5X45MM CRV CONE TIP TI ANT LMBR -,SUP-132.145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4334.79,3034.353,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN MARS 5.5X50MM CRV CONE TIP TI ANT LMBR -,SUP-132.150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN MARS 5.5X55MM CRV CONE TIP TI ANT LMBR -,SUP-132.155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4334.79,3034.353,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN MARS 5.5X60MM CRV CONE TIP TI ANT LMBR -,SUP-132.160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW REVIEVE 2.2MM X 6MM SELF TAPPING -,SUP-136.506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1235.02,864.514,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FEMORAL HEAD BIOLOX 32MM +5 12 -,SUP-1365-32-720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5432.32,3802.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FEMORAL HEAD BIOLOX DELTA TS CERAMIC  36MM +1.5 12/14 TAPER -,SUP-1365-36-710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5432.32,3802.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CERAMIC FEMORAL HEAD 40MM X 1.5 BIOLOX DELTA TS -,SUP-1365-40-710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FORTIFY I 12MM UPPER ENDPLATE 12 X 14MM 0 DEG -,SUP-137.300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FORTIFY I 12MM UPPER ENDPLATE 12 X 14MM 3.5 DEG -,SUP-137.301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FORTIFY I 12MM LOWER ENDPLATE 12 X 14MM 0 DEG -,SUP-137.350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FORTIFY I 12MM LOWER ENDPLAE 12 X 14MM 3.5 DEG -,SUP-137.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FORTIFY I 12MM LOWER ENDPLATE 12 X 14MM 3.5 DEG -,SUP-137.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
KT BONE CMNT 2.5% GENT40 GM CEMEX GENTA RX STRL -,SUP-1400-AG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEPIN ORTHO 3.2MM STNMN 14IN THRD -,SUP-14012-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,213.27,149.289,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEPIN ORTHO 3.2MMX9IN THRD -,SUP-140129,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X52MM CORT VERSANAIL FT ST NON-DRV END SLD HEX HEAD -,SUP-14022-52,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW AUTOFIX 2.0 X 10MM -,SUP-141-2010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW  AUTOFIX 2.0 X 12MM -,SUP-141-2012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
AUTOFIX HEADLESS SCREW 2.0 X 13 -,SUP-141-2013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW AUTOFIX HEADLESS 2.0 X 13 -,SUP-141-2013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW AUTOFIX HEADLESS 2.0 X 14 -,SUP-141-2014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANNULATED 2.0 X 15MM -,SUP-141-2015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW AUTOFIX 2.0 X 16 -,SUP-141-2016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2X17MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD MOD -,SUP-1412017,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2X18MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD MOD -,SUP-141-2018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANNULATED 2.0 X 19MM -,SUP-141-2019,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW AUTOFIX COMPRESSION 2.0 X 20MM -,SUP-141-2020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW AUTOFIX 2.0 X 21MM -,SUP-141-2021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW AUTOFIX 2.5 X 23MM -,SUP-141-2023,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW AUTOFIX 2.5 X 24MM -,SUP-141-2024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
AUTOFIX SCREW 2.0 X 25MM -,SUP-141-2025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW AUTOFIX 2.0 X 26MM -,SUP-141-2026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW AUTOFIX 2.5 X 28MM -,SUP-141-2028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
AUTOFIX 2.0 X 29MM SCREW -,SUP-141-2029,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW AUTOFIX COMPRESSION 2.0 X 30MM -,SUP-141-2030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW AUTOFIX 2.5 X 10 -,SUP-141-2510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW AUTOFIX HEADLESS 2.5 X 14 -,SUP-141-2514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANNULATED 25 X 15MM -,SUP-141-2515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
AUTOFIX 2.0/2.5 16MM -,SUP-141-2516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEADLESS 2.5 X 17MM -,SUP-141-2517,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW AUTOFIX 2.5 X 18MM -,SUP-141-2518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW AUTOFIX 2.5 X 19 -,SUP-141-2519,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW AUTOFIX 2.5 X 21MM -,SUP-141-2521,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
AUTOFIX 2.0/2.5 23MM -,SUP-141-2523,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5X24MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD -,SUP-1412524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEADLESS 2.5 X 25MM -,SUP-141-2525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEADLESS 2.5 X 26MM -,SUP-141-2526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
AUTOFIX 2.5/2.5 27MM -,SUP-141-2527,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEADLESS 2.5 X 28MM -,SUP-141-2528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5X30MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD -,SUP-141-2529,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5X30MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD -,SUP-1412530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE 2.5MM 30MM AUTOFIX STAINLESS STEEL T7 FOOT ANKLE -,SUP-141-2530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WASHER ORTHO 8MM TI -,SUP-14191,CDM,C1713,HCPCS,278,RC,,,outpatient,,,175.05,122.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 8X100MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 8X105MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 8X110MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 8X40MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 8X45MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 8X50MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 8X55MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 8X60MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 8X65MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 8X70MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 8X75MM CANN LAG CANC ACE THRD SD/ST CUT FLUTX4 TMX NS -,SUP-14192-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 8X85MM CANN LAG CANC ACE 24MM THRD SD/ST CUT FLUTX4 -,SUP-14192-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 8X90MM CANN LAG CANC ACE 24MM THRD SD/ST CUT FLUTX4 -,SUP-14192-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 8X95MM CANN LAG CANC ACE 24MM THRD SD/ST CUT FLUTX4 -,SUP-14192-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X100MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X105MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X110MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X115MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X120MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X25MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X30MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X35MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X40MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X45MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X50MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X55MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X60MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X65MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X70MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X75MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X80MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X85MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X90MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X95MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X100MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X105MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT -,SUP-14197-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X110MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT -,SUP-14197-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X40MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X45MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X50MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X55MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X60MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X65MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X70MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X75MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X80MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X85MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X90MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X95MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PRECISION PIN TM TAPERED D3.2/3.9X450MM -,SUP-1420-0065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X20MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X22MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X24MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X26MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X28MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X30MM CANNULATEDLAG CORT FT TMX NS -,SUP-14200-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X32MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X34MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X36MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X38MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X40MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X42MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X44MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X46MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X48MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X50MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X55MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X60MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X65MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X70MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X36MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-14223036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X30MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14250-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X32MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X34MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X36MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X38MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X40MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X42MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X44MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X46MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14250-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X48MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14250-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X50MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X55MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X60MM CANN LAG CORT 20MM FT SD/ST BIOCMPT TMX NS -,SUP-14250-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X65MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X70MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WASHER ORTHO F/4.5-5.0MM CANN SCR SYS FLT -,SUP-14260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,504.67,353.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 10HL 100DG TBLR -,SUP-14355-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,557.3,390.11,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN ALPS 9.2X49MM 3.5MM 4HL 1.3MM LCK TI 100DG ANG TBLR -,SUP-143554,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN ALPS 9.2X73MM 3.5MM 6HL LCK COMPR TMX ANTMC THRD HL -,SUP-143556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN ALPS 9.2X85MM 3.5MM 7HL LCK TI ANTMC NS -,SUP-143557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN ALPS 9.2X97MM 3.5MM 8HL LCK TI 100DG ANG TBLR ANTMC -,SUP-143558,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X14MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X16MM CANC -,SUP-14376-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,977.89,684.523,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X24MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X34MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-1437634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X40MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X42MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X44MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X46MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X48MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X50MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X55MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X60MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X65MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X70MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BONE PIN- 4 x 110MM- STERILE (2 Pack) -,SUP-144110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BONE PIN- 4 x 140MM- STERILE (2 Pack) -,SUP-144140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BONE PIN- 4 x 170MM- STERILE (2 Pack) -,SUP-144170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER ANT CERV 14X6X12MM SOLITAIRE 12DG LRDTC S/MED -,SUP-14-520506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12505.38,8753.766,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER ANT CERV 14X7X12MM SOLITAIRE 12DG LRDTC S/MED -,SUP-14-520507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12505.38,8753.766,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER ANT CERV 14X9X12MM SOLITAIRE 12DG LRDTC S/MED -,SUP-14-520509,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12505.38,8753.766,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER 10X27X8MM ZYSTON 6DG LRDTC CRV TAPR -,SUP-14-533128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER 10X25X7MM ZYSTON STR CNVX -,SUP-14-534067,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE 3.5MM X46MM CANNULATED -,SUP-148.146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.2X13MM PROVIDENCE SD FX-ANG -,SUP-150.013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.2MM X 14MM -,SUP-150.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN PROVIDENCE 12MM 4HL LVL1 TI LCK -,SUP-150.112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN PROVIDENCE 14MM 4HL LVL1 TI LCK -,SUP-150.114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN PROVIDENCE 16MM 4HL LVL1 TI LCK -,SUP-150.116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN PROVIDENCE 18MM 4HL LVL1 TI LCK -,SUP-150.118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANTERIOR CERVICAL PLATE 1-LEVEL -,SUP-150.120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE ANTERIOR CERVICAL 1-LEVEL 22MM PROV -,SUP-150.122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE ANTERIOR CERVICAL 24MM 1 LEVEL PROVIDENCE -,SUP-150.124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANTERIOR CERVICAL PLATE 14MM LORD -,SUP-150.134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN PROVIDENCE 28MM 6HL LVL2 TI LCK -,SUP-150.228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN PROVIDENCE 30MM 6HL LVL2 TI LCK -,SUP-150.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN PROVIDENCE 32MM 6HL LVL2 TI LCK -,SUP-150.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN PROVIDENCE 34MM 6HL LVL2 TI LCK -,SUP-150.234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN PROVIDENCE 36MM 6HL LVL2 TI LCK -,SUP-150.236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE CERVICAL ANTERIOR 2-LEVEL 38MM -,SUP-150.238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN PROVIDENCE 45MM 8HL LVL3 TI LCK -,SUP-150.345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN PROVIDENCE 48MM 8HL LVL3 TI LCK -,SUP-150.348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN PROVIDENCE 51MM 8HL LVL3 TI LCK -,SUP-150.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN PROVIDENCE 54MM 8HL LVL3 TI LCK -,SUP-150.354,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN PROVIDENCE 57MM 8HL LVL3 TI LCK -,SUP-150.357,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PROVIDENCE ANTERIOR CERVICAL PLATE 3-LVL 60MM -,SUP-150.360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANTERIOR CERVICAL PLATE 4-LEVEL 69MM -,SUP-150.469,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW PROV 4.6MM FIXED ANGLE SELF DRILL 14MM -,SUP-150.514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.6X16MM PROVIDENCE ST FA TI ALY -,SUP-150.536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.6X18MM PROVIDENCE SD FA TI ALY -,SUP-150.538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.2X12MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.2X13MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.613,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.2X14MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.2X15MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.2X16MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SELF DRILLING 4.6MM X 12MM VAR ANGLE PROV -,SUP-150.712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.6X13MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.713,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.6X14MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.6X16MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SELF DRILLING 4.2MM X 12MM VAR ANGLE PROV -,SUP-150.812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PROVIDENCE 4.2MM VARIABLE ANGLE SCREW SELF-TAP 14MM -,SUP-150.814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW PROVIDENCE 4.6MM VARIABLE ANGLE 16MM SELF TAPPING -,SUP-150.816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW PROVIDENCE 4.2MM VARIABLE ANGLE - 20MM -,SUP-150.820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TRNSCONN 4.6X12MM PROVIDENCE ST VAR ANG TI ANT CERV -,SUP-150.912,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.6X14MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.914,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.6X15MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.915,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.6X16MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.916,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.6X18MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.918,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SELF TAPPING 4.6 X 20 VAR ANGLE PROV -,SUP-150.920,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
OSS POLY LOCK PIN -,SUP-150478,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1865.78,1306.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FORTIFY 12MM CORE HEIGHT 21-29MM -,SUP-151.052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FORTIFY 12MM CORE HEIGHT 25-37MM -,SUP-151.053,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CORE FORTIFY 012MM HEIGHT 33-53MM -,SUP-151.054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ENDPLATE UPPER 012MM 12X14 FOOTPRINT 3.5 DEG -,SUP-151.323,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ENDPLATE LOWER 012MM 12 X 14 FOOTPRINT 7 DEG FORTIFY -,SUP-151.374,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SYSTEM CLENCH STAPEL 9MM X 7MM -,SUP-152-30907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SYSTEM CLENCH STAPLE 15MM X 12MM -,SUP-152-31512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SYSTEM CLENCH STAPLE 18MM X 18MM -,SUP-152-31818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
STAPLE CLENCH 15MM X 12MM -,SUP-152-41512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BED F/PROC STRECHER UPR FRM ASMB -,SUP-16042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.68,1.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE OSS RS NON MOD LONG 59 -,SUP-161022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20050.2,14035.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN FX STNMN 2MMX9IN SMTH SGL END PLN DMD PT NS -,SUP-1620-609NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21.41,14.987,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN FX STNMN 2.4MMX9IN SMTH SGL END PLN DMD PT NS -,SUP-1624-609NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21.41,14.987,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN FX STNMN 4.8MMX9IN SMTH SGL END PLN DMD PT NS -,SUP-1648-609X,CDM,C1713,HCPCS,278,RC,,,outpatient,,,29.18,20.426,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TIBIAL INSERT PS SZ 6 13MM -,SUP-166-5613,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SHELL ACETABULAR ESCALADE 46MM -,SUP-170-0146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ESCALADE EXL LINER +1 28 X 46MM -,SUP-170-2846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
EXPANSION BOLT RECONSTRUCTION PROSTHESIS -,SUP-172-947/38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
MESH SURG 17X22X50MM OVL TI HARMS -,SUP-1741-48-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17992.27,12594.589,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
MESH SURG 17X22X70MM OVL TI HARMS -,SUP-1741-49,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20248.85,14174.195,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
MESH SURG 22X28X70MM OVL TI HARMS -,SUP-1741-52-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20248.85,14174.195,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
MESH SURG 22X28X90MM OVL TI HARMS -,SUP-1741-53-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,24291.37,17003.959,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
MESH SURG 26X33X50MM OVL TI HARMS -,SUP-1741-54-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17992.27,12594.589,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
MESH SURG 26X33X70MM OVL TI HARMS -,SUP-1741-55-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21889.99,15322.993,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WASHER SPIN TI POLY IEXP -,SUP-1754-91-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NUT SPIN TI BOLT SWVL LCK IEXP -,SUP-1754-91-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,543.24,380.268,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE 50MM RND 10MM SGL LVL TI -,SUP-1760-10-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17292.37,12104.659,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE 50MM RND 12MM SGL LVL TI -,SUP-1760-12-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17292.37,12104.659,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE 90MM RND 12MM SGL LVL TI -,SUP-1760-12-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18873.18,13211.226,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE 50MM RND 14MM SGL LVL TI -,SUP-1760-14-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17292.37,12104.659,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE 90MM RND 14MM SGL LVL TI -,SUP-1760-14-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19307.6,13515.32,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE 50MM RND 16MM SGL LVL TI -,SUP-1760-16-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16483.86,11538.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
MESH ROUND 16MM X 90MM SPN -,SUP-1760-16-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19754.09,13827.863,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
MESH SURG 12X23MM DIA 12X14MM OVL TRPZD TI HARMS -,SUP-1762-02-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10345.35,7241.745,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NUT ORTHO DOME TI SWVL F/MONARCH SPN SYS -,SUP-1770-91-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,481.97,337.379,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN SKNLC 47MM LVL2 TI LPRO -,SUP-1796-02-047,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6079.53,4255.671,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SET SCREW SPIN EXPEDIUM TI POST PDCL THORLUM SQ THRD -,SUP-1797-02-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SET SCREW SPIN EXPEDIUM TI POST PDCL THORLUM SQ THRD -,SUP-1797-02-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
VIPER TI SAI POLY 8X90MM -,SUP-179704890,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7.5X45MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7.5X50MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-179712050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7.5X65MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.35X20MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.35X25MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.35X30MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.35X35MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.35X40MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5 X 25MM POLYAXIAL SI -,SUP-179712525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X40MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X45MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X50MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6X30MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6X35MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6X55MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7X35MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-735,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7X45MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-745,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7X50MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7X55MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
EXP TI POLY SCREW 8 X 40MM -,SUP-179712840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW POLYAXIAL 8MM X 65MM -,SUP-179712865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN EXPEDIUM 5.5X480MM HEX END TI POST PDCL THORLUM -,SUP-179762480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN EXPEDIUM 5.5X35MM CRV TI POST PDCL THORLUM PRELRD -,SUP-1797-71-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN EXPEDIUM 5.5X40MM CRV TI POST PDCL THORLUM PRELRD -,SUP-1797-71-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD PRE-LODOSED W/LINE 65MM -,SUP-179771065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD PRE-LORDOSED 75MM W/LINE -,SUP-179771075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD PRE-LORDOSED W/LINE 85MM -,SUP-179771085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CONNECTOR 20MM EXPEDIUM LAT OFST OPN F/10MM TI -,SUP-1797-92-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CONNECTOR 50MM EXPEDIUM LAT OFST OPN F/5.5MM TI -,SUP-1797-92-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CONNECTOR 20MM EXPEDIUM OPN F/5.5MM TI ILC -,SUP-1797-97-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X42MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-49-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X46MM TMX CANN RDC HEAD -,SUP-1802-49-046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X30MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X32MM CANN -,SUP-1802-53-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X34MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X36MM CANN -,SUP-1802-53-036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X38MM CANN -,SUP-1802-53-038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X40MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X42MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X44MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X50MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COMP SCR 5MM CANN LAG P/T SD/ST TMX 55MM -,SUP-1802-53-055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X60MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X65MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X70MM CANN LAG CANC P/T SD/ST SM HEAD TMX -,SUP-1802-53-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X75MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X80MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5MMSMX85MM CANN LAG CANC PARTIALY THRD SD/ST RDC HEAD -,SUP-1802-53-085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X90MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5MMSMX95MM CANNULATEDLAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X100MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.75X15MM LCK CMPRHNSV RVRS FX TI ALY HAP CTD BLU -,SUP-180500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.75X20MM NLCKG CMPRHNSV RVRS FX TI ALY HAP CTD GOLD -,SUP-180508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.75X25MM NLCKG CMPRHNSV RVRS FX TI ALY HAP CTD GOLD -,SUP-180509,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.75X15MM LCK CORT FX 3.5MM HEX HEAD TI ALY HAP CTD -,SUP-180550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
4.75 X 20MM FIXED LOCKING SCREW 3.5MM HEX -,SUP-180551,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COMP LK SCR 3.5 HEX 4.75 X 25 ST -,SUP-180552,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW COMP LK 3.5 HEX 4.75 X 30 ST -,SUP-180553,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW COMP LK 3.5 HEX 4.75 X 35 ST -,SUP-180554,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COMP LK SCR 3.5 HEX 4.75 X 40 ST -,SUP-180555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.75X15MM NLCKG CORT VAR ANG 3.5MM HEX HEAD TI ALY HAP -,SUP-180557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.75X20MM NLCKG CORT VAR ANG 3.5MM HEX HEAD TI ALY HAP -,SUP-180558,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.75X25MM NLCKG CORT VAR ANG 3.5MM HEX HEAD TI ALY HAP -,SUP-180559,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COMP NLK SCREW 3.5 HEX 4.75 X 30 ST -,SUP-180560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.75X35MM NLCKG CMPRHNSV 3.5MM HX HEX HEAD TMX HAP CTD -,SUP-180561,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
K-WIRE- STERILE 3 x 285MM -,SUP-1806-0050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,459.86,321.902,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
STRYKER PLATE -,SUP-1806-0150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,793.85,555.695,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10X320MM VERSANAIL CANN FEM TI ALY -,SUP-1813-10-320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7410.02,5187.014,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 13X400MM VERSANAIL CANN RT TROCH FEM TI ALY -,SUP-1814-13-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10160.14,7112.098,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 7X220MM VERSANAIL CANN HUM TI ALY -,SUP-1817-07-221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 8X200MM VERSANAIL CANN HUM TI ALY -,SUP-1817-08-201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 9X260MM VERSANAIL CANN HUM TI ALY -,SUP-1817-09-261,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
T2 ANKLE COMPRESSION SCREW -,SUP-1818-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1161.6,813.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10X150MM VERSANAIL CANN PROX HUM SS -,SUP-1818-10-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7282.7,5097.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL T2 ANKLE ARTHRODESIS LEFT -,SUP-1818-1020S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
T2 ANKLE NAIL 11x200MM LEFT -,SUP-1818-1120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
T2 ANKLE ARTHRODESIS NAIL LEFT 11X300MM -,SUP-1818-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 12X200MM T2 CANN LT ANKL TI ALY BIOMECH -,SUP-1818-1220S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
T2 ANKLE ARTHRODESIS NAIL RIGHT 11 X 150MM -,SUP-1819-1115S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 12X200MM T2 CANN RT ANKL TI ALY BIOMECH -,SUP-1819-1220S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.8MMX20MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-35-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X24MM CORT 3.5MM HX NS F/2.9MM DRLBT -,SUP-1819-35-024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X30MM CORT 3.5MM HX NS F/2.9MM DRLBT -,SUP-1819-35-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.8MMX30MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.8MMX32MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 4.8MMX42MM 3.6MM HX NS -,SUP-1819-48-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.8MMX44MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.8MMX46MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.8MMX50MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X24MM ELLIPSE POLYAX TI -,SUP-182.224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MM X 26MM ELLIPSE POLYAXIAL SHOULDER -,SUP-182.226,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X28MM ELLIPSE POLYAX TI. -,SUP-182.228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X30MM ELLIPSE POLYAX TI. -,SUP-182.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X32MM ELLIPSE POLYAX TI -,SUP-182.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X34MM ELLIPSE POLYAX TI -,SUP-182.234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X10MM ELLIPSE POLYAX TI -,SUP-182.310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X12MM ELLIPSE POLYAX TI -,SUP-182.312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X14MM ELLIPSE POLYAX TI -,SUP-182.314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ELLIPSE POLYAXIAL 3.5MM X 16MM -,SUP-182.316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X18MM ELLIPSE POLYAX TI -,SUP-182.318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X20MM ELLIPSE POLYAX TI -,SUP-182.320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X22MM ELLIPSE POLYAX TI -,SUP-182.322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X26MM ELLIPSE POLYAX TI -,SUP-182.326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X28MM ELLIPSE POLYAX TI -,SUP-182.328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X30MM ELLIPSE POLYAX TI -,SUP-182.330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X10MM ELLIPSE POLYAX TI -,SUP-182.410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X12MM ELLIPSE POLYAX TI -,SUP-182.412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X14MM ELLIPSE POLYAX TI -,SUP-182.414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
4.0MM ELLIPSE POLYAXIAL SCREW 16MM -,SUP-182.416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X18MM ELLIPSE POLYAX TI -,SUP-182.418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X20MM ELLIPSE POLYAX TI -,SUP-182.420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X22MM ELLIPSE POLYAX TI -,SUP-182.422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X24MM ELLIPSE POLYAX TI -,SUP-182.424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X26MM ELLIPSE POLYAX TI -,SUP-182.426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ELLIPSE POLYAXIAL 4.0 X 28MM -,SUP-182.428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ELLIPSE LOCKING CAP -,SUP-182.500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
HOOK SPIN INLN ELLIPSE -,SUP-182.501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ELLIPSE POLYAXIAL 4.5 X 20 -,SUP-182.520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X22MM ELLIPSE POLYAX TI -,SUP-182.522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X24MM ELLIPSE POLYAX TI -,SUP-182.524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X26MM ELLIPSE POLYAX TI -,SUP-182.526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ELLIPSE POLYAXIAL 4.5 X 28 -,SUP-182.528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ELLIPSE POLYAXIAL 4.5 X 30 -,SUP-182.530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD TO ROD CLAMP CT TO CT 7MM -,SUP-182.741,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD TO ROD CLAMP CT TO CT 9MM -,SUP-182.770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN ELLIPSE 6.35X80MM TI POST OCT -,SUP-182.801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN ELLIPSE 6.35X120MM TI POST OCT -,SUP-182.802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN ELLIPSE 3.5X240MM TI POST OCT -,SUP-182.803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN ELLIPSE 3.5X40MM TI POST OCT -,SUP-182.804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ENDCAP SPIN ELLIPSE T-SHP HD-TO-HD -,SUP-182.900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NUT SPIN ELLIPSE F/HD-TO-HD TRANSV CONN T-SHP -,SUP-182.901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TRNSCONN 27-33MM ELLIPSE HD-TO-HD F/3.5MM T-SHP POST OCT -,SUP-182.912,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TRNSCONN 26-46MM ELLIPSE F/3.5MM CRV POST OCT -,SUP-182.924,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE OCPTL SM ELLIPSE -,SUP-182.950,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 8MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0828S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 8MMSTDX300MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0830S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 8MMSTDX315MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0831S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 8MMSTDX330MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0833S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 8MMSTDX360MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0836S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 8MMSTDX390MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0839S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1028S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TIBIAL NAIL 10 X 390MM -,SUP-1822-1039S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1128S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
T2 STD. TIBIAL NAIL 11MM X 300MM -,SUP-1822-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TIBIAL NAIL 11 X 375MM -,SUP-1822-1137S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
11 X 390MM TIBIA NAIL -,SUP-1822-1139S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 12MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1228S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 12MMSTDX315MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1231S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 12MMSTDX345MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 12MMSTDX360MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
T2 TIBIAL NAIL SYSTEM  12 X 390MM -,SUP-1822-1239S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 8MM COMPR T2 CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1825-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.67,530.369,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 8X5MM COMPR T2 CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1825-0005S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.67,530.369,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL SYS T2 FEMUR A/R 010 X 340MM -,SUP-1825-1034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10X360MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1038S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11X280MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1128S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11X320MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1132S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11X340MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11X400MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1140S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1144S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 12X280MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1228S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 12X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1230S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 12X360MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 12X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1238S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 12X420MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1242S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 12X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1244S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 13X180MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1318S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 13X240MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1324S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 13X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1330S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 13X340MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1334S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 13X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1338S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 13X400MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 13X420MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1342S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 13X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1344S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 14X240MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1424S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 14X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1430S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 14X320MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1432S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 14X340MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1434S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 14X360MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1436S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 14X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1438S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 14X400MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 14X420MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1442S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 14X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1444S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAP ORTHO 8X4MM TI E CAP PROT -,SUP-1826-0003S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,771.97,540.379,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
T2 SUPRACONDYLAR NAIL 9X340MM -,SUP-1826-0934S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
T2 SUPRACONDYLAR NAIL 9X380MM -,SUP-1826-0938S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1020S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SUPRACONDYLAR NAIL 10 X 320 -,SUP-1826-1032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10MMLNGX340MM T2 CANN SPRACON TI BIOMECH -,SUP-1826-1034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10MMLNGX360MM T2 CANN SPRACON TI BIOMECH -,SUP-1826-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL SUPRACONDYLAR 10MM X 400MM -,SUP-1826-1040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11MMLNGX240MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1124S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11MMLNGX320MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1132S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SUPRACONDYLAR NAIL 11 X 360MM -,SUP-1826-1136S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL SUPRACONDYLAR 11 X 380 -,SUP-1826-1138S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL SUPRACONDYLAR 11 X 420 -,SUP-1826-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 12MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1220S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 12MMLNGX280MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1228S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 12MMLNGX300MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1230S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 12MMLNGX320MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1232S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 12MM X 340MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL SUPRACONDYLAR 12 X 360 -,SUP-1826-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
T2 SUPRACONDYLAR NAIL 12X400MM -,SUP-1826-1240S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 13MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 13MMLNGX300MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1330S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 13MMLNGX340MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1334S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL SUPRACONDYLAR 13MM X 360MM -,SUP-1826-1336S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 13MMLNGX380MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1338S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 13MMLNGX400MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 13MMLNGX420MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1342S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL SUPRACONDYLAR 14 X 380 -,SUP-1826-1438S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL FEMORAL 10 X 360 -,SUP-1828-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5072.64,3550.848,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL FEMORAL 11 X 340MM -,SUP-1828-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5072.64,3550.848,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL FEMORAL 11 X 400 -,SUP-1828-1140S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5072.64,3550.848,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 13X740MM T2 CANN RT KN TI ALY BIOMECH -,SUP-1829-1374S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,28428.72,19900.104,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WASHER ORTHO 10MM TI ALY SQ STRL -,SUP-1830-0009S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,718.87,503.209,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 7X210MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0721S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 7X220MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0722S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 7X240MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0724S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 8X240MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0824S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 8X250MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0825S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 8X280MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0828S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 9X210MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0921S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 9X220MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0922S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 9X240MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0924S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 9X250MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0925S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ENDCAP ORTHO 6MM STD TI T2 STRL -,SUP-1832-0003S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,725,507.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 8MMLNGX150MM T2 CANN LT PROX HUM TI ALY -,SUP-1832-1035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6798.89,4759.223,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 8MMLNGX240MM T2 CANN LT PROX HUM TI ALY BIOMECH -,SUP-1832-2824S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 8MMLNGX260MM T2 CANN LT PROX HUM TI ALY BIOMECH -,SUP-1832-2826S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 8MMLNGX220MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3822S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11MMLNGX240MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3824S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 8MMLNGX260MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3826S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11MMLNGX280MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3828S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE 3.6MM VAR SELF-TAPPING 14MM -,SUP-184.114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE 3.6MM VAR SELF-TAPPING 16MM -,SUP-184.116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 9MM 1.5M RAD 340MM T2 RECON CANN LT FEM TI ALY RECON -,SUP-1843-0934S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
T2 RECON NAIL R1.5- RIGHT 9 X 360MM X 125DG -,SUP-1845-0936S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
T2 RECON NAIL R1.5- RIGHT 9 X 380MM X 125DG -,SUP-1845-0938S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10MM 1.5M RAD 360MM T2 RECON CANN RT FEM TI ALY -,SUP-1845-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL T2 RECON R1 11MM X 420MM X 125 -,SUP-1845-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ENDCAP SPIN REVERE THORLUM NTHRD REVOLVE -,SUP-185.000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN REVOLVE 5.5X80MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN REVOLVE 5.5X90MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN REVOLVE 5.5X100MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN REVOLVE 5.5X110MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5X30MM REVOLVE POLYAX TI -,SUP-185.452,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5X35MM REVOLVE POLYAX TI -,SUP-185.453,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5X40MM REVOLVE POLYAX TI -,SUP-185.454,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5X45MM REVOLVE POLYAX TI -,SUP-185.455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5X50MM REVOLVE POLYAX TI -,SUP-185.456,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5X55MM REVOLVE POLYAX TI -,SUP-185.457,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X30MM REVOLVE POLYAX TI -,SUP-185.462,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X35MM REVOLVE POLYAX TI -,SUP-185.463,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X40MM REVOLVE POLYAX TI -,SUP-185.464,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X45MM REVOLVE POLYAX TI -,SUP-185.465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X50MM REVOLVE POLYAX TI -,SUP-185.466,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FEMORAL NAIL RIGHT 9 X 360MM -,SUP-1851-0936S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6489.92,4542.944,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10X380MM T2 CANN RT GTR TROCH FEM TI ALY RECON -,SUP-1851-1038S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6489.92,4542.944,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CABLE SINGLE LOOP TITANIUM WITH CRIMP -,SUP-186.200S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2978.98,2085.286,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER 28X8MM LPRD 5DG LRDTC BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE 28X9MM LPRD 5DG LRDTC BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER 28X7MM LPRD PRLL BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER 28X9MM LPRD PRLL BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER 28X11MM LPRD PRLL BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SET INNER MIS -,SUP-186715000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SET SCREW SPIN VIPER 2 TI PDCL SQ THRD SGL INNIE -,SUP-1867-15-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6X35MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6X35MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6X40MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6X40MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6 X 45 POLYAXIAL CANNULA -,SUP-186715645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6X45MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6X50MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6X50MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6X55MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7X40MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7X50MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X55MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X40MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6X30MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6X40MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6X45MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW TI CORT FIX 6X50MM -,SUP-186731650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW TI CORT FIX 6X55MM -,SUP-186731655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6X35MM VIPER 2 DBL LD THRD CANN ULTRA TI -,SUP-1867-60-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6X40MM VIPER 2 DBL LD THRD CANN ULTRA TI -,SUP-1867-60-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN VIPER 5.5X35MM CRV PREBNT TI F/MN INV SURG NS -,SUP-1867-62-635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN VIPER 5.5X40MM CRV PREBNT TI F/MN INV SURG NS -,SUP-1867-62-640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN VIPER 2  - 5.5 X 35MM LORDOTIC -,SUP-186788035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN VIPER 2 5.5X35MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN VIPER 2 5.5X40MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN VIPER 2 5.5X45MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN VIPER 2 5.5X50MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TRNSCONN REVERE ADDITION RD-TO-RD F/5.5MM PRLL -,SUP-1867-88-055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN VIPER 2 5.5X65MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD VIPER 2 LORDOTIC 75MM -,SUP-186788075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD LORDOTIC 80MM VIPER2 -,SUP-186788080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD LORDOTIC 90MM VIPER2 -,SUP-186788090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN SKYLINE 16X12MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN SKYLINE 16X14MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN SKYLINE 16X16MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN SKYLINE 16X18MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN SKYLINE 16X20MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN SKYLINE 16X22MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN SKYLINE 16X24MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN SKYLINE 16X26MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SKY 1 LEVEL PLATE 28MM -,SUP-1868-01-028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN SKYLINE 16X30MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 28MM SKYLINE 2 LEVEL TI -,SUP-186802028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN SKYLINE 16X30MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN SKYLINE 16X32MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN SKYLINE 16X34MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN SKYLINE 16X36MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN SKYLINE 16X40MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN SKYLINE 16X42MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN SKYLINE 16X44MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN SKYLINE 16X45MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN SKYLINE 16X48MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN SKYLINE 16X51MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN SKYLINE 16X54MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN SKYLINE 16X57MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-057,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X12MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL BLU -,SUP-1868-50-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X14MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL GOLD -,SUP-1868-50-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X16MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL MAG -,SUP-1868-50-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X18MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL -,SUP-1868-50-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X12MM SKYLINE ST VAR ANG HX LOBE HEAD TI STRL BLU -,SUP-1868-52-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X14MM SKYLINE ST VAR ANG HX LOBE HEAD TI STRL GOLD -,SUP-1868-52-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X16MM SKYLINE ST VAR ANG HX LOBE HEAD TI STRL MAG -,SUP-1868-52-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SKY VARIABLE S-T 18MM TI -,SUP-186852018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X12MM SKYLINE ST VAR ANG OVSZ HX LOBE HEAD TI STRL -,SUP-1868-54-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X14MM SKYLINE ST VAR ANG OVSZ HX LOBE HEAD TI STRL -,SUP-1868-54-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X16MM SKYLINE ST VAR ANG OVSZ HX LOBE HEAD TI STRL -,SUP-1868-54-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X14MM SKYLINE ST FA CNSTRN OVSZ HX LOBE HEAD TI -,SUP-1868-64-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
IMPLANT COUGAR SM 12MM 5 DEG -,SUP-187105112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COUGAR IMPLANT MED 14MM 50DEG -,SUP-187105214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER 14MM COUGAR 10DG SM CFRP -,SUP-1871-10-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COUGAR IMPLANT MED 14MM 10DEG -,SUP-187110214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN EXPEDIUM 5.5X70MM STR TI ANT PCUT NS -,SUP-1877-03-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BULLETT CONCORD 9 X 7 X 23 -,SUP-187823107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE 9X8X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE 9X9X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE 9X10X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE 9X8X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE 9X9X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-187823409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE 9X9X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE 9X10X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE 9X11X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE 9X12X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE 11X12X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CONCORDE BUL LOR 11X13X23 5DG -,SUP-187823513,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE 9X7X27MM CONCORDE -,SUP-187827107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE 9X7X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE 9X8X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE 9X9X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE 9X10X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE 11X12X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE 9X8X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-27-408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE 9X9X27MM CONCORDE 5DG LRDTC BLLT NOSE STNT LPRO CFRP -,SUP-1878-27-409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE 9X10X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-27-410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CONCORDE BUL LOR 9 X 11 X 27 -,SUP-187827411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE 9X11X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-27-411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE 11X12X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-187827512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE 9X7X23MM CONCORDE PRLL CFRP -,SUP-1879-23-107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14828.79,10380.153,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE 11X13X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1879-27-513,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CONNECTOR SPIN MOUNTAINEER LAT OFST TI -,SUP-1883-12-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X10MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X12MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X18MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X26MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X12MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X22MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X24MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X26MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X12MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X16MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X20MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X22MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X26MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X22MM MOUNTAINEER MINI POLYAX TAPR TI STRL BLU SHNK -,SUP-1883-19-422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X26MM MOUNTAINEER MINI POLYAX TAPR TI STRL BLU SHNK -,SUP-1883-19-426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X50MM MOUNTAINEER MINI POLYAX TAPR TI STRL BLU SHNK -,SUP-1883-19-450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.35X20MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.35X25MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.35X30MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.35X35MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.35X40MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X20MM MOUNTAINEER MINI POLYAX SHNK TAPR TI STRL -,SUP-1883-20-320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X28MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X32MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X34MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X36MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X38MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X40MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
XCONN 21MM MOUNTAINEER HD-TO-HD TI OCT -,SUP-1883-41-021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X12MM MOUNTAINEER MINI POLYAX TI STRL -,SUP-188362012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE OC 37MM -,SUP-188362037,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
MNTR OC PLATE LARGE -,SUP-188362045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.25X8MM MOUNTAINEER MINI POLYAX TI STRL -,SUP-188362108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
MNTR OC PREBENT ROD 3.5X120 -,SUP-188363200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,921.93,645.351,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN SKYLINE 34MM LVL2 PRELRD TI VSBL GFT SITE -,SUP-1888-02-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5856.72,4099.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE ANTLAT 33-46MMH X-MESH 0DG MED TI -,SUP-1889-01-033,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20402.94,14282.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE 0DG ANTLAT 51-71MM X-MESH MED TI -,SUP-1889-01-051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22445.09,15711.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X35MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,820.98,574.686,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X40MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,812.82,568.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X45MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,812.82,568.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X55MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,812.82,568.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X60MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,820.98,574.686,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X65MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,820.98,574.686,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SFX-5.5 TI LAT SIZE F4 -,SUP-189401104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DEPUY SPINE SFX F5 CROSSLINK -,SUP-189401105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CONNECTOR SZ F6 EXPEDIUM SFX FX F/5.5MM TI MDL -,SUP-1894-01-206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CONNECTOR SZ F7 EXPEDIUM SFX FX F/5.5MM TI MDL -,SUP-1894-01-207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CONNECTOR SPIN EXPEDIUM CX TI -,SUP-1894-01-209,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SFX 5.5 TI LAT SIZE A2 -,SUP-189401302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CONNECTOR SZ A4 EXPEDIUM SFX F/5.5MM TI MDL NS -,SUP-1894-01-404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CONNECTOR SZ A5 EXPEDIUM SFX F/5.5MM TI MDL NS -,SUP-1894-01-405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CONNECTOR SZ A6 EXPEDIUM SFX F/5.5MM TI MDL NS -,SUP-1894-01-406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW T2 CONDYLE 5MM X 50MM -,SUP-1895-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X60MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X75MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X80MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X85MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X20MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4020S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X22MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4022S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X26MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X28MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4028S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X30MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
T2 F/T LOCKING SCREW 4MM X 32MM -,SUP-1896-4032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X36MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X38MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4038S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X45MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X55MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW T2 F/T LOCK 5 X 30 -,SUP-1896-5030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5MMX32.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW T2 F/T LOCK 5 X 35 -,SUP-1896-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5MMX37.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW T2 F/T LOCK 5 X 40 -,SUP-1896-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5MMX42.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW T2 F/T LOCK 5 X 45 -,SUP-1896-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5MMX47.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5047S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW T2 F/T LOCK 5 X 50 -,SUP-1896-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5MMX52.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5052S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW T2 F/T LOCK 5 X 55 -,SUP-1896-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5MMX57.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5057S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW T2 F/T LOCK 5 X 60 -,SUP-1896-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW T2 F/T LOCK 5 X 65 -,SUP-1896-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW T2 F/T LOCK 5 X 70 -,SUP-1896-5070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW T2 F/T LOCK 5 X 75 -,SUP-1896-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X80MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X85MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X90MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X100MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN UNIPLATE 2 36MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-02-036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN UNIPLATE 2 38MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-02-038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.6X12MM UNIPLATE ST CANC TI BLU -,SUP-1897-06-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.6X13MM UNIPLATE ST CANC TI BLU -,SUP-1897-06-013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.6X14MM UNIPLATE ST CANC TI GOLD -,SUP-189706014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE 14MM UNIPLATE SPINE CERVICAL ANTERIOR SELF -,SUP-1897-06-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1293.32,905.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.6X15MM UNIPLATE ST CANC TI LBLU -,SUP-1897-06-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.6X18MM UNIPLATE ST CANC TI LBLU -,SUP-1897-06-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.2MMX14MM UNIPLATE OVSZ CANC TI GOLD -,SUP-1897-06-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.2MMX18MM UNIPLATE ST CANC TI GOLD -,SUP-1897-06-118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.6X12MM UNIPLATE SD CANC TI BLU -,SUP-1897-07-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.6X13MM UNIPLATE SD CANC TI VIOL -,SUP-1897-07-013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.6X15MM UNIPLATE SD CANC TI LBLU -,SUP-1897-07-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN UNIPLATE 2 14MM LVL1 PRELRD TI NRW MDLN NO- BND -,SUP-189721014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN UNIPLATE 2 16MM LVL1 PRELRD TI NRW MDLN NO- BND -,SUP-189721016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN UNIPLATE 2 28MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-22-028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN UNIPLATE 2 32MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-22-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN UNIPLATE 2 34MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-22-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW T2 RECON LAG 6.5MM X 75MM -,SUP-1897-6075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW T2 RECON LAG 6.5MM X 80MM -,SUP-1897-6080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LAG T2 RECON SYSTEM 6.5 X 85 -,SUP-1897-6085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LAG BONE T2 RECON SYSTEM 6.5 X 90 -,SUP-1897-6090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LAG T2 RECON 6.5MM X 100MM -,SUP-1897-6100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LEVEL 1 PLATE 20MM -,SUP-19-0120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CALBIBER SPACER 10 X 22MM- 10-15MM -,SUP-194.222,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SEMI CONST DRILL 4.0 X 14 -,SUP-19-6514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2MMX6MM LCK COMPR CORT LCP FT STD CRUCIF RCESS SS NS -,SUP-201.006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,93.36,65.352,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.4MMX10MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CLIP ANEUR 2.4MMX12MM SS LCP ST -,SUP-201.762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.4MMX13MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.763,CDM,C1713,HCPCS,278,RC,,,outpatient,,,411.37,287.959,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.4MMX14MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.764,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.4MMX18MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.768,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.4MMX22MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.772,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2X10MM LCK COMPR LCP THRD ST FA T6 STRDRV RCESS SS NS -,SUP-201.880,CDM,C1713,HCPCS,278,RC,,,outpatient,,,830.26,581.182,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MMX10MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,328.22,229.754,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MMX12MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,328.22,229.754,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MMX26MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MMX28MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MMX30MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MMX32MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MMX34MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MMX36MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MMX38MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MMX40MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MMX45MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MMX50MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MMX55MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X10MM LCK COMPR LCP THRD ST T8 STRDRV RCESS SS NS -,SUP-202.210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,886.92,620.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X30MM LCK COMPR LCP THRD ST T8 STRDRV RCESS SS NS -,SUP-202.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.01,516.607,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X40MM LCK COMPR LCP THRD ST T8 STRDRV RCESS SS NS -,SUP-202.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.01,516.607,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3X14MM CANN LNG THRD SD/ST CRUCIF RCESS SS NS -,SUP-202.714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1530.52,1071.364,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X16MM LCK COMPR CORT LCP FT ST T8 STRDRV RCESS SS -,SUP-202.876,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X18MM LCK COMPR CORT LCP FT ST T8 STRDRV RCESS SS -,SUP-202.878,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTEX SLF TPNG 2.7 X 20MM T8 SD REC -,SUP-202.880,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X24MM LCK COMPR CORT LCP FT ST T8 STRDRV RCESS SS -,SUP-202.884,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTEX SLF TPNG 2.7 X 26MM T8 SD REC -,SUP-202.886,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTEX SLF TPNG 2.7 X 28MM T8 SD REC -,SUP-202.888,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTEX SLF TPNG 2.7 X 30MM T8 SD REC -,SUP-202.890,CDM,C1713,HCPCS,278,RC,,,outpatient,,,577.67,404.369,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BODY PHOENIX SHRT OPN BD -,SUP-20-2070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BODY STD PHOENIX OPN BD POST PDCL F/MN INV FX SYS -,SUP-20-2090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
6.5 X 40MM CANCELLOUS BONE SCREW -,SUP-2030-6540-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ACTB 6.5X55MM OMNIFIT -,SUP-2030-6555-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ACTB 6.5X60MM OMNIFIT -,SUP-2030-6560-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X10MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X12MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X14MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,192.56,134.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X16MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX18MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX20MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX22MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX24MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX26MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX28MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX32MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX34MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX36MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX38MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX40MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX45MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X50MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X28MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X30MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X32MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X34MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X36MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X38MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X14MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X20MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X22MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X24MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X26MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X28MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X32MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X34MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.834,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X48MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.848,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN PHOENIX 35MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN PHOENIX 40MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN PHOENIX 45MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN PHOENIX 50MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN PHOENIX 55MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN PHOENIX 70MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN PHOENIX 75MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX10MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX12MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX14MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.61,257.327,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX16MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.61,257.327,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX18MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.61,257.327,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX22MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX24MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX26MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX30MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX35MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX40MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX45MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX50MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX55MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX60MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FEM PRESSURIZING SEAL - SMALL -,SUP-206-545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,101.12,70.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X10MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X12MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X14MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X16MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X18MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X20MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X22MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X24MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X26MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X28MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X30MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,157.55,110.285,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X40MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X45MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X50MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX34MM LCK CANN LCP LNG THRD SD/ST 2.5MM SM HEX SCKT -,SUP-207.734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7MMX35MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7MMX40MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7MMX45MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7MMX50MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7MMX70MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7MMX75MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X95MM LCK CANN 32MM THRD SD/ST REVCT FLUT 4MM LRG -,SUP-208.441,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1770.37,1239.259,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7MMX45MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7MMX50MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7MMX55MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7MMX80MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7X32MM CANN -,SUP-209.750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7.3X75MM LCK CANN THRD SD/ST REVCT FLUT HEX SCKT -,SUP-209.875,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1710.52,1197.364,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUT SQA + THRDR TAB TI NTNL -,SUP-210.309,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2065.07,1445.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SUBSTITUTE TCP 1.2ML FOAM PK VITOSS RESRB COMPR RSIS -,SUP-2102-1401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1579.18,1105.426,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
VITOSS BIOACTIVE PACK 2.5CC -,SUP-2102-1602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3430.26,2401.182,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
VITOSS BA2X FOAM PK BONE GRAFT 1.2CC -,SUP-2102-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2600.96,1820.672,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
VITOSS BA2X FOAM PACK 1.2CC -,SUP-2102-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2600.96,1820.672,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
VITOSS BA2X BONE GRAFT 2.5CC -,SUP-2102-2102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4015.89,2811.123,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
VITOSS BA2X BONE GRAFT 5CC -,SUP-2102-2105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6693.85,4685.695,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
VITOSS BA2X BONE GRAFT 10CC -,SUP-2102-2110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10931.81,7652.267,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.4MMX12MM CANN 0.5IN LNG THRD SD/ST T8 STRDRV RCESS -,SUP-211.812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1577.85,1104.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CANNULATED SCREW 2.4mm X15mm -,SUP-211.815,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANNULATED 2.4MM X17MM L -,SUP-211.817,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1431.14,1001.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.4MM CANN SCREW LONG 19MM -,SUP-211.819,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1431.14,1001.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX55MM LCK COMPR LCP FT ST SS NS GRN -,SUP-212.123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,813.98,569.786,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BONE PIN- 3.2 x 110MM- STERILE (2 Pack) -,SUP-213524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BONE PIN- 3.2 x 140MM- STERILE (2 Pack) -,SUP-213527,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX16MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX28MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX30MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX32MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX36MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX38MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX40MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX46MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX50MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX52MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX56MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX34MM LCK CANN P/T SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1518.59,1063.013,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX42MM LCK CANN P/T SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1518.59,1063.013,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX44MM LCK CANN P/T SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1518.59,1063.013,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX40MM LCK CANN FT SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1562.32,1093.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX44MM LCK CANN FT SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1562.32,1093.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX50MM LCK CANN FT SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1562.32,1093.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MMX40MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-216.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MMX55MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MMX60MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MMX65MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MMX70MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MMX75MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 9MM SHRT FASTFLAP 2HL STR 1.6MM NEURO SYS STRL -,SUP-218-0022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.42,222.194,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE CRNL 22MM 5HL 0.5MM STR FAST FLAP 1.6MM NEURO SYS TI -,SUP-218-0030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,868.25,607.775,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE CRANFC MED FST-FLP MSH 5HL TI BUR HL GRV SHNT 1.6MM -,SUP-218-0069,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE CRNL LNG 2HL 0.25MM STR FAST FLAP 1.6MM NEURO SYS TI -,SUP-218-0093,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.8,316.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE CRNL 22MM LRG 0.25MM FAST FLAP BUR HL CVR 1.6MM NEURO -,SUP-218-0095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1077.06,753.942,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE CRANFC 90X90MM FST-FLP OSTFRM MSH TI PREFRM 1.6MM -,SUP-218-2006-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6545.95,4582.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WASHER ORTHO 10MM F/4.5MM CANN SCR RND NS -,SUP-219.910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,218.81,153.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WASHER ORTHO 13MM F/6.5MM CANC LRG BN SCR RND NS -,SUP-219.990,CDM,C1713,HCPCS,278,RC,,,outpatient,,,223.19,156.233,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ACCELFIX LUMBAR EXPANDABLE CAGE 8 22 X 11 X 8MM -,SUP-2211-0808S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19669.62,13768.734,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ACCELFIX EXPANDABLE LUMBAR CAGE 15 22 X 11 X 8 -,SUP-2211-0815S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19669.62,13768.734,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE ACCELFIX LUMB EXPAND 8 DEG 22 X 11 X 12 -,SUP-2211-1208S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUT HEALIX ADVANCE 4.5MM MUL-THRD BCRL RAPIDE -,SUP-222.295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1643.16,1150.212,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SUTURE ORTHOCORD #2 MO-7 36IN BRD BLU VIOL 223114 1/2CIR MPK -,SUP-223.114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.04,210.028,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN LC-DCP 11X77MM 3.5MM 6HL LC BSC LCK DCP SS SM NS -,SUP-223.560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2413.05,1689.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN LC-DCP 11X90MM 3.5MM 7HL LC BSC LCK DCP SS SM NS -,SUP-223.570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2504.49,1753.143,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN LC-DCP 11X103MM 3.5MM 8HL LC BSC DCP SS SM NS -,SUP-223.580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2631.7,1842.19,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN LC-DCP 11X116MM 3.5MM 9HL LC BSC LCK DCP SS SM NS -,SUP-223.590,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2466.96,1726.872,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN LC-DCP 11X129MM 3.5MM 10HL LC BSC LCK DCP SS SM NS -,SUP-223.600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2542.16,1779.512,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEPIN ORTHO BRKWY 2.5MM GLOBAL APG + -,SUP-2230-00-019,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1126.16,788.312,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN LC-DCP 13.5X155MM 12HL 4.2MM LC COMPR SS 3.5MM BRD -,SUP-225.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2321.62,1625.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SUBSTITUTE DEMIN CANC TISS 0.75ML G2 DIVERTED MRSL VOID FIL -,SUP-227005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1139.61,797.727,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SUBSTITUTE G2 TISS 0.5ML STRIP PREFL ATF STR TUBE -,SUP-227010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,846.08,592.256,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
KT ORTHO MILAGRO FEM -,SUP-232.300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2199.71,1539.797,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
END CAP LOWER EXTREMITY 8 +0MM -,SUP-2330-0000S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1195.26,836.682,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
T2 ALFPHA COMPRESSION SCREW FEMUR 5.5 -,SUP-2330-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1333.08,933.156,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
END CAP GT/PF T2 ALPHA 013 +10 -,SUP-2330-0010S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1195.26,836.682,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL FEMORAL GT LEFT 11 X 320MM -,SUP-2331-1132S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FEMORAL NAIL GT- LEFT Ã˜11X420MM -,SUP-2331-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9735.49,6814.843,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FEMORAL NAIL GT LEFT 13 X 400MM -,SUP-2331-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10095.65,7066.955,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FEMORAL NAIL GT RT 10 X 360 -,SUP-2333-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12776.73,8943.711,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FEMORAL NAIL GT RIGHT 10 X 420MM -,SUP-2333-1042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL INTRAMEDULLARY T2 ALPHA FEMUR ANTEGRADE SYSTEM 11 X 380 -,SUP-2333-1138S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FEMORAL NAIL GT RIGHT 11 X 420MM -,SUP-2333-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FEMORAL NAIL GT RIGHT 11 X 440MM -,SUP-2333-1144S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FEMORAL NAIL GT RIGHT 13MM X 400MM -,SUP-2333-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10095.65,7066.955,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FEMORAL NAIL RETROGRADE D10X360MM -,SUP-2339-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FEMORAL NAIL RETROGRADE D10X400MM -,SUP-2339-1040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SYS FEMUR RETROGRADE NAIL 11 X 200MM T2 ALPHA SHORT -,SUP-2339-1120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FEMORAL NAIL RETROGRADE 11 X 300MM -,SUP-2339-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL T2 FEMUR ALPHA RETROGRADE 11 X 340MM -,SUP-2339-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FEMORAL NAIL RETROGRADE D11X380MM -,SUP-2339-1138S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FEMORAL NAIL RETROGRADE 12 X 340MM -,SUP-2339-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10561.63,7393.141,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
T2 ALPA FEMUR NAIL RETROGRADE 12 X 360 -,SUP-2339-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10559.77,7391.839,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FEMORAL NAIL RETROGRADE 13X340MM -,SUP-2339-1334S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10561.63,7393.141,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FEMORAL NAIL RETROGRADE D13X360MM -,SUP-2339-1336S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10559.77,7391.839,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW INTFR CANN 8X23MM THRD BABSRB PLLA -,SUP-234-010-162,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW INTFR CANN BIOSTEON 7X28MM 1MM CANN FLLY BLNT THRD -,SUP-234-010-164,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW INTFR CANN BIOSTEON 8X28MM BABSRB WDG SHP HAP PLLA -,SUP-234-010-165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW INTFR CANN 9X28MM THRD BABSRB PLLA -,SUP-234-010-166,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW INTFR CANN BIOSTEON 11X35MM 1MM CANN FLLY BLNT THRD -,SUP-234-010-179,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW INTFR CANN BIOSTEON 12X35MM 1MM CANN FLLY BLNT THRD -,SUP-234-010-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2187.89,1531.523,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COMPRESSION SCREW TIBIA 5.5 -,SUP-2341-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1333.08,933.156,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
END CAP TIBIA T2 ALPHA 11.5 X +5MM -,SUP-2341-0005S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
END CAP TIBIA T2 ALPHA 11.5 X 10MM -,SUP-2341-0010S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
END CAP TIBIA T2 ALPHA 11.5 X 15MM -,SUP-2341-0015S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEPIN ENDO VERSITOMIC SHP MEM ALY TECH FLXB -,SUP-234-108-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2166.31,1516.417,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEPIN ENDO VERSITOMIC FLXB -,SUP-234-108-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2187.89,1531.523,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TIBIAL NAIL 9 X 285MM -,SUP-2341-0928S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TIBIAL NAIL T2 ALPHA 9 X 300 -,SUP-2341-0930S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TIBIAL NAIL T2 09 X 315MM -,SUP-2341-0931S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL TIBIAL 9 X 330 T2 ALPHA -,SUP-2341-0933S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TIBIAL NAIL 9 X 345 -,SUP-2341-0934S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TIBIAL NAIL 9 X 360 -,SUP-2341-0936S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TIBIAL NAIL 9 X 375 -,SUP-2341-0937S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TIBIAL NAIL 9 X 390MM -,SUP-2341-0939S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TIBIAL NAIL 10X285MM -,SUP-2341-1028S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10764.14,7534.898,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM 10 X 300 -,SUP-2341-1030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM 10 X 315 -,SUP-2341-1031S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM -,SUP-2341-1033S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
T2 ALPHA TIBIA NAIL 10X345MM SYS -,SUP-2341-1034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL TIBIAL 10 X 360 T2 ALPHA -,SUP-2341-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL TIBIAL 10 X 375MM T2 ALPHA -,SUP-2341-1037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL TIBIAL 10 X 390 T2 ALPHA -,SUP-2341-1039S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL TIBIAL T2 ALPHA 11 X 300MM -,SUP-2341-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL TIBIAL T2 11 X 315 -,SUP-2341-1131S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TIBIAL NAIL 11 X 330 -,SUP-2341-1133S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL SYSTEM T2 ALPHA TIBIA 11 X 345MM -,SUP-2341-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM -,SUP-2341-1136S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TIBIAL NAIL T2 ALPHA 11 X 375 -,SUP-2341-1137S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
T2 ALPHA TIBIA NAIL 11 X 390MM -,SUP-2341-1139S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL TIBIAL T2 ALPHA 12 X 315MM -,SUP-2341-1231S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL TIBIAL T2 ALPHA 12 X 330MM -,SUP-2341-1233S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
T2 ALPHA TIBIA SYSTEM TIBIAL NAIL -,SUP-2341-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
T2 ALPHA TIBIAL NAIL 12 X 380MM -,SUP-2341-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10764.1,7534.87,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TIBIAL NAIL 12 X 375MM -,SUP-2341-1237S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 8X50MM -,SUP-234500150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,885.69,619.983,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOCKING SCREW 5 X 25MM -,SUP-2360-5025S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOCKING SCREW 5 X 27.5MM -,SUP-2360-5027S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 5X32MM -,SUP-2360-5032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW IMN SYSTEM LOCKING SCREW 5 X 35 -,SUP-2360-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
IMN LOCKING SCREW 5 X 37.5MM -,SUP-2360-5037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
IMN SCREW SYSTEM LOCKING SCREW 5 X 40 -,SUP-2360-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 5X42MM -,SUP-2360-5042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOCKING SCREW 05 X 45MM -,SUP-2360-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
IMN LOCKING SCREW 5X47.5MM -,SUP-2360-5047S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
IMN LCK SCREW 5X50 -,SUP-2360-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
IMN LCK SCREW 5X52 -,SUP-2360-5052S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LCK STRYKER 5 X 55 -,SUP-2360-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
IMN LOCKING SCREW 5X57.5MM -,SUP-2360-5057S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
IMN LOCKING SCREW 0.5 X 60MM -,SUP-2360-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1836.62,1285.634,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING SYS IMN 5 X 60MM -,SUP-2360-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
IMN LOCKING SCREW 0.5 X 65MM -,SUP-2360-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 5 X 70MM -,SUP-2360-5070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE T2 ALPHA IMN LOCKING  0.5 X 75MM -,SUP-2360-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING SYS IMN 5 X 65MM -,SUP-2360-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 5 X 85 -,SUP-2360-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 5 X 90 -,SUP-2360-5090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW IMN T2 ALPHA LOCKING  5MM X 95MM -,SUP-2360-5095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING SYS IMN 5 X 100MM -,SUP-2360-5100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ADVANCED LOCKING SCREW 5X30MM -,SUP-2361-5030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ADVANCED LOCKING 5MM X 32.5MM -,SUP-2361-5032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ADVANCED LOCKING 5 X 35 -,SUP-2361-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING ADVANCED IMN 05 X 37.5MM -,SUP-2361-5037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING ADVANCED IMN 05 X 40MM -,SUP-2361-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ADVANCED LOCKING 5MM X 42.5MM -,SUP-2361-5042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ADVANCED LOCKING SCREW 5MM X 45MM -,SUP-2361-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW IMN LCK 5 X 45 -,SUP-2361-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ADVANCED LOCKING 5MM X 47.5MM -,SUP-2361-5047S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING ADVANCED 5X50MM -,SUP-2361-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ADVANCED LOCKING SCREW 5MM X 52.5MM -,SUP-2361-5052S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ADVANCED LOCKING 5MM X 55MM -,SUP-2361-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ADVANCED LOCKING SCREW 5 X 57.5MM -,SUP-2361-5057S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X60MM IMN ADVANCED LOCKING -,SUP-2361-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ADVANCED LOCKING 5MM X 65MM -,SUP-2361-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ADVANCED LOCKING 5MM X 70MM -,SUP-2361-5070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ADVANCED LOCKING SCREW 5 X 57MM -,SUP-2361-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ADVANCED LOCKING SCREW 5 X 80 -,SUP-2361-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
IMN ADVANCED LOCKING SCREW 5MM X 85MM -,SUP-2361-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ADVANCED LOCKING SCREW 5 X 90MM -,SUP-2361-5090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1553.05,1087.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW IMN LOCKING 5MM X 95MM -,SUP-2361-5095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN LCP 83MM 4/5MM 4HL BSC LCK COMPR SS LRG T-SHP NS -,SUP-240.141,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3467.5,2427.25,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN STERNAL TALON 14MM D FT PLATE LEGX2 SGL TI SM STRL -,SUP-24-009-14-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN STERNAL TALON SGL LEGX2 BIOCMPT TI SM STRL -,SUP-24-009-17-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FOOT PLATE BN STERNAL TALON SGL VRSN TI 17MM MED STRL LEGX2 -,SUP-24-010-17-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN STERNAL TALON 20MM D LEGX2 SGL TI MED STRL -,SUP-24-010-20-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FOOT PLATE XL 12X20MM STERNAL TALON SGL -,SUP-24-012-20-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
STERNAL SCREW 2.3 -,SUP-24-023-09-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X11MM LCK DRL-FR MAXDRIVE THREADLOCK TS SLF RET TI -,SUP-24-023-11-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X13MM LCK DRL-FR MAXDRIVE THREADLOCK TS SLF RET TI -,SUP-24-023-13-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
STERNAL SCREW 2.3 X 15MM -,SUP-24-023-15-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.3MM SELF DRILLING STERNAL SCREWS -,SUP-24-023-17-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE LEVEL 1 THORACIC STERNAL LKG STR 2.3MM SCRW 20 HL -,SUP-24-025-07-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3118.62,2183.034,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
STERNAL PLATE LOCK 6-HOLE 1.8 -,SUP-24-025-42-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2398.48,1678.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 8HL 1.8MM LCK TI X-SHP -,SUP-24-025-44-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2224.88,1557.416,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
4 HOLE STRAIGHT -,SUP-24-025-48-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2155.98,1509.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE LEVEL ONE THORACIC STERNAL LKG STR W/2.3MM SCREW -,SUP-24-025-50-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2580.02,1806.014,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
9 HOLE Y PLATE -,SUP-24-025-52-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2613.77,1829.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 4 HOLE ANGLE -,SUP-24-025-59-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1906.85,1334.795,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN LC-DCP 10X50MM 3.5MM 3HL HD/SHFT LC DCP SS T-SHP RT -,SUP-241.130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,781.42,546.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN LC-DCP 11X64MM 3.5MM HLX3/5 HD/SHFT LC DCP SS T-SHP -,SUP-241.150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,944.22,660.954,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN LC-DCP 10X53MM 3.5MM 3HL HD/SHFT LC LCK DCP SS -,SUP-241.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1176.71,823.697,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN LC-DCP 10X63MM 3.5MM 0.75HL HD/SHFT LC LCK DCP SS -,SUP-241.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1296.45,907.515,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN LC-DCP 10X75MM 3.5MM HLX3/5 HD/SHFT LC LCK DCP SS -,SUP-241.250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1282.72,897.904,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN LC-DCP 9X25MM 3.5MM 2HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN LC-DCP 9X49MM 3.5MM 4HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN LC-DCP 9X61MM 3.5MM 5HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN LCP 9X57MM 2.7/3.5MM 5HL CONTR LCK COMPR SS SM 1/3 -,SUP-241.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1594.13,1115.891,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN LC-DCP 9X85MM 3.5MM 7HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1268.14,887.698,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN LC-DCP 9X97MM 3.5MM 8HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1315.85,921.095,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN LC-DCP 9X121MM 3.5MM 10HL LC DCP SS SM MINI 1/3 -,SUP-241.400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN LCP 9X117MM 2.7/3.5MM 10HL CONTR LCK COMPR SS SM -,SUP-241.401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1745.19,1221.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN LCP 15MM D 3.5MM 5HL PRCONT LCK COMPR SS HOOK STRL -,SUP-241-085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4546.38,3182.466,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN LCP 6.3X49MM 2.4MM 0.75HL HD/SHFT FA CONTR LCK -,SUP-242.507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2479.52,1735.664,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER TNDN 6X24MM SILASTIC PLYSTR COR SWN-HNT STRL -,SUP-24270006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7240.26,5068.182,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 82MM 3.5MM 7HL RECON SS STR NS -,SUP-245.170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3397.89,2378.523,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN LC-DCP 94MM 3.5MM 8HL RECON DCP SS STR NS -,SUP-245.181,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3544.7,2481.29,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN LC-DCP 106MM 3.5MM 9HL RECON DCP SS STR NS -,SUP-245.190,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3738.04,2616.628,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 53MM 2MM HLX2/8 HD/SHFT 1.2MM RECON SS T-SHP NS -,SUP-247.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1616.65,1131.655,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN LCP 54MM 2MM 7HL RECON LCK COMPR SS NS -,SUP-247.349,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4745.36,3321.752,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN LCP 44MM 2.4MM 5HL RECON ADPR LCK COMPR SS STR NS -,SUP-247.375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2573.19,1801.233,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN LCP 36MM 2.4MM 4HL RECON LCK COMPR SS STR NS -,SUP-249.674,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2496.8,1747.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN LCP 59MM 2.4MM 7HL RECON LCK COMPR SS STR NS -,SUP-249.679,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3862.17,2703.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN LCP 58MM 2.7MM 6HL RECON LCK COMPR SS STR NS -,SUP-249.682,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3247.51,2273.257,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN LCP 67MM 2.7MM 7HL RECON LCK COMPR SS STR NS -,SUP-249.683,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2544.54,1781.178,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN LCP 32MM 2.7MM 0.66HL HD/SHFT RECON LCK COMPR SS -,SUP-249.685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCK -,SUP-250-1001-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 8.5MM SHTH INTRAFIX PEEK PP NS F/ACL FX -,SUP-254.683,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LCK CRNMXF 2.3X11MM CROSS-DRIVE TI ALY -,SUP-25-773-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE 7 MWX8MMX21MM TRAXIS PEEK/ TI -,SUP-2601070921,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE VERT 25MM VUE 7MM/9MM LD /TRAILING DIA SGL LVL PEEK -,SUP-2601070925,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE 9X21X9MM TRAXIS VUE 9MM/9MM DIA LD /TRAILING DIA SGL -,SUP-2601090921,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDE DRILL POR F/KN ARTHPL -,SUP-261-0060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
USTAR II KNEE CEMENTED STR STEM RHS 17X125 -,SUP-2715-3117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BLADE IM NAIL 12.5X105MM SS HLCL NS F /LCP DHS -,SUP-282.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2284.52,1599.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BLADE IM NAIL 12.5X120MM SS HLCL NS F /LCP DHS -,SUP-282.243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2277.41,1594.187,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ORTHOFIX CAGE 6.5 -,SUP-28-2180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ORTHOFIX CAGE 8.5 -,SUP-28-2182,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ORTHOFIX CAGE 6.5 X 24 XP -,SUP-28-3140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE XP LORDOTIC 8.5 -,SUP-28-3142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ORTHOFIX FORZA XP CAGE 10.5H X 10W X 24L -,SUP-28-3144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ORTHOFIX 12H EXPANDABLE CAGE -,SUP-28-3146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
EXPANDABLE CAGE 6.5MMX10MM WIDE X28MM -,SUP-28-3180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE FORZA XP ORTHOFIX 10.5MM -,SUP-28-3184,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ORTHOFIX HYPERLORDOTIC CAGE 8.5 -,SUP-28-4142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE 10.5HL HYPER XP -,SUP-28-4144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ORTHOFIX CAGE 12.5 X 24. HL -,SUP-28-4146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
USTAR II KNEE SEGMENT PART RHS 25MM -,SUP-2915-1025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22014.38,15410.066,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER VERT 22X8MM CAP STN VERTSTCK PEEK -,SUP-2960822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER VERT 26X8MM CAP STN VERTSTCK PEEK -,SUP-2960826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20245.95,14172.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER VERT 22X10MM CAP STN VERTSTCK 8DG PEEK -,SUP-2961022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X12MM LCK ACU-LOC 2 HXLB DRIVE F/VOLAR DIST RAD -,SUP-30-0234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,822.74,575.918,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X14MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X18MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0237,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X20MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X22MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0239,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X24MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X26MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0241,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X30MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X32MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X36MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0246,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X45MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0249,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X22MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0262,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X24MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0263,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X26MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0264,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X32MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0267,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X40MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0271,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X45MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0272,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X50MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0273,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X55MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0274,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3X40MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0294,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW Ti SET 8X17.5MM -,SUP-3003-0822S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,858.1,600.67,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X14MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0327,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X16MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X18MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0329,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X20MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X22MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0331,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAP END +10MM TI GAMMA3 -,SUP-3005-1110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,858.1,600.67,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.7X45MM ACUTRAK 2 NS -,SUP-30-0645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.7X50MM ACUTRAK 2 NS -,SUP-30-0650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.3X26MM LCK POLARUS 3 HXLB DRV TI STRL -,SUP-3011-43026-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.3X46MM HXLB -,SUP-3011-43046-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.6MM/4.5MM DIA TIP/BK END 20MM CANN HDLS BIOTRAK -,SUP-3017-0009-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3465.92,2426.144,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.6MM/4.6MM DIA TIP/BK END 22MM CANN HDLS BIOTRAK -,SUP-3017-0010-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3465.92,2426.144,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER THORLUM VERT 10X26X8MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER THORLUM VERT 10X26X9MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER THORLUM VERT 10X26X10MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER THORLUM VERT 10X26X11MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER THORLUM VERT 10X26X12MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER THORLUM VERT 8X22X8MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.078,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER THORLUM VERT 8X22X9MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.079,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER THORLUM VERT 8X22X10MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER THORLUM VERT 8X22X11MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.081,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER THORLUM VERT 8X22X12MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER THORLUM VERT 8X22X13MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.083,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER THORLUM VERT 10X22X8MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.088,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER THORLUM VERT 10X22X9MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.089,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER THORLUM VERT 10X22X10MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER THORLUM VERT 10X22X11MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.091,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER THORLUM VERT 10X22X12MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.092,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER THORLUM VERT 10X22X13MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.093,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER THORLUM VERT 10X22X15MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER THORLUM VERT 12X26X10MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.970,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER THORLUM VERT 12X26X17MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.977,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LAG SCREW TI 10.5 X 75mm -,SUP-3060-0075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW GAMMA3 LAG TI 10.5X80 -,SUP-3060-0080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW GAMMA3 LAG Ti 10.5X85 -,SUP-3060-0085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 90MM -,SUP-3060-0090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW GAMMA3 LAG Ti 10.5X95 -,SUP-3060-0095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GAMMA3 LAG SCREW TI 10.5X100 -,SUP-3060-0100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW GAMMA3 LAG T1 10.5X105 -,SUP-3060-0105S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 110MM -,SUP-3060-0110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 115MM -,SUP-3060-0115S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 120MM -,SUP-3060-0120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 125MM -,SUP-3060-0125S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 130MM -,SUP-3060-0130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
U-BLADE SET TI 10.5 X 95MM -,SUP-3066-0095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2850.17,1995.119,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GRAFT DBM 1ML PTTY OSTEOSELECT VOID FIL OSTCONDC -,SUP-309010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
OSTEOSELECT 2.5CC -,SUP-309025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1749.17,1224.419,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SUBSTITUTE DBM 5ML PTTY OSTEOSELECT VOID FIL OSTCONDC -,SUP-309050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SUBSTITUTE DBM 10ML PTTY OSTEOSELECT -,SUP-309100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER RADIOLUCENT 7MM CANOPY -,SUP-3102.6007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
5CC BIO4 VIABLE BONE MATRIX -,SUP-3102-2105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8594.1,6015.87,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 15.5/11X180MM GAMMA3 LT TROCH FEM TI BIOMECH STRGTH -,SUP-3120-1180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4598.63,3219.041,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TROCHANTERIC NAIL KIT 10X170MMX125DG -,SUP-3125-0170S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5413.56,3789.492,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL GAMMA3 TROCHANTARIC 180 -,SUP-3125-1180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4598.63,3219.041,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
KIT TROCHANTERIC KIT 11X180 SF -,SUP-3130-1180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4598.63,3219.041,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DRILL BIT RINGLOC + QUICK CONNECT 3.2MM X 20MM -,SUP-31-323220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
EQUINOXE SHLDR -,SUP-320-15-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LCK COMPR EQUINOXE F/RVRS BALL/SCKT SURG -,SUP-320-15-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SET SCREW INTNL FX EQUINOXE SHLDR RVRS TRQ DEFINING LCK -,SUP-320-20-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X22MM LCK COMPR EQUINOXE BLK F/RVRS BALL/SCKT SURG -,SUP-320-20-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X34MM LCK COMPR EQUINOXE RD F/RVRS BALL/SCKT SURG -,SUP-320-20-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LONG NAIL GAMMA KIT 11X300 RIG -,SUP-3225-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LONG GAMMA NAIL 11X320 RIGHT -,SUP-3225-0320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL KIT LONG R2.0 TI RT. GAMM -,SUP-3225-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LONG GAMMA NAIL 11X380 RIGHT -,SUP-3225-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LONG GAMMA NAIL 11X400 RIGHT -,SUP-3225-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LONG GAMMA NAIL 11X420 RIGHT -,SUP-3225-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL LONG RT GAMMA3 KIT 11MM X -,SUP-3225-0440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 15MM/13MM DIA P/D 2MM RAD LNG 340MM GAMMA3 RT TROCH -,SUP-3225-3340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX16MM CANN ASNIS III 8MM P/T SD/ST REVCT FLUT SS NS -,SUP-325016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX24MM CANN ASNIS III 8MM P/T SD/ST REVCT FLUT SS NS -,SUP-325024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW PT CANN ASNIS 4.0 X 28 -,SUP-325028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX30MM CANN ASNIS III 10MM P/T SD/ST REVCT FLUT SS -,SUP-325030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX32MM CANN ASNIS III 11MM P/T SD/ST REVCT FLUT SS -,SUP-325032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX34MM CANN ASNIS III 11.5MM P/T SD/ST REVCT FLUT SS -,SUP-325034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX34MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-325034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX36MM CANN ASNIS III 12MM P/T SD/ST REVCT FLUT SS -,SUP-325036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX38MM CANN ASNIS III 13MM P/T SD/ST REVCT FLUT SS -,SUP-325038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX40MM CANN ASNIS III 13.5MM P/T SD/ST REVCT FLUT SS -,SUP-325040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX42MM CANN ASNIS III 14MM P/T SD/ST REVCT FLUT SS -,SUP-325042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX44MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325044S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX46MM CANN ASNIS III 15.5MM P/T SD/ST REVCT FLUT SS -,SUP-325046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX46MM CANN ASNIS III 0.33IN P/T SD/ST REVCT FLUT SS -,SUP-325046S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX48MM CANN ASNIS III 16MM P/T SD/ST REVCT FLUT SS -,SUP-325048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX50MM CANN ASNIS III 17MM P/T SD/ST REVCT FLUT SS -,SUP-325050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX55MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-325060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX60MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX70MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANNULATED 4.0 X 32 -,SUP-325232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X42MM CANN FT -,SUP-325242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X44MM CANN FT -,SUP-325244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5MMX70MM CANN ASNIS III 23.5MM P/T SD/ST REVCT FLUT SS -,SUP-325470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANNULATED 5.0 X 60MM -,SUP-325660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ASNIS III SS CANNULATED SCR 5 X 70MM -,SUP-325670S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SS CANN 6.5 X 70MM ASNIS -,SUP-326070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X75MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X80MM CANN ASNIS III P/T SD/ST REVCT FLUT SS NS -,SUP-326080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X80MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X85MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X85MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X90MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X90MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS 6.5MM 95MM -,SUP-326095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X95MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS 6.5MM 100MM -,SUP-326100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X100MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X105MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326105S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS 6.5 X 110 -,SUP-326110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X110MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X115MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326115S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X120MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW S.S. TL40 6.5 X 55 -,SUP-326255,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
6.5MM PARTIALLY THREADED 40MM SCREW 60MM LENGTH -,SUP-326260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW S.S. TL40 6.5 X 70 -,SUP-326270,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MMX75MM CANN ASNIS III 40MM THRD SD/ST REVCT FLUT -,SUP-326275,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MMX80MM CANN ASNIS III 40MM THRD SD/ST REVCT FLUT -,SUP-326280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS CAN 6.5 X 85 -,SUP-326285,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS CAN 6.5 X 90 -,SUP-326290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS CAN 6.5 X 95 -,SUP-326295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.94,757.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS CAN 6.5 X 95 -,SUP-326295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS CAN 6.5 X 100 -,SUP-326300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW S.S. TL40 6.5 X 110 -,SUP-326310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW S.S. TL40 6.5 X 115 -,SUP-326315,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW S.S. TL40 6.5 X 120 -,SUP-326320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1196.43,837.501,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 80 -,SUP-326480S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 85 -,SUP-326485S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANNULATED FULLY THREADED 6.5 X 90MM -,SUP-326490S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS III SS CANNULATED 6.5X95MM -,SUP-326495S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS III SS CANNULATED 6.5X100MM -,SUP-326500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS III SS CANNULATED 6.5X105MM -,SUP-326505S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS III SS CANNULATED 6.5X110MM -,SUP-326510S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS III SS CANNULATED 6.5X115MM -,SUP-326515S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS III SS CANNULATED 6.5X120MM -,SUP-326520S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS III SS CANNULATED 6.5X125MM -,SUP-326525S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS III SS CANNULATED 6.5X130MM -,SUP-326530S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS III CANN 8.0 X 70MM -,SUP-326670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW S.S. TL25 8.0 X 75 -,SUP-326675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS 8.0 X 80MM -,SUP-326680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS CANNULATED 8.0 X 85MM -,SUP-326685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 8MMX90MM CANN ASNIS III 25MM P/T SD/ST REVCT FLUT SS -,SUP-326690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 8MMX95MM CANN ASNIS III 25MM P/T SD/ST REVCT FLUT SS -,SUP-326695,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANNULATED PARTIALLY THREADED 8MM X 95MM TL25MM -,SUP-326695S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 8MMX100MM CANN ASNIS III 25MM P/T SD/ST REVCT FLUT SS -,SUP-326700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
8 x 105MM ASNIS SCREW -,SUP-326705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
8 X 110MM ASNIS SCREW -,SUP-326710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
C/M 16MM & 25MM PLUG WITH NOZZLE -,SUP-32810503800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1313.46,919.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LONG NAIL KIT LEFT 300mm -,SUP-3325-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL LONG KIT 11X320MMX125 GAM -,SUP-3325-0320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL GAMMA LGN LEFT 11X360 -,SUP-3325-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL LONG GAMMA3 11X380 LFT -,SUP-3325-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LONG GAMMA NAIL 11X400 LEFT -,SUP-3325-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LONG GAMMA NAIL 11X420 LEFT -,SUP-3325-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LONG GAMMA NAIL 11X440 LEFT -,SUP-3325-0440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 13MMLNGX340MM GAMMA3 LT TROCH FEM TI BIOMECH STRGTH -,SUP-3325-3340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN OPLS 2HL STD BRL COMPR SDE 130DG ANG -,SUP-3362-1-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 130DG ANG -,SUP-3362-1-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN OPLS 2HL STD BRL COMPR SDE 135DG ANG KYLS -,SUP-3362-1-102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE HIP COMP 135-5-HOLE -,SUP-3362-1-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE HIP OMEGA 135 6 HOLE - OBSOLETE DO NOT USE -,SUP-3362-1-106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN OPLS SLOTX2 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN OPLS SLOTX5 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN OPLS SLOTX6 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN OPLS SLOTX8 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN OPLS SLOTX3 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-303,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN OPLS SLOTX5 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-305,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2896.15,2027.305,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN OPLS SLOTX6 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2896.15,2027.305,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN OPLS SLOTX8 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN OPLS SLOTX10 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 150DG ANG -,SUP-3362-1-404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN OPLS SLOTX8 STD BRL COMPR SDE 150DG ANG -,SUP-3362-1-408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN OPLS SLOTX10 STD BRL COMPR SDE 150DG ANG -,SUP-3362-1-410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3570.95,2499.665,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN OPLS SLOTX12 25.4MM BRL 98DG ANG PRE- KY -,SUP-3362-2-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4883.15,3418.205,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN OMG SLOTX4 STD BRL COMPR 130DG ANG KYLS -,SUP-3362-3-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN OMG SLOTX2 STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN OMG SLOTX3 STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-103,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN OPLS 4HL STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN OMG SLOTX6 STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN OMG SLOTX5 STD BRL COMPR 140DG ANG KYLS -,SUP-3362-3-205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 50MM -,SUP-3362-5-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 55MM -,SUP-3362-5-055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1205.86,844.102,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 60MM -,SUP-3362-5-060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1205.86,844.102,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 65MM -,SUP-3362-5-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 70MM -,SUP-3362-5-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 75MM -,SUP-3362-5-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 80MM -,SUP-3362-5-080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 90MM -,SUP-3362-5-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 95MM -,SUP-3362-5-095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 100MM -,SUP-3362-5-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 105MM -,SUP-3362-5-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X10MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X12MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X14MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X16MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X18MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X20MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X22MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X24MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X26MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X28MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X30MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X32MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X34MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X36MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X38MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X40MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X42MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X44MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X45MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X46MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X48MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X50MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X55MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X60MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X65MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X70MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5 X 75 CORTICAL -,SUP-338675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X80MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL 3.5MM X 85MM -,SUP-338685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SELF TAP CORTICAL 3.5 X 115MM -,SUP-338715,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SELF TAP CORTICAL 3.5 X 120MM -,SUP-338720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X14MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV CUT -,SUP-340614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX16MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX18MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX20MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX22MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX24MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX26MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX28MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX30MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX34MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX34MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX36MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX36MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX38MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX38MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX40MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX40MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX42MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX42MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX44MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX44MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX46MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX48MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX48MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX50MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL 4.5 X 52 -,SUP-340652,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL 4.5 X 54 -,SUP-340654,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX55MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX56MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340656,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX58MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340658,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL 4.5 X 60MM -,SUP-340660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX65MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX75MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MMX35MM MATTA CANC OMEGA3 SPS 16MM P/T 3.5MM HEX -,SUP-341035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MMX40MM MATTA CANC OMEGA3 SPS 16MM P/T 3.5MM HEX -,SUP-341040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER KIKO CORPECTOMY SMALL 12 X 14 0 DEG 21MM -,SUP-342.721,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11547.43,8083.201,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB. -,SUP-3420-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11MMX320MM RT TI BIOMECH STRGTH STAB 120DG ANG -,SUP-3420-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11MMX340MM RT TI BIOMECH STRGTH STAB 120DG ANG -,SUP-3420-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MMX80MM MATTA CANC OMEGA3 SPS 32MM P/T 3.5MM HEX -,SUP-342080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MMX85MM MATTA CANC OMEGA3 SPS 32MM P/T 3.5MM HEX -,SUP-342085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10MMX300MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10MMX320MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10MMX340MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10MMX360MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB. -,SUP-3425-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10MMX380MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10MMX400MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LONG NAIL 10MM X 420MM X 125 DEGREES -,SUP-3425-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11MMX300MM GAMMA3 RT HIP TI BIOMECH STRGTH STAB -,SUP-3425-1300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11MMX320MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11MMX340MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11MMX360MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11MMX380MM GAMMA3 RT TI BIOMECH STRGTH STAB -,SUP-3425-1380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11MMX400MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANCL FT 6.5 X 20 -,SUP-343020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANCL FT 6.5 X 25 -,SUP-343025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANCL FT 6.5 X 30 -,SUP-343030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANCL FT 6.5 X 40 -,SUP-343040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MMX85MM MATTA CANC OMEGA3 SPS FT 3.5MM HEX DRV CUT -,SUP-343085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX10MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX12MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX14MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX16MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX18MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX20MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX22MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX24MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX26MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX28MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX30MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX32MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX34MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX36MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX38MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CNCL LCK 4.0 X 40 -,SUP-345440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX45MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX50MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX55MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX60MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX65MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX75MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345475,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX80MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX90MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX10MM LCK CANC AXSOS SPS 5MM P/T ST 2.5MM HEX DRV -,SUP-345510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX14MM LCK CANC AXSOS SPS 6MM P/T ST 2.5MM HEX DRV -,SUP-345514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX18MM LCK CANC AXSOS SPS 6MM P/T ST 2.5MM HEX DRV -,SUP-345518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX34MM LCK CANC AXSOS SPS 14MM P/T ST 2.5MM HEX DRV -,SUP-345534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX36MM LCK CANC AXSOS SPS 14MM P/T ST 2.5MM HEX DRV -,SUP-345536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX38MM LCK CANC AXSOS SPS 14MM P/T ST 2.5MM HEX DRV -,SUP-345538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX40MM LCK CANC AXSOS SPS P/T ST 2.5MM HEX DRV CUT -,SUP-345540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX45MM LCK CANC AXSOS SPS 15MM P/T ST 2.5MM HEX DRV -,SUP-345545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX50MM LCK CANC AXSOS SPS 15MM P/T ST 2.5MM HEX DRV -,SUP-345550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX55MM LCK CANC AXSOS SPS 16MM P/T ST 2.5MM HEX DRV -,SUP-345555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX60MM LCK CANC AXSOS SPS 16MM P/T ST 2.5MM HEX DRV -,SUP-345560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX70MM LCK CANC AXSOS SPS P/T ST 2.5MM HEX DRV CUT -,SUP-345570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX80MM LCK CANC AXSOS SPS P/T ST 2.5MM HEX DRV CUT -,SUP-345580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MMX8MM CORT AXSOS ISO SPS FT ST 2.5MM HEX DRV CUT -,SUP-349608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL 2.7 X 14MM -,SUP-349614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MMX16MM CORT AXSOS ISO SPS FT ST 2.5MM HEX DRV CUT -,SUP-349616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MMX18MM CORT AXSOS ISO SPS FT ST 2.5MM HEX DRV CUT -,SUP-349618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CORTEX SCREW SELF TAPPING STEEL 2.7MM X 60MM -,SUP-349660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,127.9,89.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ASSEMBLY CBL CRLGE TI CBL LOCK SPRCBL ISO-ELAS -,SUP-35-100-1010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2597.25,1818.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CABLE ORTHO SUPERCABLE 1.5MM CERVICAL CERCLAGE -,SUP-35-100-1040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2477.71,1734.397,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE KINAMED 2 HOLE SUPERCABLE -,SUP-35-200-1020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8377.66,5864.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN SPRCBL 190MM 4HL TI TROCH GRP -,SUP-35-200-1030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10233.03,7163.121,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11MMX340MM GAMMA3 LT TI 120DG ANG -,SUP-3520-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11MMX360MM GAMMA3 LT TI 120DG ANG -,SUP-3520-1360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11MMX380MM GAMMA3 LT TI 120DG ANG -,SUP-3520-1380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CABLE ORTHO SUPER CBL TI PLATE 6HL -,SUP-35-220-1010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5831.26,4081.882,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CABLE-PLATE 8 HOLE STRAIGHT -,SUP-35-220-2010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7363.34,5154.338,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SUPERCABLE GRIP AND PLATE 10 HOLE STRAIGHT -,SUP-35-220-3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9661.23,6762.861,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN SPRCBL 290MM 10HL TI TROCH GRP -,SUP-35-220-3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10530.07,7371.049,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GRIP AND PLATE SYSTEM COMPRESSION BONE SCREW 4.5X12MM -,SUP-35-230-4512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,250.91,175.637,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SUPERCABLE GRIP AND PLATE SYS COP BONE SCREW 4.5 X 14MM -,SUP-35-230-4514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,250.91,175.637,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GRIP AND PLATE COMPRESSION BONE SCREW 4.5 X 16MM -,SUP-35-230-4516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,250.91,175.637,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SUPERCABLE BONE SCREW 4.5 X 30 -,SUP-35-230-4530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SUPERCABLE BONE SCREW 4.5 X 32 -,SUP-35-230-4532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE SUPERCABLE GRIP AND PLATE COMP  4.5 X 34 -,SUP-35-230-4534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X36MM COMPR SPRCBL F/GRP PLATE SYS -,SUP-35-230-4536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X38MM COMPR SPRCBL F/GRP PLATE SYS -,SUP-35-230-4538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X40MM COMPR SPRCBL F/GRP PLATE SYS -,SUP-35-230-4540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GRIP AND PLATE SYS COMP BONE SCREW 4.5MM X 45MM -,SUP-35-230-4545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
KINAMED SUPERCABLE SCREW -,SUP-35-230-4550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X12MM LCK SPRCBL F/GRP PLATE SYS -,SUP-35-234-5012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X16MM LCK SPRCBL F/GRP PLATE SYS -,SUP-35-234-5016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X18MM LCK SPRCBL F/GRP PLATE SYS -,SUP-35-234-5018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE SUPERCABLE GRIP AND PLATE LOCK 5 X 20 -,SUP-35-234-5020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10MMX300MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10MMX340MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10MMX380MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
"NAIL LONG KIT R1.5 TI LEFT 010 X 125"" -",SUP-3525-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11MMX420MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11MMX440MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11MMX300MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11MMX320MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11MMX340MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11MMX380MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11MMX400MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
"NAIL LONG KIT R15 TI 011 X 400MM X 125"" LEFT GAMMAX3 SYS -",SUP-3525-1400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL LONG KIT R1 5 TI LEFT -,SUP-3525-1420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GAMMA LONG NAIL KIT R1.5 LEFT 11X440MM -,SUP-3525-1440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB. -,SUP-3530-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DBM PUTTY - OSTEOSELECT 2.5CC -,SUP-359025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1749.17,1224.419,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DBM PUTTY - OSTEOSELECT 5CC -,SUP-359050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DBM PUTTY - OSTEOSELECT 10CC -,SUP-359100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN FX STNMN 2.8X230MM SMTH TROC PNT 3-SDE SHNK SS -,SUP-3611-3-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13.5,9.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SET SCREW -,SUP-36-2001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TULIP BODY -,SUP-36-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
REDUCTION HEAD -,SUP-36-2103,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW JANUS ORTHOFIX 4.5 X 30 -,SUP-36-2430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5MM X 35 ORTHOFIX -,SUP-36-2535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW JANUS ORTHOFIX 5.5 X 40 -,SUP-36-2540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SREW ORTHOFIX FIREBIRD 5.5 X 45MM -,SUP-36-2545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MM X 30MM ORTHOFIX -,SUP-36-2630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW JANUS 6.5X35MM ORTHOFIX -,SUP-36-2635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW JANUS ORTHOFIX 6.5 X 40 -,SUP-36-2640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW JANUS CANN 5.5 X 35 -,SUP-36-3535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW JANUS CANN 5.5 X 40 -,SUP-36-3540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW JANUS CANN 5.5 X 45 -,SUP-36-3545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW JANUS CANN 65 X 35 -,SUP-36-3635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW JANUS CANN 65 X 45 -,SUP-36-3645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5 X 25MM ORTHOFIX -,SUP-36-4425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW JANUS 4.5 X 30MM FENESTRATE ORTHOFIX -,SUP-36-4430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW JANUS 4.5 X 35MM FENESTRATE ORTHOFIX -,SUP-36-4435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW JANUS ORTHOFIX 6.5 X 30MM -,SUP-36-4630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW JANUS ORTHOFIX 6.5 X 35MM -,SUP-36-4635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER ACDF COLONIAL 12 X 14 X 6MM 7 DEGREE -,SUP-365.406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER ACDF COLONIAL 12 X 14 X 8MM 7 DEGREE -,SUP-365.408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X10MM LCK AXSOS ST T20 DRV SS NS -,SUP-370110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X12MM LCK AXSOS ST T20 DRV SS NS -,SUP-370112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X14MM LCK AXSOS ST.T20 DRV SS NS -,SUP-370114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X16MM LCK AXSOS ST T20 DRV SS NS -,SUP-370116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X14MM LCK AXSOS ST-T20 DRV SS NS -,SUP-370118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X14MM LCK AXSOS ST..T20 DRV SS NS -,SUP-370120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X14MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.17,457.219,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X26MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X28MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X30MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X32MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X34MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X36MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X40MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X44MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X65MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X70MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X75MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X80MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X85MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370385,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X90MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X95MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CABLE ORTHO 1.6MM DLMLS HIP SS BEAD SM SLV -,SUP-3704-0-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CABLE/SLEEVE FX 0.2MM DLMLS SS BEAD -,SUP-3704-0-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN DLMLS 165MM 4.5MM 5HL RECON SC SS BRD GROOVEX6 -,SUP-3704-3-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN DLMLS F/RECON TRMA 7HL GROOVEX8 RECON COMPR SS -,SUP-3704-3-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN DLMLS 254MM 4.5MM 9HL RECON SC SS BRD GROOVEX10 -,SUP-3704-3-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN DLMLS 305MM 4.5MM 11HL RECON SC SS GROOVEX12 -,SUP-3704-3-130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CABLE ORTHO 2MM HIP SS -,SUP-3704-8-240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS -,SUP-370528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS. -,SUP-370532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS- -,SUP-370538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS_ -,SUP-370540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS.NS -,SUP-370542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS.. -,SUP-370544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS -,SUP-370546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS__ -,SUP-370570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS-- -,SUP-370575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X28MM LCK AXSOS ST T15 DRV-SS NS -,SUP-370585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LCK ST 3.0 X 10 -,SUP-371010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,301.9,211.33,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3X16MM LCK AXSOS -,SUP-371016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,301.9,211.33,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X14MM LCK AXSOS ST.T20 DRV SS NS DIST LAT PERIART -,SUP-371314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCK 5.0 X 16 -,SUP-371316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X14MM LCK AXSOS ST_T20 DRV SS NS DIST LAT PERIART -,SUP-371318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X14MM LCK AXSOS ST T20 DRV SS NS DIST LAT PERIART -,SUP-371320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X22MM LCK AXSOS ST T20 DRV SS NS -,SUP-371322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X26MM LCK AXSOS ST T20 DRV SS NS -,SUP-371326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X28MM LCK AXSOS ST T20 DRV SS NS -,SUP-371328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCK 5.0 X 30 -,SUP-371330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X32MM LCK AXSOS ST T20 DRV SS NS -,SUP-371332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X34MM LCK AXSOS ST T20 DRV SS NS -,SUP-371334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X36MM LCK AXSOS ST T20 DRV SS NS -,SUP-371336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X38MM LCK AXSOS ST T20 DRV SS NS -,SUP-371338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X40MM LCK AXSOS ST T20 DRV SS NS -,SUP-371340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X42MM LCK AXSOS ST T20 DRV SS NS -,SUP-371342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X44MM LCK AXSOS ST T20 DRV SS NS -,SUP-371344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X46MM LCK AXSOS ST T20 DRV SS NS -,SUP-371346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X48MM LCK AXSOS ST T20 DRV SS NS -,SUP-371348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X50MM LCK AXSOS ST T20 DRV SS NS -,SUP-371350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X60MM LCK AXSOS ST T20 DRV SS NS -,SUP-371360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X70MM LCK AXSOS ST T20 DRV SS NS -,SUP-371370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X75MM LCK AXSOS ST T20 DRV SS NS -,SUP-371375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X80MM LCK AXSOS ST T20 DRV SS NS -,SUP-371380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X90MM LCK AXSOS ST T20 DRV SS NS -,SUP-371390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X95MM LCK AXSOS ST T20 DRV SS NS -,SUP-371395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LCK 4.0 X 14 -,SUP-371514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X16MM LCK AXSOS ST T15 DRV SS NS -,SUP-371516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X20MM LCK AXSOS ST T15 DRV SS NS -,SUP-371520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X22MM LCK AXSOS ST T15 DRV SS NS -,SUP-371522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X24MM LCK AXSOS ST T15 DRV SS NS -,SUP-371524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X26MM LCK AXSOS ST T15 DRV SS NS -,SUP-371526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X28MM LCK AXSOS ST_T15 DRV SS NS PERIART -,SUP-371528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X30MM LCK AXSOS ST T15 DRV SS NS -,SUP-371530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X28MM LCK AXSOS ST.T15 DRV SS NS PERIART -,SUP-371532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X34MM LCK AXSOS ST T15 DRV SS NS -,SUP-371534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X36MM LCK AXSOS ST T15 DRV SS NS -,SUP-371536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X28MM LCK AXSOS ST-T15 DRV SS NS PERIART -,SUP-371538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS.PERIART -,SUP-371542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS_PERIART -,SUP-371544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS-PERIART -,SUP-371546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X48MM LCK AXSOS ST T15 DRV SS NS -,SUP-371548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X50MM LCK AXSOS ST T15 DRV SS NS -,SUP-371550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X55MM LCK AXSOS ST T15 DRV SS NS -,SUP-371555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X60MM LCK AXSOS ST T15 DRV SS NS -,SUP-371560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X65MM LCK AXSOS ST T15 DRV SS NS -,SUP-371565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X28MM-LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X28MM.LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X80MM LCK AXSOS ST T15 DRV SS NS -,SUP-371580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X28MM_LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X95MM LCK AXSOS ST T15 DRV SS NS -,SUP-371595,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEPIN ORTHO 2.4MM -,SUP-373-0224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BIT DRILL 6MM BN -,SUP-3815-1-660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,371.28,259.896,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER THORLUM 12X14X6MM COALITION 0DG -,SUP-384.006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER THORLUM 12X14X8MM COALITION 0DG -,SUP-384.008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEPIN ORTHO 2.8MMX23CM THRD TIP -,SUP-3861-0-628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,82.92,58.044,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WASHER ORTHO 13MM ASNIS III 6.5/8.0MM SS RND NS -,SUP-390016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,182.99,128.093,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WASHER ORTHO 4MM ASNIS III F/4MM BN SCR SS RND NS -,SUP-390018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,132.57,92.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WASHER ORTHO 4.1MM ASNIS III F/9MM BN SCR SS RND NS -,SUP-390019,CDM,C1713,HCPCS,278,RC,,,outpatient,,,145.64,101.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
REDUCTION PIN 4.5MM DIA 150MM -,SUP-390082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,624.75,437.325,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUT 5.5MM ZIP PEEK #2 SUT FORCE FIB NDL -,SUP-3910-200-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUT 5.5MM ZIP PEEK #2 SUTX2 FORCE FIB -,SUP-3910-200-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUT 5.5MM ZIP PEEK #2 SUTX2 FORCE FIB -,SUP-3910-200-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUT 6.5MM ZIP PEEK #2 SUTX2 FORCE FIB 1/2CIR TAPR NDL -,SUP-3910-200-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUT 6.5MM ZIP PEEK #2 SUTX2 FORCE FIB -,SUP-3910-200-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUT INTRALINE 4.5MM HA/PLLA COMP BIOSTEON SUTX2 W/O -,SUP-3910-200-080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2648.5,1853.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUT TWINLOOP 3.5MM ZIP PEEK #2 SUT FORCE FIB -,SUP-3910-400-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1151.37,805.959,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUT TWINLOOP 3.5MM ZIP PEEK #2 SUTX2 FORCE FIB EYLT -,SUP-3910-400-235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2055.64,1438.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUT ICONIX 2.3MM PILOT HL 3 STRN #2 FORCE FIB PLYSTR -,SUP-3910-500-532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2376.27,1663.389,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAP PROT STRL F/2.5MM K-WR -,SUP-392.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5.72,4.004,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAP ORTHO -,SUP-393.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11.67,8.169,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAP PROT F/11MM CFBR EXTFIX ROD -,SUP-394.970,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5.02,3.514,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAP PROT F/4.0MM CRBN FIBRE BAR ROD BLK -,SUP-394.990,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5.43,3.801,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAP PROT NS F/4MM FX PIN YEL -,SUP-394.991,CDM,C1713,HCPCS,278,RC,,,outpatient,,,28.24,19.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
HYDROSET HA BONE SUB 3CC -,SUP-397003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4410.87,3087.609,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
HYDROSET BONE SUB 15CC -,SUP-397015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17072.08,11950.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 150MM POLARUS 3 PROX HUM LCK -,SUP-4001-1015R-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10270.16,7189.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3X90MM COMPR DL -TRAK CUT FLUT TI ALY NS -,SUP-40-0137,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6336.29,4435.403,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SUBSTITUTE CANC 30ML CHP FRZDR VOID FIL 1.7-10MM -,SUP-400150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1681.8,1177.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GRAFT HUM TIS WDG FRZDR 10-17 MMX14-20MM TRCORT ILC CRST -,SUP-400405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4361,3052.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTEX TI SLF TPNG 2.4 X 10 T8 SD REC -,SUP-401.760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,656.44,459.508,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTEX TI SLF TPNG 2.4 X 14 T8 SD REC -,SUP-401.764,CDM,C1713,HCPCS,278,RC,,,outpatient,,,656.44,459.508,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTEX TI SLF TPNG 2.4 X 30 T8 SD REC -,SUP-401.780,CDM,C1713,HCPCS,278,RC,,,outpatient,,,656.44,459.508,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SMALL CALCANEOUS FOOT -,SUP-40-10102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2915.48,2040.836,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE CALCANEUS SMALL STANDARD -,SUP-40-10112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2915.48,2040.836,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE CALCANEUS STANDARD LARGE -,SUP-40-10116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2915.48,2040.836,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 36MM 2.7MM 4HL RECON POLYAX LCK TI NS -,SUP-40-15011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2418.35,1692.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CURVED PLATE 5 HOLES RIGHT -,SUP-40-15012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.07,1837.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 49MM 2.7MM 6HL RECON POLYAX LCK TI NS -,SUP-40-15014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2657.78,1860.446,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
H-PLATE SMALL -,SUP-40-15021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2050.76,1435.532,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE MED-H -,SUP-40-15022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2610.76,1827.532,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE LARGE -,SUP-40-15023,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2451.75,1716.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
RECTANGLE PLATE SZ 1 -,SUP-40-15032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2451.75,1716.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 48MM 2.7/3.5MM 5HL 1MM RECON POLYAX LCK TI -,SUP-40-15041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2439.24,1707.468,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
VARIAX FOOT PLATE -,SUP-40-15042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2547.84,1783.488,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 51MM 2.7/3.5MM 6HL 1MM RECON POLYAX LCK TI -,SUP-40-15062,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2785.68,1949.976,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 35MM 2.7MM 4HL RECON POLYAX LCK TI NS -,SUP-40-15081,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1737.5,1216.25,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2MMX8MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2MMX9MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2MMX10MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2MMX11MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2MMX12MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2MMX13MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2MMX14MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2MMX15MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2MMX16MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2MMX18MM CANN ASNIS 5MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2MMX20MM CANN ASNIS 5MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2MMX22MM CANN ASNIS 5MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2MMX24MM CANN ASNIS 6MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2MMX26MM CANN ASNIS 6MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2MMX28MM CANN ASNIS 6MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 28.5MM 2MM 2HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 60MM 2MM 4HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1910.88,1337.616,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 72MM 2MM 5HL 2MM PRCONT POLYAX TI STR SMRTLC -,SUP-40-20805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 84MM 2MM 6HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20806,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 96MM 2MM 7HL 2MM PRCONT POLYAX TI STR SMRTLC -,SUP-40-20807,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 108MM 2MM 8HL 2MM PRCONT POLYAX TI STR -,SUP-40-20808,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 132MM 2MM 10HL 2MM PRCONT POLYAX TI STR -,SUP-40-20810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1812.72,1268.904,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 156MM 2MM 12HL 2MM PRCONT POLYAX TI STR -,SUP-40-20812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2549.91,1784.937,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WASHER ORTHO 2MM ASNIS MICRO F/CANN SCR SYS NS -,SUP-40-20900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,304.88,213.416,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 77MM 2MM 3HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.1,1787.87,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 89MM 2MM 4HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.1,1787.87,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 101MM 2MM 5HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.1,1787.87,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 113MM 2MM 6HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2388.81,1672.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 125MM 2MM 7HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2591.95,1814.365,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 137MM 2MM 8HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20908,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2591.95,1814.365,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 149MM 2MM 9HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20909,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2591.95,1814.365,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TOTAL JNT SUBCHONDROPLASTY -,SUP-402201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11788.78,8252.146,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X14MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X16MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X18MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NON-LOCKING 2.7 X 20MM -,SUP-40-27020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X22MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X24MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X26MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X28MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE T7 2.7 X 38MM -,SUP-40-27038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE T7 2.7 X 40 -,SUP-40-27040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE T7 2.7 X 45MM -,SUP-40-27045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X12MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-2761,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X10MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X16MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X18MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X20MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X22MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X24MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X26MM LCK -,SUP-4027626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X28MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3MMX8MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3MMX10MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3MMX12MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3MMX13MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3MMX14MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3MMX15MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3MMX16MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3MMX17MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
MICRO ASNIS SCREW 3.0MM X 18MM -,SUP-40-30118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3MMX18MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.48,659.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3MMX19MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30119,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3MMX20MM CANN ASNIS THRD REVCT FLUT TI NS PUR -,SUP-40-30120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3MMX22MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3MMX24MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3MMX26MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3MMX28MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3MMX30MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3MMX32MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3MMX34MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
3.0 MICRO ASNIS SCREW -,SUP-40-30134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3MMX36MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3MMX40MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WASHER ORTHO 3MM ASNIS MICRO F/CANN SCR SYS NS -,SUP-40-30900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,339.01,237.307,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X10MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X12MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X14MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X16MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X18MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X20MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X22MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X24MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X26MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X28MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X30MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X32MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X34MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X36MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X38MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X40MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X42MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X44MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X46MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X48MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X50MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X55MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X60MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X65MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X70MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X10MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X12MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X14MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X16MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X18MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X20MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X22MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X24MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X26MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
3.5MM LOCKING 28MM SCREW -,SUP-40-35628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
3.5MM LOCKING 34MM SCREW -,SUP-40-35634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X40MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WASHER ORTHO F/3.5MM BN SCR -,SUP-40-35900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,376.01,263.207,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX28MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX36MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.836,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX38MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.838,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX55MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.855,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW EXHAL SZ 8-32X.375 -,SUP-4-072623-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6.48,4.536,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEPIN ORTHO 2.4MMX23CM -,SUP-410236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,407.52,285.264,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SET SCREWS MARINER SPINE -,SUP-41-1010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
POLYAXIAL HEAD G2 -,SUP-41-3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
HEAD SCREW SEASPINE MARINER POLY EXTEND -,SUP-41-4010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
30MM OFFSET -,SUP-41-4130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLUG CEMENT SMALL DIA 10MM -,SUP-414994,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLUG CEMENT SMALL DIA 12MM -,SUP-414995,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE SCREW 5.5 X 30MM -,SUP-41-5530-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
MARINER SOLD SCREW 5.5 X35MM -,SUP-41-5535-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SEASPINE MARINER SOLID 5.5MM X 35MM -,SUP-41-5535-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE SCREW 5.5 X 40 -,SUP-41-5540-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5 X 45MM -,SUP-41-5545-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SEASPINE MARINER SOLID 6.5MM X 35MM -,SUP-41-6535-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE SCREW 6.5 X 45MM -,SUP-41-6545-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7.5 X 70MM -,SUP-41-7570-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEPIN ORTHO TRUMATCH RT -,SUP-420901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6242.92,4370.044,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEPIN ORTHO TRUMATCH LT -,SUP-420902,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4990.94,3493.658,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEPIN SZ5 ATTUNE TRUMATCH LT KN -,SUP-420945,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE CRANFC 100X100MM MATRIXNEURO LPRO MSH 0.6MM TI SQ -,SUP-421.534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8428.58,5900.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X26MM LCK CANN SD 3.5MM HEX RCESS CNCL HEAD TI NS -,SUP-422.392,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1537.15,1076.005,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X55MM LCK CANN SD 3.5MM HEX RCESS CNCL HEAD TI NS -,SUP-422.394,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1515.94,1061.158,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X65MM LCK CANN SD 3.5MM HEX RCESS CNCL HEAD TI NS -,SUP-422.395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1515.94,1061.158,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BEARING FIXED ASF UC 14MM PLY R 4-11 EF PERSONA -,SUP-42-5212-005-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SYSTEM KNEE PERSONA ASF UC 35MM PLY R 7-12 GH 9.0 THICKNESS -,SUP-42-5400-000-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE CURVED PELVIC R 108MM/L58.5MM/4HOLE -,SUP-425604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE CURV PELV R 108MM L74.5MM 5 HOLE -,SUP-425605,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 8 HOLE -,SUP-425608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
10 HOLE PLATE -,SUP-425610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE CURV. PELV 108MM/L186.5MM/12H -,SUP-425612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE PELV CURV R 108MM L218.5MM 14HOLE -,SUP-425614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE PELV CURV R 108MM L250.5MM 16 HOLE -,SUP-425616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5273.81,3691.667,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE PELV CURV R 108MM L282.5MM 18H -,SUP-425618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5273.81,3691.667,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE PELV CURV R 108MM L314.5MM 20H -,SUP-425620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5273.81,3691.667,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SYMPYSIS -,SUP-425654,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 10.5MMX74.5MM F/3.5MM/4.5MM SCR 4HL MATTA SS 88MM -,SUP-425655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 6 HOLE R88 PELVIS -,SUP-425656,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 8HOLE R88 -,SUP-425658,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE PELV CURVED R 88MM/L154.5MM/10H -,SUP-425660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE R88 12 HOLE -,SUP-425662,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE R88 CURVED 218.5 14 HOLE -,SUP-425664,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 16 HOLE R88 PELVIS -,SUP-425666,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE PELV CURV R 88MM L282.5 18H -,SUP-425668,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE PELV CURV R 88MM L314.5MM 20H -,SUP-425670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE PELV STRAIGHT L 26.5MM -,SUP-425702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4046.3,2832.41,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PELVIC PLATE -,SUP-425753,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4676.37,3273.459,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE STRT ACET L 46.5MM 14 HOLE -,SUP-425754,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4676.37,3273.459,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE STRAIGHT ACET L 70.5M 6 HOLE -,SUP-425756,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4571.81,3200.267,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 8HOLE FLEX -,SUP-425758,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4571.81,3200.267,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 10 HOLE FLEX -,SUP-425760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4571.81,3200.267,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE STRT ACET L 142.5MM 12 HOLE -,SUP-425762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5044.63,3531.241,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SYMPHYSIS 4 HOLE -,SUP-425794,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6110.34,4277.238,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE PRO SUPRAPECTINEAL QLS LEFT -,SUP-425912S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.77,7018.039,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
INFRAPECTINEAL PLATE SMALL QLS LEFT -,SUP-425932S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8017.17,5612.019,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN AXSOS 45MM 4MM 3HL LCK COMPR SS WAIST SM FRAG NS -,SUP-427003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,557.83,390.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN AXSOS 71MM 4MM 5HL LCK COMPR SS WAIST SM FRAG NS -,SUP-427005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,716.54,501.578,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN AXSOS 97MM 4MM 7HL LCK COMPR SS WAIST RND TAPR END -,SUP-427007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,716.54,501.578,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN AXSOS 110MM 4MM 8HL LCK COMPR SS WAIST RND TAPR END -,SUP-427008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,795.89,557.123,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN AXSOS 123MM 4MM 9HL LCK COMPR SS WAIST SM FRAG STRL -,SUP-427009S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,795.89,557.123,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN AXSOS 136MM 4MM 10HL LCK COMPR SS WAIST RND TAPR -,SUP-427010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,795.89,557.123,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN AXSOS 266MM 4MM 20HL LCK COMPR SS WAIST SM FRAG NS -,SUP-427020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.32,779.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN AXSOS 48MM 4MM 4HL RECON LCK COMPR SS SM FRAG NS -,SUP-427034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1836.09,1285.263,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN AXSOS 60MM 4MM 5HL RECON LCK COMPR SS SM FRAG NS -,SUP-427035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1836.09,1285.263,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN AXSOS 72MM 4MM 6HL RECON LCK COMPR SS ADLT SM FRAG -,SUP-427036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2071.44,1450.008,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN AXSOS 96MM 4MM 8HL RECON LCK COMPR SS ADLT SM FRAG -,SUP-427038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2298.3,1608.81,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN AXSOS 76MM 3MM 6HL LCK SS 1/3 TBLR SM FRAG NS -,SUP-427066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,669.86,468.902,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN AXSOS 89MM 3MM 8HL LCK SS 1/3 TBLR SM FRAG NS -,SUP-427068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,725.87,508.109,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN AXSOS 169MM 5MM 9HL LCK COMPR SS NRW WAIST BSC FRAG -,SUP-427109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,898.59,629.013,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN AXSOS 223MM 5MM 12HL LCK COMPR SS NRW WAIST BSC -,SUP-427112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1075.97,753.179,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN AXSOS 259MM 5MM 14HL LCK COMPR SS NRW WAIST BSC -,SUP-427114S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1075.97,753.179,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE WSTD CMP BRD HL8 -,SUP-427138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN AXSOS 173MM 5MM 9HL LCK COMPR SS BRD WAIST BSC FRAG -,SUP-427139S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN AXSOS 263MM 5MM 14HL LCK COMPR SS BRD WAIST BSC ST -,SUP-427144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1159.75,811.825,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GRAFT HUM TIS HEMI FRZN 10-10.5 MMX8-13CM PTLR TNDN 30-75MM -,SUP-430007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11007.78,7705.446,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 10X60MM F/3.5MM/4MM SCR 5HL SHFT 2.8MM RECON -,SUP-430105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.67,1007.769,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 25MM 3MM 2HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,234.51,164.157,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 38MM 3MM 3HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,234.51,164.157,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 64MM 3MM 5HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,289.01,202.307,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 77MM 3MM 6HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,289.01,202.307,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 90MM 3MM 7HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.42,222.194,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 103MM 3MM 8HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,355.35,248.745,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 129MM 3MM 10HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,355.35,248.745,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
MESH TITANIUM 6X6 - DISCONTINUED DO NOT USE -,SUP-43-1022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 10X49MM F/3.5MM/4.5MM SCR 0.75HL HD/SHFT 1.2MM SS -,SUP-431024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,634.85,444.395,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 10X66MM F/3.5MM/4.5MM SCR HLX3/6 HD/SHFT 1.2MM SS -,SUP-431026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,871.75,610.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
MOLD CMNT SPCR 48MM SIL SS STAGEONE STRL -,SUP-431181,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5199.96,3639.972,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
HIP HEAD CEMENT MOLD 52MM -,SUP-431182,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5199.96,3639.972,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SHOULDER MOLD 12STD 54 X 21 X 64 -,SUP-431412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11946.58,8362.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
60MM FEMORAL KNEE CEMENT MOLD -,SUP-432160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8413.73,5889.611,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
MOLD BNCMNT FEM 65MM SIL STAGEONE STRL -,SUP-432165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8413.73,5889.611,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 158MM 4.5MM 10HL RECON SS -,SUP-432210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1420.32,994.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE RECON HL 4.5 X 14 HOLE -,SUP-432214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.92,1168.944,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE T 6 HOLE L=111MM -,SUP-433106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.57,778.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
70MM TIBIAL KNEE CEMENT MOLD -,SUP-433170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4530.53,3171.371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
MOLD BNCMNT TIB 75MM SIL STAGEONE STRL -,SUP-433175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4530.53,3171.371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN AXSOS 86MM 4MM 3HL CONTR LCK SS NS 1STRN/PK -,SUP-437123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5167.49,3617.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN AXSOS 112MM 4MM 5HL CONTR LCK SS NS -,SUP-437125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5167.49,3617.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN AXSOS 95MM 4MM HLX2/5 SHFT/METPHYSL CONTR LCK SS NS -,SUP-437302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN AXSOS 121MM 4MM HLX4/5 SHFT/METPHYSL CONTR LT TIB -,SUP-437304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN AXSOS 147MM 4MM HLX6/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN AXSOS 121MM 4MM HLX4/5 SHFT/METPHYSL CONTR RT TIB -,SUP-437324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN AXSOS 173MM 4MM HLX8/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN AXSOS 97MM 4MM HLX4/3 SHFT/METPHYSL CONTR LCK SS -,SUP-437424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4738,3316.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN AXSOS 166MM 5MM HLX6/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5434.02,3803.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN AXSOS 202MM 5MM HLX8/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN AXSOS 238MM 5MM HLX10/5 SHFT/METPHYSL CONTR LCK SS. -,SUP-437510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN AXSOS 310MM 5MM HLX14/5 SHFT/METPHYSL CONTR LCK SS- -,SUP-437514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN AXSOS 238MM 5MM HLX10/5 SHFT/METPHYSL CONTR LCK SS- -,SUP-437530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN AXSOS 310MM 5MM HLX14/5 SHFT/METPHYSL CONTR LCK SS. -,SUP-437534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN AXSOS 343MM 5MM HLX16/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LINER 32X49MM EPSLN STD DRSUL PRIM HOOD -,SUP-4377-32-049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3174.71,2222.297,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SET SCREW SPIN STD FIREBIRD TI -,SUP-44-2001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FIREBIRD TOP LOADING HEAD -,SUP-44-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ORTHOFIX 4.5 X 30 SCREW -,SUP-44-5430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ORTHOFIX SCREW 4.5 X 35 -,SUP-44-5435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ORTHOFIX SCREW 4.5 X 40 -,SUP-44-5440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ORTHOFIX SCREW 4.5 X 45 -,SUP-44-5445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ORTHOFIX SCREW 5.5 X 30 -,SUP-44-5530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ORTHOFIX SCREW 5.5 X 35 -,SUP-44-5535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ORTHOFIX SCREW 5.5 X 40 -,SUP-44-5540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ORTHOFIX SCREW 5.5 X 45 -,SUP-44-5545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ORTHOFIX SCREW 6.5 X 30 -,SUP-44-5630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
6.5 X 35 SHANK -,SUP-44-5635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
6.5 X 40 SHANK -,SUP-44-5640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
6.5 X 45 SHANK -,SUP-44-5645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
7.5 X 40 SHANK -,SUP-44-5740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW FIREBIRD ORTHOFIX 7.5 X 45 -,SUP-44-5745,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ORTHOFIX SCREW 7.5 X 50 -,SUP-44-5750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ORTHOFIX SCREW 6.5 X 35 -,SUP-44-6535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ORTHOFIX SCREW 6.5 X 40 -,SUP-44-6540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WASHER 3.5 -,SUP-45-35900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,139.05,97.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
MICROCOIL EMBL 4MMX 5CML AZUR DTCH 18 -,SUP-45-480405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3570.95,2499.665,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
IMPLANT PHALANX 2MM PRO- TOE VO 13MM 10DG ANG -,SUP-45712010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
MINI STICK MAX 5FR X 10CM -,SUP-45-756,CDM,C1713,HCPCS,278,RC,,,outpatient,,,431.21,301.847,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COUNTERSINK FOR SCREWS 02.7/3.5mm AO FITTING -,SUP-45-80040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,516.4,361.48,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3X12MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115401200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3X16MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115401600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3X18MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115401800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3X20MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115402000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER SYSTEM CONSTRUX MINI PEEK -,SUP-47-3009SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2X10MM CORT SM HX DRV -,SUP-4820-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.04,88.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX24MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-48-3502-41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COUPLING DELTA ROD TO ROD MULTI 05/8/11 5MM PIN -,SUP-4922-1-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4759.25,3331.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CLAMP 5 HOLE PIN -,SUP-4922-2-020-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3516.77,2461.739,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD VECTRAN COATED 11MM X 100MM CARBON CONN -,SUP-4922-8-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1854.96,1298.472,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WIRE BOLT SHORT -,SUP-4933-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,750.96,525.672,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WIRE BOLT MEDIUM -,SUP-4933-1-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,750.96,525.672,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WIRE BOLT ADAPTER SHORT -,SUP-4933-1-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1798.46,1258.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
M8 CONNECTING NUT -,SUP-4933-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,199.56,139.692,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
POST EXTERNAL FIXATION SHORT L44 MM OD8 MM HOFFMANN -,SUP-4933-1-644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,819.23,573.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BOLT FOR RING -,SUP-4933-1-702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,220.56,154.392,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WASHER YELLOW 2MM -,SUP-4933-1-711,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.1,249.97,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CARBON FIBER FULL RING 210MM -,SUP-4933-5-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10863.87,7604.709,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CARBON FIBER OPEN RING 180MM -,SUP-4933-6-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9858.39,6900.873,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CARBON FIBER OPEN RING 210MM -,SUP-4933-6-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9316.66,6521.662,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WIRE WITH OLIVE 1.8 X 450 -,SUP-4933-8-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,850.74,595.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
K-WIRE 2.0 OLIVE -,SUP-4933-8-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,887.5,621.25,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
HII COMPACT MRI PERIARTICULAR PIN CLAMP -,SUP-4941-2-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1539.11,1077.377,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SYNMESH 15MM DIA 8MM HEIGHT ROUND CAGE -,SUP-495.361,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9527.78,6669.446,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
END RING 10MM DIAM / 0 DEG -,SUP-495.384,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1024.04,716.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SYNMESH 10MM DIAM 20MM HEIGHT -,SUP-495.603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9664.94,6765.458,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CRNMXF UPR FACE 1.2X5MM UNIVERSAL NEURO II ST TI NS -,SUP-50-12005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,372.97,261.079,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CRNMXF UPR FACE 1.2X10MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-12010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,372.97,261.079,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CRNMXF UPR FACE 1.2X12MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-12012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,372.97,261.079,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CRNMXF UPR FACE 1.2X3MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-12903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,417.55,292.285,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN WND CLSR 200MM -,SUP-5014-5-200S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,680.36,476.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CANC HALF-PIN 5MM SHAFT 6MM X 250 THREAD -,SUP-5015-7-250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CRNMXF MIDFC 1.7X6MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-17006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.31,222.117,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CRNMXF MIDFC 1.7X8MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-17008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.31,222.117,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CRNMXF MIDFC 1.7X10MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-17010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.31,222.117,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ER CRNMXF MIDFC 1.7X4MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-17304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,441.77,309.239,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LCK CRNMXF MIDFC 1.7X4MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-17504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,416.09,291.263,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LCK CRNMXF MIDFC 1.7X5MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-17505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,416.09,291.263,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
HALF PIN FX APEX 5MM SS HA CTD SD/TAP180MML 50MM THRD -,SUP-5017-5-180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,642.67,449.869,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CRNMXF MIDFC 1.7X3MM CX PIN HD UNIVERSAL NEURO II SD -,SUP-50-17903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,356.29,249.403,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CRNMXF MIDFC 1.7X4MM CX PIN HD UNIVERSAL NEURO II ST. -,SUP-50-17904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,356.29,249.403,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN EXTFIX 5X150MM SS APEX 40MM THRD SD/ST -,SUP-5018-5-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
HALFPIN EXTFIX 5X150MM SS APEX 50MM THRD SD/ST -,SUP-5018-6-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN EXTFIX 5X50MM HLF SS APEX 180MM THRD SD -,SUP-5018-6-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CRNMXF MIDFC 1.9X3MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-19003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,348.64,244.048,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CRNMXF MAND 2X4MM CX PIN HD UNIVERSAL NEURO II ST TI -,SUP-50-20404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.62,210.434,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CRNMXF MAND 2X6MM CX PIN HD UNIVERSAL NEURO II ST TI -,SUP-50-20406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.62,210.434,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CRNMXF MAND 2X8MM CX PIN HD UNIVERSAL NEURO II ST TI -,SUP-50-20408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.62,210.434,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LCK CRNMXF MAND 2X12MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-20512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,551.06,385.742,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LCK CRNMXF MAND 2X14MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-20514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,551.06,385.742,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LCK CRNMXF MAND 2X16MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-20516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,551.06,385.742,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SELF DRILLING LOCKING 2 X 6MM -,SUP-50-20596,CDM,C1713,HCPCS,278,RC,,,outpatient,,,830.96,581.672,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN EXTFIX 6X200MM HLF SS APEX 70MM THRD SD/ST -,SUP-5021-8-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN EXTFIX 4X120MM SS APEX 30MM THRD SD/ST -,SUP-5023-3-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CRNMXF MAND 2.3X16MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-23416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.43,257.201,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN EXTFIX 4X120MM HLF SS APEX 35MM THRD SD/ST -,SUP-5023-5-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN EXTFIX 4X150MM HLF SS APEX 50MM THRD SD/ST -,SUP-5023-6-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN EXTFIX 4X180MM SS HLF PIN APEX 50MM THRD SD/ST -,SUP-5023-6-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN HYBRID APEX -,SUP-5026-8-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,591.79,414.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAP EXTFIX 5MM HOFFMN XPRESS 40MM THRD F/PIN TIP -,SUP-5027-1-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17.15,12.005,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ER CRNMXF MAND 2.7X12MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-27412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,416.21,291.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LCK CRNMXF MAND 2.7X10MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-27510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,708.49,495.943,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD CONNECTING VECTRAN COATED CARBON 8MM X 400MM -,SUP-5028-8-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1100.81,770.567,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TRANSFIX PIN 4X300MM -,SUP-5030-4-300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
APEX TRANSFIX 4 X 250 PIN 5 X 50 THR -,SUP-5030-5-250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN EXTFIX 3X100MM TRNSFX SS APEX 25MM THRD SD/ST F/BILAT -,SUP-5038-2-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,329.79,230.853,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN EXTFIX 3X200MM TRNSFX SS APEX -,SUP-5045-5-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD HII COMPACT MRI CONNECTING 5MM X 65MM -,SUP-5048-5-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
HII COMPACT MRI CONNECTING ROD 5MM X 100MM -,SUP-5048-5-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
HII COMPACT MRI CONNECTING ROD 5MM X 150MM -,SUP-5048-5-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD HII COMPACT MRI CONNECTING 5MM X 200MM -,SUP-5048-5-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN TRANSFIXING 300MM 5/6 -,SUP-5050-4-300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN EXTFIX 5MM/4X300MM TRNSFX SS APEX 50MM THRD SD/ST -,SUP-5050-5-250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,623.82,436.674,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BLADE SAW 13X90MM OSCIL/SGTL 0.89MM -,SUP-506123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,460.97,322.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN EXTFIX 2X45MM SS APEX 20MM THRD ST -,SUP-5065-4-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,297.76,208.432,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CARBON CONNECTING ROD 3MMX120MM -,SUP-5079-6-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,290.23,203.161,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
HALFPIN EXTFIX 2X45MM SS U THRD DBL HLCL FLUT APEX 12MM P/T -,SUP-5080-2-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,346.77,242.739,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN 2MM X 45MM HALF HOFFMANN II APEX STAINLESS STEEL MICRO -,SUP-5080-2-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,346.77,242.739,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW POLY THRD 4.5X25MM CREO -,SUP-5119.1327,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW POLY THRD 5.5 4.5X30MM CREO -,SUP-5119.1330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CREO 5.5 4.5MM X 40MM POLYAXIAL SCREW -,SUP-5119.1340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CREO 5.5 4.5MM X 45MM POLYAXIAL -,SUP-5119.1345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5 X 40 POLYAXIAL CREO -,SUP-5119.1440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CREO THREADED 5.0 X 45MM POLYAXIAL SCREW -,SUP-5119.1447,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5 X 35 POLYAXIAL CREO -,SUP-5119.1535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5 X 40 POLYAXIAL CREO -,SUP-5119.1540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5X45MM CREO THRD PRASMB F/5.5MM TI STRL -,SUP-5119.1545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CREO THREADED 5.5 X 45MM POLYAXIAL SCREW -,SUP-5119.1547,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW POLYAXIAL 5.5 X 50 -,SUP-5119.1550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW POLYAXIAL 5.5 6.5 X 30 CREO -,SUP-5119.1630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X35MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.1635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X40MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.1640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X45MM CREO THRD PRASMB F/5.5MM TI STRL -,SUP-5119.1645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW POLYAXIAL CREO 6.5 X 50 -,SUP-5119.1650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CREO 5.5 6.5 X 60MM POLYAXIAL SCREW -,SUP-5119.1660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5-5.5X30MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5-5.5X35MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3337,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL CREO 5.5- 6.0-5.0X25MM -,SUP-5119.3427,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6-5X30MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.3432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6-5X35MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.3437,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5-6.5X30MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5-6.5X35MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3537,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CREO 5.5 5.5MM X 45MM CORTICAL -,SUP-5119.3547,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER CERV 14X6X12MM MOSAIC PEEK-OPTIMA -,SUP-51412-206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER CERV 14X7X12MM MOSAIC PEEK-OPTIMA -,SUP-51412-207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11436.04,8005.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
UNITED HIP CANCELLOUS LOCKING SCREW 6.5MM X 15MM -,SUP-5208-1015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
UNITED CANCELLOUS LOCKING SCREW 6.5 X 20 -,SUP-5208-1020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
UNITED CANCELLOUS LOCKING SCREW 6.5 X 25 -,SUP-5208-1025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
UNITED CANCELLOUS LOCKING SCREW 6.5 X 30 -,SUP-5208-1030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
UNITED HIP CANCELLOUS LOCKING SCREW 6.5MM X 35MM -,SUP-5208-1035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
UNITED CANCELLOUS LOCKING SCREW 6.5 X 45 -,SUP-5208-1045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD FIREBIRD 40MM ORTHOFIX -,SUP-52-2040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ORTHOFIX NXG 70 ROD -,SUP-52-2070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ORTHOFIX 80MM ROD -,SUP-52-2080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
90MM TI ROD STRAIGHT -,SUP-52-2090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
100MM TI ROD STRAIGHT -,SUP-52-2100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NXG 110MM ROD -,SUP-52-2110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD FIREBIRD 120MM TI STRAIGHT ORTHOFIX -,SUP-52-2120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD FIREBIRD STRAIGHT 140MM TI ORTHOFIX -,SUP-52-2140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD 160MM NXG DIA 5.5MM TI ORTHOFIX -,SUP-52-2160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ORTHOFIX ROD 180 -,SUP-52-2180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ORTHOFIX ROD 200MM -,SUP-52-2200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD HEX TITANIUM 400MM -,SUP-52-2450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD 35MM ORTHOFIX -,SUP-52-6035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
40MM ROD TI CURVED -,SUP-52-6040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD 45MM ORTHOFIX -,SUP-52-6045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ORTHOFIX ROD 50MM -,SUP-52-6050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ACTB 6.5X12MM OSTLOK -,SUP-5260-5-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ACTB 6.5X14MM OSTLOK -,SUP-5260-5-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ACTB 6.5X18MM OSTLOK -,SUP-5260-5-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ACTB 6.5X30MM OSTLOK -,SUP-5260-5-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ACTB 6.5X35MM OSTLOK -,SUP-5260-5-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ACTB 6.5X40MM OSTLOK -,SUP-5260-5-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ACTB 6.5 X 45MM OSTLOK -,SUP-5260-5-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ACTB 6.5X50MM OSTLOK -,SUP-5260-5-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ORTHOFIX ROD 55MM -,SUP-52-6055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ORTHOFIX NXG 60MM ROD -,SUP-52-6060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ORTHOFIX NXG 65MM ROD -,SUP-52-6065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ORTHOFIX 70MM ROD -,SUP-52-6070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ORTHOFIX 75MM ROD -,SUP-52-6075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ORTHOFIX 80 ROD -,SUP-52-6080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
OPEN CONNCETOR 5.5 - 5.5 -,SUP-52-6805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE CRANFC 12MM BAR UNIV NEURO III LPRO 2HL TI STR 1.5MM -,SUP-53-05212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,705.92,494.144,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE CRANFC 2HL 16MM BAR STR UNIV NEURO III 1.5MM TI NS -,SUP-53-05216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,844.97,591.479,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE CRANFC 4HL 28MM BAR 3D BX UNIV NEURO III 1.5MM TI NS -,SUP-53-05228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.88,735.616,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE CRANFC LRG 2HL 3D BX LEIBINGER UNIV NEURO 2 1.5MM TI -,SUP-53-05240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1443.7,1010.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE CRANFC 6MM BAR 4HL STR LEIBINGER UNIV NEURO 2 1.5MM TI -,SUP-53-05406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,702.42,491.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COVER CRANFC 7MM UNIV NEURO III LPRO TI -,SUP-53-05507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1211.85,848.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COVER CRANFC 10MM UNIVERSAL NEURO II LPRO TI NS -,SUP-53-05510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1211.85,848.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COVER CRANFC 14MM UNIVERSAL NEURO II LPRO TI NS -,SUP-53-05514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1211.85,848.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COVER CRANFC 20MM UNIVERSAL NEURO II LPRO TI NS -,SUP-53-05520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1338.06,936.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE CRANFC 8MM UNIV NEURO III LPRO 6HL TI DBL Y 1.5MM NS -,SUP-53-05608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1331.38,931.966,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE STR LP GAP SMALL -,SUP-53-05612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1587.66,1111.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE STR LP GAP LARGE -,SUP-53-05622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1748.42,1223.894,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE CRANFC 4HL X-SHP LEIBINGER UNIV NEURO 2 1.5MM TI NS -,SUP-53-05630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1344.26,940.982,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE CRANFC 8HL STR LEIBINGER UNIV NEURO 2 1.5MM TI NS W/O -,SUP-53-05804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.28,665.896,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE CRANFC 12MM 2HL UNIV NEURO III XTR RGD TI NS -,SUP-53-06212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,597.33,418.131,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL SFT TIS BIO- ABSB LPRO 1.5X20MM PLYLC ACD PLYMR KN -,SUP-531520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,798.11,558.677,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.7X5MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17005E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LCK 1.7 X 06 -,SUP-53-17006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,518.32,362.824,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.7X8MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.7X9MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LCK 1.7 X 10 -,SUP-53-17010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.83,308.581,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.7X12MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LCK 1.7 X 16 -,SUP-53-17016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.7X16MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX -,SUP-53-20616E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2X18MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX NS -,SUP-53-20618E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2X20MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX NS -,SUP-53-20620E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2X22MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX NS -,SUP-53-20622E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.7X24MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX -,SUP-53-20624E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.7X26MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX. -,SUP-53-20626E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X6MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X8MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X9MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X10MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X11MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23011E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X12MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X13MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23013E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X16MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X18MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23018E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 2.3MM X 20MM -,SUP-53-23020E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.88,310.016,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 2.3 X 24 -,SUP-53-23024E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 2.3 X 26 -,SUP-53-23026E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X10MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23210E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X14MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23214E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X16MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23216E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X18MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23218E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X20MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23220E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X22MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23222E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X24MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23224E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X26MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23226E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X28MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23228E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X30MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23230E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X32MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23232E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X34MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23234E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X36MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23236E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X38MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23238E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X10MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23610E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X12MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23612E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X14MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT. -,SUP-53-23614E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X16MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23616E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X18MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT. -,SUP-53-23618E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X20MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23620E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X22MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23622E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X24MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23624E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X26MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23626E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X28MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23628E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X30MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23630E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X32MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23632E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X34MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23634E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X36MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23636E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X38MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23638E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X16MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27116E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X18MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27118E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X20MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27120E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X22MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27122E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X24MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27124E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X26MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27126E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X10MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27210E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NON LOCK 2.7 X 12MM -,SUP-53-27212E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NON LOCK 2.7 X 14 -,SUP-53-27214E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X16MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27216E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X18MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27218E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X20MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27220E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X22MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27222E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X24MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27224E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X25MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27226E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X10MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27610E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X12MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27612E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X14MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27614E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X16MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27616E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X18MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27618E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X20MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27620E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 2.7 X 22 -,SUP-53-27622E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X24MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27624E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X26MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27626E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE MSH CRANFC MIDFC MICRO 60X120MM 0.1MM MLBL 1.2MM TI NS -,SUP-54-00261,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3755.99,2629.193,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
MICRO/MESH 120 X 120 X .2MM / GOLD -,SUP-54-00270,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8602.59,6021.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
MICRO/MESH 120 X 60 X .2MM / GOLD -,SUP-54-00271,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6438.15,4506.705,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BLUE DYNAMIC MESH  90X90MM 0.3MM MLBL 1.7MM TI NS -,SUP-54-00346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2066.2,1446.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOCKING SCREW 3.5MM T15 L40MM -,SUP-541540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1621.95,1135.365,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 60MMX1.5MM 2.7MM ANTMC POLYAX TI SMRTLC RT -,SUP-54-25290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 60MMX1.5MM 2.7MM ANTMC POLYAX TI SMRTLC LT -,SUP-54-25291,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE WIDE DORSAL RIGHT -,SUP-54-25292,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 60MMX1.5MM 2.7MM ANTMC POLYAX TI W SMRTLC -,SUP-54-25293,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 81MMX1.5MM 2.7MM ANTMC POLYAX TI XLNG SMRTLC -,SUP-54-25295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4270.06,2989.042,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 56MM 2.7MM 9HL 2MM ANTMC POLYAX TI SMRTLC -,SUP-54-25374,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 76MM 2.7MM 2MM ANTMC POLYAX TI LNG NRW LT -,SUP-54-25375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 56MM 2.7MM 11HL ANTMC POLYAX TI STD SMRTLC -,SUP-54-25376,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 76MM 2.7MM 13HL 2MM ANTMC POLYAX TI STD LNG -,SUP-54-25377,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 56MM 2.7MM 9HL ANTMC POLYAX TI STD SMRTLC -,SUP-54-25384,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 76MM 2.7MM 2MM ANTMC POLYAX TI LNG NRW RT -,SUP-54-25385,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 56MM 2.7MM STD ANTMC TI SMRTLC -,SUP-54-25386,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE VOLAR 76MM L 14 HOLE 2MM H STAN LONG RT -,SUP-54-25387,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 53MM 2.7MM 2MM POLYAX TI MED/SHRT UNIV XLN -,SUP-54-25394,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3450.36,2415.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 53MM 2.7MM 2MM POLYAX TI SHRT UNIV STD -,SUP-54-25396,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3450.36,2415.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 53MM 2.7MM 2MM POLYAX TI SHRT UNIV W SMRTLC -,SUP-54-25398,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3450.36,2415.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 44MM 2.7MM 1MM ANTMC POLYAX TI SHRT NRW CLMN -,SUP-54-25400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 57MM 2.7MM ANTMC POLYAX TI LNG CLMN SMRTLC -,SUP-54-25401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 40MMX1MM FRAG SPEC POLYAX TI SHRT SMRTLC -,SUP-54-25402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 40MMX1MM 2.7MM FRAG SPEC POLYAX TI SHRT -,SUP-54-25403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 53MMX1MM FRAG SPEC POLYAX TI LNG SMRTLC -,SUP-54-25405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 2.7 X 189 15 HOLE -,SUP-54-25420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7093.08,4965.156,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 2.7 145 11 HOLES -,SUP-54-25424S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7093.08,4965.156,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 2.7MM XXL VOLAR L100MM 8 HOLE -,SUP-54-25428S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6203.58,4342.506,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE VOLAR XXL 7MM -,SUP-54-25442S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7093.08,4965.156,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 2.7MM XXL VOLAR NARROW 8 HOLE -,SUP-54-25444S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6203.58,4342.506,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 8 HOLES / 100MM / 2.7MM XXL -,SUP-54-25446S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6203.58,4342.506,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 3HL XSH NRW -,SUP-54-25573,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 8HL XSH -,SUP-54-25583,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN XSH -,SUP-54-25673,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 2X56MM 11HL INTMD ANTMC SHRT NS -,SUP-54-25674,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE INT LNG LEFT 14 HOLE -,SUP-54-25677,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4468.42,3127.894,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX F/DIST RAD SYS 10HL INTMD XSH -,SUP-54-25683,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 11HL INTMD SHRT -,SUP-54-25684,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 14HL INTMD LNG -,SUP-54-25687,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4468.42,3127.894,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX F/DIST RAD SYS 10HL STD XSH -,SUP-54-25773,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 10HL STD XSH -,SUP-54-25783,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
RESTRICTOR BNCMNT FEM SZ3 13.25MM UHMWPE -,SUP-5460-14-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1026.96,718.872,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
RESTRICTOR BNCMNT FEM SZ3 15.75MM UHMWPE -,SUP-5460-16-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1150.21,805.147,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
RESTRICTOR FMCNL BNCMNT SZ5 18.25MM UHMWPE HIP -,SUP-5460-18-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1070.7,749.49,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE HYBRID MMP -,SUP-55-02950,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1731.83,1212.281,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE CRANFC UPR FACE 18HL 3D SHP UNIVERSAL NEURO II MLBL -,SUP-55-04218,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2608.27,1825.789,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE CRANFC UPR FACE HLX2X2 3D UNIVERSAL NEURO II MLBL -,SUP-55-04231,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.51,834.757,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE CRANFC UPR FACE HLX6X2 0.5MM 3D UNIV 2 MLBL 1.2MM TI -,SUP-55-04233,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2146.54,1502.578,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE UPR FACE 7HL 0.5MM DBL Y UNIVERSAL NEURO II MLBL 1.2MM -,SUP-55-04240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1128.37,789.859,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE CRANFC UPR FACE 24HL 0.5MM STR UNIV 2 MLBL 1.2MM TI NS -,SUP-55-04424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2500,1750,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE CRANFC MIDFC 20HL 0.55MM UNIV 2 MLBL 1.7MM TI NS BLU -,SUP-55-04720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2468.01,1727.607,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE CRANFC MIDFC 24HL 0.55MM STR UNIV 2 MLBL CNDSD 1.7MM -,SUP-55-04724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.85,1788.395,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE CRANFC MIDFC 7HL 0.6MM UNIVERSAL NEURO II STD 1.7MM TI -,SUP-55-05164,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.58,742.406,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE ORBT MIDFC 6HL CRV LEIBINGER UNIV 2 STD 1.7MM TI NS -,SUP-55-05188,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1255.9,879.13,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE LCK CRANFC MIDFC HL 2X2 0.8MM 3D SHP UNIVERSAL NEURO -,SUP-55-05731,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1390.43,973.301,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE CRANFC UPR FACE 8HL STR UNIVERSAL NEURO II STD 1.2MM -,SUP-55-06208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1389.47,972.629,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE CRANFC UPR FACE HLX2X2 3D SHP UNIVERSAL NEURO II STD -,SUP-55-06231,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.43,785.001,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
3D PLATE 6 X 2 HL UPPERFACE -,SUP-55-06233,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2014.51,1410.157,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
3D PLATE 6 X 6 HL UPPERFACE -,SUP-55-06235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4305.34,3013.738,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLT/7 HOLE DOUBLE Y UPPERFACE -,SUP-55-06240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1022.23,715.561,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE MIDFC 4HL STR UNIVERSAL NEURO II STD 1.7MM TI NS BAR -,SUP-55-06704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.58,457.506,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE CRANFC MIDFC 8HL STR UNIVERSAL NEURO II STD 1.7MM TI -,SUP-55-06708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1319.35,923.545,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE MIDFC 24HL STR UNIVERSAL NEURO II STD 1.7MM TI NS BAR -,SUP-55-06724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2527.07,1768.949,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE STR 2 X 2 3D -,SUP-55-06731,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1207.72,845.404,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE MIDFC 10HL UNIVERSAL NEURO II STD 1.7MM TI NS BAR GOLD -,SUP-55-06750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1390.43,973.301,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE MIDFC 4HL CRV UNIVERSAL NEURO II STD 1.7MM TI NS GOLD -,SUP-55-06754,CDM,C1713,HCPCS,278,RC,,,outpatient,,,804.35,563.045,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE RT CRANFC MIDFC 2MM 5HL 0.6MM LEIBINGER UNIVERSAL -,SUP-55-06761,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1100.48,770.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE RT CRANFC MIDFC 5MM 5HL 0.6MM UNIVERSAL NEURO II STD -,SUP-55-06763,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1133.97,793.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE LCK MAND MINI 4HL 1MM STR UNIVERSAL NEURO II 2MM TI NS -,SUP-55-10504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,513.89,359.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE LCK MAND MINI 6HL 8MM STR UNIVERSAL NEURO II 2MM TI NS -,SUP-55-10507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.51,834.757,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE 10MM VUSION TS -,SUP-551-5210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE CRANFC MAND 4HL STR UNIVERSAL NEURO II RECON FX 2MM TI -,SUP-55-15505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1918.09,1342.663,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLT/FRACTURE 6 HOLES W. BAR -,SUP-55-15507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2440.83,1708.581,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE 10 X 9 X 25 -,SUP-551-7410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
INSERT TIB BEARING SZ2 9MM TRIATHLON X3 CR ARTCSURF -,SUP-5530-C-209,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BEARING TIB INSERT CS 9MM SZ1 TRIATHLON X3 -,SUP-5531-G-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BEARING TIB INSERT CS 10MM SZ 1TRIATHLON X3 -,SUP-5531-G-110-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BEARING TIB INSERT CS 11MM SZ 1 TRIATHLON X3 -,SUP-5531-G-111-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
INSERT TIBIAL BEARING  SZ. 5 / 11MM TYPE CS -,SUP-5531-G-511-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TIBIAL BEARING INSERT SZ.7 / CS / 11MM -,SUP-5531-G-711-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TIBIAL BEARING INSERT SZ.8 CS 9MM TRIATHLON X3 -,SUP-5531-G-809-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
9MM INSERT TRIAL PS#3 -,SUP-5532-T-309,CDM,C1713,HCPCS,278,RC,,,outpatient,,,728.5,509.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COMPONENT TIBIAL TRITANIUM SZ 1 TRIATHLON -,SUP-5536-B-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ORTHOFIX CROSSLINK 25 -,SUP-55-5325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CONNECTOR ROD FIREBIRD 45MM CROSSLINK ORTHOFIX -,SUP-55-5345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
4.5MM PERIPHERAL SCREW 16MM -,SUP-5572-4516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
4.5MM PERIPHERAL SCREW 24MM -,SUP-5572-4524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
4.5MM PERIPHERAL SCREW 36MM -,SUP-5572-4536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
6.5MM CENTER SCREW 32MM -,SUP-5573-6532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4573.49,3201.443,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX MODULAR TRIATH -,SUP-5575-X-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BONESCREW AXS ST 1.2 X 3MM 5P -,SUP-56-12003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BONESCREW - AXS ST 1.2 X 4MM 5P -,SUP-56-12004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BONESCREW AXS SD 1.2 X 3MM 5P -,SUP-56-12903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,636.37,445.459,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BONESCREW AXS SD 1.2 X 4MM 5P -,SUP-56-12904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,636.37,445.459,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE ER AXS ST 1.4 3MM 5P -,SUP-56-14003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,593.3,415.31,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BONESCREW AXS SD 1.7 X 4MM 5P -,SUP-56-17904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BONESCREW AXS SD 1.7 X 6MM 5P -,SUP-56-17906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GRAFT HUM TIS PTTY 1ML OSTEOSPARX SYR LF -,SUP-562-100-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X30MM CORT FT ST HEX HEAD -,SUP-5645-1-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X32MM CORT FT ST HEX HEAD -,SUP-5645-1-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X44MM CORT FT ST HEX HEAD -,SUP-5645-1-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X48MM CORT FT ST HEX HEAD -,SUP-5645-1-048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X50MM CORT FT ST HEX HEAD -,SUP-5645-1-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X52MM CORT FT ST HEX HEAD -,SUP-5645-1-052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X54MM CORT FT ST HEX HEAD -,SUP-5645-1-054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
STEM EXTENSION CEMENTED 12X30MM -,SUP-565-1203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
MESH HYBRID MEDIUM MALL 90 X 90 X .3 BLUE -,SUP-56-90344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7015.12,4910.584,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PROFYLE 0.55MM 1.2MM 4HL STD PRCONT NLCKG TI XS STR -,SUP-57-05101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE PRF 1.7 X 4 HL -,SUP-57-05202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE PRF 1.7 X 6 HL LT L -,SUP-57-05221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE HAND -,SUP-57-05240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE PRF 1.7 X 7 HL T -,SUP-57-05260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1028.42,719.894,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PROFYLE 0.55MM 1.7MM 1HL PRX2 STD PRCONT NLCKG TI -,SUP-57-05285,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1307.9,915.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE PRF 1.7 X 3 X 2 3D -,SUP-57-05291,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1307.9,915.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE PRF 1.7 X 4X2 RP 3D -,SUP-57-05295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1307.9,915.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE PRF 2.3 6 HL LT L -,SUP-57-10121,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2457.66,1720.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE PRF 2.3 X 6 HL NRW T -,SUP-57-10140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2457.66,1720.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PROFYLE 1MM 2.3MM 7HL SHFT PRCONT VAR ANG NLCKG TI -,SUP-57-10170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2457.66,1720.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE PRF 2.3 X 5HL ROT -,SUP-57-10185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2395.78,1677.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 1.5MM 1.7MM 10HL PRCONT VAR ANG TI SM NRW -,SUP-57-10310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 1.7 X 6 HL LT L -,SUP-57-10321,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 1MM 1.7MM 6HL PRCONT VAR ANG TI SM NRW T-SHP -,SUP-57-10340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 1.7 X 7 HL T -,SUP-57-10360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 1MM 1.7MM 5HL ROT PRCONT VAR ANG TI SM -,SUP-57-10380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 1MM 1.7MM HLX3X2 PRCONT VAR ANG TI SM 3D SHP -,SUP-57-10391,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PROFYLE 1MM 2.3MM 6HL PRCONT NLCKG COMPR TI MED STR -,SUP-57-10407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2921.69,2045.183,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PROFYLE 1MM 2.3MM 7HL PRCONT NLCKG COMPR TI MED Y -,SUP-57-10470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2921.69,2045.183,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PROFYLE 1.3MM 2.3MM 6HL SHFT PRCONT NLCKG COMPR TI -,SUP-57-13150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.06,784.742,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE HAND 2.3 LP 4 HOLE -,SUP-57-13402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PROFYLE 1.3MM 2.3MM 5HL PRCONT NLCKG COMPR TI LRG -,SUP-57-13405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PROFYLE 1.3MM 2.3MM 6HL PRCONT NLCKG COMPR TI LRG -,SUP-57-13408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE T 1O HOLE NARROW COMPRESSION -,SUP-57-13442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 1.5MM 2.3MM 4HL PRCONT VAR ANG TI MED STR -,SUP-57-15301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 1.5MM 2.3MM 4HL_PRCONT VAR ANG TI MED STR -,SUP-57-15302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 1.5MM 2.3MM 16HL PRCONT VAR ANG TI MED -,SUP-57-15316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 1.5MM 2.3MM 4HL PRCONT VAR ANG TI MED SMRTLC -,SUP-57-15340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 1.5MM 2.3MM 7HL PRCONT VAR ANG TI MED SMRTLC -,SUP-57-15370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE PROFYLE 2.3 X 13 HL NRWZ -,SUP-57-15379,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 1.5MM 2.3MM 5HL PRCONT VAR ANG TI MED SMRTLC -,SUP-57-15385,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.2X5MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12005E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.2X6MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.2X7MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12007E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.2X8MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.2X14MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX -,SUP-58-12014E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
MIDFOOT FUSION U-PLATE MD LT ORTHOLOC -,SUP-5817002L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5793.06,4055.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.7X8MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.7X9MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.7X10MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.7X11MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17011E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.7X12MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BONE SCREW 1.7 X 16MM STRYKER -,SUP-58-17016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE 2.3 X 6 -,SUP-58-23006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X8MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X9MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X10MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X11MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23011E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X12MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X13MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23013E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X14MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23014E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NL 2.3 X 15MM -,SUP-58-23015E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X16MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X20MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23020E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X24MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23024E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW EMERGENCY 2.5 X 6 -,SUP-58-25006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW EMERGENCY 2.5 X 8MM CROSSPIN LEFT -,SUP-58-25008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
MTP FUSIOIN MEDIUM 0DG RT ORTHOLOC 3DI PLATING SYSTEM -,SUP-587220RT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5046.12,3532.284,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING LG HD 2.7 X 12MM ORTHOLOC 3DI PLATING SYS -,SUP-58802712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING LG HD 2.7 14MM ORTHOLOCK 3DI PLATING SYS -,SUP-58802714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING LG HD  2.7 X 16MM ORTHOLOCK 3DI PLATING SYS -,SUP-58802716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOW PRO CORT 2.7 X 12MM ORTHOLOC SYS -,SUP-58812712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOW PRO CORT SCREW 2.7 X 14MM ORTHOLOC SYSTEM -,SUP-58812714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOW PRO CORT SCREW 2.7 X 16MM ORTHOLOC SYSTEM -,SUP-58812716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOW PRO CORT 2.7 X 18MM ORTHOLOC SYS -,SUP-58812718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOW PRO CORT SCREW 3.5 X 12MM ORTHOLOC SYSTEM -,SUP-58813512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOW PRO CORT SCREW 3.5 X 14MM ORTHOLOC SYSTEM -,SUP-58813514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOW PRO CORT SCREW 3.5 X 16MM ORTHOLOC SYSTEM -,SUP-58813516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NON LOCKING 3.5 X 18 -,SUP-58813518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOW-PRO CORT SCREW 3.5X22MM ORTHOLOC -,SUP-58813522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOW-PRO CORT SCREW 3.5X28MM ORTHOLOC -,SUP-58813528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOW-PRO CORT SCREW 3.5X34MM ORTHOLOC -,SUP-58813534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOW-PRO CORT SCREW 3.5X38MM ORTHOLOC -,SUP-58813538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WASHER ORTHO F/1.2MM SCR TI RND FLT HEAD NS -,SUP-59-12049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.24,105.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WASHER ORTHO F/1.7MM/1.9MM TI RND BN SCR TITIANIUM FLT EDGE -,SUP-59-17049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.24,105.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X10MM CORT PROFYLE ST CX PIN HD TI GOLD -,SUP-59-23010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 16MM -,SUP-59-23016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 18MM -,SUP-59-23018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 20MM -,SUP-59-23020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WASHER ORTHO F/2.3MM SCR TI RND FLT HEAD NS -,SUP-59-23049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.24,105.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 32.3MM COMPR OMEGA3 SS STRL -,SUP-596001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,329.09,230.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
STANDARD BARRELL HIP PLATE- 130DEG- 2 HOLES -,SUP-597002S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2817.14,1971.998,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN OMG 3 63MM 3HL STD BRL LCK COMPR SS 135DG ANG KY -,SUP-597023S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE HIP STD BARREL 4 HOLE KEYED 135DEG -,SUP-597024S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
HIP PLATE OMEGA 3 STD BARREL KEYED 135 DEG 6 HOLES -,SUP-597026S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE HIP STD BARREL 3 HOLE KEYED 140DEG -,SUP-597043S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE HIP STD BARREL 4 HOLE KEYED 145DEG -,SUP-597064S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE EXTFIX STD 47MM SS HIP 135DG ANG OMEGA3 KYLS BRL -,SUP-597122S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN OMG 3 79MM 4HL STD BRL LCK COMPR SS 135DG ANG KYLS -,SUP-597124S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN OMG 3 95MM 5HL STD BRL LCK COMPR SS 150DG ANG KYLS -,SUP-597185S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN OMG 3 79MM 4HL SHRT BRL LCK COMPR SS 135DG ANG KYLS -,SUP-597264S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2470.03,1729.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE ANT CERV 12MM BAK HOL CHMFR EDGE 8MM TI -,SUP-6000-0812-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DEVICE ANT CERV 12MM BAK/ C HOL CHMFR EDGE 10MM TI -,SUP-6000-1012-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GW ORTHO 2MM TOEMOTION MRH AXLE -,SUP-6007-1200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN DSTRCT 12MM ASSURE -,SUP-601.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ASNIS III CANN SCREW 5 X 28MM -,SUP-601628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS TI 5.0 X 30MM -,SUP-601630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ASNIS III CANN SCREW 5 X 32MM -,SUP-601632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS III CANN P/T 5.0MM X 42MM -,SUP-601642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS III CANN 5.0 X 44MM -,SUP-601644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE ASNIS PT 5 X 46 -,SUP-601646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS PT 5.0 X 48 -,SUP-601648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5MMX50MM CANN ASNIS III 17MM P/T SD/ST REVCT FLUT TI -,SUP-601650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5MMX55MM CANN ASNIS III 18.5MM P/T SD/ST REVCT FLUT TI -,SUP-601655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5MMX75MM CANN ASNIS III 27MM P/T SD/ST REVCT FLUT TI -,SUP-601675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5MMX80MM CANN ASNIS III 27MM P/T SD/ST REVCT FLUT TI -,SUP-601680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW FULLY THREADED 5MM X 38MM -,SUP-601738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW FULLY THREADED 5MM X 40MM -,SUP-601740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW FT 5MM X 42MM TITANIUM CANNULATED -,SUP-601742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS FT 5 X 44 -,SUP-601744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANNULATED 5 X 50 -,SUP-601750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANNULATED 5 X 55 -,SUP-601755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW FULLY THREADED 5 X 60 -,SUP-601760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANN HEADED 5.0 X 65MM ASNIS -,SUP-601765,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANNULATED 5MM X 70MM -,SUP-601770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANN TI 6.5 X 60MM -,SUP-602660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS TI TL20 6.5 X 65MM -,SUP-602665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANN TI 6.5 X 70MM -,SUP-602670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MMX75MM CANN ASNIS III 20MM THRD SD/ST HEX DRV -,SUP-602675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANN TI 6.5 X 80MM -,SUP-602680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MMX80MM CANN ASNIS III 20MM THRD SD/ST HEX DRV -,SUP-602680S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANN ASNIS TI 6.5 X 85MM -,SUP-602685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MMX90MM CANN ASNIS III 20MM THRD SD/ST HEX DRV NS -,SUP-602690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MMX90MM CANN ASNIS III 20MM THRD SD/ST HEX DRV STRL -,SUP-602690S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MMX95MM CANN ASNIS III 20MM THRD SD/ST HEX DRV NS -,SUP-602695,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MMX95MM CANN ASNIS III 20MM THRD SD/ST HEX DRV STRL -,SUP-602695S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MMX100MM CANN ASNIS III 20MM THRD SD/ST HEX DRV -,SUP-602700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW TI CANNULATED 6.5 X 105MM ASNIS -,SUP-602705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANNULATED TI 6.5X 110MM -,SUP-602710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS TI TL20 6.5 X 115 -,SUP-602715,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS TI TL40 6.5 X 60 -,SUP-602860,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS TI TL40 6.5 X 65 -,SUP-602865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS 6.5 X 70MM -,SUP-602870,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS TI TL40 6.5 X 75MM -,SUP-602875,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS TI CANNULATED 6.5 X 80MM -,SUP-602880,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS TI TL40 6.5 X 85 -,SUP-602885,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW TI 6.5 X 90MM ASNIS TL40 CANNULATED -,SUP-602890,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS TI TL40 6.5 X 95 -,SUP-602895,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS TI TL40 6.5 X 100 -,SUP-602900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS TI CANNULATED 6.5 X 105MM -,SUP-602905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX28MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE CAN TI 4.0 X 30MM -,SUP-604630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX32MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
4.0 X 34MM ASNIS CANN SCREW -,SUP-604634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX34MM CANN ASNIS III 11.5MM P/T SD/ST REVCT FLUT TI -,SUP-604634S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE CAN PT 4.0 X 36 -,SUP-604636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX38MM CANN ASNIS III -,SUP-604638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX40MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX40MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY -,SUP-604640S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX42MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX44MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX46MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE CAN PT 4.0 X 48 -,SUP-604648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX50MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX50MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY -,SUP-604650S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX55MM CANN ASNIS III 18.5MM P/T SD/ST REVCT FLUT TI -,SUP-604655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX55MM CANN ASNIS III 18.5MM.P/T SD/ST REVCT FLUT TI -,SUP-604655S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT TI- -,SUP-604660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT TI- -,SUP-604660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT TI_ -,SUP-604660S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX65MM CANN ASNIS III 22MM P/T SD/ST REVCT FLUT TI -,SUP-604665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX65MM CANN ASNIS III 22MM P/T SD/ST REVCT FLUT TI -,SUP-604665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX70MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX70MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY -,SUP-604670S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX40MM CANN ASNIS III FT SD/ST REVCT FLUT TI ALY NS -,SUP-604740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS III TI 4.0 X 42MM -,SUP-604742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANN FT 4.0 X 44MM -,SUP-604744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MMX50MM CANN ASNIS III FT SD/ST REVCT FLUT TI ALY NS -,SUP-604750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW TI SELF TAP CORTICAL 2.7MM X 22MM -,SUP-605022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.06,81.242,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW TI SELF TAP CORTICAL 2.7MM X 26MM -,SUP-605026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.06,81.242,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW TI SELF TAP CORTICAL 2.7MM X 28MM -,SUP-605028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.06,81.242,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW TI ASNIS III CANNULATED 6.5 X 85MM -,SUP-606085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 90 -,SUP-606090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 95 -,SUP-606095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANNULATED FULLY THREADED 6.5 X 100 -,SUP-606100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANNULATED FULLY THREADED 6.5 X 110 -,SUP-606110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANCELLOUS FT 4 X 14 -,SUP-607314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANCELLOUS FT 4.0 X 16 -,SUP-607316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X18MM CANC FT TI -,SUP-607318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANCELLOUS 4.0 X 20 -,SUP-607320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X22MM CANC FT TI -,SUP-607322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X24MM CANC FT TI -,SUP-607324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANCELLOUS 4.0 X 26MM -,SUP-607326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANCELLOUS 4.0 X 28MM -,SUP-607328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANCELLOUS 4.0 X 32MM -,SUP-607332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X34MM CANC FT TI -,SUP-607334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X36MM CANC FT TI -,SUP-607336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X38MM CANC FT TI -,SUP-607338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X40MM CANC FT TI -,SUP-607340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.0 X 42MM CANC FT TI -,SUP-607342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANN TI 4.0 X 48MM FULL -,SUP-607348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
4.0 CANCELLOUS SCREW 50MM FULLY THREADED -,SUP-607350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANCELLOUS 4.0 X 50MM -,SUP-607350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.0 X 55MM CANC FT TI -,SUP-607355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X60MM CANC FT TI -,SUP-607360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X65MM CANC FT TI -,SUP-607365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X70MM CANC FT TI -,SUP-607370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANCELLOUS FT 4.0 X 14MM STRYKER -,SUP-607414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANCELLOUS PT 4 X 16 -,SUP-607416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANCELLOUS PT 4 X 20 -,SUP-607420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X36MM CANC 16MM THRD TI -,SUP-607436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X38MM CANC 16MM THRD TI -,SUP-607438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X44MM CANC 16MM THRD TI -,SUP-607444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X46MM CANC 16MM THRD TI -,SUP-607446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X50MM CANC 16MM THRD TI -,SUP-607450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X65MM CANC 16MM THRD TI -,SUP-607465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X70MM CANC 16MM THRD TI -,SUP-607470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANC 6.0MM X 20MM  FULL THREAD -,SUP-608020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANCELLOUS 6 X 25 -,SUP-608025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CAN FT 6.0 X 35 -,SUP-608035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANCELLOUS 6.0 X 40MM -,SUP-608040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6X45MM CANC FT TI -,SUP-608045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.0MM X 50MM CANCELLOUS FULL THREAD -,SUP-608050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6X60MM CANC FT TI -,SUP-608060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL 3.5 X 60 FT -,SUP-608070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6X75MM CANC FT TI -,SUP-608075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6X80MM CANC FT TI -,SUP-608080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANCELLOUS FT 6.0 X 85 -,SUP-608085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CAN TL 16 6.0 X 35 -,SUP-608235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CAN TL 16 6.0 X 75 -,SUP-608275,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CAN TL 16 6.0 X 80 -,SUP-608280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANCELLOUS 6.0MM 90MM -,SUP-608290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6X70MM CANC 32MM THRD TI -,SUP-608470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6X80MM CANC 32MM THRD TI -,SUP-608480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6X85MM CANC 32MM THRD TI -,SUP-608485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6MM CANCELLOUS TI 6.0MM L90 TL32MM -,SUP-608490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,304.82,213.374,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS TI TL25 8.0 X 70MM -,SUP-611070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CANNULATED SCREW 8.0 X 75MM TI -,SUP-611075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
8.0 X 80MM TI CANNULATED SCREW -,SUP-611080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS TI TL25 8.0 X 85MM -,SUP-611085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ANSIS TI TL25 8.0 X 90MM -,SUP-611090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X8MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X12MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X14MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X16MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X18MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.7 X 20MM LOCKING SCREW -,SUP-614520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X22MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING T10 2.7 X 24MM -,SUP-614524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X26MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7 LOCKING ST 28 -,SUP-614528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X30MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7 LOCKING ST 34 -,SUP-614534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X36MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X38MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X40MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X55MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X60MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X8MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X10MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X12MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X14MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X16MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X18MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X20MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X22MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X24MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X26MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 3.5 X 28MM -,SUP-614628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X30MM LOCKING -,SUP-614630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X32MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
36MM 3.5 LOCKING SCREW -,SUP-614636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5 LCK ST 38 -,SUP-614638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5 X 40MM LOCKING -,SUP-614640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X42MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X44MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5 LCK ST 48 -,SUP-614648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X50MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE OLECRANON LEFT 8 HOLE -,SUP-614655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 3.5 X 55MM T10 -,SUP-614655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X60MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 3.5 X 65MM -,SUP-614665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 3.5 X 70MM -,SUP-614670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X8MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X12MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X14MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X16MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X18MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X20MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X22MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X24MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7 NON LOCKING ST 26 -,SUP-614726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X32MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614732,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X34MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X36MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X38MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X40MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7 NONLCK ST 44 -,SUP-614744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7 NONLOCKING ST 46 -,SUP-614746,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X55MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE T10 2.7 X 60MM -,SUP-614760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X8MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614808,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X10MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X12MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X14MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X16MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X18MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X20MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X22MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X24MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X26MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X28MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X30MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614830,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X32MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X34MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614834,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X36MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614836,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5 NONLCK ST 38 -,SUP-614838,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X40MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X42MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614842,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5 X 44 NONLOCK -,SUP-614844,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
46MM 3.5 SCREW -,SUP-614846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5 NONLOCK ST 46 -,SUP-614846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE 3.5 X 48MM NON-LOCK -,SUP-614848,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X50MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614850,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X60MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614860,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5 NONLOCK ST 65 -,SUP-614865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X70MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614870,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BONE CEMENT SIMPLEX -,SUP-6191-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,431.79,302.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CEMENT BONE SIMPLEX P -,SUP-6191-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BONE CEMENT SPEEDSET SIMPLEX P FULL DOSE -,SUP-6192-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,431.79,302.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CEMENT SIMPLEX SPEED SET -,SUP-6192-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CEMENT BONE SIMPLEX HV -,SUP-6194-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CEMENT BONE SIMPLEX GENTAMICIN -,SUP-6195-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CEMENT BONE SIMPLEX TOBRAMYCIN -,SUP-6197-9-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WASHER ORTHO ASNIS III F/6.5/8MM BN SCR TI RND -,SUP-619904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,157.55,110.285,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WASHER ORTHO ASNIS III 4MM TI RND -,SUP-619905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,122.54,85.778,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WASHER ORTHO 5MM ASNIS III 5MM TI RND -,SUP-619906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.64,107.548,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WASHER FOR 2.3MM BONE SCREWS -,SUP-619915,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.91,88.837,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
Washer T8 & T10 Scrws 2.4/2.7/3.5 -,SUP-619920,CDM,C1713,HCPCS,278,RC,,,outpatient,,,124.4,87.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WASHER 19 FOR SCREWS 6.5/8.0MM -,SUP-619990,CDM,C1713,HCPCS,278,RC,,,outpatient,,,882.25,617.575,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
STIMULAN 5CC -,SUP-620-005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
STIMULAN 10CC -,SUP-620-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SPIN 12MM ASPEN -,SUP-6201-0012-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN ASPEN 14MM -,SUP-6211-0014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,26874.69,18812.283,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 10HL TI -,SUP-621410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7788.16,5451.712,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLUG BONE H MED 25 -,SUP-6215-5-011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
MIS CALCANEAL PLATE S7 7 HOLES -,SUP-622102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
MIS CALCANEAL PLATE M8 8 HOLE -,SUP-622104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
INSERT 10 DEG POLYETHYLENE 32MM D TRIDENT X3 -,SUP-623-10-32D,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BONE SCREW 6.5X30 SELF-TAP -,SUP-6250-65-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ONE-THIRD TUBULAR PLATE 2 HOLE / L23MM -,SUP-626672,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1523.42,1066.394,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TUBULAR PLATE ONE-THIRD 4 HOLE -,SUP-626674,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ONE-THIRD TUBULAR PLATE 5 HOLE / L59MM -,SUP-626675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ONE-THIRD TUBULAR PLATE 6 HOLE / L71MM -,SUP-626676,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TUBULAR PLATE ONE-THIRD 6 HOLE -,SUP-626676S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ONE-THIRD TUBULAR PLATE 7 HOLE L83MM -,SUP-626677,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 8 HOLE -,SUP-626678,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE TUBULAR HOLE 9 -,SUP-626679,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2203.63,1542.541,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE TUBULAR HOLE 12 -,SUP-626682,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2203.63,1542.541,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE TUBULAR 16HL -,SUP-626686,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2746.15,1922.305,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE POLYAXIAL LKG TALO-NAVICULAR LONG T10 -,SUP-626762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4305.48,3013.836,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
VARIAX NAVICULAR PLATE -,SUP-626881,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4186.99,2930.893,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
POLYAXIAL LOCKING PLATE CUBOID (T8) -,SUP-626885,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.24,2762.368,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 3 HOLE SLIM -,SUP-626963,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5843.99,4090.793,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 6 HOLE SLIM -,SUP-626966,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5843.99,4090.793,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SLIM STRAIGHT 7 HOLE T8 -,SUP-626967,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5843.99,4090.793,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2 HOLE FOREFOOT PLATE -,SUP-626972,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BROAD 3 HOLE -,SUP-626973,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BROAD STRAIGHT PLATE 4 HOLE -,SUP-626974,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
5 HOLE FOREFOOT PLATE -,SUP-626975,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
6 HOLE BROAD Y-PLATE -,SUP-626976,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BROAD STRAIGHT T10 7 HOLE -,SUP-626977,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SLIM -,SUP-626982,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
3-HOLE 4-PLATE- SLIM -,SUP-626983,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE-Y 4 HOLE SLIM -,SUP-626984,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 5 HOLE SLIM Y -,SUP-626985,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BROAD Y PLATE 2 SHAFT HOLES -,SUP-626992,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BROAD Y PLATE 3 HOLE -,SUP-626993,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BROAD Y-PLATE- 3 SHAFT -,SUP-626993,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
STRYKER PLATE -,SUP-626994,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
VARIAX 2 FOREFOOT 5 HOLE PLATE -,SUP-626995,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BONE VARIAX BROAD Y 6 SHAFT HOLES T10 -,SUP-626996,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BROAD Y-PLATE- 7 SHAFT HOLES (T10) -,SUP-626997,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BROAD Y PLATE - 7 HOLES -,SUP-626997,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 3HL TI -,SUP-627203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
4 HOLE PLATE HUMERUS -,SUP-627204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 5-HOLE -,SUP-627205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE PROX LAT HUMERUS LEFT 6 HOLE L125MM -,SUP-627206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8796.54,6157.578,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE PROXIMAL LATERAL HUMERUS 8 HOLE -,SUP-627208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9123.11,6386.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 12 HOLE LEFT PROX LAT HUMERAL -,SUP-627212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9529.9,6670.93,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PROXIMAL LATERAL HUMERUS PLATE -,SUP-627216S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10146.77,7102.739,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 3 HOLE PROXIMAL LATERAL HUMERUS -,SUP-627233,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
4 HOLE PLATE RIGHT -,SUP-627234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BONE AXSOS 3 TI 6 HOLE HUMERUS RIGHT PROXIMAL LATERAL -,SUP-627236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8796.54,6157.578,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
8 HOLE PLATE STRYKER -,SUP-627238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9123.11,6386.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
10 HOLE PROXIMAL HUMERUS PLATE - RIGHT -,SUP-627240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9123.11,6386.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE HUMERUS 12 HOLE RIGHT PR -,SUP-627242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9529.9,6670.93,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PROXIMAL LATERAL HUMERUS PLATE FOR RIGHT HUMERUS 14 HOLE -,SUP-627244S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10146.77,7102.739,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2 HOLE PLATE LEFT TIBIA -,SUP-627302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7207.59,5045.313,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 121MM 4HL -,SUP-627304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7356.55,5149.585,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 147MM 6HL -,SUP-627306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7509.33,5256.531,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 8 HOLE PROX LATERAL FOR LEFT TIBIA L173MM -,SUP-627308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7658.3,5360.81,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE PROXIMAL LATERAL TIBIA FOR LEFT TIBIA 10 HOLE -,SUP-627310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8099.46,5669.622,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
AXSOS 3 TI PROX LAT TIBIA LEFT 12 HOLE PLATE -,SUP-627312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8414.58,5890.206,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 95MM 2HL F-SHP RT TIB -,SUP-627332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7207.59,5045.313,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 4HL -,SUP-627334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7356.55,5149.585,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE RIGHT HOLE 6 -,SUP-627336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8887.66,6221.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE PROXIMAL MEDIAL TIBIA 8 HOLE RIGHT -,SUP-627338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7658.3,5360.81,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 10 HOLE RIGHT PROX LATERAL TIBIA -,SUP-627340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8099.46,5669.622,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE RIGHT HOLE 12 -,SUP-627342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8252.25,5776.575,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE RIGHT HOLE 14 -,SUP-627344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8414.58,5890.206,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 6HL LT DIST -,SUP-627406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7102.55,4971.785,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE DIST RAD TIB 12 HOLE LFT -,SUP-627412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7996.33,5597.431,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 14HL TI -,SUP-627414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8206.41,5744.487,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN MED DST -,SUP-627434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6900.11,4830.077,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 6HL MDL/DIST RIGHT -,SUP-627436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7102.55,4971.785,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE DIST MED TIB 8HOLE RIGHT -,SUP-627438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7304.99,5113.493,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE DIST MEDIAL 10 HOLE RT -,SUP-627440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7788.16,5451.712,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE DIST MED LKD 12 HOLE RT -,SUP-627442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7996.33,5597.431,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 14 HOLE RIGHT DISTAL MEDICAL PLATE -,SUP-627444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8206.41,5744.487,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 4HL TI RT DIST -,SUP-627454,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.44,5926.508,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BONE AXSOS 3 TITANIUM 127 MM TIBIAL LEFT DISTAL -,SUP-627456,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7802.17,5461.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 8 HOLE LEFT ANTEROLATERAL -,SUP-627458,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7975.32,5582.724,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW DIST ANTERIORLATERAL TIBIA LFT 10HL 178MM -,SUP-627460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8370.53,5859.371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE TIBIA  14 HOLE LEFT L229MM DISTAL ANTEROLATERAL -,SUP-627464,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8724.98,6107.486,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 4 HOLE -,SUP-627484,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7631.05,5341.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 6 HOLE RIGHT ANT-LAT -,SUP-627486,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7802.17,5461.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE TIBIA DISTAL ANTEROLATERAL RIGHT 8 HOLE L153MM -,SUP-627488,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7975.32,5582.724,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE DISTAL ANTEROLAT TIBIA RIGHT 10 HOLE 178MM -,SUP-627490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8370.53,5859.371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE LKG COMP 11 HOLD L149MM X 4.0MM -,SUP-627511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5647.28,3953.096,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 12HOLE COMPRESSION -,SUP-627512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5647.28,3953.096,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 14 HOLE AXSOS STRAIGHT -,SUP-627514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5809.61,4066.727,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE LOCKING COMPRESSION 18 HOLE L240MM 4.0MM -,SUP-627518S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6099.9,4269.93,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 7 HOLE NARROW COMPRESSION -,SUP-627537,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6619.37,4633.559,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 8 HOLE NARROW COMPRESSION -,SUP-627538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.27,4961.089,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 9 HOLE NARROW -,SUP-627539,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.27,4961.089,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 10 HOLE STRAIGHT -,SUP-627540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7348.91,5144.237,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE STRAIGHT BROAD 9 HOLE COMPR 173 LENGTH -,SUP-627569,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.27,4961.089,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE STRAIGHT BROAD 10 HOLE COMPRESSION -,SUP-627570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7348.91,5144.237,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE LOCKING COMPRESSION BROAD 12 HOLE -,SUP-627572,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7348.91,5144.237,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 13 HOLE 5.0 COMPRESSION PLATE -,SUP-627573,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7518.88,5263.216,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BROAD 14 HOLE -,SUP-627574,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7518.88,5263.216,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DISTAL LATERAL FEMUR PLATE FOR LEFT FEMUR 4 HOLE -,SUP-627604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7824.24,5476.968,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 166MM 6HL LT DIST LAT FEM -,SUP-627606,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9329.8,6530.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 8HL LT -,SUP-627608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8189.22,5732.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 238MM 10HL LT DIST LAT FEM -,SUP-627610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8683.22,6078.254,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 12HL -,SUP-627612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8871.66,6210.162,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 343MM 16HL LT -,SUP-627616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9250.22,6475.154,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE DISTAL FEMUR -,SUP-627618S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9623.69,6736.583,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DISTAL LATERAL FEMUR 4 HOLE -,SUP-627634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7824.24,5476.968,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 166MM 6HL DIST LAT FEM -,SUP-627636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8009.28,5606.496,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE DISTAL LATERAL FEMUR -,SUP-627638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8189.22,5732.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 238MM 10HL RT DIST LAT FEM -,SUP-627640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8683.22,6078.254,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 274MM 12HL -,SUP-627642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8871.66,6210.162,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 343MM 16HL 1STRN/PK RT -,SUP-627646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9250.22,6475.154,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE AXSOS 3 TI DISTAL LAT FEMUR RT 18 HOLE L379MM -,SUP-627648S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9623.69,6736.583,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE TIBAL 4 HOLE LEFT/L71MM -,SUP-627704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.9,4447.73,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE MEDIAL PROXIMAL TIBIAL 5 HOLES LEFT -,SUP-627705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6560.16,4592.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE MEDIAL 6 HOLES STRYKER -,SUP-627706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6764.51,4735.157,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE PROX MED TIBIA FOR LEFT TIBIA 8HOLE L-123MM -,SUP-627708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6966.95,4876.865,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 14 HOLE PROX MEDIAL FOR LEFT TIBIA L201MM -,SUP-627714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7866.47,5506.529,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE PROXIMAL MEDIAL TIBIA FOR LEFT TIBIA 16 HOLE -,SUP-627716S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8278.98,5795.286,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOCKED TIBIAL PLATE -,SUP-627734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.9,4447.73,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE TIBIAL LATERAL 5 HOLE -,SUP-627735,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6560.16,4592.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE PROX MED TIB RT 6 HL -,SUP-627736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6764.51,4735.157,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PROXIMAL MEDIA TIBIA 97MM LENGTH -,SUP-627736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6764.51,4735.157,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE PROXIMAL MEDIAL TIBIA 8 HOLE RIGHT -,SUP-627738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8247.49,5773.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN AXSOS 10HL RT PROX MDL TIB COMPR -,SUP-627740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7438.67,5207.069,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PROXIMAL MEDIAL TIBIA PLATE FOR RT TIBIA 12 HOLE 175MM -,SUP-627742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7654.48,5358.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
INTERPROSTHETIC FEMUR PLATE RIGHT 334MM -,SUP-627846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,27813.56,19469.492,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DISTAL FEMUR PLATE RIGHT 280MM -,SUP-627863,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19576.64,13703.648,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
6 HOLE PLATE - LEFT -,SUP-628006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 88MM 7HL STD PRCONT VAR ANG TI ALY DECREASED -,SUP-628007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 99MM 8HL STD PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 122MM 10HL STD PRCONT VAR ANG TI ALY -,SUP-628010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SUPERIOR 7 HOLE RIGHT DECREASED -,SUP-628027,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 99MM 8HL STD PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE VARIAX 99MM CLAVICLE RIGHT SUPERIOR DECREASED 8 HOLE -,SUP-628028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 99MM 6HL BRDG PRCONT VAR ANG TI ALY LT CLVCL -,SUP-628046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 122MM 8HL BRDG PRCONT VAR ANG TI ALY -,SUP-628048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 99MM 6HL BRDG PRCONT VAR ANG TI ALY RT CLCVL -,SUP-628066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BRIDGE 8 HOLE SUPERIOR D -,SUP-628068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 8 HOLE STRYKER -,SUP-628108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 10 HOLE STRYKER -,SUP-628110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE CLAVICLE INC CURVED 8 HOLE -,SUP-628128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE CLAVICLE IC 10 HOLE -,SUP-628130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 6 HOLE BRIDGE -,SUP-628166,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SUPERIOR LATERAL PLATE - 3 HOLE / LEFT -,SUP-628203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 98MM 5HL PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SUPERIOR LATERAL PLATES -,SUP-628207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4698.11,3288.677,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 86MM 4HL PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE RIGHT LATERAL 5-HOLE #628225 -,SUP-628225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 7 HOLE LATERAL -,SUP-628227,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4698.11,3288.677,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 86MM 7HL PRCONT VAR ANG TI ALY UNIV SMRTLC -,SUP-628307,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 16MMX68MM PRCONT VAR ANG TI ALY LAT -,SUP-628525S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4480.35,3136.245,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
HOOK PLATE 7 HOLE 16MM RIGHT -,SUP-628537S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4480.35,3136.245,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DISTAL LATERAL HUMERUS PLATE 4 HOLE 109MM -,SUP-629204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 8 HOLE LEFT LATERAL -,SUP-629208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 3HL RT DIST LAT HUM COMPR -,SUP-629223S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE DISTAL LATERAL 4 HOLE 109MM -,SUP-629224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 12 HOLE RIGHT HUMERUS L203MM VARIAX DIST LATERAL -,SUP-629232S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE HUMERUS DIST POST LATERAL LEFT 3 HOLE -,SUP-629243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 105MM 4HL PRCONT VAR ANG LCK TI ALY NS LT -,SUP-629244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 128MM 6HL SHFT PRCONT VAR ANG LCK TI ALY NS -,SUP-629246,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 150MM 8HL PRCONT VAR ANG LCK TI ALY NS LT -,SUP-629248,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE DIST POST LATERAL HUMERUS 10 HOLE L173MM -,SUP-629250S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 105MM 4HL PRCONT VAR ANG LCK TI ALY NS RT -,SUP-629264,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 150MM 8HL PRCONT VAR ANG LCK TI ALY NS RT -,SUP-629268,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE HUMERUS DISTAL POSTERIOR LATERAL 12 HOLE -,SUP-629272S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE EXTENDED MEDIAL LEFT 3 HOLE -,SUP-629283,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 96MM 4HL PRCONT VAR ANG LCK TI ALY -,SUP-629284,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE DISTAL MEDIAL HUMERUS 6 HOLE EXTEND -,SUP-629286,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 104MM 4HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 151MM 8HL SHFT PRCONT VAR ANG LCK TI ALY NS -,SUP-629308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE DIST POST MEDIAL HUMERUS 12 HOLE L199MM -,SUP-629312S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DISTAL POSTERIOR MEDIAL HUMERUS PLATE FOR RT HUM 3 HOLE -,SUP-629323,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE DIST POST MDL RIGHT 4 -,SUP-629324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE DISTAL POSTERIOR MEDIAL 8 HOLE -,SUP-629328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE DIST POST MEDIAL HUMERUS 12 HOLE L199MM -,SUP-629332S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE OLECRARON LEFT 3 HOLE -,SUP-629343,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 89MM 4HL PRCONT VAR ANG LCK TI ALY NS LT -,SUP-629344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
3 HOLE RIGHT PLATE -,SUP-629363,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 89MM 4HL PRCONT VAR ANG LCK TI ALY NS RT -,SUP-629364,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 113MM 6HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629366,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 137MM 8HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629368,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE MEDIAL 3 HOLE -,SUP-629383,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 92MM 4HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629384,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 116MM 6HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629386,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 139MM 8HL LCK TI ALY NS -,SUP-629388,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE DISTAL MEDIAL HUMERUS LEFT 10HOLE 163MM -,SUP-629390S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE DISTAL MEDIAL HUMERUS 12 HOLE -,SUP-629392S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE COMPRESSION NARROW STRAIGHT 4 HOLES -,SUP-629504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1289.93,902.951,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE COMPRESSION NARROW STRAIGHT 5 HOLES -,SUP-629505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 6 HOLE COM PR NRW STR -,SUP-629506S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 7HL COMPR NRW STR -,SUP-629507S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX COMPR TI ALY NRW STR 629508S STRL -,SUP-629508S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE COMP 9 HOLE NARROW STR -,SUP-629509S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 10HL COMPR NRW STR -,SUP-629510S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE COMPRESSION NARROW STRAIGHT 12 HOLES -,SUP-629512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
14 HOLE NARROW COMPRESSION PLATE VARIAX -,SUP-629514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX COMPR TI ALY NRW STR 629527S STRL -,SUP-629527S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 7HL COMPR BRD STR -,SUP-629537S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COMPRESSION PLATE BROAD STRAIGHT 6 HOLES -,SUP-629546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 8HL COMPR NRW STR -,SUP-629548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COMPRESSION PLATE BROAD STRAIGHT 9 HOLES/L115MM -,SUP-629549S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2509.57,1756.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
VARIAX COMPRESSION PLATE BROAD CURVED 9 HOLES -,SUP-629559,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN VARIAX 8HL COMPR BRD CRV -,SUP-629560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE COMPRESSION BROAD CURVED 11 HOLES -,SUP-629561,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE COMP VARIAX BROAD CURVED 10 HOLES -,SUP-629562,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SHORT BEND -,SUP-629589,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8642.06,6049.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE PROFILE 2.0 4HOLE -,SUP-629604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1944.22,1360.954,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE PROFILE 2.0 X L33MM 6 HOLE -,SUP-629606,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1944.22,1360.954,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PROFILE PLATE 2.0 54MM -,SUP-629610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1944.22,1360.954,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PROFILE PLATE 2.0 L108MM 20HOLES -,SUP-629620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE NARROW LOCKING 2.0 4 HOLE -,SUP-629624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2488.21,1741.747,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE NARROW LOCK 2.0 L34MM 6 HOLES -,SUP-629626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2488.21,1741.747,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 8 HOLE NARROW -,SUP-629628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2488.21,1741.747,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 2.0MM BROAD LOCKING 6 HOLES STRAIGHT -,SUP-629646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BROAD LOCKING 2.0 / 10 HOLE -,SUP-629650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE PROFILE 8 HOLE 2.4 -,SUP-629666,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE PROFILE 2.4 8HOLE -,SUP-629668,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE VARIAX LOW PROFILE 2.4 X L66MM 10 HOLES -,SUP-629670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE NARROW LOCK 2.4 X L28MM 4 HOLE -,SUP-629684,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
6 HOLE NARROW PLATE -,SUP-629686,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 2.4MM 8 HOLE -,SUP-629688,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BONE VARIAX NARROW LOCK 2.4 L69MM 10 HOLE -,SUP-629690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 4 HOLE -,SUP-629704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BROAD LOCKING 2.4 6 HOLE -,SUP-629706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 8 HOLE STRAIGHT 2.4 -,SUP-629708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BONE VARIAX BROAD LOCK 2.4 L80MM 10HOLES -,SUP-629710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BROAD LOCKING 2.4 12 HOLE -,SUP-629712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 4 HOLE NARROW -,SUP-629724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 2.7 6 HOLE STRAIGHT -,SUP-629726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 8 HOLE -,SUP-629728,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 10 HOLE -,SUP-629730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE STRAIGHT 10 HOLE -,SUP-629740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BROAD LOCK 2.7 L39MM 4 HOLE -,SUP-629744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 2.7 6 HOLE -,SUP-629746,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BROAD LOCK 2.7 X 73MM 8HL -,SUP-629748,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
T-PLATE 2.7MM 3 X 10 -,SUP-629748,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BROAD LOCKING 2.7 10HOLE -,SUP-629750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 12 HOLE BROAD STRAIGHT -,SUP-629752,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3870.76,2709.532,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
T-PLATE NARROW LOCKING 2.0 2 X 5 HOLE -,SUP-629770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NARROW LOCK T-PLATE 2.0 L62MM 2X10HOLES -,SUP-629771,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2716.41,1901.487,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE NARROW LCK T 2.0 3X5 HOLE -,SUP-629772,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
T-PLATE 2.4MM NARROW LOCKING 2 X 5 -,SUP-629776,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
T-PLATE -,SUP-629777,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BONE VARIAX NARROW LOCK T-PLATE 2.4 L41MM 3X5 HOLES -,SUP-629778,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE T 2.4 NARROW -,SUP-629779,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE NARROW T 2.4 X L76MM 5X10 HOLES LKG -,SUP-629781,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE NARROW LOCKING T 5 HOLE -,SUP-629782,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 10 HOLE -,SUP-629783,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE AXSOS TITANIUM 5 HOLE -,SUP-629784,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE NARROW LOCKING T  2.7 X 87MM 10HOLE -,SUP-629785,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE T NARROW LOCK 2.7 L8 7MM X 5 X 10 HOLES -,SUP-629787,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 2.7 Y- PLATE -,SUP-629788,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4103.73,2872.611,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 2.7MM TRIANGLE -,SUP-629789,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4103.73,2872.611,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE Y 2.4MM -,SUP-629790,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE NARROW LOCK TRIANGLE 2.4 X 81MM 10 HOLE -,SUP-629791,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANTERIOR TT PLATE LEFT -,SUP-630101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10381.67,7267.169,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANTERIOR TT PLATE RIGHT -,SUP-630102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10381.67,7267.169,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
IMPLANT FLEXBLOCK -,SUP-6314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7031.8,4922.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN FX 38MM TRIATH HD F/T/K SYS -,SUP-6541-4-515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ABC IM ROD TRIATHLON INSTRUMENTS -,SUP-6541-4-516E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2213.49,1549.443,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN FX 19MM TRIATH HD F/T/K SYS -,SUP-6541-4-575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,327.34,229.138,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING T8 FULL THREAD 2.4 X 6 -,SUP-656006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING T8 FULL THREAD 2.4 X 7 -,SUP-656007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LCK T8 FULL THREAD 2.4X8 -,SUP-656008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING T8 FULL THREAD 2.4 X 10 -,SUP-656010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 2.4 X 11 -,SUP-656011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LCK T8 FII THRD 2.4 X 12 -,SUP-656012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING T8 FULL THREAD 2.4MM L14 -,SUP-656014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.4MM X 16MM LOCKING -,SUP-656016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING T8 FULL TRHEAD 2.4MM L 18MM -,SUP-656018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING T8 FULL THREAD 2.4 X 22 -,SUP-656022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING T8 FULL THREAD 2.4MM X 24MM -,SUP-656024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOCKING SCREW T8 FULL THREAD 2.4MM X 26MM -,SUP-656026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING T8 FULL THREAD 2.4 X 28 -,SUP-656028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING T8 FULL THREAD 2.4 X 30 -,SUP-656030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING T8 FULL THREAD 2.4 X 32 -,SUP-656032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING T8 FULL THREAD 2.4 X 34 -,SUP-656034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING T8 FULL THREAD 2.4 X 36 -,SUP-656036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 2.4MM X 38MM -,SUP-656038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN T8 FULL THREAD 2.4X6 -,SUP-656106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN T8 FULL THREAD 2.4X7 -,SUP-656107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN T8 FULL THREAD 2.4X8 -,SUP-656108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN T8 FULL THREAD 2.4X9 -,SUP-656109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN T8 FULL THREAD 2.4X12 -,SUP-656112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN T8 FULL THREAD 2.4X14 -,SUP-656114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.4 X 15 NL -,SUP-656115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN T8 FULL THREAD 2.4X18 -,SUP-656118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN T8 FULL THREAD 2.4X20 -,SUP-656120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN T8 FULL THREAD 2.4X24 -,SUP-656124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN T8 FULL THREAD 2.4X26 -,SUP-656126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN T8 FULL THREAD 2.4X28 -,SUP-656128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN T8 FULL THREAD 2.4X30 -,SUP-656130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN T8 FULL THREAD 2.4X32 -,SUP-656132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN T8 FULL THREAD 2.4X34 -,SUP-656134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN T8 FULL THREAD 2.4X36 -,SUP-656136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN T8 FULL THREAD 2.4X38 -,SUP-656138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE T8  2.4MM X L40MM NL -,SUP-656140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NON LOCKING 3.5 X 42 -,SUP-656142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NON LOCKING 3.5 X 44 -,SUP-656144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN T8 FULL THREAD 2.4X48 -,SUP-656148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN T8 FULL THREAD 2.4X50 -,SUP-656150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE VARIAX T8 2.4MM L55MM -,SUP-656155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN T8 FULL THREAD 2.4X60 -,SUP-656160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 2.7MM X 6MM -,SUP-656306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING T8 FULL THREAD 2.7 X 7 -,SUP-656307,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1150.21,805.147,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING T8 FULL THREAD 2.7X8 -,SUP-656308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 2.7MM X 9MM -,SUP-656309,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LCK T8 FULL THREAD 2.7X10 -,SUP-656310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LCK T8 2.7 X 11MM -,SUP-656311,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 2.7MM X 12MM -,SUP-656312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7 X 13 LOCKING -,SUP-656313,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 2.7MM X 14MM -,SUP-656314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LCK T8 2.7 X 15MM -,SUP-656315,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 2.7MM X 16MM -,SUP-656316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 2.7MM X 18MM -,SUP-656318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 2.7MM X 20MM -,SUP-656320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 2.7MM X 22MM -,SUP-656322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 2.7MM X 24MM -,SUP-656324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 2.7MM X 26MM -,SUP-656326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 2.7MM X 22MM -,SUP-656328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7 X 3 LOCKING -,SUP-656330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 2.7MM X 32MM -,SUP-656332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 2.7 X 34 -,SUP-656334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 2.7MM X 36MM -,SUP-656336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 2.7MM X 38MM -,SUP-656338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 2.7MM X 40MM -,SUP-656340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 2.7 X 42 -,SUP-656342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 2.7MM X 44MM -,SUP-656344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 2.7 X 45 -,SUP-656345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 2.7MM X 50MM -,SUP-656350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.7MM X 55MM LOCKING SCREW -,SUP-656355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE VARIAX T8 2.7MM  X  L 60MM LOCKING -,SUP-656360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 2.7 X 70 -,SUP-656370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE VARIAX T8 2.7MM X L 75MM LOCKING SCREW -,SUP-656375S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,694.95,486.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE VARIAX T8 2.7MM X L 80MM LOCKING -,SUP-656380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,694.95,486.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW T8 FULL THREAD NON LCK 2.7 X 6 -,SUP-656406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE VARIAX T8  7MM X 2.7MM -,SUP-656407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE T8 FULL THREAD 2.7MM X 9 -,SUP-656409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MM X 10MM NON LOCKING -,SUP-656410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE T8 2.7 X11MM -,SUP-656411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW N/L 2.7MM X 12MM -,SUP-656412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7 X 13 NL -,SUP-656413,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW N/L 2.7MM X 14MM -,SUP-656414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NON LOCKING 2.7 X 15 -,SUP-656415,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW N/L 2.7MM X 16MM -,SUP-656416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW N/L 2.7MM X 18MM -,SUP-656418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7 X 20MM NLCKG FT T8 STRDRV RCESS -,SUP-656420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NON-LOCKING 2.7MM X 22MM -,SUP-656422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NON LOCKING 2.7 X 26MM -,SUP-656426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.7MM NON LOCKING BONE SCREW 28MM -,SUP-656428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN T8 FLL THRD 2.7 X 30 -,SUP-656430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN T8 FLL THRD 2.7 X 32 -,SUP-656432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN T8 FLL THRD 2.7 X 34 -,SUP-656434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN T8 FLL THRD 2.7 X 36 -,SUP-656436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NON LOCKING 2.7 X 38 -,SUP-656438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE T8 FULL THREAD 2.7 X 40 -,SUP-656440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NON LOCKING 2.7 X 40 -,SUP-656440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NON LOCKING 2.7MM X 42MM -,SUP-656442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NON LOCKING 2.7 X 45 -,SUP-656445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NON LOCKING 2.7 X 46 -,SUP-656446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN T8 FLL THRD 2.7 X 48MM -,SUP-656448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7 X 50 NL -,SUP-656450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7 X 55 NL -,SUP-656455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NON LOCKING 2.7MM X 60MM -,SUP-656460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NON LOCKING 2.7MM X 65MM -,SUP-656465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NL 2.7 X 70 -,SUP-656470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE 2.7MM X 75MM T8 -,SUP-656475S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE VAIRAX T8 2.7MM X L 80MM -,SUP-656480S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING T10 FULL THREAD 2.7 X 8 -,SUP-657008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X12MM LCK FT T10 HX DRV -,SUP-657012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X14MM LCK FT T10 HX DRV -,SUP-657014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X16MM LCK FT T10 HX DRV -,SUP-657016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X20MM LCK FT T10 HX DRV -,SUP-657020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING T10 FULL 2.7 X 22 -,SUP-657022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING T10 FULL 2.7MM  X 22MM VARIAX -,SUP-657024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7 X 26 LOCKING -,SUP-657026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7 X 28 LOCKING -,SUP-657028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7 X 30 LOCKING -,SUP-657030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING T10 FULL 2.7 X 32 -,SUP-657032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOCKING SCREW T10 FULL THREAD 2.7MM L34MM -,SUP-657034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING T10 FULL 2.7 X 36 -,SUP-657036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7 X 38 LOCKING -,SUP-657038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MM X 40MM LOCKING -,SUP-657040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING T10 2.7 X 50 -,SUP-657050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING T10 2.7 X 55 -,SUP-657055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOCKING SCREW T10 FULL THREAD 2.7MM X 60MM -,SUP-657060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING T10 FULL THREAD 2.7 X 65 -,SUP-657065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING T10 FULL THREAD 2.7 X 70 -,SUP-657070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE T10 FULL THREAD 2.7 X 8 -,SUP-657108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X12MM FT T10 HX DRV -,SUP-657112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X14MM FT T10 HX DRV -,SUP-657114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X16MM FT T10 HX DRV -,SUP-657116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X18MM FT T10 HX DRV -,SUP-657118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X20MM FT T10 HX DRV -,SUP-657120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X22MM FT T10 HX DRV -,SUP-657122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE T10 FULL THREAD 2.7 X 26 -,SUP-657126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE T10 FULL THREAD 2.7 X 28 -,SUP-657128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
30MM BONE SCREW NONLOCKING 2.7MM -,SUP-657130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NL 2.7 X 32 -,SUP-657132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NL 2.7 X 34 -,SUP-657134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE T10 FULL THREAD 2.7MM /L36MM -,SUP-657136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NL 2.7 X 38 -,SUP-657138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE T10 FULL THREAD 2.7MM /L40MM -,SUP-657140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE T10 FULL THREAD 2.7MM /L42MM -,SUP-657142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE T10 FULL THREAD 2.7mm / L44mm -,SUP-657144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE T10 FULL THREAD 2.7MM /L46MM -,SUP-657146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE T10 FULL THREAD 2.7mm / L48mm -,SUP-657148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE T10 FULL THREAD 2.7MM /L50MM -,SUP-657150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE T10 FULL THREAD 2.7MM /L55MM -,SUP-657155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE T10 FULL THREAD 2.7MM /L60MM -,SUP-657160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE T10 FULL THREAD 2.7 X 65 -,SUP-657165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE T10 FULL THREAD 2.7 X 70 -,SUP-657170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING T10 FULL THREAD 3.5 X 8 -,SUP-657308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X10MM LCK FT T10 HX DRV -,SUP-657310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE 3.5MM 12MM VARIAX T10 FULL THREAD LOCK NONSTERILE -,SUP-657312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X14MM LCK FT T10 HX DRV -,SUP-657314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X16MM LCK FT T10 HX DRV -,SUP-657316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X18MM LCK FT T10 HX DRV -,SUP-657318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING T10 3.5MM / L20MM FULL THREAD -,SUP-657320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING T10 3.5MM / L22MM FULL THREAD -,SUP-657322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 3.5 X 22 -,SUP-657322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 3.5 X 24 -,SUP-657324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 3.5 X 26 -,SUP-657326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 3.5 X 30 -,SUP-657330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 3.5 X 32 -,SUP-657332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 3.5 X 34 -,SUP-657334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 3.5 X 38 -,SUP-657338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING T10 FULL THREAD 3.5 X 40 -,SUP-657340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING T10 FULL THREAD 3.5 X 42 -,SUP-657342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 3.5 X 44 -,SUP-657344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 3.5 X 46 -,SUP-657346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING T10FULL THREAD 3.5MM X 48MM -,SUP-657348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING T10 FULL THREAD 3.5MM X 50MM -,SUP-657350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING T10 FULL THREAD 3.5 X 60 -,SUP-657360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING T10 FULL THREAD 3.5 X 65 -,SUP-657365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING T10 FULL THREAD 3.5 X 70 -,SUP-657370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE T10 FULL THREAD 3.5 X 8 -,SUP-657408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE T10 FULL THREAD 3.5 X 8 -,SUP-657408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE T10 FULL THREAD 3.5MM /L10MM -,SUP-657410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MM X12MM NON LOCKING -,SUP-657412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5 NON LOCKING 12MM -,SUP-657412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X14MM FT T10 HX DRV -,SUP-657414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X16MM FT T10 HX DRV -,SUP-657416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X18MM FT T10 HX DRV -,SUP-657418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X20MM FT T10 HX DRV -,SUP-657420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NON-LOCKING 3.5 MM X 22 -,SUP-657422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5 NON LOCK FT 24MM -,SUP-657424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5 NON LOCK FT 26MM -,SUP-657426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MM NONLOCKING FT 28MM -,SUP-657428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MM NONLOCKING FT 30MM -,SUP-657430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
VARIAX 305MM NON LOCKING SCREW  32MM -,SUP-657432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
3.5MM NON-LOCKING SCREW 34MM -,SUP-657434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
3.5MM NON-LOCKING SCREW 36MM -,SUP-657436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE T10 FULL THREAD 3.5 X 38 -,SUP-657438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW  BONE T10 FULL THREAD NON LOCKING 3.5 X 40 -,SUP-657440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE T10 FULL THREAD 3.5MM X 42MM -,SUP-657442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
VARIAX 3.5MM NON LOCKING SCREW 44MM -,SUP-657444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BONE SCREW T10 FULL THREAD 3.5MM / L46MM -,SUP-657446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE T10FULL THREAD 3.5 X 48 -,SUP-657448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MM NONLOCKING FT 50MM -,SUP-657450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE T10 FULL THREAD 3.5 X 55 -,SUP-657455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE T10 FULL THREAD 3.5 X 60 -,SUP-657460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE T10 FULL THREAD 3.5 X 65 -,SUP-657465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE T10 FULL THREAD 3.5 X 70 -,SUP-657470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW VARIAX LOCKING T6 2.0MM L8MM -,SUP-657608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING T6 2.0MM L9MM -,SUP-657609,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW VARIAX LOCKING T6 2.0MM L10MM -,SUP-657610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING T6 2.0MM L11MM -,SUP-657611,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.0MM  X 12MM LOCKING -,SUP-657612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING T6 2 X 14MM -,SUP-657614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LCK T6 2.0 X 16MM -,SUP-657616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LCK T6 2.0 X 18MM -,SUP-657618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2-0MM LOCKING 20MM LENGTH -,SUP-657620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LCK T6 2.0 X 22MM -,SUP-657622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING T6 2.0 X 26MM -,SUP-657626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING VARIAX T6 2.0MM X L30MM -,SUP-657630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE 2.0M X L6MM T6 -,SUP-657706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NONLCK 2.0 X 10MM -,SUP-657710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2 X 11 -,SUP-657711,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.0MM X 12MM NON LOCKING -,SUP-657712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.0MM X 14MM NON LOCKING -,SUP-657714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2 X 16 -,SUP-657716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW VARIAX 2.0 X 18 -,SUP-657718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.9 NON LOCKING 20MM LENGTH -,SUP-657720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NON LOCKING 2 X 22 -,SUP-657722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE T6 2.0MM X L 24MM NON-LOCKING -,SUP-657724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE T6 2.0MM L26MM -,SUP-657726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.0MM NON LOCKING 28MM LENGTH -,SUP-657728,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE T6 2.0MM L30MM -,SUP-657730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE VARIAX T6 2.0MM X L34MM -,SUP-657734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NON LOCKING 2 X 36 -,SUP-657736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE VARIAX T6 2.0MM X L38MM -,SUP-657738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW FIXOS 4.0 30MM -,SUP-658030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEADLESS 4.0 FIXOS 38MM -,SUP-658038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
4.0 FIXOS 46MM SCREW -,SUP-658046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
4.0 FIXOS 48MM SCREW -,SUP-658048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEADLESS COMP. 7.0MM 50M -,SUP-658050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
4.0 FIXOS 55MM SCREW -,SUP-658055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEADLESS LONG THREAD 7.0 X 70MM -,SUP-658070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEADLESS COMP. 7.0MM 75M -,SUP-658075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
4.0 FIXOS SCREW 80MM -,SUP-658080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEADLESS 5 X 32 -,SUP-658132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW FIXOS 5.0 X 34MM -,SUP-658134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW FIXOS 5.0 X 36MM -,SUP-658136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
HEADLESS COMPRESSION SCREW 5MM X 38MM -,SUP-658138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
5.0 HEADLESS SCREW 44 MM -,SUP-658144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANNULATED 5.0 X 46MM FIXOS -,SUP-658146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
5.0 FIXOS 48MM SCREW -,SUP-658148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANNULATED 5.0 X 55MM FI -,SUP-658155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
HEADLESS COMPRESSION SCREW 5.0mm / L65mm -,SUP-658165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
HEADLESS COMPRESSION SCREW 5.0mm / L70mm -,SUP-658170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2402.19,1681.533,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW FIXOS 5 X 70MM -,SUP-658170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE FIXOS 5 X 75 -,SUP-658175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW FIXOS 5 X 80 -,SUP-658180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
HEADLESS COMPRESSION SCREW 7MM / L40MM ST -,SUP-658340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEADLESS COMP. 7.0MM 6.5 FIXOS -,SUP-658365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEADLESS COMP. 7.0MM 70M -,SUP-658370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEADLESS SHORT THREAD 7.0 X 75MM -,SUP-658375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEADLESS SHORT THREAD 7.0 X 90MM -,SUP-658390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEADLESS COMP. 7.0MM 12.5 FIXOS -,SUP-658425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
HEADLESS COMPRESSION SCREW 7MM / L65MM ST -,SUP-658565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEADLESS LONG THREAD 7.0 X 70MM -,SUP-658570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
HEADLESS COMPRESSION SCREW Ã˜7.0MM / L75MM LONG THREAD -,SUP-658575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7.0 FIXOS 80MM -,SUP-658580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
HEADLESS COMPRESSION SCREW 7MM X 85MM LONG THREAD -,SUP-658585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
HEADLESS COMPRESSION SCREW 7MM X25MM -,SUP-658625,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 8X20MM -,SUP-660H0820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 9X35MM -,SUP-660H0935,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X14MM LCK -,SUP-661014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X18MM LCK -,SUP-661018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X20MM LCK -,SUP-661020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X22MM LCK -,SUP-661022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X24MM LCK -,SUP-661024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X26MM LCK -,SUP-661026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X28MM LCK -,SUP-661028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X30MM LCK -,SUP-661030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X32MM LCK -,SUP-661032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X34MM LCK -,SUP-661034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X36MM LCK -,SUP-661036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X38MM LCK -,SUP-661038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X40MM LCK -,SUP-661040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1154.51,808.157,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X42MM LCK -,SUP-661042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X44MM LCK -,SUP-661044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X46MM LCK -,SUP-661046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X48MM LCK -,SUP-661048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X50MM LCK -,SUP-661050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCK 4.0 X 55MM -,SUP-661055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X60MM LCK -,SUP-661060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X65MM LCK -,SUP-661065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X70MM LCK -,SUP-661070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X75MM LCK -,SUP-661075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X80MM LCK -,SUP-661080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X85MM LCK -,SUP-661085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X90MM LCK -,SUP-661090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X95MM LCK -,SUP-661095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X14MM LCK -,SUP-661114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X16MM LCK -,SUP-661116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X18MM LCK -,SUP-661118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X20MM LCK -,SUP-661120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X22MM LCK -,SUP-661122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X24MM LCK -,SUP-661124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X26MM LCK -,SUP-661126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X28MM LCK -,SUP-661128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X30MM LCK -,SUP-661130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X32MM LCK -,SUP-661132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X34MM LCK -,SUP-661134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X36MM LCK -,SUP-661136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X38MM LCK -,SUP-661138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X40MM LCK -,SUP-661140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X42MM LCK -,SUP-661142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X44MM LCK -,SUP-661144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X46MM LCK -,SUP-661146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5 X 48MM LCK -,SUP-661148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X55MM LCK -,SUP-661155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X60MM LCK -,SUP-661160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,854.24,597.968,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X65MM LCK -,SUP-661165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X70MM LCK -,SUP-661170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X75MM LCK -,SUP-661175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X80MM LCK -,SUP-661180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X85MM LCK -,SUP-661185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X90MM LCK -,SUP-661190,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X95MM LCK -,SUP-661195,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOCKING SCREW FLAT TIP 5.0MM T20 L10MM -,SUP-661210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2630.74,1841.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOCKING SCREW FLAT TIP 5.0MM /T20 /L20 -,SUP-661220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2630.74,1841.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X8MM LCK ST PRPRSTHTC -,SUP-661308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 5.0 X 10MM PERIP -,SUP-661310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 5.0 X 12MM PERIP -,SUP-661312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X14MM LCK ST PRPRSTHTC -,SUP-661314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X16MM PERI- LCK AXSOS -,SUP-661316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X16MM LCK ST PRPRSTHTC -,SUP-661316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X18MM LCK ST PRPRSTHTC -,SUP-661318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X20MM LCK ST PRPRSTHTC -,SUP-661320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NON LOCKING 3.5 X 14MM -,SUP-661414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X18MM CORT TI -,SUP-661418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NON LOCKING 3.5 X 20MM -,SUP-661420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X22MM CORT TI -,SUP-661422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X24MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X26MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X28MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X30MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X32MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X34MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X36MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X38MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X40MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X42MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X44MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X46MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL 3.5 X 46 -,SUP-661447,CDM,C1713,HCPCS,278,RC,,,outpatient,,,239.99,167.993,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X48MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X50MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X55MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X65MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X70MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X75MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661475,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X80MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X85MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X90MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTEX 3.5MM X 120MM -,SUP-661520S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTEX TI 4.5 X 14MM -,SUP-661714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTEX SELF TAPPING 4.5 X 16 -,SUP-661716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORT 4.5 X 18 -,SUP-661718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL 4.5 X 20MM -,SUP-661720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X22MM CORT TI -,SUP-661722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORT 4.5 X 24 -,SUP-661724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORT 4.5 X 26 -,SUP-661726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORITCAL 4.5MM X 28MM -,SUP-661728,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X30MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X32MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661732,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X34MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X36MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X38MM LCK CORT VARIAX SELF TAPPING -,SUP-661738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X38MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X40MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X42MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X44MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X46MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661746,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X48MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661748,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X50MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X55MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X60MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X65MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661765,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X70MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X75MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661775,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X80MM CORT TI -,SUP-661780,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL 4.5 X 85 -,SUP-661785,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3MMX8IN ER CANC CORT VARIAX FT POLYAX ST T7 STRDRV -,SUP-661795,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CABLE PLUG 5.0MM -,SUP-662202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1868.43,1307.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOCKING SCREW 5.0MM /T20 / L24MM -,SUP-662324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOCKING SCREW 5.0MM /T20 /L30MM -,SUP-662330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOCKING SCREW 5.0MM /T20 / L40MM -,SUP-662340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOCKING SCREW 5.0MM T20 L46MM -,SUP-662346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOCKING SCREW 5.0MM T20 L50MM -,SUP-662350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOCKING SCREW 5.0MM T20 L60MM -,SUP-662360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOCKING SCREW 5.0MM /T20 / L65MM -,SUP-662365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOCKING SCREW 5.0MM T20 L70MM -,SUP-662370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOCKING SCREW 5.0MM /T20 / L75MM -,SUP-662375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOCKING SCREW 5.0MM /T20 /L80MM -,SUP-662380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LCK 1.7 X 5 -,SUP-662505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,497.14,347.998,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING T5 1.7MM X 9MM -,SUP-662509,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOCKING SCREW T5 1.7MM X 22MM -,SUP-662522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,497.14,347.998,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE 1.7 X 6 -,SUP-662606,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BONE SCREW T5 1.7MM X 8MM -,SUP-662608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE 1.7 X 9 -,SUP-662609,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.7 X 11 NON LOCKING -,SUP-662611,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.7 X 15 -,SUP-662615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.7 X 16 NL -,SUP-662616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.7 X 18 NL -,SUP-662618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW EMERGENCY 1.9 X 5 -,SUP-662705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW EMERGENCY T5 1.9MM/L12MM 12 HOLE LEFT -,SUP-662712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANNULATED 4.0MM X 38MM COMP -,SUP-663038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WASHER 5MM -,SUP-663101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,202.42,141.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW JFX CANNULATED 5 X 46MM -,SUP-663146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IMPCTR HD XTRCT SHRT 3.2X19MM DURACN -,SUP-6633-7-615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,376.53,263.571,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SOLID COMPRESSION 4.0MM X 36MM L -,SUP-663436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SOLID COMPRESSION 4.0MM X 38MM -,SUP-663438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COMPRESSION SCREW SOLID A 4.0MM/ L40MM -,SUP-663440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SOLID COMPRESSION 4 X 22 -,SUP-663442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
4.0 SOLID COMPRESSION SCREW 48MM -,SUP-663448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SOLID COMPRESSION 4.0MM X L50MM -,SUP-663450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.32,2719.724,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SOLID COMPRESSION 5.0MM X 36MM L -,SUP-663536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SOLID COMP 5MM X 40MM -,SUP-663540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW COMPRESSION 5 X 42 -,SUP-663542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
5.0MM L 44MM COMPRESSION SCREW -,SUP-663544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COMPRESSION SCREW 5.0MM -,SUP-663546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5 X 48 MM SOLID -,SUP-663548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SOLID COMPRESSION 5.0MM X L50MM -,SUP-663550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 2.3MM X 16MM -,SUP-663716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,498.89,349.223,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 2.3MM X 18MM -,SUP-663718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,498.89,349.223,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE 2.3 X 8 -,SUP-663808,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE 2.3  X 9 -,SUP-663809,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE 2.3 X 10 -,SUP-663810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NON LOCKING 2.3MM X 13MM -,SUP-663813,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NON-LOCKING 2.3MM 16MM -,SUP-663816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE 2.3 X 20 -,SUP-663820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW EMERGENCY  2.5 X 6 -,SUP-663906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW EMERGENCY 2.5 X 8 -,SUP-663908,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CORTEX SCREW DIA 4.0MM L38MM -,SUP-666138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CANLTD SCRW 16MM THREAD DIA 6.5MM L45MM -,SUP-666445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CANLTD SCREW 16MM THREAD DIA 6.5MM L50MM -,SUP-666450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CANLTD SCREW 16MM THREAD DIA 6.5MM L65MM -,SUP-666465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANNULATED 6.5 X 70 -,SUP-666470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANNULATED 6.5 X 80 -,SUP-666480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANNULATED 6.5 X 85 -,SUP-666485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER MOLD LG FEMORAL 53A/P X 75M/L -,SUP-669-1075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6663.08,4664.156,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GRIP CBL 1.6MM DLMLS VITAL -,SUP-6704-0-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3931.1,2751.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CABLE ORTHO 1.6MM DLMLS VITAL MED GRP + 2 -,SUP-6704-0-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3931.1,2751.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GRIP LARGE W/2 CABLES DALL MIL -,SUP-6704-0-310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3931.1,2751.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CABLE ORTHO DLMLS 1.6MM VITAL BEAD SM SLV -,SUP-6704-0-420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CABLE ORTHO DLMLS 2MM VITAL MED SLV -,SUP-6704-0-510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DALL-MILES 2.0MM VIT BEADED CABLE/SLEEVE SET -,SUP-6704-0-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SET CABLE SLEEVE BEADED  2.0 D -,SUP-6704-0-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN DLMLS 100MM GRP VITAL MED 2MM CBLX2 -,SUP-6704-3-081,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4408.24,3085.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN DLMLS 150MM GRP VITAL MED 2MM CBLX2 -,SUP-6704-3-082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5744.68,4021.276,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE TROC DLMLS 110MM GRP LRG W/2 CBS -,SUP-6704-3-091,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4408.24,3085.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN DLMLS 160MM GRP VITAL LRG 2MM CBLX2 -,SUP-6704-3-092,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5744.68,4021.276,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CENTURION 3.5 X 12 -,SUP-69-3312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CENTURION 3.5 X 18 -,SUP-69-3318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CENTURION 3.5 X 12 -,SUP-69-3412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CENTURION 4.0 X 14 -,SUP-69-3414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CENTURION 4.0 X 30 -,SUP-69-3430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CENTURION 4.5 X 30 -,SUP-69-3530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CENTURION 5.0 X 30 -,SUP-69-3630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
STAPLE INTNL 12X23MM VITAL ELLISON LF -,SUP-6982-1-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1703.05,1192.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
STAPLE INTNL 14X23MM VITAL ELLISON LF -,SUP-6982-2-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1602.87,1122.009,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GRAFT BONE I FACTOR 2.5CC ALLOGRAFT PUTTY SYRINGE -,SUP-700-025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 8HL STR -,SUP-70-0095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 8HL STR -,SUP-70-0096,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 3.5MM 9HL LCK TI NS RT -,SUP-70-0116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.27,4447.289,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 3.5MM 9HL LCK TI NS LT -,SUP-70-0117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.27,4447.289,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 2.3MM 16HL LCK TI NS -,SUP-70-0124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6989.87,4892.909,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 2.3MM 13HL LCK TI NS -,SUP-70-0126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.27,4447.289,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 8HL LT CLAV LPRO TI STR NS -,SUP-70-0286,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 8HL RT CLAV LPRO TI STR NS -,SUP-70-0287,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN F/ELB PLATE SYS 8HL LCK TI LRG NS -,SUP-70-0289,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN F/ELB PLATE SYS 10HL LCK TI NS -,SUP-70-0294,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN F/ELB PLATE SYS 6HL LCK TI NS LT CLVCL -,SUP-70-0296,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN F/ELB PLATE SYS 6HL LCK TI NS RT CLVCL -,SUP-70-0297,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 8HL LT CLAV NRW-PRFL TI STR NS -,SUP-70-0298,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 8HL RT CLAV NRW-PRFL TI STR NS -,SUP-70-0299,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 8HL CONTR LCK TI LRG NS LT -,SUP-70-0300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 8HL CONTR LCK TI LRG NS RT -,SUP-70-0301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 65MM 3HL CONTR LCK TI STD NS -,SUP-70-0302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6535.76,4575.032,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 110MM 7HL CONTR LCK TI STD NS -,SUP-70-0306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7414.27,5189.989,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 90MM 5HL TAP-LCK TI EXTEND NS -,SUP-70-0313,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6535.76,4575.032,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEPIN ORTHO 2MM ASNIS III THRD -,SUP-7007-1300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
K-WIRE ASNIS III 3.2 -,SUP-702463S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,505.08,353.556,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
IRON BENDING -,SUP-702901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.85,795.795,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
AXSOS 5.0 ADAPTOR NUT -,SUP-702977,CDM,C1713,HCPCS,278,RC,,,outpatient,,,559.11,391.377,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOW PROFILE HEX 6.5 X 15 -,SUP-7030-6515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEX LOW PROFILE 6.5MM X 20MM -,SUP-7030-6520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MM LOW PROFILE HEX -,SUP-7030-6525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEX 6.5MM X 30MM LOW PROFILE -,SUP-7030-6530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEX 6.5MM X 35MM LOW PROFILE -,SUP-7030-6535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
6.5x40MM LOW PROFILE HEX SCREW -,SUP-7030-6540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
6.5X45MM LOW PROFILE HEX SCREW -,SUP-7030-6545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
6.5x50MM LOW PROFILE HEX SCREW -,SUP-7030-6550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOW PROFILE HEX 6.5MM x 55MM -,SUP-7030-6555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
IMPLANT HIP 7X35MM POR TI PLASM SPRY SCRILAC IFUSE STRL -,SUP-7035-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDE WIRE WITH CALIBRATION 3.2MM X 230MM QUICK RELEASE -,SUP-705237,CDM,C1713,HCPCS,278,RC,,,outpatient,,,606.84,424.788,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ELEVATOR PERIOSTEAL 6MM ROUND EDGE -,SUP-705294,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1361.01,952.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
IMPLANT HIP 7X65MM POR TI PLASM SPRY SCRILAC IFUSE STRL -,SUP-7065-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN EXTFIX 3X120MM 16MM THRD COVE PNT -,SUP-71022001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN EXTFIX 3X120MM 22MM THRD COVE PNT -,SUP-71022002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN EXTFIX 3X120MM 28MM THRD COVE PNT -,SUP-71022003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X70MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X80MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X85MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X95MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X110MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X130MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 58MM 3.5MM 5HL RECON STR -,SUP-71140105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4158.44,2910.908,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 70MM 3.5MM 6HL RECON STR -,SUP-71140106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4651.85,3256.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 82MM 3.5MM 7HL RECON STR -,SUP-71140107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4446.01,3112.207,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 94MM 3.5MM 8HL RECON STR -,SUP-71140108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5084.1,3558.87,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 75MM 3.5MM 6HL SM T-SHP RT ANG -,SUP-71140406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2349.66,1644.762,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WASHER ORTHO 3.7X7MM SS -,SUP-71143107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,441.48,309.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 87MM 9HL Y STRL TMPLT -,SUP-71144012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7101.27,4970.889,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TROCAR PIN GEN 1/8 X 3 -,SUP-71210002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.63,108.241,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEPIN ORTHO 3MM GENESIS 12.5CM TROC TIP -,SUP-71210003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.63,108.241,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MM MINI 16MM CORT TC-100 FT HEX HEAD SS -,SUP-71220016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,359.67,251.769,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 15MM REF SPHER HEAD -,SUP-71332515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,811.07,567.749,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 20MM REF SPER HEAD -,SUP-71332520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,811.07,567.749,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CABLE ORTHO 2MM ACCORD COCR -,SUP-71340020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,977.36,684.152,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
INSERT PS LGN XLPE SZ 3-4 11MM -,SUP-71453247,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4520.12,3164.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ENDCAP ORTHO 0MM TRIGEN STRL -,SUP-71634000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2293.1,1605.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ENDCAP PROT 5MM TI STRL TRIGEN F/OB GYNAECOLOGICAL PROC TIB -,SUP-71634005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2293.1,1605.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ENDCAP ORTHO 20MM TRIGEN STRL -,SUP-71634020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2293.1,1605.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX25MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2401.07,1680.749,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX30MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX35MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642135,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX40MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX45MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX55MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MMX65MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5MMX20MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5MMX25MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5MMX35MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5MMX50MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5MMX60MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5MMX65MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642265,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5MMX75MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642275,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X35MM TRIGEN -,SUP-71645035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X45MM TRIGEN -,SUP-71645045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10X380MM TRIGEN TAN CANN LT TROCH FEM TI ALY ANTGRD -,SUP-71647238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15450.91,10815.637,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11.5X380MM TRIGEN TAN CANN LT TROCH FEM TI ALY -,SUP-71647338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15450.91,10815.637,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10X320MM TRIGEN META-NAIL CANN DIST FEM TI ALY RTRGD -,SUP-71653032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14208.35,9945.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 8.5X330MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655033,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 8.5X340MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 8.5X350MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10X280MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10X290MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655129,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10MMX30CM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10X310MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655131,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10X320MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10X340MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10X350MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655135,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10MMX37CM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655137,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11.5X300MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11.5X360MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11.5X390MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655239,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11.5MMX40CM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEPIN ORTHO 3.2MM TRIGEN 343MM THRD BRAD TIP -,SUP-71674130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1491.03,1043.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10X180MM TRIGEN INTERTAN 1.5 CANN TROCH FEM TI 125DG -,SUP-71675201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11.5X180MM TRIGEN INTERTAN 1.5 CANN TROCH FEM TI -,SUP-71675202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 13X180MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11.5X200MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 13X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10X180MM TRIGEN INTERTAN 1.5 CANN TROCH FEM TI 130DG -,SUP-71675207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11.5MM 180MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP -,SUP-71675208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 13X180MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71675209,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71675210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10X320MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP -,SUP-71675219,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10MMX32CM TRIGEN INTERTAN 1.5 CANN INTST HIP TI -,SUP-71675220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675222,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CAN LT INTS HIP TI LIME -,SUP-71675223,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI125 -,SUP-71675224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10X380MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10X400MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP -,SUP-71675227,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11.5X320MM TRIGEN INTERTAN 1.5 CANN RT INTS HIP TI.. -,SUP-71675242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71675244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11.5X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675245,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71675246,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI_ -,SUP-71675250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11.5X420MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675251,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI130 -,SUP-71675268,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 13X280MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 13X320MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 13MMX32CM TRIGEN INTERTAN 1.5 CANN INTST HIP TI -,SUP-71675408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 13X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 13X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 13X180MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71675412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 13X380MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675413,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 13X400MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675415,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 13X400MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 13X440MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10X320MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71676507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TIRSE -,SUP-71676510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71676511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676513,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10X380MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11.5X320MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI- -,SUP-71676552,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTS HIP TI.. -,SUP-71676553,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI- -,SUP-71676554,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11.5MMX36CM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71676555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11.5X360MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11.5X380MM TRIGEN INTERTAN 1.5 CANN LT INTST TI -,SUP-71676557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11.5MMX38CM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71676558,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11.5X400MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 13X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71676598,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 13X360MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 13X380MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71676602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 70MM/75MM -,SUP-71677075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 75MM/80MM -,SUP-71677080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 80MM/85MM -,SUP-71677085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 85MM/90MM -,SUP-71677090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 90MM/95MM -,SUP-71677095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI_ -,SUP-71677100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI- -,SUP-71677105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI.. -,SUP-71677110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI. -,SUP-71677115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 11MM TRIGEN INTERTAN LAG 100MM -,SUP-71678010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 11X110MM LAG TRIGEN INTERTAN -,SUP-71678011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 11X115MM TRIGEN INTERTAN SBTRCHNTRC TI -,SUP-71678015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 11MM TRIGEN INTERTAN LAG 85MM -,SUP-71678085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 11MM TRIGEN INTERTAN LAG 90MM -,SUP-71678090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 11MM TRIGEN INTERTAN LAG 95MM -,SUP-71678095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEPIN ORTHO 3.2MMX24.8CM THRD DRILL TIP -,SUP-71751147,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X20MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X22MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X24MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X30MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X24MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X26MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X30MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X32MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X34MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X36MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X38MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X40MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X42MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X44MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X46MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 8/ 7MMLNGX260MM TRIGEN CANN PROX HUM TI ALY -,SUP-71770826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 9/ 7.5MMLNGX240MM TRIGEN CANN PROX HUM TI ALY -,SUP-71770924,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10/ 8.5MMLNGX220MM TRIGEN CANN PROX HUM TI ALY -,SUP-71771022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10/ 8.5MMLNGX240MM TRIGEN CANN PROX HUM TI ALY -,SUP-71771024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 10/ 8.5MMLNGX280MM TRIGEN CANN PROX HUM TI ALY -,SUP-71771028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC 193MM 4.5MM 8HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16207.25,11345.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC 286MM 4.5MM 13HL CONTR SCALLP LCK SS BVL LT -,SUP-71800013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17251.71,12076.197,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC 342MM 4.5MM 16HL CONTR SCALLP LCK SS BVL LT -,SUP-71800016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17575.86,12303.102,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC 193MM 4.5MM 8HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16207.25,11345.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC 342MM 4.5MM 16HL CONTR SCALLP LCK SS BVL RT -,SUP-71800116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17575.86,12303.102,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC 94MM 4.5MM 4HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17341.75,12139.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC 130MM 4.5MM 6HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17575.86,12303.102,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 93MM 4.5MM 3HL CONTR SCALLP LCK BVL TIP -,SUP-71801603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17053.62,11937.534,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X10MM CORT PERILOC ST SS -,SUP-71804010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X12MM CORT PERILOC ST SS -,SUP-71804012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X14MM CORT PERILOC ST SS -,SUP-71804014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X16MM CORT PERILOC ST SS -,SUP-71804016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X18MM CORT PERILOC ST SS -,SUP-71804018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X20MM CORT PERILOC ST SS -,SUP-71804020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X24MM CORT PERILOC ST SS -,SUP-71804024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X32MM CORT PERILOC ST SS -,SUP-71804032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X34MM CORT PERILOC ST SS -,SUP-71804034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X36MM CORT PERILOC ST SS -,SUP-71804036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X38MM CORT PERILOC ST SS -,SUP-71804038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X40MM CORT PERILOC ST SS -,SUP-71804040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X50MM CORT PERILOC ST SS -,SUP-71804050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X55MM CORT PERILOC ST SS -,SUP-71804055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X60MM CORT PERILOC ST SS -,SUP-71804060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X12MM LCK CORT PERILOC ST SS -,SUP-71805012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1866.36,1306.452,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X20MM LCK CORT PERILOC ST SS -,SUP-71805020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1866.36,1306.452,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X14MM CANC PERILOC FT SS -,SUP-71805214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,496.09,347.263,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X36MM CORT PERILOC ST SS -,SUP-71806036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X38MM CORT PERILOC ST SS -,SUP-71806038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X40MM CORT PERILOC ST SS -,SUP-71806040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X42MM NLCKG CORT PERILOC ST SS -,SUP-71806042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X46MM NLCKG CORT PERILOC ST SS -,SUP-71806046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X50MM NLCKG CORT PERILOC ST SS -,SUP-71806050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X70MM NLCKG CORT PERILOC ST SS -,SUP-71806070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X32MM LCK CORT PERILOC ST SS -,SUP-71807032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X34MM LCK CORT PERILOC ST SS PERIART -,SUP-71807034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X36MM LCK CORT PERILOC ST SS PERIART -,SUP-71807036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X38MM LCK CORT PERILOC ST SS -,SUP-71807038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X48MM LCK CORT PERILOC ST SS -,SUP-71807048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X56MM LCK CORT PERILOC ST SS -,SUP-71807056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X58MM LCK CORT PERILOC ST SS -,SUP-71807058,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X60MM LCK CORT PERILOC ST SS PERIART -,SUP-71807060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X74MM LCK CORT PERILOC ST SS -,SUP-71807074,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.7X65MM LCK CANN PERILOC FT SS -,SUP-71808065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC 193MM 4.5MM 13HL CONTR SCALLP LCK SS BVL -,SUP-71820008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12497.59,8748.313,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 230MM 4.5MM 10HL CONTR SCALLP LCK SS BVL TIP -,SUP-71820010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12767.71,8937.397,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC 98MM 3.5MM 6HL CONTR SCALLP LCK SS BVL TIP -,SUP-71820506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13524.05,9466.835,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 196MM 3.5MM 10HL CONTR SCALLP LCK BVL TIP -,SUP-71821010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15522.94,10866.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X34MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X36MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X40MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X50MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X55MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X60MM LCK PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG -,SUP-71821160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX6MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
RETRACTOR EYELID DSMRS 1.12MMX5.5IN STN FNSH LID V. MUELLER -,SUP-71821208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
RETRACTOR LNG ALLISON 12.25IN 2.125IN BLD SS F/CV V. MUELLER -,SUP-71821210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX12MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX14MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX16MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX18MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821218,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX22MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821222,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX24MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX26MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821226,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX28MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX30MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX34MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX36MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX40MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC 89MM 3.5MM 3HL CONTR LCK SS BVL TIP -,SUP-71821303,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14982.7,10487.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX6MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM STD -,SUP-71821306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX8MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM STD -,SUP-71821308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX10MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX12MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX14MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX16MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX18MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX20MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX22MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX24MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX26MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX28MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX32MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX34MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX36MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX38MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX40MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX44MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX46MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX50MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC 89MM 3.5MM 3HL CONTR LCK SS BVL TIP NS -,SUP-71821403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14982.7,10487.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC 115MM 3.5MM 5HL CONTR LCK SS BVL TIP -,SUP-71821405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15414.89,10790.423,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC 79MM 2.7/3.5MM 5HL CONTR LCK SS BVL TIP -,SUP-71821805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11921.33,8344.931,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5MMX10MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5MMX12MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5MMX14MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5MMX16MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX18MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5MMX20MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5MMX38MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX40MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X10MM LCK CORT PERILOC FT ST SS NS -,SUP-71822310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X12MM LCK CORT PERILOC FT ST SS NS -,SUP-71822312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X14MM LCK CORT PERILOC FT ST SS NS -,SUP-71822314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X16MM LCK CORT PERILOC FT ST SS NS -,SUP-71822316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X18MM LCK CORT PERILOC FT ST SS NS -,SUP-71822318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X20MM LCK CORT PERILOC FT ST SS NS -,SUP-71822320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X24MM LCK CORT PERILOC FT ST SS NS -,SUP-71822324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X28MM LCK CORT PERILOC FT ST SS NS -,SUP-71822328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X30MM LCK CORT PERILOC FT ST SS NS -,SUP-71822330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X36MM LCK CORT PERILOC FT ST SS NS -,SUP-71822336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X40MM LCK CORT PERILOC FT ST SS NS -,SUP-71822340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X45MM LCK CORT PERILOC FT ST SS NS -,SUP-71822345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X50MM LCK CORT PERILOC FT ST SS NS -,SUP-71822350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X60MM LCK CORT PERILOC FT ST SS NS -,SUP-71822360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1413.91,989.737,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5X10MM LCK CORT PERILOC FT ST SS -,SUP-71822410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5X12MM LCK CORT PERILOC FT ST SS -,SUP-71822412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5X14MM LCK CORT PERILOC FT ST SS -,SUP-71822414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5X16MM LCK CORT PERILOC FT ST SS -,SUP-71822416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5X18MM LCK CORT PERILOC FT ST SS -,SUP-71822418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5X20MM LCK CORT PERILOC FT ST SS -,SUP-71822420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5X22MM LCK CORT PERILOC FT ST SS -,SUP-71822422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5X24MM LCK CORT PERILOC FT ST SS -,SUP-71822424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5X26MM LCK CORT PERILOC FT ST SS -,SUP-71822426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 153MM 2.7MM 11HL CONTR SS BVL TIP -,SUP-71822511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14982.7,10487.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC 80MM 2.7/3.5MM 5HL CONTR LCK SS BVL TIP -,SUP-71822705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12245.47,8571.829,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC 81MM 6HL LCK SS CORNL BND -,SUP-71822906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14406.44,10084.508,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC 107MM 8HL LCK SS CORNL BND -,SUP-71822908,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15522.94,10866.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MMX10MM LCK CORT PERILOC VLP ST VAR ANG CP 2.5MM -,SUP-71823010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MMX12MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MMX14MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MMX16MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MMX18MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DIRECTOR ORAL NO. 2522 7.25IN V. MUELLER SS GZE LIG TUCKER -,SUP-71823020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MMX22MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MMX24MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MMX26MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MMX30MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MMX40MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MMX45MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MMX50MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MMX55MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7MMX60MM LCK CORT PERILOC VLP ST FLUTX3 2.5MM STD HX -,SUP-71823060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,611.27,427.889,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC 62MM 2.5MM 3HL STD HEAD LCK SS -,SUP-71823110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC 86MM 2.5MM 5HL STD HEAD LCK SS LT VOLAR -,SUP-71823112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9562.27,6693.589,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC 62MM 2.5MM 3HL HEAD LCK SS STD -,SUP-71823114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC 86MM 2.5MM 5HL STD HEAD LCK SS RT VOLAR -,SUP-71823116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9562.27,6693.589,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC 62MM 2.5MM 3HL W HEAD LCK SS LT VOLAR RADL -,SUP-71823118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC 62MM 2.5MM 3HL W HEAD LCK SS RT VOLAR RADL -,SUP-71823122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC 97MM 3.5MM 8HL LCK SS -,SUP-71823401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8830.28,6181.196,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC 109MM 3.5MM 6HL LCK SS LT CLVCL -,SUP-71823403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9036.11,6325.277,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC 109MM 3.5MM 6HL LCK SS RT CLVCL -,SUP-71823404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9036.11,6325.277,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC 81MM 2.7MM LCK SS -,SUP-71823407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9036.11,6325.277,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC 81MM 6HL LCK SS -,SUP-71823906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14406.44,10084.508,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X10MM NLCKG CORT PERILOC ST SS -,SUP-71824010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X16MM NLCKG CORT PERILOC ST SS -,SUP-71824016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X22MM NLCKG CORT PERILOC ST SS -,SUP-71824022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X24MM NLCKG CORT PERILOC ST SS -,SUP-71824024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X26MM NLCKG CORT PERILOC ST SS -,SUP-71824026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X28MM NLCKG CORT PERILOC ST SS -,SUP-71824028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X30MM NLCKG CORT PERILOC ST SS -,SUP-71824030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X50MM NLCKG CORT PERILOC ST SS -,SUP-71824050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X18MM LCK CORT PERILOC ST SS -,SUP-71825018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X22MM LCK CORT PERILOC ST SS -,SUP-71825022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X24MM LCK CORT PERILOC ST SS -,SUP-71825024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X26MM LCK CORT PERILOC ST SS -,SUP-71825026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X28MM LCK CORT PERILOC ST SS -,SUP-71825028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X30MM LCK CORT PERILOC ST SS -,SUP-71825030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X32MM LCK CORT PERILOC ST SS -,SUP-71825032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X34MM LCK CORT PERILOC ST SS -,SUP-71825034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X50MM LCK CORT PERILOC ST SS -,SUP-71825050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X55MM LCK CORT PERILOC ST SS -,SUP-71825055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X60MM LCK CORT PERILOC ST SS -,SUP-71825060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X65MM LCK CORT PERILOC ST SS -,SUP-71825065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X80MM LCK CORT PERILOC ST SS -,SUP-71825080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X10MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X12MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X16MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X18MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825218,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X36MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X45MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825245,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X50MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X60MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X65MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825265,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X35MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825335,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X40MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X45MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X55MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X60MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X26MM NLCKG CORT PERILOC ST SS -,SUP-71826026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X30MM NLCKG CORT PERILOC ST SS -,SUP-71826030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X34MM NLCKG CORT PERILOC ST SS -,SUP-71826034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X40MM NLCKG CORT PERILOC ST SS -,SUP-71826040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X44MM NLCKG CORT PERILOC ST SS -,SUP-71826044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X48MM NLCKG CORT PERILOC ST SS -,SUP-71826048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X52MM NLCKG CORT PERILOC ST SS -,SUP-71826052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X60MM NLCKG CORT PERILOC ST SS -,SUP-71826060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X68MM NLCKG CORT PERILOC ST SS -,SUP-71826068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X72MM NLCKG CORT PERILOC ST SS -,SUP-71826072,CDM,C1713,HCPCS,278,RC,,,outpatient,,,594.29,416.003,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X74MM NLCKG CORT PERILOC ST SS -,SUP-71826074,CDM,C1713,HCPCS,278,RC,,,outpatient,,,594.29,416.003,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X10MM LCK CORT PERILOC ST SS -,SUP-71827010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X12MM LCK CORT PERILOC ST BLNT TIP SS -,SUP-71827012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X18MM LCK CORT PERILOC ST SS -,SUP-71827018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X20MM LCK CORT PERILOC ST SS -,SUP-71827020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X24MM LCK CORT PERILOC ST SS -,SUP-71827024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X26MM LCK CORT PERILOC ST SS -,SUP-71827026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X28MM LCK CORT PERILOC ST SS -,SUP-71827028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X30MM LCK CORT PERILOC ST SS -,SUP-71827030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X32MM LCK CORT PERILOC ST SS -,SUP-71827032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X34MM LCK CORT PERILOC ST SS -,SUP-71827034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X36MM LCK CORT PERILOC ST SS PROX FEM -,SUP-71827036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X40MM LCK CORT PERILOC ST SS -,SUP-71827040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X42MM LCK CORT PERILOC ST SS -,SUP-71827042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X46MM LCK CORT PERILOC ST SS -,SUP-71827046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X50MM LCK CORT PERILOC ST SS -,SUP-71827050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X52MM LCK CORT PERILOC ST SS -,SUP-71827052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X60MM LCK CORT PERILOC ST SS PROX FEM -,SUP-71827060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X66MM LCK CORT PERILOC ST SS -,SUP-71827066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X68MM LCK CORT PERILOC ST SS -,SUP-71827068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X70MM LCK CORT PERILOC ST SS -,SUP-71827070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1924.08,1346.856,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X70MM LCK CORT PERILOC ST SS -,SUP-71827070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X72MM LCK CORT PERILOC ST SS -,SUP-71827072,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X76MM LCK CORT PERILOC ST SS -,SUP-71827076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X80MM LCK CORT PERILOC ST SS -,SUP-71827080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X85MM LCK CORT PERILOC ST SS -,SUP-71827085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X90MM LCK CORT PERILOC ST SS -,SUP-71827090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1979.47,1385.629,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.7MMX20MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.7MMX25MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.7MMX35MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.7MMX40MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.7MMX45MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.7MMX50MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.7MMX55MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
RETRACTOR UTR DE LEE UNIV 2INX2.75IN 9.5IN HNDL SS V.MUELLER -,SUP-71828060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.7MMX65MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.7MMX70MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.7MMX80MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.7MMX85MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC CONTR + 57MM 3.5MM 4HL LCK COMPR SS 1/3 -,SUP-71829004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2601.59,1821.113,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC CONTR + 82MM 3.5MM 6HL LCK COMPR SS 1/3 -,SUP-71829006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2601.59,1821.113,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC CONTR + 107MM 3.5MM 8HL LCK COMPR SS 1/3 -,SUP-71829008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2533.04,1773.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC 93MM F/3.5MM 6HL NLCKG COMPR SS 1/3 TBLR SM -,SUP-71829406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2395.93,1677.151,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 106MM 3.5MM 7HL NLCKG COMPR 1/3 TBLR SM FRAG -,SUP-71829407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2514.19,1759.933,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 50MM 4.33HL TBLR NS -,SUP-71829434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.31,800.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 62MM 5.33HL TBLR NS -,SUP-71829435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.31,800.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 74MM 6.33HL TBLR NS -,SUP-71829436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1064.29,745.003,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 86MM 7.33HL TBLR NS -,SUP-71829437,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1064.29,745.003,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 98MM 8.33HL TBLR NS -,SUP-71829438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1095.14,766.598,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 122MM 10.33HL TBLR NS -,SUP-71829440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1095.14,766.598,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 70MM 3.5MM 6HL RECON SM FRAG -,SUP-71829516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4693.02,3285.114,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 94MM 3.5MM 8HL RECON -,SUP-71829518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5145.85,3602.095,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC 96MM F/3.5MM SM MUL FRAG SYS 6HL LCK COMPR -,SUP-71829706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4528.9,3170.23,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCR- SFTSLK-2.0 PKG.7X20 STER -,SUP-7207256,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SOFTSILK 2.0 7 X 25 -,SUP-7207257,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCR- SFTSLK-2.0 PKG.8X20 STER -,SUP-7207259,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SOFTSILK 2.0 8 X 25 -,SUP-7207260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DEVICE SUT ARSCP ENDBTTN CL 30MM STRL LF -,SUP-7210082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DEVICE SUT ARSCP ENDBTTN CL 35MM STRL LF -,SUP-7210083,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DEVICE SUT ARSCP ENDBTTN CL 40MM STRL LF -,SUP-7210084,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BUTTONENDO CL BTB STER 45MM -,SUP-7210085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BUTTON ENDO 15MM CL -,SUP-7220-0146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.98,1373.386,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ULTRA FAST FIX CURVED -,SUP-7220-1494,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2143.15,1500.205,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUT FTPRNT 5.5MM ARSCP NABSB OUTR SHL INR PLG -,SUP-7220-1697,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2143.95,1500.765,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW INTFR CANN BIOSURE 9X25MM ABSB TAPR PLLA HAP KN -,SUP-72201781,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1574.57,1102.199,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SUT ANCHOR OSTEORAPTOR  2.9 -,SUP-72201995,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2049.44,1434.608,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FAST-FIX 360 STRAIGHT -,SUP-72202467,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2543.73,1780.611,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FAST FIX 360 CVD NEEDLE -,SUP-72202468,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2543.73,1780.611,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FAST-FIX 360 REVERSE CURVED -,SUP-72202469,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2543.73,1780.611,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDE DRILL SZ1.2 ENDBTTN CL ULTRA PAC -,SUP-7220-2799,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2118.19,1482.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUTURE 4.5MM HEALICOIL -,SUP-7220-3378,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2261.88,1583.316,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR HEALICOIL 4.75MM REGENE -,SUP-72203697,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3911.82,2738.274,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR HEALICOIL 4.75MM -,SUP-72203704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2249.43,1574.601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW EVOS 2.7MM X 17MM CTX -,SUP-72402717,CDM,C1713,HCPCS,278,RC,,,outpatient,,,400.46,280.322,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW EVOS 2.7MM X 24MM CTX -,SUP-72402724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,188.59,132.013,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW EVOS 3.5MM X 14MM CTX -,SUP-72403514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.9,95.13,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW EVOS 3.5MM X 15MM CTX -,SUP-72403515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW EVOS 3.5MM X 16MM CTX -,SUP-72403516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW EVOS 3.5MM X 17MM CTX -,SUP-72403517,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW EVOS 3.5MM X 18MM CTX -,SUP-72403518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW EVOS 2.7MM X 18MM LCK -,SUP-72412718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,598.38,418.866,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW EVOS 2.7MM X 19MM LCK -,SUP-72412719,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.55,802.585,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW EVOS 2.7MM X 20MM LCK -,SUP-72412720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.55,802.585,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE EVOS VOLAR 10H R STD 138MM -,SUP-72468210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8021.16,5614.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC VLP 64MM 3.5MM 4HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10840.85,7588.595,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC VLP 72MM 3.5MM 5HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8521.53,5965.071,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC VLP 47MM 3.5MM 3HL VAR ANG CONTR LCK SS -,SUP-7282-0303,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7945.19,5561.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC VLP 89MM 3.5MM 3HL VAR ANG CONTR LCK SS -,SUP-7282-0603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10840.85,7588.595,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC VLP 89MM 3.5MM 3HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10840.85,7588.595,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC VLP 62MM 3.5MM 5HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6051.52,4236.064,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC VLP 86MM 3.5MM 7HL 1.5-MM VAR ANG CONTR LCK -,SUP-7282-0807,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7163.02,5014.114,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC VLP 74MM 3.5MM 6HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6607.27,4625.089,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC VLP 86MM 3.5MM 7HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7163.02,5014.114,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC VLP 59MM 3.5MM 3HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-1003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7060.11,4942.077,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC VLP 71MM 3.5MM 4HL VAR ANG CONTR LCK SS LT -,SUP-7282-1004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7492.36,5244.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC VLP 83MM 3.5MM 5HL VAR ANG CONTR LCK SS LT -,SUP-7282-1005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7924.61,5547.227,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC VLP 107MM 3.5MM 7HL 2MM VAR ANG CONTR LCK -,SUP-7282-1007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8336.28,5835.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC VLP 131MM 3.5MM 9HL VAR ANG CONTR LCK SS LT -,SUP-7282-1009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8830.28,6181.196,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC VLP 59MM 3.5MM 3HL VAR ANG CONTR LCK SS -,SUP-7282-2003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6977.77,4884.439,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC VLP 71MM 3.5MM 4HL VAR ANG CONTR LCK SS -,SUP-7282-2004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7451.19,5215.833,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC VLP 83MM 3.5MM 5HL VAR ANG CONTR LCK SS RT -,SUP-7282-2005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7862.86,5504.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC VLP 131MM 3.5MM 9HL VAR ANG CONTR LCK SS RT -,SUP-7282-2009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8768.53,6137.971,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC VLP 62MM 3.5MM 5HL VAR ANG CONTR LCK SS -,SUP-7282-3005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2852.56,1996.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC VLP 74MM 3.5MM 6HL VAR ANG CONTR LCK SS -,SUP-7282-3006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3223.02,2256.114,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERILOC VLP 86MM 3.5MM 7HL VAR ANG CONTR LCK SS -,SUP-7282-3007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3570.33,2499.231,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LCK ORLMXLFCL 2.4X14MM STERNALOCK SD TI GOLD -,SUP-73-2414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LCK ORLMXLFCL 2.4X16MM STERNALOCK SD TI GOLD -,SUP-73-2416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LCK ORLMXLFCL 2.4X18MM STERNALOCK SD TI GOLD -,SUP-73-2418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,460.97,322.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LCK ORLMXLFCL 2.4X20MM STERNALOCK SD TI GOLD -,SUP-73-2420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,460.97,322.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE ORLMXLFCL 8HL STERNALOCK 4HL BX TI BLU -,SUP-73-2622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2835.76,1985.032,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE ORLMXLFCL 12HL STERNALOCK LDDR TI BLU -,SUP-73-2632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4401.63,3081.141,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE ORLMXLFCL 12HL STERNALOCK W LDDR TI BLU -,SUP-73-2634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4401.63,3081.141,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE STRNM 8HL JL SHP STERNALOCK BLU TI -,SUP-73-2645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4124.74,2887.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COMP JRNY II CR FEM OX NP LT SZ 6 -,SUP-74021166,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BASEPLATE TIBIA JOURNEY NP LT SZ 5 -,SUP-74022225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
INSERT JOURNEY II CR XLPE RT SZ 5-6 9MM -,SUP-74025661,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
MESH CAGE 30MM H -,SUP-74-1030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE NGAGE 16MM X 12MM CORPECT -,SUP-74-1216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE N-GAGE TI 16 X 50MM -,SUP-74-1650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TONIER HUMERAL NAIL DISTAL SCREW 4.3MM X 20MM -,SUP-7424520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TONIER HUMERAL NAIL DISTAL SCREW 4.3MM X 22MM -,SUP-7424522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAP END N-GAGE ZERO DEGREE -,SUP-74-5016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ENDCAP 2.5 DEG 10MM -,SUP-74-6010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAP NPLATE 7.5 DEGREE -,SUP-74-6012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NUT LCK F/C IN ADVANCED IMPL SYS -,SUP-7642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.87,143.409,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SET SCREW SPIN 6.35MM CD HORIZN LEGC SS -,SUP-7660000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,869.18,608.426,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5X35MM FIREBIRD DBL LD THRD ST CANN TI GRN -,SUP-77-8535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5X40MM FIREBIRD DBL LD THRD ST CANN TI GRN -,SUP-77-8540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5X45MM FIREBIRD DBL LD THRD ST CANN GRN -,SUP-77-8545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X35MM FIREBIRD DBL LD THRD ST CANN TI GOLD -,SUP-77-8635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X40MM FIREBIRD DBL LD THRD ST CANN GOLD -,SUP-77-8640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X45MM FIREBIRD DBL LD THRD ST CANN TI GOLD -,SUP-77-8645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X50MM FIREBIRD DBL LD THRD ST CANN TI GOLD -,SUP-77-8650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
3.5MM COCR ROD- 240MM -,SUP-782.803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SET -,SUP-79-2003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CABLE SPIN 1.2MM TI DBL LOP INTGR CRIMPX2 STRL -,SUP-7925011S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1755.53,1228.871,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SUBSTITUTE CA PHOS HAP 5ML PTTY CMNT INJ HYDR ST SYNTH -,SUP-79-43905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6318.89,4423.223,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CEMENT BN CA PHOS HAP 10ML HYDR ST -,SUP-79-43910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10521.16,7364.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SUBSTITUTE CA PHOS HAP 15ML PTTY CMNT INJ HYDR ST SLF-SET -,SUP-79-43915,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15098.17,10568.719,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEPIN ORTHO 2.5MM HEMICAP -,SUP-8007-1200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
IMPLANT SHT CRANFC 50X76MM 0.85MM MEDPOR EMBD TI MSH F/RECON -,SUP-81020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5562.27,3893.589,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
MESH TITAN SHEET MTB 76 X 50 X 1MM -,SUP-81027,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6586.43,4610.501,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
IMPLANT PE SHT EMBD TI MSH CRANFC 50X76MM -,SUP-81029,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6345.33,4441.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
IMPLANT SHT 76X100MM 1.5MM MEDPOR TITAN MAX F/CRANFC -,SUP-81040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10857.55,7600.285,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X12MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X14MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X16MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X18MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN SPIDER 20MM TMX -,SUP-814100003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERI 70.1MM 5HL COMPR TMX TBLR BLLT -,SUP-814123005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,980.28,686.196,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PE.R.I. 83.1MM 6HL COMP TIMEX 1/3 TBLR -,SUP-814123006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 95.5MM 7HL COMPR COMP TBLR BLLT-SHP -,SUP-814123007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PERI 109.2MM 30MM COMPR TMX TBLR BLLT -,SUP-814123008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PE.R.I. 122.2MM 9HL NLCKG PERMTR RDC COMP TBLR -,SUP-814123009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 179.4MM 6HL LCK SHFT STRL -,SUP-814130106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN POLYAX 233.5MM 9HL LCK TMX STRL -,SUP-814131109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 287.6MM 12HL LCK SHFT -,SUP-814131112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN POLYAX 99.6MM 2HL PRCONT LCK TMX STRL -,SUP-814133002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 13MMSHRTX180MM AFFIXUS TROCH ANTGRD AN-ROT 125DG ANG -,SUP-814313180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7282.7,5097.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 10.5MM AFFIXUS CANN LAG THRD ST TMX 80MM -,SUP-814510080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3265.42,2285.794,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 10.5MM AFFIXUS CANN LAG THRD ST TMX 105MM -,SUP-814510105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3265.42,2285.794,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 13MMSHRTX180MM AFFIXUS TROCH ANTGRD AN-ROT 130DG ANG -,SUP-814513180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7282.7,5097.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X34MM CORT AFFIXUS VERSANAIL FT ST 3.5MM HX DRV SCKT -,SUP-814550034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X40MM CORT AFFIXUS VERSANAIL FT ST 3.5MM HX DRV SCKT -,SUP-814550040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X20MM CORT ALPS FT ST HX DRV TMX -,SUP-8150-36-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,134.21,93.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X10MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X12MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X14MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X20MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X22MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X24MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X26MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X28MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X30MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X34MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X38MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X42MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X44MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X46MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X48MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X50MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X55MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X60MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X65MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X26MM LCK SHFT CORT POLYAX FT POLYAX ST FA TMX NS -,SUP-815045526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X28MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X30MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X32MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X34MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X36MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X40MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X45MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X55MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X60MM LCK CANC POLYAX FT POLYAX ST FA BLLT SHP TIP TI -,SUP-815304060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X75MM LCK CANC POLYAX FT POLYAX ST FA BLLT SHP TIP TI -,SUP-815304075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 8X70MM LCK DUAL CORE POLYAX FT POLYAX ST FA BLLT SHP -,SUP-815308070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 8X75MM LCK DUAL CORE POLYAX FT POLYAX ST FA BLLT SHP -,SUP-815308075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X10MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X14MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X16MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X18MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X20MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X24MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X26MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X28MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X34MM CANC FT -,SUP-8153-41-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,278.62,195.034,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X44MM LAG CANC FT -,SUP-8153-41-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,198.39,138.873,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X50MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X55MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5X30MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5X45MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5X60MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5X65MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5X70MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5X75MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5X65MM NLCKG CANC POLYAX P/T POLYAX TI NS -,SUP-815455065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X20MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X24MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X28MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X30MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X32MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X36MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X42MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X46MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LAG SCREW D10.5X85MM -,SUP-8160-0085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4287.05,3000.935,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X10MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X12MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X14MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X16MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X18MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORT LOCK 3.5 X 20MM NS -,SUP-816135020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X20MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW  CORT LOCK 3.5 X 22MM NS -,SUP-816135022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X22MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X24MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-8161-35-024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
3.5MM CORT LOCK SCREW 26MM NS -,SUP-816135026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X28MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
3.5MM CORTLOCK SCREW 30MM NS -,SUP-816135030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X30MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X32MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X34MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X36MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X38MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X40MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X42MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
3.5MM CORT LOCK SCREW 50MM NS -,SUP-816135050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORT LOCK 3.5 X 52MM NS -,SUP-816135052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 3.5 X 54 CORT NS -,SUP-816135054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X56MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X60MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X65MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X10MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X12MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X14MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X16MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X18MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X26MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X28MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X46MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X60MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X65MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X70MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN ALPS 199MM 12HL PRCONT LCK COMPR TMX W ANTMC FST -,SUP-816200012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6798.89,4759.223,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN ALPS 77MM 6HL THRD LCK TMX ANTMC NS BLU -,SUP-816204006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN ALPS 92MM 7HL THRD LCK TMX ANTMC NS BLU -,SUP-816204007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN ALPS 103MM 8HL THRD LCK TMX ANTMC NS BLU -,SUP-816204008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1526.54,1068.578,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN ALPS 3.5MM 5HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1208.51,845.957,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN ALPS 3.5MM 6HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1208.51,845.957,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN ALPS HCP 3.5MM 7HL HYBRID LCK COMPR TMX THN ANTMC -,SUP-816235007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN ALPS 3.5MM 8HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1335.73,935.011,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN ALPS 3.5MM 9HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1335.73,935.011,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN ALPS 3.5MM 12HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN ALPS 3HL PRCONT LCK TMX STD CRV ANTMC LT TIB -,SUP-816235703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5627.54,3939.278,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN ALPS 5HL PRCONT LCK TMX STD CRV ANTMC -,SUP-816235705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5678.47,3974.929,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN ALPS 3HL PRCONT LCK TMX STD CRV ANTMC RT TIB -,SUP-816235803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5627.54,3939.278,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X22MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X26MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X32MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X50MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X55MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X56MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X65MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER SPNL ANT CERV 13X15X6MM ALTA 5DG PEEK. -,SUP-8401-0506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN FX 1.3MM ABSB -,SUP-84-1052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1153.11,807.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER SPNL ANT CERV 13X15X6MM ALTA 5DG PEEK.. -,SUP-8411-0506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER ANT CERV 13X15X7MM ALTA 5DG PEEK -,SUP-8411-0507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COVER LOCKING SHORELINE 8-12 MM STANDALONE GRAY -,SUP-85-2008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TEMP FIX PIN -,SUP-85-2100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LONG NAIL LEFT 13X340MM X 125 DEG -,SUP-8525-3340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13986.87,9790.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5 X 12MM SELF DRILLING -,SUP-85-3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5 X 14MM SELF DRILLING -,SUP-85-3014SD,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GRAVITY SYNCHFIX SYNDESMOSIS #5 SUTURE -,SUP-86SYN005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4349.11,3044.377,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER TRNSFRMNL POST LMBR 9X23X6MM FORZA 0DG STR BLLT NOSE -,SUP-89-1006SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER TRNSFRMNL POST LMBR 9X23X8MM FORZA 0DG STR BLLT NOSE -,SUP-89-1008SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER TRNSFRMNL POST LMBR 9X27X7MM FORZA 0DG CRV BLLT NOSE -,SUP-89-1707SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER TRNSFRMNL POST LMBR 9X27X8MM FORZA 0DG CRV BLLT NOSE -,SUP-89-1708SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER TRNSFRMNL POST LMBR 9X27X9MM FORZA 0DG CRV BLLT NOSE -,SUP-89-1709SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
IMPLANT HUM TIS 9X27X7MM SZ0 FORZA STR -,SUP-89-3007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPACER TRNSFRMNL POST LMBR 9X27X10MM FORZA 0DG STR BLLT NOSE -,SUP-89-3010SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BONE CEMENT HYDROSET XT INJECTABLE HA -,SUP-897003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5310.31,3717.217,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CEMENT BONE HYDROSET XT HA 5CC -,SUP-897005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8517.71,5962.397,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CEMENT BONE HYDROSET XT HA 10CC -,SUP-897010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14367.75,10057.425,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
HYDROSET XT -,SUP-897015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20614.72,14430.304,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GRAFT BONE BIO4 VIABLE BONE MATRIX 2.5CC -,SUP-90174424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEADLESS COMPRESSION 2.5MM X 28MM TI -,SUP-90176298,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN FIXATION IJS 2.5MM X 50MM AXIS -,SUP-90176511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1918.78,1343.146,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW FREEFIX COMPRESSION 4.5MM X 18MM TI -,SUP-90176560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1009.46,706.622,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW FREEFIX LOCKING 4.5MM X 14MM TI -,SUP-90176561,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW FREEFIX LOCKING 4.5MM X 16MM TI -,SUP-90176562,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW FREEFIX LOCKING 4.5MM X 18MM TI -,SUP-90176563,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW FREEFIX LOCKING 4.5MM X 20MM TI -,SUP-90176564,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE MIDSHAFT HUMERUS NARROW 172MM -,SUP-90176565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5334.71,3734.297,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE FREEFIX 173MM ULNA MIDSHAFT -,SUP-90176755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE FREEFIX DISTAL HUMERUS 85MM ASSEMBLED LAT HELICAL LEFT -,SUP-90176827,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW FREEFIX COMPRESSION 3.5MM X 12MM TI -,SUP-90176828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW FREEFIX LOCKING 3.5MM X 10MM TI -,SUP-90176829,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.51,808.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW POLYAXIAL LOCKING 3.0MM X 34MM CANNULATED COCR -,SUP-90176830,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW POLYAXIAL LOCKING 3.0MM X 50MM CANNULATED COCR -,SUP-90176831,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW POLYAXIAL LOCKING 3.0MM X 60MM CANNULATED COCR -,SUP-90176832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW POLYAXIAL LOCKING 3.0MM X 65MM CANNULATED COCR -,SUP-90176833,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEADLESS COMPRESSION 2.5MM X 20MM TI -,SUP-90176987,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ASSEMBLED FREE FIX DISTAL HUM PLATE LAT DIRECT 85MM RIGHT -,SUP-90178750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ASSEMBLED FREE FIX DISTAL HUM PLATE MED DIRECT 75MM RIGHT -,SUP-90178751,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8504.98,5953.486,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW FREEFIX COMPRESSION 3.5MM X 16MM TI -,SUP-90178752,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW FREEFIX COMPRESSION 3.5MM X 28MM TI -,SUP-90178753,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW FREEFIX LOCKING 3.5MM X 30MM TI -,SUP-90178754,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MULTI-THREAD LOCKING 2.7MM X 16MM TI -,SUP-90178756,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MULTI-THREAD LOCKING 2.7MM X 24MM TI -,SUP-90178757,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ASSEMBLED FREEFIX DIST HUM PLATE LAT DIRECT 85MM LEFT -,SUP-90178787,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DISTAL TROCHLEA COMPRESSION SCREW 3.5MM X 40MM TI -,SUP-90178788,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MULTI-THREAD LOCKING 2.7MM X 26MM TI -,SUP-90178789,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MULTI-THREAD LOCKING 2.7MM X 42MM TI -,SUP-90178790,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
HIGH COMPRESSION LOCKING PEG 2.7MM X 24MM TI -,SUP-90178898,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DRILL CANNULATED 3.7MM X 30MM -,SUP-90178926,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ASSEMBLY DOUBLE IJS -,SUP-90178927,CDM,C1713,HCPCS,278,RC,,,outpatient,,,27394.51,19176.157,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
IJS-E AXIS PIN FEMALE 30MM COCR -,SUP-90178928,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
THREADED HAND NAIL 4.5MM X 45MM TI -,SUP-90178982,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4258.41,2980.887,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
KT SPINAL 4.5MMX30-40MM PEDICAL COMPR TRANSFACET W/SCREWX2 -,SUP-9045-02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
IMPLANT ELB JNT TOGGLELOC -,SUP-909854,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4344.34,3041.038,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PK VALVE F/INFECT FLD WST MGMT ULTRA QUAD CART -,SUP-91530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CRNL 1.5X4MM STRDRV RCESS SD TI -,SUP-92-15904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,413.82,289.674,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CRNL 1.5X5MM STRDRV RCESS SD TI -,SUP-92-15905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,413.82,289.674,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CRNL 1.5X5MM STRDRV RCESS SD TI -,SUP-92-15905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,82.76,57.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE INSERT LOCKING 2.7MM -,SUP-940372,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN FX STNMN 2.8MMX9IN SMTH STRL F /THE VUEPASS PORTAL -,SUP-94152,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2711.63,1898.141,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PFC SIGMA DISTAL AUG COM CEMT SIZE 5 X 4MM RIGHT -,SUP-960901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PFC SIGMA DISTAL AUG COM CEMT SIZE 5 X 8MM RIGHT -,SUP-960903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TIBAL INSERT ROTATING PLATFORM (STAB) 5- 10MM -,SUP-962151,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
INSERT TIBIAL ROTATING PLATFORM SZ 2.5MM X 20MM TCS -,SUP-96-2335,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
5.0MM VARIABLE ANGLE EXTENSION ARM -,SUP-991088S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2160.48,1512.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAP TOT JNT SM PLST -,SUP-9911186002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1043.01,730.107,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
IMPLANT HUM TIS CHP ALLOGRAFT CANC 15ML -,SUP-A00035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.87,918.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TEMPORARY TENSION BOLT -,SUP-A-2791.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.07,775.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DRILL BIT AO FIXATION 1.2MM X 25MM X L81MM -,SUP-A-3230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1173.53,821.471,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COUNTERSINK M 1.2/1.5 -,SUP-A-3310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1607.11,1124.977,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
3.0 CCS COUNTERSINK- AO -,SUP-A-3938,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1978.15,1384.705,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
HOOK PLATE1.5 2 HOLE 2 HOOKS T0.6 -,SUP-A-4200.40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2365.61,1655.927,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
HOOK PLATE 4 HOLE 4 HOOKS T0.6 -,SUP-A-4200.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2632.76,1842.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
IMPLANT HUM TIS STRIP 1X20CMX8MM H GRFTN MATRIX -,SUP-A42280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8571.82,6000.274,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE M FIX 4 HOLE STRAIGHT -,SUP-A-4300.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2106.42,1474.494,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE M FIX 6 HOLE STRAIGHT -,SUP-A-4300.03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.98,1080.086,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE M FIX 16 H STRAIGHT -,SUP-A-4300.04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2571.75,1800.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE M FIX 16 H CURVED -,SUP-A-4300.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2092.11,1464.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE M FIX16 HOLE OFF SET -,SUP-A-4300.06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2700.17,1890.119,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN APTUS 10X27MM F/1.2MM/1.5MM FX SCR HLX3X5 TI T-SHP -,SUP-A-4300.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1852.52,1296.764,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE M FIX 2/3 H RIGHT L -,SUP-A-4300.21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1852.52,1296.764,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE M GD FIX 2X2 RECT LEA -,SUP-A-4300.51,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2632.23,1842.561,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE FIXATION GOLD GRID 2 X 2-HOLE TAPAZOID -,SUP-A-4300.54,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2632.23,1842.561,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN APTUS 15MM F/1.2MM/1.5MM SCR HLX3X2 0.6MM GRID FX -,SUP-A-4300.55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2074.62,1452.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN HLX4X2 FA MED L-SHP GRID -,SUP-A-4300.64,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2156.24,1509.368,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GRID 5 X 2 HOLE TRAPAZOID -,SUP-A-4300.66,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.52,1855.364,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE M CONDYLE 5 H PIN L -,SUP-A-4340.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2542.12,1779.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN APTUS F/1.2-1.5MM SCR 1HL HOOKX2 COMPR TI TRILOCK -,SUP-A-4340.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3184.74,2229.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE APTUS TRILOCK PI 4 HOLE STRAIGHT IO 8 -,SUP-A-4350.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3757.14,2629.998,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE M TRILOCK STR 4 HOLE -,SUP-A-4350.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2752.69,1926.883,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE TRILOCK PI 3/5 HOLE T -,SUP-A-4350.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4001.57,2801.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN APTUS 11X25MM 0.8MM 8HL HND TRILOCK TI T-SHP -,SUP-A-4350.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4001.57,2801.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE TRILOCK ROTATING 3 HOLE 1.2/1.5 -,SUP-A-4350.23,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4080.82,2856.574,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN APTUS 9X23MM F/1.2MM/1.5MM SCR FX/ROT 6HL 0.8MM VAR -,SUP-A-4350.23,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.67,2999.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE M TRILOCK T 5/4 HL -,SUP-A-4350.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4152.43,2906.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOCKING PLATE 1.5 BLUE -,SUP-A-4350.56,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3415.8,2391.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE M TRILOCK GRID HL 4 X 2 -,SUP-A-4350.62,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4381.08,3066.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 1.2/1.5 TRILOCK GRID 5X2H TRAPZ T 0.8 -,SUP-A-4350.66,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4471.05,3129.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE LOCKING TRILOCK BLUE 1.5 TRAPEZ 10.8 -,SUP-A-4350.80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3868.85,2708.195,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
IMPLANT HUM TIS GRFTN DBM OTHBLND -,SUP-A44135,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5713.91,3999.737,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN APTUS 55MM F/2MM/2.3MM SCR 8HL COMPR TI STR TRILOCK -,SUP-A-4645.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2466.32,1726.424,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN APTUS 35MM F/2MM/2.3MM SCR HLX2X4 COMPR TI T-SHP -,SUP-A-4645.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2428.06,1699.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE M COMP L 2/8 HOLE RIGHT -,SUP-A-4645.23,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2405.14,1683.598,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE LOCKING 1.0MM THCK 2./2.3 STRAIGHT BLUE -,SUP-A-4650.03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7191.46,5034.022,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOCKING PLATE 2.0/2.3 BLUE T-2/4 HOLE -,SUP-A-4650.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3100.24,2170.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE TRILOCK 3/4 HOLE -,SUP-A-4650.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3100.24,2170.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
"PLATE M LK ""Y"" 2/5 H -",SUP-A-4650.13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3199.53,2239.671,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE L 2/4 HOLE RIGHT -,SUP-A-4650.21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3601.51,2521.057,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN APTUS 45MM F/2MM/2.3MM SCR 8HL 1MM GRID TI -,SUP-A-4650.67,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3910.86,2737.602,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BLUE LOCKING 2.0 /2.3 4 HOLE STRAIGHT -,SUP-A-4655.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4610.73,3227.511,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE LOCKING T1.3MM 4 HOLE STRAIGHT 2.0/2.3 -,SUP-A-4655.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3973.88,2781.716,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BLUE 2.0 / 2.23 5 HOLE STRAIGHT -,SUP-A-4655.02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4308.93,3016.251,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN APTUS 32MM F/2MM/2.3MM SCR 5HL 1.3MM GRID TI STR -,SUP-A-4655.02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4294.08,3005.856,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE TRILOCK 8 HOLE STRAIGHT 2 X 3 -,SUP-A-4655.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4971,3479.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE TRILOCK STRAIGHT 8 HOLE 2.0/2.3 -,SUP-A-4655.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4969.72,3478.804,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE TRILOCK 2.0/2.3 T 2/4 HOLE T1.3 -,SUP-A-4655.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5024.05,3516.835,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE M TRILOCK T 2/4 HL -,SUP-A-4655.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5024.05,3516.835,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN APTUS 56MM 2.0/2.3MM 10HL 1.3MM GRID TI T-SHP -,SUP-A-4655.16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5311.37,3717.959,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.0/2.3 TRILOCK PLATE 2/4 HOLE LEFT -,SUP-A-4655.20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4600.23,3220.161,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE M TRILOCK L RT 2/4 HL -,SUP-A-4655.21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5024.05,3516.835,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE M TRILOCK L LT 2/8 HL -,SUP-A-4655.22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4539.38,3177.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE ROTATION 3/3 HOLE T 1.3 -,SUP-A-4655.24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4738.2,3316.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE TRILOCK GRIDPI 4 X2H TRAPEZ -,SUP-A-4655.62,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5438.26,3806.782,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE TRILOCK GRIDPI 5 X2 H TRAPEZ -,SUP-A-4655.66,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5679.32,3975.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 2.0 TRILOCK RADIAL HEAD RIM -,SUP-A-4656.68,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7432.09,5202.463,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.0 TRILOCK RADIAL HEAD BUTTRESS -,SUP-A-4656.69,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7017.88,4912.516,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE TRILOCK 4CF 2 X 2.3 -,SUP-A-4660.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7727.9,5409.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE M BABYFOOT LONG RT -,SUP-A-4750.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5479,3835.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 2.5 ADAPT II TRILOCK DISTRAD L 10 H NARROW -,SUP-A-4750.101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5810.88,4067.616,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE M ADAPTIVE II NARROW RT -,SUP-A-4750.102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7626.89,5338.823,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DISTAL RADIUS LOCKING PLATE RIGHT 12 NARROW-LONG -,SUP-A-4750.104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 2.5 ADAPTIVE II TRILOCK DISTRAD NARR LONG -,SUP-A-4750.104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8591.98,6014.386,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE ADAPTIVE 2.5 X 12HL NRW LNG -,SUP-A-4750.104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6904.56,4833.192,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE M ADAPTIVE II LT -,SUP-A-4750.105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5810.88,4067.616,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE M ADAPTIVE II LT -,SUP-A-4750.105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7626.89,5338.823,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE STD WATERSHED RIGHT ADAP -,SUP-A-4750.106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8008.43,5605.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ADAPTIVE II TRILOCK 2.5 DISTRAD. PLATE 13 HOLE -,SUP-A-4750.107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DISTAL RADIUS LOCKING PLATE RIGHT 13 LONG -,SUP-A-4750.108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8591.98,6014.386,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE M ADAPTIVE II LONG RIGHT -,SUP-A-4750.108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN APTUS 28X52MM 2.5MM 14HL TI TRILOCK TECH -,SUP-A-4750.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 2.5 ADAPTIVE II DISTAL RADIUS LEFT WIDE LONG -,SUP-A-4750.111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 2.5 ADAPTIVE II TRILOCK DIST RAD 15H WIDE LONG -,SUP-A-4750.112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6234.44,4364.108,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DISTAL RADIUS CORRECTION PLATE WIDE -,SUP-A-4750.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE M FPL LT -,SUP-A-4750.123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8106.46,5674.522,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE MEDARTIS 14HL -,SUP-A-4750.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6904.56,4833.192,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE ADAPTIVE 2.5 X 15 HOLE -,SUP-A-4750.15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7057.35,4940.145,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE ADAPTIVE 2.5 X 16 HOLE -,SUP-A-4750.16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7057.35,4940.145,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN APTUS 22X62MM 2.5MM 12HL 1.6MM TI LNG NRW TRILOCK -,SUP-A-4750.19,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 2.5TRILOCK WR SPANNINGPI DOR. STRAIGHT 11 HOLE TL6-3.4 -,SUP-A-4750.193S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13227.56,9259.292,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN APTUS 23X44MM 2.5MM 10HL 1.6MM TI NRW TRILOCK TECH -,SUP-A-4750.31,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN APTUS 23X44MM 2.5MM 10HL TI SHRT NRW TRILOCK TECH -,SUP-A-4750.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN APTUS 30X64MM F/2.5MM FX 1.6MM LCK TI FRM -,SUP-A-4750.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5815.98,4071.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN APTUS 30X64MM F/2.5 TRILOCK SYS 1.6MM LCK TI -,SUP-A-4750.42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5815.98,4071.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN APTUS 49MM 2.5MM 6HL TI STR TRILOCK TECH -,SUP-A-4750.54,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4373.94,3061.758,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN APTUS 23X54MM 2.5MM 13HL TI TRILOCK TECH RT WRST -,SUP-A-4750.62,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN APTUS 23X68MM 2.5MM 15HL TI LNG TRILOCK TECH LT -,SUP-A-4750.64,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6307.43,4415.201,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WASHER BICONCAVE 2.5/2.8 -,SUP-A-4750.70/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,340.18,238.126,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN APTUS 46MM 2.5MM 7HL VAR ANG CONTR TI Y -,SUP-A-4750.91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4323.36,3026.352,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN APTUS 67MM 2.5MM 10HL 1.6MM VAR ANG CONTR LCK TI Y -,SUP-A-4750.92,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4557.21,3190.047,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.5 TRILOCK ULNA SHORTENING PLATE -,SUP-A-4750.95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9650.43,6755.301,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.5 TRILOCK ULNA SHORTENING PLATE 10HL -,SUP-A-4750.95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9650.43,6755.301,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 2.5 TRILOCK WRIST FUSION PI SHORT BEND -,SUP-A-4760.02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11734.57,8214.199,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN APTUS 2.5MM 15HL LCK TI STR MULDIR TRILOCK -,SUP-A-4760.03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9292.66,6504.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE STRAIGHT 2.5 TRILOCK TOTAL WRIST FUS -,SUP-A-4760.04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11159.79,7811.853,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.5 TRILOCK TOTAL WRIST FUS PL LONG BEND 16HL T1.8-2.6 DRSL -,SUP-A-4760.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11734.57,8214.199,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.5 TRILOCK TOTAL WRIST FUS PI SHORT BEND 16 HOLE T1.8-2.6 D -,SUP-A-4760.06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11734.57,8214.199,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 2.5 TRILOCK WRIST FUSION SHORT BEND 12 HOLE -,SUP-A-4760.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11462.03,8023.421,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE TENSION 2.8 TRILOCK 6 HOLE OLECRANON -,SUP-A-4856.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5373.33,3761.331,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE TRILOCK T1-6 OLECRANON 7H RIGHT -,SUP-A-4856.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5556.24,3889.368,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 2.8 TRILOC OLECRANON 7H LEFT -,SUP-A-4856.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5557.94,3890.558,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE TRILOCK OLECRANON 2.8 7H STRAIGHT -,SUP-A-4856.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5306.27,3714.389,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TRILOCK PLATE 2.8 - 10H- RIGHT -,SUP-A-4856.13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5674.23,3971.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TRILOCK PLATE 10H STRAIGHT -,SUP-A-4856.15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5576.62,3903.634,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.8 TRILOCK DIST HUM PL MEDIAL 17H L -,SUP-A-4856.29,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10465.7,7325.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 2.8 TRILOCK DIST HUM MEDIAL 12H R -,SUP-A-4856.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9692.45,6784.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TriLock Dist. Hum Pl. Medial- 10h- l -,SUP-A-4856.33,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9291.81,6504.267,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.8 TRILOCK DIST HUM PL LATERAL 18H L -,SUP-A-4856.39,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9432.88,6603.016,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 2.8 TRILCK DIST HUM MEDIAL 10H LFT -,SUP-A-4856.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9692.45,6784.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE M TRILOCK GRID H 2X2 -,SUP-A-4856.44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9291.81,6504.267,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 10HL 2.8MM TRILOCK TECH RT OLCRN -,SUP-A-4856-13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4323.36,3026.352,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 10HL 2.8MM TRILOCK TECH LT OLCRN -,SUP-A-4856-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5674.23,3971.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
K-WIRES LNCET 150MM 1.8MM -,SUP-A-5042.51/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,247.99,173.593,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
1.1 K-WIRE- TROCAR- 2-END. 100MM -,SUP-A-5043.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,297.59,208.313,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.2X4MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.2X5MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.2X6MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.2X7MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.2X8MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.2X9MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.2X10MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.2X11MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.2X12MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.2X14MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW M CORTEX 1.2 X 16MM -,SUP-A-5100.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.5X4MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.5X5MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.5X6MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW M CORTEX 1.5 X 07 -,SUP-A-5200.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW M CORTEX 1.5 X 07 -,SUP-A-5200.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW M CORTEX 1.5 X 08 -,SUP-A-5200.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.5X9MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.5X10MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.5X11MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.5X12MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.5X13MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.5X14MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.5X15MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.5X15MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI. -,SUP-A-5200.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTEX 1.5 X 16 MEDARTIS -,SUP-A-5200.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTEX 1.5 X 17MM CORTICAL HD4 -,SUP-A-5200.17/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.5X18MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.5X19MM CORT APTUS DBL THRD ST/RET HEXDRV 4 TI GOLD -,SUP-A-5200.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW M CORTEX 1.5 X 21 -,SUP-A-5200.21/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL 1.5 22MM HD4 -,SUP-A-5200.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW M CORTEX 1.5 X 24 -,SUP-A-5200.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE APTUS 1.5 SPEEDTIP 10MM HD4 PK/1 -,SUP-A-5210.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1076.56,753.592,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE 1.5MM SPEEDTIP 14MM HD4 PK/1 -,SUP-A-5210.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1076.56,753.592,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.5X4MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.5X5MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.5X6MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.5X7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.5 X 7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.5X8MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.5X9MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.5X10MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.5X11MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.5X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.5X13MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 1.5 X 16 -,SUP-A-5250.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.8,742.56,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE CANNULATED COMPRESSION 10/4MM -,SUP-A-5281.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.7 CCS LONG THREAD 15/06MM 1/PKG -,SUP-A-5281.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.7 CCS LONG THREAD 16/07MM 1/PKG -,SUP-A-5281.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
1.7 CCS LONG THREAD 18/07MM -,SUP-A-5281.18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.7CCS LONG THREAD 20/08MM -,SUP-A-5281.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.7 CCS FULLY THREADED 10MM 1/PKG -,SUP-A-5282.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.7CCS FULLY THREADED 13MM -,SUP-A-5282.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.7CCS FULLY THREADED 14MM -,SUP-A-5282.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CORTEX BONE SCREWS 1.8MM 06MM LENGTH GOLD -,SUP-A-5300.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,884,618.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW M CORTEX 1.8 X 10 -,SUP-A-5300.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,654.69,458.283,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2X4MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2X5MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2X6MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2X7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5400.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2X8MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2X9MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5400.09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2X10MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2X11MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2X13MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2X14MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5400.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2X15MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.0 CORTICAL SCREW 16MM -,SUP-A-5400.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.0 X 17MM MEDARTIS -,SUP-A-5400.17/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL 2.0 X 18MM HD6 -,SUP-A-5400.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW APTUS TI CORTEX BONE GOLD 2.0 X 19MM -,SUP-A-5400.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2X20MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.0 CORTICAL SCREW 24MM -,SUP-A-5400.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2X6MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5450.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2X7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2X8MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5450.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2X9MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2X10MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2X11MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,295.02,206.514,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2X12MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2X13MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2X14MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW TRILOCK 2.0 X 14MM HD6 -,SUP-A-5450.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2X16MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.0 TRILOCK SCREW 18MM -,SUP-A-5450.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.0 TRILOCK SCREW 20MM -,SUP-A-5450.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.0 TRILOCK 20MM HD6 -,SUP-A-5450.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X5MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X6MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X7MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X8MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X9MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X10MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X11MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X12MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X13MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X14MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X18MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X19MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW M CORTEX 2.3 X 20 -,SUP-A-5500.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW M CORTEX 2.3 X 18 -,SUP-A-5500.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORT MEDARTIS 2.5 8MM -,SUP-A-5700.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5X10MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORT MEDARTIS 2.5 11MM -,SUP-A-5700.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5X12MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5X13MM NLCKG CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5700.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORT MEDARTIS 2.5 14MM -,SUP-A-5700.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW M CORT 2.5 X 15 -,SUP-A-5700.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NON LOCKING BONE SCREW 16MM -,SUP-A-5700.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOCKING SCREW 16 MM BLUE 2.5MM -,SUP-A-5700.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORT MEDARTIS 2.5 16MM -,SUP-A-5700.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5X18MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOCKING SCREW 18MM BLUE 2.5MM -,SUP-A-5700.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOCKING SCREW 20MM BLUE 2.5 -,SUP-A-5700.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5X20MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5X22MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.85,662.095,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5X24MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5X30MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,623.76,436.632,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CORTEX GOLD NON LCK 2.5 32MM  SCREW -,SUP-A-5700.32/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW M CORT 2.5 X 34MM -,SUP-A-5700.34/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5X20MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5720.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5X22MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5720.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5X10MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TRILOCK SCREW 2.5 12MM -,SUP-A-5750.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5X14MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5X16MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5X18MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCK MEDARTIS 2.5 18MM -,SUP-A-5750.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5X24MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5X26MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BLUE 2.5 X 28 LOCKING -,SUP-A-5750.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW M LOCKING 2.5 X 30MM -,SUP-A-5750.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5X32MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.8,742.56,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.5 TRILOCK SCREW 34MM -,SUP-A-5750.34/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5 TRILOCK EXPRESS 14MM HD7 PK/1 -,SUP-A-5755.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1158.25,810.775,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SILVER LOCKING SCREW 18MM -,SUP-A-5755.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1158.25,810.775,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SILVER LOCKING SCREW 20MM -,SUP-A-5755.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1158.25,810.775,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE APTUS 2.2 CANN COMP 10MM HD7 DISTAL THREAD 4MM -,SUP-A-5780.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE APTUS 2.2 CANN COMP 11MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE APTUS 2.2 CANN COMP 14MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE APTUS 2.2 CANN COMP 15MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE APTUS 2.2 CANN COMP 16MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANULATED COPR 17MM -,SUP-A-5780.17/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE APTUS 2.2 CANN COMP 19MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.2 CANNULATED SCREW COMPRESSION 20MM -,SUP-A-5780.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.2 CANNULATED COMPR 26MM DISTAL THREAD 6MM -,SUP-A-5780.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANULATED COPR 27MM -,SUP-A-5780.27/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.2 CANNULATED COMPR 30MM DISTAL THREAD 6MM -,SUP-A-5780.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MEDART CANN CMPR 2.2 X 22 -,SUP-A-5781.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MEDART CANN CMPR 2.2 X 24MM -,SUP-A-5781.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANNULATED 2.2 COMPRESSION LONG THREAD 26MM -,SUP-A-5781.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW COMPR CANNULATED 2.2 X 28MM -,SUP-A-5781.28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW COMPR CANNULATED 2.2 X 30MM -,SUP-A-5781.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MEDART CANN COMPR 2.2 X 32 -,SUP-A-5781.32/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW COMPR CANNULATED 2.2 X 36MM -,SUP-A-5781.36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW COMPR CANNULATED 2.2 X 38MM -,SUP-A-5781.38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.8 CORTICAL SCREW 10MM HD7 -,SUP-A-5800.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.8 CORTICAL SCREW 12MM HD7 -,SUP-A-5800.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.8X16MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.8X18MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.8X20MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.8X22MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.8X24MM CORT -,SUP-A-5800.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,654.69,458.283,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.8 CORTICAL SCREW 26MM HD7 -,SUP-A-5800.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.8 CORTICAL SCREW 28MM -,SUP-A-5800.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.8 CORTICAL SCREW 30MM HD7 -,SUP-A-5800.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.8 CORTICAL SCREW 32MM HD7 -,SUP-A-5800.32/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.8  CORTICAL SCREW 38MM- HD7 -,SUP-A-5800.38/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.8 GOLD CORTEX BONE 40MM HD7 -,SUP-A-5800.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.8X45MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.45/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORITCAL 50MM HD7 2.8 -,SUP-A-5800.50/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.8X55MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.55/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LAG 2.8 X 40 HD7 -,SUP-A-5830.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,654.69,458.283,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.8X14MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW TRILOCK BLUE 2.8 LOCKING16MM HD7 -,SUP-A-5850.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.8X18MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.8X20MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.8X22MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW TRILOCK 2.8 X 24MM HD7 -,SUP-A-5850.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW TRILOCK BLUE 2.8 LOCKING 26MM HD7 -,SUP-A-5850.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.8 TRILOCK  SCREW 28MM HD7 -,SUP-A-5850.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW TRILOCK BLUE 2.8 LOCKING 30MM HD7 -,SUP-A-5850.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.8 TRILOCK SCREW 32MM- HD7 -,SUP-A-5850.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.8 TRILOCK SCREW 36MM- HD7 -,SUP-A-5850.36/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.8 TRILOCK SCREW 38MM HD7 -,SUP-A-5850.38/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.8 TRILOCK SCREW 40MM HD7 -,SUP-A-5850.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.8 TRILOCK SCREW 50MM- HD7 -,SUP-A-5850.50/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.8 TRILOCK SCREW 55MM- HD7 -,SUP-A-5850.55/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.8 TRILCK 55MM -,SUP-A-5850.55/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.8,742.56,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.8 TRILOCK SCREW 70MM HD7 -,SUP-A-5850.70/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANNULATED SPEED TIP 3MM X 15MM -,SUP-A-5880.15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2326.39,1628.473,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANN SPEED TIP 3MM X 20MM -,SUP-A-5880.20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2326.87,1628.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3X24MM CANN SPEEDTIP CCS S/T SD HEXDRIVE 10 TI -,SUP-A-5880.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3X26MM CANN SPEEDTIP CCS S/T SD HEXDRIVE 10 TI -,SUP-A-5880.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.0 CANN COMPR 40 -,SUP-A-5880.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3X26MM CANN SPEEDTIP CCS LNG THRD SD HEXDRIVE 10 TI -,SUP-A-5881.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
3.0 CANNULATED COMPRSCREW28MM-HD10- DISTAL THREAD 9MM -,SUP-A-5881.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2326.39,1628.473,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3 X 30 CANN COMPR DISTAL THREAD -,SUP-A-5881.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3 X 36 CANN COMPR DISTAL THREAD -,SUP-A-5881.36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW EXTFIX 6/5MM DIA 100/ 40MM CORT TAPR DYNFX THRD -,SUP-A6010040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW EXTFIX 6MM/5X150MM CORT TAPR DYNFX VISION 50MM THRD -,SUP-A6015050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW EXTFIX 6MM/5X180MM CORT TAPR DYNFX VISION 50MM THRD -,SUP-A6018050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANULATED COMPR 44MM -,SUP-A-8112.44/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1707.29,1195.103,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
"PLATE M LK ""L"" 2/4 H LEFT -",SUP-AÂ€4650.20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3601.51,2521.057,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SYS BONE CMNT BIOCARTILAGE 3ML STRL -,SUP-ABS-1000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BIOCARTILAGE KIT SMALL JOINT -,SUP-ABS-1000-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FUNNEL BNCMNT BIOCARTILAGE -,SUP-ABS-1003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,163.38,114.366,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BIOCARTILAGE 1CC -,SUP-ABS-1010-BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4678.52,3274.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TACKER ABSORBATACK 5MM 30X -,SUP-ABSTACK30X,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2266.08,1586.256,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WAVEFORM C INTERBODY 16 X 14 X 7MM 7 DEG 3D -,SUP-AC4-264077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE WAVEFORM C INTERBODY 16 X 14X 8MM 7 DEGREE 3D -,SUP-AC4-264087,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 24MM COMPR HDLS ACUTRAK ACUTWIST FLLY W THRD PTCH -,SUP-AI-0024-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 26MM COMPR HDLS ACUTRAK ACUTWIST FLLY W THRD PTCH -,SUP-AI-0026-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 28MM COMPR HDLS ACUTRAK ACUTWIST FLLY W THRD PTCH -,SUP-AI-0028-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4-5X25MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0025-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4-5X30MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0030-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4-5X35MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0035-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4-5X40MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0040-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 45MM ACUTRAK 4/5 -,SUP-AM-0045-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5-6.5X50MM CANN HDLS ACUTRAK + 3MM HX DRV TI ALY STRL -,SUP-AP-0050-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2410.87,1687.609,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5-6.5X60MM CANN HDLS ACUTRAK + 3MM HX DRV TI ALY STRL -,SUP-AP-0060-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2410.87,1687.609,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE PLATE 10MM -,SUP-AP1-110010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 12MM -,SUP-AP1-110012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE 13MM PLATE -,SUP-AP1-110013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE ADMIRAL 14MM PLATE -,SUP-AP1-110014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE ANTERIOR CERVICAL PLATE 16MM -,SUP-AP1-110016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 30MM -,SUP-AP1-200030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ADMIRAL PLATE 36MM -,SUP-AP1-200036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE PLATE 28MM -,SUP-AP1-210028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE ADMIRAL 32MM SEASPINE -,SUP-AP1-210032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE ADMIRAL 36MM SPINE CERVICAL 2 LEVEL SEASPINE -,SUP-AP1-210036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE PLATE 54MM -,SUP-AP1-310054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ST 4 X 14 -,SUP-AP1-604014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ADMIRAL SCREW 4X14 -,SUP-AP1-614014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE SCREW 4 X 10 -,SUP-AP1-704010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 12MM -,SUP-AP1-704012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ADMIRA 4 X 14MM SPINE SELF TAP VARIABLE ANGLE SEASPINE -,SUP-AP1-704014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ADMIRAL 4.3 X 12MM SEASPINE -,SUP-AP1-704312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ADMIRAL 4.3 X 14MM SPINE SELF TAP VARIABLE ANGLE -,SUP-AP1-704314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ADMIRAL 4 X 12MM SEASPINE -,SUP-AP1-714012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE SCREW 4MM X 14MM SD -,SUP-AP1-714014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ADMIRAL 4 X 16MM SEASPINE -,SUP-AP1-714016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
4.0 X 14 FIX SCREW -,SUP-AP1-724014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6-7.5X70MM CANN HDLS ACUTRAK 6/7 4MM HX DRV TI ALY -,SUP-AP-6770-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6-7.5X75MM CANN HDLS ACUTRACK 6/7 4MM HX DRV TI ALY -,SUP-AP-6775-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE PROXIMAL ULNA 73MM LEFT -,SUP-APL-PUP-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5428.08,3799.656,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE PROXIMAL ULNA 108MM / LEFT -,SUP-APL-PUP-6HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6175.02,4322.514,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE PROXIMAL ULNA 108MM / RIGHT -,SUP-APL-PUP-6HR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6175.02,4322.514,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BONE 151MM ULNA LEFT PROXIMAL -,SUP-APL-PUP-9HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6531.52,4572.064,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEPIN ARSCP 1.1MM BLNT TIP F/BIOINTF SCR -,SUP-AR-1249,CDM,C1713,HCPCS,278,RC,,,outpatient,,,122.54,85.778,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEPIN ARSCP 2.4MM DRILL TIP F/BIOINTF SCR -,SUP-AR-1250L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DRILL SYSTEM FIXATION TIGHTROPE BTBT IB W/FLIPCUTTER III -,SUP-AR-1288BTBIB-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4816.94,3371.858,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DRILL TIGHTROPE RT IB W/FLIPCUTTER III -,SUP-AR-1288RTIB-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4477.42,3134.194,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FIBERTAG TIGHTROPE II IMPLANT W/ FLIPCUTTER III DRILL -,SUP-AR-1288RTT2-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FIBER TAG TIGHTROPE WITH FLIPCUTTER III -,SUP-AR-1288RTT-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEPIN ARSCP 2.4MM SUT EYE -,SUP-AR-1297L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X10MM CORT FT SLD TI STRL F/OSTMY SYS -,SUP-AR-13120T-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X10MM CANN LAG CORT P/T ST SLD TI F/OSTMY SYS -,SUP-AR-13120T-10C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X12MM CANN LAG CORT P/T ST SLD TI F/OSTMY SYS -,SUP-AR-13120T-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X14MM CANN LAG CORT P/T ST SLD TI F/OSTMY SYS -,SUP-AR-13120T-14C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X16MM CANN LAG CORT P/T ST SLD TI STRL F/OSTMY SYS -,SUP-AR-13120T-16C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NANO CORKSCREW FT TI W3-0 FW -,SUP-AR-1317FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUTURE MICRO CORKSCREW FT 2.2 X 4MM -,SUP-AR-1318FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 12.5MM OPN WDG SS -,SUP-AR-13200-12.5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 12.5MM TI SLP STRL -,SUP-AR-13200ST-12.5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUTURE TAK MICRO 2.4 X 6.5 BIOCOMPOSITE -,SUP-AR-1320BCNF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BB-TAK THREADED -,SUP-AR-13226T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SUTURETAPE S-TAK ASSY 3.0 SINGLE LOADED -,SUP-AR-1322BCST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SUTURETAPE S-TAK ASSY 3.0 SINGLE LOADED -,SUP-AR-1322BCST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X45MM CANC HTO PLATE TI F/OSTMY SYS -,SUP-AR-13280-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5X50MM CANC HTO PLATE TI F/OSTMY SYS -,SUP-AR-13280-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEPIN ARSCP 2.4MM F/OSTM -,SUP-AR-13303-2.4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,215.9,151.13,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEPIN SURG 3MM -,SUP-AR-13303-3.0,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SUBSTITUTE B TCP OPN WDG OSFERION 7MM 30MM -,SUP-AR-13370-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SUBSTITUTE B TCP WDG OSFERION 15X35MM -,SUP-AR-13370-4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X40MM CORT HTO PLATE TI F/OSTMY SYS -,SUP-AR-13380-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X46MM CORT HTO PLATE TI F/OSTMY SYS -,SUP-AR-13380-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUT IBALANCE 6.5X24MM HI TIB OPN PEEK -,SUP-AR-13401-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUT IBALANCE 6.5X28MM HI TIB OPN PEEK -,SUP-AR-13401-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SFT TIS CORT 4.5X38MM IBALANCE HTO -,SUP-AR-13402-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUT IBALANCE 4.5X40MM HI TIB OPN PEEK -,SUP-AR-13402-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUT IBALANCE HTO 4.5X48MM HI TIB OPN NABSB PEEK -,SUP-AR-13402-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN ARSCP FX 5X40MM PLLA FEM ABSB TRNSFX II F/ACL RECON -,SUP-AR-1351B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN ARSCP FX 5X50MM PLLA FEM ABSB TRNSFX II F/ACL RECON -,SUP-AR-1351LB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW INTFR CANN 6X23MM RND HEAD STP TAPR BIOCMPS FEM DBL -,SUP-AR-1360C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SILK 7 X 20 NON SHEATHED -,SUP-AR-1370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.64,822.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW INTFR CANN 7X23MM ABSB SHTH RND HEAD STP TAPR BIOCMPS -,SUP-AR-1370B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 7X23 BIOCOMPOSITE -,SUP-AR-1370C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW INTFR CANN TIGHTROPE RT 7X28MM FT ABSB RND HEAD STP -,SUP-AR-1370TC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN CONTR LOCK HTO 12.5MM A/P SLP WDG -,SUP-AR-13725-12.5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 8X23MM BIO -,SUP-AR-1380C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW INTFR CANN 8X28MM FT ABSB TAPR PLLA TIB KN STRL -,SUP-AR-1380TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 8 X 25 -,SUP-AR-1381,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SILK 9 X 2O NON SHEATHED -,SUP-AR-1390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.64,822.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW INTFR CANN TIGHTROPE RT 9X23MM SHTH ABSB HEX HEAD PLLA -,SUP-AR-1390B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 9 X 23 BIOCOMPOSITE -,SUP-AR-1390C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW INTFR CANN 9X28MM FT ABSB TAPR BIOCMPS PLLA TIB KN -,SUP-AR-1390TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SILK 9 X 25 NON SHEATHED -,SUP-AR-1391,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.64,822.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN SUTUREPLATE 90MM 3HL POLYAX TI STRL -,SUP-AR-14003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW INTFR CANN 10X23MM ABSB SHTH PLLA TIB KN GRD STRL -,SUP-AR-1400B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 10 X 23 BIOCOMPOSITE -,SUP-AR-1400C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW INTFR CANN 10X28MM ABSB FT TAPR PLLA TIB KN STRL -,SUP-AR-1400TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X18MM NLCKG CORT SUTUREPLATE TI STRL F/ARTHPL -,SUP-AR-14118NL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,262.58,183.806,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X20MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X22MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X26MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X26MM NLCKG CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14126NL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,262.58,183.806,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X28MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X32MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X34MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X36MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X38MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X40MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X50MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X28MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X32MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X38MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X48MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14248,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
KIT TENODESIS SCREW 3X8 DISPOSABLE -,SUP-AR-1530DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FOREFOOT IB IMPLANT SYS PEEK -,SUP-AR-1530P-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5920.38,4144.266,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW TENODESIS PEEK 3.5 X 8 -,SUP-AR-1530PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2146.7,1502.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4 X 10MM BIOTENODESIS -,SUP-AR-1540BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW TENODESIS PEEK 4X10 -,SUP-AR-1540PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW INTFR BIO-TENODESIS 4.75X15MM BABSRB BIOCMPS ANKL/FT -,SUP-AR-1547BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW TENODESIS PEEK 4.75X15MM INTERFERENCE -,SUP-AR-1547PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW TENODESIS PEEK  5.5 X 15 -,SUP-AR-1555PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW INTFR CANN BIO-TENODESIS 6.25X15MM BABSRB PEEK HND -,SUP-AR-1562BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW TENODESIS PEEK 6.25X15 -,SUP-AR-1562PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW INTFR CANN BIO-TENODESIS 7X23MM BABSRB PLLA HND WRST -,SUP-AR-1570BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW INTFR CANN BIO-TENODESIS 8X23MM BABSRB PLLA HND WRST -,SUP-AR-1580BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 9X20MM CORT RETROSCREW FT RTRGD RND HEAD PLLA STRL -,SUP-AR-1586RB-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1131.99,792.393,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
RETRO BUTTON 15MM -,SUP-AR-1588-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
RETRO BUTTON 20mm -,SUP-AR-1588-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
RETRO BUTTON 12mm/25 -,SUP-AR-1588-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
RETRO BUTTON 12MM/30MM -,SUP-AR-1588-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SYS ARTHROSCOPIC FX BTB TIGHTROPE RT F/ACL RECON -,SUP-AR-1588BTB-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2358.72,1651.104,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TIGHTROPE II RT WITH DEPLOYING SUTURE -,SUP-AR-1588RT-2J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2464.73,1725.311,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FIXATION TIGHTROPE RT DBL -,SUP-AR-1588RT-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FIXATION ACL TIGHTROPE RT -,SUP-AR-1588RT-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ACL TIGHTROPE WITH FIBER TAG -,SUP-AR-1588RTT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FIXATION ACL FEM TIGHTROPE -,SUP-AR-1588T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TIGHTROPE ABS BUTTON 11MM -,SUP-AR-1588TB-3IB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TIGHTROPE ABS BUTTON 14MM -,SUP-AR-1588TB-4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TIGHTROPE ABS BUTTON 20MM -,SUP-AR-1588TB-5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TIGHTROPE ABS BUTTON ROUND CONCAVE 20MM -,SUP-AR-1588TB-5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
IMPLANT TIGHTROPE ABS -,SUP-AR-1588TN,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
OPEN TIGHTROPE ABS -,SUP-AR-1588TN-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1131.99,792.393,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
IMPLANT FIXATION TIGHTROPE II ABS -,SUP-AR-1588TN-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TIGHTROPE II ABS- IMPLANT OPEN -,SUP-AR-1588TN-21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ACL TIGHTROPE WITH FIBER TAG ABS -,SUP-AR-1588TNT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1775.67,1242.969,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TIGHTROPE BUTTON EXTENDER -,SUP-AR-1589RT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW INTFR CANN BIO-TENODESIS 9X23MM BABSRB PLLA HND WRST -,SUP-AR-1590BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW INTFR BIO-TENODESIS 5.5X10MM BABSRB PEEK ANKL/FT HND -,SUP-AR-1655PS-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW INTFR BIO-TENODESIS 5.5X12MM PEEK SHOLUDER ELB -,SUP-AR-1655PS-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SWIVELOCK  BIOCOMPOSITE 8MM X 19.5MM -,SUP-AR-1662BC-8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2305.72,1614.004,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SYSTEM LATERAL ANKLE RECON -,SUP-AR-1675BC-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW INTFR CANN BIO-TENODESIS 8X12MM BABSRB PLLA SFT TIS -,SUP-AR-1680BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
KIT IB BC W/CC FT AND JUMPSTART -,SUP-AR-1788J-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
KIT IB BC W/CC FT AND JUMPSTART IMPLANT SYSTEM -,SUP-AR-1788J-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SWIVEL LOCK INTERNAL BRACE -,SUP-AR-1788J-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOW PROFILE SCREW 1.0 X 6MM CORTICAL TI -,SUP-AR-18710-06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOW PROFILE SCREW 1.0 X 7MM CORTICAL TI -,SUP-AR-18710-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOW PROFILE 2.4 X 10 CORTICAL -,SUP-AR-18724-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOW PROFILE 2.4 X 26 CORTICAL -,SUP-AR-18724-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
T-PLATE 2.4MM 6 HOLE -,SUP-AR-18724P-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TISSUE TAK TENDON ANCHOR -,SUP-AR-19021TT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUTURE CORKSCREW FT 3.5X10MM -,SUP-AR-1915FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ARTHREX SUTURE ANCHCRKSCRW FT3.5X10MM -,SUP-AR-1915FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUT CRKSCR 3.5X12MM THRD TI #2 SUT -,SUP-AR-1915S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUT CRKSCR 5X15MM ABSB -,SUP-AR-1920BF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1378.13,964.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUTURE CORKSCREW 5.0 -,SUP-AR-1920S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUT PSHLK 4.5X24MM BIOCMPS -,SUP-AR-1922BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUT BIO-PSHLK 4.5MMX18.5MM ABSB SLF-PNCH PLLA TI TIP -,SUP-AR-1922BM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2067.2,1447.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR PUSHLOCK 2.9 X 15.5 BIO -,SUP-AR-1923BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR PUSHLOK PEEK 2.9X15.5 -,SUP-AR-1923PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUT CRKSCR 6.5MMX15.5MM THRD ST TI SZ2 GRN WHT SUT -,SUP-AR-1925S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR CORKSCREW 6.5 FIBER 2 2 -,SUP-AR-1925SF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BIO-PUSHLOCK COMPOSITE 3.5MM -,SUP-AR-1926BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUT PSHLK 3.5MMX19.5MM PEEK HNDL INSRTR DRIVER -,SUP-AR-1926PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUT CRKSCR FT 5.5MMX14.7MM ARSCP FT BABSRB BIOCMPS -,SUP-AR-1927BCF-3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1802.17,1261.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR 4.5 BIO-COMPOSITE -,SUP-AR-1927BCF-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
6.5 BIOCOMPOSITE ANCHORS -,SUP-AR-1927BCF-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1775.67,1242.969,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR BIO CORKSCREW 5.5 -,SUP-AR-1927BCT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1881.68,1317.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR CORKSCREW 5.5 PEEK (BOX OF 5) -,SUP-AR-1927PSF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUT SUTAK 3MMX14.5MM ARSCP BIOCMPS ABSB #2 -,SUP-AR-1934BCF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1616.65,1131.655,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR BIOCOMPOSITE 3MM DBL -,SUP-AR-1934BCF-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUT SUTAK 2.4X12MM ARSCP BIOCMPS FIBERWIREX2 -,SUP-AR-1934BCF-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1616.65,1131.655,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUT SUTAK 2.4X12MM ARSCP BIOCMPS FIBERWIRE -,SUP-AR-1934BCF-24-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR BIOCOMPOSITE 3MM SING -,SUP-AR-1934BCT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1802.17,1261.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BIO SUTURE TAK DISPOSABLE -,SUP-AR-1934DS-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
KIT SUTURE TAK 3MM PERCUTANEOUS INSERTION -,SUP-AR-1934PI-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR KNOTLESS SUT TAK 3MM BI -,SUP-AR-1938BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR PEEK SUT TAK 3MM KNOTLESS -,SUP-AR-1938PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
IMPLANT DISTAL BICEP REPAIR 7 X 10MM -,SUP-AR-2260BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BUTTON SUT 2.6MM TI 12MM LF -,SUP-AR-2261,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BUTTON SUT DOG BN LF -,SUP-AR-2270,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SWIVEL LOCK 5.5 -,SUP-AR-2323BCC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUT SWIVLK C 5.5MMX19.1MM ABSB CLSD EYLT PLLA -,SUP-AR-2323BSLC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1987.69,1391.383,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SWIVELOCK- SP BC KL 5.5MM -,SUP-AR-2323KBCSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUT SWIVLK 5.5MMX24.5MM SLF-PNCH PEEK -,SUP-AR2323PSLM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUT SWIVLK C 4.7MMX19.1MM CLSD EYLT BIOCMPS WHT/BLK -,SUP-AR-2324BCCTT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR BIO COMP SWIVELOCK SP 4 (MIN 5 EACH) -,SUP-AR-2324BCM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SWIVELOCK  BIOCOMPOSITE 4.75MM X  22MM DOUBLE LOADED -,SUP-AR-2324BCT-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR BIO-SWIVELLOCK 4.75 -,SUP-AR-2324BCT-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR BIOCOMPOSITE SWIVEL W\FIBERTAPE -,SUP-AR-2324BCT-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SWIVELOCK KNOTLESS 4.75MM BC -,SUP-AR-2324KBCC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
KNOTLESS SWIVELOK 4.75MM BC W/TAPE -,SUP-AR-2324KBCCTT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2530.22,1771.154,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SWIVELOCK- SP BC KL 4.75MM -,SUP-AR-2324KBCSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUT BIO- SWIVLK SP 4.75MMX24.5MM SLF-PNCH PEEK TI -,SUP-AR-2324PSLM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BC SWIVELOCK 3.9 X 17.9 MM -,SUP-AR-2326BCC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
KIT SPEEDBRIDGE SHOULDER -,SUP-AR-2600SBS-8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8106.04,5674.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE DISTAL CLAVICLE 22 DEG RIGHT -,SUP-AR-2622DR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 8HL PRCONT SS LT CLVCL -,SUP-AR-2651CL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PRCONT SS RT CNTRL CLVCL -,SUP-AR-2653CR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN PRCONT SS LT CNTRL CLVCL -,SUP-AR-2654CL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE CLAVICLE DISTAL SHOR LEFT SS -,SUP-AR-2656DL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE CLAVICLE DISTAL SHORT RIGHT SS -,SUP-AR-2656DR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 8HL PRCONT SS RT CLVCL -,SUP-AR-2657DR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE DISTAL CLAVICLE BUTTON -,SUP-AR-2658,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DISTAL CLAVICLE REPAIR ASSEMBLY -,SUP-AR-2658T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SUTURE ANCHOR- BIOCOMPOSITE- HIP PUSHLOCK- SHORT 2.9 x 12.5 -,SUP-AR-2923BCH,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
KIT DISPOSABLES FOR FIBERTAK SUTR ANCH -,SUP-AR-3600DC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FIBERTAK WITH SUTURETAPE -,SUP-AR-3602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1881.68,1317.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.6 FIBERTAK ANCHOR DOUBLE  LOADED -,SUP-AR-3632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FIBERTAK ANCHOR TRIPLE LOADED -,SUP-AR-3633,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SELF-PUNCHING TRIPLE LOADED FIBERTAK -,SUP-AR-3633SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR FIBERTAK KNOTLESS -,SUP-AR-3636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FIBERTAK SHOULDER 1.8 SELF BUNCHING -,SUP-AR-3636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FIBERTAK HIP 1.8 SELF BUNCHING -,SUP-AR-3636H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
KNOTLESS 1.8 FIBERTAK W/ #2 SUTURE -,SUP-AR-3638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
KNOTLESS HIP FIBERTAK SUTURE ANCHOR- CURVED -,SUP-AR-3638DHC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
KIT FIBERTAK KNOTLESS STRAIGHT DISPOSABLE -,SUP-AR-3638DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SP FBTAK RC TGRTPE WH/BLK & STTPE WH/BL -,SUP-AR-3652SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SP FBTAC RC RBRTPE BLU & STTPE WH/BLK -,SUP-AR-3652TSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SP FBTAC RC RBRTPE BLK/BLU & STTPE BLU -,SUP-AR-3652TTSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
KL FBTK RC (WH/BLK)TT & (BLU)#2 MTS -,SUP-AR-3653SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2530.22,1771.154,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
KL FBTK RC W/(BLU)FT & (W/BLK) #2 MTS -,SUP-AR-3653TSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2530.22,1771.154,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
KNOTLESS TENSIONABLE FIBERTAK BICEP -,SUP-AR-3687,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ARTHROSCOPIC FX CHNDR -,SUP-AR-4005B-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW VENTED BC IF 7 X 20MM -,SUP-AR-4020C-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW VENTED BC IF 8 X 20MM -,SUP-AR-4020C-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW VENTED BC IF 9 X 20MM -,SUP-AR-4020C-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW VENTED BC IF 10 X 20MM -,SUP-AR-4020C-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ARTHREX PEEK SCREW 7 X 20MM FAST THREAD -,SUP-AR-4020P-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ARTHREX PEEK 8 X 20MM FAST THREAD -,SUP-AR-4020P-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ARTHREX PEEK 9 X 20MM FAST THREAD -,SUP-AR-4020P-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ARTHREX PEEK 10 X 20MM FAST THREAD -,SUP-AR-4020P-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW VENTED BC IF 7 X 30MM -,SUP-AR-4030C-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW VENTED BC IF 8 X 30MM -,SUP-AR-4030C-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW VENTED BC IF 9 X 30MM -,SUP-AR-4030C-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW VENTED BC IF 10 X 30MM -,SUP-AR-4030C-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW VENTED BC IF 11 X 30MM -,SUP-AR-4030C-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ARTHREX PEEK SCREW 7 X 30MM FAST THREAD -,SUP-AR-4030P-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ARTHREX PEEK 8 X 20MM FAST THREAD -,SUP-AR-4030P-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ARTHREX PEEK 9 X 30MM FAST THREAD -,SUP-AR-4030P-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ARTHREX PEEK 10 X 30MM FAST THREAD -,SUP-AR-4030P-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DEVICE SUT 1.5X5MM CRV C IN MNSCL 2-0 FIBERWIRE NDLX2 MINI -,SUP-AR-4500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
KIT BIOCOMPOSITE MENISCAL ROOT REPAIR -,SUP-AR-4550BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FIBER STITCH CURVED -,SUP-AR-4570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUTURE FIBERSTITCH FIBERWIRE POLYESTER 24 D 2-0 CURVE -,SUP-AR-4570-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
KIT ARTHROSCOPIC FIXATION FIBERSTITCH REVERSE CURVE -,SUP-AR-4570R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUTURE FIBERSTITCH STRAIGHT -,SUP-AR-4570S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW INTFR BIOCMPRSN 3X18MM BABSRB HDLS PLLA KN TAPR STP -,SUP-AR-5025B-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW INTFR BIOCMPRSN 2.7X20MM BABSRB HDLS PLLA KN TAPR STP -,SUP-AR-5025B-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 8 X 28 BIOCOMPOSITE -,SUP-AR-5028C-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 9X28 DELTA -,SUP-AR-5028C-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 10 X 28 BIOCOMPOSITE -,SUP-AR-5028C-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 11 X 28 DELTA -,SUP-AR-5028C-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 9 X 35 DELTA -,SUP-AR-5035TC-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 10 X 35 BIOCOMPOSITE -,SUP-AR-5035TC-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 11 X 35 DELTA -,SUP-AR-5035TC-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 12 X 35 BIOCOMPOSITE -,SUP-AR-5035TC-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WIRE GUIDE 1.35MM DUAL TROCAR -,SUP-AR-5050-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,239.24,167.468,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GRAFTBOLT TIBIAL 7MM -,SUP-AR-5100-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GRAFTBOLT TIBIAL 8MM -,SUP-AR-5100-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GRAFTBOLT TIBIAL 9MM -,SUP-AR-5100-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GRAFTBOLT TIBIAL 10MM -,SUP-AR-5100-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SUTURE ANCHOR- SWIVELOCK TENODESIS- PEEK -,SUP-AR-7324PSL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2969.43,2078.601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOW PROFILE SCREW TI 4.5 X 26MM -,SUP-AR-8545-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOW PROFILE SCREW TI 4.5 X 34MM -,SUP-AR-8545-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOW PROFILE SCREW TI 4.5 X 36MM -,SUP-AR-8545-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LO-PRO LOCK SCREW TI 4.5 X 28MM -,SUP-AR-8545L-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X55MM LCK -,SUP-AR-8545L-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X60MM LCK -,SUP-AR-8545L-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
IMPLANT SYSTEM CPR MINI SCORPION DX -,SUP-AR-8690DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
STAPLE BN FX QUICKFIX SM SS -,SUP-AR-8710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NITINOL COMPRESSION STAPLE- 9WX7L -,SUP-AR-8717-0907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NITINOL COMPRESSION STAPLE- 9WX10L -,SUP-AR-8717-0910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DYNANITE NITI STAPLE W/INSTRS 9WX10L -,SUP-AR-8717DS-0910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DYNANITE NITI STAPLE W/INSTRS 10W X 11L -,SUP-AR-8717DS-1110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DYNANITE NITI STAPLE W/INSTRS 11W X 15\12L -,SUP-AR-8717DS-111512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NITINOL COMP STAPLE 15W X 12L -,SUP-AR-8718-1512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
STAPLER DYNAMITE NITI  W/INSTRS 13W X 10L -,SUP-AR-8718DS-1310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8042.38,5629.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DYN NITI STAPLE W/INSTRS 15W X 12L -,SUP-AR-8718DS-1512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8042.38,5629.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
STAPLE 15W X 15L DYNANITE NITI W/INSTRS -,SUP-AR-8719DS-1515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DYN NITI STAPLE W/INSTRS 18W X 15L -,SUP-AR-8719DS-1815,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
STAPLE DYNANITE NITI W/INSTRS 18W X 18L -,SUP-AR-8719DS-1818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DYNANITE NITI STAPLE WINSTRS 20W X 20L -,SUP-AR-8719DS-2020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
QCKFIX SCRW TI CANN PT 2.0 X 10MM -,SUP-AR-8720-10PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.4X12MM HD CORT QUICKFIX ST SLD STND ALONE TI STRL -,SUP-AR-8724-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOW PROFILE 2.4 X 14 CORTEX -,SUP-AR-8724-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOW PROFILE SCREW 2.4 X 18MM CORTEX -,SUP-AR-8724-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW QUICKFIX 2.4 X 18MM TI CANNULATED -,SUP-AR-8724-18PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,846.08,592.256,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW QUICKFIX 2.4 X 22MM TI CANNULATED -,SUP-AR-8724-22PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,846.08,592.256,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.4X24MM CANN QUICKFIX P/T T8 HXLB DRV TI F/CMPRHNSV -,SUP-AR-8724-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOW PROFILE SCREW 2.4 X 32MM CORTEX -,SUP-AR-8724-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOW PROFILE SCREW 2.4 X 36MM CORTEX -,SUP-AR-8724-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.4 X 8 VAL TI -,SUP-AR-8724V-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.4 X 12 VAL TI -,SUP-AR-8724V-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.4 X 16 VAL TI -,SUP-AR-8724V-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.4MM X 18MM V AL SCREW TI -,SUP-AR-8724V-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW VAL TI 2.4MM X 18MM -,SUP-AR-8724V-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.4MM X 22MMV AL SCREW TI -,SUP-AR-8724V-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW VAL KREULOCK TI 2.4X12 -,SUP-AR-8724VCL-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW VAL KREULOCK TI 2.4X16 -,SUP-AR-8724VCL-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW COMPRESSION FT 2.5MM MICRO X 8MM LGTH -,SUP-AR-8725-08H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5MMX14MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-14H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5MMX16MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-16H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5MMX18MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-18H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5MMX20MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-20H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW COMPR FT 2.5 MICRO 22MM -,SUP-AR-8725-22H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5MMX24MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-24H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5MMX26MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-26H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COMPR FT SCREW 2.5 MICRO 28MM LGTH -,SUP-AR-8725-28H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEADLESS MICRO 2.5X 30MM -,SUP-AR-8725-30H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COMPR FT SCREW 2.5 MICRO 32MM LGTH -,SUP-AR-8725-32H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW QUICKFIX TI CANC PT 3.0 X 12MM -,SUP-AR-8730-12PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX14MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8730-14H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3MMX14MM DUAL CORE QUICKFIX -,SUP-AR-8730-14PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COMPR FT SCREW 3.5 MINI 16MM -,SUP-AR-8730-16H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3MMX16MM DUAL CORE QUICKFIX -,SUP-AR-8730-16PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COMPR FT SCRW 3.5 MINI 18MM LGTH -,SUP-AR-8730-18H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3MMX18MM DUAL CORE QUICKFIX -,SUP-AR-8730-18PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COMP SCREW 3.5 MINI 20MM -,SUP-AR-8730-20H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3MM X 20MM DUAL CORE QUICKFIX -,SUP-AR-8730-20PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COMPR FT SCREW 3.5 MINI 22MM -,SUP-AR-8730-22H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3MMX22MM DUAL CORE QUICKFIX -,SUP-AR-8730-22PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW FT COMPR 3.5 X 24MM -,SUP-AR-8730-24H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3MMX24MM DUAL CORE QUICKFIX -,SUP-AR-8730-24PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW COMPR FT 3.5 X 26 MINI -,SUP-AR-8730-26H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3MMX26MM DUAL CORE QUICKFIX P/T SD/ST T10 HXLB DRV TI -,SUP-AR-8730-26PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW COMPR FT 3.5 MINI 28MM -,SUP-AR-8730-28H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW FT COMPR 3.5 X 30MM -,SUP-AR-8730-30H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.6MMX32MM COMPR HDLS QUICKFIX P/T SD/ST T10 HXLB DRV -,SUP-AR-8730-32H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COMPR FT SCREW 3.5 MINI 34MM LGTH -,SUP-AR-8730-34H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
QCKFIX SCREW TI CANC PT 3.0 X 38MM -,SUP-AR-8730-38PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOW PROFILE SCREW CORTICAL 3.5MM X 14MM DRP -,SUP-AR-8735-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOW PROFILE SCREW CORTICAL 3.5MM X 16MM DRP -,SUP-AR-8735-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOW PROFILE SCREW CORTICAL 3.5MM X 18MM DRP -,SUP-AR-8735-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
3.5X32MM BEVELED FT SCREW -,SUP-AR-8735BV-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BEVELED FT 3.5MM X40MM -,SUP-AR-8735BV-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5 X 44MM BEVELED FT -,SUP-AR-8735BV-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOW PROFILE SCREW LOCKING 3.5MM X 16MM DRP -,SUP-AR-8735L-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEWIRE 0.86MM W/ LASER LINE SS -,SUP-AR-8737-21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,87.53,61.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW COMPR FT 4.0 STD 20MM LGTH -,SUP-AR-8740-20H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW COMPR FT 4.0 STD 22MM LGTH -,SUP-AR-8740-22H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COMPRESSION SCREW 4.0 24MM LENGTH -,SUP-AR-8740-24H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COMPRESSION SCREW 4.0 26MM LENGTH -,SUP-AR-8740-26H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COMPRESSION SCREW 4.0 28MM LENGTH -,SUP-AR-8740-28H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW COMPR FT 4.0 STD 30MM LGTH -,SUP-AR-8740-30H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW QUICKFIX TI CANN ST 4.0 X 38MM CANC -,SUP-AR-8740-38PTS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW QUICKFIX TI CANN 4.0 X 40MM ST CANC -,SUP-AR-8740-40PTS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
4X46MM BEVELED FT SCREW -,SUP-AR-8740BV-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4 X 50MM BEVELED FT -,SUP-AR-8740BV-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4 X 52MM BEVELED FT -,SUP-AR-8740BV-52,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WASHER 7.0MM TI -,SUP-AR-8740W,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEWIRE 1.6MM- 4MM BEVELED FT -,SUP-AR-8741-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEWIRE 1.6X150MM CAPITAL FRAG -,SUP-AR-8741-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW COMPR FT 5.0 X 42MM -,SUP-AR-8750-42H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW COMPR FT 5.0 X 55MM -,SUP-AR-8750-55H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COMPR FT SCREW 7.0 XL 65MM LGTH -,SUP-AR-8770-65H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COMPR FT SCREW 7.0 XL 70MM LGTH -,SUP-AR-8770-70H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COMPR FT SCREW 7.0 XL 75MM LGTH -,SUP-AR-8770-75H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUT BIO-PSHLK 2.5X8MM KNTLS PLLA ABSB #2 FIBERWIRE -,SUP-AR-8825B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUTURE PEEK MINI PUSHLOCK -,SUP-AR-8825P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
KREULOCK COMPRESSION SCREW SS 2.7 X 12MM -,SUP-AR-8827CL-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
KREULOCK COMPRESSION SCREW SS 2.7 X 14MM -,SUP-AR-8827CL-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
KREULOCK COMPRESSION SCREW SS 2.7 X 16MM -,SUP-AR-8827CL-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
KREULOCK COMPRESSION SCREW SS 2.7 X 18MM -,SUP-AR-8827CL-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
KREULOCK COMPRESSION SCREW SS 2.7 X 20MM -,SUP-AR-8827CL-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X10MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X12MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X18MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X20MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LO-PRO LOCK SS 2.7 X 22 -,SUP-AR-8827L-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LO-PRO LOCK 2.7 X 24 -,SUP-AR-8827L-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CANCLUS SCREW FULLY THREADED SS 3 X 24MM -,SUP-AR-8830-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LO-PRO SCREW TM SS 3.5 X 12MM CORT -,SUP-AR-8835-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X14MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X16MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X18MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X22MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X26MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X28MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X30MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X35MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X45MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X10MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X14MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X16MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X18MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X20MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X14MM NLCKG CANC TIGHTROPE FT SD T15 HXLB DRV SS -,SUP-AR-8840-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X16MM NLCKG CANC TIGHTROPE FT SD T15 HXLB DRV SS -,SUP-AR-8840-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X30MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X40MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X45MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X60MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X30MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X35MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X50MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X60MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PARS Suture Implant Kit w/ SutureTape -,SUP-AR-8862DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TIGHTROPE MINI 1.1MM -,SUP-AR-8914DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
VOLAR DISTAL RAD PLT TI NARROW LT 3HOLE -,SUP-AR-8916VNL-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
VOLAR DISTAL RAD PLT TI NARROW RT 3H -,SUP-AR-8916VNR-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
IMPLANT MINI TIGHTROPE 1.1 - 0 -,SUP-AR-8919DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
KT ARTHROSCOPIC FX TIGHTROPE ANKL 6.5MM RND BTN 3.5X10MM -,SUP-AR-8920CDS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
KT ARTHROSCOPIC FX TIGHTROPE ANKL 3.5MM RND/10MM OBLNG BTN -,SUP-AR-8921CDS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TIGHTROPE XP KNOTLESS TITANIUM -,SUP-AR-8925T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TIGHTROPE KNOTLESS -,SUP-AR-8926SS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4986.7,3490.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BIO-COMP ACHILLE SPEEDBRIDGE -,SUP-AR-8928BCJ-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SYSTEM IMPLANT MPFL BIOCOMPOSITE -,SUP-AR-8929BC-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6310.83,4417.581,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2X10MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI COLR F -,SUP-AR-8930-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2X11MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI MAG F -,SUP-AR-8930-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2X12MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI BLU F -,SUP-AR-8930-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2X13MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI GRN F -,SUP-AR-8930-13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2X14MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI PUR F -,SUP-AR-8930-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2X16MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI PUR F -,SUP-AR8930-16PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2X20MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI PUR F -,SUP-AR-8930-20PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3X12MM CANN CORT P/T TI -,SUP-AR-8933-12PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3X14MM CANN CORT P/T TI -,SUP-AR-8933-14PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LP SCREW 3 X 16MM CORTICAL MTP TI -,SUP-AR-8933-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3X16MM CANN CORT P/T TI -,SUP-AR-8933-16PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LO-PRO SCREW TI 3.0MM X 18MM CORT -,SUP-AR-8933-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3X18MM CANN CORT P/T TI -,SUP-AR-8933-18PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LO-PRO SCREW TI 3.0MM X 20MM CORT -,SUP-AR-8933-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LO-PRO SCREW TI 3.0MM X 22MM CORT -,SUP-AR-8933-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LO-PRO SCREW TI 3.0MM X 36MM CORT -,SUP-AR-8933-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3X14MM LCK CORT P/T TI BLU -,SUP-AR-8933L-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3X16MM LCK CORT P/T TI BLU -,SUP-AR-8933L-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
VAL KREULOCK SCREW TI 3 X 16 -,SUP-AR-8933VCL-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
VAL KREULOCK SCREW TI 3 X 18 -,SUP-AR-8933VCL-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
VAL KREULOCK SCREW TI 3 X 20 -,SUP-AR-8933VCL-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW VAL KREULOCK 3.0 X 22MM TI -,SUP-AR-8933VCL-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW VAL KREULOCK 3.0 X 26MM TI -,SUP-AR-8933VCL-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SUTURETAPE S-TAK ASSY 3.0 DOUBLE LOADED -,SUP-AR-8934BCST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
3.0 DOUBLE LOADED SUTURETAPE S-TAK ASSY -,SUP-AR-8934BCST-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LO-PRO SCREW TI 3.5MM X 12MM -,SUP-AR-8935-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LO-PRO SCREW TI 3.5MM X 22MM -,SUP-AR-8935-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LO-PRO SCREW TI 3.5MM X 24MM -,SUP-AR-8935-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LO-PRO TI 3.5MM X 26MM -,SUP-AR-8935-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LO-PRO TI 3.5MM X 30MM -,SUP-AR-8935-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LO-PRO SCREW TI 3.5MM X 32MM -,SUP-AR-8935-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LO-PRO TI 3.5MM X 34MM -,SUP-AR-8935-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LO-PRO SCREW TI 3.5MM X 36MM -,SUP-AR-8935-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LO-PRO SCREW TI 3.5MM X 38MM -,SUP-AR-8935-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LO-PRO SCREW TI 3.5MM X 40MM -,SUP-AR-8935-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LO-PRO SCREW TI 3.5MM X 42MM -,SUP-AR-8935-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LO-PRO SCREW TI 3.5MM X 44MM -,SUP-AR-8935-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LO-PRO SCREW TI 3.5MM X 46MM -,SUP-AR-8935-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LO-PRO SCREW TI 3.5MM X 48MM -,SUP-AR-8935-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW KREULOCK TI 3.5 X 24MM -,SUP-AR-8935CL-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW KREULOCK TI 3.5 X 26 -,SUP-AR-8935CL-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
KREULOCK SCREW TI 3.5 X 28 -,SUP-AR-8935CL-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW KREULOCK TI 3.5 X 28MM -,SUP-AR-8935CL-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW KREULOCK TI 3.5 X 30 -,SUP-AR-8935CL-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW KREULOCK TI 3.5 X 32 -,SUP-AR-8935CL-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
KREULOCK SCREW TI 3.5 X 34 -,SUP-AR-8935CL-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
KREULOCK SCREW TI 3.5 X 36 -,SUP-AR-8935CL-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LO-PRO LOCK SCREW TI 3.5MM X 12MM -,SUP-AR-8935L-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOCKING SCREW  TI 3.5MM X 14MM -,SUP-AR-8935L-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X24MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X26MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOCKING SCREW TITANIUM 3.5MM X 28MM -,SUP-AR-8935L-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING TITANIUM 3.5MM X 28MM -,SUP-AR-8935L-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X30MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X32MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOCKING SCREW TITANIUM 3.5MM X 34MM -,SUP-AR-8935L-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOCKING SCREW TITANIUM 3.5MM X 44MM -,SUP-AR-8935L-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
KIT ENDOSCOPIC BOSTROM REPAIR IMPLANT SYS -,SUP-AR-8936BC-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X30MM CANC FT SD TI STRL F/H-PLATE LPDS SURG -,SUP-AR-8940-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LO-PRO TI 4.0MM X 36MM -,SUP-AR-8940-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X40MM CANC FT SD TI -,SUP-AR-8940-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN TIGHTROPE 79MM F/SYNDSMS RPR 4HL SS BTRSS LT -,SUP-AR-8943BL-04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN TIGHTROPE 79MM F/SYNDSMS RPR 4HL SS BTRSS RT -,SUP-AR-8943BR-04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN TIGHTROPE 91MM F/SYNDSMS RPR 5HL SS BTRSS -,SUP-AR-8943BR-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN TIGHTROPE 104MM F/SYNDSMS RPR 6HL SS BTRSS -,SUP-AR-8943BR-06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN TIGHTROPE 61MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943H-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN TIGHTROPE F/DLTD LGMNT ATTCH AVULSION FX SYNDSMS -,SUP-AR-8943H-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN TIGHTROPE 47MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943T-04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN TIGHTROPE 72MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943T-06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN TIGHTROPE 98MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943T-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1404.63,983.241,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN TIGHTROPE F/SYNDSMS AVULSION FX MGMT 10HL LCK SS -,SUP-AR-8943T-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1484.14,1038.898,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN TIGHTROPE 72MM F/SYNDSMS AVULSION FX MGMT 3HL SS -,SUP-AR-8943TH-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN TIGHTROPE F/SYNDSMS AVULSION FX MGMT 7HL LCK SS 1/3 -,SUP-AR-8943TH-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN TIGHTROPE 43MM TI BTRSS 3.5MM LPS SCR 2.4MM GW -,SUP-AR-8947DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.1,3045.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 7.5MM STP -,SUP-AR-8949-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LISFRANC PLATE MEDIUM LEFT TI -,SUP-AR-8951ML,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE MEDIUM RIGHT TITANIUM LISFRANC -,SUP-AR-8951MR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LISFRANC PLATE SMALL RIGHT TI -,SUP-AR-8951SR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.5MM 2HOLE L-PLATE TI 5H RT -,SUP-AR-8952ML-05R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 3MM 5HL TI STR -,SUP-AR-8952TS-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CALCFX PERCPLT STD ANTERIOR PROCESS L -,SUP-AR-8954ML-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE LONG CALCANEUS RIGHT TUBEROSITY 3.5/4 MM PERCUTANEOUS -,SUP-AR-8954YR-L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BONE TAP CANNULATED 6.0MM -,SUP-AR-8956C-60T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE LONG METATARSAL RIGHT HOOK -,SUP-AR-8956R-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 2 HOLE TITANIUM -,SUP-AR-8958-02S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANTEROLATERAL PILON FUSION PLATE 5 HOLE LT -,SUP-AR-8963ALF-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12624.2,8836.94,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANTEROLATERAL PILON FUSION PLATE 7H RT -,SUP-AR-8963ARF-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.7X65MM CANN 18MM THRD SD/ST TI -,SUP-AR-8967-1865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WASHER ORTHO 13MM TI -,SUP-AR-8967W,CDM,C1713,HCPCS,278,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
KIT DX SWIVELOCK SL 3.5X8.5MM -,SUP-AR-8978DS-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SWIVELOCK DX SL 3.5 X 8.5 -,SUP-AR-8978P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SYSTEM INTERNAL FIXATION FIBERLOCK SUSPENSION  3.5 X 8.5 -,SUP-AR-8988-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5889.19,4122.433,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUTURE FIBER TAK DX -,SUP-AR-8990ST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2464.73,1725.311,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR FIBERTAK DOUBLE-LOADED DX SUTURE -,SUP-AR-8990ST-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2878.72,2015.104,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DX FIBERTAK SUTURE ANCHOR #2 MTS W/NDL -,SUP-AR-8991,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SWIVELOCK DISP KIT NANO 2.5 X 7 -,SUP-AR-8998DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NANO SWIVELOCK 2.5 X 7 WITH FORK EYELET -,SUP-AR-8998T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X45MM P/T TI F /5TH MTRSL JONES FX SYS -,SUP-AR-9045-45PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X55MM P/T TI GRN -,SUP-AR-9045-55PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LO-PRO SCREW PT THREADED TI 5.5MM X 40MM -,SUP-AR-9055-40PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LO-PRO SCRW PT THD TI 6.0MM X 40MM -,SUP-AR-9060-40PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCK GLENOID PERIPH -,SUP-AR-9145-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CENTRAL NL 6.5 X 25MM -,SUP-AR-9165-25NL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BC ACHILLES SPDBRG W/KL DX CC 3.9MM -,SUP-AR-9928BCK-DX,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10749.14,7524.398,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LP SCREW 3 X 18MM CORTICAL MTP TI -,SUP-AR-9933-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LP SCREW 3 X 20MM CORTICAL MTP TI -,SUP-AR-9933-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LP 3.0 X 22MM CORTICAL MTP TI -,SUP-AR-9933-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LP 3.0 X 24MM CORTICAL MTP TI -,SUP-AR-9933-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LP SCREW 3 X 16MM CORTICAL HYBRID MTP TI -,SUP-AR-9933HY-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOCK MED HOOK PLATE TI 3H -,SUP-AR-9943H-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
MAXFORCE MTP PLATE PETITE 0-0 RIGHT -,SUP-AR-9944P-0R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE MAXFORCE STD 5-5 RIGHT MTP -,SUP-AR-9944S-5R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 12.5MM CANN HDLS ACUTRAK STD TI ALY -,SUP-AT-1125-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.3-3.8X15MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI -,SUP-AT-1150-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.3-3.9MM 17.5MM CANN HDLS ACUTRAK FT ST STD 2MM HX -,SUP-AT-1175-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 20MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI ALY -,SUP-AT-1200-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.3-4.2MM 22.5MM CANN HDLS ACUTRAK FT ST STD 2MM HX -,SUP-AT-1225-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.3-4.4X25MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI -,SUP-AT-1250-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.3-4.5MM 27.5MM CANN HDLS ACUTRAK FT ST STD 2MM HX -,SUP-AT-1275-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.3-4.6X30MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI -,SUP-AT-1300-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5-2.8 MMX8MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5-2.8 MMX9MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5-2.8 MMX12MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5-2.8 MMX14MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5-2.8 MMX16MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5-2.8 MMX18MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5-2.8 MMX20MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5-2.8 MMX26MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5-2.8 MMX28MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5-3.6 MMX16MM CANN HDLS ACUTRAK 2 FT SLF CT 2MM HX -,SUP-AT2-M16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5-3.6 MMX22MM CANN HDLS ACUTRAK 2 FT SLF CT 2MM HX -,SUP-AT2-M22-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5-3.6 MMX24MM CANN HDLS ACUTRAK 2 FT SLF CT 2MM HX -,SUP-AT2-M24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4-4.1X16MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT STD -,SUP-AT2-S16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4-4.1X26MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT STD -,SUP-AT2-S26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4-4.1X34MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST CUT STD -,SUP-AT2-S34-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3-2.5X24MM CANN HDLS ACUTRAK FUSION FT ST 1.5MM/2MM -,SUP-ATF-240-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1966.49,1376.543,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3-3.5X32MM CANN HDLS ACUTRAK FUSION FT ST 1.5MM/2MM -,SUP-ATF-320-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1966.49,1376.543,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.8-3.2 MMX10MM CANN HDLS ACUTRAK FT ST 1.5MM HX DRV -,SUP-ATM-100-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
UNIVERSAL CEMENT RESTRICOTR SM 18.5MM -,SUP-B000-0185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
RESTRICTOR CMNT UNIV 24MM OSTEONICS -,SUP-B000-0240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
RESTRICTOR CEMENT UNIVERSAL SMALL INSERTER -,SUP-B000-1185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
RESTRICTOR CMNT MED UNIV STRL -,SUP-B000-1240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
RESTRICTOR BNCMNT 11MM -,SUP-B0010110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
RESTRICTOR BNCMNT 15.5MM -,SUP-B0020125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
RESTRICTOR BNCMNT 14MM -,SUP-B0030140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5MMX110MM CANC DYNFX 50MM THRD TAPR -,SUP-B6011050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW EXTFIX 6/5MM DIA 130/ 60MM CORT/CANC TAPR DYNFX THRD -,SUP-B6013060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,485.47,339.829,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW TITAN REV SHOULDER LARGE -,SUP-BBS-0960-21LRG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
REVERSE BODY SMALL AND REVERSCE BODY SCREW -,SUP-BBS-0960-21SML,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BALLOON 6FR PTA 200CM X 3MM X 120MM METACROSS -,SUP-BD-P30150ER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
AFX2 BIFURCATED ENDOGRAFT SYSTEM -,SUP-BEA25-80/I13-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
STENT BIFURCATED ENDOGRAFT AFX2  28MM X 80MM -I16-40 -,SUP-BEA28-80/I16-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,37002.53,25901.771,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN TRIMED VOLAR BUTT 20 -,SUP-BP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
RSS BODY SCREW -,SUP-BSC-0960-021-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW TI F/TITAN MODLR SHLDR SYS -,SUP-BSW-0920-021-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,758.61,531.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
MIXER CEMENT KYPHON W  CEMENT -,SUP-C01B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,919.01,643.307,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
"K-WIRE PIN COVER .028"" -",SUP-C-028NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X12MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-C03120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X16MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-C03160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
"K-WIRE PIN COVER .035"" -",SUP-C-035NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
"K-WIRE PIN COVER .045"" -",SUP-C-045NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
"K-WIRE PIN COVER .054"" -",SUP-C-054NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
"K-WIRE PIN COVER .062"" -",SUP-C-062NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
EXTERNAL FX 0.375IN BALL COLR F/CAP VRS SZ K-WIRE -,SUP-C50-COL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.5,771.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4X14MM LCK CANC ACU-LOC 2 HEX HEAD TI NS F/MAYO -,SUP-CA-4140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,542.66,379.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GRAFT CANC 30ML CHP RDIGRF FRZDR CRSH VOID FIL 1-8MM -,SUP-CAN30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1984.24,1388.968,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
EXPERT KNEE CAPITATED REVISION SYSTEM -,SUP-CAP PRICE,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21164.1,14814.87,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CEMENT CARTRIDGE CC02A CDS -,SUP-CC02A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DISC CERVICAL SIZE 6MM LL M6 -,SUP-CDL-637L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CERVICAL DISC SIZE 6MM M6 ORTHOFIX -,SUP-CDM-625,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CERVICAL DISC 6 MEDIUM LONG ARTIFICIAL -,SUP-CDM-635L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CEMENT GUN AND BONE FILLER CDS2A SIZE 2 -,SUP-CDS2A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2361.37,1652.959,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
EXCLUDER ILIAC 23MM X 10MM X 10CM 16FR BRANCH ENDO -,SUP-CEB231010A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31520.86,22064.602,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
IMPLANT VARILIFT- C STND ALONE XPD -,SUP-CIC1-7.5-12-BP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5835.5,4084.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE VARILIFT- C ST -,SUP-CIC1-9.0-12-BP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5835.5,4084.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
KT SUTURE REM SUT PRB KNT PSHR/CTR INTRO CROSSFIX II DISP -,SUP-CM-8000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DEVICE MENISCOTOME UP CRV STRONGER STF NDL HI STRGTH SUT -,SUP-CM-8002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR JK 2.9 SL WT/BL NS BK JUGGERKNOT -,SUP-CM-99329B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2067.2,1447.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR JK 2.9 BDL WT/BL NS BKLU BB JUGGERKNOT -,SUP-CM-99429B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2067.2,1447.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X12MM NLCKG CORT ACU-LOK 2 TI NS F/MAYO -,SUP-CO-2712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X14MM NLCKG CORT ACU-LOK 2 TI NS F/MAYO -,SUP-CO-2714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X16MM NLCKG CORT ACU-LOK 2 TI NS F/MAYO -,SUP-CO-2716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X20MM NLCKG CORT ACU-LOC 2 TI NS F/MAYO -,SUP-CO-2720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X22MM NLCKG CORT ACU-LOC 2 TI NS F/MAYO -,SUP-CO-2722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X6MM NLCKG CORT ACU-LOK 2 TI NS -,SUP-CO-3060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X10MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X12MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X14MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X16MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X24MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X25MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X26MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X28MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X30MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X32MM NLCKG CORT ACU-LOC 2 POLARUS TI NS COLR -,SUP-CO-3320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X12MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X14MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X16MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.7X18MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X8MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X10MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X12MM LCK CORT -,SUP-COL-3120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X14MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X20MM LCK CORT FT TI F/MAYO PLATE/MODULAR/UNIV SYS -,SUP-COL-3200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X22MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORITICAL LOCKING TI 3.5 X 13MM -,SUP-COLS -35130-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW GEMINUS CORTICAL LOCKING 3.5MM X 8MM TI -,SUP-COLS-35080-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL LOCKING 3.5 X 9 -,SUP-COLS-35090-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL LOCKING 3.5 X 10 -,SUP-COLS-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL LOCKING 3.5MM X 11MM -,SUP-COLS-35110-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL LOCKING 3.5MM X 12MM -,SUP-COLS-35120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW- CORTICAL LOCKING 3.5MM X 12MM -,SUP-COLS-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORT LOCKING 3.5MM X 15MM -,SUP-COLS-35150-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL LOCKING 3.5MM X 16MM -,SUP-COLS-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL LOCKING 3.5 X 18 -,SUP-COLS-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL LOCKING 3.5MM X 20MM TI -,SUP-COLS-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL LOCKING 3.5 X 24 -,SUP-COLS-35240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL LOCKING 3.5 X 26 -,SUP-COLS-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X14MM CORT ACU-LOC 2 FT NTOGG TI NS F/UNIV SYS -,SUP-CO-N2314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X22MM CORT ACU-LOC 2 FT NTOGG TI NS F/UNIV SYS -,SUP-CO-N2322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X14MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X16MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X18MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.3X20MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
RTR CROSS CONNECTOR -,SUP-CPF-CR 26 32-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CROSS CONNECTOR 32-44 -,SUP-CPF-CR 32 44-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL 3.5 X 12 -,SUP-CPF-CS 35 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CC PREFERRED ANGLE 3.5 X 14 -,SUP-CPF-CS 35 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CC PREFERRED ANGLE 3.5 X 18 -,SUP-CPF-CS 35 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CC PREFERRED ANGLE 3.5 X 20 -,SUP-CPF-CS 35 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LARGE OFFSET -,SUP-CPF-LC 00 0L-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SPINEART ML PREFERRED ANGLE 4MM X 12MM -,SUP-CPF-MS 04 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ML PREFERRED ANGLE SCRE 4 X 16 -,SUP-CPF-MS 04 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ML PREFERRED ANGLE SCRE 4 X 18 -,SUP-CPF-MS 04 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ML PREFERRED ANGLE 4 X 20 -,SUP-CPF-MS 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ML PREFERRED ANGLE 4 X 24 -,SUP-CPF-MS 04 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPINEART PERLA ML PREFERRED ANGLE SCREW 4 X 28 -,SUP-CPF-MS 04 28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ML PREFERRED 3.5 X 12 -,SUP-CPF-MS 35 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ML 35 X 14 -,SUP-CPF-MS 35 14S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW PERLA ML PREFERRED ANGLE 3.5MM X 16MM -,SUP-CPF-MS 35 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ML PREFERRED 3.5 X 18 -,SUP-CPF-MS 35 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ML 35 X 20 -,SUP-CPF-MS 35 20S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ML 35 X 24 -,SUP-CPF-MS 35 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SPINEART ML PREFERRED ANGLE 4MM X 14MM -,SUP-CPF-MS-04 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CONNECTOR PARALLEL 3-3 -,SUP-CPF-PC 30 3C-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CONNECTOR PARALLEL 3-5 -,SUP-CPF-PC 3C 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD PERLA 90MM TI -,SUP-CPF-PF T0 90-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PREBENT ROD COBALT CHROMIUM 45MM -,SUP-CPF-PR C0 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD PREBENT TITANIUM 3.5 X 40MM -,SUP-CPF-PR T0 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD 50MM -,SUP-CPF-PR T0 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD 60MM PREBENT TITANIUM -,SUP-CPF-PR T0 60-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PERLA PREBENT ROD TITANIUM 3.5 X 65MM -,SUP-CPF-PR T0 65-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD 70MM -,SUP-CPF-PR T0 70-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PERLA PREBENT ROD TITANIUM 3.5 X 75MM -,SUP-CPF-PR T0 75-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD PREBENT TITANIUM 3.5 L80 -,SUP-CPF-PR T0 80-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD 85MM -,SUP-CPF-PR T0 85-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD 45MM -,SUP-CPF-PR TO 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PREBENT TITANIUM ROD 3.5 X L12 PERLA -,SUP-CPF-PR TO 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD PREBENT TITANIUM 55MM -,SUP-CPF-PR TO 55-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD 60MM -,SUP-CPF-PR TO 60-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PRE-BENT ROD 3.5 X 90MM -,SUP-CPF-PR TO 90-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW POLY PERLA 4 X 10MM -,SUP-CPF-PS 04 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PERLA SCREW 12MM -,SUP-CPF-PS 04 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW POLYAXIAL PERLA 4MM X 12MM -,SUP-CPF-PS 04 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW POLYAXIAL 4MM X 14MM -,SUP-CPF-PS 04 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW POLYAXIAL 4 X 16 -,SUP-CPF-PS 04 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW POLY 4 X 18MM -,SUP-CPF-PS 04 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW POLYAXIAL PERLA 4MM X 20MM -,SUP-CPF-PS 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW POLY PERLA 4.0 X 24MM -,SUP-CPF-PS 04 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE PERLA 4MM X 32MM SPINE POLYAXIAL -,SUP-CPF-PS 04 32-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PERLA POLYAXIAL SCREW 3.5 X 10MM -,SUP-CPF-PS 35 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW POLY 3.5 X 12MM PERLA -,SUP-CPF-PS 35 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW PERLA 3.5 X 14 -,SUP-CPF-PS 35 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
3.5 x 16MM POLY SCREW -,SUP-CPF-PS 35 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW POLY 3.5 X 18MM PERLA -,SUP-CPF-PS 35 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PERLA POLYAXIAL SCREW 3.5 X 20MM -,SUP-CPF-PS 35 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
POLYAXIAL SCREW 3.5 X 24 -,SUP-CPF-PS 35 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW POLY PERLA 3.5MM X 28MM -,SUP-CPF-PS 35 28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
POLYAXIAL SCREW 3.5 X 12 -,SUP-CPF-PS 3512-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
POLYAXIAL SCREW 4.0 X 28 -,SUP-CPF-PS-0428-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
3.5 X 28 POLY SCREW -,SUP-CPF-PS-3528-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREWS SET PERLA -,SUP-CPF-SC 00 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPINEART STRAIGHT ROD CHROMIUM 350MM -,SUP-CPF-SR C3 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD TITANIUM 40MM -,SUP-CPF-SR CO 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD TITANIUM 80MM -,SUP-CPF-SR T0 80-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PERLA STRAIGHT ROD TITANIUM 03.5 L100 -,SUP-CPF-SR T1 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD TI 120MM -,SUP-CPF-SR T1 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD 240 -,SUP-CPF-SR T2 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SMOOTH SHANK SCREW 4MM Z 20 -,SUP-CPF-SS 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SS 3.5 X 20 -,SUP-CPF-SS 35 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SS 3.5 X 22 -,SUP-CPF-SS 35 22-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SS 3.5 X 24 -,SUP-CPF-SS 35 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREWS SS 3.5 X 26 -,SUP-CPF-SS 35 26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
3.5 x 28MM SMOOTH SHANK -,SUP-CPF-SS 35 28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SS 3.5 X 34 -,SUP-CPF-SS 35 34-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
3.5 X 30MM POLY SCREW -,SUP-CPF-SS-35 30-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X12MM CORT DVR FT CRUCIF HEAD MAG -,SUP-CS12000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X16MM CORT DVR FT CRUCIF HEAD MAG -,SUP-CS16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X18MM CORT DVR FT CRUCIF HEAD MAG -,SUP-CS18000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GRAFT STRUT MATRGRF FRZDR 15X100MM -,SUP-CST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3457.04,2419.928,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BONE CEMENT CX01B XPEDE W MIXER US -,SUP-CX01B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1598.1,1118.67,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
HEADLESS 3.0X40 SCREW -,SUP-D2N30040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.61,678.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TORNIER LONG HUMERAL NAIL LEFT 7MM X 230MM -,SUP-DHN5796,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13273.98,9291.786,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE DISTAL HUMERUS MEDIAL DIRECT 105MM -,SUP-DHPF-MDL-5HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN SCREW DISTRACTION 12MM -,SUP-DP-12-TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,145.88,102.116,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN SCREW DISTRACTION 14MM -,SUP-DP-14-TY,CDM,C1713,HCPCS,278,RC,,,outpatient,,,145.88,102.116,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ULNAR STEM 6.0MM 2CM EXT STEM -,SUP-DRUJ-IS260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9932.28,6952.596,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOCKING RADIAL PLATE SZ 20-15MM ASSY -,SUP-DRUJ-LP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19433.84,13603.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
14MM 3.5 LOCKING SCREW -,SUP-DRUJ-LSC14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,799.4,559.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
20MM 3.5 LOCKING SCREW -,SUP-DRUJ-LSC20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,799.4,559.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
22MM 3.5 LOCKING SCREW -,SUP-DRUJ-LSC22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,799.4,559.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
20MM 3.5 CORTICAL SCREW -,SUP-DRUJ-SC20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,636.02,445.214,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW DISTAL TROCHLEA COMP 3.5 X 45 TI -,SUP-DTCS-35045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW DISTAL TROCHLEA COMP 3.5 X 50 -,SUP-DTCS-35050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN DVR 24.4MMX51.3MM 4HL STD SHRT NS LT -,SUP-DVRAL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN DVR ANTMC NRW -,SUP-DVRANR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3828.27,2679.789,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN DVR 21.6MMX48.9MM 4HL SHRT BTRSS NRW NS -,SUP-DVRANSL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN DVR 21.6MMX48.9MM 4HL SHRT NS -,SUP-DVRANSR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN DVR 24.4MMX51.3MM 4HL STD SHRT NS RT -,SUP-DVRAR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN DVR 24.4MMX51.3MM 4HL STD SHRT NS RT RADL -,SUP-DVRASR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN DVR 28.2MMX62.6MM 4HL W NS -,SUP-DVRAWL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN DVR 28.2MMX62.6MM 4HL W BTRSS NS -,SUP-DVRAWR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN DVR 24.4MMX89.5MM 4HL EXTEND XLNG BTRSS NS -,SUP-DVRAXL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN DVR 24.4MMX59.5MM 4HL NS LT -,SUP-DVR-L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TORNIER PERFORM REVERESED CTRSCREW 6.5MM X 25MM NON ST -,SUP-DWJ125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TORNIER PERFORM REVERSED PERIPSCREW 5.0MM X 14MM NON ST -,SUP-DWJ314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1144.91,801.437,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TORNIER PERFORM REVERSED PERIPSCREW 5.0MM X 18MM NON ST -,SUP-DWJ318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1144.91,801.437,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
RESTRICTOR HUM CMNT 24MM F/TOT ELB PROS LTD -,SUP-EB0101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1166.11,816.277,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
RESTRICTOR CMNT TORNIER -,SUP-EBO101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1293.32,905.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ROMEO POLYAXIAL 6 X 40 -,SUP-ELL-PS 06 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X25MM SIGNTR POLYAX FX F /ROMEO PDCL SYS TI ALY -,SUP-ELL-PS0525-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X30MM SIGNTR POLYAX FX F /ROMEO PDCL SYS TI ALY -,SUP-ELL-PS0530-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW POLYAXIAL 5 X 35 -,SUP-ELL-PS0535-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW POLYAXIAL 6 X 30 -,SUP-ELL-PS0630-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6X35MM SIGNTR POLYAX FX F /ROMEO PDCL SYS TI ALY -,SUP-ELL-PS0635-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD 30MM -,SUP-ELL-RD 00 30 S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD ROMEO STRAIGHT HEX TIP 0.54 L240 -,SUP-ELL-RD 22 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPIN ROMEO 5.4X50MM PREBNT TI LMBR SFT MLBL F/TRNSCONN -,SUP-ELL-RD0050-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SET SCREW SPIN ROMEO2 -,SUP-ELL-SC 00 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GRAFT STENT 49E X 36MM X 36MM ENDURANT II AO EXT -,SUP-ETCF3636C49E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18052.61,12636.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
STENT ENDURANT II GRAFT 16F X 16MM X 146MM LIMB -,SUP-ETLW1616C146E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GRAFT STENT ENDUR II LIMB ELTW1620C146E -,SUP-ETLW1620C146E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
INFRAME IMPLANT 2.0MM X 32MM -,SUP-EXINF922032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
INFRAME EXSOMED IMPLANT 2.0MM X 36MM -,SUP-EXINF922036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6972.89,4881.023,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
INNATE IMPLANT 3.6MM X 35MM -,SUP-EXINN923635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL INTRAMEDULLARY INNATE IMPLANT 3.6MM X 40MM -,SUP-EXINN923640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
INNATE IMPLANT 3.6MM X 50MM -,SUP-EXINN923650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL INTRAMEDULLARY INNATE IMPLANT 3.6MM X 55MM -,SUP-EXINN923655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL INTRAMEDULLARY INNATE IMPLANT 4.5MM X 45MM -,SUP-EXINN924545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL INNATE IMPLANT 4.5MM X 50MM -,SUP-EXINN924550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
INNATE IMPLANT 4.5 X 55 -,SUP-EXINN924555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
STRYKER EASY CLIP STAPLE -,SUP-EZ 20-20-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9747.74,6823.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
EASYCLIP 15 X 15 X 15 -,SUP-EZ15-15-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8823.28,6176.296,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
EASYCLIP FIXATION DEVICE 18 X 19 X 17 -,SUP-EZ18-19-17,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8823.28,6176.296,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
EASYCLIP FIXATION DEVICE 20 X 20 X 20 -,SUP-EZ20-20-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9747.74,6823.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
EASYCLIP 8 X 8 X 8MM -,SUP-EZM08-08-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6512.42,4558.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BONE FILLER DEVICE SIZE 3 -,SUP-F04B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,577.67,404.369,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DEVICE BN FIL FEM SZ2 KYPHX EXP STRL -,SUP-F06A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,577.67,404.369,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ORTHOFIX 8.5 CAGE -,SUP-F28-3182,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SHAFT FROZEN BISECTED FEM -,SUP-FBFS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4383.06,3068.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CLAMP CRANIAL 11MM CRANIOFIX -,SUP-FF490T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,695.9,487.13,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CLAMP CRANIAL 16MM TITANIUM CRANIOFIX 2 -,SUP-FF491T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,862.41,603.687,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CLAMP CRANIAL 20MM TITANIUM CRANIOFIX 2 -,SUP-FF492T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1035.56,724.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW FREEFIX  COMPRESSION 3.5MM X 20MM TI -,SUP-FFC-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW FREEFIX COMPRESSION 3.5MM X 22MM TI -,SUP-FFC-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW FREEFIX COMPRESSION 3.5MM X 24MM TI -,SUP-FFC-35240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW FREEFIX COMPRESSION 4.5MM X 20MM TI -,SUP-FFC-45200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1009.46,706.622,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW FREEFIX COMPRESSION 4.5MM X 20MM TI -,SUP-FFC-45240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1009.46,706.622,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GRAFT HUMAN TISSUE FEMORAL HEAD 43MM -,SUP-FFH,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4839.09,3387.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GRAFT HUMAN TISSUE FEMORAL HEAD 43MM -,SUP-FFH,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4839.09,3387.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WEDGE FIBULA 18MM FROZEN -,SUP-FFIBW8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2636.84,1845.788,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW FREEFIX LOCKING 3.5MM X 20MM TI -,SUP-FFL-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW FREEFIX LOCKING 3.5MM X 22MM TI -,SUP-FFL-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW FREEFIX LOCKING 3.5MM X 26MM TI -,SUP-FFL-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW FREEFIX LOCKING 4.5MM 22MM TI -,SUP-FFL-45220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PRESUTURED ALLOGRAFT -,SUP-FGL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9411.49,6588.043,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GRAFT HUM TIS SPCR FRZN FLEXIGRAFT MNSCS R/M LF -,SUP-FMNRM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14676.34,10273.438,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.5X8MM LCK FT TI ALPS -,SUP-FP08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.5X10MM LCK FT TI ALPS NS -,SUP-FP10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.5X11MM LCK FT TI ALPS NS -,SUP-FP11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.5X12MM LCK FT TI ALPS NS -,SUP-FP12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.5X13MM LCK FT TI ALPS NS -,SUP-FP13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.5X14MM LCK FT TI ALPS -,SUP-FP14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.5X15MM LCK FT TI ALPS -,SUP-FP15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.5X16MM LCK FT TI ALPS -,SUP-FP16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2X18MM LCK FT TI DVR NS -,SUP-FP18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.5X20MM LCK FT TI DVR NS -,SUP-FP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.5X22MM LCK FT TI F3 NS -,SUP-FP22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.5X24MM LCK FT TI ALPS -,SUP-FP24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.5X26MM LCK FT TI ALPS NS -,SUP-FP26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.5X28MM LCK FT TI ALPS -,SUP-FP28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.5X30MM LCK FT TI F3 NS -,SUP-FP30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GRAFT HUM TIS FRZN 230CM 7.5MM FLEXIGRAFT PRNS LONGUS TNDN -,SUP-FPLT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.1,4960.97,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD 120MM -,SUP-G100-5-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD 200MM -,SUP-G100-5-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD 400MM -,SUP-G100-5-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD 6.0MM STRAIGHT -,SUP-G100-5-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD 100MM -,SUP-G150-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TIROD 200MM STRAIGHT -,SUP-G150-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD 30MM -,SUP-G150-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD 35MM -,SUP-G150-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD 40MM CURVED -,SUP-G150-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD CURVED 40MM -,SUP-G150-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD 45MM -,SUP-G150-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD CURVED 50MM -,SUP-G150-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD 55MM -,SUP-G150-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD CURVED 60MM -,SUP-G150-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD 65MM GENESYS -,SUP-G15065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD 70MM GENESYS -,SUP-G150-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD 75MM -,SUP-G150-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD 80MM GENESYS -,SUP-G150-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD 85MM SPINAL -,SUP-G150-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD 90MM -,SUP-G150-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD 95MM -,SUP-G150-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD 300MM GENESYS -,SUP-G300-5-300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CONNECTOR CROSS LINK LARGE -,SUP-G301-LRG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CROSSLINK MED -,SUP-G301-MED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CROSS LINK -,SUP-G301-SM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
27-35MM CC -,SUP-G301-XSM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
COIL MICRONESTER EMBOLIZATION 0.018 X 7CM X 6MM -,SUP-G52738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,916.1,641.27,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEADLESS COMP. 4.0MM 36M -,SUP-G58036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL 5.5 X 30MM -,SUP-G700-55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL 6.5 X 35MM -,SUP-G700-65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5 X 30MM GENESYS -,SUP-G701-55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW PEDICLE 5.5 X 35MM TI LO -,SUP-G701-55-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW PEDICLE 5.5MM X 40MM -,SUP-G701-55-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW TI LOCK 5.5 X 45MM -,SUP-G701-55-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW PEDICLE 6.5 X 30MM -,SUP-G701-65-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW PEDICLE 6.5 X 35MM -,SUP-G701-65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW PEDICLE 6.5 X 40MM -,SUP-G701-65-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW TI LOCK 6.5 X 45MM -,SUP-G701-65-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
6.5 X 50MM PEDICLE SCREW -,SUP-G701-65-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW TI-LOCK 7.5 X 30MM -,SUP-G701-75-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW TI-LOCK 7.5 X 35MM -,SUP-G701-75-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW PEDICLE 7.5 X 40MM -,SUP-G701-75-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW TI-LOCK 7.5 X 45MM -,SUP-G701-75-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
7.5 X 50MM PEDICLE SCREW -,SUP-G701-75-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 8.5MM X 70MM -,SUP-G701-85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CROSSLINK -,SUP-G701-XSM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MM X 25MM -,SUP-G702-45-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5MM X 30MM -,SUP-G702-45-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL 5.0 X 25MM -,SUP-G702-50-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL 5.0 X 30MM NEW -,SUP-G702-50-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CORTICAL SCREW 25 X 5.5MM -,SUP-G7025525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL 5.5 X 25 -,SUP-G702-55-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5 X 45 GENESYS -,SUP-G702-55-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL 6.5 X 40MM -,SUP-G702-65-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL 7.5 X 45 -,SUP-G702-75-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 8.5MM X 45MM -,SUP-G710-85-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ILIAC 8.5 X 60 -,SUP-G710-85-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SPINE 8.5 X 70 -,SUP-G710-85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SPINE 8.5 X 80 -,SUP-G710-85-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HI TOP 6.5 X 35 -,SUP-G711-65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ILIAC 8.5 X 70 -,SUP-G741-85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
OFFSET -,SUP-G780-21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
OFFSET 61 -,SUP-G780-61,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAP CIRCULAR TI LOCKING -,SUP-G826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SET 8.5 -,SUP-G826-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAP LOCKING TI -,SUP-G828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SET CAPS -,SUP-G828-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE 5MM SMALL -,SUP-GAC-05-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR APACHE CAGE 7MM -,SUP-GAC-07-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
APACHE CAGE ANCHORED 8MM -,SUP-GAC-08 SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE H8 -,SUP-GAC-08-SC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
APACHE ANCHORED 8MM -,SUP-GAC-08-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE 9MM -,SUP-GAC-09-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE APACHE ANCHORED 10MM -,SUP-GAC-10SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
APACHE ANCHORED 6MM -,SUP-GAC3D06-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
APACHE ANCHOR LARGE -,SUP-GAC-LG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR MEDIUM -,SUP-GAC-MD,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SMALL -,SUP-GAC-SM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR GREEN XL -,SUP-GAC-XL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR XXL BROWN -,SUP-GAC-XXL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BUTTRES 22MM -,SUP-GBP1-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 22MM 5.5 -,SUP-GBP1-2255,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
9mm CERVICAL PECK CAGE APACHE -,SUP-GCL-09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE SMALL APACHE 11MM -,SUP-GCL-11-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 12MM -,SUP-GCP10012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 14MM -,SUP-GCP10014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 14MM RESCU -,SUP-GCP10014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 16MM -,SUP-GCP10016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 35MM -,SUP-GCP20035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BINARY 12MM -,SUP-GCP2-112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 14MM -,SUP-GCP2-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 16MM -,SUP-GCP2-116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE CERVICAL 49MM -,SUP-GCP2-349,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.75MM X 16MM BINARY AUGER TIP FIXED -,SUP-GCP2-AF316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREWS 3.75 X 14MM SCREWS -,SUP-GCP2-AV314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.75MM X 18MM BINARY AUGER TIP VAIABLE -,SUP-GCP2-AV318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREWS 4.25 X 12MM -,SUP-GCP2-AV412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW FIXED CERV 3.75 X 14MM -,SUP-GCSF37514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BN 14MM -,SUP-GCSV37514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW VA 16MM -,SUP-GCSV37516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW RESCUE 16MM -,SUP-GCSV42516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
APACHE ANCHOR 6MM -,SUP-GCV-06-SO,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE APACHE 6MM -,SUP-GCV-06-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE APACHE ANCHORED 8MM -,SUP-GCV-08-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE APACHE ANCHORED 9MM -,SUP-GCV-09-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR LARGE -,SUP-GCV-LG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDE PIN 2.0MM X 125MM -,SUP-GDW-890-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.44,297.108,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
6.5 X 40MM PEDICLE SCREW -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CERVICAL APACHE CAGE 8MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BINARY 2 LEVEL CERVICAL 30MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE CERVICAL 2 LEVEL 32MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL 7.5 X 30MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW REDUCTION 6.5 X 30MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE STANDARD 31MM -,SUP-GLP-131,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 22MM -,SUP-GLPV-55 22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPINE 60MM -,SUP-GM150-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SET SCREW -,SUP-GM520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
MODULAR CORT IMPLANT HEAD -,SUP-GM557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
MODULAR LOCK SCREW -,SUP-GM820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE DORSAL SPANNING SHORT -,SUP-GMN-DSP-160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6217.46,4352.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BONE GEMINUS TITANIUM DORSAL SPANNING LONG -,SUP-GMN-DSP-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6416.93,4491.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BONE GEMINUS TITANIUM RADIAL DISTAL DORSAL HOOK -,SUP-GMN-HP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2592.28,1814.596,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW PLATE BONE GEMINUS TITANIUM RADIAL DISTAL DORSAL HOOK -,SUP-GMN-HP-SCRW,CDM,C1713,HCPCS,278,RC,,,outpatient,,,566,396.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ASSEMBLED GEMINUS VOLAR DISTAL RADIUS PLATE NARR 120MM LEFT -,SUP-GMN-LTN-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9969.16,6978.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE DIST RAD NARR 3 HOLE LEFT GEMINUS VOLAR -,SUP-GMN-LTN-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE NARROW DIS RAD 4 HOLE LEFT -,SUP-GMN-LTN-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE VOLAR DIST RAD STANDARD 3 HL LEFT -,SUP-GMN-LTS-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE GEMINUS VOLAR DISTAL RADIUS STANDARD 4 HOLE LEFT -,SUP-GMN-LTS-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE ASSEMBLED GEMINUS VOLAR DIST RAD NARROW 120MM RIGHT -,SUP-GMN-RTN-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9969.16,6978.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE VOLAR DISTAL RADIUS NARROW 3 HOLE RIGHT -,SUP-GMN-RTN-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DISTAL RADIUS PLATE- NARROW 4 HOLE RT. -,SUP-GMN-RTN-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE VOLAR DIST RADIUS STD 3 HOLD RIGHTTI GEMINUS -,SUP-GMN-RTS-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE DISTAL RADIUS VOLAR GEMINUS WIDE 4HL RIGHT -,SUP-GMN-RTW-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4621.72,3235.204,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5 X 30 -,SUP-GMSD 55 30-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5 X 45 -,SUP-GMSD 55 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL 4.5 X 30MM -,SUP-GMSD45-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5 X 35 -,SUP-GMSD-50 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL 5.0 X 30MM -,SUP-GMSD50-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL 5.0 X 35MM NEW -,SUP-GMSD50-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.0 X 4.0 -,SUP-GMSD50-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 55 X 35 -,SUP-GMSD-55 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL 5.5 X 30 -,SUP-GMSD55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CORTICAL MODULAR SCREW 5.5 X 35 -,SUP-GMSD55-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL 5.5 X 35 -,SUP-GMSD55-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL SPINE 5.5 X 40 -,SUP-GMSD55-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL 5.5 X 45 -,SUP-GMSD55-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL 6 X 35 -,SUP-GMSD-60 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL 6 X 30 -,SUP-GMSD60-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CORTICAL SCREW 6 X 35 -,SUP-GMSD60-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GENESYS CORTICAL SCREW 6.5MM X 35MM -,SUP-GMSD60-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MODULAR 6.0 x 40 -,SUP-GMSD60-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 65 X 35 -,SUP-GMSD-65 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORITCAL SPINE 6.5 X 35 -,SUP-GMSD65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL SPINE 6.5 X 40 -,SUP-GMSD65-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL 6.5 X 45 -,SUP-GMSD65-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW GENESYS MODULAR 6.5 X 50MM -,SUP-GMSD65-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL 7.5 X 40 -,SUP-GMSD75-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL 75 X 45 -,SUP-GMSD75-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL 75 X 50 -,SUP-GMSD75-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL 8.5 X 70 -,SUP-GMSD85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5 X 30 -,SUP-GMSP55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.0 X 30 -,SUP-GMSP60-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2-PIECE PIN TIP SECTION-TROCAR TIP -,SUP-GSI209-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,571.83,400.281,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2-PIECE PIN-TAIL SECTION 750MM W/TIP -,SUP-GSI210-02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2P PIN TAIL -,SUP-GSI210-02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
350 TROCAR PIN -,SUP-GSI211-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 9.5 X 35 -,SUP-GSI-SDW09535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 9.5 X 40 -,SUP-GSI-SDW09540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 9.5 X 40 -,SUP-GSI-SDW09545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 9.5 X 60 SI SUAL THREAD WASHER HEAD -,SUP-GSI-SDW09560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
POSTERIOR ALLOGRAFT 20MM -,SUP-GSPA-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
APACHE ANCHOR 8MM -,SUP-GVC-08-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
APACHE ANCHORED 9MM -,SUP-GVC-09-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDE PIN 2.0MM X 150MM -,SUP-GW0920061501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,306.34,214.438,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE CAN PT TI 4.0 X 26MM -,SUP-H00693,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE CAN PT TI 4.0 X 24MM -,SUP-H00693,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X40MM CANC POLARUS FT CNTRSNK TI NS -,SUP-HCA-5140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5X45MM CANC POLARUS FT CNTRSNK TI NS -,SUP-HCA-5145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.3X35MM LCK CANC POLARUS FT TI STRL -,SUP-HCA-L5335-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.3X40MM LCK CANC POLARUS FT TI STRL -,SUP-HCA-L5340-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.3X45MM LCK CANC POLARUS FT TI STRL -,SUP-HCA-L5345-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG HIGH COMPRESSION LOCKING 2.7 X 18 -,SUP-HCLP-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG HIGH COMPRESSION LOCKING 2.7MM  X 19MM TI -,SUP-HCLP-27190-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG HIGH COMPRESSION LOCKING 2.7MM  X 20M TI -,SUP-HCLP-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG HIGH COMPRESSION LOCKING 2.7MM  X 21M TI -,SUP-HCLP-27210-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
HIGH COMP PEG LCK 2.7 X 22 -,SUP-HCLP-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
HIGH COMPRESSION LOCKING PEG 2.7MM X 28MM TI -,SUP-HCLP-27280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X20MM NLCKG CORT POLARUS TI STRL -,SUP-HCO3200-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X25MM NLCKG CORT POLARUS TI STRL -,SUP-HCO3250-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MMX32.5MM NLCKG CORT POLARUS TI STRL -,SUP-HCO3325-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEADLESS COMP 2.5 X 14 -,SUP-HCS-25014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEADLESS COMP 2.5 X 16 -,SUP-HCS-25016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEADLESS COMPRESSION 2.5MM X 18MM -,SUP-HCS-25018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEADLESS COMP 2.5MM X 22MM TI -,SUP-HCS-25022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEADLESS COMP 2.5MM X 24MM TI -,SUP-HCS-25024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEADLESS COMP 2.5MM X 26MM TI -,SUP-HCS-25026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEADLESS COMPRESSION 2.5MM X 30MM -,SUP-HCS-25030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD IM 8X240MM POLARUS + CANN TAPR PRFL HUM TI STAB -,SUP-HR-0824-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9312.2,6518.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD IM 11X150MM POLARUS PROX HUM -,SUP-HR-L1115-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10452.97,7317.079,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEADED 2.5 X 12MM -,SUP-IC2512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.5MM HEADED SCREW LENGTH 14MM -,SUP-IC2514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE MINI HEADED 2.5 X 18MM -,SUP-IC2518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5 HEADED 20MM LENGTH -,SUP-IC2520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEADED 2.5 X 22MM -,SUP-IC2522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.5 MM HEADED 26MM LENGTH MINI CANN SCREW -,SUP-IC2526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
MINI SET SCREW 2.5X28MM -,SUP-IC2528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.5 MM HEADED 30MM LENGTH MINI CANN SCREW -,SUP-IC2530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
3.0 X 10MM CANNULATED SCREW -,SUP-IC3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.0 HEADED 18MM -,SUP-IC3018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
3.0MM HEADED 22MM LENGTH CANN SCREW -,SUP-IC3022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
3.0MM HEADED 24MM LENGTH CANN SCREW -,SUP-IC3024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
3.0MM HEADED 26MM LENGTH MINI CANN SCREW -,SUP-IC3026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3MM X 30MM -,SUP-IC3030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.0 HEADED 32MM LENGTH -,SUP-IC3032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.0MM HEADED 34MM LENGTH -,SUP-IC3034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.0MM HEADED 38MM LENGTH -,SUP-IC3038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEADED 3.0 X 40MM -,SUP-IC3040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
4.0MM HEADED 20MM LENGTH MINI CANN SCREW -,SUP-IC4020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
4.0MM HEADED SCREW LENGTH 32MM -,SUP-IC4032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
4.0MM HEADED SCREW LENGTH 34MM -,SUP-IC4034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
4.0MM HEADED 36MM LENGTH MINI CANN SCREW -,SUP-IC4036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
4.0MM HEADED 38MM LENGTH MINI CANN SCREW -,SUP-IC4038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
4.0MM HEADED 40MM LENGTH MINI CANN SCREW -,SUP-IC4040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE MINI 46MM X 4MM HEAD NONSTERILE -,SUP-IC4046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
4.0MM HEADED SCREW LENGTH 48MM -,SUP-IC4048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE MINI 50MM X 4MM HEAD NONSTERILE -,SUP-IC4050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
INFLUX SPARC (IBM) 1CC -,SUP-IFLX-CM-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2597.25,1818.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
INFLUX SPARC (IBM) 5CC -,SUP-IFLX-CM-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8530.44,5971.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
HEADLESS SCREW 2.5X10MM -,SUP-IH2510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.5MM HEADLESS SCREW LENGTH 20MM -,SUP-IH2520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.5MM HEADLESS SCREW LENGTH 24MM -,SUP-IH2524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.5MM HEADLESS SCREW LENGTH 26MM -,SUP-IH2526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
2.5MM HEADLESS SCREW LENGTH  30MM -,SUP-IH2530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE MINI 2.5 X 36MM HEADLESS -,SUP-IH2536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
3.0 X 14MM HEADLESS SCREW -,SUP-IH3014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.0 X 22MM HEADLESS -,SUP-IH3022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.0 X 24MM HEADLESS -,SUP-IH3024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.0 X 26MM HEADLESS -,SUP-IH3026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEADLESS 3.0MM X 30MM -,SUP-IH3030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
3.0 X 32MM HEADLESS SCREW -,SUP-IH3032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
3.0 X 34MM HEADLESS SCREW -,SUP-IH3034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEADLESS 3.0MM X 36MM -,SUP-IH3036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEADLESS 3.0MM X 38MM -,SUP-IH3038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEADLESS 3.0MM X 40MM -,SUP-IH3040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
4.0MM HEADLESS SCREW LENGTH 32MM -,SUP-IH4032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEADLESS 4.0MM X 16MM X 36MM -,SUP-IH4036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEADLESS 4.0MM X 38MM -,SUP-IH4038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEADLESS 4.0MM X 40MM -,SUP-IH4040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEADLESS 4.0MM X 42MM -,SUP-IH4042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEADLESS 4.0MM X 46MM -,SUP-IH4046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEADLESS 4.0MM X 50MM -,SUP-IH4050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN AXIS 2.5MM X 40MM IJS-E -,SUP-IJS-EAP-25400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1727.96,1209.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN IJS-E AXIS 2.5MM X 45MM -,SUP-IJS-EAP-25450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1727.96,1209.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BLADE T10 DRIVER 4.0 SCREWS -,SUP-IS1108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,921.23,644.861,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PK SCREW INTNL FX STRL CONTR -,SUP-JG303R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21.15,14.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE 28MMX10MM JULIET OL LD SHARING ANTMC PEEK -,SUP-JUL-OL 28 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE 7X28MM STR -,SUP-JUL-OX2807-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE LUMBAR POSTERIOR TI L24 W8 H7 -,SUP-JUN-P6 24 07-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
8 X 24 PLIF TITANIUM CAGE -,SUP-JUN-P6 24 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE LUMBAR POSTERIOR TI L24 W8 H09 6 DEGREE NARROW JULIET -,SUP-JUN-P6 24 09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE PLIF TI 24 X 8.5 X 10 -,SUP-JUN-P6 24 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LUMBAR POSTERIOR TI CAGE L24 W9 H11 -,SUP-JUN-P6 24 11-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE 24 X 9 X 12 PLIF 6 DEGREE -,SUP-JUN-P6 24 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE LUMBAR POSTERIOR TI 14 X 9 X 24 6DEG -,SUP-JUN-P6 24 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LUMBAR POSTERIOR TI CAGE L24 X W8 X H07 6 DEGREE -,SUP-JUN-P62407-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LUMBAR POSTERIOR TI CAGE L24 W8.5 H10 -,SUP-JUN-P62410-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE POSTERIOR LUMBAR TI L24 X W9 X H11 6DEG JULIET -,SUP-JUN-P62411-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TITANIUM PLIF CAGE L24 X W9 X H12 6 DEGREE -,SUP-JUN-P62412-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LUMBAR POSTERIOR TI CAGE L24 W10.5 -,SUP-JUT PX 24 09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE TRANSORAMINLA LUMBAR TI L30 W 10.5 -,SUP-JUT-T6 30 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE LUMBAR TRANSFORAMINAL L30 W 10.5 -,SUP-JUT-T6 30 09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE TRANSFORAMINAL LUMBAR TI CAGE L30 W 10.5 H10 -,SUP-JUT-T6 30 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE TRANSFORAMINAL LUMBAR TI L30 W 10.5 H 11 -,SUP-JUT-T6 30 11-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE TRANSFORAMINAL LUMBAR TI L30 W10.5 H12 6 DEG -,SUP-JUT-T6 30 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE TRANSORAMINAL LUMBAR TI L 30 W 10.5 H 13 -,SUP-JUT-T6 30 13-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SYS BONE CMNT PARALLAX EZFLOW -,SUP-KP-CDS-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
KT DEVICE PARALLAX CONTR -,SUP-KP-CTR-1508C-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7002.6,4901.82,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
STENT ADVANIX BIL 10FR X 3CM DBL PIGTAIL -,SUP-M00532240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DISK SPIN MOBI- C COCR MLYBDNM EPLT UHMWPE INLAY 13X15X5MM -,SUP-MB3355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PROSTHESIS CERV DISC 13 X 17 H -,SUP-MB3375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DISC SPIN MOBI- C COCR MLYBDNM EPLT UHMWPE INLAY 15X15X5MM -,SUP-MB3555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DISC SPIN MOBI- C PROS COCR MLYBDNM EPLT UHMWPE INLAY -,SUP-MB3576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE 40MM ROD -,SUP-MC1-200040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
IMPLANT ROI-C 7MM 12 X 14MM LO -,SUP-MC1343P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE CERV 10MM/7.2MM H A/P ROI- C LRDTC -,SUP-MC1426P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE CERV 5MM/2.3MM H A/P ROI- C LRDTC -,SUP-MC1441P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE CERV 6MM/3.1MM H A/P ROI- C LRDTC -,SUP-MC1442P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE CERV 8MM/5.1MM H A/P ROI- C LRDTC -,SUP-MC1444P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE CERV 9MM/6.1MM H A/P ROI- C LRDTC -,SUP-MC1445P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
IMPLANT ROI-C LORDOSED 12X15.5 -,SUP-MC1454P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.8X22MM S3 MULDIR NS -,SUP-MD22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.8X24MM S3 MULDIR NS -,SUP-MD24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.8X26MM S3 MULDIR NS -,SUP-MD26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.8X28MM S3 MULDIR NS -,SUP-MD-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.8X28MM S3 MULDIR NS -,SUP-MD-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.8X30MM S3 MULDIR NS -,SUP-MD30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.8X32MM S3 MULDIR NS -,SUP-MD32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.8X34MM S3 MULDIR NS -,SUP-MD34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.8X36MM S3 MULDIR NS -,SUP-MD36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.8X38MM S3 MULDIR NS -,SUP-MD38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5MM X 40MM CANNULATED POLYAXIAL -,SUP-MPF-PX  55 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5MM X 35MM CANNULATED POLYAXIAL -,SUP-MPF-PX 55 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
MIDSHAFT RADIUS PLATE 112MM -,SUP-MRP-112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5996.77,4197.739,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE FREEFIX MIDSHAFT RADIUS 127MM -,SUP-MRP-127,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SIZER NATRELLE INSPIRA 325CC FULL -,SUP-MSZ-F325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SIZER NATRELLE INSPIRA 345CC FULL -,SUP-MSZ-F345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SIZER NATRELLE INSPIRA 450CC FULL -,SUP-MSZ-F450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SIZER NATRELLE INSPIRA 485CC FULL -,SUP-MSZ-F485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SIZER NATRELLE INSPIRA 330CC MODERATE -,SUP-MSZ-M330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SIZER NATRELLE INSPIRA 445CC MODERATE -,SUP-MSZ-M445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SIZER NATRELLE INSPIRA 485CC MODERATE -,SUP-MSZ-M485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MULTI-THREAD LOCKING 2.7MM X 18MM TI -,SUP-MTLS-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MULTI-THREAD LOCKING 2.7MM X 20MM -,SUP-MTLS-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MULTI-THREAD LOCKING 2.7 X 22 -,SUP-MTLS-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MULTI THREAD LOCKING 2.7MM X 32MM TI -,SUP-MTLS-27320-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MULTI THREADED LOCKING 3.0MM X 10MM TI -,SUP-MTLS-30100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MULTI THREADED LOCKING 3.0MM X 12MM TI -,SUP-MTLS-30120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MULTI THREADED LOCKING 3.0MM X 14MM TI -,SUP-MTLS-30140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MT LOCKING 3.5MM X 8MM TI -,SUP-MTLS-35080-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MT LOCKING 3.5MM X 10MM TI -,SUP-MTLS-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MT LOCKING 3.5MM X 12MM TI -,SUP-MTLS-35120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MT LOCKING 3.5MM X 14MM TI -,SUP-MTLS-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MT LOCKING 3.5MM X 16MM TI -,SUP-MTLS-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MT LOCKING 3.5MM X 18MM TI -,SUP-MTLS-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MT LOCKING 3.5MM X 20MM TI -,SUP-MTLS-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MT LOCKING 3.5MM X 22MM TI -,SUP-MTLS-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MT LOCKING 3.5MM X 24MM TI -,SUP-MTLS-35240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MT LOCKING 3.5MM X 26MM TI -,SUP-MTLS-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MT LOCKING 3.5MM X 28MM TI -,SUP-MTLS-35280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE LKG 3.5MM X 32MM MULTITHREAD TI -,SUP-MTLS-35320-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE TITANIUM MULTI-THREAD LOCKING 3.5 X 34 -,SUP-MTLS-35340-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MULTI-THREAD LOCKING 3.5MM X 36MM TI -,SUP-MTLS-35360-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MULTI-THREAD LOCKING 3.5MM X 38MM TI -,SUP-MTLS-35380-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE TITANIUM MULTI-THREAD LOCKING 3.5 X 40 -,SUP-MTLS-35400-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MULTI THREAD LOCKING 3.5MM X 42MM TI -,SUP-MTLS-35420-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MULTI-THREAD LOCKING 3.5MM X 55MM TI -,SUP-MTLS-35550-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MULTI-THREAD COMPRESSION 3 X 10 -,SUP-MTNL-30100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MULTI THREAD COMP 3.0MM X 12MM TI -,SUP-MTNL-30120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MULTI-THREAD COMPRESSION 3.0MM X 16MM TI -,SUP-MTNL-30160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE TITANIUM MULTI-THREAD LOCKING 3.5 X 10 -,SUP-MTNL-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MT COMP 3.5MM X 14MM TI -,SUP-MTNL-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MT COMP 3.5MM X 16MM TI -,SUP-MTNL-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MT COMP 3.5MM X 18MM TI -,SUP-MTNL-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MT COMP 3.5MM X 22MM TI -,SUP-MTNL-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MT COMP 3.5MM X 40MM TI -,SUP-MTNL-35400-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MULTI THREAD COMPRESSION 3.5MM X 42MM TI -,SUP-MTNL-35420-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MT COMP 3.5MM X 45MM TI -,SUP-MTNL-35450-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MT COMP 3.5MM X 50MM TI -,SUP-MTNL-35500-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW MT COMP 3.5MM X 60MM TI -,SUP-MTNL-35600-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
MIDSHAFT ULNA PLATE 97MM -,SUP-MUP-097,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5937.36,4156.152,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE MIDSHAFT ULNA 112MM -,SUP-MUP-112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5996.77,4197.739,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
MACROFORM NOVABONE 5CC -,SUP-NB1002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
MACROFORM 5CC -,SUP-NB4305,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.8X20MM LCK S3 90DG ANG TI NS -,SUP-NL20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.8X24MM LCK S3 90DG ANG TI NS -,SUP-NL24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.8X26MM LCK S3 90DG ANG TI NS -,SUP-NL-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.8X28MM LCK S3 90DG ANG TI NS -,SUP-NL28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.8X30MM LCK S3 90DG ANG TI NS -,SUP-NL30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.8X32MM LCK S3 90DG ANG TI NS -,SUP-NL32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LCK 90DG ST BN HND SHLDR -,SUP-NL-SS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,408.45,285.915,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LCK 90DG ST BN HND SHLDR -,SUP-NL-SS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN FX STNMN 18INX9IN DBL END TROC SMTH SS -,SUP-OM 71-0459,CDM,C1713,HCPCS,278,RC,,,outpatient,,,69.73,48.811,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ARTHROSCOPIC FX MAGNUM2 ACC F/SHLDR FT/ANKL RPR HALLUX -,SUP-OM-1502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1106.83,774.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUT MAG PI -,SUP-OM-4500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DEVICE SUT MAG 2 + SMARTSTITCH KNTLS -,SUP-OM-9026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SFT TIS 3.2MM KNTLS FX W/PERFECTPASSER MAGNUMWR SUT -,SUP-OM-9146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3079.23,2155.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SFT TIS 3.2MM PNCH MAG PI + -,SUP-OM-9147,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3079.23,2155.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2X14MM LCK SMTH TI DVR NS -,SUP-P14000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2X16MM LCK SMTH TI DVR NS -,SUP-P16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2X20MM LCK SMTH TI DVR NS -,SUP-P20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2X22MM LCK SMTH TI DVR NS -,SUP-P22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2X26MM LCK SMTH TI DVR NS -,SUP-P26000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW POLYAXIAL LCK 2.5 X 10 CANNULATED COCR -,SUP-PALS-25100-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW POLYAXIAL LCK 2.5 X 16 CANNULATED COCR -,SUP-PALS-25160-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW POLYAXIAL LCK 2.5 X 22MM CANNULATED COCR -,SUP-PALS-25220-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE GEMINUS POLY LOCKING 2.5MM X 24MM CANN COCR -,SUP-PALS-25240-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW POLYAXL LCK 2.5MM X 26MM CANN -,SUP-PALS-25260-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW POLYAXIAL LOCKING 3.0MM X 18MM CANNULATED -,SUP-PALS-30180-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW POLYAXIAL LOCKING 3.0MM X 22MM CANNULATED -,SUP-PALS-30220-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW POLYAXIAL LOCKING 3.0MM X 24MM CANN -,SUP-PALS-30240-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW POLYAXAIL LCK 3.0 X 34 -,SUP-PALS-30340-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW POLYAXIAL LOCKING 3.0MM X 55MM CANNULATED -,SUP-PALS-30550-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
THREADED PEG CORTICAL NON-LOCKING 2.7MM X 10MM TI -,SUP-PANL-27140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL NON LOCKING 2.7 X 16 -,SUP-PANL-27160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW PEG THREADED CORTICAL NON-LOCKING 2.7MM X 18MM TI -,SUP-PANL-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG THREADED CORTICAL NON-LOCKING 2.7MM X 20MM TI -,SUP-PANL-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG THREADED CORTICAL NON-LOCKING 2.7MM X 22MM TI -,SUP-PANL-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG THREADED CORTICAL NL 2.7MM X 26MM TI -,SUP-PANL-27260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL NON LOCKING 3.5 X 9 -,SUP-PANL-35090-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL NON LOCKING 3.5 X 10 -,SUP-PANL-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL NON LOCKING 3.5MM X 11MM -,SUP-PANL-35110-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW- CORTICAL NON-LOCKING 3.5MM X 12MM -,SUP-PANL-35120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NON-LOCK 3.5 X 13 POLY TI -,SUP-PANL-35130-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE ASSEMBLED PROTEAN FRAGMENT DOUBLE HOCKEY STICK -,SUP-PANL-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4596.25,3217.375,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NON-LOCK 3.5 X 14 POLY TI -,SUP-PANL-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NON-LOCK 3.5 X 15 POLY TI -,SUP-PANL-35150-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW POLYAXIAL NON LOCKING 3.5MM X 16MM TI -,SUP-PANL-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW POLYAXIAL NON LOCKING 3.5MM X 18MM TI -,SUP-PANL-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NON-LOCK 3.5 X 20 POLY TI -,SUP-PANL-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NON-LOCK 3.5 X 22 POLY TI -,SUP-PANL-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL NON LCK 3.5MM X 26MM TI -,SUP-PANL-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW POLYAXIAL NON LOCKING 3.5MM X 28MM TI -,SUP-PANL-35280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MM X 10MM -,SUP-PC1-003510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5MM X 12MM -,SUP-PC1-003512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NORTHSTAR 3.5 X 14 SCREW -,SUP-PC1-003514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE 3.5MM X 16MM SCREW -,SUP-PC1-003516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NORTHSTAR SCREW 3.5 X 18 -,SUP-PC1-003518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW POLY SEASPINE 3.5 MM X 20 MM -,SUP-PC1-003520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE SCREW 3.5MM X 22MM -,SUP-PC1-003522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE SCREW 35 X 24 -,SUP-PC1-003524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE SCREW 3.5 X 26 -,SUP-PC1-003526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE SCREW 4MM X 10MM -,SUP-PC1-004010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE NORTHSTAR 4MM X 12MM SCREW -,SUP-PC1-004012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MM X 14MM SPINE POLYAXIAL -,SUP-PC1-004014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4MM X 16MM SPINE POLYAXIAL -,SUP-PC1004016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3007.62,2105.334,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW POLYAXIAL 4.0 X 16 SEASPINE -,SUP-PC1-004016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SEASPINE 4.0 X 18 POLYAXIAL -,SUP-PC1-004018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NORTHSTAR SCREW 4 X 20 -,SUP-PC1-004020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SEASPINE 4.0 X 22 POLYAXIAL -,SUP-PC1-004022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SEASPINE 4.0 X 24 POLYAXIAL -,SUP-PC1-004024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE SCREW 4MM X 26MM -,SUP-PC1-004026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE SCREW 4MM X 28MM -,SUP-PC1-004028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4 X 30 -,SUP-PC1-004030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE SCREW 4.0 X 34 -,SUP-PC1-004034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CROSS LINK MED 3.5 -,SUP-PC1-013502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CROSSHOLE LARGE 3.5MM -,SUP-PC1-013503,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE MD CROSSLINK -,SUP-PC1-014002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE LARGE CROSSLINK -,SUP-PC1-014003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LATERAL OFFSET -,SUP-PC1-020015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE 0-0CONNECTOR -,SUP-PC1-023540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PARALLELL TOP LOADING 5.5 -,SUP-PC1-023560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE 0-C CONNECTOR -,SUP-PC1-063535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE SCREW 4.5MM X 24MM -,SUP-PC1-104524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE 4.5 X 26 NS#2 -,SUP-PC1-104526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE 5.5 X 26 NS#2 -,SUP-PC1-104526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE SCREW 4.5MM X 28MM -,SUP-PC1-104528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE SCREW 4.5 X 30 NS#2 -,SUP-PC1-104530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE SCREW 4.5 X 34 -,SUP-PC1-104534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE SCREW 3.5 X 24 SS -,SUP-PC1-203524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE SCREW 3.5 X 26 SS -,SUP-PC1-203526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE SCREW 3.5 X 18 -,SUP-PC1-203528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
3.5 X 30MM SMOOTH SHANK SCREW -,SUP-PC1-203530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE REDUCTION SCREW 3.5 X 14 -,SUP-PC1-303514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SET OCCIPITOCERVICOTHORACIC FIXATION SYSTEM -,SUP-PC1-400000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE ROD OCC 3.5 X 170 -,SUP-PC1-503177,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPINAL100MM TITANIUM CONTOUR -,SUP-PC1-503500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE ROD -,SUP-PC1-503502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE 30MM ROD -,SUP-PC1-503530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPINAL 40MM -,SUP-PC1-503540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD 50MM -,SUP-PC1-503550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD SPINAL 60MM TITANIUM CONTOUR -,SUP-PC1-503560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD 70MM -,SUP-PC1-503570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD 80MM -,SUP-PC1-503580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE NORTHSTAR 90MM ROD -,SUP-PC1-503590,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE ROD 4 X 120MM -,SUP-PC1-504002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE ROD 4X200MM -,SUP-PC1-504003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE ROD 80MM -,SUP-PC1-504080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE ROD 4 X 120 -,SUP-PC1-514012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE TRAN ROD 3.5 X 5.5 -,SUP-PC1-523555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1166.11,816.277,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE OCC PLATE -,SUP-PC1-700000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BONE CHIPS CANCELLOUS CRUSHED 1-8 MM 15 CC CHIP -,SUP-PCAN15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.36,804.552,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SUBSTITUTE CANC 30ML CUBE RDIGRF PRESERVON CRSH VOID FIL -,SUP-PCANCUBE30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2148.98,1504.286,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
0 PDS PLUS VIOLET 1 X 27 CT-1 -,SUP-PDP340H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18.26,12.782,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAVIO BONE PIN 4.0MM X 89 -,SUP-PFSD-01008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.46,508.522,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SUBSTITUTE WDG MATRGRF PRESERVON 18MM -,SUP-PICW8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3831.09,2681.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LEG CONTRA EXCLUDER AAA ENDO 16MM X 18MM X 11.5CM 12FR -,SUP-PLC181200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN F/ELB PLATE SYS 16HL LCK TI LNG NS -,SUP-PL-LEM16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6824.35,4777.045,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN 11X84MM 7HL LCK TI CONGR NS PNK -,SUP-PL-LEM7,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6017.99,4212.593,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN ANCHORAGE 6HL PRCONT LCK TI GRN LT -,SUP-PLP10341,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN ANCHORAGE 6HL PRCONT LCK TI GRN RT -,SUP-PLP10342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN ANCHORAGE F /HALLUX VALGUS V1 8HL PRCONT LCK TI LNG -,SUP-PLP10462,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE MTP 5-HOLE -,SUP-PLP11341,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN ANCHORAGE F /HALLUX VALGUS V2 5HL PRCONT LCK TI GRN -,SUP-PLP11342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN ANCHORAGE F/CX PLATE SYS 1.5MM TI THRD HL COLR -,SUP-PLP14341,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHORAGE MTP CP PLATE RIGHT -,SUP-PLP14342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN ANCHORAGE F/CX PLATE SYS TI THRD HL GRN -,SUP-PLP14342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN ANCHORAGE F/LPDS FUSION 0MM STP PRCONT LCK TI YEL -,SUP-PLP20342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN ANCHORAGE F/LPDS FUSION 0MM STP PRCONT LCK TI CP -,SUP-PLP29371,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN ANCHORAGE 28MM 4HL PRCONT SYM LCK UTIL TI PNK -,SUP-PLP40280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4564.66,3195.262,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN POLARUS 4HL SLOTX3 TI LRG NS -,SUP-PL-PHGR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5967.06,4176.942,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3X10MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3X12MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3X14MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3X16MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3X18MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3X20MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X16MM LCK ANCHORAGE T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3X10MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3X12MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3X14MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,657.84,460.488,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3X16MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,657.84,460.488,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3X18MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,657.84,460.488,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3X20MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3X22MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3X24MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X18MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 3.5X24MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHORAGE STANDARD SCREW 3.5 X 26MM -,SUP-PLSS3526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TROCAR CLOSURE SUTURE GRASPER -,SUP-PMI-TC-SG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,64.19,44.933,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TEMPORARY FIXATION PIN ADMIRAL -,SUP-PN AP2-100506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN FIXATION -,SUP-PN0920051001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,233.4,163.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE ASSEMBLED PROTEAN CENTRAL COLUMN LEFT -,SUP-PRT-CCP-LT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4681.13,3276.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PROTEAN CORONOID PLATE RIGHT -,SUP-PRT-CRD-RT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5237.1,3665.97,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE PROTEAN FRAG DIST ULNA -,SUP-PRT-FSP-DU,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5054.6,3538.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE Y PROTEAN FRAGMENT -,SUP-PRT-FSP-YS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4596.25,3217.375,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
DEVICE FIXATION SIZE 18 4FUSION -,SUP-QUA-4F-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11849.67,8294.769,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 12MM X 2.7MM FUCHSIA U PLUS LOCKING -,SUP-RBL1224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1070.7,749.49,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 14MM X 2.7MM GOLD U PLUS LOCKING -,SUP-RBL1225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1070.7,749.49,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 50MM UPLUS RIB -,SUP-RBL1301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6463.61,4524.527,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X50MM -,SUP-RFS-S4500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
TRUNK IPSI EXCLUDER AAA ENDO 26MM X 14.5MM X 12CM 16FR -,SUP-RLT261412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,32100.6,22470.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SIZER SMOOTH ROUND MODERATE GEL XTRA 755 CC -,SUP-RSZSHPX755S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SIZER SMOOTH ROUND MODERATE GEL HP XTRA 790 CC -,SUP-RSZSHPX790S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL IM 1.6MMX12.7MM SBFS SS -,SUP-SBFS062,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE CERVICAL LORDOTIC ANT D12 W15 H08 -,SUP-SCA-AC LS 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CERVICAL 3 X 14MM -,SUP-SCA-CS 3014-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
RSS 4.5MM STAR SCREW AND CAP 15MM L -,SUP-SCW-0961-046-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
RSS 4.5MM STAR SCREW AND CAP 20MM L -,SUP-SCW-0961-046-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
RSS 4.5MM STAR SCREW AND CAP 25MM L -,SUP-SCW-0961-046-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
RSS 4.5MM STAR SCREW AND CAP 30MM -,SUP-SCW-0961-046-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
KIT IMPLANT 10 X 9MM SPEED 1.5 X 1.5MM -,SUP-SE-0910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4623.62,3236.534,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPEED IMPLANT 11 X 08 X 08MM -,SUP-SE-1108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPEED IMPLANT 11X10X10MM -,SUP-SE-1110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPEED IMPLANT 15X15X15MM -,SUP-SE-1515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5690.99,3983.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
STAPLE -,SUP-SE-1815,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPEEDTITAM 18X15X15MM -,SUP-SE-1815TI,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7289.07,5102.349,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPEED IMPLANT TI 18X18X18MM -,SUP-SE-1818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5690.99,3983.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPEED COMPRESSION IMPLANT KIT 20X20X20 -,SUP-SE-2020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPEED TITAN IMPLANT 20 X 20 X 20MM -,SUP-SE-2020TI,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5644.52,3951.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WASHER ORTHO -,SUP-SFCW,CDM,C1713,HCPCS,278,RC,,,outpatient,,,379.28,265.496,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCARLET AL-T BONE SCREW 5 X 25MM -,SUP-SJT-LS 50 25-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5X20MM CORT/CANC DVR FT HEX HEAD TI -,SUP-SP 20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,545.51,381.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.5X10MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP10000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG 2.5X11MM NLCKG SCR CANC DVR FT ST HEX HEAD TI NS F/ANTMC -,SUP-SP11000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.5X12MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP12000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.5X13MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP13000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.5X14MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP14000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.5X15MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP15000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.5X16MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.5X16MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.5X18MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP18000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.5X20MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.5X20MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.5X22MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.5X22MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.5X22MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,534.37,374.059,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.5X24MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP24000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.5X26MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP26000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.5X34MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP34000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG SMOTH LOCKING 2 X 14 -,SUP-SPLS-20140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG SMOOTH LOCKING 2 X 16 -,SUP-SPLS-20160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG SMOOTH LOCKING TI GRAY 2.0MM X 17MM -,SUP-SPLS-20170-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG SMOOTH LOCKING 2 X 18 -,SUP-SPLS-20180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SMOOTH PEG LOCKING 2.0MM X 18MM TI -,SUP-SPLS-20180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG SMOOTH LOCKING TI GRAY 2.0MM X 19MM -,SUP-SPLS-20190-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG SMOOTH LOCKING 2 X 20 -,SUP-SPLS-20200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG SMOOTH LOCKING TI GRAY 2.0MM X 21MM -,SUP-SPLS-20210-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG SMOOTH LOCKING TI GRAY 2.0MM X 22MM -,SUP-SPLS-20220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN S3 16X71MM 16MM 3HL CONTR LCK SS SUT HL FST GUIDE -,SUP-SSPL3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5703.94,3992.758,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN S3 16X84MM 4HL CONTR LCK SS SUT HL FST GUIDE TECH -,SUP-SSPL4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5703.94,3992.758,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN S3 16X70MM 16MM 3HL CONTR LCK SS SUT HL FST GUIDE -,SUP-SSPR3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5703.94,3992.758,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN S3 16X150MM 8HL CONTR LCK SS SUT HL FST GUIDE TECH -,SUP-SSPR8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7359.1,5151.37,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SIZER IMPLANT NATR INSPIRA SIL 485CC SINGLE USE FULL PROFILE -,SUP-SSZ-F485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SIZER IMPLANT NATR INSPIRA SIL 605CC SINGLE USE FULL PROFILE -,SUP-SSZ-F605,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SIZER IMPLANT NATR INSPIRA SIL 650CC SINGLE USE FULL PROFILE -,SUP-SSZ-F650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SIZER IMPLANT NATR INSPIRA SIL 695CC SINGLE USE FULL PROFILE -,SUP-SSZ-F695,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SIZER IMPLANT NATR INSPIRA SIL 560CC SINGLE USE MOD PROFILE -,SUP-SSZ-M560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SIZER IMPLANT NATR INSPIRA SIL 600CC SINGLE USE MOD PROFILE -,SUP-SSZ-M600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 4MMSTDX20MM LCK SMTH TI S3 -,SUP-STP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 4MMSTDX25MM LCK SMTH TI S3 NS -,SUP-STP25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 4MMSTDX32.5MM LCK SMTH TI S3 -,SUP-STP325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 4MMSTDX37.5MM LCK SMTH TI S3 NS -,SUP-STP375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 4MMSTDX42.5MM LCK SMTH TI S3 NS -,SUP-STP425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 4MMSTDX45MM LCK SMTH TI S3 -,SUP-STP45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 4MMSTDX47.5MM LCK SMTH TI S3 NS -,SUP-STP475,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 4MMSTDX50MM LCK SMTH TI S3 NS -,SUP-STP50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 4MMSTDX40MM LCK THRD TI S3 NS -,SUP-STPT40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 4MMSTDX50MM LCK THRD TI S3 NS -,SUP-STPT50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ENDOSCOPIC FX SECURESTRAP W/12 ABSB STRP F/HRN RPR -,SUP-STRAP12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1878.06,1314.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SECURESTRAP 5MM ASORB STRAP -,SUP-STRAP25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2542.51,1779.757,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ASNIS III SS CANN SCREW 6.5 X 105MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BONE SCREW T8 FULLY THREADED 2.7 X 24MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BONE SCREW T10 NON-LOCKING 2.7 X 70MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BONE SCREW T10 NON-LOCKING 2.7 X 30MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
BONE SCREW T8 FULLY THREADED 2.7 X 18MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTEX 3.5 X 22MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL LONG R2.0 TI LEFT 13 X 320MM GAMMA -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 2.3 X 15MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.88,310.016,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING ST 3.5 X 46MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING FULLY THREADED T10 3.5 X 28MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING FULLY THREADED T10 3.5 X 20MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WRIST FUSION PLATE STRAIGHT 120MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8642.06,6049.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WRIST FUSION PLATE STANDARD BEND 120MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8642.06,6049.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5MMX16MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5MMX20MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5MMX26MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2.5MMX30MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
3-0 20CM STRATAFIX SPIRAL MONOCRYL PLUS UNDYED SH -,SUP-SXMP1B427,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.67,104.769,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
4-0 STRATAFIX SPIRAL MONOCRYL PLUS 45 X 45CM UNDYED PS-2 -,SUP-SXMP2B151,CDM,C1713,HCPCS,278,RC,,,outpatient,,,125.22,87.654,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SUTURE STRATAFIX 2-0 CT-1 PDS VIOL 45CM -,SUP-SXPP1A403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,117.01,81.907,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
0 STRATAFIX SYMMETRIC PDS PLUS 23CM CT-1 -,SUP-SXPP1A425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.1,107.87,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SUTURE STRATAFIX 0 CT-1 PDS VIOL 45CM -,SUP-SXPP1B407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.07,107.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SUTURE STRATAFIX 3-0 SH SPIRAL PDS VIOLET 15CM -,SUP-SXPP1B420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,183.51,128.457,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
"SUTURE STRATAFIX SPIRAL PDS PLUS 2-0 9"" 23CM VIOLET CT-2 -",SUP-SXPP1B432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,155.78,109.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SUT STRATAFIX 0 30CM SPIRAL PDS PLUS VIOLET CT-1 -,SUP-SXPP1B450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,157.03,109.921,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SET HERNIA KUMAR T ANCHORS -,SUP-TA-008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,46.32,32.424,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE REEF TA INTERBODY 9X28X8MM -,SUP-TA1-928088,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
REEF TA INTERBODY 9 X 28 X 10MM 15DEG -,SUP-TA1-928105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
REEF TA 9X 28 X 11MM INTERBODY -,SUP-TA1-928115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SEASPINE REEF TA INTERBODY 9X32X8MM -,SUP-TA1-932088,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
INTERBODY 9X32X11 15DEG -,SUP-TA1-932115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN 70MM TENSION BAND -,SUP-TB-1570K,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1219.12,853.384,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW TROCHLEAR COMPRESSION FEMALE -,SUP-TCS-F,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1833.97,1283.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW TROCHLEAR COMPRESSION LOCKING CAP -,SUP-TCS-LC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1303.92,912.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW TROCHLEAR COMPRESSION MALE 60MM -,SUP-TCS-M-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD 35MM -,SUP-TLF-5P T0 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD 40MM -,SUP-TLF-5P T0 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD 45MM -,SUP-TLF-5P T0 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD PREBENT TITANIUM 50MM -,SUP-TLF-5P T0 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PREBENT ROD TITANIUM 55MM -,SUP-TLF-5P T0 55-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD 60MM -,SUP-TLF-5P T0 60-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PERLA TL PREBENT ROD TITANIUM 90MM -,SUP-TLF-5P T0 90-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD 5.5 X  70 -,SUP-TLF-5P TO 70-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ROD PREBENT 6MM X 40MM -,SUP-TLF-6P T0 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5 X 35 -,SUP-TLF-CS 55 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 5.5MM X 40MM -,SUP-TLF-CS 55 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CORTICAL BONE SCREW 5.5 X 45 -,SUP-TLF-CS 55 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5MM X 30MM -,SUP-TLF-CS 65 30-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5 X 35 -,SUP-TLF-CS 65 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCEW 6.5 X 40 -,SUP-TLF-CS 65 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 6.5 X 45 -,SUP-TLF-CS 65 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEAD -,SUP-TLF-MH PL 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
REDUCTION HEAD -,SUP-TLF-MH RE 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SET -,SUP-TLF-SC 00 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.5X10MM LCK LAG P/T TI DVR NS -,SUP-TP10000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.5X14MM TI DVR NS -,SUP-TP14000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.5X16MM TI DVR NS -,SUP-TP16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.5X18MM TI DVR NS -,SUP-TP18000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.5X20MM P/T -,SUP-TP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,534.37,374.059,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.5X20MM TI DVR NS -,SUP-TP20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG BN FX 2.5X28MM TI DVR NS -,SUP-TP28000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
THREADED PEG FLUTED LCK 2.3 X 20 -,SUP-TPFL-23200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG FIXATION LOCKING 2.3 X 10 TI -,SUP-TPLS-23100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG THREADED LOCKING 2.3MM X 12MM TI -,SUP-TPLS-23120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
THREADED PEG- LOCKING- 2.3MM X 16MM -,SUP-TPLS-23160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LCK TRH PEG 2.3 X 17MM -,SUP-TPLS-23170-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
THREADED PEG- LOCKING- 2.3MM X 18MM -,SUP-TPLS-23180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG THREADED LOCKING 2.3MM X 19MM -,SUP-TPLS-23190-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LCK TRH PEG 2.3 X 20MM -,SUP-TPLS-23200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
THREADED PEG- LOCKING 2.3MM X 21MM -,SUP-TPLS-23210-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
THREADED PEG LOCKING 2.3MM X 22MM -,SUP-TPLS-23220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
THREADED PEG- LOCKING 2.3MM X 23MM -,SUP-TPLS-23230-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG THREADED LOCKING TI PINK 2.3MM X 24MM -,SUP-TPLS-23240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
THREADED PEG- LOCKING 2.3MM X 26MM -,SUP-TPLS-23260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG THREADED 2.3 X 28 LOCKING -,SUP-TPLS-23280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG TRHEADED NON-LOCKING 2.7MM X 10MM TI -,SUP-TPNL-27100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG THREADES NON LOCKING 2.7 X 12 -,SUP-TPNL-27120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG THREADED NON LOCKING 2.7MM X 14MM -,SUP-TPNL-27140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG THREADES NON LOCKING 2.7 X 16 -,SUP-TPNL-27160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG THREADED NON LOCKING 2.7 X 18 -,SUP-TPNL-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NON-LCK TRH PEG 2.7 X 20MM -,SUP-TPNL-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NON-LCK TRH PEG 2.7 X 22MM -,SUP-TPNL-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG THREADED NON-LOCKING 2.7MM X 24MM -,SUP-TPNL-27240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG THREADED NON-LOCKING 2.7MM X 26MM -,SUP-TPNL-27260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PEG THREADED NON LOCKING 2.7MM X 28MM -,SUP-TPNL-27280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SUBSTITUTE DBM 5ML PTTY OPTIUM FRZDR -,SUP-TPUT05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2696.31,1887.417,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CAGE CERVICAL LORDOTIC D12 W14 H07 -,SUP-TRY-CL 12 07-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
CERVICAL CAGE-LORDOTIC D12 W14 H08 -,SUP-TRY-CL 12 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BONE 20MM 1-LEVEL SPINE CERVICAL -,SUP-TRY-CP 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 22MM -,SUP-TRY-CP 04 22-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 24MM 1-LEVEL -,SUP-TRY-CP 04 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 26MM 1-LEVEL -,SUP-TRY-CP 04 26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 2 LEVEL 36MM -,SUP-TRY-CP 06 36-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 38MM 2-LEVEL -,SUP-TRY-CP 06 38-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 40MM 2 LEVEL -,SUP-TRY-CP 06 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 43MM 2-LEVEL -,SUP-TRY-CP 06 43-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 46MM 2-LEVEL -,SUP-TRY-CP 06 46-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SPINEART TRYPTIK 2- PLATE-52MM-3-LEVEL -,SUP-TRY-CP 08 52-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 55MM 3-LEVEL -,SUP-TRY-CP 08 55-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE TRYPTIK 58MM 3-LEVEL -,SUP-TRY-CP 08 58-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 61MM 3-LEVEL -,SUP-TRY-CP 08 61-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE TRYPTIK 72MM 3 LEVEL -,SUP-TRY-CP 08 72-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 12MM SELF DRILLING POLYAXIAL -,SUP-TRY-PD 40 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SELF-DRILLING POLYAXIAL 4 X 14 -,SUP-TRY-PD 40 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SELF-DRILLING POLYAXIAL 4 X 16 -,SUP-TRY-PD 40 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SELF DRILLING POLYAXIAL 4.5 X 16 -,SUP-TRY-PD 45 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW SELF TAPPING 4 X 14 -,SUP-TRY-PS 40 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW TRYPTIK SELF-TAPPING 4 X 16 -,SUP-TRY-PS 40 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
STENT GRAFT 28 X 14 X 140MM OVATION ILIAC LIMB -,SUP-TV-IL1428140-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEPIN ORTHO THRD DRILL TIP -,SUP-U000-0200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHORAGE LISFRANC PLATING MED -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHOR SUT 2.3MM FIBERWIREX2 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ANCHORAGE LAPIDUS PLATING LS 0 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
FEMORAL AUGMENT DISTAL SZ3 12M -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOCKING COMP BROAD 16 HOLE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.44,869.708,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LOCKING PLATE 6 HOLE 2.0/2.3 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4600.23,3220.161,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL LONG R1/5 RT 11 X 440MM X -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL TI LNG RT 15 X 440MM X1 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 6 HOLE STRAIGHT -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BROAD 7 HOLE VARIAX COMP -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE DIAMOND FUSION LARGE NON -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7238.14,5066.698,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL LONG LT TI 11X400 130 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 6 HOLE CURVED -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL FLEXIBLE 2.5MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.59,822.213,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE CERVICAL 2 LEVEL 30MM GE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE DIST POST LAT HUMERAL 6H -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE GRIP TRICHANTERIC W/2 CA -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7111.03,4977.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE HUMERUS RT. 14 HOLE L218 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ANCHORAGE 3.0 X 28MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ANCHORAGE 3.5MM X 16MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ANCHORAGE LOCK 3.5 X 14 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS 6.5MM X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.94,757.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
LO-PRO MTP PLT TM CONTRDSHTLTI -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE 2.3 X 18MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE T10 2.7 X 48MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL 5.5 X 40MM HIGH -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL FLEXIBLE 1.5MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
NAIL FLEXIBLE 2.0MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEADLESS 2.5 X 12MM MICR -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCK LP 4.5 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCK LP 4.5 X 26MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCK LP 4.5 X 46MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NON LOCKING 2.3 X 21MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,408.04,285.628,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW TRILOCK 2.8 X 12MM HD7 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE 10 HOLE LOCKING COMPR BR -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE M ADAPTIVE II 2.5 TRI DI -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5810.88,4067.616,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SCREW GAP 6.5MM 20MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,663.67,464.569,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE RT ANTERIOR ANKLE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8806.3,6164.41,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SCREW GAP 6.5MM 30MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,663.67,464.569,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE SUPERIOR 6H INCREASED -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE WSTD CMP BRD 16 HOLE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.44,869.708,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WASHER ORTHO -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,158.48,110.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ANCHORAGE 3.5MM X 20MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ANCHORAGE 3.5MM X 32MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS CANN TI 5.0 X 60MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS TI 5.0 X 36MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW AUTOFIX 2.5 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE 2.3 X 26 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE 3.5 X 46MM NON-LOCK -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANN ASNIS III 5.0X 70MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTICAL 5.5 X 30MM GENE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 1.2 X 12MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW EMERGENCY 1.4 X 3 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW HEADLESS COMP. 4.0MM 32M -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LCK ST 2.7 X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCK LP 4.5 X 24MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCK LP 4.5 X 32MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCK LP 4.5 X 44MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 2.3 X 12MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING T10 2.7 X 48MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NON LOCK LP 4.5 X 30MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NON LOCKING 3.5 X 55MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NON-LOCK LP 4.5 X 28MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW VA 4.25 X 14MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ANCHORAGE LOCK 3.5 X 12 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS 5.0MM 60MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ANCHORAGE 3.5MM X 14MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ANCHORAGE LOCK 3.5 X 18 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ANSIS 4.0 X 44MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS III SS CANN 5 X 38 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS III SS CANN 5 X 46 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW ASNIS TI 5.0 X 40MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW BONE T10 2.7 X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANN ASNIS III 5.0X 65MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CANN FT 4.0 X 40MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORT HI-TOP 5.5 X 35MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW CORTEX T8 2.4MM X 8MM SE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING 2.3 X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING T10 2.7 X 20MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LP 5.5 X 55MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW M CORTEX 2.3 X 16MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NON LOCKING 2.3 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LO-PRO PT 5MM X 50MM THR -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW LOCKING SILVER 2.5 X 16M -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW TI LOCK 5.5 X 35MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW TRILOCK 2.8 X 34MM HD7 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NON-LOCK LP 4.5 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.5,297.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW NON-LOCK LP 4.5 X 24MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW PERIPH NL 4.5 X 30MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW S-FIX 2.5LG X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW T2 F/T LOCK 5 X 105MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW TRILOCK 2.8 X 10MM HD7 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WIRE TEMP KIRSCH 1X100MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.71,106.197,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PLATE BN ULTRA PIN -,SUP-UPP3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X23MM COMPR AEQUALIS REVERSED II ST NS F/BSPLT -,SUP-VDV223,CDM,C1713,HCPCS,278,RC,,,outpatient,,,980.28,686.196,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 4.5X35MM COMPR AEQUALIS REVERSED II ST NS F/BSPLT -,SUP-VDV235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
"V-LOC 180 ABSORABLE RELOAD 2-0 6"" ES-9 TAPER -",SUP-VLOCA206L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,211.29,147.903,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SUTURE V-LOC ABSORBABLE 2-0 8 IN FOR ENDOSTITCH -,SUP-VLOCA208L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,249.42,174.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
"SUT V-LOC 180 2-0 P-12 12""CLEAR -",SUP-VLOCL0015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.68,88.676,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
"V-LOC 0 ABS 12"" GS-21 GREEN -",SUP-VLOCL0316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,125.34,87.738,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
"V-LOC 2-0 ABS 18"" GS-21 GREEN -",SUP-VLOCL0325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,125.34,87.738,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
"V-LOC 0 ABS 18"" GS-21 GREEN -",SUP-VLOCL0326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,130.1,91.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
"SUT V-LOC 180 0 GS-21 9"" GREEN -",SUP-VLOCL0346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,124.81,87.367,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
"V-LOC 3-0 ABS 6"" V-20 GREEN -",SUP-VLOCL0604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.66,927.962,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
"V-LOC 180 GREEN 12"" V-20 TAPER -",SUP-VLOCL0614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
"SUTURE VLOC 9"" 1/2 CIRCLE 26MM -",SUP-VLOCL0644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
"SUT V-LOC 180 3-0 CV-23 6"" GREEN -",SUP-VLOCL0804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
"SUT V-LOC 180 3-0 CV-23 12"" GREEN -",SUP-VLOCL0814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
"V-LOC 2-0 ABS 9"" GS-22 GREEN -",SUP-VLOCL2145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
"V-LOC 3-0 ABS 18"" P-14 UNDYED -",SUP-VLOCM0124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.68,88.676,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
"V-LOC 3-0 ABS  6"" CV-23 VIOLET -",SUP-VLOCM0804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
"V-LOC 3-0 ABS 18"" P-17 UNDYED -",SUP-VLOCM1824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.68,88.676,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SUT V-LOC 90 2-0 GS-22 TAPER 12IN VIOLET -,SUP-VLOCM2115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,136.19,95.333,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
"SUTURE V-LOC 0 NON-ABS 6"" GS-21 BLUE -",SUP-VLOCN0306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,90.79,63.553,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
"V-LOC 2-0 PBT NON-ABS 6"" V-20 BLUE -",SUP-VLOCN0605,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1309.01,916.307,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
"V-LOC 2-0 NON-ABS 12"" V-20 BLUE -",SUP-VLOCN0615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
VLOC PBT 1 BLU 12 GS-22 -,SUP-VLOCN2117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,131.58,92.106,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
VLOC PBT 0 BLU 9 GS-22 NON-ABS -,SUP-VLOCN2146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,131.58,92.106,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GRAFT VALLIANT STENT 20F 31 X 90 NACION THORACIC -,SUP-VNMC3131C90TU,CDM,C1713,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN BALL JURGAN .045 YELLOW -,SUP-W045-YL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PK CAP PROT 0.375IN PIN BALL W-SRS F/0.045IN K-WR XTRNFXTR -,SUP-W045-YL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,256.74,179.718,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PIN BALL JURGAN .062 GREEN -,SUP-W062-GN,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PK CAP PROT 0.375IN PIN HEAD JRGN PIN BALL W-SRS F/.0938IN -,SUP-W332-CR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PK CAP PROT 0.375IN PIN HEAD JRGN PIN BALL W-SRS F/.0781IN -,SUP-W564-BL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PK CAP PROT 0.375IN PIN HEAD JRGN PIN BALL W-SRS F/.0781IN -,SUP-W564-BL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,256.74,179.718,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WASHER INSIDE 2.7MM OUTSIDE 5MM -,SUP-WBTN-2750-T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.27,240.989,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WASHER BUTTON BRONZE -,SUP-WBTN-HCLP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.93,224.651,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2MMX12MM NCANN TWST-OFF W- FX FIXOS MICROTHREADED -,SUP-WS12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 13MM NCANN TWST-OFF W- FX FIXOS MICROTHREADED -,SUP-WS13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SNAP OFF SCREW DIAM 2.1 LG.14 -,SUP-WS14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2MMX15MM NCANN W- FX FIXOS MICROTHREADED SD/ST/RM -,SUP-WS15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SCREW 2MMX16MM NCANN W- FX FIXOS MICROTHREADED SD/ST/RM -,SUP-WS16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
ORTHO 0.35MM -,SUP-WSO906ST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.7,81.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
WOUND MATRIX 6 LAYER 10CM X 15CM 150SQCM -,SUP-WSX1015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16411.46,11488.022,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
PK PIN BALL PIN BALL PROT REFL 0.125IN 0.1094X.125IN F/3MM -,SUP-X003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SUTURE MONODERM QUILL 3-0 MONO CLR YA-1023Q 30CMX30CM L BARB -,SUP-YA-1023Q,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.56,90.692,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
SUTURE MONODERM QUILL #0 MONO CLR YA-1029Q 36CMX36CM L BARB -,SUP-YA-1029Q,CDM,C1713,HCPCS,278,RC,,,outpatient,,,136.04,95.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.518595,35041.66656,other,Non-Reimbursable List,,
GUIDEWIRE HI-TORQUE CONNECT 250FT -,SUP-1012595,CDM,C1714,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List,,
EARLY ACCESSORY DROP OFF FEE -,SUP-10595-10169,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List,,
K-WIRE GAMMA 3.2 X 450MM -,SUP-1210-6451S,CDM,C1714,HCPCS,272,RC,,,outpatient,,,478.7,335.09,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List,,
SCREWDRIVER FLEXIBLE GAMMA -,SUP-1320-0233,CDM,C1714,HCPCS,272,RC,,,outpatient,,,2438.28,1706.796,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List,,
LEE RT ANG BRONCHUS CLAMP 9 39MM JAW -,SUP-320200,CDM,C1714,HCPCS,272,RC,,,outpatient,,,779.26,545.482,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List,,
PROBE BALL TIP 3MM TIP PEDICLE SCREW D344 -,SUP-3603-00-TE,CDM,C1714,HCPCS,272,RC,,,outpatient,,,601.01,420.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List,,
"KWIRE SINGLE POINT STST 150MM X .045"" -",SUP-451-1045,CDM,C1714,HCPCS,272,RC,,,outpatient,,,152.76,106.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List,,
10X30CM PICO14 DRESSING KIT -,SUP-66022043,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1562.06,1093.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List,,
HOLDER/POSITIOINER PLATE 1.2/1.55 FOR INSTRUMENT -,SUP-A-2350,CDM,C1714,HCPCS,272,RC,,,outpatient,,,4147.65,2903.355,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List,,
HOLDER/POSITIOINER PLATE 2.0/2.3 FOR INSTRUMENT -,SUP-A-2650,CDM,C1714,HCPCS,272,RC,,,outpatient,,,4147.65,2903.355,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List,,
KIT FIBERTAK KNOTLESS CURVED DISPOSABLE -,SUP-AR-3638DC,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List,,
B CROSSTELLAÂ® RX PTA Balloon Dilatation Cath 6mm x 150mm -,SUP-BD-F60150LR,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List,,
BALLOON R2P CROSTELLA  RX- 200cm- 6mm x 150mm -,SUP-BD-Q60150ER,CDM,C1714,HCPCS,272,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List,,
CATH BLNOCC 1.3MM 5FR SHTH 146CM 20CM LUM C RSSR 14S RX -,SUP-CRU14S,CDM,C1714,HCPCS,272,RC,,,outpatient,,,9315.58,6520.906,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List,,
CATH BLNOCC 1.1MM 5FR SHTH 146CM C RSSR 14P OTW PERIPH -,SUP-CRUO14PA,CDM,C1714,HCPCS,272,RC,,,outpatient,,,9315.58,6520.906,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List,,
CATH PTCA 0.05IN C RSSR S6 156CM RECANALIZATION PERIPH 5FR -,SUP-CRUS6A,CDM,C1714,HCPCS,272,RC,,,outpatient,,,9315.58,6520.906,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List,,
DRILL KIT FOR CONTINUOUS COMPRESSION -,SUP-DK-265C,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1863.92,1304.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List,,
INTERSTIM BELT FIXATION LARGE SCS PH -,SUP-FP9000L,CDM,C1714,HCPCS,272,RC,,,outpatient,,,233.4,163.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List,,
DILATOR COONS -,SUP-G04051,CDM,C1714,HCPCS,272,RC,,,outpatient,,,102.05,71.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List,,
CATH ANG 5FR DAV 100CM ADVANTG BRD VSCR -,SUP-G08581,CDM,C1714,HCPCS,272,RC,,,outpatient,,,151.7,106.19,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List,,
BALLOON EXTRACTOR PRO XL RETREIVAL 9-12 -,SUP-M00547130,CDM,C1714,HCPCS,272,RC,,,outpatient,,,612.32,428.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List,,
SET DELIVERY SIROS -,SUP-SIR-10300,CDM,C1714,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List,,
BLADE HOOK DISSECTING SYNERGY HARMONIC -,SUP-SNGHK,CDM,C1714,HCPCS,272,RC,,,outpatient,,,2781.64,1947.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List,,
SUTURE 3-0 MONO PLUS 16 X 16CM UNDYED -,SUP-SXMP2B402,CDM,C1714,HCPCS,272,RC,,,outpatient,,,166.17,116.319,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List,,
DRESSING KCI VERAFLO CLEANSE CHOICE LARGE -,SUP-ULTVCC05LG,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1428.85,1000.195,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List,,
DRESSING NEG PRSS SM 10X7.5X3.3CM VAC GRANUFOAM -,SUP-XF-DSMF1,CDM,C1714,HCPCS,272,RC,,,outpatient,,,163.38,114.366,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.910225,6679.27086,other,Non-Reimbursable List,,
NEEDLE BRCHTX 18GAX20CM ULTRA-SHRP TIP PLSH SURF PRELD BN -,SUP-818205,CDM,C1715,CPT,272,RC,,,outpatient,,,84.61,59.227,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,18.994945,416.02,other,Non-Reimbursable List,,
CURRENT DR RF 2207-36 AICD -,SUP-2207-36,CDM,C1721,HCPCS,275,RC,,,outpatient,,,44309.79,31016.853,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR LUMAX 740 DR-T 2CHMBR CARD IMPL W/HOME MNTR -,SUP-365606,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30837.5,21586.25,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR ILESTO DR-T DF-1 2CHMBR HI ENRG CARD IMPL W/TI -,SUP-383562,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25644.47,17951.129,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR ILESTO DR-T DF-4 2CHMBR HI ENRG CARD IMPL W/TI -,SUP-383564,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25644.47,17951.129,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR ITREVIA 7 DR-T DF-4 2CHMBR CARD IMPL W/TI -,SUP-392426,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25644.47,17951.129,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR CRNT + DR DF-4 2CHMBR RR V- PCNG RDC 50X74MM -,SUP-CD2211-36Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR FORTIFY DR DF-1 2CHMBR 40X74MM 14MM 35ML 76GM -,SUP-CD2231-40,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR FORTIFY DR DF-4 2CHMBR RR V- PCNG RDC 40X71MM -,SUP-CD2231-40Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR FORTIFY ASSURA DR DF-1 TELEM 2CHMBR 40X74MM -,SUP-CD2257-40,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR FORTIFY ASSURA DR DF-4 TELEM 2CHMBR 40X71MM -,SUP-CD2257-40Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR ELLIPSE DR DF-1 IS-1 CONN 2CHMBR DEFT RESPONSE -,SUP-CD2311-36,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR ELLIPSE DR DF-4 2CHMBR DEFT RESPONSE RF TELEM -,SUP-CD2311-36Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR FORTIFY ASSURA DR DF-4 2CHMBR CARD IMPL 40C -,SUP-CD2357-40C,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR FORTIFY ASSURA DR DF-4 2CHMBR CARD IMP 40Q -,SUP-CD2357-40Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR ELLIPSE VR IS-1 DF-1 2CHMBR 51X68MM 12MM 31ML -,SUP-CD2411-36C,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR ELLIPSE ASSURA DR DF-4 2CHMBR CARD IMPL -,SUP-CD2411-36Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
ENTRANT ICD CDDRA300Q -,SUP-CDDRA300Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37130,25991,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
ENTRANT DR ICD DF1 CONNECTOR REF: CDDRA300T -,SUP-CDDRA300T,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37130,25991,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
GALLANT ICD CDDRA500Q -,SUP-CDDRA500Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,26150.2,18305.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
GALLANT DR ICD DF1 CONNECTOR REF: CDDRA500T -,SUP-CDDRA500T,CDM,C1721,HCPCS,275,RC,,,outpatient,,,26150.2,18305.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR INOGEN DF-1 SGL-CHMBR 5.23X7.14X0.99 CM D -,SUP-D013,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25975.04,18182.528,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DYNAGEN MINI ICD DR D022 -,SUP-D022,CDM,C1721,HCPCS,275,RC,,,outpatient,,,36747.56,25723.292,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
ICD MOMENTUM EO DR D121 -,SUP-D121,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25903.5,18132.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR D142 INOGEN MUL PRGM OPTN EXTEND LNGVT DR DF-4 -,SUP-D142,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25091.86,17564.302,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DYNAGEN D153 EL ICD -DF-1 -,SUP-D153,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25091.86,17564.302,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR CONSULTA DF-4 CARD IMPL -,SUP-D204TRM,CDM,C1721,HCPCS,275,RC,,,outpatient,,,48626.05,34038.235,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR SECURA DR 2CHMBR RR V- PCNG RDC 51X64MM 15MM -,SUP-D224DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,35700.82,24990.574,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR SECURA VR SGL-CHMBR RR V- PCNG RDC 51X64MM -,SUP-D224VRC,CDM,C1721,HCPCS,275,RC,,,outpatient,,,31901.76,22331.232,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
ICD DUAL VIGILANT EL DR DF4 MRI CONDITIONAL -,SUP-D233,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25903.5,18132.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR MAXIMO II DR WRLS TELEM 2CHMBR RR V- PCNG RDC -,SUP-D284DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34217.29,23952.103,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR PROTECTA XT DR DF-1 IS-1 CONN 2CHMBR RR -,SUP-D314DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37579.81,26305.867,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR PROTECTA DR DF-1 IS-1 CONN 2CHMBR RR V- PCNG -,SUP-D334DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32749.43,22924.601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR PROTECTA DR DF-4 2CHMBR CARD IMPL -,SUP-D334DRM,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32749.43,22924.601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
ICD PERCIVA DR D401 -,SUP-D401,CDM,C1721,HCPCS,275,RC,,,outpatient,,,27894.37,19526.059,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
ICD PERCIVA DR DF4 D413 MRI CONDITIONAL -,SUP-D413,CDM,C1721,HCPCS,275,RC,,,outpatient,,,27894.37,19526.059,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR EVERA S DR DF-1 2CHMBR CARD IMPL -,SUP-DDBC3D1,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32071,22449.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR EVERA S DR DF-4 2CHMBR CARD IMPL -,SUP-DDBC3D4,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32071,22449.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR EVERA MRI XT DR SURSCN DF-4 CARD IMPL -,SUP-DDMB1D1,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37251.7,26076.19,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
EVERA MRI S DR SURESCAN MODEL DDMC3D1 -,SUP-DDMC3D1,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34784.7,24349.29,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR EVERA 2CHMBR CARD IMPL -,SUP-DDMC3D4,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34784.7,24349.29,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
ICD DUAL COBALT DR MRI REF: DDPB3D4 -,SUP-DDPB3D4,CDM,C1721,HCPCS,275,RC,,,outpatient,,,38485.2,26939.64,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR OVATIO CARD 6550 -,SUP-DR6550,CDM,C1721,HCPCS,275,RC,,,outpatient,,,45639.5,31947.65,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DYNAGEN CRT-D G151 -,SUP-G151,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32897.45,23028.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR VITALITY II DR IS-1 DF-1 2CHMBR V- PCNG RDC -,SUP-T167,CDM,C1721,HCPCS,275,RC,,,outpatient,,,43197.17,30238.019,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR VITALITY HE IS-1 DF-1 2CHMBR 66MMX82.6MM -,SUP-T180,CDM,C1721,HCPCS,275,RC,,,outpatient,,,41877.33,29314.131,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR PARADYM RF VR IMPL 9250 -,SUP-TDF011U,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25661.73,17963.211,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,37344.8064,other,SI=N Exclusions ,,
DEFIBRILLATOR SQ-RX DF-1 SGL-CHMBR 65.5MMX78.2MMX15.7MM D -,SUP-1010,CDM,C1722,HCPCS,275,RC,,,outpatient,,,46873,32811.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
DEFIBRILLATOR CRNT VR RF SGL-CHMBR VNTRC PCNG CARD IMPL -,SUP-1207/36,CDM,C1722,HCPCS,275,RC,,,outpatient,,,37656.29,26359.403,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
DEFIBRILLATOR LUMAX 540 VR-T IS-1 CONN SGL-CHMBR RR 55X66MM -,SUP-360348,CDM,C1722,HCPCS,275,RC,,,outpatient,,,30895.47,21626.829,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
DEFIBRILLATOR LUMAX 740 VR-T SGL-CHMBR CARD IMPL W/HOME MNTR -,SUP-365609,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28370.5,19859.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
DEFIBRILLATOR LUMAX 740 VR-T DX CARD IMPL CELL GSM HOME MNTR -,SUP-372419,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28370.5,19859.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
DEFIBRILLATOR ILESTO VR-T SGL-CHMBR CARD IMPL -,SUP-383578,CDM,C1722,HCPCS,275,RC,,,outpatient,,,30837.5,21586.25,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
DEFIBRILLATOR ILESTO VR SGL-CHMBR HI ENRG CARD IMPL W/TI -,SUP-383580,CDM,C1722,HCPCS,275,RC,,,outpatient,,,30837.5,21586.25,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
DEFIBRILLATOR ILESTO DX HI ENRG CARD IMPL W/TI LANDLINE HOME -,SUP-383594,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35737.63,25016.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
DEFIBRILLATOR ITREVIA 7 VR-T DX HI ENRG CARD IMPL -,SUP-393037,CDM,C1722,HCPCS,275,RC,,,outpatient,,,24694.67,17286.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
DEVICE HI ENRG CARD IMPL TI -,SUP-393041,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35737.63,25016.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
ICD INTICA NEO 7 VR-T DX REF:429559 -,SUP-429559,CDM,C1722,HCPCS,275,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
DEFIBRILLATOR EMBLEM S SQ-1 CONN 83.1MMX69.1MMX12.7MM D -,SUP-A209,CDM,C1722,HCPCS,275,RC,,,outpatient,,,46873,32811.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
S-ICD Emblem MRI A219 -,SUP-A219,CDM,C1722,HCPCS,275,RC,,,outpatient,,,44406,31084.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
DEFIBRILLATOR CRNT + VR SJ-4 CONN SGL-CHMBR 50X74MM 14MM -,SUP-CD1211-36Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
DEFIBRILLATOR FORTIFY VR DF-1 SGL-CHMBR 40X73MM 14MM 35ML -,SUP-CD1231-40,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
DEFIBRILLATOR FORTIFY VR DF-4 ATP TERM AUTOMATICITY -,SUP-CD1231-40Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
DEFIBRILLATOR FORTIFY ASSURA VR DF-1 TELEM SGL-CHMBR 40X73MM -,SUP-CD1257-40,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
DEFIBRILLATOR FORTIFY ASSURA VR DF-4 SGL-CHMBR RF TELEM -,SUP-CD1257-40Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
DEFIBRILLATOR ELLIPSE VR DF-1 IS-1 CONN SGL-CHMBR DEFT -,SUP-CD1311-36,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
DEFIBRILLATOR ELLIPSE VR DF-4 DF-1 IS-1 CONN SGL-CHMBR DEFT -,SUP-CD1311-36Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,25163.4,17614.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
DEFIBRILLATOR FORTIFY ASSURA VR DF-1 IS-1 CONN SGL-CHMBR -,SUP-CD1357-40C,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
DEFIBRILLATOR FORTIFY ASSURA VR DF-4 SGL-CHMBR 40X71MM 14MM -,SUP-CD1357-40Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
DEFIBRILLATOR ELLIPSE VR IS-1 DF-1 SGL-CHMBR 51X68MM 12MM -,SUP-CD1411-36C,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
DEFIBRILLATOR ELLIPSE VR-ICD MRLN DF-4 SGL-CHMBR -,SUP-CD1411-36Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
ENTRANT ICD CDVRA300Q -,SUP-CDVRA300Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35273.5,24691.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
ENTRANT VR ICD DF1 CONNECTOR REF: CDVRA300T -,SUP-CDVRA300T,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35273.5,24691.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
GALLANT ICD CDVRA500Q -,SUP-CDVRA500Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36201.75,25341.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
GALLANT VR ICD DF1 CONNECTOR REF: CDVRA500T -,SUP-CDVRA500T,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36201.75,25341.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
DEFIBRILLATOR INOGEN DF-1 SGL-CHMBR 5.23X7.14X0.99 CM D. -,SUP-D011,CDM,C1722,HCPCS,275,RC,,,outpatient,,,26643.6,18650.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
ICD MOMENTUM EL VR D120 -,SUP-D120,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36573.05,25601.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
DEFIBRILLATOR INOGEN EXTEND LNGVT 5.37X7.36X0.99IN 68.9G -,SUP-D140,CDM,C1722,HCPCS,275,RC,,,outpatient,,,34746.25,24322.375,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
DYNAGEN EL ICD VR MODEL D151 -,SUP-D151,CDM,C1722,HCPCS,275,RC,,,outpatient,,,34746.25,24322.375,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
DEFIBRILLATOR SECURA DR DF-4 2CHMBR CARD IMPL -,SUP-D204DRM,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35700.82,24990.574,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
DEFIBRILLATOR SECURA VR DF-4 SGL-CHMBR CARD IMPL -,SUP-D204VRM,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31901.76,22331.232,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
ICD VIGILANT EO VR DF4 D232 MRI CONDITIONAL -,SUP-D232,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36573.05,25601.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
DEFIBRILLATOR PROTECTA VR DF-1 IS-1 CONN SGL-CHMBR RR -,SUP-D334VRG,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28710.95,20097.665,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
DEFIBRILLATOR PROTECTA VR DF-4 SGL-CHMBR CARD IMPL -,SUP-D334VRM,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28710.95,20097.665,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
ICD SINGLE PERCIVA VR REF: D400 -,SUP-D400,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36573.05,25601.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
ICD PERCIVA VR DF4 D142 MRI CONDITIONAL -,SUP-D412,CDM,C1722,HCPCS,275,RC,,,outpatient,,,25827.02,18078.914,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
ICD RESONATE EL VR -,SUP-D432,CDM,C1722,HCPCS,275,RC,,,outpatient,,,29019.32,20313.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
COBALT XT DR MRI ICD REF: DDPA2D4 -,SUP-DDPA2D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,41837.85,29286.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
DEFIBRILLATOR EVERA S VR DF-1 SGL-CHMBR CARD IMPL -,SUP-DVBC3D1,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28617.2,20032.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
DEFIBRILLATOR EVERA S VR DF-4 SGL-CHMBR CARD IMPL -,SUP-DVBC3D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28617.2,20032.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
VISIA AF MRI VR ICD DVFB1D1 -,SUP-DVFB1D1,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
ICD VISIA AF MRI SURESCAN VR -,SUP-DVFB1D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
DEFIBRILLATOR CARDIAC VISIA AF MRI SURESCAN DVFC3D1 -,SUP-DVFC3D1,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
DEFIBRILLATOR EVERA MRI XT DR SURSCN DF-4 CARD IMPL -,SUP-DVMB1D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,35998.464,other,Non-Reimbursable List,,
EXPLANT TRUNCATED BLADE 56MM -,SUP-00-7053-056-10,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List,,
C 0.9M .014IN OTW TURBO ELITE -,SUP-410-152,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List,,
C 1.4M .014IN OTW TURBO ELITE -,SUP-414-151,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List,,
"2.0mm .018"" TURBO ELITE LASER -",SUP-420-006,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List,,
C 2.3M .018IN OTW TURBO ELITE -,SUP-423-001,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List,,
C 7FR LASER GUIDE 2.0MM TURBO -,SUP-423-050,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12234.34,8564.038,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List,,
DEVICE ATHRCMY STEALTH 360 1.5MM MICRO CRWN 145CM SHFT DMD -,SUP-DBE-150,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12605.64,8823.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List,,
CATH ATHRCMY DIAMONDBACK 360 1.25MM CROWN 135CM SHAFT -,SUP-DBEC-125,CDM,C1724,HCPCS,272,RC,,,outpatient,,,14833.44,10383.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List,,
DEVICE ATHRCMY PREDATOR 360 2MM CRWN DMD CTD SLD ART -,SUP-DBG-SCT30-200,CDM,C1724,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List,,
DEVICE ARTHREC 1.25 SOLID -,SUP-DBP-125MICRO145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List,,
SYSTEM ATHERECTOMY DBP-125MICRO145 -,SUP-DBP-125MICRO145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List,,
DEVICE ARTHREC STEALTH 1.25S -,SUP-DBP-125SOLID145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List,,
DEVICE ARTHREC STEALTH 1.50MM 5F -,SUP-DBP-150SOLID145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List,,
DBP-200SOLID145 -,SUP-DBP-200SOLID145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List,,
CATH ATHRCMY DIAMONDBACK 360 1.50MM X 145CM SOLID -,SUP-DBP-EX-150SOL145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,14462.14,10123.498,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List,,
ROTAPRO ADVANCER 1.25MM -,SUP-H749394671250,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7999.94,5599.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List,,
ROTAPRO ADVANCER 1.5MM -,SUP-H749394671500,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7999.94,5599.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List,,
ROTAPRO ADVANCER 1.75MM -,SUP-H749394671750,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List,,
ROTAPRO ADVANCER 2.0MM -,SUP-H749394672000,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List,,
ROTAPRO ADVANCER 2.25MM -,SUP-H749394672250,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List,,
ROTAPRO ADVANCER 2.38MM -,SUP-H749394672380,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List,,
ROTAPRO ADVANCER 2.5MM -,SUP-H749394672500,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List,,
ROTAPRO ADVANCER 2.15MM -,SUP-H7494672150,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List,,
CATH ATHRCMY ROTLNK + 1.25MM BUR 0.58IN SHTH 135CM TFLN PTFE -,SUP-H802227680020,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4502.88,3152.016,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List,,
BURR ROTALINK 1.50MM 0.58IN SHTH 135CM EXCHGL -,SUP-H802227680030,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4953.17,3467.219,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List,,
CATH ATHRCMY ROTLNK + 1.75MM BUR 0.58IN SHTH 135CM EXCHGL -,SUP-H802227680040,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4953.17,3467.219,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List,,
CATH ATHRCMY ROTLNK + 2MM BUR 0.58IN SHTH 135CM EXCHGL ROT -,SUP-H802227680050,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4502.88,3152.016,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List,,
CATH ATHRCMY ROTLNK 2.15MM BUR 0.58IN SHTH 135CM TFLN PTFE -,SUP-H802227680150,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4502.88,3152.016,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List,,
PHOENIX 1.8MM X130CM -,SUP-P18130,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List,,
1.8MM PHOENIX 149CM -,SUP-P18149K,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List,,
PHOENIX 2.2MM X 130CM -,SUP-P22130K,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List,,
PHOENIX ARTHERECTOMY 2.4MM 7FR -,SUP-P22149K,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List,,
ARTHERECTOMY JTSTRM 1.85MM -,SUP-PV3118F,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12754.16,8927.912,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List,,
ARTHERECTOMY JTSTRM 2.1/3MM -,SUP-PV31300,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12624.2,8836.94,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List,,
CATH ARTHERECTOMY JTSTRM 2.4/3.4MM LT -,SUP-PV41340,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12624.2,8836.94,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10635.57648,other,Non-Reimbursable List,,
CATHETER BALLOON VALVULOPLASTY  22MX4.5CMX110CM -,SUP-00224512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATHETER BALLOON VALAVULOPLASTY 20MMX4.5X110CM TRUE DILATION -,SUP-0204511,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATHETER BALLOON VALVULOPLASTY 21MMX4.5CMX110CM TRUE DILATIO -,SUP-0214512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATHETER BALLOON VALVULOPLASTY 23MMX4.5CMX120CM TRUE DILATIO -,SUP-0234512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATHETER BALLOON VALVULOPLASTY 24MMX4.5CMX110CM TRUE DILAT -,SUP-0244512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATHETER TRUE DILATATION 25MM X 4.5CM REF: 0254513 -,SUP-0254513,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATHETER TRUE DILATION 26MM -,SUP-0264513,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATHETER BALLOON VALVULOPLASTY 28MMX4.5CMX110CM TRUE DILAT -,SUP-0284514,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH IABP LINEAR 7.5FR 40CC -,SUP-0684-00-0480-01,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4203.6,2942.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATHETER IABP 7.5FR 40CC SENSATION PLUS -,SUP-0684-00-0568-01U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4524.1,3166.87,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATHETER IABP 8FR 50CC SENSATION PLUS -,SUP-0684-00-0576-01U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4524.1,3166.87,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
GAIA SECOND 190CM MICRO J,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
GAIA THIRD 190CM MICRO J,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
GAIA FIRST 190CM MICRO J,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
RG3 330CM,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X18MM PWRSL 143CM RX F/PTCA COR HYDRCT 0.024IN GW -,SUP-1005527-18,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1086.6,760.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X15MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008189-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
4MM X 20MM X 135CM VIATRAC 14 PLUS BALLOON -,SUP-1008189-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ABBOTT VIATRAC BALLOON 4.5 X 20 X 135 -,SUP-1008191-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5X20MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008193-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ABBOTT VIATRAC BALLOON 5.5 X 20 X 135 -,SUP-1008195-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6X20MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008197-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6X40MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008197-40,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH CV 4.5X20MM VIATRAC LF -,SUP-10081991-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ABBOTT VIATRAC BALLOON 6.5 X 20 X 135 -,SUP-1008199-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 7X20MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008201-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.2X6MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012268-06U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON MINI TREK RX 1.20MM X 08MM REF: 1012268-08U -,SUP-1012268-08U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.2X12MM MINI TREK II RX UL-LPRO NC COR HYDRCT -,SUP-1012268-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.2X12MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012268-12U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON MINI TREK RX 1.20MM X 15MM REF: 1012268-15U -,SUP-1012268-15U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.2X20MM MINI TREK II RX UL-LPRO NC COR HYDRCT -,SUP-1012268-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.2X20MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012268-20U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.5X8MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.5X12MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.5X15MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.5X20MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X8MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X12MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X15MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X20MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X25MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X30MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X30MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON TREK RX 2.75MM X 08MM REF: 1012273-08 -,SUP-1012273-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON TREK RX 2.75MM X 12MM REF: 1012273-12 -,SUP-1012273-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON TREK RX 2.75MM X 20MM REF: 1012273-20 -,SUP-1012273-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X30MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON TREK RX 4.0MM X 8MM REF: 1012278-08 -,SUP-1012278-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012278-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON TREK RX 4.0MM X 15MM REF: 1012278-15 -,SUP-1012278-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON TREK RX 4.0MM X 20MM REF: 1012278-20 -,SUP-1012278-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012278-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X30MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012278-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4.5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012279-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON TREK RX 4.5MM X 15MM REF: 1012279-15 -,SUP-1012279-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012280-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON TREK RX 5.0MM X 15MM REF: 1012280-15 -,SUP-1012280-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.2X6MM MINI TREK II OTW UL-LPRO NC COR HYDRCT CTD -,SUP-1012401-06Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.2X8MM MINI TREK II OTW UL-LPRO NC COR HYDRCT CTD -,SUP-1012401-08Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.2X12MM MINI TREK II OTW UL-LPRO NC COR HYDRCT -,SUP-1012401-12Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.2X15MM MINI TREK II OTW UL-LPRO NC COR HYDRCT -,SUP-1012401-15Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.2X20MM MINI TREK II OTW UL-LPRO NC COR HYDRCT -,SUP-1012401-20Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.5X8MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.5X12MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.5X15MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.5X20MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X8MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012403-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X12MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X15MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X20MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X30MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X30MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012407-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X30MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X12MM NC TREK OTW SM-PRFL NC COR RND TIP HYDRCT -,SUP-1012433-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.75X15MM NC TREK OTW SM-PRFL NC COR RND TIP -,SUP-1012436-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.5X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X25MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.75X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.75X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.75X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.75X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.75X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X25MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X12 MM NC TREK RX ULLPRO NC COR RND TIP HYDRCT -,SUP-1012450-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X25MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.75X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.75X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.75X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.75X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
2.0MM X 60 MM X 150CM ARMADA 18 BALLOON OTW -,SUP-1013463-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA BALLOON 2.5MM X 40MM X 150CM -,SUP-1013464-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 18 2.5 X 200 X 150 -,SUP-1013464-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA BALLOON 2.5MM X 80MM X 150CM -,SUP-1013464-80,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA BALLOON .018 3MM X 60MM X 150CM -,SUP-1013465-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1155.33,808.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA BALLOON .018 3.0MM X 80MM X 150CM -,SUP-1013465-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA BALLOON .018 3.0MM X 100MM X 150CM -,SUP-1013465-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATHETER ARMADA 18 3.0MM X 120MM X 150CM -,SUP-1013465-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATHETER ARMADA 18 PTA -,SUP-1013465-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA BALLOON .018 3 X 200 X 150 -,SUP-1013465-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 18 4 X 20MM -,SUP-1013466-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
4MM X 40MM X 150CM ARMADA 18 BALLOON -,SUP-1013466-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
4MM X 60MM X 150CM ARMADA 18 -,SUP-1013466-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 4MM X 80MM X 150CM 18 -,SUP-1013466-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON ARMADA 4 X 150 X 150MM -,SUP-1013466-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 18 BALLOON 5MM X 20MM -,SUP-1013468-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
5mm x 40mm armada 18 -,SUP-1013468-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
5mm x 60mm Armada 18 Balloon -,SUP-1013468-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 18 BALLOON 5MM X 80MM -,SUP-1013468-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B ARMADA .018 5MM X 100MM -,SUP-1013468-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA BALLOON 5 MM X 150MM -,SUP-1013468-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA BALLOON 5MM X 200MM -,SUP-1013468-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 18 BALLOON 6 X 20MM -,SUP-1013470-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
6MM X 40MM X 150CM ARMADA 18 BALLOON -,SUP-1013470-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 18 B 6MM X 60MM X 150CM -,SUP-1013470-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 018 6MM X 80 MM -,SUP-1013470-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 6MM X 100MM 18 BALLOON -,SUP-1013470-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 6MM X 150MM 0.018 -,SUP-1013470-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 6MM X 200MM 0.018 -,SUP-1013470-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON TREK RX 3.75MM X 8MM REF: 1012277-08 -,SUP-102277-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 1.50MM X 8MM REF: 1400150-08 -,SUP-1400150-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 1.50MM X 12MM REF: 1400150-12 -,SUP-1400150-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 1.50MM X 15MM REF: 1400150-15 -,SUP-1400150-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 1.50MM X 20MM REF: 1400150-20 -,SUP-1400150-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 2.00MM X 8MM REF: 1400200-08 -,SUP-1400200-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 2.00MM X 12MM REF: 1400200-12 -,SUP-1400200-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 2.00MM X 15MM REF: 1400200-15 -,SUP-1400200-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 2.00MM X 20MM REF: 1400200-20 -,SUP-1400200-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 2.25MM X 08MM REF: 1400225-08 -,SUP-1400225-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 2.25MM X 12MM REF: 1400225-12 -,SUP-1400225-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 2.25MM X 15MM REF: 1400225-15 -,SUP-1400225-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 2.25MM X 20MM REF: 1400225-20 -,SUP-1400225-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 2.50MM X 8MM REF: 1400250-08 -,SUP-1400250-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 2.50MM X 12MM REF: 1400250-12 -,SUP-1400250-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 2.50MM X 15MM REF: 1400250-15 -,SUP-1400250-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 2.50MM X 20MM REF: 1400250-20 -,SUP-1400250-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 2.75MM X 8MM REF: 1400275-08 -,SUP-1400275-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 2.75MM X 12MM REF: 1400275-12 -,SUP-1400275-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 2.75MM X 15MM REF: 1400275-15 -,SUP-1400275-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 2.75MM X 20MM REF: 1400275-20 -,SUP-1400275-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 3.00MM X 8MM REF: 1400300-08 -,SUP-1400300-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 3.00MM X 15MM REF: 1400300-15 -,SUP-1400300-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 3.00MM X 20MM REF: 1400300-20 -,SUP-1400300-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 3.25MM X 8MM REF: 1400325-08 -,SUP-1400325-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 3.25MM X 12MM REF: 1400325-12 -,SUP-1400325-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 3.25MM X 15MM REF: 1400325-15 -,SUP-1400325-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 3.25MM X 20MM REF: 1400325-20 -,SUP-1400325-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 3.50MM X 8MM REF: 1400350-08 -,SUP-1400350-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 3.50MM X 12MM REF: 1400350-12 -,SUP-1400350-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 3.50MM X 15MM REF: 1400350-15 -,SUP-1400350-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 3.50MM X 20MM REF: 1400350-20 -,SUP-1400350-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 3.75MM X 12MM REF: 1400375-12 -,SUP-1400375-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 3.75MM X 20MM REF: 1400375-20 -,SUP-1400375-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 4.00MM X 8MM REF: 1400400-08 -,SUP-1400400-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 4.00MM X 12MM REF: 1400400-12 -,SUP-1400400-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 4.00MM X 15MM REF: 1400400-15 -,SUP-1400400-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 4.00MM X 20MM REF: 1400400-20 -,SUP-1400400-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 4.50MM X 8MM REF: 1400450-08 -,SUP-1400450-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 4.50MM X 12MM REF: 1400450-12 -,SUP-1400450-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 4.50MM X 20MM REF: 1400450-20 -,SUP-1400450-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 5.00MM X 12MM REF: 1400500-12 -,SUP-1400500-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 5.00MM X 15MM REF: 1400500-15 -,SUP-1400500-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 5.50MM X 12MM REF: 1400550-12 -,SUP-1400550-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 5.50MM X 15MM REF: 1400550-15 -,SUP-1400550-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 6.00MM X 12MM REF: 1400600-12 -,SUP-1400600-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 6.00MM X 15MM REF: 1400600-15 -,SUP-1400600-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH BLNOCC 15MM LRG 23X71X2.5CM ENDOCATH LPRO PLYISPRN -,SUP-20-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X20MM 2.7CM ANGIOSCULPT XL 137CM OTW F/PTCA -,SUP-2039-2520,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X20MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2076-4020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X40MM ANGIOSCULPT XL 137CM OTW -,SUP-2076-4040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5X40MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2076-5040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6X40MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2076-6040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6X20MM ANGIOSCULPT XL 90CM OTW F/PTCA SEM-COM -,SUP-2092-6020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATHETER SAPPHIRE II PRO L5 MM 5F -,SUP-210-053-5UU,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATHETER SAPPHIRE II PRO L15 MM 5F -,SUP-210-153-5UU,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X40MM ANGIOSCULPT XL 155CM OTW F/PTCA SEM-COM -,SUP-2155-2540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR TAPR -,SUP-2200-2006-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X10MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2010-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2015-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.0X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2020-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2506-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X10MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2510-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2515-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2520-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR TAPR -,SUP-2200-3006-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X10MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3010-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3015-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.0X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3020-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3506-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X10MM ANGIOSCULPT 137CM RX F /PTCA SEM-COM COR -,SUP-2200-3510-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3515-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3520-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5X100MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2237-50100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6X100MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2237-60100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B ANGIOSCULPT 7MM X 40MM -,SUP-2333-7040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6X100MM STERLNG 135CM OTW COAX SEM-COM PERIPH TAPR -,SUP-39032-60101,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATHETER PCA 4MM X 30MM x 145CM COYOTE ES M -,SUP-39135-40301,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 14MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-1440L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATHETER DILATION16MM X 4MM -,SUP-417-1640L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 18MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-1840L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 20MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-2040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 22MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-2240L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 25MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-2540L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 12MMX4CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-2040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3MMX4CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-3040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3MMX8CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-3080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4MMX10CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-4000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4MMX2CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-4020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
MIRROR SURG 16.4MMX7.625IN LRYNG HEX HNDL V. MUELLER -,SUP-419-4040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4MMX6CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-4060L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5MMX10CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-5000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 8MMX8CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-8080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-5040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5MM 5FR SHFT 6CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-5060L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5MM 5FR SHFT 8CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-5080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6MM 5FR SHFT 6FR SHTH 10CM POWERFLX P3 110CM OTW -,SUP-420-6000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6MM 5FR SHFT 5FR SHTH 2CM POWERFLX P3 110CM OTW -,SUP-420-6020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-6040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6MM 5FR SHFT 6CM POWERFLX P3 80CM OTW F/PTA PERIPH -,SUP-420-6060S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6MM 5FR SHFT 8CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-6080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 7MM 5FR SHFT 10CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-7000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 7MM 5FR SHFT 2CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-7020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 7MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-7040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 8MM 5FR SHFT 6FR SHTH 2CM POWERFLX P3 110CM OTW -,SUP-420-8020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 8MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-8040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4MMX2CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-4020W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4MMX3CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-4030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
RETRACTOR RGNL 6IN DBL END STN FNSH SS DLCT V. MUELLER NS -,SUP-424-5030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6MMX3CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-6030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 7MMX3CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-7030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH DIL 3MM 4FR SHTH 4CM BLN 150CM F/PTA -,SUP-425-3004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3MMX4CM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-3004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X120MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X40MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-4004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5X40MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-5004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5X100MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-5010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5MMX28CM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-5028X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1696.16,1187.312,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5MMX6CM SAVVY 120CM OTW COAX MOD PRSS PERIPH TAPR -,SUP-435-506L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1155.51,808.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4MMX22CM SAVVY LONG 120CM OTW COAX MOD PRSS PERIPH -,SUP-436-4022L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1420.53,994.371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4MMX22CM SAVVY LONG 150CM OTW COAX MOD PRSS PERIPH -,SUP-436-4022X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1420.53,994.371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0302S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0402S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4MMX4CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0404S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X220MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0422X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5MMX2CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0502S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0504S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5X60MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5X100MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5X220MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0522X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6MMX2CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0602S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6MMX4CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0604S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6X100MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0610X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6X150MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0615X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,840.24,588.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 7X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0702S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 7X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0704S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 7X40MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0704X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 8X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0802S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 8X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0804S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 9X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0902S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 10X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-1004S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
TURNPIKE 150 CM MICRO CATH -,SUP-5643,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2859.63,2001.741,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 22MMX4CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-610462,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 25MMX4CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-610463,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 28MMX4CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-610465,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA BALLOON DILATAION 22X4X100 Z-MED II -,SUP-611761,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 30MMX2CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-611801,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 28MMX2CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-611803,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 25MMX3CM Z-MED 100CM LPRO COAX F/PTA HPRS PERIPH -,SUP-611816,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATHETER PTV 16MMX4CM TYSHAK II REF:611920 -,SUP-611920,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATHETER PTV 18MMX4CM TYSHAK II REF:611928 -,SUP-611928,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATHETER PTV 20MMX4CM TYSHAK II REF:611932 -,SUP-611932,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATHETER PTV 22MMX4CM TYSHAK II REF:611936 -,SUP-611936,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATHETER PTV 25MMX4CM TYSHAK II REF:611944 -,SUP-611944,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH GUID 0.07IN 6FR MPA-1 90CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-270-90,CDM,C1725,HCPCS,272,RC,,,outpatient,,,309.26,216.482,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X6MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R06350N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R10200N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10225N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10250N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10325N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10350N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R10400N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R12250N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R12300N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R12325N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.75X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R12350N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R12400N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R15250N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R15300N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R15325N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R15340N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R15400N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
C PIG 5FR 20/1CM MARKS -,SUP-7602-20M65SH,CDM,C1725,HCPCS,272,RC,,,outpatient,,,528.13,369.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X12MM EMPIRA 139CM RX F/PTCA SEM-COM -,SUP-85R12250S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X12MM EMPIRA 139CM RX F/PTCA SEM-COM DURALYN -,SUP-85R12300S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X12MM EMPIRA 139CM RX F/PTCA SEM-COM -,SUP-85R12325S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X15MM EMPIRA 139CM RX F/PTCA SEM-COM -,SUP-85R15250S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X15MM EMPIRA 139CM RX F/PTCA SEM-COM DURALYN -,SUP-85R15300S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 3.00MM X 12MM REF: 1400300-12 -,SUP-90176431,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 4.50MM X 15MM REF: 1400450-15 -,SUP-90176448,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON TREK RX 2.75MM X 15MM REF: 1012273-15 -,SUP-90176463,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON TREK RX 3.75MM X 12MM REF: 1012277-12 -,SUP-90176465,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON TREK RX 3.75MM X 15MM REF: 1012277-15 -,SUP-90176466,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC TREK NEO 3.75MM X 15MM REF: 1400375-15 -,SUP-90176697,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH ANG 6FR 18MM 70CM 3.5CM BLN AMPLATZER SZ LUMX3 FLXB -,SUP-9-SB-018,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH ANG 24MM 7FR 70CM 4.5CM BLN AMPLATZER SZ LUMX3 FLXB -,SUP-9-SB-024,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.5X20MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2015-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 14 1.5MM X 40MM X 150CM -,SUP-A2015-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X20MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X60MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X80MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X200MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2025-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND -,SUP-A2025-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X200MM ARMADA 14 150CM LPRO F/PTA PERIPH RND -,SUP-A2025-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X20MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X60MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X80MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B ARMADA 14 PTA C 3.0 X 200M -,SUP-A2030-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X60MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X80MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X200MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X40MM NANOCROSS ELITE 150CM OTW ULTRA LO XING -,SUP-AB14W030040150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2093.7,1465.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X80MM NANOCROSS ELITE 150CM OTW ULTRA LO XING -,SUP-AB14W030080150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2093.7,1465.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
4MM X 40MM STELLAREX DCB -,SUP-AB35SX040040135,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON ATLAS PTA CATHETER 16MMX 40MM X 120CM REF: AT120164 -,SUP-AT120164,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1966.49,1376.543,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B ATLAS 12MM X 4CM X 75CM -,SUP-AT-75124,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B ATLAS 14MM X 4CM X 75CM -,SUP-AT-75144,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B ATLAS 16MM X 4CM X 75CM -,SUP-AT-75164,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1966.49,1376.543,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B ATLAS 18MM X 4CM X 75CM -,SUP-AT75184,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1966.49,1376.543,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ATLAS BALLOON 20 X 40 -,SUP-AT75204,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2276.62,1593.634,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ATLAS BALLOON 24 X 40 -,SUP-AT75244,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2910.99,2037.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 26MMX4CM ATLAS 75CM OTW COAX ULTRA NC PERIPH 12FR -,SUP-AT-75264,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2826.21,1978.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ATLAS GOLD PTA DILATATION CATHETER 120CM -,SUP-ATG120164,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1913.48,1339.436,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH ATLAS GOLD PTA DILATATION 16 X 6 X 80MM - 8 FR -,SUP-ATG80166,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1913.48,1339.436,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 35  4.0MM X 20MM X 80CM -,SUP-B1040-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 35 4.0MM X 40MM X 80CM -,SUP-B1040-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
4MM X 80MM X 80CM ARMADA 35 BALLOON -,SUP-B1040-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON ARMADA 4MM X 80MM X 80CM -,SUP-B1040-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 5MM X 20MM X 80CM -,SUP-B1050-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B ARMADA 35 5MM X 40MM X 80CM -,SUP-B1050-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5X40MM ARMADA  .035 -,SUP-B1050-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 35 5MM X 60MM X 80CM -,SUP-B1050-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B ARMADA 35 5.0 X 80 X 80 PTA CATH -,SUP-B1050-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON ARMADA 5MM X 100MM X 80CM -,SUP-B1050-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 5MM X 120MM X 80CM -,SUP-B1050-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 35 6MM X 40MM X 80CM -,SUP-B1060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 6MMx40MMx80CM -,SUP-B1060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
6MM X 60MM X 80CM ARMADA 35 BALLOON -,SUP-B1060-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 35 6.0MM X 60MM X80CM -,SUP-B1060-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
6MM X 80MM X 80CM ARMADA 35 BALLOON -,SUP-B1060-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON ARMADA 6MM X 100MM X 80CM -,SUP-B1060-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 6 X 150 X 80 -,SUP-B1060-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON 35 ARMADA 7 X 20 X 80 PTA -,SUP-B1070-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA PTA 7MM X 40MM X 80CM -,SUP-B1070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA B  35  7.0X60X80 PTA -,SUP-B1070-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 35 7MM X 60MM X 80CM -,SUP-B1070-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B ARMADA 35 7MM X 80MM X 80CM -,SUP-B1070-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 35 7 X 80MM X 80CM -,SUP-B1070-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B ARMADA 35 7.0 X 100 X 80 PTA CATH -,SUP-B1070-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON ARMADA 7MM X 150MM X 80CM -,SUP-B1070-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 35 8MM X 20MM X 80CM -,SUP-B1080-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
8mm x 40mm x 80cm Armada 35 -,SUP-B1080-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
XARMADA 35 8.0MM X 40MM X 80C -,SUP-B1080-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 35 8mmx60mmX80cm -,SUP-B1080-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B ARMADA 35 8MM X 60MM ON 80MM -,SUP-B1080-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
8MM X 80MM X 80CM ARMADA 35 BALLOON -,SUP-B1080-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 35 8.0MM X 80MM X 80CM -,SUP-B1080-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
9MM X 20MM X 80CM ARMADA 35 BALLOON -,SUP-B1090-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 35 BALLOON 9 X 40MM X 80CM -,SUP-B1090-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
10MM X 20MM X 80CM ARMADA 35 BALLOON -,SUP-B1100-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
10.0MM X 40MM X 80 ARMADA 35 BALLOON -,SUP-B1100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 35 10.0MM X 40MM X 80CM -,SUP-B1100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
10MM X 60MM X 80CM ARMADA 35 BALLOON -,SUP-B1100-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 35 10MM 60MM X 80CM -,SUP-B1100-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
12MM X 20MM X 80CM ARMADA 35 BALLOON -,SUP-B1120-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 35 12.0MM X 40MM X 80CM -,SUP-B1120-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 35 12.0MM X 60MM X 80CM -,SUP-B1120-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 35 12 X 60MM X 80CM -,SUP-B1120-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 35 14.0MM X 20MM X 80CM -,SUP-B1140-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
14MM X 40MM X 80CM ARMADA 35 BALLOON -,SUP-B1140-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 35 14MM X 60MM X 80CM -,SUP-B1140-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
4MM X 20MM X 135CM ARMADA 35 BALLOON -,SUP-B2040-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
Armada 4 x 40 x 135 Balloon -,SUP-B2040-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 4MM X 60MM X 135CM -,SUP-B2040-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 35 4X100X135 -,SUP-B2040-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
5MM X 20MM X 135CM ARMADA 35 -,SUP-B2050-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
5MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2050-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
5MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2050-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA PTA 0.035MM X 5MM X 60MM X 135CM -,SUP-B2050-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA PTA .035  5MM X 80MM X 135CM -,SUP-B2050-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
5MMX100MMX135CM ARMADA 35 -,SUP-B2050-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
5MM X 200MM X 135CM ARMADA 35 BALLOON -,SUP-B2050-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
6MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA PTA 0.035 6MM X 40MM X 135CM -,SUP-B2060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
6MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2060-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 35 6MM 80MM 135CM -,SUP-B2060-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 35 6MM 100MM 135CM -,SUP-B2060-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
6mm x 150mm x 135cm ARMADA 35 -,SUP-B2060-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
6MM X 200MM X 135CM ARMADA 35 BALLOON -,SUP-B2060-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
7MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 35  BALLOON  7.0MM X 40MM X 135CM -,SUP-B2070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B ARMADA 35  7MM X 40MM X 135CM -,SUP-B2070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
7MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2070-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 35 7MM X 100MM BALLOON -,SUP-B2070-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
7MM X 200MM X 135CM ARMADA 35 BALLOON -,SUP-B2070-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 35 8MM X 20MM X 135CM -,SUP-B2080-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 35 8MM X 40MM X 135CM -,SUP-B2080-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 35  8MM X 60MM X 135CM -,SUP-B2080-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 8MM X 80MM 35 BALLOON -,SUP-B2080-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON 9MM X 20MM X 135CM CATH ARMADA 35 -,SUP-B2090-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
9MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2090-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA PTA CATHETER 9MM X 60MM X 135CM -,SUP-B2090-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA PTA 10MM X 20MM X 135CM -,SUP-B2100-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
10MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA PTA 10MM X 40MM X 135CM -,SUP-B2100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA PTA 10MM X 60MM X 135MM -,SUP-B2100-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 35 12MM X 40MM X 135CM -,SUP-B2120-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
12MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2120-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ARMADA 35 BALLOON DIAL CATH 14X20X135 -,SUP-B2140-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
14MM X 40MM X 135CM ARMADA 35 BALOON -,SUP-B2140-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH BALLOON DILATION R2P PTA 4.0MM X 150MM CROSPERIO RX -,SUP-BD-B40150LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1229.72,860.804,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH BALLOON DIL CROSPERIO RX 0.014 X 4.0MM X 150CM 4FR -,SUP-BD-B40150LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1229.72,860.804,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CROSTELLA RX PTA DIL CATH 3MM X 8MM X 150CM -,SUP-BD-F30080LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CROSSTELLA OTW 3MM X 200MM 150CM -,SUP-BD-F30200LW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH CROSTELLA BALLOON RX PTA 4.0MM X 40MM 150CM 4FR -,SUP-BD-F40040LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH CROSTELLA BALLOON RX PTA 5.0MM X 80MM 150CM 4FR -,SUP-BD-F50080LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CROSSTELLAÂ® RX PTA Balloon Dil Cath 5mm x 150mm -,SUP-BD-F50150LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON METACROS 5MM X 150 X .030 PTCA -,SUP-BD-P50150ER,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON R2P CROSTELLA RX 2MM X 40MM X 200CM -,SUP-BD-Q20040ER,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5X120MM CHOC 120CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CB1812050120OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X40MM CHOC 150CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CF1415025040OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X120MM CHOC 150CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CF1415025120OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X120MM CHOC 150CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CF1415030120OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 10MMX4CM CONQUST 75CM OTW COAX ULTRA NC PERIPH -,SUP-CQ-75104,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 12MMX4CM CONQUST 75CM OTW COAX ULTRA NC PERIPH -,SUP-CQ-75124,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1490.45,1043.315,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6MMX2CM CONQUST 75CM OTW COAX ULTRA NC PERIPH -,SUP-CQ-7562,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B CONQUEST 6 X 4 X 75 -,SUP-CQ-7564,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B CONQUEST 7 X 4 X 75 -,SUP-CQ-7574,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B CONQUEST 8 X 4 X 75 -,SUP-CQ-7584,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH BALLOON CHOLANGIOGRAPHY -,SUP-CS-01701,CDM,C1725,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON DILATATION CATH OTW TAKERU 1.5X6MM REF:DC-PY1506UA1 -,SUP-DC-PY1506UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU OTW 1.5X12MM REF: DC-PY1512UA1 -,SUP-DC-PY1512UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON DILATATION CATH OTW TAKERU 1.5X15MM REF:DC-PY1515UA1 -,SUP-DC-PY1515UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU OTW 1.5X20MM REF: DC-PY1520UA1 -,SUP-DC-PY1520UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU OTW 2.0X8MM REF: DC-PY2008UA2 -,SUP-DC-PY2008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU OTW 2.0X12MM REF: DC-PY2012UA2 -,SUP-DC-PY2012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON DILATATION CATH OTW TAKERU 2.0X15MM REF:DC-PY2015UA2 -,SUP-DC-PY2015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON DILATATION CATH OTW TAKERU 2.0X20MM REF:DC-PY2020UA2 -,SUP-DC-PY2020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU OTW 2.25X12MM REF: DC-PY2212UA2 -,SUP-DC-PY2212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU OTW 2.25X15MM REF: DC-PY2215UA2 -,SUP-DC-PY2215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU OTW 2.25X20MM REF: DC-PY2220UA2 -,SUP-DC-PY2220UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU OTW 2.5X8MM REF: DC-PY2508UA2 -,SUP-DC-PY2508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU OTW 2.5X15MM REF: DC-PY2515UA2 -,SUP-DC-PY2515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU OTW 2.5X20MM REF: DC-PY2520UA2 -,SUP-DC-PY2520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU OTW 3.0X8MM REF: DC-PY3008UA2 -,SUP-DC-PY3008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU OTW 3.0X12MM REF: DC-PY3012UA2 -,SUP-DC-PY3012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU OTW 3.0X15MM REF: DC-PY3015UA2 -,SUP-DC-PY3015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU OTW 3.0X20MM REF: DC-PY3020UA2 -,SUP-DC-PY3020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU OTW 3.5X8MM REF: DC-PY3508UA2 -,SUP-DC-PY3508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU OTW 3.5X12MM REF: DC-PY3512UA2 -,SUP-DC-PY3512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU OTW 3.5X15MM REF: DC-PY3515UA2 -,SUP-DC-PY3515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU OTW 3.5X20MM REF: DC-PY3520UA2 -,SUP-DC-PY3520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU OTW 4.0X8MM REF: DC-PY4008UA2 -,SUP-DC-PY4008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU OTW 4.0X12MM REF: DC-PY4012UA2 -,SUP-DC-PY4012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU OTW 4.0X20MM REF: DC-PY4020UA2 -,SUP-DC-PY4020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON DILATATION CATH RX TAKERU 1.5X6MM REF:DC-RY1506UA1 -,SUP-DC-RY1506UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX 1.5X12MM REF: DC-RY1512UA1 -,SUP-DC-RY1512UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON DILATATION CATH RX TAKERU 1.5X15MM REF:DC-RY1515UA1 -,SUP-DC-RY1515UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON DILATATION CATH RX TAKERU 1.5X20MM REF:DC-RY1520UA1 -,SUP-DC-RY1520UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX 2.0X8MM REF: DC-RY2008UA2 -,SUP-DC-RY2008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX 2.0X12MM REF: DC-RY2012UA2 -,SUP-DC-RY2012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON DILATATION CATH RX TAKERU 2.0X15MM REF:DC-RY2015UA2 -,SUP-DC-RY2015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON DILATATION CATH RX TAKERU 2.0X20MM REF:DC-RY2020UA2 -,SUP-DC-RY2020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX 2.25X12MM REF: DC-RY2212UA2 -,SUP-DC-RY2212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX 2.25X15MM REF: DC-RY2215UA2 -,SUP-DC-RY2215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX 2.5X8MM REF: DC-RY2508UA2 -,SUP-DC-RY2508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX 2.5X12MM REF: DC-RY2512UA2 -,SUP-DC-RY2512UA,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX 2.5X15MM REF: DC-RY2515UA2 -,SUP-DC-RY2515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX 2.5X20MM REF: DC-RY2520UA2 -,SUP-DC-RY2520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX 3.0X8MM REF: DC-RY3008UA2 -,SUP-DC-RY3008UA,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX 3.0X12MM REF: DC-RY3012UA2 -,SUP-DC-RY3012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX 3.0X15MM REF: DC-RY3015UA2 -,SUP-DC-RY3015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX 3.0X20MM REF: DC-RY3020UA2 -,SUP-DC-RY3020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX 3.5X8MM REF: DC-RY3508UA2 -,SUP-DC-RY3508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX 3.5X12MM REF: DC-RY3512UA2 -,SUP-DC-RY3512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX 3.5X15MM REF: DC-RY3515UA2 -,SUP-DC-RY3515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX 3.5X20MM REF: DC-RY3520UA2 -,SUP-DC-RY3520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX 4.0X8MM REF: DC-RY4008UA2 -,SUP-DC-RY4008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX 4.0X12MM REF: DC-RY4012UA2 -,SUP-DC-RY4012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX 4.0X15MM REF: DC-RY4015UA2 -,SUP-DC-RY4015UA,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX 4.0X20MM REF: DC-RY4020UA2 -,SUP-DC-RY4020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX NC 2.0X8MM REF: DC-RZ2008UA2 -,SUP-DC-RZ2008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX NC 2.0X12MM REF: DC-RZ2012UA2 -,SUP-DC-RZ2012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX NC 2.0X15MM REF: DC-RZ2015UA2 -,SUP-DC-RZ2015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX NC 2.0X21MM REF: DC-RZ2021UA2 -,SUP-DC-RZ2021UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX NC 2.25X8MM REF: DC-RZ2208UA2 -,SUP-DC-RZ2208UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX NC 2.25X12MM REF: DC-RZ2212UA2 -,SUP-DC-RZ2212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX NC 2.25X15MM REF: DC-RZ2215UA2 -,SUP-DC-RZ2215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX NC 2.25X21MM REF: DC-RZ2221UA2 -,SUP-DC-RZ2221UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX NC 2.5X8MM REF: DC-RZ2508UA2 -,SUP-DC-RZ2508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX NC 2.5X12MM REF: DC-RZ2512UA2 -,SUP-DC-RZ2512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX NC 2.5X15MM REF: DC-RZ2515UA2 -,SUP-DC-RZ2515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX NC 2.5X21MM REF: DC-RZ2521UA2 -,SUP-DC-RZ2521UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX NC 2.75X8MM REF: DC-RZ2708UA2 -,SUP-DC-RZ2708UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX NC 2.75X12MM REF: DC-RZ2712UA2 -,SUP-DC-RZ2712UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX NC 2.75X15MM REF: DC-RZ2715UA2 -,SUP-DC-RZ2715UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX NC 2.75X21MM REF: DC-RZ2721UA2 -,SUP-DC-RZ2721UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX NC 3.0X8MM REF: DC-RZ3008UA2 -,SUP-DC-RZ3008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX NC 3.0X12MM REF: DC-RZ3012UA2 -,SUP-DC-RZ3012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX NC 3.0X15MM REF: DC-RZ3015UA2 -,SUP-DC-RZ3015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX NC 3.0X21MM REF: DC-RZ3021UA2 -,SUP-DC-RZ3021UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX NC 3.25X8MM REF: DC-RZ3208UA2 -,SUP-DC-RZ3208UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX NC 3.25X12MM REF: DC-RZ3212UA2 -,SUP-DC-RZ3212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX NC 3.25X15MM REF: DC-RZ3215UA2 -,SUP-DC-RZ3215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX NC 3.25X21MM REF: DC-RZ3221UA2 -,SUP-DC-RZ3221UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX NC 3.5X08MM REF: DC-RZ3508UA2 -,SUP-DC-RZ3508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX NC 3.5X12MM REF: DC-RZ3512UA2 -,SUP-DC-RZ3512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX NC 3.5X15MM REF: DC-RZ3515UA2 -,SUP-DC-RZ3515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX NC 3.5X21MM REF: DC-RZ3521UA2 -,SUP-DC-RZ3521UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX NC 4.0X8MM REF: DC-RZ4008UA2 -,SUP-DC-RZ4008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX NC 4.0X12MM REF: DC-RZ4012UA2 -,SUP-DC-RZ4012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX NC 4.0X15MM REF: DC-RZ4015UA2 -,SUP-DC-RZ4015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU RX NC 4.0X21MM REF: DC-RZ4021UA2 -,SUP-DC-RZ4021UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATH TAKERU OTW 2.5X12MM REF: DC-PY2512UA2 -,SUP-D-PY2512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4MMX2CM DORADO 40CM OTW F/PTA ULTRA NC PERIPH 5FR -,SUP-DR4042,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1335.73,935.011,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 7MMX6CM DORADO 80CM OTW F/PTA ULTRA NC PERIPH 6FR -,SUP-DR8076,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1335.73,935.011,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP1506X EUPHORA RX -,SUP-EUP1506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP1512X EUPHORA RX -,SUP-EUP1512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP1515X EUPHORA RX -,SUP-EUP1515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP1520X EUPHORA RX -,SUP-EUP1520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP2006X EUPHORA RX -,SUP-EUP2006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP2010X EUPHORA RX -,SUP-EUP2010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP2012X EUPHORA RX -,SUP-EUP2012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP2015X EUPHORA RX -,SUP-EUP2015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP2020X EUPHORA RX -,SUP-EUP2020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP2025X EUPHORA RX -,SUP-EUP2025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP2030X EUPHORA RX -,SUP-EUP2030X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP22506X EUPHORA RX -,SUP-EUP22506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP22510X EUPHORA RX -,SUP-EUP22510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP22512X EUPHORA RX -,SUP-EUP22512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP22515X EUPHORA RX -,SUP-EUP22515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP22520X EUPHORA RX -,SUP-EUP22520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP22525X EUPHORA RX -,SUP-EUP22525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP2506X EUPHORA RX -,SUP-EUP2506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP2510X EUPHORA RX -,SUP-EUP2510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP2512X EUPHORA RX -,SUP-EUP2512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP2515X EUPHORA RX -,SUP-EUP2515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP2520X EUPHORA RX -,SUP-EUP2520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP2525X EUPHORA RX -,SUP-EUP2525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP2530X EUPHORA RX -,SUP-EUP2530X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP27506X EUPHORA RX -,SUP-EUP27506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP27510X EUPHORA RX -,SUP-EUP27510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP27512X EUPHORA RX -,SUP-EUP27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP27515X EUPHORA RX -,SUP-EUP27515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP27520X EUPHORA RX -,SUP-EUP27520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP27525X EUPHORA RX -,SUP-EUP27525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP3006X EUPHORA RX -,SUP-EUP3006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP3010X EUPHORA RX -,SUP-EUP3010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP3012X EUPHORA RX -,SUP-EUP3012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP3015X EUPHORA RX -,SUP-EUP3015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP3020X EUPHORA RX -,SUP-EUP3020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP3025X EUPHORA RX -,SUP-EUP3025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP3030X EUPHORA RX -,SUP-EUP3030X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP32506X EUPHORA RX -,SUP-EUP32506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP32510X EUPHORA RX -,SUP-EUP32510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP32512X EUPHORA RX -,SUP-EUP32512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP32515X EUPHORA RX -,SUP-EUP32515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP32520X EUPHORA RX -,SUP-EUP32520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP32525X EUPHORA RX -,SUP-EUP32525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP3506X EUPHORA RX -,SUP-EUP3506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP3510X EUPHORA RX -,SUP-EUP3510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP3512X EUPHORA RX -,SUP-EUP3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP3515X EUPHORA RX -,SUP-EUP3515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP3520X EUPHORA RX -,SUP-EUP3520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP3525X EUPHORA RX -,SUP-EUP3525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP3530X EUPHORA RX -,SUP-EUP3530X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP37506X EUPHORA RX -,SUP-EUP37506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP37510X EUPHORA RX -,SUP-EUP37510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP37512X EUPHORA RX -,SUP-EUP37512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP37515X EUPHORA RX -,SUP-EUP37515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP37520X EUPHORA RX -,SUP-EUP37520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP37525X EUPHORA RX -,SUP-EUP37525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP4006X EUPHORA RX -,SUP-EUP4006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP4010X EUPHORA RX -,SUP-EUP4010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP4012X EUPHORA RX -,SUP-EUP4012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP4015X EUPHORA RX -,SUP-EUP4015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP4020X EUPHORA RX -,SUP-EUP4020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP4025X EUPHORA RX -,SUP-EUP4025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EUP4030X EUPHORA RX -,SUP-EUP4030X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH BLNOCC 9FRX120CM CODA -,SUP-G03831,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2702.08,1891.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.5MMX4CM ADVANCE MICRO 14 150CM OTW UL-LPRO F/PTA -,SUP-G26614,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2289.76,1602.832,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2MMX12CM ADVANCE MICRO 14 150CM OTW UL-LPRO F/PTA -,SUP-G26641,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2289.76,1602.832,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6MMX2CM ADVANCE ATB 80CM OTW F/PTA MIN-CMPLNT -,SUP-G26895,CDM,C1725,HCPCS,272,RC,,,outpatient,,,705.98,494.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH DIL 4MMX12CM ADVANCE 18 LP 150CM LPRO F/PTA 4FR SHTH -,SUP-G30949,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30952,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5MMX15CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30955,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ANGIOPLASTY 5 - 15 PTA -,SUP-G30956,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B 18LP ADVANCE 5MM X 15CM -,SUP-G30956,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ANGIOPLASTY / PTA4-18-150-5-20 -,SUP-G30958,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30958,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH DIL 6MMX12CM ADVANCE 18 LP 150CM LPRO F/PTA 5FR SHTH -,SUP-G30961,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ANGIOPLASTY 6 - 15 PTA -,SUP-G30962,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30964,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 7MMX12CM ADVANCE 18 LP 150CM LPRO F/PTA 5FR SHTH -,SUP-G30967,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 7MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30970,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3MMX4CM ADVANCE 18LP 150CM LPRO F/PTA -,SUP-G34319,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
3X6X150 PTA ADVANCE CATH -,SUP-G34320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3MMX8CM ADVANCE 18LP -,SUP-G34321,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON ADVANCE .018 3MM X 10CM X 150CM -,SUP-G34322,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G34331,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G34336,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5MMX6CM ADVANCE 35LP 135CM LPRO PERIPH D-SHP -,SUP-G35532,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATHETER ADVANCED LOW PROFILE BALLOON 6MM X 20MM X 135CM -,SUP-G35536,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 7MMX20CM ADVANCE 35LP 135CM LPRO F/PTA -,SUP-G35540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 10MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G35546,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH ANG 5FRX80CM ADVANCE LPRO -,SUP-G35547,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
GW ENDO 0.035INX260CM ACROBAT CLBRT TIP -,SUP-G47614,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1038.63,727.041,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G49479,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50216,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50218,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50222,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50224,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5MMX10CM ADVANCE 18LP 135CM LUMX2 -,SUP-G50226,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4MMX4CM ADVANCE 18LP - USE 0141543 DISC. -,SUP-G50228,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50230,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50235,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50237,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50239,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50241,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 -,SUP-G50243,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50245,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50247,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50249,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50251,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50253,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 7MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50257,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 7MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50262,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 7MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50264,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2MMX2CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50313,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50314,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2MMX6CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50315,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50316,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50317,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50318,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50319,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50321,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1836.57,1285.599,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5MMX6CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50322,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50323,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50324,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50325,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ADVANCE 14 LP BALLOON CATHETER -,SUP-G50327,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50328,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3MMX4CM ADVANCE 14LP 60MM LPRO LUMX2 F/PTA SEM-COM -,SUP-G50329,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50330,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50332,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50333,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4MMX2CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50334,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50335,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4MMX6CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50336,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50337,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50338,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50339,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50340,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52251,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52253,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52254,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52257,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52258,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5MMX6CM ADVANCE 35LP 135CM LPRO PERIPH -,SUP-G52259,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52260,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52261,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5MMX14CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52263,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52265,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52266,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52267,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52268,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6MMX14CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 7MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52271,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 7MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52272,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 7MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52273,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 7MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52274,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 7MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52275,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 7MMX14CM ADVANCE 35LP 135CM LPRO F/PTA -,SUP-G52277,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 8MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52278,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 8MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52279,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 8MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52280,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 8MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52282,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 9MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52286,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 9MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52287,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 10MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52293,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 10MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52294,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 12MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52299,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 12MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
US PRE PP-CA-422 DIR BALLOON CATHER T3 20-23 -,SUP-G57885,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATHETER US PRE PP-CA-422 DIR BALLOON T3 20-23 -,SUP-G57887,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ADVANCE SERENITY 14 150-20-220 -,SUP-G57889,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATHETER BALLOON DILATATION ADVANCE SERENITY 14 2.5MM X10CM -,SUP-G57894,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CATHETER T3 20-23 -,SUP-G57896,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
DIRECT BALLOON CATHETERS T2 23-26 -,SUP-G57897,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATHETER US PRE PP-CA-422 DIR BALLOON  T3 20-23 -,SUP-G57900,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ADVANCE SERENITY 14 HYDROPHILIC PTA BALLOON DILA CATH 3 X 10 -,SUP-G57901,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ADVANCE SERENITY 14 HYDROPHILIC PTA BALLOON DILA CATH 3 X 22 -,SUP-G57903,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
US PRE PP-CA-422 DIR BALLOON CATHETER T3 20-23 150-40-20 -,SUP-G57911,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ADVANCE SERENITY 14 4MM x 100MM x 150CM -,SUP-G57915,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATHETER BALLOON DIR SERENITY 14 4MM X 15CM 150CM -,SUP-G57916,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATHETER US PRE PP-CA-422 DIR BALLOON  T3 20-23 -,SUP-G57917,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PIG 0.045IN 5FR PIG 125CM EXPO -,SUP-H749085262151,CDM,C1725,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.5X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP 0.014IN -,SUP-H7493895808200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.75X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP 0.014IN -,SUP-H7493895808300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP 0.014IN -,SUP-H7493895808400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.5X12MM APEX FLX UL-LPRO NC -,SUP-H7493895812150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.75X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.75X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.5X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.75X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.75X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.5X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.75X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.75X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X30MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895830250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,991.95,694.365,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.5X8MM APEX FLEX MONORAIL RX UL-LPRO NC -,SUP-H7493895908150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.75X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.5X12MM APEX FLEX MONORAIL RX UL-LPRO -,SUP-H7493895912150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.75X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.75X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.5X15MM APEX FLEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.75X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.75X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.5X20MM APEX FLEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.75X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.75X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B APEX MR  30MM X 2.50 MONORAIL RX -,SUP-H7493895930250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.0X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.5X8MM APEX OTW UL-LPRO F/PTCA OPTILEAP -,SUP-H7493896008150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.5X12MM APEX MONORAIL OTW UL-LPRO PSH -,SUP-H7493896012150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.5X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493896015150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.5X20MM APEX OTW UL-LPRO F/PTCA OPTILEAP -,SUP-H7493896020150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.5X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493896108150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.5X12MM APEX MONORAIL RX UL-LPRO PSH -,SUP-H7493896112150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.5X15MM APEX MONORAIL RX UL-LPRO -,SUP-H7493896115150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.5X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493896120150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
STERLING MONORAIL RAPID EXCHANGE 3 X 60 -,SUP-H74939031306010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON FG STERLING MR 4.5MM X 20MM X 135CM 4FR -,SUP-H74939031452010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2014.19,1409.933,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
STERLING MONORAIL .018 5X20X80CM 4F -,SUP-H74939031502080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6X20MM STERLNG MONORAIL 135CM RX LPRO COAX SEM-COM -,SUP-H74939031602010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH BALLOON STERLING 7.0MM X 40MM X 80CM 4FR FG MONORL -,SUP-H74939031704080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B STERLING OTW 10.0 X 60 135 -,SUP-H74939032106010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B STERLING OTW 10.0 X 80 135 -,SUP-H74939032108010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B STERLING OTW 4 X 10 X 135 39 -,SUP-H74939032401010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X220MM STERLNG 150CM OTW COAX SEM-COM PERIPH TAPR -,SUP-H74939032402210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B STERLING OTW 4.0 X 30 135 -,SUP-H74939032403010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B STERLING OTW 4 X 40 X 135 MA -,SUP-H74939032404010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B STERLING OTW 4.0 X 60 135 -,SUP-H74939032406010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1669.29,1168.503,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B STERLING OTW 4.0 X 80 135 -,SUP-H74939032408010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1669.29,1168.503,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B STERLING OTW 5 X 10 X 135 39 -,SUP-H74939032501010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B STERLING OTW 5.0 X 120 150 -,SUP-H74939032501210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B STERLING OTW 5.0 X 150 150 -,SUP-H74939032501510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B STERLING OTW 5.0 X 200 150 -,SUP-H74939032502110,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B STERLING OTW 5.0 X 220 150 -,SUP-H74939032502210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B STERLING OTW 5.0 X 30 135 -,SUP-H74939032503010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B STERLING OTW 5 X 4 X 135 390 -,SUP-H74939032504010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B STERLING OTW 5.0 X 60 135 -,SUP-H74939032506010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B STERLING OTW 5.0 X 80 135 -,SUP-H74939032508010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B STERLING OTW 6 X 10 X 135 39 -,SUP-H74939032601010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6X120MM 150CM -,SUP-H74939032601210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B STERLING OTW 6.0 X 150 150 -,SUP-H74939032601510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B STERLING OTW 6.0 X 200 150 -,SUP-H74939032602110,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B STERLING OTW 6.0 X 220 150 -,SUP-H7493903260221,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B STERLING OTW 6.0X30X135 -,SUP-H74939032603010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B STERLING OTW 6 X 4 X 135 390 -,SUP-H74939032604010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B STERLING OTW 6.0 X 80 135 -,SUP-H74939032608010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B STERLING OTW 7.0 X 100 135 -,SUP-H74939032701010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B STERLING OTW 7.0 X 120 150 -,SUP-H74939032701210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B STERLING OTW 7.0 X 150 150 -,SUP-H74939032701510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B STERLING OTW 7.0 X 200 150 -,SUP-H74939032702110,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B STERLING OTW 7.0 X 220 150 -,SUP-H74939032702210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B STERLING OTW 7.0 X 30 135 -,SUP-H74939032703010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B STERLING OTW 7.0 X 40 135 -,SUP-H74939032704010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B STERLING OTW 7.0 X 60 135 -,SUP-H74939032706010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B STERLING OTW 7.0 X 80 135 -,SUP-H74939032708010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B STERLING OTW 8.0 X 30 135 -,SUP-H74939032803010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B STERLING OTW 8.0 X 40 135 -,SUP-H74939032804010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B STERLING OTW 8.0 X 60 135 -,SUP-H74939032806010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B STERLING OTW 8.0 X 80 135 -,SUP-H74939032808010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B STERLING OTW 9.0 X 60 135 -,SUP-H74939032906010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B STERLING OTW 9.0 X 80 135 -,SUP-H74939032908010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.75X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.75X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4.5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912412200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.75X12MM NC QUANTM APEX MONORAIL UL-LPRO NC -,SUP-H7493912412270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X12MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912412320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.75X12MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912412370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X12MM NC QUANTM APEX MONORAIL RX UL -LPRO NC -,SUP-H7493912412400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4.5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912412450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912412500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.75X15MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912415270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X15MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912415320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.75X15MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912415370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4.5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912420200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.75X20MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912420270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X20MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912420320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.75X20MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912420370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4.5X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912420450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5 X 20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912430200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.75X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4732.06,3312.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.75X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.75X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.75X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4732.06,3312.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4.5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.75X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.75X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4.5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.75X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.75X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4.5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.75X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.75X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4.5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.75X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.75X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X40MM COYOTE ES MONORAIL 145CM RX SEM-COM PERIPH -,SUP-H74939134204010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON COYOTE 2.5MM X 40MM X 145CM  .014 -,SUP-H74939134254010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X20MM COYOTE ES 143CM OTW UL-LPRO SEM-COM PERIPH -,SUP-H74939134302010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X30MM COYOTE ES 144MM OTW UL-LPRO SEM-COM PERIPH -,SUP-H74939134303010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X40MM COYOTE ES 145CM OTW UL-LPRO SEM-COM PERIPH -,SUP-H74939134404010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.5X20MM COYOTE ES MONORAIL 143CM RX SEM-COM -,SUP-H74939135152010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X20MM COYOTE ES MONORAIL 143CM RX SEM-COM PERIPH -,SUP-H74939135202010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X20MM COYOTE ES MONORAIL 144CM RX SEM-COM PERIPH -,SUP-H74939135302010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X30MM COYOTE ES MONORAIL 145CM RX SEM-COM PERIPH -,SUP-H74939135303010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X40MM COYOTE ES MONORAIL 146CM RX SEM-COM PERIPH -,SUP-H74939135304010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X20MM COYOTE ES MONORAIL 144CM RX SEM-COM -,SUP-H74939135352010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X30MM COYOTE ES MONORAIL 145CM RX SEM-COM -,SUP-H74939135353010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X20MM COYOTE ES MONORAIL 144CM RX SEM-COM PERIPH -,SUP-H74939135402010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X30MM COYOTE ES MONORAIL 145CM RX SEM-COM PERIPH -,SUP-H74939135403010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X40MM COYOTE ES MONORAIL 146CM RX SEM-COM PERIPH -,SUP-H74939135404010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X100MM STERLNG SL 150CM OTW COAX SEM-COM PERIPH -,SUP-H74939148401510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 3.0 X 20 135CM -,SUP-H74939171030210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171030270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 3.0 X 40 135CM -,SUP-H74939171030410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
3MM X 40MM X 40CM MUSTANG -,SUP-H74939171030440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171030470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 3.0 X 60 135CM -,SUP-H74939171030610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
MUSTANG 3 X 60 X 75 -,SUP-H74939171030670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 3.0 X 80 135CM -,SUP-H74939171030810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 3.0 X 100 135C -,SUP-H74939171031010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 3.0 X 120 135C -,SUP-H74939171031210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 3.0 X 150 135C -,SUP-H74939171031510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 3.0 X 180 135C -,SUP-H74939171031810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 3.0 200 135CM -,SUP-H74939171032010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 4.0 X 20 135CM -,SUP-H74939171040210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171040270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 4.0 X 40 135CM -,SUP-H74939171040410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
MUSTANG 4MM X 40MM X 40CM -,SUP-H74939171040440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171040470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 4.0 X 60 135CM -,SUP-H74939171040610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171040670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 4.0 X 80 135CM -,SUP-H74939171040810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
MUSTANG 4MM X 80MM X 40CM -,SUP-H74939171040840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 4.0 X 100 135C -,SUP-H74939171041010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171041070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 4.0 X 120 135C -,SUP-H74939171041210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 4.0 X 150 135C -,SUP-H74939171041510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 4.0 X 180 135C -,SUP-H74939171041810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 4.0X200 135CM -,SUP-H74939171042010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 5.0 X 20 135CM -,SUP-H74939171050210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5X30MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 5.0 X 40 135CM -,SUP-H74939171050410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
MUSTANG 5MM X 40MM X 40 CM -,SUP-H74939171050440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 5.0 X 60 135CM -,SUP-H74939171050610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 5.0 X 80 135CM -,SUP-H74939171050810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
MUSTANG 5MM X 80MM X 40CM -,SUP-H74939171050840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 5.0 X 100 135C -,SUP-H74939171051010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171051070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 5.0 X 120 135C -,SUP-H74939171051210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 5.0 X 150 135C -,SUP-H74939171051510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 5.0 180 135CM -,SUP-H74939171051810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 5.0 200 135CM -,SUP-H74939171052010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 6.0 X 20 135CM -,SUP-H74939171060210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 6.0 X 40 135CM -,SUP-H74939171060410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6X40MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1079.48,755.636,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
MUSTANG 6MM X 40MM X 40CM -,SUP-H74939171060440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 6.0 X 60 135CM -,SUP-H74939171060610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 6.0 X 80 135CM -,SUP-H74939171060810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
6MM X 80MM X 40CM MUSTANG PTA -,SUP-H74939171060840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
MUSTANG 6MM X 80MM X 40CM -,SUP-H74939171060840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 6.0 X 100 135C -,SUP-H74939171061010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 6.0 X 120 135C -,SUP-H74939171061210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6X150MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171061510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6X150MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171061570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 6.0 180 135CM -,SUP-H74939171061810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6X200MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171062010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 7.0 X 20 135CM -,SUP-H74939171070210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 7X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 7.0 X 40 135cm -,SUP-H74939171070410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
7MM X 40MM X 40CM MUSTANG -,SUP-H74939171070440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 7X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 7.0 X 60 135CM -,SUP-H74939171070610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 7X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 7X80MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 7X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 7.0 X 100 135C -,SUP-H74939171071010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 7X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171071070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 7.0 X 120 135C -,SUP-H74939171071210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 7X150MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171071510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 7X150MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171071570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 7.0 180 135CM -,SUP-H74939171071810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 7X200MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171072010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 7X200MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171072070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 8.0 X 20 135CM -,SUP-H74939171080210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 8X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171080270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 8.0 X 40 135CM -,SUP-H74939171080410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
8MM X 40MM X 40CM MUSTANG -,SUP-H74939171080440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON MUSTANG 8MM X 40MM X 40CM -,SUP-H74939171080440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON MUSTANG 7.0MM X 80MM X 40CM -,SUP-H74939171080440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 8X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171080470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 8.0 X 60 135CM -,SUP-H74939171080610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 8.0 X 80 135CM -,SUP-H74939171080810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
8MM X 80MM X 40CM MUSTANG PTA -,SUP-H74939171080840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 8X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171080870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 8.0 X 100 135C -,SUP-H74939171081010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 8X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171081070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 8.0 X 120 135C -,SUP-H74939171081210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 8X150MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171081570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 8.0 180 135CM -,SUP-H74939171081810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 8X200MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171082010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 8X200MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171082070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 9.0 X 20 135CM -,SUP-H74939171090210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 9X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 9.0 X 40 135CM -,SUP-H74939171090410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 9X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 9X60MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 9X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 9.0 X 80 135CM -,SUP-H74939171090810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 9X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 10.0 X 20 135C -,SUP-H74939171100210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 10X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 10.0X40 135CM -,SUP-H74939171100410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
MUSTANG BALLOON 10MM X 40MM X 40CM -,SUP-H74939171100440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 10X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 10.0 X 60 135C -,SUP-H74939171100610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 10X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 10.0 X 80 135C -,SUP-H74939171100810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
MUSTANG 10MM X 80MM X 40CM -,SUP-H74939171100840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 10X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 12.0X20 135CM -,SUP-H74939171120210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 12X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171120270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 12.0X40 135CM -,SUP-H74939171120410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 12X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171120470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 12X60MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171120610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 12X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171120670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 12.0 X 80 135C -,SUP-H74939171120810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B MUSTANG PTA 12MM X 80MM 40CM -,SUP-H74939171120840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B CATH COYOTE OTW 1.5X40X150 -,SUP-H74939186150410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B CATH COYOTE OTW 2X60X150 -,SUP-H74939186200610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B CATH COYOTE OTW 2X80X150 -,SUP-H74939186200810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B CATH COYOTE OTW 2X100X150 -,SUP-H74939186201010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B CATH COYOTE OTW 2X120X150 -,SUP-H74939186201210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B CATH COYOTE OTW 2X220X150 -,SUP-H74939186202210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
COYOTE 2 X 220 -,SUP-H74939186202290,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B CATH COYOTE OTW 2.5X60X150 -,SUP-H74939186250610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B CATH COYOTE OTW 2.5X80X150 -,SUP-H74939186250810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B CATH COYOTE OW 2.5X100X150 -,SUP-H74939186251010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B CATH COYOTE OW 2.5X120X150 -,SUP-H74939186251210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B CATH COYOTE OW 2.5X220X150 -,SUP-H74939186252210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B CATH COYOTE OTW 3X60X150 -,SUP-H74939186300610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B CATH COYOTE OTW 3X80X150 -,SUP-H74939186300810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B CATH COYOTE OTW 3X100X150 -,SUP-H74939186301010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B CATH COYOTE OTW 3X120X150 -,SUP-H74939186301210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B CATH COYOTE OTW 3X150X150 -,SUP-H74939186301510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B CATH COYOTE OTW 3X220X150 -,SUP-H74939186302210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B CATH COYOTE OTW 3.5X60X150 -,SUP-H74939186350610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B CATH COYOTE OTW 3.5X80X150 -,SUP-H7493918635081,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1637.85,1146.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B CATH COYOTE OW 3.5X100X150 -,SUP-H74939186351010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B CATH COYOTE OW 3.5X120X150 -,SUP-H74939186351210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B CATH COYOTE OW 3.5X150X150 -,SUP-H74939186351510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B CATH COYOTE OW 3.5X220X150 -,SUP-H74939186352210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B CATH COYOTE OTW 4X60X150 -,SUP-H74939186400610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B CATH COYOTE OTW 4X80X150 -,SUP-H74939186400810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B CATH COYOTE OTW 4X100X150 -,SUP-H74939186401010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1637.85,1146.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B CATH COYOTE OTW 4X120X150 -,SUP-H74939186401210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1637.85,1146.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B CATH COYOTE OTW 4X150X150 -,SUP-H74939186401510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B CATH COYOTE OTW 4X220X150 -,SUP-H74939186402210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 1.20MM X 8MM -,SUP-H7493918908120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 1.50MM X 8MM -,SUP-H7493918908150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 2.00 MM X 8MM -,SUP-H7493918908200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 2.50 MM X 8MM -,SUP-H7493918908250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 2.75 MM X 8MM -,SUP-H7493918908270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 3.00 MM X 8MM -,SUP-H7493918908300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 3.25 MM X 8MM -,SUP-H7493918908320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 3.50 MM X 8MM -,SUP-H7493918908350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 3.75 MM X 8MM -,SUP-H7493918908370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 4.00MM X 8MM -,SUP-H7493918908400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 1.20MM X 12MM -,SUP-H7493918912120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 1.50MM X 12MM -,SUP-H7493918912150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 2.00 MM X 12 MM -,SUP-H7493918912200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 2.25 MM X 12MM -,SUP-H7493918912220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 2.50 MM X 12 MM -,SUP-H7493918912250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 2.75 MM X 12MM -,SUP-H7493918912270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 3.00 MM X 12MM -,SUP-H7493918912300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 3.25 MM X 12MM -,SUP-H7493918912320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 3.50 MM X 12MM -,SUP-H7493918912350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 3.75 MM X 12MM -,SUP-H7493918912370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 4.00MM X 12MM -,SUP-H7493918912400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 1.20MM X 15MM -,SUP-H7493918915120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 1.50MM X 15MM -,SUP-H7493918915150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 2.00 MM X 15 MM -,SUP-H7493918915200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 2.25 MM X 15MM -,SUP-H7493918915220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 2.50 MM X 15MM -,SUP-H7493918915250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 2.75 MM X 15MM -,SUP-H7493918915270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 3.00 MM X 15MM -,SUP-H7493918915300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 3.25 MM X 15MM -,SUP-H7493918915320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 3.50 MM X 15MM -,SUP-H7493918915350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 3.75 MM X 15MM -,SUP-H7493918915370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 4.00MM X 15MM -,SUP-H7493918915400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 1.20MM X 20MM -,SUP-H7493918920120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 1.50MM X 20MM -,SUP-H7493918920150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 2.00 MM X 20 MM -,SUP-H7493918920200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 2.25 MM X 20MM -,SUP-H7493918920220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 2.50 MM X 20 MM -,SUP-H7493918920250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 2.75 MM X 20MM -,SUP-H7493918920270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 3.00 MM X 20 MM -,SUP-H7493918920300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 3.25 MM X 20MM -,SUP-H7493918920320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 3.50 MM X 20MM -,SUP-H7493918920350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 3.75 MM X 20MM -,SUP-H7493918920370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 4.00MM X 20MM -,SUP-H7493918920400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 2.00 MM X 30MM -,SUP-H7493918930200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 2.25 MM X 30MM -,SUP-H7493918930220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 2.50 MM X 30MM -,SUP-H7493918930250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 2.75 MM X 30MM -,SUP-H7493918930270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 3.00 MM X 30MM -,SUP-H7493918930300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 3.25 MM X 30MM -,SUP-H7493918930320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 3.50 MM X 30MM -,SUP-H7493918930350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 3.75 MM X 30MM -,SUP-H7493918930370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE MR 4.00MM X 30MM -,SUP-H7493918930400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE PUSH MR 1.20MM X 8MM -,SUP-H7493919008120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE PUSH MR 1.50MM X 8MM -,SUP-H7493919008150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE PUSH MR 1.20MM X 12MM -,SUP-H7493919012120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE PUSH MR 1.50MM X 12MM -,SUP-H7493919012150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE PUSH MR 1.20MM X 15MM -,SUP-H7493919015120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE PUSH MR 1.50MM X 15MM -,SUP-H7493919015150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE PUSH MR 1.20MM X 20MM -,SUP-H7493919020120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE PUSH MR 1.50MM X 20MM -,SUP-H7493919020150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 1.20MM X 8MM -,SUP-H7493919108120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 1.50MM X 8MM -,SUP-H7493919108150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 2.00MM X 8MM -,SUP-H7493919108200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 2.25MM X 8MM -,SUP-H7493919108220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 2.50MM X 8MM -,SUP-H7493919108250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 2.75MM X 8MM -,SUP-H7493919108270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 3.00MM X 8MM -,SUP-H7493919108300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 3.25MM X 8MM -,SUP-H7493919108320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 3.50MM X 8MM -,SUP-H7493919108350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 3.75MM X 8MM -,SUP-H7493919108370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 4.00MM X 8MM -,SUP-H7493919108400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 1.20MM X 12MM -,SUP-H7493919112120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 1.50MM X 12MM -,SUP-H7493919112150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 2.00MM X 12MM -,SUP-H7493919112200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 2.25MM X 12MM -,SUP-H7493919112220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 2.50MM X 12MM -,SUP-H7493919112250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 2.75MM X 12MM -,SUP-H7493919112270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 3.00MM X 12MM -,SUP-H7493919112300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 3.25MM X 12MM -,SUP-H7493919112320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 3.50MM X 12MM -,SUP-H7493919112350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 3.75MM X 12MM -,SUP-H7493919112370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 4.00MM X 12MM -,SUP-H7493919112400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 1.20MM X 15MM -,SUP-H7493919115120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 1.50MM X 15MM -,SUP-H7493919115150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 2.00MM X 15MM -,SUP-H7493919115200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 2.25MM X 15MM -,SUP-H7493919115220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 2.50MM X 15MM -,SUP-H7493919115250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 2.75MM X 15MM -,SUP-H7493919115270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 3.00MM X 15MM -,SUP-H7493919115300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 3.25MM X 15MM -,SUP-H7493919115320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 3.50MM X 15MM -,SUP-H7493919115350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 3.75MM X 15MM -,SUP-H7493919115370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 4.00MM X 15MM -,SUP-H7493919115400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 1.20MM X 20MM -,SUP-H7493919120120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 1.50MM X 20MM -,SUP-H7493919120150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 2.25MM X 20MM -,SUP-H7493919120220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 2.50MM X 20MM -,SUP-H7493919120250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 2.75MM X 20MM -,SUP-H7493919120270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 3.00MM X 20MM -,SUP-H7493919120300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 3.25MM X 20MM -,SUP-H7493919120320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 3.50MM X 20MM -,SUP-H7493919120350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 3.75MM X 20MM -,SUP-H7493919120370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 4.00MM X 20MM -,SUP-H7493919120400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 2.00MM X 30MM -,SUP-H7493919130200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 2.00MM X 20MM -,SUP-H7493919130200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 2.25MM X 30MM -,SUP-H7493919130220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 2.50MM X 30MM -,SUP-H7493919130250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 2.75MM X 30MM -,SUP-H7493919130270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 3.00MM X 30MM -,SUP-H7493919130300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 3.25MM X 30MM -,SUP-H7493919130320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 3.50MM X 30MM -,SUP-H7493919130350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 3.75MM X 30MM -,SUP-H7493919130370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE OTW 4.00MM X 30MM -,SUP-H7493919130400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE PUSH OTW 1.20MM X 8MM -,SUP-H7493919208120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE PUSH OTW 1.50MM X 8MM -,SUP-H7493919208150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE PUSH OTW 1.20MM X 12MM -,SUP-H7493919212120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE PUSH OTW 1.50MM X 12MM -,SUP-H7493919212150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE PUSH OTW 1.20MM X 15MM -,SUP-H7493919215120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE PUSH OTW 1.50MM X 15MM -,SUP-H7493919215150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE PUSH OTW 1.20MM X 20MM -,SUP-H7493919220120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON EMERGE PUSH OTW 1.50MM X 20MM -,SUP-H7493919220150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CHARGER BALLOON 3 X 20 X 135 -,SUP-H74939206030210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CHARGER BALLOON 3 X 20 X 75 -,SUP-H74939206030270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CHARGER BALLOON 3MM X 40MM X 130CM -,SUP-H74939206030410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CHARGER BALLOON 3MM X 80MM X 135CM -,SUP-H74939206030810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
3MM X 100MM X 135CM CHARGER -,SUP-H74939206031010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CHARGER 3MM X 120MM -,SUP-H74939206031210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
3.0MM X 150MM X 135CM CHARGER BALLOON -,SUP-H74939206031510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CHARGER 3MM X 200MM X 135CM -,SUP-H74939206032010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CHARGER OTW 4 X 20MM X135CM BALLOON -,SUP-H74939206040210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
4MM X 20MM X 75CM CHARGER BALLOON -,SUP-H74939206040270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
PTA BALLOON 5F -,SUP-H74939206040670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CHARGER BALLOON 4MM X 80MM X 75CM -,SUP-H74939206040870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CHARGER 4MM X 100MM X 135CM -,SUP-H74939206041010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
4MM X 100MM X 75CM CHARGER BALLOON -,SUP-H74939206041070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CHARGER BALLOON 4MM X 150MM X 135CM -,SUP-H74939206041510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
5MM X 20MM X 75CM .035 CHARGER SHORT SHAFT -,SUP-H74939206050270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CHARGER 5MM X 40MM X 135CM -,SUP-H74939206050410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CHARGER BALLOON 5MM X 60MM X 135CM -,SUP-H74939206050610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CHARGER BALLOON 5MM X 80MM X 135CM -,SUP-H74939206050810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
5MM X 80MM X 75CM CHARGER BALLOON -,SUP-H74939206050870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CHARGER 5MM X 100MM X 135CM -,SUP-H74939206051010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CHARGER 5MM X 120MM X 135CM -,SUP-H74939206051210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CHARGER BALLOON 5 X 150MM -,SUP-H74939206051510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
5MM X 200MM X 135CM CHARGER -,SUP-H74939206052010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
6MM X 20MM X 135CM CHARGER -,SUP-H74939206060210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
6MM X 20MM X 75CM .035 CHARGER SHORT SHAFT -,SUP-H74939206060270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CHARGER BALLOON 6MM X 40MM X 135CM -,SUP-H74939206060410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CHARGER 6MM X 40MM X 75CM BALLOON -,SUP-H74939206060470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
6.0MM X 60MM X 75CM CHARGER -,SUP-H74939206060670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
6MM X 8MM X 135CM CHARGER -,SUP-H74939206060810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CHARGER 6.0MM X 80MM X 75CM -,SUP-H74939206060870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CHARGER BALLOON 6MM X 100MM X 135CM -,SUP-H74939206061010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CHARGER 6MM X 100MM X 75CM -,SUP-H74939206061070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CHARGER BALLOON 6MM X 150MM X 135CM -,SUP-H74939206061510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
7MM X 20MM X 135CM CHARGER -,SUP-H74939206070210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
7MM X 40MM X 135CM CHARGER BALLOON -,SUP-H74939206070410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
7MM X 40MM X 75CM CHARGER BALLOON -,SUP-H74939206070470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CHARGER 7MM X 80MM X 135CM -,SUP-H74939206070610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CHARGER BALLOON .035 7MM X 60MM X 75CM -,SUP-H74939206070670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
7MM X 80MM X 75CM CHARGER BALLOON -,SUP-H74939206070870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
7MM X 100MM X 135CM CHARGER BALLOON -,SUP-H74939206071010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
7MM X 100MM X 75CM CHARGER PTA -,SUP-H74939206071070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CHARGER BALLOON 8MM X 40MM X 135CM -,SUP-H74939206080410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CHARGER 8MM X 40MM X 75CM -,SUP-H74939206080470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
8MM X 60MM X 75CM CHARGER PTA -,SUP-H74939206080670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
8MM X 80MM X 135CM CHARGER BALLOON -,SUP-H74939206080810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
8.0MM X 80MM X 75CM CHARGER -,SUP-H74939206080870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CHARGER PTA 8MM X 100MM X 135CM -,SUP-H74939206081010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
8MM X 100MM X 75CM CHARGER PTA -,SUP-H74939206081070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CHARGER 8MM X 180MM X 135CM -,SUP-H74939206081810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
8.0MM X 200MM X 135XM CHARGER BALLOON -,SUP-H74939206082010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
9MM X 40MM X 135CM CHARGER BALLOON -,SUP-H74939206090410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
9MM X 40MM X 75CM CHARGER BALLOON -,SUP-H74939206090470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CHARGER 9MM X 60MM X 75CM -,SUP-H74939206090670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CHARGER OTW 10 X 20 BALLOON 135CM -,SUP-H74939206100210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CHARGER .035 10MM X 40MM X 135CM -,SUP-H74939206100410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
10MM X 40MM X 75CM CHARGER PTA -,SUP-H74939206100470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
10.0MM X 80MM X 75CM CHARGER BALLOON -,SUP-H74939206100870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
12MM X 20MM X 75CM CHARGER -,SUP-H74939206120270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
12MM X 40MM X 135CM CHARGER -,SUP-H74939206120410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
12MM X 40MM X 75CM CHARGER -,SUP-H74939206120470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CHARGER 12MM X 60MM X 75CM -,SUP-H74939206120670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CHARGER 12MM X 80MM X 75CM -,SUP-H74939206120870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 2.00MM x 6MM -,SUP-H7493926706200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 2.25MM x 6MM -,SUP-H7493926706220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 2.50MM x 6MM -,SUP-H7493926706250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 2.75MM x 6MM -,SUP-H7493926706270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 3.00MM x 6MM -,SUP-H7493926706300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 3.25MM x 6MM -,SUP-H7493926706320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 3.50MM x 6MM -,SUP-H7493926706350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 3.75MM x 6MM -,SUP-H7493926706370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 4.00MM X 6MM -,SUP-H7493926706400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 4.50MM x 6MM -,SUP-H7493926706450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 5.00MM x 6MM -,SUP-H7493926706500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 2.00MM x 8MM -,SUP-H7493926708200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 2.25MM x 8MM -,SUP-H7493926708220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 2.50MM x 8MM -,SUP-H7493926708250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 2.75MM x 8MM -,SUP-H7493926708270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 3.00MM x 8MM -,SUP-H7493926708300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 3.25MM x 8MM -,SUP-H7493926708320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 3.50MM x 8MM -,SUP-H7493926708350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 3.75MM x 8MM -,SUP-H7493926708370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 4.0 MM X 8 MM -,SUP-H7493926708400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 4.50MM x 8MM -,SUP-H7493926708450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 5.00MM x 8MM -,SUP-H7493926708500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 5.50MM x 8MM -,SUP-H7493926708550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 6.00MM x 8MM -,SUP-H7493926708600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 2.00MM X 12MM -,SUP-H7493926712200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 2.25MM x 12MM -,SUP-H7493926712220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 2.50 MM X 12 MM -,SUP-H7493926712250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 2.75MM x 12MM -,SUP-H7493926712270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 3.00MM x 12MM -,SUP-H7493926712300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 3.25MM x 12MM -,SUP-H7493926712320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 3.50MM x 12MM -,SUP-H7493926712350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 3.75MM x 12MM -,SUP-H7493926712370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 4.00MM x 12MM -,SUP-H7493926712400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 4.50MM x 12MM -,SUP-H7493926712450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 5.0 MM X 12 MM -,SUP-H7493926712500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 5.50MM x 12MM -,SUP-H7493926712550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 6.00MM x 12MM -,SUP-H7493926712600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 2.00MM x 15MM -,SUP-H7493926715200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 2.25MM x 15MM -,SUP-H7493926715220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 2.50 MM X 15 MM -,SUP-H7493926715250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 2.75MM x 15MM -,SUP-H7493926715270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 3.0 MM X 15 MM -,SUP-H7493926715300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 3.25MM x 15MM -,SUP-H7493926715320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 3.50MM x 15MM -,SUP-H7493926715350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 3.75MM x 15MM -,SUP-H7493926715370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 4.00MM X 15MM -,SUP-H7493926715400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 4.50MM x 15MM -,SUP-H7493926715450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 5.00MM x 15MM -,SUP-H7493926715500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 5.50MM x 15MM -,SUP-H7493926715550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 6.00MM x 15MM -,SUP-H7493926715600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 2.00MM x 20MM -,SUP-H7493926720200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 2.25MM x 20MM -,SUP-H7493926720220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 2.50 MM X 20 MM -,SUP-H7493926720250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 2.75MM x 20MM -,SUP-H7493926720270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 3.0 MM X 20 MM -,SUP-H7493926720300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 3.25MM x 20MM -,SUP-H7493926720320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 3.50MM x 20MM -,SUP-H7493926720350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 3.75MM x 20MM -,SUP-H7493926720370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 4.00MM x 20MM -,SUP-H7493926720400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 4.50MM x 20MM -,SUP-H7493926720450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 5.00MM x 20MM -,SUP-H7493926720500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 5.50MM x 20MM -,SUP-H7493926720550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 6.00MM x 20MM -,SUP-H7493926720600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 2.00MM x 30MM -,SUP-H7493926730200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 2.25MM x 30MM -,SUP-H7493926730220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 2.50MM x 30MM -,SUP-H7493926730250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 2.75MM x 30MM -,SUP-H7493926730270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 3.00MM x 30MM -,SUP-H7493926730300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 3.25MM x 30MM -,SUP-H7493926730320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 3.50MM x 30MM -,SUP-H7493926730350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 3.75MM x 30MM -,SUP-H7493926730370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE MR 4.00MM x 30MM -,SUP-H7493926730400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 2.00MM x 6MM -,SUP-H7493926806200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 2.25MM x 6MM -,SUP-H7493926806220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 2.50MM x 6MM -,SUP-H7493926806250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 2.75MM x 6MM -,SUP-H7493926806270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 3.00MM x 6MM -,SUP-H7493926806300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 3.25MM x 6MM -,SUP-H7493926806320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 3.50MM x 6MM -,SUP-H7493926806350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 3.75MM x 6MM -,SUP-H7493926806370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 4.00MM x 6MM -,SUP-H7493926806400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 4.50MM x 6MM -,SUP-H7493926806450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 5.00MM x 6MM -,SUP-H7493926806500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 2.00MM x 8MM -,SUP-H7493926808200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 2.25MM x 8MM -,SUP-H7493926808220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 2.50MM x 8MM -,SUP-H7493926808250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 2.75MM x 8MM -,SUP-H7493926808270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 3.00MM x 8MM -,SUP-H7493926808300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 3.25MM x 8MM -,SUP-H7493926808320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 3.50MM x 8MM -,SUP-H7493926808350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 3.75MM x 8MM -,SUP-H7493926808370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 4.00MM x 8MM -,SUP-H7493926808400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 4.50MM x 8MM -,SUP-H7493926808450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 5.00MM x 8MM -,SUP-H7493926808500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 5.50MM x 8MM -,SUP-H7493926808550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 6.00MM x 8MM -,SUP-H7493926808600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 2.00MM x 12MM -,SUP-H7493926812200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 2.25MM x 12MM -,SUP-H7493926812220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 2.50MM x 12MM -,SUP-H7493926812250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 2.75MM X 12MM -,SUP-H7493926812270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 3.00MM x 12MM -,SUP-H7493926812300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 3.25MM x 12MM -,SUP-H7493926812320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 3.50MM x 12MM -,SUP-H7493926812350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 3.75MM x 12MM -,SUP-H7493926812370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 4.00MM x 12MM -,SUP-H7493926812400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 4.50MM x 12MM -,SUP-H7493926812450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 5.00MM x 12MM -,SUP-H7493926812500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 5.50MM x 12MM -,SUP-H7493926812550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 6.00MM x 12MM -,SUP-H7493926812600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 2.00MM x 15MM -,SUP-H7493926815200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 2.25MM x 15MM -,SUP-H7493926815220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 2.50MM x 15MM -,SUP-H7493926815250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 2.75MM x 15MM -,SUP-H7493926815270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 3.00MM x 15MM -,SUP-H7493926815300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 3.25MM x 15MM -,SUP-H7493926815320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 3.50MM x 15MM -,SUP-H7493926815350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 3.75MM x 15MM -,SUP-H7493926815370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 4.00MM x 15MM -,SUP-H7493926815400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 4.50MM x 15MM -,SUP-H7493926815450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 5.00MM x 15MM -,SUP-H7493926815500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 5.50MM x 15MM -,SUP-H7493926815550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 6.00MM x 15MM -,SUP-H7493926815600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 2.00MM x 20MM -,SUP-H7493926820200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 2.25MM x 20MM -,SUP-H7493926820220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 2.50MM x 20MM -,SUP-H7493926820250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 2.75MM x 20MM -,SUP-H7493926820270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 3.00MM x 20MM -,SUP-H7493926820300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 3.25MM x 20MM -,SUP-H7493926820320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 3.50MM x 20MM -,SUP-H7493926820350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 3.75MM x 20MM -,SUP-H7493926820370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 4.00MM x 20MM -,SUP-H7493926820400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 4.50MM x 20MM -,SUP-H7493926820450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 5.00MM x 20MM -,SUP-H7493926820500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 5.50MM x 20MM -,SUP-H7493926820550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 6.00MM x 20MM -,SUP-H7493926820600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 2.00MM x 30MM -,SUP-H7493926830200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 2.25MM x 30MM -,SUP-H7493926830220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 2.50MM x 20MM -,SUP-H7493926830250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 2.75MM x 30MM -,SUP-H7493926830270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 3.00MM x 30MM -,SUP-H7493926830300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 3.25MM x 30MM -,SUP-H7493926830320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 3.50MM x 30MM -,SUP-H7493926830350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 3.75MM x 30MM -,SUP-H7493926830370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NC EMERGE OTW 4.00MM x 30MM -,SUP-H7493926830400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CUTTING 6MMX2.0MM WOLVERINE -,SUP-H74939401062000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CUTTING 6MMX2.5MM WOLVERINE -,SUP-H74939401062500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CUTTING 6MMX3.0MM WOLVERINE -,SUP-H74939401063000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CUTTING 6MMX3.5MM WOLVERINE -,SUP-H74939401063500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CUTTING 6MMX4.0MM WOLVERINE -,SUP-H74939401064000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CUTTING 10MMX2.0MM WOLVERINE -,SUP-H74939401102000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CUTTING 10MMX2.5MM WOLVERINE -,SUP-H74939401102500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CUTTING 10MMX3.0MM WOLVERINE -,SUP-H74939401103000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CUTTING 10MMX3.5MM WOLVERINE -,SUP-H74939401103500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CUTTING 10MMX4.0MM WOLVERINE -,SUP-H74939401104000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CUTTING 15MX2.00MM WOLVERINE -,SUP-H74939401152000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CUTTING 15MX2.50MM WOLVERINE -,SUP-H74939401152500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON CUTTING 15MMX3.0MM WOLVERINE -,SUP-H74939401153000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
RANGER GLOBAL DCB OTW 6.0 X 150MM 150CM -,SUP-H74939419601510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
RANGER DCB OTW  7.0MM x 40MM x 80CM -,SUP-H74939419700480,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT BLN -,SUP-H749CBM3200100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X6MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3225060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3225100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X6MM FLEXTOME CUT BLN MONORAIL 142CM RX -,SUP-H749CBM3250060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3250100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3250150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.75X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3275100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.75X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3275150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT BLN -,SUP-H749CBM3300100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT BLN -,SUP-H749CBM3300150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3325100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X15MM FLEXTOME CUT BLN MONORAIL 142CM RX -,SUP-H749CBM3325150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3350100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3350150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.75X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3375100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3200060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3200100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3225060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3225100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X15MM FLEXTOME BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3225150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3250060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3250100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X15MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3250150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.75X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3275100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.75X15MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3275150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3300060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X15MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3300150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3325100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X15MM FLEXTOME CUT BLN 142CM CUT BLN NC -,SUP-H749CBO3325150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN -,SUP-H749CBO3350100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH DX 2.4FR ID 3.4FR RND TIP 135CM CROSSBOSS XING MUL-WIRE -,SUP-H749M2000A0,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4648.07,3253.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH ANG 0.045IN 5FR FR4 125CM EXPO FUL-R WIRE BRD ROBST -,SUP-H759085262251,CDM,C1725,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATHETER IABP 7.5FR 40CC ULTRA FLEX REF: IAB-06840-U -,SUP-IAB-06840-U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATHETER IABP 8FR 40CC REDIGUARD REF: IAB-S840C -,SUP-IAB-S840C,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4010.16,2807.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
INFLATION KIT 30/30 BASIX -,SUP-IN4530,CDM,C1725,HCPCS,272,RC,,,outpatient,,,364.57,255.199,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5X220MM LUTONIX -,SUP-LX3513052205F,CDM,C1725,HCPCS,272,RC,,,outpatient,,,8063.6,5644.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
LUTONIX BALLOON 7MM X 80MM -,SUP-LX351307805F,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5305,3713.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
LUTONIX PTA 5MM X 60MM X 75CM -,SUP-LX3575560V,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
LUTONIX BALLOON 7 X 80 -,SUP-LX3575780V,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
LUTONIX 8 X 80 -,SUP-LX3575880V,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B XXL 14MM 4CM 75 14-514 -,SUP-M001145140,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B CATH XXL VASC 12 X 6 X 75CM -,SUP-M001145300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 14X60MM 2XL 75CM LPRO F/PTA PERIPH NYBAX LUB -,SUP-M001145320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON XXL 16 X 4 X 75 -,SUP-M001145530,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON XXL 16 X 4  5.8/120 -,SUP-M001145530,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 16X60MM 2XL 75CM LPRO PERIPH NYBAX LUB BIOSLD CTD -,SUP-M001145540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B CATH XXL 18MM X 4CM 120CM -,SUP-M001145580,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH DIL 18MM 8FR SHEA 0.037IN TIP 5.8FRX75CM 6CM BLN GALWAY -,SUP-M001145590,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X40MM ULTR-THN DMD 75CM F/PTA PERIPH 5FR SHTH -,SUP-M001164230,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6X20MM ULTR-THN DMD 75CM F/PTA PERIPH 5FR SHTH -,SUP-M001164570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 7X20MM ULTR-THN DMD 75CM F/PTA PERIPH 5FR SHTH -,SUP-M001164770,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B DUT 8MM 4CM 75CM  16-505 -,SUP-M001165050,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
AST-GN45 -,SUP-M001NC20000001,CDM,C1725,HCPCS,272,RC,,,outpatient,,,358.85,251.195,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 7X40MM POLAR 120CM COAX F/PTA CLD THRP PERIPH -,SUP-M001P740120010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2807.11,1964.977,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 7X60MM POLAR 120CM COAX F/PTA CLD THRP PERIPH -,SUP-M001P760120010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2807.11,1964.977,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 8X20MM POLAR 120CM COAX F/PTA CLD THRP PERIPH -,SUP-M001P820120010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
DEVICE INFL POLAR N2O -,SUP-M001PCIU400000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4927.28,3449.096,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X40MM POLAR 150CM COAX F/PTA CLD THRP PERIPH -,SUP-M001T3040150010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X40MM POLAR 150CM COAX F/PTA CLD THRP PERIPH -,SUP-M001T4040150010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
RETRACTOR ORTHO HHMN 18MMX9.25IN STN FNSH SS V. MUELLER -,SUP-M001T5040135010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6X40MM POLAR 135CM COAX F/PTA CLD THRP PERIPH -,SUP-M001T6040135010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATHETER  SHOCKWAVE M5+ IVL CATHETER 5.0X60MM -,SUP-M5PIVL5060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATHETER SHOCKWAVE 5.5 X 60 MM M5+ -,SUP-M5PIVL5560,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATHETER- SHOCKWAVE M5+ IVL CATHETER- 6.0X60MM -,SUP-M5PIVL6060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATHETER- SHOCKWAVE M5+ IVL CATHETER- 7.0X60MM -,SUP-M5PIVL7060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATHETER- SHOCKWAVE M5+ IVL CATHETER- 8.0X60MM -,SUP-M5PIVL8060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP2006X NCEUPHORA RX -,SUP-NCEUP2006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP2008X NCEUPHORA RX -,SUP-NCEUP2008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP2012X NCEUPHORA RX -,SUP-NCEUP2012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP2015X NCEUPHORA RX -,SUP-NCEUP2015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP2020X NCEUPHORA RX -,SUP-NCEUP2020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP22506X NCEUPHORA RX -,SUP-NCEUP22506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP22508X NCEUPHORA RX -,SUP-NCEUP22508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP22512X NCEUPHORA RX -,SUP-NCEUP22512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP22515X NCEUPHORA RX -,SUP-NCEUP22515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP22520X NCEUPHORA RX -,SUP-NCEUP22520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP2506X NCEUPHORA RX -,SUP-NCEUP2506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP2508X NCEUPHORA RX -,SUP-NCEUP2508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP2512X NCEUPHORA RX -,SUP-NCEUP2512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP2515X NCEUPHORA RX -,SUP-NCEUP2515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP2520X NCEUPHORA RX -,SUP-NCEUP2520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP2527X NCEUPHORA RX -,SUP-NCEUP2527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP27506X NCEUPHORA RX -,SUP-NCEUP27506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP27508X NCEUPHORA RX -,SUP-NCEUP27508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP27512X NCEUPHORA RX -,SUP-NCEUP27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP27515X NCEUPHORA RX -,SUP-NCEUP27515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP27520X NCEUPHORA RX -,SUP-NCEUP27520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP27527X NCEUPHORA RX -,SUP-NCEUP27527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP3006X NCEUPHORA RX -,SUP-NCEUP3006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP3008X NCEUPHORA RX -,SUP-NCEUP3008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP3012X NCEUPHORA RX -,SUP-NCEUP3012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP3015X NCEUPHORA RX -,SUP-NCEUP3015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP3020X NCEUPHORA RX -,SUP-NCEUP3020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP3027X NCEUPHORA RX -,SUP-NCEUP3027X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP32506X NCEUPHORA RX -,SUP-NCEUP32506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP32508X NCEUPHORA RX -,SUP-NCEUP32508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP32512X NCEUPHORA RX -,SUP-NCEUP32512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP32515X NCEUPHORA RX -,SUP-NCEUP32515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP32520X NCEUPHORA RX -,SUP-NCEUP32520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP32527X NCEUPHORA RX -,SUP-NCEUP32527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP3506X NCEUPHORA RX -,SUP-NCEUP3506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP3508X NCEUPHORA RX -,SUP-NCEUP3508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP3512X NCEUPHORA RX -,SUP-NCEUP3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP3515X NCEUPHORA RX -,SUP-NCEUP3515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP3520X NCEUPHORA RX -,SUP-NCEUP3520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP3527X NCEUPHORA RX -,SUP-NCEUP3527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP37506X NCEUPHORA RX -,SUP-NCEUP37506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP37508X NCEUPHORA RX -,SUP-NCEUP37508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP37512X NCEUPHORA RX -,SUP-NCEUP37512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP37515X NCEUPHORA RX -,SUP-NCEUP37515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP37520X NCEUPHORA RX -,SUP-NCEUP37520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP37527X NCEUPHORA RX -,SUP-NCEUP37527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP4006X NCEUPHORA RX -,SUP-NCEUP4006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP4008X NCEUPHORA RX -,SUP-NCEUP4008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP4012X NCEUPHORA RX -,SUP-NCEUP4012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP4015X NCEUPHORA RX -,SUP-NCEUP4015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP4020X NCEUPHORA RX -,SUP-NCEUP4020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP4027X NCEUPHORA RX -,SUP-NCEUP4027X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP4508X NCEUPHORA RX -,SUP-NCEUP4508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP4512X NCEUPHORA RX -,SUP-NCEUP4512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP4515X NCEUPHORA RX -,SUP-NCEUP4515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP4520X NCEUPHORA RX -,SUP-NCEUP4520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP5008X NCEUPHORA RX -,SUP-NCEUP5008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP5012X NCEUPHORA RX -,SUP-NCEUP5012,CDM,C1725,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
BALLOON NCEUP5015X NCEUPHORA RX -,SUP-NCEUP5015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X6MM NC STRMR 138CM OTW NC COR 3- FOLD FLCRM + -,SUP-NCS2506W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X11MM NC STRMR 138CM OTW NC COR 3- FOLD FLCRM + -,SUP-NCS2511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS2514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.75X6MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS27506W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.75X11MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM -,SUP-NCS27511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.75X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS27514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.75X16MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS27516W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X6MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS3006W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X11MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS3011W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS3014W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X16MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS3016W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X11MM NC STRMR 138CM OTW NC COR 5- FOLD FLCRM -,SUP-NCS32511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS32514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X11MM NC STRMR 138CM OTW NC COR 5- FOLD FLCRM + -,SUP-NCS3511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X16MM NC STRMR 138CM OTW NC COR 5- FOLD FLCRM + -,SUP-NCS3516W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.75X11MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS37511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.75X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS37514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X11MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS4011W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X16MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS4016W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X21MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS4021W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X6MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP2506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP2512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP2515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.75X6MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP27506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.75X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.75X21MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP27521X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X6MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT FLCRM -,SUP-NCSP3006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X21MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3021X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X12MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP32512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X15MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP32515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X27MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.75X12MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP37512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.75X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP37515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X21MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4021X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4.5X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5X15MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP5015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
PALADIN CAROTID PTA CATHETER WITH INTEGRATED EMB PRO -,SUP-PD-5520-140-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATHETER ADVANCE MICRO 14 ULTRA LOW PROFILE BALLOON -,SUP-PTA3-14-90-2.5-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2289.76,1602.832,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATHETER PTA BALLOON DILATION 18LP ADVANCE LP 2MM X 20CM -,SUP-PTA4-18-150-2-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4MMX10CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4MMX6CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-8,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
B CATH ADVANCE 18LP 5X10 150 -,SUP-PTA4-18-150-510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-5-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-5-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5MMX6CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-5-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6MMX10CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-6-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-6-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH ANG 4FR 0.018/ 150CM/6MM DIA 6CM ADVANCE RNL POPLT PTA -,SUP-PTA4-18-150-6-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 7MMX10CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-710,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 7MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 7MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 7MMX6CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 7MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-8,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 10MMX3CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-PTA5-35-135-103,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-PTA5-35-135-44,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-PTA5-35-13562.0,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 8MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-PTA5-35-135-8-8,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-PTAX4141702.520,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-PTAX414170312,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 26MM 12FRX2.5CM INOUE 70CM PVC 0.025IN GW COMP -,SUP-PTMC-26,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10025.1,7017.57,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 28MM 12FRX2.5CM INOUE 70CM PVC 0.025IN GW COMP -,SUP-PTMC-28,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10025.1,7017.57,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 30MM 12FRX2.5CM INOUE 70CM PVC 0.025IN GW COMP -,SUP-PTMC-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10025.1,7017.57,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
SHOCKWAVE 3.0 X 40MM IVL KIT -,SUP-S4IVLK3040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ADV SERENITY 14 HYDROPHILIC PTA BALL DIL CATH 2.5X60X150CM -,SUP-SER14-150-25-60,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ADVANCE SERENITY 14 HYDROPHILIC PTA BALLOON DIL CATH -,SUP-SER14-150-30-60,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.25X6MM SPRINTER LEGEND 152CM OTW SEM-COM COR -,SUP-SPL12506WL,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.25X6MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.25X10MM SPRINTER LEGEND 152CM OTW SEM-COM COR -,SUP-SPL12510WL,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.25X10MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.25X12MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.25X15MM SPRINTER LEGEND 152CM OTW SEM-COM COR -,SUP-SPL12515WL,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.25X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.5X6MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL15006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.5X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL15012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.5X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL15015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL20012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL20015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X20MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL20020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X6MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL22506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL22515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL25012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL25015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X20MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL25020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X25MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL25025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.75X12MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.75X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL27515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.75X20MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL27520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL30012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL30015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X20MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL30020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X12MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL40012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL40015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.5X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR1512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 1.5X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR1515W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2012W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2015W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X20MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2020W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X25MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2025W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.25X12MM SPRINTER 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR22512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X6MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2506W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2515W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5X20MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2520W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.75X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR27512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.75X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR27515W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3012W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3015W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3X20MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3020W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.25X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR32512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3.5X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR4015W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ENROUTE ENFLATE TRANSCAROTID RX BALLOON -,SUP-SR-4525-BC,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2008.89,1406.223,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
ENROUTE ENFLATE TRANSCAROTID RX BALLOON -,SUP-SR-5035-BC,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2008.89,1406.223,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH ANG 4FR STR 125CM TEMPO AQ SLCT BRD SHFT NO SH NYL -,SUP-SRD6667,CDM,C1725,HCPCS,272,RC,,,outpatient,,,269.58,188.706,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATHETER BALLOON TRUE FLOW 24 MM x 3.5CM REF: TF0243514 -,SUP-TF0243514,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6153.8,4307.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CABLE ADPTR IABP -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,344.79,241.353,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4X15MM 140CM OTW PERIPH -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4134.28,2893.996,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH SHEATH RITESITE C315H1802 -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2X15MM 140CM OTW PERIPH -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4134.28,2893.996,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2MMX2CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V142020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V142040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 2.5MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V142540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3MMX2CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V143020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3319.12,2323.384,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V143040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 3MMX6CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V143060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4MMX12CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V1840120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 4MMX8CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V184080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V185040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 5MMX6CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V185060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATH PTCA 6MMX12CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V1860120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
CATHETER PTV DILATATION 26MX4CM VIDA REF:VDA100264 -,SUP-VDA100264,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2802.82,1961.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.650485,9184.66245,other,Non-Reimbursable List,,
DILATOR 6-30FR DIA TIP 30CM PE/PTFE -,SUP-118768,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1395.36,976.752,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
LEAD DEFIB IMPL BIPLR PERMNT PCNG ETAK RELIANCE G_59CM -,SUP-5843,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
KT MNMTRY BLN ADLT RCTL BLN -,SUP-A86-1070,CDM,C1726,HCPCS,272,RC,,,outpatient,,,52.52,36.764,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CATH DIL 6MMX16MM RELIEVA ULTIRRA SIN 2LUM SHFT ENDO F/IRR -,SUP-BC0616RU,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3728.49,2609.943,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CATH DIL 6MMX16MM RELIEVA SOLO PRO SIN 2LUM SHFT ENDO F/IRR -,SUP-BC0616SP,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3265.42,2285.794,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
KIT CATHETER SURGILUBE VINYL PEDIATRIC FEMALE OD8 FR SOFT LF -,SUP-CKF105L,CDM,C1726,HCPCS,272,RC,,,outpatient,,,18.99,13.293,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
KIT CATHETER SURGILUBE VINYL PEDIATRIC FEMALE OD8 FR SOFT LF -,SUP-CKF105L,CDM,C1726,HCPCS,272,RC,,,outpatient,,,18.96,13.272,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
TRAY URETHRAL 8FR FEMALE VINYL PVP URINE COLLECTION DEVICE -,SUP-CKF105L,CDM,C1726,HCPCS,272,RC,,,outpatient,,,18.15,12.705,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
BALLOON CERVICAL RIPENING W/STYLET -,SUP-G19891,CDM,C1726,HCPCS,272,RC,,,outpatient,,,243.61,170.527,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
IMPLANT PIP MCP SZ5 SWNSN SIL -,SUP-G470-0005,CDM,C1726,HCPCS,272,RC,,,outpatient,,,4413.76,3089.632,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
HURRICANE RX 4 X 4 -,SUP-G49219,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
HURRICANE RX 6 X 4 -,SUP-G49220,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
HURRICANE RX 8 X 4 -,SUP-G49221,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
HURRICANE RX 10 X 4 -,SUP-G49222,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CATH DIL 7FR CATH 7-5FR TIP 200CM 2CM BLN FUSION BIL TAPR -,SUP-G49571,CDM,C1726,HCPCS,272,RC,,,outpatient,,,676.86,473.802,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CATH DIL 8.5FR CATH 8.5-6FR TAPR 200CM 2CM BLN FUSION BIL -,SUP-G49572,CDM,C1726,HCPCS,272,RC,,,outpatient,,,676.86,473.802,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CATH DIL 7FR TAPR 200CM 2CM BLN FUSION BIL DOME TIP ENDO -,SUP-G49573,CDM,C1726,HCPCS,272,RC,,,outpatient,,,676.86,473.802,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CATH PTCA 6X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171061070,CDM,C1726,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
B CUTTING 5 X 2 X 135 -,SUP-M001PCB50201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
BALLOON 2CM PERIPHERAL CUTTING -,SUP-M001PCB50201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CATH PTCA 5MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-M001PCB50201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
PERIPHERAL CUTTING BALLOON  5MM X 2CM  50CM -,SUP-M001PCB5020500,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
B 6 X 2 X 135 CUTTING BAL -,SUP-M001PCB60201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
B CUTTING 7 X 2 X 135 -,SUP-M001PCB70201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CATH PTCA 7MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-M001PCB70201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CATH PTCA 7X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-M001PCB7020900,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
B CUTTING 8 X 2 X 135 -,SUP-M001PCB80201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CATH PTCA 8MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-M001PCB80201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CATH PTCA 8X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-M001PCB8020900,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CATH PTCA 1.5X3MM CUT BLN 140CM OTW PERIPH 0.018IN GW COMP -,SUP-M001PCBO3015140,CDM,C1726,HCPCS,272,RC,,,outpatient,,,4134.28,2893.996,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
B PERIPHERAL 6F 3.0X15X140 M00 -,SUP-M001PCBO3015140F0,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
B PER CUT OTW FLEX 4X15X140 M0 -,SUP-M001PCBO4015140F0,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CUTTING BALLOON 4MM X 1.5CM  X 135CM -,SUP-M001PCBO4015140F0,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CATH DIL 5.8FR 6MM BLN 180CM 4CM BLN HURRCN SS BIL RX ENDO -,SUP-M00545920,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CATH DIL 5.8FR 8MM BLN 180CM 4CM BLN HURRCN SS BIL RX ENDO -,SUP-M00545940,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CATHETER CHOLANGIOGRAM SPYGLASS 65CM CHOLANGIOSCOPY -,SUP-M00546780,CDM,C1726,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
DILATOR BLN 36-40.5-45FR OD BLN 75CM 5.5CM CRE ESPH WG ENDO -,SUP-M00550300,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1649.04,1154.328,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
DILATOR BLN 24-27-30FR OD BLN 75CM 3CM CRE ESPH WG ENDO -,SUP-M00550330,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1649.04,1154.328,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
DILATOR BLN 30-33-36FR OD BLN 75CM 3CM CRE ESPH WG ENDO -,SUP-M00550340,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1649.04,1154.328,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
DILATOR BALLOON 35MM RIGIFLEX -,SUP-M00554510,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3112.17,2178.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
DILATOR BLN 7.5FR 6-7-8 MMX180CM 5.5CM BLN CRE PEBAX ESPH FX -,SUP-M00556860,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CRE 8-10MM 8CM F/G -,SUP-M00558340,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CRE 10-12MM 8CM F/G -,SUP-M00558350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CRE 12-15MM 8CM F/G -,SUP-M00558360,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
DILATOR BLN 6FR 12-13.5-15 MMX180CM 8CM BLN CRE PEBAX ESPH -,SUP-M00558360,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CRE 15-18MM 8CM F/G -,SUP-M00558370,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CRE 18-20MM 8CM F/G -,SUP-M00558380,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
DILATOR BLN 6FR 18-19-20 MMX180CM 8CM BLN CRE PEBAX ESPH FX -,SUP-M00558380,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
DILATOR WIREGUIDED CRE 15-18 180CM -,SUP-M00558430,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
DILATOR BLN 7.5FR 10-11-12 MMX240CM 5.5CM BLN CRE PEBAX ESPH -,SUP-M00558470,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
DILATOR BLN 7.5FR 12-13.5-15 MMX240CM 5.5CM BLN CRE PEBAX -,SUP-M00558480,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
DILATOR WIREGUIDED CRE 8-10 180CM -,SUP-M00558610,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
DILATOR WIREGUIDED CRE 10-12 180CM -,SUP-M00558620,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
DILATOR WIREGUIDED CRE 12-15 180CM -,SUP-M00558630,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CRE PRO WIREGUIDED 6-7-8MM 240CM -,SUP-M00558660,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CRE PRO WIREGUIDE 8-9-10MM 240 -,SUP-M00558670,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CRE PRO WIREGUIDE 10-11-12MM 240 -,SUP-M00558680,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CRE PRO WIREGUIDE 12-13.5-15MM 240 -,SUP-M00558690,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CRE PRO WIREGUIDE 15-16.5-18MM 240 -,SUP-M00558700,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
DILATOR BLN 7.5FR 15-16.5-18 MMX240CM 5.5CM BLN CRE PEBAX -,SUP-M00558700,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CRE PRO WIREGUIDE 18-19-20MM 240 -,SUP-M00558710,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CATH BILIARY BALLOON DILATATION CRE 8-10 3CM -,SUP-M00558920,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1517,1061.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CATH BILIARY BALLOON DILATATION CRE 10-12 3CM -,SUP-M00558930,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1517,1061.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CATH BILIARY BALLOON DILATATION CRE 12-15 3CM -,SUP-M00558940,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1517,1061.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CATH NEPH DIL 7FR 30FR BLN LPRO NPHRMX LF MRKR STPCK 17CM -,SUP-M0062101170,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1232.21,862.547,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CATH NEPH 7FR 10MM NPHRMX LF MRKR PTFE SHTH STPCK INFL DVC -,SUP-M0062101180,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1347.23,943.061,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CATH NEPH DIL 7FR 30FR BLN LPRO NPHRMX LF MRKR STPCK 20CM -,SUP-M0062101440,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1303.92,912.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CATH URET 4MM BLN 12FR INFL 3FR SHFT 150CM HYDRPLS CTD SS -,SUP-M0062181100,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1434.32,1004.024,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
PASSPORT BALLOON CATH 2CM -,SUP-M0062181200,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1540.27,1078.189,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CATH URET 5.8FRX4MM OD BLN 12FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251000,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1208.3,845.81,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
URO-MAX 2Q 4CM BALLOON KIT -,SUP-M0062251010,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1252.72,876.904,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CATH URET 5.8FRX10MM OD BLN 30FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251050,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1170.62,819.434,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
UROMAX 2/Q CATH 6CM 15FR SINGLE -,SUP-M0062251070,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1170.62,819.434,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CATH UROMAX U2Q\8-8 SINGLE -,SUP-M0062251100,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1170.62,819.434,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
UROMAX 2/Q CATH 10CM 15FR -,SUP-M0062251160,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1252.72,876.904,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CATH URET 5.8FRX6MM OD BLN 15FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251360,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1464.74,1025.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CATH URET 5.8FRX6MM OD BLN 18FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251370,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1384.17,968.919,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
APPLICATOR ENDO BLN US F /BF-UC16F-OL8 LTX STRL -,SUP-MAJ-1351,CDM,C1726,HCPCS,272,RC,,,outpatient,,,191.19,133.833,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CUFF BLN ADLT ENDO US F -,SUP-MAJ-249,CDM,C1726,HCPCS,272,RC,,,outpatient,,,157.36,110.152,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CATH ESPH 4.2MMX1CM SPC HI-RESOLTN CHNLX36 MANOSCAN -,SUP-MSC-1286,CDM,C1726,HCPCS,272,RC,,,outpatient,,,25903.5,18132.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CATHETER HEMOSTATIC BALLOON NEXPOWDER -,SUP-NHS03,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CATH ATHRCMY PERIPH CUT BLN 4MMX140MM OTW PERIPH -,SUP-PCB04015140F,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CATH PTCA 6MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-PCB6020135,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CATH PTCA 7X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-PCB702090,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
CATH PTCA 8X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-PCB802090,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.074675,18572.8095,other,Non-Reimbursable List,,
HERNIA BALLOON #OMS-PDBS2 -,SUP-OMS-PDBS2,CDM,C1727,HCPCS,272,RC,,,outpatient,,,1296.65,907.655,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,291.097925,929.69805,other,Non-Reimbursable List,,
CATH BRCHTX MULTLUM 4-5CM CONTURA STRL -,SUP-B01245,CDM,C1728,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,195.18479,8389.93965,other,Non-Reimbursable List,,
APPLICATOR BRCHTX MULTLUM 5-6CM BLN CONTURA STRL SUD -,SUP-B01256,CDM,C1728,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,195.18479,8389.93965,other,Non-Reimbursable List,,
CATH BRCHTX 5-6CM CONTURAFLEX LF -,SUP-B13256,CDM,C1728,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,195.18479,8389.93965,other,Non-Reimbursable List,,
CATH BRCHTX F/CVTY MNTN CONTURA -,SUP-B90012,CDM,C1728,HCPCS,272,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,195.18479,8389.93965,other,Non-Reimbursable List,,
TRY APPLICATOR BRCHTX SAVI 6-1 -,SUP-SAVI-06,CDM,C1728,HCPCS,272,RC,,,outpatient,,,9468.15,6627.705,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,195.18479,8389.93965,other,Non-Reimbursable List,,
APPLICATOR BRCHTX SGL-ENTRY MUL-CATH SAVI PREP -,SUP-SPC-01,CDM,C1728,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,195.18479,8389.93965,other,Non-Reimbursable List,,
CT/MR APPLICATOR W/BASE PLATE -,SUP-UNDEFINED,CDM,C1728,HCPCS,272,RC,,,outpatient,,,11701.45,8191.015,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,195.18479,8389.93965,other,Non-Reimbursable List,,
DRAIN PENROSE19MM 30CM 32MM FLAT -,SUP-00000,CDM,C1729,HCPCS,272,RC,,,outpatient,,,4.14,2.898,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH NEPH PEZ 28FR EYEX2 PRPRTN HEAD LTX MSHRM SHP -,SUP-064028,CDM,C1729,HCPCS,272,RC,,,outpatient,,,44.17,30.919,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH NEPH MLCT 14FR WNGX4 LTX -,SUP-086014,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.82,46.074,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH MALECOT 18FR BARD -,SUP-086018,CDM,C1729,HCPCS,272,RC,,,outpatient,,,49.29,34.503,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH MALECOT 20FR BARD -,SUP-086020,CDM,C1729,HCPCS,272,RC,,,outpatient,,,49.29,34.503,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH MALECOT 22FR BARD -,SUP-086022,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.06,45.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH MALECOT 24FR BARD -,SUP-086024,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.07,45.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH MALECOT 34FR PROPORTIONATE HEAD LATEX -,SUP-086034,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.07,45.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH NEPH MLCT 38FR WNGX4 LTX -,SUP-086038,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.06,45.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH NEPH MLCT 40FR WNGX4 LTX -,SUP-086040,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.89,45.423,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
24FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14024,CDM,C1729,HCPCS,272,RC,,,outpatient,,,123.9,86.73,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
28FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14028,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
32 FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14032,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
36FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14036,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH DRN 10.2FRX25CM SDPRTX6 COOK-COPE TY LCK LOOP -,SUP-192550,CDM,C1729,HCPCS,272,RC,,,outpatient,,,429.81,300.867,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH DRN 16FRX25CM SDPRTX6 COOK-COPE TY LCK LOOP -,SUP-193581,CDM,C1729,HCPCS,272,RC,,,outpatient,,,609.7,426.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH BIL DRN 12FRX40CM SDPRTX32 MA C -LOC LCK LOOP -,SUP-228702,CDM,C1729,HCPCS,272,RC,,,outpatient,,,545.51,381.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH DRN 12 FR X 25CM J-CRV THAL-QUICK PVC SDPRTX3 -,SUP-228707,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH DRN 14FRX25CM SDPRTX6 MA C -LOC LCK LOOP -,SUP-228709,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
TUBE VACUTNR 4ML GRN CAP NAHEP SAFTY PLST PPR LBL STRL HG-FR -,SUP-367871,CDM,C1729,HCPCS,272,RC,,,outpatient,,,0.94,0.658,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
THORACENTESIS TRAY/P4340A -,SUP-4340A,CDM,C1729,HCPCS,272,RC,,,outpatient,,,176.04,123.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
TRY THORCNTS 14GAX2IN L INTRO NDLX4 3WAY STP C LOCK BTRFLY -,SUP-4341B,CDM,C1729,HCPCS,272,RC,,,outpatient,,,228.45,159.915,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH VNTRC DRN 80CM TUOHY NDL FX TAB BLNT NDL STRN RLF OPN -,SUP-464-20,CDM,C1729,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
THORACENTESIS 30IN TUBING 4653 -,SUP-4653-48,CDM,C1729,HCPCS,272,RC,,,outpatient,,,23.96,16.772,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
SYS VNTRC DRN 35CM DUET W/ICP LN NDL-FR PRTX3 DRP CHMBR TBG -,SUP-469-13,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1120.58,784.406,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
SYS BAG VNTRC DRN REPL 35CM INTLNK NDL-FR INJ SITE -,SUP-469-14,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1120.58,784.406,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
KIT CSF DRAINAGE W CATH -,SUP-46916,CDM,C1729,HCPCS,272,RC,,,outpatient,,,2091.05,1463.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATHETER PLEURAL PLEURX KIT -,SUP-50-7000B,CDM,C1729,HCPCS,272,RC,,,outpatient,,,3841.3,2688.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH WORD BARTHOLIN GLAND 10FR 5CM -,SUP-564000,CDM,C1729,HCPCS,272,RC,,,outpatient,,,104.15,72.905,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATHETER THORACIC 28F STRAIGHT -,SUP-8028,CDM,C1729,HCPCS,272,RC,,,outpatient,,,35.56,24.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATHETER THORACIC 32FR STERILE -,SUP-8032,CDM,C1729,HCPCS,272,RC,,,outpatient,,,35.05,24.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATHETER THORACIC 36F STRAIGHT -,SUP-8036,CDM,C1729,HCPCS,272,RC,,,outpatient,,,35.88,25.116,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATHETER THORACIC 24FR RT ANGL -,SUP-8124,CDM,C1729,HCPCS,272,RC,,,outpatient,,,57.26,40.082,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATHETER THORACIC  32F RT ANGLE -,SUP-8132,CDM,C1729,HCPCS,272,RC,,,outpatient,,,54.52,38.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
DRAIN CATH LUMBAR KTXTRN DRN 0.76MM 1.65MMX46CM -,SUP-82-1706,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1526.54,1068.578,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH VNTRC DRN 1.5MM BCTSL EVD SIL 0.15% CLNDMCN -,SUP-82-1745,CDM,C1729,HCPCS,272,RC,,,outpatient,,,2522.1,1765.47,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
DRAIN PENROSE 5/8 WND 0.625X12IN GRVTY  FLT LTX -,SUP-8888515007,CDM,C1729,HCPCS,272,RC,,,outpatient,,,223.25,156.275,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH TROCAR 12FR ARGYLE -,SUP-8888561027,CDM,C1729,HCPCS,272,RC,,,outpatient,,,106.84,74.788,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH TROCAR 20FR X 16 ARGYLE -,SUP-8888561043,CDM,C1729,HCPCS,272,RC,,,outpatient,,,78.42,54.894,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH TROCAR 28FR X 16 ARGYLE -,SUP-8888561068,CDM,C1729,HCPCS,272,RC,,,outpatient,,,110.81,77.567,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
KT DRN 20FRX10IN ARGYLE PVC GLVX2 PREP SWB /CUPX2 FEN DRAPE -,SUP-8888565036,CDM,C1729,HCPCS,272,RC,,,outpatient,,,192.93,135.051,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATHETER TROCAR KIT 28 FR NSQ -,SUP-8888565044,CDM,C1729,HCPCS,272,RC,,,outpatient,,,199.28,139.496,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH THORACIC 12FR MAR -,SUP-8888570507,CDM,C1729,HCPCS,272,RC,,,outpatient,,,55.61,38.927,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH THORACIC 16FR MAR -,SUP-8888570515,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.3,26.81,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATHETER THORACIC 16FR -,SUP-8888570515,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.3,26.81,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH THORACIC 20FR MAR -,SUP-8888570523,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.68,27.076,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
"CATHETER THORACIC 20FR X 20"" RADIOPAQUE 5 EYELETS -",SUP-8888570523,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.69,27.083,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH THORACIC 24FR MAR -,SUP-8888570531,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.18,27.426,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATHETER THORACIC 24FR -,SUP-8888570531,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.15,27.405,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATHETER THORACIC 28FR -,SUP-8888570549,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.44,27.608,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH THORACIC 28FR MAR -,SUP-8888570549,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.44,27.608,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH THORACIC 32FR MAR -,SUP-8888570556,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.85,27.895,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATHETER THORACIC 32FR -,SUP-8888570556,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.85,27.895,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATHETER THORACIC 36FR -,SUP-8888570564,CDM,C1729,HCPCS,272,RC,,,outpatient,,,40.26,28.182,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH THORACIC 36FR MAR -,SUP-8888570564,CDM,C1729,HCPCS,272,RC,,,outpatient,,,40.24,28.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH THORACIC 40FR MAR -,SUP-8888570572,CDM,C1729,HCPCS,272,RC,,,outpatient,,,40.63,28.441,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
TUBE CHEST RIGHT ANGLE 28 -,SUP-8888571042,CDM,C1729,HCPCS,272,RC,,,outpatient,,,77.11,53.977,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH THORCNTS 18FRX20IN LT VNTRC -,SUP-8888590216,CDM,C1729,HCPCS,272,RC,,,outpatient,,,193.84,135.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
KIT LUMBAR DRAINAGE CATH -,SUP-910121,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1076.58,753.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH DISTAL ATRIAL PERITONEAL SOPHYSA -,SUP-B905S,CDM,C1729,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATHETER VENTRICULAR STR 1.3 X 2.5 MM (INCL IN ITEM 0154508) -,SUP-BO19-10,CDM,C1729,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
TRAY CHEST TUBE 10FR THAL QUICK LUMX1 SDPRTX3 18GA ECHOTIP -,SUP-C-TQTSY-1000,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1096.98,767.886,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH PERFUS 12FR STR PVC -,SUP-EM012,CDM,C1729,HCPCS,272,RC,,,outpatient,,,263.92,184.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
EVACUATOR TBG UNIV ELLIK -,SUP-ET,CDM,C1729,HCPCS,272,RC,,,outpatient,,,74.71,52.297,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
BILIARY DRAINAGE CATH 8.5FR. -,SUP-G09497,CDM,C1729,HCPCS,272,RC,,,outpatient,,,545.51,381.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH BIL DRN 10.2FRX40CM MAC-LOC SDPRTX32 MA C -LOC LCK LOOP -,SUP-G09498,CDM,C1729,HCPCS,272,RC,,,outpatient,,,545.51,381.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH DRN 8.5FRX25CM LCK LOOP -,SUP-G09501,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH DRN 10FR NEPHROSTOMY TUBE -,SUP-G09502,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH MP DRAINAGE 10.2F 45CM UL -,SUP-G09766,CDM,C1729,HCPCS,272,RC,,,outpatient,,,554.27,387.989,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH DRN 12FRX45CM BND SDPRTX6 MA C -LOC LCK LOOP -,SUP-G09767,CDM,C1729,HCPCS,272,RC,,,outpatient,,,554.27,387.989,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH DRN 6FR UNIV 25CM CRV SDPRTX3 -,SUP-G10956,CDM,C1729,HCPCS,272,RC,,,outpatient,,,539.68,377.776,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
SET COLON DECOMPRESION 14FR -,SUP-G22181,CDM,C1729,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
Set Fuhrman Pleural Pneumopericardial Drainage -,SUP-G55723,CDM,C1729,HCPCS,272,RC,,,outpatient,,,711.87,498.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
Tray Fuhrman Pleural Pneumopericardial Drainage -,SUP-G55724,CDM,C1729,HCPCS,272,RC,,,outpatient,,,968.61,678.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
UNIV. LOOP DRAINAGE SET 10FR -,SUP-G55802,CDM,C1729,HCPCS,272,RC,,,outpatient,,,887.5,621.25,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
UNIV.  LOOP DRAINAGE SET 14FR X 30 -,SUP-G55804,CDM,C1729,HCPCS,272,RC,,,outpatient,,,887.5,621.25,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
ST UNIVERSA MALEOCOT16FRX22CM BLN SS NDL OBTR CON TUBE 3ML -,SUP-G55825,CDM,C1729,HCPCS,272,RC,,,outpatient,,,307.21,215.047,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
TRAY WAYNE PNEUMOTHORAX CATHETER 14.0 FR 29 CM -,SUP-G56537,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1250.92,875.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH PERC DRN 8FRX25CM STD LOOP TIP EXODUS LF -,SUP-H965101431,CDM,C1729,HCPCS,272,RC,,,outpatient,,,511.85,358.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH DRN 10FRX20CM EXODUS LF -,SUP-H965101511,CDM,C1729,HCPCS,272,RC,,,outpatient,,,511.85,358.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATHETER DRN 8FRX25CM EXODUS TIGHT TIP LOOP -,SUP-H965104031,CDM,C1729,HCPCS,272,RC,,,outpatient,,,537.4,376.18,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH DRN 10FRX25CM EXODUS TIGHT TIP LOOP -,SUP-H965104111,CDM,C1729,HCPCS,272,RC,,,outpatient,,,537.4,376.18,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH MULTIPURPOSE 14FR  25CM STD ;OOP W/MARKER BAND -,SUP-H965105621,CDM,C1729,HCPCS,272,RC,,,outpatient,,,2440.88,1708.616,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
SYSTEM EXTERNAL DRAINAGE WITHOUT VENTRICULAR CATH ACCUDRAIN -,SUP-INS8401,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1401.56,981.092,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH NEPH 14FR VTC -,SUP-M001245290,CDM,C1729,HCPCS,272,RC,,,outpatient,,,570.95,399.665,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH DRN 6FRX25CM PIGTL FOGARTY LOOP -,SUP-M001271380,CDM,C1729,HCPCS,272,RC,,,outpatient,,,468.26,327.782,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH DRN MP 10FR UNIV 30CM LCK PIGTL HUB LOCK CANN NTNL NAVR -,SUP-NNU10LPT,CDM,C1729,HCPCS,272,RC,,,outpatient,,,661.69,463.183,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
DRAIN SURG 30CM 12FR UNIV NTNL PIGTL MP -,SUP-NNU12LPT,CDM,C1729,HCPCS,272,RC,,,outpatient,,,661.69,463.183,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATH DRN MP 8FR UNIV 30CM NTNL LCK PIGTL HUB LOCK CANN NAVR -,SUP-NNU8LPT,CDM,C1729,HCPCS,272,RC,,,outpatient,,,661.69,463.183,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
KIT PERICARDIOCENTESIS 6F PIGTAIL CATH -,SUP-PC101,CDM,C1729,HCPCS,272,RC,,,outpatient,,,542.95,380.065,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
KT PERICRDCTS PIGTL 8.3FRX40CM ACC LF -,SUP-PC801,CDM,C1729,HCPCS,272,RC,,,outpatient,,,676.86,473.802,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
VALVE POLARIS ADJ 30-200 SHUNT WITH ITEM BO19-10 INCL -,SUP-SPVA-2010,CDM,C1729,HCPCS,272,RC,,,outpatient,,,14425.01,10097.507,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
CATHETER FIXATION SYSTEM 8F -,SUP-TFK-08,CDM,C1729,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
TRAY THORACENTESIS PARACENTESIS -,SUP-TPT1000SP,CDM,C1729,HCPCS,272,RC,,,outpatient,,,195.82,137.074,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.21103,10342.73217,other,Non-Reimbursable List,,
ELECTRODE PCNG 5FRX110CM BIPLR NON- HEP BND -,SUP-006173P,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1018.79,713.153,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List,,
CATH QUAD  MARINR-MDT -,SUP-072322M,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1378.13,964.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List,,
CATH EP P- TY CRV 5FR 2-8-2MM SPC 110CM DECAPL MP POLEX10 -,SUP-1085122RT,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1505.34,1053.738,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List,,
CATH ACHIEVE ADVANCE 2ACH20 MAPPING -,SUP-2ACH20,CDM,C1730,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List,,
CATH ACHIEVE ADVANCE 2ACH20 REPROCESS MAPPING -,SUP-2ACH20,CDM,C1730,HCPCS,272,RC,,,outpatient,,,2983.75,2088.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List,,
CATH EP RESPONSE CRD-SJM QUAD 6FR -,SUP-401226,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List,,
CATH RESPONSE CRD -REPROC QUAD 6FR -,SUP-401226,CDM,C1730,HCPCS,272,RC,,,outpatient,,,185.14,129.598,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List,,
CATH EP RESPONSE JSN -SJM QUAD  6FR -,SUP-401227,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List,,
CATH RESPONSE JSN-REPROC 6FR -,SUP-401227,CDM,C1730,HCPCS,272,RC,,,outpatient,,,185.14,129.598,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List,,
CATH EP RESPONSE CRD-SJM  DECAPOLAR -,SUP-401305,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1081.3,756.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List,,
CATH EP RESPONSE CSL-SJM 6FR  DECAPOLAR  STEER -,SUP-401381,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List,,
CATH RESPONSE DEC CSL-REPROC -,SUP-401381,CDM,C1730,HCPCS,272,RC,,,outpatient,,,349.87,244.909,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List,,
CATH EP SPRM JSPHSN CRV 6FR 2-5-2MM ELCTRD SPC 120CM FX QDPL -,SUP-401451,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List,,
CATH EP LIVEWIRE MED SWEEP-REPROC DECAPOLAR -,SUP-401575,CDM,C1730,HCPCS,272,RC,,,outpatient,,,588.34,411.838,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List,,
CATH EP LIVEWIRE MED SWEEP-SJM DECAPOLAR -,SUP-401575,CDM,C1730,HCPCS,272,RC,,,outpatient,,,2056.59,1439.613,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List,,
CATH LIVEWIRE QUAD STEERABLE REPROC -,SUP-401606,CDM,C1730,HCPCS,272,RC,,,outpatient,,,593.19,415.233,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List,,
CATH EP LIVEWIRE LRG SWP-SJM  QUAD STEERABLE  2-5-2 -,SUP-401606,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1876.38,1313.466,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List,,
BIPOLAR PACING CATH BALLOON TIP 5 FR 110CM- PACEL REF:401763 -,SUP-401763,CDM,C1730,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List,,
CATH  LIVEWIRE 7F DUO SUPER LRG CURL-REPROC 2/10 -,SUP-401904,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1154.02,807.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List,,
CATH EP LIVEWIRE SUPER LRG CURL- SJM DECA 2-10-2 -,SUP-401904,CDM,C1730,HCPCS,272,RC,,,outpatient,,,4392.08,3074.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List,,
CATH LIVEWIRE MED CRL-REPROC 2-2-2 NO SPACE -,SUP-401908,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1591.63,1114.141,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List,,
CATH EP LIVEWIRE EXTRA LGE CURL-REPROC  DECAPL 2-5-2 -,SUP-401915,CDM,C1730,HCPCS,272,RC,,,outpatient,,,612.91,429.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List,,
CATH EP  LIVEWIRE EXTRA LGE CURL-SJM  DECAPL 2-5-2 -,SUP-401915,CDM,C1730,HCPCS,272,RC,,,outpatient,,,2258.01,1580.607,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List,,
CATH  LIVEWIRE DUO DEC SUPER LGE CURL-REPROC 2-8-2-60-2-8-2 -,SUP-401932,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1208.14,845.698,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List,,
CATH EP LIVEWIRE LRG SWP -REPROC  QUAD STEER 5-5-5 NO SPACE -,SUP-401934,CDM,C1730,HCPCS,272,RC,,,outpatient,,,593.19,415.233,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List,,
CATH EP LIVEWIRE LRG SWP -SJM  QUAD STEER 5-5-5 NO SPACE -,SUP-401934,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1876.38,1313.466,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List,,
CATH EP SUPREME CRD-2 -SJM QUAD -,SUP-402004,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List,,
CATH RESPONSE CRD-2 REPROC 6FR -,SUP-402004,CDM,C1730,HCPCS,272,RC,,,outpatient,,,193.84,135.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List,,
INQUIRY STEERABLE  SJM EP CATH 6FR -,SUP-81102,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List,,
CATH 20MM ACHIEVE MAPPING EP CRV 3.3FRX6MM SPC 165CM BIPLR -,SUP-990063020,CDM,C1730,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List,,
MEDIGUIDE LV CATH MED SWEEP MODEL D402058 -,SUP-D402058,CDM,C1730,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List,,
ADVISOR HD GRID MAPPING CATHETER D-AVHD-DF16 -,SUP-D-AVHD-DF-16,CDM,C1730,HCPCS,272,RC,,,outpatient,,,9090.65,6363.455,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List,,
ADVISOR HD GRID MAPPING CATHETER D-AVHD-DF 16 REPRO -,SUP-D-AVHD-DF-16,CDM,C1730,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List,,
EPSTAR CATHETER DCF-2-8-55-130 -,SUP-DCF-2-8-55-130,CDM,C1730,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List,,
CATHETER INQUIRY STEER 4 FR DEC 1110-4-2-M IBI-81530 -,SUP-IBI-81530,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List,,
CATH EP POLARISX270DG ANG 6FR 2.5-5-2.5MM SPC 105CM QDPL -,SUP-M0047003D0,CDM,C1730,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.56393,6517.99605,other,Non-Reimbursable List,,
BLAZER DX -20 CATHETER SUPERLARGE CURVE -,SUP-20SL2860,CDM,C1731,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,4619.19363,other,Non-Reimbursable List,,
CATH EP LIVEWIRE MED CURL-SJM  2-2-2 -,SUP-401908,CDM,C1731,HCPCS,272,RC,,,outpatient,,,4392.08,3074.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,4619.19363,other,Non-Reimbursable List,,
CATH EP LIVEWIRE SUPER LGE CURL-SJM 2-8-2-60-2-8-2 -,SUP-401932,CDM,C1731,HCPCS,272,RC,,,outpatient,,,4596.25,3217.375,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,4619.19363,other,Non-Reimbursable List,,
CATH EP REFLEXION SPIRAL SJM -,SUP-D402893,CDM,C1731,HCPCS,272,RC,,,outpatient,,,6442.39,4509.673,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,4619.19363,other,Non-Reimbursable List,,
CATH ABLT BLAZER D X-20 SUPER LRG 7FR SHFT 2-10-2MM SPC -,SUP-M00420SL21020,CDM,C1731,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,4619.19363,other,Non-Reimbursable List,,
CATH ACHIEVE ADVANCE 2ACH15 MAPPING -,SUP-2ACH15,CDM,C1732,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List,,
CATH ACHIEVE ADVANCE 2ACH15 REPROCESS MAPPING -,SUP-2ACH15,CDM,C1732,HCPCS,272,RC,,,outpatient,,,2983.75,2088.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List,,
CATH ACHIEVE ADVANCE 2ACH25  MAPPING -,SUP-2ACH25,CDM,C1732,HCPCS,272,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List,,
SOFTWARE MED ENSITE FUSION REGST MOD XPD F/SEG CT -,SUP-75-05772-001,CDM,C1732,HCPCS,272,RC,,,outpatient,,,27847.5,19493.25,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List,,
CATHETER PVAC GOLD - REF:990078 -,SUP-990078,CDM,C1732,HCPCS,272,RC,,,outpatient,,,25991,18193.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List,,
CATH ABLT THERMOCOOL SF CARTO XP D-F CRV 8FR 2-5-2MM SPC -,SUP-BNI35DFH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,11324.65,7927.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List,,
CATH ABLT THERMOCOOL SF NAV F-J CRV 8FR 2-5-2MM SPC 115CM -,SUP-BNI35FJH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,11324.65,7927.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List,,
CATH EP LASSO NAV ECO D-TYP CRV 7FR 4FR LOOP 25-15MM 2-6-2MM -,SUP-D134301,CDM,C1732,HCPCS,272,RC,,,outpatient,,,7257.24,5080.068,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List,,
CATH EP WEBSTER CS CS-D CRV 6FR 2-8-2MM SPC 115CM SGL-BRD -,SUP-D135303,CDM,C1732,HCPCS,272,RC,,,outpatient,,,2644.95,1851.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List,,
CATH EP WEBSTER CS CS-F CRV 6FR2MM TIP 2-8-2MM SPC 115CM FX -,SUP-D135304,CDM,C1732,HCPCS,272,RC,,,outpatient,,,2014.19,1409.933,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List,,
CATH ABLT NAVISTAR C F-TY CRV 7FR EP -,SUP-D17TCFLRT,CDM,C1732,HCPCS,272,RC,,,outpatient,,,7057.77,4940.439,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List,,
POLARX FIT BALLOON CATHETER ST REF:M004CRBS2060 -,SUP-M004CRBS2060,CDM,C1732,HCPCS,272,RC,,,outpatient,,,14852,10396.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List,,
POLARX FIT BALLOON CATHETER LT REF:M004CRBS2160 -,SUP-M004CRBS2160,CDM,C1732,HCPCS,272,RC,,,outpatient,,,14852,10396.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List,,
CATH POLARMAP CIRCULAR DX MAPPING CATHETER REF:M004CRBS7210 -,SUP-M004CRBS7210,CDM,C1732,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List,,
CATHETER INTELLANAV ST 7/110/2.5/7-4 QUAD STD -,SUP-M004R5031TH0,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List,,
CATHETER INTELLANAV ST K2 7/110/2.5/7-4 QUAD -,SUP-M004R5031THK20,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List,,
INTELLAMAP ORION CATHETER M004RC64S0 -,SUP-M004RC64S0,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List,,
CATH ABLT NAVISTAR THERMOCOOL D-CRV 8FR 2-5-2MM SPC 115CM -,SUP-NI75TCDH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List,,
CATH ABLT THERMOCOOL F-TY CRV 7.5FR 2-5-2MM SPC 115CM COOL -,SUP-NI75TCFH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List,,
CATH ABLT NAVISTAR C D-TYP CRV 7FR 1-7-4MM SPC 4MM TIP 115CM -,SUP-NS7TCDL174HS,CDM,C1732,HCPCS,272,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List,,
CATH ABLT NAVISTAR DS F-TY CRV 7FR 1-7-4MM SPC 8MM TIP 115CM -,SUP-NS7TCF8L174HS,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List,,
CATH ABLT NAVISTAR F-TY CRV 7FR 1-7-4MM SPC 4MM TIP 115CM -,SUP-NS7TCFL174HS,CDM,C1732,HCPCS,272,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19966.6575,other,Non-Reimbursable List,,
CATH ABLT FREEZOR 4MM TIP MDT -,SUP-207F3,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
CATH CRYABL FREEZOR MAX CRV 9FR 3-5-2MM SPC 90CM STEER BIDIR -,SUP-209F3,CDM,C1733,HCPCS,272,RC,,,outpatient,,,9124.6,6387.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
CATH ABLT FREEZOR XTRA 6MM 7FR 2-5-2MM SPC 108CM -,SUP-217F3,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
CATH ABLT FREEZOR XTRA LG CURVE 6MM 7FR REF:217F5 -,SUP-217F5,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
CATH CRYABL ARCTIC FRN 23MM STEER BIDIR EP -,SUP-2AF234,CDM,C1733,HCPCS,272,RC,,,outpatient,,,16337.2,11436.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
CATH CRYABL ARCTIC FRN 28MM STEER BIDIR EP -,SUP-2AF284,CDM,C1733,HCPCS,272,RC,,,outpatient,,,16337.2,11436.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
CATH ESPH ABLT 18MM 360DG ELCTRD ARRAY 85CM BARRX RF -,SUP-32041-18,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8339.46,5837.622,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
CATH PCNG 5FRX2.5CM SPC 110CM PACEL TEMP BIPLR 60DG CRV RT -,SUP-401775,CDM,C1733,HCPCS,272,RC,,,outpatient,,,513.48,359.436,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
CATH ABLT SAFIRE MED SWP 7FR 2-5-2MM SPC 115CM QDPL BIDIR -,SUP-402807,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3010.01,2107.007,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
CATH ABL SAFIRE LRG SWP 7FR -,SUP-402808,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3208.13,2245.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
CATH SAFIRE 7F 4MM SM CRL US -,SUP-402809,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3010.01,2107.007,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
CATH ABLT SAFIRE MED CURL 7FR 2-5-2MM SPC 115CM 7MM BIDIR -,SUP-402810,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3208.13,2245.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
CATH ABLT SAFIRE LRG CRV 7FR 2-5-2MM SPC 115CM QDPL BIDIR -,SUP-402811,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3208.13,2245.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
CATH ABLT SAFIRE LRG CRV 7FR 2-5-2MM 115CM 5MM QDPL BIDIR -,SUP-402817,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3232,2262.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
CATH SAFIRE TX  MED 7F 8 MM BI-DIR -,SUP-402839,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4501.88,3151.316,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
CATH SAFIRE TX  LRG  BI-DIR  7F 8MM -,SUP-402840,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4501.88,3151.316,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
FARAWAVE PFA CATHETER REF:41C601 -,SUP-41C601,CDM,C1733,HCPCS,272,RC,,,outpatient,,,25062.75,17543.925,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
FARAWAVE PFA CATHETER 35MM REF:41C602 -,SUP-41C602,CDM,C1733,HCPCS,272,RC,,,outpatient,,,25062.75,17543.925,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
CATHETER BARRX RFA EXPRESS RFA BALLOON -,SUP-64082,CDM,C1733,HCPCS,272,RC,,,outpatient,,,10218.18,7152.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
CATH ABLT THRP 7FR 2-5-2 MMMEDX110CM 4MM -,SUP-83365,CDM,C1733,HCPCS,272,RC,,,outpatient,,,2491.24,1743.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
CATH ABLT THRP 7FR 2-5-2 MMX110CM 4MM -,SUP-83366,CDM,C1733,HCPCS,272,RC,,,outpatient,,,2634.35,1844.045,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
CATH ABLT THRP 2-5-2 MMMEDX110CM DL -8 -,SUP-83371,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
CATH ABLT THRP 7FR MED 8MM DL -,SUP-83372,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3542.31,2479.617,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
CATH ABLT THRP DL -8 EXTEND REACH CRV 7FR 2-5-2MM SPC 110CM -,SUP-83374,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
CATHETER BARRX FOCAL 90 RFA 20MMX 13MM -,SUP-90-9100,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8492.24,5944.568,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
CATHETER BARRX FOCAL 90 RFA 40MM X 13MM -,SUP-90-9500,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7469.44,5228.608,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
CATH ABLT SAFIRE BLU LRG CURL DIST REACH CRV 7FR 2-5-2MM SPC -,SUP-A088109,CDM,C1733,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
CATH CRYABL ARCTIC FRN ADVANCED PRO 28MM STEER BIDIR EP -,SUP-AFAPRO28,CDM,C1733,HCPCS,272,RC,,,outpatient,,,16337.2,11436.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
FLEXABILITY SENSOR ENABLED BI DIR IRR CATH FJ CURVE -,SUP-A-FASE-FJ,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8190.92,5733.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
CATH ABLT WEBSTER EZ STEER D-F ASYM CRV 7FR 2-8-2MM SPC -,SUP-BD710DF282RTS,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3547.08,2482.956,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
CATH 7F D/F BI-DIRECT CS REPROC -,SUP-BD710DF282RTS,CDM,C1733,HCPCS,272,RC,,,outpatient,,,1132.05,792.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
CATH CV 7FRX3CM SIL CLSR FST LF ACC -,SUP-CF7-3-60,CDM,C1733,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
CATH ELCSURG 7FRX60CM RF FLXB CLSR FST -,SUP-CF7-7-60,CDM,C1733,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
AGILLIS NXT STEERABLE INTRO DUAL-REACH REF: I-V2-MED -,SUP-I-V2-MED,CDM,C1733,HCPCS,624,RC,,,outpatient,,,5.89,4.123,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,2.360123,1.322305,17969.99175,percent of total billed charges,,,
CATH ABLT BLAZER II STD CRV 7FRX2.5MM SPC 4MM TIP QDPL DIST -,SUP-M0045031TH0,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
CATH ABLT BLAZER II STD CRV 7FRX2.5MM SPC QDPL EXTEND DIST -,SUP-M0045086TL0,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
CATH ABLT BLAZER PRIM XP LRG CRV 8MM TIP QDPL EP -,SUP-M004P4500THK20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7427,5198.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
CATH ABLT BLAZER PRIM XP STD CRV STR 7FR 8FR TIP 2.5MM SPC -,SUP-M004P4790TH0,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7639.2,5347.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
CATH ABLT BLAZER PRIM XP LRG CRV 10mm  8FRX2.5MM SPC 110CM -,SUP-M004P4790THK20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7639.2,5347.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
CATH ABLT BLAZER PRIM HTD ASYM CRV 7FRX2.5MM SPC 110CM QDPL -,SUP-M004P5031THN40,CDM,C1733,HCPCS,272,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
CATH ABLT INTELLATIP MIFI XP STD CRV STR 7FR 8FR TIP 2.5MM -,SUP-M004PM45000,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
CATH ABLT INTELLATIP MIFI XP LRG CRV STR 7FR 8FR TIP 2.5MM -,SUP-M004PM4500K20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
CATHETER INTELLANAV MIFI OI 7.5/110/2.5.4.5 STD -,SUP-M004PMR96200,CDM,C1733,HCPCS,272,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
CATHETER INTELLANAV MIFI K2 OI 7.5/110/2.5/4.5 -,SUP-M004PMR9620K20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
PULSESELECT PFA LOOP CATHETER REF: PSCC100 -,SUP-PSCC100,CDM,C1733,HCPCS,272,RC,,,outpatient,,,23763.2,16634.24,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.322305,17969.99175,other,Non-Reimbursable List,,
VOLT PFA CATHETER REF: P-SPI-DF8 -,SUP-VOLT PFA CATHETER REF: P-SPI-DF8,CDM,C1733,HCPCS,624,RC,,,outpatient,,,5.89,4.123,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,2.360123,1.322305,17969.99175,percent of total billed charges,,,
CATHETER 27CM GLIDEPATH LONG TERM HEMO -,SUP-5393270,CDM,C1750,HCPCS,278,RC,,,outpatient,,,2210.31,1547.217,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List,,
CATH HMDLYS HEMOSPLIT 14.5FRX31CM -,SUP-5733310,CDM,C1750,HCPCS,278,RC,,,outpatient,,,2390.53,1673.371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List,,
CATH SHNT 1.2X2.5MM HLTR 65CM SIL RBR T-SHP 1PC -,SUP-82-1699,CDM,C1750,HCPCS,278,RC,,,outpatient,,,2533.64,1773.548,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List,,
CATH PERITONEALTENCKHOFF42CM -,SUP-8810888003,CDM,C1750,HCPCS,278,RC,,,outpatient,,,255.92,179.144,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List,,
CATH TENCKHOFF 15FRX62CM -,SUP-8811313010,CDM,C1750,HCPCS,278,RC,,,outpatient,,,366.38,256.466,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List,,
KIT CATHETER PERITONEAL DIALYSIS ARGYLE 62CM SILICONE CURLED -,SUP-8817278006,CDM,C1750,HCPCS,278,RC,,,outpatient,,,450.39,315.273,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List,,
KT DLYS 60CM CURL STYL 60CM PREPERITONEIAL CUF CLMP ADPTR -,SUP-8817278010,CDM,C1750,HCPCS,278,RC,,,outpatient,,,537.58,376.306,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List,,
KT HMDLYS PRMCTH 36CM SIL RBR LUMX2 -,SUP-8817748001,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1012.58,708.806,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List,,
CATH HMDLYS MHRKR 11.5FRX16CM PU ACUTE LUMX2 ACC -,SUP-8817749001,CDM,C1750,HCPCS,278,RC,,,outpatient,,,923.47,646.429,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List,,
CATH HMDLYS PALINDROME 14.5FRX19CM -,SUP-8888119360P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1259.4,881.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List,,
KIT CATHETER PALINDROME 14.5FR X 19CM -,SUP-8888145014P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List,,
KIT CATHETER PALINDROME 14.5FR X 23CM -,SUP-8888145015P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List,,
KIT CATHETER PALINDROME 14.5FR X 28CM -,SUP-8888145016P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List,,
KIT CATHETER PALINDROME 14.5FR X 33CM -,SUP-8888145042P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List,,
STENCIL PERITONEAL DIALYSIS RITUS PRE-OPERATIVE -,SUP-8888412305,CDM,C1750,HCPCS,278,RC,,,outpatient,,,55.72,39.004,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List,,
KIT CATHETER PERITONEAL DIALYSIS ARGYLE 62.5CM SILICONE -,SUP-8888413823,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1150.95,805.665,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List,,
KT HMDLYS PALINDROME 15FRX43CM CRBTHN ACC -,SUP-8888541023P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1612.03,1128.421,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List,,
KT HMDLYS PALINDROME 15FRX48CM CRBTHN ACC -,SUP-8888541028P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1612.03,1128.421,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List,,
CATH TESIO LEFT BFL-6 -,SUP-BFL-6,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1595.45,1116.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List,,
CATH HMDLYS BFL TSO 10FR 22CM/25CM CUF -,SUP-BFR-6,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1690.86,1183.602,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List,,
ST HMDLYS TESIO 10FRX52CM PU LUMX2 INTRO NDL GW TUNNLER -,SUP-BFR-6E,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1881.68,1317.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List,,
CATH ARROW NEXT STEP 23CM HEMODIALYSIS -,SUP-CS-15232-X,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1436.44,1005.508,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List,,
CATH ARROW NEXT STEP 27CM HEMODIALSIS -,SUP-CS-15272-X,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1436.44,1005.508,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List,,
CATHETER KIT DIALYSIS 15FR ARROW -,SUP-CS-15282-SPM,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.50914,1945.83552,other,Non-Reimbursable List,,
HC Try Cv Lumx3 5fr Triple Powerpicc Acc,PX-27200312,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1544,1080.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
HC Needle Provena 4fr Dl Picc 4fr Dl Max Barrier,PX-27200313,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1417,991.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
HC Needle Provena 4fr Dl Provena Midline Max Barrier,PX-27200314,CDM,C1751,HCPCS,272,RC,,,outpatient,,,967,676.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
HC Cath Cv Lumx2 4frx20 Cm Dual Mdln,PX-27200315,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1012,708.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
HC Needle Provena 3fr Sl Provena Midline Max Barrier,PX-27200316,CDM,C1751,CPT,272,RC,,,outpatient,,,831,581.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
KIT URETERAL IRIS INFRARED -,SUP-0220180518,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1863.01,1304.107,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
TRY CV LUMX2 9FRX90CM SIL PED HKMN LF ACC -,SUP-0600604,CDM,C1751,HCPCS,272,RC,,,outpatient,,,2291.14,1603.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH SWAN GANZ TD 6FR X 110 - 096F6P -,SUP-096F6P,CDM,C1751,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH GUIDE ECHELON 14 MICRO STR AIGHT REF:105-5092-150 -,SUP-105-5092-150,CDM,C1751,HCPCS,272,RC,,,outpatient,,,4838.16,3386.712,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
TRY CV LUMX1 4FR PU POWERPICC LF ACC SINGLE -,SUP-1174108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1252.61,876.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
5FR POWERPICC TRAY CV LUMX2 DBL PU  LF ACC -,SUP-1275108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1232.53,862.771,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH SWAN GANZ TD 7FR 131F7P -,SUP-131F7P,CDM,C1751,HCPCS,272,RC,,,outpatient,,,501.81,351.267,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATHETER IV JELCO PROTECTIV 24G X 3/4IN YELLOW -,SUP-305306,CDM,C1751,HCPCS,272,RC,,,outpatient,,,12.2,8.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATHETER IV WINGED HUB PEDI 24G X 5/8â€ PERIPHERAL RADIOPAQUE -,SUP-307300,CDM,C1751,HCPCS,272,RC,,,outpatient,,,11.94,8.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
TRY CV LUMX1 5FRX55CM PU POWERPICC LF ACC -,SUP-3175155,CDM,C1751,HCPCS,272,RC,,,outpatient,,,456.94,319.858,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH IV PROT 22GAX1IN FEP PLYMR SAFTY STR HUB WNG INDWL VPNT -,SUP-326010,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.66,7.462,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH IV PROTECTIVE 22 X 1 -,SUP-326010,CDM,C1751,HCPCS,272,RC,,,outpatient,,,12.05,8.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH IV PROT 24GAX.75IN FEP PLYMR SAFTY STR HUB WNG INDWL -,SUP-326310,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.68,7.476,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH IV PROTECTIVE 24 X 3/4 RA -,SUP-326310,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.68,7.476,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH IV PROT 20GAX1IN FEP PLYMR SAFTY STR HUB WNG INDWL VPNT -,SUP-326710,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.28,6.496,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH IV PROTECTIVE 20 X 1 -,SUP-326710,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.28,6.496,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH IV 14GA X 1.25 IN VIAVALVE -,SUP-3268,CDM,C1751,HCPCS,272,RC,,,outpatient,,,12.05,8.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
TRY CV LUMX2 5FRX55CM PU POWERPICC LF ACC -,SUP-3275335,CDM,C1751,HCPCS,272,RC,,,outpatient,,,602.11,421.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH IV ANGIOCATH 14 X 1.88 -,SUP-381167,CDM,C1751,HCPCS,272,RC,,,outpatient,,,22.71,15.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH IV 24G X .56 IN INSYTE BD -,SUP-381411,CDM,C1751,HCPCS,272,RC,,,outpatient,,,14.41,10.087,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH IV 20G X 1.88 IN INSYTE BD -,SUP-381437,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.86,6.902,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH IV INSYT AUTOGRD 20GAX48MM VIALON SAFTY WNG INDWL BLD -,SUP-381437,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.86,6.902,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH IV 14G X 1.75 IN INSYTE BD -,SUP-381467,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.87,6.909,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH IV 24G X .56 IN INSYTE BD -,SUP-381511,CDM,C1751,HCPCS,272,RC,,,outpatient,,,14.42,10.094,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH IV 22G x 1 IN INSYTE AUTOGUARD BC -,SUP-382523,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.12,7.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH IV 16G X 1.16 IN INSYTE BD -,SUP-382554,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.86,6.902,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH IV SAF-T-INTIMA 23GAX0.75IN VIALON SAFTY WNG INDWL -,SUP-383323,CDM,C1751,HCPCS,272,RC,,,outpatient,,,20.11,14.077,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH IV SAF-T-INTIMA 20GAX1IN VIALON SAFTY WNG INDWL SLFBNT -,SUP-383336,CDM,C1751,HCPCS,272,RC,,,outpatient,,,19.62,13.734,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH IV 24G X .75 IN NEXIVA BD -,SUP-383511,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH IV 22GA X 1 IN NEXIVA BD -,SUP-383512,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH IV 20GA X 1 IN NEXIVA BD -,SUP-383516,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH IV 18GA X 1.25 IN NEXIVA BD -,SUP-383519-A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
ST NEEDLE INFS 24GAX0.75IN NEXIVA SAFTY LRG BORE WNG DL PRT -,SUP-383531,CDM,C1751,HCPCS,272,RC,,,outpatient,,,31.28,21.896,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
KT ARTERIAL LN 20GAX20CM 1ST MI D CATH MDLN SFN -,SUP-384304,CDM,C1751,HCPCS,272,RC,,,outpatient,,,468.67,328.069,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATHETER IV 16 X 2 SFR -,SUP-4082,CDM,C1751,HCPCS,272,RC,,,outpatient,,,11.6,8.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH IV 14 X 2.25in JELCO -,SUP-4088,CDM,C1751,HCPCS,272,RC,,,outpatient,,,20.36,14.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
TRY MIDLINE CATH 4FR 18GA LUM LUMX1 LF -,SUP-4154108,CDM,C1751,HCPCS,272,RC,,,outpatient,,,526.32,368.424,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
TRY CV LUMX1 4FR PU LF ACC -,SUP-4154108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1151.36,805.952,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH IV INTROCAN SAFTY 20GAX1.75IN FEP POYMER SAFTY STR HUB -,SUP-4252527-02,CDM,C1751,HCPCS,272,RC,,,outpatient,,,7.39,5.173,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH IV INTROCAN SAFTY 18GAX2.5IN TFLN FEP PLYMR SAFTY STR -,SUP-4252561-02,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.22,6.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH CV 5FRX8CM POWERWAND PWR-INJ MDLN QCK CHRNFLX C -,SUP-72135,CDM,C1751,HCPCS,272,RC,,,outpatient,,,811.07,567.749,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
PICC LINE CHANGE KIT IVAD ACCE -,SUP-73240B,CDM,C1751,HCPCS,272,RC,,,outpatient,,,17.27,12.089,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
PORT INFS 8FR 1LUM -,SUP-7711802,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1505.34,1053.738,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH PA 8FRX110CM SWAN-GNZ C CMB VOL LUMX7 INJ PRT ANTMIC -,SUP-777HF8,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1446.77,1012.739,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
SWAN-GANZ VIP/ OXIMETRY THERMOD CATHETER -,SUP-782F75M,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1519.92,1063.944,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
KT IT F/LEGEND SYNCHROMED INFS PMP RPR -,SUP-8590-9,CDM,C1751,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
TRY CV LUMX1 4FRX60CM PU POLY P-Q-CTH LF ACC -,SUP-9154108,CDM,C1751,HCPCS,272,RC,,,outpatient,,,908.45,635.915,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
TRY CV LUMX1 4FR STD 55CM PU POWERPICC LF ACC -,SUP-9174108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1953.71,1367.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH CV 5FRX10CM POWERWAND PWR-INJ MDLN CHRNFLX C -,SUP-92006,CDM,C1751,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
TRY CV LUMX2 5FRX60CM PU POLY P-Q-CTH LF ACC -,SUP-9255108,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1040.96,728.672,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH PA 7.5FRX110CM SWAN-GNZ PCNG LUMX5 AMC THRMBSHLD HPCT -,SUP-931HF75,CDM,C1751,HCPCS,272,RC,,,outpatient,,,303.24,212.268,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
TRY CV LUMX3 6FR STD 55CM PU POWERPICC LF ACC -,SUP-9386108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,2085.78,1460.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH PA 8FRX110CM SWAN-GNZ A-V PCNG LUMX6 INJ PRT ANTMIC AMC -,SUP-991HF8,CDM,C1751,HCPCS,272,RC,,,outpatient,,,787.2,551.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
"ACCUCATH 22G 1.25"" BASIC KIT -",SUP-AC0221250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,133.27,93.289,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
KIT CATHETER ACCUCATH ACE 18G 2.25 BASIC -,SUP-AC1182250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,254.41,178.087,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
"ACCUCATH 20G 1.25"" BASIC KIT -",SUP-AC1201250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,133.27,93.289,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
ACCUCATH ACE 20G X 2.25IN BASIC KIT -,SUP-AC1202250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,254.41,178.087,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH PRSS MONTR BLN WDG 5FR -,SUP-AI-07124,CDM,C1751,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH A-LN BLN WDG LUMX2 6FRX110CM PA INDWL 1ML CTRL STRK SYR -,SUP-AI-07126,CDM,C1751,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH PA 6FRX110CM BLN -,SUP-AI-07365-NHL,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
ST ARTERIAL CATH 20GAX1.75IN SHRP SAFTY LF -,SUP-AK-04020-SPC,CDM,C1751,HCPCS,272,RC,,,outpatient,,,145.29,101.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
KT A-LN 20GAX5IN PA INDWL 0.25IN SPR STR SFT TIP JTP GW -,SUP-AK-04510-S,CDM,C1751,HCPCS,272,RC,,,outpatient,,,164.55,115.185,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
KIT CENTRAL VENOUS TWO LUMEN -,SUP-AK-11142-D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,568.91,398.237,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
KT CV LUMX2 4FRX8CM PU ARROW G+ARD LF ACC -,SUP-AK-25402,CDM,C1751,HCPCS,272,RC,,,outpatient,,,431.79,302.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
FEMORAL ARTERY CATH KIT  5FR REF: G58398 -,SUP-APM-5.0-35J-1-15-NY,CDM,C1751,HCPCS,272,RC,,,outpatient,,,259.07,181.349,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
KIT CATH TRIPLE LUMEN 20CM CEN -,SUP-ASK-45703-PSCH,CDM,C1751,HCPCS,272,RC,,,outpatient,,,847.94,593.558,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
KT CV MULTLUM 20CM ARROW G+ARD LF ACC -,SUP-ASK-45703-PSCH,CDM,C1751,HCPCS,272,RC,,,outpatient,,,847.94,593.558,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
KT CV LUMX3 7FRX16CM PU ARW HWS LF ACC -,SUP-CDC-12703-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,352.9,247.03,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
KT CV LUMX3 7FRX20CM PU ARW HWS LF ACC -,SUP-CDC-15703-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,408.63,286.041,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
KT CV LUMX1 16GAX20CM PU ARROW G+ARD LF ACC -,SUP-CDC-24301-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,395.61,276.927,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
KT CV LUMX1 16GAX20CM PU ARROW G+ARD LF ACC -,SUP-CDC-24301-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,395.61,276.927,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
ARROW PEDI CENTRAL LINE KIT 13CM -,SUP-CDC-24402-X1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,754.66,528.262,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
SWAN -GANZ TEMP PACR STR EDWARDS -,SUP-D97120F5,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1130.07,791.049,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
SWAN-GANZ BIPOLAR PACING CATH J-TIP 5 FR 90CM -,SUP-D97130F5,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1130.07,791.049,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH PERFUS 20FRX.25IN ACPT 6CM PRFX STR PVC -,SUP-E063,CDM,C1751,HCPCS,272,RC,,,outpatient,,,239.59,167.713,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
ST ARTERIAL CATH 18GAX4.25IN LF -,SUP-FA-04018,CDM,C1751,HCPCS,272,RC,,,outpatient,,,81.46,57.022,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CENTRAL VENOUS CATHETER TRAY 4.0FR -,SUP-G02138,CDM,C1751,HCPCS,272,RC,,,outpatient,,,245.65,171.955,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH INFS 3FR STR 135CM SLIP-CATH NYL SS HYDRCT 0.025IN GW -,SUP-G12044,CDM,C1751,HCPCS,272,RC,,,outpatient,,,283,198.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH INFS 3FR STR 150CM SLIP-CATH NYL SS HYDRCT 0.025IN GW -,SUP-G12045,CDM,C1751,HCPCS,272,RC,,,outpatient,,,283,198.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
KT BLOOD GS ART 182CM CHMBR IV SPK 3W STPCKX2 122IN PRESSMNT -,SUP-H965700361481,CDM,C1751,HCPCS,272,RC,,,outpatient,,,164.55,115.185,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH INFS 4FRX135CM 10CM INFS ACCESSPLUS VLV PEBAX OCL WIRE -,SUP-IS4-135-10,CDM,C1751,HCPCS,272,RC,,,outpatient,,,793.56,555.492,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH INFS 4FRX135CM 20CM INFS ACCESSPLUS VLV PEBAX OCL WIRE -,SUP-IS4-135-20,CDM,C1751,HCPCS,272,RC,,,outpatient,,,793.56,555.492,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
KT INTRAVENOUS CATH 20GAX8CM POWERGLIDE LF -,SUP-M020081,CDM,C1751,HCPCS,272,RC,,,outpatient,,,493.06,345.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
KT INTRAVENOUS CATH 20GAX10CM POWERGLIDE -,SUP-M020101,CDM,C1751,HCPCS,272,RC,,,outpatient,,,493.06,345.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH VASC ACCESS 3FR LUMX1 MDLN PU PRELD STYL INTRO GW SYR -,SUP-ML3S20FN,CDM,C1751,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH CV LUMX1 4FRX200CM SINGLE MDLN -,SUP-MLCT4S20FN,CDM,C1751,HCPCS,272,RC,,,outpatient,,,805.52,563.864,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH PICC LUMX1 6FR PWR PICC -,SUP-MR17036306MB,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1081.3,756.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
ARTERIAL CATHETERIZATION KIT 20G -,SUP-NA-04550-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,303.42,212.394,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH CV LUMX2 4FRX20 CM DUAL MDLN -,SUP-P4254108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,982.38,687.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH RADIAL ARTERY 20G -,SUP-RA-04020,CDM,C1751,HCPCS,272,RC,,,outpatient,,,55.96,39.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
CATH SET RADIAL ARTERY 20GX1.5 -,SUP-RA-04220,CDM,C1751,HCPCS,272,RC,,,outpatient,,,70.49,49.343,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
SET RAPID INFUSION 7FR CATHETER EXCHANGE -,SUP-RC-09700,CDM,C1751,HCPCS,272,RC,,,outpatient,,,61.73,43.211,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
SET RAPID INFUSION 8.5FR CATHETER EXCHANGE -,SUP-RC-09850,CDM,C1751,HCPCS,272,RC,,,outpatient,,,59.52,41.664,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
STYLET ELCSURG 6FRX12CM RF D MRKNG CLOSURERFS -,SUP-RFS2612,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1908.18,1335.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
TRY CV LUMX3 5FR TRIPLE  POWERPICC ACC -,SUP-S1385108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1499.41,1049.587,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
MULTI-LUMEN VENOUS CATH 8FR -,SUP-SS-14703,CDM,C1751,HCPCS,272,RC,,,outpatient,,,187.89,131.523,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
C 6FR TRIPLE LUMEN PICC -,SUP-UNDEFINED,CDM,C1751,HCPCS,272,RC,,,outpatient,,,669.86,468.902,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.659055,3468.96072,other,Non-Reimbursable List,,
KT HMDLYS PWR TRIALYSIS 13FRX20CM LUMX3 SHRT TERM -,SUP-5603200,CDM,C1752,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.92327,4457.91882,other,Non-Reimbursable List,,
TRY HMDLYS PWR TRIALYSIS 13FRX15CM PU ACUTE SHRT TERM LUMX3 -,SUP-5605150,CDM,C1752,HCPCS,272,RC,,,outpatient,,,6217.46,4352.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.92327,4457.91882,other,Non-Reimbursable List,,
KT HMDLYS PWR -TRIALYSIS 13FRX20CM SHRT TERM LUMX3 ACC -,SUP-5605200,CDM,C1752,HCPCS,272,RC,,,outpatient,,,6217.46,4352.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.92327,4457.91882,other,Non-Reimbursable List,,
KT HMDLYS PWR -TRIALYSIS 13FRX20CM SHRT TERM LUMX3 ACC -,SUP-5605200,CDM,C1752,HCPCS,272,RC,,,outpatient,,,1553.05,1087.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.92327,4457.91882,other,Non-Reimbursable List,,
KT HMDLYS PWR -TRIALYSIS 13FRX15CM SHRT TERM LUMX3 ACC -,SUP-5613150,CDM,C1752,HCPCS,272,RC,,,outpatient,,,1372.83,960.981,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.92327,4457.91882,other,Non-Reimbursable List,,
MAHUKAR CATH DUAL 19FR. -,SUP-8813793009,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.92327,4457.91882,other,Non-Reimbursable List,,
MAHUKUR CATH DUAL 10 FR. -,SUP-8817146007,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.92327,4457.91882,other,Non-Reimbursable List,,
KT HMDLYS MHRKR 11.5FR LNG EXTEND 16CM LUMX2 ACUTE ACC -,SUP-8830415001,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.92327,4457.91882,other,Non-Reimbursable List,,
TRY HMDLYS MHRKR 11.5FRX24CM PU 1% 5ML LIDOCN LUMX2 ACC -,SUP-8831663001,CDM,C1752,HCPCS,272,RC,,,outpatient,,,443.65,310.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.92327,4457.91882,other,Non-Reimbursable List,,
CATH MAHURKAR CURVED 12FR 16CM -,SUP-8888101002HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,553.17,387.219,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.92327,4457.91882,other,Non-Reimbursable List,,
MAHURKER CATH DUAL 13.5 FR. -,SUP-8888135192,CDM,C1752,HCPCS,272,RC,,,outpatient,,,415.92,291.144,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.92327,4457.91882,other,Non-Reimbursable List,,
MAHURKAR STRAIGHT CATH KIT 12FR -,SUP-8888221220,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.92327,4457.91882,other,Non-Reimbursable List,,
TRY MHRKR ELITE ACUTE 12FRX20CM -,SUP-8888233420,CDM,C1752,HCPCS,272,RC,,,outpatient,,,859.55,601.685,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.92327,4457.91882,other,Non-Reimbursable List,,
KT HMDLYS MHRKR 12FRX20CM PU LUMX3 ACUTE ACC -,SUP-8888340629HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,471.37,329.959,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.92327,4457.91882,other,Non-Reimbursable List,,
KIT HEMODIALYSIS MAHURKAR 12FRX24CM PU LUMX3 ACUTE ACC -,SUP-8888340637HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,489.29,342.503,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.92327,4457.91882,other,Non-Reimbursable List,,
KT HMDLYS MHRKR 12FRX16CM PU LUMX3 ACUTE ACC -,SUP-8888345611HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,471.37,329.959,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.92327,4457.91882,other,Non-Reimbursable List,,
KT HEMODIALYSIS MHRKR TLC- C E 12FRX20CM LF -,SUP-8888345637,CDM,C1752,HCPCS,272,RC,,,outpatient,,,499.18,349.426,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.92327,4457.91882,other,Non-Reimbursable List,,
KT HMDLYS 12FR PU LUMX3 ACUTE ACC CVD -,SUP-8888345637HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,471.37,329.959,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,80.92327,4457.91882,other,Non-Reimbursable List,,
IVUS 0.014P RX CATHETER -,SUP-014R,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7720.4409,other,Non-Reimbursable List,,
CATH US 8FRX90CM ACUNAV 4W STEER -,SUP-10135936,CDM,C1753,HCPCS,272,RC,,,outpatient,,,10767.7,7537.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7720.4409,other,Non-Reimbursable List,,
CATH DRAGONFLY OPSTAR REF: 1014651 -,SUP-1014651,CDM,C1753,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7720.4409,other,Non-Reimbursable List,,
CATH US 5FR20MM IMG TAPR 150CM EAGLE EYE GOLD OTW COR PERIPH -,SUP-85900,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7720.4409,other,Non-Reimbursable List,,
CATH US EAGLE EYE PLATINUM REF: 85900P -,SUP-85900P,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7720.4409,other,Non-Reimbursable List,,
CATH US 5FR ID 20MM STR 150CM EAGLE EYE RX COR GLYDX PLTNM -,SUP-85900P,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7720.4409,other,Non-Reimbursable List,,
CATH US EAGLE EYE PLTNM SHORT TIP -,SUP-85900PST,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7720.4409,other,Non-Reimbursable List,,
CATH VISIONS PV 0.018 -,SUP-86700,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7720.4409,other,Non-Reimbursable List,,
C VOLCANO IVUS PV035 -,SUP-88901,CDM,C1753,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7720.4409,other,Non-Reimbursable List,,
CATH DX VIEWFLEXX ICE 4W -,SUP-D087031,CDM,C1753,HCPCS,272,RC,,,outpatient,,,8496.49,5947.543,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7720.4409,other,Non-Reimbursable List,,
CATH DX VIEWFLEX ECO ICE CATHERTER REPROC REF: D087031-R -,SUP-D087031-R,CDM,C1753,HCPCS,272,RC,,,outpatient,,,5544.79,3881.353,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7720.4409,other,Non-Reimbursable List,,
ECHO ATLANTIS ICE -,SUP-H749389790,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7720.4409,other,Non-Reimbursable List,,
CATHETER OPTICROSS HD IVUS 5FR -,SUP-H74939352040,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3843.07,2690.149,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7720.4409,other,Non-Reimbursable List,,
CATHETER OPTICROSS HD IVUS 6FR -,SUP-H74939354080,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3843.07,2690.149,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7720.4409,other,Non-Reimbursable List,,
CATH US 9FR 9 MHZ 110CM ULTRA ICE IMG COR -,SUP-M00499000,CDM,C1753,HCPCS,272,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7720.4409,other,Non-Reimbursable List,,
CATH US 6FR CRV NDL 120CM PIONEER + TRPL BRD SHFT PERC -,SUP-PPLUS120,CDM,C1753,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7720.4409,other,Non-Reimbursable List,,
KIT EPIDURAL MINI BREVI-XL -,SUP-181-2340,CDM,C1755,HCPCS,278,RC,,,outpatient,,,481.1,336.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List,,
ST NEEDLE NRV BLCK CONTIPLEX -,SUP-331686,CDM,C1755,HCPCS,278,RC,,,outpatient,,,209.88,146.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List,,
TRAY EPIDURAL PERIFIX 17GA -,SUP-332079,CDM,C1755,HCPCS,278,RC,,,outpatient,,,140.22,98.154,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List,,
TRAY EPIDURAL WITH DURAPREP -,SUP-332215,CDM,C1755,HCPCS,278,RC,,,outpatient,,,192.5,134.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List,,
EPIDURAL CATHETER SET 20GA -,SUP-333540,CDM,C1755,HCPCS,278,RC,,,outpatient,,,46,32.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List,,
TRY EPDRL/SPIN CONT TUOHY WHITACRE 18GA PERISAFE 1% LIDOCN -,SUP-406048,CDM,C1755,HCPCS,278,RC,,,outpatient,,,114.89,80.423,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List,,
TRAY SPINAL LIDOCAINE 25GA X 3.5IN WHITACRE 0.75% HCL D8.25W -,SUP-406704,CDM,C1755,HCPCS,278,RC,,,outpatient,,,159.23,111.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List,,
LUMBAR PUNCTURE TRAY PEDI 22GA 1.5IN -,SUP-646,CDM,C1755,HCPCS,278,RC,,,outpatient,,,75.04,52.528,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List,,
TRAY LUMBAR PUNCTURE 20G -,SUP-648,CDM,C1755,HCPCS,278,RC,,,outpatient,,,92.06,64.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List,,
PASSER SURG SS HOL OBTR STRL -,SUP-8591-38,CDM,C1755,HCPCS,278,RC,,,outpatient,,,571.83,400.281,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List,,
KT IT 4FR CLSD TIP SIL MRKNG GW SPIN NDL ANCHR RLR -,SUP-8598A,CDM,C1755,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List,,
KT IT SIL RBR CLSD TIP SIL MRKNG GW SPIN NDL ANCHR RLR -,SUP-8709SC,CDM,C1755,HCPCS,278,RC,,,outpatient,,,3150.84,2205.588,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List,,
CATH IT 0.53MM 1.4MM/2.2MM SPIN/PMP SEG SIL RBR TRMBL CLSD -,SUP-8731SC,CDM,C1755,HCPCS,278,RC,,,outpatient,,,3150.84,2205.588,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List,,
CATHETER INTRA MEDTRONIC -,SUP-8780,CDM,C1755,HCPCS,278,RC,,,outpatient,,,4430.74,3101.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List,,
CATHETER INTRATHECAL  MEDTRONIC -,SUP-8781,CDM,C1755,HCPCS,278,RC,,,outpatient,,,4430.74,3101.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List,,
PROCEDURE 20GA 3.5IN NDL SF-T + F/LP -,SUP-974,CDM,C1755,HCPCS,278,RC,,,outpatient,,,130.65,91.455,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List,,
PROCEDURE 20GA 3.5IN NDL SF-T + F/LP -,SUP-974,CDM,C1755,HCPCS,278,RC,,,outpatient,,,130.65,91.455,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List,,
KIT SINGLE SHOT EPIDURAL -,SUP-A4082-20,CDM,C1755,HCPCS,278,RC,,,outpatient,,,85.52,59.864,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List,,
KT NEEDLE NRV BLCK 20GA STIMUCATH CONT INSL 4CM -,SUP-AB-20604-KS,CDM,C1755,HCPCS,278,RC,,,outpatient,,,518.08,362.656,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List,,
ST NEEDLE NRV BLCK 20GA STIMUCATH CONT INSL -,SUP-AB-20604-S,CDM,C1755,HCPCS,278,RC,,,outpatient,,,369.64,258.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List,,
KT NEEDLE NRV BLCK 20GA STIMUCATH CONT INSL 8CM -,SUP-AB-20608-KS,CDM,C1755,HCPCS,278,RC,,,outpatient,,,256.13,179.291,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List,,
SPACEOAR KITS -,SUP-SO-2101,CDM,C1755,HCPCS,278,RC,,,outpatient,,,11779.68,8245.776,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List,,
SPINAL -,SUP-UNDEFINED,CDM,C1755,HCPCS,278,RC,,,outpatient,,,80.87,56.609,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.327,9046.79424,other,Non-Reimbursable List,,
POWER PULSE KIT ANGIO JET Y SE -,SUP-104834-0020,CDM,C1757,HCPCS,272,RC,,,outpatient,,,214.56,150.192,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
SET POWER PULSE Y SPIKE ANGIO -,SUP-104834-0021,CDM,C1757,HCPCS,272,RC,,,outpatient,,,214.56,150.192,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
C ANGIOJET AVX -,SUP-105039-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,3746.49,2622.543,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
DISC INJ F/THRMB -,SUP-105040001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,5326.22,3728.354,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATH THRMB 5FRX140CM ANGIOJET XVG HYDRCT -,SUP-105042-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,6917.72,4842.404,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
THROMBECTOMY 16.5INX54INX25IN D ANGIOJET -,SUP-105650-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,85111.5,59578.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATH THRMB 4.2FR FETCH -,SUP-106127-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATH THRMB 4FRX135CM ANGIOJET SPIROFLEX RX CX-STRM TECH -,SUP-106553-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10062.52,7043.764,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATH THRMB 5FRX135CM ANGIOJET SPIROFLEXVG RX CX-STRM TECH -,SUP-106608-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10062.52,7043.764,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATH THRMB 6FRX90CM ANGIOJET SOLENT PROXI OTW SPRL CUT PROX -,SUP-109676-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10503.9,7352.73,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
6FR 120CM ANGIOJET SOLENT OMNI -,SUP-109681-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9202.73,6441.911,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
4FRX145CM ANGIOJET  SOLENT DISTA THROMBECTOMY SE -,SUP-111303-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11183.56,7828.492,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
ANGIOIJET ZELANTEDVT 8X105CM -,SUP-114610-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10452.1,7316.47,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATH FOGARTY 3FR EMB 3 / SHORT -,SUP-120403FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATH FOGARTY 4FR EMB 4 SHORT -,SUP-120404FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATH FOGARTY 2FR / EMB 2 SHORT -,SUP-120602FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,493.23,345.261,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATH FOGARTY 3FR / EMB 3 -,SUP-120803FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATH FOGARTY 4FR 9MM  EMB 4 -,SUP-120804F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATH EMBCMT 4FR 9MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120804FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATH EMBCMT 5FR 11MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120805FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATH EMBCMT 6FR 13MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120806FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATH EMBCMT 7FR 14MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120807FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
C FOGARTY 3FR 12TLW403F -,SUP-12TLW403F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
C FOGARTY 4FR 12TLW404F -,SUP-12TLW404F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
C FOGARTY 5F 40 CM -,SUP-12TLW405F35,CDM,C1757,HCPCS,272,RC,,,outpatient,,,567.98,397.586,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
C FOGARTY 6FR 40CM -,SUP-12TLW406F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATH FOGARTY THRU LUMEN 3 -,SUP-12TLW803F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
C FOGARTY 4 80CM -,SUP-12TLW804F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
C FOGARTY 5.5 80CM OTW -,SUP-12TLW805F35,CDM,C1757,HCPCS,272,RC,,,outpatient,,,567.98,397.586,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
C FOGARTY 6 80CM -,SUP-12TLW806F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,567.98,397.586,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATH EMBCMT 7FRX14MM/8FR INFL/DFLT BLN 80CM FOGARTY OTW -,SUP-12TLW807F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATH FOGARTY 6FR. ACC 6/10 -,SUP-1408010,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1347.12,942.984,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATH FOGARTY 6FR. / EMB 6 -,SUP-160246F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1992.72,1394.904,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATH THRMB 5.5FR 138CM PRONTO V4 LRG LUM LNGTDNL WIRE HYDRCT -,SUP-4005,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1765.07,1235.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATH PTCA 4MMX4CM SAVVY 120CM OTW COAX MOD PRSS PERIPH TAPR -,SUP-435-404L,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1155.51,808.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATH US 5.2FRX106CM 12CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-55112,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATH US 5.2FRX106CM 18CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-55118,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATH US 5.2FRX106CM 24CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-55124,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATH US 5.2FRX135CM 12CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56112,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATH US 5.2FRX135CM 30CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56130,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATH US 5.2FRX135CM 40CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56140,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATH US 5.2FRX135CM 50CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56150,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATH THRMB 0.066IN 6FRX140CM WKG PRONTO LP LPRO XTRCT HYDRCT -,SUP-5010,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1929.38,1350.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CLOT TRIEVER SHEATH -,SUP-50-101,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CLOTTRIEVER SHEATH 16FR X 15CM -,SUP-51-101,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
INDIGO CATHETER 5 + LARGE LUMEN ASPIRATION TUBING -,SUP-90178584,CDM,C1757,HCPCS,272,RC,,,outpatient,,,6599.42,4619.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
INDIGO CATHETER 6 + LARGE LUMEN ASPIRATION TUBING -,SUP-90178585,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9782.42,6847.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATH INFS 6FR 3-10 MMX80CM 10CM BLN TRELLIS OTW MULTLUM INFS -,SUP-BVT608010,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8891.18,6223.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATH THRMB 8FRX80CM 15CM TRELLIS INFS PTRN -,SUP-BVT808015,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8891.18,6223.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATH THRMB 8FRX80CM 30CM TRELLIS INFS PTRN -,SUP-BVT808030,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9145.82,6402.074,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATH INFS 8FR 5-16 MMX120CM 30CM BLN TRELLIS OTW MULTLUM -,SUP-BVT812030,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8891.18,6223.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATH THRMB 0.041IN/0.032IN ID 4.1FR/3.4FR P/D 150CM INDIGO -,SUP-CAT3,CDM,C1757,HCPCS,272,RC,,,outpatient,,,5114.02,3579.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATH THRMB 0.064IN/0.054IN ID 6FR/5FR P/D 132CM INDIGO -,SUP-CAT5,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4753.28,3327.296,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATH THRMB 6FRX135CM INDIGO -,SUP-CAT6,CDM,C1757,HCPCS,272,RC,,,outpatient,,,7936.28,5555.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
INDIGO CATHETER 7D PLUS DYNAMIC ASPIRATION TUBING -,SUP-CAT7DKIT,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9913.71,6939.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATH THRMB 8FRX115CM INDIGO -,SUP-CAT8XTORQ115,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10804.83,7563.381,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATHETER D + INDIGO LARGE LUMEN ASPIRATING TUBING -,SUP-CATD,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9913.71,6939.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
INDIGO CATHETER RX 140 CM + LG LUMEN ASPIRATION TUBING -,SUP-CATRXKIT,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8063.6,5644.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATHETER SILICONE EMBOLECTOMY 4FR 80CM -,SUP-E1801-48,CDM,C1757,HCPCS,272,RC,,,outpatient,,,811.07,567.749,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATHETER SILICONE EMBOLECTOMY 5FR 80CM -,SUP-E1801-58,CDM,C1757,HCPCS,272,RC,,,outpatient,,,811.07,567.749,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
EXCIPIO SV THROMBECTOMY DEVICE 8MM -,SUP-EXC-0940-165,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11101.87,7771.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATH EXPORT AP ASPIRATION 6F 0 -,SUP-EXPORTAP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATH PTCA 4MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50233,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATH EMBCMT 7FRX145CM EXPORT AP BRD ASPIR SFT TIP FLXB -,SUP-GEZ6200US7B,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
EKOS+ KIT 106CM 8 CM -,SUP-H74939605106080,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
DEVICE THROMBECTOMY EKOS+ 106CM X 2.62CM TREATMENT ZONE 12CM -,SUP-H74939605106120,CDM,C1757,HCPCS,272,RC,,,outpatient,,,13181.15,9226.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
EKOS+ KIT 106CM 16 CM -,SUP-H74939605106160,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
EKOS+ KIT 106CM 20 CM -,SUP-H74939605106200,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
EKOS+ KIT 135CM 20 CM -,SUP-H74939605135200,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
INDIGO CATHETER 12 115CM HTORQ -,SUP-LITNG12HTORQ115,CDM,C1757,HCPCS,272,RC,,,outpatient,,,25137.01,17595.907,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
INDIGO CATHETER 7 130CM XTORQ -,SUP-LITNG7XTORQ130,CDM,C1757,HCPCS,272,RC,,,outpatient,,,20681.41,14476.987,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
INDIGO CATHETER 8 115CM XTORQ -,SUP-LITNG8XTORQ115,CDM,C1757,HCPCS,272,RC,,,outpatient,,,21424.01,14996.807,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-5080-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-5120-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-6080-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-6120-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-6200-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
ACCESSORY KIT JETI NON STERILE DISPOSABLE -,SUP-WV1500,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
JETI CATHETER KIT 6FR -,SUP-WV6203A,CDM,C1757,HCPCS,272,RC,,,outpatient,,,12141.51,8499.057,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
JETI CATHETER KIT 8FR -,SUP-WV8803A,CDM,C1757,HCPCS,272,RC,,,outpatient,,,17109.5,11976.65,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.14178,61024.9455,other,Non-Reimbursable List,,
CATH URETH 5FR TIGTL PU LF 70CM NPRT EYE FLXB OPN TIP -,SUP-0139005,CDM,C1758,HCPCS,272,RC,,,outpatient,,,549.07,384.349,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,11.97932,751.60242,other,Non-Reimbursable List,,
CATH URETERAL POLLACK 5 70 -,SUP-021305,CDM,C1758,HCPCS,272,RC,,,outpatient,,,94.44,66.108,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,11.97932,751.60242,other,Non-Reimbursable List,,
CATH FOLEY 6FR 2W LUBRI-SIL SIL LF PED -,SUP-175806N,CDM,C1758,HCPCS,272,RC,,,outpatient,,,146.07,102.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,11.97932,751.60242,other,Non-Reimbursable List,,
CATH URET 6FRX70CM PVC OP-EN TIP LF PVC SOF-FLEX -,SUP-G15942,CDM,C1758,HCPCS,272,RC,,,outpatient,,,65.41,45.787,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,11.97932,751.60242,other,Non-Reimbursable List,,
CATH URET 5FRX80CM VNYL LUMX1 LF BUSH SL CATHX2 CMN L/S -,SUP-G16746,CDM,C1758,HCPCS,272,RC,,,outpatient,,,1048.26,733.782,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,11.97932,751.60242,other,Non-Reimbursable List,,
CATH ANG 5FR KMP 100CM SLIP-CATH BRD HYDRCT -,SUP-G28535,CDM,C1758,HCPCS,272,RC,,,outpatient,,,379.26,265.482,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,11.97932,751.60242,other,Non-Reimbursable List,,
CATHETER ACCESS 6FR AXXCESS -,SUP-M0064001161,CDM,C1758,HCPCS,272,RC,,,outpatient,,,61.04,42.728,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,11.97932,751.60242,other,Non-Reimbursable List,,
CATH 5FR X 70 CONE TIP BX/20 -,SUP-M0064002111,CDM,C1758,HCPCS,272,RC,,,outpatient,,,53.36,37.352,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,11.97932,751.60242,other,Non-Reimbursable List,,
CATH DUAL LUMEN URETERAL -,SUP-M0064051000,CDM,C1758,HCPCS,272,RC,,,outpatient,,,384.35,269.045,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,11.97932,751.60242,other,Non-Reimbursable List,,
CATHETER 5.5 S2 -,SUP-1000100,CDM,C1759,HCPCS,272,RC,,,outpatient,,,101147,70802.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,72522.399,other,Non-Reimbursable List,,
CATH US 10FRX90CM 5.5-10 MHZ SOUNDSTAR NAV COR -,SUP-SNDSTR10,CDM,C1759,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,72522.399,other,Non-Reimbursable List,,
DEVICE SUT -,SUP-123250101,CDM,C1760,HCPCS,278,RC,,,outpatient,,,116.7,81.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List,,
CLOSURE PERCLOSE PROGLIDE 6F -,SUP-12673-03,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List,,
PERCLOSE PROSTYLE -,SUP-12773-03,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List,,
DEVICE VASC CLSR 56FR STARCLOSE SE -,SUP-14679-01,CDM,C1760,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List,,
STAR CLOSE SELF -,SUP-14679-01,CDM,C1760,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List,,
ANGIO SEAL STS VIP/PLUS 6FR -,SUP-610119,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List,,
ANGIO SEAL STS VIP/PLUS 8FR -,SUP-610121,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List,,
DEVICE VASC CLSR 6FR ANGIO-SEAL VIP -,SUP-610130,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List,,
DEVICE VASC CLSR 8FR ANGIO-SE  70CM -,SUP-610131,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List,,
VASCADE MVP - VENOUS VASCULAR CLOSURE SYSTEM 6-12F -,SUP-800-612C-10U,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List,,
SYS ATRICLIP STD 40 -,SUP-ACH140,CDM,C1760,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List,,
SYS ATRICLIP STD 45 -,SUP-ACH145,CDM,C1760,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List,,
DEVICE VASC CLSR 5FR EXOSEAL -,SUP-EX500,CDM,C1760,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List,,
DEVICE VASC CLSR 6FR EXOSEAL -,SUP-EX600,CDM,C1760,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List,,
PAS-PORT PROXIMAL ANASTOMOSIS -,SUP-FG-000001-13,CDM,C1760,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List,,
CELT ACD 5FR CLOSURE DEVICE -,SUP-KCLT-05,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List,,
CELT ACD 6FR CLOSURE DEVICE -,SUP-KCLT-06,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List,,
CELT ACD 7FR CLOSURE DEVICE -,SUP-KCLT-07,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List,,
MYNX GRIP 5FR CLOSURE DEVICE M - MULTIPLES OF 10 ONLY -,SUP-M465MX50210C,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List,,
DEVICE 6F/7F MYNX GRIP CLOSURE -,SUP-MX6721,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List,,
DEVICE VASC CLSR 6FR MYNXGRIP -,SUP-MX6721,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List,,
VENASEAL SYSTEM CLOSURE -,SUP-VS-404,CDM,C1760,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3585.3312,other,Non-Reimbursable List,,
BALLOON SHOCKWAVE C2 + IVL CATHETER 2.5X12 REF: C2PIVL2512 -,SUP-C2PIVL2512,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,6992.65577,399.86,14791.55236,percent of total billed charges,,,
BALLOON SHOCKWAVE C2 + IVL CATHETER 3.0X12 REF: C2PIVL3012 -,SUP-C2PIVL3012,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,6992.65577,399.86,14791.55236,percent of total billed charges,,,
BALLOON SHOCKWAVE C2 + IVL CATHETER 3.5X12 REF: C2PIVL3512 -,SUP-C2PIVL3512,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,6992.65577,399.86,14791.55236,percent of total billed charges,,,
BALLOON SHOCKWAVE C2 + IVL CATHETER 4.0X12 REF: C2PIVL4012 -,SUP-C2PIVL4012,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,6992.65577,399.86,14791.55236,percent of total billed charges,,,
CATHETER  SHOCKWAVE L6 1VL- 8.0 X 30 MM -,SUP-L6IVL080030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,5132.906895,399.86,14791.55236,percent of total billed charges,,,
CATHETER  SHOCKWAVE L6 1VL- 9.0 X 30 MM -,SUP-L6IVL090030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,5132.906895,399.86,14791.55236,percent of total billed charges,,,
CATHETER  SHOCKWAVE L6 1VL- 10.0 X 30 MM -,SUP-L6IVL100030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,5132.906895,399.86,14791.55236,percent of total billed charges,,,
CATHETER  SHOCKWAVE L6 1VL- 12.0 X 30 MM -,SUP-L6IVL120030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,5132.906895,399.86,14791.55236,percent of total billed charges,,,
CATHETER SHOCKWAVE 6.5 X 60 MM M5+ -,SUP-M5PIVL6560,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,5132.906895,399.86,14791.55236,percent of total billed charges,,,
TENDON SEMITENINOSIS -,SUP-004023,CDM,C1762,HCPCS,278,RC,,,outpatient,,,5817.25,4072.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List,,
GRAFT HUM TIS NAT DENOVO LF -,SUP-00560600010,CDM,C1762,HCPCS,278,RC,,,outpatient,,,17339.71,12137.797,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List,,
ADVANCE NERVE GRAFT D 1-2MM X 15MM -,SUP-111215,CDM,C1762,HCPCS,278,RC,,,outpatient,,,8649.27,6054.489,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List,,
ADVANCE NERVE ALLOGRAFT -,SUP-111230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List,,
STRATTICE RECONSTRUCTIVE TISSUE MATRIX 16 X 20CM -,SUP-1620002,CDM,C1762,HCPCS,278,RC,,,outpatient,,,30012.18,21008.526,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List,,
STRATTICE RECONSTRUCTIVE TISSUE MATRIX 20 X 20CM -,SUP-2020002,CDM,C1762,HCPCS,278,RC,,,outpatient,,,24926.57,17448.599,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List,,
GRAFT HUM TIS SPORTSMED TIB IRRAD LF -,SUP-208002,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List,,
GRAFT HUM TIS SPORTSMED TIB TNDN POST TIB IRRAD LF -,SUP-208003,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List,,
AVANCE NERVE GRAFT 2MM DIAM / 30MM LENGTH -,SUP-211230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List,,
ADVANCE NERVE GRAFT 3-4MM X 30MM -,SUP-311230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List,,
AXOGEN ADVANCE NERVE GRAFT 3.4MM X 70MM -,SUP-311270,CDM,C1762,HCPCS,278,RC,,,outpatient,,,25322.66,17725.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List,,
NERVE GRAFT ADVANCED 4-5MM X 30MM -,SUP-411230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List,,
AXOGEN ADVANCE NERVE GRAFT 4.5MM X 70MM -,SUP-411270,CDM,C1762,HCPCS,278,RC,,,outpatient,,,25322.66,17725.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List,,
GRAFT HUM TIS FRZN 6-12 MMX20-38CM ANT TIB TNDN LF -,SUP-430335,CDM,C1762,HCPCS,278,RC,,,outpatient,,,8376.38,5863.466,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List,,
TENDON TIBIALIS POSTERIOR -,SUP-430343,CDM,C1762,HCPCS,278,RC,,,outpatient,,,8168.81,5718.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List,,
GRAFT HUM TIS FRZN 3-10 MMX26-38CM SEMITNDS TNDN LF -,SUP-430350,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List,,
GRAFT HUM TIS FRZN 3-10 MMX20-25.9CM ANT TIB TNDN LF -,SUP-430355,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List,,
IMPLANT HUM TIS PS 10MM TNDN ACH -,SUP-450200,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10971.92,7680.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List,,
GRAFT HUM TIS FRZDR 2X14CM IOPATCH TUTOPLAST FSCA LATA -,SUP-68021,CDM,C1762,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List,,
GRAFT HUM TIS DHYDR 1.5X1.5CM IOPATCH TUTOPLAST PROC -,SUP-68250,CDM,C1762,HCPCS,278,RC,,,outpatient,,,1404.63,983.241,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List,,
GRAFT HUM TIS PTCH DHYDR 1X3CM IOPATCH TUTOPLAST SCLR IRRAD -,SUP-68334,CDM,C1762,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List,,
GRAFT HTM NMSH SFT REGEN 5X5CM STD GRAFTJACKET ACLR DERM 1MM -,SUP-8600-5X05,CDM,C1762,HCPCS,278,RC,,,outpatient,,,9761.2,6832.84,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List,,
GRAFT HTM FRZDR SFT REGEN 2X4CM GRAFTJACKET COLL 1.5MM UND -,SUP-86MX-2X04,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10752.85,7526.995,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List,,
PATELLA TENDON W/ EXTENSION MECHANISM -,SUP-92-3300,CDM,C1762,HCPCS,278,RC,,,outpatient,,,26622.21,18635.547,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List,,
GRAFT HUM TIS SPLT THK VSNGRFT CRNA NON-IMMUNOGENIC XLNK -,SUP-C0301AL-90,CDM,C1762,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List,,
CORNEA HUMAN -,SUP-CORNEA,CDM,C1762,HCPCS,278,RC,,,outpatient,,,16467.16,11527.012,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List,,
IMPLANT HUM TIS BLCK AT -,SUP-FATB,CDM,C1762,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List,,
IMPLANT HUM TIS ALLOGRAFT BIOCLEANSE GRCLS TNDN FRZN -,SUP-FGRACILIS,CDM,C1762,HCPCS,278,RC,,,outpatient,,,5267.78,3687.446,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List,,
GRAFT HUM TIS FRZDR 30X150MM MED RDIGRF FSCA LATA LF -,SUP-FLM,CDM,C1762,HCPCS,278,RC,,,outpatient,,,4565.66,3195.962,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List,,
GRAFT HUM TIS SFT 230MM 7.5MM FLEXIGRAFT POST TIB TNDN FRZN -,SUP-FPOST.TIBIAL,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7087.1,4960.97,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List,,
FLEXIGRAFT QUADLINK-ZORC -,SUP-FQL,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10482.68,7337.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List,,
GRAFT HUM TIS HAMSTRING FRZN >150MM4MM-5.5MM DIA FLEXIGRAFT -,SUP-FROPE,CDM,C1762,HCPCS,278,RC,,,outpatient,,,3719.57,2603.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List,,
GRAFT HUM TIS HAMSTRING FRZN 160-250MM 4-6MM FLEXIGRAFT -,SUP-FSTP,CDM,C1762,HCPCS,278,RC,,,outpatient,,,3657.31,2560.117,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List,,
SLING TRNVAG RPLFRM COLL 5X10CM NABSB FEM FRZDR SLF-ANCHR -,SUP-M0068202450,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7456.11,5219.277,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List,,
SLING TRNVAG RPLFRM COLL 6X12CM NABSB FEM FRZDR SLF-ANCHR -,SUP-M0068202460,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7882.17,5517.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List,,
MACROFORM COMPOSITE NOVABONE 10CC -,SUP-NB1003,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List,,
NOVABONE BIOACTIVE BONE GRAFT 10CC LONG STRIP -,SUP-NB2310L,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List,,
NOVABONE 10CC STRIP -,SUP-NB2310S,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List,,
NOVABONE 2.5CC PUTTY -,SUP-NB2602,CDM,C1762,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List,,
NOVABONE 5CC PUTTY -,SUP-NB2605,CDM,C1762,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List,,
NOVABONE 10CC PUTTY SYRINGE -,SUP-NB2610,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List,,
GRAFT HUM TIS FRZN >=150MM TIB POST TNDN LF -,SUP-X30820,CDM,C1762,HCPCS,278,RC,,,outpatient,,,6302.34,4411.638,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,315.339435,23049.35424,other,Non-Reimbursable List,,
IMPLANT BIO TISS 15X20CM RECT PRCN COLL MATRIX NXLNK XENMTRX -,SUP-1161520,CDM,C1763,HCPCS,278,RC,,,outpatient,,,31189.2,21832.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List,,
EPIDISK -,SUP-1417100,CDM,C1763,HCPCS,278,RC,,,outpatient,,,1203.21,842.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List,,
IMPLANT COLL MEMBR 50X40MM GEISTLICH BIO-GIDE BILAYER RESRB -,SUP-20153,CDM,C1763,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List,,
SHEET MEDPOR 38 X 50 X 0.85 ORBITAL IMPLANT -,SUP-7210,CDM,C1763,HCPCS,278,RC,,,outpatient,,,2390.53,1673.371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List,,
SUBSTITUTE CA SLPHT 5ML GRNL MIIGX3 RESRB SYNTH PREFL -,SUP-84XS-0405,CDM,C1763,HCPCS,278,RC,,,outpatient,,,7940.52,5558.364,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List,,
SUBSTITUTE CA SLPHT 5ML GRNL MIIGX3 RESRB SYNTH PREFL -,SUP-84XS-0405,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9145.82,6402.074,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List,,
GRID CRNL 106X97MM 6MM MEDPOR FLEXBLOCK -,SUP-9524,CDM,C1763,HCPCS,278,RC,,,outpatient,,,15136.27,10595.389,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List,,
NERVE PROTECTOR WRAP 2MM X 20MM -,SUP-AG0220,CDM,C1763,HCPCS,278,RC,,,outpatient,,,8118.77,5683.139,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List,,
NERVE PROTECTOR WRAP 3.5MM X 20MM -,SUP-AG0320,CDM,C1763,HCPCS,278,RC,,,outpatient,,,8118.77,5683.139,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List,,
NERVE WRAP AVANCE 3.5MM X 40MM -,SUP-AG0340,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9921.14,6944.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List,,
NERVE WRAP AVANCE 3.5MM X 40MM -,SUP-AG0340,CDM,C1763,HCPCS,278,RC,,,outpatient,,,10525.12,7367.584,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List,,
NERVE PROTECTOR 7MM X 40MM - USE 0169678 -,SUP-AG0740,CDM,C1763,HCPCS,278,RC,,,outpatient,,,10121.64,7085.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List,,
NERVE PROTECTOR 7MM X 40MM -,SUP-AG0740,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9442.16,6609.512,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List,,
AXOGUARD NERVE PROTECTOR 40MM 10MM -,SUP-AG1040,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9442.16,6609.512,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List,,
AXOGAURD NERVE CONNECTOR 2 X 15 -,SUP-AGX215,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List,,
AXOGAURD NERVE CONNECTOR D 3MM L 15MM -,SUP-AGX315,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List,,
AXOGAURD NERVE CONNECTOR D 4MM L 15MM -,SUP-AGX415,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List,,
CONNECTOR AXOGUARD NERVE D 5MM L 15MM -,SUP-AGX515,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List,,
PLUG ANAL FISTULA -,SUP-G53614,CDM,C1763,HCPCS,278,RC,,,outpatient,,,5071.58,3550.106,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List,,
IMPLANT GYN 17X70CM SYNTH UPHOLD LT -,SUP-M0068317170,CDM,C1763,HCPCS,278,RC,,,outpatient,,,8668.37,6067.859,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List,,
SURGICAL MATRIX THICK 10 X 20CM -,SUP-PSMT1020,CDM,C1763,HCPCS,278,RC,,,outpatient,,,20941.32,14658.924,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List,,
5 X 5CM 6 LAYER GENTRIX SURGICAL MATRIX DRESSING -,SUP-PSMX0505,CDM,C1763,HCPCS,278,RC,,,outpatient,,,3471.65,2430.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List,,
ROD TNDN 3X250MM PLYSTR COR SIL PSS KNOB END HNTR STRL STR -,SUP-PT300000,CDM,C1763,HCPCS,278,RC,,,outpatient,,,5254.07,3677.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List,,
ROD TNDN 5X250MM PLYSTR COR SIL PSS KNOB END HNTR STRL STR -,SUP-PT500000,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6315.07,4420.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List,,
ROD TNDN STD 4X245MM PLYSTR COR SIL PSS HNTR STRL STR -,SUP-TR400000,CDM,C1763,HCPCS,278,RC,,,outpatient,,,5254.07,3677.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List,,
WOUND MATRIX 6 LAYER 10 X 15 -,SUP-WSX1015,CDM,C1763,HCPCS,278,RC,,,outpatient,,,16411.46,11488.022,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,270.120645,23953.3056,other,Non-Reimbursable List,,
RECORDER LOOP 2-AF BIOMONITOR -,SUP-398493,CDM,C1764,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,14243.66592,other,SI=N Exclusions ,,
MONITOR CARD IMPL REVEAL XT 19X62MM TI 9ML 15GM -,SUP-9529,CDM,C1764,HCPCS,278,RC,,,outpatient,,,13348.24,9343.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,14243.66592,other,SI=N Exclusions ,,
MONITOR CARD IMPL CNFRM 18.5MMX56.3MM 6.5ML 12GM FRZDR LRDTC -,SUP-DM2100,CDM,C1764,HCPCS,278,RC,,,outpatient,,,11346.93,7942.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,14243.66592,other,SI=N Exclusions ,,
LOOP RECORDER NEXT GEN JOT DX REF: DM4500 -,SUP-DM4500,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,14243.66592,other,SI=N Exclusions ,,
LOOP RECORDER ASSERT IQ3+ ICM REF: DM5300 -,SUP-DM5300,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,14243.66592,other,SI=N Exclusions ,,
LOOP RECORDER ASSERT IQ EL+ ICM REF: DM5500 -,SUP-DM5500,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17636.75,12345.725,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,14243.66592,other,SI=N Exclusions ,,
REVEAL LINQ ICM SYSTEM LOOP RECORDER MDT -,SUP-LINQSYS,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17246.89,12072.823,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,14243.66592,other,SI=N Exclusions ,,
LOOP RECORDER REVEAL LINQ II SYSTEM REF: LNQ22SYS -,SUP-LNQ22SYS,CDM,C1764,HCPCS,278,RC,,,outpatient,,,18546.44,12982.508,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,14243.66592,other,SI=N Exclusions ,,
LUX DX INSERTABLE CARDIAC MONITOR M301 -,SUP-M301,CDM,C1764,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,14243.66592,other,SI=N Exclusions ,,
LUX -DX II+ INSERTABLE CARDIAC MONITOR REF: M312 -,SUP-M312,CDM,C1764,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,14243.66592,other,SI=N Exclusions ,,
GELFILM OPTH -,SUP-0009-0297-03,CDM,C1765,HCPCS,278,RC,,,outpatient,,,1102.46,771.722,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,247.50227,1378.95936,other,Non-Reimbursable List,,
"BARRIER ADHESION SEPRAFILM 5 X 6"" -",SUP-430102,CDM,C1765,HCPCS,278,RC,,,outpatient,,,1691.39,1183.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,247.50227,1378.95936,other,Non-Reimbursable List,,
BARRIER INTERCEED 3X4 -,SUP-4350,CDM,C1765,HCPCS,278,RC,,,outpatient,,,1795.52,1256.864,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,247.50227,1378.95936,other,Non-Reimbursable List,,
FLEXCATH CONTOUR STERERABLE SHEATH REF:10FCC13 -,SUP-10FCC13,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,109.158635,4260.1272,other,Non-Reimbursable List,,
FLEXCATH CONTOUR STERRABLE SHEATH 10FRX20MM REF:10FCC20 -,SUP-10FCC20,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,109.158635,4260.1272,other,Non-Reimbursable List,,
FLEXCATH CONTOUR STEERABLE SHEATH 12FRx13MM REF:12FCC13 -,SUP-12FCC13,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,109.158635,4260.1272,other,Non-Reimbursable List,,
FLEXCATH CONTOUR STEERABLE SHEATH 12FRx20MM REF:12FCC20 -,SUP-12FCC20,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,109.158635,4260.1272,other,Non-Reimbursable List,,
FARADRIVE STEERABLE SHEATH REF: 21C602 -,SUP-21C602,CDM,C1766,HCPCS,272,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,109.158635,4260.1272,other,Non-Reimbursable List,,
AGILIS SHEATH SMALL -SJM  8.5FRX91CM -,SUP-408309,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4139.92,2897.944,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,109.158635,4260.1272,other,Non-Reimbursable List,,
SHEATH AGILIS SM- REPROC 8.5FR -,SUP-408309,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2639.83,1847.881,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,109.158635,4260.1272,other,Non-Reimbursable List,,
AGILIS SHEATH  MED - SJM 8.5FR X 91CM -,SUP-408310,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4267.96,2987.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,109.158635,4260.1272,other,Non-Reimbursable List,,
INTRO SHTH FLEXCATH ADVANCE 12FR -,SUP-4FC12,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,109.158635,4260.1272,other,Non-Reimbursable List,,
CATH ABLT CARTO 3 XTRN REF -,SUP-CREFP6,CDM,C1766,HCPCS,272,RC,,,outpatient,,,486.23,340.361,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,109.158635,4260.1272,other,Non-Reimbursable List,,
SHEATH AGILIS LGE- REPROC  8.5FR -,SUP-G408234,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2473.84,1731.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,109.158635,4260.1272,other,Non-Reimbursable List,,
AGILIS SHEATH LRG CURL SFT 3MM J FNGR SJM -,SUP-G408324,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4172.48,2920.736,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,109.158635,4260.1272,other,Non-Reimbursable List,,
SHEATH POLARSHEATH STEERABLE SHEATH REF:M004CRBS3150 -,SUP-M004CRBS3150,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,109.158635,4260.1272,other,Non-Reimbursable List,,
AMULET STEERABLE DELIVERY SHEATH REF: STRBL-14F-075 -,SUP-STRBL-14F-075,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,109.158635,4260.1272,other,Non-Reimbursable List,,
TOURGUIDE 7FR X 55CM -,SUP-TG0705509,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,109.158635,4260.1272,other,Non-Reimbursable List,,
SHEATH GRAFT 7FR. 9MM 45CM -,SUP-UNDEFINED,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,109.158635,4260.1272,other,Non-Reimbursable List,,
SHEATH 6.5 FR. 55CM -,SUP-UNDEFINED,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,109.158635,4260.1272,other,Non-Reimbursable List,,
GENERATOR NEURSTM INTSTM TI 60MMX55MM SCRL NRV MRI-COND -,SUP-3023,CDM,C1767,HCPCS,278,RC,,,outpatient,,,36758.7,25731.09,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,39874.22976,other,SI=N Exclusions ,,
INTERSTIM STIMULATOR EXTERNAL NEURO -,SUP-353101,CDM,C1767,HCPCS,278,RC,,,outpatient,,,1987.69,1391.383,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,39874.22976,other,SI=N Exclusions ,,
PROCLAIM 5 ELITE -,SUP-3660ANS,CDM,C1767,HCPCS,278,RC,,,outpatient,,,40409.46,28286.622,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,39874.22976,other,SI=N Exclusions ,,
NEUROSTIMULATOR PROCLAIM 5 -,SUP-3661,CDM,C1767,HCPCS,278,RC,,,outpatient,,,45984.88,32189.416,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,39874.22976,other,SI=N Exclusions ,,
PROCLAIM 7 PULSE GENERATOR -,SUP-3663,CDM,C1767,HCPCS,278,RC,,,outpatient,,,44998.08,31498.656,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,39874.22976,other,SI=N Exclusions ,,
PROCLAIM DRG IPG 5.3AHG MRI EIFU RED -,SUP-3664,CDM,C1767,HCPCS,278,RC,,,outpatient,,,51919.57,36343.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,39874.22976,other,SI=N Exclusions ,,
DEVICE NEURSTM PRIM ADVANCED 2.6INX1.9IN PERC MRI-COND -,SUP-377-02,CDM,C1767,HCPCS,278,RC,,,outpatient,,,29604,20722.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,39874.22976,other,SI=N Exclusions ,,
NEURSTM PRGM ITREL 60MMX55MM SPIN CRD PRIM CELL -,SUP-377-03,CDM,C1767,HCPCS,278,RC,,,outpatient,,,27012.08,18908.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,39874.22976,other,SI=N Exclusions ,,
INS 977006 PAIN PC M -,SUP-977006,CDM,C1767,HCPCS,278,RC,,,outpatient,,,50457.55,35320.285,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,39874.22976,other,SI=N Exclusions ,,
NEURSTM IMPL PRIM ADVANCED 65X49X15MM SPIN CRD MRI-COND -,SUP-9770-2,CDM,C1767,HCPCS,278,RC,,,outpatient,,,32564.4,22795.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,39874.22976,other,SI=N Exclusions ,,
INTELLIS BATTERY #97715 -,SUP-97715,CDM,C1767,HCPCS,278,RC,,,outpatient,,,44376.4,31063.48,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,39874.22976,other,SI=N Exclusions ,,
INTERSTIM X NEUROSTIMULATOR IMPLANT -,SUP-97800,CDM,C1767,HCPCS,278,RC,,,outpatient,,,26510.38,18557.266,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,39874.22976,other,SI=N Exclusions ,,
PLEDGET FELT PTFE BARD 6 X 6IN -,SUP-007837,CDM,C1768,HCPCS,278,RC,,,outpatient,,,589.34,412.538,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT HEMA MDV BIF 20 10 40 -,SUP-0085201,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT VASC 20MM 15CM HEMASHLD GOLD STR KNTD DBL VELR AOR BVN -,SUP-095120,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1996.38,1397.466,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT HEMA 16MM 30CM MDV -,SUP-095216,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2628.78,1840.146,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT HEMA 18MM 30CM MDV -,SUP-095218,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2628.78,1840.146,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT VASC 22MM 30CM HEMASHLD GOLD STR KNTD DBL VELR AOR BVN -,SUP-095222,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2628.78,1840.146,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT VASC 1X6CM GORE-TEX 0.6MM PTCH -,SUP-1702515006,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2581.34,1806.938,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT HEMASHIELD D:28MM L:30CM -,SUP-175428P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT VASC 32MM 32X30CM HEMASHLD PLTNM STR WVN AOR COLL -,SUP-175432P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT VASC 38MMX30CM HEMASHLD PLTNM FINESSE STR WVN AOR BVN -,SUP-175438P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT VASC 20MM THOR 10MM BRNCH 50CM HEMASHLD PLTNM STR 20CM -,SUP-175820P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5377.66,3764.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT VASC 26MM THOR 10MM/10MM/8MM/8MM ID BRNCH 50CM -,SUP-175926P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6299.92,4409.944,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT VASC 7X10CM GORE-HYBRID PRECLUDE 0.1MM MEMBR PERICARD -,SUP-1PCM001,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1812.77,1268.939,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT ATRIUM VXT 4 7 45CM  - DISCONTINUED DO NOT USE -,SUP-22115,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2091.84,1464.288,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
KT INFL 20/20 PRIORITY PACK -,SUP-22297,CDM,C1768,HCPCS,278,RC,,,outpatient,,,227.57,159.299,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT VASC 6MM 50CM FLIXENE STR GRAD WL REINF SFT WRP TNLR -,SUP-25058,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5114.4,3580.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT VASC 6MM 40CM FLIXENE STR GRAD WL REINF SFT WRP TNLR -,SUP-25061,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4720.98,3304.686,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT VASC 4-7MM 30CM FLIXENE STR REINF SFT-WRP TNLR ATTCH -,SUP-25098,CDM,C1768,HCPCS,278,RC,,,outpatient,,,9358.02,6550.614,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT FLIXENE GTW GW 4 7 35 -,SUP-25129,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6294.62,4406.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT VASC 8MM 80CM STR HEP FUSION BIOLINE CTD RNG SUPP -,SUP-503088B,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10403.74,7282.618,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
VALVE AOR 6-30MM CRYOVALVE CONDT -,SUP-AV00,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39965.4,27975.78,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT STENT BIFURCATED -,SUP-BEA22-70/I16-30,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
AFX2 BIFURCATED ENDOGRAFT SYSTEM -,SUP-BEA25-80/113-40,CDM,C1768,HCPCS,278,RC,,,outpatient,,,14944.83,10461.381,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT STENT BIFURCATED -,SUP-BEA25-80/I20-40,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT STENT 90MM 28MM 16MM AFX2 2 BRANCH MAIN BODY ILIAC LIM -,SUP-BEA28-90/I16-30,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT VASC 7X15CM CORMATRIX PERICARD COLL GRW FACT PRTN -,SUP-CMCV-003-402,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT DISTAFLO VASCULAR 6X70 -,SUP-DFM7006SC,CDM,C1768,HCPCS,278,RC,,,outpatient,,,30067.87,21047.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
PATCH BOVINE 0.8 X 8CM DURAVESS PERICARDIAL -,SUP-DP08X8,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1126.45,788.515,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
PATCH BOVINE 2 X 9 DURAVESS PERICARDIUM -,SUP-DP2X9,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1655.24,1158.668,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT VASC 4-7MM 45CM ACUSEAL -,SUP-ECH470045A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6675.81,4673.067,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT ZENITH FLEX LEG 20X56 -,SUP-G55241,CDM,C1768,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT GORE PROPATEN 6 X 40 -,SUP-H060040A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4766.01,3336.207,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT GORE H470045A -,SUP-H470045A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5661.5,3963.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
PROPATEN AXILLO BIFEMORAL VASC GRAFT -,SUP-HAX02A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,17306.29,12114.403,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT VASC 26X34MM SKRT 15CM CARDIOROOT 26MM SKRT 10MM CLLR -,SUP-HEWROOT0026,CDM,C1768,HCPCS,278,RC,,,outpatient,,,8640.74,6048.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT VASC 6MM 70CM HEMAGARD STR 0.49MM KNTD RVRS LOCKNIT -,SUP-HGK000670,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2112.2,1478.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT VASC PROPATEN 6 X 80 -,SUP-HT066080A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10957.06,7669.942,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
PROPATEN VASCULAR GRAFT 7MM X 80CM -,SUP-HT076080A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10957.06,7669.942,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT PROPATEN 8 X 70 -,SUP-HT087080A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,11287.52,7901.264,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT FUSION BIOLINE 6 X 80 RING SUPPORTED -,SUP-M00201503086B0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10403.74,7282.618,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT CARDIOVASCULAR HEMASHIELD GOLD MDV BIF 14X7 40CM -,SUP-M002020851470,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT 16X8 40CM HEMA BIF MDV -,SUP-M002020851680,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT HEMA MDV BIF 18X9 40CM -,SUP-M002020851890,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT HEMA MDV BIF 22X11X40 -,SUP-M002020852210,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT HEMASHIELD D:6MM L:15CM GOLD -,SUP-M002020951060,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1879.03,1315.321,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT HEMASHIELD D:8MM L:15CM GOLD -,SUP-M002020951080,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1879.03,1315.321,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT HEMASHIELD D:10MM L:30CM GOLD -,SUP-M002020954100,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2538.41,1776.887,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT HEMASHIELD GOLD 10MM X 30CM -,SUP-M002020954100,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2538.41,1776.887,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT VASC 8MM 30CM HEMASHLD PLTNM STR WVN DBL VELR AOR BVN -,SUP-M00202175208P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2473.41,1731.387,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT HEMASHIELD 22MM X 30CM -,SUP-M00202175422P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2644.27,1850.989,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT HEMASHIELD D:24MM L:30CM -,SUP-M00202175424P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2644.27,1850.989,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT HEMASHIELD D:26MM L:30CM -,SUP-M00202175426P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT HEMASHIELD D:30MM L:30CM -,SUP-M00202175430P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT HEMASHIELD D:32MM L:30CM -,SUP-M00202175432P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
PERICARDIUM PERIGUARD 6X8 -,SUP-PC0608SNBIO,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2602.81,1821.967,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
PERICARDIUM PEROGIARD 8X14 -,SUP-PC0814SNBIO,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3079.33,2155.531,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT VASC 6MM 40CM GORE-TEX STR 30CM RNG SECT THNWL STRCH -,SUP-RRT06030040L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3933.78,2753.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT VASC 6MM 70CM GORE-TEX STR 60CM RNG SECT THNWL STRCH -,SUP-RRT06060070L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5648.76,3954.132,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT VASC 8MM 40CM GORE-TEX STR 30CM RNG SECT THNWL STRCH -,SUP-RRT08030040L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3933.78,2753.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT VASC 6MM 50CM GORE-TEX STR STD WL STRCH EPTFE -,SUP-S0605,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3403.86,2382.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT VASC 14X7MM 40CM GORE-TEX BIFUR THNWL STRCH EPTFE -,SUP-SBT1401D,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4303.42,3012.394,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT VASC 16X8MM 40CM GORE-TEX BIFUR THNWL STRCH -,SUP-SBT1601,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4000.61,2800.427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
STRETCH THIN WALL BIFURCATED GRAFT 16-8MM X 50CM -,SUP-SBT1602D,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5377.15,3764.005,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT VASC 8MM 40CM GORE-TEX STR THNWL STRCH LN REM RNG AOR -,SUP-SRRT08030040L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4387.31,3071.117,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT VASC 8MM 80CM GORE-TEX STR 70CM RNG SECT THNWL -,SUP-SRRT08070080L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,7032.31,4922.617,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT VASC 6MM 40CM GORE-TEX STR THNWL STRCH AOR EPTFE -,SUP-ST0604,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3232,2262.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT VASC 6MM 80CM GORE-TEX -,SUP-ST0608,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5330.46,3731.322,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
AORTIC BODY ALTO TM ABDOMINAL STENT GRAFT -,SUP-TV-AB2080-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
ALTO ABDOMINAL STENT GRAFT SYSTEM 23MM -,SUP-TV-AB2380-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
ALTO ABDOMINAL STENT GRAFT SYSTEM 26MM -,SUP-TV-AB2680-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
OVATION IX ABDOMINAL STENT GRAFT SYSTEM 29MM ALTO -,SUP-TV-AB2980-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
ALTO ABDOMINAL STENT GRAFT SYSTEM 34MM -,SUP-TV-AB3480-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
ILIAC GRAFT OVATION IX 10 X 160MM -,SUP-TV-IL1410160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT STENT TRIVASCULAR OVATION IX 12 X 140 ILIAC LIMB -,SUP-TV-IL1412140-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
ILIAC GRAFT 14 X 100MM -,SUP-TV-IL1414100-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
OVATION IX ILAC STENT GRAFT 14 X 160MM -,SUP-TV-IL1414160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
OVATION IX ILIAC STENT GRAFT 18MM X 140MM -,SUP-TV-IL1418140-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT STENT OVATION IX ILIAC LIMB 18 X 160MM -,SUP-TV-IL1418160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
OVATION IX 22 X 100MM -,SUP-TV-IL1422100-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT STENT TRIVASCULAR OVATION IX 28 X 120 ILIAC LIMB -,SUP-TV-IL1428120-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT STENT TRIVASCULAR OVATION IX 28 X 160 ILIAC LIMB -,SUP-TV-IL1428160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT HUM TIS VEIN CRYPRSR CRYOVEIN SAPHENOUS -,SUP-V010,CDM,C1768,HCPCS,278,RC,,,outpatient,,,30011.06,21007.742,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT VASC 6MM 50CM VENAFLO II STR CRBN IMPREG EPTFE CUF -,SUP-VL5006C,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6999.2,4899.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GRAFT VASC 6MM 80CM GORE-TEX THNWL LN EPTFE -,SUP-VT06080L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4621.23,3234.861,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,51.089465,30693.4272,other,Non-Reimbursable List,,
GUIDEWIRE SPRING TIP REUSABLE MARKED -,SUP-000150,CDM,C1769,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.038INX260CM 3MM JTP TAPR FXCR STD PTFE-CTD 6CM -,SUP-00-8634,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.43,38.801,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW CATH 0.025IN GW LNR SS PTFE-CTD -,SUP-0684-00-0254-09,CDM,C1769,HCPCS,272,RC,,,outpatient,,,123.7,86.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX300CM HTORQ ALL STAR STR XTR SUPP INTMD -,SUP-1001741,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
HI-TORQUE SUPRACORE 35 (300cm) -,SUP-1002703-02,CDM,C1769,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.018INX190CM HTORQ STLCOR 18 STR FLXB SFT SS MICGLD -,SUP-1003281,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.018INX300CM HTORQ STLCOR 18 STR FLXB SFT SS MICGLD -,SUP-1003282,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX190CM HTORQ XIT 100XT STR SS/CTD 3CM 1.7GM -,SUP-1003309H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
SPARTA CORE 190CM ST -,SUP-1005202,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
SPARTACORE 14 WIRE (0.014IN- 300CM) -,SUP-1005203,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX190CM HTORQ SPARTACORE STR SFT SS SHFT -,SUP-1005205,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX300CM HTORQ SPARTACORE STR SFT SS SHFT -,SUP-1005206,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX190CM HTORQ  WHISPER MS STR SFT DURASTEEL -,SUP-1005357H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX300CM HTORQ WHISPER MS STR SFT DURASTEEL/ -,SUP-1005359H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX190CM HTORQ BAL MDWT UNIV STR RBN INTMD -,SUP-1009660,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDEWIRE HI-TORQUE BALANCE MIDDLEWEIGHT UNIVERSAL II 190CM -,SUP-1009664,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX190CM HTORQ PILOT 50 STR SFT DURASTEEL/ -,SUP-1010480-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX190CM HTORQ PILOT 150 STR STF DURASTEEL/ -,SUP-1010481-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX190CM HTORQ PILOT 200 STR DURASTEEL/ SS/CTD -,SUP-1010482-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX300CM HTORQ PILOT 50 STR SFT DURASTEEL/ -,SUP-1010483-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX300CM HTORQ PILOT 150 STR DURASTEEL/ SS/CTD -,SUP-1010484-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX300CM HTORQ PILOT 200 STR SFT DURASTEEL -,SUP-1010485-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
HI-TORQUE WHISPER GUIDE WIRE -,SUP-1011835H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX180CM ASAHI FIELDER F C STR XTR SUPP CTD 3CM -,SUP-1011895-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDEWIRE HI-TORQUE COMMAND 18 ST WORKHORSE 0.018IN x 210CM -,SUP-1013730,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.018INX300CM HTORQ COMMAND ES SS/NTNL/CTD 30CM -,SUP-1013731,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDEWIRE VERRATA 185 CM STRAIGHT TIP -,SUP-10185,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDEWIRE VERRATA 185 CM J-TIP -,SUP-10185J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDEWIRE VERRATA PLUS 185 CM J-TIP -,SUP-10185JP,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDEWIRE VERRATA 300 CM STRAIGHT TIP -,SUP-10300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDEWIRE VERRATA 300 CM J-TIP -,SUP-10300J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDEWIRE VERRATA PLUS 300 CM J-TIP -,SUP-10300JP,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDEWIRE VERRATA PLUS 300 CM STRAIGHT TIP -,SUP-10300P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
ST INTUB 11FRX110CM RTRGD 0.38IN STR/3MM J WG INTRO NDL SYR -,SUP-110-70-38J-110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1022.29,715.603,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INSHRTX182CM CHC STR SPR COIL HYDRCT SS -,SUP-12132-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,480.8,336.56,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDEWIRE ASAHI PROWATER 180 L -,SUP-12776-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX300CM ASAHI MIRACLEBROS 3 STR STEER FLXB SS -,SUP-14937-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW URO 0.38IN NTNL -,SUP-150NSA38,CDM,C1769,HCPCS,272,RC,,,outpatient,,,221.73,155.211,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW URO 0.038INX150CM NICORE NTNL HYDRCT STR STF COR -,SUP-150NSS38,CDM,C1769,HCPCS,272,RC,,,outpatient,,,221.73,155.211,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.009INX180CM ASAHI CONFIANZA PRO PTCA STR STEER -,SUP-20629-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDEWIRE VASCULAR HI-TORQUE COMMAND 0.014IN X 190CM -,SUP-2078174,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX300CM HTORQ COMMAND ES SS/NTNL/CTD 30CM -,SUP-2078175,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014IN/0.018IN DIA 145CM -,SUP-22260,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX190CM HTORQ FLPY II JTP RBN LGT SUPP SFT SS -,SUP-22339MJ,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX300CM HTORQ FLPY II STR RBN LGT SUPP SFT SS -,SUP-22359M,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX300CM HTORQ FLPY II JTP RBN LGT SUPP SFT SS -,SUP-22359MJ,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX300CM HTORQ WIGGLE STR RBN SS HYDRPHB -,SUP-22359M-W2,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX300CM HTORQ TRAV STR STD SHFT SS/CTD 3CM -,SUP-22379H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WIRE FLTR DLV BAREWIRE 0.014INX315CM SS COR PTFE-CTD -,SUP-22440-31,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX180CM RUNTHROUGH NS STR STEER EXTEND WIRE SS -,SUP-25-1011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX300CM RUNTHROUGH NS STR WIRE SS -,SUP-25-1013,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDE WIRE PTCA RUNTHROUGH NS HYPERCOAT 0.014X180CM -,SUP-25-3011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX150CM RUNTHROUGH NS STEER EXTEND WIRE SS -,SUP-25-9092,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.035INX260CM STR FXCR PTFE-CTD -,SUP-395369,CDM,C1769,HCPCS,272,RC,,,outpatient,,,218.81,153.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.035INX200CM STR FXCR PTFE-CTD -,SUP-395703,CDM,C1769,HCPCS,272,RC,,,outpatient,,,218.81,153.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC GUIDERIGHT 0.035INX150CM  3MM J REF:404570 -,SUP-404570,CDM,C1769,HCPCS,272,RC,,,outpatient,,,40.85,28.595,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDEWIRE GUIDERIGHT 3 MM J CURVE  L180 CM L5 CM OD.035 -,SUP-404571,CDM,C1769,HCPCS,272,RC,,,outpatient,,,43.76,30.632,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDEWIRE VASCULAR GUIDERIGHT J CURVE L260 CM L5 CM OD.35 -,SUP-404577,CDM,C1769,HCPCS,272,RC,,,outpatient,,,93.36,65.352,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDEWIRE VASCULAR GUIDERIGHT BENTSON L150 CM L15 CM OD.035 -,SUP-404843,CDM,C1769,HCPCS,272,RC,,,outpatient,,,54.27,37.989,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 190CM WHISPER VW HTORQ -,SUP-4483,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC WHISPER VW HTORQ -,SUP-4639,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDEWIRE EMERALD 0.35INx260CM J TIP  FLEX FIXED CORE PTFE -,SUP-502455,CDM,C1769,HCPCS,272,RC,,,outpatient,,,52.52,36.764,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.038INX150CM EMERLD 3MM JTP FXCR FLXB STD PTFE-CTD -,SUP-502-520,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.14,38.598,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.032INX150CM EMERLD 3MM JTP FXCR FLXB STD PTFE-CTD -,SUP-502-526,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.14,38.598,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.035INX150CM EMERLD STR FXCR FLXB STD PTFE-CTD 7CM -,SUP-502-542,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.14,38.598,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.035INX300CM STORQ ANG STEER 1PC COR SFT SGL OUTR -,SUP-503-356Y,CDM,C1769,HCPCS,272,RC,,,outpatient,,,404.37,283.059,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX300CM STBR + STR STEER S-SFT 3CM -,SUP-507-114X,CDM,C1769,HCPCS,272,RC,,,outpatient,,,349.22,244.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX300CM STBR XS STR STEER XTR SUPP SFT -,SUP-527-300E,CDM,C1769,HCPCS,272,RC,,,outpatient,,,560.16,392.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
PLATE LEFT ANTER LATERAL -,SUP-630111,CDM,C1769,HCPCS,272,RC,,,outpatient,,,10381.67,7267.169,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDEWIRE WARRIOR 200CM REF: 7388 -,SUP-7388,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1131.99,792.393,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDEWIRE R350 350CM REF: 7390 -,SUP-7390,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1367.53,957.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDEWIRE BANDIT 200CM REF: 7444 -,SUP-7444,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1131.99,792.393,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WIRE GUIDE .035X260 STIFF SUPER -,SUP-80129-406,CDM,C1769,HCPCS,272,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX300CM ASAHI PROWATER FLEX STR FLXB SPR COIL -,SUP-82358-02,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
"GUIDEWIRE 0.014"" X300CM PTCA STRAIGHT -",SUP-82902-02,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
PRESSURE GUIDEWIRE OMNIWIRE 185CM STRAIGHT TIP REF:89185 -,SUP-89185,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
PRESSURE GUIDEWIRE OMNIWIRE 185CM J-TIP REF:89185J -,SUP-89185J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.035INX260CM AMPLATZER MOD 1.5MM JTP NOODLEWIRE -,SUP-9-GW-002,CDM,C1769,HCPCS,272,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
EXTENSION GW ASAHI -,SUP-AG14900-0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDEWIRE VASCULAR MIRACLEBROS 6 L180 CM OD.014 IN STERILE L -,SUP-AG14M060,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDEWIRE ASAHI MIRACLEBROS 6 300CM DUPLICATE -,SUP-AG14M360,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
W VASC 0.014INX300CM ASAHI MIRACLEBROS 12 STR STEER FLXB SS -,SUP-AG14M370,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX300CM ASAHI CONFIANZA 9 STR XTR SUPP SPR -,SUP-AGH143390,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDEWIRE ASAHI PROWATER 300 CM .014 -,SUP-AGH146300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.009INX180CM ASAHI FIELDER F C PTCA JTP 1.2GM LD -,SUP-AGP1400-01J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.009INX190CM ASAHI FIELDER XT STR SPR COIL -,SUP-AGP140002,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.009INX300CM ASAHI FIELDER XT STR SPR COIL -,SUP-AGP140302,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDE WIRE ASAHI SION BLUE 180/190CM -,SUP-AHW14R004S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GAIA FIRST 190CM MICRO J -,SUP-AHW14R007P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GAIA SECOND 190CM MICRO J -,SUP-AHW14R008P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GAIA THIRD 190CM MICRO J -,SUP-AHW14R011P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX300CM ASAHI SOFT STR STEER COR-TO-TIP SS -,SUP-AHW14R304S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,490.14,343.098,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW GLADIUS MONGO190CM REF: AP14R023S -,SUP-AP14R023S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW FIELDER XT-A 190CM REF: APW14R009S -,SUP-APW14R009S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDE WIRE ASAHI SION BLACK 190CM STRAIGHT REF:APW14R010S -,SUP-APW14R010S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,566,396.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDE WIRE DOUBLE ENDED TROCAR .86MM -,SUP-AR-8737-39KD,CDM,C1769,HCPCS,272,RC,,,outpatient,,,175.05,122.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.018INX25CM 2FLX STR DBL END SPR WIRE SS -,SUP-AW-04018,CDM,C1769,HCPCS,272,RC,,,outpatient,,,53.92,37.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDE SPRING WIRE .018D 25CM -,SUP-AW-04018,CDM,C1769,HCPCS,272,RC,,,outpatient,,,53.92,37.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
"GUIDE SPRING WIRE .032"" -",SUP-AW-04432,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.08,38.556,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 175CM PRESSUREWIRE CERTUS SS NTNL PTFE-CTD -,SUP-C12008,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
PRESSUREWIRE X GUIDEWIRE 0.014INX175CM -,SUP-C12059,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 300CM PRESSUREWIRE CERTUS STEER CTD -,SUP-C12308,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
PRESSUREWIRE X GUIDEWIRE .014MMX300CM -,SUP-C12358,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.035INX260CM TIGRWRE ANG TAPR STEER FLXB FLPY SFT -,SUP-C405085,CDM,C1769,HCPCS,272,RC,,,outpatient,,,390.95,273.665,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.035INX180CM TIGRWRE ANG TAPR STEER FLXB FLPY SFT -,SUP-C405086,CDM,C1769,HCPCS,272,RC,,,outpatient,,,390.95,273.665,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
INTRO LAP 6MM SHTH 18GA 50CM -,SUP-C-LASS-6-10,CDM,C1769,HCPCS,272,RC,,,outpatient,,,431.79,302.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
ST CRICO MLKR 5MM PTFE XSTIF WG ENTRY NDLHLDR CUP GZE -,SUP-C-TCCSB-500-UNI,CDM,C1769,HCPCS,272,RC,,,outpatient,,,2450.49,1715.343,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
CPS EXCEL MEDIGUIDE MEDIUM GUIDEWIRE -,SUP-DS2M028,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
CPS EXCEL MEDIGUIDE STIFF GUIDEWIRE -,SUP-DS2M029,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
MEDIGUIDE GUIDEWIRE TORQUE CLIP -,SUP-DS2M030,CDM,C1769,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.035INX145CM STR 3MM JTP DBL END FLPY SS HEP -,SUP-G00362,CDM,C1769,HCPCS,272,RC,,,outpatient,,,93.3,65.31,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
W 15J .035 145CM x 15MM CURVE -,SUP-G00509,CDM,C1769,HCPCS,272,RC,,,outpatient,,,67.04,46.928,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.035INX145CM 3MM JTP CRV FXCR STD FLXB SS NO HEP -,SUP-G00511,CDM,C1769,HCPCS,272,RC,,,outpatient,,,67.04,46.928,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WIRE GUIDE .035 260 SAFE-T-J T -,SUP-G00517,CDM,C1769,HCPCS,272,RC,,,outpatient,,,104.97,73.479,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.035INX50CM 3MM NWTN JTP FNGR STR FXCR FLXB FLPY -,SUP-G00524,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.63,57.141,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WIRE GUIDE FIXED CORE 3MM J CURVED -,SUP-G00524,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.63,57.141,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.038INX145CM 3MM JTP FXCR FLXB SS HEP PTFE-CTD 6CM -,SUP-G00541,CDM,C1769,HCPCS,272,RC,,,outpatient,,,67.04,46.928,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WIRE GUIDE FIXED CORE STRAIGHT -,SUP-G00650,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.37,38.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
W BENTSON .035 145CM -,SUP-G00691,CDM,C1769,HCPCS,272,RC,,,outpatient,,,87.47,61.229,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.035INX180CM SAFE-T-J-TIP FXCR FLPY SS PTFE-CTD -,SUP-G00902,CDM,C1769,HCPCS,272,RC,,,outpatient,,,72.88,51.016,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
W .035 260 BENTSON TSFB-35-260 -,SUP-G01063,CDM,C1769,HCPCS,272,RC,,,outpatient,,,116.64,81.648,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.035INX260CM CRV RSN TIP FXCR FLPY W/OUT HEP -,SUP-G01253,CDM,C1769,HCPCS,272,RC,,,outpatient,,,104.97,73.479,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
THSCF 35 260 1.5 ROSEN 43700 -,SUP-G01253,CDM,C1769,HCPCS,272,RC,,,outpatient,,,104.97,73.479,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
W THSCF-35-180-1.5 ROSEN WIRE -,SUP-G01264,CDM,C1769,HCPCS,272,RC,,,outpatient,,,78.71,55.097,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WTSFB-35-180 BENTSON -,SUP-G01290,CDM,C1769,HCPCS,272,RC,,,outpatient,,,96.22,67.354,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.025INX180CM 3MM JTP FXCR STD FLXB SS HEP PTFE-CTD -,SUP-G01602,CDM,C1769,HCPCS,272,RC,,,outpatient,,,84.55,59.185,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WIRE GUIDE 0.032 IN X180CM SAFE T JTP PTFE-C  - G02335 -,SUP-G02335,CDM,C1769,HCPCS,272,RC,,,outpatient,,,84.55,59.185,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WIRE GUIDE 0.032 IN X260CM SAFE T J HEAVY DUTY - G03133 -,SUP-G03133,CDM,C1769,HCPCS,272,RC,,,outpatient,,,294.61,206.227,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WIRE AMPLATZ  0.035 INX145CM J CRV TIP XSTIF FLPY SS -,SUP-G03203,CDM,C1769,HCPCS,272,RC,,,outpatient,,,169.16,118.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WIRE AMPLATZ  0.025 IN X 145 OR 180 CM SAFE-T-J XTR-STF -,SUP-G03304,CDM,C1769,HCPCS,272,RC,,,outpatient,,,457.99,320.593,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.035INX180CM AMP STR XSTIF SS PTFE-CTD 7CM TAPR 3CM -,SUP-G03330,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.31,89.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WIRE AMPLATZ 0.032 IN X180CM JTP XSTIF FLPY SS PTFE-CTD -,SUP-G03584,CDM,C1769,HCPCS,272,RC,,,outpatient,,,125.39,87.773,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.038INX80CM AMP STR XSTIF FLPY SS PTFE-CTD 9.5CM -,SUP-G04003,CDM,C1769,HCPCS,272,RC,,,outpatient,,,148.73,104.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
SET CRIC MELKER 3.5MM 3.8CM -,SUP-G06245,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1139.28,797.496,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDEWIRE ROADRUNNER EXTRA SUP -,SUP-G07640,CDM,C1769,HCPCS,272,RC,,,outpatient,,,676.8,473.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 60CM NTNL -,SUP-G08427,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.18,167.426,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
W PMG-18SP-60-COPE-NT -,SUP-G08427,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.18,167.426,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
W PMG-18SP-COPE-NT -,SUP-G08733,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.18,167.426,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
COPE WIRE 60CM ST -,SUP-G09395,CDM,C1769,HCPCS,272,RC,,,outpatient,,,262.52,183.764,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.035INX180CM AMP STR ULTRA STF FLPY SS PTFE-CTD -,SUP-G09956,CDM,C1769,HCPCS,272,RC,,,outpatient,,,119.56,83.692,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
SHORT TAPER AMPLATZ WIRE 1CM -,SUP-G23639,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.31,89.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WIREGLIDE AMPLATZ EXTRA STIFF 0.035 X 180CM -,SUP-G23639,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.31,89.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WIRE UNIGLIDE ANG .018 260CM -,SUP-G30489,CDM,C1769,HCPCS,272,RC,,,outpatient,,,251.48,176.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WIRE UNIGLIDE ANG. .035 260CM -,SUP-G30492,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WIRE UNIGLIDE SIFF STR .035 260CM -,SUP-G30496,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.018INX260CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-G30500,CDM,C1769,HCPCS,272,RC,,,outpatient,,,269.57,188.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WIRE UNIGLIDE STR .018 260CM -,SUP-G30500,CDM,C1769,HCPCS,272,RC,,,outpatient,,,269.57,188.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WIRE UNIGLIDE STR .035 260CM -,SUP-G30502,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WIRE UNIGLIDE STIFF ANG .035 260CM -,SUP-G30506,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.035INX260CM LNDRQST STR XSTIF FLXB SS PTFE-CTD 4CM -,SUP-G31453,CDM,C1769,HCPCS,272,RC,,,outpatient,,,919.6,643.72,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW ENDO 0.035INX260CM TRACER METRO DRCT -,SUP-G31914,CDM,C1769,HCPCS,272,RC,,,outpatient,,,770.22,539.154,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
ACROBAT STR WIRE GUIDE 260 .03 -,SUP-G34265,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1042.19,729.533,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
SET GASTRONOMY ENTUIT START INIT PLCMT SM FOR 12/14FR -,SUP-G34442,CDM,C1769,HCPCS,272,RC,,,outpatient,,,551.35,385.945,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WIRE GUIDE HIWIRE HYDROPHILIC ANGLED 35 -,SUP-G36284,CDM,C1769,HCPCS,272,RC,,,outpatient,,,215.3,150.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WIRE HI .035 X 150CM STIFF ANGLED -,SUP-G36290,CDM,C1769,HCPCS,272,RC,,,outpatient,,,215.3,150.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WIRE HI .035 X 260CM STIFF STRAIGHT -,SUP-G36327,CDM,C1769,HCPCS,272,RC,,,outpatient,,,308.08,215.656,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WIRE GUIDE EX-STIFF 35-300 LUN -,SUP-G45408,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1025.79,718.053,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.035INX450CM ACROBAT 2 CTD -,SUP-G47616,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1038.63,727.041,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX190CM PRO-LT NTNL/PTFE-CTD/SS/PD 8CM TAPR -,SUP-G47736,CDM,C1769,HCPCS,272,RC,,,outpatient,,,339.6,237.72,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
LUNDERQUIST WIRE 0.035 x 180CM -,SUP-G49228,CDM,C1769,HCPCS,272,RC,,,outpatient,,,593.41,415.387,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WIRE METRO TRACER .035 X 600 -,SUP-G50660,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX190CM CTO MICROWIRE FLPY SS/PTFE-CTD/PLTNM -,SUP-G50788,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
CATH CTO 25 GRAM X 014 X 190CM -,SUP-G50789,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
W CTO 6G CMW-14-300-6G -,SUP-G50790,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
W CTO 12G CMW-14-300-12G -,SUP-G50791,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
W CTO 18G GUIDE WIRE -,SUP-G50792,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
W CTO 25G -,SUP-G50793,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX190CM HYDR ST MICRO FLPY SS/PTFE-CTD/PLTNM -,SUP-G52938,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1038.57,726.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX300CM HYDR ST MICRO FLPY SS/PTFE-CTD/PLTNM -,SUP-G52939,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1038.57,726.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.018INX180CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-G56141,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WIRE UNIGLIDE STR .018 180CM -,SUP-G56141,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WIRE UNIGLIDE STR .035 180CM -,SUP-G56150,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
W GLIDE STIFF .035 180 STR -,SUP-G56153,CDM,C1769,HCPCS,272,RC,,,outpatient,,,308.15,215.705,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WIRE UNIGLIDE STIFF STR .035 180CM -,SUP-G56153,CDM,C1769,HCPCS,272,RC,,,outpatient,,,260.81,182.567,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WIRE UNIGLIDE ANG .018 180CM -,SUP-G56160,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WIRE UNIGLIDE STR .035 260CM -,SUP-G56174,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WIRE UNIGLIDE STIFF ANG .035 180CM -,SUP-G56177,CDM,C1769,HCPCS,272,RC,,,outpatient,,,260.81,182.567,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GLIDEWIRE ADV .014 300CM ANG -,SUP-GA1430,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
W GLIDE ADVANTAGE 300 .018 -,SUP-GA1830,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1431.14,1001.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.035INX150CM GLIDEWIR ADVANTG ANG STF SHFT FLXB STD -,SUP-GA3501,CDM,C1769,HCPCS,272,RC,,,outpatient,,,933.6,653.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
W GLIDE ADVANTAGE 260 .035 -,SUP-GA3502,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.018INX300CM GLIDEWIR GOLD 45DG ANG FLXB -,SUP-GM1831,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1115.94,781.158,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.018INX300CM GLIDEWIR 70DG ANG GOLDBAND FLXB TIP -,SUP-GM1832,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1115.94,781.158,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDEWIRE .018/180 STRAIGHT -,SUP-GR1803,CDM,C1769,HCPCS,272,RC,,,outpatient,,,354.24,247.968,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GLIDEWIRE .018 150 ANGLED -,SUP-GR1805,CDM,C1769,HCPCS,272,RC,,,outpatient,,,354.24,247.968,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WIRE GLIDEWIRE 0.018INX180CM ANG STD FLXB -,SUP-GR1806,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.018INX260CM GLIDEWIR ANG STF SHFT STD FLXB -,SUP-GR1807,CDM,C1769,HCPCS,272,RC,,,outpatient,,,251.48,176.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
W GLIDE .035 180 STR -,SUP-GR3503,CDM,C1769,HCPCS,272,RC,,,outpatient,,,261.7,183.19,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WIRE GLIDE .035 260 STR -,SUP-GR3504,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.035INX150CM GLIDEWIR ANG STF SHFT STD FLXB -,SUP-GR3506,CDM,C1769,HCPCS,272,RC,,,outpatient,,,194.95,136.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WIRE GLIDE .035 180 ANG  GR3508 -,SUP-GR3508,CDM,C1769,HCPCS,272,RC,,,outpatient,,,261.7,183.19,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WIRE GLIDE .035 260 ANGLED -,SUP-GR3509,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.038INX180CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-GR3803,CDM,C1769,HCPCS,272,RC,,,outpatient,,,261.7,183.19,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.038INX260CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-GR3804,CDM,C1769,HCPCS,272,RC,,,outpatient,,,292.57,204.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDEWIRE VASCULAR GLIDEWIRE NITINOL STRAIGHT 260CM -,SUP-GS3504,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WIRE GLIDE 0.035 IN X 80 CM ANG STIFF -,SUP-GS3505,CDM,C1769,HCPCS,272,RC,,,outpatient,,,297.59,208.313,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WIRE GLIDE STIFF .035 180CM -,SUP-GS3508,CDM,C1769,HCPCS,272,RC,,,outpatient,,,260.81,182.567,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDEWIRE VASCULAR GLIDEWIRE NITINOL HYDROPHILIC ANGLE 260CM -,SUP-GS3509,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.035INX270CM LINEARGUIDEV ANG PTFE-CTD -,SUP-G-V210-3527A,CDM,C1769,HCPCS,272,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC VIPERWIRE .014IN TIP X 325CM -,SUP-GWC-12325LG-FLP,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC VIPERWIRE W/FLEX TIP .014IN TIP X 325CM -,SUP-GWC-12325LG-FT,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX300CM MLMN STR SUPER RAIL SUPP FLXB SPR COIL -,SUP-H74912120012,CDM,C1769,HCPCS,272,RC,,,outpatient,,,480.8,336.56,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDEWIRE MAILMAN 182CM STRAIGHT TIP 0.014 -,SUP-H74912136011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,480.8,336.56,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.14X190CM PLTNM + STR SUPER RAIL SUPP INTMD SPR -,SUP-H74917511,CDM,C1769,HCPCS,272,RC,,,outpatient,,,485.59,339.913,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.035INX300CM PLTNM + STR SUPER RAIL SUPP INTMD SPR -,SUP-H74917521,CDM,C1769,HCPCS,272,RC,,,outpatient,,,485.61,339.927,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.018INX300CM PLTNM + STR SUPER RAIL SUPP INTMD SPR -,SUP-H74917541,CDM,C1769,HCPCS,272,RC,,,outpatient,,,485.61,339.927,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX300CM VCT 14 CTRL WIRE STR SHRT TAPR ICE CTD -,SUP-H74939216730010,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
PRESSURE WIRE COMET II -,SUP-H74939359110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3926.81,2748.767,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDEWIRE SAFARI2  0.035 x 0275 CM XSMALL CURVE -,SUP-H74939406XS1,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3007.62,2105.334,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX330CM RTBLTR RTWR FLXB FLPY SS/CTD 2.2CM -,SUP-H74939462005,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1518.31,1062.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.009INX330CM RTWR 1.5MM RSN JTP CRV STF XTR SUPP -,SUP-H74939463005,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1518.31,1062.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX300CM VCT 14 12GM CTRL WIRE STR LNG TAPR -,SUP-H74939470300120,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1219.12,853.384,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX300CM VCT 14 18GM CTRL WIRE STR LNG TAPR -,SUP-H74939470300180,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1219.12,853.384,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX300CM VCT 14 25GM CTRL WIRE STR LNG TAPR -,SUP-H74939471300250,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX300CM VCT 14 30GM CTRL WIRE STR LNG TAPR -,SUP-H74939471300300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
COMET FFR WIRE 555111 -,SUP-H7495551110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3414.6,2390.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX300CM STINGRAY CTD CONN -,SUP-H749M3004A0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1625.29,1137.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX145CM STINGRAY CTD CONN -,SUP-H749M3010A0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,521.24,364.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX185CM STINGRAY CTD CONN -,SUP-H749M3012A0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1789.24,1252.468,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX180CM INTUITION STR SS SIL CTD -,SUP-INTU180SS,CDM,C1769,HCPCS,272,RC,,,outpatient,,,169.22,118.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WIRE GUIDE .035 260 INQWIRE REF: IQ35F260J3 -,SUP-IQ35F260J3,CDM,C1769,HCPCS,272,RC,,,outpatient,,,59.63,41.741,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDEWIRE AMPLATZ INQWIRE 0.035 X 71IN STRAIGHT SHORT TIP -,SUP-IQA511,CDM,C1769,HCPCS,272,RC,,,outpatient,,,255.63,178.941,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.035INX150CM ZIPWIRE STR STEER STF SHFT FLXB -,SUP-M00146306B1,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.24,167.468,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW AMPLATZ 0.035INX180CM J-TIP SUPER STIFF -,SUP-M001465011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
AMPLATZ WIRE SUPER STIFF  0.035 X 260 J -,SUP-M001465021,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.035IN X 260CM SUPER STIFF AMP STR SHRT TAPR FLXB -,SUP-M001465091,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
W AMPLATZ SS ST 35 145 BX/5 GU -,SUP-M001465231,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.035INX145CM SUPER STIFF AMP STR SHRT TAPR STD -,SUP-M001465241,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.035INX180CM SUPER STIFF AMP STR STD STEER SHFT -,SUP-M001465251,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
W AMPL SS EXCHANGE 260 STR -,SUP-M001465261,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
MAGIC TORQUE DLVR GW .035/315CM -,SUP-M001465301,CDM,C1769,HCPCS,272,RC,,,outpatient,,,805.23,563.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
W TORQUE 35 180 MAGIC 46-591 -,SUP-M001465911,CDM,C1769,HCPCS,272,RC,,,outpatient,,,443.46,310.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDEWIRE MAGIC TORQUE STRAIGHT 35-260 -,SUP-M001465921,CDM,C1769,HCPCS,272,RC,,,outpatient,,,443.46,310.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.018INX260CM PLTNM + SHRT TAPR STEER STF SHFT FLXB -,SUP-M001466050,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WIRE PLATINUM PLUS PTFE .014 X -,SUP-M001467120,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
W CON V18 8 200 46-852 -,SUP-M001468520,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDEWIRE V18 18 300    46-854 -,SUP-M001468540,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.018INX200CM 12CM V-18 CTRL WIRE STR STEER SFT SCTN -,SUP-M001468580,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.035INX150CM STRTR 3MM J FNGR STR FXCR STD SPR COIL -,SUP-M001491181,CDM,C1769,HCPCS,272,RC,,,outpatient,,,70.02,49.014,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
J WIRE 0.035 X 180CM -,SUP-M001491201,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.69,57.183,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.035INX260CM STRTR 3MM J FNGR STR FXCR STD SPR COIL -,SUP-M001491211,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.69,57.183,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.018INX190CM THRUWAY STR SHRT TAPR STEER SFT FLXB -,SUP-M001492791,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.018INX300CM THRUWAY STR SHRT TAPR STEER SFT FLXB -,SUP-M001492831,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
BSX THRUWAY 190CM 0.014 WIRE -,SUP-M001492921,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WIRE THRUWAY .014 X 300 STR -,SUP-M001492971,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.016INX180CM FATHOM 16 STR STEER NTNL ALY/PLTNM -,SUP-M001509100,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1563.65,1094.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW ENDO 0.035INX180CM JGWR -,SUP-M00515171,CDM,C1769,HCPCS,272,RC,,,outpatient,,,735.47,514.829,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
NOVAGOLD .018/260 -,SUP-M00552000,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1082.39,757.673,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW ENDO 0.035INX260CM HYD JGWR STF SHFT -,SUP-M00556061,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
DREAMWIRE .035/260 -,SUP-M00556100,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
DREAMWIRE .035/260 ANGLED -,SUP-M00556110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
DREAMWIRE .035/260 STIFF -,SUP-M00556120,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
DREAMWIRE .035/450 -,SUP-M00556140,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW ENDO 0.035IN STD 450CM DREAMWIRE HI-PRFRM DIST TIP -,SUP-M00556141,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
DREAMWIRE ANGLED 0.035 X 450CM -,SUP-M00556150,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW ENDO 0.035INX450CM DREAMWIRE HIPERF STF -,SUP-M00556161,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
JAGWIRE .038 / 260CM STRIAGHT -,SUP-M00556620,CDM,C1769,HCPCS,272,RC,,,outpatient,,,594.64,416.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
JAG-REVOLUTION WIRE .025/260 -,SUP-M00557000,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WIRE JAG REVOLUTION .025/450 -,SUP-M00557021,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
TUBE PEG 24FR ENDOVIVE LPRO PUL LF -,SUP-M00566480,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
"SPHINTEROTOME JAGTOME RX 44 0.35"" X 260CM -",SUP-M00573040,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1685.56,1179.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDEWIRE .038 -,SUP-M0066201010,CDM,C1769,HCPCS,272,RC,,,outpatient,,,65.06,45.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW URO 0.035INX150CM ZIPWIRE NTNL COR HYDRCT STR STD SHFT -,SUP-M006630205B1,CDM,C1769,HCPCS,272,RC,,,outpatient,,,219.51,153.657,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDEWIRE SENSOR .038 ANGLED -,SUP-M0066703021,CDM,C1769,HCPCS,272,RC,,,outpatient,,,241.45,169.015,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDEWIRE SENSOR -,SUP-M0066703091,CDM,C1769,HCPCS,272,RC,,,outpatient,,,230.6,161.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW URO 0.018IN X 150CM STD ZIPWIRE STRAIGHT -,SUP-M0066802001,CDM,C1769,HCPCS,272,RC,,,outpatient,,,298.43,208.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GLIDEWIRE STRAIGHT STIFF .035 SS -,SUP-M0066802221,CDM,C1769,HCPCS,272,RC,,,outpatient,,,302.94,212.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GLIDEWIRE STRAIGHT .038 SS -,SUP-M0066802251,CDM,C1769,HCPCS,272,RC,,,outpatient,,,302.94,212.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GLIDEWIRE ANGLED .038 SS STIFF -,SUP-M0066802261,CDM,C1769,HCPCS,272,RC,,,outpatient,,,302.94,212.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.018INX40CM SS -,SUP-MAK001,CDM,C1769,HCPCS,272,RC,,,outpatient,,,114.37,80.059,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.018INX40CM NTNL PLTNM -,SUP-MAK001N,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.37,89.859,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW METRO TRACER .035 X 480 -,SUP-METII-35-480,CDM,C1769,HCPCS,272,RC,,,outpatient,,,770.22,539.154,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDEWIRE W/NITREX .018 80CM STRAIGHT -,SUP-N180801,CDM,C1769,HCPCS,272,RC,,,outpatient,,,348.82,244.174,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014/ 0.008INX300CM ASTATO XS 20 STR TAPR PTFE-CTD -,SUP-PAGH143392,CDM,C1769,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.0180.0 13INX300CM ASTATO 30 STR PTFE-CTD 15CM 30GM -,SUP-PAGH18M371,CDM,C1769,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX300CM REGALIA XS 1 STR STF SHFT FLXB SPR -,SUP-PAGP140300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
TUBE JEJUNAL 12FR X 60CM PEG24 -,SUP-PEGJ-12-24,CDM,C1769,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
PHOENIX .014 FLOPPY TIP WIRE EXTRA SUPPORT -,SUP-PG14300XF,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
PIGTAIL WIRE PRO TRACK 175CM -,SUP-PTW-25-175,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1120.32,784.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WIRE DX 0.025IN BD PIGTL 230CM PROTRACK -,SUP-PTW-25-230,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1120.32,784.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
ILLUMINATION RELIEVA LUMA SENTRY -,SUP-SIS-100B,CDM,C1769,HCPCS,272,RC,,,outpatient,,,2273.91,1591.737,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDEWIRE 0.014 TCAR ENROUTE -,SUP-SR-014-GW,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WIRE SAFESEPT TRASEPTAL  0.014INX135CM -,SUP-SS-135,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1102.82,771.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
PK PROC CUST CARD CATHETERISATION LAB SLHSFR -,SUP-STLM004-13,CDM,C1769,HCPCS,272,RC,,,outpatient,,,288.66,202.062,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
DEVICE TRQ SGL HND F/0.010-0.038IN GW MUL-TRQ VISE STRL -,SUP-TD01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,38.34,26.838,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WIRE AMPLATZ 0.035 IN X 260CM CRV TIP XSTIF FLXB SS PTFE-CTD -,SUP-THSCF-025-260-3,CDM,C1769,HCPCS,272,RC,,,outpatient,,,166.24,116.368,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.032INX260CM AMP CRV JTP XSTIF FLPY SS PTFE-CTD 8CM -,SUP-THSCF322603AES,CDM,C1769,HCPCS,272,RC,,,outpatient,,,166.24,116.368,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.035INX145CM CRV RSN TIP FXCR FLXB FLPY SS PTFE-CTD -,SUP-THSCF351451.5R,CDM,C1769,HCPCS,272,RC,,,outpatient,,,78.71,55.097,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDE WIRE TORAY TRG-25230 -,SUP-TRG-25230,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.021INX180CM 3MM JTP FXCR FLXB SS PTFE-CTD 7CM TAPR -,SUP-TSCF-21-180-3BH,CDM,C1769,HCPCS,272,RC,,,outpatient,,,96.04,67.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.035INX180CM 3MM JTP FXCR FLXB SS HEP PTFE-CTD 6CM -,SUP-TSCF-35-180-3,CDM,C1769,HCPCS,272,RC,,,outpatient,,,72.88,51.016,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.035INX260CM LNDRQST FLXB LO SURF FRCTN EXTEND CRV -,SUP-TSCMG35260ELESD,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1025.79,718.053,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
WIRE GUIDE LUNDERQUIST .035 -,SUP-TSCMG35260LESDC,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1025.79,718.053,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC HTORQ WHISPER VW EDS -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
LOOP TIP WIRE GUIDE .035 X 480 -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1085.31,759.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
W MOVEABLE CORE 1.5J 035 145CM -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,151.71,106.197,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
W MOVEABLE CORE 3J 035 145CM -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,151.71,106.197,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDE WIRE VIPER .014 TIP -,SUP-VPR-GW-14,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GUIDE WIRE VIPER .017 335CM -,SUP-VPR-GW-FLEX18,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
GW VASC 0.014INX180CM ZINGER LS RSN JTP CRV LGT SUPP FRMG -,SUP-ZNGRLS180J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,169.22,118.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.60733,7443.65739,other,Non-Reimbursable List,,
COIL MRI ENDORECTAL DISP BPX15 -,SUP-BPX 15,CDM,C1770,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,144.095325,460.20645,other,Non-Reimbursable List,,
SYS SLING MALE VIRTUE -,SUP-50020,CDM,C1771,HCPCS,278,RC,,,outpatient,,,20164.56,14115.192,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,248.891925,15486.38208,other,Non-Reimbursable List,,
SLING SINGLE INCISION ALTIS -,SUP-519650,CDM,C1771,HCPCS,278,RC,,,outpatient,,,6206.85,4344.795,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,248.891925,15486.38208,other,Non-Reimbursable List,,
SYS SLING URETH ADVANCE MALE 3.55X36CM NABSB MSH NDLHLDRX2 -,SUP-720088-01,CDM,C1771,HCPCS,278,RC,,,outpatient,,,18026.62,12618.634,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,248.891925,15486.38208,other,Non-Reimbursable List,,
MESH SURG MINI ARC SLNG -,SUP-720095-01,CDM,C1771,HCPCS,278,RC,,,outpatient,,,5623.3,3936.31,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,248.891925,15486.38208,other,Non-Reimbursable List,,
MESH MINI ARC SLING PRECISE - DISCONTINUED -,SUP-720191-01,CDM,C1771,HCPCS,278,RC,,,outpatient,,,6578.45,4604.915,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,248.891925,15486.38208,other,Non-Reimbursable List,,
PROSTHESIS PENL MONARCH + 1.1CMX35CM SAL FIL CYL NABSB -,SUP-724041-93,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4807.35,3365.145,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,248.891925,15486.38208,other,Non-Reimbursable List,,
SLING GYN TVT PP 1.1X45CM URETH FEM MECH CUT -,SUP-810041B,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4965.48,3475.836,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,248.891925,15486.38208,other,Non-Reimbursable List,,
KIT TRANS OBTURATOR W TAPE INC -,SUP-93-4001,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4720.05,3304.035,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,248.891925,15486.38208,other,Non-Reimbursable List,,
ANCHORSURE SACROSPINOUS LIGAMENT FIXATION -,SUP-A-SURE,CDM,C1771,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,248.891925,15486.38208,other,Non-Reimbursable List,,
NEOMEDIC ANCHORSURE ANCHOR SYSTEM 2 ANCHORS -,SUP-A-SURE02,CDM,C1771,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,248.891925,15486.38208,other,Non-Reimbursable List,,
SLING URETH PP NABSB FEM -,SUP-M006850200051,CDM,C1771,HCPCS,278,RC,,,outpatient,,,3571.91,2500.337,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,248.891925,15486.38208,other,Non-Reimbursable List,,
SLING ADVANTAGE TRAN VAGINAL -,SUP-M0068502110,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4616.84,3231.788,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,248.891925,15486.38208,other,Non-Reimbursable List,,
SLING GYN ADVANTG FIT PP TRNVAG MI D URETH FEM -,SUP-M0068502110,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4616.84,3231.788,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,248.891925,15486.38208,other,Non-Reimbursable List,,
SLING LYNX MID URETHRAL SUPRAPUBIC BLUE SYSTEM -,SUP-M0068503010,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4439.29,3107.503,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,248.891925,15486.38208,other,Non-Reimbursable List,,
SLING GYN OBTRYX II -,SUP-M0068505110,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4420,3094,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,248.891925,15486.38208,other,Non-Reimbursable List,,
SLING GYN SOLYX SGL-INCS -,SUP-ML00001621,CDM,C1771,HCPCS,278,RC,,,outpatient,,,5030.63,3521.441,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,248.891925,15486.38208,other,Non-Reimbursable List,,
PUMP IT 87.5MM 19.5MM 20ML 165/185 GM EMTY/FUL 0.22UM FLTR -,SUP-8637-20,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29090.86,20363.602,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,23012.49024,other,SI=N Exclusions ,,
PUMP IT 87.5X26MM THK 40ML 175/215 GM EMTY/FUL 0.22UM FLTR -,SUP-8637-40,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29090.86,20363.602,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,23012.49024,other,SI=N Exclusions ,,
PUMP 8667-20 SYNCHROMEDIII INFUSION 20ML -,SUP-8667-20,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29964.18,20974.926,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,23012.49024,other,SI=N Exclusions ,,
PUMP 8667-40 SYNCHROMEDIII INFUSION 40ML -,SUP-8667-40,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29964.18,20974.926,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,23012.49024,other,SI=N Exclusions ,,
TIGHTRAIL SUB-C  9FR 560-009 -,SUP-560-009,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7193.58,5035.506,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List,,
TIGHTRAIL SUB-C 11FR 560-011 -,SUP-560-011,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7830.18,5481.126,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List,,
TIGHTRAIL SUB-C 13FR 560-013 -,SUP-560-013,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7830.18,5481.126,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List,,
SHEATH CATH DLV 10FRX80CM AMPLATZER TORQVUE VASC 45DG ANG -,SUP-9-ATV10F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List,,
SHEATH CATH DLV 9FRX80CM AMPLATZER TORQVUE VASC 45DG ANG SFT -,SUP-9-EITV09F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List,,
SHEATH CATH DLV 12FRX80CM AMPLATZER TORQVUE VASC 45DG ANG -,SUP-9-EITV12F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List,,
SYSTEM AMPLATZER DELIVERY TORQVUE 9-ITV06F 180/80 -,SUP-9-ITV06F 180/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,3909.91,2736.937,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List,,
SHEATH CATH DLV 6FRX60CM AMPLATZER TORQVUE VASC 45DG ANG SFT -,SUP-9-ITV06F45/60,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List,,
SHEATH CATH DLV 7FRX80CM AMPLATZER TORQVUE VASC 180DG ANG -,SUP-9-ITV07F180/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List,,
SHEATH CATH DLV 7FRX80CM AMPLATZER TORQVUE VASC 45DG ANG SFT -,SUP-9-ITV07F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List,,
SHEATH CATH DLV AMPLATZER TORQVUE/TREVISIO VASC 45DG ANG SFT -,SUP-9-ITV08F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List,,
SHEATH CATH DLV 9FRX80CM AMPLATZER TORQVUE VASC 45DG ANG -,SUP-9-ITV09F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List,,
SHEATH CATH DLV 12FRX80CM AMPLATZER TORQVUE VASC 45DG ANG- -,SUP-9-ITV12F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List,,
AMPLATZER TALISMAN DELIVERY SHEATH 8F 80 -,SUP-9-TDS-08F45-80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List,,
AMPLATZER TALISMAN DELIVERY SHEATH 9FR 80 -,SUP-9-TDS-09F45-80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List,,
COMP LOADING SYS CLS-3000- 18F -,SUP-CLS-3000-18F-US,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2067.2,1447.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List,,
VALVE DEL SYS COMM 26/29/31 -,SUP-DCS-C4-18F-US,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List,,
CATH DELIVERY EVOLUT FX 23-29 REF: D-EVOLUTFX-2329 -,SUP-D-EVOLUTFX-2329,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List,,
CATH DELIVERY EVOLUT FX 34 REF: D-EVOLUTFX-34 -,SUP-D-EVOLUTFX-34,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List,,
CATH DELIVERY EVPROP2329US -,SUP-D-EVPROP2329US,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List,,
SNARE ENSNARE SYSTEM 9-15 120 -,SUP-EN2006015,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1779.27,1245.489,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List,,
SNARE ENSNARE 18 30 CM -,SUP-EN2007030,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List,,
SNARE VASC EN SNR 27-45MM 7FR CATH 120CM 3 PREFRM LOOP NTNL -,SUP-EN2007045,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2644.95,1851.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List,,
GTRS-200-RB RETREIVAL SET TULI -,SUP-G13287,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1590.1,1113.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List,,
EXTRACTION TOOL 13FR MANUAL CONTROL ROTATION DILATOR SHEATH -,SUP-G23747,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7285.21,5099.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List,,
SHEATH DILATOR 11FR EVOLUTION SHORTIE RL PERC -,SUP-G23749,CDM,C1773,HCPCS,272,RC,,,outpatient,,,5843.14,4090.198,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List,,
SNARE VASC EYE SNR 13MMX94CM FLSH PRT NTNL 16FR WRKSTN -,SUP-G26517,CDM,C1773,HCPCS,272,RC,,,outpatient,,,5674.23,3971.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List,,
SNARE VASC AMP GOOSENECK 15MM/6FR LOOP/CATH 120CM GOLD TUNG -,SUP-GN1500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List,,
SNARE EV AMP GOOSENECK 20X120MM GOLD TUNG NTNL 6FRX102CM -,SUP-GN2000,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List,,
SNARE VASC AMP GOOSENECK 25MM/6FR LOOP/CATH 120CM GOLD TUNG -,SUP-GN2500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List,,
KIT GOOSE NECK SNARE 25MM LOOP -,SUP-GN3000,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List,,
SNARE GOOSENECK GN3500 -,SUP-GN3500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List,,
SNARE AMPLATZ GN 5MM -,SUP-GN500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List,,
STYLET LD LIBERATOR 140CM -,SUP-LR-OFA01,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2639.4,1847.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List,,
CATHETER INTRODUCER AVEIR 50CM REF:LSN25501 -,SUP-LSN25501,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List,,
BASKET STONE SEGURA -,SUP-M0063801120,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1030.93,721.651,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List,,
SNARE ONE700 175CM 7MM LOOP -,SUP-ONE700,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2851.99,1996.393,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List,,
SNARE ONE701 200CM 7MM LOOP -,SUP-ONE701,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2959.88,2071.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List,,
SNARE VASC AMP GOOSENECK 7X175MM GOLD TUNG NTNL -,SUP-SK700,CDM,C1773,HCPCS,272,RC,,,outpatient,,,3126.44,2188.508,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,231.443785,6420.62028,other,Non-Reimbursable List,,
HEAD FEM 12/ 1440MMX3.5MM NK TAPR -,SUP-00080184001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 40MM -,SUP-00080184002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 15X190MM WAGNER SL REVISN PROTASUL-100 POR CTD -,SUP-00100101915,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 18X225MM WAGNER SL REVISN PROTASUL-100 POR CTD -,SUP-00100102218,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 9MM PRFT ANTMC 110MM PROTASUL-100 UNCEM TAPR SHLDR -,SUP-00104201092,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 40X14MM -,SUP-00104212400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 44X16MM PROTASUL-21 WF ANTMCREM -,SUP-00104212440,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 46X16MM PROTASUL-21 WF ANTMC REM -,SUP-00104212460,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 48X17MM ANTMC SHLDR PROTASUL-21 REM -,SUP-00104212480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 50X18MM PROTASUL-21 WF ANTMC REM -,SUP-00104212500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP 24MM SM ANTMC SHLDR 16MM PE PG CMNT -,SUP-00104214340,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP 28MM MED ANTMC SHLDR 19MM PE PG CMNT -,SUP-00104214370,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ3 39.68MM OFST 141MM AVENIR MULLER STD 56.11MM NK -,SUP-00106010003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ4 40.22MM OFST 147MM AVENIR MULLER STD 56.88MM NK -,SUP-00106010004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM LAT AVENIR MUELLER SZ 4 -,SUP-00106010104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 12/14 TAPR M/L HIP -,SUP-00106010107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
WEDGE ANKL JNT OSSEOTI 15X15MM POR MTL -,SUP-00110003821,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8785.08,6149.556,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CEMENT BN PLYMTHL MTHCRYLT 40GM PLC R HVISC -,SUP-00111214001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INTEGRAL SHORT GTR W/2 CABLES 23 X 53 -,SUP-00223200204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6861.23,4802.861,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 46X18MM BGLNI/FLTW STD ZML MODULAR OFST -,SUP-00430004618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP 40MM BGLNI/FLTW SHLDR UHMWPE SS PG -,SUP-00430008500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP 46MM BGLNI/FLTW SHLDR UHMWPE SS PG -,SUP-00430008600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 40X18MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 40X21MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP 40MM 46MM ARTC SURF BGLNI/FLTW SHLDR UHMWPE SS PG -,SUP-00430204046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 46X15MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204615,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 46X17MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 46MM OFST MODULAR -,SUP-00430204618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 46X19MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 46X27MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204627,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP 46MM BGLNI/FLTW SHLDR W/52MM SS PG -,SUP-00430204652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BF OFFSET HUM HEAD 18MM X 52MM -,SUP-00430205218,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 52X19MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430205219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 52X21MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430205221,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 10MM INTOP FLXB 130MM TM 42DG ANG NK SHLDR -,SUP-00434211013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 11MM INTOP FLXB 130MM TM 42DG ANG NK SHLDR -,SUP-00434211113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 6MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434810613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 8MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434810813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 9MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434810913,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 10MM TM 130MM 48DG ANG SHLDR -,SUP-00434811013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 11MM TM 130MM 48DG ANG SHLDR -,SUP-00434811113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 12MM TM 130MM 48DG ANG SHLDR -,SUP-00434811213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 13MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434811313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 12MM RVRS 130MM TM LPRO SHLDR -,SUP-00434901213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18477.37,12934.159,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 32X53MM EPSLN STD DRSL UHMWPE PRIM HD -,SUP-00437732053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 42MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500104200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 43MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500104300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 28X47-49MM VERSYS BIPLR UHMWPE -,SUP-00500104728,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 49MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500104900,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 28X50-52MM VERSYS BIPLR UHMWPE -,SUP-00500105028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 51MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 52MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 28X53-55MM VERSYS BIPLR UHMWPE -,SUP-00500105328,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 54MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 55MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 60MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500106000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT LMRL KN SZ2 27MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800227,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HALF BLOCK TRABECULAR TIBIAL AUGMENT RT LATERAL/LT MEDIAL -,SUP-00-5448-002-28,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10465.7,7325.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT RM/LL KN SZ2 37MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800237,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HALF BLOCK TRABECULAR TIBIAL AUGMENT LT LATERAL/RT MEDIAL -,SUP-00-5448-002-38,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10465.7,7325.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT LMRL KN SZ3 27MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800327,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT LMRL KN SZ3 26MM NEXGEN 5MM WDG FUL BLCK TM TIV PMMA -,SUP-00544800337,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT LMRL KN SZ5 27MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800527,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT RM/LL KN SZ5 37MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT KN 31MMMEDX31MM TM -,SUP-00545001331,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15863.61,11104.527,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT KN 36MM MED 25MMX36MM TM -,SUP-00545001336,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CONE TIBIAL TM LARGE 51 X 34 RIGHT -,SUP-00-5450-013-52,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CONE FEMORAL LT SM 30MM -,SUP-00545001730,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT RT DPHSL KN SZ30 SM TM -,SUP-00545001731,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT RT DPHSL KN SZ30 MED TM -,SUP-00545001831,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TM FEM DIAPHYSEAL CONE- 30 LARGE- RIGHT -,SUP-00-5450-019-31,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT KN SZ48 XS NEXGEN 15MM TM -,SUP-00545004801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19404.14,13582.898,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT TRAB METALTIB SZ 52-51MM FULL SMALL -,SUP-00-5450-052-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19404.14,13582.898,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT DIST KN SZ-D NEXGEN 5MM BLCK REVISN TM TIV -,SUP-00549003401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT KN SZ-D NEXGEN 5MM DIST BLCK REVISN TM TIV -,SUP-00549003410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT KN SZ-D NEXGEN 10MM BLCK REVISN TM TIV -,SUP-00549003420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT POST 5MM BLCK SZ-E NEXGEN BLCK REVISN TM TIV -,SUP-00549003501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT DIST KN SZ-E NEXGEN 5MM BLCK REVISN TM TIV -,SUP-00549003510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT KN SZ-E NEXGEN 10MM DIST BLCK REVISN TM TIV -,SUP-00549003520,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT POST KN SZ-F NEXGEN 5MM DIST BLCK REVISN TM TIV -,SUP-00549003601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT KN SZ-F NEXGEN 10MM POST BLCK REVISN TM TIV -,SUP-00549003602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT DIST KN SZ-F NEXGEN 5MM DIST BLCK REVISN TM TIV -,SUP-00549003610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-E MINUS NEXGEN GENDR SOL LT KN CR CMNT ZML PMMA -,SUP-00575001505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-E MINUS NEXGEN GENDR SOL LT KN CR CMNT COCR FLEX -,SUP-00575201505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-E MINUS NEXGEN GENDR SOL RT KN CR CMNT COCR FLEX -,SUP-00575201506,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-D NEXGEN LEGC GENDR SOL LT KN PS CMNT ZML FLEX -,SUP-00576401451,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-E NEXGEN LEGC GENDR SOL LT KN PS CMNT ZML FLEX -,SUP-00576401551,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-E NEXGEN LEGC GENDR SOL RT KN PS CMNT ZML FLEX -,SUP-00576401552,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-F NEXGEN LEGC GENDR SOL LT KN PS CMNT ZML FLEX -,SUP-00576401651,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBPLT SZ2 44/25MM LMRL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBPLT SZ3 47/27MM LMRL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBPLT SZ4 50/29MM LL/RM KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBPLT SZ5 53/31MM LMRL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBPLT SZ5 53/31MM RM/LL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-D 23/48MM NEXGEN LMRL CONDL UNICMPT ZML HI FLEX -,SUP-00584201401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-E 24/51.5MM NEXGEN LMRL CONDL UNICMPT ZML HI -,SUP-00584201501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-F 25/55.5MM NEXGEN LMRL CONDL UNICMPT ZML HI -,SUP-00584201601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-F 25/55.5MM NEXGEN LL/RM KN UNICMPT ZML HI FLEX -,SUP-00584201602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL SIZE G RM/LL -,SUP-00584201702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ARTICULAR SURFACE SIZE 2 11MM -,SUP-00584202211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 8MM UNICMPT ARTCSURF NET SHP KN-HI FLEX MLD -,SUP-00584202308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ARTICULAR SURFACE SIZE 5 8MM -,SUP-00584202508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ2 9MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3229.61,2260.727,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 8MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ4 8MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ4 10MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4521.46,3165.022,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5 8MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 32MM MED 19.5MM TM PMMA NEXGEN -,SUP-00587601019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16244.38,11371.066,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 29MM MICRO 10MM PEGX3 POR -,SUP-00587806129,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 32X10MM THK TM PMMA NEXGEN PRIM POR -,SUP-00587806532,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
NEXGEN POROUS TM PATELLA 10MM X 32MM -,SUP-00-5878-065-32,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 38X10MM THK TM PMMA NEXGEN PRIM POR -,SUP-00-5878-065-41,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIB SZ C-H FEM 3 TIB 10X67/43MM NEXGEN PRFT CR MBLK -,SUP-00588604310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12109.95,8476.965,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIB SZ C-H FEM 5 TIB 10X75/47.5MM NEXGEN PRFT CR MBLK -,SUP-00588604510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10860.53,7602.371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SCREW HEADED HEX 3.5MM X -,SUP-00-5901-035-33,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ1 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ2 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT. -,SUP-00592601201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ2 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ3 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ3 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ4 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ4 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
NEXTGEN CR FLEX PROLONG ART SURF C-H/1-2 SPUR- 14MM -,SUP-00-5952.021-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
NEXGEN CR FLEX PROLONG  ART SURF -,SUP-00-5952-021-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ A-B/1-2 10MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596202010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ C-D/1-2 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596202212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ C-D SZ1-2 FEM 14MM NEXGEN PS ARTCSURF KN FLEX -,SUP-00596202214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ C-D/1-2 17MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596202217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ-E SZ1-2 FEM 10MM NEXGEN PS ARTCSURF KN FLEX FX -,SUP-00596202410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ E-F/3-4 10MM NEXGEN LEGACY ARTCSURF KN PS FLEX -,SUP-00596203210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ E-F/3-4 14MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596203214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ E-F/3-4 17MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596203217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
NEXTGEN LPS-FLEX FIXED PROLONG ART SUR EF 3-4- 20MM -,SUP-00-5962-032-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ E-F/5-6 10MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ E-F/5-6 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ E-F/5-6 17MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ G-H/5-6 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ G-H/5-6 14MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ E-F/7-10 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596205112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-E 68/62.5MM NEXGEN LEGC RT KN PS CMNT ZML FLEX -,SUP-00596401552,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-F 72/65.5MM NEXGEN LEGC R/L KN PS CMNT ZML FLEX -,SUP-00596401652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-G 76.5/71.5MM NEXGEN LEGC L/L KN PS CMNT ZML -,SUP-00596401751,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-G 76.5/71.5MM NEXGEN LEGC R/L KN PS CMNT ZML -,SUP-00596401752,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ C-D/3-4 14MM NEXGEN LPS ARTCSURF NET SHP KN -,SUP-00596403012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-D NEXGEN LEGC LT KN PS CMNT TIV NPOR FLEX FX -,SUP-00596801451,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-F NEXGEN LEGC LT KN PS CMNT TIV NPOR FLEX FX -,SUP-00596801651,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-G NEXGEN LEGC RT KN PS CMNT TIV NPOR FLEX FX -,SUP-00596801752,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 29MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206529,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 32MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206532,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 35MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 38MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206538,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 29MM PRLNG NEXGEN ON ST -,SUP-00597206629,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 32MM PRLNG NEXGEN ON ST -,SUP-00597206632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PATELLA NEXGEN PROLONG ALLPOLY 35MM -,SUP-00597206635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 38MM PRLNG NEXGEN ON ST -,SUP-00597206638,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
NEXGEN AC ART SURF 5-6 GREEN 12MM -,SUP-00597604012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT KN SZ3 NEXGEN 5MM CR PRCTD TIV PMMA -,SUP-00-5988-003-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5398.37,3778.859,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT L/R KN SZ4 NEXGEN 10MM HLF BLCK CR TIV PMMA -,SUP-00598800427,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5398.37,3778.859,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 11MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 12MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SCISSORS OPTH KNAPP 4IN SS CRV V. MUELLER MIRR FNSH S/S IRIS -,SUP-00-5988-010-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 16MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 18MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 20MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 16MM NEXGEN 155MM TIV ALY STR FEM/TBL KN -,SUP-00598801116,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 12.7MM NEXGEN 30MM TIV ALY STR FEM/TBL KN -,SUP-00598801212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 15MM NEXGEN 30MM TIV ALY STR FEM/TBL KN -,SUP-00598801215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SCISSORS OPTH STVNS 4IN SS STR V. MUELLER MIRR FNSH -,SUP-00598802011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SCOOP SURG SM 11IN SLVR PLT CMN DCT MLBL V. MUELLER -,SUP-00598802012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 13MM NEXGEN OFST 100MM TIV ALY FEM/TBL KN -,SUP-00598802013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 14MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 15MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 16MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 17MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 12MM NEXGEN OFST 155MM TIV ALY FEM/TBL KN -,SUP-00598802112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 11MM NEXGEN OFST 155MM TIV ALY FEM/TBL KN -,SUP-00598802115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT ANT KN SZ-D NEXGEN 5MM WDG BLCK TIV PMMA -,SUP-00599003431,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5398.37,3778.859,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-C 60/53.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401392,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-D 64/57.5MM NEXGEN LEGC LT CONDL KN CNSTRN -,SUP-00599401491,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-D 64/57.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401492,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-E 68/61.5MM NEXGEN LEGC LT CONDL KN CNSTRN -,SUP-00599401591,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-E 68/61.5MM NEXGEN LEGC RT KN REVISN CNSTRN -,SUP-00599401592,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-F 72/65.5MM NEXGEN LEGC LT KN REVISN CNSTRN -,SUP-00599401691,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-F 72/65.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401692,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-G 76.5/70.5MM NEXGEN LEGC LT KN REVISN CNSTRN -,SUP-00599401791,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ-G 76.5/70.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401792,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ C-D/1-2 MICRO 10X58/40MM NEXGEN LEGC CNSTRN -,SUP-00599402210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ C-D/1-2 MICRO 12X58/40MM NEXGEN LEGC CNSTRN -,SUP-00599402212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ C-D/1-2 MICRO 14X58/40MM NEXGEN LEGC CNSTRN -,SUP-00599402214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB 0.5X20MM THK 58MM/40MM M/L A/P NEXGEN LEGC CNSTRN -,SUP-00599402220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ C-D/3-4 17X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ C-D/3-4 20X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ E-F/3-4 10X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ E-F/3-4 12X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ E-F/3-4 14X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ E-F SZ3-4 FEM 17MM 66MM/42MM M/L/A/P NEXGEN -,SUP-00599403217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
NEXGEN LCCK ART SURF EF 3-4/STR YELLOW 20MM -,SUP-00599403220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9695.93,6787.151,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ E-F/5-6 10X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ E-F/5-6 14X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ E-F/5-6 17X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ E-F/5-6 20X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ-G 5-6 17X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ G-H/7-10 14X82/50MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599405014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIA ALL POLY NEXGEN LPS SZ 8 BLUE 14MM FEM G H -,SUP-00599600814,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4638.69,3247.083,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 32X50MM TRILOGY 10DG TIV ALY UHMWPE 6.3MM PRIM -,SUP-00615405032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8097.55,5668.285,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 32X68MM TRILOGY 10DG TIV ALY UHMWPE 12.4MM PRIM -,SUP-00615406832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8097.55,5668.285,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 54MM TRILOGY PRIM MUL-HL TIV POR CTD SLD HMSPHR -,SUP-00620005420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6960.16,4872.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 44MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620204420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 48MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620204820,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 50MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620205020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 54MM PRIM MODULAR REVISN CLUS-HL TM TNTLM TIV SLD -,SUP-00620205422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 56MM PRIM MODULAR REVISN NO-HL TM TNTLM TIV SLD -,SUP-00620205620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 22X62MM TRILOGY PRIM MODULAR REVISN CLUS-HL TM -,SUP-00620206220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 68MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620206820,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 32X48MM XL TRILOGY 0DG STD LNGVT XLPE 5.3MM PRIM -,SUP-00630504832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 36X50MM TRILOGY 0DG STD LNGVT XLPE 6.8MM PRIM -,SUP-00630505036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 28X44MM TRILOGY 10DG ELEV RM LNGVT XLPE 5.2MM -,SUP-00631004428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 28X46MM TRILOGY 10DG ELEV RM LNGVT XLPE 6.3MM -,SUP-00631004628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 36X58MM XL TRILOGY 10DG STD LNGVT XLPE 8.9MM PRIM -,SUP-00631005836,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 32X62MM TRILOGY 10DG LNGVT XLPE 9.3MM PRIM -,SUP-00631006236,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 28X44MM TRILOGY 20DG ELEV RM LNGVT XLPE 5.2MM -,SUP-00632004428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 28X46MM TRILOGY 20DG ELEV RM LNGVT XLPE 6.3MM -,SUP-00632004628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 32X48MM TRILOGY 20DG ELEV RM LNGVT XLPE 5.3MM -,SUP-00632004832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 32X56MM TRILOGY 20DG ELEV RM LNGVT XLPE 6.4MM -,SUP-00632005632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 28X50MM TRILOGY LNGVT XLPE 7.2MM CNSTRN MODULAR -,SUP-00633405028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14191.09,9933.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 32X56MM TRILOGY LNGVT XLPE 6.4MM CNSTRN MODULAR -,SUP-00633405632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14191.09,9933.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRABECULAR METAL REVISION SHELL 56MM -,SUP-00700005620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16582.26,11607.582,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BLADE EXPLANT TRUNCATED 60MM -,SUP-00705306010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BLADE FULL EXPLANT 60MM -,SUP-00705306020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 6X111MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 TAPR -,SUP-00771100600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 10X119MM PRFT EXTEND OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 11X121MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 12.5X124MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 15X129MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM VERSYS 41MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM VERSYS 43MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM VERSYS 44MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM VERSYS 47MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM VERSYS 50MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781805000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM VERSYS 51MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781805100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM VERSYS 52MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781805200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ADAPTER HIP VERSYS ENPROS TIV TAPR. -,SUP-00781809901,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ11 120MM VERSYS LD/FX PRFT ZML CMNT HIP -,SUP-00783301100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ12 125MM VERSYS LD/FX PRFT ZML CMNT HIP -,SUP-00783301200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ14 135MM VERSYS LD/FX PRFT ZML CMNT HIP -,SUP-00783301400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
NECK FEM SZ K2 KINECTIV M/L HIP MODULAR COCR -,SUP-00784802001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
NECK FEM SZ S2 KINECTIV M/L HIP MODULAR COCR -,SUP-00784803001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
NECK FEM SZ P2 KINECTIV M/L HIP MODULAR COCR STR 12/14 TAPR -,SUP-00784803101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
KINECTIV MODULAR NECK G2 -,SUP-00784803201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4916.67,3441.669,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
NECK FEM SZ R2 KINECTIV M/L HIP MODULAR COCR STR 12/14 TAPR -,SUP-00784804201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ13 130MM VERSYS ADVCT PRIM STD OFST NON V-LIGN -,SUP-00785001300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM VERSYS CMTD STD 14X135 -,SUP-00785001400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CENTRALIZER DIST FEM HIP 11MM VERSYS PMMA CMNT -,SUP-00785901100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CENTRALIZER DIST FEM HIP 13MM VERSYS PMMA CMNT -,SUP-00785901300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 14X135MM VERSYS PRIM EXTEND OFST TIV POR CTD FM -,SUP-00786201420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 16X145MM VERSYS PRIM STD OFST TIV POR CTD FM TAPR -,SUP-00786201600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 16X145MM VERSYS PRIM EXTEND OFST TIV POR CTD FM -,SUP-00786201620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 18X155MM VERSYS PRIM STD LRG OFST TIV POR CTD FM -,SUP-00786201830,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 20X155MM VERSYS PRIM EXTEND LRG OFST TIV POR CTD FM -,SUP-00786202050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 13X170MM VERSYS REVISN ZML CMNT CLCR HIP -,SUP-00787101360,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21520.55,15064.385,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 13X210MM VERSYS REVISN ZML CMNT CLCR HIP -,SUP-00-7871-013-61,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21520.55,15064.385,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ15 220MM VERSYS REVISN ZML CMNT CLCR HIP -,SUP-00787101561,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21520.55,15064.385,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM VERSYS 28X0MM NK ZML 12/14 TAPR STRL -,SUP-00801802802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM VERSYS 28MM +3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801802803,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM VERSYS 28MM +7MM NK ZML 12/14 TAPR STRL -,SUP-00801802814,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM VERSYS 32MM-3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM VERSYS 32MM +3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM VERSYS 32MM +7MM NK ZML 12/14 TAPR STRL -,SUP-00801803214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM VERSYS 36MM-3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM VERSYS 36X0MM NK ZML 12/14 TAPR STRL -,SUP-00801803602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM VERSYS 36MM +3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803603,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ELEV RIM 32MM I.D. LONGE -,SUP-00875200832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 36X52MM II SHL CONTIN ELEV LNGVT XLPE 4.7MM F -,SUP-00875201036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RIM LINER 36MM SIZE JJ LONGEVITY HIGHLY CROSSLINKED POLY -,SUP-00-8752-011-36,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ EE 44MM CONTIN CLUS-HL TM TIV SNP FIT LCK GRV -,SUP-00875704401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ FF 46MM CONTIN MUL-HL TM TIV SNP FIT LCK GRV -,SUP-00875704602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ GG 48MM CONTIN CLUS-HL TM TIV SNP FIT LCK GRV -,SUP-00875704801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ HH 50MM CONTIN CLUS-HL TM TIV SNP FIT LCK GRV -,SUP-00875705001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ II LINER 52MM CONTIN CLUS-HL TM TIV SNP FIT -,SUP-00875705201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ II 52MM CONTIN MUL-HL TM TIV SNP FIT LCK GRV -,SUP-00875705202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ JJ LINER 54MM CONTIN MUL-HL TM TIV SNP FIT LCK -,SUP-00875705401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 28MMX-3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877502801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BIOLOX DELTA FEM HEAD 28MM +0MM -,SUP-00877502802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 32MM-3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 32MM +0MML NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 36MM-3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEMORAL 36MM CERAMIC -,SUP-00-8775-036-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 36MM +3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503603,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 36MM +7MM BIOLOX DELTA CER -,SUP-00-8775-036-04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BIOLOX DELTA OPTION FEM HEAD 28MM +0MM -,SUP-00-8777-028-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3150.84,2205.588,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BIOLOX OPTION HEAD 36/+3.5 TAPER 12/14 -,SUP-00-8777-036-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9780.3,6846.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BIOLOX OPTION HEAD XL 36/+7 TAPER 12/14 -,SUP-00-8777-036-04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9780.3,6846.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 28X44MM EE SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 28X46MM FF SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200728,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 32X48MM GG SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 32X50MM HH SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200932,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 36NN ID 52MM II SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885201036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 36X54MM JJ SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885201136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 22MMLNGX5.5MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902602300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 28MM SHRT +0MML NK ZML 6DG TAPR ANTMC STRL -,SUP-00902602800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 28MMMEDX+7MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902602900,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 28MMLNGX+14MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902603000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 32MMSHRTX3.5MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902603235,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD 6DEGREE COCR FEM 36MM +3.5 S+ -,SUP-00-9026-036-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD 6 DEGREE COCR FEM 36MM +7 M -,SUP-00-9026-036-07,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 15X185MM ZMR REVISN MODULAR TIV PLASM SPRY POR CTD -,SUP-00998201518,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14636.65,10245.655,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BODY HIP SZ A 17.7MM BD 40MM OFST ZMR REVISN MODULAR 45MM NK -,SUP-00999601745,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21253.21,14877.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM WAGNER REVISION 135 NK ANGLE 18MM X 265MM -,SUP-01.00102.618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB DURAM -,SUP-01.00214.152,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16626.81,11638.767,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CONE WAGNER 135 DEG X 21MM -,SUP-01.00561.321,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13856.92,9699.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SIDUS STEM-FREE SHOULDER HUMERAL HEAD 48-17 -,SUP-01.04555.480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM AVENIR STANDARD CEM 4 -,SUP-01.06010.204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM STD CEMENTED 7 TAPER 12/14 AVENIR -,SUP-01.06010.207,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AVENIR LATERAL STEM CEM 4 -,SUP-01.06010.304,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM AVENIR LATERAL CEM 8 -,SUP-01.06010.308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP RVRS 25MM BSPLT HA+ADPTR -,SUP-010000589,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL G7 ACETABULAR PPS LTD 46B -,SUP-010000660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 PPS LTD ACET SHELL 48C -,SUP-010000661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 PPS LTD ACET SHELL 50D -,SUP-010000662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL G7 ACETABULAR PPS LTD 52E -,SUP-010000663,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL G7 ACET PPS LTD SHELL 54F -,SUP-010000664,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 PPS LTD ACET SHELL 56F -,SUP-010000665,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 PPS LTD ACET SHELL 60G -,SUP-010000667,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL G7 PPS LTD ACET 46 B -,SUP-010000719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER G7 NEUTRAL ARCOMXL 32MM B -,SUP-010000729,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 NEUTRAL ARCOMXL LNR 36MM D -,SUP-010000739,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 NEUTRAL ARCOMXL LNR 36MM E -,SUP-010000740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ARCOMXL G7 NEUTRAL 36MM F -,SUP-010000741,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 ACETABULAR LINER 36MM / G -,SUP-010000742,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 NEUTRAL ARCOMXL LNR 40MM G -,SUP-010000748,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 NEUTRAL E1 LINER 28MM C -,SUP-010000837,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 NEUTRAL E1 LINER 32MM -,SUP-010000846,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 NEUTRAL E1 LINER 32MM C -,SUP-010000847,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 NEUTRAL E1 LINER 36MM D -,SUP-010000856,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 NEUTRAL E1 LINER 36MM F -,SUP-010000858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 FREEDOM CONST E1 LNR 36MM -,SUP-010000982,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 FREEDOM COSTR E1 LNR 36MM G -,SUP-010000985,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD COCR FEM 40MM TYPE 1 +9MM -,SUP-010001032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COCR FEM HD 40MM TYPE 1 +6MM -,SUP-010001033,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEMORAL COCR 40MM TYPE 1 STD -,SUP-010001035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COCR FEM HD 40MM TYPE 1-3MM -,SUP-010001036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
WAGNER SL REVISION STEM 135 NK ANGLE 15MM X 225MM -,SUP-0100102215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
WAGNER SL REV STEM 135 NK ANGLE 14 X 265 -,SUP-0100102614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CONE WAGNER 125 DEG X 19MM -,SUP-0100561219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13856.92,9699.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ADAPTER ANTMC BGLNI 42 -,SUP-0104250042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AS B/F ADAPTOR 48 DEG -,SUP-0104250048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AC-CONNECTOR -,SUP-0104440000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM AVENIR 5 TAPER 12/14 MULL -,SUP-0106010005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM AVENIR 6 TAPER 12/14 MULL -,SUP-0106010006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
MORSE TAPER HEAD +5 OFFSET WITH LFIT 32MM -,SUP-01-3205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PLATE 2.7/3.5 VA ANTLAT DSTL TIB PL/10 H/LFT -,SUP-02.118.209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10401.04,7280.728,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BONE PREP KIT 21-1000 SFN -,SUP-0206-710-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,740.32,518.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LOW FRICTION ION TREATMENT -,SUP-06-2200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
C-TAPER LFIT HEAD LOW FRI ION TREATMENT -,SUP-06-2205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 26X0MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-06-2600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEMORAL LFIT COCR +5 MM OFFSET C TAPER 26MM HIP -,SUP-06-2605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
C-TAPER LFIT HEAD LOW FRICTION SZ. 26MM / +10 -,SUP-06-2610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 28X0MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-062800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
C-TAPER LFIT HEAD LOW FRICTION SZ. 28MM / +10 -,SUP-06-2810,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 32X0MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-063200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 32MM-5MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-063299,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 36MM +0MML NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-063600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 40MM-2.5MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-064097,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM PLASMA SPRAY STD SIZE 2 TI6AI4V -,SUP-101-0002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HIP STEM PLASAM STD SZ 3 -,SUP-101-0003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ4 37MM OFST 110MM OVATN STD OFST 29MM 7MM M/L/A/P -,SUP-101-0004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ5 OVATN STD OFST TI PLASM SPRY CTD 12/14 TAPR -,SUP-101-0005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ6 38MM OFST 118MM OVATN STD OFST 31MM 9MM M/L/A/P -,SUP-101-0006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ7 32MM OFST 122MM OVATN STD OFST 32MM 10MM -,SUP-101-0007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ8 43MM OFST 126MM OVATN STD OFST 34MM 11MM -,SUP-101-0008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ9 44MM OFST 130MM OVATN STD OFST 36MM 13MM -,SUP-101-0009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ10 47MM OFST 134MM OVATN STD OFST 38MM 16MM -,SUP-101-0010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ5 44MM OFST 114MM OVATN EXTEND OFST 30MM 8MM -,SUP-101-1005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8233.36,5763.352,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ6 9/31X118MM OVATN EXTEND OFST 33MM LEG 44MM HZNT -,SUP-101-1006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ7 49MM OFST 122MM OVATN EXTEND OFST 32MM 10MM -,SUP-101-1007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ8 50MM OFST 126MM OVATN EXTEND OFST 34MM 11MM -,SUP-101-1008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ9 STD OVATN EXTEND OFST TI PLASM SPRY CTD 12/14 -,SUP-101-1009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ10 55MM OFST 134MM TI PLASM SPRY CTD HIP OVATN -,SUP-101-1010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SELF CENT HIP 41X28 RUST -,SUP-1035-41-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
WIRE EXTFIX 1.8MM BAYNT PNT -,SUP-104.690,CDM,C1776,HCPCS,278,RC,,,outpatient,,,367.02,256.914,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RING ACTB SZ23 TI HIP LCK LINER YEL RINGLOC STRL SUD -,SUP-1054-23,CDM,C1776,HCPCS,278,RC,,,outpatient,,,770.22,539.154,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SPACER DIST HIP 10MM ACCOLADE C SZ SMALL -,SUP-1059-2310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SPACER FEM CMNT RNG STYL MED 12MM DIST F/STM 4/5 ACCOLADE -,SUP-1059-4512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RINGLOC + HIP SYSTEM SZ 21 -,SUP-106021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SPACER DIST FEM HIP UNIV 8MM ACCOLADE CMNT -,SUP-1067-0008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SPACER DIST FEM HIP 9MM UNIV CMNT -,SUP-1067-0009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SPACER DIST FEM HIP 10MM UNIV CMNT -,SUP-1067-0010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SPACER DIST FEM HIP 11MM UNIV RECON CMNT -,SUP-1067-0011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SPACER DIST FEM HIP 12MM UNIV CMNT -,SUP-1067-0012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SPACER DIST FEM HIP 13MM UNIV CMNT -,SUP-1067-0013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SPACER DIST FEM HIP 14MM UNIV CMNT -,SUP-1067-0014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SPACER DIST FEM HIP 15MM UNIV CMNT -,SUP-1067-0015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OMNIFIT UNIVERSAL DISTAL CEMENT SPACER 16MM -,SUP-1067-0016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CEMENT SPACER UNIVERSAL DISTAL -,SUP-1067-0017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
VARIO CUP 28MM X 47MM -,SUP-107-220/47,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5160.7,3612.49,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
VARIO CUP 28MM X 48MM -,SUP-107-220/48,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5160.7,3612.49,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
VARIO-CUP SYSTEM OUTER 50MM HEAD 28MM -,SUP-107-220/50,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5160.7,3612.49,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 OSSEOTI 3 HOLE SHELL 50MM D -,SUP-110010243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 OSSEOTI MULTIHOLE 50MM D -,SUP-110010263,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 MULTIHOLE 52MM -,SUP-110010264,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 OSSEOTI MULTIHOLE 54MM F -,SUP-110010265,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 OSSEOTI MULTIHOLE 56MM F -,SUP-110010266,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 OSSEO TI ACETABULAR SHELL 58MM / G -,SUP-110010267,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 OSSEO TI MULTIHOLE 60MM G -,SUP-110010268,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL G7 OSSEO TI MULTIHOLE 62MM H -,SUP-110010269,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 OSSEO TI MULTIHOLE 64MM H -,SUP-110010270,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER G7 DUAL MOBILITY 38MM C -,SUP-110024461,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 DUAL MOBILITY LINER 42MM E -,SUP-110024463,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 DUAL MOBILITY LINER 44MM F -,SUP-110024464,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 DUAL MOBILITY LINER 50MM H -,SUP-110024466,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPR VRS GLEN PPS MIN TPR ADR -,SUP-110027734,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26395.72,18477.004,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PRX HUM LO PLT LT 4H 83MM -,SUP-110030101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6875.28,4812.696,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
40MM VERSA-DIAL GLEN STD -,SUP-110030776,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
40MM VERSA-DIAL GLEN +3 -,SUP-110030777,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BEARING VIVACIT-E DM 28 X 44MM -,SUP-110031012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BEARING VIVACIT-E DM 28 X 50MM -,SUP-110031015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
VERSA-DIAL TAPER ADAPTOR 25MM -,SUP-110031378,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HMRL TRAY STD STD -,SUP-110031399,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRAY HMRL STD SHOULDER REVERSE TI -,SUP-110031408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HMRLBEARING 36MM +3 PRLNG -,SUP-110031419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HMRL BEARING 40MM STD PRLNG -,SUP-110031421,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HMRL BEARING 36 MM STD VITE -,SUP-110031424,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HMRL BEARING 36 MM +3 VITE -,SUP-110031425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BEARING HUMERAL 40MM STD VITE -,SUP-110031427,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPR AUG BSPLT W ADP SM -,SUP-110032410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPR AUG BSPLT W ADP MD -,SUP-110032420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPR AUG BSPLT W ADP LG -,SUP-110032430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HMRL BEARING 36MM STD PRLNG -,SUP-11031418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FREEDOM CONSTR HD 36MM T1 -,SUP-11-107016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7259.36,5081.552,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FREEDOM CONSTR 36MM T1 +9MM -,SUP-11-107021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7259.36,5081.552,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 6MM MAC PRIM RVRS CMPRHNSV 140MM COCR PLASM CTD -,SUP-11-113556,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PROXIMAL FEMORAL OMPONENT RHS LEFT -,SUP-1115-9110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22682.72,15877.904,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL CHECKPOINT STERILE -,SUP-111651,CDM,C1776,HCPCS,278,RC,,,outpatient,,,260.65,182.455,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RINGLOC BIPOLAR 28X49MM -,SUP-11-165222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD RADL SZ12 22MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6332.05,4432.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD RADL SZ14 24MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM RADL SZ7 26MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7295.44,5106.808,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM RADL SZ8 28MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210063,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7507.64,5255.348,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM STR DIST ARCOS 23MM X 150MM TAPER -,SUP-11-300823,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STS DISTAL STEM 15 X 190MM -,SUP-11-300915,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
DIST ARCOS 19 X 190MM SPL TPR -,SUP-11-300919,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CON ARCOS SZ A STD 60MM -,SUP-11-301301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CON ARCOS SZ A STD HI 50MM -,SUP-11-301310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ARCOS CON SIZE E HI 70MM -,SUP-11-301335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STANDARD CONE PROX BODY 80MM -,SUP-11-301342,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ARCOS CON SIZE B HI 80MM -,SUP-11-301352,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
VERSA-DIAL 38 X 19 X 39 HUM HEAD -,SUP-113022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
VERSA-DIAL 38X21X38 HUM HEAD -,SUP-113024,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 42MM 46X18MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
VERSA DIAL 42 X 21 X 43 HUM HEAD -,SUP-113034,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 46X53MM 18MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 46X50MM 24MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 46X46MM 27MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 50MM 57X21MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 50X50MM 27MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113057,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
MODULAR HEAD 54MM 21MM 64MM -,SUP-113063,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TAPER ADAPTER 54MM X 24MM -,SUP-113065,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM VERSA-DIAL 54X27X55 -,SUP-113067,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HUM HEAD VERSA-DIAL 58 X 24 X 64 -,SUP-113075,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE COMP FX HUM POS 8MM -,SUP-113576,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE COMP FX HUM POS 9MM -,SUP-113577,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
POSTIONING SLEEVE COMP FX HUM 10MM -,SUP-113578,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE COMP FX HUM POS 11MM -,SUP-113579,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FX HUM POS SLEEVE 12MM -,SUP-113580,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FX HUM POS SLEEVE 13MM -,SUP-113581,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PRIMARY STEM 9MM MICRO -,SUP-113609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PRIMARY STEM 10MM MICRO -,SUP-113610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PRIMARY STEM 11MM MICRO -,SUP-113611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PRIMARY STEM 12MM MICRO -,SUP-113612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM COMP PRIMARY MICRO 13MM -,SUP-113613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM COMP PRIMARY MICRO 14MM -,SUP-113614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PRIMARY STEM 15MM MICRO -,SUP-113615,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PRIMARY STEM 17MM MICRO -,SUP-113617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PRIMARY STEM 19MM MICRO -,SUP-113619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM COMP PRIMARY 5MM MINI -,SUP-113625,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM COMP PRIMARY 6MM MINI -,SUP-113626,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PRIMARY STEM 7MM MINI -,SUP-113627,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM COMP PRIMARY 8MM MINI -,SUP-113628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPREHENSIVE HUMERAL STEM 9MM MINI -,SUP-113629,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
POROUS PLASMA 10MM 83MM LONG -,SUP-113630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PRIMARY STEM 11MM MINI -,SUP-113631,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPREHENSIVE HUMERAL STEM 12MM MINI -,SUP-113632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM COMP PRIMARY 13MM MINI -,SUP-113633,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM COMP PRIMARY 14MM MINI -,SUP-113634,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM COMP PRIMARY 15MM MINI -,SUP-113635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM COMP PRIMARY 16MM MINI -,SUP-113636,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD MOD 36MM COCR 3MM -,SUP-11-363661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD COCR MOD HD STD 36MM -,SUP-11-363662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD 36MM COCR MOD +36MM -,SUP-11-363663,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM COMP PRIMARY 17MM MINI -,SUP-113637,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 7MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113647,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 8MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113648,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 12MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 15MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113655,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 16MM STD PRIM PRFT RVRS CMPRHNSV 122MM COCR PLASM -,SUP-113656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP MODULAR HYBRID SHLDR POST 4MM UHMWPE PG -,SUP-113951,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP SM MODULAR HYBRID SHLDR BS 4MM UHMWPE PG -,SUP-113952,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP MED MODULAR HYBRID SHLDR BS 4MM UHMWPE PG -,SUP-113954,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SPHERE GLND 36MM STD CMPRHNSV VERSA-DIAL RVRS HAP POR CTD -,SUP-115310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SPHERE GLND +3MM 36MM CMPRHNSV VERSA-DIAL RVRS HAP POR CTD -,SUP-115313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE 28MM CMPRHNSV SHLDR RVRS -,SUP-115330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRY HUMERAL STD 44MM COCR SHLDR RVRS CMPRHNSV STRL SUD -,SUP-115370,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PIN INSRTR 24.5CM FRLCK F/VFX2 FEM FX SYS -,SUP-118001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
KT BONE CMNT PREP-IM -,SUP-121010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3685.53,2579.871,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM COMPR 6MM HUM FRACT PPS -,SUP-12-113556,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPR 8MM HUM FRACT STEM PPS -,SUP-12-113558,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPR 10MM HUM FRACT STEM PPS -,SUP-12-113560,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPR 12NN HUM FRACT STEM PPS -,SUP-12-113562,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD MODULAR CER BIOLOXD 28MM -3 NK -,SUP-12-115109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CER BIOLOXD MOD HD 28MM STD NK -,SUP-12-115110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CER BIOLOXD MOD HD 28MM +3 NK -,SUP-12-115111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CER BIOLOXD MOD HD 32MM-3NK -,SUP-12-115114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD CERAMIC BIOLOX STANDARD NECK -,SUP-12-115115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CER BIOLOXD MOD HD 36MM STD NK -,SUP-12-115121,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CER BIOLOXD MOD HD 36MM +3 NK -,SUP-12-115122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CER BIOLOXD MOD HD 36MM +6 NK -,SUP-12-115123,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD ENDO II MOD SIZE 49 -,SUP-12-139022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 54MM PINNCL NO-HL POR CTD LCK RNG SLD -,SUP-1217-01-054,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4847.45,3393.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 58MM PINNCL NO-HL POR CTD LCK RNG SLD -,SUP-1217-01-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4992.9,3495.03,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 60MM PINNCL NO-HL POR CTD LCK RNG SLD -,SUP-1217-01-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4992.9,3495.03,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 46MM PINNCL MUL-HL BANTAM POR CTD PLASM SPRY LCK -,SUP-1217-20-046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6137.89,4296.523,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 48MM PINNCL MUL-HL BANTAM PE POR CTD LCK RNG SLD -,SUP-1217-22-048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6215.13,4350.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 52MM PINNCL MUL-HL BANTAM SECT PE POR CTD LCK RNG -,SUP-1217-22-052,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4847.45,3393.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 54MM PINNCL MUL-HL BANTAM SECT PE POR CTD LCK RNG -,SUP-1217-22-054,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4706.3,3294.41,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 62MM PINNCL PRFT NO-HL GRIPTN -,SUP-1217-31-062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16040.16,11228.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 48MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CUP ACETABULAR 50MM -,SUP-1217-32-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 52MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-052,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10299.17,7209.419,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 54MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-054,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 56MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10299.17,7209.419,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 58MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10509.65,7356.755,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 60MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10299.17,7209.419,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 62MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACETABULAR PINNACLE 54 47 -,SUP-121854047,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13117.66,9182.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PINNACLE DM LINER 56 49 -,SUP-121856049,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13117.66,9182.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER DUR MAR +4 10D 36 X 54 -,SUP-122036554,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 32X50MM PINNCL NEUT ALTRX BLU -,SUP-1221-32-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 32X48MM PINNCL +4 10DG ALTRX BLU -,SUP-1221-32-148,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 32X50MM PINNCL +4 10DG ALTRX BLU -,SUP-1221-32-150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 36X58MM PINNCL NEUT ALTRX ORNG -,SUP-1221-36-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 36X52MM PINNCL +4 10DG ALTRX ORNG -,SUP-1221-36-152,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 36X54MM PINNCL +4 10DG ALTRX ORNG -,SUP-1221-36-154,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 36X56MM PINNCL +4 10DG ALTRX ORNG -,SUP-1221-36-156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 40X56MM PINNCL NEUT ALTRX -,SUP-1221-40-056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 40X58MM PINNCL NEUT ALTRX WHT -,SUP-1221-40-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 40X62MM PINNCL NEUT ALTRX -,SUP-1221-40-062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 40X56MM PINNCL LD +4 10DG ALTRX PNK -,SUP-1221-40-156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 40X58MM PINNCL LD +4 10DG ALTRX PNK -,SUP-1221-40-158,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ALTRX +4 10D 40IDX620D -,SUP-1221-40-162,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CATALYST R1 SHORT STEM HUMERAL SIZE 36S -,SUP-1230-7501-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CATALYST R1 POLY INSERT IMPLANT36 +0 -,SUP-1230-7504-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CATALYST R1 POLY INSERT SIZE 36 +4 -,SUP-1230-7504-002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CATALYST R1 STANDARD BASEPLATE IMPLANT -,SUP-1230-7506-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10674.88,7472.416,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CATALYST R1 GLENOSHERE SIZE 36 STD -,SUP-1230-7513-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9761.2,6832.84,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 52MM RESTOR ADM X3 PRFT MBL BRNG CMNTLS SLF-LCK -,SUP-1235-2-521,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 54MM RESTOR ADM X3 PRFT MBL BRNG CMNTLS SLF-LCK -,SUP-1235-2-541,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 60MM RESTOR ADM PRIM -,SUP-1235-2-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 28X48MM RESTOR ADM 0DG DURATION PE 6.9MM -,SUP-1235-2-848,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 28X54MM RESTOR ADM 0DG DURATION PE 9.9MM -,SUP-1235-2-854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 28X60MM RESTOR ADM 0DG DURATION PE 12.9MM -,SUP-1235-2-860,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 36X22.2MM RECON ADM MDM X3 UHMWPE PRIM ASYM -,SUP-1236-2-242,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 38X22.2MM RECON ADM MDM X3 UHMWPE PRIM ASYM -,SUP-1236-2-244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 28X48MM RESTOR ADM X3 PE 6.9MM REVISN -,SUP-1236-2-848,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT RESTORATION ADM/MD/ 29MM X 28/48 SIZE 42E X3 -,SUP-1236-2-848,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 28X52MM RESTOR ADM X3 PE 8.9MM REVISN -,SUP-1236-2-852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT RESTORATION ADM/MD/ 28MM X 28/52 SIZE 46F X3 -,SUP-1236-2-852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 28X54MM RESTOR ADM X3 PE 9.9MM REVISN -,SUP-1236-2-854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT RESTORATION ADM/MDM 28MM X 52H X3 SZ 28/58MM -,SUP-1236-2-858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RES INSERT ADM/MDM 28MM SZ54I -,SUP-1236-2-860,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PROSTHESIS HEAD A 28MM NECK L S +3.5 TAPER 12/14 -,SUP-128-791/03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PROSTHESIS HEAD A 32MM MED 12/14 -,SUP-128-792/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PROSTHESIS HEAD A 36MM NECK L S -4 TAPER 12/14 -,SUP-128-793/01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PROSTHESIS HEAD A 36MM NECK M NECK LEN 0 TAPER 12/14 -,SUP-128-793/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PROSTHESIS HEAD A 36MM NECK LARGE +4 TAPER 12/14 -,SUP-128-793/03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINK PROSTHESIS HEAD A CERAMIC 8MM -,SUP-128-793/04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PROSTHESIS HEAD A 40MM NECK M TAPER 12/14 -,SUP-128-794/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD PROSTESIS B 24MM 12/14 M -,SUP-128-824/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PROSTHESIS HEAD B 28MM M NEC L 0 12/14 -,SUP-128-828/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PROSTHESIS HEAD B NECK XL +10.5 -,SUP-128-828/04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINK PROSTHESIS HEAD B 36MM +4 -,SUP-128-836/03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ2.5 69.6/45.8MM KN CMNT STM SIGMA COCR PS -,SUP-1294-33-125,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ3 KN CMNT STM SIGMA COCR PS TCMPRTMNTL MBL -,SUP-1294-33-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ5 KN CMNT STM SIGMA COCR PS TCMPRTMNTL MBL -,SUP-1294-33-150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ6 KN CMNT STM SIGMA COCR PS TCMPRTMNTL MBL -,SUP-1294-33-160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ2.5 67/44MM KN CMNT SIGMA COCR PS REVISN MBL -,SUP-1294-35-125,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ3 70MM M/L 46MM A/P KN CMNT SIGMA COCR PS -,SUP-1294-35-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIB TRAY ROT PLAT MBT REV SZ 4 -,SUP-129435140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
REV MBT TIBIAL ROT PLAT TRAY SZ. 3 -,SUP-1294-35-315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
REVISION MBT TIBIAL TRAY SZ. 4 / 15MM -,SUP-1294-35-415,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRAY TIBIAL ROTATING PLAT MBT REV SZ 4 25MM THICK CEMENTED -,SUP-1294-35-425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE FEMORAL UNIV DISTAL PORUS 34MM -,SUP-1294-53-225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE UNIV FEMORAL 48MM FULL POROUS -,SUP-1294-53-246,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE TIB 29X29/26MM LCS COMPL MODULAR REVISN BEAR KN RP -,SUP-1294-54-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE TIB 37X37/27MM LCS COMPL MODULAR REVISN BEAR KN RP -,SUP-1294-54-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE TIB 45X45/27MM LCS COMPL MODULAR REVISN BEAR KN RP -,SUP-1294-54-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE METAPHYSEAL 53MM POUROUS MBT REV -,SUP-1294-54-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
METAPHYSEAL SLEEVE POROUS -,SUP-1294-54-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
METAPHYSEAL SLEEVE 29MM CEMENTED REV -,SUP-1294-54-140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
UNITED HIP FULL XPE CUP I.D. 32MM O.D. 48MM -,SUP-1302-3248,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
UNITED HIP FULL XPE CUP I.D. 32MM O.D. 50MM -,SUP-1302-3250,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
UNITED HIP FULL XPE CUP I.D. 28MM O.D. 46MM -,SUP-1302-3846,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
UNITED HIP LOCKING CAGE OD58MM LEFT -,SUP-1308-1158,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
UNITED HIP LOCKING CAGE OD54MM RIGHT -,SUP-1308-1254,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
UNITED HIP LOCKING CAGE OD 58MM RIGHT -,SUP-1308-1258,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
UNITED HIP SYS LOCKING CAGE 62MM RIGHT -,SUP-1308-1262,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
UNIPOLAR 42MM OD -,SUP-132-0042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD SOLITUDE UNIPOLAR 43MM -,SUP-132-0043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
UNIPOLAR 47MM -,SUP-132-0047,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
UNIPOLAR 53MM SOLITUDE -,SUP-132-0053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
UNIPOLAR SOLITUDE 55MM -,SUP-132-0055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
UNIPOLAR 57MM -,SUP-132-0057,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ADAPTER SOLITUDE UNIPOLAR +0MM -,SUP-132-1200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ADAPTER +6MM 12/14 -,SUP-132-1206,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ADAPTER OFFSET 9MM 12/14 -,SUP-132-1209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP 3MM SOLITUDE OFST ADPTR UNIPL COCR 12/14 TAPR -,SUP-132-1230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL BIPOLAR PIVOT 22 X 40 ACETABULAR -,SUP-133-2240,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PIVOT BIPOLAR 22 X 43MM BIPOLAR -,SUP-133-2243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM 22X44MM SHL OFST L CUP BIPLR TI COCR UHMWPE -,SUP-133-2244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM 28X46MM SHL OFST L CUP BIPLR TI COCR UHMWPE -,SUP-133-2846,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CUP BIPOLAR MOD COCR 28X47MM -,SUP-133-2847,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PIVOT BIPOLAR 28 X 49 -,SUP-133-2849,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PIVOT BIPOLAR 28 X 50MM -,SUP-133-2850,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BIPOLAR 28MM ID 51MM OD -,SUP-133-2851,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PIVOT BIPOLAR 28 X 52 BIPOLAR -,SUP-133-2852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL BIPOLAR PIVOT 28MM X 53MM -,SUP-133-2853,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL BIPOLAR PIVOT 28X54MM -,SUP-133-2854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PIVOT BIPOLAR 28 X 55 -,SUP-133-2855,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PIVOT BIPOLAR 28X56MM BIPOLAR -,SUP-133-2856,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PIVOT BIPOLAR 28MM X 57MM -,SUP-133-2857,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEMORAL CERAMIC 28MM -,SUP-136-2800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEMORAL CERAMIC DELTA 28MM 3 BIOLOX -,SUP-136-2830,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TAPERED SPACER ARTICUL/EZE -3 -,SUP-136308000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SPACER HIP ARTICL/EZ MODULAR CATHCART UNIPL +0MML NK 12/14 -,SUP-1363-10-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1144.83,801.381,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SPACER HIP ARTICL/EZ MODULAR CATHCART UNIPL +5MM NK 12/14 -,SUP-1363-12-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1144.83,801.381,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL HEAD 32MM -3 CERAMIC 12/14 TAPER -,SUP-136-3230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 51MM UNIPL MODLR CATHCART BALL ORTHCNTRC DSGN -,SUP-1363-51-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1933.62,1353.534,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
MODULAR CATHCART BALL 53MM OD -,SUP-136353000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD 36MM +0 BIOLOX DELTA CERAMIC FEMORAL -,SUP-136-3600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM BIOLOX DELTA 36MM XL MODULAR -,SUP-136-3604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEMORAL 36MM +3 BIOLOX DELTA CERAMIC -,SUP-136-3613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEMORAL 36MM +6 CERAMIC 12/14 TAPER -,SUP-136-3616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEMORAL BIOLOX DELTA CERAMIC 36MM -3 -,SUP-136-3630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FERMORAL HEAD BIOLOX DELTA CERAMIC 36MM -6 -,SUP-136-3660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD CERAMIC FEMORAL DELTA -,SUP-136-4000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 40MMMEDX-1MM NK BIOLOX DELTA 12/14 TAPR -,SUP-136-4002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2570.74,1799.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL HEAD CERAMIC 40MM +3 BIOLOX -,SUP-136-4013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL CERAMIC HEAD 40MM +9 -,SUP-136-4019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL HEAD CERAMIC 40MM -3 BIOLOX -,SUP-136-4030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ARTICUL/EZE BALL 28 +1.5 GR -,SUP-136511000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM ARTICL/EZ 28MMSTDX+8.5MM NK BIOLOX DELTA TS CERM -,SUP-1365-13-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ARTIUL/EZE BALL 28 +12 BLK -,SUP-136514000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4405.7,3083.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEMORAL BIOLOX DELTA 28MM +5 12/14 TAPER CERAMIC REV -,SUP-1365-28-720,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8563.54,5994.478,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ARTICUL/EZE BALL 22.225+4 NK -,SUP-136529000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4405.7,3083.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD S-ROM M 36MM +0 -,SUP-136531000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL HEAD M-SPEC METAL 36MM +3 11/13 -,SUP-1365-32-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CERAMIC FEMORAL HEAD 32MM +0 11/13 TAPER -,SUP-1365-32-210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12117,8481.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD BIOLOX DELTA CERAMIC FEMORAL 36MM -,SUP-1365-36-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4487.56,3141.292,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CERAMIC FEMORAL HEAD 40MM X +8.5 BIOLOX DELTA TS 12/14 TAPER -,SUP-1365-40-730,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CERAMIC FEMORAL HEAD 40MM +12 BIOLOX DELTA TS -,SUP-1365-40-740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM ARTICL/EZ 44MM +1.5MM NK COCR 12/14 TAPR CONTR -,SUP-1365-61-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CEMENTRALIZER 11.0 -,SUP-137620000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 22MM BIPLR COCR MODLR -,SUP-138-2200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL HEAD 22MM +3 COCR -,SUP-138-2203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL HEAD COCR 22MM -3 -,SUP-138-2230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM OVATN 28MM +0MML NK COCR 12/14 TAPR STRL -,SUP-138-2800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL HEAD 28MM +9 12/14 TAPER -,SUP-138-2809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEMORAL COCR 28MM -,SUP-138-2830,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM OVATN 36MM +0MML NK COCR 12/14 TAPR -,SUP-138-3600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL HEAD COCR 36MM +6 -,SUP-138-3606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL HEAD COCR 36MM +9 -,SUP-138-3609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM OVATN 36MM-3MM NK COCR 12/14 TAPR -,SUP-138-3630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL HEAD 40MM +3 -,SUP-138-4003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COCR FEMORAL HEAD -,SUP-138-4009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ENDO II TAPER STD 0MM T -,SUP-139247,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FRDM CNSTR 36MM T12/14 -6MM -,SUP-14-107016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7206.31,5044.417,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FRDM CNSTR HD 36MM T 12/14 - 14-107018 -,SUP-14-107018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7206.31,5044.417,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BAR ORTHO INTLOK TI ASCENT MAXIM L/R KN CR PRIM STRL -,SUP-141205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1136.02,795.214,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRAY TIBIAL ILOK PRI 79MM BIOMET -,SUP-141215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL PLATE 67MM -,SUP-141232,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRAY COCR CRUCIATE 71MM CC BIOMET -,SUP-141233,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HIP FINNED PRI 80 X 10MM BIOMET -,SUP-141316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PIN FX STNMN 2MMX6IN SMTH PLN BAYNT PNT FA KN -,SUP-141796,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7206.31,5044.417,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM BMT SPLINED KNEE V2 12 X 40 -,SUP-148287,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM BMT SPLINED KNEE V2 14 X 40 -,SUP-148289,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SPLINED KNEE STEM V2 -,SUP-148291,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM BMT SPLINED KNEE V2 10 X 80 -,SUP-148300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 7MM PRSRVN RM/LL KN -,SUP-1498-11-306,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5824.89,4077.423,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 9.5MM PRSRVN RM/LL KN -,SUP-1498-11-308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5824.89,4077.423,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM OSS CEMENTED IM 9MM X 90MM -,SUP-150358,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9594.39,6716.073,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM OSS CEMENTED IM 12MM X 90MM -,SUP-150361,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9594.39,6716.073,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OSS CEMENTED IM STEM 13MM X 90MM -,SUP-150362,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9594.39,6716.073,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OSS CEMENTED IM STEM 13X150 -,SUP-150367,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10426.1,7298.27,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM OSS POUROUS IM 11.5MM X 90MM -,SUP-150382,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ3 ATTUNE LT KN CR CMNT -,SUP-1504-00-103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ9 ATTUNE LT KN CR CMNT -,SUP-1504-00-109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OSS POROUS IM STEM 12.5 X 225 -,SUP-150402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OSS POROUS IM STEM 14.5 X 225 -,SUP-150403,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OSS POROUS IM STEM 18.5 X 225 -,SUP-150405,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OSS TIBAL POLY BEARING 14MM -,SUP-150411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7469.44,5228.608,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OSS TIBAL POLY BEARING 18MM -,SUP-150413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7469.44,5228.608,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PLATE OSS NON-MOD TIBAL SHORT 67MM -,SUP-150417,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19307.6,13515.32,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OSS MOD TIBAL BASEPLATE 71MM -,SUP-150422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20436.35,14305.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BLOCK OSS TIB 20 X 63/67 MR/LL -,SUP-150429,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BLOCK OSS TIB 20 X 63/67 MR/LR -,SUP-150430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
REVISION CRS FEMORAL SZ 7 LEFT CEMENTED -,SUP-1504-40-107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24255.17,16978.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OSS FINN MOD PROX FMRL RT 7CM -,SUP-150457,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26939.64,18857.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT OSS LETSON MOD PROX FMRL R 7CM -,SUP-150459,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26939.64,18857.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OSS 3CM ELLIP DIAPHYSEAL SEG -,SUP-150461,CDM,C1776,HCPCS,278,RC,,,outpatient,,,35466.58,24826.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OSS POLY TIBIAL BUSHING -,SUP-150476,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2501.84,1751.288,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OSS POLY FEMORAL BUSHINGS 2PK -,SUP-150477,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1738.56,1216.992,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OSS AXLE -,SUP-150480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3399.09,2379.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OSS REINFORCED YOKE -,SUP-150493,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6994.11,4895.877,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL BASE FIXED BEARING -,SUP-1506-40-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12048.69,8434.083,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASE TIBIAL REV RP SIZE 4 CEM -,SUP-1506-60-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18338.51,12836.957,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIA SLV M/L ATUNE 29MM FULL POR -,SUP-1511-11-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13490.44,9443.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
REVISED CEMENTED SYSTEM -,SUP-1512-14-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4423.31,3096.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM PRESSFIT STR ATUNE 16 X 60MM -,SUP-1513-16-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.93,4893.651,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 6MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-306,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5 10MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ6 6MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ9 7MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-907,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT FIXED BEARING POSTERIOR STABILIZED -,SUP-1516-40-412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBAL INSERT FIXED BEARING POST STAB 7X10MM -,SUP-1516-40-710,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT PS RP SZ 5 ATTUNE 16MM -,SUP-1516-50-516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 41MM ATTUNE MDL DOME -,SUP-1518-20-041,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2364.02,1654.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUG TIBIL UNIV ATUE SZ 3/4 X 5MM -,SUP-1523-03-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5835.5,4084.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ1 41MM OFST 120MM PROSTALAC HI OFST 26MM LEG COCR -,SUP-1541-06-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19493.25,13645.275,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CUP ACTB PROSTALAC CMNT PE 32X42MM -,SUP-1541-42-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3762.63,2633.841,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OXFORD PARTIAL KNEE SYM FIXED LATERAL TIBIAL LEFT -,SUP-154335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FIXED LATERAL TIBIAL COSTRUCT LEFT  (E3) -,SUP-154340,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OXF FIX LAT BRG E4 LEFT -,SUP-154341,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OXF FIX LAT BRG B3 RIGHT -,SUP-154355,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OXFORD FIX LAT BRG E5 RIGHT -,SUP-154372,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OXFORD FIX LAT BRG F3 RIGHT -,SUP-154375,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SM OXFORD KN UNICMPT COCR -,SUP-154600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM MED OXFORD KN UNICMPT COCR -,SUP-154601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9586.97,6710.879,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
REVISION DISTAL FEMORAL AUGMENT SZ 7X4MM CEMENTED -,SUP-1547-07-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5135.24,3594.668,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ A LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154718,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ A R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ B LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154720,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ B R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154721,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ-C L/M PMA ARTC OXFORD TI NIOBM NTRD CTD UHMWP -,SUP-154722,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ-C LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154722,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ-C R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154723,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ-D LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154724,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ-D R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154725,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ-E R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154727,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
REVISION POSTERIOR FEMORAL AUGMENT SZ 7X4MM -,SUP-1549-07-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5135.24,3594.668,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SUMMIT BASIC CEMENTED SZ 6 -,SUP-157006120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ4 OFST 12/14 TAPR W/ POROCOAT -,SUP-1570-11-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL STEM 12/14 TAPER / SZ 5 / 145MM -,SUP-1570-11-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ6 12/14 TAPER W/ PORCOAT -,SUP-1570-11-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL STEM 12/14 TAPER SZ7X155MM -,SUP-1570-11-135,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB XS OXFORD UNICMPT ANTMC BEAR LT FEM MNSCL KN -,SUP-159530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OXFORD KNEED RIGHT MEDIAL TIBIAL TRAY SZAA -,SUP-159532,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SM SZ4 PMA OXFORD UNICMPT ANTMC BRG LT MNSCL -,SUP-159541,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SM 5MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159542,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SM 6MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159543,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SM 9MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159546,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB MED 3MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159547,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB MED 4MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159548,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB MED 6MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159550,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB LRG 3MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159554,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB LRG 6MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159557,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB XL 4MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159562,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB XL 5MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159563,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SM 3MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159568,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SM 6MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159571,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SM 7MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159572,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SM 8MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159573,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SM 9MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159574,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB MED 3MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159575,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB MED 4MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159576,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OXF ANAT BRG RT MD SZ 5 PMA -,SUP-159577,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB MED 6MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159578,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB MED 7MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159579,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB MED 8MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159580,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB LRG 3MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159582,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB LRG 4MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159583,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB LRG 5MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159584,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB LRG 6MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159585,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB XL 3MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL KN -,SUP-159589,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB XL 4MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL KN -,SUP-159590,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB XS 4MM OXFORD UNICMPT ANTMC ARTC BEAR LT MNSCL KN -,SUP-159791,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ5 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-05132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ6 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD. -,SUP-1601-06127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ6 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-06132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ7 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD. -,SUP-1601-07127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ7 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-07132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ8 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD. -,SUP-1601-08127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ8 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-08132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8806.3,6164.41,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ9 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-09127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HIP STEM SZ.9 34MM 142MM V40 -,SUP-1601-09132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HIP STEM SZ.10 34MM / 148MM -,SUP-1601-10132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ11 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-11132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB XS 4MM OXFORD UNIV ANTMC ARTC BEAR RT KN -,SUP-160791,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OSS 3CM PROXIMAL TIBIAL SLEEVE -,SUP-161000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13099.46,9169.622,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OSS RS 3 CM RESURF FMRL-LT -,SUP-161006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26742.28,18719.596,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OSS RS 7 CM MOD SEG FMRL-RT -,SUP-161011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28518.52,19962.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE OSS RS 3 CM PROX TIBIAL -,SUP-161023,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13663.84,9564.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BUSHING OSS RS POLY FEM SET/2 -,SUP-161034,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3131.74,2192.218,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AXLE OSS RS -,SUP-161035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3399.09,2379.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SEGMENT OSS 3CM LG ELLIPT DIAPH -,SUP-161079,CDM,C1776,HCPCS,278,RC,,,outpatient,,,35466.58,24826.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
MOD BEARING TIBIAL OSS RS 63MM -,SUP-161088,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21683.92,15178.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BEARING TIBIAL OSS RS 12MM LS -,SUP-161094,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BEARING TIBIAL OSS RS 16MM LS -,SUP-161096,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BEARING TIBIAL OSS RS 18MM LS -,SUP-161097,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT LT SZ 2 FEMORAL PS NONPOROUS -,SUP-161-1201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL PS RIGHT SZ 2 NON-POROUS -,SUP-161-1202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SEG OSS RS 8.5CM FMRL LEFT -,SUP-161124,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29722.42,20805.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ3 BAL KN LT PS NPOR -,SUP-161-1301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ3 BAL KN RT KN PS NPOR -,SUP-161-1302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ4 BAL KN LT KN PS NPOR -,SUP-161-1401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ4 BAL KN RT KN PS NPOR -,SUP-161-1402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT FEMORAL BALANCED KNEE COCR NONPOROUS 4N KNEE LEFT -,SUP-161-1405,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL PS NARROW RIGHT SZ 4 NON-POROUS -,SUP-161-1406,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 BAL KN LT KN PS NPOR -,SUP-161-1501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 BAL KN RT KN PS NPOR -,SUP-161-1502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL PS NARROW LEFT SZ 5 NON-POROUS -,SUP-161-1505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL PS NARROW RIGHT SZ 5 NON-POROUS -,SUP-161-1506,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ6 BAL KN LT KN PS NPOR -,SUP-161-1601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ6 BAL KN RT KN PS NPOR -,SUP-161-1602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ7 BAL KN LT KN PS NPOR -,SUP-161-1701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ7 BAL KN RT KN PS NPOR -,SUP-161-1702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RT SIZE 2 FEMORAL CR NONPOROUS -,SUP-161-3202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ4 BAL KN LT KN CR NPOR -,SUP-161-3401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 BAL KN LT KN CR NPOR -,SUP-161-3501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 BAL KN RT KN CR NPOR -,SUP-161-3502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ6 BAL KN LT KN CR NPOR -,SUP-161-3601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ6 BAL KN RT KN CR NPOR -,SUP-161-3602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM XS OXFORD KN TWN PG PRT CMNT COCR MLYBDNM ALY -,SUP-161467,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SM OXFORD KN TWN PG PRT CMNT COCR MLYBDNM ALY -,SUP-161468,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM MED OXFORD KN TWN PG PRT CMNT COCR MLYBDNM ALY -,SUP-161469,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TWIN PEGGED FEMORAL LRG KNEE -,SUP-161470,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ2 BAL KN NPOR -,SUP-162-1200A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ3 BAL KN NPOR -,SUP-162-1300A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ4 BAL KN NPOR -,SUP-162-1400A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ5 BAL KN NPOR -,SUP-162-1500A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ6 BAL KN NPOR -,SUP-162-1600A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL TRAY NONPOROUS SIZE 7 -,SUP-162-1700A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 11MM PS KN -,SUP-163-1311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5 8MM PS KN -,SUP-163-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5 13MM PS KN -,SUP-163-1513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ6 12MM PS KN -,SUP-163-1612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ2 13MM UL CONG KN -,SUP-163-3213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 11MM UL CONG KN -,SUP-163-3311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 16MM UL CONG KN -,SUP-163-3316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ4 9MM UL CONG KN PE -,SUP-163-3409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5 14MM UL CONG KN -,SUP-163-3514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2726.14,1908.298,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ6 10MM UL CONG KN -,SUP-163-3610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ6 11MM UL CONG KN -,SUP-163-3611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ6 14MM UL CONG KN -,SUP-163-3614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
MODULAR HEAD COMPONENT 32MM DIA HD 3MM NK -,SUP-163661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
28MM DIA COCR MOD HD -,SUP-163665,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
MODULAR HEAD COMPONENT 32MM -,SUP-163674,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PATELLA  29MM VITAMIN 3 -,SUP-164-5029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PATELLA 32MM VITAMIN E -,SUP-164-5032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PATELLA 35MM VITAMIN E -,SUP-164-5035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PATELLA 38MM VITAMIN E -,SUP-164-5038,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
41MM PATELLA VITAMIN E -,SUP-164-5041,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL PS RIGHT SZ 4 NON-POROUS -,SUP-165-1402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL CR LEFT SZ 6 NON-POROUS -,SUP-165-3601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT PS SIZE 2 7MM VITAMIN E -,SUP-166-5207,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT BKS E-VITALIZE 9MM SZ 2 -,SUP-166-5209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT PS TIBIAL 10MM SIZE 2 V -,SUP-166-5210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT PS TIBIAL SIZE 2 11MM VITAMIN E -,SUP-166-5211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT PS VITAMIN E SIZE 2 12MM -,SUP-166-5212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT PS TIBIAL SIZE 3 7MM VITAMIN E -,SUP-166-5307,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL PS SIZE 3 8MM VITAMIN E -,SUP-166-5308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SIZE 3 9MM TIBIAL INSERT PS VITAMIN E -,SUP-166-5309,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT PS TIBIAL 10MM SIZE 3 V -,SUP-166-5310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL PS SIZE 3 10MM VITAMIN E -,SUP-166-5310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL PS 11MM SIZE 3 V -,SUP-166-5311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL PS 12MM SIZE 3 V -,SUP-166-5312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL PS 13MM SIZE 3 V -,SUP-166-5313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT PS TIBIAL 14MM SIZE 3 V -,SUP-166-5314,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL PS 16MM SIZE 3 V -,SUP-166-5316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SIZE 3 18MM VIT E -,SUP-166-5318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SIZE 3 20MM -,SUP-166-5320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT PS VITAMIN E SZ4 7MM -,SUP-166-5407,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL PS 8MM SIZE 4 VITAMIN E -,SUP-166-5408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT PS TIBIAL 9MM SIZE 4 HI -,SUP-166-5409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT PS TIBIAL 10MM SIZE 4 V -,SUP-166-5410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL PS SIZE 4 10MM VITAMIN E -,SUP-166-5410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT PS VITAMIN E SZ 4 10MM -,SUP-166-5410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL PS 11MM SIZE 4 VITAMIN E -,SUP-166-5411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL PS 11MM SIZE 4 V -,SUP-166-5411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT PS TIBIAL 12MM SIZE 4 H -,SUP-166-5412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL PS SIZE 4 12MM VITAMIN E -,SUP-166-5412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT PS TIBIAL 13MM SIZE 4 H -,SUP-166-5413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL 14MM SIZE 4 HIGH -,SUP-166-5414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SIZE 4 16MM VIT E -,SUP-166-5416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT PS SIZE 4 18MM -,SUP-166-5418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT PS VIT 3 SIZE 4 20MM -,SUP-166-5420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT PS SIZE 5 7 MM VIT E -,SUP-166-5507,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIIAL PS SIZE 5 8MM VITAMIN E -,SUP-166-5508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT PS SIZE 5 9MM TIBIAL VITAMIN E -,SUP-166-5509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL PS SIZE 5 10MM VITAMIN E -,SUP-166-5510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL PS 10MM SIZE 5 V -,SUP-166-5510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL NONPOROUS SIZE 5 -,SUP-166-5511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL 11MM PS SIZE 5 HIGH FLEX VITAMIN E -,SUP-166-5511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL PS 12MM SIZE 5 V -,SUP-166-5512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL PS SIZE 5 12MM VITAMIN E -,SUP-166-5512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL PS 14MM SIZE 5 H -,SUP-166-5514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SIZE 5 16MM VIT E -,SUP-166-5516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SIZE 5 20MM -,SUP-166-5520,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SIZE 6 7MM -,SUP-166-5607,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SIZE 6 8MM VIT E -,SUP-166-5608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SZ 6 9MM PS -,SUP-166-5609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL PS 10MM SIZE 6 H -,SUP-166-5610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SIZE 6 10MM TIBIAL INSERT PS VITAMIN E -,SUP-166-5610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL PS 11MM SIZE 6 VITAMIN E -,SUP-166-5611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SIZE 6 12MM VIT E -,SUP-166-5612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SIZE6 14MM VITAMIN E -,SUP-166-5614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT PS SZ 6 16MM VITAMN-E -,SUP-166-5616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT INSERT PS SIZE 7 10MM VIT E XLPE -,SUP-166-5710,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT CR SZ 5 10MM VITAMIN E -,SUP-166-6510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SZ 2 12MM VIT E -,SUP-166-7212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT UC SZ 3 9MM VIT-E -,SUP-166-7309,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SIZE 3 11MM VIT E XLPE -,SUP-166-7311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT UC SZ 4 8MM VIT E -,SUP-166-7408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SZ 4 9MM VIT E -,SUP-166-7409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT UC SIZE 4 10MM VIT E -,SUP-166-7410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SIZE 4 11MM VIT E -,SUP-166-7411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SIZE 4 12MM VIT E -,SUP-166-7412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SIZE 4 13MM -,SUP-166-7413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT UC SZ 4 14MM VIT E -,SUP-166-7414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SZ 5 7MM VIT E -,SUP-166-7507,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT UC SZ 5 8MM VITAMIN-E -,SUP-166-7508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL UC SZ 5 9MM E-VITALIZE KNEE -,SUP-166-7509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SIZE 5 10MM VIT E -,SUP-166-7510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT BKS E-VITALIZE 11MM SZ 5 -,SUP-166-7511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT UC SZ 5 12MM VIT-E -,SUP-166-7512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SIZE 5 13MM VITAMIN E -,SUP-166-7513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SIZE 5 14MM VIT E -,SUP-166-7514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT UC SIZE 5 16MM VIT-E -,SUP-166-7516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SIZE 6 10MM VIT E -,SUP-166-7610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SIZE 6 11MM VITAMIN E -,SUP-166-7611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SIZE 6 12MM VIT E -,SUP-166-7612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT UC SIZE 6 13MM VIT E -,SUP-166-7613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SIZE 6 14MM VIT E -,SUP-166-7614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT SIZE 7 11MM VIT E -,SUP-166-7711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE HIP UNITRAX V40 UNIPL TI -,SUP-170000E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL THREE HOLE 44MM -,SUP-170-0144,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 48MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0148,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4630.78,3241.546,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 50MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 52MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0152,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 56MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 58MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0158,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 60MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 62MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0162,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ESCALADE 68MM THREE HOLE -,SUP-170-0168,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACETABULAR LEGEND OD50 MM 3 HOLE -,SUP-170-0550,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
POROUS ACET SHELL THREE HOLE 52MM OD -,SUP-170-0552,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
POROUS ACETABULAR SHELL THREE-HOLE 54MM OD -,SUP-170-0554,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
POROUS ACETABULAR SHELL THREE HOLE 56MM OD -,SUP-170-0556,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4630.78,3241.546,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 32MM X 52MM NEUTRAL HXLPE -,SUP-170-3252,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 36MM 52MM SHL ESCALADE +3 NEUT -,SUP-170-3652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 36MM 54MM SHL ESCALADE +1 NEUT -,SUP-170-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 36MM 56MM SHL ESCALADE +0 NEUT -,SUP-170-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 36MM 58MM SHL ESCALADE +0 NEUT -,SUP-170-3658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 36MM 60MM SHL ESCALADE +0 NEUT -,SUP-170-3660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 36X62MM ESCALDE +ODEG NEUT F/T/H ARTHPL -,SUP-170-3662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER +3 NEUTRAL 40 X 56MM HXL -,SUP-170-4056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER NEUTRAL +1 ESCALADE -,SUP-170-4058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 40X60MM ESCALDE +ODEG NEUT F/T/H ARTHPL -,SUP-170-4060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 40X62MM ESCALDE +ODEG NEUT F/T/H ARTHPL -,SUP-170-4062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ACETABULAR LINER 36 X 52 +3 HOODED HXLPE -,SUP-171-3652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACETABULAR 36 X 54 HOODED -,SUP-171-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 36X56MM ESCALDE +ODEG HD F/T/H ARTHPL -,SUP-171-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER 28MM ID 44MM OD NEUTRAL HXLPE -,SUP-172-2844,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER 32MM ID 46MM OD NEUTRAL HXLPE -,SUP-172-3246,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER 36MM ID 50MM OD NEUTRAL HXLPE -,SUP-172-3650,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER 36MM ID 52MM OD NEUTRAL HXLPE -,SUP-172-3652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER 36MM ID 54MM OD NEUTRAL HXLPE -,SUP-172-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER 36MM ID 56MM OD NEUTRAL HXLPE -,SUP-172-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER 36MM ID 58MM OD NEUTRAL HXLPE -,SUP-172-3658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER 36MM ID 60MM OD NEUTRAL HXLPE -,SUP-172-3660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER 36MM 64-70MM OD NEUTRAL -,SUP-172-3664,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER 40MM ID 56MM OD NEUTRAL HXLPE -,SUP-172-4056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER 40MM ID 58MM OD NEUTRAL HXLPE -,SUP-172-4058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER 40MM ID 60MM OD NEUTRAL HXLPE -,SUP-172-4060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM WITH MICROPOUROUS SUR 14MM X 12MM X 180CM -,SUP-172-918/14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM WITH MICROPOROUS SURGACE 14MM X 16MM L 180MM -,SUP-172-918/16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM WITH MICROPOROUS SURFACE 18MM X 16MM L180MM -,SUP-172-918/18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEMORAL LINK W/MICROPOROUS CEMTLESS 20MM X 18MM X 180MM -,SUP-172-918/20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINK STEM WITH MICROP SUR 14MM X 16MM -,SUP-172-921/16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM WITH MICROPOROUS SURFACE 16 X 18 X 210 -,SUP-172-921/18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINK STEM WITH MICROP SUR 14MM X 11MM X 120MM -,SUP-172-925/14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM WITH MICROPOROUS SURFACE 12.5MM X 16MM L 250MM -,SUP-172-925/16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM MICROPOROUS SURF 14.5MM X 18MM L 250MM CEMENTLESS -,SUP-172-925/18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SPACER PROXIMAL 20MM X 14MM COCRMO -,SUP-172-950/20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1484.14,1038.898,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINK NECK SEGMENT WITHOUT COLLAR CEMLESS 65MM 126CCD -,SUP-172-964/26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
NECK FEMORAL W/O COLLAR CEMENTLESS TILASTAN TI6AI-4V LINK -,SUP-172-964/35,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
NECK SEGMENT WITHOUT COLLAR CEMENTLESS -,SUP-172-965/26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
NECK SEGMENT XXL W/O COLLAR 65MM 12/14MM CEMENTLESS -,SUP-172-984/26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINK NECK SEG XXL WITHOUT COLLAR CEMENLESS 65MM -,SUP-172-984/35,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER 36MM ID 50MM OD HOODED HXLPE -,SUP-173-3650,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER 36MM ID 54MM OD HOODED HXLPE -,SUP-173-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER 36MM ID 56MM OD HOODED -,SUP-173-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER 36MM ID 58MM OD HOODED HXLPE -,SUP-173-3658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM ABC 36X0MM NK ALMN C-TAPR PRIM -,SUP-173600E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ASCENT ANT STBLZD TIBIAL BEARING 14 X 67 -,SUP-179822,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5551.15,3885.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP RESTORIS SZ 3 LEFT MAKO PATELLOFEMORAL COCRMO -,SUP-180403,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT RESTORIS MCK SIZE 4 LEFT PATELLOFEMORAL COCRMO -,SUP-180404,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP RESTORIS MCK PAT/FEM SZ 5 RIGHT COCRMO -,SUP-180415,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT FEMORAL RESTORIS MCK SIZE 1 LM/RL -,SUP-180501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT FEMORAL SZ 3 LM/RL RESTORIS MAKO COCRMO -,SUP-180503,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT FEMORAL SIZE 4 LM/RL RESTORIS MCK COCRMO -,SUP-180504,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT FEMORAL SZ 5 LM/RL RESTORIS MAKO COCRMO -,SUP-180505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT FEMORAL SZ 6 LM/RL RESTORIS MAKO COCRMO -,SUP-180506,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT FEMORAL SZ 1 RM/LL RESTORIS MAKO COCRMO -,SUP-180511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT FEM ONLAY SZ 3 RM/LL RESTORIS MAKO COCRMO -,SUP-180513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT FEMORAL SZ 4 RM/LL RESTORIS MAKO COCRMO -,SUP-180514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT FEMORAL RESTORIS MCK SZ 5 RM/LL COCRMO MAKO -,SUP-180515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT FEMORAL RESTORIS MCK SZ 6 RM/LL COCRMO MAKO -,SUP-180516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT FEM RESTORIS MCK SZ 7 RM/LL COCRMO -,SUP-180517,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIBIAL RESTORIS MCK ONLAY SIZE 2 LM/RL -,SUP-180602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIBIAL RESTORIS SZ 3 LM/RL T/6A/4V ONLAY MAKO -,SUP-180603,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE ONLAY TIBIAL SZ 4 LM/RL T/6A/4V RESTORIS MAKO -,SUP-180604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE ONLAY TIBIAL 5 LM/RL RESTORIS MCK -,SUP-180605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE ONLAY TIBIAL 6 LM/RL RESTORIS MCK -,SUP-180606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE ONLAY TIBIAL SZ 2 RM/LL Ti6AI4V RESTORIS MAKO -,SUP-180612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE ONLAY TIBIAL SIZE 3 RM/LL RESTORIS MCK TI6AI4V -,SUP-180613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE ONLAY TIBIAL SZ 4 RM/LL Ti6AI4V RESTORIS MAKO -,SUP-180614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIBIAL RESTORIS MCK SZ 5 RM/LL ONLAY MAKO TI6AI4V -,SUP-180615,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE ONLAY TIBIAL 6 RM/LL RESTORIS MCK -,SUP-180616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE ONLAY TIBIAL 7 RM/LL RESTORIS MCK TI6A14V -,SUP-180617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIBIAL RESTORIS MCK SZ 8 RM/LL TI6I4V -,SUP-180618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL SIZE 2 UNI X 8MM MAKO X3 ONLAY -,SUP-180732-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL MAKO X3 UNI ONLAY SIZE 2 X 8MM -,SUP-180732-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL MAKO X3 3 X 8 MM KNEE ONLAY -,SUP-180733-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ONLAY TIBIAL SZ 4 X 8MM MAKO X3 UNI -,SUP-180734-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL SIZE 4 X 8MM UNI ONLAY MAKO X3 -,SUP-180734-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL UNI ONLAY SIZE 4 X 9MM THKNS MAKO X3 -,SUP-180734-2,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL ONLAY SZ 5 X 8MM MAKO X3 UNI -,SUP-180735-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL ONLAY SZ 5 X 9MM MAKO X3 UNI -,SUP-180735-2,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ONLAY TIBIAL SZ 6 X 8MM MAKO X3 UNI -,SUP-180736-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL ONLAY SZ 6 X 8MM MAKO X3 UNI -,SUP-180736-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ONLAY TIBIAL SZ 7 X 8MM MAKO X3 UNI -,SUP-180737-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ONLAY TIBIAL MAKO X3 UNI SZ 8 X 8MM THKNS -,SUP-180738-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 28MM +0MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-18-2800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM 55MM VANGRD RT KN CR ANTMC CMNT COCR NPOR INTLOK -,SUP-183000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM 62.5MM VANGRD RT KN CR ANTMC CMNT COCR NPOR INTLOK -,SUP-183006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMUR CR INTERLOCK RIGHT 65MM VANGUARD -,SUP-183008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
VANGUARD CR ILOK FEM-LT 62.5 -,SUP-183026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM 57.5MM VANGRD LT KN CR ANTMC CMNTLS TI POR -,SUP-183062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM 62.5MM VANGRD LT KN CR ANTMC CMNTLS TI POR -,SUP-183066,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM 70MM VANGRD LT KN CR ANTMC CMNTLS TI POR -,SUP-183072,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM 57.5MM VANGRD RT FEM OPN BX CMNT COCR -,SUP-183102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM 60MM VANGRD RT KN PS OPN BX CMNT COCR NPOR INTLOK -,SUP-183104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PS OPEN BOX FEMORAL - LEFT 62.5MM -,SUP-183126,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PLATE VN PS OPEN INTL FEM-LT 70 -,SUP-183132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 32MM +0MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 32MM +5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB 10X63/67MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-183520,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB 16X63/67MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-183526,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 36MM +0MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 36MM +5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB 12X63/67MM VANGRD PS MODULAR ARTC BEAR 0DG SLP KN -,SUP-183622,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 36MM -5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-18365,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 36MM +7.5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183675,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL BEARING 14MM X 63/67 MM -,SUP-183724,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BRIDGE VANGUARD PS+TIB 20 X63/67MM -,SUP-183730,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL BEARING 14MM X 71/75MM -,SUP-183744,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BRIDGE VNGD PS+TIB 24 X79/83MM -,SUP-183774,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
VNGD SSK PSC TIB BRG 20 X 71/75 -,SUP-183890,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9735.49,6814.843,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 31MM STD 8MM TI SS UNMWPE PEGX3 VANGRD -,SUP-184764,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SERIES A ASYMMETRIC PAT 31X8 -,SUP-184792,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SERIES-A ASYMMETRICAL PATELLA 31MM / 8MM -,SUP-184792,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SERIES A ASYMMETRIC PAT 34X8.5 -,SUP-184793,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
DRILL HEADLESS TROCAR PIN 75MM -,SUP-185086,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9557.26,6690.082,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL TRAY WITH TI LCK BAR AND SCREW -,SUP-185203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11606.84,8124.788,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OFFSET ADAPTER WITH SCREWS -,SUP-185210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4611.68,3228.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ADAPTER OFFSET BMT 360 TIB 6.0 -,SUP-185211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4611.68,3228.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT BMT 360 TIBIAL 7 X 5MM -,SUP-185223,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5321.98,3725.386,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT BMT 360 TIBIAL 71 X 15MM RL/LM -,SUP-185243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5321.98,3725.386,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT BMT 360 TIBIAL 71 X 15MM LL/RM -,SUP-185253,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5321.98,3725.386,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
VNGD SSK 360 L FEMORAL R 67.5 -,SUP-185265,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29741.13,20818.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
VNGD SSK 360 L FEMORAL 65MM -,SUP-185284,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29741.13,20818.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT VG 360 DIST FM 67.5 X 5 RL/LM -,SUP-185305,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT VG 360 DIST FM 67.5 X 5 LL/RM -,SUP-185325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT VG 360 UNIV PST FM 65 X 10 -,SUP-185424,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT VG 360 UNIV PST FM 67.5 X 10 -,SUP-185425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
WING BMT 360 TIBIAL SM CRUCIATE -,SUP-185650,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
VANGUARD ANT STBLZD BRG 12X67 -,SUP-189042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BRIDGE VANGUARD ANT STBLZD 14 X 67 -,SUP-189044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BRIDGE ANT TIBIAL STABILIZED10 X 71MM VANGD -,SUP-189060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE HIP UNIV TRIDENT PRIM ADPTR +0MML NK OFST BIOLOX -,SUP-19-0000T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ADAPTER UNIV C-TAPER +5MM SLEE -,SUP-19-0005T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
UNIVERSAL C-TAPER +2.5MM ADAPTER SLEEVE -,SUP-19-0025T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
UNITED HIP SYSTEM ISCHIAL FLANGE -,SUP-1908-5401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6459.37,4521.559,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM ECHO POR FEMORAL LAT NC 28 X 44MM -,SUP-192114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BOLT LOCKING CONICAL PROX BODY CEMENTLESS 24 X 95 -,SUP-1975-24-095,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17895.36,12526.752,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM DISTAL TAPERED 15 X 190 STRAIGHT -,SUP-1976-15-190,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15238.52,10666.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ7 FNDTN LT KN CR TI NPOR -,SUP-201-01-107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 LONGEVITY NEUTRIAL 32MM C -,SUP-20103203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 LONGEVITY NEUTRIAL 32MM D -,SUP-20103204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3174.71,2222.297,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL G7 LONGEVITY NEUTRIAL 32MM D -,SUP-20103204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 LONGEVITY NEUTRIAL 32MM E -,SUP-20103205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 LONGEVITY NEUTRAL 36MM D -,SUP-20103604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 LONGEVITY NEUTRAL 36MM E -,SUP-20103605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 LONGEVITY NEUTRAL 36MM F -,SUP-20103606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 LONGEVITY NEUTRAL 36MM G -,SUP-20103607,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 LONGEVITY NEUTRAL 40MM F -,SUP-20104006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 LONGEVITY NEUTRAL 40MM G -,SUP-20104007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 FNDTN RT KN CR TI NPOR -,SUP-202-01-105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ7 FNDTN RT KN CR TI NPOR -,SUP-202-01-107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 28X58-60MM SHL OMNIFIT 10DG CROSSFIRE 13.1MM -,SUP-2041C-2858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4587.76,3211.432,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT OMNIFIT SERIES II 20 DEGREE 32MM -,SUP-2042-3250,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3800.96,2660.672,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
JIG TOT JNT RT TIB KN PERSONA ROT -,SUP-20-8070-002-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
JIG TOT JNT LT KN PERSONA PREF -,SUP-20-8070-010-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GW ORTHO TM PT SPEC INST -,SUP-20-8075-001-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 28X58MM OSTEONICS 0DG BIPLR PE 5.8-10.4MM THK -,SUP-2099-2858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9662.67,6763.869,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR KNEE SYS FEMORAL COMPONENT HINGED #3 LEFT -,SUP-2115-1330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR II KNEE SYSTEM FEMORAL COMPONENT HINGED #4 LEFT -,SUP-2115-1340,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR KNEE FEMORAL COMPONENT HINGED #5 LEFT -,SUP-2115-1350,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
UNITED II KNEE FEMORAL COMPONENT HINGED #6 HINGED -,SUP-2115-1360,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
URSTAR II KNEE SYSTEM FEMORAL COMPONENT HINGED #3 RIGHT -,SUP-2115-1430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR II KNEE FEMORAL COMPONENT HINGED #5 RIGHT -,SUP-2115-1450,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR II KNEE DISTAL FEMORAL COMPONENT RHS S LEFT -,SUP-2115-3310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30242.39,21169.673,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR II KNEE DISTAL FEMORAL COMP RHS S RIGHT -,SUP-2115-3410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30242.39,21169.673,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ4 FNDTN LT KN PS TI NPOR -,SUP-213-01-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ8 FNDTN LT KN PS TI NPOR -,SUP-213-01-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ8 FNDTN RT KN PS TI NPOR -,SUP-214-01-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ12 FNDTN RT KN PS TI NPOR -,SUP-214-01-012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
IMPLANT  CUSTOM PFR KINEMATCH -,SUP-22-100-1001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19864.55,13905.185,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR II TIBIAL BASEPLATE HINGED #1 -,SUP-2215-1410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIBIAL USTAR II HINGED 2 KNEE -,SUP-2215-1420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIBIAL SYSTEM USTAR II HINGED 3 -,SUP-2215-1430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIBIAL USTAR II HINGED 4 KNEE -,SUP-2215-1440,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT TIBIAL USTAR II KNEE PROXIMAL RHS S -,SUP-2215-3410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,34950.47,24465.329,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL KNEE USTAR II XPE SMALL 12MM -,SUP-2315-3211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL USTAR II KNEE XPE S 14MM -,SUP-2315-3212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL USTAR II KNEE XPE S 17MM -,SUP-2315-3213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL USTAR II XPE H20 SMALL 20MM -,SUP-2315-3214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR II KNEE XPE TIBIAL INSERT M 17MM -,SUP-2315-3243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR II KNEE XPE TIBIAL INSERT M 20MM -,SUP-2315-3244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL USTAR II KNEW XPE M 23MM -,SUP-2315-3245,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT FEMORAL U2 PSA COCR 5 4MM POSTERIOR SET -,SUP-2603-5051,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5852.48,4096.736,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AGUMENT FEMORAL U2 TOTAL KNEE SET DISTAL #5 12MM -,SUP-2603-5353,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5852.48,4096.736,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEADED PIN 17-4 PH S.S. -,SUP-262-0520A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PS Insert Trial Size 2  14mm -,SUP-263-1214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 40X17MM COCR -,SUP-265 108,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9253.24,6477.268,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
U2 TOTAL KNEE STRAIGHT STEM PSA 14MM X 75MM -,SUP-2703-5013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TIBIAL U2 PSA TI STRAIGHT 16MM X 75MM KNEE -,SUP-2703-5014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
U2 TOTAL KNEE SYSTEM STRAIGHT STEM PSA 22MM DIA 75MM STEM -,SUP-2703-5017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
U2 TOTAL  KNEE STRAIGHT STEM PSA 24MM DIA 75MM STEM LENGTH -,SUP-2703-5018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
U2 TOTAL KNEE STRAIGHT STEM PSA 12MM DIA 100MM STEM LENGTH -,SUP-2703-5022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TIBIAL U2 PSA STRAIGHT 20MM X 150MM TOTAL KNEE -,SUP-2703-5056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR II KNEE CEMENTED STRT STEM RHS NON COAT 9 X 100 -,SUP-2715-3009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR II KNEE SYS CEMENTED STR STEM RHS NON-COAT 11X100 -,SUP-2715-3011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR II KNEE CEMENTED STRAIGHT STEM RHS NON COATED 13 X 100 -,SUP-2715-3013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR II KNEE CEMENTED STRT STEM RHS NON COATED 15 X 100 -,SUP-2715-3015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR II KNEE CEMENTED STRAIGHT STEM RHS NON COAT 17X100 -,SUP-2715-3017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CEMENTED STRAIGHT STEM RHS COLLARLESS 9 X 125MM -,SUP-2715-3109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR II KNEE CEMENTED STRAIGHT STEM RHS NON COATED 11X125 -,SUP-2715-3111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR CEMENTED STRAIGHT STEM RHS NON COATED 13 X 125MM -,SUP-2715-3113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
KNEE SYSTEM CEMENTED STRAIGHT STEM RHS NON COATED 15 X 125MM -,SUP-2715-3115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR II KEE CEMENTED TIBIAL STEM 9MM X 20MM STEM LENG -,SUP-2715-5109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR II KNEE CEMENTED TIBIAL STEM 9MM X 45MM STEM -,SUP-2715-5209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TIBIAL USTAR II 9MM X 95MM KNEE CEMENT -,SUP-2715-5409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR II KNEE TIBIAL STEM 12.5MM X 70MM -,SUP-2715-7312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR II KNEE TIBIAL AUGMENT #2 10MM THICK -,SUP-2815-1022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5215.88,3651.116,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR SEGMENT PART RHS 50MM LENGTH -,SUP-2915-1050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22014.38,15410.066,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
USTAR II KNEE SEGMENT PART RHS 70MM LENGTH -,SUP-2915-1070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22014.38,15410.066,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 11MM 8.5MM MDL OFST PRIM PRFT EQUINOXE 110MM TI ALY -,SUP-300-01-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 15MM 9.5MM MDL OFST PRIM PRFT EQUINOXE 120MM TI ALY -,SUP-300-01-15,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PLATE BN EQUINOXE F/RVRS SYS ANTMC REPLICATOR TI ALY 4.5MM -,SUP-300-10-45,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4686.87,3280.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER G7 VIT E NEUTRAL 36MM E -,SUP-30103605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER G7 VIT E NEUTRAL 36MM F -,SUP-30103606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
G7 VIT E HIGH WALL LNR 36MM D -,SUP-30123604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER G7 VIT E HIGH WALL 36MM F -,SUP-30123606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER G7 VIT E HIGH WALL 40MM H -,SUP-30124008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER G7 VIT E +5MM 40MM H -,SUP-30154008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8963.33,6274.331,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 47MM SHRT 18MM EQUINOXE 1.5MM OFST COCR -,SUP-310-01-47,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7808.96,5466.272,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 53MM SHRT EQUINOXE -,SUP-310-21-53,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6472.1,4530.47,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP B MED EQUINOXE SHLDR PG -,SUP-314-02-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4010.16,2807.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SPHERE GLND 38MM EQUINOXE RVRS -,SUP-320-01-38,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRY ADAPTER HUM WDG +0MM RVRS BALL SCKT EQUINOXE -,SUP-320-10-00,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 10MM FNDTN MODULAR REVISN 100MM TIB KN -,SUP-320-10-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER HUM 38MM STD EQUINOXE -,SUP-320-38-00,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4559.17,3191.419,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER HUM 38MM STD RVRS EQUINOXE -,SUP-320-38-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4559.17,3191.419,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BLOCK CUT SZ4 10MM RM/LL FNDTN KN REVISN F/SPCR -,SUP-321-101-04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ4 RT KN STM FNDTN REVISN MODULAR NPOR -,SUP-322-01-104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BLOCK CUT SZ4 5MM RL/LM FNDTN KN REVISN F/SPCR -,SUP-322-05-104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BLOCK CUT SZ4 10MM RL/LM FNDTN KN REVISN F/SPCR -,SUP-322-10-104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ2 10.9MM FNDTN PS ARTC CONGR KN COMPR MLD -,SUP-360-09-510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ2 11MM FNDTN PS ARTC CONGR KN COMPR MLD UHMWPE -,SUP-360-11-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ2 13MM FNDTN PS ARTC CONGR KN COMPR MLD UHMWPE -,SUP-360-13-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB 4MM AXSOS LCK -,SUP-370002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,240.4,168.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ORTHO 14X8.5MM DIA FEM LCK 5MM HL AXSOS NS -,SUP-370003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,274.83,192.381,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ2 13MM FNDTN CR PRIM CNSTRN ARTC CONGR L/R KN -,SUP-385-13-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CENTRALIZER DIST HIP TI ALY -,SUP-400-03-002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 36MM +4MM NK BIOLOX DELTA CERM -,SUP-400-03-363,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4487.56,3141.292,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM BIOLOX DELTA 40MM NEUT CERM -,SUP-400-03-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP REV SHLDER 9 IN STEINMANN -,SUP-405800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SEASPINE TULIP HEADS -,SUP-41-1000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE HIP NEUT OFST UNIPL ANG -,SUP-411-00-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 46MM UNIPL -,SUP-411-00-146,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PLUG SMALL DIA CEMENT 8MM -,SUP-414993,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
KT THR SZ3 FEM 3 TIB RT HIP TRUMATCH -,SUP-420859,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
KT TKR LT HIPERF 3T/3F -,SUP-420878,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
KT TKR RT HIPERF -,SUP-420890,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMUR PERSONA CEMENTED CCR NARROW SIZE 5 R -,SUP-42500005802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMUR PERSONA CEMENTED NARROW PS LT SZ 6 -,SUP-42500006001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMUR PERSONA CEMENTED CCR NARROW SIZE 8 R -,SUP-42-5000-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT PSN FEM PS CMT CCR SZ 7 R STD -,SUP-42-5006-062-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT PSN FEM PS CCR STD SIZE 10 L -,SUP-42500606801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ3 PERSONA RT KN CR CMNT COCR NRW -,SUP-42-5020-054-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ6 PERSONA LT KN CR CMNT COCR NRW -,SUP-42-5020-060-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ7 PERSONA LT KN CR CMNT COCR NRW -,SUP-42-5020-062-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ7 PERSONA RT KN CR CMNT COCR NRW -,SUP-42-5020-062-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMUR PERSONA CEMENTED CR NARROW RT SZ 9 -,SUP-42502006602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMUR PERSONA CEMENTED KNEE CR   RT SZ10 -,SUP-42-5020-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 PERSONA LT KN CR CMNT COCR POR NRW -,SUP-42-5022-058-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ6 PERSONA LT KN CR CMNT COCR POR NRW -,SUP-42-5022-060-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMUR FEMORAL CR POR CCR NRW SIZE 6 RIGHT PERSONA -,SUP-42-5022-060-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ7 PERSONA RT KN CR CMNT COCR POR NRW -,SUP-42-5022-062-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PSN FEM SZ 10 R CR CCR POR NRW -,SUP-42-5022-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ6 LEFT PERSONA KN CR STD CMNT CCR -,SUP-42-5026-060-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PERSONA FEMUR CMNT STD CCR SIZE 7 RIGHT -,SUP-42502606202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ8 PERSONA LT KN CR STD CMNT COCR NRW -,SUP-42-5026-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ8 RIGHT PERSONA KN CR STD CMNT COCR -,SUP-42-5026-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ10 PERSONA RT KN CR STD CMNT COCR NRW -,SUP-42-5026-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PSN FEM CR POR CCR STD SZ7 L -,SUP-42-5028-062-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ8 PERSONA LT KN CR STD COCR POR -,SUP-42-5028-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ8 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ9 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-066-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PERSONA KNEE SYSTEM FEMUR -,SUP-42-5028-068-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ10 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ11 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-070-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ12 R PERSONA RT KN CCR STD COCR POR -,SUP-42-5028-074-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PSN REV FEM CMT CCR STD SZ 5 R -,SUP-42-5046-058-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,33973.95,23781.765,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PSN REV FEM CMT CCR STD SZ 9 L -,SUP-42-5046-066-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,31746.15,22222.305,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PSN ASF CR 12MM PLY L 3-11 EF -,SUP-42-5110-005-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ8 139MM LNR PRFT LAT OFST CLLRLS 47.4MM NK TI POR -,SUP-425-11-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ13 148.5MM LNR PRFT LAT OFST CLLRLS 49.8MM NK TI -,SUP-425-11-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SYS PERSONA KNEE ASF UC 18MM PLY L-4-11 EF -,SUP-42-5112-005-18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PERSONA KNEE SYSTEM ARTICULAR SURFACE -,SUP-42-5112-006-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ C-D/3-9 10MM PERSONA CR ARTCSURF LT KN PE -,SUP-42-5120-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ C-D/3-9 11MM PERSONA CR ARTCSURF LT KN PE -,SUP-42-5120-004-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ C-D/3-9 12MM PERSONA CR ARTCSURF LT KN PE -,SUP-42-5120-004-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ E-F SZ3-11 FEM 10MM PERSONA ARTCSURF LT KN PE -,SUP-42-5120-005-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PSN ASF CR 12MM VE L 3-11EF -,SUP-42-5120-005-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PERSONA ARTICULAR SURFACE LEFT 11MM -,SUP-42-5121-007-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PSN MC VE ASF L 12MM 12/GH -,SUP-42-5121-010-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ C-D SZ3-7 FEM 12MM PERSONA CR ARTCSURF LT KN -,SUP-42-5122-004-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SURFACE ARTICULAR PERSONA VIVACIT-E 3-7 UC C-D 10MM KNEE LFT -,SUP-42512200410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PERSONA ARTICULAR FIXED BEARING LEFT 16MM -,SUP-42512200516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PERSONA ARTICULAR SURFACE 10MM -,SUP-42-5122-006-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ARTICULAR SURFACE PERSONA LT 16MM -,SUP-42512600516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PSN ASF CPS 14MM VE L 6-9 GH -,SUP-42-5126-009-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PSN PK VE PLY- LM- SZ E- 8MM -,SUP-42-5182-005-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ7 PERSONA LT KN CR STD COCR POR -,SUP-42-5208-062-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PSN FEMORALASF UC 10MM POLY R 4-11 EF -,SUP-42-5212-00-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BEARING FIXED ASF UC 12MM PLY 3-7CD PERSONA -,SUP-42-5212-004-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BEARING FIXED ASF UC 12MM PLY R 4-11 EF PERSONA -,SUP-42-5212-005-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BEARING PSN ASF UC 10MM PLY R 7-12 GH -,SUP-42521200610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PSN ASF UC 12MM PLY R 7-12 GH -,SUP-42-5212-006-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ C-D SZ3-9 FEM 10MM PERSONA CR ARTCSURF RT KN -,SUP-42-5220-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ C-D/3-9 11MM PERSONA CR ARTCSURF RT KN PE -,SUP-42-5220-004-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ E-F/3-11 11MM PERSONA CR ARTCSURF RT KN PE -,SUP-42-5220-005-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SURFACE ARTICULAR 10MM HEIGHT RIGHT -,SUP-42-5221-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ARTICULAR SURFACE PERSONA MC VE RT 13MM -,SUP-42522100513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ARTICULAR SURFACE PERSONA MC RT 10MM -,SUP-42522100810,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ARTICULAR SURFACE RIGHT 10MM /SIZES E-F/CR 8-11 -,SUP-42-5221-008-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ARTICULAR SURFACE PERSONA MC RT 11MM -,SUP-42-5221-008-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SURFACE ARTICULAR PERSONA RIGHT 10MM X 12/GH MC VE ASF -,SUP-42-5221-010-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ C-D/3-7 10MM PERSONA ARTCSURF UL CONG RT KN PE -,SUP-42-5222-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ E-F 10MM PERSONA UL CONG ARTCSURF RT KN PE -,SUP-42-5222-005-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HIGHLY CROSSLINKED POLY ARTICULAR FIXED BEARING -,SUP-42-5222-005-18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
VIVICIT-E PERSONA ASF UC 11MM 7 - 12GH -,SUP-42-5222-006-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CD PERSONA ASF PS 16MM VE R 3-5 -,SUP-42522400416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL PSN ASF PS 13MM VE R 6-9 CD -,SUP-42-5224-005-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PSN ASF CPS 14MM VE R 3-5CD -,SUP-42-5226-004-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PERSONA HIGHLY CROSSLINKED POLY 6-9EF VE R -,SUP-42-5226-007-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PERSONA HIGHLY CROSSLINKED POLYETHLENE 6-9EF -,SUP-42-5226-007-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PSN REV CCK ART SURF VE 12MM R 7-9+ CD -,SUP-42522800512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIB SZ-C PERSONA PEGX2 LT KN POR TM -,SUP-42-5300-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIB SZ-D PERSONA PEGX2 RT KN POR TM -,SUP-42-5300-067-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PSN TIB POR 2 PEG SZ E L -,SUP-42-5300-071-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIB SZ-F PERSONA PEGX2 RT KN POR TM -,SUP-42-5300-075-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PSN TIB POR 2 PEG SZ G L -,SUP-42-5300-079-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PSN TIB POR 2 PEG SZ G R -,SUP-42530007902,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PSN TIB POR 2 PEG SZ H R -,SUP-42-5300-083-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TIB SZ-C 5DG PERSONA LT KN -,SUP-42-5320-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM PERSONA ASF 16MM VE 3-5 R CD -,SUP-42532006402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TIB SZ-C 5DG PERSONA RT KN -,SUP-42-5320-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TIB 5DG SZ-D PERSONA LT KN -,SUP-42-5320-067-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TIB SZ-D 5DG PERSONA RT KN -,SUP-42-5320-067-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TIB 5DG SZ-E PERSONA LT KN -,SUP-42-5320-071-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIA PERSONA CEMENTED STEMMED RT SZ E -,SUP-42532007102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
NAT TIBIA CEME 5 DG SIZE F -,SUP-42-5320-075-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TIB SZ-F 5DG PERSONA RT KN -,SUP-42-5320-075-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PSN PK CMT TIB- LM- SZ E -,SUP-42-5380-005-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT PATELLAR PERSONA ALL POLY PAT PLY 41MM -,SUP-42540000041,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
DIA ALL POLY PAT PERSONA  29MM -,SUP-42540200029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 29MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-29,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 32MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-32,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 35MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-35,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 41MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-41,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ8 SHRT TAPR FIL TI POR CTD P-SQUARED HIP -,SUP-425-41-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ15 SHRT TAPR FIL TI POR CTD P-SQUARED HIP -,SUP-425-41-015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
KEEL PSN REV TIB FIXED CMT SIZE C R -,SUP-42-5420-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11361.78,7953.246,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PSN REV TIB FIXED KEEL CMT SZ G L -,SUP-42-5420-079-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11361.78,7953.246,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUG PSN REV FEM DISTAL SZ 5 5MM -,SUP-42-5566-058-05,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5602.08,3921.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTENSION PERSONA CEMETED TPRD 14MM X +30MM -,SUP-42557000114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PSN PK CMT FEM- LM- SZ 3 -,SUP-42-5580-003-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PSN PK CMT FEM- RM SZ.4 -,SUP-42558000402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PSN REV TAPERED SMOOTH STEM EXT 14 X 75MM -,SUP-42-5600-075-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8199.41,5739.587,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM PSN REV 6MM OFFSET EXT 10MM X 135MM -,SUP-42-5606-135-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11584.56,8109.192,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMUR PSN CR CMT TIN NRW SIZE 6R -,SUP-42-5720-060-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT FEMORAL PERSONA 7 KNEE -,SUP-42572606201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT PSN FEMORAL TIN STD SIZE 9L -,SUP-42-5726-066-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ8 109MM TAPR FIL PRFT LAT OFST 37MM NK TI POR CTD -,SUP-425-96-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ8 109MM TAPR FIL PRFT LAT OFST 42.5MM NK TI POR -,SUP-425-97-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ9 111MM TAPR FIL PRFT LAT OFST 42.5MM NK TI POR -,SUP-425-97-009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ12 LRG TAPR FIL PRFT LAT OFST TI POR COAT -,SUP-425-97-012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ13 117MM TAPR FIL PRFT LAT OFST 42.5MM NK TI POR -,SUP-425-97-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 13MM STD BGLNI/FLTW 130MM -,SUP-4300-13-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5470.69,3829.483,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 46X21MM BGLNI/FLTW ZML MODULAR OFST -,SUP-4302-46-21,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 48MM POR STRUCTURED TECH HMSPHR -,SUP-430-98-048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM STAGEONE SLCT 56MM SIL MODULAR SPCR STRL -,SUP-431183,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5199.96,3639.972,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ADAPTER STD STAGEONE CMNT MLD SPCR -,SUP-431186,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1636.53,1145.571,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HIP ADAPTER STD STAGEONE 6MM -,SUP-431188,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1428.48,999.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 15X155MM STG 1 HIP -,SUP-431193,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6510.3,4557.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HIP MOLD STEM W/REINF 13 X 200 -,SUP-431197,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6510.3,4557.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 12MM FNDTN CLLR FRG COCR CMNT 132DG ANG TAPR HIP -,SUP-450-01-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD RADL 26MM 10.5MM EVOLVE PROLINE COCR MODULAR -,SUP-496H026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7999.94,5599.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 28MM SHRT -3.5MM NK COCR MODULAR -,SUP-497-28-035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ-G 62MM RIM TRIDENT PRIM MODULAR HAP CTD -,SUP-500-01-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ-C 48MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-48C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ-D 50MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ-D 52MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-52D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ-E 54MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ-E 56MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-56E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ-F 58MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL SOLID BACK 60MM F -,SUP-500-03-60F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 48MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-5001-48,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ-C 46MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-01-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ-C 48MM RIM TRIDENT PRIM MODULAR CLUS-HL. -,SUP-502-03-48C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB 50MM TRIDENT PRIM MODULAR CLUS-HL X3 TRTNM LCK -,SUP-502-03-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ-D 52MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-03-52D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL HEMISPHERICAL 54MM SZ-E RIM CLUSTER HOLE -,SUP-502-03-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ-E 56MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-03-56E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ-D 50MM RIM TRIDENT PRIM.MODULAR CLUS-HL -,SUP-502-03-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ-F 60MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-03-60F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ-D 50MM RIM TRIDENT PRIM MODULAR.CLUS-HL -,SUP-502-11-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ANATOMIC HEMISPHERICAL SHELL  56MM D RT -,SUP-504-02-56D-R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12514.18,8759.926,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEMISPHERICAL SHELL ANATOMIC RESTORATION -,SUP-504-02-58D-L,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12514.18,8759.926,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEMISPHERICAL SHELL 64MM -,SUP-504-02-64E-R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12514.18,8759.926,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT HUM 4MM 32MM STD PE RVRS SCKT F/RSP STRL -,SUP-508-00-432,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4559.17,3191.419,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL TRIDENT HEMISPHERICAL ACETABULAR 46MM C -,SUP-508-11-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL HEMI ACETABULAR 48MM -,SUP-508-11-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ-D 50MM RIM TRIDENT PRIM MODULAR MUL-HL -,SUP-508-11-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ACETABULAR SHELL 52MM -,SUP-508-11-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ-E 54MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL HEMISPHERICAL 56MM E TRI -,SUP-509-02-56E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ-F 58MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ-F 60MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-60F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ-G 62MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ-G 64MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-64G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ H LINER 66MM RIM TRIDENT REVISN MUL-HL -,SUP-509-02-66H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ H LINER 68MM RIM TRIDENT REVISN MUL-HL -,SUP-509-02-68H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIDENT TRITANIUM HEMI SHELL SZ 70MM -,SUP-509-02-70I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT ACTB 50MM RESTOR REVISN RECON HIP 15MM -,SUP-5096-5015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT ACTB 50MM RESTOR REVISN RECON HIP 20MM -,SUP-5096-5020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
WEDGE AUGMENT RESTORATION ACET 54MM X 56MM X 15MM -,SUP-5096-5415,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT ACTB 58MM RESTOR REVISN RECON HIP -,SUP-5096-5815,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 6MM PRIM MBLK RVRS RSP 101MM CMNT 150DG ANG NK CYL -,SUP-510-00-006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19030.28,13321.196,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TPRLC 133 FP TYPE 1 PPS SO 5.0 -,SUP-51-100050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TPRLC 133 FP TYPE 1 PPS SO 6.0 -,SUP-51-100060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TPRLC 133 FP TYPE1 PPS SO 7.0 -,SUP-51-100070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TPRLC 133 FP TYPE1 PPS SO 8.0 -,SUP-51-100080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEMORAL TPRLC 133 FP PPS TYPE 1  6.0 H -,SUP-51-101060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TPRLC 133 FP PPS TYPE 1 HO 7.0 -,SUP-51-101070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TPRLC 133 FP PPS TYPE 1 HO 8.0 -,SUP-51-101080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TPRLC XR FP TYPE 1 PPS 5 X 130MM -,SUP-51-102050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TPRLC XR FP TYPE 1 PPS 6 X 132MM -,SUP-51-102060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TPRLC XR FP TYPE 1 PPS 8 X 136MM -,SUP-51-102080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TPRLC 133 TYPE 1 PPS SO 9 X 137MM -,SUP-51-103090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TPRLC 133 TYPE 1 PPS SO 10 X 140MM -,SUP-51-103100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TPRLC 133 TYPE 1 PPS SO 11 X 142MM -,SUP-51-103110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TPRLC 133 T1 PPS SO 12 X 144MM -,SUP-51-103120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TPRLC 133 T1 PPS SO 13 X 146MM -,SUP-51-103130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TPRLC 133 T1 PPS SO 14 X 148MM -,SUP-51-103140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TPRLC 133 TYPE 1 PPS SO 15 X 150MM -,SUP-51-103150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TAPERLOC 133 T1 9 X 137MM -,SUP-51-104090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TPRLC 133 T1 PPS 11 X 142MM -,SUP-51-104110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TPRLC 133 T1 PPS HO 13 X 146MM -,SUP-51-104130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TPRLC TYPE 1 PPS HO 14 X 148MM FEM POR -,SUP-51-104140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TPRLC TYPE 1 PPS HO 15 X 150MM FEM POR -,SUP-51-104150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TPRLC 133 TYPE 1 PPS HO 16 X 152MM -,SUP-51-104160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TAPERLOC 133 T1 PPS HO 20 X 160MM -,SUP-51-104200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TAPERLOC 10 X 140MM COMP XR FEM POR T1 TAPER -,SUP-51-105100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TAPERLOC 11 X 142MM COMP XR 123 FEM POR T1 TAPER -,SUP-51-105110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TPRLC 133 MP TYPE 1 PPS SO 11.0 -,SUP-51-106110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TPRLC 133 MP TYPE1 PPS HO 9.0 -,SUP-51-107090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TPRLC 133 MP TYPE1 PPS HO 14.0 -,SUP-51-107140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TPRLC 133 MP TYPE1 PPS HO 16.0 -,SUP-51-107160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TPRLC 133 MP TYPE1 PPS HO 17.0 -,SUP-51-107170,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TPRL 133 MP TYPE1 PPS SO 4.0 -,SUP-51-108040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TPRLC 133 MP T1 PPS SO 5X95MM -,SUP-51-108050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TPRLC133 MP 6X97.5MM -,SUP-51-108060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TPRLC 133 MP T1 PPS SO 8X101MM -,SUP-51-108080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TLOC 133 MP SP T1 PPSHO 6X97.5 -,SUP-51-109060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TLOC 133 MP SP T1 PPS HO 8X101 -,SUP-51-109080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM S-ROM 28MMSTDX+6MM NK COCR 11/13 TAPR MODULAR -,SUP-52-2029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4824.58,3377.206,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SCREW 2.3X12MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23212E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 45X15MM -,SUP-5350-4515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6472.1,4530.47,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 12MM SOLAR 130MM TI SHLDR -,SUP-5351-4108,CDM,C1776,HCPCS,278,RC,,,outpatient,,,33064.27,23144.989,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 40X15MM OFST -,SUP-5352-4015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6472.1,4530.47,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACTB SZ-D 46MM 47.8MM RIM TRIDENT PSL PRIM MODULAR HAP -,SUP-540-11-46D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ1 TRIATH LT KN CR CMNT -,SUP-5510-F-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ1 TRIATH RT KN CR CMNT -,SUP-5510-F-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ2 TRIATH LT KN CR CMNT -,SUP-5510-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ2 TRIATH RT KN CR CMNT -,SUP-5510-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ3 TRIATH LT KN CR CMNT -,SUP-5510-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ3 TRIATH RT KN CR CMNT -,SUP-5510-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ4 TRIATH LT KN CR CMNT -,SUP-5510-F-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ4 TRIATH RT KN CR CMNT -,SUP-5510-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 TRIATH LT KN CR CMNT -,SUP-5510-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 TRIATH RT KN CR CMNT -,SUP-5510-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ6 TRIATH LT KN CR CMNT -,SUP-5510-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ6 TRIATH RT KN CR CMNT -,SUP-5510-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ7 TRIATH LT KN CR CMNT -,SUP-5510-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ7 TRIATH RT KN CR CMNT -,SUP-5510-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ8 TRIATH LT KN CR CMNT -,SUP-5510-F-801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ1 59/53MM TRIATH RT KN TOTAL STABILIZED REVISN -,SUP-5512-F-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ2 62/56MM TRIATH LT KN TOTAL STABILIZED REVISN -,SUP-5512-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT FEMORAL TOTAL STABILIZER #2 RT TS -,SUP-5512-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ3 65/59MM TRIATH LT KN CRCTE STAB REVISN COCR -,SUP-5512-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ3 65/59MM TRIATH RT KN CRCTE STAB REVISN COCR -,SUP-5512-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ4 68/62MM TRIATH LT KN CRCTE STAB REVISN COCR -,SUP-5512-F-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ4 68/62MM TRIATH RT KN CRCTE STAB REVISN COCR -,SUP-5512-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 71/65MM TRIATH LT KN CRCTE STAB REVISN COCR -,SUP-5512-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 71/65MM TRIATH RT KN CRCTE STAB REVISN COCR -,SUP-5512-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ6 74/68MM TRIATH LT KN TOTAL STABILIZED REVISN -,SUP-5512-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TOTAL STABILIZER COMPONET FEMORAL -,SUP-5512-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ7 77/71MM TRIATH LT KN TOTAL STABILIZED REVISN -,SUP-5512-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STABILIZER TOTAL FEM COMP SZ 7 RIGHT TS TRIATHLON -,SUP-5512-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ8 80/75MM TRIATH RT KN TOTAL STABILIZED REVISN -,SUP-5512-F-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ1 TRIATH LT KN PS CMNT -,SUP-5515-F-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ2 TRIATH LT KN PS CMNT -,SUP-5515-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ2 TRIATH RT KN PS CMNT -,SUP-5515-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ3 TRIATH LT KN PS CMNT -,SUP-5515-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ3 TRIATH RT KN PS CMNT -,SUP-5515-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ4 TRIATH RT KN PS CMNT -,SUP-5515-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 TRIATH LT KN PS CMNT -,SUP-5515-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 TRIATH RT KN PS CMNT -,SUP-5515-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ6 TRIATH LT KN PS CMNT -,SUP-5515-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ6 TRIATH RT KN PS CMNT -,SUP-5515-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ7 TRIATH LT KN PS CMNT -,SUP-5515-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ7 TRIATH RT KN PS CMNT -,SUP-5515-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIATHLON PS FEM COMP SZ 8 CEMENTED -,SUP-5515-F-801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ8 TRIATH RT KN PS CMNT -,SUP-5515-F-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
POSTERIOR STABILIZED FEMORAL -,SUP-5516-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIATHLON CRUCLATE RETAINING FEMORAL SZ #1 LEFT CR -,SUP-5517-F-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIATHLON CRUCLATE RETAINING FEMORAL SZ #1 RIGHT CR -,SUP-5517-F-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIATHLON CR FEM COMPONENT - BEADED W/PA -,SUP-5517-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ2 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ3 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ3 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ4 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ4 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ6 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ6 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ7 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ7 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ8 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIATHLON CRUCIATE RETAINING FEMORAL -,SUP-5517-F-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ1 KN CMNT TRIATH PRIM -,SUP-5520-B-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ2 KN CMNT TRIATH PRIM -,SUP-5520-B-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ3 KN CMNT TRIATH PRIM -,SUP-5520-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ4 KN CMNT TRIATH PRIM -,SUP-5520-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ5 KN CMNT TRIATH PRIM -,SUP-5520-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ6 KN CMNT TRIATH PRIM -,SUP-5520-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ7 KN CMNT TRIATH PRIM -,SUP-5520-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ8 KN CMNT TRIATH PRIM -,SUP-5520-B-800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ1 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ2 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ3 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL BASEPLATE TRIATHLON UNIV SIZE 4 -,SUP-5521-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ5 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ6 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ7 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ8 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ3 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ4 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ5 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ6 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ7 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ1 9MM TRIATH CR ARTC KN X3 -,SUP-5530-G-109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ1 11MM TRIATH CR ARTC KN X3 -,SUP-5530-G-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ1 13MM TRIATH CR ARTC KN X3 -,SUP-5530-G-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ1 16MM TRIATH CR ARTC KN X3 -,SUP-5530-G-116,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ1 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-119,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL BEARING INSERT CR SZ2 9MM -,SUP-5530-G-209-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ2 13MM TRIATH CR ARTC KN X3 -,SUP-5530-G-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ2 16MM TRIATH CR ARTC KN X3 -,SUP-5530-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ2 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL BEARING SZ 3 X 10MM CR X3 TRIATHLON -,SUP-5530-G-310-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL BEARING CR SZ4 9MM -,SUP-5530-G-409-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL BEARING CR SZ4 10MM TRIATHLON X3 -,SUP-5530-G-410-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL BEARING INSERT CR SZ4 11MM -,SUP-5530-G-411-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ4 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5 10MM TRIATH CR ARTCSURF KN X3 UHMWPE -,SUP-5530-G-510-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-519,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL BEARING SZ6 10MM TRIATH X3 CR -,SUP-5530-G-610-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ6 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBAL BEARING CR SZ 7 X 9MM TRIATHLON X3 -,SUP-5530-G-709-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBAL BEARING CR SZ 7 X 10MM TRIATHLON X3 -,SUP-5530-G-710-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ7 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ8 13MM TRIATH CR ARTC KN X3 -,SUP-5530-G-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ8 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-819,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIATHALON INSERT CS #1 12MM X3 -,SUP-5531-G-112-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ2 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-209-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL BEARING CS SZ 2 X 10MM TRIATHLON X3 -,SUP-5531-G-210-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ2 11MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT BEARING TIBIAL CS SIZE 2 X 11MM TRIATHLON X3 -,SUP-5531-G-211-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL BEARING CS SZ 2 X 12MM TRIATHLON X3 -,SUP-5531-G-212-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ2 13MM TRIATH CS BEAR KN X3 -,SUP-5531-G-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TRIATHLON X3 TIBIAL BEARING SIZE 2 X 13MM CS -,SUP-5531-G-213-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ2 16MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-309-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 11MM TRIATH CS BEAR KN X3 -,SUP-5531-G-311-A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL BEARING INSERT  SZ.3 / CS / 12MM -,SUP-5531-G-312-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 13MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL BEARING CS SIZE 3 X 13MM TRIATHLON X3 -,SUP-5531-G-313-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 16MM TRIATH CS ARTCSURF KN X3 UHMWPE -,SUP-5531-G-316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 19MM TRIATH ARTCSURF KN X3 UHMWPE -,SUP-5531-G-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ4 9MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-409-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ4 11MM TRIATH CS BEAR X3 -,SUP-5531-G-411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ4 11MM TRIATH CS BEAR KN X3 -,SUP-5531-G-411-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ4 13MM TRIATH CS BEAR KN X3 -,SUP-5531-G-413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT BEARING TIBIAL CS SIZE 4 X 13MM TRIATHLON X3 -,SUP-5531-G-413-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ4 16MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ4 19MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL BEARING SZ 5 CS 9MM TRIATHLON X3 -,SUP-5531-G-509-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL BEARING INSERT  SZ. 5 / 10MM -,SUP-5531-G-510-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5 11MM TRIATH CS BEAR KN X3 -,SUP-5531-G-511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TRIATHLON X3 TIBIAL BEARING CS -,SUP-5531-G-512-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5 13MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
X3 TRIATHILON CS INS SIZE 5 13MM -,SUP-5531-G-513-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5 16MM TRIATH CS BEAR KN X3 -,SUP-5531-G-516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL BEARING CS SIZE 5 X 19MM TRIATHLON X3 -,SUP-5531-G-519-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ6 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-609-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ6 11MM TRIATH CONDL STAB BEAR KN -,SUP-5531-G-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ6 11MM TRIATH CONDL STAB BEAR CS X3 -,SUP-5531-G-611-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ6 13MM TRIATH CS BEAR KN X3 -,SUP-5531-G-613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ6 13MM TRIATH X3 CS BEAR X3 -,SUP-5531-G-613-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ6 16MM TRIATH ARTCSURF KN X3 UHMWPE -,SUP-5531-G-616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ6 19MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ7 9MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-709-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ7 11MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ7 13MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-713,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ7 16MM TRIATH CS BEAR KN X3 -,SUP-5531-G-716,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL TRIATHLON X3 SZ 7 16MM BEARING INSERT-CS -,SUP-5531-G-716-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ8 9MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIATHLON TIBIAL BEARING INSERT - CS SZ8 11MM -,SUP-5531-G-811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ1 13MM TRIATH PS ARTC KN X3 -,SUP-5532-G-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ2 9MM TRIATH PS ARTC KN X3 -,SUP-5532-G-209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIATHLON PS X3 TIBIAL INSERT -,SUP-5532-G-209-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ2 11MM TRIATH PS ARTCSURF KN X3 UHMWPE -,SUP-5532-G-211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB H TRTHLN PS 2-13MM -,SUP-5532-G-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ2 16MM TRIATH PS ARTC KN X3 -,SUP-5532-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ2 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL BEARING PS SZ 3 X 16MM TRIATHLON X3 -,SUP-5532-G-316-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL BEARING PS SZ 4 X 11MM TRIATHLON X3 -,SUP-5532-G-411-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ4 16MM TRIATH PS ARTCSURF KN X3 UHMWPE -,SUP-5532-G-416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ4 19MM TRIATH PS ARTC KN X3 -,SUP-5532-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ4 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5 22MM TRIATH PS ARTC KN X3 -,SUP-5532-G-522,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-525,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL BEARING INSERT TRI - PS SZ.6 / 9MM -,SUP-5532-G-609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ6 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-625,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ7 9MM TRIATH PS ARTC KN X3 -,SUP-5532-G-709,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ7 16MM TRIATH PS ARTC KN X3 -,SUP-5532-G-716,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL BEARING / SZ. 7  / 19MM -,SUP-5532-G-719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ7 22MM TRIATH PS ARTC KN X3 -,SUP-5532-G-722,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ7 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-725,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ8 9MM TRIATH PS ARTC KN X3 -,SUP-5532-G-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIATHLON PS X3 TIBIAL INSERT SZ 8 -,SUP-5532-G-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT TIBIAL SIZE 2 X 16MM PS TRIATHLON ALL POLY -,SUP-5535-A-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT TIBIAL SIZE 5 X 9MM PS TRIATHLON ALL POLY -,SUP-5535-A-509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT TRIATHLON ALL POLY TIBIAL PS SIZE 5 13MM -,SUP-5535-A-513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT TRIATHLON ALL POLY TIBIAL PS SIZE 6 16MM -,SUP-5535-A-616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL COMPONENT TRITANIUM #2 -,SUP-5536-B-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ3 KN TRIATH TRTNM -,SUP-5536-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ4 KN TRIATH TRTNM -,SUP-5536-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ5 KN TRIATH TRTNM -,SUP-5536-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ6 KN TRIATH TRTNM -,SUP-5536-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ7 KN TRIATH TRTNM -,SUP-5536-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIATHLON TIBIAL COMPONENT -,SUP-5536-B-800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ1 19MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-119,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ2 11MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ2 10MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT TOTAL STABILIZER #2 19MM TS -,SUP-5537-G-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ2 22MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
NO 3 TRIATHLON TS PLUS TIBIAL INSERT X3 POLY -,SUP-5537-G-309-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 19MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 22MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 25MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TOTAL STABILIZER+ TIBIAL INSERT -,SUP-5537-G-409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL TOTAL STABILIZER + SIZE 4 X 9MM TS TRIATH X3 -,SUP-5537-G-409-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT TRIATHLON X3 TOTAL STABILIZER SIZE F 11MM TS -,SUP-5537-G-411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ4 13MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ4 16MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
NO 4 TRIATHLON TS PLUS TIBIAL INSERT X3 POLY 16MM -,SUP-5537-G-416-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ4 19MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ4 22MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ4 25MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ4 28MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL TOTAL STAB SIZE 5 X 16MM TS TRIATHLON X3 -,SUP-5537-G-516-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL TOTAL STABILIZER+ SIZE 5 X 19MM TRIATHLON X3 -,SUP-5537-G-519-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5 22MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-522,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5 28MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-528,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5 31MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-531,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ6 9MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ6 11MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ6 16MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ6 19MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ6 25MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-625,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TOTAL STABILIZER TIBIAL INSERT SZ7 -,SUP-5537-G-711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ7 16MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-716,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ8 22MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-822,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT RT DIST KN SZ1 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT LT DIST KN SZ2 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL DISTAL AUGMENT - RIGHT -,SUP-5540-A-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT LT DIST KN SZ4 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT RT DIST KN SZ4 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL DISTAL AUGMENT - RIGHT -,SUP-5540-A-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT RT DIST KN SZ8 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL DISTAL AUGMENT RIGHT #2 10MM -,SUP-5541-A-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT FEMORAL DISTAL LEFT TRIATHLON SIZE 3 10MM -,SUP-5541-A-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT LT DIST KN SZ4 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5541-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT LT DIST KN SZ5 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5541-A-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT FEMORAL DISTAL RIGHT SZ 7 X 10MM TRIATHLON -,SUP-5541-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT FEMORAL DISTAL RIGHT SZ 7 X 5MM TRIATHLON -,SUP-5541-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIATHLON FEMORAL DISTAL SUGMENT 15MM SIZE 4 LEFT -,SUP-5542-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4581.78,3207.246,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT FEMORAL DISTAL RIGHT SZ 7 X 15MM TRIATHLON -,SUP-5542-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4581.78,3207.246,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP SZ48 7MM REUNION ALLOGRAFT SHOLUDER PG -,SUP-5542-P-0048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP SZ56 7MM REUNION ALLOGRAFT SHOLUDER PG -,SUP-5542-P-0056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT POST KN SZ1 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT POST KN SZ2 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT POST KN SZ3 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT POST KN SZ4 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT POST KN SZ5 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT POST KN SZ6 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT POST KN SZ7 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT POST KN SZ2 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT POST KN SZ3 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT POST KN SZ4 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT POST KN SZ5 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT POST KN SZ6 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HALF BLOCK TIBIAL AUGMENT SIZE 3 X 5MM TRIATHLON -,SUP-5545-A-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT RM/LL KN SZ3 TRIATH 5MM BLCK TOTAL STABILIZED AUG -,SUP-5545-A-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT LMRL KN SZ7 TRIATH 5MM BLCK TOTAL STABILIZED AUG -,SUP-5545-A-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT RM/LL KN SZ7 TRIATH 5MM BLCK TOTAL STABILIZED AUG -,SUP-5545-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT LMRL KN SZ1 TRIATH 10MM BLCK TOTAL STABILIZED AUG -,SUP-5546-A-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT RM/LL KN SZ1 TRIATH 10MM BLCK TOTAL STABILIZED AUG -,SUP-5546-A-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL AUGMENT HALF BLOCK -,SUP-5546-A-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL AUGMENT HALF BLOCK - 10MM -,SUP-5546-A-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT LMRL KN SZ3 TRIATH 10MM HLF BLCK TOTAL STABILIZED -,SUP-5546-A-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL AUGMENT HALF BLOCK / SZ.3 -,SUP-5546-A-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT LMRL KN SZ4 TRIATH 10MM HLF BLCK TOTAL STABILIZED -,SUP-5546-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT RM/LL KN SZ4 TRIATH 10MM HLF BLCK TOTAL STABILIZED -,SUP-5546-A-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL SYMMETRIC CONE AUGMENT SIZE A -,SUP-5549-A-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13500.17,9450.119,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL SYMMETRIC CONE AUGMENT -,SUP-5549-A-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13500.17,9450.119,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL SYMMETRIC CONE AUGMENT SIZE C -,SUP-5549-A-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13500.17,9450.119,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL CONE AUGMENT SZ 1&2 RT -,SUP-5549-A-322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15374.42,10762.094,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIATH TRITNUM CNTRLFEMCONE AUG SZ 3&4 LEFT -,SUP-5549-A-641,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15375.53,10762.871,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIATH TRITNUM CNTRLFEMCONE AUG SZ 3 & 4 RIGHT -,SUP-5549-A-642,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15375.53,10762.871,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT CENTRAL FEM CONE SZ 7&8 RIGHT TRIATHLON -,SUP-5549-A-672,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15375.53,10762.871,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PATELLA SYMMETRIC SZ S27MM X 8MM TRIATHLON X3 -,SUP-5550-G-278-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIATHLON SYMMETRIC X3 PATELLA -,SUP-5550-G-298-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIATHLON X3 SYMMETRIC PATELLA 31MM 9MM -,SUP-5550-G-319-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 33X9MM THK X3 TRIATH PRIM SYM -,SUP-5550-G-339,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 39X11MM THK X3 TRIATH PRIM SYM -,SUP-5550-G-391,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 29X9MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-299-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 32X10MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-320-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 35X10MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-350-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 38X11MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-381-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SINGLE RADIUS HUMERAL HEAD SIZE 44 19MM -,SUP-5552-E-4419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13563.59,9494.513,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 4MM OFST 52X17 REUNION -,SUP-5552-E-5217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 29X9MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-299,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 32X10MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 35X10MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-350,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 38X11MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-381,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PATELLA ASYMMETRIC A40/11MM -,SUP-5552-L-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 56MM STD REUNION SGL RAD -,SUP-5552-S-5622,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 32X10MM THK X3 PERIAPATITE TRIATH ASYM MTL BK -,SUP-5554-L-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 35X10MM THK X3 PERIAPATITE TRIATH ASYM MTL BK -,SUP-5554-L-350,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 38X11MM THK X3 PERIAPATITE ASYM BEADX3 MTL BK -,SUP-5554L381,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 40X11MM THK X3 PERIAPATITE ASYM BEADX3 MTL BK -,SUP-5554L401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND SZ1 12MM TRIATH TOTAL STABILIZED 50MM COCR FEM -,SUP-5560-S-112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TOTAL KNEE 9MM X 100MM -,SUP-5560-S-209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND SZ2 12MM TRIATH TOTAL STABILIZED 100MM COCR FEM -,SUP-5560-S-212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND SZ2 15MM TRIATH TOTAL STABILIZED 50MM COCR FEM -,SUP-5560-S-215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND SZ3 12MM TRIATH TOTAL STABILIZED 50MM COCR FEM -,SUP-5560-S-312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 10MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 11MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 12MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 13MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 14MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 15MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 16MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 17MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FLUTED STEM 18MM / 100MM / TS -,SUP-5565-S-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 18MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 19MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 20MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 21MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 22MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 13MM TRIATH PRFT REVISN TOTAL STABILIZED 150MM -,SUP-5566-S-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4789.23,3352.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FLUTED STEM 14MM / 150MM / TS -,SUP-5566-S-014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4789.23,3352.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HUMERAL FRATURE STEM 7 X 113 -,SUP-5568-0007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,32158.29,22510.803,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
REUNION RFX-HUMERAL FRACTURE STEM 9MM -,SUP-5568-0009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,31160.68,21812.476,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUMERAL FRACTURE 11MM X 123MM REUNION RFX -,SUP-5568-0011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,33766.02,23636.214,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HUMERAL CUP 36MM DIA X 4MM THK -,SUP-5570-3604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16968.41,11877.887,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ADAPTER FEM 2MM OFST TRIATH RECON KN REVISN TOTAL STABILIZED -,SUP-5570-S-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4348.4,3043.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ADAPTER FEM 4MM OFST TRIATH RECON KN REVISN TOTAL STABILIZED -,SUP-5570-S-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4348.4,3043.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ADAPTER FEM 6MM OFST TRIATH RECON KN REVISN TOTAL STABILIZED -,SUP-5570-S-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4348.4,3043.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
EXTENDER STEM TRIATHLON 25MM LENGTH -,SUP-5571-S-025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4512.24,3158.568,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
X3 HUMERAL INSERT 36MM X 4MM STANDARD -,SUP-5571-S-3604-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13571.02,9499.714,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE 28MM X 10.05MM -,SUP-5572-2802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18676.39,13073.473,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GLENOSPHERE 36MM DIA X 2MM THK CONCENTRIC -,SUP-5573-C-3602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16968.41,11877.887,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ2 TRIATH LMRL KN UNICMPT PRIM PRT RSRFC COCR -,SUP-5610-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ2 TRIATH RM/LL KN UNICMPT PRIM PRT RSRFC COCR -,SUP-5610-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL REVISION LEFT SZ 2 NON-POROUS -,SUP-561-1201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ3 BAL KN MODULAR REVISN RT KN -,SUP-561-1302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ4 BAL KN MODULAR REVISN LT KN -,SUP-561-1401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ4 BAL KN RT KN MODULAR REVISN SYS -,SUP-561-1402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 BAL KN LT KN MODULAR REVISN SYS -,SUP-561-1501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 BAL KN RT KN MODULAR REVISN SYS -,SUP-561-1502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ6 BAL KN LT KN MODULAR REVISN SYS -,SUP-561-1601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
MODULAR FEMORAL LEFT SIZE 7 -,SUP-561-1701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
MODULAR FEMORAL SIZE 7 -,SUP-561-1702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ3 27/47MM LMRL KN TRIATH COCR PRIM REVISN -,SUP-5620-B-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ3 27/47MM RM/LL KN TRIATH COCR PRIM REVISN -,SUP-5620-B-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ2 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRAY TIBIAL REVISION SZ 2 NEUTRAL NON-POROUS -,SUP-562-1200A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ3 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL TRAY REVISION SZ 3 NEUTRAL NON-POROUS -,SUP-562-1300A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ4 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL TRAY REVISION SZ 4 NEUTRAL NON-POROUS -,SUP-562-1400A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ5 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL TRAY REVISION SZ 5 NEUTRAL NON-POROUS -,SUP-562-1500A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ6 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL TRAY SLOPED SIZE 5 MODULAR -,SUP-562-2500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9431.02,6601.714,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CONE TIBIAL CENTRAL 31MM -,SUP-562-7031,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12705.89,8894.123,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CONE TIBIAL CENTRAL 34MM -,SUP-562-7034,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12705.89,8894.123,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CONE TIBIAL CENTRAL 36MM -,SUP-562-7036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12705.89,8894.123,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CONE TIBIAL 25MM M-L 35MM A-P -,SUP-562-7135,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12223.2,8556.24,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CONE TIBIAL LARGE 47MM M/L 31MM A/P -,SUP-562-7247,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15108.2,10575.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 8MM TRIATH BEAR LMRL KN X3 UHMWPE -,SUP-5630-G-308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 8MM TRIATH BEAR RM/LL KN X3 UHMWPE -,SUP-5630-G-328,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 8MM CNSTRN -,SUP-563-1308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 10MM CNSTRN -,SUP-563-1310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 12MM CNSTRN -,SUP-563-1312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 14MM CNSTRN -,SUP-563-1314,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 16MM CNSTRN -,SUP-563-1316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 18MM CNSTRN -,SUP-563-1318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 20MM CNSTRN -,SUP-563-1320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SROM*ST XL 36+8LINK 18 X 13 X 255L -,SUP-563138L,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27357.55,19150.285,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL CK SZ 4 8MM -,SUP-563-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT CK SIZE 4 18MM -,SUP-563-1418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT CK SIZE 4 24MM -,SUP-563-1424,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5 8MM CNSTRN -,SUP-563-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5 10MM CNSTRN -,SUP-563-1510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5 12MM CNSTRN -,SUP-563-1512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT CK SIZE 6 8MM -,SUP-563-1608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ6 10MM CNSTRN -,SUP-563-1610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT CK SIZE 6 14MM -,SUP-563-1614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SZ 2 10MM -,SUP-563-2210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SZ 2 12MM -,SUP-563-2212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL REVISION CK SZ 2 14MM -,SUP-563-2214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SZ 2 18MM -,SUP-563-2218,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SZ 2 20MM -,SUP-563-2220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SZ 2 22MM -,SUP-563-2222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SZ 3 8MM -,SUP-563-2308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SZ 3 12MM -,SUP-563-2312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SZ 3 14MM -,SUP-563-2314,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SZ 3 18MM -,SUP-563-2318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL REV CK SZ 3 20MM -,SUP-563-2320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SZ 3 24MM -,SUP-563-2324,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SZ 4 8MM -,SUP-563-2408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SZ 4 10MM -,SUP-563-2410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SZ 4 12MM -,SUP-563-2412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SZ 4 14MM -,SUP-563-2414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SZ 4 16MM -,SUP-563-2416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SZ 4 18MM -,SUP-563-2418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SZ 4 22MM -,SUP-563-2422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SZ 5 10MM -,SUP-563-2510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SZ 5 12MM -,SUP-563-2512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SZ5 14MM -,SUP-563-2514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SZ 5 16MM -,SUP-563-2516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL REVISION CK SZ 6.8MM -,SUP-563-2608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT REVISION CK SIZE 6 14MM -,SUP-563-2614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM 12MM X 50MM CEMENTED -,SUP-565-1205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM 12 X 80 CEMENTED -,SUP-565-1208,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXT CEMENTED 12MM X 110MM -,SUP-565-1211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTENSION CEMENTED 14MM X 30MM -,SUP-565-1403,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4481.66,3137.162,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM 14MM X 50MM CEMENTED -,SUP-565-1405,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 14MM BAL KN 80MM CMNT -,SUP-565-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4481.66,3137.162,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 10MM BAL KN 80MM FEM/TBL -,SUP-566-1008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM 10 X 150MM EXT FLUTED -,SUP-566-1015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 12MM BAL KN 80MM FEM/TBL -,SUP-566-1208,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 13MM BAL KN 80MM FEM/TBL -,SUP-566-1308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 13MM BAL KN 150MM FEM/TBL -,SUP-566-1315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 14MM BAL KN 80MM FEM/TBL -,SUP-566-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTENSION FLUTED 14 X 110 -,SUP-566-1411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 15MM BAL KN 80MM FEM/TBL -,SUP-566-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 16MM BAL KN 80MM FEM/TBL -,SUP-566-1608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 17MM BAL KN 80MM FEM/TBL -,SUP-566-1708,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTENSION FLUTED 17MM X 110MM -,SUP-566-1711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 18MM BAL KN 80MM FEM/TBL -,SUP-566-1808,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM 18MM X 110MM FLUTED -,SUP-566-1811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 20MM BAL KN 80MM FEM/TBL -,SUP-566-2008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTENSION FLUTED 20 X 110 -,SUP-566-2011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTENSION FLUTED 24 X 80MM -,SUP-566-2408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTENSION FLUTED 24 X 110MM -,SUP-566-2411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT RM/LL KN SZ3 BAL KN 5MM BLCK REVISN -,SUP-567-5103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL AUGMENT BLOCK 5MM RT LAT LT MED SIZE 4 -,SUP-567-5104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT RM/LL KN SZ3 BAL KN BLCK REVISN -,SUP-567-5203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL AUGMENT SZ 3 15MM BLOCK LT LATERAL RT MEDIAL -,SUP-567-7203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT DIST KN SZ3 BAL KN 4MM REVISN -,SUP-568-1304,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL AUGMENT DISTAL SIZE 3 8MM -,SUP-568-1308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT DIST KN SZ4 BAL KN 4MM REVISN -,SUP-568-1404,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT FEMORAL SZ 4 4MM DISTAL -,SUP-568-1404A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT DIST KN SZ4 BAL KN 8MM REVISN -,SUP-568-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL AUGMENT SZ 4 8MM DISTAL -,SUP-568-1408A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT DIST KN SZ5 BAL KN 4MM REVISN -,SUP-568-1504,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL AUGMENT SZ 5 4MM DISTAL -,SUP-568-1504A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL AUGMENT DISTA SIZE 5 8MM -,SUP-568-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL AUGMENT DISTAL 12MM -,SUP-568-1512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT DISTAL 4MM SIZE 6 -,SUP-568-1604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL AUGMENT SZ 6 8MM DISTAL -,SUP-568-1608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT POST KN SZ4 BAL KN 4MM REVISN -,SUP-568-2404,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FERMORAL AUGMENT POSTERIOR 4MM SIZE 6 -,SUP-568-2604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 14MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-5988-10-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4394.75,3076.325,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 14MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-5988-10-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
EXTENSION STM 15X30MM -,SUP-5988-12-15,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4394.75,3076.325,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ0 33MM OFST 86MM ACCOLADE PRFT STD OFST 30MM NK -,SUP-6020-0030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ1 34MM OFST 110MM RECON ACCOLADE PRFT PRIM STD -,SUP-6020-0130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ2 35MM OFST 115MM ACCOLADE PRFT STD OFST 30MM NK -,SUP-6020-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ3 39MM OFST 120MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-0335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ4 40MM OFST 125MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ5 44MM OFST 130MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-0537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ2.5 36MM OFST 118MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-2530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ3.5 39MM OFST 124MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-3535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ4.5 41MM OFST 129MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-4535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ5.5 45MM OFST 133MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-5537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ0 +0MM 37MM OFST 86MM ACCOLADE PRFT EXTEND OFST -,SUP-6021-0030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ1 +0MM 38MM OFST 110MM ACCOLADE PRFT EXTEND OFST -,SUP-6021-0130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ2 39MM OFST 115MM ACCOLADE PRFT PRIM EXTEND OFST -,SUP-6021-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ3 43MM OFST 120MM ACCOLADE RECON PRFT PRIM HI -,SUP-6021-0335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ4 44MM OFST 125MM ACCOLADE RECON PRFT PRIM HI -,SUP-6021-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ5 48MM OFST 130MM ACCOLADE RECON PRFT PRIM EXTEND -,SUP-6021-0537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ2.5 40MM OFST 118MM ACCOLADE RECON PRFT PRIM -,SUP-6021-2530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ3.5 124MM RECON ACCOLADE PRFT PRIM EXTEND OFST -,SUP-6021-3535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ4.5 45MM OFST 130MM ACCOLADE RECON PRFT PRIM -,SUP-6021-4535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ5.5 49MM OFST 133MM ACCOLADE PRFT EXTEND OFST -,SUP-6021-5537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ4 OMNIFIT PRIM CLLR CMNT MDL CLCR HIP -,SUP-6034-0425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ6 30MM OFST 132MM SECUR-FIT PRFT PRIM 25MM -,SUP-6051-0625S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ7 35.1MM OFST 132MM SECUR-FIT MAX PRFT PRIM 30MM -,SUP-6051-0730S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ8 132MM RECON SECUR-FIT MAX PRFT PRIM TI HAP CTD -,SUP-6051-0830S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ9 40.8MM OFST 132MM SECUR-FIT MAX PRFT PRIM 35MM -,SUP-6051-0935S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ10 132MM RECON SECUR-FIT MAX PRFT PRIM TI HAP CTD -,SUP-6051-1035S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ11 132MM RECON SECUR-FIT MAX PRFT PRIM TI HAP CTD -,SUP-6051-1140S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ12 47.3MM OFST 132MM SECUR-FIT MAX PRFT PRIM 40MM -,SUP-6051-1240S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HIP STEM SIZE 6 25MM C-TPR -,SUP-6052-0625S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ7 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-0730S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ8 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-0830S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ9 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-0935S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ10 127 DEG SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-1035S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ13 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-1340S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HIP SECUR-FIT PLUS MAX SZ 11 C-TPR 40MM X 170MM -,SUP-6054-1115S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HIP 127 DEG NECK ANGLE SZ 12 C-TPR 40MM X 170MM -,SUP-6054-1216S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HIP STEM 127 DEG CEMENTED SZ 2 V40 TPR 30MM X 124MM ACCOLADE -,SUP-6057-0230D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HIP ACCOLADE 127 DEG CEM NK 35MM SZ 3 V40 131MM LGTH -,SUP-6057-0335D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HIP CEM SZ4 V40 TPR 35MM X 137MM 127 DEG -,SUP-6057-0435D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HIP ACCOLADE 127 DEC CEM NK 37MM SZ 5 V40 145MM LGTH -,SUP-6057-0537D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HIP ACCOLADE 127 DEG CEM NK 37MM SZ 6 V40 158MM LGTH -,SUP-6057-0637D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HIP 127 DEG CEMENTED SZ 7 V40 TPR 40MM X 158MM ACCOLADE -,SUP-6057-0740D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HIP 132 DEG SIZE 3 V40 X 35MM X 131MM CEM ACCOLADE C -,SUP-6058-0335D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HIP 132 DEG CEMENTED SZ 4 V40 35MM X 137MM ACCOLADE -,SUP-6058-0435D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HIP STEM 132 DEG CEMENTED SZ 5 V40 TPR 37MM X 145MM -,SUP-6058-0537D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ10 42MM OFST 160MM OMNIFIT HFX RECON PRIM 35MM NK -,SUP-6070-1035A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ11 132MM OMNIFIT HFX PRIM COCR CMNT HIP -,SUP-6070-1140A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ5 35MM OFST 110MM RECON OMNIFIT HFX PRIM 25MM NK -,SUP-6076-0525A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ6 36MM OFST 120MM OMNIFIT HFX PRIM 25MM NK COCR -,SUP-6076-0625A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ7 41MM OFST 130MM OMNIFIT HFX PRIM 30MM NK COCR -,SUP-6076-0730A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ8 42MM OFST 140MM RECON OMNIFIT HFX PRIM 30MM NK -,SUP-6076-0830A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ2 +0MM 43MM OFST 120MM ACCOLADE HFX PRFT PRIM -,SUP-6077-0335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ4 +0MM 44MM OFST 125MM ACCOLADE HFX PRFT PRIM -,SUP-6077-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ5 +0MM 48MM OFST 130MM ACCOLADE HFX PRFT PRIM -,SUP-6077-0537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OMNIFIT CEMENTED LONG STEM RIGHT -,SUP-6088-0730-200R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17512.18,12258.526,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ4 33MM OFST 100MM OMNIFIT EON PRIM EXTEND OFST -,SUP-6097-0425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ5 8.9MM DIST TIP 39MM OFST 110MM OMNIFIT EON PRIM -,SUP-6097-0530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ6 9.6MM DIST TIP 40MM OFST 120MM OMNIFIT EON PRIM -,SUP-6097-0630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ7 10.4MM DIST TIP 45MM OFST 130MM OMNIFIT EON -,SUP-6097-0735,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ8 46MM OFST 135MM OMNIFIT EON PRIM EXTEND OFST -,SUP-6097-0835,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HIP OMNIFIT EON PLUS SIZE 11 C-TPR 40MM X 150MM -,SUP-6097-1140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ5 8.9MM DIST TIP 35MM OFST 110MM OMNIFIT EON STD -,SUP-6098-0530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ6 9.6MM DIST TIP 36MM OFST 120MM OMNIFIT EON PRIM -,SUP-6098-0630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ7 9.6MM DIST TIP 41MM OFST 130MM OMNIFIT EON PRIM -,SUP-6098-0735,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ8 11.3MM DIST TIP 42MM OFST 135MM OMNIFIT EON STD -,SUP-6098-0835,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ9 46MM OFST 140MM OMNIFIT EON STD OFST 40MM NK -,SUP-6098-0940,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
MODULAR CUP REPLACEMTN LOCK RING 54MM -,SUP-6201-54,CDM,C1776,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRABECULAR METAL LOCKING RING -,SUP-6201-56,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL MULTI HOLE TRABECULAR METAL 54MM -,SUP-6202-54-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9990.38,6993.266,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 36X58-60MM G SHL TRIDENT 0DG CROSSFIRE PRIM -,SUP-621-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 28X46-48MM D SHL TRIDENT 0DG NEUT X3 7.9MM PRIM -,SUP-623-00-28D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT 00 DEG X3 32MM ID TRIDENT -,SUP-623-00-32C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 32X44MM C SHL TRIDENT 0DG NEUT X3 4.9MM PRIM -,SUP-623-00-32C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT POLYETHLENE 0 DEG 32MM CODE D TRIDENT X3 -,SUP-623-00-32D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 32X54-56MM F SHL TRIDENT 0DG NEUT X3 9.9MM PRIM -,SUP-623-00-32F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT POLYETHLENE 0 DEG 36MM CODE D TRIDENT X3 -,SUP-623-00-36D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT POLYETHLENE 0 DEG 36MM CODE E TRIDENT X3 -,SUP-623-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 36X54-56MM F SHL TRIDENT 0DG NEUT X3 7.9MM PRIM -,SUP-623-00-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT POLYETHLENE 0 DEG 36MM CODE F TRIDENT X3 -,SUP-623-00-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT POLY ZERO DEGREE 36MM X ALPHA G TRIDENT X3 -,SUP-623-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 36X58-60MM G SHL TRIDENT 0DG NEUT X3 9.4MM PRIM -,SUP-623-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACET TRIDENT X3 0 DEG POLY 36MM H -,SUP-623-00-36H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIDENT X3 0 DG  POLY INSERT 40MM SZ E -,SUP-623-00-40E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIDENT X3 0 DG POLYETTHYLENE INSERT 40MM SZ E RIM -,SUP-623-00-40E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT 0 DEG POLYETHYLENE 40MM ALPHA CODE F TRIDENT X3 -,SUP-623-00-40F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 40X58-60MM G SHL TRIDENT 0DG X3 7.4MM PRIM -,SUP-623-00-40G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT POLY ZERO DEGREE 40MM X ALPHA G TRIDENT X3 -,SUP-623-00-40G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT POLY ZERO DEGREE 40MM X ALPHA H TRIDENT X3 -,SUP-623-00-40H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 40X62-64MM H SHL TRIDENT 0DG X3 9.1MM PRIM -,SUP-623-00-40H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TRIDENT X3 0 D POLY 40MM ALPHA I -,SUP-623-00-40I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 44X54-56MM F SHL TRIDENT 0DG X3 3.8MM PRIM -,SUP-623-00-44F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 44X58-60MM G SHL TRIDENT 0DG X3 5.4MM PRIM -,SUP-623-00-44G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 44X62-64MM H SHL TRIDENT 0DG X3 7.1MM PRIM -,SUP-623-00-44H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TRIDENT X3 0 DEGREE POLY 44MM ALPHA I -,SUP-623-00-44I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 22X42MM B SHL TRIDENT 10DG X3 8.8MM PRIM -,SUP-623-10-22B,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 32X54-56MM F SHL TRIDENT 10DG X3 9.9MM PRIM -,SUP-623-10-32F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT 10 DEG POLYETHYLENE 36MM E TRIDENT X3 -,SUP-623-10-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 36X50-52MM E SHL TRIDENT 10DG X3 5.9MM PRIM -,SUP-623-10-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 36X54-56MM F SHL TRIDENT 10DG X3 7.9MM PRIM -,SUP-623-10-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT 10 DEG X3 36MM ID TRIDENT -,SUP-623-10-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT 10 DEGREE POLY 36MM G TRIDENT X3 -,SUP-623-10-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 36X58-60MM G SHL TRIDENT 10DG X3 9.4MM PRIM -,SUP-623-10-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 36X66-68MM I SHL TRIDENT 10DG X3 12.7MM PRIM -,SUP-623-10-36I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM DISTAL 19MM DIA CENTRALIZER-CEMENTED -,SUP-6259-8-180,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 32X50-52MM E SHL TRIDENT 0DG ALMN CERM PRIM -,SUP-625-OT-32E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 36MM D SHL RECON MDM CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-36C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 38MM D SHL MDM RECON CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-38D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 42MM E SHL RECON MDM CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-42E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 46MM F SHL RECON MDM CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-46F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 48MM G SHL MDM RECON CMNTLS COCR REVISN MODULAR -,SUP-626-00-48G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER MDM 52MM H CEMENTLESS -,SUP-626-00-52H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 22.2MMSTDX0MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-4-122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 26MM-3MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 26MM +4MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-226,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 26MM +8MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-326,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 26MM +12MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-426,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 26MM -3MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 40MM -4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 44MM -4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 22MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 26MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-126,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V40 28MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-128,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 36MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 40MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL HEAD LFIT V40 22.2MM +3MM -,SUP-6260-9-222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 26MM +4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-226,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 28MM +4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-228,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 40MM +4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-240,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 26MM +8MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-326,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 28MM +8MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-328,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 32MM +8MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-332,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 36MM +10MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-336,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 26MM +12MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-426,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V40 28MM +12MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL HEAD LFIT ANATOMIC V40 6.5MM X 16MM -,SUP-6260-9-440,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ15 47MM OFST 140MM PARTNERSHIP RELIANCE PF PRFT -,SUP-6265-2-005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ6 50MM OFST 150MM PARTNERSHIP RELIANCE PF PRFT -,SUP-6265-2-006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CENTRALIZER DIST HIP 13MM TY A -,SUP-6265-4-413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,601.24,420.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CENTRALIZER DIST HIP 14MM TY A -,SUP-6265-4-414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,601.24,420.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CENTRALIZER DIST HIP 15MM TY B -,SUP-6265-4-515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,601.24,420.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ1 10X34MM OFST 115MM PARTNERSHIP CITNN PRFT PRIM -,SUP-6265-5101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ2 36MM OFST 120MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ4 44MM OFST 130MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ5 47MM OFST 135MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ0 9X34MM OFST 110MM PARTNERSHIP CITNN PRFT PRIM -,SUP-6265-5110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ1 34MM OFST 118MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ2 36MM OFST 120MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ3 40MM OFST 133MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ4 44MM OFST 130MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ5 47MM OFST 135MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BODY PROX HIP 21MM STD RESTOR MODULAR REVISN BOLT CNCL -,SUP-6276-1-021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SYS HIP RESTORATION MODULAR SZ 21MM +0 HT V40 TPR -,SUP-6276-1-021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BODY PROX HIP 25MM STD RESTOR MODULAR REVISN BOLT CNCL -,SUP-6276-1-025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BODY PROX HIP 19MM RESTOR MODULAR REVISN BOLT +10MM NK CNCL -,SUP-6276-1-119,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BODY PROX HIP 21MM RESTOR MODULAR REVISN BOLT +11MM NK CNCL -,SUP-6276-1-121,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIP SUCT ACORN STD V. MUELLER 1.0625IN SIL RBR -,SUP-6276-1-123,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
MODULAR HIP SYSTEM RESTORATION 25MM X +10 X V40 TPR -,SUP-6276-1-125,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SYSTEM HIP MODULAR 27MM X +10 X V40 TPR RESTORAITON -,SUP-6276-1-127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BODY PROX HIP 19MM RESTOR MODULAR REVISN BOLT +20MM NK CNCL -,SUP-6276-1-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BODY PROX HIP 21MM RESTOR MODULAR REVISN BOLT +20MM NK CNCL -,SUP-6276-1-221,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BODY PROX HIP 25MM RESTOR MODULAR REVISN BOLT +10MM NK CNCL -,SUP-6276-1-225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BODY PROX HIP 19MM RESTOR MODULAR REVISN BOLT +30MM NK CNCL -,SUP-6276-1-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BODY PROX HIP 21MM RESTOR MODULAR REVISN BOLT +30MM NK CNCL -,SUP-6276-1-321,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BODY PROX HIP 23MM RESTOR MODULAR REVISN BOLT +30MM NK CNCL -,SUP-6276-1-323,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RESTORATION MODULAR HIP SYSTEM 25MM X 30 V40 -,SUP-6276-1-325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 14X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 15X155MM RESTOR REVISN MODULAR STR CNCL DIST HIP -,SUP-6276-7-015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 16X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 17X155MM RESTOR REVISN MODULAR STR CNCL DIST HIP -,SUP-6276-7-017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 18X155MM RESTOR REVISN MODULAR STR CNCL DIST HIP -,SUP-6276-7-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 19X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HIP RESTORATION MODULAR 20MM X 155MM -,SUP-6276-7-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RESTORATION MODULAR HIP SYS 22MM X 155MM -,SUP-6276-7-022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 23X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-023,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 14X195MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10547.44,7383.208,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 14X195MM RESTOR REVISN MODULAR HIP -,SUP-6276-7-214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 15X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 16X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 19X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 21X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RESTORATION MODULAR HIP SYSTEM 21MM X 195MM -,SUP-6276-7-221,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 24X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-224,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 15X235MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11716.67,8201.669,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RESTORATION HIP STEM 235MM X 19MM -,SUP-6276-7-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11716.67,8201.669,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 22X235MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11716.67,8201.669,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SYS RESTORATION MOD HIP 18MM X 115MM -,SUP-6276-7-418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24628.33,17239.831,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM PCA 28X0MM NK COCR REVISN -,SUP-6280-0-136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM PCA 32MM +5MM NK COCR REVISN -,SUP-6280-0-232,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM PCA 36MM +5MM NK COCR REVISN -,SUP-6280-0-236,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM PCA 32MM +10MM NK COCR REVISN -,SUP-6280-0-332,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM PCA 36MM +10MM NK COCR REVISN -,SUP-6280-0-336,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 32X52-55MM DURATION 10DG UHMWPE PCA -,SUP-6299-7-525,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4020.85,2814.595,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINEAR STANDARD TRILOGY ACETABULAR SYSTEM -,SUP-6305-50-36,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5260.44,3682.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB SZ P6 28X62-64MM SHL S12 +4 10DG CROSSFIRE CONGR -,SUP-6352-5-076,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4458.11,3120.677,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CROSSFIRE SYSTEM 12 POLYETHYLENE INSERT 10 -,SUP-6352-5-105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4458.11,3120.677,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR SM 9MM PE PEGX3 AVON RND DOME REVISN OFST -,SUP-6430-0-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4079.19,2855.433,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR MED 9.5MM PE PEGX3 AVON RND DOME REVISN OFST -,SUP-6430-0-030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4079.19,2855.433,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR LRG 10MM PE PEGX3 AVON RND DOME REVISN OFST -,SUP-6430-0-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4079.19,2855.433,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM XS 43.5MMX42.5MM AVON KN CMNT PEGX4 COCR -,SUP-6430-0-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14140.63,9898.441,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM MED 50.3MMX47.5MM AVON KN CMNT PEGX4 COCR -,SUP-6430-0-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14140.63,9898.441,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 36MM E SHL TRIDENT 0DG ELEV RM ECCT X3 PRIM -,SUP-643-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIDENT ELEVATED RIM INSERT 36MM G -,SUP-643-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND XS KINEMAX PLUS PRFT REVISN MODULAR 80MM COCR -,SUP-6476-8-260,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3594.54,2516.178,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 14MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 16MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 19MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-645,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 23MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-665,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TITANIUM FLUTED 16MM X 155MM -,SUP-6478-6-715,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 17MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-720,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 21MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 SM M LT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 SM M RT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 MED M LT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 LRG M RT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-131,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
MRH KNEE FEMORAL DISTAL BLOCK MED 10MM -,SUP-6481-1-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3438.71,2407.097,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIB STD XS XL KN GMRS COCR MRH -,SUP-6481-2-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11254.62,7878.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL BEARING COMPONENT MRH -,SUP-6481-2-103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11254.62,7878.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ7 STD GMRS KN MODULAR REVISN BUSHNG COCR ROT HNG -,SUP-6481-2-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1628.47,1139.929,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ7 STD GMRS KN MODULAR REVISN AXLE COCR ROT HNG -,SUP-6481-2-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4454.42,3118.094,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB BEAR KN PE -,SUP-6481-2-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3005.95,2104.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
MRH KNEE BUMPER INSERT 3 DEGREES -,SUP-6481-2-133,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3005.95,2104.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE TIB SZ4 MODULAR BMPR DIST KN ROT HNG DURATION -,SUP-6481-2-140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2514.7,1760.29,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ1 KN GMRS COCR MODULAR KLD ROT HNG -,SUP-6481-3-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12573.67,8801.569,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ2 SM KN GMRS COCR MODULAR KLD ROT HNG -,SUP-6481-3-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12573.67,8801.569,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ2 LRG KN GMRS COCR MODULAR KLD ROT HNG -,SUP-6481-3-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12573.67,8801.569,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ1-2 XS/SM 10MM PS ARTCSURF KN PE -,SUP-6481-3-210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ1-2 XS/SM 13MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ1-2 XS/SM 16MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ1-2 XS/SM 20MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB MED 2/ L2 13MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5011.74,3508.218,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB MED 2/ L2 24MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-324,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5011.74,3508.218,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
KINEMATIC ROTATING HINGE KNEE XSM 8MM -,SUP-6485-2-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HINGE KNEE ROTATING SIZE XSM 11MM THKNS KINEMATIC -,SUP-6485-2-011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
KINEMATIC ROTATING HINGE KNEE -,SUP-6485-2-016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
KINEMATIC ROTATING  HINGE KNEE SM 8MM -,SUP-6485-2-108,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
KINEMATIC ROTATING HINGE KNEE -,SUP-6485-2-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
KINEMATIC ROTATING HINGE KNEE 16MM MEDIUM -,SUP-6485-2-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
KINEMATIC ROTATING HINGE KNEE LARGE 21MM -,SUP-6485-2-321,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM STRAIGHT CEMENTED 10MM X 102MM -,SUP-6485-3-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM REPLACEMENT STRAIGHT CEMENTED 8MM X 102MM -,SUP-6485-3-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM REPLACEMENT STRAIGHT 9MM X 102MM -,SUP-6485-3-019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM CEMENTED STRAIGHT 11 X 127 -,SUP-6485-3-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM MRS STRAIGHT CEMENTED 13 X 127 -,SUP-6485-3-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM-REPLACEMENT CURVED CEMENTED 10MM X 102MM -,SUP-6485-3-310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM REPLACEMENT CURVED CEMENTED 8MM X 102MM -,SUP-6485-3-318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM REPLACEMENT CURVED CEMENTED -,SUP-6485-3-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 11MM LNG GMRS MODULAR 203MM TI HAP PLASM SPRY CTD -,SUP-6485-3-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14897,10427.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 17X203MM MRS MODULAR COCR POR CTD CMNT CRV DIST HIP -,SUP-6485-3-617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14897,10427.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
MRS CURVED CEMENTED STEM 11MM X 127MM -,SUP-6485-3-811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
MRS CURVED CEMENTED STEM 13MM X 127MM -,SUP-6485-3-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM CEMENTED STEM 15 X 127 -,SUP-6485-3-815,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM CEMENTED 17MM X 127MM CURVED -,SUP-6485-3-817,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GMRS PROXIMAL FEMORAL COMPONENT V40 -,SUP-6495-1-002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19014.24,13309.968,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT DISTAL FEMORAL SMALL LEFT 65MM -,SUP-6495-2-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27396.07,19177.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
DISTAL FEMORAL COMPONENT SMALL RT 65MM -,SUP-6495-2-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27396.07,19177.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM STD 65MM GMRS LT DIST KN MODULAR COCR ROT HNG -,SUP-6495-2-030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27152.28,19006.596,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM STD 65MM GMRS RT DIST KN MODULAR COCR ROT HNG -,SUP-6495-2-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27152.28,19006.596,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BUSHING FOR SMALL DISTAL FEMUR -,SUP-6495-2-105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1672.63,1170.841,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AXLE GMRS -,SUP-6495-2-115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4462.74,3123.918,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT FOR SMALL PROXIMAL TIBIAL COMPONENT 13MM -,SUP-6495-3-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT FOR SMALL PROXIMAL TIBIAL COMPONENT 24MM -,SUP-6495-3-024,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PROXIMAL TIBIA GMRS SM 80MM -,SUP-6495-3-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27343.31,19140.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIA PROXIMAL STD 80MM -,SUP-6495-3-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27343.31,19140.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL ROTATING COMPONENT SM -,SUP-6495-3-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11240.07,7868.049,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND GMRS REVISN MODULAR 30MM FEM KN -,SUP-6495-6-030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PIECE EXTENSION GMRS 40MM LENGTH -,SUP-6495-6-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GMRS EXTENSION PIECE 50MM -,SUP-6495-6-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
EXTENSION PIECE GMRS -,SUP-6495-6-070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GMRS EXTENSION PIECE 120MM -,SUP-6495-6-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GRAFT HUM TIS 6X10CM TISSUEMEND COLL -,SUP-6495-9-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10181.42,7126.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD DELTA CERAMIC FEMORAL 36/-3MM -,SUP-650-0660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD DELTA CERAMIC FEMORAL 36/0MM -,SUP-650-0661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD DELTA CERAMIC FEMORAL 36/+3MM -,SUP-650-0662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CERAMIC HEAD BIOLOX DELTA  OP HIP SYSTEM 28MM -,SUP-650-1055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD CER BIOLOX D OPTION 28MM -,SUP-650-1055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD CER BIOLOXD OPTION 36MM -,SUP-650-1057,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CER OPTION TYPE 1 TPR SLEEVE +3 -,SUP-650-1067,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
+6MM NECK BIOLOCK OPTION HIP SYSTEM -,SUP-650-1068,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEMORAL G7 BIOLOX DELTA -3 MM OFFSET OD28 MM HIP -,SUP-650-1159,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL HEAD UNIVERSAL TAPER 28MM OD BIOLOX DELTA -,SUP-6519-1-028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL HEAD UNIVERSAL TAPER BIOLOX DELTA -,SUP-6519-1-032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 36MM UNIV +0MML NK BIOLOX DELTA CERM TAPR PRIM -,SUP-6519-1-036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEMORAL 40MM BIOLOX DELTA -,SUP-6519-1-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
UNIVERSAL V40  -2.5MM ADAPTER SLEEVE (TI) -,SUP-6519-T-025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE HIP UNIV V-40 RECON PRIM ADPTR +0MML NK OFST TI TAPR -,SUP-6519-T-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE HIP +4MM OFST UNIV V-40 RECON PRIM ADPTR TI TAPR -,SUP-6519-T-204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
IMPACTOR SURG F/TIB INS TRIATH -,SUP-6541-4-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2125.24,1487.668,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 36MM-5MM NK ALMN PRIM -,SUP-6565-0-036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 32X0MM NK ALMN PRIM -,SUP-6565-0-132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 28MM -2.7MM OFST BIOLOX DELTA CERAMIC -,SUP-6570-0-028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 32MM -4MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 36MM -5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 28MM +0MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-128,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 32MM +0MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 36MM +0MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 28MM +4MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-228,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 32MM +4MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-232,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 36MM +5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-236,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 36MM -2.5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-436,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 36MM +2.5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-536,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM V-40 36MM +7.5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-736,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 36X54-56MM F SHL TRIDENT 0DG ECCT X3 PRIM -,SUP-663-00-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT KN SZ1 SM DURACN 10MM WDG BLCK REVISN VITAL -,SUP-6630-6-510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5255.98,3679.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
DURACON TOTAL KNEE FULL FLAT TIBIAL WEDGE SM-2 10MM -,SUP-6630-6-515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5255.98,3679.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 32X46-48MM D SHL TRIDENT 10DG ECCT X3 16.8MM -,SUP-663-10-32D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 36X58-60MM G SHL TRIDENT 10DG ECCT X3 18.8MM -,SUP-663-10-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 36X62-64MM H SHL TRIDENT 10DG ECCT X3 20.4MM -,SUP-663-10-36H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CK Insert Trial Sz 4 8mm -,SUP-663-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CK Insert Trial Sz 5 16mm -,SUP-663-1516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB LRG 9X77/53MM DURACN CR A/P LIP ARTC L/R KN -,SUP-6642-1-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3601.27,2520.889,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT A-P LIPPED DURACON XLGE 9MM -,SUP-6642-1-909,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3601.27,2520.889,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR XS PE DURACON DURATION ASYM -,SUP-6642-2-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR MED PE DURACON DURATION ASYM -,SUP-6642-2-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SM 11MMX45MM A/P DURACN CNSTRN ARTC L/R KN -,SUP-6642-9-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB LRG 9MMX55MM ARTCSURF L/R KN PE -,SUP-6642-9-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB LRG 11MMX55MM A/P DURACN CNSTRN ARTC L/R KN -,SUP-6642-9-811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB LRG 13MMX55MM A/P DURACN CNSTRN ARTC L/R KN -,SUP-6642-9-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TibAugSz1Trial20Â°WedgeLtLat/RtMed -,SUP-667-2201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TibAugSz2Trial20Â°WedgeLtLat/RtMed -,SUP-667-2202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ2 33MM OFST 99MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ3 35MM OFST 102MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ4 38MM OFST 105MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ5 35MM OFST 108MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ6 41MM OFST 111MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ7 46MM OFST 114MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0737,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HIP ACCOLADE 132 SZ 8 -,SUP-6720-0837,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HIP 132 DEG SZ #9 37MM X 120MM V40 ANGLE ACCOLADE II -,SUP-6720-0937,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
NECK ANGLE HIP STEM SZ# 0 / 27MM / 93MM / V40 -,SUP-6721-0027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ1 34MM OFST 96MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ2 37MM OFST 99MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ3 30MM OFST 102MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ4 42MM OFST 105MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ACCOLADE II SZ5 35MM NECK ANGLE HIP STEM 108MM V40 -,SUP-6721-0535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ6 35MM OFST 111MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ7 50MM OFST 114MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0737,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ8 51MM OFST 117MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0837,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ9 53MM OFST 120MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0937,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM SZ10 57MM OFST 123MM ACCOLADE II V40 PRFT PRIM -,SUP-6721-1040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SM 9MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4186.89,2930.823,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SM 11MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4186.89,2930.823,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SM 16MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-116,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4186.89,2930.823,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ2 16MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB LRG 9MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-309,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 11MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB LRG 16MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 22X50-52MM D SHL TRIDENT 0DG ECCT UHMWPE CNSTRN -,SUP-690-00-22D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 22X50-52MM E SHL TRIDENT 0DG ECCT UHMWPE CNSTRN -,SUP-690-00-22E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 22X54-56MM F SHL TRIDENT 0DG ECCT UHMWPE CNSTRN -,SUP-690-00-28F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIDENT 0 DG ACETABULAR INSERT SZ H -,SUP-690-00-32H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIDENT ALL POLY CONSTRAINED ACETABULAR INSERT -,SUP-69-2244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10027.4,7019.18,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ALL POLY CONSTRAINED INSERT 46MM -,SUP-69-2246,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10027.4,7019.18,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM UNITRAX 40MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM UNITRAX 42MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM UNITRAX 43MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM UNITRAX 46MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM UNITRAX 47MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-047,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE HIP UNITRAX V40 PRIM MODULAR UNIPL -4MM NK TAPR -,SUP-6942-6-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE HIP UNITRAX V40 PRIM MODULAR UNIPL +0MML NK TAPR -,SUP-6942-6-065,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE HIP UNITRAX V40 PRIM MODULAR UNIPL +8MM NK TAPR -,SUP-6942-6-075,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE HIP UNITRAX C UNIPL -3MM NK C-TAPR -,SUP-6942-7-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE HIP UNITRAX C UNIPL +0MML NK C-TAPR -,SUP-6942-7-065,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE HIP UNITRAX C UNIPL +5MM NK C-TAPR -,SUP-6942-7-075,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE HIP UNITRAX C UNIPL +10MM NK C-TAPR -,SUP-6942-7-085,CDM,C1776,HCPCS,278,RC,,,outpatient,,,810.6,567.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HIP HIGH OFFSET INSIGNIA SZ 4 X 36MM X 103MM -,SUP-7000-6604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL CLUSTERHOLE ACET 46MM C TRIDENT TRITANIUM -,SUP-702-04-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIDENT IITRITANIUM CLUSTERHOLE 48MM D -,SUP-702-04-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL TRIDENT II TRITANIUM CLUSTERHOLE ACETABULAR 50MM D -,SUP-702-04-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIDENT II TRITANIUM CLUSTERHOLE ACETABULAR SHELL -,SUP-702-04-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIDENT II TRITANIUM CLUSTERHOLE ACET SHELL 54MM -,SUP-702-04-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIDENT II TRITANIUM CLUSTERHOLE ACE SHELL 56MM F -,SUP-702-04-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIDENT II TRITANIUM CLUSTERHOLE ACE SHELL 58MM F -,SUP-702-04-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIDENT II TRITANIUM CLUST ACE SHELL SZ 60MM G -,SUP-702-04-60G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL CLUSTERHOLE ACET SIZE 62MM G TRIDENT II TRITANIUM -,SUP-702-04-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACET 64MM H TRIDENT II TRIT CLUSTERHOLE -,SUP-702-04-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
44MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-44B,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
46MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
48MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
52MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
54MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
56MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
58MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
60MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-60G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
62MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
64MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
66MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-66H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIDENT II TRITANIUM MULTIHOLE ACE SHELL 48MM D -,SUP-709-04-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL TRIDENT II TITAN MLTHLE ACE SIZE 52MM E -,SUP-709-04-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL TRIDENT II TRITANIUM MLTHOLE ACE 54MM E -,SUP-709-04-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIDENT II TRITANIUM MULTHL SHELL 56MM F -,SUP-709-04-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL MULTIHOLE ACETABULAR 62MM X G TRIDENT II TRITANIUM -,SUP-709-04-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL TRIDENT II TITANIUM 64MM H MULTIHOLE -,SUP-709-04-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL MULTIHOLE ACET SZ 66MM H TRIDENT II TRITANIUM -,SUP-709-04-66H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACETABULAR 68MM ALPHA I MULTIHOLE TRIDENT II TRITANIUM -,SUP-709-04-68I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP ACTB 22X42MM SHL TANDEM AN-ROT BIPLR COCR UHMWPE MAX -,SUP-71322042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2755.51,1928.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
REF XLPE 36 20 DEG 54-56F -,SUP-7133-3345,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9094.89,6366.423,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ACET LINER 36 X 58 R3 20 DEG XLPE -,SUP-71335758,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6230.19,4361.133,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COVER SCR HL HIP THRD R3 REFLC STRL -,SUP-71336500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,407.81,285.467,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SHELL ACETABULAR 58MM R3 MULTI HOLE -,SUP-71338668,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8734.15,6113.905,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OXINIUM HD 12/14 22MM +4 -,SUP-71342204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7011.09,4907.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM 36MM +0MML NK OXNM 12/14 TAPR STRL -,SUP-71343600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8339.46,5837.622,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GNS II CMT TIB SIZE 2 LEFT -,SUP-71420162,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GNS II CMT TIBIAL SIZE 3 LEFT -,SUP-71420164,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GNS II CMT TIB SIZE 5 LEFT -,SUP-71420168,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ3 64/48MM RT KN CMNT GENESIS II NPOR -,SUP-71420182,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4286.44,3000.508,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GNS II CMT TIB SIZE 4 RIGHT -,SUP-71420184,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GNS II CMT TIB SIZE 6 RIGHT -,SUP-71420188,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GNSII CON INS SZ3-4 11MM -,SUP-71420524,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT GENESIS II SZ 3-4 13MM -,SUP-71420526,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3-4 15MM 68-71MM M/L 48-50MM A/P GENESIS II -,SUP-71420528,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GNS II CON INS SZ 3-4 18MM -,SUP-71420530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GNS II CON INS SZ5-6 15MM -,SUP-71420542,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GNS II RESUR PAT 29MM -,SUP-71420574,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RESURF PAT GEN II 32MM -,SUP-71420576,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 35X9MM THK UHMWPE PEGX3 RSRFC GENESIS II -,SUP-71420578,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GNS II RESURF PAT 26MM -,SUP-71420580,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5-6 13MM 74-77MM M/L 52-54MM A/P GENESIS II PS -,SUP-71420834,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2502.77,1751.939,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEGION CON ART INS 9MM SZ 1-2 -,SUP-71420959,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT G2 CONST SZ1-2 11MM -,SUP-71420960,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ARTICULAR G2 CONST SIZE 1-2 13MM -,SUP-71420962,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEMORAL SIZE 4 RIGHT LEGI -,SUP-71420964,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ1-2 18MM 60-64MM M/L 42-45MM A/P GENESIS II -,SUP-71420966,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LGN HM ST 3-4 5MM LTMD-RTLA -,SUP-71421142,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6854.06,4797.842,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ3 LEGION LT KN CNSTRN REVISN OXNM -,SUP-71421163,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LGN OX CONSTRAINED FEM 4 LT -,SUP-71421164,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LGN OX CONSTRAINED FEM 6 LT -,SUP-71421166,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT FEMORAL SIZE 4 RIGHT -,SUP-71421174,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29666.87,20766.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEGION OX CONSTRAINED FEM 5 RT -,SUP-71421175,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEGION PS OIN FEM SZ3 RT -,SUP-71421203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ4 LEGION RT KN PS OXNM POR -,SUP-71421204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10489.23,7342.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 LEGION RT KN PS OXNM POR -,SUP-71421205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ6 LEGION PS OXIN RIGHT -,SUP-71421206,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEGION PS OXIN FEM SZ4 LT -,SUP-71421214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEGION PS OXIN FEM SZ6 LT -,SUP-71421216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 LEGION RT KN CR REVISN OXNM POR -,SUP-71421225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9893.85,6925.695,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEGION CR OXIN FEM SZ6 RT -,SUP-71421226,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEGION NARROW PS OXIN SZ 4N LT -,SUP-71421264,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEGION NARROW PS OXIN SZ 6N LT -,SUP-71421266,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEGION NARROW PS OXIN SZ 5N RT -,SUP-71421275,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEGION NARROW PS OXIN SZ 6N RT -,SUP-71421276,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9574.46,6702.122,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3-4 13MM GENESIS II PS ARTC L/R KN-HI FLEX OXNM -,SUP-71421510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3539.59,2477.713,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GEN II PS HIGH FLEXION ARTICULAR INSERT SZ 5-6 13 -,SUP-71421517,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5975.55,4182.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT DIST KN SZ3 LEGION 10MM WDG BLCK -,SUP-71421658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
WEDGE FEM LGN SCRW DIS SZ4 5MM -,SUP-71421661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEGION SCREW DIS FEM WDG SZ5 5MM -,SUP-71421664,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6068.92,4248.244,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEGION SCW LWDG S5 5D X 5P -,SUP-71421741,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8891.18,6223.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
JUNI OX FB FEM SZ 3 LM RL -,SUP-71422343,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
JUNI OX FB FEM SZ 5 LM RL -,SUP-71422345,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
JUNI OX FB FEM SZ 7 LM RL -,SUP-71422347,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT FEMORAL JOURNEY OXINIUM SZ 5 RM LL -,SUP-71422355,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LGN RK/HK HEMI SZ 3-4 LL/RM 5MM -,SUP-71423420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8496.49,5947.543,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LGN RK/HK HEMI SZ 3-4 LM/RL 5MM -,SUP-71423432,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8496.49,5947.543,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEGION REVISION TIBIAL BASEPLATE -,SUP-71424001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE REVISION LONG TIBIA SIZE 2 LT -,SUP-71424002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIA BASE LGN REV SIZE 4 LT -,SUP-71424004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LGN REV TIBIA BASE SZ 5 LT -,SUP-71424005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIBIAL SIZE 2 RIGHT -,SUP-71424012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11863.04,8304.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE TIB SZ3 RT KN LEGION TI REVISN -,SUP-71424013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEGION REV TIBIA BASE SZ 5 RT -,SUP-71424015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM PRESSFIT LONG 10MM X 120MM -,SUP-71424023,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LGN PRESSFIT STEM 12MM X 120MM -,SUP-71424025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 13MM LEGION PRFT REVISN 120MM TI FEM KN -,SUP-71424026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM STRAIGHT 14MM X 120MM LEG -,SUP-71424027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM LGN PRESSFIT 15MM X 120MM -,SUP-71424028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LGN PRESSFIT STEM 16MM X 120MM -,SUP-71424029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTENSION LEGION TI PRESSFIT 18MM X 120MM -,SUP-71424031,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LGN PRESSFIT STEM 11MM X 160MM -,SUP-71424044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM LGN PRESSFIT 12MM X 160MM -,SUP-71424045,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM LGN PRESSFIT 13MM X 160MM -,SUP-71424046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LGN PRESSFIT STEM 15MM X 160MM -,SUP-71424048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 16MM LEGION PRFT REVISN 160MM TI FEM KN -,SUP-71424049,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM LGN CEMENT 14MM X 160MM STRT -,SUP-71424206,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6527.27,4569.089,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LGN OFFSET COUPLER 2MM -,SUP-71424223,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6132.58,4292.806,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LGN OFFSET COUPLER 4MM -,SUP-71424225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6132.58,4292.806,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LGN CR HIGH FLEX XLPE SZ 3-4 9MM -,SUP-71453111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT LEGION CR HIGH FLEX XLPE SZ 3-4 -,SUP-71453112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3-4 9MM LEGION CR KN XLPE -,SUP-71453146,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LGN PS HIGH FLEX XLPE SZ 1-2 10MM -,SUP-71453171,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LGN PS HIGH FLEX XLPE SZ 3-4 12MM -,SUP-71453174,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LGN PS HIGH FLEX XLPE SZ 1-2 15MM -,SUP-71453204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LGN PS HIGH FLEX XLPE SZ 3-4 9MM -,SUP-71453211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEGION PS HIGH FLEX XLPE SZ 3-4 11MM -,SUP-71453212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LGN PS HIGH FLEX SLPE SZ 3-4 13MM -,SUP-71453213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEGION PS HIGH FLEX XLPE SZ 3-4 15MM -,SUP-71453214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4308.51,3015.957,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LGN PS HIGH FLEX XLPE SZ 5-6 15MM -,SUP-71453224,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3-4 13MM PS KN LEGION XLPE -,SUP-71453248,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LGN XLPE DISHED ISRT SZ 5-6 15MM -,SUP-71453287,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
JOURNEY PFJ IMPLANT X-SM LT -,SUP-71461010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
JOURNEY PFJ IMPLANT X-SMALL RIGHT -,SUP-71461011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12604.89,8823.423,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
JOURNEY PFJ IMPLANT SM LT -,SUP-71461012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
JOURNEY PF IMPLANT SM RT -,SUP-71461013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SCREW 5MMX55MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642255,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
UNIPL -,SUP-71701035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14184.25,9928.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 38X9MM THK GENESIS II REVISN PS -,SUP-71926225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GEN II 7.5MM RESUR PAT 26MM -,SUP-71932634,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GEN II 7.5MM RESUR PAT 29MM -,SUP-71932635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3366.62,2356.634,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEGION REV TIB BASE W/JRNY LOCK SZ 5 -,SUP-71933571,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11863.04,8304.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CONE TIB LGN ID 18 SHORT -,SUP-71935386,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22278,15594.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
WEDGE TIB LEGION CONE ID 20 SHORT -,SUP-71935387,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21210.51,14847.357,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEGION TIB CONE ID 22 SHORT -,SUP-71935388,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21210.51,14847.357,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL CONE LEGION 18 LONG -,SUP-71935393,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22927.78,16049.446,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEGION TIB CONE ID 22 LONG -,SUP-71935395,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21210.51,14847.357,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEM CONE LGN ID 18MM LEFT -,SUP-71935400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22324.41,15627.087,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEGION FEM CONE ID 20MM LEFT -,SUP-71935401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22324.41,15627.087,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEGION FEM CONE ID 22MM LEFT -,SUP-71935402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22324.41,15627.087,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
WEDGE FEMORAL LEGION CONE ID 18MM KNEE RIGHT -,SUP-71935407,CDM,C1776,HCPCS,278,RC,,,outpatient,,,23447.6,16413.32,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEMORAL ANTHOLOGY AFIT SO POR PL HA SZ7 -,SUP-71935567,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6009.5,4206.65,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SCROPIO-FLEX X3 TIBIAL BEARING INSERT CR SZ11 -,SUP-72-26-1110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 36X46-48MM D SHL TRIDENT 0DG NEUT X3 3.9MM PRIM -,SUP-723-00-36D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 36X50-52MM E SHL TRIDENT 0DG NEUT X3 5.9MM PRIM -,SUP-723-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 40X54-56MM G SHL TRIDENT 0DG X3 5.8MM PRIM -,SUP-723-00-40F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ACTB 28MM X 54MM RESTOR ADM/MDM X3 48G -,SUP-7236-2-854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ7 24X71/47MM 18X27MM SCORP CNSTRN TOTAL -,SUP-72-4-0724,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5828.45,4079.915,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PIN NONRIM SPEED 65 STERILE -,SUP-74013480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,128.37,89.859,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PIN NONRIM SPEED 80 STERILE -,SUP-74013490,CDM,C1776,HCPCS,278,RC,,,outpatient,,,122.54,85.778,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
JOURNEY II CR FEM OX NP RT SZ. 4 -,SUP-74021154,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP JRNY II CR FEM OX NP LT SZ 4 -,SUP-74021164,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
JRNY II BCS FEMORAL OXIN RT SZ 3 -,SUP-74022113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
JOURNEY TIBIA BASE NP RT SZ 2 -,SUP-74022212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
JOURNEY TIBIA BASE NP RT SZ 3 -,SUP-74022213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
JOURNEY TIBA BASE NP RT SZ. 4 -,SUP-74022214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4218.31,2952.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
JOURNEY TIBIA BASE NP LT SZ3 -,SUP-74022223,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
JOURNEY BCS PAT RESRF RD 32 MM STD -,SUP-74024832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2017.9,1412.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
JOURNEY II CR ISRT XLPE RT SZ 3-4 9MM -,SUP-74025631,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
JRNY II ISRT XLPE DD LT SZ 3-4 9MM -,SUP-74025741,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
JRNY II BCS XLPE ART ISRT SZ 1-2 RT 12MM -,SUP-74027214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
JRNY II BCS XLPE ART ISRT SZ 5-6 LT 12MM -,SUP-74027264,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
44MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-44B,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
48MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
50MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
52MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
54MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
56MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
58MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
64MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
POLARCUP XLPE INSERT 43/22 NON-CEM -,SUP-75018942,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4478.01,3134.607,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
POLARCUP SHELL 43 CEMENTED -,SUP-75100451,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT DIST KN SZ7 SCORP 5MM WDG BLCK CMNT SPCR TOTAL -,SUP-75-1-0705,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4305.81,3014.067,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT POST KN SZ7 SCORP 5MM WDG BLCK SPCR TOTAL STABILIZED -,SUP-75-2-0705,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4305.81,3014.067,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL LEFT MEDIAL SZ 4 NON-POROUS -,SUP-761-1401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL LEFT MEDIAL SIZE 6 NON-POROUS -,SUP-761-1601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL TRAY LEFT MEDIAL SIZE 3 NON-POROUS -,SUP-762-3100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL TRAY LEFT MEDIAL SZ 4 NON-POROUS -,SUP-762-4100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TRIDENT X3 ECCENTRIC 0DEG 36MM -,SUP-763-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT LEFT MEDIAL SZ 4 7MM -,SUP-763-4071,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ7 66MM M/L 60-62MM A/P SCORP LT KN TOTAL -,SUP-76-4107L,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17711.12,12397.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL HEAD 12/14 COCR 36MM +3.5 -,SUP-8018-36-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD 12/14 COCR FRDM 36MM X +6 -,SUP-802403605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7259.36,5081.552,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
3.5MM CORT LOCK SCR 48MM NS -,SUP-816135048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,882.25,617.575,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SPACER NO PROFILE 16 X 14 X 8MM 7IN STERILE SHORELINE -,SUP-85-0208-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9039.72,6327.804,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ4 76/51MM L/R KN PFC TI CR MODULAR + NPOR -,SUP-86-0124,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11851.9,8296.33,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ2 64/43MM L/R KN PFC SIG KLD NPOR -,SUP-86-4180,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TAPER SIDMA 13 X 120 CEMENTED -,SUP-86-6498,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM TAPER 13 X 150 -,SUP-86-6499,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 12MM UNIV PFC PRFT MODULAR 75MM CMNT TIB KN -,SUP-86-7412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM EXTEND 14MM UNIV PFC PRFT MODULAR 75MM CMNT TIB KN -,SUP-86-7414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM UNIVERSAL FLUTED 75MM X 18MM -,SUP-86-7418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM UNIVERSAL FLUTED 75MM X 24MM -,SUP-86-7421,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FLUTED 115 X 16MM -,SUP-86-7430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM UNIVERSAL FLUTED 115MM X 18MM -,SUP-86-7432,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM UNIVERSAL FLUTED 115MM X 20MM -,SUP-86-7433,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM RADIAL ALIGN TITANIUM 11MM X 0MM -,SUP-90176510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10481.8,7337.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 28X48-50MM X-ALT 0DG NEUT STD HXLPE 6MM NON- HD F -,SUP-931-28-248,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB 36X52-54MM X-ALT 0DG NEUT STD HXLPE 6MM HD F /FMP -,SUP-932-36-252,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ2.5 63/59MM SIGMA FB RT KN CR CMNT COCR NPOR -,SUP-96-0018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7199.14,5039.398,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SIGMA TC3 FEM RT SZ2 -,SUP-96-0087,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL TC3 CEMENTED SIGMA SIZE 5 RIGHT -,SUP-96-0090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
FEMORAL TC3 CEMENTED SIGMA SIZE 2.5 RIGHT -,SUP-96-0092,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 32MM XS UHMWPE PEGX3 PFC SIG OVL DOME -,SUP-96-0100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 38MM STD UHMWPE PEGX3 PFC SIG OVL DOME -,SUP-96-0102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP PTLR 41MM LRG UHMWPE PEGX3 PFC SIG OVL DOME -,SUP-96-0103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ADAPTER FEM 5DG PFC SIGMA TC3 KN REVISN CMNT TI -,SUP-96-0781,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8615.53,6030.871,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BOLT FEMORAL ADAPTER +2/-2 OFF -,SUP-96-0784,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1623.81,1136.667,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
DISTAL AUGMENT SIZE 2 4MM RIGHT -,SUP-96-0821,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
DISTAL AUGMENT SIZE 2 8MM RIGHT -,SUP-96-0823,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
DISTAL AUGMENT SIZE 2.5 8MM RIGHT -,SUP-96-0843,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
DISTAL  AUGMENT  COMBO  SIZE 2.5 16MM RIGHT -,SUP-96-0852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT FEM SZ4 PFC SIG POST KN WDG/BLCK 4MM COCR -,SUP-96-0886,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMBO PFC SIGMA POST AUG CEMENTED SIZE 5 X 8MM -,SUP-960908,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMBO PFC SIGMA DIST AUG CEMENTED SIZE 6 X 12MM LEFT -,SUP-96-0909,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMBO PFC SIGMA DIST AUG CEMENTED SIZE 6 X 16MM LEFT -,SUP-96-0911,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5 10MM 74MM/47MM M/L/A/P PFC SIG PS ARTCSURF -,SUP-96-2051,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT ROTATING PLTFRM SIZE 3 X 12.5MM -,SUP-96-2132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBAL INSERT ROT PLAT STAB SZ4 12.5MM -,SUP-96-2142,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBAL INSERT ROTATING PLATFORM (STAB) 4- 20MM -,SUP-96-2145,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT ROT PLTFRM TC3 SZ 2 12.5MM -,SUP-96-2322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT ROTATING PLATFORM SIZE 2 20MM -,SUP-96-2325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT ROTATING PLATFORM TC3 SZ 12.5 -,SUP-96-2332,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT ROTATING PLTFRM SZ3 30MM -,SUP-96-2348,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL INSERT TC3 RP S4 12.5 -,SUP-96-2352,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL PLATFORM TCS SZ 5 GVF 22.5MM -,SUP-96-2366,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBTRY SZ3 8MM KN PFC SIG UHMWPE CR POST LIP -,SUP-96-2540,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6645.51,4651.857,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ5 15X89/55MM PFC SIG PS TCMPRTMNTL BEAR ARTC -,SUP-97-0473,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM UNIPL COCR POR -,SUP-98000100400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12559.22,8791.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
KT THR PRFT SUMMIT -,SUP-98-0001-006-00,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12559.22,8791.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB LRG VIVACIT VIT-E XLNK PE CNSTRN F/T/H ARTHPL -,SUP-98000125053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21605.69,15123.983,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
KT THR PRIM KINECTIV -,SUP-98000132001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21605.69,15123.983,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
KT THR PERSONA -,SUP-98-0002-415-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21605.69,15123.983,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SYS TKR PRIM CONSTRUT -,SUP-98000600000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20654.23,14457.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ3 10MM PFC SIG MODULAR CS STAB ANTMC KN POR CTD -,SUP-98-6061,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINK NECK SEGMENT WITHOUTH COLLAR 12/14MM 126 DEG 65MM -,SUP-99-0984/30,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19311.31,13517.917,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE HIP +5MM 12/14 TAPR ASR UNIPL -,SUP-9998-00-315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1022.29,715.603,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SLEEVE HIP +8MM 12/14 TAPR ASR ADPR UNIPL -,SUP-9998-00-318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RADIAL HEAD 22MM -,SUP-ALN-RH1-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9803.64,6862.548,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD RADIAL 20MM -,SUP-ALN-RHI-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9803.64,6862.548,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RADIAL HEAD 24MM -,SUP-ALN-RHI-240,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9803.64,6862.548,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM 8MM X 0MM -,SUP-ALN-RST-0800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM 8MM X 2MM -,SUP-ALN-RST-0802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RADAIL STEM ALIGN 9MM X 0MM -,SUP-ALN-RST-0900,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM 10MM X 0MM -,SUP-ALN-RST-1000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PACKAGED RADIAL STEM 11MM X 2MM -,SUP-ALN-RST-1102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT KN 7DG 8DG XL LRG 9.83 MDL OPN 78-88MM 88-96 MM -,SUP-AR-13400L-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT KN 11DG 12DG XL LRG 14.13 MDL OPN 78-88MM 88-96 MM -,SUP-AR-13400L-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PIP DART PEEK 10 DEGREE 2.5X30MM -,SUP-AR-4154PS-3010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
IMPLANT PIP 3MM PEEK 30MM 10DG ANG -,SUP-AR-4155PS-3010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SCREW 7X12 PROSTOP ARTHROEREISIS -,SUP-AR-4207-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SCREW 8 X 14 MM PROSTOP SFT THRD -,SUP-AR-4208-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6154.44,4308.108,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SCREW 9X14 PROSTOP ARTHROEREISIS -,SUP-AR-4209-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SCREW 10X14MM PROSTOP SFT THRD CNCL TI F /ARTHROEREISIS -,SUP-AR-4210-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SCREW 11X16MM PROSTOP SFT THRD CNCL TI F /ARTHROEREISIS -,SUP-AR-4211-16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SCREW 12X16 PROSTOP ARTHROEREISI S -,SUP-AR-4212-16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
"GUIDE WIRE .045"" X 5.91"" -",SUP-AR-8933K,CDM,C1776,HCPCS,278,RC,,,outpatient,,,40.85,28.595,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUMERAL UNIVERS  SZ 6 -,SUP-AR-9100-06P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13645.28,9551.696,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 10MM UNIVERS II 148MM SHLDR -,SUP-AR-9100-10P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13645.28,9551.696,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GLENOID UNIV BASEPLATE SMALL -,SUP-AR-9120-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7278.46,5094.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 54X23MM UNIVERS II ECCT -,SUP-AR-9154-23P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ANATOEMIC PROSTHESIS 17MM -,SUP-AR-9500-170,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ANATOEMIC PROSTHESIS 18.5MM -,SUP-AR-9500-185,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ANATOEMIC PROSTHESIS 20MM -,SUP-AR-9500-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ANATOEMIC PROSTHESIS 21.5 MM -,SUP-AR-9500-215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RESTRICTOR CEMENT REV 30MM -,SUP-B000-0300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
REVERSE BODY STANDARD AND REVERSE BODY SCREW -,SUP-BBS-0960-21STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS PRIMARY PROXIMAL BODY 2.5 08STD -,SUP-BOD-0923-020-08STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BODY TSS PRIMARY PROXIMAL 10 LRG -,SUP-BOD-0923-020-10LRG,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BODY TSS PRIMARY PROXIMAL 10 STD -,SUP-BOD-0923-020-10STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BODY TSS PRIMARY PROXIMAL 2.5 X 12 STD -,SUP-BOD-0923-020-12STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BODY HUM LRG 40MM TI PROX GFT TITAN F/MODULAR SHLDR SYS -,SUP-BOD-0923-020-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6836.57,4785.599,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BODY TSS PRIMARY PROX 2.5 14 LRG -,SUP-BOD-0923-020-14LRG,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS PRIMARY PROXIMAL BODY 2.5 14STD -,SUP-BOD-0923-020-14STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS FRACTURE BODY 2.5 08LRG -,SUP-BOD-0923-021-08LRG,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS FRACTURE BODY 2.5 08STD -,SUP-BOD-0923-021-08STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ULNAR STEM 5.0MM 2CM EXT STEM -,SUP-DRUJ-IS250,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9932.28,6952.596,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AEQREVSD FX/ADAPTER LATRLZD HMRL INSRT 36MM 9MM -,SUP-DWD861,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8929.38,6250.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AEQUALIS REVERSED FX STEM 11MM X 130MM -,SUP-DWD903,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24223.61,16956.527,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TORNIER PERFORM REVERSED STANDARD GLENOSPHERE DIA 36MM -,SUP-DWJ012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15178.74,10625.118,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LINER ACTB SZ23 36MM MAX-ROM RINGLOC +3 HW E1 -,SUP-EP108323,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BEARING E1 44-36 STD HMRL -,SUP-EP-115393,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB 10X71/75MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-EP-183540,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB 12X71/75MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-EP-183542,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB 18MMX67MM M/L VANGRD ANT STAB MODULAR ARTC BEAR -,SUP-EP-189048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ACT ARTIC E1 HIP BRG 28X42MM -,SUP-EP-200148,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ACT ARTIC E1 HIP BRG 28X44MM -,SUP-EP-200150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ACT ARTIC E1 HIP BRG 28 X 50MM -,SUP-EP-200156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
IMPLANT TOE JOINT PRIMUS SIZE 40 -,SUP-FGT-40T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6915.85,4841.095,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RSS GLENOID BASEPLATE-S -,SUP-GBP-0961-094-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS PEGGED GLENOID XS -,SUP-GLN-0920-030-00P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9802.32,6861.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GLENOID TSS PEGGED S -,SUP-GLN-0920-030-01P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4010.16,2807.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS PEGGED GLENOID S -,SUP-GLN-0920-030-01P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9802.32,6861.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS PEGGED GLENOID -,SUP-GLN-0920-030-02P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9802.32,6861.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS PEGGED GLENOID L -,SUP-GLN-0920-030-03P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4010.16,2807.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GLENDOID S FIN-LOCK -,SUP-GLN-0926-030-01A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5882.18,4117.526,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RSS GLENOSPHERE CONCENTRIC -S 2MM -,SUP-GLS-0961-02C-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RSS GLENOSPHERE CONCENTRIC -S 5MM -,SUP-GLS-0961-05C-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS PEGGED GLENOID XS -,SUP-GN092003000P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10292.44,7204.708,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
KEY SURG 26MM F /UHR ACTB HEAD REM -,SUP-HIUHRK26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1195.26,836.682,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASE PLATE ASSEMBLY IJS-E -,SUP-IJS-ELB-BPA,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21316.33,14921.431,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STANDARD POLY LINER +0 -,SUP-LNR-0960-00S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RSS HXL LINER STANDARD +35 -,SUP-LNR-0960-191-3S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RSS HXL LINER STANDARD +65 -,SUP-LNR-0960-191-6S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RSS HXL LINER STANDARD +9S -,SUP-LNR-0960-191-9S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RSS HXL LINER STANDARD +OS -,SUP-LNR-0960-191-OS,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
RSS HXL LINER RETENTIVE +6R -,SUP-LNR-0960-192-6R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SYSTEM GREAT TOE MOVEMENT PROX PHALANX HEMI -,SUP-MGT-890-20PPH,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10627.83,7439.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SYS MOVEMENT GREAT TOE SIZE 40 HEMI PROX PHALANX -,SUP-MGT89040PPH,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10627.83,7439.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM 44X19MM TITAN 2.5 ECCT COCR -,SUP-MHH-0920-010-4419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6991.01,4893.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS COCR ECCENTRIC HEAD 2.5 40 X 15MM -,SUP-MHH-0923-010-4015E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS COCR CONCENTRIC HEAD 2.5 44 X 19MM -,SUP-MHH-0923-010-4419C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD TSS COCR ECCENTRIC 2.5 44 X 19MM -,SUP-MHH-0923-010-4419E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CONCENTRIC HEAD TSS COCR 2.5 46 X 14MM -,SUP-MHH-0923-010-4614C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS COCR ECCENTRIC HEAD 2.5 46 X 14MM -,SUP-MHH-0923-010-4614E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD CONCENTRIC TSS COCR 2.5 46MM X 17MM -,SUP-MHH-0923-010-4617C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD TSS COCR ECCENTRIC 2.5 46 X 17MM -,SUP-MHH-0923-010-4617E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS COCR CONCENTRIC HEAD 2.5 46 X 20MM -,SUP-MHH-0923-010-4620C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS COCR CONCENTRIC HEAD 2.5 48 X 18MM -,SUP-MHH-0923-010-4818C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD HUM COCR CONC 2.5 X 48 X 21MM TSS -,SUP-MHH-0923-010-4821C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD TSS COCR ECCENTRIC 2.5 48 X 21MM -,SUP-MHH-0923-010-4821E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS COCR CONCENTRIC HEAD 2.5 50 X 19MM -,SUP-MHH-0923-010-5019C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS COCR CONCENTRIC HEAD 2.5 50 X 22MM -,SUP-MHH-0923-010-5022C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD TSS COCR CONCENTRIC 2.5 52 X 20MM -,SUP-MHH-0923-010-5220C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
IMPLANT SZ30 -,SUP-MHT-30,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6017.99,4212.593,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT LT SIZE 7 FEMORAL CR NONPOROUS COCR -,SUP-ORTHO DEV,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL PS 8MM SIZE 5 VITAMIN E -,SUP-ORTHO DEV,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEMORAL 36MM +3 BIOLOX DELTA -,SUP-ORTHO DEV,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM PLASMA SPRAY STD SIZE 11 -,SUP-ORTHO DEVELOPMENT,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIB SZ1 STRIDE LL/RM -,SUP-PFSI-00001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIB SZ2 STRIDE LL/RM -,SUP-PFSI-00003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIB SZ2 STRIDE RL/LM -,SUP-PFSI-00004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STRIDE TIBIA BASEPLATE SIZE 3 RM/LL -,SUP-PFSI00005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIB SZ3 STRIDE LL/RM -,SUP-PFSI-00005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIB SZ3 STRIDE RL/LM -,SUP-PFSI-00006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIBIAL STRIDE SZ 4 RMLL -,SUP-PFSI00007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STRIDE TIBIA BASEPLATE SZ. 4 LM/RL -,SUP-PFSI00008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIB SZ4 STRIDE RL/LM -,SUP-PFSI-00008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP TIB SZ5 STRIDE LL/RM -,SUP-PFSI-00009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5156.46,3609.522,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL 8MM SIZE A -,SUP-PFSI00021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ A 9MM -,SUP-PFSI-00022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIB SZ B 8MM -,SUP-PFSI00027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STRIDE POLY INSERT SZ. B 8MM -,SUP-PFSI00027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STRIDE POLY INSERT TIB SZ-C 8MM -,SUP-PFSI00033,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ1 STRIDE LL/RM -,SUP-PFSI-00052,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STRIDE FEMUR SZ. 3 LM/RL -,SUP-PFSI00055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10492.44,7344.708,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ3 STRIDE LL/RM -,SUP-PFSI00056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10492.44,7344.708,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STRIDE FEMUR SIZE 4 RM/LL -,SUP-PFSI00058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10492.44,7344.708,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP FEM SZ5 STRIDE LL/RM -,SUP-PFSI-00060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP COMPREHESIVE MODULAR HYBRID REGNREX SHLDR POST -,SUP-PT-113950,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 9MM LNG REUNION COCR HAP CTD SHLDR -,SUP-R53514509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SPACER KN 46MM FEM MODHD ANTBTC REMEDY -,SUP-RHHDSM,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8093.31,5665.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM MED MODULAR -,SUP-RHSTMD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD FEM REFLEX HYBRID 32MM +2.5MM NK COCR C-TAPR PRIM LFRIC -,SUP-S1400HH32,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
C-TAPER LFIT INTER HEAD 28MM +2.5 -,SUP-S-1400-HH82,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
C-TAPER HEAD +7.5 OFFSET LFIT SZ. 28MM / +7.5 -,SUP-S-1400-HH84,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PEG 4 MOD GLEN SZ 2 -,SUP-SAGL2042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
4 PEG MOD GLEN SZ 3 -,SUP-SAGL2043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PEG 4 MOD GLEN SZ 4 -,SUP-SAGL2044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PEG 4 MOD GLEN SZ5 -,SUP-SAGL2045,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT 4 PEG MOD GLEN LT AUG SZ 2 -,SUP-SAGL2142,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
4 PEG MOD GLEN LT AUG SZ 3 -,SUP-SAGL2143,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PEG 4 MOD GLEN LT AUG SZ 5 -,SUP-SAGL2145,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
4 PEG MOD GLEN RT AUG SZ 2 -,SUP-SAGL2242,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
4 PEG MOD GLEN RT AUG SZ 3 -,SUP-SAGL2243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
4 PEG MOD GLEN RT AUG SZ 4 -,SUP-SAGL2244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PEG 4 MOD GLEN RT AUG SZ 5 -,SUP-SAGL2245,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
MODULAR POST PPS -,SUP-SAGP0001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
MODULAR POST TM -,SUP-SAGP0002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 10MM SHLDR -,SUP-SEM092002510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
OXINIUM LEGION PS-SPC FEMUR LEFT SIZE 5 -,SUP-SMITH & NE,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9155.58,6408.906,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 16.7MM PROX 10MM DIST SM 150MM INTSPC HI RELS 25MM -,SUP-SPC0022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12735.59,8914.913,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 10.5MM/21.9MM DIA P/D MED/SHRT 156MM INTSPC HI RELS -,SUP-SPC0122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12364.29,8655.003,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SPACER THR CMNT XL 54MM HIP REVISN INTSPC -,SUP-SPC0421,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11101.87,7771.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM FEM 10.5MM/21.9MM DIA P/D MED LNG 271MM INTSPC HI RELS -,SUP-SPC0422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SPACER THR CMNT LNG STM 60MM HIP REVISN INTSPC -,SUP-SPC0522,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
SMART TOE INTRAMEDULLARY ARTHRODEAL 11MM -,SUP-ST0XS-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6409.29,4486.503,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS PRESS FIT STEM SZ. O7 -,SUP-STEM-0920-025-07,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS PRESS FIT STEM SIZE 08 -,SUP-STEM-0920-025-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS PRESS FIT HUM STEM SIZE 09 -,SUP-STEM-0920-025-09,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 12MM PRFT TITAN -,SUP-STEM-0920-025-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS PRESS FIT STEM SZ 10 -,SUP-STEM-0920-025-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 11MM PRFT TITAN -,SUP-STEM-0920-025-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM PRESS FIT TSS SZ 12 -,SUP-STEM-0920-025-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HUM 13MM PRFT TITAN -,SUP-STEM-0920-025-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS PRESS FIT STEM SZ 14 -,SUP-STEM-0920-025-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM PRESS FIT TSS SZ 15 -,SUP-STEM-0920-025-15,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS PRESS FIT STEM SIZE 16 -,SUP-STEM-0920-025-16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TSS CEMENTED STEM SZ 08 -,SUP-STEM-0950-025-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT ECCENTRIC CUP 10' X 36MM X3 CODE E TRIDENT -,SUP-STRYKER,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
WEDGE ACETABULAR AUGMENT 54MM X 56MM X 15MM -,SUP-STRYKER,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP VRSDL GLNSPR 36MM TI -,SUP-TI-115310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP ACTB 26X42MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-42-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP ACTB 26X43MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-43-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP ACTB 26X44MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-44-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP ACTB 26X45MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-45-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP ACTB 26X46MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-46-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP ACTB 26X47MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-47-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP ACTB 26X48MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-48-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP ACTB 26X50MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-50-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP ACTB 26X51MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-51-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP ACTB 26X52MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-52-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP ACTB 26X53MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-53-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP ACTB 26X54MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-54-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP ACTB 26X55MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-55-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP ACTB 26X56MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-56-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMP ACTB 26X58MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-58-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE MED GLENOID UNIVER -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7278.46,5094.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BASEPLATE 3LT REV TIBIA LNG -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT FEM DIST 12MM SIZE 4 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
AUGMENT TIBIAL HALF BLOCK #6 T -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GLENOID REVERS 39 +4 LAT -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CONE FEMORAL MEDIUM LEFT 30MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CONE PROX BODY SIZE 0 60MM TYP -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CONE TIBIAL 31 X 31 X 25MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CUP PIVOT BIPOLAR 22 X 45MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT LGN OX FEMORAL 5LT C -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPONENT LT MOD FEM SIZE 3 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
CUP UNIVERS REVERS 39 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7575.54,5302.878,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HUMERAL HEAD UNIVERS 44/17 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT TIBIAL #5 13MM TS -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GLENOID POLY WITH PEG LG -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
GLENOID POLY WITH PEG SMALL -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
HEAD 40 CER 16/18 TAPER BIOLOXD -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
INSERT HUMERAL M/39 +3 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
POSTERIOR FEM AUGMENT 8MM SZ 4 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM DIST CONICAL 21MM X 155MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HIP MODULAR 12MM X 127MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10941.84,7659.288,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM STR DIST 21MM X 150MM TAP -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBAL INSERT TOTAL STAB SZ.3 9 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIAL KNEE INSERT 3X12 PS ORTH -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
WEDGE ACET AUGMENT 46MM X 15MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM HIP MODULAR 13MM X 127MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10941.84,7659.288,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM STR DIST 21MM X 90MM TAPE -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
STEM UNIVERS SZ10 CAP COATED -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10546.34,7382.438,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIBIAL HALF BLOCK #6 5MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TIB TRAY ROTATING REV  SZ 2 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
TRIAL CONE MED 31 X 31 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2768.92,1938.244,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPR NANO HMRL PPS 36MM -,SUP-US-115736,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24134.5,16894.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPR NANO HMRL PPS 38MM -,SUP-US-115738,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24134.5,16894.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
COMPR NANO HMRL PPS 40MM -,SUP-US-115740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24134.5,16894.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
BEARING HUM 44-36MM XL STD RVRS CMPRHNSV ARCM -,SUP-XL115363,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
ARCOM XL 44-36 STD HMRL BRNG -,SUP-XL-115363,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
44MM X 36MM CURV HUMERAL BEARING -,SUP-XL-115364,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
PERSONA FEMUR CEMENTED STD CCR SIZE 7 LEFT -,SUP-ZIMMER,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.170825,27238.33344,other,SI=N Exclusions ,,
LEAD DEFIB IMPL BIPLR PERMNT PCNG ETAK RELIANCE 59CM 9FR -,SUP-0137,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List,,
ENDOTAK RELIANCE S 64CM REF: 0138 -,SUP-0138,CDM,C1777,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List,,
LEAD PCNG 64CM ETAK RELIANCE SG -,SUP-0181,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List,,
ENDOTAK RELIANCE S 0272 59CM -,SUP-0272-59,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List,,
ENDOTAK RELIANCE S 0273 64CM -,SUP-0273-64,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List,,
LEAD ENDOTAK RELIANCE SINGLE C -,SUP-0292,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List,,
LEAD DEFIB PCNG ETAK RELIANCE 59CM GORE-HYBRID ETFE CTD STRD -,SUP-0292-59,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List,,
LEAD ICD RELIANCE 4-FRONT DEFIB -,SUP-0672-59,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List,,
LEAD DEFIB IMPL LINOX SMRT S 65CM ECRD SIL INSL SGL COIL -,SUP-369818,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List,,
LEAD DEFIB IMPL LINOX SMRT S 60CM ECRD SIL INSL SGL COIL -,SUP-375012,CDM,C1777,HCPCS,278,RC,,,outpatient,,,12976.94,9083.858,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List,,
LEAD PCNG PROTEGO T FX -,SUP-379967,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List,,
DEFIBRILLATOR PROTEGO S SGL COIL 75CM LD CARD IMPL -,SUP-379968,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List,,
DEFIBRILLATOR PROTEGO S SGL COIL 60CM LD CARD IMPL -,SUP-379970,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List,,
PLEXA PROMRI DF-1 S DS 65/15 -,SUP-414005,CDM,C1777,HCPCS,278,RC,,,outpatient,,,10734.28,7513.996,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List,,
LEAD DEFIB TRIPLR SPRNT QUATTRO 58CM 8.6FRX12MM SPC RT ECRD -,SUP-6935-58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List,,
LEAD DEFIB TRIPLR SPRNT QUATTRO 75CM 8.6FRX12MM SPC SIL -,SUP-6935M,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List,,
LEAD DEFIB TRIPLR SPRNT QUATTRO 72CM 8.6FRX12MM SPC SIL -,SUP-6935M72,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List,,
LEAD DEFIB UNIPL 58CM 7.5FR SUBQ SIL INSL SUT ON ANCHR SLV -,SUP-6996SQ58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List,,
LEAD DEFIB TRUE BIPLR DURATA 60CM 7FR VNTRC OPTIM INSL STRD -,SUP-7122/60,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List,,
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FR VNTRC OPTIM INSL STRD -,SUP-7122/65,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List,,
LEAD DEFIB TRUE BIPLR DURATA 52CM 7FR VNTRC OPTIM INSL SGL. -,SUP-7122Q/52,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List,,
LEAD DEFIB 7FRX58CM DURATA TRUE BIPLR HLCL TIP AV SGL SHOCK. -,SUP-7122Q/58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List,,
LEAD DEFIB 7FRX65CM DURATA TRUE BIPLR HLCL TIP AV SGL SHOCK -,SUP-7122Q/65,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List,,
LEAD DEFIB 8FR INTRO 58CM OPTISURE TRUE BIPLR SGL COIL -,SUP-LDA210Q/58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List,,
LEAD DEFIB 8FR INTRO 65CM OPTISURE TRUE BIPLR SGL COIL -,SUP-LDA210Q-65,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9966.28992,other,Non-Reimbursable List,,
PK LEAD NEURSTM ACC -,SUP-30571SC,CDM,C1778,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List,,
KT LEAD NEURSTM OCTRODE 60CM ACC -,SUP-3186,CDM,C1778,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List,,
OCTRODE -,SUP-3189,CDM,C1778,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List,,
LEAD NEURSTM PENTA 60CM PDL -,SUP-3228,CDM,C1778,HCPCS,278,RC,,,outpatient,,,14480.7,10136.49,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List,,
KT LEAD NEURSTM LMTRD S-8 60CM ACC -,SUP-3286,CDM,C1778,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List,,
KT 8MMX60CM LDX1 REVISN F/MDTRNC DEEP BRN STIM DBS -,SUP-3550-27,CDM,C1778,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List,,
KT EXTENSION NEURSTM 40CM ACC -,SUP-3708140,CDM,C1778,HCPCS,278,RC,,,outpatient,,,3007.62,2105.334,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List,,
KT LEAD NEURSTM PLTNM-IRDM ELCTRD 60CM STD ACC -,SUP-3777-60,CDM,C1778,HCPCS,278,RC,,,outpatient,,,7193.58,5035.506,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List,,
KT LEAD NEURSTM 60CM PERC CMPCT ACC -,SUP-3778-60,CDM,C1778,HCPCS,278,RC,,,outpatient,,,7193.58,5035.506,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List,,
KT LEAD NEURSTM PLTNM-IRDM ELCTRD PU SLVR COR 75CM PERC -,SUP-3778-75,CDM,C1778,HCPCS,278,RC,,,outpatient,,,7193.58,5035.506,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List,,
LEAD PCNG 56CM TIP PISCES QUAD -,SUP-3887-56,CDM,C1778,HCPCS,278,RC,,,outpatient,,,4498.64,3149.048,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List,,
KT LEAD NEURSTM SPEC FLRPLYMR PLTNM-IRDM SIL RBR PLYSTR PU -,SUP-3956530,CDM,C1778,HCPCS,278,RC,,,outpatient,,,17822.4,12475.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List,,
KT LEAD NEURSTM SPEC 65CM SPIN CRD 5-6-5 LD ACC -,SUP-3956565,CDM,C1778,HCPCS,278,RC,,,outpatient,,,17822.4,12475.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List,,
REACTIV8 IMPLANTABLE LEAD 45CM -,SUP-8145,CDM,C1778,HCPCS,278,RC,,,outpatient,,,11127.86,7789.502,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List,,
STIMULATOR NERVE SPRINT ENDURA PNS SYSTEM -,SUP-9244-6001,CDM,C1778,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List,,
STIMULATOR NERVE SPRINT EXTENSA PNS SYSTEM -,SUP-9288-6002,CDM,C1778,HCPCS,278,RC,,,outpatient,,,30075.3,21052.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List,,
LEAD NEURSTM VECTRIS SURECAN 60CM PERC IMPL -,SUP-977A260,CDM,C1778,HCPCS,278,RC,,,outpatient,,,8347.95,5843.565,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List,,
SYS PROGRAMMER NEURSTM VECTRIS SURSCN 75CM SPIN CRD CMPCT -,SUP-977A275,CDM,C1778,HCPCS,278,RC,,,outpatient,,,8347.95,5843.565,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List,,
SURESCAN MRI -,SUP-977C165,CDM,C1778,HCPCS,278,RC,,,outpatient,,,20681.41,14476.987,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List,,
LEAD SPECIFY SURESCAN MRI LEAD -,SUP-977C265,CDM,C1778,HCPCS,278,RC,,,outpatient,,,20681.41,14476.987,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List,,
SURESCAN 2 X 8 PADDLE LEAD -,SUP-977C290,CDM,C1778,HCPCS,278,RC,,,outpatient,,,20681.41,14476.987,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List,,
LEAD INTERSTIM MICRO 28CM SSMRI TINED -,SUP-978A128,CDM,C1778,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List,,
INTERSTIM MRI LEAD KIT 2.16MM X 28CM -,SUP-978B128,CDM,C1778,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List,,
LEAD NEUROSTIMULATOR INTERSTIM L41 CM TINE SSMRI -,SUP-978B133,CDM,C1778,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List,,
FREEDOM 4A NEUROSTIMULATOR FR4A-TRL-A0 -,SUP-FR4A-TRL-A0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List,,
FREEDOM 4A NEUROSTIMULATOR FR4A-TRL-B0 -,SUP-FR4A-TRL-B0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List,,
FREEDOM-8A TRIAL KIT CH A US -,SUP-FR8A-TRL-A0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List,,
FREEDOM 8A NEUROSTIMULATOR FR8A-TRL-B0 -,SUP-FR8A-TRL-B0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List,,
KIT INTELLIS TRIAL LEAD 2 -,SUP-INTELTRIAL2,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List,,
BLUE PERC LEAD KIT -,SUP-LEAD1058-70B,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List,,
NEVRO 70CM SURGICAL LEAD KIT -,SUP-LEAD3005-70B,CDM,C1778,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List,,
KT NEURSTM PRGMR PRECISN ACC -,SUP-M365SC550040,CDM,C1778,HCPCS,278,RC,,,outpatient,,,6196.24,4337.368,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List,,
VECTRIS SURESCAN MRI COMPACT LEAD KIT 1 X 8 SC -,SUP-MEDTRONIC INC,CDM,C1778,HCPCS,278,RC,,,outpatient,,,8347.95,5843.565,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List,,
SLIM TIP DRG -,SUP-MN10450-50A,CDM,C1778,HCPCS,278,RC,,,outpatient,,,9331.07,6531.749,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List,,
SLIMTIP DRG 90A -,SUP-MN10450-90A,CDM,C1778,HCPCS,278,RC,,,outpatient,,,9509.36,6656.552,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List,,
KIT NEUROSTIMULATOR TUNNEL TOOL -,SUP-MN15000,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2572.47,1800.729,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List,,
FREEDOM -4A PNS SYSTEM -,SUP-Q4SP-1-US DW,CDM,C1778,HCPCS,278,RC,,,outpatient,,,40705.5,28493.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List,,
FREEDOM -4A PNS SYSTEM -,SUP-Q4SP-2-US,CDM,C1778,HCPCS,278,RC,,,outpatient,,,44406,31084.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List,,
COVEREDGE 32 MRI PADDLE LEAD 50CM -,SUP-SC-8436-50,CDM,C1778,HCPCS,278,RC,,,outpatient,,,29704,20792.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List,,
TRIAL LEAD KIT -,SUP-TLEAD1058-70B,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,34103.808,other,Non-Reimbursable List,,
LEAD PCNG 9FRX12MM SPC AV + DX PERMNT BIPLR STRD ELUT TND FX -,SUP-1368,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,2035.392,other,Non-Reimbursable List,,
LEAD PCNG 9FRX12MM SPC 52CM AV + DX PERMNT BIPLR STRD ELUT -,SUP-1368/52,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,2035.392,other,Non-Reimbursable List,,
LEAD PCNG 9FRX12MM SPC 58CM AV + DX PERMNT BIPLR STRD ELUT -,SUP-1368/58,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,2035.392,other,Non-Reimbursable List,,
PACING  LEAD TENDRIL STS 2088TC-65 -,SUP-2088TC-65,CDM,C1779,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,2035.392,other,Non-Reimbursable List,,
LEAD PCNG 58CM SOLOX IMPL BIPLR ECRD SGL -PASS PSS FX -,SUP-333900,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,2035.392,other,Non-Reimbursable List,,
MESH SURG LRG 5.4X7IN OVL PP EPTFE CMPSX KL NABSB PTCH -,SUP-0010202,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5029.22,3520.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH SURG SM 3.1X4.7IN OVL MONO PP PDS EPTFE VENTRIO PRT -,SUP-0010211,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3818.72,2673.104,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH SURG LRG 5.4X7IN OVL MONO PP PDS EPTFE VENTRIO PRT ABSB -,SUP-0010212,CDM,C1781,HCPCS,278,RC,,,outpatient,,,7123.55,4986.485,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH SURG 4.5IN LRG CIR MONO PP PDS EPTFE VENTRIO PRT ABSB -,SUP-0010214,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4340.04,3038.028,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH SURG MED 4.3X5.5IN OVL MONO PP PDS EPTFE VENTRIO PRT -,SUP-0010215,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5013.01,3509.107,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH SURG 8CM LRG 3.2X3.2IN CIR PP EPTFE VENTRALEX NABSB -,SUP-0010303,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4167.7,2917.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH PERFIX PLUG MED -,SUP-0112760,CDM,C1781,HCPCS,278,RC,,,outpatient,,,984.1,688.87,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH PERFIX PLUG LRG -,SUP-0112770,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1660.12,1162.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH PLUG PERFIX X-LRG -,SUP-0112780,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1159.39,811.573,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH 3DMAX DAVOL LRG LEFT -,SUP-0115311,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH 3DMAX DAVOL X-LRG LEFT -,SUP-0115312,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1187.9,831.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH 3DMAX DAVOL LRG RIGHT -,SUP-0115321,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH 3DMAX DAVOL X-LRG RIGHT -,SUP-0115322,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1187.9,831.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH MOD KUGEL 3.5 X 5 -,SUP-0115816,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH SURG 4X6IN ELLIP MONO PP EPTFE COMPOSIX E /X NABSB -,SUP-0123460,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2954.63,2068.241,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH ATRIUM 1 X 4 - DISC DO NOT USE -,SUP-1000104-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,116.7,81.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH ATRIUM 2 X 4 -  DISC DO NOT USE -,SUP-1000204-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,128.37,89.859,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH ATRIUM 6 X 6 - DO NOT USE DISCONTINUED -,SUP-1000606-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,163.38,114.366,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH ATRIUM 6X6 - DISCONTINUED DO NOT USE -,SUP-1000606-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,163.38,114.366,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH SURG 10X14IN PP KNTD PROLITE NABSB SHT -,SUP-1001014-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,478.47,334.929,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH ATRIUM PRE SHAPED -,SUP-1010306-02,CDM,C1781,HCPCS,278,RC,,,outpatient,,,192.56,134.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH SURG 20X30CM RECT EPTFE GORE-TEX PTCH -,SUP-1320030020,CDM,C1781,HCPCS,278,RC,,,outpatient,,,18928.87,13250.209,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH SURG 5X10CM EPTFE GORE-TEX PTCH -,SUP-1405010010,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1754.47,1228.129,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH SURG 10X15CM OVL EPTFE GORE-TEX PLG -,SUP-1410015010,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4014.93,2810.451,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
IMPLANT ARTELON 0.3X16CM -,SUP-31052,CDM,C1781,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
IMPLANT ARTELON 0.7X16CM -,SUP-31056,CDM,C1781,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH PROLENE 3D PATCH LRG -,SUP-3DPL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3399.12,2379.384,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH PROLENE 3D PATCH MED -,SUP-3DPM,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3399.12,2379.384,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH RESTORELLE 24CM X 4CM -,SUP-501420,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4419.28,3093.496,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH VENTRALEX ST SM 4.3CM -,SUP-5950007,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2292.25,1604.575,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH VENTRALEX ST MD 6.4CM -,SUP-5950008,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2488.78,1742.146,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH VENTRALEX ST LRG 8.0CM -,SUP-5950009,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3167.55,2217.285,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH SURG 3IN SM CIR MONO PP CO-KNTD VENTRALEX ST ECHO PS -,SUP-5950010,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3765.73,2636.011,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH SURG SM 3.1X4.7IN OVL MONO PP CO-KNTD VENTRALEX ST ECHO -,SUP-5950030,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4634.12,3243.884,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH SURG MED 4.3.X5.5IN OVL MONO PP CO-KNTD VENTRALEX ST -,SUP-5950040,CDM,C1781,HCPCS,278,RC,,,outpatient,,,6128.34,4289.838,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH SURG XL 8.7X10.7IN OVL MONO PP PTFE HYDRGL CO-KNTD -,SUP-5950080,CDM,C1781,HCPCS,278,RC,,,outpatient,,,12018.24,8412.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH SURG 4X6IN ELLIP MONO PP PTFE HYDRGL CO-KNTD -,SUP-5954460,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3720.86,2604.602,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH SURG 15CM MED RND ACCUMESH PSTN -,SUP-AMPPCO15X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3904.18,2732.926,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH SURG 20CM MED RND ACCUMESH PSTN -,SUP-AMPPCO20X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4655.67,3258.969,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH PARIETEX 15CM X 10CM RT -,SUP-AUTO-VTX1510,CDM,C1781,HCPCS,278,RC,,,outpatient,,,465.28,325.696,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH DEXTILE MEDIUM LEFT 13 X 9CM ANATOMICAL -,SUP-DXT1309AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH DEXTILE MEDIUM RIGHT 13 X 9CM ANATOMICAL -,SUP-DXT1309AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH DEXTILE LARGE LEFT 15 X 10CM ANATOMICAL -,SUP-DXT1510AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,846.08,592.256,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH DEXTILE LARGE RIGHT 15 X 10CM ANATOMICAL -,SUP-DXT1510AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,846.08,592.256,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH DEXTILE XL LEFT 16 X 12CM ANATOMICAL -,SUP-DXT1612AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH DEXTILE XL RIGHT 16 X 12CM ANATOMICAL -,SUP-DXT1612AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
PATCH BOVINE 0.8 X 8CM -,SUP-E0.8P8,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1160.81,812.567,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
PATCH BOVINE 2.0 X 9CM -,SUP-E2P9,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2008.89,1406.223,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
GORE BIOABSORBABLE SYNTHETIC MESH 7CM X 10CM -,SUP-HH0710,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH LAP PROGRIP 15 X 10 -,SUP-LPG1510,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1664.57,1165.199,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH PROGRIP ANATOM 15x10 L -,SUP-LPG1510AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1878.87,1315.209,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH PROGRIP ANATOM 15x10 R -,SUP-LPG1510AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1878.87,1315.209,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH PROGRIP LAPAROSCOPIC SELF-FIX 16 X 12 -,SUP-LPG1612,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1888.04,1321.628,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH PROGRIP ANATOM 16X12 L -,SUP-LPG1612AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2098.94,1469.258,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH PROGRIP ANATOMICAL RIGHT 16CM X 12CM -,SUP-LPG1612AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2098.94,1469.258,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
UPSYLON TRADITIONAL Y MESH -,SUP-M0068318200,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4180.97,2926.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH PROCEED 6IN X 8IN -,SUP-PCDG1,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4886.8,3420.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH PROCEED 4IN X 6IN -,SUP-PCDN1,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2936.68,2055.676,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
IMPLANT BIO TISS 10X15CM 3D RND PLYSTR PRCN COLL OPN SKRT -,SUP-PCO1510OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2440.67,1708.469,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
IMPLANT PLYSTR PRCN COLL 10X15CM PRTX 1.7MM ABSB 3D RND KNTD -,SUP-PCO1510X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1920.48,1344.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
IMPLANT BIO TISS 15CM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCO15X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2513.71,1759.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
IMPLANT BIO TISS 15X20CM 3D RECT PLYSTR PRCN COLL KNTD PRTX -,SUP-PCO2015OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3387.39,2371.173,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
IMPLANT BIO TISS 15X20CM 3D RND PLYSTR PRCN COLL KNTD PRTX -,SUP-PCO2015X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3237.25,2266.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH PARIETEX HEART SHAPED -,SUP-PCO2H1,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1862.49,1303.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH PARIETEX HORSE SHOE -,SUP-PCO2H3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1999.72,1399.804,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
IMPLANT BIO TISS 20X30CM 3D RECT PLYSTR PRCN COLL KNTD PRTX -,SUP-PCO3020X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5125.65,3587.955,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
PATCH VENTRAL PARITEX 4.6CM -,SUP-PCO4VP,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1712.49,1198.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
PATCH VENTRAL PARITEX 6.6CM -,SUP-PCO6VP,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2052.19,1436.533,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
IMPLANT BIO TISS 8CM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCO8OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2365.35,1655.745,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
IMPLANT BIO TISS 8CM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCO8OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2128.52,1489.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
PATCH VENTRAL PARITEX 8.6CM -,SUP-PCO8VP,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2635.99,1845.193,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
IMPLANT BIO TISS 50MM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCOPM15H50,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2579.06,1805.342,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH PROLENE HERNIA SYSTEM LARGE -,SUP-PHSL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2038.93,1427.251,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH PROLENE HERNIA SYSTEM MEDIUM -,SUP-PHSM,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2038.93,1427.251,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH PARIENTENE PROGRIP 15CM X 9CM -,SUP-PP1509G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1083.58,758.506,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH PARITENE MACROPOROUS 15 X 10 -,SUP-PPM1510X3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,223.71,156.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH PARITENE MACROPOROUS 15 X 15 -,SUP-PPM1515X3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,259.54,181.678,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH PARIETENE 20 X 20 -,SUP-PPM2020,CDM,C1781,HCPCS,278,RC,,,outpatient,,,301.09,210.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH PARIETENE 30 X 30 -,SUP-PPM3030,CDM,C1781,HCPCS,278,RC,,,outpatient,,,563.14,394.198,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH PARIETENE 45 X 30 -,SUP-PPM4530,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1191.23,833.861,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
DURASORB PTM 0616 6 X 16 -,SUP-PTM 0616,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
DURASORB PTM1 025 10 X 25 -,SUP-PTM1025,CDM,C1781,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
DURASORB PTM 2025 -,SUP-PTM2025,CDM,C1781,HCPCS,278,RC,,,outpatient,,,20050.2,14035.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH SURG 6X11CM RECT PLYSTR KNTD MERSILN NABSB SHT -,SUP-RMS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,992.11,694.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH SYMBOTEX 25 X 20 0118362 -,SUP-SMY2520OS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,6454.57,4518.199,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH SYMBOTEX VENTRAL 12CM -,SUP-SYM12,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1989.6,1392.72,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH SYMBOTEX VENTRAL 15CM -,SUP-SYM15,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2571.48,1800.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH SYMBOTEX VENTRAL 15CM -,SUP-SYM15,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2490.4,1743.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH SYMBOTEX VENTRAL 15 X 10 NON SKIRTED -,SUP-SYM1510,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1808.74,1266.118,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH SYMBOTEX 15 X 10 -,SUP-SYM1510OS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2418.08,1692.656,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH SYMBOTEX 2012E -,SUP-SYM2012E,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2774.79,1942.353,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH SYMBOTEX 20 X 15 CM -,SUP-SYM2015,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2613.29,1829.303,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH SYMBOTEX 20 X 15 SKIRTED -,SUP-SYM2015OS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3726.15,2608.305,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH SURG 25X15CM ELLIP MONO PLYSTR COLL SYMBOTEX NABSB -,SUP-SYM2515E,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4592.69,3214.883,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH PARIETENE DS COMPOSITE 25CM X 20CM -,SUP-SYM2520,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4274.74,2992.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH SYMBOTEX 25 X 20 -,SUP-SYM2520,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4118.24,2882.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH SYMBOTEX 30 X 20 -,SUP-SYM3020,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5381.94,3767.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH SYMBOTEX COMPOSITE -,SUP-SYM3728,CDM,C1781,HCPCS,278,RC,,,outpatient,,,6391.04,4473.728,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
Symbotexâ„¢ Composite Mesh- 42 x 32 cm -,SUP-SYM4232,CDM,C1781,HCPCS,278,RC,,,outpatient,,,7515.87,5261.109,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH SYMBOTEX VENTRAL 9CM -,SUP-SYM9,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1450.75,1015.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH SURG 10X15CM PLYSTR KNTD PRTX SHT -,SUP-TECT1510ADPL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,734.63,514.241,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
"MESH PARIETEX ANATOMICAL LEFT 6X4"" -",SUP-TECT1510AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,648.04,453.628,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
"MESH PARIETEX ANATOMICAL RIGHT 6X4"" -",SUP-TECT1510AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,648.04,453.628,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH SURG 8X12CM MONO PLYSTR KNTD PRTX PROGRIP PRT -,SUP-TEM1208GL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1175.76,823.032,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH SURG 8X12CM MONO PLYSTR KNTD PRTX PROGRIP PRT ABSB -,SUP-TEM1208GR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1175.76,823.032,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH PARIETEX PROGRIP 15cm x 9cm -,SUP-TEM1509G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1083.58,758.506,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH PARIETEX PROGRIP 15 X 15CM -,SUP-TEM1515G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1131.55,792.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH PARIETEX PROGRIP 20X15 -,SUP-TEM2015G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1382.48,967.736,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH PARIETEX PROGRIP 30X15 -,SUP-TEM3015G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1925.62,1347.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH SURG 30X30CM 3D PLYSTR KNTD PRTX EASEGRIP SHT -,SUP-TET3030,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1054.85,738.395,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH SURG 3X6IN RECT MONO PLGCPRN-25 PP KNTD ULTRAPRO PRT -,SUP-UMR3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,908.96,636.272,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
GRAFT HEMASHIELD 10MM X100CM G -,SUP-UNDEFINED,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2550.8,1785.56,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH VENTRIO XL 10 X 13 -,SUP-UNDEFINED,CDM,C1781,HCPCS,278,RC,,,outpatient,,,8233.36,5763.352,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
MESH VICRYL WOVEN FLAT12IN x 12IN ABSORBABLE HERNIA REPAIR -,SUP-VWML,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4702.1,3291.47,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,15398.5536,other,Non-Reimbursable List,,
STENT DES 2.25X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332220,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,200.09685,4563.1488,other,SI=N Exclusions ,,
STENT DES 2.5X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332250,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,200.09685,4563.1488,other,SI=N Exclusions ,,
STENT DES 3X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332300,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,200.09685,4563.1488,other,SI=N Exclusions ,,
STENT DES 3.5X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332350,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,200.09685,4563.1488,other,SI=N Exclusions ,,
STENT DES 4X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332400,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,200.09685,4563.1488,other,SI=N Exclusions ,,
STENT DES 2.75X38MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902338270,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,200.09685,4563.1488,other,SI=N Exclusions ,,
STENT DES 3.5X38MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902338350,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,200.09685,4563.1488,other,SI=N Exclusions ,,
STENT DES 4X38MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902338400,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,200.09685,4563.1488,other,SI=N Exclusions ,,
IMPLANT BIO TISS 6.5CM 3D RND PLYSTR PRCN COLL KNTD PRTX -,SUP-PNP6X3,CDM,C1784,HCPCS,278,RC,,,outpatient,,,891.3,623.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,200.09685,4563.1488,other,SI=N Exclusions ,,
PACEMAKER UNIPL BIPLR INSGA I ULTRA 2CHMBR RR 10.8ML 25.4GM -,SUP-1290,CDM,C1785,HCPCS,275,RC,,,outpatient,,,21052.71,14736.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER UNIPL BIPLR EVIA 2CHMBR 44.5X53MM 6.5MM 12ML 25GM -,SUP-359529,CDM,C1785,HCPCS,275,RC,,,outpatient,,,11220.69,7854.483,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER UNIPL BIPLR EVIA 2CHMBR RR 44.5X53MM 6.5MM 12ML -,SUP-377848,CDM,C1785,HCPCS,275,RC,,,outpatient,,,14573.53,10201.471,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER IMPL ENTOVIS PROMRI 2CHMBR IS-1 CONN SR-T ACC -,SUP-404722,CDM,C1785,HCPCS,275,RC,,,outpatient,,,18565,12995.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER IMPL UNIPL VERITY ADX MS DR 2CHMBR RR 45X52MM 6MM -,SUP-5357M/S,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9332.85,6532.995,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
GENERATOR TEMP PLS 2CHMBR 5392 ACC -,SUP-5392KIT,CDM,C1785,HCPCS,275,RC,,,outpatient,,,27828.94,19480.258,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER IMPL UNIPL BIPLR VCT DR 2CHMBR RR V- PCNG RDC -,SUP-5810,CDM,C1785,HCPCS,275,RC,,,outpatient,,,13842.06,9689.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER IMPL UNIPL BIPLR VCT XL DR 2CHMBR RR V- PCNG RDC -,SUP-5816,CDM,C1785,HCPCS,275,RC,,,outpatient,,,13842.06,9689.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER IMPL UNIPL BIPLR ZPHR 2CHMBR RR 43X44MM 6MM 8.5ML -,SUP-5820,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9332.85,6532.995,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER IMPL UNIPL BIPLR ZPHR 2CHMBR RR 43X44MM 6MM 8.5ML -,SUP-5820,CDM,C1785,HCPCS,275,RC,,,outpatient,,,22278,15594.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER IMPL UNIPL BIPLR ZPHR DR 2CHMBR RR 44X52MM 6MM -,SUP-5826,CDM,C1785,HCPCS,275,RC,,,outpatient,,,18565,12995.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER IMPL SURSCN ADVISA 2CHMBR RR MUL-PRGM IS-1 CONN SR -,SUP-A2DR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16337.2,11436.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER IMPL UNIPL ADAPTA DR 2CHMBR RR 12ML 21GM IS-1 -,SUP-ADAPTADRK2,CDM,C1785,HCPCS,275,RC,,,outpatient,,,27828.94,19480.258,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER IMPL BIPLR ADAPT 2CHMBR RR 13.1ML 31.3GM IS-1 CONN -,SUP-ADDRL1,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16567.96,11597.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER IMPL UNIPL BIPLR ADAPTA 2CHMBR RR 42.9MMX44.7MM -,SUP-ADDRS1,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16567.96,11597.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
GENERATOR 2CHMBR -,SUP-DR2550,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16708.5,11695.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER ESSENTIO DR DYNMC ADJ TI ACC -,SUP-L101,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9341.91,6539.337,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER ESSENTIO DR MRI L111 -,SUP-L111,CDM,C1785,HCPCS,275,RC,,,outpatient,,,12460.83,8722.581,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER IMPL ESSENTIO EL DR 2CHMBR 4.45X5.88X0.75IN 29.1GM -,SUP-L121,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9341.91,6539.337,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER ACCOLADE DR -REF: L301 -,SUP-L301,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9442.9,6610.03,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER ACCOLADE MRI DR L311 -,SUP-L311,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10582.05,7407.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER IMPL UNIPL BIPLR ACCENT DR 2CHMBR RR WRLS TELEM -,SUP-PM2110,CDM,C1785,HCPCS,275,RC,,,outpatient,,,12438.55,8706.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER ENDURITY 2CHMBR 50X46MM 6MM 10.4ML 19GM IS-1 CONN -,SUP-PM2160,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10470.66,7329.462,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER IMPL ACCENT DR 2CHMBR RR 52X52MM 6MM 12.8ML 23GM -,SUP-PM2210,CDM,C1785,HCPCS,275,RC,,,outpatient,,,12438.55,8706.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER IMPL ASSURITY 2CHMBR RR 50X47MM 6MM 10.4ML 20GM -,SUP-PM2240,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10732.43,7512.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
ASSURITY MRI PACEMAKER DR-RF PM2272 -,SUP-PM2272,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10582.05,7407.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER IMPL BIPLR REVO 2CHMBR RR SURSCN PCNG -,SUP-REVOMRIPEEM,CDM,C1785,HCPCS,275,RC,,,outpatient,,,23622.66,16535.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER IMPL BIPLR REVO SURSCN 2CHMBR RR 45X51X8MM 12.7ML -,SUP-RVDR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,17439.96,12207.972,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER ALTRUA 20 DDDR MUL-PRGM 43X49X8MM 29.6GM 12.6ML -,SUP-S202,CDM,C1785,HCPCS,275,RC,,,outpatient,,,17451.1,12215.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER ALTRUA 20 MUL-PRGM 42X44X8MM 25.4GM 10.8ML IS-1 -,SUP-S203,CDM,C1785,HCPCS,275,RC,,,outpatient,,,14373.02,10061.114,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER BIPLR ALTRUA 60 2CHMBR RR 42X44MM 8MM 10.8ML -,SUP-S603,CDM,C1785,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER IMPL UNIPL BIPLR SENSIA 2CHMBR RR -,SUP-SEDR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10396.4,7277.48,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
GENERATOR VERSA DUAL CHAMBER -,SUP-UNDEFINED,CDM,C1785,HCPCS,275,RC,,,outpatient,,,20402.94,14282.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER ALTRUA 20 DR 2 LD -,SUP-UNDEFINED,CDM,C1785,HCPCS,275,RC,,,outpatient,,,19827.42,13879.194,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
VERSA DR VEDR01 -,SUP-VEDR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10396.4,7277.48,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER MRI AZURE XT DR SURESCAN -,SUP-W1DR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,18565,12995.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
Azure S DR MRI Surescan W3DR01 -,SUP-W3DR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16708.5,11695.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21372.62592,other,SI=N Exclusions ,,
PACEMAKER BIPLR INSGA ULTRA SR SGL-CHMBR RR 10ML 23.4GM IS-1 -,SUP-1190,CDM,C1786,HCPCS,275,RC,,,outpatient,,,17451.1,12215.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
PACEMAKER RELAY INTMD UNIPL CARD 5MM -,SUP-293-03,CDM,C1786,HCPCS,275,RC,,,outpatient,,,16151.55,11306.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
PACEMAKER UNIPL BIPLR EVIA SR-T SGL-CHMBR RR 39X53MM 6.5MM -,SUP-359 533,CDM,C1786,HCPCS,275,RC,,,outpatient,,,10983.05,7688.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
PACEMAKER IMPL ENTOVIS SR-T PROMRI SGL-CHMBR ACC -,SUP-404723,CDM,C1786,HCPCS,275,RC,,,outpatient,,,10457.22,7320.054,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
GENERATOR IMPL VERF SGL-CHMBR -,SUP-5156,CDM,C1786,HCPCS,275,RC,,,outpatient,,,11792.49,8254.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
PACEMAKER IMPL UNIPL VERITY ADX MS DR SGL-CHMBR RR 42X52MM -,SUP-5157M/S,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8533.24,5973.268,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
PACEMAKER IMPL UNIPL BIPLR ZPHR SGL-CHMBR RR 41X44MM 6MM 8ML -,SUP-5620,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8533.24,5973.268,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
PACEMAKER IMPL UNIPL BIPLR ZPHR XL SR SGL-CHMBR RR 52X42MM -,SUP-5626,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8533.24,5973.268,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
PACEMAKER IMPL SURSCN ADVISA 1CHMBR IS-1 CONN SR -,SUP-A3SR01,CDM,C1786,HCPCS,275,RC,,,outpatient,,,14852,10396.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
PACEMAKER IMPL UNIPL ADAPTA SR SGL-CHMBR RR 7.5MM 11ML -,SUP-ADSR06,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9952.18,6966.526,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
GENERATOR PCMKR  SR SSIR -,SUP-ICV1122,CDM,C1786,HCPCS,275,RC,,,outpatient,,,12497.96,8748.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
ESSENTIO 4.45X4.81X0.75 CM D 13.2ML TI -,SUP-L100,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8899.67,6229.769,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
PACEMAKER ESSENTIO SR MRI -,SUP-L110,CDM,C1786,HCPCS,275,RC,,,outpatient,,,10901.37,7630.959,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
PACEMAKER ACCOLADE SR -REF: L300 -,SUP-L300,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
ACCOLADE MRI SR PACEMAKER L310 -,SUP-L310,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
PACEMAKER LEADLESS SINGLE AVEIR RV REF: LSP112V -,SUP-LSP112V,CDM,C1786,HCPCS,275,RC,,,outpatient,,,37130,25991,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
MICRA MDT TRANSCATHER PACING MICRA SYSTEM -,SUP-MC1VR01,CDM,C1786,HCPCS,275,RC,,,outpatient,,,26520.25,18564.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
MICRA AV TRANSCATHETER  MC1AVR1 -,SUP-MICRAAVTCPSYSTEM,CDM,C1786,HCPCS,275,RC,,,outpatient,,,38855.25,27198.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
TRANSCATHETER PACING SYSTEM INC:CAPSULEDELIV CATHINTROD -,SUP-MICRATCPSYSTEM,CDM,C1786,HCPCS,275,RC,,,outpatient,,,26520.25,18564.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
PACEMAKER IMPL UNIPL BIPLR ACCENT SR SGL-CHMBR RR WRLS TELEM -,SUP-PM1110,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9375.33,6562.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
PACEMAKER ENDURITY SGL-CHMBR 50X41X6MM 6MM 19GM 9.7ML IS-1 -,SUP-PM1160,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
PACEMAKER IMPL UNIPL BIPLR ACCENT SR SGL-CHMBR RR WRLS TELEM -,SUP-PM1210,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9375.33,6562.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
PACEMAKER IMPL ASSURITY SGL-CHMBR RR 50X47MM 6MM 10.4ML 20GM -,SUP-PM1240,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
ASSURITY MRI PACEMAKER SR-RF -,SUP-PM1272,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
PACEMAKER ALTRUA 40 SR SGL-CHMBR RR 42X42X8MM 10ML 23.4GM -,SUP-S401,CDM,C1786,HCPCS,275,RC,,,outpatient,,,12887.82,9021.474,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
SYS ADAPTER PCMKR F/SR -,SUP-UNDEFINED,CDM,C1786,HCPCS,275,RC,,,outpatient,,,23744.64,16621.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
DEFIBRILLATOR VIVA QUAD S CRTN -,SUP-VIVA QUAD S CRT-D,CDM,C1786,HCPCS,275,RC,,,outpatient,,,60532.78,42372.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
Azure S SR NRI SureScan W3SR01 -,SUP-W3SR01,CDM,C1786,HCPCS,275,RC,,,outpatient,,,16708.5,11695.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46489.17504,other,SI=N Exclusions ,,
GENERATOR PROCLAIM 7 ELITE -,SUP-3662,CDM,C1787,HCPCS,272,RC,,,outpatient,,,40409.46,28286.622,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,28973.58282,other,SI=N Exclusions ,,
PROGRAMMER NEURSTM MYSTIM HNDHLD DVC -,SUP-377-44,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4606.91,3224.837,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,28973.58282,other,SI=N Exclusions ,,
PROGRAMMER NEURSTM MYSTIM 2.2X3.7X1.1IN -,SUP-377-46,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4606.91,3224.837,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,28973.58282,other,SI=N Exclusions ,,
PROGRAMMER NEURSTM IMMG-LN -,SUP-3852,CDM,C1787,HCPCS,272,RC,,,outpatient,,,2517.74,1762.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,28973.58282,other,SI=N Exclusions ,,
PRODIGY 3856 -,SUP-3856,CDM,C1787,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,28973.58282,other,SI=N Exclusions ,,
PROCLAIM DRG CONTROLLER LEAD -,SUP-7883,CDM,C1787,HCPCS,272,RC,,,outpatient,,,6212.96,4349.072,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,28973.58282,other,SI=N Exclusions ,,
PROGRAMMER PATIENT 97740 -,SUP-97740,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4507.13,3154.991,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,28973.58282,other,SI=N Exclusions ,,
CONTROLLER 97745NT INTELLIS PTM NONTRIAL -,SUP-97745NT,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4507.13,3154.991,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,28973.58282,other,SI=N Exclusions ,,
INTERSTIM KIT COMM W/HANDSET GU US -,SUP-TH90Q01,CDM,C1787,HCPCS,272,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,28973.58282,other,SI=N Exclusions ,,
PORT IMPLINFN NPWR 8FRX1.6MM ID 12.7MM X- PRT ISP PU LF -,SUP-0607540,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1620.15,1134.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List,,
PORT IMPLINFN NPWR 9.5FR CATH X- PRT PLST PRT LF MRI-COND -,SUP-0607675,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2417.77,1692.439,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List,,
PORT POWER LOW PROFILE 8F -,SUP-1708060,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2318.07,1622.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List,,
PORT IMPLINFN PWR INJ 6FR CATH PWR PRT TI LF 1LUM -,SUP-1716000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2242.11,1569.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List,,
PORT IMPLINFN PWR INJ 8FR CATH PWR PRT M R I ISP PU LF 1LUM -,SUP-1808000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2243.33,1570.331,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List,,
PORT POWER 8F #1808000 -,SUP-1808000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2243.33,1570.331,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List,,
PORT INFS 9FR CATH PWR PRT DUO M R I PLST LF LUMX2 -,SUP-1829500,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2559.29,1791.503,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List,,
KT NEEDLE INFS 20GAX1IN POWERLOC PRT ACCESS SAFTY YST NACL -,SUP-2672010,CDM,C1788,HCPCS,278,RC,,,outpatient,,,99.2,69.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List,,
PORT INFS PWR INJ 8FR CATH PWR PRT VUE ISP PU CATH LF -,SUP-5608062,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1261.52,883.064,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List,,
PORT INFS 8FR MRI-SF PWR SLIM -,SUP-5618000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1261.52,883.064,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List,,
TRY CV LUMX2 9.5FRX60CM GRSHNG LF ACC -,SUP-7726952,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1902.88,1332.016,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List,,
CATH INFS PRT 6.6FR SMRT PRT CT TI /CARBOTHAN/ PU LPRO INJ -,SUP-CT66LTPD,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List,,
CATH INFS PRT 8FR SMRT PRT CT TI/SIL INJ -,SUP-CT75STSD,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List,,
CATH INFS PRT 8FR SMRT PRT CT FLUOROMAX TI/PU INJ -,SUP-CT80STPD,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List,,
CATH INFS PRT 6.6FR MINI SMRT PRT CT TI /CARBOTHAN/ PU INJ -,SUP-H787CT66PTPD0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List,,
SMARTPORT PLASTIC W/VORTEX TECH IF FILLED DETATCHED -,SUP-H787CT80LPPDVI0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List,,
CATH INFS PRT 9.6FR SMRT PRT CT FLUOROMAX TI/SIL INJ -,SUP-H787CT96STSD0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List,,
CATH INFS PRT 12/11.4 FR DIA INTRO/CATH VORT LP TI SIL DL -,SUP-H787LVTX52130,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List,,
PORT IMPLINFN 8FR INTRO 7.2FR CATH VORT VX TI SIL LF -,SUP-H787P12355K0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List,,
PORT VORTEX VASC 9.6 -,SUP-H787P5455K0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List,,
PORT XCELA PLUS POWER INDECTABLE 8F FILLED DETATCHED -,SUP-H965440320,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List,,
PORT INFS 8FR MED DIGNITY -,SUP-MRDP80AMS,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1404.63,983.241,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,22.2704,1965.53472,other,Non-Reimbursable List,,
EXPANDER TISSUE SMOOTH 600CC NATRELLE FULL HT VAR -,SUP-133S-FV-14-T,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BRST 397ML 13.1CM NATRLL 4.2CM PRJCT -,SUP-15-397,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BRST 125ML SIL GEL MOD+ RND 8.9CM MEMORYGEL 2.8CM -,SUP-350-1251BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BRST SIL GEL MOD+ RND 150CC -,SUP-350-1501BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BRST 175ML SIL GEL MOD+ RND 10CM MEMORYGEL 3.1CM -,SUP-350-1751BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BRST 200ML SIL GEL MOD+ RND 10.5CM MEMORYGEL 3.2CM -,SUP-350-2001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BRST 350-420ML SAL MOD+ RND 12.1-11.7CM MENTOR -,SUP-350-2350,CDM,C1789,HCPCS,278,RC,,,outpatient,,,2597.25,1818.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BRST 250ML SIL GEL HPRO RND 10.5CM MEMORYGEL 4.3CM -,SUP-350-2504BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BRST 600ML SIL GEL MOD+ RND 15CM MEMORYGEL 4.6CM -,SUP-350-6001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4320.47,3024.329,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BRST 650ML SIL GEL MOD+ RND 15.4CM MEMORYGEL 4.7CM -,SUP-350-6501BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4320.47,3024.329,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BRST 650ML SIL GEL HPRO RND 14.4CM MEMORYGEL 5.7CM -,SUP-350-6504BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BRST 700ML SIL GEL MOD+ RND 15.8CM MEMORYGEL 4.9CM -,SUP-350-7001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4320.47,3024.329,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BRST 130ML SIL GEL MOD CLASS RND 9.6CM MEMORYGEL -,SUP-350-7130MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BRST 150ML SIL GEL MOD CLASS RND 10.3CM MEMORYGEL -,SUP-350-7150MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BRST SIL GEL MOD+ RND CLSSC 190CC -,SUP-350-7190MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BRST SIL GEL MOD+ RND CLSSC 215CC -,SUP-350-7215MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BRST 750ML SIL GEL MOD CLASS RND 16.1CM MEMORYGEL -,SUP-350-7501BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
BREAST IMPLANT SMOOTH ROUND MODERATE 750CC -,SUP-350-7750MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
BREAST IMPLANT SMOOTH ROUND MODERATE 800CC -,SUP-350-7800MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BRST 800ML SIL GEL HPRO RND 16.5CM MEMORYGEL 5.1CM -,SUP-350-8001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BRST 800ML SIL GEL HPRO RND 15.5CM MEMORYGEL 6CM -,SUP-350-8004BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BRST 330-350ML SIL SAL BIOCELL PTOTIC SHP NATRLL -,SUP-363LF-330,CDM,C1789,HCPCS,278,RC,,,outpatient,,,3628.24,2539.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
NATRELLE SALINE FILLED SMOOTH ROUND IMLANTS 640CC -,SUP-68HP-600,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1637.85,1146.495,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
NATRELLE SMOOTH ROUND SALINE IMPLANTS 68LP-225 -,SUP-68LP-225,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
NATRELLE SMOOTH ROUND SALINE IMPLANTS 250CC -,SUP-68LP-250,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
NATRELLE SMOOTH ROUND SALINE IMPLANTS 275CC -,SUP-68LP-275,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
SIZER IMPLANT NATRELLE INSPIRA 295CC FULL PROFILE -,SUP-MSZ-F295,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
SIZER NATRELLE INSPIRA 335CC FULL -,SUP-MSZ-F335,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
SIZER IMPLANT NATRELLE INSPIRA 650CC FULL PROFILE -,SUP-MSZ-F650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 200CC NATRELLE INSPIRA FULL -,SUP-SCF-200,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 240CC NATRELLE INSPIRA FULL -,SUP-SCF-240,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 265CC NATRELLE INSPIRA FULL -,SUP-SCF-265,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 295CC NATRELLE INSPIRA FULL -,SUP-SCF-295,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 335CC NATRELLE INSPIRA FULL -,SUP-SCF-335,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 345CC NATRELLE INSPIRA FULL -,SUP-SCF-345,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 365CC NATRELLE INSPIRA FULL -,SUP-SCF-365,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 385CC NATRELLE INSPIRA FULL -,SUP-SCF-385,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 415CC NATRELLE INSPIRA FULL -,SUP-SCF-415,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 450CC NATRELLE INSPIRA FULL -,SUP-SCF-450,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 485CC NATRELLE INSPIRA FULL -,SUP-SCF-485,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4787.23,3351.061,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 520CC NATRELLE INSPIRA FULL -,SUP-SCF-520,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 560CC NATRELLE INSPIRA FULL -,SUP-SCF-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 605CC NATRELLE INSPIRA FULL -,SUP-SCF-605,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5623.3,3936.31,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 650CC NATRELLE INSPIRA FULL -,SUP-SCF-650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHES GEL 695CC NATRELLE INSPIRA FULL -,SUP-SCF-695,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
NATRELLE INSPIRA COHESIVE IMPLANT 745 -,SUP-SCF-745,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
NATRELLE INSPIRA COHESIVE IMPLANT 770 -,SUP-SCF-770,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST 460CC NATRELLE SMOOTH ROUND -,SUP-SCL-460,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST 490CC SMOOTH COHESIVE LOW PLUS PROFILE -,SUP-SCLP-490,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST 540CC SMOOTH COHESIVE LOW PLUS PROFILE -,SUP-SCLP-540,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST 330CC NATRELLE SMOOTH ROUND -,SUP-SCM-330,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST 360CC NATRELLE SMOOTH ROUND -,SUP-SCM-360,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SILICONE 375CC NATRELLE INSPIRA STYLE MODERAT -,SUP-SCM-375,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST 375CC NATRELLE SMOOTH ROUND -,SUP-SCM-375,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST 405CC NATRELLE SMOOTH ROUND -,SUP-SCM-405,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHES 485CC NATRELLE INSPIRA MODERATE -,SUP-SCM-485,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 560CC NATRELLE INSPIRA MOD -,SUP-SCM-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 600CC NATRELLE INSPIRA MOD -,SUP-SCM-600,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 640CC NAT INSPIRA MOD -,SUP-SCM-640,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHES GEL 685CC NATRELLE INSPIRA MOD -,SUP-SCM-685,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHES GEL 755CC NATRELLE INSPIRA MOD -,SUP-SCM-755,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 340CC NATRELLE INSPIRA FULL -,SUP-SCX-340,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 375CC NATRELLE INSP EXTRA FUL -,SUP-SCX-375,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 525CC NATRELLE INSPIRA FULL -,SUP-SCX-525,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 545CC NATRELLE INSPIRA FULL -,SUP-SCX-545,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST 560CC SMOOTH COHESIVE NATRELLE INSPIRA FULL -,SUP-SCX-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST 580CC SMOOTH COHESIVE NATRELLE INSPIRA FULL -,SUP-SCX-580,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST 615CC SMOOTH COHESIVE NATRELLE INSPIRA FULL -,SUP-SCX-615,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH COHESIVE 650CC NATRELLE INSP EX-FULL -,SUP-SCX-650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
NATRELLE INSPIRA COHESIVE IMPLANT 700 -,SUP-SCX-700,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
NATRELLE INSPIRA COHESIVE IMPLANT 750 -,SUP-SCX-750,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
NATRELLE INSPIRA COHESIVE IMPLANT 800CC -,SUP-SCX-800,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT SMOOTH HIGH PROFILE XTRA 755 CC -,SUP-SHPX755,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5211.63,3648.141,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT SMOOTH HIGH PROFILE XTRA 790 CC -,SUP-SHPX790,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5211.63,3648.141,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH FULL 450CC NATRELLE INSPIRA FULL -,SUP-SSF-450,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH FULL 520CC NATRELLE INSPIRA FULL -,SUP-SSF-520,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH FULL 560CC NATRELLE INSPIRA FULL -,SUP-SSF-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH FULL 650CC NATRELLE INSPIRA FULL -,SUP-SSF-650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH FULL 695CC NATRELLE INSPIRA FULL -,SUP-SSF-695,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH FULL 745CC NATRELLE INSPIRA FULL -,SUP-SSF-745,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH SOFT TOUCH 330CC NATRELLE INSPIRA MOD -,SUP-SSM-330,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH SOFT TOUCH 445CC NATRELLE INSPIRA MOD -,SUP-SSM-445,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH SOFT TOUCH 485CC NATRELLE INSPIRA MOD -,SUP-SSM-485,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST SMOOTH SOFT TOUCH 520CC NATRELLE INSPIRA MOD -,SUP-SSM-520,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST EXTRA FULL SOFT TOUCH 750CC -,SUP-SSX-750,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
IMPLANT BREAST EXTRA FULL SOFT TOUCH 800CC -,SUP-SSX-800,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,261.9915,4400.1792,other,SI=N Exclusions ,,
PROSTHESIS PENL CL SPCTR MALE 9.5MMX12CM CNCLBL SNP FIT TIP -,SUP-720054-01,CDM,C1813,HCPCS,278,RC,,,outpatient,,,20421.5,14295.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
PROSTHESIS PENL CL SPCTR MALE 9.5MMX16CM SIL PE TI SEG -,SUP-720054-02,CDM,C1813,HCPCS,278,RC,,,outpatient,,,21238.36,14866.852,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
PROSTHESIS PENL AMS SPCTR MALE 12MMX20CM SIL PE TI SEG CYL -,SUP-720074-03,CDM,C1813,HCPCS,278,RC,,,outpatient,,,28358.17,19850.719,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
PROSTHESIS PENL AMS 700 LGX 100CM SAL FIL INFL MOMNTRY SQZ -,SUP-720185-01,CDM,C1813,HCPCS,278,RC,,,outpatient,,,12122.95,8486.065,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
AMS 800 PRESSURE REGULATION BALLOON -,SUP-72400024,CDM,C1813,HCPCS,278,RC,,,outpatient,,,12791.29,8953.903,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
KT PROSTHESIS PENL URIN ARTF SPHNCR IMPL SAL FIL SCRT CYL -,SUP-724000-95,CDM,C1813,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
PUMP URIN SPHNCR AMS 800 MALE SIL CNCLD FLD-FIL W/O INHBZN -,SUP-724000-98,CDM,C1813,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
PROSTHESIS PENL AMBICOR 11MM/12.5MM DIA FIL PMP 16CM SAL FIL -,SUP-72401451,CDM,C1813,HCPCS,278,RC,,,outpatient,,,31752.76,22226.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
AMS AMBICOR PENILE PROTHESIS -,SUP-72401452,CDM,C1813,HCPCS,278,RC,,,outpatient,,,34352.98,24047.086,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
AMS AMBICOR PENILE PROTHESIS 18CM X 14 MM -,SUP-72401454,CDM,C1813,HCPCS,278,RC,,,outpatient,,,31752.76,22226.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
RESERVOIR PROS -,SUP-724014-77,CDM,C1813,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
PROSTHESIS PENL AMS 700 LGX 65CM SAL FIL INFL MOMNTRY SQZ -,SUP-724041-55,CDM,C1813,HCPCS,278,RC,,,outpatient,,,12122.95,8486.065,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
PROSTHESIS PENL AMS 700 CX MALE 100ML SAL FIL INFL CYL TIP -,SUP-72404156,CDM,C1813,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
PROSTHESIS PENL PMP AMS 700 CX MALE SAL FIL INFL STRL -,SUP-724042-09,CDM,C1813,HCPCS,278,RC,,,outpatient,,,15498.06,10848.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
18CM 700CX -,SUP-72404232,CDM,C1813,HCPCS,278,RC,,,outpatient,,,25200.41,17640.287,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
PUMP AMS 700 12MM X 18CM CX MS PENILE -,SUP-72404232-10,CDM,C1813,HCPCS,278,RC,,,outpatient,,,31466.59,22026.613,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
AMS 700 CX MS PUMP IZ 21CM -,SUP-72404233-12,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26705.28,18693.696,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
PROSTHESIS PENL AMS 700 LGX 15MM CL INFL PRECNCT W/MS PMP -,SUP-724042-51,CDM,C1813,HCPCS,278,RC,,,outpatient,,,28543.19,19980.233,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
PROSTHESIS PENL AMS 700 LGX 18CM SAL FIL INFL MOMNTRY SQZ -,SUP-72404252,CDM,C1813,HCPCS,278,RC,,,outpatient,,,36034.67,25224.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
AMS 700 LGX MS PUMP IZ 21CM X 12MM -,SUP-72404253-12,CDM,C1813,HCPCS,278,RC,,,outpatient,,,32354.71,22648.297,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
PROSTHESIS PENL AMS 700 CXR 14CM X 9.5MM -,SUP-72404262,CDM,C1813,HCPCS,278,RC,,,outpatient,,,25200.41,17640.287,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
AMS CXR MS PUMP IZ -,SUP-72404264,CDM,C1813,HCPCS,278,RC,,,outpatient,,,32749.43,22924.601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
EXTENDER PENL AMS SPCTR 12MM/14MM DIA CL 3CM REAR TIP -,SUP-724043-23,CDM,C1813,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
IMPLANT PENL RSVR CLPLST 75ML HYDRPHL CTD LKOUT VLV STRL -,SUP-90-9075K-LOC,CDM,C1813,HCPCS,278,RC,,,outpatient,,,5602.08,3921.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
PROSTHESIS PENL TITAN 16CM HYDRPHL RST CTD CYL 3 PRT REFL -,SUP-90-9916SC,CDM,C1813,HCPCS,278,RC,,,outpatient,,,24505.8,17154.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
PROSTHESIS PENL STD 18CM BIOFLEX/SIL MALE SCRT CL/PMP ST -,SUP-90-9918SNCOTR,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26752.17,18726.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
PROSTHESIS PENL STD 20CM BIOFLEX/SIL MALE SCRT CL/PMP ST -,SUP-90-9920SCOTR,CDM,C1813,HCPCS,278,RC,,,outpatient,,,24505.8,17154.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
KT PROSTHESIS PENL TITAN MALE NRW BS EXTEND ESSAY NDLX1 -,SUP-91-9480SNC,CDM,C1813,HCPCS,278,RC,,,outpatient,,,2507.14,1754.998,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
PROSTHESIS PENL RSVR TITAN 75ML BIOFLEX SIL INFL SLF-CNTN -,SUP-ER8075,CDM,C1813,HCPCS,278,RC,,,outpatient,,,6938.94,4857.258,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
ST PROSTHESIS PENL TITAN 18CM BIOFLEX SIL CYL INFL SLF-CNTN -,SUP-ES2918,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26956.38,18869.466,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
ST PROSTHESIS TITAN 22CM BIOFLEX SIL TCH ZERO DG CL PMP -,SUP-ES2922,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26956.38,18869.466,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
PROSTHESIS PENL TITAN 18CM 0DG ANG CYL INFL 1-TCH RELS -,SUP-ESR918,CDM,C1813,HCPCS,278,RC,,,outpatient,,,27550.46,19285.322,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
ST UROLOGICAL PMP/CL TITAN 20CM BIOFLEX SIL 0DG ANG PENL -,SUP-ESR920,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26752.17,18726.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
AMS AMBICOR 16CM X 14MM -,SUP-UNDEFINED,CDM,C1813,HCPCS,278,RC,,,outpatient,,,30531.59,21372.113,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,150.646235,27674.62656,other,SI=N Exclusions ,,
PROSTHESIS PENL 3.5CM INFL SCRT INHBZN CONTINENCE -,SUP-720157-01,CDM,C1815,HCPCS,278,RC,,,outpatient,,,16337.2,11436.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21443.91168,other,SI=N Exclusions ,,
PUMP CORTIAL 700 PROSTHESIS -,SUP-72404127,CDM,C1815,HCPCS,278,RC,,,outpatient,,,26900.69,18830.483,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21443.91168,other,SI=N Exclusions ,,
SYS UROLOGICAL AMS 800 4CM CUF BLT W/IZ -,SUP-724041-30,CDM,C1815,HCPCS,278,RC,,,outpatient,,,27921.76,19545.232,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21443.91168,other,SI=N Exclusions ,,
PROSTHESIS PENL AMS 800 4.5CM SAL FIL CNCLD CYL SCRT INHBZN -,SUP-72404131,CDM,C1815,HCPCS,278,RC,,,outpatient,,,27921.76,19545.232,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21443.91168,other,SI=N Exclusions ,,
PROSTHESIS PENL AMS 800 5.0CM SAL FIL CNCLD CYL SCRT INHBZN -,SUP-72404132,CDM,C1815,HCPCS,278,RC,,,outpatient,,,26585.08,18609.556,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21443.91168,other,SI=N Exclusions ,,
PROSTHESIS PENL AMS 800 6.0CM SAL FIL ARTIF URINARY SPHINCTR -,SUP-72404134,CDM,C1815,HCPCS,278,RC,,,outpatient,,,25935.31,18154.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,21443.91168,other,SI=N Exclusions ,,
OCCLUDERS FLO RESTER 1.5 -,SUP-50150,CDM,C1817,HCPCS,278,RC,,,outpatient,,,470.8,329.56,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDERS FLO RESTER 2.5 -,SUP-50250,CDM,C1817,HCPCS,278,RC,,,outpatient,,,470.8,329.56,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER VASC 2MM BLB 30MM INTNL VES FLO-RST DISP -,SUP-60200,CDM,C1817,HCPCS,278,RC,,,outpatient,,,443.78,310.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
AMPLATZER AMULET 16MM WW REF: 9-ACP2-007-016 -,SUP-9-ACP2-007-016,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
AMPLATZER AMULET 18MM WW REF: 9-ACP2-007-018 -,SUP-9-ACP2-007-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
AMPLATZER AMULET 20 MM WW REF: 9-ACP2-007-020 -,SUP-9-ACP2-007-020,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
AMPLATZER AMULET 22 MM WW REF: 9-ACP2-007-022 -,SUP-9-ACP2-007-022,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
AMPLATZER AMULET 25 MM WW REF: 9-ACP2-010-025 -,SUP-9-ACP2-010-025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
AMPLATZER AMULET 28 MM WW REF: 9-ACP2-010-028 -,SUP-9-ACP2-010-028,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
AMPLATZER AMULET 31 MM WW REF: 9-ACP2-010-031 -,SUP-9-ACP2-010-031,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
AMPLATZER AMULET 34 MM WW REF: 9-ACP2-010-034 -,SUP-9-ACP2-010-034,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER AMPLATZER SEPTAL 5MM  REF: 9-ASD-005 -,SUP-9-ASD-005,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER AMPLATZER SEPTAL 6MM  REF: 9-ASD-006 -,SUP-9-ASD-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 08MM WST 16MM/20MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-008,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 10MM WST 18MM/22MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-010,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 11MM WST 21MM/25MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-011,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 12MM WST 22MM/26MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-012,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 13MM WST 23MM/27MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-013,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 14MM WST 24MM/28MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-014,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 15MM WST 25MM/29MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-015,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 16MM WST 26MM/30MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-016,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 18MM WST 28MM/32MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 19MM WST 28MM/32MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-019,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 20MM WST 30MM/34MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-020,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 22MM WST 32MM/36MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-022,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 24MM WST 34MM/38MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-024,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 26MM WST 36MM/40MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-026,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 28MM WST 38MM/42MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-028,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 30MM WST 40MM/44MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-030,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 32MM WST 42MM/46MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-032,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 34MM WST 44MM/50MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-034,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 36MM WST 46MM/52MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-036,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 18MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 25MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 30MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-030,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER SPT 35MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-035,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
GRAFT VASC 5MMX12.5MM AMPLATZER OCLR SE FUL CX-SECT CVRGLS -,SUP-9-AVP038-005,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
GRAFT VASC 6X11MM AMPLATZER PLG SE FUL CX-SECT CVRGLS LT ATR -,SUP-9-AVP038-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
GRAFT VASC 7MMX12.5MM AMPLATZER PLG OCLR SE FUL CX-SECT -,SUP-9-AVP038-007,CDM,C1817,HCPCS,278,RC,,,outpatient,,,5177.68,3624.376,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
PLUG VASCULAR AMPLATZER 6MM REF:09-AVP2-006 -,SUP-9-AVP2-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
PLUG VASCULAR AMPLATZER 8 -,SUP-9-AVP2-008,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
PLUG VASCULAR AMPLATZER 10 011 -,SUP-9-AVP2-010,CDM,C1817,HCPCS,278,RC,,,outpatient,,,3971.97,2780.379,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
PLUG VASCULAR AMPLATZER 12 -,SUP-9-AVP2-012,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
PLUG VASCULAR AMPLATZER 16 -,SUP-9-AVP2-016,CDM,C1817,HCPCS,278,RC,,,outpatient,,,3971.97,2780.379,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
PLUG VASCULAR AMPLATZER 18 -,SUP-9-AVP2-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
GRAFT VASC 22X6MM AMPLATZER PLG SE MUL-LOBE LT ATR NTNL -,SUP-9-AVP2-022,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER DCT 5MM/4MM DIA DSCND AOR/PA AMPLATZER NTNL INTRWVN -,SUP-9-PDA-003,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER DCT 6MM/4MM DIA DSCND AOR/PA AMPLATZER NTNL INTRWVN -,SUP-9-PDA-004,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER DCT 8MM/6MM DIA DSCND AOR/PA AMPLATZER NTNL INTRWVN -,SUP-9-PDA-005,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
10/8 AMPLATZER DUCT OCCLUDER -,SUP-9-PDA-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER VASC DCT 12MM/10MM DIA/DSCND/PULM AOR 7FRX8MM NTNL -,SUP-9-PDA-007,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER DUCT II AMPLATZER 3MMX4MM -,SUP-9-PDA2-03-04,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER DCT 5MM/4MM DIA WST/DISC AMPLATZER NTNL DBL DISC -,SUP-9-PDA2-05-04,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER DCT 5MM/6MM DIA WST/DISC AMPLATZER NTNL DBL DISC. -,SUP-9-PDA2-05-06,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER DUCT II AMPLATZER 6MMX4MM -,SUP-9-PDA2-06-04,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER DCT 5MM/11MM DIA WST/DISC AMPLATZER NTNL DBL DISC.. -,SUP-9-PDA2-06-06,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER DUCT II AMPLATZER 6MMX6MM -,SUP-9-PDA2-06-06,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCULUDER AMPLATZER PFO 18MM -,SUP-9-PFO-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER AMPLATZER PFO 25MM -,SUP-9-PFO-025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
OCCLUDER AMPLATZER PFO 35MM -,SUP-9-PFO-035,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
AMPLATZER TALISMAN PFO OCCLUDER 8FR 18MM REF:9-PFO-1818 -,SUP-9-PFO-1818,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
AMPLATZER TALISMAN PFO OCCLUDER 25-18MM -,SUP-9-PFO-2518,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
AMPLATZER TALISMAN PFO OCCLUDER 30-25MM -,SUP-9-PFO-3025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
TORQVUE SHEATH 12F 80CM 45X45 REF: 9-TV45X45-12F-080 -,SUP-9-TV45X45-12F-080,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4676.89,3273.823,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
CLOSURE DEVICE WATCHMAN FLEX 27MM -,SUP-M635WU0270,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
SHEATH WATCHMAN 21MM 12FR CLSR 75CM TRNSEPT -,SUP-M635WU21060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
SHEATH WATCHMAN 24MM 12FR CLSR 75CM  TRNSEPT -,SUP-M635WU24060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
SHEATH WATCHMAN 27MM 12FR CLSR 75CM  TRNSEPT -,SUP-M635WU27060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
SHEATH WATCHMAN 30MM 12FR CLSR 75CM TRNSEPT -,SUP-M635WU30060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
SHEATH WATCHMAN 33MM 12FR CLSR 75CM TRANSEPT -,SUP-M635WU33060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
CLOSURE DEVICE WATCHMAN FLEX 20MM -,SUP-M635WU50200,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
CLOSURE DEVICE WATCHMAN FLEX 31MM -,SUP-M635WU50310,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
CLOSURE DEVICE WATCHMAN FLEX 35MM -,SUP-M635WU50350,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
CLOSURE DEVICE WATCHMAN FLEX PRO 20MM REF:M635WU60200 -,SUP-M635WU60200,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
CLOSURE DEVICE WATCHMAN FLEX PRO 24MM REF:M635WU60240 -,SUP-M635WU60240,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
CLOSURE DEVICE WATCHMAN FLEX PRO 27MM REF:M635WU60270 -,SUP-M635WU60270,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
CLOSURE DEVICE WATCHMAN FLEX PRO 31MM REF:M635WU60310 -,SUP-M635WU60310,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
CLOSURE DEVICE WATCHMAN FLEX PRO 35MM REF:M635WU60350 -,SUP-M635WU60350,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
CLOSURE DEVICE WATCHMAN FLEX PRO 40MM REF:M635WU60400 -,SUP-M635WU60400,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
CLOSURE DEVICE WATCHMAN FLEX 24MM -,SUP-M63WU50240,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,99.62861,33156.48,other,SI=N Exclusions ,,
TULOC LOCALIZATION WIRE 20G X 5CM -,SUP-271660,CDM,C1819,HCPCS,278,RC,,,outpatient,,,200.72,140.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,45.06164,416.02,other,Non-Reimbursable List,,
TULOC LOCALIZATION WIRE 20G X 9CM -,SUP-271661,CDM,C1819,HCPCS,278,RC,,,outpatient,,,200.72,140.504,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,45.06164,416.02,other,Non-Reimbursable List,,
TULOC PREMIUM LOCALIZATION WIRE 20G X 5CM -,SUP-271880,CDM,C1819,HCPCS,278,RC,,,outpatient,,,256.74,179.718,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,45.06164,416.02,other,Non-Reimbursable List,,
TULOC PREMIUM LOCALIZATION WIRE 20G X 9CM -,SUP-271881,CDM,C1819,HCPCS,278,RC,,,outpatient,,,256.74,179.718,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,45.06164,416.02,other,Non-Reimbursable List,,
ETERNA IMPLANTABLE PULSE GENERATOR -,SUP-32400,CDM,C1820,HCPCS,278,RC,,,outpatient,,,45639.5,31947.65,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,41625.59232,other,SI=N Exclusions ,,
PRODIGY 3730 -,SUP-3730,CDM,C1820,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,41625.59232,other,SI=N Exclusions ,,
SYS GENERATOR NEURSTM RSTOR ADVANCED PERC MUL-PRGM RCHG ACC -,SUP-377-13,CDM,C1820,HCPCS,278,RC,,,outpatient,,,31108.87,21776.209,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,41625.59232,other,SI=N Exclusions ,,
NEURSTM IMPL RESTORESENSOR 2.1INX2.1IN PERC SMALLEST -,SUP-377-14,CDM,C1820,HCPCS,278,RC,,,outpatient,,,38238.5,26766.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,41625.59232,other,SI=N Exclusions ,,
PRODIGY MRI -,SUP-3772,CDM,C1820,HCPCS,278,RC,,,outpatient,,,38929.26,27250.482,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,41625.59232,other,SI=N Exclusions ,,
NEURSTM IMPL RESTORESENSOR SURSCN 9X54X54MM SPIN CRD RCHG -,SUP-97714,CDM,C1820,HCPCS,278,RC,,,outpatient,,,38238.5,26766.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,41625.59232,other,SI=N Exclusions ,,
INTERSTIM MICRO MRI RECHARGEABLE NEUROSTIMULATOR -,SUP-97810,CDM,C1820,HCPCS,278,RC,,,outpatient,,,25644.47,17951.129,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,41625.59232,other,SI=N Exclusions ,,
MICROSTIMULATOR INS 97810 RECHARGEABLE -,SUP-97810,CDM,C1820,HCPCS,278,RC,,,outpatient,,,25644.47,17951.129,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,41625.59232,other,SI=N Exclusions ,,
KT GENERATOR NEURSTM PRECISN SPCTR -,SUP-M365SC1110020,CDM,C1820,HCPCS,278,RC,,,outpatient,,,54199.99,37939.993,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,41625.59232,other,SI=N Exclusions ,,
VERTIFLEX SUPERION IDS-10MM -,SUP-101-9810,CDM,C1821,HCPCS,278,RC,,,outpatient,,,25619.7,17933.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
VERTIFLEX SUPERION IDS-12MM -,SUP-101-9812,CDM,C1821,HCPCS,278,RC,,,outpatient,,,25619.7,17933.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
VERTIFLEX SUPERION IDS -14MM -,SUP-101-9814,CDM,C1821,HCPCS,278,RC,,,outpatient,,,25619.7,17933.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
SPACER CERV 8X27MMX0.016IN ZYSTON -,SUP-14-533108,CDM,C1821,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
SPACER ANT CERV 19-25MMH FORTIFY OPTMZ FIT TI -,SUP-151.051,CDM,C1821,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
SPACER ANT CERV 15X18MM FTPRNT FORTIFY 7DG OPTMZ FIT TI -,SUP-151.334,CDM,C1821,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
SPACER ANT CERV 15X18MM FTPRNT FORTIFY 7DG OPTMZ FIT TI. -,SUP-151.384,CDM,C1821,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
MESH 14MM ROUND 30MM HGT -,SUP-176014030,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11221.61,7855.127,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
MESH SURG 23X27MM DIA 12X14MM OBLNG TRPZD TI HARMS -,SUP-1763-02-012,CDM,C1821,HCPCS,278,RC,,,outpatient,,,14854.78,10398.346,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
RISE SPACER 8 X 22MM- 7-13MM -,SUP-193.001,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
SPACER RISE 8 X 22MM 8-14MM 10 DEG -,SUP-193.021,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
SPACER RISE 10 X 22 7-13 -,SUP-193.101,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
SPACER RISE 10 X 26MM 7-14MM -,SUP-193.102,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
SPACER RISE 10 X 26MM 10-17MM -,SUP-193.112,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
RISE SPACER 10X22MM 8-14MM 10 DEGREES -,SUP-193.121,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
RISE SPACER 10MM X 26MM 8-15MM 10 DEGREES -,SUP-193.122,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
SPACER SPINAL RISE 10MM X 30MM 8-15MM 10 DEG -,SUP-193.123,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
RISE SPACER 10 X 26MM 10-17MM -,SUP-193.142,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
RISER SPACER 10X22MM- 9-15MM -,SUP-193.151,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
NORMANDY 12X14 30MM 10DEGREES -,SUP-250-1214-30-10,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19597.21,13718.047,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
CAGE 12X14 44-76 10 DEGREE -,SUP-250-1214-4410,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19597.21,13718.047,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
SPACER THORLUM VERT 12X26X12MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.972,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
SPACER SMALL 12 X 14 ZERO DEG 19MM NIKO CORPECTOMY -,SUP-342.719,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11547.43,8083.201,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
SPACER SPINAL NIKO PEEK 7 D D12 MM SMALL 14X15MM CORPECTOMY -,SUP-342.815,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11547.43,8083.201,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
SEASPINE 7H CAGE -,SUP-AC4-143077,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9901.25,6930.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
SEASPINE CAGE 16X14X6MM 7 DEGREE 3D INTERBODY -,SUP-AC4-264067,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
GENESYS 6H CAGE -,SUP-ACC804-06S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
CAGE 9 X 26 X 12 6-20 DEGREES -,SUP-ET1-102612,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19678.9,13775.23,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
SEASPINE 9 X 26 0-14 DEGREE LORDOTIC CAGE -,SUP-ET1-142608,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
SEASPINE 10H 17 DEGREE CAGE -,SUP-ET1-172610,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
CAGE EXPANDABLE SEASPINE 10H 9W 30L -,SUP-ET1-173010,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
SEASPINE 10-14MM 8 DEGREE CAGE -,SUP-ET1-382810,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
APACHE SPACER 8MM -,SUP-GAC-08SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
TITANIUM APACHE CAGE 5MM -,SUP-GAC3D-05SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
TITANIUM APACHE CAGE 6MM -,SUP-GAC3D-06SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
7MM CAGE APACHE -,SUP-GAC3D-07SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
CAGE TLIF 7MM X 30MM -,SUP-GP-07-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
CAGE APACHE PEEK SPACER 8 X 30 -,SUP-GP-08-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
CAGE 25 STRAIGHT 9MM -,SUP-GP-09,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
CAGE 9 X 30 -,SUP-GP-09-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
CAGE 10MM STANDARD PLIF -,SUP-GP-10,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
CAGE PEEK 30 X 10MM -,SUP-GP-10-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
CAGE APACHE 11MM -,SUP-GP-11,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
CAGE 8MM BI-CONVEX PLIF -,SUP-GPC2-08,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
CAGE 9MM CONVEX PLIF -,SUP-GPC2-09,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
SPACER PEEK 10 X 24 CONVEX -,SUP-GPC2-10,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
CAGE PEEK APACHE 11MM -,SUP-GPC2-11,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
SPINEART LUMBAR POSTERIOR TI CAGE L24 W10.5 H08 12 DEG -,SUP-JUT-PX 24 08-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
JULIET TI PO LUMBAR POSTERIOR TI CAGE L24 W10.5 H10 12DEG -,SUP-JUT-PX 24 10-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
CAGE LUMBAR POSTERIOR TI L24 W10.5 H11 12 DEG -,SUP-JUT-PX 24 11-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
CAGE LUMBAR POSTERIOR TI L24 W10.5 H12 -,SUP-JUT-PX 24 12-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
CAGE TRANSORAMINAL LUMBAR TI L 30 W 10.5 H 14 -,SUP-JUT-T6 30 14-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
TRANSFORMATIONAL LUMBAR TI CAGE L34 W10.5 H12 06 DEG -,SUP-JUT-T6 34 12-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
CAGE CERV 7MM/4.1MM H A/P ROI- C LRDTC -,SUP-MC1443P,CDM,C1821,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
CAGE CERV 10MM/7.1MM H A/P ROI- C LRDTC -,SUP-MC1446P,CDM,C1821,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
PATHLOC LUMBAR INTERBODY FUSION CAGE 12MM 15 DEGREES -,SUP-PT2211-0815S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19678.9,13775.23,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
SCARLET AL-T SECURED ANTERIOR CAGE SMALL H12 15' -,SUP-SCA-LS 15 12-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
CAGE 11MM LUCENT STR -,SUP-UNDEFINED,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11695.95,8187.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,19675.9296,other,SI=N Exclusions ,,
NPG IMPLANT AND CHARGER -,SUP-HFX-D,CDM,C1822,HCPCS,278,RC,,,outpatient,,,60441.5,42309.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46419.072,other,Non-Reimbursable List,,
KIT BLUE LEAD 90CM WITH 5MM SPACING -,SUP-LEAD1058-90B,CDM,C1822,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46419.072,other,Non-Reimbursable List,,
IPG KIT -,SUP-NIPG2500,CDM,C1822,HCPCS,278,RC,,,outpatient,,,60441.5,42309.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46419.072,other,Non-Reimbursable List,,
NEVRO IPG KIT WITH NEW BATTERY -,SUP-NIPG3000,CDM,C1822,HCPCS,278,RC,,,outpatient,,,60441.5,42309.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,46419.072,other,Non-Reimbursable List,,
STENT DES 4X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-10074400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3X15MM XIENCE V RX BE PRMNT 143CM EVEROL CMPLNT -,SUP-1009541-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT 2.8X16MM GRAFTMS RX 143CM SEM-COM HYDRCT -,SUP-1012580-16,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT 4X16MM GRAFTMS RX 143CM SEM-COM HYDRCT -,SUP-1012582-16,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT 4X26MM GRAFTMS RX 143CM SEM-COM HYDRCT -,SUP-1012582-26,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.25X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.25X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.25X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.25X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.25X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.25X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.25X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.25X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.25X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.25X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.25X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.25X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.25X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.25X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.5X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.5X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.5X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.5X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.5X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.5X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.5X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.5X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.25X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125225-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.25X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.25X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.25X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.25X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.25X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125275-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.25X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.25X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.25X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35644.8,24951.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.25X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.25X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT 3X19MM JOST GRAFTMS OTW BE 143CM SEM-COM HYDREX CTD -,SUP-12744-19,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT 4X19MM JOST GRAFTMS OTW BE 143CM SEM-COM HYDREX CTD -,SUP-12746-19,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.25X8MM XIENCE SKYPOINT -,SUP-1804225-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.25X12MM XIENCE SKYPOINT -,SUP-1804225-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.25X15MM XIENCE SKYPOINT -,SUP-1804225-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.25X18MM XIENCE SKYPOINT -,SUP-1804225-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.25X23MM XIENCE SKYPOINT -,SUP-1804225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.25X28MM XIENCE SKYPOINT -,SUP-1804225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.25X33MM XIENCE SKYPOINT -,SUP-1804225-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.25X38MM XIENCE SKYPOINT -,SUP-1804225-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X8MM XIENCE SKYPOINT -,SUP-1804250-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X12MM XIENCE SKYPOINT -,SUP-1804250-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X15MM XIENCE SKYPOINT -,SUP-1804250-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X18MM XIENCE SKYPOINT -,SUP-1804250-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X23MM XIENCE SKYPOINT -,SUP-1804250-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X28MM XIENCE SKYPOINT -,SUP-1804250-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X33MM XIENCE SKYPOINT -,SUP-1804250-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X38MM XIENCE SKYPOINT -,SUP-1804250-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X8MM XIENCE SKYPOINT -,SUP-1804275-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X12MM XIENCE SKYPOINT -,SUP-1804275-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X15MM XIENCE SKYPOINT -,SUP-1804275-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X18MM XIENCE SKYPOINT -,SUP-1804275-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X23MM XIENCE SKYPOINT -,SUP-1804275-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X28MM XIENCE SKYPOINT -,SUP-1804275-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X33MM XIENCE SKYPOINT -,SUP-1804275-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X38MM XIENCE SKYPOINT -,SUP-1804275-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.0X8MM XIENCE SKYPOINT -,SUP-1804300-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.0X12MM XIENCE SKYPOINT -,SUP-1804300-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.0X15MM XIENCE SKYPOINT -,SUP-1804300-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.0X18MM XIENCE SKYPOINT -,SUP-1804300-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.0X23MM XIENCE SKYPOINT -,SUP-1804300-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.0X28MM XIENCE SKYPOINT -,SUP-1804300-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.0X33MM XIENCE SKYPOINT -,SUP-1804300-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.0X38MM XIENCE SKYPOINT -,SUP-1804300-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.25X8MM XIENCE SKYPOINT -,SUP-1804325-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.25X12MM XIENCE SKYPOINT -,SUP-1804325-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.25X15MM XIENCE SKYPOINT -,SUP-1804325-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.25X18MM XIENCE SKYPOINT -,SUP-1804325-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.25X23MM XIENCE SKYPOINT -,SUP-1804325-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.25X28MM XIENCE SKYPOINT -,SUP-1804325-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.25X33MM XIENCE SKYPOINT -,SUP-1804325-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.25X38MM XIENCE SKYPOINT -,SUP-1804325-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.5X8MM XIENCE SKYPOINT -,SUP-1804350-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.5X12MM XIENCE SKYPOINT -,SUP-1804350-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.5X15MM XIENCE SKYPOINT -,SUP-1804350-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.5X18MM XIENCE SKYPOINT -,SUP-1804350-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.5X23MM XIENCE SKYPOINT -,SUP-1804350-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.5X28MM XIENCE SKYPOINT -,SUP-1804350-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.5X33MM XIENCE SKYPOINT -,SUP-1804350-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.5X38MM XIENCE SKYPOINT -,SUP-1804350-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4.0X8MM XIENCE SKYPOINT -,SUP-1804400-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4.0X12MM XIENCE SKYPOINT -,SUP-1804400-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4.0X15MM XIENCE SKYPOINT -,SUP-1804400-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4.0X18MM XIENCE SKYPOINT -,SUP-1804400-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4.0X23MM XIENCE SKYPOINT -,SUP-1804400-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4.0X28MM XIENCE SKYPOINT -,SUP-1804400-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4.0X33MM XIENCE SKYPOINT -,SUP-1804400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4.0X38MM XIENCE SKYPOINT -,SUP-1804400-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4.5 X12MM XIENCE SKYPOINT -,SUP-1804450-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4.5 X15MM XIENCE SKYPOINT -,SUP-1804450-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4.5 X18MM XIENCE SKYPOINT -,SUP-1804450-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4.5 X23MM XIENCE SKYPOINT -,SUP-1804450-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4.5 X28MM XIENCE SKYPOINT -,SUP-1804450-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4.5 X33MM XIENCE SKYPOINT -,SUP-1804450-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 5.0 X12MM XIENCE SKYPOINT -,SUP-1804500-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 5.0 X15MM XIENCE SKYPOINT -,SUP-1804500-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 5.0 X18MM XIENCE SKYPOINT -,SUP-1804500-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 5.0 X23MM XIENCE SKYPOINT -,SUP-1804500-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 5.0 X28MM XIENCE SKYPOINT -,SUP-1804500-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 5.0 X33MM XIENCE SKYPOINT -,SUP-1804500-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 30MM PROX 30MM DIST 25-27MM OD AOR 140MM ZENITH TX2 -,SUP-2TEG-2P-30-140-,CDM,C1874,HCPCS,278,RC,,,outpatient,,,29835.9,20885.13,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
DETACHABLE COIL 4MM X 8MM -,SUP-36-152,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT PK PAPYRUS 2.5/15 -,SUP-434887,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT PK PAPYRUS 3.0/15 -,SUP-434888,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT PK PAPYRUS 3.5/15 -,SUP-434889,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT PK PAPYRUS 4.0/15 -,SUP-434890,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT PK PAPYRUS 4.5/15 -,SUP-434891,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT PK PAPYRUS 5.0/15 -,SUP-434892,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT PK PAPYRUS 2.5/20 -,SUP-434893,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT PK PAPYRUS 3.0/20 -,SUP-434894,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT PK PAPYRUS 3.5/20 -,SUP-434895,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT PK PAPYRUS 4.0/20 -,SUP-434896,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT PK PAPYRUS 4.5/20 -,SUP-434897,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT PK PAPYRUS 5.0/20 -,SUP-434898,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT PK PAPYRUS 3.0/26 -,SUP-434899,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT PK PAPYRUS 3.5/26 -,SUP-434900,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT PK PAPYRUS 4.0/26 -,SUP-434901,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT PK PAPYRUS 4.5/26 -,SUP-434902,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT PK PAPYRUS 5.0/26 -,SUP-434903,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
COVERA VASCULAR COVERED STENT 6 x 60 Ref: AVFM06060 -,SUP-AVFM06060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
COVERA VASCULAR COVERED STENT 7 X 80 8F -,SUP-AVFM07080,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
COVERA 8MM X 40MM FLARED -,SUP-AVFM08040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
COVERA 8MM X 60MM FLARED -,SUP-AVFM08060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT VASCULAR COVERA FLARE 8MM X 80MM -,SUP-AVFM08080,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
COVERA STENT GRAFT 10 X 40 -,SUP-AVFM10040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
COVERA VASCULAR COVERED STENT 6 x 40 Ref: AVSM06040 -,SUP-AVSM06040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
COVERA AV STENT GRAFT 8MM X 60MM X 80MM -,SUP-AVSM08060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT COVERA AV GRAFT 8MM X 80MM X 80MM -,SUP-AVSM08080,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT COVERA AV GRAFT 10MM X 60MM 80CM STRAIGHT -,SUP-AVSM10060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
VIABAHN BALLOON EXPANDABLE 7MM X 29MM STENT -,SUP-BXA072902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12468.25,8727.775,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
BALLOON EXPANDABLE ENDOPROSTHESIS VIABAHN 8-11 7FR 29LGTH -,SUP-BXA082902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13199.72,9239.804,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
BALLOON EXPANDABLE ENDOPROSTHESIS VIABAHN 8-11 7FR 39LGTH -,SUP-BXA083902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
BALLOON EXPANDABLE ENDOPROSTHESIS VIABAHN 8-11 7FR 59 LGTH -,SUP-BXA085902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12468.25,8727.775,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT VIABAHN 11MM X 39CM GORE -,SUP-BXA113902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11844.47,8291.129,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
VIABAHN BALLOON EXPANDABLE 1MM X 59MM STENT -,SUP-BXA115902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT VIABAHN VBX BALLOON EXPANDABLE ENDOPROSTHESIS 2 -,SUP-BXAL082901A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
VIABAHN VBX BALLOON EXPANDABLE ENDOPROSTHESIS -,SUP-BXAL082902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT VIABAHN VBX 8MM X 39MM BALLOON EXPANDABLE -,SUP-BXAL083901A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
VIABAHN VBX 8MM X 59MM BALLOON AXPANDABLE STENT -,SUP-BXAL085901A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
VIABAHN VBX BALLOON EXPANDABLE ENDOPROSTHESIS -,SUP-BXAL085902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
EXCLUDER CONFORM AAA EXT ENDO 26MM X 4.5CM 15FR -,SUP-CXA260005,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19511.82,13658.274,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT 3.5X15MM DRIVER OTW BE  143CM 0.014IN GW COMP -,SUP-DRV35015W,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 22X39MM ZENITH FLEX BIFUR MAIN BD EXTEND Z-TRAK -,SUP-ESBE-22-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 24X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-24-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 26X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-26-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 28MM DI 39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK -,SUP-ESBE-28-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 30X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-30-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 32X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-32-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 36X50MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-36-50-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT STENT ENDURANT 23MM -,SUP-ESBF2314C103E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 28/14X103MM ENDURANT IIS BIFUR STNT PRELD PROX -,SUP-ESBF2814C103E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,36592.73,25614.911,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 32/14X103MM ENDURANT IIS BIFUR STNT PRELD PROX -,SUP-ESBF3214C103E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
CONVERTER EV 12MM DIST 24MM PROX 80MM ZENITH FLEX Z-TRAK -,SUP-ESC-24-12-80-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
CONVERTER EV 28MMX12MMX80MM ZENITH FLEX Z-TRAK INTRO SYS -,SUP-ESC-28-12-80ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
CONVERTER EV 32MMX12MMX80MM ZENITH FLEX Z-TRAK INTRO SYS -,SUP-ESC-32-12-80-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
CONVERTER EV 36MMX12MMX82MM ZENITH FLEX Z-TRAK INTRO SYS -,SUP-ESC-36-12-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 18X55MM ZENITH AOR -,SUP-ESLE-18-55-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8246.09,5772.263,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
SYS STENT ENDURANT II GRAFT BI -,SUP-ETBF2316C145E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT GRAFT ENDURANT II AORTIC EXTENSION 49E -,SUP-ETCF2323C49E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14726.69,10308.683,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT GRAFT ENDURANT II AO EXT -,SUP-ETCF2828C49E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15079.42,10555.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STEN GRAFT ENDURANT II AORTIC EXT 49E -,SUP-ETCF3232C49E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16783.13,11748.191,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT GRAFT ENDURANTII ILEXT -,SUP-ETEW1313C82E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16402.18,11481.526,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT GRAFT ENDUR II LIMB -,SUP-ETLW1610C156E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT STENT ENDUR II LIMB -,SUP-ETLW1610C199E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,22910.14,16037.098,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT STENT ENDUR IIS LIMB -,SUP-ETLW1610C93E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17372.2,12160.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 16/13X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1613C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17548.57,12283.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 16/13X156MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1613C156E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,24713.73,17299.611,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 16/16X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1616C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,18067.09,12646.963,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 16/16X82MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1616C82E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17280.3,12096.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 16/20X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1620C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17548.57,12283.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 16/20X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1620C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,18250.51,12775.357,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT GRAFT ENDUR II LIMB -,SUP-ETLW1624C156E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT GRAFT CONTRAL ENDURANT -,SUP-ETLW1624C93E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17372.2,12160.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT GRAFT ENDURANT II AUI -,SUP-ETUF2314C102E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 28/14X102MM ENDURANT II BIFUR STNT AOR ILC PRELD -,SUP-ETUF2814C102E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT STENT ENDURANT II 14MM X 36 X102MM -,SUP-ETUF3614C102E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 7MM 9FR CATH 50MM 120CM TOT 80CM DLV SYS FLAIR FLR -,SUP-FAF07050,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 8MM 9FR CATH 40MM 800CM TOT 80CM DLV SYS FLAIR FLR -,SUP-FAF08040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 7MM 9FR CATH 40MM 120CM TOT 80CM DLV SYS FLAIR STR -,SUP-FAS07040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9995.4,6996.78,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ENPROS 10MM 9FR CATH 40MM FLUENCY+ 117CM TRACHBR SE -,SUP-FTL10040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9825.92,6878.144,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ENPROS 7MM 8FR CATH 60MM FLUENCY+ 80CM TRACHBR SE -,SUP-FTM07060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10077.08,7053.956,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ENPROS 8MM 9FR CATH 40MM FLUENCY+ 80CM TRACHBR SE -,SUP-FTM08040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10077.08,7053.956,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ENPROS 12X54MM ZENITH AAA CNTRLAT ILC LEG WVN PLYSTR -,SUP-G12446,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 12MM IPSI LEG DIA 106MM DIST LEG 28MM DIST BD -,SUP-G32500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 30MM PROX 24-26MM OD AOR 94MM PROX BD ZENITH FEN -,SUP-G32533,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
ZENITH FENESTRATED PROXIMAL BODY -,SUP-G32537,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7045.04,4931.528,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT CUST ZFEN-P 2-24-124-R -,SUP-G32540,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 28MM PROX 23-24MM OD AOR 124MM PROX BD ZENITH FEN -,SUP-G32542,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 30MM PROX 24-26MM OD AOR 124MM PROX BD ZENITH FEN -,SUP-G32543,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT ZENITH FEN PROXIMAL BODY - ZFEN-P-2-32-124-R -,SUP-G32544,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 36MM PROX 29-31MM OD AOR 122MM PROX BD ZENITH FEN -,SUP-G32548,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT ZENITH DISTAL BODY - ZFEN-12-28-91 -,SUP-G32554,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 24/12X113MM ZENITH RENU ANCLRY CNVTR H&L-B 1-SHOT -,SUP-G36155,CDM,C1874,HCPCS,278,RC,,,outpatient,,,24186.48,16930.536,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
DRUG ELUTING STENT 80 PTX -,SUP-G38480,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
S ZILVER PTX 6 X 120 X 125 DRU -,SUP-G38482,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9315.54,6520.878,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT PTX 7MM X 40MM -,SUP-G38486,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5487.45,3841.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
DRUG ELUTING STENT 7 - 60 PTX -,SUP-G38487,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6981.34,4886.938,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
DRUG ELUTING STENT 7 - 100 PTX -,SUP-G38489,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ZILVER PTX 7MM X 120MM P -,SUP-G38490,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9315.54,6520.878,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT 8mm x 40mm PTX ZILVER -,SUP-G38495,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5487.45,3841.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ZILVER 8MM X 80MM PTX DRUG ELUTING PERIP -,SUP-G38518,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ZIV6-35-125-8-120-PTX -,SUP-G38532,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9315.54,6520.878,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 20X30MM ZENITH FLEX BIFUR ILC PLG H&L-B 1-SHOT -,SUP-G43055,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7775.01,5442.507,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 36MMX11.3CM ZENITH FLEX AAA BIFUR STNT 20FR DLV SYS -,SUP-G43357,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30491.16,21343.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 36MMX12MMX127MM ZENITH RENU ANCLRY CNVTR H&L-B -,SUP-G43366,CDM,C1874,HCPCS,278,RC,,,outpatient,,,23484.73,16439.311,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
ZENITH TX2 DISSECTION ENDOVASCULAR GRAFT STRAIGHT COMPONENT -,SUP-G47454,CDM,C1874,HCPCS,278,RC,,,outpatient,,,49547.23,34683.061,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
COMPONENT STRAIGHT ENDO GRAFT ZENITH TX2 DISSECTION -,SUP-G47457,CDM,C1874,HCPCS,278,RC,,,outpatient,,,43823.79,30676.653,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
ZENITH FLEX AAA ENDOVASC GRAFT MAIN BODY -,SUP-G48403,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 24MM BD 20-21MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-G48408,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT ZENITH FLEX AAA ENDOVASCULAR BIFURC MAIN BODY -,SUP-G48409,CDM,C1874,HCPCS,278,RC,,,outpatient,,,34530.9,24171.63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
ENDOGRAFT 32-82 ZENITH FLEX -,SUP-G48427,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 36MM BD 29-32MM OD AOR 95MM ZENITH FLEX BIFUR MAIN -,SUP-G48428,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
ZENITH FLEX AAA ENDOVASCULAR GRAFT 20FR -,SUP-G48429,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT ZEINTH 36X95MM ENDOVAS A -,SUP-G48432,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 36MM BD 29-32MM OD AOR 113MM ZENITH FLEX BIFUR MAIN -,SUP-G48433,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 14MM MAIN BD 37MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-G48454,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 22MM MAIN BD 39MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-G48472,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11454.61,8018.227,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 24MM MAIN BD 39MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-G48476,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11454.61,8018.227,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT COLONIC 18MM X 23MM X 12 -,SUP-G51183,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ESOPHAGEAL EVOLUTION FULLY COVERED 20-25-8 -,SUP-G52225,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 38MM PROX 38MM DIST 33-34MM OD AOR 202MM ZENITH TX2 -,SUP-G53435,CDM,C1874,HCPCS,278,RC,,,outpatient,,,29835.9,20885.13,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT ZENITH FLES Z-TRAK AAA ENDOVASC MAIN BODY EXT -,SUP-G55213,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9273.14,6491.198,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
ZENITH FLEX WITH SPIRAL Z ENDOVASCULAR GRAFT -,SUP-G55221,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT ZENITH FLEX LEG 13X56 -,SUP-G55231,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 16MM DIST 56MM ZENITH SPRL-Z CNTRLAT IPSI ILC LEG -,SUP-G55237,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT ZENITH FLEX LEG 16X74 14FR -,SUP-G55238,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT ZENITH FLEX LEG 20MM X 39MM -,SUP-G55240,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 24MM DIST 90MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-G55247,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT ZENITH 22 X 113 -,SUP-G55357,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30944.14,21660.898,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
ZENITH RENU AAA ANCILLARY GRAFT CON 12MM X 28MM X 113MM -,SUP-G55376,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30944.14,21660.898,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
ICAST COVERED STENT- 9MMX38MMX120CM -,SUP-G60511,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9841.79,6889.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
SYNERGY II US MR 2.5X8 -,SUP-H493926008250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
SYNERGY II US MR 2.75X8 -,SUP-H493926008270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
SYNERGY II US MR 3.5X8 -,SUP-H7433926008350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X24MM TAXUS EXPR2 OTW BE PRMNT 135CM PACLIT -,SUP-H7493896824250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.5X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.25X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.5X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X16MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902316250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4X16MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902316400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X20MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902320270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3X20MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902320300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4X20MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902320400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.25X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.5X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.25X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.25X16MM ION MONORAIL RX BE PRMNT 144CM PACLIT -,SUP-H7493902416220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X16MM ION MONORAIL RX BE PRMNT 144CM PACLIT -,SUP-H7493902416270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3X20MM ION MONORAIL RX BE PRMNT 144CM PACLIT THN -,SUP-H7493902420300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3X28MM ION MONORAIL RX BE PRMNT 144CM PACLIT THN -,SUP-H7493902428300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X32MM ION MONORAIL RX BE PRMNT 144CM PACLIT THN -,SUP-H7493902432250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X32MM ION MONORAIL RX BE PRMNT 144CM PACLIT -,SUP-H7493902432270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.25X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.5X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.25X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.5X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.25X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.5X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.25X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.5X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.25X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.5X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.25X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.5X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.25X32MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911432220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X32MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911432250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.5X32MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911432350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.5X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.25X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SV -,SUP-H7493911608220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911608250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911608270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL WKHRS -,SUP-H7493911608300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911608400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.25X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911612250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.5X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911612400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.25X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.5X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911616400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.5X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911620400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.25X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.5X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911624400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.25X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911628250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.5X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911628400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.25X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911632250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.5X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911632400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.5X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911638250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911638270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911638300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3.5X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911638350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911638400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 2.25 X 8 -,SUP-H7493926008220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
SYNERGY II US MR 2.25X8 -,SUP-H7493926008220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 2.50 X 8 -,SUP-H7493926008250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 2.75 X 8 -,SUP-H7493926008270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 3.00 X 8 -,SUP-H7493926008300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
SYNERGY II US MR 3.00X8 -,SUP-H7493926008300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 3.50 X 8 -,SUP-H7493926008350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
SYNERGY II US MR 4.0X8 -,SUP-H7493926008400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 4.00 X 8 -,SUP-H7493926008400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 2.25 X 12 -,SUP-H7493926012220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 2.50 X 12 -,SUP-H7493926012250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 2.75 X 12 -,SUP-H7493926012270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 3.00 X 12 -,SUP-H7493926012300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 3.50 X 12 -,SUP-H7493926012350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 4.00 X 12 -,SUP-H7493926012400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 2.25 X 16 -,SUP-H7493926016220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 2.50 X 16 -,SUP-H7493926016250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 2.75 X 16 -,SUP-H7493926016270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 3.00 X 16 -,SUP-H7493926016300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 3.50 X 16 -,SUP-H7493926016350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 4.00 X 16 -,SUP-H7493926016400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 2.25 X 20 -,SUP-H7493926020220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 2.50 X 20 -,SUP-H7493926020250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 2.50 X 24 -,SUP-H7493926020250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 2.50 X 28 -,SUP-H7493926020250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 2.75 X 20 -,SUP-H7493926020270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 3.00 X 20 -,SUP-H749392602030,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 3.50 X 20 -,SUP-H7493926020350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 4.00 X 20 -,SUP-H7493926020400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 2.25 X 24 -,SUP-H7493926024220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 2.75 X 24 -,SUP-H7493926024270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 3.00 X 24 -,SUP-H7493926024300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 3.50 X 24 -,SUP-H7493926024350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 4.00 X 24 -,SUP-H7493926024400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 2.25 X 28 -,SUP-H7493926028220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 2.75 X 28 -,SUP-H7493926028270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 3.00 X 28 -,SUP-H7493926028300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 3.50 X 28 -,SUP-H7493926028350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 4.00 X 28 -,SUP-H7493926028400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 2.50 X 32 -,SUP-H7493926032250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 2.75 X 32 -,SUP-H7493926032270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 3.00 X 32 -,SUP-H7493926032300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 3.50 X 32 -,SUP-H7493926032350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 4.00 X 32 -,SUP-H7493926032400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 2.25 X 38 -,SUP-H7493926038220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 2.50 X 38 -,SUP-H7493926038250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 2.75 X 38 -,SUP-H7493926038270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 3.00 X 38 -,SUP-H7493926038300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 3.50 X 38 -,SUP-H7493926038350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES MR 4.00 X 38 -,SUP-H7493926038400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 2.25 X 8 -,SUP-H7493926108220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 2.50 X 8 -,SUP-H7493926108250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 2.75 X 8 -,SUP-H7493926108270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 3.00 X 8 -,SUP-H7493926108300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 3.50 X 8 -,SUP-H7493926108350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 4.00 X 8 -,SUP-H7493926108400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 2.25 X 12 -,SUP-H7493926112220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 2.50 X 12 -,SUP-H7493926112250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 2.75 X 12 -,SUP-H7493926112270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 3.00 X 12 -,SUP-H7493926112300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 3.50 X 12 -,SUP-H7493926112350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 4.00 X 12 -,SUP-H7493926112400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 2.25 X 16 -,SUP-H7493926116220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 2.50 X 16 -,SUP-H7493926116250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 2.75 X 16 -,SUP-H7493926116270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 3.00 X 16 -,SUP-H7493926116300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 3.50 X 16 -,SUP-H7493926116350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 4.00 X 16 -,SUP-H7493926116400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 2.25 X 20 -,SUP-H7493926120220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 2.50 X 20 -,SUP-H7493926120250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 2.75 X 20 -,SUP-H7493926120270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 3.00 X 20 -,SUP-H7493926120300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 3.50 X 20 -,SUP-H7493926120350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 4.00 X 20 -,SUP-H7493926120400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 2.25 X 24 -,SUP-H7493926124220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 2.50 X 24 -,SUP-H7493926124250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 2.75 X 24 -,SUP-H7493926124270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 3.00 X 24 -,SUP-H7493926124300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 3.50 X 24 -,SUP-H7493926124350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 4.00 X 24 -,SUP-H7493926124400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 2.25 X 28 -,SUP-H7493926128220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 2.50 X 28 -,SUP-H7493926128250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 2.75 X 28 -,SUP-H7493926128270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 3.00 X 28 -,SUP-H7493926128300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 3.50 X 28 -,SUP-H7493926128350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 4.00 X 28 -,SUP-H7493926128400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 2.25 X 32 -,SUP-H7493926132220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 2.50 X 32 -,SUP-H7493926132250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 2.75 X 32 -,SUP-H7493926132270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 3.00 X 32 -,SUP-H7493926132300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 3.50 X 32 -,SUP-H7493926132350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 4.00 X 32 -,SUP-H7493926132400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 2.25 X 38 -,SUP-H7493926138220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 2.50 X 38 -,SUP-H7493926138250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 2.75 X 38 -,SUP-H7493926138270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 3.00 X 38 -,SUP-H7493926138300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 3.50 X 38 -,SUP-H7493926138350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY DES OTW 4.00 X 38 -,SUP-H7493926138400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
ELUVIA US 6MM X 40MM X 130CM -,SUP-H74939294600410,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
ELUVIA US 6MM X 60MM X 130CM -,SUP-H74939294600610,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
ELUVIA US 6MM X 80MM X 130CM -,SUP-H74939294600810,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
ELUVIA US 6MM X 100MM X 130CM -,SUP-H74939294601010,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
ELUVIA US 6MM X 120MM X 130CM -,SUP-H74939294601210,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10749.14,7524.398,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
ELUVIA US 6X150 130 cm -,SUP-H74939294601510,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13719.54,9603.678,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
ELUVIA 7MM x 40MM x 130CM -,SUP-H74939294700410,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
ELUVIA 7MM x 60MM x 130CM -,SUP-H74939294700610,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
ELUVIA DRUG-ELUTING VASCULAR STENT SYSTEM 7MM X 80MM X 130CM -,SUP-H74939294700810,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
ELUVIA 7MM x 100MM x 130CM -,SUP-H74939294701010,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
ELUVIA 7MM x 120MM x 130CM -,SUP-H74939294701210,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10749.14,7524.398,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
ELUVIA US 7X150 130 cm -,SUP-H74939294701510,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13719.54,9603.678,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT PROMUS ELITE US MR 4.0 X 8MM -,SUP-H7493941208400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT PROMUS ELITE US MR 4.0 X 12MM -,SUP-H7493941212400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT PROMUS ELITE US MR 2.50 X 32MM -,SUP-H7493941232250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT PROMUS ELITE US MR 3.50 X 32MM -,SUP-H7493941232350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT PROMUS ELITE US MR 3.50 X 38MM -,SUP-H7493941238350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 2.25 X 8 -,SUP-H7493941808220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 2.50 X 8 -,SUP-H7493941808250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 2.75 X 8 -,SUP-H7493941808270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 3.0 X 8 -,SUP-H7493941808300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 3.5 X 8 -,SUP-H7493941808350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 4.0 X 8 -,SUP-H7493941808400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 2.25 X 12 -,SUP-H7493941812220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 2.50 X 12 -,SUP-H7493941812250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 2.75 X 12 -,SUP-H7493941812270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 3.0 X 12 -,SUP-H7493941812300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 3.5 X 12 -,SUP-H7493941812350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 4.0 X 12 -,SUP-H7493941812400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 4.5 X 12 -,SUP-H7493941812450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 5.0 X 12 -,SUP-H7493941812500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 2.25 X 16 -,SUP-H7493941816220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 2.50 X 16 -,SUP-H7493941816250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 2.75 X 16 -,SUP-H7493941816270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 3.0 X 16 -,SUP-H7493941816300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 3.5 X 16 -,SUP-H7493941816350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 4.0 X 16 -,SUP-H7493941816400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 4.5 X 16 -,SUP-H7493941816450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 5.0 X 16 -,SUP-H7493941816500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 2.25 X 20 -,SUP-H7493941820220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 2.50 X 20 -,SUP-H7493941820250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 2.75 X 20 -,SUP-H7493941820270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 3.0 X 20 -,SUP-H7493941820300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 3.5 X 20 -,SUP-H7493941820350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 4.0 X 20 -,SUP-H7493941820400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 4.5 X 20 -,SUP-H7493941820450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 5.0 X 20 -,SUP-H7493941820500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 2.25 X 24 -,SUP-H7493941824220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 2.50 X 24 -,SUP-H7493941824250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 2.75 X 24 -,SUP-H7493941824270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 3.0 X 24 -,SUP-H7493941824300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 3.5 X 24 -,SUP-H7493941824350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 4.0 X 24 -,SUP-H7493941824400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 4.5 X 24 -,SUP-H7493941824450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 5.0 X 24 -,SUP-H7493941824500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 2.25 X 28 -,SUP-H7493941828220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 2.50 X 28 -,SUP-H7493941828250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 2.75 X 28 -,SUP-H7493941828270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 3.0 X 28 -,SUP-H7493941828300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 3.5 X 28 -,SUP-H7493941828350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 4.0 X 28 -,SUP-H7493941828400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 4.5 X 28 -,SUP-H7493941828450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 5.0 X 28 -,SUP-H7493941828500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 2.25 X 32 -,SUP-H7493941832220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 2.50 X 32 -,SUP-H7493941832250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 2.75 X 32 -,SUP-H7493941832270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 3.0 X 32 -,SUP-H7493941832300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 3.5 X 32 -,SUP-H7493941832350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 4.0 X 32 -,SUP-H7493941832400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 4.5 X 32 -,SUP-H7493941832450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 5.0 X 32 -,SUP-H7493941832500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 2.25 X 38 -,SUP-H7493941838220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 2.50 X 38 -,SUP-H7493941838250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 2.75 X 38 -,SUP-H7493941838270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 3.0 X 38 -,SUP-H7493941838300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 3.5 X 38 -,SUP-H7493941838350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR 4.0 X 38 -,SUP-H7493941838400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR US 2.5 X 48MM REF:H7493941848250 -,SUP-H7493941848250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR US 2.75 X 48MM REF:H7493941848270 -,SUP-H7493941848270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR US 3 X 48MM REF:H7493941848300 -,SUP-H7493941848300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR US 3.5 X 48MM REF:H7493941848350 -,SUP-H7493941848350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT SYNERGY XD DES MR US 4 X 48MM REF:H7493941848400 -,SUP-H7493941848400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT S MEGATRON DES US MR 3.5 X 16MM REF:H7493942816350 -,SUP-H7493942816350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT S MEGATRON DES US MR 3.5 X 20MM REF:H7493942820350 -,SUP-H7493942820350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT S MEGATRON DES US MR 4 X 20MM REF:H7493942820400 -,SUP-H7493942820400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT S MEGATRON DES US MR 4.5 X 20MM REF:H7493942820450 -,SUP-H7493942820450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT S MEGATRON DES US MR 5 X 20MM REF:H7493942820500 -,SUP-H7493942820500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT S MEGATRON DES US MR 3.5 X 24MM REF:H7493942824350 -,SUP-H7493942824350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT S MEGATRON DES US MR 4 X 24MM REF:H7493942824400 -,SUP-H7493942824400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT S MEGATRON DES US MR 4.5 X 24MM REF:H7493942824450 -,SUP-H7493942824450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT S MEGATRON DES US MR 5 X 24MM REF:H7493942824500 -,SUP-H7493942824500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT S MEGATRON DES US MR 3.5 X 28MM REF:H7493942828350 -,SUP-H7493942828350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT S MEGATRON DES US MR 4.0 X 28MM REF:H7493942828400 -,SUP-H7493942828400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT S MEGATRON DES US MR 4.5 X 28MM REF:H7493942828450 -,SUP-H7493942828450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT S MEGATRON DES US MR 5.0 X 28MM REF:H7493942828500 -,SUP-H7493942828500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT S MEGATRON DES US MR 3.5 X 32MM REF:H7493942832350 -,SUP-H7493942832350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT S MEGATRON DES US MR 4.0 X 32MM REF:H7493942832400 -,SUP-H7493942832400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT S MEGATRON DES US MR 4.5 X 32MM REF:H7493942832450 -,SUP-H7493942832450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT S MEGATRON DES US MR 5.0 X 32MM REF:H7493942832500 -,SUP-H7493942832500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
SYNERGY II US MR 2.25X12 -,SUP-H749396012220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT BIL 10X60MM 194CM CATH WALLSTNT SE UNCNTSTR CVR ENPROS -,SUP-H965431100,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7116.04,4981.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT BALLOON EXPANDABLE VASC COVERED -,SUP-LSMU0800737,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT LIFESTREAM 7MM X 58MM BALLOON EXP -,SUP-LSMU0800758,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
LIFESTREAM BALLOON EP VASC COVERED STENT 80CM X 26MM -,SUP-LSMU0800826,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
12MM X 38MM LIFE STREAM -,SUP-LSMU0801238,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT LIFESTREAM 5MM X 26MM -,SUP-LSMU1350526,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
LIFESTREAM 12MM X 38MM X 80CM -,SUP-LSMU1350626,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
FIBERED PLATINUM COIL 2 X 5MM -,SUP-M0013120211,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2243.7,1570.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
FIBERED PLATNUM COIL 4 X 4MM -,SUP-M0013120221,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2243.7,1570.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
DETACHABLE COIL 3MM X 6MM -,SUP-M001361500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2622.16,1835.512,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
DETACHABLE COIL 6MM X 10MM -,SUP-M001361560,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
PUSHER SURG ARSCP 0.016INX177CM VASC COIL 16 -,SUP-M0014012160,CDM,C1874,HCPCS,278,RC,,,outpatient,,,1036.3,725.41,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ESPH 18MM BD 13MM BD 23MM FLR 15CM POLYFLEX SE SIL LF -,SUP-M00514320,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8623.21,6036.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ESPH 18MM 25/23MM OD P/D FLR 18.5FR CATH 10CM WALLFLX -,SUP-M00516700,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ESPH 18MM 25/23MM OD P/D FLR 12CM WALLFLX SE BRD FLLY -,SUP-M00516710,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
WALLFLEX ESOPHAGEAL FULLY COVERED 18 X 15 -,SUP-M00516720,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
WALLFLEX ESOPHAGEAL FULLY COVERED 23 X 10 -,SUP-M00516730,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ESPH 23MM 28/28MM OD P/D FLR 10CM WALLFLX SE BRD FLLY -,SUP-M00516730,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
WALLFLEX ESOPHAGEAL FULLY COVERED 23 X 12 -,SUP-M00516740,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ESPH 23MM 28/28MM OD P/D FLR 12CM WALLFLX SE BRD FLLY -,SUP-M00516740,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
WALLFLEX ESOPHAGEAL FULLY COVERED 18 X 15 -,SUP-M00516750,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ESPH 18MM 23/23MM OD P/D FLR 10CM WALLFLX SE BRD FLLY -,SUP-M00516900,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9314.91,6520.437,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
WALLFLEX ESOPHAGEAL PARTIALLY COVERED 18 X 10 -,SUP-M00516900,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ESPH 18MM 23/23MM OD P/D FLR 123MM WALLFLX SE BRD FLLY -,SUP-M00516910,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
WALLFLEX ESOPHAGEAL PARTIALLY COVERED 18 X 12 -,SUP-M00516910,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
WALLFLEX PC ESOPH STENT 23/28MM X 105MM -,SUP-M00516930,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
WALLFLEX ESOPHAGEAL PARTIALLY COVERED 23 X 12 -,SUP-M00516940,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT AXIOS ELECTROCAUTERY-ENHANCED 15mm X 10mm -,SUP-M00553650,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17317.43,12122.201,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT CYST GASTROSTOMY AXIOS -,SUP-M00553650,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19659.22,13761.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT AXIOS 10 X 20 EE LO -,SUP-M00553660,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19659.22,13761.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT BIL 10X60MM WALLSTNT RX SE PRT CVR MTL 0.035IN GW COMP -,SUP-M00569710,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7266.24,5086.368,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT WALLFLEX BILIARY FULLY COVERED -,SUP-M00570350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
S WALLFLEX BILI 10X40 RX COV -,SUP-M00570360,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT BIL 10X60MM WALLFLX RX SE FLLY CVR PLATINOL 0.035IN GW -,SUP-M00570370,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT BIL 10X80MM WALLFLX RX SE FLLY CVR PLATINOL 0.035IN GW -,SUP-M00570380,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT PARTIALLY COVERED 8 X 100 -,SUP-M00570730,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9639.76,6747.832,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ULTRAFLEX 8 X 40 25MM TR -,SUP-M00576520,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT TRACHBR 10MM XPND 18FR COMPRESS 30MM ULFLX PRT CVR -,SUP-M00576530,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT RX COVRD 15 X 30 -,SUP-M00576550,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT RX COVRD 25 X 40 -,SUP-M00576560,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT CVRD ULTRAFLEX 14 X 40 -,SUP-M00576580,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT CVRD ULTRAFLEX 14 X 60 -,SUP-M00576590,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT TRACHBR 16MMX40MM ULFLX CVR DIST RELS SIL DIST RELS -,SUP-M00576610,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ULTRAFLEX 16X45 -,SUP-M00576620,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT CVRD ULTRAFLEX 18 X 40 -,SUP-M00576640,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT CVRD ULTRAFLEX 20 X 40 -,SUP-M00576670,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11747.93,8223.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT CVRD ULTRAFLEX 20 X 80 -,SUP-M00576690,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ESOPHAGEAL 23 X 150 ENDO -,SUP-MAXX-2315,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9175.53,6422.871,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  2.00 x 08MM -,SUP-ONYXNG20008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  2.00 x 12MM -,SUP-ONYXNG20012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  2.00 x 15MM -,SUP-ONYXNG20015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  2.00 x 18MM -,SUP-ONYXNG20018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  2.00 x 30MM -,SUP-ONYXNG20030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  2.25 x 08MM -,SUP-ONYXNG22508UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  2.25 x 12MM -,SUP-ONYXNG22512UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  2.25 x 15MM -,SUP-ONYXNG22515UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  2.25 x 18MM -,SUP-ONYXNG22518UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  2.25 x 22MM -,SUP-ONYXNG22522UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  2.25 x 26MM -,SUP-ONYXNG22526UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  2.25 x 30MM -,SUP-ONYXNG22530UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  2.25 x 34MM -,SUP-ONYXNG22534UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  2.25 x 38MM -,SUP-ONYXNG22538UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  2.50 x 08MM -,SUP-ONYXNG25008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  2.50 x 12MM -,SUP-ONYXNG25012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  2.50 x 15MM -,SUP-ONYXNG25015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  2.50 x 18MM -,SUP-ONYXNG25018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  2.50 x 22MM -,SUP-ONYXNG25022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  2.50 x 26MM -,SUP-ONYXNG25026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  2.50 x 30MM -,SUP-ONYXNG25030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  2.50 x 34MM -,SUP-ONYXNG25034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  2.50 x 38MM -,SUP-ONYXNG25038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  2.75 x 08MM -,SUP-ONYXNG27508UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  2.75 x 12MM -,SUP-ONYXNG27512UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  2.75 x 15MM -,SUP-ONYXNG27515UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  2.75 x 18MM -,SUP-ONYXNG27518UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  2.75 x 22MM -,SUP-ONYXNG27522UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  2.75 x 26MM -,SUP-ONYXNG27526UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  2.75 x 30MM -,SUP-ONYXNG27530UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  2.75 x 34MM -,SUP-ONYXNG27534UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  2.75 x 38MM -,SUP-ONYXNG27538UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  3.0 x 08MM -,SUP-ONYXNG30008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  3.0 x 12MM -,SUP-ONYXNG30012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  3.0 x 15MM -,SUP-ONYXNG30015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  3.0 x 18MM -,SUP-ONYXNG30018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  3.0 x 22MM -,SUP-ONYXNG30022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  3.0 x 26MM -,SUP-ONYXNG30026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  3.0 x 30MM -,SUP-ONYXNG30030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  3.0 x 34MM -,SUP-ONYXNG30034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  3.0 x 38MM -,SUP-ONYXNG30038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  3.5 x 08MM -,SUP-ONYXNG35008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  3.5 x 12MM -,SUP-ONYXNG35012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  3.5 x 15MM -,SUP-ONYXNG35015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  3.5 x 18MM -,SUP-ONYXNG35018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  3.5 x 22MM -,SUP-ONYXNG35022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  3.5 x 26MM -,SUP-ONYXNG35026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  3.5 x 30MM -,SUP-ONYXNG35030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  3.5 x 34MM -,SUP-ONYXNG35034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  3.5 x 38MM -,SUP-ONYXNG35038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  4.0 x 12MM -,SUP-ONYXNG40012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  4.0 x 15MM -,SUP-ONYXNG40015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  4.0 x 18MM -,SUP-ONYXNG40018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  4.0 x 22MM -,SUP-ONYXNG40022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  4.0 x 26MM -,SUP-ONYXNG40026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  4.0 x 30MM -,SUP-ONYXNG40030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  4.0 x 34MM -,SUP-ONYXNG40034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  4.0 x 38MM -,SUP-ONYXNG40038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  4.5 x 12MM -,SUP-ONYXNG45012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  4.5 x 15MM -,SUP-ONYXNG45015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  4.5 x 18MM -,SUP-ONYXNG45018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  4.5 x 22MM -,SUP-ONYXNG45022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  4.5 x 26MM -,SUP-ONYXNG45026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  4.5 x 30MM -,SUP-ONYXNG45030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  5.0 x 18MM -,SUP-ONYXNG50018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  5.0 x 22MM -,SUP-ONYXNG50022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ONYX DES  5.0 x 30MM -,SUP-ONYXNG50030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT BIL 5X18MM 135CM PALMZ GENESIS RX BE TRNSHEP SS -,SUP-PG1850BAX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4882.72,3417.904,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
EXCLUDER AAA ENDO EXTENDER 26MMX3.3CM 16FR -,SUP-PLA260300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13934.89,9754.423,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 32MM 27-29MM AOR 4.5CM EXCLDR AOR EXTEND LPRO SULS -,SUP-PLA320400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13934.89,9754.423,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
EXCLUDER AAA ENDO EXTENDER 36MM X 4.5CM 18FR -,SUP-PLA360400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13934.89,9754.423,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
EXCLUDER AAA ENDOPROSTHESIS L 16MM X 12MM X 14CM 12F -,SUP-PLC121400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
EXCLUDER CONTRALATERAL LEG 16MM X 14.5MM X 10CM 12F -,SUP-PLC141000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GORE EXCLUDER AAA ENDOPROSTHESIS -,SUP-PLC141200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 13.5-14.5MM 16MM ILC 9.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PLC161000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 13.5-14.5MM 16MM ILC 11.5CM EXCLDR CNTRLAT LEG ILC -,SUP-PLC161200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 13.5-14.5MM 16MM ILC 13.5CM EXCLDR CNTRLAT LEG ILC -,SUP-PLC161400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EXCLUDER AAA ENDO CONTRA LEG 16 X 18 X 9.5CM 12FR -,SUP-PLC181000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
EXCLUDER AAA ENDO CONTRA LEG 16MM X 20MM X 11.5CM 12FR -,SUP-PLC201200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
EXCLUDER AAA ENDO CONTRA LEG 16 X 23 X 12 14FR -,SUP-PLC231200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
EXCLUDER AAA ENDO CONTRA LEG 16MM X 23MM X 14CM 14FR -,SUP-PLC231400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GORE EXCLUDER AAA CONTRALATERAL LEG 16 X 27 X 100MM -,SUP-PLK271000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GORE VIATORR 10MM X 6CM -,SUP-PTB8106275,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17651.6,12356.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GORE VIATORR 10MM X 7CM -,SUP-PTB8107275,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17651.6,12356.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 10-11MM 12MM ILC 10CM EXCLDR CNTRLAT LEG LPRO SULS -,SUP-PXC121000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 12-13.5MM 14.5MM ILC 12CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC141200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 13.5-14.5 MM 6MMX11.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC161200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 16.5-18.5 MM 20MMX11.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC201200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 16.5-18.5 MM 20MMX13.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC201400-L,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 10MMX7CM EXCLDR ILC EXTEND LPRO SULS CNSTRCT SEAL -,SUP-PXL161007,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11510.3,8057.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 12MMX7CM EXCLDR ILC EXTEND LPRO SULS CNSTRCT SEAL -,SUP-PXL161207,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10953.35,7667.345,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 27-29/12-13.5MM 31/14.5MM DIA AOR/ILC 18CM EXCLDR -,SUP-RLT311413,CDM,C1874,HCPCS,278,RC,,,outpatient,,,32100.6,22470.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 2.75X18MM RESOLUT IN RX BE PRMNT 140CM ZOTARO -,SUP-RSINT27518UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30022W,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30026W,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 3X38MM RESOLUT IN RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT30038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT DES 4X38MM RESOLUT IN RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT40038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 22MM 18FR SHTH 8.2CM BIFUR -,SUP-TFFB-22-82,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30491.16,21343.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT 22X82 ZENITH ENDOVASC AA -,SUP-TFFB-22-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 22MM BD 18-19MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-22-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT ZENITH 24X82 ENDOVASC -,SUP-TFFB-24-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 26MM BD 22MM AOR 111MM ZENITH FLEX BIFUR MAIN BD -,SUP-TFFB-26-111-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT 26X82 ZEINTH ENDOV AAA -,SUP-TFFB-26-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 26MM BD 22MM AOR 96MM ZENITH FLEX BIFUR MAIN BD -,SUP-TFFB-26-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 28MM BD 23-24MM OD AOR 111MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-28-111-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 28MM BD 23-24MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-28-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 30MM BD 25-26MM OD AOR 11.1CM ZENITH FLEX BIFUR -,SUP-TFFB-30-111,CDM,C1874,HCPCS,278,RC,,,outpatient,,,31404.55,21983.185,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 30MM BD 25-26MM OD AOR 111MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-30-111-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT 30X82 ZEINTH ENDOVASC AB -,SUP-TFFB-30-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV ZENITH FLEX 30MM 20FRX9.6MM BIFUR MAIN BD EXTEND -,SUP-TFFB-30-96,CDM,C1874,HCPCS,278,RC,,,outpatient,,,29150.76,20405.532,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 30MM BD 25-26MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-30-96-2T,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
COOK GRAFT TFFB-30-96-ZT -,SUP-TFFB-30-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ENPROS 12X71MM ZENITH AAA CNTRLAT ILC LEG WVN PLYSTR -,SUP-TFLE-12-71,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ENPROS 14X54MM ZENITH AAA CNTRLAT ILC LEG WVN PLYSTR -,SUP-TFLE-14-54,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 14MM MAIN 56MM LEG ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-TFLE-14-56-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11454.61,8018.227,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 14MM MAIN BD 73MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-TFLE-14-73,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 14X56MM ZENITH FLEX AAA Z-TRAK BIFUR ILC CNTRLAT -,SUP-TFLE-15-56,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ENPROS 18MM 16FR SHTH 54MM ZENITH AAA CNTRLAT ILC LEG -,SUP-TFLE-18-54,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT ZENITH FLEX AAA 28X82M -,SUP-TTFB-28-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GORE VIATORR 10MM X 8CM -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16385.47,11469.829,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT STENT ENDUR IIS BIF BODY -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
S VIABAHN 7MM X 7CM VIA VAS -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT POLYFLEX AIRWAY 16X40 -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8267.48,5787.236,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ESOPHAGEAL 21X150 -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9175.53,6422.871,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
VALIANT THORACIC CAPTIVA STENT GRAFT 26MM X 112MM 22FR -,SUP-VAMF2626C100TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,40668.87,28468.209,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT GRAFT VALIANT CAPTIVA WITH DELIVERY SYSTEM -,SUP-VAMF2828C100TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,40668.5,28467.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ENPROS 5MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART. -,SUP-VBH051002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12063.54,8444.478,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ENPROS 6MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART. -,SUP-VBH061002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12152.65,8506.855,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ENPROS 6MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC_ART. -,SUP-VBH061502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13968.31,9777.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ENPROS 7MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBH071002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12152.65,8506.855,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ENPROS 8MMX10CM 120CM VIABAHN SE LPRO TIP TO HUB DPLY -,SUP-VBH081002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12152.65,8506.855,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ENPROS 9MMX15CM 120CM VIABAHN SE LPRO TIP TO HUB DPLY -,SUP-VBH091502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13968.31,9777.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
S 10MMX 5.0CM VIA VASC 120CM -,SUP-VBH100502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11785.06,8249.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ENPROS 10MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBH101502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14495.55,10146.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GORE VIABAHN ENDOPROSTHESIS- 7MMX5CM 8FR 120CMCATH -,SUP-VBHR070502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12910.1,9037.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ENPROS 8MM 8FR DVC 5CM GORE-HYBRID VIABAHN 120CM NTNL -,SUP-VBHR080502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12910.1,9037.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ENPROS 6MMX5CM 120CM VIABAHN FEM ILC ART TIP TO HUB -,SUP-VBJ060502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11268.96,7888.272,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ENPROS 6MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART. -,SUP-VBJ061502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14347.03,10042.921,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ENPROS 6MMX25CM 120CM GORE-HYBRID VIABAHN SUPRFC FEM -,SUP-VBJ062502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,23555.27,16488.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ENPROS 7MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJ071502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14347.03,10042.921,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ENPROS 8MMX5CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJ080502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10923.65,7646.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ENPROS 8MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJ081002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12445.98,8712.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ENPROS 5MM 6FRX5CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR050502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11669.96,8168.972,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ENPROS 5MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR051002A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12761.58,8933.106,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ENPROS 5MMX15CM VIABAHN 120MM CATH -,SUP-VBJR051502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14885.42,10419.794,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ENPROS 5MM 6FRX25CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR052502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,24297.87,17008.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ENPROS 6MMX5CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR060502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13403.93,9382.751,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ENPROS 6MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR061002A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ENPROS 6MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR061502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14224.5,9957.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ENPROS 6MM 6FRX25CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR062502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,23351.06,16345.742,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ENPROS 7MM 7FRX5CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR070502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12226.91,8558.837,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ENPROS 7MM 7FRX10CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR071002A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT ENPROS 7MMX25CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR072502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26414.28,18489.996,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
VALIANT NAVION THORACIC STENT GRAFT SYSTEM -,SUP-VNMC2020C94TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
THORACIC STENT GRAFT 94MM 25MM -,SUP-VNMC2525C94TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT GRAFT VALION NAVION THORACIC -,SUP-VNMC4040C55TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT GORE VIABIL 10MM X 6CM BILIARY -,SUP-VSWVN1006,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT GORE VIABIL 10MM X 8CM BILIARY -,SUP-VSWVN1008,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 28MM PROX BD DIA 94MM PROX BD ZENITH FEN INTNL -,SUP-ZFEN-9-2-28-94R,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 12MM IPSI LEG DIA 121MM DIST LEG 28MM DIST BD -,SUP-ZFEN-D-1228121C,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
FENESTRATED DISTAL BODY -,SUP-ZFEN-D-12-2876C,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT HUM TIS FEN 26MM ZENITH EV PROX BD LF -,SUP-ZFEN-P-226124-R,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 36MM PROX 29-31MM OD AOR 107MM PROX BD ZENITH FEN -,SUP-ZFEN-P-2-36107R,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT VASC DES ZILVER PTX 6X100MM 125CM OTW SE PRELD -,SUP-ZISV6351256100,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT VASC DES ZILVER PTX 6X60MM 125CM OTW SE PRELD -,SUP-ZIV6-35-125660,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6981.34,4886.938,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT VASC DES ZILVER PTX 7X100MM 125CM OTW SE PRELD -,SUP-ZIV6351257100PT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7617.98,5332.586,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT VASC DES ZILVER PTX 7X80MM 125CM OTW SE PRELD -,SUP-ZIV635125780PTX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7617.98,5332.586,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 11MM DIST 56MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-ZSLE-11-56-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14387.88,10071.516,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 11MM DIST 74MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-ZSLE-11-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT ZENITH FLEX LEG 13X74 -,SUP-ZSLE-13-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT ZENITH AAA LEG 13X90MM -,SUP-ZSLE-13-90-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 16MMX90MM ZENITH SPRL -Z BIFUR CNTRLAT IPSI -,SUP-ZSLE-16-16-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 16MM DIST 39MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-ZSLE-16-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT ZENITH AAA LEG 20X74MM -,SUP-ZSLE-20-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT ZENITH AAA 24 X 56MM LEG -,SUP-ZSLE-24-56-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
GRAFT EV 24MM 16FR ID 6MM INTRO SHTH 74MM ZENITH SPRL -Z -,SUP-ZSLE-24-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,232.64935,38052.27264,other,Non-Reimbursable List,,
STENT 4.5X13MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003381-13,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 4.5X18MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003381-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 4.5X28MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003381-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 5X13MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003382-13,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2X8MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2X12MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2X15MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2X18MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2X23MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2X28MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.25X8MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.25X12MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.25X15MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.25X18MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.25X23MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.25X28MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.5X8MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.5X12MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.5X15MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.5X18MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.5X23MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.5X28MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.75X8MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007847-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.75X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007847-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.75X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007847-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3X8MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3X23MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3.5X8MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3.5X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3.5X23MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3.5X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 4X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007850-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 4X23MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007850-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 4X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007850-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.75X15MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010142-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.75X23MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010142-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3X8MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010143-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3X15MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010143-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VISION OTW 3.5 X 15 -,SUP-1010144-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VISION OTW 3.5 X 23 -,SUP-1010144-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3.5X28MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010144-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 4X18MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010145-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 4X23MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010145-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2X8MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3.5X12MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2X15MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3.5X18MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2X23MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2X28MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.25X8MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.25X12MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.25X15MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.25X18MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.25X23MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.25X28MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.5X8MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.5X12MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.5X15MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.5X18MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.5X23MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC ACCULINK 5X20MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011337-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC ACCULINK 5X30MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011337-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC ACCULINK 5X40MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011337-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S RX ACCULINK 7.0MM X 30MM X 132CM -,SUP-1011339-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC ACCULINK 7X40MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011339-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
6-8 mm X 30mm RX ACCULINK STENT -,SUP-1011343-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC ACCULINK 6-8X40MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011343-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
ACCULINK STENT 7-10 X 40MM -,SUP-1011344-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 4X12MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011487-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 4X18MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011487-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 4.5X15MM 135CM DLV CATH HERCULINK ELITE RX BE -,SUP-1011490-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 5X15MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011493-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 5X18MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011493-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR SELF-EXPANDING 6.0MM X 100MM X 80CM -,SUP-1012528-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR SELF-EXPANDING 6.0MM X 20MM X 80CM -,SUP-1012528-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR SELF-EXPANDING 6.0MM X 30MM X 80CM -,SUP-1012528-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR SELF-EXPANDING 6.0MM X 40MM X 80CM -,SUP-1012528-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR SEL-EXPANDING 6.0MM X 60MM X 80CM -,SUP-1012528-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAT SELF-EXPANDING 6.0MM X 80MM X 80CM -,SUP-1012528-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 100MM X 80CM -,SUP-1012529-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 20MM X 80CM -,SUP-1012529-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 30MM X 80CM -,SUP-1012529-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 40MM X 80CM -,SUP-1012529-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 60MM X 80CM -,SUP-1012529-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 80MM X 80CM -,SUP-1012529-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
ABSOLUTE PRO 8 X 100MM X 80CM -,SUP-1012530-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCUALR SELF-EXPANDING 8.0MM X 20MM X 80CM -,SUP-1012530-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR SELF-EXPANDING 8.0MM X 30MM X 80CM -,SUP-1012530-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
ABSOLUTE PRO VASCULAR SELF-EXPANDING STENT SYS 8 X 40 -,SUP-1012530-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
ABSOLUTE PRO 8 X 60MM X 80CM -,SUP-1012530-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
ABSOLUTE PRO 8 X 80MM X 80CM -,SUP-1012530-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR SELF-EXPANDING 9.0MM X 100MM X 80CM -,SUP-1012531-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR SELF-EXPANDING 9.0MM 20MM X 80CM -,SUP-1012531-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR SELF-EXPANDING 9.0MM X 30MM X 80CM -,SUP-1012531-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR SELF-EXPANDING 9.0MM X 40MM X 80CM -,SUP-1012531-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR SELF-EXPANDING 9.0MM X 60MM X 80CM -,SUP-1012531-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR SELF-EXPANDING 9.0MM X 80MM X 80CM -,SUP-1012531-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 100MM X 80CM -,SUP-1012532-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 20MM X 80CM -,SUP-1012532-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 30MM X 80CM -,SUP-1012532-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT ABSOLUTE PRO 10 X 40MM X 80CM -,SUP-1012532-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC ABSOLUTE PRO 10X60CM -,SUP-1012532-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
ABSOLUTE PRO SELF EXPANDING STENT 10MM X 80MM C 80CM -,SUP-1012532-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC ABSOLUTE PRO 6X100MM 135CM OTW SE PRMNT -,SUP-1012534-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC ABSOLUTE PRO 6X40MM 135CM OTW SE PRMNT -,SUP-1012534-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC ABSOLUTE PRO 7.0X100MM 135CM -,SUP-1012535-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 20MM X 135CM -,SUP-1012535-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 30MM X 135CM -,SUP-1012535-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC ABSOLUTE PRO 7X40MM 135CM OTW SE PRMNT -,SUP-1012535-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC ABSOLUTE PRO 7X60MM 135CM OTW SE PRMNT -,SUP-1012535-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 80MM X 135CM -,SUP-1012535-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR SELF-EXPANDING 8.0MM X 100MM X 135CM -,SUP-1012536-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR SELF-EXPANDING 8.0MM X 20MM X 135CM -,SUP-1012536-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR SELF-EXPANDING 8.0MM X 30MM X 135CM -,SUP-1012536-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR SELF-EXPANDING 8.0MM X 40MM X 135CM -,SUP-1012536-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC ABSOLUTE PRO 8.0 X 60MM X 135CM -,SUP-1012536-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR SELF-EXPANDING 9.0MM X 100MM X 135CM -,SUP-1012537-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR SELF-EXPANDED 9.0MM X 40MM X 135CM -,SUP-1012537-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR SELF-EXPANDING 9.0MM X 80MM X 135CM -,SUP-1012537-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 100MM X 135CM -,SUP-1012538-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 20MM X 135CM -,SUP-1012538-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 30MM X 135CM -,SUP-1012538-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 40MM X 135CM -,SUP-1012538-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 60MM X 135CM -,SUP-1012538-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 80MM X 135CM -,SUP-1012538-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR BALLOON-EXPANDABLE 6.0MM X 16MM X 80CM -,SUP-1012622-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC OMNILINK ELITE 6X19MM 80CM OTW BE PRMNT -,SUP-1012622-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC OMNILINK ELITE 6X29MM 80CM OTW BE PRMNT -,SUP-1012622-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC OMNILINK ELITE 6X39MM 80CM OTW BE PRMNT -,SUP-1012622-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC OMNILINK ELITE 6X59MM 80CM OTW BE PRMNT -,SUP-1012622-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 12MM X 80CM -,SUP-1012623-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 16MM X 80CM -,SUP-1012623-16,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC OMNILINK ELITE 7X19MM 80CM OTW BE PRMNT -,SUP-1012623-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC OMNILINK ELITE 7X29MM 80CM OTW BE PRMNT -,SUP-1012623-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC OMNILINK ELITE 7X39MM 80CM OTW BE PRMNT -,SUP-1012623-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC OMNILINK ELITE 7X59MM 80CM OTW BE PRMNT -,SUP-1012623-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC OMNILINK ELITE 8X19MM 80CM OTW BE PRMNT -,SUP-1012624-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC OMNILINK ELITE 8X29MM 80CM OTW BE PRMNT -,SUP-1012624-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC OMNILINK ELITE 8X39MM 80CM OTW BE PRMNT -,SUP-1012624-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC OMNILINK ELITE 8X59MM 80CM OTW BE PRMNT -,SUP-1012624-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC OMNILINK ELITE 9X19MM 80CM OTW BE PRMNT -,SUP-1012625-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC OMNILINK ELITE 9X29MM 80CM OTW BE PRMNT -,SUP-1012625-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC OMNILINK ELITE 9X39MM 80CM OTW BE PRMNT -,SUP-1012625-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC OMNILINK ELITE 9X59MM 80CM OTW BE PRMNT -,SUP-1012625-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC OMNILINK ELITE 10X19MM 80CM OTW BE PRMNT -,SUP-1012626-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC OMNILINK ELITE 10X29MM 80CM OTW BE PRMNT -,SUP-1012626-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC OMNILINK ELITE 10X39MM 80CM OTW BE PRMNT -,SUP-1012626-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC OMNILINK ELITE 10X59MM 80CM OTW BE PRMNT -,SUP-1012626-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR BALLOON-EXPANDABLE 6.0MM X 16MM X 135 -,SUP-1012629-16,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC OMNILINK ELITE 6X19MM 135CM OTW BE PRMNT -,SUP-1012629-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC OMNILINK ELITE 6X29MM 135CM OTW BE PRMNT -,SUP-1012629-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC OMNILINK ELITE 6X39MM 135CM OTW BE PRMNT -,SUP-1012629-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC OMNILINK ELITE 6X59MM 135CM OTW BE PRMNT -,SUP-1012629-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 12MM X 135CM -,SUP-1012630-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 16MM X 135CM -,SUP-1012630-16,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC OMNILINK ELITE 7X19MM 135CM OTW BE PRMNT -,SUP-1012630-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC OMNILINK ELITE 7X29MM 135CM OTW BE PRMNT -,SUP-1012630-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC OMNILINK ELITE 7X39MM 135CM OTW BE PRMNT -,SUP-1012630-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC OMNILINK ELITE 7X59MM 135CM OTW BE PRMNT -,SUP-1012630-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC OMNILINK ELITE 8X19MM 135CM OTW BE PRMNT -,SUP-1012631-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC OMNILINK ELITE 8X29MM 135CM OTW BE PRMNT -,SUP-1012631-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC OMNILINK ELITE 8X39MM 135CM OTW BE PRMNT -,SUP-1012631-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC OMNILINK ELITE 8X59MM 135CM OTW BE PRMNT -,SUP-1012631-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC OMNILINK ELITE 9X19MM 135CM OTW BE PRMNT -,SUP-1012632-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC OMNILINK ELITE 9X29MM 135CM OTW BE PRMNT -,SUP-1012632-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC OMNILINK ELITE 9X39MM 135CM OTW BE PRMNT -,SUP-1012632-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC OMNILINK ELITE 9X59MM 135CM OTW BE PRMNT -,SUP-1012632-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC OMNILINK ELITE 10X19MM 135CM OTW BE PRMNT -,SUP-1012633-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC OMNILINK ELITE 10X29MM 135CM OTW BE PRMNT -,SUP-1012633-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC OMNILINK ELITE 10X39MM 135CM OTW BE PRMNT -,SUP-1012633-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC OMNILINK ELITE 10X59MM 135CM OTW BE PRMNT -,SUP-1012633-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 4X12MM JOST GRAFTMS OTW BE 143CM SEM-COM HYDREX CTD -,SUP-12746-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
BIOMIMICS 3-D STENT 5MM X 60MM -,SUP-142122-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
BIOMIMICS 3-D STENT 6MM X 60MM -,SUP-142122-02,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
BIOMIMICS 3-D STENT 7MM X 60MM -,SUP-142122-03,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
BIOMIMICS 3-D STENT 5MM X 80MM -,SUP-142122-05,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
BIOMIMICS 3-D STENT 6MM X 80MM -,SUP-142122-06,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
BIOMIMICS 3-D STENT 7MM X 80MM -,SUP-142122-07,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
BIOMIMICS 3-D STENT 5MM X 100MM -,SUP-142122-09,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
BIOMIMICS 3-D STENT 6MM X 100MM -,SUP-142122-10,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
BIOMIMICS 3-D STENT 7MM X 100MM -,SUP-142122-11,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
BIOMIMICS 3-D STENT 5MM X 125MM -,SUP-142122-13,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
BIOMIMICS 3-D STENT 6MM X 125MM -,SUP-142122-14,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
BIOMIMICS 3-D STENT 7MM X 125MM -,SUP-142122-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
BIOMIMICS 3-D STENT 5MM X 150MM -,SUP-144700-05,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
BIOMIMICS 3-D STENT 6MM X 150MM -,SUP-144700-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
BIOMIMICS 3-D STENT 7MM X 150MM -,SUP-144700-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S BILIARY LD PMTD 8 X 37 X75 6 -,SUP-38046-84075,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 8X37MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38046-84075,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 9 X 25MM 75CM EXP LD -,SUP-38046-92075,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 10X25MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-12013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 10X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-16013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 6X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-63013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 7X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-76013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S BILIARY EXPRESS 8X37X135CM L -,SUP-38047-84013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 8X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-38047-84013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
PULSAR 18 - 6 X 40 X 135 -,SUP-390724,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
PULSAR 18 - 6 X 120 X 135 -,SUP-390728,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
PULSAR 18 - 6 X 150 X 135 -,SUP-390729,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
PULSAR 18  7X40X135  .018 -,SUP-390734,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC OTW 6 X 120 X 120 -,SUP-39200-06122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC EPIC 6X120MM 120CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-39200-06122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-XPD 7X118X120 -,SUP-39200-07122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC EPIC 7X120MM 163CM/120CM WKG CATH SE MTLC ILC -,SUP-39200-07122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-XPD 7X79X120 -,SUP-39200-07802,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC EPIC 7X80MM 120CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-39200-07802,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-XPD 9X40X120 -,SUP-39200-09402,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
EPIC STENT 10MM X 40MM X 120CM -,SUP-39200-10402,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
EPIC STENT 10MM X 60MM X 120CM -,SUP-39200-10602,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
EPIC STENT 12MM X 60MM X 120CM -,SUP-39200-12602,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT ENPROS 24MM 11FR CATH 70MM WALLSTNT RP 100CM TOT 75CM -,SUP-40512,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT PULSAR - 18 T3 4/20/135 -,SUP-430477,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT PULSAR - 18 T3 4/40/135 -,SUP-430479,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT PULSAR - 18 T3 4/80/135 -,SUP-430481,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT PULSAR - 18 T3  5/80/135 -,SUP-430491,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT PULSAR - 18 T3 5/120/135 -,SUP-430493,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT PULSAR - 18 T3 5/200/135 -,SUP-430496,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT PULSAR - 18 T3 6/40/135 -,SUP-430499,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT PULSAR - 18 T3 6/80/135 -,SUP-430501,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT PULSAR - 18 T3 6/120/135 -,SUP-430503,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT PULSAR - 18 T3 6/150/135 -,SUP-430504,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT PULSAR - 18 T3 6/200/135 -,SUP-430506,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT PULSAR - 18 T3 7/120/135 -,SUP-430513,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT PULSAR - 18 T3 7/150/135 -,SUP-430514,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
WRENCH SPLTY HX F /CPI -,SUP-6563,CDM,C1876,HCPCS,278,RC,,,outpatient,,,175.05,122.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT URET 6FR 22-32CM INLAY OPTM PLYMR BLND DBL PIGTL TAPR -,SUP-788600,CDM,C1876,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC XACT 7-9X40MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82086-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC XACT 7-9X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82087-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC XACT 9X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82088-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC XACT 9X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82089-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC XACT 6-8X40MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82090-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC XACT 6-8X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82091-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC XACT 8X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82092-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC XACT 8X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82093-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC XACT 7X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82094-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC XACT 7X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82095-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC XACT 10.8MM X 40MM X 136CM -,SUP-82096-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC XACT 10X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82098-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC XACT 10X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82099-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
ABRE STENTS 16MM X 80MM -,SUP-AB9U16080090,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6896.5,4827.55,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
ABRE STENTS 18MM X 100MM -,SUP-AB9U18100090,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6896.5,4827.55,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
ABRE STENTS 18MM X 120MM -,SUP-AB9U18120090,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6896.5,4827.55,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
COVERA AV STENT GRAFT 7MM X 60MM X 80MM -,SUP-AVSM07060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC SMART CONT 6X30MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06030ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC SMART CONT 6X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC SMART CONT 6X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC SMART CONT 6X80MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06080ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC SMART CONT 6X100MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06100ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC SMART CONT 6X120MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06120ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC SMART CONT 6X150MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06150ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC SMART CONT 7X30MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07030ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC SMART CONT 7X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC SMART CONT 7X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC SMART CONT 7X80MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07080ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC SMART CONT 7X100MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07100ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC SMART CONT 7X120MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07120ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC SMART CONT 7X150MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07150ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC SMART CONT 8X30MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08030ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC SMART CONT 8X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC SMART CONT 8X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC SMART CONT 8X80MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08080ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC SMART CONT 8X100MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08100ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC SMART CONT 8X120MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08120ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC SMART CONT 8X150MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08150ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC SMART CONT 10X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C10040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC SMART CONT 10X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C10060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 12X40MM 120CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-C12040MB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 12X60MM 120CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-C12060MB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 12X60MM 80CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-C12060SB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 6X100MM 130CM LIFESTENT SE HLCL NTNL 0.035IN GW -,SUP-EX061003CD,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9230.7,6461.49,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC LIFESTENT 6X150MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX061503CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC LIFESTENT 6X170MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX061703CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC LIFESTENT 6X200MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX062003CL,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC LIFESTENT 7X60MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX070603CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
GRAFT EV 8MM 9FR CATH 40MM 120CM TOT 80CM DLV SYS FLAIR STR -,SUP-FAS08040,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11020.18,7714.126,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
COIL MICRONESTER EMBOLIZATION 0.018 X 5CM X 3MM -,SUP-G23520,CDM,C1876,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 5MM 7FR GUID CATH 30MM 125CM ZILVER 518 OTW SE -,SUP-G31351,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S ZILVER 518 5X40 125CM S-E ZI -,SUP-G31352,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 4X40MM 125CM ZILVER 518 OTW SE PRELD FLXB SLT TUBE -,SUP-G31439,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 8MM 6FRX40MM 80CM SE PRELD MTL NTNL 5FR SHTH MUL -,SUP-G32020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S ZILVER .035 125CM 5 X 60 -,SUP-G32033,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 8X80MM MTL SE 6FRX125CM PRELD DLV SYS NTNL 6FR -,SUP-G36025,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S ZILVER 518 5X80 125CM S-E -,SUP-G36048,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 14X30MM 80CM ZILVER 635 OTW SE PRELD FLXB SLT TUBE -,SUP-G36233,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 12MM 8FR GUID CATH 40MM 125CM ZILVER 635 OTW SE -,SUP-G36239,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
12MM X 8CM ZILVER 635 STENT -,SUP-G36241,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 14MM 8FR GUID CATH 40MM 125CM ZILVER 635 OTW SE -,SUP-G36244,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 14X60MM 125CM ZILVER 635 OTW SE PRELD 0.035IN GW -,SUP-G36245,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 5X20MM 135CM FRMLA 418 BLN-XPD GUID CATH 5/6 FR -,SUP-G42956,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4034.03,2823.821,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 6X24MM 135CM FRMLA 418 OTW BE U STRUT TAPR 0.018IN -,SUP-G42962,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S ZILVER 518 VASC 6X40 125CM S -,SUP-G43771,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S ZILVER518 VASC 6X60 125CM -,SUP-G43772,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S ZILVER 518 VASC 6X80 125CM S -,SUP-G43773,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
7x40x125 ZILVER STENT 0.018 -,SUP-G43776,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC ZILVER 518 7X80MM 125CM OTW SE 0.018IN/5FR -,SUP-G43778,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC ZILVER 518 8X60MM 125CM OTW SE 0.018IN/5FR -,SUP-G43782,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S ZILVER .035 125CM 6 X 60 012 -,SUP-G43822,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S ZILVER .035 125CM 6 X 80 012 -,SUP-G43823,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC ZILVER 635 7X30MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43825,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC ZILVER 635 7X40MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43826,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC ZILVER 635 7X60MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43827,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC ZILVER 635 7X80MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43828,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC ZILVER 635 8X30MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC ZILVER 635 8X40MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43831,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC ZILVER 635 8X60MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43832,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC ZILVER 635 8X80MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43833,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC ZILVER 635 10X40MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43841,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC ZILVER 635 10X60MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43842,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC ZILVER 635 10X80MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43843,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
COIL NESTOR 3 X 5 -,SUP-G47334,CDM,C1876,HCPCS,278,RC,,,outpatient,,,577.61,404.327,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
COIL MICRONESTOR EMBOLIZATION .018 X 7CM X 4MM PLAT -,SUP-G47339,CDM,C1876,HCPCS,278,RC,,,outpatient,,,638.87,447.209,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
ZENITH DISSECTION ENDOVASCULAR STENT -,SUP-G47492,CDM,C1876,HCPCS,278,RC,,,outpatient,,,41924.2,29346.94,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
ZENITH DISSECTION ENDOVASCULAR STENT -,SUP-G47493,CDM,C1876,HCPCS,278,RC,,,outpatient,,,41924.2,29346.94,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT ENDOVASCULAR DISSECTION ZENITH -,SUP-G47496,CDM,C1876,HCPCS,278,RC,,,outpatient,,,37318.31,26122.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT DUODENAL EVOLUTION CONTROL RELEASE 22-27-9 -,SUP-G48026,CDM,C1876,HCPCS,278,RC,,,outpatient,,,8886.94,6220.858,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S ZILVER .035 125CM 5 X 100 -,SUP-G50162,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 7MM 8FR GUID CATH LNG 100MM 125CM ZILVER FLEX 35 -,SUP-G50168,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 7MM 8FR GUID CATH LNG 120MM 125CM ZILVER FLEX 35 -,SUP-G50169,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 7X140MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-G50170,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 8X100MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-G50171,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 8MM 8FR GUID CATH LNG 140MM 125CM ZILVER FLEX 35 -,SUP-G50173,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 10X100MM 80CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-G50177,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
Z STENT BILIARY 8 X 8 -,SUP-G50623,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC FRMLA 418 5X16MM 80CM OTW BE PRMNT -,SUP-G56609,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC FRMLA 418 5X20MM 80CM OTW BE PRMNT -,SUP-G56610,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC FRMLA 418 6X12MM 80CM OTW BE PRMNT -,SUP-G56611,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC FRMLA 418 6X16MM 80CM OTW BE PRMNT -,SUP-G56613,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC FRMLA 418 6X20MM 80CM OTW BE PRMNT -,SUP-G56614,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC FRMLA 418 7X16MM 80CM -,SUP-G56617,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC FRMLA 418 5X12MM 80CM OTW BE PRMNT -,SUP-G56631,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC FRMLA 414 5X20MM 80CM RX BE PRMNT 0.014IN/5FR/6FR -,SUP-G56950,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC FRMLA 414 5X16MM 135CM RX BE PRMNT -,SUP-G56958,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
0.14 ZILVER 5MM X 120MM X 135CM -,SUP-G56966,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC FRMLA 414 5X20MM 135CM RX BE PRMNT -,SUP-G56969,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC FRMLA 414 6X12MM 135CM RX BE PRMNT -,SUP-G56970,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC FRMLA 414 6X16MM 135CM RX BE PRMNT -,SUP-G56971,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC FRMLA 414 6X20MM 135CM RX BE PRMNT -,SUP-G56972,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
0.14 ZILVER 7MM X 160MM X 135CM -,SUP-G56974,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC FRMLA 414 7X20MM 135CM RX BE PRMNT -,SUP-G56975,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
US PRE PP-CA-397 P&B BARE METAL STENT ZVT7-35-120-16-60 -,SUP-G57453,CDM,C1876,HCPCS,278,RC,,,outpatient,,,8016.87,5611.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
SYS STENT VASCULAR ZILVER VENA 16MM 100MM 120CM VEIN OTW -,SUP-G57454,CDM,C1876,HCPCS,278,RC,,,outpatient,,,8016.87,5611.809,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
VENOUS WALLSTENT 10X94X75CM -,SUP-H74912044109470,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
VENOUS WALLSTENT 12X60X75CM -,SUP-H74912044126070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
VENOUS WALLSTENT 12X90X75CM -,SUP-H74912044129070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
VENOUS WALLSTENT 14X60X75CM -,SUP-H74912044146070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
VENOUS WALLSTENT 14X90X75CM -,SUP-H74912044149070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
VENOUS WALLSTENT 16X40X75CM -,SUP-H74912044164070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
VENOUS WALLSTENT 16X60X75CM -,SUP-H74912044166070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
VENOUS WALLSTENT 16X90X75CM -,SUP-H74912044169070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
VENOUS WALLSTENT 18X40X75CM -,SUP-H74912044184070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
VENOUS WALLSTENT 18X60X75CM -,SUP-H74912044186070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
VENOUS WALLSTENT 18X90X75CM -,SUP-H74912044189070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
VENOUS WALLSTENT 20X40X75CM -,SUP-H74912044204070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
VENOUS WALLSTENT 20X55X75CM -,SUP-H74912044205570,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
VENOUS WALLSTENT 20X80X75CM -,SUP-H74912044208070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
VICI VENOUS STENT 12MM X60MM X 100CM -,SUP-H74912060100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
VICI VENOUS STENT 14MM X 60MM X 100CM -,SUP-H74914060100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
VICI VENOUS STENT 14MM X 90MM X 100CM -,SUP-H74914090100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
VICI VENOUS STENT 16MM X 60MM X 100CM -,SUP-H74916060100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
VICI VENOUS STENT 16MM X90MM X 100CM -,SUP-H74916090100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 6X14MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937911614150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
FG EXP SD RENAL-BILIARY 7.0mmX15mmX150cm -,SUP-H74937911715150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 4X19MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912419150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 5X19MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912519150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 6X18MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912618150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 7X19MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912719150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 10X37MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046104070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 10X57MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046106070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S BIL EXPRESS PMTD  6X27X75 -,SUP-H74938046630750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 6X27MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046630750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S BILIARY LD PMTD 6X37X75 6FR -,SUP-H74938046640750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 6X37MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046640750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S BILI LD PMTD 6 X 57 X 75 EXP -,SUP-H74938046660750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 6X57MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046660750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 7X27MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046730750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S BILIARY LD PMTD 7X37X75 40CM -,SUP-H74938046740750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S  BILI LD PMTD 7 X 57 X 75 EX -,SUP-H74938046760750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EXPRESS B-I LD 8 X 27 X 75 P -,SUP-H74938046830750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 8X27MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046830750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
BEACON 8MM X 37MM X 75CM  ILIAC STENT -,SUP-H74938046840750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
8 X 57 X 75CM EXPRESS STENT -,SUP-H74938046860750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S BILI LD PMTD 8 X 57 X 75 EXP -,SUP-H74938046860750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 9X57MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046960750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 10X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047140130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 5X17MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047520130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 5X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047530130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 5X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047540130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 5X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047560130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 6X17MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047620130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 6X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047640130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 6X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047660130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 7X17MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047720130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 7X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047730130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 7X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047740130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
7 X 57MM EXPRESS ILIAC / BILIARY STENT 135CM -,SUP-H74938047760130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 8X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047830130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 8X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047860130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 9X25MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047920130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 9X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047940130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 9X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047960130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3X16MM VERIFLEX OTW BE PRMNT LO XING THN STRUT HYDRCT -,SUP-H7493893516300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3294.06,2305.842,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-XPD 6X100X120 -,SUP-H74939200061020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-XPD 6X19X120 -,SUP-H74939200062020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-XPD 6X29X120 -,SUP-H74939200063020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-XPD 6X40X120 -,SUP-H74939200064020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-XPD 6X51X120 -,SUP-H74939200065020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-XPD 6X61X120 -,SUP-H74939200066020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-XPD 6X71X120 -,SUP-H74939200067020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-XPD 6X80X120 -,SUP-H74939200068020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-XPD 7X99X120 -,SUP-H74939200071020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-XPD 7X19X120 -,SUP-H74939200072020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-XPD 7X29X120 -,SUP-H74939200073020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-XPD 7X41X120 -,SUP-H74939200074020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-XPD 7X50X120 -,SUP-H74939200075020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-XPD 7X60X120 -,SUP-H74939200076020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-XPD 7X70X120 -,SUP-H74939200077020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-XPD 8X100X120 -,SUP-H74939200081020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-XPD 8X120X120 -,SUP-H74939200081220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-XPD 8X20X120 -,SUP-H74939200082020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-XPD 8X31X120 -,SUP-H74939200083020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-XPD 8X41X120 -,SUP-H74939200084020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-XPD 8X51X120 -,SUP-H74939200085020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-XPD 8X61X120 -,SUP-H74939200086020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-XPD 8X72X120 -,SUP-H74939200087020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-XPD 8X82X120 -,SUP-H74939200088020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-XPD 9X99X120 -,SUP-H74939200091020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-XPD 9X21X120 -,SUP-H74939200092020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-XPD 9X30X120 -,SUP-H74939200093020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-XPD 9X51X120 -,SUP-H74939200095020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-XPD 9X61X120 -,SUP-H74939200096020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-XPD 9X81X120 -,SUP-H74939200098020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-XPD 10X98X120 -,SUP-H74939200101020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-EXP 10X20X120 -,SUP-H74939200102020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-EXP 10X30X120 -,SUP-H74939200103020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-XPD 10X40X120 -,SUP-H74939200104020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-XPD 10X50X120 -,SUP-H74939200105020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC EPIC 10X60MM 120CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939200106020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-XPD 10X71X120 -,SUP-H74939200107020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-XPD 10X80X120 -,SUP-H74939200108020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-EXP 12X32X120 -,SUP-H74939200123020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-XPD 12X42X120 -,SUP-H74939200124020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-XPD 12X52X120 -,SUP-H74939200125020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S EPIC ILIAC S-XPD 12X61X120 -,SUP-H74939200126020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.2X8MM REBEL MR RX BE -,SUP-H7493927408220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.5X8MM REBEL MR RX BE -,SUP-H7493927408250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.75X8MM REBEL MR RX BE -,SUP-H7493927408270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3X8MM REBEL MR RX BE -,SUP-H7493927408300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3.5X8MM REBEL MR RX BE -,SUP-H7493927408350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 4X8MM REBEL MR RX BE -,SUP-H7493927408400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.25X12MM REBEL MR RX BE -,SUP-H7493927412220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.5X12MM REBEL MR RX BE -,SUP-H7493927412250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.75X12MM REBEL MR RX BE -,SUP-H7493927412270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3X12MM REBEL MR RX BE -,SUP-H7493927412300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3.5X12MM REBEL MR RX BE -,SUP-H7493927412350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 4X12MM REBEL MR RX BE -,SUP-H7493927412400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 4.5X12MM REBEL MR RX BE -,SUP-H7493927412450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.25X16MM REBEL MR RX BE -,SUP-H7493927416220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.5X16MM REBEL MR RX BE -,SUP-H7493927416250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.75X16MM REBEL MR RX BE -,SUP-H7493927416270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3X16MM REBEL MR RX BE -,SUP-H7493927416300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3.5X16MM REBEL MR RX BE -,SUP-H7493927416350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 4X16MM REBEL MR RX BE -,SUP-H7493927416400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 4.5X16MM REBEL MR RX BE -,SUP-H7493927416450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.25X20MM REBEL MR RX BE -,SUP-H7493927420220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.5X20MM REBEL MR RX BE -,SUP-H7493927420250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.75X20MM REBEL MR RX BE -,SUP-H7493927420270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3X20MM REBEL MR RX BE -,SUP-H7493927420300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3.5X20MM REBEL MR RX BE -,SUP-H7493927420350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 4X20MM REBEL MR RX BE -,SUP-H7493927420400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 4.5X20MM REBEL MR RX BE -,SUP-H7493927420450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.25X24MM REBEL MR RX BE -,SUP-H7493927424220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.5X24MM REBEL MR RX BE -,SUP-H7493927424250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.75X24MM REBEL MR RX BE -,SUP-H7493927424270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3X24MM REBEL MR RX BE -,SUP-H7493927424300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3.5X24MM REBEL MR RX BE -,SUP-H7493927424350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 4X24MM REBEL MR RX BE -,SUP-H7493927424400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 4.5X24MM REBEL MR RX BE -,SUP-H7493927424450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.25X28MM REBEL MR RX BE -,SUP-H7493927428220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.5X28MM REBEL MR RX BE -,SUP-H7493927428250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.75X28MM REBEL MR RX BE -,SUP-H7493927428270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3X28MM REBEL MR RX BE -,SUP-H7493927428300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3.5X28MM REBEL MR RX BE -,SUP-H7493927428350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 4X28MM REBEL MR RX BE -,SUP-H7493927428400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 4.5X28MM REBEL MR RX BE -,SUP-H7493927428450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.75X32MM REBEL MR RX BE -,SUP-H7493927432270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3X32MM REBEL MR RX BE -,SUP-H7493927432300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3.5X32MM REBEL MR RX BE -,SUP-H7493927432350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 4X32MM REBEL MR RX BE -,SUP-H7493927432400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 4.5X32MM REBEL MR RX BE -,SUP-H7493927432450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.25X8MM REBEL OTW BE -,SUP-H7493927508220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.5X8MM REBEL OTW BE -,SUP-H7493927508250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.75X8MM REBEL OTW BE -,SUP-H7493927508270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3X8MM REBEL OTW BE -,SUP-H7493927508300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3.5X8MM REBEL OTW BE -,SUP-H7493927508350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 4X8MM REBEL OTW BE -,SUP-H7493927508400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.25X12MM REBEL OTW BE -,SUP-H7493927512220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.5X12MM REBEL OTW BE -,SUP-H7493927512250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.75X12MM REBEL OTW BE -,SUP-H7493927512270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3X12MM REBEL OTW BE -,SUP-H7493927512300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3.5X12MM REBEL OTW BE -,SUP-H7493927512350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 4X12MM REBEL OTW BE -,SUP-H7493927512400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 4.5X12MM REBEL OTW BE -,SUP-H7493927512450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.25X16MM REBEL OTW BE -,SUP-H7493927516220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.5X16MM REBEL OTW BE -,SUP-H7493927516250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.75X16MM REBEL OTW BE -,SUP-H7493927516270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3X16MM REBEL OTW BE -,SUP-H7493927516300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3.5X16MM REBEL OTW BE -,SUP-H7493927516350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 4X16MM REBEL OTW BE -,SUP-H7493927516400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 4.5X16MM REBEL OTW BE -,SUP-H7493927516450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.25X20MM REBEL OTW BE -,SUP-H7493927520220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.5X20MM REBEL OTW BE -,SUP-H7493927520250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.75X20MM REBEL OTW BE -,SUP-H7493927520270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3X20MM REBEL OTW BE -,SUP-H7493927520300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3.5X20MM REBEL OTW BE -,SUP-H7493927520350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 4X20MM REBEL OTW BE -,SUP-H7493927520400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 4.5X20MM REBEL OTW BE -,SUP-H7493927520450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.25X24MM REBEL OTW BE -,SUP-H7493927524220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.5X24MM REBEL OTW BE -,SUP-H7493927524250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.75X24MM REBEL OTW BE -,SUP-H7493927524270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3X24MM REBEL OTW BE -,SUP-H7493927524300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3.5X24MM REBEL OTW BE -,SUP-H7493927524350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 4X24MM REBEL OTW BE -,SUP-H7493927524400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 4.5X24MM REBEL OTW BE -,SUP-H7493927524450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.25X28MM REBEL OTW BE -,SUP-H7493927528220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.5X28MM REBEL OTW BE -,SUP-H7493927528250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.75X28MM REBEL OTW BE -,SUP-H7493927528270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3X28MM REBEL OTW BE -,SUP-H7493927528300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3.5X28MM REBEL OTW BE -,SUP-H7493927528350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 4X28MM REBEL OTW BE -,SUP-H7493927528400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 4.5X28MM REBEL OTW BE -,SUP-H7493927528450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 2.75X32MM REBEL OTW BE -,SUP-H7493927532270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3X32MM REBEL OTW BE -,SUP-H7493927532300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3.5X32MM REBEL OTW BE -,SUP-H7493927532350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 4X32MM REBEL OTW BE -,SUP-H7493927532400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 4.5X32MM REBEL OTW BE -,SUP-H7493927532450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC INNOVA 5X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293050230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC INNOVA 5X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC INNOVA 5X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC INNOVA 5X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC INNOVA 5X180MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC INNOVA 5X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293052030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9018.5,6312.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC INNOVA 5X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293054030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC INNOVA 5X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293056030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC INNOVA 5X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293058030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC INNOVA 6X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293060230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC INNOVA 6X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC INNOVA 6X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC INNOVA 6X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC INNOVA 6X180MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC INNOVA 6X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293062030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC INNOVA 6X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293064030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC INNOVA 6X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293066030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC INNOVA 6X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293068030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC INNOVA 7X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293070230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC INNOVA 7X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293071030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC INNOVA 7X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293071230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC INNOVA 7X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293071530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC INNOVA 7X180X130 SE ILC -,SUP-H74939293071830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC INNOVA 7X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293072030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC INNOVA 7X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293074030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC INNOVA 7X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293076030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC INNOVA 7X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293078030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC INNOVA 8X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293080230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC INNOVA 8X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293081030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC INNOVA 8X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293081230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC INNOVA 8X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293081530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC INNOVA 8X180X130 SE ILC -,SUP-H74939293081830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC INNOVA 8X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293082030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC INNOVA 8X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293084030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC INNOVA 8X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293086030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC INNOVA 8X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293088030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT ENPROS 22MM 10FR CATH 45MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965404510,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT ENPROS 22MM 10FR CATH 70MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965404520,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT ENPROS 24MM 11FR CATH 35MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965405100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT ENPROS 24MM 11FR CATH 45MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965405110,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
WALLSTENT 24X70 X 75CM/11F UNI PLUS 1 -,SUP-H965405120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 2.25X8MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22508UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 2.25X8MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 2.25X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22512UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 2.25X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 2.25X14MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22514UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 2.25X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22518UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 2.25X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 2.25X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22522UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 2.25X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 2.25X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22526UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 2.25X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 2.5X8MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25008UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 2.5X8MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25008W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 2.5X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 2.5X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 2.5X14MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25014UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS #1 27IN INTGRTY MO-4 DTCH 140CM MONO GUT TAPR PNT -,SUP-INT25014W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 2.5X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 2.5X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 2.5X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 2.5X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 2.5X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 2.5X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 2.75X8MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27508UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 2.75X8MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 2.75X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27512UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 2.75X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 2.75X14MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27514UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 2.75X14MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27514W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 2.75X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27518UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 2.75X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 2.75X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27522UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 2.75X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 2.75X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27526UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 2.75X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 3X9MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30009UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 3X9MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 3X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 3X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 3X15MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30015UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 3X15MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 3X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 3X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 3X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 3X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 3X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 3X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 3X30MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30030UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 3X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 3.5X9MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35009UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 3.5X9MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 3.5X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 3.5X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 3.5X15MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35015UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 3.5X15MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 3.5X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 3.5X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 3.5X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 3.5X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 3.5X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 3.5X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 3.5X30MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35030UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 3.5X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 4X9MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40009UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 4X9MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 4X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 4X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 4X15MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40015UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 4X15MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 4X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 4X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 4X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 4X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 4X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 4X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 4X30MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40030UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 4X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT LIFESTREAM 7MM X 26MM X 80MM -,SUP-LSMU0800726,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT ENPROS 8MM 6FR CATH 80MM WALLSTNT RP 100CM TOT 75CM -,SUP-M001711300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7320.9,5124.63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT ESPH 18MM BD 23MMX7CM ULFLX NON- CVR FLR END MTL LF -,SUP-M00514070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT DUOD 22MMX6CM WALLFLX 230CM DLV SYS TTS/ OTW NTNL FLR -,SUP-M00565010,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT WALLFLEX DUODENAL 22 X 60 -,SUP-M00565010,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT DUOD 22MMX9CM WALLFLX 230CM NON- CVR NTNL LF -,SUP-M00565020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT WALLFLEX DUODENAL 22 X 90 -,SUP-M00565020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT WALLFLEX DUODENAL 22 X 120 -,SUP-M00565030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT WALLFLEX COLONIC 25 X 60 -,SUP-M00565040,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT WALLFLEX COLONIC 25 X 90 -,SUP-M00565050,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT WALLFLEX COLONIC 25 X 120 -,SUP-M00565060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT WALLFLEX COLONIC 22 X 60 -,SUP-M00565100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT WALLFLEX COLONIC 22 X 90 -,SUP-M00565110,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT WALLFLEX COLONIC 22 X 120 -,SUP-M00565120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT ENPROS 10FR 20X60MM WALLSTNT 135CM HRP -,SUP-M00565620,CDM,C1876,HCPCS,278,RC,,,outpatient,,,116.7,81.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT COLN 22MM BD 10FR CATH 6CM WALLSTNT 135CM CATH 160CM -,SUP-M00565640,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7434.26,5203.982,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 10X80MM WALLSTNT RX SE UNCVR MTL 0.035IN GW COMP -,SUP-M00569660,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6340.15,4438.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 8X80MM WALLFLX RX SE UNCVR PLATINOL 0.035IN GW -,SUP-M00570620,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 8X100MM WALLFLX RX SE NON- CVR PLATINOL 0.035IN GW -,SUP-M00570630,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 10X60MM WALLFLX RX SE NON- CVR PLATINOL 0.035IN GW -,SUP-M00570640,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
CATH GUID 6FRX68CM ACUITY BREAK-AWAY COR CS-IC 130 -,SUP-M00570650,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
WALLFLEX BILIARY RX UNCOVERED 10 X 80 -,SUP-M00570650,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
WALLFLEX RX UNCOVERED BILIARY STENT 10MM X 100MM -,SUP-M00570660,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
WALLFLEX BILIARY RX UNCOVERED 10 X 40 -,SUP-M00570890,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 14X60MM 120CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-N1460BB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT PULSAR - 18 T3 5/40/135 -,SUP-NO MANUFACTURE IN DICTIONARY,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 10X30MM PALMZ XL BE UNMT TRNSHEP CLSD CELLFLEX SEG -,SUP-P3110,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 5X15MM 135CM PALMZ BLU RX BE TRNSHEP COCR 0.014IN -,SUP-PB1550BAX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4882.72,3417.904,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 5X15MM 135CM PALMZ BLU OTW BE TRNSHEP COCR 0.018IN -,SUP-PB1550BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 6X18MM 80CM PALMZ BLU OTW BE TRNSHEP COCR 0.014IN -,SUP-PB1860BSS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 6X18MM 135CM PALMZ BLU OTW BE TRNSHEP COCR 0.018IN -,SUP-PB1860BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 6X24MM 135CM PALMZ BLU OTW BE TRNSHEP COCR 0.018IN -,SUP-PB2460BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 6X18MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG1860BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 6X18MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG1860BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 9X19MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG1990BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 6X24MM 135CM PALMZ GENESIS RX BE TRNSHEP SS -,SUP-PG2460BAX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4948.93,3464.251,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 6X24MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2460BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 8X24MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG2480BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 10X29MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2910BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 5X29MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG2950BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 5X30MM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW COMP -,SUP-PG2950BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 6X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2960BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 7X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2970BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 7X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN. -,SUP-PG2970BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 8X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN. -,SUP-PG2980BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 8X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN- -,SUP-PG2980BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 10X39MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3910BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 6X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3960BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 7X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3970BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 8X29MM 135CM PALMZ_GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3980BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 8X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3980BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 7X59MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG5970BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 7X59MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG5970BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 8X59MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG5980BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 6X79MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG7960BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 6X20MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506020120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 6X40MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 6X60MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 6X80MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506080120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 6X100MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506100120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 6X120MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506120120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 6X150MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506150120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 6X200MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506200120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,12141.51,8499.057,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 7X20MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507020120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 7X40MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 7X60MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 7X80MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507080120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 7X120MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507120120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 7X150MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507150120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 8X40MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3508040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 8X60MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3508060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 8X80MM 120CM EVERFLX SE SUPRFC FEM/PROX POPLT ART -,SUP-PRB3508080120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC EVERFLX 10X120MM 120CM SE 3-WV PEAK DSGN PRECISN -,SUP-PRB3508100120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 12X120MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT -,SUP-PRB3508120120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 8X150MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3508150120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 7X37MM 135CM VISI-PRO BE MNT SS 0.035IN/6FR -,SUP-PXB350737135,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 8X27MM 135CM VISI-PRO BE MNT SS 0.035IN/6FR -,SUP-PXB350827135,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 8X37MM 135CM VISI-PRO BE MNT SS 0.035IN/6FR -,SUP-PXB350837135,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT DES 2.25X8MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT DES 2.25X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT DES 2.25X14MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22514W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT DES 2.25X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT DES 2.25X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT DES 2.25X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BMS 2.25X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22530W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT DES 2.5X8MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25008W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT DES 2.5X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT DES 2.5X14MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25014W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT DES 2.5X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT DES 2.5X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT DES 2.5X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT DES 2.5X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT DES 2.75X8MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT DES 2.75X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT DES 2.75X14MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27514W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT DES 2.75X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT DES 2.75X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT DES 2.75X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT DES 2.75X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27530W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT DES 3X9MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT30009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT DES 3X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT DES 3X15MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT DES 3X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT DES 3X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT DES 3.5X9MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT DES 3.5X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT DES 3.5X15MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT DES 3.5X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT DES 3.5X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT DES 3.5X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT DES 3.5X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT DES 4X9MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT40009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT DES 4X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT DES 4X15MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT DES 4X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT DES 4X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT DES 4X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT DES 4X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 4MM 6FR CATH 60MM 120CM SUPERA TRNSHEP -,SUP-S-04-060-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 5MM 6FR CATH 40MM 120CM SUPERA TRNSHEP -,SUP-S-05-040-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 5MM 6FR CATH 80MM 120CM SUPERA TRNSHEP -,SUP-S-05-080-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6599.42,4619.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 5MM 6FR CATH 100MM 120CM SUPERA TRNSHEP -,SUP-S-05-100-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6599.42,4619.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 6MM 6FR CATH 40MM 120CM SUPERA TRNSHEP -,SUP-S-06-040-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7617.98,5332.586,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 7MM 6FR CATH 60MM 120CM SUPERA TRNSHEP -,SUP-S-07-060-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 8X100MM 120CM SUPERA TRNSHEP -,SUP-S-08-100-120-G3,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6599.42,4619.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT PERIPHERAL 4.5MM X 20MM X 120CM  6F -,SUP-S-45-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT PERIPHERAL 4.5MM X 30MM X 120CM  6F -,SUP-S-45-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC SUPERA 4.5X40MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-45-040-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC SUPERA 4.5X60MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-45-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT PERIPHERAL 4.5MM X 80MM X 120CM  6F -,SUP-S-45-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT PERIPHERAL 4.5MM X 100MM X 120CM  6F -,SUP-S-45-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC SUPERA 4.5X120MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-45-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT PERIPHERAL 5MM X 20MM X 120CM  6F -,SUP-S-50-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT PERIPHERAL 5MM X 30MM X 120CM  6F -,SUP-S-50-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC SUPERA 5 X 60MM 120 -,SUP-S-50-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT  VASC SUPERA 5 X 80MM x 120 -,SUP-S-50-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
5MM X 100MM X 120CM SUPERA STENT -,SUP-S-50-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
5MM x 120MM x 120CM SUPERA STENT -,SUP-S-50-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC SUPERA 5.5X40MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-040-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC SUPERA 5.5X60MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC SUPERA 5.5X80MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
SUPERA PERIPHERAL STENT SYSTEM 5.5MM X 100MM X 120CM -,SUP-S-55-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5495.98,3847.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC SUPERA 5.5X120MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC SUPERA 5.5X150MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-150-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT PERIPHERAL 6MM X 30MM X 120CM  6F -,SUP-S-60-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT SUPERA 6.0MM X 80 X 120CM -,SUP-S-60-080-120-P,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5920.38,4144.266,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT SUPERA 6MM X 80 X 120CM -,SUP-S-60-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S SUPERA 6.0MM X 100 X 120CM -,SUP-S-60-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S SUPERA 6.0MM X 120 X 120CM -,SUP-S-60-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S SUPERA 6.0MM X 150 X 120CM -,SUP-S-60-150-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT PERIPHERAL  6.5MM X 20MM X 120CM 6F -,SUP-S-65-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT PERIPHERAL 6.5MM X 30MM X 120CM  6F -,SUP-S-65-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC SUPERA 6.5X40MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-040-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC SUPERA 6.5X60MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC SUPERA 6.5X80MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC SUPERA 6.5X100MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC SUPERA 6.5X120MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC SUPERA 6.5X150MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-150-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT PERIPHERAL 7.0MM X 020MM X 120CM  6F -,SUP-S-70-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT PERIPHERAL 7.0MM X 030MM X 120CM  6F -,SUP-S-70-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 10X40MM 120CM PROTEGE GPS OTW SE PRMNT OPN LATTICE -,SUP-SERB651040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 10X60MM 120CM PROTEGE GPS OTW SE PRMNT OPN LATTICE -,SUP-SERB651060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 12X20MM 120CM PROTEGE GPS OTW SE PRMNT OPN LATTICE -,SUP-SERB651220120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
7MM X 30MM TCAR STENT ENROUTE -,SUP-SR-0730-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
7MM X 40MM STENT TCAR ENROUTE -,SUP-SR-0740-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
8MM X 30MM STENT TCAR ENROUTE -,SUP-SR-0830-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
8MM X 40MM STENT TCAR ENROUTE -,SUP-SR-0840-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
9MM X 30MM STENT TCAR ENROUTE -,SUP-SR-0930-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
9MM X 40MM STENT TCAR ENROUTE -,SUP-SR-0940-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
ENROUTE TANSCAROTID STENT SYSTEM SR-1030-CS -,SUP-SR-1030-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
ENROUTE TANSCAROTID STENT -,SUP-SR-1040-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC MISAGO 6MM X120MM X 200CM RX R -,SUP-SXR06120R,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC MISAGO 6X150MM 135CM SELF EXPANDING -,SUP-SXR06150R,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
GRAFT EV 14X40 ILC -,SUP-UNDEFINED,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S BILI EXPRESS 5X15X150 -,SUP-UNDEFINED,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 5X18 GENESIS AVIATOR -,SUP-UNDEFINED,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
VENOUS 8F 10mm x 80 mm 120cm CATHETER LENGTH -,SUP-VENUM10080,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
VENOVO VENOUS STENT 12MM X 60MM -,SUP-VENUM12060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
16MM x 60MM x 80CM VENOVO STENT -,SUP-VENUM16060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
VENOUS STENT 14MM x 100MM 120CM CATHETER LENGTH -,SUP-VENUM16080,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
VENOVO VENOUS STENT 18MM X 100MM X 80CM -,SUP-VENUM18100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
VENOUS STENT SYSTEM 18X 120MM 80CM CATH LENGTH -,SUP-VENUM18120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
VENOVO 10FR 20MM X 60MM- 80CM CATHETER LENGTH -,SUP-VENUM20060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 4MMX6CM 125CM ZILVER 518 OTW SE PRELD SLT TUBE -,SUP-ZIB5-125-4.0-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 4MMX8CM 125CM ZILVER 518 OTW SE PRELD SLT TUBE -,SUP-ZIB5-125-4.0-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S ZILVER 518 5X60 125CM S-E -,SUP-ZIB5-125-5.0-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 12MM 8FR GUID CATH 60MM 125CM ZILVER 635 OTW SE -,SUP-ZIB6-125-12.060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S ZILVER .035 120CM 5 X 40 -,SUP-ZIB6-125-5.0-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S ZILVER .035 125CM 5 X 80 -,SUP-ZIB6-125-5.0-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 6X100MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-ZIB6-35-1256100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT BIL 6X140MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-ZIB6-35-1256140,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT ZILVER 6MM X 60MM X 125MM -,SUP-ZIV5-18-125-6-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC ZILVER 518 8X40MM 125CM OTW SE 0.018IN/5FR -,SUP-ZIV5-18-125-840,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC ZILVER 518 8X80MM 125CM OTW SE 0.018IN/5FR -,SUP-ZIV5-18-125-880,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
S ZILVER 6 X 30 -,SUP-ZIV6-35-125-630,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT ZILVER 6 X 40 -,SUP-ZIV6-35-125-640,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT VASC DES ZILVER PTX 6X40MM 125CM OTW SE PRELD -,SUP-ZIV635125640PTX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5487.45,3841.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,32197.7856,other,Non-Reimbursable List,,
STENT 3.5X18MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010144-18,CDM,C1877,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,198.065125,7007.6928,other,Non-Reimbursable List,,
CATH GUID 7FR AL 0.75 SH 100CM -,SUP-G782AL75,CDM,C1877,HCPCS,278,RC,,,outpatient,,,882.25,617.575,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,198.065125,7007.6928,other,Non-Reimbursable List,,
STENT ESPH 18MM 23/23MM OD P/D FLR 153MM WALLFLX SE BRD FLLY -,SUP-M00516920,CDM,C1877,HCPCS,278,RC,,,outpatient,,,9124.6,6387.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,198.065125,7007.6928,other,Non-Reimbursable List,,
PALMAZ UNMOUNTED STENT DIA 1 -,SUP-P4010,CDM,C1877,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,198.065125,7007.6928,other,Non-Reimbursable List,,
STENT BIL 10X59MM PALMZ GENESIS BE UNMT TRNSHEP SS 0.035IN -,SUP-PG5910B,CDM,C1877,HCPCS,278,RC,,,outpatient,,,3986.29,2790.403,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,198.065125,7007.6928,other,Non-Reimbursable List,,
IMPLANT VOCAL CRD PST PROLARYN PLUS 1ML SYR -,SUP-8044M0K5,CDM,C1878,HCPCS,278,RC,,,outpatient,,,3246.32,2272.424,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,2621.49888,other,Non-Reimbursable List,,
IMPLANT VOCAL CORD PROLARYN GEL 1CC NEEDLE -,SUP-8602M0K5,CDM,C1878,HCPCS,278,RC,,,outpatient,,,3413.41,2389.387,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,2621.49888,other,Non-Reimbursable List,,
IMPLANT THYRPL MONT SZ9 SIL EAR FEM STRL -,SUP-MTF.09,CDM,C1878,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,2621.49888,other,Non-Reimbursable List,,
KIT THYROPLASTY MALE -,SUP-MT-SPM,CDM,C1878,HCPCS,278,RC,,,outpatient,,,3308.38,2315.866,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,2621.49888,other,Non-Reimbursable List,,
FILTER VASC BIRDS NEST 40MMX40CM SS VC MRKR -,SUP-178242,CDM,C1880,HCPCS,278,RC,,,outpatient,,,9467.05,6626.935,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.22547,6153.5825,other,Non-Reimbursable List,,
FILTER EMBL PROT OPTEASE 6FR ID 8FR INTRO SHTH 55CM SLF CNTR -,SUP-466-F220A,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3189.03,2232.321,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.22547,6153.5825,other,Non-Reimbursable List,,
FILTER OPTEASE FEMORAL 55CM -,SUP-466-F230AF,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3189.03,2232.321,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.22547,6153.5825,other,Non-Reimbursable List,,
FILTER VASC BIRD S NEST 40MM 11FR CATH 12FR INTRO 75CM SS VC -,SUP-BNF-75-PB,CDM,C1880,HCPCS,278,RC,,,outpatient,,,9467.05,6626.935,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.22547,6153.5825,other,Non-Reimbursable List,,
FILTER EMBL NAVALIGN CELECT 30X48MM FEM VC -,SUP-G03767,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.22547,6153.5825,other,Non-Reimbursable List,,
FILTER CELECT VENA CAVA UNI -,SUP-G34505,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4773.95,3341.765,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.22547,6153.5825,other,Non-Reimbursable List,,
VENA CAVA FILTER FEMORAL & JUG -,SUP-G34505,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4773.95,3341.765,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.22547,6153.5825,other,Non-Reimbursable List,,
FILTER EMBL CELECT 30MM 7FR INTRO SHTH 48MM UNISET VC -,SUP-G52915,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.22547,6153.5825,other,Non-Reimbursable List,,
FILTER EMBL GUNTHER TULIP 30X50MM FEM VC -,SUP-G52917,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3819.15,2673.405,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.22547,6153.5825,other,Non-Reimbursable List,,
FILTER VASC NAVALIGN CELECT 30MM 7FR CATH UNIV 49MM UNISET -,SUP-IGTCFS651UNICEL,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4773.95,3341.765,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.22547,6153.5825,other,Non-Reimbursable List,,
FILTER VASC GUNTHER TULIP 30MM 8.5FR INTRO SHTH 50MM PRELD -,SUP-IGTCFS-65-FEM,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.22547,6153.5825,other,Non-Reimbursable List,,
FILTER VENA CAVA TULIP UNI GUNTHER -,SUP-IGTCFS-65-UNI,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3819.15,2673.405,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.22547,6153.5825,other,Non-Reimbursable List,,
FILTER VASC GUNTHER TULIP 30MM 8.5FR INTRO SHTH 50MM- -,SUP-IGTCFS-65-UNI,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.22547,6153.5825,other,Non-Reimbursable List,,
FILTER GREENFIELD JUG -,SUP-M001503000,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4249.67,2974.769,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.22547,6153.5825,other,Non-Reimbursable List,,
FILTER GREENFIELD FEM -,SUP-M001503010,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4249.67,2974.769,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.22547,6153.5825,other,Non-Reimbursable List,,
DILATOR VASC 18GA GW 0.038IN DILATOR 8/10/12 FR DIA SYR -,SUP-M001503500,CDM,C1880,HCPCS,278,RC,,,outpatient,,,776.06,543.242,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.22547,6153.5825,other,Non-Reimbursable List,,
FILTER VASC MERIDIAN NTNL VC -,SUP-MD800F,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.22547,6153.5825,other,Non-Reimbursable List,,
FILTER VASC MERIDIAN NTNL SBCLVN VC -,SUP-MD800J,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.22547,6153.5825,other,Non-Reimbursable List,,
FILTER OPTEASE JUGULAR 55CM -,SUP-UNDEFINED,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3189.03,2232.321,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.22547,6153.5825,other,Non-Reimbursable List,,
FILTER OPTEASE JUGULAR 90CM -,SUP-UNDEFINED,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,174.22547,6153.5825,other,Non-Reimbursable List,,
DEFIBRILLATOR PRMT RF DF-1 2CHMBR 50X81MM 14MM 43ML 82GM -,SUP-3207-36,CDM,C1882,HCPCS,275,RC,,,outpatient,,,59022.98,41316.086,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
DEFIBRILLATOR LUMAX 540 HF-T DF-1 IS-1 CONN 3 CHMBR RR. -,SUP-360347,CDM,C1882,HCPCS,275,RC,,,outpatient,,,38238.5,26766.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
DEFIBRILLATOR LUMAX 740 HF-T BIVEN PCNG CARD IMPL W/HOME -,SUP-365608,CDM,C1882,HCPCS,275,RC,,,outpatient,,,40705.5,28493.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
DEFIBRILLATOR ILESTO HF-T DF-1 BIVEN PCNG RDC HI ENRG CARD -,SUP-383547,CDM,C1882,HCPCS,275,RC,,,outpatient,,,40705.5,28493.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
DEFIBRILLATOR ILESTO HF-T DF-4 BIVEN PCNG HI ENRG CARD IMPL -,SUP-383549,CDM,C1882,HCPCS,275,RC,,,outpatient,,,32036.46,22425.522,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
DEFIBRILLATOR LUMAX 740 HF-T CARD IMPL W/HOME MNTR MBL -,SUP-393803,CDM,C1882,HCPCS,275,RC,,,outpatient,,,39472,27630.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
DEFIB HI ENRG BIVEN CARD IMPL TI -,SUP-401662,CDM,C1882,HCPCS,275,RC,,,outpatient,,,34503.46,24152.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
DEFIBRILLATOR PRMT + DF-4 RR V- PCNG RDC 50X75MM 14MM 42ML -,SUP-CD3211-36Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
DEFIBRILLATOR UNIFY IS-1 CONN 40X79MM 14MM 36ML 78GM CARD -,SUP-CD3231-40,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
DEFIBRILLATOR UNIFY QUADRA DF-4 IS-4 IS-1 CONN 41X75MM 14MM -,SUP-CD3249-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43251.44,30276.008,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
DEFIBRILLATOR UNIFY ASSURA DF-1 IS-1 DF-4 BIVEN PCNG 40X79MM -,SUP-CD3257-40,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
DEFIBRILLATOR UNIFY ASSURA DF-4 TELEM 2CHMBR 40X73MM 14MM -,SUP-CD3257-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
DEFIBRILLATOR QUADRA ASSURA DF-1 BIVEN PCNG 41X83MM 14MM -,SUP-CD3265-40,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43251.44,30276.008,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
DEFIBRILLATOR QUADRA ASSURA DF-4 IS-4 IS-1 CONN BIVEN PCNG -,SUP-CD3265-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43251.44,30276.008,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
DEFIBRILLATOR UNIFY ASSURA CARD IMPL PARYLENE CTD -,SUP-CD3357-40C,CDM,C1882,HCPCS,275,RC,,,outpatient,,,29974.05,20981.835,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
UNIFY ASSURA NXGEN CRT-D 40 MEDIGUIDE -,SUP-CD3357-40C,CDM,C1882,HCPCS,275,RC,,,outpatient,,,47726.58,33408.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
DEFIBRILLATOR UNIFY ASSURA DF-4 CARD IMPL PARYLENE CTD CD -,SUP-CD3357-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,29974.05,20981.835,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
CRT-D 40 QUADRA ASSURA -,SUP-CD3365-40C CELL,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35225.31,24657.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
DEFIBRILLATOR QUADRA ASSURA DF-4 SGL/2CHMBR 41X75MM 14MM -,SUP-CD3365-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35225.31,24657.717,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
CRT-D QUADRA ASSURA MP CD3369-40C -,SUP-CD3369-40C,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
CRT-D QUADRA ASSURA MP DFR CON -,SUP-CD3369-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
ENTRANT CRT-D CDHFA300Q -,SUP-CDHFA300Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35771.5,25040.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
ENTRANT HF CRT-D DF1 CONNECTOR REF: CDHFA300T -,SUP-CDHFA300T,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35771.5,25040.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
GALLANT CRT-D CDHFA500Q -,SUP-CDHFA500Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,38238.5,26766.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
GALLANT HF CRT-D DF1 CONNECTOR REF: CDHFA500T -,SUP-CDHFA500T,CDM,C1882,HCPCS,275,RC,,,outpatient,,,38238.5,26766.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
DEFIBRILLATOR INOGEN MUL PRGM OPTN EXTEND LNGVT VR -,SUP-D141,CDM,C1882,HCPCS,275,RC,,,outpatient,,,28370.5,19859.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
DEFIBRILLATOR CONSULTA DF-1 IS-1 CONN WRLS TELEM 2CHMBR RR -,SUP-D224TRK,CDM,C1882,HCPCS,275,RC,,,outpatient,,,48626.05,34038.235,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
DEFIBRILLATOR PROTECTA DF-4 CARD IMPL -,SUP-D334TRM,CDM,C1882,HCPCS,275,RC,,,outpatient,,,39911.13,27937.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
EVERA MRI MRT XT DR DDMB1D4 -,SUP-DDMB1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,37251.7,26076.19,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
VIVA CARD IMPL -,SUP-DTBA1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50599.65,35419.755,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
DEFIBRILLATOR VIVA XT IS-1 DF-1 ADPTVCRT PHYCRV SMRTSHCK -,SUP-DTBA1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50599.65,35419.755,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
DEFIBRILLATOR VIVA S DF-4 IS-1 CONN SGL-CHMBR CARD IMPL -,SUP-DTBB1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,42839.46,29987.622,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
DEFIBRILLATOR VIVA S DF-4 IS-1 CONN SGL-CHMBR CARD IMPL. -,SUP-DTBB1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,42839.46,29987.622,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
DEFIB  VIVA QUAD S CRT-D DF-1 IS-4 CONN CARD IMPL -,SUP-DTBB1Q1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43172.5,30220.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
DEFIBRILLATOR VIVA QUAD S DF-4 IS-4 CONN CARD IMPL -,SUP-DTBB1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,42839.46,29987.622,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
CLARIA MRI CRT-D DTMA1D1 -,SUP-DTMA1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49006.96,34304.872,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
CLARIA MRI CRT-D MODEL DTMA1D1 -,SUP-DTMA1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49006.96,34304.872,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
CLARIA MRI CRT-D DTMA1D4 -,SUP-DTMA1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49006.96,34304.872,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
CLARIA MRI QUAD CRT-D DTMA1QQ -,SUP-DTMA1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50326.8,35228.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
CLARIA MRI QUAD CRT-D Model DTMA1QQ -,SUP-DTMA1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50326.8,35228.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
AMPLIA MRI CRT-D DTMB1D1 -,SUP-DTMB1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,47773.46,33441.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
CRTD DTMB1D1 AMPLIA MRI US DF1 -,SUP-DTMB1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,47773.46,33441.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
AMPLIA CRT-D MRI DEVICE -,SUP-DTMB1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,54249.33,37974.531,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
AMPLIA MRI QUAD CRT-D -,SUP-DTMB1Q1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
AMPLIA MRI QUAD CRT-D SURESCAN DTMB1Q1 -,SUP-DTMB1Q1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
AMPLIA CRT-D DTMB 1 QQ -,SUP-DTMB1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
ICD COBALT HF CRT-D MRI SURESCAN REF: DTPB2D1 -,SUP-DTPB2D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,48237.25,33766.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
COBALT HF QUAD CRTD REF: DTPB2QQ -,SUP-DTPB2QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,52793.8,36955.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
CROME MRI CRTD REF: DTPC2D4 -,SUP-DTPC2D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50240.46,35168.322,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
CRT-D MOMENTUM IS1 DF4 G124 -,SUP-G124,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
CRT-D MOMENTUM IS1 DF1 G125 -,SUP-G125,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
CRT-D MOMENTUM LV-1 G126 -,SUP-G126,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
CRT-D MOMENTUM X4 IS4-DF1 G138 -,SUP-G138,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
PACEMAKER INOGEN CARD -,SUP-G140,CDM,C1882,HCPCS,275,RC,,,outpatient,,,39225.3,27457.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
DEFIBRILLATOR INOGEN CARD -,SUP-G141,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
DEFIBRILLATOR INOGEN DF-1 SGL-CHMBR 5.37CMX8.08CMX0.99CM D -,SUP-G146,CDM,C1882,HCPCS,275,RC,,,outpatient,,,41692.3,29184.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
DEFIBRILLATOR INOGEN DF-4 5.37CMX8.08CMX0.99CM D 32ML CARD -,SUP-G148,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
DYNAGEN CRT-D MODEL G150 -,SUP-G150,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
DYNAGEN CRT-D G-154 DEFIBRILLATOR -,SUP-G154,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
CRT-D DYNAGEN X4 G156 -,SUP-G156,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33218.16,23252.712,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
CRT-D VIGILANT X4 IS4 DF4 MRI CONDITIONAL -,SUP-G247,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
COMPIA CRT-D MRI QUAD -,SUP-UNDEFINED,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,45329.64864,other,Non-Reimbursable List,,
ANCHOR LD C IN 94IN LF ACC -,SUP-1194,CDM,C1883,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3519.77472,other,Non-Reimbursable List,,
KIT EXTENSION INTERSTIM 10CM S  - DISCONTINUED DO NOT USE -,SUP-3095-10,CDM,C1883,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3519.77472,other,Non-Reimbursable List,,
KIT REVISION INTERSTIM -,SUP-3550-05,CDM,C1883,HCPCS,278,RC,,,outpatient,,,1079.48,755.636,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3519.77472,other,Non-Reimbursable List,,
KT EXTENSION NEURSTM INTSTM 60CM PERC MRI-COND INSL MULI- -,SUP-3708160,CDM,C1883,HCPCS,278,RC,,,outpatient,,,3007.62,2105.334,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3519.77472,other,Non-Reimbursable List,,
LEAD ADPTR -,SUP-5866,CDM,C1883,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3519.77472,other,Non-Reimbursable List,,
CABLE PCNG -,SUP-5867AS,CDM,C1883,HCPCS,278,RC,,,outpatient,,,116.7,81.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3519.77472,other,Non-Reimbursable List,,
EXTENDER LD UNIPL -,SUP-6981M,CDM,C1883,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3519.77472,other,Non-Reimbursable List,,
EXTENDER LD BIPLR MRI-COND -,SUP-6984M,CDM,C1883,HCPCS,278,RC,,,outpatient,,,1079.48,755.636,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3519.77472,other,Non-Reimbursable List,,
ADAPTER NEURSTM 27.4CM SPIN CRD 2X4 PCKT -,SUP-740-02,CDM,C1883,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,26.19915,3519.77472,other,Non-Reimbursable List,,
FILTER EMBL PROT EMBOSHIELD NAV6 5MMX190CM WIRE UNCNTSTR -,SUP-22437-19,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,5331.24633,other,Non-Reimbursable List,,
FILTER EMBL PROT EMBOSHIELD NAV6 7.2MMSMX190CM WIRE UNCNTSTR -,SUP-22438-19,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,5331.24633,other,Non-Reimbursable List,,
FILTER EMBL PROT FLTWR EZ 3.2FRX190CM WIRE NTNL LOOP CRTD -,SUP-H749201001900,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6875.28,4812.696,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,5331.24633,other,Non-Reimbursable List,,
FILTER EMBL PROT FLTWR EZ 3.2FRX300CM WIRE NTNL LOOP CRTD -,SUP-H749201003000,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7078.99,4955.293,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,5331.24633,other,Non-Reimbursable List,,
EMBOLIC PROT FLTWR EZ 0.042IN 0.014 DIA GW 110U FLTR 190CM -,SUP-H749390711900,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7435.49,5204.843,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,5331.24633,other,Non-Reimbursable List,,
FILTERWIRE EMBL EZ 2.25MM 3.5MMX300CM FEM VC -,SUP-H74939071300,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6457.03,4519.921,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,5331.24633,other,Non-Reimbursable List,,
DEVICE EMBL PROT SPIDERFX 3MM FLTR BSKT 0.014IN GW 0.066IN -,SUP-SPD2US030320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,5331.24633,other,Non-Reimbursable List,,
DEVICE EMBL PROT SPIDERFX 4MM FLTR BSKT 0.014IN GW 0.066IN -,SUP-SPD2US040320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,5331.24633,other,Non-Reimbursable List,,
SPIDER FX 5MM 320 .014 EMBOLIC -,SUP-SPD2US050320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,5331.24633,other,Non-Reimbursable List,,
SPIDER FX 6MM 320 .014 EMBOLIC -,SUP-SPD2US060320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,5331.24633,other,Non-Reimbursable List,,
DEVICE EMBL PROT SPIDERFX 7MM FLTR BSKT 0.014IN GW 0.066IN -,SUP-SPD2US070320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,5331.24633,other,Non-Reimbursable List,,
CATHETER LASER CORONARY ATHETECTOMY 0.9X80 ELACX-80 -,SUP-110-004,CDM,C1885,HCPCS,272,RC,,,outpatient,,,10588.78,7412.146,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7592.15526,other,Non-Reimbursable List,,
CATHETER 1.4MM ELCA CORONARY LASER ATHE -,SUP-114-009,CDM,C1885,HCPCS,272,RC,,,outpatient,,,10588.78,7412.146,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7592.15526,other,Non-Reimbursable List,,
C 1.7M .018IN OTW TURBO ELITE -,SUP-417-152,CDM,C1885,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7592.15526,other,Non-Reimbursable List,,
CATH ABLT 4MM 90DG 160CM BARRX ULTRA LNG LF -,SUP-90-9200,CDM,C1886,HCPCS,272,RC,,,outpatient,,,9419.88,6593.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7607.37,other,Non-Reimbursable List,,
CATHETER BRONCHIAL THERMOPLAST -,SUP-M005ATS25010,CDM,C1886,HCPCS,272,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7607.37,other,Non-Reimbursable List,,
CATH SHEATH RITESITE C315H40,SUP-,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
GUIDE 8F MARK 1 AL 2 -,SUP-34358-20,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
GUIDE 8F MARK 1 IM -,SUP-34358-26,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
LEAD PCNG 6.6FR 7FR INTRO 53CM TILDA HELIX ELECTRICALLY -,SUP-382889,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
LEAD PCNG 6.6FR 7FR INTRO 60CM TILDA HELIX ELECTRICALLY -,SUP-382895,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATHETER GUIDE 6FR X 85CM INTERNAL MAMMARY -,SUP-38969-122/H749389691220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 5FR IL-3.5 HEARTRAIL III NO SH COR SS FLTWR PTFE -,SUP-40-5370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 5FR IKARI RT 2 HEARTRAIL III NO SH COR SS FLTWR -,SUP-40-5382,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 6FR ID 0.081IN IL-3.5 100CM HEARTRAIL III LRG LUM -,SUP-40-6370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 6FR ID 0.081IN IL-4.5 100CM HEARTRAIL III LRG LUM -,SUP-40-6375,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
MICRO GUIDE CATH NHANCER RX REF: 451669 -,SUP-451669,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATHETER GUIDE -,SUP-490107,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH DX 0.039/0.026IN DIA P/D 45DG ANG TAPR 135CM QCK-CX -,SUP-518-032,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH DX 0.044/0.030IN DIA P/D 15MM SPC 45DG ANG TAPR 90CM -,SUP-518-033,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
C QUICKCROSS .018 150CM -,SUP-518-035,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH DX 0.063/0.050IN DIA P/D 15MM SPC 45DG ANG TAPR 90CM -,SUP-518-036,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
C QUICKCROSS .035 135CM -,SUP-518-037,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
C QUICKCROSS .035 150CM -,SUP-518-038,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
C 0.014-150CM QUICK CROSS -,SUP-518-065,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH DX 0.052/0.059IN DIA P/D 15MM SPC 45DG ANG TAPR 135CM -,SUP-518-081,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
C QUICK CROSS SEL .035 150CM -,SUP-518-083,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
C QUICK CROSS SEL .014 150 -,SUP-518-087,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
C QUICK CROSS SEL .018 150 -,SUP-518-093,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH DX 3FR ID 1.9FRX140CM TWN PASS RX LPRO LUMX2 COR PERIPH -,SUP-5200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2003.59,1402.513,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATHETER SUPERCROSS 45 ANGLED 0.014 X 130CM -,SUP-5302,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
SUPERCROSS 90 ANGLED TIP CATH -,SUP-5305,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2279.22,1595.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
MICRO GUIDE CATH SUPERCROSS 120 ANGLED TIP REF: 5306 -,SUP-5306,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2472.93,1731.051,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH ANG INFINITI 5FR JR4 REF: 534521T -,SUP-534521T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH ANG 5FR 145 PIGTL 110CM INFINITI REF: 534-552S -,SUP-534552S,CDM,C1887,HCPCS,272,RC,,,outpatient,,,43.47,30.429,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH ANG 5FR IMA CRV 100CM INFIN SLCT 3 STG BRD NBRD PROX -,SUP-534-560T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH ANG INFINITI 6FR JL4 REF: 534620T -,SUP-534620T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH ANG INFINITI 6FR JR4 REF: 534-621T -,SUP-534-621T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH ANG INFINITI 6FR AR MOD REF: 534648T -,SUP-534648T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH ANG INFINITI 6FR RCB REF: 534670T -,SUP-534670T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH ANG INFINITI 6FR LCB REF: 534672T -,SUP-534672T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
SHEATH GUID 5FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-54-54501,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH DX 6FR 145DG PIGTL 110CM LANGSTON BRD LUMX2 LO XING -,SUP-5540,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1088.81,762.167,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.056IN 5FRX100CM 2.5MM VISTA BRITE TIP SS PTFE -,SUP-556-002-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.056IN 5FR JL3.5 100CM VISTA BRITE TIP BRD -,SUP-556-002-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.056IN 5FR LT COR EBU 3.5 100CM 2.5MM VISTA BRITE -,SUP-556-054-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.056IN 5FR  XBLAD 3.5 LBT 100CM 2.5MM VISTA -,SUP-556-060-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.056IN 5FR BARB 100CM VISTA BRITE TIP BRD MUL-SEG -,SUP-556-174-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATHETER 6FRX150CM TRAPLINER REF:5566 -,SUP-5566,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3652.11,2556.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATHETER 7FRX150CM TRAPLINER REF:5567 -,SUP-5567,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3652.11,2556.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH DX 6FRX150CM GUIDELINER V2 RX COAX PERIPH -,SUP-5571,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2183.81,1528.667,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH DX 7FRX150CM GUIDELINER V2 RX COAX PERIPH -,SUP-5572,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2183.81,1528.667,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH DX 8FRX150CM GUIDELINER V2 RX COAX PERIPH -,SUP-5573,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2173.21,1521.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
TURNPIKE GOLD 135CM MICRO CATH -,SUP-5621,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3294.06,2305.842,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
TURNPIKE LP 135 ON MICRO CATHETER -,SUP-5638,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3771.46,2640.022,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
TURNPIKE LP 150CM MICRO CATH -,SUP-5639,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2931.24,2051.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATHETER TURNPIKE SPIRAL 135CM -,SUP-5640,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3771.46,2640.022,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.018IN 3.5FR SHFT 70CM 8MM VENTURE OTW CS PED -,SUP-5822,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3146.07,2202.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.088IN 8FR JL4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-588-823,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.088IN 8FR LT COR EBU3 100CM 2.5MM VISTA BRITE -,SUP-588-829,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.088IN 8FR JR4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-588-830,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.088IN 8FR JL3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-588-851,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID VISTA 8FR XB 3.5 -,SUP-588-882,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.088IN 8FR LT COR EBU 4 100CM 2.5MM VISTA BRIT -,SUP-588-894,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH DX 0.054IN 6FRX100CM 2CM PERFORM ULTMT 2 -,SUP-610038ULT2,CDM,C1887,HCPCS,272,RC,,,outpatient,,,140.74,98.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 130DG CRV ATTAIN SELECT COR STR 5.5FR INR CATH -,SUP-6248DEL,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATHETER ATTAIN SELECT REF: 6248V-130 -,SUP-6248V-130,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1284.84,899.388,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH 6248V-90 ATTAIN SELECT II -,SUP-6248V-90,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1284.84,899.388,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATHETER  CRDM Adaptor 6250V-EH -,SUP-6250V-EH,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATHETER ATTAIN COMMAND REF: 6250V-MPR -,SUP-6250V-MPR,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.96MM/MIN 2.4MM/MAX MPX COR 50CM ATTAIN COMMAND -,SUP-6250VMPX,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.07IN 6FR JL3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-002-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.07IN 6FR JL4 100CM VISTA BRITE TIP BRD -,SUP-670-004-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.07IN 6FR JL4 SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-005-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.07IN 6FR JL4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-014-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.07IN 6FR AL1 100CM .75MM SH VISTA BRITE TIP -,SUP-67003500,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.07IN 6FR ALC1 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-036-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.07IN 6FR ALC2 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-040-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.07IN 6FR  XB3 100CM 1.8MM VISTA BRITE TIP -,SUP-670-052-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.07IN 6FR XB 3 SH 100CM VISTA BRITE TIP -,SUP-670-053-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUIDING 6FR XB 3.5 VISTA -,SUP-670-054-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUIDING 6FR XB 3.5 VISTA LBT -,SUP-670-054-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,253.82,177.674,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.07IN 6FR LT COR EBU3.5 SH 100CM 2.5MM VISTA -,SUP-670-055-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.07IN 6FR XB4 100CM 2.5MM VISTA BRITE TIP -,SUP-670-056-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.07IN 6FR XB4.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-67005800,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.07IN 6FR XBLAD 3.5 100CM  VISTA BRITE -,SUP-670-060-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.07IN 6FR XBLAD 4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-062-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 6FR XBLAD 4.5 100CM VISTA BRITE TIP -,SUP-67006400,CDM,C1887,HCPCS,272,RC,,,outpatient,,,198.39,138.873,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.07IN 6FR XBLAD 3 100CM VISTA BRITE TIP -,SUP-670-066-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.07IN 6FR JR3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-080-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.07IN 6FR JR4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-67008200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.07IN 6FR JR4 55CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-082-55,CDM,C1887,HCPCS,272,RC,,,outpatient,,,355.35,248.745,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.07IN 6FR JR4 SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-083-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.07IN 6FR ARC1 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-67011000,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.07IN 6FR XBRCA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-126-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.07IN 6FR JEAN- FJL 100CM 2.5MM VISTA BRITE TIP -,SUP-670-166-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 6FR JFL LT REF: 670-166-00 -,SUP-670-166-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.07IN 6FR BARB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-174-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.07IN 6FR LCB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-180-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.07IN 6FR LCB 90CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-180-90,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.07IN 6FR RCB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-182-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.07IN 6FR RCB 90CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-182-90,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.07IN 6FR IMA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-190-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.07IN 6FR VERT 55CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-190-55,CDM,C1887,HCPCS,272,RC,,,outpatient,,,355.35,248.745,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.07IN 6FR IM SH REF: 670-191-00 -,SUP-670-191-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 6FR IM VB-1 100CM VISTA BRITE TIP -,SUP-67019200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,198.39,138.873,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.07IN 6FR RNL CRV 55CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-212-55,CDM,C1887,HCPCS,272,RC,,,outpatient,,,355.35,248.745,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.07IN 6FR HS 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-278-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.07IN 6FR HS SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-279-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.078IN 7FR JL4 100CM 2.5MM VISTA BRITE TIP BD -,SUP-778-004-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATHETER GUIDING 7FR JL 5 SH JUDKINS -,SUP-77800900,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUIDE 7FR AL2 REF: 778704000 -,SUP-77804000,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.078IN 7FR LT EBU LAD 3 100CM 2.5MM VISTA BRITE -,SUP-778-052-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.078IN 7FR XB 3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-054-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUIDING  7FR XB3.5 SH VIS -,SUP-778-055-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.078IN 7FR XB4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-056-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.078IN 7FR LT EBU LAD 4.5 100CM 2.5MM VISTA BRITE -,SUP-778-058-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUIDING 7FR XBLAD 3.5 100CM 2.5MM VISTA -,SUP-778-060-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.078IN 7FR LT COR EBU LAD 4 100CM 2.5MM VISTA -,SUP-778-062-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.078IN 7FR JR4 100CM 2.5MM VISTA BRITE BRD -,SUP-778-082-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.078IN 7FR JR4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-083-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.078IN 7FR ARC1 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-110-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.078IN 7FR ARC2 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-112-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.078IN 7FR RCB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-182-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.078IN 7FR IMA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-190-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.078IN 7FR MPA-1 COR 100CM 2.5MM VISTA BRITE TIP -,SUP-778-270-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.078IN 7FR HS 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-278-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.078IN 7FR HS SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-279-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH BLN OCCULSION 2.1FRX135CM ASAHI TORNUS SUPP CHRNC OTW -,SUP-82380-01,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH DX 2.6FRX135CM ASAHI TORNUS SUPP OTW THRD COR SS -,SUP-82381-01,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3795.33,2656.731,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATHETER CENTER POINT REF:9181 -,SUP-9181,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATHETER CENTER POINT REF:9182 -,SUP-9182,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATHETER CENTER POINT REF:9183 -,SUP-9183,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATHETER CENTER POINT REF:9184 -,SUP-9184,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH SHEATH RITESITE C315H2002 -,SUP-C315H2002,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH SHEATH RITESITE C315H4002 -,SUP-C315H4002,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH SHEATH C315HIS02 -,SUP-C315HIS02,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
HIS SHEATH DELIVERY SYSTEM C315HIS02 -,SUP-C315HIS02,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH SHEATH RITESITE C315J02 -,SUP-C315J02,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH SHEATH RITESITE C315S1002 -,SUP-C315S1002,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH SHEATH RITESITE C315S402 -,SUP-C315S402,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH SHEATH RITESITE C315S502 -,SUP-C315S502,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH ELCSURG 7FRX100CM RF FLXB CLSR FST -,SUP-CF7-7-100,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
GLIDECATH MG1 4F 125CM  LONG -,SUP-CG440,CDM,C1887,HCPCS,272,RC,,,outpatient,,,295.54,206.878,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
GLIDECATH MG2 4F 135CM  LONG -,SUP-CG441,CDM,C1887,HCPCS,272,RC,,,outpatient,,,295.54,206.878,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH ABLT CLSR FST 65CM PROC KT MIS-7F11 INTRO -,SUP-CPK6511,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1908.18,1335.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH ABLT CLSR FST 73CM PROC KT MIS-7F11 INTRO -,SUP-CPK8511,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1908.18,1335.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
ASAHI CARAVEL MICROCATHETER 150 CM -,SUP-CRV150-19P,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATHETER CORSAIR PRO XS 150CM REF: CSR150-21S -,SUP-CSR150-21S,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATHETER CORSAIR PRO 150CM CSR150-26P ASAHI -,SUP-CSR150-26P,CDM,C1887,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
"CATHETER CXI SUPPORT 4.OFR X 135CM STR TIP .035"" MAX GUIDEWR -",SUP-CXI-4.0-35-135-P-NS-O,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATHETER CPS LOCATOR 3D- SMALL REF:DS2C100-42 -,SUP-DS2C100-42,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATHETER CPS LOCATOR 3D- MEDIUM REF:DS2C200-42 -,SUP-DS2C200-42,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATHETER CPS LOCATOR 3D- LAGE REF:DS2C300-42 -,SUP-DS2C300-42,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATHETER AGILIS HISPRO DS3H010-38  BUNDLE -,SUP-DS3H010-38,CDM,C1887,HCPCS,272,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATHETER AGILIS HISPRO DS3H010-38 -,SUP-DS3H010-38,CDM,C1887,HCPCS,272,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH ANG 0.056IN 6FR AR1 100CM DXTERITY REF: DXT6AR10 -,SUP-DXT6AR10,CDM,C1887,HCPCS,272,RC,,,outpatient,,,9.92,6.944,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
RING TRANS-JUG ACCESS SET WITH 10fr -,SUP-G06541,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2542.11,1779.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
TRANSJUGLAR LIVER ACCESS SET R -,SUP-G06929,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2558.82,1791.174,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
BEACON TIP 5.0 FR ANGIOGRAPHIC CATHETER - C2 -,SUP-G08442,CDM,C1887,HCPCS,272,RC,,,outpatient,,,151.7,106.19,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATHETER RIM 5FR X 100CM -,SUP-G12870,CDM,C1887,HCPCS,272,RC,,,outpatient,,,758.49,530.943,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH DX 2.6FR STR 65CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G18367,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1051.93,736.351,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATHETER CXI SUPPORT -,SUP-G18368,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1051.93,736.351,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CXI-2.3-14-65-0 -,SUP-G18369,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH CXI 2.3FR X 65CM X 014 SU -,SUP-G18370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH CXI 2.3FR X 90CM X 014 SU -,SUP-G18371,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CXI-2.3-14-90-ANG -,SUP-G18372,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CXI-2.3-14-150-ANG -,SUP-G18376,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH DX 2.6FR ANG 150CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G50003,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH DX 2.6FR STR 90CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G50004,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH DX 3FR/1.9FR P/D STR 135CM CROSSCATH SUPP LUMX1 PERIPH -,SUP-G51573,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH DX 4.8FR/3.7FR P/D STR 90CM CROSSCATH SUPP LUMX1 PERIPH -,SUP-G51580,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH DX 4.8FR/3.7FR P/D STR 135CM CROSSCATH SUPP LUMX1 -,SUP-G51581,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH DX 3.4FR/2.2FR P/D STR 135CM CROSSCATH SUPP LUMX1 -,SUP-G51583,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH DX 4FR DAV 135CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G52543,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH DX 4FR DAV 150CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G52545,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
C NAVICROSS ANG 150CM .035 -,SUP-G52545,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATHETER CXI SUPPORT 4FR X 90CM STR TIP .035 MAX GUIDEWRE -,SUP-G52546,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH ANG 90CM NAVICROSS -,SUP-G52547,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH DX 4FR DAV 90CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G52547,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.07IN 7FR XBRCA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-G778126,CDM,C1887,HCPCS,272,RC,,,outpatient,,,882.25,617.575,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID RELIEVA FLEX SIN S-0 SFT DIST TIP ENDO -,SUP-GC000RF,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1961.19,1372.833,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID RELIEVA FLEX SIN F-70 C SFT DIST TIP ENDO -,SUP-GC070CRF,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1961.19,1372.833,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID RELIEVA FLEX SIN M-110 SFT DIST TIP ENDO -,SUP-GC110RF,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1961.19,1372.833,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH ANGIO IMPULSE 5FR FL3.5 REF:H74916391212 -,SUP-H74916391212,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATHETER 5FR FL4 IMPULSE REF:H74916391222 -,SUP-H74916391222,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH ANGIO IMPULSE 5FR AR1 REF:H74916391842 -,SUP-H74916391842,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH ANG 0.045IN 5FR AL1 100CM IMPULSE REF:H74916391962 -,SUP-H74916391962,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATHETER 5FR AL2 IMPULSE REF:H74916391982 -,SUP-H74916391982,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
ANGIO CATH PIG 6F IMPULSE -,SUP-H74916599412,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.070IN 6FR AL3 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934356210,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATHETER GUIDING 6FR Mach 1 AL .75 -,SUP-H74934356220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 6FR MACH 1 ML 3.5 REF: H749343565370 -,SUP-H749343565370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.081IN 7FR FL3 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934357050,CDM,C1887,HCPCS,272,RC,,,outpatient,,,306.51,214.557,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.081IN 7FR FL3.5 100CM MACH1 4X2 RND BRD LRG LUM -,SUP-H74934357060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 7FR IM 85CM MACH1 -,SUP-H749343571220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 7FR AL.75 100CM MACH1 REF:H74934357220 -,SUP-H74934357220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.081IN 7FR RCB 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934357240,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.081IN 7FR Q- TY CRV 4 100CM MACH1 4X2 RND BRD -,SUP-H749343572940,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.070IN 7FR Q4.5 MACH 1 -,SUP-H749343572950,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.081IN 7FR MP1 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934357380,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUIDE 7FR MP2 REF: H74934357390 -,SUP-H74934357390,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.081IN 7FR FR3.5 SH 100CM MACH1 2X2 RND BRD -,SUP-H74934357470,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.081IN 7FR FL4.5 100CM MACH1 2X2 RND BRD LRG LUM -,SUP-H74934357540,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.081IN 7FR CNTRLAT 3 100CM MACH1 2X2 RND BRD LRG -,SUP-H749343575730,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.081IN 7FR CLS 3.5 100CM MACH1 4X2 RND BRD LRG -,SUP-H749343575740,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.081IN 7FR VL3 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934357710,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.081IN 7FR VL3.5 100CM MACH1 4X2 RND BRD LRG LUM -,SUP-H74934357720,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.081IN 7FR FR4 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934357920,CDM,C1887,HCPCS,272,RC,,,outpatient,,,306.51,214.557,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.091IN 8FR FR3.5 100CM MACH1 2X2 RND BRD SD HOL -,SUP-H74934358010,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.091IN 8FR FR4 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934358020,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.091IN 8FR FL3.5 100CM MACH1 4X2 RND BRD LRG LUM -,SUP-H74934358060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.091IN 8FR FL4.5 100CM MACH1 2X2 RND BRD LRG LUM -,SUP-H74934358080,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID MACH1 8FR AL.75 SH  90CM - H749343581920 -,SUP-H749343581920,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.091IN 8FR LCB 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934358250,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.091IN 8FR FR4 100CM MACH1 4X2 RND BRD LRG LUM SH -,SUP-H74934358480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.070IN 6FR FR3.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969010,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.070IN 6FR FR4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969020,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.07IN 6FR FL3 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969050,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.07IN 6FR FL3.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.07IN 6FR FL4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969070,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.070IN 6FR FL4.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969080,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.070IN 6FR FEM HS 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H749389691410,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.070IN 6FR AR2 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969180,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.070IN 6FR AL1 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969190,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.070IN 6FR AL2 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.07IN 6FR FRC BYPS 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H74938969240,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.070IN 6FR LCB RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969250,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.070IN 6FR IMA RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969260,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.070IN 6FR FL4 ST RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H74938969290,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.070IN 6FR Q3.5 -,SUP-H749389692930,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.070IN 6FR Q4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389692940,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.070IN 6FR Q4.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389692950,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.07IN 6FR MP1 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969380,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.070IN 6FR FEM MP 2 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H74938969390,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.070IN 6FR HS RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969410,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.070IN 6FR IMA 90CM RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389694460,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.070IN 6FR RC 4 SC RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389694480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.070IN 6FR RC 3.5 SC RUNWAY 2X2 RND BRD LRG LUM -,SUP-H74938969460,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.070IN 6FR FR3.5 RUNWAY 2X2 RND BRD LRG LUM SH -,SUP-H74938969470,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.070IN 6FR FR4 RUNWAY 2X2 RND BRD LRG LUM SH FEM -,SUP-H74938969480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.070IN 6FR ART3 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389694960,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.070IN 6FR ART3.5 RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389694980,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.070IN 6FR ART3.5 RUNWAY 2X2 RND BRD LRG LUM SH -,SUP-H749389694990,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.070IN 6FR ART4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389695000,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.070IN 6FR FL 3.5 SH RUNWAY 2X2 RND BRD LRG -,SUP-H74938969520,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.070IN 6FR MUTA LT 3 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695360,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.070IN 6FR MUTA LT 3.5 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.070IN 6FR MUTA LT 4 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695380,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.070IN 6FR MUTA LT 4.5 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695390,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.07IN 6FR FEM CLS 3 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H749389695730,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.070IN 6FR CLS 3.5 RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389695740,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.070IN 6FR CLS 4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389695750,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.070IN 6FR CLS 3.5 RUNWAY 2X2 RND BRD LRG LUM SH -,SUP-H749389695780,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUIDE RUNWAY 6F CLS4 SH -,SUP-H749389695790,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.070IN 6FR KRT HZNT 3H RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389696480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.081IN 7FR VL3.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389696620,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.070IN 6FR FEM JL5 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H749389696640,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.07IN 6FR FEM AL1 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H74938969680,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.070IN 6FR VL3 RUNWAY -,SUP-H74938969710,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.070IN 6FR FL BK -UP 4 100CM RUNWAY 2X2 RND BRD -,SUP-H749389697160,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.070IN 6FR FR4 ST RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H74938969920,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.070IN 6FR MP1 125CM RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389699530,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
MICRO GUIDE CATH MAMBA FLEX 135 REF: H7493928713540 -,SUP-H7493928713540,CDM,C1887,HCPCS,272,RC,,,outpatient,,,5071.58,3550.106,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
STINGRAY LP BALLOON 3.2FR -,SUP-H749393120SR0,CDM,C1887,HCPCS,272,RC,,,outpatient,,,6490.48,4543.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
GUIDE EXTENSION CATHETER GUIDEZILLA II 6F -,SUP-H7493933515060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
GUIDE EXTENSION CATHETER GUIDEZILLA II 6F LONG -,SUP-H74939335150610,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
GUIDE EXTENSION CATHETER GUIDEZILLA II 7F -,SUP-H7493933515070,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
GUIDE EXTENSION CATHETER GUIDEZILLA II 8F -,SUP-H7493933515080,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH PTCA 135CM CROSSBOSS STINGRAY F/COR CTO -,SUP-H749M1000A0,CDM,C1887,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH ANG 4FR STR 65CM RADIFOCUS GLIDECATH DBL BRD SM-PRFL -,SUP-H787117140155,CDM,C1887,HCPCS,272,RC,,,outpatient,,,388.61,272.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
4FR GLIDECATH LONG 100CM STRAIGHT -,SUP-H787117140225,CDM,C1887,HCPCS,272,RC,,,outpatient,,,295.54,206.878,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH ANG 5FR ANG TAPR 65CM RADIFOCUS GLIDECATH SGL-BRD LRG -,SUP-H787117221045,CDM,C1887,HCPCS,272,RC,,,outpatient,,,388.61,272.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH ANG 5FR STR TAPR 65CM RADIFOCUS GLIDECATH SGL-BRD LRG -,SUP-H787117315025,CDM,C1887,HCPCS,272,RC,,,outpatient,,,388.61,272.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH ANG 4FR JB3 TIP 100CM TORCONNB ADVANTG BEACN BRD PERIPH -,SUP-HNBR4.0-35-100-P-NS-JB3,CDM,C1887,HCPCS,272,RC,,,outpatient,,,227.57,159.299,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.071IN 5FR EBU3.5 100CM LAUNCHR BRD LRG LUM DIST -,SUP-LA5EBU35,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 6FR 3D RIGHT LAUNCHR REF: LA63DRIGHT -,SUP-LA63DRIGHT,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.071IN 6FR AL1 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6AL10,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 6FR AL75 100CM LAUNCHR REF: LA6AL75 -,SUP-LA6AL75,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.071IN 6FR AR1 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6AR10,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.071IN 6FR BU LT EBU 3 100CM LAUNCHR BRD LRG LUM -,SUP-LA6EBU30,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.071IN 6FR BU LT EBU 3.5 100CM LAUNCHR BRD LRG -,SUP-LA6EBU35,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.071IN 6FR BU LT EBU 3.75 100CM LAUNCHR BRD LRG -,SUP-LA6EBU375,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.071IN 6FR BU LT EBU 4 100CM LAUNCHR BRD LRG LUM -,SUP-LA6EBU40,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.071IN 6FR EBU 4.5 100CM LAUNCHR -,SUP-LA6EBU45,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.071IN 6FR BYPS IMA 90CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6IMAD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.071IN 6FR STD JR4 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6JR40,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 7FR 3D RIGHT LAUNCHR REF: LA73DRIGHT -,SUP-LA73DRIGHT,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUIDE 7 FR AL.75 SH D REF: LA7AL75SHD -,SUP-LA7AL75SHD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.081IN 7FR COR EBU3.5 100CM LAUNCHR BRD LRG LUM -,SUP-LA7EBU35,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.081IN 7FR COR EBU4 100CM LAUNCHR BRD LRG LUM -,SUP-LA7EBU40,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.081IN 7FR EBU4.5 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA7EBU45,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 7FR JR4 90CM LAUNCHR -,SUP-LA7JR40D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,256.74,179.718,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
GUIDE 8F AL 1.0 SH 90CM -,SUP-LA8AL10D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
GUIDE 8F AL 2.0 90CM MICR CATH -,SUP-LA8AL20D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
GUIDE 8F AL .75 90CM CATH -,SUP-LA8AL75D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
GUIDE 8F EBU 3.5 90CM -,SUP-LA8EBU35D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
GUIDE 8F EBU 3.5 SH 90CM -,SUP-LA8EBU35D SHD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
GUIDE 8F EBU 4.0 90CM -,SUP-LA8EBU40D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
GUIDE 8F JL 4.0 90CM -,SUP-LA8JL40D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
GUIDE 8F JL 4.0 SH 90CM -,SUP-LA8JL40D SHD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 105CM 20CM -,SUP-M001181250,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2497.81,1748.467,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D C 1 130CM 20CM -,SUP-M001181310,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2497.81,1748.467,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 150CM 20CM STC-18 -,SUP-M001181370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2497.81,1748.467,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 130CM 20CM -,SUP-M001182520,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1981.8,1387.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 150CM 20CM -,SUP-M001182530,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2297.77,1608.439,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
C RENEGADE HI-FLO MICROCATH -,SUP-M001183030,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2589.9,1812.93,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
MICROCATH INTVN 0.021IN SWAN 130CM DIREXION HI-FLO -,SUP-M001195300,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3221.16,2254.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH MICRO DREXION HI FLO J TO -,SUP-M001195470,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2566.03,1796.221,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.081IN 7FR LIMA 55CM MACH1 4X2 RND BRD LRG LUM -,SUP-M001197620,CDM,C1887,HCPCS,272,RC,,,outpatient,,,560.22,392.154,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH GUID 0.091IN 8FR LIMA 55CM MACH1 RND BRD LRG LUM PERIPH -,SUP-M001198620,CDM,C1887,HCPCS,272,RC,,,outpatient,,,560.22,392.154,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH ANG 4FR PIGTL 65CM IMAGER II SLCT FLSH BRD TRQ TUNG -,SUP-M001315091,CDM,C1887,HCPCS,272,RC,,,outpatient,,,58.24,40.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH ANG 4FR PIGTL 90CM IMAGER II FLSH BRD TRQ MED-GLD CTD -,SUP-M001315111,CDM,C1887,HCPCS,272,RC,,,outpatient,,,58.24,40.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH ANG 4FR CNTRLAT 2 CRV 65CM IMAGER II SLCT BRD TRQ SDE -,SUP-M001316581,CDM,C1887,HCPCS,272,RC,,,outpatient,,,58.24,40.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
MICRO GUIDE CATH FINECROSS M3 2.5 Fr 130 CM REF: M3-1430 -,SUP-M3-1430,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
MICRO GUIDE CATH FINECROSS M3 2.5 Fr 150 CM REF: M3-1450 -,SUP-M3-1450,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
PROGREAT 2.0 70 DEGREE ANGLE  150CM -,SUP-MC*PC2015ZRA,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3652.11,2556.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
PROGREAT COAXIAL MICROCATHETER2.4 FR  150CM   DEGREE ANGLE -,SUP-MC*PE24151YV,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2673.44,1871.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
PROGREAT COAXIAL 2.8 FR  150CM   RO MARKER BAND -,SUP-MC*PE28151YV,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2673.44,1871.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
PROGREAT 2.4  70 DEGREE ANGLE  150CM -,SUP-MC*PV2415ZRA,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2061.89,1443.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
PROGREAT MICROCATHETER 2.4x150CM -,SUP-MCPV2415Y,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1749.17,1224.419,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATHETER NAVICROSS 018 65CM ANGLED STAINLESS STEEL -,SUP-NC18651,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATHETER NAVICROSS 018 90CM ANGLED STAINLESS STEEL -,SUP-NC18901,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
C NAVICROSS 135CM .035 STR T -,SUP-NC35130,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
C NAVICROSS 135CM .035 ANGLE -,SUP-NC35131,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH INTVN 12MM TIP STR TAPR 150CM NAVICROSS SUPP DBL BRD -,SUP-NC35150,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATHETER SUPPORT NAVICROSS 0.035 150CM ANGLED -,SUP-NC35151,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
SHEATH GUID 6FRX90CM PINNACLE -,SUP-RSC03,CDM,C1887,HCPCS,272,RC,,,outpatient,,,743.96,520.772,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
SHEATH GUID 6FRX90CM PINNCL DSTNTN VASC STR CRV GOLD COIL. -,SUP-RSC05,CDM,C1887,HCPCS,272,RC,,,outpatient,,,743.96,520.772,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
SHEATH GUID 6FRX90CM PINNCL DSTNTN VASC MP CRV GOLD COIL -,SUP-RSC07,CDM,C1887,HCPCS,272,RC,,,outpatient,,,743.96,520.772,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
SHEATH GUID 6FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL- -,SUP-RSR01,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
SHEATH GUID 7FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-RSR04,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
SHEATH GUID 7FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-RSR04,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
TIP GUIDE CATH RELIEVA SPIN SPND SIN S-0 SHP TIP BLN WND ORT -,SUP-RSS0,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1696.16,1187.312,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH DX TAPR 65CM TRAILBLAZER SUPP HYDRCT -,SUP-SC035065,CDM,C1887,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATHETER GUIDING 6FR X 125 JL 5 JUDKINS -,SUP-SM7361,CDM,C1887,HCPCS,272,RC,,,outpatient,,,882.25,617.575,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
SHEATH 6.5 FR X 55CM X 17MM -,SUP-TG0655517,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH SHEATH RITESITE C315S1001 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH SHEATH RITESITE C315S4 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH SHEATH RITESITE C315S401 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH SHEATH RITESITE C315S501 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH SHEATH RITESITE C315G -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH SHEATH RITESITE C315J01 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH SHEATH RITESITE C315H20 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH SHEATH RITESITE C315H40 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH SHEATH RITESITE C315J -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH SHEATH RITESITE C315S5 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH SHEATH RITESITE C315H2001 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH SHEATH RITESITE C315H4001 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH SHEATH RITESITE C315S10 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
COIL MICRO RENEGADE STR FIBER -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2297.77,1608.439,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH OCL 0.97MM 6FR SHTH 110CM WILDCAT FLSH OTW 2MM XING -,SUP-W400,CDM,C1887,HCPCS,272,RC,,,outpatient,,,6769.18,4738.426,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
CATH OCL 0.43MM 5FR SHTH 150CM KITTYCAT 2 OTW 1.7MM XING -,SUP-W550,CDM,C1887,HCPCS,272,RC,,,outpatient,,,6769.18,4738.426,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.22704,7607.37,other,Non-Reimbursable List,,
TUBE PEG 20FR PONSKY NBR NON BALLOON REPLACEMENT -,SUP-000700,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1250.92,875.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
TUBE JJUNO 16FRX108IN PVC/PLST 15ML BLN LUMX2 -,SUP-0042510,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1602.34,1121.638,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
TUBE GASTROSTOMY 14 FR -,SUP-0100-14LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
TUBE GASTROSTOMY FEEDING 16 FR -,SUP-010016LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,220.33,154.231,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
TUBE GASTROSTOMY 16FR -,SUP-0100-16LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
TUBE GASTROSTOMY FEEDING 18FR -,SUP-0100-18,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
MIC GASTROSTOMY TUBE 20 FR -,SUP-0100-20,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
TUBE GASTROSTOMY FEEDING 20 FR -,SUP-0100-20,CDM,C1889,HCPCS,278,RC,,,outpatient,,,45.16,31.612,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
TUBE GASTROSTOMY FEEDING 22 FR -,SUP-0100-22,CDM,C1889,HCPCS,278,RC,,,outpatient,,,225.87,158.109,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
MIC GASTROSTOMY TUBE 24 FR -,SUP-0100-24,CDM,C1889,HCPCS,278,RC,,,outpatient,,,43.52,30.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
TUBE GASTROSTOMY 26 FR -,SUP-0100-26,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
TUBE JJUNO 12FR SIL MI C SECUR-LOK XTRN RETEN RNG -,SUP-0200-12LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
TUBE JJUNO 14FR SIL 7-10ML BLN MI C SECUR-LOK XTRN RETEN RNG -,SUP-0200-14,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
TUBE FEEDING JEJUNAL 16F -,SUP-0200-16,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
TUBE JJUNO 18FR SIL 7-10ML BLN MIC-KEY SECUR-LOK XTRN RETEN -,SUP-0200-18,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
TUBE JEJUNOSTOMY 22FR MIC SECUR-LOK SILICONE -,SUP-0200-22,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
TUBE JJUNO 22FRX45CM SIL 7-10ML BLN MIC-KEY LPRO -,SUP-0250-22,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1221.18,854.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
TUBE MIC JEJUNOSTOMY 14FR / DR. GLEESON -,SUP-0301-14,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1113.49,779.443,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
TUBE NG 6FR SALEM SMP 60CM VYGON -,SUP-1340.06,CDM,C1889,HCPCS,278,RC,,,outpatient,,,79.12,55.384,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
CONNECTOR CATHETER NYLON STRAIGHT 1.5 X 1.0 X 1.9 -,SUP-45103,CDM,C1889,HCPCS,278,RC,,,outpatient,,,481.1,336.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
CONNECTOR CSF CATH STRAIGHT 3 WAY IMP 2 X 1.5 X 1.8 X 1.0 -,SUP-45105,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1359.53,951.671,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
AZUR 18D SYSTEM 4MM X 5CM -,SUP-45-480405,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3570.95,2499.665,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
AZUR CX 35D 4MM X 7C3 DETACHABLE -,SUP-45-750407,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
AZUR CX .035 5MM X 11CM DETACH -,SUP-45-750511,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
AZUR CX DETACH 035 6MMX17CM -,SUP-45-750617,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
AZUR CK DETACHABLE 035 8MM X 12CM -,SUP-45-750812,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
AZUR CX DETACH 035 8MMX24CM -,SUP-45-750824,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
AZUR CX DETACH 035 10MMX19CM -,SUP-45-751019,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
AZUR CX 35 DETACH 13MMX24CM CX COIL -,SUP-45-751324,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
AZUR CX 35D 16MM X 32 CM -,SUP-45-751632,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
AZUR CX 35D 20MM X 39 CM -,SUP-45-752039,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
AZUR CX DETACHABLE 018 6MM X 20CM -,SUP-45-780620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
AZUR CX DETACHABLE 018 7MM X 24CM -,SUP-45-780724,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
AZUR CX DETACHABLE 018 8MM X 28CM -,SUP-45-780828,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
COIL EMBOLIZATION POD 0.020IN 4MM 30CM FULLY DETACHABLE RESH -,SUP-90178538,CDM,C1889,HCPCS,278,RC,,,outpatient,,,8190.92,5733.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
KIT INTRO GASTROSTOMY FEED -,SUP-98432,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1149.84,804.888,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
SENTINEL CEREBRAL PROTECTION SYSTEM REF: CMS15-10C-US -,SUP-CMS15-10C-US,CDM,C1889,HCPCS,278,RC,,,outpatient,,,14852,10396.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
COIL EMBOLIZATION NESTER MICROCOIL PLATINUM L3 CM OD2 MM . -,SUP-G47331,CDM,C1889,HCPCS,278,RC,,,outpatient,,,577.61,404.327,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
14X14 NESTER COIL 0.035 -,SUP-G47347,CDM,C1889,HCPCS,278,RC,,,outpatient,,,705.98,494.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
CATH COOK AIRWAY EXCHANGE 14FR 83CM. -,SUP-G57622,CDM,C1889,HCPCS,278,RC,,,outpatient,,,374.02,261.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
SPACER BONE CERVICAL LOR 6MM -,SUP-LGAL906,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
SPACER BONE CERVICAL LOR 7MM -,SUP-LGAL907,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
SPACER BONE CERVICAL LOR 8MM -,SUP-LGAL908,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
SPACER BONE CERVICAL PAR 6MM -,SUP-LGAP906-P,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
SPACER BONE CERVICAL PAR 7MM -,SUP-LGAP907-P,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
SPACER BONE CERVICAL PAR 8MM -,SUP-LGAP908-P,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
CATHETER DELIVERY AVEIR REF:LSCD111 -,SUP-LSCD111,CDM,C1889,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
BASKET SPECIMEN RETRIEVAL ZERO TIP 0.8MM 12MM ENDOSCOPIC -,SUP-M00513200,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1398.8,979.16,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
PROBE BILIARY EHL -,SUP-M00546620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2273.91,1591.737,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
TUBE PEG 16FR ENDOVIVE LPRO PUL LF -,SUP-M00582060,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
TUBE PEG 18FR ENDOVIVE LPRO PUL LF -,SUP-M00582070,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
KIT BALLOON REPLACEMENT STRAIGHT BOLSTER 20FR -,SUP-M00582080,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
KT TUBE PEG 24FR ENDOVIVE LPRO PUL LF -,SUP-M00582090,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
KIT BALLOON REPLACEMENT RIGHT ANGLE BOLSTER 20FR -,SUP-M00582150,CDM,C1889,HCPCS,278,RC,,,outpatient,,,192.44,134.708,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
TUBE PEG 24FR 3ML BLN SIL ENDOVIVE RT ANG LF -,SUP-M00582160,CDM,C1889,HCPCS,278,RC,,,outpatient,,,192.44,134.708,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
WATCHMAN FXD CURVE ACCESS SYSTEM SGL US REF: M635TU80010 -,SUP-M635TU80010,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
WATCHMAN FXD CURVE ACCESS SYSTEM DBL US REF: M635TU80020 -,SUP-M635TU80020,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
TUBE PEG 14FR 5ML BALLON TRITON LTX -,SUP-PEG-14-BRT-TR1,CDM,C1889,HCPCS,278,RC,,,outpatient,,,233.4,163.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
COIL EMBL 3MMX5CM RUBY MICRO CMPLX STD FRM FLLY DTCH RSHEATH -,SUP-RBY2C0305,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
COIL EMBL 3MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0320,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4769.23,3338.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
COIL EMBL 4MMX10CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0410,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
COIL EMBL 4MMX15CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0415,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
COIL EMBL 4MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0420,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
COIL EMBL 4MMX35CM RUBY CMPLX STD FRM FLLY DTCH RSHEATH -,SUP-RBY2C0435,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
COIL EMBL 5MMX12CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0512,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
COIL EMBL 5MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0520,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
COIL EMBL 5MMX30CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0530,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
COIL EMBL 6MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4769.23,3338.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
COIL EMBL 6MMX30CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0630,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
COIL EMBL 7MMX25CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0725,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
COIL EMBL 8MMX25CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0825,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
COIL EMBL 8MMX40CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0840,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
COIL EMBL 9MMX30CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0930,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
COIL EMBL 10MMX35CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1035,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
COIL EMBL 12MMX40CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1240,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
COIL EMBL 12MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1260,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
COIL EMBL 14MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1460,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
COIL EMBL 16MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1660,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
COIL EMBL 18MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1857,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
COIL EMBL 20MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C2060,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
COIL EMBL 24MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C2457,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
COIL EMBL 28MMX60CM RUBY MICRO CMPLX STD FRM FLLY -,SUP-RBY2C2860,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
COIL EMBL 32MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C3260,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
RUBYCOIL 36MM X 60MM STANDARD -,SUP-RBY2C3660,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
RUBYCOIL 40MM X 60MM STANDARD -,SUP-RBY2C4060,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
COIL EMBL 2MMX4CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH PLTNM -,SUP-RBY4C0204,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3814.43,2670.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
COIL EMBL 3MMX5CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH PLTNM -,SUP-RBY4C0305,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
COIL EMBL 3MMX15CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0315,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
COIL EMBL 4MMX6CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH PLTNM -,SUP-RBY4C0406,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
COIL EMBL 4MMX15CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0415,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
COIL EMBL 6MMX20CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
COIL EMBL 6MMX30CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0630,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
COIL EMBL 8MMX35CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0835,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
COIL EMBL 8MMX60CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0860,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
COIL EMBL 16MMX50CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C1650,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
RUBY COIL LP- 1 MM x 5 CM PERIPHERAL EMBOLIZATION COILS -,SUP-RBYLP0105,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
RUBY COIL LP- 2 MM x 10 CM PERIPHERAL EMBOLIZATION COILS -,SUP-RBYLP0210,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
RUBY COIL LP- 3 MM x 4 CM PERIPHERAL EMBOLIZATION COILS -,SUP-RBYLP0304,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
PENUMBRA RUBY POD 6MM X 50CM -,SUP-RBYPOD6,CDM,C1889,HCPCS,278,RC,,,outpatient,,,8190.92,5733.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
SPACE OAR VUE HYDROGEL -,SUP-SV-2101,CDM,C1889,HCPCS,278,RC,,,outpatient,,,12791.29,8953.903,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.77024,11406.336,other,Non-Reimbursable List,,
INTRO SHTH 6FRX14CM J SHP TIP 12ML SYR DI-LOK DILATOR 18GA -,SUP-405104,CDM,C1892,HCPCS,272,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.121935,3080.6622,other,Non-Reimbursable List,,
INTRO SHTH 7FRX14CM 0.038INX50CM JTP GW 18GA XTW NDL 12ML -,SUP-405108,CDM,C1892,HCPCS,272,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.121935,3080.6622,other,Non-Reimbursable List,,
KT 12FR 18GAX14CM 0.38INX50CM GW CV 3MM JTP PEEL-AWAY -,SUP-405120,CDM,C1892,HCPCS,272,RC,,,outpatient,,,186.72,130.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.121935,3080.6622,other,Non-Reimbursable List,,
INTRO SHTH 10.5FRX14CM 0.038INX50CM JTP GW 18GA XTW NDL 12ML -,SUP-405122,CDM,C1892,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.121935,3080.6622,other,Non-Reimbursable List,,
INTRO SHTH 8T-TW FR DIA 14CM 0.038INX50CM JTP GW 18GA XTW -,SUP-405129,CDM,C1892,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.121935,3080.6622,other,Non-Reimbursable List,,
INTRO SHTH 8FRX14CM J SHP TIP 12ML SYR DI-LOK DILATOR 18GA -,SUP-405145,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.121935,3080.6622,other,Non-Reimbursable List,,
INTRO LD 9FR PEEL-AWAY SHTH SGL-CHMBR -,SUP-405147,CDM,C1892,HCPCS,272,RC,,,outpatient,,,320.93,224.651,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.121935,3080.6622,other,Non-Reimbursable List,,
INTRO SHTH 8FRX14CM 0.038IN GW DI- LOCK DILATOR -,SUP-405412,CDM,C1892,HCPCS,272,RC,,,outpatient,,,90.56,63.392,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.121935,3080.6622,other,Non-Reimbursable List,,
INTRO SHTH 9FRX14CM 0.038IN GW DI- LOCK DILATOR -,SUP-405416,CDM,C1892,HCPCS,272,RC,,,outpatient,,,89.63,62.741,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.121935,3080.6622,other,Non-Reimbursable List,,
TRANSDC TRANSTHORACIC BTRY PK VIEWMATE -,SUP-405422,CDM,C1892,HCPCS,272,RC,,,outpatient,,,175.05,122.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.121935,3080.6622,other,Non-Reimbursable List,,
INTRO SHTH 11FRX14CM 0.038INX50CM JTP GW 18GA XTW NDL 12ML -,SUP-405424,CDM,C1892,HCPCS,272,RC,,,outpatient,,,175.05,122.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.121935,3080.6622,other,Non-Reimbursable List,,
INTRO VASC 8FR SUPER SHTH INFS SDPRT -,SUP-CLS-1008,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.121935,3080.6622,other,Non-Reimbursable List,,
INTRO VASC 8.5FR SUPER SHTH INFS SDPRT -,SUP-CLS-1008.5,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.121935,3080.6622,other,Non-Reimbursable List,,
INTRO VASC 10.5FR SUPER SHTH INFS SDPRT -,SUP-CLS-1010.5,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.121935,3080.6622,other,Non-Reimbursable List,,
INTRO VASC 8FR LNG SUPER SHTH INFS SDPRT -,SUP-CLS-2508,CDM,C1892,HCPCS,272,RC,,,outpatient,,,301.67,211.169,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.121935,3080.6622,other,Non-Reimbursable List,,
CPS DIRECT MEDI GUIDE ENABLED OUT CATH  RIGHT -,SUP-DS2M044,CDM,C1892,HCPCS,272,RC,,,outpatient,,,4296.6,3007.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.121935,3080.6622,other,Non-Reimbursable List,,
SET INTRODUCER PEEL-AWAY SAFE-T-J -,SUP-G04496,CDM,C1892,HCPCS,272,RC,,,outpatient,,,397.66,278.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.121935,3080.6622,other,Non-Reimbursable List,,
SHEATH SAFE PRELUDE 6F 13CM LN -,SUP-PLS-1006,CDM,C1892,HCPCS,272,RC,,,outpatient,,,274.25,191.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.121935,3080.6622,other,Non-Reimbursable List,,
INTRODUCER MERIT PRELUDE 9F 25CM -,SUP-PLS-2509,CDM,C1892,HCPCS,272,RC,,,outpatient,,,301.67,211.169,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.121935,3080.6622,other,Non-Reimbursable List,,
INTRODUCER 9FR OPTISEAL -,SUP-UNDEFINED,CDM,C1892,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.121935,3080.6622,other,Non-Reimbursable List,,
CATH GUID 7FR COR -,SUP-358735,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2448.83,1714.181,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,165.054645,2224.9227,other,Non-Reimbursable List,,
INTRO  SL1  CURVE - SJM 8.5FRX 63CM -,SUP-406849,CDM,C1893,HCPCS,272,RC,,,outpatient,,,892.76,624.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,165.054645,2224.9227,other,Non-Reimbursable List,,
INTRO GUID 8.5FRX60CM FAST-CATH SWARTZ TRNSEPT SAFL CRV -,SUP-406868,CDM,C1893,HCPCS,272,RC,,,outpatient,,,898.59,629.013,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,165.054645,2224.9227,other,Non-Reimbursable List,,
INTRO GUID 8FRX60CM FAST-CATH SWARTZ TRNSEPT SAFL CRV -,SUP-406871,CDM,C1893,HCPCS,272,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,165.054645,2224.9227,other,Non-Reimbursable List,,
INTRO GUID 8FRX60CM FAST-CATH SWARTZ TRNSEPT SEPT CRV -,SUP-406885,CDM,C1893,HCPCS,272,RC,,,outpatient,,,904.43,633.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,165.054645,2224.9227,other,Non-Reimbursable List,,
INTRO SEPT CURVE-SJM  8.5FRX60CM -,SUP-406894,CDM,C1893,HCPCS,272,RC,,,outpatient,,,898.59,629.013,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,165.054645,2224.9227,other,Non-Reimbursable List,,
INTRO  RAMP  CURVE - SJM 8.5FRX 63CM -,SUP-406965,CDM,C1893,HCPCS,272,RC,,,outpatient,,,735.21,514.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,165.054645,2224.9227,other,Non-Reimbursable List,,
SHEATH GUIDE LAMP 45 407363 -,SUP-407363,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1015.29,710.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,165.054645,2224.9227,other,Non-Reimbursable List,,
INTRODUCER CATHETER BRITE TIP RADIANZ GUIDING 6FR 110CM -,SUP-687280110,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1363.55,954.485,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,165.054645,2224.9227,other,Non-Reimbursable List,,
INTRODUCER CATHETER BRITE TIP RADIANZ GUIDING 6FR 135CM -,SUP-687280135,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1363.55,954.485,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,165.054645,2224.9227,other,Non-Reimbursable List,,
TRANSSEPTAL ACCESS STYSTEM ACQCROSS QX AG 71 CM REF: 900301 -,SUP-900301,CDM,C1893,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,165.054645,2224.9227,other,Non-Reimbursable List,,
TRANSSEPTAL ACCESS STYSTEM ACQCROSS QX - FC 65CM REF: 900304 -,SUP-900304,CDM,C1893,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,165.054645,2224.9227,other,Non-Reimbursable List,,
TRANSSEPTAL ACCESS STYSTEM ACQCROSS  WT 75CM REF: 900308 -,SUP-900308,CDM,C1893,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,165.054645,2224.9227,other,Non-Reimbursable List,,
FLEXCATH CROSS FCC 65CM 10FR REF:900310 -,SUP-900310,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,165.054645,2224.9227,other,Non-Reimbursable List,,
FLEXCATH CROSS FCC 65CM 12FR REF:900311 -,SUP-900311,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,165.054645,2224.9227,other,Non-Reimbursable List,,
CATHETER CPS LOCATOR 3D- LAGE EXTRA LONG REF:DS2C300-45 -,SUP-DS2C300-45,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,165.054645,2224.9227,other,Non-Reimbursable List,,
SHEATH GUID WORLEY RNL TLSCP GUIDE -,SUP-LVI7556207RE,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2464.73,1725.311,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,165.054645,2224.9227,other,Non-Reimbursable List,,
TORFLEX TRANSSEPTAL GUIDING SH -,SUP-TF85-32-63-45,CDM,C1893,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,165.054645,2224.9227,other,Non-Reimbursable List,,
DILATOR VESSEL 5 FR 35 -,SUP-040037A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,23.34,16.338,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
MICINTRO VASC 4.5FRX50CM MICRO EZ FNL DSGN SMTH DILATOR PTFE -,SUP-0928945,CDM,C1894,HCPCS,272,RC,,,outpatient,,,205.74,144.018,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
MICINTRO VASC 5FRX50CM MICRO EZ FNL DSGN SMTH DILATOR PTFE -,SUP-0928950,CDM,C1894,HCPCS,272,RC,,,outpatient,,,213.56,149.492,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
MICINTRO VASC 6FRX50CM MICRO EZ SMTH DILATOR PTFE 7CM A BVL -,SUP-0928960,CDM,C1894,HCPCS,272,RC,,,outpatient,,,189.64,132.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH INTRO 6FRX10CM PINNCL TIF TIP PERIPH 0.038INX45CM SS -,SUP-10-2032,CDM,C1894,HCPCS,272,RC,,,outpatient,,,72.94,51.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO INFS 7FR PEEL-AWAY -,SUP-120089,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.83,253.281,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH INTRO 5FRX10CM GLIDESHEATH RADL STR GOLD COIL MRKR -,SUP-20 -1050,CDM,C1894,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH INTRO 6FRX10CM GLIDESHEATH RADL STR GOLD COIL MRKR -,SUP-20 -1060,CDM,C1894,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
S COOK 7FR X 6CM -,SUP-242381,CDM,C1894,HCPCS,272,RC,,,outpatient,,,170.73,119.511,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH INTRO 5FRX10CM GLIDESHEATH RADL STR CRV GOLD COIL -,SUP-30-1050,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.48,364.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH INTRO 6FRX10CM GLIDESHEATH RADL STR CRV GOLD COIL -,SUP-30-1060,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.48,364.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH INTRO 6FRX10CM GLIDESHEATH RADL  STR CRV GOLD COIL -,SUP-30-1065,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.48,364.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH GUID 0.110IN 8FRX62CM PREFACE MP ST TAPR PRFL -,SUP-301803MS,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO CATH 4FRX3.2CM INTRSYT-N PERC SHLD -,SUP-384011,CDM,C1894,HCPCS,272,RC,,,outpatient,,,234.57,164.199,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO CATH 1.9FRX1.9CM INTRSYT-N PERC SHLD -,SUP-384021,CDM,C1894,HCPCS,272,RC,,,outpatient,,,280.08,196.056,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
FORTRESS SHEALTH 5FRx45CM -,SUP-386591,CDM,C1894,HCPCS,272,RC,,,outpatient,,,102.7,71.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
FORTRESS SHEATH 5FR x 45CM -,SUP-386591,CDM,C1894,HCPCS,272,RC,,,outpatient,,,102.7,71.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 10FRX11CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-011M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
S BRITE TIP 10FR 11CM  RB -,SUP-401-011M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH BRITE TIP 4F 11CM -,SUP-401411M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH 5FR 11CM BRITE TIP -,SUP-401511M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH 5FR BRITE TIP 23CM -,SUP-401-523M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 5FRX55CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-555M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 6FRX5.5CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401605M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 6FRX5.5CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-605M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH 6FR 11CM BRITE TIP -,SUP-401-611M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 6FRX5.5CM X 23CM CANN BRT TIP PERC TAPR SMTH -,SUP-401-623M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH 6F 23CM BRITE TIP -,SUP-401-623M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 6FRX55CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-655M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH 7 FR 11CM BRITE TIP -,SUP-401-711M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH 7FR X 23CM BRITE TIP -,SUP-401-723M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 7FRX45CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-745M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH 8FR 11CM BRITE TIP -,SUP-401-811M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
S BRITE TIP 8FR 23CM RB -,SUP-401-823M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 8FRX45CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-845M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
S BRITE TIP 9FR X 11CM RB -,SUP-401-911M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHTH INTRO 11FR X 11CM CANN BRT -,SUP-402611X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,43.18,30.226,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 6FR STD L 11CM REF: 402656X -,SUP-402656X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,43.18,30.226,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 2MM ANCURE -,SUP-40320,CDM,C1894,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
HEMOSTASIS INTRODUCER FAST CATH 10FRX30CM REF: 406180 -,SUP-406180,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.77,253.239,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
HEMOSTASIS INTRODUCER FAST CATH 14FRX30CM REF: 406188 -,SUP-406188,CDM,C1894,HCPCS,272,RC,,,outpatient,,,385.11,269.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
FAST CATH DUO SHEATH 12F  12CM -,SUP-406301,CDM,C1894,HCPCS,272,RC,,,outpatient,,,140.04,98.028,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 7FRX12CM FAST-CATH CATH-LOCK PERC JTP STR SNP -,SUP-406702,CDM,C1894,HCPCS,272,RC,,,outpatient,,,62.26,43.582,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 8FRX12CM FAST-CATH CATH-LOCK PERC JTP STR SNP -,SUP-406706,CDM,C1894,HCPCS,272,RC,,,outpatient,,,105.03,73.521,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 4FRX12CM FAST-CATH CATH-LOCK PERC JTP STR SNP -,SUP-406709,CDM,C1894,HCPCS,272,RC,,,outpatient,,,105.03,73.521,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 8FRX60CM FAST-CATH TRNSEPT MLNS CRV SNP LOCK -,SUP-406805,CDM,C1894,HCPCS,272,RC,,,outpatient,,,501.81,351.267,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SR0 CURVE-SJM -,SUP-406853,CDM,C1894,HCPCS,272,RC,,,outpatient,,,898.59,629.013,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH AGILIS MED-REPROC  8.5X 71CM -,SUP-408310,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2473.84,1731.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 4FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-604X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 6FR MI D L 23CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-606D,CDM,C1894,HCPCS,272,RC,,,outpatient,,,93.36,65.352,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 7FR MI D L 23CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-607T,CDM,C1894,HCPCS,272,RC,,,outpatient,,,93.36,65.352,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH INTRODUCER AVANTI 7FR X 11 CM -,SUP-504-607X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 8FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-608X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 9FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-609X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 10FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504610X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 11FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-611X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 5MS FR DIA MI D L 23CM CANN AVANTI + PERC TAPR SS -,SUP-504-655T,CDM,C1894,HCPCS,272,RC,,,outpatient,,,103.57,72.499,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 5MS DIA STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-655X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 5MS DIA STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-655X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 6MS FR DIA MI D L 23CM CANN AVANTI + PERC TAPR SS -,SUP-504-656T,CDM,C1894,HCPCS,272,RC,,,outpatient,,,93.36,65.352,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 6FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-656X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 6FR STD L 11CM CANN AVANTI  PERC TAPR SS W/O -,SUP-504-656X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
MONITORING SHEATH 7 FR INTRO -,SUP-504-657X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 8MS DIA STD L 11CM CANN AVANTI PERC TAPR SS W/O -,SUP-504-658X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
TIGHTRAIL MINI 11FR 545-011 -,SUP-540-011,CDM,C1894,HCPCS,272,RC,,,outpatient,,,7193.58,5035.506,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
TIGHTRAIL MINI  9FR 545-009 -,SUP-545-009,CDM,C1894,HCPCS,272,RC,,,outpatient,,,7193.58,5035.506,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
TIGHTRAIL LONG  9FR 545-509 -,SUP-545-509,CDM,C1894,HCPCS,272,RC,,,outpatient,,,10121.94,7085.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
TIGHTRAIL LONG 11FR 545-511 -,SUP-545-511,CDM,C1894,HCPCS,272,RC,,,outpatient,,,10121.94,7085.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
TIGHTRAIL LONG 13FR 545-513 -,SUP-545-513,CDM,C1894,HCPCS,272,RC,,,outpatient,,,10121.94,7085.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH GUID 8FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-54-84501,CDM,C1894,HCPCS,272,RC,,,outpatient,,,609.76,426.832,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
GLIDESHEATH SLENDER 6FR X 10CM X .021CM SS GLIDEWIRE -,SUP-60-1060,CDM,C1894,HCPCS,272,RC,,,outpatient,,,353.02,247.114,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
GLIDESHEATH SLENDER A KIT 0.025 GW 6FR 10CM -,SUP-60-1065,CDM,C1894,HCPCS,272,RC,,,outpatient,,,619.97,433.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
GLIDESHEATH SLENDER A KIT 0.025 GW 7FR 10CM -,SUP-60-1075,CDM,C1894,HCPCS,272,RC,,,outpatient,,,619.97,433.979,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 7FRX11CM INPUT PS PERC 0.038IN GW COMP VES -,SUP-700-11,CDM,C1894,HCPCS,272,RC,,,outpatient,,,56.02,39.214,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRODUCER SET 11 FR - DISCONTINUED DO NOT USE -,SUP-7097,CDM,C1894,HCPCS,272,RC,,,outpatient,,,320.93,224.651,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
GLIDESHEATH SLENDER SS KIT 0.025 GW 6FR 10CM -,SUP-80-1065,CDM,C1894,HCPCS,272,RC,,,outpatient,,,353.02,247.114,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
GLIDESHEATH SLENDER SS KIT 0.025 GW 7FR 10CM -,SUP-80-1075,CDM,C1894,HCPCS,272,RC,,,outpatient,,,353.02,247.114,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
AMPLATZER DELIVERY SHEATH TORQVUE 2 5FR REF: 9-TV2-05F120 -,SUP-90176109,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
AMPLATZER DELIVERY SHEATH TORQVUE 2 6FR REF: 9-TV2-06F120 -,SUP-9-TV2-06F120,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
TORQVUE SHEATH 14F 80CM 45X45 REF: 9-TV45X45-14F-080 -,SUP-9-TV45X45-14F-080,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4676.89,3273.823,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
OBTURATOR VASC 8FR SHRT -,SUP-AO-09000,CDM,C1894,HCPCS,272,RC,,,outpatient,,,13.65,9.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
CATH PA 7FR X 110CM SWAN-GNZ LUMX4 PLYMR BLND -,SUP-C146F7,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2531.31,1771.917,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRODUCER SHEATH 8.5FR CATH-GARD PERC ARROW KIT -,SUP-CDC-09803-1A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,430.62,301.434,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
9FR. PERC SHEATH INTRO KIT -,SUP-CDC-09903-1A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,418.37,292.859,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 10FRX35CM SUPER ARROW-FLEX PERC SNP-LOCK MIN -,SUP-CL-07035,CDM,C1894,HCPCS,272,RC,,,outpatient,,,547.82,383.474,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 5FR SHTH 4.375IN SHTH 0.035-0.038IN GW HEMSTS VLV -,SUP-CL-07511,CDM,C1894,HCPCS,272,RC,,,outpatient,,,182.55,127.785,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 6FRX24CM SUPER ARROW-FLEX PERC 0.038IN GW COMP -,SUP-CL-07624,CDM,C1894,HCPCS,272,RC,,,outpatient,,,431.79,302.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 6FRX45CM SUPER ARROW-FLEX PERC ANTMIC SURF PU -,SUP-CL-07645,CDM,C1894,HCPCS,272,RC,,,outpatient,,,553.38,387.366,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 7FRX24CM SUPER ARROW-FLEX PERC INTGR HEMSTS -,SUP-CL-07724,CDM,C1894,HCPCS,272,RC,,,outpatient,,,379.08,265.356,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 7FRX45CM SUPER ARROW-FLEX PERC ANTMIC SURF PU -,SUP-CL-07745,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.82,364.574,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH CLASSICSHEATH 6FR STD 13CM CRV GRN CAP -,SUP-CLS-1006,CDM,C1894,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO VASC 7FR SAFESHEATH INFS SDPRT -,SUP-CLS-1007,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.77,253.239,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO VASC 10FR SUPER SHTH INFS SDPRT -,SUP-CLS-1010,CDM,C1894,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 5FRX11CM SUPER ARROW-FLEX PERC 0.035IN GW COMP -,SUP-CP-07511,CDM,C1894,HCPCS,272,RC,,,outpatient,,,148.79,104.153,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
DRYSEAL FLEX INTRODUCER SHEATH - 1233 -,SUP-DSF1233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3695.08,2586.556,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH INTRO 12FRX28CM DRYSEAL HYDRCT -,SUP-DSF1233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3695.08,2586.556,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH DRYSEAL INTRODUCER -,SUP-DSF1245,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4821.18,3374.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
DRYSEAL FLEX INTRODUCER SHEATH 14FR REF: DSF1433 -,SUP-DSF1433,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
GORE INTRODUCER SHEATH 16 -,SUP-DSF1633,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3695.08,2586.556,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
DRYSEAL SHEATH--16 FR X 65CM -,SUP-DSF1665,CDM,C1894,HCPCS,272,RC,,,outpatient,,,5780.33,4046.231,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
GORE INTRODUCER SHEATH 18 -,SUP-DSF1833,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
22FR X 33CM DRYSEAL SHEATH -,SUP-DSF2233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
GORE DRY SEAL SHEATH 22F X 33CM -,SUP-DSF2233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
22FR X 65CM DRYSEAL SHEATH -,SUP-DSF2265,CDM,C1894,HCPCS,272,RC,,,outpatient,,,5780.33,4046.231,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
GORE DRY SEAL SHEATH 26F X 33CM -,SUP-DSF2633,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH INTRO 18FRX28CM DRYSEAL HYDRCT -,SUP-DSL1828,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
URETHRAL ACCESS SHTH 9.5FR ID AQ HYDRCT TAPR LUMX1 DILATOR -,SUP-FUS-095045,CDM,C1894,HCPCS,272,RC,,,outpatient,,,774.6,542.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
URETHRAL ACCESS SHTH 14FRX28CM AQ HYDRCT FLEXOR TAPR LUMX1 -,SUP-FUS-120028,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
URETHRAL ACCESS SHTH 12FR ID HYDRCT LUMX1 DILATOR -,SUP-FUS-120035,CDM,C1894,HCPCS,272,RC,,,outpatient,,,762.34,533.638,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
URETHRAL ACCESS SHTH 12FRX45CM HYDRCT TAPR LUMX1 DILATOR -,SUP-FUS-120045,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
DILATOR VASCULAR 16FR 20CM REF G01212 -,SUP-G01212,CDM,C1894,HCPCS,272,RC,,,outpatient,,,49.54,34.678,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH MICROPUN TRANSTLS TIP 0.018INX40CM GW PEDAL -,SUP-G02972,CDM,C1894,HCPCS,272,RC,,,outpatient,,,349.52,244.664,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 16FRX30CM PEEL-AWAY 0.038IN GW COMP -,SUP-G02997,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO CATH 22FRX13CM PEEL-AWAY LNG COONS TAPR STR 0.038IN GW -,SUP-G04096,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.57,194.299,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 18FRX15.5CM PEEL-AWAY LNG COONS TAPR STR 20CM VES -,SUP-G06444,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 20FRX13CM PEEL-AWAY PERC STR 20CM VES DILATOR W/O -,SUP-G06445,CDM,C1894,HCPCS,272,RC,,,outpatient,,,273.6,191.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 24FRX13CM PEEL-AWAY PERC STR 20CM VES DILATOR W/O -,SUP-G06446,CDM,C1894,HCPCS,272,RC,,,outpatient,,,273.6,191.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 12FRX15.5CM PEEL-AWAY PERC STR 0.038IN GW COMP -,SUP-G06492,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 14FRX15.5CM PEEL-AWAY PERC STR 0.038IN GW COMP -,SUP-G06496,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SET INTRODUCER PEEL-AWAY .038IN 15.5CM 15FR -,SUP-G06497,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
RING TRANS-JUG ACCESS SET WITH 9Fr -,SUP-G06541,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2759.32,1931.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 4MM 12FRX13CM PERFORM JTP 0.038IN GW COMP -,SUP-G07369,CDM,C1894,HCPCS,272,RC,,,outpatient,,,293.56,205.492,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 2.9MM 8FRX13CM FLEXOR 0.038IN GW SM CHECK-FLO VLV -,SUP-G07856,CDM,C1894,HCPCS,272,RC,,,outpatient,,,243.44,170.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH CHECKFLO PERFORMA 10FRX30CM -,SUP-G08686,CDM,C1894,HCPCS,272,RC,,,outpatient,,,419.77,293.839,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRODUCER CHECK-FLO PERFORMER 12FR 30CM -,SUP-G08956,CDM,C1894,HCPCS,272,RC,,,outpatient,,,419.77,293.839,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRODUCER CHECK-FLO PERFORMER 14FR 30CM -,SUP-G08957,CDM,C1894,HCPCS,272,RC,,,outpatient,,,419.77,293.839,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
CHECK FLOW PERFORMER INTRODUCER 16FR 70CM REF:G09582 -,SUP-G09582,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRODUCER CHECK-FLO PERFORMER 16FR 30CM -,SUP-G09691,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SET INTRODUCER CHECK-FLO EXTRA LARGE 18FR 40CM -,SUP-G10626,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH GUID 2.2MM 6FRX45CM FLEXOR CHECK-FLO BLKN UP/ OVR -,SUP-G10634,CDM,C1894,HCPCS,272,RC,,,outpatient,,,313.51,219.457,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
S COOK 6FR X 6CM -,SUP-G10675,CDM,C1894,HCPCS,272,RC,,,outpatient,,,170.73,119.511,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SET INTRODUCER CATHETER NEFF 4/6FR -,SUP-G10797,CDM,C1894,HCPCS,272,RC,,,outpatient,,,513.42,359.394,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 5FRX9CM PEEL-AWAY MICROPUNCTURE DENNY MOD LCK -,SUP-G11566,CDM,C1894,HCPCS,272,RC,,,outpatient,,,465.11,325.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 6FRX9CM PEEL-AWAY PERC DENNY MOD 0.018IN GW COMP -,SUP-G11568,CDM,C1894,HCPCS,272,RC,,,outpatient,,,465.11,325.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 8FRX9CM PEEL-AWAY PERC DENNY MOD 0.038IN GW COMP -,SUP-G11570,CDM,C1894,HCPCS,272,RC,,,outpatient,,,375.77,263.039,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
VALVE CHECK-FLO 7F 55C RAABE K -,SUP-G11633,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH RAABE FLEXOR 7FR X 90CM -,SUP-G11634,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH GUID 7FRX70CM FLEXOR CHECK-FLO RAABE MOD STR 0.038IN -,SUP-G11635,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH GUID 6FRX70CM FLEXOR CHECK-FLO RAABE MOD STR 0.038IN -,SUP-G11636,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH GUID 2.9MM 8FRX70CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G11637,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH 6FR STRAIGHT FLEXOR -,SUP-G11638,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH GUID 2.2MM 6FRX55CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G11638,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
CHECK FLOW PERFORMER INTRODUCER 18FR X 30CM -,SUP-G11672,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
VALVE CHECK-FLO 8F 55C RAABE K -,SUP-G12242,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH 6FR 90CM RAABE KCFW-6.0 -,SUP-G12266,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH GUID 3.2MM 9FRX70CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G12606,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRODUCER CHECK-FLO PERFORMER 22FR 25CM -,SUP-G12831,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2364.02,1654.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH GUID 2.5MM 7FRX90CM FLEXOR SHTL SFT TIP HYDRCT -,SUP-G12835,CDM,C1894,HCPCS,272,RC,,,outpatient,,,611.39,427.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH GUID 1.9MM 5FRX55CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G13009,CDM,C1894,HCPCS,272,RC,,,outpatient,,,268.41,187.887,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH GUID 1.9MM 5FRX90CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G13069,CDM,C1894,HCPCS,272,RC,,,outpatient,,,348.58,244.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 5FRX70CM FLEXOR CHECK-FLO RAABE MOD STR 0.038IN -,SUP-G13091,CDM,C1894,HCPCS,272,RC,,,outpatient,,,268.41,187.887,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH 6FR. 80CM -,SUP-G13539,CDM,C1894,HCPCS,272,RC,,,outpatient,,,611.39,427.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
URETHRAL ACCESS SHTH 9.5FR ID HYDRCT TAPR LUMX1 DILATOR -,SUP-G19174,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
URETHRAL ACCESS SHTH 9.5FRX28CM AQ HYDRCT FLEXOR TAPR LUMX1 -,SUP-G19176,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH 20F X 25CM COOK -,SUP-G28999,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2364.02,1654.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 12FRX24CM PEEL-AWAY PERC CRV 0.038IN GW COMP 34CM -,SUP-G29839,CDM,C1894,HCPCS,272,RC,,,outpatient,,,689.99,482.993,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 14FRX24CM PEEL-AWAY CRV 0.038IN GW COMP 18GA 12ML -,SUP-G29840,CDM,C1894,HCPCS,272,RC,,,outpatient,,,689.99,482.993,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH GUID 2.5MM 7FRX45CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29885,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
5Fr. 45cm ANSEL SHEATH WITH ANGLE KCFW-5.0-18/38/45-RB-ANL1- -,SUP-G29981,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH GUID 1.9MM 5FRX45CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29981,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH GUID 1.9MM 5FRX90MM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29988,CDM,C1894,HCPCS,272,RC,,,outpatient,,,586.83,410.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH 6F ANSEL 90CM FLEXOR KC -,SUP-G29989,CDM,C1894,HCPCS,272,RC,,,outpatient,,,586.83,410.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH GUID 2.2MM 6FRX55MM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29996,CDM,C1894,HCPCS,272,RC,,,outpatient,,,420.18,294.126,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH GUID 2.2MM 6FRX55MM FLEXOR CHECK-FLO ANSEL MOD RNL -,SUP-G29997,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHUTTLE SELECT GUIDE SHEATH KS -,SUP-G31138,CDM,C1894,HCPCS,272,RC,,,outpatient,,,617.11,431.977,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH CHECKFLOW 3.4MM 10FRX40CM FLEXOR -,SUP-G32233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,385.81,270.067,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH GUID 4.1MM 12FRX40CM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-G32373,CDM,C1894,HCPCS,272,RC,,,outpatient,,,444.22,310.954,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SET MICROPUNCTURE 5.0F 10CM -,SUP-G36333,CDM,C1894,HCPCS,272,RC,,,outpatient,,,159.7,111.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH GUID 3.2MM 9FRX55CM FLEXOR CHECK-FLO RAABE MOD -,SUP-G36393,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
MICRO PUNCTURE  5FR X 10CM  0.018INX40CM -,SUP-G43870,CDM,C1894,HCPCS,272,RC,,,outpatient,,,191.21,133.847,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH 5F ANSEL 45CM ANLO -,SUP-G44153,CDM,C1894,HCPCS,272,RC,,,outpatient,,,300.62,210.434,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH 6F ANSEL 45CM -,SUP-G44154,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH MICROPUNCTURE TRANSTLS TIP 0.018INX40CM PLTNM TIP -,SUP-G47942,CDM,C1894,HCPCS,272,RC,,,outpatient,,,190.1,133.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
MICROPUNCTURE STIFF 4F NIT -,SUP-G48003,CDM,C1894,HCPCS,272,RC,,,outpatient,,,281.36,196.952,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
MICROPUNCTURE TRANSITIONLESS STIFFENED CANNULA ACCESS SET -,SUP-G48005,CDM,C1894,HCPCS,272,RC,,,outpatient,,,281.36,196.952,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
WIRE FOR  MICROPUNCTURE 0.018 IN X 40 CM PLTNM TIP -,SUP-G48007,CDM,C1894,HCPCS,272,RC,,,outpatient,,,281.36,196.952,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH GUID 1.5MM 4FRX45MM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-G48186,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH 4F ANSEL 90CM -,SUP-G48188,CDM,C1894,HCPCS,272,RC,,,outpatient,,,620.26,434.182,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH 5F 90 RB ANSEL KCF-5.0- -,SUP-G48189,CDM,C1894,HCPCS,272,RC,,,outpatient,,,620.26,434.182,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH 7F X 55CM ANSEL 1 -,SUP-G49043,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH GUID 2.9MM 8FRX45CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G49100,CDM,C1894,HCPCS,272,RC,,,outpatient,,,356.11,249.277,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH GUID 3.2MM 9FRX45MM FLEXOR CHECK-FLO ANSEL MOD ANL1 -,SUP-G49102,CDM,C1894,HCPCS,272,RC,,,outpatient,,,356.11,249.277,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH GUID 6FRX70CM FLEXOR 0.038IN GW COMP HYDRCT -,SUP-G56221,CDM,C1894,HCPCS,272,RC,,,outpatient,,,452.45,316.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH GUIDING 7FR x 70CM STRAIGHT -,SUP-G56222,CDM,C1894,HCPCS,272,RC,,,outpatient,,,452.45,316.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH GUID 2.2MM 6FRX70CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G56226,CDM,C1894,HCPCS,272,RC,,,outpatient,,,452.45,316.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH GUID 1.9MM 5FRX55CM FLEXOR CHECK-FLO ANSEL MOD STR. -,SUP-G56230,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH GUID 1.9MM 5FRX55CM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-G56235,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH 6F X 55 ANSEL 1 -,SUP-G56236,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH FLEXOR PARALLEL 9.5CM x 28CM - URETERAL -,SUP-G56429,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1012.66,708.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH FLEXOR PARALLEL 9.5FR x 45CM URETERAL -,SUP-G56431,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1012.66,708.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SET MICROPUNCTURE INTRODUCER 21G -,SUP-G84006,CDM,C1894,HCPCS,272,RC,,,outpatient,,,252.07,176.449,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH GUIDING DESTINATION SLENDER 105CM 6FR STRAIGHT -,SUP-GS-R6ST1C10W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1599.43,1119.601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SYS SHEATH RTRVL 4FR BNTP EMBL PROT FLTWR EZ -,SUP-H749501001500,CDM,C1894,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
COAXIAL MICROINTRODUCER KIT 4FR -,SUP-H965457531,CDM,C1894,HCPCS,272,RC,,,outpatient,,,175.05,122.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO PERC 6FR SHTH INTROFLEX -,SUP-I500-F6,CDM,C1894,HCPCS,272,RC,,,outpatient,,,288.25,201.775,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 9FR STD INTROFLEX PERC W/O LIDOCN -,SUP-I505BF9C,CDM,C1894,HCPCS,272,RC,,,outpatient,,,243.32,170.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 5FRX10CM MICROPUNCTURE STF CANN COAX CATH PR -,SUP-JCD5.01810.0MPI,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.06,81.242,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
10fr 0.035 Flexer Guiding Sheath -,SUP-KCFW-10.0-35-RB-RTPS-100,CDM,C1894,HCPCS,272,RC,,,outpatient,,,641.79,449.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 2.2MM 6FRX30CM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-KCFW6.0-38-30RB,CDM,C1894,HCPCS,272,RC,,,outpatient,,,268.35,187.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO CATH 6FRX13CM SHTH FLEXOR NTPR 0.038IN GW VES DILATOR -,SUP-KCFW-6.0-38-RB,CDM,C1894,HCPCS,272,RC,,,outpatient,,,243.44,170.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO 4.5FRX5CM MICRO-ACCESS TEARAWAY 0.018INX4.CM MRK NTNL -,SUP-KIT-010-03,CDM,C1894,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
CATHETER RETRIEVAL AVEIR REF:LSCR111 -,SUP-LSCR111,CDM,C1894,HCPCS,272,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
LOADING SYSTEM ENVEO R  LS-MDT2-2629-US -,SUP-LS-MDT2-2629-US,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2067.2,1447.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
CATHETER INTRODUCER AVEIR 30CM REF:LSN25301 -,SUP-LSN25301,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 21GA ACCUSTICK II STF CANN -,SUP-M001207020,CDM,C1894,HCPCS,272,RC,,,outpatient,,,416.39,291.473,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH INTRO 8.5FRX60CM HEARTSPAN TRNSEPT 55DG CRV TAPR -,SUP-M0045660550,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1108.65,776.055,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH URET 11/13FRX36CM NAVIGATOR -,SUP-M0062502021,CDM,C1894,HCPCS,272,RC,,,outpatient,,,567.91,397.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH NAVIGATOR HD 11/13 X 28 -,SUP-M0062502210,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH NAVIGATOR HD 11 13 36 -,SUP-M0062502220,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH NAVIGATOR HD 11 13 46 -,SUP-M0062502230,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH NAVIGATOR HD 12 14 36 -,SUP-M0062502250,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH NAVIGATOR 12F/14F X 46CM -,SUP-M0062502260,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
ST DILATOR URETH 8-30FR OD 35CM 30CM SHTH TFLN-CT TAPR GRAD -,SUP-M0062601000,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1208.3,845.81,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
ST DILATOR URETH SHTH 8FR/10FR 70CM/35CM L PTFE TAPR LF -,SUP-M0062601200,CDM,C1894,HCPCS,272,RC,,,outpatient,,,280.31,196.217,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
URETHRAL ACCESS SHTH 34FR TAPR -,SUP-M0062601600,CDM,C1894,HCPCS,272,RC,,,outpatient,,,344.5,241.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
MICRO PUNCTURE 4FR X 10 CM NTNL 0.018X 40 -,SUP-MAK401NPD,CDM,C1894,HCPCS,272,RC,,,outpatient,,,91.84,64.288,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
MICRO PUNCTURE  5FR X 10CM  0.018INX40CM - MAK501N -,SUP-MAK501N,CDM,C1894,HCPCS,272,RC,,,outpatient,,,151.42,105.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
MICRA INTRO SHEATH HYDRO COAT -,SUP-MI2355A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
MICINTRO SHTH 7FRX7CM VENEFIT ECHGNC TIP 21GA -,SUP-MIS7F07,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
MICRO INTRO SHEATH 7F 11CM -,SUP-MIS-7F11,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH MICROPUNCTURE TRANSTLS TIP 0.018INX40CM PLTNM TIP -,SUP-MPIS-401-NT,CDM,C1894,HCPCS,272,RC,,,outpatient,,,190.1,133.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 4FR MICROPUNCTURE TRANSTLS TIP 0.018INX40CM PLTNM -,SUP-MPIS401PEDNTSST,CDM,C1894,HCPCS,272,RC,,,outpatient,,,197.05,137.935,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 5FRX10CM MICROPUNCTURE TRANSTLS TIP 0.018INX40CM -,SUP-MPIS-501-NT,CDM,C1894,HCPCS,272,RC,,,outpatient,,,191.21,133.847,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO ORTHO 4FR MICRO-STK NTNL WIRE -,SUP-MR190421,CDM,C1894,HCPCS,272,RC,,,outpatient,,,105.03,73.521,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 18FRX85CM PERFORM 0.038IN GW 97CM VES DILATOR -,SUP-RCFW18.0P3885RB,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 2.6MM 8FRX63CM PERFORM MLNS CRV 0.038IN GW COMP -,SUP-RCFW8.0-38-63,CDM,C1894,HCPCS,272,RC,,,outpatient,,,433.42,303.394,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH INTRO 6FRX10CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB602,CDM,C1894,HCPCS,272,RC,,,outpatient,,,152.29,106.603,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH INTRO 7FR X 10CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB702,CDM,C1894,HCPCS,272,RC,,,outpatient,,,152.29,106.603,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH INTRO 8FRX25CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB803,CDM,C1894,HCPCS,272,RC,,,outpatient,,,193.72,135.604,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH INTRO 9FRX10CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB902,CDM,C1894,HCPCS,272,RC,,,outpatient,,,152.29,106.603,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH INTRO 9FRX25CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB903,CDM,C1894,HCPCS,272,RC,,,outpatient,,,193.72,135.604,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH INTRO 5FRX10CM PINNCL PERIPH STR CRV 0.035IN GW COMP -,SUP-RSS501,CDM,C1894,HCPCS,272,RC,,,outpatient,,,63.43,44.401,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH 8FR 10CM PINNACLE -,SUP-RSS802,CDM,C1894,HCPCS,272,RC,,,outpatient,,,60.68,42.476,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH 9FR 10CM PINNACLE -,SUP-RSS901,CDM,C1894,HCPCS,272,RC,,,outpatient,,,63.43,44.401,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 14FRX28CM SENTRANT 0.035IN GW HYDRCT -,SUP-SENSH1428W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1108.65,776.055,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
INTRO SHTH 16FRX28CM SENTRANT 0.035IN GW COMP HYDRCT -,SUP-SENSH1628W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1123.71,786.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH 18FR MEDTRONIC -,SUP-SENSH1828W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1123.71,786.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH 20FR X 28CM MEDTRONIC -,SUP-SENSH2028W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1258.87,881.209,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
MICRO PUNCTURE  5FR X 10CM  0.018INX40CM STIFF- S-MAK501N -,SUP-S-MAK501N,CDM,C1894,HCPCS,272,RC,,,outpatient,,,210.06,147.042,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH NAVIGATOR 12F/14F X 28CM -,SUP-STRYKER INSTRUMENTS,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
9.5F SAFESHEATH PEEL AWAY HEMO -,SUP-UNDEFINED,CDM,C1894,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SHEATH INTRO 6FR BRT TIP -,SUP-UNDEFINED,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
CATAPULT US 5F 15CM STRAIGHT 5PK -,SUP-US-35015-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,519.32,363.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
CATAPULT US 5F 45CM STRAIGHT 5PK -,SUP-US-35045-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,636.02,445.214,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
CATAPULT US 5F 60CM STRAIGHT 5PK -,SUP-US-35060-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,694.37,486.059,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
CATAPULT US 5F 90CM STRAIGHT 5PK -,SUP-US-35090-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
TRANSEPTAL ACCESS SET VERSACROSS REF: VXSK0032 -,SUP-VXSK0032,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4630.78,3241.546,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
SET INTRODUCER CHECK-FLO EXTRA LARGE 20FR 40CM -,SUP-XVCFW-20.0-35-40,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2364.02,1654.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.064425,7986.663,other,Non-Reimbursable List,,
LEAD DEFIB IMPL BIPLR PERMNT PCNG ETAK RELIANCE 59CM 8FR -,SUP-0157,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List,,
LEAD DEFIB ETAK RELIANCE 59CM -,SUP-0275-59,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List,,
LEAD DEFIB ETAK RELIANCE 64CM -,SUP-0276-64,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List,,
LEAD DEFIB ENDOTAK RELIANCE G 64CM -,SUP-0286,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List,,
LEAD DEFIB PCNG ETAK RELIANCE 64CM GORE-HYBRID ETFE CTD STRD -,SUP-0293-64,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10470.66,7329.462,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List,,
LEAD DEFIB IMPL BIPLR ETAK RELIANCE 4- SITE 59CM RT ECRD -,SUP-0295,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List,,
LEAD DEFIB IMPL BIPLR ETAK RELIANCE 4- SITE 64CM RT ECRD -,SUP-0296,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List,,
LEAD RELIANCE 4-FRONT 0673 64 CM -,SUP-0673-64,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List,,
LEAD DEFIB BIPLR PERMNT PCNG KENTROX SL 65CM 7.8FRX180MM SPC -,SUP-350054,CDM,C1895,HCPCS,278,RC,,,outpatient,,,14265.35,9985.745,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List,,
LEAD DEFIB IMPL LINOX SMRT SD 65CM 18CM ECRD SIL INSL DL -,SUP-359067,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List,,
LEAD PCNG 60MM LINOX SD IMPL BIPLR RV STRD ELUT ACT -,SUP-363303,CDM,C1895,HCPCS,278,RC,,,outpatient,,,14265.35,9985.745,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List,,
LEAD DEFIB TRIPLR SPRNT QUATTRO 65CM 8.6FRX12MM SPC RT ECRD -,SUP-6935-65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List,,
LEAD DEFIB 8.6FRX12MM SPC 55CM SPRNT QUATTRO TRIPLR STRD -,SUP-6935M55,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List,,
LEAD DEFIB TRIPLR SPRNT QUATTRO 62CM 8.6FRX12MM SPC SIL -,SUP-6935M62,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List,,
LEAD PCNG 8.6FRX12MM SPC 58CM SPRNT QUATTRO PERMNT QDPL -,SUP-6947-58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List,,
LEAD PCNG 8.6FRX12MM SPC 65CM SPRNT QUATTRO PERMNT QDPL -,SUP-6947-65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List,,
LEAD DEFIB QDPL SPRNT QUATTRO 55CM 8.6FRX12MM SPC RT ECRD -,SUP-6947M55,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List,,
LEAD DEFIB QDPL SPRNT QUATTRO 62CM 8.6FRX12MM SPC RT ECRD -,SUP-6947M62,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List,,
LEAD DEFIB QDPL SPRNT QUATTRO 72CM 8.6FRX12MM SPC RT ECRD -,SUP-6947M72,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List,,
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FRX170MM SPC VNTRC OPTIM -,SUP-7120/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List,,
LEAD DEFIB TRUE BIPLR DURATA 52CM 7FRX170MM SPC VNTRC OPTIM -,SUP-7120Q/52,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List,,
LEAD DEFIB TRUE BIPLR DURATA 58CM 7FR VNTRC OPTIM INSL SGL -,SUP-7120Q/58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List,,
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FR VNTRC OPTIM INSL SGL -,SUP-7120Q/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List,,
LEAD DEFIBRILLATOR DURATA OPTIM L21 CM OD7 FR 2 COIL -,SUP-7121,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11031.32,7721.924,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List,,
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FRX210MM SPC VNTRC OPTIM -,SUP-7121/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List,,
LEAD DEFIB TRUE BIPLR DURATA 52CM 7FR VNTRC OPTIM INSL SGL -,SUP-7121Q/52,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List,,
LEAD DEFIB DURATA IMPL -,SUP-7131,CDM,C1895,HCPCS,278,RC,,,outpatient,,,17543.93,12280.751,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List,,
LEAD DEFIB TRUE BIPLR DURATA 58CM 17CM-TO-PROX COIL 7FR -,SUP-7170Q/58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List,,
LEAD DEFIB TRUE BIPLR DURATA 58CM 21CM-TO-PROX COIL 7FR -,SUP-7171Q/58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List,,
LEAD DEFIB 8FR INTRO 65CM OPTISURE TRUE BIPLR XTD-RETRAC -,SUP-LDA230Q/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,13473.73824,other,Non-Reimbursable List,,
ELECTRODE DEFIB 12FR DIST TIP 9FR COIL 45CM Q-TRAK TRIPLR -,SUP-3400,CDM,C1896,HCPCS,278,RC,,,outpatient,,,14852,10396.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,11406.336,other,Non-Reimbursable List,,
ELECTRODE DEFIB 12FR DIST TIP 45CM EMBLEM TRIPLR SUBQ DIST -,SUP-3401,CDM,C1896,HCPCS,278,RC,,,outpatient,,,14852,10396.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,11406.336,other,Non-Reimbursable List,,
EMBLEM S-ICD LEAD 3501-45CM -,SUP-3501-45,CDM,C1896,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,11406.336,other,Non-Reimbursable List,,
LEAD EPICARDIAC 5071 -,SUP-5071,CDM,C1896,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,11406.336,other,Non-Reimbursable List,,
LEAD PCNG 58CM TRANSVENE IMPL UNIPL ECRD CS SVC -,SUP-6937A58,CDM,C1896,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,11406.336,other,Non-Reimbursable List,,
OPTISURE DEFIBRILLATION LEAD DF1 SINGLE COIL LDA210-65 -,SUP-LDA210-65,CDM,C1896,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,11406.336,other,Non-Reimbursable List,,
KT LEAD NEURSTM OCTRODE 60CM PERC ACC -,SUP-3086ANS,CDM,C1897,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,196.493625,28414.1568,other,Non-Reimbursable List,,
KT LEAD NEURSTM 60CM PERC ACC 6MM -,SUP-3873-60,CDM,C1897,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,196.493625,28414.1568,other,Non-Reimbursable List,,
KT LEAD NEURSTM 60CM PERC SUBCOMPACT ACC -,SUP-3875-60,CDM,C1897,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,196.493625,28414.1568,other,Non-Reimbursable List,,
REACTIV8 IMPLANTABLE PULSE GENERATOR -,SUP-5100,CDM,C1897,HCPCS,278,RC,,,outpatient,,,36997.6,25898.32,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,196.493625,28414.1568,other,Non-Reimbursable List,,
KT IT REVISN INTFC TRANSP STRN RLF SLVX2 NS RLR F/SULS PMP -,SUP-8578,CDM,C1897,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,196.493625,28414.1568,other,Non-Reimbursable List,,
LEAD NEURSTM VECTRIS SURSCN 60CM PERC SPIN CRD MRI-COND -,SUP-977D260,CDM,C1897,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,196.493625,28414.1568,other,Non-Reimbursable List,,
SLIM TIP DRG TRIAL LEAD KIT -,SUP-MN10350-50A,CDM,C1897,HCPCS,278,RC,,,outpatient,,,4874.15,3411.905,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,196.493625,28414.1568,other,Non-Reimbursable List,,
SLIP TIP DRG -,SUP-MN10350-90A,CDM,C1897,HCPCS,278,RC,,,outpatient,,,4909.5,3436.65,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,196.493625,28414.1568,other,Non-Reimbursable List,,
STIMWAVE NEUROSTIMULATOR RECEIVER KIT -,SUP-STQ4-RCV-A0,CDM,C1897,HCPCS,278,RC,,,outpatient,,,32936.92,23055.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,196.493625,28414.1568,other,Non-Reimbursable List,,
PNS PERMANENT TINED RECEIVER KIT CHANNEL B -,SUP-STQ4-RCV-B0,CDM,C1897,HCPCS,278,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,196.493625,28414.1568,other,Non-Reimbursable List,,
LEAD NRV STIM 50CM F/TRL -,SUP-UNDEFINED,CDM,C1897,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,196.493625,28414.1568,other,Non-Reimbursable List,,
LEAD PCNG 8FR INTRO 58CM TENDRIL DX PERMNT BIPLR AV -,SUP-1388TC/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 1642T X 46 -,SUP-1642T/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 7FR INTRO 10MM SPC 52CM ISFLX PERMNT BIPLR STR AV -,SUP-1646T/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 1646T-58 ISFLX PERMNT BIPLR_STR AV -,SUP-1646T/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 46CM TENDRIL -,SUP-1688TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
TENDRIL SDX 1688TC/46 -,SUP-1688TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD TENDRIL 1688 TC/58 -,SUP-1688TC-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 6FR INTRO 10MM SPC 52CM TENDRILL SDX PERMNT BIPLR -,SUP-1788TC/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 6FR INTRO 10MM SPC 58CM TENDRILL SDX PERMNT BIPLR -,SUP-1788TC/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 7FR INTRO 10MM SPC 46CM TENDRILL ST PERMNT BIPLR -,SUP-1882TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 7FR INTRO 10MM SPC 52CM TENDRILL ST PERMNT BIPLR -,SUP-1882TC/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 6FR INTRO 10MM SPC 46CM TENDRILL ST PERMNT BIPLR -,SUP-1888TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 6FR INTRO 10MM SPC 52CM TENDRILL ST PERMNT BIPLR -,SUP-1888TC/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 6FR INTRO 10MM SPC 58CM TENDRILL ST PERMNT BIPLR -,SUP-1888TC/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD ISOFLEX OPTIM J 1944-46CM -,SUP-1944/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 7FR INTRO 10MM SPC 52CM ISFLX PERMNT BIPLR J-SHP -,SUP-1944/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG ISOFLEX 1948-52 ISFLX PERMNT BIPLR STR AV. -,SUP-1948/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 7FR INTRO 10MM SPC 58CM ISFLX PERMNT BIPLR STR AV -,SUP-1948/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD OPINSENSE  MODEL 1999-52 -,SUP-1999/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD CATH DELIVERED 3830 69CM,SUP-2,CDM,C1898,HCPCS,275,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 6FRX46CM TENDRIL STS IMPL BIPLR RAV ACT SCR IN FX -,SUP-2088TC-46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 6FRX52CM TENDRIL STS IMPL BIPLR RAV ACT SCR IN FX -,SUP-2088TC-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 6FRX58CM TENDRIL STS IMPL BIPLR RAV ACT SCR IN FX -,SUP-2088TC-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 6.6FRX15MM SPC 60CM SELOX ST 60 PERMNT IMPL BIPLR -,SUP-346367,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 6.6FRX15MM SPC 53CM SELOX JT 53 PERMNT IMPL BIPLR -,SUP-346368,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 6.6FRX10MM SPC 45CM SETROX DX PERMNT IMPL BIPLR -,SUP-350973,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 7FRX10MM SPC 53CM SETROX DX PERMNT IMPL BIPLR HLCL -,SUP-350974,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 6.6FRX10MM SPC 60CM SETROX DX PERMNT IMPL BIPLR -,SUP-350975,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 6.6FR 7FR INTRO 53CM TILDA STR PSS FX -,SUP-382872,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD CATH DELIVERED 3830 69 CM -,SUP-383069,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 52CM SELUTE PICOTIP COMPLIANCE PRACTITIONERS -,SUP-4064,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 5.7FRX10MM SPC 35CM CAP NOV PERMNT BIPLR AV STRD -,SUP-4076-35,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2570.74,1799.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PPM 45CM CAPSURE FIX NOVUS 4076-45 -,SUP-4076-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 5.7FRX10MM SPC 45CM CAP NOV IMPL BIPLR AV STRD -,SUP-4076-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 5.3FRX9MM SPC 52CM CPSR SP NOVUS PERMNT BIPLR AV -,SUP-4092-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 5.3FRX9MM SPC 58CM CPSR SP NOVUS PERMNT BIPLR AV -,SUP-4092-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 6.7FRX10MM SPC 53CM DEXTRUS PERMNT BIPLR HLCL TIP -,SUP-4136-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 6.7FRX10MM SPC 60CM DEXTRUS PERMNT BIPLR HLCL TIP -,SUP-4137,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 5.7FRX16MM SPC 58CM FNLN STRX PERMNT BIPLR STR -,SUP-4457,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 1.7X16MM SPC_45CM FINELINE II EZ STEROX PERMNT -,SUP-4469,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 1.7X16MM SPC 45CM FINELINE II EZ STEROX PERMNT -,SUP-4469-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 1.7X16MM SPC 52CM FINELINE II EZ STEROX PERMNT -,SUP-4470-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 1.7X16MM SPC 58CM FINELINE II EZ STEROX PERMNT -,SUP-4471,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 5.7FRX45CM FNLN STRX AJ PERMNT BIPLR JTP RA ECRD -,SUP-4479,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 5.7FRX52CM FNLN STRX AJ PERMNT BIPLR JTP RA ECRD -,SUP-4480-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 5.3FRX9MM SPC 45CM CPSR SP NOVUS PERMNT BIPLR JTP -,SUP-4592-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 5.3FR CPSR SP NOVUS J-SHP ATR BIPLR -,SUP-4592-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD MEDTRONIC CAPSURE VDD-2 5038S-52 -,SUP-5038S-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD MEDTRONIC CAPSURE VDD-2 5038S-58 -,SUP-5038S-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG EPCRD -,SUP-5071-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PPM 45CM CAPSUREFIX SURSCN NOVUS 5076-45 -,SUP-5076-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 6.2FRX10MM SPC 52CM CAPSUREFIX SURSCN NOVUS IMPL -,SUP-5076-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 6.2FR X10MM SPC 58CM CAPSUREFIX SURSCN NOVUS IMPL -,SUP-5076-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 6.2FRX10MM SPC 65CM CAPSUREFIX SURSCN NOVUS IMPL -,SUP-5076-65,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 7FRX45CM CPSR FX MRI BIPLR STR AV ACT SCR IN FX -,SUP-5086MRI-45CM,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 7FRX52CM CPSR FX MRI BIPLR STR AV ACT SCR IN FX -,SUP-5086MRI-52CM,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 7FRX58CM CAPSUREFIX BIPLR STR AV ACT SCR IN FX -,SUP-5086MRI-58CM,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD MYOPORE BIPOLAR 511211 -,SUP-511211,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 35MM MYOPORE IMPL BIPLR EPCRD AV STRD ELUT ACT SCR -,SUP-511211,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 54CM MYOPORE IMPL BIPLR EPCRD AV STRD ELUT ACT SCR -,SUP-511212,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 7.2FRX53CM CAPSUREFIX PERMNT BIPLR J-SHP TIP ATR -,SUP-5568-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
BIPOLAR TEMPORARY MYOCARDIAL PACING LEAD -,SUP-6495F,CDM,C1898,HCPCS,278,RC,,,outpatient,,,408.45,285.915,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
OIL MNRL F/EZ INS STYL -,SUP-6529,CDM,C1898,HCPCS,278,RC,,,outpatient,,,175.05,122.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD INGEVITY MRI 7731 52 CM P -,SUP-7731,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD INGEVITY MRI 7732-59 ( PASSIVE ) -,SUP-7732,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD INGEVITY MRI 7732 59 -,SUP-7732-59,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
INGEVITY MRI  MODEL 7735-45 -,SUP-7735,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD INGEVITY MRI 7736-52 ( PASSIVE J ) -,SUP-7736,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD INGEVITY MRI 7740 -,SUP-7740,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD INGEVITY MRI 7741 52CM -,SUP-7741,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD INGEVITY MRI 7742 59CM -,SUP-7742,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
INGEVITY + 7840-45cm -,SUP-7840,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
INGEVITY + 7841/52 -,SUP-7841/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
INGEVITY + 7842/59 LEAD -,SUP-7842/59,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG ELAFIX ATR -,SUP-ELAFIX P2 752,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2549.32,1784.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 7FRX52CM BIPLR ECRD THN TND -,SUP-ELAPASSP752,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 7FRX58CM BIPLR ECRD THN TND -,SUP-ELAPASSP758,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2549.32,1784.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 7FRX52CM BIPLR J-SHP ECRD THN TND -,SUP-ELAPASSPJ752,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
TENDRIL MRI LEAD 46CM -,SUP-LPA1200M/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
TENDRIL MRI LEAD- 52CM -,SUP-LPA1200M/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
TENDRIL MRI LEAD- 58CM -,SUP-LPA1200M/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD CATH DELIVERED 3830 74CM -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD CATH DELIVERED 3830 49CM -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD CATH DELIVERED 3830 59CM -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD GENTR -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,39.298725,2053.20192,other,Non-Reimbursable List,,
LEAD PCNG 7FR INTRO 20MM SPC 86CM QUICKFLEX PERMNT BIPLR -,SUP-1156T/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List,,
LEAD PCNG 5FRX20MM SPC 75CM QUICKFLEX U BIPLR STYP CRV LH -,SUP-1258T/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List,,
LEAD PCNG 5FRX20MM SPC 86CM QUICKFLEX U BIPLR STYP CRV LH -,SUP-1258T/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List,,
LEAD PCNG 5FRX20MM SPC 92CM QUICKFLEX U BIPLR STYP CRV LH -,SUP-1258T/92,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List,,
Lead Quartet 1456/75Q LV Lead -,SUP-1456/75Q,CDM,C1900,HCPCS,278,RC,,,outpatient,,,8445.56,5911.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List,,
LEAD QUARTET 1456Q/86 LV LEAD -,SUP-1456/86Q,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List,,
QUARTET LEAD DOUBLE BEND- 75 CM MODEL 1457Q/75 -,SUP-1457Q/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List,,
QUARTET LEAD DOUBLE BEND-86CM MODEL 1457Q/86 -,SUP-1457Q/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List,,
LEAD PCNG 7FR INTRO 75CMX16MM QRTT CRT STYP CRV LH LPRO -,SUP-1458Q/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List,,
LEAD PCNG 7FR INTRO 86CMX16MM QRTT CRT STYP CRV LH LPRO -,SUP-1458Q/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List,,
LEAD QUARTET 75 WIDE SPACING -,SUP-1458QL/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List,,
LEAD QUARTET 1458QL 86 WIDE SPACING -,SUP-1458QL/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List,,
LEAD PCNG 5.4FRX18MM SPC 77CM COROX PERMNT IMPL BIPLR HMSPHR -,SUP-355148,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5228.61,3660.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List,,
LEAD SENTUS OTW QP L-75 -,SUP-386835,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List,,
LEAD SENTUS OTW QP S-75 -,SUP-400719,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List,,
LV LEAD SENTUS OTW QP L 75/49 -,SUP-408718,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List,,
LV LEAD SENTUS OTW QP L 85/49 -,SUP-408719,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List,,
LEAD PCNG 5FRX88CM ATTAIN PERMNT UNIPL CANTED LT VNTRC OTW -,SUP-4195-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List,,
LEAD PCNG 4FRX21MM SPC 88CM ATTAIN PERMNT BIPLR ANG LT VNTRC -,SUP-4196-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List,,
LEAD PCNG 5.3FRX21MM SPC 88CM ATTAIN ABILITY + IMPL BIPLR -,SUP-4296-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List,,
LEAD ATTAIN PERFORMA LV REF:429878 -,SUP-429878,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List,,
LEAD PCNG 5.3FRX21MM SPC 78CM ATTAIN PERFORM QDPL DBL CRV LT -,SUP-4298-78,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List,,
LEAD ATTAIN PERFORM 4298-88 CM QDPL DBL CRV LT -,SUP-4298-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List,,
LEAD ATTAIN PERFORMA QUAD LV  88 -,SUP-439888,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List,,
LEAD PCNG 6FRX11MM SPC 80CM EASYTRAK 2 IMPL UNIPL BIPLR LT -,SUP-4542,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5585.1,3909.57,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List,,
LEAD PCNG 6FRX11MM SPC 90CM EASYTRAK 2 IMPL UNIPL BIPLR LT -,SUP-4543,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5585.1,3909.57,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List,,
LEAD PCNG 6FRX11MM SPC 90CM EASYTRAK 3 IMPL UNIPL BIPLR LT -,SUP-4549,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5585.1,3909.57,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List,,
LEAD PCNG 4.5FRX90CM ACUITY IMPL UNIPL LT ECRD VNTRC SPRL FX -,SUP-4592,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List,,
LEAD ATTAIN PERFORMA LV 4598-78 -,SUP-4598-78,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List,,
LEAD ATTAIN PERFORMA LV 4598-88 -,SUP-4598-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List,,
LEAD ACUITY X4 86CM STRAIGHT -,SUP-4671,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List,,
LEAD ACUITY X4 95CM STRAIGHT -,SUP-4672-95,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List,,
LV LEAD ACUTIY SPIRAL S MODEL 4674-86 -,SUP-4674,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List,,
LEAD ACUITY X4 95CM SPIRAL S -,SUP-4675-95,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List,,
LEAD ACUITY X4 86CM SPIRAL L -,SUP-4677,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List,,
LEAD ACUITY X4 95CM SPIRAL L -,SUP-4678-95,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List,,
LEAD ATTAIN STABILITY QUAD MRI SURESCAN LV LEAD REF:4798-88 -,SUP-4798-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10247.88,7173.516,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List,,
LV LEAD SENTUS OTW QP S 75/49 MODEL 406081 -,SUP-706081,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List,,
LEAD COROX OTW-L 75-BP -,SUP-UNDEFINED,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5228.61,3660.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List,,
LEAD COROX OTW-L 85-BP -,SUP-UNDEFINED,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5228.61,3660.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,9410.2272,other,Non-Reimbursable List,,
PROBE PERC SPIN 17GAX6IN -,SUP-0407-250-000,CDM,C2614,HCPCS,270,RC,,,outpatient,,,8309.75,5816.825,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6381.888,other,Non-Reimbursable List,,
SIR-SPHERES Y-90 RESIN MICROSPHERES -,SUP-SIR-Y001,CDM,C2616,HCPCS,278,RC,,,outpatient,,,44393.67,31075.569,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,36549.06,,,36549.06,399.86,42246.08608,fee schedule,,,
STENT BLDR 14F/7FRX24CM RETROMAX + PERCUFLEX HYDRPLS CTD -,SUP-145-148,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1085.19,759.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT 6FR OPEN END -,SUP-160205,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT URET 8FRX80CM PERCUFLEX STR OPEN TIP -,SUP-160215,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
URINARY STENT 7FR CLOSED TIP -,SUP-160230,CDM,C2617,HCPCS,278,RC,,,outpatient,,,535.8,375.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT PANC 7FR PSHR CATH 5CM FREEMN -ALIPERT FLEX-STNT -,SUP-6521,CDM,C2617,HCPCS,278,RC,,,outpatient,,,320.93,224.651,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT PANC 7FRX9CM FREEMN FLX-STNT SGL PIGTL DBL XTRN FLNG -,SUP-6575,CDM,C2617,HCPCS,278,RC,,,outpatient,,,268.41,187.887,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT URET 4.7FRX26CM INLAY DBL PIGTL TAPR -,SUP-778426,CDM,C2617,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT BIL 10FRX5CM COTTON-LEUNG CRV TAPR PE -,SUP-CLSO 10-5,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT BIL 7FRX7CM COTTON-LEUNG CRV TAPR PE P/D FLP -,SUP-CLSO 7-7,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT BILIARY ZIMMON 8FR 12CM 0.035IN GW 3.2MM -,SUP-G21404,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT BIL 10FRX7CM COTTON-LEUNG CRV TAPR PE -,SUP-G21469,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT BIL 10FRX8CM COTTON-LEUNG CRV TAPR PE P/D FLP -,SUP-G21472,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT BIL 10FRX10CM COTTON-LEUNG CRV TAPR PE P/D FLP -,SUP-G21807,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT BILIARY ZIMMON 10-5 -,SUP-G21975,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT PANC 5FRX5CM ZIMMON SPRL SH PE PIGTL TAPR FLP LF MRI -,SUP-G22980,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT PANC 3FRX4CM ZIMMON SPRL SH PE PIGTL TAPR OPTN DCT FLP -,SUP-G24566,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT PANC 5FRX9CM GEENEN SPRL SH SOF-FLEX OFST PROX FLP LF -,SUP-G49666,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT PANC 5FR 7CM GEENEN SOF-FLEX NO INTERNAL FLAP -,SUP-G49670,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT PANC 5FR 9CM GEENEN SOF-FLEX NO INTERNAL FLAP -,SUP-G49671,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT BIL 7FRX5CM COMPASS BDS DBL PIGTL TAPR PLST 0.035IN GW -,SUP-G55519,CDM,C2617,HCPCS,278,RC,,,outpatient,,,414.29,290.003,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT PANC 5FR 3CM GEENEN SOF-FLEX NO INTERNAL FLAP -,SUP-GPSOS-SF-5-3,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT PANC 5FR 5CM GEENEN SOF-FLEX NO INTERNAL PLAP -,SUP-GPSOS-SF-5-5,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT URET 8FRX22CM PERCUFLEX DBL PIGTL FLXB STF -,SUP-M001245500,CDM,C2617,HCPCS,278,RC,,,outpatient,,,826.41,578.487,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT URET 6FRX22CM PERCUFLEX DBL PIGTL -,SUP-M001245730,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT URET 6FRX24CM PERCUFLEX DBL PIGTL -,SUP-M001245740,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT URET 6FRX26CM PERCUFLEX DBL PIGTL -,SUP-M001245750,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT URET 6FRX28CM PERCUFLEX DBL PIGTL -,SUP-M001245760,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT URET 8FRX26CM FLEXIMA DBL PIGTL -,SUP-M001274030,CDM,C2617,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT ADVANIX 7FR X 3CM DOUBLE PIGTAIL -,SUP-M00532160,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
ADVANIX DOUBLE PIGTAIL 7FR X 5CM -,SUP-M00532180,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
ADVANIX DOUBLE PIGTAIL 7FR X 7CM -,SUP-M00532190,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
ADVANIX DOUBLE PIGTAIL 7FR X 10CM -,SUP-M00532210,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
ADVANIX DOUBLE PIGTAIL 10FR X 5CM -,SUP-M00532260,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT BIL 10FRX5CM ADVANIX RX SGL DBL PIGTL PLST 4.2MM WKG -,SUP-M00532260,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
ADVANIX DOUBLE PIGTAIL 10FR X 7CM -,SUP-M00532270,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT BIL 10FRX15CM WALLSTNT DUOD BND PERCUFLEX -,SUP-M00533700,CDM,C2617,HCPCS,278,RC,,,outpatient,,,290.87,203.609,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT URET 8FRX22CM PERCUFLEX DBL PIGTL PSTNR -,SUP-M0061453800,CDM,C2617,HCPCS,278,RC,,,outpatient,,,441.13,308.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
SCISSORS SURG KAYE CRV 7.5IN SERR DSCT V. MUELLER LF -,SUP-M0061552310,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT URET 6FRX24CM POLARIS LOOP PERCUFLEX -,SUP-M0061552320,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT URET 6FRX26CM POLARIS LOOP PERCUFLEX -,SUP-M0061552330,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT URET 6FRX28CM POLARIS LOOP PERCUFLEX -,SUP-M0061552340,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT URET 8FRX26CM POLARIS LOOP PERCUFLEX -,SUP-M0061552530,CDM,C2617,HCPCS,278,RC,,,outpatient,,,836.51,585.557,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT URET 7FRX80CM PERCUFLEX STR LF -,SUP-M006160210,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT PERC PLUS 4.8 X 24 -,SUP-M0061752520,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT PERC PLUS 4.8 X 26 -,SUP-M0061752530,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT PERC PLUS 4.8 X 28 -,SUP-M0061752540,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT PERCUFLEX PLUS 6 X 22 -,SUP-M0061752610,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT PERCUFLEX PLUS 6 X 24 -,SUP-M0061752620,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT PERCUFLEX PLUS 6 X 26 -,SUP-M0061752630,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT PERCUFLEX PLUS 6 X 28 -,SUP-M0061752640,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT PERCUFLEX PLUS 6 X 30 -,SUP-M0061752650,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT PERCUFLEX PLUS 7FR X 24CM -,SUP-M0061752720,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT PERCUFLEX PLUS 7FR X 26CM -,SUP-M0061752730,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT PERCUFLEX PLUS 8 X 26 -,SUP-M0061752830,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT PERCUFLEX PLUS 8 X 28 NO -,SUP-M0061752840,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT URET 8FRX30CM PERCUFLEX DBL PIGTL TAPR -,SUP-M0061752850,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT URET 4.8FR 22-30CM CONTR VL PERCUFLEX DBL PIGTL TAPR -,SUP-M0061801550,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT URET 6FR 22-30CM CONTR VL PERCUFLEX DBL PIGTL TAPR -,SUP-M0061801560,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT URET CONTOUR 6 X 22 -,SUP-M0061802210,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT URET CONTOUR 6 X 28 -,SUP-M0061802240,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT URET 8FRX28CM PERCUFLEX TAPR LF -,SUP-M00618022440,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT URET CONTOUR 8 X 24 -,SUP-M0061802420,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT URET 6FRX22CM NTNL/PTFE DBL PIGTL -,SUP-M006190131090,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1073.17,751.219,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT URET 6FRX24CM NTNL/PTFE DBL PIGTL -,SUP-M006190132090,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1073.17,751.219,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT URET 6FRX22CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921310,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT URET 6FRX24CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921320,CDM,C2617,HCPCS,278,RC,,,outpatient,,,791.28,553.896,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT URET 6FRX26CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921330,CDM,C2617,HCPCS,278,RC,,,outpatient,,,791.28,553.896,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT URET 6FRX28CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921340,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT URET 8FRX22CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921510,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT URET 8FRX26CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921530,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT PANC 5FRX5CM ZIMMON SPRL SH PE PIGTL TAPR OPTN DCT FLP -,SUP-SPSOF-5-5,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT BIL 7FRX10CM ZIMMON DBL PIGTL TAPR PE -,SUP-ZSO-7-10,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
STENT BIL 7FRX7CM ZIMMON DBL PIGTL TAPR PE -,SUP-ZSO-7-7,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,734.3115,other,Non-Reimbursable List,,
PROBE CRYOSPHERE 11IN -,SUP-CRYOS,CDM,C2618,HCPCS,272,RC,,,outpatient,,,10397.8,7278.46,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7607.37,other,Non-Reimbursable List,,
PROBE CRYOSPHERE 18IN -,SUP-CRYOS-L,CDM,C2618,HCPCS,272,RC,,,outpatient,,,9468.15,6627.705,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7607.37,other,Non-Reimbursable List,,
ICEROD 1.5C X 90 NEEDLE -,SUP-FPRPR3533,CDM,C2618,HCPCS,272,RC,,,outpatient,,,8042.38,5629.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7607.37,other,Non-Reimbursable List,,
NEEDLE ICEROD CX 90 VL -,SUP-FPRPR3533,CDM,C2618,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7607.37,other,Non-Reimbursable List,,
NEEDLE ICEPEARL  2.1C X 90 -,SUP-FPRPR3601,CDM,C2618,HCPCS,272,RC,,,outpatient,,,8042.38,5629.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7607.37,other,Non-Reimbursable List,,
NEEDLE ICEFORCE 2.1 X 90 -,SUP-FPRPR3602,CDM,C2618,HCPCS,272,RC,,,outpatient,,,10610,7427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7607.37,other,Non-Reimbursable List,,
PACEMAKER IMPL BIPLR ADAPTA VDD SGL-CHMBR RR 11.1ML 23.6GM -,SUP-ADVDD01,CDM,C2619,HCPCS,275,RC,,,outpatient,,,16567.96,11597.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,12724.19328,other,SI=N Exclusions ,,
PACEMAKER IMPL EVIA HF-T TRI CHMBR 14ML 27GM IS-1 CONN -,SUP-377208,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25991,18193.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24381.0432,other,SI=N Exclusions ,,
PACEMAKER IMPL SYNCRA 15ML 26GM DR -,SUP-C2TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24381.0432,other,SI=N Exclusions ,,
PACEMAKER IMPL CONSULTA CRT-P SGL-CHMBR 15ML 26GM IS-1 CONN -,SUP-C4TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24381.0432,other,SI=N Exclusions ,,
PACEMAKER IMPL ANTHEM 2CHMBR RR 52X58MM 6MM 13.7ML 25GM IS-1 -,SUP-PM3210,CDM,C2621,HCPCS,275,RC,,,outpatient,,,19897.97,13928.579,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24381.0432,other,SI=N Exclusions ,,
PACEMAKER IMPL ALLURE RF 59X55MM 6MM 14ML 24GM IS-1 CONN -,SUP-PM3222,CDM,C2621,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24381.0432,other,SI=N Exclusions ,,
PACEMAKER IMPL QDPL ALLURE QUADRA RF 2CHMBR RR 59X56MM 6MM -,SUP-PM3242,CDM,C2621,HCPCS,275,RC,,,outpatient,,,20792.8,14554.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24381.0432,other,SI=N Exclusions ,,
CRT-PACER QUADRA ALLURE MP  RF -,SUP-PM3262,CDM,C2621,HCPCS,275,RC,,,outpatient,,,21813.88,15269.716,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24381.0432,other,SI=N Exclusions ,,
QUADRA ALLURE MP MRI PM3562 -,SUP-PM3562,CDM,C2621,HCPCS,275,RC,,,outpatient,,,20792.8,14554.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24381.0432,other,SI=N Exclusions ,,
PACEMAKER ALTRUA 60 49MMX43X8MM 12.1ML TI -,SUP-S606 DR EL,CDM,C2621,HCPCS,275,RC,,,outpatient,,,18193.7,12735.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24381.0432,other,SI=N Exclusions ,,
VALITUDE CRT-P U125 -,SUP-U125,CDM,C2621,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24381.0432,other,SI=N Exclusions ,,
CRT-P VALITUDE MODEL - U128 -,SUP-U128,CDM,C2621,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24381.0432,other,SI=N Exclusions ,,
VISIONIST CRT-P MODEL U226 BI-V PACEMAKER -,SUP-U226,CDM,C2621,HCPCS,275,RC,,,outpatient,,,27736.11,19415.277,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24381.0432,other,SI=N Exclusions ,,
CRT-P VISIONIST X4 - U228 -,SUP-U228,CDM,C2621,HCPCS,275,RC,,,outpatient,,,20313.82,14219.674,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24381.0432,other,SI=N Exclusions ,,
PACEMAKER IMPL INVIVE CRT-PS SMARTDELAY ALGORITHM RPM -,SUP-V172,CDM,C2621,HCPCS,275,RC,,,outpatient,,,31746.15,22222.305,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24381.0432,other,SI=N Exclusions ,,
PACEMAKER INTUA CARD -,SUP-V272,CDM,C2621,HCPCS,275,RC,,,outpatient,,,28590.1,20013.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24381.0432,other,SI=N Exclusions ,,
PACEMAKER PERCEPTA CRT-P MRI W1TR01 -,SUP-W1TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25991,18193.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24381.0432,other,SI=N Exclusions ,,
SOLARA CRT-P MRI W1TR03 -,SUP-W1TR03,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24381.0432,other,SI=N Exclusions ,,
PACEMAKER PERCEPTA QUAD CRT-P MRI W4TR01 -,SUP-W4TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25991,18193.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24381.0432,other,SI=N Exclusions ,,
PACEMAKER SERENA QUAD CRT-P MRI W4TR02 -,SUP-W4TR02,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25248.4,17673.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24381.0432,other,SI=N Exclusions ,,
SOLARA QUAD CRT-P MRI W4TR03 -,SUP-W4TR03,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24381.0432,other,SI=N Exclusions ,,
PROSTHESIS PENL CNCLBL 14MMX16CM ANG RGD CONN MIN SPR BK -,SUP-720056-02,CDM,C2622,HCPCS,278,RC,,,outpatient,,,24383.27,17068.289,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,23086.3872,other,SI=N Exclusions ,,
IMPLANT PENL CL 12MMX12CM SIL PE TI SEG MALE CNCLBL SNP FIT -,SUP-720074-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,20421.5,14295.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,23086.3872,other,SI=N Exclusions ,,
PROSTHESIS TACTRA 9.5MM X 14CM-23CM MALLEABLE -,SUP-720080-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,30060.4,21042.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,23086.3872,other,SI=N Exclusions ,,
TACTRA 11CM MALLEABLE PROSTHESIS -,SUP-720081-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,30060.4,21042.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,23086.3872,other,SI=N Exclusions ,,
TACTRA 13MM X 18CM-27CM MALLEABLE PROSTHESIS -,SUP-720082-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,28358.17,19850.719,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,23086.3872,other,SI=N Exclusions ,,
IMPLANT PENL DURA 11 10MMX14CM CL HX WRNCH STRL -,SUP-720093-10,CDM,C2622,HCPCS,278,RC,,,outpatient,,,15579.75,10905.825,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,23086.3872,other,SI=N Exclusions ,,
TIP PROS DURA II 10MMX1CM UNIV PENL STRL -,SUP-720093-12,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,23086.3872,other,SI=N Exclusions ,,
TIP PROS DURA II 10MMX5CM PROX PENL STRL -,SUP-720093-16,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,23086.3872,other,SI=N Exclusions ,,
TIP PROS DURA II 10MMX4CM DIST PENL STRL -,SUP-720093-23,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,23086.3872,other,SI=N Exclusions ,,
TIP PROS DURA II 10MMX2CM UNIV PENL STRL -,SUP-720093-60,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,23086.3872,other,SI=N Exclusions ,,
KT PROSTHESIS PENL 11MMX25CM MALE CYL MLBL TRMBL ADPR W/TAIL -,SUP-91-9511SC,CDM,C2622,HCPCS,278,RC,,,outpatient,,,20291.55,14204.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,23086.3872,other,SI=N Exclusions ,,
BARD BALLOON LUTONIX .035 4.0 X 150MM -,SUP-BSLX3513041505F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8912.4,6238.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
CATH PTCA 6MMX130CM LUTONIX 60MM DRG CTD 0.035IN GW COMP -,SUP-BSLX351306605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
LUTONIX BALLOON 6MM X 80MM -,SUP-BSLX351306805F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,7214.8,5050.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
RANGER DCB OTW  4.0MM x 40MM x 135CM -,SUP-H74939419400410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
RANGER GLOBAL DCB OTW 4.0 X 80MM 135CM -,SUP-H74939419400810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
RANGER GLOBAL DCB OTW 4.0 X 100MM 135CM -,SUP-H74939419401010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
RANGER GLOBAL DCB OTW 4.0 X 150MM 150CM -,SUP-H74939419401510,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
RANGER GLOBAL DCB OTW 4.0 X 200MM 150CM -,SUP-H74939419402010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
RANGER GLOBAL DCB OTW 4.0 X 200MM 150CM -,SUP-H74939419500410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
RANGER GLOBAL DCB OTW 5.0 X 60MM 135CM -,SUP-H74939419500610,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
CATH BALLOON RANGER GLOBAL 5.0 X 80MM X 135CM GLOBAL DCB OTW -,SUP-H74939419500810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
RANGER GLOBAL DCB OTW 5.0 X 100MM 135CM -,SUP-H74939419501010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
RANGER GLOBAL DCB OTW 5.0 X 120MM 150CM -,SUP-H74939419501210,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5708.18,3995.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
RANGER GLOBAL DCB OTW 5.0 X 150MM 150CM -,SUP-H74939419501510,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
RANGER DCB OTW 5.0MM x 200MM x 150CM -,SUP-H74939419502010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
RANGER GLOBAL DCB OTW 5.0 X 200MM 90CM -,SUP-H74939419502090,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
RANGER GLOBAL DCB OTW 6.0 X 40MM 135CM -,SUP-H74939419600410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
RANGER GLOBAL DCB OTW 6.0 X 60MM 135CM -,SUP-H74939419600610,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
CATH BALLOON RANGER GLOBAL 6.0 X 80MM X 135CM GLOBAL DCB OTW -,SUP-H74939419600810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
RANGER GLOBAL DCB OTW 6.0 X 100MM 135CM -,SUP-H74939419601010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
RANGER GLOBAL DCB OTW 6.0 X 200MM 150CM -,SUP-H74939419602010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
RANGER GLOBAL DCB OTW 7.0 X 40MM 135CM -,SUP-H74939419700410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
RANGER GLOBAL DCB OTW 7.0 X 60MM 135CM -,SUP-H74939419700610,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
RANGER GLOBAL DCB OTW 7.0 X 80MM 135CM -,SUP-H74939419700810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
RANGER GLOBAL DCB OTW 7.0 X 100MM 135CM -,SUP-H74939419701010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
RANGER GLOBAL DCB OTW 7.0 X 150MM 150CM -,SUP-H74939419701510,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
RANGER GLOBAL DCB OTW 7.0 X 200MM 150CM -,SUP-H74939419702010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
LUTONIX 018 6 X 80MM -,SUP-LX181306805F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
CATH PTCA 4MMX130CM LUTONIX 40MM DRG CTD 0.035IN GW COMP -,SUP-LX351304405F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
CATH PTCA 4MMX130CM LUTONIX 60MM DRG CTD 0.035IN GW COMP -,SUP-LX351304605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
CATH PTCA 5MMX130CM LUTONIX 100MM DRG CTD 0.035IN GW COMP -,SUP-LX3513051005F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
CATH PTCA 5X150MM LUTONIX 130CM -,SUP-LX3513051505F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
CATH PTCA 5MMX130CM LUTONIX 60MM DRG CTD 0.035IN GW COMP -,SUP-LX351305605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
B LUTONIX 6MM X 100MM X 130 -,SUP-LX3513061005F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
CATH PTCA 6X150MM LUTONIX 130CM -,SUP-LX3513061505F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
LUTONIX BALLOON -,SUP-LX3513062205F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8700.2,6090.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
CATH PTCA LUTONIX 0.035 X 6.0MM X 130CM 6FR DRG CTD GW GROUP -,SUP-LX351306605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
CATH PTCA 6MMX130CM LUTONIX 80MM DRG CTD 0.035IN GW COMP -,SUP-LX351306805F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
LUTONIX BALLOON 7MM X 100MM X 130M -,SUP-LX3513071005F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
S LUTONIX 7 X 40 X 130 -,SUP-LX351307405F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
S LUTONIX 7 X 60 X 130 -,SUP-LX351307605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
BALLOON LUTONIX .035 X 10MM X 40MM -,SUP-LX35751040V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
BALLOON LUTONIX .035 X 10MM X 60MM -,SUP-LX35751060V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
LUTONIX 12MM X 40MMX 75CM -,SUP-LX35751240V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6896.5,4827.55,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
BALLOON LUTONIX .035  4.0MM X 40MM -,SUP-LX3575440V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
CATH LUTONIX BALLOON DILATATION 6MM 75CM 40MM PACLITAXEL LF -,SUP-LX3575640V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
CATH LUTONIX BALLOON DILATATION 6MM 75CM 60MM PACLITAXEL LF -,SUP-LX3575660V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
LUTONIX DCB BALLOON 6 X 80 X 75 -,SUP-LX3575680V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
BALLOON LUTONIX .035  7.0MM X 40MM -,SUP-LX3575740V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
BALLOON LUTONIX .035  4 X 60 X 75 -,SUP-LX3575760V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
BALLOON LUTONIX .035 X 8MM X 40MM X 75CM -,SUP-LX3575840V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
BALLOON LUTONIX  .035 8 X 60 X 75 -,SUP-LX3575860V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
BALLOON LUTONIX .035 9.0MM X 40MM X 75CM -,SUP-LX3575940V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,6390.1908,other,Non-Reimbursable List,,
STENT NEPHURET 8.5FRX22CM ULTRATHANE COPE DBL PIGTL BND -,SUP-240735,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT NEPHURET 8.5FRX24CM ULTRATHANE COPE DBL PIGTL BND -,SUP-240736,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT NEPHURET 8.5FRX28 CM ULTRATHANE COPE DBL PIGTL BND -,SUP-244806,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT URET 4.7FRX24CM INLAY DBL PIGTL TAPR -,SUP-778424,CDM,C2625,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
8FR X 22 BARD OPTIMA INLAY URETERAL STENT -,SUP-778822,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
8FR X 24 BARD OPTIMA INLAY URETERAL STENT -,SUP-778824,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
8FR X 26 BARD OPTIMA INLAY URETERAL STENT -,SUP-778826,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
8FR X 28 BARD OPTIMA INLAY URETERAL STENT -,SUP-778828,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT URETERAL INLAY 6F 20 OPT -,SUP-788620,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT URETERAL INLAY 6F 22 OPT -,SUP-788622,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT URETERAL INLAY 6F 24 -,SUP-788624,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT URETERAL INLAY 6F 26 -,SUP-788626,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT URETERAL INLAY 6F 28 -,SUP-788628,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT URETERAL INLAY 6F 30 -,SUP-788630,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
BARD OPTIMA INLAY STENT 7 X 24 -,SUP-788724,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
BARD OPTIMA INLAY STENT 7 X 26 -,SUP-788726,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
BARD OPTIMA INLAY STENT 7 X 28 -,SUP-788728,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT BIL 7FRX5CM COTTON-LEUNG CRV TAPR PE P/D FLP PSH CATH -,SUP-CLBS-7-5,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT FANELLI BILIARY -,SUP-G13699,CDM,C2625,HCPCS,278,RC,,,outpatient,,,2999.5,2099.65,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT URET 7FRX75CM BNDR RT SOF-FLEX -,SUP-G14779,CDM,C2625,HCPCS,278,RC,,,outpatient,,,446.79,312.753,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT URET 7FRX75CM BNDR PTFE -,SUP-G14780,CDM,C2625,HCPCS,278,RC,,,outpatient,,,451.1,315.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT BILIARY DOUBLE PIGTAIL 7 X 7 -,SUP-G21396,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT BILIARY DOUBLE PIGTAIL 7 X 9 -,SUP-G21398,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT GEENAN PANCREATIC 7X7 -,SUP-G21479,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT GEENAN PANCREATIC 7X9 -,SUP-G21480,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT SET ZIMMON BILIARY 7-12 -,SUP-G21526,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT ZIMON BILIARY 7 X 15 -,SUP-G21529,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT ZIMMON DBL PIGTAIL 10X4 -,SUP-G21781,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT BIL 10MMX5CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN -,SUP-G25379,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT BIL 10MMX7CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN -,SUP-G25380,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT BIL 7MMX5CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN GW -,SUP-G25656,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT BIL 7MMX7CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN GW -,SUP-G25657,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT SOLUS DOUBLE PIGTAIL 10FR 3CM -,SUP-G25670,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT SOLUS DBL PIGTAIL 10 X 4 -,SUP-G25671,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT SOLUS DBL PIGTAIL 10 X 5 -,SUP-G25672,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT DBLE PIGTAIL 10F 1CM -,SUP-G26829,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT SOLUS DOUBLE PIGTAIL 10FR 1CM -,SUP-G26829,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT NEPHURET 10.2FRX22CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48162,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT NEPHURET 8.5FRX24CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48176,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT NEPHURET 8.5FRX26CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48180,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT NEPHURET 8.5FRX26CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48180,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
COMPASS BDS BILIARY STENT 7FR 15CM -,SUP-G58990,CDM,C2625,HCPCS,278,RC,,,outpatient,,,408.45,285.915,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT PANC 3FRX4CM GEENEN 170CM/320CM PSH/GUID CATH SPRL SH -,SUP-GEPD3-4,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
TUBE LRNCMY JCKSN SZ8 12MMX7CM OSDE V. MUELLER CRV MIRR FNSH -,SUP-GEPD3-5,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
CATH DRN 10FR NAVIFLEX RX -,SUP-M00533580,CDM,C2625,HCPCS,278,RC,,,outpatient,,,512.08,358.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT ADVANIX RX 7FR X 5CM PRELOADED -,SUP-M00534200,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT ADVANIX RX 7FR X 7CM PRELOADED -,SUP-M00534210,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT ADVANIX RX 7FR X 9CM PRELOADED -,SUP-M00534220,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT BIL 2.3MMX9CM ADVANIX RX PRELD DUOD BND PLST 3.2MM WKG -,SUP-M00534220,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT ADVANIX RX 7FR X 12CM PRELOADED -,SUP-M00534230,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT ADVANIX RX 10FR X 5CM PRELOADED -,SUP-M00534320,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT ADVANIX RX 10FR X 5CM PRELOADED -,SUP-M00534330,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT BIL 10FRX9CM ADVANIX RX PRELD DUOD BND PLST 4.2MM WKG -,SUP-M00534340,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT ADVANIX RX 10FR X 9CM PRELOADED -,SUP-M00534340,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT BIL 10FRX12CM ADVANIX RX PRELD DUOD BND PLST 4.2MM WKG -,SUP-M00534350,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT ADVANIX RX 10FR X 12CM PRELOADED -,SUP-M00534350,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT ADVANIX RX 10FR X 15CM -,SUP-M00534360,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT BIL 10FRX15CM ADVANIX RX PRELD DUOD BND PLST 4.2MM WKG -,SUP-M00534360,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT BIL 8.5FRX7CM ADVANIX RX PRELD CTR BND PLST 3.2MM WKG -,SUP-M00534630,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT BIL 8.5FRX9CM ADVANIX RX PRELD CTR BND PLST 3.2MM WKG -,SUP-M00534640,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT BIL 10FRX7CM ADVANIX RX PRELD CTR BND PLST 4.2MM WKG -,SUP-M00534690,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT BIL 10FRX12CM ADVANIX RX PRELD CTR BND PLST 4.2MM WKG -,SUP-M00534710,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT ADVANTIX 5X3 PANCREATIC NO LEADING BARB SINGLE PIGTAIL -,SUP-M00537390,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT ADVANTIX 5 X 4 PANCREATIC - NO LEADING BARB -,SUP-M00537400,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT ADVANTIX 5X5 PANCREATIC NO LEADING BARB SINGLE PIGTAIL -,SUP-M00537410,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT ADVANTIX 5 X 3 PANCREATIC -LEADING BARB -,SUP-M00537430,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT ADVANTIX 5 X 4 PANCREATIC -LEADING BARB -,SUP-M00537440,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT ADVANTIX 5X3 PANCREATIC NO LEADING BARB STRAIGHT -,SUP-M00537500,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT ADVANTIX 5X5 PANCREATIC NO LEADING BARB STRAIGHT -,SUP-M00537520,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT KIT PANCREATIC 5FR X 3CM -,SUP-M00537540,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
STENT BIL 7FRX4CM ZIMMON DBL PIGTL TAPR PE 170CM PSH CATH -,SUP-ZEBD-7-4,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,89.07711,1949.675,other,Non-Reimbursable List,,
PAIN CONTROL DEVICE BEELINE -,SUP-UNDEFINED,CDM,C2626,HCPCS,278,RC,,,outpatient,,,758.55,530.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,170.294475,582.5664,other,SI=N Exclusions ,,
HC Cath Stamey Suprapubic 14,PX-27200045,CDM,C2627,HCPCS,272,RC,,,outpatient,,,306,214.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,24.890315,416.02,other,Non-Reimbursable List,,
ST SUPRAPUBIC 12FRX25CM CONN TUBEX1/NDL OBTURATORX1/ 1W -,SUP-G14313,CDM,C2627,HCPCS,272,RC,,,outpatient,,,357.1,249.97,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,24.890315,416.02,other,Non-Reimbursable List,,
CATHETER MALECOT DRAINAGE 14FR 30CM -,SUP-G55824,CDM,C2627,HCPCS,272,RC,,,outpatient,,,307.21,215.047,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,24.890315,416.02,other,Non-Reimbursable List,,
LAWRENCE SUPRA-FOLEY 16F -,SUP-SF-S16-851,CDM,C2627,HCPCS,272,RC,,,outpatient,,,110.87,77.609,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,24.890315,416.02,other,Non-Reimbursable List,,
OCCULSION BALLOON CATH 90CM BR -,SUP-590-001,CDM,C2628,HCPCS,272,RC,,,outpatient,,,4415.95,3091.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,23.64434,10635.57648,other,Non-Reimbursable List,,
CATH OCL 6FRX10MM BLN ATTAIN COR -,SUP-6215,CDM,C2628,HCPCS,272,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,23.64434,10635.57648,other,Non-Reimbursable List,,
CATHETER PRUITT OCCLUSION 3F 7MM 27CM -,SUP-E2103-36,CDM,C2628,HCPCS,272,RC,,,outpatient,,,1743.86,1220.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,23.64434,10635.57648,other,Non-Reimbursable List,,
CATH ANG 5FR SHTH 135CM 3.75X20X1.5MM BLN ENTEER PERIPH -,SUP-ENB37520135,CDM,C2628,HCPCS,272,RC,,,outpatient,,,10273.24,7191.268,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,23.64434,10635.57648,other,Non-Reimbursable List,,
CATHETER OCCLUSION ER-REBOA PLUS -,SUP-ER7232PLUS,CDM,C2628,HCPCS,272,RC,,,outpatient,,,14833.44,10383.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,23.64434,10635.57648,other,Non-Reimbursable List,,
CATH HSG 5FRX30CM SIL 1ML BLN/SYR OPN TIP MRI-COND STRL SUD -,SUP-G17147,CDM,C2628,HCPCS,272,RC,,,outpatient,,,171.9,120.33,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,23.64434,10635.57648,other,Non-Reimbursable List,,
B CODA-2-10.0-35-140-46 -,SUP-G23773,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2702.08,1891.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,23.64434,10635.57648,other,Non-Reimbursable List,,
CODA BALLOON 46MM -,SUP-G23773,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2702.08,1891.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,23.64434,10635.57648,other,Non-Reimbursable List,,
CATH URET 6.2FRX26CM LF W/HSG/SHG MLBL STYL -,SUP-J-UHSG-062026,CDM,C2628,HCPCS,272,RC,,,outpatient,,,105.32,73.724,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,23.64434,10635.57648,other,Non-Reimbursable List,,
KIT CATHETER REBOA CONVENIENCE -,SUP-KT1835C,CDM,C2628,HCPCS,272,RC,,,outpatient,,,1192.61,834.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,23.64434,10635.57648,other,Non-Reimbursable List,,
CATHETER BALLOON MOLDING OCCLUSION 10MM X 37MM 10FR -,SUP-MOB37,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2740.28,1918.196,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,23.64434,10635.57648,other,Non-Reimbursable List,,
CATH OUTBACK RE-ENTRY 120CM -,SUP-OTB59120A,CDM,C2628,HCPCS,272,RC,,,outpatient,,,8021.16,5614.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,23.64434,10635.57648,other,Non-Reimbursable List,,
Q50X STENT GRAFT BALLOON CATHETER -,SUP-Q50-100-X,CDM,C2628,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,23.64434,10635.57648,other,Non-Reimbursable List,,
CATH GUID 8FR 10-46MM INFL 100CM RELIANT PU 12FR SHTH -,SUP-REL46,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2500.25,1750.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,23.64434,10635.57648,other,Non-Reimbursable List,,
MICRO INTRO KIT 21G 4FR 7CM TCAR - MULT'S OF 10EA -,SUP-SR-4F21G7D-MP,CDM,C2628,HCPCS,272,RC,,,outpatient,,,1167,816.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,23.64434,10635.57648,other,Non-Reimbursable List,,
HSG CATHETER -,SUP-UNDEFINED,CDM,C2628,HCPCS,272,RC,,,outpatient,,,207.35,145.145,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,23.64434,10635.57648,other,Non-Reimbursable List,,
CATH ABLT THRP COOL PATH MED CURL 7FR 2-5-2MM SPC 110CM QDPL -,SUP-A088047,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List,,
CATH ABLT THRP COOL PATH LRG CURL 7FR 2-5-2MM SPC 110CM QDPL -,SUP-A088049,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List,,
CATH ABLT SAFIRE BLU MED SWP DIST REACH CRV 7FR 2-5-2MM SPC -,SUP-A088106,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List,,
CATH ABLT SAFIRE BLU MED CURL DIST REACH CRV 7FR 2-5-2MM SPC -,SUP-A088107,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List,,
CATH ABLT SAFIRE BLU LRG SWP 7FR 2-5-2MM SPC LRG SWP 110CM -,SUP-A088108,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List,,
CATH ABLT SAFIRE BLU MED CURL DIST REACH CRV 7FR HGH TRQ -,SUP-A402871,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List,,
CATH ABLT SAFIRE BLU LRG CURL DIST REACH CRV HGH TRQ SHFT -,SUP-A402872,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List,,
CATH ABLT SAFIRE BLU MED CURL CRV EP DUO -,SUP-A700455,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List,,
CATH ABLT TACTICATH SE BI-D DF -,SUP-A-TCSE-DF,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10440.96,7308.672,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List,,
CATH ABLT TACTI SE BI-D FJ -,SUP-A-TCSE-FJ,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10440.96,7308.672,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List,,
CATH ABLT TACTIFLEX SE BID DF REF: A-TFSE-DF -,SUP-A-TFSE-DF,CDM,C2630,HCPCS,272,RC,,,outpatient,,,14387.88,10071.516,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List,,
CATH ABLT TACTIFLEX SE BID FJ REF: A-TFSE-FJ -,SUP-A-TFSE-FJ,CDM,C2630,HCPCS,272,RC,,,outpatient,,,14387.88,10071.516,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List,,
CATH ABLT THERMOCOOL SF F-J CRV 8FR 2-5-2MM SPC 115CM BIDIR -,SUP-BDI35FJRT,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7957.5,5570.25,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List,,
CATH ABLT THERMOCOOL SF B- CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131601,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List,,
CATH ABLT THERMOCOOL SF D-CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131602,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List,,
CATH ABLT THERMOCOOL SF F-CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131603,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List,,
CATH ABLT THERMOCOOL SF J-CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131604,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List,,
CATH ABLT THERMOCOOL SF CARTO XP F-TY CRV STEER UNI- DRCT -,SUP-D131803,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List,,
CATH ABLT THERMOCOOL SF CARTO XP J CRV STEER UNI- DRCT HTORQ -,SUP-D131804,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List,,
CATH ABLT CHILLI II STD CRV 7.5FRX2.5MM SPC 4MM TIP 110CM -,SUP-M00490310,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7151.14,5005.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List,,
CATH ABLT THRMCPL CRV 7.5FR LRG 110CM 2.5/2.5MM SPC -,SUP-M0049031K20,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7151.14,5005.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List,,
CATH ABLT TACTICATH 65 MM -,SUP-PN-004 065,CDM,C2630,HCPCS,272,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List,,
CATH ABLT TACTICATH 75MM -,SUP-PN-004075,CDM,C2630,HCPCS,272,RC,,,outpatient,,,11139,7797.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10316.10996,other,Non-Reimbursable List,,
DEVICE SUTCAP 12MM OPN ACCESS -,SUP-M0068311251,CDM,C2631,HCPCS,272,RC,,,outpatient,,,2073.95,1451.765,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,1487.02215,other,SI=N Exclusions ,,
HC Mra- W/Dye- Upper Extremity,PX-61000005,CDM,C8934,CPT,610,RC,,,outpatient,,,2034,1423.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,1724.0184,other,Non-Reimbursable List,,
HC Mra- W/O Dye- Upper Extr,PX-61000006,CDM,C8935,CPT,610,RC,,,outpatient,,,1745,1221.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,267.439885,1479.062,other,Non-Reimbursable List,,
HC Mra- W/O&W/Dye- Upper Extr,PX-61000007,CDM,C8936,CPT,610,RC,,,outpatient,,,3036,2125.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,2573.3136,other,Non-Reimbursable List,,
HC Cad Breast MRI,PX-61000089,CDM,C8937,HCPCS,610,RC,,,outpatient,,,344,240.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,77.228,836,other,Non-Reimbursable List,,
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML IJ SOLN,RX-155306,CDM,C9088,HCPCS,636,RC,47426-0301-02,NDC,outpatient,14,ML,1200.46,840.322,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.71,921.95328,other,Non-Reimbursable List,,
PANTOPRAZOLE SODIUM 40 MG IV SOLR,RX-26226,CDM,C9113,HCPCS,636,RC,00008-0923-55,NDC,outpatient,1,UN,8.55,5.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.69273,416.02,other,SI=N Exclusions ,,
PANTOPRAZOLE SODIUM 40 MG IV SOLR,RX-26226,CDM,C9113,HCPCS,636,RC,55150-0202-10,NDC,outpatient,1,UN,7.54,5.278,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.69273,416.02,other,SI=N Exclusions ,,
PANTOPRAZOLE SODIUM 40 MG IV SOLR,RX-26226,CDM,C9113,HCPCS,636,RC,00008-0923-51,NDC,outpatient,1,UN,8.55,5.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.69273,416.02,other,SI=N Exclusions ,,
PANTOPRAZOLE SODIUM 40 MG IV SOLR,RX-26226,CDM,C9113,HCPCS,636,RC,55150-0202-00,NDC,outpatient,1,UN,7.54,5.278,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.69273,416.02,other,SI=N Exclusions ,,
PANTOPRAZOLE SODIUM 40 MG IV SOLR,RX-26226,CDM,C9113,HCPCS,636,RC,00008-0923-60,NDC,outpatient,1,UN,8.55,5.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.69273,416.02,other,SI=N Exclusions ,,
COCAINE HCL 4 % EX SOLN,RX-1792,CDM,C9143,HCPCS,636,RC,70839-0362-04,NDC,outpatient,4,ML,1089.63,762.741,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.92,,,307.2,1.4,836.83584,fee schedule,,,
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-01,NDC,outpatient,50,ML,360.88,252.616,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.39,416.02,other,Non-Reimbursable List,,
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-10,NDC,outpatient,50,ML,344.88,241.416,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,,,,,3.39,416.02,other,Non-Reimbursable List,,
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-01,NDC,outpatient,50,ML,344.88,241.416,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,,,,,3.39,416.02,other,Non-Reimbursable List,,
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-10,NDC,outpatient,50,ML,360.88,252.616,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.39,416.02,other,Non-Reimbursable List,,
LACOSAMIDE 200 MG/20ML IV SOLN,RX-96972,CDM,C9254,HCPCS,636,RC,72603-0140-02,NDC,outpatient,20,ML,100.4,70.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.31,416.02,other,Non-Reimbursable List,,
LACOSAMIDE 200 MG/20ML IV SOLN,RX-96972,CDM,C9254,HCPCS,636,RC,00131-1810-67,NDC,outpatient,20,ML,278.22,194.754,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.31,416.02,other,Non-Reimbursable List,,
LACOSAMIDE 200 MG/20ML IV SOLN,RX-96972,CDM,C9254,HCPCS,636,RC,72603-0140-01,NDC,outpatient,20,ML,100.4,70.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.31,416.02,other,Non-Reimbursable List,,
BUPIVACAINE LIPOSOME 1.3 % IJ SUSP,RX-112781,CDM,C9290,HCPCS,636,RC,65250-0266-09,NDC,outpatient,20,ML,1495.03,1046.521,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.36,1148.18304,other,Non-Reimbursable List,,
BUPIVACAINE LIPOSOME 1.3 % IJ SUSP,RX-112781,CDM,C9290,HCPCS,636,RC,65250-0266-20,NDC,outpatient,20,ML,1495.03,1046.521,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.36,1148.18304,other,Non-Reimbursable List,,
CAP NERVE AXOGEN 2MM X 15MM -,SUP-AGT215,CDM,C9353,HCPCS,278,RC,,,outpatient,,,6688.54,4681.978,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,5136.79872,other,Non-Reimbursable List,,
CAP NERVE AXOGEN 3MM X 15MM -,SUP-AGT315,CDM,C9353,HCPCS,278,RC,,,outpatient,,,6688.54,4681.978,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,5136.79872,other,Non-Reimbursable List,,
CAP NERVE AXOGEN 4 X 15 -,SUP-AGT415,CDM,C9353,HCPCS,278,RC,,,outpatient,,,6688.54,4681.978,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,5136.79872,other,Non-Reimbursable List,,
NEUROMATRIX 6.0MM DIAMETER 2.5CM LENGTH -,SUP-CNC6025,CDM,C9355,HCPCS,278,RC,,,outpatient,,,5756.22,4029.354,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,182.24,5164.04736,other,Non-Reimbursable List,,
NEUROFLEX NERVE 4MM X 2.5CM -,SUP-CNCF4025,CDM,C9355,HCPCS,278,RC,,,outpatient,,,6724.02,4706.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,182.24,5164.04736,other,Non-Reimbursable List,,
NEUROFLEX NERVE 6MM X 2.5CM -,SUP-CNCF6025,CDM,C9355,HCPCS,278,RC,,,outpatient,,,6724.02,4706.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,182.24,5164.04736,other,Non-Reimbursable List,,
MESH SURGIMEND 5X6CM 1.0MM -,SUP-606-001-002,CDM,C9358,HCPCS,636,RC,,,outpatient,,,2525.06,1767.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24858.15552,other,Non-Reimbursable List,,
MESH SURGIMEND 5X6CM 1.0MM - C -,SUP-606-001-002,CDM,C9358,HCPCS,636,RC,,,outpatient,,,2525.06,1767.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24858.15552,other,Non-Reimbursable List,,
MESH SURGIMEND BOVINE 10 X 15CM -,SUP-606-001-006,CDM,C9358,HCPCS,636,RC,,,outpatient,,,9819.33,6873.531,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24858.15552,other,Non-Reimbursable List,,
IMPLANT NDNTR COLL 4X7CM SRGMND RECT -,SUP-606-001-013,CDM,C9358,HCPCS,636,RC,,,outpatient,,,2616.64,1831.648,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24858.15552,other,Non-Reimbursable List,,
SURGIMEND PRS 10CM X 20CM RECT -,SUP-606-004-102,CDM,C9358,HCPCS,636,RC,,,outpatient,,,16238.36,11366.852,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24858.15552,other,Non-Reimbursable List,,
MESH SURGIMEND 8CM X 16CM SEMI OVAL FENESTRAED -,SUP-606-004-103,CDM,C9358,HCPCS,636,RC,,,outpatient,,,10392.54,7274.778,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24858.15552,other,Non-Reimbursable List,,
GRAFT FTL BVN NDNTR COLL MATRIX 20X30CM SRGMND 2MM SHT RECT -,SUP-606-200-017,CDM,C9358,HCPCS,636,RC,,,outpatient,,,27546.57,19282.599,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24858.15552,other,Non-Reimbursable List,,
MESH SURGIMEND 3.0 13 X 25CM -,SUP-606-300-009,CDM,C9358,HCPCS,636,RC,,,outpatient,,,26387.33,18471.131,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24858.15552,other,Non-Reimbursable List,,
MESH SURGIMEND 20 X 30 X 3MM -,SUP-606-300-017,CDM,C9358,HCPCS,636,RC,,,outpatient,,,32367.39,22657.173,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24858.15552,other,Non-Reimbursable List,,
GENTRIX SURGICAL MATRIX HIATAL 7.5 X 6CM -,SUP-HIAT0706,CDM,C9358,HCPCS,636,RC,,,outpatient,,,4704.78,3293.346,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,24858.15552,other,Non-Reimbursable List,,
MESH SURGIMEND 3.0 10 X 15CM -,SUP-603-300-006,CDM,C9360,HCPCS,636,RC,,,outpatient,,,12178.79,8525.153,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,41430.25152,other,Non-Reimbursable List,,
MESH SURGIMEND 10 X 15CM 2.0 -,SUP-606-200-006,CDM,C9360,HCPCS,636,RC,,,outpatient,,,10364.84,7255.388,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,41430.25152,other,Non-Reimbursable List,,
IMPLANT NDNTR COLL 13X20CM SRGMND RECT -,SUP-606-200-009,CDM,C9360,HCPCS,636,RC,,,outpatient,,,22457.19,15720.033,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,41430.25152,other,Non-Reimbursable List,,
MESH SURGIMEND 25X40 X 3.0MM -,SUP-606-300-016,CDM,C9360,HCPCS,636,RC,,,outpatient,,,53945.64,37761.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,41430.25152,other,Non-Reimbursable List,,
NEUROMEND12MM X 2.5CM -,SUP-CNW12025,CDM,C9361,HCPCS,636,RC,,,outpatient,,,6724.07,4706.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,177.26,5164.08576,other,Non-Reimbursable List,,
NEUROMEND 4MM X 2.25CM -,SUP-CNW4025,CDM,C9361,HCPCS,636,RC,,,outpatient,,,6464.93,4525.451,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,177.26,5164.08576,other,Non-Reimbursable List,,
IMPLANT BIO TISS 3X8CM 3D HYDR PRCN COLL MATRIX PERMACOL SHT -,SUP-P100308,CDM,C9364,HCPCS,636,RC,,,outpatient,,,2987.95,2091.565,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,18.39,18739.8144,other,Non-Reimbursable List,,
MESH PERMACOL 5X10CM 1.0MM -,SUP-P100510,CDM,C9364,HCPCS,636,RC,,,outpatient,,,4648.41,3253.887,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,18.39,18739.8144,other,Non-Reimbursable List,,
IMPLANT BIO TISS 10X10CM 3D HYDR PRCN DERM COLL PERMACOL SHT -,SUP-P101010,CDM,C9364,HCPCS,636,RC,,,outpatient,,,9294.36,6506.052,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,18.39,18739.8144,other,Non-Reimbursable List,,
IMPLANT BIO TISS 15X20CM 3D HYDR PRCN COLL MATRIX PERMACOL -,SUP-P151520,CDM,C9364,HCPCS,636,RC,,,outpatient,,,24400.8,17080.56,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,18.39,18739.8144,other,Non-Reimbursable List,,
SARILUMAB 200 MG/1.14ML SC SOAJ,RX-143091,CDM,C9399,HCPCS,636,RC,00024-5922-01,NDC,outpatient,1.14,ML,5813.71,4069.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,2329.553597,399.86,4927.700596,percent of total billed charges,,,
CANGRELOR TETRASODIUM 50 MG IV SOLR,RX-131579,CDM,C9460,HCPCS,636,RC,10122-0620-01,NDC,outpatient,1,UN,2428.93,1700.251,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,18.2,1865.41824,other,Non-Reimbursable List,,
CANGRELOR TETRASODIUM 50 MG IV SOLR,RX-131579,CDM,C9460,HCPCS,636,RC,10122-0620-10,NDC,outpatient,1,UN,2428.93,1700.251,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,18.2,1865.41824,other,Non-Reimbursable List,,
HC Perc Drug-El Cor Stent Sing,PX-48100003,CDM,C9600,CPT,481,RC,,,outpatient,,,32584,22808.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17933.72,,,13380.03,399.86,25024.512,fee schedule,,,
HC Perc Drug-El Cor Stent Bran,PX-48100004,CDM,C9601,CPT,481,RC,,,outpatient,,,33887,23720.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,26025.216,other,Non-Reimbursable List,,
HC Perc D-E Cor Stent Ather S,PX-48100005,CDM,C9602,CPT,481,RC,,,outpatient,,,33887,23720.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17933.72,,,16999.04,399.86,26793.51305,fee schedule,,,
HC Perc D-E Cor Revasc T Cabg S,PX-48100007,CDM,C9604,CPT,481,RC,,,outpatient,,,33887,23720.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17933.72,,,13380.03,399.86,26025.216,fee schedule,,,
HC Perc D-E Cor Revasc T Cabg B,PX-48100008,CDM,C9605,CPT,481,RC,,,outpatient,,,33887,23720.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,26025.216,other,SI=N Exclusions ,,
HC Perc D-E Cor Revasc Chro Sin,PX-48100010,CDM,C9607,CPT,481,RC,,,outpatient,,,33887,23720.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17933.72,,,16999.04,399.86,26793.51305,fee schedule,,,
HC Perc D-E Cor Revasc Chro Add,PX-48100011,CDM,C9608,CPT,481,RC,,,outpatient,,,33887,23720.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,26025.216,other,SI=N Exclusions ,,
HC Admin Influenza Virus Vac,PX-77100001,CDM,G0008,CPT,771,RC,,,outpatient,,,193,135.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,62.4,,,85.68,19.95,416.02,fee schedule,,,
HC Immuniz-Admin-Each Addl,PX-77100005,CDM,G0008,CPT,771,RC,,,outpatient,,,215,150.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.95,416.02,other,SI=N Exclusions ,,
HC Admin Pneumococcal Vaccine,PX-77100002,CDM,G0009,CPT,771,RC,,,outpatient,,,193,135.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,62.4,,,85.68,19.95,416.02,fee schedule,,,
HC Immuniz-Admin-Each Addl,PX-77100006,CDM,G0009,CPT,771,RC,,,outpatient,,,215,150.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.95,416.02,other,SI=N Exclusions ,,
HC Admin Hepatitis B Vaccine,PX-77100003,CDM,G0010,CPT,771,RC,,,outpatient,,,193,135.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,62.4,,,59.14,19.95,416.02,fee schedule,,,
HC Immuniz-Admin-Each Addl,PX-77100007,CDM,G0010,CPT,771,RC,,,outpatient,,,215,150.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,62.4,,,59.14,19.95,416.02,fee schedule,,,
HC Inject for Sacroiliac Joint,PX-36900022,CDM,G0259,CPT,369,RC,,,outpatient,,,827,578.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,185.6615,1592,other,SI=N Exclusions ,,
HC Inj for Sacroiliac Jt Anesth,PX-36900023,CDM,G0260,CPT,369,RC,,,outpatient,,,1722,1205.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1306.94,,,1238.82,386.589,2141,fee schedule,,,
HC Occlusive Device in Vein Art,PX-48100001,CDM,G0269,CPT,481,RC,,,outpatient,,,202,141.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,45.349,1592,other,Non-Reimbursable List,,
HC Iliac Art Angio-Cardiac Cath,PX-32000003,CDM,G0278,CPT,320,RC,,,outpatient,,,113,79.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,25.3685,416.02,other,Non-Reimbursable List,,
HC Elec Stim Other Than Wound,PX-42000003,CDM,G0283,CPT,420,RC,,,outpatient,,,123,86.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,31.44,,,29.8,12.01,416.02,fee schedule,,,
HC Observation Time,PX-76200003,CDM,G0378,CPT,762,RC,,,outpatient,,,101,70.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,104.83,,,104.83,22.6745,6652,per diem,,,
HC Observation Carve-Out,PX-76200004,CDM,G0378,CPT,762,RC,,,outpatient,,,101,70.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,104.83,,,104.83,22.6745,6652,per diem,,,
HC Direct Refer Hospital Observ,PX-76200001,CDM,G0379,CPT,762,RC,,,outpatient,,,1442,1009.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,104.83,,,104.83,104.83,6652,per diem,,,
HC PR Trauma Respons W/Hosp Criti,PX-68200001,CDM,G0390,HCPCS,682,RC,,,outpatient,,,10370,7259,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7964.16,other,Non-Reimbursable List,,
HC Full Trauma,PX-68200002,CDM,G0390,HCPCS,682,RC,,,outpatient,,,10370,7259,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7964.16,other,Non-Reimbursable List,,
HC Partial Trauma,PX-68200003,CDM,G0390,HCPCS,682,RC,,,outpatient,,,7029,4920.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,7964.16,other,Non-Reimbursable List,,
HC Mod Sedat Endo Service >5yrs,PX-37000025,CDM,G0500,HCPCS,370,RC,,,outpatient,,,240,168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,53.88,416.02,other,Non-Reimbursable List,,
HC Inter Devc Remote 30d,PX-48000092,CDM,G2066,HCPCS,480,RC,,,outpatient,,,118,82.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,47.2826,26.491,416.02,percent of total billed charges,,,
ABATACEPT 250 MG IV SOLR,RX-70287,CDM,J0129,HCPCS,636,RC,00003-2187-13,NDC,outpatient,1,UN,3823.57,2676.499,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,43.73,,,1067.5,43.27,2936.50176,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0131,HCPCS,636,RC,36000-0306-60,NDC,outpatient,100,ML,53.83,37.681,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.04,416.02,other,SI=N Exclusions ,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0131,HCPCS,636,RC,67457-0940-10,NDC,outpatient,100,ML,44.93,31.451,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.04,416.02,other,SI=N Exclusions ,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0131,HCPCS,636,RC,67457-0940-10,NDC,outpatient,100,ML,44.93,31.451,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.04,416.02,other,SI=N Exclusions ,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0131,HCPCS,636,RC,36000-0306-60,NDC,outpatient,100,ML,53.83,37.681,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.04,416.02,other,SI=N Exclusions ,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0131,HCPCS,636,RC,67457-0940-10,NDC,outpatient,100,ML,44.93,31.451,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.04,416.02,other,SI=N Exclusions ,,
ACETYLCYSTEINE 200 MG/ML IV SOLN,RX-38303,CDM,J0132,HCPCS,636,RC,00574-0805-30,NDC,outpatient,30,ML,278.49,194.943,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.57,416.02,other,SI=N Exclusions ,,
ACETYLCYSTEINE 200 MG/ML IV SOLN,RX-38303,CDM,J0132,HCPCS,636,RC,00574-0805-00,NDC,outpatient,30,ML,278.49,194.943,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.57,416.02,other,SI=N Exclusions ,,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-09,NDC,outpatient,20,ML,18.52,12.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.02,416.02,other,SI=N Exclusions ,,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-20,NDC,outpatient,20,ML,18.52,12.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.02,416.02,other,SI=N Exclusions ,,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,55150-0154-10,NDC,outpatient,10,ML,11.47,8.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.02,416.02,other,SI=N Exclusions ,,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-03,NDC,outpatient,10,ML,8.9,6.23,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.02,416.02,other,SI=N Exclusions ,,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-10,NDC,outpatient,10,ML,8.9,6.23,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.02,416.02,other,SI=N Exclusions ,,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,55150-0155-20,NDC,outpatient,20,ML,19.14,13.398,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.02,416.02,other,SI=N Exclusions ,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,40.48,28.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.05,,,5,0.04,416.02,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,24.48,17.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.05,,,5,0.04,416.02,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,40.48,28.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.05,,,5,0.04,416.02,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,24.48,17.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.05,,,5,0.04,416.02,fee schedule,,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,40.48,28.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.05,,,5,0.04,416.02,fee schedule,,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,24.48,17.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.05,,,5,0.04,416.02,fee schedule,,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,40.48,28.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.05,,,5,0.04,416.02,fee schedule,,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,24.48,17.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.05,,,5,0.04,416.02,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,40.48,28.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.05,,,5,0.04,416.02,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,40.48,28.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.05,,,5,0.04,416.02,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,24.48,17.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.05,,,5,0.04,416.02,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,24.48,17.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.05,,,5,0.04,416.02,fee schedule,,,
ADALIMUMAB 40 MG/0.8ML SC PSKT,RX-129739,CDM,J0135,HCPCS,636,RC,00074-3799-02,NDC,outpatient,1,UN,9266.62,6486.634,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,3713.134634,336.23,7116.76416,percent of total billed charges,,,
ADALIMUMAB 40 MG/0.8ML SC PNKT,RX-129742,CDM,J0135,HCPCS,636,RC,00074-4339-02,NDC,outpatient,1,UN,9266.62,6486.634,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,3713.134634,336.23,7116.76416,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,23.59,16.513,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.05,,,5,0.05,416.02,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,39.59,27.713,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.05,,,5,0.05,416.02,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0136,HCPCS,636,RC,00264-4100-95,NDC,outpatient,100,ML,39.59,27.713,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.05,,,5,0.05,416.02,fee schedule,,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,23.59,16.513,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.05,,,5,0.05,416.02,fee schedule,,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,39.59,27.713,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.05,,,5,0.05,416.02,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,23.59,16.513,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.05,,,5,0.05,416.02,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0136,HCPCS,636,RC,00264-4100-95,NDC,outpatient,100,ML,39.59,27.713,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.05,,,5,0.05,416.02,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,39.59,27.713,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.05,,,5,0.05,416.02,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,34.69,24.283,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.05,,,7,0.05,416.02,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,34.69,24.283,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.05,,,7,0.05,416.02,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,18.69,13.083,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.05,,,7,0.05,416.02,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,18.69,13.083,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.05,,,7,0.05,416.02,fee schedule,,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,34.69,24.283,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.05,,,7,0.05,416.02,fee schedule,,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,34.69,24.283,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.05,,,7,0.05,416.02,fee schedule,,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,18.69,13.083,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.05,,,7,0.05,416.02,fee schedule,,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,18.69,13.083,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.05,,,7,0.05,416.02,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,18.69,13.083,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.05,,,7,0.05,416.02,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,34.69,24.283,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.05,,,7,0.05,416.02,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,18.69,13.083,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.05,,,7,0.05,416.02,fee schedule,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,34.69,24.283,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.05,,,7,0.05,416.02,fee schedule,,,
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,RX-15330,CDM,J0153,HCPCS,636,RC,16714-0997-01,NDC,outpatient,30,ML,109.72,76.804,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,631.24992,other,SI=N Exclusions ,,
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,RX-15330,CDM,J0153,HCPCS,636,RC,55150-0193-01,NDC,outpatient,30,ML,91.83,64.281,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,631.24992,other,SI=N Exclusions ,,
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,RX-15330,CDM,J0153,HCPCS,636,RC,67457-0857-30,NDC,outpatient,30,ML,821.94,575.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,631.24992,other,SI=N Exclusions ,,
ADENOSINE 6 MG/2ML IV SOLN,RX-38703,CDM,J0153,HCPCS,636,RC,67457-0855-02,NDC,outpatient,2,ML,24.68,17.276,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,631.24992,other,SI=N Exclusions ,,
ADENOSINE 6 MG/2ML IV SOLN,RX-38703,CDM,J0153,HCPCS,636,RC,67457-0855-00,NDC,outpatient,2,ML,24.68,17.276,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,631.24992,other,SI=N Exclusions ,,
EPINEPHRINE 0.15 MG/0.3ML IJ SOAJ,RX-124855,CDM,J0171,HCPCS,636,RC,49502-0101-02,NDC,outpatient,1,UN,616.75,431.725,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.73,960.94464,other,SI=N Exclusions ,,
EPINEPHRINE 0.15 MG/0.3ML IJ SOAJ,RX-124855,CDM,J0171,HCPCS,636,RC,49502-0501-02,NDC,outpatient,1,UN,1251.23,875.861,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.73,960.94464,other,SI=N Exclusions ,,
EPINEPHRINE 0.15 MG/0.3ML IJ SOAJ,RX-124855,CDM,J0171,HCPCS,636,RC,49502-0101-01,NDC,outpatient,1,UN,616.75,431.725,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.73,960.94464,other,SI=N Exclusions ,,
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,49502-0500-02,NDC,outpatient,1,UN,1251.23,875.861,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.73,960.94464,other,SI=N Exclusions ,,
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,00115-1694-30,NDC,outpatient,1,UN,506.88,354.816,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.73,960.94464,other,SI=N Exclusions ,,
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,00115-1694-49,NDC,outpatient,1,UN,506.88,354.816,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.73,960.94464,other,SI=N Exclusions ,,
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,49502-0102-01,NDC,outpatient,1,UN,616.75,431.725,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.73,960.94464,other,SI=N Exclusions ,,
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,49502-0102-02,NDC,outpatient,1,UN,616.75,431.725,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.73,960.94464,other,SI=N Exclusions ,,
EPINEPHRINE INFUSION PREMIX 1 MG IN 250 ML,RX-4080061,CDM,J0171,HCPCS,636,RC,99999-0001-65,NDC,outpatient,250,ML,83.79,58.653,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.73,960.94464,other,SI=N Exclusions ,,
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER,RX-4080099,CDM,J0171,HCPCS,636,RC,42023-0159-01,NDC,outpatient,1,ML,57.57,40.299,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.73,960.94464,other,SI=N Exclusions ,,
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER,RX-4080099,CDM,J0171,HCPCS,636,RC,42023-0159-25,NDC,outpatient,1,ML,57.57,40.299,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.73,960.94464,other,SI=N Exclusions ,,
EPINEPHRINE HCL 0.1 MG/ML IJ WRAPPER,RX-4080103,CDM,J0171,HCPCS,636,RC,76329-3318-01,NDC,outpatient,10,ML,42.5,29.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.73,960.94464,other,SI=N Exclusions ,,
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER FOR CODE NARRATOR,RX-4081384,CDM,J0171,HCPCS,636,RC,42023-0159-01,NDC,outpatient,1,ML,57.57,40.299,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.73,960.94464,other,SI=N Exclusions ,,
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER FOR CODE NARRATOR,RX-4081384,CDM,J0171,HCPCS,636,RC,42023-0159-25,NDC,outpatient,1,ML,57.57,40.299,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.73,960.94464,other,SI=N Exclusions ,,
EPINEPHRINE PF 1 MG/ML IJ SOLN,RX-140555,CDM,J0173,HCPCS,636,RC,54288-0103-10,NDC,outpatient,1,ML,35.98,25.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.86,,,17.1,1.61,416.02,fee schedule,,,
EPINEPHRINE PF 1 MG/ML IJ SOLN,RX-140555,CDM,J0173,HCPCS,636,RC,54288-0103-01,NDC,outpatient,1,ML,35.98,25.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.86,,,17.1,1.61,416.02,fee schedule,,,
AGALSIDASE BETA 35 MG IV SOLR,RX-35775,CDM,J0180,HCPCS,636,RC,58468-0040-01,NDC,outpatient,1,UN,20575.06,14402.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,222.93,,,7616,215.38,15801.64608,fee schedule,,,
AGALSIDASE BETA 5 MG IV SOLR,RX-38494,CDM,J0180,HCPCS,636,RC,58468-0041-01,NDC,outpatient,1,UN,2938.8,2057.16,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,222.93,,,1088,215.38,15801.64608,fee schedule,,,
ALGLUCOSIDASE ALFA 50 MG IV SOLR,RX-76353,CDM,J0221,HCPCS,636,RC,58468-0160-01,NDC,outpatient,1,UN,2661.83,1863.281,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,201.67,,,985.35,194.92,2044.28544,fee schedule,,,
REMDESIVIR 100 MG IV SOLR,RX-150611,CDM,J0248,HCPCS,636,RC,61958-2901-02,NDC,outpatient,1,UN,1654.57,1158.199,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6.35,,,606,5.51,1270.70976,fee schedule,,,
ALPHA1-PROTEINASE INHIBITOR 1000 MG/20ML IV SOLN,RX-141646,CDM,J0256,HCPCS,636,RC,13533-0705-01,NDC,outpatient,1,UN,1462.8,1023.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.83,,,481,4.88,1606.272,fee schedule,,,
ALPHA1-PROTEINASE INHIBITOR 1000 MG/20ML IV SOLN,RX-141646,CDM,J0256,HCPCS,636,RC,13533-0705-11,NDC,outpatient,1,UN,1462.8,1023.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.83,,,481,4.88,1606.272,fee schedule,,,
ZEMAIRA 1000 MG IV SOLR,RX-36564,CDM,J0256,HCPCS,636,RC,00053-7201-02,NDC,outpatient,1,UN,2091.5,1464.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.83,,,481,4.88,1606.272,fee schedule,,,
ALPROSTADIL 500 MCG/ML IJ SOLN,RX-9001,CDM,J0270,HCPCS,636,RC,00009-3169-01,NDC,outpatient,1,ML,564.52,395.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10.89,,,4260,2.98,4260,fee schedule,,,
ALPROSTADIL 500 MCG/ML IJ SOLN,RX-9001,CDM,J0270,HCPCS,636,RC,00009-3169-06,NDC,outpatient,1,ML,564.52,395.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10.89,,,4260,2.98,4260,fee schedule,,,
AMIKACIN SULFATE 500 MG/2ML IJ SOLN,RX-108131,CDM,J0278,HCPCS,636,RC,23155-0290-41,NDC,outpatient,2,ML,17.6,12.32,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.77,416.02,other,SI=N Exclusions ,,
AMIKACIN SULFATE 500 MG/2ML IJ SOLN,RX-108131,CDM,J0278,HCPCS,636,RC,23155-0290-31,NDC,outpatient,2,ML,17.6,12.32,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.77,416.02,other,SI=N Exclusions ,,
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5921-01,NDC,outpatient,10,ML,61.06,42.742,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.51,416.02,other,SI=N Exclusions ,,
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5921-16,NDC,outpatient,10,ML,61.06,42.742,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.51,416.02,other,SI=N Exclusions ,,
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5922-01,NDC,outpatient,20,ML,38.54,26.978,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.51,416.02,other,SI=N Exclusions ,,
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5922-16,NDC,outpatient,20,ML,38.54,26.978,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.51,416.02,other,SI=N Exclusions ,,
AMIODARONE HCL IN DEXTROSE 900-5 MG/500ML-% IV SOLN,RX-135815,CDM,J0282,HCPCS,636,RC,70092-1005-38,NDC,outpatient,500,ML,218.97,153.279,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.46,416.02,other,SI=N Exclusions ,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,67457-0153-00,NDC,outpatient,3,ML,16.55,11.585,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.46,416.02,other,SI=N Exclusions ,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,67457-0153-03,NDC,outpatient,3,ML,16.55,11.585,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.46,416.02,other,SI=N Exclusions ,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,67457-0153-18,NDC,outpatient,18,ML,55.43,38.801,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.46,416.02,other,SI=N Exclusions ,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-01,NDC,outpatient,3,ML,9.41,6.587,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.46,416.02,other,SI=N Exclusions ,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-02,NDC,outpatient,9,ML,22.43,15.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.46,416.02,other,SI=N Exclusions ,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,00143-9875-25,NDC,outpatient,3,ML,3.58,2.506,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.46,416.02,other,SI=N Exclusions ,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,00143-9875-01,NDC,outpatient,3,ML,3.58,2.506,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.46,416.02,other,SI=N Exclusions ,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-03,NDC,outpatient,3,ML,9.41,6.587,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.46,416.02,other,SI=N Exclusions ,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-09,NDC,outpatient,9,ML,22.43,15.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.46,416.02,other,SI=N Exclusions ,,
AMPHOTERICIN B 50 MG IV SOLR,RX-464,CDM,J0285,HCPCS,636,RC,39822-1055-05,NDC,outpatient,1,UN,155.22,108.654,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,34.84689,416.02,other,SI=N Exclusions ,,
AMPHOTERICIN B LIPID 5 MG/ML IV SUSP,RX-22981,CDM,J0287,HCPCS,636,RC,57665-0101-41,NDC,outpatient,20,ML,431.74,302.218,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,11.13,,,111.3,11.13,416.02,fee schedule,,,
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,RX-21900,CDM,J0289,HCPCS,636,RC,00469-3051-30,NDC,outpatient,1,UN,1268.66,888.062,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21.63,,,139.6,23.33,974.33088,fee schedule,,,
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,RX-21900,CDM,J0289,HCPCS,636,RC,62756-0233-01,NDC,outpatient,1,UN,328.95,230.265,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21.63,,,139.6,23.33,974.33088,fee schedule,,,
AMPICILLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080940,CDM,J0290,HCPCS,636,RC,25021-0136-10,NDC,outpatient,1,UN,10.62,7.434,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions ,,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,67850-0024-00,NDC,outpatient,1,UN,8.62,6.034,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions ,,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,67850-0024-10,NDC,outpatient,1,UN,8.62,6.034,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions ,,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,00781-3407-78,NDC,outpatient,1,UN,4.29,3.003,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions ,,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,65219-0016-10,NDC,outpatient,1,UN,5.52,3.864,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions ,,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,00781-3407-95,NDC,outpatient,1,UN,4.29,3.003,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions ,,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,65219-0016-01,NDC,outpatient,1,UN,5.52,3.864,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions ,,
AMPICILLIN SODIUM 1 G IJ SOLR,RX-469,CDM,J0290,HCPCS,636,RC,25021-0136-10,NDC,outpatient,1,UN,10.62,7.434,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions ,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,25021-0137-20,NDC,outpatient,1,UN,16.54,11.578,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions ,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,55150-0114-20,NDC,outpatient,1,UN,13.5,9.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions ,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,72485-0422-01,NDC,outpatient,1,UN,18.51,12.957,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions ,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,44567-0103-10,NDC,outpatient,1,UN,45.23,31.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions ,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,65219-0020-03,NDC,outpatient,1,UN,32.57,22.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions ,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,65219-0020-23,NDC,outpatient,1,UN,32.57,22.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions ,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,72485-0422-10,NDC,outpatient,1,UN,18.51,12.957,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions ,,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,00781-3407-95,NDC,outpatient,1,UN,4.29,3.003,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions ,,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,65219-0016-01,NDC,outpatient,1,UN,5.52,3.864,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions ,,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,67850-0024-10,NDC,outpatient,1,UN,8.62,6.034,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions ,,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,00781-3407-78,NDC,outpatient,1,UN,4.29,3.003,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions ,,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,65219-0016-10,NDC,outpatient,1,UN,5.52,3.864,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions ,,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,67850-0024-00,NDC,outpatient,1,UN,8.62,6.034,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions ,,
AMPICILLIN-SULBACTAM SODIUM 15 (10-5) G IV SOLR,RX-105616,CDM,J0295,HCPCS,636,RC,00049-0024-28,NDC,outpatient,1,UN,84.11,58.877,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.600685,416.02,other,SI=N Exclusions ,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IV SOLR,RX-27283,CDM,J0295,HCPCS,636,RC,00409-2987-03,NDC,outpatient,1,UN,24.87,17.409,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.600685,416.02,other,SI=N Exclusions ,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IV SOLR,RX-27283,CDM,J0295,HCPCS,636,RC,00409-2987-23,NDC,outpatient,1,UN,24.87,17.409,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.600685,416.02,other,SI=N Exclusions ,,
AMPICILLIN-SULBACTAM 3 G 100 ML ADD-VANTAGE BAG,RX-400006,CDM,J0295,HCPCS,636,RC,99999-0003-15,NDC,outpatient,100,ML,43.51,30.457,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.600685,416.02,other,SI=N Exclusions ,,
AMPICILLIN-SULBACTAM 3 G 100 ML IVPB BATCHED,RX-4081206,CDM,J0295,HCPCS,636,RC,99999-0003-29,NDC,outpatient,100,ML,29.73,20.811,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.600685,416.02,other,SI=N Exclusions ,,
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR,RX-9083,CDM,J0295,HCPCS,636,RC,55150-0116-20,NDC,outpatient,1,UN,7.13,4.991,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.600685,416.02,other,SI=N Exclusions ,,
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR,RX-9083,CDM,J0295,HCPCS,636,RC,71288-0031-20,NDC,outpatient,1,UN,21.1,14.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.600685,416.02,other,SI=N Exclusions ,,
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR,RX-9083,CDM,J0295,HCPCS,636,RC,71288-0031-21,NDC,outpatient,1,UN,21.1,14.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.600685,416.02,other,SI=N Exclusions ,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,55150-0117-20,NDC,outpatient,1,UN,13.78,9.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.600685,416.02,other,SI=N Exclusions ,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,71288-0032-20,NDC,outpatient,1,UN,33.6,23.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.600685,416.02,other,SI=N Exclusions ,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,71288-0032-21,NDC,outpatient,1,UN,33.6,23.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.600685,416.02,other,SI=N Exclusions ,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,72485-0417-01,NDC,outpatient,1,UN,18.05,12.635,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.600685,416.02,other,SI=N Exclusions ,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,00641-6117-01,NDC,outpatient,1,UN,28.2,19.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.600685,416.02,other,SI=N Exclusions ,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,00641-6117-10,NDC,outpatient,1,UN,28.2,19.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.600685,416.02,other,SI=N Exclusions ,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,25021-0143-30,NDC,outpatient,1,UN,36.19,25.333,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.600685,416.02,other,SI=N Exclusions ,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,55150-0117-01,NDC,outpatient,1,UN,13.78,9.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.600685,416.02,other,SI=N Exclusions ,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,55150-0117-10,NDC,outpatient,1,UN,13.78,9.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.600685,416.02,other,SI=N Exclusions ,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,70594-0082-01,NDC,outpatient,1,UN,37.01,25.907,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.600685,416.02,other,SI=N Exclusions ,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,72485-0417-10,NDC,outpatient,1,UN,18.05,12.635,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.600685,416.02,other,SI=N Exclusions ,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,70594-0082-02,NDC,outpatient,1,UN,37.01,25.907,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.600685,416.02,other,SI=N Exclusions ,,
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,70004-0908-09,NDC,outpatient,5,ML,95.5,66.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.82,416.02,other,SI=N Exclusions ,,
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,69374-0920-05,NDC,outpatient,5,ML,14.14,9.898,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.82,416.02,other,SI=N Exclusions ,,
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,70004-0910-09,NDC,outpatient,5,ML,31.6,22.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.82,416.02,other,SI=N Exclusions ,,
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,70092-1086-44,NDC,outpatient,5,ML,84.42,59.094,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.82,416.02,other,SI=N Exclusions ,,
ANIDULAFUNGIN 100 MG IV SOLR,RX-88093,CDM,J0348,HCPCS,636,RC,00049-0116-28,NDC,outpatient,1,UN,139.38,97.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.46,416.02,other,SI=N Exclusions ,,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,55150-0400-01,NDC,outpatient,1,ML,14.72,10.304,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.732165,416.02,other,SI=N Exclusions ,,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,63323-0614-01,NDC,outpatient,1,ML,14.49,10.143,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.732165,416.02,other,SI=N Exclusions ,,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,00641-6231-25,NDC,outpatient,1,ML,12.17,8.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.732165,416.02,other,SI=N Exclusions ,,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,63323-0614-00,NDC,outpatient,1,ML,14.49,10.143,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.732165,416.02,other,SI=N Exclusions ,,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,00641-6231-01,NDC,outpatient,1,ML,12.17,8.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.732165,416.02,other,SI=N Exclusions ,,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,55150-0400-25,NDC,outpatient,1,ML,14.72,10.304,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.732165,416.02,other,SI=N Exclusions ,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,63323-0398-10,NDC,outpatient,1,UN,8.17,5.719,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.834165,416.02,other,SI=N Exclusions ,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70436-0019-82,NDC,outpatient,1,UN,12.13,8.491,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.834165,416.02,other,SI=N Exclusions ,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70860-0100-10,NDC,outpatient,1,UN,13.9,9.73,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.834165,416.02,other,SI=N Exclusions ,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70860-0100-41,NDC,outpatient,1,UN,13.9,9.73,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.834165,416.02,other,SI=N Exclusions ,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,00069-3150-84,NDC,outpatient,1,UN,24.39,17.073,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.834165,416.02,other,SI=N Exclusions ,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70095-0025-01,NDC,outpatient,1,UN,8.79,6.153,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.834165,416.02,other,SI=N Exclusions ,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,00069-3150-83,NDC,outpatient,1,UN,24.39,17.073,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.834165,416.02,other,SI=N Exclusions ,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,55150-0174-10,NDC,outpatient,1,UN,9.22,6.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.834165,416.02,other,SI=N Exclusions ,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,63323-0398-01,NDC,outpatient,1,UN,8.17,5.719,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.834165,416.02,other,SI=N Exclusions ,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70095-0025-02,NDC,outpatient,1,UN,8.79,6.153,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.834165,416.02,other,SI=N Exclusions ,,
AZITHROMYCIN 500 MG IN 250 ML NS PREMIX,RX-4080917,CDM,J0456,HCPCS,636,RC,99999-0001-37,NDC,outpatient,255,ML,46.12,32.284,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.834165,416.02,other,SI=N Exclusions ,,
AZTREONAM 1 G IJ SOLR 100 MG/ML,RX-4081004,CDM,J0457,HCPCS,636,RC,00409-0829-11,NDC,outpatient,1,UN,98.69,69.083,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.13,,,25.2,1.97,416.02,fee schedule,,,
AZTREONAM 1 G IJ SOLR 100 MG/ML,RX-4081004,CDM,J0457,HCPCS,636,RC,00409-0829-01,NDC,outpatient,1,UN,98.69,69.083,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.13,,,25.2,1.97,416.02,fee schedule,,,
AZTREONAM 1 G IJ SOLR 100 MG/ML,RX-4081004,CDM,J0457,HCPCS,636,RC,00003-2560-16,NDC,outpatient,1,UN,122.23,85.561,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.13,,,25.2,1.97,416.02,fee schedule,,,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,00003-2570-16,NDC,outpatient,1,UN,244.45,171.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.13,,,50.4,1.97,416.02,fee schedule,,,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,00409-0830-11,NDC,outpatient,1,UN,201.48,141.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.13,,,50.4,1.97,416.02,fee schedule,,,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,63323-0402-01,NDC,outpatient,1,UN,201.48,141.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.13,,,50.4,1.97,416.02,fee schedule,,,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,00409-0830-01,NDC,outpatient,1,UN,201.48,141.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.13,,,50.4,1.97,416.02,fee schedule,,,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,63323-0402-20,NDC,outpatient,1,UN,201.48,141.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.13,,,50.4,1.97,416.02,fee schedule,,,
AZTREONAM 1 G IJ SOLR,RX-9185,CDM,J0457,HCPCS,636,RC,00003-2560-16,NDC,outpatient,1,UN,122.23,85.561,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.13,,,25.2,1.97,416.02,fee schedule,,,
AZTREONAM 1 G IJ SOLR,RX-9185,CDM,J0457,HCPCS,636,RC,00409-0829-01,NDC,outpatient,1,UN,98.69,69.083,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.13,,,25.2,1.97,416.02,fee schedule,,,
AZTREONAM 1 G IJ SOLR,RX-9185,CDM,J0457,HCPCS,636,RC,00409-0829-11,NDC,outpatient,1,UN,98.69,69.083,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.13,,,25.2,1.97,416.02,fee schedule,,,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,00409-0830-01,NDC,outpatient,1,UN,201.48,141.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.13,,,50.4,1.97,416.02,fee schedule,,,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,00003-2570-16,NDC,outpatient,1,UN,244.45,171.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.13,,,50.4,1.97,416.02,fee schedule,,,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,00409-0830-11,NDC,outpatient,1,UN,201.48,141.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.13,,,50.4,1.97,416.02,fee schedule,,,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,63323-0402-01,NDC,outpatient,1,UN,201.48,141.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.13,,,50.4,1.97,416.02,fee schedule,,,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,63323-0402-20,NDC,outpatient,1,UN,201.48,141.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.13,,,50.4,1.97,416.02,fee schedule,,,
ATROPINE SULFATE 0.1 MG/ML IJ SOLN WRAPPER,RX-4080930,CDM,J0461,HCPCS,636,RC,76329-3340-01,NDC,outpatient,10,ML,42.72,29.904,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.08,,,9,0.09,416.02,fee schedule,,,
ATROPINE SULFATE 0.4 MG/ML IJ SOLN WRAPPER,RX-4080931,CDM,J0461,HCPCS,636,RC,00517-1004-25,NDC,outpatient,1,ML,19.31,13.517,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.08,,,3.6,0.09,416.02,fee schedule,,,
ATROPINE SULFATE 0.4 MG/ML IJ SOLN WRAPPER,RX-4080931,CDM,J0461,HCPCS,636,RC,00517-1004-01,NDC,outpatient,1,ML,19.31,13.517,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.08,,,3.6,0.09,416.02,fee schedule,,,
ATROPINE SULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4081335,CDM,J0461,HCPCS,636,RC,00517-1001-01,NDC,outpatient,1,ML,30.76,21.532,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.08,,,9,0.09,416.02,fee schedule,,,
ATROPINE SULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4081335,CDM,J0461,HCPCS,636,RC,00517-1001-25,NDC,outpatient,1,ML,30.76,21.532,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.08,,,9,0.09,416.02,fee schedule,,,
ATROPINE SULFATE 0.25 MG/5ML IJ SOSY,RX-729,CDM,J0461,HCPCS,636,RC,00409-9630-15,NDC,outpatient,5,ML,87.58,61.306,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.08,,,2.25,0.09,416.02,fee schedule,,,
ATROPINE SULFATE 0.25 MG/5ML IJ SOSY,RX-729,CDM,J0461,HCPCS,636,RC,00409-9630-05,NDC,outpatient,5,ML,87.58,61.306,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.08,,,2.25,0.09,416.02,fee schedule,,,
BACLOFEN 10000 MCG/20ML IT WRAPPER,RX-4081072,CDM,J0475,HCPCS,636,RC,66794-0155-01,NDC,outpatient,20,ML,794.33,556.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,177.58,,,182.26,174.58,1359.95136,fee schedule,,,
BACLOFEN 20000 MCG/20ML IT WRAPPER,RX-4081073,CDM,J0475,HCPCS,636,RC,66794-0156-02,NDC,outpatient,20,ML,1497.87,1048.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,177.58,,,364.52,174.58,1359.95136,fee schedule,,,
BACLOFEN 40000 MCG/20ML IT WRAPPER,RX-4081074,CDM,J0475,HCPCS,636,RC,66794-0157-02,NDC,outpatient,20,ML,1770.77,1239.539,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,177.58,,,729.04,174.58,1359.95136,fee schedule,,,
BACLOFEN 50 MCG/ML IT SOSY,RX-107798,CDM,J0476,HCPCS,636,RC,66794-0151-01,NDC,outpatient,1,ML,326.81,228.767,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,40.38,416.02,other,SI=N Exclusions ,,
BELIMUMAB 120 MG IV SOLR,RX-108842,CDM,J0490,HCPCS,636,RC,49401-0101-01,NDC,outpatient,1,UN,1753.47,1227.429,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,54.13,,,623.64,50.93,4488.66816,fee schedule,,,
BELIMUMAB 400 MG IV SOLR,RX-108843,CDM,J0490,HCPCS,636,RC,49401-0102-01,NDC,outpatient,1,UN,5844.62,4091.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,54.13,,,2078.8,50.93,4488.66816,fee schedule,,,
DICYCLOMINE HCL 10 MG/ML IM SOLN,RX-2417,CDM,J0500,HCPCS,636,RC,14789-0010-02,NDC,outpatient,2,ML,41.12,28.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.23144,416.02,other,SI=N Exclusions ,,
DICYCLOMINE HCL 10 MG/ML IM SOLN,RX-2417,CDM,J0500,HCPCS,636,RC,58914-0080-52,NDC,outpatient,2,ML,345.64,241.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.23144,416.02,other,SI=N Exclusions ,,
DICYCLOMINE HCL 10 MG/ML IM SOLN,RX-2417,CDM,J0500,HCPCS,636,RC,14789-0010-07,NDC,outpatient,2,ML,41.12,28.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.23144,416.02,other,SI=N Exclusions ,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9233-01,NDC,outpatient,2,ML,97.73,68.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,16.21,416.02,other,SI=N Exclusions ,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9729-05,NDC,outpatient,2,ML,114.01,79.807,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,16.21,416.02,other,SI=N Exclusions ,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,68382-0860-02,NDC,outpatient,2,ML,102.98,72.086,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,16.21,416.02,other,SI=N Exclusions ,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9233-05,NDC,outpatient,2,ML,97.73,68.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,16.21,416.02,other,SI=N Exclusions ,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9729-01,NDC,outpatient,2,ML,114.01,79.807,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,16.21,416.02,other,SI=N Exclusions ,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,68382-0860-10,NDC,outpatient,2,ML,102.98,72.086,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,16.21,416.02,other,SI=N Exclusions ,,
PENICILLIN G BENZATHINE & PROC 1200000 UNIT/2ML IM SUSP,RX-108051,CDM,J0558,HCPCS,636,RC,60793-0600-02,NDC,outpatient,2,ML,908.68,636.076,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19.52,,,188.88,15.67,697.86624,fee schedule,,,
PENICILLIN G BENZATHINE & PROC 1200000 UNIT/2ML IM SUSP,RX-108051,CDM,J0558,HCPCS,636,RC,60793-0600-10,NDC,outpatient,2,ML,908.68,636.076,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,19.52,,,188.88,15.67,697.86624,fee schedule,,,
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SUSY,RX-158171,CDM,J0561,HCPCS,636,RC,60793-0700-01,NDC,outpatient,1,ML,595.58,416.906,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,23.97,,,120.96,20.17,1623.552,fee schedule,,,
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SUSY,RX-158171,CDM,J0561,HCPCS,636,RC,60793-0700-10,NDC,outpatient,1,ML,595.58,416.906,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,23.97,,,120.96,20.17,1623.552,fee schedule,,,
PENICILLIN G BENZATHINE 1200000 UNIT/2ML IM SUSY,RX-158172,CDM,J0561,HCPCS,636,RC,60793-0701-10,NDC,outpatient,2,ML,1139.95,797.965,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,23.97,,,241.92,20.17,1623.552,fee schedule,,,
PENICILLIN G BENZATHINE 1200000 UNIT/2ML IM SUSY,RX-158172,CDM,J0561,HCPCS,636,RC,60793-0701-02,NDC,outpatient,2,ML,1139.95,797.965,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,23.97,,,241.92,20.17,1623.552,fee schedule,,,
PENICILLIN G BENZATHINE 2400000 UNIT/4ML IM SUSY,RX-162947,CDM,J0561,HCPCS,636,RC,60793-0702-10,NDC,outpatient,4,ML,2114,1479.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,23.97,,,483.84,20.17,1623.552,fee schedule,,,
PENICILLIN G BENZATHINE 2400000 UNIT/4ML IM SUSY,RX-162947,CDM,J0561,HCPCS,636,RC,60793-0702-04,NDC,outpatient,4,ML,2114,1479.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,23.97,,,483.84,20.17,1623.552,fee schedule,,,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,16729-0275-03,NDC,outpatient,1,UN,294.51,206.157,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.17,416.02,other,SI=N Exclusions ,,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,00781-3158-95,NDC,outpatient,1,UN,308.39,215.873,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.17,416.02,other,SI=N Exclusions ,,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,16729-0275-67,NDC,outpatient,1,UN,294.51,206.157,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.17,416.02,other,SI=N Exclusions ,,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,00781-3158-94,NDC,outpatient,1,UN,308.39,215.873,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.17,416.02,other,SI=N Exclusions ,,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,55150-0210-10,NDC,outpatient,1,UN,189.45,132.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.17,416.02,other,SI=N Exclusions ,,
ONABOTULINUMTOXINA 100 UNITS IJ SOLR,RX-100610,CDM,J0585,HCPCS,636,RC,00023-1145-01,NDC,outpatient,1,UN,1749.84,1224.888,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6.38,,,633,6.15,1343.87712,fee schedule,,,
BUPRENORPHINE HCL 0.3 MG/ML IJ SOLN,RX-9320,CDM,J0592,HCPCS,636,RC,42023-0179-01,NDC,outpatient,1,ML,53.16,37.212,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.03,416.02,other,SI=N Exclusions ,,
BUPRENORPHINE HCL 0.3 MG/ML IJ SOLN,RX-9320,CDM,J0592,HCPCS,636,RC,42023-0179-05,NDC,outpatient,1,ML,53.16,37.212,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.03,416.02,other,SI=N Exclusions ,,
BUTORPHANOL TARTRATE 2 MG/ML IJ SOLN,RX-9334,CDM,J0595,HCPCS,636,RC,00409-1626-21,NDC,outpatient,1,ML,29.94,20.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.06,416.02,other,SI=N Exclusions ,,
BUTORPHANOL TARTRATE 2 MG/ML IJ SOLN,RX-9334,CDM,J0595,HCPCS,636,RC,00409-1626-01,NDC,outpatient,1,ML,29.94,20.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.06,416.02,other,SI=N Exclusions ,,
EDETATE CALCIUM DISODIUM 1 GM/5ML IJ SOLN,RX-108094,CDM,J0600,HCPCS,250,RC,64980-0588-05,NDC,outpatient,5,ML,16465.83,11526.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6913.11,,,6913.11,60.43,12645.75744,fee schedule,,,
EDETATE CALCIUM DISODIUM 1 GM/5ML IJ SOLN,RX-108094,CDM,J0600,HCPCS,250,RC,64980-0588-51,NDC,outpatient,5,ML,16465.83,11526.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6913.11,,,6913.11,60.43,12645.75744,fee schedule,,,
CALCIUM GLUCONATE 10 % IV SOLN,RX-1312,CDM,J0612,HCPCS,636,RC,63323-0360-19,NDC,outpatient,10,ML,36.54,25.578,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.04,,,5,0.04,416.02,fee schedule,,,
CALCIUM GLUCONATE 10 % IV SOLN,RX-1312,CDM,J0612,HCPCS,636,RC,63323-0360-01,NDC,outpatient,10,ML,36.54,25.578,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.04,,,5,0.04,416.02,fee schedule,,,
CALCIUM GLUCONATE-NACL 1-0.8 GM/100ML-% IV SOLN,RX-156703,CDM,J0613,HCPCS,636,RC,44567-0622-01,NDC,outpatient,100,ML,37.38,26.166,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.09,,,9,0.08,416.02,fee schedule,,,
CALCIUM GLUCONATE-NACL 1-0.8 GM/100ML-% IV SOLN,RX-156703,CDM,J0613,HCPCS,636,RC,44567-0622-24,NDC,outpatient,100,ML,37.38,26.166,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.09,,,9,0.08,416.02,fee schedule,,,
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-01,NDC,outpatient,100,ML,37.38,26.166,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.09,,,9,0.08,416.02,fee schedule,,,
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-24,NDC,outpatient,100,ML,53.38,37.366,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.09,,,9,0.08,416.02,fee schedule,,,
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-01,NDC,outpatient,100,ML,53.38,37.366,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.09,,,9,0.08,416.02,fee schedule,,,
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-24,NDC,outpatient,100,ML,37.38,26.166,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.09,,,9,0.08,416.02,fee schedule,,,
CALCITONIN (SALMON) 200 UNIT/ML IJ SOLN,RX-9347,CDM,J0630,HCPCS,636,RC,42023-0205-01,NDC,outpatient,2,ML,2193.21,1535.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1071.97,,,1296.36,399.86,2155.44576,fee schedule,,,
CALCITONIN (SALMON) 200 UNIT/ML IJ SOLN,RX-9347,CDM,J0630,HCPCS,636,RC,67457-0675-02,NDC,outpatient,2,ML,2806.57,1964.599,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1071.97,,,1296.36,399.86,2155.44576,fee schedule,,,
LEUCOVORIN CALCIUM IM INJECTION,RX-4080923,CDM,J0640,HCPCS,636,RC,25021-0813-10,NDC,outpatient,50,ME,16.97,11.879,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.43,,,4.46,2.68951,416.02,fee schedule,,,
LEUCOVORIN CALCIUM 350 MG IJ SOLR,RX-4393,CDM,J0640,HCPCS,636,RC,00143-9552-01,NDC,outpatient,1,UN,106.72,74.704,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.43,,,31.22,2.68951,416.02,fee schedule,,,
LEUCOVORIN CALCIUM 50 MG IJ SOLR,RX-4394,CDM,J0640,HCPCS,636,RC,25021-0813-10,NDC,outpatient,50,ME,11.98,8.386,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.43,,,4.46,2.68951,416.02,fee schedule,,,
LEVOTHYROXINE SODIUM 100 MCG IV SOLR,RX-113060,CDM,J0651,HCPCS,250,RC,63323-0649-07,NDC,outpatient,1,UN,279.46,195.622,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9.4,39.5,,110.39,4.2921885,416.02,percent of total billed charges,,,
LEVOTHYROXINE SODIUM 100 MCG IV SOLR,RX-113060,CDM,J0651,HCPCS,250,RC,63323-0885-10,NDC,outpatient,5,ML,293.44,205.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9.4,39.5,,115.91,4.2921885,416.02,percent of total billed charges,,,
LEVOTHYROXINE SODIUM 100 MCG IV SOLR,RX-113060,CDM,J0651,HCPCS,250,RC,63323-0885-12,NDC,outpatient,5,ML,293.44,205.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,9.4,39.5,,115.91,4.2921885,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-18,NDC,outpatient,10,ML,8.79,6.153,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,1,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1559-19,NDC,outpatient,30,ML,19.59,13.713,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,3,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-02,NDC,outpatient,30,ML,8.79,6.153,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,3,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-19,NDC,outpatient,30,ML,8.79,6.153,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,3,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1559-30,NDC,outpatient,30,ML,19.59,13.713,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,3,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-01,NDC,outpatient,10,ML,8.79,6.153,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,1,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,55150-0167-10,NDC,outpatient,10,ML,10.85,7.595,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,1,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,55150-0168-30,NDC,outpatient,30,ML,11.11,7.777,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,3,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,63323-0464-01,NDC,outpatient,10,ML,6.48,4.536,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,1,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,63323-0464-17,NDC,outpatient,10,ML,6.48,4.536,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,1,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00143-9330-01,NDC,outpatient,10,ML,7.82,5.474,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,1,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00143-9330-10,NDC,outpatient,10,ML,7.82,5.474,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,1,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,63323-0466-01,NDC,outpatient,30,ML,9.57,6.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,6,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1162-01,NDC,outpatient,10,ML,10.08,7.056,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,2,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1560-18,NDC,outpatient,10,ML,19.43,13.601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,2,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1560-19,NDC,outpatient,30,ML,17.89,12.523,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,6,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,55150-0170-30,NDC,outpatient,30,ML,12.34,8.638,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,6,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1162-02,NDC,outpatient,30,ML,9.72,6.804,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,6,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,63323-0466-37,NDC,outpatient,30,ML,9.57,6.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,6,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,63323-0472-01,NDC,outpatient,30,ML,12.8,8.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,9,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,00409-1165-02,NDC,outpatient,30,ML,16.97,11.879,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,9,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,00409-1165-19,NDC,outpatient,30,ML,16.97,11.879,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,9,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,63323-0472-37,NDC,outpatient,30,ML,12.8,8.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,9,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL 0.25 % IJ SOLN,RX-1222,CDM,J0665,HCPCS,636,RC,63323-0465-01,NDC,outpatient,5,ML,5.5,3.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,0.5,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL 0.25 % IJ SOLN,RX-1222,CDM,J0665,HCPCS,636,RC,63323-0465-57,NDC,outpatient,5,ML,5.5,3.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,0.5,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL 0.5 % IJ SOLN,RX-1223,CDM,J0665,HCPCS,636,RC,00409-1163-18,NDC,outpatient,5,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,1,0.01,416.02,fee schedule,,,
BUPIVACAINE HCL 0.5 % IJ SOLN,RX-1223,CDM,J0665,HCPCS,636,RC,00409-1163-01,NDC,outpatient,5,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,1,0.01,416.02,fee schedule,,,
BUPIVACAINE IN DEXTROSE 0.75-8.25 % IT SOLN,RX-9316,CDM,J0665,HCPCS,636,RC,00409-1761-18,NDC,outpatient,2,ML,20.36,14.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,0.6,0.01,416.02,fee schedule,,,
BUPIVACAINE IN DEXTROSE 0.75-8.25 % IT SOLN,RX-9316,CDM,J0665,HCPCS,636,RC,00409-1761-10,NDC,outpatient,2,ML,20.36,14.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,0.6,0.01,416.02,fee schedule,,,
MEPIVACAINE HCL (PF) 2 % IJ SOLN,RX-105638,CDM,J0670,HCPCS,636,RC,63323-0294-27,NDC,outpatient,20,ML,27.95,19.565,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.08,416.02,other,SI=N Exclusions ,,
MEPIVACAINE HCL (PF) 2 % IJ SOLN,RX-105638,CDM,J0670,HCPCS,636,RC,63323-0294-01,NDC,outpatient,20,ML,27.95,19.565,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.08,416.02,other,SI=N Exclusions ,,
CEFAZOLIN IVPB 2 G IN 100 ML D4W PREMIX|DISCARDED DRUG NOT ADMINISTERED,RX-4080727,CDM,J0689,HCPCS,636,RC,00338-3508-41,NDC,outpatient,100,ML,26.74,18.718,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,1.27,,,4.84,1.22,416.02,fee schedule,,,
CEFAZOLIN IVPB 2 G IN 100 ML D4W PREMIX,RX-4080727,CDM,J0689,HCPCS,636,RC,00338-3508-41,NDC,outpatient,100,ML,42.74,29.918,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.27,,,4.84,1.22,416.02,fee schedule,,,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,25021-0101-10,NDC,outpatient,1,UN,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,60505-6142-05,NDC,outpatient,1,UN,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,00143-9924-90,NDC,outpatient,1,UN,5.85,4.095,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,44567-0707-25,NDC,outpatient,1,UN,7.84,5.488,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,60505-6142-00,NDC,outpatient,1,UN,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 10 G IJ SOLR,RX-1446,CDM,J0690,HCPCS,636,RC,00143-9983-03,NDC,outpatient,1,UN,40.9,28.63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 10 G IJ SOLR,RX-1446,CDM,J0690,HCPCS,636,RC,00143-9983-91,NDC,outpatient,1,UN,40.9,28.63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 500 MG IJ SOLR,RX-1448,CDM,J0690,HCPCS,636,RC,44567-0706-25,NDC,outpatient,1,UN,4.28,2.996,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 2 G IJ SOLR,RX-158156,CDM,J0690,HCPCS,636,RC,60505-6231-05,NDC,outpatient,1,UN,18.74,13.118,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 2 G IJ SOLR,RX-158156,CDM,J0690,HCPCS,636,RC,60505-6231-00,NDC,outpatient,1,UN,18.74,13.118,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 1 G IV SOLR ADD-VANTAGE,RX-27297,CDM,J0690,HCPCS,636,RC,00409-2585-01,NDC,outpatient,1,UN,12.17,8.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 1 G IV SOLR ADD-VANTAGE,RX-27297,CDM,J0690,HCPCS,636,RC,00409-2585-11,NDC,outpatient,1,UN,12.17,8.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,44567-0707-25,NDC,outpatient,1,UN,7.84,5.488,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,00143-9924-90,NDC,outpatient,1,UN,5.85,4.095,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,60505-6142-00,NDC,outpatient,1,UN,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,60505-6142-05,NDC,outpatient,1,UN,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,25021-0101-10,NDC,outpatient,1,UN,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,00143-9924-90,NDC,outpatient,1,UN,5.85,4.095,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,44567-0707-25,NDC,outpatient,1,UN,7.84,5.488,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,25021-0101-10,NDC,outpatient,1,UN,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,60505-6142-00,NDC,outpatient,1,UN,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,60505-6142-05,NDC,outpatient,1,UN,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFAZOLIN SODIUM 1 G 100 ML ADD-VANTAGE BAG,RX-4081138,CDM,J0690,HCPCS,636,RC,99999-0003-01,NDC,outpatient,100,ML,32.9,23.03,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,00409-9566-01,NDC,outpatient,1,UN,16.63,11.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,44567-0240-10,NDC,outpatient,1,UN,23.44,16.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,60505-6146-00,NDC,outpatient,1,UN,12,8.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,25021-0121-20,NDC,outpatient,1,UN,17.97,12.579,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,60505-6146-04,NDC,outpatient,1,UN,12,8.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,00409-9566-10,NDC,outpatient,1,UN,16.63,11.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,25021-0122-50,NDC,outpatient,1,UN,32.22,22.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,60505-6246-04,NDC,outpatient,1,UN,19.47,13.629,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,70594-0090-02,NDC,outpatient,1,UN,40.3,28.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,00409-9735-01,NDC,outpatient,1,UN,25.5,17.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,00409-9735-10,NDC,outpatient,1,UN,25.5,17.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,44567-0241-10,NDC,outpatient,1,UN,40.3,28.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,60505-6246-00,NDC,outpatient,1,UN,19.47,13.629,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,70594-0090-01,NDC,outpatient,1,UN,40.3,28.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME IVPB 1 G IN 100 ML NS COMPOUNDED,RX-4080828,CDM,J0692,HCPCS,636,RC,99999-0001-09,NDC,outpatient,100,ML,48.93,34.251,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,44567-0241-10,NDC,outpatient,1,UN,40.3,28.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,60505-6147-00,NDC,outpatient,1,UN,34.31,24.017,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,60505-6147-04,NDC,outpatient,1,UN,19.47,13.629,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,70594-0090-02,NDC,outpatient,1,UN,40.3,28.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,00409-9735-10,NDC,outpatient,1,UN,25.5,17.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,00409-9735-01,NDC,outpatient,1,UN,25.5,17.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,70594-0090-01,NDC,outpatient,1,UN,40.3,28.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,25021-0121-20,NDC,outpatient,1,UN,17.97,12.579,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,00409-9566-10,NDC,outpatient,1,UN,16.63,11.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,60505-6146-00,NDC,outpatient,1,UN,12,8.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,60505-6146-04,NDC,outpatient,1,UN,12,8.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,00409-9566-01,NDC,outpatient,1,UN,16.63,11.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,44567-0240-10,NDC,outpatient,1,UN,23.44,16.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.22,416.02,other,SI=N Exclusions ,,
CEFOXITIN SODIUM-DEXTROSE 2-2.2 GM-%(50ML) IV SOLR,RX-144407,CDM,J0694,HCPCS,636,RC,00264-3125-11,NDC,outpatient,1,UN,147.33,103.131,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.679555,416.02,other,SI=N Exclusions ,,
CEFOXITIN IVPB 2 G IN 100 ML NS COMPOUNDED,RX-4080864,CDM,J0694,HCPCS,636,RC,99999-0001-16,NDC,outpatient,100,ML,46.14,32.298,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.679555,416.02,other,SI=N Exclusions ,,
CEFOXITIN SODIUM 1 G IV SOLR 1000 MG/10.5 ML,RX-4080998,CDM,J0694,HCPCS,636,RC,25021-0109-10,NDC,outpatient,1,UN,16.39,11.473,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.679555,416.02,other,SI=N Exclusions ,,
CEFOXITIN SODIUM 1 G IV SOLR 1000 MG/10.5 ML,RX-4080998,CDM,J0694,HCPCS,636,RC,44567-0245-25,NDC,outpatient,1,UN,40.92,28.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.679555,416.02,other,SI=N Exclusions ,,
CEFOXITIN SODIUM 2 G IV SOLR 2000 MG/11.1 ML,RX-4081009,CDM,J0694,HCPCS,636,RC,25021-0110-20,NDC,outpatient,1,UN,30.34,21.238,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.679555,416.02,other,SI=N Exclusions ,,
CEFOXITIN SODIUM 2 G IV SOLR 2000 MG/11.1 ML,RX-4081009,CDM,J0694,HCPCS,636,RC,44567-0246-25,NDC,outpatient,1,UN,82.04,57.428,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.679555,416.02,other,SI=N Exclusions ,,
CEFOXITIN SODIUM 1 G IV SOLR,RX-9461,CDM,J0694,HCPCS,636,RC,44567-0245-25,NDC,outpatient,1,UN,40.92,28.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.679555,416.02,other,SI=N Exclusions ,,
CEFOXITIN SODIUM 1 G IV SOLR,RX-9461,CDM,J0694,HCPCS,636,RC,25021-0109-10,NDC,outpatient,1,UN,16.39,11.473,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.679555,416.02,other,SI=N Exclusions ,,
CEFOXITIN SODIUM 2 G IV SOLR,RX-9463,CDM,J0694,HCPCS,636,RC,25021-0110-20,NDC,outpatient,1,UN,30.34,21.238,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.679555,416.02,other,SI=N Exclusions ,,
CEFOXITIN SODIUM 2 G IV SOLR,RX-9463,CDM,J0694,HCPCS,636,RC,44567-0246-25,NDC,outpatient,1,UN,82.04,57.428,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.679555,416.02,other,SI=N Exclusions ,,
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G IV SOLR,RX-129169,CDM,J0695,HCPCS,636,RC,67919-0030-01,NDC,outpatient,1,UN,652.32,456.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8.24,,,149.6,7.54,500.98176,fee schedule,,,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00143-9857-01,NDC,outpatient,1,UN,5.23,3.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00143-9857-25,NDC,outpatient,1,UN,5.23,3.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00781-3208-85,NDC,outpatient,1,UN,17.99,12.593,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,44567-0701-25,NDC,outpatient,1,UN,4.75,3.325,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00781-3208-95,NDC,outpatient,1,UN,17.99,12.593,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,25021-0106-10,NDC,outpatient,1,UN,9.22,6.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00143-9856-25,NDC,outpatient,1,UN,9.12,6.384,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,44567-0702-25,NDC,outpatient,1,UN,9.03,6.321,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00781-3209-95,NDC,outpatient,1,UN,11.14,7.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,25021-0107-20,NDC,outpatient,1,UN,18.72,13.104,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00143-9856-01,NDC,outpatient,1,UN,9.12,6.384,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00781-3209-90,NDC,outpatient,1,UN,11.14,7.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00143-9857-01,NDC,outpatient,1,UN,5.23,3.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00143-9857-25,NDC,outpatient,1,UN,5.23,3.661,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00409-7332-11,NDC,outpatient,1,UN,6.94,4.858,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00781-3208-95,NDC,outpatient,1,UN,17.99,12.593,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,44567-0701-25,NDC,outpatient,1,UN,4.75,3.325,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00781-3208-85,NDC,outpatient,1,UN,17.99,12.593,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00409-7332-01,NDC,outpatient,1,UN,6.94,4.858,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,25021-0106-10,NDC,outpatient,1,UN,9.22,6.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00143-9856-01,NDC,outpatient,1,UN,9.12,6.384,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00781-3209-95,NDC,outpatient,1,UN,11.14,7.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00143-9856-25,NDC,outpatient,1,UN,9.12,6.384,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,25021-0107-20,NDC,outpatient,1,UN,18.72,13.104,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,44567-0702-25,NDC,outpatient,1,UN,9.03,6.321,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00781-3209-90,NDC,outpatient,1,UN,11.14,7.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00143-9859-25,NDC,outpatient,1,UN,4.32,3.024,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00781-3206-95,NDC,outpatient,1,UN,6.33,4.431,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00409-7337-11,NDC,outpatient,1,UN,3.47,2.429,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00143-9859-01,NDC,outpatient,1,UN,4.32,3.024,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00409-7337-01,NDC,outpatient,1,UN,3.47,2.429,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00781-3206-85,NDC,outpatient,1,UN,6.33,4.431,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions ,,
CEFUROXIME SODIUM 750 MG IJ SOLR,RX-1465,CDM,J0697,HCPCS,636,RC,00143-9979-90,NDC,outpatient,1,UN,12.5,8.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.88,416.02,other,SI=N Exclusions ,,
CEFUROXIME SODIUM 750 MG IJ SOLR,RX-1465,CDM,J0697,HCPCS,636,RC,25021-0118-10,NDC,outpatient,1,UN,9.6,6.72,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.88,416.02,other,SI=N Exclusions ,,
CEFUROXIME SODIUM 750 MG IJ SOLR,RX-1465,CDM,J0697,HCPCS,636,RC,00143-9979-22,NDC,outpatient,1,UN,12.5,8.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.88,416.02,other,SI=N Exclusions ,,
CEFUROXIME SODIUM 1.5 G IV SOLR,RX-27299,CDM,J0697,HCPCS,636,RC,00143-9977-90,NDC,outpatient,1,UN,21.64,15.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.88,416.02,other,SI=N Exclusions ,,
CEFUROXIME SODIUM 1.5 G IV SOLR,RX-27299,CDM,J0697,HCPCS,636,RC,00143-9977-22,NDC,outpatient,1,UN,21.64,15.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.88,416.02,other,SI=N Exclusions ,,
CEFUROXIME SODIUM 750 MG IJ SOLR 750 MG/8.3 ML,RX-4080994,CDM,J0697,HCPCS,636,RC,00143-9979-22,NDC,outpatient,1,UN,12.5,8.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.88,416.02,other,SI=N Exclusions ,,
CEFUROXIME SODIUM 750 MG IJ SOLR 750 MG/8.3 ML,RX-4080994,CDM,J0697,HCPCS,636,RC,00143-9979-90,NDC,outpatient,1,UN,12.5,8.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.88,416.02,other,SI=N Exclusions ,,
CEFUROXIME SODIUM 750 MG IJ SOLR 750 MG/8.3 ML,RX-4080994,CDM,J0697,HCPCS,636,RC,25021-0118-10,NDC,outpatient,1,UN,9.6,6.72,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.88,416.02,other,SI=N Exclusions ,,
CEFUROXIME SODIUM 1.5 G IJ SOLR IN 16 ML,RX-4081008,CDM,J0697,HCPCS,636,RC,00143-9977-90,NDC,outpatient,1,UN,21.64,15.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.88,416.02,other,SI=N Exclusions ,,
CEFUROXIME SODIUM 1.5 G IJ SOLR IN 16 ML,RX-4081008,CDM,J0697,HCPCS,636,RC,00143-9977-22,NDC,outpatient,1,UN,21.64,15.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.88,416.02,other,SI=N Exclusions ,,
BETAMETHASONE SOD PHOS & ACET 6 (3-3) MG/ML IJ SUSP,RX-9266,CDM,J0702,HCPCS,636,RC,00517-0720-01,NDC,outpatient,5,ML,143.92,100.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6.96,416.02,other,SI=N Exclusions ,,
BETAMETHASONE SOD PHOS & ACET 6 (3-3) MG/ML IJ SUSP,RX-9266,CDM,J0702,HCPCS,636,RC,78206-0118-01,NDC,outpatient,5,ML,170.75,119.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6.96,416.02,other,SI=N Exclusions ,,
CAFFEINE CITRATE 60 MG/3ML IV SOLN,RX-109034,CDM,J0706,HCPCS,636,RC,51754-0500-01,NDC,outpatient,3,ML,26.75,18.725,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.65,416.02,other,SI=N Exclusions ,,
CEFTAROLINE FOSAMIL 400 MG IV SOLR,RX-107670,CDM,J0712,HCPCS,636,RC,00456-0400-10,NDC,outpatient,1,UN,806.58,564.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.03,,,154.4,3.89,619.45344,fee schedule,,,
CEFTAROLINE FOSAMIL 400 MG IV SOLR,RX-107670,CDM,J0712,HCPCS,636,RC,00456-0400-01,NDC,outpatient,1,UN,806.58,564.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.03,,,154.4,3.89,619.45344,fee schedule,,,
CEFTAROLINE FOSAMIL 600 MG IV SOLR,RX-107671,CDM,J0712,HCPCS,636,RC,00456-0600-10,NDC,outpatient,1,UN,806.58,564.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.03,,,231.6,3.89,619.45344,fee schedule,,,
CEFTAROLINE FOSAMIL 600 MG IV SOLR,RX-107671,CDM,J0712,HCPCS,636,RC,00456-0600-01,NDC,outpatient,1,UN,806.58,564.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.03,,,231.6,3.89,619.45344,fee schedule,,,
CEFTAZIDIME 2 G IV SOLR,RX-27291,CDM,J0713,HCPCS,636,RC,44567-0236-10,NDC,outpatient,1,UN,23.52,16.464,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.66,416.02,other,SI=N Exclusions ,,
CEFTAZIDIME 2 G IV SOLR,RX-27291,CDM,J0713,HCPCS,636,RC,25021-0128-50,NDC,outpatient,1,UN,37.01,25.907,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.66,416.02,other,SI=N Exclusions ,,
CEFTAZIDIME 1 MG/ML IJ SOLR,RX-4080666,CDM,J0713,HCPCS,636,RC,00409-5082-16,NDC,outpatient,1,UN,14.25,9.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.66,416.02,other,SI=N Exclusions ,,
CEFTAZIDIME 1 G IJ SOLR 1000 MG/10.8 ML,RX-4081001,CDM,J0713,HCPCS,636,RC,00409-5082-16,NDC,outpatient,1,UN,14.25,9.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.66,416.02,other,SI=N Exclusions ,,
CEFTAZIDIME 2 G IJ SOLR 2000 MG/11.5 ML,RX-4081002,CDM,J0713,HCPCS,636,RC,25021-0128-50,NDC,outpatient,1,UN,37.01,25.907,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.66,416.02,other,SI=N Exclusions ,,
CEFTAZIDIME 1 G IJ SOLR,RX-9474,CDM,J0713,HCPCS,636,RC,00409-5082-16,NDC,outpatient,1,UN,14.25,9.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.66,416.02,other,SI=N Exclusions ,,
CEFTAZIDIME 1 G IJ SOLR,RX-9474,CDM,J0713,HCPCS,636,RC,00409-5082-11,NDC,outpatient,1,UN,14.25,9.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.66,416.02,other,SI=N Exclusions ,,
CEFTAZIDIME 1 G IJ SOLR,RX-9474,CDM,J0713,HCPCS,636,RC,44567-0235-25,NDC,outpatient,1,UN,13.87,9.709,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.66,416.02,other,SI=N Exclusions ,,
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G IV SOLR,RX-130403,CDM,J0714,HCPCS,636,RC,00456-2700-01,NDC,outpatient,1,UN,1625.76,1138.032,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,100.2,,,381.76,92.48,1248.58368,fee schedule,,,
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G IV SOLR,RX-130403,CDM,J0714,HCPCS,636,RC,00456-2700-10,NDC,outpatient,1,UN,1625.76,1138.032,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,100.2,,,381.76,92.48,1248.58368,fee schedule,,,
CLONIDINE HCL (ANALGESIA) 100 MCG/ML EP SOLN,RX-19333,CDM,J0735,HCPCS,636,RC,67457-0218-10,NDC,outpatient,10,ML,45.22,31.654,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.15189,416.02,other,SI=N Exclusions ,,
CLONIDINE HCL (ANALGESIA) 500 MCG/ML EP SOLN,RX-27113,CDM,J0735,HCPCS,636,RC,39822-2010-01,NDC,outpatient,10,ML,402.95,282.065,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.15189,416.02,other,SI=N Exclusions ,,
CLINDAMYCIN PHOSPHATE 150 MG/ML IJ WRAPPER,RX-4080195,CDM,J0736,HCPCS,636,RC,00009-0775-20,NDC,outpatient,4,ML,13.99,9.793,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.39,,,4.04,1.61,416.02,fee schedule,,,
CLINDAMYCIN PHOSPHATE 150 MG/ML IJ WRAPPER,RX-4080195,CDM,J0736,HCPCS,636,RC,00009-0775-26,NDC,outpatient,4,ML,13.99,9.793,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.39,,,4.04,1.61,416.02,fee schedule,,,
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0736,HCPCS,636,RC,00781-3288-09,NDC,outpatient,50,ML,48.27,33.789,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.39,,,2.02,1.61,416.02,fee schedule,,,
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0736,HCPCS,636,RC,00781-3288-91,NDC,outpatient,50,ML,48.27,33.789,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.39,,,2.02,1.61,416.02,fee schedule,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-91,NDC,outpatient,50,ML,64.73,45.311,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.39,,,4.04,1.61,416.02,fee schedule,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-09,NDC,outpatient,50,ML,48.73,34.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,2.39,,,4.04,1.61,416.02,fee schedule,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-91,NDC,outpatient,50,ML,48.73,34.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,2.39,,,4.04,1.61,416.02,fee schedule,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-09,NDC,outpatient,50,ML,64.73,45.311,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.39,,,4.04,1.61,416.02,fee schedule,,,
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0737,HCPCS,636,RC,00338-3410-24,NDC,outpatient,50,ML,30.91,21.637,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.26,,,2.59,2.59,416.02,fee schedule,,,
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0737,HCPCS,636,RC,00338-3410-50,NDC,outpatient,50,ML,30.91,21.637,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.26,,,2.59,2.59,416.02,fee schedule,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-24,NDC,outpatient,50,ML,34.25,23.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.26,,,5.18,2.59,416.02,fee schedule,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-50,NDC,outpatient,50,ML,34.25,23.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.26,,,5.18,2.59,416.02,fee schedule,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-24,NDC,outpatient,50,ML,18.25,12.775,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,3.26,,,5.18,2.59,416.02,fee schedule,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-50,NDC,outpatient,50,ML,34.25,23.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.26,,,5.18,2.59,416.02,fee schedule,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-24,NDC,outpatient,50,ML,34.25,23.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.26,,,5.18,2.59,416.02,fee schedule,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-50,NDC,outpatient,50,ML,18.25,12.775,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,3.26,,,5.18,2.59,416.02,fee schedule,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-50,NDC,outpatient,50,ML,18.25,12.775,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,3.26,,,5.18,2.59,416.02,fee schedule,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-24,NDC,outpatient,50,ML,18.25,12.775,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,3.26,,,5.18,2.59,416.02,fee schedule,,,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-50,NDC,outpatient,50,ML,38.7,27.09,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.26,,,7.77,2.59,416.02,fee schedule,,,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-24,NDC,outpatient,50,ML,22.7,15.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,3.26,,,7.77,2.59,416.02,fee schedule,,,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-50,NDC,outpatient,50,ML,22.7,15.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,3.26,,,7.77,2.59,416.02,fee schedule,,,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-24,NDC,outpatient,50,ML,38.7,27.09,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.26,,,7.77,2.59,416.02,fee schedule,,,
IMIPENEM-CILASTATIN 250 MG IV SOLR,RX-9602,CDM,J0743,HCPCS,636,RC,63323-0349-25,NDC,outpatient,1,UN,25.58,17.906,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.74271,416.02,other,SI=N Exclusions ,,
IMIPENEM-CILASTATIN 500 MG IV SOLR,RX-9603,CDM,J0743,HCPCS,636,RC,63323-0322-25,NDC,outpatient,1,UN,43.92,30.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.74271,416.02,other,SI=N Exclusions ,,
IMIPENEM-CILASTATIN 500 MG IV SOLR,RX-9603,CDM,J0743,HCPCS,636,RC,63323-0322-01,NDC,outpatient,1,UN,43.92,30.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.74271,416.02,other,SI=N Exclusions ,,
CIPROFLOXACIN IN D5W 200 MG/100ML IV SOLN,RX-108130,CDM,J0744,HCPCS,636,RC,00409-2300-24,NDC,outpatient,100,ML,26.8,18.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.86,416.02,other,SI=N Exclusions ,,
CIPROFLOXACIN IN D5W 200 MG/100ML IV SOLN,RX-108130,CDM,J0744,HCPCS,636,RC,00409-2300-01,NDC,outpatient,100,ML,26.8,18.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.86,416.02,other,SI=N Exclusions ,,
CIPROFLOXACIN IN D5W 400 MG/200ML IV SOLN,RX-108132,CDM,J0744,HCPCS,636,RC,25021-0114-87,NDC,outpatient,200,ML,42.7,29.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.86,416.02,other,SI=N Exclusions ,,
COLISTIMETHATE SODIUM (CBA) 150 MG IJ SOLR,RX-142413,CDM,J0770,HCPCS,636,RC,70594-0023-04,NDC,outpatient,1,UN,46.34,32.438,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.40333,416.02,other,SI=N Exclusions ,,
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,14789-0700-07,NDC,outpatient,2,ML,14.97,10.479,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.01,416.02,other,SI=N Exclusions ,,
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,00713-0351-09,NDC,outpatient,2,ML,15.66,10.962,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.01,416.02,other,SI=N Exclusions ,,
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,00713-0351-25,NDC,outpatient,2,ML,13.73,9.611,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.01,416.02,other,SI=N Exclusions ,,
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,14789-0700-02,NDC,outpatient,2,ML,14.97,10.479,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.01,416.02,other,SI=N Exclusions ,,
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,00713-0351-02,NDC,outpatient,2,ML,13.73,9.611,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.01,416.02,other,SI=N Exclusions ,,
COSYNTROPIN 0.25 MG IJ SOLR,RX-9686,CDM,J0834,HCPCS,636,RC,00781-3440-71,NDC,outpatient,1,UN,356.89,249.823,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,16.61749,416.02,other,SI=N Exclusions ,,
COSYNTROPIN 0.25 MG IJ SOLR,RX-9686,CDM,J0834,HCPCS,636,RC,00781-3440-95,NDC,outpatient,1,UN,356.89,249.823,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,16.61749,416.02,other,SI=N Exclusions ,,
COSYNTROPIN 0.25 MG IJ SOLR,RX-9686,CDM,J0834,HCPCS,636,RC,00548-5900-00,NDC,outpatient,1,UN,74.02,51.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,16.61749,416.02,other,SI=N Exclusions ,,
DAPTOMYCIN 500 MG IV SOLR,RX-36989,CDM,J0873,HCPCS,636,RC,70594-0034-01,NDC,outpatient,1,UN,65.78,46.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.03,,,60,0.04,416.02,fee schedule,,,
DALBAVANCIN HCL 500 MG IV SOLR,RX-125774,CDM,J0875,HCPCS,636,RC,57970-0100-01,NDC,outpatient,1,UN,2550.24,1785.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15.79,,,1521,14.7,4668.927562,fee schedule,,,
DAPTOMYCIN 350 MG IV SOLR,RX-143414,CDM,J0878,HCPCS,636,RC,16729-0434-45,NDC,outpatient,1,UN,201.59,141.113,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.03,416.02,other,SI=N Exclusions ,,
DAPTOMYCIN 350 MG IV SOLR,RX-143414,CDM,J0878,HCPCS,636,RC,16729-0434-05,NDC,outpatient,1,UN,201.5,141.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.03,416.02,other,SI=N Exclusions ,,
DAPTOMYCIN 500 MG IV SOLR,RX-36989,CDM,J0878,HCPCS,636,RC,00143-9378-01,NDC,outpatient,1,UN,57.59,40.313,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.03,416.02,other,SI=N Exclusions ,,
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0883,HCPCS,636,RC,00143-9559-01,NDC,outpatient,50,ML,438.53,306.971,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.71,,,185.5,1.35,1059.84,fee schedule,,,
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0883,HCPCS,636,RC,16729-0430-43,NDC,outpatient,50,ML,358.65,251.055,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.71,,,185.5,1.35,1059.84,fee schedule,,,
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0883,HCPCS,636,RC,00143-9559-01,NDC,outpatient,50,ML,422.53,295.771,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,3.71,,,185.5,1.35,1059.84,fee schedule,,,
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0883,HCPCS,636,RC,25021-0414-50,NDC,outpatient,50,ML,317.29,222.103,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,3.71,,,185.5,1.35,1059.84,fee schedule,,,
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0883,HCPCS,636,RC,16729-0430-43,NDC,outpatient,50,ML,342.65,239.855,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,3.71,,,185.5,1.35,1059.84,fee schedule,,,
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0883,HCPCS,636,RC,25021-0414-50,NDC,outpatient,50,ML,333.29,233.303,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.71,,,185.5,1.35,1059.84,fee schedule,,,
ARGATROBAN 250 MG/2.5ML IV SOLN,RX-28947,CDM,J0883,HCPCS,636,RC,00409-1140-01,NDC,outpatient,2.5,ML,226.15,158.305,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.71,,,927.5,1.35,1059.84,fee schedule,,,
ARGATROBAN 250 MG/2.5ML IV SOLN,RX-28947,CDM,J0883,HCPCS,636,RC,00143-9674-01,NDC,outpatient,2.5,ML,1380,966,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.71,,,927.5,1.35,1059.84,fee schedule,,,
ARGATROBAN 250 MG/2.5ML IV SOLN,RX-28947,CDM,J0883,HCPCS,636,RC,63323-0526-03,NDC,outpatient,2.5,ML,1328.82,930.174,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.71,,,927.5,1.35,1059.84,fee schedule,,,
EPOETIN ALFA 10000 UNIT/ML IJ SOLN,RX-9938,CDM,J0885,HCPCS,636,RC,59676-0310-01,NDC,outpatient,1,ML,622.94,436.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8.13,,,70.9,6.88,478.41792,fee schedule,,,
EPOETIN ALFA 10000 UNIT/ML IJ SOLN,RX-9938,CDM,J0885,HCPCS,636,RC,59676-0310-00,NDC,outpatient,1,ML,622.94,436.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8.13,,,70.9,6.88,478.41792,fee schedule,,,
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,55513-0148-10,NDC,outpatient,1,ML,283.41,198.387,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8.13,,,28.36,6.88,478.41792,fee schedule,,,
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,59676-0304-00,NDC,outpatient,1,ML,456.83,319.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8.13,,,28.36,6.88,478.41792,fee schedule,,,
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,55513-0148-01,NDC,outpatient,1,ML,283.41,198.387,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8.13,,,28.36,6.88,478.41792,fee schedule,,,
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,59676-0304-01,NDC,outpatient,1,ML,456.83,319.781,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,8.13,,,28.36,6.88,478.41792,fee schedule,,,
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0891,HCPCS,636,RC,16729-0430-11,NDC,outpatient,50,ML,358.65,251.055,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.2,,,18.5,0.46,416.02,fee schedule,,,
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0891,HCPCS,636,RC,16729-0430-11,NDC,outpatient,50,ML,342.65,239.855,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,4.2,,,18.5,0.46,416.02,fee schedule,,,
DECITABINE 50 MG IV SOLR,RX-76364,CDM,J0894,HCPCS,636,RC,16729-0224-05,NDC,outpatient,1,UN,335.38,234.766,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.43,,,57.5,1.63,416.02,fee schedule,,,
DEFEROXAMINE MESYLATE 500 MG IJ SOLR,RX-9723,CDM,J0895,HCPCS,636,RC,60505-6236-00,NDC,outpatient,1,UN,46.34,32.438,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6.78,416.02,other,SI=N Exclusions ,,
DEFEROXAMINE MESYLATE 500 MG IJ SOLR,RX-9723,CDM,J0895,HCPCS,636,RC,60505-6236-06,NDC,outpatient,1,UN,46.34,32.438,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,6.78,416.02,other,SI=N Exclusions ,,
DENOSUMAB 120 MG/1.7ML SC SOLN,RX-106804,CDM,J0897,HCPCS,636,RC,55513-0730-01,NDC,outpatient,1.7,ML,8861.12,6202.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26.75,,,2906.4,24.19,6805.34016,fee schedule,,,
DENOSUMAB 60 MG/ML SC SOSY,RX-146195,CDM,J0897,HCPCS,636,RC,55513-0710-01,NDC,outpatient,1,ML,4649.31,3254.517,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,26.75,,,1453.2,24.19,6805.34016,fee schedule,,,
METHYLPREDNISOLONE ACETATE 40 MG/ML IJ SUSP,RX-4995,CDM,J1030,HCPCS,636,RC,00009-3073-03,NDC,outpatient,1,ML,22.62,15.834,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.07819,416.02,other,SI=N Exclusions ,,
METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP,RX-4996,CDM,J1040,HCPCS,636,RC,70121-1574-05,NDC,outpatient,1,ML,25.94,18.158,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.82353,416.02,other,SI=N Exclusions ,,
METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP,RX-4996,CDM,J1040,HCPCS,636,RC,00009-3475-03,NDC,outpatient,1,ML,34.96,24.472,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.82353,416.02,other,SI=N Exclusions ,,
METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP,RX-4996,CDM,J1040,HCPCS,636,RC,70121-1574-01,NDC,outpatient,1,ML,25.95,18.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.82353,416.02,other,SI=N Exclusions ,,
TESTOSTERONE CYPIONATE 200 MG/ML IM SOLN,RX-7784,CDM,J1071,HCPCS,636,RC,00009-0417-01,NDC,outpatient,1,ML,41.92,29.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.03,416.02,other,SI=N Exclusions ,,
DEXAMETHASONE SOD PHOSPHATE PF 10 MG/ML IJ SOLN,RX-116345,CDM,J1100,HCPCS,636,RC,99999-0003-18,NDC,outpatient,1,ML,8.17,5.719,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.11,,,1.3,0.11,416.02,fee schedule,,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,00641-6145-25,NDC,outpatient,1,ML,4.14,2.898,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.11,,,0.52,0.11,416.02,fee schedule,,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,63323-0165-02,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.11,,,0.52,0.11,416.02,fee schedule,,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,67457-0423-12,NDC,outpatient,1,ML,3.69,2.583,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.11,,,0.52,0.11,416.02,fee schedule,,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,55150-0237-01,NDC,outpatient,1,ML,4.01,2.807,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.11,,,0.52,0.11,416.02,fee schedule,,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,67457-0423-00,NDC,outpatient,1,ML,3.69,2.583,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.11,,,0.52,0.11,416.02,fee schedule,,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,00641-6145-01,NDC,outpatient,1,ML,4.14,2.898,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.11,,,0.52,0.11,416.02,fee schedule,,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,63323-0165-01,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.11,,,0.52,0.11,416.02,fee schedule,,,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,00641-0367-25,NDC,outpatient,1,ML,6.11,4.277,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.11,,,1.3,0.11,416.02,fee schedule,,,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,70069-0021-25,NDC,outpatient,1,ML,8.17,5.719,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.11,,,1.3,0.11,416.02,fee schedule,,,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,63323-0506-01,NDC,outpatient,1,ML,6.99,4.893,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.11,,,1.3,0.11,416.02,fee schedule,,,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,00641-0367-21,NDC,outpatient,1,ML,6.11,4.277,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.11,,,1.3,0.11,416.02,fee schedule,,,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,70069-0021-01,NDC,outpatient,1,ML,8.17,5.719,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.11,,,1.3,0.11,416.02,fee schedule,,,
DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN,RX-9859,CDM,J1110,HCPCS,636,RC,81284-0411-00,NDC,outpatient,1,ML,179.49,125.643,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,40.295505,416.02,other,SI=N Exclusions ,,
DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN,RX-9859,CDM,J1110,HCPCS,636,RC,81284-0411-05,NDC,outpatient,1,ML,220.97,154.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,40.295505,416.02,other,SI=N Exclusions ,,
DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN,RX-9859,CDM,J1110,HCPCS,636,RC,81284-0411-10,NDC,outpatient,1,ML,179.49,125.643,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,40.295505,416.02,other,SI=N Exclusions ,,
ACETAZOLAMIDE SODIUM 500 MG IJ SOLR,RX-114,CDM,J1120,HCPCS,636,RC,67457-0853-50,NDC,outpatient,1,UN,164.43,115.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.29108,416.02,other,SI=N Exclusions ,,
ACETAZOLAMIDE SODIUM 500 MG IJ SOLR,RX-114,CDM,J1120,HCPCS,636,RC,00143-9503-01,NDC,outpatient,1,UN,178.94,125.258,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.29108,416.02,other,SI=N Exclusions ,,
ACETAZOLAMIDE SODIUM 500 MG IJ SOLR,RX-114,CDM,J1120,HCPCS,636,RC,23155-0313-31,NDC,outpatient,1,UN,45.84,32.088,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.29108,416.02,other,SI=N Exclusions ,,
DIGOXIN 0.25 MG/ML IJ SOLN,RX-2442,CDM,J1160,HCPCS,636,RC,00641-1410-35,NDC,outpatient,2,ML,14.62,10.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.28219,416.02,other,SI=N Exclusions ,,
DIGOXIN 0.25 MG/ML IJ SOLN,RX-2442,CDM,J1160,HCPCS,636,RC,00641-1410-31,NDC,outpatient,2,ML,14.62,10.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.28219,416.02,other,SI=N Exclusions ,,
DIGOXIN 0.1 MG/ML IJ SOLN,RX-9853,CDM,J1160,HCPCS,636,RC,70515-0263-10,NDC,outpatient,1,ML,449.39,314.573,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.28219,416.02,other,SI=N Exclusions ,,
DIGOXIN IMMUNE FAB 40 MG IV SOLR,RX-31432,CDM,J1162,HCPCS,636,RC,50633-0120-11,NDC,outpatient,1,UN,12197.8,8538.46,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4777.44,,,4593.57,399.86,9367.9104,fee schedule,,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,00641-0493-21,NDC,outpatient,2,ML,5.82,4.074,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions ,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-02,NDC,outpatient,2,ML,10.45,7.315,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions ,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-05,NDC,outpatient,5,ML,10.7,7.49,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions ,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-30,NDC,outpatient,5,ML,10.7,7.49,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions ,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,00641-0493-25,NDC,outpatient,2,ML,5.82,4.074,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions ,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-10,NDC,outpatient,2,ML,10.45,7.315,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.44,416.02,other,SI=N Exclusions ,,
HYDROMORPHONE HCL PF 10 MG/ML IJ SOLN,RX-116809,CDM,J1170,HCPCS,636,RC,00703-0113-01,NDC,outpatient,10,ML,44.91,31.437,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.507665,416.02,other,SI=N Exclusions ,,
HYDROMORPHONE HCL PF 10 MG/ML IJ SOLN,RX-116809,CDM,J1170,HCPCS,636,RC,00703-0113-03,NDC,outpatient,10,ML,44.91,31.437,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.507665,416.02,other,SI=N Exclusions ,,
HYDROMORPHONE HCL PF 10 MG/ML IJ SOLN,RX-116809,CDM,J1170,HCPCS,636,RC,00409-2634-25,NDC,outpatient,10,ML,71.61,50.127,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.507665,416.02,other,SI=N Exclusions ,,
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,00409-1283-03,NDC,outpatient,1,ML,11.43,8.001,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.507665,416.02,other,SI=N Exclusions ,,
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,76045-0009-01,NDC,outpatient,1,ML,11.73,8.211,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.507665,416.02,other,SI=N Exclusions ,,
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,00409-1283-31,NDC,outpatient,1,ML,11.43,8.001,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.507665,416.02,other,SI=N Exclusions ,,
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,76045-0009-06,NDC,outpatient,0.5,ML,12.4,8.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.507665,416.02,other,SI=N Exclusions ,,
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,76045-0009-11,NDC,outpatient,1,ML,11.73,8.211,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.507665,416.02,other,SI=N Exclusions ,,
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,76045-0009-96,NDC,outpatient,0.5,ML,12.4,8.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.507665,416.02,other,SI=N Exclusions ,,
HYDROMORPHONE HCL 2 MG/ML IJ SOLN,RX-3758,CDM,J1170,HCPCS,636,RC,00641-6151-01,NDC,outpatient,1,ML,11.17,7.819,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.507665,416.02,other,SI=N Exclusions ,,
HYDROMORPHONE HCL 2 MG/ML IJ SOLN,RX-3758,CDM,J1170,HCPCS,636,RC,00641-6151-25,NDC,outpatient,1,ML,11.17,7.819,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.507665,416.02,other,SI=N Exclusions ,,
CONC DILAUDID 10 MG/ML PCA,RX-4080160,CDM,J1170,HCPCS,636,RC,99999-0000-95,NDC,outpatient,50,ML,267.65,187.355,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.507665,416.02,other,SI=N Exclusions ,,
DEXRAZOXANE HCL 500 MG IV SOLR,RX-146172,CDM,J1190,HCPCS,636,RC,51991-0942-98,NDC,outpatient,1,UN,575.66,402.962,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,100.67,,,247.76,87.49,442.10688,fee schedule,,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-00,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-41,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,00641-0376-25,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,72485-0101-25,NDC,outpatient,1,ML,4.75,3.325,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,00641-0376-21,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-16,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-01,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,72485-0101-01,NDC,outpatient,1,ML,4.75,3.325,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
CHLOROTHIAZIDE SODIUM 500 MG IV SOLR,RX-9526,CDM,J1205,HCPCS,636,RC,25021-0305-20,NDC,outpatient,1,UN,139.6,97.72,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,31.3402,416.02,other,SI=N Exclusions ,,
DIMETHYL SULFOXIDE 50 % IS SOLN,RX-9873,CDM,J1212,HCPCS,636,RC,67457-0177-50,NDC,outpatient,50,ML,1852.55,1296.785,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,706.17,,,681.74,399.86,1422.7584,fee schedule,,,
METHADONE HCL 10 MG/ML IJ SOLN,RX-10546,CDM,J1230,HCPCS,636,RC,99999-0000-89,NDC,outpatient,1,ML,43.49,30.443,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.763505,945.2928,other,SI=N Exclusions ,,
METHADONE HCL 10 MG/ML IJ SOLN,RX-10546,CDM,J1230,HCPCS,636,RC,67457-0217-20,NDC,outpatient,20,ML,869.71,608.797,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.763505,945.2928,other,SI=N Exclusions ,,
METHADONE 10 MG/ML PCA,RX-4080162,CDM,J1230,HCPCS,636,RC,99999-0000-13,NDC,outpatient,50,ML,1230.85,861.595,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.763505,945.2928,other,SI=N Exclusions ,,
METHADONE 1 MG/ML IV INFUSION PREMIX,RX-4080178,CDM,J1230,HCPCS,636,RC,99999-0000-27,NDC,outpatient,200,ML,874.19,611.933,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.763505,945.2928,other,SI=N Exclusions ,,
DIPYRIDAMOLE 5 MG/ML IV SOLN,RX-9891,CDM,J1245,HCPCS,636,RC,00641-2569-41,NDC,outpatient,10,ML,75.79,53.053,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.78,416.02,other,SI=N Exclusions ,,
DIPYRIDAMOLE 5 MG/ML IV SOLN,RX-9891,CDM,J1245,HCPCS,636,RC,00641-2569-44,NDC,outpatient,10,ML,75.79,53.053,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.78,416.02,other,SI=N Exclusions ,,
DOBUTAMINE-DEXTROSE 1-5 MG/ML-% IV SOLN,RX-18314,CDM,J1250,HCPCS,636,RC,00409-2346-32,NDC,outpatient,250,ML,52.72,36.904,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.15774,416.02,other,SI=N Exclusions ,,
DOBUTAMINE-DEXTROSE 1-5 MG/ML-% IV SOLN,RX-18314,CDM,J1250,HCPCS,636,RC,00338-1073-02,NDC,outpatient,250,ML,38.25,26.775,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.15774,416.02,other,SI=N Exclusions ,,
DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN,RX-18315,CDM,J1250,HCPCS,636,RC,00338-1075-02,NDC,outpatient,250,ML,52.72,36.904,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.15774,416.02,other,SI=N Exclusions ,,
DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN,RX-18315,CDM,J1250,HCPCS,636,RC,00409-2347-32,NDC,outpatient,250,ML,72.74,50.918,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.15774,416.02,other,SI=N Exclusions ,,
DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN,RX-18315,CDM,J1250,HCPCS,636,RC,00409-2347-31,NDC,outpatient,250,ML,72.74,50.918,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.15774,416.02,other,SI=N Exclusions ,,
DOBUTAMINE 50 MG IN D5W 50 ML SYRINGE FROM PREMIX BAG (NEO/PED),RX-4081532,CDM,J1250,HCPCS,636,RC,99999-0004-34,NDC,outpatient,50,ML,24.49,17.143,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.15774,416.02,other,SI=N Exclusions ,,
DOBUTAMINE HCL 250 MG/20ML IV SOLN,RX-77318,CDM,J1250,HCPCS,636,RC,00143-9141-01,NDC,outpatient,20,ML,18.52,12.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.15774,416.02,other,SI=N Exclusions ,,
DOBUTAMINE HCL 250 MG/20ML IV SOLN,RX-77318,CDM,J1250,HCPCS,636,RC,00143-9141-10,NDC,outpatient,20,ML,18.52,12.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.15774,416.02,other,SI=N Exclusions ,,
DOBUTAMINE HCL 250 MG/20ML IV SOLN,RX-77318,CDM,J1250,HCPCS,636,RC,00409-2344-01,NDC,outpatient,20,ML,27.59,19.313,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.15774,416.02,other,SI=N Exclusions ,,
DOPAMINE-DEXTROSE 0.8-5 MG/ML-% IV SOLN,RX-14844,CDM,J1265,HCPCS,636,RC,00338-1005-02,NDC,outpatient,250,ML,41.59,29.113,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.7,416.02,other,SI=N Exclusions ,,
DOPAMINE-DEXTROSE 1.6-5 MG/ML-% IV SOLN,RX-14845,CDM,J1265,HCPCS,636,RC,00409-7809-11,NDC,outpatient,250,ML,50.49,35.343,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.7,416.02,other,SI=N Exclusions ,,
DOPAMINE-DEXTROSE 1.6-5 MG/ML-% IV SOLN,RX-14845,CDM,J1265,HCPCS,636,RC,00338-1007-02,NDC,outpatient,250,ML,48.27,33.789,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.7,416.02,other,SI=N Exclusions ,,
DOPAMINE-DEXTROSE 1.6-5 MG/ML-% IV SOLN,RX-14845,CDM,J1265,HCPCS,636,RC,00409-7809-22,NDC,outpatient,250,ML,50.49,35.343,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.7,416.02,other,SI=N Exclusions ,,
DOPAMINE HCL 40 MG/ML IV SOLN,RX-2595,CDM,J1265,HCPCS,636,RC,00409-9104-21,NDC,outpatient,10,ML,13.16,9.212,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.7,416.02,other,SI=N Exclusions ,,
DOPAMINE HCL 40 MG/ML IV SOLN,RX-2595,CDM,J1265,HCPCS,636,RC,00409-9104-20,NDC,outpatient,10,ML,13.16,9.212,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.7,416.02,other,SI=N Exclusions ,,
DOPAMINE 40 MG IN D5W 50 ML SYRINGE FROM PREMIX BAG (NEO/PED),RX-4081531,CDM,J1265,HCPCS,636,RC,99999-0004-33,NDC,outpatient,50,ML,21.92,15.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.7,416.02,other,SI=N Exclusions ,,
ECULIZUMAB 300 MG/30ML IV SOLN,RX-81696,CDM,J1300,HCPCS,636,RC,25682-0001-01,NDC,outpatient,30,ML,18003.46,12602.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,225.47,,,6757.8,224.63,13826.65728,fee schedule,,,
VELETRI 1.5 MG IV SOLR,RX-106514,CDM,J1325,HCPCS,636,RC,66215-0402-01,NDC,outpatient,1,UN,260.55,182.385,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,15.86,416.02,other,SI=N Exclusions ,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00143-9398-01,NDC,outpatient,1,UN,100.74,70.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00409-3510-21,NDC,outpatient,1,UN,135.69,94.983,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,42023-0221-01,NDC,outpatient,1,UN,95.49,66.843,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00409-3510-22,NDC,outpatient,1,UN,135.69,94.983,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,16714-0889-10,NDC,outpatient,1,UN,129.15,90.405,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,60505-6196-04,NDC,outpatient,1,UN,127.17,89.019,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,16714-0889-01,NDC,outpatient,1,UN,129.15,90.405,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00143-9398-10,NDC,outpatient,1,UN,100.74,70.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,42023-0221-10,NDC,outpatient,1,UN,95.49,66.843,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,55150-0282-20,NDC,outpatient,1,UN,111.68,78.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,60505-6196-00,NDC,outpatient,1,UN,127.17,89.019,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00143-9398-10,NDC,outpatient,1,UN,100.74,70.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00409-3510-22,NDC,outpatient,1,UN,135.69,94.983,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,55150-0282-20,NDC,outpatient,1,UN,111.68,78.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00143-9398-01,NDC,outpatient,1,UN,100.74,70.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,42023-0221-01,NDC,outpatient,1,UN,95.49,66.843,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,42023-0221-10,NDC,outpatient,1,UN,95.49,66.843,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,60505-6196-00,NDC,outpatient,1,UN,127.17,89.019,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00409-3510-21,NDC,outpatient,1,UN,135.69,94.983,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,16714-0889-10,NDC,outpatient,1,UN,129.15,90.405,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,60505-6196-04,NDC,outpatient,1,UN,127.17,89.019,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,16714-0889-01,NDC,outpatient,1,UN,129.15,90.405,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.42,416.02,other,SI=N Exclusions ,,
ERYTHROMYCIN LACTOBIONATE 500 MG IV SOLR,RX-2903,CDM,J1364,HCPCS,636,RC,00409-6482-01,NDC,outpatient,1,UN,236.03,165.221,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,69.79,,,83.64,52.988735,416.02,fee schedule,,,
ERYTHROMYCIN LACTOBIONATE 500 MG IV SOLR,RX-2903,CDM,J1364,HCPCS,636,RC,00409-6482-11,NDC,outpatient,1,UN,236.03,165.221,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,69.79,,,83.64,52.988735,416.02,fee schedule,,,
ESTROGENS CONJUGATED 25 MG IJ SOLR,RX-9972,CDM,J1410,HCPCS,636,RC,00046-0749-05,NDC,outpatient,1,UN,1513.36,1059.352,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,384.03,,,372.48,339.74932,1162.26048,fee schedule,,,
FERRIC CARBOXYMALTOSE 750 MG/15ML IV SOLN,RX-122648,CDM,J1439,HCPCS,636,RC,00517-0650-01,NDC,outpatient,15,ML,2478.29,1734.803,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.13,,,840,1.1,1903.32672,fee schedule,,,
FLUCONAZOLE IN SODIUM CHLORIDE 200-0.9 MG/100ML-% IV SOLN,RX-10049,CDM,J1450,HCPCS,636,RC,25021-0184-82,NDC,outpatient,100,ML,36.03,25.221,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.61,416.02,other,SI=N Exclusions ,,
FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN,RX-10050,CDM,J1450,HCPCS,636,RC,00409-4688-16,NDC,outpatient,200,ML,35.54,24.878,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.61,416.02,other,SI=N Exclusions ,,
FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN,RX-10050,CDM,J1450,HCPCS,636,RC,69784-0003-06,NDC,outpatient,200,ML,35.58,24.906,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.61,416.02,other,SI=N Exclusions ,,
FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN,RX-10050,CDM,J1450,HCPCS,636,RC,00409-4688-12,NDC,outpatient,200,ML,35.54,24.878,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.61,416.02,other,SI=N Exclusions ,,
FLUCONAZOLE IVPB,RX-4080630,CDM,J1450,HCPCS,636,RC,99999-0001-23,NDC,outpatient,50,ML,23.46,16.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.61,416.02,other,SI=N Exclusions ,,
FOMEPIZOLE 1 GM/ML IV SOLN,RX-22185,CDM,J1451,HCPCS,636,RC,70710-1478-01,NDC,outpatient,1.5,ML,2014.79,1410.353,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13.18,,,1590,7.3781655,1590,fee schedule,,,
FOMEPIZOLE 1 GM/ML IV SOLN,RX-22185,CDM,J1451,HCPCS,636,RC,67457-0211-02,NDC,outpatient,1.5,ML,1680.9,1176.63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13.18,,,1590,7.3781655,1590,fee schedule,,,
FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR,RX-106783,CDM,J1453,HCPCS,636,RC,00006-3061-00,NDC,outpatient,1,UN,1375.94,963.158,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.17,,,18,0.14,1056.72192,fee schedule,,,
FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR,RX-106783,CDM,J1453,HCPCS,636,RC,00006-3061-01,NDC,outpatient,1,UN,1375.94,963.158,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.17,,,18,0.14,1056.72192,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0439-93,NDC,outpatient,400,ML,10769.52,7538.664,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,48.67,,,3807.2,47.99,8270.99136,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0437-10,NDC,outpatient,100,ML,2692.38,1884.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,48.67,,,951.8,47.99,8270.99136,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0437-91,NDC,outpatient,100,ML,2692.38,1884.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,48.67,,,951.8,47.99,8270.99136,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0439-40,NDC,outpatient,400,ML,10769.52,7538.664,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,48.67,,,3807.2,47.99,8270.99136,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0436-05,NDC,outpatient,100,ML,2692.38,1884.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,48.67,,,951.8,47.99,8270.99136,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0436-90,NDC,outpatient,100,ML,2692.38,1884.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,48.67,,,951.8,47.99,8270.99136,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0438-20,NDC,outpatient,200,ML,5384.76,3769.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,48.67,,,1903.6,47.99,8270.99136,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) IM INJ,RX-15342,CDM,J1460,HCPCS,636,RC,13533-0335-04,NDC,outpatient,2,ML,422.8,295.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50.07,,,97.54,48.47,416.02,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) IM INJ,RX-15342,CDM,J1460,HCPCS,636,RC,13533-0335-40,NDC,outpatient,2,ML,422.8,295.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,50.07,,,97.54,48.47,416.02,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-20,NDC,outpatient,100,ML,2099.81,1469.867,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,49.58,,,985.2,48.81,6450.61632,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-72,NDC,outpatient,100,ML,2099.81,1469.867,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,49.58,,,985.2,48.81,6450.61632,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-25,NDC,outpatient,200,ML,4199.62,2939.734,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,49.58,,,1970.4,48.81,6450.61632,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-41,NDC,outpatient,400,ML,8399.24,5879.468,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,49.58,,,3940.8,48.81,6450.61632,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-71,NDC,outpatient,100,ML,2099.81,1469.867,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,49.58,,,985.2,48.81,6450.61632,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-21,NDC,outpatient,100,ML,2099.81,1469.867,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,49.58,,,985.2,48.81,6450.61632,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-24,NDC,outpatient,200,ML,4199.62,2939.734,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,49.58,,,1970.4,48.81,6450.61632,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-40,NDC,outpatient,400,ML,8399.24,5879.468,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,49.58,,,3940.8,48.81,6450.61632,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD S/D  5 % IGA <=2.2,RX-4080223,CDM,J1566,HCPCS,636,RC,00944-2620-03,NDC,outpatient,5,GR,934.5,654.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,79.9,,,765.7,77.77,1531.4,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD S/D  5 % IGA <= 1,RX-4080224,CDM,J1566,HCPCS,636,RC,00944-2656-03,NDC,outpatient,5,GR,577.48,404.236,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,79.9,,,765.7,77.77,1531.4,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD S/D  5 % IGA <= 1,RX-4080224,CDM,J1566,HCPCS,636,RC,00944-2658-04,NDC,outpatient,10,GR,1154.96,808.472,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,79.9,,,1531.4,77.77,1531.4,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) OCTAGAM 5 % IV SOLN,RX-4080225,CDM,J1568,HCPCS,636,RC,68209-0843-03,NDC,outpatient,200,ML,1884.53,1319.171,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,47.74,,,895.8,44.12,1447.31904,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) OCTAGAM 5 % IV SOLN,RX-4080225,CDM,J1568,HCPCS,636,RC,68209-0843-04,NDC,outpatient,200,ML,1884.53,1319.171,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,47.74,,,895.8,44.12,1447.31904,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-02,NDC,outpatient,100,ML,2726.33,1908.431,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45.07,,,889.2,46.03,6281.46432,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-05,NDC,outpatient,100,ML,2726.33,1908.431,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45.07,,,889.2,46.03,6281.46432,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-06,NDC,outpatient,200,ML,5452.66,3816.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45.07,,,1778.4,46.03,6281.46432,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-08,NDC,outpatient,100,ML,2726.33,1908.431,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45.07,,,889.2,46.03,6281.46432,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-10,NDC,outpatient,100,ML,2726.33,1908.431,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45.07,,,889.2,46.03,6281.46432,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-12,NDC,outpatient,200,ML,5452.66,3816.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45.07,,,1778.4,46.03,6281.46432,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-04,NDC,outpatient,100,ML,2726.33,1908.431,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45.07,,,889.2,46.03,6281.46432,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-07,NDC,outpatient,300,ML,8178.99,5725.293,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45.07,,,2667.6,46.03,6281.46432,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-13,NDC,outpatient,300,ML,8178.99,5725.293,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45.07,,,2667.6,46.03,6281.46432,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-03,NDC,outpatient,100,ML,2726.33,1908.431,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45.07,,,889.2,46.03,6281.46432,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-09,NDC,outpatient,100,ML,2726.33,1908.431,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45.07,,,889.2,46.03,6281.46432,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-11,NDC,outpatient,100,ML,2726.33,1908.431,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,45.07,,,889.2,46.03,6281.46432,fee schedule,,,
GANCICLOVIR SODIUM 500 MG IV SOLR,RX-10101,CDM,J1570,HCPCS,636,RC,70436-0089-55,NDC,outpatient,1,UN,165.87,116.109,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,36.41,416.02,other,SI=N Exclusions ,,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-08,NDC,outpatient,200,ML,2125.2,1487.64,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,56.12,,,1122.4,48.52,3264.3072,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-00,NDC,outpatient,400,ML,4250.4,2975.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,56.12,,,2244.8,48.52,3264.3072,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-03,NDC,outpatient,200,ML,2125.2,1487.64,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,56.12,,,1122.4,48.52,3264.3072,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-04,NDC,outpatient,200,ML,2125.2,1487.64,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,56.12,,,1122.4,48.52,3264.3072,fee schedule,,,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-05,NDC,outpatient,400,ML,4250.4,2975.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,56.12,,,2244.8,48.52,3264.3072,fee schedule,,,
GENTAMICIN 80 MG IN NS 50 ML IV SOLN PREMIX,RX-15911,CDM,J1580,HCPCS,636,RC,00338-0509-41,NDC,outpatient,50,ML,25,17.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.23924,416.02,other,SI=N Exclusions ,,
GENTAMICIN 80 MG IN NS 50 ML IV SOLN PREMIX,RX-15911,CDM,J1580,HCPCS,636,RC,99999-0002-93,NDC,outpatient,50,ML,25.25,17.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.23924,416.02,other,SI=N Exclusions ,,
GENTAMICIN SULFATE 10 MG/ML IJ SOLN,RX-3425,CDM,J1580,HCPCS,636,RC,63323-0173-02,NDC,outpatient,2,ML,9.88,6.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.23924,416.02,other,SI=N Exclusions ,,
GENTAMICIN SULFATE 10 MG/ML IJ SOLN,RX-3425,CDM,J1580,HCPCS,636,RC,63323-0173-01,NDC,outpatient,2,ML,9.88,6.916,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.23924,416.02,other,SI=N Exclusions ,,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-20,NDC,outpatient,20,ML,102.62,71.834,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.23924,416.02,other,SI=N Exclusions ,,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,00409-1207-13,NDC,outpatient,2,ML,12.55,8.785,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.23924,416.02,other,SI=N Exclusions ,,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-01,NDC,outpatient,2,ML,5.52,3.864,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.23924,416.02,other,SI=N Exclusions ,,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-02,NDC,outpatient,2,ML,5.52,3.864,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.23924,416.02,other,SI=N Exclusions ,,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,00409-1207-03,NDC,outpatient,2,ML,12.55,8.785,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.23924,416.02,other,SI=N Exclusions ,,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-03,NDC,outpatient,20,ML,102.62,71.834,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.23924,416.02,other,SI=N Exclusions ,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,00143-9682-25,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.46,,,2.76,0.51,416.02,fee schedule,,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,00517-4601-25,NDC,outpatient,1,ML,7.56,5.292,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.46,,,2.76,0.51,416.02,fee schedule,,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,70121-1394-05,NDC,outpatient,1,ML,17.13,11.991,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.46,,,2.76,0.51,416.02,fee schedule,,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,71288-0414-01,NDC,outpatient,1,ML,4.37,3.059,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.46,,,2.76,0.51,416.02,fee schedule,,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,00143-9682-01,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.46,,,2.76,0.51,416.02,fee schedule,,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,71288-0414-03,NDC,outpatient,1,ML,4.37,3.059,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.46,,,2.76,0.51,416.02,fee schedule,,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,16714-0536-01,NDC,outpatient,1,ML,5.69,3.983,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.46,,,2.76,0.51,416.02,fee schedule,,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,16714-0536-25,NDC,outpatient,1,ML,5.69,3.983,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.46,,,2.76,0.51,416.02,fee schedule,,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,70121-1394-01,NDC,outpatient,1,ML,17.13,11.991,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.46,,,2.76,0.51,416.02,fee schedule,,,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00597-0053-01,NDC,outpatient,1,UN,403.75,282.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,189.46,,,187.5,90.641875,579.456,fee schedule,,,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00597-0053-45,NDC,outpatient,1,UN,403.75,282.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,189.46,,,187.5,90.641875,579.456,fee schedule,,,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00597-0260-10,NDC,outpatient,1,UN,403.75,282.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,189.46,,,187.5,90.641875,579.456,fee schedule,,,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00548-5850-00,NDC,outpatient,1,UN,754.5,528.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,189.46,,,187.5,90.641875,579.456,fee schedule,,,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1611,HCPCS,636,RC,63323-0593-03,NDC,outpatient,1,UN,610.59,427.413,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,129.67,,,110.76,101.41,468.94848,fee schedule,,,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1611,HCPCS,636,RC,63323-0596-11,NDC,outpatient,1,UN,610.61,427.427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,129.67,,,110.76,101.41,468.94848,fee schedule,,,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1611,HCPCS,636,RC,63323-0596-13,NDC,outpatient,1,UN,610.61,427.427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,129.67,,,110.76,101.41,468.94848,fee schedule,,,
GRANISETRON HCL 1 MG/ML IV SOLN,RX-12552,CDM,J1626,HCPCS,636,RC,00143-9744-01,NDC,outpatient,1,ML,11.46,8.022,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.28,416.02,other,SI=N Exclusions ,,
GRANISETRON HCL 1 MG/ML IV SOLN,RX-12552,CDM,J1626,HCPCS,636,RC,00143-9744-10,NDC,outpatient,1,ML,11.46,8.022,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.28,416.02,other,SI=N Exclusions ,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,67457-0426-00,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,00143-9501-25,NDC,outpatient,1,ML,7.22,5.054,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,63323-0474-01,NDC,outpatient,1,ML,3.76,2.632,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,67457-0426-12,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,76045-0737-10,NDC,outpatient,1,ML,15.64,10.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,00143-9501-01,NDC,outpatient,1,ML,7.22,5.054,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,63323-0474-00,NDC,outpatient,1,ML,3.76,2.632,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,76045-0737-01,NDC,outpatient,1,ML,15.64,10.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
HEPARIN LOCK FLUSH 100 UNIT/ML IV SOLN WRAPPER,RX-4080200,CDM,J1642,HCPCS,636,RC,64253-0333-35,NDC,outpatient,5,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.02,416.02,other,Non-Reimbursable List,,
HEPARIN LOCK FLUSH 100 UNIT/ML IV SOLN WRAPPER,RX-4080200,CDM,J1642,HCPCS,636,RC,08290-3064-24,NDC,outpatient,5,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.02,416.02,other,Non-Reimbursable List,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,25021-0400-10,NDC,outpatient,10,ML,16.81,11.767,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0276-01,NDC,outpatient,2,ML,21.8,15.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-15,NDC,outpatient,10,ML,18.71,13.097,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-33,NDC,outpatient,30,ML,21.77,15.239,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-36,NDC,outpatient,30,ML,21.77,15.239,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0920-11,NDC,outpatient,1,ML,3.83,2.681,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0385-99,NDC,outpatient,10,ML,19.64,13.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,71288-0400-02,NDC,outpatient,2,ML,19.86,13.902,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0276-02,NDC,outpatient,2,ML,21.8,15.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,00409-2720-02,NDC,outpatient,10,ML,15.99,11.193,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,25021-0400-01,NDC,outpatient,1,ML,5.04,3.528,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-05,NDC,outpatient,10,ML,18.71,13.097,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0372-12,NDC,outpatient,1,ML,13.11,9.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0385-10,NDC,outpatient,10,ML,19.64,13.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,00409-2720-31,NDC,outpatient,10,ML,15.99,11.193,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0920-25,NDC,outpatient,1,ML,3.83,2.681,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0931-14,NDC,outpatient,10,ML,10.28,7.196,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0931-28,NDC,outpatient,10,ML,10.28,7.196,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0372-99,NDC,outpatient,1,ML,13.11,9.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,71288-0400-03,NDC,outpatient,2,ML,19.86,13.902,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 20000 UNIT/ML IJ SOLN,RX-10178,CDM,J1644,HCPCS,636,RC,63739-0986-11,NDC,outpatient,1,ML,33.86,23.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 20000 UNIT/ML IJ SOLN,RX-10178,CDM,J1644,HCPCS,636,RC,63739-0986-25,NDC,outpatient,1,ML,33.86,23.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,63739-0953-25,NDC,outpatient,1,ML,6.36,4.452,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,00409-2723-02,NDC,outpatient,1,ML,3.99,2.793,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,71288-0403-01,NDC,outpatient,1,ML,3.33,2.331,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,71288-0403-02,NDC,outpatient,1,ML,3.33,2.331,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,63739-0953-11,NDC,outpatient,1,ML,6.36,4.452,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,00409-2723-31,NDC,outpatient,1,ML,3.99,2.793,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN (PORCINE) IN NACL 25000-0.45 UT/250ML-% IV SOLN,RX-135728,CDM,J1644,HCPCS,636,RC,00409-7650-52,NDC,outpatient,250,ML,63.84,44.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN (PORCINE) IN NACL 25000-0.45 UT/250ML-% IV SOLN,RX-135728,CDM,J1644,HCPCS,636,RC,00409-7650-62,NDC,outpatient,250,ML,63.84,44.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SOD (PORCINE) IN D5W 100 UNIT/ML IV SOLN,RX-24329,CDM,J1644,HCPCS,636,RC,63323-0523-74,NDC,outpatient,250,ML,44.93,31.451,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SOD (PORCINE) IN D5W 100 UNIT/ML IV SOLN,RX-24329,CDM,J1644,HCPCS,636,RC,00264-9587-20,NDC,outpatient,250,ML,77.19,54.033,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SOD (PORCINE) IN D5W 100 UNIT/ML IV SOLN,RX-24329,CDM,J1644,HCPCS,636,RC,63323-0523-01,NDC,outpatient,250,ML,44.93,31.451,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SOD (PORCINE) PREMIX 30000 UNITS IN 1L NS,RX-4080227,CDM,J1644,HCPCS,636,RC,70092-1281-08,NDC,outpatient,1000,ML,120.09,84.063,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN SOD (PORCINE) PREMIX 30000 UNITS IN 1L NS,RX-4080227,CDM,J1644,HCPCS,636,RC,99999-0921-33,NDC,outpatient,1000,ML,91.43,64.001,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-1005-01,NDC,outpatient,500,ML,33.99,23.793,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-1005-20,NDC,outpatient,500,ML,33.99,23.793,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-7620-03,NDC,outpatient,500,ML,33.99,23.793,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-7620-13,NDC,outpatient,500,ML,33.99,23.793,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00264-9872-10,NDC,outpatient,500,ML,33.8,23.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00338-0424-18,NDC,outpatient,500,ML,28.85,20.195,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,63323-0519-77,NDC,outpatient,500,ML,31.42,21.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,99999-0002-94,NDC,outpatient,5,ML,16.13,11.291,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,63323-0519-02,NDC,outpatient,500,ML,31.42,21.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,99999-0001-81,NDC,outpatient,1000,ML,22.86,16.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,99999-0001-71,NDC,outpatient,500,ML,22,15.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN (PORCINE) IN NACL 25000-0.9 UT/250ML-% IV SOLN,RX-4081544,CDM,J1644,HCPCS,636,RC,99999-0003-32,NDC,outpatient,250,ML,30.4,21.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
HEPARIN (PORCINE) IN NACL 25000-0.9 UT/250ML-% IV SOLN,RX-4081544,CDM,J1644,HCPCS,636,RC,99999-0003-31,NDC,outpatient,250,ML,42.73,29.911,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,SI=N Exclusions ,,
ENOXAPARIN SODIUM 30 MG/0.3ML IJ SOSY,RX-158184,CDM,J1650,HCPCS,636,RC,00548-5601-00,NDC,outpatient,0.3,ML,20.03,14.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.57,416.02,other,SI=N Exclusions ,,
ENOXAPARIN SODIUM 40 MG/0.4ML IJ SOSY,RX-158185,CDM,J1650,HCPCS,636,RC,00548-5602-00,NDC,outpatient,0.4,ML,26.7,18.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.57,416.02,other,SI=N Exclusions ,,
ENOXAPARIN SODIUM 60 MG/0.6ML IJ SOSY,RX-158186,CDM,J1650,HCPCS,636,RC,00548-5603-00,NDC,outpatient,0.6,ML,40.05,28.035,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.57,416.02,other,SI=N Exclusions ,,
ENOXAPARIN SODIUM 80 MG/0.8ML IJ SOSY,RX-158187,CDM,J1650,HCPCS,636,RC,00548-5604-00,NDC,outpatient,0.8,ML,53.4,37.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.57,416.02,other,SI=N Exclusions ,,
ENOXAPARIN SODIUM 100 MG/ML IJ SOSY,RX-158188,CDM,J1650,HCPCS,636,RC,00548-5605-00,NDC,outpatient,1,ML,66.75,46.725,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.57,416.02,other,SI=N Exclusions ,,
ENOXAPARIN SODIUM 120 MG/0.8ML IJ SOSY,RX-158189,CDM,J1650,HCPCS,636,RC,00548-5606-00,NDC,outpatient,0.8,ML,80.1,56.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.57,416.02,other,SI=N Exclusions ,,
ENOXAPARIN SODIUM 150 MG/ML IJ SOSY,RX-158190,CDM,J1650,HCPCS,636,RC,00548-5607-00,NDC,outpatient,1,ML,100.13,70.091,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.57,416.02,other,SI=N Exclusions ,,
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,55150-0231-00,NDC,outpatient,0.4,ML,58.52,40.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions ,,
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,55150-0231-10,NDC,outpatient,0.4,ML,58.52,40.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions ,,
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,67457-0583-04,NDC,outpatient,0.4,ML,146.14,102.298,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions ,,
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,67457-0583-00,NDC,outpatient,0.4,ML,146.14,102.298,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions ,,
FONDAPARINUX SODIUM 7.5 MG/0.6ML SC SOLN,RX-108028,CDM,J1652,HCPCS,636,RC,55111-0680-10,NDC,outpatient,0.6,ML,45.65,31.955,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions ,,
FONDAPARINUX SODIUM 7.5 MG/0.6ML SC SOLN,RX-108028,CDM,J1652,HCPCS,636,RC,55111-0680-11,NDC,outpatient,0.6,ML,45.65,31.955,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions ,,
FONDAPARINUX SODIUM 10 MG/0.8ML SC SOLN,RX-108029,CDM,J1652,HCPCS,636,RC,67457-0585-00,NDC,outpatient,0.8,ML,146.14,102.298,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions ,,
FONDAPARINUX SODIUM 10 MG/0.8ML SC SOLN,RX-108029,CDM,J1652,HCPCS,636,RC,67457-0585-08,NDC,outpatient,0.8,ML,146.14,102.298,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions ,,
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55150-0230-00,NDC,outpatient,0.5,ML,20.75,14.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions ,,
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55111-0678-10,NDC,outpatient,0.5,ML,21,14.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions ,,
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55150-0230-10,NDC,outpatient,0.5,ML,20.75,14.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions ,,
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55111-0678-11,NDC,outpatient,0.5,ML,21,14.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions ,,
TETANUS IMMUNE GLOBULIN 250 UNIT/ML IM SOSY,RX-156399,CDM,J1670,HCPCS,636,RC,13533-0634-02,NDC,outpatient,1,ML,1484.53,1039.171,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,564.92,,,584.39,333.276985,1140.11904,fee schedule,,,
TETANUS IMMUNE GLOBULIN 250 UNIT/ML IM SOSY,RX-156399,CDM,J1670,HCPCS,636,RC,13533-0634-20,NDC,outpatient,1,ML,1484.53,1039.171,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,564.92,,,584.39,333.276985,1140.11904,fee schedule,,,
HYDROCORTISONE SOD SUC (PF) 250 MG IJ SOLR,RX-160127,CDM,J1720,HCPCS,636,RC,00009-0013-05,NDC,outpatient,1,UN,153.4,107.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,13.56878,416.02,other,SI=N Exclusions ,,
HYDROCORTISONE SOD SUC (PF) 500 MG IJ SOLR,RX-160129,CDM,J1720,HCPCS,636,RC,00009-0016-12,NDC,outpatient,1,UN,308.7,216.09,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,13.56878,416.02,other,SI=N Exclusions ,,
HYDROCORTISONE NA SUCCINATE PF 100 MG IJ WRAPPER,RX-4080176,CDM,J1720,HCPCS,636,RC,00009-0825-01,NDC,outpatient,1,UN,60.44,42.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,13.56878,416.02,other,SI=N Exclusions ,,
HYDROCORTISONE NA SUCCINATE PF 100 MG IJ WRAPPER,RX-4080176,CDM,J1720,HCPCS,636,RC,00009-0011-04,NDC,outpatient,1,UN,83.69,58.583,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,13.56878,416.02,other,SI=N Exclusions ,,
IBANDRONATE SODIUM 3 MG/3ML IV SOLN,RX-110306,CDM,J1740,HCPCS,636,RC,60505-6097-00,NDC,outpatient,3,ML,291.8,204.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,28.72,,,74.7,27.14,416.02,fee schedule,,,
IBUTILIDE FUMARATE 1 MG/10ML IV SOLN,RX-100740,CDM,J1742,HCPCS,636,RC,00009-3794-01,NDC,outpatient,10,ML,380.26,266.182,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,316.2,,,316.2,85.36837,416.02,fee schedule,,,
INFLIXIMAB 100 MG IV SOLR,RX-23796,CDM,J1745,HCPCS,636,RC,57894-0030-01,NDC,outpatient,1,UN,3124.93,2187.451,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,31.71,,,326.4,32.22,2399.94624,fee schedule,,,
IRON DEXTRAN 50 MG/ML IJ SOLN,RX-3990,CDM,J1750,HCPCS,636,RC,00023-6082-01,NDC,outpatient,2,ML,145.94,102.158,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17.99,,,34.82,17.18,416.02,fee schedule,,,
IRON DEXTRAN 50 MG/ML IJ SOLN,RX-3990,CDM,J1750,HCPCS,636,RC,00023-6082-10,NDC,outpatient,2,ML,145.94,102.158,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,17.99,,,34.82,17.18,416.02,fee schedule,,,
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2310-01,NDC,outpatient,10,ML,278.93,195.251,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.23,,,42,0.21,416.02,fee schedule,,,
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2340-01,NDC,outpatient,5,ML,137.29,96.103,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.23,,,21,0.21,416.02,fee schedule,,,
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2310-05,NDC,outpatient,10,ML,278.93,195.251,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.23,,,42,0.21,416.02,fee schedule,,,
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2340-10,NDC,outpatient,5,ML,131.72,92.204,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.23,,,21,0.21,416.02,fee schedule,,,
DROPERIDOL 2.5 MG/ML IJ SOLN,RX-2654,CDM,J1790,HCPCS,636,RC,00517-9702-25,NDC,outpatient,2,ML,31.33,21.931,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.83,416.02,other,SI=N Exclusions ,,
DROPERIDOL 2.5 MG/ML IJ SOLN,RX-2654,CDM,J1790,HCPCS,636,RC,00517-9702-01,NDC,outpatient,2,ML,31.33,21.931,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.83,416.02,other,SI=N Exclusions ,,
PROPRANOLOL HCL 1 MG/ML IV SOLN,RX-29335,CDM,J1800,HCPCS,636,RC,63323-0604-01,NDC,outpatient,1,ML,8.17,5.719,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.834165,416.02,other,SI=N Exclusions ,,
PROPRANOLOL HCL 1 MG/ML IV SOLN,RX-29335,CDM,J1800,HCPCS,636,RC,63323-0604-00,NDC,outpatient,1,ML,8.17,5.719,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.834165,416.02,other,SI=N Exclusions ,,
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN,RX-29805,CDM,J1805,HCPCS,636,RC,25021-0308-84,NDC,outpatient,250,ML,336.4,235.48,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.26,,,62.5,0.19,416.02,fee schedule,,,
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-29805,CDM,J1805,HCPCS,636,RC,25021-0308-84,NDC,outpatient,250,ML,320.4,224.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.26,,,62.5,0.19,416.02,fee schedule,,,
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-29805,CDM,J1805,HCPCS,636,RC,67457-0657-25,NDC,outpatient,250,ML,410.52,287.364,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.26,,,62.5,0.19,416.02,fee schedule,,,
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN,RX-29805,CDM,J1805,HCPCS,636,RC,67457-0657-25,NDC,outpatient,250,ML,426.52,298.564,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.26,,,62.5,0.19,416.02,fee schedule,,,
ESMOLOL HCL 100 MG/10ML IV SOLN,RX-82085,CDM,J1805,HCPCS,636,RC,67457-0182-10,NDC,outpatient,10,ML,17.12,11.984,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.26,,,2.5,0.19,416.02,fee schedule,,,
ESMOLOL HCL 100 MG/10ML IV SOLN,RX-82085,CDM,J1805,HCPCS,636,RC,55150-0194-10,NDC,outpatient,10,ML,10.39,7.273,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.26,,,2.5,0.19,416.02,fee schedule,,,
ESMOLOL HCL 100 MG/10ML IV SOLN,RX-82085,CDM,J1805,HCPCS,636,RC,67457-0182-00,NDC,outpatient,10,ML,17.12,11.984,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.26,,,2.5,0.19,416.02,fee schedule,,,
ESMOLOL HCL 2500 MG/250ML IV SOLN,RX-142051,CDM,J1806,HCPCS,636,RC,44567-0811-10,NDC,outpatient,250,ML,430.97,301.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.4,,,117.5,0.36,416.02,fee schedule,,,
ESMOLOL HCL 2500 MG/250ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-142051,CDM,J1806,HCPCS,636,RC,44567-0811-10,NDC,outpatient,250,ML,414.97,290.479,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.4,,,117.5,0.36,416.02,fee schedule,,,
INTERFERON BETA-1B 0.3 MG SC KIT,RX-124318,CDM,J1830,HCPCS,636,RC,50419-0524-35,NDC,outpatient,1,UN,1865.02,1305.514,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,738.43,,,1089.82,114.43,1432.33536,fee schedule,,,
INTERFERON BETA-1B 0.3 MG SC KIT,RX-124318,CDM,J1830,HCPCS,636,RC,50419-0524-01,NDC,outpatient,1,UN,1865.02,1305.514,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,738.43,,,1089.82,114.43,1432.33536,fee schedule,,,
ISAVUCONAZONIUM SULFATE 372 MG IV SOLR,RX-130407,CDM,J1833,HCPCS,636,RC,00469-0420-01,NDC,outpatient,1,UN,1572.32,1100.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.09,,,386.88,1,1207.54176,fee schedule,,,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-24,NDC,outpatient,100,ML,24.23,16.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.03,,,1,0.02,416.02,fee schedule,,,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,47335-0993-01,NDC,outpatient,100,ML,23.2,16.24,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.03,,,1,0.02,416.02,fee schedule,,,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-01,NDC,outpatient,100,ML,8.23,5.761,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.03,,,1,0.02,416.02,fee schedule,,,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,47335-0993-01,NDC,outpatient,100,ML,7.2,5.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.03,,,1,0.02,416.02,fee schedule,,,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,00338-1055-48,NDC,outpatient,100,ML,21.14,14.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.03,,,1,0.02,416.02,fee schedule,,,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-01,NDC,outpatient,100,ML,24.23,16.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.03,,,1,0.02,416.02,fee schedule,,,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,25021-0131-82,NDC,outpatient,100,ML,25.77,18.039,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.03,,,1,0.02,416.02,fee schedule,,,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-24,NDC,outpatient,100,ML,8.23,5.761,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.03,,,1,0.02,416.02,fee schedule,,,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,00338-1055-48,NDC,outpatient,100,ML,5.14,3.598,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.03,,,1,0.02,416.02,fee schedule,,,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,25021-0131-82,NDC,outpatient,100,ML,9.77,6.839,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.03,,,1,0.02,416.02,fee schedule,,,
METRONIDAZOLE IN NACL IVPB,RX-4080369,CDM,J1836,HCPCS,636,RC,99999-0001-74,NDC,outpatient,50,ML,20.37,14.259,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.03,,,0.5,0.02,416.02,fee schedule,,,
METRONIDAZOLE IV SYRINGE (PEDIATRIC),RX-40840043,CDM,J1836,HCPCS,636,RC,99999-0001-74,NDC,outpatient,50,ML,20.37,14.259,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.03,,,0.5,0.02,416.02,fee schedule,,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,63323-0162-01,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.55,416.02,other,SI=N Exclusions ,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,72266-0118-01,NDC,outpatient,1,ML,4.8,3.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.55,416.02,other,SI=N Exclusions ,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,00409-3795-01,NDC,outpatient,1,ML,18.43,12.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.55,416.02,other,SI=N Exclusions ,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,72266-0118-25,NDC,outpatient,1,ML,4.8,3.36,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.55,416.02,other,SI=N Exclusions ,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,00409-3795-19,NDC,outpatient,1,ML,18.43,12.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.55,416.02,other,SI=N Exclusions ,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,00338-0072-25,NDC,outpatient,1,ML,3.57,2.499,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.55,416.02,other,SI=N Exclusions ,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,62332-0600-01,NDC,outpatient,1,ML,9.77,6.839,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.55,416.02,other,SI=N Exclusions ,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,62332-0600-25,NDC,outpatient,1,ML,9.77,6.839,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.55,416.02,other,SI=N Exclusions ,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,63323-0162-00,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.55,416.02,other,SI=N Exclusions ,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,00409-2267-54,NDC,outpatient,40,ML,40.77,28.539,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.17,,,7.2,0.24,416.02,fee schedule,,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,00409-2339-34,NDC,outpatient,4,ML,35.3,24.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.17,,,0.72,0.24,416.02,fee schedule,,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,36000-0320-01,NDC,outpatient,4,ML,16.17,11.319,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.17,,,0.72,0.24,416.02,fee schedule,,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,36000-0320-10,NDC,outpatient,4,ML,16.17,11.319,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.17,,,0.72,0.24,416.02,fee schedule,,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,00409-2339-24,NDC,outpatient,4,ML,35.3,24.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.17,,,0.72,0.24,416.02,fee schedule,,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,25021-0317-20,NDC,outpatient,20,ML,9.98,6.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.17,,,3.6,0.24,416.02,fee schedule,,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,72266-0102-01,NDC,outpatient,20,ML,12.14,8.498,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.17,,,3.6,0.24,416.02,fee schedule,,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1921,HCPCS,636,RC,00143-9622-01,NDC,outpatient,20,ML,8.85,6.195,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.13,,,54.4,1.24,416.02,fee schedule,,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1921,HCPCS,636,RC,00143-9623-01,NDC,outpatient,40,ML,18.87,13.209,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.13,,,108.8,1.24,416.02,fee schedule,,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0572-10,NDC,outpatient,10,ML,8.64,6.048,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.62,,,4.6,0.62,416.02,fee schedule,,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,72205-0101-01,NDC,outpatient,4,ML,12.36,8.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.62,,,1.84,0.62,416.02,fee schedule,,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,72205-0101-07,NDC,outpatient,4,ML,12.36,8.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.62,,,1.84,0.62,416.02,fee schedule,,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6007-10,NDC,outpatient,10,ML,15.42,10.794,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.62,,,4.6,0.62,416.02,fee schedule,,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6008-10,NDC,outpatient,4,ML,14.21,9.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.62,,,1.84,0.62,416.02,fee schedule,,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0570-04,NDC,outpatient,4,ML,8.04,5.628,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.62,,,1.84,0.62,416.02,fee schedule,,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0572-01,NDC,outpatient,10,ML,8.64,6.048,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.62,,,4.6,0.62,416.02,fee schedule,,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6007-01,NDC,outpatient,10,ML,15.42,10.794,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.62,,,4.6,0.62,416.02,fee schedule,,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6008-01,NDC,outpatient,4,ML,14.21,9.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.62,,,1.84,0.62,416.02,fee schedule,,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0570-01,NDC,outpatient,4,ML,8.04,5.628,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.62,,,1.84,0.62,416.02,fee schedule,,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-32,NDC,outpatient,4,ML,4.75,3.325,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,416.02,other,SI=N Exclusions ,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,25021-0311-10,NDC,outpatient,10,ML,7.25,5.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,416.02,other,SI=N Exclusions ,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,36000-0283-25,NDC,outpatient,4,ML,5.41,3.787,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,416.02,other,SI=N Exclusions ,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,63323-0280-26,NDC,outpatient,4,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,416.02,other,SI=N Exclusions ,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,72603-0251-25,NDC,outpatient,4,ML,3.79,2.653,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,416.02,other,SI=N Exclusions ,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,63323-0280-03,NDC,outpatient,4,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,416.02,other,SI=N Exclusions ,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,70860-0302-42,NDC,outpatient,4,ML,4.94,3.458,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,416.02,other,SI=N Exclusions ,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,72603-0251-01,NDC,outpatient,4,ML,3.79,2.653,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,416.02,other,SI=N Exclusions ,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-33,NDC,outpatient,10,ML,7.2,5.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,416.02,other,SI=N Exclusions ,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-44,NDC,outpatient,10,ML,7.2,5.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,416.02,other,SI=N Exclusions ,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,63323-0280-04,NDC,outpatient,4,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,416.02,other,SI=N Exclusions ,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,70860-0302-04,NDC,outpatient,4,ML,4.94,3.458,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,416.02,other,SI=N Exclusions ,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,71288-0203-05,NDC,outpatient,4,ML,3.66,2.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,416.02,other,SI=N Exclusions ,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,00409-6102-04,NDC,outpatient,4,ML,9.24,6.468,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,416.02,other,SI=N Exclusions ,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,00409-6102-18,NDC,outpatient,4,ML,9.24,6.468,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,416.02,other,SI=N Exclusions ,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-42,NDC,outpatient,4,ML,4.75,3.325,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,416.02,other,SI=N Exclusions ,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,36000-0284-25,NDC,outpatient,10,ML,8.33,5.831,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,416.02,other,SI=N Exclusions ,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,71288-0203-04,NDC,outpatient,4,ML,3.66,2.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.4,416.02,other,SI=N Exclusions ,,
LEUPROLIDE ACETATE 3.75 MG IM KIT,RX-13691,CDM,J1950,HCPCS,636,RC,00074-3641-03,NDC,outpatient,1,UN,4758.7,3331.09,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1673.93,,,1524.34,399.86,10964.15232,fee schedule,,,
LEUPROLIDE ACETATE (3 MONTH) 11.25 MG IM KIT,RX-21044,CDM,J1950,HCPCS,636,RC,00074-3663-03,NDC,outpatient,1,UN,14276.24,9993.368,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1673.93,,,4573.02,399.86,10964.15232,fee schedule,,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,44567-0502-01,NDC,outpatient,100,ML,49.38,34.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions ,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,67457-0265-00,NDC,outpatient,100,ML,64.06,44.842,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions ,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,70860-0603-82,NDC,outpatient,100,ML,63.62,44.534,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions ,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,14789-0220-08,NDC,outpatient,100,ML,48.49,33.943,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions ,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,14789-0220-10,NDC,outpatient,100,ML,48.49,33.943,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions ,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,67457-0265-10,NDC,outpatient,100,ML,64.06,44.842,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions ,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,00264-1009-90,NDC,outpatient,100,ML,43.15,30.205,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions ,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,43598-0636-10,NDC,outpatient,100,ML,87.65,61.355,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions ,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,43598-0636-52,NDC,outpatient,100,ML,87.65,61.355,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions ,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,44567-0502-10,NDC,outpatient,100,ML,49.38,34.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions ,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,70860-0603-41,NDC,outpatient,100,ML,63.62,44.534,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions ,,
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,44567-0503-01,NDC,outpatient,100,ML,60.06,42.042,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions ,,
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,44567-0503-10,NDC,outpatient,100,ML,60.06,42.042,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions ,,
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,70860-0604-82,NDC,outpatient,100,ML,79.64,55.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions ,,
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,70860-0604-41,NDC,outpatient,100,ML,79.64,55.748,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions ,,
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,00409-1886-22,NDC,outpatient,5,ML,6.38,4.466,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions ,,
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,00409-1886-02,NDC,outpatient,5,ML,6.38,4.466,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions ,,
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,67457-0790-05,NDC,outpatient,5,ML,10.7,7.49,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions ,,
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,55150-0177-05,NDC,outpatient,5,ML,5.07,3.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions ,,
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,67457-0790-00,NDC,outpatient,5,ML,10.7,7.49,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions ,,
LEVOFLOXACIN IN D5W 250 MG/50ML IV SOLN,RX-108118,CDM,J1956,HCPCS,636,RC,25021-0132-81,NDC,outpatient,50,ML,25.26,17.682,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions ,,
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00143-9721-01,NDC,outpatient,100,ML,25.77,18.039,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions ,,
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00409-0528-23,NDC,outpatient,100,ML,28.85,20.195,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions ,,
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00409-0528-25,NDC,outpatient,100,ML,28.85,20.195,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions ,,
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00143-9721-24,NDC,outpatient,100,ML,25.77,18.039,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions ,,
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,25021-0132-82,NDC,outpatient,100,ML,26.28,18.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions ,,
LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN,RX-108120,CDM,J1956,HCPCS,636,RC,00409-0528-35,NDC,outpatient,150,ML,32.2,22.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions ,,
LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN,RX-108120,CDM,J1956,HCPCS,636,RC,00409-0528-31,NDC,outpatient,150,ML,32.2,22.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions ,,
LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN,RX-108120,CDM,J1956,HCPCS,636,RC,25021-0132-83,NDC,outpatient,150,ML,33.74,23.618,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions ,,
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,00143-9722-24,NDC,outpatient,50,ML,23.97,16.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions ,,
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,36000-0046-24,NDC,outpatient,50,ML,26.54,18.578,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions ,,
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,25021-0132-81,NDC,outpatient,50,ML,25.26,17.682,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions ,,
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,63323-0355-50,NDC,outpatient,50,ML,45.6,31.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92,416.02,other,SI=N Exclusions ,,
LIDOCAINE IN D5W 4-5 MG/ML-% IV SOLN,RX-14868,CDM,J2001,HCPCS,636,RC,00338-0409-03,NDC,outpatient,500,ML,42.7,29.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.02,416.02,other,Non-Reimbursable List,,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,00781-3433-95,NDC,outpatient,300,ML,100.11,70.077,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.08,416.02,other,SI=N Exclusions ,,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,63323-0713-03,NDC,outpatient,300,ML,49.38,34.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.08,416.02,other,SI=N Exclusions ,,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,00781-3433-46,NDC,outpatient,300,ML,100.11,70.077,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.08,416.02,other,SI=N Exclusions ,,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,57664-0683-31,NDC,outpatient,300,ML,46.71,32.697,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.08,416.02,other,SI=N Exclusions ,,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,63323-0713-13,NDC,outpatient,300,ML,49.38,34.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.08,416.02,other,SI=N Exclusions ,,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,55150-0242-51,NDC,outpatient,300,ML,53.38,37.366,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.08,416.02,other,SI=N Exclusions ,,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,57664-0683-57,NDC,outpatient,300,ML,46.71,32.697,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.08,416.02,other,SI=N Exclusions ,,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,00781-3433-46,NDC,outpatient,300,ML,100.11,70.077,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.08,416.02,other,SI=N Exclusions ,,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,57664-0683-31,NDC,outpatient,300,ML,46.71,32.697,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.08,416.02,other,SI=N Exclusions ,,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,63323-0713-13,NDC,outpatient,300,ML,49.38,34.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.08,416.02,other,SI=N Exclusions ,,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,00781-3433-95,NDC,outpatient,300,ML,100.11,70.077,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.08,416.02,other,SI=N Exclusions ,,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,63323-0713-03,NDC,outpatient,300,ML,49.38,34.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.08,416.02,other,SI=N Exclusions ,,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,55150-0242-51,NDC,outpatient,300,ML,53.38,37.366,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.08,416.02,other,SI=N Exclusions ,,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,57664-0683-57,NDC,outpatient,300,ML,46.71,32.697,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.08,416.02,other,SI=N Exclusions ,,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00409-1985-03,NDC,outpatient,1,ML,16.06,11.242,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.85,416.02,other,SI=N Exclusions ,,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00409-1985-30,NDC,outpatient,1,ML,16.06,11.242,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.85,416.02,other,SI=N Exclusions ,,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6044-25,NDC,outpatient,1,ML,4.94,3.458,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.85,416.02,other,SI=N Exclusions ,,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6207-25,NDC,outpatient,1,ML,5.04,3.528,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.85,416.02,other,SI=N Exclusions ,,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6207-01,NDC,outpatient,1,ML,5.04,3.528,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.85,416.02,other,SI=N Exclusions ,,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6044-01,NDC,outpatient,1,ML,4.94,3.458,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.85,416.02,other,SI=N Exclusions ,,
LORAZEPAM INFUSION PREMIX,RX-4080084,CDM,J2060,HCPCS,636,RC,SH408-0084-01,NDC,outpatient,100,ML,126.59,88.613,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.85,416.02,other,SI=N Exclusions ,,
MANNITOL 25 % IV SOLN,RX-4750,CDM,J2150,HCPCS,636,RC,00409-4031-01,NDC,outpatient,50,ML,10.28,7.196,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.30786,416.02,other,SI=N Exclusions ,,
MANNITOL 25 % IV SOLN,RX-4750,CDM,J2150,HCPCS,636,RC,00409-4031-16,NDC,outpatient,50,ML,10.28,7.196,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.30786,416.02,other,SI=N Exclusions ,,
MEPERIDINE 10 MG/ML PCA,RX-400415,CDM,J2175,HCPCS,636,RC,99999-0000-09,NDC,outpatient,50,ML,59.93,41.951,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.386435,416.02,other,SI=N Exclusions ,,
MEPERIDINE HCL 25 MG/ML IJ SOLN,RX-4903,CDM,J2175,HCPCS,636,RC,00641-6052-25,NDC,outpatient,1,ML,10.63,7.441,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.386435,416.02,other,SI=N Exclusions ,,
MEPERIDINE HCL 25 MG/ML IJ SOLN,RX-4903,CDM,J2175,HCPCS,636,RC,00641-6052-01,NDC,outpatient,1,ML,10.63,7.441,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.386435,416.02,other,SI=N Exclusions ,,
MEPERIDINE HCL 50 MG/ML IJ SOLN,RX-4904,CDM,J2175,HCPCS,636,RC,00641-6053-25,NDC,outpatient,1,ML,11.08,7.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.386435,416.02,other,SI=N Exclusions ,,
MEPERIDINE HCL 50 MG/ML IJ SOLN,RX-4904,CDM,J2175,HCPCS,636,RC,00641-6053-01,NDC,outpatient,1,ML,11.08,7.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.386435,416.02,other,SI=N Exclusions ,,
MEPOLIZUMAB 100 MG SC SOLR,RX-131231,CDM,J2182,HCPCS,636,RC,00173-0881-01,NDC,outpatient,1,UN,8145.21,5701.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,30.46,,,3017,29.75,6255.52128,fee schedule,,,
MEROPENEM 500 MG IV SOLR,RX-17379,CDM,J2185,HCPCS,636,RC,55150-0207-20,NDC,outpatient,1,UN,7.45,5.215,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.35,416.02,other,SI=N Exclusions ,,
MEROPENEM 500 MG IV SOLR,RX-17379,CDM,J2185,HCPCS,636,RC,63323-0507-20,NDC,outpatient,1,UN,14.25,9.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.35,416.02,other,SI=N Exclusions ,,
MEROPENEM 500 MG IV SOLR,RX-17379,CDM,J2185,HCPCS,636,RC,63323-0507-01,NDC,outpatient,1,UN,14.25,9.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.35,416.02,other,SI=N Exclusions ,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,70121-1453-01,NDC,outpatient,1,UN,45.95,32.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.35,416.02,other,SI=N Exclusions ,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,70121-1453-07,NDC,outpatient,1,UN,45.95,32.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.35,416.02,other,SI=N Exclusions ,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00409-1391-22,NDC,outpatient,1,UN,20.02,14.014,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.35,416.02,other,SI=N Exclusions ,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00781-3098-94,NDC,outpatient,1,UN,48.95,34.265,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.35,416.02,other,SI=N Exclusions ,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00409-1391-21,NDC,outpatient,1,UN,20.02,14.014,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.35,416.02,other,SI=N Exclusions ,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00781-3098-95,NDC,outpatient,1,UN,48.95,34.265,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.35,416.02,other,SI=N Exclusions ,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,55150-0208-30,NDC,outpatient,1,UN,17.23,12.061,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.35,416.02,other,SI=N Exclusions ,,
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,00517-0740-20,NDC,outpatient,1,ML,89.19,62.433,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,15.18518,416.02,other,SI=N Exclusions ,,
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,51991-0144-17,NDC,outpatient,1,ML,67.64,47.348,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,15.18518,416.02,other,SI=N Exclusions ,,
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,00517-0740-01,NDC,outpatient,1,ML,89.19,62.433,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,15.18518,416.02,other,SI=N Exclusions ,,
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,51991-0144-99,NDC,outpatient,1,ML,67.64,47.348,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,15.18518,416.02,other,SI=N Exclusions ,,
METHYLNALTREXONE BROMIDE 12 MG/0.6ML SC SOLN,RX-91651,CDM,J2212,HCPCS,636,RC,65649-0551-02,NDC,outpatient,0.6,ML,659.14,461.398,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.07677,506.21952,other,SI=N Exclusions ,,
MICAFUNGIN SODIUM 50 MG IV SOLR,RX-41144,CDM,J2248,HCPCS,636,RC,70710-1724-06,NDC,outpatient,1,UN,160.37,112.259,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.42,,,37.5,0.29,590.53056,fee schedule,,,
MICAFUNGIN SODIUM 50 MG IV SOLR,RX-41144,CDM,J2248,HCPCS,636,RC,00469-3250-10,NDC,outpatient,1,UN,384.44,269.108,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.42,,,37.5,0.29,590.53056,fee schedule,,,
MICAFUNGIN SODIUM 50 MG IV SOLR,RX-41144,CDM,J2248,HCPCS,636,RC,70710-1724-01,NDC,outpatient,1,UN,160.37,112.259,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.42,,,37.5,0.29,590.53056,fee schedule,,,
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,00469-3211-10,NDC,outpatient,1,UN,768.92,538.244,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.42,,,75,0.29,590.53056,fee schedule,,,
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,70710-1725-06,NDC,outpatient,1,UN,320.73,224.511,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.42,,,75,0.29,590.53056,fee schedule,,,
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,25021-0191-10,NDC,outpatient,1,UN,136.09,95.263,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.42,,,75,0.29,590.53056,fee schedule,,,
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,70710-1725-01,NDC,outpatient,1,UN,320.73,224.511,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.42,,,75,0.29,590.53056,fee schedule,,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,23155-0600-41,NDC,outpatient,2,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.13,416.02,other,SI=N Exclusions ,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,00409-2305-17,NDC,outpatient,2,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.13,416.02,other,SI=N Exclusions ,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,23155-0600-31,NDC,outpatient,2,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.13,416.02,other,SI=N Exclusions ,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-18,NDC,outpatient,5,ML,13.45,9.415,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.13,416.02,other,SI=N Exclusions ,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-25,NDC,outpatient,5,ML,13.45,9.415,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.13,416.02,other,SI=N Exclusions ,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,00409-2305-16,NDC,outpatient,2,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.13,416.02,other,SI=N Exclusions ,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-12,NDC,outpatient,2,ML,6.08,4.256,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.13,416.02,other,SI=N Exclusions ,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-15,NDC,outpatient,2,ML,6.08,4.256,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.13,416.02,other,SI=N Exclusions ,,
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2250,HCPCS,636,RC,99999-0001-46,NDC,outpatient,100,ML,75.72,53.004,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.13,416.02,other,SI=N Exclusions ,,
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2250,HCPCS,636,RC,70004-0411-59,NDC,outpatient,100,ML,159.16,111.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.13,416.02,other,SI=N Exclusions ,,
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00409-2308-01,NDC,outpatient,1,ML,3.95,2.765,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.13,416.02,other,SI=N Exclusions ,,
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00641-6060-01,NDC,outpatient,10,ML,8.07,5.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.13,416.02,other,SI=N Exclusions ,,
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00409-2308-21,NDC,outpatient,1,ML,3.95,2.765,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.13,416.02,other,SI=N Exclusions ,,
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00641-6060-10,NDC,outpatient,10,ML,8.07,5.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.13,416.02,other,SI=N Exclusions ,,
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2251,HCPCS,636,RC,44567-0611-01,NDC,outpatient,100,ML,77.41,54.187,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.21,,,29,0.18,416.02,fee schedule,,,
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2251,HCPCS,636,RC,44567-0611-10,NDC,outpatient,100,ML,77.41,54.187,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.21,,,29,0.18,416.02,fee schedule,,,
MILRINONE IN DEXTROSE 20 MG/100ML IV SOLN,RX-122186,CDM,J2260,HCPCS,636,RC,00143-9719-10,NDC,outpatient,100,ML,44.93,31.451,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.41,416.02,other,SI=N Exclusions ,,
MILRINONE IN DEXTROSE 20 MG/100ML IV SOLN,RX-122186,CDM,J2260,HCPCS,636,RC,25021-0313-82,NDC,outpatient,100,ML,50.27,35.189,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.41,416.02,other,SI=N Exclusions ,,
MILRINONE IN DEXTROSE 20 MG/100ML IV SOLN,RX-122186,CDM,J2260,HCPCS,636,RC,00143-9719-01,NDC,outpatient,100,ML,44.93,31.451,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.41,416.02,other,SI=N Exclusions ,,
MILRINONE LACTATE 10 MG/10ML IV SOLN,RX-122188,CDM,J2260,HCPCS,636,RC,00143-9710-10,NDC,outpatient,10,ML,16.45,11.515,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.41,416.02,other,SI=N Exclusions ,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00409-1891-01,NDC,outpatient,1,ML,9.04,6.328,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.02948,416.02,other,SI=N Exclusions ,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00641-6125-25,NDC,outpatient,1,ML,10.46,7.322,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.02948,416.02,other,SI=N Exclusions ,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00409-1891-03,NDC,outpatient,1,ML,9.04,6.328,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.02948,416.02,other,SI=N Exclusions ,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00641-6125-01,NDC,outpatient,1,ML,10.46,7.322,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.02948,416.02,other,SI=N Exclusions ,,
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2270,HCPCS,636,RC,00641-6127-01,NDC,outpatient,1,ML,10.68,7.476,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.02948,416.02,other,SI=N Exclusions ,,
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2270,HCPCS,636,RC,00641-6127-25,NDC,outpatient,1,ML,10.68,7.476,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.02948,416.02,other,SI=N Exclusions ,,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2270,HCPCS,636,RC,52533-0161-45,NDC,outpatient,1,ML,33.38,23.366,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.02948,416.02,other,SI=N Exclusions ,,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2270,HCPCS,636,RC,00409-1890-03,NDC,outpatient,1,ML,9.93,6.951,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.02948,416.02,other,SI=N Exclusions ,,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2270,HCPCS,636,RC,00409-1890-01,NDC,outpatient,1,ML,9.93,6.951,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.02948,416.02,other,SI=N Exclusions ,,
MORPHINE SULFATE 50 MG/ML IV SOLN,RX-27393,CDM,J2270,HCPCS,636,RC,00409-1134-05,NDC,outpatient,50,ML,115.7,80.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.02948,416.02,other,SI=N Exclusions ,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2272,HCPCS,636,RC,76045-0005-10,NDC,outpatient,1,ML,8.79,6.153,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.55,,,7.07,1.816205,416.02,fee schedule,,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2272,HCPCS,636,RC,63323-0454-00,NDC,outpatient,1,ML,8.51,5.957,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.55,,,7.07,1.816205,416.02,fee schedule,,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2272,HCPCS,636,RC,63323-0454-01,NDC,outpatient,1,ML,8.51,5.957,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.55,,,7.07,1.816205,416.02,fee schedule,,,
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2272,HCPCS,636,RC,63323-0451-00,NDC,outpatient,1,ML,9.36,6.552,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.55,,,7.07,1.816205,416.02,fee schedule,,,
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2272,HCPCS,636,RC,63323-0451-01,NDC,outpatient,1,ML,9.36,6.552,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.55,,,7.07,1.816205,416.02,fee schedule,,,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2272,HCPCS,636,RC,63323-0452-00,NDC,outpatient,1,ML,8.27,5.789,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.55,,,7.07,1.816205,416.02,fee schedule,,,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2272,HCPCS,636,RC,76045-0004-10,NDC,outpatient,1,ML,8.09,5.663,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.55,,,7.07,1.816205,416.02,fee schedule,,,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2272,HCPCS,636,RC,63323-0452-01,NDC,outpatient,1,ML,8.27,5.789,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.55,,,7.07,1.816205,416.02,fee schedule,,,
MORPHINE SULFATE (PF) 1 MG/ML IJ SOLN,RX-15852,CDM,J2274,HCPCS,636,RC,00641-6019-01,NDC,outpatient,10,ML,82.11,57.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.46,1022.48448,other,SI=N Exclusions ,,
MORPHINE SULFATE (PF) 1 MG/ML IJ SOLN,RX-15852,CDM,J2274,HCPCS,636,RC,00641-6019-10,NDC,outpatient,10,ML,82.11,57.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.46,1022.48448,other,SI=N Exclusions ,,
MORPHINE SULF MICROINFUSION PF 200 MG/20ML (10 MG/ML) IJ SOLN,RX-77009,CDM,J2274,HCPCS,636,RC,00641-6039-01,NDC,outpatient,20,ML,695.45,486.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.46,1022.48448,other,SI=N Exclusions ,,
MORPHINE SULF MICROINFUSION PF 500 MG/20ML (25 MG/ML) IJ SOLN,RX-77010,CDM,J2274,HCPCS,636,RC,00641-6040-01,NDC,outpatient,20,ML,1331.36,931.952,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,10.46,1022.48448,other,SI=N Exclusions ,,
NALBUPHINE HCL 10 MG/ML IJ SOLN,RX-5339,CDM,J2300,HCPCS,636,RC,00409-1463-71,NDC,outpatient,1,ML,17.79,12.453,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.72,416.02,other,SI=N Exclusions ,,
NALBUPHINE HCL 10 MG/ML IJ SOLN,RX-5339,CDM,J2300,HCPCS,636,RC,00409-1463-01,NDC,outpatient,1,ML,17.79,12.453,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.72,416.02,other,SI=N Exclusions ,,
NITROGLYCERIN IN D5W 400-5 MCG/ML-% IV SOLN,RX-14895,CDM,J2305,HCPCS,636,RC,00338-1051-02,NDC,outpatient,250,ML,62.73,43.911,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.34,,,25.8,1.3,416.02,fee schedule,,,
NITROGLYCERIN IN D5W 400-5 MCG/ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-14895,CDM,J2305,HCPCS,636,RC,00338-1051-02,NDC,outpatient,250,ML,46.73,32.711,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,1.34,,,25.8,1.3,416.02,fee schedule,,,
NITROGLYCERIN IN D5W 100-5 MCG/ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-15858,CDM,J2305,HCPCS,636,RC,00338-1047-02,NDC,outpatient,250,ML,40.05,28.035,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,1.34,,,6.45,1.3,416.02,fee schedule,,,
NITROGLYCERIN IN D5W 100-5 MCG/ML-% IV SOLN,RX-15858,CDM,J2305,HCPCS,636,RC,00338-1047-02,NDC,outpatient,250,ML,56.05,39.235,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.34,,,6.45,1.3,416.02,fee schedule,,,
NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-15859,CDM,J2305,HCPCS,636,RC,00338-1049-02,NDC,outpatient,250,ML,42.28,29.596,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,1.34,,,12.9,1.3,416.02,fee schedule,,,
NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN,RX-15859,CDM,J2305,HCPCS,636,RC,00338-1049-02,NDC,outpatient,250,ML,58.28,40.796,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.34,,,12.9,1.3,416.02,fee schedule,,,
NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN,RX-15859,CDM,J2305,HCPCS,636,RC,99999-0004-40,NDC,outpatient,250,ML,45.49,31.843,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.34,,,12.9,1.3,416.02,fee schedule,,,
NITROGLYCERIN 5 MG/ML IV SOLN,RX-5599,CDM,J2305,HCPCS,636,RC,00517-4810-25,NDC,outpatient,10,ML,51.4,35.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.34,,,12.9,1.3,416.02,fee schedule,,,
NITROGLYCERIN 5 MG/ML IV SOLN,RX-5599,CDM,J2305,HCPCS,636,RC,00517-4810-01,NDC,outpatient,10,ML,51.4,35.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.34,,,12.9,1.3,416.02,fee schedule,,,
NALOXONE HCL 2 MG/2ML IJ SOSY,RX-136113,CDM,J2310,HCPCS,636,RC,76329-3369-01,NDC,outpatient,2,ML,42.08,29.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.03075,416.02,other,SI=N Exclusions ,,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,00409-1215-01,NDC,outpatient,1,ML,63.16,44.212,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.03075,416.02,other,SI=N Exclusions ,,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,00409-1215-21,NDC,outpatient,1,ML,63.16,44.212,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.03075,416.02,other,SI=N Exclusions ,,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,67457-0292-00,NDC,outpatient,1,ML,15.44,10.808,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.03075,416.02,other,SI=N Exclusions ,,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,36000-0308-01,NDC,outpatient,1,ML,13.5,9.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.03075,416.02,other,SI=N Exclusions ,,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,36000-0308-10,NDC,outpatient,1,ML,13.5,9.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.03075,416.02,other,SI=N Exclusions ,,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,67457-0292-02,NDC,outpatient,1,ML,15.44,10.808,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.03075,416.02,other,SI=N Exclusions ,,
OCTREOTIDE ACETATE 50 MCG/ML IJ SOLN,RX-91278,CDM,J2354,HCPCS,636,RC,67457-0239-00,NDC,outpatient,1,ML,17.58,12.306,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.86,416.02,other,SI=N Exclusions ,,
OCTREOTIDE ACETATE 50 MCG/ML IJ SOLN,RX-91278,CDM,J2354,HCPCS,636,RC,67457-0239-01,NDC,outpatient,1,ML,17.58,12.306,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.86,416.02,other,SI=N Exclusions ,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,23155-0688-31,NDC,outpatient,1,ML,11.88,8.316,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.86,416.02,other,SI=N Exclusions ,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,00641-6175-01,NDC,outpatient,1,ML,7.84,5.488,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.86,416.02,other,SI=N Exclusions ,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,23155-0688-41,NDC,outpatient,1,ML,11.88,8.316,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.86,416.02,other,SI=N Exclusions ,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,63323-0376-01,NDC,outpatient,1,ML,11.92,8.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.86,416.02,other,SI=N Exclusions ,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,63323-0376-00,NDC,outpatient,1,ML,11.92,8.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.86,416.02,other,SI=N Exclusions ,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,00641-6175-10,NDC,outpatient,1,ML,7.84,5.488,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.86,416.02,other,SI=N Exclusions ,,
OCTREOTIDE ACETATE 200 MCG/ML IJ SOLN,RX-91280,CDM,J2354,HCPCS,636,RC,00641-6177-01,NDC,outpatient,0.5,ML,25.17,17.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.86,416.02,other,SI=N Exclusions ,,
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,00641-6176-01,NDC,outpatient,1,ML,46.52,32.564,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.86,416.02,other,SI=N Exclusions ,,
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,00641-6176-10,NDC,outpatient,1,ML,46.52,32.564,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.86,416.02,other,SI=N Exclusions ,,
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,63323-0377-00,NDC,outpatient,1,ML,41.91,29.337,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.86,416.02,other,SI=N Exclusions ,,
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,63323-0377-01,NDC,outpatient,1,ML,41.91,29.337,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.86,416.02,other,SI=N Exclusions ,,
OMALIZUMAB 150 MG/ML SC SOSY,RX-144954,CDM,J2357,HCPCS,636,RC,50242-0215-01,NDC,outpatient,1,ML,3822.49,2675.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,38.33,,,1172.7,38.29,2935.67232,fee schedule,,,
OMALIZUMAB 75 MG/0.5ML SC SOSY,RX-144955,CDM,J2357,HCPCS,636,RC,50242-0214-01,NDC,outpatient,0.5,ML,1911.25,1337.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,38.33,,,586.35,38.29,2935.67232,fee schedule,,,
OMALIZUMAB 150 MG SC SOLR,RX-36151,CDM,J2357,HCPCS,636,RC,50242-0040-62,NDC,outpatient,1,UN,3822.49,2675.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,38.33,,,1172.7,38.29,2935.67232,fee schedule,,,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,55150-0308-01,NDC,outpatient,1,UN,77.39,54.173,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.98,,,17.8,0.92,416.02,fee schedule,,,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00781-9105-72,NDC,outpatient,1,UN,62.44,43.708,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.98,,,17.8,0.92,416.02,fee schedule,,,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00002-7597-01,NDC,outpatient,1,UN,206.8,144.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.98,,,17.8,0.92,416.02,fee schedule,,,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00517-0955-01,NDC,outpatient,1,UN,115.66,80.962,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.98,,,17.8,0.92,416.02,fee schedule,,,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00781-3159-72,NDC,outpatient,1,UN,62.44,43.708,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.98,,,17.8,0.92,416.02,fee schedule,,,
ORPHENADRINE CITRATE 30 MG/ML IJ SOLN,RX-5886,CDM,J2360,HCPCS,636,RC,00641-6182-10,NDC,outpatient,2,ML,19.23,13.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.317135,416.02,other,SI=N Exclusions ,,
ORPHENADRINE CITRATE 30 MG/ML IJ SOLN,RX-5886,CDM,J2360,HCPCS,636,RC,00641-6182-01,NDC,outpatient,2,ML,19.23,13.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.317135,416.02,other,SI=N Exclusions ,,
PHENYLEPHRINE HCL 100 MCG/ML SYRINGE,RX-4080501,CDM,J2371,HCPCS,636,RC,70004-0810-11,NDC,outpatient,5,ML,23.81,16.667,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,0.25,0.01,416.02,fee schedule,,,
PHENYLEPHRINE HCL 100 MCG/ML SYRINGE,RX-4080501,CDM,J2371,HCPCS,636,RC,70004-0810-12,NDC,outpatient,10,ML,25.28,17.696,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,0.5,0.01,416.02,fee schedule,,,
PHENYLEPHRINE HCL 100 MCG/ML SYRINGE,RX-4080501,CDM,J2371,HCPCS,636,RC,70092-1046-46,NDC,outpatient,10,ML,24.79,17.353,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,0.5,0.01,416.02,fee schedule,,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70069-0801-25,NDC,outpatient,1,ML,6.49,4.543,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,5,0.01,416.02,fee schedule,,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1577-01,NDC,outpatient,1,ML,9.89,6.923,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,5,0.01,416.02,fee schedule,,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,00781-3422-92,NDC,outpatient,1,ML,12.34,8.638,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,5,0.01,416.02,fee schedule,,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1578-01,NDC,outpatient,5,ML,19.7,13.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,25,0.01,416.02,fee schedule,,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1578-07,NDC,outpatient,5,ML,19.7,13.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,25,0.01,416.02,fee schedule,,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,00781-3422-71,NDC,outpatient,1,ML,12.34,8.638,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,5,0.01,416.02,fee schedule,,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70069-0801-01,NDC,outpatient,1,ML,6.49,4.543,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,5,0.01,416.02,fee schedule,,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1577-05,NDC,outpatient,1,ML,9.89,6.923,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,5,0.01,416.02,fee schedule,,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,25021-0315-01,NDC,outpatient,1,ML,3.42,2.394,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.01,,,5,0.01,416.02,fee schedule,,,
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,00143-9209-10,NDC,outpatient,20,ML,51.18,35.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.03,,,16,0.03,416.02,fee schedule,,,
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,63323-0477-01,NDC,outpatient,20,ML,78.86,55.202,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.03,,,16,0.03,416.02,fee schedule,,,
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,63323-0477-27,NDC,outpatient,20,ML,78.86,55.202,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.03,,,16,0.03,416.02,fee schedule,,,
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,00143-9209-01,NDC,outpatient,20,ML,51.18,35.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.03,,,16,0.03,416.02,fee schedule,,,
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,00143-9210-10,NDC,outpatient,20,ML,54.03,37.821,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.03,,,24,0.03,416.02,fee schedule,,,
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,00143-9210-01,NDC,outpatient,20,ML,54.03,37.821,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.03,,,24,0.03,416.02,fee schedule,,,
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,63323-0478-01,NDC,outpatient,20,ML,82.77,57.939,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.03,,,24,0.03,416.02,fee schedule,,,
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,63323-0478-27,NDC,outpatient,20,ML,82.77,57.939,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.03,,,24,0.03,416.02,fee schedule,,,
NICARDIPINE HCL 2.5 MG/ML IV SOLN,RX-12370,CDM,J2404,HCPCS,636,RC,00143-9689-01,NDC,outpatient,10,ML,41.12,28.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.11,,,22.5,0.54,416.02,fee schedule,,,
NICARDIPINE HCL 2.5 MG/ML IV SOLN,RX-12370,CDM,J2404,HCPCS,636,RC,00143-9689-10,NDC,outpatient,10,ML,41.12,28.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.11,,,22.5,0.54,416.02,fee schedule,,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00409-4755-18,NDC,outpatient,2,ML,6.09,4.263,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,SI=N Exclusions ,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00641-6078-25,NDC,outpatient,2,ML,3.61,2.527,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,SI=N Exclusions ,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00409-4755-03,NDC,outpatient,2,ML,6.09,4.263,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,SI=N Exclusions ,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,36000-0012-25,NDC,outpatient,2,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,SI=N Exclusions ,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,23155-0547-31,NDC,outpatient,2,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,SI=N Exclusions ,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,23155-0549-31,NDC,outpatient,20,ML,18.1,12.67,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,SI=N Exclusions ,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,60505-6130-00,NDC,outpatient,2,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,SI=N Exclusions ,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,60505-6130-05,NDC,outpatient,2,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,SI=N Exclusions ,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00641-6078-01,NDC,outpatient,2,ML,3.61,2.527,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,SI=N Exclusions ,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,23155-0547-42,NDC,outpatient,2,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,SI=N Exclusions ,,
PAMIDRONATE DISODIUM 30 MG/10ML IV SOLN,RX-32589,CDM,J2430,HCPCS,636,RC,61703-0324-18,NDC,outpatient,10,ML,46.42,32.494,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.263845,416.02,other,SI=N Exclusions ,,
PAMIDRONATE DISODIUM 30 MG/10ML IV SOLN,RX-32589,CDM,J2430,HCPCS,636,RC,67457-0430-10,NDC,outpatient,10,ML,36.81,25.767,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,8.263845,416.02,other,SI=N Exclusions ,,
PALONOSETRON HCL 0.25 MG/5ML IV SOLN,RX-36591,CDM,J2469,HCPCS,636,RC,60505-6193-01,NDC,outpatient,5,ML,13.32,9.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.98,,,8.8,0.62,416.02,fee schedule,,,
PALONOSETRON HCL 0.25 MG/5ML IV SOLN,RX-36591,CDM,J2469,HCPCS,636,RC,55111-0694-07,NDC,outpatient,5,ML,25.1,17.57,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.98,,,8.8,0.62,416.02,fee schedule,,,
PARICALCITOL 5 MCG/ML IV SOLN,RX-22960,CDM,J2501,HCPCS,636,RC,00074-1658-01,NDC,outpatient,1,ML,40.71,28.497,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.5,416.02,other,SI=N Exclusions ,,
PEGLOTICASE 8 MG/ML IV SOLN,RX-107664,CDM,J2507,HCPCS,636,RC,75987-0080-10,NDC,outpatient,1,ML,59467.57,41627.299,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3447.06,,,26456.4,399.86,45671.09376,fee schedule,,,
PENICILLIN G POT IN DEXTROSE 60000 UNIT/ML IV WRAPPER,RX-4080111,CDM,J2540,HCPCS,636,RC,00338-1025-41,NDC,outpatient,50,ML,55.67,38.969,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.01,416.02,other,SI=N Exclusions ,,
PENICILLIN G POTASSIUM 5000000 UNITS IJ SOLR,RX-6086,CDM,J2540,HCPCS,636,RC,44567-0311-10,NDC,outpatient,1,UN,17.93,12.551,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.01,416.02,other,SI=N Exclusions ,,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,55150-0121-50,NDC,outpatient,1,UN,18.43,12.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.1,416.02,other,SI=N Exclusions ,,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,72485-0404-01,NDC,outpatient,1,UN,18.51,12.957,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.1,416.02,other,SI=N Exclusions ,,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,72485-0404-10,NDC,outpatient,1,UN,18.51,12.957,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.1,416.02,other,SI=N Exclusions ,,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,00781-3114-95,NDC,outpatient,1,UN,30.55,21.385,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.1,416.02,other,SI=N Exclusions ,,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,44567-0803-10,NDC,outpatient,1,UN,27.96,19.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.1,416.02,other,SI=N Exclusions ,,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,00781-3114-91,NDC,outpatient,1,UN,30.55,21.385,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.1,416.02,other,SI=N Exclusions ,,
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,64679-0056-02,NDC,outpatient,1,UN,13.78,9.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.1,416.02,other,SI=N Exclusions ,,
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,60505-6157-04,NDC,outpatient,1,UN,9.79,6.853,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.1,416.02,other,SI=N Exclusions ,,
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,55150-0120-30,NDC,outpatient,1,UN,12.91,9.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.1,416.02,other,SI=N Exclusions ,,
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,60505-6157-00,NDC,outpatient,1,UN,9.79,6.853,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.1,416.02,other,SI=N Exclusions ,,
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,64679-0056-01,NDC,outpatient,1,UN,13.78,9.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.1,416.02,other,SI=N Exclusions ,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00781-3110-95,NDC,outpatient,1,UN,17.66,12.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.1,416.02,other,SI=N Exclusions ,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,44567-0801-10,NDC,outpatient,1,UN,14.21,9.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.1,416.02,other,SI=N Exclusions ,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,55150-0119-30,NDC,outpatient,1,UN,8.76,6.132,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.1,416.02,other,SI=N Exclusions ,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,60505-6156-00,NDC,outpatient,1,UN,7.94,5.558,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.1,416.02,other,SI=N Exclusions ,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,60505-6156-04,NDC,outpatient,1,UN,7.94,5.558,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.1,416.02,other,SI=N Exclusions ,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00409-3383-02,NDC,outpatient,1,UN,25.13,17.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.1,416.02,other,SI=N Exclusions ,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00409-3383-11,NDC,outpatient,1,UN,25.13,17.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.1,416.02,other,SI=N Exclusions ,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00781-3110-90,NDC,outpatient,1,UN,17.66,12.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.1,416.02,other,SI=N Exclusions ,,
PROMETHAZINE HCL 25 MG/ML IJ SOLN,RX-6618,CDM,J2550,HCPCS,636,RC,00641-1495-35,NDC,outpatient,1,ML,7.75,5.425,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.739875,416.02,other,SI=N Exclusions ,,
PROMETHAZINE HCL 25 MG/ML IJ SOLN,RX-6618,CDM,J2550,HCPCS,636,RC,00641-1495-31,NDC,outpatient,1,ML,7.75,5.425,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.739875,416.02,other,SI=N Exclusions ,,
PHENOBARBITAL SODIUM 130 MG/ML IJ SOLN,RX-6221,CDM,J2560,HCPCS,636,RC,00641-0477-21,NDC,outpatient,1,ML,155.87,109.109,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,32.77,,,72.5,13.89655,416.02,fee schedule,,,
PHENOBARBITAL SODIUM 130 MG/ML IJ SOLN,RX-6221,CDM,J2560,HCPCS,636,RC,00641-0477-25,NDC,outpatient,1,ML,155.87,109.109,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,32.77,,,72.5,13.89655,416.02,fee schedule,,,
PHENOBARBITAL SODIUM 65 MG/ML IJ SOLN,RX-6224,CDM,J2560,HCPCS,636,RC,00641-0476-21,NDC,outpatient,1,ML,61.9,43.33,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,32.77,,,36.25,13.89655,416.02,fee schedule,,,
PHENOBARBITAL SODIUM 65 MG/ML IJ SOLN,RX-6224,CDM,J2560,HCPCS,636,RC,00641-0476-25,NDC,outpatient,1,ML,61.9,43.33,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,32.77,,,36.25,13.89655,416.02,fee schedule,,,
OXYTOCIN 10 UNIT/ML IJ SOLN,RX-5944,CDM,J2590,HCPCS,636,RC,42023-0116-25,NDC,outpatient,1,ML,7.42,5.194,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
OXYTOCIN 10 UNIT/ML IJ SOLN,RX-5944,CDM,J2590,HCPCS,636,RC,63323-0012-06,NDC,outpatient,0.3,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
OXYTOCIN 10 UNIT/ML IJ SOLN,RX-5944,CDM,J2590,HCPCS,636,RC,63323-0012-10,NDC,outpatient,0.3,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.74534,416.02,other,SI=N Exclusions ,,
DESMOPRESSIN ACETATE 4 MCG/ML IJ SOLN WRAPPER,RX-4081353,CDM,J2597,HCPCS,636,RC,69918-0899-01,NDC,outpatient,1,ML,91.9,64.33,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5.56,,,24.6,5.42,416.02,fee schedule,,,
DESMOPRESSIN ACETATE 4 MCG/ML IJ SOLN WRAPPER,RX-4081353,CDM,J2597,HCPCS,636,RC,69918-0899-10,NDC,outpatient,1,ML,91.9,64.33,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5.56,,,24.6,5.42,416.02,fee schedule,,,
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-01,NDC,outpatient,100,ML,550.45,385.315,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.93,,,102.4,1.62,422.7456,fee schedule,,,
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-01,NDC,outpatient,100,ML,534.45,374.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,1.93,,,102.4,1.62,422.7456,fee schedule,,,
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-10,NDC,outpatient,100,ML,550.45,385.315,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.93,,,102.4,1.62,422.7456,fee schedule,,,
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-10,NDC,outpatient,100,ML,534.45,374.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,1.93,,,102.4,1.62,422.7456,fee schedule,,,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42023-0164-25,NDC,outpatient,1,ML,50.82,35.574,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.93,,,51.2,1.62,422.7456,fee schedule,,,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42367-0570-87,NDC,outpatient,0.25,ML,175.83,123.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.93,,,12.8,1.62,422.7456,fee schedule,,,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,55150-0370-01,NDC,outpatient,0.25,ML,21.94,15.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.93,,,12.8,1.62,422.7456,fee schedule,,,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42367-0570-22,NDC,outpatient,0.25,ML,175.83,123.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.93,,,12.8,1.62,422.7456,fee schedule,,,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,55150-0370-25,NDC,outpatient,0.25,ML,21.94,15.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.93,,,12.8,1.62,422.7456,fee schedule,,,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42023-0164-01,NDC,outpatient,1,ML,50.82,35.574,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.93,,,51.2,1.62,422.7456,fee schedule,,,
FLUPHENAZINE HCL 2.5 MG/ML IJ SOLN,RX-3216,CDM,J2679,HCPCS,636,RC,63323-0281-10,NDC,outpatient,0.5,ML,19.62,13.734,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,7.31,,,9.79,4.40469,416.02,fee schedule,,,
FLUPHENAZINE DECANOATE 25 MG/ML IJ SOLN,RX-3215,CDM,J2680,HCPCS,636,RC,42023-0129-01,NDC,outpatient,0.5,ML,20.43,14.301,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.586535,416.02,other,SI=N Exclusions ,,
FLUPHENAZINE DECANOATE 25 MG/ML IJ SOLN,RX-3215,CDM,J2680,HCPCS,636,RC,63323-0272-05,NDC,outpatient,0.5,ML,32.89,23.023,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.586535,416.02,other,SI=N Exclusions ,,
PROCAINAMIDE HCL 100 MG/ML IJ SOLN,RX-6562,CDM,J2690,HCPCS,636,RC,00409-1902-01,NDC,outpatient,1,ML,24.43,17.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.484535,1082.90304,other,SI=N Exclusions ,,
PROCAINAMIDE HCL 100 MG/ML IJ SOLN,RX-6562,CDM,J2690,HCPCS,636,RC,00409-1902-11,NDC,outpatient,1,ML,24.43,17.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.484535,1082.90304,other,SI=N Exclusions ,,
PROCAINAMIDE HCL 500 MG/ML IJ SOLN,RX-6563,CDM,J2690,HCPCS,636,RC,14789-0900-07,NDC,outpatient,2,ML,1410.03,987.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.484535,1082.90304,other,SI=N Exclusions ,,
PROCAINAMIDE HCL 500 MG/ML IJ SOLN,RX-6563,CDM,J2690,HCPCS,636,RC,14789-0900-02,NDC,outpatient,2,ML,1410.03,987.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.484535,1082.90304,other,SI=N Exclusions ,,
OXACILLIN SODIUM 10 G IV SOLR,RX-150085,CDM,J2700,HCPCS,636,RC,25021-0163-99,NDC,outpatient,1,UN,489.5,342.65,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.87,416.02,other,SI=N Exclusions ,,
OXACILLIN SODIUM 10 G IV SOLR,RX-150085,CDM,J2700,HCPCS,636,RC,55150-0129-99,NDC,outpatient,1,UN,150.46,105.322,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.87,416.02,other,SI=N Exclusions ,,
OXACILLIN SODIUM 10 G IV SOLR,RX-150085,CDM,J2700,HCPCS,636,RC,63323-0811-00,NDC,outpatient,1,UN,137.38,96.166,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.87,416.02,other,SI=N Exclusions ,,
OXACILLIN SODIUM 1 G IJ SOLR,RX-5924,CDM,J2700,HCPCS,636,RC,55150-0127-15,NDC,outpatient,1,UN,19.11,13.377,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.87,416.02,other,SI=N Exclusions ,,
OXACILLIN SODIUM 1 G IJ SOLR,RX-5924,CDM,J2700,HCPCS,636,RC,64679-0698-02,NDC,outpatient,1,UN,20.97,14.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.87,416.02,other,SI=N Exclusions ,,
OXACILLIN SODIUM 1 G IJ SOLR,RX-5924,CDM,J2700,HCPCS,636,RC,64679-0698-01,NDC,outpatient,1,UN,20.97,14.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.87,416.02,other,SI=N Exclusions ,,
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,63323-0812-20,NDC,outpatient,1,UN,25.17,17.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.87,416.02,other,SI=N Exclusions ,,
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,63323-0812-01,NDC,outpatient,1,UN,25.17,17.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.87,416.02,other,SI=N Exclusions ,,
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,64679-0699-01,NDC,outpatient,1,UN,38.24,26.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.87,416.02,other,SI=N Exclusions ,,
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,64679-0699-02,NDC,outpatient,1,UN,38.24,26.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.87,416.02,other,SI=N Exclusions ,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0209-10,NDC,outpatient,20,ML,9.98,6.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-33,NDC,outpatient,50,ML,18.47,12.929,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0528-10,NDC,outpatient,20,ML,9.98,6.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0977-20,NDC,outpatient,50,ML,18.69,13.083,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,25021-0608-50,NDC,outpatient,50,ML,28.71,20.097,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,63323-0269-22,NDC,outpatient,20,ML,9.57,6.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0209-01,NDC,outpatient,20,ML,9.98,6.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0234-01,NDC,outpatient,50,ML,21.59,15.113,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0234-20,NDC,outpatient,50,ML,21.59,15.113,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-24,NDC,outpatient,100,ML,36.94,25.858,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0690-01,NDC,outpatient,100,ML,32.93,23.051,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0690-10,NDC,outpatient,100,ML,32.93,23.051,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,25021-0608-20,NDC,outpatient,20,ML,10.49,7.343,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,43598-0548-21,NDC,outpatient,50,ML,20.47,14.329,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0248-01,NDC,outpatient,100,ML,43.17,30.219,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0248-10,NDC,outpatient,100,ML,43.17,30.219,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-53,NDC,outpatient,50,ML,18.47,12.929,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-54,NDC,outpatient,100,ML,36.94,25.858,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0977-01,NDC,outpatient,50,ML,18.69,13.083,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,63323-0269-29,NDC,outpatient,20,ML,9.57,6.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0528-01,NDC,outpatient,20,ML,8.95,6.265,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,25021-0608-51,NDC,outpatient,100,ML,57.41,40.187,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,43598-0548-50,NDC,outpatient,50,ML,20.47,14.329,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-24,NDC,outpatient,100,ML,52.94,37.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-53,NDC,outpatient,50,ML,34.47,24.129,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0977-20,NDC,outpatient,50,ML,34.69,24.283,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,25021-0608-50,NDC,outpatient,50,ML,44.71,31.297,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,25021-0608-51,NDC,outpatient,100,ML,73.41,51.387,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0234-01,NDC,outpatient,50,ML,37.59,26.313,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0234-20,NDC,outpatient,50,ML,37.59,26.313,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0248-01,NDC,outpatient,100,ML,59.17,41.419,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0248-10,NDC,outpatient,100,ML,59.17,41.419,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-33,NDC,outpatient,50,ML,34.47,24.129,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0690-10,NDC,outpatient,100,ML,48.93,34.251,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0977-01,NDC,outpatient,50,ML,34.69,24.283,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,43598-0548-21,NDC,outpatient,50,ML,36.47,25.529,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,43598-0548-50,NDC,outpatient,50,ML,36.47,25.529,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-54,NDC,outpatient,100,ML,52.94,37.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0690-01,NDC,outpatient,100,ML,48.93,34.251,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,Non-Reimbursable List,,
NEOSTIGMINE METHYLSULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4080613,CDM,J2710,HCPCS,636,RC,70121-1479-01,NDC,outpatient,10,ML,34.98,24.486,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.43,416.02,other,SI=N Exclusions ,,
NEOSTIGMINE METHYLSULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4080613,CDM,J2710,HCPCS,636,RC,70121-1479-07,NDC,outpatient,10,ML,34.98,24.486,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.43,416.02,other,SI=N Exclusions ,,
PROTAMINE SULFATE 10 MG/ML IV SOLN,RX-6677,CDM,J2720,HCPCS,636,RC,63323-0229-05,NDC,outpatient,5,ML,44.82,31.374,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.95,416.02,other,SI=N Exclusions ,,
PROTAMINE SULFATE 10 MG/ML IV SOLN,RX-6677,CDM,J2720,HCPCS,636,RC,63323-0229-30,NDC,outpatient,25,ML,134.62,94.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.95,416.02,other,SI=N Exclusions ,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,76045-0101-20,NDC,outpatient,2,ML,9.08,6.356,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92943,416.02,other,SI=N Exclusions ,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-3414-18,NDC,outpatient,2,ML,4.14,2.898,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92943,416.02,other,SI=N Exclusions ,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-5255-02,NDC,outpatient,2,ML,4.14,2.898,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92943,416.02,other,SI=N Exclusions ,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00703-4502-01,NDC,outpatient,2,ML,17.23,12.061,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92943,416.02,other,SI=N Exclusions ,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-3414-01,NDC,outpatient,2,ML,4.14,2.898,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92943,416.02,other,SI=N Exclusions ,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-5255-25,NDC,outpatient,2,ML,4.14,2.898,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92943,416.02,other,SI=N Exclusions ,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00703-4502-04,NDC,outpatient,2,ML,17.23,12.061,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.92943,416.02,other,SI=N Exclusions ,,
QUINUPRISTIN-DALFOPRISTIN 500 MG IV SOLR,RX-26335,CDM,J2770,HCPCS,636,RC,61570-0260-01,NDC,outpatient,1,UN,1916.14,1341.298,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,493.97,,,493.97,7.136465,1471.59552,fee schedule,,,
QUINUPRISTIN-DALFOPRISTIN 500 MG IV SOLR,RX-26335,CDM,J2770,HCPCS,636,RC,61570-0260-10,NDC,outpatient,1,UN,1916.14,1341.298,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,493.97,,,493.97,7.136465,1471.59552,fee schedule,,,
RASBURICASE 1.5 MG IV SOLR,RX-33591,CDM,J2783,HCPCS,636,RC,00024-5150-10,NDC,outpatient,1,UN,3073.12,2151.184,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,370.9,,,1075.29,357.36,11800.75008,fee schedule,,,
RASBURICASE 7.5 MG IV SOLR,RX-76868,CDM,J2783,HCPCS,636,RC,00024-5151-75,NDC,outpatient,1,UN,15365.56,10755.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,370.9,,,5376.45,357.36,11800.75008,fee schedule,,,
REGADENOSON 0.4 MG/5ML IV SOLN,RX-91408,CDM,J2785,HCPCS,636,RC,00469-6501-89,NDC,outpatient,5,ML,593.55,415.485,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.88,455.8464,other,SI=N Exclusions ,,
REGADENOSON 0.4 MG/5ML IV SOLN,RX-91408,CDM,J2785,HCPCS,636,RC,67457-0994-05,NDC,outpatient,5,ML,26.97,18.879,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.88,455.8464,other,SI=N Exclusions ,,
REGADENOSON 0.4 MG/5ML IV SOLN,RX-91408,CDM,J2785,HCPCS,636,RC,71288-0201-85,NDC,outpatient,5,ML,30.71,21.497,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.88,455.8464,other,SI=N Exclusions ,,
RHO D IMMUNE GLOBULIN 5000 UNIT/4.4ML IJ SOLN,RX-70574,CDM,J2792,HCPCS,636,RC,70257-0310-51,NDC,outpatient,4.4,ML,3912.94,2739.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,33.72,,,1673,33.71,3005.13792,fee schedule,,,
RHO D IMMUNE GLOBULIN 5000 UNIT/4.4ML IJ SOLN,RX-70574,CDM,J2792,HCPCS,636,RC,70257-0310-04,NDC,outpatient,4.4,ML,3912.94,2739.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,33.72,,,1673,33.71,3005.13792,fee schedule,,,
RISPERIDONE MICROSPHERES ER 37.5 MG IM SRER,RX-148032,CDM,J2794,HCPCS,636,RC,50458-0307-11,NDC,outpatient,1,UN,2304,1612.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12.16,,,911.25,10.7,2359.38048,fee schedule,,,
RISPERIDONE MICROSPHERES ER 50 MG IM SRER,RX-148033,CDM,J2794,HCPCS,636,RC,50458-0308-11,NDC,outpatient,1,UN,3072.11,2150.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12.16,,,1215,10.7,2359.38048,fee schedule,,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,43066-0023-01,NDC,outpatient,30,ML,15.73,11.011,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions ,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-01,NDC,outpatient,20,ML,59.55,41.685,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions ,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,55150-0198-30,NDC,outpatient,30,ML,20.21,14.147,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions ,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-20,NDC,outpatient,20,ML,59.55,41.685,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions ,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-35,NDC,outpatient,30,ML,20.56,14.392,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions ,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,70069-0064-01,NDC,outpatient,30,ML,20.21,14.147,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions ,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,43066-0023-10,NDC,outpatient,30,ML,15.73,11.011,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions ,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-11,NDC,outpatient,30,ML,20.56,14.392,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions ,,
ROMIPLOSTIM 125 MCG SC SOLR,RX-148858,CDM,J2796,HCPCS,636,RC,55513-0223-01,NDC,outpatient,1,UN,3455.52,2418.864,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,100.81,,,1244.75,95.47,5307.61728,fee schedule,,,
ROMIPLOSTIM 125 MCG SC SOLR|DISCARDED DRUG NOT ADMINISTERED,RX-148858,CDM,J2796,HCPCS,636,RC,55513-0223-01,NDC,outpatient,1,UN,3455.52,2418.864,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,100.81,,,1149,95.47,5307.61728,fee schedule,,,
ROMIPLOSTIM 250 MCG SC SOLR,RX-93566,CDM,J2796,HCPCS,636,RC,55513-0221-01,NDC,outpatient,1,UN,6910.96,4837.672,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,100.81,,,2393.75,95.47,5307.61728,fee schedule,,,
SILTUXIMAB 100 MG IV SOLR,RX-125552,CDM,J2860,HCPCS,636,RC,73090-0420-01,NDC,outpatient,1,UN,4143.92,2900.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,153.16,,,1489.6,139.22,12730.14528,fee schedule,,,
SILTUXIMAB 400 MG IV SOLR,RX-125553,CDM,J2860,HCPCS,636,RC,73090-0421-01,NDC,outpatient,1,UN,16575.71,11602.997,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,153.16,,,5958.4,139.22,12730.14528,fee schedule,,,
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00024-2792-01,NDC,outpatient,5,ML,35.83,25.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.12,416.02,other,SI=N Exclusions ,,
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00143-9570-01,NDC,outpatient,5,ML,61.68,43.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.12,416.02,other,SI=N Exclusions ,,
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00143-9570-10,NDC,outpatient,5,ML,61.68,43.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.12,416.02,other,SI=N Exclusions ,,
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00024-2792-10,NDC,outpatient,5,ML,35.83,25.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.12,416.02,other,SI=N Exclusions ,,
METHYLPREDNISOLONE SODIUM SUCC 40 MG IJ SOLR,RX-10580,CDM,J2920,HCPCS,636,RC,00009-0039-30,NDC,outpatient,1,UN,20.03,14.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.24,416.02,other,SI=N Exclusions ,,
METHYLPREDNISOLONE SODIUM SUCC 40 MG IJ SOLR,RX-10580,CDM,J2920,HCPCS,636,RC,00009-0039-28,NDC,outpatient,1,UN,20.03,14.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.24,416.02,other,SI=N Exclusions ,,
METHYLPREDNISOLONE SODIUM SUCC 1000 MG IJ SOLR,RX-10577,CDM,J2930,HCPCS,636,RC,00009-0698-01,NDC,outpatient,1,UN,79.04,55.328,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.73,565.07136,other,SI=N Exclusions ,,
METHYLPREDNISOLONE SODIUM SUCC 125 MG IJ SOLR,RX-10578,CDM,J2930,HCPCS,636,RC,00009-0047-25,NDC,outpatient,1,UN,31.87,22.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.73,565.07136,other,SI=N Exclusions ,,
METHYLPREDNISOLONE SODIUM SUCC 125 MG IJ SOLR,RX-10578,CDM,J2930,HCPCS,636,RC,00009-0047-22,NDC,outpatient,1,UN,31.87,22.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.73,565.07136,other,SI=N Exclusions ,,
METHYLPREDNISOLONE SODIUM SUCC 2000 MG IJ SOLR,RX-10579,CDM,J2930,HCPCS,636,RC,00009-0850-01,NDC,outpatient,1,UN,735.77,515.039,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.73,565.07136,other,SI=N Exclusions ,,
METHYLPREDNISOLONE SODIUM SUCC 500 MG IJ SOLR,RX-10581,CDM,J2930,HCPCS,636,RC,00009-0758-01,NDC,outpatient,1,UN,87,60.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.73,565.07136,other,SI=N Exclusions ,,
METHYLPREDNISOLONE SODIUM SUCC 1000 MG IJ ACT-O-VIAL,RX-4081056,CDM,J2930,HCPCS,636,RC,00009-0018-20,NDC,outpatient,1,UN,235.14,164.598,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.73,565.07136,other,SI=N Exclusions ,,
METHYLPREDNISOLONE SODIUM SUCC 500 MG IJ ACT-O-VIAL,RX-4081057,CDM,J2930,HCPCS,636,RC,00009-0003-02,NDC,outpatient,1,UN,180.85,126.595,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.73,565.07136,other,SI=N Exclusions ,,
ALTEPLASE 2 MG IJ SOLR,RX-31310,CDM,J2997,HCPCS,636,RC,50242-0041-64,NDC,outpatient,1,UN,725.13,507.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,91.34,,,178.32,89.15,17236.24704,fee schedule,,,
ALTEPLASE 2 MG IJ SOLR,RX-31310,CDM,J2997,HCPCS,636,RC,99999-0000-50,NDC,outpatient,2,ML,723.71,506.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,91.34,,,178.32,89.15,17236.24704,fee schedule,,,
ALTEPLASE 100 MG IV SOLR,RX-9002,CDM,J2997,HCPCS,636,RC,50242-0085-27,NDC,outpatient,1,UN,22443.03,15710.121,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,91.34,,,8916,89.15,17236.24704,fee schedule,,,
ALTEPLASE 50 MG IV SOLR,RX-9003,CDM,J2997,HCPCS,636,RC,50242-0044-13,NDC,outpatient,1,UN,11221.53,7855.071,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,91.34,,,4458,89.15,17236.24704,fee schedule,,,
STREPTOMYCIN SULFATE 1 G IM SOLR,RX-7508,CDM,J3000,HCPCS,636,RC,39822-0706-02,NDC,outpatient,1,UN,186.61,130.627,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,31.57,416.02,other,SI=N Exclusions ,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-02,NDC,outpatient,2,ML,7.42,5.194,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.84,416.02,other,SI=N Exclusions ,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-13,NDC,outpatient,5,ML,9.41,6.587,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.84,416.02,other,SI=N Exclusions ,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00641-6027-25,NDC,outpatient,2,ML,6.08,4.256,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.84,416.02,other,SI=N Exclusions ,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-12,NDC,outpatient,2,ML,7.31,5.117,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.84,416.02,other,SI=N Exclusions ,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-22,NDC,outpatient,2,ML,7.31,5.117,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.84,416.02,other,SI=N Exclusions ,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-41,NDC,outpatient,50,ML,40.05,28.035,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.84,416.02,other,SI=N Exclusions ,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00641-6027-01,NDC,outpatient,2,ML,6.08,4.256,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.84,416.02,other,SI=N Exclusions ,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-12,NDC,outpatient,2,ML,7.42,5.194,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.84,416.02,other,SI=N Exclusions ,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-61,NDC,outpatient,50,ML,40.05,28.035,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.84,416.02,other,SI=N Exclusions ,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-05,NDC,outpatient,5,ML,9.41,6.587,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.84,416.02,other,SI=N Exclusions ,,
TENECTEPLASE 50 MG IV KIT,RX-28530,CDM,J3101,HCPCS,636,RC,50242-0120-47,NDC,outpatient,1,UN,19380.84,13566.588,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,157.47,,,7655,152.7,14884.48512,fee schedule,,,
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,00143-9746-10,NDC,outpatient,1,ML,6.05,4.235,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.358225,416.02,other,SI=N Exclusions ,,
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,00143-9746-01,NDC,outpatient,1,ML,6.05,4.235,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.358225,416.02,other,SI=N Exclusions ,,
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,63323-0665-00,NDC,outpatient,1,ML,6.42,4.494,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.358225,416.02,other,SI=N Exclusions ,,
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,63323-0665-01,NDC,outpatient,1,ML,6.42,4.494,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.358225,416.02,other,SI=N Exclusions ,,
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,00641-1398-35,NDC,outpatient,2,ML,108.05,75.635,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.63291,416.02,other,SI=N Exclusions ,,
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,55150-0318-25,NDC,outpatient,1,ML,65.18,45.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.63291,416.02,other,SI=N Exclusions ,,
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,55150-0318-01,NDC,outpatient,1,ML,65.18,45.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.63291,416.02,other,SI=N Exclusions ,,
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,00641-1398-31,NDC,outpatient,2,ML,108.05,75.635,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.63291,416.02,other,SI=N Exclusions ,,
THYROTROPIN ALFA 0.9 MG IM SOLR,RX-156409,CDM,J3240,HCPCS,636,RC,58468-0030-02,NDC,outpatient,1,UN,5457.19,3820.033,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2065.84,,,2011.27,399.86,4191.12192,fee schedule,,,
TIGECYCLINE 50 MG IV SOLR,RX-41652,CDM,J3243,HCPCS,636,RC,55150-0228-10,NDC,outpatient,1,UN,119.66,83.762,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.58,,,31,0.52,416.02,fee schedule,,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-02,NDC,outpatient,250,ML,723.13,506.191,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,3.96,,,201,3.83,567.65184,fee schedule,,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0429-01,NDC,outpatient,100,ML,219.39,153.573,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,3.96,,,80.4,3.83,567.65184,fee schedule,,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-01,NDC,outpatient,100,ML,285.69,199.983,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,3.96,,,80.4,3.83,567.65184,fee schedule,,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-03,NDC,outpatient,100,ML,198.47,138.929,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,3.96,,,80.4,3.83,567.65184,fee schedule,,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-01,NDC,outpatient,100,ML,301.69,211.183,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.96,,,80.4,3.83,567.65184,fee schedule,,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-02,NDC,outpatient,250,ML,739.13,517.391,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.96,,,201,3.83,567.65184,fee schedule,,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-03,NDC,outpatient,100,ML,214.47,150.129,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.96,,,80.4,3.83,567.65184,fee schedule,,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0430-01,NDC,outpatient,250,ML,513.98,359.786,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,3.96,,,201,3.83,567.65184,fee schedule,,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0429-01,NDC,outpatient,100,ML,235.39,164.773,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.96,,,80.4,3.83,567.65184,fee schedule,,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0430-01,NDC,outpatient,250,ML,529.98,370.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.96,,,201,3.83,567.65184,fee schedule,,,
TRIMETHOBENZAMIDE HCL 100 MG/ML IM SOLN,RX-8178,CDM,J3250,HCPCS,636,RC,42023-0119-25,NDC,outpatient,2,ML,199.22,139.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,44.72489,416.02,other,SI=N Exclusions ,,
TOBRAMYCIN SULFATE 1.2 G IJ SOLR,RX-11565,CDM,J3260,HCPCS,636,RC,39822-0412-01,NDC,outpatient,1,UN,217.92,152.544,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.882285,416.02,other,SI=N Exclusions ,,
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,00409-3578-01,NDC,outpatient,2,ML,13.74,9.618,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.882285,416.02,other,SI=N Exclusions ,,
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,67457-0473-00,NDC,outpatient,2,ML,3.93,2.751,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.882285,416.02,other,SI=N Exclusions ,,
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,63323-0306-02,NDC,outpatient,2,ML,16.01,11.207,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.882285,416.02,other,SI=N Exclusions ,,
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,00409-3578-11,NDC,outpatient,2,ML,13.74,9.618,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.882285,416.02,other,SI=N Exclusions ,,
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,67457-0473-22,NDC,outpatient,2,ML,3.93,2.751,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.882285,416.02,other,SI=N Exclusions ,,
TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN,RX-97790,CDM,J3260,HCPCS,636,RC,67457-0428-30,NDC,outpatient,30,ML,45.26,31.682,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.882285,416.02,other,SI=N Exclusions ,,
TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN,RX-97790,CDM,J3260,HCPCS,636,RC,63323-0306-30,NDC,outpatient,30,ML,60.48,42.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.882285,416.02,other,SI=N Exclusions ,,
TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN,RX-97790,CDM,J3260,HCPCS,636,RC,67457-0428-00,NDC,outpatient,30,ML,45.26,31.682,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.882285,416.02,other,SI=N Exclusions ,,
TOCILIZUMAB 20 MG/ML IV WRAPPER,RX-4080174,CDM,J3262,HCPCS,636,RC,50242-0137-01,NDC,outpatient,20,ML,7110.21,4977.147,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5.95,,,2476,5.91,5460.64128,fee schedule,,,
TOCILIZUMAB 20 MG/ML IV WRAPPER,RX-4080174,CDM,J3262,HCPCS,636,RC,50242-0135-01,NDC,outpatient,4,ML,1422.05,995.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5.95,,,495.2,5.91,5460.64128,fee schedule,,,
TOCILIZUMAB 20 MG/ML IV WRAPPER,RX-4080174,CDM,J3262,HCPCS,636,RC,50242-0136-01,NDC,outpatient,10,ML,3555.08,2488.556,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5.95,,,1238,5.91,5460.64128,fee schedule,,,
TRIAMCINOLONE ACETONIDE 10 MG/ML IJ SUSP,RX-11584,CDM,J3301,HCPCS,636,RC,00003-0494-20,NDC,outpatient,5,ML,49.71,34.797,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.9,416.02,other,SI=N Exclusions ,,
TRIAMCINOLONE ACETONIDE 40 MG/ML IJ SUSP,RX-8120,CDM,J3301,HCPCS,636,RC,00003-0293-05,NDC,outpatient,1,ML,38.5,26.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.9,416.02,other,SI=N Exclusions ,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,76045-0204-00,NDC,outpatient,2,ML,59.63,41.741,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.25,416.02,other,SI=N Exclusions ,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00409-1273-03,NDC,outpatient,2,ML,106.04,74.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.25,416.02,other,SI=N Exclusions ,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,69339-0136-03,NDC,outpatient,2,ML,63.74,44.618,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.25,416.02,other,SI=N Exclusions ,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,69339-0136-34,NDC,outpatient,2,ML,63.74,44.618,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.25,416.02,other,SI=N Exclusions ,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00409-1273-32,NDC,outpatient,2,ML,106.04,74.228,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.25,416.02,other,SI=N Exclusions ,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00641-6244-01,NDC,outpatient,2,ML,60.45,42.315,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.25,416.02,other,SI=N Exclusions ,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00641-6244-10,NDC,outpatient,2,ML,60.45,42.315,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.25,416.02,other,SI=N Exclusions ,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,76045-0204-20,NDC,outpatient,2,ML,59.63,41.741,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.25,416.02,other,SI=N Exclusions ,,
VANCOMYCIN HCL IN DEXTROSE 750 MG/150ML IV SOLN,RX-108740,CDM,J3370,HCPCS,636,RC,00338-3580-48,NDC,outpatient,150,ML,49.93,34.951,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VANCOMYCIN HCL IN DEXTROSE 750 MG/150ML IV SOLN,RX-108740,CDM,J3370,HCPCS,636,RC,99999-0000-88,NDC,outpatient,150,ML,35.17,24.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,63323-0314-61,NDC,outpatient,10,GR,107.34,75.138,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,25021-0158-99,NDC,outpatient,10,GR,205.59,143.913,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,70594-0048-01,NDC,outpatient,10,GR,267,186.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,67457-0342-10,NDC,outpatient,10,GR,875.85,613.095,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VANCOMYCIN HCL IN DEXTROSE 500 MG/100ML IV SOLN,RX-11632,CDM,J3370,HCPCS,636,RC,00338-3551-48,NDC,outpatient,100,ML,52.94,37.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VANCOMYCIN HCL IN NACL 750-0.9 MG/150ML-% IV SOLN,RX-134904,CDM,J3370,HCPCS,636,RC,00338-3582-01,NDC,outpatient,150,ML,73.41,51.387,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,00143-9357-10,NDC,outpatient,1,UN,12.35,8.645,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,00143-9357-01,NDC,outpatient,1,UN,12.35,8.645,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,67457-0340-01,NDC,outpatient,1,UN,16.63,11.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,16714-0309-01,NDC,outpatient,1,UN,11.19,7.833,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,16714-0309-10,NDC,outpatient,1,UN,11.19,7.833,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,67457-0340-00,NDC,outpatient,1,UN,16.63,11.641,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VANCOMYCIN HCL 5 G IV SOLR,RX-144290,CDM,J3370,HCPCS,636,RC,00409-6509-01,NDC,outpatient,5,GR,364.64,255.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VANCOMYCIN HCL 5 G IV SOLR,RX-144290,CDM,J3370,HCPCS,636,RC,25021-0157-99,NDC,outpatient,5,GR,81.22,56.854,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VANCOMYCIN HCL 5 G IV SOLR,RX-144290,CDM,J3370,HCPCS,636,RC,67457-0341-05,NDC,outpatient,5,GR,361.57,253.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VANCOMYCIN HCL 1.5 G IV SOLR,RX-145320,CDM,J3370,HCPCS,636,RC,00409-3515-11,NDC,outpatient,1,UN,51.81,36.267,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VANCOMYCIN HCL 1.5 G IV SOLR,RX-145320,CDM,J3370,HCPCS,636,RC,00409-3515-01,NDC,outpatient,1,UN,51.81,36.267,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VANCOMYCIN HCL 500 MG IV SOLR,RX-8443,CDM,J3370,HCPCS,636,RC,72611-0761-01,NDC,outpatient,1,UN,15.42,10.794,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VANCOMYCIN HCL 500 MG IV SOLR,RX-8443,CDM,J3370,HCPCS,636,RC,72611-0761-10,NDC,outpatient,1,UN,15.42,10.794,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VANCOMYCIN HCL IN DEXTROSE 1 GM/200ML IV SOLN,RX-92895,CDM,J3370,HCPCS,636,RC,00338-3552-48,NDC,outpatient,200,ML,52.27,36.589,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.16,672.6528,other,SI=N Exclusions ,,
VEDOLIZUMAB 300 MG IV SOLR,RX-125757,CDM,J3380,HCPCS,636,RC,64764-0300-20,NDC,outpatient,1,UN,23919.77,16743.839,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,22.88,,,6690,22.26,18370.38336,fee schedule,,,
HYDROXYZINE HCL 50 MG/ML IM SOLN,RX-3770,CDM,J3410,HCPCS,636,RC,00517-5601-25,NDC,outpatient,1,ML,82.29,57.603,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.41,416.02,other,SI=N Exclusions ,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,25021-0500-02,NDC,outpatient,0.5,ML,4.68,3.276,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.88453,416.02,other,SI=N Exclusions ,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,55150-0273-01,NDC,outpatient,0.5,ML,4.61,3.227,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.88453,416.02,other,SI=N Exclusions ,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,67457-0196-02,NDC,outpatient,0.5,ML,3.94,2.758,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.88453,416.02,other,SI=N Exclusions ,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,00641-6228-25,NDC,outpatient,0.5,ML,4.75,3.325,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.88453,416.02,other,SI=N Exclusions ,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,67457-0196-00,NDC,outpatient,0.5,ML,3.94,2.758,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.88453,416.02,other,SI=N Exclusions ,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,55150-0273-25,NDC,outpatient,0.5,ML,4.61,3.227,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.88453,416.02,other,SI=N Exclusions ,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,00641-6228-01,NDC,outpatient,0.5,ML,4.75,3.325,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.88453,416.02,other,SI=N Exclusions ,,
PYRIDOXINE HCL 100 MG/ML IJ SOLN,RX-6744,CDM,J3415,HCPCS,636,RC,63323-0180-00,NDC,outpatient,0.5,ML,20.17,14.119,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.528165,416.02,other,SI=N Exclusions ,,
PYRIDOXINE HCL 100 MG/ML IJ SOLN,RX-6744,CDM,J3415,HCPCS,636,RC,63323-0180-01,NDC,outpatient,0.5,ML,20.17,14.119,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.528165,416.02,other,SI=N Exclusions ,,
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,63323-0044-00,NDC,outpatient,1,ML,6.18,4.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.15,416.02,other,SI=N Exclusions ,,
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,63323-0044-01,NDC,outpatient,1,ML,6.18,4.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.15,416.02,other,SI=N Exclusions ,,
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,00143-9621-01,NDC,outpatient,1,ML,10.83,7.581,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.15,416.02,other,SI=N Exclusions ,,
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,00143-9621-25,NDC,outpatient,1,ML,10.83,7.581,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.15,416.02,other,SI=N Exclusions ,,
HYDROXOCOBALAMIN 5 G IV SOLR,RX-111437,CDM,J3424,HCPCS,250,RC,50633-0310-11,NDC,outpatient,1,UN,2471.2,1729.84,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5.29,39.5,,976.12,5.69,1897.8816,percent of total billed charges,,,
PHYTONADIONE 1 MG/0.5ML IJ SOLN WRAPPER,RX-4080206,CDM,J3430,HCPCS,636,RC,76329-1240-01,NDC,outpatient,0.5,ML,98.15,68.705,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.51,416.02,other,SI=N Exclusions ,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,69097-0708-31,NDC,outpatient,1,ML,82.7,57.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.51,416.02,other,SI=N Exclusions ,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,00409-9158-01,NDC,outpatient,1,ML,85.53,59.871,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.51,416.02,other,SI=N Exclusions ,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,43598-0405-11,NDC,outpatient,1,ML,78.97,55.279,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.51,416.02,other,SI=N Exclusions ,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,69097-0708-96,NDC,outpatient,1,ML,82.7,57.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.51,416.02,other,SI=N Exclusions ,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,00409-9158-50,NDC,outpatient,1,ML,85.53,59.871,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.51,416.02,other,SI=N Exclusions ,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,43598-0405-16,NDC,outpatient,1,ML,78.97,55.279,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.51,416.02,other,SI=N Exclusions ,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,00409-9158-31,NDC,outpatient,1,ML,85.53,59.871,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.51,416.02,other,SI=N Exclusions ,,
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,00781-3416-94,NDC,outpatient,1,UN,325.92,228.144,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions ,,
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,70436-0029-80,NDC,outpatient,1,UN,78.41,54.887,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions ,,
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,00049-3190-28,NDC,outpatient,1,UN,59.15,41.405,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions ,,
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,39822-1077-01,NDC,outpatient,1,UN,89.45,62.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.78,416.02,other,SI=N Exclusions ,,
HYALURONIDASE HUMAN 15 UNIT/ML INJECTION SYRINGE,RX-4081350,CDM,J3473,HCPCS,636,RC,99999-0004-00,NDC,outpatient,1,ML,164.85,115.395,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.36,416.02,other,SI=N Exclusions ,,
HYALURONIDASE HUMAN 150 UNIT/ML IJ SOLN,RX-76338,CDM,J3473,HCPCS,636,RC,18657-0117-01,NDC,outpatient,1,ML,164.85,115.395,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.36,416.02,other,SI=N Exclusions ,,
HYALURONIDASE HUMAN 150 UNIT/ML IJ SOLN,RX-76338,CDM,J3473,HCPCS,636,RC,18657-0117-04,NDC,outpatient,1,ML,164.85,115.395,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.36,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00338-1709-40,NDC,outpatient,100,ML,22.17,15.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00409-6727-11,NDC,outpatient,100,ML,46.71,32.697,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,63323-0108-01,NDC,outpatient,100,ML,26.28,18.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00264-4400-54,NDC,outpatient,100,ML,30.4,21.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,63323-0108-00,NDC,outpatient,100,ML,26.28,18.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,67457-0567-00,NDC,outpatient,100,ML,30.4,21.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00409-6727-23,NDC,outpatient,100,ML,46.71,32.697,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,44567-0420-00,NDC,outpatient,50,ML,43.82,30.674,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,47335-0992-01,NDC,outpatient,50,ML,28.85,20.195,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,25021-0612-81,NDC,outpatient,50,ML,24.74,17.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,63323-0106-02,NDC,outpatient,50,ML,32.45,22.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,63323-0106-05,NDC,outpatient,50,ML,32.45,22.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,67457-0553-00,NDC,outpatient,50,ML,33.74,23.618,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,00338-1708-40,NDC,outpatient,50,ML,28.6,20.02,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,00409-6729-11,NDC,outpatient,50,ML,36.31,25.417,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,44567-0420-24,NDC,outpatient,50,ML,43.82,30.674,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,00409-6729-24,NDC,outpatient,50,ML,36.31,25.417,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 40 MG/ML SOLN WRAPPER,RX-4080721,CDM,J3475,HCPCS,636,RC,00409-2050-20,NDC,outpatient,500,ML,38.25,26.775,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 40 MG/ML SOLN WRAPPER,RX-4080721,CDM,J3475,HCPCS,636,RC,63323-0106-15,NDC,outpatient,500,ML,33.99,23.793,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 40 MG/ML SOLN WRAPPER,RX-4080721,CDM,J3475,HCPCS,636,RC,00409-2050-01,NDC,outpatient,500,ML,38.25,26.775,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-04,NDC,outpatient,10,ML,6.53,4.571,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,99999-0002-95,NDC,outpatient,2,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-03,NDC,outpatient,2,ML,5.46,3.822,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-11,NDC,outpatient,10,ML,6.53,4.571,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0642-02,NDC,outpatient,50,ML,55.41,38.787,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0642-50,NDC,outpatient,2,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions ,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-01,NDC,outpatient,2,ML,5.46,3.822,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.47,416.02,other,SI=N Exclusions ,,
POTASSIUM CHLORIDE 10 MEQ/100ML IV SOLN,RX-11074,CDM,J3480,HCPCS,636,RC,00338-0709-48,NDC,outpatient,100,ML,26.8,18.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions ,,
POTASSIUM CHLORIDE 10 MEQ/100ML IV SOLN,RX-11074,CDM,J3480,HCPCS,636,RC,00990-7074-26,NDC,outpatient,100,ML,36.92,25.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions ,,
POTASSIUM CHLORIDE 20 MEQ/100ML IV SOLN,RX-11076,CDM,J3480,HCPCS,636,RC,00338-0705-48,NDC,outpatient,100,ML,26.8,18.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions ,,
POTASSIUM CHLORIDE 20 MEQ/100ML IV SOLN,RX-11076,CDM,J3480,HCPCS,636,RC,00990-7075-26,NDC,outpatient,100,ML,37.81,26.467,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions ,,
POTASSIUM CHLORIDE 20 MEQ/50ML IV SOLN,RX-11077,CDM,J3480,HCPCS,636,RC,00338-0703-41,NDC,outpatient,50,ML,26.28,18.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions ,,
POTASSIUM CHLORIDE 20 MEQ/50ML IV SOLN,RX-11077,CDM,J3480,HCPCS,636,RC,00990-7077-14,NDC,outpatient,50,ML,37.59,26.313,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions ,,
POTASSIUM CHLORIDE IN NACL 20-0.9 MEQ/L-% IV SOLN,RX-11081,CDM,J3480,HCPCS,636,RC,00338-0691-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions ,,
POTASSIUM CHLORIDE IN NACL 40-0.9 MEQ/L-% IV SOLN,RX-11082,CDM,J3480,HCPCS,636,RC,00338-0695-04,NDC,outpatient,1000,ML,31.42,21.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions ,,
KCL IN NACL 0.9% 10 MEQ/100ML IV SOLN,RX-166975,CDM,J3480,HCPCS,636,RC,99999-0001-77,NDC,outpatient,100,ML,26.28,18.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions ,,
POTASSIUM CHLORIDE IN NACL 20-0.45 MEQ/L-% IV SOLN,RX-36046,CDM,J3480,HCPCS,636,RC,00338-0704-34,NDC,outpatient,1000,ML,26.28,18.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions ,,
POTASSIUM CHLORIDE IN NACL 20 MEQ/50ML IV SOLN,RX-4081006,CDM,J3480,HCPCS,636,RC,99999-0001-79,NDC,outpatient,50,ML,31.17,21.819,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions ,,
POTASSIUM CHLORIDE IN NACL 20 MEQ/100ML IV SOLN,RX-4081007,CDM,J3480,HCPCS,636,RC,99999-0001-78,NDC,outpatient,100,ML,30.91,21.637,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions ,,
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN,RX-6429,CDM,J3480,HCPCS,636,RC,63323-0965-02,NDC,outpatient,20,ML,6.48,4.536,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions ,,
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN,RX-6429,CDM,J3480,HCPCS,636,RC,63323-0965-20,NDC,outpatient,20,ML,6.48,4.536,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions ,,
POTASSIUM CL IN DEXTROSE 5% 20 MEQ/L IV SOLN,RX-9791,CDM,J3480,HCPCS,636,RC,00338-0683-04,NDC,outpatient,1000,ML,31.42,21.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions ,,
KCL IN DEXTROSE-NACL 20-5-0.9 MEQ/L-%-% IV SOLN,RX-9795,CDM,J3480,HCPCS,636,RC,00338-0803-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions ,,
KCL IN DEXTROSE-NACL 20-5-0.9 MEQ/L-%-% IV SOLN,RX-9795,CDM,J3480,HCPCS,636,RC,00264-7652-00,NDC,outpatient,1000,ML,38.25,26.775,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions ,,
KCL IN DEXTROSE-NACL 10-5-0.45 MEQ/L-%-% IV SOLN,RX-9799,CDM,J3480,HCPCS,636,RC,00338-0669-04,NDC,outpatient,1000,ML,31.42,21.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions ,,
KCL IN DEXTROSE-NACL 10-5-0.45 MEQ/L-%-% IV SOLN,RX-9799,CDM,J3480,HCPCS,636,RC,00990-7993-09,NDC,outpatient,1000,ML,47.15,33.005,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions ,,
KCL IN DEXTROSE-NACL 20-5-0.2 MEQ/L-%-% IV SOLN,RX-9800,CDM,J3480,HCPCS,636,RC,00264-7645-00,NDC,outpatient,1000,ML,47.15,33.005,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions ,,
KCL IN DEXTROSE-NACL 20-5-0.2 MEQ/L-%-% IV SOLN,RX-9800,CDM,J3480,HCPCS,636,RC,00338-0663-04,NDC,outpatient,1000,ML,31.42,21.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions ,,
KCL IN DEXTROSE-NACL 20-5-0.45 MEQ/L-%-% IV SOLN,RX-9801,CDM,J3480,HCPCS,636,RC,00338-0671-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions ,,
KCL IN DEXTROSE-NACL 40-5-0.45 MEQ/L-%-% IV SOLN,RX-9807,CDM,J3480,HCPCS,636,RC,00338-0675-04,NDC,outpatient,1000,ML,31.42,21.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions ,,
ZIDOVUDINE 10 MG/ML IV SOLN,RX-11691,CDM,J3485,HCPCS,636,RC,49702-0213-01,NDC,outpatient,20,ML,126.03,88.221,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.51,416.02,other,SI=N Exclusions ,,
ZIDOVUDINE 10 MG/ML IV SOLN,RX-11691,CDM,J3485,HCPCS,636,RC,49702-0213-26,NDC,outpatient,20,ML,126.03,88.221,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.51,416.02,other,SI=N Exclusions ,,
ZIPRASIDONE MESYLATE 20 MG IM SOLR,RX-33175,CDM,J3486,HCPCS,636,RC,00049-3920-20,NDC,outpatient,1,UN,264.92,185.444,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7.43,416.02,other,SI=N Exclusions ,,
ZIPRASIDONE MESYLATE 20 MG IM SOLR,RX-33175,CDM,J3486,HCPCS,636,RC,00049-3920-83,NDC,outpatient,1,UN,264.92,185.444,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7.43,416.02,other,SI=N Exclusions ,,
ZOLEDRONIC ACID 4 MG/5ML IV CONC,RX-35640,CDM,J3489,HCPCS,636,RC,67457-0390-54,NDC,outpatient,5,ML,30.53,21.371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5.73,,,27.72,6.47,416.02,fee schedule,,,
ZOLEDRONIC ACID 5 MG/100ML IV SOLN,RX-81434,CDM,J3489,HCPCS,636,RC,67457-0619-10,NDC,outpatient,100,ML,182.43,127.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5.73,,,34.65,6.47,416.02,fee schedule,,,
ZOLEDRONIC ACID 5 MG/100ML IV SOLN,RX-81434,CDM,J3489,HCPCS,636,RC,55111-0688-52,NDC,outpatient,100,ML,126.81,88.767,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5.73,,,34.65,6.47,416.02,fee schedule,,,
IDARUCIZUMAB 2.5 GM/50ML IV SOLN,RX-132721,CDM,J3590,HCPCS,636,RC,00597-0197-05,NDC,outpatient,100,ML,13473.22,9431.254,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,10347.43296,other,SI=N Exclusions ,,
SODIUM CHLORIDE 0.45 % IV SOLN,RX-7318,CDM,J7030,HCPCS,250,RC,00338-0043-03,NDC,outpatient,500,ML,23.71,16.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.54,416.02,other,SI=N Exclusions ,,
SODIUM CHLORIDE 0.45 % IV SOLN,RX-7318,CDM,J7030,HCPCS,250,RC,00338-0043-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.54,416.02,other,SI=N Exclusions ,,
DEXTROSE-SODIUM CHLORIDE 5-0.9 % IV SOLN,RX-9815,CDM,J7042,HCPCS,636,RC,00338-0089-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.14,416.02,other,SI=N Exclusions ,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-02,NDC,outpatient,250,ML,22.43,15.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.81,416.02,other,SI=N Exclusions ,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-31,NDC,outpatient,50,ML,22.43,15.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.81,416.02,other,SI=N Exclusions ,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-41,NDC,outpatient,50,ML,22.94,16.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.81,416.02,other,SI=N Exclusions ,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,63323-0624-04,NDC,outpatient,250,ML,25,17.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.81,416.02,other,SI=N Exclusions ,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-11,NDC,outpatient,50,ML,22.43,15.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.81,416.02,other,SI=N Exclusions ,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-48,NDC,outpatient,100,ML,22.69,15.883,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.81,416.02,other,SI=N Exclusions ,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,63323-0624-74,NDC,outpatient,250,ML,25,17.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.81,416.02,other,SI=N Exclusions ,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-03,NDC,outpatient,500,ML,23.71,16.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.81,416.02,other,SI=N Exclusions ,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-38,NDC,outpatient,100,ML,22.17,15.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.81,416.02,other,SI=N Exclusions ,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00409-7100-02,NDC,outpatient,250,ML,30.14,21.098,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.81,416.02,other,SI=N Exclusions ,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00409-7100-04,NDC,outpatient,250,ML,30.14,21.098,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.81,416.02,other,SI=N Exclusions ,,
DEXTROSE 5 % IV PVC FREE SOLN,RX-4080550,CDM,J7060,HCPCS,636,RC,00338-6346-03,NDC,outpatient,500,ML,42.7,29.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.81,416.02,other,SI=N Exclusions ,,
DEXTROSE 5 % IV PVC FREE SOLN,RX-4080550,CDM,J7060,HCPCS,636,RC,00264-7510-10,NDC,outpatient,500,ML,33.99,23.793,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.81,416.02,other,SI=N Exclusions ,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7070,HCPCS,636,RC,00338-0017-04,NDC,outpatient,1000,ML,21.14,14.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.62,416.02,other,SI=N Exclusions ,,
DEXTRAN 40 IN D5W 10 % IV SOLN,RX-9759,CDM,J7100,HCPCS,636,RC,00409-7418-03,NDC,outpatient,500,ML,116.13,81.291,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.23,416.02,other,SI=N Exclusions ,,
DEXTRAN 40 IN D5W 10 % IV SOLN,RX-9759,CDM,J7100,HCPCS,636,RC,00409-7418-13,NDC,outpatient,500,ML,116.13,81.291,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,19.23,416.02,other,SI=N Exclusions ,,
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00264-7750-20,NDC,outpatient,250,ML,33.8,23.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.39,416.02,other,SI=N Exclusions ,,
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00338-0117-02,NDC,outpatient,250,ML,22.43,15.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.39,416.02,other,SI=N Exclusions ,,
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00338-0117-03,NDC,outpatient,500,ML,23.71,16.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.39,416.02,other,SI=N Exclusions ,,
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00338-0117-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.39,416.02,other,SI=N Exclusions ,,
DEXTROSE IN LACTATED RINGERS 5 % IV SOLN,RX-9788,CDM,J7121,HCPCS,636,RC,00338-0125-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,5.89986,416.02,other,SI=N Exclusions ,,
PROTHROMBIN COMPLEX CONC HUMAN 500 UNITS IV KIT,RX-122122,CDM,J7168,HCPCS,636,RC,63833-0386-02,NDC,outpatient,1,UN,3022.2,2115.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.16,,,1580,2.568211,4642.0992,fee schedule,,,
PROTHROMBIN COMPLEX CONC HUMAN 1000 UNITS IV KIT,RX-125272,CDM,J7168,HCPCS,636,RC,63833-0387-02,NDC,outpatient,1,UN,6044.4,4231.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.16,,,3160,2.568211,4642.0992,fee schedule,,,
ANTIHEMOPHILIC FACTOR-VWF 500-500 UNITS IV KIT,RX-134441,CDM,J7183,HCPCS,636,RC,68982-0182-01,NDC,outpatient,1,UN,1449,1014.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.27,,,650,1.26,2225.664,fee schedule,,,
ANTIHEMOPHILIC FACTOR-VWF 1000-1000 UNITS IV KIT,RX-134442,CDM,J7183,HCPCS,636,RC,68982-0182-02,NDC,outpatient,1,UN,2898,2028.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.27,,,1300,1.26,2225.664,fee schedule,,,
ANTIHEMOPHILIC FACTOR-VWF 250-600 UNITS IV SOLR,RX-70404,CDM,J7187,HCPCS,636,RC,63833-0625-01,NDC,outpatient,1,UN,1821.6,1275.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.4,,,810,1.23,3240,fee schedule,,,
ANTIHEMOPHILIC FACTOR-VWF 250-600 UNITS IV SOLR,RX-70404,CDM,J7187,HCPCS,636,RC,63833-0615-02,NDC,outpatient,1,UN,1821.6,1275.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.4,,,810,1.23,3240,fee schedule,,,
ANTIHEMOPHILIC FACTOR-VWF 500-1200 UNITS IV SOLR,RX-70405,CDM,J7187,HCPCS,636,RC,63833-0616-02,NDC,outpatient,1,UN,3643.2,2550.24,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.4,,,1620,1.23,3240,fee schedule,,,
ANTIHEMOPHILIC FACTOR-VWF 500-1200 UNITS IV SOLR,RX-70405,CDM,J7187,HCPCS,636,RC,63833-0626-01,NDC,outpatient,1,UN,3643.2,2550.24,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.4,,,1620,1.23,3240,fee schedule,,,
ANTIHEMOPHILIC FACTOR-VWF 1000-2400 UNITS IV SOLR,RX-70406,CDM,J7187,HCPCS,636,RC,63833-0617-02,NDC,outpatient,1,UN,3036,2125.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.4,,,3240,1.23,3240,fee schedule,,,
ANTIHEMOPHILIC FACTOR-VWF 1000-2400 UNITS IV SOLR,RX-70406,CDM,J7187,HCPCS,636,RC,63833-0627-01,NDC,outpatient,1,UN,3036,2125.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.4,,,3240,1.23,3240,fee schedule,,,
COAGULATION FACTOR VIIA RECOMB 1 MG IV SOLR,RX-92853,CDM,J7189,HCPCS,636,RC,00169-7211-11,NDC,outpatient,1,UN,6342.76,4439.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.54,,,2410,2.13,24356.18304,fee schedule,,,
COAGULATION FACTOR VIIA RECOMB 1 MG IV SOLR,RX-92853,CDM,J7189,HCPCS,636,RC,00169-7201-01,NDC,outpatient,1,UN,6342.76,4439.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.54,,,2410,2.13,24356.18304,fee schedule,,,
COAGULATION FACTOR VIIA RECOMB 2 MG IV SOLR,RX-92854,CDM,J7189,HCPCS,636,RC,00169-7202-01,NDC,outpatient,1,UN,12685.52,8879.864,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.54,,,4820,2.13,24356.18304,fee schedule,,,
COAGULATION FACTOR VIIA RECOMB 2 MG IV SOLR,RX-92854,CDM,J7189,HCPCS,636,RC,00169-7212-11,NDC,outpatient,1,UN,12685.52,8879.864,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.54,,,4820,2.13,24356.18304,fee schedule,,,
COAGULATION FACTOR VIIA RECOMB 5 MG IV SOLR,RX-92855,CDM,J7189,HCPCS,636,RC,00169-7205-01,NDC,outpatient,1,UN,31713.78,22199.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.54,,,12050,2.13,24356.18304,fee schedule,,,
ANTIHEMOPHILIC FACTOR VIII RAHF-PFM 500 UNITS IV SOLR,RX-76366,CDM,J7192,HCPCS,636,RC,00944-3052-02,NDC,outpatient,1,UN,1863,1304.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.55,,,750,1.25,2861.568,fee schedule,,,
ANTIHEMOPHILIC FACTOR VIII RAHF-PFM 1000 UNITS IV SOLR,RX-76367,CDM,J7192,HCPCS,636,RC,00944-3053-02,NDC,outpatient,1,UN,3726,2608.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.55,,,1500,1.25,2861.568,fee schedule,,,
ANTITHROMBIN III (HUMAN) 500 UNITS IV SOLR,RX-9116,CDM,J7197,HCPCS,636,RC,13533-0606-12,NDC,outpatient,1,UN,4954.2,3467.94,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.89,,,1855,3.35,3804.8256,fee schedule,,,
ANTITHROMBIN III (HUMAN) 500 UNITS IV SOLR,RX-9116,CDM,J7197,HCPCS,636,RC,13533-0602-50,NDC,outpatient,1,UN,4954.2,3467.94,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.89,,,1855,3.35,3804.8256,fee schedule,,,
ANTIINHIBITOR COAGULANT CMPLX 2500 UNITS IV SOLR,RX-146201,CDM,J7198,HCPCS,636,RC,64193-0425-02,NDC,outpatient,1,UN,13869,9708.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.36,,,5750,1.94,10651.392,fee schedule,,,
SODIUM HYALURONATE (VISCOSUP) 25 MG/2.5ML IX SOSY,RX-127543,CDM,J7321,HCPCS,636,RC,89130-4444-01,NDC,outpatient,2.5,ML,1023.91,716.737,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,73.22,786.36288,other,SI=N Exclusions ,,
AZATHIOPRINE 50 MG ORAL TABS,RX-9183,CDM,J7500,HCPCS,259,RC,68084-0229-01,NDC,outpatient,1,UN,2.39,1.673,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.536555,416.02,other,SI=N Exclusions ,,
AZATHIOPRINE 50 MG ORAL TABS,RX-9183,CDM,J7500,HCPCS,259,RC,68084-0229-11,NDC,outpatient,1,UN,2.39,1.673,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.536555,416.02,other,SI=N Exclusions ,,
CYCLOSPORINE 50 MG/ML IV SOLN,RX-9705,CDM,J7516,HCPCS,636,RC,00574-0866-10,NDC,outpatient,5,ML,142.85,99.995,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,15.32,416.02,other,SI=N Exclusions ,,
MYCOPHENOLATE MOFETIL HCL 500 MG IV SOLR,RX-23968,CDM,J7519,HCPCS,636,RC,71288-0803-20,NDC,outpatient,1,UN,89.27,62.489,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.54,,,77,0.52,416.02,fee schedule,,,
MYCOPHENOLATE MOFETIL HCL 500 MG IV SOLR,RX-23968,CDM,J7519,HCPCS,636,RC,00004-0298-09,NDC,outpatient,1,UN,298.3,208.81,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.54,,,77,0.52,416.02,fee schedule,,,
METHACHOLINE CHLORIDE 100 MG IN SOLR,RX-27032,CDM,J7674,HCPCS,636,RC,64281-0100-06,NDC,outpatient,1,UN,341.28,238.896,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.86,416.02,other,Non-Reimbursable List,,
METHACHOLINE CHLORIDE 100 MG IN SOLR,RX-27032,CDM,J7674,HCPCS,636,RC,64281-0100-00,NDC,outpatient,1,UN,341.28,238.896,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.86,416.02,other,Non-Reimbursable List,,
ETOPOSIDE 50 MG ORAL CAPS,RX-10001,CDM,J8560,HCPCS,636,RC,00378-3266-32,NDC,outpatient,1,UN,309.74,216.818,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,75.76,,,76.53,69.53663,416.02,fee schedule,,,
ETOPOSIDE 50 MG ORAL CAPS,RX-10001,CDM,J8560,HCPCS,636,RC,00378-3266-94,NDC,outpatient,1,UN,309.74,216.818,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,75.76,,,76.53,69.53663,416.02,fee schedule,,,
MERCAPTOPURINE 50 MG ORAL TABS,RX-10531,CDM,J8999,HCPCS,259,RC,00054-4581-11,NDC,outpatient,1,UN,14.11,9.877,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,5.653877,0.370425,416.02,percent of total billed charges,,,
MERCAPTOPURINE 50 MG ORAL TABS,RX-10531,CDM,J8999,HCPCS,259,RC,00378-3547-52,NDC,outpatient,1,UN,4.39,3.073,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1.759073,0.370425,416.02,percent of total billed charges,,,
BICALUTAMIDE 50 MG ORAL TABS,RX-15746,CDM,J8999,HCPCS,259,RC,16729-0023-10,NDC,outpatient,1,UN,2.86,2.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1.146002,0.370425,416.02,percent of total billed charges,,,
ANASTROZOLE 1 MG ORAL TABS,RX-16205,CDM,J8999,HCPCS,259,RC,60687-0112-11,NDC,outpatient,1,UN,3.22,2.254,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1.290254,0.370425,416.02,percent of total billed charges,,,
ANASTROZOLE 1 MG ORAL TABS,RX-16205,CDM,J8999,HCPCS,259,RC,60687-0112-21,NDC,outpatient,1,UN,3.22,2.254,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1.290254,0.370425,416.02,percent of total billed charges,,,
MEGESTROL ACETATE 40 MG ORAL TABS,RX-4871,CDM,J8999,HCPCS,259,RC,64380-0159-01,NDC,outpatient,1,UN,1.65,1.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,0.661155,0.370425,416.02,percent of total billed charges,,,
MEGESTROL ACETATE 400 MG/10ML ORAL SUSP,RX-76824,CDM,J8999,HCPCS,259,RC,00121-0945-10,NDC,outpatient,10,ML,15.58,10.906,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,6.242906,0.370425,416.02,percent of total billed charges,,,
MEGESTROL ACETATE 400 MG/10ML ORAL SUSP,RX-76824,CDM,J8999,HCPCS,259,RC,99999-0003-95,NDC,outpatient,10,ML,8.73,6.111,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,3.498111,0.370425,416.02,percent of total billed charges,,,
MEGESTROL ACETATE 400 MG/10ML ORAL SUSP,RX-76824,CDM,J8999,HCPCS,259,RC,00121-0945-40,NDC,outpatient,10,ML,15.58,10.906,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,6.242906,0.370425,416.02,percent of total billed charges,,,
TAMOXIFEN CITRATE 10 MG ORAL TABS,RX-7711,CDM,J8999,HCPCS,259,RC,63739-0143-10,NDC,outpatient,1,UN,1.98,1.386,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,0.793386,0.370425,416.02,percent of total billed charges,,,
DOXORUBICIN HCL 2 MG/ML IV PUSH SOLN,RX-2616,CDM,J9000,HCPCS,636,RC,00069-3030-20,NDC,outpatient,5,ML,19.68,13.776,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.5,525.12,other,SI=N Exclusions ,,
DOXORUBICIN HCL 2 MG/ML IV PUSH SOLN,RX-2616,CDM,J9000,HCPCS,636,RC,00069-3031-20,NDC,outpatient,10,ML,34.71,24.297,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.5,525.12,other,SI=N Exclusions ,,
DOXORUBICIN HCL 2 MG/ML IV PUSH SOLN,RX-2616,CDM,J9000,HCPCS,636,RC,00069-3032-20,NDC,outpatient,25,ML,44.02,30.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.5,525.12,other,SI=N Exclusions ,,
DOXORUBICIN HCL 10 MG IV SOLR,RX-2617,CDM,J9000,HCPCS,636,RC,00143-9092-01,NDC,outpatient,1,UN,143.64,100.548,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.5,525.12,other,SI=N Exclusions ,,
DOXORUBICIN HCL 50 MG IV SOLR,RX-2619,CDM,J9000,HCPCS,636,RC,00143-9277-01,NDC,outpatient,1,UN,683.75,478.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.5,525.12,other,SI=N Exclusions ,,
ARSENIC TRIOXIDE 12 MG/6ML IV SOLN,RX-141420,CDM,J9017,HCPCS,636,RC,63459-0601-06,NDC,outpatient,6,ML,3082.97,2158.079,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10.69,,,222,7.2,2367.72096,fee schedule,,,
ARSENIC TRIOXIDE 12 MG/6ML IV SOLN,RX-141420,CDM,J9017,HCPCS,636,RC,63459-0601-11,NDC,outpatient,6,ML,3082.97,2158.079,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10.69,,,222,7.2,2367.72096,fee schedule,,,
AZACITIDINE 100 MG IJ SUSR,RX-78420,CDM,J9025,HCPCS,636,RC,63323-0771-39,NDC,outpatient,1,UN,117.36,82.152,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.44,,,41,0.32,416.02,fee schedule,,,
AZACITIDINE 100 MG IJ SUSR,RX-78420,CDM,J9025,HCPCS,636,RC,43598-0305-62,NDC,outpatient,1,UN,83.86,58.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.44,,,41,0.32,416.02,fee schedule,,,
BENDAMUSTINE HCL 5 MG/ML IV SOLR WRAPPER,RX-4080211,CDM,J9033,HCPCS,636,RC,63459-0390-08,NDC,outpatient,5,ML,889.43,622.601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5.36,,,285.5,5.43,2152.77312,fee schedule,,,
BENDAMUSTINE HCL 5 MG/ML IV SOLR WRAPPER,RX-4080211,CDM,J9033,HCPCS,636,RC,63459-0391-20,NDC,outpatient,20,ML,2803.09,1962.163,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5.36,,,1142,5.43,2152.77312,fee schedule,,,
BENDAMUSTINE HCL 100 MG/4ML IV SOLN,RX-133070,CDM,J9034,HCPCS,636,RC,63459-0348-04,NDC,outpatient,4,ML,5078.48,3554.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13.61,,,1586,12.95,3900.27264,fee schedule,,,
BEVACIZUMAB 25 MG/ML IV WRAPPER,RX-4080193,CDM,J9035,HCPCS,636,RC,50242-0060-01,NDC,outpatient,4,ML,2279.25,1595.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,72.46,,,738.1,72.7,7001.856,fee schedule,,,
BEVACIZUMAB 25 MG/ML IV WRAPPER,RX-4080193,CDM,J9035,HCPCS,636,RC,50242-0061-01,NDC,outpatient,16,ML,9117,6381.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,72.46,,,2952.4,72.7,7001.856,fee schedule,,,
BLEOMYCIN SULFATE 30 UNITS IJ SOLR,RX-17012,CDM,J9040,HCPCS,636,RC,63323-0137-20,NDC,outpatient,1,UN,120.16,84.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.931495,416.02,other,SI=N Exclusions ,,
BLEOMYCIN SULFATE 15 UNITS IJ SOLR *TEST DOSE*,RX-9289,CDM,J9040,HCPCS,636,RC,16714-0886-01,NDC,outpatient,1,UN,66.51,46.557,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,14.931495,416.02,other,SI=N Exclusions ,,
BORTEZOMIB 3.5 MG IJ SOLR,RX-123070,CDM,J9041,HCPCS,636,RC,00143-9098-01,NDC,outpatient,1,UN,58.7,41.09,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.73,,,80.15,1.57,905.322979,fee schedule,,,
BORTEZOMIB 3.5 MG IJ SOLR,RX-123070,CDM,J9041,HCPCS,636,RC,10019-0991-01,NDC,outpatient,1,UN,147.6,103.32,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1.73,,,80.15,1.57,905.322979,fee schedule,,,
BRENTUXIMAB VEDOTIN 50 MG IV SOLR,RX-111348,CDM,J9042,HCPCS,636,RC,51144-0050-01,NDC,outpatient,1,UN,32323.72,22626.604,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,239.6,,,11105.5,221.96,24824.61696,fee schedule,,,
CABAZITAXEL 60 MG/1.5ML IV SOLN,RX-105644,CDM,J9043,HCPCS,636,RC,00024-5824-11,NDC,outpatient,6,ML,39665.77,27766.039,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,215.5,,,12560.4,206.03,30463.31136,fee schedule,,,
CARBOPLATIN 10 MG/ML IV SOLN WRAPPER,RX-4080212,CDM,J9045,HCPCS,636,RC,61703-0339-50,NDC,outpatient,45,ML,157.96,110.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.41,416.02,other,SI=N Exclusions ,,
CARBOPLATIN 10 MG/ML IV SOLN WRAPPER,RX-4080212,CDM,J9045,HCPCS,636,RC,00703-4248-01,NDC,outpatient,45,ML,63.71,44.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.41,416.02,other,SI=N Exclusions ,,
CARFILZOMIB 60 MG IV SOLR,RX-117047,CDM,J9047,HCPCS,636,RC,76075-0101-01,NDC,outpatient,1,UN,8945.66,6261.962,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,49.63,,,2814,47.04,6870.26688,fee schedule,,,
CETUXIMAB 200 MG/100ML IV SOLN,RX-108072,CDM,J9055,HCPCS,636,RC,66733-0958-23,NDC,outpatient,100,ML,4373.8,3061.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,75.63,,,1445.6,72.08,3359.0784,fee schedule,,,
CETUXIMAB 100 MG/50ML IV SOLN,RX-37989,CDM,J9055,HCPCS,636,RC,66733-0948-23,NDC,outpatient,50,ML,2186.9,1530.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,75.63,,,722.8,72.08,3359.0784,fee schedule,,,
CISPLATIN 1 MG/ML IV WRAPPER,RX-4080194,CDM,J9060,HCPCS,636,RC,00703-5748-11,NDC,outpatient,100,ML,67.89,47.523,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.37,416.02,other,SI=N Exclusions ,,
CLADRIBINE 1 MG/ML IV SOLN WRAPPER,RX-4080791,CDM,J9065,HCPCS,636,RC,63323-0140-10,NDC,outpatient,10,ML,347.72,243.404,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13.28,,,167.6,14.25,416.02,fee schedule,,,
CYCLOPHOSPHAMIDE 1 G IJ SOLR,RX-38270,CDM,J9070,HCPCS,636,RC,00781-3244-94,NDC,outpatient,1,UN,1602.63,1121.841,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,49.31,,,179.4,17.09,1230.81984,fee schedule,,,
CYCLOPHOSPHAMIDE 500 MG IJ SOLR,RX-38271,CDM,J9070,HCPCS,636,RC,00781-3233-94,NDC,outpatient,1,UN,1017.09,711.963,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,49.31,,,89.7,17.09,1230.81984,fee schedule,,,
CYCLOPHOSPHAMIDE 2 G IJ SOLR,RX-38280,CDM,J9070,HCPCS,636,RC,10019-0957-01,NDC,outpatient,1,UN,1524.13,1066.891,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,49.31,,,358.8,17.09,1230.81984,fee schedule,,,
CYTARABINE (PF) 100 MG/ML IJ SOLN,RX-20156,CDM,J9100,HCPCS,636,RC,63323-0120-20,NDC,outpatient,20,ML,40.95,28.665,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.77,416.02,other,SI=N Exclusions ,,
CYTARABINE (PF) 100 MG/ML IJ SOLN,RX-20156,CDM,J9100,HCPCS,636,RC,61703-0319-22,NDC,outpatient,20,ML,53.29,37.303,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.77,416.02,other,SI=N Exclusions ,,
CYTARABINE (PF) 20 MG/ML IJ SOLN,RX-96982,CDM,J9100,HCPCS,636,RC,61703-0303-46,NDC,outpatient,50,ML,62.44,43.708,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.77,416.02,other,SI=N Exclusions ,,
CYTARABINE (PF) 20 MG/ML IJ SOLN,RX-96982,CDM,J9100,HCPCS,636,RC,61703-0305-38,NDC,outpatient,5,ML,16.81,11.767,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.77,416.02,other,SI=N Exclusions ,,
CYTARABINE (PF) 20 MG/ML IJ SOLN,RX-96982,CDM,J9100,HCPCS,636,RC,61703-0305-58,NDC,outpatient,5,ML,16.81,11.767,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.77,416.02,other,SI=N Exclusions ,,
CYTARABINE 20 MG/ML IJ SOLN,RX-9709,CDM,J9100,HCPCS,636,RC,61703-0304-36,NDC,outpatient,25,ML,34.67,24.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.77,416.02,other,SI=N Exclusions ,,
DACARBAZINE 200 MG IV SOLR,RX-2091,CDM,J9130,HCPCS,636,RC,00143-9245-01,NDC,outpatient,1,UN,16.44,11.508,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.69078,416.02,other,SI=N Exclusions ,,
DACARBAZINE 200 MG IV SOLR,RX-2091,CDM,J9130,HCPCS,636,RC,00143-9245-10,NDC,outpatient,1,UN,16.44,11.508,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.69078,416.02,other,SI=N Exclusions ,,
DEGARELIX ACETATE(240 MG DOSE) 120 MG/VIAL SC SOLR,RX-150086,CDM,J9155,HCPCS,636,RC,55566-8403-01,NDC,outpatient,1,UN,1744.22,1220.954,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.27,,,495.6,4.18,1339.56096,fee schedule,,,
DEGARELIX ACETATE 80 MG SC SOLR,RX-96986,CDM,J9155,HCPCS,636,RC,55566-8303-01,NDC,outpatient,1,UN,1117.94,782.558,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,4.27,,,330.4,4.18,1339.56096,fee schedule,,,
DOCETAXEL 20 MG/ML IV CONC WRAPPER,RX-4080197,CDM,J9171,HCPCS,636,RC,16729-0267-65,NDC,outpatient,8,ML,615.8,431.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.79,1115.136,other,SI=N Exclusions ,,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,00409-0201-02,NDC,outpatient,2,ML,45.67,31.969,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.79,1115.136,other,SI=N Exclusions ,,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,66758-0050-02,NDC,outpatient,8,ML,726,508.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.79,1115.136,other,SI=N Exclusions ,,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,43066-0006-01,NDC,outpatient,8,ML,120.55,84.385,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.79,1115.136,other,SI=N Exclusions ,,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,66758-0050-01,NDC,outpatient,2,ML,181.5,127.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.79,1115.136,other,SI=N Exclusions ,,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,66758-0050-03,NDC,outpatient,16,ML,1452,1016.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.79,1115.136,other,SI=N Exclusions ,,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,00409-0201-20,NDC,outpatient,16,ML,345.35,241.745,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.79,1115.136,other,SI=N Exclusions ,,
EPIRUBICIN HCL 2 MG/ML IV SOLN WRAPPER,RX-4080365,CDM,J9178,HCPCS,636,RC,00009-5091-01,NDC,outpatient,25,ML,112.35,78.645,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.34,416.02,other,SI=N Exclusions ,,
ERIBULIN MESYLATE 1 MG/2ML IV PUSH SOLN,RX-106773,CDM,J9179,HCPCS,636,RC,62856-0389-01,NDC,outpatient,2,ML,4032.6,2822.82,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,141.29,,,1308.7,128.78,3097.0368,fee schedule,,,
ETOPOSIDE 100 MG/5ML IV SOLN,RX-124543,CDM,J9181,HCPCS,636,RC,16729-0114-08,NDC,outpatient,25,ML,169.25,118.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.7,416.02,other,SI=N Exclusions ,,
ETOPOSIDE 100 MG/5ML IV SOLN,RX-124543,CDM,J9181,HCPCS,636,RC,16729-0114-31,NDC,outpatient,5,ML,33.84,23.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.7,416.02,other,SI=N Exclusions ,,
FLUDARABINE PHOSPHATE 25 MG/ML IV WRAPPER,RX-4080526,CDM,J9185,HCPCS,636,RC,25021-0242-02,NDC,outpatient,2,ML,278.39,194.873,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,62.498555,604.75,other,SI=N Exclusions ,,
FLUOROURACIL 50 MG/ML IV SOLN WRAPPER,RX-4080199,CDM,J9190,HCPCS,636,RC,16729-0276-11,NDC,outpatient,50,ML,99.65,69.755,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.22,,,14.2,1.83,416.02,fee schedule,,,
FLUOROURACIL 500 MG/10ML IV PUSH SOLN,RX-82200,CDM,J9190,HCPCS,636,RC,63323-0117-10,NDC,outpatient,10,ML,8.43,5.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.22,,,2.84,1.83,416.02,fee schedule,,,
FLUOROURACIL 500 MG/10ML IV PUSH SOLN,RX-82200,CDM,J9190,HCPCS,636,RC,63323-0117-00,NDC,outpatient,10,ML,8.43,5.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,3.22,,,2.84,1.83,416.02,fee schedule,,,
GEMCITABINE HCL 200 MG/5.26ML IV SOLN,RX-112786,CDM,J9201,HCPCS,636,RC,00409-0183-01,NDC,outpatient,5.26,ML,31.43,22.001,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.79,416.02,other,SI=N Exclusions ,,
GEMCITABINE HCL 1 GM/26.3ML IV SOLN,RX-112787,CDM,J9201,HCPCS,636,RC,00409-0181-01,NDC,outpatient,26.3,ML,133.66,93.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.79,416.02,other,SI=N Exclusions ,,
GEMCITABINE HCL 200 MG IV SOLR,RX-17121,CDM,J9201,HCPCS,636,RC,25021-0234-10,NDC,outpatient,1,UN,27.81,19.467,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.79,416.02,other,SI=N Exclusions ,,
GEMCITABINE HCL 1 G IV SOLR,RX-17122,CDM,J9201,HCPCS,636,RC,16714-0930-01,NDC,outpatient,1,UN,63.54,44.478,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.79,416.02,other,SI=N Exclusions ,,
GOSERELIN ACETATE 3.6 MG SC IMPL,RX-10137,CDM,J9202,HCPCS,636,RC,70720-0950-36,NDC,outpatient,1,UN,2706.82,1894.774,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,659.53,,,611.35,399.86,5828.5824,fee schedule,,,
GOSERELIN ACETATE 10.8 MG SC IMPL,RX-16254,CDM,J9202,HCPCS,636,RC,70720-0951-30,NDC,outpatient,1,UN,7589.3,5312.51,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,659.53,,,1834.05,399.86,5828.5824,fee schedule,,,
IRINOTECAN HCL 20 MG/ML IV SOLN WRAPPER,RX-4080202,CDM,J9206,HCPCS,636,RC,61703-0349-09,NDC,outpatient,5,ML,56.89,39.823,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.71,,,10.3,2.5,416.02,fee schedule,,,
IRINOTECAN HCL 20 MG/ML IV SOLN WRAPPER,RX-4080202,CDM,J9206,HCPCS,636,RC,61703-0349-16,NDC,outpatient,2,ML,43.49,30.443,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.71,,,4.12,2.5,416.02,fee schedule,,,
IRINOTECAN HCL 20 MG/ML IV SOLN WRAPPER,RX-4080202,CDM,J9206,HCPCS,636,RC,60505-6128-01,NDC,outpatient,5,ML,26.29,18.403,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2.71,,,10.3,2.5,416.02,fee schedule,,,
IXABEPILONE 15 MG IV SOLR,RX-88652,CDM,J9207,HCPCS,636,RC,70020-1910-01,NDC,outpatient,1,UN,5537.91,3876.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,133.16,,,1913.55,122.55,12759.31392,fee schedule,,,
IXABEPILONE 45 MG IV SOLR,RX-88653,CDM,J9207,HCPCS,636,RC,70020-1911-01,NDC,outpatient,1,UN,16613.69,11629.583,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,133.16,,,5740.65,122.55,12759.31392,fee schedule,,,
IFOSFAMIDE 1 G IV SOLR,RX-10248,CDM,J9208,HCPCS,636,RC,10019-0925-82,NDC,outpatient,1,UN,94.35,66.045,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,21.181575,416.02,other,SI=N Exclusions ,,
IFOSFAMIDE 1 G IV SOLR,RX-10248,CDM,J9208,HCPCS,636,RC,10019-0925-01,NDC,outpatient,1,UN,94.35,66.045,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,21.181575,416.02,other,SI=N Exclusions ,,
IFOSFAMIDE 3 G IV SOLR,RX-10249,CDM,J9208,HCPCS,636,RC,00338-3993-01,NDC,outpatient,1,UN,350.95,245.665,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,21.181575,416.02,other,SI=N Exclusions ,,
IFOSFAMIDE 3 G IV SOLR,RX-10249,CDM,J9208,HCPCS,636,RC,10019-0926-02,NDC,outpatient,1,UN,288.44,201.908,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,21.181575,416.02,other,SI=N Exclusions ,,
IFOSFAMIDE 3 G IV SOLR,RX-10249,CDM,J9208,HCPCS,636,RC,10019-0926-16,NDC,outpatient,1,UN,288.44,201.908,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,21.181575,416.02,other,SI=N Exclusions ,,
MESNA 100 MG/ML IV SOLN,RX-10537,CDM,J9209,HCPCS,636,RC,00338-1305-01,NDC,outpatient,10,ML,28.36,19.852,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.67,416.02,other,SI=N Exclusions ,,
MESNA 100 MG/ML IV SOLN,RX-10537,CDM,J9209,HCPCS,636,RC,63323-0733-11,NDC,outpatient,10,ML,222.31,155.617,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.67,416.02,other,SI=N Exclusions ,,
IDARUBICIN HCL 1 MG/ML IV SOLN WRAPPER,RX-4080583,CDM,J9211,HCPCS,636,RC,00013-2576-91,NDC,outpatient,5,ML,121.76,85.232,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,27.33512,416.02,other,SI=N Exclusions ,,
LEUPROLIDE ACETATE 7.5 MG IM KIT,RX-10392,CDM,J9217,HCPCS,636,RC,00074-3642-03,NDC,outpatient,1,UN,5670.76,3969.532,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,180.54,,,166.69,165.86,17420.48256,fee schedule,,,
LEUPROLIDE ACETATE (3 MONTH) 22.5 MG IM KIT,RX-21045,CDM,J9217,HCPCS,636,RC,00074-3346-03,NDC,outpatient,1,UN,17012.14,11908.498,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,180.54,,,500.07,165.86,17420.48256,fee schedule,,,
LEUPROLIDE ACETATE (4 MONTH) 30 MG IM KIT,RX-21108,CDM,J9217,HCPCS,636,RC,00074-3683-03,NDC,outpatient,1,UN,22682.92,15878.044,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,180.54,,,666.76,165.86,17420.48256,fee schedule,,,
LEUPROLIDE ACETATE (4 MONTH) 30 MG SC KIT,RX-35236,CDM,J9217,HCPCS,636,RC,62935-0303-30,NDC,outpatient,1,UN,1549.29,1084.503,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,180.54,,,666.76,165.86,17420.48256,fee schedule,,,
IPILIMUMAB 5 MG/ML IV SOLN WRAPPER,RX-4080201,CDM,J9228,HCPCS,636,RC,00003-2327-11,NDC,outpatient,10,ML,24402.93,17082.051,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,176.78,,,8428,167.93,74965.60128,fee schedule,,,
IPILIMUMAB 5 MG/ML IV SOLN WRAPPER,RX-4080201,CDM,J9228,HCPCS,636,RC,00003-2328-22,NDC,outpatient,40,ML,97611.46,68328.022,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,176.78,,,33712,167.93,74965.60128,fee schedule,,,
METHOTREXATE SODIUM 25 MG/ML IJ SOLN WRAPPER,RX-4080788,CDM,J9250,HCPCS,636,RC,61703-0350-38,NDC,outpatient,0.5,ML,3.4,2.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.27,416.02,other,SI=N Exclusions ,,
METHOTREXATE SODIUM 25 MG/ML IJ SOLN WRAPPER,RX-4080788,CDM,J9250,HCPCS,636,RC,61703-0350-37,NDC,outpatient,0.5,ML,3.4,2.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.27,416.02,other,SI=N Exclusions ,,
METHOTREXATE SODIUM (PF) 25 MG/ML IJ SOLN WRAPPER,RX-4080789,CDM,J9260,HCPCS,636,RC,00143-9519-10,NDC,outpatient,2,ML,6.58,4.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.47721,416.02,other,SI=N Exclusions ,,
METHOTREXATE SODIUM (PF) 25 MG/ML IJ SOLN WRAPPER,RX-4080789,CDM,J9260,HCPCS,636,RC,00143-9519-01,NDC,outpatient,2,ML,6.58,4.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.47721,416.02,other,SI=N Exclusions ,,
NELARABINE 5 MG/ML IV SOLN,RX-70267,CDM,J9261,HCPCS,636,RC,00078-0683-61,NDC,outpatient,50,ML,2241.96,1569.372,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,73.32,,,583.25,72.53,1721.82528,fee schedule,,,
OXALIPLATIN 5 MG/ML IV SOLR WRAPPER,RX-4080205,CDM,J9263,HCPCS,636,RC,00703-3986-01,NDC,outpatient,20,ML,216.64,151.648,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions ,,
OXALIPLATIN 5 MG/ML IV SOLR WRAPPER,RX-4080205,CDM,J9263,HCPCS,636,RC,67457-0469-10,NDC,outpatient,10,ML,50.32,35.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.06,416.02,other,SI=N Exclusions ,,
PACLITAXEL PROTEIN-BOUND PART 100 MG IV SUSR,RX-40475,CDM,J9264,HCPCS,636,RC,68817-0134-50,NDC,outpatient,1,UN,4383.41,3068.387,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,13.24,,,1479,12.06,3366.45888,fee schedule,,,
PACLITAXEL 6 MG/ML IV CONC WRAPPER,RX-4080637,CDM,J9267,HCPCS,636,RC,61703-0342-50,NDC,outpatient,50,ML,238.31,166.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions ,,
PACLITAXEL 6 MG/ML IV CONC WRAPPER,RX-4080637,CDM,J9267,HCPCS,636,RC,63323-0763-50,NDC,outpatient,50,ML,433.61,303.527,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.1,416.02,other,SI=N Exclusions ,,
PENTOSTATIN 10 MG IV SOLR,RX-10910,CDM,J9268,HCPCS,636,RC,00409-0801-01,NDC,outpatient,1,UN,6377.89,4464.523,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,2537.07,,,2336.98,399.86,4898.21952,fee schedule,,,
PEMBROLIZUMAB 25 MG/ML IV SOLN WRAPPER,RX-4080564,CDM,J9271,HCPCS,636,RC,00006-3026-02,NDC,outpatient,4,ML,16212.43,11348.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,56.66,,,5641,54.81,12451.14624,fee schedule,,,
MITOMYCIN 20 MG IV SOLR,RX-10630,CDM,J9280,HCPCS,636,RC,16729-0108-11,NDC,outpatient,1,UN,505.56,353.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,54.16,,,382.44,42.51,2565.35808,fee schedule,,,
MITOMYCIN 40 MG IV SOLR,RX-10631,CDM,J9280,HCPCS,636,RC,00143-9280-01,NDC,outpatient,1,UN,3340.31,2338.217,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,54.16,,,764.88,42.51,2565.35808,fee schedule,,,
MITOMYCIN 40 MG IV SOLR,RX-10631,CDM,J9280,HCPCS,636,RC,16729-0116-38,NDC,outpatient,1,UN,3340.2,2338.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,54.16,,,764.88,42.51,2565.35808,fee schedule,,,
MITOMYCIN 5 MG IV SOLR,RX-10632,CDM,J9280,HCPCS,636,RC,16729-0115-05,NDC,outpatient,1,UN,734.35,514.045,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,54.16,,,95.61,42.51,2565.35808,fee schedule,,,
MITOXANTRONE HCL 20 MG/10ML IV CONC,RX-93748,CDM,J9293,HCPCS,636,RC,61703-0343-18,NDC,outpatient,10,ML,279.99,195.993,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,55.11,,,165.56,29.06,416.02,fee schedule,,,
NIVOLUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080562,CDM,J9299,HCPCS,636,RC,00003-3734-13,NDC,outpatient,24,ML,21406.97,14984.879,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,31.6,,,7303.2,30.46,16440.55296,fee schedule,,,
NIVOLUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080562,CDM,J9299,HCPCS,636,RC,00003-3774-12,NDC,outpatient,10,ML,8919.54,6243.678,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,31.6,,,3043,30.46,16440.55296,fee schedule,,,
NIVOLUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080562,CDM,J9299,HCPCS,636,RC,00003-3772-11,NDC,outpatient,4,ML,3567.83,2497.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,31.6,,,1217.2,30.46,16440.55296,fee schedule,,,
OBINUTUZUMAB 1000 MG/40ML IV SOLN,RX-124650,CDM,J9301,HCPCS,636,RC,50242-0070-01,NDC,outpatient,40,ML,23571.67,16500.169,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,74.15,,,7029,70.55,18103.04256,fee schedule,,,
PANITUMUMAB 20 MG/ML IV SOLN WRAPPER,RX-4080216,CDM,J9303,HCPCS,636,RC,55513-0954-01,NDC,outpatient,5,ML,4571.26,3199.882,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,158.69,,,1497.2,149.71,14042.8032,fee schedule,,,
PANITUMUMAB 20 MG/ML IV SOLN WRAPPER,RX-4080216,CDM,J9303,HCPCS,636,RC,55513-0956-01,NDC,outpatient,20,ML,18284.9,12799.43,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,158.69,,,5988.8,149.71,14042.8032,fee schedule,,,
PEMETREXED DISODIUM 500 MG IV SOLR,RX-37894,CDM,J9305,HCPCS,636,RC,00002-7623-01,NDC,outpatient,1,UN,11216.1,7851.27,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5.62,,,161,4.18,8613.9648,fee schedule,,,
PEMETREXED DISODIUM 100 MG IV SOLR,RX-89350,CDM,J9305,HCPCS,636,RC,00002-7640-01,NDC,outpatient,1,UN,2243.22,1570.254,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,5.62,,,32.2,4.18,8613.9648,fee schedule,,,
PERTUZUMAB 420 MG/14ML IV SOLN,RX-116596,CDM,J9306,HCPCS,636,RC,50242-0145-01,NDC,outpatient,14,ML,18666.61,13066.627,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,15.95,,,6476.4,15.37,14335.95648,fee schedule,,,
PRALATREXATE 20 MG/ML IV SOLN WRAPPER,RX-4080207,CDM,J9307,HCPCS,636,RC,72893-0003-01,NDC,outpatient,1,ML,20371.07,14259.749,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,299.13,,,5963.6,356.51,15644.98176,fee schedule,,,
RAMUCIRUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080567,CDM,J9308,HCPCS,636,RC,00002-7669-01,NDC,outpatient,10,ML,4084.74,2859.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,71.26,,,1380,68.87,15685.39392,fee schedule,,,
RAMUCIRUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080567,CDM,J9308,HCPCS,636,RC,00002-7678-01,NDC,outpatient,50,ML,20423.69,14296.583,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,71.26,,,6900,68.87,15685.39392,fee schedule,,,
RITUXIMAB 10 MG/ML IV SOLN WRAPPER,RX-4080719,CDM,J9312,HCPCS,636,RC,50242-0051-21,NDC,outpatient,10,ML,2687.03,1880.921,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,77.68,,,801.9,77.31,10318.18752,fee schedule,,,
RITUXIMAB 10 MG/ML IV SOLN WRAPPER,RX-4080719,CDM,J9312,HCPCS,636,RC,50242-0053-06,NDC,outpatient,50,ML,13435.14,9404.598,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,77.68,,,4009.5,77.31,10318.18752,fee schedule,,,
STREPTOZOCIN 1 G IV SOLR,RX-11436,CDM,J9320,HCPCS,636,RC,00703-4636-01,NDC,outpatient,1,UN,1171.99,820.393,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,370.18,,,370.18,223.44,900.08832,fee schedule,,,
TEMSIROLIMUS 25 MG/ML IV SOLN,RX-82228,CDM,J9330,HCPCS,636,RC,00008-1179-01,NDC,outpatient,2.5,ML,5549.29,3884.503,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,30.75,,,742,32.21,4261.85472,fee schedule,,,
TOPOTECAN HCL 1 MG/ML IV SOLN WRAPPER,RX-4080561,CDM,J9351,HCPCS,636,RC,16729-0151-31,NDC,outpatient,1,UN,263.29,184.303,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.5,416.02,other,SI=N Exclusions ,,
ADO-TRASTUZUMAB EMTANSINE 100 MG IV SOLR,RX-120086,CDM,J9354,HCPCS,636,RC,50242-0088-01,NDC,outpatient,1,UN,11130.41,7791.287,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,40.04,,,3834,38.33,13677.02016,fee schedule,,,
ADO-TRASTUZUMAB EMTANSINE 160 MG IV SOLR,RX-120087,CDM,J9354,HCPCS,636,RC,50242-0087-01,NDC,outpatient,1,UN,17808.62,12466.034,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,40.04,,,6134.4,38.33,13677.02016,fee schedule,,,
TRASTUZUMAB 21 MG/ML IV SOLR WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080954,CDM,J9355,HCPCS,636,RC,50242-0132-01,NDC,outpatient,150,ME,4456.89,3119.823,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,78.08,,,1211.85,77.94,3651.07968,fee schedule,,,
TRASTUZUMAB 21 MG/ML IV SOLR WRAPPER,RX-4080954,CDM,J9355,HCPCS,636,RC,50242-0132-01,NDC,outpatient,150,ME,4754.01,3327.807,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,78.08,,,2423.7,77.94,3651.07968,fee schedule,,,
VINBLASTINE SULFATE 1 MG/ML IV SOLN IV PUSH,RX-8594,CDM,J9360,HCPCS,636,RC,63323-0278-10,NDC,outpatient,10,ML,173.56,121.492,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.95,416.02,other,SI=N Exclusions ,,
VINCRISTINE SULFATE 1 MG/ML IV SOLN,RX-8597,CDM,J9370,HCPCS,636,RC,61703-0309-06,NDC,outpatient,2,ML,92.35,64.645,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7.49,416.02,other,SI=N Exclusions ,,
VINCRISTINE SULFATE 1 MG/ML IV SOLN,RX-8597,CDM,J9370,HCPCS,636,RC,61703-0309-16,NDC,outpatient,2,ML,46.03,32.221,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7.49,416.02,other,SI=N Exclusions ,,
VINORELBINE TARTRATE 10 MG/ML IV SOLN WRAPPER,RX-4080209,CDM,J9390,HCPCS,636,RC,25021-0204-05,NDC,outpatient,5,ML,163.03,114.121,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,7.59,416.02,other,SI=N Exclusions ,,
FULVESTRANT 250 MG/5ML IM SOSY,RX-160451,CDM,J9394,HCPCS,636,RC,63323-0715-01,NDC,outpatient,10,ML,518.07,362.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12.26,,,1060,1.65,1060,fee schedule,,,
FULVESTRANT 250 MG/5ML IM SOSY,RX-160451,CDM,J9394,HCPCS,636,RC,63323-0715-05,NDC,outpatient,10,ML,518.07,362.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,12.26,,,1060,1.65,1060,fee schedule,,,
COLLAR CERV FOAM LARGE -,SUP-00273900400,CDM,L0120,HCPCS,274,RC,,,outpatient,,,175.05,122.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.41367,416.02,other,Non-Reimbursable List,,
COLLAR SM 20.5INX3.5IN SFT DENS BRTHBL STCKNT CVR FOAM/CTTN -,SUP-1018-02,CDM,L0120,HCPCS,274,RC,,,outpatient,,,22.99,16.093,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.41367,416.02,other,Non-Reimbursable List,,
COLLAR CERVICAL STAT MEDIUM -,SUP-1018-03,CDM,L0120,HCPCS,274,RC,,,outpatient,,,19.66,13.762,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.41367,416.02,other,Non-Reimbursable List,,
CERVICAL COLLAR XL SOFT 22x3.5 -,SUP-1050-24,CDM,L0120,HCPCS,274,RC,,,outpatient,,,23.75,16.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.41367,416.02,other,Non-Reimbursable List,,
COLLAR PHILADELPHIA CERVICAL SM TRACH 2PC 4.25IN X 10-13IN -,SUP-1044-11,CDM,L0172,HCPCS,274,RC,,,outpatient,,,126.85,88.795,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.10504,416.02,other,Non-Reimbursable List,,
COLLAR PHILADELPHIA CERVICAL MD TRACH 2PC 4.25IN X 13-16IN -,SUP-1044-12,CDM,L0172,HCPCS,274,RC,,,outpatient,,,126.85,88.795,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.10504,416.02,other,Non-Reimbursable List,,
COLLAR PHILADELPHIA CERVICAL LRG TRACH 2PC 4.25IN X 16-19IN -,SUP-1044-13,CDM,L0172,HCPCS,274,RC,,,outpatient,,,126.85,88.795,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.10504,416.02,other,Non-Reimbursable List,,
COLLAR CERVICAL RIGID MED TRACH 2PC 3.25IN X 13-16IN -,SUP-1113MPP,CDM,L0172,HCPCS,274,RC,,,outpatient,,,53.92,37.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.10504,416.02,other,Non-Reimbursable List,,
COLLAR CERVICAL RIGID SM TRACH 2PC 3.25IN X 10-13IN -,SUP-1113SPP,CDM,L0172,HCPCS,274,RC,,,outpatient,,,53.92,37.744,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.10504,416.02,other,Non-Reimbursable List,,
COLLAR PHILADELPHIA SM 3.25IN 10-13 IN -,SUP-79-83133,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.23,46.361,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.10504,416.02,other,Non-Reimbursable List,,
COLLAR PHILADELPHIA MD 3.25IN x 13-16 IN -,SUP-79-83135,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.23,46.361,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.10504,416.02,other,Non-Reimbursable List,,
COLLAR PHILADELPHIA LG 3.25IN x 16-19IN -,SUP-79-83137,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.23,46.361,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.10504,416.02,other,Non-Reimbursable List,,
COLLAR PHILADELPHIA SM 4.25IN x 10-13IN -,SUP-79-83143,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.46,46.522,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.10504,416.02,other,Non-Reimbursable List,,
COLLAR PHILADELPHIA LG 4.25IN x 16-19IN -,SUP-79-83147,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.46,46.522,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.10504,416.02,other,Non-Reimbursable List,,
KNEE SUPPORT- HINGED PULL UP- MEDIUM -,SUP-NE7711-73,CDM,L1820,HCPCS,274,RC,,,outpatient,,,136.07,95.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,29.06826,416.02,other,Non-Reimbursable List,,
KNEE SUPPORT HINGED PULL UP- LRG -,SUP-NE7711-74,CDM,L1820,HCPCS,274,RC,,,outpatient,,,129.48,90.636,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,29.06826,416.02,other,Non-Reimbursable List,,
SUPPORT KNEE HINGED PULL UP LARGE -,SUP-NE7711-74,CDM,L1820,HCPCS,274,RC,,,outpatient,,,136.13,95.291,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,29.06826,416.02,other,Non-Reimbursable List,,
KNEE SUPPORT HINGED PULL UP X-LRG -,SUP-NE7711-75,CDM,L1820,HCPCS,274,RC,,,outpatient,,,136.07,95.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,29.06826,416.02,other,Non-Reimbursable List,,
SUPPORT KNEE HINGED PULL UP X-LARGE -,SUP-NE7711-75,CDM,L1820,HCPCS,274,RC,,,outpatient,,,129.48,90.636,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,29.06826,416.02,other,Non-Reimbursable List,,
BRACE KNEE ENHANCED TROM - DONJOY -,SUP-11-9114-9,CDM,L1832,HCPCS,274,RC,,,outpatient,,,544.99,381.493,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,110.03643,1222.676,other,Non-Reimbursable List,,
KNEE BRACE HINGED TROM DONJOY -,SUP-11-9114-9,CDM,L1832,HCPCS,274,RC,,,outpatient,,,544.99,381.493,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,110.03643,1222.676,other,Non-Reimbursable List,,
BRACE KN POSTOP 18-26IN FIT UPTO 34IN THG 6IN ABV MI D PTLR -,SUP-75-7500-000,CDM,L1832,HCPCS,274,RC,,,outpatient,,,490.14,343.098,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,110.03643,1222.676,other,Non-Reimbursable List,,
ANKLE BRACE SPORTS ORTHOSIS LACE UP BOA SMALL -,SUP-AB3000-12,CDM,L1902,HCPCS,274,RC,,,outpatient,,,105.56,73.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,23.579235,416.02,other,Non-Reimbursable List,,
ANKLE BRACE SPORTS ORTHOSIS LACE UP BOA MEDIUM -,SUP-AB3000-14,CDM,L1902,HCPCS,274,RC,,,outpatient,,,105.03,73.521,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,23.579235,416.02,other,Non-Reimbursable List,,
BRACE ANKLE SPORTS ORTHOSIS LACE UP BOA LARGE -,SUP-AB3000-16,CDM,L1902,HCPCS,274,RC,,,outpatient,,,105.56,73.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,23.579235,416.02,other,Non-Reimbursable List,,
BRACE ANKLE- SPORTS ORTHOSIS LACE UP BOA- XL -,SUP-AB3000-18,CDM,L1902,HCPCS,274,RC,,,outpatient,,,111.45,78.015,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,23.579235,416.02,other,Non-Reimbursable List,,
SPLINT ORTHO LT ANKL/FT LRG SZ8-10 PLST CLSD HL MLD HK/LOP -,SUP-A508LL,CDM,L1930,HCPCS,274,RC,,,outpatient,,,180.48,126.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,34.77954,420.504,other,Non-Reimbursable List,,
SPLINT ORTHO LT ANKL/FT MED SZ8-10 PLST CLSD HL MLD HK/LOP -,SUP-A508LM,CDM,L1930,HCPCS,274,RC,,,outpatient,,,179.78,125.846,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,34.77954,420.504,other,Non-Reimbursable List,,
SPLINT ORTHO RT ANKL/FT LRG SZ8-10 MALE PLST CLSD HL MLD -,SUP-A508RL,CDM,L1930,HCPCS,274,RC,,,outpatient,,,180.48,126.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,34.77954,420.504,other,Non-Reimbursable List,,
SPLINT ORTHO RT ANKL/FT LRG SZ8-10 PLST CLSD HL MLD HK/LOP -,SUP-A508RM,CDM,L1930,HCPCS,274,RC,,,outpatient,,,175.28,122.696,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,34.77954,420.504,other,Non-Reimbursable List,,
SPLINT ORTHO RT ANKL/FT SM SZ3-6 FEM PLST CLSD HL MLD HK/LOP -,SUP-A508RS,CDM,L1930,HCPCS,274,RC,,,outpatient,,,226.22,158.354,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,34.77954,420.504,other,Non-Reimbursable List,,
AFO FOR FOOT AND ANKLE -,SUP-XEE64330,CDM,L1930,HCPCS,274,RC,,,outpatient,,,154.92,108.444,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,34.77954,420.504,other,Non-Reimbursable List,,
AFO FOR FOOT AND ANKLE -,SUP-XEE64331,CDM,L1930,HCPCS,274,RC,,,outpatient,,,154.92,108.444,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,34.77954,420.504,other,Non-Reimbursable List,,
SYS FOOT OTHTC SM PEGASSIST DARCO -,SUP-PW1,CDM,L3002,HCPCS,274,RC,,,outpatient,,,73.46,51.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,29.435422,16.49177,416.02,percent of total billed charges,,,
SYS FOOT OTHTC MED PEGASSIST DARCO -,SUP-PW2,CDM,L3002,HCPCS,274,RC,,,outpatient,,,73.46,51.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,29.435422,16.49177,416.02,percent of total billed charges,,,
SYS FOOT OTHTC XL PEGASSIST DARCO -,SUP-PW4,CDM,L3002,HCPCS,274,RC,,,outpatient,,,73.46,51.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,29.435422,16.49177,416.02,percent of total billed charges,,,
SHOE POSTOP SZ5-6.5 SM MALE RT/LT LACE-UP CLSR -,SUP-2020-01,CDM,L3260,HCPCS,274,RC,,,outpatient,,,31.86,22.302,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List,,
SHOE POSTOP SZ7-8.5 MED MALE RT/LT LACE-UP CLSR -,SUP-2020-02,CDM,L3260,HCPCS,274,RC,,,outpatient,,,31.86,22.302,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List,,
SHOE POSTOP SZ9-11 LRG MALE RT/LT LACE-UP CLSR -,SUP-2020-03,CDM,L3260,HCPCS,274,RC,,,outpatient,,,31.86,22.302,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List,,
SHOE POSTOP SZ4-6 SM FEM RT/LT LACE-UP CLSR -,SUP-2021-01,CDM,L3260,HCPCS,274,RC,,,outpatient,,,30.87,21.609,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List,,
SHOE POSTOP SZ6.5-8 MED FEM RT/LT LACE-UP CLSR -,SUP-2021-02,CDM,L3260,HCPCS,274,RC,,,outpatient,,,30.87,21.609,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List,,
SHOE POSTOP SZ8.5-10 LRG L/R ANKL OPN TOE CLSD HL CNVS RBR -,SUP-2021-03,CDM,L3260,HCPCS,274,RC,,,outpatient,,,30.87,21.609,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List,,
BOOT CAST SM 4.5X8.5IN CNVS FT RCKR SOLE NSLIP HK/LOP CLSR -,SUP-2035-02,CDM,L3260,HCPCS,274,RC,,,outpatient,,,27.25,19.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List,,
CAST SHOE MED CANVAS ROCKER -,SUP-2035-03,CDM,L3260,HCPCS,274,RC,,,outpatient,,,27.6,19.32,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List,,
SHOE CAST LRG 5.25X11.5IN CNVS FT RCKR SOLE NSLIP HK/LOP -,SUP-2035-04,CDM,L3260,HCPCS,274,RC,,,outpatient,,,27.25,19.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List,,
SURGICAL SHOE MENS XL -,SUP-5701024,CDM,L3260,HCPCS,274,RC,,,outpatient,,,39.56,27.692,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List,,
SHOE ORTHO ANKL SM SZ7.5-10 MSH CLSD HL CLSD TOE HK/LOP STRP -,SUP-92732502,CDM,L3260,HCPCS,274,RC,,,outpatient,,,221.73,155.211,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List,,
SHOE ORTHO ANKL MED SZ8.5-10 MALE MSH CLSD HL CLSD TOE -,SUP-92732503,CDM,L3260,HCPCS,274,RC,,,outpatient,,,214.44,150.108,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List,,
SHOE ORTHO ANKL LRG SZ10.5-12 MSH CLSD HL CLSD TOE HK/LOP -,SUP-92732504,CDM,L3260,HCPCS,274,RC,,,outpatient,,,214.44,150.108,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List,,
SHOE CAST SZ6-8 MALE SZ7.5-10 FEM SM FT DARCO HEELWEDGE -,SUP-92732602,CDM,L3260,HCPCS,274,RC,,,outpatient,,,116.41,81.487,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List,,
SHOE CAST SZ8.5-10 MALE 10.5-13 FEM MED FT DARCO HEELWEDGE -,SUP-92732603,CDM,L3260,HCPCS,274,RC,,,outpatient,,,124.52,87.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List,,
SHOE POST-OP NYLON RUBBER HOOK/LOOP MALE SMALL -,SUP-A152305,CDM,L3260,HCPCS,274,RC,,,outpatient,,,20.66,14.462,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List,,
POST OP SHOE NYLON RUBBER HOOK/LOOP MALE LRG -,SUP-A152307,CDM,L3260,HCPCS,274,RC,,,outpatient,,,22.29,15.603,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List,,
SHOE POSTOP MENS SM SIZES 6-8 MEDSURG -,SUP-MQM1B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List,,
SHOE POSTOP MENS MED SIZES 8.5-10 MEDSURG -,SUP-MQM2B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List,,
SHOE POSTOP MENS LG SIZES 10.5-12 MEDSURG -,SUP-MQM3B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List,,
SHOE POSTOP MENS XL SIZES 12.5-14 MEDSURG -,SUP-MQM4B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List,,
SHOE POSTOP WOMENS SM SIZES 4-6 MEDSURG -,SUP-MQW1B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List,,
SHOE POSTOP SZ6.5-8 FEM MED MEDSURG OPN TOE CLSD HL RCKR BTM -,SUP-MQW2B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,110.4,77.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List,,
SHOE POSTOP WOMENS MED SIZES 6.5- 8 MEDSURG -,SUP-MQW2B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List,,
SHOE POSTOP WOMENS LG SIZES  8.5 -10 MEDSURG -,SUP-MQW3B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List,,
SHOE DARCO SURGICAL MENS SMALL -,SUP-MSM1N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,28.47,19.929,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List,,
SHOES DARCO MENS MEDIUM -,SUP-MSM2N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,47.21,33.047,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List,,
SHOES DARCO MENS LARGE -,SUP-MSM3N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,48.55,33.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List,,
SHOES DARCO WOMENS SMALL -,SUP-MSW1N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,48.55,33.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List,,
SHOES DARCO WOMENS MEDIUM -,SUP-MSW2N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,28.47,19.929,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List,,
SHOES DARCO WOMENS LARGE -,SUP-MSW3N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,45.63,31.941,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List,,
BOOT CAST REG FT PD WVN TCC-EZ -,SUP-TCC21100,CDM,L3260,HCPCS,274,RC,,,outpatient,,,393.57,275.499,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List,,
BOOT CAST LRG FT PD WVN TCC-EZ -,SUP-TCC21114,CDM,L3260,HCPCS,274,RC,,,outpatient,,,444.34,311.038,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List,,
BOOT CAST LRG FT CHARCOT PD WVN TCC-EZ -,SUP-TCC21116,CDM,L3260,HCPCS,274,RC,,,outpatient,,,538.28,376.796,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List,,
SYS CAST 3IN FT CHARCOT PD WVN W/REGULARX2 BT TCC-EZ -,SUP-TCC23000,CDM,L3260,HCPCS,274,RC,,,outpatient,,,627.97,439.579,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List,,
SYS CAST SZ4 IN FT PD WVN W/2 REG BT TCC-EZ -,SUP-TCC24000,CDM,L3260,HCPCS,274,RC,,,outpatient,,,627.97,439.579,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,4.63817,482.28096,other,Non-Reimbursable List,,
IMMOBILIZER SHLDR LRG ELAS HUM CUF RB WRP -,SUP-00078300300,CDM,L3670,HCPCS,274,RC,,,outpatient,,,291.75,204.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.81201,416.02,other,Non-Reimbursable List,,
IMMOBILIZER SHLDR LRG ELAS HUM CUF CONTR RB WRP -,SUP-00078400300,CDM,L3670,HCPCS,274,RC,,,outpatient,,,233.4,163.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.81201,416.02,other,Non-Reimbursable List,,
IMMOBILIZER SHLDR SMALL ULTRASLING III BLACK -,SUP-11-0449-2,CDM,L3670,HCPCS,274,RC,,,outpatient,,,305.46,213.822,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.81201,416.02,other,Non-Reimbursable List,,
IMMOBILIZER SHLDR MED ULTRASLING III BLACK -,SUP-11-0449-3,CDM,L3670,HCPCS,274,RC,,,outpatient,,,305.46,213.822,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.81201,416.02,other,Non-Reimbursable List,,
SUPPORT RT SHLDR SM 11IN MSH FBRC ULSNG ER HUM CUF 15DEG -,SUP-11-1343-2-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.81201,416.02,other,Non-Reimbursable List,,
SUPPORT LT SHLDR ARM SM UPTO 11IN MSH FBRC ULSNG ER BRTHBL -,SUP-11-1344-2-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.81201,416.02,other,Non-Reimbursable List,,
SUPPORT LT SHLDR ARM LRG ABV 13IN MSH FBRC ULSNG ER BRTHBL -,SUP-11-1344-4-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.81201,416.02,other,Non-Reimbursable List,,
SUPPORT RT SHLDR SM 11IN MSH FBRC ULSNG ER HUM CUF 30DEG -,SUP-11-1345-2,CDM,L3670,HCPCS,274,RC,,,outpatient,,,371.22,259.854,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.81201,416.02,other,Non-Reimbursable List,,
SUPPORT RT SHLDR LRG 13-15IN MSH FBRC ULSNG ER HUM 30DEG -,SUP-11-1345-4-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.81201,416.02,other,Non-Reimbursable List,,
SUPPORT LT SHLDR LRG 13-15IN MSH FBRC ULSNG ER BRTHBL HUM -,SUP-11-1346-4-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.81201,416.02,other,Non-Reimbursable List,,
IMMOBILIZER SHLDR SLING MED 7IN X 17IN -,SUP-11630006,CDM,L3670,HCPCS,274,RC,,,outpatient,,,243.14,170.198,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.81201,416.02,other,Non-Reimbursable List,,
IMMOBILIZER SHLDR SLING LRG 7IN X 18IN -,SUP-11630007,CDM,L3670,HCPCS,274,RC,,,outpatient,,,243.14,170.198,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.81201,416.02,other,Non-Reimbursable List,,
IIMMOBILIZER SHOULDER VELPEAU M -,SUP-23-1872,CDM,L3670,HCPCS,274,RC,,,outpatient,,,29.7,20.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.81201,416.02,other,Non-Reimbursable List,,
IMMOBILIZER SHOULDER VELPEAU L -,SUP-23-1873-000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,29.7,20.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.81201,416.02,other,Non-Reimbursable List,,
IMMOBILIZER SHLDR SM PD WRST/HUM CUF SHLDR/WST STRP -,SUP-667110,CDM,L3670,HCPCS,274,RC,,,outpatient,,,343.1,240.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.81201,416.02,other,Non-Reimbursable List,,
IMMOBILIZER RT/LT SHLDR XS CTTN CLTH 6X12.5IN PCH CLSD/OPN -,SUP-9002-01,CDM,L3670,HCPCS,274,RC,,,outpatient,,,29.12,20.384,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.81201,416.02,other,Non-Reimbursable List,,
IMMOBILIZER SHOULDER UNIVERSAL -,SUP-9013-00,CDM,L3670,HCPCS,274,RC,,,outpatient,,,56.25,39.375,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.81201,416.02,other,Non-Reimbursable List,,
SHOULDER IMMOBILIZER W/FOAM SMALL -,SUP-A111015,CDM,L3670,HCPCS,274,RC,,,outpatient,,,19.02,13.314,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.81201,416.02,other,Non-Reimbursable List,,
SHOULDER IMMOBILIZER W/FOAM WAIST STRAP M -,SUP-A111016,CDM,L3670,HCPCS,274,RC,,,outpatient,,,19.02,13.314,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.81201,416.02,other,Non-Reimbursable List,,
IMMOBILIZER SHLDR X-LRG 9IN X 22.5IN -,SUP-A111018,CDM,L3670,HCPCS,274,RC,,,outpatient,,,16.98,11.886,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.81201,416.02,other,Non-Reimbursable List,,
IMMOBILIZER SHOULDER VELP XLG -,SUP-TX9023-04,CDM,L3670,HCPCS,274,RC,,,outpatient,,,31.1,21.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.81201,416.02,other,Non-Reimbursable List,,
SPLINT RT HND SM 6.5-7.25IN ALIFLEECE LINER THRMPLST DLX FIG -,SUP-5183,CDM,L3807,HCPCS,274,RC,,,outpatient,,,286.27,200.389,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,31.76675,416.02,other,Non-Reimbursable List,,
SPLINT RT HND LRG 8.25-9.25IN ALIFLEECE LINER THRMPLST DLX -,SUP-5187,CDM,L3807,HCPCS,274,RC,,,outpatient,,,284.4,199.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,31.76675,416.02,other,Non-Reimbursable List,,
SPLINT LT SM RST -,SUP-5812,CDM,L3807,HCPCS,274,RC,,,outpatient,,,273.08,191.156,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,31.76675,416.02,other,Non-Reimbursable List,,
SPLINT WRST MED POLY FOAM CCKUP -,SUP-A1601P,CDM,L3807,HCPCS,274,RC,,,outpatient,,,141.5,99.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,31.76675,416.02,other,Non-Reimbursable List,,
EXTERNAL FIX DIGIT WIDGET -,SUP-DWD-232,CDM,L3921,HCPCS,274,RC,,,outpatient,,,7002.6,4901.82,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,335.72,5377.9968,other,Non-Reimbursable List,,
SPLINT THUMB SPICA RIGHT MED/LRG 3.5IN - 4.25IN -,SUP-340M/LR,CDM,L3924,HCPCS,274,RC,,,outpatient,,,68.27,47.789,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,27.355789,15.326615,416.02,percent of total billed charges,,,
THUMB SPLINT COMFORT COOL CMC LT MEDIUM -,SUP-348ML,CDM,L3924,HCPCS,274,RC,,,outpatient,,,92.66,64.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,37.128862,15.326615,416.02,percent of total billed charges,,,
THUMB SPLINT COMFORT COOL CMC RT MEDIUM -,SUP-348MR,CDM,L3924,HCPCS,274,RC,,,outpatient,,,92.66,64.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,37.128862,15.326615,416.02,percent of total billed charges,,,
LMB SPRING PIP EXTENSION ASSIST -,SUP-704103,CDM,L3925,HCPCS,274,RC,,,outpatient,,,89.16,62.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,17.225885,416.02,other,Non-Reimbursable List,,
SPLINT FINGER EXTENSION LMB SPRING SIZE A -,SUP-704200,CDM,L3925,HCPCS,274,RC,,,outpatient,,,76.73,53.711,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,17.225885,416.02,other,Non-Reimbursable List,,
SPLINT FINGER EXTENSION SPRING LMB SIZE C -,SUP-704202,CDM,L3925,HCPCS,274,RC,,,outpatient,,,76.79,53.753,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,17.225885,416.02,other,Non-Reimbursable List,,
BOOT WALKER LRG AIRCAST SZ10-13 MALE SZ11-15 FEM PED -,SUP-01EF-L,CDM,L4361,HCPCS,274,RC,,,outpatient,,,269.52,188.664,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,107.996664,50.613525,568.638,percent of total billed charges,,,
BOOT WALKER MED AIRCAST SZ7-10 MALE SZ8-11 FEM -,SUP-01EF-M,CDM,L4361,HCPCS,274,RC,,,outpatient,,,269.52,188.664,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,107.996664,50.613525,568.638,percent of total billed charges,,,
BOOT WALKER SM AIRCAST SZ4-7 MALE SZ5-8 FEM -,SUP-01F-S,CDM,L4361,HCPCS,274,RC,,,outpatient,,,263.86,184.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,105.728702,50.613525,568.638,percent of total billed charges,,,
BOOT WALKER XL AIRCAST SZ 13+ MALE SZ 15+ FEM -,SUP-01F-XL,CDM,L4361,HCPCS,274,RC,,,outpatient,,,263.86,184.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,105.728702,50.613525,568.638,percent of total billed charges,,,
BOOT WALKER LRG SHELL 10-13M/11-15F -,SUP-1175LPP,CDM,L4361,HCPCS,274,RC,,,outpatient,,,225.45,157.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,90.337815,50.613525,568.638,percent of total billed charges,,,
WALKER FULL SHELL 2 SHORT- SMALL -,SUP-15500047,CDM,L4361,HCPCS,274,RC,,,outpatient,,,274.6,192.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,110.03222,50.613525,568.638,percent of total billed charges,,,
WALKER- FULL SHELL 2 SHORT- MEDIUM -,SUP-15500048,CDM,L4361,HCPCS,274,RC,,,outpatient,,,249.74,174.818,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,100.070818,50.613525,568.638,percent of total billed charges,,,
WALKER FULL SHELL 2 SHORT LARGE -,SUP-1550049,CDM,L4361,HCPCS,274,RC,,,outpatient,,,234.33,164.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,93.896031,50.613525,568.638,percent of total billed charges,,,
BOOT ORTHO FT MED/L FLEECE LINER OPN TOE SEMI- FLXB SHL -,SUP-6963,CDM,L4394,HCPCS,274,RC,,,outpatient,,,127.09,88.963,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,20.61,416.02,other,Non-Reimbursable List,,
VALVE SPK 15X23MM PASSY-MUIR WHITE -,SUP-PMV 005,CDM,L8501,HCPCS,274,RC,,,outpatient,,,429.46,300.622,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,52.37136,418.655068,other,Non-Reimbursable List,,
VALVE SPK PASSY-MUIR PMV 15X22MM LPRO REUS FLEX AQUA -,SUP-PMV 007,CDM,L8501,HCPCS,274,RC,,,outpatient,,,493.93,345.751,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,52.37136,418.655068,other,Non-Reimbursable List,,
VALVE SPK/SWALW IN G 15X23MM PASSY-MUIR PMV 1W  CLEAR -,SUP-PMV 2000,CDM,L8501,HCPCS,274,RC,,,outpatient,,,429.46,300.622,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,52.37136,418.655068,other,Non-Reimbursable List,,
VALVE PASSY MUIR PURPLE SPEAK SWALLOW IN G 15X23MM PMV -,SUP-PMV 2001,CDM,L8501,HCPCS,274,RC,,,outpatient,,,429.46,300.622,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,52.37136,418.655068,other,Non-Reimbursable List,,
VALVE SPK SHILEY 0.66MM MINI STRL MONOKA PHONATE W/O O2 PRT -,SUP-SSV,CDM,L8501,HCPCS,274,RC,,,outpatient,,,233.28,163.296,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,52.37136,418.655068,other,Non-Reimbursable List,,
PROSTHESIS VOCAL CRD BLOM-SINGER CLASSIC 20FRX8MM INDWL STRL -,SUP-IN 2008-SO,CDM,L8509,HCPCS,274,RC,,,outpatient,,,1378.13,964.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,125.65,1058.40384,other,Non-Reimbursable List,,
PROSTHESIS VOCAL CRD BLOM-SINGER 20FRX14MM INDWL STRL -,SUP-IN2014-SO,CDM,L8509,HCPCS,274,RC,,,outpatient,,,1378.13,964.691,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,125.65,1058.40384,other,Non-Reimbursable List,,
IMPLANT BRST 600ML SIL GEL HPRO RND 14CM MEMORYGEL 5.6CM -,SUP-350-6004BC,CDM,L8600,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,3409.78176,other,Non-Reimbursable List,,
BULKAMID URETHRAL BULKING SYSTEM -,SUP-50050,CDM,L8606,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,252.25,3748.3008,other,Non-Reimbursable List,,
COAPTITE SYRINGE 1ML -,SUP-M0068903000,CDM,L8606,HCPCS,278,RC,,,outpatient,,,1975.44,1382.808,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,252.25,3748.3008,other,Non-Reimbursable List,,
SPHERE EYE 18MM -,SUP-14254,CDM,L8610,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,70.737705,686.06,other,Non-Reimbursable List,,
IMPLANT OSS PRT WIET 1.14MM SHFT 3.25MMX5MM OFF-CTR HAP FLEX -,SUP-0516,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List,,
PROSTHESIS OSS PRT 4X5MM CTR HAP FLEX TI MLBL -,SUP-0550,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2565.44,1795.808,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List,,
MNP TOTAL TITANIUM .2 X 3.00MM -,SUP-1004434,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List,,
MNP TOTAL TITANIUM .2 X 3.5MM -,SUP-1004436,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List,,
OMEGA CONNECTOR 1.5MM X 8MMX0.5 -,SUP-1004930,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1219.12,853.384,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List,,
PROSTHESIS OSS ASTN PLAS-PR MOD PORP 3MM FLNG DIA 1MM SHFT -,SUP-14-0063,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1300.05,910.035,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List,,
PISTON OTO SCHKNT 0.8MMX4.25MM WIRE LOOP FLPLS SS -,SUP-14-0105,CDM,L8613,HCPCS,278,RC,,,outpatient,,,628.66,440.062,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List,,
LOOP WIRE HOUSE TYPE .12 X 4.0 -,SUP-140184,CDM,L8613,HCPCS,278,RC,,,outpatient,,,268.41,187.887,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List,,
LOOP WIRE HOUSE TYPE .12 X 4.25 -,SUP-140184,CDM,L8613,HCPCS,278,RC,,,outpatient,,,346.6,242.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List,,
PISTON OTO RCHRD 0.6MMX3.50MM RBN LOOP FLPLS PLTNM -,SUP-14-0781,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List,,
PISTON OTO RCHRD 0.6X4MM RBN LOOP FLPLS PLTNM -,SUP-14-0783,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List,,
PISTON OTO RCHRD 0.6MMX4.25MM RBN LOOP FLPLS PLTNM -,SUP-14-0784,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List,,
PISTON OTO RCHRD 0.8X4MM RBN LOOP FLPLS PLTNM -,SUP-14-0792,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1024.74,717.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List,,
PISTON OTO RCHRD 0.8MMX4.5MM RBN LOOP FLPLS PLTNM -,SUP-14-0794,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List,,
PLATE OSS MED 10MM POR HAP ATTIC DFCT -,SUP-14-0863,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1063.14,744.198,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List,,
PLATE OSS 14MM LRG POR HAP ATTIC DFCT -,SUP-14-0864,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1072.41,750.687,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List,,
PROSTHESIS OSS APLBM SM 2X2MM 1MM CANN HAP INCSTP -,SUP-14-0956,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2182.32,1527.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List,,
PROSTHESIS OSS PRT GLDNBRG 1.5MM 1.14MM FLLY CANN HAP EAR -,SUP-14-0963,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2038.36,1426.852,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List,,
PROSTHESIS OSS APLBM 2.5X3MM HAP INCUS -,SUP-14-0973,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2205.54,1543.878,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List,,
PROSTHESIS OSS RCHRD 0.4MM PSTN 1MM WELL 4.50MM CUP PED -,SUP-142152,CDM,L8613,HCPCS,278,RC,,,outpatient,,,761.58,533.106,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List,,
Eclipse Flat Ribbon Piston .6MM X 4.50MM -,SUP-472-450,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1863.34,1304.338,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List,,
Eclipse Flat Ribbon Piston .6MM X 4.75MM -,SUP-472-475,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1863.34,1304.338,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List,,
Eclipse Flat Ribbon Piston .6MM X 5.00MM -,SUP-472-500,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1863.34,1304.338,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List,,
PROSTHESIS OSS UM TORP 2X10MM CTR TI ADJ -,SUP-7014-1044,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1852.68,1296.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List,,
PROSTHESIS OSS UM TORP 2X5MM CTR TI ADJ -,SUP-7014-1046,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1852.68,1296.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List,,
PISTON OSS SMRT 0.6X4MM WIRE LOOP FLPLS NTNL STPS ADLT -,SUP-70145926,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1601.92,1121.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List,,
PISTON OSS SMRT 0.6MMX4.25MM WIRE LOOP FLPLS NTNL STPS ADLT -,SUP-70145927,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1601.92,1121.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List,,
PISTON OSS SMRT 0.6MMX4.50MM WIRE LOOP FLPLS NTNL STPS ADLT -,SUP-70145928,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1601.92,1121.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List,,
DISTANCE PLATES REPLACEMENT 0.1 /0.2 /0.3 -,SUP-8000140,CDM,L8613,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,60.258045,2016.5376,other,Non-Reimbursable List,,
JOINT FINGER SWANSON 1 MCP FLEXIBLE STERILE W/O GROMMETS SIL -,SUP-4700001,CDM,L8630,HCPCS,278,RC,,,outpatient,,,4602.62,3221.834,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,3534.81216,other,Non-Reimbursable List,,
IMPLANT PIP MCP SZ4 SWNSN SIL -,SUP-G470-0004,CDM,L8630,HCPCS,278,RC,,,outpatient,,,4413.76,3089.632,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,3534.81216,other,Non-Reimbursable List,,
PROSTHESIS PENL TOROSA LRG SAL FIL CYL INFL PRECNCT SCRT -,SUP-450-1329,CDM,L8699,HCPCS,278,RC,,,outpatient,,,8471.02,5929.714,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,163.74581,6505.74336,other,SI=N Exclusions ,,
PROSTHESIS TSTCLR 2.9CMX4.5IN -,SUP-96-450-1329,CDM,L8699,HCPCS,278,RC,,,outpatient,,,7002.6,4901.82,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,163.74581,6505.74336,other,SI=N Exclusions ,,
LEAD ANCHOR KIT -,SUP-ACCK5300,CDM,L8699,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,163.74581,6505.74336,other,SI=N Exclusions ,,
WEIGHT EYELID THN 0.6MM PLTNM 0.6GM SPHRCL CRV TAPR EDGE RND -,SUP-LL 6006,CDM,L8699,HCPCS,278,RC,,,outpatient,,,1749.17,1224.419,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,163.74581,6505.74336,other,SI=N Exclusions ,,
UROLIFT ATC IMPLANT CARTRIDGE -,SUP-UL2ATC-C,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4986.7,3490.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,163.74581,6505.74336,other,SI=N Exclusions ,,
IMPLANT UROLOGICAL UROLIFT 2 CARTRIDGE -,SUP-UL2-C,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,163.74581,6505.74336,other,SI=N Exclusions ,,
IMPLANT CARTRIDGE UROLIFT -,SUP-UL2-C,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4350.1,3045.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,163.74581,6505.74336,other,SI=N Exclusions ,,
IMPLANT HANDLE CARTRIDGE UROLIFT -,SUP-UL2-CHK,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,163.74581,6505.74336,other,SI=N Exclusions ,,
KIT HANDLE UROLIFT DELIVERY HANDLE IMPLANT CARTRIDGE -,SUP-UL2-CHK,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,163.74581,6505.74336,other,SI=N Exclusions ,,
HC Bebtelovimab Injection,PX-26000018,CDM,M0222,HCPCS,260,RC,,,outpatient,,,1455,1018.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,583.0185,326.6475,1117.44,percent of total billed charges,,,
HC Cryoprecipitate Each Unit,PX-39000006,CDM,P9012,CPT,390,RC,,,outpatient,,,1227,858.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,181.67,,,172.2,49.4,942.336,fee schedule,,,
HC RBC Leukocytes Reduced,PX-39000007,CDM,P9016,CPT,390,RC,,,outpatient,,,551,385.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,282.46,,,313.84,123.6995,423.168,fee schedule,,,
HC Plasma 1 Donor Frz W/in 8 Hr,PX-39000008,CDM,P9017,CPT,390,RC,,,outpatient,,,379,265.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,181.83,,,172.35,71.53,416.02,fee schedule,,,
HC Red Blood Cells Unit,PX-39000009,CDM,P9021,CPT,390,RC,,,outpatient,,,471,329.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,350.65,,,332.37,105.7395,416.02,fee schedule,,,
HC Washed Red Blood Cells Unit,PX-39000010,CDM,P9022,CPT,390,RC,,,outpatient,,,1028,719.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,684.69,,,649.01,163,871.3328,fee schedule,,,
HC Platelets Leukocytes Reduced,PX-39000011,CDM,P9031,CPT,390,RC,,,outpatient,,,1397,977.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,273.38,,,259.13,136.61,1072.896,fee schedule,,,
HC Platelets Leukoreduced Irrad,PX-39000012,CDM,P9033,CPT,390,RC,,,outpatient,,,1633,1143.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,361.42,,,342.58,163,1384.1308,fee schedule,,,
HC Platelet Pheres Leukoreduced,PX-39000013,CDM,P9035,CPT,390,RC,,,outpatient,,,1233,863.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1181.08,,,1119.53,163,1119.53,fee schedule,,,
HC Plate Pheres Leukoredu Irrad,PX-39000014,CDM,P9037,CPT,390,RC,,,outpatient,,,1624,1136.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1557.38,,,1476.21,163,1476.21,fee schedule,,,
HC RBC Deglycerolized,PX-39000015,CDM,P9039,CPT,390,RC,,,outpatient,,,2586,1810.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1108.25,,,1050.49,163,2191.8936,fee schedule,,,
HC RBC Leukoreduced Irradiated,PX-39000016,CDM,P9040,CPT,390,RC,,,outpatient,,,636,445.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,631.1,,,598.2,142.782,598.2,fee schedule,,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,44206-0310-90,NDC,outpatient,250,ML,199.57,139.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,114.85,25.321355,416.02,fee schedule,,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,68982-0623-03,NDC,outpatient,500,ML,363.1,254.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,229.7,25.321355,416.02,fee schedule,,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,76125-0790-26,NDC,outpatient,250,ML,171.75,120.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,114.85,25.321355,416.02,fee schedule,,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,44206-0310-25,NDC,outpatient,250,ML,199.57,139.699,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,114.85,25.321355,416.02,fee schedule,,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,68516-5214-03,NDC,outpatient,250,ML,168.42,117.894,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,114.85,25.321355,416.02,fee schedule,,,
ALBUMIN HUMAN 5 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8982,CDM,P9045,HCPCS,636,RC,68982-0623-03,NDC,outpatient,500,ML,347.1,242.97,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.5,,,229.7,25.321355,416.02,fee schedule,,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,00944-0495-05,NDC,outpatient,250,ML,112.79,78.953,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,114.85,25.321355,416.02,fee schedule,,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,68516-5214-01,NDC,outpatient,250,ML,168.42,117.894,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,114.85,25.321355,416.02,fee schedule,,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,76125-0790-25,NDC,outpatient,250,ML,171.75,120.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,114.85,25.321355,416.02,fee schedule,,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,00944-0495-06,NDC,outpatient,250,ML,112.79,78.953,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,114.85,25.321355,416.02,fee schedule,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-04,NDC,outpatient,100,ML,48.49,33.943,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,229.7,7.294005,416.02,fee schedule,,,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-02,NDC,outpatient,100,ML,304.83,213.381,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.5,,,229.7,7.294005,416.02,fee schedule,,,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-08,NDC,outpatient,100,ML,414.3,290.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.5,,,229.7,7.294005,416.02,fee schedule,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-03,NDC,outpatient,50,ML,209.58,146.706,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,114.85,7.294005,416.02,fee schedule,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-04,NDC,outpatient,100,ML,320.83,224.581,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,229.7,7.294005,416.02,fee schedule,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-08,NDC,outpatient,100,ML,430.3,301.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,229.7,7.294005,416.02,fee schedule,,,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,64208-2512-07,NDC,outpatient,100,ML,293.7,205.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.5,,,229.7,7.294005,416.02,fee schedule,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-02,NDC,outpatient,100,ML,320.83,224.581,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,229.7,7.294005,416.02,fee schedule,,,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-02,NDC,outpatient,100,ML,32.49,22.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.5,,,229.7,7.294005,416.02,fee schedule,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-01,NDC,outpatient,50,ML,209.58,146.706,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,114.85,7.294005,416.02,fee schedule,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-02,NDC,outpatient,100,ML,48.49,33.943,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,229.7,7.294005,416.02,fee schedule,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,64208-2512-07,NDC,outpatient,100,ML,309.7,216.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,229.7,7.294005,416.02,fee schedule,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-00,NDC,outpatient,100,ML,309.7,216.79,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,229.7,7.294005,416.02,fee schedule,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-01,NDC,outpatient,50,ML,168.42,117.894,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,114.85,7.294005,416.02,fee schedule,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-03,NDC,outpatient,50,ML,168.42,117.894,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.5,,,114.85,7.294005,416.02,fee schedule,,,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-04,NDC,outpatient,100,ML,32.49,22.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.5,,,229.7,7.294005,416.02,fee schedule,,,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-00,NDC,outpatient,100,ML,293.7,205.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.5,,,229.7,7.294005,416.02,fee schedule,,,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-04,NDC,outpatient,100,ML,304.83,213.381,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],JW,0.5,,,229.7,7.294005,416.02,fee schedule,,,
HC Platelets- Hla-M- L/R- Unit,PX-39000026,CDM,P9052,HCPCS,390,RC,,,outpatient,,,1807,1264.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1791.37,,,1698,163,1698,fee schedule,,,
HC RBC- Frz/Deg/Wsh- L/R- Irrad,PX-39000023,CDM,P9057,CPT,390,RC,,,outpatient,,,2062,1443.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,851.71,,,807.32,163,1747.7512,fee schedule,,,
HC RBC- L/R- Cmv-Neg- Irrad,PX-39000024,CDM,P9058,CPT,390,RC,,,outpatient,,,1235,864.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,661.98,,,627.48,163,1046.786,fee schedule,,,
HC Plasma- Frz Between 8-24hour,PX-39000025,CDM,P9059,CPT,390,RC,,,outpatient,,,222,155.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,174.48,,,165.39,49.839,416.02,fee schedule,,,
HC Platelets- Pheresis- Pathogen-Reduced- Each Unit,PX-39000028,CDM,P9073,HCPCS,390,RC,,,outpatient,,,1626,1138.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,1334.98,,,1265.41,163,1265.41,fee schedule,,,
HC Pathogen Test for Platelets,PX-30000897,CDM,P9100,HCPCS,300,RC,,,outpatient,,,89,62.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,58.91,,,55.84,19.9805,416.02,fee schedule,,,
FERUMOXYTOL 510 MG/17ML IV SOLN,RX-98312,CDM,Q0138,HCPCS,636,RC,59338-0775-01,NDC,outpatient,17,ML,945.71,661.997,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.33,,,255,0.34,726.30528,fee schedule,,,
ONDANSETRON HCL 4 MG ORAL TABS,RX-10778,CDM,Q0162,HCPCS,259,RC,00904-6551-61,NDC,outpatient,1,UN,1.57,1.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.01,416.02,other,SI=N Exclusions ,,
ONDANSETRON 4 MG ORAL TBDP,RX-27697,CDM,Q0162,HCPCS,259,RC,65862-0390-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.01,416.02,other,SI=N Exclusions ,,
ONDANSETRON 4 MG ORAL TBDP,RX-27697,CDM,Q0162,HCPCS,259,RC,68462-0157-13,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.01,416.02,other,SI=N Exclusions ,,
ONDANSETRON 4 MG ORAL TBDP,RX-27697,CDM,Q0162,HCPCS,259,RC,68462-0157-40,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.01,416.02,other,SI=N Exclusions ,,
PROCHLORPERAZINE MALEATE 5 MG ORAL TABS,RX-6583,CDM,Q0164,HCPCS,259,RC,50268-0684-15,NDC,outpatient,1,UN,3.56,2.492,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.35,416.02,other,SI=N Exclusions ,,
PROCHLORPERAZINE MALEATE 5 MG ORAL TABS,RX-6583,CDM,Q0164,HCPCS,259,RC,50268-0684-11,NDC,outpatient,1,UN,3.56,2.492,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.35,416.02,other,SI=N Exclusions ,,
DRONABINOL 2.5 MG ORAL CAPS,RX-9904,CDM,Q0167,HCPCS,259,RC,60687-0375-11,NDC,outpatient,1,UN,18.82,13.174,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.73,416.02,other,SI=N Exclusions ,,
DRONABINOL 2.5 MG ORAL CAPS,RX-9904,CDM,Q0167,HCPCS,259,RC,60687-0375-21,NDC,outpatient,1,UN,18.82,13.174,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.73,416.02,other,SI=N Exclusions ,,
PROMETHAZINE HCL 25 MG ORAL TABS,RX-6622,CDM,Q0169,HCPCS,259,RC,00904-7304-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,SI=N Exclusions ,,
PROMETHAZINE HCL 25 MG ORAL TABS,RX-6622,CDM,Q0169,HCPCS,259,RC,68382-0041-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.09,416.02,other,SI=N Exclusions ,,
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,00069-6001-21,NDC,outpatient,10,ML,77.92,54.544,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.55,416.02,other,SI=N Exclusions ,,
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,00069-6001-10,NDC,outpatient,10,ML,77.92,54.544,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.55,416.02,other,SI=N Exclusions ,,
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,63323-0403-01,NDC,outpatient,2,ML,19.75,13.825,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.55,416.02,other,SI=N Exclusions ,,
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,63323-0403-02,NDC,outpatient,2,ML,19.75,13.825,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.55,416.02,other,SI=N Exclusions ,,
DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ,RX-27431,CDM,Q2050,HCPCS,636,RC,47335-0050-40,NDC,outpatient,25,ML,1589.76,1112.832,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,136.23,,,724.25,87.98,1653.428703,fee schedule,,,
DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ,RX-27431,CDM,Q2050,HCPCS,636,RC,00338-0067-01,NDC,outpatient,25,ML,1408.44,985.908,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,136.23,,,724.25,87.98,1653.428703,fee schedule,,,
HC Telehealth Originating Site Facility Fee,PX-78000001,CDM,Q3014,HCPCS,780,RC,,,outpatient,,,373,261.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,83.7385,416.02,other,Non-Reimbursable List,,
IMPLANT TY I COLL 1X1IN DURAMATRIX-ONLAY -,SUP-CDSLM11,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,1553.95,1087.765,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,348.861775,3862.93248,other,Non-Reimbursable List,,
DURAMATRIX SUTURABLE 2 X 2 -,SUP-DMS22,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,2490.5,1743.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,348.861775,3862.93248,other,Non-Reimbursable List,,
DURAMATRIX SUTURABLE  3x3 -,SUP-DMS33,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,4042.29,2829.603,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,348.861775,3862.93248,other,Non-Reimbursable List,,
DURAMATRIX SUTURABLE 4 X 5 -,SUP-DMS45,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,5029.86,3520.902,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,348.861775,3862.93248,other,Non-Reimbursable List,,
HC Skin Apligraf,PX-63600004,CDM,Q4101,HCPCS,636,RC,,,outpatient,,,8745,6121.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,30.42,6716.16,other,Non-Reimbursable List,,
HC Matrix Wound Oasis by Sq Cm,PX-63600006,CDM,Q4102,HCPCS,636,RC,,,outpatient,,,65,45.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.25,659.42016,other,Non-Reimbursable List,,
DRESSING WND 3 X 3.5CM OASIS WND MATRIX -,SUP-8213-1000-33,CDM,Q4102,CPT,278,RC,,,outpatient,,,858.62,601.034,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,12.25,659.42016,other,Non-Reimbursable List,,
INTEGRA BILAYER MATRIX WOUND DRESSING 4 x 5 -,SUP-BMW4051,CDM,Q4104,HCPCS,278,RC,,,outpatient,,,24698.88,17289.216,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.96,24594.91584,other,Non-Reimbursable List,,
MATRIX MESHED BILAYER 2X2 INTE -,SUP-MWM2021,CDM,Q4104,HCPCS,278,RC,,,outpatient,,,20440.07,14308.049,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.96,24594.91584,other,Non-Reimbursable List,,
MATRIX MESH BILAYER 4 X 5 -,SUP-MWM4051,CDM,Q4104,HCPCS,278,RC,,,outpatient,,,32024.63,22417.241,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,48.96,24594.91584,other,Non-Reimbursable List,,
HC Primatrix Mesh by Sq Cm,PX-63600008,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,186,130.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.757,4074.24,other,Non-Reimbursable List,,
PRIMATRIX 0.2 x 26.5 ROPE 3 UNITS/BOX -,SUP-607-001-009,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,2157.3,1510.11,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.757,4074.24,other,Non-Reimbursable List,,
PRIMATRIX 2X2 MESHED -,SUP-607-005-220,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,2364.02,1654.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.757,4074.24,other,Non-Reimbursable List,,
PRIMATRIX 3X3 MESHED -,SUP-607-005-330,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,2506.35,1754.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.757,4074.24,other,Non-Reimbursable List,,
PRIMATRIX 4 X 4CM  MESH -,SUP-607-005-440,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,3074.46,2152.122,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.757,4074.24,other,Non-Reimbursable List,,
PRIMATRIX 6 X 6 MESH -,SUP-607-005-660,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,5305,3713.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.757,4074.24,other,Non-Reimbursable List,,
PRIMATRIX 4X4 AG -,SUP-UNDEFINED,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,41.757,4074.24,other,Non-Reimbursable List,,
ALLODERM LARGE THK1.04-2.28 MM THICK L12 CM X W4 CM 48CM2 -,SUP-102050,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,5700.37,3990.259,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,31.11,14996.48256,other,Non-Reimbursable List,,
ALLODERM LARGE THK2-2.8 MM THICK L12CM X W6CM 72CM2 -,SUP-151972,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,4655.67,3258.969,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,31.11,14996.48256,other,Non-Reimbursable List,,
GRAFT SOFT TISSUE AXIS TUTOPLAST DERMIS 12CM X 8CM ALLODERM -,SUP-939812,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,10961.89,7673.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,31.11,14996.48256,other,Non-Reimbursable List,,
ALLODERM CONTOUR LARGE PERF L21.5 CM X W10 230.05CM2 -,SUP-CL1519P,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,19526.67,13668.669,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,31.11,14996.48256,other,Non-Reimbursable List,,
ALLODERM CONTOUR MED PERF THICK 19.3 CM X 9.6 CM 185.28CM2 -,SUP-CM1519P,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,15267.86,10687.502,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,31.11,14996.48256,other,Non-Reimbursable List,,
ACELL MICROMATRIX POWDER 200MG -,SUP-MM0200,CDM,Q4118,HCPCS,278,RC,,,outpatient,,,2929.8,2050.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.5,8051.0208,other,Non-Reimbursable List,,
ACELL MICRO MATRIX 500 MG -,SUP-MM0500,CDM,Q4118,HCPCS,278,RC,,,outpatient,,,5728.55,4009.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.5,8051.0208,other,Non-Reimbursable List,,
ACELL MICRO MATRIX 1000 MG -,SUP-MM1000,CDM,Q4118,HCPCS,278,RC,,,outpatient,,,10483.1,7338.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,2.5,8051.0208,other,Non-Reimbursable List,,
SURGICLOSE MICRO 38CM2 -,SUP-50205P04D0D,CDM,Q4121,HCPCS,636,RC,,,outpatient,,,8488,5941.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,46.98,6518.784,other,SI=N Exclusions ,,
HC Matrix Wound Oasis Ultra by Sq Cm,PX-63600010,CDM,Q4124,HCPCS,636,RC,,,outpatient,,,61,42.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.16,4034.304,other,Non-Reimbursable List,,
HC Matrix Oasis Ultra 7 X 10,PX-63600014,CDM,Q4124,HCPCS,636,RC,,,outpatient,,,5253,3677.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.16,4034.304,other,Non-Reimbursable List,,
GRAFT ARTHROFLEX DERMIS THK1.5MM 35MM X 35MM 12.25CM2 -,SUP-AFLEX100,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,7779.25,5445.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,209.5932,10851.38688,other,Non-Reimbursable List,,
DERMIS DECELLULARIZED 35MM X 35MM X 2.0MM 12.25SQCM -,SUP-AFLEX200,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,11781.35,8246.945,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,209.5932,10851.38688,other,Non-Reimbursable List,,
ARTHROFLEX 40MM X 70MM X 3.0 DERMIS DECELLULARIZED 28SQCM -,SUP-AFLEX301,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,14129.41,9890.587,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,209.5932,10851.38688,other,Non-Reimbursable List,,
ARTHROFLEX 25 X 30 X 1MM 7.5SQCM -,SUP-AFLEX403,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,209.5932,10851.38688,other,Non-Reimbursable List,,
CONNECT PRE-SUTURED TENDON-ZORC 4.5 x 160MM -,SUP-FCON,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,5187.44,3631.208,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,209.5932,10851.38688,other,Non-Reimbursable List,,
SURGICLOSE 7 X 10CM- 70SQCM -,SUP-50205N03D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,16121.85,11285.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.06,20434.45248,other,Non-Reimbursable List,,
SURGICLOSE 6 X 8 MESHED 2:1 UP TO 86CM2 -,SUP-50205N18D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,10804.83,7563.381,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.06,20434.45248,other,Non-Reimbursable List,,
SURGICLOSE MESHED 2:1 4X6 CM- 24SQCM -,SUP-50205N20D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,6934.7,4854.29,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.06,20434.45248,other,Non-Reimbursable List,,
SURGICLOSE MESHED 7 X 20 -,SUP-50205N21D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,26607.36,18625.152,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.06,20434.45248,other,Non-Reimbursable List,,
SURGICLOSE MICRO 95 CM2 -,SUP-50205P31D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,15965.9,11176.13,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,3.06,20434.45248,other,Non-Reimbursable List,,
ACELL WOUND/BURN MATRIX 2 LAYER -,SUP-BMM0710,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,4509.25,3156.475,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,18.9,9453.0048,other,Non-Reimbursable List,,
CYTAL BURN MATRIX -,SUP-BMM1015,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,8116.65,5681.655,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,18.9,9453.0048,other,Non-Reimbursable List,,
CYTAL WOUND MATRIX 1 LAYER 3 X 7CM -,SUP-WS0307,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,853.08,597.156,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,18.9,9453.0048,other,Non-Reimbursable List,,
MATRIX WOUND ACELL GENTRIX 5M X 5CM 25CM2 3 LAYERS -,SUP-WSR0505,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,4118.77,2883.139,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,18.9,9453.0048,other,Non-Reimbursable List,,
WOUND MATRIX CYTEL 3 LAYER 7 X 10CM -,SUP-WSR0710,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,8206.84,5744.788,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,18.9,9453.0048,other,Non-Reimbursable List,,
WOUND MATRIX 3 LAYER 10 X 15CM -,SUP-WSR1015,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,12308.6,8616.02,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,18.9,9453.0048,other,Non-Reimbursable List,,
ACELL WOUND MATRIX 6-LAYER MESH -,SUP-WSX0505,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,4869.99,3408.993,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,18.9,9453.0048,other,Non-Reimbursable List,,
CYTAL WOUND MATRIX 6 LAYER 7 X 10CM -,SUP-WSX0710,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,9562.83,6693.981,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,18.9,9453.0048,other,Non-Reimbursable List,,
HC Epifix- per Square Centimeter,PX-63600024,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,501,350.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,112.4745,3643.99872,other,Non-Reimbursable List,,
EPIFIX DISK 14MM -,SUP-GS-5140,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,1746.51,1222.557,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,112.4745,3643.99872,other,Non-Reimbursable List,,
EPIFIX DISK 18MM -,SUP-GS-5180,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,3733.27,2613.289,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,112.4745,3643.99872,other,Non-Reimbursable List,,
EPIFIX 2 X 2 CM -,SUP-GS-5220,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,4744.79,3321.353,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,112.4745,3643.99872,other,Non-Reimbursable List,,
PURAPLY AM 2CMX2CM -,SUP-00000000000000000000000000000,CDM,Q4196,HCPCS,636,RC,,,outpatient,,,4057.9,2840.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,102.28,3422.3616,other,SI=N Exclusions ,,
PURAPLY AM 2CMX4CM -,SUP-PURAPLYAM-COM 2X4,CDM,Q4196,HCPCS,636,RC,,,outpatient,,,4456.2,3119.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,102.28,3422.3616,other,SI=N Exclusions ,,
FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY,RX-132201,CDM,Q5101,HCPCS,636,RC,61314-0318-01,NDC,outpatient,0.5,ML,603.11,422.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.25,,,51,0.18,741.12768,fee schedule,,,
FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY,RX-132201,CDM,Q5101,HCPCS,636,RC,61314-0318-10,NDC,outpatient,0.5,ML,603.14,422.198,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.25,,,51,0.18,741.12768,fee schedule,,,
FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY,RX-132201,CDM,Q5101,HCPCS,636,RC,61314-0318-05,NDC,outpatient,0.5,ML,603.14,422.198,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.25,,,51,0.18,741.12768,fee schedule,,,
FILGRASTIM-SNDZ 480 MCG/0.8ML IJ SOSY,RX-132202,CDM,Q5101,HCPCS,636,RC,61314-0326-10,NDC,outpatient,0.8,ML,965.01,675.507,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.25,,,81.6,0.18,741.12768,fee schedule,,,
FILGRASTIM-SNDZ 480 MCG/0.8ML IJ SOSY,RX-132202,CDM,Q5101,HCPCS,636,RC,61314-0326-05,NDC,outpatient,0.8,ML,965.01,675.507,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,0.25,,,81.6,0.18,741.12768,fee schedule,,,
INFLIXIMAB-DYYB 100 MG IV SOLR,RX-136637,CDM,Q5103,HCPCS,636,RC,00069-0809-01,NDC,outpatient,1,UN,1389.66,972.762,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,10.66,,,139.3,13.62,1653.428703,fee schedule,,,
INFLIXIMAB-ABDA 100 MG IV SOLR,RX-139995,CDM,Q5104,HCPCS,636,RC,00006-4305-01,NDC,outpatient,1,UN,1902.38,1331.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29.91,,,325.6,27.18,1653.428703,fee schedule,,,
INFLIXIMAB-ABDA 100 MG IV SOLR,RX-139995,CDM,Q5104,HCPCS,636,RC,00006-4305-02,NDC,outpatient,1,UN,1902.38,1331.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,29.91,,,325.6,27.18,1653.428703,fee schedule,,,
EPOETIN ALFA-EPBX 2000 UNIT/ML IJ SOLN,RX-143174,CDM,Q5106,HCPCS,636,RC,00069-1305-10,NDC,outpatient,1,ML,79.46,55.622,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6.82,,,14.5,7.5,416.02,fee schedule,,,
EPOETIN ALFA-EPBX 2000 UNIT/ML IJ SOLN,RX-143174,CDM,Q5106,HCPCS,636,RC,00069-1305-01,NDC,outpatient,1,ML,79.46,55.622,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6.82,,,14.5,7.5,416.02,fee schedule,,,
EPOETIN ALFA-EPBX 3000 UNIT/ML IJ SOLN,RX-143175,CDM,Q5106,HCPCS,636,RC,00069-1306-01,NDC,outpatient,1,ML,119.19,83.433,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6.82,,,21.75,7.5,416.02,fee schedule,,,
EPOETIN ALFA-EPBX 3000 UNIT/ML IJ SOLN,RX-143175,CDM,Q5106,HCPCS,636,RC,00069-1306-10,NDC,outpatient,1,ML,119.19,83.433,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6.82,,,21.75,7.5,416.02,fee schedule,,,
EPOETIN ALFA-EPBX 4000 UNIT/ML IJ SOLN,RX-143176,CDM,Q5106,HCPCS,636,RC,00069-1307-01,NDC,outpatient,1,ML,158.92,111.244,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6.82,,,29,7.5,416.02,fee schedule,,,
EPOETIN ALFA-EPBX 4000 UNIT/ML IJ SOLN,RX-143176,CDM,Q5106,HCPCS,636,RC,00069-1307-10,NDC,outpatient,1,ML,158.92,111.244,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6.82,,,29,7.5,416.02,fee schedule,,,
EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN,RX-143177,CDM,Q5106,HCPCS,636,RC,00069-1308-01,NDC,outpatient,1,ML,377.7,264.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6.82,,,72.5,7.5,416.02,fee schedule,,,
EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN,RX-143177,CDM,Q5106,HCPCS,636,RC,00069-1308-10,NDC,outpatient,1,ML,377.7,264.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6.82,,,72.5,7.5,416.02,fee schedule,,,
EPOETIN ALFA-EPBX 40000 UNIT/ML IJ SOLN,RX-143178,CDM,Q5106,HCPCS,636,RC,00069-1309-01,NDC,outpatient,0.05,ML,75.54,52.878,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6.82,,,14.5,7.5,416.02,fee schedule,,,
EPOETIN ALFA-EPBX 40000 UNIT/ML IJ SOLN,RX-143178,CDM,Q5106,HCPCS,636,RC,00069-1309-04,NDC,outpatient,0.05,ML,75.54,52.878,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,6.82,,,14.5,7.5,416.02,fee schedule,,,
RITUXIMAB-ABBS 10 MG/ML IV SOLN WRAPPER,RX-4081244,CDM,Q5115,HCPCS,636,RC,63459-0104-50,NDC,outpatient,50,ML,6662.37,4663.659,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,33.7,,,1881.5,33.59,7269.974281,fee schedule,,,
RITUXIMAB-ABBS 10 MG/ML IV SOLN WRAPPER,RX-4081244,CDM,Q5115,HCPCS,636,RC,63459-0103-10,NDC,outpatient,10,ML,1691.22,1183.854,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,33.7,,,376.3,33.59,7269.974281,fee schedule,,,
INFLIXIMAB-AXXQ 100 MG IV SOLR,RX-150921,CDM,Q5121,HCPCS,636,RC,55513-0670-01,NDC,outpatient,1,UN,2071.48,1450.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,21.89,,,264.7,21.29,1590.89664,fee schedule,,,
MEDIA CONTR PRFLTRN LPD MICSPHR INJ SUSP VL DEFINITY -,SUP-DE16,CDM,Q9957,CPT,636,RC,,,outpatient,,,554.33,388.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,40.92,438.4896,other,Non-Reimbursable List,,
DEFINITY DE-4 -,SUP-DE4,CDM,Q9957,CPT,636,RC,,,outpatient,,,570.95,399.665,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,40.92,438.4896,other,Non-Reimbursable List,,
DIATRIZOATE MEGLUMINE & SODIUM 66-10 % ORAL SOLN,RX-9828,CDM,Q9963,HCPCS,636,RC,00270-0445-40,NDC,outpatient,7.5,ML,3.71,2.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.22,416.02,other,Non-Reimbursable List,,
IOHEXOL 180 MG/ML IJ SOLN,RX-10319,CDM,Q9965,HCPCS,636,RC,00407-1411-10,NDC,outpatient,3,ML,16.35,11.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.56,416.02,other,Non-Reimbursable List,,
IOHEXOL 180 MG/ML IJ SOLN,RX-10319,CDM,Q9965,HCPCS,636,RC,99999-0004-10,NDC,outpatient,3,ML,16.35,11.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,1.56,416.02,other,Non-Reimbursable List,,
IOPAMIDOL 41 % IJ SOLN,RX-10325,CDM,Q9966,HCPCS,636,RC,00270-1411-11,NDC,outpatient,10,ML,98.1,68.67,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.38,416.02,other,Non-Reimbursable List,,
IOHEXOL 240 MG/ML IJ SOLN,RX-119843,CDM,Q9966,HCPCS,636,RC,00407-1412-33,NDC,outpatient,10,ML,32.7,22.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.38,416.02,other,Non-Reimbursable List,,
IOHEXOL 240 MG/ML IJ SOLN,RX-119843,CDM,Q9966,HCPCS,636,RC,99999-0004-07,NDC,outpatient,10,ML,32.7,22.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.38,416.02,other,Non-Reimbursable List,,
IOHEXOL 240 MG/ML IJ SOLN,RX-119843,CDM,Q9966,HCPCS,636,RC,00407-1412-30,NDC,outpatient,10,ML,32.7,22.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.38,416.02,other,Non-Reimbursable List,,
IOPAMIDOL 61 % IJ SOLN,RX-10327,CDM,Q9967,HCPCS,636,RC,00270-1412-15,NDC,outpatient,15,ML,81.75,57.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.14,416.02,other,Non-Reimbursable List,,
IOPAMIDOL 76 % IV SOLN,RX-10328,CDM,Q9967,HCPCS,636,RC,00270-1316-35,NDC,outpatient,50,ML,272.5,190.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.14,416.02,other,Non-Reimbursable List,,
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-10,NDC,outpatient,5,ML,10.9,7.63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.14,416.02,other,Non-Reimbursable List,,
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-58,NDC,outpatient,5,ML,10.9,7.63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.14,416.02,other,Non-Reimbursable List,,
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-59,NDC,outpatient,5,ML,10.9,7.63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.14,416.02,other,Non-Reimbursable List,,
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-63,NDC,outpatient,5,ML,10.9,7.63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.14,416.02,other,Non-Reimbursable List,,
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-61,NDC,outpatient,5,ML,10.9,7.63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.14,416.02,other,Non-Reimbursable List,,
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,99999-0004-09,NDC,outpatient,5,ML,10.9,7.63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.14,416.02,other,Non-Reimbursable List,,
IOPAMIDOL 61 % IV SOLN,RX-27737,CDM,Q9967,HCPCS,636,RC,00270-1315-25,NDC,outpatient,30,ML,163.5,114.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.14,416.02,other,Non-Reimbursable List,,
IOVERSOL 68 % IJ SOLN,RX-39700,CDM,Q9967,HCPCS,636,RC,00019-1323-02,NDC,outpatient,20,ML,109,76.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.14,416.02,other,Non-Reimbursable List,,
ISOSULFAN BLUE 1 % SC SOLN,RX-10358,CDM,Q9968,HCPCS,636,RC,67457-0220-00,NDC,outpatient,5,ML,2840.8,1988.56,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.53,2181.7344,other,Non-Reimbursable List,,
ISOSULFAN BLUE 1 % SC SOLN,RX-10358,CDM,Q9968,HCPCS,636,RC,67457-0220-05,NDC,outpatient,5,ML,2840.8,1988.56,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,9.53,2181.7344,other,Non-Reimbursable List,,
ACETAMINOPHEN 160 MG/5ML ORAL SOLN,RX-100,CDM,S5000,HCPCS,259,RC,00121-1971-21,NDC,outpatient,650,ME,11.57,8.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACETAMINOPHEN 160 MG/5ML ORAL SOLN,RX-100,CDM,S5000,HCPCS,259,RC,81033-0002-20,NDC,outpatient,650,ME,11.57,8.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACETAMINOPHEN 160 MG/5ML ORAL SOLN,RX-100,CDM,S5000,HCPCS,259,RC,00121-1971-00,NDC,outpatient,650,ME,11.57,8.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACETAMINOPHEN 160 MG/5ML ORAL SOLN,RX-100,CDM,S5000,HCPCS,259,RC,81033-0002-30,NDC,outpatient,650,ME,11.57,8.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FAMOTIDINE 40 MG/5ML ORAL SUSR,RX-10010,CDM,S5000,HCPCS,259,RC,70954-0316-10,NDC,outpatient,50,ML,117.71,82.397,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FAMOTIDINE 40 MG/5ML ORAL SUSR,RX-10010,CDM,S5000,HCPCS,259,RC,99999-0004-18,NDC,outpatient,2.5,ML,4.86,3.402,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FAMOTIDINE 20 MG ORAL TABS,RX-10011,CDM,S5000,HCPCS,259,RC,50268-0299-15,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FAMOTIDINE 20 MG ORAL TABS,RX-10011,CDM,S5000,HCPCS,259,RC,62332-0001-31,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FAMOTIDINE 20 MG ORAL TABS,RX-10011,CDM,S5000,HCPCS,259,RC,00904-7193-06,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FAMOTIDINE 20 MG ORAL TABS,RX-10011,CDM,S5000,HCPCS,259,RC,50268-0299-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FAMOTIDINE 20 MG ORAL TABS,RX-10011,CDM,S5000,HCPCS,259,RC,63739-0645-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FELBAMATE 600 MG ORAL TABS,RX-10025,CDM,S5000,HCPCS,259,RC,72578-0057-16,NDC,outpatient,1,UN,5.99,4.193,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FINASTERIDE 5 MG ORAL TABS,RX-10037,CDM,S5000,HCPCS,259,RC,00904-6830-61,NDC,outpatient,1,UN,2.18,1.526,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FINASTERIDE 5 MG ORAL TABS,RX-10037,CDM,S5000,HCPCS,259,RC,60687-0428-01,NDC,outpatient,1,UN,2.29,1.603,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FINASTERIDE 5 MG ORAL TABS,RX-10037,CDM,S5000,HCPCS,259,RC,60687-0428-11,NDC,outpatient,1,UN,2.29,1.603,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FINASTERIDE 5 MG ORAL TABS,RX-10037,CDM,S5000,HCPCS,259,RC,00904-6830-06,NDC,outpatient,1,UN,1.66,1.162,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLECAINIDE ACETATE 100 MG ORAL TABS,RX-10041,CDM,S5000,HCPCS,259,RC,50268-0321-15,NDC,outpatient,1,UN,2.86,2.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLECAINIDE ACETATE 100 MG ORAL TABS,RX-10041,CDM,S5000,HCPCS,259,RC,00054-0011-21,NDC,outpatient,1,UN,2.98,2.086,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLECAINIDE ACETATE 100 MG ORAL TABS,RX-10041,CDM,S5000,HCPCS,259,RC,50268-0321-11,NDC,outpatient,1,UN,2.86,2.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLECAINIDE ACETATE 50 MG ORAL TABS,RX-10043,CDM,S5000,HCPCS,259,RC,00054-0010-20,NDC,outpatient,1,UN,2.45,1.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLECAINIDE ACETATE 50 MG ORAL TABS,RX-10043,CDM,S5000,HCPCS,259,RC,50268-0320-15,NDC,outpatient,1,UN,3.66,2.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLECAINIDE ACETATE 50 MG ORAL TABS,RX-10043,CDM,S5000,HCPCS,259,RC,50268-0320-11,NDC,outpatient,1,UN,3.66,2.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLUCONAZOLE 100 MG ORAL TABS,RX-10044,CDM,S5000,HCPCS,259,RC,68084-0728-11,NDC,outpatient,1,UN,4.94,3.458,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLUCONAZOLE 100 MG ORAL TABS,RX-10044,CDM,S5000,HCPCS,259,RC,00904-6500-61,NDC,outpatient,1,UN,4.03,2.821,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLUCONAZOLE 100 MG ORAL TABS,RX-10044,CDM,S5000,HCPCS,259,RC,68084-0728-01,NDC,outpatient,1,UN,4.94,3.458,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLUCONAZOLE 200 MG ORAL TABS,RX-10045,CDM,S5000,HCPCS,259,RC,00904-6501-61,NDC,outpatient,1,UN,6.68,4.676,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VITAMIN D2 (ERGOCALCIFEROL) 1.25 MG (50000 UNITS) ORAL CAPS,RX-100493,CDM,S5000,HCPCS,259,RC,50268-0297-11,NDC,outpatient,1,UN,3.93,2.751,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VITAMIN D2 (ERGOCALCIFEROL) 1.25 MG (50000 UNITS) ORAL CAPS,RX-100493,CDM,S5000,HCPCS,259,RC,50268-0297-15,NDC,outpatient,1,UN,3.93,2.751,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VITAMIN D2 (ERGOCALCIFEROL) 1.25 MG (50000 UNITS) ORAL CAPS,RX-100493,CDM,S5000,HCPCS,259,RC,64380-0737-06,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLUCYTOSINE 500 MG ORAL CAPS,RX-10052,CDM,S5000,HCPCS,259,RC,42794-0010-08,NDC,outpatient,1,UN,233.01,163.107,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLUDROCORTISONE ACETATE 0.1 MG ORAL TABS,RX-10054,CDM,S5000,HCPCS,259,RC,50268-0330-15,NDC,outpatient,1,UN,2.26,1.582,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLUDROCORTISONE ACETATE 0.1 MG ORAL TABS,RX-10054,CDM,S5000,HCPCS,259,RC,00115-7033-01,NDC,outpatient,1,UN,2.43,1.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLUDROCORTISONE ACETATE 0.1 MG ORAL TABS,RX-10054,CDM,S5000,HCPCS,259,RC,50268-0330-11,NDC,outpatient,1,UN,2.26,1.582,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLUOROURACIL 5 % EX CREA,RX-10065,CDM,S5000,HCPCS,259,RC,51672-4118-06,NDC,outpatient,40,GR,108.41,75.887,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLUOROURACIL 5 % EX CREA,RX-10065,CDM,S5000,HCPCS,259,RC,16729-0542-35,NDC,outpatient,40,GR,458.18,320.726,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLUOXETINE HCL 10 MG ORAL CAPS,RX-10069,CDM,S5000,HCPCS,259,RC,16714-0720-02,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLUOXETINE HCL 20 MG ORAL CAPS,RX-10070,CDM,S5000,HCPCS,259,RC,00904-7346-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLURBIPROFEN SODIUM 0.03 % OP SOLN,RX-10080,CDM,S5000,HCPCS,259,RC,69292-0722-25,NDC,outpatient,2.5,ML,140.89,98.623,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLUVOXAMINE MALEATE 50 MG ORAL TABS,RX-10085,CDM,S5000,HCPCS,259,RC,60505-0165-01,NDC,outpatient,1,UN,1.63,1.141,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FOSINOPRIL SODIUM 10 MG ORAL TABS,RX-10094,CDM,S5000,HCPCS,259,RC,69097-0856-05,NDC,outpatient,1,UN,1.76,1.232,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RITONAVIR 100 MG ORAL TABS,RX-100995,CDM,S5000,HCPCS,259,RC,00074-2340-30,NDC,outpatient,1,UN,37.01,25.907,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GLIPIZIDE 5 MG ORAL TABS,RX-10117,CDM,S5000,HCPCS,259,RC,00904-6637-61,NDC,outpatient,1,UN,1.21,0.847,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GLIPIZIDE 5 MG ORAL TABS,RX-10117,CDM,S5000,HCPCS,259,RC,60505-0141-00,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GLYBURIDE 2.5 MG ORAL TABS,RX-10126,CDM,S5000,HCPCS,259,RC,00093-8343-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GLYCOPYRROLATE 1 MG ORAL TABS,RX-10130,CDM,S5000,HCPCS,259,RC,23155-0606-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GUANFACINE HCL 1 MG ORAL TABS,RX-10149,CDM,S5000,HCPCS,259,RC,68094-0065-62,NDC,outpatient,1,UN,8.9,6.23,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GUANFACINE HCL 1 MG ORAL TABS,RX-10149,CDM,S5000,HCPCS,259,RC,68094-0065-59,NDC,outpatient,1,UN,8.9,6.23,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACETAMINOPHEN 500 MG ORAL TABS,RX-102,CDM,S5000,HCPCS,259,RC,00904-6730-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROCORTISONE 5 MG ORAL TABS,RX-10209,CDM,S5000,HCPCS,259,RC,64380-0970-25,NDC,outpatient,1,UN,1.23,0.861,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROCORTISONE 5 MG ORAL TABS,RX-10209,CDM,S5000,HCPCS,259,RC,59762-0073-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROCORTISONE 100 MG/60ML RE ENEM,RX-10210,CDM,S5000,HCPCS,259,RC,62559-0138-07,NDC,outpatient,60,ML,88.11,61.677,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROCORTISONE 100 MG/60ML RE ENEM,RX-10210,CDM,S5000,HCPCS,259,RC,62559-0138-11,NDC,outpatient,60,ML,88.11,61.677,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROCORTISONE MICRONIZED POWD,RX-10217,CDM,S5000,HCPCS,259,RC,51552-0020-05,NDC,outpatient,100,GR,1580.42,1106.294,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROXYCHLOROQUINE SULFATE 200 MG ORAL TABS,RX-10235,CDM,S5000,HCPCS,259,RC,68084-0269-11,NDC,outpatient,1,UN,4.87,3.409,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROXYCHLOROQUINE SULFATE 200 MG ORAL TABS,RX-10235,CDM,S5000,HCPCS,259,RC,00904-7046-61,NDC,outpatient,1,UN,3.27,2.289,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROXYCHLOROQUINE SULFATE 200 MG ORAL TABS,RX-10235,CDM,S5000,HCPCS,259,RC,68084-0269-01,NDC,outpatient,1,UN,4.87,3.409,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROXYUREA 500 MG ORAL CAPS,RX-10236,CDM,S5000,HCPCS,259,RC,68084-0284-01,NDC,outpatient,1,UN,3.02,2.114,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROXYUREA 500 MG ORAL CAPS,RX-10236,CDM,S5000,HCPCS,259,RC,68084-0284-11,NDC,outpatient,1,UN,3.02,2.114,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,00121-0914-00,NDC,outpatient,5,ML,2.5,1.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,00121-0914-05,NDC,outpatient,5,ML,2.5,1.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,51672-2130-08,NDC,outpatient,120,ML,11.22,7.854,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,59651-0032-05,NDC,outpatient,5,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,68094-0494-62,NDC,outpatient,5,ML,2.59,1.813,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,59651-0032-47,NDC,outpatient,473,ML,67.36,47.152,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,68094-0494-59,NDC,outpatient,5,ML,2.54,1.778,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,99999-0004-24,NDC,outpatient,5,ML,1.37,0.959,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,68094-0494-61,NDC,outpatient,5,ML,2.54,1.778,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
INDIGOTINDISULFONATE SODIUM 8 MG/ML IJ SOLN,RX-10265,CDM,S5000,HCPCS,250,RC,81284-0315-00,NDC,outpatient,5,ML,1398.02,978.614,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
INDIGOTINDISULFONATE SODIUM 8 MG/ML IJ SOLN,RX-10265,CDM,S5000,HCPCS,250,RC,81284-0315-05,NDC,outpatient,5,ML,1398.02,978.614,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
INDOCYANINE GREEN 25 MG IV SOLR,RX-10266,CDM,S5000,HCPCS,250,RC,70100-0424-02,NDC,outpatient,1,UN,501.97,351.379,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
INDOCYANINE GREEN 25 MG IV SOLR,RX-10266,CDM,S5000,HCPCS,250,RC,70100-0424-01,NDC,outpatient,1,UN,501.97,351.379,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
INDOMETHACIN SODIUM 1 MG IV SOLR,RX-10267,CDM,S5000,HCPCS,250,RC,63323-0659-03,NDC,outpatient,1,UN,1192.43,834.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
INSULIN NPH (HUMAN) (ISOPHANE) 100 UNIT/ML SC SUSP,RX-10284,CDM,S5000,HCPCS,259,RC,00002-8315-01,NDC,outpatient,10,ML,61.5,43.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
INSULIN REGULAR HUMAN 100 UNIT/ML IJ SOLN,RX-10289,CDM,S5000,HCPCS,259,RC,00002-8215-01,NDC,outpatient,10,ML,61.5,43.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACETAMINOPHEN 120 MG RE SUPP,RX-103,CDM,S5000,HCPCS,259,RC,45802-0732-30,NDC,outpatient,1,UN,1.69,1.183,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BETAMETHASONE VALERATE 0.1 % EX CREA,RX-1031,CDM,S5000,HCPCS,259,RC,00713-0326-15,NDC,outpatient,15,GR,50.4,35.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BETAMETHASONE VALERATE 0.1 % EX CREA,RX-1031,CDM,S5000,HCPCS,259,RC,00472-0370-15,NDC,outpatient,15,GR,93.12,65.184,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BETAMETHASONE VALERATE 0.1 % EX LOTN,RX-1032,CDM,S5000,HCPCS,259,RC,00168-0041-60,NDC,outpatient,60,ML,267,186.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ISOSORBIDE MONONITRATE 20 MG ORAL TABS,RX-10357,CDM,S5000,HCPCS,259,RC,00228-2620-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ISRADIPINE 5 MG ORAL CAPS,RX-10363,CDM,S5000,HCPCS,259,RC,16252-0540-01,NDC,outpatient,1,UN,8.59,6.013,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ITRACONAZOLE 100 MG ORAL CAPS,RX-10364,CDM,S5000,HCPCS,259,RC,16714-0743-02,NDC,outpatient,1,UN,5.65,3.955,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
KETOCONAZOLE 2 % EX CREA,RX-10368,CDM,S5000,HCPCS,259,RC,00168-0099-15,NDC,outpatient,15,GR,22.57,15.799,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
KETOROLAC TROMETHAMINE 10 MG ORAL TABS,RX-10371,CDM,S5000,HCPCS,259,RC,70710-1710-01,NDC,outpatient,1,UN,3.63,2.541,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
KETOROLAC TROMETHAMINE 10 MG ORAL TABS,RX-10371,CDM,S5000,HCPCS,259,RC,00093-0314-01,NDC,outpatient,1,UN,4.33,3.031,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LABETALOL HCL 100 MG ORAL TABS,RX-10373,CDM,S5000,HCPCS,259,RC,60687-0439-01,NDC,outpatient,1,UN,1.32,0.924,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LABETALOL HCL 100 MG ORAL TABS,RX-10373,CDM,S5000,HCPCS,259,RC,60687-0439-11,NDC,outpatient,1,UN,1.32,0.924,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LABETALOL HCL 200 MG ORAL TABS,RX-10374,CDM,S5000,HCPCS,259,RC,60687-0450-01,NDC,outpatient,1,UN,1.81,1.267,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LABETALOL HCL 200 MG ORAL TABS,RX-10374,CDM,S5000,HCPCS,259,RC,60687-0450-11,NDC,outpatient,1,UN,1.81,1.267,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMMONIUM LACTATE 12 % EX LOTN,RX-10380,CDM,S5000,HCPCS,259,RC,00904-5984-26,NDC,outpatient,226,GR,13.08,9.156,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMMONIUM LACTATE 12 % EX LOTN,RX-10380,CDM,S5000,HCPCS,259,RC,16864-0000-18,NDC,outpatient,225,GR,41.06,28.742,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMMONIUM LACTATE 12 % EX LOTN,RX-10380,CDM,S5000,HCPCS,259,RC,30781-7098-79,NDC,outpatient,225,GR,41.06,28.742,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMMONIUM LACTATE 12 % EX LOTN,RX-10380,CDM,S5000,HCPCS,259,RC,63044-0484-09,NDC,outpatient,225,GR,29.04,20.328,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMMONIUM LACTATE 12 % EX LOTN,RX-10380,CDM,S5000,HCPCS,259,RC,51672-1300-05,NDC,outpatient,225,GR,61.08,42.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TAMSULOSIN HCL 0.4 MG ORAL CAPS,RX-103890,CDM,S5000,HCPCS,259,RC,57237-0014-01,NDC,outpatient,1,UN,1.24,0.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TAMSULOSIN HCL 0.4 MG ORAL CAPS,RX-103890,CDM,S5000,HCPCS,259,RC,63739-0567-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TAMSULOSIN HCL 0.4 MG ORAL CAPS,RX-103890,CDM,S5000,HCPCS,259,RC,68084-0299-01,NDC,outpatient,1,UN,1.04,0.728,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TAMSULOSIN HCL 0.4 MG ORAL CAPS,RX-103890,CDM,S5000,HCPCS,259,RC,68084-0299-11,NDC,outpatient,1,UN,1.04,0.728,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TAMSULOSIN HCL 0.4 MG ORAL CAPS,RX-103890,CDM,S5000,HCPCS,259,RC,72603-0115-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACETAMINOPHEN 325 MG RE SUPP,RX-104,CDM,S5000,HCPCS,259,RC,51672-2116-02,NDC,outpatient,1,UN,2.7,1.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACETAMINOPHEN 325 MG RE SUPP,RX-104,CDM,S5000,HCPCS,259,RC,51672-2116-04,NDC,outpatient,1,UN,1.99,1.393,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVOTHYROXINE SODIUM 88 MCG ORAL TABS,RX-10403,CDM,S5000,HCPCS,259,RC,42292-0038-20,NDC,outpatient,1,UN,2.39,1.673,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVOTHYROXINE SODIUM 88 MCG ORAL TABS,RX-10403,CDM,S5000,HCPCS,259,RC,60687-0486-01,NDC,outpatient,1,UN,2.07,1.449,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVOTHYROXINE SODIUM 88 MCG ORAL TABS,RX-10403,CDM,S5000,HCPCS,259,RC,60687-0486-11,NDC,outpatient,1,UN,2.07,1.449,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVOTHYROXINE SODIUM 88 MCG ORAL TABS,RX-10403,CDM,S5000,HCPCS,259,RC,42292-0038-01,NDC,outpatient,1,UN,2.39,1.673,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVOTHYROXINE SODIUM 112 MCG ORAL TABS,RX-10404,CDM,S5000,HCPCS,259,RC,42292-0039-01,NDC,outpatient,1,UN,2.79,1.953,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVOTHYROXINE SODIUM 112 MCG ORAL TABS,RX-10404,CDM,S5000,HCPCS,259,RC,42292-0039-20,NDC,outpatient,1,UN,2.79,1.953,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVOTHYROXINE SODIUM 112 MCG ORAL TABS,RX-10404,CDM,S5000,HCPCS,259,RC,69238-1835-01,NDC,outpatient,1,UN,1.64,1.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVOTHYROXINE SODIUM 137 MCG ORAL TABS,RX-10405,CDM,S5000,HCPCS,259,RC,00074-3727-90,NDC,outpatient,1,UN,6.49,4.543,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVOTHYROXINE SODIUM 137 MCG ORAL TABS,RX-10405,CDM,S5000,HCPCS,259,RC,00378-1823-77,NDC,outpatient,1,UN,2.29,1.603,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVOTHYROXINE SODIUM 137 MCG ORAL TABS,RX-10405,CDM,S5000,HCPCS,259,RC,00527-3287-46,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVOTHYROXINE SODIUM 175 MCG ORAL TABS,RX-10406,CDM,S5000,HCPCS,259,RC,42292-0040-20,NDC,outpatient,1,UN,3.47,2.429,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVOTHYROXINE SODIUM 175 MCG ORAL TABS,RX-10406,CDM,S5000,HCPCS,259,RC,42292-0040-01,NDC,outpatient,1,UN,3.47,2.429,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00143-9595-01,NDC,outpatient,5,ML,7.61,5.327,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-04,NDC,outpatient,2,ML,4.85,3.395,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-09,NDC,outpatient,5,ML,6.46,4.522,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00409-4279-16,NDC,outpatient,30,ML,13.42,9.394,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00409-4713-12,NDC,outpatient,5,ML,4.55,3.185,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,55150-0163-30,NDC,outpatient,30,ML,6.17,4.319,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-97,NDC,outpatient,10,ML,24.48,17.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00143-9595-25,NDC,outpatient,5,ML,7.61,5.327,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00409-4279-02,NDC,outpatient,30,ML,13.42,9.394,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00409-4713-02,NDC,outpatient,5,ML,4.55,3.185,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00409-4713-26,NDC,outpatient,5,ML,4.55,3.185,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,55150-0159-74,NDC,outpatient,5,ML,3.68,2.576,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-08,NDC,outpatient,10,ML,24.48,17.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-27,NDC,outpatient,2,ML,4.85,3.395,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-57,NDC,outpatient,5,ML,6.46,4.522,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00143-9594-25,NDC,outpatient,5,ML,7.61,5.327,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-4282-02,NDC,outpatient,10,ML,10.34,7.238,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-4282-11,NDC,outpatient,2,ML,4.57,3.199,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-2066-10,NDC,outpatient,5,ML,11.34,7.938,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,55150-0164-02,NDC,outpatient,2,ML,4.16,2.912,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,55150-0165-05,NDC,outpatient,5,ML,4.63,3.241,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-2066-05,NDC,outpatient,5,ML,11.34,7.938,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-4282-12,NDC,outpatient,10,ML,10.34,7.238,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-4282-25,NDC,outpatient,2,ML,4.57,3.199,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0495-07,NDC,outpatient,5,ML,6.46,4.522,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0495-09,NDC,outpatient,2,ML,8.69,6.083,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00143-9594-01,NDC,outpatient,5,ML,7.61,5.327,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-4282-01,NDC,outpatient,2,ML,4.57,3.199,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0495-04,NDC,outpatient,5,ML,6.46,4.522,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0495-27,NDC,outpatient,2,ML,8.69,6.083,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0496-03,NDC,outpatient,10,ML,28.48,19.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0496-97,NDC,outpatient,10,ML,28.48,19.936,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE-EPINEPHRINE 0.5 %-1:200000 IJ SOLN,RX-10426,CDM,S5000,HCPCS,250,RC,00409-3177-01,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE-EPINEPHRINE 0.5 %-1:200000 IJ SOLN,RX-10426,CDM,S5000,HCPCS,250,RC,00409-3177-16,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE-EPINEPHRINE 0.5 %-1:200000 IJ SOLN,RX-10426,CDM,S5000,HCPCS,250,RC,63323-0481-57,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE-EPINEPHRINE 0.5 %-1:200000 IJ SOLN,RX-10426,CDM,S5000,HCPCS,250,RC,63323-0481-01,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,00409-3178-02,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,63323-0482-27,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,63323-0482-01,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,63323-0482-17,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,00409-3178-01,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,00409-3178-16,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,00409-3178-17,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,63323-0482-03,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE-EPINEPHRINE 1.5 %-1:200000 IJ SOLN,RX-10429,CDM,S5000,HCPCS,250,RC,63323-0488-37,NDC,outpatient,30,ML,30.31,21.217,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE-EPINEPHRINE 1.5 %-1:200000 IJ SOLN,RX-10429,CDM,S5000,HCPCS,250,RC,63323-0488-07,NDC,outpatient,30,ML,30.31,21.217,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BETHANECHOL CHLORIDE 10 MG ORAL TABS,RX-1043,CDM,S5000,HCPCS,259,RC,00832-0511-89,NDC,outpatient,1,UN,1.83,1.281,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BETHANECHOL CHLORIDE 10 MG ORAL TABS,RX-1043,CDM,S5000,HCPCS,259,RC,00832-0511-01,NDC,outpatient,1,UN,1.83,1.281,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN,RX-10430,CDM,S5000,HCPCS,250,RC,00409-3182-01,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN,RX-10430,CDM,S5000,HCPCS,250,RC,00409-3182-11,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN,RX-10430,CDM,S5000,HCPCS,250,RC,63323-0483-03,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN,RX-10430,CDM,S5000,HCPCS,250,RC,63323-0483-27,NDC,outpatient,1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN,RX-10431,CDM,S5000,HCPCS,250,RC,00409-3183-01,NDC,outpatient,20,ML,16.35,11.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN,RX-10431,CDM,S5000,HCPCS,250,RC,00409-3183-11,NDC,outpatient,20,ML,16.35,11.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN,RX-10431,CDM,S5000,HCPCS,250,RC,63323-0489-17,NDC,outpatient,10,ML,19.13,13.391,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN,RX-10431,CDM,S5000,HCPCS,250,RC,63323-0489-02,NDC,outpatient,20,ML,30.18,21.126,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN,RX-10431,CDM,S5000,HCPCS,250,RC,63323-0489-27,NDC,outpatient,20,ML,30.18,21.126,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BETHANECHOL CHLORIDE 25 MG ORAL TABS,RX-1044,CDM,S5000,HCPCS,259,RC,00832-0512-89,NDC,outpatient,1,UN,2.51,1.757,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BETHANECHOL CHLORIDE 25 MG ORAL TABS,RX-1044,CDM,S5000,HCPCS,259,RC,00832-0512-01,NDC,outpatient,1,UN,2.51,1.757,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIOTHYRONINE SODIUM 10 MCG/ML IV SOLN,RX-10442,CDM,S5000,HCPCS,250,RC,39822-0151-01,NDC,outpatient,1,ML,1739.29,1217.503,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIOTHYRONINE SODIUM 5 MCG ORAL TABS,RX-10443,CDM,S5000,HCPCS,259,RC,68382-0582-01,NDC,outpatient,1,UN,2.45,1.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIOTHYRONINE SODIUM 5 MCG ORAL TABS,RX-10443,CDM,S5000,HCPCS,259,RC,00093-2179-01,NDC,outpatient,1,UN,2.45,1.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LISINOPRIL 10 MG ORAL TABS,RX-10449,CDM,S5000,HCPCS,259,RC,68180-0980-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LISINOPRIL 10 MG ORAL TABS,RX-10449,CDM,S5000,HCPCS,259,RC,68180-0980-03,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LISINOPRIL 10 MG ORAL TABS,RX-10449,CDM,S5000,HCPCS,259,RC,00904-6798-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LISINOPRIL 5 MG ORAL TABS,RX-10451,CDM,S5000,HCPCS,259,RC,00904-6797-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LITHIUM CARBONATE ER 300 MG ORAL TBCR,RX-10454,CDM,S5000,HCPCS,259,RC,68084-0640-11,NDC,outpatient,1,UN,1.52,1.064,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LITHIUM CARBONATE ER 300 MG ORAL TBCR,RX-10454,CDM,S5000,HCPCS,259,RC,68084-0640-01,NDC,outpatient,1,UN,1.52,1.064,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LITHIUM CARBONATE ER 450 MG ORAL TBCR,RX-10455,CDM,S5000,HCPCS,259,RC,68084-0655-11,NDC,outpatient,1,UN,2.55,1.785,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LITHIUM CARBONATE ER 450 MG ORAL TBCR,RX-10455,CDM,S5000,HCPCS,259,RC,68084-0655-01,NDC,outpatient,1,UN,2.55,1.785,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LITHIUM CARBONATE ER 450 MG ORAL TBCR,RX-10455,CDM,S5000,HCPCS,259,RC,68462-0224-01,NDC,outpatient,1,UN,1,0.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRANEXAMIC ACID 650 MG ORAL TABS,RX-104576,CDM,S5000,HCPCS,259,RC,50268-0772-11,NDC,outpatient,1,UN,11.87,8.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRANEXAMIC ACID 650 MG ORAL TABS,RX-104576,CDM,S5000,HCPCS,259,RC,69918-0301-30,NDC,outpatient,1,UN,6.2,4.34,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRANEXAMIC ACID 650 MG ORAL TABS,RX-104576,CDM,S5000,HCPCS,259,RC,62559-0265-30,NDC,outpatient,1,UN,10.97,7.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRANEXAMIC ACID 650 MG ORAL TABS,RX-104576,CDM,S5000,HCPCS,259,RC,50268-0772-13,NDC,outpatient,1,UN,11.87,8.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RIFAXIMIN 550 MG ORAL TABS,RX-104604,CDM,S5000,HCPCS,259,RC,65649-0303-02,NDC,outpatient,1,UN,223.91,156.737,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RIFAXIMIN 550 MG ORAL TABS,RX-104604,CDM,S5000,HCPCS,259,RC,65649-0303-03,NDC,outpatient,1,UN,223.91,156.737,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LORATADINE 10 MG ORAL TABS,RX-10466,CDM,S5000,HCPCS,259,RC,51079-0246-20,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LORATADINE 10 MG ORAL TABS,RX-10466,CDM,S5000,HCPCS,259,RC,00904-6852-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LORATADINE 10 MG ORAL TABS,RX-10466,CDM,S5000,HCPCS,259,RC,51079-0246-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SIROLIMUS 0.5 MG ORAL TABS,RX-104764,CDM,S5000,HCPCS,259,RC,59762-1001-01,NDC,outpatient,1,UN,20.25,14.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SIROLIMUS 0.5 MG ORAL TABS,RX-104764,CDM,S5000,HCPCS,259,RC,68382-0520-01,NDC,outpatient,1,UN,18.05,12.635,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MAFENIDE ACETATE 85 MG/GM EX CREA,RX-10478,CDM,S5000,HCPCS,259,RC,16571-0723-60,NDC,outpatient,56.7,GR,282.85,197.995,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CAFFEINE CITRATE 60 MG/3ML ORAL SOLN,RX-104787,CDM,S5000,HCPCS,259,RC,63323-0406-01,NDC,outpatient,3,ML,31.83,22.281,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CAFFEINE CITRATE 60 MG/3ML ORAL SOLN,RX-104787,CDM,S5000,HCPCS,259,RC,51754-0501-03,NDC,outpatient,3,ML,27.32,19.124,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CAFFEINE CITRATE 60 MG/3ML ORAL SOLN,RX-104787,CDM,S5000,HCPCS,259,RC,25021-0602-03,NDC,outpatient,3,ML,26.44,18.508,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CAFFEINE CITRATE 60 MG/3ML ORAL SOLN,RX-104787,CDM,S5000,HCPCS,259,RC,63323-0406-03,NDC,outpatient,3,ML,31.83,22.281,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MAGNESIUM OXIDE 140 MG ORAL CAPS,RX-10490,CDM,S5000,HCPCS,259,RC,60569-0495-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACETAMINOPHEN 650 MG RE SUPP,RX-105,CDM,S5000,HCPCS,259,RC,45802-0730-30,NDC,outpatient,1,UN,1.95,1.365,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACETAMINOPHEN 650 MG RE SUPP,RX-105,CDM,S5000,HCPCS,259,RC,45802-0730-33,NDC,outpatient,1,UN,1.05,0.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MEDIUM CHAIN TRIGLYCERIDES ORAL OIL,RX-10518,CDM,S5000,HCPCS,259,RC,99999-0003-05,NDC,outpatient,15,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MEDIUM CHAIN TRIGLYCERIDES ORAL OIL,RX-10518,CDM,S5000,HCPCS,259,RC,41679-0365-03,NDC,outpatient,946,ML,46.31,32.417,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MEDIUM CHAIN TRIGLYCERIDES ORAL OIL,RX-10518,CDM,S5000,HCPCS,259,RC,99999-0003-04,NDC,outpatient,1,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MEDIUM CHAIN TRIGLYCERIDES ORAL OIL,RX-10518,CDM,S5000,HCPCS,259,RC,41679-0365-13,NDC,outpatient,946,ML,46.31,32.417,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MESALAMINE ER 250 MG ORAL CPCR,RX-10533,CDM,S5000,HCPCS,259,RC,54092-0189-81,NDC,outpatient,1,UN,12.49,8.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BROMOCRIPTINE MESYLATE 0.8 MG ORAL TABS,RX-105409,CDM,S5000,HCPCS,259,RC,68012-0258-20,NDC,outpatient,1,UN,23.23,16.261,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METFORMIN HCL 500 MG ORAL TABS,RX-10544,CDM,S5000,HCPCS,259,RC,60687-0155-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METFORMIN HCL 500 MG ORAL TABS,RX-10544,CDM,S5000,HCPCS,259,RC,60687-0155-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METFORMIN HCL 500 MG ORAL TABS,RX-10544,CDM,S5000,HCPCS,259,RC,00904-7162-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LACOSAMIDE 10 MG/ML ORAL SOLN,RX-105482,CDM,S5000,HCPCS,259,RC,99999-0001-42,NDC,outpatient,20,ML,187.97,131.579,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LACOSAMIDE 10 MG/ML ORAL SOLN,RX-105482,CDM,S5000,HCPCS,259,RC,00131-5410-72,NDC,outpatient,5,ML,47,32.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METHENAMINE HIPPURATE 1 G ORAL TABS,RX-10549,CDM,S5000,HCPCS,259,RC,60687-0694-11,NDC,outpatient,1,UN,7.92,5.544,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METHENAMINE HIPPURATE 1 G ORAL TABS,RX-10549,CDM,S5000,HCPCS,259,RC,60687-0694-21,NDC,outpatient,1,UN,7.92,5.544,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METHIMAZOLE 5 MG ORAL TABS,RX-10553,CDM,S5000,HCPCS,259,RC,23155-0070-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METHIMAZOLE 5 MG ORAL TABS,RX-10553,CDM,S5000,HCPCS,259,RC,60687-0669-01,NDC,outpatient,1,UN,2.25,1.575,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METHIMAZOLE 5 MG ORAL TABS,RX-10553,CDM,S5000,HCPCS,259,RC,60687-0669-11,NDC,outpatient,1,UN,2.25,1.575,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-1746-70,NDC,outpatient,10,ML,17.38,12.166,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-1746-30,NDC,outpatient,30,ML,36.85,25.795,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-1746-71,NDC,outpatient,30,ML,36.85,25.795,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-9042-01,NDC,outpatient,10,ML,18.15,12.705,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-9042-11,NDC,outpatient,10,ML,18.15,12.705,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,63323-0468-02,NDC,outpatient,30,ML,28.84,20.188,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,63323-0468-17,NDC,outpatient,10,ML,18.16,12.712,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-1746-10,NDC,outpatient,10,ML,17.38,12.166,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,63323-0468-01,NDC,outpatient,10,ML,18.16,12.712,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,63323-0468-37,NDC,outpatient,30,ML,28.84,20.188,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,00409-9045-16,NDC,outpatient,30,ML,11.88,8.316,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-01,NDC,outpatient,30,ML,30.98,21.686,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,00409-9045-01,NDC,outpatient,10,ML,11.21,7.847,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-02,NDC,outpatient,30,ML,25.5,17.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-04,NDC,outpatient,10,ML,18.61,13.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-17,NDC,outpatient,10,ML,18.61,13.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,00409-9045-11,NDC,outpatient,10,ML,11.21,7.847,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-37,NDC,outpatient,30,ML,30.98,21.686,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,00409-9045-17,NDC,outpatient,30,ML,11.88,8.316,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-31,NDC,outpatient,30,ML,25.5,17.85,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METHYLERGONOVINE MALEATE 0.2 MG ORAL TABS,RX-10572,CDM,S5000,HCPCS,259,RC,60687-0813-11,NDC,outpatient,1,UN,190.6,133.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METHYLERGONOVINE MALEATE 0.2 MG ORAL TABS,RX-10572,CDM,S5000,HCPCS,259,RC,60687-0813-94,NDC,outpatient,1,UN,190.6,133.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METHYLERGONOVINE MALEATE 0.2 MG ORAL TABS,RX-10572,CDM,S5000,HCPCS,259,RC,69238-1605-08,NDC,outpatient,1,UN,71.96,50.372,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METHYLERGONOVINE MALEATE 0.2 MG ORAL TABS,RX-10572,CDM,S5000,HCPCS,259,RC,69238-1605-02,NDC,outpatient,1,UN,78.51,54.957,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METOLAZONE 2.5 MG ORAL TABS,RX-10587,CDM,S5000,HCPCS,259,RC,51079-0023-01,NDC,outpatient,1,UN,11.25,7.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METOLAZONE 2.5 MG ORAL TABS,RX-10587,CDM,S5000,HCPCS,259,RC,51079-0023-20,NDC,outpatient,1,UN,11.25,7.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METOLAZONE 5 MG ORAL TABS,RX-10588,CDM,S5000,HCPCS,259,RC,51079-0024-01,NDC,outpatient,1,UN,12.79,8.953,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METOLAZONE 5 MG ORAL TABS,RX-10588,CDM,S5000,HCPCS,259,RC,51079-0024-20,NDC,outpatient,1,UN,12.79,8.953,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METRONIDAZOLE 0.75 % VA GEL,RX-10592,CDM,S5000,HCPCS,259,RC,16714-0557-01,NDC,outpatient,70,GR,66.67,46.669,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MEXILETINE HCL 150 MG ORAL CAPS,RX-10595,CDM,S5000,HCPCS,259,RC,50742-0239-01,NDC,outpatient,1,UN,1.39,0.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MEXILETINE HCL 150 MG ORAL CAPS,RX-10595,CDM,S5000,HCPCS,259,RC,62559-0820-01,NDC,outpatient,1,UN,1.38,0.966,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MEXILETINE HCL 150 MG ORAL CAPS,RX-10595,CDM,S5000,HCPCS,259,RC,00093-8739-01,NDC,outpatient,1,UN,2.26,1.582,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MEXILETINE HCL 200 MG ORAL CAPS,RX-10596,CDM,S5000,HCPCS,259,RC,00093-8740-01,NDC,outpatient,1,UN,3.1,2.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MICONAZOLE NITRATE 2 % EX POWD,RX-10599,CDM,S5000,HCPCS,259,RC,11701-0038-16,NDC,outpatient,85,GR,25.73,18.011,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MICONAZOLE NITRATE 2 % EX POWD,RX-10599,CDM,S5000,HCPCS,259,RC,53329-0169-79,NDC,outpatient,85,GR,16.27,11.389,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MICROFIBRILLAR COLL HEMOSTAT EX PADS,RX-10605,CDM,S5000,HCPCS,259,RC,53276-1010-08,NDC,outpatient,1,UN,496.85,347.795,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MICROFIBRILLAR COLL HEMOSTAT EX POWD,RX-10606,CDM,S5000,HCPCS,250,RC,53276-1010-02,NDC,outpatient,1,GR,993.69,695.583,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ULIPRISTAL ACETATE 30 MG ORAL TABS,RX-106079,CDM,S5000,HCPCS,259,RC,73302-0456-01,NDC,outpatient,1,UN,159.36,111.552,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MIDODRINE HCL 2.5 MG ORAL TABS,RX-10609,CDM,S5000,HCPCS,259,RC,00378-1901-01,NDC,outpatient,1,UN,2.12,1.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MIDODRINE HCL 2.5 MG ORAL TABS,RX-10609,CDM,S5000,HCPCS,259,RC,00245-0211-11,NDC,outpatient,1,UN,1.99,1.393,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,51079-0453-20,NDC,outpatient,1,UN,1.17,0.819,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,00245-0212-89,NDC,outpatient,1,UN,2.4,1.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,00904-6818-61,NDC,outpatient,1,UN,2.24,1.568,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,51079-0453-01,NDC,outpatient,1,UN,1.17,0.819,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,63739-0145-10,NDC,outpatient,1,UN,1.05,0.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,00245-0212-01,NDC,outpatient,1,UN,2.4,1.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NEOMYCIN-POLYMYXIN-DEXAMETH 3.5-10000-0.1 OP SUSP,RX-106248,CDM,S5000,HCPCS,259,RC,24208-0830-60,NDC,outpatient,5,ML,59.63,41.741,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NEOMYCIN-POLYMYXIN-DEXAMETH 3.5-10000-0.1 OP OINT,RX-106249,CDM,S5000,HCPCS,259,RC,61314-0631-36,NDC,outpatient,3.5,GR,69.78,48.846,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MISOPROSTOL 100 MCG ORAL TABS,RX-10628,CDM,S5000,HCPCS,259,RC,59762-5007-01,NDC,outpatient,1,UN,2.08,1.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MISOPROSTOL 100 MCG ORAL TABS,RX-10628,CDM,S5000,HCPCS,259,RC,60687-0735-11,NDC,outpatient,1,UN,9.27,6.489,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MISOPROSTOL 100 MCG ORAL TABS,RX-10628,CDM,S5000,HCPCS,259,RC,00025-1451-34,NDC,outpatient,1,UN,17.24,12.068,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MISOPROSTOL 100 MCG ORAL TABS,RX-10628,CDM,S5000,HCPCS,259,RC,60687-0735-01,NDC,outpatient,1,UN,9.27,6.489,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MISOPROSTOL 200 MCG ORAL TABS,RX-10629,CDM,S5000,HCPCS,259,RC,60687-0746-11,NDC,outpatient,1,UN,7.19,5.033,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MISOPROSTOL 200 MCG ORAL TABS,RX-10629,CDM,S5000,HCPCS,259,RC,60687-0746-01,NDC,outpatient,1,UN,7.19,5.033,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL (PF) 0.5 % IJ SOLN,RX-106363,CDM,S5000,HCPCS,250,RC,00409-4278-16,NDC,outpatient,50,ML,10.28,7.196,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL (PF) 0.5 % IJ SOLN,RX-106363,CDM,S5000,HCPCS,250,RC,00409-4278-01,NDC,outpatient,50,ML,10.28,7.196,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DABIGATRAN ETEXILATE MESYLATE 75 MG ORAL CAPS,RX-106490,CDM,S5000,HCPCS,259,RC,00597-0355-61,NDC,outpatient,1,UN,12.92,9.044,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DABIGATRAN ETEXILATE MESYLATE 75 MG ORAL CAPS,RX-106490,CDM,S5000,HCPCS,259,RC,00597-0355-56,NDC,outpatient,1,UN,12.92,9.044,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DABIGATRAN ETEXILATE MESYLATE 150 MG ORAL CAPS,RX-106491,CDM,S5000,HCPCS,259,RC,00597-0360-55,NDC,outpatient,1,UN,12.92,9.044,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DABIGATRAN ETEXILATE MESYLATE 150 MG ORAL CAPS,RX-106491,CDM,S5000,HCPCS,259,RC,00597-0360-82,NDC,outpatient,1,UN,12.92,9.044,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MORPHINE SULFATE (CONCENTRATE) 20 MG/ML ORAL SOLN,RX-10655,CDM,S5000,HCPCS,259,RC,99999-0002-18,NDC,outpatient,1,ML,2.33,1.631,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MORPHINE SULFATE (CONCENTRATE) 20 MG/ML ORAL SOLN,RX-10655,CDM,S5000,HCPCS,259,RC,00406-8003-30,NDC,outpatient,0.25,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MUPIROCIN 2 % EX OINT,RX-10674,CDM,S5000,HCPCS,259,RC,45802-0112-22,NDC,outpatient,22,GR,13.61,9.527,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MUPIROCIN 2 % EX OINT,RX-10674,CDM,S5000,HCPCS,259,RC,51672-1312-00,NDC,outpatient,22,GR,11.07,7.749,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MUPIROCIN 2 % EX OINT,RX-10674,CDM,S5000,HCPCS,259,RC,68462-0180-22,NDC,outpatient,22,GR,18.61,13.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NABUMETONE 500 MG ORAL TABS,RX-10676,CDM,S5000,HCPCS,259,RC,60687-0630-11,NDC,outpatient,1,UN,3.85,2.695,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NABUMETONE 500 MG ORAL TABS,RX-10676,CDM,S5000,HCPCS,259,RC,00591-3670-01,NDC,outpatient,1,UN,1.2,0.84,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NABUMETONE 500 MG ORAL TABS,RX-10676,CDM,S5000,HCPCS,259,RC,60687-0630-21,NDC,outpatient,1,UN,3.85,2.695,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NALTREXONE HCL 50 MG ORAL TABS,RX-10685,CDM,S5000,HCPCS,259,RC,00406-1170-03,NDC,outpatient,1,UN,4.49,3.143,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NALTREXONE HCL 50 MG ORAL TABS,RX-10685,CDM,S5000,HCPCS,259,RC,68084-0291-11,NDC,outpatient,1,UN,8.68,6.076,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NALTREXONE HCL 50 MG ORAL TABS,RX-10685,CDM,S5000,HCPCS,259,RC,00904-7036-04,NDC,outpatient,1,UN,7.95,5.565,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NALTREXONE HCL 50 MG ORAL TABS,RX-10685,CDM,S5000,HCPCS,259,RC,68084-0291-21,NDC,outpatient,1,UN,8.68,6.076,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NICARDIPINE HCL 20 MG ORAL CAPS,RX-10712,CDM,S5000,HCPCS,259,RC,68462-0120-90,NDC,outpatient,1,UN,18.98,13.286,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NICARDIPINE HCL 20 MG ORAL CAPS,RX-10712,CDM,S5000,HCPCS,259,RC,62559-0205-90,NDC,outpatient,1,UN,35.49,24.843,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NICARDIPINE HCL 30 MG ORAL CAPS,RX-10713,CDM,S5000,HCPCS,259,RC,68462-0121-90,NDC,outpatient,1,UN,27.58,19.306,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NICARDIPINE HCL 30 MG ORAL CAPS,RX-10713,CDM,S5000,HCPCS,259,RC,42806-0502-09,NDC,outpatient,1,UN,24.73,17.311,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NICOTINE POLACRILEX 2 MG MT GUM,RX-10717,CDM,S5000,HCPCS,259,RC,00536-1362-23,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NICOTINE POLACRILEX 2 MG MT GUM,RX-10717,CDM,S5000,HCPCS,259,RC,00536-3029-23,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NICOTINE POLACRILEX 4 MG MT GUM,RX-10718,CDM,S5000,HCPCS,259,RC,00536-1372-23,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NICOTINE POLACRILEX 4 MG MT GUM,RX-10718,CDM,S5000,HCPCS,259,RC,00135-0242-08,NDC,outpatient,1,UN,2.37,1.659,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NIMODIPINE 30 MG ORAL CAPS,RX-10722,CDM,S5000,HCPCS,259,RC,23155-0512-00,NDC,outpatient,1,UN,5.11,3.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NIMODIPINE 30 MG ORAL CAPS,RX-10722,CDM,S5000,HCPCS,259,RC,23155-0512-11,NDC,outpatient,1,UN,5.11,3.577,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,16714-0439-01,NDC,outpatient,1,UN,7.17,5.019,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,50268-0625-11,NDC,outpatient,1,UN,7.34,5.138,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,60687-0633-01,NDC,outpatient,1,UN,9.67,6.769,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,60687-0633-11,NDC,outpatient,1,UN,9.67,6.769,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,00904-7137-61,NDC,outpatient,1,UN,6.96,4.872,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,50268-0625-15,NDC,outpatient,1,UN,7.34,5.138,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPRENORPHINE 5 MCG/HR TD PTWK,RX-107660,CDM,S5000,HCPCS,259,RC,50742-0372-01,NDC,outpatient,1,UN,146.92,102.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPRENORPHINE 5 MCG/HR TD PTWK,RX-107660,CDM,S5000,HCPCS,259,RC,42858-0750-40,NDC,outpatient,1,UN,220.77,154.539,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPRENORPHINE 5 MCG/HR TD PTWK,RX-107660,CDM,S5000,HCPCS,259,RC,50742-0372-04,NDC,outpatient,1,UN,146.92,102.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPRENORPHINE 10 MCG/HR TD PTWK,RX-107661,CDM,S5000,HCPCS,259,RC,00093-3657-21,NDC,outpatient,1,UN,232.52,162.764,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPRENORPHINE 10 MCG/HR TD PTWK,RX-107661,CDM,S5000,HCPCS,259,RC,00093-3657-40,NDC,outpatient,1,UN,232.52,162.764,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OLSALAZINE SODIUM 250 MG ORAL CAPS,RX-10773,CDM,S5000,HCPCS,259,RC,00037-6860-10,NDC,outpatient,1,UN,61.39,42.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VALPROIC ACID 250 MG/5ML ORAL SOLN,RX-107838,CDM,S5000,HCPCS,259,RC,00121-4675-00,NDC,outpatient,5,ML,4.92,3.444,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VALPROIC ACID 250 MG/5ML ORAL SOLN,RX-107838,CDM,S5000,HCPCS,259,RC,00121-4675-05,NDC,outpatient,5,ML,7.15,5.005,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VALPROIC ACID 250 MG/5ML ORAL SOLN,RX-107838,CDM,S5000,HCPCS,259,RC,00121-4675-40,NDC,outpatient,5,ML,7.15,5.005,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VALPROIC ACID 250 MG/5ML ORAL SOLN,RX-107838,CDM,S5000,HCPCS,259,RC,99999-0001-41,NDC,outpatient,5,ML,2.27,1.589,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BISACODYL 5 MG ORAL TBEC,RX-1079,CDM,S5000,HCPCS,259,RC,00904-6407-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BISACODYL 10 MG RE SUPP,RX-1080,CDM,S5000,HCPCS,259,RC,00574-7050-12,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BISACODYL 10 MG RE SUPP,RX-1080,CDM,S5000,HCPCS,259,RC,58980-0415-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BISACODYL 10 MG RE SUPP,RX-1080,CDM,S5000,HCPCS,259,RC,58980-0415-50,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BISACODYL 10 MG RE SUPP,RX-1080,CDM,S5000,HCPCS,259,RC,00574-7050-50,NDC,outpatient,1,UN,1.02,0.714,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BISACODYL 10 MG RE SUPP,RX-1080,CDM,S5000,HCPCS,259,RC,81421-0021-03,NDC,outpatient,1,UN,3.38,2.366,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TESTOSTERONE 25 MG/2.5GM (1%) TD GEL,RX-108038,CDM,S5000,HCPCS,259,RC,64380-0151-01,NDC,outpatient,2.5,GR,13.58,9.506,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TESTOSTERONE 25 MG/2.5GM (1%) TD GEL,RX-108038,CDM,S5000,HCPCS,259,RC,64380-0151-02,NDC,outpatient,2.5,GR,13.58,9.506,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TESTOSTERONE 50 MG/5GM (1%) TD GEL,RX-108039,CDM,S5000,HCPCS,259,RC,00591-3524-26,NDC,outpatient,5,GR,13.67,9.569,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TESTOSTERONE 50 MG/5GM (1%) TD GEL,RX-108039,CDM,S5000,HCPCS,259,RC,00591-3524-30,NDC,outpatient,5,GR,13.67,9.569,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXYCODONE HCL 100 MG/5ML ORAL CONC,RX-10812,CDM,S5000,HCPCS,259,RC,99999-0002-27,NDC,outpatient,1,ML,7.21,5.047,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXYCODONE HCL 100 MG/5ML ORAL CONC,RX-10812,CDM,S5000,HCPCS,259,RC,00406-8557-30,NDC,outpatient,30,ML,133.24,93.268,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXYCODONE HCL 5 MG/5ML ORAL SOLN,RX-10813,CDM,S5000,HCPCS,259,RC,64950-0354-55,NDC,outpatient,5,ML,8.79,6.153,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXYCODONE HCL 5 MG/5ML ORAL SOLN,RX-10813,CDM,S5000,HCPCS,259,RC,64950-0354-05,NDC,outpatient,5,ML,8.79,6.153,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,00904-6966-61,NDC,outpatient,1,UN,1.01,0.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,68084-0354-11,NDC,outpatient,1,UN,1.65,1.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,00406-0552-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,00406-0552-23,NDC,outpatient,1,UN,1.17,0.819,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,00406-0552-62,NDC,outpatient,1,UN,1.17,0.819,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,42858-0001-10,NDC,outpatient,1,UN,1,0.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,68084-0354-01,NDC,outpatient,1,UN,1.65,1.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,10702-0018-50,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PAROXETINE HCL 20 MG ORAL TABS,RX-10855,CDM,S5000,HCPCS,259,RC,63739-0963-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BISMUTH SUBCARBONATE POWD,RX-1086,CDM,S5000,HCPCS,259,RC,62991-2844-02,NDC,outpatient,100,GR,276.06,193.242,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BISMUTH SUBSALICYLATE 262 MG/15ML ORAL SUSP,RX-1090,CDM,S5000,HCPCS,259,RC,99999-0001-91,NDC,outpatient,30,ML,2.01,1.407,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BISMUTH SUBSALICYLATE 262 MG/15ML ORAL SUSP,RX-1090,CDM,S5000,HCPCS,259,RC,37000-0475-08,NDC,outpatient,10,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PERMETHRIN 5 % EX CREA,RX-10917,CDM,S5000,HCPCS,259,RC,00472-0242-60,NDC,outpatient,60,GR,76.37,53.459,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,00310-0095-30,NDC,outpatient,1,UN,54.75,38.325,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,31722-0623-90,NDC,outpatient,1,UN,7.15,5.005,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,60687-0786-21,NDC,outpatient,1,UN,7.84,5.488,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,00378-1905-77,NDC,outpatient,1,UN,17.44,12.208,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,42571-0259-30,NDC,outpatient,1,UN,4.47,3.129,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,60687-0786-11,NDC,outpatient,1,UN,7.84,5.488,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PHENOXYBENZAMINE HCL 10 MG ORAL CAPS,RX-10945,CDM,S5000,HCPCS,259,RC,66993-0066-02,NDC,outpatient,1,UN,73.53,51.471,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PHENTOLAMINE MESYLATE 5 MG IJ SOLR,RX-10947,CDM,S5000,HCPCS,259,RC,00143-9564-10,NDC,outpatient,1,UN,1233.54,863.478,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PHENTOLAMINE MESYLATE 5 MG IJ SOLR,RX-10947,CDM,S5000,HCPCS,259,RC,00143-9564-01,NDC,outpatient,1,UN,1208.89,846.223,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LINAGLIPTIN 5 MG ORAL TABS,RX-109773,CDM,S5000,HCPCS,259,RC,00597-0140-61,NDC,outpatient,1,UN,56.14,39.298,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RILPIVIRINE HCL 25 MG ORAL TABS,RX-109909,CDM,S5000,HCPCS,259,RC,59676-0278-01,NDC,outpatient,1,UN,209.04,146.328,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PHENYTOIN 50 MG ORAL CHEW,RX-11018,CDM,S5000,HCPCS,259,RC,00904-7199-07,NDC,outpatient,1,UN,3.73,2.611,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PHENYTOIN 50 MG ORAL CHEW,RX-11018,CDM,S5000,HCPCS,259,RC,60687-0156-95,NDC,outpatient,1,UN,4.05,2.835,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PHENYTOIN 50 MG ORAL CHEW,RX-11018,CDM,S5000,HCPCS,259,RC,60687-0156-25,NDC,outpatient,1,UN,4.05,2.835,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PHENYTOIN SODIUM EXTENDED 30 MG ORAL CAPS,RX-11019,CDM,S5000,HCPCS,259,RC,00071-3740-66,NDC,outpatient,1,UN,5.97,4.179,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PHYTONADIONE 5 MG ORAL TABS,RX-11024,CDM,S5000,HCPCS,259,RC,60687-0381-94,NDC,outpatient,1,UN,227.6,159.32,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PHYTONADIONE 5 MG ORAL TABS,RX-11024,CDM,S5000,HCPCS,259,RC,60687-0381-11,NDC,outpatient,1,UN,227.6,159.32,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RIVAROXABAN 10 MG ORAL TABS,RX-110250,CDM,S5000,HCPCS,259,RC,50458-0580-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RIVAROXABAN 10 MG ORAL TABS,RX-110250,CDM,S5000,HCPCS,259,RC,50458-0580-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FIDAXOMICIN 200 MG ORAL TABS,RX-110360,CDM,S5000,HCPCS,259,RC,52015-0080-01,NDC,outpatient,1,UN,501.77,351.239,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TICAGRELOR 90 MG ORAL TABS,RX-110427,CDM,S5000,HCPCS,259,RC,00186-0777-39,NDC,outpatient,1,UN,30.77,21.539,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CALCIUM POLYCARBOPHIL 625 MG ORAL TABS,RX-11046,CDM,S5000,HCPCS,259,RC,00536-4306-05,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CALCIUM POLYCARBOPHIL 625 MG ORAL TABS,RX-11046,CDM,S5000,HCPCS,259,RC,00904-2500-91,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POLYSACCHARIDE IRON COMPLEX 150 MG ORAL CAPS,RX-11050,CDM,S5000,HCPCS,259,RC,00904-5395-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POTASSIUM CITRATE ER 10 MEQ (1080 MG) ORAL TBCR,RX-11083,CDM,S5000,HCPCS,259,RC,68084-0850-33,NDC,outpatient,1,UN,8.47,5.929,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POTASSIUM CITRATE ER 10 MEQ (1080 MG) ORAL TBCR,RX-11083,CDM,S5000,HCPCS,259,RC,00178-0610-01,NDC,outpatient,1,UN,7.92,5.544,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POTASSIUM CITRATE ER 10 MEQ (1080 MG) ORAL TBCR,RX-11083,CDM,S5000,HCPCS,259,RC,68084-0850-32,NDC,outpatient,1,UN,8.47,5.929,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OSELTAMIVIR PHOSPHATE 6 MG/ML ORAL SUSR,RX-110998,CDM,S5000,HCPCS,259,RC,68180-0678-01,NDC,outpatient,60,ML,26.7,18.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OSELTAMIVIR PHOSPHATE 6 MG/ML ORAL SUSR,RX-110998,CDM,S5000,HCPCS,259,RC,27241-0139-09,NDC,outpatient,60,ML,35.52,24.864,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OSELTAMIVIR PHOSPHATE 6 MG/ML ORAL SUSR,RX-110998,CDM,S5000,HCPCS,259,RC,00004-0822-05,NDC,outpatient,60,ML,624.52,437.164,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OSELTAMIVIR PHOSPHATE 6 MG/ML ORAL SUSR,RX-110998,CDM,S5000,HCPCS,259,RC,99999-0000-41,NDC,outpatient,5,ML,52.63,36.841,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PRAVASTATIN SODIUM 10 MG ORAL TABS,RX-11110,CDM,S5000,HCPCS,259,RC,00904-5891-61,NDC,outpatient,1,UN,1.35,0.945,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PRAVASTATIN SODIUM 20 MG ORAL TABS,RX-11111,CDM,S5000,HCPCS,259,RC,51079-0458-20,NDC,outpatient,1,UN,2.39,1.673,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PRAVASTATIN SODIUM 20 MG ORAL TABS,RX-11111,CDM,S5000,HCPCS,259,RC,00904-5892-61,NDC,outpatient,1,UN,2.3,1.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PRAVASTATIN SODIUM 20 MG ORAL TABS,RX-11111,CDM,S5000,HCPCS,259,RC,51079-0458-01,NDC,outpatient,1,UN,2.39,1.673,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PRIMIDONE 50 MG ORAL TABS,RX-11129,CDM,S5000,HCPCS,259,RC,68084-0202-01,NDC,outpatient,1,UN,2.64,1.848,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PRIMIDONE 50 MG ORAL TABS,RX-11129,CDM,S5000,HCPCS,259,RC,68084-0202-11,NDC,outpatient,1,UN,2.64,1.848,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PROCHLORPERAZINE 25 MG RE SUPP,RX-11138,CDM,S5000,HCPCS,259,RC,00574-7226-12,NDC,outpatient,1,UN,26.18,18.326,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PROMETHAZINE HCL 12.5 MG RE SUPP,RX-11143,CDM,S5000,HCPCS,259,RC,00713-0536-06,NDC,outpatient,1,UN,43.38,30.366,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PROMETHAZINE HCL 12.5 MG RE SUPP,RX-11143,CDM,S5000,HCPCS,259,RC,00713-0536-12,NDC,outpatient,1,UN,43.38,30.366,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PROMETHAZINE HCL 25 MG RE SUPP,RX-11144,CDM,S5000,HCPCS,259,RC,00713-0526-12,NDC,outpatient,1,UN,43.38,30.366,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PROPAFENONE HCL 150 MG ORAL TABS,RX-11146,CDM,S5000,HCPCS,259,RC,00591-0582-01,NDC,outpatient,1,UN,1.95,1.365,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PROPAFENONE HCL 225 MG ORAL TABS,RX-11147,CDM,S5000,HCPCS,259,RC,00591-0583-01,NDC,outpatient,1,UN,1.32,0.924,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PYRIDOSTIGMINE BROMIDE 60 MG ORAL TABS,RX-11239,CDM,S5000,HCPCS,259,RC,00904-6622-61,NDC,outpatient,1,UN,3.64,2.548,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PYRIDOSTIGMINE BROMIDE 60 MG ORAL TABS,RX-11239,CDM,S5000,HCPCS,259,RC,68382-0659-06,NDC,outpatient,1,UN,1.59,1.113,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PYRIDOSTIGMINE BROMIDE ER 180 MG ORAL TBCR,RX-11240,CDM,S5000,HCPCS,259,RC,47781-0335-30,NDC,outpatient,1,UN,71.76,50.232,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PYRIMETHAMINE 25 MG ORAL TABS,RX-11246,CDM,S5000,HCPCS,259,RC,43598-0672-01,NDC,outpatient,1,UN,1019.51,713.657,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POLIDOCANOL 1 % IV SOLN,RX-112481,CDM,S5000,HCPCS,250,RC,67850-0141-00,NDC,outpatient,2,ML,92.93,65.051,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POLIDOCANOL 1 % IV SOLN,RX-112481,CDM,S5000,HCPCS,250,RC,67850-0141-05,NDC,outpatient,2,ML,92.93,65.051,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RAMIPRIL 1.25 MG ORAL CAPS,RX-11258,CDM,S5000,HCPCS,259,RC,68382-0144-06,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RAMIPRIL 5 MG ORAL CAPS,RX-11261,CDM,S5000,HCPCS,259,RC,68382-0146-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RAMIPRIL 5 MG ORAL CAPS,RX-11261,CDM,S5000,HCPCS,259,RC,57237-0224-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLOBAZAM 10 MG ORAL TABS,RX-112703,CDM,S5000,HCPCS,259,RC,60687-0423-11,NDC,outpatient,1,UN,9.33,6.531,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLOBAZAM 10 MG ORAL TABS,RX-112703,CDM,S5000,HCPCS,259,RC,60687-0423-21,NDC,outpatient,1,UN,9.33,6.531,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLOBAZAM 10 MG ORAL TABS,RX-112703,CDM,S5000,HCPCS,259,RC,68180-0157-01,NDC,outpatient,1,UN,2.47,1.729,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RIVAROXABAN 15 MG ORAL TABS,RX-112834,CDM,S5000,HCPCS,259,RC,50458-0578-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RIVAROXABAN 15 MG ORAL TABS,RX-112834,CDM,S5000,HCPCS,259,RC,50458-0578-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RIBAVIRIN 200 MG ORAL CAPS,RX-11286,CDM,S5000,HCPCS,259,RC,65862-0290-84,NDC,outpatient,1,UN,5.94,4.158,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RIFABUTIN 150 MG ORAL CAPS,RX-11290,CDM,S5000,HCPCS,259,RC,59762-1350-01,NDC,outpatient,1,UN,47.58,33.306,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RIFAMPIN 600 MG IV SOLR,RX-11291,CDM,S5000,HCPCS,250,RC,63323-0351-20,NDC,outpatient,1,UN,246.71,172.697,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RIFAMPIN 600 MG IV SOLR,RX-11291,CDM,S5000,HCPCS,250,RC,00068-0597-01,NDC,outpatient,1,UN,360.5,252.35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RIFAMPIN 600 MG IV SOLR,RX-11291,CDM,S5000,HCPCS,250,RC,67457-0445-60,NDC,outpatient,1,UN,242,169.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RIFAMPIN 150 MG ORAL CAPS,RX-11292,CDM,S5000,HCPCS,259,RC,60687-0575-21,NDC,outpatient,1,UN,10.17,7.119,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RIFAMPIN 150 MG ORAL CAPS,RX-11292,CDM,S5000,HCPCS,259,RC,60687-0575-11,NDC,outpatient,1,UN,10.17,7.119,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RIFAMPIN 300 MG ORAL CAPS,RX-11293,CDM,S5000,HCPCS,259,RC,60687-0586-11,NDC,outpatient,1,UN,6.25,4.375,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RIFAMPIN 300 MG ORAL CAPS,RX-11293,CDM,S5000,HCPCS,259,RC,60687-0586-01,NDC,outpatient,1,UN,6.25,4.375,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACETAZOLAMIDE 250 MG ORAL TABS,RX-113,CDM,S5000,HCPCS,259,RC,60687-0619-01,NDC,outpatient,1,UN,9.15,6.405,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACETAZOLAMIDE 250 MG ORAL TABS,RX-113,CDM,S5000,HCPCS,259,RC,60687-0619-11,NDC,outpatient,1,UN,9.15,6.405,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RACEPINEPHRINE HCL 2.25 % IN NEBU,RX-113082,CDM,S5000,HCPCS,259,RC,00487-5901-99,NDC,outpatient,1,UN,5.79,4.053,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FIRST-OMEPRAZOLE 2 MG/ML ORAL SUSP,RX-113272,CDM,S5000,HCPCS,259,RC,65628-0070-03,NDC,outpatient,5,ML,27.75,19.425,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FIRST-OMEPRAZOLE 2 MG/ML ORAL SUSP,RX-113272,CDM,S5000,HCPCS,259,RC,99999-9003-64,NDC,outpatient,5,ML,27.75,19.425,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,16714-0612-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,16714-0612-04,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,68180-0352-09,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,76282-0213-18,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,60687-0242-01,NDC,outpatient,1,UN,1.35,0.945,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,60687-0242-11,NDC,outpatient,1,UN,1.35,0.945,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,00904-6925-61,NDC,outpatient,1,UN,1.38,0.966,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LURASIDONE HCL 20 MG ORAL TABS,RX-113587,CDM,S5000,HCPCS,259,RC,63402-0302-30,NDC,outpatient,1,UN,165.29,115.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LURASIDONE HCL 20 MG ORAL TABS,RX-113587,CDM,S5000,HCPCS,259,RC,67877-0638-30,NDC,outpatient,1,UN,1.86,1.302,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LURASIDONE HCL 20 MG ORAL TABS,RX-113587,CDM,S5000,HCPCS,259,RC,16729-0346-10,NDC,outpatient,1,UN,5,3.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SILVER NITRATE-POT NITRATE 75-25 % EX MISC,RX-11359,CDM,S5000,HCPCS,259,RC,12870-0001-01,NDC,outpatient,10,UN,28.31,19.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SOD CITRATE-CITRIC ACID 500-334 MG/5ML ORAL SOLN,RX-11394,CDM,S5000,HCPCS,259,RC,00121-1190-00,NDC,outpatient,30,ML,19.63,13.741,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SOD CITRATE-CITRIC ACID 500-334 MG/5ML ORAL SOLN,RX-11394,CDM,S5000,HCPCS,259,RC,00121-1190-30,NDC,outpatient,30,ML,19.63,13.741,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE 0.9 % IR SOLN,RX-11403,CDM,S5000,HCPCS,250,RC,00338-0048-04,NDC,outpatient,1000,ML,15.82,11.074,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE 0.9 % IR SOLN,RX-11403,CDM,S5000,HCPCS,250,RC,00338-0048-03,NDC,outpatient,500,ML,11.87,8.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE (HYPERTONIC) 2 % OP SOLN,RX-11404,CDM,S5000,HCPCS,259,RC,24208-0276-15,NDC,outpatient,15,ML,65.35,45.745,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SOTALOL HCL 80 MG ORAL TABS,RX-11421,CDM,S5000,HCPCS,259,RC,68084-0654-11,NDC,outpatient,1,UN,4.36,3.052,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SOTALOL HCL 80 MG ORAL TABS,RX-11421,CDM,S5000,HCPCS,259,RC,68084-0654-01,NDC,outpatient,1,UN,4.36,3.052,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,62135-0436-90,NDC,outpatient,1,UN,16.45,11.515,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,00093-2210-01,NDC,outpatient,1,UN,1.34,0.938,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,29033-0003-05,NDC,outpatient,1,UN,1.06,0.742,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,51079-0753-01,NDC,outpatient,1,UN,1.48,1.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,51079-0753-20,NDC,outpatient,1,UN,1.48,1.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,59762-0401-05,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TERBUTALINE SULFATE 2.5 MG ORAL TABS,RX-11508,CDM,S5000,HCPCS,259,RC,00527-1318-01,NDC,outpatient,1,UN,19.38,13.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TERBUTALINE SULFATE 2.5 MG ORAL TABS,RX-11508,CDM,S5000,HCPCS,259,RC,62559-0721-01,NDC,outpatient,1,UN,4.45,3.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TETRACAINE HCL 1 % IJ SOLN,RX-11517,CDM,S5000,HCPCS,250,RC,54288-0127-01,NDC,outpatient,2,ML,164.48,115.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TETRACAINE HCL 1 % IJ SOLN,RX-11517,CDM,S5000,HCPCS,250,RC,54288-0127-10,NDC,outpatient,2,ML,164.48,115.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
THROMBIN 20000 UNITS EX KIT,RX-11544,CDM,S5000,HCPCS,250,RC,60793-0217-21,NDC,outpatient,1,UN,883.55,618.485,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
THROMBIN 20000 UNITS EX KIT,RX-11544,CDM,S5000,HCPCS,250,RC,60793-0217-22,NDC,outpatient,1,UN,883.55,618.485,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
THROMBIN 5000 UNITS EX SOLR,RX-11548,CDM,S5000,HCPCS,250,RC,60793-0215-05,NDC,outpatient,1,UN,195.76,137.032,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TIMOLOL MALEATE 0.25 % OP SOLN,RX-11561,CDM,S5000,HCPCS,259,RC,64980-0513-05,NDC,outpatient,5,ML,10.28,7.196,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TIMOLOL MALEATE 0.25 % OP SOLN,RX-11561,CDM,S5000,HCPCS,259,RC,60758-0802-05,NDC,outpatient,5,ML,11.17,7.819,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TIMOLOL MALEATE 0.5 % OP SOLN,RX-11562,CDM,S5000,HCPCS,259,RC,60758-0801-05,NDC,outpatient,5,ML,22.48,15.736,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TIMOLOL MALEATE 0.5 % OP SOLN,RX-11562,CDM,S5000,HCPCS,259,RC,64980-0514-05,NDC,outpatient,5,ML,21.94,15.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OP OINT,RX-11566,CDM,S5000,HCPCS,259,RC,00078-0876-01,NDC,outpatient,3.5,GR,1115.32,780.724,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OP SUSP,RX-11567,CDM,S5000,HCPCS,259,RC,24208-0295-25,NDC,outpatient,2.5,ML,173.64,121.548,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRIAMTERENE 50 MG ORAL CAPS,RX-11588,CDM,S5000,HCPCS,259,RC,59212-0002-01,NDC,outpatient,1,UN,60.49,42.343,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRIAMTERENE 50 MG ORAL CAPS,RX-11588,CDM,S5000,HCPCS,259,RC,66993-0831-02,NDC,outpatient,1,UN,36.58,25.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRIFLURIDINE 1 % OP SOLN,RX-11595,CDM,S5000,HCPCS,259,RC,61314-0044-75,NDC,outpatient,7.5,ML,948.02,663.614,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POLYMYXIN B-TRIMETHOPRIM 10000-0.1 UNIT/ML-% OP SOLN,RX-11596,CDM,S5000,HCPCS,259,RC,24208-0315-10,NDC,outpatient,10,ML,47.84,33.488,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POLYMYXIN B-TRIMETHOPRIM 10000-0.1 UNIT/ML-% OP SOLN,RX-11596,CDM,S5000,HCPCS,259,RC,61314-0628-10,NDC,outpatient,10,ML,43.88,30.716,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG ORAL TABS,RX-11599,CDM,S5000,HCPCS,259,RC,00904-2725-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
URSODIOL 300 MG ORAL CAPS,RX-11624,CDM,S5000,HCPCS,259,RC,60687-0100-01,NDC,outpatient,1,UN,15.37,10.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
URSODIOL 300 MG ORAL CAPS,RX-11624,CDM,S5000,HCPCS,259,RC,60687-0100-11,NDC,outpatient,1,UN,15.37,10.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VECURONIUM BROMIDE 10 MG IV SOLR,RX-11634,CDM,S5000,HCPCS,250,RC,55150-0235-01,NDC,outpatient,1,UN,11.52,8.064,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VECURONIUM BROMIDE 10 MG IV SOLR,RX-11634,CDM,S5000,HCPCS,250,RC,55150-0235-10,NDC,outpatient,1,UN,11.52,8.064,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VECURONIUM BROMIDE 20 MG IV SOLR,RX-11635,CDM,S5000,HCPCS,250,RC,00143-9232-01,NDC,outpatient,1,UN,41.49,29.043,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VECURONIUM BROMIDE 20 MG IV SOLR,RX-11635,CDM,S5000,HCPCS,250,RC,00143-9232-10,NDC,outpatient,1,UN,41.49,29.043,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
WARFARIN SODIUM 1 MG ORAL TABS,RX-11664,CDM,S5000,HCPCS,259,RC,00832-1211-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
WARFARIN SODIUM 1 MG ORAL TABS,RX-11664,CDM,S5000,HCPCS,259,RC,00832-1211-89,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IPRATROPIUM-ALBUTEROL 20-100 MCG/ACT IN AERS,RX-116728,CDM,S5000,HCPCS,259,RC,00597-0024-02,NDC,outpatient,4,GR,2012.08,1408.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ZIDOVUDINE 100 MG ORAL CAPS,RX-11692,CDM,S5000,HCPCS,259,RC,65862-0107-01,NDC,outpatient,1,UN,6.23,4.361,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ZIDOVUDINE 10 MG/ML ORAL SYRP,RX-11693,CDM,S5000,HCPCS,259,RC,,,outpatient,5,ML,3.1,2.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ZOLPIDEM TARTRATE 5 MG ORAL TABS,RX-11701,CDM,S5000,HCPCS,259,RC,00904-6082-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LINACLOTIDE 145 MCG ORAL CAPS,RX-117352,CDM,S5000,HCPCS,259,RC,00456-1201-30,NDC,outpatient,1,UN,74.11,51.877,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RIVASTIGMINE 13.3 MG/24HR TD PT24,RX-117356,CDM,S5000,HCPCS,259,RC,00378-9072-16,NDC,outpatient,1,UN,6.86,4.802,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RIVASTIGMINE 13.3 MG/24HR TD PT24,RX-117356,CDM,S5000,HCPCS,259,RC,00378-9072-93,NDC,outpatient,1,UN,6.86,4.802,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RIVASTIGMINE 13.3 MG/24HR TD PT24,RX-117356,CDM,S5000,HCPCS,259,RC,70710-1198-01,NDC,outpatient,1,UN,8.83,6.181,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RIVASTIGMINE 13.3 MG/24HR TD PT24,RX-117356,CDM,S5000,HCPCS,259,RC,70710-1198-07,NDC,outpatient,1,UN,8.83,6.181,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MORPHINE SULFATE ER 30 MG ORAL TBCR,RX-119007,CDM,S5000,HCPCS,259,RC,00406-8330-23,NDC,outpatient,1,UN,4.35,3.045,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MORPHINE SULFATE ER 30 MG ORAL TBCR,RX-119007,CDM,S5000,HCPCS,259,RC,00406-8330-62,NDC,outpatient,1,UN,4.35,3.045,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MORPHINE SULFATE ER 30 MG ORAL TBCR,RX-119007,CDM,S5000,HCPCS,259,RC,00904-6558-61,NDC,outpatient,1,UN,5.15,3.605,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MORPHINE SULFATE ER 30 MG ORAL TBCR,RX-119007,CDM,S5000,HCPCS,259,RC,00406-8330-01,NDC,outpatient,1,UN,1.46,1.022,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
APIXABAN 2.5 MG ORAL TABS,RX-119040,CDM,S5000,HCPCS,259,RC,00003-0893-31,NDC,outpatient,1,UN,6.17,4.319,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
APIXABAN 2.5 MG ORAL TABS,RX-119040,CDM,S5000,HCPCS,259,RC,00003-0893-21,NDC,outpatient,1,UN,6.17,4.319,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,00703-2056-01,NDC,outpatient,10,ML,102.35,71.645,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,00703-2056-03,NDC,outpatient,10,ML,102.35,71.645,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,70069-0161-10,NDC,outpatient,10,ML,30.13,21.091,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,71288-0714-11,NDC,outpatient,10,ML,30.26,21.182,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,70069-0161-01,NDC,outpatient,10,ML,30.13,21.091,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,71288-0714-10,NDC,outpatient,10,ML,30.26,21.182,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MORPHINE SULFATE ER 15 MG ORAL TBCR,RX-119246,CDM,S5000,HCPCS,259,RC,00228-4270-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MORPHINE SULFATE ER 15 MG ORAL TBCR,RX-119246,CDM,S5000,HCPCS,259,RC,63304-0450-01,NDC,outpatient,1,UN,1.05,0.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MORPHINE SULFATE ER 15 MG ORAL TBCR,RX-119246,CDM,S5000,HCPCS,259,RC,00406-8315-62,NDC,outpatient,1,UN,2.2,1.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MORPHINE SULFATE ER 15 MG ORAL TBCR,RX-119246,CDM,S5000,HCPCS,259,RC,00406-8315-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MORPHINE SULFATE ER 15 MG ORAL TBCR,RX-119246,CDM,S5000,HCPCS,259,RC,00406-8315-23,NDC,outpatient,1,UN,2.2,1.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MORPHINE SULFATE ER 100 MG ORAL TBCR,RX-119248,CDM,S5000,HCPCS,259,RC,00406-8390-62,NDC,outpatient,1,UN,12.34,8.638,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MORPHINE SULFATE ER 100 MG ORAL TBCR,RX-119248,CDM,S5000,HCPCS,259,RC,00406-8390-23,NDC,outpatient,1,UN,12.34,8.638,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
INFUVITE ADULT IV INJ,RX-119571,CDM,S5000,HCPCS,250,RC,54643-5649-01,NDC,outpatient,10,ML,39.65,27.755,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
INFUVITE ADULT IV INJ,RX-119571,CDM,S5000,HCPCS,250,RC,54643-5650-09,NDC,outpatient,10,ML,3.96,2.772,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
INFUVITE ADULT IV INJ,RX-119571,CDM,S5000,HCPCS,250,RC,54643-5650-28,NDC,outpatient,10,ML,3.96,2.772,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
INFUVITE ADULT IV INJ,RX-119571,CDM,S5000,HCPCS,250,RC,54643-5650-02,NDC,outpatient,10,ML,3.96,2.772,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
APIXABAN 5 MG ORAL TABS,RX-119614,CDM,S5000,HCPCS,259,RC,00003-0894-31,NDC,outpatient,1,UN,6.17,4.319,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MESALAMINE 400 MG ORAL CPDR,RX-119913,CDM,S5000,HCPCS,259,RC,00023-5853-18,NDC,outpatient,1,UN,15.96,11.172,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MESALAMINE 400 MG ORAL CPDR,RX-119913,CDM,S5000,HCPCS,259,RC,59762-0117-01,NDC,outpatient,1,UN,10.4,7.28,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MESALAMINE 400 MG ORAL CPDR,RX-119913,CDM,S5000,HCPCS,259,RC,60687-0556-33,NDC,outpatient,1,UN,23.14,16.198,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MESALAMINE 400 MG ORAL CPDR,RX-119913,CDM,S5000,HCPCS,259,RC,60687-0556-32,NDC,outpatient,1,UN,23.14,16.198,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MECLIZINE HCL 12.5 MG ORAL TABS,RX-12024,CDM,S5000,HCPCS,259,RC,60687-0775-11,NDC,outpatient,1,UN,1.73,1.211,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MECLIZINE HCL 12.5 MG ORAL TABS,RX-12024,CDM,S5000,HCPCS,259,RC,60687-0775-01,NDC,outpatient,1,UN,1.73,1.211,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
THEOPHYLLINE ER 300 MG ORAL TB12,RX-12098,CDM,S5000,HCPCS,259,RC,62332-0025-31,NDC,outpatient,1,UN,11.73,8.211,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
THEOPHYLLINE ER 300 MG ORAL TB12,RX-12098,CDM,S5000,HCPCS,259,RC,68462-0721-01,NDC,outpatient,1,UN,5.92,4.144,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MEMANTINE HCL ER 14 MG ORAL CP24,RX-121474,CDM,S5000,HCPCS,259,RC,00456-3414-33,NDC,outpatient,1,UN,7.56,5.292,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MEMANTINE HCL ER 21 MG ORAL CP24,RX-121475,CDM,S5000,HCPCS,259,RC,00456-3421-33,NDC,outpatient,1,UN,7.56,5.292,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MEMANTINE HCL ER 28 MG ORAL CP24,RX-121476,CDM,S5000,HCPCS,259,RC,00456-3428-33,NDC,outpatient,1,UN,63.71,44.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOXYLAMINE-PYRIDOXINE 10-10 MG ORAL TBEC,RX-121504,CDM,S5000,HCPCS,259,RC,55494-0100-10,NDC,outpatient,1,UN,13.41,9.387,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOXYLAMINE-PYRIDOXINE 10-10 MG ORAL TBEC,RX-121504,CDM,S5000,HCPCS,259,RC,70505-0100-10,NDC,outpatient,1,UN,13.18,9.226,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
QUINIDINE GLUCONATE ER 324 MG ORAL TBCR,RX-12197,CDM,S5000,HCPCS,259,RC,53489-0141-01,NDC,outpatient,1,UN,24.15,16.905,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VENLAFAXINE HCL 25 MG ORAL TABS,RX-12203,CDM,S5000,HCPCS,259,RC,68084-0896-95,NDC,outpatient,1,UN,3.98,2.786,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VENLAFAXINE HCL 25 MG ORAL TABS,RX-12203,CDM,S5000,HCPCS,259,RC,68084-0896-25,NDC,outpatient,1,UN,3.98,2.786,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VENLAFAXINE HCL 75 MG ORAL TABS,RX-12206,CDM,S5000,HCPCS,259,RC,68084-0856-01,NDC,outpatient,1,UN,3.02,2.114,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VENLAFAXINE HCL 75 MG ORAL TABS,RX-12206,CDM,S5000,HCPCS,259,RC,68084-0856-11,NDC,outpatient,1,UN,3.02,2.114,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VENLAFAXINE HCL 75 MG ORAL TABS,RX-12206,CDM,S5000,HCPCS,259,RC,57664-0395-88,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VENLAFAXINE HCL 37.5 MG ORAL TABS,RX-12207,CDM,S5000,HCPCS,259,RC,68084-0844-01,NDC,outpatient,1,UN,2.34,1.638,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VENLAFAXINE HCL 37.5 MG ORAL TABS,RX-12207,CDM,S5000,HCPCS,259,RC,68084-0844-11,NDC,outpatient,1,UN,2.34,1.638,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DORNASE ALFA 2.5 MG/2.5ML IN SOLN,RX-12211,CDM,S5000,HCPCS,259,RC,50242-0100-39,NDC,outpatient,2.5,ML,560.63,392.441,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DORNASE ALFA 2.5 MG/2.5ML IN SOLN,RX-12211,CDM,S5000,HCPCS,259,RC,50242-0100-40,NDC,outpatient,2.5,ML,560.63,392.441,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IRON-VITAMIN C 65-125 MG ORAL TABS,RX-122332,CDM,S5000,HCPCS,259,RC,63736-0123-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXYCODONE HCL ER 10 MG ORAL T12A,RX-122363,CDM,S5000,HCPCS,259,RC,59011-0410-20,NDC,outpatient,1,UN,22.52,15.764,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXYCODONE HCL ER 20 MG ORAL T12A,RX-122366,CDM,S5000,HCPCS,259,RC,59011-0420-10,NDC,outpatient,1,UN,40.9,28.63,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXYCODONE HCL ER 20 MG ORAL T12A,RX-122366,CDM,S5000,HCPCS,259,RC,59011-0420-20,NDC,outpatient,1,UN,41.94,29.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXYCODONE HCL ER 40 MG ORAL T12A,RX-122368,CDM,S5000,HCPCS,259,RC,59011-0440-20,NDC,outpatient,1,UN,71.8,50.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOLUTEGRAVIR SODIUM 50 MG ORAL TABS,RX-122784,CDM,S5000,HCPCS,259,RC,49702-0228-13,NDC,outpatient,1,UN,324.81,227.367,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LURASIDONE HCL 60 MG ORAL TABS,RX-122968,CDM,S5000,HCPCS,259,RC,65162-0082-03,NDC,outpatient,1,UN,1.48,1.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LURASIDONE HCL 60 MG ORAL TABS,RX-122968,CDM,S5000,HCPCS,259,RC,16729-0348-10,NDC,outpatient,1,UN,5,3.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,00409-3308-11,NDC,outpatient,30,ML,57.68,40.376,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,00517-7604-01,NDC,outpatient,4,ML,26.92,18.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,63323-0690-30,NDC,outpatient,30,ML,25.77,18.039,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,99999-0002-61,NDC,outpatient,3,ML,9.75,6.825,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,00409-3308-03,NDC,outpatient,30,ML,57.68,40.376,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,00517-7604-25,NDC,outpatient,4,ML,26.92,18.844,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,63323-0694-04,NDC,outpatient,4,ML,17.02,11.914,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,99999-0002-60,NDC,outpatient,3,ML,9.75,6.825,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,63323-0690-22,NDC,outpatient,30,ML,25.77,18.039,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,63323-0694-22,NDC,outpatient,4,ML,17.02,11.914,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,70860-0605-41,NDC,outpatient,2,ML,9.94,6.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,66794-0230-02,NDC,outpatient,2,ML,21.6,15.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,70860-0605-03,NDC,outpatient,2,ML,9.94,6.958,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,71288-0505-03,NDC,outpatient,2,ML,11.79,8.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,66794-0230-42,NDC,outpatient,2,ML,21.6,15.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,71288-0505-02,NDC,outpatient,2,ML,11.79,8.253,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CETIRIZINE HCL 5 MG/5ML ORAL SOLN,RX-124298,CDM,S5000,HCPCS,259,RC,51672-4070-08,NDC,outpatient,2.5,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CETIRIZINE HCL 5 MG/5ML ORAL SOLN,RX-124298,CDM,S5000,HCPCS,259,RC,99999-0004-13,NDC,outpatient,5,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TOBRAMYCIN 0.3 % OP SOLN,RX-124312,CDM,S5000,HCPCS,259,RC,61314-0643-05,NDC,outpatient,5,ML,42.15,29.505,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TOBRAMYCIN 0.3 % OP SOLN,RX-124312,CDM,S5000,HCPCS,259,RC,70069-0131-01,NDC,outpatient,5,ML,22.25,15.575,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
EXENATIDE 5 MCG/0.02ML SC SOPN,RX-124738,CDM,S5000,HCPCS,259,RC,00310-6512-01,NDC,outpatient,1.2,ML,2102.55,1471.785,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
EXENATIDE 10 MCG/0.04ML SC SOPN,RX-124739,CDM,S5000,HCPCS,259,RC,00310-6524-01,NDC,outpatient,2.4,ML,2102.55,1471.785,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIRAGLUTIDE 18 MG/3ML SC SOPN,RX-124740,CDM,S5000,HCPCS,250,RC,00169-4060-12,NDC,outpatient,3,ML,1117.4,782.18,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIRAGLUTIDE 18 MG/3ML SC SOPN,RX-124740,CDM,S5000,HCPCS,250,RC,00169-4060-13,NDC,outpatient,3,ML,1117.41,782.187,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ESTRADIOL 0.5 MG ORAL TABS,RX-12491,CDM,S5000,HCPCS,259,RC,00555-0899-02,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ESTRADIOL 0.5 MG ORAL TABS,RX-12491,CDM,S5000,HCPCS,259,RC,42806-0087-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TOBRAMYCIN 0.3 % OP OINT,RX-125351,CDM,S5000,HCPCS,259,RC,00078-0813-01,NDC,outpatient,3.5,GR,1047.63,733.341,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DIPHENHYDRAMINE HCL 12.5 MG/5ML ORAL LIQD,RX-12556,CDM,S5000,HCPCS,259,RC,00904-6985-20,NDC,outpatient,2.5,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,60687-0394-83,NDC,outpatient,2.5,ML,1.05,0.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,00487-9801-01,NDC,outpatient,2.5,ML,1.51,1.057,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,00487-9801-60,NDC,outpatient,2.5,ML,1.12,0.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,60687-0394-79,NDC,outpatient,2.5,ML,1.05,0.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,00378-7970-93,NDC,outpatient,2.5,ML,1.02,0.714,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,76204-0100-01,NDC,outpatient,2.5,ML,1.24,0.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PHENYLEPHRINE-COCOA BUTTER 0.25-88.44 % RE SUPP,RX-125849,CDM,S5000,HCPCS,259,RC,00536-1186-12,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CAFFEINE 200 MG ORAL TABS,RX-1259,CDM,S5000,HCPCS,259,RC,46017-0018-40,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DANTROLENE SODIUM 250 MG IV SUSR,RX-126042,CDM,S5000,HCPCS,250,RC,42367-0540-32,NDC,outpatient,1,UN,5868.29,4107.803,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
EMPAGLIFLOZIN 10 MG ORAL TABS,RX-126076,CDM,S5000,HCPCS,259,RC,00597-0152-30,NDC,outpatient,1,UN,55.29,38.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
EMPAGLIFLOZIN 10 MG ORAL TABS,RX-126076,CDM,S5000,HCPCS,259,RC,00597-0152-37,NDC,outpatient,1,UN,55.29,38.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
EMPAGLIFLOZIN 25 MG ORAL TABS,RX-126078,CDM,S5000,HCPCS,259,RC,00597-0153-37,NDC,outpatient,1,UN,55.29,38.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML IJ SOLN,RX-1262,CDM,S5000,HCPCS,250,RC,00517-2502-10,NDC,outpatient,2,ML,107.33,75.131,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML IJ SOLN,RX-1262,CDM,S5000,HCPCS,250,RC,00517-2502-01,NDC,outpatient,2,ML,107.33,75.131,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TERBINAFINE HCL 250 MG ORAL TABS,RX-12724,CDM,S5000,HCPCS,259,RC,65862-0079-30,NDC,outpatient,1,UN,1.29,0.903,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRIAMTERENE-HCTZ 37.5-25 MG ORAL CAPS,RX-12729,CDM,S5000,HCPCS,259,RC,00781-2074-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FAMOTIDINE IN NACL 20-0.9 MG/50ML-% IV SOLN,RX-12735,CDM,S5000,HCPCS,250,RC,00338-5197-41,NDC,outpatient,50,ML,24.23,16.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML ORAL ELIX,RX-127530,CDM,S5000,HCPCS,259,RC,75826-0127-05,NDC,outpatient,5,ML,13.49,9.443,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML ORAL ELIX,RX-127530,CDM,S5000,HCPCS,259,RC,75826-0127-04,NDC,outpatient,5,ML,13.49,9.443,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML ORAL ELIX,RX-127530,CDM,S5000,HCPCS,259,RC,75826-0128-05,NDC,outpatient,5,ML,45.71,31.997,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML ORAL ELIX,RX-127530,CDM,S5000,HCPCS,259,RC,75826-0128-04,NDC,outpatient,5,ML,45.71,31.997,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML ORAL ELIX,RX-127530,CDM,S5000,HCPCS,259,RC,99999-0002-29,NDC,outpatient,5,ML,70.67,49.469,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPRENORPHINE 7.5 MCG/HR TD PTWK,RX-127562,CDM,S5000,HCPCS,259,RC,42858-0353-40,NDC,outpatient,1,UN,309.07,216.349,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PILOCARPINE HCL 5 MG ORAL TABS,RX-12803,CDM,S5000,HCPCS,259,RC,68084-0928-95,NDC,outpatient,1,UN,10.51,7.357,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PILOCARPINE HCL 5 MG ORAL TABS,RX-12803,CDM,S5000,HCPCS,259,RC,68084-0928-25,NDC,outpatient,1,UN,10.51,7.357,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PILOCARPINE HCL 5 MG ORAL TABS,RX-12803,CDM,S5000,HCPCS,259,RC,00527-1313-01,NDC,outpatient,1,UN,4.2,2.94,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TIOTROPIUM BROMIDE MONOHYDRATE 2.5 MCG/ACT IN AERS,RX-128423,CDM,S5000,HCPCS,259,RC,00597-0100-51,NDC,outpatient,4,GR,308.39,215.873,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PENTOSAN POLYSULFATE SODIUM 100 MG ORAL CAPS,RX-12912,CDM,S5000,HCPCS,259,RC,50458-0098-01,NDC,outpatient,1,UN,46.46,32.522,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TACROLIMUS 1 MG ORAL CAPS,RX-12933,CDM,S5000,HCPCS,259,RC,51079-0818-01,NDC,outpatient,1,UN,4.95,3.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TACROLIMUS 1 MG ORAL CAPS,RX-12933,CDM,S5000,HCPCS,259,RC,00904-7097-61,NDC,outpatient,1,UN,4.43,3.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TACROLIMUS 1 MG ORAL CAPS,RX-12933,CDM,S5000,HCPCS,259,RC,51079-0818-20,NDC,outpatient,1,UN,4.95,3.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOMEBORO EX PACK,RX-129475,CDM,S5000,HCPCS,259,RC,57074-0001-77,NDC,outpatient,1,UN,2.6,1.82,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DARUNAVIR-COBICISTAT 800-150 MG ORAL TABS,RX-129730,CDM,S5000,HCPCS,259,RC,59676-0575-30,NDC,outpatient,1,UN,354.92,248.444,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PYRIDOSTIGMINE BROMIDE 10 MG/2ML IV SOLN,RX-129741,CDM,S5000,HCPCS,250,RC,00781-3040-95,NDC,outpatient,2,ML,130.52,91.364,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PYRIDOSTIGMINE BROMIDE 10 MG/2ML IV SOLN,RX-129741,CDM,S5000,HCPCS,250,RC,00781-3040-72,NDC,outpatient,2,ML,130.52,91.364,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SCOPOLAMINE 1 MG/3DAYS TD PT72,RX-129902,CDM,S5000,HCPCS,259,RC,10019-0553-90,NDC,outpatient,1,UN,23.54,16.478,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SCOPOLAMINE 1 MG/3DAYS TD PT72,RX-129902,CDM,S5000,HCPCS,259,RC,10019-0553-04,NDC,outpatient,1,UN,23.54,16.478,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SCOPOLAMINE 1 MG/3DAYS TD PT72,RX-129902,CDM,S5000,HCPCS,259,RC,50742-0505-01,NDC,outpatient,1,UN,42.28,29.596,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SCOPOLAMINE 1 MG/3DAYS TD PT72,RX-129902,CDM,S5000,HCPCS,259,RC,50742-0505-24,NDC,outpatient,1,UN,23.2,16.24,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,00143-9318-01,NDC,outpatient,4,ML,15.67,10.969,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,25021-0316-04,NDC,outpatient,4,ML,19.53,13.671,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,67457-0852-00,NDC,outpatient,4,ML,24.37,17.059,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,70121-1576-01,NDC,outpatient,4,ML,19.72,13.804,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,70121-1576-07,NDC,outpatient,4,ML,19.72,13.804,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,00143-9318-10,NDC,outpatient,4,ML,15.67,10.969,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,00409-3375-14,NDC,outpatient,4,ML,23.45,16.415,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,67457-0852-04,NDC,outpatient,4,ML,24.37,17.059,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,00409-3375-04,NDC,outpatient,4,ML,23.45,16.415,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CALCIUM CARBONATE 600 MG ORAL TABS,RX-1302,CDM,S5000,HCPCS,259,RC,00904-3232-92,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CALCIUM CARBONATE 600 MG ORAL TABS,RX-1302,CDM,S5000,HCPCS,259,RC,20555-0005-00,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE 4 % EX PTCH,RX-130376,CDM,S5000,HCPCS,259,RC,41167-0058-40,NDC,outpatient,1,UN,6.13,4.291,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE 4 % EX PTCH,RX-130376,CDM,S5000,HCPCS,259,RC,70512-0812-30,NDC,outpatient,1,UN,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE 4 % EX PTCH,RX-130376,CDM,S5000,HCPCS,259,RC,00536-1202-07,NDC,outpatient,1,UN,3.11,2.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DESVENLAFAXINE SUCCINATE ER 25 MG ORAL TB24,RX-130484,CDM,S5000,HCPCS,259,RC,59762-1210-03,NDC,outpatient,1,UN,2.76,1.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DESVENLAFAXINE SUCCINATE ER 25 MG ORAL TB24,RX-130484,CDM,S5000,HCPCS,259,RC,68180-0604-06,NDC,outpatient,1,UN,2.56,1.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CALCIUM CHLORIDE 10 % IV SOLN,RX-1306,CDM,S5000,HCPCS,250,RC,00409-4928-34,NDC,outpatient,10,ML,55.67,38.969,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CALCIUM CHLORIDE 10 % IV SOLN,RX-1306,CDM,S5000,HCPCS,250,RC,00409-1631-10,NDC,outpatient,10,ML,41.92,29.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CALCIUM CHLORIDE 10 % IV SOLN,RX-1306,CDM,S5000,HCPCS,250,RC,00409-4928-11,NDC,outpatient,10,ML,55.67,38.969,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CALCIUM CHLORIDE 10 % IV SOLN,RX-1306,CDM,S5000,HCPCS,250,RC,76329-3304-01,NDC,outpatient,10,ML,39.08,27.356,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CALCIUM CHLORIDE 10 % IV SOLN,RX-1306,CDM,S5000,HCPCS,250,RC,00409-1631-40,NDC,outpatient,10,ML,41.92,29.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VERAPAMIL HCL ER 240 MG ORAL TBCR,RX-13073,CDM,S5000,HCPCS,259,RC,60687-0515-01,NDC,outpatient,1,UN,5.2,3.64,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VERAPAMIL HCL ER 240 MG ORAL TBCR,RX-13073,CDM,S5000,HCPCS,259,RC,68462-0260-01,NDC,outpatient,1,UN,1.48,1.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VERAPAMIL HCL ER 240 MG ORAL TBCR,RX-13073,CDM,S5000,HCPCS,259,RC,60687-0515-11,NDC,outpatient,1,UN,5.2,3.64,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TIOTROPIUM BROMIDE-OLODATEROL 2.5-2.5 MCG/ACT IN AERS,RX-131078,CDM,S5000,HCPCS,259,RC,00597-0155-70,NDC,outpatient,4,GR,308.39,215.873,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VITAMIN D3 10 MCG (400 UNIT) ORAL TABS,RX-13108,CDM,S5000,HCPCS,259,RC,00904-5823-60,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VITAMIN D3 10 MCG (400 UNIT) ORAL TABS,RX-13108,CDM,S5000,HCPCS,259,RC,50268-0863-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VITAMIN D3 10 MCG (400 UNIT) ORAL TABS,RX-13108,CDM,S5000,HCPCS,259,RC,50268-0863-15,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ELVITEG-COBIC-EMTRICIT-TENOFAF 150-150-200-10 MG ORAL TABS,RX-131233,CDM,S5000,HCPCS,259,RC,61958-1901-01,NDC,outpatient,1,UN,572.84,400.988,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VALACYCLOVIR HCL 500 MG ORAL TABS,RX-13133,CDM,S5000,HCPCS,259,RC,63739-0077-10,NDC,outpatient,1,UN,4,2.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VALACYCLOVIR HCL 500 MG ORAL TABS,RX-13133,CDM,S5000,HCPCS,259,RC,68084-0215-01,NDC,outpatient,1,UN,4.3,3.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VALACYCLOVIR HCL 500 MG ORAL TABS,RX-13133,CDM,S5000,HCPCS,259,RC,68084-0215-11,NDC,outpatient,1,UN,4.3,3.01,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VALACYCLOVIR HCL 500 MG ORAL TABS,RX-13133,CDM,S5000,HCPCS,259,RC,00904-6565-61,NDC,outpatient,1,UN,4.32,3.024,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SACUBITRIL-VALSARTAN 24-26 MG ORAL TABS,RX-131630,CDM,S5000,HCPCS,259,RC,00078-0659-20,NDC,outpatient,1,UN,46.68,32.676,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SACUBITRIL-VALSARTAN 49-51 MG ORAL TABS,RX-131631,CDM,S5000,HCPCS,259,RC,00078-0777-20,NDC,outpatient,1,UN,46.68,32.676,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SACUBITRIL-VALSARTAN 97-103 MG ORAL TABS,RX-131632,CDM,S5000,HCPCS,259,RC,00078-0696-20,NDC,outpatient,1,UN,46.68,32.676,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMINOCAPROIC ACID 0.25 GM/ML ORAL SOLN,RX-131645,CDM,S5000,HCPCS,259,RC,99999-0001-90,NDC,outpatient,5,ML,202.39,141.673,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VERAPAMIL HCL ER 120 MG ORAL TBCR,RX-13184,CDM,S5000,HCPCS,259,RC,68462-0292-01,NDC,outpatient,1,UN,1.05,0.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPIVACAINE-EPINEPHRINE (PF) 0.75% -1:200000 IJ SOLN,RX-132205,CDM,S5000,HCPCS,250,RC,63323-0460-37,NDC,outpatient,30,ML,34.71,24.297,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TICAGRELOR 60 MG ORAL TABS,RX-132286,CDM,S5000,HCPCS,259,RC,00186-0776-60,NDC,outpatient,1,UN,30.77,21.539,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
KETAMINE HCL 10 MG/ML IN NS IV SYRINGE,RX-132334,CDM,S5000,HCPCS,250,RC,69374-0982-55,NDC,outpatient,5,ML,26.7,18.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
KETAMINE HCL 10 MG/ML IN NS IV SYRINGE,RX-132334,CDM,S5000,HCPCS,250,RC,70092-1119-44,NDC,outpatient,5,ML,20.39,14.273,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
KETAMINE HCL 10 MG/ML IN NS IV SYRINGE,RX-132334,CDM,S5000,HCPCS,250,RC,70092-9119-44,NDC,outpatient,5,ML,27.82,19.474,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
KETAMINE HCL 10 MG/ML IN NS IV SYRINGE,RX-132334,CDM,S5000,HCPCS,250,RC,70004-0430-09,NDC,outpatient,5,ML,28.93,20.251,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CALCIUM ACETATE (PHOS BINDER) 667 MG ORAL CAPS,RX-132734,CDM,S5000,HCPCS,259,RC,68084-0479-01,NDC,outpatient,1,UN,5.45,3.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CALCIUM ACETATE (PHOS BINDER) 667 MG ORAL CAPS,RX-132734,CDM,S5000,HCPCS,259,RC,68084-0479-11,NDC,outpatient,1,UN,5.45,3.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CALCIUM ACETATE (PHOS BINDER) 667 MG ORAL CAPS,RX-132734,CDM,S5000,HCPCS,259,RC,00904-7119-06,NDC,outpatient,1,UN,3.29,2.303,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPRENORPHINE HCL 75 MCG BU FILM,RX-132950,CDM,S5000,HCPCS,259,RC,59385-0021-60,NDC,outpatient,1,UN,29.34,20.538,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPRENORPHINE HCL 75 MCG BU FILM,RX-132950,CDM,S5000,HCPCS,259,RC,59385-0021-01,NDC,outpatient,1,UN,29.34,20.538,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPRENORPHINE HCL 300 MCG BU FILM,RX-132952,CDM,S5000,HCPCS,259,RC,59385-0023-01,NDC,outpatient,1,UN,46.07,32.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPRENORPHINE HCL 300 MCG BU FILM,RX-132952,CDM,S5000,HCPCS,259,RC,59385-0023-60,NDC,outpatient,1,UN,46.07,32.249,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPRENORPHINE HCL 750 MCG BU FILM,RX-132955,CDM,S5000,HCPCS,259,RC,59385-0026-60,NDC,outpatient,1,UN,70.24,49.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPRENORPHINE HCL 750 MCG BU FILM,RX-132955,CDM,S5000,HCPCS,259,RC,59385-0026-01,NDC,outpatient,1,UN,70.24,49.168,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPRENORPHINE HCL 900 MCG BU FILM,RX-132956,CDM,S5000,HCPCS,259,RC,59385-0027-60,NDC,outpatient,1,UN,72.31,50.617,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPRENORPHINE HCL 900 MCG BU FILM,RX-132956,CDM,S5000,HCPCS,259,RC,59385-0027-01,NDC,outpatient,1,UN,72.31,50.617,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NALOXONE HCL 4 MG/0.1ML NA LIQD,RX-132964,CDM,S5000,HCPCS,259,RC,00093-2165-68,NDC,outpatient,1,UN,146.88,102.816,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NALOXONE HCL 4 MG/0.1ML NA LIQD,RX-132964,CDM,S5000,HCPCS,259,RC,00093-2165-19,NDC,outpatient,1,UN,146.88,102.816,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PRENATAL VITAMIN PLUS LOW IRON 27-1 MG ORAL TABS,RX-133380,CDM,S5000,HCPCS,259,RC,39328-0106-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FAMCICLOVIR 500 MG ORAL TABS,RX-13358,CDM,S5000,HCPCS,259,RC,60505-3247-03,NDC,outpatient,1,UN,1.93,1.351,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRANEXAMIC ACID 1000 MG/10ML IV SOLN,RX-133831,CDM,S5000,HCPCS,250,RC,72485-0510-10,NDC,outpatient,10,ML,14.6,10.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRANEXAMIC ACID 1000 MG/10ML IV SOLN,RX-133831,CDM,S5000,HCPCS,250,RC,81284-0611-10,NDC,outpatient,10,ML,24.48,17.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRANEXAMIC ACID 1000 MG/10ML IV SOLN,RX-133831,CDM,S5000,HCPCS,250,RC,72485-0510-01,NDC,outpatient,10,ML,14.6,10.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRANEXAMIC ACID 1000 MG/10ML IV SOLN,RX-133831,CDM,S5000,HCPCS,250,RC,39822-1000-01,NDC,outpatient,10,ML,23.86,16.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRANEXAMIC ACID 1000 MG/10ML IV SOLN,RX-133831,CDM,S5000,HCPCS,250,RC,81284-0611-00,NDC,outpatient,10,ML,24.48,17.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
INSULIN REGULAR HUMAN (CONC) 500 UNIT/ML SC SOPN,RX-134373,CDM,S5000,HCPCS,259,RC,00002-8824-27,NDC,outpatient,3,ML,1168.7,818.09,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
INSULIN REGULAR HUMAN (CONC) 500 UNIT/ML SC SOPN,RX-134373,CDM,S5000,HCPCS,259,RC,00002-8824-01,NDC,outpatient,3,ML,1168.7,818.09,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
EMTRICITABINE-TENOFOVIR AF 200-25 MG ORAL TABS,RX-134420,CDM,S5000,HCPCS,259,RC,61958-2002-01,NDC,outpatient,1,UN,316.88,221.816,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DILTIAZEM HCL-DEXTROSE 125-5 MG/125ML-% IV SOLN,RX-134429,CDM,S5000,HCPCS,250,RC,70004-0540-35,NDC,outpatient,125,ML,123.38,86.366,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DILTIAZEM HCL-DEXTROSE 125-5 MG/125ML-% IV SOLN,RX-134429,CDM,S5000,HCPCS,250,RC,70092-1007-36,NDC,outpatient,125,ML,77.9,54.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DILTIAZEM HCL-DEXTROSE 125-5 MG/125ML-% IV SOLN,RX-134429,CDM,S5000,HCPCS,250,RC,70092-1575-36,NDC,outpatient,125,ML,81.02,56.714,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PSYLLIUM 400 MG ORAL CAPS,RX-134482,CDM,S5000,HCPCS,259,RC,37000-0405-14,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CARBAMAZEPINE 100 MG ORAL CHEW,RX-1355,CDM,S5000,HCPCS,259,RC,00904-3854-61,NDC,outpatient,1,UN,1.65,1.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CARBAMAZEPINE 100 MG ORAL CHEW,RX-1355,CDM,S5000,HCPCS,259,RC,60687-0479-01,NDC,outpatient,1,UN,1.69,1.183,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CARBAMAZEPINE 100 MG ORAL CHEW,RX-1355,CDM,S5000,HCPCS,259,RC,60687-0479-11,NDC,outpatient,1,UN,1.69,1.183,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CARBAMAZEPINE 100 MG/5ML ORAL SUSP,RX-1356,CDM,S5000,HCPCS,259,RC,99999-0001-92,NDC,outpatient,10,ML,6.06,4.242,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METHYLENE BLUE (ANTIDOTE) 50 MG/10ML IV SOLN,RX-135699,CDM,S5000,HCPCS,250,RC,00517-0374-01,NDC,outpatient,10,ML,411.18,287.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METHYLENE BLUE (ANTIDOTE) 50 MG/10ML IV SOLN,RX-135699,CDM,S5000,HCPCS,250,RC,00517-0374-05,NDC,outpatient,10,ML,411.18,287.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CARBAMAZEPINE 200 MG ORAL TABS,RX-1357,CDM,S5000,HCPCS,259,RC,00904-6172-61,NDC,outpatient,1,UN,2.42,1.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE-SODIUM BICARBONATE 1-8.4 % IJ SOSY,RX-135806,CDM,S5000,HCPCS,250,RC,70004-0725-05,NDC,outpatient,1,ML,19.02,13.314,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE-SODIUM BICARBONATE 1-8.4 % IJ SOSY,RX-135806,CDM,S5000,HCPCS,250,RC,99999-0003-11,NDC,outpatient,1.1,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE-SODIUM BICARBONATE 1-8.4 % IJ SOSY,RX-135806,CDM,S5000,HCPCS,250,RC,70092-1443-43,NDC,outpatient,1,ML,22.08,15.456,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VANCOMYCIN HCL IN NACL 0.9 % 1500 MG/250ML IV SOLN,RX-135845,CDM,S5000,HCPCS,250,RC,99999-0001-84,NDC,outpatient,280,ML,33.42,23.394,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VANCOMYCIN HCL IN NACL 0.9 % 1500 MG/250ML IV SOLN,RX-135845,CDM,S5000,HCPCS,250,RC,70004-0924-59,NDC,outpatient,280,ML,189.24,132.468,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VANCOMYCIN HCL IN NACL 0.9 % 1500 MG/250ML IV SOLN,RX-135845,CDM,S5000,HCPCS,250,RC,70092-9056-05,NDC,outpatient,280,ML,121.34,84.938,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CARBAMIDE PEROXIDE 6.5 % OT SOLN,RX-1359,CDM,S5000,HCPCS,259,RC,78112-0736-21,NDC,outpatient,15,ML,17.89,12.523,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CARBAMIDE PEROXIDE 6.5 % OT SOLN,RX-1359,CDM,S5000,HCPCS,259,RC,00904-6627-35,NDC,outpatient,15,ML,6.35,4.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CARBAMIDE PEROXIDE 6.5 % OT SOLN,RX-1359,CDM,S5000,HCPCS,259,RC,78112-0736-23,NDC,outpatient,15,ML,15.56,10.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METHOTREXATE SODIUM 2.5 MG ORAL TABS,RX-13594,CDM,S5000,HCPCS,259,RC,00054-8550-25,NDC,outpatient,1,UN,5.49,3.843,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METHOTREXATE SODIUM 2.5 MG ORAL TABS,RX-13594,CDM,S5000,HCPCS,259,RC,50268-0527-15,NDC,outpatient,1,UN,5.12,3.584,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METHOTREXATE SODIUM 2.5 MG ORAL TABS,RX-13594,CDM,S5000,HCPCS,259,RC,50268-0527-11,NDC,outpatient,1,UN,5.12,3.584,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DEXMEDETOMIDINE HCL 1000 MCG/10ML IV SOLN,RX-136367,CDM,S5000,HCPCS,250,RC,44567-0601-04,NDC,outpatient,10,ML,205.59,143.913,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MICONAZOLE NITRATE 2 % EX OINT,RX-13651,CDM,S5000,HCPCS,259,RC,11701-0067-23,NDC,outpatient,57,GR,25.88,18.116,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MICONAZOLE NITRATE 2 % EX OINT,RX-13651,CDM,S5000,HCPCS,259,RC,53329-0172-10,NDC,outpatient,71,GR,15.17,10.619,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VANCOMYCIN HCL IN NACL 0.9 % 1250 MG/250ML IV SOLN,RX-136649,CDM,S5000,HCPCS,250,RC,70092-9054-05,NDC,outpatient,275,ML,111.55,78.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VANCOMYCIN HCL IN NACL 0.9 % 1250 MG/250ML IV SOLN,RX-136649,CDM,S5000,HCPCS,250,RC,71506-0015-58,NDC,outpatient,275,ML,93.39,65.373,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VANCOMYCIN HCL IN NACL 0.9 % 1250 MG/250ML IV SOLN,RX-136649,CDM,S5000,HCPCS,250,RC,99999-0001-85,NDC,outpatient,275,ML,59.61,41.727,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VANCOMYCIN HCL IN NACL 0.9 % 1250 MG/250ML IV SOLN,RX-136649,CDM,S5000,HCPCS,250,RC,70004-0923-59,NDC,outpatient,275,ML,170.02,119.014,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GUAIFENESIN 100 MG/5ML ORAL LIQD,RX-13748,CDM,S5000,HCPCS,259,RC,00121-2232-00,NDC,outpatient,15,ML,6.68,4.676,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GUAIFENESIN 100 MG/5ML ORAL LIQD,RX-13748,CDM,S5000,HCPCS,259,RC,00121-2232-15,NDC,outpatient,15,ML,6.68,4.676,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DILTIAZEM HCL-SODIUM CHLORIDE 125-0.9 MG/125ML-% IV SOLN,RX-137908,CDM,S5000,HCPCS,250,RC,99999-0003-40,NDC,outpatient,125,ML,51.6,36.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DILTIAZEM HCL-SODIUM CHLORIDE 125-0.9 MG/125ML-% IV SOLN,RX-137908,CDM,S5000,HCPCS,250,RC,76154-0818-05,NDC,outpatient,125,ML,82.75,57.925,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXYTOCIN-SODIUM CHLORIDE 30-0.9 UT/500ML-% IV SOLN,RX-137935,CDM,S5000,HCPCS,250,RC,70092-1068-07,NDC,outpatient,500,ML,106.3,74.41,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXYTOCIN-SODIUM CHLORIDE 30-0.9 UT/500ML-% IV SOLN,RX-137935,CDM,S5000,HCPCS,250,RC,70092-1552-07,NDC,outpatient,500,ML,97.53,68.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LINACLOTIDE 72 MCG ORAL CAPS,RX-138008,CDM,S5000,HCPCS,259,RC,00456-1203-30,NDC,outpatient,1,UN,74.11,51.877,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BACITRACIN ZINC 500 UNIT/GM EX OINT,RX-13818,CDM,S5000,HCPCS,259,RC,00536-1263-28,NDC,outpatient,28,GR,4.99,3.493,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BACITRACIN ZINC 500 UNIT/GM EX OINT,RX-13818,CDM,S5000,HCPCS,259,RC,57896-0145-14,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BACITRACIN ZINC 500 UNIT/GM EX OINT,RX-13818,CDM,S5000,HCPCS,259,RC,58980-0011-10,NDC,outpatient,28.35,GR,10.1,7.07,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VANCOMYCIN HCL IN NACL 2-0.9 GM/500ML-% IV SOLN,RX-138299,CDM,S5000,HCPCS,250,RC,71506-0019-59,NDC,outpatient,540,ML,128.46,89.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VANCOMYCIN HCL IN NACL 2-0.9 GM/500ML-% IV SOLN,RX-138299,CDM,S5000,HCPCS,250,RC,99999-0002-01,NDC,outpatient,540,ML,36.84,25.788,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VANCOMYCIN HCL IN NACL 1.75-0.9 GM/500ML-% IV SOLN,RX-138322,CDM,S5000,HCPCS,250,RC,99999-0002-00,NDC,outpatient,535,ML,35.39,24.773,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VANCOMYCIN HCL IN NACL 1.75-0.9 GM/500ML-% IV SOLN,RX-138322,CDM,S5000,HCPCS,250,RC,71506-0017-59,NDC,outpatient,535,ML,119.16,83.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BENZOCAINE 20 % MT AERO,RX-138339,CDM,S5000,HCPCS,259,RC,00283-0679-02,NDC,outpatient,57,GR,120.74,84.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PORACTANT ALFA 120 MG/1.5ML INTRATRACHEA SUSP,RX-138354,CDM,S5000,HCPCS,250,RC,10122-0510-01,NDC,outpatient,1.5,ML,1807.78,1265.446,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PORACTANT ALFA 240 MG/3ML INTRATRACHEA SUSP,RX-138355,CDM,S5000,HCPCS,250,RC,10122-0510-03,NDC,outpatient,3,ML,2153.49,1507.443,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
COLESTIPOL HCL 1 G ORAL TABS,RX-13884,CDM,S5000,HCPCS,259,RC,60687-0715-21,NDC,outpatient,1,UN,12.93,9.051,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
COLESTIPOL HCL 1 G ORAL TABS,RX-13884,CDM,S5000,HCPCS,259,RC,00009-0450-03,NDC,outpatient,1,UN,9.24,6.468,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
COLESTIPOL HCL 1 G ORAL TABS,RX-13884,CDM,S5000,HCPCS,259,RC,59762-0450-01,NDC,outpatient,1,UN,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
COLESTIPOL HCL 1 G ORAL TABS,RX-13884,CDM,S5000,HCPCS,259,RC,00115-5211-16,NDC,outpatient,1,UN,4.6,3.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
COLESTIPOL HCL 1 G ORAL TABS,RX-13884,CDM,S5000,HCPCS,259,RC,60687-0715-11,NDC,outpatient,1,UN,12.93,9.051,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MORPHINE SULFATE 100 MG IN NACL 0.9 % 100 ML IV PREMIX,RX-138903,CDM,S5000,HCPCS,250,RC,70092-1380-36,NDC,outpatient,100,ML,69.27,48.489,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MORPHINE SULFATE 100 MG IN NACL 0.9 % 100 ML IV PREMIX,RX-138903,CDM,S5000,HCPCS,250,RC,99999-0003-24,NDC,outpatient,100,ML,48.85,34.195,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MORPHINE SULFATE 100 MG IN NACL 0.9 % 100 ML IV PREMIX,RX-138903,CDM,S5000,HCPCS,250,RC,70092-1130-36,NDC,outpatient,100,ML,83.73,58.611,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DAPAGLIFLOZIN PROPANEDIOL 5 MG ORAL TABS,RX-138997,CDM,S5000,HCPCS,259,RC,00310-6205-30,NDC,outpatient,1,UN,54.15,37.905,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DAPAGLIFLOZIN PROPANEDIOL 5 MG ORAL TABS,RX-138997,CDM,S5000,HCPCS,259,RC,66993-0456-30,NDC,outpatient,1,UN,54.61,38.227,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DAPAGLIFLOZIN PROPANEDIOL 10 MG ORAL TABS,RX-138998,CDM,S5000,HCPCS,259,RC,66993-0457-30,NDC,outpatient,1,UN,57.77,40.439,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DAPAGLIFLOZIN PROPANEDIOL 10 MG ORAL TABS,RX-138998,CDM,S5000,HCPCS,259,RC,00310-6210-39,NDC,outpatient,1,UN,54.15,37.905,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OCUVITE-LUTEIN ORAL TABS,RX-139063,CDM,S5000,HCPCS,259,RC,00536-5090-08,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OCUVITE-LUTEIN ORAL TABS,RX-139063,CDM,S5000,HCPCS,259,RC,24208-0387-62,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SARILUMAB 200 MG/1.14ML SC SOSY,RX-139347,CDM,S5000,HCPCS,250,RC,00024-5910-00,NDC,outpatient,1.14,ML,5813.71,4069.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SARILUMAB 200 MG/1.14ML SC SOSY,RX-139347,CDM,S5000,HCPCS,250,RC,00024-5910-01,NDC,outpatient,1.14,ML,5813.71,4069.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CARISOPRODOL 350 MG ORAL TABS,RX-1395,CDM,S5000,HCPCS,259,RC,50228-0109-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LAMOTRIGINE 25 MG ORAL TABS,RX-13981,CDM,S5000,HCPCS,259,RC,51672-4130-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LAMOTRIGINE 25 MG ORAL TABS,RX-13981,CDM,S5000,HCPCS,259,RC,00904-7007-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LAMOTRIGINE 25 MG ORAL TABS,RX-13981,CDM,S5000,HCPCS,259,RC,68084-0318-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LAMOTRIGINE 25 MG ORAL TABS,RX-13981,CDM,S5000,HCPCS,259,RC,68084-0318-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LAMOTRIGINE 100 MG ORAL TABS,RX-13982,CDM,S5000,HCPCS,259,RC,51672-4131-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LAMOTRIGINE 100 MG ORAL TABS,RX-13982,CDM,S5000,HCPCS,259,RC,68084-0319-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LAMOTRIGINE 100 MG ORAL TABS,RX-13982,CDM,S5000,HCPCS,259,RC,00904-7008-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LAMOTRIGINE 100 MG ORAL TABS,RX-13982,CDM,S5000,HCPCS,259,RC,68084-0319-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CALCIUM CARBONATE ANTACID 1250 MG/5ML ORAL SUSP,RX-140541,CDM,S5000,HCPCS,259,RC,00121-4766-05,NDC,outpatient,5,ML,9.19,6.433,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DILTIAZEM HCL ER 60 MG ORAL CP12,RX-14100,CDM,S5000,HCPCS,259,RC,51079-0924-01,NDC,outpatient,1,UN,13.61,9.527,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DILTIAZEM HCL ER 60 MG ORAL CP12,RX-14100,CDM,S5000,HCPCS,259,RC,51079-0924-20,NDC,outpatient,1,UN,13.61,9.527,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DILTIAZEM HCL ER 90 MG ORAL CP12,RX-14101,CDM,S5000,HCPCS,259,RC,51079-0925-20,NDC,outpatient,1,UN,16,11.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DILTIAZEM HCL ER 90 MG ORAL CP12,RX-14101,CDM,S5000,HCPCS,259,RC,51079-0925-01,NDC,outpatient,1,UN,16,11.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
KETOCONAZOLE 2 % EX SHAM,RX-14132,CDM,S5000,HCPCS,259,RC,45802-0465-64,NDC,outpatient,120,ML,53.4,37.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BECLOMETHASONE DIPROP HFA 40 MCG/ACT IN AERB,RX-141345,CDM,S5000,HCPCS,259,RC,59310-0302-40,NDC,outpatient,10.6,GR,878.5,614.95,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BECLOMETHASONE DIPROP HFA 80 MCG/ACT IN AERB,RX-141346,CDM,S5000,HCPCS,259,RC,59310-0304-80,NDC,outpatient,10.6,GR,1176.28,823.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BICTEGRAVIR-EMTRICITAB-TENOFOV 50-200-25 MG ORAL TABS,RX-142007,CDM,S5000,HCPCS,259,RC,61958-2501-01,NDC,outpatient,1,UN,572.84,400.988,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLUCONAZOLE 40 MG/ML ORAL SUSR,RX-14233,CDM,S5000,HCPCS,259,RC,59762-5030-01,NDC,outpatient,35,ML,84.73,59.311,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLUCONAZOLE 40 MG/ML ORAL SUSR,RX-14233,CDM,S5000,HCPCS,259,RC,99999-0002-78,NDC,outpatient,5,ML,12.62,8.834,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLUCONAZOLE 40 MG/ML ORAL SUSR,RX-14233,CDM,S5000,HCPCS,259,RC,16714-0696-01,NDC,outpatient,35,ML,43.77,30.639,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MAGNESIUM CHLORIDE 64 MG ORAL TBEC,RX-142395,CDM,S5000,HCPCS,259,RC,68585-0005-75,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MAGNESIUM CHLORIDE 64 MG ORAL TBEC,RX-142395,CDM,S5000,HCPCS,259,RC,57896-0635-06,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MAGNESIUM CHLORIDE 64 MG ORAL TBEC,RX-142395,CDM,S5000,HCPCS,259,RC,10006-0700-13,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POTASSIUM IODIDE (EXPECTORANT) 1 GM/ML ORAL SOLN,RX-142406,CDM,S5000,HCPCS,259,RC,71740-0112-30,NDC,outpatient,0.25,ML,14.74,10.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POTASSIUM IODIDE (EXPECTORANT) 1 GM/ML ORAL SOLN,RX-142406,CDM,S5000,HCPCS,259,RC,99999-0003-49,NDC,outpatient,1,ML,58.94,41.258,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DARUN-COBIC-EMTRICIT-TENOFAF 800-150-200-10 MG ORAL TABS,RX-143657,CDM,S5000,HCPCS,259,RC,59676-0800-30,NDC,outpatient,1,UN,678.69,475.083,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PIMAVANSERIN TARTRATE 34 MG ORAL CAPS,RX-143683,CDM,S5000,HCPCS,259,RC,63090-0340-30,NDC,outpatient,1,UN,740.93,518.651,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM ZIRCONIUM CYCLOSILICATE 10 G ORAL PACK,RX-143885,CDM,S5000,HCPCS,259,RC,00310-1110-39,NDC,outpatient,1,UN,69.73,48.811,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM ZIRCONIUM CYCLOSILICATE 10 G ORAL PACK,RX-143885,CDM,S5000,HCPCS,259,RC,00310-1110-01,NDC,outpatient,1,UN,69.73,48.811,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLONIDINE 0.1 MG/24HR TD PTWK,RX-144285,CDM,S5000,HCPCS,259,RC,00378-0871-99,NDC,outpatient,1,UN,58.96,41.272,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLONIDINE 0.1 MG/24HR TD PTWK,RX-144285,CDM,S5000,HCPCS,259,RC,52817-0610-04,NDC,outpatient,1,UN,36.6,25.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLONIDINE 0.1 MG/24HR TD PTWK,RX-144285,CDM,S5000,HCPCS,259,RC,00378-0871-16,NDC,outpatient,1,UN,58.96,41.272,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLONIDINE 0.2 MG/24HR TD PTWK,RX-144286,CDM,S5000,HCPCS,259,RC,82089-0102-34,NDC,outpatient,1,UN,502.38,351.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLONIDINE 0.2 MG/24HR TD PTWK,RX-144286,CDM,S5000,HCPCS,259,RC,00591-3509-04,NDC,outpatient,1,UN,89.34,62.538,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLONIDINE 0.2 MG/24HR TD PTWK,RX-144286,CDM,S5000,HCPCS,259,RC,51862-0454-01,NDC,outpatient,1,UN,43.76,30.632,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLONIDINE 0.2 MG/24HR TD PTWK,RX-144286,CDM,S5000,HCPCS,259,RC,00591-3509-54,NDC,outpatient,1,UN,89.34,62.538,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLONIDINE 0.2 MG/24HR TD PTWK,RX-144286,CDM,S5000,HCPCS,259,RC,51862-0454-04,NDC,outpatient,1,UN,43.76,30.632,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLONIDINE 0.3 MG/24HR TD PTWK,RX-144287,CDM,S5000,HCPCS,259,RC,00591-3510-04,NDC,outpatient,1,UN,122.13,85.491,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLONIDINE 0.3 MG/24HR TD PTWK,RX-144287,CDM,S5000,HCPCS,259,RC,00591-3510-54,NDC,outpatient,1,UN,122.13,85.491,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RIVAROXABAN 2.5 MG ORAL TABS,RX-144544,CDM,S5000,HCPCS,259,RC,50458-0577-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RIVAROXABAN 2.5 MG ORAL TABS,RX-144544,CDM,S5000,HCPCS,259,RC,50458-0577-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DORZOLAMIDE HCL 2 % OP SOLN,RX-14471,CDM,S5000,HCPCS,259,RC,42571-0141-26,NDC,outpatient,10,ML,151.26,105.882,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DORZOLAMIDE HCL 2 % OP SOLN,RX-14471,CDM,S5000,HCPCS,259,RC,61314-0019-10,NDC,outpatient,10,ML,71.78,50.246,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DORZOLAMIDE HCL 2 % OP SOLN,RX-14471,CDM,S5000,HCPCS,259,RC,24208-0485-10,NDC,outpatient,10,ML,36.09,25.263,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
REVEFENACIN 175 MCG/3ML IN SOLN,RX-145104,CDM,S5000,HCPCS,259,RC,49502-0806-32,NDC,outpatient,3,ML,93.63,65.541,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
REVEFENACIN 175 MCG/3ML IN SOLN,RX-145104,CDM,S5000,HCPCS,259,RC,49502-0806-93,NDC,outpatient,3,ML,93.63,65.541,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TERAZOSIN HCL 1 MG ORAL CAPS,RX-14550,CDM,S5000,HCPCS,259,RC,50268-0764-11,NDC,outpatient,1,UN,2.5,1.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TERAZOSIN HCL 1 MG ORAL CAPS,RX-14550,CDM,S5000,HCPCS,259,RC,50268-0764-15,NDC,outpatient,1,UN,2.5,1.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TERAZOSIN HCL 5 MG ORAL CAPS,RX-14553,CDM,S5000,HCPCS,259,RC,50268-0766-11,NDC,outpatient,1,UN,2.67,1.869,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TERAZOSIN HCL 5 MG ORAL CAPS,RX-14553,CDM,S5000,HCPCS,259,RC,50268-0766-15,NDC,outpatient,1,UN,2.67,1.869,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ABLYSINOL IA SOLN,RX-145979,CDM,S5000,HCPCS,250,RC,54288-0105-02,NDC,outpatient,5,ML,2091.2,1463.84,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ABLYSINOL IA SOLN,RX-145979,CDM,S5000,HCPCS,250,RC,54288-0105-15,NDC,outpatient,5,ML,2091.2,1463.84,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PYRIDOSTIGMINE BROMIDE 60 MG/5ML ORAL SOLN,RX-146239,CDM,S5000,HCPCS,259,RC,99999-0002-40,NDC,outpatient,5,ML,47,32.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PYRIDOSTIGMINE BROMIDE 60 MG/5ML ORAL SOLN,RX-146239,CDM,S5000,HCPCS,259,RC,69238-1731-02,NDC,outpatient,473,ML,2201.68,1541.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VERAPAMIL HCL ER 180 MG ORAL TBCR,RX-14626,CDM,S5000,HCPCS,259,RC,75834-0158-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
INDOMETHACIN ER 75 MG ORAL CPCR,RX-14628,CDM,S5000,HCPCS,259,RC,68084-0411-21,NDC,outpatient,1,UN,9.29,6.503,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
INDOMETHACIN ER 75 MG ORAL CPCR,RX-14628,CDM,S5000,HCPCS,259,RC,68084-0411-11,NDC,outpatient,1,UN,9.29,6.503,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRAMADOL HCL 50 MG ORAL TABS,RX-14632,CDM,S5000,HCPCS,259,RC,00093-0058-05,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRAMADOL HCL 50 MG ORAL TABS,RX-14632,CDM,S5000,HCPCS,259,RC,00904-7179-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRAMADOL HCL 50 MG ORAL TABS,RX-14632,CDM,S5000,HCPCS,259,RC,29300-0355-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRAMADOL HCL 50 MG ORAL TABS,RX-14632,CDM,S5000,HCPCS,259,RC,60687-0795-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRAMADOL HCL 50 MG ORAL TABS,RX-14632,CDM,S5000,HCPCS,259,RC,60687-0795-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACETIC ACID 5 % SOLN,RX-14702,CDM,S5000,HCPCS,259,RC,99999-0000-92,NDC,outpatient,60,ML,12.55,8.785,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METFORMIN HCL 850 MG ORAL TABS,RX-14719,CDM,S5000,HCPCS,259,RC,60687-0143-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METFORMIN HCL 850 MG ORAL TABS,RX-14719,CDM,S5000,HCPCS,259,RC,00904-7163-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METFORMIN HCL 850 MG ORAL TABS,RX-14719,CDM,S5000,HCPCS,259,RC,60687-0143-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GLYBURIDE MICRONIZED 1.5 MG ORAL TABS,RX-14777,CDM,S5000,HCPCS,259,RC,00093-8034-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
INSULIN REGULAR(HUMAN) IN NACL 100-0.9 UT/100ML-% IV SOLN,RX-147794,CDM,S5000,HCPCS,250,RC,00338-0126-12,NDC,outpatient,100,ML,98.33,68.831,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRANEXAMIC ACID-NACL 1000-0.7 MG/100ML-% IV SOLN,RX-147865,CDM,S5000,HCPCS,250,RC,51754-0108-01,NDC,outpatient,100,ML,46.71,32.697,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRANEXAMIC ACID-NACL 1000-0.7 MG/100ML-% IV SOLN,RX-147865,CDM,S5000,HCPCS,250,RC,51754-0108-03,NDC,outpatient,100,ML,46.71,32.697,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DORZOLAMIDE HCL-TIMOLOL MAL PF 2-0.5 % OP SOLN,RX-147878,CDM,S5000,HCPCS,259,RC,82584-0604-01,NDC,outpatient,1,UN,14.17,9.919,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DORZOLAMIDE HCL-TIMOLOL MAL PF 2-0.5 % OP SOLN,RX-147878,CDM,S5000,HCPCS,259,RC,82584-0604-30,NDC,outpatient,1,UN,14.17,9.919,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TIZANIDINE HCL 2 MG ORAL TABS,RX-14792,CDM,S5000,HCPCS,259,RC,50268-0759-15,NDC,outpatient,1,UN,2.93,2.051,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TIZANIDINE HCL 2 MG ORAL TABS,RX-14792,CDM,S5000,HCPCS,259,RC,50268-0759-11,NDC,outpatient,1,UN,2.93,2.051,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TIZANIDINE HCL 4 MG ORAL TABS,RX-14793,CDM,S5000,HCPCS,259,RC,00904-6418-61,NDC,outpatient,1,UN,1.85,1.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LANSOPRAZOLE 30 MG ORAL TBDD,RX-148035,CDM,S5000,HCPCS,259,RC,68382-0772-77,NDC,outpatient,1,UN,20.73,14.511,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LANSOPRAZOLE 30 MG ORAL TBDD,RX-148035,CDM,S5000,HCPCS,259,RC,00378-6982-32,NDC,outpatient,1,UN,22.99,16.093,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LANSOPRAZOLE 30 MG ORAL TBDD,RX-148035,CDM,S5000,HCPCS,259,RC,00378-6982-88,NDC,outpatient,1,UN,22.99,16.093,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LANSOPRAZOLE 30 MG ORAL TBDD,RX-148035,CDM,S5000,HCPCS,259,RC,64764-0544-11,NDC,outpatient,1,UN,56.9,39.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LANSOPRAZOLE 30 MG ORAL TBDD,RX-148035,CDM,S5000,HCPCS,259,RC,68382-0772-30,NDC,outpatient,1,UN,20.73,14.511,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LOSARTAN POTASSIUM 25 MG ORAL TABS,RX-14823,CDM,S5000,HCPCS,259,RC,68084-0346-01,NDC,outpatient,1,UN,1.75,1.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LOSARTAN POTASSIUM 25 MG ORAL TABS,RX-14823,CDM,S5000,HCPCS,259,RC,68084-0346-11,NDC,outpatient,1,UN,1.75,1.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LOSARTAN POTASSIUM 50 MG ORAL TABS,RX-14824,CDM,S5000,HCPCS,259,RC,31722-0701-90,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LOSARTAN POTASSIUM 50 MG ORAL TABS,RX-14824,CDM,S5000,HCPCS,259,RC,50268-0505-11,NDC,outpatient,1,UN,1.24,0.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LOSARTAN POTASSIUM 50 MG ORAL TABS,RX-14824,CDM,S5000,HCPCS,259,RC,00904-7048-61,NDC,outpatient,1,UN,1.68,1.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LOSARTAN POTASSIUM 50 MG ORAL TABS,RX-14824,CDM,S5000,HCPCS,259,RC,31722-0701-30,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LOSARTAN POTASSIUM 50 MG ORAL TABS,RX-14824,CDM,S5000,HCPCS,259,RC,50268-0505-15,NDC,outpatient,1,UN,1.24,0.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FOSFOMYCIN TROMETHAMINE 3 G ORAL PACK,RX-14825,CDM,S5000,HCPCS,259,RC,69097-0579-67,NDC,outpatient,1,UN,204.35,143.045,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FOSFOMYCIN TROMETHAMINE 3 G ORAL PACK,RX-14825,CDM,S5000,HCPCS,259,RC,70700-0268-94,NDC,outpatient,1,UN,214.58,150.206,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FOSFOMYCIN TROMETHAMINE 3 G ORAL PACK,RX-14825,CDM,S5000,HCPCS,259,RC,70700-0268-99,NDC,outpatient,1,UN,214.58,150.206,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ATOVAQUONE 750 MG/5ML ORAL SUSP,RX-14953,CDM,S5000,HCPCS,259,RC,70748-0299-01,NDC,outpatient,210,ML,615.84,431.088,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ATOVAQUONE 750 MG/5ML ORAL SUSP,RX-14953,CDM,S5000,HCPCS,259,RC,99999-0004-54,NDC,outpatient,5,ML,14.67,10.269,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BACTERIOSTATIC WATER(BENZ ALC) IJ SOLN,RX-14979,CDM,S5000,HCPCS,250,RC,00409-3977-01,NDC,outpatient,30,ML,8.02,5.614,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BACTERIOSTATIC WATER(BENZ ALC) IJ SOLN,RX-14979,CDM,S5000,HCPCS,250,RC,00409-3977-03,NDC,outpatient,30,ML,8.02,5.614,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MOEXIPRIL HCL 7.5 MG ORAL TABS,RX-15025,CDM,S5000,HCPCS,259,RC,68462-0209-01,NDC,outpatient,1,UN,3.46,2.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VITAMIN A 3 MG (10000 UT) ORAL CAPS,RX-150260,CDM,S5000,HCPCS,259,RC,40093-0101-44,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VITAMIN A 3 MG (10000 UT) ORAL CAPS,RX-150260,CDM,S5000,HCPCS,259,RC,00904-2085-60,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VITAMIN A 3 MG (10000 UT) ORAL CAPS,RX-150260,CDM,S5000,HCPCS,259,RC,40093-0140-03,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROCORT-PRAMOXINE (PERIANAL) 2.5-1 % EX CREA,RX-150325,CDM,S5000,HCPCS,259,RC,45802-0472-64,NDC,outpatient,30,GR,583,408.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACETIC ACID 3 % SOLN,RX-15091,CDM,S5000,HCPCS,259,RC,99999-0001-49,NDC,outpatient,60,ML,11.75,8.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACETIC ACID 3 % SOLN,RX-15091,CDM,S5000,HCPCS,259,RC,51552-0051-06,NDC,outpatient,500,ML,97.9,68.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LOPERAMIDE HCL 1 MG/7.5ML ORAL SOLN,RX-150997,CDM,S5000,HCPCS,259,RC,68094-0129-62,NDC,outpatient,15,ML,10.55,7.385,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LOPERAMIDE HCL 1 MG/7.5ML ORAL SOLN,RX-150997,CDM,S5000,HCPCS,259,RC,68094-0129-59,NDC,outpatient,15,ML,10.55,7.385,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MYCOPHENOLATE MOFETIL 250 MG ORAL CAPS,RX-15113,CDM,S5000,HCPCS,259,RC,60687-0494-01,NDC,outpatient,1,UN,2.25,1.575,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MYCOPHENOLATE MOFETIL 250 MG ORAL CAPS,RX-15113,CDM,S5000,HCPCS,259,RC,51079-0721-20,NDC,outpatient,1,UN,2.18,1.526,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MYCOPHENOLATE MOFETIL 250 MG ORAL CAPS,RX-15113,CDM,S5000,HCPCS,259,RC,60687-0494-11,NDC,outpatient,1,UN,2.25,1.575,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MYCOPHENOLATE MOFETIL 250 MG ORAL CAPS,RX-15113,CDM,S5000,HCPCS,259,RC,51079-0721-01,NDC,outpatient,1,UN,2.18,1.526,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POLY-VI-SOL/IRON 11 MG/ML ORAL SOLN,RX-151638,CDM,S5000,HCPCS,259,RC,99999-0001-69,NDC,outpatient,0.5,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POLY-VI-SOL/IRON 11 MG/ML ORAL SOLN,RX-151638,CDM,S5000,HCPCS,259,RC,00087-0405-01,NDC,outpatient,0.5,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TACROLIMUS ER 1 MG ORAL TB24,RX-151676,CDM,S5000,HCPCS,259,RC,68992-3010-03,NDC,outpatient,1,UN,3.04,2.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TACROLIMUS ER 0.75 MG ORAL TB24,RX-151678,CDM,S5000,HCPCS,259,RC,68992-3075-03,NDC,outpatient,1,UN,2.28,1.596,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TACROLIMUS ER 4 MG ORAL TB24,RX-151679,CDM,S5000,HCPCS,259,RC,68992-3040-03,NDC,outpatient,1,UN,12.17,8.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SENNOSIDES 8.8 MG/5ML ORAL SYRP,RX-15168,CDM,S5000,HCPCS,259,RC,00536-1266-10,NDC,outpatient,10,ML,1.5,1.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SENNOSIDES 8.8 MG/5ML ORAL SYRP,RX-15168,CDM,S5000,HCPCS,259,RC,00536-1266-59,NDC,outpatient,10,ML,1.5,1.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SENNOSIDES 8.8 MG/5ML ORAL SYRP,RX-15168,CDM,S5000,HCPCS,259,RC,57896-0472-08,NDC,outpatient,5,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SENNOSIDES 8.8 MG/5ML ORAL SYRP,RX-15168,CDM,S5000,HCPCS,259,RC,99999-0002-42,NDC,outpatient,10,ML,1.6,1.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SENNOSIDES 8.8 MG/5ML ORAL SYRP,RX-15168,CDM,S5000,HCPCS,259,RC,57896-0472-10,NDC,outpatient,10,ML,1.39,0.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRACE MINERALS CU-MN-SE-ZN 300-55-60-3000 MCG/ML IV SOLN,RX-151858,CDM,S5000,HCPCS,250,RC,00517-9305-25,NDC,outpatient,1,ML,93.05,65.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRACE MINERALS CU-MN-SE-ZN 300-55-60-3000 MCG/ML IV SOLN,RX-151858,CDM,S5000,HCPCS,250,RC,00517-9305-01,NDC,outpatient,1,ML,93.05,65.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METHACHOLINE CHLORIDE IN KIT,RX-151916,CDM,S5000,HCPCS,259,RC,69374-0542-06,NDC,outpatient,18,ML,600.75,420.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DICLOFENAC SODIUM 1 % EX GEL,RX-152701,CDM,S5000,HCPCS,259,RC,43598-0977-10,NDC,outpatient,100,GR,59.19,41.433,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DICLOFENAC SODIUM 1 % EX GEL,RX-152701,CDM,S5000,HCPCS,259,RC,00536-1294-97,NDC,outpatient,100,GR,33.38,23.366,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DICLOFENAC SODIUM 1 % EX GEL,RX-152701,CDM,S5000,HCPCS,259,RC,69097-0524-44,NDC,outpatient,100,GR,59.63,41.741,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SUMATRIPTAN SUCCINATE 25 MG ORAL TABS,RX-15327,CDM,S5000,HCPCS,259,RC,65862-0146-36,NDC,outpatient,1,UN,1.72,1.204,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DICLOFENAC SODIUM 50 MG ORAL TBEC,RX-15340,CDM,S5000,HCPCS,259,RC,61442-0102-01,NDC,outpatient,1,UN,1.24,0.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DICLOFENAC SODIUM 50 MG ORAL TBEC,RX-15340,CDM,S5000,HCPCS,259,RC,00228-2550-11,NDC,outpatient,1,UN,1.63,1.141,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DICLOFENAC SODIUM 50 MG ORAL TBEC,RX-15340,CDM,S5000,HCPCS,259,RC,16571-0202-10,NDC,outpatient,1,UN,1.23,0.861,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DICLOFENAC SODIUM 50 MG ORAL TBEC,RX-15340,CDM,S5000,HCPCS,259,RC,60687-0606-01,NDC,outpatient,1,UN,2.07,1.449,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DICLOFENAC SODIUM 50 MG ORAL TBEC,RX-15340,CDM,S5000,HCPCS,259,RC,60687-0606-11,NDC,outpatient,1,UN,2.07,1.449,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DICLOFENAC SODIUM 75 MG ORAL TBEC,RX-15341,CDM,S5000,HCPCS,259,RC,16571-0201-06,NDC,outpatient,1,UN,1.46,1.022,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AYR SALINE NASAL NA GEL,RX-15372,CDM,S5000,HCPCS,259,RC,05928-0000-99,NDC,outpatient,28.4,GR,22.75,15.925,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AYR SALINE NASAL NA GEL,RX-15372,CDM,S5000,HCPCS,259,RC,00225-0525-47,NDC,outpatient,14.1,GR,10.92,7.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RIMANTADINE HCL 100 MG ORAL TABS,RX-15440,CDM,S5000,HCPCS,259,RC,00115-1911-01,NDC,outpatient,1,UN,10.21,7.147,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CHERRY ORAL SYRP,RX-1562,CDM,S5000,HCPCS,259,RC,00395-2662-16,NDC,outpatient,473,ML,78.58,55.006,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FAT EMULSION PLANT BASED (SOY) 20 % IV EMUL,RX-156372,CDM,S5000,HCPCS,250,RC,00338-0519-09,NDC,outpatient,250,ML,59.39,41.573,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FAT EMULSION PLANT BASED (SOY) 20 % IV EMUL,RX-156372,CDM,S5000,HCPCS,250,RC,00338-0519-13,NDC,outpatient,500,ML,73.85,51.695,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMANTADINE HCL 50 MG/5ML ORAL SOLN,RX-156382,CDM,S5000,HCPCS,259,RC,00121-0646-10,NDC,outpatient,10,ML,13.67,9.569,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALENDRONATE SODIUM 10 MG ORAL TABS,RX-15661,CDM,S5000,HCPCS,259,RC,16714-0631-01,NDC,outpatient,1,UN,1.72,1.204,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM THIOSULFATE 250 MG/ML IV SOLN,RX-156724,CDM,S5000,HCPCS,250,RC,60267-0705-50,NDC,outpatient,50,ML,431.65,302.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PRISMASOL BGK 0/2.5 32-2.5 MEQ/L EC SOLN,RX-156740,CDM,S5000,HCPCS,250,RC,24571-0108-06,NDC,outpatient,5000,ML,294.88,206.416,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PRISMASOL BGK 4/2.5 32-4-2.5 MEQ/L EC SOLN,RX-156741,CDM,S5000,HCPCS,250,RC,24571-0105-06,NDC,outpatient,5000,ML,294.88,206.416,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PRISMASOL BGK 2/0 32-2 MEQ/L EC SOLN,RX-156742,CDM,S5000,HCPCS,250,RC,24571-0102-06,NDC,outpatient,5000,ML,294.88,206.416,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PRISMASOL BGK 2/3.5 32-2-3.5 MEQ/L EC SOLN,RX-156743,CDM,S5000,HCPCS,250,RC,24571-0103-06,NDC,outpatient,5000,ML,325.06,227.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SOTALOL HCL 120 MG ORAL TABS,RX-15723,CDM,S5000,HCPCS,259,RC,60505-0159-00,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SOTALOL HCL 120 MG ORAL TABS,RX-15723,CDM,S5000,HCPCS,259,RC,00093-1060-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CALCITONIN (SALMON) 200 UNIT/ACT NA SOLN,RX-15738,CDM,S5000,HCPCS,259,RC,49884-0161-11,NDC,outpatient,3.7,ML,207.33,145.131,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CALCITONIN (SALMON) 200 UNIT/ACT NA SOLN,RX-15738,CDM,S5000,HCPCS,259,RC,60505-0823-06,NDC,outpatient,3.7,ML,230.15,161.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CARVEDILOL 6.25 MG ORAL TABS,RX-15747,CDM,S5000,HCPCS,259,RC,00904-6301-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CARVEDILOL 12.5 MG ORAL TABS,RX-15749,CDM,S5000,HCPCS,259,RC,68382-0094-05,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CARVEDILOL 12.5 MG ORAL TABS,RX-15749,CDM,S5000,HCPCS,259,RC,00904-6302-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AZITHROMYCIN 200 MG/5ML ORAL SUSR,RX-15797,CDM,S5000,HCPCS,259,RC,59762-3120-01,NDC,outpatient,18.75,ML,76.85,53.795,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AZITHROMYCIN 200 MG/5ML ORAL SUSR,RX-15797,CDM,S5000,HCPCS,259,RC,00093-2026-23,NDC,outpatient,18.75,ML,62.17,43.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AZITHROMYCIN 200 MG/5ML ORAL SUSR,RX-15797,CDM,S5000,HCPCS,259,RC,99999-0002-81,NDC,outpatient,6.25,ML,21.03,14.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DARUNAVIR 800 MG ORAL TABS,RX-158170,CDM,S5000,HCPCS,259,RC,59676-0566-30,NDC,outpatient,1,UN,310.53,217.371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
INSULIN LISPRO 100 UNIT/ML IJ SOLN,RX-158181,CDM,S5000,HCPCS,259,RC,00002-7533-01,NDC,outpatient,3,ML,80.06,56.042,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
INSULIN LISPRO 100 UNIT/ML IJ SOLN,RX-158181,CDM,S5000,HCPCS,259,RC,00024-5924-10,NDC,outpatient,10,ML,322.63,225.841,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
INSULIN LISPRO 100 UNIT/ML IJ SOLN,RX-158181,CDM,S5000,HCPCS,259,RC,00024-5926-05,NDC,outpatient,3,ML,50.03,35.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LAMIVUDINE 150 MG ORAL TABS,RX-15880,CDM,S5000,HCPCS,259,RC,00904-6583-04,NDC,outpatient,1,UN,21.27,14.889,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LAMIVUDINE 150 MG ORAL TABS,RX-15880,CDM,S5000,HCPCS,259,RC,64380-0710-03,NDC,outpatient,1,UN,2.38,1.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LAMIVUDINE 10 MG/ML ORAL SOLN,RX-15881,CDM,S5000,HCPCS,259,RC,54838-0566-70,NDC,outpatient,15,ML,23.1,16.17,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACARBOSE 50 MG ORAL TABS,RX-15895,CDM,S5000,HCPCS,259,RC,64380-0759-06,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DAKINS (1/2 STRENGTH) 0.25 % EX SOLN,RX-15950,CDM,S5000,HCPCS,259,RC,00436-0936-16,NDC,outpatient,473,ML,52.63,36.841,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NIRMATRELVIR&RITONAVIR 150/100 10 X 150 MG & 10 X 100MG ORAL TBPK,RX-159847,CDM,S5000,HCPCS,259,RC,00069-5317-20,NDC,outpatient,1,UN,3544.84,2481.388,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NIRMATRELVIR&RITONAVIR 150/100 10 X 150 MG & 10 X 100MG ORAL TBPK,RX-159847,CDM,S5000,HCPCS,259,RC,00069-5317-02,NDC,outpatient,1,UN,571.55,400.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NIRMATRELVIR&RITONAVIR 300/100 20 X 150 MG & 10 X 100MG ORAL TBPK,RX-159848,CDM,S5000,HCPCS,259,RC,00069-5321-03,NDC,outpatient,1,UN,571.55,400.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NIRMATRELVIR&RITONAVIR 300/100 20 X 150 MG & 10 X 100MG ORAL TBPK,RX-159848,CDM,S5000,HCPCS,259,RC,00069-5321-30,NDC,outpatient,1,UN,3544.84,2481.388,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METHADONE HCL 10 MG/ML ORAL CONC,RX-15996,CDM,S5000,HCPCS,259,RC,99999-0002-10,NDC,outpatient,10,ML,27.28,19.096,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METHADONE HCL 10 MG/ML ORAL CONC,RX-15996,CDM,S5000,HCPCS,259,RC,00406-0527-10,NDC,outpatient,0.5,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ESTROGENS CONJUGATED 0.625 MG/GM VA CREA,RX-160113,CDM,S5000,HCPCS,259,RC,00046-0872-21,NDC,outpatient,30,GR,1850.58,1295.406,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CALCIPOTRIENE 0.005 % EX CREA,RX-16034,CDM,S5000,HCPCS,259,RC,16714-0763-01,NDC,outpatient,60,GR,327.35,229.145,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GLUCOSE 4 G ORAL CHEW,RX-16050,CDM,S5000,HCPCS,259,RC,80681-0100-00,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GLUCOSE 4 G ORAL CHEW,RX-16050,CDM,S5000,HCPCS,259,RC,56151-1610-11,NDC,outpatient,1,UN,3.58,2.506,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GLUCOSE 4 G ORAL CHEW,RX-16050,CDM,S5000,HCPCS,259,RC,56151-1610-51,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DESMOPRESSIN ACETATE 0.2 MG ORAL TABS,RX-16053,CDM,S5000,HCPCS,259,RC,23155-0490-01,NDC,outpatient,1,UN,1.27,0.889,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DESMOPRESSIN ACETATE 0.2 MG ORAL TABS,RX-16053,CDM,S5000,HCPCS,259,RC,60687-0732-11,NDC,outpatient,1,UN,7.9,5.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DESMOPRESSIN ACETATE 0.2 MG ORAL TABS,RX-16053,CDM,S5000,HCPCS,259,RC,60687-0732-21,NDC,outpatient,1,UN,7.9,5.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METHYLENE BLUE 1 % IV SOLN,RX-160649,CDM,S5000,HCPCS,250,RC,54288-0147-01,NDC,outpatient,10,ML,616.77,431.739,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACTIDOSE WITH SORBITOL 25 GM/120ML ORAL SUSP,RX-160655,CDM,S5000,HCPCS,259,RC,00574-0520-74,NDC,outpatient,120,ML,51.8,36.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACTIDOSE WITH SORBITOL 25 GM/120ML ORAL SUSP,RX-160655,CDM,S5000,HCPCS,259,RC,66689-0203-04,NDC,outpatient,120,ML,73.16,51.212,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IPRATROPIUM BROMIDE 0.03 % NA SOLN,RX-16070,CDM,S5000,HCPCS,259,RC,24208-0398-30,NDC,outpatient,30,ML,45.66,31.962,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IPRATROPIUM BROMIDE 0.03 % NA SOLN,RX-16070,CDM,S5000,HCPCS,259,RC,00054-0045-44,NDC,outpatient,30,ML,160.2,112.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CALCIUM CARB-CHOLECALCIFEROL 600-5 MG-MCG ORAL TABS,RX-160700,CDM,S5000,HCPCS,259,RC,80681-0138-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IPRATROPIUM BROMIDE 0.06 % NA SOLN,RX-16071,CDM,S5000,HCPCS,259,RC,00054-0046-41,NDC,outpatient,15,ML,147.99,103.593,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IPRATROPIUM BROMIDE 0.06 % NA SOLN,RX-16071,CDM,S5000,HCPCS,259,RC,60505-0827-01,NDC,outpatient,15,ML,69.49,48.643,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FAMCICLOVIR 250 MG ORAL TABS,RX-16081,CDM,S5000,HCPCS,259,RC,60505-3246-03,NDC,outpatient,1,UN,1.06,0.742,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CALCIUM CITRATE-VITAMIN D 200-6.25 MG-MCG ORAL TABS,RX-160846,CDM,S5000,HCPCS,259,RC,16500-0535-03,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CALCIUM CITRATE-VITAMIN D 200-6.25 MG-MCG ORAL TABS,RX-160846,CDM,S5000,HCPCS,259,RC,00536-3223-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CALCIUM CITRATE-VITAMIN D 200-6.25 MG-MCG ORAL TABS,RX-160846,CDM,S5000,HCPCS,259,RC,16500-0535-02,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RILUZOLE 50 MG ORAL TABS,RX-16124,CDM,S5000,HCPCS,259,RC,67877-0286-60,NDC,outpatient,1,UN,2.96,2.072,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CALCITRIOL 1 MCG/ML ORAL SOLN,RX-16218,CDM,S5000,HCPCS,259,RC,00054-3120-41,NDC,outpatient,1,ML,24.45,17.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CALCITRIOL 1 MCG/ML ORAL SOLN,RX-16218,CDM,S5000,HCPCS,259,RC,63304-0241-59,NDC,outpatient,1,ML,19.3,13.51,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CALCITRIOL 1 MCG/ML ORAL SOLN,RX-16218,CDM,S5000,HCPCS,259,RC,99999-0002-71,NDC,outpatient,1,ML,19.3,13.51,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CHLORDIAZEPOXIDE HCL 25 MG ORAL CAPS,RX-1623,CDM,S5000,HCPCS,259,RC,51079-0141-20,NDC,outpatient,1,UN,2.52,1.764,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CHLORDIAZEPOXIDE HCL 25 MG ORAL CAPS,RX-1623,CDM,S5000,HCPCS,259,RC,00555-0159-02,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CHLORDIAZEPOXIDE HCL 25 MG ORAL CAPS,RX-1623,CDM,S5000,HCPCS,259,RC,51079-0141-01,NDC,outpatient,1,UN,2.52,1.764,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CHLORDIAZEPOXIDE HCL 5 MG ORAL CAPS,RX-1624,CDM,S5000,HCPCS,259,RC,51079-0374-01,NDC,outpatient,1,UN,2.65,1.855,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CHLORDIAZEPOXIDE HCL 5 MG ORAL CAPS,RX-1624,CDM,S5000,HCPCS,259,RC,51079-0374-20,NDC,outpatient,1,UN,2.65,1.855,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
EUCERIN ORIGINAL HEALING EX CREA,RX-162713,CDM,S5000,HCPCS,259,RC,72140-0038-68,NDC,outpatient,57,GR,20.04,14.028,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GLIMEPIRIDE 2 MG ORAL TABS,RX-16356,CDM,S5000,HCPCS,259,RC,68084-0326-11,NDC,outpatient,1,UN,2.06,1.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GLIMEPIRIDE 2 MG ORAL TABS,RX-16356,CDM,S5000,HCPCS,259,RC,55111-0321-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GLIMEPIRIDE 2 MG ORAL TABS,RX-16356,CDM,S5000,HCPCS,259,RC,68084-0326-01,NDC,outpatient,1,UN,2.06,1.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CHLORPHENIRAMINE MALEATE 4 MG ORAL TABS,RX-1645,CDM,S5000,HCPCS,259,RC,00904-0012-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CHLORPHENIRAMINE MALEATE 4 MG ORAL TABS,RX-1645,CDM,S5000,HCPCS,259,RC,00904-0012-59,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PHENYLEPH-SHARK LIV OIL-MO-PET 0.25-3-14-71.9 % RE OINT,RX-16462,CDM,S5000,HCPCS,259,RC,00573-2871-93,NDC,outpatient,28,GR,25.8,18.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CHLORPROMAZINE HCL 10 MG ORAL TABS,RX-1653,CDM,S5000,HCPCS,259,RC,00904-7129-61,NDC,outpatient,1,UN,10.41,7.287,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CHLORPROMAZINE HCL 10 MG ORAL TABS,RX-1653,CDM,S5000,HCPCS,259,RC,50268-0162-15,NDC,outpatient,1,UN,4.66,3.262,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CHLORPROMAZINE HCL 10 MG ORAL TABS,RX-1653,CDM,S5000,HCPCS,259,RC,50268-0162-11,NDC,outpatient,1,UN,4.66,3.262,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CHLORPROMAZINE HCL 100 MG ORAL TABS,RX-1654,CDM,S5000,HCPCS,259,RC,69238-1060-01,NDC,outpatient,1,UN,6.98,4.886,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CHLORPROMAZINE HCL 100 MG ORAL TABS,RX-1654,CDM,S5000,HCPCS,259,RC,00904-7132-61,NDC,outpatient,1,UN,20.86,14.602,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CHLORPROMAZINE HCL 25 MG ORAL TABS,RX-1656,CDM,S5000,HCPCS,259,RC,50268-0163-11,NDC,outpatient,1,UN,7.19,5.033,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CHLORPROMAZINE HCL 25 MG ORAL TABS,RX-1656,CDM,S5000,HCPCS,259,RC,50268-0163-15,NDC,outpatient,1,UN,7.19,5.033,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CHLORPROMAZINE HCL 25 MG ORAL TABS,RX-1656,CDM,S5000,HCPCS,259,RC,69238-1056-01,NDC,outpatient,1,UN,2.88,2.016,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
KETOTIFEN FUMARATE 0.035 % OP SOLN,RX-165824,CDM,S5000,HCPCS,259,RC,00065-4011-05,NDC,outpatient,5,ML,42.77,29.939,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
KETOTIFEN FUMARATE 0.035 % OP SOLN,RX-165824,CDM,S5000,HCPCS,259,RC,00536-1252-40,NDC,outpatient,5,ML,30.09,21.063,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
KETOTIFEN FUMARATE 0.035 % OP SOLN,RX-165824,CDM,S5000,HCPCS,259,RC,72485-0617-10,NDC,outpatient,5,ML,28.93,20.251,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CHLORTHALIDONE 25 MG ORAL TABS,RX-1661,CDM,S5000,HCPCS,259,RC,51079-0058-20,NDC,outpatient,1,UN,7.86,5.502,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CHLORTHALIDONE 25 MG ORAL TABS,RX-1661,CDM,S5000,HCPCS,259,RC,51079-0058-01,NDC,outpatient,1,UN,7.86,5.502,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PAROXETINE HCL 10 MG ORAL TABS,RX-16632,CDM,S5000,HCPCS,259,RC,68084-0044-01,NDC,outpatient,1,UN,2.56,1.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PAROXETINE HCL 10 MG ORAL TABS,RX-16632,CDM,S5000,HCPCS,259,RC,68084-0044-11,NDC,outpatient,1,UN,2.56,1.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PAROXETINE HCL 10 MG ORAL TABS,RX-16632,CDM,S5000,HCPCS,259,RC,63739-0888-10,NDC,outpatient,1,UN,2.7,1.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FERROUS SULFATE ER 45 MG ORAL TBCR,RX-167735,CDM,S5000,HCPCS,259,RC,10006-0730-13,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACD FORMULA A 0.73-2.45-2.2 GM/100ML VI SOLN,RX-16825,CDM,S5000,HCPCS,250,RC,00942-0641-04,NDC,outpatient,1000,ML,60.15,42.105,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,50268-0524-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,20555-0036-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,68094-0110-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,77333-0516-25,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,50268-0524-15,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,68094-0110-59,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,77333-0516-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYOSCYAMINE SULFATE ER 0.375 MG ORAL TB12,RX-17010,CDM,S5000,HCPCS,259,RC,51525-0115-01,NDC,outpatient,1,UN,1.16,0.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRANDOLAPRIL 1 MG ORAL TABS,RX-17017,CDM,S5000,HCPCS,259,RC,68180-0566-01,NDC,outpatient,1,UN,2.46,1.722,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SELEGILINE HCL 5 MG ORAL CAPS,RX-17280,CDM,S5000,HCPCS,259,RC,60505-0055-01,NDC,outpatient,1,UN,2.47,1.729,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DERMAPHOR EX OINT,RX-17369,CDM,S5000,HCPCS,259,RC,72140-0452-31,NDC,outpatient,50,GR,20.25,14.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DERMAPHOR EX OINT,RX-17369,CDM,S5000,HCPCS,259,RC,61924-0184-04,NDC,outpatient,106,GR,13.68,9.576,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DERMAPHOR EX OINT,RX-17369,CDM,S5000,HCPCS,259,RC,72140-0031-47,NDC,outpatient,396,GR,61.68,43.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RISPERIDONE 1 MG/ML ORAL SOLN,RX-17377,CDM,S5000,HCPCS,259,RC,65162-0673-84,NDC,outpatient,0.25,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RISPERIDONE 1 MG/ML ORAL SOLN,RX-17377,CDM,S5000,HCPCS,259,RC,27808-0002-01,NDC,outpatient,0.25,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RISPERIDONE 1 MG/ML ORAL SOLN,RX-17377,CDM,S5000,HCPCS,259,RC,99999-0003-81,NDC,outpatient,1,ML,4.12,2.884,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AZITHROMYCIN 600 MG ORAL TABS,RX-17387,CDM,S5000,HCPCS,259,RC,62332-0253-30,NDC,outpatient,1,UN,1.72,1.204,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLINDAMYCIN HCL 150 MG ORAL CAPS,RX-1740,CDM,S5000,HCPCS,259,RC,00904-5959-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NEVIRAPINE 200 MG ORAL TABS,RX-17403,CDM,S5000,HCPCS,259,RC,31722-0505-60,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLINDAMYCIN PHOSPHATE 1 % EX SOLN,RX-1742,CDM,S5000,HCPCS,259,RC,00168-0201-60,NDC,outpatient,60,ML,139.11,97.377,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLINDAMYCIN PHOSPHATE 1 % EX SOLN,RX-1742,CDM,S5000,HCPCS,259,RC,45802-0562-02,NDC,outpatient,60,ML,48.6,34.02,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MIRTAZAPINE 15 MG ORAL TABS,RX-17466,CDM,S5000,HCPCS,259,RC,51079-0086-20,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MIRTAZAPINE 15 MG ORAL TABS,RX-17466,CDM,S5000,HCPCS,259,RC,00904-6519-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MIRTAZAPINE 15 MG ORAL TABS,RX-17466,CDM,S5000,HCPCS,259,RC,51079-0086-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CANDIDA ALBICANS SKN TST ANTGN ID SOLN,RX-17524,CDM,S5000,HCPCS,250,RC,59584-0138-01,NDC,outpatient,0.1,ML,121.71,85.197,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLONIDINE HCL 0.1 MG ORAL TABS,RX-1755,CDM,S5000,HCPCS,259,RC,60687-0113-01,NDC,outpatient,1,UN,1.25,0.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLONIDINE HCL 0.1 MG ORAL TABS,RX-1755,CDM,S5000,HCPCS,259,RC,60687-0113-11,NDC,outpatient,1,UN,1.25,0.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLORAZEPATE DIPOTASSIUM 3.75 MG ORAL TABS,RX-1759,CDM,S5000,HCPCS,259,RC,13107-0319-01,NDC,outpatient,1,UN,4.43,3.101,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLOTRIMAZOLE 1 % EX CREA,RX-1767,CDM,S5000,HCPCS,259,RC,45802-0434-11,NDC,outpatient,30,GR,10.42,7.294,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLOTRIMAZOLE 1 % EX CREA,RX-1767,CDM,S5000,HCPCS,259,RC,51672-2002-02,NDC,outpatient,30,GR,6.01,4.207,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLOTRIMAZOLE 1 % EX SOLN,RX-1768,CDM,S5000,HCPCS,259,RC,51672-1260-03,NDC,outpatient,30,ML,97.86,68.502,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLOTRIMAZOLE 1 % VA CREA,RX-1769,CDM,S5000,HCPCS,259,RC,51672-2003-06,NDC,outpatient,45,GR,11.82,8.274,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS,RX-17837,CDM,S5000,HCPCS,259,RC,00093-3174-31,NDC,outpatient,8.5,GR,117.83,82.481,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS,RX-17837,CDM,S5000,HCPCS,259,RC,00173-0682-24,NDC,outpatient,8,GR,92.49,64.743,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS,RX-17837,CDM,S5000,HCPCS,259,RC,66993-0019-68,NDC,outpatient,18,GR,146.67,102.669,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BRIMONIDINE TARTRATE 0.2 % OP SOLN,RX-17881,CDM,S5000,HCPCS,259,RC,70069-0231-01,NDC,outpatient,5,ML,7.26,5.082,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BRIMONIDINE TARTRATE 0.2 % OP SOLN,RX-17881,CDM,S5000,HCPCS,259,RC,61314-0143-05,NDC,outpatient,5,ML,13.04,9.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BRIMONIDINE TARTRATE 0.2 % OP SOLN,RX-17881,CDM,S5000,HCPCS,259,RC,24208-0411-05,NDC,outpatient,5,ML,61.95,43.365,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BRIMONIDINE TARTRATE 0.2 % OP SOLN,RX-17881,CDM,S5000,HCPCS,259,RC,71921-0185-05,NDC,outpatient,5,ML,41.12,28.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
B COMPLEX ORAL CAPS,RX-17882,CDM,S5000,HCPCS,259,RC,54629-0560-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OLANZAPINE 5 MG ORAL TABS,RX-17936,CDM,S5000,HCPCS,259,RC,00904-6377-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DEXAMETHASONE 1 MG/ML ORAL CONC,RX-17946,CDM,S5000,HCPCS,259,RC,00054-3176-44,NDC,outpatient,30,ML,90.92,63.644,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ZAFIRLUKAST 20 MG ORAL TABS,RX-17960,CDM,S5000,HCPCS,259,RC,68084-0059-21,NDC,outpatient,1,UN,10.83,7.581,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ZAFIRLUKAST 20 MG ORAL TABS,RX-17960,CDM,S5000,HCPCS,259,RC,68084-0059-11,NDC,outpatient,1,UN,10.83,7.581,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMMONIUM LACTATE 12 % EX CREA,RX-17997,CDM,S5000,HCPCS,259,RC,45802-0513-77,NDC,outpatient,140,GR,35.52,24.864,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CODEINE SULFATE 15 MG ORAL TABS,RX-1801,CDM,S5000,HCPCS,259,RC,00054-0243-24,NDC,outpatient,1,UN,2.94,2.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SENNA 8.6 MG ORAL TABS,RX-18138,CDM,S5000,HCPCS,259,RC,00904-7252-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
COLCHICINE 0.6 MG ORAL TABS,RX-1821,CDM,S5000,HCPCS,259,RC,42292-0054-01,NDC,outpatient,1,UN,13.56,9.492,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
COLCHICINE 0.6 MG ORAL TABS,RX-1821,CDM,S5000,HCPCS,259,RC,42292-0054-03,NDC,outpatient,1,UN,13.56,9.492,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
COLCHICINE 0.6 MG ORAL TABS,RX-1821,CDM,S5000,HCPCS,259,RC,65162-0710-09,NDC,outpatient,1,UN,2.83,1.981,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BISOPROLOL FUMARATE 5 MG ORAL TABS,RX-18288,CDM,S5000,HCPCS,259,RC,29300-0126-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BISOPROLOL-HYDROCHLOROTHIAZIDE 10-6.25 MG ORAL TABS,RX-18289,CDM,S5000,HCPCS,259,RC,10135-0742-30,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BISOPROLOL-HYDROCHLOROTHIAZIDE 10-6.25 MG ORAL TABS,RX-18289,CDM,S5000,HCPCS,259,RC,29300-0189-01,NDC,outpatient,1,UN,2.16,1.512,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BISOPROLOL-HYDROCHLOROTHIAZIDE 5-6.25 MG ORAL TABS,RX-18290,CDM,S5000,HCPCS,259,RC,29300-0188-01,NDC,outpatient,1,UN,2.18,1.526,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BISOPROLOL-HYDROCHLOROTHIAZIDE 2.5-6.25 MG ORAL TABS,RX-18291,CDM,S5000,HCPCS,259,RC,68462-0878-30,NDC,outpatient,1,UN,1.61,1.127,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BISOPROLOL-HYDROCHLOROTHIAZIDE 2.5-6.25 MG ORAL TABS,RX-18291,CDM,S5000,HCPCS,259,RC,29300-0187-01,NDC,outpatient,1,UN,2.03,1.421,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TORSEMIDE 10 MG ORAL TABS,RX-18292,CDM,S5000,HCPCS,259,RC,50268-0755-11,NDC,outpatient,1,UN,1.14,0.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TORSEMIDE 10 MG ORAL TABS,RX-18292,CDM,S5000,HCPCS,259,RC,50268-0755-15,NDC,outpatient,1,UN,1.14,0.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,00054-0077-29,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,68084-0539-01,NDC,outpatient,1,UN,1.28,0.896,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,00054-0077-25,NDC,outpatient,1,UN,1.1,0.77,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,50268-0756-11,NDC,outpatient,1,UN,1.5,1.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,68084-0539-11,NDC,outpatient,1,UN,1.28,0.896,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,50268-0756-15,NDC,outpatient,1,UN,1.5,1.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TORSEMIDE 100 MG ORAL TABS,RX-18294,CDM,S5000,HCPCS,259,RC,31722-0532-01,NDC,outpatient,1,UN,2.32,1.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TORSEMIDE 100 MG ORAL TABS,RX-18294,CDM,S5000,HCPCS,259,RC,50268-0757-15,NDC,outpatient,1,UN,1.64,1.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TORSEMIDE 100 MG ORAL TABS,RX-18294,CDM,S5000,HCPCS,259,RC,50268-0757-11,NDC,outpatient,1,UN,1.64,1.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GABAPENTIN 400 MG ORAL CAPS,RX-18307,CDM,S5000,HCPCS,259,RC,00904-6667-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GABAPENTIN 400 MG ORAL CAPS,RX-18307,CDM,S5000,HCPCS,259,RC,63739-0904-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,45963-0556-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,60687-0591-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,63739-0903-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,16714-0662-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,00904-6666-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,60687-0591-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GABAPENTIN 100 MG ORAL CAPS,RX-18309,CDM,S5000,HCPCS,259,RC,00904-6665-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GABAPENTIN 100 MG ORAL CAPS,RX-18309,CDM,S5000,HCPCS,259,RC,60687-0580-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GABAPENTIN 100 MG ORAL CAPS,RX-18309,CDM,S5000,HCPCS,259,RC,63739-0902-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GABAPENTIN 100 MG ORAL CAPS,RX-18309,CDM,S5000,HCPCS,259,RC,60687-0580-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RISPERIDONE 2 MG ORAL TABS,RX-18311,CDM,S5000,HCPCS,259,RC,00904-7363-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RISPERIDONE 1 MG ORAL TABS,RX-18313,CDM,S5000,HCPCS,259,RC,00904-7362-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RISPERIDONE 1 MG ORAL TABS,RX-18313,CDM,S5000,HCPCS,259,RC,42291-0910-60,NDC,outpatient,1,UN,11.7,8.19,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPROPION HCL ER (SR) 100 MG ORAL TB12,RX-18385,CDM,S5000,HCPCS,259,RC,68084-0697-01,NDC,outpatient,1,UN,2.72,1.904,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPROPION HCL ER (SR) 100 MG ORAL TB12,RX-18385,CDM,S5000,HCPCS,259,RC,68084-0697-11,NDC,outpatient,1,UN,2.72,1.904,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPROPION HCL ER (SR) 150 MG ORAL TB12,RX-18386,CDM,S5000,HCPCS,259,RC,68084-0708-95,NDC,outpatient,1,UN,2.27,1.589,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPROPION HCL ER (SR) 150 MG ORAL TB12,RX-18386,CDM,S5000,HCPCS,259,RC,68084-0708-25,NDC,outpatient,1,UN,2.27,1.589,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
REMIFENTANIL HCL 1 MG IV SOLR,RX-18398,CDM,S5000,HCPCS,250,RC,00143-9391-01,NDC,outpatient,1,UN,164.07,114.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
REMIFENTANIL HCL 1 MG IV SOLR,RX-18398,CDM,S5000,HCPCS,250,RC,63323-0723-01,NDC,outpatient,1,UN,164.48,115.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
REMIFENTANIL HCL 1 MG IV SOLR,RX-18398,CDM,S5000,HCPCS,250,RC,00143-9391-10,NDC,outpatient,1,UN,164.07,114.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
REMIFENTANIL HCL 1 MG IV SOLR,RX-18398,CDM,S5000,HCPCS,250,RC,63323-0723-03,NDC,outpatient,1,UN,164.48,115.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CARVEDILOL 3.125 MG ORAL TABS,RX-18551,CDM,S5000,HCPCS,259,RC,00904-6300-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LATANOPROST 0.005 % OP SOLN,RX-18621,CDM,S5000,HCPCS,259,RC,59762-0333-02,NDC,outpatient,2.5,ML,18.92,13.244,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LATANOPROST 0.005 % OP SOLN,RX-18621,CDM,S5000,HCPCS,259,RC,70069-0421-01,NDC,outpatient,2.5,ML,19.9,13.93,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LATANOPROST 0.005 % OP SOLN,RX-18621,CDM,S5000,HCPCS,259,RC,24208-0463-25,NDC,outpatient,2.5,ML,46.77,32.739,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LATANOPROST 0.005 % OP SOLN,RX-18621,CDM,S5000,HCPCS,259,RC,61314-0547-01,NDC,outpatient,2.5,ML,19.1,13.37,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DONEPEZIL HCL 5 MG ORAL TABS,RX-18786,CDM,S5000,HCPCS,259,RC,00904-6477-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NITROPRUSSIDE SODIUM 25 MG/ML IV SOLN,RX-18908,CDM,S5000,HCPCS,250,RC,43598-0587-23,NDC,outpatient,2,ML,87.58,61.306,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NITROPRUSSIDE SODIUM 25 MG/ML IV SOLN,RX-18908,CDM,S5000,HCPCS,250,RC,67457-0839-02,NDC,outpatient,2,ML,53.45,37.415,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NITROPRUSSIDE SODIUM 25 MG/ML IV SOLN,RX-18908,CDM,S5000,HCPCS,250,RC,72485-0105-01,NDC,outpatient,2,ML,69.91,48.937,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVOFLOXACIN 250 MG ORAL TABS,RX-18918,CDM,S5000,HCPCS,259,RC,00904-6351-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVOFLOXACIN 500 MG ORAL TABS,RX-18919,CDM,S5000,HCPCS,259,RC,00904-6352-61,NDC,outpatient,1,UN,1.04,0.728,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TOPIRAMATE 25 MG ORAL TABS,RX-18920,CDM,S5000,HCPCS,259,RC,68084-0342-11,NDC,outpatient,1,UN,1.38,0.966,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TOPIRAMATE 25 MG ORAL TABS,RX-18920,CDM,S5000,HCPCS,259,RC,68084-0342-01,NDC,outpatient,1,UN,1.38,0.966,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TOPIRAMATE 100 MG ORAL TABS,RX-18922,CDM,S5000,HCPCS,259,RC,68084-0344-01,NDC,outpatient,1,UN,2.19,1.533,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TOPIRAMATE 100 MG ORAL TABS,RX-18922,CDM,S5000,HCPCS,259,RC,68084-0344-11,NDC,outpatient,1,UN,2.19,1.533,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ATORVASTATIN CALCIUM 10 MG ORAL TABS,RX-19176,CDM,S5000,HCPCS,259,RC,00904-6290-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ATORVASTATIN CALCIUM 20 MG ORAL TABS,RX-19178,CDM,S5000,HCPCS,259,RC,00904-6291-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AZELASTINE HCL 0.1 % NA SOLN,RX-19179,CDM,S5000,HCPCS,259,RC,60505-0833-05,NDC,outpatient,30,ML,24.97,17.479,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CABERGOLINE 0.5 MG ORAL TABS,RX-19226,CDM,S5000,HCPCS,259,RC,23155-0823-73,NDC,outpatient,1,UN,8.36,5.852,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CABERGOLINE 0.5 MG ORAL TABS,RX-19226,CDM,S5000,HCPCS,259,RC,50742-0118-08,NDC,outpatient,1,UN,13.91,9.737,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CABERGOLINE 0.5 MG ORAL TABS,RX-19226,CDM,S5000,HCPCS,259,RC,59762-1005-01,NDC,outpatient,1,UN,22.17,15.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PHENYLEPHRINE HCL 10 % OP SOLN,RX-19636,CDM,S5000,HCPCS,259,RC,70756-0614-30,NDC,outpatient,5,ML,178,124.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BENZOCAINE 20 % MT GEL,RX-19691,CDM,S5000,HCPCS,259,RC,10310-0566-20,NDC,outpatient,11.9,GR,20.34,14.238,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CARBACHOL 0.01 % IO SOLN,RX-19704,CDM,S5000,HCPCS,259,RC,00065-0023-15,NDC,outpatient,1.5,ML,66,46.2,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DIAZOXIDE 50 MG/ML ORAL SUSP,RX-19713,CDM,S5000,HCPCS,259,RC,00254-1010-19,NDC,outpatient,30,ML,1132.89,793.023,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DIAZOXIDE 50 MG/ML ORAL SUSP,RX-19713,CDM,S5000,HCPCS,259,RC,99999-0003-50,NDC,outpatient,1,ML,37.77,26.439,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DICLOFENAC SODIUM 0.1 % OP SOLN,RX-19714,CDM,S5000,HCPCS,259,RC,24208-0457-05,NDC,outpatient,5,ML,46.46,32.522,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DICLOFENAC SODIUM 0.1 % OP SOLN,RX-19714,CDM,S5000,HCPCS,259,RC,61314-0014-25,NDC,outpatient,2.5,ML,39.79,27.853,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLUOROMETHOLONE 0.25 % OP SUSP,RX-19722,CDM,S5000,HCPCS,259,RC,11980-0228-05,NDC,outpatient,5,ML,692.51,484.757,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP,RX-19736,CDM,S5000,HCPCS,250,RC,00009-0746-30,NDC,outpatient,1,ML,216.41,151.487,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP,RX-19736,CDM,S5000,HCPCS,250,RC,00548-5400-00,NDC,outpatient,1,ML,75.65,52.955,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METHYLCELLULOSE (LAXATIVE) 500 MG ORAL TABS,RX-19740,CDM,S5000,HCPCS,259,RC,00135-0199-02,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METHYLCELLULOSE (LAXATIVE) 500 MG ORAL TABS,RX-19740,CDM,S5000,HCPCS,259,RC,49348-0541-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OFLOXACIN 0.3 % OP SOLN,RX-19746,CDM,S5000,HCPCS,259,RC,60505-0560-00,NDC,outpatient,5,ML,32.22,22.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OFLOXACIN 0.3 % OP SOLN,RX-19746,CDM,S5000,HCPCS,259,RC,64980-0515-05,NDC,outpatient,5,ML,58.61,41.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POVIDONE-IODINE 5 % OP SOLN,RX-19791,CDM,S5000,HCPCS,259,RC,00065-0411-30,NDC,outpatient,30,ML,45.26,31.682,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NEOMYCIN-POLYMYXIN-PRAMOXINE 1 % EX CREA,RX-19880,CDM,S5000,HCPCS,259,RC,12547-0407-40,NDC,outpatient,14.2,GR,19.03,13.321,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SERTRALINE HCL 25 MG ORAL TABS,RX-19882,CDM,S5000,HCPCS,259,RC,60687-0231-01,NDC,outpatient,1,UN,1.26,0.882,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SERTRALINE HCL 25 MG ORAL TABS,RX-19882,CDM,S5000,HCPCS,259,RC,60687-0231-11,NDC,outpatient,1,UN,1.26,0.882,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NELFINAVIR MESYLATE 250 MG ORAL TABS,RX-20032,CDM,S5000,HCPCS,259,RC,63010-0010-30,NDC,outpatient,1,UN,17.47,12.229,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MESNA 400 MG ORAL TABS,RX-20077,CDM,S5000,HCPCS,259,RC,67108-3565-09,NDC,outpatient,1,UN,287.17,201.019,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CYANOCOBALAMIN 100 MCG ORAL TABS,RX-2008,CDM,S5000,HCPCS,259,RC,50268-0852-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CYANOCOBALAMIN 100 MCG ORAL TABS,RX-2008,CDM,S5000,HCPCS,259,RC,50268-0852-15,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CYCLOBENZAPRINE HCL 10 MG ORAL TABS,RX-2017,CDM,S5000,HCPCS,259,RC,60687-0558-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CYCLOBENZAPRINE HCL 10 MG ORAL TABS,RX-2017,CDM,S5000,HCPCS,259,RC,60687-0558-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CYCLOPENTOLATE HCL 1 % OP SOLN,RX-2025,CDM,S5000,HCPCS,259,RC,24208-0735-06,NDC,outpatient,15,ML,121.82,85.274,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CYCLOPENTOLATE HCL 1 % OP SOLN,RX-2025,CDM,S5000,HCPCS,259,RC,24208-0735-01,NDC,outpatient,2,ML,47.31,33.117,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CYPROHEPTADINE HCL 4 MG ORAL TABS,RX-2033,CDM,S5000,HCPCS,259,RC,50268-0189-15,NDC,outpatient,1,UN,2.94,2.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CYPROHEPTADINE HCL 4 MG ORAL TABS,RX-2033,CDM,S5000,HCPCS,259,RC,50268-0189-11,NDC,outpatient,1,UN,2.94,2.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CYSTEINE HCL 50 MG/ML IV SOLN,RX-2034,CDM,S5000,HCPCS,250,RC,51754-1007-03,NDC,outpatient,10,ML,375.94,263.158,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CYSTEINE HCL 50 MG/ML IV SOLN,RX-2034,CDM,S5000,HCPCS,250,RC,51754-1007-01,NDC,outpatient,10,ML,375.94,263.158,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ANAGRELIDE HCL 0.5 MG ORAL CAPS,RX-20446,CDM,S5000,HCPCS,259,RC,00172-5241-60,NDC,outpatient,1,UN,3.43,2.401,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ANAGRELIDE HCL 0.5 MG ORAL CAPS,RX-20446,CDM,S5000,HCPCS,259,RC,13668-0453-01,NDC,outpatient,1,UN,2.97,2.079,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,00143-9506-01,NDC,outpatient,10,ML,25.46,17.822,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,00143-9507-10,NDC,outpatient,20,ML,27.51,19.257,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,55150-0221-10,NDC,outpatient,10,ML,12.44,8.708,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,00143-9507-01,NDC,outpatient,20,ML,27.51,19.257,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,72266-0146-10,NDC,outpatient,10,ML,13.73,9.611,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,00143-9506-10,NDC,outpatient,10,ML,25.46,17.822,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,72266-0146-01,NDC,outpatient,10,ML,13.73,9.611,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MELOXICAM 7.5 MG ORAL TABS,RX-20566,CDM,S5000,HCPCS,259,RC,50268-0525-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MELOXICAM 7.5 MG ORAL TABS,RX-20566,CDM,S5000,HCPCS,259,RC,50268-0525-15,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PYRETHRINS-PIPERONYL BUTOXIDE 0.33-4 % EX LIQD,RX-20781,CDM,S5000,HCPCS,259,RC,49348-0443-34,NDC,outpatient,118,ML,21.53,15.071,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MIGLITOL 25 MG ORAL TABS,RX-20799,CDM,S5000,HCPCS,259,RC,69367-0303-01,NDC,outpatient,1,UN,7.35,5.145,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,70860-0784-41,NDC,outpatient,5,ML,10.16,7.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,63323-0494-01,NDC,outpatient,5,ML,9.31,6.517,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,63323-0494-05,NDC,outpatient,5,ML,9.31,6.517,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,70860-0784-05,NDC,outpatient,5,ML,10.16,7.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,00143-9785-01,NDC,outpatient,5,ML,20.56,14.392,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,00143-9785-10,NDC,outpatient,5,ML,20.56,14.392,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AZITHROMYCIN 250 MG ORAL TABS,RX-20943,CDM,S5000,HCPCS,259,RC,60687-0742-11,NDC,outpatient,1,UN,3.5,2.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AZITHROMYCIN 250 MG ORAL TABS,RX-20943,CDM,S5000,HCPCS,259,RC,65862-0641-63,NDC,outpatient,1,UN,1.45,1.015,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AZITHROMYCIN 250 MG ORAL TABS,RX-20943,CDM,S5000,HCPCS,259,RC,60687-0742-01,NDC,outpatient,1,UN,3.5,2.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVOCARNITINE 200 MG/ML IV SOLN,RX-20954,CDM,S5000,HCPCS,250,RC,00143-9852-10,NDC,outpatient,5,ML,94.7,66.29,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVOCARNITINE 200 MG/ML IV SOLN,RX-20954,CDM,S5000,HCPCS,250,RC,54482-0147-01,NDC,outpatient,5,ML,99.51,69.657,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVOCARNITINE 200 MG/ML IV SOLN,RX-20954,CDM,S5000,HCPCS,250,RC,00143-9852-01,NDC,outpatient,5,ML,94.7,66.29,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OLANZAPINE 2.5 MG ORAL TABS,RX-21057,CDM,S5000,HCPCS,259,RC,00904-6283-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXCARBAZEPINE 300 MG ORAL TABS,RX-21061,CDM,S5000,HCPCS,259,RC,60687-0722-01,NDC,outpatient,1,UN,2.53,1.771,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXCARBAZEPINE 300 MG ORAL TABS,RX-21061,CDM,S5000,HCPCS,259,RC,60687-0722-11,NDC,outpatient,1,UN,2.53,1.771,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXCARBAZEPINE 300 MG ORAL TABS,RX-21061,CDM,S5000,HCPCS,259,RC,62756-0184-88,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CITALOPRAM HYDROBROMIDE 20 MG ORAL TABS,RX-21062,CDM,S5000,HCPCS,259,RC,00904-6085-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMPHETAMINE-DEXTROAMPHETAMINE 5 MG ORAL TABS,RX-21284,CDM,S5000,HCPCS,259,RC,42806-0339-01,NDC,outpatient,1,UN,1.83,1.281,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PRAMIPEXOLE DIHYDROCHLORIDE 1 MG ORAL TABS,RX-21288,CDM,S5000,HCPCS,259,RC,60687-0592-11,NDC,outpatient,1,UN,3.34,2.338,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PRAMIPEXOLE DIHYDROCHLORIDE 1 MG ORAL TABS,RX-21288,CDM,S5000,HCPCS,259,RC,60687-0592-21,NDC,outpatient,1,UN,3.34,2.338,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PRAMIPEXOLE DIHYDROCHLORIDE 1.5 MG ORAL TABS,RX-21289,CDM,S5000,HCPCS,259,RC,68462-0334-90,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PRAMIPEXOLE DIHYDROCHLORIDE 0.25 MG ORAL TABS,RX-21290,CDM,S5000,HCPCS,259,RC,00904-6704-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PENTOXIFYLLINE ER 400 MG ORAL TBCR,RX-21300,CDM,S5000,HCPCS,259,RC,60505-0033-06,NDC,outpatient,1,UN,2.18,1.526,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PENTOXIFYLLINE ER 400 MG ORAL TBCR,RX-21300,CDM,S5000,HCPCS,259,RC,00904-5448-61,NDC,outpatient,1,UN,1.11,0.777,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DAPSONE 100 MG ORAL TABS,RX-2131,CDM,S5000,HCPCS,259,RC,70954-0136-10,NDC,outpatient,1,UN,5.05,3.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DAPSONE 25 MG ORAL TABS,RX-2132,CDM,S5000,HCPCS,259,RC,70954-0135-10,NDC,outpatient,1,UN,4.35,3.045,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LETROZOLE 2.5 MG ORAL TABS,RX-21509,CDM,S5000,HCPCS,259,RC,00078-0249-15,NDC,outpatient,1,UN,108.93,76.251,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LETROZOLE 2.5 MG ORAL TABS,RX-21509,CDM,S5000,HCPCS,259,RC,59651-0180-30,NDC,outpatient,1,UN,1.55,1.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CARMUSTINE IN POLIFEPROSAN 7.7 MG IL WAFR,RX-21672,CDM,S5000,HCPCS,250,RC,24338-0050-08,NDC,outpatient,8,UN,110831.48,77582.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ROPINIROLE HCL 0.25 MG ORAL TABS,RX-21688,CDM,S5000,HCPCS,259,RC,00904-6373-61,NDC,outpatient,1,UN,1.51,1.057,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ROPINIROLE HCL 1 MG ORAL TABS,RX-21689,CDM,S5000,HCPCS,259,RC,00904-6374-61,NDC,outpatient,1,UN,1.76,1.232,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ROPINIROLE HCL 2 MG ORAL TABS,RX-21690,CDM,S5000,HCPCS,259,RC,50268-0744-15,NDC,outpatient,1,UN,2.46,1.722,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ROPINIROLE HCL 2 MG ORAL TABS,RX-21690,CDM,S5000,HCPCS,259,RC,50268-0744-11,NDC,outpatient,1,UN,2.46,1.722,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
QUETIAPINE FUMARATE 25 MG ORAL TABS,RX-21823,CDM,S5000,HCPCS,259,RC,00904-6638-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
QUETIAPINE FUMARATE 25 MG ORAL TABS,RX-21823,CDM,S5000,HCPCS,259,RC,60687-0327-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
QUETIAPINE FUMARATE 25 MG ORAL TABS,RX-21823,CDM,S5000,HCPCS,259,RC,60687-0327-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
QUETIAPINE FUMARATE 100 MG ORAL TABS,RX-21824,CDM,S5000,HCPCS,259,RC,00904-6640-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TIAGABINE HCL 4 MG ORAL TABS,RX-21827,CDM,S5000,HCPCS,259,RC,62756-0224-83,NDC,outpatient,1,UN,16.11,11.277,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IRBESARTAN 150 MG ORAL TABS,RX-21848,CDM,S5000,HCPCS,259,RC,31722-0730-90,NDC,outpatient,1,UN,1.91,1.337,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IRBESARTAN 150 MG ORAL TABS,RX-21848,CDM,S5000,HCPCS,259,RC,33342-0048-10,NDC,outpatient,1,UN,1.15,0.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLOPIDOGREL BISULFATE 75 MG ORAL TABS,RX-22142,CDM,S5000,HCPCS,259,RC,00904-6294-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RALOXIFENE HCL 60 MG ORAL TABS,RX-22143,CDM,S5000,HCPCS,259,RC,60687-0266-11,NDC,outpatient,1,UN,23.4,16.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RALOXIFENE HCL 60 MG ORAL TABS,RX-22143,CDM,S5000,HCPCS,259,RC,60687-0266-21,NDC,outpatient,1,UN,23.4,16.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DILTIAZEM HCL 100 MG IV SOLR,RX-22156,CDM,S5000,HCPCS,250,RC,00409-4350-13,NDC,outpatient,1,UN,40.12,28.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DILTIAZEM HCL 100 MG IV SOLR,RX-22156,CDM,S5000,HCPCS,250,RC,00409-4350-03,NDC,outpatient,1,UN,40.12,28.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TOBRAMYCIN 300 MG/5ML IN NEBU,RX-22240,CDM,S5000,HCPCS,259,RC,68180-0962-04,NDC,outpatient,5,ML,27.71,19.397,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TOBRAMYCIN 300 MG/5ML IN NEBU,RX-22240,CDM,S5000,HCPCS,259,RC,70756-0604-56,NDC,outpatient,5,ML,19.47,13.629,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TOBRAMYCIN 300 MG/5ML IN NEBU,RX-22240,CDM,S5000,HCPCS,259,RC,68180-0962-56,NDC,outpatient,5,ML,27.71,19.397,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TOBRAMYCIN 300 MG/5ML IN NEBU,RX-22240,CDM,S5000,HCPCS,259,RC,70756-0604-44,NDC,outpatient,5,ML,19.47,13.629,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MUPIROCIN CALCIUM 2 % EX CREA,RX-22251,CDM,S5000,HCPCS,259,RC,51672-1370-01,NDC,outpatient,15,GR,62.62,43.834,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MUPIROCIN CALCIUM 2 % EX CREA,RX-22251,CDM,S5000,HCPCS,259,RC,68462-0564-17,NDC,outpatient,15,GR,861.28,602.896,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OFLOXACIN 0.3 % OT SOLN,RX-22257,CDM,S5000,HCPCS,259,RC,24208-0410-05,NDC,outpatient,5,ML,214.49,150.143,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OFLOXACIN 0.3 % OT SOLN,RX-22257,CDM,S5000,HCPCS,259,RC,70756-0609-15,NDC,outpatient,5,ML,31.29,21.903,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LACTASE 3000 UNITS ORAL TABS,RX-22469,CDM,S5000,HCPCS,259,RC,00904-5224-52,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LACTASE 3000 UNITS ORAL TABS,RX-22469,CDM,S5000,HCPCS,259,RC,77333-0430-50,NDC,outpatient,1,UN,1.55,1.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LACTASE 3000 UNITS ORAL TABS,RX-22469,CDM,S5000,HCPCS,259,RC,77333-0430-25,NDC,outpatient,1,UN,1.55,1.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MONTELUKAST SODIUM 10 MG ORAL TABS,RX-22509,CDM,S5000,HCPCS,259,RC,00904-6808-06,NDC,outpatient,1,UN,1.19,0.833,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MONTELUKAST SODIUM 10 MG ORAL TABS,RX-22509,CDM,S5000,HCPCS,259,RC,00904-6808-61,NDC,outpatient,1,UN,1.44,1.008,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MONTELUKAST SODIUM 5 MG ORAL CHEW,RX-22510,CDM,S5000,HCPCS,259,RC,50268-0574-15,NDC,outpatient,1,UN,2.8,1.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MONTELUKAST SODIUM 5 MG ORAL CHEW,RX-22510,CDM,S5000,HCPCS,259,RC,50268-0574-11,NDC,outpatient,1,UN,2.8,1.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML ORAL SUSP,RX-22560,CDM,S5000,HCPCS,259,RC,00121-0853-40,NDC,outpatient,20,ML,60.61,42.427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML ORAL SUSP,RX-22560,CDM,S5000,HCPCS,259,RC,99999-0002-45,NDC,outpatient,20,ML,22.52,15.764,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML ORAL SUSP,RX-22560,CDM,S5000,HCPCS,259,RC,00121-0853-20,NDC,outpatient,20,ML,60.61,42.427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
REPAGLINIDE 2 MG ORAL TABS,RX-22585,CDM,S5000,HCPCS,259,RC,65862-0672-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
REPAGLINIDE 1 MG ORAL TABS,RX-22586,CDM,S5000,HCPCS,259,RC,65862-0671-01,NDC,outpatient,1,UN,1.06,0.742,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POTASSIUM CITRATE-CITRIC ACID 1100-334 MG/5ML ORAL SOLN,RX-22646,CDM,S5000,HCPCS,259,RC,00121-0676-16,NDC,outpatient,15,ML,3.61,2.527,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POTASSIUM CITRATE-CITRIC ACID 1100-334 MG/5ML ORAL SOLN,RX-22646,CDM,S5000,HCPCS,259,RC,60258-0003-16,NDC,outpatient,10,ML,5.88,4.116,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POTASSIUM CITRATE-CITRIC ACID 1100-334 MG/5ML ORAL SOLN,RX-22646,CDM,S5000,HCPCS,259,RC,99999-0002-34,NDC,outpatient,15,ML,3.14,2.198,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
URSODIOL 250 MG ORAL TABS,RX-22660,CDM,S5000,HCPCS,259,RC,00904-6890-04,NDC,outpatient,1,UN,10.99,7.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
URSODIOL 250 MG ORAL TABS,RX-22660,CDM,S5000,HCPCS,259,RC,68462-0473-01,NDC,outpatient,1,UN,2.31,1.617,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
URSODIOL 250 MG ORAL TABS,RX-22660,CDM,S5000,HCPCS,259,RC,60687-0527-11,NDC,outpatient,1,UN,6.99,4.893,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
URSODIOL 250 MG ORAL TABS,RX-22660,CDM,S5000,HCPCS,259,RC,60687-0527-21,NDC,outpatient,1,UN,6.99,4.893,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DESIPRAMINE HCL 25 MG ORAL TABS,RX-2286,CDM,S5000,HCPCS,259,RC,50742-0113-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PAROXETINE HCL 10 MG/5ML ORAL SUSP,RX-22959,CDM,S5000,HCPCS,259,RC,70954-0319-10,NDC,outpatient,5,ML,32.69,22.883,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PAROXETINE HCL 10 MG/5ML ORAL SUSP,RX-22959,CDM,S5000,HCPCS,259,RC,99999-0001-34,NDC,outpatient,10,ML,72.98,51.086,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN,RX-22982,CDM,S5000,HCPCS,259,RC,70069-0051-01,NDC,outpatient,10,ML,38.99,27.293,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN,RX-22982,CDM,S5000,HCPCS,259,RC,24208-0486-10,NDC,outpatient,10,ML,45.62,31.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN,RX-22982,CDM,S5000,HCPCS,259,RC,65862-0946-01,NDC,outpatient,10,ML,89,62.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN,RX-22982,CDM,S5000,HCPCS,259,RC,71921-0226-10,NDC,outpatient,10,ML,45.39,31.773,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN,RX-22982,CDM,S5000,HCPCS,259,RC,82584-0605-10,NDC,outpatient,10,ML,996.05,697.235,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMOXICILLIN-POT CLAVULANATE 250-125 MG ORAL TABS,RX-22992,CDM,S5000,HCPCS,259,RC,00781-1874-31,NDC,outpatient,1,UN,6.58,4.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMOXICILLIN-POT CLAVULANATE 250-125 MG ORAL TABS,RX-22992,CDM,S5000,HCPCS,259,RC,42571-0160-30,NDC,outpatient,1,UN,9.65,6.755,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CAPECITABINE 500 MG ORAL TABS,RX-22994,CDM,S5000,HCPCS,259,RC,00004-1101-50,NDC,outpatient,1,UN,195.05,136.535,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CAPECITABINE 500 MG ORAL TABS,RX-22994,CDM,S5000,HCPCS,259,RC,16729-0073-29,NDC,outpatient,1,UN,1.65,1.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RISEDRONATE SODIUM 30 MG ORAL TABS,RX-23015,CDM,S5000,HCPCS,259,RC,00093-3100-56,NDC,outpatient,1,UN,220.55,154.385,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CAMPHOR-MENTHOL 0.5-0.5 % EX LOTN,RX-23063,CDM,S5000,HCPCS,259,RC,00536-1268-12,NDC,outpatient,222,ML,16.8,11.76,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CAMPHOR-MENTHOL 0.5-0.5 % EX LOTN,RX-23063,CDM,S5000,HCPCS,259,RC,46122-0573-10,NDC,outpatient,222,ML,11.13,7.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLINISOL SF 15 % IV SOLN,RX-23068,CDM,S5000,HCPCS,250,RC,00338-0502-06,NDC,outpatient,2000,ML,211.8,148.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLINIMIX E/DEXTROSE (5/15) 5 % IV SOLN,RX-23165,CDM,S5000,HCPCS,250,RC,00338-1147-03,NDC,outpatient,1000,ML,122.8,85.96,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLINIMIX E/DEXTROSE (5/15) 5 % IV SOLN,RX-23165,CDM,S5000,HCPCS,250,RC,00338-1123-04,NDC,outpatient,2000,ML,211.8,148.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DEXAMETHASONE 0.5 MG ORAL TABS,RX-2322,CDM,S5000,HCPCS,259,RC,00054-8179-25,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CANDESARTAN CILEXETIL 4 MG ORAL TABS,RX-23229,CDM,S5000,HCPCS,259,RC,62332-0341-90,NDC,outpatient,1,UN,4.08,2.856,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CANDESARTAN CILEXETIL 4 MG ORAL TABS,RX-23229,CDM,S5000,HCPCS,259,RC,33342-0114-07,NDC,outpatient,1,UN,5.64,3.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CANDESARTAN CILEXETIL 16 MG ORAL TABS,RX-23231,CDM,S5000,HCPCS,259,RC,33342-0116-07,NDC,outpatient,1,UN,4.6,3.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DEXAMETHASONE 1 MG ORAL TABS,RX-2324,CDM,S5000,HCPCS,259,RC,00054-8174-25,NDC,outpatient,1,UN,1.46,1.022,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DEXAMETHASONE 4 MG ORAL TABS,RX-2327,CDM,S5000,HCPCS,259,RC,00054-8175-25,NDC,outpatient,1,UN,4.2,2.94,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DEXAMETHASONE 4 MG ORAL TABS,RX-2327,CDM,S5000,HCPCS,259,RC,66993-0730-51,NDC,outpatient,1,UN,4.47,3.129,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DEXAMETHASONE 4 MG ORAL TABS,RX-2327,CDM,S5000,HCPCS,259,RC,66993-0730-80,NDC,outpatient,1,UN,4.47,3.129,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DEXAMETHASONE 6 MG ORAL TABS,RX-2328,CDM,S5000,HCPCS,259,RC,00054-8183-25,NDC,outpatient,1,UN,6.68,4.676,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DEXAMETHASONE SODIUM PHOSPHATE 0.1 % OP SOLN,RX-2335,CDM,S5000,HCPCS,259,RC,24208-0720-02,NDC,outpatient,5,ML,228.82,160.174,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE 4 % EX CREA,RX-23461,CDM,S5000,HCPCS,259,RC,39328-0024-30,NDC,outpatient,30,GR,40.32,28.224,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE 4 % EX CREA,RX-23461,CDM,S5000,HCPCS,259,RC,00496-0882-05,NDC,outpatient,5,GR,12.51,8.757,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE 4 % EX CREA,RX-23461,CDM,S5000,HCPCS,259,RC,00496-0882-06,NDC,outpatient,5,GR,12.51,8.757,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DEXTROSE 10 % IV SOLN,RX-2357,CDM,S5000,HCPCS,250,RC,00338-0023-02,NDC,outpatient,250,ML,25,17.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DEXTROSE 10 % IV SOLN,RX-2357,CDM,S5000,HCPCS,250,RC,00338-0023-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DEXTROSE 20 % IV SOLN,RX-2359,CDM,S5000,HCPCS,250,RC,00990-7935-19,NDC,outpatient,500,ML,62.73,43.911,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DEXTROSE 250 MG/ML IV SOLN,RX-2361,CDM,S5000,HCPCS,250,RC,00409-1775-10,NDC,outpatient,10,ML,57.77,40.439,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-7517-16,NDC,outpatient,50,ML,31.82,22.274,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-4902-34,NDC,outpatient,50,ML,59.41,41.587,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-6648-16,NDC,outpatient,50,ML,19.02,13.314,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-7517-66,NDC,outpatient,50,ML,58.08,40.656,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-6648-02,NDC,outpatient,50,ML,19.02,13.314,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,76329-3302-01,NDC,outpatient,50,ML,66.31,46.417,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-4902-64,NDC,outpatient,50,ML,59.41,41.587,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,69374-0953-50,NDC,outpatient,50,ML,66.75,46.725,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,69623-0201-39,NDC,outpatient,50,ML,93.45,65.415,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
EFAVIRENZ 200 MG ORAL CAPS,RX-23900,CDM,S5000,HCPCS,259,RC,64980-0407-09,NDC,outpatient,1,UN,33.64,23.548,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DIAZEPAM 2 MG ORAL TABS,RX-2404,CDM,S5000,HCPCS,259,RC,00172-3925-60,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DIAZEPAM 2 MG ORAL TABS,RX-2404,CDM,S5000,HCPCS,259,RC,51079-0284-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DIAZEPAM 2 MG ORAL TABS,RX-2404,CDM,S5000,HCPCS,259,RC,51079-0284-20,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DIAZEPAM 5 MG ORAL TABS,RX-2405,CDM,S5000,HCPCS,259,RC,51079-0285-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DIAZEPAM 5 MG ORAL TABS,RX-2405,CDM,S5000,HCPCS,259,RC,51079-0285-20,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MICONAZOLE NITRATE 4 % VA CREA,RX-24050,CDM,S5000,HCPCS,259,RC,63736-0442-01,NDC,outpatient,15,GR,44.73,31.311,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DICLOXACILLIN SODIUM 250 MG ORAL CAPS,RX-2414,CDM,S5000,HCPCS,259,RC,00093-3123-01,NDC,outpatient,1,UN,2.5,1.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DICLOXACILLIN SODIUM 250 MG ORAL CAPS,RX-2414,CDM,S5000,HCPCS,259,RC,59651-0565-01,NDC,outpatient,1,UN,2.33,1.631,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MIDAZOLAM HCL 2 MG/ML ORAL SYRP,RX-24176,CDM,S5000,HCPCS,259,RC,68094-0764-59,NDC,outpatient,5,ML,21.65,15.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MIDAZOLAM HCL 2 MG/ML ORAL SYRP,RX-24176,CDM,S5000,HCPCS,259,RC,68094-0764-62,NDC,outpatient,5,ML,21.65,15.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DICYCLOMINE HCL 10 MG ORAL CAPS,RX-2418,CDM,S5000,HCPCS,259,RC,60687-0369-11,NDC,outpatient,1,UN,1.75,1.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DICYCLOMINE HCL 10 MG ORAL CAPS,RX-2418,CDM,S5000,HCPCS,259,RC,60687-0369-01,NDC,outpatient,1,UN,1.75,1.225,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DICYCLOMINE HCL 20 MG ORAL TABS,RX-2420,CDM,S5000,HCPCS,259,RC,60687-0380-01,NDC,outpatient,1,UN,1.8,1.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DICYCLOMINE HCL 20 MG ORAL TABS,RX-2420,CDM,S5000,HCPCS,259,RC,60687-0380-11,NDC,outpatient,1,UN,1.8,1.26,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG ORAL TABS,RX-24216,CDM,S5000,HCPCS,259,RC,60687-0622-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG ORAL TABS,RX-24216,CDM,S5000,HCPCS,259,RC,60687-0622-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG ORAL TABS,RX-24216,CDM,S5000,HCPCS,259,RC,63739-0432-02,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG ORAL TABS,RX-24216,CDM,S5000,HCPCS,259,RC,00536-1248-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ISOSORBIDE MONONITRATE ER 60 MG ORAL TAB,RX-24268,CDM,S5000,HCPCS,259,RC,00904-6450-61,NDC,outpatient,1,UN,1.31,0.917,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TELMISARTAN 40 MG ORAL TABS,RX-24335,CDM,S5000,HCPCS,259,RC,00597-0040-37,NDC,outpatient,1,UN,19.23,13.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROCORTISONE-ACETIC ACID 1-2 % OT SOLN,RX-24385,CDM,S5000,HCPCS,259,RC,51672-3007-01,NDC,outpatient,10,ML,303.14,212.198,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ABACAVIR SULFATE 300 MG ORAL TABS,RX-24438,CDM,S5000,HCPCS,259,RC,68084-0021-21,NDC,outpatient,1,UN,26.71,18.697,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ABACAVIR SULFATE 300 MG ORAL TABS,RX-24438,CDM,S5000,HCPCS,259,RC,00378-4105-91,NDC,outpatient,1,UN,13.01,9.107,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ABACAVIR SULFATE 300 MG ORAL TABS,RX-24438,CDM,S5000,HCPCS,259,RC,68084-0021-11,NDC,outpatient,1,UN,26.71,18.697,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DIGOXIN 125 MCG ORAL TABS,RX-2444,CDM,S5000,HCPCS,259,RC,00904-5921-61,NDC,outpatient,1,UN,3.14,2.198,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXYBUTYNIN CHLORIDE ER 5 MG ORAL TB24,RX-24470,CDM,S5000,HCPCS,259,RC,00904-6570-61,NDC,outpatient,1,UN,5.08,3.556,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXYBUTYNIN CHLORIDE ER 5 MG ORAL TB24,RX-24470,CDM,S5000,HCPCS,259,RC,68084-0480-11,NDC,outpatient,1,UN,4.79,3.353,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXYBUTYNIN CHLORIDE ER 5 MG ORAL TB24,RX-24470,CDM,S5000,HCPCS,259,RC,68084-0480-01,NDC,outpatient,1,UN,4.79,3.353,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXYBUTYNIN CHLORIDE ER 5 MG ORAL TB24,RX-24470,CDM,S5000,HCPCS,259,RC,00904-6570-04,NDC,outpatient,1,UN,7.7,5.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXYBUTYNIN CHLORIDE ER 5 MG ORAL TB24,RX-24470,CDM,S5000,HCPCS,259,RC,63739-0548-33,NDC,outpatient,1,UN,5.24,3.668,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CILOSTAZOL 100 MG ORAL TABS,RX-24474,CDM,S5000,HCPCS,259,RC,50268-0177-11,NDC,outpatient,1,UN,3.18,2.226,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CILOSTAZOL 100 MG ORAL TABS,RX-24474,CDM,S5000,HCPCS,259,RC,50268-0177-15,NDC,outpatient,1,UN,3.18,2.226,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CELECOXIB 100 MG ORAL CAPS,RX-24500,CDM,S5000,HCPCS,259,RC,60687-0436-01,NDC,outpatient,1,UN,3.16,2.212,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CELECOXIB 100 MG ORAL CAPS,RX-24500,CDM,S5000,HCPCS,259,RC,00904-6502-61,NDC,outpatient,1,UN,3.56,2.492,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CELECOXIB 100 MG ORAL CAPS,RX-24500,CDM,S5000,HCPCS,259,RC,60687-0436-11,NDC,outpatient,1,UN,3.16,2.212,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CELECOXIB 200 MG ORAL CAPS,RX-24501,CDM,S5000,HCPCS,259,RC,00904-6503-61,NDC,outpatient,1,UN,5.49,3.843,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CELECOXIB 200 MG ORAL CAPS,RX-24501,CDM,S5000,HCPCS,259,RC,60505-3849-01,NDC,outpatient,1,UN,2.67,1.869,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ISOSORBIDE MONONITRATE ER 30 MG ORAL TB24,RX-24521,CDM,S5000,HCPCS,259,RC,00904-6449-61,NDC,outpatient,1,UN,1.08,0.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MODAFINIL 100 MG ORAL TABS,RX-24702,CDM,S5000,HCPCS,259,RC,00904-6791-04,NDC,outpatient,1,UN,21.38,14.966,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MODAFINIL 100 MG ORAL TABS,RX-24702,CDM,S5000,HCPCS,259,RC,50268-0570-11,NDC,outpatient,1,UN,25.83,18.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MODAFINIL 100 MG ORAL TABS,RX-24702,CDM,S5000,HCPCS,259,RC,68084-0621-11,NDC,outpatient,1,UN,21.38,14.966,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MODAFINIL 100 MG ORAL TABS,RX-24702,CDM,S5000,HCPCS,259,RC,68084-0621-21,NDC,outpatient,1,UN,21.38,14.966,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MODAFINIL 100 MG ORAL TABS,RX-24702,CDM,S5000,HCPCS,259,RC,50268-0570-12,NDC,outpatient,1,UN,25.83,18.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BELLADONNA ALKALOIDS-OPIUM 16.2-60 MG RE SUPP,RX-24731,CDM,S5000,HCPCS,259,RC,00574-7040-12,NDC,outpatient,1,UN,104.53,73.171,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DILTIAZEM HCL 30 MG ORAL TABS,RX-2475,CDM,S5000,HCPCS,259,RC,60687-0717-01,NDC,outpatient,1,UN,1.81,1.267,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DILTIAZEM HCL 30 MG ORAL TABS,RX-2475,CDM,S5000,HCPCS,259,RC,00093-0318-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DILTIAZEM HCL 30 MG ORAL TABS,RX-2475,CDM,S5000,HCPCS,259,RC,60687-0717-11,NDC,outpatient,1,UN,1.81,1.267,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DIMENHYDRINATE 50 MG ORAL TABS,RX-2485,CDM,S5000,HCPCS,259,RC,00904-2051-59,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TACROLIMUS 0.5 MG ORAL CAPS,RX-24914,CDM,S5000,HCPCS,259,RC,00904-6623-61,NDC,outpatient,1,UN,2.82,1.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU,RX-24915,CDM,S5000,HCPCS,259,RC,00093-4146-56,NDC,outpatient,3,ML,7.12,4.984,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU,RX-24915,CDM,S5000,HCPCS,259,RC,00093-4146-45,NDC,outpatient,3,ML,7.12,4.984,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU,RX-24915,CDM,S5000,HCPCS,259,RC,76204-0800-01,NDC,outpatient,3,ML,5.32,3.724,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU,RX-24915,CDM,S5000,HCPCS,259,RC,76204-0800-11,NDC,outpatient,3,ML,5.32,3.724,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVALBUTEROL HCL 1.25 MG/3ML IN NEBU,RX-24916,CDM,S5000,HCPCS,259,RC,76204-0900-01,NDC,outpatient,3,ML,5.47,3.829,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVALBUTEROL HCL 1.25 MG/3ML IN NEBU,RX-24916,CDM,S5000,HCPCS,259,RC,76204-0900-11,NDC,outpatient,3,ML,5.47,3.829,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,00487-9501-01,NDC,outpatient,3,ML,1.41,0.987,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,47335-0703-49,NDC,outpatient,3,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,47335-0703-48,NDC,outpatient,3,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,76204-0200-01,NDC,outpatient,3,ML,1.18,0.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,60687-0395-79,NDC,outpatient,3,ML,1.02,0.714,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,60687-0395-83,NDC,outpatient,3,ML,1.02,0.714,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,76204-0200-60,NDC,outpatient,3,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,00378-8270-31,NDC,outpatient,3,ML,1.22,0.854,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,00378-8270-55,NDC,outpatient,3,ML,1.22,0.854,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,47335-0703-52,NDC,outpatient,3,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL SUSR,RX-25005,CDM,S5000,HCPCS,259,RC,66689-0307-08,NDC,outpatient,160,ML,1111.44,778.008,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL SUSR,RX-25005,CDM,S5000,HCPCS,259,RC,99999-0002-21,NDC,outpatient,2.5,ML,69.2,48.44,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DIPHENHYDRAMINE HCL 25 MG ORAL CAPS,RX-2509,CDM,S5000,HCPCS,259,RC,00904-7237-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DIPHENHYDRAMINE HCL 12.5 MG/5ML ORAL SOLN,RX-2511,CDM,S5000,HCPCS,259,RC,00121-0489-00,NDC,outpatient,5,ML,15.4,10.78,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DIPHENHYDRAMINE HCL 12.5 MG/5ML ORAL SOLN,RX-2511,CDM,S5000,HCPCS,259,RC,00121-0489-05,NDC,outpatient,5,ML,15.4,10.78,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CIPROFLOXACIN HCL 250 MG ORAL TABS,RX-25118,CDM,S5000,HCPCS,259,RC,65862-0076-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CIPROFLOXACIN HCL 250 MG ORAL TABS,RX-25118,CDM,S5000,HCPCS,259,RC,00143-9927-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CIPROFLOXACIN HCL 250 MG ORAL TABS,RX-25118,CDM,S5000,HCPCS,259,RC,62135-0308-01,NDC,outpatient,1,UN,12.1,8.47,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DIPHENOXYLATE-ATROPINE 2.5-0.025 MG ORAL TABS,RX-2516,CDM,S5000,HCPCS,259,RC,69315-0910-01,NDC,outpatient,1,UN,2.4,1.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DIPHENOXYLATE-ATROPINE 2.5-0.025 MG ORAL TABS,RX-2516,CDM,S5000,HCPCS,259,RC,00406-1236-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALBUTEROL SULFATE 2 MG/5ML ORAL SYRP,RX-252,CDM,S5000,HCPCS,259,RC,99999-0003-98,NDC,outpatient,5,ML,1.34,0.938,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALBUTEROL SULFATE 2 MG/5ML ORAL SYRP,RX-252,CDM,S5000,HCPCS,259,RC,00472-0825-16,NDC,outpatient,5,ML,1.24,0.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALBUTEROL SULFATE 2 MG/5ML ORAL SYRP,RX-252,CDM,S5000,HCPCS,259,RC,70752-0102-12,NDC,outpatient,5,ML,1.91,1.337,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DIPYRIDAMOLE 25 MG ORAL TABS,RX-2528,CDM,S5000,HCPCS,259,RC,64980-0133-01,NDC,outpatient,1,UN,5.27,3.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALBUTEROL SULFATE 2 MG ORAL TABS,RX-253,CDM,S5000,HCPCS,259,RC,68084-0949-25,NDC,outpatient,1,UN,27.72,19.404,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALBUTEROL SULFATE 2 MG ORAL TABS,RX-253,CDM,S5000,HCPCS,259,RC,68084-0949-95,NDC,outpatient,1,UN,27.72,19.404,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DISOPYRAMIDE PHOSPHATE 100 MG ORAL CAPS,RX-2535,CDM,S5000,HCPCS,259,RC,00093-3127-01,NDC,outpatient,1,UN,5.28,3.696,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DISULFIRAM 250 MG ORAL TABS,RX-2540,CDM,S5000,HCPCS,259,RC,47781-0607-30,NDC,outpatient,1,UN,7.69,5.383,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POLYETHYLENE GLYCOL 3350 17 G ORAL PACK,RX-25424,CDM,S5000,HCPCS,259,RC,00904-6931-81,NDC,outpatient,1,UN,3.67,2.569,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POLYETHYLENE GLYCOL 3350 17 G ORAL PACK,RX-25424,CDM,S5000,HCPCS,259,RC,00904-6931-86,NDC,outpatient,1,UN,3.67,2.569,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POLYETHYLENE GLYCOL 3350 17 G ORAL PACK,RX-25424,CDM,S5000,HCPCS,259,RC,62559-0157-17,NDC,outpatient,1,UN,3.43,2.401,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POLYETHYLENE GLYCOL 3350 17 G ORAL PACK,RX-25424,CDM,S5000,HCPCS,259,RC,62559-0157-10,NDC,outpatient,1,UN,3.43,2.401,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DIVALPROEX SODIUM 125 MG ORAL TBEC,RX-2551,CDM,S5000,HCPCS,259,RC,60687-0211-21,NDC,outpatient,1,UN,3.46,2.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DIVALPROEX SODIUM 125 MG ORAL TBEC,RX-2551,CDM,S5000,HCPCS,259,RC,60687-0211-11,NDC,outpatient,1,UN,3.46,2.422,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RISPERIDONE 0.25 MG ORAL TABS,RX-25519,CDM,S5000,HCPCS,259,RC,68084-0270-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RISPERIDONE 0.25 MG ORAL TABS,RX-25519,CDM,S5000,HCPCS,259,RC,68084-0270-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RISPERIDONE 0.25 MG ORAL TABS,RX-25519,CDM,S5000,HCPCS,259,RC,68382-0112-14,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DIVALPROEX SODIUM 250 MG ORAL TBEC,RX-2552,CDM,S5000,HCPCS,259,RC,68084-0776-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DIVALPROEX SODIUM 250 MG ORAL TBEC,RX-2552,CDM,S5000,HCPCS,259,RC,68084-0776-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RISPERIDONE 0.5 MG ORAL TABS,RX-25520,CDM,S5000,HCPCS,259,RC,00904-7361-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PIOGLITAZONE HCL 15 MG ORAL TABS,RX-25528,CDM,S5000,HCPCS,259,RC,60687-0391-01,NDC,outpatient,1,UN,3.42,2.394,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PIOGLITAZONE HCL 15 MG ORAL TABS,RX-25528,CDM,S5000,HCPCS,259,RC,60687-0391-11,NDC,outpatient,1,UN,3.42,2.394,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DIVALPROEX SODIUM 500 MG ORAL TBEC,RX-2553,CDM,S5000,HCPCS,259,RC,68084-0782-61,NDC,outpatient,1,UN,1.16,0.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DIVALPROEX SODIUM 500 MG ORAL TBEC,RX-2553,CDM,S5000,HCPCS,259,RC,68084-0782-11,NDC,outpatient,1,UN,1.16,0.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DIVALPROEX SODIUM 500 MG ORAL TBEC,RX-2553,CDM,S5000,HCPCS,259,RC,00904-6861-90,NDC,outpatient,1,UN,1.2,0.84,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOCUSATE SODIUM 100 MG ORAL CAPS,RX-2566,CDM,S5000,HCPCS,259,RC,00904-7280-60,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOCUSATE SODIUM 100 MG ORAL CAPS,RX-2566,CDM,S5000,HCPCS,259,RC,00904-7280-80,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOCUSATE SODIUM 100 MG ORAL CAPS,RX-2566,CDM,S5000,HCPCS,259,RC,00904-7183-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IVERMECTIN 3 MG ORAL TABS,RX-25820,CDM,S5000,HCPCS,259,RC,00006-0032-20,NDC,outpatient,1,UN,19.14,13.398,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IVERMECTIN 3 MG ORAL TABS,RX-25820,CDM,S5000,HCPCS,259,RC,42799-0806-01,NDC,outpatient,1,UN,14.59,10.213,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOXEPIN HCL 10 MG ORAL CAPS,RX-2608,CDM,S5000,HCPCS,259,RC,00904-7052-61,NDC,outpatient,1,UN,2.19,1.533,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOXEPIN HCL 10 MG ORAL CAPS,RX-2608,CDM,S5000,HCPCS,259,RC,51079-0436-01,NDC,outpatient,1,UN,2.53,1.771,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOXEPIN HCL 10 MG ORAL CAPS,RX-2608,CDM,S5000,HCPCS,259,RC,51079-0436-20,NDC,outpatient,1,UN,2.53,1.771,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOXEPIN HCL 100 MG ORAL CAPS,RX-2609,CDM,S5000,HCPCS,259,RC,51079-0651-01,NDC,outpatient,1,UN,6.84,4.788,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOXEPIN HCL 100 MG ORAL CAPS,RX-2609,CDM,S5000,HCPCS,259,RC,51079-0651-20,NDC,outpatient,1,UN,6.84,4.788,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOXEPIN HCL 100 MG ORAL CAPS,RX-2609,CDM,S5000,HCPCS,259,RC,00378-6410-01,NDC,outpatient,1,UN,5.48,3.836,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOXEPIN HCL 25 MG ORAL CAPS,RX-2611,CDM,S5000,HCPCS,259,RC,51079-0437-20,NDC,outpatient,1,UN,2.89,2.023,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOXEPIN HCL 25 MG ORAL CAPS,RX-2611,CDM,S5000,HCPCS,259,RC,00378-3125-01,NDC,outpatient,1,UN,2.29,1.603,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOXEPIN HCL 25 MG ORAL CAPS,RX-2611,CDM,S5000,HCPCS,259,RC,51079-0437-01,NDC,outpatient,1,UN,2.89,2.023,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MUSCLE RUB 10-15 % EX CREA,RX-26210,CDM,S5000,HCPCS,259,RC,57896-0116-03,NDC,outpatient,85,GR,10.97,7.679,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MUSCLE RUB 10-15 % EX CREA,RX-26210,CDM,S5000,HCPCS,259,RC,00536-1101-45,NDC,outpatient,85,GR,10.6,7.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MUSCLE RUB 10-15 % EX CREA,RX-26210,CDM,S5000,HCPCS,259,RC,00536-1349-57,NDC,outpatient,85,GR,9.08,6.356,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,00143-9381-10,NDC,outpatient,1,UN,49.76,34.832,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,63323-0130-02,NDC,outpatient,1,UN,45.64,31.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,68382-0910-01,NDC,outpatient,1,UN,107.52,75.264,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,00143-9381-01,NDC,outpatient,1,UN,49.76,34.832,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,68382-0910-10,NDC,outpatient,1,UN,107.52,75.264,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,67457-0437-10,NDC,outpatient,1,UN,68.55,47.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,63323-0130-11,NDC,outpatient,1,UN,45.64,31.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,67457-0437-00,NDC,outpatient,1,UN,68.55,47.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PANTOPRAZOLE SODIUM 40 MG ORAL TBEC,RX-26225,CDM,S5000,HCPCS,259,RC,35573-0428-80,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PANTOPRAZOLE SODIUM 40 MG ORAL TBEC,RX-26225,CDM,S5000,HCPCS,259,RC,00904-6474-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PANTOPRAZOLE SODIUM 40 MG ORAL TBEC,RX-26225,CDM,S5000,HCPCS,259,RC,51079-0051-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PANTOPRAZOLE SODIUM 40 MG ORAL TBEC,RX-26225,CDM,S5000,HCPCS,259,RC,35573-0428-51,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PANTOPRAZOLE SODIUM 40 MG ORAL TBEC,RX-26225,CDM,S5000,HCPCS,259,RC,51079-0051-20,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOXYCYCLINE HYCLATE 100 MG ORAL TABS,RX-2625,CDM,S5000,HCPCS,259,RC,00904-0430-06,NDC,outpatient,1,UN,5.29,3.703,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOXYCYCLINE HYCLATE 100 MG ORAL TABS,RX-2625,CDM,S5000,HCPCS,259,RC,62584-0693-11,NDC,outpatient,1,UN,4.84,3.388,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOXYCYCLINE HYCLATE 100 MG ORAL TABS,RX-2625,CDM,S5000,HCPCS,259,RC,00143-2112-50,NDC,outpatient,1,UN,1.07,0.749,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOXYCYCLINE HYCLATE 100 MG ORAL TABS,RX-2625,CDM,S5000,HCPCS,259,RC,62584-0693-21,NDC,outpatient,1,UN,4.84,3.388,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CARBIDOPA-LEVODOPA ER 50-200 MG ORAL TBCR,RX-26371,CDM,S5000,HCPCS,259,RC,68084-0282-11,NDC,outpatient,1,UN,4.16,2.912,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CARBIDOPA-LEVODOPA ER 50-200 MG ORAL TBCR,RX-26371,CDM,S5000,HCPCS,259,RC,68084-0282-01,NDC,outpatient,1,UN,4.16,2.912,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAPS,RX-26546,CDM,S5000,HCPCS,259,RC,64380-0799-01,NDC,outpatient,1,UN,8.24,5.768,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAPS,RX-26546,CDM,S5000,HCPCS,259,RC,31722-0632-31,NDC,outpatient,1,UN,4.28,2.996,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ENTACAPONE 200 MG ORAL TABS,RX-26547,CDM,S5000,HCPCS,259,RC,27241-0049-10,NDC,outpatient,1,UN,2.4,1.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ENTACAPONE 200 MG ORAL TABS,RX-26547,CDM,S5000,HCPCS,259,RC,60687-0188-11,NDC,outpatient,1,UN,18.43,12.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ENTACAPONE 200 MG ORAL TABS,RX-26547,CDM,S5000,HCPCS,259,RC,60687-0188-21,NDC,outpatient,1,UN,18.43,12.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
EXEMESTANE 25 MG ORAL TABS,RX-26551,CDM,S5000,HCPCS,259,RC,59762-2858-01,NDC,outpatient,1,UN,6.65,4.655,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVETIRACETAM 500 MG ORAL TABS,RX-26817,CDM,S5000,HCPCS,259,RC,65862-0246-08,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVETIRACETAM 500 MG ORAL TABS,RX-26817,CDM,S5000,HCPCS,259,RC,00904-7124-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MOXIFLOXACIN HCL 400 MG ORAL TABS,RX-26854,CDM,S5000,HCPCS,259,RC,65862-0603-30,NDC,outpatient,1,UN,13.67,9.569,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOFETILIDE 125 MCG ORAL CAPS,RX-26965,CDM,S5000,HCPCS,259,RC,16729-0490-12,NDC,outpatient,1,UN,6.58,4.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOFETILIDE 125 MCG ORAL CAPS,RX-26965,CDM,S5000,HCPCS,259,RC,72205-0039-60,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOFETILIDE 125 MCG ORAL CAPS,RX-26965,CDM,S5000,HCPCS,259,RC,69452-0131-17,NDC,outpatient,1,UN,2.23,1.561,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOFETILIDE 250 MCG ORAL CAPS,RX-26966,CDM,S5000,HCPCS,259,RC,69452-0132-17,NDC,outpatient,1,UN,2.23,1.561,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOFETILIDE 250 MCG ORAL CAPS,RX-26966,CDM,S5000,HCPCS,259,RC,00904-6682-08,NDC,outpatient,1,UN,13.18,9.226,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOFETILIDE 250 MCG ORAL CAPS,RX-26966,CDM,S5000,HCPCS,259,RC,42291-0412-60,NDC,outpatient,1,UN,1.48,1.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOFETILIDE 500 MCG ORAL CAPS,RX-26967,CDM,S5000,HCPCS,259,RC,00904-6683-08,NDC,outpatient,1,UN,13.31,9.317,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOFETILIDE 500 MCG ORAL CAPS,RX-26967,CDM,S5000,HCPCS,259,RC,42291-0413-60,NDC,outpatient,1,UN,1.4,0.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TERBINAFINE HCL 1 % EX CREA,RX-27023,CDM,S5000,HCPCS,259,RC,51672-2080-01,NDC,outpatient,15,GR,24.57,17.199,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREDNISOLONE ACETATE 0.12 % OP SUSP,RX-27038,CDM,S5000,HCPCS,259,RC,11980-0174-05,NDC,outpatient,5,ML,659.54,461.678,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXCARBAZEPINE 150 MG ORAL TABS,RX-27049,CDM,S5000,HCPCS,259,RC,60687-0711-01,NDC,outpatient,1,UN,1.81,1.267,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXCARBAZEPINE 150 MG ORAL TABS,RX-27049,CDM,S5000,HCPCS,259,RC,60687-0711-11,NDC,outpatient,1,UN,1.81,1.267,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CHARCOAL ACTIVATED ORAL LIQD,RX-27099,CDM,S5000,HCPCS,259,RC,66689-0202-04,NDC,outpatient,120,ML,82.77,57.939,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RISEDRONATE SODIUM 5 MG ORAL TABS,RX-27112,CDM,S5000,HCPCS,259,RC,33342-0107-07,NDC,outpatient,1,UN,11.13,7.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NIACIN ER (ANTIHYPERLIPIDEMIC) 500 MG ORAL TBCR,RX-27181,CDM,S5000,HCPCS,259,RC,47335-0539-81,NDC,outpatient,1,UN,1.02,0.714,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NIACIN ER (ANTIHYPERLIPIDEMIC) 500 MG ORAL TBCR,RX-27181,CDM,S5000,HCPCS,259,RC,59651-0018-90,NDC,outpatient,1,UN,1.7,1.19,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MAGNESIUM SULFATE (LAXATIVE) ORAL GRAN,RX-27322,CDM,S5000,HCPCS,259,RC,49580-0394-04,NDC,outpatient,1814,GR,16.15,11.305,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MAGNESIUM SULFATE (LAXATIVE) ORAL GRAN,RX-27322,CDM,S5000,HCPCS,259,RC,70677-0038-01,NDC,outpatient,454,GR,8.09,5.663,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MAGNESIUM SULFATE (LAXATIVE) ORAL GRAN,RX-27322,CDM,S5000,HCPCS,259,RC,70677-1210-01,NDC,outpatient,454,GR,8.09,5.663,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MINERAL OIL LIGHT OIL,RX-27386,CDM,S5000,HCPCS,259,RC,63323-0254-02,NDC,outpatient,2,ML,34.38,24.066,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MINERAL OIL LIGHT OIL,RX-27386,CDM,S5000,HCPCS,259,RC,63323-0254-10,NDC,outpatient,10,ML,39.03,27.321,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
THEOPHYLLINE ER 100 MG ORAL CP24,RX-27418,CDM,S5000,HCPCS,259,RC,52244-0100-10,NDC,outpatient,1,UN,14.48,10.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PENTAMIDINE ISETHIONATE 300 MG IJ SOLR,RX-27430,CDM,S5000,HCPCS,250,RC,63323-0113-10,NDC,outpatient,1,UN,686.14,480.298,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DINOPROSTONE 10 MG VA INST,RX-27467,CDM,S5000,HCPCS,259,RC,55566-2800-01,NDC,outpatient,1,UN,2100.63,1470.441,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NITROGLYCERIN 0.1 MG/HR TD PT24,RX-27471,CDM,S5000,HCPCS,259,RC,00378-9102-16,NDC,outpatient,1,UN,2.47,1.729,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NITROGLYCERIN 0.1 MG/HR TD PT24,RX-27471,CDM,S5000,HCPCS,259,RC,00378-9102-93,NDC,outpatient,1,UN,2.47,1.729,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NITROGLYCERIN 0.2 MG/HR TD PT24,RX-27472,CDM,S5000,HCPCS,259,RC,00378-9104-93,NDC,outpatient,1,UN,2.2,1.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NITROGLYCERIN 0.2 MG/HR TD PT24,RX-27472,CDM,S5000,HCPCS,259,RC,00378-9104-16,NDC,outpatient,1,UN,2.2,1.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NITROGLYCERIN 0.3 MG/HR TD PT24,RX-27473,CDM,S5000,HCPCS,259,RC,50742-0515-01,NDC,outpatient,1,UN,217.89,152.523,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NITROGLYCERIN 0.3 MG/HR TD PT24,RX-27473,CDM,S5000,HCPCS,259,RC,50742-0515-30,NDC,outpatient,1,UN,217.89,152.523,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NITROGLYCERIN 0.4 MG/HR TD PT24,RX-27474,CDM,S5000,HCPCS,259,RC,00378-9112-16,NDC,outpatient,1,UN,2.77,1.939,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NITROGLYCERIN 0.4 MG/HR TD PT24,RX-27474,CDM,S5000,HCPCS,259,RC,00378-9112-93,NDC,outpatient,1,UN,2.77,1.939,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NITROGLYCERIN 0.4 MG/HR TD PT24,RX-27474,CDM,S5000,HCPCS,259,RC,43598-0894-30,NDC,outpatient,1,UN,9.32,6.524,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NITROGLYCERIN 0.6 MG/HR TD PT24,RX-27475,CDM,S5000,HCPCS,259,RC,00378-9116-16,NDC,outpatient,1,UN,3.17,2.219,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NITROGLYCERIN 0.6 MG/HR TD PT24,RX-27475,CDM,S5000,HCPCS,259,RC,00378-9116-93,NDC,outpatient,1,UN,3.17,2.219,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FELODIPINE ER 2.5 MG ORAL TB24,RX-27489,CDM,S5000,HCPCS,259,RC,13668-0132-01,NDC,outpatient,1,UN,1.96,1.372,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FELODIPINE ER 2.5 MG ORAL TB24,RX-27489,CDM,S5000,HCPCS,259,RC,68462-0233-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FELODIPINE ER 2.5 MG ORAL TB24,RX-27489,CDM,S5000,HCPCS,259,RC,00603-3581-21,NDC,outpatient,1,UN,1.73,1.211,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DM-GUAIFENESIN ER 30-600 MG ORAL TB12,RX-27543,CDM,S5000,HCPCS,259,RC,00536-1161-37,NDC,outpatient,1,UN,1.77,1.239,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DM-GUAIFENESIN ER 30-600 MG ORAL TB12,RX-27543,CDM,S5000,HCPCS,259,RC,63824-0056-34,NDC,outpatient,1,UN,1.93,1.351,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DIVALPROEX SODIUM 125 MG ORAL CSDR,RX-27631,CDM,S5000,HCPCS,259,RC,68084-0313-11,NDC,outpatient,1,UN,3.24,2.268,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DIVALPROEX SODIUM 125 MG ORAL CSDR,RX-27631,CDM,S5000,HCPCS,259,RC,68382-0106-01,NDC,outpatient,1,UN,1.55,1.085,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DIVALPROEX SODIUM 125 MG ORAL CSDR,RX-27631,CDM,S5000,HCPCS,259,RC,68084-0313-01,NDC,outpatient,1,UN,3.24,2.268,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CARBAMAZEPINE ER 200 MG ORAL CP12,RX-27632,CDM,S5000,HCPCS,259,RC,50268-0171-13,NDC,outpatient,1,UN,7.06,4.942,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CARBAMAZEPINE ER 200 MG ORAL CP12,RX-27632,CDM,S5000,HCPCS,259,RC,50268-0171-11,NDC,outpatient,1,UN,7.06,4.942,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CARBAMAZEPINE ER 300 MG ORAL CP12,RX-27633,CDM,S5000,HCPCS,259,RC,66993-0409-32,NDC,outpatient,1,UN,5.66,3.962,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CARBAMAZEPINE ER 100 MG ORAL TB12,RX-27634,CDM,S5000,HCPCS,259,RC,51672-4123-01,NDC,outpatient,1,UN,1.04,0.728,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CARBAMAZEPINE ER 400 MG ORAL TB12,RX-27636,CDM,S5000,HCPCS,259,RC,51672-4125-01,NDC,outpatient,1,UN,2.24,1.568,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ASPIRIN-DIPYRIDAMOLE ER 25-200 MG ORAL CP12,RX-27644,CDM,S5000,HCPCS,259,RC,49884-0007-02,NDC,outpatient,1,UN,22.19,15.533,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ASPIRIN-DIPYRIDAMOLE ER 25-200 MG ORAL CP12,RX-27644,CDM,S5000,HCPCS,259,RC,68462-0405-60,NDC,outpatient,1,UN,2.36,1.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NIFEDIPINE ER OSMOTIC RELEASE 60 MG ORAL TB24,RX-27659,CDM,S5000,HCPCS,259,RC,68084-0598-11,NDC,outpatient,1,UN,8.9,6.23,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NIFEDIPINE ER OSMOTIC RELEASE 60 MG ORAL TB24,RX-27659,CDM,S5000,HCPCS,259,RC,68084-0598-01,NDC,outpatient,1,UN,8.9,6.23,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NIFEDIPINE ER OSMOTIC RELEASE 90 MG ORAL TB24,RX-27660,CDM,S5000,HCPCS,259,RC,62175-0262-37,NDC,outpatient,1,UN,9.51,6.657,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NIFEDIPINE ER OSMOTIC RELEASE 90 MG ORAL TB24,RX-27660,CDM,S5000,HCPCS,259,RC,68084-0603-21,NDC,outpatient,1,UN,11.24,7.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NIFEDIPINE ER OSMOTIC RELEASE 90 MG ORAL TB24,RX-27660,CDM,S5000,HCPCS,259,RC,68084-0603-11,NDC,outpatient,1,UN,11.24,7.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLUORESCEIN SODIUM 1 MG OP STRP,RX-27663,CDM,S5000,HCPCS,259,RC,17238-0900-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TROLAMINE SALICYLATE 10 % EX CREA,RX-27680,CDM,S5000,HCPCS,259,RC,41167-0057-24,NDC,outpatient,141,GR,30.75,21.525,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DESMOPRESSIN ACE SPRAY REFRIG 0.01 % NA SOLN,RX-27770,CDM,S5000,HCPCS,259,RC,24208-0342-05,NDC,outpatient,5,ML,655.13,458.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ZONISAMIDE 100 MG ORAL CAPS,RX-27780,CDM,S5000,HCPCS,259,RC,50268-0816-11,NDC,outpatient,1,UN,2.24,1.568,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ZONISAMIDE 100 MG ORAL CAPS,RX-27780,CDM,S5000,HCPCS,259,RC,50268-0816-15,NDC,outpatient,1,UN,2.24,1.568,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,,,outpatient,500,ML,21.14,14.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00409-7101-67,NDC,outpatient,100,ML,25.77,18.039,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-04,NDC,outpatient,1000,ML,21.14,14.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-38,NDC,outpatient,100,ML,22.17,15.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-03,NDC,outpatient,500,ML,23.71,16.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-41,NDC,outpatient,50,ML,22.94,16.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-48,NDC,outpatient,100,ML,22.69,15.883,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00264-1800-32,NDC,outpatient,100,ML,28.85,20.195,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-02,NDC,outpatient,250,ML,22.43,15.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-31,NDC,outpatient,50,ML,22.43,15.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-9543-02,NDC,outpatient,250,ML,25,17.5,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-9543-04,NDC,outpatient,500,ML,26.7,18.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00487-4301-10,NDC,outpatient,100,ML,28.85,20.195,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VENLAFAXINE HCL ER 37.5 MG ORAL CP24,RX-27857,CDM,S5000,HCPCS,259,RC,68084-0698-11,NDC,outpatient,1,UN,2.07,1.449,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VENLAFAXINE HCL ER 37.5 MG ORAL CP24,RX-27857,CDM,S5000,HCPCS,259,RC,68084-0698-01,NDC,outpatient,1,UN,2.07,1.449,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VENLAFAXINE HCL ER 75 MG ORAL CP24,RX-27858,CDM,S5000,HCPCS,259,RC,68084-0709-01,NDC,outpatient,1,UN,2.26,1.582,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VENLAFAXINE HCL ER 75 MG ORAL CP24,RX-27858,CDM,S5000,HCPCS,259,RC,00904-7077-61,NDC,outpatient,1,UN,1.54,1.078,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VENLAFAXINE HCL ER 75 MG ORAL CP24,RX-27858,CDM,S5000,HCPCS,259,RC,68084-0709-11,NDC,outpatient,1,UN,2.26,1.582,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NICOTINE 7 MG/24HR TD PT24,RX-27860,CDM,S5000,HCPCS,259,RC,43598-0446-74,NDC,outpatient,1,UN,4.78,3.346,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NICOTINE 14 MG/24HR TD PT24,RX-27862,CDM,S5000,HCPCS,259,RC,43598-0447-74,NDC,outpatient,1,UN,5.28,3.696,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NICOTINE 21 MG/24HR TD PT24,RX-27863,CDM,S5000,HCPCS,259,RC,00536-5896-33,NDC,outpatient,1,UN,7.5,5.25,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NICOTINE 21 MG/24HR TD PT24,RX-27863,CDM,S5000,HCPCS,259,RC,43598-0448-74,NDC,outpatient,1,UN,4.94,3.458,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NICOTINE 21 MG/24HR TD PT24,RX-27863,CDM,S5000,HCPCS,259,RC,00536-5896-88,NDC,outpatient,1,UN,7.5,5.25,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NICOTINE 21 MG/24HR TD PT24,RX-27863,CDM,S5000,HCPCS,259,RC,43598-0448-28,NDC,outpatient,1,UN,5.25,3.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE VISCOUS HCL 2 % MT SOLN,RX-27898,CDM,S5000,HCPCS,259,RC,62135-0712-42,NDC,outpatient,5,ML,20.16,14.112,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE VISCOUS HCL 2 % MT SOLN,RX-27898,CDM,S5000,HCPCS,259,RC,00054-3500-49,NDC,outpatient,5,ML,2.23,1.561,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE VISCOUS HCL 2 % MT SOLN,RX-27898,CDM,S5000,HCPCS,259,RC,72888-0125-26,NDC,outpatient,5,ML,2.5,1.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE VISCOUS HCL 2 % MT SOLN,RX-27898,CDM,S5000,HCPCS,259,RC,99999-0002-05,NDC,outpatient,15,ML,60.48,42.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FENTANYL 25 MCG/HR TD PT72,RX-27905,CDM,S5000,HCPCS,259,RC,47781-0424-47,NDC,outpatient,1,UN,17.49,12.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FENTANYL 25 MCG/HR TD PT72,RX-27905,CDM,S5000,HCPCS,259,RC,47781-0424-11,NDC,outpatient,1,UN,17.49,12.243,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FENTANYL 50 MCG/HR TD PT72,RX-27906,CDM,S5000,HCPCS,259,RC,00378-9122-16,NDC,outpatient,1,UN,37.78,26.446,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FENTANYL 50 MCG/HR TD PT72,RX-27906,CDM,S5000,HCPCS,259,RC,00378-9122-98,NDC,outpatient,1,UN,37.78,26.446,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FENTANYL 50 MCG/HR TD PT72,RX-27906,CDM,S5000,HCPCS,259,RC,47781-0426-11,NDC,outpatient,1,UN,25.49,17.843,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FENTANYL 50 MCG/HR TD PT72,RX-27906,CDM,S5000,HCPCS,259,RC,47781-0426-47,NDC,outpatient,1,UN,25.49,17.843,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FENTANYL 75 MCG/HR TD PT72,RX-27907,CDM,S5000,HCPCS,259,RC,47781-0427-47,NDC,outpatient,1,UN,37.66,26.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FENTANYL 75 MCG/HR TD PT72,RX-27907,CDM,S5000,HCPCS,259,RC,47781-0427-11,NDC,outpatient,1,UN,37.66,26.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FENTANYL 100 MCG/HR TD PT72,RX-27908,CDM,S5000,HCPCS,259,RC,00378-9124-16,NDC,outpatient,1,UN,93.74,65.618,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FENTANYL 100 MCG/HR TD PT72,RX-27908,CDM,S5000,HCPCS,259,RC,00378-9124-98,NDC,outpatient,1,UN,93.74,65.618,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
EMPTY STERILIZED CONTAINER,RX-2795,CDM,S5000,HCPCS,250,RC,63323-0001-30,NDC,outpatient,1,UN,4.71,3.297,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
EMPTY STERILIZED CONTAINER,RX-2795,CDM,S5000,HCPCS,250,RC,63323-0001-10,NDC,outpatient,1,UN,3.99,2.793,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM POLYSTYRENE SULFONATE 15 GM/60ML ORAL SUSP,RX-27999,CDM,S5000,HCPCS,259,RC,46287-0006-60,NDC,outpatient,60,ML,91.85,64.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SERTRALINE HCL 20 MG/ML ORAL CONC,RX-28011,CDM,S5000,HCPCS,259,RC,16714-0601-02,NDC,outpatient,2.5,ML,10.37,7.259,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SERTRALINE HCL 20 MG/ML ORAL CONC,RX-28011,CDM,S5000,HCPCS,259,RC,99999-0003-51,NDC,outpatient,2.5,ML,10.37,7.259,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FE FUMARATE-B12-VIT C-FA-IFC ORAL CAPS,RX-28030,CDM,S5000,HCPCS,259,RC,51991-0635-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BENZOCAINE-MENTHOL 20-0.5 % EX AERO,RX-28048,CDM,S5000,HCPCS,259,RC,16864-0680-01,NDC,outpatient,78,GR,22.91,16.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BENZOCAINE-MENTHOL 20-0.5 % EX AERO,RX-28048,CDM,S5000,HCPCS,259,RC,16864-0680-02,NDC,outpatient,56,GR,17.7,12.39,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ASPIRIN BUF(CACARB-MGCARB-MGO) 325 MG ORAL TABS,RX-28122,CDM,S5000,HCPCS,259,RC,00904-2015-59,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,00093-5245-19,NDC,outpatient,1,UN,2.89,2.023,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,55111-0262-81,NDC,outpatient,1,UN,3.06,2.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,00093-5245-65,NDC,outpatient,1,UN,2.89,2.023,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,33342-0083-07,NDC,outpatient,1,UN,3.81,2.667,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,55111-0262-79,NDC,outpatient,1,UN,3.06,2.142,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,60505-3275-00,NDC,outpatient,1,UN,1.9,1.33,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OLANZAPINE 10 MG ORAL TBDP,RX-28160,CDM,S5000,HCPCS,259,RC,49884-0321-52,NDC,outpatient,1,UN,2.45,1.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OLANZAPINE 10 MG ORAL TBDP,RX-28160,CDM,S5000,HCPCS,259,RC,49884-0321-55,NDC,outpatient,1,UN,2.45,1.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LINEZOLID 600 MG ORAL TABS,RX-28224,CDM,S5000,HCPCS,259,RC,00904-6553-04,NDC,outpatient,1,UN,7.73,5.411,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LINEZOLID 600 MG ORAL TABS,RX-28224,CDM,S5000,HCPCS,259,RC,67877-0419-84,NDC,outpatient,1,UN,7.42,5.194,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LINEZOLID 600 MG ORAL TABS,RX-28224,CDM,S5000,HCPCS,259,RC,67877-0419-33,NDC,outpatient,1,UN,7.42,5.194,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LINEZOLID 100 MG/5ML ORAL SUSR,RX-28225,CDM,S5000,HCPCS,259,RC,59762-1308-04,NDC,outpatient,150,ML,1694.12,1185.884,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LINEZOLID 100 MG/5ML ORAL SUSR,RX-28225,CDM,S5000,HCPCS,259,RC,99999-0002-85,NDC,outpatient,30,ML,340.43,238.301,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PENTAMIDINE ISETHIONATE 300 MG IN SOLR,RX-28235,CDM,S5000,HCPCS,259,RC,63323-0877-15,NDC,outpatient,1,UN,686.24,480.368,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RIVASTIGMINE TARTRATE 1.5 MG ORAL CAPS,RX-28278,CDM,S5000,HCPCS,259,RC,00904-7107-61,NDC,outpatient,1,UN,10.27,7.189,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RIVASTIGMINE TARTRATE 3 MG ORAL CAPS,RX-28279,CDM,S5000,HCPCS,259,RC,55111-0353-60,NDC,outpatient,1,UN,2.6,1.82,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
INSULIN GLARGINE 100 UNIT/ML SC SOLN,RX-28282,CDM,S5000,HCPCS,259,RC,00088-2220-33,NDC,outpatient,10,ML,252.19,176.533,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
COLESEVELAM HCL 625 MG ORAL TABS,RX-28372,CDM,S5000,HCPCS,259,RC,60687-0385-25,NDC,outpatient,1,UN,13.08,9.156,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
COLESEVELAM HCL 625 MG ORAL TABS,RX-28372,CDM,S5000,HCPCS,259,RC,60687-0385-95,NDC,outpatient,1,UN,13.08,9.156,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROCODONE-ACETAMINOPHEN 10-325 MG ORAL TABS,RX-28384,CDM,S5000,HCPCS,259,RC,00406-0125-23,NDC,outpatient,1,UN,2,1.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROCODONE-ACETAMINOPHEN 10-325 MG ORAL TABS,RX-28384,CDM,S5000,HCPCS,259,RC,00406-0125-62,NDC,outpatient,1,UN,2,1.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ESTRADIOL 0.05 MG/24HR TD PTWK,RX-28408,CDM,S5000,HCPCS,259,RC,00378-3350-16,NDC,outpatient,1,UN,65.95,46.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ESTRADIOL 0.05 MG/24HR TD PTWK,RX-28408,CDM,S5000,HCPCS,259,RC,00378-3350-99,NDC,outpatient,1,UN,65.95,46.165,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ESTRADIOL 0.1 MG/24HR TD PTWK,RX-28409,CDM,S5000,HCPCS,259,RC,00378-3352-99,NDC,outpatient,1,UN,65.26,45.682,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ESTRADIOL 0.1 MG/24HR TD PTWK,RX-28409,CDM,S5000,HCPCS,259,RC,00378-3352-16,NDC,outpatient,1,UN,65.26,45.682,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NIFEDIPINE ER OSMOTIC RELEASE 30 MG ORAL TB24,RX-28643,CDM,S5000,HCPCS,259,RC,68084-0597-11,NDC,outpatient,1,UN,5.37,3.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NIFEDIPINE ER OSMOTIC RELEASE 30 MG ORAL TB24,RX-28643,CDM,S5000,HCPCS,259,RC,68084-0597-01,NDC,outpatient,1,UN,5.37,3.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METHYLPHENIDATE HCL ER (OSM) 18 MG ORAL TBCR,RX-28750,CDM,S5000,HCPCS,259,RC,13811-0706-10,NDC,outpatient,1,UN,3.22,2.254,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METHYLPHENIDATE HCL ER (OSM) 18 MG ORAL TBCR,RX-28750,CDM,S5000,HCPCS,259,RC,50458-0585-01,NDC,outpatient,1,UN,53.04,37.128,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUDESONIDE 0.25 MG/2ML IN SUSP,RX-28774,CDM,S5000,HCPCS,259,RC,00186-1988-04,NDC,outpatient,2,ML,35.8,25.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUDESONIDE 0.25 MG/2ML IN SUSP,RX-28774,CDM,S5000,HCPCS,259,RC,00487-9601-01,NDC,outpatient,2,ML,17.76,12.432,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,00093-6816-45,NDC,outpatient,2,ML,39.45,27.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,00093-6816-73,NDC,outpatient,2,ML,39.45,27.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,00487-9701-01,NDC,outpatient,2,ML,14.93,10.451,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,68180-0984-05,NDC,outpatient,2,ML,5.21,3.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,68180-0984-30,NDC,outpatient,2,ML,5.21,3.647,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,69097-0319-53,NDC,outpatient,2,ML,12.55,8.785,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,69097-0319-86,NDC,outpatient,2,ML,8.61,6.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,69097-0319-87,NDC,outpatient,2,ML,8.61,6.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,47335-0632-49,NDC,outpatient,1,ML,6.14,4.298,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,69097-0319-32,NDC,outpatient,2,ML,12.55,8.785,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,00168-0053-21,NDC,outpatient,28.35,GR,7.2,5.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,38779-3068-00,NDC,outpatient,30,GR,75.03,52.521,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,53329-0993-04,NDC,outpatient,113,GR,5.26,3.682,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,00521-2311-00,NDC,outpatient,52.5,GR,7.25,5.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,00521-2335-00,NDC,outpatient,390,GR,19.1,13.37,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,08080-4302-01,NDC,outpatient,30,ML,5.88,4.116,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,00168-0053-16,NDC,outpatient,453.6,GR,58.59,41.013,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SUSP,RX-28810,CDM,S5000,HCPCS,259,RC,61314-0645-11,NDC,outpatient,10,ML,217.88,152.516,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SUSP,RX-28810,CDM,S5000,HCPCS,259,RC,24208-0635-62,NDC,outpatient,10,ML,221.08,154.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GLYCERIN LIQD,RX-28815,CDM,S5000,HCPCS,259,RC,00395-1031-96,NDC,outpatient,177,ML,23.63,16.541,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MAGNESIUM HYDROXIDE 400 MG/5ML ORAL SUSP,RX-28836,CDM,S5000,HCPCS,259,RC,00121-0431-30,NDC,outpatient,30,ML,4.14,2.898,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CYCLOSPORINE MODIFIED 25 MG ORAL CAPS,RX-28842,CDM,S5000,HCPCS,259,RC,00093-9018-19,NDC,outpatient,1,UN,1.84,1.288,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CYCLOSPORINE MODIFIED 25 MG ORAL CAPS,RX-28842,CDM,S5000,HCPCS,259,RC,00093-9018-65,NDC,outpatient,1,UN,1.84,1.288,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CYCLOSPORINE MODIFIED 100 MG ORAL CAPS,RX-28843,CDM,S5000,HCPCS,259,RC,00078-0248-61,NDC,outpatient,1,UN,46.19,32.333,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CYCLOSPORINE MODIFIED 100 MG ORAL CAPS,RX-28843,CDM,S5000,HCPCS,259,RC,00078-0248-15,NDC,outpatient,1,UN,46.19,32.333,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CYCLOSPORINE MODIFIED 100 MG/ML ORAL SOLN,RX-28844,CDM,S5000,HCPCS,259,RC,00172-7313-20,NDC,outpatient,50,ML,396.5,277.55,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ERYTHROMYCIN 2 % EX SOLN,RX-2887,CDM,S5000,HCPCS,259,RC,45802-0038-46,NDC,outpatient,60,ML,71.56,50.092,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ERYTHROMYCIN 5 MG/GM OP OINT,RX-2888,CDM,S5000,HCPCS,259,RC,24208-0910-19,NDC,outpatient,1,GR,31.03,21.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ERYTHROMYCIN 5 MG/GM OP OINT,RX-2888,CDM,S5000,HCPCS,259,RC,00574-4024-11,NDC,outpatient,1,GR,31.37,21.959,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ERYTHROMYCIN 5 MG/GM OP OINT,RX-2888,CDM,S5000,HCPCS,259,RC,00574-4024-50,NDC,outpatient,1,GR,31.37,21.959,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ERYTHROMYCIN 5 MG/GM OP OINT,RX-2888,CDM,S5000,HCPCS,259,RC,48102-0057-11,NDC,outpatient,1,GR,40.3,28.21,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,00406-8515-62,NDC,outpatient,1,UN,2.43,1.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,68084-0975-11,NDC,outpatient,1,UN,4.25,2.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,68094-0005-59,NDC,outpatient,1,UN,2.33,1.631,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,68084-0975-01,NDC,outpatient,1,UN,4.25,2.975,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,00406-8515-23,NDC,outpatient,1,UN,2.43,1.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,68094-0005-61,NDC,outpatient,1,UN,2.33,1.631,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ERYTHROMYCIN BASE 250 MG ORAL TBEC,RX-2891,CDM,S5000,HCPCS,259,RC,24338-0122-03,NDC,outpatient,1,UN,24.57,17.199,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ERYTHROMYCIN BASE 250 MG ORAL TBEC,RX-2891,CDM,S5000,HCPCS,259,RC,13668-0586-30,NDC,outpatient,1,UN,21.71,15.197,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NA HYALUR & NA CHOND-NA HYALUR 0.4-0.35 ML IO KIT,RX-28916,CDM,S5000,HCPCS,250,RC,08065-1831-35,NDC,outpatient,0.75,ML,867.31,607.117,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVOFLOXACIN 750 MG ORAL TABS,RX-28964,CDM,S5000,HCPCS,259,RC,00904-6353-61,NDC,outpatient,1,UN,2.17,1.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5ML ORAL SUSR,RX-2899,CDM,S5000,HCPCS,259,RC,75834-0295-01,NDC,outpatient,100,ML,494.4,346.08,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5ML ORAL SUSR,RX-2899,CDM,S5000,HCPCS,259,RC,24338-0134-02,NDC,outpatient,100,ML,1005.7,703.99,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5ML ORAL SUSR,RX-2899,CDM,S5000,HCPCS,259,RC,99999-0002-77,NDC,outpatient,5,ML,50.87,35.609,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METFORMIN HCL ER 500 MG ORAL TB24,RX-28995,CDM,S5000,HCPCS,259,RC,70010-0491-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METFORMIN HCL ER 500 MG ORAL TB24,RX-28995,CDM,S5000,HCPCS,259,RC,51224-0007-50,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALENDRONATE SODIUM 70 MG ORAL TABS,RX-29048,CDM,S5000,HCPCS,259,RC,16714-0633-01,NDC,outpatient,1,UN,2.67,1.869,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALENDRONATE SODIUM 35 MG ORAL TABS,RX-29072,CDM,S5000,HCPCS,259,RC,16714-0632-01,NDC,outpatient,1,UN,5.43,3.801,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,42192-0608-40,NDC,outpatient,6,ML,15.62,10.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,59762-5050-06,NDC,outpatient,6,ML,2.26,1.582,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,65162-0698-90,NDC,outpatient,473,ML,168.39,117.873,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,42192-0608-16,NDC,outpatient,470,ML,144.32,101.024,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,59762-5050-07,NDC,outpatient,470,ML,154.78,108.346,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,99999-0003-42,NDC,outpatient,6,ML,2.43,1.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,42192-0608-06,NDC,outpatient,6,ML,15.62,10.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,65162-0698-06,NDC,outpatient,6,ML,2.47,1.729,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DILTIAZEM HCL ER COATED BEADS 120 MG ORAL CP24,RX-29270,CDM,S5000,HCPCS,259,RC,60687-0195-01,NDC,outpatient,1,UN,1.87,1.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DILTIAZEM HCL ER COATED BEADS 120 MG ORAL CP24,RX-29270,CDM,S5000,HCPCS,259,RC,60687-0195-11,NDC,outpatient,1,UN,1.87,1.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DILTIAZEM HCL ER COATED BEADS 120 MG ORAL CP24,RX-29270,CDM,S5000,HCPCS,259,RC,68682-0993-98,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DILTIAZEM HCL ER COATED BEADS 120 MG ORAL CP24,RX-29270,CDM,S5000,HCPCS,259,RC,50742-0248-30,NDC,outpatient,1,UN,1.44,1.008,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DILTIAZEM HCL ER COATED BEADS 120 MG ORAL CP24,RX-29270,CDM,S5000,HCPCS,259,RC,50742-0248-90,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DILTIAZEM HCL ER COATED BEADS 180 MG ORAL CP24,RX-29272,CDM,S5000,HCPCS,259,RC,00904-7218-61,NDC,outpatient,1,UN,1.28,0.896,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DILTIAZEM HCL ER COATED BEADS 180 MG ORAL CP24,RX-29272,CDM,S5000,HCPCS,259,RC,60687-0206-01,NDC,outpatient,1,UN,1.65,1.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DILTIAZEM HCL ER COATED BEADS 180 MG ORAL CP24,RX-29272,CDM,S5000,HCPCS,259,RC,62037-0598-90,NDC,outpatient,1,UN,2.27,1.589,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DILTIAZEM HCL ER COATED BEADS 180 MG ORAL CP24,RX-29272,CDM,S5000,HCPCS,259,RC,60687-0206-11,NDC,outpatient,1,UN,1.65,1.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DILTIAZEM HCL ER COATED BEADS 240 MG ORAL CP24,RX-29274,CDM,S5000,HCPCS,259,RC,60687-0217-01,NDC,outpatient,1,UN,2.46,1.722,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DILTIAZEM HCL ER COATED BEADS 240 MG ORAL CP24,RX-29274,CDM,S5000,HCPCS,259,RC,00904-7219-61,NDC,outpatient,1,UN,1.59,1.113,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DILTIAZEM HCL ER COATED BEADS 240 MG ORAL CP24,RX-29274,CDM,S5000,HCPCS,259,RC,60687-0217-11,NDC,outpatient,1,UN,2.46,1.722,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DILTIAZEM HCL ER COATED BEADS 300 MG ORAL CP24,RX-29276,CDM,S5000,HCPCS,259,RC,24979-0029-07,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DILTIAZEM HCL ER COATED BEADS 300 MG ORAL CP24,RX-29276,CDM,S5000,HCPCS,259,RC,60687-0228-11,NDC,outpatient,1,UN,6.23,4.361,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DILTIAZEM HCL ER COATED BEADS 300 MG ORAL CP24,RX-29276,CDM,S5000,HCPCS,259,RC,60687-0228-01,NDC,outpatient,1,UN,6.23,4.361,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOCOSANOL 10 % EX CREA,RX-29287,CDM,S5000,HCPCS,259,RC,00135-0300-01,NDC,outpatient,2,GR,72.76,50.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,50268-0102-11,NDC,outpatient,1,UN,5.8,4.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,72789-0149-69,NDC,outpatient,1,UN,1.89,1.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,00054-0079-28,NDC,outpatient,1,UN,1.72,1.204,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,50268-0102-13,NDC,outpatient,1,UN,5.8,4.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,65649-0101-02,NDC,outpatient,1,UN,26.86,18.802,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,60505-2575-07,NDC,outpatient,1,UN,1.09,0.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % EX CREA,RX-29424,CDM,S5000,HCPCS,259,RC,16714-0496-01,NDC,outpatient,15,GR,55.61,38.927,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % EX CREA,RX-29424,CDM,S5000,HCPCS,259,RC,00168-0258-15,NDC,outpatient,15,GR,71.29,49.903,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NATEGLINIDE 60 MG ORAL TABS,RX-29437,CDM,S5000,HCPCS,259,RC,60687-0673-21,NDC,outpatient,1,UN,7.98,5.586,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NATEGLINIDE 60 MG ORAL TABS,RX-29437,CDM,S5000,HCPCS,259,RC,60687-0673-11,NDC,outpatient,1,UN,7.98,5.586,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MIRTAZAPINE 15 MG ORAL TBDP,RX-29531,CDM,S5000,HCPCS,259,RC,65862-0021-06,NDC,outpatient,1,UN,1.96,1.372,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ZIPRASIDONE HCL 20 MG ORAL CAPS,RX-29778,CDM,S5000,HCPCS,259,RC,00904-6269-08,NDC,outpatient,1,UN,11.99,8.393,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ZIPRASIDONE HCL 60 MG ORAL CAPS,RX-29780,CDM,S5000,HCPCS,259,RC,50268-0813-12,NDC,outpatient,1,UN,7.96,5.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ZIPRASIDONE HCL 60 MG ORAL CAPS,RX-29780,CDM,S5000,HCPCS,259,RC,68084-0105-09,NDC,outpatient,1,UN,7.81,5.467,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ZIPRASIDONE HCL 60 MG ORAL CAPS,RX-29780,CDM,S5000,HCPCS,259,RC,68084-0105-11,NDC,outpatient,1,UN,7.81,5.467,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ZIPRASIDONE HCL 60 MG ORAL CAPS,RX-29780,CDM,S5000,HCPCS,259,RC,50268-0813-11,NDC,outpatient,1,UN,7.96,5.572,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ZIPRASIDONE HCL 80 MG ORAL CAPS,RX-29781,CDM,S5000,HCPCS,259,RC,00781-2168-60,NDC,outpatient,1,UN,1.24,0.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ZIPRASIDONE HCL 80 MG ORAL CAPS,RX-29781,CDM,S5000,HCPCS,259,RC,68084-0106-09,NDC,outpatient,1,UN,7.81,5.467,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ZIPRASIDONE HCL 80 MG ORAL CAPS,RX-29781,CDM,S5000,HCPCS,259,RC,68084-0106-11,NDC,outpatient,1,UN,7.81,5.467,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GALANTAMINE HYDROBROMIDE 4 MG ORAL TABS,RX-29806,CDM,S5000,HCPCS,259,RC,68084-0729-11,NDC,outpatient,1,UN,14.03,9.821,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GALANTAMINE HYDROBROMIDE 4 MG ORAL TABS,RX-29806,CDM,S5000,HCPCS,259,RC,68084-0729-21,NDC,outpatient,1,UN,14.03,9.821,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GALANTAMINE HYDROBROMIDE 4 MG ORAL TABS,RX-29806,CDM,S5000,HCPCS,259,RC,70436-0004-06,NDC,outpatient,1,UN,1.21,0.847,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,00904-6322-61,NDC,outpatient,1,UN,2.19,1.533,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,45963-0709-11,NDC,outpatient,1,UN,1.28,0.896,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,51079-0169-01,NDC,outpatient,1,UN,2.11,1.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,51079-0169-20,NDC,outpatient,1,UN,2.11,1.477,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,00904-6322-06,NDC,outpatient,1,UN,1.21,0.847,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,50742-0615-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
EYE STREAM OP SOLN,RX-2999,CDM,S5000,HCPCS,259,RC,00065-0530-01,NDC,outpatient,30,ML,81.97,57.379,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METOPROLOL SUCCINATE ER 50 MG ORAL TAB,RX-30070,CDM,S5000,HCPCS,259,RC,50742-0616-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METOPROLOL SUCCINATE ER 50 MG ORAL TAB,RX-30070,CDM,S5000,HCPCS,259,RC,51079-0170-01,NDC,outpatient,1,UN,1.9,1.33,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METOPROLOL SUCCINATE ER 50 MG ORAL TAB,RX-30070,CDM,S5000,HCPCS,259,RC,68382-0565-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METOPROLOL SUCCINATE ER 50 MG ORAL TAB,RX-30070,CDM,S5000,HCPCS,259,RC,00904-6323-61,NDC,outpatient,1,UN,2.29,1.603,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METOPROLOL SUCCINATE ER 50 MG ORAL TAB,RX-30070,CDM,S5000,HCPCS,259,RC,51079-0170-20,NDC,outpatient,1,UN,1.9,1.33,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,50268-0542-11,NDC,outpatient,1,UN,2.35,1.645,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,51079-0171-01,NDC,outpatient,1,UN,5.81,4.067,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,51079-0171-03,NDC,outpatient,1,UN,5.81,4.067,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,60687-0413-11,NDC,outpatient,1,UN,3.08,2.156,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,50268-0542-15,NDC,outpatient,1,UN,2.35,1.645,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,60687-0413-01,NDC,outpatient,1,UN,3.08,2.156,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,00904-6324-61,NDC,outpatient,1,UN,2.66,1.862,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VALGANCICLOVIR HCL 450 MG ORAL TABS,RX-30148,CDM,S5000,HCPCS,259,RC,68084-0965-25,NDC,outpatient,1,UN,121.31,84.917,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VALGANCICLOVIR HCL 450 MG ORAL TABS,RX-30148,CDM,S5000,HCPCS,259,RC,68084-0965-95,NDC,outpatient,1,UN,121.31,84.917,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VALGANCICLOVIR HCL 450 MG ORAL TABS,RX-30148,CDM,S5000,HCPCS,259,RC,63739-0357-33,NDC,outpatient,1,UN,93.6,65.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CITALOPRAM HYDROBROMIDE 10 MG ORAL TABS,RX-30264,CDM,S5000,HCPCS,259,RC,00904-6084-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXCARBAZEPINE 300 MG/5ML ORAL SUSP,RX-30479,CDM,S5000,HCPCS,259,RC,68094-0123-62,NDC,outpatient,5,ML,23.66,16.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXCARBAZEPINE 300 MG/5ML ORAL SUSP,RX-30479,CDM,S5000,HCPCS,259,RC,68094-0123-59,NDC,outpatient,5,ML,23.66,16.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXCARBAZEPINE 300 MG/5ML ORAL SUSP,RX-30479,CDM,S5000,HCPCS,259,RC,99999-0002-25,NDC,outpatient,5,ML,33.09,23.163,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXCARBAZEPINE 300 MG/5ML ORAL SUSP,RX-30479,CDM,S5000,HCPCS,259,RC,00078-0357-52,NDC,outpatient,5,ML,39.3,27.51,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MELATONIN 5 MG SL SUBL,RX-30511,CDM,S5000,HCPCS,259,RC,54629-0615-00,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FERROUS SULFATE 325 (65 FE) MG ORAL TABS,RX-3074,CDM,S5000,HCPCS,259,RC,00904-7591-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FERROUS SULFATE 325 (65 FE) MG ORAL TABS,RX-3074,CDM,S5000,HCPCS,259,RC,00904-7590-60,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FERROUS SULFATE 325 (65 FE) MG ORAL TABS,RX-3074,CDM,S5000,HCPCS,259,RC,20555-0021-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,00904-7041-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,51079-0205-20,NDC,outpatient,1,UN,1.23,0.861,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,55111-0729-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,60687-0677-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,16714-0576-02,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,51079-0205-01,NDC,outpatient,1,UN,1.23,0.861,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,60687-0677-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALLOPURINOL 300 MG ORAL TABS,RX-311,CDM,S5000,HCPCS,259,RC,51079-0206-01,NDC,outpatient,1,UN,1.68,1.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALLOPURINOL 300 MG ORAL TABS,RX-311,CDM,S5000,HCPCS,259,RC,00904-6572-61,NDC,outpatient,1,UN,1.71,1.197,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALLOPURINOL 300 MG ORAL TABS,RX-311,CDM,S5000,HCPCS,259,RC,51079-0206-20,NDC,outpatient,1,UN,1.68,1.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FISH OIL 1000 MG ORAL CAPS,RX-3113,CDM,S5000,HCPCS,259,RC,77333-0308-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FISH OIL 1000 MG ORAL CAPS,RX-3113,CDM,S5000,HCPCS,259,RC,77333-0308-25,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMOXICILLIN-POT CLAVULANATE 600-42.9 MG/5ML ORAL SUSR,RX-31177,CDM,S5000,HCPCS,259,RC,99999-0002-82,NDC,outpatient,5,ML,8.55,5.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMOXICILLIN-POT CLAVULANATE 600-42.9 MG/5ML ORAL SUSR,RX-31177,CDM,S5000,HCPCS,259,RC,00143-9853-75,NDC,outpatient,75,ML,63.42,44.394,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VALSARTAN 160 MG ORAL TABS,RX-31210,CDM,S5000,HCPCS,259,RC,60687-0634-01,NDC,outpatient,1,UN,4.62,3.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VALSARTAN 160 MG ORAL TABS,RX-31210,CDM,S5000,HCPCS,259,RC,31722-0153-90,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VALSARTAN 160 MG ORAL TABS,RX-31210,CDM,S5000,HCPCS,259,RC,33342-0064-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VALSARTAN 160 MG ORAL TABS,RX-31210,CDM,S5000,HCPCS,259,RC,60687-0634-11,NDC,outpatient,1,UN,4.62,3.234,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUDESONIDE 3 MG ORAL CPEP,RX-31576,CDM,S5000,HCPCS,259,RC,00574-9855-10,NDC,outpatient,1,UN,2.52,1.764,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUDESONIDE 3 MG ORAL CPEP,RX-31576,CDM,S5000,HCPCS,259,RC,65162-0778-10,NDC,outpatient,1,UN,2.47,1.729,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALBUTEROL SULFATE 0.63 MG/3ML IN NEBU,RX-31577,CDM,S5000,HCPCS,259,RC,76204-0010-55,NDC,outpatient,3,ML,1.98,1.386,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALBUTEROL SULFATE 0.63 MG/3ML IN NEBU,RX-31577,CDM,S5000,HCPCS,259,RC,00487-0301-01,NDC,outpatient,3,ML,2.43,1.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALBUTEROL SULFATE 1.25 MG/3ML IN NEBU,RX-31578,CDM,S5000,HCPCS,259,RC,00487-9904-01,NDC,outpatient,3,ML,2.43,1.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALBUTEROL SULFATE 1.25 MG/3ML IN NEBU,RX-31578,CDM,S5000,HCPCS,259,RC,00487-9904-25,NDC,outpatient,3,ML,2.43,1.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMPHETAMINE-DEXTROAMPHET ER 10 MG ORAL CP24,RX-31587,CDM,S5000,HCPCS,259,RC,70010-0030-01,NDC,outpatient,1,UN,3.45,2.415,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMPHETAMINE-DEXTROAMPHET ER 10 MG ORAL CP24,RX-31587,CDM,S5000,HCPCS,259,RC,00228-3059-11,NDC,outpatient,1,UN,12.55,8.785,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMPHETAMINE-DEXTROAMPHET ER 10 MG ORAL CP24,RX-31587,CDM,S5000,HCPCS,259,RC,64850-0511-01,NDC,outpatient,1,UN,2,1.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
UREA 40 % EX LOTN,RX-31683,CDM,S5000,HCPCS,259,RC,81542-0201-08,NDC,outpatient,226.8,GR,454.17,317.919,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
UREA 40 % EX LOTN,RX-31683,CDM,S5000,HCPCS,259,RC,54295-0312-18,NDC,outpatient,226.8,GR,419.86,293.902,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TENOFOVIR DISOPROXIL FUMARATE 300 MG ORAL TABS,RX-31684,CDM,S5000,HCPCS,259,RC,61958-0401-01,NDC,outpatient,1,UN,180.36,126.252,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLUOCINONIDE 0.05 % EX CREA,RX-3187,CDM,S5000,HCPCS,259,RC,00093-0262-15,NDC,outpatient,15,GR,162.14,113.498,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLUOCINONIDE 0.05 % EX CREA,RX-3187,CDM,S5000,HCPCS,259,RC,51672-1386-01,NDC,outpatient,15,GR,35.32,24.724,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLUOCINONIDE 0.05 % EX OINT,RX-3189,CDM,S5000,HCPCS,259,RC,51672-1264-01,NDC,outpatient,15,GR,55.01,38.507,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLUOCINONIDE 0.05 % EX SOLN,RX-3190,CDM,S5000,HCPCS,259,RC,51672-1273-02,NDC,outpatient,20,ML,137.87,96.509,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLUOROMETHOLONE 0.1 % OP SUSP,RX-3208,CDM,S5000,HCPCS,259,RC,60758-0880-05,NDC,outpatient,5,ML,308.83,216.181,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLUPHENAZINE HCL 1 MG ORAL TABS,RX-3218,CDM,S5000,HCPCS,259,RC,00527-1788-01,NDC,outpatient,1,UN,6.6,4.62,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLUPHENAZINE HCL 2.5 MG ORAL TABS,RX-3220,CDM,S5000,HCPCS,259,RC,70954-0274-10,NDC,outpatient,1,UN,2.47,1.729,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLUPHENAZINE HCL 2.5 MG ORAL TABS,RX-3220,CDM,S5000,HCPCS,259,RC,00527-1789-01,NDC,outpatient,1,UN,10.2,7.14,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLUPHENAZINE HCL 5 MG ORAL TABS,RX-3221,CDM,S5000,HCPCS,259,RC,69238-1680-01,NDC,outpatient,1,UN,6.45,4.515,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLUPHENAZINE HCL 5 MG ORAL TABS,RX-3221,CDM,S5000,HCPCS,259,RC,00527-1790-01,NDC,outpatient,1,UN,13.8,9.66,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FOLIC ACID 5 MG/ML IJ SOLN,RX-3232,CDM,S5000,HCPCS,250,RC,39822-1100-01,NDC,outpatient,0.2,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FOLIC ACID 5 MG/ML IJ SOLN,RX-3232,CDM,S5000,HCPCS,250,RC,63323-0184-10,NDC,outpatient,0.2,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FOLIC ACID 1 MG ORAL TABS,RX-3233,CDM,S5000,HCPCS,259,RC,00904-7224-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FOLIC ACID 1 MG ORAL TABS,RX-3233,CDM,S5000,HCPCS,259,RC,60687-0681-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FOLIC ACID 1 MG ORAL TABS,RX-3233,CDM,S5000,HCPCS,259,RC,60687-0681-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALPRAZOLAM 0.25 MG ORAL TABS,RX-324,CDM,S5000,HCPCS,259,RC,65862-0676-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALPRAZOLAM 0.25 MG ORAL TABS,RX-324,CDM,S5000,HCPCS,259,RC,00781-1061-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALPRAZOLAM 0.5 MG ORAL TABS,RX-325,CDM,S5000,HCPCS,259,RC,00781-1077-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PAROXETINE HCL ER 12.5 MG ORAL TB24,RX-32631,CDM,S5000,HCPCS,259,RC,62175-0470-32,NDC,outpatient,1,UN,4.97,3.479,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METHYLPHENIDATE HCL ER (OSM) 27 MG ORAL TBCR,RX-32654,CDM,S5000,HCPCS,259,RC,13811-0707-10,NDC,outpatient,1,UN,3.33,2.331,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OLMESARTAN MEDOXOMIL 20 MG ORAL TABS,RX-32762,CDM,S5000,HCPCS,259,RC,00713-0861-30,NDC,outpatient,1,UN,39.98,27.986,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OLMESARTAN MEDOXOMIL 20 MG ORAL TABS,RX-32762,CDM,S5000,HCPCS,259,RC,68462-0437-30,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OLMESARTAN MEDOXOMIL 20 MG ORAL TABS,RX-32762,CDM,S5000,HCPCS,259,RC,33342-0179-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RISEDRONATE SODIUM 35 MG ORAL TABS,RX-32895,CDM,S5000,HCPCS,259,RC,33342-0109-50,NDC,outpatient,1,UN,18.52,12.964,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FUROSEMIDE 10 MG/ML ORAL SOLN,RX-3292,CDM,S5000,HCPCS,259,RC,68094-0756-59,NDC,outpatient,4,ML,7.04,4.928,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FUROSEMIDE 10 MG/ML ORAL SOLN,RX-3292,CDM,S5000,HCPCS,259,RC,68094-0756-62,NDC,outpatient,4,ML,7.04,4.928,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FUROSEMIDE 8 MG/ML ORAL SOLN,RX-3293,CDM,S5000,HCPCS,259,RC,68094-0867-59,NDC,outpatient,5,ML,7.04,4.928,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FUROSEMIDE 8 MG/ML ORAL SOLN,RX-3293,CDM,S5000,HCPCS,259,RC,68094-0867-62,NDC,outpatient,5,ML,7.04,4.928,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FUROSEMIDE 20 MG ORAL TABS,RX-3294,CDM,S5000,HCPCS,259,RC,00904-7177-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FUROSEMIDE 20 MG ORAL TABS,RX-3294,CDM,S5000,HCPCS,259,RC,00054-8297-25,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FUROSEMIDE 40 MG ORAL TABS,RX-3295,CDM,S5000,HCPCS,259,RC,51079-0073-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FUROSEMIDE 40 MG ORAL TABS,RX-3295,CDM,S5000,HCPCS,259,RC,51079-0073-20,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FUROSEMIDE 80 MG ORAL TABS,RX-3296,CDM,S5000,HCPCS,259,RC,00054-8301-25,NDC,outpatient,1,UN,2.07,1.449,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FUROSEMIDE 80 MG ORAL TABS,RX-3296,CDM,S5000,HCPCS,259,RC,51079-0527-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FUROSEMIDE 80 MG ORAL TABS,RX-3296,CDM,S5000,HCPCS,259,RC,51079-0527-20,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMPHETAMINE-DEXTROAMPHET ER 5 MG ORAL CP24,RX-33005,CDM,S5000,HCPCS,259,RC,54092-0381-01,NDC,outpatient,1,UN,29.29,20.503,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VORICONAZOLE 200 MG ORAL TABS,RX-33009,CDM,S5000,HCPCS,259,RC,00904-7024-04,NDC,outpatient,1,UN,43.81,30.667,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMOXICILLIN-POT CLAVULANATE 500-125 MG ORAL TABS,RX-33227,CDM,S5000,HCPCS,259,RC,00781-1831-01,NDC,outpatient,1,UN,1.59,1.113,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMOXICILLIN-POT CLAVULANATE 875-125 MG ORAL TABS,RX-33228,CDM,S5000,HCPCS,259,RC,42571-0162-01,NDC,outpatient,1,UN,2.67,1.869,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMOXICILLIN-POT CLAVULANATE 875-125 MG ORAL TABS,RX-33228,CDM,S5000,HCPCS,259,RC,00143-9249-20,NDC,outpatient,1,UN,5.26,3.682,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMOXICILLIN-POT CLAVULANATE 875-125 MG ORAL TABS,RX-33228,CDM,S5000,HCPCS,259,RC,65862-0503-01,NDC,outpatient,1,UN,2.34,1.638,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMOXICILLIN-POT CLAVULANATE 875-125 MG ORAL TABS,RX-33228,CDM,S5000,HCPCS,259,RC,65862-0503-20,NDC,outpatient,1,UN,1.87,1.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ESCITALOPRAM OXALATE 10 MG ORAL TABS,RX-33512,CDM,S5000,HCPCS,259,RC,00904-6426-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ESCITALOPRAM OXALATE 10 MG ORAL TABS,RX-33512,CDM,S5000,HCPCS,259,RC,68084-0617-11,NDC,outpatient,1,UN,1.04,0.728,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ESCITALOPRAM OXALATE 10 MG ORAL TABS,RX-33512,CDM,S5000,HCPCS,259,RC,68084-0617-01,NDC,outpatient,1,UN,1.04,0.728,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VALSARTAN 40 MG ORAL TABS,RX-33541,CDM,S5000,HCPCS,259,RC,60687-0612-21,NDC,outpatient,1,UN,3.18,2.226,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VALSARTAN 40 MG ORAL TABS,RX-33541,CDM,S5000,HCPCS,259,RC,31722-0151-30,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VALSARTAN 40 MG ORAL TABS,RX-33541,CDM,S5000,HCPCS,259,RC,60687-0612-11,NDC,outpatient,1,UN,3.18,2.226,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GEMFIBROZIL 600 MG ORAL TABS,RX-3378,CDM,S5000,HCPCS,259,RC,60687-0224-11,NDC,outpatient,1,UN,1.15,0.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GEMFIBROZIL 600 MG ORAL TABS,RX-3378,CDM,S5000,HCPCS,259,RC,60687-0224-01,NDC,outpatient,1,UN,1.15,0.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METAXALONE 800 MG ORAL TABS,RX-33963,CDM,S5000,HCPCS,259,RC,00527-1435-01,NDC,outpatient,1,UN,2.54,1.778,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DUTASTERIDE 0.5 MG ORAL CAPS,RX-34089,CDM,S5000,HCPCS,259,RC,42806-0549-09,NDC,outpatient,1,UN,1.7,1.19,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
EZETIMIBE 10 MG ORAL TABS,RX-34153,CDM,S5000,HCPCS,259,RC,60687-0373-11,NDC,outpatient,1,UN,18.75,13.125,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
EZETIMIBE 10 MG ORAL TABS,RX-34153,CDM,S5000,HCPCS,259,RC,00904-7103-04,NDC,outpatient,1,UN,18.36,12.852,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
EZETIMIBE 10 MG ORAL TABS,RX-34153,CDM,S5000,HCPCS,259,RC,51660-0200-90,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
EZETIMIBE 10 MG ORAL TABS,RX-34153,CDM,S5000,HCPCS,259,RC,60687-0373-21,NDC,outpatient,1,UN,18.75,13.125,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GENTAMICIN SULFATE 0.1 % EX CREA,RX-3423,CDM,S5000,HCPCS,259,RC,45802-0056-35,NDC,outpatient,15,GR,170.02,119.014,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GENTAMICIN SULFATE 0.1 % EX OINT,RX-3424,CDM,S5000,HCPCS,259,RC,45802-0046-35,NDC,outpatient,15,GR,132.44,92.708,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GENTAMICIN SULFATE 0.3 % OP SOLN,RX-3428,CDM,S5000,HCPCS,259,RC,24208-0580-60,NDC,outpatient,5,ML,23.41,16.387,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GENTAMICIN SULFATE 0.3 % OP SOLN,RX-3428,CDM,S5000,HCPCS,259,RC,61314-0633-05,NDC,outpatient,5,ML,21.99,15.393,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ARIPIPRAZOLE 10 MG ORAL TABS,RX-34369,CDM,S5000,HCPCS,259,RC,60687-0179-01,NDC,outpatient,1,UN,22.5,15.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ARIPIPRAZOLE 10 MG ORAL TABS,RX-34369,CDM,S5000,HCPCS,259,RC,60687-0179-11,NDC,outpatient,1,UN,22.5,15.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ARIPIPRAZOLE 15 MG ORAL TABS,RX-34370,CDM,S5000,HCPCS,259,RC,60687-0191-11,NDC,outpatient,1,UN,27.24,19.068,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ARIPIPRAZOLE 15 MG ORAL TABS,RX-34370,CDM,S5000,HCPCS,259,RC,60687-0191-21,NDC,outpatient,1,UN,27.24,19.068,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ARIPIPRAZOLE 15 MG ORAL TABS,RX-34370,CDM,S5000,HCPCS,259,RC,27241-0054-03,NDC,outpatient,1,UN,2.88,2.016,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ARIPIPRAZOLE 15 MG ORAL TABS,RX-34370,CDM,S5000,HCPCS,259,RC,63739-0078-33,NDC,outpatient,1,UN,22.38,15.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DIVALPROEX SODIUM ER 250 MG ORAL TB24,RX-34418,CDM,S5000,HCPCS,259,RC,68084-0310-01,NDC,outpatient,1,UN,2.75,1.925,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DIVALPROEX SODIUM ER 250 MG ORAL TB24,RX-34418,CDM,S5000,HCPCS,259,RC,68084-0310-11,NDC,outpatient,1,UN,2.75,1.925,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ATOMOXETINE HCL 10 MG ORAL CAPS,RX-34444,CDM,S5000,HCPCS,259,RC,35573-0415-30,NDC,outpatient,1,UN,14,9.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ATOMOXETINE HCL 10 MG ORAL CAPS,RX-34444,CDM,S5000,HCPCS,259,RC,55111-0519-30,NDC,outpatient,1,UN,7.25,5.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ATOMOXETINE HCL 10 MG ORAL CAPS,RX-34444,CDM,S5000,HCPCS,259,RC,68462-0265-30,NDC,outpatient,1,UN,4.5,3.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ATOMOXETINE HCL 10 MG ORAL CAPS,RX-34444,CDM,S5000,HCPCS,259,RC,31722-0714-30,NDC,outpatient,1,UN,8.16,5.712,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ATOMOXETINE HCL 25 MG ORAL CAPS,RX-34446,CDM,S5000,HCPCS,259,RC,16714-0757-01,NDC,outpatient,1,UN,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ATOMOXETINE HCL 25 MG ORAL CAPS,RX-34446,CDM,S5000,HCPCS,259,RC,64980-0375-03,NDC,outpatient,1,UN,7.25,5.075,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ATOMOXETINE HCL 40 MG ORAL CAPS,RX-34447,CDM,S5000,HCPCS,259,RC,60687-0326-95,NDC,outpatient,1,UN,14.68,10.276,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ATOMOXETINE HCL 40 MG ORAL CAPS,RX-34447,CDM,S5000,HCPCS,259,RC,68462-0268-30,NDC,outpatient,1,UN,2.91,2.037,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ATOMOXETINE HCL 40 MG ORAL CAPS,RX-34447,CDM,S5000,HCPCS,259,RC,00093-3545-56,NDC,outpatient,1,UN,17.9,12.53,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ATOMOXETINE HCL 40 MG ORAL CAPS,RX-34447,CDM,S5000,HCPCS,259,RC,60687-0326-25,NDC,outpatient,1,UN,14.68,10.276,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROCODONE-ACETAMINOPHEN 5-325 MG ORAL TABS,RX-34505,CDM,S5000,HCPCS,259,RC,00406-0123-23,NDC,outpatient,1,UN,1.5,1.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROCODONE-ACETAMINOPHEN 5-325 MG ORAL TABS,RX-34505,CDM,S5000,HCPCS,259,RC,00406-0123-62,NDC,outpatient,1,UN,1.5,1.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROCODONE-ACETAMINOPHEN 5-325 MG ORAL TABS,RX-34505,CDM,S5000,HCPCS,259,RC,00406-0123-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPRENORPHINE HCL 2 MG SL SUBL,RX-34711,CDM,S5000,HCPCS,259,RC,60687-0481-11,NDC,outpatient,1,UN,6.96,4.872,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPRENORPHINE HCL 2 MG SL SUBL,RX-34711,CDM,S5000,HCPCS,259,RC,60687-0481-21,NDC,outpatient,1,UN,6.96,4.872,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPRENORPHINE HCL 8 MG SL SUBL,RX-34712,CDM,S5000,HCPCS,259,RC,60687-0492-11,NDC,outpatient,1,UN,11.98,8.386,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPRENORPHINE HCL 8 MG SL SUBL,RX-34712,CDM,S5000,HCPCS,259,RC,60687-0492-21,NDC,outpatient,1,UN,11.98,8.386,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPRENORPHINE HCL 8 MG SL SUBL,RX-34712,CDM,S5000,HCPCS,259,RC,42858-0502-03,NDC,outpatient,1,UN,2.47,1.729,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPRENORPHINE HCL-NALOXONE HCL 2-0.5 MG SL SUBL,RX-34713,CDM,S5000,HCPCS,259,RC,00054-0188-13,NDC,outpatient,1,UN,2.47,1.729,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPRENORPHINE HCL-NALOXONE HCL 2-0.5 MG SL SUBL,RX-34713,CDM,S5000,HCPCS,259,RC,65162-0416-03,NDC,outpatient,1,UN,2.45,1.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPRENORPHINE HCL-NALOXONE HCL 8-2 MG SL SUBL,RX-34714,CDM,S5000,HCPCS,259,RC,42858-0602-03,NDC,outpatient,1,UN,27,18.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPRENORPHINE HCL-NALOXONE HCL 8-2 MG SL SUBL,RX-34714,CDM,S5000,HCPCS,259,RC,50268-0145-11,NDC,outpatient,1,UN,14.96,10.472,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPRENORPHINE HCL-NALOXONE HCL 8-2 MG SL SUBL,RX-34714,CDM,S5000,HCPCS,259,RC,50268-0145-15,NDC,outpatient,1,UN,14.96,10.472,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SOLN,RX-34814,CDM,S5000,HCPCS,259,RC,24208-0631-10,NDC,outpatient,10,ML,205.06,143.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SOLN,RX-34814,CDM,S5000,HCPCS,259,RC,61314-0646-10,NDC,outpatient,10,ML,188.28,131.796,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ROSUVASTATIN CALCIUM 10 MG ORAL TABS,RX-35134,CDM,S5000,HCPCS,259,RC,00904-6779-61,NDC,outpatient,1,UN,3.97,2.779,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ROSUVASTATIN CALCIUM 10 MG ORAL TABS,RX-35134,CDM,S5000,HCPCS,259,RC,60687-0245-01,NDC,outpatient,1,UN,4.01,2.807,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ROSUVASTATIN CALCIUM 10 MG ORAL TABS,RX-35134,CDM,S5000,HCPCS,259,RC,60687-0245-11,NDC,outpatient,1,UN,4.01,2.807,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,60687-0256-01,NDC,outpatient,1,UN,5.36,3.752,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,60687-0256-11,NDC,outpatient,1,UN,5.36,3.752,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,50268-0710-11,NDC,outpatient,1,UN,2.29,1.603,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,50268-0710-15,NDC,outpatient,1,UN,2.29,1.603,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,16714-0990-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,00904-6780-61,NDC,outpatient,1,UN,3.57,2.499,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CYCLOSPORINE 0.05 % OP EMUL,RX-35209,CDM,S5000,HCPCS,259,RC,00023-9163-30,NDC,outpatient,1,UN,44.22,30.954,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALUMINUM HYDROXIDE GEL 320 MG/5ML ORAL SUSP,RX-353,CDM,S5000,HCPCS,259,RC,00536-0091-85,NDC,outpatient,5,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALUMINUM HYDROXIDE GEL 320 MG/5ML ORAL SUSP,RX-353,CDM,S5000,HCPCS,259,RC,99999-0002-48,NDC,outpatient,30,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GRISEOFULVIN ULTRAMICROSIZE 250 MG ORAL TABS,RX-3536,CDM,S5000,HCPCS,259,RC,00115-1725-01,NDC,outpatient,1,UN,20.98,14.686,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXYBUTYNIN 3.9 MG/24HR TD PTTW,RX-35495,CDM,S5000,HCPCS,259,RC,00023-9637-01,NDC,outpatient,1,UN,10.21,7.147,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXYBUTYNIN 3.9 MG/24HR TD PTTW,RX-35495,CDM,S5000,HCPCS,259,RC,00023-6153-08,NDC,outpatient,1,UN,349.43,244.601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXYBUTYNIN 3.9 MG/24HR TD PTTW,RX-35495,CDM,S5000,HCPCS,259,RC,00023-6153-01,NDC,outpatient,1,UN,349.43,244.601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXYBUTYNIN 3.9 MG/24HR TD PTTW,RX-35495,CDM,S5000,HCPCS,259,RC,00023-9637-08,NDC,outpatient,1,UN,10.21,7.147,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RISPERIDONE 0.5 MG ORAL TBDP,RX-35686,CDM,S5000,HCPCS,259,RC,49884-0311-52,NDC,outpatient,1,UN,2.41,1.687,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RISPERIDONE 0.5 MG ORAL TBDP,RX-35686,CDM,S5000,HCPCS,259,RC,49884-0311-55,NDC,outpatient,1,UN,2.41,1.687,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RISPERIDONE 1 MG ORAL TBDP,RX-35687,CDM,S5000,HCPCS,259,RC,49884-0315-52,NDC,outpatient,1,UN,2.77,1.939,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RISPERIDONE 1 MG ORAL TBDP,RX-35687,CDM,S5000,HCPCS,259,RC,49884-0315-55,NDC,outpatient,1,UN,2.77,1.939,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MOXIFLOXACIN HCL 0.5 % OP SOLN,RX-35699,CDM,S5000,HCPCS,259,RC,72266-0158-01,NDC,outpatient,3,ML,45.03,31.521,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MOXIFLOXACIN HCL 0.5 % OP SOLN,RX-35699,CDM,S5000,HCPCS,259,RC,00832-1410-03,NDC,outpatient,3,ML,113.88,79.716,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METFORMIN HCL ER 750 MG ORAL TB24,RX-35771,CDM,S5000,HCPCS,259,RC,62756-0143-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METFORMIN HCL ER 750 MG ORAL TB24,RX-35771,CDM,S5000,HCPCS,259,RC,67877-0414-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METFORMIN HCL ER 750 MG ORAL TB24,RX-35771,CDM,S5000,HCPCS,259,RC,70010-0492-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HALOPERIDOL 0.5 MG ORAL TABS,RX-3578,CDM,S5000,HCPCS,259,RC,51079-0733-20,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HALOPERIDOL 0.5 MG ORAL TABS,RX-3578,CDM,S5000,HCPCS,259,RC,51079-0733-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HALOPERIDOL 2 MG ORAL TABS,RX-3581,CDM,S5000,HCPCS,259,RC,00378-0214-01,NDC,outpatient,1,UN,2.45,1.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HALOPERIDOL 2 MG ORAL TABS,RX-3581,CDM,S5000,HCPCS,259,RC,00832-1530-11,NDC,outpatient,1,UN,1.81,1.267,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HALOPERIDOL 5 MG ORAL TABS,RX-3583,CDM,S5000,HCPCS,259,RC,51079-0736-20,NDC,outpatient,1,UN,1.41,0.987,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HALOPERIDOL 5 MG ORAL TABS,RX-3583,CDM,S5000,HCPCS,259,RC,51079-0736-01,NDC,outpatient,1,UN,1.41,0.987,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONC,RX-3585,CDM,S5000,HCPCS,259,RC,99999-0003-09,NDC,outpatient,0.5,ML,2.5,1.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONC,RX-3585,CDM,S5000,HCPCS,259,RC,54838-0501-15,NDC,outpatient,0.5,ML,2.5,1.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POTASSIUM CHLORIDE CRYS ER 10 MEQ ORAL TBCR,RX-35942,CDM,S5000,HCPCS,259,RC,00245-5317-01,NDC,outpatient,1,UN,1.08,0.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POTASSIUM CHLORIDE CRYS ER 10 MEQ ORAL TBCR,RX-35942,CDM,S5000,HCPCS,259,RC,63739-0972-10,NDC,outpatient,1,UN,1.14,0.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POTASSIUM CHLORIDE CRYS ER 10 MEQ ORAL TBCR,RX-35942,CDM,S5000,HCPCS,259,RC,00245-5317-89,NDC,outpatient,1,UN,1.08,0.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POTASSIUM CHLORIDE CRYS ER 20 MEQ ORAL TBCR,RX-35943,CDM,S5000,HCPCS,259,RC,00832-5325-11,NDC,outpatient,1,UN,1.25,0.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POTASSIUM CHLORIDE CRYS ER 20 MEQ ORAL TBCR,RX-35943,CDM,S5000,HCPCS,259,RC,00245-5319-01,NDC,outpatient,1,UN,1.25,0.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POTASSIUM CHLORIDE CRYS ER 20 MEQ ORAL TBCR,RX-35943,CDM,S5000,HCPCS,259,RC,00245-5319-89,NDC,outpatient,1,UN,1.25,0.875,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ATAZANAVIR SULFATE 150 MG ORAL CAPS,RX-36149,CDM,S5000,HCPCS,259,RC,42385-0920-60,NDC,outpatient,1,UN,11.33,7.931,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ATAZANAVIR SULFATE 200 MG ORAL CAPS,RX-36150,CDM,S5000,HCPCS,259,RC,65862-0712-60,NDC,outpatient,1,UN,13.22,9.254,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREMASOL 10 % IV SOLN,RX-36160,CDM,S5000,HCPCS,250,RC,00338-1130-03,NDC,outpatient,500,ML,98.33,68.831,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
EMTRICITABINE 200 MG ORAL CAPS,RX-36252,CDM,S5000,HCPCS,259,RC,61958-0601-01,NDC,outpatient,1,UN,77.2,54.04,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMANTADINE HCL 100 MG ORAL CAPS,RX-364,CDM,S5000,HCPCS,259,RC,50268-0069-15,NDC,outpatient,1,UN,4.75,3.325,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMANTADINE HCL 100 MG ORAL CAPS,RX-364,CDM,S5000,HCPCS,259,RC,50268-0069-11,NDC,outpatient,1,UN,4.75,3.325,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ARIPIPRAZOLE 5 MG ORAL TABS,RX-36438,CDM,S5000,HCPCS,259,RC,60687-0168-01,NDC,outpatient,1,UN,15.64,10.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ARIPIPRAZOLE 5 MG ORAL TABS,RX-36438,CDM,S5000,HCPCS,259,RC,60687-0168-11,NDC,outpatient,1,UN,15.64,10.948,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % OT SUSP,RX-36576,CDM,S5000,HCPCS,259,RC,62756-0427-90,NDC,outpatient,7.5,ML,336.96,235.872,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % OT SUSP,RX-36576,CDM,S5000,HCPCS,259,RC,16714-0628-01,NDC,outpatient,7.5,ML,422.83,295.981,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % OT SUSP,RX-36576,CDM,S5000,HCPCS,259,RC,43598-0326-75,NDC,outpatient,7.5,ML,438.69,307.083,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVETIRACETAM 100 MG/ML ORAL SOLN,RX-36590,CDM,S5000,HCPCS,259,RC,00121-4799-05,NDC,outpatient,5,ML,9.93,6.951,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVETIRACETAM 100 MG/ML ORAL SOLN,RX-36590,CDM,S5000,HCPCS,259,RC,60687-0249-40,NDC,outpatient,5,ML,12.02,8.414,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVETIRACETAM 100 MG/ML ORAL SOLN,RX-36590,CDM,S5000,HCPCS,259,RC,60687-0249-67,NDC,outpatient,5,ML,12.02,8.414,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVETIRACETAM 100 MG/ML ORAL SOLN,RX-36590,CDM,S5000,HCPCS,259,RC,00121-4799-40,NDC,outpatient,5,ML,9.93,6.951,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ROSUVASTATIN CALCIUM 5 MG ORAL TABS,RX-36612,CDM,S5000,HCPCS,259,RC,00904-6778-61,NDC,outpatient,1,UN,2.9,2.03,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
KETOROLAC TROMETHAMINE 0.4 % OP SOLN,RX-36631,CDM,S5000,HCPCS,259,RC,60758-0773-05,NDC,outpatient,5,ML,248.94,174.258,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPROPION HCL ER (XL) 150 MG ORAL TB24,RX-36775,CDM,S5000,HCPCS,259,RC,00904-7084-04,NDC,outpatient,1,UN,5.27,3.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPROPION HCL ER (XL) 150 MG ORAL TB24,RX-36775,CDM,S5000,HCPCS,259,RC,16729-0443-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPROPION HCL ER (XL) 150 MG ORAL TB24,RX-36775,CDM,S5000,HCPCS,259,RC,00904-7084-61,NDC,outpatient,1,UN,6.35,4.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOCUSATE SODIUM 50 MG/5ML ORAL LIQD,RX-36962,CDM,S5000,HCPCS,259,RC,00121-1870-00,NDC,outpatient,10,ML,6.46,4.522,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOCUSATE SODIUM 50 MG/5ML ORAL LIQD,RX-36962,CDM,S5000,HCPCS,259,RC,63739-0976-10,NDC,outpatient,10,ML,3.61,2.527,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOCUSATE SODIUM 50 MG/5ML ORAL LIQD,RX-36962,CDM,S5000,HCPCS,259,RC,99999-0001-96,NDC,outpatient,10,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOCUSATE SODIUM 50 MG/5ML ORAL LIQD,RX-36962,CDM,S5000,HCPCS,259,RC,63739-0976-01,NDC,outpatient,10,ML,3.61,2.527,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOCUSATE SODIUM 50 MG/5ML ORAL LIQD,RX-36962,CDM,S5000,HCPCS,259,RC,00121-1870-10,NDC,outpatient,10,ML,6.46,4.522,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
THEOPHYLLINE ER 400 MG ORAL TB24,RX-36973,CDM,S5000,HCPCS,259,RC,29033-0001-01,NDC,outpatient,1,UN,5.44,3.808,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
THEOPHYLLINE ER 400 MG ORAL TB24,RX-36973,CDM,S5000,HCPCS,259,RC,42858-0701-01,NDC,outpatient,1,UN,3.89,2.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PHENOL 1.4 % MT LIQD,RX-36976,CDM,S5000,HCPCS,259,RC,78112-0011-03,NDC,outpatient,177,ML,17.33,12.131,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PHENOL 1.4 % MT LIQD,RX-36976,CDM,S5000,HCPCS,259,RC,00904-6305-21,NDC,outpatient,177,ML,7.09,4.963,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PHENOL 1.4 % MT LIQD,RX-36976,CDM,S5000,HCPCS,259,RC,49348-0991-36,NDC,outpatient,177,ML,7.88,5.516,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDRALAZINE HCL 10 MG ORAL TABS,RX-3698,CDM,S5000,HCPCS,259,RC,51079-0074-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDRALAZINE HCL 10 MG ORAL TABS,RX-3698,CDM,S5000,HCPCS,259,RC,51079-0074-20,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALFUZOSIN HCL ER 10 MG ORAL TB24,RX-36982,CDM,S5000,HCPCS,259,RC,29300-0155-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALFUZOSIN HCL ER 10 MG ORAL TB24,RX-36982,CDM,S5000,HCPCS,259,RC,57237-0114-90,NDC,outpatient,1,UN,2,1.4,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
EPLERENONE 25 MG ORAL TABS,RX-36983,CDM,S5000,HCPCS,259,RC,60687-0451-21,NDC,outpatient,1,UN,18.55,12.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
EPLERENONE 25 MG ORAL TABS,RX-36983,CDM,S5000,HCPCS,259,RC,51991-0877-33,NDC,outpatient,1,UN,1.68,1.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
EPLERENONE 25 MG ORAL TABS,RX-36983,CDM,S5000,HCPCS,259,RC,59762-1710-02,NDC,outpatient,1,UN,5.59,3.913,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
EPLERENONE 25 MG ORAL TABS,RX-36983,CDM,S5000,HCPCS,259,RC,60687-0451-11,NDC,outpatient,1,UN,18.55,12.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ZONISAMIDE 25 MG ORAL CAPS,RX-36987,CDM,S5000,HCPCS,259,RC,68462-0128-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,23155-0833-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,51079-0075-20,NDC,outpatient,1,UN,1.14,0.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,63739-0327-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,51079-0075-01,NDC,outpatient,1,UN,1.14,0.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,31722-0520-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,60687-0822-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,60687-0822-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
THERA M PLUS ORAL TABS,RX-37053,CDM,S5000,HCPCS,259,RC,00536-3445-08,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
THERA M PLUS ORAL TABS,RX-37053,CDM,S5000,HCPCS,259,RC,57896-0621-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,00832-1112-60,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,60687-0173-57,NDC,outpatient,1,UN,2.01,1.407,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,00591-3870-44,NDC,outpatient,1,UN,1.42,0.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,60687-0173-11,NDC,outpatient,1,UN,2.01,1.407,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,00904-6505-61,NDC,outpatient,1,UN,1.34,0.938,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,00591-3870-45,NDC,outpatient,1,UN,1.42,0.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROCHLOROTHIAZIDE 25 MG ORAL TABS,RX-3720,CDM,S5000,HCPCS,259,RC,60687-0593-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROCHLOROTHIAZIDE 25 MG ORAL TABS,RX-3720,CDM,S5000,HCPCS,259,RC,60687-0593-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROCORTISONE 1 % EX CREA,RX-3726,CDM,S5000,HCPCS,259,RC,49348-0521-72,NDC,outpatient,28.4,GR,6.32,4.424,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROCORTISONE 1 % EX CREA,RX-3726,CDM,S5000,HCPCS,259,RC,00536-1277-80,NDC,outpatient,28,GR,5.24,3.668,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROCORTISONE 1 % EX LOTN,RX-3728,CDM,S5000,HCPCS,259,RC,00096-0732-04,NDC,outpatient,120,ML,56.61,39.627,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROCORTISONE 1 % EX LOTN,RX-3728,CDM,S5000,HCPCS,259,RC,00394-0859-32,NDC,outpatient,114,ML,22.83,15.981,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROCORTISONE 1 % EX OINT,RX-3731,CDM,S5000,HCPCS,259,RC,00168-0020-31,NDC,outpatient,28.35,GR,18.05,12.635,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROCORTISONE 10 MG ORAL TABS,RX-3733,CDM,S5000,HCPCS,259,RC,59762-0074-01,NDC,outpatient,1,UN,1.14,0.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROCORTISONE 10 MG ORAL TABS,RX-3733,CDM,S5000,HCPCS,259,RC,60687-0582-11,NDC,outpatient,1,UN,6.08,4.256,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROCORTISONE 10 MG ORAL TABS,RX-3733,CDM,S5000,HCPCS,259,RC,60687-0582-01,NDC,outpatient,1,UN,6.08,4.256,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROCORTISONE ACETATE 25 MG RE SUPP,RX-3738,CDM,S5000,HCPCS,259,RC,00574-7090-12,NDC,outpatient,1,UN,5.54,3.878,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROCORTISONE ACETATE 25 MG RE SUPP,RX-3738,CDM,S5000,HCPCS,259,RC,10135-0751-12,NDC,outpatient,1,UN,7.8,5.46,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,42806-0270-95,NDC,outpatient,1,UN,3.48,2.436,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,42806-0270-98,NDC,outpatient,1,UN,3.48,2.436,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,49884-0466-65,NDC,outpatient,1,UN,2.84,1.988,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,00245-0036-60,NDC,outpatient,1,UN,3.71,2.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,49884-0466-63,NDC,outpatient,1,UN,2.84,1.988,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,00245-0036-89,NDC,outpatient,1,UN,3.71,2.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CARBAMAZEPINE ER 100 MG ORAL CP12,RX-37567,CDM,S5000,HCPCS,259,RC,50268-0170-13,NDC,outpatient,1,UN,7.06,4.942,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CARBAMAZEPINE ER 100 MG ORAL CP12,RX-37567,CDM,S5000,HCPCS,259,RC,50268-0170-11,NDC,outpatient,1,UN,7.06,4.942,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BSS IO SOLN,RX-37579,CDM,S5000,HCPCS,259,RC,00065-0795-15,NDC,outpatient,15,ML,24.7,17.29,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROMORPHONE HCL 2 MG ORAL TABS,RX-3760,CDM,S5000,HCPCS,259,RC,42858-0301-01,NDC,outpatient,1,UN,1.14,0.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROMORPHONE HCL 2 MG ORAL TABS,RX-3760,CDM,S5000,HCPCS,259,RC,60687-0579-11,NDC,outpatient,1,UN,1.27,0.889,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROMORPHONE HCL 2 MG ORAL TABS,RX-3760,CDM,S5000,HCPCS,259,RC,00406-3243-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROMORPHONE HCL 2 MG ORAL TABS,RX-3760,CDM,S5000,HCPCS,259,RC,42858-0301-25,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROMORPHONE HCL 2 MG ORAL TABS,RX-3760,CDM,S5000,HCPCS,259,RC,60687-0579-01,NDC,outpatient,1,UN,1.27,0.889,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROMORPHONE HCL 4 MG ORAL TABS,RX-3761,CDM,S5000,HCPCS,259,RC,00406-3244-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROMORPHONE HCL 4 MG ORAL TABS,RX-3761,CDM,S5000,HCPCS,259,RC,60687-0590-01,NDC,outpatient,1,UN,1.06,0.742,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROMORPHONE HCL 4 MG ORAL TABS,RX-3761,CDM,S5000,HCPCS,259,RC,60687-0590-11,NDC,outpatient,1,UN,1.06,0.742,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROMORPHONE HCL 4 MG ORAL TABS,RX-3761,CDM,S5000,HCPCS,259,RC,42858-0234-01,NDC,outpatient,1,UN,17.03,11.921,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METOPROLOL TARTRATE 25 MG ORAL TABS,RX-37637,CDM,S5000,HCPCS,259,RC,00378-0018-05,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METOPROLOL TARTRATE 25 MG ORAL TABS,RX-37637,CDM,S5000,HCPCS,259,RC,62584-0265-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METOPROLOL TARTRATE 25 MG ORAL TABS,RX-37637,CDM,S5000,HCPCS,259,RC,51079-0255-20,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METOPROLOL TARTRATE 25 MG ORAL TABS,RX-37637,CDM,S5000,HCPCS,259,RC,51079-0255-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METOPROLOL TARTRATE 25 MG ORAL TABS,RX-37637,CDM,S5000,HCPCS,259,RC,62584-0265-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLINDAMYCIN PALMITATE HCL 75 MG/5ML ORAL SOLR,RX-37642,CDM,S5000,HCPCS,259,RC,23155-0603-51,NDC,outpatient,100,ML,170.44,119.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLINDAMYCIN PALMITATE HCL 75 MG/5ML ORAL SOLR,RX-37642,CDM,S5000,HCPCS,259,RC,59762-0016-01,NDC,outpatient,100,ML,170.44,119.308,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLINDAMYCIN PALMITATE HCL 75 MG/5ML ORAL SOLR,RX-37642,CDM,S5000,HCPCS,259,RC,99999-0002-90,NDC,outpatient,10,ML,18.43,12.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GLIPIZIDE ER 2.5 MG ORAL TB24,RX-37648,CDM,S5000,HCPCS,259,RC,60687-0768-11,NDC,outpatient,1,UN,4.6,3.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GLIPIZIDE ER 2.5 MG ORAL TB24,RX-37648,CDM,S5000,HCPCS,259,RC,60687-0768-21,NDC,outpatient,1,UN,4.6,3.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GLIPIZIDE ER 5 MG ORAL TB24,RX-37649,CDM,S5000,HCPCS,259,RC,68084-0111-11,NDC,outpatient,1,UN,2.4,1.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GLIPIZIDE ER 5 MG ORAL TB24,RX-37649,CDM,S5000,HCPCS,259,RC,68084-0111-01,NDC,outpatient,1,UN,2.4,1.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GUAIFENESIN ER 600 MG ORAL TB12,RX-37651,CDM,S5000,HCPCS,259,RC,00904-6718-39,NDC,outpatient,1,UN,2.32,1.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GUAIFENESIN ER 600 MG ORAL TB12,RX-37651,CDM,S5000,HCPCS,259,RC,63824-0008-50,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GUAIFENESIN ER 600 MG ORAL TB12,RX-37651,CDM,S5000,HCPCS,259,RC,68084-0572-01,NDC,outpatient,1,UN,2.76,1.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GUAIFENESIN ER 600 MG ORAL TB12,RX-37651,CDM,S5000,HCPCS,259,RC,68084-0572-11,NDC,outpatient,1,UN,2.76,1.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROXYZINE HCL 10 MG/5ML ORAL SYRP,RX-3771,CDM,S5000,HCPCS,259,RC,62135-0750-47,NDC,outpatient,5,ML,21.74,15.218,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROXYZINE HCL 10 MG/5ML ORAL SYRP,RX-3771,CDM,S5000,HCPCS,259,RC,99999-0002-50,NDC,outpatient,5,ML,1.16,0.812,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROXYZINE HCL 10 MG/5ML ORAL SYRP,RX-3771,CDM,S5000,HCPCS,259,RC,54838-0502-80,NDC,outpatient,5,ML,2.88,2.016,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROXYZINE HCL 10 MG ORAL TABS,RX-3772,CDM,S5000,HCPCS,259,RC,63739-0483-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROXYZINE HCL 25 MG ORAL TABS,RX-3774,CDM,S5000,HCPCS,259,RC,60687-0675-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROXYZINE HCL 25 MG ORAL TABS,RX-3774,CDM,S5000,HCPCS,259,RC,00904-6617-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROXYZINE HCL 25 MG ORAL TABS,RX-3774,CDM,S5000,HCPCS,259,RC,60687-0675-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROXYZINE HCL 25 MG ORAL TABS,RX-3774,CDM,S5000,HCPCS,259,RC,63739-0486-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TALC 5 G PL SUSR,RX-37812,CDM,S5000,HCPCS,259,RC,63256-0200-05,NDC,outpatient,1,UN,458.35,320.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CINACALCET HCL 30 MG ORAL TABS,RX-38100,CDM,S5000,HCPCS,259,RC,60687-0525-11,NDC,outpatient,1,UN,64.87,45.409,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CINACALCET HCL 30 MG ORAL TABS,RX-38100,CDM,S5000,HCPCS,259,RC,00904-7067-04,NDC,outpatient,1,UN,76.53,53.571,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CINACALCET HCL 30 MG ORAL TABS,RX-38100,CDM,S5000,HCPCS,259,RC,55513-0073-30,NDC,outpatient,1,UN,75.45,52.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CINACALCET HCL 30 MG ORAL TABS,RX-38100,CDM,S5000,HCPCS,259,RC,60687-0525-21,NDC,outpatient,1,UN,64.87,45.409,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CINACALCET HCL 30 MG ORAL TABS,RX-38100,CDM,S5000,HCPCS,259,RC,70436-0007-04,NDC,outpatient,1,UN,1.94,1.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ORPHENADRINE CITRATE ER 100 MG ORAL TB12,RX-38213,CDM,S5000,HCPCS,259,RC,43386-0480-24,NDC,outpatient,1,UN,2.27,1.589,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PROPRANOLOL HCL ER 60 MG ORAL CP24,RX-38224,CDM,S5000,HCPCS,259,RC,42291-0522-01,NDC,outpatient,1,UN,1.68,1.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PROPRANOLOL HCL ER 60 MG ORAL CP24,RX-38224,CDM,S5000,HCPCS,259,RC,62559-0530-01,NDC,outpatient,1,UN,2.1,1.47,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PROPRANOLOL HCL ER 60 MG ORAL CP24,RX-38224,CDM,S5000,HCPCS,259,RC,00228-2778-11,NDC,outpatient,1,UN,6.75,4.725,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PROPRANOLOL HCL ER 80 MG ORAL CP24,RX-38225,CDM,S5000,HCPCS,259,RC,00228-2779-11,NDC,outpatient,1,UN,8.57,5.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PROPRANOLOL HCL ER 80 MG ORAL CP24,RX-38225,CDM,S5000,HCPCS,259,RC,00527-4117-37,NDC,outpatient,1,UN,1.14,0.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PROPRANOLOL HCL ER 120 MG ORAL CP24,RX-38226,CDM,S5000,HCPCS,259,RC,00228-2780-11,NDC,outpatient,1,UN,10.29,7.203,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PROPRANOLOL HCL ER 120 MG ORAL CP24,RX-38226,CDM,S5000,HCPCS,259,RC,42291-0524-01,NDC,outpatient,1,UN,2.42,1.694,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LACTULOSE 10 GM/15ML ORAL SOLN,RX-38245,CDM,S5000,HCPCS,259,RC,00121-1154-30,NDC,outpatient,30,ML,4.94,3.458,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LACTULOSE 10 GM/15ML ORAL SOLN,RX-38245,CDM,S5000,HCPCS,259,RC,99999-0001-83,NDC,outpatient,30,ML,2.16,1.512,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LACTULOSE 10 GM/15ML ORAL SOLN,RX-38245,CDM,S5000,HCPCS,259,RC,45963-0439-30,NDC,outpatient,30,ML,2.01,1.407,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LACTULOSE 10 GM/15ML ORAL SOLN,RX-38245,CDM,S5000,HCPCS,259,RC,45963-0439-65,NDC,outpatient,15,ML,1.01,0.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LACTULOSE 10 GM/15ML ORAL SOLN,RX-38245,CDM,S5000,HCPCS,259,RC,00121-1154-00,NDC,outpatient,30,ML,4.94,3.458,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CETIRIZINE HCL 5 MG ORAL CHEW,RX-38402,CDM,S5000,HCPCS,259,RC,00781-5283-64,NDC,outpatient,1,UN,12.96,9.072,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CETIRIZINE HCL 5 MG ORAL CHEW,RX-38402,CDM,S5000,HCPCS,259,RC,00781-5283-06,NDC,outpatient,1,UN,12.96,9.072,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IBUPROFEN 200 MG ORAL TABS,RX-3841,CDM,S5000,HCPCS,259,RC,00904-7914-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,00904-5853-60,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,60687-0446-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,60687-0446-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,67877-0319-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,00904-5853-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,67877-0319-05,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IBUPROFEN 600 MG ORAL TABS,RX-3844,CDM,S5000,HCPCS,259,RC,00904-5854-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
INFUVITE PEDIATRIC IV SOLN,RX-38445,CDM,S5000,HCPCS,250,RC,54643-5646-09,NDC,outpatient,1,ML,15.58,10.906,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
INFUVITE PEDIATRIC IV SOLN,RX-38445,CDM,S5000,HCPCS,250,RC,54643-5646-01,NDC,outpatient,4,ML,53.96,37.772,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IBUPROFEN 800 MG ORAL TABS,RX-3845,CDM,S5000,HCPCS,259,RC,00904-5855-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLUOXETINE HCL 20 MG/5ML ORAL SOLN,RX-38488,CDM,S5000,HCPCS,259,RC,00121-4721-05,NDC,outpatient,5,ML,14.38,10.066,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IMIPRAMINE HCL 10 MG ORAL TABS,RX-3860,CDM,S5000,HCPCS,259,RC,69584-0425-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IMIPRAMINE HCL 25 MG ORAL TABS,RX-3861,CDM,S5000,HCPCS,259,RC,69584-0426-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NEOMYCIN-BACITRACIN ZN-POLYMYX 5-400-10000 OP OINT,RX-38701,CDM,S5000,HCPCS,259,RC,24208-0780-55,NDC,outpatient,3.5,GR,57.59,40.313,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
INDAPAMIDE 2.5 MG ORAL TABS,RX-3879,CDM,S5000,HCPCS,259,RC,00228-2571-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
INDAPAMIDE 2.5 MG ORAL TABS,RX-3879,CDM,S5000,HCPCS,259,RC,62559-0511-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SELENIUM SULFIDE 1 % EX SHAM,RX-38961,CDM,S5000,HCPCS,259,RC,00536-1995-53,NDC,outpatient,207,ML,9.22,6.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PEG 3350-KCL-NABCB-NACL-NASULF 240 G ORAL SOLR,RX-38965,CDM,S5000,HCPCS,259,RC,43386-0060-19,NDC,outpatient,4000,ML,53.4,37.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
INDOMETHACIN 25 MG ORAL CAPS,RX-3897,CDM,S5000,HCPCS,259,RC,50268-0430-11,NDC,outpatient,1,UN,1.4,0.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
INDOMETHACIN 25 MG ORAL CAPS,RX-3897,CDM,S5000,HCPCS,259,RC,50268-0430-15,NDC,outpatient,1,UN,1.4,0.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
INDOMETHACIN 50 MG RE SUPP,RX-3901,CDM,S5000,HCPCS,259,RC,69344-0102-33,NDC,outpatient,1,UN,1095.8,767.06,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RIFAXIMIN 200 MG ORAL TABS,RX-39063,CDM,S5000,HCPCS,259,RC,65649-0301-03,NDC,outpatient,1,UN,43.55,30.485,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMILORIDE HCL 5 MG ORAL TABS,RX-391,CDM,S5000,HCPCS,259,RC,00574-0292-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NYSTATIN 100000 UNIT/GM EX POWD,RX-39136,CDM,S5000,HCPCS,259,RC,16714-0769-01,NDC,outpatient,15,GR,25.04,17.528,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NYSTATIN 100000 UNIT/GM EX POWD,RX-39136,CDM,S5000,HCPCS,259,RC,69315-0306-15,NDC,outpatient,15,GR,24.5,17.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NYSTATIN 100000 UNIT/GM EX POWD,RX-39136,CDM,S5000,HCPCS,259,RC,00832-0465-15,NDC,outpatient,15,GR,37.52,26.264,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NYSTATIN 100000 UNIT/GM EX POWD,RX-39136,CDM,S5000,HCPCS,259,RC,68308-0152-15,NDC,outpatient,15,GR,27.84,19.488,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NYSTATIN 100000 UNIT/GM EX POWD,RX-39136,CDM,S5000,HCPCS,259,RC,68382-0370-01,NDC,outpatient,15,GR,31.18,21.826,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
EMTRICITABINE-TENOFOVIR DF 200-300 MG ORAL TABS,RX-39255,CDM,S5000,HCPCS,259,RC,61958-0701-01,NDC,outpatient,1,UN,265.08,185.556,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DULOXETINE HCL 20 MG ORAL CPEP,RX-39275,CDM,S5000,HCPCS,259,RC,00904-7043-04,NDC,outpatient,1,UN,3.3,2.31,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DULOXETINE HCL 20 MG ORAL CPEP,RX-39275,CDM,S5000,HCPCS,259,RC,60687-0723-11,NDC,outpatient,1,UN,3.39,2.373,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DULOXETINE HCL 20 MG ORAL CPEP,RX-39275,CDM,S5000,HCPCS,259,RC,60687-0723-21,NDC,outpatient,1,UN,3.39,2.373,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DULOXETINE HCL 30 MG ORAL CPEP,RX-39276,CDM,S5000,HCPCS,259,RC,00904-7044-61,NDC,outpatient,1,UN,3.08,2.156,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DULOXETINE HCL 30 MG ORAL CPEP,RX-39276,CDM,S5000,HCPCS,259,RC,57237-0018-90,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DULOXETINE HCL 30 MG ORAL CPEP,RX-39276,CDM,S5000,HCPCS,259,RC,60687-0734-01,NDC,outpatient,1,UN,3.41,2.387,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DULOXETINE HCL 30 MG ORAL CPEP,RX-39276,CDM,S5000,HCPCS,259,RC,60687-0734-11,NDC,outpatient,1,UN,3.41,2.387,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVALBUTEROL HCL 1.25 MG/0.5ML IN NEBU,RX-39278,CDM,S5000,HCPCS,259,RC,00378-6993-93,NDC,outpatient,1,UN,20.14,14.098,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVALBUTEROL HCL 1.25 MG/0.5ML IN NEBU,RX-39278,CDM,S5000,HCPCS,259,RC,00378-6993-31,NDC,outpatient,1,UN,20.14,14.098,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CEFDINIR 250 MG/5ML ORAL SUSR,RX-39522,CDM,S5000,HCPCS,259,RC,99999-0002-80,NDC,outpatient,6,ML,3.93,2.751,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CEFDINIR 250 MG/5ML ORAL SUSR,RX-39522,CDM,S5000,HCPCS,259,RC,68180-0723-04,NDC,outpatient,60,ML,87.31,61.117,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CEFDINIR 250 MG/5ML ORAL SUSR,RX-39522,CDM,S5000,HCPCS,259,RC,65862-0219-60,NDC,outpatient,60,ML,88.92,62.244,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MESALAMINE ER 500 MG ORAL CPCR,RX-39575,CDM,S5000,HCPCS,259,RC,54092-0191-12,NDC,outpatient,1,UN,24.97,17.479,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IODINE STRONG 5 % ORAL SOLN,RX-3961,CDM,S5000,HCPCS,259,RC,51552-0019-44,NDC,outpatient,14,ML,5.44,3.808,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IODINE STRONG 5 % ORAL SOLN,RX-3961,CDM,S5000,HCPCS,259,RC,48433-0230-15,NDC,outpatient,14,ML,132.64,92.848,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACAMPROSATE CALCIUM 333 MG ORAL TBEC,RX-39720,CDM,S5000,HCPCS,259,RC,60687-0121-95,NDC,outpatient,1,UN,6.9,4.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACAMPROSATE CALCIUM 333 MG ORAL TBEC,RX-39720,CDM,S5000,HCPCS,259,RC,60687-0121-25,NDC,outpatient,1,UN,6.9,4.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLUMAZENIL 0.5 MG/5ML IV SOLN,RX-39744,CDM,S5000,HCPCS,250,RC,00143-9784-10,NDC,outpatient,5,ML,13.42,9.394,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLUMAZENIL 0.5 MG/5ML IV SOLN,RX-39744,CDM,S5000,HCPCS,250,RC,36000-0148-10,NDC,outpatient,5,ML,12.98,9.086,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLUMAZENIL 0.5 MG/5ML IV SOLN,RX-39744,CDM,S5000,HCPCS,250,RC,00143-9784-01,NDC,outpatient,5,ML,13.42,9.394,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLUMAZENIL 0.5 MG/5ML IV SOLN,RX-39744,CDM,S5000,HCPCS,250,RC,36000-0148-01,NDC,outpatient,5,ML,12.98,9.086,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLUMAZENIL 0.5 MG/5ML IV SOLN,RX-39744,CDM,S5000,HCPCS,250,RC,63323-0424-05,NDC,outpatient,5,ML,15.68,10.976,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVOFLOXACIN 25 MG/ML ORAL SOLN,RX-39970,CDM,S5000,HCPCS,259,RC,00527-1948-68,NDC,outpatient,10,ML,85.98,60.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVOFLOXACIN 25 MG/ML ORAL SOLN,RX-39970,CDM,S5000,HCPCS,259,RC,99999-0002-53,NDC,outpatient,10,ML,37.07,25.949,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LANTHANUM CARBONATE 500 MG ORAL CHEW,RX-39975,CDM,S5000,HCPCS,259,RC,54092-0252-90,NDC,outpatient,1,UN,49.37,34.559,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LANTHANUM CARBONATE 500 MG ORAL CHEW,RX-39975,CDM,S5000,HCPCS,259,RC,68180-0819-42,NDC,outpatient,1,UN,24.73,17.311,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LANTHANUM CARBONATE 500 MG ORAL CHEW,RX-39975,CDM,S5000,HCPCS,259,RC,68180-0819-52,NDC,outpatient,1,UN,24.73,17.311,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LANTHANUM CARBONATE 500 MG ORAL CHEW,RX-39975,CDM,S5000,HCPCS,259,RC,54092-0252-45,NDC,outpatient,1,UN,49.37,34.559,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FENOFIBRATE 48 MG ORAL TABS,RX-40009,CDM,S5000,HCPCS,259,RC,51079-0599-20,NDC,outpatient,1,UN,4.01,2.807,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FENOFIBRATE 48 MG ORAL TABS,RX-40009,CDM,S5000,HCPCS,259,RC,51079-0599-01,NDC,outpatient,1,UN,4.01,2.807,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FENOFIBRATE 145 MG ORAL TABS,RX-40010,CDM,S5000,HCPCS,259,RC,51079-0608-20,NDC,outpatient,1,UN,10.74,7.518,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FENOFIBRATE 145 MG ORAL TABS,RX-40010,CDM,S5000,HCPCS,259,RC,60687-0629-21,NDC,outpatient,1,UN,4.19,2.933,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MAGIC MOUTHWASH ORAL SUSPENSION *HOSPITAL USE ONLY*,RX-400477,CDM,S5000,HCPCS,259,RC,65628-0050-04,NDC,outpatient,5,ML,14,9.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MAGIC MOUTHWASH ORAL SUSPENSION *HOSPITAL USE ONLY*,RX-400477,CDM,S5000,HCPCS,259,RC,99999-0000-82,NDC,outpatient,10,ML,19.54,13.678,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MAGIC MOUTHWASH ORAL SUSPENSION *HOSPITAL USE ONLY*,RX-400477,CDM,S5000,HCPCS,259,RC,65628-0050-01,NDC,outpatient,10,ML,19.54,13.678,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MAGIC MOUTHWASH ORAL SUSPENSION *HOSPITAL USE ONLY*,RX-400477,CDM,S5000,HCPCS,259,RC,99999-0000-61,NDC,outpatient,180,ML,12.46,8.722,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RIFAMPIN 10 MG/ML ORAL SUSPENSION,RX-400484,CDM,S5000,HCPCS,259,RC,99999-0001-44,NDC,outpatient,120,ML,34,23.8,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METOPROLOL TARTRATE 12.5 MG ORAL SPLIT TABLET,RX-400503,CDM,S5000,HCPCS,259,RC,99999-0002-12,NDC,outpatient,12.5,ME,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METOPROLOL TARTRATE 12.5 MG ORAL SPLIT TABLET,RX-400503,CDM,S5000,HCPCS,259,RC,SH040-0403-01,NDC,outpatient,12.5,ME,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METOPROLOL TARTRATE 12.5 MG ORAL SPLIT TABLET,RX-400503,CDM,S5000,HCPCS,259,RC,,,outpatient,12.5,ME,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CEFAZOLIN EYE DROPS 50 MG/ML 20 ML BOTTLE,RX-400598,CDM,S5000,HCPCS,259,RC,SH408-0378-01,NDC,outpatient,20,ML,18.41,12.887,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MISOPROSTOL 25 MCG ORAL SPLIT TABS,RX-400620,CDM,S5000,HCPCS,259,RC,,,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MISOPROSTOL 25 MCG ORAL SPLIT TABS,RX-400620,CDM,S5000,HCPCS,259,RC,SH040-0620-01,NDC,outpatient,1,UN,1.69,1.183,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ISONIAZID 100 MG ORAL TABS,RX-4026,CDM,S5000,HCPCS,259,RC,00555-0066-02,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMINOCAPROIC ACID 250 MG/ML IV SOLN,RX-403,CDM,S5000,HCPCS,250,RC,00517-9120-25,NDC,outpatient,4,ML,8,5.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMINOCAPROIC ACID 250 MG/ML IV SOLN,RX-403,CDM,S5000,HCPCS,250,RC,00409-4346-16,NDC,outpatient,20,ML,18.34,12.838,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMINOCAPROIC ACID 250 MG/ML IV SOLN,RX-403,CDM,S5000,HCPCS,250,RC,00517-9120-01,NDC,outpatient,4,ML,8,5.6,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMINOCAPROIC ACID 250 MG/ML IV SOLN,RX-403,CDM,S5000,HCPCS,250,RC,00409-4346-73,NDC,outpatient,20,ML,18.34,12.838,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN,RX-4034,CDM,S5000,HCPCS,250,RC,14789-0015-05,NDC,outpatient,5,ML,1453.64,1017.548,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN,RX-4034,CDM,S5000,HCPCS,250,RC,14789-0015-07,NDC,outpatient,5,ML,1453.64,1017.548,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN,RX-4034,CDM,S5000,HCPCS,250,RC,00548-9502-00,NDC,outpatient,5,ML,246.51,172.557,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MESALAMINE 1000 MG RE SUPP,RX-40369,CDM,S5000,HCPCS,259,RC,69918-0560-30,NDC,outpatient,1,UN,7.56,5.292,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MESALAMINE 1000 MG RE SUPP,RX-40369,CDM,S5000,HCPCS,259,RC,59762-0118-03,NDC,outpatient,1,UN,22.5,15.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SOLIFENACIN SUCCINATE 5 MG ORAL TABS,RX-40392,CDM,S5000,HCPCS,259,RC,51248-0150-01,NDC,outpatient,1,UN,52.84,36.988,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CYANOCOBALAMIN 500 MCG SL SUBL,RX-40518,CDM,S5000,HCPCS,259,RC,00743-1203-59,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CYANOCOBALAMIN 500 MCG SL SUBL,RX-40518,CDM,S5000,HCPCS,259,RC,74312-0035-95,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ISOSORBIDE DINITRATE 10 MG ORAL TABS,RX-4064,CDM,S5000,HCPCS,259,RC,68084-0082-01,NDC,outpatient,1,UN,2.67,1.869,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ISOSORBIDE DINITRATE 10 MG ORAL TABS,RX-4064,CDM,S5000,HCPCS,259,RC,68084-0082-11,NDC,outpatient,1,UN,2.67,1.869,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ISOSORBIDE DINITRATE 20 MG ORAL TABS,RX-4065,CDM,S5000,HCPCS,259,RC,00904-6620-61,NDC,outpatient,1,UN,2.27,1.589,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE 0.9 % IV PVC FREE SOLN,RX-4080010,CDM,S5000,HCPCS,250,RC,00264-7800-10,NDC,outpatient,500,ML,31.42,21.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE 0.9 % IV PVC FREE SOLN,RX-4080010,CDM,S5000,HCPCS,250,RC,00264-7800-20,NDC,outpatient,250,ML,30.14,21.098,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE 0.9 % IV PVC FREE SOLN,RX-4080010,CDM,S5000,HCPCS,250,RC,00264-1800-32,NDC,outpatient,100,ML,28.85,20.195,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROMORPHONE 100 MG/100 ML INFUSION,RX-4080055,CDM,S5000,HCPCS,250,RC,99999-0000-26,NDC,outpatient,100,ML,168.65,118.055,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DILTIAZEM ADDVANTAGE INFUSION IN NS,RX-4080056,CDM,S5000,HCPCS,250,RC,99999-0000-00,NDC,outpatient,100,ML,54.5,38.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FENTANYL INFUSION PREMIX 10 MCG/ML 250 ML,RX-4080065,CDM,S5000,HCPCS,250,RC,70004-0202-40,NDC,outpatient,250,ML,236.1,165.27,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FENTANYL INFUSION PREMIX 10 MCG/ML 250 ML,RX-4080065,CDM,S5000,HCPCS,250,RC,70004-0229-40,NDC,outpatient,250,ML,277.66,194.362,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FENTANYL INFUSION PREMIX 10 MCG/ML 250 ML,RX-4080065,CDM,S5000,HCPCS,250,RC,70092-1093-37,NDC,outpatient,250,ML,130.86,91.602,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FENTANYL INFUSION PREMIX 10 MCG/ML 250 ML,RX-4080065,CDM,S5000,HCPCS,250,RC,99999-0001-54,NDC,outpatient,250,ML,37.36,26.152,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
KETAMINE INFUSION 500 MG IN 250 ML INFUSION,RX-4080078,CDM,S5000,HCPCS,250,RC,99999-9990-03,NDC,outpatient,250,ML,37.81,26.467,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
KETAMINE INFUSION 500 MG IN 250 ML INFUSION,RX-4080078,CDM,S5000,HCPCS,250,RC,70004-0442-40,NDC,outpatient,250,ML,112.79,78.953,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MORPHINE INFUSION 250 MG IN D5W 250 ML PREMIX,RX-4080096,CDM,S5000,HCPCS,250,RC,99999-0001-61,NDC,outpatient,250,ML,35.02,24.514,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FAMOTIDINE 10 MG/ML IJ WRAPPER,RX-4080100,CDM,S5000,HCPCS,250,RC,00641-6022-25,NDC,outpatient,2,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FAMOTIDINE 10 MG/ML IJ WRAPPER,RX-4080100,CDM,S5000,HCPCS,250,RC,67457-0433-22,NDC,outpatient,2,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FAMOTIDINE 10 MG/ML IJ WRAPPER,RX-4080100,CDM,S5000,HCPCS,250,RC,00641-6022-01,NDC,outpatient,2,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FAMOTIDINE 10 MG/ML IJ WRAPPER,RX-4080100,CDM,S5000,HCPCS,250,RC,67457-0433-00,NDC,outpatient,2,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ARTIFICIAL TEARS EYE SOLN WRAPPER,RX-4080101,CDM,S5000,HCPCS,259,RC,00065-0426-36,NDC,outpatient,15,ML,27.17,19.019,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ARTIFICIAL TEARS EYE SOLN WRAPPER,RX-4080101,CDM,S5000,HCPCS,259,RC,57896-0181-05,NDC,outpatient,15,ML,5.55,3.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NAFCILLIN SODIUM 1 G IJ WRAPPER,RX-4080106,CDM,S5000,HCPCS,250,RC,63323-0327-10,NDC,outpatient,1,UN,15.49,10.843,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NAFCILLIN SODIUM 2 G IJ WRAPPER,RX-4080107,CDM,S5000,HCPCS,250,RC,44567-0222-10,NDC,outpatient,1,UN,90.46,63.322,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NAFCILLIN SODIUM 2 G IJ WRAPPER,RX-4080107,CDM,S5000,HCPCS,250,RC,55150-0123-15,NDC,outpatient,1,UN,30.45,21.315,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NAFCILLIN SODIUM 2 G IJ WRAPPER,RX-4080107,CDM,S5000,HCPCS,250,RC,63323-0328-20,NDC,outpatient,1,UN,24.64,17.248,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NOREPINEPHRINE PREMIX 4 MG IN 250 ML NS,RX-4080110,CDM,S5000,HCPCS,250,RC,70004-0781-40,NDC,outpatient,250,ML,123.78,86.646,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NOREPINEPHRINE PREMIX 4 MG IN 250 ML NS,RX-4080110,CDM,S5000,HCPCS,250,RC,70092-1650-05,NDC,outpatient,250,ML,102.2,71.54,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NOREPINEPHRINE PREMIX 4 MG IN 250 ML NS,RX-4080110,CDM,S5000,HCPCS,250,RC,71266-5020-02,NDC,outpatient,250,ML,112.97,79.079,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PHENYLEPHRINE IV PREMIX 40 MG IN 250 ML NS,RX-4080112,CDM,S5000,HCPCS,250,RC,42852-0838-25,NDC,outpatient,250,ML,158.85,111.195,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PHENYLEPHRINE IV PREMIX 40 MG IN 250 ML NS,RX-4080112,CDM,S5000,HCPCS,250,RC,70004-0812-40,NDC,outpatient,250,ML,93.12,65.184,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PHENYLEPHRINE IV PREMIX 40 MG IN 250 ML NS,RX-4080112,CDM,S5000,HCPCS,250,RC,70092-9170-05,NDC,outpatient,250,ML,146.26,102.382,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PHENYLEPHRINE IV PREMIX 10 MG IN 250 ML NS,RX-4080113,CDM,S5000,HCPCS,250,RC,70004-0811-40,NDC,outpatient,250,ML,109.23,76.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PHENYLEPHRINE IV PREMIX 10 MG IN 250 ML NS,RX-4080113,CDM,S5000,HCPCS,250,RC,71506-0010-58,NDC,outpatient,250,ML,88.76,62.132,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VANCOMYCIN HCL IN DEXTROSE 1250 MG/250 ML IV SOLN,RX-4080122,CDM,S5000,HCPCS,250,RC,99999-0000-46,NDC,outpatient,275,ML,64.38,45.066,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VANCOMYCIN HCL IN DEXTROSE 1500 MG/250 ML IV SOLN,RX-4080123,CDM,S5000,HCPCS,250,RC,99999-0000-47,NDC,outpatient,280,ML,80.8,56.56,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CARDIOPLEGIA SOLN HIGH POTASSIUM 4:1 INDUCTION,RX-4080154,CDM,S5000,HCPCS,250,RC,72196-0101-01,NDC,outpatient,500,ML,673.36,471.352,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CARDIOPLEGIA SOLN LOW POTASSION 4:1 REPERFUSATE,RX-4080155,CDM,S5000,HCPCS,250,RC,71285-0007-01,NDC,outpatient,238.75,ML,1537.64,1076.348,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CARDIOPLEGIA SOLN LOW POTASSIUM 4:1 MAINTENANCE,RX-4080156,CDM,S5000,HCPCS,250,RC,72196-0104-01,NDC,outpatient,1000,ML,1042.09,729.463,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CONCENTRATED DILAUDID 1 MG/ML PCA,RX-4080157,CDM,S5000,HCPCS,250,RC,70004-0303-62,NDC,outpatient,50,ML,212.25,148.575,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DILAUDID 0.2 MG/ML PCA (HYDROMORPHONE),RX-4080159,CDM,S5000,HCPCS,250,RC,70004-0300-62,NDC,outpatient,50,ML,69.63,48.741,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PRISMASATE K 0/CA 3.5 CRRT SOLUTION,RX-4080163,CDM,S5000,HCPCS,250,RC,00000-1053-53,NDC,outpatient,5000,ML,188.44,131.908,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FENTANYL 2 MCG/ML WITH BUPIVACAINE 0.125 % EPIDURAL,RX-4080168,CDM,S5000,HCPCS,250,RC,70092-9202-75,NDC,outpatient,100,ML,251.94,176.358,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FENTANYL 2 MCG/ML WITH BUPIVACAINE 0.125 % EPIDURAL,RX-4080168,CDM,S5000,HCPCS,250,RC,99999-0001-52,NDC,outpatient,100,ML,30.84,21.588,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FENTANYL 2 MCG/ML WITH BUPIVACAINE 0.125 % EPIDURAL,RX-4080168,CDM,S5000,HCPCS,250,RC,70004-0231-64,NDC,outpatient,100,ML,109.23,76.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FENTANYL 2 MCG/ML WITH BUPIVACAINE 0.125 % EPIDURAL,RX-4080168,CDM,S5000,HCPCS,250,RC,70092-1202-75,NDC,outpatient,100,ML,258.44,180.908,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FENTANYL 5 MCG/ML WITH BUPIVACAINE 0.075 % EPIDURAL,RX-4080169,CDM,S5000,HCPCS,250,RC,99999-0001-55,NDC,outpatient,100,ML,34.55,24.185,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FENTANYL 3 MCG/ML WITH BUPIVACAINE 0.075 % EPIDURAL,RX-4080170,CDM,S5000,HCPCS,250,RC,99999-0000-03,NDC,outpatient,100,ML,67.18,47.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FENTANYL CITRATE (PF) 0.05 MG/ML NASAL SOLUTION,RX-4080181,CDM,S5000,HCPCS,259,RC,00409-9094-12,NDC,outpatient,2,ML,6.33,4.431,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FENTANYL CITRATE (PF) 0.05 MG/ML NASAL SOLUTION,RX-4080181,CDM,S5000,HCPCS,259,RC,00409-9094-22,NDC,outpatient,2,ML,6.33,4.431,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MIDAZOLAM HCL 5 MG/ML NASAL SOLUTION,RX-4080183,CDM,S5000,HCPCS,250,RC,00409-2308-01,NDC,outpatient,1,ML,3.42,2.394,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MIDAZOLAM HCL 5 MG/ML NASAL SOLUTION,RX-4080183,CDM,S5000,HCPCS,250,RC,00409-2308-21,NDC,outpatient,1,ML,3.42,2.394,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NICARDIPINE HCL IN NACL 1 MG/10 ML IV SYRINGE,RX-4080192,CDM,S5000,HCPCS,250,RC,70004-0756-12,NDC,outpatient,10,ML,39.83,27.881,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NICARDIPINE HCL IN NACL 1 MG/10 ML IV SYRINGE,RX-4080192,CDM,S5000,HCPCS,250,RC,99999-0001-50,NDC,outpatient,10,ML,10.7,7.49,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DILTIAZEM HCL 5 MG/ML IV WRAPPER,RX-4080196,CDM,S5000,HCPCS,250,RC,00641-6013-10,NDC,outpatient,5,ML,14.35,10.045,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DILTIAZEM HCL 5 MG/ML IV WRAPPER,RX-4080196,CDM,S5000,HCPCS,250,RC,00641-6014-10,NDC,outpatient,10,ML,22.61,15.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DILTIAZEM HCL 5 MG/ML IV WRAPPER,RX-4080196,CDM,S5000,HCPCS,250,RC,00641-6013-01,NDC,outpatient,5,ML,14.35,10.045,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DILTIAZEM HCL 5 MG/ML IV WRAPPER,RX-4080196,CDM,S5000,HCPCS,250,RC,00641-6014-01,NDC,outpatient,10,ML,22.61,15.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NIFEDIPINE-LIDOCAINE 0.3%-1.5% OINT,RX-408020,CDM,S5000,HCPCS,259,RC,00000-0000-03,NDC,outpatient,30,GR,333.75,233.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METOPROLOL TARTRATE 1 MG/ML IV SOLN WRAPPER,RX-4080203,CDM,S5000,HCPCS,250,RC,00409-1778-05,NDC,outpatient,5,ML,3.47,2.429,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METOPROLOL TARTRATE 1 MG/ML IV SOLN WRAPPER,RX-4080203,CDM,S5000,HCPCS,250,RC,00409-1778-15,NDC,outpatient,5,ML,3.47,2.429,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DIBUCAINE 1 % EX OINT WRAPPER,RX-4080210,CDM,S5000,HCPCS,259,RC,00536-1211-95,NDC,outpatient,28,GR,13.84,9.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DIBUCAINE 1 % EX OINT WRAPPER,RX-4080210,CDM,S5000,HCPCS,259,RC,71399-2829-01,NDC,outpatient,28,GR,14.21,9.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
COCOA BUTTER STICK,RX-4080278,CDM,S5000,HCPCS,259,RC,07570-7011-00,NDC,outpatient,30,ML,4.41,3.087,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CAPSAICIN 0.025 % EX CREAM WRAPPER,RX-4080289,CDM,S5000,HCPCS,259,RC,00536-2525-25,NDC,outpatient,60,GR,10.95,7.665,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE-PRILOCAINE 2.5-2.5 % EX CREAM WRAPPER,RX-4080290,CDM,S5000,HCPCS,259,RC,00168-0357-55,NDC,outpatient,5,GR,29.95,20.965,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE-PRILOCAINE 2.5-2.5 % EX CREAM WRAPPER,RX-4080290,CDM,S5000,HCPCS,259,RC,62332-0582-31,NDC,outpatient,30,GR,87.18,61.026,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE-PRILOCAINE 2.5-2.5 % EX CREAM WRAPPER,RX-4080290,CDM,S5000,HCPCS,259,RC,62332-0582-04,NDC,outpatient,5,GR,24.68,17.276,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NITROGLYCERIN IN D5W 2000 MCG/20 ML IV SYRINGE,RX-4080358,CDM,S5000,HCPCS,250,RC,SH408-0358-01,NDC,outpatient,20,ML,3.71,2.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NITROGLYCERIN IN D5W 2000 MCG/20 ML IV SYRINGE,RX-4080358,CDM,S5000,HCPCS,250,RC,99999-0000-54,NDC,outpatient,20,ML,3.71,2.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MULTIVITAMIN CHILDRENS ORAL CHEW WRAPPER,RX-4080360,CDM,S5000,HCPCS,259,RC,80681-0049-00,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMPHOTERICIN B EYE DROPS 0.2 MG/ML 10 ML BOTTLE,RX-4080376,CDM,S5000,HCPCS,259,RC,SH408-0376-01,NDC,outpatient,10,ML,61.86,43.302,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ASPIRIN 1 MG/ML ORAL SUSPENSION 81 ML FOR ASA DESENSITIZATION,RX-4080380,CDM,S5000,HCPCS,259,RC,SH408-0380-01,NDC,outpatient,81,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CEFTAZIDIME EYE DROPS 22.5 MG/ML SYRINGE,RX-4080386,CDM,S5000,HCPCS,259,RC,99999-0000-32,NDC,outpatient,1,ML,37.46,26.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLINDAMYCIN MOUTH WASH 3 MG/ML,RX-4080388,CDM,S5000,HCPCS,259,RC,99999-0000-33,NDC,outpatient,250,ML,10.02,7.014,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDO 4%-EPI 0.05%-TETRACAINE 0.5% (LET) GEL 3 ML,RX-4080408,CDM,S5000,HCPCS,259,RC,88888-0926-28,NDC,outpatient,3,ML,22.25,15.575,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDO 4%-EPI 0.05%-TETRACAINE 0.5% (LET) GEL 3 ML,RX-4080408,CDM,S5000,HCPCS,259,RC,99999-0003-19,NDC,outpatient,3,ML,14.57,10.199,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDO 4%-EPI 0.05%-TETRACAINE 0.5% (LET) GEL 3 ML,RX-4080408,CDM,S5000,HCPCS,259,RC,69623-0801-14,NDC,outpatient,3,ML,35.6,24.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDO 4%-EPI 0.05%-TETRACAINE 0.5% (LET) GEL 3 ML,RX-4080408,CDM,S5000,HCPCS,259,RC,70092-1135-44,NDC,outpatient,3,ML,49.22,34.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MAG SULFATE-GLYCERIN-WATER ENEMA 180 ML,RX-4080412,CDM,S5000,HCPCS,259,RC,00000-0000-02,NDC,outpatient,180,ML,28.04,19.628,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METOPROLOL TARTRATE ORAL SUSPENSION 1 MG/ML,RX-4080416,CDM,S5000,HCPCS,259,RC,99999-0003-46,NDC,outpatient,12.5,ML,1.93,1.351,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,00121-0759-20,NDC,outpatient,20,ML,13.44,9.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,00121-0885-16,NDC,outpatient,480,ML,1149.17,804.419,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,42799-0815-01,NDC,outpatient,237,ML,151.87,106.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,99999-0002-35,NDC,outpatient,20,ML,13.44,9.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,62135-0250-20,NDC,outpatient,20,ML,98.71,69.097,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,62135-0250-37,NDC,outpatient,240,ML,1184.42,829.094,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,00121-0759-08,NDC,outpatient,237,ML,159.26,111.482,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,69238-2122-20,NDC,outpatient,20,ML,14.96,10.472,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,99999-0002-36,NDC,outpatient,5,ML,2.94,2.058,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MORPHINE 0.4 MG/ML 1 ML NEONATAL ORAL SYRINGE,RX-4080423,CDM,S5000,HCPCS,259,RC,99999-0001-12,NDC,outpatient,1,ML,1.09,0.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MORPHINE 0.4 MG/ML 1 ML NEONATAL ORAL SYRINGE,RX-4080423,CDM,S5000,HCPCS,259,RC,SH408-0423-01,NDC,outpatient,1,ML,1.09,0.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE 1 MEQ/ML 1 ML ORAL SYRINGE,RX-4080424,CDM,S5000,HCPCS,259,RC,99999-0001-25,NDC,outpatient,1,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE-MINERAL OIL-GLYCERIN ENEMA,RX-4080430,CDM,S5000,HCPCS,259,RC,SH408-0430-01,NDC,outpatient,135,ML,9.22,6.454,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POTASSIUM CHLORIDE 2 MEQ/1.5 ML ORAL SYRINGE,RX-4080432,CDM,S5000,HCPCS,259,RC,,,outpatient,1.5,ML,1.92,1.344,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POTASSIUM CHLORIDE 2 MEQ/1.5 ML ORAL SYRINGE,RX-4080432,CDM,S5000,HCPCS,259,RC,99999-0001-26,NDC,outpatient,1.5,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SPIRONOLACTONE 6 MG/3 ML ORAL SYRINGE,RX-4080435,CDM,S5000,HCPCS,259,RC,99999-0000-28,NDC,outpatient,3,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CEFAZOLIN IVPB 2 G IN 100 ML NS PREMIX,RX-4080437,CDM,S5000,HCPCS,250,RC,99999-0000-45,NDC,outpatient,100,ML,47.78,33.446,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VANCOMYCIN INTRACAMERAL INJECTION 10 MG/ML,RX-4080449,CDM,S5000,HCPCS,259,RC,SH408-0449-01,NDC,outpatient,2,ML,22.21,15.547,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VANCOMYCIN INTRACAMERAL INJECTION 10 MG/ML,RX-4080449,CDM,S5000,HCPCS,259,RC,SH408-0450-01,NDC,outpatient,0.1,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VANCOMYCIN EYE SOLUTION 25 MG/ML,RX-4080451,CDM,S5000,HCPCS,259,RC,SH408-0451-01,NDC,outpatient,20,ML,54.07,37.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VANCOMYCIN EYE SOLUTION 50 MG/ML ,RX-4080452,CDM,S5000,HCPCS,259,RC,SH408-0452-01,NDC,outpatient,20,ML,54.07,37.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
WARFARIN SODIUM 0.5 MG ORAL SPLIT TABS,RX-4080479,CDM,S5000,HCPCS,259,RC,76282-0327-01,NDC,outpatient,1,UN,1.15,0.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
WARFARIN SODIUM 0.5 MG ORAL SPLIT TABS,RX-4080479,CDM,S5000,HCPCS,259,RC,99999-0002-46,NDC,outpatient,0.5,ME,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
WARFARIN SODIUM 0.5 MG ORAL SPLIT TABS,RX-4080479,CDM,S5000,HCPCS,259,RC,51672-4027-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
WARFARIN SODIUM 1.25 MG ORAL SPLIT TABS,RX-4080485,CDM,S5000,HCPCS,259,RC,99999-0002-47,NDC,outpatient,1.25,ME,4.53,3.171,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
WARFARIN SODIUM 1.25 MG ORAL SPLIT TABS,RX-4080485,CDM,S5000,HCPCS,259,RC,51672-4029-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,70004-0775-40,NDC,outpatient,250,ML,320.83,224.581,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,70092-1468-05,NDC,outpatient,250,ML,192.22,134.554,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,69374-0533-25,NDC,outpatient,250,ML,140.6,98.42,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,70092-1652-05,NDC,outpatient,250,ML,216.97,151.879,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,81298-9658-03,NDC,outpatient,250,ML,261.87,183.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,69374-0315-25,NDC,outpatient,250,ML,118.35,82.845,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,70004-0785-40,NDC,outpatient,250,ML,301.03,210.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,81298-9658-01,NDC,outpatient,250,ML,261.87,183.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
THIAMINE HCL 100 MG ORAL TABS WRAPPER,RX-4080502,CDM,S5000,HCPCS,259,RC,48433-0108-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
THIAMINE HCL 100 MG ORAL TABS WRAPPER,RX-4080502,CDM,S5000,HCPCS,259,RC,77333-0934-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
THIAMINE HCL 100 MG ORAL TABS WRAPPER,RX-4080502,CDM,S5000,HCPCS,259,RC,00904-7191-06,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
THIAMINE HCL 100 MG ORAL TABS WRAPPER,RX-4080502,CDM,S5000,HCPCS,259,RC,77333-0934-25,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NEOSTIGMINE METHYLSULFATE 1 MG/ML SYRINGE,RX-4080506,CDM,S5000,HCPCS,250,RC,70092-1084-44,NDC,outpatient,5,ML,61.01,42.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NEOSTIGMINE METHYLSULFATE 1 MG/ML SYRINGE,RX-4080506,CDM,S5000,HCPCS,250,RC,76045-0383-13,NDC,outpatient,3,ML,51.74,36.218,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NEOSTIGMINE METHYLSULFATE 1 MG/ML SYRINGE,RX-4080506,CDM,S5000,HCPCS,250,RC,70004-0750-09,NDC,outpatient,5,ML,78.06,54.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NEOSTIGMINE METHYLSULFATE 1 MG/ML SYRINGE,RX-4080506,CDM,S5000,HCPCS,250,RC,69374-0932-03,NDC,outpatient,3,ML,45.62,31.934,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NEOSTIGMINE METHYLSULFATE 1 MG/ML SYRINGE,RX-4080506,CDM,S5000,HCPCS,250,RC,76045-0383-30,NDC,outpatient,3,ML,51.74,36.218,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FERROUS GLUCONATE 324 MG ORAL TABS WRAPPER,RX-4080542,CDM,S5000,HCPCS,259,RC,00574-0508-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FERROUS GLUCONATE 324 MG ORAL TABS WRAPPER,RX-4080542,CDM,S5000,HCPCS,259,RC,20555-0019-00,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ARTIFICIAL TEARS OP OINT WRAPPER,RX-4080546,CDM,S5000,HCPCS,259,RC,00065-0518-01,NDC,outpatient,3.5,GR,29.43,20.601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ARTIFICIAL TEARS OP OINT WRAPPER,RX-4080546,CDM,S5000,HCPCS,259,RC,10119-0022-39,NDC,outpatient,3.5,GR,30.17,21.119,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE 1 % FOR PLEURODESIS,RX-4080551,CDM,S5000,HCPCS,250,RC,99999-0003-43,NDC,outpatient,50,ML,13.37,9.359,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POTASSIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080554,CDM,S5000,HCPCS,250,RC,00409-7295-01,NDC,outpatient,15,ML,59.41,41.587,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POTASSIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080554,CDM,S5000,HCPCS,250,RC,65219-0052-09,NDC,outpatient,5,ML,93.68,65.576,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POTASSIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080554,CDM,S5000,HCPCS,250,RC,00409-7295-11,NDC,outpatient,15,ML,59.41,41.587,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POTASSIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080554,CDM,S5000,HCPCS,250,RC,65219-0052-29,NDC,outpatient,5,ML,93.68,65.576,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,00409-4888-12,NDC,outpatient,10,ML,9.82,6.874,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,00409-4888-01,NDC,outpatient,10,ML,9.82,6.874,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,00409-4888-02,NDC,outpatient,10,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,63323-0186-01,NDC,outpatient,10,ML,3.71,2.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,00409-4888-10,NDC,outpatient,10,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,63323-0186-10,NDC,outpatient,10,ML,3.71,2.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MENTHOL-ZINC OXIDE 0.44-20.625 % EX OINT WRAPPER,RX-4080556,CDM,S5000,HCPCS,259,RC,10135-0701-04,NDC,outpatient,113,GR,13.58,9.506,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MENTHOL-ZINC OXIDE 0.44-20.625 % EX OINT WRAPPER,RX-4080556,CDM,S5000,HCPCS,259,RC,00799-0001-04,NDC,outpatient,113,GR,20.12,14.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DILTIAZEM 100 MG ADDVANTAGE INFUSION IN D5W 100 ML,RX-4080558,CDM,S5000,HCPCS,250,RC,99999-0000-01,NDC,outpatient,100,ML,48.09,33.663,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HIV POST EXPOSURE KIT,RX-4080559,CDM,S5000,HCPCS,259,RC,SH408-0559-01,NDC,outpatient,1,UN,1178.97,825.279,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPIVACAINE 0.125 % IN 100 ML NS NERVE BLOCK CASSETTE,RX-4080570,CDM,S5000,HCPCS,250,RC,61553-0829-48,NDC,outpatient,100,ML,76.93,53.851,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FENTANYL 3 MCG/ML WITH BUPIVACAINE 0.125 % EPIDURAL,RX-4080589,CDM,S5000,HCPCS,250,RC,99999-0000-04,NDC,outpatient,100,ML,79.95,55.965,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VEIN GRAFT SOLUTION,RX-4080591,CDM,S5000,HCPCS,250,RC,99999-0000-07,NDC,outpatient,505.67,ML,73.5,51.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLECAINIDE ACETATE 20 MG/ML ORAL SUSP,RX-4080607,CDM,S5000,HCPCS,259,RC,99999-0003-52,NDC,outpatient,2.5,ML,2.45,1.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYOSCYAMINE SULFATE 0.125 MG SL SUBL WRAPPER,RX-4080632,CDM,S5000,HCPCS,259,RC,42192-0338-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MESALAMINE 4 G RE ENEM WRAPPER,RX-4080640,CDM,S5000,HCPCS,259,RC,45802-0098-51,NDC,outpatient,60,ML,33.11,23.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MESALAMINE 4 G RE ENEM WRAPPER,RX-4080640,CDM,S5000,HCPCS,259,RC,45802-0098-46,NDC,outpatient,60,ML,33.11,23.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MESALAMINE 4 G RE ENEM WRAPPER,RX-4080640,CDM,S5000,HCPCS,259,RC,45802-0923-41,NDC,outpatient,60,ML,80.91,56.637,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MAGNESIUM OXIDE 400 MG ORAL TABS WRAPPER,RX-4080641,CDM,S5000,HCPCS,259,RC,64980-0339-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MAGNESIUM OXIDE 400 MG ORAL TABS WRAPPER,RX-4080641,CDM,S5000,HCPCS,259,RC,10006-0700-28,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MAGNESIUM OXIDE 400 MG ORAL TABS WRAPPER,RX-4080641,CDM,S5000,HCPCS,259,RC,64980-0339-90,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MAGNESIUM GLUCONATE 500 MG ORAL TABS WRAPPER,RX-4080642,CDM,S5000,HCPCS,259,RC,60258-0172-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GI COCKTAIL SUSPENSION,RX-4080647,CDM,S5000,HCPCS,259,RC,99999-0000-39,NDC,outpatient,55,ML,82.33,57.631,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CARDIOPLEGIA SOLN DEL NIDO,RX-4080676,CDM,S5000,HCPCS,250,RC,99999-0004-39,NDC,outpatient,1052.8,ML,113.01,79.107,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
EPINEPHRINE PF 10 MCG/ML 10 ML SYRINGE,RX-4080700,CDM,S5000,HCPCS,250,RC,70092-1512-46,NDC,outpatient,10,ML,20.96,14.672,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
EPINEPHRINE PF 10 MCG/ML 10 ML SYRINGE,RX-4080700,CDM,S5000,HCPCS,250,RC,70092-1617-46,NDC,outpatient,10,ML,31.42,21.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE 0.9 % IV SOLN MINI-BAG 100 ML,RX-4080711,CDM,S5000,HCPCS,250,RC,00338-0553-18,NDC,outpatient,100,ML,29.37,20.559,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HYDROCORTISONE ORAL SUSPENSION 2.5 MG/ML COMPOUNDED PRODUCT,RX-4080716,CDM,S5000,HCPCS,259,RC,99999-0000-80,NDC,outpatient,1,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLUDROCORTISONE ACETATE SUSP 0.2 MG/ML,RX-4080718,CDM,S5000,HCPCS,259,RC,99999-0000-81,NDC,outpatient,1,ML,4.96,3.472,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ZINC OXIDE 40 % (BOUDREAUX'S) PASTE,RX-4080754,CDM,S5000,HCPCS,259,RC,62103-0323-02,NDC,outpatient,57,GR,14.72,10.304,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ZINC OXIDE 40 % (BOUDREAUX'S) PASTE,RX-4080754,CDM,S5000,HCPCS,259,RC,74300-0000-71,NDC,outpatient,113,GR,26.15,18.305,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NALOXONE INHALATION KIT - HOSPITAL USE ONLY,RX-4080774,CDM,S5000,HCPCS,259,RC,99999-0000-90,NDC,outpatient,1,UN,110.81,77.567,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CISATRACURIUM BESYLATE 10 MG/ML IV SOLN WRAPPER,RX-4080786,CDM,S5000,HCPCS,250,RC,00409-1103-11,NDC,outpatient,20,ML,230.78,161.546,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CISATRACURIUM BESYLATE 10 MG/ML IV SOLN WRAPPER,RX-4080786,CDM,S5000,HCPCS,250,RC,00409-1103-01,NDC,outpatient,20,ML,230.78,161.546,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CEFAZOLIN IVPB 3 G IN 100 ML NS PREMIX,RX-4080801,CDM,S5000,HCPCS,250,RC,99999-0001-10,NDC,outpatient,130,ML,33.43,23.401,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PERICAPSULAR MIXTURE INJECTION,RX-4080804,CDM,S5000,HCPCS,250,RC,70092-1433-50,NDC,outpatient,50,ML,216.36,151.452,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PERICAPSULAR MIXTURE INJECTION,RX-4080804,CDM,S5000,HCPCS,250,RC,99999-0000-98,NDC,outpatient,50,ML,59.06,41.342,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRANEXAMIC ACID 5 % MOUTHWASH ORAL SUSPENSION,RX-4080811,CDM,S5000,HCPCS,259,RC,99999-0001-06,NDC,outpatient,169,ML,77.47,54.229,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP *DYE FREE*,RX-4080831,CDM,S5000,HCPCS,259,RC,99999-0001-17,NDC,outpatient,5,ML,1.37,0.959,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP *DYE FREE*,RX-4080831,CDM,S5000,HCPCS,259,RC,50580-0170-05,NDC,outpatient,5,ML,1.37,0.959,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP *DYE FREE*,RX-4080831,CDM,S5000,HCPCS,259,RC,00045-0166-04,NDC,outpatient,120,ML,28.31,19.817,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BABY BUTT BALM,RX-4080852,CDM,S5000,HCPCS,259,RC,99999-0001-13,NDC,outpatient,118.7,GR,70.96,49.672,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACETAZOLAMIDE 25 MG/ML SUSPENSION,RX-4080874,CDM,S5000,HCPCS,259,RC,99999-0001-21,NDC,outpatient,5,ML,10.93,7.651,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,00005-4344-62,NDC,outpatient,15,ML,2.09,1.463,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,68094-0120-61,NDC,outpatient,15,ML,7.68,5.376,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,68094-0120-59,NDC,outpatient,15,ML,7.68,5.376,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,00573-0513-15,NDC,outpatient,15,ML,2.32,1.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,99999-0002-20,NDC,outpatient,15,ML,2.01,1.407,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,00573-0513-30,NDC,outpatient,15,ML,2.32,1.624,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,69618-0008-58,NDC,outpatient,15,ML,2.55,1.785,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FERRIC SUBSULFATE SOLN WRAPPER,RX-4080921,CDM,S5000,HCPCS,250,RC,38779-1284-08,NDC,outpatient,8,ML,2.35,1.645,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FERRIC SUBSULFATE SOLN WRAPPER,RX-4080921,CDM,S5000,HCPCS,250,RC,10481-0112-08,NDC,outpatient,8,ML,47.67,33.369,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FERRIC SUBSULFATE SOLN WRAPPER,RX-4080921,CDM,S5000,HCPCS,250,RC,49452-3081-02,NDC,outpatient,8,ML,2.35,1.645,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FERRIC SUBSULFATE SOLN WRAPPER,RX-4080921,CDM,S5000,HCPCS,250,RC,10481-0112-02,NDC,outpatient,8,ML,9.33,6.531,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080937,CDM,S5000,HCPCS,250,RC,63323-0170-05,NDC,outpatient,5,ML,35.56,24.892,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080937,CDM,S5000,HCPCS,250,RC,63323-0881-16,NDC,outpatient,15,ML,169.35,118.545,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080937,CDM,S5000,HCPCS,250,RC,63323-0884-01,NDC,outpatient,5,ML,79.73,55.811,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080937,CDM,S5000,HCPCS,250,RC,63323-0884-06,NDC,outpatient,5,ML,79.73,55.811,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080937,CDM,S5000,HCPCS,250,RC,63323-0881-01,NDC,outpatient,15,ML,169.35,118.545,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,00143-9250-10,NDC,outpatient,5,ML,10.46,7.322,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,25021-0662-05,NDC,outpatient,5,ML,11.88,8.316,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,39822-4200-05,NDC,outpatient,10,ML,22.61,15.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,39822-4200-06,NDC,outpatient,10,ML,22.61,15.827,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,72611-0756-01,NDC,outpatient,5,ML,24.17,16.919,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,00143-9250-01,NDC,outpatient,5,ML,10.46,7.322,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,43066-0007-10,NDC,outpatient,5,ML,8.46,5.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,63323-0426-05,NDC,outpatient,5,ML,7.05,4.935,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,67457-0228-02,NDC,outpatient,5,ML,6.84,4.788,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,55150-0226-10,NDC,outpatient,10,ML,18.46,12.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,66794-0228-41,NDC,outpatient,5,ML,6.84,4.788,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,72611-0756-10,NDC,outpatient,5,ML,24.17,16.919,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,55150-0225-05,NDC,outpatient,5,ML,9.23,6.461,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,63323-0426-02,NDC,outpatient,5,ML,7.05,4.935,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMIODARONE ORAL SUSPENSION 40 MG/ML,RX-4080970,CDM,S5000,HCPCS,259,RC,99999-0001-63,NDC,outpatient,10,ML,2.04,1.428,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MORPHINE SULFATE 100 MG/100 ML IN D5W PF PREMIX,RX-4081012,CDM,S5000,HCPCS,250,RC,99999-0000-99,NDC,outpatient,100,ML,312.37,218.659,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
EPHEDRINE SULFATE 5 MG/ML IJ WRAPPER,RX-4081019,CDM,S5000,HCPCS,250,RC,42023-0243-01,NDC,outpatient,10,ML,42.55,29.785,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
EPHEDRINE SULFATE 5 MG/ML IJ WRAPPER,RX-4081019,CDM,S5000,HCPCS,250,RC,14789-0250-10,NDC,outpatient,10,ML,61.68,43.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
EPHEDRINE SULFATE 5 MG/ML IJ WRAPPER,RX-4081019,CDM,S5000,HCPCS,250,RC,14789-0250-07,NDC,outpatient,10,ML,61.68,43.176,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
INSULIN REGULAR 1 UNIT/ML INFUSION PREMIX,RX-4081020,CDM,S5000,HCPCS,250,RC,99999-0000-87,NDC,outpatient,100,ML,34.01,23.807,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
INSULIN REGULAR 1 UNIT/ML INFUSION PREMIX,RX-4081020,CDM,S5000,HCPCS,250,RC,00338-0126-12,NDC,outpatient,100,ML,98.33,68.831,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DILTIAZEM 100 MG IN 100 ML NS BATCHED INFUSION,RX-4081050,CDM,S5000,HCPCS,250,RC,99999-0002-64,NDC,outpatient,100,ML,56.68,39.676,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
URSODIOL 50 MG/ML ORAL SUSPENSION,RX-4081064,CDM,S5000,HCPCS,259,RC,99999-0002-69,NDC,outpatient,1,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPRENORPHINE-NALOXONE (SUBOXONE) SL FILM 8 MG-2 MG KIT,RX-4081171,CDM,S5000,HCPCS,259,RC,99999-0003-16,NDC,outpatient,1,UN,142.33,99.631,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,00409-4903-34,NDC,outpatient,5,ML,17.92,12.544,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,00409-4903-11,NDC,outpatient,5,ML,17.92,12.544,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,63323-0208-05,NDC,outpatient,5,ML,7.41,5.187,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,76329-3390-01,NDC,outpatient,5,ML,27.15,19.005,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,00409-1323-05,NDC,outpatient,5,ML,19.63,13.741,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,00409-1323-15,NDC,outpatient,5,ML,19.63,13.741,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRANEXAMIC ACID 100 MG/ML FOR INHALATION,RX-4081187,CDM,S5000,HCPCS,250,RC,39822-1000-01,NDC,outpatient,10,ML,23.86,16.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRANEXAMIC ACID 100 MG/ML FOR INHALATION,RX-4081187,CDM,S5000,HCPCS,250,RC,81284-0611-10,NDC,outpatient,10,ML,24.48,17.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRANEXAMIC ACID 100 MG/ML FOR INHALATION,RX-4081187,CDM,S5000,HCPCS,250,RC,72485-0510-10,NDC,outpatient,10,ML,12.64,8.848,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRANEXAMIC ACID 100 MG/ML FOR INHALATION,RX-4081187,CDM,S5000,HCPCS,250,RC,72485-0510-01,NDC,outpatient,10,ML,12.64,8.848,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRANEXAMIC ACID 100 MG/ML FOR INHALATION,RX-4081187,CDM,S5000,HCPCS,250,RC,81284-0611-00,NDC,outpatient,10,ML,24.48,17.136,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MORPHINE SULFATE 100 MG/100 ML IN NS PF PREMIX,RX-4081195,CDM,S5000,HCPCS,250,RC,99999-0003-26,NDC,outpatient,100,ML,312.37,218.659,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PANTOPRAZOLE 80 MG/100 ML INFUSION PREMIX,RX-4081208,CDM,S5000,HCPCS,250,RC,99999-0000-77,NDC,outpatient,100,ML,36.56,25.592,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NICARDIPINE HCL 40 MG IN NACL 200 ML IV SOLN WRAPPER,RX-4081293,CDM,S5000,HCPCS,250,RC,00143-9633-10,NDC,outpatient,200,ML,242.06,169.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NICARDIPINE HCL 40 MG IN NACL 200 ML IV SOLN WRAPPER,RX-4081293,CDM,S5000,HCPCS,250,RC,00143-9633-01,NDC,outpatient,200,ML,242.06,169.442,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE 3 % IV ONCE,RX-4081432,CDM,S5000,HCPCS,250,RC,99999-0003-86,NDC,outpatient,100,ML,18.06,12.642,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FAMOTIDINE IN NACL 20-0.9 MG/10 ML-% IV SOSY,RX-4081444,CDM,S5000,HCPCS,250,RC,99999-0003-96,NDC,outpatient,5,ML,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM HYALURONATE 10 MG/ML IO SOLN WRAPPER,RX-4081458,CDM,S5000,HCPCS,250,RC,05047-4508-38,NDC,outpatient,0.4,ML,397.92,278.544,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV *BATCHED*,RX-4081542,CDM,S5000,HCPCS,250,RC,99999-0004-35,NDC,outpatient,50,ML,157.29,110.103,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NALOXONE HCL 4 MG/0.1ML NA LIQD FOR CODE NARRATOR,RX-4081549,CDM,S5000,HCPCS,259,RC,00093-2165-19,NDC,outpatient,1,UN,146.88,102.816,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NALOXONE HCL 4 MG/0.1ML NA LIQD FOR CODE NARRATOR,RX-4081549,CDM,S5000,HCPCS,259,RC,00093-2165-68,NDC,outpatient,1,UN,146.88,102.816,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MORPHINE SULFATE 1 MG/ML 100 ML PCA,RX-4081551,CDM,S5000,HCPCS,250,RC,70092-1518-75,NDC,outpatient,100,ML,209.09,146.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MORPHINE SULFATE 1 MG/ML 100 ML PCA,RX-4081551,CDM,S5000,HCPCS,250,RC,99999-0004-53,NDC,outpatient,100,ML,48.85,34.195,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PRASUGREL HCL 10 MG TABS - OMNICELL CATH LAB USE ONLY,RX-4081602,CDM,S5000,HCPCS,259,RC,65862-0830-30,NDC,outpatient,0.5,UN,1,0.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PRASUGREL HCL 10 MG TABS - OMNICELL CATH LAB USE ONLY,RX-4081602,CDM,S5000,HCPCS,259,RC,00378-5186-93,NDC,outpatient,0.5,UN,4.12,2.884,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PRASUGREL HCL 10 MG TABS - OMNICELL CATH LAB USE ONLY,RX-4081602,CDM,S5000,HCPCS,259,RC,65162-0002-03,NDC,outpatient,0.5,UN,2.9,2.03,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METHADONE 10 MG TABLET DISCHARGE KIT,RX-4081610,CDM,S5000,HCPCS,259,RC,99999-0004-50,NDC,outpatient,1,UN,6.15,4.305,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PRISMASATE K 4/CA 2.5 CRRT SOLUTION,RX-40840045,CDM,S5000,HCPCS,250,RC,SH408-4045-01,NDC,outpatient,5000,ML,188.44,131.908,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PRISMASATE K 2/CA 0 CRRT SOLUTION,RX-40840046,CDM,S5000,HCPCS,250,RC,SH408-4046-01,NDC,outpatient,5000,ML,188.44,131.908,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BENZOCAINE-MENTHOL 6-10 MG MT LOZG,RX-41085,CDM,S5000,HCPCS,259,RC,78112-0012-66,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BENZOCAINE-MENTHOL 6-10 MG MT LOZG,RX-41085,CDM,S5000,HCPCS,259,RC,78112-0011-06,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GALANTAMINE HYDROBROMIDE ER 8 MG ORAL CP24,RX-41138,CDM,S5000,HCPCS,259,RC,47335-0835-83,NDC,outpatient,1,UN,5.27,3.689,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GALANTAMINE HYDROBROMIDE ER 8 MG ORAL CP24,RX-41138,CDM,S5000,HCPCS,259,RC,63629-2364-01,NDC,outpatient,1,UN,6.03,4.221,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IPRATROPIUM BROMIDE HFA 17 MCG/ACT IN AERS,RX-41142,CDM,S5000,HCPCS,259,RC,00597-0087-17,NDC,outpatient,12.9,GR,1940.98,1358.686,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ENTECAVIR 0.5 MG ORAL TABS,RX-41147,CDM,S5000,HCPCS,259,RC,00003-1611-12,NDC,outpatient,1,UN,197.48,138.236,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ENTECAVIR 1 MG ORAL TABS,RX-41148,CDM,S5000,HCPCS,259,RC,65862-0842-30,NDC,outpatient,1,UN,8.95,6.265,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FENTANYL 12 MCG/HR TD PT72,RX-41382,CDM,S5000,HCPCS,259,RC,47781-0423-11,NDC,outpatient,1,UN,21.37,14.959,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FENTANYL 12 MCG/HR TD PT72,RX-41382,CDM,S5000,HCPCS,259,RC,47781-0423-47,NDC,outpatient,1,UN,21.37,14.959,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FENTANYL 12 MCG/HR TD PT72,RX-41382,CDM,S5000,HCPCS,259,RC,00378-9119-16,NDC,outpatient,1,UN,50.62,35.434,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FENTANYL 12 MCG/HR TD PT72,RX-41382,CDM,S5000,HCPCS,259,RC,00378-9119-98,NDC,outpatient,1,UN,50.62,35.434,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PARICALCITOL 1 MCG ORAL CAPS,RX-41497,CDM,S5000,HCPCS,259,RC,65862-0936-30,NDC,outpatient,1,UN,5.24,3.668,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PARICALCITOL 1 MCG ORAL CAPS,RX-41497,CDM,S5000,HCPCS,259,RC,49483-0687-03,NDC,outpatient,1,UN,4.45,3.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVOCARNITINE 1 GM/10ML ORAL SOLN,RX-41623,CDM,S5000,HCPCS,259,RC,52817-0830-04,NDC,outpatient,1,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVOCARNITINE 1 GM/10ML ORAL SOLN,RX-41623,CDM,S5000,HCPCS,259,RC,99999-0002-52,NDC,outpatient,10,ML,6.37,4.459,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM TETRADECYL SULFATE 3 % IV SOLN,RX-41793,CDM,S5000,HCPCS,250,RC,24201-0201-01,NDC,outpatient,0.5,ML,58.03,40.621,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM TETRADECYL SULFATE 3 % IV SOLN,RX-41793,CDM,S5000,HCPCS,250,RC,67457-0163-00,NDC,outpatient,0.5,ML,58.19,40.733,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM TETRADECYL SULFATE 3 % IV SOLN,RX-41793,CDM,S5000,HCPCS,250,RC,67457-0163-02,NDC,outpatient,0.5,ML,64.31,45.017,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM TETRADECYL SULFATE 3 % IV SOLN,RX-41793,CDM,S5000,HCPCS,250,RC,24201-0201-05,NDC,outpatient,0.5,ML,58.03,40.621,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OMEGA-3-ACID ETHYL ESTERS 1 G ORAL CAPS,RX-41822,CDM,S5000,HCPCS,259,RC,64380-0761-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE 5 % EX OINT,RX-41831,CDM,S5000,HCPCS,259,RC,64380-0789-32,NDC,outpatient,35.44,GR,61.67,43.169,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE 5 % EX OINT,RX-41831,CDM,S5000,HCPCS,259,RC,65162-0918-38,NDC,outpatient,35.44,GR,50,35,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SILDENAFIL CITRATE 20 MG ORAL TABS,RX-41832,CDM,S5000,HCPCS,259,RC,00904-6671-04,NDC,outpatient,1,UN,2.21,1.547,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SILDENAFIL CITRATE 20 MG ORAL TABS,RX-41832,CDM,S5000,HCPCS,259,RC,63739-0072-33,NDC,outpatient,1,UN,2.21,1.547,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METRONIDAZOLE 1 % EX GEL,RX-41899,CDM,S5000,HCPCS,259,RC,51672-4215-03,NDC,outpatient,60,GR,258.99,181.293,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AVEENO SOOTHING BATH TREATMENT EX PACK,RX-41904,CDM,S5000,HCPCS,259,RC,08137-0036-40,NDC,outpatient,1,UN,2.74,1.918,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RAMELTEON 8 MG ORAL TABS,RX-42064,CDM,S5000,HCPCS,259,RC,50268-0708-11,NDC,outpatient,1,UN,11.47,8.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RAMELTEON 8 MG ORAL TABS,RX-42064,CDM,S5000,HCPCS,259,RC,70010-0028-03,NDC,outpatient,1,UN,6.31,4.417,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RAMELTEON 8 MG ORAL TABS,RX-42064,CDM,S5000,HCPCS,259,RC,50268-0708-15,NDC,outpatient,1,UN,11.47,8.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DICYCLOMINE HCL 10 MG/5ML ORAL SOLN,RX-42119,CDM,S5000,HCPCS,259,RC,00054-0622-63,NDC,outpatient,5,ML,3.5,2.45,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DICYCLOMINE HCL 10 MG/5ML ORAL SOLN,RX-42119,CDM,S5000,HCPCS,259,RC,99999-0003-12,NDC,outpatient,5,ML,5.06,3.542,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREGABALIN 25 MG ORAL CAPS,RX-42162,CDM,S5000,HCPCS,259,RC,50228-0350-90,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREGABALIN 25 MG ORAL CAPS,RX-42162,CDM,S5000,HCPCS,259,RC,60687-0473-01,NDC,outpatient,1,UN,1.96,1.372,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREGABALIN 25 MG ORAL CAPS,RX-42162,CDM,S5000,HCPCS,259,RC,60687-0473-11,NDC,outpatient,1,UN,1.96,1.372,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREGABALIN 50 MG ORAL CAPS,RX-42163,CDM,S5000,HCPCS,259,RC,00904-6992-61,NDC,outpatient,1,UN,2.3,1.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREGABALIN 50 MG ORAL CAPS,RX-42163,CDM,S5000,HCPCS,259,RC,72205-0012-90,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREGABALIN 50 MG ORAL CAPS,RX-42163,CDM,S5000,HCPCS,259,RC,00071-1013-41,NDC,outpatient,1,UN,45.77,32.039,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREGABALIN 75 MG ORAL CAPS,RX-42164,CDM,S5000,HCPCS,259,RC,00904-7000-61,NDC,outpatient,1,UN,2.47,1.729,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREGABALIN 75 MG ORAL CAPS,RX-42164,CDM,S5000,HCPCS,259,RC,60687-0495-11,NDC,outpatient,1,UN,1.87,1.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREGABALIN 75 MG ORAL CAPS,RX-42164,CDM,S5000,HCPCS,259,RC,62332-0121-90,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREGABALIN 75 MG ORAL CAPS,RX-42164,CDM,S5000,HCPCS,259,RC,00071-1014-41,NDC,outpatient,1,UN,45.77,32.039,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREGABALIN 75 MG ORAL CAPS,RX-42164,CDM,S5000,HCPCS,259,RC,60687-0495-01,NDC,outpatient,1,UN,1.87,1.309,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREGABALIN 100 MG ORAL CAPS,RX-42165,CDM,S5000,HCPCS,259,RC,69238-1313-09,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREGABALIN 100 MG ORAL CAPS,RX-42165,CDM,S5000,HCPCS,259,RC,00904-7001-61,NDC,outpatient,1,UN,2.38,1.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREGABALIN 100 MG ORAL CAPS,RX-42165,CDM,S5000,HCPCS,259,RC,62332-0122-90,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREGABALIN 150 MG ORAL CAPS,RX-42166,CDM,S5000,HCPCS,259,RC,00071-1016-41,NDC,outpatient,1,UN,45.77,32.039,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREGABALIN 150 MG ORAL CAPS,RX-42166,CDM,S5000,HCPCS,259,RC,00904-7002-61,NDC,outpatient,1,UN,2.56,1.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
KETAMINE HCL 10 MG/ML IJ SOLN,RX-4236,CDM,S5000,HCPCS,250,RC,42023-0113-10,NDC,outpatient,20,ML,41.57,29.099,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
KETAMINE HCL 100 MG/ML IJ SOLN,RX-4237,CDM,S5000,HCPCS,250,RC,42023-0115-10,NDC,outpatient,5,ML,53.45,37.415,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
KETAMINE HCL 50 MG/ML IJ SOLN,RX-4238,CDM,S5000,HCPCS,250,RC,00143-9508-10,NDC,outpatient,10,ML,23.23,16.261,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
KETAMINE HCL 50 MG/ML IJ SOLN,RX-4238,CDM,S5000,HCPCS,250,RC,00143-9508-01,NDC,outpatient,10,ML,23.23,16.261,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMITRIPTYLINE HCL 10 MG ORAL TABS,RX-432,CDM,S5000,HCPCS,259,RC,50268-0037-15,NDC,outpatient,1,UN,1.35,0.945,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMITRIPTYLINE HCL 10 MG ORAL TABS,RX-432,CDM,S5000,HCPCS,259,RC,70756-0201-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMITRIPTYLINE HCL 10 MG ORAL TABS,RX-432,CDM,S5000,HCPCS,259,RC,50268-0037-11,NDC,outpatient,1,UN,1.35,0.945,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMITRIPTYLINE HCL 25 MG ORAL TABS,RX-435,CDM,S5000,HCPCS,259,RC,00781-1487-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMITRIPTYLINE HCL 25 MG ORAL TABS,RX-435,CDM,S5000,HCPCS,259,RC,60687-0433-11,NDC,outpatient,1,UN,1.4,0.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMITRIPTYLINE HCL 25 MG ORAL TABS,RX-435,CDM,S5000,HCPCS,259,RC,60687-0433-01,NDC,outpatient,1,UN,1.4,0.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DIGOXIN 0.05 MG/ML ORAL SOLN,RX-43556,CDM,S5000,HCPCS,259,RC,00054-0057-46,NDC,outpatient,60,ML,612.5,428.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DIGOXIN 0.05 MG/ML ORAL SOLN,RX-43556,CDM,S5000,HCPCS,259,RC,99999-0004-03,NDC,outpatient,2.5,ML,25.53,17.871,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMITRIPTYLINE HCL 50 MG ORAL TABS,RX-436,CDM,S5000,HCPCS,259,RC,60687-0444-01,NDC,outpatient,1,UN,1.83,1.281,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMITRIPTYLINE HCL 50 MG ORAL TABS,RX-436,CDM,S5000,HCPCS,259,RC,60687-0444-11,NDC,outpatient,1,UN,1.83,1.281,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL 4 % MT SOLN,RX-43717,CDM,S5000,HCPCS,259,RC,76329-6300-05,NDC,outpatient,4,ML,116.7,81.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMMONIA AROMATIC IN INHA,RX-439,CDM,S5000,HCPCS,259,RC,67777-0251-01,NDC,outpatient,1,UN,1.04,0.728,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEUCOVORIN CALCIUM 5 MG ORAL TABS,RX-4398,CDM,S5000,HCPCS,259,RC,00054-8496-19,NDC,outpatient,1,UN,7.46,5.222,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEUCOVORIN CALCIUM 5 MG ORAL TABS,RX-4398,CDM,S5000,HCPCS,259,RC,00555-0484-02,NDC,outpatient,1,UN,5.35,3.745,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVOTHYROXINE SODIUM 25 MCG ORAL TABS,RX-4420,CDM,S5000,HCPCS,259,RC,60687-0453-01,NDC,outpatient,1,UN,1.54,1.078,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVOTHYROXINE SODIUM 25 MCG ORAL TABS,RX-4420,CDM,S5000,HCPCS,259,RC,60687-0453-11,NDC,outpatient,1,UN,1.54,1.078,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVOTHYROXINE SODIUM 25 MCG ORAL TABS,RX-4420,CDM,S5000,HCPCS,259,RC,51079-0444-01,NDC,outpatient,1,UN,2.38,1.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVOTHYROXINE SODIUM 25 MCG ORAL TABS,RX-4420,CDM,S5000,HCPCS,259,RC,51079-0444-20,NDC,outpatient,1,UN,2.38,1.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVOTHYROXINE SODIUM 50 MCG ORAL TABS,RX-4421,CDM,S5000,HCPCS,259,RC,60687-0464-01,NDC,outpatient,1,UN,1.67,1.169,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVOTHYROXINE SODIUM 50 MCG ORAL TABS,RX-4421,CDM,S5000,HCPCS,259,RC,60687-0464-11,NDC,outpatient,1,UN,1.67,1.169,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVOTHYROXINE SODIUM 50 MCG ORAL TABS,RX-4421,CDM,S5000,HCPCS,259,RC,51079-0440-20,NDC,outpatient,1,UN,2.52,1.764,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVOTHYROXINE SODIUM 50 MCG ORAL TABS,RX-4421,CDM,S5000,HCPCS,259,RC,51079-0440-01,NDC,outpatient,1,UN,2.52,1.764,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVOTHYROXINE SODIUM 50 MCG ORAL TABS,RX-4421,CDM,S5000,HCPCS,259,RC,00074-4552-11,NDC,outpatient,1,UN,6.49,4.543,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVOTHYROXINE SODIUM 75 MCG ORAL TABS,RX-4422,CDM,S5000,HCPCS,259,RC,51079-0441-20,NDC,outpatient,1,UN,2.6,1.82,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVOTHYROXINE SODIUM 75 MCG ORAL TABS,RX-4422,CDM,S5000,HCPCS,259,RC,60687-0475-01,NDC,outpatient,1,UN,2.04,1.428,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVOTHYROXINE SODIUM 75 MCG ORAL TABS,RX-4422,CDM,S5000,HCPCS,259,RC,60687-0475-11,NDC,outpatient,1,UN,2.04,1.428,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVOTHYROXINE SODIUM 75 MCG ORAL TABS,RX-4422,CDM,S5000,HCPCS,259,RC,51079-0441-01,NDC,outpatient,1,UN,2.6,1.82,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVOTHYROXINE SODIUM 100 MCG ORAL TABS,RX-4423,CDM,S5000,HCPCS,259,RC,51079-0442-01,NDC,outpatient,1,UN,2.67,1.869,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVOTHYROXINE SODIUM 100 MCG ORAL TABS,RX-4423,CDM,S5000,HCPCS,259,RC,00074-6624-11,NDC,outpatient,1,UN,6.49,4.543,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVOTHYROXINE SODIUM 100 MCG ORAL TABS,RX-4423,CDM,S5000,HCPCS,259,RC,51079-0442-20,NDC,outpatient,1,UN,2.67,1.869,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVOTHYROXINE SODIUM 125 MCG ORAL TABS,RX-4424,CDM,S5000,HCPCS,259,RC,51079-0443-01,NDC,outpatient,1,UN,3.14,2.198,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVOTHYROXINE SODIUM 125 MCG ORAL TABS,RX-4424,CDM,S5000,HCPCS,259,RC,51079-0443-20,NDC,outpatient,1,UN,3.14,2.198,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVOTHYROXINE SODIUM 150 MCG ORAL TABS,RX-4425,CDM,S5000,HCPCS,259,RC,60687-0530-01,NDC,outpatient,1,UN,2.51,1.757,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVOTHYROXINE SODIUM 150 MCG ORAL TABS,RX-4425,CDM,S5000,HCPCS,259,RC,00074-7069-11,NDC,outpatient,1,UN,6.49,4.543,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL 4 % EX SOLN,RX-4450,CDM,S5000,HCPCS,259,RC,60432-0465-51,NDC,outpatient,50,ML,131.72,92.204,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL 4 % EX SOLN,RX-4450,CDM,S5000,HCPCS,259,RC,00527-6004-80,NDC,outpatient,50,ML,75.88,53.116,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL 4 % EX SOLN,RX-4450,CDM,S5000,HCPCS,259,RC,00054-3505-47,NDC,outpatient,50,ML,107.03,74.921,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL 0.5 % IJ SOLN,RX-4451,CDM,S5000,HCPCS,250,RC,63323-0484-57,NDC,outpatient,50,ML,22.7,15.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL 1 % IJ SOLN,RX-4452,CDM,S5000,HCPCS,250,RC,00409-4276-01,NDC,outpatient,20,ML,4.63,3.241,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL 1 % IJ SOLN,RX-4452,CDM,S5000,HCPCS,250,RC,00409-4276-17,NDC,outpatient,50,ML,8.23,5.761,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL 1 % IJ SOLN,RX-4452,CDM,S5000,HCPCS,250,RC,00409-4276-02,NDC,outpatient,50,ML,8.23,5.761,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL 1 % IJ SOLN,RX-4452,CDM,S5000,HCPCS,250,RC,00409-4276-16,NDC,outpatient,20,ML,4.63,3.241,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,00409-4277-01,NDC,outpatient,20,ML,5.14,3.598,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0202-01,NDC,outpatient,2,ML,11.73,8.211,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,55150-0254-10,NDC,outpatient,10,ML,3.76,2.632,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,55150-0255-20,NDC,outpatient,20,ML,4.22,2.954,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0202-02,NDC,outpatient,2,ML,11.73,8.211,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0486-01,NDC,outpatient,10,ML,16.35,11.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0486-27,NDC,outpatient,20,ML,18.2,12.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,00409-4277-16,NDC,outpatient,20,ML,5.14,3.598,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0486-02,NDC,outpatient,20,ML,18.2,12.74,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0486-17,NDC,outpatient,10,ML,16.35,11.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0486-26,NDC,outpatient,20,ML,8.02,5.614,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMOXICILLIN 250 MG ORAL CAPS,RX-450,CDM,S5000,HCPCS,259,RC,65862-0016-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMOXICILLIN 250 MG ORAL CAPS,RX-450,CDM,S5000,HCPCS,259,RC,16714-0298-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIOTHYRONINE SODIUM 25 MCG ORAL TABS,RX-4504,CDM,S5000,HCPCS,259,RC,00093-2178-01,NDC,outpatient,1,UN,3.21,2.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIOTHYRONINE SODIUM 25 MCG ORAL TABS,RX-4504,CDM,S5000,HCPCS,259,RC,59762-1207-01,NDC,outpatient,1,UN,3.28,2.296,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LIOTHYRONINE SODIUM 25 MCG ORAL TABS,RX-4504,CDM,S5000,HCPCS,259,RC,51862-0321-01,NDC,outpatient,1,UN,3.45,2.415,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMOXICILLIN 500 MG ORAL CAPS,RX-451,CDM,S5000,HCPCS,259,RC,16714-0299-03,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LITHIUM CARBONATE 150 MG ORAL CAPS,RX-4528,CDM,S5000,HCPCS,259,RC,00054-8526-25,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LITHIUM CARBONATE 300 MG ORAL CAPS,RX-4529,CDM,S5000,HCPCS,259,RC,00054-8527-25,NDC,outpatient,1,UN,1.04,0.728,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LITHIUM CARBONATE 300 MG ORAL CAPS,RX-4529,CDM,S5000,HCPCS,259,RC,31722-0545-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMOXICILLIN 250 MG/5ML ORAL SUSR,RX-454,CDM,S5000,HCPCS,259,RC,00093-4155-79,NDC,outpatient,80,ML,14.6,10.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMOXICILLIN 250 MG/5ML ORAL SUSR,RX-454,CDM,S5000,HCPCS,259,RC,99999-0002-83,NDC,outpatient,10,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMOXICILLIN 250 MG/5ML ORAL SUSR,RX-454,CDM,S5000,HCPCS,259,RC,00143-9889-15,NDC,outpatient,150,ML,20.7,14.49,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LOPERAMIDE HCL 2 MG ORAL CAPS,RX-4560,CDM,S5000,HCPCS,259,RC,60687-0229-11,NDC,outpatient,1,UN,2.63,1.841,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LOPERAMIDE HCL 2 MG ORAL CAPS,RX-4560,CDM,S5000,HCPCS,259,RC,60687-0229-01,NDC,outpatient,1,UN,2.63,1.841,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LOPERAMIDE HCL 2 MG ORAL CAPS,RX-4560,CDM,S5000,HCPCS,259,RC,51079-0690-20,NDC,outpatient,1,UN,3,2.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LOPERAMIDE HCL 2 MG ORAL CAPS,RX-4560,CDM,S5000,HCPCS,259,RC,51079-0690-01,NDC,outpatient,1,UN,3,2.1,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LORAZEPAM 2 MG/ML ORAL CONC,RX-4571,CDM,S5000,HCPCS,259,RC,00121-0770-01,NDC,outpatient,30,ML,33.11,23.177,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LORAZEPAM 2 MG/ML ORAL CONC,RX-4571,CDM,S5000,HCPCS,259,RC,99999-0001-38,NDC,outpatient,1,ML,3.55,2.485,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LORAZEPAM 2 MG/ML ORAL CONC,RX-4571,CDM,S5000,HCPCS,259,RC,00054-3532-44,NDC,outpatient,30,ML,100.26,70.182,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LORAZEPAM 0.5 MG ORAL TABS,RX-4572,CDM,S5000,HCPCS,259,RC,13107-0083-05,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LORAZEPAM 0.5 MG ORAL TABS,RX-4572,CDM,S5000,HCPCS,259,RC,00093-3425-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LORAZEPAM 0.5 MG ORAL TABS,RX-4572,CDM,S5000,HCPCS,259,RC,00904-6007-60,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LORAZEPAM 0.5 MG ORAL TABS,RX-4572,CDM,S5000,HCPCS,259,RC,00904-6007-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LORAZEPAM 0.5 MG ORAL TABS,RX-4572,CDM,S5000,HCPCS,259,RC,69315-0904-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LORAZEPAM 1 MG ORAL TABS,RX-4573,CDM,S5000,HCPCS,259,RC,00093-3426-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LORAZEPAM 1 MG ORAL TABS,RX-4573,CDM,S5000,HCPCS,259,RC,69315-0905-05,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LORAZEPAM 1 MG ORAL TABS,RX-4573,CDM,S5000,HCPCS,259,RC,00904-6008-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LORAZEPAM 1 MG ORAL TABS,RX-4573,CDM,S5000,HCPCS,259,RC,69315-0905-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LOXAPINE SUCCINATE 25 MG ORAL CAPS,RX-4600,CDM,S5000,HCPCS,259,RC,00591-0371-01,NDC,outpatient,1,UN,2.33,1.631,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LOXAPINE SUCCINATE 5 MG ORAL CAPS,RX-4601,CDM,S5000,HCPCS,259,RC,00591-0369-01,NDC,outpatient,1,UN,1.31,0.917,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MAGNESIUM CITRATE 1.745 GM/30ML ORAL SOLN,RX-4711,CDM,S5000,HCPCS,259,RC,70677-1111-01,NDC,outpatient,296,ML,7.91,5.537,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MANNITOL 20 % IV SOLN,RX-4749,CDM,S5000,HCPCS,250,RC,00338-0357-03,NDC,outpatient,500,ML,80.53,56.371,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MANNITOL 20 % IV SOLN,RX-4749,CDM,S5000,HCPCS,250,RC,00990-7715-03,NDC,outpatient,500,ML,93.88,65.716,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MANNITOL 20 % IV SOLN,RX-4749,CDM,S5000,HCPCS,250,RC,00338-0357-02,NDC,outpatient,250,ML,79.42,55.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MANNITOL 20 % IV SOLN,RX-4749,CDM,S5000,HCPCS,250,RC,00990-7715-13,NDC,outpatient,500,ML,93.88,65.716,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MEDROXYPROGESTERONE ACETATE 10 MG ORAL TABS,RX-4854,CDM,S5000,HCPCS,259,RC,00555-0779-02,NDC,outpatient,1,UN,1.07,0.749,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MEDROXYPROGESTERONE ACETATE 2.5 MG ORAL TABS,RX-4855,CDM,S5000,HCPCS,259,RC,00555-0872-02,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METHADONE HCL 10 MG ORAL TABS,RX-4953,CDM,S5000,HCPCS,259,RC,00406-5771-23,NDC,outpatient,1,UN,1.39,0.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METHADONE HCL 10 MG ORAL TABS,RX-4953,CDM,S5000,HCPCS,259,RC,00054-0710-20,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METHADONE HCL 10 MG ORAL TABS,RX-4953,CDM,S5000,HCPCS,259,RC,00406-5771-62,NDC,outpatient,1,UN,1.39,0.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METHADONE HCL 5 MG ORAL TABS,RX-4954,CDM,S5000,HCPCS,259,RC,00406-5755-62,NDC,outpatient,1,UN,1.17,0.819,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METHADONE HCL 5 MG ORAL TABS,RX-4954,CDM,S5000,HCPCS,259,RC,00406-5755-23,NDC,outpatient,1,UN,1.17,0.819,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METHAZOLAMIDE 50 MG ORAL TABS,RX-4962,CDM,S5000,HCPCS,259,RC,00574-0791-01,NDC,outpatient,1,UN,6.49,4.543,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METHOCARBAMOL 500 MG ORAL TABS,RX-4971,CDM,S5000,HCPCS,259,RC,31722-0533-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METHOCARBAMOL 500 MG ORAL TABS,RX-4971,CDM,S5000,HCPCS,259,RC,76385-0123-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METHOCARBAMOL 500 MG ORAL TABS,RX-4971,CDM,S5000,HCPCS,259,RC,00904-7057-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METHYLPHENIDATE HCL 10 MG ORAL TABS,RX-4986,CDM,S5000,HCPCS,259,RC,68084-0823-11,NDC,outpatient,1,UN,5.13,3.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METHYLPHENIDATE HCL 10 MG ORAL TABS,RX-4986,CDM,S5000,HCPCS,259,RC,00406-1144-01,NDC,outpatient,1,UN,1.43,1.001,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METHYLPHENIDATE HCL 10 MG ORAL TABS,RX-4986,CDM,S5000,HCPCS,259,RC,68084-0823-21,NDC,outpatient,1,UN,5.13,3.591,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METHYLPREDNISOLONE 16 MG ORAL TABS,RX-4992,CDM,S5000,HCPCS,259,RC,59762-0050-01,NDC,outpatient,1,UN,8.54,5.978,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METHYLPREDNISOLONE 4 MG ORAL TABS,RX-4993,CDM,S5000,HCPCS,259,RC,68084-0149-11,NDC,outpatient,1,UN,4.95,3.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METHYLPREDNISOLONE 4 MG ORAL TABS,RX-4993,CDM,S5000,HCPCS,259,RC,68084-0149-01,NDC,outpatient,1,UN,4.95,3.465,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METHYLPREDNISOLONE 4 MG ORAL TABS,RX-4993,CDM,S5000,HCPCS,259,RC,00904-6914-61,NDC,outpatient,1,UN,4.37,3.059,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METOCLOPRAMIDE HCL 10 MG ORAL TABS,RX-5005,CDM,S5000,HCPCS,259,RC,60687-0631-01,NDC,outpatient,1,UN,2.56,1.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METOCLOPRAMIDE HCL 10 MG ORAL TABS,RX-5005,CDM,S5000,HCPCS,259,RC,60687-0631-11,NDC,outpatient,1,UN,2.56,1.792,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METOPROLOL TARTRATE 50 MG ORAL TABS,RX-5009,CDM,S5000,HCPCS,259,RC,51079-0801-20,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METOPROLOL TARTRATE 50 MG ORAL TABS,RX-5009,CDM,S5000,HCPCS,259,RC,62584-0266-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METOPROLOL TARTRATE 50 MG ORAL TABS,RX-5009,CDM,S5000,HCPCS,259,RC,51079-0801-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METOPROLOL TARTRATE 50 MG ORAL TABS,RX-5009,CDM,S5000,HCPCS,259,RC,62584-0266-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METRONIDAZOLE 250 MG ORAL TABS,RX-5015,CDM,S5000,HCPCS,259,RC,00904-7156-61,NDC,outpatient,1,UN,1.09,0.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METRONIDAZOLE 500 MG ORAL TABS,RX-5016,CDM,S5000,HCPCS,259,RC,29300-0227-01,NDC,outpatient,1,UN,1.76,1.232,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METRONIDAZOLE 500 MG ORAL TABS,RX-5016,CDM,S5000,HCPCS,259,RC,60687-0550-11,NDC,outpatient,1,UN,2.17,1.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METRONIDAZOLE 500 MG ORAL TABS,RX-5016,CDM,S5000,HCPCS,259,RC,60687-0550-01,NDC,outpatient,1,UN,2.17,1.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MICONAZOLE NITRATE 2 % EX CREA,RX-5039,CDM,S5000,HCPCS,259,RC,61269-0735-14,NDC,outpatient,14,GR,7.54,5.278,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MINERAL OIL ORAL OIL,RX-5086,CDM,S5000,HCPCS,259,RC,48433-0202-30,NDC,outpatient,30,ML,5.08,3.556,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MINERAL OIL ORAL OIL,RX-5086,CDM,S5000,HCPCS,259,RC,99999-0002-15,NDC,outpatient,30,ML,1.39,0.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MINOCYCLINE HCL 50 MG ORAL CAPS,RX-5111,CDM,S5000,HCPCS,259,RC,00591-5694-60,NDC,outpatient,1,UN,1.26,0.882,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MINOXIDIL 10 MG ORAL TABS,RX-5114,CDM,S5000,HCPCS,259,RC,68084-0205-11,NDC,outpatient,1,UN,2.48,1.736,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MINOXIDIL 10 MG ORAL TABS,RX-5114,CDM,S5000,HCPCS,259,RC,68084-0205-01,NDC,outpatient,1,UN,2.48,1.736,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MINOXIDIL 2.5 MG ORAL TABS,RX-5115,CDM,S5000,HCPCS,259,RC,68084-0204-01,NDC,outpatient,1,UN,2.25,1.575,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MINOXIDIL 2.5 MG ORAL TABS,RX-5115,CDM,S5000,HCPCS,259,RC,68084-0204-11,NDC,outpatient,1,UN,2.25,1.575,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MINOXIDIL 2.5 MG ORAL TABS,RX-5115,CDM,S5000,HCPCS,259,RC,00591-5642-01,NDC,outpatient,1,UN,1.01,0.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,00121-0904-05,NDC,outpatient,5,ML,4.01,2.807,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,68094-0001-59,NDC,outpatient,5,ML,4.7,3.29,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,00054-0237-49,NDC,outpatient,100,ML,37.38,26.166,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,00121-0904-94,NDC,outpatient,5,ML,4.01,2.807,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,68094-0001-62,NDC,outpatient,5,ML,4.7,3.29,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,99999-0002-19,NDC,outpatient,5,ML,2.14,1.498,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MORPHINE SULFATE 15 MG ORAL TABS,RX-5178,CDM,S5000,HCPCS,259,RC,00054-0235-25,NDC,outpatient,1,UN,2.1,1.47,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MORPHINE SULFATE 15 MG ORAL TABS,RX-5178,CDM,S5000,HCPCS,259,RC,00054-0235-24,NDC,outpatient,1,UN,3.2,2.24,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MORPHINE SULFATE 10 MG RE SUPP,RX-5180,CDM,S5000,HCPCS,259,RC,00574-7112-12,NDC,outpatient,1,UN,19.66,13.762,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NADOLOL 20 MG ORAL TABS,RX-5330,CDM,S5000,HCPCS,259,RC,60687-0302-95,NDC,outpatient,1,UN,11.38,7.966,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NADOLOL 20 MG ORAL TABS,RX-5330,CDM,S5000,HCPCS,259,RC,60687-0302-25,NDC,outpatient,1,UN,11.38,7.966,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NADOLOL 40 MG ORAL TABS,RX-5331,CDM,S5000,HCPCS,259,RC,69097-0868-07,NDC,outpatient,1,UN,1.13,0.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NADOLOL 40 MG ORAL TABS,RX-5331,CDM,S5000,HCPCS,259,RC,00904-7071-07,NDC,outpatient,1,UN,9.11,6.377,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NAPROXEN 250 MG ORAL TABS,RX-5391,CDM,S5000,HCPCS,259,RC,50268-0594-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NAPROXEN 250 MG ORAL TABS,RX-5391,CDM,S5000,HCPCS,259,RC,65162-0188-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NAPROXEN 250 MG ORAL TABS,RX-5391,CDM,S5000,HCPCS,259,RC,50268-0594-15,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NAPROXEN 375 MG ORAL TABS,RX-5392,CDM,S5000,HCPCS,259,RC,65162-0189-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NAPROXEN 375 MG ORAL TABS,RX-5392,CDM,S5000,HCPCS,259,RC,50268-0595-15,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NAPROXEN 375 MG ORAL TABS,RX-5392,CDM,S5000,HCPCS,259,RC,50268-0595-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NAPROXEN 500 MG ORAL TABS,RX-5393,CDM,S5000,HCPCS,259,RC,65862-0522-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NAPROXEN 500 MG ORAL TABS,RX-5393,CDM,S5000,HCPCS,259,RC,65162-0190-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NAPROXEN 500 MG ORAL TABS,RX-5393,CDM,S5000,HCPCS,259,RC,63739-0403-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NEOMYCIN SULFATE 500 MG ORAL TABS,RX-5472,CDM,S5000,HCPCS,259,RC,39822-0310-05,NDC,outpatient,1,UN,3.09,2.163,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NEOMYCIN SULFATE 500 MG ORAL TABS,RX-5472,CDM,S5000,HCPCS,259,RC,39822-0310-07,NDC,outpatient,1,UN,3.09,2.163,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NEOMYCIN-POLYMYXIN-GRAMICIDIN 1.75-10000-.025 OP SOLN,RX-5474,CDM,S5000,HCPCS,259,RC,24208-0790-62,NDC,outpatient,10,ML,150.86,105.602,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NIACIN 100 MG ORAL TABS,RX-5539,CDM,S5000,HCPCS,259,RC,80681-0057-00,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NIFEDIPINE 10 MG ORAL CAPS,RX-5558,CDM,S5000,HCPCS,259,RC,23155-0194-01,NDC,outpatient,1,UN,1.98,1.386,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NITROFURANTOIN MACROCRYSTAL 50 MG ORAL CAPS,RX-5595,CDM,S5000,HCPCS,259,RC,57664-0232-88,NDC,outpatient,1,UN,3.41,2.387,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NITROGLYCERIN 0.3 MG SL SUBL,RX-5603,CDM,S5000,HCPCS,259,RC,72888-0138-01,NDC,outpatient,1,UN,1.43,1.001,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NITROGLYCERIN 0.3 MG SL SUBL,RX-5603,CDM,S5000,HCPCS,259,RC,68462-0638-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NITROGLYCERIN 0.3 MG SL SUBL,RX-5603,CDM,S5000,HCPCS,259,RC,00071-0417-24,NDC,outpatient,1,UN,3.05,2.135,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NITROGLYCERIN 0.4 MG SL SUBL,RX-5604,CDM,S5000,HCPCS,259,RC,68462-0639-45,NDC,outpatient,0.75,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NITROGLYCERIN 0.4 MG SL SUBL,RX-5604,CDM,S5000,HCPCS,259,RC,68462-0639-25,NDC,outpatient,0.75,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NITROGLYCERIN 0.4 MG SL SUBL,RX-5604,CDM,S5000,HCPCS,259,RC,43598-0436-11,NDC,outpatient,0.75,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NITROGLYCERIN 0.4 MG SL SUBL,RX-5604,CDM,S5000,HCPCS,259,RC,43598-0436-35,NDC,outpatient,0.75,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NITROGLYCERIN 2 % TD OINT,RX-5606,CDM,S5000,HCPCS,259,RC,00281-0326-08,NDC,outpatient,1,GR,9.96,6.972,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NORTRIPTYLINE HCL 25 MG ORAL CAPS,RX-5675,CDM,S5000,HCPCS,259,RC,60687-0293-11,NDC,outpatient,1,UN,1.89,1.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NORTRIPTYLINE HCL 25 MG ORAL CAPS,RX-5675,CDM,S5000,HCPCS,259,RC,60687-0293-01,NDC,outpatient,1,UN,1.89,1.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NYSTATIN 100000 UNIT/GM EX CREA,RX-5749,CDM,S5000,HCPCS,259,RC,51672-1289-01,NDC,outpatient,15,GR,18.83,13.181,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NYSTATIN 100000 UNIT/GM EX CREA,RX-5749,CDM,S5000,HCPCS,259,RC,00713-0678-15,NDC,outpatient,15,GR,53.4,37.38,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NYSTATIN 100000 UNIT/GM EX CREA,RX-5749,CDM,S5000,HCPCS,259,RC,45802-0059-35,NDC,outpatient,15,GR,17.03,11.921,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NYSTATIN 100000 UNIT/GM EX OINT,RX-5750,CDM,S5000,HCPCS,259,RC,00472-0166-15,NDC,outpatient,15,GR,61.35,42.945,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NYSTATIN 100000 UNIT/GM EX OINT,RX-5750,CDM,S5000,HCPCS,259,RC,45802-0048-35,NDC,outpatient,15,GR,13.29,9.303,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,00121-0868-05,NDC,outpatient,5,ML,4.74,3.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,63739-0160-70,NDC,outpatient,5,ML,2.63,1.841,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,99999-0003-91,NDC,outpatient,5,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,00121-0868-00,NDC,outpatient,5,ML,4.74,3.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,00121-1045-16,NDC,outpatient,5,ML,4.21,2.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,63739-0160-10,NDC,outpatient,5,ML,2.63,1.841,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NYSTATIN-TRIAMCINOLONE 100000-0.1 UNIT/GM-% EX CREA,RX-5754,CDM,S5000,HCPCS,259,RC,51672-1263-01,NDC,outpatient,15,GR,15.02,10.514,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NYSTATIN-TRIAMCINOLONE 100000-0.1 UNIT/GM-% EX OINT,RX-5755,CDM,S5000,HCPCS,259,RC,51672-1272-01,NDC,outpatient,15,GR,22.37,15.659,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ORA-PLUS ORAL LIQD,RX-5851,CDM,S5000,HCPCS,259,RC,00574-0303-16,NDC,outpatient,473,ML,130.96,91.672,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ORA-SWEET SF ORAL SYRP,RX-5853,CDM,S5000,HCPCS,259,RC,00574-0302-16,NDC,outpatient,473,ML,130.96,91.672,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXAZEPAM 10 MG ORAL CAPS,RX-5930,CDM,S5000,HCPCS,259,RC,62584-0812-11,NDC,outpatient,1,UN,8.63,6.041,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXAZEPAM 10 MG ORAL CAPS,RX-5930,CDM,S5000,HCPCS,259,RC,00228-2067-10,NDC,outpatient,1,UN,3.24,2.268,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXAZEPAM 10 MG ORAL CAPS,RX-5930,CDM,S5000,HCPCS,259,RC,62584-0812-01,NDC,outpatient,1,UN,8.63,6.041,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXAZEPAM 15 MG ORAL CAPS,RX-5931,CDM,S5000,HCPCS,259,RC,62584-0813-11,NDC,outpatient,1,UN,9.09,6.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXAZEPAM 15 MG ORAL CAPS,RX-5931,CDM,S5000,HCPCS,259,RC,62584-0813-01,NDC,outpatient,1,UN,9.09,6.363,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXYBUTYNIN CHLORIDE 5 MG ORAL TABS,RX-5938,CDM,S5000,HCPCS,259,RC,60687-0670-01,NDC,outpatient,1,UN,1.85,1.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXYBUTYNIN CHLORIDE 5 MG ORAL TABS,RX-5938,CDM,S5000,HCPCS,259,RC,60687-0670-11,NDC,outpatient,1,UN,1.85,1.295,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXYBUTYNIN CHLORIDE 5 MG ORAL TABS,RX-5938,CDM,S5000,HCPCS,259,RC,00904-7027-61,NDC,outpatient,1,UN,1.69,1.183,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXYCODONE-ACETAMINOPHEN 5-325 MG ORAL TABS,RX-5940,CDM,S5000,HCPCS,259,RC,00406-0512-23,NDC,outpatient,1,UN,1.65,1.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OXYCODONE-ACETAMINOPHEN 5-325 MG ORAL TABS,RX-5940,CDM,S5000,HCPCS,259,RC,00406-0512-62,NDC,outpatient,1,UN,1.65,1.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PAPAVERINE HCL 30 MG/ML IJ SOLN,RX-6030,CDM,S5000,HCPCS,250,RC,14789-0121-07,NDC,outpatient,2,ML,78.96,55.272,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PAPAVERINE HCL 30 MG/ML IJ SOLN,RX-6030,CDM,S5000,HCPCS,250,RC,14789-0121-05,NDC,outpatient,2,ML,78.96,55.272,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PAPAVERINE HCL 30 MG/ML IJ SOLN,RX-6030,CDM,S5000,HCPCS,250,RC,54288-0142-01,NDC,outpatient,2,ML,69.91,48.937,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PAPAVERINE HCL 30 MG/ML IJ SOLN,RX-6030,CDM,S5000,HCPCS,250,RC,54288-0142-10,NDC,outpatient,2,ML,69.91,48.937,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PAPAVERINE HCL 30 MG/ML IJ SOLN,RX-6030,CDM,S5000,HCPCS,250,RC,00517-4002-25,NDC,outpatient,2,ML,103.84,72.688,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PENICILLIN G SODIUM 5000000 UNITS IJ SOLR,RX-6087,CDM,S5000,HCPCS,250,RC,00781-6153-95,NDC,outpatient,1,UN,142.02,99.414,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PENICILLIN G SODIUM 5000000 UNITS IJ SOLR,RX-6087,CDM,S5000,HCPCS,250,RC,00781-6153-94,NDC,outpatient,1,UN,142.02,99.414,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PENICILLIN V POTASSIUM 250 MG/5ML ORAL SOLR,RX-6091,CDM,S5000,HCPCS,259,RC,00093-4127-73,NDC,outpatient,100,ML,26.7,18.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PENICILLIN V POTASSIUM 250 MG/5ML ORAL SOLR,RX-6091,CDM,S5000,HCPCS,259,RC,99999-0002-88,NDC,outpatient,10,ML,2.67,1.869,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PENICILLIN V POTASSIUM 250 MG ORAL TABS,RX-6092,CDM,S5000,HCPCS,259,RC,57237-0040-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PENICILLIN V POTASSIUM 500 MG ORAL TABS,RX-6093,CDM,S5000,HCPCS,259,RC,00093-1174-01,NDC,outpatient,1,UN,1.67,1.169,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PENICILLIN V POTASSIUM 500 MG ORAL TABS,RX-6093,CDM,S5000,HCPCS,259,RC,00143-9836-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PERPHENAZINE 2 MG ORAL TABS,RX-6157,CDM,S5000,HCPCS,259,RC,00904-6599-61,NDC,outpatient,1,UN,2.75,1.925,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PERPHENAZINE 8 MG ORAL TABS,RX-6159,CDM,S5000,HCPCS,259,RC,00904-6601-61,NDC,outpatient,1,UN,5.02,3.514,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PHENAZOPYRIDINE HCL 100 MG ORAL TABS,RX-6193,CDM,S5000,HCPCS,259,RC,65162-0681-10,NDC,outpatient,1,UN,1.61,1.127,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,99999-0002-30,NDC,outpatient,5,ML,2.5,1.75,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,00121-0942-05,NDC,outpatient,5,ML,7.01,4.907,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,54932-0501-81,NDC,outpatient,473,ML,75.78,53.046,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,13517-0107-16,NDC,outpatient,473,ML,307.31,215.117,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,16571-0675-16,NDC,outpatient,473,ML,82.09,57.463,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,00121-0942-50,NDC,outpatient,5,ML,7.01,4.907,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PHENOBARBITAL 32.4 MG ORAL TABS,RX-6217,CDM,S5000,HCPCS,259,RC,16571-0673-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PHENOBARBITAL 32.4 MG ORAL TABS,RX-6217,CDM,S5000,HCPCS,259,RC,00904-6575-61,NDC,outpatient,1,UN,1.34,0.938,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PHENYLEPHRINE HCL 0.25 % NA SOLN,RX-6243,CDM,S5000,HCPCS,259,RC,00225-0800-47,NDC,outpatient,15,ML,13.42,9.394,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PHENYLEPHRINE HCL 0.5 % NA SOLN,RX-6244,CDM,S5000,HCPCS,259,RC,00225-0805-47,NDC,outpatient,15,ML,13.42,9.394,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PHENYLEPHRINE HCL 1 % NA SOLN,RX-6245,CDM,S5000,HCPCS,259,RC,00225-0810-47,NDC,outpatient,15,ML,15.09,10.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PHENYLEPHRINE HCL 2.5 % OP SOLN,RX-6246,CDM,S5000,HCPCS,259,RC,70756-0629-25,NDC,outpatient,2,ML,146.94,102.858,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PHENYTOIN 125 MG/5ML ORAL SUSP,RX-6255,CDM,S5000,HCPCS,259,RC,60687-0275-66,NDC,outpatient,4,ML,13.48,9.436,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PHENYTOIN 125 MG/5ML ORAL SUSP,RX-6255,CDM,S5000,HCPCS,259,RC,60687-0275-62,NDC,outpatient,4,ML,13.48,9.436,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAPS,RX-6257,CDM,S5000,HCPCS,259,RC,57664-0808-88,NDC,outpatient,1,UN,1.19,0.833,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAPS,RX-6257,CDM,S5000,HCPCS,259,RC,65862-0692-01,NDC,outpatient,1,UN,1.74,1.218,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PILOCARPINE HCL 1 % OP SOLN,RX-6279,CDM,S5000,HCPCS,259,RC,61314-0203-15,NDC,outpatient,15,ML,342.03,239.421,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PILOCARPINE HCL 2 % OP SOLN,RX-6280,CDM,S5000,HCPCS,259,RC,70069-0191-01,NDC,outpatient,15,ML,140.98,98.686,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PILOCARPINE HCL 2 % OP SOLN,RX-6280,CDM,S5000,HCPCS,259,RC,61314-0204-15,NDC,outpatient,15,ML,351.44,246.008,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PILOCARPINE HCL 4 % OP SOLN,RX-6282,CDM,S5000,HCPCS,259,RC,61314-0206-15,NDC,outpatient,15,ML,326.81,228.767,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PIROXICAM 10 MG ORAL CAPS,RX-6310,CDM,S5000,HCPCS,259,RC,42571-0176-01,NDC,outpatient,1,UN,3.12,2.184,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POLY-VI-SOL ORAL SOLN,RX-6374,CDM,S5000,HCPCS,259,RC,00087-0402-03,NDC,outpatient,1,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POLY-VI-SOL ORAL SOLN,RX-6374,CDM,S5000,HCPCS,259,RC,99999-0001-68,NDC,outpatient,1,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POLYMYXIN B SULFATE 500000 UNITS IJ SOLR,RX-6393,CDM,S5000,HCPCS,250,RC,55150-0234-10,NDC,outpatient,1,UN,16.13,11.291,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POTASSIUM ACETATE 2 MEQ/ML IV SOLN,RX-6420,CDM,S5000,HCPCS,250,RC,00409-8183-01,NDC,outpatient,20,ML,16.35,11.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POTASSIUM ACETATE 2 MEQ/ML IV SOLN,RX-6420,CDM,S5000,HCPCS,250,RC,51754-2001-04,NDC,outpatient,20,ML,18.07,12.649,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POTASSIUM ACETATE 2 MEQ/ML IV SOLN,RX-6420,CDM,S5000,HCPCS,250,RC,00409-8183-11,NDC,outpatient,20,ML,16.35,11.445,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POVIDONE-IODINE 10 % EX SOLN,RX-6458,CDM,S5000,HCPCS,259,RC,52380-1905-00,NDC,outpatient,59,ML,4.73,3.311,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PRAZOSIN HCL 1 MG ORAL CAPS,RX-6468,CDM,S5000,HCPCS,259,RC,51079-0630-20,NDC,outpatient,1,UN,6.21,4.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PRAZOSIN HCL 1 MG ORAL CAPS,RX-6468,CDM,S5000,HCPCS,259,RC,51079-0630-01,NDC,outpatient,1,UN,6.21,4.347,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PRAZOSIN HCL 1 MG ORAL CAPS,RX-6468,CDM,S5000,HCPCS,259,RC,68084-0996-01,NDC,outpatient,1,UN,5.34,3.738,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PRAZOSIN HCL 1 MG ORAL CAPS,RX-6468,CDM,S5000,HCPCS,259,RC,68084-0996-11,NDC,outpatient,1,UN,5.34,3.738,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PRAZOSIN HCL 5 MG ORAL CAPS,RX-6470,CDM,S5000,HCPCS,259,RC,51079-0632-01,NDC,outpatient,1,UN,14.76,10.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PRAZOSIN HCL 5 MG ORAL CAPS,RX-6470,CDM,S5000,HCPCS,259,RC,51079-0632-20,NDC,outpatient,1,UN,14.76,10.332,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREDNISOLONE ACETATE 1 % OP SUSP,RX-6487,CDM,S5000,HCPCS,259,RC,11980-0180-05,NDC,outpatient,5,ML,534.23,373.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREDNISOLONE ACETATE 1 % OP SUSP,RX-6487,CDM,S5000,HCPCS,259,RC,60758-0119-05,NDC,outpatient,5,ML,106.58,74.606,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREDNISOLONE ACETATE 1 % OP SUSP,RX-6487,CDM,S5000,HCPCS,259,RC,61314-0637-05,NDC,outpatient,5,ML,113.48,79.436,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREDNISONE 1 MG ORAL TABS,RX-6493,CDM,S5000,HCPCS,259,RC,59651-0484-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREDNISONE 1 MG ORAL TABS,RX-6493,CDM,S5000,HCPCS,259,RC,00054-8739-25,NDC,outpatient,1,UN,1.06,0.742,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREDNISONE 1 MG ORAL TABS,RX-6493,CDM,S5000,HCPCS,259,RC,00054-4741-25,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREDNISONE 10 MG ORAL TABS,RX-6494,CDM,S5000,HCPCS,259,RC,00904-6923-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREDNISONE 10 MG ORAL TABS,RX-6494,CDM,S5000,HCPCS,259,RC,00054-0017-20,NDC,outpatient,1,UN,1.02,0.714,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREDNISONE 10 MG ORAL TABS,RX-6494,CDM,S5000,HCPCS,259,RC,00603-5338-21,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREDNISONE 10 MG ORAL TABS,RX-6494,CDM,S5000,HCPCS,259,RC,60687-0134-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREDNISONE 10 MG ORAL TABS,RX-6494,CDM,S5000,HCPCS,259,RC,60687-0134-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREDNISONE 2.5 MG ORAL TABS,RX-6495,CDM,S5000,HCPCS,259,RC,00054-8740-25,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREDNISONE 2.5 MG ORAL TABS,RX-6495,CDM,S5000,HCPCS,259,RC,00054-4742-25,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,60687-0145-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,60687-0145-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,64380-0785-07,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,00054-0018-20,NDC,outpatient,1,UN,1.09,0.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,00904-7127-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,59746-0175-06,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREDNISONE 5 MG ORAL TABS,RX-6497,CDM,S5000,HCPCS,259,RC,60687-0122-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREDNISONE 5 MG ORAL TABS,RX-6497,CDM,S5000,HCPCS,259,RC,00054-8724-25,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREDNISONE 5 MG ORAL TABS,RX-6497,CDM,S5000,HCPCS,259,RC,60687-0122-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREDNISONE 50 MG ORAL TABS,RX-6498,CDM,S5000,HCPCS,259,RC,00054-0019-20,NDC,outpatient,1,UN,1.23,0.861,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREDNISONE 50 MG ORAL TABS,RX-6498,CDM,S5000,HCPCS,259,RC,00054-0019-25,NDC,outpatient,1,UN,1.08,0.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREDNISONE 50 MG ORAL TABS,RX-6498,CDM,S5000,HCPCS,259,RC,10135-0779-01,NDC,outpatient,1,UN,1.24,0.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PREDNISONE 50 MG ORAL TABS,RX-6498,CDM,S5000,HCPCS,259,RC,59651-0489-01,NDC,outpatient,1,UN,1.61,1.127,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ASCORBIC ACID 500 MG/ML IJ SOLN,RX-654,CDM,S5000,HCPCS,250,RC,67157-0101-51,NDC,outpatient,50,ML,1099.15,769.405,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PRIMIDONE 250 MG ORAL TABS,RX-6544,CDM,S5000,HCPCS,259,RC,50268-0687-15,NDC,outpatient,1,UN,2.53,1.771,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PRIMIDONE 250 MG ORAL TABS,RX-6544,CDM,S5000,HCPCS,259,RC,50268-0687-11,NDC,outpatient,1,UN,2.53,1.771,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PROBENECID 500 MG ORAL TABS,RX-6561,CDM,S5000,HCPCS,259,RC,00591-5347-01,NDC,outpatient,1,UN,2.65,1.855,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PROMETHAZINE-CODEINE 6.25-10 MG/5ML ORAL SYRP,RX-6627,CDM,S5000,HCPCS,259,RC,99999-0002-39,NDC,outpatient,5,ML,1.21,0.847,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PROMETHAZINE-CODEINE 6.25-10 MG/5ML ORAL SYRP,RX-6627,CDM,S5000,HCPCS,259,RC,27808-0065-02,NDC,outpatient,2.5,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ASCORBIC ACID 500 MG ORAL TABS,RX-664,CDM,S5000,HCPCS,259,RC,00904-0523-60,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ASCORBIC ACID 500 MG ORAL TABS,RX-664,CDM,S5000,HCPCS,259,RC,00904-0523-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PROPARACAINE HCL 0.5 % OP SOLN,RX-6644,CDM,S5000,HCPCS,259,RC,61314-0016-01,NDC,outpatient,15,ML,111.21,77.847,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PROPARACAINE HCL 0.5 % OP SOLN,RX-6644,CDM,S5000,HCPCS,259,RC,24208-0730-06,NDC,outpatient,15,ML,110.61,77.427,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PROPRANOLOL HCL 20 MG/5ML ORAL SOLN,RX-6654,CDM,S5000,HCPCS,259,RC,00054-3727-63,NDC,outpatient,500,ML,209.15,146.405,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PROPRANOLOL HCL 20 MG/5ML ORAL SOLN,RX-6654,CDM,S5000,HCPCS,259,RC,00121-0908-40,NDC,outpatient,5,ML,10.08,7.056,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PROPRANOLOL HCL 20 MG/5ML ORAL SOLN,RX-6654,CDM,S5000,HCPCS,259,RC,00121-0908-05,NDC,outpatient,5,ML,10.08,7.056,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PROPRANOLOL HCL 10 MG ORAL TABS,RX-6656,CDM,S5000,HCPCS,259,RC,60687-0587-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PROPRANOLOL HCL 10 MG ORAL TABS,RX-6656,CDM,S5000,HCPCS,259,RC,60687-0587-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PROPRANOLOL HCL 10 MG ORAL TABS,RX-6656,CDM,S5000,HCPCS,259,RC,69238-2077-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PROPRANOLOL HCL 10 MG ORAL TABS,RX-6656,CDM,S5000,HCPCS,259,RC,00378-0182-01,NDC,outpatient,1,UN,1.22,0.854,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PROPRANOLOL HCL 40 MG ORAL TABS,RX-6658,CDM,S5000,HCPCS,259,RC,60687-0609-11,NDC,outpatient,1,UN,2.26,1.582,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PROPRANOLOL HCL 40 MG ORAL TABS,RX-6658,CDM,S5000,HCPCS,259,RC,00603-5484-21,NDC,outpatient,1,UN,1.21,0.847,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PROPRANOLOL HCL 40 MG ORAL TABS,RX-6658,CDM,S5000,HCPCS,259,RC,60687-0609-01,NDC,outpatient,1,UN,2.26,1.582,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PROPYLTHIOURACIL 50 MG ORAL TABS,RX-6662,CDM,S5000,HCPCS,259,RC,00228-2348-10,NDC,outpatient,1,UN,3.18,2.226,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PROPYLTHIOURACIL 50 MG ORAL TABS,RX-6662,CDM,S5000,HCPCS,259,RC,67253-0651-10,NDC,outpatient,1,UN,2.63,1.841,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PSEUDOEPHEDRINE HCL 30 MG ORAL TABS,RX-6714,CDM,S5000,HCPCS,259,RC,00904-5053-59,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PSEUDOEPHEDRINE HCL 30 MG ORAL TABS,RX-6714,CDM,S5000,HCPCS,259,RC,00904-6990-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PYRAZINAMIDE 500 MG ORAL TABS,RX-6738,CDM,S5000,HCPCS,259,RC,33342-0447-11,NDC,outpatient,1,UN,19.28,13.496,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PYRAZINAMIDE 500 MG ORAL TABS,RX-6738,CDM,S5000,HCPCS,259,RC,70954-0484-10,NDC,outpatient,1,UN,17.43,12.201,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PYRAZINAMIDE 500 MG ORAL TABS,RX-6738,CDM,S5000,HCPCS,259,RC,10135-0735-60,NDC,outpatient,1,UN,15.09,10.563,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PYRIDOXINE HCL 50 MG ORAL TABS,RX-6748,CDM,S5000,HCPCS,259,RC,77333-0940-25,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PYRIDOXINE HCL 50 MG ORAL TABS,RX-6748,CDM,S5000,HCPCS,259,RC,50268-0858-15,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PYRIDOXINE HCL 50 MG ORAL TABS,RX-6748,CDM,S5000,HCPCS,259,RC,50268-0858-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PYRIDOXINE HCL 50 MG ORAL TABS,RX-6748,CDM,S5000,HCPCS,259,RC,77333-0940-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
QUININE SULFATE 324 MG ORAL CAPS,RX-6781,CDM,S5000,HCPCS,259,RC,50742-0238-30,NDC,outpatient,1,UN,2.82,1.974,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ASPIRIN 81 MG ORAL CHEW,RX-680,CDM,S5000,HCPCS,259,RC,00904-6794-80,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ASPIRIN 81 MG ORAL CHEW,RX-680,CDM,S5000,HCPCS,259,RC,00904-6794-30,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ASPIRIN 81 MG ORAL CHEW,RX-680,CDM,S5000,HCPCS,259,RC,63739-0434-02,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ASPIRIN 81 MG ORAL CHEW,RX-680,CDM,S5000,HCPCS,259,RC,66553-0002-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ASPIRIN 325 MG ORAL TABS,RX-681,CDM,S5000,HCPCS,259,RC,57896-0901-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ASPIRIN 325 MG ORAL TABS,RX-681,CDM,S5000,HCPCS,259,RC,66553-0001-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ASPIRIN 325 MG ORAL TBEC,RX-685,CDM,S5000,HCPCS,259,RC,57896-0921-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ASPIRIN 81 MG ORAL TBEC,RX-688,CDM,S5000,HCPCS,259,RC,63739-0212-02,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ASPIRIN 81 MG ORAL TBEC,RX-688,CDM,S5000,HCPCS,259,RC,00536-1234-41,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ASPIRIN 81 MG ORAL TBEC,RX-688,CDM,S5000,HCPCS,259,RC,00904-6783-70,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ASPIRIN 300 MG RE SUPP,RX-693,CDM,S5000,HCPCS,259,RC,00574-7034-12,NDC,outpatient,1,UN,4.58,3.206,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
INSULIN DETEMIR 100 UNIT/ML SC SOLN,RX-70261,CDM,S5000,HCPCS,259,RC,00169-3687-12,NDC,outpatient,10,ML,388.27,271.789,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PACK,RX-70284,CDM,S5000,HCPCS,259,RC,71351-0010-99,NDC,outpatient,1,UN,1.65,1.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PACK,RX-70284,CDM,S5000,HCPCS,259,RC,60258-0006-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PACK,RX-70284,CDM,S5000,HCPCS,259,RC,60258-0006-15,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PACK,RX-70284,CDM,S5000,HCPCS,259,RC,71351-0010-01,NDC,outpatient,1,UN,1.65,1.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SALINE NASAL SPRAY 0.65 % NA SOLN,RX-7030,CDM,S5000,HCPCS,259,RC,49348-0356-25,NDC,outpatient,44,ML,5.88,4.116,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SALINE NASAL SPRAY 0.65 % NA SOLN,RX-7030,CDM,S5000,HCPCS,259,RC,00904-3865-75,NDC,outpatient,44,ML,3.33,2.331,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRAMADOL HCL ER 200 MG ORAL TB24,RX-70353,CDM,S5000,HCPCS,259,RC,68180-0698-06,NDC,outpatient,1,UN,19.84,13.888,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RANOLAZINE ER 500 MG ORAL TB12,RX-70434,CDM,S5000,HCPCS,259,RC,60687-0549-11,NDC,outpatient,1,UN,5.08,3.556,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RANOLAZINE ER 500 MG ORAL TB12,RX-70434,CDM,S5000,HCPCS,259,RC,50268-0722-15,NDC,outpatient,1,UN,5.07,3.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RANOLAZINE ER 500 MG ORAL TB12,RX-70434,CDM,S5000,HCPCS,259,RC,68462-0319-60,NDC,outpatient,1,UN,1.05,0.735,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RANOLAZINE ER 500 MG ORAL TB12,RX-70434,CDM,S5000,HCPCS,259,RC,60687-0549-21,NDC,outpatient,1,UN,5.08,3.556,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RANOLAZINE ER 500 MG ORAL TB12,RX-70434,CDM,S5000,HCPCS,259,RC,50268-0722-11,NDC,outpatient,1,UN,5.07,3.549,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LUBIPROSTONE 24 MCG ORAL CAPS,RX-70472,CDM,S5000,HCPCS,259,RC,00254-3029-02,NDC,outpatient,1,UN,4.45,3.115,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLUTICASONE PROPIONATE 50 MCG/ACT NA SUSP,RX-70536,CDM,S5000,HCPCS,259,RC,00536-1183-99,NDC,outpatient,9.9,ML,45.6,31.92,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FLUTICASONE PROPIONATE 50 MCG/ACT NA SUSP,RX-70536,CDM,S5000,HCPCS,259,RC,00054-3270-99,NDC,outpatient,16,GR,32.12,22.484,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
INSULIN LISPRO PROT & LISPRO (75-25) 100 UNIT/ML SC SUSP,RX-70693,CDM,S5000,HCPCS,259,RC,00002-7511-01,NDC,outpatient,10,ML,211.82,148.274,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ATENOLOL 25 MG ORAL TABS,RX-717,CDM,S5000,HCPCS,259,RC,51079-0759-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ATENOLOL 25 MG ORAL TABS,RX-717,CDM,S5000,HCPCS,259,RC,51079-0759-20,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ATENOLOL 50 MG ORAL TABS,RX-718,CDM,S5000,HCPCS,259,RC,51079-0684-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ATENOLOL 50 MG ORAL TABS,RX-718,CDM,S5000,HCPCS,259,RC,51079-0684-20,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SILVER SULFADIAZINE 1 % EX CREA,RX-7224,CDM,S5000,HCPCS,259,RC,61570-0131-55,NDC,outpatient,50,GR,30.49,21.343,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SILVER SULFADIAZINE 1 % EX CREA,RX-7224,CDM,S5000,HCPCS,259,RC,43598-0210-40,NDC,outpatient,400,GR,153.08,107.156,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SILVER SULFADIAZINE 1 % EX CREA,RX-7224,CDM,S5000,HCPCS,259,RC,43598-0210-50,NDC,outpatient,50,GR,55.18,38.626,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SIMETHICONE 80 MG ORAL CHEW,RX-7227,CDM,S5000,HCPCS,259,RC,00904-7206-60,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SIMETHICONE 80 MG ORAL CHEW,RX-7227,CDM,S5000,HCPCS,259,RC,49348-0188-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SIMETHICONE 80 MG ORAL CHEW,RX-7227,CDM,S5000,HCPCS,259,RC,69618-0033-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SIMETHICONE 80 MG ORAL CHEW,RX-7227,CDM,S5000,HCPCS,259,RC,77333-0812-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SIMETHICONE 80 MG ORAL CHEW,RX-7227,CDM,S5000,HCPCS,259,RC,77333-0812-25,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SIMETHICONE 40 MG/0.6ML ORAL SUSP,RX-7228,CDM,S5000,HCPCS,259,RC,49348-0740-27,NDC,outpatient,0.6,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SIMETHICONE 40 MG/0.6ML ORAL SUSP,RX-7228,CDM,S5000,HCPCS,259,RC,00536-1303-75,NDC,outpatient,0.3,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SIMETHICONE 40 MG/0.6ML ORAL SUSP,RX-7228,CDM,S5000,HCPCS,259,RC,99999-0003-45,NDC,outpatient,0.6,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM ACETATE 2 MEQ/ML IV SOLN,RX-7301,CDM,S5000,HCPCS,250,RC,00409-7299-73,NDC,outpatient,20,ML,14.91,10.437,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM ACETATE 2 MEQ/ML IV SOLN,RX-7301,CDM,S5000,HCPCS,250,RC,00409-7299-83,NDC,outpatient,20,ML,14.91,10.437,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM ACETATE 4 MEQ/ML IV SOLN,RX-7302,CDM,S5000,HCPCS,250,RC,63323-0032-04,NDC,outpatient,100,ML,36.05,25.235,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM ACETATE 4 MEQ/ML IV SOLN,RX-7302,CDM,S5000,HCPCS,250,RC,63323-0032-00,NDC,outpatient,100,ML,36.05,25.235,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM BICARBONATE 4.2 % IV SOLN,RX-7306,CDM,S5000,HCPCS,250,RC,00409-5555-12,NDC,outpatient,5,ML,19.45,13.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM BICARBONATE 4.2 % IV SOLN,RX-7306,CDM,S5000,HCPCS,250,RC,63323-0083-05,NDC,outpatient,5,ML,33.6,23.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM BICARBONATE 4.2 % IV SOLN,RX-7306,CDM,S5000,HCPCS,250,RC,00409-5534-14,NDC,outpatient,10,ML,57.94,40.558,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM BICARBONATE 4.2 % IV SOLN,RX-7306,CDM,S5000,HCPCS,250,RC,00409-5534-24,NDC,outpatient,10,ML,57.94,40.558,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM BICARBONATE 4.2 % IV SOLN,RX-7306,CDM,S5000,HCPCS,250,RC,00409-5555-02,NDC,outpatient,5,ML,19.45,13.615,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM BICARBONATE 7.5 % IV SOLN,RX-7308,CDM,S5000,HCPCS,250,RC,00409-4916-24,NDC,outpatient,50,ML,85.67,59.969,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM BICARBONATE 7.5 % IV SOLN,RX-7308,CDM,S5000,HCPCS,250,RC,00409-4916-14,NDC,outpatient,50,ML,85.67,59.969,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-4900-14,NDC,outpatient,10,ML,71.78,50.246,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,69374-0214-50,NDC,outpatient,50,ML,48.95,34.265,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-6625-14,NDC,outpatient,50,ML,35.83,25.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-6637-14,NDC,outpatient,50,ML,54.74,38.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-6637-24,NDC,outpatient,50,ML,54.74,38.318,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-4900-24,NDC,outpatient,10,ML,71.78,50.246,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,51754-5001-04,NDC,outpatient,50,ML,22.7,15.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,63323-0089-50,NDC,outpatient,50,ML,24.7,17.29,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-6625-22,NDC,outpatient,50,ML,35.83,25.081,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,51754-5001-01,NDC,outpatient,50,ML,22.7,15.89,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,76329-3352-01,NDC,outpatient,50,ML,66.31,46.417,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM BICARBONATE 650 MG ORAL TABS,RX-7313,CDM,S5000,HCPCS,259,RC,66553-0008-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE 3 % IV SOLN,RX-7321,CDM,S5000,HCPCS,250,RC,00338-0054-03,NDC,outpatient,500,ML,26.28,18.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE 3 % IV SOLN,RX-7321,CDM,S5000,HCPCS,250,RC,99999-0004-11,NDC,outpatient,250,ML,21.14,14.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE 4 MEQ/ML IV SOLN,RX-7322,CDM,S5000,HCPCS,250,RC,63323-0095-61,NDC,outpatient,100,ML,55.63,38.941,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE 4 MEQ/ML IV SOLN,RX-7322,CDM,S5000,HCPCS,250,RC,63323-0095-02,NDC,outpatient,100,ML,55.63,38.941,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE 0.9 % IN NEBU,RX-7325,CDM,S5000,HCPCS,259,RC,76204-0300-03,NDC,outpatient,3,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE 0.9 % IN NEBU,RX-7325,CDM,S5000,HCPCS,259,RC,00487-9301-03,NDC,outpatient,3,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE 0.9 % IN NEBU,RX-7325,CDM,S5000,HCPCS,259,RC,00487-9301-33,NDC,outpatient,3,ML,1.13,0.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE 3 % IN NEBU,RX-7327,CDM,S5000,HCPCS,259,RC,00487-9003-30,NDC,outpatient,4,ML,2.44,1.708,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE 3 % IN NEBU,RX-7327,CDM,S5000,HCPCS,259,RC,50190-0142-63,NDC,outpatient,4,ML,2.6,1.82,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE 1 G ORAL TABS,RX-7328,CDM,S5000,HCPCS,259,RC,77333-0835-10,NDC,outpatient,1,UN,1.03,0.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE 1 G ORAL TABS,RX-7328,CDM,S5000,HCPCS,259,RC,00223-1760-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE 1 G ORAL TABS,RX-7328,CDM,S5000,HCPCS,259,RC,77333-0835-25,NDC,outpatient,1,UN,1.03,0.721,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE (HYPERTONIC) 5 % OP OINT,RX-7331,CDM,S5000,HCPCS,259,RC,24208-0385-55,NDC,outpatient,3.5,GR,68.8,48.16,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE (HYPERTONIC) 5 % OP SOLN,RX-7332,CDM,S5000,HCPCS,259,RC,00536-1254-94,NDC,outpatient,15,ML,15.76,11.032,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM HYPOCHLORITE 5 % SOLN,RX-7343,CDM,S5000,HCPCS,259,RC,SH000-4343-01,NDC,outpatient,4000,ML,17.8,12.46,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM POLYSTYRENE SULFONATE ORAL POWD,RX-7356,CDM,S5000,HCPCS,259,RC,11534-0166-15,NDC,outpatient,15,GR,55.61,38.927,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SULFACETAMIDE SODIUM 10 % OP SOLN,RX-7359,CDM,S5000,HCPCS,259,RC,24208-0670-04,NDC,outpatient,15,ML,213.67,149.569,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ATROPINE SULFATE 1 % OP SOLN,RX-736,CDM,S5000,HCPCS,259,RC,60219-1749-03,NDC,outpatient,5,ML,103.02,72.114,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SPIRONOLACTONE 25 MG ORAL TABS,RX-7437,CDM,S5000,HCPCS,259,RC,51079-0103-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SPIRONOLACTONE 25 MG ORAL TABS,RX-7437,CDM,S5000,HCPCS,259,RC,63629-1061-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SPIRONOLACTONE 25 MG ORAL TABS,RX-7437,CDM,S5000,HCPCS,259,RC,00904-6927-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SPIRONOLACTONE 25 MG ORAL TABS,RX-7437,CDM,S5000,HCPCS,259,RC,51079-0103-20,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-10,NDC,outpatient,10,ML,3.6,2.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-17,NDC,outpatient,10,ML,3.6,2.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,63323-0185-20,NDC,outpatient,20,ML,7,4.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-24,NDC,outpatient,50,ML,8.74,6.118,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-25,NDC,outpatient,100,ML,13.88,9.716,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00641-6147-10,NDC,outpatient,10,ML,4.22,2.954,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-50,NDC,outpatient,50,ML,8.74,6.118,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-99,NDC,outpatient,100,ML,13.88,9.716,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00641-6147-01,NDC,outpatient,10,ML,4.79,3.353,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00641-6147-25,NDC,outpatient,10,ML,4.79,3.353,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,63323-0185-10,NDC,outpatient,10,ML,4.07,2.849,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
STERILE WATER FOR IRRIGATION IR SOLN,RX-7485,CDM,S5000,HCPCS,250,RC,00338-0004-04,NDC,outpatient,1000,ML,8.9,6.23,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
STERILE WATER FOR IRRIGATION IR SOLN,RX-7485,CDM,S5000,HCPCS,250,RC,00338-0003-47,NDC,outpatient,3000,ML,26.7,18.69,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
STOMAHESIVE PASTE PSTE,RX-7493,CDM,S5000,HCPCS,259,RC,68455-0106-90,NDC,outpatient,56.7,GR,38.61,27.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SULFADIAZINE 500 MG ORAL TABS,RX-7554,CDM,S5000,HCPCS,259,RC,42806-0757-60,NDC,outpatient,1,UN,65.91,46.137,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN,RX-7556,CDM,S5000,HCPCS,250,RC,70069-0362-10,NDC,outpatient,10,ML,27.51,19.257,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN,RX-7556,CDM,S5000,HCPCS,250,RC,00703-9514-01,NDC,outpatient,10,ML,28.26,19.782,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN,RX-7556,CDM,S5000,HCPCS,250,RC,00703-9514-03,NDC,outpatient,10,ML,28.26,19.782,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN,RX-7556,CDM,S5000,HCPCS,250,RC,70069-0362-01,NDC,outpatient,10,ML,27.51,19.257,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG ORAL TABS,RX-7557,CDM,S5000,HCPCS,259,RC,60687-0603-65,NDC,outpatient,1,UN,1.41,0.987,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG ORAL TABS,RX-7557,CDM,S5000,HCPCS,259,RC,50268-0728-15,NDC,outpatient,1,UN,1.12,0.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG ORAL TABS,RX-7557,CDM,S5000,HCPCS,259,RC,60687-0603-11,NDC,outpatient,1,UN,1.41,0.987,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG ORAL TABS,RX-7557,CDM,S5000,HCPCS,259,RC,50268-0728-11,NDC,outpatient,1,UN,1.12,0.784,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SULFASALAZINE 500 MG ORAL TABS,RX-7562,CDM,S5000,HCPCS,259,RC,59762-5000-05,NDC,outpatient,1,UN,1.02,0.714,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SULFASALAZINE 500 MG ORAL TBEC,RX-7563,CDM,S5000,HCPCS,259,RC,00013-0102-50,NDC,outpatient,1,UN,8.65,6.055,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SULFASALAZINE 500 MG ORAL TBEC,RX-7563,CDM,S5000,HCPCS,259,RC,59762-0104-05,NDC,outpatient,1,UN,1.47,1.029,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VARENICLINE TARTRATE 0.5 MG ORAL TABS,RX-76444,CDM,S5000,HCPCS,259,RC,49884-0155-76,NDC,outpatient,1,UN,6.79,4.753,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VARENICLINE TARTRATE 1 MG ORAL TABS,RX-76445,CDM,S5000,HCPCS,259,RC,60687-0648-11,NDC,outpatient,1,UN,43.68,30.576,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VARENICLINE TARTRATE 1 MG ORAL TABS,RX-76445,CDM,S5000,HCPCS,259,RC,60687-0648-21,NDC,outpatient,1,UN,43.68,30.576,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACETYLCHOLINE CHLORIDE 20 MG IO SOLR,RX-76641,CDM,S5000,HCPCS,259,RC,24208-0539-20,NDC,outpatient,1,UN,349.11,244.377,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DAKINS (1/4 STRENGTH) 0.125 % EX SOLN,RX-76724,CDM,S5000,HCPCS,259,RC,00436-0672-16,NDC,outpatient,473,ML,52.63,36.841,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DAKINS (1/4 STRENGTH) 0.125 % EX SOLN,RX-76724,CDM,S5000,HCPCS,259,RC,39328-0064-12,NDC,outpatient,473,ML,44.21,30.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,63739-0724-01,NDC,outpatient,15,ML,8.75,6.125,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,00121-0948-16,NDC,outpatient,7.5,ML,2.05,1.435,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,00121-4948-15,NDC,outpatient,15,ML,19.43,13.601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,00121-0948-15,NDC,outpatient,15,ML,3.54,2.478,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,00121-4948-40,NDC,outpatient,15,ML,19.43,13.601,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,63739-0724-50,NDC,outpatient,15,ML,8.75,6.125,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VITAMIN D3 25 MCG (1000 UT) ORAL TABS,RX-76997,CDM,S5000,HCPCS,259,RC,20555-0033-00,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TANNIC ACID POWD,RX-7715,CDM,S5000,HCPCS,259,RC,,,outpatient,20,GR,9.26,6.482,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SELENIUM 40 MCG/ML IV SOLN,RX-77308,CDM,S5000,HCPCS,250,RC,69784-0840-01,NDC,outpatient,10,ML,230.25,161.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SELENIUM 40 MCG/ML IV SOLN,RX-77308,CDM,S5000,HCPCS,250,RC,69784-0840-05,NDC,outpatient,10,ML,230.25,161.175,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SITAGLIPTIN PHOSPHATE 25 MG ORAL TABS,RX-77615,CDM,S5000,HCPCS,259,RC,00006-0221-01,NDC,outpatient,1,UN,78.54,54.978,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SITAGLIPTIN PHOSPHATE 25 MG ORAL TABS,RX-77615,CDM,S5000,HCPCS,259,RC,00006-0221-28,NDC,outpatient,1,UN,78.54,54.978,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SITAGLIPTIN PHOSPHATE 100 MG ORAL TABS,RX-77617,CDM,S5000,HCPCS,259,RC,00006-0277-01,NDC,outpatient,1,UN,78.54,54.978,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SITAGLIPTIN PHOSPHATE 100 MG ORAL TABS,RX-77617,CDM,S5000,HCPCS,259,RC,00006-0277-31,NDC,outpatient,1,UN,78.53,54.971,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SITAGLIPTIN PHOSPHATE 100 MG ORAL TABS,RX-77617,CDM,S5000,HCPCS,259,RC,00006-0277-28,NDC,outpatient,1,UN,78.54,54.978,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METOCLOPRAMIDE HCL 10 MG/10ML ORAL SOLN,RX-77710,CDM,S5000,HCPCS,259,RC,00121-1576-10,NDC,outpatient,10,ML,13.35,9.345,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
METOCLOPRAMIDE HCL 10 MG/10ML ORAL SOLN,RX-77710,CDM,S5000,HCPCS,259,RC,99999-0001-27,NDC,outpatient,1,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TETRACAINE HCL 0.5 % OP SOLN,RX-7795,CDM,S5000,HCPCS,259,RC,68682-0920-64,NDC,outpatient,15,ML,325.88,228.116,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TETRACAINE HCL 0.5 % OP SOLN,RX-7795,CDM,S5000,HCPCS,259,RC,00065-0741-14,NDC,outpatient,4,ML,54.08,37.856,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TETRACYCLINE HCL 250 MG ORAL CAPS,RX-7796,CDM,S5000,HCPCS,259,RC,23155-0766-01,NDC,outpatient,1,UN,2.97,2.079,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
THEOPHYLLINE 80 MG/15ML ORAL ELIX,RX-7820,CDM,S5000,HCPCS,259,RC,60687-0258-44,NDC,outpatient,15,ML,40.12,28.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
THEOPHYLLINE 80 MG/15ML ORAL ELIX,RX-7820,CDM,S5000,HCPCS,259,RC,00121-4820-15,NDC,outpatient,15,ML,35.25,24.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
THEOPHYLLINE 80 MG/15ML ORAL ELIX,RX-7820,CDM,S5000,HCPCS,259,RC,60687-0258-71,NDC,outpatient,15,ML,40.12,28.084,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
THEOPHYLLINE 80 MG/15ML ORAL ELIX,RX-7820,CDM,S5000,HCPCS,259,RC,00121-4820-40,NDC,outpatient,15,ML,35.25,24.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
THERA ORAL TABS,RX-7825,CDM,S5000,HCPCS,259,RC,00904-0539-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
THERA-DERM EX LOTN,RX-7831,CDM,S5000,HCPCS,259,RC,00904-4299-09,NDC,outpatient,236,ML,8.41,5.887,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MESALAMINE 1.2 G ORAL TBEC,RX-78310,CDM,S5000,HCPCS,259,RC,00527-3012-48,NDC,outpatient,1,UN,7.61,5.327,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CALAMINE 8-8 % EX LOTN,RX-78879,CDM,S5000,HCPCS,259,RC,00395-0413-96,NDC,outpatient,177,ML,11.82,8.274,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CALAMINE 8-8 % EX LOTN,RX-78879,CDM,S5000,HCPCS,259,RC,49348-0011-34,NDC,outpatient,177,ML,6.31,4.417,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CALAMINE 8-8 % EX LOTN,RX-78879,CDM,S5000,HCPCS,259,RC,00904-2533-21,NDC,outpatient,177,ML,5.52,3.864,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GUAIFENESIN-CODEINE 100-10 MG/5ML ORAL SOLN,RX-79088,CDM,S5000,HCPCS,259,RC,99999-0002-04,NDC,outpatient,5,ML,1.78,1.246,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GUAIFENESIN-CODEINE 100-10 MG/5ML ORAL SOLN,RX-79088,CDM,S5000,HCPCS,259,RC,00121-1775-40,NDC,outpatient,5,ML,11.06,7.742,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GUAIFENESIN-CODEINE 100-10 MG/5ML ORAL SOLN,RX-79088,CDM,S5000,HCPCS,259,RC,00121-1775-05,NDC,outpatient,5,ML,11.06,7.742,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
THYROID 30 MG ORAL TABS,RX-7944,CDM,S5000,HCPCS,259,RC,62559-0741-01,NDC,outpatient,1,UN,2.88,2.016,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TOLNAFTATE 1 % EX CREA,RX-8020,CDM,S5000,HCPCS,259,RC,00904-0722-36,NDC,outpatient,14.18,GR,4.36,3.052,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TOLNAFTATE 1 % EX CREA,RX-8020,CDM,S5000,HCPCS,259,RC,49348-0155-29,NDC,outpatient,15,GR,8.88,6.216,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TOLNAFTATE 1 % EX POWD,RX-8021,CDM,S5000,HCPCS,259,RC,00536-1329-26,NDC,outpatient,45,GR,7.41,5.187,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRAZODONE HCL 150 MG ORAL TABS,RX-8084,CDM,S5000,HCPCS,259,RC,50268-0776-11,NDC,outpatient,1,UN,1.77,1.239,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRAZODONE HCL 150 MG ORAL TABS,RX-8084,CDM,S5000,HCPCS,259,RC,68382-0807-01,NDC,outpatient,1,UN,1.31,0.917,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRAZODONE HCL 150 MG ORAL TABS,RX-8084,CDM,S5000,HCPCS,259,RC,50268-0776-15,NDC,outpatient,1,UN,1.77,1.239,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,42291-0868-90,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,68382-0805-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,00904-6868-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,50111-0560-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,60505-2653-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,42291-0868-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRIAMCINOLONE ACETONIDE 0.025 % EX CREA,RX-8112,CDM,S5000,HCPCS,259,RC,00168-0003-80,NDC,outpatient,80,GR,21.72,15.204,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRIAMCINOLONE ACETONIDE 0.1 % EX CREA,RX-8113,CDM,S5000,HCPCS,259,RC,67877-0251-80,NDC,outpatient,80,GR,39.16,27.412,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRIAMCINOLONE ACETONIDE 0.1 % EX CREA,RX-8113,CDM,S5000,HCPCS,259,RC,45802-0064-36,NDC,outpatient,80,GR,11.04,7.728,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRIAMCINOLONE ACETONIDE 0.5 % EX CREA,RX-8114,CDM,S5000,HCPCS,259,RC,45802-0065-35,NDC,outpatient,15,GR,20.23,14.161,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRIAMCINOLONE ACETONIDE 0.025 % EX LOTN,RX-8115,CDM,S5000,HCPCS,259,RC,70752-0129-05,NDC,outpatient,60,ML,126.03,88.221,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRIAMCINOLONE ACETONIDE 0.1 % EX LOTN,RX-8116,CDM,S5000,HCPCS,259,RC,60432-0561-61,NDC,outpatient,60,ML,66.75,46.725,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRIAMCINOLONE ACETONIDE 0.1 % EX LOTN,RX-8116,CDM,S5000,HCPCS,259,RC,00713-0676-53,NDC,outpatient,60,ML,73.43,51.401,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRIAMCINOLONE ACETONIDE 0.025 % EX OINT,RX-8117,CDM,S5000,HCPCS,259,RC,00168-0005-80,NDC,outpatient,80,GR,21.01,14.707,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRIAMCINOLONE ACETONIDE 0.1 % EX OINT,RX-8118,CDM,S5000,HCPCS,259,RC,00168-0006-80,NDC,outpatient,80,GR,22.79,15.953,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRIAMCINOLONE ACETONIDE 0.1 % EX OINT,RX-8118,CDM,S5000,HCPCS,259,RC,00713-0228-80,NDC,outpatient,80,GR,37.03,25.921,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRIAMCINOLONE ACETONIDE 0.1 % EX OINT,RX-8118,CDM,S5000,HCPCS,259,RC,45802-0055-36,NDC,outpatient,80,GR,19.58,13.706,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRIAMCINOLONE ACETONIDE 0.1 % EX OINT,RX-8118,CDM,S5000,HCPCS,259,RC,51672-1284-08,NDC,outpatient,80,GR,43.44,30.408,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRIAMCINOLONE ACETONIDE 0.5 % EX OINT,RX-8119,CDM,S5000,HCPCS,259,RC,33342-0332-15,NDC,outpatient,15,GR,28.77,20.139,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRIAMCINOLONE ACETONIDE 0.1 % MT PSTE,RX-8121,CDM,S5000,HCPCS,259,RC,64980-0320-05,NDC,outpatient,5,GR,139.78,97.846,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DIVALPROEX SODIUM ER 500 MG ORAL TB24,RX-81426,CDM,S5000,HCPCS,259,RC,00904-7182-45,NDC,outpatient,1,UN,11.3,7.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUDESONIDE-FORMOTEROL FUMARATE 80-4.5 MCG/ACT IN AERO,RX-81453,CDM,S5000,HCPCS,259,RC,00186-0372-28,NDC,outpatient,6.9,GR,250.86,175.602,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUDESONIDE-FORMOTEROL FUMARATE 80-4.5 MCG/ACT IN AERO,RX-81453,CDM,S5000,HCPCS,259,RC,00310-7372-20,NDC,outpatient,10.2,GR,973.53,681.471,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUDESONIDE-FORMOTEROL FUMARATE 160-4.5 MCG/ACT IN AERO,RX-81454,CDM,S5000,HCPCS,259,RC,00310-7370-20,NDC,outpatient,10.2,GR,1011.48,708.036,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUDESONIDE-FORMOTEROL FUMARATE 160-4.5 MCG/ACT IN AERO,RX-81454,CDM,S5000,HCPCS,259,RC,00186-0370-28,NDC,outpatient,6,GR,250.85,175.595,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRIFLUOPERAZINE HCL 1 MG ORAL TABS,RX-8161,CDM,S5000,HCPCS,259,RC,00781-8028-01,NDC,outpatient,1,UN,2.52,1.764,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRIFLUOPERAZINE HCL 5 MG ORAL TABS,RX-8164,CDM,S5000,HCPCS,259,RC,00781-8034-01,NDC,outpatient,1,UN,4.68,3.276,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRIHEXYPHENIDYL HCL 2 MG ORAL TABS,RX-8166,CDM,S5000,HCPCS,259,RC,00591-5335-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRIHEXYPHENIDYL HCL 2 MG ORAL TABS,RX-8166,CDM,S5000,HCPCS,259,RC,69452-0241-20,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TRIHEXYPHENIDYL HCL 5 MG ORAL TABS,RX-8167,CDM,S5000,HCPCS,259,RC,70954-0211-10,NDC,outpatient,1,UN,1.15,0.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CEFIXIME 200 MG/5ML ORAL SUSR,RX-81816,CDM,S5000,HCPCS,259,RC,68180-0407-03,NDC,outpatient,6.25,ML,50.07,35.049,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CEFIXIME 200 MG/5ML ORAL SUSR,RX-81816,CDM,S5000,HCPCS,259,RC,99999-0002-91,NDC,outpatient,6.25,ML,120.07,84.049,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GLUCOSE 40 % ORAL GEL,RX-81823,CDM,S5000,HCPCS,259,RC,00574-0069-15,NDC,outpatient,37.5,GR,12.35,8.645,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GLUCOSE 40 % ORAL GEL,RX-81823,CDM,S5000,HCPCS,259,RC,19962-0627-63,NDC,outpatient,31,GR,6.68,4.676,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GLUCOSE 40 % ORAL GEL,RX-81823,CDM,S5000,HCPCS,259,RC,00574-0069-30,NDC,outpatient,37.5,GR,12.35,8.645,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GLUCOSE 40 % ORAL GEL,RX-81823,CDM,S5000,HCPCS,259,RC,00574-0070-30,NDC,outpatient,37.5,GR,12.35,8.645,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GLUCOSE 40 % ORAL GEL,RX-81823,CDM,S5000,HCPCS,259,RC,19962-0626-53,NDC,outpatient,31,GR,6.68,4.676,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE 7 % IN NEBU,RX-82134,CDM,S5000,HCPCS,259,RC,50190-0141-23,NDC,outpatient,4,ML,2.6,1.82,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE 7 % IN NEBU,RX-82134,CDM,S5000,HCPCS,259,RC,83490-0207-60,NDC,outpatient,4,ML,3.01,2.107,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SODIUM CHLORIDE 7 % IN NEBU,RX-82134,CDM,S5000,HCPCS,259,RC,83490-0307-60,NDC,outpatient,4,ML,1.2,0.84,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
THROMBI-GEL 40 EX PADS,RX-82259,CDM,S5000,HCPCS,259,RC,60793-0908-04,NDC,outpatient,1,UN,254.02,177.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TROPICAMIDE 1 % OP SOLN,RX-8250,CDM,S5000,HCPCS,259,RC,70069-0121-01,NDC,outpatient,15,ML,25.3,17.71,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RIVASTIGMINE 4.6 MG/24HR TD PT24,RX-82504,CDM,S5000,HCPCS,259,RC,00078-0501-15,NDC,outpatient,1,UN,93.94,65.758,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RIVASTIGMINE 4.6 MG/24HR TD PT24,RX-82504,CDM,S5000,HCPCS,259,RC,00078-0501-61,NDC,outpatient,1,UN,93.94,65.758,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RIVASTIGMINE 9.5 MG/24HR TD PT24,RX-82505,CDM,S5000,HCPCS,259,RC,47781-0305-03,NDC,outpatient,1,UN,24.46,17.122,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RIVASTIGMINE 9.5 MG/24HR TD PT24,RX-82505,CDM,S5000,HCPCS,259,RC,47781-0305-11,NDC,outpatient,1,UN,24.46,17.122,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TUBERCULIN PPD 5 UNIT/0.1ML ID SOLN,RX-8259,CDM,S5000,HCPCS,250,RC,49281-0752-78,NDC,outpatient,0.1,ML,35.98,25.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TUBERCULIN PPD 5 UNIT/0.1ML ID SOLN,RX-8259,CDM,S5000,HCPCS,250,RC,49281-0752-21,NDC,outpatient,0.1,ML,35.98,25.186,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
UNNA-FLEX ELASTIC UNNA BOOT EX MISC,RX-8371,CDM,S5000,HCPCS,250,RC,68455-0107-63,NDC,outpatient,1,UN,44.16,30.912,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VALPROIC ACID 250 MG ORAL CAPS,RX-8429,CDM,S5000,HCPCS,259,RC,00832-0310-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VALPROIC ACID 250 MG ORAL CAPS,RX-8429,CDM,S5000,HCPCS,259,RC,69452-0150-20,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VALPROIC ACID 250 MG ORAL CAPS,RX-8429,CDM,S5000,HCPCS,259,RC,00591-4012-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BACITRA-NEOMYCIN-POLYMYXIN-HC 1 % OP OINT,RX-849,CDM,S5000,HCPCS,259,RC,24208-0785-55,NDC,outpatient,3.5,GR,70.76,49.532,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VERAPAMIL HCL 2.5 MG/ML IV SOLN,RX-8527,CDM,S5000,HCPCS,250,RC,51754-0203-02,NDC,outpatient,2,ML,15.45,10.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VERAPAMIL HCL 2.5 MG/ML IV SOLN,RX-8527,CDM,S5000,HCPCS,250,RC,51754-0203-04,NDC,outpatient,2,ML,15.45,10.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VERAPAMIL HCL 2.5 MG/ML IV SOLN,RX-8527,CDM,S5000,HCPCS,250,RC,70710-1643-07,NDC,outpatient,2,ML,44.5,31.15,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VERAPAMIL HCL 2.5 MG/ML IV SOLN,RX-8527,CDM,S5000,HCPCS,250,RC,51754-0203-01,NDC,outpatient,2,ML,15.45,10.815,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VERAPAMIL HCL 120 MG ORAL TABS,RX-8528,CDM,S5000,HCPCS,259,RC,23155-0486-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VERAPAMIL HCL 40 MG ORAL TABS,RX-8529,CDM,S5000,HCPCS,259,RC,23155-0059-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VERAPAMIL HCL 80 MG ORAL TABS,RX-8530,CDM,S5000,HCPCS,259,RC,23155-0026-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BACITRACIN-NEOMYCIN-POLYMYXIN 400-3.5-5000 EX OINT,RX-854,CDM,S5000,HCPCS,259,RC,70677-0013-01,NDC,outpatient,28.4,GR,10.49,7.343,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BACITRACIN-NEOMYCIN-POLYMYXIN 400-3.5-5000 EX OINT,RX-854,CDM,S5000,HCPCS,259,RC,49348-0029-72,NDC,outpatient,30,GR,11.49,8.043,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BACITRACIN-POLYMYXIN B 500-10000 UNIT/GM EX OINT,RX-855,CDM,S5000,HCPCS,259,RC,00501-3798-05,NDC,outpatient,14.2,GR,20.67,14.469,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BACITRACIN-POLYMYXIN B 500-10000 UNIT/GM OP OINT,RX-856,CDM,S5000,HCPCS,259,RC,24208-0555-55,NDC,outpatient,3.5,GR,22.88,16.016,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BACLOFEN 10 MG ORAL TABS,RX-860,CDM,S5000,HCPCS,259,RC,00527-1330-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BACLOFEN 10 MG ORAL TABS,RX-860,CDM,S5000,HCPCS,259,RC,00904-6475-61,NDC,outpatient,1,UN,1.6,1.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BACLOFEN 10 MG ORAL TABS,RX-860,CDM,S5000,HCPCS,259,RC,63739-0479-10,NDC,outpatient,1,UN,1.74,1.218,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VITAMIN C 250 MG ORAL TABS,RX-8679,CDM,S5000,HCPCS,259,RC,50268-0860-15,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VITAMIN C 250 MG ORAL TABS,RX-8679,CDM,S5000,HCPCS,259,RC,50268-0860-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VITAMIN E 100 UNITS ORAL CAPS,RX-8698,CDM,S5000,HCPCS,259,RC,80681-0134-00,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VITAMIN E 400 UNITS ORAL CAPS,RX-8701,CDM,S5000,HCPCS,259,RC,00536-1352-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VITAMIN E 400 UNITS ORAL CAPS,RX-8701,CDM,S5000,HCPCS,259,RC,77333-0951-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VITAMIN E 400 UNITS ORAL CAPS,RX-8701,CDM,S5000,HCPCS,259,RC,77333-0951-25,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VITAMINS A & D EX OINT,RX-8723,CDM,S5000,HCPCS,259,RC,57896-0110-14,NDC,outpatient,5,GR,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
VITAMINS A & D EX OINT,RX-8723,CDM,S5000,HCPCS,259,RC,57896-0110-05,NDC,outpatient,5,GR,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
WARFARIN SODIUM 2 MG ORAL TABS,RX-8749,CDM,S5000,HCPCS,259,RC,62584-0984-01,NDC,outpatient,1,UN,1.22,0.854,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
WARFARIN SODIUM 2 MG ORAL TABS,RX-8749,CDM,S5000,HCPCS,259,RC,62584-0984-11,NDC,outpatient,1,UN,1.22,0.854,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
WARFARIN SODIUM 2.5 MG ORAL TABS,RX-8750,CDM,S5000,HCPCS,259,RC,00832-1213-89,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
WARFARIN SODIUM 2.5 MG ORAL TABS,RX-8750,CDM,S5000,HCPCS,259,RC,68084-0027-01,NDC,outpatient,1,UN,1.29,0.903,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
WARFARIN SODIUM 2.5 MG ORAL TABS,RX-8750,CDM,S5000,HCPCS,259,RC,00832-1213-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
WARFARIN SODIUM 2.5 MG ORAL TABS,RX-8750,CDM,S5000,HCPCS,259,RC,68084-0027-11,NDC,outpatient,1,UN,1.29,0.903,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
WARFARIN SODIUM 5 MG ORAL TABS,RX-8751,CDM,S5000,HCPCS,259,RC,00832-1216-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
WARFARIN SODIUM 5 MG ORAL TABS,RX-8751,CDM,S5000,HCPCS,259,RC,00832-1216-89,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
WARFARIN SODIUM 7.5 MG ORAL TABS,RX-8752,CDM,S5000,HCPCS,259,RC,00832-1218-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
WARFARIN SODIUM 7.5 MG ORAL TABS,RX-8752,CDM,S5000,HCPCS,259,RC,00832-1218-89,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
THROMBIN 5000 UNITS EX KIT,RX-87798,CDM,S5000,HCPCS,250,RC,60793-0705-05,NDC,outpatient,1,UN,217.65,152.355,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
THROMBIN 5000 UNITS EX KIT,RX-87798,CDM,S5000,HCPCS,250,RC,60793-0205-05,NDC,outpatient,1,UN,228.51,159.957,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CALCIUM GLUCONATE (ANTIDOTE) 2.5 % EX GEL,RX-87801,CDM,S5000,HCPCS,259,RC,35181-7303-32,NDC,outpatient,25,GR,146.52,102.564,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BRIMONIDINE TARTRATE-TIMOLOL 0.2-0.5 % OP SOLN,RX-87834,CDM,S5000,HCPCS,259,RC,00023-9211-05,NDC,outpatient,5,ML,838.92,587.244,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BRIMONIDINE TARTRATE-TIMOLOL 0.2-0.5 % OP SOLN,RX-87834,CDM,S5000,HCPCS,259,RC,82182-0455-05,NDC,outpatient,5,ML,356.54,249.578,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DIAZEPAM 2.5 MG RE GEL,RX-87865,CDM,S5000,HCPCS,259,RC,68682-0650-20,NDC,outpatient,1,UN,430.63,301.441,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DIAZEPAM 10 MG RE GEL,RX-87867,CDM,S5000,HCPCS,259,RC,68682-0652-20,NDC,outpatient,1,UN,622.96,436.072,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DIAZEPAM 20 MG RE GEL,RX-87869,CDM,S5000,HCPCS,259,RC,68682-0655-20,NDC,outpatient,1,UN,601.24,420.868,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,49502-0605-61,NDC,outpatient,2,ML,20.29,14.203,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,00378-1631-32,NDC,outpatient,2,ML,38.15,26.705,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,00378-1631-93,NDC,outpatient,2,ML,38.15,26.705,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,70756-0608-60,NDC,outpatient,2,ML,11.64,8.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,00093-4061-06,NDC,outpatient,2,ML,64.19,44.933,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,00093-4061-19,NDC,outpatient,2,ML,64.19,44.933,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,62332-0655-01,NDC,outpatient,2,ML,18.21,12.747,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,62332-0655-60,NDC,outpatient,2,ML,18.21,12.747,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,70756-0608-44,NDC,outpatient,2,ML,11.64,8.148,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RALTEGRAVIR POTASSIUM 400 MG ORAL TABS,RX-88608,CDM,S5000,HCPCS,259,RC,00006-0227-61,NDC,outpatient,1,UN,143.66,100.562,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ZINC CHLORIDE 1 MG/ML IV SOLN,RX-8865,CDM,S5000,HCPCS,250,RC,00409-4090-01,NDC,outpatient,10,ML,63.68,44.576,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ZINC CHLORIDE 1 MG/ML IV SOLN,RX-8865,CDM,S5000,HCPCS,250,RC,00409-4090-11,NDC,outpatient,10,ML,63.68,44.576,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAPS,RX-88704,CDM,S5000,HCPCS,259,RC,31722-0630-31,NDC,outpatient,1,UN,3.93,2.751,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAPS,RX-88704,CDM,S5000,HCPCS,259,RC,00004-0802-85,NDC,outpatient,1,UN,57.3,40.11,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OSELTAMIVIR PHOSPHATE 45 MG ORAL CAPS,RX-88705,CDM,S5000,HCPCS,259,RC,00004-0801-85,NDC,outpatient,1,UN,57.3,40.11,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ZINC OXIDE 20 % EX OINT,RX-8874,CDM,S5000,HCPCS,259,RC,00536-1316-98,NDC,outpatient,454,GR,22.23,15.561,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ZINC OXIDE 20 % EX OINT,RX-8874,CDM,S5000,HCPCS,259,RC,75834-0170-01,NDC,outpatient,28.4,GR,13.53,9.471,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ZINC SULFATE 1 MG/ML IV SOLN,RX-8878,CDM,S5000,HCPCS,250,RC,00517-6101-01,NDC,outpatient,10,ML,75.92,53.144,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ZINC SULFATE 1 MG/ML IV SOLN,RX-8878,CDM,S5000,HCPCS,250,RC,00517-6101-25,NDC,outpatient,10,ML,75.92,53.144,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ZINC SULFATE 5 MG/ML IV SOLN,RX-8879,CDM,S5000,HCPCS,250,RC,00517-8005-25,NDC,outpatient,5,ML,189.8,132.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ZINC SULFATE 5 MG/ML IV SOLN,RX-8879,CDM,S5000,HCPCS,250,RC,00517-8005-01,NDC,outpatient,5,ML,189.8,132.86,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ZINC SULFATE 220 (50 ZN) MG ORAL CAPS,RX-8880,CDM,S5000,HCPCS,259,RC,77333-0983-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ZINC SULFATE 220 (50 ZN) MG ORAL CAPS,RX-8880,CDM,S5000,HCPCS,259,RC,77333-0983-25,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SEVELAMER CARBONATE 800 MG ORAL TABS,RX-89201,CDM,S5000,HCPCS,259,RC,00904-6707-82,NDC,outpatient,1,UN,11.14,7.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SEVELAMER CARBONATE 800 MG ORAL TABS,RX-89201,CDM,S5000,HCPCS,259,RC,68094-0034-64,NDC,outpatient,1,UN,6.38,4.466,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SEVELAMER CARBONATE 800 MG ORAL TABS,RX-89201,CDM,S5000,HCPCS,259,RC,68094-0034-59,NDC,outpatient,1,UN,6.38,4.466,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
NEBIVOLOL HCL 5 MG ORAL TABS,RX-89284,CDM,S5000,HCPCS,259,RC,00904-7189-04,NDC,outpatient,1,UN,7.99,5.593,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLOPIDOGREL BISULFATE 300 MG ORAL TABS,RX-89346,CDM,S5000,HCPCS,259,RC,00904-6467-07,NDC,outpatient,1,UN,32.67,22.869,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLOPIDOGREL BISULFATE 300 MG ORAL TABS,RX-89346,CDM,S5000,HCPCS,259,RC,00904-6467-10,NDC,outpatient,1,UN,22.14,15.498,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACEBUTOLOL HCL 200 MG ORAL CAPS,RX-8939,CDM,S5000,HCPCS,259,RC,50268-0050-11,NDC,outpatient,1,UN,5.16,3.612,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACEBUTOLOL HCL 200 MG ORAL CAPS,RX-8939,CDM,S5000,HCPCS,259,RC,50268-0050-15,NDC,outpatient,1,UN,5.16,3.612,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ZINC OXIDE 11.3 % EX CREA,RX-89412,CDM,S5000,HCPCS,259,RC,57074-0001-86,NDC,outpatient,60,GR,9.35,6.545,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ZINC OXIDE 11.3 % EX CREA,RX-89412,CDM,S5000,HCPCS,259,RC,30103-0040-00,NDC,outpatient,60,GR,12.55,8.785,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,00121-1781-05,NDC,outpatient,5,ML,4.72,3.304,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,68094-0231-59,NDC,outpatient,5,ML,2.67,1.869,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,68094-0231-62,NDC,outpatient,5,ML,2.76,1.932,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,99999-0004-23,NDC,outpatient,5,ML,2.67,1.869,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,68094-0231-61,NDC,outpatient,5,ML,2.67,1.869,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,00121-1781-00,NDC,outpatient,5,ML,4.72,3.304,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ETRAVIRINE 100 MG ORAL TABS,RX-89432,CDM,S5000,HCPCS,259,RC,59676-0570-01,NDC,outpatient,1,UN,53.89,37.723,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ETRAVIRINE 100 MG ORAL TABS,RX-89432,CDM,S5000,HCPCS,259,RC,60219-1721-07,NDC,outpatient,1,UN,36.43,25.501,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACETAMINOPHEN-CODEINE 300-30 MG ORAL TABS,RX-8949,CDM,S5000,HCPCS,259,RC,00406-0484-62,NDC,outpatient,1,UN,1.51,1.057,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACETAMINOPHEN-CODEINE 300-30 MG ORAL TABS,RX-8949,CDM,S5000,HCPCS,259,RC,00406-0484-23,NDC,outpatient,1,UN,1.51,1.057,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
THROMBIN (RECOMBINANT) 5000 UNITS EX SOLR,RX-89570,CDM,S5000,HCPCS,250,RC,00338-0322-01,NDC,outpatient,1,UN,281.38,196.966,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUTALBITAL-APAP-CAFFEINE 50-325-40 MG ORAL TABS,RX-8958,CDM,S5000,HCPCS,259,RC,60687-0672-11,NDC,outpatient,1,UN,4.66,3.262,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUTALBITAL-APAP-CAFFEINE 50-325-40 MG ORAL TABS,RX-8958,CDM,S5000,HCPCS,259,RC,60687-0672-65,NDC,outpatient,1,UN,4.66,3.262,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUTALBITAL-APAP-CAFFEINE 50-325-40 MG ORAL TABS,RX-8958,CDM,S5000,HCPCS,259,RC,00527-1695-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUTALBITAL-APAP-CAFFEINE 50-325-40 MG ORAL TABS,RX-8958,CDM,S5000,HCPCS,259,RC,00904-6938-06,NDC,outpatient,1,UN,4.29,3.003,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUTALBITAL-APAP-CAFFEINE 50-325-40 MG ORAL TABS,RX-8958,CDM,S5000,HCPCS,259,RC,10702-0253-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACETIC ACID 0.25 % IR SOLN,RX-8963,CDM,S5000,HCPCS,250,RC,00338-0656-04,NDC,outpatient,1000,ML,13.35,9.345,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACYCLOVIR 5 % EX CREA,RX-8967,CDM,S5000,HCPCS,259,RC,45802-0044-75,NDC,outpatient,5,GR,210.13,147.091,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACYCLOVIR 5 % EX CREA,RX-8967,CDM,S5000,HCPCS,259,RC,00187-0994-45,NDC,outpatient,5,GR,822.36,575.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACYCLOVIR 200 MG ORAL CAPS,RX-8969,CDM,S5000,HCPCS,259,RC,00904-5789-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACYCLOVIR 200 MG ORAL CAPS,RX-8969,CDM,S5000,HCPCS,259,RC,60505-0042-06,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACYCLOVIR 200 MG/5ML ORAL SUSP,RX-8970,CDM,S5000,HCPCS,259,RC,31722-0681-47,NDC,outpatient,473,ML,244.17,170.919,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACYCLOVIR 200 MG/5ML ORAL SUSP,RX-8970,CDM,S5000,HCPCS,259,RC,99999-0004-02,NDC,outpatient,5,ML,4.94,3.458,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACYCLOVIR 200 MG/5ML ORAL SUSP,RX-8970,CDM,S5000,HCPCS,259,RC,00472-0082-16,NDC,outpatient,473,ML,1582.85,1107.995,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACYCLOVIR 800 MG ORAL TABS,RX-8972,CDM,S5000,HCPCS,259,RC,68084-0109-01,NDC,outpatient,1,UN,3.08,2.156,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ACYCLOVIR 800 MG ORAL TABS,RX-8972,CDM,S5000,HCPCS,259,RC,68084-0109-11,NDC,outpatient,1,UN,3.08,2.156,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,00904-7325-73,NDC,outpatient,30,ML,11.09,7.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,99999-0002-58,NDC,outpatient,30,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,00121-1761-30,NDC,outpatient,30,ML,7.21,5.047,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,00904-7325-62,NDC,outpatient,30,ML,11.09,7.763,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,57896-0629-12,NDC,outpatient,10,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,70677-1063-01,NDC,outpatient,10,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,70677-1063-30,NDC,outpatient,30,ML,1.7,1.19,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMINOCAPROIC ACID 500 MG ORAL TABS,RX-9063,CDM,S5000,HCPCS,259,RC,69680-0115-30,NDC,outpatient,1,UN,26.56,18.592,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMIODARONE HCL 200 MG ORAL TABS,RX-9066,CDM,S5000,HCPCS,259,RC,63739-0051-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMIODARONE HCL 200 MG ORAL TABS,RX-9066,CDM,S5000,HCPCS,259,RC,00245-0147-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMIODARONE HCL 200 MG ORAL TABS,RX-9066,CDM,S5000,HCPCS,259,RC,00245-0147-89,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMIODARONE HCL 200 MG ORAL TABS,RX-9066,CDM,S5000,HCPCS,259,RC,00904-6993-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMLODIPINE BESYLATE 2.5 MG ORAL TABS,RX-9070,CDM,S5000,HCPCS,259,RC,00904-6369-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMLODIPINE BESYLATE 5 MG ORAL TABS,RX-9071,CDM,S5000,HCPCS,259,RC,68382-0122-16,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMLODIPINE BESYLATE 5 MG ORAL TABS,RX-9071,CDM,S5000,HCPCS,259,RC,00904-6370-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TABS,RX-9081,CDM,S5000,HCPCS,259,RC,64850-0502-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TABS,RX-9081,CDM,S5000,HCPCS,259,RC,42806-0341-01,NDC,outpatient,1,UN,1.52,1.064,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DESVENLAFAXINE SUCCINATE ER 50 MG ORAL TB24,RX-91073,CDM,S5000,HCPCS,259,RC,00008-1211-14,NDC,outpatient,1,UN,5.76,4.032,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DESVENLAFAXINE SUCCINATE ER 50 MG ORAL TB24,RX-91073,CDM,S5000,HCPCS,259,RC,00591-3659-30,NDC,outpatient,1,UN,2.77,1.939,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DESVENLAFAXINE SUCCINATE ER 50 MG ORAL TB24,RX-91073,CDM,S5000,HCPCS,259,RC,51991-0311-90,NDC,outpatient,1,UN,2.38,1.666,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ROPINIROLE HCL ER 2 MG ORAL TB24,RX-92015,CDM,S5000,HCPCS,259,RC,55111-0659-30,NDC,outpatient,1,UN,2.69,1.883,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BENAZEPRIL HCL 10 MG ORAL TABS,RX-9220,CDM,S5000,HCPCS,259,RC,50268-0110-11,NDC,outpatient,1,UN,2.09,1.463,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BENAZEPRIL HCL 10 MG ORAL TABS,RX-9220,CDM,S5000,HCPCS,259,RC,50268-0110-15,NDC,outpatient,1,UN,2.09,1.463,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BETAXOLOL HCL 0.5 % OP SOLN,RX-9268,CDM,S5000,HCPCS,259,RC,61314-0245-01,NDC,outpatient,5,ML,147.74,103.418,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BETAXOLOL HCL 10 MG ORAL TABS,RX-9269,CDM,S5000,HCPCS,259,RC,10135-0623-01,NDC,outpatient,1,UN,2.28,1.596,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BETAXOLOL HCL 10 MG ORAL TABS,RX-9269,CDM,S5000,HCPCS,259,RC,10702-0013-01,NDC,outpatient,1,UN,1.58,1.106,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
MOUTH KOTE MT SOLN,RX-92764,CDM,S5000,HCPCS,259,RC,50930-0098-02,NDC,outpatient,59,ML,21.53,15.071,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BROMOCRIPTINE MESYLATE 2.5 MG ORAL TABS,RX-9297,CDM,S5000,HCPCS,259,RC,00574-0106-03,NDC,outpatient,1,UN,3.28,2.296,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUMETANIDE 0.5 MG ORAL TABS,RX-9309,CDM,S5000,HCPCS,259,RC,42799-0119-01,NDC,outpatient,1,UN,1.43,1.001,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUMETANIDE 0.5 MG ORAL TABS,RX-9309,CDM,S5000,HCPCS,259,RC,50268-0130-11,NDC,outpatient,1,UN,5.55,3.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUMETANIDE 0.5 MG ORAL TABS,RX-9309,CDM,S5000,HCPCS,259,RC,50268-0130-15,NDC,outpatient,1,UN,5.55,3.885,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,00185-0129-01,NDC,outpatient,1,UN,1.65,1.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,50268-0131-11,NDC,outpatient,1,UN,3.09,2.163,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,60687-0384-01,NDC,outpatient,1,UN,3.38,2.366,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,69238-1490-01,NDC,outpatient,1,UN,1.61,1.127,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,60687-0384-11,NDC,outpatient,1,UN,3.38,2.366,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,00185-0129-05,NDC,outpatient,1,UN,1.38,0.966,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,50268-0131-15,NDC,outpatient,1,UN,3.09,2.163,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 IJ SOLN,RX-9318,CDM,S5000,HCPCS,250,RC,63323-0463-01,NDC,outpatient,50,ML,49.4,34.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 IJ SOLN,RX-9318,CDM,S5000,HCPCS,250,RC,63323-0463-57,NDC,outpatient,50,ML,49.4,34.58,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPROPION HCL 100 MG ORAL TABS,RX-9321,CDM,S5000,HCPCS,259,RC,00904-6636-61,NDC,outpatient,1,UN,4.6,3.22,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPROPION HCL 75 MG ORAL TABS,RX-9322,CDM,S5000,HCPCS,259,RC,60687-0340-11,NDC,outpatient,1,UN,3.85,2.695,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPROPION HCL 75 MG ORAL TABS,RX-9322,CDM,S5000,HCPCS,259,RC,50268-0142-15,NDC,outpatient,1,UN,2.99,2.093,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPROPION HCL 75 MG ORAL TABS,RX-9322,CDM,S5000,HCPCS,259,RC,60687-0340-01,NDC,outpatient,1,UN,3.85,2.695,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUPROPION HCL 75 MG ORAL TABS,RX-9322,CDM,S5000,HCPCS,259,RC,50268-0142-11,NDC,outpatient,1,UN,2.99,2.093,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUSPIRONE HCL 5 MG ORAL TABS,RX-9324,CDM,S5000,HCPCS,259,RC,00093-0053-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUSPIRONE HCL 5 MG ORAL TABS,RX-9324,CDM,S5000,HCPCS,259,RC,00904-7122-61,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUSPIRONE HCL 5 MG ORAL TABS,RX-9324,CDM,S5000,HCPCS,259,RC,51079-0985-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BUSPIRONE HCL 5 MG ORAL TABS,RX-9324,CDM,S5000,HCPCS,259,RC,51079-0985-20,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CALCITRIOL 0.25 MCG ORAL CAPS,RX-9350,CDM,S5000,HCPCS,259,RC,23155-0662-01,NDC,outpatient,1,UN,1.4,0.98,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CALCITRIOL 0.25 MCG ORAL CAPS,RX-9350,CDM,S5000,HCPCS,259,RC,69452-0207-20,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CALCIUM CARBONATE ANTACID 500 MG ORAL CHEW,RX-9385,CDM,S5000,HCPCS,259,RC,68084-0988-33,NDC,outpatient,1,UN,2.86,2.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CALCIUM CARBONATE ANTACID 500 MG ORAL CHEW,RX-9385,CDM,S5000,HCPCS,259,RC,00904-6412-92,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CALCIUM CARBONATE ANTACID 500 MG ORAL CHEW,RX-9385,CDM,S5000,HCPCS,259,RC,68084-0988-32,NDC,outpatient,1,UN,2.86,2.002,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CALCIUM CARBONATE ANTACID 500 MG ORAL CHEW,RX-9385,CDM,S5000,HCPCS,259,RC,66553-0004-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SORBITOL 70 % SOLN,RX-93927,CDM,S5000,HCPCS,259,RC,46287-0500-30,NDC,outpatient,30,ML,9.48,6.636,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,47335-0756-49,NDC,outpatient,3,ML,1.42,0.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00378-9671-30,NDC,outpatient,3,ML,2.4,1.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00378-9671-60,NDC,outpatient,3,ML,2.4,1.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00378-9671-93,NDC,outpatient,3,ML,2.4,1.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00487-0201-03,NDC,outpatient,3,ML,1.13,0.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00487-0201-01,NDC,outpatient,3,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,76204-0600-01,NDC,outpatient,3,ML,1.22,0.854,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00378-9671-31,NDC,outpatient,3,ML,2.4,1.68,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,47335-0756-48,NDC,outpatient,3,ML,1.42,0.994,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CAPTOPRIL 12.5 MG ORAL TABS,RX-9401,CDM,S5000,HCPCS,259,RC,00904-7105-61,NDC,outpatient,1,UN,6.29,4.403,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CAPTOPRIL 25 MG ORAL TABS,RX-9402,CDM,S5000,HCPCS,259,RC,00904-7106-61,NDC,outpatient,1,UN,5.2,3.64,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CARBIDOPA-LEVODOPA 10-100 MG ORAL TABS,RX-9406,CDM,S5000,HCPCS,259,RC,00093-9701-01,NDC,outpatient,1,UN,1.15,0.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CARBIDOPA-LEVODOPA 25-100 MG ORAL TABS,RX-9407,CDM,S5000,HCPCS,259,RC,00093-9702-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CARBIDOPA-LEVODOPA 25-100 MG ORAL TABS,RX-9407,CDM,S5000,HCPCS,259,RC,60687-0661-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CARBIDOPA-LEVODOPA 25-100 MG ORAL TABS,RX-9407,CDM,S5000,HCPCS,259,RC,60687-0661-11,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN,RX-9413,CDM,S5000,HCPCS,250,RC,00009-0856-08,NDC,outpatient,1,ML,319.49,223.643,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN,RX-9413,CDM,S5000,HCPCS,250,RC,00009-0856-05,NDC,outpatient,1,ML,319.49,223.643,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BENZOCAINE-MENTHOL 15-3.6 MG MT LOZG,RX-94141,CDM,S5000,HCPCS,259,RC,00904-6255-49,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RENO CAPS 1 MG ORAL CAPS,RX-94178,CDM,S5000,HCPCS,259,RC,63044-0622-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
RENO CAPS 1 MG ORAL CAPS,RX-94178,CDM,S5000,HCPCS,259,RC,60258-0162-01,NDC,outpatient,1,UN,2.43,1.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CEFACLOR 250 MG ORAL CAPS,RX-9430,CDM,S5000,HCPCS,259,RC,61442-0171-30,NDC,outpatient,1,UN,8.1,5.67,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CEFADROXIL 500 MG ORAL CAPS,RX-9436,CDM,S5000,HCPCS,259,RC,68180-0180-08,NDC,outpatient,1,UN,2.65,1.855,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CEFADROXIL 500 MG ORAL CAPS,RX-9436,CDM,S5000,HCPCS,259,RC,65862-0085-50,NDC,outpatient,1,UN,2.45,1.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CEFADROXIL 500 MG ORAL CAPS,RX-9436,CDM,S5000,HCPCS,259,RC,16714-0388-01,NDC,outpatient,1,UN,1.08,0.756,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CEFADROXIL 500 MG ORAL CAPS,RX-9436,CDM,S5000,HCPCS,259,RC,68180-0180-01,NDC,outpatient,1,UN,2.36,1.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CEFPODOXIME PROXETIL 200 MG ORAL TABS,RX-9469,CDM,S5000,HCPCS,259,RC,65862-0096-20,NDC,outpatient,1,UN,14.53,10.171,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CEFPODOXIME PROXETIL 200 MG ORAL TABS,RX-9469,CDM,S5000,HCPCS,259,RC,00781-5439-20,NDC,outpatient,1,UN,12.33,8.631,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CEFUROXIME AXETIL 250 MG ORAL TABS,RX-9495,CDM,S5000,HCPCS,259,RC,67877-0215-60,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CEFUROXIME AXETIL 250 MG ORAL TABS,RX-9495,CDM,S5000,HCPCS,259,RC,16714-0400-02,NDC,outpatient,1,UN,3.64,2.548,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CEFUROXIME AXETIL 250 MG ORAL TABS,RX-9495,CDM,S5000,HCPCS,259,RC,65862-0699-60,NDC,outpatient,1,UN,2.34,1.638,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CEPHALEXIN 250 MG ORAL CAPS,RX-9499,CDM,S5000,HCPCS,259,RC,50268-0151-11,NDC,outpatient,1,UN,1.49,1.043,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CEPHALEXIN 250 MG ORAL CAPS,RX-9499,CDM,S5000,HCPCS,259,RC,60687-0152-01,NDC,outpatient,1,UN,1.3,0.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CEPHALEXIN 250 MG ORAL CAPS,RX-9499,CDM,S5000,HCPCS,259,RC,60687-0152-11,NDC,outpatient,1,UN,1.3,0.91,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CEPHALEXIN 250 MG ORAL CAPS,RX-9499,CDM,S5000,HCPCS,259,RC,67877-0220-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CEPHALEXIN 250 MG ORAL CAPS,RX-9499,CDM,S5000,HCPCS,259,RC,50268-0151-15,NDC,outpatient,1,UN,1.49,1.043,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CHLORHEXIDINE GLUCONATE 0.12 % MT SOLN,RX-9516,CDM,S5000,HCPCS,259,RC,69339-0138-15,NDC,outpatient,15,ML,6.55,4.585,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CHLORHEXIDINE GLUCONATE 0.12 % MT SOLN,RX-9516,CDM,S5000,HCPCS,259,RC,69339-0138-19,NDC,outpatient,15,ML,6.15,4.305,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CHLOROTHIAZIDE 250 MG/5ML ORAL SUSP,RX-9525,CDM,S5000,HCPCS,259,RC,,,outpatient,5,ML,5.99,4.193,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CHLOROTHIAZIDE 250 MG/5ML ORAL SUSP,RX-9525,CDM,S5000,HCPCS,259,RC,,,outpatient,1,ML,1.39,0.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FERROUS SULFATE 75 (15 FE) MG/ML ORAL SOLN,RX-95693,CDM,S5000,HCPCS,259,RC,54838-0011-50,NDC,outpatient,50,ML,14.02,9.814,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
FERROUS SULFATE 75 (15 FE) MG/ML ORAL SOLN,RX-95693,CDM,S5000,HCPCS,259,RC,99999-0003-94,NDC,outpatient,1,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CIPROFLOXACIN HCL 0.3 % OP SOLN,RX-9610,CDM,S5000,HCPCS,259,RC,61314-0656-05,NDC,outpatient,5,ML,15.4,10.78,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CIPROFLOXACIN HCL 0.3 % OP SOLN,RX-9610,CDM,S5000,HCPCS,259,RC,69315-0308-05,NDC,outpatient,5,ML,62.3,43.61,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLARITHROMYCIN 250 MG ORAL TABS,RX-9616,CDM,S5000,HCPCS,259,RC,65862-0225-60,NDC,outpatient,1,UN,1.39,0.973,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLARITHROMYCIN 250 MG ORAL TABS,RX-9616,CDM,S5000,HCPCS,259,RC,00527-1931-06,NDC,outpatient,1,UN,1.14,0.798,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLINDAMYCIN PHOSPHATE 1 % EX GEL,RX-9623,CDM,S5000,HCPCS,259,RC,59762-3743-01,NDC,outpatient,30,GR,208.26,145.782,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLINDAMYCIN PHOSPHATE 1 % EX GEL,RX-9623,CDM,S5000,HCPCS,259,RC,00168-0202-30,NDC,outpatient,30,GR,207.33,145.131,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLOBETASOL PROPIONATE 0.05 % EX CREA,RX-9630,CDM,S5000,HCPCS,259,RC,51672-1258-02,NDC,outpatient,30,GR,31.11,21.777,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLOBETASOL PROPIONATE 0.05 % EX CREA,RX-9630,CDM,S5000,HCPCS,259,RC,69238-1532-05,NDC,outpatient,15,GR,19.83,13.881,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLOBETASOL PROPIONATE 0.05 % EX OINT,RX-9631,CDM,S5000,HCPCS,259,RC,21922-0017-05,NDC,outpatient,30,GR,42.19,29.533,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLOBETASOL PROPIONATE 0.05 % EX OINT,RX-9631,CDM,S5000,HCPCS,259,RC,51672-1259-02,NDC,outpatient,30,GR,43.53,30.471,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLOMIPRAMINE HCL 25 MG ORAL CAPS,RX-9635,CDM,S5000,HCPCS,259,RC,68084-0790-25,NDC,outpatient,1,UN,36.81,25.767,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLOMIPRAMINE HCL 25 MG ORAL CAPS,RX-9635,CDM,S5000,HCPCS,259,RC,68084-0790-95,NDC,outpatient,1,UN,36.81,25.767,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLONAZEPAM 0.5 MG ORAL TABS,RX-9637,CDM,S5000,HCPCS,259,RC,60687-0544-11,NDC,outpatient,1,UN,1.65,1.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLONAZEPAM 0.5 MG ORAL TABS,RX-9637,CDM,S5000,HCPCS,259,RC,60687-0544-01,NDC,outpatient,1,UN,1.65,1.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLONAZEPAM 1 MG ORAL TABS,RX-9638,CDM,S5000,HCPCS,259,RC,60687-0555-01,NDC,outpatient,1,UN,1.65,1.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLONAZEPAM 1 MG ORAL TABS,RX-9638,CDM,S5000,HCPCS,259,RC,16729-0137-00,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLONAZEPAM 1 MG ORAL TABS,RX-9638,CDM,S5000,HCPCS,259,RC,43547-0407-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLONAZEPAM 1 MG ORAL TABS,RX-9638,CDM,S5000,HCPCS,259,RC,60687-0555-11,NDC,outpatient,1,UN,1.65,1.155,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLOTRIMAZOLE 10 MG MT TROC,RX-9644,CDM,S5000,HCPCS,259,RC,00054-4146-22,NDC,outpatient,1,UN,1.41,0.987,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLOTRIMAZOLE 10 MG MT TROC,RX-9644,CDM,S5000,HCPCS,259,RC,00574-0107-70,NDC,outpatient,1,UN,1.34,0.938,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLOZAPINE 100 MG ORAL TABS,RX-9647,CDM,S5000,HCPCS,259,RC,51079-0922-01,NDC,outpatient,1,UN,4.21,2.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLOZAPINE 100 MG ORAL TABS,RX-9647,CDM,S5000,HCPCS,259,RC,60687-0415-01,NDC,outpatient,1,UN,2.55,1.785,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLOZAPINE 100 MG ORAL TABS,RX-9647,CDM,S5000,HCPCS,259,RC,60687-0415-11,NDC,outpatient,1,UN,2.55,1.785,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLOZAPINE 100 MG ORAL TABS,RX-9647,CDM,S5000,HCPCS,259,RC,51079-0922-20,NDC,outpatient,1,UN,4.21,2.947,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLOZAPINE 25 MG ORAL TABS,RX-9648,CDM,S5000,HCPCS,259,RC,51079-0921-01,NDC,outpatient,1,UN,2.14,1.498,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CLOZAPINE 25 MG ORAL TABS,RX-9648,CDM,S5000,HCPCS,259,RC,51079-0921-20,NDC,outpatient,1,UN,2.14,1.498,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
COLLAGENASE 250 UNIT/GM EX OINT,RX-9682,CDM,S5000,HCPCS,259,RC,50484-0010-30,NDC,outpatient,30,GR,1218.46,852.922,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CROMOLYN SODIUM 4 % OP SOLN,RX-9691,CDM,S5000,HCPCS,259,RC,61314-0237-10,NDC,outpatient,10,ML,27.77,19.439,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LACOSAMIDE 50 MG ORAL TABS,RX-96968,CDM,S5000,HCPCS,259,RC,68462-0678-60,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LACOSAMIDE 50 MG ORAL TABS,RX-96968,CDM,S5000,HCPCS,259,RC,00131-2477-60,NDC,outpatient,1,UN,53.28,37.296,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LACOSAMIDE 50 MG ORAL TABS,RX-96968,CDM,S5000,HCPCS,259,RC,00131-2477-35,NDC,outpatient,1,UN,48.43,33.901,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LACOSAMIDE 100 MG ORAL TABS,RX-96969,CDM,S5000,HCPCS,259,RC,51991-0349-06,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LACOSAMIDE 100 MG ORAL TABS,RX-96969,CDM,S5000,HCPCS,259,RC,60687-0687-11,NDC,outpatient,1,UN,5.37,3.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LACOSAMIDE 100 MG ORAL TABS,RX-96969,CDM,S5000,HCPCS,259,RC,00131-2478-60,NDC,outpatient,1,UN,83.29,58.303,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LACOSAMIDE 100 MG ORAL TABS,RX-96969,CDM,S5000,HCPCS,259,RC,60687-0687-57,NDC,outpatient,1,UN,5.37,3.759,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LACOSAMIDE 100 MG ORAL TABS,RX-96969,CDM,S5000,HCPCS,259,RC,31722-0813-60,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CYCLOPENTOLATE HCL 2 % OP SOLN,RX-9700,CDM,S5000,HCPCS,259,RC,00065-0397-02,NDC,outpatient,2,ML,180.67,126.469,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % OP SOLN,RX-9701,CDM,S5000,HCPCS,259,RC,00065-0359-02,NDC,outpatient,2,ML,144.23,100.961,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CYCLOSPORINE 100 MG ORAL CAPS,RX-9706,CDM,S5000,HCPCS,259,RC,60505-0134-00,NDC,outpatient,1,UN,46.97,32.879,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CYCLOSPORINE 100 MG ORAL CAPS,RX-9706,CDM,S5000,HCPCS,259,RC,00078-0241-61,NDC,outpatient,1,UN,74.28,51.996,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CYCLOSPORINE 100 MG ORAL CAPS,RX-9706,CDM,S5000,HCPCS,259,RC,00078-0241-15,NDC,outpatient,1,UN,74.28,51.996,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CYCLOSPORINE 25 MG ORAL CAPS,RX-9707,CDM,S5000,HCPCS,259,RC,00078-0240-15,NDC,outpatient,1,UN,18.61,13.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CYCLOSPORINE 25 MG ORAL CAPS,RX-9707,CDM,S5000,HCPCS,259,RC,00078-0240-61,NDC,outpatient,1,UN,18.61,13.027,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CYCLOSPORINE 25 MG ORAL CAPS,RX-9707,CDM,S5000,HCPCS,259,RC,68084-0879-25,NDC,outpatient,1,UN,18.44,12.908,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
CYCLOSPORINE 25 MG ORAL CAPS,RX-9707,CDM,S5000,HCPCS,259,RC,68084-0879-95,NDC,outpatient,1,UN,18.44,12.908,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DANTROLENE SODIUM 20 MG IV SOLR,RX-9716,CDM,S5000,HCPCS,250,RC,42023-0123-06,NDC,outpatient,1,UN,288.51,201.957,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DANTROLENE SODIUM 25 MG ORAL CAPS,RX-9718,CDM,S5000,HCPCS,259,RC,00115-4411-01,NDC,outpatient,1,UN,2.65,1.855,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DANTROLENE SODIUM 25 MG ORAL CAPS,RX-9718,CDM,S5000,HCPCS,259,RC,00904-7211-04,NDC,outpatient,1,UN,4.53,3.171,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SUMATRIPTAN SUCCINATE 6 MG/0.5ML SC SOLN,RX-97343,CDM,S5000,HCPCS,250,RC,55150-0173-01,NDC,outpatient,0.5,ML,17.69,12.383,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
SUMATRIPTAN SUCCINATE 6 MG/0.5ML SC SOLN,RX-97343,CDM,S5000,HCPCS,250,RC,63323-0273-01,NDC,outpatient,0.5,ML,24.66,17.262,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PROMETHAZINE HCL 6.25 MG/5ML ORAL SOLN,RX-97609,CDM,S5000,HCPCS,259,RC,60432-0608-16,NDC,outpatient,10,ML,3.48,2.436,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PROMETHAZINE HCL 6.25 MG/5ML ORAL SOLN,RX-97609,CDM,S5000,HCPCS,259,RC,99999-0002-38,NDC,outpatient,10,ML,1.5,1.05,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,99999-0001-87,NDC,outpatient,10,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,00121-1276-00,NDC,outpatient,10,ML,7.53,5.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,49348-0861-10,NDC,outpatient,10,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,00904-7135-72,NDC,outpatient,10,ML,6.5,4.55,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,00121-1276-10,NDC,outpatient,10,ML,7.53,5.271,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,49348-0861-34,NDC,outpatient,118,ML,8.93,6.251,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,61787-0513-04,NDC,outpatient,118,ML,17.33,12.131,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,61787-0513-10,NDC,outpatient,10,ML,1.7,1.19,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
TOLVAPTAN 15 MG ORAL TABS,RX-97893,CDM,S5000,HCPCS,259,RC,59148-0020-50,NDC,outpatient,1,UN,1428.57,999.999,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PANCRELIPASE (LIP-PROT-AMYL) 6000-19000 UNITS ORAL CPEP,RX-98034,CDM,S5000,HCPCS,259,RC,00032-0046-70,NDC,outpatient,1,UN,8.55,5.985,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PANCRELIPASE (LIP-PROT-AMYL) 24000-76000 UNITS ORAL CPEP,RX-98036,CDM,S5000,HCPCS,259,RC,00032-1224-01,NDC,outpatient,1,UN,33.86,23.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PANCRELIPASE (LIP-PROT-AMYL) 24000-76000 UNITS ORAL CPEP,RX-98036,CDM,S5000,HCPCS,259,RC,00032-2636-01,NDC,outpatient,1,UN,33.86,23.702,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DEXTROSE-SODIUM CHLORIDE 10-0.45 % IV SOLN,RX-9809,CDM,S5000,HCPCS,250,RC,00264-7622-00,NDC,outpatient,1000,ML,51.6,36.12,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DEXTROSE-SODIUM CHLORIDE 5-0.2 % IV SOLN,RX-9812,CDM,S5000,HCPCS,250,RC,00338-0077-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DEXTROSE-SODIUM CHLORIDE 5-0.33 % IV SOLN,RX-9813,CDM,S5000,HCPCS,250,RC,00264-7614-10,NDC,outpatient,500,ML,40.48,28.336,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DEXTROSE-SODIUM CHLORIDE 5-0.45 % IV SOLN,RX-9814,CDM,S5000,HCPCS,250,RC,00338-0085-03,NDC,outpatient,500,ML,23.71,16.597,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DEXTROSE-SODIUM CHLORIDE 5-0.45 % IV SOLN,RX-9814,CDM,S5000,HCPCS,250,RC,00338-0085-04,NDC,outpatient,1000,ML,26.28,18.396,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DRONEDARONE HCL 400 MG ORAL TABS,RX-98329,CDM,S5000,HCPCS,259,RC,00024-4142-60,NDC,outpatient,1,UN,53.6,37.52,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PRASUGREL HCL 5 MG ORAL TABS,RX-98372,CDM,S5000,HCPCS,259,RC,60505-4642-03,NDC,outpatient,1,UN,1.06,0.742,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PRASUGREL HCL 10 MG ORAL TABS,RX-98373,CDM,S5000,HCPCS,259,RC,00378-5186-93,NDC,outpatient,1,UN,4.12,2.884,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PRASUGREL HCL 10 MG ORAL TABS,RX-98373,CDM,S5000,HCPCS,259,RC,65162-0002-03,NDC,outpatient,1,UN,2.9,2.03,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
PRASUGREL HCL 10 MG ORAL TABS,RX-98373,CDM,S5000,HCPCS,259,RC,65862-0830-30,NDC,outpatient,1,UN,1,0.7,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BENZOIN COMPOUND EX TINC,RX-987,CDM,S5000,HCPCS,259,RC,00395-0243-92,NDC,outpatient,1,ML,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DINOPROSTONE 0.5 MG/3GM VA GEL,RX-9874,CDM,S5000,HCPCS,259,RC,00009-3359-01,NDC,outpatient,3,GR,1932.45,1352.715,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BENZONATATE 100 MG ORAL CAPS,RX-988,CDM,S5000,HCPCS,259,RC,42806-0714-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BENZONATATE 100 MG ORAL CAPS,RX-988,CDM,S5000,HCPCS,259,RC,00904-7153-61,NDC,outpatient,1,UN,1.32,0.924,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BENZONATATE 100 MG ORAL CAPS,RX-988,CDM,S5000,HCPCS,259,RC,69452-0143-20,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BENZONATATE 100 MG ORAL CAPS,RX-988,CDM,S5000,HCPCS,259,RC,64380-0712-06,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOXAZOSIN MESYLATE 1 MG ORAL TABS,RX-9894,CDM,S5000,HCPCS,259,RC,68084-0836-25,NDC,outpatient,1,UN,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOXAZOSIN MESYLATE 1 MG ORAL TABS,RX-9894,CDM,S5000,HCPCS,259,RC,68084-0836-95,NDC,outpatient,1,UN,3.32,2.324,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOXAZOSIN MESYLATE 1 MG ORAL TABS,RX-9894,CDM,S5000,HCPCS,259,RC,00904-5522-61,NDC,outpatient,1,UN,2.36,1.652,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOXAZOSIN MESYLATE 4 MG ORAL TABS,RX-9896,CDM,S5000,HCPCS,259,RC,60505-0095-00,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOXAZOSIN MESYLATE 4 MG ORAL TABS,RX-9896,CDM,S5000,HCPCS,259,RC,16729-0213-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOXAZOSIN MESYLATE 4 MG ORAL TABS,RX-9896,CDM,S5000,HCPCS,259,RC,00904-5524-61,NDC,outpatient,1,UN,2.28,1.596,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOXYCYCLINE MONOHYDRATE 25 MG/5ML ORAL SUSR,RX-9902,CDM,S5000,HCPCS,259,RC,68180-0657-01,NDC,outpatient,20,ML,27.06,18.942,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
DOXYCYCLINE MONOHYDRATE 25 MG/5ML ORAL SUSR,RX-9902,CDM,S5000,HCPCS,259,RC,99999-0002-89,NDC,outpatient,20,ML,27.06,18.942,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ECONAZOLE NITRATE 1 % EX CREA,RX-9915,CDM,S5000,HCPCS,259,RC,51672-1303-01,NDC,outpatient,15,GR,32.65,22.855,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ENALAPRIL MALEATE 10 MG ORAL TABS,RX-9924,CDM,S5000,HCPCS,259,RC,23155-0772-01,NDC,outpatient,1,UN,1.15,0.805,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ENALAPRIL MALEATE 10 MG ORAL TABS,RX-9924,CDM,S5000,HCPCS,259,RC,43547-0547-10,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ENALAPRIL MALEATE 2.5 MG ORAL TABS,RX-9925,CDM,S5000,HCPCS,259,RC,16714-0442-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ENALAPRILAT 1.25 MG/ML IV INJ,RX-9929,CDM,S5000,HCPCS,250,RC,00143-9786-01,NDC,outpatient,2,ML,34.39,24.073,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ENALAPRILAT 1.25 MG/ML IV INJ,RX-9929,CDM,S5000,HCPCS,250,RC,00143-9786-10,NDC,outpatient,2,ML,34.39,24.073,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OPIUM 10 MG/ML (1%) ORAL TINC,RX-99405,CDM,S5000,HCPCS,259,RC,99999-0002-24,NDC,outpatient,0.6,ML,13.98,9.786,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
OPIUM 10 MG/ML (1%) ORAL TINC,RX-99405,CDM,S5000,HCPCS,259,RC,42799-0217-01,NDC,outpatient,0.6,ML,13.98,9.786,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GLYCERIN (LAXATIVE) 1 G RE SUPP,RX-99417,CDM,S5000,HCPCS,259,RC,58980-0409-12,NDC,outpatient,1,UN,2.17,1.519,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVONORGESTREL 1.5 MG ORAL TABS,RX-99445,CDM,S5000,HCPCS,259,RC,69536-0146-19,NDC,outpatient,1,UN,133.73,93.611,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
LEVONORGESTREL 1.5 MG ORAL TABS,RX-99445,CDM,S5000,HCPCS,259,RC,69536-0162-88,NDC,outpatient,1,UN,133.64,93.548,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ESTROGENS CONJUGATED 0.3 MG ORAL TABS,RX-9973,CDM,S5000,HCPCS,259,RC,00046-1100-81,NDC,outpatient,1,UN,28.4,19.88,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ETHACRYNATE SODIUM 50 MG IV SOLR,RX-9979,CDM,S5000,HCPCS,250,RC,67457-0297-50,NDC,outpatient,1,UN,2098.98,1469.286,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ETHACRYNATE SODIUM 50 MG IV SOLR,RX-9979,CDM,S5000,HCPCS,250,RC,42023-0157-01,NDC,outpatient,1,UN,1563.3,1094.31,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BENZTROPINE MESYLATE 0.5 MG ORAL TABS,RX-998,CDM,S5000,HCPCS,259,RC,68084-0381-11,NDC,outpatient,1,UN,1.82,1.274,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BENZTROPINE MESYLATE 0.5 MG ORAL TABS,RX-998,CDM,S5000,HCPCS,259,RC,68084-0381-01,NDC,outpatient,1,UN,1.82,1.274,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ETHACRYNIC ACID 25 MG ORAL TABS,RX-9980,CDM,S5000,HCPCS,259,RC,69238-1126-01,NDC,outpatient,1,UN,8.7,6.09,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ETHAMBUTOL HCL 400 MG ORAL TABS,RX-9983,CDM,S5000,HCPCS,259,RC,68850-0012-02,NDC,outpatient,1,UN,3.21,2.247,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GUANFACINE HCL ER 1 MG ORAL TB24,RX-99835,CDM,S5000,HCPCS,259,RC,60505-3927-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GUANFACINE HCL ER 1 MG ORAL TB24,RX-99835,CDM,S5000,HCPCS,259,RC,24979-0533-01,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
GUANFACINE HCL ER 2 MG ORAL TB24,RX-99836,CDM,S5000,HCPCS,259,RC,62332-0746-31,NDC,outpatient,1,UN,0.99,0.693,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ETHOSUXIMIDE 250 MG ORAL CAPS,RX-9989,CDM,S5000,HCPCS,259,RC,23155-0532-01,NDC,outpatient,1,UN,5.34,3.738,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ETHOSUXIMIDE 250 MG ORAL CAPS,RX-9989,CDM,S5000,HCPCS,259,RC,64380-0878-06,NDC,outpatient,1,UN,1.63,1.141,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BENZTROPINE MESYLATE 1 MG ORAL TABS,RX-999,CDM,S5000,HCPCS,259,RC,68084-0388-01,NDC,outpatient,1,UN,1.62,1.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
BENZTROPINE MESYLATE 1 MG ORAL TABS,RX-999,CDM,S5000,HCPCS,259,RC,68084-0388-11,NDC,outpatient,1,UN,1.62,1.134,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ETODOLAC 200 MG ORAL CAPS,RX-9997,CDM,S5000,HCPCS,259,RC,60505-0039-01,NDC,outpatient,1,UN,1.83,1.281,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ETODOLAC 200 MG ORAL CAPS,RX-9997,CDM,S5000,HCPCS,259,RC,62559-0250-01,NDC,outpatient,1,UN,1.72,1.204,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
ETODOLAC 300 MG ORAL CAPS,RX-9998,CDM,S5000,HCPCS,259,RC,62559-0251-01,NDC,outpatient,1,UN,2.43,1.701,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,0.222255,85118.57664,other,Non-Reimbursable List,,
HC Crisis Intervention Mental Health Services- per Diem,PX-90000001,CDM,S9485,HCPCS,900,RC,,,outpatient,,,1627,1138.9,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,651.9389,365.2615,1249.536,percent of total billed charges,,,
HC Full Trauma No Notification,PX-45000633,CDM,TR450,LOCAL,450,RC,,,outpatient,,,10370,7259,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,4155.259,399.86,9291.52,percent of total billed charges,,,
HC Partial Trauma No Notification,PX-45000634,CDM,TR450,LOCAL,450,RC,,,outpatient,,,7029,4920.3,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,2816.5203,399.86,9291.52,percent of total billed charges,,,
IOL 16D 5.5X12.5MM PMMA AC CNVXPLN ACRYSOF MTA3U0 -,SUP-MTA3U0.160,CDM,V2630,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,129.686915,921.62304,other,SI=N Exclusions ,,
IOL 9.5D 5.5MMX12.5MM AC CNVXPLN -,SUP-MTA3UO.095,CDM,V2630,HCPCS,276,RC,,,outpatient,,,577.67,404.369,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,129.686915,921.62304,other,SI=N Exclusions ,,
IOL 10.5D 5.5MMX12.5MM AC CNVXPLN -,SUP-MTA3UO.105,CDM,V2630,HCPCS,276,RC,,,outpatient,,,577.67,404.369,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,129.686915,921.62304,other,SI=N Exclusions ,,
IOL 20D 5.5MMX12.5MM AC CNVXPLN -,SUP-MTA3UO.200,CDM,V2630,HCPCS,276,RC,,,outpatient,,,1200.03,840.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,129.686915,921.62304,other,SI=N Exclusions ,,
IOL 22D 5.5X13MM AC CNVXPLN -,SUP-MTA4UO.220,CDM,V2630,HCPCS,276,RC,,,outpatient,,,1200.03,840.021,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,129.686915,921.62304,other,SI=N Exclusions ,,
IOL 12.5D 5.5MMX13.5MM AC CNVXPLN -,SUP-MTA5U0.125,CDM,V2630,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,129.686915,921.62304,other,SI=N Exclusions ,,
IOL 10.5D X 13.5OP AC CNVXPLN -,SUP-MTA5UO.105,CDM,V2630,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,129.686915,921.62304,other,SI=N Exclusions ,,
IOL 8.5D PC -,SUP-AR40MN085,CDM,V2632,HCPCS,276,RC,,,outpatient,,,1021.13,714.791,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 23D 6X13MM CLARIFLEX CLRFLXC 3PC PC BICNVX SIL BLU COR -,SUP-CLRFLXC.230,CDM,V2632,HCPCS,276,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 26.5D CLARIFLEX PC -,SUP-CLRFLXC.265,CDM,V2632,HCPCS,276,RC,,,outpatient,,,612.68,428.876,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 16.5D 6X13MM ACRYSF MA60AC 3PC PC BICNVX BLU ACRYLT -,SUP-MA60AC.165,CDM,V2632,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL +1D 6X13MM ACRYSF MA60MA MULPC PC MNSCS BLU ACRYLT -,SUP-MA60MA.010,CDM,V2632,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 3D 6X13MM ACRYSF MA60MA MULPC PC MNSCS BLU ACRYLT -,SUP-MA60MA.030,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL -4D 6X13MM ACRYSF XPD SRS MULPC PC BICNVX BLU ACRYLT -,SUP-MA60MA-4.0,CDM,V2632,HCPCS,276,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
LENS I/O X.010 NEGATIVE D -,SUP-MA60MAN010,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 4D 6X13MM ACRYSF XPD SRS MULPC PC BICNVX BLU ACRYLT -,SUP-MA60MAN040,CDM,V2632,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
LENS I/O MN60AC X 8.0 -,SUP-MN60AC.080,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 28D 6X13MM ACRYSF MN60AC MULPC PC BICNVX NAT YEL ACRYLT -,SUP-MN60AC.280,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 2.0 DIA 6X13MM ACRYSF XPD SRS MULPC PC MNSCS NAT -,SUP-MN60MA.020,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 3D 6X13MM ACRYSF XPD SRS MULPC PC MNSCS NAT -,SUP-MN60MA.030,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
LENS IOL 5.0D MN60MA 6X13MM ACRYSF MULPC PC MNSCS BLU ACRYLT -,SUP-MN60MA.050,CDM,V2632,HCPCS,276,RC,,,outpatient,,,875.25,612.675,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 9D 6X13MM ACRYSF SA60AT 1-PC PC BICNVX CLR ACRYLT -,SUP-SA60AT.090,CDM,V2632,HCPCS,276,RC,,,outpatient,,,781.89,547.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 30D 6X13MM ACRYSF 1-PC PC BICNVX NAT ANT ASYM -,SUP-SN60AT.300,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 31D 6X13MM 31  ACRYSF SA60AT 1-PC PC BICNVX CLR ACRYLT -,SUP-SN60AT.310,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 34D 6X13MM ACRYSF SA60AT 1-PC PC BICNVX CLR ACRYLT -,SUP-SN60AT.340,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 6.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.065,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 7D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.070,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 9D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.090,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 9.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.095,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 10D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.100,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 10.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.105,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 11D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.110,CDM,V2632,HCPCS,276,RC,,,outpatient,,,781.89,547.323,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 11.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.115,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 12D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.120,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 13D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.130,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 13.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.135,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 14D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.140,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 14.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.145,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 16D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.160,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 16.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.165,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 17D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.170,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 17.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.175,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 18D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.180,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 19D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.190,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 20D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.200,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 21D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.210,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 21.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.215,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 22D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.220,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 22.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.225,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 23D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.230,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 24D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.240,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 24.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.245,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 25D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.250,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 26D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.260,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 26.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.265,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 19D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.190,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 20D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.200,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 20.5D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.205,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 21D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.210,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 21.5D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.215,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
LENS I/O MA60MA x 1.0 -,SUP-UNDEFINED,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
IOL 24.5D 6X13MM TECNIS ZA9003 3PC PC BICNVX HYDRPHB ACRL -,SUP-ZA9003.245,CDM,V2632,HCPCS,276,RC,,,outpatient,,,816.9,571.83,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,137.54666,3281.45664,other,Non-Reimbursable List,,
LENS ACRYSOF TORIC IQ  SN6AT3 X 9.5D -,SUP-SN6AT3.095,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,,,
IOL TORIC LENS  SN6AT3  12.0 -,SUP-SN6AT3.120,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,,,
IOL 15.5D 6X13MM ACRYSF SN6AT3 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT3.155,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,,,
IOL 16.0D  6X13MM ACRYSF  SN6AT3 -,SUP-SN6AT3.160,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,,,
IOL 17.0D  6X13MM ACRYSF  SN6AT3 -,SUP-SN6AT3.170,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,,,
IOL 18.0 D 6X13MM ACRYSF SN6AT3 -,SUP-SN6AT3.180,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,,,
IOL 19.5D 6X13MM ACRYSF SN6AT3 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT3.195,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,,,
IOL 24D 6X13MM ACRYSF  SN6 -,SUP-SN6AT3.240,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,,,
IOL 13.5D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.135,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,,,
IOL 19D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.190,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,,,
IOL 19.5D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.195,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,,,
IOL 21D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.210,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,,,
IOL 16D 6X13MM ACRYSF SN6AT5 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT5.160,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,,,
LENS ACRYSOF IQ  SN6AT5.180 -,SUP-SN6AT5.180,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,,,
IOL 21D 6X13MM ACRYSF SN6AT5 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT5.210,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,,,
IOL 23D 6X13MM ACRYSF SN6AT5 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT5.230,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,,,
IOL 11D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT6.110,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,,,
IOL 13.5D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT -,SUP-SN6AT6.135,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,,,
IOL 14D 6X13MM  ACRYSF  SN6AT6 -,SUP-SN6AT6.140,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,,,
IOL LENS SN6AT6 X 18.0 D -,SUP-SN6AT6.180,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,,,
IOL 20D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT6.200,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,,,
IOL 20.5D 6X13MM ACRYSF SN6AT6 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT6.205,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2093.7,1465.59,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,838.94559,399.86,2223.8905,percent of total billed charges,,,
IOL TORIC LENS 23.5 DIOPTER -,SUP-SN6AT6.235,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,,,
IOL 22D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT6U220,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,,,
IOL 20D 6X13MM  ACRYSF -,SUP-SN6AT7.200,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,,,
IOL 23.5D  6X13MM  ACRYSF   SN6AT7 -,SUP-SN6AT7.235,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,40.07,,1051.336625,399.86,2223.8905,percent of total billed charges,,,
AMNIOGRAFT AMNIO MEMBR HUM TIS FRZN 3.5X3.5CM SZ-C -,SUP-AG-3535,CDM,V2790,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,3992.7552,other,Non-Reimbursable List,,
GRAFT HUM TIS 3.5X3.5CM SZ-C AMNIOGRFT AMNIO MEMBR 50-100U -,SUP-AG-3535F,CDM,V2790,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],,,,,,399.86,3992.7552,other,Non-Reimbursable List,,
Bilateral procedure,,,,,,,,,,,,,,BCBS RHODE ISLAND [1010501],BCBS RHODE ISLAND HMO [101050101],50,,150,,,,,,150% payment adjustment for the item or service to which the modifier is appended.,,
HC Semi-Private Unit,PX-12100001,CDM,12100001,LOCAL,121,RC,,,inpatient,,,1577,1103.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,525.9295,1261.6,,,,
HC Med/Surg Stepdown,PX-12100003,CDM,12100003,LOCAL,121,RC,,,inpatient,,,2423,1696.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,808.0705,1938.4,,,,
HC Maternity Unit,PX-12200001,CDM,12200001,LOCAL,122,RC,,,inpatient,,,2193,1535.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,731.3655,1754.4,,,,
HC Pediatric Semi-Private Unit,PX-12300001,CDM,12300001,LOCAL,123,RC,,,inpatient,,,3323,2326.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1108.2205,2658.4,,,,
HC S.E. Rehab Semi-Private Unit,PX-12800001,CDM,12800001,LOCAL,128,RC,,,inpatient,,,1783,1248.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,594.6305,2483,,,,
HC Nursery,PX-17000001,CDM,17000001,LOCAL,170,RC,,,inpatient,,,1333,933.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,444.5555,1066.4,,,,
HC Nursery Boarder,PX-17900001,CDM,17900001,LOCAL,179,RC,,,inpatient,,,1195,836.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,398.5325,956,,,,
HC Icu/Ccu Unit,PX-20000001,CDM,20000001,LOCAL,200,RC,,,inpatient,,,4009,2806.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1337.0015,3207.2,,,,
HC Icu Surgical Unit,PX-20100001,CDM,20100001,LOCAL,201,RC,,,inpatient,,,3646,2552.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1215.941,2916.8,,,,
HC Telemetry Unit,PX-20600001,CDM,20600001,LOCAL,206,RC,,,inpatient,,,2015,1410.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,672.0025,1612,,,,
HC Trauma,PX-20800001,CDM,20800001,LOCAL,208,RC,,,inpatient,,,4810,3367,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1604.135,3848,,,,
HC Onc. Vad Kit,PX-27000020,CDM,27000020,LOCAL,270,RC,,,inpatient,,,90,63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.205,72,,,,
HC Imed Pump for Lvl II,PX-27000021,CDM,27000021,LOCAL,270,RC,,,inpatient,,,118,82.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.491,94.4,,,,
HC Imed Pump,PX-27000022,CDM,27000022,LOCAL,270,RC,,,inpatient,,,113,79.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,25.3685,90.4,,,,
HC Local Anesth Supplies,PX-27000023,CDM,27000023,LOCAL,270,RC,,,inpatient,,,80,56,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,17.96,64,,,,
HC Periop O2,PX-27000044,CDM,27000044,LOCAL,270,RC,,,inpatient,,,79,55.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,17.7355,63.2,,,,
HC Bone Bx Kit,PX-27000050,CDM,27000050,LOCAL,270,RC,,,inpatient,,,267,186.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,59.9415,213.6,,,,
HC Kit Portex Nerve Block,PX-27000051,CDM,27000051,LOCAL,270,RC,,,inpatient,,,90,63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.205,72,,,,
HC Cannister Vac W/O Gel Ats,PX-27000052,CDM,27000052,LOCAL,270,RC,,,inpatient,,,282,197.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,63.309,225.6,,,,
HC Dressing Kci Small 5/Cs,PX-27000053,CDM,27000053,LOCAL,270,RC,,,inpatient,,,268,187.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.166,214.4,,,,
HC Cannister W/Gel Ats,PX-27000054,CDM,27000054,LOCAL,270,RC,,,inpatient,,,283,198.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,63.5335,226.4,,,,
HC Compression Stocking A6530,PX-27000055,CDM,27000055,LOCAL,270,RC,,,inpatient,,,285,199.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,63.9825,228,,,,
HC Custom Molded Insert,PX-27000056,CDM,27000056,LOCAL,270,RC,,,inpatient,,,287,200.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,64.4315,229.6,,,,
HC Dressing Kci Medium 10/Cs,PX-27000057,CDM,27000057,LOCAL,270,RC,,,inpatient,,,307,214.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,68.9215,245.6,,,,
HC Surgical Boot/Shoe L3260,PX-27000058,CDM,27000058,LOCAL,270,RC,,,inpatient,,,423,296.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,94.9635,338.4,,,,
HC Vaccum Assisted Closure Pump,PX-27000059,CDM,27000059,LOCAL,270,RC,,,inpatient,,,438,306.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,98.331,350.4,,,,
HC Ortho Wedge Shoe,PX-27000060,CDM,27000060,LOCAL,270,RC,,,inpatient,,,529,370.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,118.7605,423.2,,,,
HC Foot Pressure Support A9283,PX-27000061,CDM,27000061,LOCAL,270,RC,,,inpatient,,,529,370.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,118.7605,423.2,,,,
HC Sensor Nicom,PX-27000062,CDM,27000062,LOCAL,270,RC,,,inpatient,,,816,571.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,183.192,652.8,,,,
HC 6 Channel Pneumogram,PX-27000063,CDM,27000063,LOCAL,270,RC,,,inpatient,,,3884,2718.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,871.958,3107.2,,,,
HC Pneumogram 4-Channel,PX-27000064,CDM,27000064,LOCAL,270,RC,,,inpatient,,,4891,3423.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1098.0295,3912.8,,,,
HC Pad Artic Gel Large,PX-27000065,CDM,27000065,LOCAL,270,RC,,,inpatient,,,5242,3669.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1176.829,4193.6,,,,
HC Pneumogram 6- Channel,PX-27000066,CDM,27000066,LOCAL,270,RC,,,inpatient,,,5466,3826.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1227.117,4372.8,,,,
HC Therapy Polar Cooler,PX-27000068,CDM,27000068,LOCAL,270,RC,,,inpatient,,,667,466.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,149.7415,533.6,,,,
HC Liner Foam Permanently Med,PX-27000069,CDM,27000069,LOCAL,270,RC,,,inpatient,,,353,247.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,79.2485,282.4,,,,
HC Dressing Kci Vac Small,PX-27000070,CDM,27000070,LOCAL,270,RC,,,inpatient,,,327,228.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,73.4115,261.6,,,,
HC Dressing Kci Vac Large,PX-27000071,CDM,27000071,LOCAL,270,RC,,,inpatient,,,390,273,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,87.555,312,,,,
HC Developmental Aides,PX-27000072,CDM,27000072,LOCAL,270,RC,,,inpatient,,,707,494.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,158.7215,565.6,,,,
"HC Ez Reacher 30"" Suction",PX-27100004,CDM,27100004,LOCAL,271,RC,,,inpatient,,,144,100.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,32.328,122.0544,,,,
HC Support Bra Ez-on Med 958,PX-27100005,CDM,27100005,LOCAL,271,RC,,,inpatient,,,262,183.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,58.819,222.0712,,,,
HC Support Bra Ez-on Lrg 958,PX-27100006,CDM,27100006,LOCAL,271,RC,,,inpatient,,,272,190.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,61.064,230.5472,,,,
HC Support Bra Ez-on X-Lrg 958,PX-27100007,CDM,27100007,LOCAL,271,RC,,,inpatient,,,306,214.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,68.697,259.3656,,,,
HC Support Bra Ez-on Queen,PX-27100008,CDM,27100008,LOCAL,271,RC,,,inpatient,,,377,263.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,84.6365,319.5452,,,,
HC Bra Ez-on Super Queen,PX-27100009,CDM,27100009,LOCAL,271,RC,,,inpatient,,,471,329.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,105.7395,399.2196,,,,
HC Gradient Com Stocking,PX-27100010,CDM,27100010,LOCAL,271,RC,,,inpatient,,,490,343,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,110.005,415.324,,,,
HC Kit Flexi Seal Fecal,PX-27100011,CDM,27100011,LOCAL,271,RC,,,inpatient,,,939,657.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,210.8055,795.8964,,,,
HC Port Power Loc Access Kit,PX-27200054,CDM,27200054,LOCAL,272,RC,,,inpatient,,,88,61.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.756,74.5888,,,,
HC Dressing Kci Vac White Lg,PX-27200055,CDM,27200055,LOCAL,272,RC,,,inpatient,,,95,66.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,21.3275,80.522,,,,
HC Sheath Brite Tip 11cm,PX-27200056,CDM,27200056,LOCAL,272,RC,,,inpatient,,,108,75.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,24.246,91.5408,,,,
HC Kit Refill Syncromed Sys. Pain,PX-27200057,CDM,27200057,LOCAL,272,RC,,,inpatient,,,128,89.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,28.736,108.4928,,,,
HC Sock Fracture,PX-27200058,CDM,27200058,LOCAL,272,RC,,,inpatient,,,193,135.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,43.3285,163.5868,,,,
HC Tube Gastrostomy Replacement,PX-27200059,CDM,27200059,LOCAL,272,RC,,,inpatient,,,195,136.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,43.7775,165.282,,,,
HC Mod of Depth Shoe,PX-27200060,CDM,27200060,LOCAL,272,RC,,,inpatient,,,225,157.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,50.5125,190.71,,,,
HC Catheter Broncho 39l,PX-27200061,CDM,27200061,LOCAL,272,RC,,,inpatient,,,349,244.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,78.3505,295.8124,,,,
HC Catheter Bronch 35 Left 95892,PX-27200062,CDM,27200062,LOCAL,272,RC,,,inpatient,,,349,244.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,78.3505,295.8124,,,,
HC Endo-Bronch Tube 37fr Left,PX-27200063,CDM,27200063,LOCAL,272,RC,,,inpatient,,,349,244.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,78.3505,295.8124,,,,
HC Tube Endo Bronch #35 Left,PX-27200064,CDM,27200064,LOCAL,272,RC,,,inpatient,,,349,244.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,78.3505,295.8124,,,,
HC Endo Bronch Tube #39,PX-27200065,CDM,27200065,LOCAL,272,RC,,,inpatient,,,349,244.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,78.3505,295.8124,,,,
HC Catheter Broncho 41l,PX-27200066,CDM,27200066,LOCAL,272,RC,,,inpatient,,,349,244.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,78.3505,295.8124,,,,
HC Kit Arterial Line Arrow,PX-27200067,CDM,27200067,LOCAL,272,RC,,,inpatient,,,349,244.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,78.3505,295.8124,,,,
HC Cassette Kci Veralink,PX-27200068,CDM,27200068,LOCAL,272,RC,,,inpatient,,,357,249.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.1465,302.5932,,,,
HC Shiley Trach Tube 6lpc,PX-27200069,CDM,27200069,LOCAL,272,RC,,,inpatient,,,357,249.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.1465,302.5932,,,,
HC Tube Trach Shiley 8lpc,PX-27200070,CDM,27200070,LOCAL,272,RC,,,inpatient,,,357,249.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.1465,302.5932,,,,
HC Catheter Single 4fr Bard,PX-27200071,CDM,27200071,LOCAL,272,RC,,,inpatient,,,374,261.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,83.963,317.0024,,,,
HC Bivona #7 Trach Uncuffed,PX-27200072,CDM,27200072,LOCAL,272,RC,,,inpatient,,,396,277.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,88.902,335.6496,,,,
HC Retractor C Section Large,PX-27200073,CDM,27200073,LOCAL,272,RC,,,inpatient,,,402,281.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,90.249,340.7352,,,,
HC Midline 4fr Bd#384308,PX-27200074,CDM,27200074,LOCAL,272,RC,,,inpatient,,,409,286.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,91.8205,346.6684,,,,
HC Transducer Triple W/Vamp Pls,PX-27200075,CDM,27200075,LOCAL,272,RC,,,inpatient,,,418,292.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,93.841,354.2968,,,,
HC B Pleurx Drainage Kit,PX-27200076,CDM,27200076,LOCAL,272,RC,,,inpatient,,,417,291.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,93.6165,353.4492,,,,
HC Catheter Swan Ganz J Pacing,PX-27200078,CDM,27200078,LOCAL,272,RC,,,inpatient,,,446,312.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,100.127,378.0296,,,,
HC Tube Trach Distal Xlt 5.0,PX-27200079,CDM,27200079,LOCAL,272,RC,,,inpatient,,,451,315.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,101.2495,382.2676,,,,
HC Tube Trach Distal Xlt 6.0,PX-27200080,CDM,27200080,LOCAL,272,RC,,,inpatient,,,466,326.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,104.617,394.9816,,,,
HC Tube Trach 8 Cuff Non X Long,PX-27200081,CDM,27200081,LOCAL,272,RC,,,inpatient,,,466,326.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,104.617,394.9816,,,,
HC Sling Sam Pelvic Medium,PX-27200082,CDM,27200082,LOCAL,272,RC,,,inpatient,,,470,329,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,105.515,398.372,,,,
HC Set Tube Kaci Veratrac Duo,PX-27200083,CDM,27200083,LOCAL,272,RC,,,inpatient,,,488,341.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,109.556,413.6288,,,,
HC Retractor C Section Xlarge,PX-27200084,CDM,27200084,LOCAL,272,RC,,,inpatient,,,516,361.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,115.842,437.3616,,,,
HC Kit Mini 4fr Single Lumen,PX-27200085,CDM,27200085,LOCAL,272,RC,,,inpatient,,,519,363.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,116.5155,439.9044,,,,
HC Trach Bivona Tis 6id,PX-27200086,CDM,27200086,LOCAL,272,RC,,,inpatient,,,523,366.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,117.4135,443.2948,,,,
HC Pack C Section Custom Disp,PX-27200087,CDM,27200087,LOCAL,272,RC,,,inpatient,,,541,378.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,121.4545,458.5516,,,,
HC Trach Bivona Tts 8mm,PX-27200088,CDM,27200088,LOCAL,272,RC,,,inpatient,,,541,378.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,121.4545,458.5516,,,,
HC Trach Bivona 7.5 X 10,PX-27200089,CDM,27200089,LOCAL,272,RC,,,inpatient,,,556,389.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,124.822,471.2656,,,,
HC Tube Feeding Mic Key 14f 1.7,PX-27200091,CDM,27200091,LOCAL,272,RC,,,inpatient,,,674,471.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,151.313,571.2824,,,,
HC Kit Mic-Key G Feeding 16-3.5,PX-27200092,CDM,27200092,LOCAL,272,RC,,,inpatient,,,694,485.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,155.803,588.2344,,,,
HC Kit Mic-Key G Feeding 24-3.5,PX-27200093,CDM,27200093,LOCAL,272,RC,,,inpatient,,,694,485.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,155.803,588.2344,,,,
HC Mic Key G Tube 20fr 3.5cm,PX-27200094,CDM,27200094,LOCAL,272,RC,,,inpatient,,,694,485.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,155.803,588.2344,,,,
HC Device Support Foot,PX-27200095,CDM,27200095,LOCAL,272,RC,,,inpatient,,,703,492.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,157.8235,595.8628,,,,
HC Catheter 4 Fr Mid Line,PX-27200096,CDM,27200096,LOCAL,272,RC,,,inpatient,,,719,503.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,161.4155,609.4244,,,,
HC Tcc Size 3,PX-27200097,CDM,27200097,LOCAL,272,RC,,,inpatient,,,722,505.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,162.089,611.9672,,,,
HC Femostop Gold Compress Sys,PX-27200098,CDM,27200098,LOCAL,272,RC,,,inpatient,,,731,511.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,164.1095,619.5956,,,,
HC Dot Poly Midline 4fr Sl Full,PX-27200099,CDM,27200099,LOCAL,272,RC,,,inpatient,,,765,535.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,171.7425,648.414,,,,
HC Powerwand 5fr 10cm,PX-27200100,CDM,27200100,LOCAL,272,RC,,,inpatient,,,776,543.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.212,657.7376,,,,
HC Powerwand Single Sterile 5fr,PX-27200101,CDM,27200101,LOCAL,272,RC,,,inpatient,,,776,543.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.212,657.7376,,,,
HC Needle Intraosseous Pd 15g,PX-27200102,CDM,27200102,LOCAL,272,RC,,,inpatient,,,845,591.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,189.7025,716.222,,,,
HC Needle Intraosseous Ad 15g,PX-27200103,CDM,27200103,LOCAL,272,RC,,,inpatient,,,845,591.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,189.7025,716.222,,,,
HC Needle Intraosseous,PX-27200104,CDM,27200104,LOCAL,272,RC,,,inpatient,,,845,591.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,189.7025,716.222,,,,
HC Kit Triple Lumen Cath 7 X 6,PX-27200105,CDM,27200105,LOCAL,272,RC,,,inpatient,,,895,626.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,200.9275,758.602,,,,
HC Multi Lumen Cvc Kit Toh Cust,PX-27200106,CDM,27200106,LOCAL,272,RC,,,inpatient,,,895,626.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,200.9275,758.602,,,,
HC Pad Zoll Aed Cprd Access Kit,PX-27200107,CDM,27200107,LOCAL,272,RC,,,inpatient,,,827,578.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,185.6615,700.9652,,,,
HC Kit Flexi Seal Fecal,PX-27200108,CDM,27200108,LOCAL,272,RC,,,inpatient,,,939,657.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,210.8055,795.8964,,,,
HC Powerwand Quick Kit 5fr,PX-27200109,CDM,27200109,LOCAL,272,RC,,,inpatient,,,979,685.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,219.7855,829.8004,,,,
HC Mahurkar Dual Lumen Subclav Ca,PX-27200110,CDM,27200110,LOCAL,272,RC,,,inpatient,,,1581,1106.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,354.9345,1340.0556,,,,
HC Catheter With Curved Extension,PX-27200111,CDM,27200111,LOCAL,272,RC,,,inpatient,,,1581,1106.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,354.9345,1340.0556,,,,
HC Set Cath Cricothyroidotomy,PX-27200112,CDM,27200112,LOCAL,272,RC,,,inpatient,,,1136,795.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,255.032,962.8736,,,,
HC Rusch Quick Trac Small 2.0,PX-27200113,CDM,27200113,LOCAL,272,RC,,,inpatient,,,1269,888.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,284.8905,1075.6044,,,,
HC Set Prism Prewarm M100'2,PX-27200114,CDM,27200114,LOCAL,272,RC,,,inpatient,,,1319,923.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,296.1155,1117.9844,,,,
HC Set Prismaflex M100's,PX-27200115,CDM,27200115,LOCAL,272,RC,,,inpatient,,,1399,979.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,314.0755,1185.7924,,,,
HC Bakri Postpartum Balloon,PX-27200116,CDM,27200116,LOCAL,272,RC,,,inpatient,,,1408,985.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,316.096,1193.4208,,,,
HC Flo Trac Sensor Mhd6,PX-27200117,CDM,27200117,LOCAL,272,RC,,,inpatient,,,2027,1418.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,455.0615,1718.0852,,,,
HC Pad Universal Artic Gel,PX-27200118,CDM,27200118,LOCAL,272,RC,,,inpatient,,,2219,1553.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,498.1655,1880.8244,,,,
HC Cath Presep 8.5 Oximetry,PX-27200119,CDM,27200119,LOCAL,272,RC,,,inpatient,,,2602,1821.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,584.149,2205.4552,,,,
HC Set Cricothyrotomy Cath,PX-27200120,CDM,27200120,LOCAL,272,RC,,,inpatient,,,2943,2060.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,660.7035,2494.4868,,,,
HC Pad Artic Gel Small,PX-27200121,CDM,27200121,LOCAL,272,RC,,,inpatient,,,5565,3895.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1249.3425,4716.894,,,,
HC Pad Gel Artic Medium,PX-27200122,CDM,27200122,LOCAL,272,RC,,,inpatient,,,5512,3858.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1237.444,4671.9712,,,,
HC Rhino G2 Blue,PX-27200123,CDM,27200123,LOCAL,272,RC,,,inpatient,,,4120,2884,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,924.94,3492.112,,,,
HC Pad Artic Gel Lrg,PX-27200124,CDM,27200124,LOCAL,272,RC,,,inpatient,,,5512,3858.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1237.444,4671.9712,,,,
HC Bag External Drainage Collect,PX-27200125,CDM,27200125,LOCAL,272,RC,,,inpatient,,,1349,944.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,302.8505,1143.4124,,,,
HC Catheter Thoracic 28fr,PX-27200126,CDM,27200126,LOCAL,272,RC,,,inpatient,,,39,27.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.7555,33.0564,,,,
HC Tube Endo Bronch Left 37,PX-27200127,CDM,27200127,LOCAL,272,RC,,,inpatient,,,349,244.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,78.3505,295.8124,,,,
HC Electrode Temporary Pacing 6,PX-27200128,CDM,27200128,LOCAL,272,RC,,,inpatient,,,1238,866.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,277.931,1049.3288,,,,
HC Set Pneumothorax,PX-27200129,CDM,27200129,LOCAL,272,RC,,,inpatient,,,1113,779.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,249.8685,943.3788,,,,
HC System External Drainage III,PX-27200130,CDM,27200130,LOCAL,272,RC,,,inpatient,,,1887,1320.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,423.6315,1599.4212,,,,
HC Electrode Temporary Pacing 5,PX-27200131,CDM,27200131,LOCAL,272,RC,,,inpatient,,,1097,767.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,246.2765,929.8172,,,,
HC Tray Tru Close Thoracic Vent,PX-27200132,CDM,27200132,LOCAL,272,RC,,,inpatient,,,1504,1052.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,337.648,1274.7904,,,,
HC Tube Trach Flex Laser 6.0 Mm,PX-27200133,CDM,27200133,LOCAL,272,RC,,,inpatient,,,319,223.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,71.6155,270.3844,,,,
HC Pack Cesarean Custom,PX-27200134,CDM,27200134,LOCAL,272,RC,,,inpatient,,,462,323.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,103.719,391.5912,,,,
HC Hemostat Instat 1gm,PX-27200135,CDM,27200135,LOCAL,272,RC,,,inpatient,,,1077,753.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,241.7865,912.8652,,,,
HC Tube Trach Distal Xlt 7.0,PX-27200136,CDM,27200136,LOCAL,272,RC,,,inpatient,,,486,340.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,109.107,411.9336,,,,
HC Surgicel 2 X 14 #1951,PX-27200137,CDM,27200137,LOCAL,272,RC,,,inpatient,,,447,312.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,100.3515,378.8772,,,,
HC Ligator Saeed Sx Shoot,PX-27200138,CDM,27200138,LOCAL,272,RC,,,inpatient,,,1332,932.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,299.034,1129.0032,,,,
HC Cath Swan Ganz 7.5 Vip Port,PX-27200139,CDM,27200139,LOCAL,272,RC,,,inpatient,,,297,207.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,66.6765,251.7372,,,,
HC Cath Multilumen Access,PX-27200140,CDM,27200140,LOCAL,272,RC,,,inpatient,,,537,375.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,120.5565,455.1612,,,,
HC Trach Bivona Tts 7mm,PX-27200141,CDM,27200141,LOCAL,272,RC,,,inpatient,,,565,395.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,126.8425,478.894,,,,
HC Kit Pleurx Drainage W Bottle,PX-27200142,CDM,27200142,LOCAL,272,RC,,,inpatient,,,417,291.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,93.6165,353.4492,,,,
HC Retractor Wound Alexis Lrg,PX-27200143,CDM,27200143,LOCAL,272,RC,,,inpatient,,,412,288.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,92.494,349.2112,,,,
HC Unit Cold Therapy Deroyal,PX-27200144,CDM,27200144,LOCAL,272,RC,,,inpatient,,,691,483.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,155.1295,585.6916,,,,
HC Dressing Kci Vac Silver Med,PX-27200145,CDM,27200145,LOCAL,272,RC,,,inpatient,,,506,354.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,113.597,428.8856,,,,
HC Kit Midline Cath 20ga X 20cm,PX-27200146,CDM,27200146,LOCAL,272,RC,,,inpatient,,,424,296.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,95.188,359.3824,,,,
HC Cath Mahurkar 3 Lumen 12x20,PX-27200147,CDM,27200147,LOCAL,272,RC,,,inpatient,,,594,415.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,133.353,503.4744,,,,
HC Retractor Alexis Wound Xlg,PX-27200148,CDM,27200148,LOCAL,272,RC,,,inpatient,,,529,370.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,118.7605,448.3804,,,,
HC Surgiflo Hemostatic Matrix,PX-27200149,CDM,27200149,LOCAL,272,RC,,,inpatient,,,906,634.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,203.397,767.9256,,,,
HC Kit Monitoring Press Abviser,PX-27200150,CDM,27200150,LOCAL,272,RC,,,inpatient,,,648,453.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,145.476,549.2448,,,,
HC Tray Fuhrman Pleural Drain,PX-27200151,CDM,27200151,LOCAL,272,RC,,,inpatient,,,990,693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,222.255,839.124,,,,
HC Kit Cath Triple Lumen 20cm,PX-27200152,CDM,27200152,LOCAL,272,RC,,,inpatient,,,865,605.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,194.1925,733.174,,,,
HC Dressing Kci Simplace Med,PX-27200153,CDM,27200153,LOCAL,272,RC,,,inpatient,,,433,303.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,97.2085,367.0108,,,,
HC Tube Non Balloon Replace Peg,PX-27200154,CDM,27200154,LOCAL,272,RC,,,inpatient,,,394,275.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,88.453,333.9544,,,,
HC Cath 12fr Hp Triple Lumen,PX-27200155,CDM,27200155,LOCAL,272,RC,,,inpatient,,,606,424.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,136.047,513.6456,,,,
HC Cath Pneumothorax Ak01500,PX-27200156,CDM,27200156,LOCAL,272,RC,,,inpatient,,,700,490,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,157.15,593.32,,,,
HC Kit Cranial Access 826614,PX-27200158,CDM,27200158,LOCAL,272,RC,,,inpatient,,,2205,1543.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,495.0225,1868.958,,,,
"HC Sensor Flotrac W Vamp 60""",PX-27200159,CDM,27200159,LOCAL,272,RC,,,inpatient,,,1336,935.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,299.932,1132.3936,,,,
HC Trach Lg 4.0 Quick Rusch,PX-27200160,CDM,27200160,LOCAL,272,RC,,,inpatient,,,1094,765.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,245.603,927.2744,,,,
HC Tray Pericardiocentesis Stra,PX-27200161,CDM,27200161,LOCAL,272,RC,,,inpatient,,,1188,831.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,266.706,1006.9488,,,,
HC Trocar Endo Ethicon 12 512sd,PX-27200162,CDM,27200162,LOCAL,272,RC,,,inpatient,,,1154,807.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,259.073,978.1304,,,,
HC Tube Laryngectomy 12mm Metal,PX-27200163,CDM,27200163,LOCAL,272,RC,,,inpatient,,,1154,807.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,259.073,978.1304,,,,
HC Tray Midline CT 4f 20cm Single,PX-27200164,CDM,27200164,LOCAL,272,RC,,,inpatient,,,785,549.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,176.2325,665.366,,,,
HC Tray Midline CT 5f 20cm Dual,PX-27200165,CDM,27200165,LOCAL,272,RC,,,inpatient,,,779,545.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.8855,660.2804,,,,
HC Mahurkar Triple Lumen Cath Tray #16,PX-27200166,CDM,27200166,LOCAL,272,RC,,,inpatient,,,1191,833.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,267.3795,1009.4916,,,,
HC Mahurkar Triple Lumen Cath Tray #20,PX-27200167,CDM,27200167,LOCAL,272,RC,,,inpatient,,,983,688.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,220.6835,833.1908,,,,
HC Compartment Pressure Monitoring Kit,PX-27200168,CDM,27200168,LOCAL,272,RC,,,inpatient,,,457,319.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,102.5965,387.3532,,,,
HC Kit Perc Sheath Introducer 8.5,PX-27200169,CDM,27200169,LOCAL,272,RC,,,inpatient,,,471,329.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,105.7395,399.2196,,,,
HC Cath Arrow Cvc Kit Latex Free,PX-27200170,CDM,27200170,LOCAL,272,RC,,,inpatient,,,465,325.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,104.3925,394.134,,,,
HC Electrode Temporary Pacing 4,PX-27200171,CDM,27200171,LOCAL,272,RC,,,inpatient,,,823,576.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,184.7635,697.5748,,,,
HC Catheter Bipolar Pacing 5,PX-27200172,CDM,27200172,LOCAL,272,RC,,,inpatient,,,619,433.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,138.9655,524.6644,,,,
HC Set Emergency Pneumothorax,PX-27200173,CDM,27200173,LOCAL,272,RC,,,inpatient,,,795,556.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,178.4775,673.842,,,,
HC Kit Pneumothorax,PX-27200174,CDM,27200174,LOCAL,272,RC,,,inpatient,,,722,505.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,162.089,611.9672,,,,
HC Impella Purge Cassette,PX-27200175,CDM,27200175,LOCAL,272,RC,,,inpatient,,,245,171.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,55.0025,207.662,,,,
HC Tray Midline CT 4f 20cm Singl,PX-27200176,CDM,27200176,LOCAL,272,RC,,,inpatient,,,954,667.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,214.173,808.6104,,,,
HC Tray Midline CT 5f 20cm Dual F,PX-27200177,CDM,27200177,LOCAL,272,RC,,,inpatient,,,1154,807.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,259.073,978.1304,,,,
HC Kit Microez Mst Nitinol 4.5 7c,PX-27200178,CDM,27200178,LOCAL,272,RC,,,inpatient,,,497,347.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,111.5765,421.2572,,,,
HC Kit Microez Mst 5f Nsx,PX-27200179,CDM,27200179,LOCAL,272,RC,,,inpatient,,,251,175.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,56.3495,212.7476,,,,
HC Electrode One Step Cpr Adult,PX-27200180,CDM,27200180,LOCAL,272,RC,,,inpatient,,,408,285.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,91.596,345.8208,,,,
HC Electrode One Step Pediatric,PX-27200181,CDM,27200181,LOCAL,272,RC,,,inpatient,,,447,312.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,100.3515,378.8772,,,,
HC Ambu® Ascopetm 4 Broncho Large (5.8/2.8),PX-27200196,CDM,27200196,LOCAL,272,RC,,,inpatient,,,359,251.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.5955,304.2884,,,,
HC Ambu® Ascopetm 4 Broncho Regular (5.0/2.2),PX-27200197,CDM,27200197,LOCAL,272,RC,,,inpatient,,,312,218.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,70.044,264.4512,,,,
HC Ambu® Ascopetm 4 Broncho Slim (3.8/1.2),PX-27200198,CDM,27200198,LOCAL,272,RC,,,inpatient,,,312,218.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,70.044,264.4512,,,,
HC Tray Pneumothorax Turkel 9 Cm Sys,PX-27200199,CDM,27200199,LOCAL,272,RC,,,inpatient,,,622,435.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,139.639,527.2072,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400003,CDM,27400003,LOCAL,274,RC,,,inpatient,,,552,386.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,123.924,467.8752,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400005,CDM,27400005,LOCAL,274,RC,,,inpatient,,,1221,854.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,274.1145,1034.9196,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400008,CDM,27400008,LOCAL,274,RC,,,inpatient,,,3772,2640.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,846.814,3197.1472,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400012,CDM,27400012,LOCAL,274,RC,,,inpatient,,,1954,1367.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,438.673,1656.2104,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400015,CDM,27400015,LOCAL,274,RC,,,inpatient,,,3806,2664.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,854.447,3225.9656,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400030,CDM,27400030,LOCAL,274,RC,,,inpatient,,,661,462.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,148.3945,560.2636,,,,
HC Brace Knee Enhanced Trom,PX-27400038,CDM,27400038,LOCAL,274,RC,,,inpatient,,,570,399,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,127.965,483.132,,,,
HC Brace Enhanced Trom Donjoy,PX-27400039,CDM,27400039,LOCAL,274,RC,,,inpatient,,,570,399,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,127.965,483.132,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400047,CDM,27400047,LOCAL,274,RC,,,inpatient,,,3385,2369.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,759.9325,2869.126,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400050,CDM,27400050,LOCAL,274,RC,,,inpatient,,,3185,2229.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,715.0325,2699.606,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400107,CDM,27400107,LOCAL,274,RC,,,inpatient,,,380,266,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,85.31,322.088,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400117,CDM,27400117,LOCAL,274,RC,,,inpatient,,,779,545.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.8855,660.2804,,,,
HC Add. to Lower Extremity L2210,PX-27400184,CDM,27400184,LOCAL,274,RC,,,inpatient,,,330,231,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,74.085,279.708,,,,
HC Lift Elevation Heel & Sole,PX-27400185,CDM,27400185,LOCAL,274,RC,,,inpatient,,,382,267.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,85.759,323.7832,,,,
HC Add. Lower Extremity Orthosis,PX-27400186,CDM,27400186,LOCAL,274,RC,,,inpatient,,,448,313.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,100.576,379.7248,,,,
HC Depth Shoe A5500,PX-27400187,CDM,27400187,LOCAL,274,RC,,,inpatient,,,473,331.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,106.1885,400.9148,,,,
HC Compression Stocking A6533,PX-27400188,CDM,27400188,LOCAL,274,RC,,,inpatient,,,502,351.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,112.699,425.4952,,,,
HC Collar L0172,PX-27400189,CDM,27400189,LOCAL,274,RC,,,inpatient,,,658,460.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,147.721,557.7208,,,,
HC Ko Elastic Knee Joint L1820,PX-27400190,CDM,27400190,LOCAL,274,RC,,,inpatient,,,661,462.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,148.3945,560.2636,,,,
HC Procedure Ortho Shoe/L3649,PX-27400191,CDM,27400191,LOCAL,274,RC,,,inpatient,,,703,492.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,157.8235,595.8628,,,,
HC Air Cast Boot L4386,PX-27400192,CDM,27400192,LOCAL,274,RC,,,inpatient,,,745,521.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,167.2525,631.462,,,,
HC Static Afa L4396,PX-27400193,CDM,27400193,LOCAL,274,RC,,,inpatient,,,785,549.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,176.2325,665.366,,,,
HC Brace Tlso,PX-27400194,CDM,27400194,LOCAL,274,RC,,,inpatient,,,901,630.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,202.2745,763.6876,,,,
HC Lumbar Corsette L0450,PX-27400195,CDM,27400195,LOCAL,274,RC,,,inpatient,,,915,640.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,205.4175,775.554,,,,
HC Brace Warm and Form,PX-27400196,CDM,27400196,LOCAL,274,RC,,,inpatient,,,1117,781.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,250.7665,946.7692,,,,
HC Afo L1940,PX-27400197,CDM,27400197,LOCAL,274,RC,,,inpatient,,,2560,1792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,574.72,2169.856,,,,
HC Ankle Foot Orthosis L1940,PX-27400198,CDM,27400198,LOCAL,274,RC,,,inpatient,,,2560,1792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,574.72,2169.856,,,,
HC POS OP Knee Brace L1832,PX-27400199,CDM,27400199,LOCAL,274,RC,,,inpatient,,,2974,2081.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,667.663,2520.7624,,,,
HC Afo Plastic L1960,PX-27400200,CDM,27400200,LOCAL,274,RC,,,inpatient,,,3011,2107.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,675.9695,2552.1236,,,,
HC Ankle/Foot Orthosis Afo,PX-27400201,CDM,27400201,LOCAL,274,RC,,,inpatient,,,3011,2107.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,675.9695,2552.1236,,,,
HC Left Afo Brace/Atlantic Pros,PX-27400202,CDM,27400202,LOCAL,274,RC,,,inpatient,,,3165,2215.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,710.5425,2682.654,,,,
HC Afo L1932,PX-27400203,CDM,27400203,LOCAL,274,RC,,,inpatient,,,3418,2392.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,767.341,2897.0968,,,,
HC Ankle Foot Orthosis L1970,PX-27400204,CDM,27400204,LOCAL,274,RC,,,inpatient,,,3462,2423.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,777.219,2934.3912,,,,
HC Back Brace Tlso Lo486,PX-27400205,CDM,27400205,LOCAL,274,RC,,,inpatient,,,6597,4617.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1481.0265,5591.6172,,,,
HC Cervical Collar L0172,PX-27400206,CDM,27400206,LOCAL,274,RC,,,inpatient,,,658,460.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,147.721,557.7208,,,,
HC Philly Collar No Extension,PX-27400207,CDM,27400207,LOCAL,274,RC,,,inpatient,,,658,460.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,147.721,557.7208,,,,
HC Cervical Collar 2/Piece L0174,PX-27400208,CDM,27400208,LOCAL,274,RC,,,inpatient,,,1232,862.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,276.584,1044.2432,,,,
HC Lumbar Orthosis L0627,PX-27400209,CDM,27400209,LOCAL,274,RC,,,inpatient,,,1750,1225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,392.875,1483.3,,,,
HC Lso Sagoro Rigid Frame L0631,PX-27400210,CDM,27400210,LOCAL,274,RC,,,inpatient,,,3933,2753.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,882.9585,3333.6108,,,,
HC Lso Sagittal Coronal L0637,PX-27400211,CDM,27400211,LOCAL,274,RC,,,inpatient,,,4114,2879.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,923.593,3487.0264,,,,
HC Hip Abduction Orthosis L1686,PX-27400212,CDM,27400212,LOCAL,274,RC,,,inpatient,,,4461,3122.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1001.4945,3781.1436,,,,
HC Knee Orthosis L1830,PX-27400213,CDM,27400213,LOCAL,274,RC,,,inpatient,,,466,326.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,104.617,394.9816,,,,
HC Knee Orthosis L1832,PX-27400214,CDM,27400214,LOCAL,274,RC,,,inpatient,,,2974,2081.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,667.663,2520.7624,,,,
HC Knee Orthosis L1832,PX-27400215,CDM,27400215,LOCAL,274,RC,,,inpatient,,,2974,2081.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,667.663,2520.7624,,,,
HC Knee Osthosis L1832,PX-27400216,CDM,27400216,LOCAL,274,RC,,,inpatient,,,2974,2081.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,667.663,2520.7624,,,,
HC Afo L1930,PX-27400217,CDM,27400217,LOCAL,274,RC,,,inpatient,,,1062,743.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,238.419,900.1512,,,,
HC Adj. Dorsal Splint L1930,PX-27400218,CDM,27400218,LOCAL,274,RC,,,inpatient,,,1062,743.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,238.419,900.1512,,,,
HC L'nard Boot L1930,PX-27400219,CDM,27400219,LOCAL,274,RC,,,inpatient,,,1062,743.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,238.419,900.1512,,,,
HC Hip Adj Ext L2624,PX-27400220,CDM,27400220,LOCAL,274,RC,,,inpatient,,,1445,1011.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,324.4025,1224.782,,,,
HC Bk Soft Interface L2820,PX-27400221,CDM,27400221,LOCAL,274,RC,,,inpatient,,,448,313.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,100.576,379.7248,,,,
HC Lift Elevation L3332,PX-27400222,CDM,27400222,LOCAL,274,RC,,,inpatient,,,347,242.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,77.9015,294.1172,,,,
HC Wrist Hand/Finger Ortho L3807,PX-27400223,CDM,27400223,LOCAL,274,RC,,,inpatient,,,1065,745.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,239.0925,902.694,,,,
HC Wrist Cockup Nonmolded L3908,PX-27400224,CDM,27400224,LOCAL,274,RC,,,inpatient,,,353,247.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,79.2485,299.2028,,,,
HC Orthosis Upper Limb Hum. Frac,PX-27400225,CDM,27400225,LOCAL,274,RC,,,inpatient,,,1413,989.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,317.2185,1197.6588,,,,
HC Walking Boot L4360,PX-27400226,CDM,27400226,LOCAL,274,RC,,,inpatient,,,1290,903,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,289.605,1093.404,,,,
HC Walking Boot Prefab L4360,PX-27400227,CDM,27400227,LOCAL,274,RC,,,inpatient,,,1290,903,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,289.605,1093.404,,,,
HC Walking Boot L4360,PX-27400228,CDM,27400228,LOCAL,274,RC,,,inpatient,,,2135,1494.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,479.3075,1809.626,,,,
HC Cam Walker L4386,PX-27400229,CDM,27400229,LOCAL,274,RC,,,inpatient,,,745,521.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,167.2525,631.462,,,,
HC Bk Stump Shrinker L8440,PX-27400230,CDM,27400230,LOCAL,274,RC,,,inpatient,,,262,183.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,58.819,222.0712,,,,
HC Stump Shrinker L8440,PX-27400231,CDM,27400231,LOCAL,274,RC,,,inpatient,,,262,183.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,58.819,222.0712,,,,
HC Liner Foam Permanently Lg,PX-27400232,CDM,27400232,LOCAL,274,RC,,,inpatient,,,353,247.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,79.2485,299.2028,,,,
HC Kit Electrode Pacing,PX-27500027,CDM,27500027,LOCAL,275,RC,,,inpatient,,,1286,900.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,288.707,1090.0136,,,,
HC Medical/Surgical Supplies: Other Implants,PX-27800095,CDM,27800095,LOCAL,278,RC,,,inpatient,,,649,454.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,145.7005,550.0924,,,,
HC Leg Post Rigid Brace/Sc Ortho,PX-27800096,CDM,27800096,LOCAL,278,RC,,,inpatient,,,758,530.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,170.171,642.4808,,,,
HC Kit Picc 4fr per-Q Poly Cath,PX-27800097,CDM,27800097,LOCAL,278,RC,,,inpatient,,,1063,744.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,238.6435,900.9988,,,,
HC Floseal Matrix Hemostatic,PX-27800098,CDM,27800098,LOCAL,278,RC,,,inpatient,,,1093,765.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,245.3785,926.4268,,,,
HC Kit Picc 5fr per-Q Poly Cath,PX-27800099,CDM,27800099,LOCAL,278,RC,,,inpatient,,,1217,851.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,273.2165,1031.5292,,,,
HC Tray Power Picc Dual 5f,PX-27800100,CDM,27800100,LOCAL,278,RC,,,inpatient,,,1355,948.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,304.1975,1148.498,,,,
HC Tray Power Picc Single 4f,PX-27800101,CDM,27800101,LOCAL,278,RC,,,inpatient,,,1398,978.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,313.851,1184.9448,,,,
HC Tray Power Picc Triple 5fr,PX-27800102,CDM,27800102,LOCAL,278,RC,,,inpatient,,,1474,1031.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,330.913,1249.3624,,,,
HC Tray Power Picc Triple 6f,PX-27800103,CDM,27800103,LOCAL,278,RC,,,inpatient,,,1499,1049.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,336.5255,1270.5524,,,,
HC Sepafilm/5x6,PX-27800104,CDM,27800104,LOCAL,278,RC,,,inpatient,,,1773,1241.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,398.0385,1502.7948,,,,
HC 3cg Power Picc Max 4fr Sl,PX-27800105,CDM,27800105,LOCAL,278,RC,,,inpatient,,,1585,1109.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,355.8325,1343.446,,,,
HC 3cg Power Picc Max 5fr Dl,PX-27800106,CDM,27800106,LOCAL,278,RC,,,inpatient,,,1636,1145.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,367.282,1386.6736,,,,
HC 3cg Power Picc Max 6fr Tl,PX-27800107,CDM,27800107,LOCAL,278,RC,,,inpatient,,,1749,1224.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,392.6505,1482.4524,,,,
HC Valve Passy Muir Aqua,PX-27800108,CDM,27800108,LOCAL,278,RC,,,inpatient,,,474,331.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,106.413,401.7624,,,,
HC Passy Muir Valve - Clear,PX-27800113,CDM,27800113,LOCAL,278,RC,,,inpatient,,,474,331.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,106.413,401.7624,,,,
HC Valve Passy Muir Purple,PX-27800114,CDM,27800114,LOCAL,278,RC,,,inpatient,,,474,331.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,106.413,401.7624,,,,
HC Liner Foam Permanently X-Lg,PX-27800115,CDM,27800115,LOCAL,278,RC,,,inpatient,,,328,229.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,73.636,278.0128,,,,
HC Tube Trach Proximal Xlt 7.0,PX-27800117,CDM,27800117,LOCAL,278,RC,,,inpatient,,,486,340.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,109.107,411.9336,,,,
HC Barrier Seprafilm 3x5in,PX-27800118,CDM,27800118,LOCAL,278,RC,,,inpatient,,,1773,1241.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,398.0385,1502.7948,,,,
HC Tube Feeding Low Profile 20f,PX-27800119,CDM,27800119,LOCAL,278,RC,,,inpatient,,,694,485.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,155.803,588.2344,,,,
HC Valve Speaking White #005,PX-27800121,CDM,27800121,LOCAL,278,RC,,,inpatient,,,474,331.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,106.413,401.7624,,,,
HC Tray Percu Introducer 8.5fr,PX-27800122,CDM,27800122,LOCAL,278,RC,,,inpatient,,,475,332.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,106.6375,402.61,,,,
HC Basket Zerotip Airway Retriv,PX-27800125,CDM,27800125,LOCAL,278,RC,,,inpatient,,,1710,1197,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,383.895,1449.396,,,,
HC Indwelling Prosthesis 20fr 8mm,PX-27800126,CDM,27800126,LOCAL,278,RC,,,inpatient,,,1327,928.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,297.9115,1124.7652,,,,
HC Indwelling Prosthesis 2.0,PX-27800127,CDM,27800127,LOCAL,278,RC,,,inpatient,,,1327,928.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,297.9115,1124.7652,,,,
HC Prosthesis Blom - 8mm,PX-27800128,CDM,27800128,LOCAL,278,RC,,,inpatient,,,1300,910,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,291.85,1101.88,,,,
HC Drug Collection,PX-30000005,CDM,30000005,LOCAL,300,RC,,,inpatient,,,32,22.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,7.184,27.1232,,,,
HC Cardiac Mnr Thoracic Prcd,PX-36000003,CDM,36000003,LOCAL,360,RC,,,inpatient,,,142,99.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,31.879,120.3592,,,,
HC Non-Pump Open Heart Other,PX-36000004,CDM,36000004,LOCAL,360,RC,,,inpatient,,,157,109.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,35.2465,133.0732,,,,
HC Pump Procedure,PX-36000005,CDM,36000005,LOCAL,360,RC,,,inpatient,,,152,106.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,34.124,128.8352,,,,
HC Non Pump Procedure,PX-36000006,CDM,36000006,LOCAL,360,RC,,,inpatient,,,208,145.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,46.696,176.3008,,,,
HC Sub Minor Proc,PX-36000014,CDM,36000014,LOCAL,360,RC,,,inpatient,,,60,42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,13.47,50.856,,,,
HC Pain Mgmt Proc,PX-36000015,CDM,36000015,LOCAL,360,RC,,,inpatient,,,75,52.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,16.8375,63.57,,,,
HC Endoscopy,PX-36000016,CDM,36000016,LOCAL,360,RC,,,inpatient,,,60,42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,13.47,50.856,,,,
HC Minor Proc,PX-36000017,CDM,36000017,LOCAL,360,RC,,,inpatient,,,75,52.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,16.8375,63.57,,,,
HC Major Proc,PX-36000019,CDM,36000019,LOCAL,360,RC,,,inpatient,,,99,69.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2255,83.9124,,,,
HC Intensive Major Procedure,PX-36000020,CDM,36000020,LOCAL,360,RC,,,inpatient,,,140,98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,31.43,118.664,,,,
HC Ercp,PX-36000021,CDM,36000021,LOCAL,360,RC,,,inpatient,,,138,96.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,30.981,116.9688,,,,
HC Cardiac Maj Thoracic Prcd,PX-36000022,CDM,36000022,LOCAL,360,RC,,,inpatient,,,159,111.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,35.6955,134.7684,,,,
HC Anesthesia Block,PX-37000001,CDM,37000001,LOCAL,370,RC,,,inpatient,,,700,490,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,157.15,593.32,,,,
HC Anesthesia Spinal,PX-37000002,CDM,37000002,LOCAL,370,RC,,,inpatient,,,850,595,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,190.825,720.46,,,,
HC Anesthesia General Minor,PX-37000003,CDM,37000003,LOCAL,370,RC,,,inpatient,,,1662,1163.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,373.119,1408.7112,,,,
HC Anesthesia Epidural,PX-37000004,CDM,37000004,LOCAL,370,RC,,,inpatient,,,950,665,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,213.275,805.22,,,,
HC Anesthesia General Major,PX-37000005,CDM,37000005,LOCAL,370,RC,,,inpatient,,,2924,2046.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,656.438,2478.3824,,,,
HC Anesthesia Gen/Epi,PX-37000006,CDM,37000006,LOCAL,370,RC,,,inpatient,,,1200,840,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,269.4,1017.12,,,,
HC Anesthesia General Intensive,PX-37000007,CDM,37000007,LOCAL,370,RC,,,inpatient,,,4262,2983.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,956.819,3612.4712,,,,
HC Anesthesia General Cvs Bypass Pump,PX-37000008,CDM,37000008,LOCAL,370,RC,,,inpatient,,,9166,6416.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2057.767,7769.1016,,,,
HC Anesthesia Mac,PX-37000009,CDM,37000009,LOCAL,370,RC,,,inpatient,,,1200,840,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,269.4,1017.12,,,,
HC Endo Level I,PX-49000001,CDM,49000001,LOCAL,490,RC,,,inpatient,,,3749,2624.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,841.6505,3177.6524,,,,
HC Endo Level II,PX-49000002,CDM,49000002,LOCAL,490,RC,,,inpatient,,,5356,3749.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1202.422,4539.7456,,,,
HC Endo Level III,PX-49000003,CDM,49000003,LOCAL,490,RC,,,inpatient,,,9641,6748.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2164.4045,8171.7116,,,,
HC Recovery Room,PX-71000001,CDM,71000001,LOCAL,710,RC,,,inpatient,,,25,17.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,5.6125,21.19,,,,
HC Second Stage Recovery per Minute,PX-71000002,CDM,71000002,LOCAL,710,RC,,,inpatient,,,22,15.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.939,18.6472,,,,
HC Recovery - Sub Minor Proc,PX-71000003,CDM,71000003,LOCAL,710,RC,,,inpatient,,,23,16.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,5.1635,19.4948,,,,
HC Recovery Rm - Minor Procedure,PX-71000004,CDM,71000004,LOCAL,710,RC,,,inpatient,,,28,19.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,6.286,23.7328,,,,
HC Recovery Rm,PX-71000005,CDM,71000005,LOCAL,710,RC,,,inpatient,,,29,20.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,6.5105,24.5804,,,,
HC Recovery Rm - Major Procedure,PX-71000006,CDM,71000006,LOCAL,710,RC,,,inpatient,,,33,23.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,7.4085,27.9708,,,,
HC Recovery Rm - Intensive Major,PX-71000007,CDM,71000007,LOCAL,710,RC,,,inpatient,,,38,26.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.531,32.2088,,,,
HC Extended Recovery Overnight,PX-71000009,CDM,71000009,LOCAL,710,RC,,,inpatient,,,1500,1050,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,336.75,1271.4,,,,
HC Observation Nursing Time,PX-76200006,CDM,76200006,LOCAL,762,RC,,,inpatient,,,101,70.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.6745,6652,,,,
HC Tandem Dialysis,PX-80100001,CDM,80100001,LOCAL,801,RC,,,inpatient,,,1142,799.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,256.379,967.9592,,,,
HC Single Dialysis,PX-80100002,CDM,80100002,LOCAL,801,RC,,,inpatient,,,1142,799.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,256.379,967.9592,,,,
HC Unscheduled/Emergent Dialysis,PX-80100003,CDM,80100003,LOCAL,801,RC,,,inpatient,,,1142,799.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,256.379,967.9592,,,,
HC Weekend/Holiday Dialysis,PX-80100004,CDM,80100004,LOCAL,801,RC,,,inpatient,,,1142,799.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,256.379,967.9592,,,,
HC Capd per:Exchange,PX-80300001,CDM,80300001,LOCAL,803,RC,,,inpatient,,,569,398.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,127.7405,482.2844,,,,
HC Ccpd ER,PX-80400001,CDM,80400001,LOCAL,804,RC,,,inpatient,,,569,398.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,127.7405,482.2844,,,,
HC Ccpd,PX-80400002,CDM,80400002,LOCAL,804,RC,,,inpatient,,,1142,799.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,256.379,967.9592,,,,
HC Dietary Services per 15 Mins,PX-99000006,CDM,99000006,LOCAL,990,RC,,,inpatient,,,29,20.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,6.5105,24.5804,,,,
HC Hearing Aid Batteries,PX-99000034,CDM,99000034,LOCAL,479,RC,,,inpatient,,,7,4.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.5715,163,,,,
HC Hearing Aid Tune Up,PX-99000037,CDM,99000037,LOCAL,479,RC,,,inpatient,,,43,30.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.6535,163,,,,
HC Hearing Aid Fit,PX-99000038,CDM,99000038,LOCAL,479,RC,,,inpatient,,,171,119.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,38.3895,163,,,,
HC Full Trauma No Notification,PX-45000633,CDM,TR450,LOCAL,450,RC,,,inpatient,,,10370,7259,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9291.52,,,,
HC Partial Trauma No Notification,PX-45000634,CDM,TR450,LOCAL,450,RC,,,inpatient,,,7029,4920.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6297.984,,,,
Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face- Mouth And Neck With Major O.R. Procedures,3,MS-DRG,,,,,,,inpatient,,,404600.26,283220.182,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,137408.02,,,137408.02,7771.48,434261.5728,case rate,,,
Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face- Mouth And Neck Without Major O.R. Procedures,4,MS-DRG,,,,,,,inpatient,,,379341.67,265539.169,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,85826.2,,,85826.2,7771.48,303473.336,case rate,,,
Tracheostomy For Face- Mouth And Neck Diagnoses Or Laryngectomy With McC,11,MS-DRG,,,,,,,inpatient,,,57485.95,40240.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,36295.61,,,36295.61,7771.48,109336.4384,case rate,,,
Tracheostomy For Face- Mouth And Neck Diagnoses Or Laryngectomy With Cc,12,MS-DRG,,,,,,,inpatient,,,82266.47,57586.529,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,27725.29094,,,27725.29094,7771.48,83151.2976,case rate,,,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With McC Or Chemotherapy Implant Or Epilepsy With Neurostimulator,23,MS-DRG,,,,,,,inpatient,,,82526.76,57768.732,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,40968.95,,,40968.95,7771.48,115600.0408,case rate,,,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without McC,24,MS-DRG,,,,,,,inpatient,,,54359.41,38051.587,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,28453.17118,,,28453.17118,7771.48,77031.5696,case rate,,,
Craniotomy And Endovascular Intracranial Procedures With McC,25,MS-DRG,,,,,,,inpatient,,,91861.46,64303.022,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,32499.2,,,32499.2,7771.48,90620.608,case rate,,,
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,,,inpatient,,,74058,51840.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,22125.82262,,,22125.82262,7771.48,61975.4176,case rate,,,
Craniotomy And Endovascular Intracranial Procedures Without Cc/McC,27,MS-DRG,,,,,,,inpatient,,,61484.65,43039.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,18173.8526,,,18173.8526,7771.48,50003.4464,case rate,,,
Spinal Procedures With McC,28,MS-DRG,,,,,,,inpatient,,,148126.56,103688.592,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,42109.97,,,42109.97,7771.48,123186.8824,case rate,,,
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,inpatient,,,74991.36,52493.952,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,23840.61,,,23840.61,7771.48,68016.116,case rate,,,
Spinal Procedures Without Cc/McC,30,MS-DRG,,,,,,,inpatient,,,28580.9,20006.63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,17054.54,,,17054.54,7771.48,45091.4528,case rate,,,
Ventricular Shunt Procedures With McC,31,MS-DRG,,,,,,,inpatient,,,61588.79,43112.153,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,31590.43628,,,31590.43628,7771.48,84912.2392,case rate,,,
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,,,inpatient,,,117340.84,82138.588,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,16006.13,,,16006.13,7771.48,93872.672,case rate,,,
Ventricular Shunt Procedures Without Cc/McC,33,MS-DRG,,,,,,,inpatient,,,50092.67,35064.869,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12449.94,,,12449.94,7771.48,40074.136,case rate,,,
Carotid Artery Stent Procedures With McC,34,MS-DRG,,,,,,,inpatient,,,80412.35,56288.645,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,28757.78,,,28757.78,7771.48,78796.564,case rate,,,
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,inpatient,,,59060.84,41342.588,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,16909.83,,,16909.83,7771.48,47248.672,case rate,,,
Carotid Artery Stent Procedures Without Cc/McC,36,MS-DRG,,,,,,,inpatient,,,55590.26,38913.182,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13394.15,,,13394.15,7771.48,44472.208,case rate,,,
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,inpatient,,,47239.38,33067.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11991.21,,,11991.21,7771.48,37791.504,case rate,,,
Extracranial Procedures Without Cc/McC,39,MS-DRG,,,,,,,inpatient,,,40302.61,28211.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8241.11,,,8241.11,7771.48,32242.088,case rate,,,
Peripheral- Cranial Nerve And Other Nervous System Procedures With McC,40,MS-DRG,,,,,,,inpatient,,,42423.5,29696.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,28636.22654,,,28636.22654,7771.48,76431.7552,case rate,,,
Peripheral- Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator,41,MS-DRG,,,,,,,inpatient,,,29478.8,20635.16,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,17011.13,,,17011.13,7771.48,45768.2704,case rate,,,
Peripheral- Cranial Nerve And Other Nervous System Procedures Without Cc/McC,42,MS-DRG,,,,,,,inpatient,,,40958.56,28670.992,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13637.99,,,13637.99,7771.48,35613.98,case rate,,,
Spinal Disorders And Injuries With Cc/McC,52,MS-DRG,,,,,,,inpatient,,,14188.67,9932.069,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13350.02,,,13350.02,4731.921445,40779.2736,case rate,,,
Spinal Disorders And Injuries Without Cc/McC,53,MS-DRG,,,,,,,inpatient,,,42918.11,30042.677,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8220.126579,,,8220.126579,7771.48,34334.488,case rate,,,
Nervous System Neoplasms With McC,54,MS-DRG,,,,,,,inpatient,,,16507.92,11555.544,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9882.1,,,9882.1,5505.39132,30377.7624,case rate,,,
Nervous System Neoplasms Without McC,55,MS-DRG,,,,,,,inpatient,,,15148.1,10603.67,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7549.41,,,7549.41,5051.89135,22105.9976,case rate,,,
Degenerative Nervous System Disorders With McC,56,MS-DRG,,,,,,,inpatient,,,32807.03,22964.921,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,15825.97,,,15825.97,7771.48,50741.056,case rate,,,
Degenerative Nervous System Disorders Without McC,57,MS-DRG,,,,,,,inpatient,,,21955.44,15368.808,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9146.98,,,9146.98,7322.13924,27046.3608,case rate,,,
Multiple Sclerosis And Cerebellar Ataxia With McC,58,MS-DRG,,,,,,,inpatient,,,18732.22,13112.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12565.7,,,12565.7,6247.19537,37401.2648,case rate,,,
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,inpatient,,,30559.84,21391.888,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8150.67,,,8150.67,7771.48,24793.004,case rate,,,
Multiple Sclerosis And Cerebellar Ataxia Without Cc/McC,60,MS-DRG,,,,,,,inpatient,,,18686.21,13080.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6624.72,,,6624.72,6231.851035,18083.5936,case rate,,,
Ischemic Stroke- Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With McC,61,MS-DRG,,,,,,,inpatient,,,81185.85,56830.095,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,20897.25,,,20897.25,7771.48,64948.68,case rate,,,
Ischemic Stroke- Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc,62,MS-DRG,,,,,,,inpatient,,,55465.6,38825.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,14378.17,,,14378.17,7771.48,44372.48,case rate,,,
Ischemic Stroke- Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/McC,63,MS-DRG,,,,,,,inpatient,,,65826.61,46078.627,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12371.79336,,,12371.79336,7771.48,52661.288,case rate,,,
Intracranial Hemorrhage Or Cerebral Infarction With McC,64,MS-DRG,,,,,,,inpatient,,,31988.78,22392.146,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13841.3,,,13841.3,7771.48,40307.1224,case rate,,,
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,inpatient,,,20095.65,14066.955,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7367.07,,,7367.07,6701.899275,20608.488,case rate,,,
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/McC,66,MS-DRG,,,,,,,inpatient,,,17438.35,12206.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5143.64,,,5143.64,5143.64,13950.68,case rate,,,
Nonspecific Cva And Precerebral Occlusion Without Infarction With McC,67,MS-DRG,,,,,,,inpatient,,,38053.25,26637.275,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10307.54,,,10307.54,7771.48,30442.6,case rate,,,
Nonspecific Cva And Precerebral Occlusion Without Infarction Without McC,68,MS-DRG,,,,,,,inpatient,,,27888.66,19522.062,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6429.37,,,6429.37,6429.37,22310.928,case rate,,,
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,inpatient,,,17825.05,12477.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5687.74,,,5687.74,5687.74,16215.2528,case rate,,,
Nonspecific Cerebrovascular Disorders With McC,70,MS-DRG,,,,,,,inpatient,,,36237.19,25366.033,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12129.41,,,12129.41,7771.48,35233.0168,case rate,,,
Nonspecific Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,inpatient,,,26346.94,18442.858,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7313.53,,,7313.53,7313.53,21354.2032,case rate,,,
Cranial And Peripheral Nerve Disorders With McC,73,MS-DRG,,,,,,,inpatient,,,24367.12,17056.984,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10486.97,,,10486.97,7771.48,31318.012,case rate,,,
Cranial And Peripheral Nerve Disorders Without McC,74,MS-DRG,,,,,,,inpatient,,,24431.87,17102.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7368.52,,,7368.52,7368.52,21123.1936,case rate,,,
Viral Meningitis With Cc/McC,75,MS-DRG,,,,,,,inpatient,,,38318.52,26822.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11764.74414,,,11764.74414,7771.48,34902.7136,case rate,,,
Viral Meningitis Without Cc/McC,76,MS-DRG,,,,,,,inpatient,,,18360.72,12852.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7097.19,,,7097.19,6123.30012,18580.0616,case rate,,,
Hypertensive Encephalopathy With McC,77,MS-DRG,,,,,,,inpatient,,,24086.79,16860.753,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11083.89,,,11083.89,7771.48,31332.1968,case rate,,,
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,,,inpatient,,,18407.7,12885.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6866.39,,,6866.39,6138.96795,20219.4192,case rate,,,
Nontraumatic Stupor And Coma With McC,80,MS-DRG,,,,,,,inpatient,,,17643.44,12350.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,15136.44,,,15136.44,5884.08724,40280.7792,case rate,,,
Traumatic Stupor And Coma >1 Hour With McC,82,MS-DRG,,,,,,,inpatient,,,45789.39,32052.573,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,16338.23,,,16338.23,7771.48,47014.5064,case rate,,,
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,inpatient,,,24521.38,17164.966,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9707.72,,,9707.72,7771.48,28173.0392,case rate,,,
Traumatic Stupor And Coma >1 Hour Without Cc/McC,84,MS-DRG,,,,,,,inpatient,,,12382.21,8667.547,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6542.24,,,6542.24,4129.467035,19372.384,case rate,,,
Traumatic Stupor And Coma <1 Hour With McC,85,MS-DRG,,,,,,,inpatient,,,44820.5,31374.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,16687.7,,,16687.7,7771.48,45916.1976,case rate,,,
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,inpatient,,,22755.94,15929.158,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9209.93,,,9209.93,7589.10599,26578.2624,case rate,,,
Traumatic Stupor And Coma <1 Hour Without Cc/McC,87,MS-DRG,,,,,,,inpatient,,,19756.53,13829.571,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6241.25,,,6241.25,6241.25,17913.376,case rate,,,
Concussion With McC,88,MS-DRG,,,,,,,inpatient,,,61939.59,43357.713,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10558.60463,,,10558.60463,7771.48,49551.672,case rate,,,
Concussion With Cc,89,MS-DRG,,,,,,,inpatient,,,38694.98,27086.486,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7678.2,,,7678.2,7678.2,30955.984,case rate,,,
Other Disorders Of Nervous System With McC,91,MS-DRG,,,,,,,inpatient,,,27946.92,19562.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11930.43,,,11930.43,7771.48,36937.2192,case rate,,,
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,inpatient,,,23877.59,16714.313,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7134.82,,,7134.82,7134.82,21455.5232,case rate,,,
Other Disorders Of Nervous System Without Cc/McC,93,MS-DRG,,,,,,,inpatient,,,19087.94,13361.558,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5653.01,,,5653.01,5653.01,15994.3752,case rate,,,
Bacterial And Tuberculous Infections Of Nervous System With McC,94,MS-DRG,,,,,,,inpatient,,,86655,60658.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,26286.9,,,26286.9,7771.48,73931.1776,case rate,,,
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,,,inpatient,,,61521.3,43064.91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,18146.36,,,18146.36,7771.48,49217.04,case rate,,,
Bacterial And Tuberculous Infections Of Nervous System Without Cc/McC,96,MS-DRG,,,,,,,inpatient,,,33095.5,23166.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,16869.31,,,16869.31,7771.48,48572.808,case rate,,,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With McC,97,MS-DRG,,,,,,,inpatient,,,90065.06,63045.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,27151.52,,,27151.52,7771.48,72642.3872,case rate,,,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,inpatient,,,23740.04,16618.028,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,15273.18,,,15273.18,7771.48,43954.6424,case rate,,,
Seizures With McC,100,MS-DRG,,,,,,,inpatient,,,22104.14,15472.898,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13556.23,,,13556.23,7371.73069,40228.0928,case rate,,,
Seizures Without McC,101,MS-DRG,,,,,,,inpatient,,,15944.38,11161.066,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6417.79,,,6417.79,5317.45073,18675.3024,case rate,,,
Headaches With McC,102,MS-DRG,,,,,,,inpatient,,,25624.62,17937.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8333,,,8333,7771.48,23494.0816,case rate,,,
Headaches Without McC,103,MS-DRG,,,,,,,inpatient,,,20277.76,14194.432,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5992.35,,,5992.35,5992.35,17228.4528,case rate,,,
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,,,inpatient,,,26970.92,18879.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10515.19229,,,10515.19229,7771.48,31022.1576,case rate,,,
Neurological Eye Disorders,123,MS-DRG,,,,,,,inpatient,,,18842.87,13190.009,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5537.24,,,5537.24,5537.24,16276.0448,case rate,,,
Sinus And Mastoid Procedures With Cc/McC,135,MS-DRG,,,,,,,inpatient,,,60852.06,42596.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,15488.07583,,,15488.07583,7771.48,48854.4776,case rate,,,
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,inpatient,,,50999.49,35699.643,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,15972.12343,,,15972.12343,7771.48,43533.1512,case rate,,,
Major Head And Neck Procedures Without Cc/McC,142,MS-DRG,,,,,,,inpatient,,,31036.34,21725.438,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11640.29543,,,11640.29543,7771.48,31861.0872,case rate,,,
Other Ear- Nose- Mouth And Throat O.R. Procedures With McC,143,MS-DRG,,,,,,,inpatient,,,146130.64,102291.448,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,21444.25,,,21444.25,7771.48,116904.512,case rate,,,
Other Ear- Nose- Mouth And Throat O.R. Procedures With Cc,144,MS-DRG,,,,,,,inpatient,,,29177.65,20424.355,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12665.55,,,12665.55,7771.48,35595.7424,case rate,,,
Ear- Nose- Mouth And Throat Malignancy With Cc,147,MS-DRG,,,,,,,inpatient,,,20455.22,14318.654,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9413.965929,,,9413.965929,6821.81587,25222.6008,case rate,,,
Ear- Nose- Mouth And Throat Malignancy Without Cc/McC,148,MS-DRG,,,,,,,inpatient,,,18282.89,12798.023,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5689.187157,,,5689.187157,5689.187157,16225.3848,case rate,,,
Dysequilibrium,149,MS-DRG,,,,,,,inpatient,,,21458.09,15020.663,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5321.63,,,5321.63,5321.63,17166.472,case rate,,,
Epistaxis With McC,150,MS-DRG,,,,,,,inpatient,,,36459.7,25521.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9584.72,,,9584.72,7771.48,29167.76,case rate,,,
Epistaxis Without McC,151,MS-DRG,,,,,,,inpatient,,,17762.28,12433.596,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5332.48243,,,5332.48243,5332.48243,15360.112,case rate,,,
Otitis Media And Uri With McC,152,MS-DRG,,,,,,,inpatient,,,22895.06,16026.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7791.79,,,7791.79,7635.50251,22993.5608,case rate,,,
Otitis Media And Uri Without McC,153,MS-DRG,,,,,,,inpatient,,,11257.92,7880.544,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5141.47,,,5141.47,3754.51632,14421.8888,case rate,,,
Other Ear- Nose- Mouth And Throat Diagnoses With Cc,155,MS-DRG,,,,,,,inpatient,,,14149.33,9904.531,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6561.05,,,6561.05,4718.801555,18918.4704,case rate,,,
Other Ear- Nose- Mouth And Throat Diagnoses Without Cc/McC,156,MS-DRG,,,,,,,inpatient,,,3168.14,2217.698,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,4757.99,,,4757.99,1056.57469,13625.5136,case rate,,,
Dental And Oral Diseases With McC,157,MS-DRG,,,,,,,inpatient,,,25823.75,18076.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11376.92724,,,11376.92724,7771.48,33180.2736,case rate,,,
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,inpatient,,,17794.61,12456.227,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6432.99,,,6432.99,5934.502435,19058.292,case rate,,,
Dental And Oral Diseases Without Cc/McC,159,MS-DRG,,,,,,,inpatient,,,15217,10651.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,4744.97,,,4744.97,4744.97,13366.1344,case rate,,,
Major Chest Procedures With McC,163,MS-DRG,,,,,,,inpatient,,,128830.68,90181.476,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,35895.49,,,35895.49,7771.48,103064.544,case rate,,,
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,inpatient,,,83811.85,58668.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,19095.64,,,19095.64,7771.48,67049.48,case rate,,,
Major Chest Procedures Without Cc/McC,165,MS-DRG,,,,,,,inpatient,,,63087.07,44160.949,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13845.64,,,13845.64,7771.48,50469.656,case rate,,,
Other Respiratory System O.R. Procedures With McC,166,MS-DRG,,,,,,,inpatient,,,68518.66,47963.062,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,27431.53,,,27431.53,7771.48,78036.664,case rate,,,
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,inpatient,,,50504.64,35353.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13471.57,,,13471.57,7771.48,40403.712,case rate,,,
Other Respiratory System O.R. Procedures Without Cc/McC,168,MS-DRG,,,,,,,inpatient,,,36816.23,25771.361,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9905.97,,,9905.97,7771.48,29452.984,case rate,,,
Pulmonary Embolism With McC Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,inpatient,,,27323.68,19126.576,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11172.89,,,11172.89,7771.48,28554.0024,case rate,,,
Pulmonary Embolism Without McC,176,MS-DRG,,,,,,,inpatient,,,16280.09,11396.063,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6415.62,,,6415.62,5429.410015,16505.028,case rate,,,
Respiratory Infections And Inflammations With McC,177,MS-DRG,,,,,,,inpatient,,,30316.04,21221.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13351.47,,,13351.47,7771.48,32756.756,case rate,,,
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,inpatient,,,21346.77,14942.739,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8725.16,,,8725.16,7119.147795,20103.9144,case rate,,,
Respiratory Infections And Inflammations Without Cc/McC,179,MS-DRG,,,,,,,inpatient,,,20533.98,14373.786,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6302.75,,,6302.75,6302.75,16427.184,case rate,,,
Respiratory Neoplasms With McC,180,MS-DRG,,,,,,,inpatient,,,24678.76,17275.132,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12573.66,,,12573.66,7771.48,35415.3928,case rate,,,
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,inpatient,,,15915.05,11140.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8110.15,,,8110.15,5307.669175,22497.0928,case rate,,,
Major Chest Trauma With McC,183,MS-DRG,,,,,,,inpatient,,,30366.68,21256.676,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11255.37,,,11255.37,7771.48,32163.0208,case rate,,,
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,inpatient,,,23252.15,16276.505,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7520.46,,,7520.46,7520.46,21641.952,case rate,,,
Major Chest Trauma Without Cc/McC,185,MS-DRG,,,,,,,inpatient,,,26254.04,18377.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5597.297704,,,5597.297704,5597.297704,21003.232,case rate,,,
Pleural Effusion With McC,186,MS-DRG,,,,,,,inpatient,,,23322.86,16326.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11165.65,,,11165.65,7771.48,32017.12,case rate,,,
Pleural Effusion With Cc,187,MS-DRG,,,,,,,inpatient,,,25224.41,17657.087,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7468.37,,,7468.37,7468.37,20343.0296,case rate,,,
Pleural Effusion Without Cc/McC,188,MS-DRG,,,,,,,inpatient,,,14227.72,9959.404,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5268.087459,,,5268.087459,4744.94462,14875.8024,case rate,,,
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,inpatient,,,23597.45,16518.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8861.91,,,8861.91,7771.48,25076.7,case rate,,,
Chronic Obstructive Pulmonary Disease With McC,190,MS-DRG,,,,,,,inpatient,,,20380.17,14266.119,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8131.85,,,8131.85,6796.786695,22762.5512,case rate,,,
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,inpatient,,,18415.04,12890.528,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6389.57,,,6389.57,6141.41584,17408.8024,case rate,,,
Chronic Obstructive Pulmonary Disease Without Cc/McC,192,MS-DRG,,,,,,,inpatient,,,15021,10514.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5027.87,,,5027.87,5009.5035,13114.8608,case rate,,,
Simple Pneumonia And Pleurisy With McC,193,MS-DRG,,,,,,,inpatient,,,24854.58,17398.206,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9483.43,,,9483.43,7771.48,26703.8992,case rate,,,
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,inpatient,,,16852.25,11796.575,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6244.14,,,6244.14,5620.225375,16616.48,case rate,,,
Simple Pneumonia And Pleurisy Without Cc/McC,195,MS-DRG,,,,,,,inpatient,,,11327.34,7929.138,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,4811.53,,,4811.53,3777.66789,12620.4192,case rate,,,
Interstitial Lung Disease With McC,196,MS-DRG,,,,,,,inpatient,,,25824.88,18077.416,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12561.36,,,12561.36,7771.48,38181.4288,case rate,,,
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,inpatient,,,14747.43,10323.201,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7275.91,,,7275.91,4918.267905,20059.3336,case rate,,,
Interstitial Lung Disease Without Cc/McC,198,MS-DRG,,,,,,,inpatient,,,102750.94,71925.658,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5370.829997,,,5370.829997,5370.829997,82200.752,case rate,,,
Pneumothorax With McC,199,MS-DRG,,,,,,,inpatient,,,30942.21,21659.547,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12933.98,,,12933.98,7771.48,35770.0128,case rate,,,
Pneumothorax With Cc,200,MS-DRG,,,,,,,inpatient,,,23899.07,16729.349,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7778.04,,,7778.04,7771.48,22440.3536,case rate,,,
Pneumothorax Without Cc/McC,201,MS-DRG,,,,,,,inpatient,,,14142.03,9899.421,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5133.51,,,5133.51,4716.367005,13716.7016,case rate,,,
Bronchitis And Asthma With Cc/McC,202,MS-DRG,,,,,,,inpatient,,,14008.78,9806.146,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6986.49,,,6986.49,4671.92813,19589.2088,case rate,,,
Bronchitis And Asthma Without Cc/McC,203,MS-DRG,,,,,,,inpatient,,,8434.66,5904.262,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5104.57,,,5104.57,2812.95911,14109.8232,case rate,,,
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,inpatient,,,19382.31,13567.617,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5734.05,,,5734.05,5734.05,16432.0776,case rate,,,
Other Respiratory System Diagnoses With McC,205,MS-DRG,,,,,,,inpatient,,,29471.66,20630.162,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12172.1,,,12172.1,7771.48,38252.3528,case rate,,,
Other Respiratory System Diagnoses Without McC,206,MS-DRG,,,,,,,inpatient,,,18289.13,12802.391,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6397.53,,,6397.53,6099.424855,18355.1312,case rate,,,
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,inpatient,,,153413.76,107389.632,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,41432.74,,,41432.74,7771.48,131061.4728,case rate,,,
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,inpatient,,,60056.19,42039.333,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,18394.53,,,18394.53,7771.48,54390.6024,case rate,,,
Other Heart Assist System Implant,215,MS-DRG,,,,,,,inpatient,,,163000.7,114100.49,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,80731.76,,,80731.76,7771.48,214680.8688,case rate,,,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/McC,218,MS-DRG,,,,,,,inpatient,,,144438.6,101107.02,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,37213.05785,,,37213.05785,7771.48,120552.5624,case rate,,,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/McC,221,MS-DRG,,,,,,,inpatient,,,282573.82,197801.674,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,32937.67,,,32937.67,7771.48,226059.056,case rate,,,
Coronary Bypass With Cardiac Catheterization Or Open Ablation With McC,233,MS-DRG,,,,,,,inpatient,,,335724.2,235006.94,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,56383.22,,,56383.22,7771.48,268579.36,case rate,,,
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without McC,234,MS-DRG,,,,,,,inpatient,,,168474.77,117932.339,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,38473.46,,,38473.46,7771.48,134779.816,case rate,,,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With McC,239,MS-DRG,,,,,,,inpatient,,,57370.89,40159.623,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,34792.82,,,34792.82,7771.48,102059.636,case rate,,,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,inpatient,,,51903.54,36332.478,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,20186.01,,,20186.01,7771.48,59008.768,case rate,,,
Permanent Cardiac Pacemaker Implant With McC,242,MS-DRG,,,,,,,inpatient,,,86942.73,60859.911,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,26933.74,,,26933.74,7771.48,69554.184,case rate,,,
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,inpatient,,,65531.01,45871.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,18324.35,,,18324.35,7771.48,52424.808,case rate,,,
Permanent Cardiac Pacemaker Implant Without Cc/McC,244,MS-DRG,,,,,,,inpatient,,,63411.07,44387.749,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,14946.15,,,14946.15,7771.48,50728.856,case rate,,,
Aicd Generator Procedures,245,MS-DRG,,,,,,,inpatient,,,15907.12,11134.984,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,39172.4,,,39172.4,5305.02452,99020.036,case rate,,,
Other Vascular Procedures With McC,252,MS-DRG,,,,,,,inpatient,,,85181.97,59627.379,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,24026.56,,,24026.56,7771.48,69509.5728,case rate,,,
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,inpatient,,,82797.33,57958.131,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,19200.55,,,19200.55,7771.48,66237.864,case rate,,,
Other Vascular Procedures Without Cc/McC,254,MS-DRG,,,,,,,inpatient,,,61488.65,43042.055,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13092.44,,,13092.44,7771.48,49190.92,case rate,,,
Upper Limb And Toe Amputation For Circulatory System Disorders With McC,255,MS-DRG,,,,,,,inpatient,,,163135.56,114194.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,18399.6,,,18399.6,7771.48,130508.448,case rate,,,
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,inpatient,,,13744.76,9621.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11888.47,,,11888.47,4583.87746,34319.1104,case rate,,,
Cardiac Pacemaker Device Replacement Without McC,259,MS-DRG,,,,,,,inpatient,,,51584.98,36109.486,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,15340.47,,,15340.47,7771.48,41267.984,case rate,,,
Cardiac Pacemaker Revision Except Device Replacement With McC,260,MS-DRG,,,,,,,inpatient,,,218275.68,152792.976,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,25933.08,,,25933.08,7771.48,174620.544,case rate,,,
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,inpatient,,,57651.04,40355.728,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,14407.83,,,14407.83,7771.48,46120.832,case rate,,,
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,inpatient,,,28475.53,19932.871,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,23499.1,,,23499.1,7771.48,70820.6536,case rate,,,
Aortic And Heart Assist Procedures Except Pulsation Balloon With McC,268,MS-DRG,,,,,,,inpatient,,,101907.56,71335.292,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,50319.24,,,50319.24,7771.48,135104.1408,case rate,,,
Aortic And Heart Assist Procedures Except Pulsation Balloon Without McC,269,MS-DRG,,,,,,,inpatient,,,145888.49,102121.943,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,31217.81,,,31217.81,7771.48,116710.792,case rate,,,
Other Major Cardiovascular Procedures With McC,270,MS-DRG,,,,,,,inpatient,,,185659.89,129961.923,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,37490.9,,,37490.9,7771.48,148527.912,case rate,,,
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,inpatient,,,127626.27,89338.389,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,25791.27,,,25791.27,7771.48,102101.016,case rate,,,
Other Major Cardiovascular Procedures Without Cc/McC,272,MS-DRG,,,,,,,inpatient,,,104134.1,72893.87,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,19454.52,,,19454.52,7771.48,83307.28,case rate,,,
Acute Myocardial Infarction- Discharged Alive With McC,280,MS-DRG,,,,,,,inpatient,,,31571.18,22099.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11766.19,,,11766.19,7771.48,33263.356,case rate,,,
Acute Myocardial Infarction- Discharged Alive With Cc,281,MS-DRG,,,,,,,inpatient,,,22298.62,15609.034,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6744.11,,,6744.11,6744.11,18679.3552,case rate,,,
Acute Myocardial Infarction- Discharged Alive Without Cc/McC,282,MS-DRG,,,,,,,inpatient,,,15726.17,11008.319,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5249.28,,,5249.28,5244.677695,14693.4264,case rate,,,
Acute Myocardial Infarction- Expired With McC,283,MS-DRG,,,,,,,inpatient,,,47695.81,33387.067,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13491.11,,,13491.11,7771.48,39624.2256,case rate,,,
Acute Myocardial Infarction- Expired With Cc,284,MS-DRG,,,,,,,inpatient,,,30935.67,21654.969,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5312.22,,,5312.22,5312.22,24748.536,case rate,,,
Circulatory Disorders Except Ami- With Cardiac Catheterization With McC,286,MS-DRG,,,,,,,inpatient,,,48769.97,34138.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,16019.88,,,16019.88,7771.48,44850.3112,case rate,,,
Circulatory Disorders Except Ami- With Cardiac Catheterization Without McC,287,MS-DRG,,,,,,,inpatient,,,33854.25,23697.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8320.7,,,8320.7,7771.48,27083.4,case rate,,,
Acute And Subacute Endocarditis With McC,288,MS-DRG,,,,,,,inpatient,,,36276.49,25393.543,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,19398.08,,,19398.08,7771.48,55347.0632,case rate,,,
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,inpatient,,,34648,24253.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11884.85,,,11884.85,7771.48,31948.2224,case rate,,,
Heart Failure And Shock With McC,291,MS-DRG,,,,,,,inpatient,,,22051.33,15435.931,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9701.93,,,9701.93,7354.118555,26442.4936,case rate,,,
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,inpatient,,,17435.09,12204.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6476.4,,,6476.4,5814.602515,17453.3832,case rate,,,
Cardiac Arrest- Unexplained With McC,296,MS-DRG,,,,,,,inpatient,,,34260.06,23982.042,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11539,,,11539,7771.48,33198.5112,case rate,,,
Peripheral Vascular Disorders With McC,299,MS-DRG,,,,,,,inpatient,,,30642.24,21449.568,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11080.28,,,11080.28,7771.48,32781.0728,case rate,,,
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,inpatient,,,19909.9,13936.93,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7540.72,,,7540.72,6639.95165,21692.612,case rate,,,
Peripheral Vascular Disorders Without Cc/McC,301,MS-DRG,,,,,,,inpatient,,,15022.69,10515.883,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5372.28,,,5372.28,5010.067115,14454.3112,case rate,,,
Atherosclerosis With McC,302,MS-DRG,,,,,,,inpatient,,,19965.6,13975.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7911.9,,,7911.9,6658.5276,23571.0848,case rate,,,
Atherosclerosis Without McC,303,MS-DRG,,,,,,,inpatient,,,16291.73,11404.211,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,4894.02,,,4894.02,4894.02,13625.5136,case rate,,,
Hypertension With McC,304,MS-DRG,,,,,,,inpatient,,,26689.62,18682.734,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7927.09,,,7927.09,7771.48,23806.1472,case rate,,,
Hypertension Without McC,305,MS-DRG,,,,,,,inpatient,,,17122.11,11985.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5343.34,,,5343.34,5343.34,15212.1848,case rate,,,
Cardiac Congenital And Valvular Disorders With McC,306,MS-DRG,,,,,,,inpatient,,,18809.29,13166.503,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10879.86,,,10879.86,6272.898215,30343.3136,case rate,,,
Cardiac Congenital And Valvular Disorders Without McC,307,MS-DRG,,,,,,,inpatient,,,16249.07,11374.349,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6283.21,,,6283.21,5419.064845,18770.5432,case rate,,,
Cardiac Arrhythmia And Conduction Disorders With McC,308,MS-DRG,,,,,,,inpatient,,,21486.31,15040.417,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8677.4,,,8677.4,7165.684385,24438.384,case rate,,,
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,inpatient,,,15843.59,11090.513,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5422.2,,,5422.2,5283.837265,14981.1752,case rate,,,
Cardiac Arrhythmia And Conduction Disorders Without Cc/McC,310,MS-DRG,,,,,,,inpatient,,,13559.61,9491.727,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,4040.24,,,4040.24,4040.24,11337.708,case rate,,,
Angina Pectoris,311,MS-DRG,,,,,,,inpatient,,,18298.95,12809.265,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5043.07,,,5043.07,5043.07,14639.16,case rate,,,
Syncope And Collapse,312,MS-DRG,,,,,,,inpatient,,,18654.24,13057.968,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6057.47,,,6057.47,6057.47,17656.0232,case rate,,,
Chest Pain,313,MS-DRG,,,,,,,inpatient,,,18746.43,13122.501,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5215.27,,,5215.27,5215.27,14997.144,case rate,,,
Other Circulatory System Diagnoses With McC,314,MS-DRG,,,,,,,inpatient,,,33351.93,23346.351,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,15074.21,,,15074.21,7771.48,43636.4976,case rate,,,
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,inpatient,,,17192.63,12034.841,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7055.95,,,7055.95,5733.742105,19500.0472,case rate,,,
Other Circulatory System Diagnoses Without Cc/McC,316,MS-DRG,,,,,,,inpatient,,,16812.59,11768.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5422.92,,,5422.92,5422.92,13832.2064,case rate,,,
Stomach- Esophageal And Duodenal Procedures With McC,326,MS-DRG,,,,,,,inpatient,,,70344.55,49241.185,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,38909.76,,,38909.76,7771.48,102914.7768,case rate,,,
Stomach- Esophageal And Duodenal Procedures With Cc,327,MS-DRG,,,,,,,inpatient,,,76692.68,53684.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,18881.47,,,18881.47,7771.48,61354.144,case rate,,,
Stomach- Esophageal And Duodenal Procedures Without Cc/McC,328,MS-DRG,,,,,,,inpatient,,,58306.69,40814.683,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12050.54,,,12050.54,7771.48,46645.352,case rate,,,
Major Small And Large Bowel Procedures With McC,329,MS-DRG,,,,,,,inpatient,,,92091.01,64463.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,35093.81,,,35093.81,7771.48,93046.2088,case rate,,,
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,inpatient,,,66292.87,46405.009,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,18370.66,,,18370.66,7771.48,53034.296,case rate,,,
Major Small And Large Bowel Procedures Without Cc/McC,331,MS-DRG,,,,,,,inpatient,,,44944.36,31461.052,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12373.24,,,12373.24,7771.48,35955.488,case rate,,,
Rectal Resection With McC,332,MS-DRG,,,,,,,inpatient,,,65516.56,45861.592,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,30097.05178,,,30097.05178,7771.48,70285.684,case rate,,,
Rectal Resection With Cc,333,MS-DRG,,,,,,,inpatient,,,51060.47,35742.329,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,15490.96999,,,15490.96999,7771.48,43063.0264,case rate,,,
Peritoneal Adhesiolysis With McC,335,MS-DRG,,,,,,,inpatient,,,76073.75,53251.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,28148.56,,,28148.56,7771.48,73434.7096,case rate,,,
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,inpatient,,,39391.39,27573.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,16517.67,,,16517.67,7771.48,42805.6736,case rate,,,
Peritoneal Adhesiolysis Without Cc/McC,337,MS-DRG,,,,,,,inpatient,,,43856.45,30699.515,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11812.5,,,11812.5,7771.48,35085.16,case rate,,,
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,inpatient,,,22777.13,15943.991,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11415.27,,,11415.27,7596.172855,30177.1488,case rate,,,
Minor Small And Large Bowel Procedures Without Cc/McC,346,MS-DRG,,,,,,,inpatient,,,25360.83,17752.581,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9225.12,,,9225.12,7771.48,25232.7328,case rate,,,
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,inpatient,,,21678.05,15174.635,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9712.79,,,9712.79,7229.629675,25508.3232,case rate,,,
Inguinal And Femoral Hernia Procedures With McC,350,MS-DRG,,,,,,,inpatient,,,123839.74,86687.818,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,17744.07044,,,17744.07044,7771.48,99071.792,case rate,,,
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,inpatient,,,41444.06,29010.842,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10783.63,,,10783.63,7771.48,33155.248,case rate,,,
Inguinal And Femoral Hernia Procedures Without Cc/McC,352,MS-DRG,,,,,,,inpatient,,,27314.17,19119.919,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7980.64,,,7980.64,7771.48,22341.06,case rate,,,
Hernia Procedures Except Inguinal And Femoral With McC,353,MS-DRG,,,,,,,inpatient,,,60356.38,42249.466,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,21766.22,,,21766.22,7771.48,59430.2592,case rate,,,
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,inpatient,,,30185.36,21129.752,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12900.7,,,12900.7,7771.48,34471.0904,case rate,,,
Hernia Procedures Except Inguinal And Femoral Without Cc/McC,355,MS-DRG,,,,,,,inpatient,,,34745.89,24322.123,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9834.34,,,9834.34,7771.48,27796.712,case rate,,,
Other Digestive System O.R. Procedures With McC,356,MS-DRG,,,,,,,inpatient,,,122041.99,85429.393,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,31049.95,,,31049.95,7771.48,97633.592,case rate,,,
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,inpatient,,,40025.14,28017.598,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,16306.4,,,16306.4,7771.48,45632.5016,case rate,,,
Other Digestive System O.R. Procedures Without Cc/McC,358,MS-DRG,,,,,,,inpatient,,,22899.78,16029.846,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9688.19,,,9688.19,7637.07663,27457.72,case rate,,,
Major Esophageal Disorders With McC,368,MS-DRG,,,,,,,inpatient,,,52357.14,36649.998,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,14053.3,,,14053.3,7771.48,41885.712,case rate,,,
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,inpatient,,,25013.89,17509.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7791.07,,,7791.07,7771.48,20620.6464,case rate,,,
Major Gastrointestinal Disorders And Peritoneal Infections With McC,371,MS-DRG,,,,,,,inpatient,,,31663.98,22164.786,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12504.92,,,12504.92,7771.48,35427.5512,case rate,,,
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,inpatient,,,22657.22,15860.054,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7435.09,,,7435.09,7435.09,20857.7352,case rate,,,
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/McC,373,MS-DRG,,,,,,,inpatient,,,16862.96,11804.072,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5379.51,,,5379.51,5379.51,14697.4792,case rate,,,
Digestive Malignancy With McC,374,MS-DRG,,,,,,,inpatient,,,35452.33,24816.631,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,14962.06,,,14962.06,7771.48,42787.436,case rate,,,
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,inpatient,,,28899.99,20229.993,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8717.92,,,8717.92,7771.48,24898.3768,case rate,,,
Digestive Malignancy Without Cc/McC,376,MS-DRG,,,,,,,inpatient,,,13461.5,9423.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6477.12,,,6477.12,4489.41025,17891.0856,case rate,,,
Gastrointestinal Hemorrhage With McC,377,MS-DRG,,,,,,,inpatient,,,36368.06,25457.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13015.74,,,13015.74,7771.48,36841.9784,case rate,,,
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,inpatient,,,26039.38,18227.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7186.19,,,7186.19,7186.19,20831.504,case rate,,,
Gastrointestinal Hemorrhage Without Cc/McC,379,MS-DRG,,,,,,,inpatient,,,12685.62,8879.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,4609.67,,,4609.67,4230.65427,12900.0624,case rate,,,
Complicated Peptic Ulcer With McC,380,MS-DRG,,,,,,,inpatient,,,33309.68,23316.776,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13624.96,,,13624.96,7771.48,38994.0152,case rate,,,
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,inpatient,,,25551.79,17886.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7667.34,,,7667.34,7667.34,22069.5224,case rate,,,
Uncomplicated Peptic Ulcer With McC,383,MS-DRG,,,,,,,inpatient,,,17337.01,12135.907,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9484.87,,,9484.87,5781.892835,25617.7488,case rate,,,
Uncomplicated Peptic Ulcer Without McC,384,MS-DRG,,,,,,,inpatient,,,17367.77,12157.439,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6456.86,,,6456.86,5792.151295,17621.5744,case rate,,,
Inflammatory Bowel Disease With McC,385,MS-DRG,,,,,,,inpatient,,,26393.7,18475.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11714.82,,,11714.82,7771.48,32922.9208,case rate,,,
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,inpatient,,,16705.38,11693.766,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7188.36,,,7188.36,5571.24423,20109.9936,case rate,,,
Inflammatory Bowel Disease Without Cc/McC,387,MS-DRG,,,,,,,inpatient,,,12511.84,8758.288,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5162.45,,,5162.45,4172.69864,13582.9592,case rate,,,
Gastrointestinal Obstruction With McC,388,MS-DRG,,,,,,,inpatient,,,25855.59,18098.913,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10938.46,,,10938.46,7771.48,29788.08,case rate,,,
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,inpatient,,,16977.78,11884.446,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5946.04,,,5946.04,5662.08963,16245.6488,case rate,,,
Gastrointestinal Obstruction Without Cc/McC,390,MS-DRG,,,,,,,inpatient,,,12959.35,9071.545,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,4215.34,,,4215.34,4215.34,11086.4344,case rate,,,
Esophagitis- Gastroenteritis And Miscellaneous Digestive Disorders With McC,391,MS-DRG,,,,,,,inpatient,,,20838.16,14586.712,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9003.72,,,9003.72,6949.52636,26037.2136,case rate,,,
Esophagitis- Gastroenteritis And Miscellaneous Digestive Disorders Without McC,392,MS-DRG,,,,,,,inpatient,,,16987.8,11891.46,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5530.73,,,5530.73,5530.73,15811.9992,case rate,,,
Other Digestive System Diagnoses With McC,393,MS-DRG,,,,,,,inpatient,,,37534.54,26274.178,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11964.44,,,11964.44,7771.48,33555.1576,case rate,,,
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,inpatient,,,23011.57,16108.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6791.14,,,6791.14,6791.14,19074.5032,case rate,,,
Other Digestive System Diagnoses Without Cc/McC,395,MS-DRG,,,,,,,inpatient,,,17300.89,12110.623,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,4700.83,,,4700.83,4700.83,13840.712,case rate,,,
Pancreas- Liver And Shunt Procedures With McC,405,MS-DRG,,,,,,,inpatient,,,46019.16,32213.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,41462.4,,,41462.4,7771.48,110001.0976,case rate,,,
Pancreas- Liver And Shunt Procedures With Cc,406,MS-DRG,,,,,,,inpatient,,,55926.32,39148.424,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,20816.22,,,20816.22,7771.48,56905.3648,case rate,,,
Pancreas- Liver And Shunt Procedures Without Cc/McC,407,MS-DRG,,,,,,,inpatient,,,51764.06,36234.842,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,15310.09,,,15310.09,7771.48,43275.7984,case rate,,,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,inpatient,,,23884.65,16719.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,15297.79,,,15297.79,7771.48,42479.4232,case rate,,,
Laparoscopic Cholecystectomy Without C.D.E. With McC,417,MS-DRG,,,,,,,inpatient,,,63968.01,44777.607,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,17534.97,,,17534.97,7771.48,51174.408,case rate,,,
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,inpatient,,,44129.12,30890.384,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12214.06,,,12214.06,7771.48,35303.296,case rate,,,
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/McC,419,MS-DRG,,,,,,,inpatient,,,36100.79,25270.553,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9515.98,,,9515.98,7771.48,28880.632,case rate,,,
Hepatobiliary Diagnostic Procedures With McC,420,MS-DRG,,,,,,,inpatient,,,75254.61,52678.227,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,25425.88,,,25425.88,7771.48,71515.7088,case rate,,,
Hepatobiliary Diagnostic Procedures Without Cc/McC,422,MS-DRG,,,,,,,inpatient,,,34064.62,23845.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10501.44505,,,10501.44505,7771.48,29773.8952,case rate,,,
Other Hepatobiliary Or Pancreas O.R. Procedures With McC,423,MS-DRG,,,,,,,inpatient,,,81747.41,57223.187,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,30236.69,,,30236.69,7771.48,82415.7144,case rate,,,
Cirrhosis And Alcoholic Hepatitis With McC,432,MS-DRG,,,,,,,inpatient,,,29574.59,20702.213,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13617.73,,,13617.73,7771.48,39699.2024,case rate,,,
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,inpatient,,,21623.94,15136.758,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7441.6,,,7441.6,7211.58399,21676.4008,case rate,,,
Cirrhosis And Alcoholic Hepatitis Without Cc/McC,434,MS-DRG,,,,,,,inpatient,,,14349.7,10044.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,4483.05,,,4483.05,4483.05,14111.8496,case rate,,,
Malignancy Of Hepatobiliary System Or Pancreas With McC,435,MS-DRG,,,,,,,inpatient,,,41847.14,29292.998,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12682.19,,,12682.19,7771.48,36971.668,case rate,,,
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,inpatient,,,20489.14,14342.398,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8105.08,,,8105.08,6833.12819,22849.6864,case rate,,,
Disorders Of Pancreas Except Malignancy With McC,438,MS-DRG,,,,,,,inpatient,,,28902.5,20231.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11549.85,,,11549.85,7771.48,33715.2432,case rate,,,
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,inpatient,,,16481.74,11537.218,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6109.56,,,6109.56,5496.66029,17431.0928,case rate,,,
Disorders Of Pancreas Except Malignancy Without Cc/McC,440,MS-DRG,,,,,,,inpatient,,,15295.1,10706.57,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,4383.92,,,4383.92,4383.92,12464.3864,case rate,,,
Disorders Of Liver Except Malignancy- Cirrhosis Or Alcoholic Hepatitis With McC,441,MS-DRG,,,,,,,inpatient,,,34043.85,23830.695,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13629.3,,,13629.3,7771.48,38305.0392,case rate,,,
Disorders Of Liver Except Malignancy- Cirrhosis Or Alcoholic Hepatitis With Cc,442,MS-DRG,,,,,,,inpatient,,,21274.77,14892.339,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6740.49,,,6740.49,6740.49,19579.0768,case rate,,,
Disorders Of Liver Except Malignancy- Cirrhosis Or Alcoholic Hepatitis Without Cc/McC,443,MS-DRG,,,,,,,inpatient,,,11297.88,7908.516,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,4795.62,,,4795.62,3767.84298,14237.4864,case rate,,,
Disorders Of The Biliary Tract With McC,444,MS-DRG,,,,,,,inpatient,,,39694.28,27785.996,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12074.42,,,12074.42,7771.48,34134.708,case rate,,,
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,inpatient,,,32558.38,22790.866,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7791.07,,,7791.07,7771.48,26046.704,case rate,,,
Disorders Of The Biliary Tract Without Cc/McC,446,MS-DRG,,,,,,,inpatient,,,33146.93,23202.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5905.53,,,5905.53,5905.53,26517.544,case rate,,,
Combined Anterior And Posterior Spinal Fusion With McC,453,MS-DRG,,,,,,,inpatient,,,126551.26,88585.882,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,66519.2815,,,66519.2815,7771.48,101241.008,case rate,,,
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,,,inpatient,,,108469.17,75928.419,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,44122.13,,,44122.13,7771.48,86775.336,case rate,,,
Combined Anterior And Posterior Spinal Fusion Without Cc/McC,455,MS-DRG,,,,,,,inpatient,,,115580.93,80906.651,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,34664.75,,,34664.75,7771.48,92464.744,case rate,,,
Spinal Fusion Except Cervical With Spinal Curvature- Malignancy- Infection Or Extensive Fusions With Cc,457,MS-DRG,,,,,,,inpatient,,,143333.97,100333.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,47044.50578,,,47044.50578,7771.48,116295.096,case rate,,,
Spinal Fusion Except Cervical With McC,459,MS-DRG,,,,,,,inpatient,,,98009.72,68606.804,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,48707.1984,,,48707.1984,7771.48,78407.776,case rate,,,
Spinal Fusion Except Cervical Without McC,460,MS-DRG,,,,,,,inpatient,,,99867.86,69907.502,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,28454.62,,,28454.62,7771.48,79894.288,case rate,,,
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With McC,461,MS-DRG,,,,,,,inpatient,,,327456.17,229219.319,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,43963.67672,,,43963.67672,7771.48,261964.936,case rate,,,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With McC,463,MS-DRG,,,,,,,inpatient,,,128878.42,90214.894,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,38820.76,,,38820.76,7771.48,109439.7848,case rate,,,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With Cc,464,MS-DRG,,,,,,,inpatient,,,40970.26,28679.182,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,21521.67,,,21521.67,7771.48,59750.4304,case rate,,,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Without Cc/McC,465,MS-DRG,,,,,,,inpatient,,,35885.97,25120.179,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13339.17,,,13339.17,7771.48,35176.2776,case rate,,,
Revision Of Hip Or Knee Replacement With McC,466,MS-DRG,,,,,,,inpatient,,,84828.36,59379.852,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,38673.16,,,38673.16,7771.48,103230.8952,case rate,,,
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,inpatient,,,72170.88,50519.616,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,25875.2,,,25875.2,7771.48,69402.1736,case rate,,,
Revision Of Hip Or Knee Replacement Without Cc/McC,468,MS-DRG,,,,,,,inpatient,,,88973.4,62281.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,20288.03,,,20288.03,7771.48,71178.72,case rate,,,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With McC Or Total Ankle Replacement,469,MS-DRG,,,,,,,inpatient,,,112079.98,78455.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,22316.84,,,22316.84,7771.48,89663.984,case rate,,,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without McC,470,MS-DRG,,,,,,,inpatient,,,49135.63,34394.941,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13746.52,,,13746.52,7771.48,39308.504,case rate,,,
Cervical Spinal Fusion With McC,471,MS-DRG,,,,,,,inpatient,,,68213.66,47749.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,36298.50455,,,36298.50455,7771.48,98422.248,case rate,,,
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,inpatient,,,62194.58,43536.206,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,22091.09,,,22091.09,7771.48,58704.808,case rate,,,
Cervical Spinal Fusion Without Cc/McC,473,MS-DRG,,,,,,,inpatient,,,60389.67,42272.769,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,18379.34,,,18379.34,7771.48,48311.736,case rate,,,
Amputation For Musculoskeletal System And Connective Tissue Disorders With McC,474,MS-DRG,,,,,,,inpatient,,,118369.6,82858.72,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,29468.3,,,29468.3,7771.48,94695.68,case rate,,,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,inpatient,,,42743.34,29920.338,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,15871.55,,,15871.55,7771.48,43711.4744,case rate,,,
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/McC,476,MS-DRG,,,,,,,inpatient,,,10865.65,7605.955,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8391.605322,,,8391.605322,3623.694275,23567.032,case rate,,,
Biopsies Of Musculoskeletal System And Connective Tissue With McC,477,MS-DRG,,,,,,,inpatient,,,79298.26,55508.782,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,24288.48,,,24288.48,7771.48,69683.8432,case rate,,,
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,inpatient,,,43683.25,30578.275,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,17053.09,,,17053.09,7771.48,47385.3376,case rate,,,
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/McC,479,MS-DRG,,,,,,,inpatient,,,48180.79,33726.553,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13090.99,,,13090.99,7771.48,38544.632,case rate,,,
Hip And Femur Procedures Except Major Joint With McC,480,MS-DRG,,,,,,,inpatient,,,63845.68,44691.976,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,21883.44,,,21883.44,7771.48,59596.424,case rate,,,
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,inpatient,,,51147.69,35803.383,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,15161.76,,,15161.76,7771.48,42045.7736,case rate,,,
Hip And Femur Procedures Except Major Joint Without Cc/McC,482,MS-DRG,,,,,,,inpatient,,,37492.92,26245.044,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11915.24,,,11915.24,7771.48,32146.8096,case rate,,,
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,inpatient,,,82685.37,57879.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,17265.81116,,,17265.81116,7771.48,66148.296,case rate,,,
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,inpatient,,,54953.11,38467.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,15544.51,,,15544.51,7771.48,43962.488,case rate,,,
Knee Procedures Without Principal Diagnosis Of Infection With Cc/McC,488,MS-DRG,,,,,,,inpatient,,,29907.22,20935.054,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,14287,,,14287,7771.48,39824.8392,case rate,,,
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/McC,489,MS-DRG,,,,,,,inpatient,,,28726.07,20108.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9392.98,,,9392.98,7771.48,25098.9904,case rate,,,
Lower Extremity And Humerus Procedures Except Hip- Foot And Femur With McC,492,MS-DRG,,,,,,,inpatient,,,73476.69,51433.683,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,25093.78,,,25093.78,7771.48,71957.464,case rate,,,
Lower Extremity And Humerus Procedures Except Hip- Foot And Femur With Cc,493,MS-DRG,,,,,,,inpatient,,,59232.47,41462.729,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,16823.73,,,16823.73,7771.48,48653.864,case rate,,,
Lower Extremity And Humerus Procedures Except Hip- Foot And Femur Without Cc/McC,494,MS-DRG,,,,,,,inpatient,,,55024.26,38516.982,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13399.22,,,13399.22,7771.48,44019.408,case rate,,,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/McC,497,MS-DRG,,,,,,,inpatient,,,25582.79,17907.953,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10554.26339,,,10554.26339,7771.48,27214.552,case rate,,,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/McC,498,MS-DRG,,,,,,,inpatient,,,53889.53,37722.671,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,18698.42,,,18698.42,7771.48,51160.5208,case rate,,,
Soft Tissue Procedures With McC,500,MS-DRG,,,,,,,inpatient,,,39746.36,27822.452,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,22819.7,,,22819.7,7771.48,64206.484,case rate,,,
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,inpatient,,,35413.37,24789.359,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12625.76,,,12625.76,7771.48,36169.2136,case rate,,,
Soft Tissue Procedures Without Cc/McC,502,MS-DRG,,,,,,,inpatient,,,46820.44,32774.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9628.857012,,,9628.857012,7771.48,37456.352,case rate,,,
Foot Procedures With McC,503,MS-DRG,,,,,,,inpatient,,,139085.96,97360.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,19019.66969,,,19019.66969,7771.48,111268.768,case rate,,,
Foot Procedures With Cc,504,MS-DRG,,,,,,,inpatient,,,58509.52,40956.664,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12834.86,,,12834.86,7771.48,46807.616,case rate,,,
Foot Procedures Without Cc/McC,505,MS-DRG,,,,,,,inpatient,,,18215.65,12750.955,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12834.85832,,,12834.85832,6074.919275,35575.4784,case rate,,,
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,inpatient,,,34935.4,24454.78,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10677.26502,,,10677.26502,7771.48,30375.736,case rate,,,
Major Shoulder Or Elbow Joint Procedures With Cc/McC,507,MS-DRG,,,,,,,inpatient,,,46308.19,32415.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,14632.13,,,14632.13,7771.48,39273.6584,case rate,,,
Major Shoulder Or Elbow Joint Procedures Without Cc/McC,508,MS-DRG,,,,,,,inpatient,,,21924.51,15347.157,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10230.84146,,,10230.84146,7311.824085,26152.7184,case rate,,,
Arthroscopy,509,MS-DRG,,,,,,,inpatient,,,27294.99,19106.493,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12110.59578,,,12110.59578,7771.48,35593.716,case rate,,,
Shoulder- Elbow Or Forearm Procedures- Except Major Joint Procedures With McC,510,MS-DRG,,,,,,,inpatient,,,62572,43800.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,19757.67947,,,19757.67947,7771.48,57914.512,case rate,,,
Shoulder- Elbow Or Forearm Procedures- Except Major Joint Procedures With Cc,511,MS-DRG,,,,,,,inpatient,,,55415.55,38790.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,14242.87,,,14242.87,7771.48,44332.44,case rate,,,
Shoulder- Elbow Or Forearm Procedures- Except Major Joint Procedures Without Cc/McC,512,MS-DRG,,,,,,,inpatient,,,47238.2,33066.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11259.71,,,11259.71,7771.48,37790.56,case rate,,,
Hand Or Wrist Procedures- Except Major Thumb Or Joint Procedures With Cc/McC,513,MS-DRG,,,,,,,inpatient,,,43600.38,30520.266,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11279.97,,,11279.97,7771.48,34880.304,case rate,,,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With McC,515,MS-DRG,,,,,,,inpatient,,,49277.7,34494.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,22697.42,,,22697.42,7771.48,62660.3408,case rate,,,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,inpatient,,,53176.69,37223.683,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,14189.32,,,14189.32,7771.48,42541.352,case rate,,,
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/McC,517,MS-DRG,,,,,,,inpatient,,,52111.68,36478.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10105.67,,,10105.67,7771.48,41689.344,case rate,,,
Back And Neck Procedures Except Spinal Fusion With McC Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,inpatient,,,37618.21,26332.747,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,25933.81,,,25933.81,7771.48,72622.1232,case rate,,,
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,inpatient,,,45454.66,31818.262,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,14164.72,,,14164.72,7771.48,39954.5288,case rate,,,
Back And Neck Procedures Except Spinal Fusion Without Cc/McC,520,MS-DRG,,,,,,,inpatient,,,30414.64,21290.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10255.44,,,10255.44,7771.48,29040.3384,case rate,,,
Hip Replacement With Principal Diagnosis Of Hip Fracture With McC,521,MS-DRG,,,,,,,inpatient,,,66299.82,46409.874,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,22164.89,,,22164.89,7771.48,59061.4544,case rate,,,
Hip Replacement With Principal Diagnosis Of Hip Fracture Without McC,522,MS-DRG,,,,,,,inpatient,,,59172.56,41420.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,15838.99,,,15838.99,7771.48,47338.048,case rate,,,
Fractures Of Femur With McC,533,MS-DRG,,,,,,,inpatient,,,15534.08,10873.856,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10220.71191,,,10220.71191,5180.61568,30898.5472,case rate,,,
Fractures Of Femur Without McC,534,MS-DRG,,,,,,,inpatient,,,23461.3,16422.91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5705.828554,,,5705.828554,5705.828554,18769.04,case rate,,,
Fractures Of Hip And Pelvis With McC,535,MS-DRG,,,,,,,inpatient,,,19899.42,13929.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8927.02,,,8927.02,6636.45657,26949.0936,case rate,,,
Fractures Of Hip And Pelvis Without McC,536,MS-DRG,,,,,,,inpatient,,,17540.07,12278.049,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5582.83,,,5582.83,5582.83,16432.0776,case rate,,,
Sprains- Strains- And Dislocations Of Hip- Pelvis And Thigh With Cc/McC,537,MS-DRG,,,,,,,inpatient,,,18243.05,12770.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6752.07,,,6752.07,6084.057175,18620.5896,case rate,,,
Sprains- Strains- And Dislocations Of Hip- Pelvis And Thigh Without Cc/McC,538,MS-DRG,,,,,,,inpatient,,,12750.59,8925.413,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5219.610346,,,5219.610346,4252.321765,13607.276,case rate,,,
Osteomyelitis With McC,539,MS-DRG,,,,,,,inpatient,,,15126.14,10588.298,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,14045.34,,,14045.34,5044.56769,40987.9928,case rate,,,
Osteomyelitis With Cc,540,MS-DRG,,,,,,,inpatient,,,18734.75,13114.325,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9372,,,9372,6248.039125,26229.7216,case rate,,,
Osteomyelitis Without Cc/McC,541,MS-DRG,,,,,,,inpatient,,,13958.41,9770.887,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6082.068834,,,6082.068834,4655.129735,17726.9472,case rate,,,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With McC,542,MS-DRG,,,,,,,inpatient,,,18971.85,13280.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13062.05,,,13062.05,6327.111975,37790.3336,case rate,,,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,inpatient,,,20157.83,14110.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7548.68,,,7548.68,6722.636305,21496.0512,case rate,,,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/McC,544,MS-DRG,,,,,,,inpatient,,,15770.25,11039.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5616.11,,,5616.11,5259.378375,15313.5048,case rate,,,
Connective Tissue Disorders With McC,545,MS-DRG,,,,,,,inpatient,,,29219.27,20453.489,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,18084.86,,,18084.86,7771.48,51201.0488,case rate,,,
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,inpatient,,,19656.15,13759.305,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8730.22,,,8730.22,6555.326025,23459.6328,case rate,,,
Connective Tissue Disorders Without Cc/McC,547,MS-DRG,,,,,,,inpatient,,,8610.08,6027.056,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6027.08,,,6027.08,2871.46168,15120.9968,case rate,,,
Septic Arthritis With Cc,549,MS-DRG,,,,,,,inpatient,,,46061.25,32242.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9021.81,,,9021.81,7771.48,36849,case rate,,,
Medical Back Problems With McC,551,MS-DRG,,,,,,,inpatient,,,27883.52,19518.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11743.76,,,11743.76,7771.48,34576.4632,case rate,,,
Medical Back Problems Without McC,552,MS-DRG,,,,,,,inpatient,,,22361.84,15653.288,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6815.74,,,6815.74,6815.74,19530.4432,case rate,,,
Bone Diseases And Arthropathies With McC,553,MS-DRG,,,,,,,inpatient,,,13901.34,9730.938,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9176.65,,,9176.65,4636.09689,26470.8632,case rate,,,
Bone Diseases And Arthropathies Without McC,554,MS-DRG,,,,,,,inpatient,,,18962.8,13273.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5718.85,,,5718.85,5718.85,16912.3344,case rate,,,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without McC,556,MS-DRG,,,,,,,inpatient,,,20178.82,14125.174,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5833.89,,,5833.89,5833.89,16545.556,case rate,,,
Tendonitis- Myositis And Bursitis With McC,557,MS-DRG,,,,,,,inpatient,,,32769.21,22938.447,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10085.41,,,10085.41,7771.48,31403.1208,case rate,,,
Tendonitis- Myositis And Bursitis Without McC,558,MS-DRG,,,,,,,inpatient,,,15272.59,10690.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6210.14,,,6210.14,5093.408765,17504.0432,case rate,,,
Aftercare- Musculoskeletal System And Connective Tissue With McC,559,MS-DRG,,,,,,,inpatient,,,16267.53,11387.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13514.98,,,13514.98,5425.221255,37612.0104,case rate,,,
Aftercare- Musculoskeletal System And Connective Tissue With Cc,560,MS-DRG,,,,,,,inpatient,,,15449.56,10814.692,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7788.17,,,7788.17,5152.42826,23076.6432,case rate,,,
Aftercare- Musculoskeletal System And Connective Tissue Without Cc/McC,561,MS-DRG,,,,,,,inpatient,,,9300.65,6510.455,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5723.92,,,5723.92,3101.766775,16567.8464,case rate,,,
Fracture- Sprain- Strain And Dislocation Except Femur- Hip- Pelvis And Thigh With McC,562,MS-DRG,,,,,,,inpatient,,,32385.67,22669.969,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10187.43,,,10187.43,7771.48,29660.4168,case rate,,,
Fracture- Sprain- Strain And Dislocation Except Femur- Hip- Pelvis And Thigh Without McC,563,MS-DRG,,,,,,,inpatient,,,24167.6,16917.32,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6300.58,,,6300.58,6300.58,19334.08,case rate,,,
Other Musculoskeletal System And Connective Tissue Diagnoses With McC,564,MS-DRG,,,,,,,inpatient,,,25802.93,18062.051,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10952.93,,,10952.93,7771.48,31798.2688,case rate,,,
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,inpatient,,,22006.13,15404.291,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7280.97,,,7280.97,7280.97,20661.1744,case rate,,,
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/McC,566,MS-DRG,,,,,,,inpatient,,,6764.1,4734.87,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5437.4,,,5437.4,2255.82735,15157.472,case rate,,,
Skin Debridement With McC,570,MS-DRG,,,,,,,inpatient,,,33594.41,23516.087,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,20521.74,,,20521.74,7771.48,61002.7456,case rate,,,
Skin Debridement With Cc,571,MS-DRG,,,,,,,inpatient,,,26173.08,18321.156,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11813.94,,,11813.94,7771.48,33938.1472,case rate,,,
Other Skin- Subcutaneous Tissue And Breast Procedures With McC,579,MS-DRG,,,,,,,inpatient,,,44370,31059,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,21183.77,,,21183.77,7771.48,66042.4024,case rate,,,
Other Skin- Subcutaneous Tissue And Breast Procedures With Cc,580,MS-DRG,,,,,,,inpatient,,,32530.15,22771.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11599.05,,,11599.05,7771.48,35926.0456,case rate,,,
Other Skin- Subcutaneous Tissue And Breast Procedures Without Cc/McC,581,MS-DRG,,,,,,,inpatient,,,34001.93,23801.351,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9115.87,,,9115.87,7771.48,29161.9224,case rate,,,
Mastectomy For Malignancy Without Cc/McC,583,MS-DRG,,,,,,,inpatient,,,26986.11,18890.277,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11154.07722,,,11154.07722,7771.48,33283.62,case rate,,,
Breast Biopsy- Local Excision And Other Breast Procedures With Cc/McC,584,MS-DRG,,,,,,,inpatient,,,15783.7,11048.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13242.93,,,13242.93,5263.86395,41486.4872,case rate,,,
Skin Ulcers With McC,592,MS-DRG,,,,,,,inpatient,,,11607.65,8125.355,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12203.93,,,12203.93,3871.151275,41666.8368,case rate,,,
Skin Ulcers With Cc,593,MS-DRG,,,,,,,inpatient,,,11196.69,7837.683,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8225.19,,,8225.19,3734.096115,24774.7664,case rate,,,
Skin Ulcers Without Cc/McC,594,MS-DRG,,,,,,,inpatient,,,9029.64,6320.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5923.61,,,5923.61,3011.38494,17196.0304,case rate,,,
Major Skin Disorders Without McC,596,MS-DRG,,,,,,,inpatient,,,30386.11,21270.277,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7157.25,,,7157.25,7157.25,24308.888,case rate,,,
Malignant Breast Disorders With McC,597,MS-DRG,,,,,,,inpatient,,,49956.04,34969.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11842.16,,,11842.16,7771.48,39964.832,case rate,,,
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,inpatient,,,27430.15,19201.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8039.97,,,8039.97,7771.48,21944.12,case rate,,,
Non-Malignant Breast Disorders With Cc/McC,600,MS-DRG,,,,,,,inpatient,,,13956.43,9769.501,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7204.277823,,,7204.277823,4654.469405,19396.7008,case rate,,,
Non-Malignant Breast Disorders Without Cc/McC,601,MS-DRG,,,,,,,inpatient,,,9383.02,6568.114,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,4975.05,,,4975.05,3129.23717,12148.268,case rate,,,
Cellulitis With McC,602,MS-DRG,,,,,,,inpatient,,,27986.19,19590.333,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10394.36,,,10394.36,7771.48,29775.9216,case rate,,,
Cellulitis Without McC,603,MS-DRG,,,,,,,inpatient,,,16886.67,11820.669,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6112.46,,,6112.46,5631.704445,17850.5576,case rate,,,
Trauma To The Skin- Subcutaneous Tissue And Breast With McC,604,MS-DRG,,,,,,,inpatient,,,38556.84,26989.788,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10790.14,,,10790.14,7771.48,30845.472,case rate,,,
Trauma To The Skin- Subcutaneous Tissue And Breast Without McC,605,MS-DRG,,,,,,,inpatient,,,21359.36,14951.552,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6578.42,,,6578.42,6578.42,18717.8568,case rate,,,
Minor Skin Disorders With McC,606,MS-DRG,,,,,,,inpatient,,,6185.67,4329.969,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10932.67,,,10932.67,2062.920945,32627.0664,case rate,,,
Minor Skin Disorders Without McC,607,MS-DRG,,,,,,,inpatient,,,19860.65,13902.455,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5973.54,,,5973.54,5973.54,17514.1752,case rate,,,
Adrenal And Pituitary Procedures With Cc/McC,614,MS-DRG,,,,,,,inpatient,,,37769.13,26438.391,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,17269.42885,,,17269.42885,7771.48,46177.6032,case rate,,,
Adrenal And Pituitary Procedures Without Cc/McC,615,MS-DRG,,,,,,,inpatient,,,58015.91,40611.137,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11389.2274,,,11389.2274,7771.48,46412.728,case rate,,,
Amputation Of Lower Limb For Endocrine- Nutritional And Metabolic Disorders With McC,616,MS-DRG,,,,,,,inpatient,,,66449.27,46514.489,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,28860.52,,,28860.52,7771.48,78318.3336,case rate,,,
Amputation Of Lower Limb For Endocrine- Nutritional And Metabolic Disorders With Cc,617,MS-DRG,,,,,,,inpatient,,,29882.58,20917.806,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,14717.51,,,14717.51,7771.48,39154.1008,case rate,,,
Amputation Of Lower Limb For Endocrine- Nutritional And Metabolic Disorders Without Cc/McC,618,MS-DRG,,,,,,,inpatient,,,10245.69,7171.983,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9427.71317,,,9427.71317,3416.937615,25228.68,case rate,,,
Skin Grafts And Wound Debridement For Endocrine- Nutritional And Metabolic Disorders With McC,622,MS-DRG,,,,,,,inpatient,,,103303.17,72312.219,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,26140.02,,,26140.02,7771.48,82642.536,case rate,,,
Skin Grafts And Wound Debridement For Endocrine- Nutritional And Metabolic Disorders With Cc,623,MS-DRG,,,,,,,inpatient,,,20666.05,14466.235,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13551.16,,,13551.16,6892.127675,38785.296,case rate,,,
Thyroid- Parathyroid And Thyroglossal Procedures With Cc,626,MS-DRG,,,,,,,inpatient,,,27302.86,19112.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11955.0349,,,11955.0349,7771.48,30582.4288,case rate,,,
Thyroid- Parathyroid And Thyroglossal Procedures Without Cc/McC,627,MS-DRG,,,,,,,inpatient,,,31328.53,21929.971,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8550.783902,,,8550.783902,7771.48,25670.4352,case rate,,,
Other Endocrine- Nutritional And Metabolic O.R. Procedures With McC,628,MS-DRG,,,,,,,inpatient,,,48752.32,34126.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,26757.2,,,26757.2,7771.48,79967.8232,case rate,,,
Other Endocrine- Nutritional And Metabolic O.R. Procedures With Cc,629,MS-DRG,,,,,,,inpatient,,,41481.26,29036.882,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,16980.01,,,16980.01,7771.48,45596.0264,case rate,,,
Diabetes With McC,637,MS-DRG,,,,,,,inpatient,,,33585.6,23509.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9946.49,,,9946.49,7771.48,29510.4632,case rate,,,
Diabetes With Cc,638,MS-DRG,,,,,,,inpatient,,,16607.1,11624.97,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6362.8,,,6362.8,5538.46785,18586.1408,case rate,,,
Diabetes Without Cc/McC,639,MS-DRG,,,,,,,inpatient,,,15715.82,11001.074,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,4408.52,,,4408.52,4408.52,12697.4224,case rate,,,
Miscellaneous Disorders Of Nutrition- Metabolism- Fluids And Electrolytes With McC,640,MS-DRG,,,,,,,inpatient,,,19706.61,13794.627,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8883.61,,,8883.61,6572.154435,26912.6184,case rate,,,
Miscellaneous Disorders Of Nutrition- Metabolism- Fluids And Electrolytes Without McC,641,MS-DRG,,,,,,,inpatient,,,15211.2,10647.84,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5448.25,,,5448.25,5072.9352,15836.316,case rate,,,
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,inpatient,,,44600.9,31220.63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9315.56,,,9315.56,7771.48,35680.72,case rate,,,
Endocrine Disorders With McC,643,MS-DRG,,,,,,,inpatient,,,24319.36,17023.552,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12034.62,,,12034.62,7771.48,33583.5272,case rate,,,
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,inpatient,,,18127.98,12689.586,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7367.8,,,7367.8,6045.68133,20942.844,case rate,,,
Endocrine Disorders Without Cc/McC,645,MS-DRG,,,,,,,inpatient,,,13087.48,9161.236,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5555.33,,,5555.33,4364.67458,15785.656,case rate,,,
Major Bladder Procedures With Cc,654,MS-DRG,,,,,,,inpatient,,,32847.58,22993.306,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,20984.08,,,20984.08,7771.48,57182.9816,case rate,,,
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,inpatient,,,35825.52,25077.864,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13993.97,,,13993.97,7771.48,37042.592,case rate,,,
Kidney And Ureter Procedures For Neoplasm Without Cc/McC,658,MS-DRG,,,,,,,inpatient,,,45531.4,31871.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11425.4,,,11425.4,7771.48,36425.12,case rate,,,
Kidney And Ureter Procedures For Non-Neoplasm With McC,659,MS-DRG,,,,,,,inpatient,,,43577.66,30504.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,19280.87,,,19280.87,7771.48,52366.2288,case rate,,,
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,inpatient,,,27744.56,19421.192,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10443.56,,,10443.56,7771.48,27151.7336,case rate,,,
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/McC,661,MS-DRG,,,,,,,inpatient,,,23214.29,16250.003,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7701.35,,,7701.35,7701.35,20803.0224,case rate,,,
Minor Bladder Procedures With McC,662,MS-DRG,,,,,,,inpatient,,,26200.57,18340.399,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,21198.25,,,21198.25,7771.48,63211.5216,case rate,,,
Minor Bladder Procedures Without Cc/McC,664,MS-DRG,,,,,,,inpatient,,,21663.46,15164.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8568.15,,,8568.15,7224.76391,21881.0672,case rate,,,
Prostatectomy With McC,665,MS-DRG,,,,,,,inpatient,,,440302,308211.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,21971.71,,,21971.71,7771.48,352241.6,case rate,,,
Transurethral Procedures With McC,668,MS-DRG,,,,,,,inpatient,,,48931.22,34251.854,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,19934.22,,,19934.22,7771.48,59091.8504,case rate,,,
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,inpatient,,,33035.66,23124.962,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11083.89,,,11083.89,7771.48,31358.54,case rate,,,
Transurethral Procedures Without Cc/McC,670,MS-DRG,,,,,,,inpatient,,,33732.79,23612.953,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7065.36,,,7065.36,7065.36,26986.232,case rate,,,
Other Kidney And Urinary Tract Procedures With McC,673,MS-DRG,,,,,,,inpatient,,,60478,42334.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,25056.88,,,25056.88,7771.48,84906.16,case rate,,,
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,inpatient,,,73440.29,51408.203,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,17223.12,,,17223.12,7771.48,58752.232,case rate,,,
Renal Failure With McC,682,MS-DRG,,,,,,,inpatient,,,25189.25,17632.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10637.47,,,10637.47,7771.48,30436.528,case rate,,,
Renal Failure With Cc,683,MS-DRG,,,,,,,inpatient,,,17753.72,12427.604,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6353.4,,,6353.4,5920.86562,18012.6696,case rate,,,
Renal Failure Without Cc/McC,684,MS-DRG,,,,,,,inpatient,,,9135.38,6394.766,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,4395.5,,,4395.5,3046.64923,12310.38,case rate,,,
Kidney And Urinary Tract Neoplasms With McC,686,MS-DRG,,,,,,,inpatient,,,27497.1,19247.97,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13553.33,,,13553.33,7771.48,38209.7984,case rate,,,
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,inpatient,,,25492.34,17844.638,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7581.24,,,7581.24,7581.24,21329.8864,case rate,,,
Kidney And Urinary Tract Infections With McC,689,MS-DRG,,,,,,,inpatient,,,20757.97,14530.579,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8040.69,,,8040.69,6922.782995,23716.9856,case rate,,,
Kidney And Urinary Tract Infections Without McC,690,MS-DRG,,,,,,,inpatient,,,16632.65,11642.855,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5731.88,,,5731.88,5546.988775,16263.8864,case rate,,,
Urinary Stones With McC,693,MS-DRG,,,,,,,inpatient,,,4007.39,2805.173,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9180.26,,,9180.26,1336.464565,29794.1592,case rate,,,
Urinary Stones Without McC,694,MS-DRG,,,,,,,inpatient,,,15019.62,10513.734,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5276.77,,,5276.77,5009.04327,15834.2896,case rate,,,
Kidney And Urinary Tract Signs And Symptoms With McC,695,MS-DRG,,,,,,,inpatient,,,29850.37,20895.259,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8221.57,,,8221.57,7771.48,23880.296,case rate,,,
Kidney And Urinary Tract Signs And Symptoms Without McC,696,MS-DRG,,,,,,,inpatient,,,12055.26,8438.682,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,4990.25,,,4990.25,4020.42921,14016.6088,case rate,,,
Other Kidney And Urinary Tract Diagnoses With McC,698,MS-DRG,,,,,,,inpatient,,,25421.96,17795.372,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11625.1,,,11625.1,7771.48,34061.7576,case rate,,,
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,inpatient,,,18359.1,12851.37,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7417.72,,,7417.72,6122.75985,20665.2272,case rate,,,
Other Kidney And Urinary Tract Diagnoses Without Cc/McC,700,MS-DRG,,,,,,,inpatient,,,8380.95,5866.665,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5388.92,,,5388.92,2795.046825,14065.2424,case rate,,,
Major Male Pelvic Procedures Without Cc/McC,708,MS-DRG,,,,,,,inpatient,,,55574.17,38901.919,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10790.86,,,10790.86,7771.48,44459.336,case rate,,,
Penis Procedures With Cc/McC,709,MS-DRG,,,,,,,inpatient,,,18738.26,13116.782,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,16727.5,,,16727.5,6249.20971,45533.208,case rate,,,
Transurethral Prostatectomy With Cc/McC,713,MS-DRG,,,,,,,inpatient,,,28299.1,19809.37,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10792.31,,,10792.31,7771.48,29299.7176,case rate,,,
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/McC,717,MS-DRG,,,,,,,inpatient,,,29999.37,20999.559,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13012.85,,,13012.85,7771.48,37597.8256,case rate,,,
Malignancy- Male Reproductive System With Cc,723,MS-DRG,,,,,,,inpatient,,,3972.81,2780.967,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7880.063249,,,7880.063249,1324.932135,22754.4456,case rate,,,
Benign Prostatic Hypertrophy Without McC,726,MS-DRG,,,,,,,inpatient,,,40258.34,28180.838,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5378.07,,,5378.07,5378.07,32206.672,case rate,,,
Inflammation Of The Male Reproductive System With McC,727,MS-DRG,,,,,,,inpatient,,,22656.48,15859.536,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10260.51,,,10260.51,7555.93608,29773.8952,case rate,,,
Inflammation Of The Male Reproductive System Without McC,728,MS-DRG,,,,,,,inpatient,,,13639.47,9547.629,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5813.64,,,5813.64,4548.763245,16557.7144,case rate,,,
Other Male Reproductive System Diagnoses With Cc/McC,729,MS-DRG,,,,,,,inpatient,,,16117.99,11282.593,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7270.119872,,,7270.119872,5375.349665,22306.6112,case rate,,,
Other Male Reproductive System Diagnoses Without Cc/McC,730,MS-DRG,,,,,,,inpatient,,,5959.58,4171.706,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,4093.060123,,,4093.060123,1987.51993,12298.2216,case rate,,,
Uterine And Adnexa Procedures For Non-Malignancy With Cc/McC,742,MS-DRG,,,,,,,inpatient,,,28503.79,19952.653,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12423.16,,,12423.16,7771.48,37014.2224,case rate,,,
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/McC,743,MS-DRG,,,,,,,inpatient,,,26776.68,18743.676,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8192.63,,,8192.63,7771.48,24288.4304,case rate,,,
D&C- Conization- Laparoscopy And Tubal Interruption With Cc/McC,744,MS-DRG,,,,,,,inpatient,,,42207.27,29545.089,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12980.28966,,,12980.28966,7771.48,39593.8296,case rate,,,
D&C- Conization- Laparoscopy And Tubal Interruption Without Cc/McC,745,MS-DRG,,,,,,,inpatient,,,41300.62,28910.434,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8469.023995,,,8469.023995,7771.48,33040.496,case rate,,,
Vagina- Cervix And Vulva Procedures With Cc/McC,746,MS-DRG,,,,,,,inpatient,,,54026.22,37818.354,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11644.63667,,,11644.63667,7771.48,43220.976,case rate,,,
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,,,inpatient,,,71661.69,50163.183,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9755.476337,,,9755.476337,7771.48,57329.352,case rate,,,
Other Female Reproductive System O.R. Procedures With Cc/McC,749,MS-DRG,,,,,,,inpatient,,,40397.2,28278.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,19589.09,,,19589.09,7771.48,52451.3376,case rate,,,
Malignancy- Female Reproductive System With McC,754,MS-DRG,,,,,,,inpatient,,,31179.58,21825.706,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13175.64519,,,13175.64519,7771.48,36661.6288,case rate,,,
Malignancy- Female Reproductive System With Cc,755,MS-DRG,,,,,,,inpatient,,,7660.86,5362.602,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8158.63,,,8158.63,2554.89681,22495.0664,case rate,,,
Malignancy- Female Reproductive System Without Cc/McC,756,MS-DRG,,,,,,,inpatient,,,11168.92,7818.244,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6628.340779,,,6628.340779,3724.83482,19350.0936,case rate,,,
Infections- Female Reproductive System With Cc,758,MS-DRG,,,,,,,inpatient,,,20130.99,14091.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6996.62,,,6996.62,6713.685165,20655.0952,case rate,,,
Infections- Female Reproductive System Without Cc/McC,759,MS-DRG,,,,,,,inpatient,,,18187.49,12731.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,4943.22,,,4943.22,4943.22,14549.992,case rate,,,
Menstrual And Other Female Reproductive System Disorders With Cc/McC,760,MS-DRG,,,,,,,inpatient,,,19375.46,13562.822,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6675.37,,,6675.37,6461.71591,19970.172,case rate,,,
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,inpatient,,,14024.34,9817.038,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8471.19,,,8471.19,4677.11739,22215.4232,case rate,,,
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,inpatient,,,9265.92,6486.144,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11724.22596,,,11724.22596,3090.18432,28156.828,case rate,,,
Abortion With D&C- Aspiration Curettage Or Hysterotomy,770,MS-DRG,,,,,,,inpatient,,,25214.53,17650.171,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6425.75,,,6425.75,6425.75,21802.0376,case rate,,,
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,inpatient,,,8836.34,6185.438,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5562.57,,,5562.57,2946.91939,14456.3376,case rate,,,
Cesarean Section With Sterilization With McC,783,MS-DRG,,,,,,,inpatient,,,17734.56,12414.192,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13549.71,,,13549.71,5914.47576,37326.288,case rate,,,
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,inpatient,,,18719.59,13103.713,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7922.03,,,7922.03,6242.983265,21945.912,case rate,,,
Cesarean Section With Sterilization Without Cc/McC,785,MS-DRG,,,,,,,inpatient,,,17648.18,12353.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6622.55,,,6622.55,5885.66803,17728.9736,case rate,,,
Cesarean Section Without Sterilization With McC,786,MS-DRG,,,,,,,inpatient,,,21072.73,14750.911,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11512.23,,,11512.23,7027.755455,32742.5712,case rate,,,
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,inpatient,,,18455.52,12918.864,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7689.05,,,7689.05,6154.91592,21516.3152,case rate,,,
Cesarean Section Without Sterilization Without Cc/McC,788,MS-DRG,,,,,,,inpatient,,,17822.26,12475.582,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6418.51,,,6418.51,5943.72371,18338.92,case rate,,,
Neonates- Died Or Transferred To Another Acute Care Facility,789,MS-DRG,,,,,,,inpatient,,,6500.45,4550.315,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12434.02,,,12434.02,2167.900075,36529.9128,case rate,,,
Extreme Immaturity Or Respiratory Distress Syndrome- Neonate,790,MS-DRG,,,,,,,inpatient,,,71335.38,49934.766,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,41003.68,,,41003.68,7771.48,120469.48,case rate,,,
Prematurity With Major Problems,791,MS-DRG,,,,,,,inpatient,,,39411.64,27588.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,28003.85,,,28003.85,7771.48,82273.8664,case rate,,,
Prematurity Without Major Problems,792,MS-DRG,,,,,,,inpatient,,,10975.85,7683.095,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,16896.81,,,16896.81,3660.445975,49642.7472,case rate,,,
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,inpatient,,,8093.71,5665.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,28765.74,,,28765.74,2699.252285,84513.0384,case rate,,,
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,inpatient,,,5349.51,3744.657,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10181.64,,,10181.64,1784.061585,29913.7168,case rate,,,
Normal Newborn,795,MS-DRG,,,,,,,inpatient,,,4927.51,3449.257,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,1378.34,,,1378.34,1378.34,7947.23,case rate,,,
Vaginal Delivery With Sterilization And/Or D&C With McC,796,MS-DRG,,,,,,,inpatient,,,17976.19,12583.333,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7726.672981,,,7726.672981,5995.059365,25869.0224,case rate,,,
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,inpatient,,,23001.33,16100.931,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6655.835261,,,6655.835261,6655.835261,19619.6048,case rate,,,
Vaginal Delivery With Sterilization And/Or D&C Without Cc/McC,798,MS-DRG,,,,,,,inpatient,,,14819.75,10373.825,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5985.838147,,,5985.838147,4942.386625,19619.6048,case rate,,,
Splenic Procedures With McC,799,MS-DRG,,,,,,,inpatient,,,81427.43,56999.201,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,37218.12262,,,37218.12262,7771.48,96345.188,case rate,,,
Splenic Procedures Without Cc/McC,801,MS-DRG,,,,,,,inpatient,,,60652.11,42456.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12180.77907,,,12180.77907,7771.48,48521.688,case rate,,,
Other O.R. Procedures Of The Blood And Blood Forming Organs With McC,802,MS-DRG,,,,,,,inpatient,,,94944.09,66460.863,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,26833.89,,,26833.89,7771.48,75955.272,case rate,,,
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/McC,804,MS-DRG,,,,,,,inpatient,,,22075,15452.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9870.519038,,,9870.519038,7362.0125,22401.852,case rate,,,
Vaginal Delivery Without Sterilization Or D&C With McC,805,MS-DRG,,,,,,,inpatient,,,13956.78,9769.746,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7429.3,,,7429.3,4654.58613,20221.4456,case rate,,,
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,inpatient,,,13483.61,9438.527,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5310.05,,,5310.05,4496.783935,14661.004,case rate,,,
Vaginal Delivery Without Sterilization Or D&C Without Cc/McC,807,MS-DRG,,,,,,,inpatient,,,13157.23,9210.061,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,4638.61,,,4638.61,4387.936205,12912.2208,case rate,,,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With McC,808,MS-DRG,,,,,,,inpatient,,,31882.27,22317.589,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,15757.96,,,15757.96,7771.48,46412.6656,case rate,,,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With Cc,809,MS-DRG,,,,,,,inpatient,,,26642.66,18649.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8839.48,,,8839.48,7771.48,25096.964,case rate,,,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders Without Cc/McC,810,MS-DRG,,,,,,,inpatient,,,85706.42,59994.494,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6951.04,,,6951.04,6951.04,68565.136,case rate,,,
Red Blood Cell Disorders With McC,811,MS-DRG,,,,,,,inpatient,,,33080.94,23156.658,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9967.47,,,9967.47,7771.48,28507.3952,case rate,,,
Red Blood Cell Disorders Without McC,812,MS-DRG,,,,,,,inpatient,,,21914.25,15339.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6364.97,,,6364.97,6364.97,18701.6456,case rate,,,
Coagulation Disorders,813,MS-DRG,,,,,,,inpatient,,,31592.62,22114.834,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11176.51,,,11176.51,7771.48,31366.6456,case rate,,,
Reticuloendothelial And Immunity Disorders With McC,814,MS-DRG,,,,,,,inpatient,,,15313.53,10719.471,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13679.95,,,13679.95,5107.062255,42357.8392,case rate,,,
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,inpatient,,,14949.63,10464.741,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7181.12,,,7181.12,4985.701605,20590.2504,case rate,,,
Other Antepartum Diagnoses With O.R. Procedures With McC,817,MS-DRG,,,,,,,inpatient,,,35079.77,24555.839,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,16654.42,,,16654.42,7771.48,51371.2664,case rate,,,
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,inpatient,,,56068.99,39248.293,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9525.39,,,9525.39,7771.48,44855.192,case rate,,,
Other Antepartum Diagnoses With O.R. Procedures Without Cc/McC,819,MS-DRG,,,,,,,inpatient,,,15513.53,10859.471,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7220.195681,,,7220.195681,5173.762255,16545.556,case rate,,,
Lymphoma And Leukemia With Major O.R. Procedures With McC,820,MS-DRG,,,,,,,inpatient,,,86514.51,60560.157,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,41149.83355,,,41149.83355,7771.48,117974.9816,case rate,,,
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,inpatient,,,70253.02,49177.114,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,15592.99,,,15592.99,7771.48,56202.416,case rate,,,
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/McC,822,MS-DRG,,,,,,,inpatient,,,27823.59,19476.513,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9055.814124,,,9055.814124,7771.48,23173.9104,case rate,,,
Lymphoma And Non-Acute Leukemia With Other Procedures With McC,823,MS-DRG,,,,,,,inpatient,,,49236.57,34465.599,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,32538.27,,,32538.27,7771.48,94819.3088,case rate,,,
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/McC,825,MS-DRG,,,,,,,inpatient,,,56788.87,39752.209,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10134.61077,,,10134.61077,7771.48,45431.096,case rate,,,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With McC,826,MS-DRG,,,,,,,inpatient,,,115032.85,80522.995,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,36443.21,,,36443.21,7771.48,96764.6528,case rate,,,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without Cc/McC,828,MS-DRG,,,,,,,inpatient,,,37373.35,26161.345,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12138.8138,,,12138.8138,7771.48,32479.1392,case rate,,,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/McC,829,MS-DRG,,,,,,,inpatient,,,26899.5,18829.65,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,23194.49,,,23194.49,7771.48,62486.0704,case rate,,,
Other Antepartum Diagnoses Without O.R. Procedures With McC,831,MS-DRG,,,,,,,inpatient,,,8108.51,5675.957,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8111.6,,,8111.6,2704.188085,23321.8376,case rate,,,
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,inpatient,,,9811.14,6867.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5642.16,,,5642.16,3272.01519,15143.2872,case rate,,,
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/McC,833,MS-DRG,,,,,,,inpatient,,,8494.15,5945.905,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,3878.17,,,3878.17,2832.799025,10533.2272,case rate,,,
Acute Leukemia Without Major O.R. Procedures With McC,834,MS-DRG,,,,,,,inpatient,,,33540.42,23478.294,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,43774.83,,,43774.83,7771.48,111997.1016,case rate,,,
Acute Leukemia Without Major O.R. Procedures With Cc,835,MS-DRG,,,,,,,inpatient,,,15922.85,11145.995,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,15293.44,,,15293.44,5310.270475,43279.8512,case rate,,,
Lymphoma And Non-Acute Leukemia With McC,840,MS-DRG,,,,,,,inpatient,,,35119.86,24583.902,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,23266.84,,,23266.84,7771.48,64630.0016,case rate,,,
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,inpatient,,,17465.46,12225.822,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11727.12,,,11727.12,5824.73091,31771.9256,case rate,,,
Lymphoma And Non-Acute Leukemia Without Cc/McC,842,MS-DRG,,,,,,,inpatient,,,22518.92,15763.244,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7924.922667,,,7924.922667,7510.05982,21313.6752,case rate,,,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With McC,843,MS-DRG,,,,,,,inpatient,,,21080.37,14756.259,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13768.22,,,13768.22,7030.303395,38361.7784,case rate,,,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,inpatient,,,11557.79,8090.453,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8541.38,,,8541.38,3854.522965,24217.5064,case rate,,,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/McC,845,MS-DRG,,,,,,,inpatient,,,13919.38,9743.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6131.269486,,,6131.269486,4642.11323,16954.8888,case rate,,,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With McC,846,MS-DRG,,,,,,,inpatient,,,22506.34,15754.438,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,19317.76776,,,19317.76776,7505.86439,51746.1504,case rate,,,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,inpatient,,,14849.65,10394.755,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9660.69,,,9660.69,4952.358275,25747.4384,case rate,,,
Infectious And Parasitic Diseases With O.R. Procedures With McC,853,MS-DRG,,,,,,,inpatient,,,91139.43,63797.601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,35776.11,,,35776.11,7771.48,101350.396,case rate,,,
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,inpatient,,,41334.13,28933.891,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,15153.8,,,15153.8,7771.48,40491.5248,case rate,,,
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/McC,855,MS-DRG,,,,,,,inpatient,,,41292.75,28904.925,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10816.90805,,,10816.90805,7771.48,33034.2,case rate,,,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With McC,856,MS-DRG,,,,,,,inpatient,,,65177.47,45624.229,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,32889.91,,,32889.91,7771.48,91416.9832,case rate,,,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,inpatient,,,33908.27,23735.789,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,14721.85,,,14721.85,7771.48,44153.2296,case rate,,,
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/McC,858,MS-DRG,,,,,,,inpatient,,,18266.15,12786.305,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9756.199876,,,9756.199876,6091.761025,26108.1376,case rate,,,
Postoperative And Post-Traumatic Infections With McC,862,MS-DRG,,,,,,,inpatient,,,32409.02,22686.314,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13593.85,,,13593.85,7771.48,37257.3904,case rate,,,
Postoperative And Post-Traumatic Infections Without McC,863,MS-DRG,,,,,,,inpatient,,,26972.96,18881.072,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7071.87,,,7071.87,7071.87,21578.368,case rate,,,
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,inpatient,,,18759.94,13131.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6330.97,,,6330.97,6256.43999,18195.0456,case rate,,,
Viral Illness With McC,865,MS-DRG,,,,,,,inpatient,,,22475.35,15732.745,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10700.42,,,10700.42,7495.529225,29907.6376,case rate,,,
Viral Illness Without McC,866,MS-DRG,,,,,,,inpatient,,,13589.18,9512.426,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6057.47,,,6057.47,4531.99153,17927.5608,case rate,,,
Other Infectious And Parasitic Diseases Diagnoses With McC,867,MS-DRG,,,,,,,inpatient,,,29124.07,20386.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,16131.3,,,16131.3,7771.48,43450.0688,case rate,,,
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,inpatient,,,22783.92,15948.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7657.94,,,7657.94,7598.43732,21277.2,case rate,,,
Other Infectious And Parasitic Diseases Diagnoses Without Cc/McC,869,MS-DRG,,,,,,,inpatient,,,6491.58,4544.106,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5252.89,,,5252.89,2164.94193,14579.948,case rate,,,
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,inpatient,,,165811.55,116068.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,46485.93,,,46485.93,7771.48,140966.516,case rate,,,
Septicemia Or Severe Sepsis Without Mv >96 Hours With McC,871,MS-DRG,,,,,,,inpatient,,,32860.99,23002.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13517.16,,,13517.16,7771.48,39764.0472,case rate,,,
Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC,872,MS-DRG,,,,,,,inpatient,,,22133.41,15493.387,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7391.67,,,7391.67,7381.492235,20892.184,case rate,,,
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,,,inpatient,,,167914.64,117540.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,23596.77741,,,23596.77741,7771.48,134331.712,case rate,,,
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,inpatient,,,22889.31,16022.517,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6248.48,,,6248.48,6248.48,19425.0704,case rate,,,
Depressive Neuroses,881,MS-DRG,,,,,,,inpatient,,,44762.95,31334.065,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5798.441546,,,5798.441546,5798.441546,35810.36,case rate,,,
Neuroses Except Depressive,882,MS-DRG,,,,,,,inpatient,,,10863.25,7604.275,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5954.72597,,,5954.72597,3622.893875,19491.9416,case rate,,,
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,inpatient,,,35747.4,25023.18,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10446.46,,,10446.46,7771.48,33842.9064,case rate,,,
Psychoses,885,MS-DRG,,,,,,,inpatient,,,20082.8,14057.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8950.9,,,8950.9,6697.6138,28562.108,case rate,,,
Alcohol- Drug Abuse Or Dependence- Left Ama,894,MS-DRG,,,,,,,inpatient,,,15836.23,11085.361,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,3961.38,,,3961.38,3961.38,12668.984,case rate,,,
Alcohol- Drug Abuse Or Dependence Without Rehabilitation Therapy With McC,896,MS-DRG,,,,,,,inpatient,,,35553.78,24887.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12857.29,,,12857.29,7771.48,36086.1312,case rate,,,
Alcohol- Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC,897,MS-DRG,,,,,,,inpatient,,,18541.81,12979.267,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5972.81,,,5972.81,5972.81,17876.9008,case rate,,,
Wound Debridements For Injuries With McC,901,MS-DRG,,,,,,,inpatient,,,46387.19,32471.033,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,30838.68,,,30838.68,7771.48,89773.5728,case rate,,,
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,inpatient,,,59864.86,41905.402,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,14198.73,,,14198.73,7771.48,47891.888,case rate,,,
Wound Debridements For Injuries Without Cc/McC,903,MS-DRG,,,,,,,inpatient,,,13693.85,9585.695,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8207.826416,,,8207.826416,4566.898975,24701.816,case rate,,,
Skin Grafts For Injuries With Cc/McC,904,MS-DRG,,,,,,,inpatient,,,114417.1,80091.97,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,26925.78035,,,26925.78035,7771.48,91533.68,case rate,,,
Hand Procedures For Injuries,906,MS-DRG,,,,,,,inpatient,,,51389.12,35972.384,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12978.84258,,,12978.84258,7771.48,44224.1536,case rate,,,
Other O.R. Procedures For Injuries With McC,907,MS-DRG,,,,,,,inpatient,,,48914.02,34239.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,28631.16,,,28631.16,7771.48,80721.644,case rate,,,
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,inpatient,,,44494.39,31146.073,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,14763.09,,,14763.09,7771.48,40872.488,case rate,,,
Other O.R. Procedures For Injuries Without Cc/McC,909,MS-DRG,,,,,,,inpatient,,,14125.93,9888.151,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9945.77,,,9945.77,4710.997655,25698.8048,case rate,,,
Traumatic Injury With McC,913,MS-DRG,,,,,,,inpatient,,,57017.38,39912.166,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11839.99,,,11839.99,7771.48,45613.904,case rate,,,
Traumatic Injury Without McC,914,MS-DRG,,,,,,,inpatient,,,28970.93,20279.651,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6429.37,,,6429.37,6429.37,23176.744,case rate,,,
Allergic Reactions With McC,915,MS-DRG,,,,,,,inpatient,,,42664.44,29865.108,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12282.8,,,12282.8,7771.48,35214.7792,case rate,,,
Allergic Reactions Without McC,916,MS-DRG,,,,,,,inpatient,,,12818.09,8972.663,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,4755.82,,,4755.82,4274.833015,13455.296,case rate,,,
Poisoning And Toxic Effects Of Drugs With McC,917,MS-DRG,,,,,,,inpatient,,,41573.69,29101.583,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10690.29,,,10690.29,7771.48,33258.952,case rate,,,
Poisoning And Toxic Effects Of Drugs Without McC,918,MS-DRG,,,,,,,inpatient,,,19845.67,13891.969,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5723.92,,,5723.92,5723.92,17921.4816,case rate,,,
Complications Of Treatment With McC,919,MS-DRG,,,,,,,inpatient,,,48229.35,33760.545,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13272.6,,,13272.6,7771.48,38583.48,case rate,,,
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,inpatient,,,20650.21,14455.147,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,7432.92,,,7432.92,6886.845035,20584.1712,case rate,,,
Complications Of Treatment Without Cc/McC,921,MS-DRG,,,,,,,inpatient,,,18737.44,13116.208,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5002.55,,,5002.55,5002.55,14989.952,case rate,,,
Other Injury- Poisoning And Toxic Effect Diagnoses With McC,922,MS-DRG,,,,,,,inpatient,,,42436.37,29705.459,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11486.91,,,11486.91,7771.48,34229.9488,case rate,,,
Other Injury- Poisoning And Toxic Effect Diagnoses Without McC,923,MS-DRG,,,,,,,inpatient,,,18119.88,12683.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6731.81,,,6731.81,6042.97998,20665.2272,case rate,,,
Non-Extensive Burns,935,MS-DRG,,,,,,,inpatient,,,6946.99,4862.893,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,13988.17949,,,13988.17949,2316.821165,44505.8232,case rate,,,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,inpatient,,,22686.24,15880.368,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,16045.2,,,16045.2,7565.86104,42783.3832,case rate,,,
Signs And Symptoms With McC,947,MS-DRG,,,,,,,inpatient,,,29399.47,20579.629,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,8610.84,,,8610.84,7771.48,26061.5304,case rate,,,
Signs And Symptoms Without McC,948,MS-DRG,,,,,,,inpatient,,,16042.18,11229.526,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,5684.12,,,5684.12,5350.06703,16099.748,case rate,,,
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,inpatient,,,5109.91,3576.937,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,4038.79,,,4038.79,1704.154985,11487.6616,case rate,,,
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,,,inpatient,,,149455.54,104618.878,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,45496.13232,,,45496.13232,7771.48,138360.5656,case rate,,,
Limb Reattachment- Hip And Femur Procedures For Multiple Significant Trauma,956,MS-DRG,,,,,,,inpatient,,,64530.82,45171.574,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,27847.57,,,27847.57,7771.48,77453.0608,case rate,,,
Other O.R. Procedures For Multiple Significant Trauma With McC,957,MS-DRG,,,,,,,inpatient,,,104697.23,73288.061,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,53692.38211,,,53692.38211,7771.48,151244.4168,case rate,,,
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,inpatient,,,68495.96,47947.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,30427.70911,,,30427.70911,7771.48,83274.908,case rate,,,
Other Multiple Significant Trauma With McC,963,MS-DRG,,,,,,,inpatient,,,43017.73,30112.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,19710.64944,,,19710.64944,7771.48,55049.1824,case rate,,,
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,inpatient,,,32958.94,23071.258,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,10769.15,,,10769.15,7771.48,30400.0528,case rate,,,
Hiv With Major Related Condition With McC,974,MS-DRG,,,,,,,inpatient,,,42445.87,29712.109,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,19432.09,,,19432.09,7771.48,60508.304,case rate,,,
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,,,inpatient,,,19415.36,13590.752,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9254.787349,,,9254.787349,6475.02256,28801.2232,case rate,,,
Hiv With Major Related Condition Without Cc/McC,976,MS-DRG,,,,,,,inpatient,,,36673.45,25671.415,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,6867.108649,,,6867.108649,6867.108649,29338.76,case rate,,,
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,inpatient,,,53209.61,37246.727,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,9556.5,,,9556.5,7771.48,42567.688,case rate,,,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC,981,MS-DRG,,,,,,,inpatient,,,96543.58,67580.506,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,33339.23,,,33339.23,7771.48,96341.1352,case rate,,,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,inpatient,,,54470.12,38129.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,18386.57,,,18386.57,7771.48,49616.404,case rate,,,
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/McC,983,MS-DRG,,,,,,,inpatient,,,18703.75,13092.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,11973.12,,,11973.12,6237.700625,33802.3784,case rate,,,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC,987,MS-DRG,,,,,,,inpatient,,,51141.58,35799.106,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,23602.57,,,23602.57,7771.48,70984.792,case rate,,,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,inpatient,,,31104,21772.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,12160.52,,,12160.52,7771.48,34773.024,case rate,,,
HC Fine Needle Aspiration Bx W/O Img Gdn Ea Addl,PX-36900722,CDM,10004,CPT,369,RC,,,outpatient,,,79,55.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,20.4373,17.7355,1592,percent of total billed charges,,,
HC Fine Needle Aspiration Bx W/US Gdn 1st Lesion,PX-36900723,CDM,10005,CPT,369,RC,,,outpatient,,,2116,1481.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,547.4092,399.86,2141,percent of total billed charges,,,
HC Fine Needle Aspiration Bx W/US Gdn Ea Addl,PX-36900724,CDM,10006,CPT,369,RC,,,outpatient,,,258,180.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,66.7446,57.921,1592,percent of total billed charges,,,
HC Fine Needle Aspiration W/O Imaging Guidance,PX-36900674,CDM,10021,CPT,369,RC,,,outpatient,,,871,609.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,225.3277,195.5395,1592,percent of total billed charges,,,
HC Image-Guided Catheter Fluid Collection Drainage,PX-36900043,CDM,10030,CPT,369,RC,,,outpatient,,,692,484.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,179.0204,155.354,2141,percent of total billed charges,,,
HC Plcmt of Soft Tissue Loc Device(S)- Perc- First Lesion,PX-36900637,CDM,10035,CPT,369,RC,,,outpatient,,,1860,1302,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,481.182,291.227805,2141,percent of total billed charges,,,
HC Plmt Sft Tiss Loclzj Dev Perq Each Addl Lesion,PX-36900889,CDM,10036,CPT,369,RC,,,outpatient,,,130,91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,33.631,29.185,1592,percent of total billed charges,,,
HC Drain Skin Abscess Simple,PX-36900044,CDM,10060,CPT,369,RC,,,outpatient,,,922,645.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,238.5214,206.989,1592,percent of total billed charges,,,
HC Drain Skin Abscess Complic,PX-36900045,CDM,10061,CPT,369,RC,,,outpatient,,,922,645.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,238.5214,206.989,1592,percent of total billed charges,,,
HC Drainage of Hematoma/Fluid,PX-36900048,CDM,10140,CPT,369,RC,,,outpatient,,,4838,3386.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1251.5906,399.86,3715.584,percent of total billed charges,,,
HC Puncture Drainage of Lesion,PX-36100003,CDM,10160,CPT,361,RC,,,outpatient,,,916,641.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,236.9692,205.642,1592,percent of total billed charges,,,
HC Puncture Drainage of Lesion,PX-36900049,CDM,10160,CPT,369,RC,,,outpatient,,,916,641.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,236.9692,205.642,1592,percent of total billed charges,,,
HC Complex Drainage- Wound,PX-36900050,CDM,10180,CPT,369,RC,,,outpatient,,,8640,6048,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2235.168,399.86,6635.52,percent of total billed charges,,,
HC Debridement- Infected Skin- Up to 10% Bsa,PX-36900606,CDM,11000,CPT,369,RC,,,outpatient,,,1174,821.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,303.7138,263.563,1592,percent of total billed charges,,,
HC Debridement- Infected Skin- Ea Add 10% Bsa,PX-36900607,CDM,11001,CPT,369,RC,,,outpatient,,,53,37.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.7111,11.8985,1592,percent of total billed charges,,,
HC Debride Necrotic Skin/ Tissue- Genit & Perinm,PX-36900608,CDM,11004,CPT,369,RC,,,outpatient,,,2036,1425.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,526.7132,399.86,2998,percent of total billed charges,,,
HC Dbrdmt Skn Subq T/M/F Necro Infctj Abdl Wall,PX-36900876,CDM,11005,CPT,369,RC,,,outpatient,,,2001,1400.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,517.6587,399.86,2998,percent of total billed charges,,,
HC Dbrdmt Skn Subq T/M/F Necro Infctj Gent/Abdl,PX-36900877,CDM,11006,CPT,369,RC,,,outpatient,,,1815,1270.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,469.5405,399.86,2998,percent of total billed charges,,,
HC Removal Prosthetic Matrl Abdl Wall for Infection,PX-36900878,CDM,11008,CPT,369,RC,,,outpatient,,,706,494.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,182.6422,158.497,3914,percent of total billed charges,,,
HC Dbrdmt W/Rmvl Fm Fx&/Dislc Skin&Subq Tissus,PX-36900743,CDM,11010,CPT,369,RC,,,outpatient,,,2113,1479.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,546.6331,399.86,2141,percent of total billed charges,,,
HC Dbrdmt W/Rmvl Fm Fx&/Dislc Skn Subq T/M/F Musc,PX-36900773,CDM,11011,CPT,369,RC,,,outpatient,,,2197,1537.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,568.3639,399.86,2141,percent of total billed charges,,,
HC Dbrdmt Fx&/Dislc Subq T/M/F Bone,PX-36900744,CDM,11012,CPT,369,RC,,,outpatient,,,9022,6315.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2333.9914,399.86,6928.896,percent of total billed charges,,,
HC Debridement- Skin- Sub-Q Tissue-=<20 Sq Cm,PX-36900052,CDM,11042,CPT,369,RC,,,outpatient,,,1018,712.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,263.3566,228.541,1592,percent of total billed charges,,,
HC Debridement- Skin- Sub-Q Tissue-Muscle-=<20 Sq Cm,PX-36900053,CDM,11043,CPT,369,RC,,,outpatient,,,1065,745.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,275.5155,239.0925,1592,percent of total billed charges,,,
HC Debridement- Skin- Sub-Q Tissue-Muscle-Bone-=<20 Sq Cm,PX-36900054,CDM,11044,CPT,369,RC,,,outpatient,,,2829,1980.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,731.8623,399.86,2477.315575,percent of total billed charges,,,
HC Debridement- Skin- Sub-Q Tissue-Each Add 20 Sq Cm,PX-36900055,CDM,11045,CPT,369,RC,,,outpatient,,,1203,842.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,311.2161,270.0735,1592,percent of total billed charges,,,
HC Debridement- Skin- Sub-Q Tissue-Muscle-Each Add 20 Sq Cm,PX-36900056,CDM,11046,CPT,369,RC,,,outpatient,,,1203,842.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,311.2161,270.0735,1592,percent of total billed charges,,,
HC Debridement- Skin- Sub-Q Tissue-Muscle-Bone-Each Add 20 Sq Cm,PX-36900057,CDM,11047,CPT,369,RC,,,outpatient,,,1910,1337,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,494.117,399.86,1592,percent of total billed charges,,,
HC Trim Nail(S),PX-36900064,CDM,11719,CPT,369,RC,,,outpatient,,,347,242.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,89.7689,62.19,1592,percent of total billed charges,,,
HC Debridement of Nail(S)- 1-5,PX-36900065,CDM,11720,CPT,369,RC,,,outpatient,,,347,242.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,89.7689,66.75974,1592,percent of total billed charges,,,
HC Debridement Nail Any Method 6/>,PX-36900791,CDM,11721,CPT,369,RC,,,outpatient,,,212,148.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,54.8444,47.594,1592,percent of total billed charges,,,
HC Removal of Nail Plate,PX-36900067,CDM,11730,CPT,369,RC,,,outpatient,,,431,301.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,111.4997,96.7595,1592,percent of total billed charges,,,
HC Avulsion Nail Plate Partial/Comp Simple Ea Addl,PX-36900831,CDM,11732,CPT,369,RC,,,outpatient,,,139,97.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,35.9593,31.2055,1592,percent of total billed charges,,,
HC Evacuation Subungual Hematoma,PX-36900832,CDM,11740,CPT,369,RC,,,outpatient,,,159,111.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,41.1333,35.6955,1592,percent of total billed charges,,,
HC Removal of Nail Bed,PX-36900069,CDM,11750,CPT,369,RC,,,outpatient,,,1914,1339.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,495.1518,399.86,1592,percent of total billed charges,,,
HC Biopsy Nail Unit Separate Procedure,PX-36900763,CDM,11755,CPT,369,RC,,,outpatient,,,2197,1537.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,568.3639,399.86,2141,percent of total billed charges,,,
HC Repair Nail Bed,PX-36900833,CDM,11760,CPT,369,RC,,,outpatient,,,909,636.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,235.1583,113.876282,1592,percent of total billed charges,,,
HC Wedge Excision Skin Nail Fold,PX-36900834,CDM,11765,CPT,369,RC,,,outpatient,,,1377,963.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,356.2299,156.65,1592,percent of total billed charges,,,
HC Resuperf Wnd Body <2.5cm,PX-36900070,CDM,12001,CPT,369,RC,,,outpatient,,,505,353.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,130.6435,113.3725,1592,percent of total billed charges,,,
HC Resup Npterf Wnd Body 2.6-7.5 Cm,PX-36900071,CDM,12002,CPT,369,RC,,,outpatient,,,505,353.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,130.6435,113.3725,1592,percent of total billed charges,,,
HC Resuperf Wnd Body 7.6-12.5 Cm,PX-36900072,CDM,12004,CPT,369,RC,,,outpatient,,,445,311.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,115.1215,99.9025,1592,percent of total billed charges,,,
HC Resuperf Wnd Body 12.6-20 Cm,PX-36900839,CDM,12005,CPT,369,RC,,,outpatient,,,513,359.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,132.7131,115.1685,1592,percent of total billed charges,,,
HC Resuperf Wnd Body 20.1-30 Cm,PX-36900840,CDM,12006,CPT,369,RC,,,outpatient,,,648,453.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,167.6376,145.476,1592,percent of total billed charges,,,
HC Resuperf Wnd Body >30 Cm,PX-36900841,CDM,12007,CPT,369,RC,,,outpatient,,,425,297.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,109.9475,95.4125,1592,percent of total billed charges,,,
HC Simple Repair F/E/E/N/L/M 2.5cm/<,PX-36900758,CDM,12011,CPT,369,RC,,,outpatient,,,329,230.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,85.1123,73.8605,1592,percent of total billed charges,,,
HC Resuperf Wnd Face 2.6-5 Cm,PX-36900842,CDM,12013,CPT,369,RC,,,outpatient,,,400,280,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,103.48,89.8,1592,percent of total billed charges,,,
HC Resuperf Wnd Face 5.1-7.5 Cm,PX-36900843,CDM,12014,CPT,369,RC,,,outpatient,,,479,335.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,123.9173,107.5355,1592,percent of total billed charges,,,
HC Resuperf Wnd Face 7.6-12.5 Cm,PX-36900844,CDM,12015,CPT,369,RC,,,outpatient,,,633,443.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,163.7571,142.1085,1592,percent of total billed charges,,,
HC Resuperf Wnd Face 12.6-20 Cm,PX-36900845,CDM,12016,CPT,369,RC,,,outpatient,,,779,545.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,201.5273,174.8855,1592,percent of total billed charges,,,
HC Simple Repair Suprfcl Wnds F/E/E/N/L/Mucs Membrnes;20.1-30.0 Cm,PX-36900846,CDM,12017,CPT,369,RC,,,outpatient,,,555,388.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,143.5785,124.5975,1592,percent of total billed charges,,,
HC Simple Repair Suprfcl Wnds F/E/E/N/L/Mucs Membrnes;Over 30.0 Cm,PX-36900847,CDM,12018,CPT,369,RC,,,outpatient,,,448,313.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,115.8976,100.576,1592,percent of total billed charges,,,
HC Closure Superf Wnd Dehis Simple,PX-36900848,CDM,12020,CPT,369,RC,,,outpatient,,,1377,963.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,356.2299,309.1365,1592,percent of total billed charges,,,
HC Closure Superf Wnd Dehis W Packing,PX-36900849,CDM,12021,CPT,369,RC,,,outpatient,,,809,566.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,209.2883,181.6205,1592,percent of total billed charges,,,
HC Repair Intermediate S/a/T/E 2.5 Cm/<,PX-36900757,CDM,12031,CPT,369,RC,,,outpatient,,,891,623.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,230.5017,200.0295,1592,percent of total billed charges,,,
HC Layr Clos Wnd Trunk-Arm-Leg 2.6-7.5 Cm,PX-36900850,CDM,12032,CPT,369,RC,,,outpatient,,,505,353.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,130.6435,113.3725,1592,percent of total billed charges,,,
HC Layr Clos Wnd Trunk-Arm-Leg 7.6-12.5 Cm,PX-36900851,CDM,12034,CPT,369,RC,,,outpatient,,,685,479.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,177.2095,153.7825,1592,percent of total billed charges,,,
HC Layr Clos Wnd Trunk-Arm-Leg 12.6-20 Cm,PX-36900852,CDM,12035,CPT,369,RC,,,outpatient,,,685,479.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,177.2095,153.7825,1592,percent of total billed charges,,,
HC Layr Clos Wnd Trunk-Arm-Leg 20.1-30 Cm,PX-36900853,CDM,12036,CPT,369,RC,,,outpatient,,,649,454.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,167.8963,145.7005,1592,percent of total billed charges,,,
HC Layr Clos Wnd Trunk-Arm-Leg >30 Cm,PX-36900854,CDM,12037,CPT,369,RC,,,outpatient,,,4504,3152.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1165.1848,399.86,3459.072,percent of total billed charges,,,
HC Repair Intermediate N/H/F/Xtrnl Gent 2.5cm/<,PX-36900756,CDM,12041,CPT,369,RC,,,outpatient,,,634,443.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,164.0158,142.333,1592,percent of total billed charges,,,
HC Repair Intermediate Neck/Hand/Feet/Xtrnl Gent 2.6-7.5 Cm,PX-36900806,CDM,12042,CPT,369,RC,,,outpatient,,,633,443.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,163.7571,142.1085,1592,percent of total billed charges,,,
HC Layr Clos Wnd Rest Body 7.6-12.5 Cm,PX-36900855,CDM,12044,CPT,369,RC,,,outpatient,,,623,436.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,161.1701,139.8635,1592,percent of total billed charges,,,
HC Layr Clos Wnd Rest Body 12.6-20 Cm,PX-36900856,CDM,12045,CPT,369,RC,,,outpatient,,,627,438.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,162.2049,140.7615,1592,percent of total billed charges,,,
HC Layr Clos Wnd Rest Body 20.1-30 Cm,PX-36900857,CDM,12046,CPT,369,RC,,,outpatient,,,1056,739.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,273.1872,237.072,2141,percent of total billed charges,,,
HC Repair Intermediate N/H/F/Xtrnl Gent >30.0 Cm,PX-36900858,CDM,12047,CPT,369,RC,,,outpatient,,,5238,3666.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1355.0706,399.86,4022.784,percent of total billed charges,,,
HC Repair Intermediate F/E/E/N/L&/Muc 2.5 Cm/<,PX-36900755,CDM,12051,CPT,369,RC,,,outpatient,,,891,623.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,230.5017,200.0295,1592,percent of total billed charges,,,
HC Layr Clos Wnd Face-Facial 2.5-5 Cm,PX-36900859,CDM,12052,CPT,369,RC,,,outpatient,,,596,417.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,154.1852,133.802,1592,percent of total billed charges,,,
HC Layr Clos Wnd Face-Facial 5.1-7.5 Cm,PX-36900860,CDM,12053,CPT,369,RC,,,outpatient,,,663,464.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,171.5181,148.8435,1592,percent of total billed charges,,,
HC Layr Clos Wnd Face-Facial 7.6-12.5 Cm,PX-36900861,CDM,12054,CPT,369,RC,,,outpatient,,,652,456.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,168.6724,146.374,1592,percent of total billed charges,,,
HC Layr Clos Wnd Face-Facial 12.6-20 Cm,PX-36900862,CDM,12055,CPT,369,RC,,,outpatient,,,749,524.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,193.7663,168.1505,1592,percent of total billed charges,,,
HC Layr Clos Wnd Face-Facial 20.1-30 Cm,PX-36900863,CDM,12056,CPT,369,RC,,,outpatient,,,1419,993.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,367.0953,318.5655,1592,percent of total billed charges,,,
HC Repair Intermediate F/E/E/N/L&/Muc >30.0 Cm,PX-36900864,CDM,12057,CPT,369,RC,,,outpatient,,,1132,792.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,292.8484,254.134,1592,percent of total billed charges,,,
HC Repair Complex Trunk 1.1-2.5 Cm,PX-36900788,CDM,13100,CPT,369,RC,,,outpatient,,,1831,1281.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,473.6797,399.86,1592,percent of total billed charges,,,
HC Recmpl Wnd Trunk 2.6-7.5 Cm,PX-36900865,CDM,13101,CPT,369,RC,,,outpatient,,,1090,763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,281.983,244.705,1592,percent of total billed charges,,,
HC Rep-Skin-Trunk-Cmplx-+5 Cm/<,PX-36900866,CDM,13102,CPT,369,RC,,,outpatient,,,250,175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,64.675,56.125,1592,percent of total billed charges,,,
HC Repair Complex Scalp/Arm/Leg 1.1-2.5 Cm,PX-36900754,CDM,13120,CPT,369,RC,,,outpatient,,,1761,1232.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,455.5707,395.3445,1592,percent of total billed charges,,,
HC Recmpl Wnd Scalp-Extr 2.6-7.5 Cm,PX-36900867,CDM,13121,CPT,369,RC,,,outpatient,,,735,514.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,190.1445,165.0075,1592,percent of total billed charges,,,
HC Rep-Skin-Scalp/Extrem+5 Cm/<,PX-36900868,CDM,13122,CPT,369,RC,,,outpatient,,,305,213.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,78.9035,68.4725,1592,percent of total billed charges,,,
HC Repair Complex F/C/C/M/N/Ax/G/H/F 1.1-2.5 Cm,PX-36900753,CDM,13131,CPT,369,RC,,,outpatient,,,1145,801.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,296.2115,257.0525,1592,percent of total billed charges,,,
HC Recmpl Wnd Head-Fac-Hand 2.6-7.5 Cm,PX-36900869,CDM,13132,CPT,369,RC,,,outpatient,,,723,506.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,187.0401,162.3135,1592,percent of total billed charges,,,
HC Repr-Face-Genital-Hand-Ft+5 Cmcm/<,PX-36900870,CDM,13133,CPT,369,RC,,,outpatient,,,578,404.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,149.5286,129.761,1592,percent of total billed charges,,,
HC Repair Complex Eyelid/Nose/Ear/Lip 1.1-2.5 Cm,PX-36900752,CDM,13151,CPT,369,RC,,,outpatient,,,1761,1232.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,455.5707,395.3445,1592,percent of total billed charges,,,
HC Recmpl Wnd Lid-Nos-Ear 2.5-7.5 Cm,PX-36900871,CDM,13152,CPT,369,RC,,,outpatient,,,743,520.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,192.2141,166.8035,1592,percent of total billed charges,,,
HC Repr-Eyelid-Nose-Ear-Lip+5 Cm,PX-36900872,CDM,13153,CPT,369,RC,,,outpatient,,,462,323.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,119.5194,103.719,1592,percent of total billed charges,,,
HC Secd Clos Surg Wnd Exten/Complic,PX-36900873,CDM,13160,CPT,369,RC,,,outpatient,,,4504,3152.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1165.1848,399.86,3459.072,percent of total billed charges,,,
HC Dressing Change Under Anesthesia,PX-36900774,CDM,15852,CPT,369,RC,,,outpatient,,,1831,1281.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,473.6797,108.7,1592,percent of total billed charges,,,
HC Exc Coccyx/Ulcer W Suture,PX-36900598,CDM,15920,CPT,369,RC,,,outpatient,,,3425,2397.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,886.0475,399.86,4341.777195,percent of total billed charges,,,
HC Exc Sacr Press Ulc W Pri Suture,PX-36900599,CDM,15931,CPT,369,RC,,,outpatient,,,7558,5290.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1955.2546,399.86,5804.544,percent of total billed charges,,,
HC Exc Sacr Press Ulc W Flap Clos,PX-36900600,CDM,15934,CPT,369,RC,,,outpatient,,,9536,6675.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2466.9632,399.86,7323.648,percent of total billed charges,,,
HC Exc Sacr Press Ulc W Musc Flap Clo,PX-36900601,CDM,15936,CPT,369,RC,,,outpatient,,,5831,4081.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1508.4797,399.86,4478.208,percent of total billed charges,,,
HC Exc Isch Pres Ulc W Prim Clos,PX-36900602,CDM,15940,CPT,369,RC,,,outpatient,,,7558,5290.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1955.2546,399.86,5804.544,percent of total billed charges,,,
HC Exc Isch Pres Ulc W Flap Clos,PX-36900603,CDM,15944,CPT,369,RC,,,outpatient,,,5831,4081.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1508.4797,399.86,5481.863562,percent of total billed charges,,,
HC Exc Isch Pres Ulc Bone Myocut Flap,PX-36900604,CDM,15946,CPT,369,RC,,,outpatient,,,9536,6675.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2466.9632,399.86,7323.648,percent of total billed charges,,,
HC Exc Troc Pres Ulc W Prim Clos,PX-36900605,CDM,15950,CPT,369,RC,,,outpatient,,,7558,5290.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1955.2546,399.86,5804.544,percent of total billed charges,,,
HC Initial Tx 1st Degree Burn Local Tx,PX-36900591,CDM,16000,CPT,369,RC,,,outpatient,,,393,275.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,101.6691,88.2285,1592,percent of total billed charges,,,
HC Dress/Debrid Small Burn No Anes,PX-36900090,CDM,16020,CPT,369,RC,,,outpatient,,,812,568.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,210.0644,182.294,1592,percent of total billed charges,,,
HC Dress/Debrid Med Burn No Anesth,PX-36900091,CDM,16025,CPT,369,RC,,,outpatient,,,812,568.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,210.0644,182.294,1592,percent of total billed charges,,,
HC Dress/Debrid Large Burn No Anesth,PX-36900092,CDM,16030,CPT,369,RC,,,outpatient,,,845,591.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,218.6015,189.7025,1592,percent of total billed charges,,,
HC Escharotomy Each Additional Incision,PX-36900883,CDM,16036,CPT,369,RC,,,outpatient,,,670,469,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,173.329,150.415,2998,percent of total billed charges,,,
HC Destruc Cut/Vasc 10-50 Sqcm,PX-36900094,CDM,17107,CPT,369,RC,,,outpatient,,,1763,1234.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,456.0881,395.7935,1592,percent of total billed charges,,,
HC Punc/Aspir Breast Cyst,PX-36900096,CDM,19000,CPT,369,RC,,,outpatient,,,1637,1145.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,423.4919,367.5065,2141,percent of total billed charges,,,
HC Puct/Aspir Breast Cyst-Each Addn,PX-36900097,CDM,19001,CPT,369,RC,,,outpatient,,,60,42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,13.47,1592,other,Non-Reimbursable Procedures,,
HC Bx Breast W Device 1st Lesion Stereotactic Guide,PX-36900099,CDM,19081,CPT,369,RC,,,outpatient,,,4317,3021.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1116.8079,399.86,3315.456,percent of total billed charges,,,
HC Bx Breast W Device Addl Lesion Stereotact Guide,PX-36900100,CDM,19082,CPT,369,RC,,,outpatient,,,3998,2798.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,3070.464,other,Non-Reimbursable Procedures,,
HC Bx Breast W Device 1st Lesion Ultrasound Guide,PX-36900101,CDM,19083,CPT,369,RC,,,outpatient,,,3271,2289.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,846.2077,399.86,2998,percent of total billed charges,,,
HC Bx Breast W Device Addl Lesion Ultrasound Guide,PX-36900102,CDM,19084,CPT,369,RC,,,outpatient,,,2336,1635.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,1794.048,other,Non-Reimbursable Procedures,,
HC Bx Breast W Device 1st Lesion Magnetic Res Guide,PX-36900103,CDM,19085,CPT,369,RC,,,outpatient,,,5120,3584,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1324.544,399.86,3932.16,percent of total billed charges,,,
HC Bx Breast W Device Addl Lesion Magnet Res Guide,PX-36900104,CDM,19086,CPT,369,RC,,,outpatient,,,2232,1562.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,1714.176,other,Non-Reimbursable Procedures,,
HC Perq Device Placemt Breast Loc 1st Les W Guidnce,PX-36900106,CDM,19281,CPT,369,RC,,,outpatient,,,915,640.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,236.7105,108.7,2998,percent of total billed charges,,,
HC Perq Device Placemt Breast Loc Ea Les W Guidnce,PX-36900107,CDM,19282,CPT,369,RC,,,outpatient,,,880,616,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,197.56,1592,other,Non-Reimbursable Procedures,,
HC Perq Breast Loc Device Placemt 1st Strtctc Guid,PX-36900108,CDM,19283,CPT,369,RC,,,outpatient,,,2116,1481.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,547.4092,108.7,2141,percent of total billed charges,,,
HC Perq Breast Loc Device Placemt Ea Lesion Strtctc,PX-36900109,CDM,19284,CPT,369,RC,,,outpatient,,,84,58.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,18.858,1592,other,Non-Reimbursable Procedures,,
HC Perq Breast Loc Device Placemt 1st Lesio US Imag,PX-36900110,CDM,19285,CPT,369,RC,,,outpatient,,,1175,822.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,303.9725,108.7,2141,percent of total billed charges,,,
HC Perq Breast Loc Device Placemt Each Les US Image,PX-36900111,CDM,19286,CPT,369,RC,,,outpatient,,,274,191.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,61.513,1592,other,Non-Reimbursable Procedures,,
HC Perq Breast Loc Device Placemt 1st Lesio MR Guid,PX-36900112,CDM,19287,CPT,369,RC,,,outpatient,,,2116,1481.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,547.4092,108.7,2141,percent of total billed charges,,,
HC Place Postop Breast Cath for Rad,PX-36900114,CDM,19296,CPT,369,RC,,,outpatient,,,14045,9831.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3633.4415,399.86,14403.82399,percent of total billed charges,,,
HC Muscle Biopsy,PX-36900115,CDM,20200,CPT,369,RC,,,outpatient,,,3700,2590,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,957.19,399.86,2998,percent of total billed charges,,,
HC Biopsy Muscle Deep,PX-36900764,CDM,20205,CPT,369,RC,,,outpatient,,,9022,6315.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2333.9914,399.86,6928.896,percent of total billed charges,,,
HC Needle Biopsy-Muscle,PX-36900116,CDM,20206,CPT,369,RC,,,outpatient,,,3700,2590,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,957.19,399.86,2998,percent of total billed charges,,,
HC Bone Biopsy-Trocar/Needle Superf,PX-36900117,CDM,20220,CPT,369,RC,,,outpatient,,,3847,2692.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,995.2189,399.86,2954.496,percent of total billed charges,,,
HC Bone Biopsy-Trocar/Needle Deep,PX-36900118,CDM,20225,CPT,369,RC,,,outpatient,,,3700,2590,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,957.19,399.86,2998,percent of total billed charges,,,
HC Biopsy Bone Open Superficial,PX-36900770,CDM,20240,CPT,369,RC,,,outpatient,,,9022,6315.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2333.9914,399.86,6928.896,percent of total billed charges,,,
HC Biopsy Bone Open Deep,PX-36900769,CDM,20245,CPT,369,RC,,,outpatient,,,9022,6315.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2333.9914,399.86,6928.896,percent of total billed charges,,,
HC Inject Sinus Tract for Dx W Xray,PX-36900120,CDM,20501,CPT,369,RC,,,outpatient,,,1451,1015.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,235.074116,1592,other,Non-Reimbursable Procedures,,
HC Removal Foreign Body Muscle/Tendon Sheath Simple,PX-36900749,CDM,20520,CPT,369,RC,,,outpatient,,,5218,3652.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1349.8966,399.86,4007.424,percent of total billed charges,,,
HC Rmvl Foreign Body Muscle/Tendon Sheath Deep/Comp,PX-36900748,CDM,20525,CPT,369,RC,,,outpatient,,,5793,4055.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1498.6491,399.86,4449.024,percent of total billed charges,,,
HC Injection of Tendon Sheath,PX-36900693,CDM,20550,CPT,369,RC,,,outpatient,,,823,576.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,212.9101,184.7635,1592,percent of total billed charges,,,
HC Injection Single Tendon Origin/Insertion,PX-36900793,CDM,20551,CPT,369,RC,,,outpatient,,,903,632.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,233.6061,202.7235,1592,percent of total billed charges,,,
HC Inject Trigger Point- 1 or 2,PX-36900123,CDM,20552,CPT,369,RC,,,outpatient,,,658,460.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,170.2246,147.721,1592,percent of total billed charges,,,
HC Drain/Inject Small Joint/Bursa,PX-36100004,CDM,20600,CPT,361,RC,,,outpatient,,,714,499.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,184.7118,160.293,1592,percent of total billed charges,,,
HC Drain/Inject Small Joint/Bursa,PX-36900125,CDM,20600,CPT,369,RC,,,outpatient,,,714,499.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,184.7118,160.293,1592,percent of total billed charges,,,
HC Arthrocnt Aspir&/Inj Small Jt/Bursaw/US Rec Rprt,PX-36900787,CDM,20604,CPT,369,RC,,,outpatient,,,938,656.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,242.6606,210.581,1592,percent of total billed charges,,,
HC Drain/Inject Intermediate Joint/Bursa,PX-36100005,CDM,20605,CPT,361,RC,,,outpatient,,,753,527.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,194.8011,169.0485,1592,percent of total billed charges,,,
HC Drain/Inject Intermediate Joint/Bursa,PX-36900126,CDM,20605,CPT,369,RC,,,outpatient,,,753,527.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,194.8011,169.0485,1592,percent of total billed charges,,,
HC Arthrocentesis Aspir&/Inj Interm Jt/Burs W/US,PX-36100030,CDM,20606,CPT,361,RC,,,outpatient,,,1844,1290.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,477.0428,399.86,2141,percent of total billed charges,,,
HC Drain/Inject Large Joint/Bursa,PX-36100006,CDM,20610,CPT,361,RC,,,outpatient,,,658,460.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,170.2246,147.721,1592,percent of total billed charges,,,
HC Drain/Inject Large Joint/Bursa,PX-36900127,CDM,20610,CPT,369,RC,,,outpatient,,,658,460.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,170.2246,147.721,1592,percent of total billed charges,,,
HC Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US,PX-36100031,CDM,20611,CPT,361,RC,,,outpatient,,,784,548.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,202.8208,176.008,1592,percent of total billed charges,,,
HC Ablate- Bone Tumor(S) Perq,PX-36900128,CDM,20982,CPT,369,RC,,,outpatient,,,16473,11531.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4261.5651,399.86,20110.10933,percent of total billed charges,,,
HC Biopsy Soft Tissue Neck/Chest,PX-36900130,CDM,21550,CPT,369,RC,,,outpatient,,,4796,3357.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1240.7252,399.86,3683.328,percent of total billed charges,,,
HC Vertebroplasty Each Addl Cervicothor/Lumbosacral,PX-36900134,CDM,22512,CPT,369,RC,,,outpatient,,,1695,1186.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,380.5275,1592,other,Non-Reimbursable Procedures,,
HC Biopsy Soft Tissue Shoulder Superficial,PX-36900138,CDM,23065,CPT,369,RC,,,outpatient,,,2502,1751.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,647.2674,399.86,2477.315575,percent of total billed charges,,,
HC Inj Proc Shoulder Arthrography/CT/MRI,PX-36900139,CDM,23350,CPT,369,RC,,,outpatient,,,1114,779.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,235.074116,1592,other,Non-Reimbursable Procedures,,
HC Clsd Tx Shoulder Dislc W/Manipulation W/O Anes,PX-36900581,CDM,23650,CPT,369,RC,,,outpatient,,,735,514.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,190.1445,165.0075,1592,percent of total billed charges,,,
HC Clsd Tx Shoulder Dislc W/Manipulation Req Anes,PX-36900582,CDM,23655,CPT,369,RC,,,outpatient,,,3604,2522.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,932.3548,399.86,2998,percent of total billed charges,,,
HC I&D Upper Arm/Elbow Deep Abscess/Hematoma,PX-36900784,CDM,23930,CPT,369,RC,,,outpatient,,,5218,3652.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1349.8966,399.86,4341.777195,percent of total billed charges,,,
HC Incision&Drainage Upper Arm/Elbow Bursa,PX-36900751,CDM,23931,CPT,369,RC,,,outpatient,,,3342,2339.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,864.5754,399.86,2998,percent of total billed charges,,,
HC Biopsy Soft Tissue Upper Arm/Elbow Superficial,PX-36900768,CDM,24065,CPT,369,RC,,,outpatient,,,5218,3652.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1349.8966,399.86,4007.424,percent of total billed charges,,,
HC Biopsy Soft Tissue Upper Arm/Elbow Area Deep,PX-36900767,CDM,24066,CPT,369,RC,,,outpatient,,,9022,6315.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2333.9914,399.86,6928.896,percent of total billed charges,,,
HC Injection for Elbow Arthrogram,PX-36900143,CDM,24220,CPT,369,RC,,,outpatient,,,1224,856.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,274.788,1592,other,Non-Reimbursable Procedures,,
HC I&D Forearm&/Wrist Deep Abscess/Hematoma,PX-36900782,CDM,25028,CPT,369,RC,,,outpatient,,,9952,6966.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2574.5824,399.86,7643.136,percent of total billed charges,,,
HC Incision & Drainage Forearm&/Wrist Bursa,PX-36900783,CDM,25031,CPT,369,RC,,,outpatient,,,4983,3488.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1289.1021,399.86,3826.944,percent of total billed charges,,,
HC Incision Deep Bone Cortex Forearm&/Wrist,PX-36900785,CDM,25035,CPT,369,RC,,,outpatient,,,21621,15134.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5593.3527,399.86,16604.928,percent of total billed charges,,,
HC Arthrt Rdcrpl/Midcarpl Jt W/Expl Drg/Rmvl FB,PX-36900778,CDM,25040,CPT,369,RC,,,outpatient,,,9952,6966.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2574.5824,399.86,7643.136,percent of total billed charges,,,
HC Biopsy Soft Tissue Forearm&/Wrist Superficial,PX-36900766,CDM,25065,CPT,369,RC,,,outpatient,,,5218,3652.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1349.8966,399.86,4007.424,percent of total billed charges,,,
HC Biopsy Soft Tissue Forearm&/Wrist Deep,PX-36900765,CDM,25066,CPT,369,RC,,,outpatient,,,9022,6315.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2333.9914,399.86,6928.896,percent of total billed charges,,,
HC Injection for Wrist Arthrogram,PX-36900149,CDM,25246,CPT,369,RC,,,outpatient,,,1660,1162,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,235.074116,1592,other,Non-Reimbursable Procedures,,
HC Cltx Dstl Rdl Fx/Epiphysl Sep W/Manj When Perf,PX-36900792,CDM,25605,CPT,369,RC,,,outpatient,,,2563,1794.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,663.0481,399.86,2455.793921,percent of total billed charges,,,
HC Drainage Finger Abscess Complicated,PX-36900750,CDM,26011,CPT,369,RC,,,outpatient,,,2563,1794.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,663.0481,399.86,2998,percent of total billed charges,,,
HC Drainage Tendon Sheath Digit&/Palm Each,PX-36900781,CDM,26020,CPT,369,RC,,,outpatient,,,9952,6966.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2574.5824,399.86,7643.136,percent of total billed charges,,,
HC Drainage of Palmar Bursa Single Bursa,PX-36900780,CDM,26025,CPT,369,RC,,,outpatient,,,9952,6966.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2574.5824,399.86,7643.136,percent of total billed charges,,,
HC Drainage of Palmar Bursa Multiple Bursa,PX-36900779,CDM,26030,CPT,369,RC,,,outpatient,,,9952,6966.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2574.5824,399.86,7643.136,percent of total billed charges,,,
HC Incision Bone Cortex Hand/Finger,PX-36900786,CDM,26034,CPT,369,RC,,,outpatient,,,4983,3488.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1289.1021,399.86,3826.944,percent of total billed charges,,,
HC Arthrt Expl Drg/Rmvl Loose/FB Carp/Mtcrpl Jt,PX-36900775,CDM,26070,CPT,369,RC,,,outpatient,,,4983,3488.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1289.1021,399.86,3826.944,percent of total billed charges,,,
HC Arthrt Expl Drg/Rmvl Loose/FB Mtcarphlngl Jt Ea,PX-36900777,CDM,26075,CPT,369,RC,,,outpatient,,,9952,6966.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2574.5824,399.86,7643.136,percent of total billed charges,,,
HC Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea,PX-36900776,CDM,26080,CPT,369,RC,,,outpatient,,,4983,3488.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1289.1021,399.86,3826.944,percent of total billed charges,,,
HC Bx Soft Tissues-Pelv/Hip-Superficl,PX-36900160,CDM,27040,CPT,369,RC,,,outpatient,,,3700,2590,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,957.19,399.86,2841.6,percent of total billed charges,,,
HC Bx Soft Tissues-Pelv/Hip-Deep,PX-36900161,CDM,27041,CPT,369,RC,,,outpatient,,,3700,2590,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,957.19,399.86,2841.6,percent of total billed charges,,,
HC Injection Hip Arthrogram,PX-36900162,CDM,27093,CPT,369,RC,,,outpatient,,,1589,1112.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,235.074116,1592,other,Non-Reimbursable Procedures,,
HC Closed Rx Prox/Neck Femur Fx-Manip,PX-36900886,CDM,27232,CPT,369,RC,,,outpatient,,,3499,2449.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,905.1913,399.86,2998,percent of total billed charges,,,
HC Cltx Hip Dislocation Traumatic W/O Anesthesia,PX-36900583,CDM,27250,CPT,369,RC,,,outpatient,,,902,631.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,233.3474,202.499,1592,percent of total billed charges,,,
HC Cltx Hip Dislocation Traumatic Req Anesthesia,PX-36900584,CDM,27252,CPT,369,RC,,,outpatient,,,2848,1993.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,736.7776,399.86,2455.793921,percent of total billed charges,,,
HC Cltx Post Hip Arthrp Dislc W/O Anes,PX-36900585,CDM,27265,CPT,369,RC,,,outpatient,,,671,469.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,173.5877,150.6395,1592,percent of total billed charges,,,
HC Cltx Post Hip Arthrp Dislc Req Anes,PX-36900586,CDM,27266,CPT,369,RC,,,outpatient,,,2045,1431.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,529.0415,399.86,2998,percent of total billed charges,,,
HC Unlisted Procedure Pelvis/Hip Joint,PX-36900700,CDM,27299,CPT,369,RC,,,outpatient,,,715,500.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,184.9705,160.5175,1592,percent of total billed charges,,,
HC I&D Deep Absc Bursa/Hematoma Thigh/Knee Region,PX-36900814,CDM,27301,CPT,369,RC,,,outpatient,,,7663,5364.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1982.4181,399.86,5885.184,percent of total billed charges,,,
HC Injection Knee Arthrography,PX-36900731,CDM,27369,CPT,369,RC,,,outpatient,,,1446,1012.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,324.627,1592,other,Non-Reimbursable Procedures,,
HC Injection for Ankle Arthrogram,PX-36900167,CDM,27648,CPT,369,RC,,,outpatient,,,834,583.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,187.233,1592,other,Non-Reimbursable Procedures,,
HC Closed Tx Bimalleolar Ankle Fracture W/Manj,PX-36900880,CDM,27810,CPT,369,RC,,,outpatient,,,3663,2564.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,947.6181,292.65,2813.184,percent of total billed charges,,,
HC Application Cast Shoulder Hand Long Arm,PX-36900741,CDM,29065,CPT,369,RC,,,outpatient,,,664,464.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,171.7768,149.068,1592,percent of total billed charges,,,
HC Application Cast Elbow Finger Short Arm,PX-36900739,CDM,29075,CPT,369,RC,,,outpatient,,,893,625.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,231.0191,200.4785,1592,percent of total billed charges,,,
HC Application Cast Hand & Lower Forearm Gauntlet,PX-36900740,CDM,29085,CPT,369,RC,,,outpatient,,,491,343.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,127.0217,110.2295,1592,percent of total billed charges,,,
HC Application Cast Finger,PX-36900771,CDM,29086,CPT,369,RC,,,outpatient,,,511,357.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,132.1957,114.7195,1592,percent of total billed charges,,,
HC Application Long Arm Splint Shoulder Hand,PX-36900759,CDM,29105,CPT,369,RC,,,outpatient,,,453,317.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,117.1911,101.6985,1592,percent of total billed charges,,,
HC Application Short Arm Splint Forearm-Hand Static,PX-36900576,CDM,29125,CPT,369,RC,,,outpatient,,,354,247.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,91.5798,79.473,1592,percent of total billed charges,,,
HC Application Short Arm Splint Dynamic,PX-36900577,CDM,29126,CPT,369,RC,,,outpatient,,,354,247.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,91.5798,79.473,1592,percent of total billed charges,,,
HC Application Finger Splint Static,PX-36900579,CDM,29130,CPT,369,RC,,,outpatient,,,221,154.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,57.1727,49.6145,1592,percent of total billed charges,,,
HC Application Finger Splint Dynamic,PX-36900580,CDM,29131,CPT,369,RC,,,outpatient,,,218,152.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,56.3966,48.941,1592,percent of total billed charges,,,
HC Strapping Shoulder,PX-36900761,CDM,29240,CPT,369,RC,,,outpatient,,,405,283.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,104.7735,90.9225,1592,percent of total billed charges,,,
HC Strapping Elbow/Wrist,PX-36900760,CDM,29260,CPT,369,RC,,,outpatient,,,122,85.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,31.5614,27.389,1592,percent of total billed charges,,,
HC Strapping Hand/Finger,PX-36900790,CDM,29280,CPT,369,RC,,,outpatient,,,122,85.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,31.5614,27.389,1592,percent of total billed charges,,,
HC Application Short Leg Cast Below Knee-Toe,PX-36900818,CDM,29405,CPT,369,RC,,,outpatient,,,699,489.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,180.8313,156.9255,1592,percent of total billed charges,,,
HC Application Long Leg Splint Thigh Ankle/Toes,PX-36900737,CDM,29505,CPT,369,RC,,,outpatient,,,554,387.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,143.3198,124.373,1592,percent of total billed charges,,,
HC Application Short Leg Splint Calf Foot,PX-36900578,CDM,29515,CPT,369,RC,,,outpatient,,,354,247.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,91.5798,79.473,1592,percent of total billed charges,,,
HC Ctrl Nosebleed-Anter-Simple,PX-36900181,CDM,30901,CPT,369,RC,,,outpatient,,,347,242.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,89.7689,77.9015,1592,percent of total billed charges,,,
HC PR Control Nasal Hemorrhage Anterior Simple,PX-96000041,CDM,30901,CPT,960,RC,,,outpatient,,,347,242.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,89.7689,77.9015,1592,percent of total billed charges,,,
HC Control Nasal Hemorrhage Anterior Complex,PX-36900745,CDM,30903,CPT,369,RC,,,outpatient,,,289,202.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,74.7643,64.8805,1592,percent of total billed charges,,,
HC PR Control Nasal Hemorrhage Anterior Complex,PX-96000042,CDM,30903,CPT,960,RC,,,outpatient,,,289,202.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,74.7643,64.8805,1592,percent of total billed charges,,,
HC Ctrl Nsl Hemrrg Pst Nasal Packs&/Cautery 1st,PX-36900746,CDM,30905,CPT,369,RC,,,outpatient,,,486,340.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,125.7282,109.107,1592,percent of total billed charges,,,
HC Ctrl Nsl Hemrrg Pst Nasal Packs&/Cautery Subsq,PX-36900747,CDM,30906,CPT,369,RC,,,outpatient,,,510,357,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,131.937,114.495,1592,percent of total billed charges,,,
HC Insert Emergency Endotrach Airway,PX-36100007,CDM,31500,CPT,361,RC,,,outpatient,,,544,380.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,140.7328,122.128,1592,percent of total billed charges,,,
HC Insert Emergency Endotrach Airway,PX-36900182,CDM,31500,CPT,369,RC,,,outpatient,,,544,380.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,140.7328,122.128,1592,percent of total billed charges,,,
HC PR Intubation Endotracheal Emergency Procedure,PX-96000038,CDM,31500,CPT,960,RC,,,outpatient,,,544,380.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,140.7328,122.128,1592,percent of total billed charges,,,
HC Trach Tube Change,PX-36900183,CDM,31502,CPT,369,RC,,,outpatient,,,615,430.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,159.1005,138.0675,1592,percent of total billed charges,,,
HC Laryngoscopy-Flex Fiber-Diagnostic,PX-36900185,CDM,31575,CPT,369,RC,,,outpatient,,,371,259.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,95.9777,83.2895,1592,percent of total billed charges,,,
HC Bronchoscopy-Diagnostic,PX-36900187,CDM,31622,CPT,369,RC,,,outpatient,,,3151,2205.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,815.1637,399.86,2998,percent of total billed charges,,,
HC Bronchoscopy-Diagnostic W Brush,PX-36900188,CDM,31623,CPT,369,RC,,,outpatient,,,3150,2205,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,814.905,399.86,2998,percent of total billed charges,,,
HC Brnchsc W/Brncl Alveolar Lavage,PX-36900896,CDM,31624,CPT,369,RC,,,outpatient,,,3935,2754.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1017.9845,399.86,3022.08,percent of total billed charges,,,
HC Bronchoscopy-Biopsy,PX-36900189,CDM,31625,CPT,369,RC,,,outpatient,,,3271,2289.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,846.2077,399.86,2998,percent of total billed charges,,,
HC Needle Biopsy Pleura,PX-36900190,CDM,32400,CPT,369,RC,,,outpatient,,,3700,2590,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,957.19,399.86,2998,percent of total billed charges,,,
HC Core Needle Bx Lung/Mediastinum Perq W/Img,PX-36900808,CDM,32408,CPT,369,RC,,,outpatient,,,4594,3215.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1188.4678,399.86,3528.192,percent of total billed charges,,,
HC Insertion Indwelling Tunneled Pleural Catheter,PX-36900192,CDM,32550,CPT,369,RC,,,outpatient,,,8367,5856.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2164.5429,399.86,6425.856,percent of total billed charges,,,
HC Tube Thoracostomy Includes Water Seal,PX-36100008,CDM,32551,CPT,361,RC,,,outpatient,,,1951,1365.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,504.7237,399.86,2447.133941,percent of total billed charges,,,
HC Tube Thoracostomy Includes Water Seal,PX-36900193,CDM,32551,CPT,369,RC,,,outpatient,,,1951,1365.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,504.7237,399.86,2447.133941,percent of total billed charges,,,
HC Tube Thoracostomy Includes Water Seal,PX-36900573,CDM,32551,CPT,369,RC,,,outpatient,,,1951,1365.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,504.7237,399.86,2447.133941,percent of total billed charges,,,
HC PR Tube Thoracostomy Includes Water Seal,PX-96000039,CDM,32551,CPT,960,RC,,,outpatient,,,1951,1365.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,504.7237,399.86,2447.133941,percent of total billed charges,,,
HC Removal of Indwelling Tunneled Pleural Catheter With Cuff,PX-36900194,CDM,32552,CPT,369,RC,,,outpatient,,,2265,1585.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,585.9555,399.86,2141,percent of total billed charges,,,
HC Perc Place Intra-Thoracic Interstit Rad Therapy Guide- 1/Mult,PX-36900195,CDM,32553,CPT,369,RC,,,outpatient,,,4198,2938.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.0226,399.86,3224.064,percent of total billed charges,,,
HC Thoracentesis Needle/Cath Pleura W/O Imaging,PX-36900196,CDM,32554,CPT,369,RC,,,outpatient,,,1874,1311.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,484.8038,399.86,2141,percent of total billed charges,,,
HC Thoracentesis Needle/Cath Pleura W/Imaging,PX-36100001,CDM,32555,CPT,361,RC,,,outpatient,,,1636,1145.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,423.2332,367.282,2141,percent of total billed charges,,,
HC Thoracentesis Needle/Cath Pleura W/Imaging,PX-36900197,CDM,32555,CPT,369,RC,,,outpatient,,,1636,1145.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,423.2332,367.282,2141,percent of total billed charges,,,
HC Perq Drainage Pleura Insert Cath W/O Imaging,PX-36900742,CDM,32556,CPT,369,RC,,,outpatient,,,2896,2027.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,749.1952,399.86,2998,percent of total billed charges,,,
HC Perq Drainage Pleura Insert Cath W/Imaging,PX-36900198,CDM,32557,CPT,369,RC,,,outpatient,,,1882,1317.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,486.8734,399.86,2447.133941,percent of total billed charges,,,
HC PR Instlj via Chest Tube/Cath Agent for Pleurodesis,PX-96000040,CDM,32560,CPT,960,RC,,,outpatient,,,2265,1585.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,585.9555,399.86,1739.52,percent of total billed charges,,,
HC Instlj via Ch Tube/Cath Agent Fbrnlysis 1st Day,PX-36900826,CDM,32561,CPT,369,RC,,,outpatient,,,1421,994.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,367.6127,319.0145,2141,percent of total billed charges,,,
HC Instlj Ch Tube/Cath Agent Fbrnlysis Sbsq Day,PX-36900827,CDM,32562,CPT,369,RC,,,outpatient,,,1421,994.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,367.6127,319.0145,2141,percent of total billed charges,,,
HC Pericardiocentesis W/Img Guidance When Performed,PX-36100034,CDM,33016,CPT,361,RC,,,outpatient,,,5537,3875.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1432.4219,399.86,4252.416,percent of total billed charges,,,
HC Pericardiocentesis W/Img Guidance When Performed,PX-36900797,CDM,33016,CPT,369,RC,,,outpatient,,,5537,3875.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1432.4219,399.86,4252.416,percent of total billed charges,,,
HC Inser Hart Pacer Xvenous Atrial,PX-36900204,CDM,33206,CPT,369,RC,,,outpatient,,,27344,19140.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7073.8928,399.86,21000.192,percent of total billed charges,,,
HC Inser Hart Pacer Xvenous Ventr,PX-36900205,CDM,33207,CPT,369,RC,,,outpatient,,,36767,25736.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9511.6229,399.86,28237.056,percent of total billed charges,,,
HC Inser Hart Pacer Xvenous Atr/Ventr,PX-36900206,CDM,33208,CPT,369,RC,,,outpatient,,,27344,19140.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7073.8928,399.86,21000.192,percent of total billed charges,,,
HC Inser Heart Temp Pacer One Chmbr,PX-36900207,CDM,33210,CPT,369,RC,,,outpatient,,,21456,15019.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5550.6672,399.86,16478.208,percent of total billed charges,,,
HC Insert Pulse Gener One Chmbr,PX-36900209,CDM,33212,CPT,369,RC,,,outpatient,,,21456,15019.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5550.6672,399.86,16478.208,percent of total billed charges,,,
HC Insert Pulse Gener Dual Chmbr,PX-36900210,CDM,33213,CPT,369,RC,,,outpatient,,,27344,19140.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7073.8928,399.86,21000.192,percent of total billed charges,,,
HC Upgrade of Pacemaker System,PX-36900211,CDM,33214,CPT,369,RC,,,outpatient,,,27344,19140.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7073.8928,399.86,21000.192,percent of total billed charges,,,
HC Reposition Transvenous Electrode,PX-36900212,CDM,33215,CPT,369,RC,,,outpatient,,,4029,2820.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1042.3023,399.86,4870.452937,percent of total billed charges,,,
HC Revise Electrode-Pacing-Dual,PX-36900215,CDM,33217,CPT,369,RC,,,outpatient,,,21456,15019.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5550.6672,399.86,16478.208,percent of total billed charges,,,
HC Reeletrode-Pacing-Single,PX-36900216,CDM,33218,CPT,369,RC,,,outpatient,,,9056,6339.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2342.7872,399.86,6955.008,percent of total billed charges,,,
HC Reelectrode-Pacing-Dual,PX-36900217,CDM,33220,CPT,369,RC,,,outpatient,,,9056,6339.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2342.7872,399.86,6955.008,percent of total billed charges,,,
HC Ins Pacemaker Pulse Gen Only W/Exist Mult Leads,PX-36900218,CDM,33221,CPT,369,RC,,,outpatient,,,48979,34285.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12670.8673,399.86,37615.872,percent of total billed charges,,,
HC Relocation of Skin Pocket for Pacemaker,PX-36900219,CDM,33222,CPT,369,RC,,,outpatient,,,4504,3152.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1165.1848,399.86,3459.072,percent of total billed charges,,,
HC Relocate Skin Pocket Cardioverter-Defibrillator,PX-36900220,CDM,33223,CPT,369,RC,,,outpatient,,,2716,1901.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,702.6292,399.86,2998,percent of total billed charges,,,
HC Insrt Pacing Elect-W/Attach Prev Device,PX-36900221,CDM,33224,CPT,369,RC,,,outpatient,,,27344,19140.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7073.8928,399.86,21000.192,percent of total billed charges,,,
HC Insj Eltrd Car Ven Sys Tm Insj Cvdfb/Pm Pls Gen,PX-36900222,CDM,33225,CPT,369,RC,,,outpatient,,,7571,5299.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6364,other,Non-Reimbursable Procedures,,
HC Reposit Prev Implanted Cardiac Electrode,PX-36900223,CDM,33226,CPT,369,RC,,,outpatient,,,3644,2550.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,942.7028,399.86,4870.452937,percent of total billed charges,,,
HC Remvl Perm Pm Plse Gen W/Repl Plse Gen Sngl Lead,PX-36900224,CDM,33227,CPT,369,RC,,,outpatient,,,17786,12450.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4601.2382,399.86,13659.648,percent of total billed charges,,,
HC Remvl Perm Pm Pls Gen W/Repl Plse Gen 2 Lead Sys,PX-36900225,CDM,33228,CPT,369,RC,,,outpatient,,,19652,13756.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5083.9724,399.86,16316.30039,percent of total billed charges,,,
HC Remvl Perm Pm Pls Gen W/Repl Plse Gen Mult Lead,PX-36900226,CDM,33229,CPT,369,RC,,,outpatient,,,22582,15807.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5841.9634,399.86,29773.2518,percent of total billed charges,,,
HC Ins Pacng Cvdfb Pls Gen Only W/Exist Dual Leads,PX-36900227,CDM,33230,CPT,369,RC,,,outpatient,,,67496,47247.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,17461.2152,399.86,51836.928,percent of total billed charges,,,
HC Ins Pacng Cvdfb Pls Gen Only W/Exist Multi Leads,PX-36900228,CDM,33231,CPT,369,RC,,,outpatient,,,64998,45498.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16814.9826,399.86,50269.54813,percent of total billed charges,,,
HC Remv Perm Pacer Generator,PX-36900229,CDM,33233,CPT,369,RC,,,outpatient,,,21456,15019.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5550.6672,399.86,16478.208,percent of total billed charges,,,
HC Remv Transven Pacer Electrode-1 Lead,PX-36900230,CDM,33234,CPT,369,RC,,,outpatient,,,9056,6339.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2342.7872,399.86,6955.008,percent of total billed charges,,,
HC Remv Transven Pacer Electrode-2 Lead,PX-36900231,CDM,33235,CPT,369,RC,,,outpatient,,,9056,6339.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2342.7872,399.86,6955.008,percent of total billed charges,,,
HC Rmv Pulse Generator-Sngl/Dual,PX-36900233,CDM,33241,CPT,369,RC,,,outpatient,,,9028,6319.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2335.5436,399.86,6933.504,percent of total billed charges,,,
HC Rmv Pacer/Electrd-Transven Extrct,PX-36900234,CDM,33244,CPT,369,RC,,,outpatient,,,9056,6339.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2342.7872,399.86,6955.008,percent of total billed charges,,,
HC Insert Electrd Leads/Repostion,PX-36900235,CDM,33249,CPT,369,RC,,,outpatient,,,86384,60468.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,22347.5408,399.86,66342.912,percent of total billed charges,,,
HC Rem Pac Cvdfb Plse Gen &Repl Plse Gen Sngl Lead,PX-36900236,CDM,33262,CPT,369,RC,,,outpatient,,,63006,44104.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16299.6522,399.86,48388.608,percent of total billed charges,,,
HC Rem Pac Cvdfb Plse Gen &Repl Plse Gen Dual Lead,PX-36900237,CDM,33263,CPT,369,RC,,,outpatient,,,65752,46026.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,17010.0424,399.86,50497.536,percent of total billed charges,,,
HC Rem Pac Cvdfb Pls Gen &Repl Plse Gen Multi Lead,PX-36900238,CDM,33264,CPT,369,RC,,,outpatient,,,65752,46026.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,17010.0424,399.86,50497.536,percent of total billed charges,,,
HC Replace Aortic Valve Perq Femoral Artry Approach,PX-36900544,CDM,33361,CPT,369,RC,,,outpatient,,,27728,19409.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7173.2336,399.86,21295.104,percent of total billed charges,,,
HC Replace Aortic Valve Openfemoral Artery Approach,PX-36900545,CDM,33362,CPT,369,RC,,,outpatient,,,29393,20575.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7603.9691,399.86,24913.5068,percent of total billed charges,,,
HC Replace Aortic Valve Open Axillry Artry Approach,PX-36900546,CDM,33363,CPT,369,RC,,,outpatient,,,27728,19409.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7173.2336,399.86,21295.104,percent of total billed charges,,,
HC Replace Aortic Valve Open Iliac Artery Approach,PX-36900547,CDM,33364,CPT,369,RC,,,outpatient,,,29393,20575.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7603.9691,399.86,22573.824,percent of total billed charges,,,
HC Replace Aortic Valve Open Transaortic Approach,PX-36900548,CDM,33365,CPT,369,RC,,,outpatient,,,29393,20575.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7603.9691,399.86,22573.824,percent of total billed charges,,,
HC Transcatheter Transapical Replacemt Aortic Valve,PX-36900549,CDM,33366,CPT,369,RC,,,outpatient,,,29393,20575.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7603.9691,399.86,24913.5068,percent of total billed charges,,,
HC Replace Aortic Valve W/Byp Prq Art/Venous Apprch,PX-36900550,CDM,33367,CPT,369,RC,,,outpatient,,,27728,19409.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7173.2336,399.86,23502.2528,percent of total billed charges,,,
HC Replace Aortic Valve W/Byp Open Art/Venous Aprch,PX-36900551,CDM,33368,CPT,369,RC,,,outpatient,,,29393,20575.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7603.9691,399.86,24913.5068,percent of total billed charges,,,
HC Replace Aorta Valve W/Byp Cntrl Art/Venous Aprch,PX-36900552,CDM,33369,CPT,369,RC,,,outpatient,,,29393,20575.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7603.9691,399.86,24913.5068,percent of total billed charges,,,
HC Endovasc Taa Reincl Subcl,PX-36900241,CDM,33880,CPT,369,RC,,,outpatient,,,6951,4865.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1798.2237,399.86,5338.368,percent of total billed charges,,,
HC Endovasc Taa Rew/O Subcl,PX-36900242,CDM,33881,CPT,369,RC,,,outpatient,,,5970,4179,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1544.439,399.86,4584.96,percent of total billed charges,,,
HC Insert Endovasc Prosth- Taa,PX-36900243,CDM,33883,CPT,369,RC,,,outpatient,,,4420,3094,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1143.454,399.86,3746.392,percent of total billed charges,,,
HC Endovasc Prosth- Taa- Ea Add,PX-36900244,CDM,33884,CPT,369,RC,,,outpatient,,,1649,1154.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,426.5963,370.2005,2998,percent of total billed charges,,,
HC Endovasc Dist Extens Taa Prosth- Delayed,PX-36900245,CDM,33886,CPT,369,RC,,,outpatient,,,3820,2674,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.234,399.86,3237.832,percent of total billed charges,,,
HC Car-Car Bypass Grft W/ Endovas Taa Repair,PX-36900247,CDM,33891,CPT,369,RC,,,outpatient,,,4194,2935.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1084.9878,399.86,3220.992,percent of total billed charges,,,
HC Remove Pul Art Emboli No Bypass,PX-36900248,CDM,33915,CPT,369,RC,,,outpatient,,,1800,1260,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,465.66,399.86,2998,percent of total billed charges,,,
HC Insert Intra-Aortic Balloon Asst Device,PX-36900249,CDM,33967,CPT,369,RC,,,outpatient,,,2513,1759.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,650.1131,399.86,6913,percent of total billed charges,,,
HC Rmv Aortic Balloon Device,PX-36900250,CDM,33968,CPT,369,RC,,,outpatient,,,139,97.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,35.9593,31.2055,6913,percent of total billed charges,,,
HC Insj Perq Vad W/Rs&I L Hrt Arterial Access Only,PX-36900251,CDM,33990,CPT,369,RC,,,outpatient,,,4109,2876.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.9983,399.86,3155.712,percent of total billed charges,,,
HC Removal Perq Left Hrt Vad Artl/Artl&Ven Sep Insj,PX-36900252,CDM,33992,CPT,369,RC,,,outpatient,,,4188,2931.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1083.4356,399.86,3549.7488,percent of total billed charges,,,
HC Repositioning Perq R/L Vad W/Img Gdn Sep Insj,PX-36900253,CDM,33993,CPT,369,RC,,,outpatient,,,4188,2931.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1083.4356,399.86,3549.7488,percent of total billed charges,,,
HC Insj Perq Vad W/Rs&I R Heart Venous Access Only,PX-36900809,CDM,33995,CPT,369,RC,,,outpatient,,,4109,2876.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.9983,399.86,3155.712,percent of total billed charges,,,
HC Removal Perq R Heart Vad Venous Cannula Sep Insj,PX-36900810,CDM,33997,CPT,369,RC,,,outpatient,,,4188,2931.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1083.4356,293.5896,3216.384,percent of total billed charges,,,
HC Cardiac Surg Procedure Unlist,PX-36900254,CDM,33999,CPT,369,RC,,,outpatient,,,1770,1239,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,457.899,397.365,2141,percent of total billed charges,,,
HC Cardiac Surg Procedure Unlist,PX-36900635,CDM,33999,CPT,369,RC,,,outpatient,,,1770,1239,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,457.899,397.365,2141,percent of total billed charges,,,
HC Remv Art Clot Axill-Brach-Arm Incis,PX-36900255,CDM,34101,CPT,369,RC,,,outpatient,,,12541,8778.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3244.3567,399.86,9631.488,percent of total billed charges,,,
HC Remv Art Clot Arm-Arm Incis,PX-36900256,CDM,34111,CPT,369,RC,,,outpatient,,,12541,8778.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3244.3567,399.86,9631.488,percent of total billed charges,,,
HC Remv Art Clot Iliac-Pop-Leg Incis,PX-36900257,CDM,34201,CPT,369,RC,,,outpatient,,,12541,8778.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3244.3567,399.86,9631.488,percent of total billed charges,,,
HC Remv Art Clot Low Leg-Leg Incis,PX-36900258,CDM,34203,CPT,369,RC,,,outpatient,,,12541,8778.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3244.3567,399.86,9631.488,percent of total billed charges,,,
HC Aaa Repair-Iliac Artery Occlsn Device,PX-36900264,CDM,34808,CPT,369,RC,,,outpatient,,,152,106.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,39.3224,34.124,2998,percent of total billed charges,,,
HC Aaa Repr-Expose Femoral Art-Groin Incis,PX-36900265,CDM,34812,CPT,369,RC,,,outpatient,,,238,166.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,61.5706,53.431,2998,percent of total billed charges,,,
HC Aaa Repair- Femoral-Femoral Graft,PX-36900266,CDM,34813,CPT,369,RC,,,outpatient,,,167,116.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,43.2029,37.4915,2998,percent of total billed charges,,,
HC Aaa Repr-Expose Iliac Art-Abd Incis- Unilat,PX-36900267,CDM,34820,CPT,369,RC,,,outpatient,,,337,235.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,87.1819,75.6565,2998,percent of total billed charges,,,
HC Open Iliac Art Exp W/Conduit-Unilat,PX-36900270,CDM,34833,CPT,369,RC,,,outpatient,,,447,312.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,115.6389,100.3515,2998,percent of total billed charges,,,
HC Open Brach Art Exp-Endovas Pros-Unilat,PX-36900271,CDM,34834,CPT,369,RC,,,outpatient,,,218,152.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,56.3966,48.941,2998,percent of total billed charges,,,
HC Thrombectomy a-V Graft- Exc Hemodialysis,PX-36900278,CDM,35875,CPT,369,RC,,,outpatient,,,12541,8778.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3244.3567,399.86,9631.488,percent of total billed charges,,,
HC Place Needle in Vein,PX-36900279,CDM,36000,CPT,369,RC,,,outpatient,,,343,240.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,77.0035,1592,other,Non-Reimbursable Procedures,,
HC Injection Rx Extremity Pseudoaneurysm,PX-36900280,CDM,36002,CPT,369,RC,,,outpatient,,,775,542.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,200.4925,173.9875,2141,percent of total billed charges,,,
HC Injection Proc-Extremity-Venography,PX-36900281,CDM,36005,CPT,369,RC,,,outpatient,,,258,180.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,57.921,1592,other,Non-Reimbursable Procedures,,
HC Place Cath in Vein-Svc-Ivc,PX-36900282,CDM,36010,CPT,369,RC,,,outpatient,,,541,378.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,121.4545,1592,other,Non-Reimbursable Procedures,,
HC Place Cath in Vein-Select,PX-36900283,CDM,36011,CPT,369,RC,,,outpatient,,,773,541.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,173.5385,1592,other,Non-Reimbursable Procedures,,
HC Place Cath in Vein-Subselect,PX-36900284,CDM,36012,CPT,369,RC,,,outpatient,,,909,636.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,204.0705,1592,other,Non-Reimbursable Procedures,,
HC Place Cath in Rt Hrt-Main Pulm Art,PX-36900285,CDM,36013,CPT,369,RC,,,outpatient,,,8331,5831.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6398.208,other,Non-Reimbursable Procedures,,
HC Place Cath in Lt/Rt Pulm Art,PX-36900286,CDM,36014,CPT,369,RC,,,outpatient,,,721,504.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,161.8645,1592,other,Non-Reimbursable Procedures,,
HC Place Cath in Subsegmt Pulm Art,PX-36900287,CDM,36015,CPT,369,RC,,,outpatient,,,1662,1163.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,373.119,1592,other,Non-Reimbursable Procedures,,
HC Place Cath Carot/Vert Art,PX-36900288,CDM,36100,CPT,369,RC,,,outpatient,,,628,439.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,140.986,1592,other,Non-Reimbursable Procedures,,
HC Place Cath Extrem Artery,PX-36900290,CDM,36140,CPT,369,RC,,,outpatient,,,340,238,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,76.33,1592,other,Non-Reimbursable Procedures,,
HC Place Cath Aorta via Translumbar,PX-36900293,CDM,36160,CPT,369,RC,,,outpatient,,,2609,1826.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,2003.712,other,Non-Reimbursable Procedures,,
HC Place Cath Aorta,PX-36900294,CDM,36200,CPT,369,RC,,,outpatient,,,721,504.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,161.8645,1592,other,Non-Reimbursable Procedures,,
HC Place Cath Selective Art-Neck,PX-36900295,CDM,36215,CPT,369,RC,,,outpatient,,,1030,721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.235,1592,other,Non-Reimbursable Procedures,,
HC Place Cath Subselect Art-Neck,PX-36900296,CDM,36216,CPT,369,RC,,,outpatient,,,568,397.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,127.516,1592,other,Non-Reimbursable Procedures,,
HC Place Cath Subsubselect Art-Neck,PX-36900297,CDM,36217,CPT,369,RC,,,outpatient,,,1545,1081.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,346.8525,1592,other,Non-Reimbursable Procedures,,
HC Place Cath Addn Subselec Art-Neck,PX-36900298,CDM,36218,CPT,369,RC,,,outpatient,,,109,76.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,24.4705,1592,other,Non-Reimbursable Procedures,,
HC Nonslctv Cath Thor Aorta Angio Intr/Xtrcranl Art,PX-36900299,CDM,36221,CPT,369,RC,,,outpatient,,,9691,6783.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2507.0617,399.86,7442.688,percent of total billed charges,,,
HC Slctv Cath Carotid/Innom Art Angio Xtrcranl Art,PX-36900300,CDM,36222,CPT,369,RC,,,outpatient,,,9691,6783.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2507.0617,399.86,7442.688,percent of total billed charges,,,
HC Slctv Cath Carotid/Innom Art Angio Intrcranl Art,PX-36900301,CDM,36223,CPT,369,RC,,,outpatient,,,9141,6398.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2364.7767,399.86,8396.844904,percent of total billed charges,,,
HC Slctv Cath Intrnl Carotid Art Angio Intrcrnl Art,PX-36900302,CDM,36224,CPT,369,RC,,,outpatient,,,15847,11092.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4099.6189,399.86,12170.496,percent of total billed charges,,,
HC Slctv Cath Subclavian Art Angio Vertebral Artery,PX-36900303,CDM,36225,CPT,369,RC,,,outpatient,,,9141,6398.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2364.7767,399.86,7020.288,percent of total billed charges,,,
HC Slctv Cath Vertebral Art Angio Vertebral Artery,PX-36900304,CDM,36226,CPT,369,RC,,,outpatient,,,15847,11092.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4099.6189,399.86,12170.496,percent of total billed charges,,,
HC Slctv Cath Xtrnl Carotid Angio Xtrnl Carotd Circ,PX-36900305,CDM,36227,CPT,369,RC,,,outpatient,,,515,360.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,115.6175,1592,other,Non-Reimbursable Procedures,,
HC Slctv Cath Intrcrnl Brnch Angio Intrl Carot/Vert,PX-36900306,CDM,36228,CPT,369,RC,,,outpatient,,,612,428.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.394,1592,other,Non-Reimbursable Procedures,,
HC Place Cath Select Art-Abd/Pel,PX-36900307,CDM,36245,CPT,369,RC,,,outpatient,,,1107,774.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,248.5215,1592,other,Non-Reimbursable Procedures,,
HC Place Cath Subselect Art-Abd/Pel,PX-36900308,CDM,36246,CPT,369,RC,,,outpatient,,,1236,865.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,277.482,1592,other,Non-Reimbursable Procedures,,
HC Place Cath Subsubselect Art-Abd/Pel,PX-36900309,CDM,36247,CPT,369,RC,,,outpatient,,,1442,1009.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,323.729,1592,other,Non-Reimbursable Procedures,,
HC Place Cath Addn Subsel Art-Abd/Pel,PX-36900310,CDM,36248,CPT,369,RC,,,outpatient,,,258,180.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,57.921,1592,other,Non-Reimbursable Procedures,,
HC Slctv Cath 1stord W/WO Art Punct/Fluoro/S&I Uni,PX-36900311,CDM,36251,CPT,369,RC,,,outpatient,,,9430,6601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2439.541,399.86,7242.24,percent of total billed charges,,,
HC Slctv Cath 1stord W/WO Art Punct/Fluor/S&I Bilat,PX-36900312,CDM,36252,CPT,369,RC,,,outpatient,,,9430,6601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2439.541,399.86,7242.24,percent of total billed charges,,,
HC Supslctv Cath 2nd+Ord Renl&Acces Artery/S&I Uni,PX-36900313,CDM,36253,CPT,369,RC,,,outpatient,,,9430,6601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2439.541,399.86,8396.844904,percent of total billed charges,,,
HC Supslctv Cath 2nd+Ord Renl&Acces Arter/S&I Bilat,PX-36900314,CDM,36254,CPT,369,RC,,,outpatient,,,9430,6601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2439.541,399.86,7242.24,percent of total billed charges,,,
Vnpnxr <3 Years Phys/Qhp Skill Other Vein,PX-36900875,CDM,36406,CPT,369,RC,,,outpatient,,,24,16.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,5.388,416.02,other,Non-Reimbursable Procedures,,
HC Blood Transfusion Service,PX-39100001,CDM,36430,CPT,391,RC,,,outpatient,,,923,646.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,238.7801,207.2135,1592,percent of total billed charges,,,
HC Injection; Spider Veins-Limb/Trunk,PX-36900315,CDM,36468,CPT,369,RC,,,outpatient,,,909,636.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,235.1583,156.65,1592,percent of total billed charges,,,
HC Injection Therapy Vein-One Vein,PX-36900316,CDM,36470,CPT,369,RC,,,outpatient,,,909,636.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,235.1583,204.0705,1592,percent of total billed charges,,,
HC Injection Therapy Vein-Mult Veins,PX-36900317,CDM,36471,CPT,369,RC,,,outpatient,,,383,268.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,99.0821,85.9835,1592,percent of total billed charges,,,
HC Endovenous Rf- 1st Vein,PX-36900318,CDM,36475,CPT,369,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,6623.08,percent of total billed charges,,,
HC Endovenous Rf- Vein Add-On,PX-36900319,CDM,36476,CPT,369,RC,,,outpatient,,,1797,1257.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,1592,other,Non-Reimbursable Procedures,,
HC Endovenous Laser- 1st Vein,PX-36900320,CDM,36478,CPT,369,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,5781.504,percent of total billed charges,,,
HC Endovenous Laser Vein Addon,PX-36900321,CDM,36479,CPT,369,RC,,,outpatient,,,1797,1257.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,1592,other,Non-Reimbursable Procedures,,
HC Percut Portal Vein Cath,PX-36900322,CDM,36481,CPT,369,RC,,,outpatient,,,915,640.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,205.4175,1592,other,Non-Reimbursable Procedures,,
HC Venous Select Sampling W Cath,PX-36900323,CDM,36500,CPT,369,RC,,,outpatient,,,412,288.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,92.494,1592,other,Non-Reimbursable Procedures,,
HC Cathj Umbilical Vein Dx/Ther Nb,PX-36900588,CDM,36510,CPT,369,RC,,,outpatient,,,773,541.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,173.5385,1592,other,Non-Reimbursable Procedures,,
HC Ther Apheresis-Platelets,PX-36900553,CDM,36513,CPT,369,RC,,,outpatient,,,1337,935.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,345.8819,300.1565,2081.64,percent of total billed charges,,,
HC Ther Apheresis-Plasma Pheresis,PX-36900324,CDM,36514,CPT,369,RC,,,outpatient,,,4919,3443.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1272.5453,399.86,3777.792,percent of total billed charges,,,
HC Insert Non-Tunnel Cv Cath < 5 Y/O,PX-36100009,CDM,36555,CPT,361,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,5781.504,percent of total billed charges,,,
HC Insert Non-Tunnel Cv Cath < 5 Y/O,PX-36900325,CDM,36555,CPT,369,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,5781.504,percent of total billed charges,,,
HC Insert Non-Tunnel Cv Cath,PX-36100010,CDM,36556,CPT,361,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,6012.672,percent of total billed charges,,,
HC Insert Non-Tunnel Cv Cath,PX-36900326,CDM,36556,CPT,369,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,6012.672,percent of total billed charges,,,
HC PR Insj Non-Tunneled Central Venous Cath Age 5 Yr/>,PX-96000046,CDM,36556,CPT,960,RC,,,outpatient,,,7829,5480.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2025.3623,399.86,6012.672,percent of total billed charges,,,
HC Insert Tunneled Cv Cath W/O Port or Pump < 5 Y/O,PX-36100011,CDM,36557,CPT,361,RC,,,outpatient,,,12541,8778.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3244.3567,399.86,9631.488,percent of total billed charges,,,
HC Insert Tunneled Cv Cath W/O Port or Pump < 5 Y/O,PX-36900327,CDM,36557,CPT,369,RC,,,outpatient,,,12541,8778.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3244.3567,399.86,9631.488,percent of total billed charges,,,
HC Insert Tunneled Cv Cath W/O Port or Pump,PX-36100012,CDM,36558,CPT,361,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,5781.504,percent of total billed charges,,,
HC Insert Tunneled Cv Cath W/O Port or Pump,PX-36900328,CDM,36558,CPT,369,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,5781.504,percent of total billed charges,,,
HC Insert Tunneled Cv Cath With Port <5 Y/O,PX-36100013,CDM,36560,CPT,361,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,5781.504,percent of total billed charges,,,
HC Insert Tunneled Cv Cath With Port <5 Y/O,PX-36900329,CDM,36560,CPT,369,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,5781.504,percent of total billed charges,,,
HC Insert Tunneled Cv Cath With Port,PX-36100014,CDM,36561,CPT,361,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,5781.504,percent of total billed charges,,,
HC Insert Tunneled Cv Cath With Port,PX-36900330,CDM,36561,CPT,369,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,5781.504,percent of total billed charges,,,
HC Insert Tunneled Cv Cath With Pump,PX-36100015,CDM,36563,CPT,361,RC,,,outpatient,,,12541,8778.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3244.3567,399.86,9631.488,percent of total billed charges,,,
HC Insert Tunneled Cv Cath With Pump,PX-36900331,CDM,36563,CPT,369,RC,,,outpatient,,,12541,8778.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3244.3567,399.86,9631.488,percent of total billed charges,,,
HC Insert Tunneled Cv Cath W 2 Access Sites- W/O Pump or Port,PX-36900332,CDM,36565,CPT,369,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,5781.504,percent of total billed charges,,,
HC Insert Tunneled Cv Cath W 2 Access Sites- W/ Pump or Port,PX-36900333,CDM,36566,CPT,369,RC,,,outpatient,,,12541,8778.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3244.3567,399.86,9631.488,percent of total billed charges,,,
HC Insert Picc W/O Sub-Q Port <5 Y/O,PX-36900334,CDM,36568,CPT,369,RC,,,outpatient,,,3698,2588.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,956.6726,399.86,2840.064,percent of total billed charges,,,
HC Insert Picc W/O Sub-Q Port,PX-36900335,CDM,36569,CPT,369,RC,,,outpatient,,,3698,2588.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,956.6726,399.86,2953.728,percent of total billed charges,,,
HC PR Insj Prph Cvc W/O Subq Port/Pmp Age 5 Yr/>,PX-96000047,CDM,36569,CPT,960,RC,,,outpatient,,,3846,2692.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,994.9602,399.86,2953.728,percent of total billed charges,,,
HC Insert Picc W/ Sub-Q Port <5 Y/O,PX-36900336,CDM,36570,CPT,369,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,5781.504,percent of total billed charges,,,
HC Insert Picc W/ Sub-Q Port,PX-36900337,CDM,36571,CPT,369,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,5781.504,percent of total billed charges,,,
HC Repair Cv Cath W/O Subq Port or Pump,PX-36900338,CDM,36575,CPT,369,RC,,,outpatient,,,1421,994.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,367.6127,319.0145,2141,percent of total billed charges,,,
HC Repair Cv Cath W Subq Port or Pump,PX-36900339,CDM,36576,CPT,369,RC,,,outpatient,,,3698,2588.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,956.6726,399.86,2840.064,percent of total billed charges,,,
HC Replace Cv Cath- Catheter Only W Subq Pump or Port,PX-36900340,CDM,36578,CPT,369,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,5781.504,percent of total billed charges,,,
HC Replace Cv Cath- Complete- Non-Tunneled- W/O Subq Port or Pump,PX-36900341,CDM,36580,CPT,369,RC,,,outpatient,,,3698,2588.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,956.6726,399.86,2840.064,percent of total billed charges,,,
HC Replace Cv Cath- Complete- Tunneled- W/O Subq Port or Pump,PX-36900342,CDM,36581,CPT,369,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,5781.504,percent of total billed charges,,,
HC Replace Cv Cath- Complete- Non-Tunneled- W Subq Port or Pump,PX-36900343,CDM,36582,CPT,369,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,5781.504,percent of total billed charges,,,
HC Replace Cv Cath- Complete- Tunneled- W Subq Port or Pump,PX-36900344,CDM,36583,CPT,369,RC,,,outpatient,,,12541,8778.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3244.3567,399.86,9631.488,percent of total billed charges,,,
HC Replace Picc W/O Port or Pump,PX-36900345,CDM,36584,CPT,369,RC,,,outpatient,,,3698,2588.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,956.6726,399.86,2840.064,percent of total billed charges,,,
HC Replace Picc W Port or Pump,PX-36900346,CDM,36585,CPT,369,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,5781.504,percent of total billed charges,,,
HC Removal Tunneled Cv Cath W/O Subq Port or Pump,PX-36900347,CDM,36589,CPT,369,RC,,,outpatient,,,1421,994.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,367.6127,319.0145,2141,percent of total billed charges,,,
HC Removal Tunneled Cv Cath W Subq Port or Pump,PX-36900348,CDM,36590,CPT,369,RC,,,outpatient,,,3698,2588.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,956.6726,399.86,2998,percent of total billed charges,,,
HC Collect Blood From Implant Venous Access Device,PX-76100001,CDM,36591,CPT,761,RC,,,outpatient,,,160,112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,35.92,1592,other,Non-Reimbursable Procedures,,
HC Collect Blood From Catheter Venous Nos,PX-36900349,CDM,36592,CPT,369,RC,,,outpatient,,,125,87.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,28.0625,1592,other,Non-Reimbursable Procedures,,
HC Declot of Cent Venous Catheter,PX-36900350,CDM,36593,CPT,369,RC,,,outpatient,,,806,564.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,208.5122,180.947,1592,percent of total billed charges,,,
HC Mech Remov Pericath Obstr Cv Dev via Ven Access,PX-36900351,CDM,36595,CPT,369,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,5781.504,percent of total billed charges,,,
HC Mech Remov Intralum Obstr Cv Dev Thru Lumen,PX-36900352,CDM,36596,CPT,369,RC,,,outpatient,,,3698,2588.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,956.6726,399.86,2840.064,percent of total billed charges,,,
HC Reposition Venous Catheter,PX-36900353,CDM,36597,CPT,369,RC,,,outpatient,,,3698,2588.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,956.6726,399.86,2840.064,percent of total billed charges,,,
HC Contrast Inj Cent Ven Cath- Inc Flouro,PX-36900354,CDM,36598,CPT,369,RC,,,outpatient,,,406,284.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,105.0322,91.147,1592,percent of total billed charges,,,
HC Withdrawal of Arterial Blood,PX-36900355,CDM,36600,CPT,369,RC,,,outpatient,,,297,207.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,66.6765,1592,other,Non-Reimbursable Procedures,,
HC Insert Cath-Art-Percut-Shortterm,PX-36900356,CDM,36620,CPT,369,RC,,,outpatient,,,309,216.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,69.3705,1592,other,Non-Reimbursable Procedures,,
HC Catheterization Umbilical Newborn Art Dx/Therapy,PX-36900836,CDM,36660,CPT,369,RC,,,outpatient,,,10702,7491.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2768.6074,399.86,9071.0152,percent of total billed charges,,,
HC Placement Needle Intraosseous Infusion,PX-36900592,CDM,36680,CPT,369,RC,,,outpatient,,,568,397.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,146.9416,127.516,1592,percent of total billed charges,,,
HC PR Placement Needle Intraosseous Infusion,PX-96000050,CDM,36680,CPT,960,RC,,,outpatient,,,568,397.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,146.9416,127.516,1592,percent of total billed charges,,,
HC Insert Cannula-Vein-Vein,PX-36900358,CDM,36800,CPT,369,RC,,,outpatient,,,12541,8778.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3244.3567,399.86,9631.488,percent of total billed charges,,,
HC Revise Av Fistula-W/O Thrombectomy,PX-36900359,CDM,36832,CPT,369,RC,,,outpatient,,,12541,8778.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3244.3567,399.86,9631.488,percent of total billed charges,,,
HC Insert Transven Intrahep Portosys Shunt,PX-36900361,CDM,37182,CPT,369,RC,,,outpatient,,,4120,2884,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1065.844,399.86,5756,percent of total billed charges,,,
HC Revis Transven Intrahep Portosys Shunt,PX-36900362,CDM,37183,CPT,369,RC,,,outpatient,,,13035,9124.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3372.1545,399.86,18955.84,percent of total billed charges,,,
HC Prim Perc Mech Thrombectomy- Arterial,PX-36900363,CDM,37184,CPT,369,RC,,,outpatient,,,26415,18490.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6833.5605,399.86,26793.51305,percent of total billed charges,,,
HC Prim Perc Mech Thrombectomy- Arterial Ea Add,PX-36900364,CDM,37185,CPT,369,RC,,,outpatient,,,824,576.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,184.988,4800.911611,other,Non-Reimbursable Procedures,,
HC Sec Perc Mech Thrombect- Arterial- W Other Proc,PX-36900365,CDM,37186,CPT,369,RC,,,outpatient,,,1236,865.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,277.482,8164.18419,other,Non-Reimbursable Procedures,,
HC Percut Mech Thrombectomy- Venous,PX-36900366,CDM,37187,CPT,369,RC,,,outpatient,,,26415,18490.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6833.5605,399.86,20286.72,percent of total billed charges,,,
HC Percut Mech Thrombectomy- Venous- Repeat,PX-36900367,CDM,37188,CPT,369,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,6788.57,percent of total billed charges,,,
HC Ins Intrvas Vc Filtr W/WO Vas Acs Vsl Selxn Rs&I,PX-36900368,CDM,37191,CPT,369,RC,,,outpatient,,,14030,9821,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3629.561,399.86,10775.04,percent of total billed charges,,,
HC Repsng Intrvas Vc Filtr W/WO Acs Vsl Selxn Rs&I,PX-36900369,CDM,37192,CPT,369,RC,,,outpatient,,,9628,6739.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2490.7636,399.86,7394.304,percent of total billed charges,,,
HC Rtrvl Intrvas Vc Filtr W/WO Acs Vsl Selxn Rs&I,PX-36900370,CDM,37193,CPT,369,RC,,,outpatient,,,9998,6998.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2586.4826,399.86,7678.464,percent of total billed charges,,,
HC Thrombolysis Cerebral IV Infusion,PX-36900762,CDM,37195,CPT,369,RC,,,outpatient,,,613,429.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,158.5831,137.6185,1592,percent of total billed charges,,,
HC Prq Transcatheter Rtrvl Intrvas FB With Imaging,PX-36900371,CDM,37197,CPT,369,RC,,,outpatient,,,8825,6177.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2283.0275,399.86,6777.6,percent of total billed charges,,,
HC Transcatheter Biopsy,PX-36900372,CDM,37200,CPT,369,RC,,,outpatient,,,12541,8778.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3244.3567,399.86,9631.488,percent of total billed charges,,,
HC Thrombolysis Arterial Infusion W/Imaging Init Tx,PX-36900374,CDM,37211,CPT,369,RC,,,outpatient,,,12541,8778.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3244.3567,399.86,9631.488,percent of total billed charges,,,
HC Thrombolysis Venous Infusion W/Imaging Init Tx,PX-36900375,CDM,37212,CPT,369,RC,,,outpatient,,,3239,2267.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,837.9293,399.86,4870.452937,percent of total billed charges,,,
HC Thrombolysis Art/Venous Infsn W/Image Subsq Tx,PX-36900376,CDM,37213,CPT,369,RC,,,outpatient,,,7224,5056.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1868.8488,399.86,5548.032,percent of total billed charges,,,
HC Cessation Thrombolytic Thrpy W/Catheter Removal,PX-36900377,CDM,37214,CPT,369,RC,,,outpatient,,,7224,5056.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1868.8488,399.86,5548.032,percent of total billed charges,,,
HC Transcath Stent- Cca W/Eps,PX-36900378,CDM,37215,CPT,369,RC,,,outpatient,,,553,387.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,143.0611,124.1485,2998,percent of total billed charges,,,
HC Revascularize Iliac Artery-Angioplasty- Initial Vessel,PX-36900379,CDM,37220,CPT,369,RC,,,outpatient,,,15994,11195.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4137.6478,399.86,12283.392,percent of total billed charges,,,
HC Revascularize Iliac Artery-Angioplasty/Stent- Initial Vessel,PX-36900380,CDM,37221,CPT,369,RC,,,outpatient,,,16597,11617.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4293.6439,399.86,18955.84,percent of total billed charges,,,
HC Revascularize Iliac Artery-Angioplasty- Ea Add Vessel,PX-36900381,CDM,37222,CPT,369,RC,,,outpatient,,,15818,11072.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,12148.224,other,Non-Reimbursable Procedures,,
HC Revascularize Iliac Artery-Angioplasty/Stent- Ea Add Vessel,PX-36900382,CDM,37223,CPT,369,RC,,,outpatient,,,16216,11351.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,12453.888,other,Non-Reimbursable Procedures,,
HC Revascularize Fem/Pop Artery-Angioplasty,PX-36900383,CDM,37224,CPT,369,RC,,,outpatient,,,16599,11619.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4294.1613,399.86,12748.032,percent of total billed charges,,,
HC Revascularize Fem/Pop Artery-Angioplasty/Atherectomy,PX-36900384,CDM,37225,CPT,369,RC,,,outpatient,,,34070,23849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8813.909,399.86,26793.51305,percent of total billed charges,,,
HC Revascularize Fem/Pop Artery-Angioplasty/Stent,PX-36900385,CDM,37226,CPT,369,RC,,,outpatient,,,32579,22805.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8428.1873,399.86,25020.672,percent of total billed charges,,,
HC Revascularize Fem/Pop Artery-Angioplasty/Stent/Atherectomy,PX-36900386,CDM,37227,CPT,369,RC,,,outpatient,,,59005,41303.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15264.5935,399.86,45315.84,percent of total billed charges,,,
HC Revascularize Tibial/Peron Artery-Angioplasty Initial,PX-36900387,CDM,37228,CPT,369,RC,,,outpatient,,,15999,11199.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4138.9413,399.86,16809.6787,percent of total billed charges,,,
HC Revascularize Tibial/Peron Artery-Angioplasty/Atherectomy Initial,PX-36900388,CDM,37229,CPT,369,RC,,,outpatient,,,34866,24406.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9019.8342,399.86,26793.51305,percent of total billed charges,,,
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent Initial,PX-36900389,CDM,37230,CPT,369,RC,,,outpatient,,,34070,23849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8813.909,399.86,26793.51305,percent of total billed charges,,,
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent/Atherectomy Init,PX-36900390,CDM,37231,CPT,369,RC,,,outpatient,,,58146,40702.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15042.3702,399.86,44656.128,percent of total billed charges,,,
HC Revascularize Tibial/Peron Artery-Angioplasty Ea Add,PX-36900391,CDM,37232,CPT,369,RC,,,outpatient,,,16052,11236.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,12327.936,other,Non-Reimbursable Procedures,,
HC Revascularize Tibial/Peron Artery-Angioplasty/Atherectomy Ea Add,PX-36900392,CDM,37233,CPT,369,RC,,,outpatient,,,33576,23503.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,25786.368,other,Non-Reimbursable Procedures,,
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent Ea Add,PX-36900393,CDM,37234,CPT,369,RC,,,outpatient,,,16052,11236.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,12327.936,other,Non-Reimbursable Procedures,,
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent/Atherectomy Ea Add,PX-36900394,CDM,37235,CPT,369,RC,,,outpatient,,,15818,11072.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,12148.224,other,Non-Reimbursable Procedures,,
HC Open/Perq Placement Intravascular Stent Initial,PX-36900395,CDM,37236,CPT,369,RC,,,outpatient,,,26415,18490.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6833.5605,399.86,20286.72,percent of total billed charges,,,
HC Open/Perq Placement Intravascular Stent Ea Addl,PX-36900396,CDM,37237,CPT,369,RC,,,outpatient,,,3978,2784.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,4532,other,Non-Reimbursable Procedures,,
HC Open/Perq Placement Intravascular Stent Same 1st,PX-36900397,CDM,37238,CPT,369,RC,,,outpatient,,,26415,18490.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6833.5605,399.86,20286.72,percent of total billed charges,,,
HC Open/Perq Placemt Intravasc Stent Same Ea Addl,PX-36900398,CDM,37239,CPT,369,RC,,,outpatient,,,3978,2784.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,4532,other,Non-Reimbursable Procedures,,
HC Vascular Embolization or Occlusion Venous Rs&I,PX-36900399,CDM,37241,CPT,369,RC,,,outpatient,,,26415,18490.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6833.5605,399.86,20286.72,percent of total billed charges,,,
HC Vascular Embolization or Occlusion Arterial Rs&I,PX-36900400,CDM,37242,CPT,369,RC,,,outpatient,,,26415,18490.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6833.5605,399.86,26793.51305,percent of total billed charges,,,
HC Vascular Embolize/Occlude Organ Tumor Infarct,PX-36900401,CDM,37243,CPT,369,RC,,,outpatient,,,26415,18490.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6833.5605,399.86,20286.72,percent of total billed charges,,,
HC Vascular Embolization or Occlusion Hemorrhage,PX-36100016,CDM,37244,CPT,361,RC,,,outpatient,,,26415,18490.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6833.5605,399.86,20286.72,percent of total billed charges,,,
HC Vascular Embolization or Occlusion Hemorrhage,PX-36900402,CDM,37244,CPT,369,RC,,,outpatient,,,26415,18490.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6833.5605,399.86,20286.72,percent of total billed charges,,,
HC Temporal Artery Ligatn or Bx,PX-36900554,CDM,37609,CPT,369,RC,,,outpatient,,,4643,3250.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1201.1441,399.86,3565.824,percent of total billed charges,,,
HC Phleb Veins - Extrem - to 20,PX-36900405,CDM,37765,CPT,369,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,5781.504,percent of total billed charges,,,
HC Phleb Veins - Extrem 20+,PX-36900406,CDM,37766,CPT,369,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,5781.504,percent of total billed charges,,,
HC Injection for Spleen X-Ray,PX-36900408,CDM,38200,CPT,369,RC,,,outpatient,,,381,266.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,98.5647,85.5345,1592,percent of total billed charges,,,
HC Bone Marrow; Aspiration Only,PX-36100017,CDM,38220,CPT,361,RC,,,outpatient,,,1973,1381.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,510.4151,399.86,2477.315575,percent of total billed charges,,,
HC Bone Marrow; Aspiration Only,PX-36900409,CDM,38220,CPT,369,RC,,,outpatient,,,1973,1381.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,510.4151,399.86,2477.315575,percent of total billed charges,,,
HC Bone Marrow Bx- Needle/Trocar,PX-36100018,CDM,38221,CPT,361,RC,,,outpatient,,,1972,1380.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,510.1564,399.86,2477.315575,percent of total billed charges,,,
HC Bone Marrow Bx- Needle/Trocar,PX-36900410,CDM,38221,CPT,369,RC,,,outpatient,,,1972,1380.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,510.1564,399.86,2477.315575,percent of total billed charges,,,
HC Dx Bone Marrow Bx & Aspir,PX-36100032,CDM,38222,CPT,361,RC,,,outpatient,,,4653,3257.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1203.7311,399.86,4341.777195,percent of total billed charges,,,
HC Dx Bone Marrow Bx & Aspir,PX-36900703,CDM,38222,CPT,369,RC,,,outpatient,,,4653,3257.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1203.7311,399.86,4341.777195,percent of total billed charges,,,
HC Needle Biopsy- Lymph Node(S),PX-36900411,CDM,38505,CPT,369,RC,,,outpatient,,,1973,1381.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,510.4151,399.86,2998,percent of total billed charges,,,
HC Injection for Lymphatic Xray,PX-36900412,CDM,38790,CPT,369,RC,,,outpatient,,,500,350,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,129.35,112.25,1592,percent of total billed charges,,,
HC Identify Sentinel Node,PX-36900413,CDM,38792,CPT,369,RC,,,outpatient,,,540,378,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,139.698,121.23,1592,percent of total billed charges,,,
HC Biopsy of Floor of Mouth,PX-36900555,CDM,41108,CPT,369,RC,,,outpatient,,,2598,1818.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,672.1026,399.86,2477.315575,percent of total billed charges,,,
HC Biopsy Salivary Gland-Needle,PX-36900414,CDM,42400,CPT,369,RC,,,outpatient,,,1637,1145.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,423.4919,367.5065,2141,percent of total billed charges,,,
HC Injection for Salivary X-Ray,PX-36900415,CDM,42550,CPT,369,RC,,,outpatient,,,424,296.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,95.188,1592,other,Non-Reimbursable Procedures,,
HC Dilation/Cath of Salivary Duct,PX-36900416,CDM,42660,CPT,369,RC,,,outpatient,,,533,373.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,137.8871,119.6585,1592,percent of total billed charges,,,
HC Inc/Drain Peritonsil Abscess,PX-36900812,CDM,42700,CPT,369,RC,,,outpatient,,,685,479.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,177.2095,153.7825,1592,percent of total billed charges,,,
HC Placement Ng/Og Tube by Physician,PX-36900423,CDM,43752,CPT,369,RC,,,outpatient,,,325,227.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,84.0775,72.9625,1592,percent of total billed charges,,,
HC PR Naso/Oro-Gastric Tube Plmt Req Phys&Fluor Gdnce,PX-96000043,CDM,43752,CPT,960,RC,,,outpatient,,,325,227.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,84.0775,72.9625,1592,percent of total billed charges,,,
HC Gastric Intubatj & Aspiraj W/Phys Skill/Lavage,PX-36900575,CDM,43753,CPT,369,RC,,,outpatient,,,579,405.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,129.9855,1592,other,Non-Reimbursable Procedures,,
HC Reposition Gastric Feeding Tube Thru Duodenum,PX-36900425,CDM,43761,CPT,369,RC,,,outpatient,,,496,347.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,128.3152,111.352,1592,percent of total billed charges,,,
HC Perq Replacement Gtube Not Req Revj Gstrst Trc,PX-36100033,CDM,43762,CPT,361,RC,,,outpatient,,,879,615.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,227.3973,197.3355,1592,percent of total billed charges,,,
HC Perq Replacement Gtube Not Req Revj Gstrst Trc,PX-36900727,CDM,43762,CPT,369,RC,,,outpatient,,,879,615.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,227.3973,197.3355,1592,percent of total billed charges,,,
HC Intro Long GI Tube,PX-36900427,CDM,44500,CPT,369,RC,,,outpatient,,,1673,1171.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,432.8051,375.5885,2998,percent of total billed charges,,,
HC Drainage of Pelvic Abscess,PX-36900428,CDM,45000,CPT,369,RC,,,outpatient,,,2727,1908.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,705.4749,399.86,4005.9,percent of total billed charges,,,
HC Drainage of Deep Rectal Abscess,PX-36900429,CDM,45020,CPT,369,RC,,,outpatient,,,6425,4497.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1662.1475,399.86,4934.4,percent of total billed charges,,,
HC I&D Ischiorectal&/Perirectal Abscess Spx,PX-36900738,CDM,46040,CPT,369,RC,,,outpatient,,,3716,2601.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,961.3292,399.86,2998,percent of total billed charges,,,
HC Needle Biopsy Liver,PX-36900430,CDM,47000,CPT,369,RC,,,outpatient,,,3700,2590,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,957.19,399.86,2998,percent of total billed charges,,,
HC Needle Biopsy Liver-W Othr Proc,PX-36900431,CDM,47001,CPT,369,RC,,,outpatient,,,972,680.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,218.214,1592,other,Non-Reimbursable Procedures,,
HC Ablat-Open-1+ Liver Tumor(S)-Percut Rf,PX-36900433,CDM,47382,CPT,369,RC,,,outpatient,,,13307,9314.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3442.5209,399.86,10219.776,percent of total billed charges,,,
HC Cholecystostomy-Percutaneous- Complete,PX-36900434,CDM,47490,CPT,369,RC,,,outpatient,,,8367,5856.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2164.5429,399.86,6425.856,percent of total billed charges,,,
HC Biliary Endoscopy Percut-Dil Strict,PX-36900443,CDM,47555,CPT,369,RC,,,outpatient,,,8367,5856.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2164.5429,399.86,6425.856,percent of total billed charges,,,
HC Biliary Endoscopy Percut-Dil+Stent,PX-36900444,CDM,47556,CPT,369,RC,,,outpatient,,,13307,9314.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3442.5209,399.86,15728.70471,percent of total billed charges,,,
HC Needle Biopsy of Pancreas,PX-36900446,CDM,48102,CPT,369,RC,,,outpatient,,,3700,2590,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,957.19,399.86,2998,percent of total billed charges,,,
HC Anast Panc Cyst-Bowel-Direct,PX-36900447,CDM,48520,CPT,369,RC,,,outpatient,,,1740,1218,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,450.138,390.63,2998,percent of total billed charges,,,
HC Exploratory Laparotomy Celiotomy W/WO Biopsy Spx,PX-36900881,CDM,49000,CPT,369,RC,,,outpatient,,,8564,5994.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2215.5068,399.86,6577.152,percent of total billed charges,,,
HC Reopening Recent Laparotomy,PX-36900882,CDM,49002,CPT,369,RC,,,outpatient,,,8564,5994.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2215.5068,399.86,6577.152,percent of total billed charges,,,
HC Abdom Paracentesis Dx/Ther W/O Imaging Guidance,PX-36900448,CDM,49082,CPT,369,RC,,,outpatient,,,925,647.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,239.2975,207.6625,2998,percent of total billed charges,,,
HC Abdom Paracentesis Dx/Ther W Imaging Guidance,PX-36100002,CDM,49083,CPT,361,RC,,,outpatient,,,1635,1144.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,422.9745,367.0575,2998,percent of total billed charges,,,
HC Abdom Paracentesis Dx/Ther W Imaging Guidance,PX-36900449,CDM,49083,CPT,369,RC,,,outpatient,,,1635,1144.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,422.9745,367.0575,2998,percent of total billed charges,,,
HC Percut Biopsy- Abdominal Mass,PX-36900450,CDM,49180,CPT,369,RC,,,outpatient,,,3700,2590,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,957.19,399.86,2998,percent of total billed charges,,,
HC Remove Peritoneal Foreign Body,PX-36900451,CDM,49402,CPT,369,RC,,,outpatient,,,8367,5856.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2164.5429,399.86,6425.856,percent of total billed charges,,,
HC Image-Guide Fluid Collxn Drainage Cath Visc Perq,PX-36900452,CDM,49405,CPT,369,RC,,,outpatient,,,2870,2009,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,742.469,399.86,2998,percent of total billed charges,,,
HC Img-Guide Fluid Collxn Drainag Cath Periton Perq,PX-36900453,CDM,49406,CPT,369,RC,,,outpatient,,,2647,1852.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,684.7789,399.86,2998,percent of total billed charges,,,
HC Insertion Tunnel Intraperitoneal Cath W Image Guidance,PX-36900455,CDM,49418,CPT,369,RC,,,outpatient,,,7964,5574.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2060.2868,399.86,6116.352,percent of total billed charges,,,
HC Removal Tunneled Intraperitoneal Catheter,PX-36900456,CDM,49422,CPT,369,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1947.4936,399.86,5781.504,percent of total billed charges,,,
HC Drainage Catheter Exchange,PX-36900457,CDM,49423,CPT,369,RC,,,outpatient,,,4271,2989.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1104.9077,399.86,3280.128,percent of total billed charges,,,
HC Contrast Inj-Abscess/Cyst via Cath Tube,PX-36900458,CDM,49424,CPT,369,RC,,,outpatient,,,491,343.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,110.2295,1592,other,Non-Reimbursable Procedures,,
HC Insert Gastrostomy Tube Percutaneous,PX-36900460,CDM,49440,CPT,369,RC,,,outpatient,,,4271,2989.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1104.9077,399.86,3280.128,percent of total billed charges,,,
HC Convert Gastrostomy-Gastro-Jejunostomy Tube Percutaneous,PX-36900461,CDM,49446,CPT,369,RC,,,outpatient,,,4271,2989.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1104.9077,399.86,3280.128,percent of total billed charges,,,
HC Replace Gastrostomy/Cecostomy Tube Percutaneous,PX-36100019,CDM,49450,CPT,361,RC,,,outpatient,,,1644,1150.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,425.3028,369.078,2998,percent of total billed charges,,,
HC Replace Gastrostomy/Cecostomy Tube Percutaneous,PX-36900462,CDM,49450,CPT,369,RC,,,outpatient,,,1644,1150.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,425.3028,369.078,2998,percent of total billed charges,,,
HC Replace Duodenostomy/Jejunostomy Tube Percutaneous,PX-36100020,CDM,49451,CPT,361,RC,,,outpatient,,,1692,1184.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,437.7204,379.854,2998,percent of total billed charges,,,
HC Replace Duodenostomy/Jejunostomy Tube Percutaneous,PX-36900463,CDM,49451,CPT,369,RC,,,outpatient,,,1692,1184.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,437.7204,379.854,2998,percent of total billed charges,,,
HC Replacement Gastro-Jejunostomy Tube Percutaneous,PX-36100021,CDM,49452,CPT,361,RC,,,outpatient,,,2617,1831.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,677.0179,399.86,2998,percent of total billed charges,,,
HC Replacement Gastro-Jejunostomy Tube Percutaneous,PX-36900464,CDM,49452,CPT,369,RC,,,outpatient,,,2617,1831.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,677.0179,399.86,2998,percent of total billed charges,,,
HC Obstructive Material Removal From GI Tube,PX-36900465,CDM,49460,CPT,369,RC,,,outpatient,,,2128,1489.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,550.5136,399.86,2998,percent of total billed charges,,,
HC Contrast Injection Percutaneouos Radiologic Eval GI Tube,PX-36900466,CDM,49465,CPT,369,RC,,,outpatient,,,606,424.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,156.7722,136.047,1592,percent of total billed charges,,,
CEPHALEXIN 250 MG/5ML ORAL SUSR,RX-9502,CDM,50000,HCPCS,259,RC,68180-0441-01,NDC,outpatient,100,ML,50.29,35.203,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.010023,1.160665,416.02,percent of total billed charges,,,
CEPHALEXIN 250 MG/5ML ORAL SUSR,RX-9502,CDM,50000,HCPCS,259,RC,99999-0002-84,NDC,outpatient,10,ML,5.17,3.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.337479,1.160665,416.02,percent of total billed charges,,,
HC Biopsy of Kidney-Percutaneous,PX-36900467,CDM,50200,CPT,369,RC,,,outpatient,,,3700,2590,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,957.19,399.86,2998,percent of total billed charges,,,
HC Change Ureter Stent- Percut,PX-36900468,CDM,50382,CPT,369,RC,,,outpatient,,,4709,3296.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1218.2183,399.86,4179.83,percent of total billed charges,,,
HC Remove Ureter Stent- Percut,PX-36900469,CDM,50384,CPT,369,RC,,,outpatient,,,4709,3296.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1218.2183,399.86,3616.512,percent of total billed charges,,,
HC Change Ext Transneph Ureter Stent W/ Fluoro,PX-36900470,CDM,50387,CPT,369,RC,,,outpatient,,,4709,3296.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1218.2183,399.86,3616.512,percent of total billed charges,,,
HC Remove Renal Tube W/Fluoro,PX-36900471,CDM,50389,CPT,369,RC,,,outpatient,,,1513,1059.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,391.4131,339.6685,2141,percent of total billed charges,,,
HC Percut Drain/Inject Renal Cyst,PX-36900472,CDM,50390,CPT,369,RC,,,outpatient,,,726,508.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,187.8162,162.987,2141,percent of total billed charges,,,
HC Instll Rx Agnt Into Rnal Tub,PX-36900473,CDM,50391,CPT,369,RC,,,outpatient,,,533,373.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,137.8871,119.6585,1592,percent of total billed charges,,,
HC Measure Kidney Pressure Thru Tube,PX-36900478,CDM,50396,CPT,369,RC,,,outpatient,,,1513,1059.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,391.4131,334.48,2141,percent of total billed charges,,,
HC Plmt Nephrostomy Cath Prq New Access Rs&I,PX-36900659,CDM,50432,CPT,369,RC,,,outpatient,,,5502,3851.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1423.3674,399.86,4225.536,percent of total billed charges,,,
HC Renal Endoscopy-Remv FB/Stone,PX-36900480,CDM,50561,CPT,369,RC,,,outpatient,,,11603,8122.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3001.6961,399.86,8911.104,percent of total billed charges,,,
HC Perc Radiofreq Ablate Renal Tumor,PX-36900481,CDM,50592,CPT,369,RC,,,outpatient,,,13307,9314.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3442.5209,399.86,10219.776,percent of total billed charges,,,
HC Inject Indwell Cath-Ureter X-Ray,PX-36900482,CDM,50684,CPT,369,RC,,,outpatient,,,374,261.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,83.963,1592,other,Non-Reimbursable Procedures,,
HC Change of Ureterostomy Tube via Ileal Conduit,PX-36900483,CDM,50688,CPT,369,RC,,,outpatient,,,4709,3296.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1218.2183,399.86,3616.512,percent of total billed charges,,,
HC Inject Retrograde/Conduit X-Ray,PX-36900484,CDM,50690,CPT,369,RC,,,outpatient,,,533,373.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,119.6585,1592,other,Non-Reimbursable Procedures,,
HC Ureter Endoscopy Thru Ureterostomy W Biopsy,PX-36900485,CDM,50955,CPT,369,RC,,,outpatient,,,11603,8122.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3001.6961,399.86,8911.104,percent of total billed charges,,,
HC Ureter Endoscopy Thru Ureterostomy Remv FB or Calculus,PX-36900486,CDM,50961,CPT,369,RC,,,outpatient,,,11603,8122.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3001.6961,399.86,8911.104,percent of total billed charges,,,
HC Aspiration Bladder Needle,PX-36100022,CDM,51100,CPT,361,RC,,,outpatient,,,699,489.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,180.8313,156.9255,1592,percent of total billed charges,,,
HC Aspiration Bladder Needle,PX-36900488,CDM,51100,CPT,369,RC,,,outpatient,,,699,489.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,180.8313,156.9255,1592,percent of total billed charges,,,
HC Aspiration Bladder Trocar/Intracatheter,PX-36100023,CDM,51101,CPT,361,RC,,,outpatient,,,2419,1693.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,625.7953,179.53,2998,percent of total billed charges,,,
HC Aspiration Bladder Trocar/Intracatheter,PX-36900489,CDM,51101,CPT,369,RC,,,outpatient,,,2419,1693.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,625.7953,179.53,2998,percent of total billed charges,,,
HC Aspiration Bladder Insert Suprapubic Catheter,PX-36100024,CDM,51102,CPT,361,RC,,,outpatient,,,4709,3296.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1218.2183,399.86,3616.512,percent of total billed charges,,,
HC Aspiration Bladder Insert Suprapubic Catheter,PX-36900490,CDM,51102,CPT,369,RC,,,outpatient,,,4709,3296.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1218.2183,399.86,3616.512,percent of total billed charges,,,
HC Injection for Bladder X-Ray,PX-36900491,CDM,51600,CPT,369,RC,,,outpatient,,,1455,1018.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,235.074116,1592,other,Non-Reimbursable Procedures,,
HC Inject for Retrograde Urethocysto,PX-36900492,CDM,51610,CPT,369,RC,,,outpatient,,,976,683.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,219.112,1592,other,Non-Reimbursable Procedures,,
HC Bldr Irrigation Smpl Lavage &/Instlj,PX-36900732,CDM,51700,CPT,369,RC,,,outpatient,,,879,615.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,227.3973,197.3355,1592,percent of total billed charges,,,
HC Insert-Non-Indwelling Bladder Catheter,PX-36900494,CDM,51701,CPT,369,RC,,,outpatient,,,389,272.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,100.6343,87.3305,1592,percent of total billed charges,,,
HC Insert-Temp Indwelling Blad Cath-Simple,PX-36900495,CDM,51702,CPT,369,RC,,,outpatient,,,391,273.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,101.1517,87.7795,1592,percent of total billed charges,,,
HC Insert-Temp Indwelling Blad Cath-Comp,PX-36900496,CDM,51703,CPT,369,RC,,,outpatient,,,354,247.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,91.5798,79.473,1592,percent of total billed charges,,,
HC Change of Bladder Tube-Simple,PX-36900497,CDM,51705,CPT,369,RC,,,outpatient,,,456,319.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,117.9672,102.372,1592,percent of total billed charges,,,
HC Emg Stds Anal/Urtl Sphnctr Oth/Thn Ndl,PX-36900667,CDM,51784,CPT,369,RC,,,outpatient,,,475,332.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,122.8825,106.6375,1592,percent of total billed charges,,,
HC Meas Post-Voiding Residual Urine&/Bladder Cap,PX-36900733,CDM,51798,CPT,369,RC,,,outpatient,,,212,148.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,54.8444,47.594,1592,percent of total billed charges,,,
HC Cysto/Ureteroscopy-Tx Ureter Strict,PX-36900500,CDM,52344,CPT,369,RC,,,outpatient,,,8086,5660.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2091.8482,399.86,6210.048,percent of total billed charges,,,
HC Circumcision Age >28 Days,PX-36900772,CDM,54161,CPT,369,RC,,,outpatient,,,6599,4619.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1707.1613,399.86,5068.032,percent of total billed charges,,,
HC Irrigation Corpora Cavernosa Priapism,PX-36900736,CDM,54220,CPT,369,RC,,,outpatient,,,591,413.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,152.8917,120.28264,1592,percent of total billed charges,,,
HC Biopsy of Prostate-Needle/Punch,PX-36900501,CDM,55700,CPT,369,RC,,,outpatient,,,4709,3296.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1218.2183,399.86,3616.512,percent of total billed charges,,,
HC I&D of Vulva/Perineum Abscess,PX-36900502,CDM,56405,CPT,369,RC,,,outpatient,,,829,580.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,214.4623,186.1105,1592,percent of total billed charges,,,
HC PR Colporrhaphy- Suture Vaginal Injury- Non-OB,PX-36900795,CDM,57200,CPT,369,RC,,,outpatient,,,5013,3509.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1296.8631,399.86,4777.053449,percent of total billed charges,,,
HC Cath/Inject Hysterosalpingogram,PX-36900505,CDM,58340,CPT,369,RC,,,outpatient,,,1092,764.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,235.074116,1592,other,Non-Reimbursable Procedures,,
HC Reopen Fallopian Tube-Transcerv Cath,PX-36900506,CDM,58345,CPT,369,RC,,,outpatient,,,6900,4830,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1785.03,399.86,5299.2,percent of total billed charges,,,
HC Fetal Non-Stress Test,PX-92000003,CDM,59025,CPT,920,RC,,,outpatient,,,490,343,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,126.763,110.005,416.02,percent of total billed charges,,,
HC PR Vaginal Delivery Only,PX-96000044,CDM,59409,CPT,960,RC,,,outpatient,,,3062,2143.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,792.1394,399.86,4777.053449,percent of total billed charges,,,
HC PR Delivery Placenta Separate Procedure,PX-96000045,CDM,59414,CPT,960,RC,,,outpatient,,,7176,5023.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1856.4312,399.86,5511.168,percent of total billed charges,,,
HC Biopsy of Thyroid-Percut,PX-36900512,CDM,60100,CPT,369,RC,,,outpatient,,,1514,1059.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,391.6718,339.893,2141,percent of total billed charges,,,
HC Endocrine Surgery Proc Unlisted,PX-36900513,CDM,60699,CPT,369,RC,,,outpatient,,,6035,4224.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1561.2545,399.86,11413.04,percent of total billed charges,,,
HC Brain Shunt Tube/Reserv Injectn,PX-36900514,CDM,61070,CPT,369,RC,,,outpatient,,,1885,1319.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,487.6495,399.86,2141,percent of total billed charges,,,
HC Endovasc Temp Balloon Occlus-Head/Nck,PX-36900515,CDM,61623,CPT,369,RC,,,outpatient,,,26415,18490.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6833.5605,399.86,20286.72,percent of total billed charges,,,
HC Perm Occlusion/Embolization-Percut-Cns,PX-36900516,CDM,61624,CPT,369,RC,,,outpatient,,,533,373.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,137.8871,119.6585,5756,percent of total billed charges,,,
HC Percut Cath Occlusn Non Cns Lesn,PX-36900517,CDM,61626,CPT,369,RC,,,outpatient,,,26415,18490.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6833.5605,399.86,20286.72,percent of total billed charges,,,
HC Percut Aspiration Vertebral Disc,PX-36900518,CDM,62267,CPT,369,RC,,,outpatient,,,1637,1145.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,423.4919,367.5065,2141,percent of total billed charges,,,
HC Spinal Puncture-Lumbar-Diagnostic,PX-36100025,CDM,62270,CPT,361,RC,,,outpatient,,,915,640.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,236.7105,205.4175,2141,percent of total billed charges,,,
HC Spinal Puncture-Lumbar-Diagnostic,PX-36900519,CDM,62270,CPT,369,RC,,,outpatient,,,915,640.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,236.7105,205.4175,2141,percent of total billed charges,,,
HC PR Spinal Puncture Lumbar Diagnostic,PX-96000051,CDM,62270,CPT,960,RC,,,outpatient,,,915,640.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,236.7105,205.4175,2141,percent of total billed charges,,,
HC Spinal Puncture-Therapeutic Drainage,PX-36100026,CDM,62272,CPT,361,RC,,,outpatient,,,1256,879.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,324.9272,281.972,2141,percent of total billed charges,,,
HC Spinal Puncture-Therapeutic Drainage,PX-36900520,CDM,62272,CPT,369,RC,,,outpatient,,,1256,879.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,324.9272,281.972,2141,percent of total billed charges,,,
HC Inj-Lumb Epidur-Blood/Clot Patch,PX-36900521,CDM,62273,CPT,369,RC,,,outpatient,,,915,640.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,236.7105,205.4175,2141,percent of total billed charges,,,
HC Inject-Myelography &/or CT Scan-Spinal,PX-36900522,CDM,62284,CPT,369,RC,,,outpatient,,,1312,918.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,294.544,1592,other,Non-Reimbursable Procedures,,
HC Diskectomy-Percutaneous Lumbar,PX-36900523,CDM,62287,CPT,369,RC,,,outpatient,,,6304,4412.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1630.8448,399.86,6224.0876,percent of total billed charges,,,
HC Inject Diskogram-Lumbar-Ea Level,PX-36900524,CDM,62290,CPT,369,RC,,,outpatient,,,1256,879.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,281.972,1592,other,Non-Reimbursable Procedures,,
HC Inj-Cerv/Thorac-for Diskography,PX-36900525,CDM,62291,CPT,369,RC,,,outpatient,,,1107,774.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,248.5215,1592,other,Non-Reimbursable Procedures,,
HC Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/O Img Gdn,PX-36900884,CDM,62322,CPT,369,RC,,,outpatient,,,2586,1810.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,668.9982,399.86,2141,percent of total billed charges,,,
HC Elec Anlys Implt Ithcl/Edrl Pmp W/Repr Phys/Qhp,PX-36900526,CDM,62370,CPT,369,RC,,,outpatient,,,821,574.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,212.3927,155.844464,1592,percent of total billed charges,,,
HC Inject Nerv Blck-Trigeminal,PX-36900609,CDM,64400,CPT,369,RC,,,outpatient,,,891,623.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,230.5017,200.0295,1592,percent of total billed charges,,,
HC Inject Nerv Blck-Great Occiptl,PX-36900611,CDM,64405,CPT,369,RC,,,outpatient,,,1634,1143.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,422.7158,323.2601,1592,percent of total billed charges,,,
HC Inject Nerv Blck-Vagus Nerve,PX-36900612,CDM,64408,CPT,369,RC,,,outpatient,,,877,613.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,226.8799,196.8865,1592,percent of total billed charges,,,
HC Inj-Anes Agent-Brachial Plexus-Single,PX-36900616,CDM,64415,CPT,369,RC,,,outpatient,,,1544,1080.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,399.4328,346.628,2141,percent of total billed charges,,,
HC Inj-Anes Agent-Brachial Plexus-Cont Inf,PX-36900617,CDM,64416,CPT,369,RC,,,outpatient,,,2785,1949.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,720.4795,399.86,2141,percent of total billed charges,,,
HC Inject Nerv Blck-Axillary Nerv,PX-36900618,CDM,64417,CPT,369,RC,,,outpatient,,,1544,1080.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,399.4328,346.628,2141,percent of total billed charges,,,
HC Inject Nerv Blck-Suprascap N.,PX-36900619,CDM,64418,CPT,369,RC,,,outpatient,,,1544,1080.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,399.4328,346.628,2141,percent of total billed charges,,,
HC Inject Nerv Blck-Intercostal-One,PX-36900620,CDM,64420,CPT,369,RC,,,outpatient,,,1382,967.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,357.5234,310.259,2141,percent of total billed charges,,,
HC Inject Nerv Blck-Intercost-Multpl,PX-36900621,CDM,64421,CPT,369,RC,,,outpatient,,,2785,1949.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,720.4795,399.86,2141,percent of total billed charges,,,
HC Inject Nerv Blck-Ilioingu/Iliohyp,PX-36900622,CDM,64425,CPT,369,RC,,,outpatient,,,1544,1080.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,399.4328,346.628,2141,percent of total billed charges,,,
HC Inject Nerv Blck-Pudendal,PX-36100029,CDM,64430,CPT,361,RC,,,outpatient,,,2785,1949.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,720.4795,399.86,2141,percent of total billed charges,,,
HC Inject Nerv Blck-Pudendal,PX-36900623,CDM,64430,CPT,369,RC,,,outpatient,,,2785,1949.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,720.4795,399.86,2141,percent of total billed charges,,,
HC Inject Nerv Blck-Paracervical,PX-36900624,CDM,64435,CPT,369,RC,,,outpatient,,,1544,1080.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,399.4328,346.628,2141,percent of total billed charges,,,
HC Inj-Anes Agent-Sciatic Nerve-Single,PX-36900625,CDM,64445,CPT,369,RC,,,outpatient,,,2785,1949.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,720.4795,399.86,2141,percent of total billed charges,,,
HC Inj-Anes Agent-Sciatic Nerve-Cont Inf,PX-36900626,CDM,64446,CPT,369,RC,,,outpatient,,,2785,1949.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,720.4795,399.86,2141,percent of total billed charges,,,
HC Inj-Anes Agent-Femoral Nerve-Single,PX-36900627,CDM,64447,CPT,369,RC,,,outpatient,,,1544,1080.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,399.4328,346.628,2141,percent of total billed charges,,,
HC Inj-Anes Agent-Femoral Nerve-Cont Inf,PX-36900628,CDM,64448,CPT,369,RC,,,outpatient,,,6090,4263,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1575.483,399.86,4677.12,percent of total billed charges,,,
HC N Block Inj- Lumbar Plexus,PX-36900629,CDM,64449,CPT,369,RC,,,outpatient,,,2785,1949.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,720.4795,399.86,2141,percent of total billed charges,,,
HC Inject Nerv Blck-Othr Periph Nerv,PX-36900630,CDM,64450,CPT,369,RC,,,outpatient,,,1634,1143.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,422.7158,366.833,2141,percent of total billed charges,,,
HC Njx Aa&/Strd Plantar Common Digital Nerves,PX-36900835,CDM,64455,CPT,369,RC,,,outpatient,,,825,577.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,213.4275,185.2125,1592,percent of total billed charges,,,
HC Inject Anes/Steroid Foramen Cerv/Thoracic W Img Guide -1 Level,PX-36900631,CDM,64479,CPT,369,RC,,,outpatient,,,2785,1949.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,720.4795,399.86,2141,percent of total billed charges,,,
HC Inject Anes/Steroid Foramen Cerv/Thoracic W Img Guide -Ea Add Level,PX-36900632,CDM,64480,CPT,369,RC,,,outpatient,,,230,161,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.635,1592,other,Non-Reimbursable Procedures,,
HC Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level,PX-36100027,CDM,64483,CPT,361,RC,,,outpatient,,,1693,1185.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,437.9791,380.0785,2141,percent of total billed charges,,,
HC Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level,PX-36900531,CDM,64483,CPT,369,RC,,,outpatient,,,1693,1185.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,437.9791,380.0785,2141,percent of total billed charges,,,
HC Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl,PX-36900532,CDM,64484,CPT,369,RC,,,outpatient,,,416,291.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,93.392,1592,other,Non-Reimbursable Procedures,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- 1st Level,PX-36100028,CDM,64490,CPT,361,RC,,,outpatient,,,1693,1185.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,437.9791,380.0785,2141,percent of total billed charges,,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- 1st Level,PX-36900533,CDM,64490,CPT,369,RC,,,outpatient,,,1693,1185.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,437.9791,380.0785,2141,percent of total billed charges,,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- 2nd Level,PX-36900633,CDM,64491,CPT,369,RC,,,outpatient,,,221,154.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,57.1727,49.6145,1592,percent of total billed charges,,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- Add Level,PX-36900634,CDM,64492,CPT,369,RC,,,outpatient,,,224,156.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,57.9488,50.288,1592,percent of total billed charges,,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Lumbar/Sac- 1st Level,PX-36900536,CDM,64493,CPT,369,RC,,,outpatient,,,1693,1185.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,437.9791,380.0785,2141,percent of total billed charges,,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Lumbar/Sac- 2nd Level,PX-36900537,CDM,64494,CPT,369,RC,,,outpatient,,,1693,1185.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,437.9791,380.0785,1592,percent of total billed charges,,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Lumbar/Sac- Add Level,PX-36900538,CDM,64495,CPT,369,RC,,,outpatient,,,54,37.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.9698,12.123,1592,percent of total billed charges,,,
HC Inject Nerv Blck-Celiac Plexus,PX-36900539,CDM,64530,CPT,369,RC,,,outpatient,,,2165,1515.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,560.0855,399.86,2141,percent of total billed charges,,,
HC Unlisted Procedure Nervous System,PX-36100035,CDM,64999,CPT,361,RC,,,outpatient,,,687,480.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,177.7269,154.2315,1592,percent of total billed charges,,,
HC Unlisted Procedure Nervous System,PX-36900829,CDM,64999,CPT,369,RC,,,outpatient,,,687,480.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,177.7269,154.2315,1592,percent of total billed charges,,,
HC Removal Impacted Cerumen Using Irrigation/Lavage- Unilateral,PX-36900636,CDM,69209,CPT,369,RC,,,outpatient,,,205,143.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,46.0225,1592,other,Non-Reimbursable Procedures,,
HC Removal Impacted Cerumen Instrumentation Unilat,PX-36900540,CDM,69210,CPT,369,RC,,,outpatient,,,305,213.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,66.75974,1592,other,Non-Reimbursable Procedures,,
HC X-Ray Eye for Foreign Body,PX-32000004,CDM,70030,CPT,320,RC,,,outpatient,,,271,189.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,70.1077,60.8395,416.02,percent of total billed charges,,,
HC X-Ray Jaw <4 Vw,PX-32000005,CDM,70100,CPT,320,RC,,,outpatient,,,595,416.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,153.9265,71.24,456.96,percent of total billed charges,,,
HC X-Ray Jaw 4+ Vw,PX-32000006,CDM,70110,CPT,320,RC,,,outpatient,,,489,342.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,126.5043,76.026473,416.02,percent of total billed charges,,,
HC X-Ray Mastoids <3 Vw,PX-32000007,CDM,70120,CPT,320,RC,,,outpatient,,,384,268.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,99.3408,86.208,416.02,percent of total billed charges,,,
HC X-Ray Mastoids 3+ Vw,PX-32000008,CDM,70130,CPT,320,RC,,,outpatient,,,295,206.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,76.3165,66.2275,416.02,percent of total billed charges,,,
HC X-Ray Facial Bones <3 Vw,PX-32000009,CDM,70140,CPT,320,RC,,,outpatient,,,336,235.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,86.9232,71.24,416.02,percent of total billed charges,,,
HC X-Ray Facial Bones 3+ Vw,PX-32000010,CDM,70150,CPT,320,RC,,,outpatient,,,252,176.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,65.1924,56.574,416.02,percent of total billed charges,,,
HC X-Ray Nasal Bones,PX-32000011,CDM,70160,CPT,320,RC,,,outpatient,,,319,223.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,82.5253,71.24,416.02,percent of total billed charges,,,
HC X-Ray Orbits,PX-32000012,CDM,70200,CPT,320,RC,,,outpatient,,,328,229.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,84.8536,73.636,416.02,percent of total billed charges,,,
HC X-Ray Sinuses <3 Vw,PX-32000013,CDM,70210,CPT,320,RC,,,outpatient,,,328,229.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,84.8536,71.24,416.02,percent of total billed charges,,,
HC X-Ray Sinuses 3+ Vw,PX-32000014,CDM,70220,CPT,320,RC,,,outpatient,,,444,310.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,114.8628,71.24,416.02,percent of total billed charges,,,
HC X-Ray Exam Sella,PX-32000015,CDM,70240,CPT,320,RC,,,outpatient,,,262,183.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,67.7794,58.819,416.02,percent of total billed charges,,,
HC X-Ray Skull <4 Vw,PX-32000016,CDM,70250,CPT,320,RC,,,outpatient,,,352,246.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,91.0624,76.026473,416.02,percent of total billed charges,,,
HC X-Ray Skull 4+ Vw,PX-32000017,CDM,70260,CPT,320,RC,,,outpatient,,,419,293.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,108.3953,76.026473,416.02,percent of total billed charges,,,
HC X-Ray Teeth Single,PX-32000018,CDM,70300,CPT,320,RC,,,outpatient,,,241,168.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,62.3467,54.1045,416.02,percent of total billed charges,,,
HC X-Ray Tmj Unilat,PX-32000019,CDM,70328,CPT,320,RC,,,outpatient,,,241,168.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,62.3467,54.1045,416.02,percent of total billed charges,,,
HC X-Ray Tmj Bilat,PX-32000020,CDM,70330,CPT,320,RC,,,outpatient,,,716,501.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,185.2292,71.24,549.888,percent of total billed charges,,,
HC MRI- Tmj,PX-61000008,CDM,70336,CPT,610,RC,,,outpatient,,,2588,1811.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,276.55,,,276.55,267.439885,1987.584,fee schedule,,,
HC Panoramic X-Ray of Jaws,PX-32000022,CDM,70355,CPT,320,RC,,,outpatient,,,241,168.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,62.3467,54.1045,416.02,percent of total billed charges,,,
HC X-Ray Neck Soft Tissue,PX-32000023,CDM,70360,CPT,320,RC,,,outpatient,,,232,162.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,60.0184,52.084,416.02,percent of total billed charges,,,
HC X-Ray Salivary Gland,PX-32000025,CDM,70380,CPT,320,RC,,,outpatient,,,262,183.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,67.7794,58.819,416.02,percent of total billed charges,,,
HC X-Ray Sialogram,PX-32000026,CDM,70390,CPT,320,RC,,,outpatient,,,537,375.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,120.5565,646.6965,other,Non-Reimbursable Procedures,,
HC CT Scan-Head/Brain-W/O Contrast Matl,PX-35000002,CDM,70450,CPT,350,RC,,,outpatient,,,1070,749,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,89.81,,,89.81,89.81,821.76,fee schedule,,,
HC CT Scan Head Contrast,PX-35000003,CDM,70460,CPT,350,RC,,,outpatient,,,1333,933.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,124.33,,,124.33,124.33,1023.744,fee schedule,,,
CT Head/Brain W/O & W/Contrast Material,PX-35000004,CDM,70470,CPT,350,RC,,,outpatient,,,1615,1130.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,153.75,,,153.75,153.75,1240.32,fee schedule,,,
HC CT Scan-Orbit/Sella/Post Fossa/Ear-W/O,PX-35000005,CDM,70480,CPT,350,RC,,,outpatient,,,657,459.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,182.39,,,182.39,96.160741,575,fee schedule,,,
HC CT Scan Skull Contrast,PX-35000006,CDM,70481,CPT,350,RC,,,outpatient,,,774,541.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,246.33,,,246.33,173.763,667.43,fee schedule,,,
CT Orbit Sella/Post Fossa/Ear W/O & W/Contr Matr,PX-35000007,CDM,70482,CPT,350,RC,,,outpatient,,,1619,1133.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,276.94,,,276.94,200.53123,1243.392,fee schedule,,,
HC CT Scan-Maxillofacial Area-W/O Contrast,PX-35000008,CDM,70486,CPT,350,RC,,,outpatient,,,1200,840,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,165.13,,,165.13,96.160741,921.6,fee schedule,,,
HC CT Scan- Face/Jaw Contrast,PX-35000009,CDM,70487,CPT,350,RC,,,outpatient,,,1321,924.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,204.36,,,204.36,200.53123,1014.528,fee schedule,,,
CT Maxillofacial W/O & W/Contrast Material,PX-35000010,CDM,70488,CPT,350,RC,,,outpatient,,,1158,810.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,252.22,,,252.22,200.53123,889.344,fee schedule,,,
HC CT Scan-Soft Tissue Neck-W/O Contrast,PX-35000011,CDM,70490,CPT,350,RC,,,outpatient,,,514,359.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,154.93,,,154.93,96.160741,575,fee schedule,,,
HC CT Neck Tissue Contrast,PX-35000012,CDM,70491,CPT,350,RC,,,outpatient,,,1482,1037.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,194.55,,,194.55,194.55,1138.176,fee schedule,,,
CT Soft Tissue Neck W/O & W/Contrast Material,PX-35000014,CDM,70492,CPT,350,RC,,,outpatient,,,1755,1228.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,241.63,,,241.63,200.53123,1347.84,fee schedule,,,
CT Angiography Head W/Contrast/Noncontrast,PX-35000013,CDM,70496,CPT,350,RC,,,outpatient,,,1330,931,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,396.2,,,396.2,200.53123,1021.44,fee schedule,,,
CT Angiography Neck W/Contrast/Noncontrast,PX-35000015,CDM,70498,CPT,350,RC,,,outpatient,,,1157,809.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,415.42,,,415.42,200.53123,888.576,fee schedule,,,
HC MRI- Face- Neck,PX-61000009,CDM,70540,CPT,610,RC,,,outpatient,,,5081,3556.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,324.41,,,324.41,237.688956,3902.208,fee schedule,,,
HC MRI- Face- Neck W/Contrast,PX-61000010,CDM,70542,CPT,610,RC,,,outpatient,,,2710,1897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,365.99,,,365.99,365.99,2081.28,fee schedule,,,
MRI Orbit Face & Neck W/O & W/Contrast Matrl,PX-61000011,CDM,70543,CPT,610,RC,,,outpatient,,,1692,1184.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,439.74,,,439.74,379.854,1299.456,fee schedule,,,
HC MR Angio- Head,PX-61000012,CDM,70544,CPT,610,RC,,,outpatient,,,2279,1595.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,380.9,,,380.9,267.439885,1750.272,fee schedule,,,
HC MR Angio- Head W/Contrast,PX-61000013,CDM,70545,CPT,610,RC,,,outpatient,,,2279,1595.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,374.62,,,374.62,374.62,1750.272,fee schedule,,,
Mra Head W/O & W/Contrast Material,PX-61000014,CDM,70546,CPT,610,RC,,,outpatient,,,2279,1595.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,572.73,,,572.73,301.425681,1750.272,fee schedule,,,
HC MR Angio- Neck,PX-61000015,CDM,70547,CPT,610,RC,,,outpatient,,,2182,1527.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,382.07,,,382.07,267.439885,1675.776,fee schedule,,,
HC MR Angio- Neck W/Contrast,PX-61000016,CDM,70548,CPT,610,RC,,,outpatient,,,2469,1728.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,404.43,,,404.43,399.86,1896.192,fee schedule,,,
Mra Neck W/O &W/Contrast Material,PX-61000017,CDM,70549,CPT,610,RC,,,outpatient,,,2534,1773.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,577.44,,,577.44,301.425681,1946.112,fee schedule,,,
HC MRI Brain,PX-61000018,CDM,70551,CPT,610,RC,,,outpatient,,,2090,1463,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,188.66,,,188.66,188.66,1605.12,fee schedule,,,
HC MRI Brain Contrast,PX-61000019,CDM,70552,CPT,610,RC,,,outpatient,,,5255,3678.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,268.7,,,268.7,268.7,4035.84,fee schedule,,,
MRI Brain Brain Stem W/O W/Contrast Material,PX-61000020,CDM,70553,CPT,610,RC,,,outpatient,,,2668,1867.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,307.14,,,307.14,307.14,2049.024,fee schedule,,,
HC X-Ray Exam Chest 1 View,PX-32000245,CDM,71045,CPT,320,RC,,,outpatient,,,214,149.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,55.3618,48.043,416.02,percent of total billed charges,,,
HC X-Ray Exam Chest 2 Views,PX-32000246,CDM,71046,CPT,320,RC,,,outpatient,,,232,162.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,60.0184,52.084,416.02,percent of total billed charges,,,
HC X-Ray Exam Chest 3 Views,PX-32000247,CDM,71047,CPT,320,RC,,,outpatient,,,245,171.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,63.3815,55.0025,416.02,percent of total billed charges,,,
HC X-Ray Exam Chest 4+ Views,PX-32000248,CDM,71048,CPT,320,RC,,,outpatient,,,410,287,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,106.067,76.026473,416.02,percent of total billed charges,,,
HC X-Ray Ribs- Chest 3+ Vw,PX-32000036,CDM,71101,CPT,320,RC,,,outpatient,,,484,338.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,125.2108,76.026473,416.02,percent of total billed charges,,,
HC X-Ray Ribs- Chest 4+ Vw,PX-32000038,CDM,71111,CPT,320,RC,,,outpatient,,,562,393.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,145.3894,76.026473,431.616,percent of total billed charges,,,
HC X-Ray Sternum 2+ Vw,PX-32000039,CDM,71120,CPT,320,RC,,,outpatient,,,358,250.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,92.6146,71.24,416.02,percent of total billed charges,,,
HC X-Ray Sterno-Clavicluar Jt,PX-32000040,CDM,71130,CPT,320,RC,,,outpatient,,,250,175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,64.675,56.125,416.02,percent of total billed charges,,,
HC Diagnostic Computed Tomography Thorax W/O Cntrst,PX-35000016,CDM,71250,CPT,350,RC,,,outpatient,,,1388,971.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,154.93,,,154.93,96.160741,1065.984,fee schedule,,,
HC Diagnostic Computed Tomography Thorax W/Contrast,PX-35000017,CDM,71260,CPT,350,RC,,,outpatient,,,1624,1136.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,195.34,,,195.34,195.34,1247.232,fee schedule,,,
HC Diagnostic Computed Tomography Thorax C-/C+,PX-35000018,CDM,71270,CPT,350,RC,,,outpatient,,,1982,1387.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,242.81,,,242.81,200.53123,1522.176,fee schedule,,,
HC Computed Tomography Thorax Lw Dose Lng Ca Scr C-,PX-35000070,CDM,71271,CPT,350,RC,,,outpatient,,,264,184.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,68.2968,59.268,575,percent of total billed charges,,,
CT Angiography Chest W/Contrast/Noncontrast,PX-35000019,CDM,71275,CPT,350,RC,,,outpatient,,,1592,1114.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,305.97,,,305.97,200.53123,1222.656,fee schedule,,,
HC MRI- Chest,PX-61000023,CDM,71550,CPT,610,RC,,,outpatient,,,1979,1385.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,378.94,,,378.94,237.688956,1519.872,fee schedule,,,
HC MRI- Chest- W/Contrast,PX-61000024,CDM,71551,CPT,610,RC,,,outpatient,,,3128,2189.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,424.05,,,424.05,399.86,2402.304,fee schedule,,,
MRI Chest W/O & W/Contrast Material,PX-61000025,CDM,71552,CPT,610,RC,,,outpatient,,,1547,1082.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,529.58,,,529.58,347.3015,1288.93,fee schedule,,,
HC MR Angio Chest (Mra) W/Contrast,PX-61000026,CDM,71555,CPT,610,RC,,,outpatient,,,2367,1656.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,612.3429,301.425681,1817.856,percent of total billed charges,,,
HC MR Angio Chest (Mra) Without Contrast,PX-61000071,CDM,71555,CPT,610,RC,,,outpatient,,,2367,1656.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,612.3429,301.425681,1817.856,percent of total billed charges,,,
HC MR Angio Chest (Mra) W/Without Contrast,PX-61000072,CDM,71555,CPT,610,RC,,,outpatient,,,2367,1656.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,612.3429,301.425681,1817.856,percent of total billed charges,,,
HC X-Ray Spine One View,PX-32000042,CDM,72020,CPT,320,RC,,,outpatient,,,251,175.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,64.9337,56.3495,416.02,percent of total billed charges,,,
HC Radex Spine Cervical 2 or 3 Views,PX-32000043,CDM,72040,CPT,320,RC,,,outpatient,,,296,207.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,76.5752,66.452,416.02,percent of total billed charges,,,
HC Radex Spine Cervical 4 or 5 Views,PX-32000044,CDM,72050,CPT,320,RC,,,outpatient,,,300,210,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,77.61,67.35,416.02,percent of total billed charges,,,
HC Radex Spine Cervical 6 or More Views,PX-32000045,CDM,72052,CPT,320,RC,,,outpatient,,,300,210,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,77.61,67.35,416.02,percent of total billed charges,,,
HC X-Ray Thoracic Spine 2 Vw,PX-32000046,CDM,72070,CPT,320,RC,,,outpatient,,,252,176.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,65.1924,56.574,416.02,percent of total billed charges,,,
HC X-Ray Thoracic Spine+Swim 3 Vw,PX-32000047,CDM,72072,CPT,320,RC,,,outpatient,,,283,198.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,73.2121,63.5335,416.02,percent of total billed charges,,,
HC X-Ray Thoracic Spine 4 Vw,PX-32000048,CDM,72074,CPT,320,RC,,,outpatient,,,306,214.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,79.1622,68.697,416.02,percent of total billed charges,,,
HC X-Ray Thor-Lumb Sp 2 Vw,PX-32000049,CDM,72080,CPT,320,RC,,,outpatient,,,357,249.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,92.3559,71.24,416.02,percent of total billed charges,,,
HC X-Ray Exam Entire Spi 1 Vw,PX-32000233,CDM,72081,CPT,320,RC,,,outpatient,,,241,168.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,62.3467,54.1045,416.02,percent of total billed charges,,,
HC X-Ray Exam Entire Spi 2/3 Vw,PX-32000234,CDM,72082,CPT,320,RC,,,outpatient,,,385,269.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,99.5995,86.4325,416.02,percent of total billed charges,,,
HC X-Ray Exam Entire Spi 4/5 Vw,PX-32000235,CDM,72083,CPT,320,RC,,,outpatient,,,757,529.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,195.8359,119.991125,581.376,percent of total billed charges,,,
HC X-Ray Exam Entire Spi 6/> Vw,PX-32000236,CDM,72084,CPT,320,RC,,,outpatient,,,757,529.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,195.8359,76.026473,581.376,percent of total billed charges,,,
HC X-Ray Lumbar Spine 2/3 Vw,PX-32000051,CDM,72100,CPT,320,RC,,,outpatient,,,235,164.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,60.7945,52.7575,416.02,percent of total billed charges,,,
HC X-Ray Lumbar Spine 4 Vw,PX-32000052,CDM,72110,CPT,320,RC,,,outpatient,,,323,226.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,83.5601,72.5135,416.02,percent of total billed charges,,,
HC X-Ray Lumbar Spine 6+ Vw,PX-32000053,CDM,72114,CPT,320,RC,,,outpatient,,,602,421.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,155.7374,76.026473,462.336,percent of total billed charges,,,
HC X-Ray Lumbar Spine Flex/Exten,PX-32000232,CDM,72120,CPT,320,RC,,,outpatient,,,411,287.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,106.3257,92.2695,416.02,percent of total billed charges,,,
HC CT Scan-Cervical Spine-W/O Contrast,PX-35000020,CDM,72125,CPT,350,RC,,,outpatient,,,1359,951.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,156.89,,,156.89,96.160741,1043.712,fee schedule,,,
HC CT Scan Cerv Spine Contrast,PX-35000021,CDM,72126,CPT,350,RC,,,outpatient,,,1556,1089.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,196.52,,,196.52,196.52,1195.008,fee schedule,,,
CT Cervical Spine W/O &W/Contrast Material,PX-35000022,CDM,72127,CPT,350,RC,,,outpatient,,,2239,1567.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,244.38,,,244.38,200.53123,1719.552,fee schedule,,,
HC CT Scan-Thoracic Spine-W/O Contrast,PX-35000023,CDM,72128,CPT,350,RC,,,outpatient,,,909,636.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,156.11,,,156.11,96.160741,698.112,fee schedule,,,
HC CT Scan Dorsal Sp Contrast,PX-35000024,CDM,72129,CPT,350,RC,,,outpatient,,,1037,725.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,196.52,,,196.52,196.52,796.416,fee schedule,,,
CT Thoracic Spine W/O & W/Contrast Material,PX-35000025,CDM,72130,CPT,350,RC,,,outpatient,,,2219,1553.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,247.91,,,247.91,200.53123,1704.192,fee schedule,,,
HC CT Scan-Lumbar Spine-W/O Contrast,PX-35000026,CDM,72131,CPT,350,RC,,,outpatient,,,688,481.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,155.32,,,155.32,96.160741,575,fee schedule,,,
HC CT Scan Lumbar Sp Contrast,PX-35000027,CDM,72132,CPT,350,RC,,,outpatient,,,1427,998.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,195.73,,,195.73,195.73,1095.936,fee schedule,,,
CT Lumbar Spine W/O & W/Contrast Material,PX-35000028,CDM,72133,CPT,350,RC,,,outpatient,,,1377,963.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,244.77,,,244.77,200.53123,1057.536,fee schedule,,,
HC MRI- Cerv Spine,PX-61000027,CDM,72141,CPT,610,RC,,,outpatient,,,2115,1480.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,185.92,,,185.92,185.92,1624.32,fee schedule,,,
HC MRI- Cerv Spine Contrast,PX-61000028,CDM,72142,CPT,610,RC,,,outpatient,,,3043,2130.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,270.27,,,270.27,270.27,2337.024,fee schedule,,,
HC MRI- Dorsal Spine,PX-61000029,CDM,72146,CPT,610,RC,,,outpatient,,,2222,1555.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,185.92,,,185.92,185.92,1706.496,fee schedule,,,
HC MRI- Dorsal Spine Contrast,PX-61000030,CDM,72147,CPT,610,RC,,,outpatient,,,2843,1990.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,266.73,,,266.73,266.73,2183.424,fee schedule,,,
HC MRI- Lumbar Spine,PX-61000031,CDM,72148,CPT,610,RC,,,outpatient,,,2651,1855.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,185.92,,,185.92,185.92,2035.968,fee schedule,,,
HC MRI- Lumbar Spine Contrast,PX-61000032,CDM,72149,CPT,610,RC,,,outpatient,,,2645,1851.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,265.17,,,265.17,265.17,2031.36,fee schedule,,,
MRI Spinal Canal Cervical W/O & W/Contr Matrl,PX-61000033,CDM,72156,CPT,610,RC,,,outpatient,,,3124,2186.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,307.53,,,307.53,307.53,2399.232,fee schedule,,,
MRI Spinal Canal Thoracic W/O & W/Contr Matrl,PX-61000034,CDM,72157,CPT,610,RC,,,outpatient,,,2833,1983.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,307.93,,,307.93,307.93,2175.744,fee schedule,,,
MRI Spinal Canal Lumbar W/O & W/Contr Matrl,PX-61000035,CDM,72158,CPT,610,RC,,,outpatient,,,3181,2226.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,305.58,,,305.58,305.58,2443.008,fee schedule,,,
HC X-Ray Pelvis 1/2 Vw,PX-32000054,CDM,72170,CPT,320,RC,,,outpatient,,,287,200.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,74.2469,64.4315,416.02,percent of total billed charges,,,
CT Angiography Pelvis W/Contrast/Noncontrast,PX-35000029,CDM,72191,CPT,350,RC,,,outpatient,,,1269,888.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,328.72,,,328.72,200.53123,974.592,fee schedule,,,
HC CT Scan-Pelvis-W/O Contrast,PX-35000030,CDM,72192,CPT,350,RC,,,outpatient,,,1368,957.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,106.67,,,106.67,96.160741,1050.624,fee schedule,,,
HC CT Scan of Pelvis Contrast,PX-35000031,CDM,72193,CPT,350,RC,,,outpatient,,,1561,1092.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,195.33,,,195.33,195.33,1198.848,fee schedule,,,
CT Pelvis W/O & W/Contrast Material,PX-35000032,CDM,72194,CPT,350,RC,,,outpatient,,,1902,1331.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,236.92,,,236.92,200.53123,1460.736,fee schedule,,,
HC MRI- Pelvis- W/O Contrast,PX-61000036,CDM,72195,CPT,610,RC,,,outpatient,,,2241,1568.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,335.78,,,335.78,237.688956,1721.088,fee schedule,,,
HC MRI- Pelvis W/Contrast,PX-61000037,CDM,72196,CPT,610,RC,,,outpatient,,,2850,1995,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,372.27,,,372.27,372.27,2188.8,fee schedule,,,
MRI Pelvis W/O & W/Contrast Material,PX-61000038,CDM,72197,CPT,610,RC,,,outpatient,,,2753,1927.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,447.2,,,447.2,399.547552,2114.304,fee schedule,,,
HC MR Angio Pelvis(Mra) W/Contrast,PX-61000039,CDM,72198,CPT,610,RC,,,outpatient,,,2908,2035.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,752.2996,399.86,2233.344,percent of total billed charges,,,
HC MR Angio Pelvis(Mra) Without Contrast,PX-61000073,CDM,72198,CPT,610,RC,,,outpatient,,,2710,1897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,701.077,399.86,2233.344,percent of total billed charges,,,
HC MR Angio Pelvis(Mra) W/Without Contrast,PX-61000074,CDM,72198,CPT,610,RC,,,outpatient,,,1826,1278.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,472.3862,399.86,2233.344,percent of total billed charges,,,
HC X-Ray Sacroiliac Jts 3+ Vw,PX-32000056,CDM,72202,CPT,320,RC,,,outpatient,,,443,310.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,114.6041,76.026473,416.02,percent of total billed charges,,,
HC X-Ray Sacrum/Coccyx 2+ Vw,PX-32000057,CDM,72220,CPT,320,RC,,,outpatient,,,336,235.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,86.9232,71.24,416.02,percent of total billed charges,,,
HC Myelography Cerv Spine,PX-32000058,CDM,72240,CPT,320,RC,,,outpatient,,,1478,1034.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,331.811,2051.3855,other,Non-Reimbursable Procedures,,
HC Myelography Thorax Spine,PX-32000059,CDM,72255,CPT,320,RC,,,outpatient,,,1823,1276.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,2051.3855,other,Non-Reimbursable Procedures,,
HC Myelography Lumbar Spine,PX-32000060,CDM,72265,CPT,320,RC,,,outpatient,,,1760,1232,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,395.12,2051.3855,other,Non-Reimbursable Procedures,,
HC Myelography of Entire Spine,PX-32000061,CDM,72270,CPT,320,RC,,,outpatient,,,1823,1276.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,2051.3855,other,Non-Reimbursable Procedures,,
HC X-Ray-C/T-Disk-Superv/Interpret,PX-32000062,CDM,72285,CPT,320,RC,,,outpatient,,,4306,3014.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,4977.9345,other,Non-Reimbursable Procedures,,
HC Discography Lumbar Spine,PX-32000064,CDM,72295,CPT,320,RC,,,outpatient,,,4306,3014.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,4977.9345,other,Non-Reimbursable Procedures,,
HC X-Ray Clavicle,PX-32000065,CDM,73000,CPT,320,RC,,,outpatient,,,170,119,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,43.979,38.165,416.02,percent of total billed charges,,,
HC X-Ray Scapula,PX-32000066,CDM,73010,CPT,320,RC,,,outpatient,,,306,214.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,79.1622,68.697,416.02,percent of total billed charges,,,
HC X-Ray Shoulder 1 Vw,PX-32000067,CDM,73020,CPT,320,RC,,,outpatient,,,256,179.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,66.2272,57.472,416.02,percent of total billed charges,,,
HC X-Ray Shoulder 2+ Vw,PX-32000068,CDM,73030,CPT,320,RC,,,outpatient,,,139,97.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,35.9593,31.2055,416.02,percent of total billed charges,,,
HC Arthrogram of Shoulder,PX-32000069,CDM,73040,CPT,320,RC,,,outpatient,,,1690,1183,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,379.405,1297.92,other,Non-Reimbursable Procedures,,
HC X-Ray Ac Jts,PX-32000070,CDM,73050,CPT,320,RC,,,outpatient,,,323,226.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,83.5601,71.24,416.02,percent of total billed charges,,,
HC X-Ray Humerus,PX-32000071,CDM,73060,CPT,320,RC,,,outpatient,,,178,124.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,46.0486,39.961,416.02,percent of total billed charges,,,
HC X-Ray Elbow 2 Vw,PX-32000072,CDM,73070,CPT,320,RC,,,outpatient,,,171,119.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,44.2377,38.3895,416.02,percent of total billed charges,,,
HC X-Ray Elbow 3+ Vw,PX-32000073,CDM,73080,CPT,320,RC,,,outpatient,,,129,90.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,33.3723,28.9605,416.02,percent of total billed charges,,,
HC Arthrogram of Elbow,PX-32000074,CDM,73085,CPT,320,RC,,,outpatient,,,1331,931.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,298.8095,1022.208,other,Non-Reimbursable Procedures,,
HC X-Ray Forearm 2 Vw,PX-32000075,CDM,73090,CPT,320,RC,,,outpatient,,,225,157.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,58.2075,50.5125,416.02,percent of total billed charges,,,
HC X-Ray Arm- Infant,PX-32000076,CDM,73092,CPT,320,RC,,,outpatient,,,368,257.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,95.2016,76.026473,416.02,percent of total billed charges,,,
HC X-Ray Wrist 2 Vw,PX-32000077,CDM,73100,CPT,320,RC,,,outpatient,,,190,133,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,49.153,42.655,416.02,percent of total billed charges,,,
HC X-Ray Wrist 3+ Vw,PX-32000078,CDM,73110,CPT,320,RC,,,outpatient,,,241,168.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,62.3467,54.1045,416.02,percent of total billed charges,,,
HC Arthrogram of Wrist,PX-32000079,CDM,73115,CPT,320,RC,,,outpatient,,,1722,1205.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,237.819698,1322.496,other,Non-Reimbursable Procedures,,
HC X-Ray Hand 2 Vw,PX-32000080,CDM,73120,CPT,320,RC,,,outpatient,,,306,214.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,79.1622,68.697,416.02,percent of total billed charges,,,
HC X-Ray Hand 3+ Vw,PX-32000081,CDM,73130,CPT,320,RC,,,outpatient,,,236,165.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,61.0532,52.982,416.02,percent of total billed charges,,,
HC X-Ray Exam of Finger(S),PX-32000082,CDM,73140,CPT,320,RC,,,outpatient,,,129,90.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,33.3723,28.9605,416.02,percent of total billed charges,,,
HC CT Scan-Upper Extremity-W/O Contrast,PX-35000034,CDM,73200,CPT,350,RC,,,outpatient,,,959,671.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,154.93,,,154.93,96.160741,736.512,fee schedule,,,
HC CT Scan of Arm Contrast,PX-35000035,CDM,73201,CPT,350,RC,,,outpatient,,,1388,971.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,193.37,,,193.37,193.37,1065.984,fee schedule,,,
CT Upper Extremity W/O & W/Contrast Material,PX-35000036,CDM,73202,CPT,350,RC,,,outpatient,,,1961,1372.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,261.64,,,261.64,200.53123,1506.048,fee schedule,,,
CT Angiography Upper Extremity,PX-35000037,CDM,73206,CPT,350,RC,,,outpatient,,,1345,941.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,271.05,,,271.05,200.53123,1032.96,fee schedule,,,
HC MRI- Upper Extremity W/O Contrast,PX-61000040,CDM,73218,CPT,610,RC,,,outpatient,,,2888,2021.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,331.08,,,331.08,237.688956,2217.984,fee schedule,,,
HC MRI- Upper Extremity W/Contrast,PX-61000041,CDM,73219,CPT,610,RC,,,outpatient,,,2936,2055.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,371.09,,,371.09,371.09,2254.848,fee schedule,,,
HC MRI Ext Upp No Jnt W-W/O,PX-61000042,CDM,73220,CPT,610,RC,,,outpatient,,,3144,2200.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,447.2,,,447.2,399.547552,2414.592,fee schedule,,,
MRI Any Jt Upper Extremity W/O Contrast Matrl,PX-61000043,CDM,73221,CPT,610,RC,,,outpatient,,,3039,2127.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,204.76,,,204.76,204.76,2333.952,fee schedule,,,
HC MRI- Joint Upper Extrem W/Contrast,PX-61000044,CDM,73222,CPT,610,RC,,,outpatient,,,3144,2200.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,340.49,,,340.49,340.49,2414.592,fee schedule,,,
MRI Any Jt Upper Extremity W/O & W/Contr Matrl,PX-61000045,CDM,73223,CPT,610,RC,,,outpatient,,,3060,2142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,415.03,,,415.03,399.547552,2350.08,fee schedule,,,
HC X-Ray Exam Hip Uni 1 View,PX-32000237,CDM,73501,CPT,320,RC,,,outpatient,,,222,155.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,57.4314,49.839,416.02,percent of total billed charges,,,
HC X-Ray Exam Hip Uni 2-3 Views,PX-32000238,CDM,73502,CPT,320,RC,,,outpatient,,,222,155.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,57.4314,49.839,416.02,percent of total billed charges,,,
HC X-Ray Exam Hip Uni 4/> Views,PX-32000239,CDM,73503,CPT,320,RC,,,outpatient,,,385,269.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,99.5995,86.4325,416.02,percent of total billed charges,,,
HC X-Ray Exam Hips Bi 2 Views,PX-32000240,CDM,73521,CPT,320,RC,,,outpatient,,,385,269.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,99.5995,86.4325,416.02,percent of total billed charges,,,
HC X-Ray Exam Hips Bi 5/> Views,PX-32000242,CDM,73523,CPT,320,RC,,,outpatient,,,757,529.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,195.8359,76.026473,581.376,percent of total billed charges,,,
HC Arthrogram of Hip,PX-32000086,CDM,73525,CPT,320,RC,,,outpatient,,,1616,1131.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,237.819698,1241.088,other,Non-Reimbursable Procedures,,
HC X-Ray Exam of Femur 1,PX-32000243,CDM,73551,CPT,320,RC,,,outpatient,,,213,149.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,55.1031,47.8185,416.02,percent of total billed charges,,,
HC X-Ray Exam of Femur 2/>,PX-32000244,CDM,73552,CPT,320,RC,,,outpatient,,,241,168.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,62.3467,54.1045,416.02,percent of total billed charges,,,
HC X-Ray Knee 1 or 2 View,PX-32000090,CDM,73560,CPT,320,RC,,,outpatient,,,213,149.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,55.1031,47.8185,416.02,percent of total billed charges,,,
HC X-Ray Knee 3 View,PX-32000091,CDM,73562,CPT,320,RC,,,outpatient,,,232,162.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,60.0184,52.084,416.02,percent of total billed charges,,,
HC X-Ray Knee 4+ View,PX-32000092,CDM,73564,CPT,320,RC,,,outpatient,,,260,182,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,67.262,58.37,416.02,percent of total billed charges,,,
HC X-Ray Knee Bilat Standing,PX-32000093,CDM,73565,CPT,320,RC,,,outpatient,,,394,275.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,101.9278,71.24,416.02,percent of total billed charges,,,
HC Arthrogram of Knee Joint,PX-32000094,CDM,73580,CPT,320,RC,,,outpatient,,,1704,1192.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,382.548,1308.672,other,Non-Reimbursable Procedures,,
HC X-Ray Tib + Fib- 2vw,PX-32000095,CDM,73590,CPT,320,RC,,,outpatient,,,199,139.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,51.4813,44.6755,416.02,percent of total billed charges,,,
HC X-Ray Leg- Infant,PX-32000096,CDM,73592,CPT,320,RC,,,outpatient,,,231,161.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,59.7597,51.8595,416.02,percent of total billed charges,,,
HC X-Ray Ankle 2 Vw,PX-32000097,CDM,73600,CPT,320,RC,,,outpatient,,,137,95.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,35.4419,30.7565,416.02,percent of total billed charges,,,
HC X-Ray Ankle 3+ Vw,PX-32000098,CDM,73610,CPT,320,RC,,,outpatient,,,130,91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,33.631,29.185,416.02,percent of total billed charges,,,
HC Arthrogram of Ankle,PX-32000099,CDM,73615,CPT,320,RC,,,outpatient,,,1221,854.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,237.819698,1020.2995,other,Non-Reimbursable Procedures,,
HC X-Ray Foot 2 Vw,PX-32000100,CDM,73620,CPT,320,RC,,,outpatient,,,158,110.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,40.8746,35.471,416.02,percent of total billed charges,,,
HC X-Ray Foot 3+ Vw,PX-32000101,CDM,73630,CPT,320,RC,,,outpatient,,,164,114.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,42.4268,36.818,416.02,percent of total billed charges,,,
HC X-Ray Heel,PX-32000102,CDM,73650,CPT,320,RC,,,outpatient,,,234,163.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,60.5358,52.533,416.02,percent of total billed charges,,,
HC X-Ray Toe(S),PX-32000103,CDM,73660,CPT,320,RC,,,outpatient,,,192,134.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,49.6704,43.104,416.02,percent of total billed charges,,,
HC CT Scan-Lower Extremity-W/O Contrast,PX-35000038,CDM,73700,CPT,350,RC,,,outpatient,,,968,677.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,154.93,,,154.93,96.160741,743.424,fee schedule,,,
HC CT Scan of Leg Contrast,PX-35000039,CDM,73701,CPT,350,RC,,,outpatient,,,987,690.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,196.51,,,196.51,196.51,758.016,fee schedule,,,
CT Lower Extremity W/O & W/Contrast Matrl,PX-35000040,CDM,73702,CPT,350,RC,,,outpatient,,,1903,1332.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,258.89,,,258.89,200.53123,1461.504,fee schedule,,,
CT Angiography Lower Extremity,PX-35000041,CDM,73706,CPT,350,RC,,,outpatient,,,1176,823.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,306.75,,,306.75,200.53123,903.168,fee schedule,,,
HC MRI- Lower Extrem,PX-61000046,CDM,73718,CPT,610,RC,,,outpatient,,,2836,1985.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,331.08,,,331.08,237.688956,2178.048,fee schedule,,,
HC MRI- Lower Extrem W/Contrast,PX-61000047,CDM,73719,CPT,610,RC,,,outpatient,,,2396,1677.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,372.66,,,372.66,372.66,1840.128,fee schedule,,,
HC MRI- Lower Extr- W/O Contrast F/U by Contrast,PX-61000048,CDM,73720,CPT,610,RC,,,outpatient,,,3060,2142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,450.72,,,450.72,399.547552,2350.08,fee schedule,,,
HC MRI Lower Extrem Jt- W/O Contrast,PX-61000049,CDM,73721,CPT,610,RC,,,outpatient,,,3008,2105.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,205.15,,,205.15,205.15,2310.144,fee schedule,,,
HC MRI- Joint of Leg W/Contrast,PX-61000050,CDM,73722,CPT,610,RC,,,outpatient,,,3018,2112.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,345.98,,,345.98,345.98,2317.824,fee schedule,,,
MRI Any Jt Lower Extrem W/O & W/Contrast Matrl,PX-61000051,CDM,73723,CPT,610,RC,,,outpatient,,,3098,2168.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,416.6,,,416.6,399.547552,2379.264,fee schedule,,,
HC MR Angio Lower Extrem (Mra) W/Contrast,PX-61000052,CDM,73725,CPT,610,RC,,,outpatient,,,2710,1897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,701.077,399.86,2290.176,percent of total billed charges,,,
HC MR Angio Lower Extrem (Mra) Without Contrast,PX-61000075,CDM,73725,CPT,610,RC,,,outpatient,,,2710,1897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,701.077,399.86,2290.176,percent of total billed charges,,,
HC MR Angio Lower Extrem (Mra) W/Without Contrast,PX-61000076,CDM,73725,CPT,610,RC,,,outpatient,,,2982,2087.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,771.4434,399.86,2290.176,percent of total billed charges,,,
HC X-Ray Exam Abdomen 1 View,PX-32000249,CDM,74018,CPT,320,RC,,,outpatient,,,232,162.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,60.0184,52.084,416.02,percent of total billed charges,,,
HC X-Ray Exam Abdomen 2 Views,PX-32000250,CDM,74019,CPT,320,RC,,,outpatient,,,443,310.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,114.6041,76.026473,416.02,percent of total billed charges,,,
HC X-Ray Exam Abdomen 3+ Views,PX-32000251,CDM,74021,CPT,320,RC,,,outpatient,,,410,287,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,106.067,92.045,416.02,percent of total billed charges,,,
HC CT Scan-Abdomen-W/O Contrast,PX-35000042,CDM,74150,CPT,350,RC,,,outpatient,,,1449,1014.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,104.32,,,104.32,96.160741,1112.832,fee schedule,,,
HC CT Scan of Abdomen Contrast,PX-35000043,CDM,74160,CPT,350,RC,,,outpatient,,,1586,1110.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,194.55,,,194.55,194.55,1218.048,fee schedule,,,
CT Abdomen W/O & W/Contrast Material,PX-35000044,CDM,74170,CPT,350,RC,,,outpatient,,,2058,1440.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,228.68,,,228.68,200.53123,1580.544,fee schedule,,,
HC CT Angio Abd&Plvis Cntrst Mtrl W/WO Cntrst Imges,PX-35000045,CDM,74174,CPT,350,RC,,,outpatient,,,2581,1806.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,478.18,,,478.18,329.339098,1982.208,fee schedule,,,
CT Angiography Abdomen W/Contrast/Noncontrast,PX-35000046,CDM,74175,CPT,350,RC,,,outpatient,,,1355,948.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,321.66,,,321.66,200.53123,1040.64,fee schedule,,,
HC CT Scan-Abdoment and Pelvis-W/O Contrast,PX-35000047,CDM,74176,CPT,350,RC,,,outpatient,,,1368,957.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,142.38,,,142.38,142.38,1050.624,fee schedule,,,
HC CT Scan-Abdoment and Pelvis-W Contrast,PX-35000048,CDM,74177,CPT,350,RC,,,outpatient,,,1971,1379.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,256.93,,,256.93,204.61123,1513.728,fee schedule,,,
CT Abdomen & Pelvis W/O Contrst 1/> Body Re,PX-35000049,CDM,74178,CPT,350,RC,,,outpatient,,,2122,1485.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,305.18,,,305.18,204.61123,1629.696,fee schedule,,,
HC MRI- Abdomen (MRI),PX-61000053,CDM,74181,CPT,610,RC,,,outpatient,,,2357,1649.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,291.45,,,291.45,237.688956,1810.176,fee schedule,,,
HC MRI- Abdomen W/Contrast,PX-61000054,CDM,74182,CPT,610,RC,,,outpatient,,,5081,3556.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,416.99,,,416.99,399.547552,3902.208,fee schedule,,,
MRI Abdomen W/O & W/Contrast Material,PX-61000055,CDM,74183,CPT,610,RC,,,outpatient,,,2698,1888.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,449.16,,,449.16,399.547552,2072.064,fee schedule,,,
HC MR Angio Abdomen (Mra) W/Contrast,PX-61000056,CDM,74185,CPT,610,RC,,,outpatient,,,2446,1712.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,632.7802,301.425681,1878.528,percent of total billed charges,,,
HC MR Angio Abdomen (Mra) Without Contrast,PX-61000077,CDM,74185,CPT,610,RC,,,outpatient,,,2446,1712.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,632.7802,301.425681,1878.528,percent of total billed charges,,,
HC MR Angio Abdomen (Mra) W/Without Contrast,PX-61000078,CDM,74185,CPT,610,RC,,,outpatient,,,2446,1712.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,632.7802,301.425681,1878.528,percent of total billed charges,,,
HC Esophagram,PX-32000107,CDM,74220,CPT,320,RC,,,outpatient,,,981,686.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,253.7847,76.026473,753.408,percent of total billed charges,,,
HC Swallowing Fcn-W/Cine &/or Video,PX-32000108,CDM,74230,CPT,320,RC,,,outpatient,,,874,611.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,226.1038,128.66,671.232,percent of total billed charges,,,
HC Remove Esophagus Obstruction,PX-32000109,CDM,74235,CPT,320,RC,,,outpatient,,,1157,809.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,259.7465,888.576,other,Non-Reimbursable Procedures,,
HC Xray Upper GI Tract,PX-32000110,CDM,74240,CPT,320,RC,,,outpatient,,,916,641.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,236.9692,200.53123,703.488,percent of total billed charges,,,
HC Xray Upper GI Air Contrast,PX-32000113,CDM,74246,CPT,320,RC,,,outpatient,,,865,605.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,223.7755,194.1925,664.32,percent of total billed charges,,,
HC X-Ray-Small Bowel-W/Mult Serial Films,PX-32000116,CDM,74250,CPT,320,RC,,,outpatient,,,2949,2064.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,762.9063,128.66,2264.832,percent of total billed charges,,,
HC X-Ray Small Bowel Enteroclysis,PX-32000117,CDM,74251,CPT,320,RC,,,outpatient,,,1182,827.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,305.7834,183.14,907.776,percent of total billed charges,,,
HC X-Ray Colon Contrast,PX-32000118,CDM,74270,CPT,320,RC,,,outpatient,,,1071,749.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,277.0677,200.53123,822.528,percent of total billed charges,,,
HC X-Ray Colon Air Contrast,PX-32000119,CDM,74280,CPT,320,RC,,,outpatient,,,1758,1230.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,454.7946,200.53123,1350.144,percent of total billed charges,,,
HC X-Ray Oper Cholangiogram,PX-32000123,CDM,74300,CPT,320,RC,,,outpatient,,,1336,935.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,145.12362,1026.048,other,Non-Reimbursable Procedures,,
HC X-Ray Oper Cholangio Addnl Set,PX-32000124,CDM,74301,CPT,320,RC,,,outpatient,,,289,202.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,64.8805,416.02,other,Non-Reimbursable Procedures,,
HC X-Ray Bile/Pancreas Endoscopy,PX-32000129,CDM,74330,CPT,320,RC,,,outpatient,,,1038,726.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,145.12362,797.184,other,Non-Reimbursable Procedures,,
HC X-Ray Introductn GI Tube,PX-32000130,CDM,74340,CPT,320,RC,,,outpatient,,,872,610.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,195.08,669.696,other,Non-Reimbursable Procedures,,
HC X-Ray Guide Enteroclysis Tube,PX-32000131,CDM,74355,CPT,320,RC,,,outpatient,,,2913,2039.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,260.23,2237.184,other,Non-Reimbursable Procedures,,
HC X-Ray Guide- GI Dilation,PX-32000132,CDM,74360,CPT,320,RC,,,outpatient,,,631,441.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,141.6595,484.608,other,Non-Reimbursable Procedures,,
HC Percut Transhepat Dilat-Bile Duct Strict,PX-32000133,CDM,74363,CPT,320,RC,,,outpatient,,,2462,1723.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,1890.816,other,Non-Reimbursable Procedures,,
HC X-Ray IV Pyelogram (Ivp),PX-32000134,CDM,74400,CPT,320,RC,,,outpatient,,,599,419.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,154.9613,134.4755,499.422,percent of total billed charges,,,
HC X-Ray IV Pyelogram+Tomography,PX-32000136,CDM,74415,CPT,320,RC,,,outpatient,,,2078,1454.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,537.5786,200.53123,1595.904,percent of total billed charges,,,
HC X-Ray Retrograde Pyelogram,PX-32000137,CDM,74420,CPT,320,RC,,,outpatient,,,1189,832.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,307.5943,237.819698,1020.2995,percent of total billed charges,,,
HC Antegrade Urography Radiological Supvj & Interpj,PX-32000138,CDM,74425,CPT,320,RC,,,outpatient,,,2829,1980.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,2172.672,other,Non-Reimbursable Procedures,,
HC X-Ray Cystogram- Min 3 View,PX-32000139,CDM,74430,CPT,320,RC,,,outpatient,,,1189,832.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,237.819698,1020.2995,other,Non-Reimbursable Procedures,,
HC X-Ray Urethrocystogram,PX-32000140,CDM,74450,CPT,320,RC,,,outpatient,,,762,533.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,171.069,646.6965,other,Non-Reimbursable Procedures,,
HC X-Ray Urethrocystogram+Voiding,PX-32000141,CDM,74455,CPT,320,RC,,,outpatient,,,762,533.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,171.069,646.6965,other,Non-Reimbursable Procedures,,
HC X-Ray Renal Cyst Xlumbar+Contrst,PX-32000142,CDM,74470,CPT,320,RC,,,outpatient,,,542,379.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,121.679,1393.3385,other,Non-Reimbursable Procedures,,
HC X-Ray Guide- Gu Dilation,PX-32000145,CDM,74485,CPT,320,RC,,,outpatient,,,3417,2391.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,5136.771,other,Non-Reimbursable Procedures,,
HC X-Ray Hysterosalpingogram,PX-32000146,CDM,74740,CPT,320,RC,,,outpatient,,,1695,1186.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,237.819698,1301.76,other,Non-Reimbursable Procedures,,
HC X-Ray Xcerv Cath Fallopian Tube,PX-32000147,CDM,74742,CPT,320,RC,,,outpatient,,,1270,889,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,285.115,975.36,other,Non-Reimbursable Procedures,,
HC Cardiac MRI Morphology & Function W/O Contrast,PX-61000057,CDM,75557,CPT,610,RC,,,outpatient,,,2222,1555.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,234.18,,,234.18,88.902,1706.496,fee schedule,,,
HC PR Cardiac MRI Morphology & Function W/O Contrast,PX-97200020,CDM,75557,CPT,972,RC,,,outpatient,,,396,277.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,234.18,,,234.18,88.902,1706.496,fee schedule,,,
HC Cardiac MRI W/W/O Contrast & Further Seq,PX-61000059,CDM,75561,CPT,610,RC,,,outpatient,,,2644,1850.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,336.18,,,336.18,102.5965,2030.592,fee schedule,,,
HC PR Cardiac MRI W/W/O Contrast & Further Seq,PX-97200021,CDM,75561,CPT,972,RC,,,outpatient,,,457,319.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,336.18,,,336.18,102.5965,2030.592,fee schedule,,,
HC Cardiac MRI for Velocity Flow Mapping,PX-61000061,CDM,75565,CPT,610,RC,,,outpatient,,,222,155.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,47.83,,,47.83,9.2045,836,fee schedule,,,
HC PR Cardiac MRI for Velocity Flow Mapping,PX-97200022,CDM,75565,CPT,972,RC,,,outpatient,,,41,28.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,47.83,,,47.83,9.2045,836,fee schedule,,,
HC CT Heart W/O Contrast Quant Eval Coronary Calcium,PX-35000052,CDM,75571,CPT,350,RC,,,outpatient,,,264,184.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,31.78,,,31.78,19.0825,575,fee schedule,,,
HC PR CT Heart W/O Contrast Quant Eval Coronary Calcium,PX-97200023,CDM,75571,CPT,972,RC,,,outpatient,,,85,59.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,31.78,,,31.78,19.0825,575,fee schedule,,,
HC CT Heart Contrast Eval Cardiac Struct/Morph,PX-35000053,CDM,75572,CPT,350,RC,,,outpatient,,,872,610.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,223.19,,,223.19,58.819,669.696,fee schedule,,,
HC PR CT Heart Contrast Eval Cardiac Struct/Morph,PX-97200024,CDM,75572,CPT,972,RC,,,outpatient,,,262,183.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,223.19,,,223.19,58.819,669.696,fee schedule,,,
HC CT Heart Contrast Eval Cardiac Struct/Morph- Congen Heart Disease,PX-35000054,CDM,75573,CPT,350,RC,,,outpatient,,,1016,711.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,298.51,,,298.51,58.819,780.288,fee schedule,,,
HC PR CT Heart Contrast Eval Cardiac Struct/Morph- Congen Heart Disease,PX-97200025,CDM,75573,CPT,972,RC,,,outpatient,,,262,183.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,298.51,,,298.51,58.819,780.288,fee schedule,,,
HC CT Angio Hrt Cornry Art/Bypass Grfts Contrst 3d Post,PX-35000055,CDM,75574,CPT,350,RC,,,outpatient,,,1073,751.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,320.09,,,320.09,57.921,824.064,fee schedule,,,
HC PR CT Angio Hrt Cornry Art/Bypass Grfts Contrst 3d Post,PX-97200026,CDM,75574,CPT,972,RC,,,outpatient,,,258,180.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,320.09,,,320.09,57.921,824.064,fee schedule,,,
HC N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp,PX-48000097,CDM,75580,CPT,480,RC,,,outpatient,,,2856,1999.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,738.8472,399.86,2536.61118,percent of total billed charges,,,
HC Angio Aortogram Thoracic,PX-32000148,CDM,75600,CPT,320,RC,,,outpatient,,,3155,2208.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,8249.769,other,Non-Reimbursable Procedures,,
HC Angio Aortogram Thor Serial,PX-32000149,CDM,75605,CPT,320,RC,,,outpatient,,,12541,8778.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,14233.715,other,Non-Reimbursable Procedures,,
HC Angio Aortogram Abd Serial,PX-32000150,CDM,75625,CPT,320,RC,,,outpatient,,,5654,3957.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,8249.769,other,Non-Reimbursable Procedures,,
HC Angio Aortobifemoral W Cath,PX-32000151,CDM,75630,CPT,320,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,8249.769,other,Non-Reimbursable Procedures,,
Cta Abdl Aorta&Bi Iliofem W/Contrast&Postp,PX-35000056,CDM,75635,CPT,350,RC,,,outpatient,,,1721,1204.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,330.22,,,330.22,200.53123,1321.728,fee schedule,,,
HC Angio Spinal Selectv,PX-32000153,CDM,75705,CPT,320,RC,,,outpatient,,,11403,7982.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,14233.715,other,Non-Reimbursable Procedures,,
HC Angio Extremity Unilat,PX-32000154,CDM,75710,CPT,320,RC,,,outpatient,,,6489,4542.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,8249.769,other,Non-Reimbursable Procedures,,
HC Angio Extermity Bilat,PX-32000155,CDM,75716,CPT,320,RC,,,outpatient,,,7162,5013.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,8249.769,other,Non-Reimbursable Procedures,,
HC Angio Visceral Selectv/Subselec,PX-32000156,CDM,75726,CPT,320,RC,,,outpatient,,,9831,6881.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2543.2797,399.86,14233.715,percent of total billed charges,,,
HC Angio Adrenal Unilat Select,PX-32000157,CDM,75731,CPT,320,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,8249.769,other,Non-Reimbursable Procedures,,
HC Angio Adrenal Bilat Select,PX-32000158,CDM,75733,CPT,320,RC,,,outpatient,,,6665,4665.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,8249.769,other,Non-Reimbursable Procedures,,
HC Angio Pelvis,PX-32000159,CDM,75736,CPT,320,RC,,,outpatient,,,11403,7982.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,14233.715,other,Non-Reimbursable Procedures,,
HC Angio Pulmon Unilat Select,PX-32000160,CDM,75741,CPT,320,RC,,,outpatient,,,6665,4665.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,8249.769,other,Non-Reimbursable Procedures,,
HC Angio Pulmon Bilat Select,PX-32000161,CDM,75743,CPT,320,RC,,,outpatient,,,7162,5013.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,8249.769,other,Non-Reimbursable Procedures,,
HC Angio Pulmon Bilat Nonselec,PX-32000162,CDM,75746,CPT,320,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,8249.769,other,Non-Reimbursable Procedures,,
HC Angio Intern Mammary,PX-32000163,CDM,75756,CPT,320,RC,,,outpatient,,,6665,4665.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,8249.769,other,Non-Reimbursable Procedures,,
HC Angio Ea Addnl Selectv Vessel,PX-32000164,CDM,75774,CPT,320,RC,,,outpatient,,,3538,2476.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,2717.184,other,Non-Reimbursable Procedures,,
HC Nonvascular Shuntogram,PX-32000166,CDM,75809,CPT,320,RC,,,outpatient,,,411,287.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,92.2695,416.02,other,Non-Reimbursable Procedures,,
HC Venogram Splenoportogram,PX-32000167,CDM,75810,CPT,320,RC,,,outpatient,,,7698,5388.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1991.4726,399.86,8249.769,percent of total billed charges,,,
HC Venogram Extrem Unilat,PX-32000168,CDM,75820,CPT,320,RC,,,outpatient,,,3212,2248.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,4120.349,other,Non-Reimbursable Procedures,,
HC Venogram Extrem Bilat,PX-32000169,CDM,75822,CPT,320,RC,,,outpatient,,,2940,2058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,4120.349,other,Non-Reimbursable Procedures,,
HC Venogram Infer Vena Cava,PX-32000170,CDM,75825,CPT,320,RC,,,outpatient,,,5987,4190.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,8249.769,other,Non-Reimbursable Procedures,,
HC Venogram Super Vena Cava,PX-32000171,CDM,75827,CPT,320,RC,,,outpatient,,,2874,2011.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,4120.349,other,Non-Reimbursable Procedures,,
HC Venogram Renal Unilat,PX-32000172,CDM,75831,CPT,320,RC,,,outpatient,,,6489,4542.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,8249.769,other,Non-Reimbursable Procedures,,
HC Venogram Renal Bilat,PX-32000173,CDM,75833,CPT,320,RC,,,outpatient,,,6665,4665.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,8249.769,other,Non-Reimbursable Procedures,,
HC Venogram Adrenal Unilat,PX-32000174,CDM,75840,CPT,320,RC,,,outpatient,,,7698,5388.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,8249.769,other,Non-Reimbursable Procedures,,
HC Venogram Adrenal Bilat,PX-32000175,CDM,75842,CPT,320,RC,,,outpatient,,,11403,7982.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,14233.715,other,Non-Reimbursable Procedures,,
HC Venogram Sinus/Jugular,PX-32000176,CDM,75860,CPT,320,RC,,,outpatient,,,6665,4665.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,8249.769,other,Non-Reimbursable Procedures,,
HC Venogram Super Sag Sinus,PX-32000177,CDM,75870,CPT,320,RC,,,outpatient,,,4428,3099.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,8249.769,other,Non-Reimbursable Procedures,,
HC Venogram Epidural,PX-32000178,CDM,75872,CPT,320,RC,,,outpatient,,,4428,3099.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,3400.704,other,Non-Reimbursable Procedures,,
HC Venogram Orbital,PX-32000179,CDM,75880,CPT,320,RC,,,outpatient,,,1638,1146.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,367.731,1602.0655,other,Non-Reimbursable Procedures,,
HC Percut Xhepatic Porto+Dynamic,PX-32000180,CDM,75885,CPT,320,RC,,,outpatient,,,7698,5388.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,8249.769,other,Non-Reimbursable Procedures,,
HC Percut Xhepatic Portogram,PX-32000181,CDM,75887,CPT,320,RC,,,outpatient,,,7528,5269.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,8249.769,other,Non-Reimbursable Procedures,,
HC Venogram Hepatic W Hemodynamics,PX-32000182,CDM,75889,CPT,320,RC,,,outpatient,,,5272,3690.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,8249.769,other,Non-Reimbursable Procedures,,
HC Venogram Hepatic,PX-32000183,CDM,75891,CPT,320,RC,,,outpatient,,,6665,4665.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,8249.769,other,Non-Reimbursable Procedures,,
HC Venous Sampling by Catheter,PX-32000184,CDM,75893,CPT,320,RC,,,outpatient,,,11403,7982.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,14233.715,other,Non-Reimbursable Procedures,,
HC Transcatheter Rx Embolizatn,PX-32000185,CDM,75894,CPT,320,RC,,,outpatient,,,2536,1775.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,145.12362,1947.648,other,Non-Reimbursable Procedures,,
HC Angrph Cath F-Up Std Tcat Other Than Thrombylsis,PX-32000187,CDM,75898,CPT,320,RC,,,outpatient,,,3747,2622.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,260.23,8249.769,other,Non-Reimbursable Procedures,,
HC Remove-Obst Matl-Cva Dev via Sep Ven Acc,PX-32000188,CDM,75901,CPT,320,RC,,,outpatient,,,4773,3341.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,260.23,3665.664,other,Non-Reimbursable Procedures,,
HC Remove-Obst Matl-Cva Device via Lumen,PX-32000189,CDM,75902,CPT,320,RC,,,outpatient,,,471,329.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,105.7395,416.02,other,Non-Reimbursable Procedures,,
HC Endovasc Repair Thor Aorta Incl Subclavian,PX-32000195,CDM,75956,CPT,320,RC,,,outpatient,,,1446,1012.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,324.627,1110.528,other,Non-Reimbursable Procedures,,
HC Endovasc Repair Thor Aorta Excl Subclavian,PX-32000196,CDM,75957,CPT,320,RC,,,outpatient,,,1312,918.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,294.544,1007.616,other,Non-Reimbursable Procedures,,
HC Proximal Extens Durng Endovasc Rethor Aorta,PX-32000197,CDM,75958,CPT,320,RC,,,outpatient,,,845,591.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,189.7025,648.96,other,Non-Reimbursable Procedures,,
HC Delayed Prox Extens Endovasc Rethor Aorta,PX-32000198,CDM,75959,CPT,320,RC,,,outpatient,,,744,520.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,167.028,571.392,other,Non-Reimbursable Procedures,,
HC Vascular Biopsy,PX-32000203,CDM,75970,CPT,320,RC,,,outpatient,,,2918,2042.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,145.12362,2241.024,other,Non-Reimbursable Procedures,,
HC Change Percut Tube/Drain Cath W Contrast Monit,PX-32000207,CDM,75984,CPT,320,RC,,,outpatient,,,2885,2019.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,145.12362,2215.68,other,Non-Reimbursable Procedures,,
HC Rad Guided-Percut Drainage-W/Cath Place,PX-32000208,CDM,75989,CPT,320,RC,,,outpatient,,,888,621.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,145.12362,681.984,other,Non-Reimbursable Procedures,,
HC Rad Guided-Percut Drainage-W/Cath Place,PX-35000057,CDM,75989,CPT,350,RC,,,outpatient,,,888,621.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,145.12362,681.984,other,Non-Reimbursable Procedures,,
HC Fluoroscopy Spx Up to 1 Hour Phys/Qhp Time,PX-32000209,CDM,76000,CPT,320,RC,,,outpatient,,,997,697.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,257.9239,195.08,765.696,percent of total billed charges,,,
HC X-Ray Nose-Rectum Child F.B.,PX-32000210,CDM,76010,CPT,320,RC,,,outpatient,,,340,238,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,87.958,71.24,416.02,percent of total billed charges,,,
HC X-Ray Fistula-Abscess-Sinus Tract,PX-32000211,CDM,76080,CPT,320,RC,,,outpatient,,,1950,1365,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,237.819698,1497.6,other,Non-Reimbursable Procedures,,
HC X-Ray Exam- Breast Specimen,PX-32000212,CDM,76098,CPT,320,RC,,,outpatient,,,984,688.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,254.5608,220.908,1393.3385,percent of total billed charges,,,
HC Cine/Videoradiology-Exc Where Spec Incl,PX-32000214,CDM,76120,CPT,320,RC,,,outpatient,,,382,267.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,98.8234,85.759,416.02,percent of total billed charges,,,
HC 3d Rendering W/Interp & Postprocess Supervision,PX-35000058,CDM,76376,CPT,350,RC,,,outpatient,,,352,246.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,79.024,836,other,Non-Reimbursable Procedures,,
HC 3d Rendering W/Interp & Postprocess Supervision,PX-40200003,CDM,76376,CPT,402,RC,,,outpatient,,,352,246.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,79.024,836,other,Non-Reimbursable Procedures,,
HC 3d Rendering W/Interp & Postprocess Supervision,PX-61000062,CDM,76376,CPT,610,RC,,,outpatient,,,352,246.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,79.024,836,other,Non-Reimbursable Procedures,,
HC 3d Rendering W/Interp&Postproc Diff Work Station,PX-35000059,CDM,76377,CPT,350,RC,,,outpatient,,,422,295.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,94.739,836,other,Non-Reimbursable Procedures,,
HC 3d Rendering W/Interp&Postproc Diff Work Station,PX-40200004,CDM,76377,CPT,402,RC,,,outpatient,,,422,295.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,94.739,836,other,Non-Reimbursable Procedures,,
HC 3d Rendering W/Interp&Postproc Diff Work Station,PX-61000063,CDM,76377,CPT,610,RC,,,outpatient,,,422,295.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,94.739,836,other,Non-Reimbursable Procedures,,
HC CT Scan-Limited/Localized F/U Study,PX-35000060,CDM,76380,CPT,350,RC,,,outpatient,,,928,649.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,113.35,,,113.35,71.24,712.704,fee schedule,,,
HC MRI Spectroscopy,PX-61000064,CDM,76390,CPT,610,RC,,,outpatient,,,2218,1552.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,412.28,,,412.28,81.08,1703.424,fee schedule,,,
HC Magnetic Resonance Elastography,PX-61000090,CDM,76391,CPT,610,RC,,,outpatient,,,842,589.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,217.8254,189.029,836,percent of total billed charges,,,
HC Unlisted CT Procedure,PX-35000061,CDM,76497,CPT,350,RC,,,outpatient,,,229,160.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,59.2423,51.4105,575,percent of total billed charges,,,
HC US- Head- Real Time,PX-40200005,CDM,76506,CPT,402,RC,,,outpatient,,,433,303.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,112.0171,97.2085,416.02,percent of total billed charges,,,
HC US- Head/Neck Tissues-Real Time,PX-40200006,CDM,76536,CPT,402,RC,,,outpatient,,,444,310.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,114.8628,99.678,416.02,percent of total billed charges,,,
HC US- Chest-Real Time,PX-40200007,CDM,76604,CPT,402,RC,,,outpatient,,,417,291.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,107.8779,93.6165,416.02,percent of total billed charges,,,
HC US Breast Uni Real Time With Image Complete,PX-40200056,CDM,76641,CPT,402,RC,,,outpatient,,,385,269.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,99.5995,86.4325,416.02,percent of total billed charges,,,
HC US Breast Uni Real Time With Image Limited,PX-40200055,CDM,76642,CPT,402,RC,,,outpatient,,,353,247.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,91.3211,71.24,416.02,percent of total billed charges,,,
HC US- Abdom-B-Scan &/or Real Time-Complete,PX-40200009,CDM,76700,CPT,402,RC,,,outpatient,,,461,322.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,119.2607,103.4945,416.02,percent of total billed charges,,,
HC US- Abdomen Limited,PX-40200010,CDM,76705,CPT,402,RC,,,outpatient,,,341,238.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,88.2167,76.5545,416.02,percent of total billed charges,,,
HC Ultrasound Exam Aaa Screen,PX-40200002,CDM,76706,CPT,402,RC,,,outpatient,,,261,182.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,67.5207,58.5945,416.02,percent of total billed charges,,,
HC US-Retroperit- B-Scan/Real Time-Complete,PX-40200011,CDM,76770,CPT,402,RC,,,outpatient,,,368,257.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,95.2016,82.616,416.02,percent of total billed charges,,,
HC US- Retroperitnl Abd- Ltd,PX-40200012,CDM,76775,CPT,402,RC,,,outpatient,,,345,241.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,89.2515,77.4525,416.02,percent of total billed charges,,,
HC US- Spinal Canal & Contents,PX-40200014,CDM,76800,CPT,402,RC,,,outpatient,,,595,416.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,153.9265,119.991125,456.96,percent of total billed charges,,,
HC US- OB < 14 Wks- Single Fetus,PX-40200015,CDM,76801,CPT,402,RC,,,outpatient,,,289,202.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,74.7643,64.8805,416.02,percent of total billed charges,,,
HC US- OB < 14 Wks- Add'l Fetus,PX-40200016,CDM,76802,CPT,402,RC,,,outpatient,,,224,156.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,57.9488,50.288,416.02,percent of total billed charges,,,
HC US- OB >/= 14 Wks- Sngl Fetus,PX-40200017,CDM,76805,CPT,402,RC,,,outpatient,,,421,294.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,108.9127,94.5145,416.02,percent of total billed charges,,,
HC US- OB >/= 14 Wks- Addl Fetus,PX-40200018,CDM,76810,CPT,402,RC,,,outpatient,,,713,499.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,184.4531,157.086513,547.584,percent of total billed charges,,,
HC US-Preg Uter-Fet & Mat-+ Detl Fet Exm,PX-40200019,CDM,76811,CPT,402,RC,,,outpatient,,,725,507.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,187.5575,162.7625,646.6965,percent of total billed charges,,,
HC US-Preg Uter-Fet & Mat-+ Detl Fet-Addl,PX-40200020,CDM,76812,CPT,402,RC,,,outpatient,,,240,168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,62.088,53.88,416.02,percent of total billed charges,,,
HC US-Pregnant Uterus-Limited- 1/> Fetuses,PX-40200021,CDM,76815,CPT,402,RC,,,outpatient,,,303,212.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,78.3861,68.0235,416.02,percent of total billed charges,,,
HC US-Pregnant Uterus-F/U-Transabd App,PX-40200022,CDM,76816,CPT,402,RC,,,outpatient,,,600,420,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,155.22,119.991125,460.8,percent of total billed charges,,,
HC US-Pregnant Uterus-Transvaginal,PX-40200023,CDM,76817,CPT,402,RC,,,outpatient,,,355,248.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,91.8385,79.6975,416.02,percent of total billed charges,,,
HC Fetal Biophysical Profile,PX-40200024,CDM,76818,CPT,402,RC,,,outpatient,,,439,307.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,113.5693,98.5555,416.02,percent of total billed charges,,,
HC Fetal Biophys Prof-W/O Nst,PX-40200025,CDM,76819,CPT,402,RC,,,outpatient,,,358,250.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,92.6146,80.371,416.02,percent of total billed charges,,,
HC Doppler Fetal Umbilical Artery,PX-40200026,CDM,76820,CPT,402,RC,,,outpatient,,,290,203,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,75.023,65.105,416.02,percent of total billed charges,,,
HC US-Pregnant Uterus-Limited- 1/> Fetuses,PX-40200028,CDM,76827,CPT,402,RC,,,outpatient,,,578,404.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,149.5286,119.991125,443.904,percent of total billed charges,,,
HC Sono Fetal Hrt Doppl F/U,PX-40200029,CDM,76828,CPT,402,RC,,,outpatient,,,146,102.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,37.7702,32.777,416.02,percent of total billed charges,,,
HC Echography-Transvaginal,PX-40200030,CDM,76830,CPT,402,RC,,,outpatient,,,365,255.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,94.4255,81.9425,416.02,percent of total billed charges,,,
HC Sono Exam- Hysterosonography,PX-40200031,CDM,76831,CPT,402,RC,,,outpatient,,,1006,704.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,260.2522,199.512292,772.608,percent of total billed charges,,,
HC Echo-Pelvic (Nonobstetric),PX-40200032,CDM,76856,CPT,402,RC,,,outpatient,,,361,252.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,93.3907,81.0445,416.02,percent of total billed charges,,,
HC Sono Pelvis Limited,PX-40200033,CDM,76857,CPT,402,RC,,,outpatient,,,332,232.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,85.8884,74.534,416.02,percent of total billed charges,,,
HC Echo-Scrotum & Contents,PX-40200034,CDM,76870,CPT,402,RC,,,outpatient,,,457,319.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,118.2259,102.5965,416.02,percent of total billed charges,,,
HC Echo-Transrectal,PX-40200035,CDM,76872,CPT,402,RC,,,outpatient,,,401,280.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,103.7387,90.0245,416.02,percent of total billed charges,,,
HC Echo-Transrectal-Prostate Vol,PX-40200036,CDM,76873,CPT,402,RC,,,outpatient,,,273,191.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,70.6251,61.2885,416.02,percent of total billed charges,,,
HC US-Extremity-Nonvascular-Real-Time Image-Complete,PX-40200037,CDM,76881,CPT,402,RC,,,outpatient,,,400,280,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,103.48,89.8,416.02,percent of total billed charges,,,
HC US-Extremity-Nonvascular-Real-Time Image-Limited,PX-40200038,CDM,76882,CPT,402,RC,,,outpatient,,,253,177.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,65.4511,56.7985,416.02,percent of total billed charges,,,
HC US Inft Hips R-T Img Dynamic Req Phys/Qhp Manj,PX-40200039,CDM,76885,CPT,402,RC,,,outpatient,,,412,288.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,106.5844,71.24,416.02,percent of total billed charges,,,
HC US Inft Hips R-T Img Lmtd Static Phys/Qhp Manj,PX-40200040,CDM,76886,CPT,402,RC,,,outpatient,,,412,288.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,106.5844,71.24,416.02,percent of total billed charges,,,
HC US Guid-Comp Repair-Pseudo-Aneur/Av Fist,PX-40200041,CDM,76936,CPT,402,RC,,,outpatient,,,681,476.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,176.1747,152.8845,775.5705,percent of total billed charges,,,
HC US Guide- Vascular Access,PX-40200042,CDM,76937,CPT,402,RC,,,outpatient,,,251,175.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,56.3495,416.02,other,Non-Reimbursable Procedures,,
HC US Guide- Tissue Ablation,PX-40200043,CDM,76940,CPT,402,RC,,,outpatient,,,460,322,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,103.27,416.02,other,Non-Reimbursable Procedures,,
HC Sono Guide Needle Biopsy,PX-40200044,CDM,76942,CPT,402,RC,,,outpatient,,,868,607.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,166.37,666.624,other,Non-Reimbursable Procedures,,
HC Sono Guide Amniocentesis,PX-40200045,CDM,76946,CPT,402,RC,,,outpatient,,,354,247.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,79.473,416.02,other,Non-Reimbursable Procedures,,
HC US Guid-Comp Repair-Pseudo-Aneur/Av Fist,PX-40200048,CDM,76998,CPT,402,RC,,,outpatient,,,604,422.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,135.598,463.872,other,Non-Reimbursable Procedures,,
HC Fluoroguide Cntrl Ven Access-Place-Replace-Remove,PX-32000217,CDM,77001,CPT,320,RC,,,outpatient,,,521,364.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,116.9645,416.02,other,Non-Reimbursable Procedures,,
HC Fluoroscopic Guidance Needle Placement,PX-32000218,CDM,77002,CPT,320,RC,,,outpatient,,,318,222.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,71.391,416.02,other,Non-Reimbursable Procedures,,
HC Fluorscopic Guidance Spinal Injection,PX-32000219,CDM,77003,CPT,320,RC,,,outpatient,,,518,362.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,116.291,416.02,other,Non-Reimbursable Procedures,,
HC CT Guidance Stereotactic Localization,PX-35000062,CDM,77011,CPT,350,RC,,,outpatient,,,1801,1260.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,1383.168,other,Non-Reimbursable Procedures,,
HC CT Guidance Needle Placement,PX-35000063,CDM,77012,CPT,350,RC,,,outpatient,,,1747,1222.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,63.344499,1341.696,other,Non-Reimbursable Procedures,,
HC CT Guidance Tissue Ablation,PX-35000064,CDM,77013,CPT,350,RC,,,outpatient,,,1755,1228.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,63.344499,1347.84,other,Non-Reimbursable Procedures,,
HC CT Guidance Placement Rad Therapy Fields,PX-35000065,CDM,77014,CPT,350,RC,,,outpatient,,,623,436.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,139.8635,575,other,Non-Reimbursable Procedures,,
HC MRI Guidance Needle Placement,PX-61000066,CDM,77021,CPT,610,RC,,,outpatient,,,3092,2164.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,2374.656,other,Non-Reimbursable Procedures,,
HC MRI Breast Without Contrast Material Unilateral,PX-61000083,CDM,77046,CPT,610,RC,,,outpatient,,,842,589.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,217.8254,189.029,836,percent of total billed charges,,,
HC MRI Breast Without Contrast Material Bilateral,PX-61000086,CDM,77047,CPT,610,RC,,,outpatient,,,842,589.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,217.8254,189.029,836,percent of total billed charges,,,
HC MRI Breast With Contrast W/Cad Unilateral,PX-61000084,CDM,77048,CPT,610,RC,,,outpatient,,,2118,1482.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,547.9266,399.547552,1936.896,percent of total billed charges,,,
HC MRI Breast W/Out&With Contrast W/Cad Unilateral,PX-61000085,CDM,77048,CPT,610,RC,,,outpatient,,,2522,1765.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,652.4414,399.547552,1936.896,percent of total billed charges,,,
HC MRI Breast With Contrast W/Cad Bilateral,PX-61000087,CDM,77049,CPT,610,RC,,,outpatient,,,2788,1951.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,721.2556,399.547552,2548.224,percent of total billed charges,,,
HC MRI Breast W/Out&With Contrast W/Cad Bilateral,PX-61000088,CDM,77049,CPT,610,RC,,,outpatient,,,3318,2322.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,858.3666,399.547552,2548.224,percent of total billed charges,,,
HC Digital Breast Tomosynthesis Unilateral,PX-40100006,CDM,77061,CPT,401,RC,,,outpatient,,,321,224.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,72.0645,416.02,other,Non-Reimbursable Procedures,,
HC Digital Breast Tomosynthesis Bilateral,PX-40100007,CDM,77062,CPT,401,RC,,,outpatient,,,393,275.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,88.2285,416.02,other,Non-Reimbursable Procedures,,
HC Screening Digital Breast Tomosynthesis Bi,PX-40300004,CDM,77063,CPT,403,RC,,,outpatient,,,202,141.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.99364,416.02,other,Non-Reimbursable Procedures,,
HC Dx Mammo Incl Cad Uni,PX-40100008,CDM,77065,CPT,401,RC,,,outpatient,,,393,275.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,101.6691,88.2285,416.02,percent of total billed charges,,,
HC Dx Mammo Incl Cad Bi,PX-40100009,CDM,77066,CPT,401,RC,,,outpatient,,,466,326.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,120.5542,90.800319,416.02,percent of total billed charges,,,
HC Scr Mammo Bi Incl Cad,PX-40300005,CDM,77067,CPT,403,RC,,,outpatient,,,466,326.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,120.5542,90.800319,416.02,percent of total billed charges,,,
HC Manual Appl Stress Pfrmd Phys/Qhp Joint Films,PX-32000222,CDM,77071,CPT,320,RC,,,outpatient,,,262,183.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,67.7794,58.819,416.02,percent of total billed charges,,,
HC X-Rays for Bone Age,PX-32000223,CDM,77072,CPT,320,RC,,,outpatient,,,218,152.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,56.3966,48.941,416.02,percent of total billed charges,,,
HC X-Rays- Bone Length Studies,PX-32000224,CDM,77073,CPT,320,RC,,,outpatient,,,502,351.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,129.8674,76.026473,416.02,percent of total billed charges,,,
HC X-Rays- Bone Survey- Limited,PX-32000225,CDM,77074,CPT,320,RC,,,outpatient,,,502,351.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,129.8674,112.699,416.02,percent of total billed charges,,,
HC X-Rays- Bone Survey Complete,PX-32000226,CDM,77075,CPT,320,RC,,,outpatient,,,502,351.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,129.8674,112.699,416.02,percent of total billed charges,,,
HC X-Rays- Bone Survey- Infant,PX-32000227,CDM,77076,CPT,320,RC,,,outpatient,,,502,351.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,129.8674,76.026473,416.02,percent of total billed charges,,,
HC Dexa-Bone Density- 1 + Site- Axial Skeleton,PX-32000228,CDM,77080,CPT,320,RC,,,outpatient,,,575,402.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,148.7525,119.991125,441.6,percent of total billed charges,,,
HC Dexa-Bone Density- 1 + Site- Appendiculr Skeltn,PX-32000229,CDM,77081,CPT,320,RC,,,outpatient,,,114,79.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,29.4918,25.593,416.02,percent of total billed charges,,,
HC MRI- Bone Marrow,PX-61000070,CDM,77084,CPT,610,RC,,,outpatient,,,2406,1684.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,312.36,,,312.36,267.439885,1847.808,fee schedule,,,
HC Tbs Techl Prep&Transmis Data Alys Pfrmd Elsewhr,PX-32000262,CDM,77090,CPT,320,RC,,,outpatient,,,248,173.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,55.676,416.02,other,Non-Reimbursable Procedures,,
HC Tbs Technical Calculation Only,PX-32000263,CDM,77091,CPT,320,RC,,,outpatient,,,248,173.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,55.676,416.02,other,Non-Reimbursable Procedures,,
HC Thyroid Uptake Single/Multiple Quant Measurement,PX-34100001,CDM,78012,CPT,341,RC,,,outpatient,,,935,654.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,241.8845,209.9075,1076.394,percent of total billed charges,,,
HC Thyroid Imaging With Vascular Flow,PX-34100002,CDM,78013,CPT,341,RC,,,outpatient,,,633,443.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,163.7571,142.1085,1076.394,percent of total billed charges,,,
HC Thyroid Uptake W/Blood Flow Sngle/Mult Quan Meas,PX-34100003,CDM,78014,CPT,341,RC,,,outpatient,,,982,687.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,254.0434,220.459,1076.394,percent of total billed charges,,,
HC Thyroid Met Imaging Body,PX-34100005,CDM,78018,CPT,341,RC,,,outpatient,,,1049,734.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,271.3763,235.5005,1397.122,percent of total billed charges,,,
HC Thyroid Met Uptake,PX-34100006,CDM,78020,CPT,341,RC,,,outpatient,,,171,119.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,44.2377,38.3895,416.02,percent of total billed charges,,,
HC Parathyroid Planar Imaging,PX-34100007,CDM,78070,CPT,341,RC,,,outpatient,,,1575,1102.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,407.4525,353.5875,1209.6,percent of total billed charges,,,
HC Parathyroid Planar Imaging W/WO Subtraction,PX-34100008,CDM,78071,CPT,341,RC,,,outpatient,,,1357,949.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,351.0559,304.6465,1076.394,percent of total billed charges,,,
HC Parathyroid Imaging W/Tomographic Spect & CT,PX-34100009,CDM,78072,CPT,341,RC,,,outpatient,,,1898,1328.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,491.0126,358.69,1457.664,percent of total billed charges,,,
HC Adrenal Nuclear Imaging,PX-34100010,CDM,78075,CPT,341,RC,,,outpatient,,,2974,2081.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,769.3738,399.86,3675.6585,percent of total billed charges,,,
HC Bone Marrow Imaging- Ltd,PX-34100011,CDM,78102,CPT,341,RC,,,outpatient,,,1403,982.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,362.9561,314.9735,1077.504,percent of total billed charges,,,
HC Bone Marrow Imaging- Mult,PX-34100012,CDM,78103,CPT,341,RC,,,outpatient,,,1403,982.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,362.9561,314.9735,1077.504,percent of total billed charges,,,
HC Bone Marrow Imaging- Body,PX-34100013,CDM,78104,CPT,341,RC,,,outpatient,,,659,461.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,170.4833,147.9455,1076.394,percent of total billed charges,,,
HC Spleen Imaging,PX-34100015,CDM,78185,CPT,341,RC,,,outpatient,,,971,679.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,251.1977,217.9895,1076.394,percent of total billed charges,,,
HC Lymphatics & Lymph Glands Imaging,PX-34100016,CDM,78195,CPT,341,RC,,,outpatient,,,1071,749.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,277.0677,240.4395,1397.122,percent of total billed charges,,,
HC Liver Imaging,PX-34100017,CDM,78201,CPT,341,RC,,,outpatient,,,2228,1559.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,576.3836,399.86,2239.93036,percent of total billed charges,,,
HC Liver and Spleen Imaging,PX-34100021,CDM,78215,CPT,341,RC,,,outpatient,,,1205,843.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,311.7335,270.5225,1076.394,percent of total billed charges,,,
HC Hepatobiliary Syst Imaging Including Gallbladder,PX-34100023,CDM,78226,CPT,341,RC,,,outpatient,,,1384,968.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,358.0408,310.708,1076.394,percent of total billed charges,,,
HC Hepatobil Syst Imag Inc Gb W/Pharma Intervenj,PX-34100024,CDM,78227,CPT,341,RC,,,outpatient,,,1384,968.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,358.0408,310.708,1397.122,percent of total billed charges,,,
HC Serial Salivary Imaging,PX-34100025,CDM,78231,CPT,341,RC,,,outpatient,,,788,551.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,203.8556,176.906,1076.394,percent of total billed charges,,,
HC Gastroesophageal Reflux Exam,PX-34100027,CDM,78262,CPT,341,RC,,,outpatient,,,1043,730.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,269.8241,234.1535,1076.394,percent of total billed charges,,,
HC Gastric Emptying Study,PX-34100028,CDM,78264,CPT,341,RC,,,outpatient,,,838,586.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,216.7906,188.131,1076.394,percent of total billed charges,,,
HC Acute GI Blood Loss Imaging,PX-34100031,CDM,78278,CPT,341,RC,,,outpatient,,,2079,1455.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,537.8373,399.86,1596.672,percent of total billed charges,,,
HC Bowel Imaging,PX-34100032,CDM,78290,CPT,341,RC,,,outpatient,,,893,625.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,231.0191,200.4785,1076.394,percent of total billed charges,,,
HC Leveen/Shunt Patency Exam,PX-34100033,CDM,78291,CPT,341,RC,,,outpatient,,,954,667.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,246.7998,214.173,1076.394,percent of total billed charges,,,
HC Bone Imaging- Limited Area,PX-34100034,CDM,78300,CPT,341,RC,,,outpatient,,,962,673.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,248.8694,215.969,1076.394,percent of total billed charges,,,
HC Bone Imaging- Multiple Areas,PX-34100035,CDM,78305,CPT,341,RC,,,outpatient,,,1098,768.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,284.0526,246.501,1076.394,percent of total billed charges,,,
HC Bone Imaging- Whole Body,PX-34100036,CDM,78306,CPT,341,RC,,,outpatient,,,893,625.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,231.0191,200.4785,1076.394,percent of total billed charges,,,
HC Bone Imaging- 3 Phase,PX-34100037,CDM,78315,CPT,341,RC,,,outpatient,,,956,669.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,247.3172,214.622,1076.394,percent of total billed charges,,,
HC Myocardial Spect Single Study at Rest or Stress,PX-34100040,CDM,78451,CPT,341,RC,,,outpatient,,,4510,3157,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1166.737,399.86,3675.6585,percent of total billed charges,,,
HC Myocardial Spect Multiple Studies,PX-34100041,CDM,78452,CPT,341,RC,,,outpatient,,,4510,3157,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1166.737,399.86,3675.6585,percent of total billed charges,,,
HC Myocardial Perfusion Planar 1 Study Rest/Stress,PX-34100042,CDM,78453,CPT,341,RC,,,outpatient,,,3900,2730,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1008.93,399.86,3675.6585,percent of total billed charges,,,
HC Myocardial Perfusion Planar Multiple Studies,PX-34100043,CDM,78454,CPT,341,RC,,,outpatient,,,3900,2730,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1008.93,399.86,3675.6585,percent of total billed charges,,,
HC Gated Heart- Planar Single,PX-34100048,CDM,78472,CPT,341,RC,,,outpatient,,,1586,1110.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,410.2982,356.057,1218.048,percent of total billed charges,,,
HC Heart Image- Spect,PX-34100050,CDM,78494,CPT,341,RC,,,outpatient,,,1671,1169.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,432.2877,375.1395,1283.328,percent of total billed charges,,,
HC Pulmonary Ventilation Imaging,PX-34100052,CDM,78579,CPT,341,RC,,,outpatient,,,767,536.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,198.4229,172.1915,1076.394,percent of total billed charges,,,
HC Lung Perfusion Imaging,PX-34100053,CDM,78580,CPT,341,RC,,,outpatient,,,640,448,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,165.568,143.68,1076.394,percent of total billed charges,,,
HC Pulmonary Ventilation & Perfusion Imaging,PX-34100054,CDM,78582,CPT,341,RC,,,outpatient,,,946,662.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,244.7302,212.377,1397.122,percent of total billed charges,,,
HC Quant Differential Pulm Perfusion W/WO Imaging,PX-34100055,CDM,78597,CPT,341,RC,,,outpatient,,,902,631.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,233.3474,202.499,1076.394,percent of total billed charges,,,
HC Quant Diff Pulm Prfusion & Ventlaj W/WO Imaging,PX-34100056,CDM,78598,CPT,341,RC,,,outpatient,,,1499,1049.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,387.7913,336.5255,1397.122,percent of total billed charges,,,
HC Brain Imaging < 4 Static Views W Vascular Flow,PX-34100058,CDM,78601,CPT,341,RC,,,outpatient,,,2704,1892.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,699.5248,399.86,2076.672,percent of total billed charges,,,
HC Brain Imaging Min 4 Static Views W Vascular Flow,PX-34100059,CDM,78606,CPT,341,RC,,,outpatient,,,1589,1112.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.0743,356.7305,1397.122,percent of total billed charges,,,
HC Brain Imaging Pet Metabolic,PX-40400003,CDM,78608,CPT,404,RC,,,outpatient,,,4890,3423,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1265.043,399.86,3755.52,percent of total billed charges,,,
HC CSF Fluid Scan Cisternography,PX-34100061,CDM,78630,CPT,341,RC,,,outpatient,,,2570,1799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,664.859,399.86,1973.76,percent of total billed charges,,,
HC CSF Shunt Evaluation,PX-34100062,CDM,78645,CPT,341,RC,,,outpatient,,,916,641.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,236.9692,205.642,1397.122,percent of total billed charges,,,
HC CSF Leakage Detection & Localization,PX-34100063,CDM,78650,CPT,341,RC,,,outpatient,,,3215,2250.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,831.7205,399.86,3675.6585,percent of total billed charges,,,
HC Renal Imaging- Static,PX-34100064,CDM,78700,CPT,341,RC,,,outpatient,,,1292,904.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,334.2404,290.054,1076.394,percent of total billed charges,,,
HC Renal Flow/Funct Imaging,PX-34100065,CDM,78707,CPT,341,RC,,,outpatient,,,1210,847,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,313.027,271.645,1397.122,percent of total billed charges,,,
HC Renal Flow/Funct Image-Pharm Rx,PX-34100066,CDM,78708,CPT,341,RC,,,outpatient,,,899,629.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,232.5713,201.8255,1397.122,percent of total billed charges,,,
HC Testicular Imaging & Flow,PX-34100069,CDM,78761,CPT,341,RC,,,outpatient,,,845,591.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,218.6015,189.7025,1076.394,percent of total billed charges,,,
HC Tumor Imaging- Limited Area,PX-34100070,CDM,78800,CPT,341,RC,,,outpatient,,,867,606.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,224.2929,194.6415,1076.394,percent of total billed charges,,,
HC Tumor Imaging- Whole Body- Single Day,PX-34100072,CDM,78802,CPT,341,RC,,,outpatient,,,3124,2186.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,808.1788,399.86,3675.6585,percent of total billed charges,,,
HC Tumor Imaging Spect,PX-34100073,CDM,78803,CPT,341,RC,,,outpatient,,,2419,1693.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,625.7953,399.86,3675.6585,percent of total billed charges,,,
HC Tumor Imaging- Whole Body- 2 or More Days,PX-34100074,CDM,78804,CPT,341,RC,,,outpatient,,,2916,2041.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,754.3692,399.86,3675.6585,percent of total billed charges,,,
HC Inject Radiopharm Non-Imaging Localization- IV,PX-34100080,CDM,78808,CPT,341,RC,,,outpatient,,,1227,858.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,317.4249,275.4615,1076.394,percent of total billed charges,,,
HC Pet Imaging CT for Attenuation Limited Area,PX-40400004,CDM,78814,CPT,404,RC,,,outpatient,,,5186,3630.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1341.6182,399.86,3982.848,percent of total billed charges,,,
HC Pet Imaging CT Attenuation Skull Base Mid-Thigh,PX-40400005,CDM,78815,CPT,404,RC,,,outpatient,,,6904,4832.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1786.0648,399.86,5302.272,percent of total billed charges,,,
HC Pet Imaging for CT Attenuation Whole Body,PX-40400006,CDM,78816,CPT,404,RC,,,outpatient,,,7705,5393.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1993.2835,399.86,5917.44,percent of total billed charges,,,
HC Rp Loclzj Tum Spect W/CT 1 Area 1 Day Imaging,PX-34100081,CDM,78830,CPT,341,RC,,,outpatient,,,4318,3022.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1117.0666,399.86,3675.6585,percent of total billed charges,,,
HC Rp Loclzj Tum Spect 2 Area 1d Img/1 Area Img>2+D,PX-34100082,CDM,78831,CPT,341,RC,,,outpatient,,,4318,3022.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1117.0666,399.86,3675.6585,percent of total billed charges,,,
HC Rp Loclzj Tum Spect CT 2area 1d Img/1 AR Img>2+D,PX-34100083,CDM,78832,CPT,341,RC,,,outpatient,,,4899,3429.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1267.3713,399.86,4124.5085,percent of total billed charges,,,
HC Radiopharmaceutical Quantification Meas 1 Area,PX-34100084,CDM,78835,CPT,341,RC,,,outpatient,,,203,142.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,52.5161,45.5735,416.02,percent of total billed charges,,,
HC Nuclear Therapy- Oral,PX-34200001,CDM,79005,CPT,342,RC,,,outpatient,,,782,547.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,202.3034,175.559,691.5815,percent of total billed charges,,,
HC Urinalysis- Auto- W/O Scope,PX-30000067,CDM,81003,CPT,300,RC,,,outpatient,,,32,22.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.2784,2.29,24.576,percent of total billed charges,,,
HC Urine Pregnancy Test,PX-30000713,CDM,81025,CPT,300,RC,,,outpatient,,,28,19.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.2436,6.286,21.504,percent of total billed charges,,,
HC Molecular Pathology Procedure Level 4,PX-30000097,CDM,81403,CPT,300,RC,,,outpatient,,,716,501.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,185.2292,160.742,549.888,percent of total billed charges,,,
HC Blood Occult-by Peroxid- Feces- 1-3 Simult- Non Ca Screen,PX-30000715,CDM,82272,CPT,300,RC,,,outpatient,,,24,16.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.2088,3.33,18.432,percent of total billed charges,,,
HC Glucose Blood Test,PX-30000221,CDM,82962,CPT,300,RC,,,outpatient,,,45,31.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.6415,2.4,34.56,percent of total billed charges,,,
HC Bone Marrow-Smear Interpretation,PX-31000012,CDM,85097,CPT,310,RC,,,outpatient,,,1038,726.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,268.5306,39.73,1313.895373,percent of total billed charges,,,
HC Coagulation Time- Activated,PX-30000417,CDM,85347,CPT,300,RC,,,outpatient,,,80,56,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,20.696,4.35,61.44,percent of total billed charges,,,
HC Hgb/Rbcs Fetal Fetomaternal Hemrrg Rosette,PX-30000732,CDM,85461,CPT,300,RC,,,outpatient,,,32,22.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.2784,6.78,24.576,percent of total billed charges,,,
HC Sickling RBC Reduction,PX-30000730,CDM,85660,CPT,300,RC,,,outpatient,,,25,17.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.4675,5.6125,19.2,percent of total billed charges,,,
HC Platelet Antibodies,PX-30000453,CDM,86022,CPT,300,RC,,,outpatient,,,128,89.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,33.1136,18.77,98.304,percent of total billed charges,,,
HC Cold Agglutinin Screen,PX-30000465,CDM,86156,CPT,300,RC,,,outpatient,,,158,110.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,40.8746,6.51,121.344,percent of total billed charges,,,
HC Cold Agglutinin- Titer,PX-30000466,CDM,86157,CPT,300,RC,,,outpatient,,,29,20.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.5023,6.5105,24.43,percent of total billed charges,,,
HC Leukocyte Phagocytosis,PX-30000866,CDM,86344,CPT,300,RC,,,outpatient,,,33,23.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.5371,7.4085,25.344,percent of total billed charges,,,
HC Cmv Antibody,PX-30000526,CDM,86644,CPT,300,RC,,,outpatient,,,155,108.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,40.0985,14.71,119.04,percent of total billed charges,,,
HC Hla Typing- a-B-or C /Single,PX-30000582,CDM,86812,CPT,300,RC,,,outpatient,,,252,176.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,65.1924,26.37,193.536,percent of total billed charges,,,
HC Hla Typing Dr/Dq Single Antigen,PX-30000731,CDM,86816,CPT,300,RC,,,outpatient,,,124,86.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,32.0788,27.838,95.232,percent of total billed charges,,,
HC Hla Typing- Dr/Dq-Multi Antgn,PX-30000584,CDM,86817,CPT,300,RC,,,outpatient,,,287,200.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,74.2469,64.4315,241.472,percent of total billed charges,,,
HC RBC Antibody Screen,PX-30000585,CDM,86850,CPT,300,RC,,,outpatient,,,99,69.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,25.6113,6.25,92.88556,percent of total billed charges,,,
HC RBC Antibody Elution,PX-30000586,CDM,86860,CPT,300,RC,,,outpatient,,,358,250.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,92.6146,2.072,274.944,percent of total billed charges,,,
HC RBC Antibody Identification,PX-30000587,CDM,86870,CPT,300,RC,,,outpatient,,,501,350.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,129.6087,2.842,549.235176,percent of total billed charges,,,
HC Antihuman Globulin Dir Ea Antiserum,PX-30000588,CDM,86880,CPT,300,RC,,,outpatient,,,117,81.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,30.2679,5.5,93.463636,percent of total billed charges,,,
HC Antihuman Globulin Indir Qual Ea Reagent Cell,PX-30000589,CDM,86885,CPT,300,RC,,,outpatient,,,357,249.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,92.3559,5.85,274.176,percent of total billed charges,,,
HC Antihuman Globulin Indirect Ea Antibody Titer,PX-30000590,CDM,86886,CPT,300,RC,,,outpatient,,,357,249.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,92.3559,5.29,274.176,percent of total billed charges,,,
HC Blood Typing- Abo,PX-30000592,CDM,86900,CPT,300,RC,,,outpatient,,,208,145.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,53.8096,3.05,195.186327,percent of total billed charges,,,
HC Blood Typing- Rh (D),PX-30000593,CDM,86901,CPT,300,RC,,,outpatient,,,85,59.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,21.9895,3.05,65.28,percent of total billed charges,,,
HC Blood Type Antigen Donor Reagent Serum- Ea Antigen,PX-30000594,CDM,86902,CPT,300,RC,,,outpatient,,,628,439.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,162.4636,3.91,549.235176,percent of total billed charges,,,
HC Blood Typing Antigen Screen Patient Serum/Unit,PX-30000718,CDM,86904,CPT,300,RC,,,outpatient,,,311,217.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,80.4557,9.71,238.848,percent of total billed charges,,,
HC Blood Typing- RBC Antigens,PX-30000595,CDM,86905,CPT,300,RC,,,outpatient,,,628,439.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,162.4636,3.91,549.235176,percent of total billed charges,,,
HC Blood Typing Serologic Rh Phenotyping Complete,PX-30000719,CDM,86906,CPT,300,RC,,,outpatient,,,284,198.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,73.4708,7.91,218.112,percent of total billed charges,,,
HC Compatibility Test-Spin Tech,PX-30000596,CDM,86920,CPT,300,RC,,,outpatient,,,355,248.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,91.8385,2.31,272.64,percent of total billed charges,,,
HC Compatibility Test-Incub Tech,PX-30000597,CDM,86921,CPT,300,RC,,,outpatient,,,357,249.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,92.3559,2.072,274.176,percent of total billed charges,,,
HC Compatibility Test-Antiglob Tech,PX-30000598,CDM,86922,CPT,300,RC,,,outpatient,,,357,249.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,92.3559,2.45,274.176,percent of total billed charges,,,
HC Compatibility Test- Electronic,PX-30000599,CDM,86923,CPT,300,RC,,,outpatient,,,357,249.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.862,274.176,other,Non-Reimbursable Procedures,,
HC Plasma- Fresh Frozen,PX-30000600,CDM,86927,CPT,300,RC,,,outpatient,,,312,218.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,80.7144,1.302,263.69806,percent of total billed charges,,,
HC Blood Product/Irradiation,PX-39100002,CDM,86945,CPT,391,RC,,,outpatient,,,116,81.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,30.0092,1.932,416.02,percent of total billed charges,,,
HC Pretx RBC Antibody Incubat W/Chem Agnts/Drugs Ea,PX-30000729,CDM,86970,CPT,300,RC,,,outpatient,,,110,77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,28.457,1.932,93.463636,percent of total billed charges,,,
HC Pretx RBC Antibody Incubat W/Enzymes Each,PX-30000726,CDM,86971,CPT,300,RC,,,outpatient,,,560,392,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,144.872,1.54,499.62884,percent of total billed charges,,,
HC Pretx RBC Antibody Incubat W/Density Grad Sep,PX-30000727,CDM,86972,CPT,300,RC,,,outpatient,,,358,250.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,92.6146,2.702,274.944,percent of total billed charges,,,
HC Pretx Serum RBC Antibody Incubation Drugs Each,PX-30000725,CDM,86975,CPT,300,RC,,,outpatient,,,358,250.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,92.6146,2.072,608.812631,percent of total billed charges,,,
HC Pretx Serum RBC Antibody Identification Dilution,PX-30000724,CDM,86976,CPT,300,RC,,,outpatient,,,311,217.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,80.4557,2.31,238.848,percent of total billed charges,,,
HC Pretx Serum RBC Antb ID Incubation Inhibitors Ea,PX-30000734,CDM,86977,CPT,300,RC,,,outpatient,,,509,356.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,131.6783,2.31,416.02,percent of total billed charges,,,
HC RBC Pretreatment-Serum Inhib,PX-39100003,CDM,86977,CPT,391,RC,,,outpatient,,,509,356.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,131.6783,2.31,416.02,percent of total billed charges,,,
HC Pretx Serum RBC Antibody ID Diffial Each Absrpj,PX-30000723,CDM,86978,CPT,300,RC,,,outpatient,,,311,217.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,80.4557,2.31,238.848,percent of total billed charges,,,
HC Unlisted Transfusion Medicine Procedure,PX-30000728,CDM,86999,CPT,300,RC,,,outpatient,,,299,209.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,77.3513,1.68,229.632,percent of total billed charges,,,
HC Strep a Assay W/Optic,PX-30000714,CDM,87880,CPT,300,RC,,,outpatient,,,52,36.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.4524,11.674,39.936,percent of total billed charges,,,
HC Sperm Isolation- Simple,PX-31000079,CDM,89260,CPT,310,RC,,,outpatient,,,210,147,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,54.327,47.145,416.02,percent of total billed charges,,,
HC Sperm Isolation- Complex,PX-30000709,CDM,89261,CPT,300,RC,,,outpatient,,,152,106.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,39.3224,34.124,116.736,percent of total billed charges,,,
HC Semen Analysis-Volume- Count- Motility- Diff,PX-30000711,CDM,89320,CPT,300,RC,,,outpatient,,,58,40.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15.0046,12.32,44.544,percent of total billed charges,,,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4202-01,NDC,outpatient,1,ML,650.46,455.322,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,168.274002,139.93,1690.176,percent of total billed charges,,,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4203-02,NDC,outpatient,5,ML,2200.75,1540.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,569.334025,139.93,1690.176,percent of total billed charges,,,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4202-02,NDC,outpatient,1,ML,650.46,455.322,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,168.274002,139.93,1690.176,percent of total billed charges,,,
HEPATITIS B IMMUNE GLOBULIN IM SOLN WRAPPER,RX-4081425,CDM,90371,HCPCS,636,RC,69800-4203-01,NDC,outpatient,5,ML,2200.75,1540.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,569.334025,139.93,1690.176,percent of total billed charges,,,
RABIES IMMUNE GLOBULIN 300 UNIT/ML IJ SOLN,RX-142826,CDM,90375,HCPCS,636,RC,13533-0318-10,NDC,outpatient,1,ML,1554.22,1087.954,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,402.076714,287.71,7105.5744,percent of total billed charges,,,
RABIES IMMUNE GLOBULIN 300 UNIT/ML IJ SOLN,RX-142826,CDM,90375,HCPCS,636,RC,13533-0318-01,NDC,outpatient,1,ML,1554.22,1087.954,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,402.076714,287.71,7105.5744,percent of total billed charges,,,
RABIES IMMUNE GLOBULIN 1500 UNIT/5ML IJ SOLN,RX-142827,CDM,90375,HCPCS,636,RC,13533-0318-05,NDC,outpatient,5,ML,7771.09,5439.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2010.380983,287.71,7105.5744,percent of total billed charges,,,
RABIES IMMUNE GLOBULIN 1500 UNIT/5ML IJ SOLN,RX-142827,CDM,90375,HCPCS,636,RC,13533-0318-50,NDC,outpatient,5,ML,7771.09,5439.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2010.380983,287.71,7105.5744,percent of total billed charges,,,
RABIES IMMUNE GLOBULIN 900 UNIT/3ML IJ SOLN,RX-150138,CDM,90375,HCPCS,636,RC,13533-0318-03,NDC,outpatient,3,ML,4662.66,3263.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1206.230142,287.71,7105.5744,percent of total billed charges,,,
RABIES IMMUNE GLOBULIN 900 UNIT/3ML IJ SOLN,RX-150138,CDM,90375,HCPCS,636,RC,13533-0318-30,NDC,outpatient,3,ML,4662.66,3263.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1206.230142,287.71,7105.5744,percent of total billed charges,,,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-20,NDC,outpatient,2,ML,1850.42,1295.294,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,478.703654,287.71,7105.5744,percent of total billed charges,,,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-02,NDC,outpatient,2,ML,1850.42,1295.294,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,478.703654,287.71,7105.5744,percent of total billed charges,,,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-11,NDC,outpatient,10,ML,9252.05,6476.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2393.505335,287.71,7105.5744,percent of total billed charges,,,
RABIES IMMUNE GLOBULIN 150 UNITS/ML WRAPPER,RX-4081071,CDM,90375,HCPCS,636,RC,13533-0618-10,NDC,outpatient,10,ML,9252.05,6476.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2393.505335,287.71,7105.5744,percent of total billed charges,,,
PALIVIZUMAB 50 MG/0.5ML IM SOLN,RX-108060,CDM,90378,HCPCS,636,RC,66658-0230-01,NDC,outpatient,0.5,ML,5025.03,3517.521,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1299.975261,389.10344,4791.979,percent of total billed charges,,,
RHO D IMMUNE GLOBULIN 1500 UNIT/2ML IJ SOSY,RX-129748,CDM,90384,HCPCS,636,RC,44206-0300-10,NDC,outpatient,2,ML,207.1,144.97,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,53.57677,0.5,416.02,percent of total billed charges,,,
RHO D IMMUNE GLOBULIN 1500 UNIT/2ML IJ SOSY,RX-129748,CDM,90384,HCPCS,636,RC,44206-0300-01,NDC,outpatient,2,ML,207.1,144.97,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,53.57677,0.5,416.02,percent of total billed charges,,,
RHO D IMMUNE GLOBULIN 1500 UNIT/2ML IJ SOSY,RX-129748,CDM,90384,HCPCS,636,RC,44206-0300-90,NDC,outpatient,2,ML,78.48,54.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,20.302776,0.5,416.02,percent of total billed charges,,,
HC Immuniz Admin-1 Single/Comb Vac/Toxoid,PX-77100004,CDM,90471,CPT,771,RC,,,outpatient,,,193,135.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,49.9291,43.3285,416.02,percent of total billed charges,,,
HC Immuniz-Admin-Each Addl,PX-77100008,CDM,90472,CPT,771,RC,,,outpatient,,,73,51.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,18.8851,16.3885,416.02,percent of total billed charges,,,
HC Admn Sarscov2 Vacc 1 Dose,PX-77100044,CDM,90480,CPT,771,RC,,,outpatient,,,111,77.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,28.7157,24.9195,416.02,percent of total billed charges,,,
MENINGOCOCCAL B RECOMB OMV ADJ IM SUSY,RX-129389,CDM,90620,HCPCS,636,RC,58160-0976-02,NDC,outpatient,0.5,ML,874.41,612.087,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,226.209867,0.5,671.54688,percent of total billed charges,,,
MENINGOCOCCAL B RECOMB OMV ADJ IM SUSY,RX-129389,CDM,90620,HCPCS,636,RC,58160-0976-20,NDC,outpatient,0.5,ML,874.41,612.087,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,226.209867,0.5,671.54688,percent of total billed charges,,,
HEPATITIS A VACCINE 1440 EL U/ML IM SUSP,RX-91034,CDM,90632,HCPCS,636,RC,58160-0826-43,NDC,outpatient,1,ML,337.61,236.327,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,87.339707,70.48,416.02,percent of total billed charges,,,
HEPATITIS A VACCINE 1440 EL U/ML IM SUSP,RX-91034,CDM,90632,HCPCS,636,RC,58160-0826-52,NDC,outpatient,1,ML,337.61,236.327,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,87.339707,70.48,416.02,percent of total billed charges,,,
HEPATITIS A VACCINE 720 EL U/0.5ML IM SUSP,RX-91033,CDM,90633,HCPCS,636,RC,58160-0825-43,NDC,outpatient,0.5,ML,155.01,108.507,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,40.101087,34.799745,416.02,percent of total billed charges,,,
HEPATITIS A VACCINE 720 EL U/0.5ML IM SUSP,RX-91033,CDM,90633,HCPCS,636,RC,58160-0825-52,NDC,outpatient,0.5,ML,155.01,108.507,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,40.101087,34.799745,416.02,percent of total billed charges,,,
HAEMOPHILUS B POLYSAC CONJ VAC IM SOLR,RX-11931,CDM,90648,HCPCS,636,RC,49281-0545-03,NDC,outpatient,1,UN,49.34,34.538,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.764258,11.07683,416.02,percent of total billed charges,,,
HAEMOPHILUS B POLYSAC CONJ VAC IM SOLR,RX-11931,CDM,90648,HCPCS,636,RC,49281-0547-58,NDC,outpatient,1,UN,49.34,34.538,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.764258,11.07683,416.02,percent of total billed charges,,,
HPV 9-VALENT RECOMB VACCINE IM SUSY,RX-129114,CDM,90651,HCPCS,636,RC,00006-4121-02,NDC,outpatient,0.5,ML,1147.17,803.019,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,296.772879,0.5,881.02656,percent of total billed charges,,,
HPV 9-VALENT RECOMB VACCINE IM SUSY,RX-129114,CDM,90651,HCPCS,636,RC,00006-4121-01,NDC,outpatient,0.5,ML,1147.17,803.019,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,296.772879,0.5,881.02656,percent of total billed charges,,,
INFLUENZA VAC SUBUNIT QUAD 0.5 ML IM SUSY,RX-135284,CDM,90674,HCPCS,636,RC,70461-0323-04,NDC,outpatient,0.5,ML,94.26,65.982,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,24.385062,0.5,416.02,percent of total billed charges,,,
INFLUENZA VAC SUBUNIT QUAD 0.5 ML IM SUSY,RX-135284,CDM,90674,HCPCS,636,RC,70461-0323-03,NDC,outpatient,0.5,ML,94.26,65.982,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,24.385062,0.5,416.02,percent of total billed charges,,,
RABIES VACCINE WRAPPER,RX-4080220,CDM,90675,HCPCS,636,RC,50632-0010-01,NDC,outpatient,1,UN,1460.49,1022.343,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,377.828763,91.911626,1316.02176,percent of total billed charges,,,
RABIES VACCINE WRAPPER,RX-4080220,CDM,90675,HCPCS,636,RC,49281-0252-51,NDC,outpatient,1,UN,1713.57,1199.499,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,443.300559,91.911626,1316.02176,percent of total billed charges,,,
RABIES VACCINE WRAPPER,RX-4080220,CDM,90675,HCPCS,636,RC,50632-0013-01,NDC,outpatient,1,UN,1460.49,1022.343,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,377.828763,91.911626,1316.02176,percent of total billed charges,,,
PNEUMOCOCCAL 20-VAL CONJ VACC 0.5 ML IM SUSY,RX-156044,CDM,90677,HCPCS,636,RC,00005-2000-02,NDC,outpatient,0.5,ML,1098.4,768.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,284.15608,0.5,843.5712,percent of total billed charges,,,
INFLUENZA VAC A&B SA ADJ QUAD 0.5 ML IM PRSY,RX-150230,CDM,90694,HCPCS,636,RC,70461-0123-03,NDC,outpatient,0.5,ML,241.68,169.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,62.522616,0.5,416.02,percent of total billed charges,,,
INFLUENZA VAC A&B SA ADJ QUAD 0.5 ML IM PRSY,RX-150230,CDM,90694,HCPCS,636,RC,70461-0123-04,NDC,outpatient,0.5,ML,241.68,169.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,62.522616,0.5,416.02,percent of total billed charges,,,
DIPHTH-ACELL PERTUSSIS-TETANUS 15-23-5 LF-MCG/0.5 IM SUSP,RX-140528,CDM,90700,HCPCS,636,RC,49281-0286-10,NDC,outpatient,0.5,ML,107.51,75.257,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,27.812837,24.135995,416.02,percent of total billed charges,,,
DIPHTH-ACELL PERTUSSIS-TETANUS 15-23-5 LF-MCG/0.5 IM SUSP,RX-140528,CDM,90700,HCPCS,636,RC,49281-0286-58,NDC,outpatient,0.5,ML,107.51,75.257,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,27.812837,24.135995,416.02,percent of total billed charges,,,
MEASLES- MUMPS & RUBELLA VAC IJ SOLR,RX-148019,CDM,90707,HCPCS,636,RC,00006-4681-00,NDC,outpatient,1,UN,362.53,253.771,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,93.786511,54.47,416.02,percent of total billed charges,,,
MEASLES- MUMPS & RUBELLA VAC IJ SOLR,RX-148019,CDM,90707,HCPCS,636,RC,00006-4681-01,NDC,outpatient,1,UN,362.53,253.771,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,93.786511,54.47,416.02,percent of total billed charges,,,
POLIOVIRUS VACCINE INACTIVATED IJ INJ,RX-108127,CDM,90713,HCPCS,636,RC,49281-0860-78,NDC,outpatient,0.5,ML,163.66,114.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,42.338842,25.298577,416.02,percent of total billed charges,,,
POLIOVIRUS VACCINE INACTIVATED IJ INJ,RX-108127,CDM,90713,HCPCS,636,RC,49281-0860-10,NDC,outpatient,0.5,ML,163.66,114.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,42.338842,25.298577,416.02,percent of total billed charges,,,
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,58160-0842-01,NDC,outpatient,0.5,ML,193.78,135.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,50.130886,25.298577,416.02,percent of total billed charges,,,
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,49281-0400-10,NDC,outpatient,0.5,ML,187.93,131.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,48.617491,25.298577,416.02,percent of total billed charges,,,
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,58160-0842-11,NDC,outpatient,0.5,ML,193.78,135.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,50.130886,25.298577,416.02,percent of total billed charges,,,
TETANUS-DIPHTH-ACELL PERTUSSIS IM SUSP WRAPPER,RX-4080509,CDM,90715,HCPCS,636,RC,49281-0400-58,NDC,outpatient,0.5,ML,187.93,131.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,48.617491,25.298577,416.02,percent of total billed charges,,,
VARICELLA VIRUS VACCINE LIVE 1350 PFU/0.5ML SC INJ,RX-113088,CDM,90716,HCPCS,636,RC,00006-4827-01,NDC,outpatient,1,UN,737.12,515.984,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,190.692944,0.5,566.10816,percent of total billed charges,,,
VARICELLA VIRUS VACCINE LIVE 1350 PFU/0.5ML SC INJ,RX-113088,CDM,90716,HCPCS,636,RC,00006-4827-00,NDC,outpatient,1,UN,737.12,515.984,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,190.692944,0.5,566.10816,percent of total billed charges,,,
DTAP-HEPATITIS B RECOMB-IPV IM SUSY,RX-158218,CDM,90723,HCPCS,636,RC,58160-0811-43,NDC,outpatient,0.5,ML,392.47,274.729,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,101.531989,0.5,416.02,percent of total billed charges,,,
DTAP-HEPATITIS B RECOMB-IPV IM SUSY,RX-158218,CDM,90723,HCPCS,636,RC,58160-0811-52,NDC,outpatient,0.5,ML,392.47,274.729,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,101.531989,0.5,416.02,percent of total billed charges,,,
MENINGOCOCCAL A C Y&W-135 OLIG IM SOLN,RX-161800,CDM,90734,HCPCS,636,RC,58160-0827-03,NDC,outpatient,0.5,ML,640.81,448.567,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,165.777547,0.5,492.14208,percent of total billed charges,,,
MENINGOCOCCAL A C Y&W-135 OLIG IM SOLN,RX-161800,CDM,90734,HCPCS,636,RC,58160-0827-30,NDC,outpatient,0.5,ML,640.81,448.567,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,165.777547,0.5,492.14208,percent of total billed charges,,,
HEPATITIS B VAC RECOMB ADJ 20 MCG/0.5ML IM SOSY,RX-143904,CDM,90739,HCPCS,636,RC,43528-0003-05,NDC,outpatient,0.5,ML,537.53,376.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,139.059011,0.5,416.02,percent of total billed charges,,,
HEPATITIS B VAC RECOMB ADJ 20 MCG/0.5ML IM SOSY,RX-143904,CDM,90739,HCPCS,636,RC,43528-0003-01,NDC,outpatient,0.5,ML,537.53,376.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,139.059011,0.5,416.02,percent of total billed charges,,,
HC Esophageal Motility Study- Manometry,PX-92000004,CDM,91010,CPT,920,RC,,,outpatient,,,1126,788.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,291.2962,252.787,1055.807021,percent of total billed charges,,,
HC Gerd Tst W/ Mucos Ph Electrod,PX-92000007,CDM,91035,CPT,920,RC,,,outpatient,,,1775,1242.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,459.1925,398.4875,1363.2,percent of total billed charges,,,
HC GI Trc Img Intraluminal Esophagus-Ileum W/I&R,PX-75000005,CDM,91110,CPT,750,RC,,,outpatient,,,3922,2745.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1014.6214,399.86,3012.096,percent of total billed charges,,,
HC GI Imag Intraluminal Esophagus-Ileum W/I&R,PX-92000008,CDM,91110,CPT,920,RC,,,outpatient,,,3922,2745.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1014.6214,399.86,3012.096,percent of total billed charges,,,
HC Rectal Sesation Tone & Compliance Test,PX-36900666,CDM,91120,CPT,369,RC,,,outpatient,,,752,526.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,194.5424,168.824,1592,percent of total billed charges,,,
HC Anal Pressure Record,PX-36900541,CDM,91122,CPT,369,RC,,,outpatient,,,1360,952,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,351.832,305.32,1592,percent of total billed charges,,,
COVID-19 MRNA VACC (MODERNA) 50 MCG/0.5ML IM SUSY,RX-165852,CDM,91322,HCPCS,636,RC,80777-0102-93,NDC,outpatient,0.5,ML,492.72,344.904,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,127.466664,0.5,417.629472,percent of total billed charges,,,
COVID-19 MRNA VACC (MODERNA) 50 MCG/0.5ML IM SUSY,RX-165852,CDM,91322,HCPCS,636,RC,80777-0102-01,NDC,outpatient,0.5,ML,492.72,344.904,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,127.466664,0.5,417.629472,percent of total billed charges,,,
HC Eye Photography,PX-92000009,CDM,92285,CPT,920,RC,,,outpatient,,,80,56,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,17.96,416.02,other,Non-Reimbursable Procedures,,
HC Caloric Vestibular Test Bilateral- Bithermal,PX-47100041,CDM,92537,CPT,471,RC,,,outpatient,,,1270,889,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,328.549,163,975.36,percent of total billed charges,,,
HC Caloric Vestibular Test Bilateral- Monothermal,PX-47100042,CDM,92538,CPT,471,RC,,,outpatient,,,882,617.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,228.1734,163,677.376,percent of total billed charges,,,
HC Vestibular Eval Nystag Fovl&Perph Stim Oscil Tracking,PX-47000010,CDM,92540,CPT,470,RC,,,outpatient,,,550,385,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,142.285,123.475,422.4,percent of total billed charges,,,
HC Spontaneous Nystagmus Test,PX-47000011,CDM,92541,CPT,470,RC,,,outpatient,,,155,108.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,40.0985,34.7975,416.02,percent of total billed charges,,,
HC Positional Nystagmus Test,PX-47000012,CDM,92542,CPT,470,RC,,,outpatient,,,155,108.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,40.0985,34.7975,416.02,percent of total billed charges,,,
HC Optokinetic Nystagmus Test- Bidirec- Foveal- Periph- W Record,PX-47000014,CDM,92544,CPT,470,RC,,,outpatient,,,155,108.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,40.0985,34.7975,416.02,percent of total billed charges,,,
HC Oscillating Tracking Test,PX-47000015,CDM,92545,CPT,470,RC,,,outpatient,,,696,487.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,180.0552,142.97,534.528,percent of total billed charges,,,
HC Supplemental Electrical Test,PX-47100012,CDM,92547,CPT,471,RC,,,outpatient,,,225,157.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,58.2075,50.5125,416.02,percent of total billed charges,,,
HC Tympanometry and Reflex Threshold Measurements,PX-47100013,CDM,92550,CPT,471,RC,,,outpatient,,,269,188.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,69.5903,60.3905,416.02,percent of total billed charges,,,
HC Pure Tone Audiometry- Air,PX-47100014,CDM,92552,CPT,471,RC,,,outpatient,,,230,161,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,59.501,51.635,416.02,percent of total billed charges,,,
HC Audiometry- Air & Bone,PX-47100015,CDM,92553,CPT,471,RC,,,outpatient,,,295,206.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,76.3165,61.17,416.02,percent of total billed charges,,,
HC Speech Threshold Audiometry,PX-47100016,CDM,92555,CPT,471,RC,,,outpatient,,,144,100.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,37.2528,32.328,416.02,percent of total billed charges,,,
HC Speech Audiometry- Complete,PX-47100017,CDM,92556,CPT,471,RC,,,outpatient,,,132,92.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,34.1484,29.634,416.02,percent of total billed charges,,,
HC Comprehensive Hearing Test,PX-47100018,CDM,92557,CPT,471,RC,,,outpatient,,,519,363.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,134.2653,116.5155,416.02,percent of total billed charges,,,
HC Evoked Otoacoustic Emissions Screen Auto Analys,PX-47100047,CDM,92558,CPT,471,RC,,,outpatient,,,35,24.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.0545,7.8575,416.02,percent of total billed charges,,,
HC Stenger Test- Pure Tone,PX-47100020,CDM,92565,CPT,471,RC,,,outpatient,,,95,66.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,24.5765,21.3275,416.02,percent of total billed charges,,,
HC Tympanometry,PX-47100021,CDM,92567,CPT,471,RC,,,outpatient,,,125,87.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,32.3375,28.0625,416.02,percent of total billed charges,,,
HC Acoustic Immit Test Tympanometry/Acoust Reflex/Decay,PX-47100023,CDM,92570,CPT,471,RC,,,outpatient,,,359,251.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,92.8733,80.5955,416.02,percent of total billed charges,,,
HC Visual Audiometry (Vra),PX-47100027,CDM,92579,CPT,471,RC,,,outpatient,,,500,350,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,129.35,112.25,416.02,percent of total billed charges,,,
HC Conditioning Play Audiometry,PX-47100028,CDM,92582,CPT,471,RC,,,outpatient,,,511,357.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,132.1957,114.7195,416.02,percent of total billed charges,,,
HC Select Picture Audiometry,PX-47100029,CDM,92583,CPT,471,RC,,,outpatient,,,114,79.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,29.4918,25.593,416.02,percent of total billed charges,,,
HC Evoked Auditory Test-Limited,PX-47100032,CDM,92587,CPT,471,RC,,,outpatient,,,624,436.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,161.4288,128.12716,479.602522,percent of total billed charges,,,
HC Hearing Aid Check- One Ear,PX-47100036,CDM,92592,CPT,471,RC,,,outpatient,,,116,81.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,30.0092,26.042,416.02,percent of total billed charges,,,
HC Hearing Aid Check- Both Ears,PX-47100038,CDM,92593,CPT,471,RC,,,outpatient,,,162,113.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,41.9094,36.369,416.02,percent of total billed charges,,,
HC Auditory Function- 60 Min,PX-47100039,CDM,92620,CPT,471,RC,,,outpatient,,,729,510.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,188.5923,84.99,559.872,percent of total billed charges,,,
HC Auditory Function- + 15 Min,PX-47100040,CDM,92621,CPT,471,RC,,,outpatient,,,122,85.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,31.5614,20.01,416.02,percent of total billed charges,,,
HC Aep Threshold Estimation Mlt Frequencies I&R,PX-47100043,CDM,92652,CPT,471,RC,,,outpatient,,,863,604.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,223.2581,128.12716,662.784,percent of total billed charges,,,
HC Aep Neurodiagnostic Interpretation and Report,PX-47100044,CDM,92653,CPT,471,RC,,,outpatient,,,863,604.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,223.2581,128.12716,662.784,percent of total billed charges,,,
HC Prq Trluml Coronary Angioplasty One Art/Branch,PX-48100012,CDM,92920,CPT,481,RC,,,outpatient,,,17563,12294.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4543.5481,399.86,13488.384,percent of total billed charges,,,
HC Prq Trluml Coronary Angioplasty Addl Branch,PX-48100013,CDM,92921,CPT,481,RC,,,outpatient,,,17563,12294.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13488.384,other,Non-Reimbursable Procedures,,
HC Prq Trluml Coronary Angio/Atherect One Art/Brnch,PX-48100014,CDM,92924,CPT,481,RC,,,outpatient,,,33484,23438.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8662.3108,399.86,25715.712,percent of total billed charges,,,
HC Prq Trluml Coronary Angio/Atherec Addl Art/Brnch,PX-48100015,CDM,92925,CPT,481,RC,,,outpatient,,,32854,22997.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,25231.872,other,Non-Reimbursable Procedures,,
HC Prq Trluml Coronary Stent W/Angio One Art/Brnch,PX-48100016,CDM,92928,CPT,481,RC,,,outpatient,,,32584,22808.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8429.4808,399.86,25024.512,percent of total billed charges,,,
HC Prq Trluml Coronary Stent W/Angio Addl Art/Brnch,PX-48100017,CDM,92929,CPT,481,RC,,,outpatient,,,26673,18671.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,20484.864,other,Non-Reimbursable Procedures,,
HC Prq Trluml Coronry Stent/Ath/Angio One Art/Brnch,PX-48100018,CDM,92933,CPT,481,RC,,,outpatient,,,33887,23720.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8766.5669,399.86,26793.51305,percent of total billed charges,,,
HC Prq Trluml Coronary Stent/Ath/Angio Addl Branch,PX-48100019,CDM,92934,CPT,481,RC,,,outpatient,,,26169,18318.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6769.9203,399.86,20097.792,percent of total billed charges,,,
HC Prq Trluml Coronary Byp Grft Revasc One Vessel,PX-48100020,CDM,92937,CPT,481,RC,,,outpatient,,,26673,18671.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6900.3051,399.86,20484.864,percent of total billed charges,,,
HC Prq Trluml Coronary Byp Grft Revasc Addl Vessel,PX-48100021,CDM,92938,CPT,481,RC,,,outpatient,,,26169,18318.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,20097.792,other,Non-Reimbursable Procedures,,
HC Prq Trluml Coronry Chronic Occlus Revasc One Vsl,PX-48100023,CDM,92943,CPT,481,RC,,,outpatient,,,25667,17966.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6640.0529,399.86,19712.256,percent of total billed charges,,,
HC Prq Trluml Coronry Chrnic Occlus Revasc Addl Vsl,PX-48100024,CDM,92944,CPT,481,RC,,,outpatient,,,26169,18318.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,20097.792,other,Non-Reimbursable Procedures,,
HC Heart/Lung Resuscitation (Cpr),PX-48000001,CDM,92950,CPT,480,RC,,,outpatient,,,1034,723.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.133,997.822944,other,Non-Reimbursable Procedures,,
HC PR Cardiopulmonary Resuscitation,PX-96000048,CDM,92950,CPT,960,RC,,,outpatient,,,1034,723.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.133,997.822944,other,Non-Reimbursable Procedures,,
HC Temporary External Pacing,PX-48000002,CDM,92953,CPT,480,RC,,,outpatient,,,1302,911.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,336.8274,292.299,999.936,percent of total billed charges,,,
HC Cardioversion- Elective;Extern,PX-48000003,CDM,92960,CPT,480,RC,,,outpatient,,,2006,1404.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,518.9522,399.86,1540.608,percent of total billed charges,,,
HC PR Cardioversion Elective Arrhythmia External,PX-96000049,CDM,92960,CPT,960,RC,,,outpatient,,,2006,1404.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,518.9522,399.86,1540.608,percent of total billed charges,,,
HC Prq Transluminal Coronary Mechanicl Thrombectomy,PX-48000005,CDM,92973,CPT,480,RC,,,outpatient,,,773,541.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,199.9751,173.5385,593.664,percent of total billed charges,,,
HC Intrav Optcl Chernce Tmgrphy W/S&I Intl Vesl,PX-36900031,CDM,92978,CPT,369,RC,,,outpatient,,,2785,1949.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,145.12362,2138.88,other,Non-Reimbursable Procedures,,
HC Intravasc US-Heart-1st Vessel,PX-48100025,CDM,92978,CPT,481,RC,,,outpatient,,,2785,1949.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,145.12362,2138.88,other,Non-Reimbursable Procedures,,
HC Intrav Optcal Cohrnce Tmgrphy W/S&I Adl Vesl,PX-36900032,CDM,92979,CPT,369,RC,,,outpatient,,,755,528.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,169.4975,1592,other,Non-Reimbursable Procedures,,
HC Intravasc Coronary Sono-Addn Vessel,PX-48100026,CDM,92979,CPT,481,RC,,,outpatient,,,755,528.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,169.4975,1592,other,Non-Reimbursable Procedures,,
HC Percut Aortic Valvuloplasty,PX-48100027,CDM,92986,CPT,481,RC,,,outpatient,,,17231,12061.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4457.6597,399.86,13233.408,percent of total billed charges,,,
HC Percut Mitral Valvuloplasty,PX-48100028,CDM,92987,CPT,481,RC,,,outpatient,,,17231,12061.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4457.6597,399.86,16809.6787,percent of total billed charges,,,
HC Percut Pulmonary Valvuloplasty,PX-48100029,CDM,92990,CPT,481,RC,,,outpatient,,,17231,12061.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4457.6597,399.86,16809.6787,percent of total billed charges,,,
HC Electrocardiogram- Tracing,PX-73000001,CDM,93005,CPT,730,RC,,,outpatient,,,157,109.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,40.6159,25.49469,416.02,percent of total billed charges,,,
HC PR Electrocardiogram Report,PX-98500001,CDM,93010,CPT,985,RC,,,outpatient,,,28,19.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,6.286,416.02,other,Non-Reimbursable Procedures,,
HC Cardiac Stress Tst-Tracing Only,PX-48200001,CDM,93017,CPT,482,RC,,,outpatient,,,485,339.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,125.4695,108.8825,479.602522,percent of total billed charges,,,
HC Rhythm Ecg- Tracing,PX-73000003,CDM,93041,CPT,730,RC,,,outpatient,,,120,84,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,31.044,25.49469,416.02,percent of total billed charges,,,
HC PR Rhythm Ecg 1-3 Leads Interpretation & Reprt On,PX-98500004,CDM,93042,CPT,985,RC,,,outpatient,,,22,15.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.939,416.02,other,Non-Reimbursable Procedures,,
HC Ext Ecg Record Contin 48 Hr- Record,PX-73100001,CDM,93225,CPT,731,RC,,,outpatient,,,433,303.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,112.0171,84.459332,416.02,percent of total billed charges,,,
HC Ext Ecg Record Contin 48 Hr- Scan Analysis W Report,PX-73100002,CDM,93226,CPT,731,RC,,,outpatient,,,318,222.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,82.2666,66.75974,416.02,percent of total billed charges,,,
HC PR Xtrnl Ecg Continuous Rhythm W/I&R Up to 48 Hrs,PX-98500002,CDM,93227,CPT,985,RC,,,outpatient,,,63,44.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.1435,416.02,other,Non-Reimbursable Procedures,,
HC Prgrmg Dev Eval 1 Lead Pm/Ldls Pm 1 Car Chmbr IP,PX-48000087,CDM,93279,CPT,480,RC,,,outpatient,,,118,82.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,30.5266,26.491,416.02,percent of total billed charges,,,
HC Program Eval Implantable in Persn Dual Ld Pacer,PX-92000010,CDM,93280,CPT,920,RC,,,outpatient,,,1217,851.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,314.8379,41.157815,934.656,percent of total billed charges,,,
HC Program Eval Implantable in Prsn Multi Ld Pacer,PX-48000088,CDM,93281,CPT,480,RC,,,outpatient,,,118,82.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,30.5266,26.491,416.02,percent of total billed charges,,,
HC Prgrmng Dev Eval Implantable in Persn 1 Ld Dfb,PX-48000089,CDM,93282,CPT,480,RC,,,outpatient,,,118,82.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,30.5266,26.491,416.02,percent of total billed charges,,,
HC Progrm Eval Implantable in Prsn Dual L Card/Dfb,PX-48000009,CDM,93283,CPT,480,RC,,,outpatient,,,1878,1314.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,485.8386,41.157815,1442.304,percent of total billed charges,,,
HC Prgrmg Eval Implantable in Person Multi Lead Dfb,PX-48000090,CDM,93284,CPT,480,RC,,,outpatient,,,118,82.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,30.5266,26.491,416.02,percent of total billed charges,,,
HC Prgrmg Dev Eval Scrms Phys/Qhp in Person,PX-48000091,CDM,93285,CPT,480,RC,,,outpatient,,,118,82.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,30.5266,26.491,416.02,percent of total billed charges,,,
HC Interrogation Eval in Person 1/Dual/Mlt Lead Pm,PX-48000010,CDM,93288,CPT,480,RC,,,outpatient,,,224,156.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,57.9488,41.157815,416.02,percent of total billed charges,,,
HC Interrog Eval F2f 1/Dual/Mlt Leads Impltbl Dfb,PX-48000086,CDM,93289,CPT,480,RC,,,outpatient,,,118,82.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,30.5266,26.491,416.02,percent of total billed charges,,,
HC Interrogation Evaluation in Person Ilr System,PX-92000011,CDM,93291,CPT,920,RC,,,outpatient,,,248,173.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,64.1576,23.39896,416.02,percent of total billed charges,,,
Rem Interrog Pm/Ldls Pm/Ids <90 D Tech Review,PX-48000085,CDM,93296,CPT,480,RC,,,outpatient,,,118,82.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,30.5266,26.491,416.02,percent of total billed charges,,,
HC Echo Xthoracic-Cong Anom-Complete,PX-48000014,CDM,93303,CPT,480,RC,,,outpatient,,,1337,935.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,345.8819,54.1045,1223.3,percent of total billed charges,,,
HC PR Echo Xthoracic-Cong Anom-Complete,PX-96000009,CDM,93303,CPT,960,RC,,,outpatient,,,241,168.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,62.3467,54.1045,1223.3,percent of total billed charges,,,
HC Echo Xthoracic-Cong Anom-Limited,PX-48000015,CDM,93304,CPT,480,RC,,,outpatient,,,1303,912.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,337.0861,281.81,1040.64,percent of total billed charges,,,
HC PR Echo Xthoracic-Cong Anom-Limited,PX-96000010,CDM,93304,CPT,960,RC,,,outpatient,,,1355,948.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,350.5385,281.81,1040.64,percent of total billed charges,,,
HC Echo Heart Xthoracic-Complete W Doppler W/Contrast,PX-48000016,CDM,93306,CPT,480,RC,,,outpatient,,,1347,942.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,348.4689,54.1045,1034.496,percent of total billed charges,,,
HC Echo Heart Xthoracic-Complete W Doppler W/O Contrast,PX-48000068,CDM,93306,CPT,480,RC,,,outpatient,,,1347,942.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,348.4689,54.1045,1034.496,percent of total billed charges,,,
HC PR Echo Heart Xthoracic-Complete W Doppler,PX-96000036,CDM,93306,CPT,960,RC,,,outpatient,,,241,168.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,62.3467,54.1045,1034.496,percent of total billed charges,,,
HC Echo Heart Xthoracic-Complete- W/O Doppler W/Contrast,PX-48000017,CDM,93307,CPT,480,RC,,,outpatient,,,1228,859.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,317.6836,267.439885,943.104,percent of total billed charges,,,
HC Echo Heart Xthoracic-Complete- W/O Doppler W/O Contrast,PX-48000063,CDM,93307,CPT,480,RC,,,outpatient,,,1228,859.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,317.6836,267.439885,943.104,percent of total billed charges,,,
HC Echo Heart Xthoracic-Limited W/Contrast,PX-48000018,CDM,93308,CPT,480,RC,,,outpatient,,,561,392.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,145.1307,125.9445,465.66,percent of total billed charges,,,
HC Echo Heart Xthoracic-Limited W/O Contrast,PX-48000065,CDM,93308,CPT,480,RC,,,outpatient,,,561,392.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,145.1307,125.9445,465.66,percent of total billed charges,,,
HC PR Echo Heart Xthoracic-Limited,PX-96000037,CDM,93308,CPT,960,RC,,,outpatient,,,561,392.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,145.1307,125.9445,465.66,percent of total billed charges,,,
HC Echo Heart-Transesophageal-Complete W/Contrast,PX-48000019,CDM,93312,CPT,480,RC,,,outpatient,,,1764,1234.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,456.3468,224.549385,1354.752,percent of total billed charges,,,
HC Echo Heart-Transesophageal-Complete W/O Contrast,PX-48000064,CDM,93312,CPT,480,RC,,,outpatient,,,1764,1234.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,456.3468,224.549385,1354.752,percent of total billed charges,,,
HC Echo R-T 2d W/Probe Placement Only,PX-48000083,CDM,93313,CPT,480,RC,,,outpatient,,,1501,1050.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,388.3087,336.9745,1152.768,percent of total billed charges,,,
HC 3d Echo Img&Pst-Pxessing Tee/Tte Cgen Car Anomal,PX-48000084,CDM,93319,CPT,480,RC,,,outpatient,,,352,246.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,79.024,416.02,other,Non-Reimbursable Procedures,,
HC Doppler Echo Heart-Complete,PX-48000020,CDM,93320,CPT,480,RC,,,outpatient,,,323,226.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,72.5135,416.02,other,Non-Reimbursable Procedures,,
HC Doppler Echo Heart-Limited-F/U,PX-48000021,CDM,93321,CPT,480,RC,,,outpatient,,,384,268.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,86.208,416.02,other,Non-Reimbursable Procedures,,
HC Doppler Color Flow Velocity Map,PX-48000022,CDM,93325,CPT,480,RC,,,outpatient,,,744,520.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,135.906309,571.392,other,Non-Reimbursable Procedures,,
HC Echo Heart Xthoracic- Stress/Rest W/Contrast,PX-48000023,CDM,93350,CPT,480,RC,,,outpatient,,,1384,968.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,358.0408,224.549385,1062.912,percent of total billed charges,,,
HC Echo Heart Xthoracic- Stress/Rest W/O Contrast,PX-48000066,CDM,93350,CPT,480,RC,,,outpatient,,,1384,968.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,358.0408,224.549385,1062.912,percent of total billed charges,,,
HC Echo Tthrc R-T 2d W/WO M-Mode Rest&Strs Cont Ecg W/Contrast,PX-48000024,CDM,93351,CPT,480,RC,,,outpatient,,,1785,1249.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,461.7795,224.549385,1370.88,percent of total billed charges,,,
HC Echo Tthrc R-T 2d W/WO M-Mode Rest&Strs Cont Ecg W/O Contrast,PX-48000067,CDM,93351,CPT,480,RC,,,outpatient,,,1785,1249.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,461.7795,224.549385,1370.88,percent of total billed charges,,,
HC Echo Tee Guid Tcat Icar/Vessel Structural Intvn,PX-48000052,CDM,93355,CPT,480,RC,,,outpatient,,,778,544.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,201.2686,174.661,597.504,percent of total billed charges,,,
HC Myocrd Strain Img Speckle Trck Assmt Myocrd Mech,PX-48000480,CDM,93356,CPT,480,RC,,,outpatient,,,1077,753.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,278.6199,241.7865,827.136,percent of total billed charges,,,
HC Right Heart Cath O2 Saturation & Cardiac Output,PX-48100030,CDM,93451,CPT,481,RC,,,outpatient,,,9177,6423.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2374.0899,399.86,7870.4,percent of total billed charges,,,
HC Cath Place/Coronary Angio- Img Super/Interp,PX-48100031,CDM,93454,CPT,481,RC,,,outpatient,,,10988,7691.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2842.5956,399.86,8438.784,percent of total billed charges,,,
HC Cath Place/Coronary Angio- Img Super/Interp- Bypass Angio,PX-48100032,CDM,93455,CPT,481,RC,,,outpatient,,,10988,7691.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2842.5956,399.86,8438.784,percent of total billed charges,,,
HC Cath Place/Coronary Angio- Img Super/Interp-W Right Heart Cath,PX-48100033,CDM,93456,CPT,481,RC,,,outpatient,,,10988,7691.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2842.5956,399.86,8438.784,percent of total billed charges,,,
HC Cath Place/Coron Angio- Img Super/Interp- Bypass Angio-W R Heart Cath,PX-48100034,CDM,93457,CPT,481,RC,,,outpatient,,,9755,6828.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2523.6185,399.86,7870.4,percent of total billed charges,,,
HC Cath Place/Coron Angio- Img Super/Interp-W Left Heart Ventriculography,PX-48100035,CDM,93458,CPT,481,RC,,,outpatient,,,9755,6828.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2523.6185,399.86,7870.4,percent of total billed charges,,,
HC Cath Place/Coron Angio- Img Super/Interp- Bypass Angio-W L Hrt Ventric,PX-48100036,CDM,93459,CPT,481,RC,,,outpatient,,,10988,7691.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2842.5956,399.86,8438.784,percent of total billed charges,,,
HC Cath Place/Coron Angio- Img Super/Interp-R&L Hrt Cath- L Hrt Ventric,PX-48100037,CDM,93460,CPT,481,RC,,,outpatient,,,10988,7691.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2842.5956,399.86,8438.784,percent of total billed charges,,,
HC Cath Place/Cor Ang-Img Supr/Intrp-Bypass Ang- R&L Cath- L Hrt Ventric,PX-48100038,CDM,93461,CPT,481,RC,,,outpatient,,,10988,7691.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2842.5956,399.86,8438.784,percent of total billed charges,,,
HC Left Heart Cath by Transeptal Puncture,PX-48100039,CDM,93462,CPT,481,RC,,,outpatient,,,10365,7255.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2681.4255,399.86,7960.32,percent of total billed charges,,,
HC Insert/Place Flow Direct Cath,PX-36900885,CDM,93503,CPT,369,RC,,,outpatient,,,2998,2098.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,775.5826,399.86,2532.39,percent of total billed charges,,,
HC Insert/Place Flow Direct Cath,PX-48000025,CDM,93503,CPT,480,RC,,,outpatient,,,2998,2098.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,775.5826,399.86,2532.39,percent of total billed charges,,,
HC Inject Select Cor Angio During Congenital Heart Cath,PX-48100044,CDM,93563,CPT,481,RC,,,outpatient,,,2542,1779.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,657.6154,399.86,1952.256,percent of total billed charges,,,
HC Inject Select Cor/Graft Angio During Congenital Heart Cath,PX-48100045,CDM,93564,CPT,481,RC,,,outpatient,,,1018,712.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,263.3566,228.541,1592,percent of total billed charges,,,
HC Inject Select Left Vent/Atrial Angio During Heart Cath,PX-48100046,CDM,93565,CPT,481,RC,,,outpatient,,,510,357,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,131.937,114.495,1592,percent of total billed charges,,,
HC Inject Select Right Vent/Atrial Angio During Heart Cath,PX-48100047,CDM,93566,CPT,481,RC,,,outpatient,,,1018,712.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,263.3566,228.541,1592,percent of total billed charges,,,
HC Inject Supravalvular Aortography During Heart Cath,PX-48100048,CDM,93567,CPT,481,RC,,,outpatient,,,1498,1048.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,387.5326,235.074116,1592,percent of total billed charges,,,
HC Heart Flow Reserv Measure-Init Vessl,PX-48000026,CDM,93571,CPT,480,RC,,,outpatient,,,6936,4855.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,5638.7,other,Non-Reimbursable Procedures,,
HC Heart Flow Reserv Measure-Addn Vessl,PX-48000027,CDM,93572,CPT,480,RC,,,outpatient,,,2051,1435.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,1575.168,other,Non-Reimbursable Procedures,,
HC Perc Clos-Cong Interatrial Commun W/Impl,PX-48100049,CDM,93580,CPT,481,RC,,,outpatient,,,53254,37277.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13776.8098,399.86,40899.072,percent of total billed charges,,,
HC Perc Closure-Cong Vsd W/Implant,PX-48100050,CDM,93581,CPT,481,RC,,,outpatient,,,53254,37277.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13776.8098,399.86,40899.072,percent of total billed charges,,,
HC Percutan Transcath Closure Pat Duct Arteriosus,PX-36900556,CDM,93582,CPT,369,RC,,,outpatient,,,52790,36953,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13656.773,399.86,40542.72,percent of total billed charges,,,
HC Percutan Transcath Closure Pat Duct Arteriosus,PX-48100051,CDM,93582,CPT,481,RC,,,outpatient,,,52790,36953,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13656.773,399.86,40542.72,percent of total billed charges,,,
HC Percutaneous Transcatheter Septal Reduction Ther,PX-48100055,CDM,93583,CPT,481,RC,,,outpatient,,,16899,11829.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4371.7713,399.86,12978.432,percent of total billed charges,,,
HC Heart Pacing- Mapping,PX-48000042,CDM,93631,CPT,480,RC,,,outpatient,,,8496,5947.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6909.98,other,Non-Reimbursable Procedures,,
HC Eval Cardiovert Leads-Initial,PX-48000043,CDM,93640,CPT,480,RC,,,outpatient,,,5892,4124.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,4525.056,other,Non-Reimbursable Procedures,,
HC Eval Cardiovert Leads/Puls Gen,PX-48000044,CDM,93641,CPT,480,RC,,,outpatient,,,3075,2152.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,2361.6,other,Non-Reimbursable Procedures,,
HC Electrophys Eval-Cardioverter,PX-48000045,CDM,93642,CPT,480,RC,,,outpatient,,,3083,2158.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,797.5721,399.86,2367.744,percent of total billed charges,,,
HC Tilt Table Evaluation,PX-48000049,CDM,93660,CPT,480,RC,,,outpatient,,,3083,2158.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,797.5721,399.86,2367.744,percent of total billed charges,,,
HC Intracard Echo- Ther/Dx Intervent,PX-48000050,CDM,93662,CPT,480,RC,,,outpatient,,,7689,5382.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10671.09667,other,Non-Reimbursable Procedures,,
HC Analyze Pacer Sys,PX-48000051,CDM,93724,CPT,480,RC,,,outpatient,,,1217,851.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,314.8379,73.54,934.656,percent of total billed charges,,,
HC Outpatient Cardiac Rehab W/O Cont Ecg Monitor,PX-94300002,CDM,93797,CPT,943,RC,,,outpatient,,,255,178.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,65.9685,57.2475,416.02,percent of total billed charges,,,
HC Outpatient Cardiac Rehab W/Cont Ecg Monitoring,PX-94300003,CDM,93798,CPT,943,RC,,,outpatient,,,271,189.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,70.1077,60.8395,416.02,percent of total billed charges,,,
HC Duplex Scan Extracranial-Bilat,PX-92100008,CDM,93880,CPT,921,RC,,,outpatient,,,915,640.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,236.7105,199.512292,702.72,percent of total billed charges,,,
HC Duplex Scan Extracranial-Limited,PX-92100010,CDM,93882,CPT,921,RC,,,outpatient,,,915,640.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,236.7105,119.991125,702.72,percent of total billed charges,,,
HC Transcran Doppler Intracran Art,PX-92100011,CDM,93886,CPT,921,RC,,,outpatient,,,1137,795.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,294.1419,255.2565,873.216,percent of total billed charges,,,
HC Transcran Doppler Intracran-Limited,PX-92100013,CDM,93888,CPT,921,RC,,,outpatient,,,428,299.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,110.7236,96.086,686,percent of total billed charges,,,
HC Transcran Doppl Intracran- Vasoreact,PX-92100015,CDM,93890,CPT,921,RC,,,outpatient,,,952,666.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,246.2824,213.724,731.136,percent of total billed charges,,,
HC Non-Invas Physiologic Std Extremity Art 1-2 Level,PX-92100017,CDM,93922,CPT,921,RC,,,outpatient,,,915,640.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,236.7105,135.906309,702.72,percent of total billed charges,,,
HC Non-Invasive Physiologic Study Extremity 3 Levels,PX-92100019,CDM,93923,CPT,921,RC,,,outpatient,,,701,490.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,181.3487,121.132463,686,percent of total billed charges,,,
HC Non-Invasive Lower Extrem Art Stress/Rest- Complete-Bilateral,PX-92100020,CDM,93924,CPT,921,RC,,,outpatient,,,915,640.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,236.7105,135.906309,775.5705,percent of total billed charges,,,
HC Duplex Lo Extrem Art Bilat,PX-92100022,CDM,93925,CPT,921,RC,,,outpatient,,,915,640.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,236.7105,199.512292,702.72,percent of total billed charges,,,
HC Duplex Lo Extrem Art Unilat/Ltd,PX-92100024,CDM,93926,CPT,921,RC,,,outpatient,,,441,308.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,114.0867,99.0045,686,percent of total billed charges,,,
HC Duplex Up Extrem Art Bilat,PX-92100025,CDM,93930,CPT,921,RC,,,outpatient,,,842,589.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,217.8254,135.906309,686,percent of total billed charges,,,
HC Duplex Up Extrem Art Bilat,PX-92100026,CDM,93930,CPT,921,RC,,,outpatient,,,842,589.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,217.8254,135.906309,686,percent of total billed charges,,,
HC Duplex Up Extrem Art Unilat/Ltd,PX-92100028,CDM,93931,CPT,921,RC,,,outpatient,,,915,640.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,236.7105,119.991125,702.72,percent of total billed charges,,,
HC Duplex Extrem Venous-Bilat,PX-92100031,CDM,93970,CPT,921,RC,,,outpatient,,,758,530.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,196.0946,170.171,686,percent of total billed charges,,,
HC Duplex Extrem Venous-Bilat,PX-92100032,CDM,93970,CPT,921,RC,,,outpatient,,,758,530.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,196.0946,170.171,686,percent of total billed charges,,,
HC Duplex Extrem Venous-Uni or Ltd,PX-92100034,CDM,93971,CPT,921,RC,,,outpatient,,,915,640.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,236.7105,119.991125,702.72,percent of total billed charges,,,
HC Duplex Abd/Pel Vasc Study-Complete,PX-92100036,CDM,93975,CPT,921,RC,,,outpatient,,,816,571.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,211.0992,183.192,686,percent of total billed charges,,,
HC Duplex Abd/Pel Vasc Study-Limitd,PX-92100037,CDM,93976,CPT,921,RC,,,outpatient,,,418,292.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,108.1366,93.841,686,percent of total billed charges,,,
HC Duplex Large Vessel(S)-Complete,PX-92100039,CDM,93978,CPT,921,RC,,,outpatient,,,915,640.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,236.7105,199.512292,702.72,percent of total billed charges,,,
HC Duplex Large Vessel(S)-Limited,PX-92100041,CDM,93979,CPT,921,RC,,,outpatient,,,387,270.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,100.1169,86.8815,686,percent of total billed charges,,,
HC Duplex Hemodialysis Access,PX-92100042,CDM,93990,CPT,921,RC,,,outpatient,,,614,429.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,158.8418,119.991125,686,percent of total billed charges,,,
HC Breathing Capacity Test,PX-46000002,CDM,94010,CPT,460,RC,,,outpatient,,,295,206.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,76.3165,66.2275,416.02,percent of total billed charges,,,
HC Eval of Bronchospasm,PX-46000003,CDM,94060,CPT,460,RC,,,outpatient,,,446,312.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,115.3802,100.127,479.602522,percent of total billed charges,,,
HC Eval of Bronchospasm-Prolonged,PX-46000004,CDM,94070,CPT,460,RC,,,outpatient,,,925,647.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,239.2975,163,710.4,percent of total billed charges,,,
HC Xers Tst Brncspsm Pre&Post Spmtry&Pls Ox W/Ecg,PX-46000023,CDM,94617,CPT,460,RC,,,outpatient,,,392,274.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,101.4104,88.004,416.02,percent of total billed charges,,,
HC Pulmonary Stress Testing,PX-46000022,CDM,94618,CPT,460,RC,,,outpatient,,,392,274.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,101.4104,88.004,416.02,percent of total billed charges,,,
HC Xers Tst Brncspsm Pre&Post Spmtry&Pls Ox WO /Ecg,PX-46000024,CDM,94619,CPT,460,RC,,,outpatient,,,182,127.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,47.0834,40.859,416.02,percent of total billed charges,,,
HC Inhal Rx- Airway Obst/Dx Sputum Induct,PX-41000006,CDM,94640,CPT,410,RC,,,outpatient,,,494,345.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,127.7978,59.92,416.02,percent of total billed charges,,,
HC Plethysmography Lung Volumes W/WO Airway Resist,PX-46000012,CDM,94726,CPT,460,RC,,,outpatient,,,446,312.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,115.3802,98.67,479.602522,percent of total billed charges,,,
HC Gas Dilut/Washout Lung Vol W/WO Distrib Vent&Vol,PX-46000013,CDM,94727,CPT,460,RC,,,outpatient,,,295,206.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,76.3165,66.2275,416.02,percent of total billed charges,,,
HC Diffusing Capacity,PX-46000014,CDM,94729,CPT,460,RC,,,outpatient,,,265,185.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,68.5555,59.4925,416.02,percent of total billed charges,,,
HC Noninvasv Oxygen Satur;Single,PX-46000015,CDM,94760,CPT,460,RC,,,outpatient,,,54,37.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.123,416.02,other,Non-Reimbursable Procedures,,
HC Noninvasv Oxygen Satur-Multiple,PX-46000016,CDM,94761,CPT,460,RC,,,outpatient,,,90,63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.205,416.02,other,Non-Reimbursable Procedures,,
HC Car Seat/Bed Test Initial 60 Mins,PX-46000019,CDM,94780,CPT,460,RC,,,outpatient,,,194,135.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,50.1878,43.553,416.02,percent of total billed charges,,,
HC Car Seat/Bed Test Each Addl 30 Min,PX-46000020,CDM,94781,CPT,460,RC,,,outpatient,,,194,135.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,43.553,416.02,other,Non-Reimbursable Procedures,,
HC Pulmonary Service/Procedure,PX-41000002,CDM,94799,CPT,410,RC,,,outpatient,,,367,256.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,94.9429,22.74,416.02,percent of total billed charges,,,
HC Eeg W/O Video by Tech 2-12 Hr Unmonitored,PX-74000012,CDM,95705,CPT,740,RC,,,outpatient,,,827,578.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,213.9449,185.6615,635.136,percent of total billed charges,,,
HC Eeg W/O Video by Tech 2-12 Hr Intermittent Mntr,PX-74000013,CDM,95706,CPT,740,RC,,,outpatient,,,827,578.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,213.9449,185.6615,635.136,percent of total billed charges,,,
HC Eeg W/O Video by Tech 2-12hr Continuous R-T Mntr,PX-74000014,CDM,95707,CPT,740,RC,,,outpatient,,,827,578.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,213.9449,185.6615,635.136,percent of total billed charges,,,
HC Eeg W/O Vid by Tech Ea Incr 12-26hr Unmonitored,PX-74000011,CDM,95708,CPT,740,RC,,,outpatient,,,1649,1154.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,426.5963,370.2005,1266.432,percent of total billed charges,,,
HC Eeg W/O Vid by Tech Ea Incr 12-26 Hr Intmt Mntr,PX-74000015,CDM,95709,CPT,740,RC,,,outpatient,,,1585,1109.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,410.0395,355.8325,1217.28,percent of total billed charges,,,
HC Eeg W/O Vid Tech Ea Incr 12-26 Hr Cont R-T Mntr,PX-74000016,CDM,95710,CPT,740,RC,,,outpatient,,,1585,1109.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,410.0395,355.8325,1217.28,percent of total billed charges,,,
HC Electroencephalogram Extend Monitoring 41-60 Min,PX-74000008,CDM,95812,CPT,740,RC,,,outpatient,,,812,568.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,210.0644,182.294,623.616,percent of total billed charges,,,
HC Eeg >1 Hr,PX-74000002,CDM,95813,CPT,740,RC,,,outpatient,,,958,670.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,247.8346,215.071,735.744,percent of total billed charges,,,
HC Eeg-W/Awake & Drowsy Record,PX-74000003,CDM,95816,CPT,740,RC,,,outpatient,,,701,490.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,181.3487,157.3745,538.368,percent of total billed charges,,,
HC Eeg-W/Awake & Asleep Record,PX-74000004,CDM,95819,CPT,740,RC,,,outpatient,,,786,550.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,203.3382,176.457,603.648,percent of total billed charges,,,
HC Eeg-Coma/Sleep Record Only,PX-74000005,CDM,95822,CPT,740,RC,,,outpatient,,,675,472.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,174.6225,151.5375,518.4,percent of total billed charges,,,
HC Eeg Eval Cerebral Death,PX-74000006,CDM,95824,CPT,740,RC,,,outpatient,,,675,472.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,174.6225,151.5375,829.50194,percent of total billed charges,,,
HC Needle Emg Ea Extremity W/Paraspinl Area Limited,PX-92200011,CDM,95885,CPT,922,RC,,,outpatient,,,332,232.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,85.8884,14.817,570,percent of total billed charges,,,
HC PR Needle Emg Ea Extremity W/Paraspinl Area Limited,PX-96000021,CDM,95885,CPT,960,RC,,,outpatient,,,66,46.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,17.0742,14.817,570,percent of total billed charges,,,
HC Needle Emg Ea Extremty W/Paraspinl Area Complete,PX-92200012,CDM,95886,CPT,922,RC,,,outpatient,,,332,232.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,85.8884,30.083,570,percent of total billed charges,,,
HC PR Needle Emg Ea Extremty W/Paraspinl Area Complete,PX-96000022,CDM,95886,CPT,960,RC,,,outpatient,,,134,93.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,34.6658,30.083,570,percent of total billed charges,,,
HC Needle Emg Nonextremty Mscles W/Nerve Conduction,PX-92200013,CDM,95887,CPT,922,RC,,,outpatient,,,180,126,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,46.566,20.4295,570,percent of total billed charges,,,
HC PR Needle Emg Nonextremty Mscles W/Nerve Conduction,PX-96000023,CDM,95887,CPT,960,RC,,,outpatient,,,91,63.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,23.5417,20.4295,570,percent of total billed charges,,,
HC Nerve Conduction Studies 1-2 Studies,PX-92200028,CDM,95907,CPT,922,RC,,,outpatient,,,760,532,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,196.612,94.4,583.68,percent of total billed charges,,,
HC Motor &/Sens 7-8 Nrv Cndj Preconf Eltrode Limb,PX-92200017,CDM,95910,CPT,922,RC,,,outpatient,,,696,487.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,180.0552,94.4,570,percent of total billed charges,,,
HC PR Motor &/Sens 7-8 Nrv Cndj Preconf Eltrode Limb,PX-96000027,CDM,95910,CPT,960,RC,,,outpatient,,,724,506.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,187.2988,94.4,570,percent of total billed charges,,,
HC Ionm Remote/Nearby/>1 Patient in or per Hour,PX-92000015,CDM,95941,CPT,920,RC,,,outpatient,,,879,615.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,227.3973,197.3355,675.072,percent of total billed charges,,,
HC Eeg Digital Anylysis,PX-74000010,CDM,95957,CPT,740,RC,,,outpatient,,,696,487.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,156.252,534.528,other,Non-Reimbursable Procedures,,
HC IV Inf- Hydration- 31 Min to 1 Hr,PX-26000001,CDM,96360,CPT,260,RC,,,outpatient,,,334,233.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,86.4058,74.983,416.02,percent of total billed charges,,,
HC IV Inf- Hydration- Each Add'l Hr,PX-26000002,CDM,96361,CPT,260,RC,,,outpatient,,,89,62.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,23.0243,19.9805,585.854902,percent of total billed charges,,,
HC IV Inf- Therapy - Init to 1 Hr (Spec Drug),PX-26000003,CDM,96365,CPT,260,RC,,,outpatient,,,418,292.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,108.1366,93.841,416.02,percent of total billed charges,,,
HC IV Inf- Therapy- Each Add Hr (Spec Drug),PX-26000004,CDM,96366,CPT,260,RC,,,outpatient,,,132,92.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,34.1484,29.634,585.854902,percent of total billed charges,,,
HC IV Infusion- Therap/Proph/Diagnost-Add Infusion-1st Hour,PX-26000005,CDM,96367,CPT,260,RC,,,outpatient,,,183,128.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,47.3421,41.0835,416.02,percent of total billed charges,,,
HC IV Infusion- Therap/Proph/Diagnost-Concurrent Infusion,PX-26000006,CDM,96368,CPT,260,RC,,,outpatient,,,109,76.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,24.4705,416.02,other,Non-Reimbursable Procedures,,
HC Therapeutic Prophylactic/Dx Injection Subq/Im,PX-26000007,CDM,96372,CPT,260,RC,,,outpatient,,,162,113.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,41.9094,16.16,416.02,percent of total billed charges,,,
HC Injection-Therap/Proph/Diagnost- Intra-Arterial,PX-26000008,CDM,96373,CPT,260,RC,,,outpatient,,,334,233.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,86.4058,74.983,416.02,percent of total billed charges,,,
HC IV Push- Initial,PX-26000009,CDM,96374,CPT,260,RC,,,outpatient,,,309,216.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,79.9383,69.3705,416.02,percent of total billed charges,,,
HC IV Push- Ea Add Seq- of New Sub Drug,PX-26000010,CDM,96375,CPT,260,RC,,,outpatient,,,105,73.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,27.1635,23.5725,416.02,percent of total billed charges,,,
HC Injection-Therap/Proph/Diagnost- IV Push- Ea Add- Same Drug,PX-26000011,CDM,96376,CPT,260,RC,,,outpatient,,,303,212.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,68.0235,416.02,other,Non-Reimbursable Procedures,,
HC Chemother-Non-Hormone Anti-Neopl- Sub-Q/Im,PX-33100001,CDM,96401,CPT,331,RC,,,outpatient,,,222,155.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,57.4314,49.839,416.02,percent of total billed charges,,,
HC Chemother- IV Push- Sngl Drug,PX-33100003,CDM,96409,CPT,331,RC,,,outpatient,,,691,483.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,178.7617,155.1295,530.688,percent of total billed charges,,,
HC Chemother- IV Infusion- 1 Hr,PX-33500001,CDM,96413,CPT,335,RC,,,outpatient,,,724,506.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,187.2988,162.538,556.032,percent of total billed charges,,,
HC Chemother- IV Infusion- Ea Add Hr,PX-33500002,CDM,96415,CPT,335,RC,,,outpatient,,,187,130.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,48.3769,41.9815,585.854902,percent of total billed charges,,,
HC Chemother-Ia Push Technique,PX-33100006,CDM,96420,CPT,331,RC,,,outpatient,,,668,467.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,172.8116,70.143083,517.481916,percent of total billed charges,,,
HC Chemother-Cns-W/Lumbar Puncture,PX-33100005,CDM,96450,CPT,331,RC,,,outpatient,,,657,459.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,169.9659,147.4965,585.854902,percent of total billed charges,,,
HC Ultraviolet Light Therapy,PX-94000005,CDM,96900,CPT,940,RC,,,outpatient,,,530,371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,137.111,34.385146,416.02,percent of total billed charges,,,
HC Mechanical Traction Therapy,PX-42100004,CDM,97012,CPT,421,RC,,,outpatient,,,245,171.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,63.3815,14.38,416.02,percent of total billed charges,,,
HC Electric Stimulation Therapy,PX-42100005,CDM,97014,CPT,421,RC,,,outpatient,,,123,86.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,31.8201,27.6135,416.02,percent of total billed charges,,,
HC Electrical Stimulation,PX-42100010,CDM,97032,CPT,421,RC,,,outpatient,,,123,86.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,31.8201,14.73,416.02,percent of total billed charges,,,
HC Electric Current Therapy,PX-42100011,CDM,97033,CPT,421,RC,,,outpatient,,,185,129.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,47.8595,20.02,416.02,percent of total billed charges,,,
HC Ultrasound Therapy,PX-42000005,CDM,97035,CPT,420,RC,,,outpatient,,,115,80.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,29.7505,14.44,416.02,percent of total billed charges,,,
HC Ultrasound Therapy,PX-42100013,CDM,97035,CPT,421,RC,,,outpatient,,,115,80.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,29.7505,14.44,416.02,percent of total billed charges,,,
HC Therapeutic Exercises,PX-42000006,CDM,97110,CPT,420,RC,,,outpatient,,,197,137.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,50.9639,30.33,416.02,percent of total billed charges,,,
HC Therapeutic Exercises,PX-42100014,CDM,97110,CPT,421,RC,,,outpatient,,,197,137.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,50.9639,30.33,416.02,percent of total billed charges,,,
HC Neuromusc Reeducat-1+ Areas- Ea 15 Min,PX-42000007,CDM,97112,CPT,420,RC,,,outpatient,,,115,80.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,29.7505,25.8175,416.02,percent of total billed charges,,,
HC Neuromusc Reeducat-1+ Areas- Ea 15 Min,PX-42100015,CDM,97112,CPT,421,RC,,,outpatient,,,115,80.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,29.7505,25.8175,416.02,percent of total billed charges,,,
HC Gait Training Therapy,PX-42100017,CDM,97116,CPT,421,RC,,,outpatient,,,115,80.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,25.8175,416.02,other,Non-Reimbursable Procedures,,
HC Manual Ther Tech-1+Regions-Ea 15 Min,PX-42000008,CDM,97140,CPT,420,RC,,,outpatient,,,140,98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,36.218,27.89,416.02,percent of total billed charges,,,
HC Manual Ther Tech-1+Regions-Ea 15 Min,PX-42100018,CDM,97140,CPT,421,RC,,,outpatient,,,140,98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,36.218,27.89,416.02,percent of total billed charges,,,
HC Group Therapeutic Procedures,PX-42000009,CDM,97150,CPT,420,RC,,,outpatient,,,130,91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,33.631,18.56,416.02,percent of total billed charges,,,
HC Group Therapeutic Procedures,PX-42300001,CDM,97150,CPT,423,RC,,,outpatient,,,130,91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,33.631,18.56,416.02,percent of total billed charges,,,
HC Pt Eval Low Complex,PX-42400003,CDM,97161,CPT,424,RC,,,outpatient,,,260,182,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,67.262,58.37,416.02,percent of total billed charges,,,
HC Pt Eval Mod Complex,PX-42400004,CDM,97162,CPT,424,RC,,,outpatient,,,260,182,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,67.262,58.37,416.02,percent of total billed charges,,,
HC Pt Eval High Complex,PX-42400005,CDM,97163,CPT,424,RC,,,outpatient,,,260,182,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,67.262,58.37,416.02,percent of total billed charges,,,
HC Pt Re-Eval Est Plan Care,PX-42400006,CDM,97164,CPT,424,RC,,,outpatient,,,231,161.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.8595,416.02,other,Non-Reimbursable Procedures,,
HC Therapeut Actvity Direct Pt Contact Each 15 Min,PX-42100019,CDM,97530,CPT,421,RC,,,outpatient,,,115,80.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,29.7505,25.8175,416.02,percent of total billed charges,,,
HC Self-Care/Home Mgmt Training Each 15 Minutes,PX-42100020,CDM,97535,CPT,421,RC,,,outpatient,,,115,80.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,29.7505,25.8175,416.02,percent of total billed charges,,,
HC Orthotic Mgmt and Training- Each 15 Min,PX-42100027,CDM,97760,CPT,421,RC,,,outpatient,,,115,80.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,29.7505,25.8175,416.02,percent of total billed charges,,,
HC Prosthetic Training- Each 15 Min,PX-42100028,CDM,97761,CPT,421,RC,,,outpatient,,,104,72.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,26.9048,23.348,416.02,percent of total billed charges,,,
HC Med Nutr Ther- 1st- Indiv- Ea 15 Min,PX-94200006,CDM,97802,CPT,942,RC,,,outpatient,,,182,127.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,47.0834,34.45,416.02,percent of total billed charges,,,
HC Med Nutr Ther- Subsq- Indiv- Ea 15 Min,PX-94200007,CDM,97803,CPT,942,RC,,,outpatient,,,106,74.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,27.4222,23.797,416.02,percent of total billed charges,,,
HC Med Nutr Ther- Group- Ea 30 Min,PX-94200008,CDM,97804,CPT,942,RC,,,outpatient,,,52,36.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.4524,11.674,416.02,percent of total billed charges,,,
HC Mod Sed Same Phys/Qhp <5 Yrs,PX-37000019,CDM,99151,CPT,370,RC,,,outpatient,,,230,161,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.635,416.02,other,Non-Reimbursable Procedures,,
HC Mod Sed Same Phys/Qhp 5/>Yrs,PX-37000020,CDM,99152,CPT,370,RC,,,outpatient,,,240,168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,53.88,416.02,other,Non-Reimbursable Procedures,,
HC Mod Sed Same Phys/Qhp Ea,PX-37000021,CDM,99153,CPT,370,RC,,,outpatient,,,240,168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,53.88,416.02,other,Non-Reimbursable Procedures,,
HC Mod Sed Oth Phys/Qhp <5 Yrs,PX-37000022,CDM,99155,CPT,370,RC,,,outpatient,,,361,252.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,81.0445,416.02,other,Non-Reimbursable Procedures,,
HC Mod Sed Oth Phys/Qhp 5/>Yrs,PX-37000023,CDM,99156,CPT,370,RC,,,outpatient,,,240,168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,53.88,416.02,other,Non-Reimbursable Procedures,,
HC Mod Sed Other Phys/Qhp Ea,PX-37000024,CDM,99157,CPT,370,RC,,,outpatient,,,330,231,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,74.085,416.02,other,Non-Reimbursable Procedures,,
HC Phlebotomy,PX-94000006,CDM,99195,CPT,940,RC,,,outpatient,,,312,218.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,80.7144,70.044,416.02,percent of total billed charges,,,
HC Office/Outpatient New Sf Mdm 15-29 Minutes,PX-51000025,CDM,99202,CPT,510,RC,,,outpatient,,,387,270.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,100.1169,82.56,416.02,percent of total billed charges,,,
HC Office/Outpatient New Low Mdm 30-44 Minutes,PX-51000026,CDM,99203,CPT,510,RC,,,outpatient,,,573,401.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,148.2351,126.37,473.871,percent of total billed charges,,,
HC Office/Outpatient New Moderate Mdm 45-59 Minutes,PX-51000027,CDM,99204,CPT,510,RC,,,outpatient,,,838,586.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,216.7906,179.35,693.026,percent of total billed charges,,,
HC Office/Outpatient New High Mdm 60-74 Minutes,PX-51000028,CDM,99205,CPT,510,RC,,,outpatient,,,1192,834.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,308.3704,146.954008,985.784,percent of total billed charges,,,
HC Office/Outpatient Est Pt May Not Req Phys/Qhp,PX-51000029,CDM,99211,CPT,510,RC,,,outpatient,,,287,200.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,74.2469,18.1184,416.02,percent of total billed charges,,,
HC Office/Outpatient Est Pt May Not Req Phys/Qhp,PX-76100002,CDM,99211,CPT,761,RC,,,outpatient,,,287,200.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,74.2469,18.1184,416.02,percent of total billed charges,,,
HC Office/Outpatient Est Pt May Not Req Phys/Qhp,PX-94200014,CDM,99211,CPT,942,RC,,,outpatient,,,287,200.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,74.2469,18.1184,416.02,percent of total billed charges,,,
HC Office/Outpatient Established Sf Mdm 10-19 Min,PX-51000030,CDM,99212,CPT,510,RC,,,outpatient,,,394,275.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,101.9278,50.2428,416.02,percent of total billed charges,,,
HC Office/Outpatient Established Sf Mdm 10-19 Min,PX-94200015,CDM,99212,CPT,942,RC,,,outpatient,,,394,275.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,101.9278,50.2428,416.02,percent of total billed charges,,,
HC PR Office/Outpatient Established Sf Mdm 10-19 Min,PX-98800012,CDM,99212,CPT,988,RC,,,outpatient,,,373,261.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,96.4951,50.2428,416.02,percent of total billed charges,,,
HC Office/Outpatient Established Low Mdm 20-29 Min,PX-51000031,CDM,99213,CPT,510,RC,,,outpatient,,,431,301.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,111.4997,90.68,416.02,percent of total billed charges,,,
HC Office/Outpatient Established Low Mdm 20-29 Min,PX-94200016,CDM,99213,CPT,942,RC,,,outpatient,,,431,301.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,111.4997,90.68,416.02,percent of total billed charges,,,
HC Office/Outpatient Established Mod Mdm 30-39 Min,PX-51000032,CDM,99214,CPT,510,RC,,,outpatient,,,467,326.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,120.8129,104.8415,416.02,percent of total billed charges,,,
HC Office/Outpatient Established Mod Mdm 30-39 Min,PX-94200020,CDM,99214,CPT,942,RC,,,outpatient,,,467,326.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,120.8129,104.8415,416.02,percent of total billed charges,,,
HC Office/Outpatient Established High Mdm 40-54 Min,PX-51000033,CDM,99215,CPT,510,RC,,,outpatient,,,829,580.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,214.4623,169.273,685.583,percent of total billed charges,,,
HC Office/Outpatient Established High Mdm 40-54 Min,PX-94200021,CDM,99215,CPT,942,RC,,,outpatient,,,754,527.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,195.0598,169.273,685.583,percent of total billed charges,,,
HC Critical Care Ill/Injured Patient Init 30-74 Min,PX-76000001,CDM,99291,CPT,760,RC,,,outpatient,,,3157,2209.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,816.7159,318.748996,2424.576,percent of total billed charges,,,
HC PR Critical Care Ill/Injured Patient Init 30-74 Min,PX-96000052,CDM,99291,CPT,960,RC,,,outpatient,,,3157,2209.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,816.7159,318.748996,2424.576,percent of total billed charges,,,
HC Critical Care Ill/Injured Patient Addl 30 Min,PX-76000002,CDM,99292,CPT,760,RC,,,outpatient,,,911,637.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,204.5195,699.648,other,Non-Reimbursable Procedures,,
HC PR Critical Care Ill/Injured Patient Addl 30 Min,PX-96000053,CDM,99292,CPT,960,RC,,,outpatient,,,911,637.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,204.5195,699.648,other,Non-Reimbursable Procedures,,
HC Tobacco Use Cessation Intermediate 3-10 Minutes,PX-94200022,CDM,99406,CPT,942,RC,,,outpatient,,,214,149.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,31.31797,416.02,other,Non-Reimbursable Procedures,,
HC Tobacco Use Cessation Intensive >10 Minutes,PX-94200025,CDM,99407,CPT,942,RC,,,outpatient,,,214,149.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,55.3618,31.31797,416.02,percent of total billed charges,,,
HC Arterial Stent- Xcranial Vertebral/ Thoracic Carotid- 1st Vessel,PX-36900026,CDM,0075T,CPT,369,RC,,,outpatient,,,774,541.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,200.2338,173.763,2998,percent of total billed charges,,,
HC Arterial Stent- Xcranial Vertebral/ Thoracic Carotid- Ea Add,PX-36900027,CDM,0076T,CPT,369,RC,,,outpatient,,,161,112.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,41.6507,36.1445,2998,percent of total billed charges,,,
HC Transluminal Peripheral Atherectomy- Renal Artery,PX-36900028,CDM,0234T,CPT,369,RC,,,outpatient,,,26415,18490.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6833.5605,399.86,22389.354,percent of total billed charges,,,
HC Transluminal Peripheral Atherectomy- Visceral Artery- Each,PX-36900029,CDM,0235T,CPT,369,RC,,,outpatient,,,735,514.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,190.1445,165.0075,2998,percent of total billed charges,,,
BONE BX OSTEO SITE 11G 10CM -,SUP-G36211,CDM,A4215,HCPCS,272,RC,,,outpatient,,,1924.08,1346.856,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.1,1477.69344,other,Non-Reimbursable Procedures,,
CATHETER COUDE 24FR 5CC -,SUP-1524C,CDM,A4340,HCPCS,270,RC,,,outpatient,,,45.92,32.144,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.30904,416.02,other,Non-Reimbursable Procedures,,
SILICONE CATHETER FOLEY 24FR 5CC -,SUP-8887605247,CDM,A4344,HCPCS,270,RC,,,outpatient,,,17.15,12.005,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.850175,416.02,other,Non-Reimbursable Procedures,,
CATH FOLEY 18FR 5ML BLN 3W DOVER LTX 16IN LUB -,SUP-2718,CDM,A4346,HCPCS,272,RC,,,outpatient,,,39.16,27.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.025285,416.02,other,Non-Reimbursable Procedures,,
CATHETER FOLEY 22FR 30CC 3-WAY -,SUP-2822,CDM,A4346,HCPCS,272,RC,,,outpatient,,,41.84,29.288,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.025285,416.02,other,Non-Reimbursable Procedures,,
CATHETER FOLEY 24FR 30CC 3-WAY -,SUP-2824,CDM,A4346,HCPCS,272,RC,,,outpatient,,,17.93,12.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.025285,416.02,other,Non-Reimbursable Procedures,,
CATH FOLEY SIL 3W 30CC 22FR -,SUP-8887665225,CDM,A4346,HCPCS,272,RC,,,outpatient,,,41.84,29.288,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.025285,416.02,other,Non-Reimbursable Procedures,,
SLING ORTHO ARM SM -,SUP-8023-01,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.98585,416.02,other,Non-Reimbursable Procedures,,
SLING DEROYAL ARM MEDIUM -,SUP-8023-02,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.98585,416.02,other,Non-Reimbursable Procedures,,
SLING DEROYAL ARM LARGE -,SUP-8023-03,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.98585,416.02,other,Non-Reimbursable Procedures,,
SLING ORTHO ARM XL -,SUP-8023-04,CDM,A4565,HCPCS,270,RC,,,outpatient,,,25.44,17.808,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.98585,416.02,other,Non-Reimbursable Procedures,,
SLING ARM MED STRP -,SUP-TX9901-43,CDM,A4565,HCPCS,270,RC,,,outpatient,,,13.3,9.31,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.98585,416.02,other,Non-Reimbursable Procedures,,
HC Tissue Marker,PX-27800092,CDM,A4648,HCPCS,278,RC,,,outpatient,,,418,292.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.325665,1791.14496,other,Non-Reimbursable Procedures,,
NEEDLE BRST LOC 20GAX3CM CM MRKNG STD MRKNG CANN ON WIRE -,SUP-253030,CDM,A4648,HCPCS,278,RC,,,outpatient,,,271.33,189.931,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.325665,1791.14496,other,Non-Reimbursable Procedures,,
MARKER BRSTBIO 3MM 17GA INCONEL 625 ULTRA CLP -,SUP-862017,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.325665,1791.14496,other,Non-Reimbursable Procedures,,
MARKER BRSTBIO 17GA TI ULTRA CLP II US -,SUP-863017,CDM,A4648,HCPCS,278,RC,,,outpatient,,,1097.2,768.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.325665,1791.14496,other,Non-Reimbursable Procedures,,
INSTRUMENT BX 18GA/17GA/INTRO ACHIEVE AUTO 11CM SFT TIS -,SUP-CA1811,CDM,A4648,HCPCS,278,RC,,,outpatient,,,497.49,348.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.325665,1791.14496,other,Non-Reimbursable Procedures,,
IDENTIFIER BIOPSY SITE FOR CELERO 12 THIRD SHAPE -,SUP-CELEROMARK-2S,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.325665,1791.14496,other,Non-Reimbursable Procedures,,
NEEDLE BRST LOC KOPANS 20GAX5CM BVL CUT TIP MOD REINF TIP -,SUP-DKBL-20-5.0-A,CDM,A4648,HCPCS,278,RC,,,outpatient,,,175.17,122.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.325665,1791.14496,other,Non-Reimbursable Procedures,,
NEEDLE BRST LOC KOPANS 20GAX7CM BVL CUT TIP MOD REINF TIP -,SUP-DKBL-20-7.0-A,CDM,A4648,HCPCS,278,RC,,,outpatient,,,175.17,122.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.325665,1791.14496,other,Non-Reimbursable Procedures,,
NEEDLE BRST LOC KOPANS 20GAX9CM BVL CUT TIP MOD REINF TIP -,SUP-DKBL-20-9.0-A,CDM,A4648,HCPCS,278,RC,,,outpatient,,,175.17,122.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.325665,1791.14496,other,Non-Reimbursable Procedures,,
NEEDLE 18GA X 20CM FUSIONCOIL WITH 1 X 5MM FIDUCIAL MARKER -,SUP-MTCTXFC1051820,CDM,A4648,HCPCS,278,RC,,,outpatient,,,752.72,526.904,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.325665,1791.14496,other,Non-Reimbursable Procedures,,
MARKERS CIVCO FIDUCIAL 30CM -,SUP-MTNW887835,CDM,A4648,HCPCS,278,RC,,,outpatient,,,1129.01,790.307,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.325665,1791.14496,other,Non-Reimbursable Procedures,,
MARKER BRSTBIO TI SCUR MRK MINI CORK -,SUP-SMARK-CELERO,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.325665,1791.14496,other,Non-Reimbursable Procedures,,
MARKER BRSTBIO TI SECURMARK TOP HAT SHP -,SUP-SMARK-CELERO-2S,CDM,A4648,HCPCS,278,RC,,,outpatient,,,481.1,336.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.325665,1791.14496,other,Non-Reimbursable Procedures,,
MARKER BRSTBIO TI SCUR MRK MINI CORK -,SUP-SMARK-EVIVA-13,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.325665,1791.14496,other,Non-Reimbursable Procedures,,
MARKER BRSTBIO TI SECURMARK -,SUP-SMARK-EVIVA-2S-13,CDM,A4648,HCPCS,278,RC,,,outpatient,,,373.44,261.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.325665,1791.14496,other,Non-Reimbursable Procedures,,
SCOUT 5CM DELIVERY NEEDLE AND REFLECTOR SSR05-01 -,SUP-SSR05-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.325665,1791.14496,other,Non-Reimbursable Procedures,,
SCOUT 10CM DELIVERY NEEDLE AND REFLECTOR -,SUP-SSR10-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.325665,1791.14496,other,Non-Reimbursable Procedures,,
SCOUT 7.5CM DELIVERY NEEDLE AND REFLECTOR -,SUP-SSR75-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.325665,1791.14496,other,Non-Reimbursable Procedures,,
REFLECTOR AND DELIVERY SYSTEM SINGLE HAND 16G 7.5 CM -,SUP-SSR75S-01,CDM,A4648,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.325665,1791.14496,other,Non-Reimbursable Procedures,,
IDENTIFIER BIOPSY SITE ATEC TRIMARK INTRODUCER SHEATH MARKER -,SUP-TRIMARK TD-2S-13-MR,CDM,A4648,HCPCS,278,RC,,,outpatient,,,371.98,260.386,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.325665,1791.14496,other,Non-Reimbursable Procedures,,
EXPANDER BRST 500ML BIOCELL RND NATRLL 13CMX13.5CM 5.7CM -,SUP-133FV-13,CDM,A4649,HCPCS,272,RC,,,outpatient,,,4986.7,3490.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures,,
EXPANDER TISSUE SMOOTH 600CC NATRELLE FULL HEIGHT -,SUP-133S-FV-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures,,
EXPANDER TISSUE NATRELLE SMOOTH 650CC -,SUP-133S-FX-14-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures,,
NATRELLE INSPIRA TISSUE EXPANDER 800CC -,SUP-133S-FX-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures,,
TISSUE EXPANDER 400CC NATRELLE SMOOTH MOD HEIGHT EXTRA PROT -,SUP-133S-MX-12-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures,,
TISSUE EXPANDER 500CC NATRELLE SMOOTH MOD HEIGHT EXTRA PROT -,SUP-133S-MX-13-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures,,
TISSUE EXPANDER 600CC NATRELLE -,SUP-133S-MX-14-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures,,
EXPANDER TISSUE NATRELLE SMOOTH 700CC -,SUP-133S-MX-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures,,
EXPANDER TISSUE SMOOTH 400CC SHORT HT EXTRA PROJ NATRELLE -,SUP-133S-SX-13-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5903.4,4132.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures,,
EXPANDER TISSUE SMOOTH 650CC HEIGHT EXTRA PROJ NATRELLE -,SUP-133S-SX-15-T,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures,,
EXPANDER TISS 250ML SHRT H -,SUP-133SV-12,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures,,
EXPANDER BRST UNIV NATRLL -,SUP-30-000003,CDM,A4649,HCPCS,272,RC,,,outpatient,,,63.19,44.233,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures,,
EXPANDER BREAST TISSUE CPX4 450CC -,SUP-350-9213,CDM,A4649,HCPCS,272,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures,,
650CC CPX 4 BREAST TISSUE EXPANDER W/SUTURE TABS MED. HEIGHT -,SUP-350-9215,CDM,A4649,HCPCS,272,RC,,,outpatient,,,7745.3,5421.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures,,
EXPANDER TISSUE SMOOTH 800CC CPX 4 W/SUTURE TABS MED HT -,SUP-350-9216,CDM,A4649,HCPCS,272,RC,,,outpatient,,,7745.3,5421.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures,,
EXPANDER BRST 850ML BIOCELL RND NATRLL 16CMX16.5CM 6.8CM -,SUP-37-133800,CDM,A4649,HCPCS,272,RC,,,outpatient,,,5835.5,4084.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures,,
EXPANDER BRST 600ML BIOCELL RND NATRLL 14CMX14.5CM 6.2CM -,SUP-67-133FV14,CDM,A4649,HCPCS,272,RC,,,outpatient,,,4986.7,3490.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures,,
SIZER IMPLANT NATRELLE INSPIRA 520CC FULL PROFILE -,SUP-MSZ-F520,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures,,
SIZER IMPLANT NATRELLE INSPIRA 560CC FULL PROFILE -,SUP-MSZ-F560,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures,,
SIZER IMPLANT NATRELLE INSPIRA 605CC FULL PROFILE -,SUP-MSZ-F605,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures,,
SIZER IMPLANT NATRELLE INSPIRA 695CC FULL PROFILE -,SUP-MSZ-F695,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures,,
SIZER IMPLANT NATRELLE INSPIRA 770CC FULL PROFILE -,SUP-MSZ-F770,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures,,
SIZER IMPLANT NATRELLE INSPIRA 275CC MODERATE PROFILE -,SUP-MSZ-M275,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures,,
SIZER IMPLANT NATRELLE INSPIRA 560CC MODERATE PROFILE -,SUP-MSZ-M560,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures,,
SIZER IMPLANT NATRELLE INSPIRA 600CC MODERATE PROFILE -,SUP-MSZ-M600,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures,,
SIZER IMPLANT NATRELLE INSPIRA 525CC EXTRA FULL PROFILE -,SUP-MSZ-X525,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures,,
SIZER IMPLANT NATRELLE INSPIRA 545CC EXTRA FULL PROFILE -,SUP-MSZ-X545,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures,,
SIZER IMPLANT NATRELLE INSPIRA 580CC EXTRA FULL PROFILE -,SUP-MSZ-X580,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures,,
SIZER IMPLANT NATRELLE INSPIRA 750CC XFULL PROFILE -,SUP-MSZ-X750,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures,,
SIZER IMPLANT NATRELLE INSPIRA 800CC EXTRA FULL PROFILE -,SUP-MSZ-X800,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures,,
SIZER IMPLANT NATRELLE INSPIRA 745CC FULL PROFILE -,SUP-SCF-745,CDM,A4649,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,14.186155,5948.3904,other,Non-Reimbursable Procedures,,
DRESSING WND 2X2IN PURACOL + HI GEL INTGRTY COLL LF -,SUP-MSC8622EP,CDM,A6021,HCPCS,270,RC,,,outpatient,,,32.97,23.079,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,7.401765,416.02,other,Non-Reimbursable Procedures,,
DRESSING BURN PURACOL PLUS 2X2 AG SILVER  COLLAGEN -,SUP-MSC8722EP,CDM,A6021,HCPCS,270,RC,,,outpatient,,,43.41,30.387,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,7.401765,416.02,other,Non-Reimbursable Procedures,,
SHEETING SILASTIC 4.625X5.625IN SIL GEL HYPAL SLFADH LPRO -,SUP-NC15462,CDM,A6025,HCPCS,272,RC,,,outpatient,,,180.14,126.098,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,11.99,416.02,other,Non-Reimbursable Procedures,,
DRESSING KALTOSTAT CA ALGIN 3X4.75IN ABSB -,SUP-168212,CDM,A6196,HCPCS,270,RC,,,outpatient,,,14.44,10.108,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.708445,416.02,other,Non-Reimbursable Procedures,,
DRESSING XTRA HYDROFIBER AQUACEL 2X2IN -,SUP-420671,CDM,A6196,HCPCS,270,RC,,,outpatient,,,8.66,6.062,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.708445,416.02,other,Non-Reimbursable Procedures,,
DRESSING ALGIN 2X2IN SQ NADH HI ABSB F/MOD TO HVY DRN -,SUP-MSC7022EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,7.61,5.327,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.708445,416.02,other,Non-Reimbursable Procedures,,
DRESSING MAXORB 4X4IN EXTRA -,SUP-MSC7044EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,14.23,9.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.708445,416.02,other,Non-Reimbursable Procedures,,
DRESSING WND 1X12IN FLT ROPE HI ABSORBENT1 F/WND MAXORB XTR -,SUP-MSC7112EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,20.07,14.049,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.708445,416.02,other,Non-Reimbursable Procedures,,
DRESSING MAXORB AG 2X2IN ALGIN SILVER -,SUP-MSC9422EP,CDM,A6196,HCPCS,270,RC,,,outpatient,,,18.37,12.859,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.708445,416.02,other,Non-Reimbursable Procedures,,
DRESSING GERMC AQUACEL AG EXTRA 4X4IN SLVR STRL -,SUP-420674,CDM,A6197,HCPCS,270,RC,,,outpatient,,,18.13,12.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.070185,416.02,other,Non-Reimbursable Procedures,,
DRESSING AQUACEL 4 X 5 -,SUP-420674,CDM,A6197,HCPCS,270,RC,,,outpatient,,,18.13,12.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.070185,416.02,other,Non-Reimbursable Procedures,,
DRESSING AQUACEL AG  2X2IN SQ HYDROFIBER SILVER -,SUP-422297,CDM,A6197,HCPCS,270,RC,,,outpatient,,,27.75,19.425,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.070185,416.02,other,Non-Reimbursable Procedures,,
DRESSING AQUACEL AG 6X6IN HYDROFIBER -,SUP-422298,CDM,A6197,HCPCS,270,RC,,,outpatient,,,112.45,78.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.070185,416.02,other,Non-Reimbursable Procedures,,
DRESSING ALGINATE SILVER 4X4.75IN CA ANTMIC NADH NWVN FLT -,SUP-MSC9445EP,CDM,A6197,HCPCS,270,RC,,,outpatient,,,34.27,23.989,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.070185,416.02,other,Non-Reimbursable Procedures,,
DRESSING MAXORB EXTRA AG 4X4 SILVER -,SUP-MSC9445EP,CDM,A6197,HCPCS,270,RC,,,outpatient,,,34.72,24.304,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.070185,416.02,other,Non-Reimbursable Procedures,,
DRESSING ALGIN AQUACL HYDROFIBER 0.75X18IN NADH CONFRM NWVN -,SUP-403770,CDM,A6199,HCPCS,270,RC,,,outpatient,,,19.4,13.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.3553,416.02,other,Non-Reimbursable Procedures,,
DRESSING ALGIN AQUACL HYDROFIBER 0.75X18IN NADH CONFRM NWVN -,SUP-403770,CDM,A6199,HCPCS,270,RC,,,outpatient,,,22.99,16.093,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.3553,416.02,other,Non-Reimbursable Procedures,,
DRESSING AQUACEL AG ROPE .75X18 IN -,SUP-422300,CDM,A6199,HCPCS,270,RC,,,outpatient,,,59.94,41.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.3553,416.02,other,Non-Reimbursable Procedures,,
DRESSING SILVERLON 4 X 10 -,SUP-ID-410,CDM,A6206,HCPCS,272,RC,,,outpatient,,,169.8,118.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,5.23,416.02,other,Non-Reimbursable Procedures,,
DRESSING ACTICOAT 4X5 -,SUP-66800405,CDM,A6207,HCPCS,272,RC,,,outpatient,,,81.2,56.84,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.98576,416.02,other,Non-Reimbursable Procedures,,
DRESSING ACTICOAT 4X4 -,SUP-66800406,CDM,A6207,HCPCS,272,RC,,,outpatient,,,44.48,31.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.98576,416.02,other,Non-Reimbursable Procedures,,
DRESSING ALLEVYN NONADHESIVE 2X2 NO BORDER -,SUP-66027643,CDM,A6209,HCPCS,272,RC,,,outpatient,,,14.63,10.241,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.94544,416.02,other,Non-Reimbursable Procedures,,
DRESSING FOAM 4x4 BORDERLESS -,SUP-66927637,CDM,A6209,HCPCS,272,RC,,,outpatient,,,13.12,9.184,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.94544,416.02,other,Non-Reimbursable Procedures,,
"DRESSING HYDROFERA 2.5"" X 2.5"" -",SUP-HLST-HBRT2525,CDM,A6209,HCPCS,272,RC,,,outpatient,,,268.12,187.684,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.94544,416.02,other,Non-Reimbursable Procedures,,
HYDROFERA BLUE READY TRANSFER 2.5 X 2.5 -,SUP-HLST-HRBS2214,CDM,A6209,HCPCS,272,RC,,,outpatient,,,26.78,18.746,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.94544,416.02,other,Non-Reimbursable Procedures,,
HYDROFERA BLUE READY TRANSFER 4 X 5 -,SUP-HBRS4520,CDM,A6210,HCPCS,272,RC,,,outpatient,,,40.63,28.441,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.121435,416.02,other,Non-Reimbursable Procedures,,
HYDROFERA BLUE READY TRANSFER 4 X 5 -,SUP-HLST-HRBT4050,CDM,A6210,HCPCS,272,RC,,,outpatient,,,416.5,291.55,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.121435,416.02,other,Non-Reimbursable Procedures,,
HYDROFERA BLUE READY TRANSFER 8 X 8 -,SUP-HLST-HRBS8820,CDM,A6211,HCPCS,272,RC,,,outpatient,,,92.17,64.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.692165,416.02,other,Non-Reimbursable Procedures,,
DRESSING OPTIFOAM AG 3.5 X 6 -,SUP-412010,CDM,A6212,HCPCS,270,RC,,,outpatient,,,109.06,76.342,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.79151,416.02,other,Non-Reimbursable Procedures,,
DRESSING OPTIFOAM AG 3.5 X 10 -,SUP-412011,CDM,A6212,HCPCS,270,RC,,,outpatient,,,139.34,97.538,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.79151,416.02,other,Non-Reimbursable Procedures,,
BANDAGE ADH 4X4IN ALLEVYN -,SUP-66800270,CDM,A6212,HCPCS,270,RC,,,outpatient,,,12.57,8.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.79151,416.02,other,Non-Reimbursable Procedures,,
BANDAGE ADH 4X4IN ALLEVYN -,SUP-66800270,CDM,A6212,HCPCS,270,RC,,,outpatient,,,18.72,13.104,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.79151,416.02,other,Non-Reimbursable Procedures,,
"DRESSING FOAMING ALLEYN GENTLE BORDER LITE 5.5CM X 12CM"" -",SUP-66800836,CDM,A6212,HCPCS,270,RC,,,outpatient,,,8.42,5.894,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.79151,416.02,other,Non-Reimbursable Procedures,,
DRESSING FOAM VERSATILE 2 1/8IN X 4 3/4IN SILICONE ADHESIVE -,SUP-66800836,CDM,A6212,HCPCS,270,RC,,,outpatient,,,7.98,5.586,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.79151,416.02,other,Non-Reimbursable Procedures,,
DRESSING ALLEVYN LIFE 5 1/16IN x 5 1/16IN -,SUP-66801068,CDM,A6212,HCPCS,270,RC,,,outpatient,,,14.24,9.968,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.79151,416.02,other,Non-Reimbursable Procedures,,
DRESSING OPTIFOAM AG 3.5 X 14 -,SUP-412012,CDM,A6213,HCPCS,270,RC,,,outpatient,,,148.97,104.279,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.206745,416.02,other,Non-Reimbursable Procedures,,
DRESSING FOAM SACRUM 9.4 X 8.4CM LRG -,SUP-423270,CDM,A6213,HCPCS,270,RC,,,outpatient,,,41.01,28.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.206745,416.02,other,Non-Reimbursable Procedures,,
DRESSING MEPORE 2.5 X 3 -,SUP-670800,CDM,A6219,HCPCS,270,RC,,,outpatient,,,0.55,0.385,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.04041,416.02,other,Non-Reimbursable Procedures,,
TOWEL ABSORBENT STER 7550 -,SUP-7550,CDM,A6219,HCPCS,270,RC,,,outpatient,,,4,2.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.04041,416.02,other,Non-Reimbursable Procedures,,
DRESSING WND 2X2IN ADH ISLND NWVN BRDR WTRPRF BK STRL SQ LF -,SUP-MSC3222,CDM,A6219,HCPCS,270,RC,,,outpatient,,,0.18,0.126,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.04041,416.02,other,Non-Reimbursable Procedures,,
DRESSING BORDERED 4X4IN ADH ISLAND NWVN -,SUP-MSC3244,CDM,A6219,HCPCS,270,RC,,,outpatient,,,2.39,1.673,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.04041,416.02,other,Non-Reimbursable Procedures,,
DRESSING PETRO ADPTC 3X3IN OIL EMUL NADH GZE CELLU-ACET -,SUP-2012,CDM,A6222,HCPCS,272,RC,,,outpatient,,,14.03,9.821,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.52533,416.02,other,Non-Reimbursable Procedures,,
DRESSING ADAPTIC 3INX3IN 7.6CMx7.6CM NON-ADHERING -,SUP-2012,CDM,A6222,HCPCS,272,RC,,,outpatient,,,14.03,9.821,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.52533,416.02,other,Non-Reimbursable Procedures,,
DRESSING XEROFORM 1X8 -,SUP-212,CDM,A6222,HCPCS,272,RC,,,outpatient,,,3.03,2.121,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.52533,416.02,other,Non-Reimbursable Procedures,,
DRESSING XEROFORM 2 X 2 -,SUP-214,CDM,A6222,HCPCS,272,RC,,,outpatient,,,2.34,1.638,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.52533,416.02,other,Non-Reimbursable Procedures,,
DRESSING MESALT RIBBON 3/4x39 IN DEBRIDE 0.75x39 IN ABSB -,SUP-285299,CDM,A6222,HCPCS,272,RC,,,outpatient,,,10.93,7.651,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.52533,416.02,other,Non-Reimbursable Procedures,,
DRESSING MESALT 3x3 IN GAUZE -,SUP-285780,CDM,A6222,HCPCS,272,RC,,,outpatient,,,4.67,3.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.52533,416.02,other,Non-Reimbursable Procedures,,
DRESSING WND 1.6 X 2.4IN CUTIMED SORBACT SWB PRIM STRL LF -,SUP-7216412,CDM,A6222,HCPCS,272,RC,,,outpatient,,,21.89,15.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.52533,416.02,other,Non-Reimbursable Procedures,,
DRESSING ADAPTIC 3X8 -,SUP-2013,CDM,A6223,HCPCS,272,RC,,,outpatient,,,4.43,3.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.698195,416.02,other,Non-Reimbursable Procedures,,
DRESSING PETRO VASELINE 1X36IN STRL 1-PLY IMPREG NADH LPRO -,SUP-205-12-A,CDM,A6223,HCPCS,272,RC,,,outpatient,,,3.11,2.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.698195,416.02,other,Non-Reimbursable Procedures,,
DRESSING XEROFORM 5IN X 9IN -,SUP-213,CDM,A6223,HCPCS,272,RC,,,outpatient,,,4.32,3.024,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.698195,416.02,other,Non-Reimbursable Procedures,,
DRESSING XEROFORM 5IN X 9IN -,SUP-213,CDM,A6223,HCPCS,272,RC,,,outpatient,,,4.32,3.024,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.698195,416.02,other,Non-Reimbursable Procedures,,
GAUZE VASELINE 1 X 36 -,SUP-8884412600,CDM,A6223,HCPCS,272,RC,,,outpatient,,,3.15,2.205,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.698195,416.02,other,Non-Reimbursable Procedures,,
DRESSING PETRO VASELINE 1X36IN OCL NADH STRIP STRL IMPREG -,SUP-8884412600,CDM,A6223,HCPCS,272,RC,,,outpatient,,,3.15,2.205,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.698195,416.02,other,Non-Reimbursable Procedures,,
DRESSING ADAPTIC 3X8 -,SUP-JOHN-2013,CDM,A6223,HCPCS,272,RC,,,outpatient,,,26.74,18.718,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.698195,416.02,other,Non-Reimbursable Procedures,,
GAUZE VASELINE 3IN X 18IN -,SUP-207-12-A,CDM,A6224,HCPCS,272,RC,,,outpatient,,,5.13,3.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.801465,416.02,other,Non-Reimbursable Procedures,,
GAUZE VASELINE 3IN X 18IN -,SUP-207-12-A,CDM,A6224,HCPCS,272,RC,,,outpatient,,,5.13,3.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.801465,416.02,other,Non-Reimbursable Procedures,,
"GAUZE VASELINE 3"" X 36"" -",SUP-425600,CDM,A6224,HCPCS,272,RC,,,outpatient,,,7.26,5.082,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.801465,416.02,other,Non-Reimbursable Procedures,,
GAUZE PETRO 3X36IN VASELINE -,SUP-8884415600,CDM,A6224,HCPCS,272,RC,,,outpatient,,,3.57,2.499,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.801465,416.02,other,Non-Reimbursable Procedures,,
GAUZE VASELINE 1/2 X 72 -,SUP-8884421600,CDM,A6224,HCPCS,272,RC,,,outpatient,,,5.95,4.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.801465,416.02,other,Non-Reimbursable Procedures,,
DRESSING HYDROCOLLOID DUODERM 2X4IN XTRA THIN -,SUP-187900,CDM,A6234,HCPCS,272,RC,,,outpatient,,,4.07,2.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.913715,416.02,other,Non-Reimbursable Procedures,,
DRESSING DUODERM EXTRA THIN 4X4 -,SUP-187955,CDM,A6234,HCPCS,272,RC,,,outpatient,,,6.71,4.697,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.913715,416.02,other,Non-Reimbursable Procedures,,
DRESSING WND XTHN 4X4IN DDRM STRL CONFRM NADH HYDRCL SQ -,SUP-187955,CDM,A6234,HCPCS,272,RC,,,outpatient,,,6.73,4.711,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.913715,416.02,other,Non-Reimbursable Procedures,,
DRESSING HYDROCOLLOID DUODERM 4X4IN XTRA THIN -,SUP-187955,CDM,A6234,HCPCS,272,RC,,,outpatient,,,4.49,3.143,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.913715,416.02,other,Non-Reimbursable Procedures,,
DRESSING HYDRCL XTHN 4X6IN DDRM CGF STRL XTHN CONFRM NADH -,SUP-187902,CDM,A6235,HCPCS,270,RC,,,outpatient,,,11.92,8.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.67604,416.02,other,Non-Reimbursable Procedures,,
DRESSING DUODERM 4 X 4 THICK -,SUP-187660,CDM,A6237,HCPCS,272,RC,,,outpatient,,,9.64,6.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,416.02,other,Non-Reimbursable Procedures,,
DRESSING WND 4X4IN DDRM SGNL STRL CONFRM ADH ABSB WTRPRF -,SUP-403326,CDM,A6237,HCPCS,272,RC,,,outpatient,,,11.11,7.777,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,416.02,other,Non-Reimbursable Procedures,,
DRESSING HYDROCOLLOID DUODERM 4X4IN -,SUP-403326,CDM,A6237,HCPCS,272,RC,,,outpatient,,,7.39,5.173,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,416.02,other,Non-Reimbursable Procedures,,
DRESSING HYDRCL 6X7IN DUADERM CGF STRL -,SUP-187974,CDM,A6238,HCPCS,270,RC,,,outpatient,,,42.72,29.904,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.600005,416.02,other,Non-Reimbursable Procedures,,
DRESSING WND 14X14CM DDRM SGNL STRL CONFRM ADH ABSB WTRPRF -,SUP-403327,CDM,A6238,HCPCS,270,RC,,,outpatient,,,20.49,14.343,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.600005,416.02,other,Non-Reimbursable Procedures,,
DRESSING WND 15X18CM DDRM SGNL STRL CONFRM ADH ABSB WTRPRF -,SUP-403332,CDM,A6238,HCPCS,270,RC,,,outpatient,,,21.79,15.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.600005,416.02,other,Non-Reimbursable Procedures,,
CREAM TRIAD HYDROPHILLIC WOUND DRESSING -,SUP-1964-A,CDM,A6240,HCPCS,270,RC,,,outpatient,,,31.57,22.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,7.087465,416.02,other,Non-Reimbursable Procedures,,
DRESSING HYDRCL 1.6IN TENDRWT STRL ACT CVTY LF -,SUP-MSC8401,CDM,A6242,HCPCS,270,RC,,,outpatient,,,16.34,11.438,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.66833,416.02,other,Non-Reimbursable Procedures,,
DRESSING DEBRIDE 3X3IN PLYACRL PLYMR GL CVTY PAD TENDRWT ACT -,SUP-MSC8403Z,CDM,A6242,HCPCS,270,RC,,,outpatient,,,22.7,15.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.66833,416.02,other,Non-Reimbursable Procedures,,
DRESSING GEL 30GM DDRM HYDACTV NADH FIL HYDRCL HYDACTV -,SUP-187987,CDM,A6248,HCPCS,272,RC,,,outpatient,,,13.91,9.737,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.122795,416.02,other,Non-Reimbursable Procedures,,
DRESSING SILVASORB GEL 0.25OZ  SILVER ABSB ANTMIC -,SUP-MSC93025EP,CDM,A6248,HCPCS,272,RC,,,outpatient,,,34.03,23.821,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.122795,416.02,other,Non-Reimbursable Procedures,,
SURGICAL DRESSING SILK 6 X 8IN -,SUP-NON4313,CDM,A6255,HCPCS,270,RC,,,outpatient,,,8.82,6.174,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.98009,416.02,other,Non-Reimbursable Procedures,,
DRESSING TEGADERM 1.75X1.75IN TRANPARENT FILM -,SUP-1622-W,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.17,0.819,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.262665,416.02,other,Non-Reimbursable Procedures,,
DRESSING TEGADERM 3 X 3 -,SUP-1624-W,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.17,0.819,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.262665,416.02,other,Non-Reimbursable Procedures,,
DRESSING TRANSP 2.375X2.75IN TEGADERM OCL PIC FRM STYL -,SUP-1624-W,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.17,0.819,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.262665,416.02,other,Non-Reimbursable Procedures,,
DRESSING TEAGDERM IV 2.75X3.25IN -,SUP-1633,CDM,A6257,HCPCS,270,RC,,,outpatient,,,1.63,1.141,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.262665,416.02,other,Non-Reimbursable Procedures,,
DRESSING TEGADERM IV 3.5X4.5IN TRANSPARENT -,SUP-1655,CDM,A6257,HCPCS,270,RC,,,outpatient,,,5.37,3.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.262665,416.02,other,Non-Reimbursable Procedures,,
DRESSING TRANSP 4X4.75IN TEGADERM OCL ORIG FRM STYL PLYSTR -,SUP-1626,CDM,A6258,HCPCS,270,RC,,,outpatient,,,3.38,2.366,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.75881,416.02,other,Non-Reimbursable Procedures,,
DRESSING TRANSPARENT 4IN X 4.25IN -,SUP-1626,CDM,A6258,HCPCS,270,RC,,,outpatient,,,3.38,2.366,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.75881,416.02,other,Non-Reimbursable Procedures,,
DRESSING TEGADERM 4X5 -,SUP-1626-W,CDM,A6258,HCPCS,270,RC,,,outpatient,,,3.53,2.471,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.75881,416.02,other,Non-Reimbursable Procedures,,
DRESSING TEGADERM 15X20CM -,SUP-1628,CDM,A6258,HCPCS,270,RC,,,outpatient,,,6.97,4.879,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.75881,416.02,other,Non-Reimbursable Procedures,,
DRESSING TRANSP 4X6.125IN TEGADERM OCL WND FRM STYL ADLT -,SUP-1689,CDM,A6258,HCPCS,270,RC,,,outpatient,,,10.58,7.406,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.75881,416.02,other,Non-Reimbursable Procedures,,
DRESSING TEGADERM 20CM X 30CM -,SUP-1629,CDM,A6259,HCPCS,272,RC,,,outpatient,,,9.86,6.902,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.21357,416.02,other,Non-Reimbursable Procedures,,
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7015-46,NDC,outpatient,10,ML,100.56,70.392,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.17,416.02,other,Non-Reimbursable Procedures,,
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7020-38,NDC,outpatient,10,ML,102.5,71.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.17,416.02,other,Non-Reimbursable Procedures,,
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7030-42,NDC,outpatient,10,ML,100.56,70.392,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.17,416.02,other,Non-Reimbursable Procedures,,
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7015-48,NDC,outpatient,10,ML,100.56,70.392,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.17,416.02,other,Non-Reimbursable Procedures,,
GADOPICLENOL 0.5 MMOL/ML IV SOLN,RX-161139,CDM,A9573,HCPCS,636,RC,00270-7025-40,NDC,outpatient,10,ML,100.57,70.399,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.17,416.02,other,Non-Reimbursable Procedures,,
GADOTERATE MEGLUMINE 1 MMOL/2 ML IV SOLN WRAPPER,RX-4080731,CDM,A9575,HCPCS,636,RC,67684-2000-00,NDC,outpatient,20,ML,136.25,95.375,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.12,416.02,other,Non-Reimbursable Procedures,,
7 HOLE SUPERIOR MIDSHAFT CLAVICLE RIGHT PLATE -,SUP-0000000215,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEADLESS 4.0 FIXOS X 26MM -,SUP-0000000215,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE ANCHORED APACHE 5MM -,SUP-0000006784,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CABLE ORTHO CBL-RDY COCR 635MM -,SUP-00022320418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2083.36,1458.352,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN IM 4.8X222MM RUSH SS -,SUP-00080200103,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.68,514.976,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN IM 3.2X127MM RUSH SS -,SUP-00080300104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN IM 3.2X140MM RUSH SS -,SUP-00080300105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN IM 3.2X165MM RUSH SS -,SUP-00080300107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN IM 3.2X191MM RUSH SS -,SUP-00080300109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN IM SZ 3L 3.2X241MM RUSH SS -,SUP-00080300113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN IM 3.2X254MM RUSH SS -,SUP-00080300114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X18MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS POR -,SUP-00104223018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X24MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS POR -,SUP-00104223024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X30MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-00104223030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN CANC 4.5X33MM PROTASUL-64 WF TM ANTMC SHLDR STRL -,SUP-00104223033,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN CANC 4.5X36MM PROTASUL-64 WF TM ANTMC SHLDR STRL -,SUP-00104223036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X42MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-00104223042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X48MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-00104223048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FILLER TY I COLL CA PHOS 5ML PST COPIOS DBASC -,SUP-00110302005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3752.36,2626.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FILLER TY I COLL CA PHOS 10ML PST COPIOS DBASC -,SUP-00110302010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6279,4395.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CEMENT BN PLYMTHL MTHCRYLT 40GM PLC R HVISC -,SUP-00111214001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 40X3MM ANCHR XLPE GLOBAL STRL -,SUP-00113640026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9421.68,6595.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX10MM CANN 7.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX10MM CANN 1/2 5MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX12MM CANN 9.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX12MM CANN 1/3 5MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3MMX16MM CANN 1/2 8MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114701631,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX16MM CANN 13.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114701636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3MMX19MM CANN 1/3 6.3MM THRD SD/ST HX REVCT FLUT -,SUP-00114701930,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANN 3.0MM X 20MM 1/3 TH -,SUP-00114702030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3MMX21MM CANN 1/3 7MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3MMX24MM CANN 1/2 12MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702431,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3MMX26MM CANN 1/2 13MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702631,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3MMX28MM CANN 1/2 14MM THRD SD/ST HX REVCT FLUT CRUCIF -,SUP-00114702831,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX28MM CANN 9.3MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114702835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX28MM CANN 1/3 9.3MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114702840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.27,795.389,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX28MM CANN 1/2 14MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114702841,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.27,795.389,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3MMX30MM CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX30MM CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX30MM CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT. -,SUP-00114703041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANN 1/3 10MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX34MM CANN 1/3 11.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX34MM CANN 1/3 11.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX34MM CANN 1/3 17MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703441,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.27,795.389,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX36MM CANN 1/3 12MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX36MM CANN 1/3 12MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX36MM CANN 1/3 18MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703641,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX38MM CANN 1/3 12.7MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114703840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX38MM CANN 1/3 19MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114703841,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3MMX40MM CANN 1/3 13.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1071.31,749.917,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX40MM CANN 1/3 13.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X40MM CANN 1/3 13.3MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX40MM CANN 1/3 20MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX42MM CANN 1/3 39.5MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX44MM CANN 14.7MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX44MM CANN 1/3 14.7MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX44MM CANN 1/2 22MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704441,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5MMX45MM CANN 16MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114704555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5MMX45MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114704556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX46MM CANN 15.3MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX46MM CANN 43.5MM FT SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX46MM CANN 1/3 15.3MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114704640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX46MM CANN 1/2 23MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704641,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX48MM CANN 16MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX48MM CANN 1/3 16MM THRD SD/ST 2.5MM HX REVCT FLUT -,SUP-00114704840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX50MM CANN 16.7MM P/T SD/ST 2.5MM HX REVCT FLUT -,SUP-00114705035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1134.32,794.024,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX50MM CANN 1/3 16.7MM THRD SD/ST 2.5MM HX REVCT -,SUP-00114705040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5MMX50MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5MMX50MM CANN 45.3MM FT SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705057,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MMX50MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114705065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5MMX55MM CANN 16MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5MMX55MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114705556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MMX55MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114705565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5MMX60MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114706056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MMX60MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MMX60MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5MMX65MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114706556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MMX65MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MMX65MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114706566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MMX70MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MMX70MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7.5MMX70MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7.5MMX70MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MMX75MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MMX75MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7.5MMX75MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7.5MMX75MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114707576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5MMX80MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114708056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MMX80MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MMX80MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7.5MMX80MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7.5MMX80MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7.5MMX80MM CANN 74.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114708077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEPIN ORTHO 1.6MMX6IN P/T TROC TIP -,SUP-00114708400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEPIN ORTHO 1.25MMX6IN P/T TROC TIP -,SUP-00114708500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5MMX85MM CANN 32MM THRD SD/ST 3.5MM HX REVCT FLUT -,SUP-00114708556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1125.83,788.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MMX85MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MMX85MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7.5MMX85MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7.5MMX85MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114708576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7.5MMX85MM CANN 79.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114708577,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEPIN ORTHO 2.4MMX9IN P/T TROC TIP -,SUP-00114708700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEPIN ORTHO 3.2MMX9IN P/T TROC TIP -,SUP-00114708800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEPIN ORTHO 1.6MMX9IN SMTH SHFT TROC TIP -,SUP-00114709000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,70.98,49.686,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MMX90MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7.5MMX90MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7.5MMX90MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7.5MMX90MM CANN 84.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114709077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEPIN ORTHO 2.4MMX9IN SMTH SHFT TROC TIP -,SUP-00114709100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,147.14,102.998,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEPIN ORTHO 3.2MMX9IN SMTH SHFT TROC TIP -,SUP-00114709200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,147.04,102.928,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEPIN ORTHO 1.6MMX6IN SMTH SHFT TROC TIP -,SUP-00114709400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,70.95,49.665,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WASHER ORTHO 3MM -,SUP-00114709500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MMX95MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MMX95MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709566,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7.5MMX95MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7.5MMX95MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114709576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7.5MMX95MM CANN 89.4MM FT SD/ST 5MM HX REVCT FLUT -,SUP-00114709577,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WASHER ORTHO F/3.5/4MM CANN SCR NS -,SUP-00114709600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WASHER ORTHO F/4.5MM CANN SCR SS NS -,SUP-00114709700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WASHER ORTHO F/5.5MM/7.5MM CANN SCR SS RND NS -,SUP-00114709800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,242.33,169.631,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEPIN ORTHO 3.2MMX12IN P/T TROC TIP -,SUP-00114709901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,108.18,75.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEPIN ORTHO 3.2MM 30CM -,SUP-00114709902,CDM,C1713,HCPCS,278,RC,,,outpatient,,,155.78,109.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEPIN ORTHO 3.2MMX12IN SMTH SHFT DRILL TIP -,SUP-00114709903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,155.74,109.018,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MMX100MM CANN 16MM THRD SD/ST 4.5MM HX REVCT FLUT -,SUP-00114710065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW Z CANN PT 32 6.5 X 100 -,SUP-00114710066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7.5MMX100MM CANN FT SD/ST 5MM HX REVCT FLUT BIODUR 108 -,SUP-00114710077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MMX105MM CANN 16MM THRD SD/ST 4.5MM HX REVCT FLUT -,SUP-00114710565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1278.48,894.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7.5MMX105MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114710575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1399.33,979.531,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7.5MMX105MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114710576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7.5MMX110MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7.5MMX110MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7.5MMX115MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7.5MMX115MM CANN 32MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114711576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7.5MMX120MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT -,SUP-00114712075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.25MM 2.5MM THRD MINI 10MM HRBRT MINI TIV STRL -,SUP-00115001000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2142.36,1499.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.25MM 2.5MM THRD MINI 16MM HRBRT MINI TIV STRL -,SUP-00115001600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2142.36,1499.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5MM 2.1MM THRD 14MM CANN HRBRT/WPL TIV STRL -,SUP-00115201400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2555.05,1788.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3X5MM DIA THRD MINI 18MM CANN LAG HRBRT/WPL TIV STRL -,SUP-00115201800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2555.05,1788.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEPIN ORTHO 3.2MMX23CM THRD TROC TIP FRLCK STRL -,SUP-00118102000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.84,81.788,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 12.7MM THRD VFX2 LAG 17MM S/T SS 130MM -,SUP-00119300557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1749.27,1224.489,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEPIN ORTHO 3.2MM TM -,SUP-00119703200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.19,908.033,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD FEM HIP 10MM TM TIV 25MM THRD -,SUP-00119710010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14101.97,9871.379,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN NCB 80MM 4HL CONTR LCK PROTASUL-64 STRL -,SUP-00202262104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5884.73,4119.311,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN NCB 117MM 7HL CONTR LCK PROTASUL-64 STRL -,SUP-00202262107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7175.97,5023.179,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X24MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X26MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X30MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X32MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,605.85,424.095,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X36MM LCK CORT NCB FT ST 2.5MM HX PROTASUL-100 NS -,SUP-00203131036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,605.85,424.095,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAP LCK NCB NS -,SUP-00203150300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,930.39,651.273,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X24MM NLCKG CORT NCB ST TMX NS -,SUP-00203155024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX26MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX28MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX30MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX32MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX34MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX36MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X38MM NLCKG CORT NCB ST TMX NS -,SUP-00203155038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX40MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX42MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX44MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX46MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX50MM BCORT NCB POLYAX ST 3.5MM HX PROTASUL-64 NS -,SUP-00203155050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X32MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,778.91,545.237,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X44MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,778.91,545.237,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X46MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,778.91,545.237,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X50MM CANC NCB 24MM THRD POLYAX ST 3.5MM HX HEX -,SUP-00203156050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.68,514.976,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN NCB 93MM 5HL LCK TI -,SUP-00203262005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5979.97,4185.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
STAPLE INTNL 19MMX15.9MM LF -,SUP-00222901300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,294.26,205.982,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DEVICE ORTHO 23MM LNG CBL-RDY GTR TROCH TIV 121MM STRL -,SUP-00223200205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9554.89,6688.423,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CABLE ORTHO 1.8MM CBL-RDY COCR 914MM STRL -,SUP-00223200228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2397.84,1678.488,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 305MM 4.5MM 10HL SS STRL -,SUP-00223200302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4354.7,3048.29,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CABLE PLATE 1.8MM CBL-RDY BN SS 610MM STRL -,SUP-00223200318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1493.73,1045.611,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CABLE SURG 1.8MM X 635MM CBL-RDY CRLGE SS -,SUP-00223200418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2083.36,1458.352,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CABLE FX 1.3MM CBL-RDY SS 889MM STRL -,SUP-00223201113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1788.55,1251.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ORTHOPEDIC CBL-RDY GRP 65MM PIN -,SUP-00223205021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2708.43,1895.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX12MM LCK CORT ST FA SS NS -,SUP-00234801235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX18MM LCK CORT ST FA SS NS -,SUP-00234801835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX20MM LCK CORT ST FA SS NS -,SUP-00234802035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX22MM LCK CORT ST FA SS NS -,SUP-00234802235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX26MM LCK CORT ST FA SS NS -,SUP-00234802635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX30MM LCK CORT ST FA SS NS -,SUP-00234803035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX34MM LCK CORT ST FA SS NS -,SUP-00234803435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX40MM LCK CORT ST FA SS NS -,SUP-00234804035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX100MM LCK CORT ST FA SS NS -,SUP-00234810035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 132MM 2.7/3.5MM 8HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235701708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3823.64,2676.548,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 80MM 2.7/3.5MM 4HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235701804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3310.29,2317.203,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 106MM 6HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235701806,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3540.4,2478.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 114MM 3.5MM 6HL PRCONT FX-ANG LCK SS TAPR NS -,SUP-00235800104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6389.13,4472.391,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 129MM 7HL FX-ANG LCK NS -,SUP-00235800907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.68,2924.376,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 77MM 3HL LCK SS NS -,SUP-00235801203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3788.26,2651.782,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX12MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX14MM LCK NCANN P/T ST CNCL SS NS -,SUP-00235901426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,328.92,230.244,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX14MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX14MM LCK NCANN P/T ST SS NS -,SUP-00235901438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX16MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX16MM LCK NCANN P/T ST CNCL SS NS -,SUP-00235901638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.5,439.25,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X18MM LCK NCANN FT ST CNCL SS NS -,SUP-00235901835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X30MM LCK NCANN FT ST SS NS -,SUP-00235903035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X32MM LCK NCANN FT ST SS NS -,SUP-00235903235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X36MM LCK NCANN FT ST SS NS -,SUP-00235903635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X38MM LCK NCANN FT ST SS NS -,SUP-00235903835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X40MM LCK NCANN FT ST SS NS -,SUP-00235904035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X42MM LCK NCANN FT ST SS NS -,SUP-00235904235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X44MM LCK NCANN FT ST SS NS -,SUP-00235904435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X46MM LCK NCANN FT ST SS NS -,SUP-00235904635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X48MM LCK NCANN FT ST SS NS -,SUP-00235904835,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X50MM LCK NCANN FT ST SS NS -,SUP-00235905035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,649.09,454.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCRW 14MM CASPAR PIN F/DSTRCT -,SUP-0024-LDR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEPIN ORTHO 3.2X444MM -,SUP-00281001175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
STAPLE INTNL 22MMX9.5MM COCR LF -,SUP-00406000100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.27,530.089,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
STAPLE INTNL 25MMX9.5MM COCR LF -,SUP-00406000200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.27,530.089,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN FX 3.2MM BGLNI/FLTW THRD TIP -,SUP-00430400800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,379.28,265.496,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.5MM THRD 7MM CORT FT ST HEX HEAD SS NS -,SUP-00481500701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.5MM THRD 8MM CORT FT ST HEX HEAD SS NS -,SUP-00481500801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.5MM THRD 9MM CORT FT ST HEX HEAD SS NS -,SUP-00481500901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.5MM THRD 14MM CORT FT ST HEX HEAD SS NS -,SUP-00481501401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.5MM THRD 16MM CORT FT ST HEX HEAD SS NS -,SUP-00481501601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.5MM THRD 20MM CORT FT ST HEX HEAD SS NS -,SUP-00481502001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2MM THRD 6MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482000603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2MM THRD 8MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482000803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2MM THRD 10MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2MM THRD 10MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2MM THRD 12MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2MM THRD 12MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2MM THRD 14MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2MM THRD 14MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2MM THRD 16MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2MM THRD 16MM CORT FT ST MINI CRUCIF RCESS SS NS -,SUP-00482001603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2MM THRD 18MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482001801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2MM THRD 22MM CORT FT ST MINI HEX RCESS/HEAD SS NS -,SUP-00482002201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.48,106.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MM THRD 6MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00482700601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MM THRD 8MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00482700801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MM THRD 10MM LCK CORT FT NON- ST 2.5MM SM HEX RCESS -,SUP-00482701000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,128.9,90.23,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MM THRD 10MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MM THRD 12MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MM THRD 14MM CORT FT ST 2.5MM SM HEX RCESS -,SUP-00482701401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MM THRD 16MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MM THRD 18MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482701801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,147.33,103.131,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MM THRD 20MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482702001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MM THRD 26MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-00482702601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MMX10MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482801002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MMX12MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482801202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MMX12MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482801202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MMX14MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482801402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MMX16MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482801602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MMX18MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482801802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MMX20MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482802002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MMX22MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482802202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MMX26MM LCK CANC P/T ST BIODUR 108 ALY NS -,SUP-00482802602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MMX28MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482802802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MMX30MM LCK CANC P/T ST BIODUR 108 ALY NS F/UNIV -,SUP-00482803002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,670.73,469.511,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX16MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483501601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX16MM LCK CORT 6MM P/T NON- ST 2.5MM SM HEX RCESS -,SUP-00483501604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX20MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX20MM LCK CORT 6MM P/T NON- ST 2.5MM SM HEX RCESS -,SUP-00483502004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX22MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX22MM LCK CORT 6MM P/T NON- ST 2.5MM SM HEX RCESS -,SUP-00483502204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX24MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483502404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX26MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX26MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483502604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX28MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483502801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX28MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483502804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX30MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483503001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX30MM LCK CORT 10MM P/T NON- ST 2.5MM SM HEX -,SUP-00483503004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN CORT 3.5MM 32MM SS NS FT S/T LOCK 2.5MM SM HEX -,SUP-00483503201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX34MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483503401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX34MM LCK CORT 12MM P/T NON- ST 2.5MM SM HEX -,SUP-00483503404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX45MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483504501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX45MM LCK CORT 12MM P/T NON- ST 2.5MM SM HEX -,SUP-00483504504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX50MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483505001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX55MM LCK CORT FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00483505501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX12MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484001200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX12MM CANC 5MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX14MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484001400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX14MM CANC 5MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX16MM LCK CANC FT 2.5MM SM HEX RCESS SS NS -,SUP-00484001600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX16MM CANC 6MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX18MM LCK CANC FT 2.5MM SM HEX RCESS SS NS -,SUP-00484001800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX18MM CANC 7MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484001801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX20MM LCK CANC FT 2.5MM SM HEX RCESS SS NS -,SUP-00484002000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX22MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484002200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX24MM CANC 10MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484002401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX26MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484002600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX28MM CANC 14MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484002801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX30MM CANC 14MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484003001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX34MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484003400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX38MM CANC FT ST 2.5MM SM HEX RCESS SS NS -,SUP-00484003800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX40MM CANC 14MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484004001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX50MM CANC 15MM P/T 2.5MM SM HEX RCESS SS NS -,SUP-00484005001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.83,90.881,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MM THRD 36MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484503601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MM THRD 38MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484503801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MM THRD 40MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MM THRD 40MM CORT 20.5MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00484504008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,194.77,136.339,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MM THRD 42MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MM THRD 44MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MM THRD 46MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484504601,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MM THRD 50MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484505001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MM THRD 50MM CORT 24.5MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00484505008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,194.77,136.339,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MM THRD 55MM CORT 26.5MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00484505508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,194.77,136.339,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MM THRD 58MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484505801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MM THRD 60MM CORT FT ST 3.5MM LRG HEX RCESS SS NS -,SUP-00484506001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MM THRD 45MM CANC 32MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486504502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MM THRD 50MM CANC 16MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486505001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MM THRD 50MM CANC 32MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486505002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MM THRD 55MM CANC 32MM P/T 3.5MM LRG HEX RCESS SS -,SUP-00486505502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MM THRD 60MM CANC FT 3.5MM LRG HEX RCESS SS NS -,SUP-00486506000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,225.06,157.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WASHER ORTHO 4X7MM SM 2.7/3.5/4.0MM SS RND FLT NS -,SUP-00490004051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,138.52,96.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WASHER ORTHO 13MM LRG 4.5/6.5MM RND FLT NS -,SUP-00490006551,CDM,C1713,HCPCS,278,RC,,,outpatient,,,207.73,145.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 21MM 2MM SS L-SHP OB R MINI FRAG NS -,SUP-00492000210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,386.57,270.599,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 23MM 4HL 2MM SS STR MINI FRAG NS -,SUP-00492000402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,389.49,272.643,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 32MM 2.7MM SS T-SHP MINI FRAG NS -,SUP-00492700304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.52,254.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 31MM 4HL 1MM SS 1/4 TBLR MINI FRAG NS CLLR -,SUP-00492700403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,432.72,302.904,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 104MM 3.5MM 4HL SS CLVRLF SM FRAG NS -,SUP-00493500416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1493.73,1045.611,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 61MM 5HL SS SM 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500503,CDM,C1713,HCPCS,278,RC,,,outpatient,,,406.82,284.774,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 73MM 3.5MM 6HL COMPR SS SM FRAG NS -,SUP-00493500600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,800.56,560.392,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 73MM 6HL SS SM 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.09,296.863,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 85MM 3.5MM 7HL COMPR SS SM FRAG NS -,SUP-00493500700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,822.21,575.547,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 85MM 7HL SS SM 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.09,296.863,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 97MM 3.5MM 8HL 1.1MM COMPR SS SM FRAG NS -,SUP-00493500800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 97MM 3.5MM 8HL SS 1/3 TBLR SM FRAG NS CLLR -,SUP-00493500803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,454.37,318.059,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 109MM 3.5MM 9HL 1.1MM COMPR SS SM FRAG NS -,SUP-00493500900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,887.1,620.97,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 121MM 3.5MM 10HL 1.1MM COMPR SS SM FRAG NS -,SUP-00493501000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,908.74,636.118,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 74MM 3.5MM HLX3/5 HD/SHFT 1.5MM SS T-SHP OBLQ SM -,SUP-00493503505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1100.65,770.455,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
"PLATE Z ""T"" 4 HOLE 3.5MM -",SUP-00493504404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,714.03,499.821,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 68MM 3.5MM UNIV LCK SYS 5HL LCK SS 1/3 TBLR NS -,SUP-00493600503,CDM,C1713,HCPCS,278,RC,,,outpatient,,,952.04,666.428,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 94MM 3.5MM UNIV LCK SYS 7HL LCK SS 1/3 TBLR NS -,SUP-00493600703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1016.92,711.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 107MM 3.5MM UNIV LCK SYS 8HL LCK SS 1/3 TBLR NS -,SUP-00493600803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.22,742.154,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 105MM 3.5MM UNIV LCK SYS 8HL CONTR LCK DL COMPR SS -,SUP-00493600807,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1867.15,1307.005,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 105MM 3.5MM UNIV LCK SYS 8HL RECON LCK SS NS -,SUP-00493600813,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2566.79,1796.753,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 133MM 3.5MM UNIV LCK SYS 10HL LCK SS 1/3 TBLR LRG -,SUP-00493601003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.81,757.267,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 116MM 4.5MM 6HL SHFT SS T-SHP LRG FRAG NS -,SUP-00494500604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1316.86,921.802,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE Z 4.5 COMP B 12 HOLE -,SUP-00494501201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1356.19,949.333,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
KT MIXER BNCMNT VAC MX 35ML LNG CQ/NOZ FNL CHRCL FLTR SUCT -,SUP-00504903501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,811.07,567.749,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
KT MIXER BNCMNT VAC MX 45ML LNG CQ/NOZ FNL CHRCL FLTR SUCT -,SUP-00504904501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,905.01,633.507,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WIRE PACK .028 SPADE TIP -,SUP-00505004100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,49.89,34.923,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GRAFT HUM TIS 11MM CHONDROFIX OSTCHND LF -,SUP-00560402011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15111.91,10578.337,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GRAFT BN 15MM CHONDROFIX LF -,SUP-00560402015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15891.64,11124.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 48MM HD UNICMPT SS F/HI FLEX SYS -,SUP-00579104100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 48MM HD UNICMPT SS F/HI FLEX SYS -,SUP-00579104100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.77,258.139,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
HOLDER IMPL HDLS 48MM SS GOLD F/UNICMPT HI FLEX KN SPCR BLCK -,SUP-00579104200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEX HEAD 3.5MM -,SUP-00-5901-035-27,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEX HEAD 3.5MM X 48MM -,SUP-00-5901-035-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW FLEX LCK -,SUP-00595409000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
EXTENSION STM MG2 PS TIV ALY PLG TAPR KN -,SUP-00596009900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDE SURG NEXGEN F/UNICMPT KN ARTHPL TIB PT SPEC INST HI.. -,SUP-00597000001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDE SURG NEXGEN F/UNICMPT KN ARTHPL TIB PT SPEC INST HI -,SUP-00597000002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEPIN ORTHO PERSONA CRUCIF RCESS -,SUP-00597000025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BASEPLATE TIB SZ1 58/40MM KN STM NEXGEN TIV ALY PMMA UHMWPE -,SUP-00598002701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COMP TIBPLT SZ2 62/41MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598002702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COMP TIBPLT SZ3 66/42MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598003701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COMP TIBPLT SZ3 66/42MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598003701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8452.1,5916.47,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COMP TIBPLT SZ4 66/46MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598003702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COMP TIBPLT SZ5 74/46MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598004701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COMP TIBPLT SZ6 74/50MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598004702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COMP TIBPLT SZ7 82/51MM KN STM NEXGEN TIV ALY PMMA UHMWPE CR -,SUP-00598005701,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW AUG 48MM TIV HX HD F/ARTHPL NEXGEN STRL DIST FEM KN -,SUP-00598304048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COMP TIBTRY SZ3 66/42MM KN CMNT STM WDG NEXGEN TIV PMMA CR -,SUP-00598800300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10515.22,7360.654,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COMP TIBTRY SZ4 66/46MM KN CMNT STM WDG NEXGEN TIV PMMA CR -,SUP-00598800400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10515.22,7360.654,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COMP TIBTRY SZ5 74/46MM KN CMNT STM WDG NEXGEN TIV PMMA CR -,SUP-00598800500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10515.22,7360.654,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DEVICE 11X4X11MM TM-S 7DG TM -,SUP-00610101041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10526.36,7368.452,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER 11X14X29MM VBR-11 TM -,SUP-00611100292,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15891.64,11124.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ACTB 6.5X15MM TRILOGY TIV CNTRSNK HEAD ST -,SUP-00625006515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE SELF TAPPED 6.5 X 20 -,SUP-00-6250-065-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BONE SCREW 6.5X25 SELF-TAP -,SUP-00-6250-065-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE SELF TAP 6.5 X 30 -,SUP-00-6250-065-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ACTB 6.5X35MM TRILOGY TIV CNTRSNK HEAD ST -,SUP-00625006535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE 6.5 X 40 SELF TAP -,SUP-00625006540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ACTB 6.5X40MM TRILOGY TIV CNTRSNK HEAD ST -,SUP-00625006540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE 6.5X40 SELF-TAP -,SUP-00-6250-065-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BONE SCREW 6.5 X 50MM SELF TAP -,SUP-00625006550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE 6.5 X 50 SELF-TAP -,SUP-00-6250-065-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LINER 56 X 32  TRILOGY LONGEVITY CONSTRAINED -,SUP-00-6334-056-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14191.09,9933.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HGP ACETABULAR CUP BONE SLF TP 6.5 X 20 -,SUP-00662406520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HGPAETABULAR CUP BONE SLF TP 6.5 X 30 -,SUP-00662406530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SUBSTITUTE BVN SPNG 1ML STRIP FIL COPIOS 10X20MM 5MM -,SUP-00700582001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1934.68,1354.276,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 2MMX45CM TRIMAX NANCY TI ALY E CAP -,SUP-00800620450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1462.94,1024.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLUG ACTB DOME HL HIP CONTIN -,SUP-00875700001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,379.28,265.496,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
HEAD BIOLOX OPT FEM 32MM/+3.5MM DELTA -,SUP-00-8777-032-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8566.51,5996.557,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SIDUS STEM-FREE SHOULDER HUMERAL ANCHOR M -,SUP-01.04555.120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19121.95,13385.365,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
G7 ACETABULAR SCREW 6.5MM / 20L -,SUP-010000997,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
G7 SCREW 6.5MM X 30MM -,SUP-010000999,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
G7 ACETABULAR SCREW 6.5MM / 35L -,SUP-010001000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
G7 SCREW 6.5MM X 40MM -,SUP-010001001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ENDOBUTTON 013186 -,SUP-013186,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.2,778.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BASE SLDR GFT F/ACL /PCL GRAFTMS II -,SUP-014950,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3100.9,2170.63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL FLEXIBLE PRE CURVED 1.50MM X 300MM -,SUP-0194-1500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL FLEXIBLE PRE CURVED 1.75MM X 300MM -,SUP-0194-1750S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.66,795.662,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL FLEXIBLE PRE CURVED 2.25MM X 300MM -,SUP-0194-2250S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1104.62,773.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL FLEXIBLE PRE CURVED 2.5MM X 450MM -,SUP-0194-2500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.59,822.213,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL FLEXIBLE PRE CURVED 3.5MM X 450MM -,SUP-0194-3500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1240.32,868.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL FLEXIBLE PRE CURVED 4.0MM X 450MM -,SUP-0194-4000S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1276.36,893.452,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL FLEXIBLE PRE-CURVED 2.25 X 300MM -,SUP-0195-2250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1104.62,773.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL FLEXIBLE PRE CURVED 2.5 X 450MM -,SUP-0195-2500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.59,822.213,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN LCP 158MM 3.5MM 6HL FA LC CONTR LCK COMPR SS TAPR -,SUP-02.104.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5487.49,3841.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN_VA-LCP 45MM 2.4MM HLX6/2 HD/SHFT CLMNX2 VAR ANG LCK -,SUP-02.111.621,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5084.31,3559.017,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.7/3.5 VA ANTEROLAT DSTL TIB PL/10 H/RT -,SUP-02.118.208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10401.04,7280.728,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7 METAPHYSEA SLF-TPNG T8 SD REC/48 -,SUP-02.118.548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7 METAPHYSEA SLF-TPNG T8 SD REC/50 -,SUP-02.118.550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.7 VA LOCKING ANT PATELLA PL SS CORE SILE -,SUP-02.137.003S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11077.74,7754.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7 VA LOCKING SLF-TPNG T8 SD REC 10 -,SUP-02.211.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 12 -,SUP-02.211.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 16 -,SUP-02.211.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 18 -,SUP-02.211.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.7 VA LCKNG SCR SLF-TPNG T8 SD REC 36 -,SUP-02.211.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.7 VA LCKING SCR SLF-TPNG T8 SD REC 38 -,SUP-02.211.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.7 VA LOCKING SCREW SLF-TPNG T8 SD REC 40 -,SUP-02.211.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7 VA LCKING SLF-TPNG T8 SD REC 42 -,SUP-02.211.042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.7 VA LCKNG SCR SLF-TPING T8 SD REC 46 -,SUP-02.211.046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.7MM VA LCKNG SCREW SLF-TPNG WITH T8 60MM -,SUP-02.211.060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE FUSION CLOVERLEAF SHORT 2.4/2.7 VA-LCP -,SUP-02.211.250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8683.22,6078.254,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAP FEM NCB LCK -,SUP-0203150300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,930.39,651.273,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PRESSURIZER BNCMNT PROX FEM MED -,SUP-0206-545-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.66,71.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FEM PRESSURIZING SEAL - MED -,SUP-0206-546-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.66,71.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW INTFR CANN BIOSTEON 7X23MM FT BABSRB WDG SHP HAP PLLA -,SUP-0234-010-161,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW INTFR CANN BIOSTEON 8X28MM FT BABSRB WDG SHP HAP PLLA -,SUP-0234-010-167,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW INTFR BIOSTEON 10X35MM INTFR HAP PLLA -,SUP-0234-010-178,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CROSS TITANIUM 8MM X 60MM -,SUP-0234500160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,885.69,619.983,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SYNFLATE BALLOON MED -,SUP-03.804.701S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DEVICE TK TI KNOT 5MM -,SUP-030404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1161.17,812.819,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE FUSION 2.4/2.7MM TI VA-LCP TMT -,SUP-04.211.266,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7524.61,5267.227,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN MATRIXRIB 17HL PRCONT TI NS ROSE RD -,SUP-04.501.006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7312.41,5118.687,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN MATRIXRIB 18HL 1.5MM PRCONT LCK TI NS LBLU -,SUP-04.501.007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8297.02,5807.914,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN MATRIXRIB 18HL PRCONT LCK TI NS ROSE RD -,SUP-04.501.008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7312.41,5118.687,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN MATRIXRIB 8HL PRCONT TI UNIV NS GOLD -,SUP-04.501.009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5653.01,3957.107,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.9X10MM LCK MATRIXRIB ST TI NS GOLD.. -,SUP-04.501.020.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1309.22,916.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.9X10MM LCK MATRIXRIB ST TI NS GOLD. -,SUP-04.501.020.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1147.03,802.921,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.9X12MM LCK MATRIXRIB ST TI NS GOLD -,SUP-04.501.022.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1309.22,916.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.9X14MM LCK MATRIXRIB ST TI NS GOLD -,SUP-04.501.024.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1150.21,805.147,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
IMPLANT ZERO-P IMP 8MM LORDOTIC STERILE -,SUP-04.617.128S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11510.3,8057.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
IMPLANT ZERO-P IMP 9MM LORDOTIC STERILE -,SUP-04.617.129S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11510.3,8057.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 3.0MM X 14MM TI CERVICAL SPINE -,SUP-04.617.814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
KT BONE CMNT SPINEPLEX -,SUP-0406-202-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1455.25,1018.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CEMENT BN 20GM VERTAPLEX DMSTC DUEL -,SUP-0406-402-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1853.05,1297.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PCD SYSTEM-LONG 90DEG TUBE W/VERTAPLEX -,SUP-0507-486-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2470.55,1729.385,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PCD PREC SYS LONG TUBE W/VHV -,SUP-0507-586-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2470.55,1729.385,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 8X70MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-05080000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
KT BONE CMNT AUTOPLEX STRL -,SUP-0605-687-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3912.53,2738.771,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANNULATED TI 6.5X 110MM,SUP-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.94,757.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEPIN ORTHO 2MM -,SUP-1007-1200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SUSTAIN SPACE SMALL - 11MM -,SUP-101.111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SUSTAIN SPACER SMALL NARROW 11MM -,SUP-101.711,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE ROD 5.5 X 250MM -,SUP-10-1025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X14MM CORT/CANC SS NS F/DMD CRPL FUSION PLATE -,SUP-1011602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,651.19,455.833,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X16MM CORT/CANC SS NS F/DMD CRPL FUSION PLATE -,SUP-1011603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,651.19,455.833,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X18MM CORT/CANC SS NS F/DMD CRPL FUSION PLATE -,SUP-1011604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,651.19,455.833,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SET SCREW -,SUP-1020-00-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.0 PLY 3.5 X 24MM SYMPHONY -,SUP-1020-035-124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X100MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.0 PLY 3.5 X 14MM SYMPHONY -,SUP-1020-35-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.0 PLY 3.5 X 16MM SYMPHONY -,SUP-1020-35-116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.0 PLY 3.5 X 18MM SYMPHONY -,SUP-1020-35-118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
4.0 PLY SCREW 3.5 X 20 -,SUP-102035120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.0 PLY 4.0 X 14MM SYMPHONY -,SUP-102040114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD TI 4.0 X 070 LOR -,SUP-102064070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD TI 4.0 X 075 LOR -,SUP-102064075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TI 4.0 X 090 LOR ROD -,SUP-102064090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X65MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X75MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X85MM CORT VERSANAIL FT ST DRV END F/UNIV NAIL SYS -,SUP-1020-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER 12X8X27MM LUCENT LRDTC CRV PEEK -,SUP-10227-008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER 12X9X27MM LUCENT LRDTC CRV PEEK -,SUP-10227-009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER 12X11X27MM LUCENT LRDTC CRV PEEK -,SUP-10227-011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11695.95,8187.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN F /FUSSION SS SM NS -,SUP-1024002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7238.14,5066.698,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUT ULFX MICROMITE SZ2-0 2.7MM BRD PLYSTR -,SUP-10301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1633.77,1143.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CHIP CANCELLOUS BONE 5CC 1-8 C -,SUP-103015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CREO AMP 5.5 X 50MM -,SUP-1067.1550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CREO AMP 5.5 X 45MM MOD CAN -,SUP-1067.4545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MODULAR CANNULATED 6.5 X 40MM CREO AMP -,SUP-1067.4640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD CURVED TIT ALLOY 4.75MM X 35MM -,SUP-1067.7035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD CURVED TIT ALLOY 4.75MM X 40MM -,SUP-1067.7040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ONLAY LYOPLANT 7.5 X 7.5CM -,SUP-1067040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4108.41,2875.887,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FILLER 10ML OSTEOSPONGE -,SUP-109510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4081.77,2857.239,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FILLER CANC TRBCLR DBM 15ML CHP OSTEOSPONGE ELAS OSTCONDC -,SUP-109515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FILLER DEMIN CANC BN 5ML CHP OSTEOSPONGE ELAS OSTCONDC -,SUP-109550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GRAFT DEMIN CANC BN BLCK 14MM OSTEOSPONGE ELAS OSTCONDC -,SUP-109614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3437.28,2406.096,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SUBSTITUTE CORT FBR 10CC 3DEMIN -,SUP-109760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW T15 LP CORT 3.5 X 20MM NS -,SUP-110017720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW T15 LP CORT 3.5 X 22MM NS -,SUP-110017722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW T15 LP CORT 3.5 X 24MM NS -,SUP-110017724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW T15 LP CORT 3.5 X 26MM NS -,SUP-110017726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW T15 LP CORT 3.5 X 30MM NS -,SUP-110017730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW T15 LP CORT 3.5 X 32MM NS -,SUP-110017732,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW T15 LP CORT 3.5 X 34MM NS -,SUP-110017734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW T15 LOW PROFILE CORT 3.5 X 36MM NS -,SUP-110017736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW T15 LOW PROFILE CORT 3.5  X 38MM NS -,SUP-110017738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW T15 LOW PROFILE CORT 3.5 X 40MM NS -,SUP-110017740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW T15 LP CORT 3.5 X 44 NS -,SUP-110017744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW T15 MD 3.5 X 28MM NS -,SUP-110018028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW T15 LOCK MULTIDIRECTIONAL 3.5 X 34MM NS -,SUP-110018034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW T15 MULTIDDIRECTIONAL 3.5 X 38MM NS SILVER -,SUP-110018038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW T15 MULTIDIRECTIONAL 3.5 X 40MM NS SILVER -,SUP-110018040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE T15 MULTIDIRECTIONAL 3.5 X 42MM NS SILVER -,SUP-110018042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW T15MD 3.5 X 46MM NS -,SUP-110018046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW T15 MD 3.5 X 52MM NS -,SUP-110018052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
3.2MM PEG 20MM -,SUP-110025320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
3.2MM PEG 24MM -,SUP-110025324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG FIXATION 3.2 X 26MM -,SUP-110025326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG FIXATION 3.2 X 28MM -,SUP-110025328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
3.2MM PEGS 30MM -,SUP-110025330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG 3.2 X 32 -,SUP-110025332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEGS 3.2MM X 34MM -,SUP-110025334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG 3.2 X 36MM -,SUP-110025336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG 3.2MM X 38MM -,SUP-110025338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG 3.5 X 40MM -,SUP-110025340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG 3.2 X 42 -,SUP-110025342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG 3.2MM X 44MM -,SUP-110025344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG 3.2 X 46MM -,SUP-110025346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG 3.2 X 50MM -,SUP-110025350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG 3.2 X 52MM -,SUP-110025352,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG 3.2MM X 54MM -,SUP-110025354,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG 3.2 X 56 -,SUP-110025356,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG 3.2 X 58MM -,SUP-110025358,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
3.2MM PEG 60MM -,SUP-110025360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG 3.2 X 65MM -,SUP-110025365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,735.21,514.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE PRX HUM LO LT 3H 73MM -,SUP-110030100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6671.57,4670.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PRX HUM LO PLT LT 7H 133MM -,SUP-110030102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8021.16,5614.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PRX HUM HI PLTLT 3H 80MM -,SUP-110030300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6569.71,4598.797,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PRX HUM HI PLT RT 3H 80MM -,SUP-110030400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6569.71,4598.797,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE PRX HUM HI RT 4H 90MM -,SUP-110030401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6824.35,4777.045,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
REFOBACIN BONE CEMENT R 1X14 US -,SUP-110034355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COMPR NANO 7IN STEINMANN PIN -,SUP-110045821,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3246.32,2272.424,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GRAFT PLATE CANOPY INLINE 7MM -,SUP-1102.1007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW FIXATION VARIABLE ANGLE -,SUP-111655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1457.21,1020.047,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAP SPIN CREO 5.5MM -,SUP-1119.0000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CREO THREADED LOCKING CAP -,SUP-1119.0010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CONNECTOR CROSS 38-50 LONG 5.5 CREO -,SUP-1119.0039,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CREO 5.5 CROSS CONNECTOR 48-60MM LONG -,SUP-1119.0046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TULIP HEAD FOR CORTICAL SCREW -,SUP-1119.0100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CONNECTOR CREO 5.5 LOW PROFILE CROSS  21.5-25MM LONG -,SUP-1119.0221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CREO 5.5 LOW PROFILE CROSS CONN- 24.5-31MM LONG -,SUP-1119.0224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL 5.5-4.5X25MM MOD CREO AMP -,SUP-1119.1325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
5.5-4.5 X 30MM CREO MCS SCREW -,SUP-1119.1330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5 4.5 X 35MM CORTICAL MODULAR CREO AMP -,SUP-1119.1335,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL 6.0-5.0 X 30ML -,SUP-1119.1430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
6.0-5.0 X 35MM CORTICAL SCREW -,SUP-1119.1435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORITICAL 6.5-5.5X35MM -,SUP-1119.1535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL 6.5-5.5X35MM -,SUP-1119.1535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD 5.5 X 35 TITANIUM ALLOY -,SUP-1119.5035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD STRAIGHT 5.5MM X 40 -,SUP-1119.5040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD TITANIUM ALLOY 5.5 X 45 STRAIGHT -,SUP-1119.5045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD 150MM -,SUP-1119.5150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN CREO 5.5X35MM CRV TI ALY THORLUM -,SUP-1119.7035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
5.5MM CURVED ROD TITANIUM ALLOY 40MM LENGTH -,SUP-1119.7040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD CREO 5.5X40MM -,SUP-1119.7040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD CURVED 5.5MM TITANIUM ALLOY 45MM LENGTH -,SUP-1119.7045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN CREO 5.5X50MM CRV TI ALY THORLUM -,SUP-1119.7050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN CREO 5.5X55MM CRV TI ALY THORLUM -,SUP-1119.7055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD CURVED 5.5MM TITANIUM ALLOY 60MM LENGTH -,SUP-1119.7060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD 5.5MM CURVED TIT ALLOY 65MM -,SUP-1119.7065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD CURVED 5.5MM TITANIUM ALLOY 70MM LENGTH -,SUP-1119.7070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD CURVED 5.5MM TITANIUM ALLOY 80MM LENGTH -,SUP-1119.7080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LCK EXPLOR TI ALY -,SUP-11-210099,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PELVIC ARRAY -,SUP-112230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5393.06,3775.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
STEM TPR DIST SPR 14 X 150MM ARCOS -,SUP-11-300814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
STEM TPR DIST SPR 16 X 150MM ARCOS -,SUP-11-300816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAP LOCKING CREO MIS -,SUP-1134.0010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TULIP MODULAR POLYAXIAL 30MM REDUCTION CREO MIS -,SUP-1134.0100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD CURVED 5.5MM X 50MM TITANIUM ALLOY CREO MIS -,SUP-1134.7050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
HEAD MOD 36MM COCR STD -,SUP-11-363662,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COMP 44MM GLOBAL AP SHLDR 3MM XLPE PG -,SUP-1136-41-026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8667.95,6067.565,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COMP 52MM GLOBAL AP SHLDR 3MM XLPE PG -,SUP-1136-43-026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10652.6,7456.82,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
MITRIS RESILIA MITRAL VALVE 25MM -,SUP-11400M25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
MITRIS RESILIA MITRAL VALVE 27MM -,SUP-11400M27,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
MITRIS RESILIA MITRAL VALVE 29MM -,SUP-11400M29,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
MITRIS RESILIA MITRAL VALVE 31MM -,SUP-11400M31,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31560.5,22092.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
THUMBSCREW FOR C501 ROCHE CUVETTE -,SUP-11406701001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,140.74,98.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7.5MMX100MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUTNS.. -,SUP-1147-100-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7.5MMX100MM CANN 16MM THRD SD/ST 5MM HX REVCT FLUT NS. -,SUP-1147-100-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEPIN ORTHO 3.2X353MM THRD -,SUP-115163,CDM,C1713,HCPCS,278,RC,,,outpatient,,,307.85,215.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW COMP RVS CONTROL 6.5 X 20MM ST -,SUP-115380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW COMP RVS CONTROL 6.5 X 30MM ST -,SUP-115382,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X35MM CORT RVRS CNTRL 3.5MM HEX DRV HEX HEAD TI ALY -,SUP-115383,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COMP RVS CNTRL 6.5 X 20MM ST/RST -,SUP-115394,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COMP RVS CNTRL 6.5 X 25MM ST/RST -,SUP-115395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X25MM CORT RVRS CNTRL 3.5MM HEX DRV HEX HEAD TI ALY -,SUP-115395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
6.5 X 30MM CENTRAL SCREW -,SUP-115396,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
REVERSE CENTRAL SHOULDER SCREW 3.5MM X 35MM -,SUP-115397,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COMP RVS CNTRL 6.5 X 40MM ST/RST -,SUP-115398,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COMP RVS CNTRL 6.5 X 45MM ST/RST -,SUP-115399,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER ANT THORLUM VERT 14MMX15-18MMH XPAND 0DG SM 12MM OPN -,SUP-116.101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14881.7,10417.19,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER ANT THORLUM VERT 21X23MMX37-46MM XPAND 0DG MED OPN TI -,SUP-116.207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16864.45,11805.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER ANT THORLUM VERT 21X23MMX49-70MM XPAND 0DG MED OPN TI -,SUP-116.208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16864.45,11805.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CATH ANGIOPLASTIC MARINER BERENSTEIN 4FR 100CM -,SUP-11714016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SING HEAD OPEN LAT CONN 5.5-6.0 HEAD-5.5-6.35 OPEN 12MM WIDE -,SUP-1175.9214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7265.73,5086.011,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN MOUNTAINEER 3.5-5.5X420MM CRV TI OCT LVL1 NS -,SUP-1183-11-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR LD SWIFT- LOCK SPIN CRD MECH LCK -,SUP-1192,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM-THRD -,SUP-121107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM THRD_ -,SUP-121108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM THRD- -,SUP-121109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 12.7MM THRD AMBI CLASSIC IMHS COMPR LAG 21MM THRD. -,SUP-121110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3510.13,2457.091,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 19MM COMPR LAG AMBI CLASSIC IMHS 21MM THRD STD 3.5MM -,SUP-121116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,781.07,546.749,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
12MM ROD -,SUP-12-1120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X25MM CANN 19MM THRD SD/ST REVCT FLUT SS -,SUP-121625,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X30MM CANN 16MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X35MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121627,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X40MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X45MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121629,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X50MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X55MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121631,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X60MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X65MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121633,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X70MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X75MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X80MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X85MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121637,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X90MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5 CANNULATED 9.5 -,SUP-121639,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X100MM CANN 20MM THRD SD/ST REVCT FLUT SS STRL -,SUP-121640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X105MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121641,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X110MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X115MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121643,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X120MM CANN 20MM THRD SD/ST REVCT FLUT SS -,SUP-121644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WASHER ORTHO 6.5X12.7MM F/7MM CANN BN SCR RND STRL -,SUP-121680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.23,451.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ACTB 6.5X30MM GRIFTON PINNCL LCK TI FOAM DOME ST -,SUP-1217-30-500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,537.46,376.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX10MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX12MM CANN 5MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX14MM CANN 5MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX16MM CANN 6MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX18MM CANN 7MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX22MM CANN 9MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX24MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX26MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX28MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX30MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121830,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX32MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX34MM CANN 14MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121834,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX36MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121836,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX38MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121838,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX40MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX42MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121842,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX44MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121844,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX46MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX48MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121848,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX50MM CANN P/T ST STD HEX DRV SCKT RVRS XTRCT FLUT -,SUP-121850,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX52MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121852,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX54MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121854,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX56MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121856,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX58MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121858,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANNULATED 4.0M X 60M -,SUP-121860,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX65MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX70MM CANN 15MM P/T ST STD HEX DRV SCKT RVRS XTRCT -,SUP-121870,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2318.81,1623.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
30MM CROSSLINK -,SUP-12-2052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CATALYST R1 6.5MM CENTER SCREW AND CAP SIZE 30 -,SUP-1230-7508-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CATALYST R1 4.5MM LOCKING SCREW SIZE 20 -,SUP-1230-7511-003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CATALYST R1 4.5MM LOCKING SCREW SIZE 24 -,SUP-1230-7511-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CATALYST R1 GLENOSPHERE LOCKING SCREW IMPLANT -,SUP-1230-7515-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LINER INSERT MDM X3 22.2MM ID X 36MM OD X 36C -,SUP-1236-2-242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ENDCAP SPIN REVERE -,SUP-124.000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
REV LOW PROF ADJ T-CONN 29 X 34 -,SUP-124.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X25MM REVERE DBL LD THRD POLYAX F/5.5MM TI -,SUP-124.051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X30MM REVERE DL HEAD THRD POLYAX F/5.5MM TI -,SUP-124.052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI -,SUP-124.053,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X35MM REVERE DEFRM MONOAX -,SUP-124.263,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X40MM REVERE DEFRM MONOAX -,SUP-124.264,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7.5X35MM REVERE DEFRM MONOAX -,SUP-124.273,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X30MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.443,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
4.5MM REVERE PEDICLE SCREW 45MM -,SUP-124.445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5X30MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.452,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.453,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5X40MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.454,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5X45MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5X50MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.456,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5X55MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.457,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X30MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.462,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X35MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.463,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X40MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.464,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X45MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X50MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.466,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X55MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.467,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X60MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.468,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X65MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.469,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7.5X40MM REVERE DBL LD THRD POLYAX F/5.5MM TI ALY -,SUP-124.474,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN REVERE DEFRM 5.5X100MM STR TI LPRO THORLUM NTHRD -,SUP-124.510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
5.5MM STRAIGHT ROD 125MM -,SUP-124.512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN REVERE DEFRM 5.5X150MM STR TI LPRO THORLUM NTHRD -,SUP-124.515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
5.5MM STRAIGHT ROD 400MM -,SUP-124.520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD STRAIGHT 5.5 X 500 -,SUP-124.521,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN REVERE DEFRM 5.5X45MM STR TI LPRO THORLUM NTHRD LCK -,SUP-124.545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN REVERE DEFRM 5.5X85MM STR TI LPRO THORLUM NTHRD LCK -,SUP-124.585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
5.5MM CURVED ROD 125MM -,SUP-124.612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN REVERE DEFRM 5.5X35MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN REVERE DEFRM 5.5X40MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN REVERE DEFRM 5.5X45MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN REVERE DEFRM 5.5X50MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN REVERE DEFRM 5.5X55MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN REVERE DEFRM 5.5X60MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN REVERE DEFRM 5.5X65MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN REVERE DEFRM 5.5X75MM CRV TI LPRO THORLUM NTHRD LCK -,SUP-124.675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6MM DL OD 35MM REVERE POLYAX CORT/CANC F/5.5MM TI ALY -,SUP-124.762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6MM DL OD 40MM REVERE POLYAX CORT/CANC F/5.5MM TI ALY -,SUP-124.763,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CONNECTOR ROD REVERE 5.5MM VARIABLE CROSS 38MM-50MM -,SUP-124.984,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3327.48,2329.236,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
5.5MM CLOSED OFFSET CONNECTOR 5.5MM ROD 30MM -,SUP-124.993,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ELIMINATOR ACTB THRD POS STP F/CUP DURALOC -,SUP-1246-03-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
OSTEOAMP GRANULES 1CC -,SUP-12600201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2340.97,1638.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
OSTEOAMP GRANULES 5CC -,SUP-12600401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4725.27,3307.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
OSTEOAMP GRANULES 10CC -,SUP-12600501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7875.46,5512.822,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
OSTEOAMP GRANULES 2-4MM (5CC) -,SUP-12700401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4587.68,3211.376,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEPIN ORTHO 1.3MMX15CM THRD TROC TIP -,SUP-128047,CDM,C1713,HCPCS,278,RC,,,outpatient,,,305.64,213.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
STAPLE BN FX XS COCR -,SUP-128690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2676.59,1873.613,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
STAPLE BN FX SM COCR -,SUP-128692,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2676.59,1873.613,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
RESTRICTOR BNCMNT FMCNL 25MM BUCK -,SUP-129419,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1159.24,811.468,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
UNITED HIP SYSTEM FULL XPE CUP 36MM X 54MM -,SUP-1302-3654,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
STAPLE SPIN RSTRL SM TI -,SUP-131.001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4759.68,3331.776,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
STAPLE SPIN CDL SM TI -,SUP-131.002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4759.68,3331.776,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
STAPLE SPIN ANT VERT SM TI -,SUP-131.011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3413.41,2389.387,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CONNECTOR SPIN REVERE DL CX 15MM TI -,SUP-131.115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CONNECTOR SPIN CX TI -,SUP-131.116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.5X35MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.5X40MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.5X18MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.5X24MM 20DG ANG CONE LCK THRD MULDIR SQ DRV NRW -,SUP-131211124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN TMX 12.9MMX43.7MM COMPR HI STRGTH 2D CONTR LCK Y -,SUP-1312-17-003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2534.99,1774.493,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN F 3 13MMX42.7MM HI FLEX 3D CONTR LCK NS RT -,SUP-131217100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2778.47,1944.929,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN F 3 13MMX42.7MM HI FLEX 3D CONTR LCK NS LT -,SUP-131217101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2778.47,1944.929,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WASHER ORTHO 3.5MM ALPS F/ELB PLATE SYS NS -,SUP-131218000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X14MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X16MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X28MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X30MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X36MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X40MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X44MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X48MM NLCKG CORT ALPS TRNCT SQ DRV TMX NS -,SUP-131218048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X50MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X60MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X70MM NLCKG CORT ALPS ST SQ DRV TMX NS -,SUP-131218070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN ALPS 10.7X85MM 9HL 2.4MM CONTR LCK TMX ANTMC -,SUP-131218203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN ALPS 17.5X29MM 1.5MM CONTR LCK TMX SM ANTMC NS -,SUP-131218400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3637.79,2546.453,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN SM -,SUP-1312-18-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4024.48,2817.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN ALPS 81X10IN 10HL CONTR LCK COMPR TMX SM ANTMC NS -,SUP-131218600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN ALPS 10.7X154MM 17HL 2.5MM CONTR LCK COMPR TMX LNG -,SUP-131218607,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4481.66,3137.162,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WASHER ORTHO 2.5MM ALPS THRD -,SUP-131220025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN ALPS 2.5MM PRCONT LCK COMPR TMX T-SHP ANTMC NS -,SUP-131220152,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2353.42,1647.394,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN ALPS 2.5MM PRCONT LCK COMPR TMX SM T-SHP ANTMC NS -,SUP-131220157,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2099,1469.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN ALPS 2.5MM PRCONT LCK COMPR TMX STR ANTMC NS -,SUP-131220251,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2448.83,1714.181,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN ALPS 27.6MMX73.8MM 2.5MM 1.65MM PRCONT LCK COMPR -,SUP-131220252,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2448.83,1714.181,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN ALPS 19.5MMX71.8MM 2.5MM 1.65MM PRCONT LCK COMPR -,SUP-131220253,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2448.83,1714.181,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.5X11MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.5X14MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.5X15MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220415,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.5X16MM LCK CORT ALPS ST MULDIR MODULAR SQ DRV TMX NS -,SUP-131220416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.5X12MM NLCKG CORT ALPS ST MULDIR MODULAR SQ DRV TMX -,SUP-131220512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.5X14MM NLCKG CORT ALPS ST MULDIR MODULAR SQ DRV TMX -,SUP-131220514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.5X15MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.5X16MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.5X18MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.5X20MM NLCKG CORT ALPS ST MODULAR SQ DRV TMX NS -,SUP-131220520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.7X18MM LCK SMTH DVR -,SUP-131227118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X20MM LCK CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X22MM LCK CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X14MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X15MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227215,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X16MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X26MM NLCKG CORT DVR CROSSLOCK TAPR HEAD -,SUP-131227226,CDM,C1713,HCPCS,278,RC,,,outpatient,,,420.12,294.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN DVR 24X85MM F/CROSSLOCK DIST RAD PLATE SYS LNG LCK -,SUP-131812090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4558.06,3190.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN MARS 5.5X45MM CRV CONE TIP TI ANT LMBR -,SUP-132.145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4334.79,3034.353,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN MARS 5.5X50MM CRV CONE TIP TI ANT LMBR -,SUP-132.150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN MARS 5.5X55MM CRV CONE TIP TI ANT LMBR -,SUP-132.155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4334.79,3034.353,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN MARS 5.5X60MM CRV CONE TIP TI ANT LMBR -,SUP-132.160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW REVIEVE 2.2MM X 6MM SELF TAPPING -,SUP-136.506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1235.02,864.514,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FEMORAL HEAD BIOLOX 32MM +5 12 -,SUP-1365-32-720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5432.32,3802.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FEMORAL HEAD BIOLOX DELTA TS CERAMIC  36MM +1.5 12/14 TAPER -,SUP-1365-36-710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5432.32,3802.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CERAMIC FEMORAL HEAD 40MM X 1.5 BIOLOX DELTA TS -,SUP-1365-40-710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FORTIFY I 12MM UPPER ENDPLATE 12 X 14MM 0 DEG -,SUP-137.300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FORTIFY I 12MM UPPER ENDPLATE 12 X 14MM 3.5 DEG -,SUP-137.301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FORTIFY I 12MM LOWER ENDPLATE 12 X 14MM 0 DEG -,SUP-137.350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FORTIFY I 12MM LOWER ENDPLATE 12 X 14MM 3.5 DEG -,SUP-137.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FORTIFY I 12MM LOWER ENDPLAE 12 X 14MM 3.5 DEG -,SUP-137.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3585.27,2509.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
KT BONE CMNT 2.5% GENT40 GM CEMEX GENTA RX STRL -,SUP-1400-AG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEPIN ORTHO 3.2MM STNMN 14IN THRD -,SUP-14012-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,213.27,149.289,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEPIN ORTHO 3.2MMX9IN THRD -,SUP-140129,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X52MM CORT VERSANAIL FT ST NON-DRV END SLD HEX HEAD -,SUP-14022-52,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW AUTOFIX 2.0 X 10MM -,SUP-141-2010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW  AUTOFIX 2.0 X 12MM -,SUP-141-2012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
AUTOFIX HEADLESS SCREW 2.0 X 13 -,SUP-141-2013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW AUTOFIX HEADLESS 2.0 X 13 -,SUP-141-2013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW AUTOFIX HEADLESS 2.0 X 14 -,SUP-141-2014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANNULATED 2.0 X 15MM -,SUP-141-2015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW AUTOFIX 2.0 X 16 -,SUP-141-2016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2X17MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD MOD -,SUP-1412017,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2X18MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD MOD -,SUP-141-2018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANNULATED 2.0 X 19MM -,SUP-141-2019,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW AUTOFIX COMPRESSION 2.0 X 20MM -,SUP-141-2020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW AUTOFIX 2.0 X 21MM -,SUP-141-2021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW AUTOFIX 2.5 X 23MM -,SUP-141-2023,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW AUTOFIX 2.5 X 24MM -,SUP-141-2024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
AUTOFIX SCREW 2.0 X 25MM -,SUP-141-2025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW AUTOFIX 2.0 X 26MM -,SUP-141-2026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW AUTOFIX 2.5 X 28MM -,SUP-141-2028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
AUTOFIX 2.0 X 29MM SCREW -,SUP-141-2029,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW AUTOFIX COMPRESSION 2.0 X 30MM -,SUP-141-2030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW AUTOFIX 2.5 X 10 -,SUP-141-2510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW AUTOFIX HEADLESS 2.5 X 14 -,SUP-141-2514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANNULATED 25 X 15MM -,SUP-141-2515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
AUTOFIX 2.0/2.5 16MM -,SUP-141-2516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEADLESS 2.5 X 17MM -,SUP-141-2517,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW AUTOFIX 2.5 X 18MM -,SUP-141-2518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW AUTOFIX 2.5 X 19 -,SUP-141-2519,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW AUTOFIX 2.5 X 21MM -,SUP-141-2521,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
AUTOFIX 2.0/2.5 23MM -,SUP-141-2523,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5X24MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD -,SUP-1412524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEADLESS 2.5 X 25MM -,SUP-141-2525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEADLESS 2.5 X 26MM -,SUP-141-2526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
AUTOFIX 2.5/2.5 27MM -,SUP-141-2527,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEADLESS 2.5 X 28MM -,SUP-141-2528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5X30MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD -,SUP-141-2529,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5X30MM CANN HDLS AUTOFIX STICKFIT SD/ST BTRSS THRD -,SUP-1412530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE 2.5MM 30MM AUTOFIX STAINLESS STEEL T7 FOOT ANKLE -,SUP-141-2530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.91,870.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WASHER ORTHO 8MM TI -,SUP-14191,CDM,C1713,HCPCS,278,RC,,,outpatient,,,175.05,122.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 8X100MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 8X105MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 8X110MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 8X40MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 8X45MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 8X50MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 8X55MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 8X60MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 8X65MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 8X70MM CANNULATEDLAG CANC ACE 24MM THRD SD/ST CUT -,SUP-14192-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 8X75MM CANN LAG CANC ACE THRD SD/ST CUT FLUTX4 TMX NS -,SUP-14192-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 8X85MM CANN LAG CANC ACE 24MM THRD SD/ST CUT FLUTX4 -,SUP-14192-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 8X90MM CANN LAG CANC ACE 24MM THRD SD/ST CUT FLUTX4 -,SUP-14192-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 8X95MM CANN LAG CANC ACE 24MM THRD SD/ST CUT FLUTX4 -,SUP-14192-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X100MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X105MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X110MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X115MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X120MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT -,SUP-14196-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X25MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X30MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X35MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X40MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X45MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X50MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X55MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X60MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X65MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X70MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X75MM CANNULATEDLAG CANC 22MM THRD SD/ST CUT FLUTX4 -,SUP-14196-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X80MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X85MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X90MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X95MM CANN LAG CANC 22MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14196-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X100MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X105MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT -,SUP-14197-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X110MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT -,SUP-14197-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X40MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X45MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X50MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X55MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X60MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X65MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X70MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X75MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X80MM CANN LAG CANC 40MM THRD SD/ST CUT FLUTX4 TMX -,SUP-14197-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X85MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X90MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X95MM CANNULATEDLAG CANC 40MM THRD SD/ST CUT FLUTX4 -,SUP-14197-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PRECISION PIN TM TAPERED D3.2/3.9X450MM -,SUP-1420-0065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X20MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X22MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X24MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X26MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X28MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X30MM CANNULATEDLAG CORT FT TMX NS -,SUP-14200-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X32MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X34MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X36MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X38MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X40MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X42MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X44MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X46MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X48MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14200-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X50MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X55MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X60MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14200-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X65MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X70MM CANNULATEDLAG CORT FT SD/ST BIOCMPT TMX NS -,SUP-14200-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X36MM LCK CANC ANTMC SHLDR THRD ST INV/RVRS CAP POR -,SUP-14223036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X30MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14250-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X32MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X34MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X36MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X38MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X40MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X42MM CANN LAG CORT FT SD/ST BIOCMPT TMX -,SUP-14250-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X44MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X46MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14250-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X48MM CANNULATEDLAG CORT 20MM FT SD/ST BIOCMPT TMX -,SUP-14250-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X50MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X55MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X60MM CANN LAG CORT 20MM FT SD/ST BIOCMPT TMX NS -,SUP-14250-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X65MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X70MM CANNULATEDLAG CORT P/T SD/ST BIOCMPT TMX NS -,SUP-14250-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WASHER ORTHO F/4.5-5.0MM CANN SCR SYS FLT -,SUP-14260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,504.67,353.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 10HL 100DG TBLR -,SUP-14355-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,557.3,390.11,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN ALPS 9.2X49MM 3.5MM 4HL 1.3MM LCK TI 100DG ANG TBLR -,SUP-143554,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN ALPS 9.2X73MM 3.5MM 6HL LCK COMPR TMX ANTMC THRD HL -,SUP-143556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN ALPS 9.2X85MM 3.5MM 7HL LCK TI ANTMC NS -,SUP-143557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN ALPS 9.2X97MM 3.5MM 8HL LCK TI 100DG ANG TBLR ANTMC -,SUP-143558,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X14MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X16MM CANC -,SUP-14376-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,977.89,684.523,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X24MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X34MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-1437634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X40MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X42MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X44MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X46MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X48MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X50MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X55MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X60MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X65MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X70MM NLCKG CANN LAG CANC ALPS P/T SD/ST BIOCMPT STD -,SUP-14376-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BONE PIN- 4 x 110MM- STERILE (2 Pack) -,SUP-144110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BONE PIN- 4 x 140MM- STERILE (2 Pack) -,SUP-144140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BONE PIN- 4 x 170MM- STERILE (2 Pack) -,SUP-144170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER ANT CERV 14X6X12MM SOLITAIRE 12DG LRDTC S/MED -,SUP-14-520506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12505.38,8753.766,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER ANT CERV 14X7X12MM SOLITAIRE 12DG LRDTC S/MED -,SUP-14-520507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12505.38,8753.766,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER ANT CERV 14X9X12MM SOLITAIRE 12DG LRDTC S/MED -,SUP-14-520509,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12505.38,8753.766,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER 10X27X8MM ZYSTON 6DG LRDTC CRV TAPR -,SUP-14-533128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER 10X25X7MM ZYSTON STR CNVX -,SUP-14-534067,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE 3.5MM X46MM CANNULATED -,SUP-148.146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.2X13MM PROVIDENCE SD FX-ANG -,SUP-150.013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.2MM X 14MM -,SUP-150.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN PROVIDENCE 12MM 4HL LVL1 TI LCK -,SUP-150.112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN PROVIDENCE 14MM 4HL LVL1 TI LCK -,SUP-150.114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN PROVIDENCE 16MM 4HL LVL1 TI LCK -,SUP-150.116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN PROVIDENCE 18MM 4HL LVL1 TI LCK -,SUP-150.118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANTERIOR CERVICAL PLATE 1-LEVEL -,SUP-150.120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE ANTERIOR CERVICAL 1-LEVEL 22MM PROV -,SUP-150.122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE ANTERIOR CERVICAL 24MM 1 LEVEL PROVIDENCE -,SUP-150.124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANTERIOR CERVICAL PLATE 14MM LORD -,SUP-150.134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN PROVIDENCE 28MM 6HL LVL2 TI LCK -,SUP-150.228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN PROVIDENCE 30MM 6HL LVL2 TI LCK -,SUP-150.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN PROVIDENCE 32MM 6HL LVL2 TI LCK -,SUP-150.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN PROVIDENCE 34MM 6HL LVL2 TI LCK -,SUP-150.234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN PROVIDENCE 36MM 6HL LVL2 TI LCK -,SUP-150.236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE CERVICAL ANTERIOR 2-LEVEL 38MM -,SUP-150.238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN PROVIDENCE 45MM 8HL LVL3 TI LCK -,SUP-150.345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN PROVIDENCE 48MM 8HL LVL3 TI LCK -,SUP-150.348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN PROVIDENCE 51MM 8HL LVL3 TI LCK -,SUP-150.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN PROVIDENCE 54MM 8HL LVL3 TI LCK -,SUP-150.354,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN PROVIDENCE 57MM 8HL LVL3 TI LCK -,SUP-150.357,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PROVIDENCE ANTERIOR CERVICAL PLATE 3-LVL 60MM -,SUP-150.360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANTERIOR CERVICAL PLATE 4-LEVEL 69MM -,SUP-150.469,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW PROV 4.6MM FIXED ANGLE SELF DRILL 14MM -,SUP-150.514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.6X16MM PROVIDENCE ST FA TI ALY -,SUP-150.536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.6X18MM PROVIDENCE SD FA TI ALY -,SUP-150.538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.2X12MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.2X13MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.613,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.2X14MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.2X15MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.2X16MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SELF DRILLING 4.6MM X 12MM VAR ANGLE PROV -,SUP-150.712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.6X13MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.713,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.6X14MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.6X16MM PROVIDENCE SD VAR ANG TI ALY -,SUP-150.716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SELF DRILLING 4.2MM X 12MM VAR ANGLE PROV -,SUP-150.812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PROVIDENCE 4.2MM VARIABLE ANGLE SCREW SELF-TAP 14MM -,SUP-150.814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW PROVIDENCE 4.6MM VARIABLE ANGLE 16MM SELF TAPPING -,SUP-150.816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW PROVIDENCE 4.2MM VARIABLE ANGLE - 20MM -,SUP-150.820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TRNSCONN 4.6X12MM PROVIDENCE ST VAR ANG TI ANT CERV -,SUP-150.912,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.6X14MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.914,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.6X15MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.915,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.6X16MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.916,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.6X18MM PROVIDENCE ST VAR ANG TI ALY -,SUP-150.918,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SELF TAPPING 4.6 X 20 VAR ANGLE PROV -,SUP-150.920,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
OSS POLY LOCK PIN -,SUP-150478,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1865.78,1306.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FORTIFY 12MM CORE HEIGHT 21-29MM -,SUP-151.052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FORTIFY 12MM CORE HEIGHT 25-37MM -,SUP-151.053,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CORE FORTIFY 012MM HEIGHT 33-53MM -,SUP-151.054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ENDPLATE UPPER 012MM 12X14 FOOTPRINT 3.5 DEG -,SUP-151.323,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ENDPLATE LOWER 012MM 12 X 14 FOOTPRINT 7 DEG FORTIFY -,SUP-151.374,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SYSTEM CLENCH STAPEL 9MM X 7MM -,SUP-152-30907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SYSTEM CLENCH STAPLE 15MM X 12MM -,SUP-152-31512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SYSTEM CLENCH STAPLE 18MM X 18MM -,SUP-152-31818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
STAPLE CLENCH 15MM X 12MM -,SUP-152-41512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BED F/PROC STRECHER UPR FRM ASMB -,SUP-16042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.68,1.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE OSS RS NON MOD LONG 59 -,SUP-161022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20050.2,14035.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN FX STNMN 2MMX9IN SMTH SGL END PLN DMD PT NS -,SUP-1620-609NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21.41,14.987,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN FX STNMN 2.4MMX9IN SMTH SGL END PLN DMD PT NS -,SUP-1624-609NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21.41,14.987,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN FX STNMN 4.8MMX9IN SMTH SGL END PLN DMD PT NS -,SUP-1648-609X,CDM,C1713,HCPCS,278,RC,,,outpatient,,,29.18,20.426,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TIBIAL INSERT PS SZ 6 13MM -,SUP-166-5613,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SHELL ACETABULAR ESCALADE 46MM -,SUP-170-0146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ESCALADE EXL LINER +1 28 X 46MM -,SUP-170-2846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
EXPANSION BOLT RECONSTRUCTION PROSTHESIS -,SUP-172-947/38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
MESH SURG 17X22X50MM OVL TI HARMS -,SUP-1741-48-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17992.27,12594.589,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
MESH SURG 17X22X70MM OVL TI HARMS -,SUP-1741-49,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20248.85,14174.195,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
MESH SURG 22X28X70MM OVL TI HARMS -,SUP-1741-52-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20248.85,14174.195,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
MESH SURG 22X28X90MM OVL TI HARMS -,SUP-1741-53-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,24291.37,17003.959,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
MESH SURG 26X33X50MM OVL TI HARMS -,SUP-1741-54-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17992.27,12594.589,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
MESH SURG 26X33X70MM OVL TI HARMS -,SUP-1741-55-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21889.99,15322.993,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WASHER SPIN TI POLY IEXP -,SUP-1754-91-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NUT SPIN TI BOLT SWVL LCK IEXP -,SUP-1754-91-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,543.24,380.268,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE 50MM RND 10MM SGL LVL TI -,SUP-1760-10-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17292.37,12104.659,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE 50MM RND 12MM SGL LVL TI -,SUP-1760-12-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17292.37,12104.659,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE 90MM RND 12MM SGL LVL TI -,SUP-1760-12-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18873.18,13211.226,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE 50MM RND 14MM SGL LVL TI -,SUP-1760-14-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17292.37,12104.659,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE 90MM RND 14MM SGL LVL TI -,SUP-1760-14-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19307.6,13515.32,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE 50MM RND 16MM SGL LVL TI -,SUP-1760-16-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16483.86,11538.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
MESH ROUND 16MM X 90MM SPN -,SUP-1760-16-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19754.09,13827.863,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
MESH SURG 12X23MM DIA 12X14MM OVL TRPZD TI HARMS -,SUP-1762-02-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10345.35,7241.745,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NUT ORTHO DOME TI SWVL F/MONARCH SPN SYS -,SUP-1770-91-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,481.97,337.379,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN SKNLC 47MM LVL2 TI LPRO -,SUP-1796-02-047,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6079.53,4255.671,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SET SCREW SPIN EXPEDIUM TI POST PDCL THORLUM SQ THRD -,SUP-1797-02-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SET SCREW SPIN EXPEDIUM TI POST PDCL THORLUM SQ THRD -,SUP-1797-02-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
VIPER TI SAI POLY 8X90MM -,SUP-179704890,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7.5X45MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7.5X50MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-179712050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7.5X65MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.35X20MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.35X25MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.35X30MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.35X35MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.35X40MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL -,SUP-1797-12-440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5 X 25MM POLYAXIAL SI -,SUP-179712525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X40MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X45MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X50MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6X30MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6X35MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6X55MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7X35MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-735,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7X45MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-745,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7X50MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7X55MM EXPEDIUM FLLY/DBL LD THRD POLYAX ST SGL INNIE -,SUP-1797-12-755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
EXP TI POLY SCREW 8 X 40MM -,SUP-179712840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW POLYAXIAL 8MM X 65MM -,SUP-179712865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN EXPEDIUM 5.5X480MM HEX END TI POST PDCL THORLUM -,SUP-179762480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN EXPEDIUM 5.5X35MM CRV TI POST PDCL THORLUM PRELRD -,SUP-1797-71-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN EXPEDIUM 5.5X40MM CRV TI POST PDCL THORLUM PRELRD -,SUP-1797-71-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD PRE-LODOSED W/LINE 65MM -,SUP-179771065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD PRE-LORDOSED 75MM W/LINE -,SUP-179771075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD PRE-LORDOSED W/LINE 85MM -,SUP-179771085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CONNECTOR 20MM EXPEDIUM LAT OFST OPN F/10MM TI -,SUP-1797-92-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CONNECTOR 50MM EXPEDIUM LAT OFST OPN F/5.5MM TI -,SUP-1797-92-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CONNECTOR 20MM EXPEDIUM OPN F/5.5MM TI ILC -,SUP-1797-97-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X42MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-49-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X46MM TMX CANN RDC HEAD -,SUP-1802-49-046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X30MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X32MM CANN -,SUP-1802-53-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X34MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X36MM CANN -,SUP-1802-53-036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X38MM CANN -,SUP-1802-53-038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X40MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X42MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X44MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X50MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COMP SCR 5MM CANN LAG P/T SD/ST TMX 55MM -,SUP-1802-53-055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X60MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X65MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X70MM CANN LAG CANC P/T SD/ST SM HEAD TMX -,SUP-1802-53-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X75MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X80MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5MMSMX85MM CANN LAG CANC PARTIALY THRD SD/ST RDC HEAD -,SUP-1802-53-085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X90MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5MMSMX95MM CANNULATEDLAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X100MM CANN LAG CANC P/T SD/ST RDC HEAD TMX -,SUP-1802-53-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1120.32,784.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.75X15MM LCK CMPRHNSV RVRS FX TI ALY HAP CTD BLU -,SUP-180500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.75X20MM NLCKG CMPRHNSV RVRS FX TI ALY HAP CTD GOLD -,SUP-180508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.75X25MM NLCKG CMPRHNSV RVRS FX TI ALY HAP CTD GOLD -,SUP-180509,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.75X15MM LCK CORT FX 3.5MM HEX HEAD TI ALY HAP CTD -,SUP-180550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
4.75 X 20MM FIXED LOCKING SCREW 3.5MM HEX -,SUP-180551,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COMP LK SCR 3.5 HEX 4.75 X 25 ST -,SUP-180552,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW COMP LK 3.5 HEX 4.75 X 30 ST -,SUP-180553,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW COMP LK 3.5 HEX 4.75 X 35 ST -,SUP-180554,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COMP LK SCR 3.5 HEX 4.75 X 40 ST -,SUP-180555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.75X15MM NLCKG CORT VAR ANG 3.5MM HEX HEAD TI ALY HAP -,SUP-180557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.75X20MM NLCKG CORT VAR ANG 3.5MM HEX HEAD TI ALY HAP -,SUP-180558,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.75X25MM NLCKG CORT VAR ANG 3.5MM HEX HEAD TI ALY HAP -,SUP-180559,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COMP NLK SCREW 3.5 HEX 4.75 X 30 ST -,SUP-180560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.75X35MM NLCKG CMPRHNSV 3.5MM HX HEX HEAD TMX HAP CTD -,SUP-180561,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
K-WIRE- STERILE 3 x 285MM -,SUP-1806-0050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,459.86,321.902,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
STRYKER PLATE -,SUP-1806-0150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,793.85,555.695,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10X320MM VERSANAIL CANN FEM TI ALY -,SUP-1813-10-320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7410.02,5187.014,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 13X400MM VERSANAIL CANN RT TROCH FEM TI ALY -,SUP-1814-13-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10160.14,7112.098,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 7X220MM VERSANAIL CANN HUM TI ALY -,SUP-1817-07-221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 8X200MM VERSANAIL CANN HUM TI ALY -,SUP-1817-08-201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 9X260MM VERSANAIL CANN HUM TI ALY -,SUP-1817-09-261,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
T2 ANKLE COMPRESSION SCREW -,SUP-1818-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1161.6,813.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10X150MM VERSANAIL CANN PROX HUM SS -,SUP-1818-10-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7282.7,5097.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL T2 ANKLE ARTHRODESIS LEFT -,SUP-1818-1020S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
T2 ANKLE NAIL 11x200MM LEFT -,SUP-1818-1120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
T2 ANKLE ARTHRODESIS NAIL LEFT 11X300MM -,SUP-1818-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 12X200MM T2 CANN LT ANKL TI ALY BIOMECH -,SUP-1818-1220S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
T2 ANKLE ARTHRODESIS NAIL RIGHT 11 X 150MM -,SUP-1819-1115S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 12X200MM T2 CANN RT ANKL TI ALY BIOMECH -,SUP-1819-1220S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15749.43,11024.601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.8MMX20MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-35-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X24MM CORT 3.5MM HX NS F/2.9MM DRLBT -,SUP-1819-35-024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X30MM CORT 3.5MM HX NS F/2.9MM DRLBT -,SUP-1819-35-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.8MMX30MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.8MMX32MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 4.8MMX42MM 3.6MM HX NS -,SUP-1819-48-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.8MMX44MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.8MMX46MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.8MMX50MM CANC 3.6MM HX NS F/10MM NAIL 3.8MM DRLBT -,SUP-1819-48-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X24MM ELLIPSE POLYAX TI -,SUP-182.224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MM X 26MM ELLIPSE POLYAXIAL SHOULDER -,SUP-182.226,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X28MM ELLIPSE POLYAX TI. -,SUP-182.228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X30MM ELLIPSE POLYAX TI. -,SUP-182.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X32MM ELLIPSE POLYAX TI -,SUP-182.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X34MM ELLIPSE POLYAX TI -,SUP-182.234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X10MM ELLIPSE POLYAX TI -,SUP-182.310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X12MM ELLIPSE POLYAX TI -,SUP-182.312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X14MM ELLIPSE POLYAX TI -,SUP-182.314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ELLIPSE POLYAXIAL 3.5MM X 16MM -,SUP-182.316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X18MM ELLIPSE POLYAX TI -,SUP-182.318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X20MM ELLIPSE POLYAX TI -,SUP-182.320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X22MM ELLIPSE POLYAX TI -,SUP-182.322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X26MM ELLIPSE POLYAX TI -,SUP-182.326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X28MM ELLIPSE POLYAX TI -,SUP-182.328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X30MM ELLIPSE POLYAX TI -,SUP-182.330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X10MM ELLIPSE POLYAX TI -,SUP-182.410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X12MM ELLIPSE POLYAX TI -,SUP-182.412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X14MM ELLIPSE POLYAX TI -,SUP-182.414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
4.0MM ELLIPSE POLYAXIAL SCREW 16MM -,SUP-182.416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X18MM ELLIPSE POLYAX TI -,SUP-182.418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X20MM ELLIPSE POLYAX TI -,SUP-182.420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X22MM ELLIPSE POLYAX TI -,SUP-182.422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X24MM ELLIPSE POLYAX TI -,SUP-182.424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X26MM ELLIPSE POLYAX TI -,SUP-182.426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ELLIPSE POLYAXIAL 4.0 X 28MM -,SUP-182.428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ELLIPSE LOCKING CAP -,SUP-182.500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
HOOK SPIN INLN ELLIPSE -,SUP-182.501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ELLIPSE POLYAXIAL 4.5 X 20 -,SUP-182.520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X22MM ELLIPSE POLYAX TI -,SUP-182.522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X24MM ELLIPSE POLYAX TI -,SUP-182.524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X26MM ELLIPSE POLYAX TI -,SUP-182.526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ELLIPSE POLYAXIAL 4.5 X 28 -,SUP-182.528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ELLIPSE POLYAXIAL 4.5 X 30 -,SUP-182.530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD TO ROD CLAMP CT TO CT 7MM -,SUP-182.741,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD TO ROD CLAMP CT TO CT 9MM -,SUP-182.770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN ELLIPSE 6.35X80MM TI POST OCT -,SUP-182.801,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN ELLIPSE 6.35X120MM TI POST OCT -,SUP-182.802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN ELLIPSE 3.5X240MM TI POST OCT -,SUP-182.803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN ELLIPSE 3.5X40MM TI POST OCT -,SUP-182.804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ENDCAP SPIN ELLIPSE T-SHP HD-TO-HD -,SUP-182.900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NUT SPIN ELLIPSE F/HD-TO-HD TRANSV CONN T-SHP -,SUP-182.901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TRNSCONN 27-33MM ELLIPSE HD-TO-HD F/3.5MM T-SHP POST OCT -,SUP-182.912,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TRNSCONN 26-46MM ELLIPSE F/3.5MM CRV POST OCT -,SUP-182.924,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE OCPTL SM ELLIPSE -,SUP-182.950,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 8MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0828S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 8MMSTDX300MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0830S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 8MMSTDX315MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0831S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 8MMSTDX330MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0833S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 8MMSTDX360MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0836S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 8MMSTDX390MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-0839S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1028S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TIBIAL NAIL 10 X 390MM -,SUP-1822-1039S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1128S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
T2 STD. TIBIAL NAIL 11MM X 300MM -,SUP-1822-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TIBIAL NAIL 11 X 375MM -,SUP-1822-1137S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
11 X 390MM TIBIA NAIL -,SUP-1822-1139S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 12MMSTDX285MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1228S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 12MMSTDX315MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1231S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 12MMSTDX345MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 12MMSTDX360MM T2 CANN TIB TI ALY BIOMECH -,SUP-1822-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
T2 TIBIAL NAIL SYSTEM  12 X 390MM -,SUP-1822-1239S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4411.64,3088.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 8MM COMPR T2 CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1825-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.67,530.369,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 8X5MM COMPR T2 CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1825-0005S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,757.67,530.369,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL SYS T2 FEMUR A/R 010 X 340MM -,SUP-1825-1034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10X360MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1038S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11X280MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1128S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11X320MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1132S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11X340MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11X400MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1140S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1144S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 12X280MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1228S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 12X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1230S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 12X360MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 12X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1238S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 12X420MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1242S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 12X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1244S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 13X180MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1318S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 13X240MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1324S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 13X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1330S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 13X340MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1334S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 13X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1338S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 13X400MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 13X420MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1342S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 13X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1344S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 14X240MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1424S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 14X300MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1430S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 14X320MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1432S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 14X340MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1434S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 14X360MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1436S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 14X380MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1438S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 14X400MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 14X420MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1442S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 14X440MM T2 CANN FEM TI ALY ANTGRD RTRGD BIOMECH -,SUP-1825-1444S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4592.86,3215.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAP ORTHO 8X4MM TI E CAP PROT -,SUP-1826-0003S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,771.97,540.379,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
T2 SUPRACONDYLAR NAIL 9X340MM -,SUP-1826-0934S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
T2 SUPRACONDYLAR NAIL 9X380MM -,SUP-1826-0938S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1020S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SUPRACONDYLAR NAIL 10 X 320 -,SUP-1826-1032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10MMLNGX340MM T2 CANN SPRACON TI BIOMECH -,SUP-1826-1034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10MMLNGX360MM T2 CANN SPRACON TI BIOMECH -,SUP-1826-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL SUPRACONDYLAR 10MM X 400MM -,SUP-1826-1040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11MMLNGX240MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1124S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11MMLNGX320MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1132S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SUPRACONDYLAR NAIL 11 X 360MM -,SUP-1826-1136S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL SUPRACONDYLAR 11 X 380 -,SUP-1826-1138S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL SUPRACONDYLAR 11 X 420 -,SUP-1826-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 12MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1220S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 12MMLNGX280MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1228S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 12MMLNGX300MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1230S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 12MMLNGX320MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1232S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 12MM X 340MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL SUPRACONDYLAR 12 X 360 -,SUP-1826-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
T2 SUPRACONDYLAR NAIL 12X400MM -,SUP-1826-1240S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 13MMSHRTX200MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 13MMLNGX300MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1330S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 13MMLNGX340MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1334S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL SUPRACONDYLAR 13MM X 360MM -,SUP-1826-1336S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 13MMLNGX380MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1338S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 13MMLNGX400MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 13MMLNGX420MM T2 CANN SPRACON TI ALY BIOMECH -,SUP-1826-1342S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL SUPRACONDYLAR 14 X 380 -,SUP-1826-1438S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6615.55,4630.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL FEMORAL 10 X 360 -,SUP-1828-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5072.64,3550.848,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL FEMORAL 11 X 340MM -,SUP-1828-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5072.64,3550.848,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL FEMORAL 11 X 400 -,SUP-1828-1140S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5072.64,3550.848,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 13X740MM T2 CANN RT KN TI ALY BIOMECH -,SUP-1829-1374S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,28428.72,19900.104,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WASHER ORTHO 10MM TI ALY SQ STRL -,SUP-1830-0009S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,718.87,503.209,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 7X210MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0721S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 7X220MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0722S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 7X240MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0724S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 8X240MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0824S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 8X250MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0825S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 8X280MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0828S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 9X210MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0921S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 9X220MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0922S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 9X240MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0924S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 9X250MM T2 CANN HUM TI ALY BIOMECH -,SUP-1830-0925S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4982.46,3487.722,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ENDCAP ORTHO 6MM STD TI T2 STRL -,SUP-1832-0003S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,725,507.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 8MMLNGX150MM T2 CANN LT PROX HUM TI ALY -,SUP-1832-1035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6798.89,4759.223,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 8MMLNGX240MM T2 CANN LT PROX HUM TI ALY BIOMECH -,SUP-1832-2824S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 8MMLNGX260MM T2 CANN LT PROX HUM TI ALY BIOMECH -,SUP-1832-2826S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 8MMLNGX220MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3822S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11MMLNGX240MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3824S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 8MMLNGX260MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3826S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11MMLNGX280MM T2 CANN RT PROX HUM TI ALY BIOMECH -,SUP-1832-3828S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6177.57,4324.299,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE 3.6MM VAR SELF-TAPPING 14MM -,SUP-184.114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE 3.6MM VAR SELF-TAPPING 16MM -,SUP-184.116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 9MM 1.5M RAD 340MM T2 RECON CANN LT FEM TI ALY RECON -,SUP-1843-0934S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
T2 RECON NAIL R1.5- RIGHT 9 X 360MM X 125DG -,SUP-1845-0936S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
T2 RECON NAIL R1.5- RIGHT 9 X 380MM X 125DG -,SUP-1845-0938S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10MM 1.5M RAD 360MM T2 RECON CANN RT FEM TI ALY -,SUP-1845-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL T2 RECON R1 11MM X 420MM X 125 -,SUP-1845-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6916.02,4841.214,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ENDCAP SPIN REVERE THORLUM NTHRD REVOLVE -,SUP-185.000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN REVOLVE 5.5X80MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN REVOLVE 5.5X90MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN REVOLVE 5.5X100MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN REVOLVE 5.5X110MM TI LMBR MUL-LVL CAP ABILITY NTHRD -,SUP-185.310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5X30MM REVOLVE POLYAX TI -,SUP-185.452,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5X35MM REVOLVE POLYAX TI -,SUP-185.453,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5X40MM REVOLVE POLYAX TI -,SUP-185.454,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5X45MM REVOLVE POLYAX TI -,SUP-185.455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5X50MM REVOLVE POLYAX TI -,SUP-185.456,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5X55MM REVOLVE POLYAX TI -,SUP-185.457,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X30MM REVOLVE POLYAX TI -,SUP-185.462,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X35MM REVOLVE POLYAX TI -,SUP-185.463,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X40MM REVOLVE POLYAX TI -,SUP-185.464,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X45MM REVOLVE POLYAX TI -,SUP-185.465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X50MM REVOLVE POLYAX TI -,SUP-185.466,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FEMORAL NAIL RIGHT 9 X 360MM -,SUP-1851-0936S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6489.92,4542.944,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10X380MM T2 CANN RT GTR TROCH FEM TI ALY RECON -,SUP-1851-1038S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6489.92,4542.944,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CABLE SINGLE LOOP TITANIUM WITH CRIMP -,SUP-186.200S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2978.98,2085.286,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER 28X8MM LPRD 5DG LRDTC BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE 28X9MM LPRD 5DG LRDTC BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER 28X7MM LPRD PRLL BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER 28X9MM LPRD PRLL BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER 28X11MM LPRD PRLL BLLT NOSE SYM CONTR CFRP -,SUP-1864-48-111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SET INNER MIS -,SUP-186715000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SET SCREW SPIN VIPER 2 TI PDCL SQ THRD SGL INNIE -,SUP-1867-15-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6X35MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6X35MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6X40MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6X40MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6 X 45 POLYAXIAL CANNULA -,SUP-186715645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6X45MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6X50MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6X50MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-186715655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6X55MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7X40MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7X50MM VIPER 2 DBL LD THRD POLYAX CANN TI -,SUP-1867-15-750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X55MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X40MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6X30MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6X40MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6X45MM VIPER 2 FX CORT F/5.5MM TI -,SUP-1867-31-645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW TI CORT FIX 6X50MM -,SUP-186731650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW TI CORT FIX 6X55MM -,SUP-186731655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6X35MM VIPER 2 DBL LD THRD CANN ULTRA TI -,SUP-1867-60-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6X40MM VIPER 2 DBL LD THRD CANN ULTRA TI -,SUP-1867-60-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN VIPER 5.5X35MM CRV PREBNT TI F/MN INV SURG NS -,SUP-1867-62-635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN VIPER 5.5X40MM CRV PREBNT TI F/MN INV SURG NS -,SUP-1867-62-640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN VIPER 2  - 5.5 X 35MM LORDOTIC -,SUP-186788035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN VIPER 2 5.5X35MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN VIPER 2 5.5X40MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN VIPER 2 5.5X45MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN VIPER 2 5.5X50MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TRNSCONN REVERE ADDITION RD-TO-RD F/5.5MM PRLL -,SUP-1867-88-055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN VIPER 2 5.5X65MM LRDTC CRV TI THORLUM F/MIN ACCESS -,SUP-1867-88-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD VIPER 2 LORDOTIC 75MM -,SUP-186788075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD LORDOTIC 80MM VIPER2 -,SUP-186788080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD LORDOTIC 90MM VIPER2 -,SUP-186788090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN SKYLINE 16X12MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN SKYLINE 16X14MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN SKYLINE 16X16MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN SKYLINE 16X18MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN SKYLINE 16X20MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN SKYLINE 16X22MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN SKYLINE 16X24MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN SKYLINE 16X26MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SKY 1 LEVEL PLATE 28MM -,SUP-1868-01-028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN SKYLINE 16X30MM 2.5MM LVL1 PRELRD TI VSBL GFT -,SUP-1868-01-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 28MM SKYLINE 2 LEVEL TI -,SUP-186802028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN SKYLINE 16X30MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN SKYLINE 16X32MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN SKYLINE 16X34MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN SKYLINE 16X36MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN SKYLINE 16X40MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN SKYLINE 16X42MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN SKYLINE 16X44MM 2.5MM LVL2 PRELRD TI VSBL GFT -,SUP-1868-02-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN SKYLINE 16X45MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN SKYLINE 16X48MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN SKYLINE 16X51MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN SKYLINE 16X54MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN SKYLINE 16X57MM 2.5MM LVL3 PRELRD TI VSBL GFT -,SUP-1868-03-057,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X12MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL BLU -,SUP-1868-50-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X14MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL GOLD -,SUP-1868-50-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X16MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL MAG -,SUP-1868-50-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X18MM SKYLINE SD VAR ANG HX LOBE HEAD TI STRL -,SUP-1868-50-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X12MM SKYLINE ST VAR ANG HX LOBE HEAD TI STRL BLU -,SUP-1868-52-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X14MM SKYLINE ST VAR ANG HX LOBE HEAD TI STRL GOLD -,SUP-1868-52-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X16MM SKYLINE ST VAR ANG HX LOBE HEAD TI STRL MAG -,SUP-1868-52-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SKY VARIABLE S-T 18MM TI -,SUP-186852018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X12MM SKYLINE ST VAR ANG OVSZ HX LOBE HEAD TI STRL -,SUP-1868-54-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X14MM SKYLINE ST VAR ANG OVSZ HX LOBE HEAD TI STRL -,SUP-1868-54-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X16MM SKYLINE ST VAR ANG OVSZ HX LOBE HEAD TI STRL -,SUP-1868-54-016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X14MM SKYLINE ST FA CNSTRN OVSZ HX LOBE HEAD TI -,SUP-1868-64-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
IMPLANT COUGAR SM 12MM 5 DEG -,SUP-187105112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COUGAR IMPLANT MED 14MM 50DEG -,SUP-187105214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER 14MM COUGAR 10DG SM CFRP -,SUP-1871-10-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COUGAR IMPLANT MED 14MM 10DEG -,SUP-187110214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13738.1,9616.67,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN EXPEDIUM 5.5X70MM STR TI ANT PCUT NS -,SUP-1877-03-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BULLETT CONCORD 9 X 7 X 23 -,SUP-187823107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE 9X8X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE 9X9X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE 9X10X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE 9X8X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE 9X9X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-187823409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE 9X9X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE 9X10X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE 9X11X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE 9X12X23MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-23-412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE 11X12X23MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-23-512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CONCORDE BUL LOR 11X13X23 5DG -,SUP-187823513,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE 9X7X27MM CONCORDE -,SUP-187827107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE 9X7X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE 9X8X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE 9X9X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE 9X10X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE 11X12X27MM CONCORDE 5DG PRLL BLLT NOSE CFRP -,SUP-1878-27-212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE 9X8X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-27-408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE 9X9X27MM CONCORDE 5DG LRDTC BLLT NOSE STNT LPRO CFRP -,SUP-1878-27-409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE 9X10X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-27-410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CONCORDE BUL LOR 9 X 11 X 27 -,SUP-187827411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE 9X11X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1878-27-411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE 11X12X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-187827512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE 9X7X23MM CONCORDE PRLL CFRP -,SUP-1879-23-107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14828.79,10380.153,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE 11X13X27MM CONCORDE 5DG LRDTC BLLT NOSE CFRP -,SUP-1879-27-513,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CONNECTOR SPIN MOUNTAINEER LAT OFST TI -,SUP-1883-12-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X10MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X12MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X18MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X26MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X12MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X22MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X24MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X26MM MOUNTAINEER MINI POLYAX FAVORED ANG TAPR TI -,SUP-1883-18-426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X12MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X16MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X20MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X22MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X26MM MOUNTAINEER MINI POLYAX TAPR TI STRL SLVR -,SUP-1883-19-326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X22MM MOUNTAINEER MINI POLYAX TAPR TI STRL BLU SHNK -,SUP-1883-19-422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X26MM MOUNTAINEER MINI POLYAX TAPR TI STRL BLU SHNK -,SUP-1883-19-426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X50MM MOUNTAINEER MINI POLYAX TAPR TI STRL BLU SHNK -,SUP-1883-19-450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.35X20MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.35X25MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.35X30MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.35X35MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.35X40MM MOUNTAINEER MINI POLYAX TAPR TI STRL PNK -,SUP-1883-19-540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X20MM MOUNTAINEER MINI POLYAX SHNK TAPR TI STRL -,SUP-1883-20-320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X28MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X32MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X34MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X36MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X38MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X40MM MOUNTAINEER MINI POLYAX LS TAPR TI STRL SLVR -,SUP-1883-20-340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
XCONN 21MM MOUNTAINEER HD-TO-HD TI OCT -,SUP-1883-41-021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X12MM MOUNTAINEER MINI POLYAX TI STRL -,SUP-188362012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE OC 37MM -,SUP-188362037,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
MNTR OC PLATE LARGE -,SUP-188362045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.25X8MM MOUNTAINEER MINI POLYAX TI STRL -,SUP-188362108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
MNTR OC PREBENT ROD 3.5X120 -,SUP-188363200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,921.93,645.351,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN SKYLINE 34MM LVL2 PRELRD TI VSBL GFT SITE -,SUP-1888-02-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5856.72,4099.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE ANTLAT 33-46MMH X-MESH 0DG MED TI -,SUP-1889-01-033,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20402.94,14282.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE 0DG ANTLAT 51-71MM X-MESH MED TI -,SUP-1889-01-051,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22445.09,15711.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X35MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,820.98,574.686,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X40MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,812.82,568.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X45MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,812.82,568.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X55MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,812.82,568.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X60MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,820.98,574.686,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X65MM LCK SHFT T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1891-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,820.98,574.686,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SFX-5.5 TI LAT SIZE F4 -,SUP-189401104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DEPUY SPINE SFX F5 CROSSLINK -,SUP-189401105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CONNECTOR SZ F6 EXPEDIUM SFX FX F/5.5MM TI MDL -,SUP-1894-01-206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CONNECTOR SZ F7 EXPEDIUM SFX FX F/5.5MM TI MDL -,SUP-1894-01-207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CONNECTOR SPIN EXPEDIUM CX TI -,SUP-1894-01-209,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SFX 5.5 TI LAT SIZE A2 -,SUP-189401302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CONNECTOR SZ A4 EXPEDIUM SFX F/5.5MM TI MDL NS -,SUP-1894-01-404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CONNECTOR SZ A5 EXPEDIUM SFX F/5.5MM TI MDL NS -,SUP-1894-01-405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CONNECTOR SZ A6 EXPEDIUM SFX F/5.5MM TI MDL NS -,SUP-1894-01-406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW T2 CONDYLE 5MM X 50MM -,SUP-1895-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X60MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X75MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X80MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X85MM LCK CANN T2 P/T CUT FLUTX3 TI STRL F/IM NAIL -,SUP-1895-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,825.07,577.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X20MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4020S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X22MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4022S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X26MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X28MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4028S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X30MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
T2 F/T LOCKING SCREW 4MM X 32MM -,SUP-1896-4032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X36MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X38MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4038S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X45MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X55MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-4055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,761.76,533.232,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW T2 F/T LOCK 5 X 30 -,SUP-1896-5030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5MMX32.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW T2 F/T LOCK 5 X 35 -,SUP-1896-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5MMX37.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW T2 F/T LOCK 5 X 40 -,SUP-1896-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5MMX42.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW T2 F/T LOCK 5 X 45 -,SUP-1896-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5MMX47.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5047S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW T2 F/T LOCK 5 X 50 -,SUP-1896-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5MMX52.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5052S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW T2 F/T LOCK 5 X 55 -,SUP-1896-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5MMX57.5MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5057S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW T2 F/T LOCK 5 X 60 -,SUP-1896-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW T2 F/T LOCK 5 X 65 -,SUP-1896-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW T2 F/T LOCK 5 X 70 -,SUP-1896-5070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW T2 F/T LOCK 5 X 75 -,SUP-1896-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X80MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X85MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X90MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X100MM LCK T2 FT CUT FLUTX3 TI STRL F/IM NAIL SYS -,SUP-1896-5100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN UNIPLATE 2 36MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-02-036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN UNIPLATE 2 38MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-02-038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.6X12MM UNIPLATE ST CANC TI BLU -,SUP-1897-06-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.6X13MM UNIPLATE ST CANC TI BLU -,SUP-1897-06-013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.6X14MM UNIPLATE ST CANC TI GOLD -,SUP-189706014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE 14MM UNIPLATE SPINE CERVICAL ANTERIOR SELF -,SUP-1897-06-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1293.32,905.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.6X15MM UNIPLATE ST CANC TI LBLU -,SUP-1897-06-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.6X18MM UNIPLATE ST CANC TI LBLU -,SUP-1897-06-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.2MMX14MM UNIPLATE OVSZ CANC TI GOLD -,SUP-1897-06-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.2MMX18MM UNIPLATE ST CANC TI GOLD -,SUP-1897-06-118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.6X12MM UNIPLATE SD CANC TI BLU -,SUP-1897-07-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.6X13MM UNIPLATE SD CANC TI VIOL -,SUP-1897-07-013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.6X15MM UNIPLATE SD CANC TI LBLU -,SUP-1897-07-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN UNIPLATE 2 14MM LVL1 PRELRD TI NRW MDLN NO- BND -,SUP-189721014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN UNIPLATE 2 16MM LVL1 PRELRD TI NRW MDLN NO- BND -,SUP-189721016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN UNIPLATE 2 28MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-22-028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN UNIPLATE 2 32MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-22-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN UNIPLATE 2 34MM LVL2 PRELRD TI NRW MDLN NO- BND -,SUP-1897-22-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW T2 RECON LAG 6.5MM X 75MM -,SUP-1897-6075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW T2 RECON LAG 6.5MM X 80MM -,SUP-1897-6080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LAG T2 RECON SYSTEM 6.5 X 85 -,SUP-1897-6085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LAG BONE T2 RECON SYSTEM 6.5 X 90 -,SUP-1897-6090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LAG T2 RECON 6.5MM X 100MM -,SUP-1897-6100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.03,677.621,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LEVEL 1 PLATE 20MM -,SUP-19-0120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CALBIBER SPACER 10 X 22MM- 10-15MM -,SUP-194.222,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SEMI CONST DRILL 4.0 X 14 -,SUP-19-6514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2MMX6MM LCK COMPR CORT LCP FT STD CRUCIF RCESS SS NS -,SUP-201.006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,93.36,65.352,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.4MMX10MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CLIP ANEUR 2.4MMX12MM SS LCP ST -,SUP-201.762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.4MMX13MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.763,CDM,C1713,HCPCS,278,RC,,,outpatient,,,411.37,287.959,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.4MMX14MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.764,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.4MMX18MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.768,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.4MMX22MM LCK COMPR CORT LCP ST T8 STRDRV RCESS SS NS -,SUP-201.772,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.21,316.547,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2X10MM LCK COMPR LCP THRD ST FA T6 STRDRV RCESS SS NS -,SUP-201.880,CDM,C1713,HCPCS,278,RC,,,outpatient,,,830.26,581.182,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MMX10MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,328.22,229.754,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MMX12MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,328.22,229.754,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MMX26MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MMX28MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MMX30MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MMX32MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MMX34MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MMX36MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MMX38MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MMX40MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MMX45MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MMX50MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MMX55MM LCK COMPR CORT LCP FT STD 2.5MM SM HEX SCKT -,SUP-202.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,68.56,47.992,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X10MM LCK COMPR LCP THRD ST T8 STRDRV RCESS SS NS -,SUP-202.210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,886.92,620.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X30MM LCK COMPR LCP THRD ST T8 STRDRV RCESS SS NS -,SUP-202.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.01,516.607,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X40MM LCK COMPR LCP THRD ST T8 STRDRV RCESS SS NS -,SUP-202.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.01,516.607,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3X14MM CANN LNG THRD SD/ST CRUCIF RCESS SS NS -,SUP-202.714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1530.52,1071.364,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X16MM LCK COMPR CORT LCP FT ST T8 STRDRV RCESS SS -,SUP-202.876,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X18MM LCK COMPR CORT LCP FT ST T8 STRDRV RCESS SS -,SUP-202.878,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTEX SLF TPNG 2.7 X 20MM T8 SD REC -,SUP-202.880,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X24MM LCK COMPR CORT LCP FT ST T8 STRDRV RCESS SS -,SUP-202.884,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTEX SLF TPNG 2.7 X 26MM T8 SD REC -,SUP-202.886,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTEX SLF TPNG 2.7 X 28MM T8 SD REC -,SUP-202.888,CDM,C1713,HCPCS,278,RC,,,outpatient,,,433.25,303.275,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTEX SLF TPNG 2.7 X 30MM T8 SD REC -,SUP-202.890,CDM,C1713,HCPCS,278,RC,,,outpatient,,,577.67,404.369,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BODY PHOENIX SHRT OPN BD -,SUP-20-2070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BODY STD PHOENIX OPN BD POST PDCL F/MN INV FX SYS -,SUP-20-2090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
6.5 X 40MM CANCELLOUS BONE SCREW -,SUP-2030-6540-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ACTB 6.5X55MM OMNIFIT -,SUP-2030-6555-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ACTB 6.5X60MM OMNIFIT -,SUP-2030-6560-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X10MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X12MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X14MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,192.56,134.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X16MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX18MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX20MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX22MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX24MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX26MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX28MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX32MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX34MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX36MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX38MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX40MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX45MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X50MM DCP CORT LC-DCP FT STD 2.5MM SM HEX SCKT -,SUP-204.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X28MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X30MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X32MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X34MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X36MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X38MM SHFT DCP LC-DCP P/T 2.5MM SM HEX SCKT S-HEAD -,SUP-204.238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,196.93,137.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X14MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X20MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X22MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X24MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X26MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X28MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X32MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X34MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.834,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X48MM LCK COMPR CORT LCP FT ST HX RCESS 2.5MM SM -,SUP-204.848,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN PHOENIX 35MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN PHOENIX 40MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN PHOENIX 45MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN PHOENIX 50MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN PHOENIX 55MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN PHOENIX 70MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN PHOENIX 75MM TAPR PERC PRELRD HX F/MN INV SURG NS -,SUP-20-4075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX10MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX12MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX14MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.61,257.327,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX16MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.61,257.327,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX18MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.61,257.327,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX22MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX24MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX26MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX30MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX35MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX40MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX45MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX50MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX55MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX60MM LCK COMPR CANC LCP P/T 2.5MM SM HEX SCKT HEAD -,SUP-206.060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FEM PRESSURIZING SEAL - SMALL -,SUP-206-545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,101.12,70.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X10MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X12MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X14MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X16MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X18MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X20MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X22MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X24MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X26MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X28MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X30MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,157.55,110.285,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X40MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X45MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X50MM LCK COMPR CANC LCP FT 2.5MM SM HEX SCKT HEAD SS -,SUP-207.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.92,113.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX34MM LCK CANN LCP LNG THRD SD/ST 2.5MM SM HEX SCKT -,SUP-207.734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7MMX35MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7MMX40MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7MMX45MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7MMX50MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7MMX70MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7MMX75MM CANN 16MM THRD REVCT FLUT 3.5MM LRG HEX SCKT -,SUP-208.075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X95MM LCK CANN 32MM THRD SD/ST REVCT FLUT 4MM LRG -,SUP-208.441,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1770.37,1239.259,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7MMX45MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7MMX50MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7MMX55MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7MMX80MM LCK CANN 32MM THRD REVCT FLUT 3.5MM LRG HEX -,SUP-209.080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2492.56,1744.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7X32MM CANN -,SUP-209.750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7.3X75MM LCK CANN THRD SD/ST REVCT FLUT HEX SCKT -,SUP-209.875,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1710.52,1197.364,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUT SQA + THRDR TAB TI NTNL -,SUP-210.309,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2065.07,1445.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SUBSTITUTE TCP 1.2ML FOAM PK VITOSS RESRB COMPR RSIS -,SUP-2102-1401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1579.18,1105.426,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
VITOSS BIOACTIVE PACK 2.5CC -,SUP-2102-1602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3430.26,2401.182,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
VITOSS BA2X FOAM PACK 1.2CC -,SUP-2102-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2600.96,1820.672,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
VITOSS BA2X FOAM PK BONE GRAFT 1.2CC -,SUP-2102-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2600.96,1820.672,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
VITOSS BA2X BONE GRAFT 2.5CC -,SUP-2102-2102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4015.89,2811.123,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
VITOSS BA2X BONE GRAFT 5CC -,SUP-2102-2105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6693.85,4685.695,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
VITOSS BA2X BONE GRAFT 10CC -,SUP-2102-2110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10931.81,7652.267,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.4MMX12MM CANN 0.5IN LNG THRD SD/ST T8 STRDRV RCESS -,SUP-211.812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1577.85,1104.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CANNULATED SCREW 2.4mm X15mm -,SUP-211.815,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANNULATED 2.4MM X17MM L -,SUP-211.817,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1431.14,1001.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.4MM CANN SCREW LONG 19MM -,SUP-211.819,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1431.14,1001.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX55MM LCK COMPR LCP FT ST SS NS GRN -,SUP-212.123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,813.98,569.786,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BONE PIN- 3.2 x 110MM- STERILE (2 Pack) -,SUP-213524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BONE PIN- 3.2 x 140MM- STERILE (2 Pack) -,SUP-213527,CDM,C1713,HCPCS,278,RC,,,outpatient,,,643.43,450.401,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX16MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX28MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX30MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX32MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX36MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX38MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX40MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX46MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX50MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX52MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX56MM CORT FT NON ST STD 3.5MM LRG HEX SCKT HEAD -,SUP-214.056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,354.48,248.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX34MM LCK CANN P/T SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1518.59,1063.013,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX42MM LCK CANN P/T SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1518.59,1063.013,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX44MM LCK CANN P/T SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1518.59,1063.013,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX40MM LCK CANN FT SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1562.32,1093.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX44MM LCK CANN FT SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1562.32,1093.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX50MM LCK CANN FT SD/ST REVCT FLUT 3.5MM LRG HEX -,SUP-214.750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1562.32,1093.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MMX40MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-216.040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MMX55MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MMX60MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MMX65MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MMX70MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MMX75MM LCK COMPR CANC LCP P/T 3.5MM LRG HEX SCKT -,SUP-217.075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,310.71,217.497,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 9MM SHRT FASTFLAP 2HL STR 1.6MM NEURO SYS STRL -,SUP-218-0022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.42,222.194,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE CRNL 22MM 5HL 0.5MM STR FAST FLAP 1.6MM NEURO SYS TI -,SUP-218-0030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,868.25,607.775,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE CRANFC MED FST-FLP MSH 5HL TI BUR HL GRV SHNT 1.6MM -,SUP-218-0069,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1373.89,961.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE CRNL LNG 2HL 0.25MM STR FAST FLAP 1.6MM NEURO SYS TI -,SUP-218-0093,CDM,C1713,HCPCS,278,RC,,,outpatient,,,452.8,316.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE CRNL 22MM LRG 0.25MM FAST FLAP BUR HL CVR 1.6MM NEURO -,SUP-218-0095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1077.06,753.942,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE CRANFC 90X90MM FST-FLP OSTFRM MSH TI PREFRM 1.6MM -,SUP-218-2006-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6545.95,4582.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WASHER ORTHO 10MM F/4.5MM CANN SCR RND NS -,SUP-219.910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,218.81,153.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WASHER ORTHO 13MM F/6.5MM CANC LRG BN SCR RND NS -,SUP-219.990,CDM,C1713,HCPCS,278,RC,,,outpatient,,,223.19,156.233,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ACCELFIX LUMBAR EXPANDABLE CAGE 8 22 X 11 X 8MM -,SUP-2211-0808S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19669.62,13768.734,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ACCELFIX EXPANDABLE LUMBAR CAGE 15 22 X 11 X 8 -,SUP-2211-0815S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19669.62,13768.734,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE ACCELFIX LUMB EXPAND 8 DEG 22 X 11 X 12 -,SUP-2211-1208S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUT HEALIX ADVANCE 4.5MM MUL-THRD BCRL RAPIDE -,SUP-222.295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1643.16,1150.212,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SUTURE ORTHOCORD #2 MO-7 36IN BRD BLU VIOL 223114 1/2CIR MPK -,SUP-223.114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.04,210.028,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN LC-DCP 11X77MM 3.5MM 6HL LC BSC LCK DCP SS SM NS -,SUP-223.560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2413.05,1689.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN LC-DCP 11X90MM 3.5MM 7HL LC BSC LCK DCP SS SM NS -,SUP-223.570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2504.49,1753.143,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN LC-DCP 11X103MM 3.5MM 8HL LC BSC DCP SS SM NS -,SUP-223.580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2631.7,1842.19,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN LC-DCP 11X116MM 3.5MM 9HL LC BSC LCK DCP SS SM NS -,SUP-223.590,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2466.96,1726.872,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN LC-DCP 11X129MM 3.5MM 10HL LC BSC LCK DCP SS SM NS -,SUP-223.600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2542.16,1779.512,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEPIN ORTHO BRKWY 2.5MM GLOBAL APG + -,SUP-2230-00-019,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1126.16,788.312,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN LC-DCP 13.5X155MM 12HL 4.2MM LC COMPR SS 3.5MM BRD -,SUP-225.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2321.62,1625.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SUBSTITUTE DEMIN CANC TISS 0.75ML G2 DIVERTED MRSL VOID FIL -,SUP-227005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1139.61,797.727,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SUBSTITUTE G2 TISS 0.5ML STRIP PREFL ATF STR TUBE -,SUP-227010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,846.08,592.256,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
KT ORTHO MILAGRO FEM -,SUP-232.300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2199.71,1539.797,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
END CAP LOWER EXTREMITY 8 +0MM -,SUP-2330-0000S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1195.26,836.682,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
T2 ALFPHA COMPRESSION SCREW FEMUR 5.5 -,SUP-2330-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1333.08,933.156,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
END CAP GT/PF T2 ALPHA 013 +10 -,SUP-2330-0010S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1195.26,836.682,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL FEMORAL GT LEFT 11 X 320MM -,SUP-2331-1132S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FEMORAL NAIL GT- LEFT Ã˜11X420MM -,SUP-2331-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9735.49,6814.843,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FEMORAL NAIL GT LEFT 13 X 400MM -,SUP-2331-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10095.65,7066.955,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FEMORAL NAIL GT RT 10 X 360 -,SUP-2333-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12776.73,8943.711,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FEMORAL NAIL GT RIGHT 10 X 420MM -,SUP-2333-1042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL INTRAMEDULLARY T2 ALPHA FEMUR ANTEGRADE SYSTEM 11 X 380 -,SUP-2333-1138S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FEMORAL NAIL GT RIGHT 11 X 420MM -,SUP-2333-1142S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FEMORAL NAIL GT RIGHT 11 X 440MM -,SUP-2333-1144S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9737.34,6816.138,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FEMORAL NAIL GT RIGHT 13MM X 400MM -,SUP-2333-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10095.65,7066.955,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FEMORAL NAIL RETROGRADE D10X360MM -,SUP-2339-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FEMORAL NAIL RETROGRADE D10X400MM -,SUP-2339-1040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SYS FEMUR RETROGRADE NAIL 11 X 200MM T2 ALPHA SHORT -,SUP-2339-1120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FEMORAL NAIL RETROGRADE 11 X 300MM -,SUP-2339-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL T2 FEMUR ALPHA RETROGRADE 11 X 340MM -,SUP-2339-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FEMORAL NAIL RETROGRADE D11X380MM -,SUP-2339-1138S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10184.76,7129.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FEMORAL NAIL RETROGRADE 12 X 340MM -,SUP-2339-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10561.63,7393.141,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
T2 ALPA FEMUR NAIL RETROGRADE 12 X 360 -,SUP-2339-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10559.77,7391.839,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FEMORAL NAIL RETROGRADE 13X340MM -,SUP-2339-1334S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10561.63,7393.141,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FEMORAL NAIL RETROGRADE D13X360MM -,SUP-2339-1336S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10559.77,7391.839,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW INTFR CANN 8X23MM THRD BABSRB PLLA -,SUP-234-010-162,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW INTFR CANN BIOSTEON 7X28MM 1MM CANN FLLY BLNT THRD -,SUP-234-010-164,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW INTFR CANN BIOSTEON 8X28MM BABSRB WDG SHP HAP PLLA -,SUP-234-010-165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW INTFR CANN 9X28MM THRD BABSRB PLLA -,SUP-234-010-166,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW INTFR CANN BIOSTEON 11X35MM 1MM CANN FLLY BLNT THRD -,SUP-234-010-179,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1297.35,908.145,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW INTFR CANN BIOSTEON 12X35MM 1MM CANN FLLY BLNT THRD -,SUP-234-010-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2187.89,1531.523,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COMPRESSION SCREW TIBIA 5.5 -,SUP-2341-0001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1333.08,933.156,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
END CAP TIBIA T2 ALPHA 11.5 X +5MM -,SUP-2341-0005S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
END CAP TIBIA T2 ALPHA 11.5 X 10MM -,SUP-2341-0010S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
END CAP TIBIA T2 ALPHA 11.5 X 15MM -,SUP-2341-0015S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEPIN ENDO VERSITOMIC SHP MEM ALY TECH FLXB -,SUP-234-108-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2166.31,1516.417,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEPIN ENDO VERSITOMIC FLXB -,SUP-234-108-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2187.89,1531.523,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TIBIAL NAIL 9 X 285MM -,SUP-2341-0928S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TIBIAL NAIL T2 ALPHA 9 X 300 -,SUP-2341-0930S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TIBIAL NAIL T2 09 X 315MM -,SUP-2341-0931S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL TIBIAL 9 X 330 T2 ALPHA -,SUP-2341-0933S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TIBIAL NAIL 9 X 345 -,SUP-2341-0934S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TIBIAL NAIL 9 X 360 -,SUP-2341-0936S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TIBIAL NAIL 9 X 375 -,SUP-2341-0937S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TIBIAL NAIL 9 X 390MM -,SUP-2341-0939S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TIBIAL NAIL 10X285MM -,SUP-2341-1028S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10764.14,7534.898,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM 10 X 300 -,SUP-2341-1030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM 10 X 315 -,SUP-2341-1031S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM -,SUP-2341-1033S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
T2 ALPHA TIBIA NAIL 10X345MM SYS -,SUP-2341-1034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL TIBIAL 10 X 360 T2 ALPHA -,SUP-2341-1036S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL TIBIAL 10 X 375MM T2 ALPHA -,SUP-2341-1037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL TIBIAL 10 X 390 T2 ALPHA -,SUP-2341-1039S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL TIBIAL T2 ALPHA 11 X 300MM -,SUP-2341-1130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL TIBIAL T2 11 X 315 -,SUP-2341-1131S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TIBIAL NAIL 11 X 330 -,SUP-2341-1133S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL SYSTEM T2 ALPHA TIBIA 11 X 345MM -,SUP-2341-1134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TIBIAL NAIL T2 ALPHA TIBIA SYSTEM -,SUP-2341-1136S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TIBIAL NAIL T2 ALPHA 11 X 375 -,SUP-2341-1137S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
T2 ALPHA TIBIA NAIL 11 X 390MM -,SUP-2341-1139S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8498.61,5949.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL TIBIAL T2 ALPHA 12 X 315MM -,SUP-2341-1231S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL TIBIAL T2 ALPHA 12 X 330MM -,SUP-2341-1233S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
T2 ALPHA TIBIA SYSTEM TIBIAL NAIL -,SUP-2341-1234S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
T2 ALPHA TIBIAL NAIL 12 X 380MM -,SUP-2341-1236S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10764.1,7534.87,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TIBIAL NAIL 12 X 375MM -,SUP-2341-1237S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8814.79,6170.353,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 8X50MM -,SUP-234500150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,885.69,619.983,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOCKING SCREW 5 X 25MM -,SUP-2360-5025S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOCKING SCREW 5 X 27.5MM -,SUP-2360-5027S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 5X32MM -,SUP-2360-5032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW IMN SYSTEM LOCKING SCREW 5 X 35 -,SUP-2360-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
IMN LOCKING SCREW 5 X 37.5MM -,SUP-2360-5037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
IMN SCREW SYSTEM LOCKING SCREW 5 X 40 -,SUP-2360-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 5X42MM -,SUP-2360-5042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOCKING SCREW 05 X 45MM -,SUP-2360-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
IMN LOCKING SCREW 5X47.5MM -,SUP-2360-5047S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
IMN LCK SCREW 5X50 -,SUP-2360-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
IMN LCK SCREW 5X52 -,SUP-2360-5052S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LCK STRYKER 5 X 55 -,SUP-2360-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
IMN LOCKING SCREW 5X57.5MM -,SUP-2360-5057S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
IMN LOCKING SCREW 0.5 X 60MM -,SUP-2360-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1836.62,1285.634,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING SYS IMN 5 X 60MM -,SUP-2360-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
IMN LOCKING SCREW 0.5 X 65MM -,SUP-2360-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 5 X 70MM -,SUP-2360-5070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE T2 ALPHA IMN LOCKING  0.5 X 75MM -,SUP-2360-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING SYS IMN 5 X 65MM -,SUP-2360-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 5 X 85 -,SUP-2360-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 5 X 90 -,SUP-2360-5090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW IMN T2 ALPHA LOCKING  5MM X 95MM -,SUP-2360-5095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING SYS IMN 5 X 100MM -,SUP-2360-5100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1314.52,920.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ADVANCED LOCKING SCREW 5X30MM -,SUP-2361-5030S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ADVANCED LOCKING 5MM X 32.5MM -,SUP-2361-5032S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ADVANCED LOCKING 5 X 35 -,SUP-2361-5035S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING ADVANCED IMN 05 X 37.5MM -,SUP-2361-5037S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING ADVANCED IMN 05 X 40MM -,SUP-2361-5040S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ADVANCED LOCKING 5MM X 42.5MM -,SUP-2361-5042S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ADVANCED LOCKING SCREW 5MM X 45MM -,SUP-2361-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW IMN LCK 5 X 45 -,SUP-2361-5045S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ADVANCED LOCKING 5MM X 47.5MM -,SUP-2361-5047S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING ADVANCED 5X50MM -,SUP-2361-5050S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ADVANCED LOCKING SCREW 5MM X 52.5MM -,SUP-2361-5052S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ADVANCED LOCKING 5MM X 55MM -,SUP-2361-5055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ADVANCED LOCKING SCREW 5 X 57.5MM -,SUP-2361-5057S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X60MM IMN ADVANCED LOCKING -,SUP-2361-5060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ADVANCED LOCKING 5MM X 65MM -,SUP-2361-5065S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ADVANCED LOCKING 5MM X 70MM -,SUP-2361-5070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ADVANCED LOCKING SCREW 5 X 57MM -,SUP-2361-5075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ADVANCED LOCKING SCREW 5 X 80 -,SUP-2361-5080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
IMN ADVANCED LOCKING SCREW 5MM X 85MM -,SUP-2361-5085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ADVANCED LOCKING SCREW 5 X 90MM -,SUP-2361-5090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1553.05,1087.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW IMN LOCKING 5MM X 95MM -,SUP-2361-5095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1555.7,1088.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN LCP 83MM 4/5MM 4HL BSC LCK COMPR SS LRG T-SHP NS -,SUP-240.141,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3467.5,2427.25,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN STERNAL TALON 14MM D FT PLATE LEGX2 SGL TI SM STRL -,SUP-24-009-14-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN STERNAL TALON SGL LEGX2 BIOCMPT TI SM STRL -,SUP-24-009-17-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FOOT PLATE BN STERNAL TALON SGL VRSN TI 17MM MED STRL LEGX2 -,SUP-24-010-17-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN STERNAL TALON 20MM D LEGX2 SGL TI MED STRL -,SUP-24-010-20-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FOOT PLATE XL 12X20MM STERNAL TALON SGL -,SUP-24-012-20-71,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5331.1,3731.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
STERNAL SCREW 2.3 -,SUP-24-023-09-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X11MM LCK DRL-FR MAXDRIVE THREADLOCK TS SLF RET TI -,SUP-24-023-11-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X13MM LCK DRL-FR MAXDRIVE THREADLOCK TS SLF RET TI -,SUP-24-023-13-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
STERNAL SCREW 2.3 X 15MM -,SUP-24-023-15-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.3MM SELF DRILLING STERNAL SCREWS -,SUP-24-023-17-91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,316.55,221.585,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE LEVEL 1 THORACIC STERNAL LKG STR 2.3MM SCRW 20 HL -,SUP-24-025-07-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3118.62,2183.034,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
STERNAL PLATE LOCK 6-HOLE 1.8 -,SUP-24-025-42-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2398.48,1678.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 8HL 1.8MM LCK TI X-SHP -,SUP-24-025-44-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2224.88,1557.416,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
4 HOLE STRAIGHT -,SUP-24-025-48-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2155.98,1509.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE LEVEL ONE THORACIC STERNAL LKG STR W/2.3MM SCREW -,SUP-24-025-50-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2580.02,1806.014,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
9 HOLE Y PLATE -,SUP-24-025-52-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2613.77,1829.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 4 HOLE ANGLE -,SUP-24-025-59-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1906.85,1334.795,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN LC-DCP 10X50MM 3.5MM 3HL HD/SHFT LC DCP SS T-SHP RT -,SUP-241.130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,781.42,546.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN LC-DCP 11X64MM 3.5MM HLX3/5 HD/SHFT LC DCP SS T-SHP -,SUP-241.150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,944.22,660.954,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN LC-DCP 10X53MM 3.5MM 3HL HD/SHFT LC LCK DCP SS -,SUP-241.230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1176.71,823.697,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN LC-DCP 10X63MM 3.5MM 0.75HL HD/SHFT LC LCK DCP SS -,SUP-241.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1296.45,907.515,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN LC-DCP 10X75MM 3.5MM HLX3/5 HD/SHFT LC LCK DCP SS -,SUP-241.250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1282.72,897.904,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN LC-DCP 9X25MM 3.5MM 2HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN LC-DCP 9X49MM 3.5MM 4HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN LC-DCP 9X61MM 3.5MM 5HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1232.37,862.659,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN LCP 9X57MM 2.7/3.5MM 5HL CONTR LCK COMPR SS SM 1/3 -,SUP-241.351,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1594.13,1115.891,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN LC-DCP 9X85MM 3.5MM 7HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1268.14,887.698,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN LC-DCP 9X97MM 3.5MM 8HL LC LCK DCP SS SM MINI 1/3 -,SUP-241.380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1315.85,921.095,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN LC-DCP 9X121MM 3.5MM 10HL LC DCP SS SM MINI 1/3 -,SUP-241.400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN LCP 9X117MM 2.7/3.5MM 10HL CONTR LCK COMPR SS SM -,SUP-241.401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1745.19,1221.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN LCP 15MM D 3.5MM 5HL PRCONT LCK COMPR SS HOOK STRL -,SUP-241-085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4546.38,3182.466,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN LCP 6.3X49MM 2.4MM 0.75HL HD/SHFT FA CONTR LCK -,SUP-242.507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2479.52,1735.664,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER TNDN 6X24MM SILASTIC PLYSTR COR SWN-HNT STRL -,SUP-24270006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7240.26,5068.182,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 82MM 3.5MM 7HL RECON SS STR NS -,SUP-245.170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3397.89,2378.523,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN LC-DCP 94MM 3.5MM 8HL RECON DCP SS STR NS -,SUP-245.181,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3544.7,2481.29,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN LC-DCP 106MM 3.5MM 9HL RECON DCP SS STR NS -,SUP-245.190,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3738.04,2616.628,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 53MM 2MM HLX2/8 HD/SHFT 1.2MM RECON SS T-SHP NS -,SUP-247.232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1616.65,1131.655,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN LCP 54MM 2MM 7HL RECON LCK COMPR SS NS -,SUP-247.349,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4745.36,3321.752,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN LCP 44MM 2.4MM 5HL RECON ADPR LCK COMPR SS STR NS -,SUP-247.375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2573.19,1801.233,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN LCP 36MM 2.4MM 4HL RECON LCK COMPR SS STR NS -,SUP-249.674,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2496.8,1747.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN LCP 59MM 2.4MM 7HL RECON LCK COMPR SS STR NS -,SUP-249.679,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3862.17,2703.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN LCP 58MM 2.7MM 6HL RECON LCK COMPR SS STR NS -,SUP-249.682,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3247.51,2273.257,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN LCP 67MM 2.7MM 7HL RECON LCK COMPR SS STR NS -,SUP-249.683,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2544.54,1781.178,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN LCP 32MM 2.7MM 0.66HL HD/SHFT RECON LCK COMPR SS -,SUP-249.685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCK -,SUP-250-1001-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 8.5MM SHTH INTRAFIX PEEK PP NS F/ACL FX -,SUP-254.683,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LCK CRNMXF 2.3X11MM CROSS-DRIVE TI ALY -,SUP-25-773-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE 7 MWX8MMX21MM TRAXIS PEEK/ TI -,SUP-2601070921,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE VERT 25MM VUE 7MM/9MM LD /TRAILING DIA SGL LVL PEEK -,SUP-2601070925,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE 9X21X9MM TRAXIS VUE 9MM/9MM DIA LD /TRAILING DIA SGL -,SUP-2601090921,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15576.04,10903.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDE DRILL POR F/KN ARTHPL -,SUP-261-0060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
USTAR II KNEE CEMENTED STR STEM RHS 17X125 -,SUP-2715-3117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BLADE IM NAIL 12.5X105MM SS HLCL NS F /LCP DHS -,SUP-282.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2284.52,1599.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BLADE IM NAIL 12.5X120MM SS HLCL NS F /LCP DHS -,SUP-282.243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2277.41,1594.187,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ORTHOFIX CAGE 6.5 -,SUP-28-2180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ORTHOFIX CAGE 8.5 -,SUP-28-2182,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ORTHOFIX CAGE 6.5 X 24 XP -,SUP-28-3140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE XP LORDOTIC 8.5 -,SUP-28-3142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ORTHOFIX FORZA XP CAGE 10.5H X 10W X 24L -,SUP-28-3144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ORTHOFIX 12H EXPANDABLE CAGE -,SUP-28-3146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
EXPANDABLE CAGE 6.5MMX10MM WIDE X28MM -,SUP-28-3180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE FORZA XP ORTHOFIX 10.5MM -,SUP-28-3184,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ORTHOFIX HYPERLORDOTIC CAGE 8.5 -,SUP-28-4142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE 10.5HL HYPER XP -,SUP-28-4144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ORTHOFIX CAGE 12.5 X 24. HL -,SUP-28-4146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
USTAR II KNEE SEGMENT PART RHS 25MM -,SUP-2915-1025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22014.38,15410.066,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER VERT 22X8MM CAP STN VERTSTCK PEEK -,SUP-2960822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER VERT 26X8MM CAP STN VERTSTCK PEEK -,SUP-2960826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20245.95,14172.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER VERT 22X10MM CAP STN VERTSTCK 8DG PEEK -,SUP-2961022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X12MM LCK ACU-LOC 2 HXLB DRIVE F/VOLAR DIST RAD -,SUP-30-0234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,822.74,575.918,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X14MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X18MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0237,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X20MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X22MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0239,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X24MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X26MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0241,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X30MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X32MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X36MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0246,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X45MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0249,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X22MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0262,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X24MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0263,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X26MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0264,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X32MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0267,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X40MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0271,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X45MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0272,CDM,C1713,HCPCS,278,RC,,,outpatient,,,536.82,375.774,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X50MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0273,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X55MM NLCKG ACU-LOC 2 HXLB DRV NS -,SUP-30-0274,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3X40MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0294,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW Ti SET 8X17.5MM -,SUP-3003-0822S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,858.1,600.67,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X14MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0327,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X16MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X18MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0329,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X20MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X22MM LCK ACU-LOC 2 HXLB DRV NS -,SUP-30-0331,CDM,C1713,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAP END +10MM TI GAMMA3 -,SUP-3005-1110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,858.1,600.67,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.7X45MM ACUTRAK 2 NS -,SUP-30-0645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.7X50MM ACUTRAK 2 NS -,SUP-30-0650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.3X26MM LCK POLARUS 3 HXLB DRV TI STRL -,SUP-3011-43026-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.3X46MM HXLB -,SUP-3011-43046-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.6MM/4.5MM DIA TIP/BK END 20MM CANN HDLS BIOTRAK -,SUP-3017-0009-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3465.92,2426.144,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.6MM/4.6MM DIA TIP/BK END 22MM CANN HDLS BIOTRAK -,SUP-3017-0010-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3465.92,2426.144,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER THORLUM VERT 10X26X8MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER THORLUM VERT 10X26X9MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER THORLUM VERT 10X26X10MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER THORLUM VERT 10X26X11MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER THORLUM VERT 10X26X12MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER THORLUM VERT 8X22X8MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.078,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER THORLUM VERT 8X22X9MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.079,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER THORLUM VERT 8X22X10MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER THORLUM VERT 8X22X11MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.081,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER THORLUM VERT 8X22X12MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER THORLUM VERT 8X22X13MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.083,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER THORLUM VERT 10X22X8MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.088,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER THORLUM VERT 10X22X9MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.089,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER THORLUM VERT 10X22X10MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER THORLUM VERT 10X22X11MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.091,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER THORLUM VERT 10X22X12MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.092,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER THORLUM VERT 10X22X13MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.093,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER THORLUM VERT 10X22X15MM SUSTAIN-O OBLQ SM PEEK RDLCNT -,SUP-304.095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER THORLUM VERT 12X26X10MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.970,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER THORLUM VERT 12X26X17MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.977,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LAG SCREW TI 10.5 X 75mm -,SUP-3060-0075S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW GAMMA3 LAG TI 10.5X80 -,SUP-3060-0080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW GAMMA3 LAG Ti 10.5X85 -,SUP-3060-0085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 90MM -,SUP-3060-0090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW GAMMA3 LAG Ti 10.5X95 -,SUP-3060-0095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GAMMA3 LAG SCREW TI 10.5X100 -,SUP-3060-0100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW GAMMA3 LAG T1 10.5X105 -,SUP-3060-0105S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 110MM -,SUP-3060-0110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 115MM -,SUP-3060-0115S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 120MM -,SUP-3060-0120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 125MM -,SUP-3060-0125S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 10.5MM GAMMA3 LAG THRD ST TI 130MM -,SUP-3060-0130S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2174.95,1522.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
U-BLADE SET TI 10.5 X 95MM -,SUP-3066-0095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2850.17,1995.119,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GRAFT DBM 1ML PTTY OSTEOSELECT VOID FIL OSTCONDC -,SUP-309010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
OSTEOSELECT 2.5CC -,SUP-309025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1749.17,1224.419,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SUBSTITUTE DBM 5ML PTTY OSTEOSELECT VOID FIL OSTCONDC -,SUP-309050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SUBSTITUTE DBM 10ML PTTY OSTEOSELECT -,SUP-309100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER RADIOLUCENT 7MM CANOPY -,SUP-3102.6007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
5CC BIO4 VIABLE BONE MATRIX -,SUP-3102-2105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8594.1,6015.87,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 15.5/11X180MM GAMMA3 LT TROCH FEM TI BIOMECH STRGTH -,SUP-3120-1180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4598.63,3219.041,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TROCHANTERIC NAIL KIT 10X170MMX125DG -,SUP-3125-0170S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5413.56,3789.492,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL GAMMA3 TROCHANTARIC 180 -,SUP-3125-1180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4598.63,3219.041,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
KIT TROCHANTERIC KIT 11X180 SF -,SUP-3130-1180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4598.63,3219.041,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DRILL BIT RINGLOC + QUICK CONNECT 3.2MM X 20MM -,SUP-31-323220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
EQUINOXE SHLDR -,SUP-320-15-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LCK COMPR EQUINOXE F/RVRS BALL/SCKT SURG -,SUP-320-15-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SET SCREW INTNL FX EQUINOXE SHLDR RVRS TRQ DEFINING LCK -,SUP-320-20-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X22MM LCK COMPR EQUINOXE BLK F/RVRS BALL/SCKT SURG -,SUP-320-20-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X34MM LCK COMPR EQUINOXE RD F/RVRS BALL/SCKT SURG -,SUP-320-20-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LONG NAIL GAMMA KIT 11X300 RIG -,SUP-3225-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LONG GAMMA NAIL 11X320 RIGHT -,SUP-3225-0320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL KIT LONG R2.0 TI RT. GAMM -,SUP-3225-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LONG GAMMA NAIL 11X380 RIGHT -,SUP-3225-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LONG GAMMA NAIL 11X400 RIGHT -,SUP-3225-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LONG GAMMA NAIL 11X420 RIGHT -,SUP-3225-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL LONG RT GAMMA3 KIT 11MM X -,SUP-3225-0440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 15MM/13MM DIA P/D 2MM RAD LNG 340MM GAMMA3 RT TROCH -,SUP-3225-3340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX16MM CANN ASNIS III 8MM P/T SD/ST REVCT FLUT SS NS -,SUP-325016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX24MM CANN ASNIS III 8MM P/T SD/ST REVCT FLUT SS NS -,SUP-325024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW PT CANN ASNIS 4.0 X 28 -,SUP-325028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX30MM CANN ASNIS III 10MM P/T SD/ST REVCT FLUT SS -,SUP-325030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX32MM CANN ASNIS III 11MM P/T SD/ST REVCT FLUT SS -,SUP-325032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX34MM CANN ASNIS III 11.5MM P/T SD/ST REVCT FLUT SS -,SUP-325034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX34MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-325034S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX36MM CANN ASNIS III 12MM P/T SD/ST REVCT FLUT SS -,SUP-325036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX38MM CANN ASNIS III 13MM P/T SD/ST REVCT FLUT SS -,SUP-325038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX40MM CANN ASNIS III 13.5MM P/T SD/ST REVCT FLUT SS -,SUP-325040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX42MM CANN ASNIS III 14MM P/T SD/ST REVCT FLUT SS -,SUP-325042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX44MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325044S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX46MM CANN ASNIS III 15.5MM P/T SD/ST REVCT FLUT SS -,SUP-325046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX46MM CANN ASNIS III 0.33IN P/T SD/ST REVCT FLUT SS -,SUP-325046S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX48MM CANN ASNIS III 16MM P/T SD/ST REVCT FLUT SS -,SUP-325048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX50MM CANN ASNIS III 17MM P/T SD/ST REVCT FLUT SS -,SUP-325050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX55MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325055S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-325060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX60MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325060S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX70MM CANN ASNIS III 1/3 P/T SD/ST REVCT FLUT SS -,SUP-325070S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANNULATED 4.0 X 32 -,SUP-325232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X42MM CANN FT -,SUP-325242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X44MM CANN FT -,SUP-325244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5MMX70MM CANN ASNIS III 23.5MM P/T SD/ST REVCT FLUT SS -,SUP-325470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANNULATED 5.0 X 60MM -,SUP-325660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ASNIS III SS CANNULATED SCR 5 X 70MM -,SUP-325670S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SS CANN 6.5 X 70MM ASNIS -,SUP-326070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X75MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X80MM CANN ASNIS III P/T SD/ST REVCT FLUT SS NS -,SUP-326080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X80MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326080S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X85MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X85MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X90MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X90MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS 6.5MM 95MM -,SUP-326095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X95MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS 6.5MM 100MM -,SUP-326100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X100MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X105MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326105S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS 6.5 X 110 -,SUP-326110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X110MM CANN ASNIS III P/T SD/ST REVCT FLUT SS STRL -,SUP-326110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X115MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326115S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X120MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT SS -,SUP-326120S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW S.S. TL40 6.5 X 55 -,SUP-326255,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
6.5MM PARTIALLY THREADED 40MM SCREW 60MM LENGTH -,SUP-326260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW S.S. TL40 6.5 X 70 -,SUP-326270,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MMX75MM CANN ASNIS III 40MM THRD SD/ST REVCT FLUT -,SUP-326275,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MMX80MM CANN ASNIS III 40MM THRD SD/ST REVCT FLUT -,SUP-326280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS CAN 6.5 X 85 -,SUP-326285,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS CAN 6.5 X 90 -,SUP-326290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS CAN 6.5 X 95 -,SUP-326295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.94,757.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS CAN 6.5 X 95 -,SUP-326295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS CAN 6.5 X 100 -,SUP-326300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW S.S. TL40 6.5 X 110 -,SUP-326310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW S.S. TL40 6.5 X 115 -,SUP-326315,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW S.S. TL40 6.5 X 120 -,SUP-326320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1196.43,837.501,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 80 -,SUP-326480S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 85 -,SUP-326485S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANNULATED FULLY THREADED 6.5 X 90MM -,SUP-326490S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS III SS CANNULATED 6.5X95MM -,SUP-326495S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS III SS CANNULATED 6.5X100MM -,SUP-326500S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS III SS CANNULATED 6.5X105MM -,SUP-326505S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS III SS CANNULATED 6.5X110MM -,SUP-326510S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS III SS CANNULATED 6.5X115MM -,SUP-326515S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS III SS CANNULATED 6.5X120MM -,SUP-326520S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS III SS CANNULATED 6.5X125MM -,SUP-326525S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS III SS CANNULATED 6.5X130MM -,SUP-326530S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS III CANN 8.0 X 70MM -,SUP-326670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW S.S. TL25 8.0 X 75 -,SUP-326675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS 8.0 X 80MM -,SUP-326680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS CANNULATED 8.0 X 85MM -,SUP-326685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 8MMX90MM CANN ASNIS III 25MM P/T SD/ST REVCT FLUT SS -,SUP-326690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 8MMX95MM CANN ASNIS III 25MM P/T SD/ST REVCT FLUT SS -,SUP-326695,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANNULATED PARTIALLY THREADED 8MM X 95MM TL25MM -,SUP-326695S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 8MMX100MM CANN ASNIS III 25MM P/T SD/ST REVCT FLUT SS -,SUP-326700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
8 x 105MM ASNIS SCREW -,SUP-326705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
8 X 110MM ASNIS SCREW -,SUP-326710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1163.57,814.499,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
C/M 16MM & 25MM PLUG WITH NOZZLE -,SUP-32810503800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1313.46,919.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LONG NAIL KIT LEFT 300mm -,SUP-3325-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL LONG KIT 11X320MMX125 GAM -,SUP-3325-0320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL GAMMA LGN LEFT 11X360 -,SUP-3325-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL LONG GAMMA3 11X380 LFT -,SUP-3325-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LONG GAMMA NAIL 11X400 LEFT -,SUP-3325-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LONG GAMMA NAIL 11X420 LEFT -,SUP-3325-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LONG GAMMA NAIL 11X440 LEFT -,SUP-3325-0440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7024.07,4916.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 13MMLNGX340MM GAMMA3 LT TROCH FEM TI BIOMECH STRGTH -,SUP-3325-3340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN OPLS 2HL STD BRL COMPR SDE 130DG ANG -,SUP-3362-1-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 130DG ANG -,SUP-3362-1-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN OPLS 2HL STD BRL COMPR SDE 135DG ANG KYLS -,SUP-3362-1-102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE HIP COMP 135-5-HOLE -,SUP-3362-1-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE HIP OMEGA 135 6 HOLE - OBSOLETE DO NOT USE -,SUP-3362-1-106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN OPLS SLOTX2 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN OPLS SLOTX5 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN OPLS SLOTX6 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN OPLS SLOTX8 STD BRL COMPR SDE 140DG ANG -,SUP-3362-1-208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN OPLS SLOTX3 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-303,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN OPLS SLOTX5 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-305,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2896.15,2027.305,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN OPLS SLOTX6 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2896.15,2027.305,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN OPLS SLOTX8 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN OPLS SLOTX10 STD BRL COMPR SDE 145DG ANG -,SUP-3362-1-310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN OPLS SLOTX4 STD BRL COMPR SDE 150DG ANG -,SUP-3362-1-404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN OPLS SLOTX8 STD BRL COMPR SDE 150DG ANG -,SUP-3362-1-408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3581.45,2507.015,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN OPLS SLOTX10 STD BRL COMPR SDE 150DG ANG -,SUP-3362-1-410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3570.95,2499.665,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN OPLS SLOTX12 25.4MM BRL 98DG ANG PRE- KY -,SUP-3362-2-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4883.15,3418.205,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN OMG SLOTX4 STD BRL COMPR 130DG ANG KYLS -,SUP-3362-3-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN OMG SLOTX2 STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN OMG SLOTX3 STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-103,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN OPLS 4HL STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN OMG SLOTX6 STD BRL COMPR 135DG ANG KYLS -,SUP-3362-3-106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN OMG SLOTX5 STD BRL COMPR 140DG ANG KYLS -,SUP-3362-3-205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3061.57,2143.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 50MM -,SUP-3362-5-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 55MM -,SUP-3362-5-055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1205.86,844.102,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 60MM -,SUP-3362-5-060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1205.86,844.102,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 65MM -,SUP-3362-5-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 70MM -,SUP-3362-5-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 75MM -,SUP-3362-5-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 80MM -,SUP-3362-5-080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 90MM -,SUP-3362-5-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 95MM -,SUP-3362-5-095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 100MM -,SUP-3362-5-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 13MM OPLS LAG 22MM THRD STD SS 105MM -,SUP-3362-5-105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1470.89,1029.623,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X10MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X12MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X14MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X16MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X18MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X20MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X22MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X24MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X26MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X28MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X30MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X32MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X34MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X36MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X38MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X40MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X42MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X44MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X45MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X46MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X48MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X50MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X55MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X60MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X65MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X70MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,146.87,102.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5 X 75 CORTICAL -,SUP-338675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X80MM LCK MATTA CORT ISO AXSOS FT ST 2.5MM HEX DRV -,SUP-338680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL 3.5MM X 85MM -,SUP-338685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SELF TAP CORTICAL 3.5 X 115MM -,SUP-338715,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SELF TAP CORTICAL 3.5 X 120MM -,SUP-338720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.02,94.514,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X14MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV CUT -,SUP-340614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX16MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX18MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX20MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX22MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX24MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX26MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX28MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX30MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX34MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX34MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX36MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX36MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX38MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX38MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX40MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX40MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX42MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX42MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX44MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX44MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX46MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX48MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX48MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX50MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL 4.5 X 52 -,SUP-340652,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL 4.5 X 54 -,SUP-340654,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX55MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX56MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340656,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX58MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340658,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL 4.5 X 60MM -,SUP-340660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX65MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.05,112.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX75MM MATTA CORT OMEGA3 SPS FT ST 3.5MM HEX DRV -,SUP-340675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,161.1,112.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MMX35MM MATTA CANC OMEGA3 SPS 16MM P/T 3.5MM HEX -,SUP-341035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MMX40MM MATTA CANC OMEGA3 SPS 16MM P/T 3.5MM HEX -,SUP-341040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER KIKO CORPECTOMY SMALL 12 X 14 0 DEG 21MM -,SUP-342.721,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11547.43,8083.201,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB. -,SUP-3420-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11MMX320MM RT TI BIOMECH STRGTH STAB 120DG ANG -,SUP-3420-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11MMX340MM RT TI BIOMECH STRGTH STAB 120DG ANG -,SUP-3420-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MMX80MM MATTA CANC OMEGA3 SPS 32MM P/T 3.5MM HEX -,SUP-342080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MMX85MM MATTA CANC OMEGA3 SPS 32MM P/T 3.5MM HEX -,SUP-342085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10MMX300MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10MMX320MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10MMX340MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10MMX360MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB. -,SUP-3425-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10MMX380MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10MMX400MM GAMMA3 RT TROCH TI BIOMECH STRGTH STAB -,SUP-3425-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LONG NAIL 10MM X 420MM X 125 DEGREES -,SUP-3425-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11MMX300MM GAMMA3 RT HIP TI BIOMECH STRGTH STAB -,SUP-3425-1300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11MMX320MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11MMX340MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11MMX360MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11MMX380MM GAMMA3 RT TI BIOMECH STRGTH STAB -,SUP-3425-1380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11MMX400MM GAMMA3 RT TI BIOMECH STRGTH STAB 125DG -,SUP-3425-1400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANCL FT 6.5 X 20 -,SUP-343020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANCL FT 6.5 X 25 -,SUP-343025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANCL FT 6.5 X 30 -,SUP-343030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANCL FT 6.5 X 40 -,SUP-343040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MMX85MM MATTA CANC OMEGA3 SPS FT 3.5MM HEX DRV CUT -,SUP-343085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,142.96,100.072,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX10MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX12MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX14MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX16MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX18MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX20MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX22MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX24MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX26MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX28MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX30MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX32MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX34MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX36MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX38MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CNCL LCK 4.0 X 40 -,SUP-345440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX45MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX50MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX55MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX60MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX65MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX75MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345475,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX80MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX90MM LCK CANC AXSOS SPS FT ST 2.5MM HEX DRV CUT -,SUP-345490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX10MM LCK CANC AXSOS SPS 5MM P/T ST 2.5MM HEX DRV -,SUP-345510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX14MM LCK CANC AXSOS SPS 6MM P/T ST 2.5MM HEX DRV -,SUP-345514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX18MM LCK CANC AXSOS SPS 6MM P/T ST 2.5MM HEX DRV -,SUP-345518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX34MM LCK CANC AXSOS SPS 14MM P/T ST 2.5MM HEX DRV -,SUP-345534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX36MM LCK CANC AXSOS SPS 14MM P/T ST 2.5MM HEX DRV -,SUP-345536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX38MM LCK CANC AXSOS SPS 14MM P/T ST 2.5MM HEX DRV -,SUP-345538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX40MM LCK CANC AXSOS SPS P/T ST 2.5MM HEX DRV CUT -,SUP-345540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX45MM LCK CANC AXSOS SPS 15MM P/T ST 2.5MM HEX DRV -,SUP-345545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX50MM LCK CANC AXSOS SPS 15MM P/T ST 2.5MM HEX DRV -,SUP-345550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX55MM LCK CANC AXSOS SPS 16MM P/T ST 2.5MM HEX DRV -,SUP-345555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX60MM LCK CANC AXSOS SPS 16MM P/T ST 2.5MM HEX DRV -,SUP-345560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX70MM LCK CANC AXSOS SPS P/T ST 2.5MM HEX DRV CUT -,SUP-345570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,102.11,71.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX80MM LCK CANC AXSOS SPS P/T ST 2.5MM HEX DRV CUT -,SUP-345580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.99,107.793,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MMX8MM CORT AXSOS ISO SPS FT ST 2.5MM HEX DRV CUT -,SUP-349608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL 2.7 X 14MM -,SUP-349614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MMX16MM CORT AXSOS ISO SPS FT ST 2.5MM HEX DRV CUT -,SUP-349616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MMX18MM CORT AXSOS ISO SPS FT ST 2.5MM HEX DRV CUT -,SUP-349618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.2,104.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CORTEX SCREW SELF TAPPING STEEL 2.7MM X 60MM -,SUP-349660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,127.9,89.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ASSEMBLY CBL CRLGE TI CBL LOCK SPRCBL ISO-ELAS -,SUP-35-100-1010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2597.25,1818.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CABLE ORTHO SUPERCABLE 1.5MM CERVICAL CERCLAGE -,SUP-35-100-1040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2477.71,1734.397,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE KINAMED 2 HOLE SUPERCABLE -,SUP-35-200-1020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8377.66,5864.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN SPRCBL 190MM 4HL TI TROCH GRP -,SUP-35-200-1030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10233.03,7163.121,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11MMX340MM GAMMA3 LT TI 120DG ANG -,SUP-3520-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11MMX360MM GAMMA3 LT TI 120DG ANG -,SUP-3520-1360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11MMX380MM GAMMA3 LT TI 120DG ANG -,SUP-3520-1380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CABLE ORTHO SUPER CBL TI PLATE 6HL -,SUP-35-220-1010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5831.26,4081.882,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CABLE-PLATE 8 HOLE STRAIGHT -,SUP-35-220-2010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7363.34,5154.338,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SUPERCABLE GRIP AND PLATE 10 HOLE STRAIGHT -,SUP-35-220-3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9661.23,6762.861,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN SPRCBL 290MM 10HL TI TROCH GRP -,SUP-35-220-3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10530.07,7371.049,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GRIP AND PLATE SYSTEM COMPRESSION BONE SCREW 4.5X12MM -,SUP-35-230-4512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,250.91,175.637,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SUPERCABLE GRIP AND PLATE SYS COP BONE SCREW 4.5 X 14MM -,SUP-35-230-4514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,250.91,175.637,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GRIP AND PLATE COMPRESSION BONE SCREW 4.5 X 16MM -,SUP-35-230-4516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,250.91,175.637,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SUPERCABLE BONE SCREW 4.5 X 30 -,SUP-35-230-4530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SUPERCABLE BONE SCREW 4.5 X 32 -,SUP-35-230-4532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE SUPERCABLE GRIP AND PLATE COMP  4.5 X 34 -,SUP-35-230-4534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X36MM COMPR SPRCBL F/GRP PLATE SYS -,SUP-35-230-4536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X38MM COMPR SPRCBL F/GRP PLATE SYS -,SUP-35-230-4538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X40MM COMPR SPRCBL F/GRP PLATE SYS -,SUP-35-230-4540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GRIP AND PLATE SYS COMP BONE SCREW 4.5MM X 45MM -,SUP-35-230-4545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
KINAMED SUPERCABLE SCREW -,SUP-35-230-4550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,274.25,191.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X12MM LCK SPRCBL F/GRP PLATE SYS -,SUP-35-234-5012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X16MM LCK SPRCBL F/GRP PLATE SYS -,SUP-35-234-5016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X18MM LCK SPRCBL F/GRP PLATE SYS -,SUP-35-234-5018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE SUPERCABLE GRIP AND PLATE LOCK 5 X 20 -,SUP-35-234-5020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1056.14,739.298,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10MMX300MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10MMX340MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10MMX380MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
"NAIL LONG KIT R1.5 TI LEFT 010 X 125"" -",SUP-3525-0400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11MMX420MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11MMX440MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-0440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11MMX300MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1300S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11MMX320MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1320S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11MMX340MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11MMX380MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11MMX400MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB -,SUP-3525-1400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
"NAIL LONG KIT R15 TI 011 X 400MM X 125"" LEFT GAMMAX3 SYS -",SUP-3525-1400S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL LONG KIT R1 5 TI LEFT -,SUP-3525-1420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GAMMA LONG NAIL KIT R1.5 LEFT 11X440MM -,SUP-3525-1440S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10MMX360MM GAMMA3 LT TROCH TI BIOMECH STRGTH STAB. -,SUP-3530-0360S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DBM PUTTY - OSTEOSELECT 2.5CC -,SUP-359025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1749.17,1224.419,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DBM PUTTY - OSTEOSELECT 5CC -,SUP-359050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DBM PUTTY - OSTEOSELECT 10CC -,SUP-359100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN FX STNMN 2.8X230MM SMTH TROC PNT 3-SDE SHNK SS -,SUP-3611-3-090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13.5,9.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SET SCREW -,SUP-36-2001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TULIP BODY -,SUP-36-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
REDUCTION HEAD -,SUP-36-2103,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW JANUS ORTHOFIX 4.5 X 30 -,SUP-36-2430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5MM X 35 ORTHOFIX -,SUP-36-2535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW JANUS ORTHOFIX 5.5 X 40 -,SUP-36-2540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SREW ORTHOFIX FIREBIRD 5.5 X 45MM -,SUP-36-2545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MM X 30MM ORTHOFIX -,SUP-36-2630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW JANUS 6.5X35MM ORTHOFIX -,SUP-36-2635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW JANUS ORTHOFIX 6.5 X 40 -,SUP-36-2640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW JANUS CANN 5.5 X 35 -,SUP-36-3535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW JANUS CANN 5.5 X 40 -,SUP-36-3540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW JANUS CANN 5.5 X 45 -,SUP-36-3545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW JANUS CANN 65 X 35 -,SUP-36-3635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW JANUS CANN 65 X 45 -,SUP-36-3645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5 X 25MM ORTHOFIX -,SUP-36-4425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW JANUS 4.5 X 30MM FENESTRATE ORTHOFIX -,SUP-36-4430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW JANUS 4.5 X 35MM FENESTRATE ORTHOFIX -,SUP-36-4435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW JANUS ORTHOFIX 6.5 X 30MM -,SUP-36-4630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW JANUS ORTHOFIX 6.5 X 35MM -,SUP-36-4635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER ACDF COLONIAL 12 X 14 X 6MM 7 DEGREE -,SUP-365.406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER ACDF COLONIAL 12 X 14 X 8MM 7 DEGREE -,SUP-365.408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X10MM LCK AXSOS ST T20 DRV SS NS -,SUP-370110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X12MM LCK AXSOS ST T20 DRV SS NS -,SUP-370112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X14MM LCK AXSOS ST.T20 DRV SS NS -,SUP-370114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X16MM LCK AXSOS ST T20 DRV SS NS -,SUP-370116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X14MM LCK AXSOS ST-T20 DRV SS NS -,SUP-370118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X14MM LCK AXSOS ST..T20 DRV SS NS -,SUP-370120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,733.46,513.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X14MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.17,457.219,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X26MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X28MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X30MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X32MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X34MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X36MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X40MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X44MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X65MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X70MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X75MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X80MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X85MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370385,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X90MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X95MM LCK OMEGA3 AXSOS ST T20 DRV SS NS -,SUP-370395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,738.13,516.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CABLE ORTHO 1.6MM DLMLS HIP SS BEAD SM SLV -,SUP-3704-0-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CABLE/SLEEVE FX 0.2MM DLMLS SS BEAD -,SUP-3704-0-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN DLMLS 165MM 4.5MM 5HL RECON SC SS BRD GROOVEX6 -,SUP-3704-3-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN DLMLS F/RECON TRMA 7HL GROOVEX8 RECON COMPR SS -,SUP-3704-3-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN DLMLS 254MM 4.5MM 9HL RECON SC SS BRD GROOVEX10 -,SUP-3704-3-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN DLMLS 305MM 4.5MM 11HL RECON SC SS GROOVEX12 -,SUP-3704-3-130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.16,1757.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CABLE ORTHO 2MM HIP SS -,SUP-3704-8-240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS -,SUP-370528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS. -,SUP-370532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS- -,SUP-370538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS_ -,SUP-370540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS.NS -,SUP-370542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS.. -,SUP-370544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS -,SUP-370546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS__ -,SUP-370570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS-- -,SUP-370575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X28MM LCK AXSOS ST T15 DRV-SS NS -,SUP-370585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,550.82,385.574,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LCK ST 3.0 X 10 -,SUP-371010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,301.9,211.33,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3X16MM LCK AXSOS -,SUP-371016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,301.9,211.33,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X14MM LCK AXSOS ST.T20 DRV SS NS DIST LAT PERIART -,SUP-371314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCK 5.0 X 16 -,SUP-371316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X14MM LCK AXSOS ST_T20 DRV SS NS DIST LAT PERIART -,SUP-371318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X14MM LCK AXSOS ST T20 DRV SS NS DIST LAT PERIART -,SUP-371320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X22MM LCK AXSOS ST T20 DRV SS NS -,SUP-371322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X26MM LCK AXSOS ST T20 DRV SS NS -,SUP-371326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X28MM LCK AXSOS ST T20 DRV SS NS -,SUP-371328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCK 5.0 X 30 -,SUP-371330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X32MM LCK AXSOS ST T20 DRV SS NS -,SUP-371332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X34MM LCK AXSOS ST T20 DRV SS NS -,SUP-371334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X36MM LCK AXSOS ST T20 DRV SS NS -,SUP-371336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X38MM LCK AXSOS ST T20 DRV SS NS -,SUP-371338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X40MM LCK AXSOS ST T20 DRV SS NS -,SUP-371340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X42MM LCK AXSOS ST T20 DRV SS NS -,SUP-371342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X44MM LCK AXSOS ST T20 DRV SS NS -,SUP-371344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X46MM LCK AXSOS ST T20 DRV SS NS -,SUP-371346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X48MM LCK AXSOS ST T20 DRV SS NS -,SUP-371348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X50MM LCK AXSOS ST T20 DRV SS NS -,SUP-371350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X60MM LCK AXSOS ST T20 DRV SS NS -,SUP-371360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X70MM LCK AXSOS ST T20 DRV SS NS -,SUP-371370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X75MM LCK AXSOS ST T20 DRV SS NS -,SUP-371375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X80MM LCK AXSOS ST T20 DRV SS NS -,SUP-371380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X90MM LCK AXSOS ST T20 DRV SS NS -,SUP-371390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X95MM LCK AXSOS ST T20 DRV SS NS -,SUP-371395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LCK 4.0 X 14 -,SUP-371514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X16MM LCK AXSOS ST T15 DRV SS NS -,SUP-371516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X20MM LCK AXSOS ST T15 DRV SS NS -,SUP-371520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X22MM LCK AXSOS ST T15 DRV SS NS -,SUP-371522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X24MM LCK AXSOS ST T15 DRV SS NS -,SUP-371524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X26MM LCK AXSOS ST T15 DRV SS NS -,SUP-371526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X28MM LCK AXSOS ST_T15 DRV SS NS PERIART -,SUP-371528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X30MM LCK AXSOS ST T15 DRV SS NS -,SUP-371530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X28MM LCK AXSOS ST.T15 DRV SS NS PERIART -,SUP-371532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X34MM LCK AXSOS ST T15 DRV SS NS -,SUP-371534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X36MM LCK AXSOS ST T15 DRV SS NS -,SUP-371536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X28MM LCK AXSOS ST-T15 DRV SS NS PERIART -,SUP-371538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS.PERIART -,SUP-371542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS_PERIART -,SUP-371544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X28MM LCK AXSOS ST T15 DRV SS NS-PERIART -,SUP-371546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X48MM LCK AXSOS ST T15 DRV SS NS -,SUP-371548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X50MM LCK AXSOS ST T15 DRV SS NS -,SUP-371550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X55MM LCK AXSOS ST T15 DRV SS NS -,SUP-371555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X60MM LCK AXSOS ST T15 DRV SS NS -,SUP-371560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X65MM LCK AXSOS ST T15 DRV SS NS -,SUP-371565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X28MM-LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X28MM.LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X80MM LCK AXSOS ST T15 DRV SS NS -,SUP-371580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X28MM_LCK AXSOS ST T15 DRV SS NS PERIART -,SUP-371585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X95MM LCK AXSOS ST T15 DRV SS NS -,SUP-371595,CDM,C1713,HCPCS,278,RC,,,outpatient,,,627.85,439.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEPIN ORTHO 2.4MM -,SUP-373-0224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BIT DRILL 6MM BN -,SUP-3815-1-660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,371.28,259.896,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER THORLUM 12X14X6MM COALITION 0DG -,SUP-384.006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER THORLUM 12X14X8MM COALITION 0DG -,SUP-384.008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEPIN ORTHO 2.8MMX23CM THRD TIP -,SUP-3861-0-628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,82.92,58.044,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WASHER ORTHO 13MM ASNIS III 6.5/8.0MM SS RND NS -,SUP-390016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,182.99,128.093,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WASHER ORTHO 4MM ASNIS III F/4MM BN SCR SS RND NS -,SUP-390018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,132.57,92.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WASHER ORTHO 4.1MM ASNIS III F/9MM BN SCR SS RND NS -,SUP-390019,CDM,C1713,HCPCS,278,RC,,,outpatient,,,145.64,101.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
REDUCTION PIN 4.5MM DIA 150MM -,SUP-390082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,624.75,437.325,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUT 5.5MM ZIP PEEK #2 SUT FORCE FIB NDL -,SUP-3910-200-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUT 5.5MM ZIP PEEK #2 SUTX2 FORCE FIB -,SUP-3910-200-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUT 5.5MM ZIP PEEK #2 SUTX2 FORCE FIB -,SUP-3910-200-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUT 6.5MM ZIP PEEK #2 SUTX2 FORCE FIB 1/2CIR TAPR NDL -,SUP-3910-200-070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUT 6.5MM ZIP PEEK #2 SUTX2 FORCE FIB -,SUP-3910-200-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1243.6,870.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUT INTRALINE 4.5MM HA/PLLA COMP BIOSTEON SUTX2 W/O -,SUP-3910-200-080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2648.5,1853.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUT TWINLOOP 3.5MM ZIP PEEK #2 SUT FORCE FIB -,SUP-3910-400-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1151.37,805.959,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUT TWINLOOP 3.5MM ZIP PEEK #2 SUTX2 FORCE FIB EYLT -,SUP-3910-400-235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2055.64,1438.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUT ICONIX 2.3MM PILOT HL 3 STRN #2 FORCE FIB PLYSTR -,SUP-3910-500-532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2376.27,1663.389,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAP PROT STRL F/2.5MM K-WR -,SUP-392.240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5.72,4.004,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAP ORTHO -,SUP-393.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11.67,8.169,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAP PROT F/11MM CFBR EXTFIX ROD -,SUP-394.970,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5.02,3.514,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAP PROT F/4.0MM CRBN FIBRE BAR ROD BLK -,SUP-394.990,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5.43,3.801,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAP PROT NS F/4MM FX PIN YEL -,SUP-394.991,CDM,C1713,HCPCS,278,RC,,,outpatient,,,28.24,19.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
HYDROSET HA BONE SUB 3CC -,SUP-397003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4410.87,3087.609,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
HYDROSET BONE SUB 15CC -,SUP-397015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17072.08,11950.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 150MM POLARUS 3 PROX HUM LCK -,SUP-4001-1015R-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10270.16,7189.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3X90MM COMPR DL -TRAK CUT FLUT TI ALY NS -,SUP-40-0137,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6336.29,4435.403,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SUBSTITUTE CANC 30ML CHP FRZDR VOID FIL 1.7-10MM -,SUP-400150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1681.8,1177.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GRAFT HUM TIS WDG FRZDR 10-17 MMX14-20MM TRCORT ILC CRST -,SUP-400405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4361,3052.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTEX TI SLF TPNG 2.4 X 10 T8 SD REC -,SUP-401.760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,656.44,459.508,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTEX TI SLF TPNG 2.4 X 14 T8 SD REC -,SUP-401.764,CDM,C1713,HCPCS,278,RC,,,outpatient,,,656.44,459.508,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTEX TI SLF TPNG 2.4 X 30 T8 SD REC -,SUP-401.780,CDM,C1713,HCPCS,278,RC,,,outpatient,,,656.44,459.508,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SMALL CALCANEOUS FOOT -,SUP-40-10102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2915.48,2040.836,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE CALCANEUS SMALL STANDARD -,SUP-40-10112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2915.48,2040.836,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE CALCANEUS STANDARD LARGE -,SUP-40-10116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2915.48,2040.836,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 36MM 2.7MM 4HL RECON POLYAX LCK TI NS -,SUP-40-15011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2418.35,1692.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CURVED PLATE 5 HOLES RIGHT -,SUP-40-15012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.07,1837.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 49MM 2.7MM 6HL RECON POLYAX LCK TI NS -,SUP-40-15014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2657.78,1860.446,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
H-PLATE SMALL -,SUP-40-15021,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2050.76,1435.532,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE MED-H -,SUP-40-15022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2610.76,1827.532,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE LARGE -,SUP-40-15023,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2451.75,1716.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
RECTANGLE PLATE SZ 1 -,SUP-40-15032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2451.75,1716.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 48MM 2.7/3.5MM 5HL 1MM RECON POLYAX LCK TI -,SUP-40-15041,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2439.24,1707.468,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
VARIAX FOOT PLATE -,SUP-40-15042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2547.84,1783.488,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 51MM 2.7/3.5MM 6HL 1MM RECON POLYAX LCK TI -,SUP-40-15062,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2785.68,1949.976,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 35MM 2.7MM 4HL RECON POLYAX LCK TI NS -,SUP-40-15081,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1737.5,1216.25,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2MMX8MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2MMX9MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2MMX10MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2MMX11MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2MMX12MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2MMX13MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2MMX14MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2MMX15MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2MMX16MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS BLU -,SUP-40-20116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2MMX18MM CANN ASNIS 5MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2MMX20MM CANN ASNIS 5MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2MMX22MM CANN ASNIS 5MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2MMX24MM CANN ASNIS 6MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2MMX26MM CANN ASNIS 6MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2MMX28MM CANN ASNIS 6MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-20128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 28.5MM 2MM 2HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20802,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 60MM 2MM 4HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1910.88,1337.616,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 72MM 2MM 5HL 2MM PRCONT POLYAX TI STR SMRTLC -,SUP-40-20805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 84MM 2MM 6HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20806,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 96MM 2MM 7HL 2MM PRCONT POLYAX TI STR SMRTLC -,SUP-40-20807,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 108MM 2MM 8HL 2MM PRCONT POLYAX TI STR -,SUP-40-20808,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1743.81,1220.667,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 132MM 2MM 10HL 2MM PRCONT POLYAX TI STR -,SUP-40-20810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1812.72,1268.904,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 156MM 2MM 12HL 2MM PRCONT POLYAX TI STR -,SUP-40-20812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2549.91,1784.937,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WASHER ORTHO 2MM ASNIS MICRO F/CANN SCR SYS NS -,SUP-40-20900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,304.88,213.416,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 77MM 2MM 3HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.1,1787.87,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 89MM 2MM 4HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.1,1787.87,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 101MM 2MM 5HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.1,1787.87,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 113MM 2MM 6HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2388.81,1672.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 125MM 2MM 7HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2591.95,1814.365,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 137MM 2MM 8HL PRCONT POLYAX TI SMRTLC NS -,SUP-40-20908,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2591.95,1814.365,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 149MM 2MM 9HL 2MM PRCONT POLYAX TI SMRTLC NS -,SUP-40-20909,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2591.95,1814.365,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TOTAL JNT SUBCHONDROPLASTY -,SUP-402201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11788.78,8252.146,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X14MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X16MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X18MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NON-LOCKING 2.7 X 20MM -,SUP-40-27020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X22MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X24MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X26MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X28MM NLCKG VARIAX POLYAX ST T7 HX DRV TORX HEAD TI -,SUP-40-27028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE T7 2.7 X 38MM -,SUP-40-27038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE T7 2.7 X 40 -,SUP-40-27040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE T7 2.7 X 45MM -,SUP-40-27045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.03,231.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X12MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-2761,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X10MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X16MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X18MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X20MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X22MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X24MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X26MM LCK -,SUP-4027626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X28MM LCK VARIAX FT POLYAX T7 HX DRV TORX HEAD TI -,SUP-40-27628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3MMX8MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3MMX10MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3MMX12MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3MMX13MM CANN ASNIS 4MM THRD SLF CT REVCT FLUT TI NS -,SUP-40-30113,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3MMX14MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3MMX15MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3MMX16MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3MMX17MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
MICRO ASNIS SCREW 3.0MM X 18MM -,SUP-40-30118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3MMX18MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.48,659.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3MMX19MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30119,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3MMX20MM CANN ASNIS THRD REVCT FLUT TI NS PUR -,SUP-40-30120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3MMX22MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3MMX24MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3MMX26MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3MMX28MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3MMX30MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3MMX32MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3MMX34MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
3.0 MICRO ASNIS SCREW -,SUP-40-30134S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3MMX36MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3MMX40MM CANN ASNIS THRD SLF CT REVCT FLUT TI NS PUR -,SUP-40-30140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,941.42,658.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WASHER ORTHO 3MM ASNIS MICRO F/CANN SCR SYS NS -,SUP-40-30900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,339.01,237.307,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X10MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X12MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X14MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X16MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X18MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X20MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X22MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X24MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X26MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X28MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X30MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X32MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X34MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X36MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X38MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X40MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X42MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X44MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X46MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X48MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X50MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X55MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X60MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X65MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X70MM NLCKG VARIAX FT POLYAX ST T10 DRV TORX HEAD -,SUP-40-35070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.66,257.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X10MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X12MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X14MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X16MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X18MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X20MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X22MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X24MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X26MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
3.5MM LOCKING 28MM SCREW -,SUP-40-35628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
3.5MM LOCKING 34MM SCREW -,SUP-40-35634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X40MM LCK VARIAX POLYAX ST T10 DRV TORX HEAD TI NS -,SUP-40-35640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.92,508.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WASHER ORTHO F/3.5MM BN SCR -,SUP-40-35900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,376.01,263.207,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX28MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX36MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.836,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX38MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.838,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX55MM LCK COMPR CORT LCP FT ST HEX RCESS SM HEX -,SUP-404.855,CDM,C1713,HCPCS,278,RC,,,outpatient,,,159,111.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW EXHAL SZ 8-32X.375 -,SUP-4-072623-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6.48,4.536,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEPIN ORTHO 2.4MMX23CM -,SUP-410236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,407.52,285.264,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SET SCREWS MARINER SPINE -,SUP-41-1010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
POLYAXIAL HEAD G2 -,SUP-41-3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
HEAD SCREW SEASPINE MARINER POLY EXTEND -,SUP-41-4010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
30MM OFFSET -,SUP-41-4130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLUG CEMENT SMALL DIA 10MM -,SUP-414994,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLUG CEMENT SMALL DIA 12MM -,SUP-414995,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE SCREW 5.5 X 30MM -,SUP-41-5530-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
MARINER SOLD SCREW 5.5 X35MM -,SUP-41-5535-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SEASPINE MARINER SOLID 5.5MM X 35MM -,SUP-41-5535-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE SCREW 5.5 X 40 -,SUP-41-5540-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5 X 45MM -,SUP-41-5545-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SEASPINE MARINER SOLID 6.5MM X 35MM -,SUP-41-6535-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE SCREW 6.5 X 45MM -,SUP-41-6545-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7.5 X 70MM -,SUP-41-7570-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEPIN ORTHO TRUMATCH RT -,SUP-420901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6242.92,4370.044,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEPIN ORTHO TRUMATCH LT -,SUP-420902,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4990.94,3493.658,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEPIN SZ5 ATTUNE TRUMATCH LT KN -,SUP-420945,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE CRANFC 100X100MM MATRIXNEURO LPRO MSH 0.6MM TI SQ -,SUP-421.534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8428.58,5900.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X26MM LCK CANN SD 3.5MM HEX RCESS CNCL HEAD TI NS -,SUP-422.392,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1537.15,1076.005,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X55MM LCK CANN SD 3.5MM HEX RCESS CNCL HEAD TI NS -,SUP-422.394,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1515.94,1061.158,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X65MM LCK CANN SD 3.5MM HEX RCESS CNCL HEAD TI NS -,SUP-422.395,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1515.94,1061.158,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BEARING FIXED ASF UC 14MM PLY R 4-11 EF PERSONA -,SUP-42-5212-005-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SYSTEM KNEE PERSONA ASF UC 35MM PLY R 7-12 GH 9.0 THICKNESS -,SUP-42-5400-000-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE CURVED PELVIC R 108MM/L58.5MM/4HOLE -,SUP-425604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE CURV PELV R 108MM L74.5MM 5 HOLE -,SUP-425605,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 8 HOLE -,SUP-425608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
10 HOLE PLATE -,SUP-425610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE CURV. PELV 108MM/L186.5MM/12H -,SUP-425612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE PELV CURV R 108MM L218.5MM 14HOLE -,SUP-425614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE PELV CURV R 108MM L250.5MM 16 HOLE -,SUP-425616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5273.81,3691.667,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE PELV CURV R 108MM L282.5MM 18H -,SUP-425618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5273.81,3691.667,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE PELV CURV R 108MM L314.5MM 20H -,SUP-425620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5273.81,3691.667,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SYMPYSIS -,SUP-425654,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 10.5MMX74.5MM F/3.5MM/4.5MM SCR 4HL MATTA SS 88MM -,SUP-425655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 6 HOLE R88 PELVIS -,SUP-425656,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 8HOLE R88 -,SUP-425658,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE PELV CURVED R 88MM/L154.5MM/10H -,SUP-425660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE R88 12 HOLE -,SUP-425662,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE R88 CURVED 218.5 14 HOLE -,SUP-425664,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 16 HOLE R88 PELVIS -,SUP-425666,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE PELV CURV R 88MM L282.5 18H -,SUP-425668,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE PELV CURV R 88MM L314.5MM 20H -,SUP-425670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4804.59,3363.213,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE PELV STRAIGHT L 26.5MM -,SUP-425702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4046.3,2832.41,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PELVIC PLATE -,SUP-425753,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4676.37,3273.459,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE STRT ACET L 46.5MM 14 HOLE -,SUP-425754,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4676.37,3273.459,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE STRAIGHT ACET L 70.5M 6 HOLE -,SUP-425756,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4571.81,3200.267,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 8HOLE FLEX -,SUP-425758,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4571.81,3200.267,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 10 HOLE FLEX -,SUP-425760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4571.81,3200.267,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE STRT ACET L 142.5MM 12 HOLE -,SUP-425762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5044.63,3531.241,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SYMPHYSIS 4 HOLE -,SUP-425794,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6110.34,4277.238,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE PRO SUPRAPECTINEAL QLS LEFT -,SUP-425912S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10025.77,7018.039,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
INFRAPECTINEAL PLATE SMALL QLS LEFT -,SUP-425932S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8017.17,5612.019,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN AXSOS 45MM 4MM 3HL LCK COMPR SS WAIST SM FRAG NS -,SUP-427003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,557.83,390.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN AXSOS 71MM 4MM 5HL LCK COMPR SS WAIST SM FRAG NS -,SUP-427005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,716.54,501.578,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN AXSOS 97MM 4MM 7HL LCK COMPR SS WAIST RND TAPR END -,SUP-427007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,716.54,501.578,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN AXSOS 110MM 4MM 8HL LCK COMPR SS WAIST RND TAPR END -,SUP-427008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,795.89,557.123,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN AXSOS 123MM 4MM 9HL LCK COMPR SS WAIST SM FRAG STRL -,SUP-427009S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,795.89,557.123,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN AXSOS 136MM 4MM 10HL LCK COMPR SS WAIST RND TAPR -,SUP-427010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,795.89,557.123,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN AXSOS 266MM 4MM 20HL LCK COMPR SS WAIST SM FRAG NS -,SUP-427020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.32,779.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN AXSOS 48MM 4MM 4HL RECON LCK COMPR SS SM FRAG NS -,SUP-427034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1836.09,1285.263,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN AXSOS 60MM 4MM 5HL RECON LCK COMPR SS SM FRAG NS -,SUP-427035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1836.09,1285.263,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN AXSOS 72MM 4MM 6HL RECON LCK COMPR SS ADLT SM FRAG -,SUP-427036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2071.44,1450.008,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN AXSOS 96MM 4MM 8HL RECON LCK COMPR SS ADLT SM FRAG -,SUP-427038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2298.3,1608.81,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN AXSOS 76MM 3MM 6HL LCK SS 1/3 TBLR SM FRAG NS -,SUP-427066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,669.86,468.902,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN AXSOS 89MM 3MM 8HL LCK SS 1/3 TBLR SM FRAG NS -,SUP-427068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,725.87,508.109,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN AXSOS 169MM 5MM 9HL LCK COMPR SS NRW WAIST BSC FRAG -,SUP-427109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,898.59,629.013,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN AXSOS 223MM 5MM 12HL LCK COMPR SS NRW WAIST BSC -,SUP-427112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1075.97,753.179,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN AXSOS 259MM 5MM 14HL LCK COMPR SS NRW WAIST BSC -,SUP-427114S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1075.97,753.179,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE WSTD CMP BRD HL8 -,SUP-427138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN AXSOS 173MM 5MM 9HL LCK COMPR SS BRD WAIST BSC FRAG -,SUP-427139S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN AXSOS 263MM 5MM 14HL LCK COMPR SS BRD WAIST BSC ST -,SUP-427144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1159.75,811.825,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GRAFT HUM TIS HEMI FRZN 10-10.5 MMX8-13CM PTLR TNDN 30-75MM -,SUP-430007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11007.78,7705.446,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 10X60MM F/3.5MM/4MM SCR 5HL SHFT 2.8MM RECON -,SUP-430105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.67,1007.769,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 25MM 3MM 2HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,234.51,164.157,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 38MM 3MM 3HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,234.51,164.157,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 64MM 3MM 5HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,289.01,202.307,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 77MM 3MM 6HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,289.01,202.307,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 90MM 3MM 7HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.42,222.194,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 103MM 3MM 8HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,355.35,248.745,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 129MM 3MM 10HL NLCKG SS 1/3 TBLR SM FRAG NS CLLR -,SUP-430210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,355.35,248.745,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
MESH TITANIUM 6X6 - DISCONTINUED DO NOT USE -,SUP-43-1022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 10X49MM F/3.5MM/4.5MM SCR 0.75HL HD/SHFT 1.2MM SS -,SUP-431024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,634.85,444.395,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 10X66MM F/3.5MM/4.5MM SCR HLX3/6 HD/SHFT 1.2MM SS -,SUP-431026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,871.75,610.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
MOLD CMNT SPCR 48MM SIL SS STAGEONE STRL -,SUP-431181,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5199.96,3639.972,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
HIP HEAD CEMENT MOLD 52MM -,SUP-431182,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5199.96,3639.972,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SHOULDER MOLD 12STD 54 X 21 X 64 -,SUP-431412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11946.58,8362.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
60MM FEMORAL KNEE CEMENT MOLD -,SUP-432160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8413.73,5889.611,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
MOLD BNCMNT FEM 65MM SIL STAGEONE STRL -,SUP-432165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8413.73,5889.611,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 158MM 4.5MM 10HL RECON SS -,SUP-432210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1420.32,994.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE RECON HL 4.5 X 14 HOLE -,SUP-432214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.92,1168.944,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE T 6 HOLE L=111MM -,SUP-433106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.57,778.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
70MM TIBIAL KNEE CEMENT MOLD -,SUP-433170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4530.53,3171.371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
MOLD BNCMNT TIB 75MM SIL STAGEONE STRL -,SUP-433175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4530.53,3171.371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN AXSOS 86MM 4MM 3HL CONTR LCK SS NS 1STRN/PK -,SUP-437123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5167.49,3617.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN AXSOS 112MM 4MM 5HL CONTR LCK SS NS -,SUP-437125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5167.49,3617.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN AXSOS 95MM 4MM HLX2/5 SHFT/METPHYSL CONTR LCK SS NS -,SUP-437302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN AXSOS 121MM 4MM HLX4/5 SHFT/METPHYSL CONTR LT TIB -,SUP-437304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN AXSOS 147MM 4MM HLX6/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN AXSOS 121MM 4MM HLX4/5 SHFT/METPHYSL CONTR RT TIB -,SUP-437324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN AXSOS 173MM 4MM HLX8/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4513.92,3159.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN AXSOS 97MM 4MM HLX4/3 SHFT/METPHYSL CONTR LCK SS -,SUP-437424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4738,3316.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN AXSOS 166MM 5MM HLX6/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5434.02,3803.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN AXSOS 202MM 5MM HLX8/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN AXSOS 238MM 5MM HLX10/5 SHFT/METPHYSL CONTR LCK SS. -,SUP-437510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN AXSOS 310MM 5MM HLX14/5 SHFT/METPHYSL CONTR LCK SS- -,SUP-437514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN AXSOS 238MM 5MM HLX10/5 SHFT/METPHYSL CONTR LCK SS- -,SUP-437530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN AXSOS 310MM 5MM HLX14/5 SHFT/METPHYSL CONTR LCK SS. -,SUP-437534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN AXSOS 343MM 5MM HLX16/5 SHFT/METPHYSL CONTR LCK SS -,SUP-437536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5457.78,3820.446,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LINER 32X49MM EPSLN STD DRSUL PRIM HOOD -,SUP-4377-32-049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3174.71,2222.297,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SET SCREW SPIN STD FIREBIRD TI -,SUP-44-2001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FIREBIRD TOP LOADING HEAD -,SUP-44-2101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ORTHOFIX 4.5 X 30 SCREW -,SUP-44-5430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ORTHOFIX SCREW 4.5 X 35 -,SUP-44-5435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ORTHOFIX SCREW 4.5 X 40 -,SUP-44-5440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ORTHOFIX SCREW 4.5 X 45 -,SUP-44-5445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ORTHOFIX SCREW 5.5 X 30 -,SUP-44-5530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ORTHOFIX SCREW 5.5 X 35 -,SUP-44-5535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ORTHOFIX SCREW 5.5 X 40 -,SUP-44-5540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ORTHOFIX SCREW 5.5 X 45 -,SUP-44-5545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ORTHOFIX SCREW 6.5 X 30 -,SUP-44-5630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
6.5 X 35 SHANK -,SUP-44-5635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
6.5 X 40 SHANK -,SUP-44-5640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
6.5 X 45 SHANK -,SUP-44-5645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
7.5 X 40 SHANK -,SUP-44-5740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW FIREBIRD ORTHOFIX 7.5 X 45 -,SUP-44-5745,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ORTHOFIX SCREW 7.5 X 50 -,SUP-44-5750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ORTHOFIX SCREW 6.5 X 35 -,SUP-44-6535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ORTHOFIX SCREW 6.5 X 40 -,SUP-44-6540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WASHER 3.5 -,SUP-45-35900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,139.05,97.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
MICROCOIL EMBL 4MMX 5CML AZUR DTCH 18 -,SUP-45-480405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3570.95,2499.665,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
IMPLANT PHALANX 2MM PRO- TOE VO 13MM 10DG ANG -,SUP-45712010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
MINI STICK MAX 5FR X 10CM -,SUP-45-756,CDM,C1713,HCPCS,278,RC,,,outpatient,,,431.21,301.847,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COUNTERSINK FOR SCREWS 02.7/3.5mm AO FITTING -,SUP-45-80040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,516.4,361.48,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3X12MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115401200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3X16MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115401600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3X18MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115401800,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3X20MM HDLS HRBRT DBL THRD TIV STRL -,SUP-47115402000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1611.67,1128.169,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER SYSTEM CONSTRUX MINI PEEK -,SUP-47-3009SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2X10MM CORT SM HX DRV -,SUP-4820-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.04,88.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX24MM LCK CORT FT ST 2.5MM SM HEX RCESS SS -,SUP-48-3502-41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,160.11,112.077,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COUPLING DELTA ROD TO ROD MULTI 05/8/11 5MM PIN -,SUP-4922-1-015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4759.25,3331.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CLAMP 5 HOLE PIN -,SUP-4922-2-020-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3516.77,2461.739,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD VECTRAN COATED 11MM X 100MM CARBON CONN -,SUP-4922-8-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1854.96,1298.472,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WIRE BOLT SHORT -,SUP-4933-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,750.96,525.672,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WIRE BOLT MEDIUM -,SUP-4933-1-002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,750.96,525.672,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WIRE BOLT ADAPTER SHORT -,SUP-4933-1-004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1798.46,1258.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
M8 CONNECTING NUT -,SUP-4933-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,199.56,139.692,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
POST EXTERNAL FIXATION SHORT L44 MM OD8 MM HOFFMANN -,SUP-4933-1-644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,819.23,573.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BOLT FOR RING -,SUP-4933-1-702,CDM,C1713,HCPCS,278,RC,,,outpatient,,,220.56,154.392,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WASHER YELLOW 2MM -,SUP-4933-1-711,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.1,249.97,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CARBON FIBER FULL RING 210MM -,SUP-4933-5-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10863.87,7604.709,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CARBON FIBER OPEN RING 180MM -,SUP-4933-6-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9858.39,6900.873,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CARBON FIBER OPEN RING 210MM -,SUP-4933-6-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9316.66,6521.662,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WIRE WITH OLIVE 1.8 X 450 -,SUP-4933-8-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,850.74,595.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
K-WIRE 2.0 OLIVE -,SUP-4933-8-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,887.5,621.25,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
HII COMPACT MRI PERIARTICULAR PIN CLAMP -,SUP-4941-2-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1539.11,1077.377,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SYNMESH 15MM DIA 8MM HEIGHT ROUND CAGE -,SUP-495.361,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9527.78,6669.446,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
END RING 10MM DIAM / 0 DEG -,SUP-495.384,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1024.04,716.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SYNMESH 10MM DIAM 20MM HEIGHT -,SUP-495.603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9664.94,6765.458,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CRNMXF UPR FACE 1.2X5MM UNIVERSAL NEURO II ST TI NS -,SUP-50-12005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,372.97,261.079,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CRNMXF UPR FACE 1.2X10MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-12010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,372.97,261.079,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CRNMXF UPR FACE 1.2X12MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-12012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,372.97,261.079,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CRNMXF UPR FACE 1.2X3MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-12903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,417.55,292.285,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN WND CLSR 200MM -,SUP-5014-5-200S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,680.36,476.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CANC HALF-PIN 5MM SHAFT 6MM X 250 THREAD -,SUP-5015-7-250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CRNMXF MIDFC 1.7X6MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-17006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.31,222.117,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CRNMXF MIDFC 1.7X8MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-17008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.31,222.117,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CRNMXF MIDFC 1.7X10MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-17010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,317.31,222.117,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ER CRNMXF MIDFC 1.7X4MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-17304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,441.77,309.239,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LCK CRNMXF MIDFC 1.7X4MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-17504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,416.09,291.263,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LCK CRNMXF MIDFC 1.7X5MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-17505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,416.09,291.263,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
HALF PIN FX APEX 5MM SS HA CTD SD/TAP180MML 50MM THRD -,SUP-5017-5-180S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,642.67,449.869,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CRNMXF MIDFC 1.7X3MM CX PIN HD UNIVERSAL NEURO II SD -,SUP-50-17903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,356.29,249.403,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CRNMXF MIDFC 1.7X4MM CX PIN HD UNIVERSAL NEURO II ST. -,SUP-50-17904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,356.29,249.403,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN EXTFIX 5X150MM SS APEX 40MM THRD SD/ST -,SUP-5018-5-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
HALFPIN EXTFIX 5X150MM SS APEX 50MM THRD SD/ST -,SUP-5018-6-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN EXTFIX 5X50MM HLF SS APEX 180MM THRD SD -,SUP-5018-6-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CRNMXF MIDFC 1.9X3MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-19003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,348.64,244.048,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CRNMXF MAND 2X4MM CX PIN HD UNIVERSAL NEURO II ST TI -,SUP-50-20404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.62,210.434,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CRNMXF MAND 2X6MM CX PIN HD UNIVERSAL NEURO II ST TI -,SUP-50-20406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.62,210.434,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CRNMXF MAND 2X8MM CX PIN HD UNIVERSAL NEURO II ST TI -,SUP-50-20408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,300.62,210.434,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LCK CRNMXF MAND 2X12MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-20512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,551.06,385.742,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LCK CRNMXF MAND 2X14MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-20514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,551.06,385.742,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LCK CRNMXF MAND 2X16MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-20516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,551.06,385.742,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SELF DRILLING LOCKING 2 X 6MM -,SUP-50-20596,CDM,C1713,HCPCS,278,RC,,,outpatient,,,830.96,581.672,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN EXTFIX 6X200MM HLF SS APEX 70MM THRD SD/ST -,SUP-5021-8-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,563.49,394.443,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN EXTFIX 4X120MM SS APEX 30MM THRD SD/ST -,SUP-5023-3-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CRNMXF MAND 2.3X16MM CX PIN HD UNIVERSAL NEURO II ST -,SUP-50-23416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,367.43,257.201,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN EXTFIX 4X120MM HLF SS APEX 35MM THRD SD/ST -,SUP-5023-5-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN EXTFIX 4X150MM HLF SS APEX 50MM THRD SD/ST -,SUP-5023-6-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN EXTFIX 4X180MM SS HLF PIN APEX 50MM THRD SD/ST -,SUP-5023-6-180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,456.06,319.242,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN HYBRID APEX -,SUP-5026-8-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,591.79,414.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAP EXTFIX 5MM HOFFMN XPRESS 40MM THRD F/PIN TIP -,SUP-5027-1-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17.15,12.005,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ER CRNMXF MAND 2.7X12MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-27412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,416.21,291.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LCK CRNMXF MAND 2.7X10MM CX PIN HD UNIVERSAL NEURO II -,SUP-50-27510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,708.49,495.943,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD CONNECTING VECTRAN COATED CARBON 8MM X 400MM -,SUP-5028-8-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1100.81,770.567,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TRANSFIX PIN 4X300MM -,SUP-5030-4-300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
APEX TRANSFIX 4 X 250 PIN 5 X 50 THR -,SUP-5030-5-250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN EXTFIX 3X100MM TRNSFX SS APEX 25MM THRD SD/ST F/BILAT -,SUP-5038-2-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,329.79,230.853,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN EXTFIX 3X200MM TRNSFX SS APEX -,SUP-5045-5-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD HII COMPACT MRI CONNECTING 5MM X 65MM -,SUP-5048-5-065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
HII COMPACT MRI CONNECTING ROD 5MM X 100MM -,SUP-5048-5-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
HII COMPACT MRI CONNECTING ROD 5MM X 150MM -,SUP-5048-5-150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD HII COMPACT MRI CONNECTING 5MM X 200MM -,SUP-5048-5-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,405.18,283.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN TRANSFIXING 300MM 5/6 -,SUP-5050-4-300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,523.92,366.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN EXTFIX 5MM/4X300MM TRNSFX SS APEX 50MM THRD SD/ST -,SUP-5050-5-250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,623.82,436.674,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BLADE SAW 13X90MM OSCIL/SGTL 0.89MM -,SUP-506123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,460.97,322.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN EXTFIX 2X45MM SS APEX 20MM THRD ST -,SUP-5065-4-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,297.76,208.432,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CARBON CONNECTING ROD 3MMX120MM -,SUP-5079-6-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,290.23,203.161,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
HALFPIN EXTFIX 2X45MM SS U THRD DBL HLCL FLUT APEX 12MM P/T -,SUP-5080-2-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,346.77,242.739,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN 2MM X 45MM HALF HOFFMANN II APEX STAINLESS STEEL MICRO -,SUP-5080-2-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,346.77,242.739,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW POLY THRD 4.5X25MM CREO -,SUP-5119.1327,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW POLY THRD 5.5 4.5X30MM CREO -,SUP-5119.1330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CREO 5.5 4.5MM X 40MM POLYAXIAL SCREW -,SUP-5119.1340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CREO 5.5 4.5MM X 45MM POLYAXIAL -,SUP-5119.1345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5 X 40 POLYAXIAL CREO -,SUP-5119.1440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CREO THREADED 5.0 X 45MM POLYAXIAL SCREW -,SUP-5119.1447,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5 X 35 POLYAXIAL CREO -,SUP-5119.1535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5 X 40 POLYAXIAL CREO -,SUP-5119.1540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5X45MM CREO THRD PRASMB F/5.5MM TI STRL -,SUP-5119.1545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CREO THREADED 5.5 X 45MM POLYAXIAL SCREW -,SUP-5119.1547,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW POLYAXIAL 5.5 X 50 -,SUP-5119.1550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW POLYAXIAL 5.5 6.5 X 30 CREO -,SUP-5119.1630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X35MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.1635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X40MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.1640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X45MM CREO THRD PRASMB F/5.5MM TI STRL -,SUP-5119.1645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW POLYAXIAL CREO 6.5 X 50 -,SUP-5119.1650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CREO 5.5 6.5 X 60MM POLYAXIAL SCREW -,SUP-5119.1660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5-5.5X30MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5-5.5X35MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3337,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL CREO 5.5- 6.0-5.0X25MM -,SUP-5119.3427,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6-5X30MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.3432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6-5X35MM CREO THRD PRASMB F/5.5MM TI -,SUP-5119.3437,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5-6.5X30MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5-6.5X35MM CREO THRD PRASMB CORT F/5.5MM TI -,SUP-5119.3537,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CREO 5.5 5.5MM X 45MM CORTICAL -,SUP-5119.3547,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER CERV 14X6X12MM MOSAIC PEEK-OPTIMA -,SUP-51412-206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER CERV 14X7X12MM MOSAIC PEEK-OPTIMA -,SUP-51412-207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11436.04,8005.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
UNITED HIP CANCELLOUS LOCKING SCREW 6.5MM X 15MM -,SUP-5208-1015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
UNITED CANCELLOUS LOCKING SCREW 6.5 X 20 -,SUP-5208-1020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
UNITED CANCELLOUS LOCKING SCREW 6.5 X 25 -,SUP-5208-1025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
UNITED CANCELLOUS LOCKING SCREW 6.5 X 30 -,SUP-5208-1030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
UNITED HIP CANCELLOUS LOCKING SCREW 6.5MM X 35MM -,SUP-5208-1035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
UNITED CANCELLOUS LOCKING SCREW 6.5 X 45 -,SUP-5208-1045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD FIREBIRD 40MM ORTHOFIX -,SUP-52-2040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ORTHOFIX NXG 70 ROD -,SUP-52-2070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ORTHOFIX 80MM ROD -,SUP-52-2080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
90MM TI ROD STRAIGHT -,SUP-52-2090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
100MM TI ROD STRAIGHT -,SUP-52-2100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NXG 110MM ROD -,SUP-52-2110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD FIREBIRD 120MM TI STRAIGHT ORTHOFIX -,SUP-52-2120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD FIREBIRD STRAIGHT 140MM TI ORTHOFIX -,SUP-52-2140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD 160MM NXG DIA 5.5MM TI ORTHOFIX -,SUP-52-2160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ORTHOFIX ROD 180 -,SUP-52-2180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ORTHOFIX ROD 200MM -,SUP-52-2200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD HEX TITANIUM 400MM -,SUP-52-2450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD 35MM ORTHOFIX -,SUP-52-6035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
40MM ROD TI CURVED -,SUP-52-6040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD 45MM ORTHOFIX -,SUP-52-6045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ORTHOFIX ROD 50MM -,SUP-52-6050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ACTB 6.5X12MM OSTLOK -,SUP-5260-5-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ACTB 6.5X14MM OSTLOK -,SUP-5260-5-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ACTB 6.5X18MM OSTLOK -,SUP-5260-5-018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ACTB 6.5X30MM OSTLOK -,SUP-5260-5-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ACTB 6.5X35MM OSTLOK -,SUP-5260-5-035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ACTB 6.5X40MM OSTLOK -,SUP-5260-5-040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ACTB 6.5 X 45MM OSTLOK -,SUP-5260-5-045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ACTB 6.5X50MM OSTLOK -,SUP-5260-5-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ORTHOFIX ROD 55MM -,SUP-52-6055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ORTHOFIX NXG 60MM ROD -,SUP-52-6060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ORTHOFIX NXG 65MM ROD -,SUP-52-6065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ORTHOFIX 70MM ROD -,SUP-52-6070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ORTHOFIX 75MM ROD -,SUP-52-6075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ORTHOFIX 80 ROD -,SUP-52-6080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
OPEN CONNCETOR 5.5 - 5.5 -,SUP-52-6805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE CRANFC 12MM BAR UNIV NEURO III LPRO 2HL TI STR 1.5MM -,SUP-53-05212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,705.92,494.144,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE CRANFC 2HL 16MM BAR STR UNIV NEURO III 1.5MM TI NS -,SUP-53-05216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,844.97,591.479,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE CRANFC 4HL 28MM BAR 3D BX UNIV NEURO III 1.5MM TI NS -,SUP-53-05228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.88,735.616,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE CRANFC LRG 2HL 3D BX LEIBINGER UNIV NEURO 2 1.5MM TI -,SUP-53-05240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1443.7,1010.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE CRANFC 6MM BAR 4HL STR LEIBINGER UNIV NEURO 2 1.5MM TI -,SUP-53-05406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,702.42,491.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COVER CRANFC 7MM UNIV NEURO III LPRO TI -,SUP-53-05507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1211.85,848.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COVER CRANFC 10MM UNIVERSAL NEURO II LPRO TI NS -,SUP-53-05510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1211.85,848.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COVER CRANFC 14MM UNIVERSAL NEURO II LPRO TI NS -,SUP-53-05514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1211.85,848.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COVER CRANFC 20MM UNIVERSAL NEURO II LPRO TI NS -,SUP-53-05520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1338.06,936.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE CRANFC 8MM UNIV NEURO III LPRO 6HL TI DBL Y 1.5MM NS -,SUP-53-05608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1331.38,931.966,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE STR LP GAP SMALL -,SUP-53-05612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1587.66,1111.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE STR LP GAP LARGE -,SUP-53-05622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1748.42,1223.894,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE CRANFC 4HL X-SHP LEIBINGER UNIV NEURO 2 1.5MM TI NS -,SUP-53-05630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1344.26,940.982,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE CRANFC 8HL STR LEIBINGER UNIV NEURO 2 1.5MM TI NS W/O -,SUP-53-05804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.28,665.896,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE CRANFC 12MM 2HL UNIV NEURO III XTR RGD TI NS -,SUP-53-06212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,597.33,418.131,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL SFT TIS BIO- ABSB LPRO 1.5X20MM PLYLC ACD PLYMR KN -,SUP-531520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,798.11,558.677,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.7X5MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17005E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LCK 1.7 X 06 -,SUP-53-17006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,518.32,362.824,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.7X8MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.7X9MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LCK 1.7 X 10 -,SUP-53-17010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.83,308.581,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.7X12MM LCK VARIAX FT POLYAX ST VAR ANG BLNT TIP -,SUP-53-17012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LCK 1.7 X 16 -,SUP-53-17016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,440.72,308.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.7X16MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX -,SUP-53-20616E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2X18MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX NS -,SUP-53-20618E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2X20MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX NS -,SUP-53-20620E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2X22MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX NS -,SUP-53-20622E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.7X24MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX -,SUP-53-20624E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.7X26MM CX PIN HD LCK P/T SMTH T7 DRV TI VARIAX. -,SUP-53-20626E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X6MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X8MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X9MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X10MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X11MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23011E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X12MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X13MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23013E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X16MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X18MM LCK VARIAX THRD POLYAX ST VAR ANG BLNT TIP CX -,SUP-53-23018E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 2.3MM X 20MM -,SUP-53-23020E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.88,310.016,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 2.3 X 24 -,SUP-53-23024E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 2.3 X 26 -,SUP-53-23026E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.82,309.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X10MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23210E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X14MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23214E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X16MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23216E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X18MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23218E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X20MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23220E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X22MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23222E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X24MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23224E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X26MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23226E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X28MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23228E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X30MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23230E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X32MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23232E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X34MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23234E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X36MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23236E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X38MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23238E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X10MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23610E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X12MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23612E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X14MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT. -,SUP-53-23614E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X16MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23616E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X18MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT. -,SUP-53-23618E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X20MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23620E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X22MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23622E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X24MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23624E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X26MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23626E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X28MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23628E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X30MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23630E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X32MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23632E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X34MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23634E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X36MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23636E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X38MM LCK VARIAX FT POLYAX FA T7 STRDRV RCESS BLNT -,SUP-53-23638E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X16MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27116E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X18MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27118E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X20MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27120E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X22MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27122E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X24MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27124E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X26MM VARIAX P/T T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27126E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,444.92,311.444,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X10MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27210E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NON LOCK 2.7 X 12MM -,SUP-53-27212E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NON LOCK 2.7 X 14 -,SUP-53-27214E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X16MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27216E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X18MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27218E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X20MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27220E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X22MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27222E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X24MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27224E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X25MM NLCKG VARIAX FT T7 STRDRV RCESS BLNT TIP TI -,SUP-53-27226E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X10MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27610E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X12MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27612E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X14MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27614E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X16MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27616E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X18MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27618E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X20MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27620E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 2.7 X 22 -,SUP-53-27622E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X24MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27624E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X26MM LCK VARIAX T7 STRDRV RCESS BLNT TIP TI NS -,SUP-53-27626E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,457.46,320.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE MSH CRANFC MIDFC MICRO 60X120MM 0.1MM MLBL 1.2MM TI NS -,SUP-54-00261,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3755.99,2629.193,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
MICRO/MESH 120 X 120 X .2MM / GOLD -,SUP-54-00270,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8602.59,6021.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
MICRO/MESH 120 X 60 X .2MM / GOLD -,SUP-54-00271,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6438.15,4506.705,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BLUE DYNAMIC MESH  90X90MM 0.3MM MLBL 1.7MM TI NS -,SUP-54-00346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2066.2,1446.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOCKING SCREW 3.5MM T15 L40MM -,SUP-541540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1621.95,1135.365,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 60MMX1.5MM 2.7MM ANTMC POLYAX TI SMRTLC RT -,SUP-54-25290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 60MMX1.5MM 2.7MM ANTMC POLYAX TI SMRTLC LT -,SUP-54-25291,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE WIDE DORSAL RIGHT -,SUP-54-25292,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 60MMX1.5MM 2.7MM ANTMC POLYAX TI W SMRTLC -,SUP-54-25293,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4162.07,2913.449,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 81MMX1.5MM 2.7MM ANTMC POLYAX TI XLNG SMRTLC -,SUP-54-25295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4270.06,2989.042,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 56MM 2.7MM 9HL 2MM ANTMC POLYAX TI SMRTLC -,SUP-54-25374,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 76MM 2.7MM 2MM ANTMC POLYAX TI LNG NRW LT -,SUP-54-25375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 56MM 2.7MM 11HL ANTMC POLYAX TI STD SMRTLC -,SUP-54-25376,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 76MM 2.7MM 13HL 2MM ANTMC POLYAX TI STD LNG -,SUP-54-25377,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 56MM 2.7MM 9HL ANTMC POLYAX TI STD SMRTLC -,SUP-54-25384,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 76MM 2.7MM 2MM ANTMC POLYAX TI LNG NRW RT -,SUP-54-25385,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 56MM 2.7MM STD ANTMC TI SMRTLC -,SUP-54-25386,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4084.54,2859.178,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE VOLAR 76MM L 14 HOLE 2MM H STAN LONG RT -,SUP-54-25387,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4716.38,3301.466,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 53MM 2.7MM 2MM POLYAX TI MED/SHRT UNIV XLN -,SUP-54-25394,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3450.36,2415.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 53MM 2.7MM 2MM POLYAX TI SHRT UNIV STD -,SUP-54-25396,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3450.36,2415.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 53MM 2.7MM 2MM POLYAX TI SHRT UNIV W SMRTLC -,SUP-54-25398,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3450.36,2415.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 44MM 2.7MM 1MM ANTMC POLYAX TI SHRT NRW CLMN -,SUP-54-25400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 57MM 2.7MM ANTMC POLYAX TI LNG CLMN SMRTLC -,SUP-54-25401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 40MMX1MM FRAG SPEC POLYAX TI SHRT SMRTLC -,SUP-54-25402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 40MMX1MM 2.7MM FRAG SPEC POLYAX TI SHRT -,SUP-54-25403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 53MMX1MM FRAG SPEC POLYAX TI LNG SMRTLC -,SUP-54-25405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3041.71,2129.197,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 2.7 X 189 15 HOLE -,SUP-54-25420S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7093.08,4965.156,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 2.7 145 11 HOLES -,SUP-54-25424S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7093.08,4965.156,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 2.7MM XXL VOLAR L100MM 8 HOLE -,SUP-54-25428S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6203.58,4342.506,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE VOLAR XXL 7MM -,SUP-54-25442S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7093.08,4965.156,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 2.7MM XXL VOLAR NARROW 8 HOLE -,SUP-54-25444S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6203.58,4342.506,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 8 HOLES / 100MM / 2.7MM XXL -,SUP-54-25446S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6203.58,4342.506,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 3HL XSH NRW -,SUP-54-25573,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 8HL XSH -,SUP-54-25583,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN XSH -,SUP-54-25673,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 2X56MM 11HL INTMD ANTMC SHRT NS -,SUP-54-25674,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE INT LNG LEFT 14 HOLE -,SUP-54-25677,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4468.42,3127.894,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX F/DIST RAD SYS 10HL INTMD XSH -,SUP-54-25683,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 11HL INTMD SHRT -,SUP-54-25684,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 14HL INTMD LNG -,SUP-54-25687,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4468.42,3127.894,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX F/DIST RAD SYS 10HL STD XSH -,SUP-54-25773,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 10HL STD XSH -,SUP-54-25783,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4364.06,3054.842,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
RESTRICTOR BNCMNT FEM SZ3 13.25MM UHMWPE -,SUP-5460-14-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1026.96,718.872,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
RESTRICTOR BNCMNT FEM SZ3 15.75MM UHMWPE -,SUP-5460-16-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1150.21,805.147,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
RESTRICTOR FMCNL BNCMNT SZ5 18.25MM UHMWPE HIP -,SUP-5460-18-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1070.7,749.49,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE HYBRID MMP -,SUP-55-02950,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1731.83,1212.281,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE CRANFC UPR FACE 18HL 3D SHP UNIVERSAL NEURO II MLBL -,SUP-55-04218,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2608.27,1825.789,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE CRANFC UPR FACE HLX2X2 3D UNIVERSAL NEURO II MLBL -,SUP-55-04231,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.51,834.757,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE CRANFC UPR FACE HLX6X2 0.5MM 3D UNIV 2 MLBL 1.2MM TI -,SUP-55-04233,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2146.54,1502.578,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE UPR FACE 7HL 0.5MM DBL Y UNIVERSAL NEURO II MLBL 1.2MM -,SUP-55-04240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1128.37,789.859,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE CRANFC UPR FACE 24HL 0.5MM STR UNIV 2 MLBL 1.2MM TI NS -,SUP-55-04424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2500,1750,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE CRANFC MIDFC 20HL 0.55MM UNIV 2 MLBL 1.7MM TI NS BLU -,SUP-55-04720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2468.01,1727.607,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE CRANFC MIDFC 24HL 0.55MM STR UNIV 2 MLBL CNDSD 1.7MM -,SUP-55-04724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2554.85,1788.395,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE CRANFC MIDFC 7HL 0.6MM UNIVERSAL NEURO II STD 1.7MM TI -,SUP-55-05164,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.58,742.406,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE ORBT MIDFC 6HL CRV LEIBINGER UNIV 2 STD 1.7MM TI NS -,SUP-55-05188,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1255.9,879.13,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE LCK CRANFC MIDFC HL 2X2 0.8MM 3D SHP UNIVERSAL NEURO -,SUP-55-05731,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1390.43,973.301,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE CRANFC UPR FACE 8HL STR UNIVERSAL NEURO II STD 1.2MM -,SUP-55-06208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1389.47,972.629,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE CRANFC UPR FACE HLX2X2 3D SHP UNIVERSAL NEURO II STD -,SUP-55-06231,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.43,785.001,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
3D PLATE 6 X 2 HL UPPERFACE -,SUP-55-06233,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2014.51,1410.157,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
3D PLATE 6 X 6 HL UPPERFACE -,SUP-55-06235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4305.34,3013.738,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLT/7 HOLE DOUBLE Y UPPERFACE -,SUP-55-06240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1022.23,715.561,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE MIDFC 4HL STR UNIVERSAL NEURO II STD 1.7MM TI NS BAR -,SUP-55-06704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.58,457.506,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE CRANFC MIDFC 8HL STR UNIVERSAL NEURO II STD 1.7MM TI -,SUP-55-06708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1319.35,923.545,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE MIDFC 24HL STR UNIVERSAL NEURO II STD 1.7MM TI NS BAR -,SUP-55-06724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2527.07,1768.949,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE STR 2 X 2 3D -,SUP-55-06731,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1207.72,845.404,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE MIDFC 10HL UNIVERSAL NEURO II STD 1.7MM TI NS BAR GOLD -,SUP-55-06750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1390.43,973.301,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE MIDFC 4HL CRV UNIVERSAL NEURO II STD 1.7MM TI NS GOLD -,SUP-55-06754,CDM,C1713,HCPCS,278,RC,,,outpatient,,,804.35,563.045,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE RT CRANFC MIDFC 2MM 5HL 0.6MM LEIBINGER UNIVERSAL -,SUP-55-06761,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1100.48,770.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE RT CRANFC MIDFC 5MM 5HL 0.6MM UNIVERSAL NEURO II STD -,SUP-55-06763,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1133.97,793.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE LCK MAND MINI 4HL 1MM STR UNIVERSAL NEURO II 2MM TI NS -,SUP-55-10504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,513.89,359.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE LCK MAND MINI 6HL 8MM STR UNIVERSAL NEURO II 2MM TI NS -,SUP-55-10507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.51,834.757,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE 10MM VUSION TS -,SUP-551-5210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE CRANFC MAND 4HL STR UNIVERSAL NEURO II RECON FX 2MM TI -,SUP-55-15505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1918.09,1342.663,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLT/FRACTURE 6 HOLES W. BAR -,SUP-55-15507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2440.83,1708.581,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE 10 X 9 X 25 -,SUP-551-7410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
INSERT TIB BEARING SZ2 9MM TRIATHLON X3 CR ARTCSURF -,SUP-5530-C-209,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BEARING TIB INSERT CS 9MM SZ1 TRIATHLON X3 -,SUP-5531-G-109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BEARING TIB INSERT CS 10MM SZ 1TRIATHLON X3 -,SUP-5531-G-110-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BEARING TIB INSERT CS 11MM SZ 1 TRIATHLON X3 -,SUP-5531-G-111-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
INSERT TIBIAL BEARING  SZ. 5 / 11MM TYPE CS -,SUP-5531-G-511-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TIBIAL BEARING INSERT SZ.7 / CS / 11MM -,SUP-5531-G-711-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TIBIAL BEARING INSERT SZ.8 CS 9MM TRIATHLON X3 -,SUP-5531-G-809-E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
9MM INSERT TRIAL PS#3 -,SUP-5532-T-309,CDM,C1713,HCPCS,278,RC,,,outpatient,,,728.5,509.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COMPONENT TIBIAL TRITANIUM SZ 1 TRIATHLON -,SUP-5536-B-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ORTHOFIX CROSSLINK 25 -,SUP-55-5325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CONNECTOR ROD FIREBIRD 45MM CROSSLINK ORTHOFIX -,SUP-55-5345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
4.5MM PERIPHERAL SCREW 16MM -,SUP-5572-4516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
4.5MM PERIPHERAL SCREW 24MM -,SUP-5572-4524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
4.5MM PERIPHERAL SCREW 36MM -,SUP-5572-4536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
6.5MM CENTER SCREW 32MM -,SUP-5573-6532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4573.49,3201.443,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX MODULAR TRIATH -,SUP-5575-X-000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BONESCREW AXS ST 1.2 X 3MM 5P -,SUP-56-12003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BONESCREW - AXS ST 1.2 X 4MM 5P -,SUP-56-12004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BONESCREW AXS SD 1.2 X 3MM 5P -,SUP-56-12903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,636.37,445.459,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BONESCREW AXS SD 1.2 X 4MM 5P -,SUP-56-12904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,636.37,445.459,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE ER AXS ST 1.4 3MM 5P -,SUP-56-14003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,593.3,415.31,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BONESCREW AXS SD 1.7 X 4MM 5P -,SUP-56-17904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BONESCREW AXS SD 1.7 X 6MM 5P -,SUP-56-17906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,574.16,401.912,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GRAFT HUM TIS PTTY 1ML OSTEOSPARX SYR LF -,SUP-562-100-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X30MM CORT FT ST HEX HEAD -,SUP-5645-1-030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X32MM CORT FT ST HEX HEAD -,SUP-5645-1-032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X44MM CORT FT ST HEX HEAD -,SUP-5645-1-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X48MM CORT FT ST HEX HEAD -,SUP-5645-1-048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X50MM CORT FT ST HEX HEAD -,SUP-5645-1-050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X52MM CORT FT ST HEX HEAD -,SUP-5645-1-052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X54MM CORT FT ST HEX HEAD -,SUP-5645-1-054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.84,84.588,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
STEM EXTENSION CEMENTED 12X30MM -,SUP-565-1203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
MESH HYBRID MEDIUM MALL 90 X 90 X .3 BLUE -,SUP-56-90344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7015.12,4910.584,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PROFYLE 0.55MM 1.2MM 4HL STD PRCONT NLCKG TI XS STR -,SUP-57-05101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE PRF 1.7 X 4 HL -,SUP-57-05202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE PRF 1.7 X 6 HL LT L -,SUP-57-05221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE HAND -,SUP-57-05240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE PRF 1.7 X 7 HL T -,SUP-57-05260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1028.42,719.894,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PROFYLE 0.55MM 1.7MM 1HL PRX2 STD PRCONT NLCKG TI -,SUP-57-05285,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1307.9,915.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE PRF 1.7 X 3 X 2 3D -,SUP-57-05291,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1307.9,915.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE PRF 1.7 X 4X2 RP 3D -,SUP-57-05295,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1307.9,915.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE PRF 2.3 6 HL LT L -,SUP-57-10121,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2457.66,1720.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE PRF 2.3 X 6 HL NRW T -,SUP-57-10140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2457.66,1720.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PROFYLE 1MM 2.3MM 7HL SHFT PRCONT VAR ANG NLCKG TI -,SUP-57-10170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2457.66,1720.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE PRF 2.3 X 5HL ROT -,SUP-57-10185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2395.78,1677.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 1.5MM 1.7MM 10HL PRCONT VAR ANG TI SM NRW -,SUP-57-10310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 1.7 X 6 HL LT L -,SUP-57-10321,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 1MM 1.7MM 6HL PRCONT VAR ANG TI SM NRW T-SHP -,SUP-57-10340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 1.7 X 7 HL T -,SUP-57-10360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 1MM 1.7MM 5HL ROT PRCONT VAR ANG TI SM -,SUP-57-10380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 1MM 1.7MM HLX3X2 PRCONT VAR ANG TI SM 3D SHP -,SUP-57-10391,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PROFYLE 1MM 2.3MM 6HL PRCONT NLCKG COMPR TI MED STR -,SUP-57-10407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2921.69,2045.183,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PROFYLE 1MM 2.3MM 7HL PRCONT NLCKG COMPR TI MED Y -,SUP-57-10470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2921.69,2045.183,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PROFYLE 1.3MM 2.3MM 6HL SHFT PRCONT NLCKG COMPR TI -,SUP-57-13150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.06,784.742,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE HAND 2.3 LP 4 HOLE -,SUP-57-13402,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PROFYLE 1.3MM 2.3MM 5HL PRCONT NLCKG COMPR TI LRG -,SUP-57-13405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PROFYLE 1.3MM 2.3MM 6HL PRCONT NLCKG COMPR TI LRG -,SUP-57-13408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE T 1O HOLE NARROW COMPRESSION -,SUP-57-13442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1111.78,778.246,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 1.5MM 2.3MM 4HL PRCONT VAR ANG TI MED STR -,SUP-57-15301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 1.5MM 2.3MM 4HL_PRCONT VAR ANG TI MED STR -,SUP-57-15302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 1.5MM 2.3MM 16HL PRCONT VAR ANG TI MED -,SUP-57-15316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 1.5MM 2.3MM 4HL PRCONT VAR ANG TI MED SMRTLC -,SUP-57-15340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1552.2,1086.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 1.5MM 2.3MM 7HL PRCONT VAR ANG TI MED SMRTLC -,SUP-57-15370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE PROFYLE 2.3 X 13 HL NRWZ -,SUP-57-15379,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 1.5MM 2.3MM 5HL PRCONT VAR ANG TI MED SMRTLC -,SUP-57-15385,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2095.34,1466.738,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.2X5MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12005E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.2X6MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.2X7MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12007E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.2X8MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-12008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.2X14MM NLCKG VARIAX POLYAX ST VAR ANG BLNT TIP CX -,SUP-58-12014E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
MIDFOOT FUSION U-PLATE MD LT ORTHOLOC -,SUP-5817002L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5793.06,4055.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.7X8MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.7X9MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.7X10MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.7X11MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17011E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.7X12MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-17012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BONE SCREW 1.7 X 16MM STRYKER -,SUP-58-17016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE 2.3 X 6 -,SUP-58-23006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X8MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X9MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23009E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X10MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23010E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X11MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23011E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X12MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23012E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X13MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23013E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X14MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23014E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NL 2.3 X 15MM -,SUP-58-23015E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X16MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23016E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X20MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23020E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X24MM VARIAX FT POLYAX ST VAR ANG BLNT TIP CX PIN -,SUP-58-23024E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW EMERGENCY 2.5 X 6 -,SUP-58-25006E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW EMERGENCY 2.5 X 8MM CROSSPIN LEFT -,SUP-58-25008E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
MTP FUSIOIN MEDIUM 0DG RT ORTHOLOC 3DI PLATING SYSTEM -,SUP-587220RT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5046.12,3532.284,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING LG HD 2.7 X 12MM ORTHOLOC 3DI PLATING SYS -,SUP-58802712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING LG HD 2.7 14MM ORTHOLOCK 3DI PLATING SYS -,SUP-58802714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING LG HD  2.7 X 16MM ORTHOLOCK 3DI PLATING SYS -,SUP-58802716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOW PRO CORT 2.7 X 12MM ORTHOLOC SYS -,SUP-58812712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOW PRO CORT SCREW 2.7 X 14MM ORTHOLOC SYSTEM -,SUP-58812714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOW PRO CORT SCREW 2.7 X 16MM ORTHOLOC SYSTEM -,SUP-58812716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOW PRO CORT 2.7 X 18MM ORTHOLOC SYS -,SUP-58812718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOW PRO CORT SCREW 3.5 X 12MM ORTHOLOC SYSTEM -,SUP-58813512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOW PRO CORT SCREW 3.5 X 14MM ORTHOLOC SYSTEM -,SUP-58813514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOW PRO CORT SCREW 3.5 X 16MM ORTHOLOC SYSTEM -,SUP-58813516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NON LOCKING 3.5 X 18 -,SUP-58813518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOW-PRO CORT SCREW 3.5X22MM ORTHOLOC -,SUP-58813522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOW-PRO CORT SCREW 3.5X28MM ORTHOLOC -,SUP-58813528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOW-PRO CORT SCREW 3.5X34MM ORTHOLOC -,SUP-58813534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOW-PRO CORT SCREW 3.5X38MM ORTHOLOC -,SUP-58813538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WASHER ORTHO F/1.2MM SCR TI RND FLT HEAD NS -,SUP-59-12049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.24,105.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WASHER ORTHO F/1.7MM/1.9MM TI RND BN SCR TITIANIUM FLT EDGE -,SUP-59-17049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.24,105.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X10MM CORT PROFYLE ST CX PIN HD TI GOLD -,SUP-59-23010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 16MM -,SUP-59-23016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 18MM -,SUP-59-23018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 20MM -,SUP-59-23020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.28,250.096,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WASHER ORTHO F/2.3MM SCR TI RND FLT HEAD NS -,SUP-59-23049,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.24,105.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 32.3MM COMPR OMEGA3 SS STRL -,SUP-596001S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,329.09,230.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
STANDARD BARRELL HIP PLATE- 130DEG- 2 HOLES -,SUP-597002S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2817.14,1971.998,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN OMG 3 63MM 3HL STD BRL LCK COMPR SS 135DG ANG KY -,SUP-597023S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE HIP STD BARREL 4 HOLE KEYED 135DEG -,SUP-597024S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
HIP PLATE OMEGA 3 STD BARREL KEYED 135 DEG 6 HOLES -,SUP-597026S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE HIP STD BARREL 3 HOLE KEYED 140DEG -,SUP-597043S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE HIP STD BARREL 4 HOLE KEYED 145DEG -,SUP-597064S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE EXTFIX STD 47MM SS HIP 135DG ANG OMEGA3 KYLS BRL -,SUP-597122S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN OMG 3 79MM 4HL STD BRL LCK COMPR SS 135DG ANG KYLS -,SUP-597124S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN OMG 3 95MM 5HL STD BRL LCK COMPR SS 150DG ANG KYLS -,SUP-597185S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2816.66,1971.662,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN OMG 3 79MM 4HL SHRT BRL LCK COMPR SS 135DG ANG KYLS -,SUP-597264S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2470.03,1729.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE ANT CERV 12MM BAK HOL CHMFR EDGE 8MM TI -,SUP-6000-0812-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DEVICE ANT CERV 12MM BAK/ C HOL CHMFR EDGE 10MM TI -,SUP-6000-1012-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14295.05,10006.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GW ORTHO 2MM TOEMOTION MRH AXLE -,SUP-6007-1200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN DSTRCT 12MM ASSURE -,SUP-601.012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ASNIS III CANN SCREW 5 X 28MM -,SUP-601628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS TI 5.0 X 30MM -,SUP-601630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ASNIS III CANN SCREW 5 X 32MM -,SUP-601632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS III CANN P/T 5.0MM X 42MM -,SUP-601642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS III CANN 5.0 X 44MM -,SUP-601644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE ASNIS PT 5 X 46 -,SUP-601646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS PT 5.0 X 48 -,SUP-601648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5MMX50MM CANN ASNIS III 17MM P/T SD/ST REVCT FLUT TI -,SUP-601650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5MMX55MM CANN ASNIS III 18.5MM P/T SD/ST REVCT FLUT TI -,SUP-601655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5MMX75MM CANN ASNIS III 27MM P/T SD/ST REVCT FLUT TI -,SUP-601675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5MMX80MM CANN ASNIS III 27MM P/T SD/ST REVCT FLUT TI -,SUP-601680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW FULLY THREADED 5MM X 38MM -,SUP-601738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW FULLY THREADED 5MM X 40MM -,SUP-601740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW FT 5MM X 42MM TITANIUM CANNULATED -,SUP-601742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS FT 5 X 44 -,SUP-601744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANNULATED 5 X 50 -,SUP-601750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANNULATED 5 X 55 -,SUP-601755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW FULLY THREADED 5 X 60 -,SUP-601760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANN HEADED 5.0 X 65MM ASNIS -,SUP-601765,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANNULATED 5MM X 70MM -,SUP-601770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1112.15,778.505,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANN TI 6.5 X 60MM -,SUP-602660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS TI TL20 6.5 X 65MM -,SUP-602665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANN TI 6.5 X 70MM -,SUP-602670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MMX75MM CANN ASNIS III 20MM THRD SD/ST HEX DRV -,SUP-602675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANN TI 6.5 X 80MM -,SUP-602680,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MMX80MM CANN ASNIS III 20MM THRD SD/ST HEX DRV -,SUP-602680S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANN ASNIS TI 6.5 X 85MM -,SUP-602685,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MMX90MM CANN ASNIS III 20MM THRD SD/ST HEX DRV NS -,SUP-602690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MMX90MM CANN ASNIS III 20MM THRD SD/ST HEX DRV STRL -,SUP-602690S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MMX95MM CANN ASNIS III 20MM THRD SD/ST HEX DRV NS -,SUP-602695,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.58,802.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MMX95MM CANN ASNIS III 20MM THRD SD/ST HEX DRV STRL -,SUP-602695S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MMX100MM CANN ASNIS III 20MM THRD SD/ST HEX DRV -,SUP-602700,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW TI CANNULATED 6.5 X 105MM ASNIS -,SUP-602705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANNULATED TI 6.5X 110MM -,SUP-602710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS TI TL20 6.5 X 115 -,SUP-602715,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS TI TL40 6.5 X 60 -,SUP-602860,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS TI TL40 6.5 X 65 -,SUP-602865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS 6.5 X 70MM -,SUP-602870,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS TI TL40 6.5 X 75MM -,SUP-602875,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS TI CANNULATED 6.5 X 80MM -,SUP-602880,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS TI TL40 6.5 X 85 -,SUP-602885,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW TI 6.5 X 90MM ASNIS TL40 CANNULATED -,SUP-602890,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS TI TL40 6.5 X 95 -,SUP-602895,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS TI TL40 6.5 X 100 -,SUP-602900,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS TI CANNULATED 6.5 X 105MM -,SUP-602905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.07,795.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX28MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE CAN TI 4.0 X 30MM -,SUP-604630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX32MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
4.0 X 34MM ASNIS CANN SCREW -,SUP-604634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX34MM CANN ASNIS III 11.5MM P/T SD/ST REVCT FLUT TI -,SUP-604634S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE CAN PT 4.0 X 36 -,SUP-604636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX38MM CANN ASNIS III -,SUP-604638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX40MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX40MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY -,SUP-604640S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX42MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX44MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX46MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE CAN PT 4.0 X 48 -,SUP-604648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX50MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX50MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY -,SUP-604650S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX55MM CANN ASNIS III 18.5MM P/T SD/ST REVCT FLUT TI -,SUP-604655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX55MM CANN ASNIS III 18.5MM.P/T SD/ST REVCT FLUT TI -,SUP-604655S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT TI- -,SUP-604660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT TI- -,SUP-604660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX60MM CANN ASNIS III 20MM P/T SD/ST REVCT FLUT TI_ -,SUP-604660S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX65MM CANN ASNIS III 22MM P/T SD/ST REVCT FLUT TI -,SUP-604665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX65MM CANN ASNIS III 22MM P/T SD/ST REVCT FLUT TI -,SUP-604665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX70MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY NS -,SUP-604670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX70MM CANN ASNIS III P/T SD/ST REVCT FLUT TI ALY -,SUP-604670S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX40MM CANN ASNIS III FT SD/ST REVCT FLUT TI ALY NS -,SUP-604740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS III TI 4.0 X 42MM -,SUP-604742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANN FT 4.0 X 44MM -,SUP-604744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MMX50MM CANN ASNIS III FT SD/ST REVCT FLUT TI ALY NS -,SUP-604750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW TI SELF TAP CORTICAL 2.7MM X 22MM -,SUP-605022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.06,81.242,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW TI SELF TAP CORTICAL 2.7MM X 26MM -,SUP-605026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.06,81.242,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW TI SELF TAP CORTICAL 2.7MM X 28MM -,SUP-605028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.06,81.242,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW TI ASNIS III CANNULATED 6.5 X 85MM -,SUP-606085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 90 -,SUP-606090S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS CANNULATED FULLY THREADED 6.5 X 95 -,SUP-606095S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANNULATED FULLY THREADED 6.5 X 100 -,SUP-606100S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANNULATED FULLY THREADED 6.5 X 110 -,SUP-606110S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1157.08,809.956,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANCELLOUS FT 4 X 14 -,SUP-607314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANCELLOUS FT 4.0 X 16 -,SUP-607316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X18MM CANC FT TI -,SUP-607318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANCELLOUS 4.0 X 20 -,SUP-607320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X22MM CANC FT TI -,SUP-607322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X24MM CANC FT TI -,SUP-607324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANCELLOUS 4.0 X 26MM -,SUP-607326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANCELLOUS 4.0 X 28MM -,SUP-607328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANCELLOUS 4.0 X 32MM -,SUP-607332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X34MM CANC FT TI -,SUP-607334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X36MM CANC FT TI -,SUP-607336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X38MM CANC FT TI -,SUP-607338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X40MM CANC FT TI -,SUP-607340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.0 X 42MM CANC FT TI -,SUP-607342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANN TI 4.0 X 48MM FULL -,SUP-607348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
4.0 CANCELLOUS SCREW 50MM FULLY THREADED -,SUP-607350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANCELLOUS 4.0 X 50MM -,SUP-607350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.0 X 55MM CANC FT TI -,SUP-607355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X60MM CANC FT TI -,SUP-607360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X65MM CANC FT TI -,SUP-607365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X70MM CANC FT TI -,SUP-607370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANCELLOUS FT 4.0 X 14MM STRYKER -,SUP-607414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANCELLOUS PT 4 X 16 -,SUP-607416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANCELLOUS PT 4 X 20 -,SUP-607420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X36MM CANC 16MM THRD TI -,SUP-607436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X38MM CANC 16MM THRD TI -,SUP-607438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X44MM CANC 16MM THRD TI -,SUP-607444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X46MM CANC 16MM THRD TI -,SUP-607446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X50MM CANC 16MM THRD TI -,SUP-607450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X65MM CANC 16MM THRD TI -,SUP-607465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X70MM CANC 16MM THRD TI -,SUP-607470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANC 6.0MM X 20MM  FULL THREAD -,SUP-608020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANCELLOUS 6 X 25 -,SUP-608025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CAN FT 6.0 X 35 -,SUP-608035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANCELLOUS 6.0 X 40MM -,SUP-608040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6X45MM CANC FT TI -,SUP-608045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.0MM X 50MM CANCELLOUS FULL THREAD -,SUP-608050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6X60MM CANC FT TI -,SUP-608060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL 3.5 X 60 FT -,SUP-608070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6X75MM CANC FT TI -,SUP-608075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6X80MM CANC FT TI -,SUP-608080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANCELLOUS FT 6.0 X 85 -,SUP-608085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CAN TL 16 6.0 X 35 -,SUP-608235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CAN TL 16 6.0 X 75 -,SUP-608275,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CAN TL 16 6.0 X 80 -,SUP-608280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANCELLOUS 6.0MM 90MM -,SUP-608290,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6X70MM CANC 32MM THRD TI -,SUP-608470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6X80MM CANC 32MM THRD TI -,SUP-608480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6X85MM CANC 32MM THRD TI -,SUP-608485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,228.73,160.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6MM CANCELLOUS TI 6.0MM L90 TL32MM -,SUP-608490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,304.82,213.374,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS TI TL25 8.0 X 70MM -,SUP-611070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CANNULATED SCREW 8.0 X 75MM TI -,SUP-611075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
8.0 X 80MM TI CANNULATED SCREW -,SUP-611080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS TI TL25 8.0 X 85MM -,SUP-611085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ANSIS TI TL25 8.0 X 90MM -,SUP-611090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1090.84,763.588,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X8MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614508,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X12MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X14MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X16MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X18MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.7 X 20MM LOCKING SCREW -,SUP-614520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X22MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING T10 2.7 X 24MM -,SUP-614524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X26MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7 LOCKING ST 28 -,SUP-614528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X30MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7 LOCKING ST 34 -,SUP-614534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X36MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X38MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X40MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X55MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X60MM LCK VARIAX THRD POLYAX ST T10 DRV TI ALY NS -,SUP-614560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X8MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X10MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X12MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X14MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X16MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X18MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X20MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X22MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X24MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X26MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 3.5 X 28MM -,SUP-614628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X30MM LOCKING -,SUP-614630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X32MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
36MM 3.5 LOCKING SCREW -,SUP-614636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5 LCK ST 38 -,SUP-614638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5 X 40MM LOCKING -,SUP-614640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X42MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X44MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5 LCK ST 48 -,SUP-614648,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X50MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE OLECRANON LEFT 8 HOLE -,SUP-614655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 3.5 X 55MM T10 -,SUP-614655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X60MM LCK VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614660,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 3.5 X 65MM -,SUP-614665,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 3.5 X 70MM -,SUP-614670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X8MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X12MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X14MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X16MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X18MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X20MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X22MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X24MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7 NON LOCKING ST 26 -,SUP-614726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X32MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614732,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X34MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X36MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X38MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X40MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7 NONLCK ST 44 -,SUP-614744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7 NONLOCKING ST 46 -,SUP-614746,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X55MM VARIAX THRD POLYAX ST T10 DRV TI ALY NS GOLD -,SUP-614755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE T10 2.7 X 60MM -,SUP-614760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X8MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614808,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X10MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X12MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614812,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X14MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X16MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X18MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X20MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X22MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614822,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X24MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X26MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X28MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X30MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614830,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X32MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X34MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614834,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X36MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614836,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5 NONLCK ST 38 -,SUP-614838,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X40MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614840,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X42MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614842,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5 X 44 NONLOCK -,SUP-614844,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
46MM 3.5 SCREW -,SUP-614846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5 NONLOCK ST 46 -,SUP-614846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE 3.5 X 48MM NON-LOCK -,SUP-614848,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X50MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614850,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X60MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614860,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5 NONLOCK ST 65 -,SUP-614865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X70MM NLCKG VARIAX FT POLYAX ST T10 DRV TI ALY NS -,SUP-614870,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BONE CEMENT SIMPLEX -,SUP-6191-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,431.79,302.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CEMENT BONE SIMPLEX P -,SUP-6191-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BONE CEMENT SPEEDSET SIMPLEX P FULL DOSE -,SUP-6192-1-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,431.79,302.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CEMENT SIMPLEX SPEED SET -,SUP-6192-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CEMENT BONE SIMPLEX HV -,SUP-6194-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CEMENT BONE SIMPLEX GENTAMICIN -,SUP-6195-1-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CEMENT BONE SIMPLEX TOBRAMYCIN -,SUP-6197-9-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WASHER ORTHO ASNIS III F/6.5/8MM BN SCR TI RND -,SUP-619904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,157.55,110.285,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WASHER ORTHO ASNIS III 4MM TI RND -,SUP-619905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,122.54,85.778,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WASHER ORTHO 5MM ASNIS III 5MM TI RND -,SUP-619906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,153.64,107.548,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WASHER FOR 2.3MM BONE SCREWS -,SUP-619915,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.91,88.837,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
Washer T8 & T10 Scrws 2.4/2.7/3.5 -,SUP-619920,CDM,C1713,HCPCS,278,RC,,,outpatient,,,124.4,87.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WASHER 19 FOR SCREWS 6.5/8.0MM -,SUP-619990,CDM,C1713,HCPCS,278,RC,,,outpatient,,,882.25,617.575,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
STIMULAN 5CC -,SUP-620-005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
STIMULAN 10CC -,SUP-620-010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SPIN 12MM ASPEN -,SUP-6201-0012-001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN ASPEN 14MM -,SUP-6211-0014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,26874.69,18812.283,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 10HL TI -,SUP-621410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7788.16,5451.712,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLUG BONE H MED 25 -,SUP-6215-5-011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
MIS CALCANEAL PLATE S7 7 HOLES -,SUP-622102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
MIS CALCANEAL PLATE M8 8 HOLE -,SUP-622104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
INSERT 10 DEG POLYETHYLENE 32MM D TRIDENT X3 -,SUP-623-10-32D,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BONE SCREW 6.5X30 SELF-TAP -,SUP-6250-65-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ONE-THIRD TUBULAR PLATE 2 HOLE / L23MM -,SUP-626672,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1523.42,1066.394,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TUBULAR PLATE ONE-THIRD 4 HOLE -,SUP-626674,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ONE-THIRD TUBULAR PLATE 5 HOLE / L59MM -,SUP-626675,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ONE-THIRD TUBULAR PLATE 6 HOLE / L71MM -,SUP-626676,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TUBULAR PLATE ONE-THIRD 6 HOLE -,SUP-626676S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ONE-THIRD TUBULAR PLATE 7 HOLE L83MM -,SUP-626677,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 8 HOLE -,SUP-626678,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1642.94,1150.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE TUBULAR HOLE 9 -,SUP-626679,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2203.63,1542.541,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE TUBULAR HOLE 12 -,SUP-626682,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2203.63,1542.541,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE TUBULAR 16HL -,SUP-626686,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2746.15,1922.305,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE POLYAXIAL LKG TALO-NAVICULAR LONG T10 -,SUP-626762,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4305.48,3013.836,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
VARIAX NAVICULAR PLATE -,SUP-626881,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4186.99,2930.893,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
POLYAXIAL LOCKING PLATE CUBOID (T8) -,SUP-626885,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.24,2762.368,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 3 HOLE SLIM -,SUP-626963,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5843.99,4090.793,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 6 HOLE SLIM -,SUP-626966,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5843.99,4090.793,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SLIM STRAIGHT 7 HOLE T8 -,SUP-626967,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5843.99,4090.793,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2 HOLE FOREFOOT PLATE -,SUP-626972,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BROAD 3 HOLE -,SUP-626973,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BROAD STRAIGHT PLATE 4 HOLE -,SUP-626974,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
5 HOLE FOREFOOT PLATE -,SUP-626975,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
6 HOLE BROAD Y-PLATE -,SUP-626976,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BROAD STRAIGHT T10 7 HOLE -,SUP-626977,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6959.31,4871.517,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SLIM -,SUP-626982,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
3-HOLE 4-PLATE- SLIM -,SUP-626983,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE-Y 4 HOLE SLIM -,SUP-626984,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 5 HOLE SLIM Y -,SUP-626985,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6401.65,4481.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BROAD Y PLATE 2 SHAFT HOLES -,SUP-626992,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BROAD Y PLATE 3 HOLE -,SUP-626993,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BROAD Y-PLATE- 3 SHAFT -,SUP-626993,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
STRYKER PLATE -,SUP-626994,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
VARIAX 2 FOREFOOT 5 HOLE PLATE -,SUP-626995,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BONE VARIAX BROAD Y 6 SHAFT HOLES T10 -,SUP-626996,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BROAD Y PLATE - 7 HOLES -,SUP-626997,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BROAD Y-PLATE- 7 SHAFT HOLES (T10) -,SUP-626997,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7516.97,5261.879,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 3HL TI -,SUP-627203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
4 HOLE PLATE HUMERUS -,SUP-627204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 5-HOLE -,SUP-627205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE PROX LAT HUMERUS LEFT 6 HOLE L125MM -,SUP-627206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8796.54,6157.578,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE PROXIMAL LATERAL HUMERUS 8 HOLE -,SUP-627208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9123.11,6386.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 12 HOLE LEFT PROX LAT HUMERAL -,SUP-627212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9529.9,6670.93,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PROXIMAL LATERAL HUMERUS PLATE -,SUP-627216S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10146.77,7102.739,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 3 HOLE PROXIMAL LATERAL HUMERUS -,SUP-627233,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
4 HOLE PLATE RIGHT -,SUP-627234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7625.83,5338.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BONE AXSOS 3 TI 6 HOLE HUMERUS RIGHT PROXIMAL LATERAL -,SUP-627236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8796.54,6157.578,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
8 HOLE PLATE STRYKER -,SUP-627238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9123.11,6386.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
10 HOLE PROXIMAL HUMERUS PLATE - RIGHT -,SUP-627240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9123.11,6386.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE HUMERUS 12 HOLE RIGHT PR -,SUP-627242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9529.9,6670.93,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PROXIMAL LATERAL HUMERUS PLATE FOR RIGHT HUMERUS 14 HOLE -,SUP-627244S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10146.77,7102.739,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2 HOLE PLATE LEFT TIBIA -,SUP-627302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7207.59,5045.313,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 121MM 4HL -,SUP-627304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7356.55,5149.585,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 147MM 6HL -,SUP-627306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7509.33,5256.531,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 8 HOLE PROX LATERAL FOR LEFT TIBIA L173MM -,SUP-627308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7658.3,5360.81,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE PROXIMAL LATERAL TIBIA FOR LEFT TIBIA 10 HOLE -,SUP-627310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8099.46,5669.622,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
AXSOS 3 TI PROX LAT TIBIA LEFT 12 HOLE PLATE -,SUP-627312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8414.58,5890.206,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 95MM 2HL F-SHP RT TIB -,SUP-627332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7207.59,5045.313,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 4HL -,SUP-627334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7356.55,5149.585,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE RIGHT HOLE 6 -,SUP-627336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8887.66,6221.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE PROXIMAL MEDIAL TIBIA 8 HOLE RIGHT -,SUP-627338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7658.3,5360.81,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 10 HOLE RIGHT PROX LATERAL TIBIA -,SUP-627340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8099.46,5669.622,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE RIGHT HOLE 12 -,SUP-627342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8252.25,5776.575,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE RIGHT HOLE 14 -,SUP-627344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8414.58,5890.206,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 6HL LT DIST -,SUP-627406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7102.55,4971.785,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE DIST RAD TIB 12 HOLE LFT -,SUP-627412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7996.33,5597.431,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 14HL TI -,SUP-627414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8206.41,5744.487,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN MED DST -,SUP-627434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6900.11,4830.077,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 6HL MDL/DIST RIGHT -,SUP-627436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7102.55,4971.785,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE DIST MED TIB 8HOLE RIGHT -,SUP-627438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7304.99,5113.493,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE DIST MEDIAL 10 HOLE RT -,SUP-627440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7788.16,5451.712,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE DIST MED LKD 12 HOLE RT -,SUP-627442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7996.33,5597.431,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 14 HOLE RIGHT DISTAL MEDICAL PLATE -,SUP-627444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8206.41,5744.487,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 4HL TI RT DIST -,SUP-627454,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.44,5926.508,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BONE AXSOS 3 TITANIUM 127 MM TIBIAL LEFT DISTAL -,SUP-627456,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7802.17,5461.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 8 HOLE LEFT ANTEROLATERAL -,SUP-627458,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7975.32,5582.724,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW DIST ANTERIORLATERAL TIBIA LFT 10HL 178MM -,SUP-627460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8370.53,5859.371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE TIBIA  14 HOLE LEFT L229MM DISTAL ANTEROLATERAL -,SUP-627464,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8724.98,6107.486,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 4 HOLE -,SUP-627484,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7631.05,5341.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 6 HOLE RIGHT ANT-LAT -,SUP-627486,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7802.17,5461.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE TIBIA DISTAL ANTEROLATERAL RIGHT 8 HOLE L153MM -,SUP-627488,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7975.32,5582.724,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE DISTAL ANTEROLAT TIBIA RIGHT 10 HOLE 178MM -,SUP-627490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8370.53,5859.371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE LKG COMP 11 HOLD L149MM X 4.0MM -,SUP-627511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5647.28,3953.096,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 12HOLE COMPRESSION -,SUP-627512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5647.28,3953.096,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 14 HOLE AXSOS STRAIGHT -,SUP-627514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5809.61,4066.727,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE LOCKING COMPRESSION 18 HOLE L240MM 4.0MM -,SUP-627518S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6099.9,4269.93,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 7 HOLE NARROW COMPRESSION -,SUP-627537,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6619.37,4633.559,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 8 HOLE NARROW COMPRESSION -,SUP-627538,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.27,4961.089,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 9 HOLE NARROW -,SUP-627539,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.27,4961.089,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 10 HOLE STRAIGHT -,SUP-627540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7348.91,5144.237,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE STRAIGHT BROAD 9 HOLE COMPR 173 LENGTH -,SUP-627569,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.27,4961.089,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE STRAIGHT BROAD 10 HOLE COMPRESSION -,SUP-627570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7348.91,5144.237,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE LOCKING COMPRESSION BROAD 12 HOLE -,SUP-627572,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7348.91,5144.237,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 13 HOLE 5.0 COMPRESSION PLATE -,SUP-627573,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7518.88,5263.216,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BROAD 14 HOLE -,SUP-627574,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7518.88,5263.216,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DISTAL LATERAL FEMUR PLATE FOR LEFT FEMUR 4 HOLE -,SUP-627604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7824.24,5476.968,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 166MM 6HL LT DIST LAT FEM -,SUP-627606,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9329.8,6530.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 8HL LT -,SUP-627608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8189.22,5732.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 238MM 10HL LT DIST LAT FEM -,SUP-627610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8683.22,6078.254,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 12HL -,SUP-627612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8871.66,6210.162,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 343MM 16HL LT -,SUP-627616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9250.22,6475.154,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE DISTAL FEMUR -,SUP-627618S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9623.69,6736.583,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DISTAL LATERAL FEMUR 4 HOLE -,SUP-627634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7824.24,5476.968,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 166MM 6HL DIST LAT FEM -,SUP-627636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8009.28,5606.496,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE DISTAL LATERAL FEMUR -,SUP-627638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8189.22,5732.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 238MM 10HL RT DIST LAT FEM -,SUP-627640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8683.22,6078.254,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 274MM 12HL -,SUP-627642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8871.66,6210.162,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 343MM 16HL 1STRN/PK RT -,SUP-627646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9250.22,6475.154,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE AXSOS 3 TI DISTAL LAT FEMUR RT 18 HOLE L379MM -,SUP-627648S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9623.69,6736.583,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE TIBAL 4 HOLE LEFT/L71MM -,SUP-627704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.9,4447.73,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE MEDIAL PROXIMAL TIBIAL 5 HOLES LEFT -,SUP-627705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6560.16,4592.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE MEDIAL 6 HOLES STRYKER -,SUP-627706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6764.51,4735.157,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE PROX MED TIBIA FOR LEFT TIBIA 8HOLE L-123MM -,SUP-627708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6966.95,4876.865,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 14 HOLE PROX MEDIAL FOR LEFT TIBIA L201MM -,SUP-627714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7866.47,5506.529,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE PROXIMAL MEDIAL TIBIA FOR LEFT TIBIA 16 HOLE -,SUP-627716S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8278.98,5795.286,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOCKED TIBIAL PLATE -,SUP-627734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.9,4447.73,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE TIBIAL LATERAL 5 HOLE -,SUP-627735,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6560.16,4592.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE PROX MED TIB RT 6 HL -,SUP-627736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6764.51,4735.157,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PROXIMAL MEDIA TIBIA 97MM LENGTH -,SUP-627736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6764.51,4735.157,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE PROXIMAL MEDIAL TIBIA 8 HOLE RIGHT -,SUP-627738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8247.49,5773.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN AXSOS 10HL RT PROX MDL TIB COMPR -,SUP-627740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7438.67,5207.069,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PROXIMAL MEDIAL TIBIA PLATE FOR RT TIBIA 12 HOLE 175MM -,SUP-627742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7654.48,5358.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
INTERPROSTHETIC FEMUR PLATE RIGHT 334MM -,SUP-627846,CDM,C1713,HCPCS,278,RC,,,outpatient,,,27813.56,19469.492,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DISTAL FEMUR PLATE RIGHT 280MM -,SUP-627863,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19576.64,13703.648,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
6 HOLE PLATE - LEFT -,SUP-628006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 88MM 7HL STD PRCONT VAR ANG TI ALY DECREASED -,SUP-628007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 99MM 8HL STD PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 122MM 10HL STD PRCONT VAR ANG TI ALY -,SUP-628010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SUPERIOR 7 HOLE RIGHT DECREASED -,SUP-628027,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3855.96,2699.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 99MM 8HL STD PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE VARIAX 99MM CLAVICLE RIGHT SUPERIOR DECREASED 8 HOLE -,SUP-628028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 99MM 6HL BRDG PRCONT VAR ANG TI ALY LT CLVCL -,SUP-628046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 122MM 8HL BRDG PRCONT VAR ANG TI ALY -,SUP-628048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 99MM 6HL BRDG PRCONT VAR ANG TI ALY RT CLCVL -,SUP-628066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BRIDGE 8 HOLE SUPERIOR D -,SUP-628068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 8 HOLE STRYKER -,SUP-628108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 10 HOLE STRYKER -,SUP-628110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE CLAVICLE INC CURVED 8 HOLE -,SUP-628128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE CLAVICLE IC 10 HOLE -,SUP-628130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 6 HOLE BRIDGE -,SUP-628166,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SUPERIOR LATERAL PLATE - 3 HOLE / LEFT -,SUP-628203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 98MM 5HL PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SUPERIOR LATERAL PLATES -,SUP-628207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4698.11,3288.677,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 86MM 4HL PRCONT VAR ANG TI ALY SMRTLC NS -,SUP-628224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE RIGHT LATERAL 5-HOLE #628225 -,SUP-628225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 7 HOLE LATERAL -,SUP-628227,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4698.11,3288.677,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 86MM 7HL PRCONT VAR ANG TI ALY UNIV SMRTLC -,SUP-628307,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.62,2999.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 16MMX68MM PRCONT VAR ANG TI ALY LAT -,SUP-628525S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4480.35,3136.245,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
HOOK PLATE 7 HOLE 16MM RIGHT -,SUP-628537S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4480.35,3136.245,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DISTAL LATERAL HUMERUS PLATE 4 HOLE 109MM -,SUP-629204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 8 HOLE LEFT LATERAL -,SUP-629208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 3HL RT DIST LAT HUM COMPR -,SUP-629223S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE DISTAL LATERAL 4 HOLE 109MM -,SUP-629224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 12 HOLE RIGHT HUMERUS L203MM VARIAX DIST LATERAL -,SUP-629232S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE HUMERUS DIST POST LATERAL LEFT 3 HOLE -,SUP-629243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 105MM 4HL PRCONT VAR ANG LCK TI ALY NS LT -,SUP-629244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 128MM 6HL SHFT PRCONT VAR ANG LCK TI ALY NS -,SUP-629246,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 150MM 8HL PRCONT VAR ANG LCK TI ALY NS LT -,SUP-629248,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE DIST POST LATERAL HUMERUS 10 HOLE L173MM -,SUP-629250S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 105MM 4HL PRCONT VAR ANG LCK TI ALY NS RT -,SUP-629264,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 150MM 8HL PRCONT VAR ANG LCK TI ALY NS RT -,SUP-629268,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE HUMERUS DISTAL POSTERIOR LATERAL 12 HOLE -,SUP-629272S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE EXTENDED MEDIAL LEFT 3 HOLE -,SUP-629283,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 96MM 4HL PRCONT VAR ANG LCK TI ALY -,SUP-629284,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE DISTAL MEDIAL HUMERUS 6 HOLE EXTEND -,SUP-629286,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 104MM 4HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 151MM 8HL SHFT PRCONT VAR ANG LCK TI ALY NS -,SUP-629308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE DIST POST MEDIAL HUMERUS 12 HOLE L199MM -,SUP-629312S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DISTAL POSTERIOR MEDIAL HUMERUS PLATE FOR RT HUM 3 HOLE -,SUP-629323,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE DIST POST MDL RIGHT 4 -,SUP-629324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE DISTAL POSTERIOR MEDIAL 8 HOLE -,SUP-629328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE DIST POST MEDIAL HUMERUS 12 HOLE L199MM -,SUP-629332S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE OLECRARON LEFT 3 HOLE -,SUP-629343,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 89MM 4HL PRCONT VAR ANG LCK TI ALY NS LT -,SUP-629344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
3 HOLE RIGHT PLATE -,SUP-629363,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 89MM 4HL PRCONT VAR ANG LCK TI ALY NS RT -,SUP-629364,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 113MM 6HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629366,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 137MM 8HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629368,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE MEDIAL 3 HOLE -,SUP-629383,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3946.28,2762.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 92MM 4HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629384,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 116MM 6HL PRCONT VAR ANG LCK TI ALY NS -,SUP-629386,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 139MM 8HL LCK TI ALY NS -,SUP-629388,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE DISTAL MEDIAL HUMERUS LEFT 10HOLE 163MM -,SUP-629390S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE DISTAL MEDIAL HUMERUS 12 HOLE -,SUP-629392S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE COMPRESSION NARROW STRAIGHT 4 HOLES -,SUP-629504,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1289.93,902.951,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE COMPRESSION NARROW STRAIGHT 5 HOLES -,SUP-629505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 6 HOLE COM PR NRW STR -,SUP-629506S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 7HL COMPR NRW STR -,SUP-629507S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX COMPR TI ALY NRW STR 629508S STRL -,SUP-629508S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE COMP 9 HOLE NARROW STR -,SUP-629509S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 10HL COMPR NRW STR -,SUP-629510S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE COMPRESSION NARROW STRAIGHT 12 HOLES -,SUP-629512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
14 HOLE NARROW COMPRESSION PLATE VARIAX -,SUP-629514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX COMPR TI ALY NRW STR 629527S STRL -,SUP-629527S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 7HL COMPR BRD STR -,SUP-629537S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COMPRESSION PLATE BROAD STRAIGHT 6 HOLES -,SUP-629546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 8HL COMPR NRW STR -,SUP-629548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COMPRESSION PLATE BROAD STRAIGHT 9 HOLES/L115MM -,SUP-629549S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2509.57,1756.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
VARIAX COMPRESSION PLATE BROAD CURVED 9 HOLES -,SUP-629559,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN VARIAX 8HL COMPR BRD CRV -,SUP-629560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2511.64,1758.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE COMPRESSION BROAD CURVED 11 HOLES -,SUP-629561,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE COMP VARIAX BROAD CURVED 10 HOLES -,SUP-629562,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2690.39,1883.273,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SHORT BEND -,SUP-629589,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8642.06,6049.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE PROFILE 2.0 4HOLE -,SUP-629604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1944.22,1360.954,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE PROFILE 2.0 X L33MM 6 HOLE -,SUP-629606,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1944.22,1360.954,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PROFILE PLATE 2.0 54MM -,SUP-629610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1944.22,1360.954,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PROFILE PLATE 2.0 L108MM 20HOLES -,SUP-629620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE NARROW LOCKING 2.0 4 HOLE -,SUP-629624,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2488.21,1741.747,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE NARROW LOCK 2.0 L34MM 6 HOLES -,SUP-629626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2488.21,1741.747,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 8 HOLE NARROW -,SUP-629628,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2488.21,1741.747,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 2.0MM BROAD LOCKING 6 HOLES STRAIGHT -,SUP-629646,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BROAD LOCKING 2.0 / 10 HOLE -,SUP-629650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE PROFILE 8 HOLE 2.4 -,SUP-629666,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE PROFILE 2.4 8HOLE -,SUP-629668,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE VARIAX LOW PROFILE 2.4 X L66MM 10 HOLES -,SUP-629670,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2200.77,1540.539,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE NARROW LOCK 2.4 X L28MM 4 HOLE -,SUP-629684,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
6 HOLE NARROW PLATE -,SUP-629686,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 2.4MM 8 HOLE -,SUP-629688,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BONE VARIAX NARROW LOCK 2.4 L69MM 10 HOLE -,SUP-629690,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2950.33,2065.231,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 4 HOLE -,SUP-629704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BROAD LOCKING 2.4 6 HOLE -,SUP-629706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 8 HOLE STRAIGHT 2.4 -,SUP-629708,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BONE VARIAX BROAD LOCK 2.4 L80MM 10HOLES -,SUP-629710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BROAD LOCKING 2.4 12 HOLE -,SUP-629712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 4 HOLE NARROW -,SUP-629724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 2.7 6 HOLE STRAIGHT -,SUP-629726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 8 HOLE -,SUP-629728,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 10 HOLE -,SUP-629730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3410.55,2387.385,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE STRAIGHT 10 HOLE -,SUP-629740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BROAD LOCK 2.7 L39MM 4 HOLE -,SUP-629744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 2.7 6 HOLE -,SUP-629746,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BROAD LOCK 2.7 X 73MM 8HL -,SUP-629748,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
T-PLATE 2.7MM 3 X 10 -,SUP-629748,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BROAD LOCKING 2.7 10HOLE -,SUP-629750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 12 HOLE BROAD STRAIGHT -,SUP-629752,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3870.76,2709.532,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
T-PLATE NARROW LOCKING 2.0 2 X 5 HOLE -,SUP-629770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NARROW LOCK T-PLATE 2.0 L62MM 2X10HOLES -,SUP-629771,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2716.41,1901.487,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE NARROW LCK T 2.0 3X5 HOLE -,SUP-629772,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2719.27,1903.489,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
T-PLATE 2.4MM NARROW LOCKING 2 X 5 -,SUP-629776,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
T-PLATE -,SUP-629777,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BONE VARIAX NARROW LOCK T-PLATE 2.4 L41MM 3X5 HOLES -,SUP-629778,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE T 2.4 NARROW -,SUP-629779,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE NARROW T 2.4 X L76MM 5X10 HOLES LKG -,SUP-629781,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3179.48,2225.636,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE NARROW LOCKING T 5 HOLE -,SUP-629782,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 10 HOLE -,SUP-629783,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE AXSOS TITANIUM 5 HOLE -,SUP-629784,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE NARROW LOCKING T  2.7 X 87MM 10HOLE -,SUP-629785,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE T NARROW LOCK 2.7 L8 7MM X 5 X 10 HOLES -,SUP-629787,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 2.7 Y- PLATE -,SUP-629788,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4103.73,2872.611,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 2.7MM TRIANGLE -,SUP-629789,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4103.73,2872.611,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE Y 2.4MM -,SUP-629790,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE NARROW LOCK TRIANGLE 2.4 X 81MM 10 HOLE -,SUP-629791,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3639.7,2547.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANTERIOR TT PLATE LEFT -,SUP-630101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10381.67,7267.169,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANTERIOR TT PLATE RIGHT -,SUP-630102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10381.67,7267.169,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
IMPLANT FLEXBLOCK -,SUP-6314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7031.8,4922.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN FX 38MM TRIATH HD F/T/K SYS -,SUP-6541-4-515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ABC IM ROD TRIATHLON INSTRUMENTS -,SUP-6541-4-516E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2213.49,1549.443,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN FX 19MM TRIATH HD F/T/K SYS -,SUP-6541-4-575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,327.34,229.138,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING T8 FULL THREAD 2.4 X 6 -,SUP-656006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING T8 FULL THREAD 2.4 X 7 -,SUP-656007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LCK T8 FULL THREAD 2.4X8 -,SUP-656008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING T8 FULL THREAD 2.4 X 10 -,SUP-656010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 2.4 X 11 -,SUP-656011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LCK T8 FII THRD 2.4 X 12 -,SUP-656012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING T8 FULL THREAD 2.4MM L14 -,SUP-656014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.4MM X 16MM LOCKING -,SUP-656016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING T8 FULL TRHEAD 2.4MM L 18MM -,SUP-656018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING T8 FULL THREAD 2.4 X 22 -,SUP-656022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING T8 FULL THREAD 2.4MM X 24MM -,SUP-656024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOCKING SCREW T8 FULL THREAD 2.4MM X 26MM -,SUP-656026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING T8 FULL THREAD 2.4 X 28 -,SUP-656028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING T8 FULL THREAD 2.4 X 30 -,SUP-656030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING T8 FULL THREAD 2.4 X 32 -,SUP-656032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING T8 FULL THREAD 2.4 X 34 -,SUP-656034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING T8 FULL THREAD 2.4 X 36 -,SUP-656036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 2.4MM X 38MM -,SUP-656038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN T8 FULL THREAD 2.4X6 -,SUP-656106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN T8 FULL THREAD 2.4X7 -,SUP-656107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN T8 FULL THREAD 2.4X8 -,SUP-656108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN T8 FULL THREAD 2.4X9 -,SUP-656109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN T8 FULL THREAD 2.4X12 -,SUP-656112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN T8 FULL THREAD 2.4X14 -,SUP-656114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.4 X 15 NL -,SUP-656115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN T8 FULL THREAD 2.4X18 -,SUP-656118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN T8 FULL THREAD 2.4X20 -,SUP-656120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN T8 FULL THREAD 2.4X24 -,SUP-656124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN T8 FULL THREAD 2.4X26 -,SUP-656126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN T8 FULL THREAD 2.4X28 -,SUP-656128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN T8 FULL THREAD 2.4X30 -,SUP-656130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN T8 FULL THREAD 2.4X32 -,SUP-656132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN T8 FULL THREAD 2.4X34 -,SUP-656134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN T8 FULL THREAD 2.4X36 -,SUP-656136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN T8 FULL THREAD 2.4X38 -,SUP-656138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE T8  2.4MM X L40MM NL -,SUP-656140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NON LOCKING 3.5 X 42 -,SUP-656142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NON LOCKING 3.5 X 44 -,SUP-656144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN T8 FULL THREAD 2.4X48 -,SUP-656148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN T8 FULL THREAD 2.4X50 -,SUP-656150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE VARIAX T8 2.4MM L55MM -,SUP-656155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN T8 FULL THREAD 2.4X60 -,SUP-656160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 2.7MM X 6MM -,SUP-656306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING T8 FULL THREAD 2.7 X 7 -,SUP-656307,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1150.21,805.147,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING T8 FULL THREAD 2.7X8 -,SUP-656308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 2.7MM X 9MM -,SUP-656309,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LCK T8 FULL THREAD 2.7X10 -,SUP-656310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LCK T8 2.7 X 11MM -,SUP-656311,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 2.7MM X 12MM -,SUP-656312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7 X 13 LOCKING -,SUP-656313,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 2.7MM X 14MM -,SUP-656314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LCK T8 2.7 X 15MM -,SUP-656315,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 2.7MM X 16MM -,SUP-656316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 2.7MM X 18MM -,SUP-656318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 2.7MM X 20MM -,SUP-656320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 2.7MM X 22MM -,SUP-656322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 2.7MM X 24MM -,SUP-656324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 2.7MM X 26MM -,SUP-656326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 2.7MM X 22MM -,SUP-656328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7 X 3 LOCKING -,SUP-656330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 2.7MM X 32MM -,SUP-656332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 2.7 X 34 -,SUP-656334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 2.7MM X 36MM -,SUP-656336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 2.7MM X 38MM -,SUP-656338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 2.7MM X 40MM -,SUP-656340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 2.7 X 42 -,SUP-656342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 2.7MM X 44MM -,SUP-656344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 2.7 X 45 -,SUP-656345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 2.7MM X 50MM -,SUP-656350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,538.57,376.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.7MM X 55MM LOCKING SCREW -,SUP-656355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE VARIAX T8 2.7MM  X  L 60MM LOCKING -,SUP-656360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 2.7 X 70 -,SUP-656370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE VARIAX T8 2.7MM X L 75MM LOCKING SCREW -,SUP-656375S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,694.95,486.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE VARIAX T8 2.7MM X L 80MM LOCKING -,SUP-656380S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,694.95,486.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW T8 FULL THREAD NON LCK 2.7 X 6 -,SUP-656406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE VARIAX T8  7MM X 2.7MM -,SUP-656407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE T8 FULL THREAD 2.7MM X 9 -,SUP-656409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MM X 10MM NON LOCKING -,SUP-656410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE T8 2.7 X11MM -,SUP-656411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW N/L 2.7MM X 12MM -,SUP-656412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7 X 13 NL -,SUP-656413,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW N/L 2.7MM X 14MM -,SUP-656414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NON LOCKING 2.7 X 15 -,SUP-656415,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW N/L 2.7MM X 16MM -,SUP-656416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW N/L 2.7MM X 18MM -,SUP-656418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7 X 20MM NLCKG FT T8 STRDRV RCESS -,SUP-656420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NON-LOCKING 2.7MM X 22MM -,SUP-656422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NON LOCKING 2.7 X 26MM -,SUP-656426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.7MM NON LOCKING BONE SCREW 28MM -,SUP-656428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN T8 FLL THRD 2.7 X 30 -,SUP-656430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN T8 FLL THRD 2.7 X 32 -,SUP-656432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN T8 FLL THRD 2.7 X 34 -,SUP-656434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN T8 FLL THRD 2.7 X 36 -,SUP-656436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NON LOCKING 2.7 X 38 -,SUP-656438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NON LOCKING 2.7 X 40 -,SUP-656440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE T8 FULL THREAD 2.7 X 40 -,SUP-656440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NON LOCKING 2.7MM X 42MM -,SUP-656442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NON LOCKING 2.7 X 45 -,SUP-656445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NON LOCKING 2.7 X 46 -,SUP-656446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN T8 FLL THRD 2.7 X 48MM -,SUP-656448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7 X 50 NL -,SUP-656450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7 X 55 NL -,SUP-656455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NON LOCKING 2.7MM X 60MM -,SUP-656460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NON LOCKING 2.7MM X 65MM -,SUP-656465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NL 2.7 X 70 -,SUP-656470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE 2.7MM X 75MM T8 -,SUP-656475S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE VAIRAX T8 2.7MM X L 80MM -,SUP-656480S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING T10 FULL THREAD 2.7 X 8 -,SUP-657008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X12MM LCK FT T10 HX DRV -,SUP-657012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X14MM LCK FT T10 HX DRV -,SUP-657014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X16MM LCK FT T10 HX DRV -,SUP-657016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X20MM LCK FT T10 HX DRV -,SUP-657020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING T10 FULL 2.7 X 22 -,SUP-657022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING T10 FULL 2.7MM  X 22MM VARIAX -,SUP-657024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7 X 26 LOCKING -,SUP-657026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7 X 28 LOCKING -,SUP-657028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7 X 30 LOCKING -,SUP-657030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING T10 FULL 2.7 X 32 -,SUP-657032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOCKING SCREW T10 FULL THREAD 2.7MM L34MM -,SUP-657034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING T10 FULL 2.7 X 36 -,SUP-657036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7 X 38 LOCKING -,SUP-657038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MM X 40MM LOCKING -,SUP-657040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING T10 2.7 X 50 -,SUP-657050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING T10 2.7 X 55 -,SUP-657055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOCKING SCREW T10 FULL THREAD 2.7MM X 60MM -,SUP-657060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING T10 FULL THREAD 2.7 X 65 -,SUP-657065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING T10 FULL THREAD 2.7 X 70 -,SUP-657070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE T10 FULL THREAD 2.7 X 8 -,SUP-657108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X12MM FT T10 HX DRV -,SUP-657112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X14MM FT T10 HX DRV -,SUP-657114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X16MM FT T10 HX DRV -,SUP-657116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X18MM FT T10 HX DRV -,SUP-657118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X20MM FT T10 HX DRV -,SUP-657120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X22MM FT T10 HX DRV -,SUP-657122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE T10 FULL THREAD 2.7 X 26 -,SUP-657126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE T10 FULL THREAD 2.7 X 28 -,SUP-657128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
30MM BONE SCREW NONLOCKING 2.7MM -,SUP-657130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NL 2.7 X 32 -,SUP-657132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NL 2.7 X 34 -,SUP-657134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE T10 FULL THREAD 2.7MM /L36MM -,SUP-657136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NL 2.7 X 38 -,SUP-657138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE T10 FULL THREAD 2.7MM /L40MM -,SUP-657140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE T10 FULL THREAD 2.7MM /L42MM -,SUP-657142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE T10 FULL THREAD 2.7mm / L44mm -,SUP-657144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE T10 FULL THREAD 2.7MM /L46MM -,SUP-657146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE T10 FULL THREAD 2.7mm / L48mm -,SUP-657148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE T10 FULL THREAD 2.7MM /L50MM -,SUP-657150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE T10 FULL THREAD 2.7MM /L55MM -,SUP-657155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE T10 FULL THREAD 2.7MM /L60MM -,SUP-657160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE T10 FULL THREAD 2.7 X 65 -,SUP-657165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE T10 FULL THREAD 2.7 X 70 -,SUP-657170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING T10 FULL THREAD 3.5 X 8 -,SUP-657308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X10MM LCK FT T10 HX DRV -,SUP-657310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE 3.5MM 12MM VARIAX T10 FULL THREAD LOCK NONSTERILE -,SUP-657312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X14MM LCK FT T10 HX DRV -,SUP-657314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X16MM LCK FT T10 HX DRV -,SUP-657316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X18MM LCK FT T10 HX DRV -,SUP-657318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING T10 3.5MM / L20MM FULL THREAD -,SUP-657320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 3.5 X 22 -,SUP-657322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING T10 3.5MM / L22MM FULL THREAD -,SUP-657322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 3.5 X 24 -,SUP-657324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 3.5 X 26 -,SUP-657326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 3.5 X 30 -,SUP-657330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 3.5 X 32 -,SUP-657332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 3.5 X 34 -,SUP-657334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 3.5 X 38 -,SUP-657338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING T10 FULL THREAD 3.5 X 40 -,SUP-657340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING T10 FULL THREAD 3.5 X 42 -,SUP-657342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 3.5 X 44 -,SUP-657344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 3.5 X 46 -,SUP-657346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING T10FULL THREAD 3.5MM X 48MM -,SUP-657348,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING T10 FULL THREAD 3.5MM X 50MM -,SUP-657350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING T10 FULL THREAD 3.5 X 60 -,SUP-657360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING T10 FULL THREAD 3.5 X 65 -,SUP-657365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING T10 FULL THREAD 3.5 X 70 -,SUP-657370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE T10 FULL THREAD 3.5 X 8 -,SUP-657408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,767.89,537.523,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE T10 FULL THREAD 3.5 X 8 -,SUP-657408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE T10 FULL THREAD 3.5MM /L10MM -,SUP-657410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5 NON LOCKING 12MM -,SUP-657412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MM X12MM NON LOCKING -,SUP-657412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X14MM FT T10 HX DRV -,SUP-657414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X16MM FT T10 HX DRV -,SUP-657416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X18MM FT T10 HX DRV -,SUP-657418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X20MM FT T10 HX DRV -,SUP-657420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NON-LOCKING 3.5 MM X 22 -,SUP-657422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5 NON LOCK FT 24MM -,SUP-657424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5 NON LOCK FT 26MM -,SUP-657426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MM NONLOCKING FT 28MM -,SUP-657428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MM NONLOCKING FT 30MM -,SUP-657430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
VARIAX 305MM NON LOCKING SCREW  32MM -,SUP-657432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
3.5MM NON-LOCKING SCREW 34MM -,SUP-657434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
3.5MM NON-LOCKING SCREW 36MM -,SUP-657436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE T10 FULL THREAD 3.5 X 38 -,SUP-657438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW  BONE T10 FULL THREAD NON LOCKING 3.5 X 40 -,SUP-657440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE T10 FULL THREAD 3.5MM X 42MM -,SUP-657442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
VARIAX 3.5MM NON LOCKING SCREW 44MM -,SUP-657444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BONE SCREW T10 FULL THREAD 3.5MM / L46MM -,SUP-657446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE T10FULL THREAD 3.5 X 48 -,SUP-657448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MM NONLOCKING FT 50MM -,SUP-657450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE T10 FULL THREAD 3.5 X 55 -,SUP-657455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE T10 FULL THREAD 3.5 X 60 -,SUP-657460,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE T10 FULL THREAD 3.5 X 65 -,SUP-657465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE T10 FULL THREAD 3.5 X 70 -,SUP-657470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,326.18,228.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW VARIAX LOCKING T6 2.0MM L8MM -,SUP-657608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING T6 2.0MM L9MM -,SUP-657609,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW VARIAX LOCKING T6 2.0MM L10MM -,SUP-657610,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING T6 2.0MM L11MM -,SUP-657611,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.0MM  X 12MM LOCKING -,SUP-657612,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING T6 2 X 14MM -,SUP-657614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LCK T6 2.0 X 16MM -,SUP-657616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LCK T6 2.0 X 18MM -,SUP-657618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2-0MM LOCKING 20MM LENGTH -,SUP-657620,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LCK T6 2.0 X 22MM -,SUP-657622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING T6 2.0 X 26MM -,SUP-657626,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING VARIAX T6 2.0MM X L30MM -,SUP-657630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE 2.0M X L6MM T6 -,SUP-657706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NONLCK 2.0 X 10MM -,SUP-657710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2 X 11 -,SUP-657711,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.0MM X 12MM NON LOCKING -,SUP-657712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.0MM X 14MM NON LOCKING -,SUP-657714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2 X 16 -,SUP-657716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW VARIAX 2.0 X 18 -,SUP-657718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.9 NON LOCKING 20MM LENGTH -,SUP-657720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NON LOCKING 2 X 22 -,SUP-657722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE T6 2.0MM X L 24MM NON-LOCKING -,SUP-657724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE T6 2.0MM L26MM -,SUP-657726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.0MM NON LOCKING 28MM LENGTH -,SUP-657728,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE T6 2.0MM L30MM -,SUP-657730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE VARIAX T6 2.0MM X L34MM -,SUP-657734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NON LOCKING 2 X 36 -,SUP-657736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE VARIAX T6 2.0MM X L38MM -,SUP-657738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,323.84,226.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW FIXOS 4.0 30MM -,SUP-658030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEADLESS 4.0 FIXOS 38MM -,SUP-658038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
4.0 FIXOS 46MM SCREW -,SUP-658046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
4.0 FIXOS 48MM SCREW -,SUP-658048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEADLESS COMP. 7.0MM 50M -,SUP-658050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
4.0 FIXOS 55MM SCREW -,SUP-658055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEADLESS LONG THREAD 7.0 X 70MM -,SUP-658070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEADLESS COMP. 7.0MM 75M -,SUP-658075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
4.0 FIXOS SCREW 80MM -,SUP-658080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEADLESS 5 X 32 -,SUP-658132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW FIXOS 5.0 X 34MM -,SUP-658134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW FIXOS 5.0 X 36MM -,SUP-658136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
HEADLESS COMPRESSION SCREW 5MM X 38MM -,SUP-658138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
5.0 HEADLESS SCREW 44 MM -,SUP-658144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANNULATED 5.0 X 46MM FIXOS -,SUP-658146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
5.0 FIXOS 48MM SCREW -,SUP-658148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANNULATED 5.0 X 55MM FI -,SUP-658155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
HEADLESS COMPRESSION SCREW 5.0mm / L65mm -,SUP-658165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
HEADLESS COMPRESSION SCREW 5.0mm / L70mm -,SUP-658170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2402.19,1681.533,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW FIXOS 5 X 70MM -,SUP-658170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE FIXOS 5 X 75 -,SUP-658175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW FIXOS 5 X 80 -,SUP-658180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2347.49,1643.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
HEADLESS COMPRESSION SCREW 7MM / L40MM ST -,SUP-658340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEADLESS COMP. 7.0MM 6.5 FIXOS -,SUP-658365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEADLESS COMP. 7.0MM 70M -,SUP-658370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEADLESS SHORT THREAD 7.0 X 75MM -,SUP-658375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEADLESS SHORT THREAD 7.0 X 90MM -,SUP-658390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEADLESS COMP. 7.0MM 12.5 FIXOS -,SUP-658425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
HEADLESS COMPRESSION SCREW 7MM / L65MM ST -,SUP-658565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEADLESS LONG THREAD 7.0 X 70MM -,SUP-658570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
HEADLESS COMPRESSION SCREW Ã˜7.0MM / L75MM LONG THREAD -,SUP-658575,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7.0 FIXOS 80MM -,SUP-658580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
HEADLESS COMPRESSION SCREW 7MM X 85MM LONG THREAD -,SUP-658585,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
HEADLESS COMPRESSION SCREW 7MM X25MM -,SUP-658625,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3412.84,2388.988,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 8X20MM -,SUP-660H0820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 9X35MM -,SUP-660H0935,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X14MM LCK -,SUP-661014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X18MM LCK -,SUP-661018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X20MM LCK -,SUP-661020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X22MM LCK -,SUP-661022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X24MM LCK -,SUP-661024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X26MM LCK -,SUP-661026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X28MM LCK -,SUP-661028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X30MM LCK -,SUP-661030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X32MM LCK -,SUP-661032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X34MM LCK -,SUP-661034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X36MM LCK -,SUP-661036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X38MM LCK -,SUP-661038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X40MM LCK -,SUP-661040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1154.51,808.157,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X42MM LCK -,SUP-661042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X44MM LCK -,SUP-661044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X46MM LCK -,SUP-661046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X48MM LCK -,SUP-661048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X50MM LCK -,SUP-661050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCK 4.0 X 55MM -,SUP-661055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X60MM LCK -,SUP-661060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X65MM LCK -,SUP-661065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X70MM LCK -,SUP-661070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X75MM LCK -,SUP-661075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X80MM LCK -,SUP-661080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X85MM LCK -,SUP-661085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X90MM LCK -,SUP-661090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X95MM LCK -,SUP-661095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,837.91,586.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X14MM LCK -,SUP-661114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X16MM LCK -,SUP-661116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X18MM LCK -,SUP-661118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X20MM LCK -,SUP-661120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X22MM LCK -,SUP-661122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X24MM LCK -,SUP-661124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X26MM LCK -,SUP-661126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X28MM LCK -,SUP-661128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X30MM LCK -,SUP-661130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X32MM LCK -,SUP-661132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X34MM LCK -,SUP-661134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X36MM LCK -,SUP-661136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X38MM LCK -,SUP-661138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X40MM LCK -,SUP-661140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X42MM LCK -,SUP-661142,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X44MM LCK -,SUP-661144,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X46MM LCK -,SUP-661146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5 X 48MM LCK -,SUP-661148,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X55MM LCK -,SUP-661155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X60MM LCK -,SUP-661160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,854.24,597.968,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X65MM LCK -,SUP-661165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X70MM LCK -,SUP-661170,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X75MM LCK -,SUP-661175,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X80MM LCK -,SUP-661180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X85MM LCK -,SUP-661185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X90MM LCK -,SUP-661190,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X95MM LCK -,SUP-661195,CDM,C1713,HCPCS,278,RC,,,outpatient,,,912.59,638.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOCKING SCREW FLAT TIP 5.0MM T20 L10MM -,SUP-661210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2630.74,1841.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOCKING SCREW FLAT TIP 5.0MM /T20 /L20 -,SUP-661220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2630.74,1841.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X8MM LCK ST PRPRSTHTC -,SUP-661308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 5.0 X 10MM PERIP -,SUP-661310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 5.0 X 12MM PERIP -,SUP-661312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X14MM LCK ST PRPRSTHTC -,SUP-661314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X16MM PERI- LCK AXSOS -,SUP-661316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X16MM LCK ST PRPRSTHTC -,SUP-661316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X18MM LCK ST PRPRSTHTC -,SUP-661318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X20MM LCK ST PRPRSTHTC -,SUP-661320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1057.3,740.11,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NON LOCKING 3.5 X 14MM -,SUP-661414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X18MM CORT TI -,SUP-661418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NON LOCKING 3.5 X 20MM -,SUP-661420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X22MM CORT TI -,SUP-661422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X24MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X26MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X28MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661428,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X30MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X32MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X34MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X36MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X38MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X40MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X42MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X44MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661444,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X46MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661446,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL 3.5 X 46 -,SUP-661447,CDM,C1713,HCPCS,278,RC,,,outpatient,,,239.99,167.993,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X48MM NLCKG CORT VARIAX FT POLYAX ST FA T7 DRV BLNT -,SUP-661448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X50MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X55MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661455,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X65MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X70MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X75MM NLCKG CORT VARIAX P/T POLYAX ST FA T7 DRV -,SUP-661475,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X80MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X85MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X90MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661490,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTEX 3.5MM X 120MM -,SUP-661520S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,189.05,132.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTEX TI 4.5 X 14MM -,SUP-661714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTEX SELF TAPPING 4.5 X 16 -,SUP-661716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORT 4.5 X 18 -,SUP-661718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL 4.5 X 20MM -,SUP-661720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X22MM CORT TI -,SUP-661722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORT 4.5 X 24 -,SUP-661724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORT 4.5 X 26 -,SUP-661726,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORITCAL 4.5MM X 28MM -,SUP-661728,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X30MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661730,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X32MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661732,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X34MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661734,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X36MM LCK CORT VARIAX POLYAX ST T7 STRDRV BLNT TIP -,SUP-661736,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X38MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X38MM LCK CORT VARIAX SELF TAPPING -,SUP-661738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X40MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661740,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X42MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661742,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X44MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661744,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X46MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661746,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X48MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661748,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X50MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X55MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X60MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661760,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X65MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661765,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X70MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661770,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X75MM LCK CORT VARIAX FT POLYAX ST T7 STRDRV BLNT -,SUP-661775,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X80MM CORT TI -,SUP-661780,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL 4.5 X 85 -,SUP-661785,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3MMX8IN ER CANC CORT VARIAX FT POLYAX ST T7 STRDRV -,SUP-661795,CDM,C1713,HCPCS,278,RC,,,outpatient,,,203.06,142.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CABLE PLUG 5.0MM -,SUP-662202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1868.43,1307.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOCKING SCREW 5.0MM /T20 / L24MM -,SUP-662324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOCKING SCREW 5.0MM /T20 /L30MM -,SUP-662330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOCKING SCREW 5.0MM /T20 / L40MM -,SUP-662340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOCKING SCREW 5.0MM T20 L46MM -,SUP-662346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOCKING SCREW 5.0MM T20 L50MM -,SUP-662350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOCKING SCREW 5.0MM T20 L60MM -,SUP-662360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOCKING SCREW 5.0MM /T20 / L65MM -,SUP-662365,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOCKING SCREW 5.0MM T20 L70MM -,SUP-662370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2102.6,1471.82,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOCKING SCREW 5.0MM /T20 / L75MM -,SUP-662375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOCKING SCREW 5.0MM /T20 /L80MM -,SUP-662380,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2291.94,1604.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LCK 1.7 X 5 -,SUP-662505,CDM,C1713,HCPCS,278,RC,,,outpatient,,,497.14,347.998,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING T5 1.7MM X 9MM -,SUP-662509,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOCKING SCREW T5 1.7MM X 22MM -,SUP-662522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,497.14,347.998,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE 1.7 X 6 -,SUP-662606,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BONE SCREW T5 1.7MM X 8MM -,SUP-662608,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE 1.7 X 9 -,SUP-662609,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.7 X 11 NON LOCKING -,SUP-662611,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.7 X 15 -,SUP-662615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.7 X 16 NL -,SUP-662616,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.7 X 18 NL -,SUP-662618,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW EMERGENCY 1.9 X 5 -,SUP-662705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW EMERGENCY T5 1.9MM/L12MM 12 HOLE LEFT -,SUP-662712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,390.36,273.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANNULATED 4.0MM X 38MM COMP -,SUP-663038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WASHER 5MM -,SUP-663101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,202.42,141.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW JFX CANNULATED 5 X 46MM -,SUP-663146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IMPCTR HD XTRCT SHRT 3.2X19MM DURACN -,SUP-6633-7-615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,376.53,263.571,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SOLID COMPRESSION 4.0MM X 36MM L -,SUP-663436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SOLID COMPRESSION 4.0MM X 38MM -,SUP-663438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COMPRESSION SCREW SOLID A 4.0MM/ L40MM -,SUP-663440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SOLID COMPRESSION 4 X 22 -,SUP-663442,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
4.0 SOLID COMPRESSION SCREW 48MM -,SUP-663448,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SOLID COMPRESSION 4.0MM X L50MM -,SUP-663450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.32,2719.724,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SOLID COMPRESSION 5.0MM X 36MM L -,SUP-663536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SOLID COMP 5MM X 40MM -,SUP-663540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW COMPRESSION 5 X 42 -,SUP-663542,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
5.0MM L 44MM COMPRESSION SCREW -,SUP-663544,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COMPRESSION SCREW 5.0MM -,SUP-663546,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5 X 48 MM SOLID -,SUP-663548,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SOLID COMPRESSION 5.0MM X L50MM -,SUP-663550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3885.27,2719.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 2.3MM X 16MM -,SUP-663716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,498.89,349.223,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 2.3MM X 18MM -,SUP-663718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,498.89,349.223,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE 2.3 X 8 -,SUP-663808,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE 2.3  X 9 -,SUP-663809,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE 2.3 X 10 -,SUP-663810,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NON LOCKING 2.3MM X 13MM -,SUP-663813,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NON-LOCKING 2.3MM 16MM -,SUP-663816,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE 2.3 X 20 -,SUP-663820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW EMERGENCY  2.5 X 6 -,SUP-663906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW EMERGENCY 2.5 X 8 -,SUP-663908,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CORTEX SCREW DIA 4.0MM L38MM -,SUP-666138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,392.11,274.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CANLTD SCRW 16MM THREAD DIA 6.5MM L45MM -,SUP-666445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CANLTD SCREW 16MM THREAD DIA 6.5MM L50MM -,SUP-666450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CANLTD SCREW 16MM THREAD DIA 6.5MM L65MM -,SUP-666465,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANNULATED 6.5 X 70 -,SUP-666470,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANNULATED 6.5 X 80 -,SUP-666480,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANNULATED 6.5 X 85 -,SUP-666485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2286.64,1600.648,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER MOLD LG FEMORAL 53A/P X 75M/L -,SUP-669-1075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6663.08,4664.156,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GRIP CBL 1.6MM DLMLS VITAL -,SUP-6704-0-110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3931.1,2751.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CABLE ORTHO 1.6MM DLMLS VITAL MED GRP + 2 -,SUP-6704-0-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3931.1,2751.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GRIP LARGE W/2 CABLES DALL MIL -,SUP-6704-0-310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3931.1,2751.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CABLE ORTHO DLMLS 1.6MM VITAL BEAD SM SLV -,SUP-6704-0-420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CABLE ORTHO DLMLS 2MM VITAL MED SLV -,SUP-6704-0-510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DALL-MILES 2.0MM VIT BEADED CABLE/SLEEVE SET -,SUP-6704-0-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SET CABLE SLEEVE BEADED  2.0 D -,SUP-6704-0-520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1599.37,1119.559,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN DLMLS 100MM GRP VITAL MED 2MM CBLX2 -,SUP-6704-3-081,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4408.24,3085.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN DLMLS 150MM GRP VITAL MED 2MM CBLX2 -,SUP-6704-3-082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5744.68,4021.276,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE TROC DLMLS 110MM GRP LRG W/2 CBS -,SUP-6704-3-091,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4408.24,3085.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN DLMLS 160MM GRP VITAL LRG 2MM CBLX2 -,SUP-6704-3-092,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5744.68,4021.276,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CENTURION 3.5 X 12 -,SUP-69-3312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CENTURION 3.5 X 18 -,SUP-69-3318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CENTURION 3.5 X 12 -,SUP-69-3412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CENTURION 4.0 X 14 -,SUP-69-3414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CENTURION 4.0 X 30 -,SUP-69-3430,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CENTURION 4.5 X 30 -,SUP-69-3530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CENTURION 5.0 X 30 -,SUP-69-3630,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
STAPLE INTNL 12X23MM VITAL ELLISON LF -,SUP-6982-1-012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1703.05,1192.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
STAPLE INTNL 14X23MM VITAL ELLISON LF -,SUP-6982-2-014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1602.87,1122.009,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GRAFT BONE I FACTOR 2.5CC ALLOGRAFT PUTTY SYRINGE -,SUP-700-025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 8HL STR -,SUP-70-0095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 8HL STR -,SUP-70-0096,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 3.5MM 9HL LCK TI NS RT -,SUP-70-0116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.27,4447.289,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 3.5MM 9HL LCK TI NS LT -,SUP-70-0117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.27,4447.289,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 2.3MM 16HL LCK TI NS -,SUP-70-0124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6989.87,4892.909,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 2.3MM 13HL LCK TI NS -,SUP-70-0126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6353.27,4447.289,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 8HL LT CLAV LPRO TI STR NS -,SUP-70-0286,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 8HL RT CLAV LPRO TI STR NS -,SUP-70-0287,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN F/ELB PLATE SYS 8HL LCK TI LRG NS -,SUP-70-0289,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN F/ELB PLATE SYS 10HL LCK TI NS -,SUP-70-0294,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN F/ELB PLATE SYS 6HL LCK TI NS LT CLVCL -,SUP-70-0296,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN F/ELB PLATE SYS 6HL LCK TI NS RT CLVCL -,SUP-70-0297,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 8HL LT CLAV NRW-PRFL TI STR NS -,SUP-70-0298,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 8HL RT CLAV NRW-PRFL TI STR NS -,SUP-70-0299,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 8HL CONTR LCK TI LRG NS LT -,SUP-70-0300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 8HL CONTR LCK TI LRG NS RT -,SUP-70-0301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6319.32,4423.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 65MM 3HL CONTR LCK TI STD NS -,SUP-70-0302,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6535.76,4575.032,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 110MM 7HL CONTR LCK TI STD NS -,SUP-70-0306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7414.27,5189.989,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 90MM 5HL TAP-LCK TI EXTEND NS -,SUP-70-0313,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6535.76,4575.032,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEPIN ORTHO 2MM ASNIS III THRD -,SUP-7007-1300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
K-WIRE ASNIS III 3.2 -,SUP-702463S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,505.08,353.556,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
IRON BENDING -,SUP-702901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1136.85,795.795,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
AXSOS 5.0 ADAPTOR NUT -,SUP-702977,CDM,C1713,HCPCS,278,RC,,,outpatient,,,559.11,391.377,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOW PROFILE HEX 6.5 X 15 -,SUP-7030-6515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEX LOW PROFILE 6.5MM X 20MM -,SUP-7030-6520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MM LOW PROFILE HEX -,SUP-7030-6525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEX 6.5MM X 30MM LOW PROFILE -,SUP-7030-6530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEX 6.5MM X 35MM LOW PROFILE -,SUP-7030-6535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
6.5x40MM LOW PROFILE HEX SCREW -,SUP-7030-6540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
6.5X45MM LOW PROFILE HEX SCREW -,SUP-7030-6545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
6.5x50MM LOW PROFILE HEX SCREW -,SUP-7030-6550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOW PROFILE HEX 6.5MM x 55MM -,SUP-7030-6555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
IMPLANT HIP 7X35MM POR TI PLASM SPRY SCRILAC IFUSE STRL -,SUP-7035-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDE WIRE WITH CALIBRATION 3.2MM X 230MM QUICK RELEASE -,SUP-705237,CDM,C1713,HCPCS,278,RC,,,outpatient,,,606.84,424.788,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ELEVATOR PERIOSTEAL 6MM ROUND EDGE -,SUP-705294,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1361.01,952.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
IMPLANT HIP 7X65MM POR TI PLASM SPRY SCRILAC IFUSE STRL -,SUP-7065-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN EXTFIX 3X120MM 16MM THRD COVE PNT -,SUP-71022001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN EXTFIX 3X120MM 22MM THRD COVE PNT -,SUP-71022002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN EXTFIX 3X120MM 28MM THRD COVE PNT -,SUP-71022003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X70MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X80MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X85MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X95MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X110MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X130MM CANN 32MM THRD SD/ST REVCT FLUT -,SUP-71100130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2801.62,1961.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 58MM 3.5MM 5HL RECON STR -,SUP-71140105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4158.44,2910.908,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 70MM 3.5MM 6HL RECON STR -,SUP-71140106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4651.85,3256.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 82MM 3.5MM 7HL RECON STR -,SUP-71140107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4446.01,3112.207,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 94MM 3.5MM 8HL RECON STR -,SUP-71140108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5084.1,3558.87,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 75MM 3.5MM 6HL SM T-SHP RT ANG -,SUP-71140406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2349.66,1644.762,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WASHER ORTHO 3.7X7MM SS -,SUP-71143107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,441.48,309.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 87MM 9HL Y STRL TMPLT -,SUP-71144012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7101.27,4970.889,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TROCAR PIN GEN 1/8 X 3 -,SUP-71210002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.63,108.241,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEPIN ORTHO 3MM GENESIS 12.5CM TROC TIP -,SUP-71210003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.63,108.241,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MM MINI 16MM CORT TC-100 FT HEX HEAD SS -,SUP-71220016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,359.67,251.769,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 15MM REF SPHER HEAD -,SUP-71332515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,811.07,567.749,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 20MM REF SPER HEAD -,SUP-71332520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,811.07,567.749,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CABLE ORTHO 2MM ACCORD COCR -,SUP-71340020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,977.36,684.152,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
INSERT PS LGN XLPE SZ 3-4 11MM -,SUP-71453247,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4520.12,3164.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ENDCAP ORTHO 0MM TRIGEN STRL -,SUP-71634000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2293.1,1605.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ENDCAP PROT 5MM TI STRL TRIGEN F/OB GYNAECOLOGICAL PROC TIB -,SUP-71634005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2293.1,1605.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ENDCAP ORTHO 20MM TRIGEN STRL -,SUP-71634020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2293.1,1605.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX25MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2401.07,1680.749,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX30MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX35MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642135,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX40MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX45MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX55MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MMX65MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR -,SUP-71642165,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5MMX20MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5MMX25MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5MMX35MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5MMX50MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5MMX60MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5MMX65MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642265,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5MMX75MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642275,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X35MM TRIGEN -,SUP-71645035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X45MM TRIGEN -,SUP-71645045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10X380MM TRIGEN TAN CANN LT TROCH FEM TI ALY ANTGRD -,SUP-71647238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15450.91,10815.637,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11.5X380MM TRIGEN TAN CANN LT TROCH FEM TI ALY -,SUP-71647338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15450.91,10815.637,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10X320MM TRIGEN META-NAIL CANN DIST FEM TI ALY RTRGD -,SUP-71653032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14208.35,9945.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 8.5X330MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655033,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 8.5X340MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 8.5X350MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10X280MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10X290MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655129,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10MMX30CM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10X310MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655131,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10X320MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10X340MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10X350MM TRIGEN META-NAIL CANN PROX TIB TI ALY RTRGD -,SUP-71655135,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10MMX37CM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655137,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11.5X300MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11.5X360MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11.5X390MM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655239,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11.5MMX40CM TRIGEN META-NAIL CANN PROX TIB TI ALY -,SUP-71655240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13884.21,9718.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEPIN ORTHO 3.2MM TRIGEN 343MM THRD BRAD TIP -,SUP-71674130,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1491.03,1043.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10X180MM TRIGEN INTERTAN 1.5 CANN TROCH FEM TI 125DG -,SUP-71675201,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11.5X180MM TRIGEN INTERTAN 1.5 CANN TROCH FEM TI -,SUP-71675202,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 13X180MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675203,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675204,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11.5X200MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 13X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10X180MM TRIGEN INTERTAN 1.5 CANN TROCH FEM TI 130DG -,SUP-71675207,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11.5MM 180MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP -,SUP-71675208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 13X180MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71675209,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71675210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13055.84,9139.088,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10X320MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP -,SUP-71675219,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10MMX32CM TRIGEN INTERTAN 1.5 CANN INTST HIP TI -,SUP-71675220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675221,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675222,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CAN LT INTS HIP TI LIME -,SUP-71675223,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI125 -,SUP-71675224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10X380MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10X400MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP -,SUP-71675227,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11.5X320MM TRIGEN INTERTAN 1.5 CANN RT INTS HIP TI.. -,SUP-71675242,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675243,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71675244,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11.5X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675245,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71675246,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI_ -,SUP-71675250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11.5X420MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675251,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI130 -,SUP-71675268,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 13X280MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 13X320MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 13MMX32CM TRIGEN INTERTAN 1.5 CANN INTST HIP TI -,SUP-71675408,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 13X340MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675409,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 13X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675411,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 13X180MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71675412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 13X380MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675413,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 13X400MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71675415,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 13X400MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 13X440MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71675420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10X320MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71676507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TIRSE -,SUP-71676510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10X360MM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI. -,SUP-71676511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10X200MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676513,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10X380MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11.5X320MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI- -,SUP-71676552,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN LT INTS HIP TI.. -,SUP-71676553,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11.5X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI- -,SUP-71676554,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11.5MMX36CM TRIGEN INTERTAN 1.5 CANN LT INTST HIP TI -,SUP-71676555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11.5X360MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676556,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11.5X380MM TRIGEN INTERTAN 1.5 CANN LT INTST TI -,SUP-71676557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11.5MMX38CM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71676558,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11.5X400MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 13X340MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71676598,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 13X360MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI. -,SUP-71676600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 13X380MM TRIGEN INTERTAN 1.5 CANN RT INTST HIP TI -,SUP-71676602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17431.79,12202.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 70MM/75MM -,SUP-71677075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 75MM/80MM -,SUP-71677080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 80MM/85MM -,SUP-71677085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 85MM/90MM -,SUP-71677090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI 90MM/95MM -,SUP-71677095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI_ -,SUP-71677100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI- -,SUP-71677105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI.. -,SUP-71677110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 7MM/11MM DIA TRIGEN INTERTAN COMPR LAG TI. -,SUP-71677115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6380.85,4466.595,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 11MM TRIGEN INTERTAN LAG 100MM -,SUP-71678010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 11X110MM LAG TRIGEN INTERTAN -,SUP-71678011,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 11X115MM TRIGEN INTERTAN SBTRCHNTRC TI -,SUP-71678015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 11MM TRIGEN INTERTAN LAG 85MM -,SUP-71678085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 11MM TRIGEN INTERTAN LAG 90MM -,SUP-71678090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 11MM TRIGEN INTERTAN LAG 95MM -,SUP-71678095,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5125.27,3587.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEPIN ORTHO 3.2MMX24.8CM THRD DRILL TIP -,SUP-71751147,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1938.34,1356.838,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X20MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X22MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X24MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X30MM LCK CORT TRIGEN ST TI F/NAIL SYS -,SUP-71754030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1964.05,1374.835,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X24MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X26MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X30MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X32MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X34MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X36MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X38MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X40MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X42MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X44MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X46MM LCK CANC TRIGEN ST HEX HEAD TI GRN F/NAIL SYS -,SUP-71755046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2375.37,1662.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 8/ 7MMLNGX260MM TRIGEN CANN PROX HUM TI ALY -,SUP-71770826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 9/ 7.5MMLNGX240MM TRIGEN CANN PROX HUM TI ALY -,SUP-71770924,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10/ 8.5MMLNGX220MM TRIGEN CANN PROX HUM TI ALY -,SUP-71771022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10/ 8.5MMLNGX240MM TRIGEN CANN PROX HUM TI ALY -,SUP-71771024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 10/ 8.5MMLNGX280MM TRIGEN CANN PROX HUM TI ALY -,SUP-71771028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13938.23,9756.761,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC 193MM 4.5MM 8HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16207.25,11345.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC 286MM 4.5MM 13HL CONTR SCALLP LCK SS BVL LT -,SUP-71800013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17251.71,12076.197,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC 342MM 4.5MM 16HL CONTR SCALLP LCK SS BVL LT -,SUP-71800016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17575.86,12303.102,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC 193MM 4.5MM 8HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16207.25,11345.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC 342MM 4.5MM 16HL CONTR SCALLP LCK SS BVL RT -,SUP-71800116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17575.86,12303.102,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC 94MM 4.5MM 4HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800304,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17341.75,12139.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC 130MM 4.5MM 6HL CONTR SCALLP LCK SS BVL TIP -,SUP-71800306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17575.86,12303.102,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 93MM 4.5MM 3HL CONTR SCALLP LCK BVL TIP -,SUP-71801603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17053.62,11937.534,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X10MM CORT PERILOC ST SS -,SUP-71804010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X12MM CORT PERILOC ST SS -,SUP-71804012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X14MM CORT PERILOC ST SS -,SUP-71804014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X16MM CORT PERILOC ST SS -,SUP-71804016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X18MM CORT PERILOC ST SS -,SUP-71804018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X20MM CORT PERILOC ST SS -,SUP-71804020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X24MM CORT PERILOC ST SS -,SUP-71804024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X32MM CORT PERILOC ST SS -,SUP-71804032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X34MM CORT PERILOC ST SS -,SUP-71804034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X36MM CORT PERILOC ST SS -,SUP-71804036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X38MM CORT PERILOC ST SS -,SUP-71804038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X40MM CORT PERILOC ST SS -,SUP-71804040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X50MM CORT PERILOC ST SS -,SUP-71804050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X55MM CORT PERILOC ST SS -,SUP-71804055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X60MM CORT PERILOC ST SS -,SUP-71804060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X12MM LCK CORT PERILOC ST SS -,SUP-71805012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1866.36,1306.452,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X20MM LCK CORT PERILOC ST SS -,SUP-71805020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1866.36,1306.452,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X14MM CANC PERILOC FT SS -,SUP-71805214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,496.09,347.263,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X36MM CORT PERILOC ST SS -,SUP-71806036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X38MM CORT PERILOC ST SS -,SUP-71806038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X40MM CORT PERILOC ST SS -,SUP-71806040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X42MM NLCKG CORT PERILOC ST SS -,SUP-71806042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X46MM NLCKG CORT PERILOC ST SS -,SUP-71806046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X50MM NLCKG CORT PERILOC ST SS -,SUP-71806050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X70MM NLCKG CORT PERILOC ST SS -,SUP-71806070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X32MM LCK CORT PERILOC ST SS -,SUP-71807032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X34MM LCK CORT PERILOC ST SS PERIART -,SUP-71807034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X36MM LCK CORT PERILOC ST SS PERIART -,SUP-71807036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X38MM LCK CORT PERILOC ST SS -,SUP-71807038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X48MM LCK CORT PERILOC ST SS -,SUP-71807048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X56MM LCK CORT PERILOC ST SS -,SUP-71807056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X58MM LCK CORT PERILOC ST SS -,SUP-71807058,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X60MM LCK CORT PERILOC ST SS PERIART -,SUP-71807060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X74MM LCK CORT PERILOC ST SS -,SUP-71807074,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2221.12,1554.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.7X65MM LCK CANN PERILOC FT SS -,SUP-71808065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC 193MM 4.5MM 13HL CONTR SCALLP LCK SS BVL -,SUP-71820008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12497.59,8748.313,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 230MM 4.5MM 10HL CONTR SCALLP LCK SS BVL TIP -,SUP-71820010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12767.71,8937.397,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC 98MM 3.5MM 6HL CONTR SCALLP LCK SS BVL TIP -,SUP-71820506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13524.05,9466.835,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 196MM 3.5MM 10HL CONTR SCALLP LCK BVL TIP -,SUP-71821010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15522.94,10866.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X34MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X36MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X40MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X50MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X55MM PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG ANG -,SUP-71821155,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X60MM LCK PERILOC VLP P/T 2.5MM STD HX HD RCESS 15DG -,SUP-71821160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX6MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821206,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
RETRACTOR EYELID DSMRS 1.12MMX5.5IN STN FNSH LID V. MUELLER -,SUP-71821208,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
RETRACTOR LNG ALLISON 12.25IN 2.125IN BLD SS F/CV V. MUELLER -,SUP-71821210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX12MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX14MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821214,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX16MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX18MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821218,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX22MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821222,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX24MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX26MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821226,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX28MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX30MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX34MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821234,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX36MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX40MM LCK CORT PERILOC VLP FT ST VAR ANG FLUTX3 -,SUP-71821240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1835.51,1284.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC 89MM 3.5MM 3HL CONTR LCK SS BVL TIP -,SUP-71821303,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14982.7,10487.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX6MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM STD -,SUP-71821306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX8MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM STD -,SUP-71821308,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX10MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX12MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX14MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX16MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX18MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX20MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX22MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX24MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX26MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX28MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX32MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821332,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX34MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821334,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX36MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX38MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821338,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX40MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX44MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821344,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX46MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX50MM LCK CORT PERILOC VLP FT ST VAR ANG 2.5MM -,SUP-71821350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,357.45,250.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC 89MM 3.5MM 3HL CONTR LCK SS BVL TIP NS -,SUP-71821403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14982.7,10487.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC 115MM 3.5MM 5HL CONTR LCK SS BVL TIP -,SUP-71821405,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15414.89,10790.423,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC 79MM 2.7/3.5MM 5HL CONTR LCK SS BVL TIP -,SUP-71821805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11921.33,8344.931,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5MMX10MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5MMX12MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5MMX14MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5MMX16MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX18MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5MMX20MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5MMX38MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX40MM LCK CORT PERILOC VLP FT CP 2.5MM STD HX HD -,SUP-71822040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1013.13,709.191,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X10MM LCK CORT PERILOC FT ST SS NS -,SUP-71822310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X12MM LCK CORT PERILOC FT ST SS NS -,SUP-71822312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X14MM LCK CORT PERILOC FT ST SS NS -,SUP-71822314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X16MM LCK CORT PERILOC FT ST SS NS -,SUP-71822316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X18MM LCK CORT PERILOC FT ST SS NS -,SUP-71822318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X20MM LCK CORT PERILOC FT ST SS NS -,SUP-71822320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X24MM LCK CORT PERILOC FT ST SS NS -,SUP-71822324,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X28MM LCK CORT PERILOC FT ST SS NS -,SUP-71822328,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X30MM LCK CORT PERILOC FT ST SS NS -,SUP-71822330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X36MM LCK CORT PERILOC FT ST SS NS -,SUP-71822336,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X40MM LCK CORT PERILOC FT ST SS NS -,SUP-71822340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X45MM LCK CORT PERILOC FT ST SS NS -,SUP-71822345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X50MM LCK CORT PERILOC FT ST SS NS -,SUP-71822350,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.08,917.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X60MM LCK CORT PERILOC FT ST SS NS -,SUP-71822360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1413.91,989.737,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5X10MM LCK CORT PERILOC FT ST SS -,SUP-71822410,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5X12MM LCK CORT PERILOC FT ST SS -,SUP-71822412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5X14MM LCK CORT PERILOC FT ST SS -,SUP-71822414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5X16MM LCK CORT PERILOC FT ST SS -,SUP-71822416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5X18MM LCK CORT PERILOC FT ST SS -,SUP-71822418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5X20MM LCK CORT PERILOC FT ST SS -,SUP-71822420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5X22MM LCK CORT PERILOC FT ST SS -,SUP-71822422,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5X24MM LCK CORT PERILOC FT ST SS -,SUP-71822424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5X26MM LCK CORT PERILOC FT ST SS -,SUP-71822426,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1419.05,993.335,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 153MM 2.7MM 11HL CONTR SS BVL TIP -,SUP-71822511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14982.7,10487.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC 80MM 2.7/3.5MM 5HL CONTR LCK SS BVL TIP -,SUP-71822705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12245.47,8571.829,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC 81MM 6HL LCK SS CORNL BND -,SUP-71822906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14406.44,10084.508,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC 107MM 8HL LCK SS CORNL BND -,SUP-71822908,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15522.94,10866.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MMX10MM LCK CORT PERILOC VLP ST VAR ANG CP 2.5MM -,SUP-71823010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MMX12MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MMX14MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MMX16MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MMX18MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DIRECTOR ORAL NO. 2522 7.25IN V. MUELLER SS GZE LIG TUCKER -,SUP-71823020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MMX22MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MMX24MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MMX26MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MMX30MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MMX40MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MMX45MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MMX50MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MMX55MM LCK CORT PERILOC VLP ST VAR ANG FLUTX3 -,SUP-71823055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,368.19,257.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7MMX60MM LCK CORT PERILOC VLP ST FLUTX3 2.5MM STD HX -,SUP-71823060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,611.27,427.889,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC 62MM 2.5MM 3HL STD HEAD LCK SS -,SUP-71823110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC 86MM 2.5MM 5HL STD HEAD LCK SS LT VOLAR -,SUP-71823112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9562.27,6693.589,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC 62MM 2.5MM 3HL HEAD LCK SS STD -,SUP-71823114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC 86MM 2.5MM 5HL STD HEAD LCK SS RT VOLAR -,SUP-71823116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9562.27,6693.589,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC 62MM 2.5MM 3HL W HEAD LCK SS LT VOLAR RADL -,SUP-71823118,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC 62MM 2.5MM 3HL W HEAD LCK SS RT VOLAR RADL -,SUP-71823122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10312.28,7218.596,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC 97MM 3.5MM 8HL LCK SS -,SUP-71823401,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8830.28,6181.196,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC 109MM 3.5MM 6HL LCK SS LT CLVCL -,SUP-71823403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9036.11,6325.277,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC 109MM 3.5MM 6HL LCK SS RT CLVCL -,SUP-71823404,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9036.11,6325.277,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC 81MM 2.7MM LCK SS -,SUP-71823407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9036.11,6325.277,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC 81MM 6HL LCK SS -,SUP-71823906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14406.44,10084.508,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X10MM NLCKG CORT PERILOC ST SS -,SUP-71824010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X16MM NLCKG CORT PERILOC ST SS -,SUP-71824016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X22MM NLCKG CORT PERILOC ST SS -,SUP-71824022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X24MM NLCKG CORT PERILOC ST SS -,SUP-71824024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X26MM NLCKG CORT PERILOC ST SS -,SUP-71824026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X28MM NLCKG CORT PERILOC ST SS -,SUP-71824028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X30MM NLCKG CORT PERILOC ST SS -,SUP-71824030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X50MM NLCKG CORT PERILOC ST SS -,SUP-71824050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,284.69,199.283,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X18MM LCK CORT PERILOC ST SS -,SUP-71825018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X22MM LCK CORT PERILOC ST SS -,SUP-71825022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X24MM LCK CORT PERILOC ST SS -,SUP-71825024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X26MM LCK CORT PERILOC ST SS -,SUP-71825026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X28MM LCK CORT PERILOC ST SS -,SUP-71825028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X30MM LCK CORT PERILOC ST SS -,SUP-71825030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X32MM LCK CORT PERILOC ST SS -,SUP-71825032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X34MM LCK CORT PERILOC ST SS -,SUP-71825034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1439.62,1007.734,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X50MM LCK CORT PERILOC ST SS -,SUP-71825050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X55MM LCK CORT PERILOC ST SS -,SUP-71825055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X60MM LCK CORT PERILOC ST SS -,SUP-71825060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X65MM LCK CORT PERILOC ST SS -,SUP-71825065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X80MM LCK CORT PERILOC ST SS -,SUP-71825080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X10MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X12MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825212,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X16MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X18MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825218,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X36MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825236,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X45MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825245,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X50MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X60MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X65MM LCK CANC PERILOC FT HEX HEAD SS -,SUP-71825265,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X35MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825335,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X40MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825340,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X45MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X55MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X60MM LCK CANC PERILOC P/T HEX HEAD SS -,SUP-71825360,CDM,C1713,HCPCS,278,RC,,,outpatient,,,383.77,268.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X26MM NLCKG CORT PERILOC ST SS -,SUP-71826026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X30MM NLCKG CORT PERILOC ST SS -,SUP-71826030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X34MM NLCKG CORT PERILOC ST SS -,SUP-71826034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X40MM NLCKG CORT PERILOC ST SS -,SUP-71826040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X44MM NLCKG CORT PERILOC ST SS -,SUP-71826044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X48MM NLCKG CORT PERILOC ST SS -,SUP-71826048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X52MM NLCKG CORT PERILOC ST SS -,SUP-71826052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X60MM NLCKG CORT PERILOC ST SS -,SUP-71826060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X68MM NLCKG CORT PERILOC ST SS -,SUP-71826068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.05,224.035,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X72MM NLCKG CORT PERILOC ST SS -,SUP-71826072,CDM,C1713,HCPCS,278,RC,,,outpatient,,,594.29,416.003,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X74MM NLCKG CORT PERILOC ST SS -,SUP-71826074,CDM,C1713,HCPCS,278,RC,,,outpatient,,,594.29,416.003,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X10MM LCK CORT PERILOC ST SS -,SUP-71827010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X12MM LCK CORT PERILOC ST BLNT TIP SS -,SUP-71827012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X18MM LCK CORT PERILOC ST SS -,SUP-71827018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X20MM LCK CORT PERILOC ST SS -,SUP-71827020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X24MM LCK CORT PERILOC ST SS -,SUP-71827024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X26MM LCK CORT PERILOC ST SS -,SUP-71827026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X28MM LCK CORT PERILOC ST SS -,SUP-71827028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X30MM LCK CORT PERILOC ST SS -,SUP-71827030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X32MM LCK CORT PERILOC ST SS -,SUP-71827032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X34MM LCK CORT PERILOC ST SS -,SUP-71827034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X36MM LCK CORT PERILOC ST SS PROX FEM -,SUP-71827036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X40MM LCK CORT PERILOC ST SS -,SUP-71827040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X42MM LCK CORT PERILOC ST SS -,SUP-71827042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X46MM LCK CORT PERILOC ST SS -,SUP-71827046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X50MM LCK CORT PERILOC ST SS -,SUP-71827050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X52MM LCK CORT PERILOC ST SS -,SUP-71827052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X60MM LCK CORT PERILOC ST SS PROX FEM -,SUP-71827060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X66MM LCK CORT PERILOC ST SS -,SUP-71827066,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X68MM LCK CORT PERILOC ST SS -,SUP-71827068,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X70MM LCK CORT PERILOC ST SS -,SUP-71827070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1924.08,1346.856,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X70MM LCK CORT PERILOC ST SS -,SUP-71827070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X72MM LCK CORT PERILOC ST SS -,SUP-71827072,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X76MM LCK CORT PERILOC ST SS -,SUP-71827076,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X80MM LCK CORT PERILOC ST SS -,SUP-71827080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X85MM LCK CORT PERILOC ST SS -,SUP-71827085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1928.06,1349.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X90MM LCK CORT PERILOC ST SS -,SUP-71827090,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1979.47,1385.629,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.7MMX20MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.7MMX25MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828025,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.7MMX35MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.7MMX40MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.7MMX45MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.7MMX50MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.7MMX55MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
RETRACTOR UTR DE LEE UNIV 2INX2.75IN 9.5IN HNDL SS V.MUELLER -,SUP-71828060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.7MMX65MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.7MMX70MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.7MMX80MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.7MMX85MM LCK CANN PERILOC FT SD/ST CUT FLUTX3 SS -,SUP-71828085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3514.76,2460.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC CONTR + 57MM 3.5MM 4HL LCK COMPR SS 1/3 -,SUP-71829004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2601.59,1821.113,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC CONTR + 82MM 3.5MM 6HL LCK COMPR SS 1/3 -,SUP-71829006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2601.59,1821.113,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC CONTR + 107MM 3.5MM 8HL LCK COMPR SS 1/3 -,SUP-71829008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2533.04,1773.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC 93MM F/3.5MM 6HL NLCKG COMPR SS 1/3 TBLR SM -,SUP-71829406,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2395.93,1677.151,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 106MM 3.5MM 7HL NLCKG COMPR 1/3 TBLR SM FRAG -,SUP-71829407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2514.19,1759.933,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 50MM 4.33HL TBLR NS -,SUP-71829434,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.31,800.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 62MM 5.33HL TBLR NS -,SUP-71829435,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.31,800.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 74MM 6.33HL TBLR NS -,SUP-71829436,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1064.29,745.003,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 86MM 7.33HL TBLR NS -,SUP-71829437,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1064.29,745.003,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 98MM 8.33HL TBLR NS -,SUP-71829438,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1095.14,766.598,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 122MM 10.33HL TBLR NS -,SUP-71829440,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1095.14,766.598,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 70MM 3.5MM 6HL RECON SM FRAG -,SUP-71829516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4693.02,3285.114,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 94MM 3.5MM 8HL RECON -,SUP-71829518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5145.85,3602.095,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC 96MM F/3.5MM SM MUL FRAG SYS 6HL LCK COMPR -,SUP-71829706,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4528.9,3170.23,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCR- SFTSLK-2.0 PKG.7X20 STER -,SUP-7207256,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SOFTSILK 2.0 7 X 25 -,SUP-7207257,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCR- SFTSLK-2.0 PKG.8X20 STER -,SUP-7207259,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SOFTSILK 2.0 8 X 25 -,SUP-7207260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1249.7,874.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DEVICE SUT ARSCP ENDBTTN CL 30MM STRL LF -,SUP-7210082,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DEVICE SUT ARSCP ENDBTTN CL 35MM STRL LF -,SUP-7210083,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DEVICE SUT ARSCP ENDBTTN CL 40MM STRL LF -,SUP-7210084,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BUTTONENDO CL BTB STER 45MM -,SUP-7210085,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1999.45,1399.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BUTTON ENDO 15MM CL -,SUP-7220-0146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.98,1373.386,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ULTRA FAST FIX CURVED -,SUP-7220-1494,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2143.15,1500.205,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUT FTPRNT 5.5MM ARSCP NABSB OUTR SHL INR PLG -,SUP-7220-1697,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2143.95,1500.765,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW INTFR CANN BIOSURE 9X25MM ABSB TAPR PLLA HAP KN -,SUP-72201781,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1574.57,1102.199,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SUT ANCHOR OSTEORAPTOR  2.9 -,SUP-72201995,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2049.44,1434.608,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FAST-FIX 360 STRAIGHT -,SUP-72202467,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2543.73,1780.611,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FAST FIX 360 CVD NEEDLE -,SUP-72202468,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2543.73,1780.611,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FAST-FIX 360 REVERSE CURVED -,SUP-72202469,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2543.73,1780.611,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDE DRILL SZ1.2 ENDBTTN CL ULTRA PAC -,SUP-7220-2799,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2118.19,1482.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUTURE 4.5MM HEALICOIL -,SUP-7220-3378,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2261.88,1583.316,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR HEALICOIL 4.75MM REGENE -,SUP-72203697,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3911.82,2738.274,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR HEALICOIL 4.75MM -,SUP-72203704,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2249.43,1574.601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW EVOS 2.7MM X 17MM CTX -,SUP-72402717,CDM,C1713,HCPCS,278,RC,,,outpatient,,,400.46,280.322,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW EVOS 2.7MM X 24MM CTX -,SUP-72402724,CDM,C1713,HCPCS,278,RC,,,outpatient,,,188.59,132.013,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW EVOS 3.5MM X 14MM CTX -,SUP-72403514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,135.9,95.13,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW EVOS 3.5MM X 15MM CTX -,SUP-72403515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW EVOS 3.5MM X 16MM CTX -,SUP-72403516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW EVOS 3.5MM X 17MM CTX -,SUP-72403517,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW EVOS 3.5MM X 18MM CTX -,SUP-72403518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,288.07,201.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW EVOS 2.7MM X 18MM LCK -,SUP-72412718,CDM,C1713,HCPCS,278,RC,,,outpatient,,,598.38,418.866,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW EVOS 2.7MM X 19MM LCK -,SUP-72412719,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.55,802.585,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW EVOS 2.7MM X 20MM LCK -,SUP-72412720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1146.55,802.585,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE EVOS VOLAR 10H R STD 138MM -,SUP-72468210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8021.16,5614.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC VLP 64MM 3.5MM 4HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10840.85,7588.595,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC VLP 72MM 3.5MM 5HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0205,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8521.53,5965.071,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC VLP 47MM 3.5MM 3HL VAR ANG CONTR LCK SS -,SUP-7282-0303,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7945.19,5561.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC VLP 89MM 3.5MM 3HL VAR ANG CONTR LCK SS -,SUP-7282-0603,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10840.85,7588.595,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC VLP 89MM 3.5MM 3HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10840.85,7588.595,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC VLP 62MM 3.5MM 5HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0805,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6051.52,4236.064,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC VLP 86MM 3.5MM 7HL 1.5-MM VAR ANG CONTR LCK -,SUP-7282-0807,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7163.02,5014.114,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC VLP 74MM 3.5MM 6HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0906,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6607.27,4625.089,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC VLP 86MM 3.5MM 7HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-0907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7163.02,5014.114,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC VLP 59MM 3.5MM 3HL 1.5MM VAR ANG CONTR LCK -,SUP-7282-1003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7060.11,4942.077,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC VLP 71MM 3.5MM 4HL VAR ANG CONTR LCK SS LT -,SUP-7282-1004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7492.36,5244.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC VLP 83MM 3.5MM 5HL VAR ANG CONTR LCK SS LT -,SUP-7282-1005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7924.61,5547.227,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC VLP 107MM 3.5MM 7HL 2MM VAR ANG CONTR LCK -,SUP-7282-1007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8336.28,5835.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC VLP 131MM 3.5MM 9HL VAR ANG CONTR LCK SS LT -,SUP-7282-1009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8830.28,6181.196,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC VLP 59MM 3.5MM 3HL VAR ANG CONTR LCK SS -,SUP-7282-2003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6977.77,4884.439,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC VLP 71MM 3.5MM 4HL VAR ANG CONTR LCK SS -,SUP-7282-2004,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7451.19,5215.833,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC VLP 83MM 3.5MM 5HL VAR ANG CONTR LCK SS RT -,SUP-7282-2005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7862.86,5504.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC VLP 131MM 3.5MM 9HL VAR ANG CONTR LCK SS RT -,SUP-7282-2009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8768.53,6137.971,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC VLP 62MM 3.5MM 5HL VAR ANG CONTR LCK SS -,SUP-7282-3005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2852.56,1996.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC VLP 74MM 3.5MM 6HL VAR ANG CONTR LCK SS -,SUP-7282-3006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3223.02,2256.114,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERILOC VLP 86MM 3.5MM 7HL VAR ANG CONTR LCK SS -,SUP-7282-3007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3570.33,2499.231,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LCK ORLMXLFCL 2.4X14MM STERNALOCK SD TI GOLD -,SUP-73-2414,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LCK ORLMXLFCL 2.4X16MM STERNALOCK SD TI GOLD -,SUP-73-2416,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LCK ORLMXLFCL 2.4X18MM STERNALOCK SD TI GOLD -,SUP-73-2418,CDM,C1713,HCPCS,278,RC,,,outpatient,,,460.97,322.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LCK ORLMXLFCL 2.4X20MM STERNALOCK SD TI GOLD -,SUP-73-2420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,460.97,322.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE ORLMXLFCL 8HL STERNALOCK 4HL BX TI BLU -,SUP-73-2622,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2835.76,1985.032,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE ORLMXLFCL 12HL STERNALOCK LDDR TI BLU -,SUP-73-2632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4401.63,3081.141,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE ORLMXLFCL 12HL STERNALOCK W LDDR TI BLU -,SUP-73-2634,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4401.63,3081.141,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE STRNM 8HL JL SHP STERNALOCK BLU TI -,SUP-73-2645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4124.74,2887.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COMP JRNY II CR FEM OX NP LT SZ 6 -,SUP-74021166,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BASEPLATE TIBIA JOURNEY NP LT SZ 5 -,SUP-74022225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
INSERT JOURNEY II CR XLPE RT SZ 5-6 9MM -,SUP-74025661,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
MESH CAGE 30MM H -,SUP-74-1030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE NGAGE 16MM X 12MM CORPECT -,SUP-74-1216,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE N-GAGE TI 16 X 50MM -,SUP-74-1650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TONIER HUMERAL NAIL DISTAL SCREW 4.3MM X 20MM -,SUP-7424520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TONIER HUMERAL NAIL DISTAL SCREW 4.3MM X 22MM -,SUP-7424522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAP END N-GAGE ZERO DEGREE -,SUP-74-5016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ENDCAP 2.5 DEG 10MM -,SUP-74-6010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAP NPLATE 7.5 DEGREE -,SUP-74-6012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NUT LCK F/C IN ADVANCED IMPL SYS -,SUP-7642,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.87,143.409,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SET SCREW SPIN 6.35MM CD HORIZN LEGC SS -,SUP-7660000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,869.18,608.426,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5X35MM FIREBIRD DBL LD THRD ST CANN TI GRN -,SUP-77-8535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5X40MM FIREBIRD DBL LD THRD ST CANN TI GRN -,SUP-77-8540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5X45MM FIREBIRD DBL LD THRD ST CANN GRN -,SUP-77-8545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X35MM FIREBIRD DBL LD THRD ST CANN TI GOLD -,SUP-77-8635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X40MM FIREBIRD DBL LD THRD ST CANN GOLD -,SUP-77-8640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X45MM FIREBIRD DBL LD THRD ST CANN TI GOLD -,SUP-77-8645,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X50MM FIREBIRD DBL LD THRD ST CANN TI GOLD -,SUP-77-8650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
3.5MM COCR ROD- 240MM -,SUP-782.803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SET -,SUP-79-2003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CABLE SPIN 1.2MM TI DBL LOP INTGR CRIMPX2 STRL -,SUP-7925011S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1755.53,1228.871,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SUBSTITUTE CA PHOS HAP 5ML PTTY CMNT INJ HYDR ST SYNTH -,SUP-79-43905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6318.89,4423.223,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CEMENT BN CA PHOS HAP 10ML HYDR ST -,SUP-79-43910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10521.16,7364.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SUBSTITUTE CA PHOS HAP 15ML PTTY CMNT INJ HYDR ST SLF-SET -,SUP-79-43915,CDM,C1713,HCPCS,278,RC,,,outpatient,,,15098.17,10568.719,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEPIN ORTHO 2.5MM HEMICAP -,SUP-8007-1200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,519.32,363.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
IMPLANT SHT CRANFC 50X76MM 0.85MM MEDPOR EMBD TI MSH F/RECON -,SUP-81020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5562.27,3893.589,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
MESH TITAN SHEET MTB 76 X 50 X 1MM -,SUP-81027,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6586.43,4610.501,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
IMPLANT PE SHT EMBD TI MSH CRANFC 50X76MM -,SUP-81029,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6345.33,4441.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
IMPLANT SHT 76X100MM 1.5MM MEDPOR TITAN MAX F/CRANFC -,SUP-81040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10857.55,7600.285,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X12MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X14MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X16MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X18MM NLCKG CORT ALPS FT ST HX DRV TMX NS -,SUP-814027018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN SPIDER 20MM TMX -,SUP-814100003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERI 70.1MM 5HL COMPR TMX TBLR BLLT -,SUP-814123005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,980.28,686.196,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PE.R.I. 83.1MM 6HL COMP TIMEX 1/3 TBLR -,SUP-814123006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 95.5MM 7HL COMPR COMP TBLR BLLT-SHP -,SUP-814123007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PERI 109.2MM 30MM COMPR TMX TBLR BLLT -,SUP-814123008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PE.R.I. 122.2MM 9HL NLCKG PERMTR RDC COMP TBLR -,SUP-814123009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 179.4MM 6HL LCK SHFT STRL -,SUP-814130106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN POLYAX 233.5MM 9HL LCK TMX STRL -,SUP-814131109,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 287.6MM 12HL LCK SHFT -,SUP-814131112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN POLYAX 99.6MM 2HL PRCONT LCK TMX STRL -,SUP-814133002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6722.5,4705.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 13MMSHRTX180MM AFFIXUS TROCH ANTGRD AN-ROT 125DG ANG -,SUP-814313180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7282.7,5097.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 10.5MM AFFIXUS CANN LAG THRD ST TMX 80MM -,SUP-814510080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3265.42,2285.794,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 10.5MM AFFIXUS CANN LAG THRD ST TMX 105MM -,SUP-814510105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3265.42,2285.794,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 13MMSHRTX180MM AFFIXUS TROCH ANTGRD AN-ROT 130DG ANG -,SUP-814513180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7282.7,5097.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X34MM CORT AFFIXUS VERSANAIL FT ST 3.5MM HX DRV SCKT -,SUP-814550034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X40MM CORT AFFIXUS VERSANAIL FT ST 3.5MM HX DRV SCKT -,SUP-814550040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X20MM CORT ALPS FT ST HX DRV TMX -,SUP-8150-36-020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,134.21,93.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X10MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X12MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X14MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X20MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X22MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X24MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X26MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X28MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X30MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X34MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X38MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X42MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X44MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X46MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X48MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X50MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X55MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X60MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X65MM NLCKG CORT ALPS FT ST CP BIOCMPT TMX NS COLR -,SUP-815037065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X26MM LCK SHFT CORT POLYAX FT POLYAX ST FA TMX NS -,SUP-815045526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X28MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X30MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X32MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045532,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X34MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X36MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X40MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X45MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X55MM LCK CORT POLYAX FT POLYAX ST FA TMX NS GOLD -,SUP-815045555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X60MM LCK CANC POLYAX FT POLYAX ST FA BLLT SHP TIP TI -,SUP-815304060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X75MM LCK CANC POLYAX FT POLYAX ST FA BLLT SHP TIP TI -,SUP-815304075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 8X70MM LCK DUAL CORE POLYAX FT POLYAX ST FA BLLT SHP -,SUP-815308070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 8X75MM LCK DUAL CORE POLYAX FT POLYAX ST FA BLLT SHP -,SUP-815308075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1558.35,1090.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X10MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X14MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X16MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X18MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X20MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X24MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X26MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X28MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X34MM CANC FT -,SUP-8153-41-034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,278.62,195.034,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X44MM LAG CANC FT -,SUP-8153-41-044,CDM,C1713,HCPCS,278,RC,,,outpatient,,,198.39,138.873,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X50MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X55MM NLCKG CANC ALPS FT ST HX DRV TMX NS -,SUP-815341055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5X30MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5X45MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5X60MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5X65MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5X70MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5X75MM LCK CANC POLYAX FT POLYAX TI NS -,SUP-815355075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,805.23,563.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5X65MM NLCKG CANC POLYAX P/T POLYAX TI NS -,SUP-815455065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X20MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X24MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X28MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X30MM NLCKG LAG CANC ALPS P/T HX DRV SLD TMX NS -,SUP-815540030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X32MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X36MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X42MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X46MM NLCKG CORT POLYAX FT ST SLD TI NS -,SUP-815745046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LAG SCREW D10.5X85MM -,SUP-8160-0085S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4287.05,3000.935,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X10MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X12MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X14MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X16MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X18MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X20MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORT LOCK 3.5 X 20MM NS -,SUP-816135020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW  CORT LOCK 3.5 X 22MM NS -,SUP-816135022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X22MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X24MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-8161-35-024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
3.5MM CORT LOCK SCREW 26MM NS -,SUP-816135026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X28MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
3.5MM CORTLOCK SCREW 30MM NS -,SUP-816135030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X30MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X32MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X34MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X36MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X38MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X40MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X42MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
3.5MM CORT LOCK SCREW 50MM NS -,SUP-816135050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORT LOCK 3.5 X 52MM NS -,SUP-816135052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 3.5 X 54 CORT NS -,SUP-816135054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X56MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X60MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X65MM LCK CORT ALPS THRD ST TAPR HEAD TMX NS PUR -,SUP-816135065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X10MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X12MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X14MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X16MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X18MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X26MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X28MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X46MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X60MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X65MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X70MM LCK CANC ALPS THRD ST TAPR HEAD TMX NS BLU -,SUP-816140070,CDM,C1713,HCPCS,278,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN ALPS 199MM 12HL PRCONT LCK COMPR TMX W ANTMC FST -,SUP-816200012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6798.89,4759.223,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN ALPS 77MM 6HL THRD LCK TMX ANTMC NS BLU -,SUP-816204006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN ALPS 92MM 7HL THRD LCK TMX ANTMC NS BLU -,SUP-816204007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN ALPS 103MM 8HL THRD LCK TMX ANTMC NS BLU -,SUP-816204008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1526.54,1068.578,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN ALPS 3.5MM 5HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1208.51,845.957,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN ALPS 3.5MM 6HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235006,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1208.51,845.957,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN ALPS HCP 3.5MM 7HL HYBRID LCK COMPR TMX THN ANTMC -,SUP-816235007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN ALPS 3.5MM 8HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1335.73,935.011,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN ALPS 3.5MM 9HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235009,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1335.73,935.011,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN ALPS 3.5MM 12HL HYBRID LCK COMPR TMX ANTMC NS -,SUP-816235012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN ALPS 3HL PRCONT LCK TMX STD CRV ANTMC LT TIB -,SUP-816235703,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5627.54,3939.278,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN ALPS 5HL PRCONT LCK TMX STD CRV ANTMC -,SUP-816235705,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5678.47,3974.929,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN ALPS 3HL PRCONT LCK TMX STD CRV ANTMC RT TIB -,SUP-816235803,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5627.54,3939.278,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X22MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X26MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X32MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X50MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X55MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335055,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X56MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335056,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X65MM LCK ALPS THRD ST MULDIR 2.2MM SQ DRV COCR NS -,SUP-816335065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER SPNL ANT CERV 13X15X6MM ALTA 5DG PEEK. -,SUP-8401-0506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN FX 1.3MM ABSB -,SUP-84-1052,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1153.11,807.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER SPNL ANT CERV 13X15X6MM ALTA 5DG PEEK.. -,SUP-8411-0506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER ANT CERV 13X15X7MM ALTA 5DG PEEK -,SUP-8411-0507,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COVER LOCKING SHORELINE 8-12 MM STANDALONE GRAY -,SUP-85-2008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TEMP FIX PIN -,SUP-85-2100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LONG NAIL LEFT 13X340MM X 125 DEG -,SUP-8525-3340S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13986.87,9790.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5 X 12MM SELF DRILLING -,SUP-85-3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5 X 14MM SELF DRILLING -,SUP-85-3014SD,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GRAVITY SYNCHFIX SYNDESMOSIS #5 SUTURE -,SUP-86SYN005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4349.11,3044.377,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER TRNSFRMNL POST LMBR 9X23X6MM FORZA 0DG STR BLLT NOSE -,SUP-89-1006SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER TRNSFRMNL POST LMBR 9X23X8MM FORZA 0DG STR BLLT NOSE -,SUP-89-1008SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER TRNSFRMNL POST LMBR 9X27X7MM FORZA 0DG CRV BLLT NOSE -,SUP-89-1707SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER TRNSFRMNL POST LMBR 9X27X8MM FORZA 0DG CRV BLLT NOSE -,SUP-89-1708SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER TRNSFRMNL POST LMBR 9X27X9MM FORZA 0DG CRV BLLT NOSE -,SUP-89-1709SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
IMPLANT HUM TIS 9X27X7MM SZ0 FORZA STR -,SUP-89-3007,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPACER TRNSFRMNL POST LMBR 9X27X10MM FORZA 0DG STR BLLT NOSE -,SUP-89-3010SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11038.75,7727.125,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BONE CEMENT HYDROSET XT INJECTABLE HA -,SUP-897003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5310.31,3717.217,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CEMENT BONE HYDROSET XT HA 5CC -,SUP-897005,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8517.71,5962.397,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CEMENT BONE HYDROSET XT HA 10CC -,SUP-897010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14367.75,10057.425,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
HYDROSET XT -,SUP-897015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,20614.72,14430.304,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GRAFT BONE BIO4 VIABLE BONE MATRIX 2.5CC -,SUP-90174424,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEADLESS COMPRESSION 2.5MM X 28MM TI -,SUP-90176298,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN FIXATION IJS 2.5MM X 50MM AXIS -,SUP-90176511,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1918.78,1343.146,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW FREEFIX COMPRESSION 4.5MM X 18MM TI -,SUP-90176560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1009.46,706.622,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW FREEFIX LOCKING 4.5MM X 14MM TI -,SUP-90176561,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW FREEFIX LOCKING 4.5MM X 16MM TI -,SUP-90176562,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW FREEFIX LOCKING 4.5MM X 18MM TI -,SUP-90176563,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW FREEFIX LOCKING 4.5MM X 20MM TI -,SUP-90176564,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE MIDSHAFT HUMERUS NARROW 172MM -,SUP-90176565,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5334.71,3734.297,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE FREEFIX 173MM ULNA MIDSHAFT -,SUP-90176755,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE FREEFIX DISTAL HUMERUS 85MM ASSEMBLED LAT HELICAL LEFT -,SUP-90176827,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW FREEFIX COMPRESSION 3.5MM X 12MM TI -,SUP-90176828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW FREEFIX LOCKING 3.5MM X 10MM TI -,SUP-90176829,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.51,808.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW POLYAXIAL LOCKING 3.0MM X 34MM CANNULATED COCR -,SUP-90176830,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW POLYAXIAL LOCKING 3.0MM X 50MM CANNULATED COCR -,SUP-90176831,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW POLYAXIAL LOCKING 3.0MM X 60MM CANNULATED COCR -,SUP-90176832,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW POLYAXIAL LOCKING 3.0MM X 65MM CANNULATED COCR -,SUP-90176833,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEADLESS COMPRESSION 2.5MM X 20MM TI -,SUP-90176987,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ASSEMBLED FREE FIX DISTAL HUM PLATE LAT DIRECT 85MM RIGHT -,SUP-90178750,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ASSEMBLED FREE FIX DISTAL HUM PLATE MED DIRECT 75MM RIGHT -,SUP-90178751,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8504.98,5953.486,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW FREEFIX COMPRESSION 3.5MM X 16MM TI -,SUP-90178752,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW FREEFIX COMPRESSION 3.5MM X 28MM TI -,SUP-90178753,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW FREEFIX LOCKING 3.5MM X 30MM TI -,SUP-90178754,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MULTI-THREAD LOCKING 2.7MM X 16MM TI -,SUP-90178756,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MULTI-THREAD LOCKING 2.7MM X 24MM TI -,SUP-90178757,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ASSEMBLED FREEFIX DIST HUM PLATE LAT DIRECT 85MM LEFT -,SUP-90178787,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DISTAL TROCHLEA COMPRESSION SCREW 3.5MM X 40MM TI -,SUP-90178788,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MULTI-THREAD LOCKING 2.7MM X 26MM TI -,SUP-90178789,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MULTI-THREAD LOCKING 2.7MM X 42MM TI -,SUP-90178790,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
HIGH COMPRESSION LOCKING PEG 2.7MM X 24MM TI -,SUP-90178898,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DRILL CANNULATED 3.7MM X 30MM -,SUP-90178926,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ASSEMBLY DOUBLE IJS -,SUP-90178927,CDM,C1713,HCPCS,278,RC,,,outpatient,,,27394.51,19176.157,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
IJS-E AXIS PIN FEMALE 30MM COCR -,SUP-90178928,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
THREADED HAND NAIL 4.5MM X 45MM TI -,SUP-90178982,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4258.41,2980.887,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
KT SPINAL 4.5MMX30-40MM PEDICAL COMPR TRANSFACET W/SCREWX2 -,SUP-9045-02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
IMPLANT ELB JNT TOGGLELOC -,SUP-909854,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4344.34,3041.038,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PK VALVE F/INFECT FLD WST MGMT ULTRA QUAD CART -,SUP-91530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CRNL 1.5X4MM STRDRV RCESS SD TI -,SUP-92-15904,CDM,C1713,HCPCS,278,RC,,,outpatient,,,413.82,289.674,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CRNL 1.5X5MM STRDRV RCESS SD TI -,SUP-92-15905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,413.82,289.674,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CRNL 1.5X5MM STRDRV RCESS SD TI -,SUP-92-15905,CDM,C1713,HCPCS,278,RC,,,outpatient,,,82.76,57.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE INSERT LOCKING 2.7MM -,SUP-940372,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN FX STNMN 2.8MMX9IN SMTH STRL F /THE VUEPASS PORTAL -,SUP-94152,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2711.63,1898.141,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PFC SIGMA DISTAL AUG COM CEMT SIZE 5 X 4MM RIGHT -,SUP-960901,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PFC SIGMA DISTAL AUG COM CEMT SIZE 5 X 8MM RIGHT -,SUP-960903,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TIBAL INSERT ROTATING PLATFORM (STAB) 5- 10MM -,SUP-962151,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
INSERT TIBIAL ROTATING PLATFORM SZ 2.5MM X 20MM TCS -,SUP-96-2335,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
5.0MM VARIABLE ANGLE EXTENSION ARM -,SUP-991088S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2160.48,1512.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAP TOT JNT SM PLST -,SUP-9911186002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1043.01,730.107,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
IMPLANT HUM TIS CHP ALLOGRAFT CANC 15ML -,SUP-A00035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1311.87,918.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TEMPORARY TENSION BOLT -,SUP-A-2791.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1108.07,775.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DRILL BIT AO FIXATION 1.2MM X 25MM X L81MM -,SUP-A-3230,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1173.53,821.471,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COUNTERSINK M 1.2/1.5 -,SUP-A-3310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1607.11,1124.977,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
3.0 CCS COUNTERSINK- AO -,SUP-A-3938,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1978.15,1384.705,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
HOOK PLATE1.5 2 HOLE 2 HOOKS T0.6 -,SUP-A-4200.40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2365.61,1655.927,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
HOOK PLATE 4 HOLE 4 HOOKS T0.6 -,SUP-A-4200.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2632.76,1842.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
IMPLANT HUM TIS STRIP 1X20CMX8MM H GRFTN MATRIX -,SUP-A42280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8571.82,6000.274,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE M FIX 4 HOLE STRAIGHT -,SUP-A-4300.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2106.42,1474.494,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE M FIX 6 HOLE STRAIGHT -,SUP-A-4300.03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.98,1080.086,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE M FIX 16 H STRAIGHT -,SUP-A-4300.04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2571.75,1800.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE M FIX 16 H CURVED -,SUP-A-4300.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2092.11,1464.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE M FIX16 HOLE OFF SET -,SUP-A-4300.06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2700.17,1890.119,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN APTUS 10X27MM F/1.2MM/1.5MM FX SCR HLX3X5 TI T-SHP -,SUP-A-4300.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1852.52,1296.764,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE M FIX 2/3 H RIGHT L -,SUP-A-4300.21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1852.52,1296.764,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE M GD FIX 2X2 RECT LEA -,SUP-A-4300.51,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2632.23,1842.561,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE FIXATION GOLD GRID 2 X 2-HOLE TAPAZOID -,SUP-A-4300.54,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2632.23,1842.561,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN APTUS 15MM F/1.2MM/1.5MM SCR HLX3X2 0.6MM GRID FX -,SUP-A-4300.55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2074.62,1452.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN HLX4X2 FA MED L-SHP GRID -,SUP-A-4300.64,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2156.24,1509.368,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GRID 5 X 2 HOLE TRAPAZOID -,SUP-A-4300.66,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.52,1855.364,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE M CONDYLE 5 H PIN L -,SUP-A-4340.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2542.12,1779.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN APTUS F/1.2-1.5MM SCR 1HL HOOKX2 COMPR TI TRILOCK -,SUP-A-4340.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3184.74,2229.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE APTUS TRILOCK PI 4 HOLE STRAIGHT IO 8 -,SUP-A-4350.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3757.14,2629.998,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE M TRILOCK STR 4 HOLE -,SUP-A-4350.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2752.69,1926.883,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE TRILOCK PI 3/5 HOLE T -,SUP-A-4350.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4001.57,2801.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN APTUS 11X25MM 0.8MM 8HL HND TRILOCK TI T-SHP -,SUP-A-4350.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4001.57,2801.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN APTUS 9X23MM F/1.2MM/1.5MM SCR FX/ROT 6HL 0.8MM VAR -,SUP-A-4350.23,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4284.67,2999.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE TRILOCK ROTATING 3 HOLE 1.2/1.5 -,SUP-A-4350.23,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4080.82,2856.574,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE M TRILOCK T 5/4 HL -,SUP-A-4350.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4152.43,2906.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOCKING PLATE 1.5 BLUE -,SUP-A-4350.56,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3415.8,2391.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE M TRILOCK GRID HL 4 X 2 -,SUP-A-4350.62,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4381.08,3066.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 1.2/1.5 TRILOCK GRID 5X2H TRAPZ T 0.8 -,SUP-A-4350.66,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4471.05,3129.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE LOCKING TRILOCK BLUE 1.5 TRAPEZ 10.8 -,SUP-A-4350.80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3868.85,2708.195,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
IMPLANT HUM TIS GRFTN DBM OTHBLND -,SUP-A44135,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5713.91,3999.737,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN APTUS 55MM F/2MM/2.3MM SCR 8HL COMPR TI STR TRILOCK -,SUP-A-4645.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2466.32,1726.424,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN APTUS 35MM F/2MM/2.3MM SCR HLX2X4 COMPR TI T-SHP -,SUP-A-4645.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2428.06,1699.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE M COMP L 2/8 HOLE RIGHT -,SUP-A-4645.23,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2405.14,1683.598,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE LOCKING 1.0MM THCK 2./2.3 STRAIGHT BLUE -,SUP-A-4650.03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7191.46,5034.022,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOCKING PLATE 2.0/2.3 BLUE T-2/4 HOLE -,SUP-A-4650.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3100.24,2170.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE TRILOCK 3/4 HOLE -,SUP-A-4650.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3100.24,2170.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
"PLATE M LK ""Y"" 2/5 H -",SUP-A-4650.13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3199.53,2239.671,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE L 2/4 HOLE RIGHT -,SUP-A-4650.21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3601.51,2521.057,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN APTUS 45MM F/2MM/2.3MM SCR 8HL 1MM GRID TI -,SUP-A-4650.67,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3910.86,2737.602,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE LOCKING T1.3MM 4 HOLE STRAIGHT 2.0/2.3 -,SUP-A-4655.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3973.88,2781.716,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BLUE LOCKING 2.0 /2.3 4 HOLE STRAIGHT -,SUP-A-4655.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4610.73,3227.511,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN APTUS 32MM F/2MM/2.3MM SCR 5HL 1.3MM GRID TI STR -,SUP-A-4655.02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4294.08,3005.856,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BLUE 2.0 / 2.23 5 HOLE STRAIGHT -,SUP-A-4655.02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4308.93,3016.251,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE TRILOCK 8 HOLE STRAIGHT 2 X 3 -,SUP-A-4655.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4971,3479.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE TRILOCK STRAIGHT 8 HOLE 2.0/2.3 -,SUP-A-4655.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4969.72,3478.804,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE M TRILOCK T 2/4 HL -,SUP-A-4655.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5024.05,3516.835,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE TRILOCK 2.0/2.3 T 2/4 HOLE T1.3 -,SUP-A-4655.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5024.05,3516.835,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN APTUS 56MM 2.0/2.3MM 10HL 1.3MM GRID TI T-SHP -,SUP-A-4655.16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5311.37,3717.959,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.0/2.3 TRILOCK PLATE 2/4 HOLE LEFT -,SUP-A-4655.20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4600.23,3220.161,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE M TRILOCK L RT 2/4 HL -,SUP-A-4655.21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5024.05,3516.835,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE M TRILOCK L LT 2/8 HL -,SUP-A-4655.22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4539.38,3177.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE ROTATION 3/3 HOLE T 1.3 -,SUP-A-4655.24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4738.2,3316.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE TRILOCK GRIDPI 4 X2H TRAPEZ -,SUP-A-4655.62,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5438.26,3806.782,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE TRILOCK GRIDPI 5 X2 H TRAPEZ -,SUP-A-4655.66,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5679.32,3975.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 2.0 TRILOCK RADIAL HEAD RIM -,SUP-A-4656.68,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7432.09,5202.463,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.0 TRILOCK RADIAL HEAD BUTTRESS -,SUP-A-4656.69,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7017.88,4912.516,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE TRILOCK 4CF 2 X 2.3 -,SUP-A-4660.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7727.9,5409.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE M BABYFOOT LONG RT -,SUP-A-4750.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5479,3835.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 2.5 ADAPT II TRILOCK DISTRAD L 10 H NARROW -,SUP-A-4750.101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5810.88,4067.616,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE M ADAPTIVE II NARROW RT -,SUP-A-4750.102,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7626.89,5338.823,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DISTAL RADIUS LOCKING PLATE RIGHT 12 NARROW-LONG -,SUP-A-4750.104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 2.5 ADAPTIVE II TRILOCK DISTRAD NARR LONG -,SUP-A-4750.104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8591.98,6014.386,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE ADAPTIVE 2.5 X 12HL NRW LNG -,SUP-A-4750.104,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6904.56,4833.192,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE M ADAPTIVE II LT -,SUP-A-4750.105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5810.88,4067.616,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE M ADAPTIVE II LT -,SUP-A-4750.105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7626.89,5338.823,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE STD WATERSHED RIGHT ADAP -,SUP-A-4750.106,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8008.43,5605.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ADAPTIVE II TRILOCK 2.5 DISTRAD. PLATE 13 HOLE -,SUP-A-4750.107,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DISTAL RADIUS LOCKING PLATE RIGHT 13 LONG -,SUP-A-4750.108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8591.98,6014.386,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE M ADAPTIVE II LONG RIGHT -,SUP-A-4750.108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN APTUS 28X52MM 2.5MM 14HL TI TRILOCK TECH -,SUP-A-4750.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 2.5 ADAPTIVE II DISTAL RADIUS LEFT WIDE LONG -,SUP-A-4750.111,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6546.37,4582.459,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 2.5 ADAPTIVE II TRILOCK DIST RAD 15H WIDE LONG -,SUP-A-4750.112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6234.44,4364.108,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DISTAL RADIUS CORRECTION PLATE WIDE -,SUP-A-4750.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE M FPL LT -,SUP-A-4750.123,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8106.46,5674.522,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE MEDARTIS 14HL -,SUP-A-4750.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6904.56,4833.192,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE ADAPTIVE 2.5 X 15 HOLE -,SUP-A-4750.15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7057.35,4940.145,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE ADAPTIVE 2.5 X 16 HOLE -,SUP-A-4750.16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7057.35,4940.145,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN APTUS 22X62MM 2.5MM 12HL 1.6MM TI LNG NRW TRILOCK -,SUP-A-4750.19,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 2.5TRILOCK WR SPANNINGPI DOR. STRAIGHT 11 HOLE TL6-3.4 -,SUP-A-4750.193S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13227.56,9259.292,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN APTUS 23X44MM 2.5MM 10HL 1.6MM TI NRW TRILOCK TECH -,SUP-A-4750.31,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN APTUS 23X44MM 2.5MM 10HL TI SHRT NRW TRILOCK TECH -,SUP-A-4750.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN APTUS 30X64MM F/2.5MM FX 1.6MM LCK TI FRM -,SUP-A-4750.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5815.98,4071.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN APTUS 30X64MM F/2.5 TRILOCK SYS 1.6MM LCK TI -,SUP-A-4750.42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5815.98,4071.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN APTUS 49MM 2.5MM 6HL TI STR TRILOCK TECH -,SUP-A-4750.54,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4373.94,3061.758,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN APTUS 23X54MM 2.5MM 13HL TI TRILOCK TECH RT WRST -,SUP-A-4750.62,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5535.45,3874.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN APTUS 23X68MM 2.5MM 15HL TI LNG TRILOCK TECH LT -,SUP-A-4750.64,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6307.43,4415.201,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WASHER BICONCAVE 2.5/2.8 -,SUP-A-4750.70/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,340.18,238.126,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN APTUS 46MM 2.5MM 7HL VAR ANG CONTR TI Y -,SUP-A-4750.91,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4323.36,3026.352,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN APTUS 67MM 2.5MM 10HL 1.6MM VAR ANG CONTR LCK TI Y -,SUP-A-4750.92,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4557.21,3190.047,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.5 TRILOCK ULNA SHORTENING PLATE -,SUP-A-4750.95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9650.43,6755.301,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.5 TRILOCK ULNA SHORTENING PLATE 10HL -,SUP-A-4750.95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9650.43,6755.301,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 2.5 TRILOCK WRIST FUSION PI SHORT BEND -,SUP-A-4760.02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11734.57,8214.199,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN APTUS 2.5MM 15HL LCK TI STR MULDIR TRILOCK -,SUP-A-4760.03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9292.66,6504.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE STRAIGHT 2.5 TRILOCK TOTAL WRIST FUS -,SUP-A-4760.04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11159.79,7811.853,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.5 TRILOCK TOTAL WRIST FUS PL LONG BEND 16HL T1.8-2.6 DRSL -,SUP-A-4760.05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11734.57,8214.199,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.5 TRILOCK TOTAL WRIST FUS PI SHORT BEND 16 HOLE T1.8-2.6 D -,SUP-A-4760.06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11734.57,8214.199,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 2.5 TRILOCK WRIST FUSION SHORT BEND 12 HOLE -,SUP-A-4760.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11462.03,8023.421,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE TENSION 2.8 TRILOCK 6 HOLE OLECRANON -,SUP-A-4856.01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5373.33,3761.331,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE TRILOCK T1-6 OLECRANON 7H RIGHT -,SUP-A-4856.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5556.24,3889.368,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 2.8 TRILOC OLECRANON 7H LEFT -,SUP-A-4856.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5557.94,3890.558,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE TRILOCK OLECRANON 2.8 7H STRAIGHT -,SUP-A-4856.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5306.27,3714.389,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TRILOCK PLATE 2.8 - 10H- RIGHT -,SUP-A-4856.13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5674.23,3971.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TRILOCK PLATE 10H STRAIGHT -,SUP-A-4856.15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5576.62,3903.634,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.8 TRILOCK DIST HUM PL MEDIAL 17H L -,SUP-A-4856.29,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10465.7,7325.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 2.8 TRILOCK DIST HUM MEDIAL 12H R -,SUP-A-4856.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9692.45,6784.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TriLock Dist. Hum Pl. Medial- 10h- l -,SUP-A-4856.33,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9291.81,6504.267,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.8 TRILOCK DIST HUM PL LATERAL 18H L -,SUP-A-4856.39,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9432.88,6603.016,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 2.8 TRILCK DIST HUM MEDIAL 10H LFT -,SUP-A-4856.41,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9692.45,6784.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE M TRILOCK GRID H 2X2 -,SUP-A-4856.44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9291.81,6504.267,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 10HL 2.8MM TRILOCK TECH RT OLCRN -,SUP-A-4856-13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4323.36,3026.352,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 10HL 2.8MM TRILOCK TECH LT OLCRN -,SUP-A-4856-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5674.23,3971.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
K-WIRES LNCET 150MM 1.8MM -,SUP-A-5042.51/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,247.99,173.593,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
1.1 K-WIRE- TROCAR- 2-END. 100MM -,SUP-A-5043.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,297.59,208.313,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.2X4MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.2X5MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.2X6MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.2X7MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.2X8MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.2X9MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.2X10MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.2X11MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.2X12MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.2X14MM CORT APTUS HEXADRIVE 4 TI GOLD -,SUP-A-5100.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW M CORTEX 1.2 X 16MM -,SUP-A-5100.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.5X4MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.5X5MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.5X6MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW M CORTEX 1.5 X 07 -,SUP-A-5200.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW M CORTEX 1.5 X 07 -,SUP-A-5200.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW M CORTEX 1.5 X 08 -,SUP-A-5200.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.5X9MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI GOLD -,SUP-A-5200.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.5X10MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.5X11MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.5X12MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.5X13MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.5X14MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.5X15MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.5X15MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI. -,SUP-A-5200.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTEX 1.5 X 16 MEDARTIS -,SUP-A-5200.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTEX 1.5 X 17MM CORTICAL HD4 -,SUP-A-5200.17/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.5X18MM CORT APTUS DBL THRD ST/RET HEXADRIVE 4 TI -,SUP-A-5200.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.5X19MM CORT APTUS DBL THRD ST/RET HEXDRV 4 TI GOLD -,SUP-A-5200.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW M CORTEX 1.5 X 21 -,SUP-A-5200.21/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL 1.5 22MM HD4 -,SUP-A-5200.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW M CORTEX 1.5 X 24 -,SUP-A-5200.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE APTUS 1.5 SPEEDTIP 10MM HD4 PK/1 -,SUP-A-5210.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1076.56,753.592,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE 1.5MM SPEEDTIP 14MM HD4 PK/1 -,SUP-A-5210.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1076.56,753.592,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.5X4MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.5X5MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.5X6MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.5X7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.5 X 7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.5X8MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.5X9MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.5X10MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.5X11MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.5X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.5X13MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 4 -,SUP-A-5250.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 1.5 X 16 -,SUP-A-5250.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.8,742.56,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE CANNULATED COMPRESSION 10/4MM -,SUP-A-5281.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.7 CCS LONG THREAD 15/06MM 1/PKG -,SUP-A-5281.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.7 CCS LONG THREAD 16/07MM 1/PKG -,SUP-A-5281.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
1.7 CCS LONG THREAD 18/07MM -,SUP-A-5281.18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.7CCS LONG THREAD 20/08MM -,SUP-A-5281.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.7 CCS FULLY THREADED 10MM 1/PKG -,SUP-A-5282.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.7CCS FULLY THREADED 13MM -,SUP-A-5282.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.7CCS FULLY THREADED 14MM -,SUP-A-5282.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CORTEX BONE SCREWS 1.8MM 06MM LENGTH GOLD -,SUP-A-5300.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,884,618.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW M CORTEX 1.8 X 10 -,SUP-A-5300.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,654.69,458.283,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2X4MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.04/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2X5MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2X6MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2X7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5400.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2X8MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2X9MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5400.09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2X10MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2X11MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2X13MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2X14MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5400.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2X15MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.0 CORTICAL SCREW 16MM -,SUP-A-5400.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.0 X 17MM MEDARTIS -,SUP-A-5400.17/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL 2.0 X 18MM HD6 -,SUP-A-5400.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW APTUS TI CORTEX BONE GOLD 2.0 X 19MM -,SUP-A-5400.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2X20MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5400.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.0 CORTICAL SCREW 24MM -,SUP-A-5400.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2X6MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5450.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2X7MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2X8MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM. -,SUP-A-5450.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2X9MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2X10MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2X11MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,295.02,206.514,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2X12MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2X13MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2X14MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5450.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW TRILOCK 2.0 X 14MM HD6 -,SUP-A-5450.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2X16MM LCK CORT APTUS DBL THRD ST RET HEXADRIVE 6 ATRM -,SUP-A-5450.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.0 TRILOCK SCREW 18MM -,SUP-A-5450.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.0 TRILOCK SCREW 20MM -,SUP-A-5450.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.0 TRILOCK 20MM HD6 -,SUP-A-5450.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X5MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.05/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X6MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.06/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X7MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.07/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X8MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X9MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.09/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X10MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X11MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X12MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X13MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X14MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X18MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X19MM CORT APTUS DBL THRD ST/RET HEXADRIVE 6 ATRM -,SUP-A-5500.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW M CORTEX 2.3 X 20 -,SUP-A-5500.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW M CORTEX 2.3 X 18 -,SUP-A-5500.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORT MEDARTIS 2.5 8MM -,SUP-A-5700.08/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5X10MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORT MEDARTIS 2.5 11MM -,SUP-A-5700.11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5X12MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5X13MM NLCKG CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5700.13/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORT MEDARTIS 2.5 14MM -,SUP-A-5700.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW M CORT 2.5 X 15 -,SUP-A-5700.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOCKING SCREW 16 MM BLUE 2.5MM -,SUP-A-5700.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NON LOCKING BONE SCREW 16MM -,SUP-A-5700.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORT MEDARTIS 2.5 16MM -,SUP-A-5700.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5X18MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOCKING SCREW 18MM BLUE 2.5MM -,SUP-A-5700.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOCKING SCREW 20MM BLUE 2.5 -,SUP-A-5700.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5X20MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5X22MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,945.85,662.095,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5X24MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5X30MM CORT APTUS DBL THRD ST/RET HEXADRIVE 7 ATRM -,SUP-A-5700.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,623.76,436.632,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CORTEX GOLD NON LCK 2.5 32MM  SCREW -,SUP-A-5700.32/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW M CORT 2.5 X 34MM -,SUP-A-5700.34/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5X20MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5720.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5X22MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5720.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5X10MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5X12MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TRILOCK SCREW 2.5 12MM -,SUP-A-5750.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5X14MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5X16MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5X18MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCK MEDARTIS 2.5 18MM -,SUP-A-5750.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5X24MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5X26MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BLUE 2.5 X 28 LOCKING -,SUP-A-5750.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW M LOCKING 2.5 X 30MM -,SUP-A-5750.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5X32MM LCK CORT APTUS DBL THRD ST/RET HEXADRIVE 7 -,SUP-A-5750.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.8,742.56,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.5 TRILOCK SCREW 34MM -,SUP-A-5750.34/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5 TRILOCK EXPRESS 14MM HD7 PK/1 -,SUP-A-5755.14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1158.25,810.775,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SILVER LOCKING SCREW 18MM -,SUP-A-5755.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1158.25,810.775,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SILVER LOCKING SCREW 20MM -,SUP-A-5755.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1158.25,810.775,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE APTUS 2.2 CANN COMP 10MM HD7 DISTAL THREAD 4MM -,SUP-A-5780.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE APTUS 2.2 CANN COMP 11MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.11/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE APTUS 2.2 CANN COMP 14MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE APTUS 2.2 CANN COMP 15MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.15/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE APTUS 2.2 CANN COMP 16MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANULATED COPR 17MM -,SUP-A-5780.17/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE APTUS 2.2 CANN COMP 19MM HD7 DISTAL THREAD 5MM -,SUP-A-5780.19/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.2 CANNULATED SCREW COMPRESSION 20MM -,SUP-A-5780.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.2 CANNULATED COMPR 26MM DISTAL THREAD 6MM -,SUP-A-5780.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANULATED COPR 27MM -,SUP-A-5780.27/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.2 CANNULATED COMPR 30MM DISTAL THREAD 6MM -,SUP-A-5780.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MEDART CANN CMPR 2.2 X 22 -,SUP-A-5781.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MEDART CANN CMPR 2.2 X 24MM -,SUP-A-5781.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANNULATED 2.2 COMPRESSION LONG THREAD 26MM -,SUP-A-5781.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW COMPR CANNULATED 2.2 X 28MM -,SUP-A-5781.28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW COMPR CANNULATED 2.2 X 30MM -,SUP-A-5781.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MEDART CANN COMPR 2.2 X 32 -,SUP-A-5781.32/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2540.72,1778.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW COMPR CANNULATED 2.2 X 36MM -,SUP-A-5781.36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW COMPR CANNULATED 2.2 X 38MM -,SUP-A-5781.38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2442.47,1709.729,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.8 CORTICAL SCREW 10MM HD7 -,SUP-A-5800.10/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.8 CORTICAL SCREW 12MM HD7 -,SUP-A-5800.12/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.8X16MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.8X18MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.8X20MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.8X22MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.8X24MM CORT -,SUP-A-5800.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,654.69,458.283,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.8 CORTICAL SCREW 26MM HD7 -,SUP-A-5800.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.8 CORTICAL SCREW 28MM -,SUP-A-5800.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.8 CORTICAL SCREW 30MM HD7 -,SUP-A-5800.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.8 CORTICAL SCREW 32MM HD7 -,SUP-A-5800.32/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.8  CORTICAL SCREW 38MM- HD7 -,SUP-A-5800.38/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.8 GOLD CORTEX BONE 40MM HD7 -,SUP-A-5800.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.8X45MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.45/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORITCAL 50MM HD7 2.8 -,SUP-A-5800.50/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.8X55MM CORT APTUS DBL THRD SLF RET MULDIR HEXADRIVE -,SUP-A-5800.55/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LAG 2.8 X 40 HD7 -,SUP-A-5830.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,654.69,458.283,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.8X14MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.14/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW TRILOCK BLUE 2.8 LOCKING16MM HD7 -,SUP-A-5850.16/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.8X18MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.18/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.8X20MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.20/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.8X22MM LCK APTUS DBL THRD SLF RET MULDIR HEXADRIVE 7 -,SUP-A-5850.22/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW TRILOCK 2.8 X 24MM HD7 -,SUP-A-5850.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW TRILOCK BLUE 2.8 LOCKING 26MM HD7 -,SUP-A-5850.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.8 TRILOCK  SCREW 28MM HD7 -,SUP-A-5850.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW TRILOCK BLUE 2.8 LOCKING 30MM HD7 -,SUP-A-5850.30/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.8 TRILOCK SCREW 32MM- HD7 -,SUP-A-5850.32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.8 TRILOCK SCREW 36MM- HD7 -,SUP-A-5850.36/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.8 TRILOCK SCREW 38MM HD7 -,SUP-A-5850.38/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.8 TRILOCK SCREW 40MM HD7 -,SUP-A-5850.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.8 TRILOCK SCREW 50MM- HD7 -,SUP-A-5850.50/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.8 TRILOCK SCREW 55MM- HD7 -,SUP-A-5850.55/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.8 TRILCK 55MM -,SUP-A-5850.55/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1060.8,742.56,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.8 TRILOCK SCREW 70MM HD7 -,SUP-A-5850.70/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANNULATED SPEED TIP 3MM X 15MM -,SUP-A-5880.15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2326.39,1628.473,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANN SPEED TIP 3MM X 20MM -,SUP-A-5880.20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2326.87,1628.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3X24MM CANN SPEEDTIP CCS S/T SD HEXDRIVE 10 TI -,SUP-A-5880.24/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3X26MM CANN SPEEDTIP CCS S/T SD HEXDRIVE 10 TI -,SUP-A-5880.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.0 CANN COMPR 40 -,SUP-A-5880.40/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3X26MM CANN SPEEDTIP CCS LNG THRD SD HEXDRIVE 10 TI -,SUP-A-5881.26/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
3.0 CANNULATED COMPRSCREW28MM-HD10- DISTAL THREAD 9MM -,SUP-A-5881.28/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2326.39,1628.473,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3 X 30 CANN COMPR DISTAL THREAD -,SUP-A-5881.30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3 X 36 CANN COMPR DISTAL THREAD -,SUP-A-5881.36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2656.25,1859.375,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW EXTFIX 6/5MM DIA 100/ 40MM CORT TAPR DYNFX THRD -,SUP-A6010040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW EXTFIX 6MM/5X150MM CORT TAPR DYNFX VISION 50MM THRD -,SUP-A6015050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW EXTFIX 6MM/5X180MM CORT TAPR DYNFX VISION 50MM THRD -,SUP-A6018050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANULATED COMPR 44MM -,SUP-A-8112.44/1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1707.29,1195.103,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
"PLATE M LK ""L"" 2/4 H LEFT -",SUP-AÂ€4650.20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3601.51,2521.057,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SYS BONE CMNT BIOCARTILAGE 3ML STRL -,SUP-ABS-1000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BIOCARTILAGE KIT SMALL JOINT -,SUP-ABS-1000-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FUNNEL BNCMNT BIOCARTILAGE -,SUP-ABS-1003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,163.38,114.366,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BIOCARTILAGE 1CC -,SUP-ABS-1010-BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4678.52,3274.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TACKER ABSORBATACK 5MM 30X -,SUP-ABSTACK30X,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2266.08,1586.256,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WAVEFORM C INTERBODY 16 X 14 X 7MM 7 DEG 3D -,SUP-AC4-264077,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE WAVEFORM C INTERBODY 16 X 14X 8MM 7 DEGREE 3D -,SUP-AC4-264087,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 24MM COMPR HDLS ACUTRAK ACUTWIST FLLY W THRD PTCH -,SUP-AI-0024-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 26MM COMPR HDLS ACUTRAK ACUTWIST FLLY W THRD PTCH -,SUP-AI-0026-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 28MM COMPR HDLS ACUTRAK ACUTWIST FLLY W THRD PTCH -,SUP-AI-0028-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1388.73,972.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4-5X25MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0025-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4-5X30MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0030-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4-5X35MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0035-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4-5X40MM CANN HDLS ACUTRAK 4/5 2.5MM HX DRV TAPR TI -,SUP-AM-0040-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 45MM ACUTRAK 4/5 -,SUP-AM-0045-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5-6.5X50MM CANN HDLS ACUTRAK + 3MM HX DRV TI ALY STRL -,SUP-AP-0050-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2410.87,1687.609,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5-6.5X60MM CANN HDLS ACUTRAK + 3MM HX DRV TI ALY STRL -,SUP-AP-0060-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2410.87,1687.609,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE PLATE 10MM -,SUP-AP1-110010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 12MM -,SUP-AP1-110012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE 13MM PLATE -,SUP-AP1-110013,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE ADMIRAL 14MM PLATE -,SUP-AP1-110014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE ANTERIOR CERVICAL PLATE 16MM -,SUP-AP1-110016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 30MM -,SUP-AP1-200030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ADMIRAL PLATE 36MM -,SUP-AP1-200036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE PLATE 28MM -,SUP-AP1-210028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE ADMIRAL 32MM SEASPINE -,SUP-AP1-210032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE ADMIRAL 36MM SPINE CERVICAL 2 LEVEL SEASPINE -,SUP-AP1-210036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE PLATE 54MM -,SUP-AP1-310054,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ST 4 X 14 -,SUP-AP1-604014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ADMIRAL SCREW 4X14 -,SUP-AP1-614014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE SCREW 4 X 10 -,SUP-AP1-704010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 12MM -,SUP-AP1-704012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ADMIRA 4 X 14MM SPINE SELF TAP VARIABLE ANGLE SEASPINE -,SUP-AP1-704014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ADMIRAL 4.3 X 12MM SEASPINE -,SUP-AP1-704312,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ADMIRAL 4.3 X 14MM SPINE SELF TAP VARIABLE ANGLE -,SUP-AP1-704314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ADMIRAL 4 X 12MM SEASPINE -,SUP-AP1-714012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE SCREW 4MM X 14MM SD -,SUP-AP1-714014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ADMIRAL 4 X 16MM SEASPINE -,SUP-AP1-714016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
4.0 X 14 FIX SCREW -,SUP-AP1-724014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6-7.5X70MM CANN HDLS ACUTRAK 6/7 4MM HX DRV TI ALY -,SUP-AP-6770-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6-7.5X75MM CANN HDLS ACUTRACK 6/7 4MM HX DRV TI ALY -,SUP-AP-6775-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2607.85,1825.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE PROXIMAL ULNA 73MM LEFT -,SUP-APL-PUP-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5428.08,3799.656,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE PROXIMAL ULNA 108MM / LEFT -,SUP-APL-PUP-6HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6175.02,4322.514,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE PROXIMAL ULNA 108MM / RIGHT -,SUP-APL-PUP-6HR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6175.02,4322.514,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BONE 151MM ULNA LEFT PROXIMAL -,SUP-APL-PUP-9HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6531.52,4572.064,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEPIN ARSCP 1.1MM BLNT TIP F/BIOINTF SCR -,SUP-AR-1249,CDM,C1713,HCPCS,278,RC,,,outpatient,,,122.54,85.778,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEPIN ARSCP 2.4MM DRILL TIP F/BIOINTF SCR -,SUP-AR-1250L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DRILL SYSTEM FIXATION TIGHTROPE BTBT IB W/FLIPCUTTER III -,SUP-AR-1288BTBIB-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4816.94,3371.858,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DRILL TIGHTROPE RT IB W/FLIPCUTTER III -,SUP-AR-1288RTIB-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4477.42,3134.194,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FIBERTAG TIGHTROPE II IMPLANT W/ FLIPCUTTER III DRILL -,SUP-AR-1288RTT2-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FIBER TAG TIGHTROPE WITH FLIPCUTTER III -,SUP-AR-1288RTT-FC3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEPIN ARSCP 2.4MM SUT EYE -,SUP-AR-1297L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X10MM CORT FT SLD TI STRL F/OSTMY SYS -,SUP-AR-13120T-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X10MM CANN LAG CORT P/T ST SLD TI F/OSTMY SYS -,SUP-AR-13120T-10C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X12MM CANN LAG CORT P/T ST SLD TI F/OSTMY SYS -,SUP-AR-13120T-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X14MM CANN LAG CORT P/T ST SLD TI F/OSTMY SYS -,SUP-AR-13120T-14C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X16MM CANN LAG CORT P/T ST SLD TI STRL F/OSTMY SYS -,SUP-AR-13120T-16C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NANO CORKSCREW FT TI W3-0 FW -,SUP-AR-1317FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUTURE MICRO CORKSCREW FT 2.2 X 4MM -,SUP-AR-1318FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 12.5MM OPN WDG SS -,SUP-AR-13200-12.5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 12.5MM TI SLP STRL -,SUP-AR-13200ST-12.5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUTURE TAK MICRO 2.4 X 6.5 BIOCOMPOSITE -,SUP-AR-1320BCNF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BB-TAK THREADED -,SUP-AR-13226T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SUTURETAPE S-TAK ASSY 3.0 SINGLE LOADED -,SUP-AR-1322BCST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SUTURETAPE S-TAK ASSY 3.0 SINGLE LOADED -,SUP-AR-1322BCST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X45MM CANC HTO PLATE TI F/OSTMY SYS -,SUP-AR-13280-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5X50MM CANC HTO PLATE TI F/OSTMY SYS -,SUP-AR-13280-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEPIN ARSCP 2.4MM F/OSTM -,SUP-AR-13303-2.4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,215.9,151.13,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEPIN SURG 3MM -,SUP-AR-13303-3.0,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SUBSTITUTE B TCP OPN WDG OSFERION 7MM 30MM -,SUP-AR-13370-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SUBSTITUTE B TCP WDG OSFERION 15X35MM -,SUP-AR-13370-4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X40MM CORT HTO PLATE TI F/OSTMY SYS -,SUP-AR-13380-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X46MM CORT HTO PLATE TI F/OSTMY SYS -,SUP-AR-13380-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUT IBALANCE 6.5X24MM HI TIB OPN PEEK -,SUP-AR-13401-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUT IBALANCE 6.5X28MM HI TIB OPN PEEK -,SUP-AR-13401-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SFT TIS CORT 4.5X38MM IBALANCE HTO -,SUP-AR-13402-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUT IBALANCE 4.5X40MM HI TIB OPN PEEK -,SUP-AR-13402-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUT IBALANCE HTO 4.5X48MM HI TIB OPN NABSB PEEK -,SUP-AR-13402-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN ARSCP FX 5X40MM PLLA FEM ABSB TRNSFX II F/ACL RECON -,SUP-AR-1351B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN ARSCP FX 5X50MM PLLA FEM ABSB TRNSFX II F/ACL RECON -,SUP-AR-1351LB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW INTFR CANN 6X23MM RND HEAD STP TAPR BIOCMPS FEM DBL -,SUP-AR-1360C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SILK 7 X 20 NON SHEATHED -,SUP-AR-1370,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.64,822.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW INTFR CANN 7X23MM ABSB SHTH RND HEAD STP TAPR BIOCMPS -,SUP-AR-1370B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 7X23 BIOCOMPOSITE -,SUP-AR-1370C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW INTFR CANN TIGHTROPE RT 7X28MM FT ABSB RND HEAD STP -,SUP-AR-1370TC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN CONTR LOCK HTO 12.5MM A/P SLP WDG -,SUP-AR-13725-12.5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 8X23MM BIO -,SUP-AR-1380C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW INTFR CANN 8X28MM FT ABSB TAPR PLLA TIB KN STRL -,SUP-AR-1380TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 8 X 25 -,SUP-AR-1381,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SILK 9 X 2O NON SHEATHED -,SUP-AR-1390,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.64,822.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW INTFR CANN TIGHTROPE RT 9X23MM SHTH ABSB HEX HEAD PLLA -,SUP-AR-1390B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 9 X 23 BIOCOMPOSITE -,SUP-AR-1390C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW INTFR CANN 9X28MM FT ABSB TAPR BIOCMPS PLLA TIB KN -,SUP-AR-1390TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SILK 9 X 25 NON SHEATHED -,SUP-AR-1391,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.64,822.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN SUTUREPLATE 90MM 3HL POLYAX TI STRL -,SUP-AR-14003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW INTFR CANN 10X23MM ABSB SHTH PLLA TIB KN GRD STRL -,SUP-AR-1400B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 10 X 23 BIOCOMPOSITE -,SUP-AR-1400C,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW INTFR CANN 10X28MM ABSB FT TAPR PLLA TIB KN STRL -,SUP-AR-1400TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,828.57,579.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X18MM NLCKG CORT SUTUREPLATE TI STRL F/ARTHPL -,SUP-AR-14118NL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,262.58,183.806,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X20MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X22MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14122,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X26MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14126,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X26MM NLCKG CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14126NL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,262.58,183.806,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X28MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14128,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X32MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14132,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X34MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14134,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X36MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14136,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X38MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14138,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X40MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X50MM LCK CORT SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14150,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X28MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14228,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X32MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14232,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X38MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14238,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X48MM LCK CANC SUTUREPLATE POLYAX ST TI STRL -,SUP-AR-14248,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
KIT TENODESIS SCREW 3X8 DISPOSABLE -,SUP-AR-1530DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FOREFOOT IB IMPLANT SYS PEEK -,SUP-AR-1530P-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5920.38,4144.266,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW TENODESIS PEEK 3.5 X 8 -,SUP-AR-1530PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2146.7,1502.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4 X 10MM BIOTENODESIS -,SUP-AR-1540BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW TENODESIS PEEK 4X10 -,SUP-AR-1540PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW INTFR BIO-TENODESIS 4.75X15MM BABSRB BIOCMPS ANKL/FT -,SUP-AR-1547BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW TENODESIS PEEK 4.75X15MM INTERFERENCE -,SUP-AR-1547PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW TENODESIS PEEK  5.5 X 15 -,SUP-AR-1555PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW INTFR CANN BIO-TENODESIS 6.25X15MM BABSRB PEEK HND -,SUP-AR-1562BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW TENODESIS PEEK 6.25X15 -,SUP-AR-1562PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW INTFR CANN BIO-TENODESIS 7X23MM BABSRB PLLA HND WRST -,SUP-AR-1570BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW INTFR CANN BIO-TENODESIS 8X23MM BABSRB PLLA HND WRST -,SUP-AR-1580BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 9X20MM CORT RETROSCREW FT RTRGD RND HEAD PLLA STRL -,SUP-AR-1586RB-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1131.99,792.393,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
RETRO BUTTON 15MM -,SUP-AR-1588-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
RETRO BUTTON 20mm -,SUP-AR-1588-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
RETRO BUTTON 12mm/25 -,SUP-AR-1588-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
RETRO BUTTON 12MM/30MM -,SUP-AR-1588-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SYS ARTHROSCOPIC FX BTB TIGHTROPE RT F/ACL RECON -,SUP-AR-1588BTB-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2358.72,1651.104,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TIGHTROPE II RT WITH DEPLOYING SUTURE -,SUP-AR-1588RT-2J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2464.73,1725.311,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FIXATION TIGHTROPE RT DBL -,SUP-AR-1588RT-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FIXATION ACL TIGHTROPE RT -,SUP-AR-1588RT-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ACL TIGHTROPE WITH FIBER TAG -,SUP-AR-1588RTT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FIXATION ACL FEM TIGHTROPE -,SUP-AR-1588T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TIGHTROPE ABS BUTTON 11MM -,SUP-AR-1588TB-3IB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TIGHTROPE ABS BUTTON 14MM -,SUP-AR-1588TB-4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TIGHTROPE ABS BUTTON 20MM -,SUP-AR-1588TB-5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TIGHTROPE ABS BUTTON ROUND CONCAVE 20MM -,SUP-AR-1588TB-5,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1187.31,831.117,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
IMPLANT TIGHTROPE ABS -,SUP-AR-1588TN,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
OPEN TIGHTROPE ABS -,SUP-AR-1588TN-1,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1131.99,792.393,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
IMPLANT FIXATION TIGHTROPE II ABS -,SUP-AR-1588TN-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TIGHTROPE II ABS- IMPLANT OPEN -,SUP-AR-1588TN-21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ACL TIGHTROPE WITH FIBER TAG ABS -,SUP-AR-1588TNT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1775.67,1242.969,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TIGHTROPE BUTTON EXTENDER -,SUP-AR-1589RT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW INTFR CANN BIO-TENODESIS 9X23MM BABSRB PLLA HND WRST -,SUP-AR-1590BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW INTFR BIO-TENODESIS 5.5X10MM BABSRB PEEK ANKL/FT HND -,SUP-AR-1655PS-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW INTFR BIO-TENODESIS 5.5X12MM PEEK SHOLUDER ELB -,SUP-AR-1655PS-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SWIVELOCK  BIOCOMPOSITE 8MM X 19.5MM -,SUP-AR-1662BC-8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2305.72,1614.004,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SYSTEM LATERAL ANKLE RECON -,SUP-AR-1675BC-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW INTFR CANN BIO-TENODESIS 8X12MM BABSRB PLLA SFT TIS -,SUP-AR-1680BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
KIT IB BC W/CC FT AND JUMPSTART -,SUP-AR-1788J-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
KIT IB BC W/CC FT AND JUMPSTART IMPLANT SYSTEM -,SUP-AR-1788J-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SWIVEL LOCK INTERNAL BRACE -,SUP-AR-1788J-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOW PROFILE SCREW 1.0 X 6MM CORTICAL TI -,SUP-AR-18710-06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOW PROFILE SCREW 1.0 X 7MM CORTICAL TI -,SUP-AR-18710-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOW PROFILE 2.4 X 10 CORTICAL -,SUP-AR-18724-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOW PROFILE 2.4 X 26 CORTICAL -,SUP-AR-18724-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
T-PLATE 2.4MM 6 HOLE -,SUP-AR-18724P-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TISSUE TAK TENDON ANCHOR -,SUP-AR-19021TT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUTURE CORKSCREW FT 3.5X10MM -,SUP-AR-1915FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ARTHREX SUTURE ANCHCRKSCRW FT3.5X10MM -,SUP-AR-1915FT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUT CRKSCR 3.5X12MM THRD TI #2 SUT -,SUP-AR-1915S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUT CRKSCR 5X15MM ABSB -,SUP-AR-1920BF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1378.13,964.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUTURE CORKSCREW 5.0 -,SUP-AR-1920S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUT PSHLK 4.5X24MM BIOCMPS -,SUP-AR-1922BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUT BIO-PSHLK 4.5MMX18.5MM ABSB SLF-PNCH PLLA TI TIP -,SUP-AR-1922BM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2067.2,1447.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR PUSHLOCK 2.9 X 15.5 BIO -,SUP-AR-1923BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR PUSHLOK PEEK 2.9X15.5 -,SUP-AR-1923PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUT CRKSCR 6.5MMX15.5MM THRD ST TI SZ2 GRN WHT SUT -,SUP-AR-1925S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR CORKSCREW 6.5 FIBER 2 2 -,SUP-AR-1925SF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BIO-PUSHLOCK COMPOSITE 3.5MM -,SUP-AR-1926BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUT PSHLK 3.5MMX19.5MM PEEK HNDL INSRTR DRIVER -,SUP-AR-1926PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUT CRKSCR FT 5.5MMX14.7MM ARSCP FT BABSRB BIOCMPS -,SUP-AR-1927BCF-3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1802.17,1261.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR 4.5 BIO-COMPOSITE -,SUP-AR-1927BCF-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
6.5 BIOCOMPOSITE ANCHORS -,SUP-AR-1927BCF-65,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1775.67,1242.969,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR BIO CORKSCREW 5.5 -,SUP-AR-1927BCT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1881.68,1317.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR CORKSCREW 5.5 PEEK (BOX OF 5) -,SUP-AR-1927PSF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUT SUTAK 3MMX14.5MM ARSCP BIOCMPS ABSB #2 -,SUP-AR-1934BCF,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1616.65,1131.655,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR BIOCOMPOSITE 3MM DBL -,SUP-AR-1934BCF-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUT SUTAK 2.4X12MM ARSCP BIOCMPS FIBERWIREX2 -,SUP-AR-1934BCF-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1616.65,1131.655,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUT SUTAK 2.4X12MM ARSCP BIOCMPS FIBERWIRE -,SUP-AR-1934BCF-24-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR BIOCOMPOSITE 3MM SING -,SUP-AR-1934BCT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1802.17,1261.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BIO SUTURE TAK DISPOSABLE -,SUP-AR-1934DS-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
KIT SUTURE TAK 3MM PERCUTANEOUS INSERTION -,SUP-AR-1934PI-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR KNOTLESS SUT TAK 3MM BI -,SUP-AR-1938BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR PEEK SUT TAK 3MM KNOTLESS -,SUP-AR-1938PS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
IMPLANT DISTAL BICEP REPAIR 7 X 10MM -,SUP-AR-2260BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BUTTON SUT 2.6MM TI 12MM LF -,SUP-AR-2261,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BUTTON SUT DOG BN LF -,SUP-AR-2270,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SWIVEL LOCK 5.5 -,SUP-AR-2323BCC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUT SWIVLK C 5.5MMX19.1MM ABSB CLSD EYLT PLLA -,SUP-AR-2323BSLC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1987.69,1391.383,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SWIVELOCK- SP BC KL 5.5MM -,SUP-AR-2323KBCSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUT SWIVLK 5.5MMX24.5MM SLF-PNCH PEEK -,SUP-AR2323PSLM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUT SWIVLK C 4.7MMX19.1MM CLSD EYLT BIOCMPS WHT/BLK -,SUP-AR-2324BCCTT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR BIO COMP SWIVELOCK SP 4 (MIN 5 EACH) -,SUP-AR-2324BCM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR BIOCOMPOSITE SWIVEL W\FIBERTAPE -,SUP-AR-2324BCT-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR BIO-SWIVELLOCK 4.75 -,SUP-AR-2324BCT-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SWIVELOCK  BIOCOMPOSITE 4.75MM X  22MM DOUBLE LOADED -,SUP-AR-2324BCT-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SWIVELOCK KNOTLESS 4.75MM BC -,SUP-AR-2324KBCC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2438.23,1706.761,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
KNOTLESS SWIVELOK 4.75MM BC W/TAPE -,SUP-AR-2324KBCCTT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2530.22,1771.154,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SWIVELOCK- SP BC KL 4.75MM -,SUP-AR-2324KBCSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUT BIO- SWIVLK SP 4.75MMX24.5MM SLF-PNCH PEEK TI -,SUP-AR-2324PSLM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BC SWIVELOCK 3.9 X 17.9 MM -,SUP-AR-2326BCC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
KIT SPEEDBRIDGE SHOULDER -,SUP-AR-2600SBS-8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8106.04,5674.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE DISTAL CLAVICLE 22 DEG RIGHT -,SUP-AR-2622DR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 8HL PRCONT SS LT CLVCL -,SUP-AR-2651CL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PRCONT SS RT CNTRL CLVCL -,SUP-AR-2653CR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN PRCONT SS LT CNTRL CLVCL -,SUP-AR-2654CL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE CLAVICLE DISTAL SHOR LEFT SS -,SUP-AR-2656DL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE CLAVICLE DISTAL SHORT RIGHT SS -,SUP-AR-2656DR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 8HL PRCONT SS RT CLVCL -,SUP-AR-2657DR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE DISTAL CLAVICLE BUTTON -,SUP-AR-2658,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DISTAL CLAVICLE REPAIR ASSEMBLY -,SUP-AR-2658T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SUTURE ANCHOR- BIOCOMPOSITE- HIP PUSHLOCK- SHORT 2.9 x 12.5 -,SUP-AR-2923BCH,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
KIT DISPOSABLES FOR FIBERTAK SUTR ANCH -,SUP-AR-3600DC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FIBERTAK WITH SUTURETAPE -,SUP-AR-3602,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1881.68,1317.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.6 FIBERTAK ANCHOR DOUBLE  LOADED -,SUP-AR-3632,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1961.19,1372.833,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FIBERTAK ANCHOR TRIPLE LOADED -,SUP-AR-3633,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SELF-PUNCHING TRIPLE LOADED FIBERTAK -,SUP-AR-3633SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR FIBERTAK KNOTLESS -,SUP-AR-3636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FIBERTAK SHOULDER 1.8 SELF BUNCHING -,SUP-AR-3636,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FIBERTAK HIP 1.8 SELF BUNCHING -,SUP-AR-3636H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
KNOTLESS 1.8 FIBERTAK W/ #2 SUTURE -,SUP-AR-3638,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
KNOTLESS HIP FIBERTAK SUTURE ANCHOR- CURVED -,SUP-AR-3638DHC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
KIT FIBERTAK KNOTLESS STRAIGHT DISPOSABLE -,SUP-AR-3638DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SP FBTAK RC TGRTPE WH/BLK & STTPE WH/BL -,SUP-AR-3652SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SP FBTAC RC RBRTPE BLU & STTPE WH/BLK -,SUP-AR-3652TSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SP FBTAC RC RBRTPE BLK/BLU & STTPE BLU -,SUP-AR-3652TTSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2491.24,1743.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
KL FBTK RC (WH/BLK)TT & (BLU)#2 MTS -,SUP-AR-3653SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2530.22,1771.154,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
KL FBTK RC W/(BLU)FT & (W/BLK) #2 MTS -,SUP-AR-3653TSP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2530.22,1771.154,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
KNOTLESS TENSIONABLE FIBERTAK BICEP -,SUP-AR-3687,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ARTHROSCOPIC FX CHNDR -,SUP-AR-4005B-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,706.04,494.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW VENTED BC IF 7 X 20MM -,SUP-AR-4020C-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW VENTED BC IF 8 X 20MM -,SUP-AR-4020C-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW VENTED BC IF 9 X 20MM -,SUP-AR-4020C-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW VENTED BC IF 10 X 20MM -,SUP-AR-4020C-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ARTHREX PEEK SCREW 7 X 20MM FAST THREAD -,SUP-AR-4020P-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ARTHREX PEEK 8 X 20MM FAST THREAD -,SUP-AR-4020P-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ARTHREX PEEK 9 X 20MM FAST THREAD -,SUP-AR-4020P-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ARTHREX PEEK 10 X 20MM FAST THREAD -,SUP-AR-4020P-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW VENTED BC IF 7 X 30MM -,SUP-AR-4030C-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW VENTED BC IF 8 X 30MM -,SUP-AR-4030C-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW VENTED BC IF 9 X 30MM -,SUP-AR-4030C-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW VENTED BC IF 10 X 30MM -,SUP-AR-4030C-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW VENTED BC IF 11 X 30MM -,SUP-AR-4030C-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ARTHREX PEEK SCREW 7 X 30MM FAST THREAD -,SUP-AR-4030P-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ARTHREX PEEK 8 X 20MM FAST THREAD -,SUP-AR-4030P-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ARTHREX PEEK 9 X 30MM FAST THREAD -,SUP-AR-4030P-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ARTHREX PEEK 10 X 30MM FAST THREAD -,SUP-AR-4030P-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DEVICE SUT 1.5X5MM CRV C IN MNSCL 2-0 FIBERWIRE NDLX2 MINI -,SUP-AR-4500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1510.64,1057.448,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
KIT BIOCOMPOSITE MENISCAL ROOT REPAIR -,SUP-AR-4550BC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FIBER STITCH CURVED -,SUP-AR-4570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUTURE FIBERSTITCH FIBERWIRE POLYESTER 24 D 2-0 CURVE -,SUP-AR-4570-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
KIT ARTHROSCOPIC FIXATION FIBERSTITCH REVERSE CURVE -,SUP-AR-4570R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUTURE FIBERSTITCH STRAIGHT -,SUP-AR-4570S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW INTFR BIOCMPRSN 3X18MM BABSRB HDLS PLLA KN TAPR STP -,SUP-AR-5025B-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW INTFR BIOCMPRSN 2.7X20MM BABSRB HDLS PLLA KN TAPR STP -,SUP-AR-5025B-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 8 X 28 BIOCOMPOSITE -,SUP-AR-5028C-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 9X28 DELTA -,SUP-AR-5028C-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 10 X 28 BIOCOMPOSITE -,SUP-AR-5028C-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 11 X 28 DELTA -,SUP-AR-5028C-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 9 X 35 DELTA -,SUP-AR-5035TC-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 10 X 35 BIOCOMPOSITE -,SUP-AR-5035TC-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 11 X 35 DELTA -,SUP-AR-5035TC-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 12 X 35 BIOCOMPOSITE -,SUP-AR-5035TC-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WIRE GUIDE 1.35MM DUAL TROCAR -,SUP-AR-5050-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,239.24,167.468,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GRAFTBOLT TIBIAL 7MM -,SUP-AR-5100-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GRAFTBOLT TIBIAL 8MM -,SUP-AR-5100-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GRAFTBOLT TIBIAL 9MM -,SUP-AR-5100-09,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GRAFTBOLT TIBIAL 10MM -,SUP-AR-5100-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SUTURE ANCHOR- SWIVELOCK TENODESIS- PEEK -,SUP-AR-7324PSL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2969.43,2078.601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOW PROFILE SCREW TI 4.5 X 26MM -,SUP-AR-8545-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOW PROFILE SCREW TI 4.5 X 34MM -,SUP-AR-8545-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOW PROFILE SCREW TI 4.5 X 36MM -,SUP-AR-8545-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LO-PRO LOCK SCREW TI 4.5 X 28MM -,SUP-AR-8545L-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X55MM LCK -,SUP-AR-8545L-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X60MM LCK -,SUP-AR-8545L-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
IMPLANT SYSTEM CPR MINI SCORPION DX -,SUP-AR-8690DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
STAPLE BN FX QUICKFIX SM SS -,SUP-AR-8710,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NITINOL COMPRESSION STAPLE- 9WX7L -,SUP-AR-8717-0907,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NITINOL COMPRESSION STAPLE- 9WX10L -,SUP-AR-8717-0910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DYNANITE NITI STAPLE W/INSTRS 9WX10L -,SUP-AR-8717DS-0910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DYNANITE NITI STAPLE W/INSTRS 10W X 11L -,SUP-AR-8717DS-1110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DYNANITE NITI STAPLE W/INSTRS 11W X 15\12L -,SUP-AR-8717DS-111512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NITINOL COMP STAPLE 15W X 12L -,SUP-AR-8718-1512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
STAPLER DYNAMITE NITI  W/INSTRS 13W X 10L -,SUP-AR-8718DS-1310,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8042.38,5629.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DYN NITI STAPLE W/INSTRS 15W X 12L -,SUP-AR-8718DS-1512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8042.38,5629.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
STAPLE 15W X 15L DYNANITE NITI W/INSTRS -,SUP-AR-8719DS-1515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DYN NITI STAPLE W/INSTRS 18W X 15L -,SUP-AR-8719DS-1815,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
STAPLE DYNANITE NITI W/INSTRS 18W X 18L -,SUP-AR-8719DS-1818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DYNANITE NITI STAPLE WINSTRS 20W X 20L -,SUP-AR-8719DS-2020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
QCKFIX SCRW TI CANN PT 2.0 X 10MM -,SUP-AR-8720-10PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.4X12MM HD CORT QUICKFIX ST SLD STND ALONE TI STRL -,SUP-AR-8724-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOW PROFILE 2.4 X 14 CORTEX -,SUP-AR-8724-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOW PROFILE SCREW 2.4 X 18MM CORTEX -,SUP-AR-8724-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW QUICKFIX 2.4 X 18MM TI CANNULATED -,SUP-AR-8724-18PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,846.08,592.256,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW QUICKFIX 2.4 X 22MM TI CANNULATED -,SUP-AR-8724-22PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,846.08,592.256,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.4X24MM CANN QUICKFIX P/T T8 HXLB DRV TI F/CMPRHNSV -,SUP-AR-8724-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOW PROFILE SCREW 2.4 X 32MM CORTEX -,SUP-AR-8724-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOW PROFILE SCREW 2.4 X 36MM CORTEX -,SUP-AR-8724-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.4 X 8 VAL TI -,SUP-AR-8724V-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.4 X 12 VAL TI -,SUP-AR-8724V-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.4 X 16 VAL TI -,SUP-AR-8724V-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.4MM X 18MM V AL SCREW TI -,SUP-AR-8724V-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW VAL TI 2.4MM X 18MM -,SUP-AR-8724V-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.4MM X 22MMV AL SCREW TI -,SUP-AR-8724V-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW VAL KREULOCK TI 2.4X12 -,SUP-AR-8724VCL-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW VAL KREULOCK TI 2.4X16 -,SUP-AR-8724VCL-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW COMPRESSION FT 2.5MM MICRO X 8MM LGTH -,SUP-AR-8725-08H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5MMX14MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-14H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5MMX16MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-16H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5MMX18MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-18H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5MMX20MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-20H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW COMPR FT 2.5 MICRO 22MM -,SUP-AR-8725-22H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5MMX24MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-24H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5MMX26MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8725-26H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COMPR FT SCREW 2.5 MICRO 28MM LGTH -,SUP-AR-8725-28H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEADLESS MICRO 2.5X 30MM -,SUP-AR-8725-30H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COMPR FT SCREW 2.5 MICRO 32MM LGTH -,SUP-AR-8725-32H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW QUICKFIX TI CANC PT 3.0 X 12MM -,SUP-AR-8730-12PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX14MM CANN TRL QUICKFIX FT VAR STP PTCH TI F/STND -,SUP-AR-8730-14H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3MMX14MM DUAL CORE QUICKFIX -,SUP-AR-8730-14PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COMPR FT SCREW 3.5 MINI 16MM -,SUP-AR-8730-16H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3MMX16MM DUAL CORE QUICKFIX -,SUP-AR-8730-16PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COMPR FT SCRW 3.5 MINI 18MM LGTH -,SUP-AR-8730-18H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3MMX18MM DUAL CORE QUICKFIX -,SUP-AR-8730-18PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COMP SCREW 3.5 MINI 20MM -,SUP-AR-8730-20H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3MM X 20MM DUAL CORE QUICKFIX -,SUP-AR-8730-20PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COMPR FT SCREW 3.5 MINI 22MM -,SUP-AR-8730-22H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3MMX22MM DUAL CORE QUICKFIX -,SUP-AR-8730-22PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW FT COMPR 3.5 X 24MM -,SUP-AR-8730-24H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3MMX24MM DUAL CORE QUICKFIX -,SUP-AR-8730-24PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW COMPR FT 3.5 X 26 MINI -,SUP-AR-8730-26H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3MMX26MM DUAL CORE QUICKFIX P/T SD/ST T10 HXLB DRV TI -,SUP-AR-8730-26PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW COMPR FT 3.5 MINI 28MM -,SUP-AR-8730-28H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW FT COMPR 3.5 X 30MM -,SUP-AR-8730-30H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.6MMX32MM COMPR HDLS QUICKFIX P/T SD/ST T10 HXLB DRV -,SUP-AR-8730-32H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COMPR FT SCREW 3.5 MINI 34MM LGTH -,SUP-AR-8730-34H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
QCKFIX SCREW TI CANC PT 3.0 X 38MM -,SUP-AR-8730-38PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOW PROFILE SCREW CORTICAL 3.5MM X 14MM DRP -,SUP-AR-8735-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOW PROFILE SCREW CORTICAL 3.5MM X 16MM DRP -,SUP-AR-8735-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOW PROFILE SCREW CORTICAL 3.5MM X 18MM DRP -,SUP-AR-8735-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
3.5X32MM BEVELED FT SCREW -,SUP-AR-8735BV-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BEVELED FT 3.5MM X40MM -,SUP-AR-8735BV-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5 X 44MM BEVELED FT -,SUP-AR-8735BV-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOW PROFILE SCREW LOCKING 3.5MM X 16MM DRP -,SUP-AR-8735L-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEWIRE 0.86MM W/ LASER LINE SS -,SUP-AR-8737-21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,87.53,61.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW COMPR FT 4.0 STD 20MM LGTH -,SUP-AR-8740-20H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW COMPR FT 4.0 STD 22MM LGTH -,SUP-AR-8740-22H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COMPRESSION SCREW 4.0 24MM LENGTH -,SUP-AR-8740-24H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COMPRESSION SCREW 4.0 26MM LENGTH -,SUP-AR-8740-26H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COMPRESSION SCREW 4.0 28MM LENGTH -,SUP-AR-8740-28H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW COMPR FT 4.0 STD 30MM LGTH -,SUP-AR-8740-30H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW QUICKFIX TI CANN ST 4.0 X 38MM CANC -,SUP-AR-8740-38PTS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW QUICKFIX TI CANN 4.0 X 40MM ST CANC -,SUP-AR-8740-40PTS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
4X46MM BEVELED FT SCREW -,SUP-AR-8740BV-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4 X 50MM BEVELED FT -,SUP-AR-8740BV-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4 X 52MM BEVELED FT -,SUP-AR-8740BV-52,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WASHER 7.0MM TI -,SUP-AR-8740W,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEWIRE 1.6MM- 4MM BEVELED FT -,SUP-AR-8741-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEWIRE 1.6X150MM CAPITAL FRAG -,SUP-AR-8741-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW COMPR FT 5.0 X 42MM -,SUP-AR-8750-42H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW COMPR FT 5.0 X 55MM -,SUP-AR-8750-55H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COMPR FT SCREW 7.0 XL 65MM LGTH -,SUP-AR-8770-65H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COMPR FT SCREW 7.0 XL 70MM LGTH -,SUP-AR-8770-70H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COMPR FT SCREW 7.0 XL 75MM LGTH -,SUP-AR-8770-75H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUT BIO-PSHLK 2.5X8MM KNTLS PLLA ABSB #2 FIBERWIRE -,SUP-AR-8825B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUTURE PEEK MINI PUSHLOCK -,SUP-AR-8825P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
KREULOCK COMPRESSION SCREW SS 2.7 X 12MM -,SUP-AR-8827CL-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
KREULOCK COMPRESSION SCREW SS 2.7 X 14MM -,SUP-AR-8827CL-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
KREULOCK COMPRESSION SCREW SS 2.7 X 16MM -,SUP-AR-8827CL-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
KREULOCK COMPRESSION SCREW SS 2.7 X 18MM -,SUP-AR-8827CL-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
KREULOCK COMPRESSION SCREW SS 2.7 X 20MM -,SUP-AR-8827CL-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X10MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X12MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X18MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X20MM LCK CORT TIGHTROPE FT SD T10 HXLB DRV SS -,SUP-AR-8827L-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LO-PRO LOCK SS 2.7 X 22 -,SUP-AR-8827L-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LO-PRO LOCK 2.7 X 24 -,SUP-AR-8827L-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CANCLUS SCREW FULLY THREADED SS 3 X 24MM -,SUP-AR-8830-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LO-PRO SCREW TM SS 3.5 X 12MM CORT -,SUP-AR-8835-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X14MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X16MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X18MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X22MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X26MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X28MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X30MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X35MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X45MM NLCKG CORT TIGHTROPE SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8835-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X10MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X14MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X16MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X18MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X20MM LCK CORT TIGHTROPE SD T15 HXLB DRV SS -,SUP-AR-8835L-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X14MM NLCKG CANC TIGHTROPE FT SD T15 HXLB DRV SS -,SUP-AR-8840-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X16MM NLCKG CANC TIGHTROPE FT SD T15 HXLB DRV SS -,SUP-AR-8840-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X30MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X40MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X45MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X60MM CANN TIGHTROPE S/T SS F/SYNDSMS FX MGMT SYS -,SUP-AR-8840C-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X30MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X35MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X50MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X60MM CANN TIGHTROPE LNG THRD SS F/SYNDSMS FX MGMT -,SUP-AR-8840CL-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PARS Suture Implant Kit w/ SutureTape -,SUP-AR-8862DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TIGHTROPE MINI 1.1MM -,SUP-AR-8914DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
VOLAR DISTAL RAD PLT TI NARROW LT 3HOLE -,SUP-AR-8916VNL-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
VOLAR DISTAL RAD PLT TI NARROW RT 3H -,SUP-AR-8916VNR-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
IMPLANT MINI TIGHTROPE 1.1 - 0 -,SUP-AR-8919DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
KT ARTHROSCOPIC FX TIGHTROPE ANKL 6.5MM RND BTN 3.5X10MM -,SUP-AR-8920CDS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
KT ARTHROSCOPIC FX TIGHTROPE ANKL 3.5MM RND/10MM OBLNG BTN -,SUP-AR-8921CDS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TIGHTROPE XP KNOTLESS TITANIUM -,SUP-AR-8925T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TIGHTROPE KNOTLESS -,SUP-AR-8926SS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4986.7,3490.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BIO-COMP ACHILLE SPEEDBRIDGE -,SUP-AR-8928BCJ-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SYSTEM IMPLANT MPFL BIOCOMPOSITE -,SUP-AR-8929BC-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6310.83,4417.581,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2X10MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI COLR F -,SUP-AR-8930-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2X11MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI MAG F -,SUP-AR-8930-11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2X12MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI BLU F -,SUP-AR-8930-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2X13MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI GRN F -,SUP-AR-8930-13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2X14MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI PUR F -,SUP-AR-8930-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2X16MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI PUR F -,SUP-AR8930-16PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2X20MM COMPR CORT QUICKFIX SD/ST SNP-OFF TI PUR F -,SUP-AR-8930-20PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3X12MM CANN CORT P/T TI -,SUP-AR-8933-12PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3X14MM CANN CORT P/T TI -,SUP-AR-8933-14PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LP SCREW 3 X 16MM CORTICAL MTP TI -,SUP-AR-8933-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3X16MM CANN CORT P/T TI -,SUP-AR-8933-16PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LO-PRO SCREW TI 3.0MM X 18MM CORT -,SUP-AR-8933-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3X18MM CANN CORT P/T TI -,SUP-AR-8933-18PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LO-PRO SCREW TI 3.0MM X 20MM CORT -,SUP-AR-8933-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LO-PRO SCREW TI 3.0MM X 22MM CORT -,SUP-AR-8933-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LO-PRO SCREW TI 3.0MM X 36MM CORT -,SUP-AR-8933-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3X14MM LCK CORT P/T TI BLU -,SUP-AR-8933L-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3X16MM LCK CORT P/T TI BLU -,SUP-AR-8933L-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
VAL KREULOCK SCREW TI 3 X 16 -,SUP-AR-8933VCL-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
VAL KREULOCK SCREW TI 3 X 18 -,SUP-AR-8933VCL-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
VAL KREULOCK SCREW TI 3 X 20 -,SUP-AR-8933VCL-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW VAL KREULOCK 3.0 X 22MM TI -,SUP-AR-8933VCL-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW VAL KREULOCK 3.0 X 26MM TI -,SUP-AR-8933VCL-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SUTURETAPE S-TAK ASSY 3.0 DOUBLE LOADED -,SUP-AR-8934BCST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
3.0 DOUBLE LOADED SUTURETAPE S-TAK ASSY -,SUP-AR-8934BCST-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LO-PRO SCREW TI 3.5MM X 12MM -,SUP-AR-8935-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LO-PRO SCREW TI 3.5MM X 22MM -,SUP-AR-8935-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LO-PRO SCREW TI 3.5MM X 24MM -,SUP-AR-8935-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LO-PRO TI 3.5MM X 26MM -,SUP-AR-8935-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LO-PRO TI 3.5MM X 30MM -,SUP-AR-8935-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LO-PRO SCREW TI 3.5MM X 32MM -,SUP-AR-8935-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LO-PRO TI 3.5MM X 34MM -,SUP-AR-8935-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LO-PRO SCREW TI 3.5MM X 36MM -,SUP-AR-8935-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LO-PRO SCREW TI 3.5MM X 38MM -,SUP-AR-8935-38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LO-PRO SCREW TI 3.5MM X 40MM -,SUP-AR-8935-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LO-PRO SCREW TI 3.5MM X 42MM -,SUP-AR-8935-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LO-PRO SCREW TI 3.5MM X 44MM -,SUP-AR-8935-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LO-PRO SCREW TI 3.5MM X 46MM -,SUP-AR-8935-46,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LO-PRO SCREW TI 3.5MM X 48MM -,SUP-AR-8935-48,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW KREULOCK TI 3.5 X 24MM -,SUP-AR-8935CL-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW KREULOCK TI 3.5 X 26 -,SUP-AR-8935CL-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
KREULOCK SCREW TI 3.5 X 28 -,SUP-AR-8935CL-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW KREULOCK TI 3.5 X 28MM -,SUP-AR-8935CL-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW KREULOCK TI 3.5 X 30 -,SUP-AR-8935CL-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW KREULOCK TI 3.5 X 32 -,SUP-AR-8935CL-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
KREULOCK SCREW TI 3.5 X 34 -,SUP-AR-8935CL-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
KREULOCK SCREW TI 3.5 X 36 -,SUP-AR-8935CL-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LO-PRO LOCK SCREW TI 3.5MM X 12MM -,SUP-AR-8935L-12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOCKING SCREW  TI 3.5MM X 14MM -,SUP-AR-8935L-14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X24MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X26MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOCKING SCREW TITANIUM 3.5MM X 28MM -,SUP-AR-8935L-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING TITANIUM 3.5MM X 28MM -,SUP-AR-8935L-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X30MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X32MM LCK CORT FT SD T15 HXLB DRV TI STRL BLU -,SUP-AR-8935L-32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOCKING SCREW TITANIUM 3.5MM X 34MM -,SUP-AR-8935L-34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOCKING SCREW TITANIUM 3.5MM X 44MM -,SUP-AR-8935L-44,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
KIT ENDOSCOPIC BOSTROM REPAIR IMPLANT SYS -,SUP-AR-8936BC-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X30MM CANC FT SD TI STRL F/H-PLATE LPDS SURG -,SUP-AR-8940-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LO-PRO TI 4.0MM X 36MM -,SUP-AR-8940-36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X40MM CANC FT SD TI -,SUP-AR-8940-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN TIGHTROPE 79MM F/SYNDSMS RPR 4HL SS BTRSS LT -,SUP-AR-8943BL-04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN TIGHTROPE 79MM F/SYNDSMS RPR 4HL SS BTRSS RT -,SUP-AR-8943BR-04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN TIGHTROPE 91MM F/SYNDSMS RPR 5HL SS BTRSS -,SUP-AR-8943BR-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN TIGHTROPE 104MM F/SYNDSMS RPR 6HL SS BTRSS -,SUP-AR-8943BR-06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN TIGHTROPE 61MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943H-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN TIGHTROPE F/DLTD LGMNT ATTCH AVULSION FX SYNDSMS -,SUP-AR-8943H-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN TIGHTROPE 47MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943T-04,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN TIGHTROPE 72MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943T-06,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN TIGHTROPE 98MM F/DLTD LGMNT ATTCH AVULSION FX -,SUP-AR-8943T-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1404.63,983.241,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN TIGHTROPE F/SYNDSMS AVULSION FX MGMT 10HL LCK SS -,SUP-AR-8943T-10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1484.14,1038.898,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN TIGHTROPE 72MM F/SYNDSMS AVULSION FX MGMT 3HL SS -,SUP-AR-8943TH-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN TIGHTROPE F/SYNDSMS AVULSION FX MGMT 7HL LCK SS 1/3 -,SUP-AR-8943TH-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN TIGHTROPE 43MM TI BTRSS 3.5MM LPS SCR 2.4MM GW -,SUP-AR-8947DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.1,3045.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 7.5MM STP -,SUP-AR-8949-075,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LISFRANC PLATE MEDIUM LEFT TI -,SUP-AR-8951ML,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE MEDIUM RIGHT TITANIUM LISFRANC -,SUP-AR-8951MR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LISFRANC PLATE SMALL RIGHT TI -,SUP-AR-8951SR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.5MM 2HOLE L-PLATE TI 5H RT -,SUP-AR-8952ML-05R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 3MM 5HL TI STR -,SUP-AR-8952TS-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CALCFX PERCPLT STD ANTERIOR PROCESS L -,SUP-AR-8954ML-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE LONG CALCANEUS RIGHT TUBEROSITY 3.5/4 MM PERCUTANEOUS -,SUP-AR-8954YR-L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BONE TAP CANNULATED 6.0MM -,SUP-AR-8956C-60T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE LONG METATARSAL RIGHT HOOK -,SUP-AR-8956R-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 2 HOLE TITANIUM -,SUP-AR-8958-02S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANTEROLATERAL PILON FUSION PLATE 5 HOLE LT -,SUP-AR-8963ALF-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,12624.2,8836.94,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANTEROLATERAL PILON FUSION PLATE 7H RT -,SUP-AR-8963ARF-07,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.7X65MM CANN 18MM THRD SD/ST TI -,SUP-AR-8967-1865,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WASHER ORTHO 13MM TI -,SUP-AR-8967W,CDM,C1713,HCPCS,278,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
KIT DX SWIVELOCK SL 3.5X8.5MM -,SUP-AR-8978DS-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SWIVELOCK DX SL 3.5 X 8.5 -,SUP-AR-8978P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SYSTEM INTERNAL FIXATION FIBERLOCK SUSPENSION  3.5 X 8.5 -,SUP-AR-8988-CP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5889.19,4122.433,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUTURE FIBER TAK DX -,SUP-AR-8990ST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2464.73,1725.311,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR FIBERTAK DOUBLE-LOADED DX SUTURE -,SUP-AR-8990ST-2,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2878.72,2015.104,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DX FIBERTAK SUTURE ANCHOR #2 MTS W/NDL -,SUP-AR-8991,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SWIVELOCK DISP KIT NANO 2.5 X 7 -,SUP-AR-8998DS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NANO SWIVELOCK 2.5 X 7 WITH FORK EYELET -,SUP-AR-8998T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X45MM P/T TI F /5TH MTRSL JONES FX SYS -,SUP-AR-9045-45PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X55MM P/T TI GRN -,SUP-AR-9045-55PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LO-PRO SCREW PT THREADED TI 5.5MM X 40MM -,SUP-AR-9055-40PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LO-PRO SCRW PT THD TI 6.0MM X 40MM -,SUP-AR-9060-40PT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCK GLENOID PERIPH -,SUP-AR-9145-42,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CENTRAL NL 6.5 X 25MM -,SUP-AR-9165-25NL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BC ACHILLES SPDBRG W/KL DX CC 3.9MM -,SUP-AR-9928BCK-DX,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10749.14,7524.398,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LP SCREW 3 X 18MM CORTICAL MTP TI -,SUP-AR-9933-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LP SCREW 3 X 20MM CORTICAL MTP TI -,SUP-AR-9933-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LP 3.0 X 22MM CORTICAL MTP TI -,SUP-AR-9933-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LP 3.0 X 24MM CORTICAL MTP TI -,SUP-AR-9933-24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LP SCREW 3 X 16MM CORTICAL HYBRID MTP TI -,SUP-AR-9933HY-16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOCK MED HOOK PLATE TI 3H -,SUP-AR-9943H-03,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
MAXFORCE MTP PLATE PETITE 0-0 RIGHT -,SUP-AR-9944P-0R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE MAXFORCE STD 5-5 RIGHT MTP -,SUP-AR-9944S-5R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 12.5MM CANN HDLS ACUTRAK STD TI ALY -,SUP-AT-1125-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.3-3.8X15MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI -,SUP-AT-1150-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.3-3.9MM 17.5MM CANN HDLS ACUTRAK FT ST STD 2MM HX -,SUP-AT-1175-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 20MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI ALY -,SUP-AT-1200-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.3-4.2MM 22.5MM CANN HDLS ACUTRAK FT ST STD 2MM HX -,SUP-AT-1225-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.3-4.4X25MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI -,SUP-AT-1250-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.3-4.5MM 27.5MM CANN HDLS ACUTRAK FT ST STD 2MM HX -,SUP-AT-1275-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.3-4.6X30MM CANN HDLS ACUTRAK FT ST STD 2MM HX DRV TI -,SUP-AT-1300-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5-2.8 MMX8MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5-2.8 MMX9MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5-2.8 MMX12MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5-2.8 MMX14MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5-2.8 MMX16MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5-2.8 MMX18MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5-2.8 MMX20MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST/CUT -,SUP-AT2-C20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5-2.8 MMX26MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5-2.8 MMX28MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT -,SUP-AT2-C28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5-3.6 MMX16MM CANN HDLS ACUTRAK 2 FT SLF CT 2MM HX -,SUP-AT2-M16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5-3.6 MMX22MM CANN HDLS ACUTRAK 2 FT SLF CT 2MM HX -,SUP-AT2-M22-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5-3.6 MMX24MM CANN HDLS ACUTRAK 2 FT SLF CT 2MM HX -,SUP-AT2-M24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4-4.1X16MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT STD -,SUP-AT2-S16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4-4.1X26MM CANN HDLS ACUTRAK 2 FLLY W THRD ST CUT STD -,SUP-AT2-S26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4-4.1X34MM CANN HDLS ACUTRAK 2 FLLY/W THRD ST CUT STD -,SUP-AT2-S34-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2649.57,1854.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3-2.5X24MM CANN HDLS ACUTRAK FUSION FT ST 1.5MM/2MM -,SUP-ATF-240-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1966.49,1376.543,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3-3.5X32MM CANN HDLS ACUTRAK FUSION FT ST 1.5MM/2MM -,SUP-ATF-320-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1966.49,1376.543,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.8-3.2 MMX10MM CANN HDLS ACUTRAK FT ST 1.5MM HX DRV -,SUP-ATM-100-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2454.13,1717.891,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
UNIVERSAL CEMENT RESTRICOTR SM 18.5MM -,SUP-B000-0185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
RESTRICTOR CMNT UNIV 24MM OSTEONICS -,SUP-B000-0240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
RESTRICTOR CEMENT UNIVERSAL SMALL INSERTER -,SUP-B000-1185,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
RESTRICTOR CMNT MED UNIV STRL -,SUP-B000-1240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
RESTRICTOR BNCMNT 11MM -,SUP-B0010110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
RESTRICTOR BNCMNT 15.5MM -,SUP-B0020125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
RESTRICTOR BNCMNT 14MM -,SUP-B0030140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5MMX110MM CANC DYNFX 50MM THRD TAPR -,SUP-B6011050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW EXTFIX 6/5MM DIA 130/ 60MM CORT/CANC TAPR DYNFX THRD -,SUP-B6013060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,485.47,339.829,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW TITAN REV SHOULDER LARGE -,SUP-BBS-0960-21LRG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
REVERSE BODY SMALL AND REVERSCE BODY SCREW -,SUP-BBS-0960-21SML,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BALLOON 6FR PTA 200CM X 3MM X 120MM METACROSS -,SUP-BD-P30150ER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
AFX2 BIFURCATED ENDOGRAFT SYSTEM -,SUP-BEA25-80/I13-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
STENT BIFURCATED ENDOGRAFT AFX2  28MM X 80MM -I16-40 -,SUP-BEA28-80/I16-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,37002.53,25901.771,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN TRIMED VOLAR BUTT 20 -,SUP-BP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
RSS BODY SCREW -,SUP-BSC-0960-021-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW TI F/TITAN MODLR SHLDR SYS -,SUP-BSW-0920-021-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,758.61,531.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
MIXER CEMENT KYPHON W  CEMENT -,SUP-C01B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,919.01,643.307,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
"K-WIRE PIN COVER .028"" -",SUP-C-028NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X12MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-C03120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X16MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-C03160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
"K-WIRE PIN COVER .035"" -",SUP-C-035NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
"K-WIRE PIN COVER .045"" -",SUP-C-045NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
"K-WIRE PIN COVER .054"" -",SUP-C-054NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
"K-WIRE PIN COVER .062"" -",SUP-C-062NS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2.31,1.617,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
EXTERNAL FX 0.375IN BALL COLR F/CAP VRS SZ K-WIRE -,SUP-C50-COL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.5,771.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4X14MM LCK CANC ACU-LOC 2 HEX HEAD TI NS F/MAYO -,SUP-CA-4140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,542.66,379.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GRAFT CANC 30ML CHP RDIGRF FRZDR CRSH VOID FIL 1-8MM -,SUP-CAN30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1984.24,1388.968,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
EXPERT KNEE CAPITATED REVISION SYSTEM -,SUP-CAP PRICE,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21164.1,14814.87,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CEMENT CARTRIDGE CC02A CDS -,SUP-CC02A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DISC CERVICAL SIZE 6MM LL M6 -,SUP-CDL-637L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CERVICAL DISC SIZE 6MM M6 ORTHOFIX -,SUP-CDM-625,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CERVICAL DISC 6 MEDIUM LONG ARTIFICIAL -,SUP-CDM-635L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CEMENT GUN AND BONE FILLER CDS2A SIZE 2 -,SUP-CDS2A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2361.37,1652.959,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
EXCLUDER ILIAC 23MM X 10MM X 10CM 16FR BRANCH ENDO -,SUP-CEB231010A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,31520.86,22064.602,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
IMPLANT VARILIFT- C STND ALONE XPD -,SUP-CIC1-7.5-12-BP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5835.5,4084.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE VARILIFT- C ST -,SUP-CIC1-9.0-12-BP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5835.5,4084.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
KT SUTURE REM SUT PRB KNT PSHR/CTR INTRO CROSSFIX II DISP -,SUP-CM-8000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DEVICE MENISCOTOME UP CRV STRONGER STF NDL HI STRGTH SUT -,SUP-CM-8002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR JK 2.9 SL WT/BL NS BK JUGGERKNOT -,SUP-CM-99329B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2067.2,1447.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR JK 2.9 BDL WT/BL NS BKLU BB JUGGERKNOT -,SUP-CM-99429B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2067.2,1447.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X12MM NLCKG CORT ACU-LOK 2 TI NS F/MAYO -,SUP-CO-2712,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X14MM NLCKG CORT ACU-LOK 2 TI NS F/MAYO -,SUP-CO-2714,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X16MM NLCKG CORT ACU-LOK 2 TI NS F/MAYO -,SUP-CO-2716,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X20MM NLCKG CORT ACU-LOC 2 TI NS F/MAYO -,SUP-CO-2720,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X22MM NLCKG CORT ACU-LOC 2 TI NS F/MAYO -,SUP-CO-2722,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X6MM NLCKG CORT ACU-LOK 2 TI NS -,SUP-CO-3060,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X10MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X12MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X14MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X16MM NLCKG CORT ACU-LOC 2 TI NS -,SUP-CO-3160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X24MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X25MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3250,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X26MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X28MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X30MM NLCKG CORT ACU-LOC 2 POLARUS TI NS -,SUP-CO-3300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X32MM NLCKG CORT ACU-LOC 2 POLARUS TI NS COLR -,SUP-CO-3320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,484.31,339.017,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X12MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X14MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X16MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.7X18MM LCK CORT POLARUS FT TI NS F/MAYO -,SUP-COL-2180,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X8MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X10MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X12MM LCK CORT -,SUP-COL-3120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X14MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X20MM LCK CORT FT TI F/MAYO PLATE/MODULAR/UNIV SYS -,SUP-COL-3200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X22MM LCK CORT POLARUS FT TI NS BLU F/MAYO -,SUP-COL-3220,CDM,C1713,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORITICAL LOCKING TI 3.5 X 13MM -,SUP-COLS -35130-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW GEMINUS CORTICAL LOCKING 3.5MM X 8MM TI -,SUP-COLS-35080-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL LOCKING 3.5 X 9 -,SUP-COLS-35090-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL LOCKING 3.5 X 10 -,SUP-COLS-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL LOCKING 3.5MM X 11MM -,SUP-COLS-35110-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL LOCKING 3.5MM X 12MM -,SUP-COLS-35120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW- CORTICAL LOCKING 3.5MM X 12MM -,SUP-COLS-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORT LOCKING 3.5MM X 15MM -,SUP-COLS-35150-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL LOCKING 3.5MM X 16MM -,SUP-COLS-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL LOCKING 3.5 X 18 -,SUP-COLS-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL LOCKING 3.5MM X 20MM TI -,SUP-COLS-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL LOCKING 3.5 X 24 -,SUP-COLS-35240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL LOCKING 3.5 X 26 -,SUP-COLS-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1085.31,759.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X14MM CORT ACU-LOC 2 FT NTOGG TI NS F/UNIV SYS -,SUP-CO-N2314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X22MM CORT ACU-LOC 2 FT NTOGG TI NS F/UNIV SYS -,SUP-CO-N2322,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X14MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X16MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X18MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.3X20MM LCK CORT ACU-LOC 2 FT TI NS F/UNIV SYS -,SUP-CO-T2320,CDM,C1713,HCPCS,278,RC,,,outpatient,,,653.52,457.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
RTR CROSS CONNECTOR -,SUP-CPF-CR 26 32-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CROSS CONNECTOR 32-44 -,SUP-CPF-CR 32 44-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL 3.5 X 12 -,SUP-CPF-CS 35 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CC PREFERRED ANGLE 3.5 X 14 -,SUP-CPF-CS 35 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CC PREFERRED ANGLE 3.5 X 18 -,SUP-CPF-CS 35 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CC PREFERRED ANGLE 3.5 X 20 -,SUP-CPF-CS 35 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LARGE OFFSET -,SUP-CPF-LC 00 0L-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SPINEART ML PREFERRED ANGLE 4MM X 12MM -,SUP-CPF-MS 04 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ML PREFERRED ANGLE SCRE 4 X 16 -,SUP-CPF-MS 04 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ML PREFERRED ANGLE SCRE 4 X 18 -,SUP-CPF-MS 04 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ML PREFERRED ANGLE 4 X 20 -,SUP-CPF-MS 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ML PREFERRED ANGLE 4 X 24 -,SUP-CPF-MS 04 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPINEART PERLA ML PREFERRED ANGLE SCREW 4 X 28 -,SUP-CPF-MS 04 28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ML PREFERRED 3.5 X 12 -,SUP-CPF-MS 35 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ML 35 X 14 -,SUP-CPF-MS 35 14S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW PERLA ML PREFERRED ANGLE 3.5MM X 16MM -,SUP-CPF-MS 35 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ML PREFERRED 3.5 X 18 -,SUP-CPF-MS 35 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ML 35 X 20 -,SUP-CPF-MS 35 20S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ML 35 X 24 -,SUP-CPF-MS 35 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SPINEART ML PREFERRED ANGLE 4MM X 14MM -,SUP-CPF-MS-04 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CONNECTOR PARALLEL 3-3 -,SUP-CPF-PC 30 3C-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CONNECTOR PARALLEL 3-5 -,SUP-CPF-PC 3C 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD PERLA 90MM TI -,SUP-CPF-PF T0 90-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PREBENT ROD COBALT CHROMIUM 45MM -,SUP-CPF-PR C0 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD PREBENT TITANIUM 3.5 X 40MM -,SUP-CPF-PR T0 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD 50MM -,SUP-CPF-PR T0 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD 60MM PREBENT TITANIUM -,SUP-CPF-PR T0 60-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PERLA PREBENT ROD TITANIUM 3.5 X 65MM -,SUP-CPF-PR T0 65-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD 70MM -,SUP-CPF-PR T0 70-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PERLA PREBENT ROD TITANIUM 3.5 X 75MM -,SUP-CPF-PR T0 75-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD PREBENT TITANIUM 3.5 L80 -,SUP-CPF-PR T0 80-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD 85MM -,SUP-CPF-PR T0 85-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD 45MM -,SUP-CPF-PR TO 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PREBENT TITANIUM ROD 3.5 X L12 PERLA -,SUP-CPF-PR TO 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD PREBENT TITANIUM 55MM -,SUP-CPF-PR TO 55-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD 60MM -,SUP-CPF-PR TO 60-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PRE-BENT ROD 3.5 X 90MM -,SUP-CPF-PR TO 90-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW POLY PERLA 4 X 10MM -,SUP-CPF-PS 04 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PERLA SCREW 12MM -,SUP-CPF-PS 04 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW POLYAXIAL PERLA 4MM X 12MM -,SUP-CPF-PS 04 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW POLYAXIAL 4MM X 14MM -,SUP-CPF-PS 04 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW POLYAXIAL 4 X 16 -,SUP-CPF-PS 04 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW POLY 4 X 18MM -,SUP-CPF-PS 04 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW POLYAXIAL PERLA 4MM X 20MM -,SUP-CPF-PS 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW POLY PERLA 4.0 X 24MM -,SUP-CPF-PS 04 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE PERLA 4MM X 32MM SPINE POLYAXIAL -,SUP-CPF-PS 04 32-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PERLA POLYAXIAL SCREW 3.5 X 10MM -,SUP-CPF-PS 35 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW POLY 3.5 X 12MM PERLA -,SUP-CPF-PS 35 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW PERLA 3.5 X 14 -,SUP-CPF-PS 35 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
3.5 x 16MM POLY SCREW -,SUP-CPF-PS 35 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW POLY 3.5 X 18MM PERLA -,SUP-CPF-PS 35 18-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PERLA POLYAXIAL SCREW 3.5 X 20MM -,SUP-CPF-PS 35 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
POLYAXIAL SCREW 3.5 X 24 -,SUP-CPF-PS 35 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW POLY PERLA 3.5MM X 28MM -,SUP-CPF-PS 35 28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
POLYAXIAL SCREW 3.5 X 12 -,SUP-CPF-PS 3512-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
POLYAXIAL SCREW 4.0 X 28 -,SUP-CPF-PS-0428-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
3.5 X 28 POLY SCREW -,SUP-CPF-PS-3528-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREWS SET PERLA -,SUP-CPF-SC 00 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPINEART STRAIGHT ROD CHROMIUM 350MM -,SUP-CPF-SR C3 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD TITANIUM 40MM -,SUP-CPF-SR CO 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD TITANIUM 80MM -,SUP-CPF-SR T0 80-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PERLA STRAIGHT ROD TITANIUM 03.5 L100 -,SUP-CPF-SR T1 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD TI 120MM -,SUP-CPF-SR T1 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD 240 -,SUP-CPF-SR T2 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SMOOTH SHANK SCREW 4MM Z 20 -,SUP-CPF-SS 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SS 3.5 X 20 -,SUP-CPF-SS 35 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SS 3.5 X 22 -,SUP-CPF-SS 35 22-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SS 3.5 X 24 -,SUP-CPF-SS 35 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREWS SS 3.5 X 26 -,SUP-CPF-SS 35 26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
3.5 x 28MM SMOOTH SHANK -,SUP-CPF-SS 35 28-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SS 3.5 X 34 -,SUP-CPF-SS 35 34-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
3.5 X 30MM POLY SCREW -,SUP-CPF-SS-35 30-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X12MM CORT DVR FT CRUCIF HEAD MAG -,SUP-CS12000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X16MM CORT DVR FT CRUCIF HEAD MAG -,SUP-CS16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X18MM CORT DVR FT CRUCIF HEAD MAG -,SUP-CS18000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GRAFT STRUT MATRGRF FRZDR 15X100MM -,SUP-CST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3457.04,2419.928,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BONE CEMENT CX01B XPEDE W MIXER US -,SUP-CX01B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1598.1,1118.67,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
HEADLESS 3.0X40 SCREW -,SUP-D2N30040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,968.61,678.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TORNIER LONG HUMERAL NAIL LEFT 7MM X 230MM -,SUP-DHN5796,CDM,C1713,HCPCS,278,RC,,,outpatient,,,13273.98,9291.786,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE DISTAL HUMERUS MEDIAL DIRECT 105MM -,SUP-DHPF-MDL-5HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9277.38,6494.166,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN SCREW DISTRACTION 12MM -,SUP-DP-12-TB,CDM,C1713,HCPCS,278,RC,,,outpatient,,,145.88,102.116,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN SCREW DISTRACTION 14MM -,SUP-DP-14-TY,CDM,C1713,HCPCS,278,RC,,,outpatient,,,145.88,102.116,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ULNAR STEM 6.0MM 2CM EXT STEM -,SUP-DRUJ-IS260,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9932.28,6952.596,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOCKING RADIAL PLATE SZ 20-15MM ASSY -,SUP-DRUJ-LP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19433.84,13603.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
14MM 3.5 LOCKING SCREW -,SUP-DRUJ-LSC14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,799.4,559.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
20MM 3.5 LOCKING SCREW -,SUP-DRUJ-LSC20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,799.4,559.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
22MM 3.5 LOCKING SCREW -,SUP-DRUJ-LSC22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,799.4,559.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
20MM 3.5 CORTICAL SCREW -,SUP-DRUJ-SC20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,636.02,445.214,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW DISTAL TROCHLEA COMP 3.5 X 45 TI -,SUP-DTCS-35045,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW DISTAL TROCHLEA COMP 3.5 X 50 -,SUP-DTCS-35050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN DVR 24.4MMX51.3MM 4HL STD SHRT NS LT -,SUP-DVRAL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN DVR ANTMC NRW -,SUP-DVRANR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3828.27,2679.789,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN DVR 21.6MMX48.9MM 4HL SHRT BTRSS NRW NS -,SUP-DVRANSL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN DVR 21.6MMX48.9MM 4HL SHRT NS -,SUP-DVRANSR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN DVR 24.4MMX51.3MM 4HL STD SHRT NS RT -,SUP-DVRAR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN DVR 24.4MMX51.3MM 4HL STD SHRT NS RT RADL -,SUP-DVRASR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN DVR 28.2MMX62.6MM 4HL W NS -,SUP-DVRAWL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN DVR 28.2MMX62.6MM 4HL W BTRSS NS -,SUP-DVRAWR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN DVR 24.4MMX89.5MM 4HL EXTEND XLNG BTRSS NS -,SUP-DVRAXL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN DVR 24.4MMX59.5MM 4HL NS LT -,SUP-DVR-L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TORNIER PERFORM REVERESED CTRSCREW 6.5MM X 25MM NON ST -,SUP-DWJ125,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TORNIER PERFORM REVERSED PERIPSCREW 5.0MM X 14MM NON ST -,SUP-DWJ314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1144.91,801.437,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TORNIER PERFORM REVERSED PERIPSCREW 5.0MM X 18MM NON ST -,SUP-DWJ318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1144.91,801.437,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
RESTRICTOR HUM CMNT 24MM F/TOT ELB PROS LTD -,SUP-EB0101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1166.11,816.277,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
RESTRICTOR CMNT TORNIER -,SUP-EBO101,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1293.32,905.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ROMEO POLYAXIAL 6 X 40 -,SUP-ELL-PS 06 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X25MM SIGNTR POLYAX FX F /ROMEO PDCL SYS TI ALY -,SUP-ELL-PS0525-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X30MM SIGNTR POLYAX FX F /ROMEO PDCL SYS TI ALY -,SUP-ELL-PS0530-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW POLYAXIAL 5 X 35 -,SUP-ELL-PS0535-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW POLYAXIAL 6 X 30 -,SUP-ELL-PS0630-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6X35MM SIGNTR POLYAX FX F /ROMEO PDCL SYS TI ALY -,SUP-ELL-PS0635-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD 30MM -,SUP-ELL-RD 00 30 S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD ROMEO STRAIGHT HEX TIP 0.54 L240 -,SUP-ELL-RD 22 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPIN ROMEO 5.4X50MM PREBNT TI LMBR SFT MLBL F/TRNSCONN -,SUP-ELL-RD0050-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SET SCREW SPIN ROMEO2 -,SUP-ELL-SC 00 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GRAFT STENT 49E X 36MM X 36MM ENDURANT II AO EXT -,SUP-ETCF3636C49E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18052.61,12636.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
STENT ENDURANT II GRAFT 16F X 16MM X 146MM LIMB -,SUP-ETLW1616C146E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GRAFT STENT ENDUR II LIMB ELTW1620C146E -,SUP-ETLW1620C146E,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
INFRAME IMPLANT 2.0MM X 32MM -,SUP-EXINF922032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
INFRAME EXSOMED IMPLANT 2.0MM X 36MM -,SUP-EXINF922036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6972.89,4881.023,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
INNATE IMPLANT 3.6MM X 35MM -,SUP-EXINN923635,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL INTRAMEDULLARY INNATE IMPLANT 3.6MM X 40MM -,SUP-EXINN923640,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
INNATE IMPLANT 3.6MM X 50MM -,SUP-EXINN923650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL INTRAMEDULLARY INNATE IMPLANT 3.6MM X 55MM -,SUP-EXINN923655,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL INTRAMEDULLARY INNATE IMPLANT 4.5MM X 45MM -,SUP-EXINN924545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL INNATE IMPLANT 4.5MM X 50MM -,SUP-EXINN924550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
INNATE IMPLANT 4.5 X 55 -,SUP-EXINN924555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
STRYKER EASY CLIP STAPLE -,SUP-EZ 20-20-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9747.74,6823.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
EASYCLIP 15 X 15 X 15 -,SUP-EZ15-15-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8823.28,6176.296,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
EASYCLIP FIXATION DEVICE 18 X 19 X 17 -,SUP-EZ18-19-17,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8823.28,6176.296,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
EASYCLIP FIXATION DEVICE 20 X 20 X 20 -,SUP-EZ20-20-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9747.74,6823.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
EASYCLIP 8 X 8 X 8MM -,SUP-EZM08-08-08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6512.42,4558.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BONE FILLER DEVICE SIZE 3 -,SUP-F04B,CDM,C1713,HCPCS,278,RC,,,outpatient,,,577.67,404.369,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DEVICE BN FIL FEM SZ2 KYPHX EXP STRL -,SUP-F06A,CDM,C1713,HCPCS,278,RC,,,outpatient,,,577.67,404.369,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ORTHOFIX 8.5 CAGE -,SUP-F28-3182,CDM,C1713,HCPCS,278,RC,,,outpatient,,,17265.45,12085.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SHAFT FROZEN BISECTED FEM -,SUP-FBFS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4383.06,3068.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CLAMP CRANIAL 11MM CRANIOFIX -,SUP-FF490T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,695.9,487.13,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CLAMP CRANIAL 16MM TITANIUM CRANIOFIX 2 -,SUP-FF491T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,862.41,603.687,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CLAMP CRANIAL 20MM TITANIUM CRANIOFIX 2 -,SUP-FF492T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1035.56,724.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW FREEFIX  COMPRESSION 3.5MM X 20MM TI -,SUP-FFC-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW FREEFIX COMPRESSION 3.5MM X 22MM TI -,SUP-FFC-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW FREEFIX COMPRESSION 3.5MM X 24MM TI -,SUP-FFC-35240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,997.79,698.453,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW FREEFIX COMPRESSION 4.5MM X 20MM TI -,SUP-FFC-45200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1009.46,706.622,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW FREEFIX COMPRESSION 4.5MM X 20MM TI -,SUP-FFC-45240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1009.46,706.622,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GRAFT HUMAN TISSUE FEMORAL HEAD 43MM -,SUP-FFH,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4839.09,3387.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GRAFT HUMAN TISSUE FEMORAL HEAD 43MM -,SUP-FFH,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4839.09,3387.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WEDGE FIBULA 18MM FROZEN -,SUP-FFIBW8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2636.84,1845.788,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW FREEFIX LOCKING 3.5MM X 20MM TI -,SUP-FFL-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW FREEFIX LOCKING 3.5MM X 22MM TI -,SUP-FFL-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW FREEFIX LOCKING 3.5MM X 26MM TI -,SUP-FFL-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.5,804.65,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW FREEFIX LOCKING 4.5MM 22MM TI -,SUP-FFL-45220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.3,756.91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PRESUTURED ALLOGRAFT -,SUP-FGL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9411.49,6588.043,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GRAFT HUM TIS SPCR FRZN FLEXIGRAFT MNSCS R/M LF -,SUP-FMNRM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,14676.34,10273.438,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.5X8MM LCK FT TI ALPS -,SUP-FP08,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.5X10MM LCK FT TI ALPS NS -,SUP-FP10,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.5X11MM LCK FT TI ALPS NS -,SUP-FP11,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.5X12MM LCK FT TI ALPS NS -,SUP-FP12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.5X13MM LCK FT TI ALPS NS -,SUP-FP13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.5X14MM LCK FT TI ALPS -,SUP-FP14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.5X15MM LCK FT TI ALPS -,SUP-FP15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.5X16MM LCK FT TI ALPS -,SUP-FP16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2X18MM LCK FT TI DVR NS -,SUP-FP18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.5X20MM LCK FT TI DVR NS -,SUP-FP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.5X22MM LCK FT TI F3 NS -,SUP-FP22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.5X24MM LCK FT TI ALPS -,SUP-FP24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.5X26MM LCK FT TI ALPS NS -,SUP-FP26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.5X28MM LCK FT TI ALPS -,SUP-FP28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.5X30MM LCK FT TI F3 NS -,SUP-FP30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GRAFT HUM TIS FRZN 230CM 7.5MM FLEXIGRAFT PRNS LONGUS TNDN -,SUP-FPLT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7087.1,4960.97,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD 120MM -,SUP-G100-5-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD 200MM -,SUP-G100-5-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD 400MM -,SUP-G100-5-400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD 6.0MM STRAIGHT -,SUP-G100-5-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD 100MM -,SUP-G150-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TIROD 200MM STRAIGHT -,SUP-G150-200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD 30MM -,SUP-G150-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD 35MM -,SUP-G150-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD 40MM CURVED -,SUP-G150-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD CURVED 40MM -,SUP-G150-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD 45MM -,SUP-G150-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD CURVED 50MM -,SUP-G150-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD 55MM -,SUP-G150-55,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD CURVED 60MM -,SUP-G150-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD 65MM GENESYS -,SUP-G15065,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD 70MM GENESYS -,SUP-G150-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD 75MM -,SUP-G150-75,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD 80MM GENESYS -,SUP-G150-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD 85MM SPINAL -,SUP-G150-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD 90MM -,SUP-G150-90,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD 95MM -,SUP-G150-95,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD 300MM GENESYS -,SUP-G300-5-300,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CONNECTOR CROSS LINK LARGE -,SUP-G301-LRG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CROSSLINK MED -,SUP-G301-MED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CROSS LINK -,SUP-G301-SM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
27-35MM CC -,SUP-G301-XSM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
COIL MICRONESTER EMBOLIZATION 0.018 X 7CM X 6MM -,SUP-G52738,CDM,C1713,HCPCS,278,RC,,,outpatient,,,916.1,641.27,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEADLESS COMP. 4.0MM 36M -,SUP-G58036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL 5.5 X 30MM -,SUP-G700-55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL 6.5 X 35MM -,SUP-G700-65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5 X 30MM GENESYS -,SUP-G701-55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW PEDICLE 5.5 X 35MM TI LO -,SUP-G701-55-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW PEDICLE 5.5MM X 40MM -,SUP-G701-55-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW TI LOCK 5.5 X 45MM -,SUP-G701-55-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW PEDICLE 6.5 X 30MM -,SUP-G701-65-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW PEDICLE 6.5 X 35MM -,SUP-G701-65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW PEDICLE 6.5 X 40MM -,SUP-G701-65-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW TI LOCK 6.5 X 45MM -,SUP-G701-65-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
6.5 X 50MM PEDICLE SCREW -,SUP-G701-65-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW TI-LOCK 7.5 X 30MM -,SUP-G701-75-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW TI-LOCK 7.5 X 35MM -,SUP-G701-75-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW PEDICLE 7.5 X 40MM -,SUP-G701-75-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW TI-LOCK 7.5 X 45MM -,SUP-G701-75-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
7.5 X 50MM PEDICLE SCREW -,SUP-G701-75-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 8.5MM X 70MM -,SUP-G701-85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CROSSLINK -,SUP-G701-XSM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MM X 25MM -,SUP-G702-45-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5MM X 30MM -,SUP-G702-45-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL 5.0 X 25MM -,SUP-G702-50-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL 5.0 X 30MM NEW -,SUP-G702-50-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CORTICAL SCREW 25 X 5.5MM -,SUP-G7025525,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL 5.5 X 25 -,SUP-G702-55-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5 X 45 GENESYS -,SUP-G702-55-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL 6.5 X 40MM -,SUP-G702-65-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL 7.5 X 45 -,SUP-G702-75-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 8.5MM X 45MM -,SUP-G710-85-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ILIAC 8.5 X 60 -,SUP-G710-85-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SPINE 8.5 X 70 -,SUP-G710-85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SPINE 8.5 X 80 -,SUP-G710-85-80,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HI TOP 6.5 X 35 -,SUP-G711-65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ILIAC 8.5 X 70 -,SUP-G741-85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
OFFSET -,SUP-G780-21,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
OFFSET 61 -,SUP-G780-61,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAP CIRCULAR TI LOCKING -,SUP-G826,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SET 8.5 -,SUP-G826-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAP LOCKING TI -,SUP-G828,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SET CAPS -,SUP-G828-85,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE 5MM SMALL -,SUP-GAC-05-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR APACHE CAGE 7MM -,SUP-GAC-07-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
APACHE CAGE ANCHORED 8MM -,SUP-GAC-08 SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE H8 -,SUP-GAC-08-SC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
APACHE ANCHORED 8MM -,SUP-GAC-08-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE 9MM -,SUP-GAC-09-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE APACHE ANCHORED 10MM -,SUP-GAC-10SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
APACHE ANCHORED 6MM -,SUP-GAC3D06-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
APACHE ANCHOR LARGE -,SUP-GAC-LG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR MEDIUM -,SUP-GAC-MD,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SMALL -,SUP-GAC-SM,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR GREEN XL -,SUP-GAC-XL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR XXL BROWN -,SUP-GAC-XXL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BUTTRES 22MM -,SUP-GBP1-22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 22MM 5.5 -,SUP-GBP1-2255,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
9mm CERVICAL PECK CAGE APACHE -,SUP-GCL-09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE SMALL APACHE 11MM -,SUP-GCL-11-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 12MM -,SUP-GCP10012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 14MM -,SUP-GCP10014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 14MM RESCU -,SUP-GCP10014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 16MM -,SUP-GCP10016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 35MM -,SUP-GCP20035,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BINARY 12MM -,SUP-GCP2-112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 14MM -,SUP-GCP2-114,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 16MM -,SUP-GCP2-116,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE CERVICAL 49MM -,SUP-GCP2-349,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.75MM X 16MM BINARY AUGER TIP FIXED -,SUP-GCP2-AF316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREWS 3.75 X 14MM SCREWS -,SUP-GCP2-AV314,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.75MM X 18MM BINARY AUGER TIP VAIABLE -,SUP-GCP2-AV318,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREWS 4.25 X 12MM -,SUP-GCP2-AV412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW FIXED CERV 3.75 X 14MM -,SUP-GCSF37514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BN 14MM -,SUP-GCSV37514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW VA 16MM -,SUP-GCSV37516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW RESCUE 16MM -,SUP-GCSV42516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
APACHE ANCHOR 6MM -,SUP-GCV-06-SO,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE APACHE 6MM -,SUP-GCV-06-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE APACHE ANCHORED 8MM -,SUP-GCV-08-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE APACHE ANCHORED 9MM -,SUP-GCV-09-SP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR LARGE -,SUP-GCV-LG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDE PIN 2.0MM X 125MM -,SUP-GDW-890-00,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.44,297.108,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
6.5 X 40MM PEDICLE SCREW -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CERVICAL APACHE CAGE 8MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL 7.5 X 30MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BINARY 2 LEVEL CERVICAL 30MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE CERVICAL 2 LEVEL 32MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW REDUCTION 6.5 X 30MM -,SUP-GENESYS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE STANDARD 31MM -,SUP-GLP-131,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 22MM -,SUP-GLPV-55 22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPINE 60MM -,SUP-GM150-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,688.53,481.971,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SET SCREW -,SUP-GM520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
MODULAR CORT IMPLANT HEAD -,SUP-GM557,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
MODULAR LOCK SCREW -,SUP-GM820,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE DORSAL SPANNING SHORT -,SUP-GMN-DSP-160,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6217.46,4352.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BONE GEMINUS TITANIUM DORSAL SPANNING LONG -,SUP-GMN-DSP-210,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6416.93,4491.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BONE GEMINUS TITANIUM RADIAL DISTAL DORSAL HOOK -,SUP-GMN-HP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2592.28,1814.596,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW PLATE BONE GEMINUS TITANIUM RADIAL DISTAL DORSAL HOOK -,SUP-GMN-HP-SCRW,CDM,C1713,HCPCS,278,RC,,,outpatient,,,566,396.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ASSEMBLED GEMINUS VOLAR DISTAL RADIUS PLATE NARR 120MM LEFT -,SUP-GMN-LTN-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9969.16,6978.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE DIST RAD NARR 3 HOLE LEFT GEMINUS VOLAR -,SUP-GMN-LTN-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE NARROW DIS RAD 4 HOLE LEFT -,SUP-GMN-LTN-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE VOLAR DIST RAD STANDARD 3 HL LEFT -,SUP-GMN-LTS-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE GEMINUS VOLAR DISTAL RADIUS STANDARD 4 HOLE LEFT -,SUP-GMN-LTS-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE ASSEMBLED GEMINUS VOLAR DIST RAD NARROW 120MM RIGHT -,SUP-GMN-RTN-120,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9969.16,6978.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE VOLAR DISTAL RADIUS NARROW 3 HOLE RIGHT -,SUP-GMN-RTN-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DISTAL RADIUS PLATE- NARROW 4 HOLE RT. -,SUP-GMN-RTN-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE VOLAR DIST RADIUS STD 3 HOLD RIGHTTI GEMINUS -,SUP-GMN-RTS-3HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE DISTAL RADIUS VOLAR GEMINUS WIDE 4HL RIGHT -,SUP-GMN-RTW-4HL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4621.72,3235.204,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5 X 30 -,SUP-GMSD 55 30-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5 X 45 -,SUP-GMSD 55 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL 4.5 X 30MM -,SUP-GMSD45-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5 X 35 -,SUP-GMSD-50 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL 5.0 X 30MM -,SUP-GMSD50-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL 5.0 X 35MM NEW -,SUP-GMSD50-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.0 X 4.0 -,SUP-GMSD50-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 55 X 35 -,SUP-GMSD-55 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL 5.5 X 30 -,SUP-GMSD55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CORTICAL MODULAR SCREW 5.5 X 35 -,SUP-GMSD55-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL 5.5 X 35 -,SUP-GMSD55-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL SPINE 5.5 X 40 -,SUP-GMSD55-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL 5.5 X 45 -,SUP-GMSD55-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL 6 X 35 -,SUP-GMSD-60 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL 6 X 30 -,SUP-GMSD60-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GENESYS CORTICAL SCREW 6.5MM X 35MM -,SUP-GMSD60-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CORTICAL SCREW 6 X 35 -,SUP-GMSD60-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MODULAR 6.0 x 40 -,SUP-GMSD60-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 65 X 35 -,SUP-GMSD-65 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORITCAL SPINE 6.5 X 35 -,SUP-GMSD65-35,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL SPINE 6.5 X 40 -,SUP-GMSD65-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL 6.5 X 45 -,SUP-GMSD65-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW GENESYS MODULAR 6.5 X 50MM -,SUP-GMSD65-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL 7.5 X 40 -,SUP-GMSD75-40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL 75 X 45 -,SUP-GMSD75-45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL 75 X 50 -,SUP-GMSD75-50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL 8.5 X 70 -,SUP-GMSD85-70,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5 X 30 -,SUP-GMSP55-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.0 X 30 -,SUP-GMSP60-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2-PIECE PIN TIP SECTION-TROCAR TIP -,SUP-GSI209-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,571.83,400.281,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2-PIECE PIN-TAIL SECTION 750MM W/TIP -,SUP-GSI210-02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2P PIN TAIL -,SUP-GSI210-02,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
350 TROCAR PIN -,SUP-GSI211-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 9.5 X 35 -,SUP-GSI-SDW09535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 9.5 X 40 -,SUP-GSI-SDW09540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 9.5 X 40 -,SUP-GSI-SDW09545,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 9.5 X 60 SI SUAL THREAD WASHER HEAD -,SUP-GSI-SDW09560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
POSTERIOR ALLOGRAFT 20MM -,SUP-GSPA-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10879.09,7615.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
APACHE ANCHOR 8MM -,SUP-GVC-08-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
APACHE ANCHORED 9MM -,SUP-GVC-09-SL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDE PIN 2.0MM X 150MM -,SUP-GW0920061501,CDM,C1713,HCPCS,278,RC,,,outpatient,,,306.34,214.438,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE CAN PT TI 4.0 X 24MM -,SUP-H00693,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE CAN PT TI 4.0 X 26MM -,SUP-H00693,CDM,C1713,HCPCS,278,RC,,,outpatient,,,843.86,590.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X40MM CANC POLARUS FT CNTRSNK TI NS -,SUP-HCA-5140,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5X45MM CANC POLARUS FT CNTRSNK TI NS -,SUP-HCA-5145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.3X35MM LCK CANC POLARUS FT TI STRL -,SUP-HCA-L5335-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.3X40MM LCK CANC POLARUS FT TI STRL -,SUP-HCA-L5340-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.3X45MM LCK CANC POLARUS FT TI STRL -,SUP-HCA-L5345-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1367.53,957.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG HIGH COMPRESSION LOCKING 2.7 X 18 -,SUP-HCLP-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG HIGH COMPRESSION LOCKING 2.7MM  X 19MM TI -,SUP-HCLP-27190-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG HIGH COMPRESSION LOCKING 2.7MM  X 20M TI -,SUP-HCLP-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG HIGH COMPRESSION LOCKING 2.7MM  X 21M TI -,SUP-HCLP-27210-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
HIGH COMP PEG LCK 2.7 X 22 -,SUP-HCLP-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
HIGH COMPRESSION LOCKING PEG 2.7MM X 28MM TI -,SUP-HCLP-27280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X20MM NLCKG CORT POLARUS TI STRL -,SUP-HCO3200-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X25MM NLCKG CORT POLARUS TI STRL -,SUP-HCO3250-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MMX32.5MM NLCKG CORT POLARUS TI STRL -,SUP-HCO3325-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1288.02,901.614,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEADLESS COMP 2.5 X 14 -,SUP-HCS-25014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEADLESS COMP 2.5 X 16 -,SUP-HCS-25016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEADLESS COMPRESSION 2.5MM X 18MM -,SUP-HCS-25018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEADLESS COMP 2.5MM X 22MM TI -,SUP-HCS-25022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEADLESS COMP 2.5MM X 24MM TI -,SUP-HCS-25024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEADLESS COMP 2.5MM X 26MM TI -,SUP-HCS-25026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEADLESS COMPRESSION 2.5MM X 30MM -,SUP-HCS-25030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3556.63,2489.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD IM 8X240MM POLARUS + CANN TAPR PRFL HUM TI STAB -,SUP-HR-0824-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9312.2,6518.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD IM 11X150MM POLARUS PROX HUM -,SUP-HR-L1115-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10452.97,7317.079,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEADED 2.5 X 12MM -,SUP-IC2512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.5MM HEADED SCREW LENGTH 14MM -,SUP-IC2514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE MINI HEADED 2.5 X 18MM -,SUP-IC2518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5 HEADED 20MM LENGTH -,SUP-IC2520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEADED 2.5 X 22MM -,SUP-IC2522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.5 MM HEADED 26MM LENGTH MINI CANN SCREW -,SUP-IC2526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
MINI SET SCREW 2.5X28MM -,SUP-IC2528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.5 MM HEADED 30MM LENGTH MINI CANN SCREW -,SUP-IC2530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
3.0 X 10MM CANNULATED SCREW -,SUP-IC3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.0 HEADED 18MM -,SUP-IC3018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
3.0MM HEADED 22MM LENGTH CANN SCREW -,SUP-IC3022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
3.0MM HEADED 24MM LENGTH CANN SCREW -,SUP-IC3024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
3.0MM HEADED 26MM LENGTH MINI CANN SCREW -,SUP-IC3026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3MM X 30MM -,SUP-IC3030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.0 HEADED 32MM LENGTH -,SUP-IC3032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.0MM HEADED 34MM LENGTH -,SUP-IC3034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.0MM HEADED 38MM LENGTH -,SUP-IC3038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEADED 3.0 X 40MM -,SUP-IC3040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1841.39,1288.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
4.0MM HEADED 20MM LENGTH MINI CANN SCREW -,SUP-IC4020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
4.0MM HEADED SCREW LENGTH 32MM -,SUP-IC4032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
4.0MM HEADED SCREW LENGTH 34MM -,SUP-IC4034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
4.0MM HEADED 36MM LENGTH MINI CANN SCREW -,SUP-IC4036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
4.0MM HEADED 38MM LENGTH MINI CANN SCREW -,SUP-IC4038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
4.0MM HEADED 40MM LENGTH MINI CANN SCREW -,SUP-IC4040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE MINI 46MM X 4MM HEAD NONSTERILE -,SUP-IC4046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
4.0MM HEADED SCREW LENGTH 48MM -,SUP-IC4048,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE MINI 50MM X 4MM HEAD NONSTERILE -,SUP-IC4050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1237.93,866.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
INFLUX SPARC (IBM) 1CC -,SUP-IFLX-CM-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2597.25,1818.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
INFLUX SPARC (IBM) 5CC -,SUP-IFLX-CM-05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8530.44,5971.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
HEADLESS SCREW 2.5X10MM -,SUP-IH2510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.5MM HEADLESS SCREW LENGTH 20MM -,SUP-IH2520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.5MM HEADLESS SCREW LENGTH 24MM -,SUP-IH2524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.5MM HEADLESS SCREW LENGTH 26MM -,SUP-IH2526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
2.5MM HEADLESS SCREW LENGTH  30MM -,SUP-IH2530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE MINI 2.5 X 36MM HEADLESS -,SUP-IH2536,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
3.0 X 14MM HEADLESS SCREW -,SUP-IH3014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.0 X 22MM HEADLESS -,SUP-IH3022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.0 X 24MM HEADLESS -,SUP-IH3024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.0 X 26MM HEADLESS -,SUP-IH3026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEADLESS 3.0MM X 30MM -,SUP-IH3030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
3.0 X 32MM HEADLESS SCREW -,SUP-IH3032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
3.0 X 34MM HEADLESS SCREW -,SUP-IH3034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEADLESS 3.0MM X 36MM -,SUP-IH3036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEADLESS 3.0MM X 38MM -,SUP-IH3038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEADLESS 3.0MM X 40MM -,SUP-IH3040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
4.0MM HEADLESS SCREW LENGTH 32MM -,SUP-IH4032,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEADLESS 4.0MM X 16MM X 36MM -,SUP-IH4036,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEADLESS 4.0MM X 38MM -,SUP-IH4038,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEADLESS 4.0MM X 40MM -,SUP-IH4040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEADLESS 4.0MM X 42MM -,SUP-IH4042,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEADLESS 4.0MM X 46MM -,SUP-IH4046,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEADLESS 4.0MM X 50MM -,SUP-IH4050,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2887.32,2021.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN AXIS 2.5MM X 40MM IJS-E -,SUP-IJS-EAP-25400,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1727.96,1209.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN IJS-E AXIS 2.5MM X 45MM -,SUP-IJS-EAP-25450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1727.96,1209.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BLADE T10 DRIVER 4.0 SCREWS -,SUP-IS1108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,921.23,644.861,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PK SCREW INTNL FX STRL CONTR -,SUP-JG303R,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21.15,14.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE 28MMX10MM JULIET OL LD SHARING ANTMC PEEK -,SUP-JUL-OL 28 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE 7X28MM STR -,SUP-JUL-OX2807-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE LUMBAR POSTERIOR TI L24 W8 H7 -,SUP-JUN-P6 24 07-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
8 X 24 PLIF TITANIUM CAGE -,SUP-JUN-P6 24 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE LUMBAR POSTERIOR TI L24 W8 H09 6 DEGREE NARROW JULIET -,SUP-JUN-P6 24 09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE PLIF TI 24 X 8.5 X 10 -,SUP-JUN-P6 24 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LUMBAR POSTERIOR TI CAGE L24 W9 H11 -,SUP-JUN-P6 24 11-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE 24 X 9 X 12 PLIF 6 DEGREE -,SUP-JUN-P6 24 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE LUMBAR POSTERIOR TI 14 X 9 X 24 6DEG -,SUP-JUN-P6 24 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LUMBAR POSTERIOR TI CAGE L24 X W8 X H07 6 DEGREE -,SUP-JUN-P62407-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LUMBAR POSTERIOR TI CAGE L24 W8.5 H10 -,SUP-JUN-P62410-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE POSTERIOR LUMBAR TI L24 X W9 X H11 6DEG JULIET -,SUP-JUN-P62411-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TITANIUM PLIF CAGE L24 X W9 X H12 6 DEGREE -,SUP-JUN-P62412-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LUMBAR POSTERIOR TI CAGE L24 W10.5 -,SUP-JUT PX 24 09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE TRANSORAMINLA LUMBAR TI L30 W 10.5 -,SUP-JUT-T6 30 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE LUMBAR TRANSFORAMINAL L30 W 10.5 -,SUP-JUT-T6 30 09-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE TRANSFORAMINAL LUMBAR TI CAGE L30 W 10.5 H10 -,SUP-JUT-T6 30 10-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE TRANSFORAMINAL LUMBAR TI L30 W 10.5 H 11 -,SUP-JUT-T6 30 11-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE TRANSFORAMINAL LUMBAR TI L30 W10.5 H12 6 DEG -,SUP-JUT-T6 30 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE TRANSORAMINAL LUMBAR TI L 30 W 10.5 H 13 -,SUP-JUT-T6 30 13-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SYS BONE CMNT PARALLAX EZFLOW -,SUP-KP-CDS-100,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
KT DEVICE PARALLAX CONTR -,SUP-KP-CTR-1508C-01,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7002.6,4901.82,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
STENT ADVANIX BIL 10FR X 3CM DBL PIGTAIL -,SUP-M00532240,CDM,C1713,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DISK SPIN MOBI- C COCR MLYBDNM EPLT UHMWPE INLAY 13X15X5MM -,SUP-MB3355,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PROSTHESIS CERV DISC 13 X 17 H -,SUP-MB3375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DISC SPIN MOBI- C COCR MLYBDNM EPLT UHMWPE INLAY 15X15X5MM -,SUP-MB3555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DISC SPIN MOBI- C PROS COCR MLYBDNM EPLT UHMWPE INLAY -,SUP-MB3576,CDM,C1713,HCPCS,278,RC,,,outpatient,,,21906.7,15334.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE 40MM ROD -,SUP-MC1-200040,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
IMPLANT ROI-C 7MM 12 X 14MM LO -,SUP-MC1343P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE CERV 10MM/7.2MM H A/P ROI- C LRDTC -,SUP-MC1426P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE CERV 5MM/2.3MM H A/P ROI- C LRDTC -,SUP-MC1441P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE CERV 6MM/3.1MM H A/P ROI- C LRDTC -,SUP-MC1442P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE CERV 8MM/5.1MM H A/P ROI- C LRDTC -,SUP-MC1444P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE CERV 9MM/6.1MM H A/P ROI- C LRDTC -,SUP-MC1445P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
IMPLANT ROI-C LORDOSED 12X15.5 -,SUP-MC1454P,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.8X22MM S3 MULDIR NS -,SUP-MD22,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.8X24MM S3 MULDIR NS -,SUP-MD24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.8X26MM S3 MULDIR NS -,SUP-MD26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.8X28MM S3 MULDIR NS -,SUP-MD-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.8X28MM S3 MULDIR NS -,SUP-MD-28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.8X30MM S3 MULDIR NS -,SUP-MD30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.8X32MM S3 MULDIR NS -,SUP-MD32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.8X34MM S3 MULDIR NS -,SUP-MD34,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.8X36MM S3 MULDIR NS -,SUP-MD36,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.8X38MM S3 MULDIR NS -,SUP-MD38,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5MM X 40MM CANNULATED POLYAXIAL -,SUP-MPF-PX  55 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5MM X 35MM CANNULATED POLYAXIAL -,SUP-MPF-PX 55 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
MIDSHAFT RADIUS PLATE 112MM -,SUP-MRP-112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5996.77,4197.739,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE FREEFIX MIDSHAFT RADIUS 127MM -,SUP-MRP-127,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SIZER NATRELLE INSPIRA 325CC FULL -,SUP-MSZ-F325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SIZER NATRELLE INSPIRA 345CC FULL -,SUP-MSZ-F345,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SIZER NATRELLE INSPIRA 450CC FULL -,SUP-MSZ-F450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SIZER NATRELLE INSPIRA 485CC FULL -,SUP-MSZ-F485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SIZER NATRELLE INSPIRA 330CC MODERATE -,SUP-MSZ-M330,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SIZER NATRELLE INSPIRA 445CC MODERATE -,SUP-MSZ-M445,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SIZER NATRELLE INSPIRA 485CC MODERATE -,SUP-MSZ-M485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MULTI-THREAD LOCKING 2.7MM X 18MM TI -,SUP-MTLS-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MULTI-THREAD LOCKING 2.7MM X 20MM -,SUP-MTLS-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MULTI-THREAD LOCKING 2.7 X 22 -,SUP-MTLS-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MULTI THREAD LOCKING 2.7MM X 32MM TI -,SUP-MTLS-27320-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MULTI THREADED LOCKING 3.0MM X 10MM TI -,SUP-MTLS-30100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MULTI THREADED LOCKING 3.0MM X 12MM TI -,SUP-MTLS-30120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MULTI THREADED LOCKING 3.0MM X 14MM TI -,SUP-MTLS-30140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MT LOCKING 3.5MM X 8MM TI -,SUP-MTLS-35080-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MT LOCKING 3.5MM X 10MM TI -,SUP-MTLS-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MT LOCKING 3.5MM X 12MM TI -,SUP-MTLS-35120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MT LOCKING 3.5MM X 14MM TI -,SUP-MTLS-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MT LOCKING 3.5MM X 16MM TI -,SUP-MTLS-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MT LOCKING 3.5MM X 18MM TI -,SUP-MTLS-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MT LOCKING 3.5MM X 20MM TI -,SUP-MTLS-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MT LOCKING 3.5MM X 22MM TI -,SUP-MTLS-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MT LOCKING 3.5MM X 24MM TI -,SUP-MTLS-35240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MT LOCKING 3.5MM X 26MM TI -,SUP-MTLS-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MT LOCKING 3.5MM X 28MM TI -,SUP-MTLS-35280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE LKG 3.5MM X 32MM MULTITHREAD TI -,SUP-MTLS-35320-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE TITANIUM MULTI-THREAD LOCKING 3.5 X 34 -,SUP-MTLS-35340-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MULTI-THREAD LOCKING 3.5MM X 36MM TI -,SUP-MTLS-35360-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MULTI-THREAD LOCKING 3.5MM X 38MM TI -,SUP-MTLS-35380-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE TITANIUM MULTI-THREAD LOCKING 3.5 X 40 -,SUP-MTLS-35400-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MULTI THREAD LOCKING 3.5MM X 42MM TI -,SUP-MTLS-35420-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1061.97,743.379,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MULTI-THREAD LOCKING 3.5MM X 55MM TI -,SUP-MTLS-35550-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MULTI-THREAD COMPRESSION 3 X 10 -,SUP-MTNL-30100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MULTI THREAD COMP 3.0MM X 12MM TI -,SUP-MTNL-30120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MULTI-THREAD COMPRESSION 3.0MM X 16MM TI -,SUP-MTNL-30160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE TITANIUM MULTI-THREAD LOCKING 3.5 X 10 -,SUP-MTNL-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MT COMP 3.5MM X 14MM TI -,SUP-MTNL-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MT COMP 3.5MM X 16MM TI -,SUP-MTNL-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MT COMP 3.5MM X 18MM TI -,SUP-MTNL-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MT COMP 3.5MM X 22MM TI -,SUP-MTNL-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MT COMP 3.5MM X 40MM TI -,SUP-MTNL-35400-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MULTI THREAD COMPRESSION 3.5MM X 42MM TI -,SUP-MTNL-35420-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MT COMP 3.5MM X 45MM TI -,SUP-MTNL-35450-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MT COMP 3.5MM X 50MM TI -,SUP-MTNL-35500-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW MT COMP 3.5MM X 60MM TI -,SUP-MTNL-35600-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1143.66,800.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
MIDSHAFT ULNA PLATE 97MM -,SUP-MUP-097,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5937.36,4156.152,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE MIDSHAFT ULNA 112MM -,SUP-MUP-112,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5996.77,4197.739,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
MACROFORM NOVABONE 5CC -,SUP-NB1002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
MACROFORM 5CC -,SUP-NB4305,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.8X20MM LCK S3 90DG ANG TI NS -,SUP-NL20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.8X24MM LCK S3 90DG ANG TI NS -,SUP-NL24,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.8X26MM LCK S3 90DG ANG TI NS -,SUP-NL-26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.8X28MM LCK S3 90DG ANG TI NS -,SUP-NL28,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.8X30MM LCK S3 90DG ANG TI NS -,SUP-NL30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.8X32MM LCK S3 90DG ANG TI NS -,SUP-NL32,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LCK 90DG ST BN HND SHLDR -,SUP-NL-SS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,408.45,285.915,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LCK 90DG ST BN HND SHLDR -,SUP-NL-SS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN FX STNMN 18INX9IN DBL END TROC SMTH SS -,SUP-OM 71-0459,CDM,C1713,HCPCS,278,RC,,,outpatient,,,69.73,48.811,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ARTHROSCOPIC FX MAGNUM2 ACC F/SHLDR FT/ANKL RPR HALLUX -,SUP-OM-1502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1106.83,774.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUT MAG PI -,SUP-OM-4500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DEVICE SUT MAG 2 + SMARTSTITCH KNTLS -,SUP-OM-9026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SFT TIS 3.2MM KNTLS FX W/PERFECTPASSER MAGNUMWR SUT -,SUP-OM-9146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3079.23,2155.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SFT TIS 3.2MM PNCH MAG PI + -,SUP-OM-9147,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3079.23,2155.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2X14MM LCK SMTH TI DVR NS -,SUP-P14000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2X16MM LCK SMTH TI DVR NS -,SUP-P16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2X20MM LCK SMTH TI DVR NS -,SUP-P20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2X22MM LCK SMTH TI DVR NS -,SUP-P22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2X26MM LCK SMTH TI DVR NS -,SUP-P26000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW POLYAXIAL LCK 2.5 X 10 CANNULATED COCR -,SUP-PALS-25100-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW POLYAXIAL LCK 2.5 X 16 CANNULATED COCR -,SUP-PALS-25160-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW POLYAXIAL LCK 2.5 X 22MM CANNULATED COCR -,SUP-PALS-25220-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE GEMINUS POLY LOCKING 2.5MM X 24MM CANN COCR -,SUP-PALS-25240-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW POLYAXL LCK 2.5MM X 26MM CANN -,SUP-PALS-25260-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW POLYAXIAL LOCKING 3.0MM X 18MM CANNULATED -,SUP-PALS-30180-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW POLYAXIAL LOCKING 3.0MM X 22MM CANNULATED -,SUP-PALS-30220-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW POLYAXIAL LOCKING 3.0MM X 24MM CANN -,SUP-PALS-30240-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW POLYAXAIL LCK 3.0 X 34 -,SUP-PALS-30340-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1542.45,1079.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW POLYAXIAL LOCKING 3.0MM X 55MM CANNULATED -,SUP-PALS-30550-CC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1468.24,1027.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
THREADED PEG CORTICAL NON-LOCKING 2.7MM X 10MM TI -,SUP-PANL-27140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL NON LOCKING 2.7 X 16 -,SUP-PANL-27160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW PEG THREADED CORTICAL NON-LOCKING 2.7MM X 18MM TI -,SUP-PANL-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG THREADED CORTICAL NON-LOCKING 2.7MM X 20MM TI -,SUP-PANL-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG THREADED CORTICAL NON-LOCKING 2.7MM X 22MM TI -,SUP-PANL-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG THREADED CORTICAL NL 2.7MM X 26MM TI -,SUP-PANL-27260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL NON LOCKING 3.5 X 9 -,SUP-PANL-35090-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL NON LOCKING 3.5 X 10 -,SUP-PANL-35100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL NON LOCKING 3.5MM X 11MM -,SUP-PANL-35110-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW- CORTICAL NON-LOCKING 3.5MM X 12MM -,SUP-PANL-35120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NON-LOCK 3.5 X 13 POLY TI -,SUP-PANL-35130-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE ASSEMBLED PROTEAN FRAGMENT DOUBLE HOCKEY STICK -,SUP-PANL-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4596.25,3217.375,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NON-LOCK 3.5 X 14 POLY TI -,SUP-PANL-35140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NON-LOCK 3.5 X 15 POLY TI -,SUP-PANL-35150-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW POLYAXIAL NON LOCKING 3.5MM X 16MM TI -,SUP-PANL-35160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW POLYAXIAL NON LOCKING 3.5MM X 18MM TI -,SUP-PANL-35180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NON-LOCK 3.5 X 20 POLY TI -,SUP-PANL-35200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NON-LOCK 3.5 X 22 POLY TI -,SUP-PANL-35220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL NON LCK 3.5MM X 26MM TI -,SUP-PANL-35260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW POLYAXIAL NON LOCKING 3.5MM X 28MM TI -,SUP-PANL-35280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,892.76,624.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MM X 10MM -,SUP-PC1-003510,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5MM X 12MM -,SUP-PC1-003512,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NORTHSTAR 3.5 X 14 SCREW -,SUP-PC1-003514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE 3.5MM X 16MM SCREW -,SUP-PC1-003516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NORTHSTAR SCREW 3.5 X 18 -,SUP-PC1-003518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW POLY SEASPINE 3.5 MM X 20 MM -,SUP-PC1-003520,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE SCREW 3.5MM X 22MM -,SUP-PC1-003522,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE SCREW 35 X 24 -,SUP-PC1-003524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE SCREW 3.5 X 26 -,SUP-PC1-003526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE SCREW 4MM X 10MM -,SUP-PC1-004010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE NORTHSTAR 4MM X 12MM SCREW -,SUP-PC1-004012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MM X 14MM SPINE POLYAXIAL -,SUP-PC1-004014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4MM X 16MM SPINE POLYAXIAL -,SUP-PC1004016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3007.62,2105.334,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW POLYAXIAL 4.0 X 16 SEASPINE -,SUP-PC1-004016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SEASPINE 4.0 X 18 POLYAXIAL -,SUP-PC1-004018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NORTHSTAR SCREW 4 X 20 -,SUP-PC1-004020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SEASPINE 4.0 X 22 POLYAXIAL -,SUP-PC1-004022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SEASPINE 4.0 X 24 POLYAXIAL -,SUP-PC1-004024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE SCREW 4MM X 26MM -,SUP-PC1-004026,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE SCREW 4MM X 28MM -,SUP-PC1-004028,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4 X 30 -,SUP-PC1-004030,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE SCREW 4.0 X 34 -,SUP-PC1-004034,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CROSS LINK MED 3.5 -,SUP-PC1-013502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CROSSHOLE LARGE 3.5MM -,SUP-PC1-013503,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE MD CROSSLINK -,SUP-PC1-014002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE LARGE CROSSLINK -,SUP-PC1-014003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LATERAL OFFSET -,SUP-PC1-020015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE 0-0CONNECTOR -,SUP-PC1-023540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PARALLELL TOP LOADING 5.5 -,SUP-PC1-023560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE 0-C CONNECTOR -,SUP-PC1-063535,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE SCREW 4.5MM X 24MM -,SUP-PC1-104524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE 5.5 X 26 NS#2 -,SUP-PC1-104526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE 4.5 X 26 NS#2 -,SUP-PC1-104526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE SCREW 4.5MM X 28MM -,SUP-PC1-104528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE SCREW 4.5 X 30 NS#2 -,SUP-PC1-104530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE SCREW 4.5 X 34 -,SUP-PC1-104534,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE SCREW 3.5 X 24 SS -,SUP-PC1-203524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE SCREW 3.5 X 26 SS -,SUP-PC1-203526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE SCREW 3.5 X 18 -,SUP-PC1-203528,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
3.5 X 30MM SMOOTH SHANK SCREW -,SUP-PC1-203530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE REDUCTION SCREW 3.5 X 14 -,SUP-PC1-303514,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SET OCCIPITOCERVICOTHORACIC FIXATION SYSTEM -,SUP-PC1-400000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE ROD OCC 3.5 X 170 -,SUP-PC1-503177,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPINAL100MM TITANIUM CONTOUR -,SUP-PC1-503500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE ROD -,SUP-PC1-503502,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE 30MM ROD -,SUP-PC1-503530,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPINAL 40MM -,SUP-PC1-503540,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD 50MM -,SUP-PC1-503550,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD SPINAL 60MM TITANIUM CONTOUR -,SUP-PC1-503560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD 70MM -,SUP-PC1-503570,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD 80MM -,SUP-PC1-503580,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE NORTHSTAR 90MM ROD -,SUP-PC1-503590,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE ROD 4 X 120MM -,SUP-PC1-504002,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE ROD 4X200MM -,SUP-PC1-504003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE ROD 80MM -,SUP-PC1-504080,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE ROD 4 X 120 -,SUP-PC1-514012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE TRAN ROD 3.5 X 5.5 -,SUP-PC1-523555,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1166.11,816.277,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE OCC PLATE -,SUP-PC1-700000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BONE CHIPS CANCELLOUS CRUSHED 1-8 MM 15 CC CHIP -,SUP-PCAN15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1149.36,804.552,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SUBSTITUTE CANC 30ML CUBE RDIGRF PRESERVON CRSH VOID FIL -,SUP-PCANCUBE30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2148.98,1504.286,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
0 PDS PLUS VIOLET 1 X 27 CT-1 -,SUP-PDP340H,CDM,C1713,HCPCS,278,RC,,,outpatient,,,18.26,12.782,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAVIO BONE PIN 4.0MM X 89 -,SUP-PFSD-01008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,726.46,508.522,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SUBSTITUTE WDG MATRGRF PRESERVON 18MM -,SUP-PICW8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3831.09,2681.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LEG CONTRA EXCLUDER AAA ENDO 16MM X 18MM X 11.5CM 12FR -,SUP-PLC181200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN F/ELB PLATE SYS 16HL LCK TI LNG NS -,SUP-PL-LEM16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6824.35,4777.045,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN 11X84MM 7HL LCK TI CONGR NS PNK -,SUP-PL-LEM7,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6017.99,4212.593,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN ANCHORAGE 6HL PRCONT LCK TI GRN LT -,SUP-PLP10341,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN ANCHORAGE 6HL PRCONT LCK TI GRN RT -,SUP-PLP10342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN ANCHORAGE F /HALLUX VALGUS V1 8HL PRCONT LCK TI LNG -,SUP-PLP10462,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE MTP 5-HOLE -,SUP-PLP11341,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN ANCHORAGE F /HALLUX VALGUS V2 5HL PRCONT LCK TI GRN -,SUP-PLP11342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN ANCHORAGE F/CX PLATE SYS 1.5MM TI THRD HL COLR -,SUP-PLP14341,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHORAGE MTP CP PLATE RIGHT -,SUP-PLP14342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN ANCHORAGE F/CX PLATE SYS TI THRD HL GRN -,SUP-PLP14342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN ANCHORAGE F/LPDS FUSION 0MM STP PRCONT LCK TI YEL -,SUP-PLP20342,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN ANCHORAGE F/LPDS FUSION 0MM STP PRCONT LCK TI CP -,SUP-PLP29371,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5144.7,3601.29,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN ANCHORAGE 28MM 4HL PRCONT SYM LCK UTIL TI PNK -,SUP-PLP40280,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4564.66,3195.262,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN POLARUS 4HL SLOTX3 TI LRG NS -,SUP-PL-PHGR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5967.06,4176.942,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3X10MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3X12MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3X14MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3X16MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3X18MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3X20MM LCK ANCHORAGE STD T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X16MM LCK ANCHORAGE T8 STRDRV RCESS TORX HEAD TI -,SUP-PLSL3516,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3X10MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3010,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3X12MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3012,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3X14MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3014,CDM,C1713,HCPCS,278,RC,,,outpatient,,,657.84,460.488,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3X16MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3016,CDM,C1713,HCPCS,278,RC,,,outpatient,,,657.84,460.488,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3X18MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3018,CDM,C1713,HCPCS,278,RC,,,outpatient,,,657.84,460.488,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3X20MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3X22MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3022,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3X24MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3024,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X18MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3518,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 3.5X24MM NLCKG ANCHORAGE STD T8 STRDRV RCESS TORX HEAD -,SUP-PLSS3524,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHORAGE STANDARD SCREW 3.5 X 26MM -,SUP-PLSS3526,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TROCAR CLOSURE SUTURE GRASPER -,SUP-PMI-TC-SG,CDM,C1713,HCPCS,278,RC,,,outpatient,,,64.19,44.933,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TEMPORARY FIXATION PIN ADMIRAL -,SUP-PN AP2-100506,CDM,C1713,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN FIXATION -,SUP-PN0920051001,CDM,C1713,HCPCS,278,RC,,,outpatient,,,233.4,163.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE ASSEMBLED PROTEAN CENTRAL COLUMN LEFT -,SUP-PRT-CCP-LT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4681.13,3276.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PROTEAN CORONOID PLATE RIGHT -,SUP-PRT-CRD-RT,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5237.1,3665.97,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE PROTEAN FRAG DIST ULNA -,SUP-PRT-FSP-DU,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5054.6,3538.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE Y PROTEAN FRAGMENT -,SUP-PRT-FSP-YS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4596.25,3217.375,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
DEVICE FIXATION SIZE 18 4FUSION -,SUP-QUA-4F-18,CDM,C1713,HCPCS,278,RC,,,outpatient,,,11849.67,8294.769,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 12MM X 2.7MM FUCHSIA U PLUS LOCKING -,SUP-RBL1224,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1070.7,749.49,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 14MM X 2.7MM GOLD U PLUS LOCKING -,SUP-RBL1225,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1070.7,749.49,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 50MM UPLUS RIB -,SUP-RBL1301,CDM,C1713,HCPCS,278,RC,,,outpatient,,,6463.61,4524.527,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X50MM -,SUP-RFS-S4500,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
TRUNK IPSI EXCLUDER AAA ENDO 26MM X 14.5MM X 12CM 16FR -,SUP-RLT261412,CDM,C1713,HCPCS,278,RC,,,outpatient,,,32100.6,22470.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SIZER SMOOTH ROUND MODERATE GEL XTRA 755 CC -,SUP-RSZSHPX755S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SIZER SMOOTH ROUND MODERATE GEL HP XTRA 790 CC -,SUP-RSZSHPX790S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL IM 1.6MMX12.7MM SBFS SS -,SUP-SBFS062,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1908.18,1335.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE CERVICAL LORDOTIC ANT D12 W15 H08 -,SUP-SCA-AC LS 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CERVICAL 3 X 14MM -,SUP-SCA-CS 3014-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
RSS 4.5MM STAR SCREW AND CAP 15MM L -,SUP-SCW-0961-046-15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
RSS 4.5MM STAR SCREW AND CAP 20MM L -,SUP-SCW-0961-046-20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
RSS 4.5MM STAR SCREW AND CAP 25MM L -,SUP-SCW-0961-046-25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
RSS 4.5MM STAR SCREW AND CAP 30MM -,SUP-SCW-0961-046-30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
KIT IMPLANT 10 X 9MM SPEED 1.5 X 1.5MM -,SUP-SE-0910,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4623.62,3236.534,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPEED IMPLANT 11 X 08 X 08MM -,SUP-SE-1108,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPEED IMPLANT 11X10X10MM -,SUP-SE-1110,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPEED IMPLANT 15X15X15MM -,SUP-SE-1515,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5690.99,3983.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
STAPLE -,SUP-SE-1815,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPEEDTITAM 18X15X15MM -,SUP-SE-1815TI,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7289.07,5102.349,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPEED IMPLANT TI 18X18X18MM -,SUP-SE-1818,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5690.99,3983.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPEED COMPRESSION IMPLANT KIT 20X20X20 -,SUP-SE-2020,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPEED TITAN IMPLANT 20 X 20 X 20MM -,SUP-SE-2020TI,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5644.52,3951.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WASHER ORTHO -,SUP-SFCW,CDM,C1713,HCPCS,278,RC,,,outpatient,,,379.28,265.496,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCARLET AL-T BONE SCREW 5 X 25MM -,SUP-SJT-LS 50 25-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5X20MM CORT/CANC DVR FT HEX HEAD TI -,SUP-SP 20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,545.51,381.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.5X10MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP10000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG 2.5X11MM NLCKG SCR CANC DVR FT ST HEX HEAD TI NS F/ANTMC -,SUP-SP11000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.5X12MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP12000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.5X13MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP13000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.5X14MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP14000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.5X15MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP15000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.5X16MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.5X16MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.5X18MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP18000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.5X20MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.5X20MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.5X22MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.5X22MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.5X22MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP22000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,534.37,374.059,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.5X24MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP24000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.5X26MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP26000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.5X34MM HEX HEAD NLCKG FT ST TI DVR NS -,SUP-SP34000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG SMOTH LOCKING 2 X 14 -,SUP-SPLS-20140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG SMOOTH LOCKING 2 X 16 -,SUP-SPLS-20160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG SMOOTH LOCKING TI GRAY 2.0MM X 17MM -,SUP-SPLS-20170-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG SMOOTH LOCKING 2 X 18 -,SUP-SPLS-20180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SMOOTH PEG LOCKING 2.0MM X 18MM TI -,SUP-SPLS-20180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG SMOOTH LOCKING TI GRAY 2.0MM X 19MM -,SUP-SPLS-20190-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG SMOOTH LOCKING 2 X 20 -,SUP-SPLS-20200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG SMOOTH LOCKING TI GRAY 2.0MM X 21MM -,SUP-SPLS-20210-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG SMOOTH LOCKING TI GRAY 2.0MM X 22MM -,SUP-SPLS-20220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN S3 16X71MM 16MM 3HL CONTR LCK SS SUT HL FST GUIDE -,SUP-SSPL3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5703.94,3992.758,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN S3 16X84MM 4HL CONTR LCK SS SUT HL FST GUIDE TECH -,SUP-SSPL4,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5703.94,3992.758,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN S3 16X70MM 16MM 3HL CONTR LCK SS SUT HL FST GUIDE -,SUP-SSPR3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5703.94,3992.758,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN S3 16X150MM 8HL CONTR LCK SS SUT HL FST GUIDE TECH -,SUP-SSPR8,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7359.1,5151.37,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SIZER IMPLANT NATR INSPIRA SIL 485CC SINGLE USE FULL PROFILE -,SUP-SSZ-F485,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SIZER IMPLANT NATR INSPIRA SIL 605CC SINGLE USE FULL PROFILE -,SUP-SSZ-F605,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SIZER IMPLANT NATR INSPIRA SIL 650CC SINGLE USE FULL PROFILE -,SUP-SSZ-F650,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SIZER IMPLANT NATR INSPIRA SIL 695CC SINGLE USE FULL PROFILE -,SUP-SSZ-F695,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SIZER IMPLANT NATR INSPIRA SIL 560CC SINGLE USE MOD PROFILE -,SUP-SSZ-M560,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SIZER IMPLANT NATR INSPIRA SIL 600CC SINGLE USE MOD PROFILE -,SUP-SSZ-M600,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1073.64,751.548,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 4MMSTDX20MM LCK SMTH TI S3 -,SUP-STP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 4MMSTDX25MM LCK SMTH TI S3 NS -,SUP-STP25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 4MMSTDX32.5MM LCK SMTH TI S3 -,SUP-STP325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 4MMSTDX37.5MM LCK SMTH TI S3 NS -,SUP-STP375,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 4MMSTDX42.5MM LCK SMTH TI S3 NS -,SUP-STP425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 4MMSTDX45MM LCK SMTH TI S3 -,SUP-STP45,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 4MMSTDX47.5MM LCK SMTH TI S3 NS -,SUP-STP475,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 4MMSTDX50MM LCK SMTH TI S3 NS -,SUP-STP50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,595.17,416.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 4MMSTDX40MM LCK THRD TI S3 NS -,SUP-STPT40,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 4MMSTDX50MM LCK THRD TI S3 NS -,SUP-STPT50,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ENDOSCOPIC FX SECURESTRAP W/12 ABSB STRP F/HRN RPR -,SUP-STRAP12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1878.06,1314.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SECURESTRAP 5MM ASORB STRAP -,SUP-STRAP25,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2542.51,1779.757,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ASNIS III SS CANN SCREW 6.5 X 105MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1121.16,784.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BONE SCREW T8 FULLY THREADED 2.7 X 18MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BONE SCREW T10 NON-LOCKING 2.7 X 30MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BONE SCREW T8 FULLY THREADED 2.7 X 24MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,314.04,219.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
BONE SCREW T10 NON-LOCKING 2.7 X 70MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL LONG R2.0 TI LEFT 13 X 320MM GAMMA -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 2.3 X 15MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,442.88,310.016,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING FULLY THREADED T10 3.5 X 28MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTEX 3.5 X 22MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING FULLY THREADED T10 3.5 X 20MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,599.25,419.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING ST 3.5 X 46MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WRIST FUSION PLATE STANDARD BEND 120MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8642.06,6049.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WRIST FUSION PLATE STRAIGHT 120MM -,SUP-STRYKER,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8642.06,6049.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5MMX16MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5MMX20MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5MMX26MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV26,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2.5MMX30MM CANN HDLS S- FX FIXOS THRD SD/ST/RM TI ALY -,SUP-SV30,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
3-0 20CM STRATAFIX SPIRAL MONOCRYL PLUS UNDYED SH -,SUP-SXMP1B427,CDM,C1713,HCPCS,278,RC,,,outpatient,,,149.67,104.769,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
4-0 STRATAFIX SPIRAL MONOCRYL PLUS 45 X 45CM UNDYED PS-2 -,SUP-SXMP2B151,CDM,C1713,HCPCS,278,RC,,,outpatient,,,125.22,87.654,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SUTURE STRATAFIX 2-0 CT-1 PDS VIOL 45CM -,SUP-SXPP1A403,CDM,C1713,HCPCS,278,RC,,,outpatient,,,117.01,81.907,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
0 STRATAFIX SYMMETRIC PDS PLUS 23CM CT-1 -,SUP-SXPP1A425,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.1,107.87,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SUTURE STRATAFIX 0 CT-1 PDS VIOL 45CM -,SUP-SXPP1B407,CDM,C1713,HCPCS,278,RC,,,outpatient,,,154.07,107.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SUTURE STRATAFIX 3-0 SH SPIRAL PDS VIOLET 15CM -,SUP-SXPP1B420,CDM,C1713,HCPCS,278,RC,,,outpatient,,,183.51,128.457,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
"SUTURE STRATAFIX SPIRAL PDS PLUS 2-0 9"" 23CM VIOLET CT-2 -",SUP-SXPP1B432,CDM,C1713,HCPCS,278,RC,,,outpatient,,,155.78,109.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SUT STRATAFIX 0 30CM SPIRAL PDS PLUS VIOLET CT-1 -,SUP-SXPP1B450,CDM,C1713,HCPCS,278,RC,,,outpatient,,,157.03,109.921,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SET HERNIA KUMAR T ANCHORS -,SUP-TA-008,CDM,C1713,HCPCS,278,RC,,,outpatient,,,46.32,32.424,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE REEF TA INTERBODY 9X28X8MM -,SUP-TA1-928088,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
REEF TA INTERBODY 9 X 28 X 10MM 15DEG -,SUP-TA1-928105,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
REEF TA 9X 28 X 11MM INTERBODY -,SUP-TA1-928115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SEASPINE REEF TA INTERBODY 9X32X8MM -,SUP-TA1-932088,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
INTERBODY 9X32X11 15DEG -,SUP-TA1-932115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN 70MM TENSION BAND -,SUP-TB-1570K,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1219.12,853.384,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW TROCHLEAR COMPRESSION FEMALE -,SUP-TCS-F,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1833.97,1283.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW TROCHLEAR COMPRESSION LOCKING CAP -,SUP-TCS-LC,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1303.92,912.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW TROCHLEAR COMPRESSION MALE 60MM -,SUP-TCS-M-60,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD 35MM -,SUP-TLF-5P T0 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD 40MM -,SUP-TLF-5P T0 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD 45MM -,SUP-TLF-5P T0 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD PREBENT TITANIUM 50MM -,SUP-TLF-5P T0 50-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PREBENT ROD TITANIUM 55MM -,SUP-TLF-5P T0 55-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD 60MM -,SUP-TLF-5P T0 60-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PERLA TL PREBENT ROD TITANIUM 90MM -,SUP-TLF-5P T0 90-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD 5.5 X  70 -,SUP-TLF-5P TO 70-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ROD PREBENT 6MM X 40MM -,SUP-TLF-6P T0 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5 X 35 -,SUP-TLF-CS 55 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 5.5MM X 40MM -,SUP-TLF-CS 55 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CORTICAL BONE SCREW 5.5 X 45 -,SUP-TLF-CS 55 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5MM X 30MM -,SUP-TLF-CS 65 30-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5 X 35 -,SUP-TLF-CS 65 35-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCEW 6.5 X 40 -,SUP-TLF-CS 65 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 6.5 X 45 -,SUP-TLF-CS 65 45-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEAD -,SUP-TLF-MH PL 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
REDUCTION HEAD -,SUP-TLF-MH RE 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SET -,SUP-TLF-SC 00 00-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.5X10MM LCK LAG P/T TI DVR NS -,SUP-TP10000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.5X14MM TI DVR NS -,SUP-TP14000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.5X16MM TI DVR NS -,SUP-TP16000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,567.16,397.012,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.5X18MM TI DVR NS -,SUP-TP18000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.5X20MM P/T -,SUP-TP20,CDM,C1713,HCPCS,278,RC,,,outpatient,,,534.37,374.059,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.5X20MM TI DVR NS -,SUP-TP20000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG BN FX 2.5X28MM TI DVR NS -,SUP-TP28000,CDM,C1713,HCPCS,278,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
THREADED PEG FLUTED LCK 2.3 X 20 -,SUP-TPFL-23200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG FIXATION LOCKING 2.3 X 10 TI -,SUP-TPLS-23100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG THREADED LOCKING 2.3MM X 12MM TI -,SUP-TPLS-23120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
THREADED PEG- LOCKING- 2.3MM X 16MM -,SUP-TPLS-23160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LCK TRH PEG 2.3 X 17MM -,SUP-TPLS-23170-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
THREADED PEG- LOCKING- 2.3MM X 18MM -,SUP-TPLS-23180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG THREADED LOCKING 2.3MM X 19MM -,SUP-TPLS-23190-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LCK TRH PEG 2.3 X 20MM -,SUP-TPLS-23200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
THREADED PEG- LOCKING 2.3MM X 21MM -,SUP-TPLS-23210-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
THREADED PEG LOCKING 2.3MM X 22MM -,SUP-TPLS-23220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
THREADED PEG- LOCKING 2.3MM X 23MM -,SUP-TPLS-23230-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG THREADED LOCKING TI PINK 2.3MM X 24MM -,SUP-TPLS-23240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
THREADED PEG- LOCKING 2.3MM X 26MM -,SUP-TPLS-23260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG THREADED 2.3 X 28 LOCKING -,SUP-TPLS-23280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,717.71,502.397,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG TRHEADED NON-LOCKING 2.7MM X 10MM TI -,SUP-TPNL-27100-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG THREADES NON LOCKING 2.7 X 12 -,SUP-TPNL-27120-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG THREADED NON LOCKING 2.7MM X 14MM -,SUP-TPNL-27140-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG THREADES NON LOCKING 2.7 X 16 -,SUP-TPNL-27160-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG THREADED NON LOCKING 2.7 X 18 -,SUP-TPNL-27180-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NON-LCK TRH PEG 2.7 X 20MM -,SUP-TPNL-27200-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NON-LCK TRH PEG 2.7 X 22MM -,SUP-TPNL-27220-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG THREADED NON-LOCKING 2.7MM X 24MM -,SUP-TPNL-27240-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG THREADED NON-LOCKING 2.7MM X 26MM -,SUP-TPNL-27260-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PEG THREADED NON LOCKING 2.7MM X 28MM -,SUP-TPNL-27280-TS,CDM,C1713,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SUBSTITUTE DBM 5ML PTTY OPTIUM FRZDR -,SUP-TPUT05,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2696.31,1887.417,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CAGE CERVICAL LORDOTIC D12 W14 H07 -,SUP-TRY-CL 12 07-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
CERVICAL CAGE-LORDOTIC D12 W14 H08 -,SUP-TRY-CL 12 08-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BONE 20MM 1-LEVEL SPINE CERVICAL -,SUP-TRY-CP 04 20-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 22MM -,SUP-TRY-CP 04 22-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 24MM 1-LEVEL -,SUP-TRY-CP 04 24-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 26MM 1-LEVEL -,SUP-TRY-CP 04 26-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 2 LEVEL 36MM -,SUP-TRY-CP 06 36-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 38MM 2-LEVEL -,SUP-TRY-CP 06 38-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 40MM 2 LEVEL -,SUP-TRY-CP 06 40-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 43MM 2-LEVEL -,SUP-TRY-CP 06 43-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 46MM 2-LEVEL -,SUP-TRY-CP 06 46-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SPINEART TRYPTIK 2- PLATE-52MM-3-LEVEL -,SUP-TRY-CP 08 52-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 55MM 3-LEVEL -,SUP-TRY-CP 08 55-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE TRYPTIK 58MM 3-LEVEL -,SUP-TRY-CP 08 58-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 61MM 3-LEVEL -,SUP-TRY-CP 08 61-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE TRYPTIK 72MM 3 LEVEL -,SUP-TRY-CP 08 72-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 12MM SELF DRILLING POLYAXIAL -,SUP-TRY-PD 40 12-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SELF-DRILLING POLYAXIAL 4 X 14 -,SUP-TRY-PD 40 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SELF-DRILLING POLYAXIAL 4 X 16 -,SUP-TRY-PD 40 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SELF DRILLING POLYAXIAL 4.5 X 16 -,SUP-TRY-PD 45 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW SELF TAPPING 4 X 14 -,SUP-TRY-PS 40 14-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW TRYPTIK SELF-TAPPING 4 X 16 -,SUP-TRY-PS 40 16-S,CDM,C1713,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
STENT GRAFT 28 X 14 X 140MM OVATION ILIAC LIMB -,SUP-TV-IL1428140-J,CDM,C1713,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEPIN ORTHO THRD DRILL TIP -,SUP-U000-0200,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1531.84,1072.288,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHORAGE LAPIDUS PLATING LS 0 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHORAGE LISFRANC PLATING MED -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4870.24,3409.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ANCHOR SUT 2.3MM FIBERWIREX2 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1722.66,1205.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
FEMORAL AUGMENT DISTAL SZ3 12M -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL FLEXIBLE 1.5MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1096.98,767.886,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL LONG LT TI 11X400 130 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 10 HOLE LOCKING COMPR BR -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 6 HOLE CURVED -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4360.88,3052.616,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE CERVICAL 2 LEVEL 30MM GE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE DIST POST LAT HUMERAL 6H -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4350.36,3045.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOCKING PLATE 6 HOLE 2.0/2.3 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4600.23,3220.161,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 1.2 X 12MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL TI LNG RT 15 X 440MM X1 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7471.99,5230.393,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LO-PRO MTP PLT TM CONTRDSHTLTI -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL FLEXIBLE 2.0MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1068.58,748.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE M ADAPTIVE II 2.5 TRI DI -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,5810.88,4067.616,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SCREW GAP 6.5MM 30MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,663.67,464.569,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ANCHORAGE 3.5MM X 32MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS 5.0MM 60MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS III SS CANN 5 X 46 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
LOCKING COMP BROAD 16 HOLE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.44,869.708,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS TI 5.0 X 36MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE 2.3 X 26 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANN ASNIS III 5.0X 65MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANN ASNIS III 5.0X 70MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL 5.5 X 30MM GENE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL FLEXIBLE 2.5MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1174.59,822.213,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW EMERGENCY 1.4 X 3 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEADLESS COMP. 4.0MM 32M -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2242.32,1569.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCK LP 4.5 X 24MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCK LP 4.5 X 32MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING T10 2.7 X 20MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW M CORTEX 2.3 X 16MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,900.92,630.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NON LOCKING 2.3 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NON LOCKING 3.5 X 55MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NON-LOCK LP 4.5 X 28MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
NAIL LONG R1/5 RT 11 X 440MM X -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7328.07,5129.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE GRIP TRICHANTERIC W/2 CA -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7111.03,4977.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE RT ANTERIOR ANKLE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,8806.3,6164.41,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SUPERIOR 6H INCREASED -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4709.36,3296.552,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE WSTD CMP BRD 16 HOLE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.44,869.708,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE 6 HOLE STRAIGHT -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4459.54,3121.678,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BROAD 7 HOLE VARIAX COMP -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1711.64,1198.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE DIAMOND FUSION LARGE NON -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,7238.14,5066.698,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE HUMERUS RT. 14 HOLE L218 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4933.31,3453.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE SCREW GAP 6.5MM 20MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,663.67,464.569,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WIRE TEMP KIRSCH 1X100MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,151.71,106.197,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ANCHORAGE 3.5MM X 14MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ANCHORAGE 3.5MM X 16MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ANCHORAGE LOCK 3.5 X 14 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE T10 2.7 X 48MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW HEADLESS 2.5 X 12MM MICR -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCK LP 4.5 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCK LP 4.5 X 46MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 2.3 X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NON LOCKING 2.3 X 21MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,408.04,285.628,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NON-LOCK LP 4.5 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,424.5,297.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW PERIPH NL 4.5 X 30MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW T2 F/T LOCK 5 X 105MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,751.55,526.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ANCHORAGE 3.5MM X 20MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ANCHORAGE LOCK 3.5 X 18 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ANSIS 4.0 X 44MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,841.47,589.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS CANN TI 5.0 X 60MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS III SS CANN 5 X 38 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS TI 5.0 X 40MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,926.83,648.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ANCHORAGE 3.0 X 28MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,645.12,451.584,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ANCHORAGE LOCK 3.5 X 12 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,951.11,665.777,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW ASNIS 6.5MM X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1081.94,757.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW AUTOFIX 2.5 X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1242.97,870.079,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE 2.3 X 18MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,365.56,255.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE T10 2.7 X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW BONE 3.5 X 46MM NON-LOCK -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.67,241.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTEX T8 2.4MM X 8MM SE -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORTICAL 5.5 X 40MM HIGH -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CANN FT 4.0 X 40MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1012.2,708.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW CORT HI-TOP 5.5 X 35MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LO-PRO PT 5MM X 50MM THR -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING SILVER 2.5 X 16M -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING T10 2.7 X 48MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NON-LOCK LP 4.5 X 24MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LCK ST 2.7 X 10MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,668.46,467.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCK LP 4.5 X 26MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCK LP 4.5 X 44MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW S-FIX 2.5LG X 22MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LOCKING 2.3 X 12MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,363.46,254.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW TRILOCK 2.8 X 10MM HD7 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW TRILOCK 2.8 X 12MM HD7 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW VA 4.25 X 14MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,991.95,694.365,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW LP 5.5 X 55MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW NON LOCK LP 4.5 X 30MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW TI LOCK 5.5 X 35MM -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW TRILOCK 2.8 X 34MM HD7 -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1339.97,937.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WASHER ORTHO -,SUP-UNDEFINED,CDM,C1713,HCPCS,278,RC,,,outpatient,,,158.48,110.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PLATE BN ULTRA PIN -,SUP-UPP3,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X23MM COMPR AEQUALIS REVERSED II ST NS F/BSPLT -,SUP-VDV223,CDM,C1713,HCPCS,278,RC,,,outpatient,,,980.28,686.196,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 4.5X35MM COMPR AEQUALIS REVERSED II ST NS F/BSPLT -,SUP-VDV235,CDM,C1713,HCPCS,278,RC,,,outpatient,,,490.14,343.098,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
"V-LOC 180 ABSORABLE RELOAD 2-0 6"" ES-9 TAPER -",SUP-VLOCA206L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,211.29,147.903,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SUTURE V-LOC ABSORBABLE 2-0 8 IN FOR ENDOSTITCH -,SUP-VLOCA208L,CDM,C1713,HCPCS,278,RC,,,outpatient,,,249.42,174.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
"SUT V-LOC 180 2-0 P-12 12""CLEAR -",SUP-VLOCL0015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.68,88.676,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
"V-LOC 0 ABS 12"" GS-21 GREEN -",SUP-VLOCL0316,CDM,C1713,HCPCS,278,RC,,,outpatient,,,125.34,87.738,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
"V-LOC 2-0 ABS 18"" GS-21 GREEN -",SUP-VLOCL0325,CDM,C1713,HCPCS,278,RC,,,outpatient,,,125.34,87.738,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
"V-LOC 0 ABS 18"" GS-21 GREEN -",SUP-VLOCL0326,CDM,C1713,HCPCS,278,RC,,,outpatient,,,130.1,91.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
"SUT V-LOC 180 0 GS-21 9"" GREEN -",SUP-VLOCL0346,CDM,C1713,HCPCS,278,RC,,,outpatient,,,124.81,87.367,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
"V-LOC 3-0 ABS 6"" V-20 GREEN -",SUP-VLOCL0604,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1325.66,927.962,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
"V-LOC 180 GREEN 12"" V-20 TAPER -",SUP-VLOCL0614,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
"SUTURE VLOC 9"" 1/2 CIRCLE 26MM -",SUP-VLOCL0644,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
"SUT V-LOC 180 3-0 CV-23 6"" GREEN -",SUP-VLOCL0804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
"SUT V-LOC 180 3-0 CV-23 12"" GREEN -",SUP-VLOCL0814,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
"V-LOC 2-0 ABS 9"" GS-22 GREEN -",SUP-VLOCL2145,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
"V-LOC 3-0 ABS 18"" P-14 UNDYED -",SUP-VLOCM0124,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.68,88.676,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
"V-LOC 3-0 ABS  6"" CV-23 VIOLET -",SUP-VLOCM0804,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
"V-LOC 3-0 ABS 18"" P-17 UNDYED -",SUP-VLOCM1824,CDM,C1713,HCPCS,278,RC,,,outpatient,,,126.68,88.676,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SUT V-LOC 90 2-0 GS-22 TAPER 12IN VIOLET -,SUP-VLOCM2115,CDM,C1713,HCPCS,278,RC,,,outpatient,,,136.19,95.333,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
"SUTURE V-LOC 0 NON-ABS 6"" GS-21 BLUE -",SUP-VLOCN0306,CDM,C1713,HCPCS,278,RC,,,outpatient,,,90.79,63.553,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
"V-LOC 2-0 PBT NON-ABS 6"" V-20 BLUE -",SUP-VLOCN0605,CDM,C1713,HCPCS,278,RC,,,outpatient,,,1309.01,916.307,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
"V-LOC 2-0 NON-ABS 12"" V-20 BLUE -",SUP-VLOCN0615,CDM,C1713,HCPCS,278,RC,,,outpatient,,,120.08,84.056,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
VLOC PBT 1 BLU 12 GS-22 -,SUP-VLOCN2117,CDM,C1713,HCPCS,278,RC,,,outpatient,,,131.58,92.106,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
VLOC PBT 0 BLU 9 GS-22 NON-ABS -,SUP-VLOCN2146,CDM,C1713,HCPCS,278,RC,,,outpatient,,,131.58,92.106,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GRAFT VALLIANT STENT 20F 31 X 90 NACION THORACIC -,SUP-VNMC3131C90TU,CDM,C1713,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN BALL JURGAN .045 YELLOW -,SUP-W045-YL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PK CAP PROT 0.375IN PIN BALL W-SRS F/0.045IN K-WR XTRNFXTR -,SUP-W045-YL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,256.74,179.718,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PIN BALL JURGAN .062 GREEN -,SUP-W062-GN,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PK CAP PROT 0.375IN PIN HEAD JRGN PIN BALL W-SRS F/.0938IN -,SUP-W332-CR,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PK CAP PROT 0.375IN PIN HEAD JRGN PIN BALL W-SRS F/.0781IN -,SUP-W564-BL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,256.74,179.718,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PK CAP PROT 0.375IN PIN HEAD JRGN PIN BALL W-SRS F/.0781IN -,SUP-W564-BL,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WASHER INSIDE 2.7MM OUTSIDE 5MM -,SUP-WBTN-2750-T,CDM,C1713,HCPCS,278,RC,,,outpatient,,,344.27,240.989,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WASHER BUTTON BRONZE -,SUP-WBTN-HCLP,CDM,C1713,HCPCS,278,RC,,,outpatient,,,320.93,224.651,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2MMX12MM NCANN TWST-OFF W- FX FIXOS MICROTHREADED -,SUP-WS12,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 13MM NCANN TWST-OFF W- FX FIXOS MICROTHREADED -,SUP-WS13,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SNAP OFF SCREW DIAM 2.1 LG.14 -,SUP-WS14,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2MMX15MM NCANN W- FX FIXOS MICROTHREADED SD/ST/RM -,SUP-WS15,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SCREW 2MMX16MM NCANN W- FX FIXOS MICROTHREADED SD/ST/RM -,SUP-WS16,CDM,C1713,HCPCS,278,RC,,,outpatient,,,2279.64,1595.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
ORTHO 0.35MM -,SUP-WSO906ST,CDM,C1713,HCPCS,278,RC,,,outpatient,,,116.7,81.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
WOUND MATRIX 6 LAYER 10CM X 15CM 150SQCM -,SUP-WSX1015,CDM,C1713,HCPCS,278,RC,,,outpatient,,,16411.46,11488.022,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
PK PIN BALL PIN BALL PROT REFL 0.125IN 0.1094X.125IN F/3MM -,SUP-X003,CDM,C1713,HCPCS,278,RC,,,outpatient,,,42.79,29.953,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SUTURE MONODERM QUILL 3-0 MONO CLR YA-1023Q 30CMX30CM L BARB -,SUP-YA-1023Q,CDM,C1713,HCPCS,278,RC,,,outpatient,,,129.56,90.692,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
SUTURE MONODERM QUILL #0 MONO CLR YA-1029Q 36CMX36CM L BARB -,SUP-YA-1029Q,CDM,C1713,HCPCS,278,RC,,,outpatient,,,136.04,95.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.518595,35041.66656,other,Non-Reimbursable Procedures,,
GUIDEWIRE HI-TORQUE CONNECT 250FT -,SUP-1012595,CDM,C1714,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures,,
EARLY ACCESSORY DROP OFF FEE -,SUP-10595-10169,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures,,
K-WIRE GAMMA 3.2 X 450MM -,SUP-1210-6451S,CDM,C1714,HCPCS,272,RC,,,outpatient,,,478.7,335.09,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures,,
SCREWDRIVER FLEXIBLE GAMMA -,SUP-1320-0233,CDM,C1714,HCPCS,272,RC,,,outpatient,,,2438.28,1706.796,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures,,
LEE RT ANG BRONCHUS CLAMP 9 39MM JAW -,SUP-320200,CDM,C1714,HCPCS,272,RC,,,outpatient,,,779.26,545.482,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures,,
PROBE BALL TIP 3MM TIP PEDICLE SCREW D344 -,SUP-3603-00-TE,CDM,C1714,HCPCS,272,RC,,,outpatient,,,601.01,420.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures,,
"KWIRE SINGLE POINT STST 150MM X .045"" -",SUP-451-1045,CDM,C1714,HCPCS,272,RC,,,outpatient,,,152.76,106.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures,,
10X30CM PICO14 DRESSING KIT -,SUP-66022043,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1562.06,1093.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures,,
HOLDER/POSITIOINER PLATE 1.2/1.55 FOR INSTRUMENT -,SUP-A-2350,CDM,C1714,HCPCS,272,RC,,,outpatient,,,4147.65,2903.355,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures,,
HOLDER/POSITIOINER PLATE 2.0/2.3 FOR INSTRUMENT -,SUP-A-2650,CDM,C1714,HCPCS,272,RC,,,outpatient,,,4147.65,2903.355,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures,,
KIT FIBERTAK KNOTLESS CURVED DISPOSABLE -,SUP-AR-3638DC,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures,,
B CROSSTELLAÂ® RX PTA Balloon Dilatation Cath 6mm x 150mm -,SUP-BD-F60150LR,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures,,
BALLOON R2P CROSTELLA  RX- 200cm- 6mm x 150mm -,SUP-BD-Q60150ER,CDM,C1714,HCPCS,272,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures,,
CATH BLNOCC 1.3MM 5FR SHTH 146CM 20CM LUM C RSSR 14S RX -,SUP-CRU14S,CDM,C1714,HCPCS,272,RC,,,outpatient,,,9315.58,6520.906,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures,,
CATH BLNOCC 1.1MM 5FR SHTH 146CM C RSSR 14P OTW PERIPH -,SUP-CRUO14PA,CDM,C1714,HCPCS,272,RC,,,outpatient,,,9315.58,6520.906,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures,,
CATH PTCA 0.05IN C RSSR S6 156CM RECANALIZATION PERIPH 5FR -,SUP-CRUS6A,CDM,C1714,HCPCS,272,RC,,,outpatient,,,9315.58,6520.906,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures,,
DRILL KIT FOR CONTINUOUS COMPRESSION -,SUP-DK-265C,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1863.92,1304.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures,,
INTERSTIM BELT FIXATION LARGE SCS PH -,SUP-FP9000L,CDM,C1714,HCPCS,272,RC,,,outpatient,,,233.4,163.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures,,
DILATOR COONS -,SUP-G04051,CDM,C1714,HCPCS,272,RC,,,outpatient,,,102.05,71.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures,,
CATH ANG 5FR DAV 100CM ADVANTG BRD VSCR -,SUP-G08581,CDM,C1714,HCPCS,272,RC,,,outpatient,,,151.7,106.19,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures,,
BALLOON EXTRACTOR PRO XL RETREIVAL 9-12 -,SUP-M00547130,CDM,C1714,HCPCS,272,RC,,,outpatient,,,612.32,428.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures,,
SET DELIVERY SIROS -,SUP-SIR-10300,CDM,C1714,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures,,
BLADE HOOK DISSECTING SYNERGY HARMONIC -,SUP-SNGHK,CDM,C1714,HCPCS,272,RC,,,outpatient,,,2781.64,1947.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures,,
SUTURE 3-0 MONO PLUS 16 X 16CM UNDYED -,SUP-SXMP2B402,CDM,C1714,HCPCS,272,RC,,,outpatient,,,166.17,116.319,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures,,
DRESSING KCI VERAFLO CLEANSE CHOICE LARGE -,SUP-ULTVCC05LG,CDM,C1714,HCPCS,272,RC,,,outpatient,,,1428.85,1000.195,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures,,
DRESSING NEG PRSS SM 10X7.5X3.3CM VAC GRANUFOAM -,SUP-XF-DSMF1,CDM,C1714,HCPCS,272,RC,,,outpatient,,,163.38,114.366,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.910225,6679.27086,other,Non-Reimbursable Procedures,,
NEEDLE BRCHTX 18GAX20CM ULTRA-SHRP TIP PLSH SURF PRELD BN -,SUP-818205,CDM,C1715,CPT,272,RC,,,outpatient,,,84.61,59.227,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,18.994945,416.02,other,Non-Reimbursable Procedures,,
CURRENT DR RF 2207-36 AICD -,SUP-2207-36,CDM,C1721,HCPCS,275,RC,,,outpatient,,,44309.79,31016.853,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11462.94267,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR LUMAX 740 DR-T 2CHMBR CARD IMPL W/HOME MNTR -,SUP-365606,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30837.5,21586.25,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7977.66125,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR ILESTO DR-T DF-1 2CHMBR HI ENRG CARD IMPL W/TI -,SUP-383562,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25644.47,17951.129,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6634.224389,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR ILESTO DR-T DF-4 2CHMBR HI ENRG CARD IMPL W/TI -,SUP-383564,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25644.47,17951.129,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6634.224389,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR ITREVIA 7 DR-T DF-4 2CHMBR CARD IMPL W/TI -,SUP-392426,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25644.47,17951.129,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6634.224389,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR CRNT + DR DF-4 2CHMBR RR V- PCNG RDC 50X74MM -,SUP-CD2211-36Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8001.914375,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR FORTIFY DR DF-1 2CHMBR 40X74MM 14MM 35ML 76GM -,SUP-CD2231-40,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8001.914375,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR FORTIFY DR DF-4 2CHMBR RR V- PCNG RDC 40X71MM -,SUP-CD2231-40Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8001.914375,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR FORTIFY ASSURA DR DF-1 TELEM 2CHMBR 40X74MM -,SUP-CD2257-40,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8001.914375,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR FORTIFY ASSURA DR DF-4 TELEM 2CHMBR 40X71MM -,SUP-CD2257-40Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8001.914375,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR ELLIPSE DR DF-1 IS-1 CONN 2CHMBR DEFT RESPONSE -,SUP-CD2311-36,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8001.914375,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR ELLIPSE DR DF-4 2CHMBR DEFT RESPONSE RF TELEM -,SUP-CD2311-36Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,30931.25,21651.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8001.914375,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR FORTIFY ASSURA DR DF-4 2CHMBR CARD IMPL 40C -,SUP-CD2357-40C,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8885.116175,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR FORTIFY ASSURA DR DF-4 2CHMBR CARD IMP 40Q -,SUP-CD2357-40Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8885.116175,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR ELLIPSE VR IS-1 DF-1 2CHMBR 51X68MM 12MM 31ML -,SUP-CD2411-36C,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8885.116175,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR ELLIPSE ASSURA DR DF-4 2CHMBR CARD IMPL -,SUP-CD2411-36Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34345.25,24041.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8885.116175,399.86,37344.8064,percent of total billed charges,,,
ENTRANT ICD CDDRA300Q -,SUP-CDDRA300Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37130,25991,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9605.531,399.86,37344.8064,percent of total billed charges,,,
ENTRANT DR ICD DF1 CONNECTOR REF: CDDRA300T -,SUP-CDDRA300T,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37130,25991,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9605.531,399.86,37344.8064,percent of total billed charges,,,
GALLANT ICD CDDRA500Q -,SUP-CDDRA500Q,CDM,C1721,HCPCS,275,RC,,,outpatient,,,26150.2,18305.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6765.05674,399.86,37344.8064,percent of total billed charges,,,
GALLANT DR ICD DF1 CONNECTOR REF: CDDRA500T -,SUP-CDDRA500T,CDM,C1721,HCPCS,275,RC,,,outpatient,,,26150.2,18305.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6765.05674,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR INOGEN DF-1 SGL-CHMBR 5.23X7.14X0.99 CM D -,SUP-D013,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25975.04,18182.528,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6719.742848,399.86,37344.8064,percent of total billed charges,,,
DYNAGEN MINI ICD DR D022 -,SUP-D022,CDM,C1721,HCPCS,275,RC,,,outpatient,,,36747.56,25723.292,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9506.593772,399.86,37344.8064,percent of total billed charges,,,
ICD MOMENTUM EO DR D121 -,SUP-D121,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25903.5,18132.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6701.23545,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR D142 INOGEN MUL PRGM OPTN EXTEND LNGVT DR DF-4 -,SUP-D142,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25091.86,17564.302,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6491.264182,399.86,37344.8064,percent of total billed charges,,,
DYNAGEN D153 EL ICD -DF-1 -,SUP-D153,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25091.86,17564.302,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6491.264182,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR CONSULTA DF-4 CARD IMPL -,SUP-D204TRM,CDM,C1721,HCPCS,275,RC,,,outpatient,,,48626.05,34038.235,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12579.55914,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR SECURA DR 2CHMBR RR V- PCNG RDC 51X64MM 15MM -,SUP-D224DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,35700.82,24990.574,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9235.802134,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR SECURA VR SGL-CHMBR RR V- PCNG RDC 51X64MM -,SUP-D224VRC,CDM,C1721,HCPCS,275,RC,,,outpatient,,,31901.76,22331.232,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8252.985312,399.86,37344.8064,percent of total billed charges,,,
ICD DUAL VIGILANT EL DR DF4 MRI CONDITIONAL -,SUP-D233,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25903.5,18132.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6701.23545,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR MAXIMO II DR WRLS TELEM 2CHMBR RR V- PCNG RDC -,SUP-D284DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34217.29,23952.103,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8852.012923,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR PROTECTA XT DR DF-1 IS-1 CONN 2CHMBR RR -,SUP-D314DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37579.81,26305.867,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9721.896847,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR PROTECTA DR DF-1 IS-1 CONN 2CHMBR RR V- PCNG -,SUP-D334DRG,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32749.43,22924.601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8472.277541,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR PROTECTA DR DF-4 2CHMBR CARD IMPL -,SUP-D334DRM,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32749.43,22924.601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8472.277541,399.86,37344.8064,percent of total billed charges,,,
ICD PERCIVA DR D401 -,SUP-D401,CDM,C1721,HCPCS,275,RC,,,outpatient,,,27894.37,19526.059,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7216.273519,399.86,37344.8064,percent of total billed charges,,,
ICD PERCIVA DR DF4 D413 MRI CONDITIONAL -,SUP-D413,CDM,C1721,HCPCS,275,RC,,,outpatient,,,27894.37,19526.059,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7216.273519,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR EVERA S DR DF-1 2CHMBR CARD IMPL -,SUP-DDBC3D1,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32071,22449.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8296.7677,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR EVERA S DR DF-4 2CHMBR CARD IMPL -,SUP-DDBC3D4,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32071,22449.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8296.7677,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR EVERA MRI XT DR SURSCN DF-4 CARD IMPL -,SUP-DDMB1D1,CDM,C1721,HCPCS,275,RC,,,outpatient,,,37251.7,26076.19,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9637.01479,399.86,37344.8064,percent of total billed charges,,,
EVERA MRI S DR SURESCAN MODEL DDMC3D1 -,SUP-DDMC3D1,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34784.7,24349.29,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8998.80189,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR EVERA 2CHMBR CARD IMPL -,SUP-DDMC3D4,CDM,C1721,HCPCS,275,RC,,,outpatient,,,34784.7,24349.29,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8998.80189,399.86,37344.8064,percent of total billed charges,,,
ICD DUAL COBALT DR MRI REF: DDPB3D4 -,SUP-DDPB3D4,CDM,C1721,HCPCS,275,RC,,,outpatient,,,38485.2,26939.64,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9956.12124,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR OVATIO CARD 6550 -,SUP-DR6550,CDM,C1721,HCPCS,275,RC,,,outpatient,,,45639.5,31947.65,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11806.93865,399.86,37344.8064,percent of total billed charges,,,
DYNAGEN CRT-D G151 -,SUP-G151,CDM,C1721,HCPCS,275,RC,,,outpatient,,,32897.45,23028.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8510.570315,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR VITALITY II DR IS-1 DF-1 2CHMBR V- PCNG RDC -,SUP-T167,CDM,C1721,HCPCS,275,RC,,,outpatient,,,43197.17,30238.019,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11175.10788,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR VITALITY HE IS-1 DF-1 2CHMBR 66MMX82.6MM -,SUP-T180,CDM,C1721,HCPCS,275,RC,,,outpatient,,,41877.33,29314.131,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10833.66527,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR PARADYM RF VR IMPL 9250 -,SUP-TDF011U,CDM,C1721,HCPCS,275,RC,,,outpatient,,,25661.73,17963.211,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6638.689551,399.86,37344.8064,percent of total billed charges,,,
DEFIBRILLATOR SQ-RX DF-1 SGL-CHMBR 65.5MMX78.2MMX15.7MM D -,SUP-1010,CDM,C1722,HCPCS,275,RC,,,outpatient,,,46873,32811.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR CRNT VR RF SGL-CHMBR VNTRC PCNG CARD IMPL -,SUP-1207/36,CDM,C1722,HCPCS,275,RC,,,outpatient,,,37656.29,26359.403,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR LUMAX 540 VR-T IS-1 CONN SGL-CHMBR RR 55X66MM -,SUP-360348,CDM,C1722,HCPCS,275,RC,,,outpatient,,,30895.47,21626.829,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR LUMAX 740 VR-T SGL-CHMBR CARD IMPL W/HOME MNTR -,SUP-365609,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28370.5,19859.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR LUMAX 740 VR-T DX CARD IMPL CELL GSM HOME MNTR -,SUP-372419,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28370.5,19859.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR ILESTO VR-T SGL-CHMBR CARD IMPL -,SUP-383578,CDM,C1722,HCPCS,275,RC,,,outpatient,,,30837.5,21586.25,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR ILESTO VR SGL-CHMBR HI ENRG CARD IMPL W/TI -,SUP-383580,CDM,C1722,HCPCS,275,RC,,,outpatient,,,30837.5,21586.25,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR ILESTO DX HI ENRG CARD IMPL W/TI LANDLINE HOME -,SUP-383594,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35737.63,25016.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR ITREVIA 7 VR-T DX HI ENRG CARD IMPL -,SUP-393037,CDM,C1722,HCPCS,275,RC,,,outpatient,,,24694.67,17286.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
DEVICE HI ENRG CARD IMPL TI -,SUP-393041,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35737.63,25016.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
ICD INTICA NEO 7 VR-T DX REF:429559 -,SUP-429559,CDM,C1722,HCPCS,275,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR EMBLEM S SQ-1 CONN 83.1MMX69.1MMX12.7MM D -,SUP-A209,CDM,C1722,HCPCS,275,RC,,,outpatient,,,46873,32811.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
S-ICD Emblem MRI A219 -,SUP-A219,CDM,C1722,HCPCS,275,RC,,,outpatient,,,44406,31084.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR CRNT + VR SJ-4 CONN SGL-CHMBR 50X74MM 14MM -,SUP-CD1211-36Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR FORTIFY VR DF-1 SGL-CHMBR 40X73MM 14MM 35ML -,SUP-CD1231-40,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR FORTIFY VR DF-4 ATP TERM AUTOMATICITY -,SUP-CD1231-40Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR FORTIFY ASSURA VR DF-1 TELEM SGL-CHMBR 40X73MM -,SUP-CD1257-40,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR FORTIFY ASSURA VR DF-4 SGL-CHMBR RF TELEM -,SUP-CD1257-40Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR ELLIPSE VR DF-1 IS-1 CONN SGL-CHMBR DEFT -,SUP-CD1311-36,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28308.83,19816.181,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR ELLIPSE VR DF-4 DF-1 IS-1 CONN SGL-CHMBR DEFT -,SUP-CD1311-36Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,25163.4,17614.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR FORTIFY ASSURA VR DF-1 IS-1 CONN SGL-CHMBR -,SUP-CD1357-40C,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR FORTIFY ASSURA VR DF-4 SGL-CHMBR 40X71MM 14MM -,SUP-CD1357-40Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR ELLIPSE VR IS-1 DF-1 SGL-CHMBR 51X68MM 12MM -,SUP-CD1411-36C,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR ELLIPSE VR-ICD MRLN DF-4 SGL-CHMBR -,SUP-CD1411-36Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,33417,23391.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
ENTRANT ICD CDVRA300Q -,SUP-CDVRA300Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35273.5,24691.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
ENTRANT VR ICD DF1 CONNECTOR REF: CDVRA300T -,SUP-CDVRA300T,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35273.5,24691.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
GALLANT ICD CDVRA500Q -,SUP-CDVRA500Q,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36201.75,25341.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
GALLANT VR ICD DF1 CONNECTOR REF: CDVRA500T -,SUP-CDVRA500T,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36201.75,25341.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR INOGEN DF-1 SGL-CHMBR 5.23X7.14X0.99 CM D. -,SUP-D011,CDM,C1722,HCPCS,275,RC,,,outpatient,,,26643.6,18650.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
ICD MOMENTUM EL VR D120 -,SUP-D120,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36573.05,25601.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR INOGEN EXTEND LNGVT 5.37X7.36X0.99IN 68.9G -,SUP-D140,CDM,C1722,HCPCS,275,RC,,,outpatient,,,34746.25,24322.375,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
DYNAGEN EL ICD VR MODEL D151 -,SUP-D151,CDM,C1722,HCPCS,275,RC,,,outpatient,,,34746.25,24322.375,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR SECURA DR DF-4 2CHMBR CARD IMPL -,SUP-D204DRM,CDM,C1722,HCPCS,275,RC,,,outpatient,,,35700.82,24990.574,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR SECURA VR DF-4 SGL-CHMBR CARD IMPL -,SUP-D204VRM,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31901.76,22331.232,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
ICD VIGILANT EO VR DF4 D232 MRI CONDITIONAL -,SUP-D232,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36573.05,25601.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR PROTECTA VR DF-1 IS-1 CONN SGL-CHMBR RR -,SUP-D334VRG,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28710.95,20097.665,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR PROTECTA VR DF-4 SGL-CHMBR CARD IMPL -,SUP-D334VRM,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28710.95,20097.665,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
ICD SINGLE PERCIVA VR REF: D400 -,SUP-D400,CDM,C1722,HCPCS,275,RC,,,outpatient,,,36573.05,25601.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
ICD PERCIVA VR DF4 D142 MRI CONDITIONAL -,SUP-D412,CDM,C1722,HCPCS,275,RC,,,outpatient,,,25827.02,18078.914,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
ICD RESONATE EL VR -,SUP-D432,CDM,C1722,HCPCS,275,RC,,,outpatient,,,29019.32,20313.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
COBALT XT DR MRI ICD REF: DDPA2D4 -,SUP-DDPA2D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,41837.85,29286.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR EVERA S VR DF-1 SGL-CHMBR CARD IMPL -,SUP-DVBC3D1,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28617.2,20032.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR EVERA S VR DF-4 SGL-CHMBR CARD IMPL -,SUP-DVBC3D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,28617.2,20032.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
VISIA AF MRI VR ICD DVFB1D1 -,SUP-DVFB1D1,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
ICD VISIA AF MRI SURESCAN VR -,SUP-DVFB1D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR CARDIAC VISIA AF MRI SURESCAN DVFC3D1 -,SUP-DVFC3D1,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR EVERA MRI XT DR SURSCN DF-4 CARD IMPL -,SUP-DVMB1D4,CDM,C1722,HCPCS,275,RC,,,outpatient,,,31824.3,22277.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,35998.464,other,Non-Reimbursable Procedures,,
EXPLANT TRUNCATED BLADE 56MM -,SUP-00-7053-056-10,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures,,
C 0.9M .014IN OTW TURBO ELITE -,SUP-410-152,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures,,
C 1.4M .014IN OTW TURBO ELITE -,SUP-414-151,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures,,
"2.0mm .018"" TURBO ELITE LASER -",SUP-420-006,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures,,
C 2.3M .018IN OTW TURBO ELITE -,SUP-423-001,CDM,C1724,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures,,
C 7FR LASER GUIDE 2.0MM TURBO -,SUP-423-050,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12234.34,8564.038,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures,,
DEVICE ATHRCMY STEALTH 360 1.5MM MICRO CRWN 145CM SHFT DMD -,SUP-DBE-150,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12605.64,8823.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures,,
CATH ATHRCMY DIAMONDBACK 360 1.25MM CROWN 135CM SHAFT -,SUP-DBEC-125,CDM,C1724,HCPCS,272,RC,,,outpatient,,,14833.44,10383.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures,,
DEVICE ATHRCMY PREDATOR 360 2MM CRWN DMD CTD SLD ART -,SUP-DBG-SCT30-200,CDM,C1724,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures,,
DEVICE ARTHREC 1.25 SOLID -,SUP-DBP-125MICRO145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures,,
SYSTEM ATHERECTOMY DBP-125MICRO145 -,SUP-DBP-125MICRO145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures,,
DEVICE ARTHREC STEALTH 1.25S -,SUP-DBP-125SOLID145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures,,
DEVICE ARTHREC STEALTH 1.50MM 5F -,SUP-DBP-150SOLID145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures,,
DBP-200SOLID145 -,SUP-DBP-200SOLID145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,13348.24,9343.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures,,
CATH ATHRCMY DIAMONDBACK 360 1.50MM X 145CM SOLID -,SUP-DBP-EX-150SOL145,CDM,C1724,HCPCS,272,RC,,,outpatient,,,14462.14,10123.498,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures,,
ROTAPRO ADVANCER 1.25MM -,SUP-H749394671250,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7999.94,5599.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures,,
ROTAPRO ADVANCER 1.5MM -,SUP-H749394671500,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7999.94,5599.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures,,
ROTAPRO ADVANCER 1.75MM -,SUP-H749394671750,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures,,
ROTAPRO ADVANCER 2.0MM -,SUP-H749394672000,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures,,
ROTAPRO ADVANCER 2.25MM -,SUP-H749394672250,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures,,
ROTAPRO ADVANCER 2.38MM -,SUP-H749394672380,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures,,
ROTAPRO ADVANCER 2.5MM -,SUP-H749394672500,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures,,
ROTAPRO ADVANCER 2.15MM -,SUP-H7494672150,CDM,C1724,HCPCS,272,RC,,,outpatient,,,7405.78,5184.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures,,
CATH ATHRCMY ROTLNK + 1.25MM BUR 0.58IN SHTH 135CM TFLN PTFE -,SUP-H802227680020,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4502.88,3152.016,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures,,
BURR ROTALINK 1.50MM 0.58IN SHTH 135CM EXCHGL -,SUP-H802227680030,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4953.17,3467.219,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures,,
CATH ATHRCMY ROTLNK + 1.75MM BUR 0.58IN SHTH 135CM EXCHGL -,SUP-H802227680040,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4953.17,3467.219,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures,,
CATH ATHRCMY ROTLNK + 2MM BUR 0.58IN SHTH 135CM EXCHGL ROT -,SUP-H802227680050,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4502.88,3152.016,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures,,
CATH ATHRCMY ROTLNK 2.15MM BUR 0.58IN SHTH 135CM TFLN PTFE -,SUP-H802227680150,CDM,C1724,HCPCS,272,RC,,,outpatient,,,4502.88,3152.016,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures,,
PHOENIX 1.8MM X130CM -,SUP-P18130,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures,,
1.8MM PHOENIX 149CM -,SUP-P18149K,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures,,
PHOENIX 2.2MM X 130CM -,SUP-P22130K,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures,,
PHOENIX ARTHERECTOMY 2.4MM 7FR -,SUP-P22149K,CDM,C1724,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures,,
ARTHERECTOMY JTSTRM 1.85MM -,SUP-PV3118F,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12754.16,8927.912,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures,,
ARTHERECTOMY JTSTRM 2.1/3MM -,SUP-PV31300,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12624.2,8836.94,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures,,
CATH ARTHERECTOMY JTSTRM 2.4/3.4MM LT -,SUP-PV41340,CDM,C1724,HCPCS,272,RC,,,outpatient,,,12624.2,8836.94,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10635.57648,other,Non-Reimbursable Procedures,,
CATHETER BALLOON VALVULOPLASTY  22MX4.5CMX110CM -,SUP-00224512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATHETER BALLOON VALAVULOPLASTY 20MMX4.5X110CM TRUE DILATION -,SUP-0204511,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATHETER BALLOON VALVULOPLASTY 21MMX4.5CMX110CM TRUE DILATIO -,SUP-0214512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATHETER BALLOON VALVULOPLASTY 23MMX4.5CMX120CM TRUE DILATIO -,SUP-0234512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATHETER BALLOON VALVULOPLASTY 24MMX4.5CMX110CM TRUE DILAT -,SUP-0244512,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATHETER TRUE DILATATION 25MM X 4.5CM REF: 0254513 -,SUP-0254513,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATHETER TRUE DILATION 26MM -,SUP-0264513,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3814.43,2670.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATHETER BALLOON VALVULOPLASTY 28MMX4.5CMX110CM TRUE DILAT -,SUP-0284514,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH IABP LINEAR 7.5FR 40CC -,SUP-0684-00-0480-01,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4203.6,2942.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATHETER IABP 7.5FR 40CC SENSATION PLUS -,SUP-0684-00-0568-01U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4524.1,3166.87,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATHETER IABP 8FR 50CC SENSATION PLUS -,SUP-0684-00-0576-01U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4524.1,3166.87,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
GAIA SECOND 190CM MICRO J,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
GAIA THIRD 190CM MICRO J,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
GAIA FIRST 190CM MICRO J,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
RG3 330CM,SUP-1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,828.57,579.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X18MM PWRSL 143CM RX F/PTCA COR HYDRCT 0.024IN GW -,SUP-1005527-18,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1086.6,760.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X15MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008189-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
4MM X 20MM X 135CM VIATRAC 14 PLUS BALLOON -,SUP-1008189-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ABBOTT VIATRAC BALLOON 4.5 X 20 X 135 -,SUP-1008191-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5X20MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008193-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ABBOTT VIATRAC BALLOON 5.5 X 20 X 135 -,SUP-1008195-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6X20MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008197-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6X40MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008197-40,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH CV 4.5X20MM VIATRAC LF -,SUP-10081991-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ABBOTT VIATRAC BALLOON 6.5 X 20 X 135 -,SUP-1008199-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 7X20MM VIATRAC 14 + 135CM RX LPRO F/PTA MUL-CMPLNT -,SUP-1008201-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.2X6MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012268-06U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON MINI TREK RX 1.20MM X 08MM REF: 1012268-08U -,SUP-1012268-08U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.2X12MM MINI TREK II RX UL-LPRO NC COR HYDRCT -,SUP-1012268-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.2X12MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012268-12U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON MINI TREK RX 1.20MM X 15MM REF: 1012268-15U -,SUP-1012268-15U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.2X20MM MINI TREK II RX UL-LPRO NC COR HYDRCT -,SUP-1012268-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.2X20MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012268-20U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.5X8MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.5X12MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.5X15MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.5X20MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT -,SUP-1012269-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X8MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X12MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X15MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X20MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X25MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X30MM MINI TREK RX UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012270-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012271-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X30MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012272-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON TREK RX 2.75MM X 08MM REF: 1012273-08 -,SUP-1012273-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON TREK RX 2.75MM X 12MM REF: 1012273-12 -,SUP-1012273-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON TREK RX 2.75MM X 20MM REF: 1012273-20 -,SUP-1012273-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X30MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012274-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012275-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X8MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X15MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X20MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012276-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON TREK RX 4.0MM X 8MM REF: 1012278-08 -,SUP-1012278-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012278-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON TREK RX 4.0MM X 15MM REF: 1012278-15 -,SUP-1012278-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON TREK RX 4.0MM X 20MM REF: 1012278-20 -,SUP-1012278-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X25MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012278-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X30MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012278-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4.5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012279-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON TREK RX 4.5MM X 15MM REF: 1012279-15 -,SUP-1012279-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5X12MM TREK RX UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012280-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON TREK RX 5.0MM X 15MM REF: 1012280-15 -,SUP-1012280-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.2X6MM MINI TREK II OTW UL-LPRO NC COR HYDRCT CTD -,SUP-1012401-06Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.2X8MM MINI TREK II OTW UL-LPRO NC COR HYDRCT CTD -,SUP-1012401-08Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.2X12MM MINI TREK II OTW UL-LPRO NC COR HYDRCT -,SUP-1012401-12Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.2X15MM MINI TREK II OTW UL-LPRO NC COR HYDRCT -,SUP-1012401-15Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.2X20MM MINI TREK II OTW UL-LPRO NC COR HYDRCT -,SUP-1012401-20Z,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.5X8MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.5X12MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.5X15MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.5X20MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012402-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X8MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT CTD -,SUP-1012403-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X12MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X15MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X20MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X30MM MINI TREK OTW UL-LPRO SEM-COM COR HYDRCT -,SUP-1012403-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012404-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X30MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012405-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM COR -,SUP-1012407-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X30MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012407-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012408-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X8MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X12MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X15MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X20MM TREK OTW UL-LPRO LUMX2 DIST SHFT SEM-COM -,SUP-1012409-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X12MM NC TREK OTW SM-PRFL NC COR RND TIP HYDRCT -,SUP-1012433-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.75X15MM NC TREK OTW SM-PRFL NC COR RND TIP -,SUP-1012436-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.5X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012444-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012445-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012446-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X25MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012447-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.75X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.75X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.75X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.75X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.75X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012448-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X25MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012449-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X12 MM NC TREK RX ULLPRO NC COR RND TIP HYDRCT -,SUP-1012450-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012450-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X6MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X25MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012451-25,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.75X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.75X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.75X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.75X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012452-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012453-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4.5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4.5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4.5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4.5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012454-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5X8MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5X12MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5X15MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5X20MM NC TREK RX UL-LPRO NC COR RND TIP HYDRCT -,SUP-1012455-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
2.0MM X 60 MM X 150CM ARMADA 18 BALLOON OTW -,SUP-1013463-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA BALLOON 2.5MM X 40MM X 150CM -,SUP-1013464-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 18 2.5 X 200 X 150 -,SUP-1013464-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA BALLOON 2.5MM X 80MM X 150CM -,SUP-1013464-80,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA BALLOON .018 3MM X 60MM X 150CM -,SUP-1013465-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1155.33,808.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA BALLOON .018 3.0MM X 80MM X 150CM -,SUP-1013465-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA BALLOON .018 3.0MM X 100MM X 150CM -,SUP-1013465-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATHETER ARMADA 18 3.0MM X 120MM X 150CM -,SUP-1013465-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATHETER ARMADA 18 PTA -,SUP-1013465-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA BALLOON .018 3 X 200 X 150 -,SUP-1013465-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 18 4 X 20MM -,SUP-1013466-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
4MM X 40MM X 150CM ARMADA 18 BALLOON -,SUP-1013466-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
4MM X 60MM X 150CM ARMADA 18 -,SUP-1013466-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 4MM X 80MM X 150CM 18 -,SUP-1013466-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON ARMADA 4 X 150 X 150MM -,SUP-1013466-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 18 BALLOON 5MM X 20MM -,SUP-1013468-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
5mm x 40mm armada 18 -,SUP-1013468-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
5mm x 60mm Armada 18 Balloon -,SUP-1013468-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 18 BALLOON 5MM X 80MM -,SUP-1013468-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B ARMADA .018 5MM X 100MM -,SUP-1013468-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA BALLOON 5 MM X 150MM -,SUP-1013468-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA BALLOON 5MM X 200MM -,SUP-1013468-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 18 BALLOON 6 X 20MM -,SUP-1013470-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
6MM X 40MM X 150CM ARMADA 18 BALLOON -,SUP-1013470-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 18 B 6MM X 60MM X 150CM -,SUP-1013470-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 018 6MM X 80 MM -,SUP-1013470-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 6MM X 100MM 18 BALLOON -,SUP-1013470-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 6MM X 150MM 0.018 -,SUP-1013470-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 6MM X 200MM 0.018 -,SUP-1013470-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON TREK RX 3.75MM X 8MM REF: 1012277-08 -,SUP-102277-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 1.50MM X 8MM REF: 1400150-08 -,SUP-1400150-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 1.50MM X 12MM REF: 1400150-12 -,SUP-1400150-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 1.50MM X 15MM REF: 1400150-15 -,SUP-1400150-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 1.50MM X 20MM REF: 1400150-20 -,SUP-1400150-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 2.00MM X 8MM REF: 1400200-08 -,SUP-1400200-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 2.00MM X 12MM REF: 1400200-12 -,SUP-1400200-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 2.00MM X 15MM REF: 1400200-15 -,SUP-1400200-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 2.00MM X 20MM REF: 1400200-20 -,SUP-1400200-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 2.25MM X 08MM REF: 1400225-08 -,SUP-1400225-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 2.25MM X 12MM REF: 1400225-12 -,SUP-1400225-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 2.25MM X 15MM REF: 1400225-15 -,SUP-1400225-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 2.25MM X 20MM REF: 1400225-20 -,SUP-1400225-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 2.50MM X 8MM REF: 1400250-08 -,SUP-1400250-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 2.50MM X 12MM REF: 1400250-12 -,SUP-1400250-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 2.50MM X 15MM REF: 1400250-15 -,SUP-1400250-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 2.50MM X 20MM REF: 1400250-20 -,SUP-1400250-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 2.75MM X 8MM REF: 1400275-08 -,SUP-1400275-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 2.75MM X 12MM REF: 1400275-12 -,SUP-1400275-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 2.75MM X 15MM REF: 1400275-15 -,SUP-1400275-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 2.75MM X 20MM REF: 1400275-20 -,SUP-1400275-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 3.00MM X 8MM REF: 1400300-08 -,SUP-1400300-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 3.00MM X 15MM REF: 1400300-15 -,SUP-1400300-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 3.00MM X 20MM REF: 1400300-20 -,SUP-1400300-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 3.25MM X 8MM REF: 1400325-08 -,SUP-1400325-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 3.25MM X 12MM REF: 1400325-12 -,SUP-1400325-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 3.25MM X 15MM REF: 1400325-15 -,SUP-1400325-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 3.25MM X 20MM REF: 1400325-20 -,SUP-1400325-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 3.50MM X 8MM REF: 1400350-08 -,SUP-1400350-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 3.50MM X 12MM REF: 1400350-12 -,SUP-1400350-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 3.50MM X 15MM REF: 1400350-15 -,SUP-1400350-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 3.50MM X 20MM REF: 1400350-20 -,SUP-1400350-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 3.75MM X 12MM REF: 1400375-12 -,SUP-1400375-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 3.75MM X 20MM REF: 1400375-20 -,SUP-1400375-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 4.00MM X 8MM REF: 1400400-08 -,SUP-1400400-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 4.00MM X 12MM REF: 1400400-12 -,SUP-1400400-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 4.00MM X 15MM REF: 1400400-15 -,SUP-1400400-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 4.00MM X 20MM REF: 1400400-20 -,SUP-1400400-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 4.50MM X 8MM REF: 1400450-08 -,SUP-1400450-08,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 4.50MM X 12MM REF: 1400450-12 -,SUP-1400450-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 4.50MM X 20MM REF: 1400450-20 -,SUP-1400450-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 5.00MM X 12MM REF: 1400500-12 -,SUP-1400500-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 5.00MM X 15MM REF: 1400500-15 -,SUP-1400500-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 5.50MM X 12MM REF: 1400550-12 -,SUP-1400550-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 5.50MM X 15MM REF: 1400550-15 -,SUP-1400550-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 6.00MM X 12MM REF: 1400600-12 -,SUP-1400600-12,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 6.00MM X 15MM REF: 1400600-15 -,SUP-1400600-15,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH BLNOCC 15MM LRG 23X71X2.5CM ENDOCATH LPRO PLYISPRN -,SUP-20-06,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X20MM 2.7CM ANGIOSCULPT XL 137CM OTW F/PTCA -,SUP-2039-2520,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X20MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2076-4020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X40MM ANGIOSCULPT XL 137CM OTW -,SUP-2076-4040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5X40MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2076-5040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6X40MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2076-6040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6X20MM ANGIOSCULPT XL 90CM OTW F/PTCA SEM-COM -,SUP-2092-6020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATHETER SAPPHIRE II PRO L5 MM 5F -,SUP-210-053-5UU,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATHETER SAPPHIRE II PRO L15 MM 5F -,SUP-210-153-5UU,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X40MM ANGIOSCULPT XL 155CM OTW F/PTCA SEM-COM -,SUP-2155-2540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR TAPR -,SUP-2200-2006-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X10MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2010-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2015-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.0X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2020-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2506-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X10MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2510-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2515-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-2520-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR TAPR -,SUP-2200-3006-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X10MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3010-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3015-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.0X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3020-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X6MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3506-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X10MM ANGIOSCULPT 137CM RX F /PTCA SEM-COM COR -,SUP-2200-3510-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X15MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3515-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X20 MM ANGIOSCULPT 137CM RX F/PTCA SEM-COM COR -,SUP-2200-3520-B,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5X100MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2237-50100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6X100MM ANGIOSCULPT XL 137CM OTW F/PTCA SEM-COM -,SUP-2237-60100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B ANGIOSCULPT 7MM X 40MM -,SUP-2333-7040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6X100MM STERLNG 135CM OTW COAX SEM-COM PERIPH TAPR -,SUP-39032-60101,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATHETER PCA 4MM X 30MM x 145CM COYOTE ES M -,SUP-39135-40301,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 14MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-1440L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATHETER DILATION16MM X 4MM -,SUP-417-1640L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 18MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-1840L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 20MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-2040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 22MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-2240L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1530.52,1071.364,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 25MMX4CM MAXI LD 110CM OTW COAX HPRS PERIPH -,SUP-417-2540L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 12MMX4CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-2040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3MMX4CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-3040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3MMX8CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-3080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4MMX10CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-4000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4MMX2CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-4020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
MIRROR SURG 16.4MMX7.625IN LRYNG HEX HNDL V. MUELLER -,SUP-419-4040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4MMX6CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-4060L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5MMX10CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-5000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 8MMX8CM OPTA PRO 110CM OTW F/PTA PERIPH TAPR -,SUP-419-8080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-5040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5MM 5FR SHFT 6CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-5060L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5MM 5FR SHFT 8CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-5080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6MM 5FR SHFT 6FR SHTH 10CM POWERFLX P3 110CM OTW -,SUP-420-6000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6MM 5FR SHFT 5FR SHTH 2CM POWERFLX P3 110CM OTW -,SUP-420-6020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-6040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6MM 5FR SHFT 6CM POWERFLX P3 80CM OTW F/PTA PERIPH -,SUP-420-6060S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6MM 5FR SHFT 8CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-6080L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 7MM 5FR SHFT 10CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-7000L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 7MM 5FR SHFT 2CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-7020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 7MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-7040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 8MM 5FR SHFT 6FR SHTH 2CM POWERFLX P3 110CM OTW -,SUP-420-8020L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 8MM 5FR SHFT 4CM POWERFLX P3 110CM OTW F/PTA -,SUP-420-8040L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4MMX2CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-4020W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4MMX3CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-4030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
RETRACTOR RGNL 6IN DBL END STN FNSH SS DLCT V. MUELLER NS -,SUP-424-5030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6MMX3CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-6030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 7MMX3CM AVIATR PLS 142CM RX OW- PRFL COAX F/PTA -,SUP-424-7030W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1272.12,890.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH DIL 3MM 4FR SHTH 4CM BLN 150CM F/PTA -,SUP-425-3004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3MMX4CM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-3004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X120MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X40MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-4004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5X40MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-5004X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5X100MM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-5010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5MMX28CM SLEEK 150CM OTW MOD PRSS PERIPH TAPR -,SUP-426-5028X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1696.16,1187.312,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5MMX6CM SAVVY 120CM OTW COAX MOD PRSS PERIPH TAPR -,SUP-435-506L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1155.51,808.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4MMX22CM SAVVY LONG 120CM OTW COAX MOD PRSS PERIPH -,SUP-436-4022L,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1420.53,994.371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4MMX22CM SAVVY LONG 150CM OTW COAX MOD PRSS PERIPH -,SUP-436-4022X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1420.53,994.371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0302S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0402S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4MMX4CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0404S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X220MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0422X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5MMX2CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0502S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0504S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5X60MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5X100MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5X220MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0522X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6MMX2CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0602S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6MMX4CM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-0604S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6X100MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0610X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6X150MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0615X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,840.24,588.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 7X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0702S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 7X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0704S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 7X40MM POWERFLX PRO 135CM OTW NC PERIPH DURALYN -,SUP-440-0704X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 8X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0802S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 8X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0804S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 9X20MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN MDX -,SUP-440-0902S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 10X40MM POWERFLX PRO 80CM OTW NC PERIPH DURALYN -,SUP-440-1004S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,781.89,547.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
TURNPIKE 150 CM MICRO CATH -,SUP-5643,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2859.63,2001.741,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 22MMX4CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-610462,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 25MMX4CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-610463,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 28MMX4CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-610465,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA BALLOON DILATAION 22X4X100 Z-MED II -,SUP-611761,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 30MMX2CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-611801,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 28MMX2CM Z-MED 85CM LPRO COAX F/PTA HPRS PERIPH -,SUP-611803,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 25MMX3CM Z-MED 100CM LPRO COAX F/PTA HPRS PERIPH -,SUP-611816,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3236.77,2265.739,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATHETER PTV 16MMX4CM TYSHAK II REF:611920 -,SUP-611920,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATHETER PTV 18MMX4CM TYSHAK II REF:611928 -,SUP-611928,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATHETER PTV 20MMX4CM TYSHAK II REF:611932 -,SUP-611932,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATHETER PTV 22MMX4CM TYSHAK II REF:611936 -,SUP-611936,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATHETER PTV 25MMX4CM TYSHAK II REF:611944 -,SUP-611944,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2540.68,1778.476,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH GUID 0.07IN 6FR MPA-1 90CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-270-90,CDM,C1725,HCPCS,272,RC,,,outpatient,,,309.26,216.482,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X6MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R06350N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R10200N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10225N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10250N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10325N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R10350N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X10MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R10400N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R12250N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R12300N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R12325N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.75X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R12350N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X12MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R12400N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R15250N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R15300N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R15325N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR -,SUP-75R15340N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X15MM EMPIRA 139CM RX F/PTCA SEM-COM COR DURALYN -,SUP-75R15400N,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
C PIG 5FR 20/1CM MARKS -,SUP-7602-20M65SH,CDM,C1725,HCPCS,272,RC,,,outpatient,,,528.13,369.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X12MM EMPIRA 139CM RX F/PTCA SEM-COM -,SUP-85R12250S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X12MM EMPIRA 139CM RX F/PTCA SEM-COM DURALYN -,SUP-85R12300S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X12MM EMPIRA 139CM RX F/PTCA SEM-COM -,SUP-85R12325S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X15MM EMPIRA 139CM RX F/PTCA SEM-COM -,SUP-85R15250S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X15MM EMPIRA 139CM RX F/PTCA SEM-COM DURALYN -,SUP-85R15300S,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 3.00MM X 12MM REF: 1400300-12 -,SUP-90176431,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 4.50MM X 15MM REF: 1400450-15 -,SUP-90176448,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON TREK RX 2.75MM X 15MM REF: 1012273-15 -,SUP-90176463,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON TREK RX 3.75MM X 12MM REF: 1012277-12 -,SUP-90176465,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON TREK RX 3.75MM X 15MM REF: 1012277-15 -,SUP-90176466,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC TREK NEO 3.75MM X 15MM REF: 1400375-15 -,SUP-90176697,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH ANG 6FR 18MM 70CM 3.5CM BLN AMPLATZER SZ LUMX3 FLXB -,SUP-9-SB-018,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH ANG 24MM 7FR 70CM 4.5CM BLN AMPLATZER SZ LUMX3 FLXB -,SUP-9-SB-024,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.5X20MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2015-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 14 1.5MM X 40MM X 150CM -,SUP-A2015-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X20MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X60MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X80MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X200MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2020-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2025-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND -,SUP-A2025-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X200MM ARMADA 14 150CM LPRO F/PTA PERIPH RND -,SUP-A2025-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X20MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X60MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X80MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2030-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B ARMADA 14 PTA C 3.0 X 200M -,SUP-A2030-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X40MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X60MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X80MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X120MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X200MM ARMADA 14 150CM LPRO F/PTA PERIPH RND TIP -,SUP-A2040-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X40MM NANOCROSS ELITE 150CM OTW ULTRA LO XING -,SUP-AB14W030040150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2093.7,1465.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X80MM NANOCROSS ELITE 150CM OTW ULTRA LO XING -,SUP-AB14W030080150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2093.7,1465.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
4MM X 40MM STELLAREX DCB -,SUP-AB35SX040040135,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON ATLAS PTA CATHETER 16MMX 40MM X 120CM REF: AT120164 -,SUP-AT120164,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1966.49,1376.543,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B ATLAS 12MM X 4CM X 75CM -,SUP-AT-75124,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B ATLAS 14MM X 4CM X 75CM -,SUP-AT-75144,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B ATLAS 16MM X 4CM X 75CM -,SUP-AT-75164,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1966.49,1376.543,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B ATLAS 18MM X 4CM X 75CM -,SUP-AT75184,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1966.49,1376.543,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ATLAS BALLOON 20 X 40 -,SUP-AT75204,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2276.62,1593.634,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ATLAS BALLOON 24 X 40 -,SUP-AT75244,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2910.99,2037.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 26MMX4CM ATLAS 75CM OTW COAX ULTRA NC PERIPH 12FR -,SUP-AT-75264,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2826.21,1978.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ATLAS GOLD PTA DILATATION CATHETER 120CM -,SUP-ATG120164,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1913.48,1339.436,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH ATLAS GOLD PTA DILATATION 16 X 6 X 80MM - 8 FR -,SUP-ATG80166,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1913.48,1339.436,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 35  4.0MM X 20MM X 80CM -,SUP-B1040-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 35 4.0MM X 40MM X 80CM -,SUP-B1040-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
4MM X 80MM X 80CM ARMADA 35 BALLOON -,SUP-B1040-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON ARMADA 4MM X 80MM X 80CM -,SUP-B1040-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 5MM X 20MM X 80CM -,SUP-B1050-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B ARMADA 35 5MM X 40MM X 80CM -,SUP-B1050-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5X40MM ARMADA  .035 -,SUP-B1050-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 35 5MM X 60MM X 80CM -,SUP-B1050-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B ARMADA 35 5.0 X 80 X 80 PTA CATH -,SUP-B1050-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON ARMADA 5MM X 100MM X 80CM -,SUP-B1050-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 5MM X 120MM X 80CM -,SUP-B1050-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 35 6MM X 40MM X 80CM -,SUP-B1060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 6MMx40MMx80CM -,SUP-B1060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
6MM X 60MM X 80CM ARMADA 35 BALLOON -,SUP-B1060-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 35 6.0MM X 60MM X80CM -,SUP-B1060-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
6MM X 80MM X 80CM ARMADA 35 BALLOON -,SUP-B1060-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON ARMADA 6MM X 100MM X 80CM -,SUP-B1060-120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 6 X 150 X 80 -,SUP-B1060-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON 35 ARMADA 7 X 20 X 80 PTA -,SUP-B1070-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA PTA 7MM X 40MM X 80CM -,SUP-B1070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 35 7MM X 60MM X 80CM -,SUP-B1070-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA B  35  7.0X60X80 PTA -,SUP-B1070-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 35 7 X 80MM X 80CM -,SUP-B1070-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B ARMADA 35 7MM X 80MM X 80CM -,SUP-B1070-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B ARMADA 35 7.0 X 100 X 80 PTA CATH -,SUP-B1070-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON ARMADA 7MM X 150MM X 80CM -,SUP-B1070-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 35 8MM X 20MM X 80CM -,SUP-B1080-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
8mm x 40mm x 80cm Armada 35 -,SUP-B1080-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
XARMADA 35 8.0MM X 40MM X 80C -,SUP-B1080-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 35 8mmx60mmX80cm -,SUP-B1080-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B ARMADA 35 8MM X 60MM ON 80MM -,SUP-B1080-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
8MM X 80MM X 80CM ARMADA 35 BALLOON -,SUP-B1080-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 35 8.0MM X 80MM X 80CM -,SUP-B1080-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
9MM X 20MM X 80CM ARMADA 35 BALLOON -,SUP-B1090-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 35 BALLOON 9 X 40MM X 80CM -,SUP-B1090-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
10MM X 20MM X 80CM ARMADA 35 BALLOON -,SUP-B1100-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
10.0MM X 40MM X 80 ARMADA 35 BALLOON -,SUP-B1100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 35 10.0MM X 40MM X 80CM -,SUP-B1100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
10MM X 60MM X 80CM ARMADA 35 BALLOON -,SUP-B1100-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 35 10MM 60MM X 80CM -,SUP-B1100-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
12MM X 20MM X 80CM ARMADA 35 BALLOON -,SUP-B1120-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 35 12.0MM X 40MM X 80CM -,SUP-B1120-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 35 12 X 60MM X 80CM -,SUP-B1120-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 35 12.0MM X 60MM X 80CM -,SUP-B1120-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 35 14.0MM X 20MM X 80CM -,SUP-B1140-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
14MM X 40MM X 80CM ARMADA 35 BALLOON -,SUP-B1140-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 35 14MM X 60MM X 80CM -,SUP-B1140-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
4MM X 20MM X 135CM ARMADA 35 BALLOON -,SUP-B2040-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
Armada 4 x 40 x 135 Balloon -,SUP-B2040-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 4MM X 60MM X 135CM -,SUP-B2040-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 35 4X100X135 -,SUP-B2040-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
5MM X 20MM X 135CM ARMADA 35 -,SUP-B2050-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
5MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2050-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
5MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2050-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA PTA 0.035MM X 5MM X 60MM X 135CM -,SUP-B2050-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA PTA .035  5MM X 80MM X 135CM -,SUP-B2050-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
5MMX100MMX135CM ARMADA 35 -,SUP-B2050-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
5MM X 200MM X 135CM ARMADA 35 BALLOON -,SUP-B2050-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
6MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA PTA 0.035 6MM X 40MM X 135CM -,SUP-B2060-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
6MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2060-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 35 6MM 80MM 135CM -,SUP-B2060-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 35 6MM 100MM 135CM -,SUP-B2060-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
6mm x 150mm x 135cm ARMADA 35 -,SUP-B2060-150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
6MM X 200MM X 135CM ARMADA 35 BALLOON -,SUP-B2060-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
7MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 35  BALLOON  7.0MM X 40MM X 135CM -,SUP-B2070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B ARMADA 35  7MM X 40MM X 135CM -,SUP-B2070-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
7MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2070-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 35 7MM X 100MM BALLOON -,SUP-B2070-100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
7MM X 200MM X 135CM ARMADA 35 BALLOON -,SUP-B2070-200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 35 8MM X 20MM X 135CM -,SUP-B2080-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 35 8MM X 40MM X 135CM -,SUP-B2080-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 35  8MM X 60MM X 135CM -,SUP-B2080-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 8MM X 80MM 35 BALLOON -,SUP-B2080-080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON 9MM X 20MM X 135CM CATH ARMADA 35 -,SUP-B2090-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
9MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2090-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA PTA CATHETER 9MM X 60MM X 135CM -,SUP-B2090-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA PTA 10MM X 20MM X 135CM -,SUP-B2100-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
10MM X 40MM X 135CM ARMADA 35 BALLOON -,SUP-B2100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA PTA 10MM X 40MM X 135CM -,SUP-B2100-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA PTA 10MM X 60MM X 135MM -,SUP-B2100-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 35 12MM X 40MM X 135CM -,SUP-B2120-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
12MM X 60MM X 135CM ARMADA 35 BALLOON -,SUP-B2120-060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ARMADA 35 BALLOON DIAL CATH 14X20X135 -,SUP-B2140-020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
14MM X 40MM X 135CM ARMADA 35 BALOON -,SUP-B2140-040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH BALLOON DIL CROSPERIO RX 0.014 X 4.0MM X 150CM 4FR -,SUP-BD-B40150LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1229.72,860.804,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH BALLOON DILATION R2P PTA 4.0MM X 150MM CROSPERIO RX -,SUP-BD-B40150LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1229.72,860.804,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CROSTELLA RX PTA DIL CATH 3MM X 8MM X 150CM -,SUP-BD-F30080LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CROSSTELLA OTW 3MM X 200MM 150CM -,SUP-BD-F30200LW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH CROSTELLA BALLOON RX PTA 4.0MM X 40MM 150CM 4FR -,SUP-BD-F40040LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH CROSTELLA BALLOON RX PTA 5.0MM X 80MM 150CM 4FR -,SUP-BD-F50080LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CROSSTELLAÂ® RX PTA Balloon Dil Cath 5mm x 150mm -,SUP-BD-F50150LR,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON METACROS 5MM X 150 X .030 PTCA -,SUP-BD-P50150ER,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON R2P CROSTELLA RX 2MM X 40MM X 200CM -,SUP-BD-Q20040ER,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5X120MM CHOC 120CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CB1812050120OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X40MM CHOC 150CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CF1415025040OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X120MM CHOC 150CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CF1415025120OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X120MM CHOC 150CM OTW BRD F/PTA SEM-COM PERIPH -,SUP-CF1415030120OTW,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 10MMX4CM CONQUST 75CM OTW COAX ULTRA NC PERIPH -,SUP-CQ-75104,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 12MMX4CM CONQUST 75CM OTW COAX ULTRA NC PERIPH -,SUP-CQ-75124,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1490.45,1043.315,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6MMX2CM CONQUST 75CM OTW COAX ULTRA NC PERIPH -,SUP-CQ-7562,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B CONQUEST 6 X 4 X 75 -,SUP-CQ-7564,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B CONQUEST 7 X 4 X 75 -,SUP-CQ-7574,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B CONQUEST 8 X 4 X 75 -,SUP-CQ-7584,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1447.04,1012.928,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH BALLOON CHOLANGIOGRAPHY -,SUP-CS-01701,CDM,C1725,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON DILATATION CATH OTW TAKERU 1.5X6MM REF:DC-PY1506UA1 -,SUP-DC-PY1506UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU OTW 1.5X12MM REF: DC-PY1512UA1 -,SUP-DC-PY1512UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON DILATATION CATH OTW TAKERU 1.5X15MM REF:DC-PY1515UA1 -,SUP-DC-PY1515UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU OTW 1.5X20MM REF: DC-PY1520UA1 -,SUP-DC-PY1520UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU OTW 2.0X8MM REF: DC-PY2008UA2 -,SUP-DC-PY2008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU OTW 2.0X12MM REF: DC-PY2012UA2 -,SUP-DC-PY2012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON DILATATION CATH OTW TAKERU 2.0X15MM REF:DC-PY2015UA2 -,SUP-DC-PY2015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON DILATATION CATH OTW TAKERU 2.0X20MM REF:DC-PY2020UA2 -,SUP-DC-PY2020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU OTW 2.25X12MM REF: DC-PY2212UA2 -,SUP-DC-PY2212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU OTW 2.25X15MM REF: DC-PY2215UA2 -,SUP-DC-PY2215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU OTW 2.25X20MM REF: DC-PY2220UA2 -,SUP-DC-PY2220UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU OTW 2.5X8MM REF: DC-PY2508UA2 -,SUP-DC-PY2508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU OTW 2.5X15MM REF: DC-PY2515UA2 -,SUP-DC-PY2515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU OTW 2.5X20MM REF: DC-PY2520UA2 -,SUP-DC-PY2520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU OTW 3.0X8MM REF: DC-PY3008UA2 -,SUP-DC-PY3008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU OTW 3.0X12MM REF: DC-PY3012UA2 -,SUP-DC-PY3012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU OTW 3.0X15MM REF: DC-PY3015UA2 -,SUP-DC-PY3015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU OTW 3.0X20MM REF: DC-PY3020UA2 -,SUP-DC-PY3020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU OTW 3.5X8MM REF: DC-PY3508UA2 -,SUP-DC-PY3508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU OTW 3.5X12MM REF: DC-PY3512UA2 -,SUP-DC-PY3512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU OTW 3.5X15MM REF: DC-PY3515UA2 -,SUP-DC-PY3515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU OTW 3.5X20MM REF: DC-PY3520UA2 -,SUP-DC-PY3520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU OTW 4.0X8MM REF: DC-PY4008UA2 -,SUP-DC-PY4008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU OTW 4.0X12MM REF: DC-PY4012UA2 -,SUP-DC-PY4012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU OTW 4.0X20MM REF: DC-PY4020UA2 -,SUP-DC-PY4020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON DILATATION CATH RX TAKERU 1.5X6MM REF:DC-RY1506UA1 -,SUP-DC-RY1506UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX 1.5X12MM REF: DC-RY1512UA1 -,SUP-DC-RY1512UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON DILATATION CATH RX TAKERU 1.5X15MM REF:DC-RY1515UA1 -,SUP-DC-RY1515UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON DILATATION CATH RX TAKERU 1.5X20MM REF:DC-RY1520UA1 -,SUP-DC-RY1520UA1,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX 2.0X8MM REF: DC-RY2008UA2 -,SUP-DC-RY2008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX 2.0X12MM REF: DC-RY2012UA2 -,SUP-DC-RY2012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON DILATATION CATH RX TAKERU 2.0X15MM REF:DC-RY2015UA2 -,SUP-DC-RY2015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON DILATATION CATH RX TAKERU 2.0X20MM REF:DC-RY2020UA2 -,SUP-DC-RY2020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX 2.25X12MM REF: DC-RY2212UA2 -,SUP-DC-RY2212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX 2.25X15MM REF: DC-RY2215UA2 -,SUP-DC-RY2215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX 2.5X8MM REF: DC-RY2508UA2 -,SUP-DC-RY2508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX 2.5X12MM REF: DC-RY2512UA2 -,SUP-DC-RY2512UA,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX 2.5X15MM REF: DC-RY2515UA2 -,SUP-DC-RY2515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX 2.5X20MM REF: DC-RY2520UA2 -,SUP-DC-RY2520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX 3.0X8MM REF: DC-RY3008UA2 -,SUP-DC-RY3008UA,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX 3.0X12MM REF: DC-RY3012UA2 -,SUP-DC-RY3012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX 3.0X15MM REF: DC-RY3015UA2 -,SUP-DC-RY3015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX 3.0X20MM REF: DC-RY3020UA2 -,SUP-DC-RY3020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX 3.5X8MM REF: DC-RY3508UA2 -,SUP-DC-RY3508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX 3.5X12MM REF: DC-RY3512UA2 -,SUP-DC-RY3512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX 3.5X15MM REF: DC-RY3515UA2 -,SUP-DC-RY3515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX 3.5X20MM REF: DC-RY3520UA2 -,SUP-DC-RY3520UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX 4.0X8MM REF: DC-RY4008UA2 -,SUP-DC-RY4008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX 4.0X12MM REF: DC-RY4012UA2 -,SUP-DC-RY4012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX 4.0X15MM REF: DC-RY4015UA2 -,SUP-DC-RY4015UA,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX 4.0X20MM REF: DC-RY4020UA2 -,SUP-DC-RY4020UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX NC 2.0X8MM REF: DC-RZ2008UA2 -,SUP-DC-RZ2008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX NC 2.0X12MM REF: DC-RZ2012UA2 -,SUP-DC-RZ2012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX NC 2.0X15MM REF: DC-RZ2015UA2 -,SUP-DC-RZ2015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX NC 2.0X21MM REF: DC-RZ2021UA2 -,SUP-DC-RZ2021UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX NC 2.25X8MM REF: DC-RZ2208UA2 -,SUP-DC-RZ2208UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX NC 2.25X12MM REF: DC-RZ2212UA2 -,SUP-DC-RZ2212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX NC 2.25X15MM REF: DC-RZ2215UA2 -,SUP-DC-RZ2215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX NC 2.25X21MM REF: DC-RZ2221UA2 -,SUP-DC-RZ2221UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX NC 2.5X8MM REF: DC-RZ2508UA2 -,SUP-DC-RZ2508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX NC 2.5X12MM REF: DC-RZ2512UA2 -,SUP-DC-RZ2512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX NC 2.5X15MM REF: DC-RZ2515UA2 -,SUP-DC-RZ2515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX NC 2.5X21MM REF: DC-RZ2521UA2 -,SUP-DC-RZ2521UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX NC 2.75X8MM REF: DC-RZ2708UA2 -,SUP-DC-RZ2708UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX NC 2.75X12MM REF: DC-RZ2712UA2 -,SUP-DC-RZ2712UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX NC 2.75X15MM REF: DC-RZ2715UA2 -,SUP-DC-RZ2715UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX NC 2.75X21MM REF: DC-RZ2721UA2 -,SUP-DC-RZ2721UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX NC 3.0X8MM REF: DC-RZ3008UA2 -,SUP-DC-RZ3008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX NC 3.0X12MM REF: DC-RZ3012UA2 -,SUP-DC-RZ3012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX NC 3.0X15MM REF: DC-RZ3015UA2 -,SUP-DC-RZ3015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX NC 3.0X21MM REF: DC-RZ3021UA2 -,SUP-DC-RZ3021UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX NC 3.25X8MM REF: DC-RZ3208UA2 -,SUP-DC-RZ3208UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX NC 3.25X12MM REF: DC-RZ3212UA2 -,SUP-DC-RZ3212UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX NC 3.25X15MM REF: DC-RZ3215UA2 -,SUP-DC-RZ3215UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX NC 3.25X21MM REF: DC-RZ3221UA2 -,SUP-DC-RZ3221UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX NC 3.5X08MM REF: DC-RZ3508UA2 -,SUP-DC-RZ3508UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX NC 3.5X12MM REF: DC-RZ3512UA2 -,SUP-DC-RZ3512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX NC 3.5X15MM REF: DC-RZ3515UA2 -,SUP-DC-RZ3515UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX NC 3.5X21MM REF: DC-RZ3521UA2 -,SUP-DC-RZ3521UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX NC 4.0X8MM REF: DC-RZ4008UA2 -,SUP-DC-RZ4008UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX NC 4.0X12MM REF: DC-RZ4012UA2 -,SUP-DC-RZ4012UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX NC 4.0X15MM REF: DC-RZ4015UA2 -,SUP-DC-RZ4015UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU RX NC 4.0X21MM REF: DC-RZ4021UA2 -,SUP-DC-RZ4021UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATH TAKERU OTW 2.5X12MM REF: DC-PY2512UA2 -,SUP-D-PY2512UA2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4MMX2CM DORADO 40CM OTW F/PTA ULTRA NC PERIPH 5FR -,SUP-DR4042,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1335.73,935.011,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 7MMX6CM DORADO 80CM OTW F/PTA ULTRA NC PERIPH 6FR -,SUP-DR8076,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1335.73,935.011,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP1506X EUPHORA RX -,SUP-EUP1506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP1512X EUPHORA RX -,SUP-EUP1512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP1515X EUPHORA RX -,SUP-EUP1515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP1520X EUPHORA RX -,SUP-EUP1520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP2006X EUPHORA RX -,SUP-EUP2006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP2010X EUPHORA RX -,SUP-EUP2010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP2012X EUPHORA RX -,SUP-EUP2012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP2015X EUPHORA RX -,SUP-EUP2015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP2020X EUPHORA RX -,SUP-EUP2020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP2025X EUPHORA RX -,SUP-EUP2025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP2030X EUPHORA RX -,SUP-EUP2030X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP22506X EUPHORA RX -,SUP-EUP22506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP22510X EUPHORA RX -,SUP-EUP22510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP22512X EUPHORA RX -,SUP-EUP22512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP22515X EUPHORA RX -,SUP-EUP22515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP22520X EUPHORA RX -,SUP-EUP22520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP22525X EUPHORA RX -,SUP-EUP22525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP2506X EUPHORA RX -,SUP-EUP2506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP2510X EUPHORA RX -,SUP-EUP2510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP2512X EUPHORA RX -,SUP-EUP2512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP2515X EUPHORA RX -,SUP-EUP2515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP2520X EUPHORA RX -,SUP-EUP2520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP2525X EUPHORA RX -,SUP-EUP2525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP2530X EUPHORA RX -,SUP-EUP2530X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP27506X EUPHORA RX -,SUP-EUP27506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP27510X EUPHORA RX -,SUP-EUP27510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP27512X EUPHORA RX -,SUP-EUP27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP27515X EUPHORA RX -,SUP-EUP27515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP27520X EUPHORA RX -,SUP-EUP27520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP27525X EUPHORA RX -,SUP-EUP27525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP3006X EUPHORA RX -,SUP-EUP3006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP3010X EUPHORA RX -,SUP-EUP3010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP3012X EUPHORA RX -,SUP-EUP3012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP3015X EUPHORA RX -,SUP-EUP3015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP3020X EUPHORA RX -,SUP-EUP3020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP3025X EUPHORA RX -,SUP-EUP3025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP3030X EUPHORA RX -,SUP-EUP3030X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP32506X EUPHORA RX -,SUP-EUP32506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP32510X EUPHORA RX -,SUP-EUP32510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP32512X EUPHORA RX -,SUP-EUP32512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP32515X EUPHORA RX -,SUP-EUP32515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP32520X EUPHORA RX -,SUP-EUP32520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP32525X EUPHORA RX -,SUP-EUP32525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP3506X EUPHORA RX -,SUP-EUP3506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP3510X EUPHORA RX -,SUP-EUP3510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP3512X EUPHORA RX -,SUP-EUP3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP3515X EUPHORA RX -,SUP-EUP3515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP3520X EUPHORA RX -,SUP-EUP3520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP3525X EUPHORA RX -,SUP-EUP3525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP3530X EUPHORA RX -,SUP-EUP3530X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP37506X EUPHORA RX -,SUP-EUP37506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP37510X EUPHORA RX -,SUP-EUP37510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP37512X EUPHORA RX -,SUP-EUP37512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP37515X EUPHORA RX -,SUP-EUP37515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP37520X EUPHORA RX -,SUP-EUP37520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP37525X EUPHORA RX -,SUP-EUP37525X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP4006X EUPHORA RX -,SUP-EUP4006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP4010X EUPHORA RX -,SUP-EUP4010X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP4012X EUPHORA RX -,SUP-EUP4012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP4015X EUPHORA RX -,SUP-EUP4015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP4020X EUPHORA RX -,SUP-EUP4020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP4025X EUPHORA RX -,SUP-EUP4025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EUP4030X EUPHORA RX -,SUP-EUP4030X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH BLNOCC 9FRX120CM CODA -,SUP-G03831,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2702.08,1891.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.5MMX4CM ADVANCE MICRO 14 150CM OTW UL-LPRO F/PTA -,SUP-G26614,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2289.76,1602.832,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2MMX12CM ADVANCE MICRO 14 150CM OTW UL-LPRO F/PTA -,SUP-G26641,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2289.76,1602.832,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6MMX2CM ADVANCE ATB 80CM OTW F/PTA MIN-CMPLNT -,SUP-G26895,CDM,C1725,HCPCS,272,RC,,,outpatient,,,705.98,494.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH DIL 4MMX12CM ADVANCE 18 LP 150CM LPRO F/PTA 4FR SHTH -,SUP-G30949,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30952,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5MMX15CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30955,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ANGIOPLASTY 5 - 15 PTA -,SUP-G30956,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B 18LP ADVANCE 5MM X 15CM -,SUP-G30956,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ANGIOPLASTY / PTA4-18-150-5-20 -,SUP-G30958,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30958,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH DIL 6MMX12CM ADVANCE 18 LP 150CM LPRO F/PTA 5FR SHTH -,SUP-G30961,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ANGIOPLASTY 6 - 15 PTA -,SUP-G30962,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30964,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 7MMX12CM ADVANCE 18 LP 150CM LPRO F/PTA 5FR SHTH -,SUP-G30967,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 7MMX20CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G30970,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3MMX4CM ADVANCE 18LP 150CM LPRO F/PTA -,SUP-G34319,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
3X6X150 PTA ADVANCE CATH -,SUP-G34320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3MMX8CM ADVANCE 18LP -,SUP-G34321,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON ADVANCE .018 3MM X 10CM X 150CM -,SUP-G34322,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G34331,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-G34336,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5MMX6CM ADVANCE 35LP 135CM LPRO PERIPH D-SHP -,SUP-G35532,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATHETER ADVANCED LOW PROFILE BALLOON 6MM X 20MM X 135CM -,SUP-G35536,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 7MMX20CM ADVANCE 35LP 135CM LPRO F/PTA -,SUP-G35540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 10MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G35546,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH ANG 5FRX80CM ADVANCE LPRO -,SUP-G35547,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
GW ENDO 0.035INX260CM ACROBAT CLBRT TIP -,SUP-G47614,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1038.63,727.041,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G49479,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50216,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50218,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50222,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50224,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5MMX10CM ADVANCE 18LP 135CM LUMX2 -,SUP-G50226,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4MMX4CM ADVANCE 18LP - USE 0141543 DISC. -,SUP-G50228,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50230,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50235,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50237,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50239,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50241,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 -,SUP-G50243,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6MMX2CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50245,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50247,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6MMX6CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50249,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50251,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50253,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 7MMX4CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50257,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 7MMX8CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50262,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 7MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50264,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2MMX2CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50313,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50314,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2MMX6CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50315,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50316,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50317,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50318,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50319,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50321,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1836.57,1285.599,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5MMX6CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50322,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50323,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50324,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50325,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ADVANCE 14 LP BALLOON CATHETER -,SUP-G50327,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50328,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3MMX4CM ADVANCE 14LP 60MM LPRO LUMX2 F/PTA SEM-COM -,SUP-G50329,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50330,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50332,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50333,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4MMX2CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50334,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4MMX4CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50335,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4MMX6CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50336,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4MMX8CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50337,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50338,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4MMX16CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50339,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-G50340,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52251,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52253,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52254,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52257,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52258,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5MMX6CM ADVANCE 35LP 135CM LPRO PERIPH -,SUP-G52259,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52260,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52261,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5MMX14CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52263,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52265,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52266,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52267,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52268,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6MMX14CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 7MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52271,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 7MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52272,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 7MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52273,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 7MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52274,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 7MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52275,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 7MMX14CM ADVANCE 35LP 135CM LPRO F/PTA -,SUP-G52277,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 8MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52278,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 8MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52279,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 8MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52280,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 8MMX10CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52282,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 9MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52286,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 9MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-G52287,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 10MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52293,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 10MMX6CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52294,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 12MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52299,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 12MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-G52300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
US PRE PP-CA-422 DIR BALLOON CATHER T3 20-23 -,SUP-G57885,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATHETER US PRE PP-CA-422 DIR BALLOON T3 20-23 -,SUP-G57887,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ADVANCE SERENITY 14 150-20-220 -,SUP-G57889,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATHETER BALLOON DILATATION ADVANCE SERENITY 14 2.5MM X10CM -,SUP-G57894,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CATHETER T3 20-23 -,SUP-G57896,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
DIRECT BALLOON CATHETERS T2 23-26 -,SUP-G57897,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATHETER US PRE PP-CA-422 DIR BALLOON  T3 20-23 -,SUP-G57900,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ADVANCE SERENITY 14 HYDROPHILIC PTA BALLOON DILA CATH 3 X 10 -,SUP-G57901,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ADVANCE SERENITY 14 HYDROPHILIC PTA BALLOON DILA CATH 3 X 22 -,SUP-G57903,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
US PRE PP-CA-422 DIR BALLOON CATHETER T3 20-23 150-40-20 -,SUP-G57911,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ADVANCE SERENITY 14 4MM x 100MM x 150CM -,SUP-G57915,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATHETER BALLOON DIR SERENITY 14 4MM X 15CM 150CM -,SUP-G57916,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATHETER US PRE PP-CA-422 DIR BALLOON  T3 20-23 -,SUP-G57917,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PIG 0.045IN 5FR PIG 125CM EXPO -,SUP-H749085262151,CDM,C1725,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.5X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP 0.014IN -,SUP-H7493895808200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.75X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP 0.014IN -,SUP-H7493895808300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895808350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X8MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP 0.014IN -,SUP-H7493895808400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.5X12MM APEX FLX UL-LPRO NC -,SUP-H7493895812150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.75X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.75X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X12MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895812400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.5X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.75X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.75X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X15MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895815400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.5X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.75X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.75X20MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895820370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X30MM APEX OTW UL-LPRO F/PTCA COR OPTILEAP -,SUP-H7493895830250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,991.95,694.365,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.5X8MM APEX FLEX MONORAIL RX UL-LPRO NC -,SUP-H7493895908150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.75X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895908400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.5X12MM APEX FLEX MONORAIL RX UL-LPRO -,SUP-H7493895912150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.75X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.75X12MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895912370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X12MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895912400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.5X15MM APEX FLEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.75X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.75X15MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895915370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895915400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.5X20MM APEX FLEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.75X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.75X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493895920370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5X20MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895920500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B APEX MR  30MM X 2.50 MONORAIL RX -,SUP-H7493895930250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X30MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895930400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.0X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X40MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493895940400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.5X8MM APEX OTW UL-LPRO F/PTCA OPTILEAP -,SUP-H7493896008150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.5X12MM APEX MONORAIL OTW UL-LPRO PSH -,SUP-H7493896012150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.5X15MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493896015150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.5X20MM APEX OTW UL-LPRO F/PTCA OPTILEAP -,SUP-H7493896020150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.5X8MM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493896108150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.5X12MM APEX MONORAIL RX UL-LPRO PSH -,SUP-H7493896112150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.5X15MM APEX MONORAIL RX UL-LPRO -,SUP-H7493896115150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.5X20MM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493896120150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
STERLING MONORAIL RAPID EXCHANGE 3 X 60 -,SUP-H74939031306010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON FG STERLING MR 4.5MM X 20MM X 135CM 4FR -,SUP-H74939031452010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2014.19,1409.933,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
STERLING MONORAIL .018 5X20X80CM 4F -,SUP-H74939031502080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6X20MM STERLNG MONORAIL 135CM RX LPRO COAX SEM-COM -,SUP-H74939031602010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH BALLOON STERLING 7.0MM X 40MM X 80CM 4FR FG MONORL -,SUP-H74939031704080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B STERLING OTW 10.0 X 60 135 -,SUP-H74939032106010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B STERLING OTW 10.0 X 80 135 -,SUP-H74939032108010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B STERLING OTW 4 X 10 X 135 39 -,SUP-H74939032401010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X220MM STERLNG 150CM OTW COAX SEM-COM PERIPH TAPR -,SUP-H74939032402210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B STERLING OTW 4.0 X 30 135 -,SUP-H74939032403010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B STERLING OTW 4 X 40 X 135 MA -,SUP-H74939032404010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B STERLING OTW 4.0 X 60 135 -,SUP-H74939032406010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1669.29,1168.503,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B STERLING OTW 4.0 X 80 135 -,SUP-H74939032408010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1669.29,1168.503,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B STERLING OTW 5 X 10 X 135 39 -,SUP-H74939032501010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B STERLING OTW 5.0 X 120 150 -,SUP-H74939032501210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B STERLING OTW 5.0 X 150 150 -,SUP-H74939032501510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B STERLING OTW 5.0 X 200 150 -,SUP-H74939032502110,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B STERLING OTW 5.0 X 220 150 -,SUP-H74939032502210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B STERLING OTW 5.0 X 30 135 -,SUP-H74939032503010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B STERLING OTW 5 X 4 X 135 390 -,SUP-H74939032504010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B STERLING OTW 5.0 X 60 135 -,SUP-H74939032506010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B STERLING OTW 5.0 X 80 135 -,SUP-H74939032508010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B STERLING OTW 6 X 10 X 135 39 -,SUP-H74939032601010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6X120MM 150CM -,SUP-H74939032601210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B STERLING OTW 6.0 X 150 150 -,SUP-H74939032601510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B STERLING OTW 6.0 X 200 150 -,SUP-H74939032602110,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B STERLING OTW 6.0 X 220 150 -,SUP-H7493903260221,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B STERLING OTW 6.0X30X135 -,SUP-H74939032603010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B STERLING OTW 6 X 4 X 135 390 -,SUP-H74939032604010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B STERLING OTW 6.0 X 80 135 -,SUP-H74939032608010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B STERLING OTW 7.0 X 100 135 -,SUP-H74939032701010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B STERLING OTW 7.0 X 120 150 -,SUP-H74939032701210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B STERLING OTW 7.0 X 150 150 -,SUP-H74939032701510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B STERLING OTW 7.0 X 200 150 -,SUP-H74939032702110,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B STERLING OTW 7.0 X 220 150 -,SUP-H74939032702210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,931.27,651.889,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B STERLING OTW 7.0 X 30 135 -,SUP-H74939032703010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B STERLING OTW 7.0 X 40 135 -,SUP-H74939032704010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B STERLING OTW 7.0 X 60 135 -,SUP-H74939032706010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B STERLING OTW 7.0 X 80 135 -,SUP-H74939032708010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B STERLING OTW 8.0 X 30 135 -,SUP-H74939032803010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B STERLING OTW 8.0 X 40 135 -,SUP-H74939032804010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B STERLING OTW 8.0 X 60 135 -,SUP-H74939032806010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B STERLING OTW 8.0 X 80 135 -,SUP-H74939032808010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B STERLING OTW 9.0 X 60 135 -,SUP-H74939032906010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B STERLING OTW 9.0 X 80 135 -,SUP-H74939032908010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.75X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.75X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912408400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4.5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5X8MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912408500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912412200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.75X12MM NC QUANTM APEX MONORAIL UL-LPRO NC -,SUP-H7493912412270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X12MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912412320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912412350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.75X12MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912412370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X12MM NC QUANTM APEX MONORAIL RX UL -LPRO NC -,SUP-H7493912412400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4.5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912412450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5X12MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912412500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.75X15MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912415270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X15MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912415320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.75X15MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912415370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912415400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4.5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5X15MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912415500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912420200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.75X20MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912420270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X20MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912420320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.75X20MM NC QUANTM APEX MONORAIL RX UL-LPRO -,SUP-H7493912420370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4.5X20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912420450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5 X 20MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912420500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC COR -,SUP-H7493912430200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.75X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4732.06,3312.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.75X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X30MM NC QUANTM APEX MONORAIL RX UL-LPRO NC -,SUP-H7493912430400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.75X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.75X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4732.06,3312.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4.5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912508450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5X8MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT NC -,SUP-H7493912508500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.75X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.75X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912512370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4.5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5X12MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912512500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.75X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.75X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912515370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4.5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5X15MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912515500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.75X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.75X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912520370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4.5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5X20MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912520500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.75X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.75X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR -,SUP-H7493912530370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X30MM NC QUANTM APEX OTW UL-LPRO BISEG INR SHFT -,SUP-H7493912530400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X40MM COYOTE ES MONORAIL 145CM RX SEM-COM PERIPH -,SUP-H74939134204010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON COYOTE 2.5MM X 40MM X 145CM  .014 -,SUP-H74939134254010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X20MM COYOTE ES 143CM OTW UL-LPRO SEM-COM PERIPH -,SUP-H74939134302010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X30MM COYOTE ES 144MM OTW UL-LPRO SEM-COM PERIPH -,SUP-H74939134303010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X40MM COYOTE ES 145CM OTW UL-LPRO SEM-COM PERIPH -,SUP-H74939134404010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.5X20MM COYOTE ES MONORAIL 143CM RX SEM-COM -,SUP-H74939135152010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X20MM COYOTE ES MONORAIL 143CM RX SEM-COM PERIPH -,SUP-H74939135202010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X20MM COYOTE ES MONORAIL 144CM RX SEM-COM PERIPH -,SUP-H74939135302010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X30MM COYOTE ES MONORAIL 145CM RX SEM-COM PERIPH -,SUP-H74939135303010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X40MM COYOTE ES MONORAIL 146CM RX SEM-COM PERIPH -,SUP-H74939135304010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X20MM COYOTE ES MONORAIL 144CM RX SEM-COM -,SUP-H74939135352010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X30MM COYOTE ES MONORAIL 145CM RX SEM-COM -,SUP-H74939135353010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X20MM COYOTE ES MONORAIL 144CM RX SEM-COM PERIPH -,SUP-H74939135402010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X30MM COYOTE ES MONORAIL 145CM RX SEM-COM PERIPH -,SUP-H74939135403010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X40MM COYOTE ES MONORAIL 146CM RX SEM-COM PERIPH -,SUP-H74939135404010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X100MM STERLNG SL 150CM OTW COAX SEM-COM PERIPH -,SUP-H74939148401510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,803.77,562.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 3.0 X 20 135CM -,SUP-H74939171030210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171030270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 3.0 X 40 135CM -,SUP-H74939171030410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
3MM X 40MM X 40CM MUSTANG -,SUP-H74939171030440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171030470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 3.0 X 60 135CM -,SUP-H74939171030610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
MUSTANG 3 X 60 X 75 -,SUP-H74939171030670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 3.0 X 80 135CM -,SUP-H74939171030810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 3.0 X 100 135C -,SUP-H74939171031010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 3.0 X 120 135C -,SUP-H74939171031210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 3.0 X 150 135C -,SUP-H74939171031510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 3.0 X 180 135C -,SUP-H74939171031810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 3.0 200 135CM -,SUP-H74939171032010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 4.0 X 20 135CM -,SUP-H74939171040210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171040270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 4.0 X 40 135CM -,SUP-H74939171040410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
MUSTANG 4MM X 40MM X 40CM -,SUP-H74939171040440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171040470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 4.0 X 60 135CM -,SUP-H74939171040610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171040670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 4.0 X 80 135CM -,SUP-H74939171040810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
MUSTANG 4MM X 80MM X 40CM -,SUP-H74939171040840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 4.0 X 100 135C -,SUP-H74939171041010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171041070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 4.0 X 120 135C -,SUP-H74939171041210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 4.0 X 150 135C -,SUP-H74939171041510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 4.0 X 180 135C -,SUP-H74939171041810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 4.0X200 135CM -,SUP-H74939171042010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 5.0 X 20 135CM -,SUP-H74939171050210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5X30MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 5.0 X 40 135CM -,SUP-H74939171050410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
MUSTANG 5MM X 40MM X 40 CM -,SUP-H74939171050440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 5.0 X 60 135CM -,SUP-H74939171050610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 5.0 X 80 135CM -,SUP-H74939171050810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
MUSTANG 5MM X 80MM X 40CM -,SUP-H74939171050840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171050870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 5.0 X 100 135C -,SUP-H74939171051010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171051070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 5.0 X 120 135C -,SUP-H74939171051210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 5.0 X 150 135C -,SUP-H74939171051510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 5.0 180 135CM -,SUP-H74939171051810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 5.0 200 135CM -,SUP-H74939171052010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 6.0 X 20 135CM -,SUP-H74939171060210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 6.0 X 40 135CM -,SUP-H74939171060410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6X40MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1079.48,755.636,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
MUSTANG 6MM X 40MM X 40CM -,SUP-H74939171060440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 6.0 X 60 135CM -,SUP-H74939171060610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 6.0 X 80 135CM -,SUP-H74939171060810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
6MM X 80MM X 40CM MUSTANG PTA -,SUP-H74939171060840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
MUSTANG 6MM X 80MM X 40CM -,SUP-H74939171060840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171060870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 6.0 X 100 135C -,SUP-H74939171061010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 6.0 X 120 135C -,SUP-H74939171061210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6X150MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171061510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6X150MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171061570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 6.0 180 135CM -,SUP-H74939171061810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6X200MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171062010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 7.0 X 20 135CM -,SUP-H74939171070210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 7X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 7.0 X 40 135cm -,SUP-H74939171070410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
7MM X 40MM X 40CM MUSTANG -,SUP-H74939171070440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 7X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 7.0 X 60 135CM -,SUP-H74939171070610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 7X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 7X80MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 7X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171070870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 7.0 X 100 135C -,SUP-H74939171071010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 7X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171071070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 7.0 X 120 135C -,SUP-H74939171071210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 7X150MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171071510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 7X150MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171071570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 7.0 180 135CM -,SUP-H74939171071810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 7X200MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171072010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 7X200MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171072070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 8.0 X 20 135CM -,SUP-H74939171080210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 8X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171080270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 8.0 X 40 135CM -,SUP-H74939171080410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
8MM X 40MM X 40CM MUSTANG -,SUP-H74939171080440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON MUSTANG 7.0MM X 80MM X 40CM -,SUP-H74939171080440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON MUSTANG 8MM X 40MM X 40CM -,SUP-H74939171080440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 8X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171080470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 8.0 X 60 135CM -,SUP-H74939171080610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 8.0 X 80 135CM -,SUP-H74939171080810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
8MM X 80MM X 40CM MUSTANG PTA -,SUP-H74939171080840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 8X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171080870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 8.0 X 100 135C -,SUP-H74939171081010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 8X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171081070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 8.0 X 120 135C -,SUP-H74939171081210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 8X150MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171081570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 8.0 180 135CM -,SUP-H74939171081810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 8X200MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171082010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 8X200MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171082070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 9.0 X 20 135CM -,SUP-H74939171090210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 9X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 9.0 X 40 135CM -,SUP-H74939171090410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 9X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 9X60MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 9X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 9.0 X 80 135CM -,SUP-H74939171090810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 9X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171090870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 10.0 X 20 135C -,SUP-H74939171100210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 10X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 10.0X40 135CM -,SUP-H74939171100410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
MUSTANG BALLOON 10MM X 40MM X 40CM -,SUP-H74939171100440,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 10X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 10.0 X 60 135C -,SUP-H74939171100610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 10X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 10.0 X 80 135C -,SUP-H74939171100810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
MUSTANG 10MM X 80MM X 40CM -,SUP-H74939171100840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 10X80MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171100870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 12.0X20 135CM -,SUP-H74939171120210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 12X20MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171120270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 12.0X40 135CM -,SUP-H74939171120410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 12X40MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171120470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 12X60MM MUSTNG 135CM LPRO BILUM SHFT NC PERIPH -,SUP-H74939171120610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 12X60MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171120670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 12.0 X 80 135C -,SUP-H74939171120810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B MUSTANG PTA 12MM X 80MM 40CM -,SUP-H74939171120840,CDM,C1725,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B CATH COYOTE OTW 1.5X40X150 -,SUP-H74939186150410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B CATH COYOTE OTW 2X60X150 -,SUP-H74939186200610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B CATH COYOTE OTW 2X80X150 -,SUP-H74939186200810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B CATH COYOTE OTW 2X100X150 -,SUP-H74939186201010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B CATH COYOTE OTW 2X120X150 -,SUP-H74939186201210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B CATH COYOTE OTW 2X220X150 -,SUP-H74939186202210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
COYOTE 2 X 220 -,SUP-H74939186202290,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B CATH COYOTE OTW 2.5X60X150 -,SUP-H74939186250610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B CATH COYOTE OTW 2.5X80X150 -,SUP-H74939186250810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B CATH COYOTE OW 2.5X100X150 -,SUP-H74939186251010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B CATH COYOTE OW 2.5X120X150 -,SUP-H74939186251210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B CATH COYOTE OW 2.5X220X150 -,SUP-H74939186252210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B CATH COYOTE OTW 3X60X150 -,SUP-H74939186300610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B CATH COYOTE OTW 3X80X150 -,SUP-H74939186300810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B CATH COYOTE OTW 3X100X150 -,SUP-H74939186301010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B CATH COYOTE OTW 3X120X150 -,SUP-H74939186301210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B CATH COYOTE OTW 3X150X150 -,SUP-H74939186301510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B CATH COYOTE OTW 3X220X150 -,SUP-H74939186302210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B CATH COYOTE OTW 3.5X60X150 -,SUP-H74939186350610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B CATH COYOTE OTW 3.5X80X150 -,SUP-H7493918635081,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1637.85,1146.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B CATH COYOTE OW 3.5X100X150 -,SUP-H74939186351010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B CATH COYOTE OW 3.5X120X150 -,SUP-H74939186351210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B CATH COYOTE OW 3.5X150X150 -,SUP-H74939186351510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B CATH COYOTE OW 3.5X220X150 -,SUP-H74939186352210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B CATH COYOTE OTW 4X60X150 -,SUP-H74939186400610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B CATH COYOTE OTW 4X80X150 -,SUP-H74939186400810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B CATH COYOTE OTW 4X100X150 -,SUP-H74939186401010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1637.85,1146.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B CATH COYOTE OTW 4X120X150 -,SUP-H74939186401210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1637.85,1146.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B CATH COYOTE OTW 4X150X150 -,SUP-H74939186401510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,914.64,640.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B CATH COYOTE OTW 4X220X150 -,SUP-H74939186402210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1014.41,710.087,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 1.20MM X 8MM -,SUP-H7493918908120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 1.50MM X 8MM -,SUP-H7493918908150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 2.00 MM X 8MM -,SUP-H7493918908200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 2.50 MM X 8MM -,SUP-H7493918908250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 2.75 MM X 8MM -,SUP-H7493918908270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 3.00 MM X 8MM -,SUP-H7493918908300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 3.25 MM X 8MM -,SUP-H7493918908320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 3.50 MM X 8MM -,SUP-H7493918908350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 3.75 MM X 8MM -,SUP-H7493918908370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 4.00MM X 8MM -,SUP-H7493918908400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 1.20MM X 12MM -,SUP-H7493918912120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 1.50MM X 12MM -,SUP-H7493918912150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 2.00 MM X 12 MM -,SUP-H7493918912200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 2.25 MM X 12MM -,SUP-H7493918912220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 2.50 MM X 12 MM -,SUP-H7493918912250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 2.75 MM X 12MM -,SUP-H7493918912270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 3.00 MM X 12MM -,SUP-H7493918912300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 3.25 MM X 12MM -,SUP-H7493918912320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 3.50 MM X 12MM -,SUP-H7493918912350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 3.75 MM X 12MM -,SUP-H7493918912370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 4.00MM X 12MM -,SUP-H7493918912400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 1.20MM X 15MM -,SUP-H7493918915120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 1.50MM X 15MM -,SUP-H7493918915150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 2.00 MM X 15 MM -,SUP-H7493918915200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 2.25 MM X 15MM -,SUP-H7493918915220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 2.50 MM X 15MM -,SUP-H7493918915250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 2.75 MM X 15MM -,SUP-H7493918915270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 3.00 MM X 15MM -,SUP-H7493918915300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 3.25 MM X 15MM -,SUP-H7493918915320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 3.50 MM X 15MM -,SUP-H7493918915350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 3.75 MM X 15MM -,SUP-H7493918915370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 4.00MM X 15MM -,SUP-H7493918915400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 1.20MM X 20MM -,SUP-H7493918920120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 1.50MM X 20MM -,SUP-H7493918920150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 2.00 MM X 20 MM -,SUP-H7493918920200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 2.25 MM X 20MM -,SUP-H7493918920220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 2.50 MM X 20 MM -,SUP-H7493918920250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 2.75 MM X 20MM -,SUP-H7493918920270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 3.00 MM X 20 MM -,SUP-H7493918920300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 3.25 MM X 20MM -,SUP-H7493918920320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 3.50 MM X 20MM -,SUP-H7493918920350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 3.75 MM X 20MM -,SUP-H7493918920370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 4.00MM X 20MM -,SUP-H7493918920400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 2.00 MM X 30MM -,SUP-H7493918930200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 2.25 MM X 30MM -,SUP-H7493918930220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 2.50 MM X 30MM -,SUP-H7493918930250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 2.75 MM X 30MM -,SUP-H7493918930270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 3.00 MM X 30MM -,SUP-H7493918930300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 3.25 MM X 30MM -,SUP-H7493918930320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 3.50 MM X 30MM -,SUP-H7493918930350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 3.75 MM X 30MM -,SUP-H7493918930370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE MR 4.00MM X 30MM -,SUP-H7493918930400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE PUSH MR 1.20MM X 8MM -,SUP-H7493919008120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE PUSH MR 1.50MM X 8MM -,SUP-H7493919008150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE PUSH MR 1.20MM X 12MM -,SUP-H7493919012120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE PUSH MR 1.50MM X 12MM -,SUP-H7493919012150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE PUSH MR 1.20MM X 15MM -,SUP-H7493919015120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE PUSH MR 1.50MM X 15MM -,SUP-H7493919015150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE PUSH MR 1.20MM X 20MM -,SUP-H7493919020120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE PUSH MR 1.50MM X 20MM -,SUP-H7493919020150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 1.20MM X 8MM -,SUP-H7493919108120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 1.50MM X 8MM -,SUP-H7493919108150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 2.00MM X 8MM -,SUP-H7493919108200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 2.25MM X 8MM -,SUP-H7493919108220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 2.50MM X 8MM -,SUP-H7493919108250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 2.75MM X 8MM -,SUP-H7493919108270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 3.00MM X 8MM -,SUP-H7493919108300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 3.25MM X 8MM -,SUP-H7493919108320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 3.50MM X 8MM -,SUP-H7493919108350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 3.75MM X 8MM -,SUP-H7493919108370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 4.00MM X 8MM -,SUP-H7493919108400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 1.20MM X 12MM -,SUP-H7493919112120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 1.50MM X 12MM -,SUP-H7493919112150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 2.00MM X 12MM -,SUP-H7493919112200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 2.25MM X 12MM -,SUP-H7493919112220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 2.50MM X 12MM -,SUP-H7493919112250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 2.75MM X 12MM -,SUP-H7493919112270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 3.00MM X 12MM -,SUP-H7493919112300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 3.25MM X 12MM -,SUP-H7493919112320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 3.50MM X 12MM -,SUP-H7493919112350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 3.75MM X 12MM -,SUP-H7493919112370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 4.00MM X 12MM -,SUP-H7493919112400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 1.20MM X 15MM -,SUP-H7493919115120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 1.50MM X 15MM -,SUP-H7493919115150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 2.00MM X 15MM -,SUP-H7493919115200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 2.25MM X 15MM -,SUP-H7493919115220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 2.50MM X 15MM -,SUP-H7493919115250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 2.75MM X 15MM -,SUP-H7493919115270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 3.00MM X 15MM -,SUP-H7493919115300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 3.25MM X 15MM -,SUP-H7493919115320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 3.50MM X 15MM -,SUP-H7493919115350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 3.75MM X 15MM -,SUP-H7493919115370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 4.00MM X 15MM -,SUP-H7493919115400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 1.20MM X 20MM -,SUP-H7493919120120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 1.50MM X 20MM -,SUP-H7493919120150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 2.25MM X 20MM -,SUP-H7493919120220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 2.50MM X 20MM -,SUP-H7493919120250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 2.75MM X 20MM -,SUP-H7493919120270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 3.00MM X 20MM -,SUP-H7493919120300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 3.25MM X 20MM -,SUP-H7493919120320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 3.50MM X 20MM -,SUP-H7493919120350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 3.75MM X 20MM -,SUP-H7493919120370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 4.00MM X 20MM -,SUP-H7493919120400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 2.00MM X 20MM -,SUP-H7493919130200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 2.00MM X 30MM -,SUP-H7493919130200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 2.25MM X 30MM -,SUP-H7493919130220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 2.50MM X 30MM -,SUP-H7493919130250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 2.75MM X 30MM -,SUP-H7493919130270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 3.00MM X 30MM -,SUP-H7493919130300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 3.25MM X 30MM -,SUP-H7493919130320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 3.50MM X 30MM -,SUP-H7493919130350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 3.75MM X 30MM -,SUP-H7493919130370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE OTW 4.00MM X 30MM -,SUP-H7493919130400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE PUSH OTW 1.20MM X 8MM -,SUP-H7493919208120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE PUSH OTW 1.50MM X 8MM -,SUP-H7493919208150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE PUSH OTW 1.20MM X 12MM -,SUP-H7493919212120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE PUSH OTW 1.50MM X 12MM -,SUP-H7493919212150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE PUSH OTW 1.20MM X 15MM -,SUP-H7493919215120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE PUSH OTW 1.50MM X 15MM -,SUP-H7493919215150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE PUSH OTW 1.20MM X 20MM -,SUP-H7493919220120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON EMERGE PUSH OTW 1.50MM X 20MM -,SUP-H7493919220150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CHARGER BALLOON 3 X 20 X 135 -,SUP-H74939206030210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CHARGER BALLOON 3 X 20 X 75 -,SUP-H74939206030270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CHARGER BALLOON 3MM X 40MM X 130CM -,SUP-H74939206030410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CHARGER BALLOON 3MM X 80MM X 135CM -,SUP-H74939206030810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
3MM X 100MM X 135CM CHARGER -,SUP-H74939206031010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CHARGER 3MM X 120MM -,SUP-H74939206031210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
3.0MM X 150MM X 135CM CHARGER BALLOON -,SUP-H74939206031510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CHARGER 3MM X 200MM X 135CM -,SUP-H74939206032010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CHARGER OTW 4 X 20MM X135CM BALLOON -,SUP-H74939206040210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
4MM X 20MM X 75CM CHARGER BALLOON -,SUP-H74939206040270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
PTA BALLOON 5F -,SUP-H74939206040670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CHARGER BALLOON 4MM X 80MM X 75CM -,SUP-H74939206040870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CHARGER 4MM X 100MM X 135CM -,SUP-H74939206041010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
4MM X 100MM X 75CM CHARGER BALLOON -,SUP-H74939206041070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CHARGER BALLOON 4MM X 150MM X 135CM -,SUP-H74939206041510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
5MM X 20MM X 75CM .035 CHARGER SHORT SHAFT -,SUP-H74939206050270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CHARGER 5MM X 40MM X 135CM -,SUP-H74939206050410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CHARGER BALLOON 5MM X 60MM X 135CM -,SUP-H74939206050610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CHARGER BALLOON 5MM X 80MM X 135CM -,SUP-H74939206050810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
5MM X 80MM X 75CM CHARGER BALLOON -,SUP-H74939206050870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CHARGER 5MM X 100MM X 135CM -,SUP-H74939206051010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CHARGER 5MM X 120MM X 135CM -,SUP-H74939206051210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CHARGER BALLOON 5 X 150MM -,SUP-H74939206051510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
5MM X 200MM X 135CM CHARGER -,SUP-H74939206052010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
6MM X 20MM X 135CM CHARGER -,SUP-H74939206060210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
6MM X 20MM X 75CM .035 CHARGER SHORT SHAFT -,SUP-H74939206060270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CHARGER BALLOON 6MM X 40MM X 135CM -,SUP-H74939206060410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CHARGER 6MM X 40MM X 75CM BALLOON -,SUP-H74939206060470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
6.0MM X 60MM X 75CM CHARGER -,SUP-H74939206060670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
6MM X 8MM X 135CM CHARGER -,SUP-H74939206060810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CHARGER 6.0MM X 80MM X 75CM -,SUP-H74939206060870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CHARGER BALLOON 6MM X 100MM X 135CM -,SUP-H74939206061010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CHARGER 6MM X 100MM X 75CM -,SUP-H74939206061070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CHARGER BALLOON 6MM X 150MM X 135CM -,SUP-H74939206061510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
7MM X 20MM X 135CM CHARGER -,SUP-H74939206070210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
7MM X 40MM X 135CM CHARGER BALLOON -,SUP-H74939206070410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
7MM X 40MM X 75CM CHARGER BALLOON -,SUP-H74939206070470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CHARGER 7MM X 80MM X 135CM -,SUP-H74939206070610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CHARGER BALLOON .035 7MM X 60MM X 75CM -,SUP-H74939206070670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
7MM X 80MM X 75CM CHARGER BALLOON -,SUP-H74939206070870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
7MM X 100MM X 135CM CHARGER BALLOON -,SUP-H74939206071010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
7MM X 100MM X 75CM CHARGER PTA -,SUP-H74939206071070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CHARGER BALLOON 8MM X 40MM X 135CM -,SUP-H74939206080410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CHARGER 8MM X 40MM X 75CM -,SUP-H74939206080470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
8MM X 60MM X 75CM CHARGER PTA -,SUP-H74939206080670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
8MM X 80MM X 135CM CHARGER BALLOON -,SUP-H74939206080810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
8.0MM X 80MM X 75CM CHARGER -,SUP-H74939206080870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CHARGER PTA 8MM X 100MM X 135CM -,SUP-H74939206081010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
8MM X 100MM X 75CM CHARGER PTA -,SUP-H74939206081070,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CHARGER 8MM X 180MM X 135CM -,SUP-H74939206081810,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
8.0MM X 200MM X 135XM CHARGER BALLOON -,SUP-H74939206082010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
9MM X 40MM X 135CM CHARGER BALLOON -,SUP-H74939206090410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
9MM X 40MM X 75CM CHARGER BALLOON -,SUP-H74939206090470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CHARGER 9MM X 60MM X 75CM -,SUP-H74939206090670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CHARGER OTW 10 X 20 BALLOON 135CM -,SUP-H74939206100210,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CHARGER .035 10MM X 40MM X 135CM -,SUP-H74939206100410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
10MM X 40MM X 75CM CHARGER PTA -,SUP-H74939206100470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
10.0MM X 80MM X 75CM CHARGER BALLOON -,SUP-H74939206100870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
12MM X 20MM X 75CM CHARGER -,SUP-H74939206120270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
12MM X 40MM X 135CM CHARGER -,SUP-H74939206120410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
12MM X 40MM X 75CM CHARGER -,SUP-H74939206120470,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CHARGER 12MM X 60MM X 75CM -,SUP-H74939206120670,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CHARGER 12MM X 80MM X 75CM -,SUP-H74939206120870,CDM,C1725,HCPCS,272,RC,,,outpatient,,,466.8,326.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 2.00MM x 6MM -,SUP-H7493926706200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 2.25MM x 6MM -,SUP-H7493926706220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 2.50MM x 6MM -,SUP-H7493926706250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 2.75MM x 6MM -,SUP-H7493926706270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 3.00MM x 6MM -,SUP-H7493926706300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 3.25MM x 6MM -,SUP-H7493926706320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 3.50MM x 6MM -,SUP-H7493926706350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 3.75MM x 6MM -,SUP-H7493926706370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 4.00MM X 6MM -,SUP-H7493926706400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 4.50MM x 6MM -,SUP-H7493926706450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 5.00MM x 6MM -,SUP-H7493926706500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 2.00MM x 8MM -,SUP-H7493926708200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 2.25MM x 8MM -,SUP-H7493926708220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 2.50MM x 8MM -,SUP-H7493926708250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 2.75MM x 8MM -,SUP-H7493926708270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 3.00MM x 8MM -,SUP-H7493926708300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 3.25MM x 8MM -,SUP-H7493926708320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 3.50MM x 8MM -,SUP-H7493926708350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 3.75MM x 8MM -,SUP-H7493926708370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 4.0 MM X 8 MM -,SUP-H7493926708400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 4.50MM x 8MM -,SUP-H7493926708450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 5.00MM x 8MM -,SUP-H7493926708500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 5.50MM x 8MM -,SUP-H7493926708550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 6.00MM x 8MM -,SUP-H7493926708600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 2.00MM X 12MM -,SUP-H7493926712200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 2.25MM x 12MM -,SUP-H7493926712220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 2.50 MM X 12 MM -,SUP-H7493926712250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 2.75MM x 12MM -,SUP-H7493926712270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 3.00MM x 12MM -,SUP-H7493926712300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 3.25MM x 12MM -,SUP-H7493926712320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 3.50MM x 12MM -,SUP-H7493926712350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 3.75MM x 12MM -,SUP-H7493926712370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 4.00MM x 12MM -,SUP-H7493926712400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 4.50MM x 12MM -,SUP-H7493926712450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 5.0 MM X 12 MM -,SUP-H7493926712500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 5.50MM x 12MM -,SUP-H7493926712550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 6.00MM x 12MM -,SUP-H7493926712600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 2.00MM x 15MM -,SUP-H7493926715200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 2.25MM x 15MM -,SUP-H7493926715220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 2.50 MM X 15 MM -,SUP-H7493926715250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 2.75MM x 15MM -,SUP-H7493926715270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 3.0 MM X 15 MM -,SUP-H7493926715300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 3.25MM x 15MM -,SUP-H7493926715320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 3.50MM x 15MM -,SUP-H7493926715350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 3.75MM x 15MM -,SUP-H7493926715370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 4.00MM X 15MM -,SUP-H7493926715400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 4.50MM x 15MM -,SUP-H7493926715450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 5.00MM x 15MM -,SUP-H7493926715500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 5.50MM x 15MM -,SUP-H7493926715550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 6.00MM x 15MM -,SUP-H7493926715600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 2.00MM x 20MM -,SUP-H7493926720200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1457.64,1020.348,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 2.25MM x 20MM -,SUP-H7493926720220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 2.50 MM X 20 MM -,SUP-H7493926720250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 2.75MM x 20MM -,SUP-H7493926720270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 3.0 MM X 20 MM -,SUP-H7493926720300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 3.25MM x 20MM -,SUP-H7493926720320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 3.50MM x 20MM -,SUP-H7493926720350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 3.75MM x 20MM -,SUP-H7493926720370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 4.00MM x 20MM -,SUP-H7493926720400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 4.50MM x 20MM -,SUP-H7493926720450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 5.00MM x 20MM -,SUP-H7493926720500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 5.50MM x 20MM -,SUP-H7493926720550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 6.00MM x 20MM -,SUP-H7493926720600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 2.00MM x 30MM -,SUP-H7493926730200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 2.25MM x 30MM -,SUP-H7493926730220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 2.50MM x 30MM -,SUP-H7493926730250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 2.75MM x 30MM -,SUP-H7493926730270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 3.00MM x 30MM -,SUP-H7493926730300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 3.25MM x 30MM -,SUP-H7493926730320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 3.50MM x 30MM -,SUP-H7493926730350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 3.75MM x 30MM -,SUP-H7493926730370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE MR 4.00MM x 30MM -,SUP-H7493926730400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 2.00MM x 6MM -,SUP-H7493926806200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 2.25MM x 6MM -,SUP-H7493926806220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 2.50MM x 6MM -,SUP-H7493926806250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 2.75MM x 6MM -,SUP-H7493926806270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 3.00MM x 6MM -,SUP-H7493926806300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 3.25MM x 6MM -,SUP-H7493926806320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 3.50MM x 6MM -,SUP-H7493926806350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 3.75MM x 6MM -,SUP-H7493926806370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 4.00MM x 6MM -,SUP-H7493926806400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 4.50MM x 6MM -,SUP-H7493926806450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 5.00MM x 6MM -,SUP-H7493926806500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 2.00MM x 8MM -,SUP-H7493926808200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 2.25MM x 8MM -,SUP-H7493926808220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 2.50MM x 8MM -,SUP-H7493926808250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 2.75MM x 8MM -,SUP-H7493926808270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 3.00MM x 8MM -,SUP-H7493926808300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 3.25MM x 8MM -,SUP-H7493926808320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 3.50MM x 8MM -,SUP-H7493926808350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 3.75MM x 8MM -,SUP-H7493926808370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 4.00MM x 8MM -,SUP-H7493926808400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 4.50MM x 8MM -,SUP-H7493926808450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 5.00MM x 8MM -,SUP-H7493926808500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 5.50MM x 8MM -,SUP-H7493926808550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 6.00MM x 8MM -,SUP-H7493926808600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 2.00MM x 12MM -,SUP-H7493926812200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 2.25MM x 12MM -,SUP-H7493926812220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 2.50MM x 12MM -,SUP-H7493926812250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 2.75MM X 12MM -,SUP-H7493926812270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 3.00MM x 12MM -,SUP-H7493926812300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 3.25MM x 12MM -,SUP-H7493926812320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 3.50MM x 12MM -,SUP-H7493926812350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 3.75MM x 12MM -,SUP-H7493926812370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 4.00MM x 12MM -,SUP-H7493926812400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 4.50MM x 12MM -,SUP-H7493926812450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 5.00MM x 12MM -,SUP-H7493926812500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 5.50MM x 12MM -,SUP-H7493926812550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 6.00MM x 12MM -,SUP-H7493926812600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 2.00MM x 15MM -,SUP-H7493926815200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 2.25MM x 15MM -,SUP-H7493926815220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 2.50MM x 15MM -,SUP-H7493926815250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 2.75MM x 15MM -,SUP-H7493926815270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 3.00MM x 15MM -,SUP-H7493926815300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 3.25MM x 15MM -,SUP-H7493926815320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 3.50MM x 15MM -,SUP-H7493926815350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 3.75MM x 15MM -,SUP-H7493926815370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 4.00MM x 15MM -,SUP-H7493926815400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 4.50MM x 15MM -,SUP-H7493926815450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 5.00MM x 15MM -,SUP-H7493926815500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 5.50MM x 15MM -,SUP-H7493926815550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 6.00MM x 15MM -,SUP-H7493926815600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 2.00MM x 20MM -,SUP-H7493926820200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 2.25MM x 20MM -,SUP-H7493926820220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 2.50MM x 20MM -,SUP-H7493926820250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 2.75MM x 20MM -,SUP-H7493926820270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 3.00MM x 20MM -,SUP-H7493926820300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 3.25MM x 20MM -,SUP-H7493926820320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 3.50MM x 20MM -,SUP-H7493926820350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 3.75MM x 20MM -,SUP-H7493926820370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 4.00MM x 20MM -,SUP-H7493926820400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 4.50MM x 20MM -,SUP-H7493926820450,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 5.00MM x 20MM -,SUP-H7493926820500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 5.50MM x 20MM -,SUP-H7493926820550,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 6.00MM x 20MM -,SUP-H7493926820600,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 2.00MM x 30MM -,SUP-H7493926830200,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 2.25MM x 30MM -,SUP-H7493926830220,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 2.50MM x 20MM -,SUP-H7493926830250,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 2.75MM x 30MM -,SUP-H7493926830270,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 3.00MM x 30MM -,SUP-H7493926830300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 3.25MM x 30MM -,SUP-H7493926830320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 3.50MM x 30MM -,SUP-H7493926830350,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 3.75MM x 30MM -,SUP-H7493926830370,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NC EMERGE OTW 4.00MM x 30MM -,SUP-H7493926830400,CDM,C1725,HCPCS,272,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CUTTING 6MMX2.0MM WOLVERINE -,SUP-H74939401062000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CUTTING 6MMX2.5MM WOLVERINE -,SUP-H74939401062500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CUTTING 6MMX3.0MM WOLVERINE -,SUP-H74939401063000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CUTTING 6MMX3.5MM WOLVERINE -,SUP-H74939401063500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CUTTING 6MMX4.0MM WOLVERINE -,SUP-H74939401064000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CUTTING 10MMX2.0MM WOLVERINE -,SUP-H74939401102000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CUTTING 10MMX2.5MM WOLVERINE -,SUP-H74939401102500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CUTTING 10MMX3.0MM WOLVERINE -,SUP-H74939401103000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CUTTING 10MMX3.5MM WOLVERINE -,SUP-H74939401103500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CUTTING 10MMX4.0MM WOLVERINE -,SUP-H74939401104000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CUTTING 15MX2.00MM WOLVERINE -,SUP-H74939401152000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CUTTING 15MX2.50MM WOLVERINE -,SUP-H74939401152500,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON CUTTING 15MMX3.0MM WOLVERINE -,SUP-H74939401153000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4179.64,2925.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
RANGER GLOBAL DCB OTW 6.0 X 150MM 150CM -,SUP-H74939419601510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
RANGER DCB OTW  7.0MM x 40MM x 80CM -,SUP-H74939419700480,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT BLN -,SUP-H749CBM3200100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X6MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3225060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3225100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X6MM FLEXTOME CUT BLN MONORAIL 142CM RX -,SUP-H749CBM3250060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3250100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3250150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.75X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3275100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.75X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3275150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT BLN -,SUP-H749CBM3300100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT BLN -,SUP-H749CBM3300150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3325100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X15MM FLEXTOME CUT BLN MONORAIL 142CM RX -,SUP-H749CBM3325150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3350100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X15MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3350150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.75X10MM FLEXTOME CUT BLN MONORAIL 142CM RX CUT -,SUP-H749CBM3375100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4583.04,3208.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3200060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3200100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3225060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3225100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X15MM FLEXTOME BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3225150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3250060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3250100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X15MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3250150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.75X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3275100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.75X15MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3275150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X6MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3300060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X15MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC COR -,SUP-H749CBO3300150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN NC -,SUP-H749CBO3325100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X15MM FLEXTOME CUT BLN 142CM CUT BLN NC -,SUP-H749CBO3325150,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X10MM FLEXTOME CUT BLN 142CM OTW CUT BLN -,SUP-H749CBO3350100,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH DX 2.4FR ID 3.4FR RND TIP 135CM CROSSBOSS XING MUL-WIRE -,SUP-H749M2000A0,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4648.07,3253.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH ANG 0.045IN 5FR FR4 125CM EXPO FUL-R WIRE BRD ROBST -,SUP-H759085262251,CDM,C1725,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATHETER IABP 7.5FR 40CC ULTRA FLEX REF: IAB-06840-U -,SUP-IAB-06840-U,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATHETER IABP 8FR 40CC REDIGUARD REF: IAB-S840C -,SUP-IAB-S840C,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4010.16,2807.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
INFLATION KIT 30/30 BASIX -,SUP-IN4530,CDM,C1725,HCPCS,272,RC,,,outpatient,,,364.57,255.199,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5X220MM LUTONIX -,SUP-LX3513052205F,CDM,C1725,HCPCS,272,RC,,,outpatient,,,8063.6,5644.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
LUTONIX BALLOON 7MM X 80MM -,SUP-LX351307805F,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5305,3713.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
LUTONIX PTA 5MM X 60MM X 75CM -,SUP-LX3575560V,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
LUTONIX BALLOON 7 X 80 -,SUP-LX3575780V,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
LUTONIX 8 X 80 -,SUP-LX3575880V,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B XXL 14MM 4CM 75 14-514 -,SUP-M001145140,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B CATH XXL VASC 12 X 6 X 75CM -,SUP-M001145300,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 14X60MM 2XL 75CM LPRO F/PTA PERIPH NYBAX LUB -,SUP-M001145320,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON XXL 16 X 4  5.8/120 -,SUP-M001145530,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON XXL 16 X 4 X 75 -,SUP-M001145530,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 16X60MM 2XL 75CM LPRO PERIPH NYBAX LUB BIOSLD CTD -,SUP-M001145540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B CATH XXL 18MM X 4CM 120CM -,SUP-M001145580,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH DIL 18MM 8FR SHEA 0.037IN TIP 5.8FRX75CM 6CM BLN GALWAY -,SUP-M001145590,CDM,C1725,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X40MM ULTR-THN DMD 75CM F/PTA PERIPH 5FR SHTH -,SUP-M001164230,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6X20MM ULTR-THN DMD 75CM F/PTA PERIPH 5FR SHTH -,SUP-M001164570,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 7X20MM ULTR-THN DMD 75CM F/PTA PERIPH 5FR SHTH -,SUP-M001164770,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B DUT 8MM 4CM 75CM  16-505 -,SUP-M001165050,CDM,C1725,HCPCS,272,RC,,,outpatient,,,950,665,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
AST-GN45 -,SUP-M001NC20000001,CDM,C1725,HCPCS,272,RC,,,outpatient,,,358.85,251.195,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 7X40MM POLAR 120CM COAX F/PTA CLD THRP PERIPH -,SUP-M001P740120010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2807.11,1964.977,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 7X60MM POLAR 120CM COAX F/PTA CLD THRP PERIPH -,SUP-M001P760120010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2807.11,1964.977,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 8X20MM POLAR 120CM COAX F/PTA CLD THRP PERIPH -,SUP-M001P820120010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
DEVICE INFL POLAR N2O -,SUP-M001PCIU400000,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4927.28,3449.096,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X40MM POLAR 150CM COAX F/PTA CLD THRP PERIPH -,SUP-M001T3040150010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X40MM POLAR 150CM COAX F/PTA CLD THRP PERIPH -,SUP-M001T4040150010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
RETRACTOR ORTHO HHMN 18MMX9.25IN STN FNSH SS V. MUELLER -,SUP-M001T5040135010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6X40MM POLAR 135CM COAX F/PTA CLD THRP PERIPH -,SUP-M001T6040135010,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4038.8,2827.16,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATHETER  SHOCKWAVE M5+ IVL CATHETER 5.0X60MM -,SUP-M5PIVL5060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATHETER SHOCKWAVE 5.5 X 60 MM M5+ -,SUP-M5PIVL5560,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATHETER- SHOCKWAVE M5+ IVL CATHETER- 6.0X60MM -,SUP-M5PIVL6060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATHETER- SHOCKWAVE M5+ IVL CATHETER- 7.0X60MM -,SUP-M5PIVL7060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATHETER- SHOCKWAVE M5+ IVL CATHETER- 8.0X60MM -,SUP-M5PIVL8060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP2006X NCEUPHORA RX -,SUP-NCEUP2006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP2008X NCEUPHORA RX -,SUP-NCEUP2008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP2012X NCEUPHORA RX -,SUP-NCEUP2012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP2015X NCEUPHORA RX -,SUP-NCEUP2015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP2020X NCEUPHORA RX -,SUP-NCEUP2020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP22506X NCEUPHORA RX -,SUP-NCEUP22506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP22508X NCEUPHORA RX -,SUP-NCEUP22508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP22512X NCEUPHORA RX -,SUP-NCEUP22512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP22515X NCEUPHORA RX -,SUP-NCEUP22515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP22520X NCEUPHORA RX -,SUP-NCEUP22520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP2506X NCEUPHORA RX -,SUP-NCEUP2506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP2508X NCEUPHORA RX -,SUP-NCEUP2508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP2512X NCEUPHORA RX -,SUP-NCEUP2512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP2515X NCEUPHORA RX -,SUP-NCEUP2515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP2520X NCEUPHORA RX -,SUP-NCEUP2520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP2527X NCEUPHORA RX -,SUP-NCEUP2527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP27506X NCEUPHORA RX -,SUP-NCEUP27506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP27508X NCEUPHORA RX -,SUP-NCEUP27508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP27512X NCEUPHORA RX -,SUP-NCEUP27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP27515X NCEUPHORA RX -,SUP-NCEUP27515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP27520X NCEUPHORA RX -,SUP-NCEUP27520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP27527X NCEUPHORA RX -,SUP-NCEUP27527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP3006X NCEUPHORA RX -,SUP-NCEUP3006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP3008X NCEUPHORA RX -,SUP-NCEUP3008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP3012X NCEUPHORA RX -,SUP-NCEUP3012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP3015X NCEUPHORA RX -,SUP-NCEUP3015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP3020X NCEUPHORA RX -,SUP-NCEUP3020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP3027X NCEUPHORA RX -,SUP-NCEUP3027X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP32506X NCEUPHORA RX -,SUP-NCEUP32506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP32508X NCEUPHORA RX -,SUP-NCEUP32508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP32512X NCEUPHORA RX -,SUP-NCEUP32512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP32515X NCEUPHORA RX -,SUP-NCEUP32515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP32520X NCEUPHORA RX -,SUP-NCEUP32520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP32527X NCEUPHORA RX -,SUP-NCEUP32527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP3506X NCEUPHORA RX -,SUP-NCEUP3506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP3508X NCEUPHORA RX -,SUP-NCEUP3508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP3512X NCEUPHORA RX -,SUP-NCEUP3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP3515X NCEUPHORA RX -,SUP-NCEUP3515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP3520X NCEUPHORA RX -,SUP-NCEUP3520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP3527X NCEUPHORA RX -,SUP-NCEUP3527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP37506X NCEUPHORA RX -,SUP-NCEUP37506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP37508X NCEUPHORA RX -,SUP-NCEUP37508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP37512X NCEUPHORA RX -,SUP-NCEUP37512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP37515X NCEUPHORA RX -,SUP-NCEUP37515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP37520X NCEUPHORA RX -,SUP-NCEUP37520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP37527X NCEUPHORA RX -,SUP-NCEUP37527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP4006X NCEUPHORA RX -,SUP-NCEUP4006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP4008X NCEUPHORA RX -,SUP-NCEUP4008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP4012X NCEUPHORA RX -,SUP-NCEUP4012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP4015X NCEUPHORA RX -,SUP-NCEUP4015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP4020X NCEUPHORA RX -,SUP-NCEUP4020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP4027X NCEUPHORA RX -,SUP-NCEUP4027X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP4508X NCEUPHORA RX -,SUP-NCEUP4508X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP4512X NCEUPHORA RX -,SUP-NCEUP4512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP4515X NCEUPHORA RX -,SUP-NCEUP4515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP4520X NCEUPHORA RX -,SUP-NCEUP4520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP5008X NCEUPHORA RX -,SUP-NCEUP5008X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP5012X NCEUPHORA RX -,SUP-NCEUP5012,CDM,C1725,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
BALLOON NCEUP5015X NCEUPHORA RX -,SUP-NCEUP5015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X6MM NC STRMR 138CM OTW NC COR 3- FOLD FLCRM + -,SUP-NCS2506W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X11MM NC STRMR 138CM OTW NC COR 3- FOLD FLCRM + -,SUP-NCS2511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS2514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.75X6MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS27506W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.75X11MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM -,SUP-NCS27511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.75X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS27514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.75X16MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS27516W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X6MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS3006W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X11MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS3011W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS3014W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X16MM NC STRMR 138CM OTW NC COR 4- FOLD FLCRM + -,SUP-NCS3016W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X11MM NC STRMR 138CM OTW NC COR 5- FOLD FLCRM -,SUP-NCS32511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS32514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X11MM NC STRMR 138CM OTW NC COR 5- FOLD FLCRM + -,SUP-NCS3511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X16MM NC STRMR 138CM OTW NC COR 5- FOLD FLCRM + -,SUP-NCS3516W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.75X11MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS37511W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.75X14MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM -,SUP-NCS37514W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X11MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS4011W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X16MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS4016W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X21MM NC STRMR 138CM OTW NC COR 6- FOLD FLCRM + -,SUP-NCS4021W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X6MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP2506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP2512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP2515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.75X6MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP27506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.75X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.75X21MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP27521X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X6MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT FLCRM -,SUP-NCSP3006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X21MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3021X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X12MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP32512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X15MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP32515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X27MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP3527X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.75X12MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP37512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.75X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP37515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X12MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X21MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4021X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4.5X15MM NC SPRINTR 142CM RX NC COR 3- FOLD SFT -,SUP-NCSP4515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5X15MM NC SPRINTR 138CM RX NC COR 3- FOLD SFT -,SUP-NCSP5015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
PALADIN CAROTID PTA CATHETER WITH INTEGRATED EMB PRO -,SUP-PD-5520-140-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATHETER ADVANCE MICRO 14 ULTRA LOW PROFILE BALLOON -,SUP-PTA3-14-90-2.5-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2289.76,1602.832,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATHETER PTA BALLOON DILATION 18LP ADVANCE LP 2MM X 20CM -,SUP-PTA4-18-150-2-20,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4MMX10CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-410,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4MMX6CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-4-8,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
B CATH ADVANCE 18LP 5X10 150 -,SUP-PTA4-18-150-510,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-5-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-5-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5MMX6CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-5-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6MMX10CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-610,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-6-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-6-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH ANG 4FR 0.018/ 150CM/6MM DIA 6CM ADVANCE RNL POPLT PTA -,SUP-PTA4-18-150-6-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 7MMX10CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-710,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 7MMX2CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-2,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 7MMX4CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-4,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 7MMX6CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-6,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 7MMX8CM ADVANCE 18LP 150CM LPRO LUMX2 F/PTA -,SUP-PTA4-18-150-7-8,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1431.08,1001.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 10MMX3CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH -,SUP-PTA5-35-135-103,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4MMX4CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-PTA5-35-135-44,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6MMX2CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-PTA5-35-13562.0,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 8MMX8CM ADVANCE 35LP 135CM LPRO F/PTA PERIPH D-SHP -,SUP-PTA5-35-135-8-8,CDM,C1725,HCPCS,272,RC,,,outpatient,,,916.04,641.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5MMX20CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-PTAX4141702.520,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3MMX12CM ADVANCE 14LP 170CM LPRO LUMX2 F/PTA -,SUP-PTAX414170312,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2175.8,1523.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 26MM 12FRX2.5CM INOUE 70CM PVC 0.025IN GW COMP -,SUP-PTMC-26,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10025.1,7017.57,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 28MM 12FRX2.5CM INOUE 70CM PVC 0.025IN GW COMP -,SUP-PTMC-28,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10025.1,7017.57,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 30MM 12FRX2.5CM INOUE 70CM PVC 0.025IN GW COMP -,SUP-PTMC-30,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10025.1,7017.57,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
SHOCKWAVE 3.0 X 40MM IVL KIT -,SUP-S4IVLK3040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ADV SERENITY 14 HYDROPHILIC PTA BALL DIL CATH 2.5X60X150CM -,SUP-SER14-150-25-60,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ADVANCE SERENITY 14 HYDROPHILIC PTA BALLOON DIL CATH -,SUP-SER14-150-30-60,CDM,C1725,HCPCS,272,RC,,,outpatient,,,1253.52,877.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.25X6MM SPRINTER LEGEND 152CM OTW SEM-COM COR -,SUP-SPL12506WL,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.25X6MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.25X10MM SPRINTER LEGEND 152CM OTW SEM-COM COR -,SUP-SPL12510WL,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.25X10MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12510X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.25X12MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.25X15MM SPRINTER LEGEND 152CM OTW SEM-COM COR -,SUP-SPL12515WL,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.25X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL12515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.5X6MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL15006X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.5X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL15012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.5X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL15015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL20012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL20015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X20MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL20020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X6MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL22506X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL22515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL25012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL25015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X20MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL25020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X25MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL25025X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.75X12MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL27512X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.75X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL27515X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.75X20MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL27520X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X12MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL30012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X15MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL30015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X20MM SPRINTER LEGEND 152CM RX SEM-COM COR -,SUP-SPL30020X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X12MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL40012X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X15MM SPRINTER LEGEND 142CM RX SEM-COM COR -,SUP-SPL40015X,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.5X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR1512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 1.5X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR1515W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2012W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2015W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X20MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2020W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X25MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2025W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.25X12MM SPRINTER 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR22512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X6MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2506W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2515W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5X20MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR2520W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.75X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR27512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.75X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR27515W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3012W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3015W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3X20MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3020W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.25X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR32512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3.5X12MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR3512W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X15MM SPRINTR 138CM OTW SEM-COM COR MINIWRAP- -,SUP-SPR4015W,CDM,C1725,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ENROUTE ENFLATE TRANSCAROTID RX BALLOON -,SUP-SR-4525-BC,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2008.89,1406.223,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
ENROUTE ENFLATE TRANSCAROTID RX BALLOON -,SUP-SR-5035-BC,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2008.89,1406.223,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH ANG 4FR STR 125CM TEMPO AQ SLCT BRD SHFT NO SH NYL -,SUP-SRD6667,CDM,C1725,HCPCS,272,RC,,,outpatient,,,269.58,188.706,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATHETER BALLOON TRUE FLOW 24 MM x 3.5CM REF: TF0243514 -,SUP-TF0243514,CDM,C1725,HCPCS,272,RC,,,outpatient,,,6153.8,4307.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CABLE ADPTR IABP -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,344.79,241.353,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH SHEATH RITESITE C315H1802 -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2X15MM 140CM OTW PERIPH -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4134.28,2893.996,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4X15MM 140CM OTW PERIPH -,SUP-UNDEFINED,CDM,C1725,HCPCS,272,RC,,,outpatient,,,4134.28,2893.996,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2MMX2CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V142020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V142040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 2.5MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V142540,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3MMX2CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V143020,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3319.12,2323.384,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V143040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 3MMX6CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V143060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4MMX12CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V1840120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 4MMX8CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V184080,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5MMX4CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V185040,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 5MMX6CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V185060,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATH PTCA 6MMX12CM VASCUTRAK 140CM RX F/PTA SEM-COM PERIPH -,SUP-V1860120,CDM,C1725,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
CATHETER PTV DILATATION 26MX4CM VIDA REF:VDA100264 -,SUP-VDA100264,CDM,C1725,HCPCS,272,RC,,,outpatient,,,2802.82,1961.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,19.650485,9184.66245,other,Non-Reimbursable Procedures,,
DILATOR 6-30FR DIA TIP 30CM PE/PTFE -,SUP-118768,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1395.36,976.752,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
LEAD DEFIB IMPL BIPLR PERMNT PCNG ETAK RELIANCE G_59CM -,SUP-5843,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
KT MNMTRY BLN ADLT RCTL BLN -,SUP-A86-1070,CDM,C1726,HCPCS,272,RC,,,outpatient,,,52.52,36.764,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CATH DIL 6MMX16MM RELIEVA ULTIRRA SIN 2LUM SHFT ENDO F/IRR -,SUP-BC0616RU,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3728.49,2609.943,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CATH DIL 6MMX16MM RELIEVA SOLO PRO SIN 2LUM SHFT ENDO F/IRR -,SUP-BC0616SP,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3265.42,2285.794,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
KIT CATHETER SURGILUBE VINYL PEDIATRIC FEMALE OD8 FR SOFT LF -,SUP-CKF105L,CDM,C1726,HCPCS,272,RC,,,outpatient,,,18.99,13.293,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
KIT CATHETER SURGILUBE VINYL PEDIATRIC FEMALE OD8 FR SOFT LF -,SUP-CKF105L,CDM,C1726,HCPCS,272,RC,,,outpatient,,,18.96,13.272,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
TRAY URETHRAL 8FR FEMALE VINYL PVP URINE COLLECTION DEVICE -,SUP-CKF105L,CDM,C1726,HCPCS,272,RC,,,outpatient,,,18.15,12.705,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
BALLOON CERVICAL RIPENING W/STYLET -,SUP-G19891,CDM,C1726,HCPCS,272,RC,,,outpatient,,,243.61,170.527,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
IMPLANT PIP MCP SZ5 SWNSN SIL -,SUP-G470-0005,CDM,C1726,HCPCS,272,RC,,,outpatient,,,4413.76,3089.632,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
HURRICANE RX 4 X 4 -,SUP-G49219,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
HURRICANE RX 6 X 4 -,SUP-G49220,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
HURRICANE RX 8 X 4 -,SUP-G49221,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
HURRICANE RX 10 X 4 -,SUP-G49222,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CATH DIL 7FR CATH 7-5FR TIP 200CM 2CM BLN FUSION BIL TAPR -,SUP-G49571,CDM,C1726,HCPCS,272,RC,,,outpatient,,,676.86,473.802,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CATH DIL 8.5FR CATH 8.5-6FR TAPR 200CM 2CM BLN FUSION BIL -,SUP-G49572,CDM,C1726,HCPCS,272,RC,,,outpatient,,,676.86,473.802,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CATH DIL 7FR TAPR 200CM 2CM BLN FUSION BIL DOME TIP ENDO -,SUP-G49573,CDM,C1726,HCPCS,272,RC,,,outpatient,,,676.86,473.802,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CATH PTCA 6X100MM MUSTNG 75CM LPRO BILUM SHFT NC PERIPH TAPR -,SUP-H74939171061070,CDM,C1726,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
BALLOON 2CM PERIPHERAL CUTTING -,SUP-M001PCB50201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
B CUTTING 5 X 2 X 135 -,SUP-M001PCB50201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CATH PTCA 5MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-M001PCB50201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
PERIPHERAL CUTTING BALLOON  5MM X 2CM  50CM -,SUP-M001PCB5020500,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
B 6 X 2 X 135 CUTTING BAL -,SUP-M001PCB60201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
B CUTTING 7 X 2 X 135 -,SUP-M001PCB70201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CATH PTCA 7MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-M001PCB70201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CATH PTCA 7X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-M001PCB7020900,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
B CUTTING 8 X 2 X 135 -,SUP-M001PCB80201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CATH PTCA 8MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-M001PCB80201350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CATH PTCA 8X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-M001PCB8020900,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CATH PTCA 1.5X3MM CUT BLN 140CM OTW PERIPH 0.018IN GW COMP -,SUP-M001PCBO3015140,CDM,C1726,HCPCS,272,RC,,,outpatient,,,4134.28,2893.996,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
B PERIPHERAL 6F 3.0X15X140 M00 -,SUP-M001PCBO3015140F0,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
B PER CUT OTW FLEX 4X15X140 M0 -,SUP-M001PCBO4015140F0,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CUTTING BALLOON 4MM X 1.5CM  X 135CM -,SUP-M001PCBO4015140F0,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CATH DIL 5.8FR 6MM BLN 180CM 4CM BLN HURRCN SS BIL RX ENDO -,SUP-M00545920,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CATH DIL 5.8FR 8MM BLN 180CM 4CM BLN HURRCN SS BIL RX ENDO -,SUP-M00545940,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1338.43,936.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CATHETER CHOLANGIOGRAM SPYGLASS 65CM CHOLANGIOSCOPY -,SUP-M00546780,CDM,C1726,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
DILATOR BLN 36-40.5-45FR OD BLN 75CM 5.5CM CRE ESPH WG ENDO -,SUP-M00550300,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1649.04,1154.328,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
DILATOR BLN 24-27-30FR OD BLN 75CM 3CM CRE ESPH WG ENDO -,SUP-M00550330,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1649.04,1154.328,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
DILATOR BLN 30-33-36FR OD BLN 75CM 3CM CRE ESPH WG ENDO -,SUP-M00550340,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1649.04,1154.328,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
DILATOR BALLOON 35MM RIGIFLEX -,SUP-M00554510,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3112.17,2178.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
DILATOR BLN 7.5FR 6-7-8 MMX180CM 5.5CM BLN CRE PEBAX ESPH FX -,SUP-M00556860,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CRE 8-10MM 8CM F/G -,SUP-M00558340,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CRE 10-12MM 8CM F/G -,SUP-M00558350,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CRE 12-15MM 8CM F/G -,SUP-M00558360,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
DILATOR BLN 6FR 12-13.5-15 MMX180CM 8CM BLN CRE PEBAX ESPH -,SUP-M00558360,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CRE 15-18MM 8CM F/G -,SUP-M00558370,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CRE 18-20MM 8CM F/G -,SUP-M00558380,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
DILATOR BLN 6FR 18-19-20 MMX180CM 8CM BLN CRE PEBAX ESPH FX -,SUP-M00558380,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1138.18,796.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
DILATOR WIREGUIDED CRE 15-18 180CM -,SUP-M00558430,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
DILATOR BLN 7.5FR 10-11-12 MMX240CM 5.5CM BLN CRE PEBAX ESPH -,SUP-M00558470,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
DILATOR BLN 7.5FR 12-13.5-15 MMX240CM 5.5CM BLN CRE PEBAX -,SUP-M00558480,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
DILATOR WIREGUIDED CRE 8-10 180CM -,SUP-M00558610,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
DILATOR WIREGUIDED CRE 10-12 180CM -,SUP-M00558620,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
DILATOR WIREGUIDED CRE 12-15 180CM -,SUP-M00558630,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CRE PRO WIREGUIDED 6-7-8MM 240CM -,SUP-M00558660,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CRE PRO WIREGUIDE 8-9-10MM 240 -,SUP-M00558670,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CRE PRO WIREGUIDE 10-11-12MM 240 -,SUP-M00558680,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CRE PRO WIREGUIDE 12-13.5-15MM 240 -,SUP-M00558690,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CRE PRO WIREGUIDE 15-16.5-18MM 240 -,SUP-M00558700,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
DILATOR BLN 7.5FR 15-16.5-18 MMX240CM 5.5CM BLN CRE PEBAX -,SUP-M00558700,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CRE PRO WIREGUIDE 18-19-20MM 240 -,SUP-M00558710,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1191.87,834.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CATH BILIARY BALLOON DILATATION CRE 8-10 3CM -,SUP-M00558920,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1517,1061.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CATH BILIARY BALLOON DILATATION CRE 10-12 3CM -,SUP-M00558930,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1517,1061.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CATH BILIARY BALLOON DILATATION CRE 12-15 3CM -,SUP-M00558940,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1517,1061.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CATH NEPH DIL 7FR 30FR BLN LPRO NPHRMX LF MRKR STPCK 17CM -,SUP-M0062101170,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1232.21,862.547,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CATH NEPH 7FR 10MM NPHRMX LF MRKR PTFE SHTH STPCK INFL DVC -,SUP-M0062101180,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1347.23,943.061,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CATH NEPH DIL 7FR 30FR BLN LPRO NPHRMX LF MRKR STPCK 20CM -,SUP-M0062101440,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1303.92,912.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CATH URET 4MM BLN 12FR INFL 3FR SHFT 150CM HYDRPLS CTD SS -,SUP-M0062181100,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1434.32,1004.024,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
PASSPORT BALLOON CATH 2CM -,SUP-M0062181200,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1540.27,1078.189,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CATH URET 5.8FRX4MM OD BLN 12FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251000,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1208.3,845.81,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
URO-MAX 2Q 4CM BALLOON KIT -,SUP-M0062251010,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1252.72,876.904,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CATH URET 5.8FRX10MM OD BLN 30FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251050,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1170.62,819.434,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
UROMAX 2/Q CATH 6CM 15FR SINGLE -,SUP-M0062251070,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1170.62,819.434,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CATH UROMAX U2Q\8-8 SINGLE -,SUP-M0062251100,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1170.62,819.434,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
UROMAX 2/Q CATH 10CM 15FR -,SUP-M0062251160,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1252.72,876.904,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CATH URET 5.8FRX6MM OD BLN 15FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251360,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1464.74,1025.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CATH URET 5.8FRX6MM OD BLN 18FR INFL 75CM HYDRPLS CTD TAPR -,SUP-M0062251370,CDM,C1726,HCPCS,272,RC,,,outpatient,,,1384.17,968.919,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
APPLICATOR ENDO BLN US F /BF-UC16F-OL8 LTX STRL -,SUP-MAJ-1351,CDM,C1726,HCPCS,272,RC,,,outpatient,,,191.19,133.833,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CUFF BLN ADLT ENDO US F -,SUP-MAJ-249,CDM,C1726,HCPCS,272,RC,,,outpatient,,,157.36,110.152,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CATH ESPH 4.2MMX1CM SPC HI-RESOLTN CHNLX36 MANOSCAN -,SUP-MSC-1286,CDM,C1726,HCPCS,272,RC,,,outpatient,,,25903.5,18132.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CATHETER HEMOSTATIC BALLOON NEXPOWDER -,SUP-NHS03,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CATH ATHRCMY PERIPH CUT BLN 4MMX140MM OTW PERIPH -,SUP-PCB04015140F,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3615.54,2530.878,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CATH PTCA 6MMX135CM SHFT PERIPH CUT BLN 20MM OTW PERIPH -,SUP-PCB6020135,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CATH PTCA 7X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-PCB702090,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
CATH PTCA 8X20MM CUT BLN 90CM OTW PERIPH 0.018IN GW COMP -,SUP-PCB802090,CDM,C1726,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.074675,18572.8095,other,Non-Reimbursable Procedures,,
HERNIA BALLOON #OMS-PDBS2 -,SUP-OMS-PDBS2,CDM,C1727,HCPCS,272,RC,,,outpatient,,,1296.65,907.655,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,291.097925,929.69805,other,Non-Reimbursable Procedures,,
CATH BRCHTX MULTLUM 4-5CM CONTURA STRL -,SUP-B01245,CDM,C1728,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,195.18479,8389.93965,other,Non-Reimbursable Procedures,,
APPLICATOR BRCHTX MULTLUM 5-6CM BLN CONTURA STRL SUD -,SUP-B01256,CDM,C1728,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,195.18479,8389.93965,other,Non-Reimbursable Procedures,,
CATH BRCHTX 5-6CM CONTURAFLEX LF -,SUP-B13256,CDM,C1728,HCPCS,272,RC,,,outpatient,,,10210.75,7147.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,195.18479,8389.93965,other,Non-Reimbursable Procedures,,
CATH BRCHTX F/CVTY MNTN CONTURA -,SUP-B90012,CDM,C1728,HCPCS,272,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,195.18479,8389.93965,other,Non-Reimbursable Procedures,,
TRY APPLICATOR BRCHTX SAVI 6-1 -,SUP-SAVI-06,CDM,C1728,HCPCS,272,RC,,,outpatient,,,9468.15,6627.705,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,195.18479,8389.93965,other,Non-Reimbursable Procedures,,
APPLICATOR BRCHTX SGL-ENTRY MUL-CATH SAVI PREP -,SUP-SPC-01,CDM,C1728,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,195.18479,8389.93965,other,Non-Reimbursable Procedures,,
CT/MR APPLICATOR W/BASE PLATE -,SUP-UNDEFINED,CDM,C1728,HCPCS,272,RC,,,outpatient,,,11701.45,8191.015,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,195.18479,8389.93965,other,Non-Reimbursable Procedures,,
DRAIN PENROSE19MM 30CM 32MM FLAT -,SUP-00000,CDM,C1729,HCPCS,272,RC,,,outpatient,,,4.14,2.898,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH NEPH PEZ 28FR EYEX2 PRPRTN HEAD LTX MSHRM SHP -,SUP-064028,CDM,C1729,HCPCS,272,RC,,,outpatient,,,44.17,30.919,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH NEPH MLCT 14FR WNGX4 LTX -,SUP-086014,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.82,46.074,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH MALECOT 18FR BARD -,SUP-086018,CDM,C1729,HCPCS,272,RC,,,outpatient,,,49.29,34.503,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH MALECOT 20FR BARD -,SUP-086020,CDM,C1729,HCPCS,272,RC,,,outpatient,,,49.29,34.503,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH MALECOT 22FR BARD -,SUP-086022,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.06,45.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH MALECOT 24FR BARD -,SUP-086024,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.07,45.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH MALECOT 34FR PROPORTIONATE HEAD LATEX -,SUP-086034,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.07,45.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH NEPH MLCT 38FR WNGX4 LTX -,SUP-086038,CDM,C1729,HCPCS,272,RC,,,outpatient,,,65.06,45.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH NEPH MLCT 40FR WNGX4 LTX -,SUP-086040,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.89,45.423,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
24FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14024,CDM,C1729,HCPCS,272,RC,,,outpatient,,,123.9,86.73,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
28FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14028,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
32 FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14032,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
36FR SILICONE THORACIC CATHETER STRAIGHT - ATRIUM -,SUP-14036,CDM,C1729,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH DRN 10.2FRX25CM SDPRTX6 COOK-COPE TY LCK LOOP -,SUP-192550,CDM,C1729,HCPCS,272,RC,,,outpatient,,,429.81,300.867,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH DRN 16FRX25CM SDPRTX6 COOK-COPE TY LCK LOOP -,SUP-193581,CDM,C1729,HCPCS,272,RC,,,outpatient,,,609.7,426.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH BIL DRN 12FRX40CM SDPRTX32 MA C -LOC LCK LOOP -,SUP-228702,CDM,C1729,HCPCS,272,RC,,,outpatient,,,545.51,381.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH DRN 12 FR X 25CM J-CRV THAL-QUICK PVC SDPRTX3 -,SUP-228707,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH DRN 14FRX25CM SDPRTX6 MA C -LOC LCK LOOP -,SUP-228709,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
TUBE VACUTNR 4ML GRN CAP NAHEP SAFTY PLST PPR LBL STRL HG-FR -,SUP-367871,CDM,C1729,HCPCS,272,RC,,,outpatient,,,0.94,0.658,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
THORACENTESIS TRAY/P4340A -,SUP-4340A,CDM,C1729,HCPCS,272,RC,,,outpatient,,,176.04,123.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
TRY THORCNTS 14GAX2IN L INTRO NDLX4 3WAY STP C LOCK BTRFLY -,SUP-4341B,CDM,C1729,HCPCS,272,RC,,,outpatient,,,228.45,159.915,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH VNTRC DRN 80CM TUOHY NDL FX TAB BLNT NDL STRN RLF OPN -,SUP-464-20,CDM,C1729,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
THORACENTESIS 30IN TUBING 4653 -,SUP-4653-48,CDM,C1729,HCPCS,272,RC,,,outpatient,,,23.96,16.772,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
SYS VNTRC DRN 35CM DUET W/ICP LN NDL-FR PRTX3 DRP CHMBR TBG -,SUP-469-13,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1120.58,784.406,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
SYS BAG VNTRC DRN REPL 35CM INTLNK NDL-FR INJ SITE -,SUP-469-14,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1120.58,784.406,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
KIT CSF DRAINAGE W CATH -,SUP-46916,CDM,C1729,HCPCS,272,RC,,,outpatient,,,2091.05,1463.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATHETER PLEURAL PLEURX KIT -,SUP-50-7000B,CDM,C1729,HCPCS,272,RC,,,outpatient,,,3841.3,2688.91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH WORD BARTHOLIN GLAND 10FR 5CM -,SUP-564000,CDM,C1729,HCPCS,272,RC,,,outpatient,,,104.15,72.905,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATHETER THORACIC 28F STRAIGHT -,SUP-8028,CDM,C1729,HCPCS,272,RC,,,outpatient,,,35.56,24.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATHETER THORACIC 32FR STERILE -,SUP-8032,CDM,C1729,HCPCS,272,RC,,,outpatient,,,35.05,24.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATHETER THORACIC 36F STRAIGHT -,SUP-8036,CDM,C1729,HCPCS,272,RC,,,outpatient,,,35.88,25.116,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATHETER THORACIC 24FR RT ANGL -,SUP-8124,CDM,C1729,HCPCS,272,RC,,,outpatient,,,57.26,40.082,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATHETER THORACIC  32F RT ANGLE -,SUP-8132,CDM,C1729,HCPCS,272,RC,,,outpatient,,,54.52,38.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
DRAIN CATH LUMBAR KTXTRN DRN 0.76MM 1.65MMX46CM -,SUP-82-1706,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1526.54,1068.578,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH VNTRC DRN 1.5MM BCTSL EVD SIL 0.15% CLNDMCN -,SUP-82-1745,CDM,C1729,HCPCS,272,RC,,,outpatient,,,2522.1,1765.47,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
DRAIN PENROSE 5/8 WND 0.625X12IN GRVTY  FLT LTX -,SUP-8888515007,CDM,C1729,HCPCS,272,RC,,,outpatient,,,223.25,156.275,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH TROCAR 12FR ARGYLE -,SUP-8888561027,CDM,C1729,HCPCS,272,RC,,,outpatient,,,106.84,74.788,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH TROCAR 20FR X 16 ARGYLE -,SUP-8888561043,CDM,C1729,HCPCS,272,RC,,,outpatient,,,78.42,54.894,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH TROCAR 28FR X 16 ARGYLE -,SUP-8888561068,CDM,C1729,HCPCS,272,RC,,,outpatient,,,110.81,77.567,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
KT DRN 20FRX10IN ARGYLE PVC GLVX2 PREP SWB /CUPX2 FEN DRAPE -,SUP-8888565036,CDM,C1729,HCPCS,272,RC,,,outpatient,,,192.93,135.051,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATHETER TROCAR KIT 28 FR NSQ -,SUP-8888565044,CDM,C1729,HCPCS,272,RC,,,outpatient,,,199.28,139.496,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH THORACIC 12FR MAR -,SUP-8888570507,CDM,C1729,HCPCS,272,RC,,,outpatient,,,55.61,38.927,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATHETER THORACIC 16FR -,SUP-8888570515,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.3,26.81,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH THORACIC 16FR MAR -,SUP-8888570515,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.3,26.81,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH THORACIC 20FR MAR -,SUP-8888570523,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.68,27.076,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
"CATHETER THORACIC 20FR X 20"" RADIOPAQUE 5 EYELETS -",SUP-8888570523,CDM,C1729,HCPCS,272,RC,,,outpatient,,,38.69,27.083,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATHETER THORACIC 24FR -,SUP-8888570531,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.15,27.405,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH THORACIC 24FR MAR -,SUP-8888570531,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.18,27.426,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATHETER THORACIC 28FR -,SUP-8888570549,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.44,27.608,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH THORACIC 28FR MAR -,SUP-8888570549,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.44,27.608,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH THORACIC 32FR MAR -,SUP-8888570556,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.85,27.895,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATHETER THORACIC 32FR -,SUP-8888570556,CDM,C1729,HCPCS,272,RC,,,outpatient,,,39.85,27.895,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATHETER THORACIC 36FR -,SUP-8888570564,CDM,C1729,HCPCS,272,RC,,,outpatient,,,40.26,28.182,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH THORACIC 36FR MAR -,SUP-8888570564,CDM,C1729,HCPCS,272,RC,,,outpatient,,,40.24,28.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH THORACIC 40FR MAR -,SUP-8888570572,CDM,C1729,HCPCS,272,RC,,,outpatient,,,40.63,28.441,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
TUBE CHEST RIGHT ANGLE 28 -,SUP-8888571042,CDM,C1729,HCPCS,272,RC,,,outpatient,,,77.11,53.977,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH THORCNTS 18FRX20IN LT VNTRC -,SUP-8888590216,CDM,C1729,HCPCS,272,RC,,,outpatient,,,193.84,135.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
KIT LUMBAR DRAINAGE CATH -,SUP-910121,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1076.58,753.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH DISTAL ATRIAL PERITONEAL SOPHYSA -,SUP-B905S,CDM,C1729,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATHETER VENTRICULAR STR 1.3 X 2.5 MM (INCL IN ITEM 0154508) -,SUP-BO19-10,CDM,C1729,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
TRAY CHEST TUBE 10FR THAL QUICK LUMX1 SDPRTX3 18GA ECHOTIP -,SUP-C-TQTSY-1000,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1096.98,767.886,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH PERFUS 12FR STR PVC -,SUP-EM012,CDM,C1729,HCPCS,272,RC,,,outpatient,,,263.92,184.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
EVACUATOR TBG UNIV ELLIK -,SUP-ET,CDM,C1729,HCPCS,272,RC,,,outpatient,,,74.71,52.297,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
BILIARY DRAINAGE CATH 8.5FR. -,SUP-G09497,CDM,C1729,HCPCS,272,RC,,,outpatient,,,545.51,381.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH BIL DRN 10.2FRX40CM MAC-LOC SDPRTX32 MA C -LOC LCK LOOP -,SUP-G09498,CDM,C1729,HCPCS,272,RC,,,outpatient,,,545.51,381.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH DRN 8.5FRX25CM LCK LOOP -,SUP-G09501,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH DRN 10FR NEPHROSTOMY TUBE -,SUP-G09502,CDM,C1729,HCPCS,272,RC,,,outpatient,,,493,345.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH MP DRAINAGE 10.2F 45CM UL -,SUP-G09766,CDM,C1729,HCPCS,272,RC,,,outpatient,,,554.27,387.989,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH DRN 12FRX45CM BND SDPRTX6 MA C -LOC LCK LOOP -,SUP-G09767,CDM,C1729,HCPCS,272,RC,,,outpatient,,,554.27,387.989,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH DRN 6FR UNIV 25CM CRV SDPRTX3 -,SUP-G10956,CDM,C1729,HCPCS,272,RC,,,outpatient,,,539.68,377.776,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
SET COLON DECOMPRESION 14FR -,SUP-G22181,CDM,C1729,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
Set Fuhrman Pleural Pneumopericardial Drainage -,SUP-G55723,CDM,C1729,HCPCS,272,RC,,,outpatient,,,711.87,498.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
Tray Fuhrman Pleural Pneumopericardial Drainage -,SUP-G55724,CDM,C1729,HCPCS,272,RC,,,outpatient,,,968.61,678.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
UNIV. LOOP DRAINAGE SET 10FR -,SUP-G55802,CDM,C1729,HCPCS,272,RC,,,outpatient,,,887.5,621.25,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
UNIV.  LOOP DRAINAGE SET 14FR X 30 -,SUP-G55804,CDM,C1729,HCPCS,272,RC,,,outpatient,,,887.5,621.25,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
ST UNIVERSA MALEOCOT16FRX22CM BLN SS NDL OBTR CON TUBE 3ML -,SUP-G55825,CDM,C1729,HCPCS,272,RC,,,outpatient,,,307.21,215.047,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
TRAY WAYNE PNEUMOTHORAX CATHETER 14.0 FR 29 CM -,SUP-G56537,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1250.92,875.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH PERC DRN 8FRX25CM STD LOOP TIP EXODUS LF -,SUP-H965101431,CDM,C1729,HCPCS,272,RC,,,outpatient,,,511.85,358.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH DRN 10FRX20CM EXODUS LF -,SUP-H965101511,CDM,C1729,HCPCS,272,RC,,,outpatient,,,511.85,358.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATHETER DRN 8FRX25CM EXODUS TIGHT TIP LOOP -,SUP-H965104031,CDM,C1729,HCPCS,272,RC,,,outpatient,,,537.4,376.18,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH DRN 10FRX25CM EXODUS TIGHT TIP LOOP -,SUP-H965104111,CDM,C1729,HCPCS,272,RC,,,outpatient,,,537.4,376.18,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH MULTIPURPOSE 14FR  25CM STD ;OOP W/MARKER BAND -,SUP-H965105621,CDM,C1729,HCPCS,272,RC,,,outpatient,,,2440.88,1708.616,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
SYSTEM EXTERNAL DRAINAGE WITHOUT VENTRICULAR CATH ACCUDRAIN -,SUP-INS8401,CDM,C1729,HCPCS,272,RC,,,outpatient,,,1401.56,981.092,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH NEPH 14FR VTC -,SUP-M001245290,CDM,C1729,HCPCS,272,RC,,,outpatient,,,570.95,399.665,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH DRN 6FRX25CM PIGTL FOGARTY LOOP -,SUP-M001271380,CDM,C1729,HCPCS,272,RC,,,outpatient,,,468.26,327.782,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH DRN MP 10FR UNIV 30CM LCK PIGTL HUB LOCK CANN NTNL NAVR -,SUP-NNU10LPT,CDM,C1729,HCPCS,272,RC,,,outpatient,,,661.69,463.183,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
DRAIN SURG 30CM 12FR UNIV NTNL PIGTL MP -,SUP-NNU12LPT,CDM,C1729,HCPCS,272,RC,,,outpatient,,,661.69,463.183,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATH DRN MP 8FR UNIV 30CM NTNL LCK PIGTL HUB LOCK CANN NAVR -,SUP-NNU8LPT,CDM,C1729,HCPCS,272,RC,,,outpatient,,,661.69,463.183,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
KIT PERICARDIOCENTESIS 6F PIGTAIL CATH -,SUP-PC101,CDM,C1729,HCPCS,272,RC,,,outpatient,,,542.95,380.065,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
KT PERICRDCTS PIGTL 8.3FRX40CM ACC LF -,SUP-PC801,CDM,C1729,HCPCS,272,RC,,,outpatient,,,676.86,473.802,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
VALVE POLARIS ADJ 30-200 SHUNT WITH ITEM BO19-10 INCL -,SUP-SPVA-2010,CDM,C1729,HCPCS,272,RC,,,outpatient,,,14425.01,10097.507,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
CATHETER FIXATION SYSTEM 8F -,SUP-TFK-08,CDM,C1729,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
TRAY THORACENTESIS PARACENTESIS -,SUP-TPT1000SP,CDM,C1729,HCPCS,272,RC,,,outpatient,,,195.82,137.074,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.21103,10342.73217,other,Non-Reimbursable Procedures,,
ELECTRODE PCNG 5FRX110CM BIPLR NON- HEP BND -,SUP-006173P,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1018.79,713.153,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures,,
CATH QUAD  MARINR-MDT -,SUP-072322M,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1378.13,964.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures,,
CATH EP P- TY CRV 5FR 2-8-2MM SPC 110CM DECAPL MP POLEX10 -,SUP-1085122RT,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1505.34,1053.738,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures,,
CATH ACHIEVE ADVANCE 2ACH20 MAPPING -,SUP-2ACH20,CDM,C1730,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures,,
CATH ACHIEVE ADVANCE 2ACH20 REPROCESS MAPPING -,SUP-2ACH20,CDM,C1730,HCPCS,272,RC,,,outpatient,,,2983.75,2088.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures,,
CATH EP RESPONSE CRD-SJM QUAD 6FR -,SUP-401226,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures,,
CATH RESPONSE CRD -REPROC QUAD 6FR -,SUP-401226,CDM,C1730,HCPCS,272,RC,,,outpatient,,,185.14,129.598,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures,,
CATH EP RESPONSE JSN -SJM QUAD  6FR -,SUP-401227,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures,,
CATH RESPONSE JSN-REPROC 6FR -,SUP-401227,CDM,C1730,HCPCS,272,RC,,,outpatient,,,185.14,129.598,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures,,
CATH EP RESPONSE CRD-SJM  DECAPOLAR -,SUP-401305,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1081.3,756.91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures,,
CATH RESPONSE DEC CSL-REPROC -,SUP-401381,CDM,C1730,HCPCS,272,RC,,,outpatient,,,349.87,244.909,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures,,
CATH EP RESPONSE CSL-SJM 6FR  DECAPOLAR  STEER -,SUP-401381,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures,,
CATH EP SPRM JSPHSN CRV 6FR 2-5-2MM ELCTRD SPC 120CM FX QDPL -,SUP-401451,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures,,
CATH EP LIVEWIRE MED SWEEP-REPROC DECAPOLAR -,SUP-401575,CDM,C1730,HCPCS,272,RC,,,outpatient,,,588.34,411.838,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures,,
CATH EP LIVEWIRE MED SWEEP-SJM DECAPOLAR -,SUP-401575,CDM,C1730,HCPCS,272,RC,,,outpatient,,,2056.59,1439.613,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures,,
CATH EP LIVEWIRE LRG SWP-SJM  QUAD STEERABLE  2-5-2 -,SUP-401606,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1876.38,1313.466,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures,,
CATH LIVEWIRE QUAD STEERABLE REPROC -,SUP-401606,CDM,C1730,HCPCS,272,RC,,,outpatient,,,593.19,415.233,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures,,
BIPOLAR PACING CATH BALLOON TIP 5 FR 110CM- PACEL REF:401763 -,SUP-401763,CDM,C1730,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures,,
CATH  LIVEWIRE 7F DUO SUPER LRG CURL-REPROC 2/10 -,SUP-401904,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1154.02,807.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures,,
CATH EP LIVEWIRE SUPER LRG CURL- SJM DECA 2-10-2 -,SUP-401904,CDM,C1730,HCPCS,272,RC,,,outpatient,,,4392.08,3074.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures,,
CATH LIVEWIRE MED CRL-REPROC 2-2-2 NO SPACE -,SUP-401908,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1591.63,1114.141,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures,,
CATH EP  LIVEWIRE EXTRA LGE CURL-SJM  DECAPL 2-5-2 -,SUP-401915,CDM,C1730,HCPCS,272,RC,,,outpatient,,,2258.01,1580.607,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures,,
CATH EP LIVEWIRE EXTRA LGE CURL-REPROC  DECAPL 2-5-2 -,SUP-401915,CDM,C1730,HCPCS,272,RC,,,outpatient,,,612.91,429.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures,,
CATH  LIVEWIRE DUO DEC SUPER LGE CURL-REPROC 2-8-2-60-2-8-2 -,SUP-401932,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1208.14,845.698,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures,,
CATH EP LIVEWIRE LRG SWP -REPROC  QUAD STEER 5-5-5 NO SPACE -,SUP-401934,CDM,C1730,HCPCS,272,RC,,,outpatient,,,593.19,415.233,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures,,
CATH EP LIVEWIRE LRG SWP -SJM  QUAD STEER 5-5-5 NO SPACE -,SUP-401934,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1876.38,1313.466,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures,,
CATH EP SUPREME CRD-2 -SJM QUAD -,SUP-402004,CDM,C1730,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures,,
CATH RESPONSE CRD-2 REPROC 6FR -,SUP-402004,CDM,C1730,HCPCS,272,RC,,,outpatient,,,193.84,135.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures,,
INQUIRY STEERABLE  SJM EP CATH 6FR -,SUP-81102,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures,,
CATH 20MM ACHIEVE MAPPING EP CRV 3.3FRX6MM SPC 165CM BIPLR -,SUP-990063020,CDM,C1730,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures,,
MEDIGUIDE LV CATH MED SWEEP MODEL D402058 -,SUP-D402058,CDM,C1730,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures,,
ADVISOR HD GRID MAPPING CATHETER D-AVHD-DF 16 REPRO -,SUP-D-AVHD-DF-16,CDM,C1730,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures,,
ADVISOR HD GRID MAPPING CATHETER D-AVHD-DF16 -,SUP-D-AVHD-DF-16,CDM,C1730,HCPCS,272,RC,,,outpatient,,,9090.65,6363.455,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures,,
EPSTAR CATHETER DCF-2-8-55-130 -,SUP-DCF-2-8-55-130,CDM,C1730,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures,,
CATHETER INQUIRY STEER 4 FR DEC 1110-4-2-M IBI-81530 -,SUP-IBI-81530,CDM,C1730,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures,,
CATH EP POLARISX270DG ANG 6FR 2.5-5-2.5MM SPC 105CM QDPL -,SUP-M0047003D0,CDM,C1730,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.56393,6517.99605,other,Non-Reimbursable Procedures,,
BLAZER DX -20 CATHETER SUPERLARGE CURVE -,SUP-20SL2860,CDM,C1731,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,4619.19363,other,Non-Reimbursable Procedures,,
CATH EP LIVEWIRE MED CURL-SJM  2-2-2 -,SUP-401908,CDM,C1731,HCPCS,272,RC,,,outpatient,,,4392.08,3074.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,4619.19363,other,Non-Reimbursable Procedures,,
CATH EP LIVEWIRE SUPER LGE CURL-SJM 2-8-2-60-2-8-2 -,SUP-401932,CDM,C1731,HCPCS,272,RC,,,outpatient,,,4596.25,3217.375,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,4619.19363,other,Non-Reimbursable Procedures,,
CATH EP REFLEXION SPIRAL SJM -,SUP-D402893,CDM,C1731,HCPCS,272,RC,,,outpatient,,,6442.39,4509.673,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,4619.19363,other,Non-Reimbursable Procedures,,
CATH ABLT BLAZER D X-20 SUPER LRG 7FR SHFT 2-10-2MM SPC -,SUP-M00420SL21020,CDM,C1731,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,4619.19363,other,Non-Reimbursable Procedures,,
CATH ACHIEVE ADVANCE 2ACH15 MAPPING -,SUP-2ACH15,CDM,C1732,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures,,
CATH ACHIEVE ADVANCE 2ACH15 REPROCESS MAPPING -,SUP-2ACH15,CDM,C1732,HCPCS,272,RC,,,outpatient,,,2983.75,2088.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures,,
CATH ACHIEVE ADVANCE 2ACH25  MAPPING -,SUP-2ACH25,CDM,C1732,HCPCS,272,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures,,
SOFTWARE MED ENSITE FUSION REGST MOD XPD F/SEG CT -,SUP-75-05772-001,CDM,C1732,HCPCS,272,RC,,,outpatient,,,27847.5,19493.25,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures,,
CATHETER PVAC GOLD - REF:990078 -,SUP-990078,CDM,C1732,HCPCS,272,RC,,,outpatient,,,25991,18193.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures,,
CATH ABLT THERMOCOOL SF CARTO XP D-F CRV 8FR 2-5-2MM SPC -,SUP-BNI35DFH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,11324.65,7927.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures,,
CATH ABLT THERMOCOOL SF NAV F-J CRV 8FR 2-5-2MM SPC 115CM -,SUP-BNI35FJH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,11324.65,7927.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures,,
CATH EP LASSO NAV ECO D-TYP CRV 7FR 4FR LOOP 25-15MM 2-6-2MM -,SUP-D134301,CDM,C1732,HCPCS,272,RC,,,outpatient,,,7257.24,5080.068,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures,,
CATH EP WEBSTER CS CS-D CRV 6FR 2-8-2MM SPC 115CM SGL-BRD -,SUP-D135303,CDM,C1732,HCPCS,272,RC,,,outpatient,,,2644.95,1851.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures,,
CATH EP WEBSTER CS CS-F CRV 6FR2MM TIP 2-8-2MM SPC 115CM FX -,SUP-D135304,CDM,C1732,HCPCS,272,RC,,,outpatient,,,2014.19,1409.933,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures,,
CATH ABLT NAVISTAR C F-TY CRV 7FR EP -,SUP-D17TCFLRT,CDM,C1732,HCPCS,272,RC,,,outpatient,,,7057.77,4940.439,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures,,
POLARX FIT BALLOON CATHETER ST REF:M004CRBS2060 -,SUP-M004CRBS2060,CDM,C1732,HCPCS,272,RC,,,outpatient,,,14852,10396.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures,,
POLARX FIT BALLOON CATHETER LT REF:M004CRBS2160 -,SUP-M004CRBS2160,CDM,C1732,HCPCS,272,RC,,,outpatient,,,14852,10396.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures,,
CATH POLARMAP CIRCULAR DX MAPPING CATHETER REF:M004CRBS7210 -,SUP-M004CRBS7210,CDM,C1732,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures,,
CATHETER INTELLANAV ST 7/110/2.5/7-4 QUAD STD -,SUP-M004R5031TH0,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures,,
CATHETER INTELLANAV ST K2 7/110/2.5/7-4 QUAD -,SUP-M004R5031THK20,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures,,
INTELLAMAP ORION CATHETER M004RC64S0 -,SUP-M004RC64S0,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures,,
CATH ABLT NAVISTAR THERMOCOOL D-CRV 8FR 2-5-2MM SPC 115CM -,SUP-NI75TCDH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures,,
CATH ABLT THERMOCOOL F-TY CRV 7.5FR 2-5-2MM SPC 115CM COOL -,SUP-NI75TCFH,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures,,
CATH ABLT NAVISTAR C D-TYP CRV 7FR 1-7-4MM SPC 4MM TIP 115CM -,SUP-NS7TCDL174HS,CDM,C1732,HCPCS,272,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures,,
CATH ABLT NAVISTAR DS F-TY CRV 7FR 1-7-4MM SPC 8MM TIP 115CM -,SUP-NS7TCF8L174HS,CDM,C1732,HCPCS,272,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures,,
CATH ABLT NAVISTAR F-TY CRV 7FR 1-7-4MM SPC 4MM TIP 115CM -,SUP-NS7TCFL174HS,CDM,C1732,HCPCS,272,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,19966.6575,other,Non-Reimbursable Procedures,,
CATH ABLT FREEZOR 4MM TIP MDT -,SUP-207F3,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
CATH CRYABL FREEZOR MAX CRV 9FR 3-5-2MM SPC 90CM STEER BIDIR -,SUP-209F3,CDM,C1733,HCPCS,272,RC,,,outpatient,,,9124.6,6387.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
CATH ABLT FREEZOR XTRA 6MM 7FR 2-5-2MM SPC 108CM -,SUP-217F3,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
CATH ABLT FREEZOR XTRA LG CURVE 6MM 7FR REF:217F5 -,SUP-217F5,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
CATH CRYABL ARCTIC FRN 23MM STEER BIDIR EP -,SUP-2AF234,CDM,C1733,HCPCS,272,RC,,,outpatient,,,16337.2,11436.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
CATH CRYABL ARCTIC FRN 28MM STEER BIDIR EP -,SUP-2AF284,CDM,C1733,HCPCS,272,RC,,,outpatient,,,16337.2,11436.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
CATH ESPH ABLT 18MM 360DG ELCTRD ARRAY 85CM BARRX RF -,SUP-32041-18,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8339.46,5837.622,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
CATH PCNG 5FRX2.5CM SPC 110CM PACEL TEMP BIPLR 60DG CRV RT -,SUP-401775,CDM,C1733,HCPCS,272,RC,,,outpatient,,,513.48,359.436,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
CATH ABLT SAFIRE MED SWP 7FR 2-5-2MM SPC 115CM QDPL BIDIR -,SUP-402807,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3010.01,2107.007,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
CATH ABL SAFIRE LRG SWP 7FR -,SUP-402808,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3208.13,2245.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
CATH SAFIRE 7F 4MM SM CRL US -,SUP-402809,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3010.01,2107.007,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
CATH ABLT SAFIRE MED CURL 7FR 2-5-2MM SPC 115CM 7MM BIDIR -,SUP-402810,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3208.13,2245.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
CATH ABLT SAFIRE LRG CRV 7FR 2-5-2MM SPC 115CM QDPL BIDIR -,SUP-402811,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3208.13,2245.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
CATH ABLT SAFIRE LRG CRV 7FR 2-5-2MM 115CM 5MM QDPL BIDIR -,SUP-402817,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3232,2262.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
CATH SAFIRE TX  MED 7F 8 MM BI-DIR -,SUP-402839,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4501.88,3151.316,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
CATH SAFIRE TX  LRG  BI-DIR  7F 8MM -,SUP-402840,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4501.88,3151.316,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
FARAWAVE PFA CATHETER REF:41C601 -,SUP-41C601,CDM,C1733,HCPCS,272,RC,,,outpatient,,,25062.75,17543.925,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
FARAWAVE PFA CATHETER 35MM REF:41C602 -,SUP-41C602,CDM,C1733,HCPCS,272,RC,,,outpatient,,,25062.75,17543.925,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
CATHETER BARRX RFA EXPRESS RFA BALLOON -,SUP-64082,CDM,C1733,HCPCS,272,RC,,,outpatient,,,10218.18,7152.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
CATH ABLT THRP 7FR 2-5-2 MMMEDX110CM 4MM -,SUP-83365,CDM,C1733,HCPCS,272,RC,,,outpatient,,,2491.24,1743.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
CATH ABLT THRP 7FR 2-5-2 MMX110CM 4MM -,SUP-83366,CDM,C1733,HCPCS,272,RC,,,outpatient,,,2634.35,1844.045,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
CATH ABLT THRP 2-5-2 MMMEDX110CM DL -8 -,SUP-83371,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
CATH ABLT THRP 7FR MED 8MM DL -,SUP-83372,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3542.31,2479.617,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
CATH ABLT THRP DL -8 EXTEND REACH CRV 7FR 2-5-2MM SPC 110CM -,SUP-83374,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
CATHETER BARRX FOCAL 90 RFA 20MMX 13MM -,SUP-90-9100,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8492.24,5944.568,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
CATHETER BARRX FOCAL 90 RFA 40MM X 13MM -,SUP-90-9500,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7469.44,5228.608,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
CATH ABLT SAFIRE BLU LRG CURL DIST REACH CRV 7FR 2-5-2MM SPC -,SUP-A088109,CDM,C1733,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
CATH CRYABL ARCTIC FRN ADVANCED PRO 28MM STEER BIDIR EP -,SUP-AFAPRO28,CDM,C1733,HCPCS,272,RC,,,outpatient,,,16337.2,11436.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
FLEXABILITY SENSOR ENABLED BI DIR IRR CATH FJ CURVE -,SUP-A-FASE-FJ,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8190.92,5733.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
CATH 7F D/F BI-DIRECT CS REPROC -,SUP-BD710DF282RTS,CDM,C1733,HCPCS,272,RC,,,outpatient,,,1132.05,792.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
CATH ABLT WEBSTER EZ STEER D-F ASYM CRV 7FR 2-8-2MM SPC -,SUP-BD710DF282RTS,CDM,C1733,HCPCS,272,RC,,,outpatient,,,3547.08,2482.956,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
CATH CV 7FRX3CM SIL CLSR FST LF ACC -,SUP-CF7-3-60,CDM,C1733,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
CATH ELCSURG 7FRX60CM RF FLXB CLSR FST -,SUP-CF7-7-60,CDM,C1733,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
AGILLIS NXT STEERABLE INTRO DUAL-REACH REF: I-V2-MED -,SUP-I-V2-MED,CDM,C1733,HCPCS,624,RC,,,outpatient,,,5.89,4.123,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.523743,1.322305,17969.99175,percent of total billed charges,,,
CATH ABLT BLAZER II STD CRV 7FRX2.5MM SPC 4MM TIP QDPL DIST -,SUP-M0045031TH0,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
CATH ABLT BLAZER II STD CRV 7FRX2.5MM SPC QDPL EXTEND DIST -,SUP-M0045086TL0,CDM,C1733,HCPCS,272,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
CATH ABLT BLAZER PRIM XP LRG CRV 8MM TIP QDPL EP -,SUP-M004P4500THK20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7427,5198.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
CATH ABLT BLAZER PRIM XP STD CRV STR 7FR 8FR TIP 2.5MM SPC -,SUP-M004P4790TH0,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7639.2,5347.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
CATH ABLT BLAZER PRIM XP LRG CRV 10mm  8FRX2.5MM SPC 110CM -,SUP-M004P4790THK20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,7639.2,5347.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
CATH ABLT BLAZER PRIM HTD ASYM CRV 7FRX2.5MM SPC 110CM QDPL -,SUP-M004P5031THN40,CDM,C1733,HCPCS,272,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
CATH ABLT INTELLATIP MIFI XP STD CRV STR 7FR 8FR TIP 2.5MM -,SUP-M004PM45000,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
CATH ABLT INTELLATIP MIFI XP LRG CRV STR 7FR 8FR TIP 2.5MM -,SUP-M004PM4500K20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
CATHETER INTELLANAV MIFI OI 7.5/110/2.5.4.5 STD -,SUP-M004PMR96200,CDM,C1733,HCPCS,272,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
CATHETER INTELLANAV MIFI K2 OI 7.5/110/2.5/4.5 -,SUP-M004PMR9620K20,CDM,C1733,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
PULSESELECT PFA LOOP CATHETER REF: PSCC100 -,SUP-PSCC100,CDM,C1733,HCPCS,272,RC,,,outpatient,,,23763.2,16634.24,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.322305,17969.99175,other,Non-Reimbursable Procedures,,
VOLT PFA CATHETER REF: P-SPI-DF8 -,SUP-VOLT PFA CATHETER REF: P-SPI-DF8,CDM,C1733,HCPCS,624,RC,,,outpatient,,,5.89,4.123,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.523743,1.322305,17969.99175,percent of total billed charges,,,
CATHETER 27CM GLIDEPATH LONG TERM HEMO -,SUP-5393270,CDM,C1750,HCPCS,278,RC,,,outpatient,,,2210.31,1547.217,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures,,
CATH HMDLYS HEMOSPLIT 14.5FRX31CM -,SUP-5733310,CDM,C1750,HCPCS,278,RC,,,outpatient,,,2390.53,1673.371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures,,
CATH SHNT 1.2X2.5MM HLTR 65CM SIL RBR T-SHP 1PC -,SUP-82-1699,CDM,C1750,HCPCS,278,RC,,,outpatient,,,2533.64,1773.548,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures,,
CATH PERITONEALTENCKHOFF42CM -,SUP-8810888003,CDM,C1750,HCPCS,278,RC,,,outpatient,,,255.92,179.144,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures,,
CATH TENCKHOFF 15FRX62CM -,SUP-8811313010,CDM,C1750,HCPCS,278,RC,,,outpatient,,,366.38,256.466,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures,,
KIT CATHETER PERITONEAL DIALYSIS ARGYLE 62CM SILICONE CURLED -,SUP-8817278006,CDM,C1750,HCPCS,278,RC,,,outpatient,,,450.39,315.273,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures,,
KT DLYS 60CM CURL STYL 60CM PREPERITONEIAL CUF CLMP ADPTR -,SUP-8817278010,CDM,C1750,HCPCS,278,RC,,,outpatient,,,537.58,376.306,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures,,
KT HMDLYS PRMCTH 36CM SIL RBR LUMX2 -,SUP-8817748001,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1012.58,708.806,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures,,
CATH HMDLYS MHRKR 11.5FRX16CM PU ACUTE LUMX2 ACC -,SUP-8817749001,CDM,C1750,HCPCS,278,RC,,,outpatient,,,923.47,646.429,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures,,
CATH HMDLYS PALINDROME 14.5FRX19CM -,SUP-8888119360P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1259.4,881.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures,,
KIT CATHETER PALINDROME 14.5FR X 19CM -,SUP-8888145014P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures,,
KIT CATHETER PALINDROME 14.5FR X 23CM -,SUP-8888145015P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures,,
KIT CATHETER PALINDROME 14.5FR X 28CM -,SUP-8888145016P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures,,
KIT CATHETER PALINDROME 14.5FR X 33CM -,SUP-8888145042P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1360.15,952.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures,,
STENCIL PERITONEAL DIALYSIS RITUS PRE-OPERATIVE -,SUP-8888412305,CDM,C1750,HCPCS,278,RC,,,outpatient,,,55.72,39.004,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures,,
KIT CATHETER PERITONEAL DIALYSIS ARGYLE 62.5CM SILICONE -,SUP-8888413823,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1150.95,805.665,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures,,
KT HMDLYS PALINDROME 15FRX43CM CRBTHN ACC -,SUP-8888541023P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1612.03,1128.421,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures,,
KT HMDLYS PALINDROME 15FRX48CM CRBTHN ACC -,SUP-8888541028P,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1612.03,1128.421,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures,,
CATH TESIO LEFT BFL-6 -,SUP-BFL-6,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1595.45,1116.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures,,
CATH HMDLYS BFL TSO 10FR 22CM/25CM CUF -,SUP-BFR-6,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1690.86,1183.602,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures,,
ST HMDLYS TESIO 10FRX52CM PU LUMX2 INTRO NDL GW TUNNLER -,SUP-BFR-6E,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1881.68,1317.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures,,
CATH ARROW NEXT STEP 23CM HEMODIALYSIS -,SUP-CS-15232-X,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1436.44,1005.508,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures,,
CATH ARROW NEXT STEP 27CM HEMODIALSIS -,SUP-CS-15272-X,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1436.44,1005.508,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures,,
CATHETER KIT DIALYSIS 15FR ARROW -,SUP-CS-15282-SPM,CDM,C1750,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.50914,1945.83552,other,Non-Reimbursable Procedures,,
HC Try Cv Lumx3 5fr Triple Powerpicc Acc,PX-27200312,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1544,1080.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
HC Needle Provena 4fr Dl Picc 4fr Dl Max Barrier,PX-27200313,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1417,991.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
HC Needle Provena 4fr Dl Provena Midline Max Barrier,PX-27200314,CDM,C1751,HCPCS,272,RC,,,outpatient,,,967,676.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
HC Cath Cv Lumx2 4frx20 Cm Dual Mdln,PX-27200315,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1012,708.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
HC Needle Provena 3fr Sl Provena Midline Max Barrier,PX-27200316,CDM,C1751,CPT,272,RC,,,outpatient,,,831,581.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
KIT URETERAL IRIS INFRARED -,SUP-0220180518,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1863.01,1304.107,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
TRY CV LUMX2 9FRX90CM SIL PED HKMN LF ACC -,SUP-0600604,CDM,C1751,HCPCS,272,RC,,,outpatient,,,2291.14,1603.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH SWAN GANZ TD 6FR X 110 - 096F6P -,SUP-096F6P,CDM,C1751,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH GUIDE ECHELON 14 MICRO STR AIGHT REF:105-5092-150 -,SUP-105-5092-150,CDM,C1751,HCPCS,272,RC,,,outpatient,,,4838.16,3386.712,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
TRY CV LUMX1 4FR PU POWERPICC LF ACC SINGLE -,SUP-1174108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1252.61,876.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
5FR POWERPICC TRAY CV LUMX2 DBL PU  LF ACC -,SUP-1275108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1232.53,862.771,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH SWAN GANZ TD 7FR 131F7P -,SUP-131F7P,CDM,C1751,HCPCS,272,RC,,,outpatient,,,501.81,351.267,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATHETER IV JELCO PROTECTIV 24G X 3/4IN YELLOW -,SUP-305306,CDM,C1751,HCPCS,272,RC,,,outpatient,,,12.2,8.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATHETER IV WINGED HUB PEDI 24G X 5/8â€ PERIPHERAL RADIOPAQUE -,SUP-307300,CDM,C1751,HCPCS,272,RC,,,outpatient,,,11.94,8.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
TRY CV LUMX1 5FRX55CM PU POWERPICC LF ACC -,SUP-3175155,CDM,C1751,HCPCS,272,RC,,,outpatient,,,456.94,319.858,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH IV PROTECTIVE 22 X 1 -,SUP-326010,CDM,C1751,HCPCS,272,RC,,,outpatient,,,12.05,8.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH IV PROT 22GAX1IN FEP PLYMR SAFTY STR HUB WNG INDWL VPNT -,SUP-326010,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.66,7.462,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH IV PROTECTIVE 24 X 3/4 RA -,SUP-326310,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.68,7.476,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH IV PROT 24GAX.75IN FEP PLYMR SAFTY STR HUB WNG INDWL -,SUP-326310,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.68,7.476,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH IV PROTECTIVE 20 X 1 -,SUP-326710,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.28,6.496,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH IV PROT 20GAX1IN FEP PLYMR SAFTY STR HUB WNG INDWL VPNT -,SUP-326710,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.28,6.496,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH IV 14GA X 1.25 IN VIAVALVE -,SUP-3268,CDM,C1751,HCPCS,272,RC,,,outpatient,,,12.05,8.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
TRY CV LUMX2 5FRX55CM PU POWERPICC LF ACC -,SUP-3275335,CDM,C1751,HCPCS,272,RC,,,outpatient,,,602.11,421.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH IV ANGIOCATH 14 X 1.88 -,SUP-381167,CDM,C1751,HCPCS,272,RC,,,outpatient,,,22.71,15.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH IV 24G X .56 IN INSYTE BD -,SUP-381411,CDM,C1751,HCPCS,272,RC,,,outpatient,,,14.41,10.087,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH IV INSYT AUTOGRD 20GAX48MM VIALON SAFTY WNG INDWL BLD -,SUP-381437,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.86,6.902,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH IV 20G X 1.88 IN INSYTE BD -,SUP-381437,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.86,6.902,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH IV 14G X 1.75 IN INSYTE BD -,SUP-381467,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.87,6.909,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH IV 24G X .56 IN INSYTE BD -,SUP-381511,CDM,C1751,HCPCS,272,RC,,,outpatient,,,14.42,10.094,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH IV 22G x 1 IN INSYTE AUTOGUARD BC -,SUP-382523,CDM,C1751,HCPCS,272,RC,,,outpatient,,,10.12,7.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH IV 16G X 1.16 IN INSYTE BD -,SUP-382554,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.86,6.902,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH IV SAF-T-INTIMA 23GAX0.75IN VIALON SAFTY WNG INDWL -,SUP-383323,CDM,C1751,HCPCS,272,RC,,,outpatient,,,20.11,14.077,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH IV SAF-T-INTIMA 20GAX1IN VIALON SAFTY WNG INDWL SLFBNT -,SUP-383336,CDM,C1751,HCPCS,272,RC,,,outpatient,,,19.62,13.734,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH IV 24G X .75 IN NEXIVA BD -,SUP-383511,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH IV 22GA X 1 IN NEXIVA BD -,SUP-383512,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH IV 20GA X 1 IN NEXIVA BD -,SUP-383516,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH IV 18GA X 1.25 IN NEXIVA BD -,SUP-383519-A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,23.98,16.786,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
ST NEEDLE INFS 24GAX0.75IN NEXIVA SAFTY LRG BORE WNG DL PRT -,SUP-383531,CDM,C1751,HCPCS,272,RC,,,outpatient,,,31.28,21.896,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
KT ARTERIAL LN 20GAX20CM 1ST MI D CATH MDLN SFN -,SUP-384304,CDM,C1751,HCPCS,272,RC,,,outpatient,,,468.67,328.069,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATHETER IV 16 X 2 SFR -,SUP-4082,CDM,C1751,HCPCS,272,RC,,,outpatient,,,11.6,8.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH IV 14 X 2.25in JELCO -,SUP-4088,CDM,C1751,HCPCS,272,RC,,,outpatient,,,20.36,14.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
TRY MIDLINE CATH 4FR 18GA LUM LUMX1 LF -,SUP-4154108,CDM,C1751,HCPCS,272,RC,,,outpatient,,,526.32,368.424,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
TRY CV LUMX1 4FR PU LF ACC -,SUP-4154108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1151.36,805.952,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH IV INTROCAN SAFTY 20GAX1.75IN FEP POYMER SAFTY STR HUB -,SUP-4252527-02,CDM,C1751,HCPCS,272,RC,,,outpatient,,,7.39,5.173,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH IV INTROCAN SAFTY 18GAX2.5IN TFLN FEP PLYMR SAFTY STR -,SUP-4252561-02,CDM,C1751,HCPCS,272,RC,,,outpatient,,,9.22,6.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH CV 5FRX8CM POWERWAND PWR-INJ MDLN QCK CHRNFLX C -,SUP-72135,CDM,C1751,HCPCS,272,RC,,,outpatient,,,811.07,567.749,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
PICC LINE CHANGE KIT IVAD ACCE -,SUP-73240B,CDM,C1751,HCPCS,272,RC,,,outpatient,,,17.27,12.089,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
PORT INFS 8FR 1LUM -,SUP-7711802,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1505.34,1053.738,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH PA 8FRX110CM SWAN-GNZ C CMB VOL LUMX7 INJ PRT ANTMIC -,SUP-777HF8,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1446.77,1012.739,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
SWAN-GANZ VIP/ OXIMETRY THERMOD CATHETER -,SUP-782F75M,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1519.92,1063.944,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
KT IT F/LEGEND SYNCHROMED INFS PMP RPR -,SUP-8590-9,CDM,C1751,HCPCS,272,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
TRY CV LUMX1 4FRX60CM PU POLY P-Q-CTH LF ACC -,SUP-9154108,CDM,C1751,HCPCS,272,RC,,,outpatient,,,908.45,635.915,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
TRY CV LUMX1 4FR STD 55CM PU POWERPICC LF ACC -,SUP-9174108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1953.71,1367.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH CV 5FRX10CM POWERWAND PWR-INJ MDLN CHRNFLX C -,SUP-92006,CDM,C1751,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
TRY CV LUMX2 5FRX60CM PU POLY P-Q-CTH LF ACC -,SUP-9255108,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1040.96,728.672,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH PA 7.5FRX110CM SWAN-GNZ PCNG LUMX5 AMC THRMBSHLD HPCT -,SUP-931HF75,CDM,C1751,HCPCS,272,RC,,,outpatient,,,303.24,212.268,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
TRY CV LUMX3 6FR STD 55CM PU POWERPICC LF ACC -,SUP-9386108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,2085.78,1460.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH PA 8FRX110CM SWAN-GNZ A-V PCNG LUMX6 INJ PRT ANTMIC AMC -,SUP-991HF8,CDM,C1751,HCPCS,272,RC,,,outpatient,,,787.2,551.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
"ACCUCATH 22G 1.25"" BASIC KIT -",SUP-AC0221250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,133.27,93.289,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
KIT CATHETER ACCUCATH ACE 18G 2.25 BASIC -,SUP-AC1182250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,254.41,178.087,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
"ACCUCATH 20G 1.25"" BASIC KIT -",SUP-AC1201250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,133.27,93.289,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
ACCUCATH ACE 20G X 2.25IN BASIC KIT -,SUP-AC1202250,CDM,C1751,HCPCS,272,RC,,,outpatient,,,254.41,178.087,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH PRSS MONTR BLN WDG 5FR -,SUP-AI-07124,CDM,C1751,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH A-LN BLN WDG LUMX2 6FRX110CM PA INDWL 1ML CTRL STRK SYR -,SUP-AI-07126,CDM,C1751,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH PA 6FRX110CM BLN -,SUP-AI-07365-NHL,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
ST ARTERIAL CATH 20GAX1.75IN SHRP SAFTY LF -,SUP-AK-04020-SPC,CDM,C1751,HCPCS,272,RC,,,outpatient,,,145.29,101.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
KT A-LN 20GAX5IN PA INDWL 0.25IN SPR STR SFT TIP JTP GW -,SUP-AK-04510-S,CDM,C1751,HCPCS,272,RC,,,outpatient,,,164.55,115.185,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
KIT CENTRAL VENOUS TWO LUMEN -,SUP-AK-11142-D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,568.91,398.237,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
KT CV LUMX2 4FRX8CM PU ARROW G+ARD LF ACC -,SUP-AK-25402,CDM,C1751,HCPCS,272,RC,,,outpatient,,,431.79,302.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
FEMORAL ARTERY CATH KIT  5FR REF: G58398 -,SUP-APM-5.0-35J-1-15-NY,CDM,C1751,HCPCS,272,RC,,,outpatient,,,259.07,181.349,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
KIT CATH TRIPLE LUMEN 20CM CEN -,SUP-ASK-45703-PSCH,CDM,C1751,HCPCS,272,RC,,,outpatient,,,847.94,593.558,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
KT CV MULTLUM 20CM ARROW G+ARD LF ACC -,SUP-ASK-45703-PSCH,CDM,C1751,HCPCS,272,RC,,,outpatient,,,847.94,593.558,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
KT CV LUMX3 7FRX16CM PU ARW HWS LF ACC -,SUP-CDC-12703-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,352.9,247.03,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
KT CV LUMX3 7FRX20CM PU ARW HWS LF ACC -,SUP-CDC-15703-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,408.63,286.041,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
KT CV LUMX1 16GAX20CM PU ARROW G+ARD LF ACC -,SUP-CDC-24301-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,395.61,276.927,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
KT CV LUMX1 16GAX20CM PU ARROW G+ARD LF ACC -,SUP-CDC-24301-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,395.61,276.927,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
ARROW PEDI CENTRAL LINE KIT 13CM -,SUP-CDC-24402-X1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,754.66,528.262,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
SWAN -GANZ TEMP PACR STR EDWARDS -,SUP-D97120F5,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1130.07,791.049,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
SWAN-GANZ BIPOLAR PACING CATH J-TIP 5 FR 90CM -,SUP-D97130F5,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1130.07,791.049,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH PERFUS 20FRX.25IN ACPT 6CM PRFX STR PVC -,SUP-E063,CDM,C1751,HCPCS,272,RC,,,outpatient,,,239.59,167.713,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
ST ARTERIAL CATH 18GAX4.25IN LF -,SUP-FA-04018,CDM,C1751,HCPCS,272,RC,,,outpatient,,,81.46,57.022,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CENTRAL VENOUS CATHETER TRAY 4.0FR -,SUP-G02138,CDM,C1751,HCPCS,272,RC,,,outpatient,,,245.65,171.955,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH INFS 3FR STR 135CM SLIP-CATH NYL SS HYDRCT 0.025IN GW -,SUP-G12044,CDM,C1751,HCPCS,272,RC,,,outpatient,,,283,198.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH INFS 3FR STR 150CM SLIP-CATH NYL SS HYDRCT 0.025IN GW -,SUP-G12045,CDM,C1751,HCPCS,272,RC,,,outpatient,,,283,198.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
KT BLOOD GS ART 182CM CHMBR IV SPK 3W STPCKX2 122IN PRESSMNT -,SUP-H965700361481,CDM,C1751,HCPCS,272,RC,,,outpatient,,,164.55,115.185,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH INFS 4FRX135CM 10CM INFS ACCESSPLUS VLV PEBAX OCL WIRE -,SUP-IS4-135-10,CDM,C1751,HCPCS,272,RC,,,outpatient,,,793.56,555.492,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH INFS 4FRX135CM 20CM INFS ACCESSPLUS VLV PEBAX OCL WIRE -,SUP-IS4-135-20,CDM,C1751,HCPCS,272,RC,,,outpatient,,,793.56,555.492,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
KT INTRAVENOUS CATH 20GAX8CM POWERGLIDE LF -,SUP-M020081,CDM,C1751,HCPCS,272,RC,,,outpatient,,,493.06,345.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
KT INTRAVENOUS CATH 20GAX10CM POWERGLIDE -,SUP-M020101,CDM,C1751,HCPCS,272,RC,,,outpatient,,,493.06,345.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH VASC ACCESS 3FR LUMX1 MDLN PU PRELD STYL INTRO GW SYR -,SUP-ML3S20FN,CDM,C1751,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH CV LUMX1 4FRX200CM SINGLE MDLN -,SUP-MLCT4S20FN,CDM,C1751,HCPCS,272,RC,,,outpatient,,,805.52,563.864,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH PICC LUMX1 6FR PWR PICC -,SUP-MR17036306MB,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1081.3,756.91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
ARTERIAL CATHETERIZATION KIT 20G -,SUP-NA-04550-1A,CDM,C1751,HCPCS,272,RC,,,outpatient,,,303.42,212.394,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH CV LUMX2 4FRX20 CM DUAL MDLN -,SUP-P4254108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,982.38,687.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH RADIAL ARTERY 20G -,SUP-RA-04020,CDM,C1751,HCPCS,272,RC,,,outpatient,,,55.96,39.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
CATH SET RADIAL ARTERY 20GX1.5 -,SUP-RA-04220,CDM,C1751,HCPCS,272,RC,,,outpatient,,,70.49,49.343,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
SET RAPID INFUSION 7FR CATHETER EXCHANGE -,SUP-RC-09700,CDM,C1751,HCPCS,272,RC,,,outpatient,,,61.73,43.211,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
SET RAPID INFUSION 8.5FR CATHETER EXCHANGE -,SUP-RC-09850,CDM,C1751,HCPCS,272,RC,,,outpatient,,,59.52,41.664,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
STYLET ELCSURG 6FRX12CM RF D MRKNG CLOSURERFS -,SUP-RFS2612,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1908.18,1335.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
TRY CV LUMX3 5FR TRIPLE  POWERPICC ACC -,SUP-S1385108D,CDM,C1751,HCPCS,272,RC,,,outpatient,,,1499.41,1049.587,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
MULTI-LUMEN VENOUS CATH 8FR -,SUP-SS-14703,CDM,C1751,HCPCS,272,RC,,,outpatient,,,187.89,131.523,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
C 6FR TRIPLE LUMEN PICC -,SUP-UNDEFINED,CDM,C1751,HCPCS,272,RC,,,outpatient,,,669.86,468.902,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.659055,3468.96072,other,Non-Reimbursable Procedures,,
KT HMDLYS PWR TRIALYSIS 13FRX20CM LUMX3 SHRT TERM -,SUP-5603200,CDM,C1752,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.92327,4457.91882,other,Non-Reimbursable Procedures,,
TRY HMDLYS PWR TRIALYSIS 13FRX15CM PU ACUTE SHRT TERM LUMX3 -,SUP-5605150,CDM,C1752,HCPCS,272,RC,,,outpatient,,,6217.46,4352.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.92327,4457.91882,other,Non-Reimbursable Procedures,,
KT HMDLYS PWR -TRIALYSIS 13FRX20CM SHRT TERM LUMX3 ACC -,SUP-5605200,CDM,C1752,HCPCS,272,RC,,,outpatient,,,6217.46,4352.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.92327,4457.91882,other,Non-Reimbursable Procedures,,
KT HMDLYS PWR -TRIALYSIS 13FRX20CM SHRT TERM LUMX3 ACC -,SUP-5605200,CDM,C1752,HCPCS,272,RC,,,outpatient,,,1553.05,1087.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.92327,4457.91882,other,Non-Reimbursable Procedures,,
KT HMDLYS PWR -TRIALYSIS 13FRX15CM SHRT TERM LUMX3 ACC -,SUP-5613150,CDM,C1752,HCPCS,272,RC,,,outpatient,,,1372.83,960.981,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.92327,4457.91882,other,Non-Reimbursable Procedures,,
MAHUKAR CATH DUAL 19FR. -,SUP-8813793009,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.92327,4457.91882,other,Non-Reimbursable Procedures,,
MAHUKUR CATH DUAL 10 FR. -,SUP-8817146007,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.92327,4457.91882,other,Non-Reimbursable Procedures,,
KT HMDLYS MHRKR 11.5FR LNG EXTEND 16CM LUMX2 ACUTE ACC -,SUP-8830415001,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.92327,4457.91882,other,Non-Reimbursable Procedures,,
TRY HMDLYS MHRKR 11.5FRX24CM PU 1% 5ML LIDOCN LUMX2 ACC -,SUP-8831663001,CDM,C1752,HCPCS,272,RC,,,outpatient,,,443.65,310.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.92327,4457.91882,other,Non-Reimbursable Procedures,,
CATH MAHURKAR CURVED 12FR 16CM -,SUP-8888101002HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,553.17,387.219,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.92327,4457.91882,other,Non-Reimbursable Procedures,,
MAHURKER CATH DUAL 13.5 FR. -,SUP-8888135192,CDM,C1752,HCPCS,272,RC,,,outpatient,,,415.92,291.144,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.92327,4457.91882,other,Non-Reimbursable Procedures,,
MAHURKAR STRAIGHT CATH KIT 12FR -,SUP-8888221220,CDM,C1752,HCPCS,272,RC,,,outpatient,,,360.46,252.322,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.92327,4457.91882,other,Non-Reimbursable Procedures,,
TRY MHRKR ELITE ACUTE 12FRX20CM -,SUP-8888233420,CDM,C1752,HCPCS,272,RC,,,outpatient,,,859.55,601.685,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.92327,4457.91882,other,Non-Reimbursable Procedures,,
KT HMDLYS MHRKR 12FRX20CM PU LUMX3 ACUTE ACC -,SUP-8888340629HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,471.37,329.959,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.92327,4457.91882,other,Non-Reimbursable Procedures,,
KIT HEMODIALYSIS MAHURKAR 12FRX24CM PU LUMX3 ACUTE ACC -,SUP-8888340637HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,489.29,342.503,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.92327,4457.91882,other,Non-Reimbursable Procedures,,
KT HMDLYS MHRKR 12FRX16CM PU LUMX3 ACUTE ACC -,SUP-8888345611HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,471.37,329.959,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.92327,4457.91882,other,Non-Reimbursable Procedures,,
KT HEMODIALYSIS MHRKR TLC- C E 12FRX20CM LF -,SUP-8888345637,CDM,C1752,HCPCS,272,RC,,,outpatient,,,499.18,349.426,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.92327,4457.91882,other,Non-Reimbursable Procedures,,
KT HMDLYS 12FR PU LUMX3 ACUTE ACC CVD -,SUP-8888345637HP,CDM,C1752,HCPCS,272,RC,,,outpatient,,,471.37,329.959,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,80.92327,4457.91882,other,Non-Reimbursable Procedures,,
IVUS 0.014P RX CATHETER -,SUP-014R,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3079.23,2155.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7720.4409,other,Non-Reimbursable Procedures,,
CATH US 8FRX90CM ACUNAV 4W STEER -,SUP-10135936,CDM,C1753,HCPCS,272,RC,,,outpatient,,,10767.7,7537.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7720.4409,other,Non-Reimbursable Procedures,,
CATH DRAGONFLY OPSTAR REF: 1014651 -,SUP-1014651,CDM,C1753,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7720.4409,other,Non-Reimbursable Procedures,,
CATH US 5FR20MM IMG TAPR 150CM EAGLE EYE GOLD OTW COR PERIPH -,SUP-85900,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7720.4409,other,Non-Reimbursable Procedures,,
CATH US EAGLE EYE PLATINUM REF: 85900P -,SUP-85900P,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7720.4409,other,Non-Reimbursable Procedures,,
CATH US 5FR ID 20MM STR 150CM EAGLE EYE RX COR GLYDX PLTNM -,SUP-85900P,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7720.4409,other,Non-Reimbursable Procedures,,
CATH US EAGLE EYE PLTNM SHORT TIP -,SUP-85900PST,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3556.63,2489.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7720.4409,other,Non-Reimbursable Procedures,,
CATH VISIONS PV 0.018 -,SUP-86700,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7720.4409,other,Non-Reimbursable Procedures,,
C VOLCANO IVUS PV035 -,SUP-88901,CDM,C1753,HCPCS,272,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7720.4409,other,Non-Reimbursable Procedures,,
CATH DX VIEWFLEXX ICE 4W -,SUP-D087031,CDM,C1753,HCPCS,272,RC,,,outpatient,,,8496.49,5947.543,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7720.4409,other,Non-Reimbursable Procedures,,
CATH DX VIEWFLEX ECO ICE CATHERTER REPROC REF: D087031-R -,SUP-D087031-R,CDM,C1753,HCPCS,272,RC,,,outpatient,,,5544.79,3881.353,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7720.4409,other,Non-Reimbursable Procedures,,
ECHO ATLANTIS ICE -,SUP-H749389790,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7720.4409,other,Non-Reimbursable Procedures,,
CATHETER OPTICROSS HD IVUS 5FR -,SUP-H74939352040,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3843.07,2690.149,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7720.4409,other,Non-Reimbursable Procedures,,
CATHETER OPTICROSS HD IVUS 6FR -,SUP-H74939354080,CDM,C1753,HCPCS,272,RC,,,outpatient,,,3843.07,2690.149,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7720.4409,other,Non-Reimbursable Procedures,,
CATH US 9FR 9 MHZ 110CM ULTRA ICE IMG COR -,SUP-M00499000,CDM,C1753,HCPCS,272,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7720.4409,other,Non-Reimbursable Procedures,,
CATH US 6FR CRV NDL 120CM PIONEER + TRPL BRD SHFT PERC -,SUP-PPLUS120,CDM,C1753,HCPCS,272,RC,,,outpatient,,,10582.05,7407.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7720.4409,other,Non-Reimbursable Procedures,,
KIT EPIDURAL MINI BREVI-XL -,SUP-181-2340,CDM,C1755,HCPCS,278,RC,,,outpatient,,,481.1,336.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures,,
ST NEEDLE NRV BLCK CONTIPLEX -,SUP-331686,CDM,C1755,HCPCS,278,RC,,,outpatient,,,209.88,146.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures,,
TRAY EPIDURAL PERIFIX 17GA -,SUP-332079,CDM,C1755,HCPCS,278,RC,,,outpatient,,,140.22,98.154,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures,,
TRAY EPIDURAL WITH DURAPREP -,SUP-332215,CDM,C1755,HCPCS,278,RC,,,outpatient,,,192.5,134.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures,,
EPIDURAL CATHETER SET 20GA -,SUP-333540,CDM,C1755,HCPCS,278,RC,,,outpatient,,,46,32.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures,,
TRY EPDRL/SPIN CONT TUOHY WHITACRE 18GA PERISAFE 1% LIDOCN -,SUP-406048,CDM,C1755,HCPCS,278,RC,,,outpatient,,,114.89,80.423,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures,,
TRAY SPINAL LIDOCAINE 25GA X 3.5IN WHITACRE 0.75% HCL D8.25W -,SUP-406704,CDM,C1755,HCPCS,278,RC,,,outpatient,,,159.23,111.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures,,
LUMBAR PUNCTURE TRAY PEDI 22GA 1.5IN -,SUP-646,CDM,C1755,HCPCS,278,RC,,,outpatient,,,75.04,52.528,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures,,
TRAY LUMBAR PUNCTURE 20G -,SUP-648,CDM,C1755,HCPCS,278,RC,,,outpatient,,,92.06,64.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures,,
PASSER SURG SS HOL OBTR STRL -,SUP-8591-38,CDM,C1755,HCPCS,278,RC,,,outpatient,,,571.83,400.281,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures,,
KT IT 4FR CLSD TIP SIL MRKNG GW SPIN NDL ANCHR RLR -,SUP-8598A,CDM,C1755,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures,,
KT IT SIL RBR CLSD TIP SIL MRKNG GW SPIN NDL ANCHR RLR -,SUP-8709SC,CDM,C1755,HCPCS,278,RC,,,outpatient,,,3150.84,2205.588,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures,,
CATH IT 0.53MM 1.4MM/2.2MM SPIN/PMP SEG SIL RBR TRMBL CLSD -,SUP-8731SC,CDM,C1755,HCPCS,278,RC,,,outpatient,,,3150.84,2205.588,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures,,
CATHETER INTRA MEDTRONIC -,SUP-8780,CDM,C1755,HCPCS,278,RC,,,outpatient,,,4430.74,3101.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures,,
CATHETER INTRATHECAL  MEDTRONIC -,SUP-8781,CDM,C1755,HCPCS,278,RC,,,outpatient,,,4430.74,3101.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures,,
PROCEDURE 20GA 3.5IN NDL SF-T + F/LP -,SUP-974,CDM,C1755,HCPCS,278,RC,,,outpatient,,,130.65,91.455,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures,,
PROCEDURE 20GA 3.5IN NDL SF-T + F/LP -,SUP-974,CDM,C1755,HCPCS,278,RC,,,outpatient,,,130.65,91.455,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures,,
KIT SINGLE SHOT EPIDURAL -,SUP-A4082-20,CDM,C1755,HCPCS,278,RC,,,outpatient,,,85.52,59.864,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures,,
KT NEEDLE NRV BLCK 20GA STIMUCATH CONT INSL 4CM -,SUP-AB-20604-KS,CDM,C1755,HCPCS,278,RC,,,outpatient,,,518.08,362.656,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures,,
ST NEEDLE NRV BLCK 20GA STIMUCATH CONT INSL -,SUP-AB-20604-S,CDM,C1755,HCPCS,278,RC,,,outpatient,,,369.64,258.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures,,
KT NEEDLE NRV BLCK 20GA STIMUCATH CONT INSL 8CM -,SUP-AB-20608-KS,CDM,C1755,HCPCS,278,RC,,,outpatient,,,256.13,179.291,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures,,
SPACEOAR KITS -,SUP-SO-2101,CDM,C1755,HCPCS,278,RC,,,outpatient,,,11779.68,8245.776,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures,,
SPINAL -,SUP-UNDEFINED,CDM,C1755,HCPCS,278,RC,,,outpatient,,,80.87,56.609,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,10.327,9046.79424,other,Non-Reimbursable Procedures,,
POWER PULSE KIT ANGIO JET Y SE -,SUP-104834-0020,CDM,C1757,HCPCS,272,RC,,,outpatient,,,214.56,150.192,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
SET POWER PULSE Y SPIKE ANGIO -,SUP-104834-0021,CDM,C1757,HCPCS,272,RC,,,outpatient,,,214.56,150.192,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
C ANGIOJET AVX -,SUP-105039-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,3746.49,2622.543,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
DISC INJ F/THRMB -,SUP-105040001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,5326.22,3728.354,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATH THRMB 5FRX140CM ANGIOJET XVG HYDRCT -,SUP-105042-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,6917.72,4842.404,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
THROMBECTOMY 16.5INX54INX25IN D ANGIOJET -,SUP-105650-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,85111.5,59578.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATH THRMB 4.2FR FETCH -,SUP-106127-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATH THRMB 4FRX135CM ANGIOJET SPIROFLEX RX CX-STRM TECH -,SUP-106553-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10062.52,7043.764,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATH THRMB 5FRX135CM ANGIOJET SPIROFLEXVG RX CX-STRM TECH -,SUP-106608-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10062.52,7043.764,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATH THRMB 6FRX90CM ANGIOJET SOLENT PROXI OTW SPRL CUT PROX -,SUP-109676-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10503.9,7352.73,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
6FR 120CM ANGIOJET SOLENT OMNI -,SUP-109681-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9202.73,6441.911,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
4FRX145CM ANGIOJET  SOLENT DISTA THROMBECTOMY SE -,SUP-111303-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11183.56,7828.492,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
ANGIOIJET ZELANTEDVT 8X105CM -,SUP-114610-001,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10452.1,7316.47,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATH FOGARTY 3FR EMB 3 / SHORT -,SUP-120403FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATH FOGARTY 4FR EMB 4 SHORT -,SUP-120404FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATH FOGARTY 2FR / EMB 2 SHORT -,SUP-120602FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,493.23,345.261,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATH FOGARTY 3FR / EMB 3 -,SUP-120803FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATH FOGARTY 4FR 9MM  EMB 4 -,SUP-120804F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATH EMBCMT 4FR 9MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120804FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATH EMBCMT 5FR 11MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120805FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATH EMBCMT 6FR 13MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120806FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATH EMBCMT 7FR 14MM 80CM FOGARTY FLXB SFT TIP RCESS WNDNG -,SUP-120807FP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,306.34,214.438,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
C FOGARTY 3FR 12TLW403F -,SUP-12TLW403F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
C FOGARTY 4FR 12TLW404F -,SUP-12TLW404F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
C FOGARTY 5F 40 CM -,SUP-12TLW405F35,CDM,C1757,HCPCS,272,RC,,,outpatient,,,567.98,397.586,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
C FOGARTY 6FR 40CM -,SUP-12TLW406F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATH FOGARTY THRU LUMEN 3 -,SUP-12TLW803F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
C FOGARTY 4 80CM -,SUP-12TLW804F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
C FOGARTY 5.5 80CM OTW -,SUP-12TLW805F35,CDM,C1757,HCPCS,272,RC,,,outpatient,,,567.98,397.586,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
C FOGARTY 6 80CM -,SUP-12TLW806F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,567.98,397.586,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATH EMBCMT 7FRX14MM/8FR INFL/DFLT BLN 80CM FOGARTY OTW -,SUP-12TLW807F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,540.9,378.63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATH FOGARTY 6FR. ACC 6/10 -,SUP-1408010,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1347.12,942.984,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATH FOGARTY 6FR. / EMB 6 -,SUP-160246F,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1992.72,1394.904,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATH THRMB 5.5FR 138CM PRONTO V4 LRG LUM LNGTDNL WIRE HYDRCT -,SUP-4005,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1765.07,1235.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATH PTCA 4MMX4CM SAVVY 120CM OTW COAX MOD PRSS PERIPH TAPR -,SUP-435-404L,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1155.51,808.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATH US 5.2FRX106CM 12CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-55112,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATH US 5.2FRX106CM 18CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-55118,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATH US 5.2FRX106CM 24CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-55124,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATH US 5.2FRX135CM 12CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56112,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATH US 5.2FRX135CM 30CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56130,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATH US 5.2FRX135CM 40CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56140,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11120.44,7784.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATH US 5.2FRX135CM 50CM EKOSONIC MACH4 INFS PTRN PE PU -,SUP-500-56150,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATH THRMB 0.066IN 6FRX140CM WKG PRONTO LP LPRO XTRCT HYDRCT -,SUP-5010,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1929.38,1350.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CLOT TRIEVER SHEATH -,SUP-50-101,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CLOTTRIEVER SHEATH 16FR X 15CM -,SUP-51-101,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
INDIGO CATHETER 5 + LARGE LUMEN ASPIRATION TUBING -,SUP-90178584,CDM,C1757,HCPCS,272,RC,,,outpatient,,,6599.42,4619.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
INDIGO CATHETER 6 + LARGE LUMEN ASPIRATION TUBING -,SUP-90178585,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9782.42,6847.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATH INFS 6FR 3-10 MMX80CM 10CM BLN TRELLIS OTW MULTLUM INFS -,SUP-BVT608010,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8891.18,6223.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATH THRMB 8FRX80CM 15CM TRELLIS INFS PTRN -,SUP-BVT808015,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8891.18,6223.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATH THRMB 8FRX80CM 30CM TRELLIS INFS PTRN -,SUP-BVT808030,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9145.82,6402.074,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATH INFS 8FR 5-16 MMX120CM 30CM BLN TRELLIS OTW MULTLUM -,SUP-BVT812030,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8891.18,6223.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATH THRMB 0.041IN/0.032IN ID 4.1FR/3.4FR P/D 150CM INDIGO -,SUP-CAT3,CDM,C1757,HCPCS,272,RC,,,outpatient,,,5114.02,3579.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATH THRMB 0.064IN/0.054IN ID 6FR/5FR P/D 132CM INDIGO -,SUP-CAT5,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4753.28,3327.296,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATH THRMB 6FRX135CM INDIGO -,SUP-CAT6,CDM,C1757,HCPCS,272,RC,,,outpatient,,,7936.28,5555.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
INDIGO CATHETER 7D PLUS DYNAMIC ASPIRATION TUBING -,SUP-CAT7DKIT,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9913.71,6939.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATH THRMB 8FRX115CM INDIGO -,SUP-CAT8XTORQ115,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10804.83,7563.381,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATHETER D + INDIGO LARGE LUMEN ASPIRATING TUBING -,SUP-CATD,CDM,C1757,HCPCS,272,RC,,,outpatient,,,9913.71,6939.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
INDIGO CATHETER RX 140 CM + LG LUMEN ASPIRATION TUBING -,SUP-CATRXKIT,CDM,C1757,HCPCS,272,RC,,,outpatient,,,8063.6,5644.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATHETER SILICONE EMBOLECTOMY 4FR 80CM -,SUP-E1801-48,CDM,C1757,HCPCS,272,RC,,,outpatient,,,811.07,567.749,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATHETER SILICONE EMBOLECTOMY 5FR 80CM -,SUP-E1801-58,CDM,C1757,HCPCS,272,RC,,,outpatient,,,811.07,567.749,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
EXCIPIO SV THROMBECTOMY DEVICE 8MM -,SUP-EXC-0940-165,CDM,C1757,HCPCS,272,RC,,,outpatient,,,11101.87,7771.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATH EXPORT AP ASPIRATION 6F 0 -,SUP-EXPORTAP,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATH PTCA 4MMX10CM ADVANCE 18LP 135CM LPRO LUMX2 F/PTA -,SUP-G50233,CDM,C1757,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATH EMBCMT 7FRX145CM EXPORT AP BRD ASPIR SFT TIP FLXB -,SUP-GEZ6200US7B,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
EKOS+ KIT 106CM 8 CM -,SUP-H74939605106080,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
DEVICE THROMBECTOMY EKOS+ 106CM X 2.62CM TREATMENT ZONE 12CM -,SUP-H74939605106120,CDM,C1757,HCPCS,272,RC,,,outpatient,,,13181.15,9226.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
EKOS+ KIT 106CM 16 CM -,SUP-H74939605106160,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
EKOS+ KIT 106CM 20 CM -,SUP-H74939605106200,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
EKOS+ KIT 135CM 20 CM -,SUP-H74939605135200,CDM,C1757,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
INDIGO CATHETER 12 115CM HTORQ -,SUP-LITNG12HTORQ115,CDM,C1757,HCPCS,272,RC,,,outpatient,,,25137.01,17595.907,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
INDIGO CATHETER 7 130CM XTORQ -,SUP-LITNG7XTORQ130,CDM,C1757,HCPCS,272,RC,,,outpatient,,,20681.41,14476.987,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
INDIGO CATHETER 8 115CM XTORQ -,SUP-LITNG8XTORQ115,CDM,C1757,HCPCS,272,RC,,,outpatient,,,21424.01,14996.807,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-5080-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-5120-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-6080-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-6120-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
VANGUARD IEP PERIPHERAL BALLOON ANGIOPLASTY SYSTEM -,SUP-VI-6200-135-01,CDM,C1757,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
ACCESSORY KIT JETI NON STERILE DISPOSABLE -,SUP-WV1500,CDM,C1757,HCPCS,272,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
JETI CATHETER KIT 6FR -,SUP-WV6203A,CDM,C1757,HCPCS,272,RC,,,outpatient,,,12141.51,8499.057,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
JETI CATHETER KIT 8FR -,SUP-WV8803A,CDM,C1757,HCPCS,272,RC,,,outpatient,,,17109.5,11976.65,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.14178,61024.9455,other,Non-Reimbursable Procedures,,
CATH URETH 5FR TIGTL PU LF 70CM NPRT EYE FLXB OPN TIP -,SUP-0139005,CDM,C1758,HCPCS,272,RC,,,outpatient,,,549.07,384.349,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,11.97932,751.60242,other,Non-Reimbursable Procedures,,
CATH URETERAL POLLACK 5 70 -,SUP-021305,CDM,C1758,HCPCS,272,RC,,,outpatient,,,94.44,66.108,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,11.97932,751.60242,other,Non-Reimbursable Procedures,,
CATH FOLEY 6FR 2W LUBRI-SIL SIL LF PED -,SUP-175806N,CDM,C1758,HCPCS,272,RC,,,outpatient,,,146.07,102.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,11.97932,751.60242,other,Non-Reimbursable Procedures,,
CATH URET 6FRX70CM PVC OP-EN TIP LF PVC SOF-FLEX -,SUP-G15942,CDM,C1758,HCPCS,272,RC,,,outpatient,,,65.41,45.787,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,11.97932,751.60242,other,Non-Reimbursable Procedures,,
CATH URET 5FRX80CM VNYL LUMX1 LF BUSH SL CATHX2 CMN L/S -,SUP-G16746,CDM,C1758,HCPCS,272,RC,,,outpatient,,,1048.26,733.782,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,11.97932,751.60242,other,Non-Reimbursable Procedures,,
CATH ANG 5FR KMP 100CM SLIP-CATH BRD HYDRCT -,SUP-G28535,CDM,C1758,HCPCS,272,RC,,,outpatient,,,379.26,265.482,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,11.97932,751.60242,other,Non-Reimbursable Procedures,,
CATHETER ACCESS 6FR AXXCESS -,SUP-M0064001161,CDM,C1758,HCPCS,272,RC,,,outpatient,,,61.04,42.728,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,11.97932,751.60242,other,Non-Reimbursable Procedures,,
CATH 5FR X 70 CONE TIP BX/20 -,SUP-M0064002111,CDM,C1758,HCPCS,272,RC,,,outpatient,,,53.36,37.352,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,11.97932,751.60242,other,Non-Reimbursable Procedures,,
CATH DUAL LUMEN URETERAL -,SUP-M0064051000,CDM,C1758,HCPCS,272,RC,,,outpatient,,,384.35,269.045,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,11.97932,751.60242,other,Non-Reimbursable Procedures,,
CATHETER 5.5 S2 -,SUP-1000100,CDM,C1759,HCPCS,272,RC,,,outpatient,,,101147,70802.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,72522.399,other,Non-Reimbursable Procedures,,
CATH US 10FRX90CM 5.5-10 MHZ SOUNDSTAR NAV COR -,SUP-SNDSTR10,CDM,C1759,HCPCS,272,RC,,,outpatient,,,10396.4,7277.48,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,72522.399,other,Non-Reimbursable Procedures,,
DEVICE SUT -,SUP-123250101,CDM,C1760,HCPCS,278,RC,,,outpatient,,,116.7,81.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures,,
CLOSURE PERCLOSE PROGLIDE 6F -,SUP-12673-03,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures,,
PERCLOSE PROSTYLE -,SUP-12773-03,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures,,
DEVICE VASC CLSR 56FR STARCLOSE SE -,SUP-14679-01,CDM,C1760,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures,,
STAR CLOSE SELF -,SUP-14679-01,CDM,C1760,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures,,
ANGIO SEAL STS VIP/PLUS 6FR -,SUP-610119,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures,,
ANGIO SEAL STS VIP/PLUS 8FR -,SUP-610121,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures,,
DEVICE VASC CLSR 6FR ANGIO-SEAL VIP -,SUP-610130,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures,,
DEVICE VASC CLSR 8FR ANGIO-SE  70CM -,SUP-610131,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures,,
VASCADE MVP - VENOUS VASCULAR CLOSURE SYSTEM 6-12F -,SUP-800-612C-10U,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1298.62,909.034,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures,,
SYS ATRICLIP STD 40 -,SUP-ACH140,CDM,C1760,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures,,
SYS ATRICLIP STD 45 -,SUP-ACH145,CDM,C1760,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures,,
DEVICE VASC CLSR 5FR EXOSEAL -,SUP-EX500,CDM,C1760,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures,,
DEVICE VASC CLSR 6FR EXOSEAL -,SUP-EX600,CDM,C1760,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures,,
PAS-PORT PROXIMAL ANASTOMOSIS -,SUP-FG-000001-13,CDM,C1760,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures,,
CELT ACD 5FR CLOSURE DEVICE -,SUP-KCLT-05,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures,,
CELT ACD 6FR CLOSURE DEVICE -,SUP-KCLT-06,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures,,
CELT ACD 7FR CLOSURE DEVICE -,SUP-KCLT-07,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures,,
MYNX GRIP 5FR CLOSURE DEVICE M - MULTIPLES OF 10 ONLY -,SUP-M465MX50210C,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures,,
DEVICE 6F/7F MYNX GRIP CLOSURE -,SUP-MX6721,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1102.82,771.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures,,
DEVICE VASC CLSR 6FR MYNXGRIP -,SUP-MX6721,CDM,C1760,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures,,
VENASEAL SYSTEM CLOSURE -,SUP-VS-404,CDM,C1760,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3585.3312,other,Non-Reimbursable Procedures,,
BALLOON SHOCKWAVE C2 + IVL CATHETER 2.5X12 REF: C2PIVL2512 -,SUP-C2PIVL2512,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4514.59957,399.86,14791.55236,percent of total billed charges,,,
BALLOON SHOCKWAVE C2 + IVL CATHETER 3.0X12 REF: C2PIVL3012 -,SUP-C2PIVL3012,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4514.59957,399.86,14791.55236,percent of total billed charges,,,
BALLOON SHOCKWAVE C2 + IVL CATHETER 3.5X12 REF: C2PIVL3512 -,SUP-C2PIVL3512,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4514.59957,399.86,14791.55236,percent of total billed charges,,,
BALLOON SHOCKWAVE C2 + IVL CATHETER 4.0X12 REF: C2PIVL4012 -,SUP-C2PIVL4012,CDM,C1761,HCPCS,272,RC,,,outpatient,,,17451.1,12215.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4514.59957,399.86,14791.55236,percent of total billed charges,,,
CATHETER  SHOCKWAVE L6 1VL- 8.0 X 30 MM -,SUP-L6IVL080030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3313.908195,399.86,14791.55236,percent of total billed charges,,,
CATHETER  SHOCKWAVE L6 1VL- 9.0 X 30 MM -,SUP-L6IVL090030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3313.908195,399.86,14791.55236,percent of total billed charges,,,
CATHETER  SHOCKWAVE L6 1VL- 10.0 X 30 MM -,SUP-L6IVL100030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3313.908195,399.86,14791.55236,percent of total billed charges,,,
CATHETER  SHOCKWAVE L6 1VL- 12.0 X 30 MM -,SUP-L6IVL120030,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3313.908195,399.86,14791.55236,percent of total billed charges,,,
CATHETER SHOCKWAVE 6.5 X 60 MM M5+ -,SUP-M5PIVL6560,CDM,C1761,HCPCS,272,RC,,,outpatient,,,12809.85,8966.895,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3313.908195,399.86,14791.55236,percent of total billed charges,,,
TENDON SEMITENINOSIS -,SUP-004023,CDM,C1762,HCPCS,278,RC,,,outpatient,,,5817.25,4072.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures,,
GRAFT HUM TIS NAT DENOVO LF -,SUP-00560600010,CDM,C1762,HCPCS,278,RC,,,outpatient,,,17339.71,12137.797,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures,,
ADVANCE NERVE GRAFT D 1-2MM X 15MM -,SUP-111215,CDM,C1762,HCPCS,278,RC,,,outpatient,,,8649.27,6054.489,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures,,
ADVANCE NERVE ALLOGRAFT -,SUP-111230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures,,
STRATTICE RECONSTRUCTIVE TISSUE MATRIX 16 X 20CM -,SUP-1620002,CDM,C1762,HCPCS,278,RC,,,outpatient,,,30012.18,21008.526,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures,,
STRATTICE RECONSTRUCTIVE TISSUE MATRIX 20 X 20CM -,SUP-2020002,CDM,C1762,HCPCS,278,RC,,,outpatient,,,24926.57,17448.599,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures,,
GRAFT HUM TIS SPORTSMED TIB IRRAD LF -,SUP-208002,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures,,
GRAFT HUM TIS SPORTSMED TIB TNDN POST TIB IRRAD LF -,SUP-208003,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures,,
AVANCE NERVE GRAFT 2MM DIAM / 30MM LENGTH -,SUP-211230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures,,
ADVANCE NERVE GRAFT 3-4MM X 30MM -,SUP-311230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures,,
AXOGEN ADVANCE NERVE GRAFT 3.4MM X 70MM -,SUP-311270,CDM,C1762,HCPCS,278,RC,,,outpatient,,,25322.66,17725.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures,,
NERVE GRAFT ADVANCED 4-5MM X 30MM -,SUP-411230,CDM,C1762,HCPCS,278,RC,,,outpatient,,,11725.65,8207.955,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures,,
AXOGEN ADVANCE NERVE GRAFT 4.5MM X 70MM -,SUP-411270,CDM,C1762,HCPCS,278,RC,,,outpatient,,,25322.66,17725.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures,,
GRAFT HUM TIS FRZN 6-12 MMX20-38CM ANT TIB TNDN LF -,SUP-430335,CDM,C1762,HCPCS,278,RC,,,outpatient,,,8376.38,5863.466,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures,,
TENDON TIBIALIS POSTERIOR -,SUP-430343,CDM,C1762,HCPCS,278,RC,,,outpatient,,,8168.81,5718.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures,,
GRAFT HUM TIS FRZN 3-10 MMX26-38CM SEMITNDS TNDN LF -,SUP-430350,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures,,
GRAFT HUM TIS FRZN 3-10 MMX20-25.9CM ANT TIB TNDN LF -,SUP-430355,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures,,
IMPLANT HUM TIS PS 10MM TNDN ACH -,SUP-450200,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10971.92,7680.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures,,
GRAFT HUM TIS FRZDR 2X14CM IOPATCH TUTOPLAST FSCA LATA -,SUP-68021,CDM,C1762,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures,,
GRAFT HUM TIS DHYDR 1.5X1.5CM IOPATCH TUTOPLAST PROC -,SUP-68250,CDM,C1762,HCPCS,278,RC,,,outpatient,,,1404.63,983.241,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures,,
GRAFT HUM TIS PTCH DHYDR 1X3CM IOPATCH TUTOPLAST SCLR IRRAD -,SUP-68334,CDM,C1762,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures,,
GRAFT HTM NMSH SFT REGEN 5X5CM STD GRAFTJACKET ACLR DERM 1MM -,SUP-8600-5X05,CDM,C1762,HCPCS,278,RC,,,outpatient,,,9761.2,6832.84,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures,,
GRAFT HTM FRZDR SFT REGEN 2X4CM GRAFTJACKET COLL 1.5MM UND -,SUP-86MX-2X04,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10752.85,7526.995,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures,,
PATELLA TENDON W/ EXTENSION MECHANISM -,SUP-92-3300,CDM,C1762,HCPCS,278,RC,,,outpatient,,,26622.21,18635.547,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures,,
GRAFT HUM TIS SPLT THK VSNGRFT CRNA NON-IMMUNOGENIC XLNK -,SUP-C0301AL-90,CDM,C1762,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures,,
CORNEA HUMAN -,SUP-CORNEA,CDM,C1762,HCPCS,278,RC,,,outpatient,,,16467.16,11527.012,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures,,
IMPLANT HUM TIS BLCK AT -,SUP-FATB,CDM,C1762,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures,,
IMPLANT HUM TIS ALLOGRAFT BIOCLEANSE GRCLS TNDN FRZN -,SUP-FGRACILIS,CDM,C1762,HCPCS,278,RC,,,outpatient,,,5267.78,3687.446,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures,,
GRAFT HUM TIS FRZDR 30X150MM MED RDIGRF FSCA LATA LF -,SUP-FLM,CDM,C1762,HCPCS,278,RC,,,outpatient,,,4565.66,3195.962,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures,,
GRAFT HUM TIS SFT 230MM 7.5MM FLEXIGRAFT POST TIB TNDN FRZN -,SUP-FPOST.TIBIAL,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7087.1,4960.97,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures,,
FLEXIGRAFT QUADLINK-ZORC -,SUP-FQL,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10482.68,7337.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures,,
GRAFT HUM TIS HAMSTRING FRZN >150MM4MM-5.5MM DIA FLEXIGRAFT -,SUP-FROPE,CDM,C1762,HCPCS,278,RC,,,outpatient,,,3719.57,2603.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures,,
GRAFT HUM TIS HAMSTRING FRZN 160-250MM 4-6MM FLEXIGRAFT -,SUP-FSTP,CDM,C1762,HCPCS,278,RC,,,outpatient,,,3657.31,2560.117,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures,,
SLING TRNVAG RPLFRM COLL 5X10CM NABSB FEM FRZDR SLF-ANCHR -,SUP-M0068202450,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7456.11,5219.277,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures,,
SLING TRNVAG RPLFRM COLL 6X12CM NABSB FEM FRZDR SLF-ANCHR -,SUP-M0068202460,CDM,C1762,HCPCS,278,RC,,,outpatient,,,7882.17,5517.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures,,
MACROFORM COMPOSITE NOVABONE 10CC -,SUP-NB1003,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures,,
NOVABONE BIOACTIVE BONE GRAFT 10CC LONG STRIP -,SUP-NB2310L,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures,,
NOVABONE 10CC STRIP -,SUP-NB2310S,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures,,
NOVABONE 2.5CC PUTTY -,SUP-NB2602,CDM,C1762,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures,,
NOVABONE 5CC PUTTY -,SUP-NB2605,CDM,C1762,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures,,
NOVABONE 10CC PUTTY SYRINGE -,SUP-NB2610,CDM,C1762,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures,,
GRAFT HUM TIS FRZN >=150MM TIB POST TNDN LF -,SUP-X30820,CDM,C1762,HCPCS,278,RC,,,outpatient,,,6302.34,4411.638,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,315.339435,23049.35424,other,Non-Reimbursable Procedures,,
IMPLANT BIO TISS 15X20CM RECT PRCN COLL MATRIX NXLNK XENMTRX -,SUP-1161520,CDM,C1763,HCPCS,278,RC,,,outpatient,,,31189.2,21832.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures,,
EPIDISK -,SUP-1417100,CDM,C1763,HCPCS,278,RC,,,outpatient,,,1203.21,842.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures,,
IMPLANT COLL MEMBR 50X40MM GEISTLICH BIO-GIDE BILAYER RESRB -,SUP-20153,CDM,C1763,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures,,
SHEET MEDPOR 38 X 50 X 0.85 ORBITAL IMPLANT -,SUP-7210,CDM,C1763,HCPCS,278,RC,,,outpatient,,,2390.53,1673.371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures,,
SUBSTITUTE CA SLPHT 5ML GRNL MIIGX3 RESRB SYNTH PREFL -,SUP-84XS-0405,CDM,C1763,HCPCS,278,RC,,,outpatient,,,7940.52,5558.364,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures,,
SUBSTITUTE CA SLPHT 5ML GRNL MIIGX3 RESRB SYNTH PREFL -,SUP-84XS-0405,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9145.82,6402.074,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures,,
GRID CRNL 106X97MM 6MM MEDPOR FLEXBLOCK -,SUP-9524,CDM,C1763,HCPCS,278,RC,,,outpatient,,,15136.27,10595.389,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures,,
NERVE PROTECTOR WRAP 2MM X 20MM -,SUP-AG0220,CDM,C1763,HCPCS,278,RC,,,outpatient,,,8118.77,5683.139,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures,,
NERVE PROTECTOR WRAP 3.5MM X 20MM -,SUP-AG0320,CDM,C1763,HCPCS,278,RC,,,outpatient,,,8118.77,5683.139,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures,,
NERVE WRAP AVANCE 3.5MM X 40MM -,SUP-AG0340,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9921.14,6944.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures,,
NERVE WRAP AVANCE 3.5MM X 40MM -,SUP-AG0340,CDM,C1763,HCPCS,278,RC,,,outpatient,,,10525.12,7367.584,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures,,
NERVE PROTECTOR 7MM X 40MM - USE 0169678 -,SUP-AG0740,CDM,C1763,HCPCS,278,RC,,,outpatient,,,10121.64,7085.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures,,
NERVE PROTECTOR 7MM X 40MM -,SUP-AG0740,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9442.16,6609.512,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures,,
AXOGUARD NERVE PROTECTOR 40MM 10MM -,SUP-AG1040,CDM,C1763,HCPCS,278,RC,,,outpatient,,,9442.16,6609.512,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures,,
AXOGAURD NERVE CONNECTOR 2 X 15 -,SUP-AGX215,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures,,
AXOGAURD NERVE CONNECTOR D 3MM L 15MM -,SUP-AGX315,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures,,
AXOGAURD NERVE CONNECTOR D 4MM L 15MM -,SUP-AGX415,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures,,
CONNECTOR AXOGUARD NERVE D 5MM L 15MM -,SUP-AGX515,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6849.82,4794.874,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures,,
PLUG ANAL FISTULA -,SUP-G53614,CDM,C1763,HCPCS,278,RC,,,outpatient,,,5071.58,3550.106,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures,,
IMPLANT GYN 17X70CM SYNTH UPHOLD LT -,SUP-M0068317170,CDM,C1763,HCPCS,278,RC,,,outpatient,,,8668.37,6067.859,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures,,
SURGICAL MATRIX THICK 10 X 20CM -,SUP-PSMT1020,CDM,C1763,HCPCS,278,RC,,,outpatient,,,20941.32,14658.924,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures,,
5 X 5CM 6 LAYER GENTRIX SURGICAL MATRIX DRESSING -,SUP-PSMX0505,CDM,C1763,HCPCS,278,RC,,,outpatient,,,3471.65,2430.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures,,
ROD TNDN 3X250MM PLYSTR COR SIL PSS KNOB END HNTR STRL STR -,SUP-PT300000,CDM,C1763,HCPCS,278,RC,,,outpatient,,,5254.07,3677.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures,,
ROD TNDN 5X250MM PLYSTR COR SIL PSS KNOB END HNTR STRL STR -,SUP-PT500000,CDM,C1763,HCPCS,278,RC,,,outpatient,,,6315.07,4420.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures,,
ROD TNDN STD 4X245MM PLYSTR COR SIL PSS HNTR STRL STR -,SUP-TR400000,CDM,C1763,HCPCS,278,RC,,,outpatient,,,5254.07,3677.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures,,
WOUND MATRIX 6 LAYER 10 X 15 -,SUP-WSX1015,CDM,C1763,HCPCS,278,RC,,,outpatient,,,16411.46,11488.022,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,270.120645,23953.3056,other,Non-Reimbursable Procedures,,
RECORDER LOOP 2-AF BIOMONITOR -,SUP-398493,CDM,C1764,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4034.32302,399.86,14243.66592,percent of total billed charges,,,
MONITOR CARD IMPL REVEAL XT 19X62MM TI 9ML 15GM -,SUP-9529,CDM,C1764,HCPCS,278,RC,,,outpatient,,,13348.24,9343.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3453.189688,399.86,14243.66592,percent of total billed charges,,,
MONITOR CARD IMPL CNFRM 18.5MMX56.3MM 6.5ML 12GM FRZDR LRDTC -,SUP-DM2100,CDM,C1764,HCPCS,278,RC,,,outpatient,,,11346.93,7942.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2935.450791,399.86,14243.66592,percent of total billed charges,,,
LOOP RECORDER NEXT GEN JOT DX REF: DM4500 -,SUP-DM4500,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4418.54426,399.86,14243.66592,percent of total billed charges,,,
LOOP RECORDER ASSERT IQ3+ ICM REF: DM5300 -,SUP-DM5300,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4418.54426,399.86,14243.66592,percent of total billed charges,,,
LOOP RECORDER ASSERT IQ EL+ ICM REF: DM5500 -,SUP-DM5500,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17636.75,12345.725,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4562.627225,399.86,14243.66592,percent of total billed charges,,,
REVEAL LINQ ICM SYSTEM LOOP RECORDER MDT -,SUP-LINQSYS,CDM,C1764,HCPCS,278,RC,,,outpatient,,,17246.89,12072.823,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4461.770443,399.86,14243.66592,percent of total billed charges,,,
LOOP RECORDER REVEAL LINQ II SYSTEM REF: LNQ22SYS -,SUP-LNQ22SYS,CDM,C1764,HCPCS,278,RC,,,outpatient,,,18546.44,12982.508,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4797.964028,399.86,14243.66592,percent of total billed charges,,,
LUX DX INSERTABLE CARDIAC MONITOR M301 -,SUP-M301,CDM,C1764,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4322.48895,399.86,14243.66592,percent of total billed charges,,,
LUX -DX II+ INSERTABLE CARDIAC MONITOR REF: M312 -,SUP-M312,CDM,C1764,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4322.48895,399.86,14243.66592,percent of total billed charges,,,
GELFILM OPTH -,SUP-0009-0297-03,CDM,C1765,HCPCS,278,RC,,,outpatient,,,1102.46,771.722,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,247.50227,1378.95936,other,Non-Reimbursable Procedures,,
"BARRIER ADHESION SEPRAFILM 5 X 6"" -",SUP-430102,CDM,C1765,HCPCS,278,RC,,,outpatient,,,1691.39,1183.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,247.50227,1378.95936,other,Non-Reimbursable Procedures,,
BARRIER INTERCEED 3X4 -,SUP-4350,CDM,C1765,HCPCS,278,RC,,,outpatient,,,1795.52,1256.864,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,247.50227,1378.95936,other,Non-Reimbursable Procedures,,
FLEXCATH CONTOUR STERERABLE SHEATH REF:10FCC13 -,SUP-10FCC13,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,109.158635,4260.1272,other,Non-Reimbursable Procedures,,
FLEXCATH CONTOUR STERRABLE SHEATH 10FRX20MM REF:10FCC20 -,SUP-10FCC20,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,109.158635,4260.1272,other,Non-Reimbursable Procedures,,
FLEXCATH CONTOUR STEERABLE SHEATH 12FRx13MM REF:12FCC13 -,SUP-12FCC13,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,109.158635,4260.1272,other,Non-Reimbursable Procedures,,
FLEXCATH CONTOUR STEERABLE SHEATH 12FRx20MM REF:12FCC20 -,SUP-12FCC20,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,109.158635,4260.1272,other,Non-Reimbursable Procedures,,
FARADRIVE STEERABLE SHEATH REF: 21C602 -,SUP-21C602,CDM,C1766,HCPCS,272,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,109.158635,4260.1272,other,Non-Reimbursable Procedures,,
AGILIS SHEATH SMALL -SJM  8.5FRX91CM -,SUP-408309,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4139.92,2897.944,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,109.158635,4260.1272,other,Non-Reimbursable Procedures,,
SHEATH AGILIS SM- REPROC 8.5FR -,SUP-408309,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2639.83,1847.881,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,109.158635,4260.1272,other,Non-Reimbursable Procedures,,
AGILIS SHEATH  MED - SJM 8.5FR X 91CM -,SUP-408310,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4267.96,2987.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,109.158635,4260.1272,other,Non-Reimbursable Procedures,,
INTRO SHTH FLEXCATH ADVANCE 12FR -,SUP-4FC12,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,109.158635,4260.1272,other,Non-Reimbursable Procedures,,
CATH ABLT CARTO 3 XTRN REF -,SUP-CREFP6,CDM,C1766,HCPCS,272,RC,,,outpatient,,,486.23,340.361,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,109.158635,4260.1272,other,Non-Reimbursable Procedures,,
SHEATH AGILIS LGE- REPROC  8.5FR -,SUP-G408234,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2473.84,1731.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,109.158635,4260.1272,other,Non-Reimbursable Procedures,,
AGILIS SHEATH LRG CURL SFT 3MM J FNGR SJM -,SUP-G408324,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4172.48,2920.736,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,109.158635,4260.1272,other,Non-Reimbursable Procedures,,
SHEATH POLARSHEATH STEERABLE SHEATH REF:M004CRBS3150 -,SUP-M004CRBS3150,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,109.158635,4260.1272,other,Non-Reimbursable Procedures,,
AMULET STEERABLE DELIVERY SHEATH REF: STRBL-14F-075 -,SUP-STRBL-14F-075,CDM,C1766,HCPCS,272,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,109.158635,4260.1272,other,Non-Reimbursable Procedures,,
TOURGUIDE 7FR X 55CM -,SUP-TG0705509,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,109.158635,4260.1272,other,Non-Reimbursable Procedures,,
SHEATH 6.5 FR. 55CM -,SUP-UNDEFINED,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,109.158635,4260.1272,other,Non-Reimbursable Procedures,,
SHEATH GRAFT 7FR. 9MM 45CM -,SUP-UNDEFINED,CDM,C1766,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,109.158635,4260.1272,other,Non-Reimbursable Procedures,,
GENERATOR NEURSTM INTSTM TI 60MMX55MM SCRL NRV MRI-COND -,SUP-3023,CDM,C1767,HCPCS,278,RC,,,outpatient,,,36758.7,25731.09,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9509.47569,399.86,39874.22976,percent of total billed charges,,,
INTERSTIM STIMULATOR EXTERNAL NEURO -,SUP-353101,CDM,C1767,HCPCS,278,RC,,,outpatient,,,1987.69,1391.383,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,514.215403,399.86,39874.22976,percent of total billed charges,,,
PROCLAIM 5 ELITE -,SUP-3660ANS,CDM,C1767,HCPCS,278,RC,,,outpatient,,,40409.46,28286.622,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10453.9273,399.86,39874.22976,percent of total billed charges,,,
NEUROSTIMULATOR PROCLAIM 5 -,SUP-3661,CDM,C1767,HCPCS,278,RC,,,outpatient,,,45984.88,32189.416,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11896.28846,399.86,39874.22976,percent of total billed charges,,,
PROCLAIM 7 PULSE GENERATOR -,SUP-3663,CDM,C1767,HCPCS,278,RC,,,outpatient,,,44998.08,31498.656,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11641.0033,399.86,39874.22976,percent of total billed charges,,,
PROCLAIM DRG IPG 5.3AHG MRI EIFU RED -,SUP-3664,CDM,C1767,HCPCS,278,RC,,,outpatient,,,51919.57,36343.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13431.59276,399.86,39874.22976,percent of total billed charges,,,
DEVICE NEURSTM PRIM ADVANCED 2.6INX1.9IN PERC MRI-COND -,SUP-377-02,CDM,C1767,HCPCS,278,RC,,,outpatient,,,29604,20722.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7658.5548,399.86,39874.22976,percent of total billed charges,,,
NEURSTM PRGM ITREL 60MMX55MM SPIN CRD PRIM CELL -,SUP-377-03,CDM,C1767,HCPCS,278,RC,,,outpatient,,,27012.08,18908.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6988.025096,399.86,39874.22976,percent of total billed charges,,,
INS 977006 PAIN PC M -,SUP-977006,CDM,C1767,HCPCS,278,RC,,,outpatient,,,50457.55,35320.285,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13053.36819,399.86,39874.22976,percent of total billed charges,,,
NEURSTM IMPL PRIM ADVANCED 65X49X15MM SPIN CRD MRI-COND -,SUP-9770-2,CDM,C1767,HCPCS,278,RC,,,outpatient,,,32564.4,22795.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8424.41028,399.86,39874.22976,percent of total billed charges,,,
INTELLIS BATTERY #97715 -,SUP-97715,CDM,C1767,HCPCS,278,RC,,,outpatient,,,44376.4,31063.48,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11480.17468,399.86,39874.22976,percent of total billed charges,,,
INTERSTIM X NEUROSTIMULATOR IMPLANT -,SUP-97800,CDM,C1767,HCPCS,278,RC,,,outpatient,,,26510.38,18557.266,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6858.235306,399.86,39874.22976,percent of total billed charges,,,
PLEDGET FELT PTFE BARD 6 X 6IN -,SUP-007837,CDM,C1768,HCPCS,278,RC,,,outpatient,,,589.34,412.538,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT HEMA MDV BIF 20 10 40 -,SUP-0085201,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT VASC 20MM 15CM HEMASHLD GOLD STR KNTD DBL VELR AOR BVN -,SUP-095120,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1996.38,1397.466,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT HEMA 16MM 30CM MDV -,SUP-095216,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2628.78,1840.146,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT HEMA 18MM 30CM MDV -,SUP-095218,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2628.78,1840.146,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT VASC 22MM 30CM HEMASHLD GOLD STR KNTD DBL VELR AOR BVN -,SUP-095222,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2628.78,1840.146,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT VASC 1X6CM GORE-TEX 0.6MM PTCH -,SUP-1702515006,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2581.34,1806.938,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT HEMASHIELD D:28MM L:30CM -,SUP-175428P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT VASC 32MM 32X30CM HEMASHLD PLTNM STR WVN AOR COLL -,SUP-175432P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT VASC 38MMX30CM HEMASHLD PLTNM FINESSE STR WVN AOR BVN -,SUP-175438P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT VASC 20MM THOR 10MM BRNCH 50CM HEMASHLD PLTNM STR 20CM -,SUP-175820P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5377.66,3764.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT VASC 26MM THOR 10MM/10MM/8MM/8MM ID BRNCH 50CM -,SUP-175926P,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6299.92,4409.944,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT VASC 7X10CM GORE-HYBRID PRECLUDE 0.1MM MEMBR PERICARD -,SUP-1PCM001,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1812.77,1268.939,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT ATRIUM VXT 4 7 45CM  - DISCONTINUED DO NOT USE -,SUP-22115,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2091.84,1464.288,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
KT INFL 20/20 PRIORITY PACK -,SUP-22297,CDM,C1768,HCPCS,278,RC,,,outpatient,,,227.57,159.299,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT VASC 6MM 50CM FLIXENE STR GRAD WL REINF SFT WRP TNLR -,SUP-25058,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5114.4,3580.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT VASC 6MM 40CM FLIXENE STR GRAD WL REINF SFT WRP TNLR -,SUP-25061,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4720.98,3304.686,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT VASC 4-7MM 30CM FLIXENE STR REINF SFT-WRP TNLR ATTCH -,SUP-25098,CDM,C1768,HCPCS,278,RC,,,outpatient,,,9358.02,6550.614,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT FLIXENE GTW GW 4 7 35 -,SUP-25129,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6294.62,4406.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT VASC 8MM 80CM STR HEP FUSION BIOLINE CTD RNG SUPP -,SUP-503088B,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10403.74,7282.618,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
VALVE AOR 6-30MM CRYOVALVE CONDT -,SUP-AV00,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39965.4,27975.78,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT STENT BIFURCATED -,SUP-BEA22-70/I16-30,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
AFX2 BIFURCATED ENDOGRAFT SYSTEM -,SUP-BEA25-80/113-40,CDM,C1768,HCPCS,278,RC,,,outpatient,,,14944.83,10461.381,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT STENT BIFURCATED -,SUP-BEA25-80/I20-40,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT STENT 90MM 28MM 16MM AFX2 2 BRANCH MAIN BODY ILIAC LIM -,SUP-BEA28-90/I16-30,CDM,C1768,HCPCS,278,RC,,,outpatient,,,39222.83,27455.981,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT VASC 7X15CM CORMATRIX PERICARD COLL GRW FACT PRTN -,SUP-CMCV-003-402,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT DISTAFLO VASCULAR 6X70 -,SUP-DFM7006SC,CDM,C1768,HCPCS,278,RC,,,outpatient,,,30067.87,21047.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
PATCH BOVINE 0.8 X 8CM DURAVESS PERICARDIAL -,SUP-DP08X8,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1126.45,788.515,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
PATCH BOVINE 2 X 9 DURAVESS PERICARDIUM -,SUP-DP2X9,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1655.24,1158.668,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT VASC 4-7MM 45CM ACUSEAL -,SUP-ECH470045A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6675.81,4673.067,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT ZENITH FLEX LEG 20X56 -,SUP-G55241,CDM,C1768,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT GORE PROPATEN 6 X 40 -,SUP-H060040A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4766.01,3336.207,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT GORE H470045A -,SUP-H470045A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5661.5,3963.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
PROPATEN AXILLO BIFEMORAL VASC GRAFT -,SUP-HAX02A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,17306.29,12114.403,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT VASC 26X34MM SKRT 15CM CARDIOROOT 26MM SKRT 10MM CLLR -,SUP-HEWROOT0026,CDM,C1768,HCPCS,278,RC,,,outpatient,,,8640.74,6048.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT VASC 6MM 70CM HEMAGARD STR 0.49MM KNTD RVRS LOCKNIT -,SUP-HGK000670,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2112.2,1478.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT VASC PROPATEN 6 X 80 -,SUP-HT066080A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10957.06,7669.942,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
PROPATEN VASCULAR GRAFT 7MM X 80CM -,SUP-HT076080A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10957.06,7669.942,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT PROPATEN 8 X 70 -,SUP-HT087080A,CDM,C1768,HCPCS,278,RC,,,outpatient,,,11287.52,7901.264,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT FUSION BIOLINE 6 X 80 RING SUPPORTED -,SUP-M00201503086B0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,10403.74,7282.618,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT CARDIOVASCULAR HEMASHIELD GOLD MDV BIF 14X7 40CM -,SUP-M002020851470,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT 16X8 40CM HEMA BIF MDV -,SUP-M002020851680,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT HEMA MDV BIF 18X9 40CM -,SUP-M002020851890,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT HEMA MDV BIF 22X11X40 -,SUP-M002020852210,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3384.67,2369.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT HEMASHIELD D:6MM L:15CM GOLD -,SUP-M002020951060,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1879.03,1315.321,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT HEMASHIELD D:8MM L:15CM GOLD -,SUP-M002020951080,CDM,C1768,HCPCS,278,RC,,,outpatient,,,1879.03,1315.321,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT HEMASHIELD GOLD 10MM X 30CM -,SUP-M002020954100,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2538.41,1776.887,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT HEMASHIELD D:10MM L:30CM GOLD -,SUP-M002020954100,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2538.41,1776.887,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT VASC 8MM 30CM HEMASHLD PLTNM STR WVN DBL VELR AOR BVN -,SUP-M00202175208P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2473.41,1731.387,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT HEMASHIELD 22MM X 30CM -,SUP-M00202175422P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2644.27,1850.989,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT HEMASHIELD D:24MM L:30CM -,SUP-M00202175424P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2644.27,1850.989,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT HEMASHIELD D:26MM L:30CM -,SUP-M00202175426P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT HEMASHIELD D:30MM L:30CM -,SUP-M00202175430P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT HEMASHIELD D:32MM L:30CM -,SUP-M00202175432P0,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2750.06,1925.042,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
PERICARDIUM PERIGUARD 6X8 -,SUP-PC0608SNBIO,CDM,C1768,HCPCS,278,RC,,,outpatient,,,2602.81,1821.967,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
PERICARDIUM PEROGIARD 8X14 -,SUP-PC0814SNBIO,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3079.33,2155.531,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT VASC 6MM 40CM GORE-TEX STR 30CM RNG SECT THNWL STRCH -,SUP-RRT06030040L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3933.78,2753.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT VASC 6MM 70CM GORE-TEX STR 60CM RNG SECT THNWL STRCH -,SUP-RRT06060070L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5648.76,3954.132,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT VASC 8MM 40CM GORE-TEX STR 30CM RNG SECT THNWL STRCH -,SUP-RRT08030040L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3933.78,2753.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT VASC 6MM 50CM GORE-TEX STR STD WL STRCH EPTFE -,SUP-S0605,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3403.86,2382.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT VASC 14X7MM 40CM GORE-TEX BIFUR THNWL STRCH EPTFE -,SUP-SBT1401D,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4303.42,3012.394,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT VASC 16X8MM 40CM GORE-TEX BIFUR THNWL STRCH -,SUP-SBT1601,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4000.61,2800.427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
STRETCH THIN WALL BIFURCATED GRAFT 16-8MM X 50CM -,SUP-SBT1602D,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5377.15,3764.005,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT VASC 8MM 40CM GORE-TEX STR THNWL STRCH LN REM RNG AOR -,SUP-SRRT08030040L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4387.31,3071.117,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT VASC 8MM 80CM GORE-TEX STR 70CM RNG SECT THNWL -,SUP-SRRT08070080L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,7032.31,4922.617,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT VASC 6MM 40CM GORE-TEX STR THNWL STRCH AOR EPTFE -,SUP-ST0604,CDM,C1768,HCPCS,278,RC,,,outpatient,,,3232,2262.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT VASC 6MM 80CM GORE-TEX -,SUP-ST0608,CDM,C1768,HCPCS,278,RC,,,outpatient,,,5330.46,3731.322,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
AORTIC BODY ALTO TM ABDOMINAL STENT GRAFT -,SUP-TV-AB2080-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
ALTO ABDOMINAL STENT GRAFT SYSTEM 23MM -,SUP-TV-AB2380-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
ALTO ABDOMINAL STENT GRAFT SYSTEM 26MM -,SUP-TV-AB2680-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
OVATION IX ABDOMINAL STENT GRAFT SYSTEM 29MM ALTO -,SUP-TV-AB2980-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
ALTO ABDOMINAL STENT GRAFT SYSTEM 34MM -,SUP-TV-AB3480-N,CDM,C1768,HCPCS,278,RC,,,outpatient,,,36634.95,25644.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
ILIAC GRAFT OVATION IX 10 X 160MM -,SUP-TV-IL1410160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT STENT TRIVASCULAR OVATION IX 12 X 140 ILIAC LIMB -,SUP-TV-IL1412140-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
ILIAC GRAFT 14 X 100MM -,SUP-TV-IL1414100-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
OVATION IX ILAC STENT GRAFT 14 X 160MM -,SUP-TV-IL1414160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
OVATION IX ILIAC STENT GRAFT 18MM X 140MM -,SUP-TV-IL1418140-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT STENT OVATION IX ILIAC LIMB 18 X 160MM -,SUP-TV-IL1418160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
OVATION IX 22 X 100MM -,SUP-TV-IL1422100-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT STENT TRIVASCULAR OVATION IX 28 X 120 ILIAC LIMB -,SUP-TV-IL1428120-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT STENT TRIVASCULAR OVATION IX 28 X 160 ILIAC LIMB -,SUP-TV-IL1428160-J,CDM,C1768,HCPCS,278,RC,,,outpatient,,,22463.65,15724.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT HUM TIS VEIN CRYPRSR CRYOVEIN SAPHENOUS -,SUP-V010,CDM,C1768,HCPCS,278,RC,,,outpatient,,,30011.06,21007.742,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT VASC 6MM 50CM VENAFLO II STR CRBN IMPREG EPTFE CUF -,SUP-VL5006C,CDM,C1768,HCPCS,278,RC,,,outpatient,,,6999.2,4899.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GRAFT VASC 6MM 80CM GORE-TEX THNWL LN EPTFE -,SUP-VT06080L,CDM,C1768,HCPCS,278,RC,,,outpatient,,,4621.23,3234.861,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,51.089465,30693.4272,other,Non-Reimbursable Procedures,,
GUIDEWIRE SPRING TIP REUSABLE MARKED -,SUP-000150,CDM,C1769,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.038INX260CM 3MM JTP TAPR FXCR STD PTFE-CTD 6CM -,SUP-00-8634,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.43,38.801,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW CATH 0.025IN GW LNR SS PTFE-CTD -,SUP-0684-00-0254-09,CDM,C1769,HCPCS,272,RC,,,outpatient,,,123.7,86.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX300CM HTORQ ALL STAR STR XTR SUPP INTMD -,SUP-1001741,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
HI-TORQUE SUPRACORE 35 (300cm) -,SUP-1002703-02,CDM,C1769,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.018INX190CM HTORQ STLCOR 18 STR FLXB SFT SS MICGLD -,SUP-1003281,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.018INX300CM HTORQ STLCOR 18 STR FLXB SFT SS MICGLD -,SUP-1003282,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX190CM HTORQ XIT 100XT STR SS/CTD 3CM 1.7GM -,SUP-1003309H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
SPARTA CORE 190CM ST -,SUP-1005202,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
SPARTACORE 14 WIRE (0.014IN- 300CM) -,SUP-1005203,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX190CM HTORQ SPARTACORE STR SFT SS SHFT -,SUP-1005205,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX300CM HTORQ SPARTACORE STR SFT SS SHFT -,SUP-1005206,CDM,C1769,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX190CM HTORQ  WHISPER MS STR SFT DURASTEEL -,SUP-1005357H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX300CM HTORQ WHISPER MS STR SFT DURASTEEL/ -,SUP-1005359H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX190CM HTORQ BAL MDWT UNIV STR RBN INTMD -,SUP-1009660,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDEWIRE HI-TORQUE BALANCE MIDDLEWEIGHT UNIVERSAL II 190CM -,SUP-1009664,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX190CM HTORQ PILOT 50 STR SFT DURASTEEL/ -,SUP-1010480-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX190CM HTORQ PILOT 150 STR STF DURASTEEL/ -,SUP-1010481-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX190CM HTORQ PILOT 200 STR DURASTEEL/ SS/CTD -,SUP-1010482-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX300CM HTORQ PILOT 50 STR SFT DURASTEEL/ -,SUP-1010483-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX300CM HTORQ PILOT 150 STR DURASTEEL/ SS/CTD -,SUP-1010484-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX300CM HTORQ PILOT 200 STR SFT DURASTEEL -,SUP-1010485-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
HI-TORQUE WHISPER GUIDE WIRE -,SUP-1011835H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX180CM ASAHI FIELDER F C STR XTR SUPP CTD 3CM -,SUP-1011895-H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDEWIRE HI-TORQUE COMMAND 18 ST WORKHORSE 0.018IN x 210CM -,SUP-1013730,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.018INX300CM HTORQ COMMAND ES SS/NTNL/CTD 30CM -,SUP-1013731,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDEWIRE VERRATA 185 CM STRAIGHT TIP -,SUP-10185,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDEWIRE VERRATA 185 CM J-TIP -,SUP-10185J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDEWIRE VERRATA PLUS 185 CM J-TIP -,SUP-10185JP,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDEWIRE VERRATA 300 CM STRAIGHT TIP -,SUP-10300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDEWIRE VERRATA 300 CM J-TIP -,SUP-10300J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDEWIRE VERRATA PLUS 300 CM J-TIP -,SUP-10300JP,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDEWIRE VERRATA PLUS 300 CM STRAIGHT TIP -,SUP-10300P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
ST INTUB 11FRX110CM RTRGD 0.38IN STR/3MM J WG INTRO NDL SYR -,SUP-110-70-38J-110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1022.29,715.603,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INSHRTX182CM CHC STR SPR COIL HYDRCT SS -,SUP-12132-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,480.8,336.56,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDEWIRE ASAHI PROWATER 180 L -,SUP-12776-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX300CM ASAHI MIRACLEBROS 3 STR STEER FLXB SS -,SUP-14937-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW URO 0.38IN NTNL -,SUP-150NSA38,CDM,C1769,HCPCS,272,RC,,,outpatient,,,221.73,155.211,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW URO 0.038INX150CM NICORE NTNL HYDRCT STR STF COR -,SUP-150NSS38,CDM,C1769,HCPCS,272,RC,,,outpatient,,,221.73,155.211,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.009INX180CM ASAHI CONFIANZA PRO PTCA STR STEER -,SUP-20629-01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDEWIRE VASCULAR HI-TORQUE COMMAND 0.014IN X 190CM -,SUP-2078174,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX300CM HTORQ COMMAND ES SS/NTNL/CTD 30CM -,SUP-2078175,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014IN/0.018IN DIA 145CM -,SUP-22260,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX190CM HTORQ FLPY II JTP RBN LGT SUPP SFT SS -,SUP-22339MJ,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX300CM HTORQ FLPY II STR RBN LGT SUPP SFT SS -,SUP-22359M,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX300CM HTORQ FLPY II JTP RBN LGT SUPP SFT SS -,SUP-22359MJ,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX300CM HTORQ WIGGLE STR RBN SS HYDRPHB -,SUP-22359M-W2,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX300CM HTORQ TRAV STR STD SHFT SS/CTD 3CM -,SUP-22379H,CDM,C1769,HCPCS,272,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WIRE FLTR DLV BAREWIRE 0.014INX315CM SS COR PTFE-CTD -,SUP-22440-31,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX180CM RUNTHROUGH NS STR STEER EXTEND WIRE SS -,SUP-25-1011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX300CM RUNTHROUGH NS STR WIRE SS -,SUP-25-1013,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDE WIRE PTCA RUNTHROUGH NS HYPERCOAT 0.014X180CM -,SUP-25-3011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX150CM RUNTHROUGH NS STEER EXTEND WIRE SS -,SUP-25-9092,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.035INX260CM STR FXCR PTFE-CTD -,SUP-395369,CDM,C1769,HCPCS,272,RC,,,outpatient,,,218.81,153.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.035INX200CM STR FXCR PTFE-CTD -,SUP-395703,CDM,C1769,HCPCS,272,RC,,,outpatient,,,218.81,153.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC GUIDERIGHT 0.035INX150CM  3MM J REF:404570 -,SUP-404570,CDM,C1769,HCPCS,272,RC,,,outpatient,,,40.85,28.595,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDEWIRE GUIDERIGHT 3 MM J CURVE  L180 CM L5 CM OD.035 -,SUP-404571,CDM,C1769,HCPCS,272,RC,,,outpatient,,,43.76,30.632,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDEWIRE VASCULAR GUIDERIGHT J CURVE L260 CM L5 CM OD.35 -,SUP-404577,CDM,C1769,HCPCS,272,RC,,,outpatient,,,93.36,65.352,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDEWIRE VASCULAR GUIDERIGHT BENTSON L150 CM L15 CM OD.035 -,SUP-404843,CDM,C1769,HCPCS,272,RC,,,outpatient,,,54.27,37.989,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 190CM WHISPER VW HTORQ -,SUP-4483,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC WHISPER VW HTORQ -,SUP-4639,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDEWIRE EMERALD 0.35INx260CM J TIP  FLEX FIXED CORE PTFE -,SUP-502455,CDM,C1769,HCPCS,272,RC,,,outpatient,,,52.52,36.764,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.038INX150CM EMERLD 3MM JTP FXCR FLXB STD PTFE-CTD -,SUP-502-520,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.14,38.598,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.032INX150CM EMERLD 3MM JTP FXCR FLXB STD PTFE-CTD -,SUP-502-526,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.14,38.598,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.035INX150CM EMERLD STR FXCR FLXB STD PTFE-CTD 7CM -,SUP-502-542,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.14,38.598,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.035INX300CM STORQ ANG STEER 1PC COR SFT SGL OUTR -,SUP-503-356Y,CDM,C1769,HCPCS,272,RC,,,outpatient,,,404.37,283.059,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX300CM STBR + STR STEER S-SFT 3CM -,SUP-507-114X,CDM,C1769,HCPCS,272,RC,,,outpatient,,,349.22,244.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX300CM STBR XS STR STEER XTR SUPP SFT -,SUP-527-300E,CDM,C1769,HCPCS,272,RC,,,outpatient,,,560.16,392.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
PLATE LEFT ANTER LATERAL -,SUP-630111,CDM,C1769,HCPCS,272,RC,,,outpatient,,,10381.67,7267.169,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDEWIRE WARRIOR 200CM REF: 7388 -,SUP-7388,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1131.99,792.393,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDEWIRE R350 350CM REF: 7390 -,SUP-7390,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1367.53,957.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDEWIRE BANDIT 200CM REF: 7444 -,SUP-7444,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1131.99,792.393,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WIRE GUIDE .035X260 STIFF SUPER -,SUP-80129-406,CDM,C1769,HCPCS,272,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX300CM ASAHI PROWATER FLEX STR FLXB SPR COIL -,SUP-82358-02,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
"GUIDEWIRE 0.014"" X300CM PTCA STRAIGHT -",SUP-82902-02,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
PRESSURE GUIDEWIRE OMNIWIRE 185CM STRAIGHT TIP REF:89185 -,SUP-89185,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
PRESSURE GUIDEWIRE OMNIWIRE 185CM J-TIP REF:89185J -,SUP-89185J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3461.15,2422.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.035INX260CM AMPLATZER MOD 1.5MM JTP NOODLEWIRE -,SUP-9-GW-002,CDM,C1769,HCPCS,272,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
EXTENSION GW ASAHI -,SUP-AG14900-0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDEWIRE VASCULAR MIRACLEBROS 6 L180 CM OD.014 IN STERILE L -,SUP-AG14M060,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDEWIRE ASAHI MIRACLEBROS 6 300CM DUPLICATE -,SUP-AG14M360,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
W VASC 0.014INX300CM ASAHI MIRACLEBROS 12 STR STEER FLXB SS -,SUP-AG14M370,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX300CM ASAHI CONFIANZA 9 STR XTR SUPP SPR -,SUP-AGH143390,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDEWIRE ASAHI PROWATER 300 CM .014 -,SUP-AGH146300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.009INX180CM ASAHI FIELDER F C PTCA JTP 1.2GM LD -,SUP-AGP1400-01J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.009INX190CM ASAHI FIELDER XT STR SPR COIL -,SUP-AGP140002,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.009INX300CM ASAHI FIELDER XT STR SPR COIL -,SUP-AGP140302,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDE WIRE ASAHI SION BLUE 180/190CM -,SUP-AHW14R004S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,495.98,347.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GAIA FIRST 190CM MICRO J -,SUP-AHW14R007P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GAIA SECOND 190CM MICRO J -,SUP-AHW14R008P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GAIA THIRD 190CM MICRO J -,SUP-AHW14R011P,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX300CM ASAHI SOFT STR STEER COR-TO-TIP SS -,SUP-AHW14R304S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,490.14,343.098,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW GLADIUS MONGO190CM REF: AP14R023S -,SUP-AP14R023S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW FIELDER XT-A 190CM REF: APW14R009S -,SUP-APW14R009S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDE WIRE ASAHI SION BLACK 190CM STRAIGHT REF:APW14R010S -,SUP-APW14R010S,CDM,C1769,HCPCS,272,RC,,,outpatient,,,566,396.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDE WIRE DOUBLE ENDED TROCAR .86MM -,SUP-AR-8737-39KD,CDM,C1769,HCPCS,272,RC,,,outpatient,,,175.05,122.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDE SPRING WIRE .018D 25CM -,SUP-AW-04018,CDM,C1769,HCPCS,272,RC,,,outpatient,,,53.92,37.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.018INX25CM 2FLX STR DBL END SPR WIRE SS -,SUP-AW-04018,CDM,C1769,HCPCS,272,RC,,,outpatient,,,53.92,37.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
"GUIDE SPRING WIRE .032"" -",SUP-AW-04432,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.08,38.556,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 175CM PRESSUREWIRE CERTUS SS NTNL PTFE-CTD -,SUP-C12008,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
PRESSUREWIRE X GUIDEWIRE 0.014INX175CM -,SUP-C12059,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 300CM PRESSUREWIRE CERTUS STEER CTD -,SUP-C12308,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
PRESSUREWIRE X GUIDEWIRE .014MMX300CM -,SUP-C12358,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.035INX260CM TIGRWRE ANG TAPR STEER FLXB FLPY SFT -,SUP-C405085,CDM,C1769,HCPCS,272,RC,,,outpatient,,,390.95,273.665,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.035INX180CM TIGRWRE ANG TAPR STEER FLXB FLPY SFT -,SUP-C405086,CDM,C1769,HCPCS,272,RC,,,outpatient,,,390.95,273.665,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
INTRO LAP 6MM SHTH 18GA 50CM -,SUP-C-LASS-6-10,CDM,C1769,HCPCS,272,RC,,,outpatient,,,431.79,302.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
ST CRICO MLKR 5MM PTFE XSTIF WG ENTRY NDLHLDR CUP GZE -,SUP-C-TCCSB-500-UNI,CDM,C1769,HCPCS,272,RC,,,outpatient,,,2450.49,1715.343,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
CPS EXCEL MEDIGUIDE MEDIUM GUIDEWIRE -,SUP-DS2M028,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
CPS EXCEL MEDIGUIDE STIFF GUIDEWIRE -,SUP-DS2M029,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
MEDIGUIDE GUIDEWIRE TORQUE CLIP -,SUP-DS2M030,CDM,C1769,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.035INX145CM STR 3MM JTP DBL END FLPY SS HEP -,SUP-G00362,CDM,C1769,HCPCS,272,RC,,,outpatient,,,93.3,65.31,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
W 15J .035 145CM x 15MM CURVE -,SUP-G00509,CDM,C1769,HCPCS,272,RC,,,outpatient,,,67.04,46.928,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.035INX145CM 3MM JTP CRV FXCR STD FLXB SS NO HEP -,SUP-G00511,CDM,C1769,HCPCS,272,RC,,,outpatient,,,67.04,46.928,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WIRE GUIDE .035 260 SAFE-T-J T -,SUP-G00517,CDM,C1769,HCPCS,272,RC,,,outpatient,,,104.97,73.479,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.035INX50CM 3MM NWTN JTP FNGR STR FXCR FLXB FLPY -,SUP-G00524,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.63,57.141,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WIRE GUIDE FIXED CORE 3MM J CURVED -,SUP-G00524,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.63,57.141,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.038INX145CM 3MM JTP FXCR FLXB SS HEP PTFE-CTD 6CM -,SUP-G00541,CDM,C1769,HCPCS,272,RC,,,outpatient,,,67.04,46.928,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WIRE GUIDE FIXED CORE STRAIGHT -,SUP-G00650,CDM,C1769,HCPCS,272,RC,,,outpatient,,,55.37,38.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
W BENTSON .035 145CM -,SUP-G00691,CDM,C1769,HCPCS,272,RC,,,outpatient,,,87.47,61.229,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.035INX180CM SAFE-T-J-TIP FXCR FLPY SS PTFE-CTD -,SUP-G00902,CDM,C1769,HCPCS,272,RC,,,outpatient,,,72.88,51.016,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
W .035 260 BENTSON TSFB-35-260 -,SUP-G01063,CDM,C1769,HCPCS,272,RC,,,outpatient,,,116.64,81.648,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.035INX260CM CRV RSN TIP FXCR FLPY W/OUT HEP -,SUP-G01253,CDM,C1769,HCPCS,272,RC,,,outpatient,,,104.97,73.479,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
THSCF 35 260 1.5 ROSEN 43700 -,SUP-G01253,CDM,C1769,HCPCS,272,RC,,,outpatient,,,104.97,73.479,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
W THSCF-35-180-1.5 ROSEN WIRE -,SUP-G01264,CDM,C1769,HCPCS,272,RC,,,outpatient,,,78.71,55.097,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WTSFB-35-180 BENTSON -,SUP-G01290,CDM,C1769,HCPCS,272,RC,,,outpatient,,,96.22,67.354,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.025INX180CM 3MM JTP FXCR STD FLXB SS HEP PTFE-CTD -,SUP-G01602,CDM,C1769,HCPCS,272,RC,,,outpatient,,,84.55,59.185,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WIRE GUIDE 0.032 IN X180CM SAFE T JTP PTFE-C  - G02335 -,SUP-G02335,CDM,C1769,HCPCS,272,RC,,,outpatient,,,84.55,59.185,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WIRE GUIDE 0.032 IN X260CM SAFE T J HEAVY DUTY - G03133 -,SUP-G03133,CDM,C1769,HCPCS,272,RC,,,outpatient,,,294.61,206.227,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WIRE AMPLATZ  0.035 INX145CM J CRV TIP XSTIF FLPY SS -,SUP-G03203,CDM,C1769,HCPCS,272,RC,,,outpatient,,,169.16,118.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WIRE AMPLATZ  0.025 IN X 145 OR 180 CM SAFE-T-J XTR-STF -,SUP-G03304,CDM,C1769,HCPCS,272,RC,,,outpatient,,,457.99,320.593,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.035INX180CM AMP STR XSTIF SS PTFE-CTD 7CM TAPR 3CM -,SUP-G03330,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.31,89.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WIRE AMPLATZ 0.032 IN X180CM JTP XSTIF FLPY SS PTFE-CTD -,SUP-G03584,CDM,C1769,HCPCS,272,RC,,,outpatient,,,125.39,87.773,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.038INX80CM AMP STR XSTIF FLPY SS PTFE-CTD 9.5CM -,SUP-G04003,CDM,C1769,HCPCS,272,RC,,,outpatient,,,148.73,104.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
SET CRIC MELKER 3.5MM 3.8CM -,SUP-G06245,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1139.28,797.496,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDEWIRE ROADRUNNER EXTRA SUP -,SUP-G07640,CDM,C1769,HCPCS,272,RC,,,outpatient,,,676.8,473.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 60CM NTNL -,SUP-G08427,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.18,167.426,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
W PMG-18SP-60-COPE-NT -,SUP-G08427,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.18,167.426,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
W PMG-18SP-COPE-NT -,SUP-G08733,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.18,167.426,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
COPE WIRE 60CM ST -,SUP-G09395,CDM,C1769,HCPCS,272,RC,,,outpatient,,,262.52,183.764,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.035INX180CM AMP STR ULTRA STF FLPY SS PTFE-CTD -,SUP-G09956,CDM,C1769,HCPCS,272,RC,,,outpatient,,,119.56,83.692,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WIREGLIDE AMPLATZ EXTRA STIFF 0.035 X 180CM -,SUP-G23639,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.31,89.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
SHORT TAPER AMPLATZ WIRE 1CM -,SUP-G23639,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.31,89.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WIRE UNIGLIDE ANG .018 260CM -,SUP-G30489,CDM,C1769,HCPCS,272,RC,,,outpatient,,,251.48,176.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WIRE UNIGLIDE ANG. .035 260CM -,SUP-G30492,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WIRE UNIGLIDE SIFF STR .035 260CM -,SUP-G30496,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.018INX260CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-G30500,CDM,C1769,HCPCS,272,RC,,,outpatient,,,269.57,188.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WIRE UNIGLIDE STR .018 260CM -,SUP-G30500,CDM,C1769,HCPCS,272,RC,,,outpatient,,,269.57,188.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WIRE UNIGLIDE STR .035 260CM -,SUP-G30502,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WIRE UNIGLIDE STIFF ANG .035 260CM -,SUP-G30506,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.035INX260CM LNDRQST STR XSTIF FLXB SS PTFE-CTD 4CM -,SUP-G31453,CDM,C1769,HCPCS,272,RC,,,outpatient,,,919.6,643.72,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW ENDO 0.035INX260CM TRACER METRO DRCT -,SUP-G31914,CDM,C1769,HCPCS,272,RC,,,outpatient,,,770.22,539.154,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
ACROBAT STR WIRE GUIDE 260 .03 -,SUP-G34265,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1042.19,729.533,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
SET GASTRONOMY ENTUIT START INIT PLCMT SM FOR 12/14FR -,SUP-G34442,CDM,C1769,HCPCS,272,RC,,,outpatient,,,551.35,385.945,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WIRE GUIDE HIWIRE HYDROPHILIC ANGLED 35 -,SUP-G36284,CDM,C1769,HCPCS,272,RC,,,outpatient,,,215.3,150.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WIRE HI .035 X 150CM STIFF ANGLED -,SUP-G36290,CDM,C1769,HCPCS,272,RC,,,outpatient,,,215.3,150.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WIRE HI .035 X 260CM STIFF STRAIGHT -,SUP-G36327,CDM,C1769,HCPCS,272,RC,,,outpatient,,,308.08,215.656,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WIRE GUIDE EX-STIFF 35-300 LUN -,SUP-G45408,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1025.79,718.053,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.035INX450CM ACROBAT 2 CTD -,SUP-G47616,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1038.63,727.041,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX190CM PRO-LT NTNL/PTFE-CTD/SS/PD 8CM TAPR -,SUP-G47736,CDM,C1769,HCPCS,272,RC,,,outpatient,,,339.6,237.72,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
LUNDERQUIST WIRE 0.035 x 180CM -,SUP-G49228,CDM,C1769,HCPCS,272,RC,,,outpatient,,,593.41,415.387,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WIRE METRO TRACER .035 X 600 -,SUP-G50660,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1298.62,909.034,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX190CM CTO MICROWIRE FLPY SS/PTFE-CTD/PLTNM -,SUP-G50788,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
CATH CTO 25 GRAM X 014 X 190CM -,SUP-G50789,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
W CTO 6G CMW-14-300-6G -,SUP-G50790,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
W CTO 12G CMW-14-300-12G -,SUP-G50791,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
W CTO 18G GUIDE WIRE -,SUP-G50792,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
W CTO 25G -,SUP-G50793,CDM,C1769,HCPCS,272,RC,,,outpatient,,,921.87,645.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX190CM HYDR ST MICRO FLPY SS/PTFE-CTD/PLTNM -,SUP-G52938,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1038.57,726.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX300CM HYDR ST MICRO FLPY SS/PTFE-CTD/PLTNM -,SUP-G52939,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1038.57,726.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.018INX180CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-G56141,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WIRE UNIGLIDE STR .018 180CM -,SUP-G56141,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WIRE UNIGLIDE STR .035 180CM -,SUP-G56150,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
W GLIDE STIFF .035 180 STR -,SUP-G56153,CDM,C1769,HCPCS,272,RC,,,outpatient,,,308.15,215.705,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WIRE UNIGLIDE STIFF STR .035 180CM -,SUP-G56153,CDM,C1769,HCPCS,272,RC,,,outpatient,,,260.81,182.567,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WIRE UNIGLIDE ANG .018 180CM -,SUP-G56160,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WIRE UNIGLIDE STR .035 260CM -,SUP-G56174,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WIRE UNIGLIDE STIFF ANG .035 180CM -,SUP-G56177,CDM,C1769,HCPCS,272,RC,,,outpatient,,,260.81,182.567,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GLIDEWIRE ADV .014 300CM ANG -,SUP-GA1430,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
W GLIDE ADVANTAGE 300 .018 -,SUP-GA1830,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1431.14,1001.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.035INX150CM GLIDEWIR ADVANTG ANG STF SHFT FLXB STD -,SUP-GA3501,CDM,C1769,HCPCS,272,RC,,,outpatient,,,933.6,653.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
W GLIDE ADVANTAGE 260 .035 -,SUP-GA3502,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.018INX300CM GLIDEWIR GOLD 45DG ANG FLXB -,SUP-GM1831,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1115.94,781.158,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.018INX300CM GLIDEWIR 70DG ANG GOLDBAND FLXB TIP -,SUP-GM1832,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1115.94,781.158,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDEWIRE .018/180 STRAIGHT -,SUP-GR1803,CDM,C1769,HCPCS,272,RC,,,outpatient,,,354.24,247.968,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GLIDEWIRE .018 150 ANGLED -,SUP-GR1805,CDM,C1769,HCPCS,272,RC,,,outpatient,,,354.24,247.968,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WIRE GLIDEWIRE 0.018INX180CM ANG STD FLXB -,SUP-GR1806,CDM,C1769,HCPCS,272,RC,,,outpatient,,,212.38,148.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.018INX260CM GLIDEWIR ANG STF SHFT STD FLXB -,SUP-GR1807,CDM,C1769,HCPCS,272,RC,,,outpatient,,,251.48,176.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
W GLIDE .035 180 STR -,SUP-GR3503,CDM,C1769,HCPCS,272,RC,,,outpatient,,,261.7,183.19,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WIRE GLIDE .035 260 STR -,SUP-GR3504,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.035INX150CM GLIDEWIR ANG STF SHFT STD FLXB -,SUP-GR3506,CDM,C1769,HCPCS,272,RC,,,outpatient,,,194.95,136.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WIRE GLIDE .035 180 ANG  GR3508 -,SUP-GR3508,CDM,C1769,HCPCS,272,RC,,,outpatient,,,261.7,183.19,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WIRE GLIDE .035 260 ANGLED -,SUP-GR3509,CDM,C1769,HCPCS,272,RC,,,outpatient,,,249.73,174.811,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.038INX180CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-GR3803,CDM,C1769,HCPCS,272,RC,,,outpatient,,,261.7,183.19,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.038INX260CM GLIDEWIR STR STF SHFT STD FLXB -,SUP-GR3804,CDM,C1769,HCPCS,272,RC,,,outpatient,,,292.57,204.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDEWIRE VASCULAR GLIDEWIRE NITINOL STRAIGHT 260CM -,SUP-GS3504,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WIRE GLIDE 0.035 IN X 80 CM ANG STIFF -,SUP-GS3505,CDM,C1769,HCPCS,272,RC,,,outpatient,,,297.59,208.313,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WIRE GLIDE STIFF .035 180CM -,SUP-GS3508,CDM,C1769,HCPCS,272,RC,,,outpatient,,,260.81,182.567,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDEWIRE VASCULAR GLIDEWIRE NITINOL HYDROPHILIC ANGLE 260CM -,SUP-GS3509,CDM,C1769,HCPCS,272,RC,,,outpatient,,,312.16,218.512,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.035INX270CM LINEARGUIDEV ANG PTFE-CTD -,SUP-G-V210-3527A,CDM,C1769,HCPCS,272,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC VIPERWIRE .014IN TIP X 325CM -,SUP-GWC-12325LG-FLP,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC VIPERWIRE W/FLEX TIP .014IN TIP X 325CM -,SUP-GWC-12325LG-FT,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX300CM MLMN STR SUPER RAIL SUPP FLXB SPR COIL -,SUP-H74912120012,CDM,C1769,HCPCS,272,RC,,,outpatient,,,480.8,336.56,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDEWIRE MAILMAN 182CM STRAIGHT TIP 0.014 -,SUP-H74912136011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,480.8,336.56,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.14X190CM PLTNM + STR SUPER RAIL SUPP INTMD SPR -,SUP-H74917511,CDM,C1769,HCPCS,272,RC,,,outpatient,,,485.59,339.913,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.035INX300CM PLTNM + STR SUPER RAIL SUPP INTMD SPR -,SUP-H74917521,CDM,C1769,HCPCS,272,RC,,,outpatient,,,485.61,339.927,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.018INX300CM PLTNM + STR SUPER RAIL SUPP INTMD SPR -,SUP-H74917541,CDM,C1769,HCPCS,272,RC,,,outpatient,,,485.61,339.927,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX300CM VCT 14 CTRL WIRE STR SHRT TAPR ICE CTD -,SUP-H74939216730010,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1113.11,779.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
PRESSURE WIRE COMET II -,SUP-H74939359110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3926.81,2748.767,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDEWIRE SAFARI2  0.035 x 0275 CM XSMALL CURVE -,SUP-H74939406XS1,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3007.62,2105.334,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX330CM RTBLTR RTWR FLXB FLPY SS/CTD 2.2CM -,SUP-H74939462005,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1518.31,1062.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.009INX330CM RTWR 1.5MM RSN JTP CRV STF XTR SUPP -,SUP-H74939463005,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1518.31,1062.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX300CM VCT 14 12GM CTRL WIRE STR LNG TAPR -,SUP-H74939470300120,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1219.12,853.384,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX300CM VCT 14 18GM CTRL WIRE STR LNG TAPR -,SUP-H74939470300180,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1219.12,853.384,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX300CM VCT 14 25GM CTRL WIRE STR LNG TAPR -,SUP-H74939471300250,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX300CM VCT 14 30GM CTRL WIRE STR LNG TAPR -,SUP-H74939471300300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
COMET FFR WIRE 555111 -,SUP-H7495551110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,3414.6,2390.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX300CM STINGRAY CTD CONN -,SUP-H749M3004A0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1625.29,1137.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX145CM STINGRAY CTD CONN -,SUP-H749M3010A0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,521.24,364.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX185CM STINGRAY CTD CONN -,SUP-H749M3012A0,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1789.24,1252.468,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX180CM INTUITION STR SS SIL CTD -,SUP-INTU180SS,CDM,C1769,HCPCS,272,RC,,,outpatient,,,169.22,118.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WIRE GUIDE .035 260 INQWIRE REF: IQ35F260J3 -,SUP-IQ35F260J3,CDM,C1769,HCPCS,272,RC,,,outpatient,,,59.63,41.741,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDEWIRE AMPLATZ INQWIRE 0.035 X 71IN STRAIGHT SHORT TIP -,SUP-IQA511,CDM,C1769,HCPCS,272,RC,,,outpatient,,,255.63,178.941,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.035INX150CM ZIPWIRE STR STEER STF SHFT FLXB -,SUP-M00146306B1,CDM,C1769,HCPCS,272,RC,,,outpatient,,,239.24,167.468,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW AMPLATZ 0.035INX180CM J-TIP SUPER STIFF -,SUP-M001465011,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
AMPLATZ WIRE SUPER STIFF  0.035 X 260 J -,SUP-M001465021,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.035IN X 260CM SUPER STIFF AMP STR SHRT TAPR FLXB -,SUP-M001465091,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
W AMPLATZ SS ST 35 145 BX/5 GU -,SUP-M001465231,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.035INX145CM SUPER STIFF AMP STR SHRT TAPR STD -,SUP-M001465241,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.035INX180CM SUPER STIFF AMP STR STD STEER SHFT -,SUP-M001465251,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
W AMPL SS EXCHANGE 260 STR -,SUP-M001465261,CDM,C1769,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
MAGIC TORQUE DLVR GW .035/315CM -,SUP-M001465301,CDM,C1769,HCPCS,272,RC,,,outpatient,,,805.23,563.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
W TORQUE 35 180 MAGIC 46-591 -,SUP-M001465911,CDM,C1769,HCPCS,272,RC,,,outpatient,,,443.46,310.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDEWIRE MAGIC TORQUE STRAIGHT 35-260 -,SUP-M001465921,CDM,C1769,HCPCS,272,RC,,,outpatient,,,443.46,310.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.018INX260CM PLTNM + SHRT TAPR STEER STF SHFT FLXB -,SUP-M001466050,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WIRE PLATINUM PLUS PTFE .014 X -,SUP-M001467120,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
W CON V18 8 200 46-852 -,SUP-M001468520,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDEWIRE V18 18 300    46-854 -,SUP-M001468540,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.018INX200CM 12CM V-18 CTRL WIRE STR STEER SFT SCTN -,SUP-M001468580,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.035INX150CM STRTR 3MM J FNGR STR FXCR STD SPR COIL -,SUP-M001491181,CDM,C1769,HCPCS,272,RC,,,outpatient,,,70.02,49.014,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
J WIRE 0.035 X 180CM -,SUP-M001491201,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.69,57.183,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.035INX260CM STRTR 3MM J FNGR STR FXCR STD SPR COIL -,SUP-M001491211,CDM,C1769,HCPCS,272,RC,,,outpatient,,,81.69,57.183,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.018INX190CM THRUWAY STR SHRT TAPR STEER SFT FLXB -,SUP-M001492791,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.018INX300CM THRUWAY STR SHRT TAPR STEER SFT FLXB -,SUP-M001492831,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
BSX THRUWAY 190CM 0.014 WIRE -,SUP-M001492921,CDM,C1769,HCPCS,272,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WIRE THRUWAY .014 X 300 STR -,SUP-M001492971,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.016INX180CM FATHOM 16 STR STEER NTNL ALY/PLTNM -,SUP-M001509100,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1563.65,1094.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW ENDO 0.035INX180CM JGWR -,SUP-M00515171,CDM,C1769,HCPCS,272,RC,,,outpatient,,,735.47,514.829,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
NOVAGOLD .018/260 -,SUP-M00552000,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1082.39,757.673,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW ENDO 0.035INX260CM HYD JGWR STF SHFT -,SUP-M00556061,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
DREAMWIRE .035/260 -,SUP-M00556100,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
DREAMWIRE .035/260 ANGLED -,SUP-M00556110,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
DREAMWIRE .035/260 STIFF -,SUP-M00556120,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
DREAMWIRE .035/450 -,SUP-M00556140,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW ENDO 0.035IN STD 450CM DREAMWIRE HI-PRFRM DIST TIP -,SUP-M00556141,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
DREAMWIRE ANGLED 0.035 X 450CM -,SUP-M00556150,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW ENDO 0.035INX450CM DREAMWIRE HIPERF STF -,SUP-M00556161,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
JAGWIRE .038 / 260CM STRIAGHT -,SUP-M00556620,CDM,C1769,HCPCS,272,RC,,,outpatient,,,594.64,416.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
JAG-REVOLUTION WIRE .025/260 -,SUP-M00557000,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WIRE JAG REVOLUTION .025/450 -,SUP-M00557021,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1048.35,733.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
TUBE PEG 24FR ENDOVIVE LPRO PUL LF -,SUP-M00566480,CDM,C1769,HCPCS,272,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
"SPHINTEROTOME JAGTOME RX 44 0.35"" X 260CM -",SUP-M00573040,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1685.56,1179.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDEWIRE .038 -,SUP-M0066201010,CDM,C1769,HCPCS,272,RC,,,outpatient,,,65.06,45.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW URO 0.035INX150CM ZIPWIRE NTNL COR HYDRCT STR STD SHFT -,SUP-M006630205B1,CDM,C1769,HCPCS,272,RC,,,outpatient,,,219.51,153.657,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDEWIRE SENSOR .038 ANGLED -,SUP-M0066703021,CDM,C1769,HCPCS,272,RC,,,outpatient,,,241.45,169.015,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDEWIRE SENSOR -,SUP-M0066703091,CDM,C1769,HCPCS,272,RC,,,outpatient,,,230.6,161.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW URO 0.018IN X 150CM STD ZIPWIRE STRAIGHT -,SUP-M0066802001,CDM,C1769,HCPCS,272,RC,,,outpatient,,,298.43,208.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GLIDEWIRE STRAIGHT STIFF .035 SS -,SUP-M0066802221,CDM,C1769,HCPCS,272,RC,,,outpatient,,,302.94,212.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GLIDEWIRE STRAIGHT .038 SS -,SUP-M0066802251,CDM,C1769,HCPCS,272,RC,,,outpatient,,,302.94,212.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GLIDEWIRE ANGLED .038 SS STIFF -,SUP-M0066802261,CDM,C1769,HCPCS,272,RC,,,outpatient,,,302.94,212.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.018INX40CM SS -,SUP-MAK001,CDM,C1769,HCPCS,272,RC,,,outpatient,,,114.37,80.059,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.018INX40CM NTNL PLTNM -,SUP-MAK001N,CDM,C1769,HCPCS,272,RC,,,outpatient,,,128.37,89.859,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW METRO TRACER .035 X 480 -,SUP-METII-35-480,CDM,C1769,HCPCS,272,RC,,,outpatient,,,770.22,539.154,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDEWIRE W/NITREX .018 80CM STRAIGHT -,SUP-N180801,CDM,C1769,HCPCS,272,RC,,,outpatient,,,348.82,244.174,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014/ 0.008INX300CM ASTATO XS 20 STR TAPR PTFE-CTD -,SUP-PAGH143392,CDM,C1769,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.0180.0 13INX300CM ASTATO 30 STR PTFE-CTD 15CM 30GM -,SUP-PAGH18M371,CDM,C1769,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX300CM REGALIA XS 1 STR STF SHFT FLXB SPR -,SUP-PAGP140300,CDM,C1769,HCPCS,272,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
TUBE JEJUNAL 12FR X 60CM PEG24 -,SUP-PEGJ-12-24,CDM,C1769,HCPCS,272,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
PHOENIX .014 FLOPPY TIP WIRE EXTRA SUPPORT -,SUP-PG14300XF,CDM,C1769,HCPCS,272,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
PIGTAIL WIRE PRO TRACK 175CM -,SUP-PTW-25-175,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1120.32,784.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WIRE DX 0.025IN BD PIGTL 230CM PROTRACK -,SUP-PTW-25-230,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1120.32,784.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
ILLUMINATION RELIEVA LUMA SENTRY -,SUP-SIS-100B,CDM,C1769,HCPCS,272,RC,,,outpatient,,,2273.91,1591.737,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDEWIRE 0.014 TCAR ENROUTE -,SUP-SR-014-GW,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WIRE SAFESEPT TRASEPTAL  0.014INX135CM -,SUP-SS-135,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1102.82,771.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
PK PROC CUST CARD CATHETERISATION LAB SLHSFR -,SUP-STLM004-13,CDM,C1769,HCPCS,272,RC,,,outpatient,,,288.66,202.062,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
DEVICE TRQ SGL HND F/0.010-0.038IN GW MUL-TRQ VISE STRL -,SUP-TD01,CDM,C1769,HCPCS,272,RC,,,outpatient,,,38.34,26.838,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WIRE AMPLATZ 0.035 IN X 260CM CRV TIP XSTIF FLXB SS PTFE-CTD -,SUP-THSCF-025-260-3,CDM,C1769,HCPCS,272,RC,,,outpatient,,,166.24,116.368,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.032INX260CM AMP CRV JTP XSTIF FLPY SS PTFE-CTD 8CM -,SUP-THSCF322603AES,CDM,C1769,HCPCS,272,RC,,,outpatient,,,166.24,116.368,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.035INX145CM CRV RSN TIP FXCR FLXB FLPY SS PTFE-CTD -,SUP-THSCF351451.5R,CDM,C1769,HCPCS,272,RC,,,outpatient,,,78.71,55.097,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDE WIRE TORAY TRG-25230 -,SUP-TRG-25230,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.021INX180CM 3MM JTP FXCR FLXB SS PTFE-CTD 7CM TAPR -,SUP-TSCF-21-180-3BH,CDM,C1769,HCPCS,272,RC,,,outpatient,,,96.04,67.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.035INX180CM 3MM JTP FXCR FLXB SS HEP PTFE-CTD 6CM -,SUP-TSCF-35-180-3,CDM,C1769,HCPCS,272,RC,,,outpatient,,,72.88,51.016,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.035INX260CM LNDRQST FLXB LO SURF FRCTN EXTEND CRV -,SUP-TSCMG35260ELESD,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1025.79,718.053,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
WIRE GUIDE LUNDERQUIST .035 -,SUP-TSCMG35260LESDC,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1025.79,718.053,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC HTORQ WHISPER VW EDS -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
LOOP TIP WIRE GUIDE .035 X 480 -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1085.31,759.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
W MOVEABLE CORE 3J 035 145CM -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,151.71,106.197,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
W MOVEABLE CORE 1.5J 035 145CM -,SUP-UNDEFINED,CDM,C1769,HCPCS,272,RC,,,outpatient,,,151.71,106.197,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDE WIRE VIPER .014 TIP -,SUP-VPR-GW-14,CDM,C1769,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GUIDE WIRE VIPER .017 335CM -,SUP-VPR-GW-FLEX18,CDM,C1769,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
GW VASC 0.014INX180CM ZINGER LS RSN JTP CRV LGT SUPP FRMG -,SUP-ZNGRLS180J,CDM,C1769,HCPCS,272,RC,,,outpatient,,,169.22,118.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,8.60733,7443.65739,other,Non-Reimbursable Procedures,,
COIL MRI ENDORECTAL DISP BPX15 -,SUP-BPX 15,CDM,C1770,HCPCS,272,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,144.095325,460.20645,other,Non-Reimbursable Procedures,,
SYS SLING MALE VIRTUE -,SUP-50020,CDM,C1771,HCPCS,278,RC,,,outpatient,,,20164.56,14115.192,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,248.891925,15486.38208,other,Non-Reimbursable Procedures,,
SLING SINGLE INCISION ALTIS -,SUP-519650,CDM,C1771,HCPCS,278,RC,,,outpatient,,,6206.85,4344.795,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,248.891925,15486.38208,other,Non-Reimbursable Procedures,,
SYS SLING URETH ADVANCE MALE 3.55X36CM NABSB MSH NDLHLDRX2 -,SUP-720088-01,CDM,C1771,HCPCS,278,RC,,,outpatient,,,18026.62,12618.634,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,248.891925,15486.38208,other,Non-Reimbursable Procedures,,
MESH SURG MINI ARC SLNG -,SUP-720095-01,CDM,C1771,HCPCS,278,RC,,,outpatient,,,5623.3,3936.31,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,248.891925,15486.38208,other,Non-Reimbursable Procedures,,
MESH MINI ARC SLING PRECISE - DISCONTINUED -,SUP-720191-01,CDM,C1771,HCPCS,278,RC,,,outpatient,,,6578.45,4604.915,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,248.891925,15486.38208,other,Non-Reimbursable Procedures,,
PROSTHESIS PENL MONARCH + 1.1CMX35CM SAL FIL CYL NABSB -,SUP-724041-93,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4807.35,3365.145,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,248.891925,15486.38208,other,Non-Reimbursable Procedures,,
SLING GYN TVT PP 1.1X45CM URETH FEM MECH CUT -,SUP-810041B,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4965.48,3475.836,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,248.891925,15486.38208,other,Non-Reimbursable Procedures,,
KIT TRANS OBTURATOR W TAPE INC -,SUP-93-4001,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4720.05,3304.035,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,248.891925,15486.38208,other,Non-Reimbursable Procedures,,
ANCHORSURE SACROSPINOUS LIGAMENT FIXATION -,SUP-A-SURE,CDM,C1771,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,248.891925,15486.38208,other,Non-Reimbursable Procedures,,
NEOMEDIC ANCHORSURE ANCHOR SYSTEM 2 ANCHORS -,SUP-A-SURE02,CDM,C1771,HCPCS,278,RC,,,outpatient,,,1108.65,776.055,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,248.891925,15486.38208,other,Non-Reimbursable Procedures,,
SLING URETH PP NABSB FEM -,SUP-M006850200051,CDM,C1771,HCPCS,278,RC,,,outpatient,,,3571.91,2500.337,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,248.891925,15486.38208,other,Non-Reimbursable Procedures,,
SLING ADVANTAGE TRAN VAGINAL -,SUP-M0068502110,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4616.84,3231.788,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,248.891925,15486.38208,other,Non-Reimbursable Procedures,,
SLING GYN ADVANTG FIT PP TRNVAG MI D URETH FEM -,SUP-M0068502110,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4616.84,3231.788,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,248.891925,15486.38208,other,Non-Reimbursable Procedures,,
SLING LYNX MID URETHRAL SUPRAPUBIC BLUE SYSTEM -,SUP-M0068503010,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4439.29,3107.503,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,248.891925,15486.38208,other,Non-Reimbursable Procedures,,
SLING GYN OBTRYX II -,SUP-M0068505110,CDM,C1771,HCPCS,278,RC,,,outpatient,,,4420,3094,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,248.891925,15486.38208,other,Non-Reimbursable Procedures,,
SLING GYN SOLYX SGL-INCS -,SUP-ML00001621,CDM,C1771,HCPCS,278,RC,,,outpatient,,,5030.63,3521.441,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,248.891925,15486.38208,other,Non-Reimbursable Procedures,,
PUMP IT 87.5MM 19.5MM 20ML 165/185 GM EMTY/FUL 0.22UM FLTR -,SUP-8637-20,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29090.86,20363.602,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7525.805482,399.86,23012.49024,percent of total billed charges,,,
PUMP IT 87.5X26MM THK 40ML 175/215 GM EMTY/FUL 0.22UM FLTR -,SUP-8637-40,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29090.86,20363.602,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7525.805482,399.86,23012.49024,percent of total billed charges,,,
PUMP 8667-20 SYNCHROMEDIII INFUSION 20ML -,SUP-8667-20,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29964.18,20974.926,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7751.733366,399.86,23012.49024,percent of total billed charges,,,
PUMP 8667-40 SYNCHROMEDIII INFUSION 40ML -,SUP-8667-40,CDM,C1772,HCPCS,278,RC,,,outpatient,,,29964.18,20974.926,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7751.733366,399.86,23012.49024,percent of total billed charges,,,
TIGHTRAIL SUB-C  9FR 560-009 -,SUP-560-009,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7193.58,5035.506,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures,,
TIGHTRAIL SUB-C 11FR 560-011 -,SUP-560-011,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7830.18,5481.126,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures,,
TIGHTRAIL SUB-C 13FR 560-013 -,SUP-560-013,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7830.18,5481.126,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures,,
SHEATH CATH DLV 10FRX80CM AMPLATZER TORQVUE VASC 45DG ANG -,SUP-9-ATV10F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures,,
SHEATH CATH DLV 9FRX80CM AMPLATZER TORQVUE VASC 45DG ANG SFT -,SUP-9-EITV09F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures,,
SHEATH CATH DLV 12FRX80CM AMPLATZER TORQVUE VASC 45DG ANG -,SUP-9-EITV12F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures,,
SYSTEM AMPLATZER DELIVERY TORQVUE 9-ITV06F 180/80 -,SUP-9-ITV06F 180/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,3909.91,2736.937,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures,,
SHEATH CATH DLV 6FRX60CM AMPLATZER TORQVUE VASC 45DG ANG SFT -,SUP-9-ITV06F45/60,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures,,
SHEATH CATH DLV 7FRX80CM AMPLATZER TORQVUE VASC 180DG ANG -,SUP-9-ITV07F180/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures,,
SHEATH CATH DLV 7FRX80CM AMPLATZER TORQVUE VASC 45DG ANG SFT -,SUP-9-ITV07F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures,,
SHEATH CATH DLV AMPLATZER TORQVUE/TREVISIO VASC 45DG ANG SFT -,SUP-9-ITV08F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures,,
SHEATH CATH DLV 9FRX80CM AMPLATZER TORQVUE VASC 45DG ANG -,SUP-9-ITV09F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures,,
SHEATH CATH DLV 12FRX80CM AMPLATZER TORQVUE VASC 45DG ANG- -,SUP-9-ITV12F45/80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures,,
AMPLATZER TALISMAN DELIVERY SHEATH 8F 80 -,SUP-9-TDS-08F45-80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures,,
AMPLATZER TALISMAN DELIVERY SHEATH 9FR 80 -,SUP-9-TDS-09F45-80,CDM,C1773,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures,,
COMP LOADING SYS CLS-3000- 18F -,SUP-CLS-3000-18F-US,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2067.2,1447.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures,,
VALVE DEL SYS COMM 26/29/31 -,SUP-DCS-C4-18F-US,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures,,
CATH DELIVERY EVOLUT FX 23-29 REF: D-EVOLUTFX-2329 -,SUP-D-EVOLUTFX-2329,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures,,
CATH DELIVERY EVOLUT FX 34 REF: D-EVOLUTFX-34 -,SUP-D-EVOLUTFX-34,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures,,
CATH DELIVERY EVPROP2329US -,SUP-D-EVPROP2329US,CDM,C1773,HCPCS,272,RC,,,outpatient,,,8954.84,6268.388,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures,,
SNARE ENSNARE SYSTEM 9-15 120 -,SUP-EN2006015,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1779.27,1245.489,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures,,
SNARE ENSNARE 18 30 CM -,SUP-EN2007030,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures,,
SNARE VASC EN SNR 27-45MM 7FR CATH 120CM 3 PREFRM LOOP NTNL -,SUP-EN2007045,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2644.95,1851.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures,,
GTRS-200-RB RETREIVAL SET TULI -,SUP-G13287,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1590.1,1113.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures,,
EXTRACTION TOOL 13FR MANUAL CONTROL ROTATION DILATOR SHEATH -,SUP-G23747,CDM,C1773,HCPCS,272,RC,,,outpatient,,,7285.21,5099.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures,,
SHEATH DILATOR 11FR EVOLUTION SHORTIE RL PERC -,SUP-G23749,CDM,C1773,HCPCS,272,RC,,,outpatient,,,5843.14,4090.198,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures,,
SNARE VASC EYE SNR 13MMX94CM FLSH PRT NTNL 16FR WRKSTN -,SUP-G26517,CDM,C1773,HCPCS,272,RC,,,outpatient,,,5674.23,3971.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures,,
SNARE VASC AMP GOOSENECK 15MM/6FR LOOP/CATH 120CM GOLD TUNG -,SUP-GN1500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures,,
SNARE EV AMP GOOSENECK 20X120MM GOLD TUNG NTNL 6FRX102CM -,SUP-GN2000,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures,,
SNARE VASC AMP GOOSENECK 25MM/6FR LOOP/CATH 120CM GOLD TUNG -,SUP-GN2500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures,,
KIT GOOSE NECK SNARE 25MM LOOP -,SUP-GN3000,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures,,
SNARE GOOSENECK GN3500 -,SUP-GN3500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures,,
SNARE AMPLATZ GN 5MM -,SUP-GN500,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1645.59,1151.913,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures,,
STYLET LD LIBERATOR 140CM -,SUP-LR-OFA01,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2639.4,1847.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures,,
CATHETER INTRODUCER AVEIR 50CM REF:LSN25501 -,SUP-LSN25501,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures,,
BASKET STONE SEGURA -,SUP-M0063801120,CDM,C1773,HCPCS,272,RC,,,outpatient,,,1030.93,721.651,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures,,
SNARE ONE700 175CM 7MM LOOP -,SUP-ONE700,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2851.99,1996.393,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures,,
SNARE ONE701 200CM 7MM LOOP -,SUP-ONE701,CDM,C1773,HCPCS,272,RC,,,outpatient,,,2959.88,2071.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures,,
SNARE VASC AMP GOOSENECK 7X175MM GOLD TUNG NTNL -,SUP-SK700,CDM,C1773,HCPCS,272,RC,,,outpatient,,,3126.44,2188.508,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,231.443785,6420.62028,other,Non-Reimbursable Procedures,,
HEAD FEM 12/ 1440MMX3.5MM NK TAPR -,SUP-00080184001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 40MM -,SUP-00080184002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 15X190MM WAGNER SL REVISN PROTASUL-100 POR CTD -,SUP-00100101915,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4802.7655,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 18X225MM WAGNER SL REVISN PROTASUL-100 POR CTD -,SUP-00100102218,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4802.7655,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 9MM PRFT ANTMC 110MM PROTASUL-100 UNCEM TAPR SHLDR -,SUP-00104201092,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2785.60399,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 40X14MM -,SUP-00104212400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 44X16MM PROTASUL-21 WF ANTMCREM -,SUP-00104212440,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 46X16MM PROTASUL-21 WF ANTMC REM -,SUP-00104212460,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 48X17MM ANTMC SHLDR PROTASUL-21 REM -,SUP-00104212480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 50X18MM PROTASUL-21 WF ANTMC REM -,SUP-00104212500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,,,
COMP 24MM SM ANTMC SHLDR 16MM PE PG CMNT -,SUP-00104214340,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
COMP 28MM MED ANTMC SHLDR 19MM PE PG CMNT -,SUP-00104214370,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ3 39.68MM OFST 141MM AVENIR MULLER STD 56.11MM NK -,SUP-00106010003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ4 40.22MM OFST 147MM AVENIR MULLER STD 56.88MM NK -,SUP-00106010004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
STEM LAT AVENIR MUELLER SZ 4 -,SUP-00106010104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 12/14 TAPR M/L HIP -,SUP-00106010107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
WEDGE ANKL JNT OSSEOTI 15X15MM POR MTL -,SUP-00110003821,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8785.08,6149.556,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2272.700196,9.170825,27238.33344,percent of total billed charges,,,
CEMENT BN PLYMTHL MTHCRYLT 40GM PLC R HVISC -,SUP-00111214001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,102.646986,9.170825,27238.33344,percent of total billed charges,,,
INTEGRAL SHORT GTR W/2 CABLES 23 X 53 -,SUP-00223200204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6861.23,4802.861,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1775.000201,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 46X18MM BGLNI/FLTW STD ZML MODULAR OFST -,SUP-00430004618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,,,
COMP 40MM BGLNI/FLTW SHLDR UHMWPE SS PG -,SUP-00430008500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
COMP 46MM BGLNI/FLTW SHLDR UHMWPE SS PG -,SUP-00430008600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 40X18MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 40X21MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,,,
COMP 40MM 46MM ARTC SURF BGLNI/FLTW SHLDR UHMWPE SS PG -,SUP-00430204046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 46X15MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204615,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 46X17MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 46MM OFST MODULAR -,SUP-00430204618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 46X19MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 46X27MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430204627,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,,,
COMP 46MM BGLNI/FLTW SHLDR W/52MM SS PG -,SUP-00430204652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
BF OFFSET HUM HEAD 18MM X 52MM -,SUP-00430205218,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 52X19MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430205219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 52X21MM BGLNI/FLTW ZML MODULAR OFST -,SUP-00430205221,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 10MM INTOP FLXB 130MM TM 42DG ANG NK SHLDR -,SUP-00434211013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2737.576335,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 11MM INTOP FLXB 130MM TM 42DG ANG NK SHLDR -,SUP-00434211113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2737.576335,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 6MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434810613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2737.576335,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 8MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434810813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2737.576335,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 9MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434810913,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2737.576335,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 10MM TM 130MM 48DG ANG SHLDR -,SUP-00434811013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2737.576335,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 11MM TM 130MM 48DG ANG SHLDR -,SUP-00434811113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2737.576335,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 12MM TM 130MM 48DG ANG SHLDR -,SUP-00434811213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2737.576335,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 13MM INTOP FLXB 130MM TM 48DG ANG NK SHLDR -,SUP-00434811313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10582.05,7407.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2737.576335,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 12MM RVRS 130MM TM LPRO SHLDR -,SUP-00434901213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18477.37,12934.159,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4780.095619,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 32X53MM EPSLN STD DRSL UHMWPE PRIM HD -,SUP-00437732053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 42MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500104200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,308.528207,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 43MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500104300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,308.528207,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 28X47-49MM VERSYS BIPLR UHMWPE -,SUP-00500104728,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,308.528207,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 49MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500104900,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,308.528207,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 28X50-52MM VERSYS BIPLR UHMWPE -,SUP-00500105028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,308.528207,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 51MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,308.528207,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 52MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,308.528207,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 28X53-55MM VERSYS BIPLR UHMWPE -,SUP-00500105328,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,308.528207,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 54MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,308.528207,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 55MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500105500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,308.528207,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 60MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-00500106000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,308.528207,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT LMRL KN SZ2 27MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800227,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2555.963761,9.170825,27238.33344,percent of total billed charges,,,
HALF BLOCK TRABECULAR TIBIAL AUGMENT RT LATERAL/LT MEDIAL -,SUP-00-5448-002-28,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10465.7,7325.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2707.47659,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT RM/LL KN SZ2 37MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800237,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2555.963761,9.170825,27238.33344,percent of total billed charges,,,
HALF BLOCK TRABECULAR TIBIAL AUGMENT LT LATERAL/RT MEDIAL -,SUP-00-5448-002-38,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10465.7,7325.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2707.47659,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT LMRL KN SZ3 27MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800327,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2555.963761,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT LMRL KN SZ3 26MM NEXGEN 5MM WDG FUL BLCK TM TIV PMMA -,SUP-00544800337,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2555.963761,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT LMRL KN SZ5 27MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800527,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2555.963761,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT RM/LL KN SZ5 37MM NEXGEN 10MM WDG FUL BLCK TM TIV -,SUP-00544800537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2555.963761,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT KN 31MMMEDX31MM TM -,SUP-00545001331,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15863.61,11104.527,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4103.915907,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT KN 36MM MED 25MMX36MM TM -,SUP-00545001336,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4841.187624,9.170825,27238.33344,percent of total billed charges,,,
CONE TIBIAL TM LARGE 51 X 34 RIGHT -,SUP-00-5450-013-52,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4841.187624,9.170825,27238.33344,percent of total billed charges,,,
CONE FEMORAL LT SM 30MM -,SUP-00545001730,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4841.187624,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT RT DPHSL KN SZ30 SM TM -,SUP-00545001731,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4841.187624,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT RT DPHSL KN SZ30 MED TM -,SUP-00545001831,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4841.187624,9.170825,27238.33344,percent of total billed charges,,,
TM FEM DIAPHYSEAL CONE- 30 LARGE- RIGHT -,SUP-00-5450-019-31,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4841.187624,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT KN SZ48 XS NEXGEN 15MM TM -,SUP-00545004801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19404.14,13582.898,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5019.851018,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT TRAB METALTIB SZ 52-51MM FULL SMALL -,SUP-00-5450-052-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19404.14,13582.898,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5019.851018,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT DIST KN SZ-D NEXGEN 5MM BLCK REVISN TM TIV -,SUP-00549003401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2555.963761,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT KN SZ-D NEXGEN 5MM DIST BLCK REVISN TM TIV -,SUP-00549003410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2512.807427,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT KN SZ-D NEXGEN 10MM BLCK REVISN TM TIV -,SUP-00549003420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2512.807427,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT POST 5MM BLCK SZ-E NEXGEN BLCK REVISN TM TIV -,SUP-00549003501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2555.963761,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT DIST KN SZ-E NEXGEN 5MM BLCK REVISN TM TIV -,SUP-00549003510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2512.807427,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT KN SZ-E NEXGEN 10MM DIST BLCK REVISN TM TIV -,SUP-00549003520,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2512.807427,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT POST KN SZ-F NEXGEN 5MM DIST BLCK REVISN TM TIV -,SUP-00549003601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2555.963761,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT KN SZ-F NEXGEN 10MM POST BLCK REVISN TM TIV -,SUP-00549003602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9880.03,6916.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2555.963761,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT DIST KN SZ-F NEXGEN 5MM DIST BLCK REVISN TM TIV -,SUP-00549003610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9713.21,6799.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2512.807427,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-E MINUS NEXGEN GENDR SOL LT KN CR CMNT ZML PMMA -,SUP-00575001505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-E MINUS NEXGEN GENDR SOL LT KN CR CMNT COCR FLEX -,SUP-00575201505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2526.254653,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-E MINUS NEXGEN GENDR SOL RT KN CR CMNT COCR FLEX -,SUP-00575201506,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2526.254653,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-D NEXGEN LEGC GENDR SOL LT KN PS CMNT ZML FLEX -,SUP-00576401451,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-E NEXGEN LEGC GENDR SOL LT KN PS CMNT ZML FLEX -,SUP-00576401551,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-E NEXGEN LEGC GENDR SOL RT KN PS CMNT ZML FLEX -,SUP-00576401552,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-F NEXGEN LEGC GENDR SOL LT KN PS CMNT ZML FLEX -,SUP-00576401651,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBPLT SZ2 44/25MM LMRL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1417.968331,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBPLT SZ3 47/27MM LMRL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1417.968331,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBPLT SZ4 50/29MM LL/RM KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1417.968331,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBPLT SZ5 53/31MM LMRL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1417.968331,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBPLT SZ5 53/31MM RM/LL KN TIV ALY UNICMPT HIFLX PRCTD -,SUP-00584200502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5481.13,3836.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1417.968331,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-D 23/48MM NEXGEN LMRL CONDL UNICMPT ZML HI FLEX -,SUP-00584201401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2345.273307,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-E 24/51.5MM NEXGEN LMRL CONDL UNICMPT ZML HI -,SUP-00584201501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2345.273307,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-F 25/55.5MM NEXGEN LMRL CONDL UNICMPT ZML HI -,SUP-00584201601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2345.273307,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-F 25/55.5MM NEXGEN LL/RM KN UNICMPT ZML HI FLEX -,SUP-00584201602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2345.273307,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL SIZE G RM/LL -,SUP-00584201702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9065.61,6345.927,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2345.273307,9.170825,27238.33344,percent of total billed charges,,,
ARTICULAR SURFACE SIZE 2 11MM -,SUP-00584202211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,830.437348,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 8MM UNICMPT ARTCSURF NET SHP KN-HI FLEX MLD -,SUP-00584202308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,926.27535,9.170825,27238.33344,percent of total billed charges,,,
ARTICULAR SURFACE SIZE 5 8MM -,SUP-00584202508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,830.437348,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ2 9MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3229.61,2260.727,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,835.500107,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 8MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,830.437348,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ4 8MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,830.437348,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ4 10MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4521.46,3165.022,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1169.701702,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5 8MM UNICMPT ARTCSURF KN VIV-E -,SUP-00584209508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3210.04,2247.028,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,830.437348,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 32MM MED 19.5MM TM PMMA NEXGEN -,SUP-00587601019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16244.38,11371.066,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4202.421106,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 29MM MICRO 10MM PEGX3 POR -,SUP-00587806129,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 32X10MM THK TM PMMA NEXGEN PRIM POR -,SUP-00587806532,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,,,
NEXGEN POROUS TM PATELLA 10MM X 32MM -,SUP-00-5878-065-32,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 38X10MM THK TM PMMA NEXGEN PRIM POR -,SUP-00-5878-065-41,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,,,
COMP TIB SZ C-H FEM 3 TIB 10X67/43MM NEXGEN PRFT CR MBLK -,SUP-00588604310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12109.95,8476.965,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3132.844065,9.170825,27238.33344,percent of total billed charges,,,
COMP TIB SZ C-H FEM 5 TIB 10X75/47.5MM NEXGEN PRFT CR MBLK -,SUP-00588604510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10860.53,7602.371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2809.619111,9.170825,27238.33344,percent of total billed charges,,,
SCREW HEADED HEX 3.5MM X -,SUP-00-5901-035-33,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1050.3,735.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,271.71261,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ1 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3366.739909,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ2 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT. -,SUP-00592601201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3366.739909,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ2 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3366.739909,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ3 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3366.739909,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ3 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3366.739909,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ4 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3366.739909,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ4 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3366.739909,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 32MM LRG NEXGEN GENDR SOL LT PTLFEM KN CMNT -,SUP-00592601501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3366.739909,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 32MM LRG NEXGEN GENDR SOL RT PTLFEM KN CMNT -,SUP-00592601502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13014.07,9109.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3366.739909,9.170825,27238.33344,percent of total billed charges,,,
NEXTGEN CR FLEX PROLONG ART SURF C-H/1-2 SPUR- 14MM -,SUP-00-5952.021-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,,,
NEXGEN CR FLEX PROLONG  ART SURF -,SUP-00-5952-021-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ A-B/1-2 10MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596202010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ C-D/1-2 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596202212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ C-D SZ1-2 FEM 14MM NEXGEN PS ARTCSURF KN FLEX -,SUP-00596202214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ C-D/1-2 17MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596202217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ-E SZ1-2 FEM 10MM NEXGEN PS ARTCSURF KN FLEX FX -,SUP-00596202410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ E-F/3-4 10MM NEXGEN LEGACY ARTCSURF KN PS FLEX -,SUP-00596203210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ E-F/3-4 14MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596203214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ E-F/3-4 17MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596203217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,,,
NEXTGEN LPS-FLEX FIXED PROLONG ART SUR EF 3-4- 20MM -,SUP-00-5962-032-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ E-F/5-6 10MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ E-F/5-6 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ E-F/5-6 17MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ G-H/5-6 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ G-H/5-6 14MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596204214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ E-F/7-10 12MM NEXGEN LPS ARTCSURF KN FLEX FX -,SUP-00596205112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-E 68/62.5MM NEXGEN LEGC RT KN PS CMNT ZML FLEX -,SUP-00596401552,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-F 72/65.5MM NEXGEN LEGC R/L KN PS CMNT ZML FLEX -,SUP-00596401652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-G 76.5/71.5MM NEXGEN LEGC L/L KN PS CMNT ZML -,SUP-00596401751,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-G 76.5/71.5MM NEXGEN LEGC R/L KN PS CMNT ZML -,SUP-00596401752,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ C-D/3-4 14MM NEXGEN LPS ARTCSURF NET SHP KN -,SUP-00596403012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-D NEXGEN LEGC LT KN PS CMNT TIV NPOR FLEX FX -,SUP-00596801451,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3361.93585,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-F NEXGEN LEGC LT KN PS CMNT TIV NPOR FLEX FX -,SUP-00596801651,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3361.93585,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-G NEXGEN LEGC RT KN PS CMNT TIV NPOR FLEX FX -,SUP-00596801752,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3361.93585,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 29MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206529,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 32MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206532,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 35MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 38MM STD 8MM UHMWPE PEGX3 NEXGEN ON ST -,SUP-00597206538,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 29MM PRLNG NEXGEN ON ST -,SUP-00597206629,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 32MM PRLNG NEXGEN ON ST -,SUP-00597206632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,9.170825,27238.33344,percent of total billed charges,,,
PATELLA NEXGEN PROLONG ALLPOLY 35MM -,SUP-00597206635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 38MM PRLNG NEXGEN ON ST -,SUP-00597206638,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,9.170825,27238.33344,percent of total billed charges,,,
NEXGEN AC ART SURF 5-6 GREEN 12MM -,SUP-00597604012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT KN SZ3 NEXGEN 5MM CR PRCTD TIV PMMA -,SUP-00-5988-003-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5398.37,3778.859,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1396.558319,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT L/R KN SZ4 NEXGEN 10MM HLF BLCK CR TIV PMMA -,SUP-00598800427,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5398.37,3778.859,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1396.558319,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 11MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1567.833241,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 12MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1567.833241,9.170825,27238.33344,percent of total billed charges,,,
SCISSORS OPTH KNAPP 4IN SS CRV V. MUELLER MIRR FNSH S/S IRIS -,SUP-00-5988-010-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1567.833241,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 16MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1567.833241,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 18MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1567.833241,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 20MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-00598801020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1567.833241,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 16MM NEXGEN 155MM TIV ALY STR FEM/TBL KN -,SUP-00598801116,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1567.833241,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 12.7MM NEXGEN 30MM TIV ALY STR FEM/TBL KN -,SUP-00598801212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1567.833241,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 15MM NEXGEN 30MM TIV ALY STR FEM/TBL KN -,SUP-00598801215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1567.833241,9.170825,27238.33344,percent of total billed charges,,,
SCISSORS OPTH STVNS 4IN SS STR V. MUELLER MIRR FNSH -,SUP-00598802011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2042.136408,9.170825,27238.33344,percent of total billed charges,,,
SCOOP SURG SM 11IN SLVR PLT CMN DCT MLBL V. MUELLER -,SUP-00598802012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2042.136408,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 13MM NEXGEN OFST 100MM TIV ALY FEM/TBL KN -,SUP-00598802013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2042.136408,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 14MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2042.136408,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 15MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2042.136408,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 16MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2042.136408,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 17MM NEXGEN OFST 60MM TIV ALY FEM/TBL KN -,SUP-00598802017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2042.136408,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 12MM NEXGEN OFST 155MM TIV ALY FEM/TBL KN -,SUP-00598802112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2042.136408,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 11MM NEXGEN OFST 155MM TIV ALY FEM/TBL KN -,SUP-00598802115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7893.84,5525.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2042.136408,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT ANT KN SZ-D NEXGEN 5MM WDG BLCK TIV PMMA -,SUP-00599003431,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5398.37,3778.859,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1396.558319,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-C 60/53.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401392,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7820.824375,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-D 64/57.5MM NEXGEN LEGC LT CONDL KN CNSTRN -,SUP-00599401491,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7820.824375,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-D 64/57.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401492,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7820.824375,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-E 68/61.5MM NEXGEN LEGC LT CONDL KN CNSTRN -,SUP-00599401591,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7820.824375,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-E 68/61.5MM NEXGEN LEGC RT KN REVISN CNSTRN -,SUP-00599401592,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7820.824375,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-F 72/65.5MM NEXGEN LEGC LT KN REVISN CNSTRN -,SUP-00599401691,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7820.824375,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-F 72/65.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401692,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7820.824375,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-G 76.5/70.5MM NEXGEN LEGC LT KN REVISN CNSTRN -,SUP-00599401791,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7820.824375,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ-G 76.5/70.5MM NEXGEN LEGC RT CONDL KN CNSTRN -,SUP-00599401792,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30231.25,21161.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7820.824375,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ C-D/1-2 MICRO 10X58/40MM NEXGEN LEGC CNSTRN -,SUP-00599402210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2726.048663,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ C-D/1-2 MICRO 12X58/40MM NEXGEN LEGC CNSTRN -,SUP-00599402212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2726.048663,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ C-D/1-2 MICRO 14X58/40MM NEXGEN LEGC CNSTRN -,SUP-00599402214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2726.048663,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB 0.5X20MM THK 58MM/40MM M/L A/P NEXGEN LEGC CNSTRN -,SUP-00599402220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2726.048663,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ C-D/3-4 17X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2726.048663,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ C-D/3-4 20X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2726.048663,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ E-F/3-4 10X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2726.048663,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ E-F/3-4 12X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2726.048663,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ E-F/3-4 14X66/42MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599403214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2726.048663,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ E-F SZ3-4 FEM 17MM 66MM/42MM M/L/A/P NEXGEN -,SUP-00599403217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2726.048663,9.170825,27238.33344,percent of total billed charges,,,
NEXGEN LCCK ART SURF EF 3-4/STR YELLOW 20MM -,SUP-00599403220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9695.93,6787.151,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2508.337091,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ E-F/5-6 10X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2726.048663,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ E-F/5-6 14X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2726.048663,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ E-F/5-6 17X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2726.048663,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ E-F/5-6 20X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2726.048663,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ-G 5-6 17X74/46MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599404217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2726.048663,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ G-H/7-10 14X82/50MM NEXGEN LEGC CNSTRN CONDL -,SUP-00599405014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10537.49,7376.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2726.048663,9.170825,27238.33344,percent of total billed charges,,,
TIBIA ALL POLY NEXGEN LPS SZ 8 BLUE 14MM FEM G H -,SUP-00599600814,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4638.69,3247.083,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1200.029103,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 32X50MM TRILOGY 10DG TIV ALY UHMWPE 6.3MM PRIM -,SUP-00615405032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8097.55,5668.285,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2094.836185,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 32X68MM TRILOGY 10DG TIV ALY UHMWPE 12.4MM PRIM -,SUP-00615406832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8097.55,5668.285,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2094.836185,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 54MM TRILOGY PRIM MUL-HL TIV POR CTD SLD HMSPHR -,SUP-00620005420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6960.16,4872.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1800.593392,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 44MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620204420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 48MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620204820,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 50MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620205020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 54MM PRIM MODULAR REVISN CLUS-HL TM TNTLM TIV SLD -,SUP-00620205422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 56MM PRIM MODULAR REVISN NO-HL TM TNTLM TIV SLD -,SUP-00620205620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 22X62MM TRILOGY PRIM MODULAR REVISN CLUS-HL TM -,SUP-00620206220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 68MM PRIM MODULAR REVISN MUL-HL TM TNTLM TIV SLD -,SUP-00620206820,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 32X48MM XL TRILOGY 0DG STD LNGVT XLPE 5.3MM PRIM -,SUP-00630504832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 36X50MM TRILOGY 0DG STD LNGVT XLPE 6.8MM PRIM -,SUP-00630505036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 28X44MM TRILOGY 10DG ELEV RM LNGVT XLPE 5.2MM -,SUP-00631004428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 28X46MM TRILOGY 10DG ELEV RM LNGVT XLPE 6.3MM -,SUP-00631004628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 36X58MM XL TRILOGY 10DG STD LNGVT XLPE 8.9MM PRIM -,SUP-00631005836,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 32X62MM TRILOGY 10DG LNGVT XLPE 9.3MM PRIM -,SUP-00631006236,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 28X44MM TRILOGY 20DG ELEV RM LNGVT XLPE 5.2MM -,SUP-00632004428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 28X46MM TRILOGY 20DG ELEV RM LNGVT XLPE 6.3MM -,SUP-00632004628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 32X48MM TRILOGY 20DG ELEV RM LNGVT XLPE 5.3MM -,SUP-00632004832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 32X56MM TRILOGY 20DG ELEV RM LNGVT XLPE 6.4MM -,SUP-00632005632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 28X50MM TRILOGY LNGVT XLPE 7.2MM CNSTRN MODULAR -,SUP-00633405028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14191.09,9933.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3671.234983,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 32X56MM TRILOGY LNGVT XLPE 6.4MM CNSTRN MODULAR -,SUP-00633405632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14191.09,9933.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3671.234983,9.170825,27238.33344,percent of total billed charges,,,
TRABECULAR METAL REVISION SHELL 56MM -,SUP-00700005620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16582.26,11607.582,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4289.830662,9.170825,27238.33344,percent of total billed charges,,,
BLADE EXPLANT TRUNCATED 60MM -,SUP-00705306010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
BLADE FULL EXPLANT 60MM -,SUP-00705306020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 6X111MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 TAPR -,SUP-00771100600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 10X119MM PRFT EXTEND OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 11X121MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 12.5X124MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 15X129MM PRFT STD OFST CLLRLS TIV POR CTD 12/14 -,SUP-00771101500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM VERSYS 41MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM VERSYS 43MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM VERSYS 44MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM VERSYS 47MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781804700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM VERSYS 50MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781805000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM VERSYS 51MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781805100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM VERSYS 52MM UNIPL ZML 12/14 TAPR ENPROS STRL -,SUP-00781805200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,,,
ADAPTER HIP VERSYS ENPROS TIV TAPR. -,SUP-00781809901,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,226.427175,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ11 120MM VERSYS LD/FX PRFT ZML CMNT HIP -,SUP-00783301100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ12 125MM VERSYS LD/FX PRFT ZML CMNT HIP -,SUP-00783301200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ14 135MM VERSYS LD/FX PRFT ZML CMNT HIP -,SUP-00783301400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,,,
NECK FEM SZ K2 KINECTIV M/L HIP MODULAR COCR -,SUP-00784802001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1119.881256,9.170825,27238.33344,percent of total billed charges,,,
NECK FEM SZ S2 KINECTIV M/L HIP MODULAR COCR -,SUP-00784803001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1119.881256,9.170825,27238.33344,percent of total billed charges,,,
NECK FEM SZ P2 KINECTIV M/L HIP MODULAR COCR STR 12/14 TAPR -,SUP-00784803101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1119.881256,9.170825,27238.33344,percent of total billed charges,,,
KINECTIV MODULAR NECK G2 -,SUP-00784803201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4916.67,3441.669,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1271.942529,9.170825,27238.33344,percent of total billed charges,,,
NECK FEM SZ R2 KINECTIV M/L HIP MODULAR COCR STR 12/14 TAPR -,SUP-00784804201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4328.88,3030.216,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1119.881256,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ13 130MM VERSYS ADVCT PRIM STD OFST NON V-LIGN -,SUP-00785001300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,,,
STEM VERSYS CMTD STD 14X135 -,SUP-00785001400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,,,
CENTRALIZER DIST FEM HIP 11MM VERSYS PMMA CMNT -,SUP-00785901100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,75.475725,9.170825,27238.33344,percent of total billed charges,,,
CENTRALIZER DIST FEM HIP 13MM VERSYS PMMA CMNT -,SUP-00785901300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,75.475725,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 14X135MM VERSYS PRIM EXTEND OFST TIV POR CTD FM -,SUP-00786201420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 16X145MM VERSYS PRIM STD OFST TIV POR CTD FM TAPR -,SUP-00786201600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 16X145MM VERSYS PRIM EXTEND OFST TIV POR CTD FM -,SUP-00786201620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 18X155MM VERSYS PRIM STD LRG OFST TIV POR CTD FM -,SUP-00786201830,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 20X155MM VERSYS PRIM EXTEND LRG OFST TIV POR CTD FM -,SUP-00786202050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 13X170MM VERSYS REVISN ZML CMNT CLCR HIP -,SUP-00787101360,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21520.55,15064.385,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5567.366285,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 13X210MM VERSYS REVISN ZML CMNT CLCR HIP -,SUP-00-7871-013-61,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21520.55,15064.385,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5567.366285,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ15 220MM VERSYS REVISN ZML CMNT CLCR HIP -,SUP-00787101561,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21520.55,15064.385,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5567.366285,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM VERSYS 28X0MM NK ZML 12/14 TAPR STRL -,SUP-00801802802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM VERSYS 28MM +3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801802803,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM VERSYS 28MM +7MM NK ZML 12/14 TAPR STRL -,SUP-00801802814,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM VERSYS 32MM-3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM VERSYS 32MM +3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM VERSYS 32MM +7MM NK ZML 12/14 TAPR STRL -,SUP-00801803214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM VERSYS 36MM-3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM VERSYS 36X0MM NK ZML 12/14 TAPR STRL -,SUP-00801803602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM VERSYS 36MM +3.5MM NK ZML 12/14 TAPR STRL -,SUP-00801803603,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,,,
LINER ELEV RIM 32MM I.D. LONGE -,SUP-00875200832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 36X52MM II SHL CONTIN ELEV LNGVT XLPE 4.7MM F -,SUP-00875201036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,,,
RIM LINER 36MM SIZE JJ LONGEVITY HIGHLY CROSSLINKED POLY -,SUP-00-8752-011-36,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ EE 44MM CONTIN CLUS-HL TM TIV SNP FIT LCK GRV -,SUP-00875704401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ FF 46MM CONTIN MUL-HL TM TIV SNP FIT LCK GRV -,SUP-00875704602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ GG 48MM CONTIN CLUS-HL TM TIV SNP FIT LCK GRV -,SUP-00875704801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ HH 50MM CONTIN CLUS-HL TM TIV SNP FIT LCK GRV -,SUP-00875705001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ II LINER 52MM CONTIN CLUS-HL TM TIV SNP FIT -,SUP-00875705201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ II 52MM CONTIN MUL-HL TM TIV SNP FIT LCK GRV -,SUP-00875705202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ JJ LINER 54MM CONTIN MUL-HL TM TIV SNP FIT LCK -,SUP-00875705401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 28MMX-3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877502801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,,,
BIOLOX DELTA FEM HEAD 28MM +0MM -,SUP-00877502802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 32MM-3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 32MM +0MML NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 36MM-3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEMORAL 36MM CERAMIC -,SUP-00-8775-036-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 36MM +3.5MM NK BIOLOX DELTA CERM 12/14 TAPR STRL -,SUP-00877503603,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 36MM +7MM BIOLOX DELTA CER -,SUP-00-8775-036-04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,,,
BIOLOX DELTA OPTION FEM HEAD 28MM +0MM -,SUP-00-8777-028-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3150.84,2205.588,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,815.122308,9.170825,27238.33344,percent of total billed charges,,,
BIOLOX OPTION HEAD 36/+3.5 TAPER 12/14 -,SUP-00-8777-036-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9780.3,6846.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2530.16361,9.170825,27238.33344,percent of total billed charges,,,
BIOLOX OPTION HEAD XL 36/+7 TAPER 12/14 -,SUP-00-8777-036-04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9780.3,6846.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2530.16361,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 28X44MM EE SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 28X46MM FF SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200728,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 32X48MM GG SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 32X50MM HH SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885200932,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 36NN ID 52MM II SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885201036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 36X54MM JJ SHL CONTIN ELEV VIV-E VIT-E HXPE -,SUP-00885201136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 22MMLNGX5.5MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902602300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 28MM SHRT +0MML NK ZML 6DG TAPR ANTMC STRL -,SUP-00902602800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 28MMMEDX+7MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902602900,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 28MMLNGX+14MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902603000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 32MMSHRTX3.5MM NK ZML 6DG TAPR ANTMC STRL -,SUP-00902603235,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,9.170825,27238.33344,percent of total billed charges,,,
HEAD 6DEGREE COCR FEM 36MM +3.5 S+ -,SUP-00-9026-036-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,589.634214,9.170825,27238.33344,percent of total billed charges,,,
HEAD 6 DEGREE COCR FEM 36MM +7 M -,SUP-00-9026-036-07,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,589.634214,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 15X185MM ZMR REVISN MODULAR TIV PLASM SPRY POR CTD -,SUP-00998201518,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14636.65,10245.655,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3786.501355,9.170825,27238.33344,percent of total billed charges,,,
BODY HIP SZ A 17.7MM BD 40MM OFST ZMR REVISN MODULAR 45MM NK -,SUP-00999601745,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21253.21,14877.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5498.205427,9.170825,27238.33344,percent of total billed charges,,,
STEM WAGNER REVISION 135 NK ANGLE 18MM X 265MM -,SUP-01.00102.618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4802.7655,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB DURAM -,SUP-01.00214.152,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16626.81,11638.767,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4301.355747,9.170825,27238.33344,percent of total billed charges,,,
CONE WAGNER 135 DEG X 21MM -,SUP-01.00561.321,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13856.92,9699.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3584.785204,9.170825,27238.33344,percent of total billed charges,,,
SIDUS STEM-FREE SHOULDER HUMERAL HEAD 48-17 -,SUP-01.04555.480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,,,
STEM AVENIR STANDARD CEM 4 -,SUP-01.06010.204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,,,
STEM STD CEMENTED 7 TAPER 12/14 AVENIR -,SUP-01.06010.207,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,,,
AVENIR LATERAL STEM CEM 4 -,SUP-01.06010.304,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,,,
STEM AVENIR LATERAL CEM 8 -,SUP-01.06010.308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,,,
COMP RVRS 25MM BSPLT HA+ADPTR -,SUP-010000589,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1976.26104,9.170825,27238.33344,percent of total billed charges,,,
SHELL G7 ACETABULAR PPS LTD 46B -,SUP-010000660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1204.157955,9.170825,27238.33344,percent of total billed charges,,,
G7 PPS LTD ACET SHELL 48C -,SUP-010000661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1204.157955,9.170825,27238.33344,percent of total billed charges,,,
G7 PPS LTD ACET SHELL 50D -,SUP-010000662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1204.157955,9.170825,27238.33344,percent of total billed charges,,,
SHELL G7 ACETABULAR PPS LTD 52E -,SUP-010000663,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1204.157955,9.170825,27238.33344,percent of total billed charges,,,
SHELL G7 ACET PPS LTD SHELL 54F -,SUP-010000664,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1204.157955,9.170825,27238.33344,percent of total billed charges,,,
G7 PPS LTD ACET SHELL 56F -,SUP-010000665,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1204.157955,9.170825,27238.33344,percent of total billed charges,,,
G7 PPS LTD ACET SHELL 60G -,SUP-010000667,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1204.157955,9.170825,27238.33344,percent of total billed charges,,,
SHELL G7 PPS LTD ACET 46 B -,SUP-010000719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,,,
LINER G7 NEUTRAL ARCOMXL 32MM B -,SUP-010000729,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,,,
G7 NEUTRAL ARCOMXL LNR 36MM D -,SUP-010000739,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,,,
G7 NEUTRAL ARCOMXL LNR 36MM E -,SUP-010000740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,,,
LINER ARCOMXL G7 NEUTRAL 36MM F -,SUP-010000741,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,,,
G7 ACETABULAR LINER 36MM / G -,SUP-010000742,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,,,
G7 NEUTRAL ARCOMXL LNR 40MM G -,SUP-010000748,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,,,
G7 NEUTRAL E1 LINER 28MM C -,SUP-010000837,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
G7 NEUTRAL E1 LINER 32MM -,SUP-010000846,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
G7 NEUTRAL E1 LINER 32MM C -,SUP-010000847,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
G7 NEUTRAL E1 LINER 36MM D -,SUP-010000856,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
G7 NEUTRAL E1 LINER 36MM F -,SUP-010000858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
G7 FREEDOM CONST E1 LNR 36MM -,SUP-010000982,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3602.074125,9.170825,27238.33344,percent of total billed charges,,,
G7 FREEDOM COSTR E1 LNR 36MM G -,SUP-010000985,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3602.074125,9.170825,27238.33344,percent of total billed charges,,,
HEAD COCR FEM 40MM TYPE 1 +9MM -,SUP-010001032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,,,
COCR FEM HD 40MM TYPE 1 +6MM -,SUP-010001033,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEMORAL COCR 40MM TYPE 1 STD -,SUP-010001035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,,,
COCR FEM HD 40MM TYPE 1-3MM -,SUP-010001036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,,,
WAGNER SL REVISION STEM 135 NK ANGLE 15MM X 225MM -,SUP-0100102215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4802.7655,9.170825,27238.33344,percent of total billed charges,,,
WAGNER SL REV STEM 135 NK ANGLE 14 X 265 -,SUP-0100102614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4802.7655,9.170825,27238.33344,percent of total billed charges,,,
CONE WAGNER 125 DEG X 19MM -,SUP-0100561219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13856.92,9699.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3584.785204,9.170825,27238.33344,percent of total billed charges,,,
ADAPTER ANTMC BGLNI 42 -,SUP-0104250042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,957.151195,9.170825,27238.33344,percent of total billed charges,,,
AS B/F ADAPTOR 48 DEG -,SUP-0104250048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,957.151195,9.170825,27238.33344,percent of total billed charges,,,
AC-CONNECTOR -,SUP-0104440000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,,,
STEM AVENIR 5 TAPER 12/14 MULL -,SUP-0106010005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
STEM AVENIR 6 TAPER 12/14 MULL -,SUP-0106010006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
MORSE TAPER HEAD +5 OFFSET WITH LFIT 32MM -,SUP-01-3205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
PLATE 2.7/3.5 VA ANTLAT DSTL TIB PL/10 H/LFT -,SUP-02.118.209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10401.04,7280.728,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2690.749048,9.170825,27238.33344,percent of total billed charges,,,
BONE PREP KIT 21-1000 SFN -,SUP-0206-710-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,740.32,518.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,191.520784,9.170825,27238.33344,percent of total billed charges,,,
LOW FRICTION ION TREATMENT -,SUP-06-2200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
C-TAPER LFIT HEAD LOW FRI ION TREATMENT -,SUP-06-2205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 26X0MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-06-2600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEMORAL LFIT COCR +5 MM OFFSET C TAPER 26MM HIP -,SUP-06-2605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
C-TAPER LFIT HEAD LOW FRICTION SZ. 26MM / +10 -,SUP-06-2610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 28X0MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-062800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
C-TAPER LFIT HEAD LOW FRICTION SZ. 28MM / +10 -,SUP-06-2810,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 32X0MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-063200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 32MM-5MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-063299,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 36MM +0MML NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-063600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 40MM-2.5MM NK COCR C-TAPR PRIM LFRIC ION TX -,SUP-064097,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,,,
STEM PLASMA SPRAY STD SIZE 2 TI6AI4V -,SUP-101-0002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,,,
HIP STEM PLASAM STD SZ 3 -,SUP-101-0003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ4 37MM OFST 110MM OVATN STD OFST 29MM 7MM M/L/A/P -,SUP-101-0004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ5 OVATN STD OFST TI PLASM SPRY CTD 12/14 TAPR -,SUP-101-0005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ6 38MM OFST 118MM OVATN STD OFST 31MM 9MM M/L/A/P -,SUP-101-0006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ7 32MM OFST 122MM OVATN STD OFST 32MM 10MM -,SUP-101-0007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ8 43MM OFST 126MM OVATN STD OFST 34MM 11MM -,SUP-101-0008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ9 44MM OFST 130MM OVATN STD OFST 36MM 13MM -,SUP-101-0009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ10 47MM OFST 134MM OVATN STD OFST 38MM 16MM -,SUP-101-0010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ5 44MM OFST 114MM OVATN EXTEND OFST 30MM 8MM -,SUP-101-1005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8233.36,5763.352,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2129.970232,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ6 9/31X118MM OVATN EXTEND OFST 33MM LEG 44MM HZNT -,SUP-101-1006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ7 49MM OFST 122MM OVATN EXTEND OFST 32MM 10MM -,SUP-101-1007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ8 50MM OFST 126MM OVATN EXTEND OFST 34MM 11MM -,SUP-101-1008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ9 STD OVATN EXTEND OFST TI PLASM SPRY CTD 12/14 -,SUP-101-1009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ10 55MM OFST 134MM TI PLASM SPRY CTD HIP OVATN -,SUP-101-1010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,,,
SELF CENT HIP 41X28 RUST -,SUP-1035-41-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,,,
WIRE EXTFIX 1.8MM BAYNT PNT -,SUP-104.690,CDM,C1776,HCPCS,278,RC,,,outpatient,,,367.02,256.914,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,94.948074,9.170825,27238.33344,percent of total billed charges,,,
RING ACTB SZ23 TI HIP LCK LINER YEL RINGLOC STRL SUD -,SUP-1054-23,CDM,C1776,HCPCS,278,RC,,,outpatient,,,770.22,539.154,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,199.255914,9.170825,27238.33344,percent of total billed charges,,,
SPACER DIST HIP 10MM ACCOLADE C SZ SMALL -,SUP-1059-2310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,150.95145,9.170825,27238.33344,percent of total billed charges,,,
SPACER FEM CMNT RNG STYL MED 12MM DIST F/STM 4/5 ACCOLADE -,SUP-1059-4512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,150.95145,9.170825,27238.33344,percent of total billed charges,,,
RINGLOC + HIP SYSTEM SZ 21 -,SUP-106021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,244.541349,9.170825,27238.33344,percent of total billed charges,,,
SPACER DIST FEM HIP UNIV 8MM ACCOLADE CMNT -,SUP-1067-0008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,150.95145,9.170825,27238.33344,percent of total billed charges,,,
SPACER DIST FEM HIP 9MM UNIV CMNT -,SUP-1067-0009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,150.95145,9.170825,27238.33344,percent of total billed charges,,,
SPACER DIST FEM HIP 10MM UNIV CMNT -,SUP-1067-0010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,150.95145,9.170825,27238.33344,percent of total billed charges,,,
SPACER DIST FEM HIP 11MM UNIV RECON CMNT -,SUP-1067-0011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,150.95145,9.170825,27238.33344,percent of total billed charges,,,
SPACER DIST FEM HIP 12MM UNIV CMNT -,SUP-1067-0012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,150.95145,9.170825,27238.33344,percent of total billed charges,,,
SPACER DIST FEM HIP 13MM UNIV CMNT -,SUP-1067-0013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,150.95145,9.170825,27238.33344,percent of total billed charges,,,
SPACER DIST FEM HIP 14MM UNIV CMNT -,SUP-1067-0014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,150.95145,9.170825,27238.33344,percent of total billed charges,,,
SPACER DIST FEM HIP 15MM UNIV CMNT -,SUP-1067-0015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,150.95145,9.170825,27238.33344,percent of total billed charges,,,
OMNIFIT UNIVERSAL DISTAL CEMENT SPACER 16MM -,SUP-1067-0016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,150.95145,9.170825,27238.33344,percent of total billed charges,,,
CEMENT SPACER UNIVERSAL DISTAL -,SUP-1067-0017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,150.95145,9.170825,27238.33344,percent of total billed charges,,,
VARIO CUP 28MM X 47MM -,SUP-107-220/47,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5160.7,3612.49,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1335.07309,9.170825,27238.33344,percent of total billed charges,,,
VARIO CUP 28MM X 48MM -,SUP-107-220/48,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5160.7,3612.49,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1335.07309,9.170825,27238.33344,percent of total billed charges,,,
VARIO-CUP SYSTEM OUTER 50MM HEAD 28MM -,SUP-107-220/50,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5160.7,3612.49,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1335.07309,9.170825,27238.33344,percent of total billed charges,,,
G7 OSSEOTI 3 HOLE SHELL 50MM D -,SUP-110010243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2689.54868,9.170825,27238.33344,percent of total billed charges,,,
G7 OSSEOTI MULTIHOLE 50MM D -,SUP-110010263,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4545.338304,9.170825,27238.33344,percent of total billed charges,,,
G7 MULTIHOLE 52MM -,SUP-110010264,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4545.338304,9.170825,27238.33344,percent of total billed charges,,,
G7 OSSEOTI MULTIHOLE 54MM F -,SUP-110010265,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4545.338304,9.170825,27238.33344,percent of total billed charges,,,
G7 OSSEOTI MULTIHOLE 56MM F -,SUP-110010266,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4545.338304,9.170825,27238.33344,percent of total billed charges,,,
G7 OSSEO TI ACETABULAR SHELL 58MM / G -,SUP-110010267,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4545.338304,9.170825,27238.33344,percent of total billed charges,,,
G7 OSSEO TI MULTIHOLE 60MM G -,SUP-110010268,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4545.338304,9.170825,27238.33344,percent of total billed charges,,,
SHELL G7 OSSEO TI MULTIHOLE 62MM H -,SUP-110010269,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4545.338304,9.170825,27238.33344,percent of total billed charges,,,
G7 OSSEO TI MULTIHOLE 64MM H -,SUP-110010270,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17569.92,12298.944,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4545.338304,9.170825,27238.33344,percent of total billed charges,,,
LINER G7 DUAL MOBILITY 38MM C -,SUP-110024461,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,9.170825,27238.33344,percent of total billed charges,,,
G7 DUAL MOBILITY LINER 42MM E -,SUP-110024463,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,9.170825,27238.33344,percent of total billed charges,,,
G7 DUAL MOBILITY LINER 44MM F -,SUP-110024464,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,9.170825,27238.33344,percent of total billed charges,,,
G7 DUAL MOBILITY LINER 50MM H -,SUP-110024466,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,9.170825,27238.33344,percent of total billed charges,,,
COMPR VRS GLEN PPS MIN TPR ADR -,SUP-110027734,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26395.72,18477.004,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6828.572764,9.170825,27238.33344,percent of total billed charges,,,
PRX HUM LO PLT LT 4H 83MM -,SUP-110030101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6875.28,4812.696,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1778.634936,9.170825,27238.33344,percent of total billed charges,,,
40MM VERSA-DIAL GLEN STD -,SUP-110030776,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,,,
40MM VERSA-DIAL GLEN +3 -,SUP-110030777,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,,,
BEARING VIVACIT-E DM 28 X 44MM -,SUP-110031012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1191.807617,9.170825,27238.33344,percent of total billed charges,,,
BEARING VIVACIT-E DM 28 X 50MM -,SUP-110031015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1191.807617,9.170825,27238.33344,percent of total billed charges,,,
VERSA-DIAL TAPER ADAPTOR 25MM -,SUP-110031378,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1494.74,1046.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,386.689238,9.170825,27238.33344,percent of total billed charges,,,
HMRL TRAY STD STD -,SUP-110031399,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1591.98806,9.170825,27238.33344,percent of total billed charges,,,
TRAY HMRL STD SHOULDER REVERSE TI -,SUP-110031408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1591.98806,9.170825,27238.33344,percent of total billed charges,,,
HMRLBEARING 36MM +3 PRLNG -,SUP-110031419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
HMRL BEARING 40MM STD PRLNG -,SUP-110031421,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
HMRL BEARING 36 MM STD VITE -,SUP-110031424,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1372.4035,9.170825,27238.33344,percent of total billed charges,,,
HMRL BEARING 36 MM +3 VITE -,SUP-110031425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1372.4035,9.170825,27238.33344,percent of total billed charges,,,
BEARING HUMERAL 40MM STD VITE -,SUP-110031427,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1372.4035,9.170825,27238.33344,percent of total billed charges,,,
COMPR AUG BSPLT W ADP SM -,SUP-110032410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.807,9.170825,27238.33344,percent of total billed charges,,,
COMPR AUG BSPLT W ADP MD -,SUP-110032420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.807,9.170825,27238.33344,percent of total billed charges,,,
COMPR AUG BSPLT W ADP LG -,SUP-110032430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.807,9.170825,27238.33344,percent of total billed charges,,,
HMRL BEARING 36MM STD PRLNG -,SUP-11031418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
FREEDOM CONSTR HD 36MM T1 -,SUP-11-107016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7259.36,5081.552,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1877.996432,9.170825,27238.33344,percent of total billed charges,,,
HEAD FREEDOM CONSTR 36MM T1 +9MM -,SUP-11-107021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7259.36,5081.552,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1877.996432,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 6MM MAC PRIM RVRS CMPRHNSV 140MM COCR PLASM CTD -,SUP-11-113556,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2689.54868,9.170825,27238.33344,percent of total billed charges,,,
PROXIMAL FEMORAL OMPONENT RHS LEFT -,SUP-1115-9110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22682.72,15877.904,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5868.019664,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL CHECKPOINT STERILE -,SUP-111651,CDM,C1776,HCPCS,278,RC,,,outpatient,,,260.65,182.455,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,67.430155,9.170825,27238.33344,percent of total billed charges,,,
RINGLOC BIPOLAR 28X49MM -,SUP-11-165222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,,,
HEAD RADL SZ12 22MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6332.05,4432.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1638.101335,9.170825,27238.33344,percent of total billed charges,,,
HEAD RADL SZ14 24MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1591.98806,9.170825,27238.33344,percent of total billed charges,,,
STEM RADL SZ7 26MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7295.44,5106.808,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1887.330328,9.170825,27238.33344,percent of total billed charges,,,
STEM RADL SZ8 28MM EXPLOR COCR MLYBDNM ALY MODULAR -,SUP-11-210063,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7507.64,5255.348,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1942.226468,9.170825,27238.33344,percent of total billed charges,,,
STEM STR DIST ARCOS 23MM X 150MM TAPER -,SUP-11-300823,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3826.843033,9.170825,27238.33344,percent of total billed charges,,,
STS DISTAL STEM 15 X 190MM -,SUP-11-300915,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3826.843033,9.170825,27238.33344,percent of total billed charges,,,
DIST ARCOS 19 X 190MM SPL TPR -,SUP-11-300919,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3826.843033,9.170825,27238.33344,percent of total billed charges,,,
CON ARCOS SZ A STD 60MM -,SUP-11-301301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7423.153322,9.170825,27238.33344,percent of total billed charges,,,
CON ARCOS SZ A STD HI 50MM -,SUP-11-301310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7423.153322,9.170825,27238.33344,percent of total billed charges,,,
ARCOS CON SIZE E HI 70MM -,SUP-11-301335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7423.153322,9.170825,27238.33344,percent of total billed charges,,,
STANDARD CONE PROX BODY 80MM -,SUP-11-301342,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7423.153322,9.170825,27238.33344,percent of total billed charges,,,
ARCOS CON SIZE B HI 80MM -,SUP-11-301352,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7423.153322,9.170825,27238.33344,percent of total billed charges,,,
VERSA-DIAL 38 X 19 X 39 HUM HEAD -,SUP-113022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,,,
VERSA-DIAL 38X21X38 HUM HEAD -,SUP-113024,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 42MM 46X18MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,,,
VERSA DIAL 42 X 21 X 43 HUM HEAD -,SUP-113034,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 46X53MM 18MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 46X50MM 24MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 46X46MM 27MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 50MM 57X21MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 50X50MM 27MM CMPRHNSV VERSA-DIAL BIPLR COCR -,SUP-113057,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,,,
MODULAR HEAD 54MM 21MM 64MM -,SUP-113063,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,,,
TAPER ADAPTER 54MM X 24MM -,SUP-113065,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM VERSA-DIAL 54X27X55 -,SUP-113067,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,,,
HUM HEAD VERSA-DIAL 58 X 24 X 64 -,SUP-113075,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE COMP FX HUM POS 8MM -,SUP-113576,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,150.95145,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE COMP FX HUM POS 9MM -,SUP-113577,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,150.95145,9.170825,27238.33344,percent of total billed charges,,,
POSTIONING SLEEVE COMP FX HUM 10MM -,SUP-113578,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,150.95145,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE COMP FX HUM POS 11MM -,SUP-113579,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,150.95145,9.170825,27238.33344,percent of total billed charges,,,
COMP FX HUM POS SLEEVE 12MM -,SUP-113580,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,150.95145,9.170825,27238.33344,percent of total billed charges,,,
COMP FX HUM POS SLEEVE 13MM -,SUP-113581,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,150.95145,9.170825,27238.33344,percent of total billed charges,,,
COMP PRIMARY STEM 9MM MICRO -,SUP-113609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,,,
COMP PRIMARY STEM 10MM MICRO -,SUP-113610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,,,
COMP PRIMARY STEM 11MM MICRO -,SUP-113611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,,,
COMP PRIMARY STEM 12MM MICRO -,SUP-113612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,,,
STEM COMP PRIMARY MICRO 13MM -,SUP-113613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,,,
STEM COMP PRIMARY MICRO 14MM -,SUP-113614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,,,
COMP PRIMARY STEM 15MM MICRO -,SUP-113615,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,,,
COMP PRIMARY STEM 17MM MICRO -,SUP-113617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,,,
COMP PRIMARY STEM 19MM MICRO -,SUP-113619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,,,
STEM COMP PRIMARY 5MM MINI -,SUP-113625,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,,,
STEM COMP PRIMARY 6MM MINI -,SUP-113626,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,,,
COMP PRIMARY STEM 7MM MINI -,SUP-113627,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,,,
STEM COMP PRIMARY 8MM MINI -,SUP-113628,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,,,
COMPREHENSIVE HUMERAL STEM 9MM MINI -,SUP-113629,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,,,
POROUS PLASMA 10MM 83MM LONG -,SUP-113630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,,,
COMP PRIMARY STEM 11MM MINI -,SUP-113631,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,,,
COMPREHENSIVE HUMERAL STEM 12MM MINI -,SUP-113632,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,,,
STEM COMP PRIMARY 13MM MINI -,SUP-113633,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,,,
STEM COMP PRIMARY 14MM MINI -,SUP-113634,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,,,
STEM COMP PRIMARY 15MM MINI -,SUP-113635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,,,
STEM COMP PRIMARY 16MM MINI -,SUP-113636,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,,,
HEAD MOD 36MM COCR 3MM -,SUP-11-363661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,,,
HEAD COCR MOD HD STD 36MM -,SUP-11-363662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,,,
HEAD 36MM COCR MOD +36MM -,SUP-11-363663,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,,,
STEM COMP PRIMARY 17MM MINI -,SUP-113637,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 7MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113647,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 8MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113648,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 12MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 15MM STD PRIM PRFT RVRS CMPRHNSV 140MM COCR PLASM -,SUP-113655,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 16MM STD PRIM PRFT RVRS CMPRHNSV 122MM COCR PLASM -,SUP-113656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2545.465715,9.170825,27238.33344,percent of total billed charges,,,
COMP MODULAR HYBRID SHLDR POST 4MM UHMWPE PG -,SUP-113951,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,9.170825,27238.33344,percent of total billed charges,,,
COMP SM MODULAR HYBRID SHLDR BS 4MM UHMWPE PG -,SUP-113952,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,,,
COMP MED MODULAR HYBRID SHLDR BS 4MM UHMWPE PG -,SUP-113954,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,,,
SPHERE GLND 36MM STD CMPRHNSV VERSA-DIAL RVRS HAP POR CTD -,SUP-115310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,,,
SPHERE GLND +3MM 36MM CMPRHNSV VERSA-DIAL RVRS HAP POR CTD -,SUP-115313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE 28MM CMPRHNSV SHLDR RVRS -,SUP-115330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1976.26104,9.170825,27238.33344,percent of total billed charges,,,
TRY HUMERAL STD 44MM COCR SHLDR RVRS CMPRHNSV STRL SUD -,SUP-115370,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1591.98806,9.170825,27238.33344,percent of total billed charges,,,
PIN INSRTR 24.5CM FRLCK F/VFX2 FEM FX SYS -,SUP-118001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,226.427175,9.170825,27238.33344,percent of total billed charges,,,
KT BONE CMNT PREP-IM -,SUP-121010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3685.53,2579.871,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,953.446611,9.170825,27238.33344,percent of total billed charges,,,
STEM COMPR 6MM HUM FRACT PPS -,SUP-12-113556,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2689.54868,9.170825,27238.33344,percent of total billed charges,,,
COMPR 8MM HUM FRACT STEM PPS -,SUP-12-113558,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2689.54868,9.170825,27238.33344,percent of total billed charges,,,
COMPR 10MM HUM FRACT STEM PPS -,SUP-12-113560,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2689.54868,9.170825,27238.33344,percent of total billed charges,,,
COMPR 12NN HUM FRACT STEM PPS -,SUP-12-113562,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2689.54868,9.170825,27238.33344,percent of total billed charges,,,
HEAD MODULAR CER BIOLOXD 28MM -3 NK -,SUP-12-115109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,,,
CER BIOLOXD MOD HD 28MM STD NK -,SUP-12-115110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,,,
CER BIOLOXD MOD HD 28MM +3 NK -,SUP-12-115111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,,,
CER BIOLOXD MOD HD 32MM-3NK -,SUP-12-115114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,,,
HEAD CERAMIC BIOLOX STANDARD NECK -,SUP-12-115115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,,,
CER BIOLOXD MOD HD 36MM STD NK -,SUP-12-115121,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,,,
CER BIOLOXD MOD HD 36MM +3 NK -,SUP-12-115122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,,,
CER BIOLOXD MOD HD 36MM +6 NK -,SUP-12-115123,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,,,
HEAD ENDO II MOD SIZE 49 -,SUP-12-139022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 54MM PINNCL NO-HL POR CTD LCK RNG SLD -,SUP-1217-01-054,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4847.45,3393.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1254.035315,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 58MM PINNCL NO-HL POR CTD LCK RNG SLD -,SUP-1217-01-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4992.9,3495.03,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1291.66323,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 60MM PINNCL NO-HL POR CTD LCK RNG SLD -,SUP-1217-01-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4992.9,3495.03,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1291.66323,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 46MM PINNCL MUL-HL BANTAM POR CTD PLASM SPRY LCK -,SUP-1217-20-046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6137.89,4296.523,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1587.872143,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 48MM PINNCL MUL-HL BANTAM PE POR CTD LCK RNG SLD -,SUP-1217-22-048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6215.13,4350.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1607.854131,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 52MM PINNCL MUL-HL BANTAM SECT PE POR CTD LCK RNG -,SUP-1217-22-052,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4847.45,3393.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1254.035315,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 54MM PINNCL MUL-HL BANTAM SECT PE POR CTD LCK RNG -,SUP-1217-22-054,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4706.3,3294.41,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1217.51981,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 62MM PINNCL PRFT NO-HL GRIPTN -,SUP-1217-31-062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16040.16,11228.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4149.589392,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 48MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1185.756624,9.170825,27238.33344,percent of total billed charges,,,
CUP ACETABULAR 50MM -,SUP-1217-32-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1185.756624,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 52MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-052,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10299.17,7209.419,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2664.395279,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 54MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-054,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1185.756624,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 56MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10299.17,7209.419,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2664.395279,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 58MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10509.65,7356.755,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2718.846455,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 60MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10299.17,7209.419,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2664.395279,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 62MM PINNCL PRFT SECT GRIPTN -,SUP-1217-32-062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1185.756624,9.170825,27238.33344,percent of total billed charges,,,
LINER ACETABULAR PINNACLE 54 47 -,SUP-121854047,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13117.66,9182.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3393.538642,9.170825,27238.33344,percent of total billed charges,,,
PINNACLE DM LINER 56 49 -,SUP-121856049,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13117.66,9182.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3393.538642,9.170825,27238.33344,percent of total billed charges,,,
LINER DUR MAR +4 10D 36 X 54 -,SUP-122036554,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1399.85157,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 32X50MM PINNCL NEUT ALTRX BLU -,SUP-1221-32-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 32X48MM PINNCL +4 10DG ALTRX BLU -,SUP-1221-32-148,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 32X50MM PINNCL +4 10DG ALTRX BLU -,SUP-1221-32-150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 36X58MM PINNCL NEUT ALTRX ORNG -,SUP-1221-36-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 36X52MM PINNCL +4 10DG ALTRX ORNG -,SUP-1221-36-152,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 36X54MM PINNCL +4 10DG ALTRX ORNG -,SUP-1221-36-154,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 36X56MM PINNCL +4 10DG ALTRX ORNG -,SUP-1221-36-156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 40X56MM PINNCL NEUT ALTRX -,SUP-1221-40-056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 40X58MM PINNCL NEUT ALTRX WHT -,SUP-1221-40-058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 40X62MM PINNCL NEUT ALTRX -,SUP-1221-40-062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 40X56MM PINNCL LD +4 10DG ALTRX PNK -,SUP-1221-40-156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 40X58MM PINNCL LD +4 10DG ALTRX PNK -,SUP-1221-40-158,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
ALTRX +4 10D 40IDX620D -,SUP-1221-40-162,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
CATALYST R1 SHORT STEM HUMERAL SIZE 36S -,SUP-1230-7501-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3361.93585,9.170825,27238.33344,percent of total billed charges,,,
CATALYST R1 POLY INSERT IMPLANT36 +0 -,SUP-1230-7504-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
CATALYST R1 POLY INSERT SIZE 36 +4 -,SUP-1230-7504-002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
CATALYST R1 STANDARD BASEPLATE IMPLANT -,SUP-1230-7506-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10674.88,7472.416,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2761.591456,9.170825,27238.33344,percent of total billed charges,,,
CATALYST R1 GLENOSHERE SIZE 36 STD -,SUP-1230-7513-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9761.2,6832.84,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2525.22244,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 52MM RESTOR ADM X3 PRFT MBL BRNG CMNTLS SLF-LCK -,SUP-1235-2-521,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 54MM RESTOR ADM X3 PRFT MBL BRNG CMNTLS SLF-LCK -,SUP-1235-2-541,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 60MM RESTOR ADM PRIM -,SUP-1235-2-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 28X48MM RESTOR ADM 0DG DURATION PE 6.9MM -,SUP-1235-2-848,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1207.71508,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 28X54MM RESTOR ADM 0DG DURATION PE 9.9MM -,SUP-1235-2-854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1207.71508,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 28X60MM RESTOR ADM 0DG DURATION PE 12.9MM -,SUP-1235-2-860,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1207.71508,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 36X22.2MM RECON ADM MDM X3 UHMWPE PRIM ASYM -,SUP-1236-2-242,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1207.71508,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 38X22.2MM RECON ADM MDM X3 UHMWPE PRIM ASYM -,SUP-1236-2-244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1207.71508,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 28X48MM RESTOR ADM X3 PE 6.9MM REVISN -,SUP-1236-2-848,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1207.71508,9.170825,27238.33344,percent of total billed charges,,,
INSERT RESTORATION ADM/MD/ 29MM X 28/48 SIZE 42E X3 -,SUP-1236-2-848,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1207.71508,9.170825,27238.33344,percent of total billed charges,,,
INSERT RESTORATION ADM/MD/ 28MM X 28/52 SIZE 46F X3 -,SUP-1236-2-852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1207.71508,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 28X52MM RESTOR ADM X3 PE 8.9MM REVISN -,SUP-1236-2-852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1207.71508,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 28X54MM RESTOR ADM X3 PE 9.9MM REVISN -,SUP-1236-2-854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1207.71508,9.170825,27238.33344,percent of total billed charges,,,
INSERT RESTORATION ADM/MDM 28MM X 52H X3 SZ 28/58MM -,SUP-1236-2-858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1207.71508,9.170825,27238.33344,percent of total billed charges,,,
RES INSERT ADM/MDM 28MM SZ54I -,SUP-1236-2-860,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1207.71508,9.170825,27238.33344,percent of total billed charges,,,
PROSTHESIS HEAD A 28MM NECK L S +3.5 TAPER 12/14 -,SUP-128-791/03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,589.634214,9.170825,27238.33344,percent of total billed charges,,,
PROSTHESIS HEAD A 32MM MED 12/14 -,SUP-128-792/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,589.634214,9.170825,27238.33344,percent of total billed charges,,,
PROSTHESIS HEAD A 36MM NECK L S -4 TAPER 12/14 -,SUP-128-793/01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,589.634214,9.170825,27238.33344,percent of total billed charges,,,
PROSTHESIS HEAD A 36MM NECK M NECK LEN 0 TAPER 12/14 -,SUP-128-793/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,589.634214,9.170825,27238.33344,percent of total billed charges,,,
PROSTHESIS HEAD A 36MM NECK LARGE +4 TAPER 12/14 -,SUP-128-793/03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,589.634214,9.170825,27238.33344,percent of total billed charges,,,
LINK PROSTHESIS HEAD A CERAMIC 8MM -,SUP-128-793/04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,589.634214,9.170825,27238.33344,percent of total billed charges,,,
PROSTHESIS HEAD A 40MM NECK M TAPER 12/14 -,SUP-128-794/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,589.634214,9.170825,27238.33344,percent of total billed charges,,,
HEAD PROSTESIS B 24MM 12/14 M -,SUP-128-824/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,589.634214,9.170825,27238.33344,percent of total billed charges,,,
PROSTHESIS HEAD B 28MM M NEC L 0 12/14 -,SUP-128-828/02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,589.634214,9.170825,27238.33344,percent of total billed charges,,,
PROSTHESIS HEAD B NECK XL +10.5 -,SUP-128-828/04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,589.634214,9.170825,27238.33344,percent of total billed charges,,,
LINK PROSTHESIS HEAD B 36MM +4 -,SUP-128-836/03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2279.22,1595.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,589.634214,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ2.5 69.6/45.8MM KN CMNT STM SIGMA COCR PS -,SUP-1294-33-125,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2750.350941,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ3 KN CMNT STM SIGMA COCR PS TCMPRTMNTL MBL -,SUP-1294-33-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2750.350941,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ5 KN CMNT STM SIGMA COCR PS TCMPRTMNTL MBL -,SUP-1294-33-150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2750.350941,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ6 KN CMNT STM SIGMA COCR PS TCMPRTMNTL MBL -,SUP-1294-33-160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10631.43,7442.001,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2750.350941,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ2.5 67/44MM KN CMNT SIGMA COCR PS REVISN MBL -,SUP-1294-35-125,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2305.63788,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ3 70MM M/L 46MM A/P KN CMNT SIGMA COCR PS -,SUP-1294-35-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2305.63788,9.170825,27238.33344,percent of total billed charges,,,
TIB TRAY ROT PLAT MBT REV SZ 4 -,SUP-129435140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2305.63788,9.170825,27238.33344,percent of total billed charges,,,
REV MBT TIBIAL ROT PLAT TRAY SZ. 3 -,SUP-1294-35-315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2305.63788,9.170825,27238.33344,percent of total billed charges,,,
REVISION MBT TIBIAL TRAY SZ. 4 / 15MM -,SUP-1294-35-415,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2305.63788,9.170825,27238.33344,percent of total billed charges,,,
TRAY TIBIAL ROTATING PLAT MBT REV SZ 4 25MM THICK CEMENTED -,SUP-1294-35-425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2305.63788,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE FEMORAL UNIV DISTAL PORUS 34MM -,SUP-1294-53-225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2239.762512,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE UNIV FEMORAL 48MM FULL POROUS -,SUP-1294-53-246,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2239.762512,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE TIB 29X29/26MM LCS COMPL MODULAR REVISN BEAR KN RP -,SUP-1294-54-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2239.762512,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE TIB 37X37/27MM LCS COMPL MODULAR REVISN BEAR KN RP -,SUP-1294-54-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2239.762512,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE TIB 45X45/27MM LCS COMPL MODULAR REVISN BEAR KN RP -,SUP-1294-54-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2239.762512,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE METAPHYSEAL 53MM POUROUS MBT REV -,SUP-1294-54-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2239.762512,9.170825,27238.33344,percent of total billed charges,,,
METAPHYSEAL SLEEVE POROUS -,SUP-1294-54-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2239.762512,9.170825,27238.33344,percent of total billed charges,,,
METAPHYSEAL SLEEVE 29MM CEMENTED REV -,SUP-1294-54-140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8657.76,6060.432,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2239.762512,9.170825,27238.33344,percent of total billed charges,,,
UNITED HIP FULL XPE CUP I.D. 32MM O.D. 48MM -,SUP-1302-3248,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2497.43806,9.170825,27238.33344,percent of total billed charges,,,
UNITED HIP FULL XPE CUP I.D. 32MM O.D. 50MM -,SUP-1302-3250,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2497.43806,9.170825,27238.33344,percent of total billed charges,,,
UNITED HIP FULL XPE CUP I.D. 28MM O.D. 46MM -,SUP-1302-3846,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2497.43806,9.170825,27238.33344,percent of total billed charges,,,
UNITED HIP LOCKING CAGE OD58MM LEFT -,SUP-1308-1158,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7231.042702,9.170825,27238.33344,percent of total billed charges,,,
UNITED HIP LOCKING CAGE OD54MM RIGHT -,SUP-1308-1254,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7231.042702,9.170825,27238.33344,percent of total billed charges,,,
UNITED HIP LOCKING CAGE OD 58MM RIGHT -,SUP-1308-1258,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7231.042702,9.170825,27238.33344,percent of total billed charges,,,
UNITED HIP SYS LOCKING CAGE 62MM RIGHT -,SUP-1308-1262,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27951.46,19566.022,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7231.042702,9.170825,27238.33344,percent of total billed charges,,,
UNIPOLAR 42MM OD -,SUP-132-0042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,,,
HEAD SOLITUDE UNIPOLAR 43MM -,SUP-132-0043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,438.796592,9.170825,27238.33344,percent of total billed charges,,,
UNIPOLAR 47MM -,SUP-132-0047,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,,,
UNIPOLAR 53MM SOLITUDE -,SUP-132-0053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,,,
UNIPOLAR SOLITUDE 55MM -,SUP-132-0055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,438.796592,9.170825,27238.33344,percent of total billed charges,,,
UNIPOLAR 57MM -,SUP-132-0057,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,,,
ADAPTER SOLITUDE UNIPOLAR +0MM -,SUP-132-1200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,181.14174,9.170825,27238.33344,percent of total billed charges,,,
ADAPTER +6MM 12/14 -,SUP-132-1206,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,617.059001,9.170825,27238.33344,percent of total billed charges,,,
ADAPTER OFFSET 9MM 12/14 -,SUP-132-1209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,617.059001,9.170825,27238.33344,percent of total billed charges,,,
COMP 3MM SOLITUDE OFST ADPTR UNIPL COCR 12/14 TAPR -,SUP-132-1230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,181.14174,9.170825,27238.33344,percent of total billed charges,,,
SHELL BIPOLAR PIVOT 22 X 40 ACETABULAR -,SUP-133-2240,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,9.170825,27238.33344,percent of total billed charges,,,
PIVOT BIPOLAR 22 X 43MM BIPOLAR -,SUP-133-2243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM 22X44MM SHL OFST L CUP BIPLR TI COCR UHMWPE -,SUP-133-2244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM 28X46MM SHL OFST L CUP BIPLR TI COCR UHMWPE -,SUP-133-2846,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,9.170825,27238.33344,percent of total billed charges,,,
CUP BIPOLAR MOD COCR 28X47MM -,SUP-133-2847,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,9.170825,27238.33344,percent of total billed charges,,,
PIVOT BIPOLAR 28 X 49 -,SUP-133-2849,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,9.170825,27238.33344,percent of total billed charges,,,
PIVOT BIPOLAR 28 X 50MM -,SUP-133-2850,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,9.170825,27238.33344,percent of total billed charges,,,
BIPOLAR 28MM ID 51MM OD -,SUP-133-2851,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,9.170825,27238.33344,percent of total billed charges,,,
PIVOT BIPOLAR 28 X 52 BIPOLAR -,SUP-133-2852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,9.170825,27238.33344,percent of total billed charges,,,
SHELL BIPOLAR PIVOT 28MM X 53MM -,SUP-133-2853,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,9.170825,27238.33344,percent of total billed charges,,,
SHELL BIPOLAR PIVOT 28X54MM -,SUP-133-2854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,9.170825,27238.33344,percent of total billed charges,,,
PIVOT BIPOLAR 28 X 55 -,SUP-133-2855,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,9.170825,27238.33344,percent of total billed charges,,,
PIVOT BIPOLAR 28X56MM BIPOLAR -,SUP-133-2856,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,9.170825,27238.33344,percent of total billed charges,,,
PIVOT BIPOLAR 28MM X 57MM -,SUP-133-2857,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEMORAL CERAMIC 28MM -,SUP-136-2800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEMORAL CERAMIC DELTA 28MM 3 BIOLOX -,SUP-136-2830,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,,,
TAPERED SPACER ARTICUL/EZE -3 -,SUP-136308000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1113.11,779.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,287.961557,9.170825,27238.33344,percent of total billed charges,,,
SPACER HIP ARTICL/EZ MODULAR CATHCART UNIPL +0MML NK 12/14 -,SUP-1363-10-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1144.83,801.381,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,296.167521,9.170825,27238.33344,percent of total billed charges,,,
SPACER HIP ARTICL/EZ MODULAR CATHCART UNIPL +5MM NK 12/14 -,SUP-1363-12-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1144.83,801.381,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,296.167521,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL HEAD 32MM -3 CERAMIC 12/14 TAPER -,SUP-136-3230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 51MM UNIPL MODLR CATHCART BALL ORTHCNTRC DSGN -,SUP-1363-51-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1933.62,1353.534,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,500.227494,9.170825,27238.33344,percent of total billed charges,,,
MODULAR CATHCART BALL 53MM OD -,SUP-136353000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,617.059001,9.170825,27238.33344,percent of total billed charges,,,
HEAD 36MM +0 BIOLOX DELTA CERAMIC FEMORAL -,SUP-136-3600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM BIOLOX DELTA 36MM XL MODULAR -,SUP-136-3604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEMORAL 36MM +3 BIOLOX DELTA CERAMIC -,SUP-136-3613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEMORAL 36MM +6 CERAMIC 12/14 TAPER -,SUP-136-3616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEMORAL BIOLOX DELTA CERAMIC 36MM -3 -,SUP-136-3630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,,,
FERMORAL HEAD BIOLOX DELTA CERAMIC 36MM -6 -,SUP-136-3660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,,,
HEAD CERAMIC FEMORAL DELTA -,SUP-136-4000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 40MMMEDX-1MM NK BIOLOX DELTA 12/14 TAPR -,SUP-136-4002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2570.74,1799.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,665.050438,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL HEAD CERAMIC 40MM +3 BIOLOX -,SUP-136-4013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL CERAMIC HEAD 40MM +9 -,SUP-136-4019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL HEAD CERAMIC 40MM -3 BIOLOX -,SUP-136-4030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,,,
ARTICUL/EZE BALL 28 +1.5 GR -,SUP-136511000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,617.059001,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM ARTICL/EZ 28MMSTDX+8.5MM NK BIOLOX DELTA TS CERM -,SUP-1365-13-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,617.059001,9.170825,27238.33344,percent of total billed charges,,,
ARTIUL/EZE BALL 28 +12 BLK -,SUP-136514000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4405.7,3083.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1139.75459,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEMORAL BIOLOX DELTA 28MM +5 12/14 TAPER CERAMIC REV -,SUP-1365-28-720,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8563.54,5994.478,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2215.387798,9.170825,27238.33344,percent of total billed charges,,,
ARTICUL/EZE BALL 22.225+4 NK -,SUP-136529000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4405.7,3083.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1139.75459,9.170825,27238.33344,percent of total billed charges,,,
HEAD S-ROM M 36MM +0 -,SUP-136531000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,617.059001,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL HEAD M-SPEC METAL 36MM +3 11/13 -,SUP-1365-32-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,617.059001,9.170825,27238.33344,percent of total billed charges,,,
CERAMIC FEMORAL HEAD 32MM +0 11/13 TAPER -,SUP-1365-32-210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12117,8481.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3134.6679,9.170825,27238.33344,percent of total billed charges,,,
HEAD BIOLOX DELTA CERAMIC FEMORAL 36MM -,SUP-1365-36-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4487.56,3141.292,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1160.931772,9.170825,27238.33344,percent of total billed charges,,,
CERAMIC FEMORAL HEAD 40MM X +8.5 BIOLOX DELTA TS 12/14 TAPER -,SUP-1365-40-730,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1262.61122,9.170825,27238.33344,percent of total billed charges,,,
CERAMIC FEMORAL HEAD 40MM +12 BIOLOX DELTA TS -,SUP-1365-40-740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1262.61122,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM ARTICL/EZ 44MM +1.5MM NK COCR 12/14 TAPR CONTR -,SUP-1365-61-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,722.494773,9.170825,27238.33344,percent of total billed charges,,,
CEMENTRALIZER 11.0 -,SUP-137620000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,113.214881,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 22MM BIPLR COCR MODLR -,SUP-138-2200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL HEAD 22MM +3 COCR -,SUP-138-2203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL HEAD COCR 22MM -3 -,SUP-138-2230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM OVATN 28MM +0MML NK COCR 12/14 TAPR STRL -,SUP-138-2800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL HEAD 28MM +9 12/14 TAPER -,SUP-138-2809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEMORAL COCR 28MM -,SUP-138-2830,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM OVATN 36MM +0MML NK COCR 12/14 TAPR -,SUP-138-3600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL HEAD COCR 36MM +6 -,SUP-138-3606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL HEAD COCR 36MM +9 -,SUP-138-3609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM OVATN 36MM-3MM NK COCR 12/14 TAPR -,SUP-138-3630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL HEAD 40MM +3 -,SUP-138-4003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,,,
COCR FEMORAL HEAD -,SUP-138-4009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,,,
INSERT ENDO II TAPER STD 0MM T -,SUP-139247,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,226.427175,9.170825,27238.33344,percent of total billed charges,,,
HEAD FRDM CNSTR 36MM T12/14 -6MM -,SUP-14-107016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7206.31,5044.417,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1864.272397,9.170825,27238.33344,percent of total billed charges,,,
FRDM CNSTR HD 36MM T 12/14 - 14-107018 -,SUP-14-107018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7206.31,5044.417,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1864.272397,9.170825,27238.33344,percent of total billed charges,,,
BAR ORTHO INTLOK TI ASCENT MAXIM L/R KN CR PRIM STRL -,SUP-141205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1136.02,795.214,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,293.888374,9.170825,27238.33344,percent of total billed charges,,,
TRAY TIBIAL ILOK PRI 79MM BIOMET -,SUP-141215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL PLATE 67MM -,SUP-141232,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,9.170825,27238.33344,percent of total billed charges,,,
TRAY COCR CRUCIATE 71MM CC BIOMET -,SUP-141233,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,9.170825,27238.33344,percent of total billed charges,,,
STEM HIP FINNED PRI 80 X 10MM BIOMET -,SUP-141316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
PIN FX STNMN 2MMX6IN SMTH PLN BAYNT PNT FA KN -,SUP-141796,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7206.31,5044.417,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1864.272397,9.170825,27238.33344,percent of total billed charges,,,
STEM BMT SPLINED KNEE V2 12 X 40 -,SUP-148287,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2173.887144,9.170825,27238.33344,percent of total billed charges,,,
STEM BMT SPLINED KNEE V2 14 X 40 -,SUP-148289,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2173.887144,9.170825,27238.33344,percent of total billed charges,,,
SPLINED KNEE STEM V2 -,SUP-148291,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2173.887144,9.170825,27238.33344,percent of total billed charges,,,
STEM BMT SPLINED KNEE V2 10 X 80 -,SUP-148300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2173.887144,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 7MM PRSRVN RM/LL KN -,SUP-1498-11-306,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5824.89,4077.423,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1506.899043,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 9.5MM PRSRVN RM/LL KN -,SUP-1498-11-308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5824.89,4077.423,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1506.899043,9.170825,27238.33344,percent of total billed charges,,,
STEM OSS CEMENTED IM 9MM X 90MM -,SUP-150358,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9594.39,6716.073,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2482.068693,9.170825,27238.33344,percent of total billed charges,,,
STEM OSS CEMENTED IM 12MM X 90MM -,SUP-150361,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9594.39,6716.073,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2482.068693,9.170825,27238.33344,percent of total billed charges,,,
OSS CEMENTED IM STEM 13MM X 90MM -,SUP-150362,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9594.39,6716.073,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2482.068693,9.170825,27238.33344,percent of total billed charges,,,
OSS CEMENTED IM STEM 13X150 -,SUP-150367,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10426.1,7298.27,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2697.23207,9.170825,27238.33344,percent of total billed charges,,,
STEM OSS POUROUS IM 11.5MM X 90MM -,SUP-150382,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3181.352902,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ3 ATTUNE LT KN CR CMNT -,SUP-1504-00-103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ9 ATTUNE LT KN CR CMNT -,SUP-1504-00-109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
OSS POROUS IM STEM 12.5 X 225 -,SUP-150402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3181.352902,9.170825,27238.33344,percent of total billed charges,,,
OSS POROUS IM STEM 14.5 X 225 -,SUP-150403,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3181.352902,9.170825,27238.33344,percent of total billed charges,,,
OSS POROUS IM STEM 18.5 X 225 -,SUP-150405,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12297.46,8608.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3181.352902,9.170825,27238.33344,percent of total billed charges,,,
OSS TIBAL POLY BEARING 14MM -,SUP-150411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7469.44,5228.608,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1932.344128,9.170825,27238.33344,percent of total billed charges,,,
OSS TIBAL POLY BEARING 18MM -,SUP-150413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7469.44,5228.608,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1932.344128,9.170825,27238.33344,percent of total billed charges,,,
PLATE OSS NON-MOD TIBAL SHORT 67MM -,SUP-150417,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19307.6,13515.32,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4994.87612,9.170825,27238.33344,percent of total billed charges,,,
OSS MOD TIBAL BASEPLATE 71MM -,SUP-150422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20436.35,14305.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5286.883745,9.170825,27238.33344,percent of total billed charges,,,
BLOCK OSS TIB 20 X 63/67 MR/LL -,SUP-150429,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1914.778398,9.170825,27238.33344,percent of total billed charges,,,
BLOCK OSS TIB 20 X 63/67 MR/LR -,SUP-150430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7401.54,5181.078,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1914.778398,9.170825,27238.33344,percent of total billed charges,,,
REVISION CRS FEMORAL SZ 7 LEFT CEMENTED -,SUP-1504-40-107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24255.17,16978.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6274.812479,9.170825,27238.33344,percent of total billed charges,,,
OSS FINN MOD PROX FMRL RT 7CM -,SUP-150457,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26939.64,18857.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6969.284868,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT OSS LETSON MOD PROX FMRL R 7CM -,SUP-150459,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26939.64,18857.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6969.284868,9.170825,27238.33344,percent of total billed charges,,,
OSS 3CM ELLIP DIAPHYSEAL SEG -,SUP-150461,CDM,C1776,HCPCS,278,RC,,,outpatient,,,35466.58,24826.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9175.204246,9.170825,27238.33344,percent of total billed charges,,,
OSS POLY TIBIAL BUSHING -,SUP-150476,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2501.84,1751.288,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,647.226008,9.170825,27238.33344,percent of total billed charges,,,
OSS POLY FEMORAL BUSHINGS 2PK -,SUP-150477,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1738.56,1216.992,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,449.765472,9.170825,27238.33344,percent of total billed charges,,,
OSS AXLE -,SUP-150480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3399.09,2379.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,879.344583,9.170825,27238.33344,percent of total billed charges,,,
OSS REINFORCED YOKE -,SUP-150493,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6994.11,4895.877,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1809.376257,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL BASE FIXED BEARING -,SUP-1506-40-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12048.69,8434.083,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3116.996103,9.170825,27238.33344,percent of total billed charges,,,
BASE TIBIAL REV RP SIZE 4 CEM -,SUP-1506-60-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18338.51,12836.957,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4744.172537,9.170825,27238.33344,percent of total billed charges,,,
TIBIA SLV M/L ATUNE 29MM FULL POR -,SUP-1511-11-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13490.44,9443.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3489.976828,9.170825,27238.33344,percent of total billed charges,,,
REVISED CEMENTED SYSTEM -,SUP-1512-14-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4423.31,3096.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1144.310297,9.170825,27238.33344,percent of total billed charges,,,
STEM PRESSFIT STR ATUNE 16 X 60MM -,SUP-1513-16-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.93,4893.651,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1808.553591,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 6MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-306,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1262.61122,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5 10MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1262.61122,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ6 6MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1262.61122,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ9 7MM ATTUNE CR BEAR KN FX PE -,SUP-1516-20-907,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1262.61122,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT FIXED BEARING POSTERIOR STABILIZED -,SUP-1516-40-412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1262.61122,9.170825,27238.33344,percent of total billed charges,,,
TIBAL INSERT FIXED BEARING POST STAB 7X10MM -,SUP-1516-40-710,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1262.61122,9.170825,27238.33344,percent of total billed charges,,,
INSERT PS RP SZ 5 ATTUNE 16MM -,SUP-1516-50-516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1262.61122,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 41MM ATTUNE MDL DOME -,SUP-1518-20-041,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2364.02,1654.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,611.571974,9.170825,27238.33344,percent of total billed charges,,,
AUG TIBIL UNIV ATUE SZ 3/4 X 5MM -,SUP-1523-03-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5835.5,4084.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1509.64385,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ1 41MM OFST 120MM PROSTALAC HI OFST 26MM LEG COCR -,SUP-1541-06-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19493.25,13645.275,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5042.903775,9.170825,27238.33344,percent of total billed charges,,,
CUP ACTB PROSTALAC CMNT PE 32X42MM -,SUP-1541-42-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3762.63,2633.841,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,973.392381,9.170825,27238.33344,percent of total billed charges,,,
OXFORD PARTIAL KNEE SYM FIXED LATERAL TIBIAL LEFT -,SUP-154335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2124.480618,9.170825,27238.33344,percent of total billed charges,,,
FIXED LATERAL TIBIAL COSTRUCT LEFT  (E3) -,SUP-154340,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2124.480618,9.170825,27238.33344,percent of total billed charges,,,
OXF FIX LAT BRG E4 LEFT -,SUP-154341,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2124.480618,9.170825,27238.33344,percent of total billed charges,,,
OXF FIX LAT BRG B3 RIGHT -,SUP-154355,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2124.480618,9.170825,27238.33344,percent of total billed charges,,,
OXFORD FIX LAT BRG E5 RIGHT -,SUP-154372,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2124.480618,9.170825,27238.33344,percent of total billed charges,,,
OXFORD FIX LAT BRG F3 RIGHT -,SUP-154375,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8212.14,5748.498,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2124.480618,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SM OXFORD KN UNICMPT COCR -,SUP-154600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2305.63788,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM MED OXFORD KN UNICMPT COCR -,SUP-154601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9586.97,6710.879,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2480.149139,9.170825,27238.33344,percent of total billed charges,,,
REVISION DISTAL FEMORAL AUGMENT SZ 7X4MM CEMENTED -,SUP-1547-07-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5135.24,3594.668,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1328.486588,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ A LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154718,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ A R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ B LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154720,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ B R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154721,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ-C LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154722,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ-C L/M PMA ARTC OXFORD TI NIOBM NTRD CTD UHMWP -,SUP-154722,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ-C R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154723,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ-D LM KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154724,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ-D R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154725,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ-E R/M KN ARTC OXFORD TI NIOBM NTRD CTD UHMWPE -,SUP-154727,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,,,
REVISION POSTERIOR FEMORAL AUGMENT SZ 7X4MM -,SUP-1549-07-001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5135.24,3594.668,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1328.486588,9.170825,27238.33344,percent of total billed charges,,,
SUMMIT BASIC CEMENTED SZ 6 -,SUP-157006120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1080.654575,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ4 OFST 12/14 TAPR W/ POROCOAT -,SUP-1570-11-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2468.621467,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL STEM 12/14 TAPER / SZ 5 / 145MM -,SUP-1570-11-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2468.621467,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ6 12/14 TAPER W/ PORCOAT -,SUP-1570-11-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2468.621467,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL STEM 12/14 TAPER SZ7X155MM -,SUP-1570-11-135,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2468.621467,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB XS OXFORD UNICMPT ANTMC BEAR LT FEM MNSCL KN -,SUP-159530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2305.63788,9.170825,27238.33344,percent of total billed charges,,,
OXFORD KNEED RIGHT MEDIAL TIBIAL TRAY SZAA -,SUP-159532,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SM SZ4 PMA OXFORD UNICMPT ANTMC BRG LT MNSCL -,SUP-159541,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SM 5MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159542,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SM 6MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159543,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SM 9MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159546,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB MED 3MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159547,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB MED 4MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159548,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB MED 6MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159550,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB LRG 3MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159554,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB LRG 6MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159557,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB XL 4MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159562,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB XL 5MM OXFORD UNICMPT ANTMC BEAR LT MNSCL KN -,SUP-159563,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SM 3MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159568,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SM 6MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159571,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SM 7MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159572,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SM 8MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159573,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SM 9MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159574,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB MED 3MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159575,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB MED 4MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159576,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
OXF ANAT BRG RT MD SZ 5 PMA -,SUP-159577,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB MED 6MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159578,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB MED 7MM OXFORD UNICMPT ANTMC BEAR RT MNSCL KN -,SUP-159579,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB MED 8MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159580,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB LRG 3MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159582,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB LRG 4MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159583,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB LRG 5MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159584,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB LRG 6MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL -,SUP-159585,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB XL 3MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL KN -,SUP-159589,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB XL 4MM OXFORD UNICMPT ANTMC ARTC BEAR RT MNSCL KN -,SUP-159590,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB XS 4MM OXFORD UNICMPT ANTMC ARTC BEAR LT MNSCL KN -,SUP-159791,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ5 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-05132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ6 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD. -,SUP-1601-06127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ6 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-06132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ7 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD. -,SUP-1601-07127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ7 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-07132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ8 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD. -,SUP-1601-08127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ8 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-08132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8806.3,6164.41,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2278.18981,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ9 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-09127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,,,
HIP STEM SZ.9 34MM 142MM V40 -,SUP-1601-09132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,,,
HIP STEM SZ.10 34MM / 148MM -,SUP-1601-10132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ11 SECUR-FIT ADVANCED V40 PRFT PUREFIX PLASM CTD -,SUP-1601-11132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB XS 4MM OXFORD UNIV ANTMC ARTC BEAR RT KN -,SUP-160791,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
OSS 3CM PROXIMAL TIBIAL SLEEVE -,SUP-161000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13099.46,9169.622,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3388.830302,9.170825,27238.33344,percent of total billed charges,,,
OSS RS 3 CM RESURF FMRL-LT -,SUP-161006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,26742.28,18719.596,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6918.227836,9.170825,27238.33344,percent of total billed charges,,,
OSS RS 7 CM MOD SEG FMRL-RT -,SUP-161011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28518.52,19962.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7377.741124,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE OSS RS 3 CM PROX TIBIAL -,SUP-161023,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13663.84,9564.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3534.835408,9.170825,27238.33344,percent of total billed charges,,,
BUSHING OSS RS POLY FEM SET/2 -,SUP-161034,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3131.74,2192.218,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,810.181138,9.170825,27238.33344,percent of total billed charges,,,
AXLE OSS RS -,SUP-161035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3399.09,2379.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,879.344583,9.170825,27238.33344,percent of total billed charges,,,
SEGMENT OSS 3CM LG ELLIPT DIAPH -,SUP-161079,CDM,C1776,HCPCS,278,RC,,,outpatient,,,35466.58,24826.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9175.204246,9.170825,27238.33344,percent of total billed charges,,,
MOD BEARING TIBIAL OSS RS 63MM -,SUP-161088,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21683.92,15178.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5609.630104,9.170825,27238.33344,percent of total billed charges,,,
BEARING TIBIAL OSS RS 12MM LS -,SUP-161094,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1624.925744,9.170825,27238.33344,percent of total billed charges,,,
BEARING TIBIAL OSS RS 16MM LS -,SUP-161096,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1624.925744,9.170825,27238.33344,percent of total billed charges,,,
BEARING TIBIAL OSS RS 18MM LS -,SUP-161097,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1624.925744,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT LT SZ 2 FEMORAL PS NONPOROUS -,SUP-161-1201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL PS RIGHT SZ 2 NON-POROUS -,SUP-161-1202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,,,
SEG OSS RS 8.5CM FMRL LEFT -,SUP-161124,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29722.42,20805.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7689.190054,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ3 BAL KN LT PS NPOR -,SUP-161-1301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ3 BAL KN RT KN PS NPOR -,SUP-161-1302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ4 BAL KN LT KN PS NPOR -,SUP-161-1401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ4 BAL KN RT KN PS NPOR -,SUP-161-1402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT FEMORAL BALANCED KNEE COCR NONPOROUS 4N KNEE LEFT -,SUP-161-1405,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL PS NARROW RIGHT SZ 4 NON-POROUS -,SUP-161-1406,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1701.78034,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 BAL KN LT KN PS NPOR -,SUP-161-1501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 BAL KN RT KN PS NPOR -,SUP-161-1502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL PS NARROW LEFT SZ 5 NON-POROUS -,SUP-161-1505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL PS NARROW RIGHT SZ 5 NON-POROUS -,SUP-161-1506,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ6 BAL KN LT KN PS NPOR -,SUP-161-1601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ6 BAL KN RT KN PS NPOR -,SUP-161-1602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ7 BAL KN LT KN PS NPOR -,SUP-161-1701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ7 BAL KN RT KN PS NPOR -,SUP-161-1702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,,,
RT SIZE 2 FEMORAL CR NONPOROUS -,SUP-161-3202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ4 BAL KN LT KN CR NPOR -,SUP-161-3401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 BAL KN LT KN CR NPOR -,SUP-161-3501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 BAL KN RT KN CR NPOR -,SUP-161-3502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ6 BAL KN LT KN CR NPOR -,SUP-161-3601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ6 BAL KN RT KN CR NPOR -,SUP-161-3602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM XS OXFORD KN TWN PG PRT CMNT COCR MLYBDNM ALY -,SUP-161467,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2086.05332,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SM OXFORD KN TWN PG PRT CMNT COCR MLYBDNM ALY -,SUP-161468,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2086.05332,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM MED OXFORD KN TWN PG PRT CMNT COCR MLYBDNM ALY -,SUP-161469,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2086.05332,9.170825,27238.33344,percent of total billed charges,,,
TWIN PEGGED FEMORAL LRG KNEE -,SUP-161470,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2086.05332,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ2 BAL KN NPOR -,SUP-162-1200A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ3 BAL KN NPOR -,SUP-162-1300A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ4 BAL KN NPOR -,SUP-162-1400A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ5 BAL KN NPOR -,SUP-162-1500A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ6 BAL KN NPOR -,SUP-162-1600A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL TRAY NONPOROUS SIZE 7 -,SUP-162-1700A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 11MM PS KN -,SUP-163-1311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5 8MM PS KN -,SUP-163-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5 13MM PS KN -,SUP-163-1513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ6 12MM PS KN -,SUP-163-1612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ2 13MM UL CONG KN -,SUP-163-3213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 11MM UL CONG KN -,SUP-163-3311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 16MM UL CONG KN -,SUP-163-3316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ4 9MM UL CONG KN PE -,SUP-163-3409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5 14MM UL CONG KN -,SUP-163-3514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2726.14,1908.298,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,705.252418,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ6 10MM UL CONG KN -,SUP-163-3610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ6 11MM UL CONG KN -,SUP-163-3611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ6 14MM UL CONG KN -,SUP-163-3614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
MODULAR HEAD COMPONENT 32MM DIA HD 3MM NK -,SUP-163661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,,,
28MM DIA COCR MOD HD -,SUP-163665,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,,,
MODULAR HEAD COMPONENT 32MM -,SUP-163674,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,,,
PATELLA  29MM VITAMIN 3 -,SUP-164-5029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,,,
PATELLA 32MM VITAMIN E -,SUP-164-5032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,,,
PATELLA 35MM VITAMIN E -,SUP-164-5035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,,,
PATELLA 38MM VITAMIN E -,SUP-164-5038,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,,,
41MM PATELLA VITAMIN E -,SUP-164-5041,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL PS RIGHT SZ 4 NON-POROUS -,SUP-165-1402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL CR LEFT SZ 6 NON-POROUS -,SUP-165-3601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1701.78034,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT PS SIZE 2 7MM VITAMIN E -,SUP-166-5207,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT BKS E-VITALIZE 9MM SZ 2 -,SUP-166-5209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT PS TIBIAL 10MM SIZE 2 V -,SUP-166-5210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT PS TIBIAL SIZE 2 11MM VITAMIN E -,SUP-166-5211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT PS VITAMIN E SIZE 2 12MM -,SUP-166-5212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT PS TIBIAL SIZE 3 7MM VITAMIN E -,SUP-166-5307,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL PS SIZE 3 8MM VITAMIN E -,SUP-166-5308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
SIZE 3 9MM TIBIAL INSERT PS VITAMIN E -,SUP-166-5309,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT PS TIBIAL 10MM SIZE 3 V -,SUP-166-5310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL PS SIZE 3 10MM VITAMIN E -,SUP-166-5310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL PS 11MM SIZE 3 V -,SUP-166-5311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL PS 12MM SIZE 3 V -,SUP-166-5312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL PS 13MM SIZE 3 V -,SUP-166-5313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT PS TIBIAL 14MM SIZE 3 V -,SUP-166-5314,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL PS 16MM SIZE 3 V -,SUP-166-5316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SIZE 3 18MM VIT E -,SUP-166-5318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SIZE 3 20MM -,SUP-166-5320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT PS VITAMIN E SZ4 7MM -,SUP-166-5407,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL PS 8MM SIZE 4 VITAMIN E -,SUP-166-5408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT PS TIBIAL 9MM SIZE 4 HI -,SUP-166-5409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT PS TIBIAL 10MM SIZE 4 V -,SUP-166-5410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL PS SIZE 4 10MM VITAMIN E -,SUP-166-5410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT PS VITAMIN E SZ 4 10MM -,SUP-166-5410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL PS 11MM SIZE 4 V -,SUP-166-5411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL PS 11MM SIZE 4 VITAMIN E -,SUP-166-5411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL PS SIZE 4 12MM VITAMIN E -,SUP-166-5412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT PS TIBIAL 12MM SIZE 4 H -,SUP-166-5412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT PS TIBIAL 13MM SIZE 4 H -,SUP-166-5413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL 14MM SIZE 4 HIGH -,SUP-166-5414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SIZE 4 16MM VIT E -,SUP-166-5416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT PS SIZE 4 18MM -,SUP-166-5418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT PS VIT 3 SIZE 4 20MM -,SUP-166-5420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT PS SIZE 5 7 MM VIT E -,SUP-166-5507,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIIAL PS SIZE 5 8MM VITAMIN E -,SUP-166-5508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT PS SIZE 5 9MM TIBIAL VITAMIN E -,SUP-166-5509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL PS 10MM SIZE 5 V -,SUP-166-5510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL PS SIZE 5 10MM VITAMIN E -,SUP-166-5510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL 11MM PS SIZE 5 HIGH FLEX VITAMIN E -,SUP-166-5511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL NONPOROUS SIZE 5 -,SUP-166-5511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL PS 12MM SIZE 5 V -,SUP-166-5512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL PS SIZE 5 12MM VITAMIN E -,SUP-166-5512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL PS 14MM SIZE 5 H -,SUP-166-5514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SIZE 5 16MM VIT E -,SUP-166-5516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SIZE 5 20MM -,SUP-166-5520,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SIZE 6 7MM -,SUP-166-5607,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SIZE 6 8MM VIT E -,SUP-166-5608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SZ 6 9MM PS -,SUP-166-5609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL PS 10MM SIZE 6 H -,SUP-166-5610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
SIZE 6 10MM TIBIAL INSERT PS VITAMIN E -,SUP-166-5610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL PS 11MM SIZE 6 VITAMIN E -,SUP-166-5611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SIZE 6 12MM VIT E -,SUP-166-5612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SIZE6 14MM VITAMIN E -,SUP-166-5614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT PS SZ 6 16MM VITAMN-E -,SUP-166-5616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1136.231096,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT INSERT PS SIZE 7 10MM VIT E XLPE -,SUP-166-5710,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT CR SZ 5 10MM VITAMIN E -,SUP-166-6510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SZ 2 12MM VIT E -,SUP-166-7212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT UC SZ 3 9MM VIT-E -,SUP-166-7309,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SIZE 3 11MM VIT E XLPE -,SUP-166-7311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT UC SZ 4 8MM VIT E -,SUP-166-7408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SZ 4 9MM VIT E -,SUP-166-7409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT UC SIZE 4 10MM VIT E -,SUP-166-7410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SIZE 4 11MM VIT E -,SUP-166-7411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SIZE 4 12MM VIT E -,SUP-166-7412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SIZE 4 13MM -,SUP-166-7413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT UC SZ 4 14MM VIT E -,SUP-166-7414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SZ 5 7MM VIT E -,SUP-166-7507,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT UC SZ 5 8MM VITAMIN-E -,SUP-166-7508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL UC SZ 5 9MM E-VITALIZE KNEE -,SUP-166-7509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SIZE 5 10MM VIT E -,SUP-166-7510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT BKS E-VITALIZE 11MM SZ 5 -,SUP-166-7511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT UC SZ 5 12MM VIT-E -,SUP-166-7512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SIZE 5 13MM VITAMIN E -,SUP-166-7513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SIZE 5 14MM VIT E -,SUP-166-7514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT UC SIZE 5 16MM VIT-E -,SUP-166-7516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SIZE 6 10MM VIT E -,SUP-166-7610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SIZE 6 11MM VITAMIN E -,SUP-166-7611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SIZE 6 12MM VIT E -,SUP-166-7612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT UC SIZE 6 13MM VIT E -,SUP-166-7613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SIZE 6 14MM VIT E -,SUP-166-7614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT SIZE 7 11MM VIT E -,SUP-166-7711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE HIP UNITRAX V40 UNIPL TI -,SUP-170000E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,226.427175,9.170825,27238.33344,percent of total billed charges,,,
SHELL THREE HOLE 44MM -,SUP-170-0144,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 48MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0148,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4630.78,3241.546,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1197.982786,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 50MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 52MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0152,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 56MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 58MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0158,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 60MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 62MM ESCALADE 3HL TI PLASM SPRY CTD -,SUP-170-0162,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,,,
SHELL ESCALADE 68MM THREE HOLE -,SUP-170-0168,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACETABULAR LEGEND OD50 MM 3 HOLE -,SUP-170-0550,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,,,
POROUS ACET SHELL THREE HOLE 52MM OD -,SUP-170-0552,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,,,
POROUS ACETABULAR SHELL THREE-HOLE 54MM OD -,SUP-170-0554,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,,,
POROUS ACETABULAR SHELL THREE HOLE 56MM OD -,SUP-170-0556,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4630.78,3241.546,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1197.982786,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 32MM X 52MM NEUTRAL HXLPE -,SUP-170-3252,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 36MM 52MM SHL ESCALADE +3 NEUT -,SUP-170-3652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 36MM 54MM SHL ESCALADE +1 NEUT -,SUP-170-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 36MM 56MM SHL ESCALADE +0 NEUT -,SUP-170-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 36MM 58MM SHL ESCALADE +0 NEUT -,SUP-170-3658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 36MM 60MM SHL ESCALADE +0 NEUT -,SUP-170-3660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 36X62MM ESCALDE +ODEG NEUT F/T/H ARTHPL -,SUP-170-3662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
LINER +3 NEUTRAL 40 X 56MM HXL -,SUP-170-4056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
LINER NEUTRAL +1 ESCALADE -,SUP-170-4058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 40X60MM ESCALDE +ODEG NEUT F/T/H ARTHPL -,SUP-170-4060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,957.151195,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 40X62MM ESCALDE +ODEG NEUT F/T/H ARTHPL -,SUP-170-4062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
ACETABULAR LINER 36 X 52 +3 HOODED HXLPE -,SUP-171-3652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
LINER ACETABULAR 36 X 54 HOODED -,SUP-171-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 36X56MM ESCALDE +ODEG HD F/T/H ARTHPL -,SUP-171-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,957.151195,9.170825,27238.33344,percent of total billed charges,,,
LINER 28MM ID 44MM OD NEUTRAL HXLPE -,SUP-172-2844,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
LINER 32MM ID 46MM OD NEUTRAL HXLPE -,SUP-172-3246,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
LINER 36MM ID 50MM OD NEUTRAL HXLPE -,SUP-172-3650,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
LINER 36MM ID 52MM OD NEUTRAL HXLPE -,SUP-172-3652,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
LINER 36MM ID 54MM OD NEUTRAL HXLPE -,SUP-172-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
LINER 36MM ID 56MM OD NEUTRAL HXLPE -,SUP-172-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
LINER 36MM ID 58MM OD NEUTRAL HXLPE -,SUP-172-3658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
LINER 36MM ID 60MM OD NEUTRAL HXLPE -,SUP-172-3660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
LINER 36MM 64-70MM OD NEUTRAL -,SUP-172-3664,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
LINER 40MM ID 56MM OD NEUTRAL HXLPE -,SUP-172-4056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
LINER 40MM ID 58MM OD NEUTRAL HXLPE -,SUP-172-4058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
LINER 40MM ID 60MM OD NEUTRAL HXLPE -,SUP-172-4060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
STEM WITH MICROPOUROUS SUR 14MM X 12MM X 180CM -,SUP-172-918/14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4322.48895,9.170825,27238.33344,percent of total billed charges,,,
STEM WITH MICROPOROUS SURGACE 14MM X 16MM L 180MM -,SUP-172-918/16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4322.48895,9.170825,27238.33344,percent of total billed charges,,,
STEM WITH MICROPOROUS SURFACE 18MM X 16MM L180MM -,SUP-172-918/18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4322.48895,9.170825,27238.33344,percent of total billed charges,,,
STEM FEMORAL LINK W/MICROPOROUS CEMTLESS 20MM X 18MM X 180MM -,SUP-172-918/20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4322.48895,9.170825,27238.33344,percent of total billed charges,,,
LINK STEM WITH MICROP SUR 14MM X 16MM -,SUP-172-921/16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4322.48895,9.170825,27238.33344,percent of total billed charges,,,
STEM WITH MICROPOROUS SURFACE 16 X 18 X 210 -,SUP-172-921/18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4322.48895,9.170825,27238.33344,percent of total billed charges,,,
LINK STEM WITH MICROP SUR 14MM X 11MM X 120MM -,SUP-172-925/14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4322.48895,9.170825,27238.33344,percent of total billed charges,,,
STEM WITH MICROPOROUS SURFACE 12.5MM X 16MM L 250MM -,SUP-172-925/16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4322.48895,9.170825,27238.33344,percent of total billed charges,,,
STEM MICROPOROUS SURF 14.5MM X 18MM L 250MM CEMENTLESS -,SUP-172-925/18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4322.48895,9.170825,27238.33344,percent of total billed charges,,,
SPACER PROXIMAL 20MM X 14MM COCRMO -,SUP-172-950/20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1484.14,1038.898,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,383.947018,9.170825,27238.33344,percent of total billed charges,,,
LINK NECK SEGMENT WITHOUT COLLAR CEMLESS 65MM 126CCD -,SUP-172-964/26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5148.564616,9.170825,27238.33344,percent of total billed charges,,,
NECK FEMORAL W/O COLLAR CEMENTLESS TILASTAN TI6AI-4V LINK -,SUP-172-964/35,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5148.564616,9.170825,27238.33344,percent of total billed charges,,,
NECK SEGMENT WITHOUT COLLAR CEMENTLESS -,SUP-172-965/26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5148.564616,9.170825,27238.33344,percent of total billed charges,,,
NECK SEGMENT XXL W/O COLLAR 65MM 12/14MM CEMENTLESS -,SUP-172-984/26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5148.564616,9.170825,27238.33344,percent of total billed charges,,,
LINK NECK SEG XXL WITHOUT COLLAR CEMENLESS 65MM -,SUP-172-984/35,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19901.68,13931.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5148.564616,9.170825,27238.33344,percent of total billed charges,,,
LINER 36MM ID 50MM OD HOODED HXLPE -,SUP-173-3650,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,957.151195,9.170825,27238.33344,percent of total billed charges,,,
LINER 36MM ID 54MM OD HOODED HXLPE -,SUP-173-3654,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
LINER 36MM ID 56MM OD HOODED -,SUP-173-3656,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3699.85,2589.895,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,957.151195,9.170825,27238.33344,percent of total billed charges,,,
LINER 36MM ID 58MM OD HOODED HXLPE -,SUP-173-3658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM ABC 36X0MM NK ALMN C-TAPR PRIM -,SUP-173600E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,,,
ASCENT ANT STBLZD TIBIAL BEARING 14 X 67 -,SUP-179822,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5551.15,3885.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1436.082505,9.170825,27238.33344,percent of total billed charges,,,
COMP RESTORIS SZ 3 LEFT MAKO PATELLOFEMORAL COCRMO -,SUP-180403,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2497.43806,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT RESTORIS MCK SIZE 4 LEFT PATELLOFEMORAL COCRMO -,SUP-180404,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2497.43806,9.170825,27238.33344,percent of total billed charges,,,
COMP RESTORIS MCK PAT/FEM SZ 5 RIGHT COCRMO -,SUP-180415,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2497.43806,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT FEMORAL RESTORIS MCK SIZE 1 LM/RL -,SUP-180501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT FEMORAL SZ 3 LM/RL RESTORIS MAKO COCRMO -,SUP-180503,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT FEMORAL SIZE 4 LM/RL RESTORIS MCK COCRMO -,SUP-180504,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT FEMORAL SZ 5 LM/RL RESTORIS MAKO COCRMO -,SUP-180505,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT FEMORAL SZ 6 LM/RL RESTORIS MAKO COCRMO -,SUP-180506,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT FEMORAL SZ 1 RM/LL RESTORIS MAKO COCRMO -,SUP-180511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT FEM ONLAY SZ 3 RM/LL RESTORIS MAKO COCRMO -,SUP-180513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT FEMORAL SZ 4 RM/LL RESTORIS MAKO COCRMO -,SUP-180514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT FEMORAL RESTORIS MCK SZ 5 RM/LL COCRMO MAKO -,SUP-180515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT FEMORAL RESTORIS MCK SZ 6 RM/LL COCRMO MAKO -,SUP-180516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT FEM RESTORIS MCK SZ 7 RM/LL COCRMO -,SUP-180517,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIBIAL RESTORIS MCK ONLAY SIZE 2 LM/RL -,SUP-180602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIBIAL RESTORIS SZ 3 LM/RL T/6A/4V ONLAY MAKO -,SUP-180603,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE ONLAY TIBIAL SZ 4 LM/RL T/6A/4V RESTORIS MAKO -,SUP-180604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE ONLAY TIBIAL 5 LM/RL RESTORIS MCK -,SUP-180605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE ONLAY TIBIAL 6 LM/RL RESTORIS MCK -,SUP-180606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE ONLAY TIBIAL SZ 2 RM/LL Ti6AI4V RESTORIS MAKO -,SUP-180612,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE ONLAY TIBIAL SIZE 3 RM/LL RESTORIS MCK TI6AI4V -,SUP-180613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE ONLAY TIBIAL SZ 4 RM/LL Ti6AI4V RESTORIS MAKO -,SUP-180614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIBIAL RESTORIS MCK SZ 5 RM/LL ONLAY MAKO TI6AI4V -,SUP-180615,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE ONLAY TIBIAL 6 RM/LL RESTORIS MCK -,SUP-180616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE ONLAY TIBIAL 7 RM/LL RESTORIS MCK TI6A14V -,SUP-180617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIBIAL RESTORIS MCK SZ 8 RM/LL TI6I4V -,SUP-180618,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL SIZE 2 UNI X 8MM MAKO X3 ONLAY -,SUP-180732-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL MAKO X3 UNI ONLAY SIZE 2 X 8MM -,SUP-180732-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL MAKO X3 3 X 8 MM KNEE ONLAY -,SUP-180733-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,,,
INSERT ONLAY TIBIAL SZ 4 X 8MM MAKO X3 UNI -,SUP-180734-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL SIZE 4 X 8MM UNI ONLAY MAKO X3 -,SUP-180734-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL UNI ONLAY SIZE 4 X 9MM THKNS MAKO X3 -,SUP-180734-2,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL ONLAY SZ 5 X 8MM MAKO X3 UNI -,SUP-180735-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL ONLAY SZ 5 X 9MM MAKO X3 UNI -,SUP-180735-2,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,,,
INSERT ONLAY TIBIAL SZ 6 X 8MM MAKO X3 UNI -,SUP-180736-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL ONLAY SZ 6 X 8MM MAKO X3 UNI -,SUP-180736-1-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,,,
INSERT ONLAY TIBIAL SZ 7 X 8MM MAKO X3 UNI -,SUP-180737-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,,,
INSERT ONLAY TIBIAL MAKO X3 UNI SZ 8 X 8MM THKNS -,SUP-180738-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 28MM +0MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-18-2800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM 55MM VANGRD RT KN CR ANTMC CMNT COCR NPOR INTLOK -,SUP-183000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM 62.5MM VANGRD RT KN CR ANTMC CMNT COCR NPOR INTLOK -,SUP-183006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,,,
FEMUR CR INTERLOCK RIGHT 65MM VANGUARD -,SUP-183008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,,,
VANGUARD CR ILOK FEM-LT 62.5 -,SUP-183026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM 57.5MM VANGRD LT KN CR ANTMC CMNTLS TI POR -,SUP-183062,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2526.254653,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM 62.5MM VANGRD LT KN CR ANTMC CMNTLS TI POR -,SUP-183066,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2526.254653,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM 70MM VANGRD LT KN CR ANTMC CMNTLS TI POR -,SUP-183072,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2526.254653,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM 57.5MM VANGRD RT FEM OPN BX CMNT COCR -,SUP-183102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM 60MM VANGRD RT KN PS OPN BX CMNT COCR NPOR INTLOK -,SUP-183104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,,,
PS OPEN BOX FEMORAL - LEFT 62.5MM -,SUP-183126,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,,,
PLATE VN PS OPEN INTL FEM-LT 70 -,SUP-183132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 32MM +0MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 32MM +5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB 10X63/67MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-183520,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB 16X63/67MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-183526,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 36MM +0MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 36MM +5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB 12X63/67MM VANGRD PS MODULAR ARTC BEAR 0DG SLP KN -,SUP-183622,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 36MM -5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-18365,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 36MM +7.5MM OFST BIOLOX DELTA CERM C-TAPR PRIM -,SUP-183675,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL BEARING 14MM X 63/67 MM -,SUP-183724,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,,,
BRIDGE VANGUARD PS+TIB 20 X63/67MM -,SUP-183730,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL BEARING 14MM X 71/75MM -,SUP-183744,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,,,
BRIDGE VNGD PS+TIB 24 X79/83MM -,SUP-183774,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,,,
VNGD SSK PSC TIB BRG 20 X 71/75 -,SUP-183890,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9735.49,6814.843,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2518.571263,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 31MM STD 8MM TI SS UNMWPE PEGX3 VANGRD -,SUP-184764,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,9.170825,27238.33344,percent of total billed charges,,,
SERIES A ASYMMETRIC PAT 31X8 -,SUP-184792,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,9.170825,27238.33344,percent of total billed charges,,,
SERIES-A ASYMMETRICAL PATELLA 31MM / 8MM -,SUP-184792,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,9.170825,27238.33344,percent of total billed charges,,,
SERIES A ASYMMETRIC PAT 34X8.5 -,SUP-184793,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,9.170825,27238.33344,percent of total billed charges,,,
DRILL HEADLESS TROCAR PIN 75MM -,SUP-185086,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9557.26,6690.082,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2472.463162,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL TRAY WITH TI LCK BAR AND SCREW -,SUP-185203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11606.84,8124.788,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3002.689508,9.170825,27238.33344,percent of total billed charges,,,
OFFSET ADAPTER WITH SCREWS -,SUP-185210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4611.68,3228.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1193.041616,9.170825,27238.33344,percent of total billed charges,,,
ADAPTER OFFSET BMT 360 TIB 6.0 -,SUP-185211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4611.68,3228.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1193.041616,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT BMT 360 TIBIAL 7 X 5MM -,SUP-185223,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5321.98,3725.386,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1376.796226,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT BMT 360 TIBIAL 71 X 15MM RL/LM -,SUP-185243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5321.98,3725.386,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1376.796226,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT BMT 360 TIBIAL 71 X 15MM LL/RM -,SUP-185253,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5321.98,3725.386,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1376.796226,9.170825,27238.33344,percent of total billed charges,,,
VNGD SSK 360 L FEMORAL R 67.5 -,SUP-185265,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29741.13,20818.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7694.030331,9.170825,27238.33344,percent of total billed charges,,,
VNGD SSK 360 L FEMORAL 65MM -,SUP-185284,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29741.13,20818.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7694.030331,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT VG 360 DIST FM 67.5 X 5 RL/LM -,SUP-185305,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT VG 360 DIST FM 67.5 X 5 LL/RM -,SUP-185325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT VG 360 UNIV PST FM 65 X 10 -,SUP-185424,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT VG 360 UNIV PST FM 67.5 X 10 -,SUP-185425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,,,
WING BMT 360 TIBIAL SM CRUCIATE -,SUP-185650,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1089.300329,9.170825,27238.33344,percent of total billed charges,,,
VANGUARD ANT STBLZD BRG 12X67 -,SUP-189042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,,,
BRIDGE VANGUARD ANT STBLZD 14 X 67 -,SUP-189044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,,,
BRIDGE ANT TIBIAL STABILIZED10 X 71MM VANGD -,SUP-189060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE HIP UNIV TRIDENT PRIM ADPTR +0MML NK OFST BIOLOX -,SUP-19-0000T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,226.427175,9.170825,27238.33344,percent of total billed charges,,,
ADAPTER UNIV C-TAPER +5MM SLEE -,SUP-19-0005T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,226.427175,9.170825,27238.33344,percent of total billed charges,,,
UNIVERSAL C-TAPER +2.5MM ADAPTER SLEEVE -,SUP-19-0025T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,226.427175,9.170825,27238.33344,percent of total billed charges,,,
UNITED HIP SYSTEM ISCHIAL FLANGE -,SUP-1908-5401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6459.37,4521.559,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1671.039019,9.170825,27238.33344,percent of total billed charges,,,
STEM ECHO POR FEMORAL LAT NC 28 X 44MM -,SUP-192114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
BOLT LOCKING CONICAL PROX BODY CEMENTLESS 24 X 95 -,SUP-1975-24-095,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17895.36,12526.752,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4629.529632,9.170825,27238.33344,percent of total billed charges,,,
STEM DISTAL TAPERED 15 X 190 STRAIGHT -,SUP-1976-15-190,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15238.52,10666.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3942.205124,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ7 FNDTN LT KN CR TI NPOR -,SUP-201-01-107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
G7 LONGEVITY NEUTRIAL 32MM C -,SUP-20103203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,,,
G7 LONGEVITY NEUTRIAL 32MM D -,SUP-20103204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3174.71,2222.297,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,821.297477,9.170825,27238.33344,percent of total billed charges,,,
SHELL G7 LONGEVITY NEUTRIAL 32MM D -,SUP-20103204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,,,
G7 LONGEVITY NEUTRIAL 32MM E -,SUP-20103205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,,,
G7 LONGEVITY NEUTRAL 36MM D -,SUP-20103604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,,,
G7 LONGEVITY NEUTRAL 36MM E -,SUP-20103605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,,,
G7 LONGEVITY NEUTRAL 36MM F -,SUP-20103606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,,,
G7 LONGEVITY NEUTRAL 36MM G -,SUP-20103607,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,,,
G7 LONGEVITY NEUTRAL 40MM F -,SUP-20104006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,,,
G7 LONGEVITY NEUTRAL 40MM G -,SUP-20104007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 FNDTN RT KN CR TI NPOR -,SUP-202-01-105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ7 FNDTN RT KN CR TI NPOR -,SUP-202-01-107,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 28X58-60MM SHL OMNIFIT 10DG CROSSFIRE 13.1MM -,SUP-2041C-2858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4587.76,3211.432,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1186.853512,9.170825,27238.33344,percent of total billed charges,,,
INSERT OMNIFIT SERIES II 20 DEGREE 32MM -,SUP-2042-3250,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3800.96,2660.672,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,983.308352,9.170825,27238.33344,percent of total billed charges,,,
JIG TOT JNT RT TIB KN PERSONA ROT -,SUP-20-8070-002-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
JIG TOT JNT LT KN PERSONA PREF -,SUP-20-8070-010-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
GW ORTHO TM PT SPEC INST -,SUP-20-8075-001-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 28X58MM OSTEONICS 0DG BIPLR PE 5.8-10.4MM THK -,SUP-2099-2858,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9662.67,6763.869,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2499.732729,9.170825,27238.33344,percent of total billed charges,,,
USTAR KNEE SYS FEMORAL COMPONENT HINGED #3 LEFT -,SUP-2115-1330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7300.20356,9.170825,27238.33344,percent of total billed charges,,,
USTAR II KNEE SYSTEM FEMORAL COMPONENT HINGED #4 LEFT -,SUP-2115-1340,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7300.20356,9.170825,27238.33344,percent of total billed charges,,,
USTAR KNEE FEMORAL COMPONENT HINGED #5 LEFT -,SUP-2115-1350,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7300.20356,9.170825,27238.33344,percent of total billed charges,,,
UNITED II KNEE FEMORAL COMPONENT HINGED #6 HINGED -,SUP-2115-1360,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7300.20356,9.170825,27238.33344,percent of total billed charges,,,
URSTAR II KNEE SYSTEM FEMORAL COMPONENT HINGED #3 RIGHT -,SUP-2115-1430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7300.20356,9.170825,27238.33344,percent of total billed charges,,,
USTAR II KNEE FEMORAL COMPONENT HINGED #5 RIGHT -,SUP-2115-1450,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28218.8,19753.16,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7300.20356,9.170825,27238.33344,percent of total billed charges,,,
USTAR II KNEE DISTAL FEMORAL COMPONENT RHS S LEFT -,SUP-2115-3310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30242.39,21169.673,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7823.706293,9.170825,27238.33344,percent of total billed charges,,,
USTAR II KNEE DISTAL FEMORAL COMP RHS S RIGHT -,SUP-2115-3410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,30242.39,21169.673,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7823.706293,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ4 FNDTN LT KN PS TI NPOR -,SUP-213-01-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ8 FNDTN LT KN PS TI NPOR -,SUP-213-01-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ8 FNDTN RT KN PS TI NPOR -,SUP-214-01-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ12 FNDTN RT KN PS TI NPOR -,SUP-214-01-012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
IMPLANT  CUSTOM PFR KINEMATCH -,SUP-22-100-1001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19864.55,13905.185,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5138.959085,9.170825,27238.33344,percent of total billed charges,,,
USTAR II TIBIAL BASEPLATE HINGED #1 -,SUP-2215-1410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3488.729894,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIBIAL USTAR II HINGED 2 KNEE -,SUP-2215-1420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3488.729894,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIBIAL SYSTEM USTAR II HINGED 3 -,SUP-2215-1430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3488.729894,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIBIAL USTAR II HINGED 4 KNEE -,SUP-2215-1440,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13485.62,9439.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3488.729894,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT TIBIAL USTAR II KNEE PROXIMAL RHS S -,SUP-2215-3410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,34950.47,24465.329,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9041.686589,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL KNEE USTAR II XPE SMALL 12MM -,SUP-2315-3211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1763.262982,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL USTAR II KNEE XPE S 14MM -,SUP-2315-3212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1763.262982,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL USTAR II KNEE XPE S 17MM -,SUP-2315-3213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1763.262982,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL USTAR II XPE H20 SMALL 20MM -,SUP-2315-3214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1763.262982,9.170825,27238.33344,percent of total billed charges,,,
USTAR II KNEE XPE TIBIAL INSERT M 17MM -,SUP-2315-3243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1763.262982,9.170825,27238.33344,percent of total billed charges,,,
USTAR II KNEE XPE TIBIAL INSERT M 20MM -,SUP-2315-3244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1763.262982,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL USTAR II KNEW XPE M 23MM -,SUP-2315-3245,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6815.86,4771.102,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1763.262982,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT FEMORAL U2 PSA COCR 5 4MM POSTERIOR SET -,SUP-2603-5051,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5852.48,4096.736,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1514.036576,9.170825,27238.33344,percent of total billed charges,,,
AGUMENT FEMORAL U2 TOTAL KNEE SET DISTAL #5 12MM -,SUP-2603-5353,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5852.48,4096.736,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1514.036576,9.170825,27238.33344,percent of total billed charges,,,
HEADED PIN 17-4 PH S.S. -,SUP-262-0520A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,9.170825,27238.33344,percent of total billed charges,,,
PS Insert Trial Size 2  14mm -,SUP-263-1214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,75.475725,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 40X17MM COCR -,SUP-265 108,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9253.24,6477.268,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2393.813188,9.170825,27238.33344,percent of total billed charges,,,
U2 TOTAL KNEE STRAIGHT STEM PSA 14MM X 75MM -,SUP-2703-5013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2600.216983,9.170825,27238.33344,percent of total billed charges,,,
STEM TIBIAL U2 PSA TI STRAIGHT 16MM X 75MM KNEE -,SUP-2703-5014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2600.216983,9.170825,27238.33344,percent of total billed charges,,,
U2 TOTAL KNEE SYSTEM STRAIGHT STEM PSA 22MM DIA 75MM STEM -,SUP-2703-5017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2600.216983,9.170825,27238.33344,percent of total billed charges,,,
U2 TOTAL  KNEE STRAIGHT STEM PSA 24MM DIA 75MM STEM LENGTH -,SUP-2703-5018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2600.216983,9.170825,27238.33344,percent of total billed charges,,,
U2 TOTAL KNEE STRAIGHT STEM PSA 12MM DIA 100MM STEM LENGTH -,SUP-2703-5022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2600.216983,9.170825,27238.33344,percent of total billed charges,,,
STEM TIBIAL U2 PSA STRAIGHT 20MM X 150MM TOTAL KNEE -,SUP-2703-5056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2600.216983,9.170825,27238.33344,percent of total billed charges,,,
USTAR II KNEE CEMENTED STRT STEM RHS NON COAT 9 X 100 -,SUP-2715-3009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2036.646794,9.170825,27238.33344,percent of total billed charges,,,
USTAR II KNEE SYS CEMENTED STR STEM RHS NON-COAT 11X100 -,SUP-2715-3011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2036.646794,9.170825,27238.33344,percent of total billed charges,,,
USTAR II KNEE CEMENTED STRAIGHT STEM RHS NON COATED 13 X 100 -,SUP-2715-3013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2036.646794,9.170825,27238.33344,percent of total billed charges,,,
USTAR II KNEE CEMENTED STRT STEM RHS NON COATED 15 X 100 -,SUP-2715-3015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2036.646794,9.170825,27238.33344,percent of total billed charges,,,
USTAR II KNEE CEMENTED STRAIGHT STEM RHS NON COAT 17X100 -,SUP-2715-3017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2036.646794,9.170825,27238.33344,percent of total billed charges,,,
CEMENTED STRAIGHT STEM RHS COLLARLESS 9 X 125MM -,SUP-2715-3109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2036.646794,9.170825,27238.33344,percent of total billed charges,,,
USTAR II KNEE CEMENTED STRAIGHT STEM RHS NON COATED 11X125 -,SUP-2715-3111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2036.646794,9.170825,27238.33344,percent of total billed charges,,,
USTAR CEMENTED STRAIGHT STEM RHS NON COATED 13 X 125MM -,SUP-2715-3113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2036.646794,9.170825,27238.33344,percent of total billed charges,,,
KNEE SYSTEM CEMENTED STRAIGHT STEM RHS NON COATED 15 X 125MM -,SUP-2715-3115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2036.646794,9.170825,27238.33344,percent of total billed charges,,,
USTAR II KEE CEMENTED TIBIAL STEM 9MM X 20MM STEM LENG -,SUP-2715-5109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2036.646794,9.170825,27238.33344,percent of total billed charges,,,
USTAR II KNEE CEMENTED TIBIAL STEM 9MM X 45MM STEM -,SUP-2715-5209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2036.646794,9.170825,27238.33344,percent of total billed charges,,,
STEM TIBIAL USTAR II 9MM X 95MM KNEE CEMENT -,SUP-2715-5409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7872.62,5510.834,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2036.646794,9.170825,27238.33344,percent of total billed charges,,,
USTAR II KNEE TIBIAL STEM 12.5MM X 70MM -,SUP-2715-7312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10051.09,7035.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2600.216983,9.170825,27238.33344,percent of total billed charges,,,
USTAR II KNEE TIBIAL AUGMENT #2 10MM THICK -,SUP-2815-1022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5215.88,3651.116,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1349.348156,9.170825,27238.33344,percent of total billed charges,,,
USTAR SEGMENT PART RHS 50MM LENGTH -,SUP-2915-1050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22014.38,15410.066,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5695.120106,9.170825,27238.33344,percent of total billed charges,,,
USTAR II KNEE SEGMENT PART RHS 70MM LENGTH -,SUP-2915-1070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22014.38,15410.066,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5695.120106,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 11MM 8.5MM MDL OFST PRIM PRFT EQUINOXE 110MM TI ALY -,SUP-300-01-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2785.60399,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 15MM 9.5MM MDL OFST PRIM PRFT EQUINOXE 120MM TI ALY -,SUP-300-01-15,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2785.60399,9.170825,27238.33344,percent of total billed charges,,,
PLATE BN EQUINOXE F/RVRS SYS ANTMC REPLICATOR TI ALY 4.5MM -,SUP-300-10-45,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4686.87,3280.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1212.493269,9.170825,27238.33344,percent of total billed charges,,,
LINER G7 VIT E NEUTRAL 36MM E -,SUP-30103605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
LINER G7 VIT E NEUTRAL 36MM F -,SUP-30103606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
G7 VIT E HIGH WALL LNR 36MM D -,SUP-30123604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
LINER G7 VIT E HIGH WALL 36MM F -,SUP-30123606,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
LINER G7 VIT E HIGH WALL 40MM H -,SUP-30124008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
LINER G7 VIT E +5MM 40MM H -,SUP-30154008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8963.33,6274.331,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2318.813471,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 47MM SHRT 18MM EQUINOXE 1.5MM OFST COCR -,SUP-310-01-47,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7808.96,5466.272,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2020.177952,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 53MM SHRT EQUINOXE -,SUP-310-21-53,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6472.1,4530.47,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1674.33227,9.170825,27238.33344,percent of total billed charges,,,
COMP B MED EQUINOXE SHLDR PG -,SUP-314-02-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4010.16,2807.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1037.428392,9.170825,27238.33344,percent of total billed charges,,,
SPHERE GLND 38MM EQUINOXE RVRS -,SUP-320-01-38,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1204.157955,9.170825,27238.33344,percent of total billed charges,,,
TRY ADAPTER HUM WDG +0MM RVRS BALL SCKT EQUINOXE -,SUP-320-10-00,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8403.12,5882.184,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2173.887144,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 10MM FNDTN MODULAR REVISN 100MM TIB KN -,SUP-320-10-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
LINER HUM 38MM STD EQUINOXE -,SUP-320-38-00,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4559.17,3191.419,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1179.457279,9.170825,27238.33344,percent of total billed charges,,,
LINER HUM 38MM STD RVRS EQUINOXE -,SUP-320-38-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4559.17,3191.419,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1179.457279,9.170825,27238.33344,percent of total billed charges,,,
BLOCK CUT SZ4 10MM RM/LL FNDTN KN REVISN F/SPCR -,SUP-321-101-04,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1080.654575,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ4 RT KN STM FNDTN REVISN MODULAR NPOR -,SUP-322-01-104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2305.63788,9.170825,27238.33344,percent of total billed charges,,,
BLOCK CUT SZ4 5MM RL/LM FNDTN KN REVISN F/SPCR -,SUP-322-05-104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1080.654575,9.170825,27238.33344,percent of total billed charges,,,
BLOCK CUT SZ4 10MM RL/LM FNDTN KN REVISN F/SPCR -,SUP-322-10-104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1080.654575,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ2 10.9MM FNDTN PS ARTC CONGR KN COMPR MLD -,SUP-360-09-510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ2 11MM FNDTN PS ARTC CONGR KN COMPR MLD UHMWPE -,SUP-360-11-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ2 13MM FNDTN PS ARTC CONGR KN COMPR MLD UHMWPE -,SUP-360-13-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB 4MM AXSOS LCK -,SUP-370002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,240.4,168.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,62.19148,9.170825,27238.33344,percent of total billed charges,,,
INSERT ORTHO 14X8.5MM DIA FEM LCK 5MM HL AXSOS NS -,SUP-370003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,274.83,192.381,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,71.098521,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ2 13MM FNDTN CR PRIM CNSTRN ARTC CONGR L/R KN -,SUP-385-13-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,,,
CENTRALIZER DIST HIP TI ALY -,SUP-400-03-002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,113.214881,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 36MM +4MM NK BIOLOX DELTA CERM -,SUP-400-03-363,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4487.56,3141.292,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1160.931772,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM BIOLOX DELTA 40MM NEUT CERM -,SUP-400-03-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1262.61122,9.170825,27238.33344,percent of total billed charges,,,
COMP REV SHLDER 9 IN STEINMANN -,SUP-405800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,181.14174,9.170825,27238.33344,percent of total billed charges,,,
SEASPINE TULIP HEADS -,SUP-41-1000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE HIP NEUT OFST UNIPL ANG -,SUP-411-00-000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,181.14174,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 46MM UNIPL -,SUP-411-00-146,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1696.16,1187.312,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,438.796592,9.170825,27238.33344,percent of total billed charges,,,
PLUG SMALL DIA CEMENT 8MM -,SUP-414993,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,329.097444,9.170825,27238.33344,percent of total billed charges,,,
KT THR SZ3 FEM 3 TIB RT HIP TRUMATCH -,SUP-420859,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2517.536463,9.170825,27238.33344,percent of total billed charges,,,
KT TKR LT HIPERF 3T/3F -,SUP-420878,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2517.536463,9.170825,27238.33344,percent of total billed charges,,,
KT TKR RT HIPERF -,SUP-420890,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9731.49,6812.043,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2517.536463,9.170825,27238.33344,percent of total billed charges,,,
FEMUR PERSONA CEMENTED CCR NARROW SIZE 5 R -,SUP-42500005802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,,,
FEMUR PERSONA CEMENTED NARROW PS LT SZ 6 -,SUP-42500006001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,,,
FEMUR PERSONA CEMENTED CCR NARROW SIZE 8 R -,SUP-42-5000-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT PSN FEM PS CMT CCR SZ 7 R STD -,SUP-42-5006-062-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT PSN FEM PS CCR STD SIZE 10 L -,SUP-42500606801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ3 PERSONA RT KN CR CMNT COCR NRW -,SUP-42-5020-054-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ6 PERSONA LT KN CR CMNT COCR NRW -,SUP-42-5020-060-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ7 PERSONA LT KN CR CMNT COCR NRW -,SUP-42-5020-062-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ7 PERSONA RT KN CR CMNT COCR NRW -,SUP-42-5020-062-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,,,
FEMUR PERSONA CEMENTED CR NARROW RT SZ 9 -,SUP-42502006602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,,,
FEMUR PERSONA CEMENTED KNEE CR   RT SZ10 -,SUP-42-5020-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 PERSONA LT KN CR CMNT COCR POR NRW -,SUP-42-5022-058-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ6 PERSONA LT KN CR CMNT COCR POR NRW -,SUP-42-5022-060-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,9.170825,27238.33344,percent of total billed charges,,,
FEMUR FEMORAL CR POR CCR NRW SIZE 6 RIGHT PERSONA -,SUP-42-5022-060-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ7 PERSONA RT KN CR CMNT COCR POR NRW -,SUP-42-5022-062-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,9.170825,27238.33344,percent of total billed charges,,,
COMP PSN FEM SZ 10 R CR CCR POR NRW -,SUP-42-5022-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ6 LEFT PERSONA KN CR STD CMNT CCR -,SUP-42-5026-060-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,,,
PERSONA FEMUR CMNT STD CCR SIZE 7 RIGHT -,SUP-42502606202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ8 PERSONA LT KN CR STD CMNT COCR NRW -,SUP-42-5026-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ8 RIGHT PERSONA KN CR STD CMNT COCR -,SUP-42-5026-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ10 PERSONA RT KN CR STD CMNT COCR NRW -,SUP-42-5026-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,,,
PSN FEM CR POR CCR STD SZ7 L -,SUP-42-5028-062-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ8 PERSONA LT KN CR STD COCR POR -,SUP-42-5028-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ8 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ9 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-066-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,9.170825,27238.33344,percent of total billed charges,,,
PERSONA KNEE SYSTEM FEMUR -,SUP-42-5028-068-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ10 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-068-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ11 PERSONA RT KN CR STD COCR POR -,SUP-42-5028-070-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ12 R PERSONA RT KN CCR STD COCR POR -,SUP-42-5028-074-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,9.170825,27238.33344,percent of total billed charges,,,
PSN REV FEM CMT CCR STD SZ 5 R -,SUP-42-5046-058-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,33973.95,23781.765,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8789.060865,9.170825,27238.33344,percent of total billed charges,,,
PSN REV FEM CMT CCR STD SZ 9 L -,SUP-42-5046-066-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,31746.15,22222.305,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8212.729005,9.170825,27238.33344,percent of total billed charges,,,
PSN ASF CR 12MM PLY L 3-11 EF -,SUP-42-5110-005-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ8 139MM LNR PRFT LAT OFST CLLRLS 47.4MM NK TI POR -,SUP-425-11-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2031.15718,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ13 148.5MM LNR PRFT LAT OFST CLLRLS 49.8MM NK TI -,SUP-425-11-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2031.15718,9.170825,27238.33344,percent of total billed charges,,,
SYS PERSONA KNEE ASF UC 18MM PLY L-4-11 EF -,SUP-42-5112-005-18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,,,
PERSONA KNEE SYSTEM ARTICULAR SURFACE -,SUP-42-5112-006-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ C-D/3-9 10MM PERSONA CR ARTCSURF LT KN PE -,SUP-42-5120-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ C-D/3-9 11MM PERSONA CR ARTCSURF LT KN PE -,SUP-42-5120-004-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ C-D/3-9 12MM PERSONA CR ARTCSURF LT KN PE -,SUP-42-5120-004-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ E-F SZ3-11 FEM 10MM PERSONA ARTCSURF LT KN PE -,SUP-42-5120-005-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
PSN ASF CR 12MM VE L 3-11EF -,SUP-42-5120-005-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
PERSONA ARTICULAR SURFACE LEFT 11MM -,SUP-42-5121-007-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
PSN MC VE ASF L 12MM 12/GH -,SUP-42-5121-010-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1204.157955,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ C-D SZ3-7 FEM 12MM PERSONA CR ARTCSURF LT KN -,SUP-42-5122-004-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
SURFACE ARTICULAR PERSONA VIVACIT-E 3-7 UC C-D 10MM KNEE LFT -,SUP-42512200410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
PERSONA ARTICULAR FIXED BEARING LEFT 16MM -,SUP-42512200516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
PERSONA ARTICULAR SURFACE 10MM -,SUP-42-5122-006-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
ARTICULAR SURFACE PERSONA LT 16MM -,SUP-42512600516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
PSN ASF CPS 14MM VE L 6-9 GH -,SUP-42-5126-009-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
PSN PK VE PLY- LM- SZ E- 8MM -,SUP-42-5182-005-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ7 PERSONA LT KN CR STD COCR POR -,SUP-42-5208-062-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,9.170825,27238.33344,percent of total billed charges,,,
PSN FEMORALASF UC 10MM POLY R 4-11 EF -,SUP-42-5212-00-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,,,
BEARING FIXED ASF UC 12MM PLY 3-7CD PERSONA -,SUP-42-5212-004-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,,,
BEARING FIXED ASF UC 12MM PLY R 4-11 EF PERSONA -,SUP-42-5212-005-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,,,
BEARING PSN ASF UC 10MM PLY R 7-12 GH -,SUP-42521200610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,,,
PSN ASF UC 12MM PLY R 7-12 GH -,SUP-42-5212-006-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3222.45,2255.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,833.647815,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ C-D SZ3-9 FEM 10MM PERSONA CR ARTCSURF RT KN -,SUP-42-5220-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ C-D/3-9 11MM PERSONA CR ARTCSURF RT KN PE -,SUP-42-5220-004-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ E-F/3-11 11MM PERSONA CR ARTCSURF RT KN PE -,SUP-42-5220-005-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
SURFACE ARTICULAR 10MM HEIGHT RIGHT -,SUP-42-5221-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
ARTICULAR SURFACE PERSONA MC VE RT 13MM -,SUP-42522100513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
ARTICULAR SURFACE PERSONA MC RT 10MM -,SUP-42522100810,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
ARTICULAR SURFACE RIGHT 10MM /SIZES E-F/CR 8-11 -,SUP-42-5221-008-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
ARTICULAR SURFACE PERSONA MC RT 11MM -,SUP-42-5221-008-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
SURFACE ARTICULAR PERSONA RIGHT 10MM X 12/GH MC VE ASF -,SUP-42-5221-010-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ C-D/3-7 10MM PERSONA ARTCSURF UL CONG RT KN PE -,SUP-42-5222-004-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ E-F 10MM PERSONA UL CONG ARTCSURF RT KN PE -,SUP-42-5222-005-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
HIGHLY CROSSLINKED POLY ARTICULAR FIXED BEARING -,SUP-42-5222-005-18,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
VIVICIT-E PERSONA ASF UC 11MM 7 - 12GH -,SUP-42-5222-006-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
CD PERSONA ASF PS 16MM VE R 3-5 -,SUP-42522400416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL PSN ASF PS 13MM VE R 6-9 CD -,SUP-42-5224-005-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
PSN ASF CPS 14MM VE R 3-5CD -,SUP-42-5226-004-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
PERSONA HIGHLY CROSSLINKED POLY 6-9EF VE R -,SUP-42-5226-007-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
PERSONA HIGHLY CROSSLINKED POLYETHLENE 6-9EF -,SUP-42-5226-007-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1399.85157,9.170825,27238.33344,percent of total billed charges,,,
PSN REV CCK ART SURF VE 12MM R 7-9+ CD -,SUP-42522800512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2881.6593,9.170825,27238.33344,percent of total billed charges,,,
COMP TIB SZ-C PERSONA PEGX2 LT KN POR TM -,SUP-42-5300-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,,,
COMP TIB SZ-D PERSONA PEGX2 RT KN POR TM -,SUP-42-5300-067-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,,,
PSN TIB POR 2 PEG SZ E L -,SUP-42-5300-071-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,,,
COMP TIB SZ-F PERSONA PEGX2 RT KN POR TM -,SUP-42-5300-075-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,,,
PSN TIB POR 2 PEG SZ G L -,SUP-42-5300-079-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,,,
PSN TIB POR 2 PEG SZ G R -,SUP-42530007902,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,,,
PSN TIB POR 2 PEG SZ H R -,SUP-42-5300-083-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,,,
STEM TIB SZ-C 5DG PERSONA LT KN -,SUP-42-5320-064-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
STEM PERSONA ASF 16MM VE 3-5 R CD -,SUP-42532006402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
STEM TIB SZ-C 5DG PERSONA RT KN -,SUP-42-5320-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
STEM TIB 5DG SZ-D PERSONA LT KN -,SUP-42-5320-067-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
STEM TIB SZ-D 5DG PERSONA RT KN -,SUP-42-5320-067-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
STEM TIB 5DG SZ-E PERSONA LT KN -,SUP-42-5320-071-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
TIBIA PERSONA CEMENTED STEMMED RT SZ E -,SUP-42532007102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
NAT TIBIA CEME 5 DG SIZE F -,SUP-42-5320-075-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
STEM TIB SZ-F 5DG PERSONA RT KN -,SUP-42-5320-075-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
PSN PK CMT TIB- LM- SZ E -,SUP-42-5380-005-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT PATELLAR PERSONA ALL POLY PAT PLY 41MM -,SUP-42540000041,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,9.170825,27238.33344,percent of total billed charges,,,
DIA ALL POLY PAT PERSONA  29MM -,SUP-42540200029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 29MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-29,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 32MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-32,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 35MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-35,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 41MM PE VIV-E CMNT PERSONA -,SUP-42-5402-000-41,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ8 SHRT TAPR FIL TI POR CTD P-SQUARED HIP -,SUP-425-41-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2468.621467,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ15 SHRT TAPR FIL TI POR CTD P-SQUARED HIP -,SUP-425-41-015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2468.621467,9.170825,27238.33344,percent of total billed charges,,,
KEEL PSN REV TIB FIXED CMT SIZE C R -,SUP-42-5420-064-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11361.78,7953.246,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2939.292486,9.170825,27238.33344,percent of total billed charges,,,
PSN REV TIB FIXED KEEL CMT SZ G L -,SUP-42-5420-079-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11361.78,7953.246,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2939.292486,9.170825,27238.33344,percent of total billed charges,,,
AUG PSN REV FEM DISTAL SZ 5 5MM -,SUP-42-5566-058-05,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5602.08,3921.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1449.258096,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTENSION PERSONA CEMETED TPRD 14MM X +30MM -,SUP-42557000114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,,,
PSN PK CMT FEM- LM- SZ 3 -,SUP-42-5580-003-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2086.05332,9.170825,27238.33344,percent of total billed charges,,,
PSN PK CMT FEM- RM SZ.4 -,SUP-42558000402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2086.05332,9.170825,27238.33344,percent of total billed charges,,,
PSN REV TAPERED SMOOTH STEM EXT 14 X 75MM -,SUP-42-5600-075-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8199.41,5739.587,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2121.187367,9.170825,27238.33344,percent of total billed charges,,,
STEM PSN REV 6MM OFFSET EXT 10MM X 135MM -,SUP-42-5606-135-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11584.56,8109.192,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2996.925672,9.170825,27238.33344,percent of total billed charges,,,
FEMUR PSN CR CMT TIN NRW SIZE 6R -,SUP-42-5720-060-02,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3361.93585,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT FEMORAL PERSONA 7 KNEE -,SUP-42572606201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3361.93585,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT PSN FEMORAL TIN STD SIZE 9L -,SUP-42-5726-066-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3361.93585,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ8 109MM TAPR FIL PRFT LAT OFST 37MM NK TI POR CTD -,SUP-425-96-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2468.621467,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ8 109MM TAPR FIL PRFT LAT OFST 42.5MM NK TI POR -,SUP-425-97-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2468.621467,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ9 111MM TAPR FIL PRFT LAT OFST 42.5MM NK TI POR -,SUP-425-97-009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2468.621467,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ12 LRG TAPR FIL PRFT LAT OFST TI POR COAT -,SUP-425-97-012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2468.621467,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ13 117MM TAPR FIL PRFT LAT OFST 42.5MM NK TI POR -,SUP-425-97-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9542.41,6679.687,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2468.621467,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 13MM STD BGLNI/FLTW 130MM -,SUP-4300-13-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5470.69,3829.483,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1415.267503,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 46X21MM BGLNI/FLTW ZML MODULAR OFST -,SUP-4302-46-21,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1317.50736,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 48MM POR STRUCTURED TECH HMSPHR -,SUP-430-98-048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.52,3208.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1185.756624,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM STAGEONE SLCT 56MM SIL MODULAR SPCR STRL -,SUP-431183,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5199.96,3639.972,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1345.229652,9.170825,27238.33344,percent of total billed charges,,,
ADAPTER STD STAGEONE CMNT MLD SPCR -,SUP-431186,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1636.53,1145.571,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,423.370311,9.170825,27238.33344,percent of total billed charges,,,
HIP ADAPTER STD STAGEONE 6MM -,SUP-431188,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1428.48,999.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,369.547776,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 15X155MM STG 1 HIP -,SUP-431193,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6510.3,4557.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1684.21461,9.170825,27238.33344,percent of total billed charges,,,
HIP MOLD STEM W/REINF 13 X 200 -,SUP-431197,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6510.3,4557.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1684.21461,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 12MM FNDTN CLLR FRG COCR CMNT 132DG ANG TAPR HIP -,SUP-450-01-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1262.61122,9.170825,27238.33344,percent of total billed charges,,,
HEAD RADL 26MM 10.5MM EVOLVE PROLINE COCR MODULAR -,SUP-496H026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7999.94,5599.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2069.584478,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 28MM SHRT -3.5MM NK COCR MODULAR -,SUP-497-28-035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,617.059001,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ-G 62MM RIM TRIDENT PRIM MODULAR HAP CTD -,SUP-500-01-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ-C 48MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-48C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ-D 50MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ-D 52MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-52D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ-E 54MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ-E 56MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-56E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ-F 58MM RIM MDMX3 PRIM MODULAR TRTNM LCK -,SUP-500-03-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,,,
SHELL SOLID BACK 60MM F -,SUP-500-03-60F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 48MM VERSYS LD/FX MULTPLR BIPLR MTL TIV ALY ZML -,SUP-5001-48,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,308.528207,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ-C 46MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-01-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ-C 48MM RIM TRIDENT PRIM MODULAR CLUS-HL. -,SUP-502-03-48C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB 50MM TRIDENT PRIM MODULAR CLUS-HL X3 TRTNM LCK -,SUP-502-03-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ-D 52MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-03-52D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,,,
SHELL HEMISPHERICAL 54MM SZ-E RIM CLUSTER HOLE -,SUP-502-03-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ-E 56MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-03-56E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ-D 50MM RIM TRIDENT PRIM.MODULAR CLUS-HL -,SUP-502-03-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ-F 60MM RIM TRIDENT PRIM MODULAR CLUS-HL -,SUP-502-03-60F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ-D 50MM RIM TRIDENT PRIM MODULAR.CLUS-HL -,SUP-502-11-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,,,
ANATOMIC HEMISPHERICAL SHELL  56MM D RT -,SUP-504-02-56D-R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12514.18,8759.926,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3237.418366,9.170825,27238.33344,percent of total billed charges,,,
HEMISPHERICAL SHELL ANATOMIC RESTORATION -,SUP-504-02-58D-L,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12514.18,8759.926,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3237.418366,9.170825,27238.33344,percent of total billed charges,,,
HEMISPHERICAL SHELL 64MM -,SUP-504-02-64E-R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12514.18,8759.926,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3237.418366,9.170825,27238.33344,percent of total billed charges,,,
INSERT HUM 4MM 32MM STD PE RVRS SCKT F/RSP STRL -,SUP-508-00-432,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4559.17,3191.419,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1179.457279,9.170825,27238.33344,percent of total billed charges,,,
SHELL TRIDENT HEMISPHERICAL ACETABULAR 46MM C -,SUP-508-11-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,,,
SHELL HEMI ACETABULAR 48MM -,SUP-508-11-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ-D 50MM RIM TRIDENT PRIM MODULAR MUL-HL -,SUP-508-11-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,,,
ACETABULAR SHELL 52MM -,SUP-508-11-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ-E 54MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2609.439638,9.170825,27238.33344,percent of total billed charges,,,
SHELL HEMISPHERICAL 56MM E TRI -,SUP-509-02-56E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2609.439638,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ-F 58MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2609.439638,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ-F 60MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-60F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2609.439638,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ-G 62MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2609.439638,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ-G 64MM RIM TRIDENT REVISN MUL-HL TRTNM -,SUP-509-02-64G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2609.439638,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ H LINER 66MM RIM TRIDENT REVISN MUL-HL -,SUP-509-02-66H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2609.439638,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ H LINER 68MM RIM TRIDENT REVISN MUL-HL -,SUP-509-02-68H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2609.439638,9.170825,27238.33344,percent of total billed charges,,,
TRIDENT TRITANIUM HEMI SHELL SZ 70MM -,SUP-509-02-70I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10086.74,7060.718,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2609.439638,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT ACTB 50MM RESTOR REVISN RECON HIP 15MM -,SUP-5096-5015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2137.886452,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT ACTB 50MM RESTOR REVISN RECON HIP 20MM -,SUP-5096-5020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2137.886452,9.170825,27238.33344,percent of total billed charges,,,
WEDGE AUGMENT RESTORATION ACET 54MM X 56MM X 15MM -,SUP-5096-5415,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2137.886452,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT ACTB 58MM RESTOR REVISN RECON HIP -,SUP-5096-5815,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2137.886452,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 6MM PRIM MBLK RVRS RSP 101MM CMNT 150DG ANG NK CYL -,SUP-510-00-006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19030.28,13321.196,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4923.133436,9.170825,27238.33344,percent of total billed charges,,,
STEM TPRLC 133 FP TYPE 1 PPS SO 5.0 -,SUP-51-100050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
STEM TPRLC 133 FP TYPE 1 PPS SO 6.0 -,SUP-51-100060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
STEM TPRLC 133 FP TYPE1 PPS SO 7.0 -,SUP-51-100070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
STEM TPRLC 133 FP TYPE1 PPS SO 8.0 -,SUP-51-100080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
STEM FEMORAL TPRLC 133 FP PPS TYPE 1  6.0 H -,SUP-51-101060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
STEM TPRLC 133 FP PPS TYPE 1 HO 7.0 -,SUP-51-101070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
STEM TPRLC 133 FP PPS TYPE 1 HO 8.0 -,SUP-51-101080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
TPRLC XR FP TYPE 1 PPS 5 X 130MM -,SUP-51-102050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
TPRLC XR FP TYPE 1 PPS 6 X 132MM -,SUP-51-102060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
TPRLC XR FP TYPE 1 PPS 8 X 136MM -,SUP-51-102080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
STEM TPRLC 133 TYPE 1 PPS SO 9 X 137MM -,SUP-51-103090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
STEM TPRLC 133 TYPE 1 PPS SO 10 X 140MM -,SUP-51-103100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
STEM TPRLC 133 TYPE 1 PPS SO 11 X 142MM -,SUP-51-103110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
STEM TPRLC 133 T1 PPS SO 12 X 144MM -,SUP-51-103120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
STEM TPRLC 133 T1 PPS SO 13 X 146MM -,SUP-51-103130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
STEM TPRLC 133 T1 PPS SO 14 X 148MM -,SUP-51-103140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
STEM TPRLC 133 TYPE 1 PPS SO 15 X 150MM -,SUP-51-103150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
TAPERLOC 133 T1 9 X 137MM -,SUP-51-104090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
TPRLC 133 T1 PPS 11 X 142MM -,SUP-51-104110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
TPRLC 133 T1 PPS HO 13 X 146MM -,SUP-51-104130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
TPRLC TYPE 1 PPS HO 14 X 148MM FEM POR -,SUP-51-104140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
TPRLC TYPE 1 PPS HO 15 X 150MM FEM POR -,SUP-51-104150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
TPRLC 133 TYPE 1 PPS HO 16 X 152MM -,SUP-51-104160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
STEM TAPERLOC 133 T1 PPS HO 20 X 160MM -,SUP-51-104200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
STEM TAPERLOC 10 X 140MM COMP XR FEM POR T1 TAPER -,SUP-51-105100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
STEM TAPERLOC 11 X 142MM COMP XR 123 FEM POR T1 TAPER -,SUP-51-105110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
TPRLC 133 MP TYPE 1 PPS SO 11.0 -,SUP-51-106110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
TPRLC 133 MP TYPE1 PPS HO 9.0 -,SUP-51-107090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
TPRLC 133 MP TYPE1 PPS HO 14.0 -,SUP-51-107140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
TPRLC 133 MP TYPE1 PPS HO 16.0 -,SUP-51-107160,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
TPRLC 133 MP TYPE1 PPS HO 17.0 -,SUP-51-107170,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
TPRL 133 MP TYPE1 PPS SO 4.0 -,SUP-51-108040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
TPRLC 133 MP T1 PPS SO 5X95MM -,SUP-51-108050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
TPRLC133 MP 6X97.5MM -,SUP-51-108060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
TPRLC 133 MP T1 PPS SO 8X101MM -,SUP-51-108080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
TLOC 133 MP SP T1 PPSHO 6X97.5 -,SUP-51-109060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
TLOC 133 MP SP T1 PPS HO 8X101 -,SUP-51-109080,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8275.8,5793.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2140.94946,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM S-ROM 28MMSTDX+6MM NK COCR 11/13 TAPR MODULAR -,SUP-52-2029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4824.58,3377.206,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1248.118846,9.170825,27238.33344,percent of total billed charges,,,
SCREW 2.3X12MM NLCKG VARIAX FT POLYAX FA T7 STRDRV RCESS -,SUP-53-23212E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,342.57,239.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,88.622859,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 45X15MM -,SUP-5350-4515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6472.1,4530.47,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1674.33227,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 12MM SOLAR 130MM TI SHLDR -,SUP-5351-4108,CDM,C1776,HCPCS,278,RC,,,outpatient,,,33064.27,23144.989,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8553.726649,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 40X15MM OFST -,SUP-5352-4015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6472.1,4530.47,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1674.33227,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACTB SZ-D 46MM 47.8MM RIM TRIDENT PSL PRIM MODULAR HAP -,SUP-540-11-46D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ1 TRIATH LT KN CR CMNT -,SUP-5510-F-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ1 TRIATH RT KN CR CMNT -,SUP-5510-F-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ2 TRIATH LT KN CR CMNT -,SUP-5510-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ2 TRIATH RT KN CR CMNT -,SUP-5510-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ3 TRIATH LT KN CR CMNT -,SUP-5510-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ3 TRIATH RT KN CR CMNT -,SUP-5510-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ4 TRIATH LT KN CR CMNT -,SUP-5510-F-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ4 TRIATH RT KN CR CMNT -,SUP-5510-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 TRIATH LT KN CR CMNT -,SUP-5510-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 TRIATH RT KN CR CMNT -,SUP-5510-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ6 TRIATH LT KN CR CMNT -,SUP-5510-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ6 TRIATH RT KN CR CMNT -,SUP-5510-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ7 TRIATH LT KN CR CMNT -,SUP-5510-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ7 TRIATH RT KN CR CMNT -,SUP-5510-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ8 TRIATH LT KN CR CMNT -,SUP-5510-F-801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ1 59/53MM TRIATH RT KN TOTAL STABILIZED REVISN -,SUP-5512-F-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5473.049439,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ2 62/56MM TRIATH LT KN TOTAL STABILIZED REVISN -,SUP-5512-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5473.049439,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT FEMORAL TOTAL STABILIZER #2 RT TS -,SUP-5512-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5473.049439,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ3 65/59MM TRIATH LT KN CRCTE STAB REVISN COCR -,SUP-5512-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5473.049439,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ3 65/59MM TRIATH RT KN CRCTE STAB REVISN COCR -,SUP-5512-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5473.049439,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ4 68/62MM TRIATH LT KN CRCTE STAB REVISN COCR -,SUP-5512-F-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5473.049439,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ4 68/62MM TRIATH RT KN CRCTE STAB REVISN COCR -,SUP-5512-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5473.049439,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 71/65MM TRIATH LT KN CRCTE STAB REVISN COCR -,SUP-5512-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5473.049439,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 71/65MM TRIATH RT KN CRCTE STAB REVISN COCR -,SUP-5512-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5473.049439,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ6 74/68MM TRIATH LT KN TOTAL STABILIZED REVISN -,SUP-5512-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5473.049439,9.170825,27238.33344,percent of total billed charges,,,
TOTAL STABILIZER COMPONET FEMORAL -,SUP-5512-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5473.049439,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ7 77/71MM TRIATH LT KN TOTAL STABILIZED REVISN -,SUP-5512-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5473.049439,9.170825,27238.33344,percent of total billed charges,,,
STABILIZER TOTAL FEM COMP SZ 7 RIGHT TS TRIATHLON -,SUP-5512-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5473.049439,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ8 80/75MM TRIATH RT KN TOTAL STABILIZED REVISN -,SUP-5512-F-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21155.97,14809.179,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5473.049439,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ1 TRIATH LT KN PS CMNT -,SUP-5515-F-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ2 TRIATH LT KN PS CMNT -,SUP-5515-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ2 TRIATH RT KN PS CMNT -,SUP-5515-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ3 TRIATH LT KN PS CMNT -,SUP-5515-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ3 TRIATH RT KN PS CMNT -,SUP-5515-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ4 TRIATH RT KN PS CMNT -,SUP-5515-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 TRIATH LT KN PS CMNT -,SUP-5515-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 TRIATH RT KN PS CMNT -,SUP-5515-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ6 TRIATH LT KN PS CMNT -,SUP-5515-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ6 TRIATH RT KN PS CMNT -,SUP-5515-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ7 TRIATH LT KN PS CMNT -,SUP-5515-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ7 TRIATH RT KN PS CMNT -,SUP-5515-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,,,
TRIATHLON PS FEM COMP SZ 8 CEMENTED -,SUP-5515-F-801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ8 TRIATH RT KN PS CMNT -,SUP-5515-F-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,9.170825,27238.33344,percent of total billed charges,,,
POSTERIOR STABILIZED FEMORAL -,SUP-5516-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
TRIATHLON CRUCLATE RETAINING FEMORAL SZ #1 LEFT CR -,SUP-5517-F-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
TRIATHLON CRUCLATE RETAINING FEMORAL SZ #1 RIGHT CR -,SUP-5517-F-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
TRIATHLON CR FEM COMPONENT - BEADED W/PA -,SUP-5517-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ2 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ3 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ3 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ4 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ4 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ6 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ6 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ7 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ7 TRIATH RT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ8 TRIATH LT KN CR CMNTLS PERIAPT CTD BEAD -,SUP-5517-F-801,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
TRIATHLON CRUCIATE RETAINING FEMORAL -,SUP-5517-F-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ1 KN CMNT TRIATH PRIM -,SUP-5520-B-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ2 KN CMNT TRIATH PRIM -,SUP-5520-B-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ3 KN CMNT TRIATH PRIM -,SUP-5520-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ4 KN CMNT TRIATH PRIM -,SUP-5520-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ5 KN CMNT TRIATH PRIM -,SUP-5520-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ6 KN CMNT TRIATH PRIM -,SUP-5520-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ7 KN CMNT TRIATH PRIM -,SUP-5520-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ8 KN CMNT TRIATH PRIM -,SUP-5520-B-800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ1 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1701.78034,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ2 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1701.78034,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ3 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1701.78034,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL BASEPLATE TRIATHLON UNIV SIZE 4 -,SUP-5521-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1701.78034,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ5 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1701.78034,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ6 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1701.78034,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ7 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1701.78034,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ8 UNIV L/R KN CMNT TRIATH COCR TOTAL -,SUP-5521-B-800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1701.78034,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ3 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1701.78034,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ4 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1701.78034,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ5 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1701.78034,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ6 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1701.78034,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ7 KN CMNT TRIATH COCR PERIAPT PRIM BEAD -,SUP-5526-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1701.78034,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ1 9MM TRIATH CR ARTC KN X3 -,SUP-5530-G-109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ1 11MM TRIATH CR ARTC KN X3 -,SUP-5530-G-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ1 13MM TRIATH CR ARTC KN X3 -,SUP-5530-G-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ1 16MM TRIATH CR ARTC KN X3 -,SUP-5530-G-116,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ1 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-119,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL BEARING INSERT CR SZ2 9MM -,SUP-5530-G-209-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ2 13MM TRIATH CR ARTC KN X3 -,SUP-5530-G-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ2 16MM TRIATH CR ARTC KN X3 -,SUP-5530-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ2 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL BEARING SZ 3 X 10MM CR X3 TRIATHLON -,SUP-5530-G-310-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL BEARING CR SZ4 9MM -,SUP-5530-G-409-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL BEARING CR SZ4 10MM TRIATHLON X3 -,SUP-5530-G-410-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL BEARING INSERT CR SZ4 11MM -,SUP-5530-G-411-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ4 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5 10MM TRIATH CR ARTCSURF KN X3 UHMWPE -,SUP-5530-G-510-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-519,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL BEARING SZ6 10MM TRIATH X3 CR -,SUP-5530-G-610-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ6 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBAL BEARING CR SZ 7 X 9MM TRIATHLON X3 -,SUP-5530-G-709-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBAL BEARING CR SZ 7 X 10MM TRIATHLON X3 -,SUP-5530-G-710-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ7 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ8 13MM TRIATH CR ARTC KN X3 -,SUP-5530-G-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ8 19MM TRIATH CR ARTC KN X3 -,SUP-5530-G-819,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
TRIATHALON INSERT CS #1 12MM X3 -,SUP-5531-G-112-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ2 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-209-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL BEARING CS SZ 2 X 10MM TRIATHLON X3 -,SUP-5531-G-210-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ2 11MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT BEARING TIBIAL CS SIZE 2 X 11MM TRIATHLON X3 -,SUP-5531-G-211-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL BEARING CS SZ 2 X 12MM TRIATHLON X3 -,SUP-5531-G-212-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ2 13MM TRIATH CS BEAR KN X3 -,SUP-5531-G-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TRIATHLON X3 TIBIAL BEARING SIZE 2 X 13MM CS -,SUP-5531-G-213-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ2 16MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-309-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 11MM TRIATH CS BEAR KN X3 -,SUP-5531-G-311-A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL BEARING INSERT  SZ.3 / CS / 12MM -,SUP-5531-G-312-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 13MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL BEARING CS SIZE 3 X 13MM TRIATHLON X3 -,SUP-5531-G-313-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 16MM TRIATH CS ARTCSURF KN X3 UHMWPE -,SUP-5531-G-316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 19MM TRIATH ARTCSURF KN X3 UHMWPE -,SUP-5531-G-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ4 9MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-409-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ4 11MM TRIATH CS BEAR X3 -,SUP-5531-G-411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ4 11MM TRIATH CS BEAR KN X3 -,SUP-5531-G-411-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ4 13MM TRIATH CS BEAR KN X3 -,SUP-5531-G-413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT BEARING TIBIAL CS SIZE 4 X 13MM TRIATHLON X3 -,SUP-5531-G-413-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ4 16MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ4 19MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL BEARING SZ 5 CS 9MM TRIATHLON X3 -,SUP-5531-G-509-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL BEARING INSERT  SZ. 5 / 10MM -,SUP-5531-G-510-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5 11MM TRIATH CS BEAR KN X3 -,SUP-5531-G-511,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TRIATHLON X3 TIBIAL BEARING CS -,SUP-5531-G-512-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5 13MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
X3 TRIATHILON CS INS SIZE 5 13MM -,SUP-5531-G-513-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5 16MM TRIATH CS BEAR KN X3 -,SUP-5531-G-516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL BEARING CS SIZE 5 X 19MM TRIATHLON X3 -,SUP-5531-G-519-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ6 9MM TRIATH CS BEAR KN X3 -,SUP-5531-G-609-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ6 11MM TRIATH CONDL STAB BEAR KN -,SUP-5531-G-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ6 11MM TRIATH CONDL STAB BEAR CS X3 -,SUP-5531-G-611-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ6 13MM TRIATH CS BEAR KN X3 -,SUP-5531-G-613,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ6 13MM TRIATH X3 CS BEAR X3 -,SUP-5531-G-613-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ6 16MM TRIATH ARTCSURF KN X3 UHMWPE -,SUP-5531-G-616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ6 19MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ7 9MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-709-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ7 11MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ7 13MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-713,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ7 16MM TRIATH CS BEAR KN X3 -,SUP-5531-G-716,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL TRIATHLON X3 SZ 7 16MM BEARING INSERT-CS -,SUP-5531-G-716-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ8 9MM TRIATH CONDL STAB BEAR KN X3 -,SUP-5531-G-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
TRIATHLON TIBIAL BEARING INSERT - CS SZ8 11MM -,SUP-5531-G-811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ1 13MM TRIATH PS ARTC KN X3 -,SUP-5532-G-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ2 9MM TRIATH PS ARTC KN X3 -,SUP-5532-G-209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
TRIATHLON PS X3 TIBIAL INSERT -,SUP-5532-G-209-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ2 11MM TRIATH PS ARTCSURF KN X3 UHMWPE -,SUP-5532-G-211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB H TRTHLN PS 2-13MM -,SUP-5532-G-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ2 16MM TRIATH PS ARTC KN X3 -,SUP-5532-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ2 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL BEARING PS SZ 3 X 16MM TRIATHLON X3 -,SUP-5532-G-316-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL BEARING PS SZ 4 X 11MM TRIATHLON X3 -,SUP-5532-G-411-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ4 16MM TRIATH PS ARTCSURF KN X3 UHMWPE -,SUP-5532-G-416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ4 19MM TRIATH PS ARTC KN X3 -,SUP-5532-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ4 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5 22MM TRIATH PS ARTC KN X3 -,SUP-5532-G-522,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-525,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL BEARING INSERT TRI - PS SZ.6 / 9MM -,SUP-5532-G-609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ6 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-625,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ7 9MM TRIATH PS ARTC KN X3 -,SUP-5532-G-709,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ7 16MM TRIATH PS ARTC KN X3 -,SUP-5532-G-716,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL BEARING / SZ. 7  / 19MM -,SUP-5532-G-719,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ7 22MM TRIATH PS ARTC KN X3 -,SUP-5532-G-722,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ7 25MM TRIATH PS ARTC KN X3 -,SUP-5532-G-725,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ8 9MM TRIATH PS ARTC KN X3 -,SUP-5532-G-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
TRIATHLON PS X3 TIBIAL INSERT SZ 8 -,SUP-5532-G-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT TIBIAL SIZE 2 X 16MM PS TRIATHLON ALL POLY -,SUP-5535-A-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1591.98806,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT TIBIAL SIZE 5 X 9MM PS TRIATHLON ALL POLY -,SUP-5535-A-509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1591.98806,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT TRIATHLON ALL POLY TIBIAL PS SIZE 5 13MM -,SUP-5535-A-513,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1591.98806,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT TRIATHLON ALL POLY TIBIAL PS SIZE 6 16MM -,SUP-5535-A-616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1591.98806,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL COMPONENT TRITANIUM #2 -,SUP-5536-B-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1591.98806,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ3 KN TRIATH TRTNM -,SUP-5536-B-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1591.98806,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ4 KN TRIATH TRTNM -,SUP-5536-B-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1591.98806,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ5 KN TRIATH TRTNM -,SUP-5536-B-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1591.98806,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ6 KN TRIATH TRTNM -,SUP-5536-B-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1591.98806,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ7 KN TRIATH TRTNM -,SUP-5536-B-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1591.98806,9.170825,27238.33344,percent of total billed charges,,,
TRIATHLON TIBIAL COMPONENT -,SUP-5536-B-800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1591.98806,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ1 19MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-119,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ2 11MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ2 10MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT TOTAL STABILIZER #2 19MM TS -,SUP-5537-G-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ2 22MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,,,
NO 3 TRIATHLON TS PLUS TIBIAL INSERT X3 POLY -,SUP-5537-G-309-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 19MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 22MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 25MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,,,
TOTAL STABILIZER+ TIBIAL INSERT -,SUP-5537-G-409,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL TOTAL STABILIZER + SIZE 4 X 9MM TS TRIATH X3 -,SUP-5537-G-409-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT TRIATHLON X3 TOTAL STABILIZER SIZE F 11MM TS -,SUP-5537-G-411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ4 13MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ4 16MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,,,
NO 4 TRIATHLON TS PLUS TIBIAL INSERT X3 POLY 16MM -,SUP-5537-G-416-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ4 19MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ4 22MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ4 25MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ4 28MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL TOTAL STAB SIZE 5 X 16MM TS TRIATHLON X3 -,SUP-5537-G-516-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL TOTAL STABILIZER+ SIZE 5 X 19MM TRIATHLON X3 -,SUP-5537-G-519-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5 22MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-522,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5 28MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-528,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5 31MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-531,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ6 9MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-609,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ6 11MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ6 16MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-616,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ6 19MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-619,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ6 25MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-625,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,,,
TOTAL STABILIZER TIBIAL INSERT SZ7 -,SUP-5537-G-711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ7 16MM TRIATH STD TOTAL STABILIZED ARTCSURF KN -,SUP-5537-G-716,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ8 22MM TRIATH STD TOTAL STABILIZED + ARTC KN -,SUP-5537-G-822,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT RT DIST KN SZ1 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1210.271036,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT LT DIST KN SZ2 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1210.271036,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL DISTAL AUGMENT - RIGHT -,SUP-5540-A-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1210.271036,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT LT DIST KN SZ4 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1210.271036,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT RT DIST KN SZ4 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1210.271036,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL DISTAL AUGMENT - RIGHT -,SUP-5540-A-602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1210.271036,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT RT DIST KN SZ8 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5540-A-802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4678.28,3274.796,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1210.271036,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL DISTAL AUGMENT RIGHT #2 10MM -,SUP-5541-A-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1130.092145,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT FEMORAL DISTAL LEFT TRIATHLON SIZE 3 10MM -,SUP-5541-A-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1130.092145,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT LT DIST KN SZ4 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5541-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1130.092145,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT LT DIST KN SZ5 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5541-A-501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1130.092145,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT FEMORAL DISTAL RIGHT SZ 7 X 5MM TRIATHLON -,SUP-5541-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1130.092145,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT FEMORAL DISTAL RIGHT SZ 7 X 10MM TRIATHLON -,SUP-5541-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1130.092145,9.170825,27238.33344,percent of total billed charges,,,
TRIATHLON FEMORAL DISTAL SUGMENT 15MM SIZE 4 LEFT -,SUP-5542-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4581.78,3207.246,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1185.306486,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT FEMORAL DISTAL RIGHT SZ 7 X 15MM TRIATHLON -,SUP-5542-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4581.78,3207.246,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1185.306486,9.170825,27238.33344,percent of total billed charges,,,
COMP SZ48 7MM REUNION ALLOGRAFT SHOLUDER PG -,SUP-5542-P-0048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
COMP SZ56 7MM REUNION ALLOGRAFT SHOLUDER PG -,SUP-5542-P-0056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT POST KN SZ1 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1130.092145,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT POST KN SZ2 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1130.092145,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT POST KN SZ3 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1130.092145,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT POST KN SZ4 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1130.092145,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT POST KN SZ5 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1130.092145,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT POST KN SZ6 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1130.092145,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT POST KN SZ7 TRIATH 5MM TOTAL STABILIZED COCR -,SUP-5543-A-700,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1130.092145,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT POST KN SZ2 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1130.092145,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT POST KN SZ3 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1130.092145,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT POST KN SZ4 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1130.092145,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT POST KN SZ5 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1130.092145,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT POST KN SZ6 TRIATH 10MM TOTAL STABILIZED COCR -,SUP-5544-A-600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4368.35,3057.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1130.092145,9.170825,27238.33344,percent of total billed charges,,,
HALF BLOCK TIBIAL AUGMENT SIZE 3 X 5MM TRIATHLON -,SUP-5545-A-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1159.770209,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT RM/LL KN SZ3 TRIATH 5MM BLCK TOTAL STABILIZED AUG -,SUP-5545-A-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1159.770209,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT LMRL KN SZ7 TRIATH 5MM BLCK TOTAL STABILIZED AUG -,SUP-5545-A-701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1159.770209,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT RM/LL KN SZ7 TRIATH 5MM BLCK TOTAL STABILIZED AUG -,SUP-5545-A-702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1159.770209,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT LMRL KN SZ1 TRIATH 10MM BLCK TOTAL STABILIZED AUG -,SUP-5546-A-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1133.069782,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT RM/LL KN SZ1 TRIATH 10MM BLCK TOTAL STABILIZED AUG -,SUP-5546-A-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1133.069782,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL AUGMENT HALF BLOCK -,SUP-5546-A-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1133.069782,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL AUGMENT HALF BLOCK - 10MM -,SUP-5546-A-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1133.069782,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT LMRL KN SZ3 TRIATH 10MM HLF BLCK TOTAL STABILIZED -,SUP-5546-A-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1133.069782,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL AUGMENT HALF BLOCK / SZ.3 -,SUP-5546-A-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1133.069782,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT LMRL KN SZ4 TRIATH 10MM HLF BLCK TOTAL STABILIZED -,SUP-5546-A-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1133.069782,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT RM/LL KN SZ4 TRIATH 10MM HLF BLCK TOTAL STABILIZED -,SUP-5546-A-402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1133.069782,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL SYMMETRIC CONE AUGMENT SIZE A -,SUP-5549-A-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13500.17,9450.119,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3492.493979,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL SYMMETRIC CONE AUGMENT -,SUP-5549-A-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13500.17,9450.119,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3492.493979,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL SYMMETRIC CONE AUGMENT SIZE C -,SUP-5549-A-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13500.17,9450.119,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3492.493979,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL CONE AUGMENT SZ 1&2 RT -,SUP-5549-A-322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15374.42,10762.094,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3977.362454,9.170825,27238.33344,percent of total billed charges,,,
TRIATH TRITNUM CNTRLFEMCONE AUG SZ 3&4 LEFT -,SUP-5549-A-641,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15375.53,10762.871,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3977.649611,9.170825,27238.33344,percent of total billed charges,,,
TRIATH TRITNUM CNTRLFEMCONE AUG SZ 3 & 4 RIGHT -,SUP-5549-A-642,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15375.53,10762.871,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3977.649611,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT CENTRAL FEM CONE SZ 7&8 RIGHT TRIATHLON -,SUP-5549-A-672,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15375.53,10762.871,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3977.649611,9.170825,27238.33344,percent of total billed charges,,,
PATELLA SYMMETRIC SZ S27MM X 8MM TRIATHLON X3 -,SUP-5550-G-278-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,562.209427,9.170825,27238.33344,percent of total billed charges,,,
TRIATHLON SYMMETRIC X3 PATELLA -,SUP-5550-G-298-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,562.209427,9.170825,27238.33344,percent of total billed charges,,,
TRIATHLON X3 SYMMETRIC PATELLA 31MM 9MM -,SUP-5550-G-319-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,562.209427,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 33X9MM THK X3 TRIATH PRIM SYM -,SUP-5550-G-339,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,562.209427,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 39X11MM THK X3 TRIATH PRIM SYM -,SUP-5550-G-391,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,562.209427,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 29X9MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-299-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,562.209427,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 32X10MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-320-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,562.209427,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 35X10MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-350-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2173.21,1521.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,562.209427,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 38X11MM THK X3 TRIATH PRIM ASYM -,SUP-5551-G-381-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,,,
SINGLE RADIUS HUMERAL HEAD SIZE 44 19MM -,SUP-5552-E-4419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13563.59,9494.513,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3508.900733,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 4MM OFST 52X17 REUNION -,SUP-5552-E-5217,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 29X9MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-299,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 32X10MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 35X10MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-350,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 38X11MM THK TRTNM TRIATH ASYM MTL BK -,SUP-5552-L-381,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,,,
PATELLA ASYMMETRIC A40/11MM -,SUP-5552-L-401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 56MM STD REUNION SGL RAD -,SUP-5552-S-5622,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 32X10MM THK X3 PERIAPATITE TRIATH ASYM MTL BK -,SUP-5554-L-320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 35X10MM THK X3 PERIAPATITE TRIATH ASYM MTL BK -,SUP-5554-L-350,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 38X11MM THK X3 PERIAPATITE ASYM BEADX3 MTL BK -,SUP-5554L381,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 40X11MM THK X3 PERIAPATITE ASYM BEADX3 MTL BK -,SUP-5554L401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,802.77197,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND SZ1 12MM TRIATH TOTAL STABILIZED 50MM COCR FEM -,SUP-5560-S-112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1143.508327,9.170825,27238.33344,percent of total billed charges,,,
STEM TOTAL KNEE 9MM X 100MM -,SUP-5560-S-209,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1143.508327,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND SZ2 12MM TRIATH TOTAL STABILIZED 100MM COCR FEM -,SUP-5560-S-212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1143.508327,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND SZ2 15MM TRIATH TOTAL STABILIZED 50MM COCR FEM -,SUP-5560-S-215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1143.508327,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND SZ3 12MM TRIATH TOTAL STABILIZED 50MM COCR FEM -,SUP-5560-S-312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4420.21,3094.147,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1143.508327,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 10MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1198.207855,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 11MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1198.207855,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 12MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1198.207855,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 13MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1198.207855,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 14MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1198.207855,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 15MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1198.207855,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 16MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1198.207855,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 17MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1198.207855,9.170825,27238.33344,percent of total billed charges,,,
FLUTED STEM 18MM / 100MM / TS -,SUP-5565-S-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1198.207855,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 18MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1198.207855,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 19MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1198.207855,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 20MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1198.207855,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 21MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1198.207855,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 22MM TRIATH PRFT REVISN TOTAL STABILIZED 100MM -,SUP-5565-S-022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4631.65,3242.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1198.207855,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 13MM TRIATH PRFT REVISN TOTAL STABILIZED 150MM -,SUP-5566-S-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4789.23,3352.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1238.973801,9.170825,27238.33344,percent of total billed charges,,,
FLUTED STEM 14MM / 150MM / TS -,SUP-5566-S-014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4789.23,3352.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1238.973801,9.170825,27238.33344,percent of total billed charges,,,
HUMERAL FRATURE STEM 7 X 113 -,SUP-5568-0007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,32158.29,22510.803,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8319.349623,9.170825,27238.33344,percent of total billed charges,,,
REUNION RFX-HUMERAL FRACTURE STEM 9MM -,SUP-5568-0009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,31160.68,21812.476,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8061.267916,9.170825,27238.33344,percent of total billed charges,,,
STEM HUMERAL FRACTURE 11MM X 123MM REUNION RFX -,SUP-5568-0011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,33766.02,23636.214,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8735.269374,9.170825,27238.33344,percent of total billed charges,,,
HUMERAL CUP 36MM DIA X 4MM THK -,SUP-5570-3604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16968.41,11877.887,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4389.727667,9.170825,27238.33344,percent of total billed charges,,,
ADAPTER FEM 2MM OFST TRIATH RECON KN REVISN TOTAL STABILIZED -,SUP-5570-S-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4348.4,3043.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1124.93108,9.170825,27238.33344,percent of total billed charges,,,
ADAPTER FEM 4MM OFST TRIATH RECON KN REVISN TOTAL STABILIZED -,SUP-5570-S-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4348.4,3043.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1124.93108,9.170825,27238.33344,percent of total billed charges,,,
ADAPTER FEM 6MM OFST TRIATH RECON KN REVISN TOTAL STABILIZED -,SUP-5570-S-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4348.4,3043.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1124.93108,9.170825,27238.33344,percent of total billed charges,,,
EXTENDER STEM TRIATHLON 25MM LENGTH -,SUP-5571-S-025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4512.24,3158.568,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1167.316488,9.170825,27238.33344,percent of total billed charges,,,
X3 HUMERAL INSERT 36MM X 4MM STANDARD -,SUP-5571-S-3604-E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13571.02,9499.714,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3510.822874,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE 28MM X 10.05MM -,SUP-5572-2802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18676.39,13073.473,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4831.582093,9.170825,27238.33344,percent of total billed charges,,,
GLENOSPHERE 36MM DIA X 2MM THK CONCENTRIC -,SUP-5573-C-3602,CDM,C1776,HCPCS,278,RC,,,outpatient,,,16968.41,11877.887,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4389.727667,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ2 TRIATH LMRL KN UNICMPT PRIM PRT RSRFC COCR -,SUP-5610-F-201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ2 TRIATH RM/LL KN UNICMPT PRIM PRT RSRFC COCR -,SUP-5610-F-202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL REVISION LEFT SZ 2 NON-POROUS -,SUP-561-1201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4725.921252,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ3 BAL KN MODULAR REVISN RT KN -,SUP-561-1302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4725.921252,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ4 BAL KN MODULAR REVISN LT KN -,SUP-561-1401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4725.921252,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ4 BAL KN RT KN MODULAR REVISN SYS -,SUP-561-1402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4725.921252,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 BAL KN LT KN MODULAR REVISN SYS -,SUP-561-1501,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4725.921252,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 BAL KN RT KN MODULAR REVISN SYS -,SUP-561-1502,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4725.921252,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ6 BAL KN LT KN MODULAR REVISN SYS -,SUP-561-1601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4725.921252,9.170825,27238.33344,percent of total billed charges,,,
MODULAR FEMORAL LEFT SIZE 7 -,SUP-561-1701,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4725.921252,9.170825,27238.33344,percent of total billed charges,,,
MODULAR FEMORAL SIZE 7 -,SUP-561-1702,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4725.921252,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ3 27/47MM LMRL KN TRIATH COCR PRIM REVISN -,SUP-5620-B-301,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ3 27/47MM RM/LL KN TRIATH COCR PRIM REVISN -,SUP-5620-B-302,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ2 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.807,9.170825,27238.33344,percent of total billed charges,,,
TRAY TIBIAL REVISION SZ 2 NEUTRAL NON-POROUS -,SUP-562-1200A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.807,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ3 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.807,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL TRAY REVISION SZ 3 NEUTRAL NON-POROUS -,SUP-562-1300A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.807,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ4 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.807,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL TRAY REVISION SZ 4 NEUTRAL NON-POROUS -,SUP-562-1400A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.807,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ5 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.807,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL TRAY REVISION SZ 5 NEUTRAL NON-POROUS -,SUP-562-1500A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.807,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ6 NEUT BAL KN TI MODULAR REVISN SLD BS -,SUP-562-1600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.807,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL TRAY SLOPED SIZE 5 MODULAR -,SUP-562-2500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9431.02,6601.714,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2439.804874,9.170825,27238.33344,percent of total billed charges,,,
CONE TIBIAL CENTRAL 31MM -,SUP-562-7031,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12705.89,8894.123,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3287.013743,9.170825,27238.33344,percent of total billed charges,,,
CONE TIBIAL CENTRAL 34MM -,SUP-562-7034,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12705.89,8894.123,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3287.013743,9.170825,27238.33344,percent of total billed charges,,,
CONE TIBIAL CENTRAL 36MM -,SUP-562-7036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12705.89,8894.123,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3287.013743,9.170825,27238.33344,percent of total billed charges,,,
CONE TIBIAL 25MM M-L 35MM A-P -,SUP-562-7135,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12223.2,8556.24,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3162.14184,9.170825,27238.33344,percent of total billed charges,,,
CONE TIBIAL LARGE 47MM M/L 31MM A/P -,SUP-562-7247,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15108.2,10575.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3908.49134,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 8MM TRIATH BEAR LMRL KN X3 UHMWPE -,SUP-5630-G-308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 8MM TRIATH BEAR RM/LL KN X3 UHMWPE -,SUP-5630-G-328,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 8MM CNSTRN -,SUP-563-1308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1407.537547,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 10MM CNSTRN -,SUP-563-1310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 12MM CNSTRN -,SUP-563-1312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1407.537547,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 14MM CNSTRN -,SUP-563-1314,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1407.537547,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 16MM CNSTRN -,SUP-563-1316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1407.537547,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 18MM CNSTRN -,SUP-563-1318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5411.1,3787.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1399.85157,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 20MM CNSTRN -,SUP-563-1320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1407.537547,9.170825,27238.33344,percent of total billed charges,,,
SROM*ST XL 36+8LINK 18 X 13 X 255L -,SUP-563138L,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27357.55,19150.285,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7077.398185,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL CK SZ 4 8MM -,SUP-563-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT CK SIZE 4 18MM -,SUP-563-1418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT CK SIZE 4 24MM -,SUP-563-1424,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1407.537547,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5 8MM CNSTRN -,SUP-563-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5 10MM CNSTRN -,SUP-563-1510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1407.537547,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5 12MM CNSTRN -,SUP-563-1512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1407.537547,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT CK SIZE 6 8MM -,SUP-563-1608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1407.537547,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ6 10MM CNSTRN -,SUP-563-1610,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5440.81,3808.567,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1407.537547,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT CK SIZE 6 14MM -,SUP-563-1614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SZ 2 10MM -,SUP-563-2210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SZ 2 12MM -,SUP-563-2212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL REVISION CK SZ 2 14MM -,SUP-563-2214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SZ 2 18MM -,SUP-563-2218,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SZ 2 20MM -,SUP-563-2220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SZ 2 22MM -,SUP-563-2222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SZ 3 8MM -,SUP-563-2308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SZ 3 12MM -,SUP-563-2312,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SZ 3 14MM -,SUP-563-2314,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SZ 3 18MM -,SUP-563-2318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL REV CK SZ 3 20MM -,SUP-563-2320,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SZ 3 24MM -,SUP-563-2324,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SZ 4 8MM -,SUP-563-2408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SZ 4 10MM -,SUP-563-2410,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SZ 4 12MM -,SUP-563-2412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SZ 4 14MM -,SUP-563-2414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SZ 4 16MM -,SUP-563-2416,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SZ 4 18MM -,SUP-563-2418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SZ 4 22MM -,SUP-563-2422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SZ 5 10MM -,SUP-563-2510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SZ 5 12MM -,SUP-563-2512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SZ5 14MM -,SUP-563-2514,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SZ 5 16MM -,SUP-563-2516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL REVISION CK SZ 6.8MM -,SUP-563-2608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT REVISION CK SIZE 6 14MM -,SUP-563-2614,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5389.88,3772.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1394.361956,9.170825,27238.33344,percent of total billed charges,,,
STEM 12MM X 50MM CEMENTED -,SUP-565-1205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1147.329326,9.170825,27238.33344,percent of total billed charges,,,
STEM 12 X 80 CEMENTED -,SUP-565-1208,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1147.329326,9.170825,27238.33344,percent of total billed charges,,,
STEM EXT CEMENTED 12MM X 110MM -,SUP-565-1211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1147.329326,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTENSION CEMENTED 14MM X 30MM -,SUP-565-1403,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4481.66,3137.162,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1159.405442,9.170825,27238.33344,percent of total billed charges,,,
STEM 14MM X 50MM CEMENTED -,SUP-565-1405,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4434.98,3104.486,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1147.329326,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 14MM BAL KN 80MM CMNT -,SUP-565-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4481.66,3137.162,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1159.405442,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 10MM BAL KN 80MM FEM/TBL -,SUP-566-1008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1190.14935,9.170825,27238.33344,percent of total billed charges,,,
STEM 10 X 150MM EXT FLUTED -,SUP-566-1015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1190.14935,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 12MM BAL KN 80MM FEM/TBL -,SUP-566-1208,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1174.777396,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 13MM BAL KN 80MM FEM/TBL -,SUP-566-1308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1190.14935,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 13MM BAL KN 150MM FEM/TBL -,SUP-566-1315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4600.5,3220.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1190.14935,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 14MM BAL KN 80MM FEM/TBL -,SUP-566-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1174.777396,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTENSION FLUTED 14 X 110 -,SUP-566-1411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1174.777396,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 15MM BAL KN 80MM FEM/TBL -,SUP-566-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1174.777396,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 16MM BAL KN 80MM FEM/TBL -,SUP-566-1608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1174.777396,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 17MM BAL KN 80MM FEM/TBL -,SUP-566-1708,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1174.777396,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTENSION FLUTED 17MM X 110MM -,SUP-566-1711,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1174.777396,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 18MM BAL KN 80MM FEM/TBL -,SUP-566-1808,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1174.777396,9.170825,27238.33344,percent of total billed charges,,,
STEM 18MM X 110MM FLUTED -,SUP-566-1811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1174.777396,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 20MM BAL KN 80MM FEM/TBL -,SUP-566-2008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1174.777396,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTENSION FLUTED 20 X 110 -,SUP-566-2011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1174.777396,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTENSION FLUTED 24 X 80MM -,SUP-566-2408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1174.777396,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTENSION FLUTED 24 X 110MM -,SUP-566-2411,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4541.08,3178.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1174.777396,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT RM/LL KN SZ3 BAL KN 5MM BLCK REVISN -,SUP-567-5103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1292.255653,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL AUGMENT BLOCK 5MM RT LAT LT MED SIZE 4 -,SUP-567-5104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1292.255653,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT RM/LL KN SZ3 BAL KN BLCK REVISN -,SUP-567-5203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1292.255653,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL AUGMENT SZ 3 15MM BLOCK LT LATERAL RT MEDIAL -,SUP-567-7203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1279.080062,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT DIST KN SZ3 BAL KN 4MM REVISN -,SUP-568-1304,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1279.080062,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL AUGMENT DISTAL SIZE 3 8MM -,SUP-568-1308,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1279.080062,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT DIST KN SZ4 BAL KN 4MM REVISN -,SUP-568-1404,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1292.255653,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT FEMORAL SZ 4 4MM DISTAL -,SUP-568-1404A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1279.080062,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT DIST KN SZ4 BAL KN 8MM REVISN -,SUP-568-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1292.255653,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL AUGMENT SZ 4 8MM DISTAL -,SUP-568-1408A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1279.080062,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT DIST KN SZ5 BAL KN 4MM REVISN -,SUP-568-1504,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1279.080062,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL AUGMENT SZ 5 4MM DISTAL -,SUP-568-1504A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1279.080062,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL AUGMENT DISTA SIZE 5 8MM -,SUP-568-1508,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1292.255653,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL AUGMENT DISTAL 12MM -,SUP-568-1512,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1279.080062,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT DISTAL 4MM SIZE 6 -,SUP-568-1604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1279.080062,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL AUGMENT SZ 6 8MM DISTAL -,SUP-568-1608,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1279.080062,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT POST KN SZ4 BAL KN 4MM REVISN -,SUP-568-2404,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1279.080062,9.170825,27238.33344,percent of total billed charges,,,
FERMORAL AUGMENT POSTERIOR 4MM SIZE 6 -,SUP-568-2604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4944.26,3460.982,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1279.080062,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 14MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-5988-10-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4394.75,3076.325,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1136.921825,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 14MM NEXGEN 100MM TIV ALY STR FEM/TBL KN -,SUP-5988-10-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6060.43,4242.301,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1567.833241,9.170825,27238.33344,percent of total billed charges,,,
EXTENSION STM 15X30MM -,SUP-5988-12-15,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4394.75,3076.325,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1136.921825,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ0 33MM OFST 86MM ACCOLADE PRFT STD OFST 30MM NK -,SUP-6020-0030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ1 34MM OFST 110MM RECON ACCOLADE PRFT PRIM STD -,SUP-6020-0130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ2 35MM OFST 115MM ACCOLADE PRFT STD OFST 30MM NK -,SUP-6020-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ3 39MM OFST 120MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-0335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ4 40MM OFST 125MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ5 44MM OFST 130MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-0537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ2.5 36MM OFST 118MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-2530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ3.5 39MM OFST 124MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-3535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ4.5 41MM OFST 129MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-4535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ5.5 45MM OFST 133MM ACCOLADE RECON PRFT PRIM STD -,SUP-6020-5537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ0 +0MM 37MM OFST 86MM ACCOLADE PRFT EXTEND OFST -,SUP-6021-0030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ1 +0MM 38MM OFST 110MM ACCOLADE PRFT EXTEND OFST -,SUP-6021-0130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ2 39MM OFST 115MM ACCOLADE PRFT PRIM EXTEND OFST -,SUP-6021-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ3 43MM OFST 120MM ACCOLADE RECON PRFT PRIM HI -,SUP-6021-0335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ4 44MM OFST 125MM ACCOLADE RECON PRFT PRIM HI -,SUP-6021-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ5 48MM OFST 130MM ACCOLADE RECON PRFT PRIM EXTEND -,SUP-6021-0537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ2.5 40MM OFST 118MM ACCOLADE RECON PRFT PRIM -,SUP-6021-2530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ3.5 124MM RECON ACCOLADE PRFT PRIM EXTEND OFST -,SUP-6021-3535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ4.5 45MM OFST 130MM ACCOLADE RECON PRFT PRIM -,SUP-6021-4535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ5.5 49MM OFST 133MM ACCOLADE PRFT EXTEND OFST -,SUP-6021-5537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ4 OMNIFIT PRIM CLLR CMNT MDL CLCR HIP -,SUP-6034-0425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ6 30MM OFST 132MM SECUR-FIT PRFT PRIM 25MM -,SUP-6051-0625S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ7 35.1MM OFST 132MM SECUR-FIT MAX PRFT PRIM 30MM -,SUP-6051-0730S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ8 132MM RECON SECUR-FIT MAX PRFT PRIM TI HAP CTD -,SUP-6051-0830S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ9 40.8MM OFST 132MM SECUR-FIT MAX PRFT PRIM 35MM -,SUP-6051-0935S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ10 132MM RECON SECUR-FIT MAX PRFT PRIM TI HAP CTD -,SUP-6051-1035S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ11 132MM RECON SECUR-FIT MAX PRFT PRIM TI HAP CTD -,SUP-6051-1140S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ12 47.3MM OFST 132MM SECUR-FIT MAX PRFT PRIM 40MM -,SUP-6051-1240S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
HIP STEM SIZE 6 25MM C-TPR -,SUP-6052-0625S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ7 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-0730S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ8 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-0830S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ9 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-0935S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ10 127 DEG SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-1035S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ13 127MM SECUR-FIT MAX PRFT PRIM TI PUREFIX HIP -,SUP-6052-1340S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
STEM HIP SECUR-FIT PLUS MAX SZ 11 C-TPR 40MM X 170MM -,SUP-6054-1115S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
STEM HIP 127 DEG NECK ANGLE SZ 12 C-TPR 40MM X 170MM -,SUP-6054-1216S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
HIP STEM 127 DEG CEMENTED SZ 2 V40 TPR 30MM X 124MM ACCOLADE -,SUP-6057-0230D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,,,
STEM HIP ACCOLADE 127 DEG CEM NK 35MM SZ 3 V40 131MM LGTH -,SUP-6057-0335D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,,,
STEM HIP CEM SZ4 V40 TPR 35MM X 137MM 127 DEG -,SUP-6057-0435D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,,,
STEM HIP ACCOLADE 127 DEC CEM NK 37MM SZ 5 V40 145MM LGTH -,SUP-6057-0537D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,,,
STEM HIP ACCOLADE 127 DEG CEM NK 37MM SZ 6 V40 158MM LGTH -,SUP-6057-0637D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,,,
STEM HIP 127 DEG CEMENTED SZ 7 V40 TPR 40MM X 158MM ACCOLADE -,SUP-6057-0740D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,,,
STEM HIP 132 DEG SIZE 3 V40 X 35MM X 131MM CEM ACCOLADE C -,SUP-6058-0335D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,,,
STEM HIP 132 DEG CEMENTED SZ 4 V40 35MM X 137MM ACCOLADE -,SUP-6058-0435D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,,,
HIP STEM 132 DEG CEMENTED SZ 5 V40 TPR 37MM X 145MM -,SUP-6058-0537D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ10 42MM OFST 160MM OMNIFIT HFX RECON PRIM 35MM NK -,SUP-6070-1035A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ11 132MM OMNIFIT HFX PRIM COCR CMNT HIP -,SUP-6070-1140A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ5 35MM OFST 110MM RECON OMNIFIT HFX PRIM 25MM NK -,SUP-6076-0525A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ6 36MM OFST 120MM OMNIFIT HFX PRIM 25MM NK COCR -,SUP-6076-0625A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ7 41MM OFST 130MM OMNIFIT HFX PRIM 30MM NK COCR -,SUP-6076-0730A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ8 42MM OFST 140MM RECON OMNIFIT HFX PRIM 30MM NK -,SUP-6076-0830A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ2 +0MM 43MM OFST 120MM ACCOLADE HFX PRFT PRIM -,SUP-6077-0335,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ4 +0MM 44MM OFST 125MM ACCOLADE HFX PRFT PRIM -,SUP-6077-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ5 +0MM 48MM OFST 130MM ACCOLADE HFX PRFT PRIM -,SUP-6077-0537,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,,,
OMNIFIT CEMENTED LONG STEM RIGHT -,SUP-6088-0730-200R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17512.18,12258.526,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4530.400966,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ4 33MM OFST 100MM OMNIFIT EON PRIM EXTEND OFST -,SUP-6097-0425,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ5 8.9MM DIST TIP 39MM OFST 110MM OMNIFIT EON PRIM -,SUP-6097-0530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ6 9.6MM DIST TIP 40MM OFST 120MM OMNIFIT EON PRIM -,SUP-6097-0630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ7 10.4MM DIST TIP 45MM OFST 130MM OMNIFIT EON -,SUP-6097-0735,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ8 46MM OFST 135MM OMNIFIT EON PRIM EXTEND OFST -,SUP-6097-0835,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,,,
STEM HIP OMNIFIT EON PLUS SIZE 11 C-TPR 40MM X 150MM -,SUP-6097-1140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ5 8.9MM DIST TIP 35MM OFST 110MM OMNIFIT EON STD -,SUP-6098-0530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ6 9.6MM DIST TIP 36MM OFST 120MM OMNIFIT EON PRIM -,SUP-6098-0630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ7 9.6MM DIST TIP 41MM OFST 130MM OMNIFIT EON PRIM -,SUP-6098-0735,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ8 11.3MM DIST TIP 42MM OFST 135MM OMNIFIT EON STD -,SUP-6098-0835,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ9 46MM OFST 140MM OMNIFIT EON STD OFST 40MM NK -,SUP-6098-0940,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,,,
MODULAR CUP REPLACEMTN LOCK RING 54MM -,SUP-6201-54,CDM,C1776,HCPCS,278,RC,,,outpatient,,,816.9,571.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,211.33203,9.170825,27238.33344,percent of total billed charges,,,
TRABECULAR METAL LOCKING RING -,SUP-6201-56,CDM,C1776,HCPCS,278,RC,,,outpatient,,,700.2,490.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,181.14174,9.170825,27238.33344,percent of total billed charges,,,
SHELL MULTI HOLE TRABECULAR METAL 54MM -,SUP-6202-54-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9990.38,6993.266,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2584.511306,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 36X58-60MM G SHL TRIDENT 0DG CROSSFIRE PRIM -,SUP-621-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,926.27535,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 28X46-48MM D SHL TRIDENT 0DG NEUT X3 7.9MM PRIM -,SUP-623-00-28D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
INSERT 00 DEG X3 32MM ID TRIDENT -,SUP-623-00-32C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 32X44MM C SHL TRIDENT 0DG NEUT X3 4.9MM PRIM -,SUP-623-00-32C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
INSERT POLYETHLENE 0 DEG 32MM CODE D TRIDENT X3 -,SUP-623-00-32D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 32X54-56MM F SHL TRIDENT 0DG NEUT X3 9.9MM PRIM -,SUP-623-00-32F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
INSERT POLYETHLENE 0 DEG 36MM CODE D TRIDENT X3 -,SUP-623-00-36D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
INSERT POLYETHLENE 0 DEG 36MM CODE E TRIDENT X3 -,SUP-623-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 36X54-56MM F SHL TRIDENT 0DG NEUT X3 7.9MM PRIM -,SUP-623-00-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
INSERT POLYETHLENE 0 DEG 36MM CODE F TRIDENT X3 -,SUP-623-00-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
INSERT POLY ZERO DEGREE 36MM X ALPHA G TRIDENT X3 -,SUP-623-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 36X58-60MM G SHL TRIDENT 0DG NEUT X3 9.4MM PRIM -,SUP-623-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACET TRIDENT X3 0 DEG POLY 36MM H -,SUP-623-00-36H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
TRIDENT X3 0 DG  POLY INSERT 40MM SZ E -,SUP-623-00-40E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
TRIDENT X3 0 DG POLYETTHYLENE INSERT 40MM SZ E RIM -,SUP-623-00-40E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
INSERT 0 DEG POLYETHYLENE 40MM ALPHA CODE F TRIDENT X3 -,SUP-623-00-40F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 40X58-60MM G SHL TRIDENT 0DG X3 7.4MM PRIM -,SUP-623-00-40G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
INSERT POLY ZERO DEGREE 40MM X ALPHA G TRIDENT X3 -,SUP-623-00-40G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
INSERT POLY ZERO DEGREE 40MM X ALPHA H TRIDENT X3 -,SUP-623-00-40H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 40X62-64MM H SHL TRIDENT 0DG X3 9.1MM PRIM -,SUP-623-00-40H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
INSERT TRIDENT X3 0 D POLY 40MM ALPHA I -,SUP-623-00-40I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 44X54-56MM F SHL TRIDENT 0DG X3 3.8MM PRIM -,SUP-623-00-44F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 44X58-60MM G SHL TRIDENT 0DG X3 5.4MM PRIM -,SUP-623-00-44G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 44X62-64MM H SHL TRIDENT 0DG X3 7.1MM PRIM -,SUP-623-00-44H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
INSERT TRIDENT X3 0 DEGREE POLY 44MM ALPHA I -,SUP-623-00-44I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 22X42MM B SHL TRIDENT 10DG X3 8.8MM PRIM -,SUP-623-10-22B,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 32X54-56MM F SHL TRIDENT 10DG X3 9.9MM PRIM -,SUP-623-10-32F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 36X50-52MM E SHL TRIDENT 10DG X3 5.9MM PRIM -,SUP-623-10-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
INSERT 10 DEG POLYETHYLENE 36MM E TRIDENT X3 -,SUP-623-10-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
INSERT 10 DEG X3 36MM ID TRIDENT -,SUP-623-10-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 36X54-56MM F SHL TRIDENT 10DG X3 7.9MM PRIM -,SUP-623-10-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
INSERT 10 DEGREE POLY 36MM G TRIDENT X3 -,SUP-623-10-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 36X58-60MM G SHL TRIDENT 10DG X3 9.4MM PRIM -,SUP-623-10-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 36X66-68MM I SHL TRIDENT 10DG X3 12.7MM PRIM -,SUP-623-10-36I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
STEM DISTAL 19MM DIA CENTRALIZER-CEMENTED -,SUP-6259-8-180,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,150.95145,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 32X50-52MM E SHL TRIDENT 0DG ALMN CERM PRIM -,SUP-625-OT-32E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1372.4035,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 36MM D SHL RECON MDM CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-36C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1344.95543,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 38MM D SHL MDM RECON CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-38D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1344.95543,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 42MM E SHL RECON MDM CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-42E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1344.95543,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 46MM F SHL RECON MDM CMNTLS COCR PRIM MODULAR DL -,SUP-626-00-46F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1344.95543,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 48MM G SHL MDM RECON CMNTLS COCR REVISN MODULAR -,SUP-626-00-48G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1344.95543,9.170825,27238.33344,percent of total billed charges,,,
LINER MDM 52MM H CEMENTLESS -,SUP-626-00-52H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1344.95543,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 22.2MMSTDX0MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-4-122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 26MM-3MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 26MM +4MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-226,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 26MM +8MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-326,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 26MM +12MM NK COCR TAPR PRIM INCRS OFST -,SUP-6260-5-426,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 26MM -3MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 40MM -4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 44MM -4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 22MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 26MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-126,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V40 28MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-128,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 36MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 40MM +0MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL HEAD LFIT V40 22.2MM +3MM -,SUP-6260-9-222,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 26MM +4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-226,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 28MM +4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-228,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 40MM +4MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-240,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 26MM +8MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-326,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 28MM +8MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-328,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 32MM +8MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-332,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 36MM +10MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-336,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 26MM +12MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-426,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V40 28MM +12MM OFST COCR TAPR PRIM MODULAR ANTMC -,SUP-6260-9-428,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL HEAD LFIT ANATOMIC V40 6.5MM X 16MM -,SUP-6260-9-440,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ15 47MM OFST 140MM PARTNERSHIP RELIANCE PF PRFT -,SUP-6265-2-005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ6 50MM OFST 150MM PARTNERSHIP RELIANCE PF PRFT -,SUP-6265-2-006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.0338,9.170825,27238.33344,percent of total billed charges,,,
CENTRALIZER DIST HIP 13MM TY A -,SUP-6265-4-413,CDM,C1776,HCPCS,278,RC,,,outpatient,,,601.24,420.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,155.540788,9.170825,27238.33344,percent of total billed charges,,,
CENTRALIZER DIST HIP 14MM TY A -,SUP-6265-4-414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,601.24,420.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,155.540788,9.170825,27238.33344,percent of total billed charges,,,
CENTRALIZER DIST HIP 15MM TY B -,SUP-6265-4-515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,601.24,420.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,155.540788,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ1 10X34MM OFST 115MM PARTNERSHIP CITNN PRFT PRIM -,SUP-6265-5101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ2 36MM OFST 120MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ4 44MM OFST 130MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5104,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ5 47MM OFST 135MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1921.3649,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ0 9X34MM OFST 110MM PARTNERSHIP CITNN PRFT PRIM -,SUP-6265-5110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ1 34MM OFST 118MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ2 36MM OFST 120MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ3 40MM OFST 133MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ4 44MM OFST 130MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ5 47MM OFST 135MM PARTNERSHIP CITNN PRFT PRIM STD -,SUP-6265-5115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
BODY PROX HIP 21MM STD RESTOR MODULAR REVISN BOLT CNCL -,SUP-6276-1-021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3595.87826,9.170825,27238.33344,percent of total billed charges,,,
SYS HIP RESTORATION MODULAR SZ 21MM +0 HT V40 TPR -,SUP-6276-1-021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3595.87826,9.170825,27238.33344,percent of total billed charges,,,
BODY PROX HIP 25MM STD RESTOR MODULAR REVISN BOLT CNCL -,SUP-6276-1-025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3595.87826,9.170825,27238.33344,percent of total billed charges,,,
BODY PROX HIP 19MM RESTOR MODULAR REVISN BOLT +10MM NK CNCL -,SUP-6276-1-119,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3595.87826,9.170825,27238.33344,percent of total billed charges,,,
BODY PROX HIP 21MM RESTOR MODULAR REVISN BOLT +11MM NK CNCL -,SUP-6276-1-121,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3595.87826,9.170825,27238.33344,percent of total billed charges,,,
TIP SUCT ACORN STD V. MUELLER 1.0625IN SIL RBR -,SUP-6276-1-123,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3595.87826,9.170825,27238.33344,percent of total billed charges,,,
MODULAR HIP SYSTEM RESTORATION 25MM X +10 X V40 TPR -,SUP-6276-1-125,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3595.87826,9.170825,27238.33344,percent of total billed charges,,,
SYSTEM HIP MODULAR 27MM X +10 X V40 TPR RESTORAITON -,SUP-6276-1-127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3595.87826,9.170825,27238.33344,percent of total billed charges,,,
BODY PROX HIP 19MM RESTOR MODULAR REVISN BOLT +20MM NK CNCL -,SUP-6276-1-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3595.87826,9.170825,27238.33344,percent of total billed charges,,,
BODY PROX HIP 21MM RESTOR MODULAR REVISN BOLT +20MM NK CNCL -,SUP-6276-1-221,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3595.87826,9.170825,27238.33344,percent of total billed charges,,,
BODY PROX HIP 25MM RESTOR MODULAR REVISN BOLT +10MM NK CNCL -,SUP-6276-1-225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3595.87826,9.170825,27238.33344,percent of total billed charges,,,
BODY PROX HIP 19MM RESTOR MODULAR REVISN BOLT +30MM NK CNCL -,SUP-6276-1-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3595.87826,9.170825,27238.33344,percent of total billed charges,,,
BODY PROX HIP 21MM RESTOR MODULAR REVISN BOLT +30MM NK CNCL -,SUP-6276-1-321,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3595.87826,9.170825,27238.33344,percent of total billed charges,,,
BODY PROX HIP 23MM RESTOR MODULAR REVISN BOLT +30MM NK CNCL -,SUP-6276-1-323,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3595.87826,9.170825,27238.33344,percent of total billed charges,,,
RESTORATION MODULAR HIP SYSTEM 25MM X 30 V40 -,SUP-6276-1-325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13899.8,9729.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3595.87826,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 14X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-014,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2576.481258,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 15X155MM RESTOR REVISN MODULAR STR CNCL DIST HIP -,SUP-6276-7-015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2576.481258,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 16X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2576.481258,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 17X155MM RESTOR REVISN MODULAR STR CNCL DIST HIP -,SUP-6276-7-017,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2576.481258,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 18X155MM RESTOR REVISN MODULAR STR CNCL DIST HIP -,SUP-6276-7-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2576.481258,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 19X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2576.481258,9.170825,27238.33344,percent of total billed charges,,,
STEM HIP RESTORATION MODULAR 20MM X 155MM -,SUP-6276-7-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2576.481258,9.170825,27238.33344,percent of total billed charges,,,
RESTORATION MODULAR HIP SYS 22MM X 155MM -,SUP-6276-7-022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2576.481258,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 23X155MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-023,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2576.481258,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 14X195MM RESTOR REVISN MODULAR CNCL STR DIST HIP -,SUP-6276-7-114,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10547.44,7383.208,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2728.622728,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 14X195MM RESTOR REVISN MODULAR HIP -,SUP-6276-7-214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2879.863922,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 15X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2879.863922,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 16X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2879.863922,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 19X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-219,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2879.863922,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 21X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2879.863922,9.170825,27238.33344,percent of total billed charges,,,
RESTORATION MODULAR HIP SYSTEM 21MM X 195MM -,SUP-6276-7-221,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2879.863922,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 24X195MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-224,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11132.06,7792.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2879.863922,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 15X235MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11716.67,8201.669,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3031.102529,9.170825,27238.33344,percent of total billed charges,,,
RESTORATION HIP STEM 235MM X 19MM -,SUP-6276-7-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11716.67,8201.669,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3031.102529,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 22X235MM RESTOR REVISN MODULAR CNCL BW DIST HIP -,SUP-6276-7-322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11716.67,8201.669,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3031.102529,9.170825,27238.33344,percent of total billed charges,,,
SYS RESTORATION MOD HIP 18MM X 115MM -,SUP-6276-7-418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24628.33,17239.831,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6371.348971,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM PCA 28X0MM NK COCR REVISN -,SUP-6280-0-136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM PCA 32MM +5MM NK COCR REVISN -,SUP-6280-0-232,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM PCA 36MM +5MM NK COCR REVISN -,SUP-6280-0-236,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM PCA 32MM +10MM NK COCR REVISN -,SUP-6280-0-332,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM PCA 36MM +10MM NK COCR REVISN -,SUP-6280-0-336,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 32X52-55MM DURATION 10DG UHMWPE PCA -,SUP-6299-7-525,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4020.85,2814.595,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1040.193895,9.170825,27238.33344,percent of total billed charges,,,
LINEAR STANDARD TRILOGY ACETABULAR SYSTEM -,SUP-6305-50-36,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5260.44,3682.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1360.875828,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB SZ P6 28X62-64MM SHL S12 +4 10DG CROSSFIRE CONGR -,SUP-6352-5-076,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4458.11,3120.677,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1153.313057,9.170825,27238.33344,percent of total billed charges,,,
CROSSFIRE SYSTEM 12 POLYETHYLENE INSERT 10 -,SUP-6352-5-105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4458.11,3120.677,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1153.313057,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR SM 9MM PE PEGX3 AVON RND DOME REVISN OFST -,SUP-6430-0-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4079.19,2855.433,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1055.286453,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR MED 9.5MM PE PEGX3 AVON RND DOME REVISN OFST -,SUP-6430-0-030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4079.19,2855.433,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1055.286453,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR LRG 10MM PE PEGX3 AVON RND DOME REVISN OFST -,SUP-6430-0-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4079.19,2855.433,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1055.286453,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM XS 43.5MMX42.5MM AVON KN CMNT PEGX4 COCR -,SUP-6430-0-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14140.63,9898.441,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3658.180981,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM MED 50.3MMX47.5MM AVON KN CMNT PEGX4 COCR -,SUP-6430-0-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14140.63,9898.441,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3658.180981,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 36MM E SHL TRIDENT 0DG ELEV RM ECCT X3 PRIM -,SUP-643-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
TRIDENT ELEVATED RIM INSERT 36MM G -,SUP-643-00-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND XS KINEMAX PLUS PRFT REVISN MODULAR 80MM COCR -,SUP-6476-8-260,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3594.54,2516.178,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,929.907498,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 14MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-620,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1137.713447,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 16MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-630,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1137.713447,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 19MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-645,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1137.713447,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 23MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-665,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1137.713447,9.170825,27238.33344,percent of total billed charges,,,
STEM TITANIUM FLUTED 16MM X 155MM -,SUP-6478-6-715,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1137.713447,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 17MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-720,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1137.713447,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 21MM REG GMRS KINEMAX PLUS PRFT REVISN MODULAR -,SUP-6478-6-740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4397.81,3078.467,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1137.713447,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 SM M LT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5310.580665,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 SM M RT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5310.580665,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 MED M LT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5310.580665,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 LRG M RT KN MODULAR REVISN COCR ROT HNG -,SUP-6481-1-131,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20527.95,14369.565,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5310.580665,9.170825,27238.33344,percent of total billed charges,,,
MRH KNEE FEMORAL DISTAL BLOCK MED 10MM -,SUP-6481-1-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3438.71,2407.097,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,889.594277,9.170825,27238.33344,percent of total billed charges,,,
COMP TIB STD XS XL KN GMRS COCR MRH -,SUP-6481-2-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11254.62,7878.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2911.570194,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL BEARING COMPONENT MRH -,SUP-6481-2-103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11254.62,7878.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2911.570194,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ7 STD GMRS KN MODULAR REVISN BUSHNG COCR ROT HNG -,SUP-6481-2-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1628.47,1139.929,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,421.285189,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ7 STD GMRS KN MODULAR REVISN AXLE COCR ROT HNG -,SUP-6481-2-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4454.42,3118.094,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.358454,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB BEAR KN PE -,SUP-6481-2-130,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3005.95,2104.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,777.639265,9.170825,27238.33344,percent of total billed charges,,,
MRH KNEE BUMPER INSERT 3 DEGREES -,SUP-6481-2-133,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3005.95,2104.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,777.639265,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE TIB SZ4 MODULAR BMPR DIST KN ROT HNG DURATION -,SUP-6481-2-140,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2514.7,1760.29,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,650.55289,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ1 KN GMRS COCR MODULAR KLD ROT HNG -,SUP-6481-3-110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12573.67,8801.569,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3252.808429,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ2 SM KN GMRS COCR MODULAR KLD ROT HNG -,SUP-6481-3-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12573.67,8801.569,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3252.808429,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ2 LRG KN GMRS COCR MODULAR KLD ROT HNG -,SUP-6481-3-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12573.67,8801.569,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3252.808429,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ1-2 XS/SM 10MM PS ARTCSURF KN PE -,SUP-6481-3-210,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1285.777805,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ1-2 XS/SM 13MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1285.777805,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ1-2 XS/SM 16MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1285.777805,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ1-2 XS/SM 20MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1285.777805,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB MED 2/ L2 13MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-313,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5011.74,3508.218,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1296.537138,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB MED 2/ L2 24MM MODULAR PS ARTC KN ROT HNG -,SUP-6481-3-324,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5011.74,3508.218,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1296.537138,9.170825,27238.33344,percent of total billed charges,,,
KINEMATIC ROTATING HINGE KNEE XSM 8MM -,SUP-6485-2-008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1705.940236,9.170825,27238.33344,percent of total billed charges,,,
HINGE KNEE ROTATING SIZE XSM 11MM THKNS KINEMATIC -,SUP-6485-2-011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1705.940236,9.170825,27238.33344,percent of total billed charges,,,
KINEMATIC ROTATING HINGE KNEE -,SUP-6485-2-016,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1705.940236,9.170825,27238.33344,percent of total billed charges,,,
KINEMATIC ROTATING  HINGE KNEE SM 8MM -,SUP-6485-2-108,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1705.940236,9.170825,27238.33344,percent of total billed charges,,,
KINEMATIC ROTATING HINGE KNEE -,SUP-6485-2-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1705.940236,9.170825,27238.33344,percent of total billed charges,,,
KINEMATIC ROTATING HINGE KNEE 16MM MEDIUM -,SUP-6485-2-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1705.940236,9.170825,27238.33344,percent of total billed charges,,,
KINEMATIC ROTATING HINGE KNEE LARGE 21MM -,SUP-6485-2-321,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6594.28,4615.996,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1705.940236,9.170825,27238.33344,percent of total billed charges,,,
STEM STRAIGHT CEMENTED 10MM X 102MM -,SUP-6485-3-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.954459,9.170825,27238.33344,percent of total billed charges,,,
STEM REPLACEMENT STRAIGHT CEMENTED 8MM X 102MM -,SUP-6485-3-018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.954459,9.170825,27238.33344,percent of total billed charges,,,
STEM REPLACEMENT STRAIGHT 9MM X 102MM -,SUP-6485-3-019,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.954459,9.170825,27238.33344,percent of total billed charges,,,
STEM CEMENTED STRAIGHT 11 X 127 -,SUP-6485-3-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.954459,9.170825,27238.33344,percent of total billed charges,,,
STEM MRS STRAIGHT CEMENTED 13 X 127 -,SUP-6485-3-113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.954459,9.170825,27238.33344,percent of total billed charges,,,
STEM-REPLACEMENT CURVED CEMENTED 10MM X 102MM -,SUP-6485-3-310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.954459,9.170825,27238.33344,percent of total billed charges,,,
STEM REPLACEMENT CURVED CEMENTED 8MM X 102MM -,SUP-6485-3-318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.954459,9.170825,27238.33344,percent of total billed charges,,,
STEM REPLACEMENT CURVED CEMENTED -,SUP-6485-3-319,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.954459,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 11MM LNG GMRS MODULAR 203MM TI HAP PLASM SPRY CTD -,SUP-6485-3-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14897,10427.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3853.8539,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 17X203MM MRS MODULAR COCR POR CTD CMNT CRV DIST HIP -,SUP-6485-3-617,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14897,10427.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3853.8539,9.170825,27238.33344,percent of total billed charges,,,
MRS CURVED CEMENTED STEM 11MM X 127MM -,SUP-6485-3-811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.954459,9.170825,27238.33344,percent of total billed charges,,,
MRS CURVED CEMENTED STEM 13MM X 127MM -,SUP-6485-3-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.954459,9.170825,27238.33344,percent of total billed charges,,,
STEM CEMENTED STEM 15 X 127 -,SUP-6485-3-815,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.954459,9.170825,27238.33344,percent of total billed charges,,,
STEM CEMENTED 17MM X 127MM CURVED -,SUP-6485-3-817,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610.57,7427.399,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.954459,9.170825,27238.33344,percent of total billed charges,,,
GMRS PROXIMAL FEMORAL COMPONENT V40 -,SUP-6495-1-002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19014.24,13309.968,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4918.983888,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT DISTAL FEMORAL SMALL LEFT 65MM -,SUP-6495-2-010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27396.07,19177.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7087.363309,9.170825,27238.33344,percent of total billed charges,,,
DISTAL FEMORAL COMPONENT SMALL RT 65MM -,SUP-6495-2-020,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27396.07,19177.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7087.363309,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM STD 65MM GMRS LT DIST KN MODULAR COCR ROT HNG -,SUP-6495-2-030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27152.28,19006.596,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7024.294836,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM STD 65MM GMRS RT DIST KN MODULAR COCR ROT HNG -,SUP-6495-2-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27152.28,19006.596,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7024.294836,9.170825,27238.33344,percent of total billed charges,,,
BUSHING FOR SMALL DISTAL FEMUR -,SUP-6495-2-105,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1672.63,1170.841,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,432.709381,9.170825,27238.33344,percent of total billed charges,,,
AXLE GMRS -,SUP-6495-2-115,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4462.74,3123.918,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1154.510838,9.170825,27238.33344,percent of total billed charges,,,
INSERT FOR SMALL PROXIMAL TIBIAL COMPONENT 13MM -,SUP-6495-3-013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1285.777805,9.170825,27238.33344,percent of total billed charges,,,
INSERT FOR SMALL PROXIMAL TIBIAL COMPONENT 24MM -,SUP-6495-3-024,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4970.15,3479.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1285.777805,9.170825,27238.33344,percent of total billed charges,,,
PROXIMAL TIBIA GMRS SM 80MM -,SUP-6495-3-101,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27343.31,19140.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7073.714297,9.170825,27238.33344,percent of total billed charges,,,
TIBIA PROXIMAL STD 80MM -,SUP-6495-3-102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,27343.31,19140.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7073.714297,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL ROTATING COMPONENT SM -,SUP-6495-3-601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11240.07,7868.049,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2907.806109,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND GMRS REVISN MODULAR 30MM FEM KN -,SUP-6495-6-030,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2972.287084,9.170825,27238.33344,percent of total billed charges,,,
PIECE EXTENSION GMRS 40MM LENGTH -,SUP-6495-6-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2972.287084,9.170825,27238.33344,percent of total billed charges,,,
GMRS EXTENSION PIECE 50MM -,SUP-6495-6-050,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2972.287084,9.170825,27238.33344,percent of total billed charges,,,
EXTENSION PIECE GMRS -,SUP-6495-6-070,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2972.287084,9.170825,27238.33344,percent of total billed charges,,,
GMRS EXTENSION PIECE 120MM -,SUP-6495-6-120,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11489.32,8042.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2972.287084,9.170825,27238.33344,percent of total billed charges,,,
GRAFT HUM TIS 6X10CM TISSUEMEND COLL -,SUP-6495-9-004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10181.42,7126.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2633.933354,9.170825,27238.33344,percent of total billed charges,,,
HEAD DELTA CERAMIC FEMORAL 36/-3MM -,SUP-650-0660,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,,,
HEAD DELTA CERAMIC FEMORAL 36/0MM -,SUP-650-0661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,,,
HEAD DELTA CERAMIC FEMORAL 36/+3MM -,SUP-650-0662,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,,,
CERAMIC HEAD BIOLOX DELTA  OP HIP SYSTEM 28MM -,SUP-650-1055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,,,
HEAD CER BIOLOX D OPTION 28MM -,SUP-650-1055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,,,
HEAD CER BIOLOXD OPTION 36MM -,SUP-650-1057,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,,,
CER OPTION TYPE 1 TPR SLEEVE +3 -,SUP-650-1067,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,226.427175,9.170825,27238.33344,percent of total billed charges,,,
+6MM NECK BIOLOCK OPTION HIP SYSTEM -,SUP-650-1068,CDM,C1776,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,226.427175,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEMORAL G7 BIOLOX DELTA -3 MM OFFSET OD28 MM HIP -,SUP-650-1159,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL HEAD UNIVERSAL TAPER 28MM OD BIOLOX DELTA -,SUP-6519-1-028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL HEAD UNIVERSAL TAPER BIOLOX DELTA -,SUP-6519-1-032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 36MM UNIV +0MML NK BIOLOX DELTA CERM TAPR PRIM -,SUP-6519-1-036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEMORAL 40MM BIOLOX DELTA -,SUP-6519-1-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,,,
UNIVERSAL V40  -2.5MM ADAPTER SLEEVE (TI) -,SUP-6519-T-025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,241.52232,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE HIP UNIV V-40 RECON PRIM ADPTR +0MML NK OFST TI TAPR -,SUP-6519-T-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,241.52232,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE HIP +4MM OFST UNIV V-40 RECON PRIM ADPTR TI TAPR -,SUP-6519-T-204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,241.52232,9.170825,27238.33344,percent of total billed charges,,,
IMPACTOR SURG F/TIB INS TRIATH -,SUP-6541-4-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2125.24,1487.668,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,549.799588,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 36MM-5MM NK ALMN PRIM -,SUP-6565-0-036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 32X0MM NK ALMN PRIM -,SUP-6565-0-132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 28MM -2.7MM OFST BIOLOX DELTA CERAMIC -,SUP-6570-0-028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 32MM -4MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-032,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 36MM -5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-036,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 28MM +0MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-128,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 32MM +0MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 36MM +0MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-136,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 28MM +4MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-228,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 32MM +4MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-232,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 36MM +5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-236,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 36MM -2.5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-436,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 36MM +2.5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-536,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM V-40 36MM +7.5MM OFST BIOLOX DELTA CERM TAPR PRIM -,SUP-6570-0-736,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1142.406265,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 36X54-56MM F SHL TRIDENT 0DG ECCT X3 PRIM -,SUP-663-00-36F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT KN SZ1 SM DURACN 10MM WDG BLCK REVISN VITAL -,SUP-6630-6-510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5255.98,3679.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1359.722026,9.170825,27238.33344,percent of total billed charges,,,
DURACON TOTAL KNEE FULL FLAT TIBIAL WEDGE SM-2 10MM -,SUP-6630-6-515,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5255.98,3679.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1359.722026,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 32X46-48MM D SHL TRIDENT 10DG ECCT X3 16.8MM -,SUP-663-10-32D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 36X58-60MM G SHL TRIDENT 10DG ECCT X3 18.8MM -,SUP-663-10-36G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 36X62-64MM H SHL TRIDENT 10DG ECCT X3 20.4MM -,SUP-663-10-36H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
CK Insert Trial Sz 4 8mm -,SUP-663-1408,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,298.883871,9.170825,27238.33344,percent of total billed charges,,,
CK Insert Trial Sz 5 16mm -,SUP-663-1516,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1155.33,808.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,298.883871,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB LRG 9X77/53MM DURACN CR A/P LIP ARTC L/R KN -,SUP-6642-1-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3601.27,2520.889,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,931.648549,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT A-P LIPPED DURACON XLGE 9MM -,SUP-6642-1-909,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3601.27,2520.889,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,931.648549,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR XS PE DURACON DURATION ASYM -,SUP-6642-2-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR MED PE DURACON DURATION ASYM -,SUP-6642-2-100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SM 11MMX45MM A/P DURACN CNSTRN ARTC L/R KN -,SUP-6642-9-611,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2193.100793,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB LRG 9MMX55MM ARTCSURF L/R KN PE -,SUP-6642-9-809,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2193.100793,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB LRG 11MMX55MM A/P DURACN CNSTRN ARTC L/R KN -,SUP-6642-9-811,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2193.100793,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB LRG 13MMX55MM A/P DURACN CNSTRN ARTC L/R KN -,SUP-6642-9-813,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8477.39,5934.173,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2193.100793,9.170825,27238.33344,percent of total billed charges,,,
TibAugSz1Trial20Â°WedgeLtLat/RtMed -,SUP-667-2201,CDM,C1776,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,244.541349,9.170825,27238.33344,percent of total billed charges,,,
TibAugSz2Trial20Â°WedgeLtLat/RtMed -,SUP-667-2202,CDM,C1776,HCPCS,278,RC,,,outpatient,,,945.27,661.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,244.541349,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ2 33MM OFST 99MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ3 35MM OFST 102MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ4 38MM OFST 105MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ5 35MM OFST 108MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ6 41MM OFST 111MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ7 46MM OFST 114MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6720-0737,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,,,
STEM HIP ACCOLADE 132 SZ 8 -,SUP-6720-0837,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,,,
STEM HIP 132 DEG SZ #9 37MM X 120MM V40 ANGLE ACCOLADE II -,SUP-6720-0937,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,,,
NECK ANGLE HIP STEM SZ# 0 / 27MM / 93MM / V40 -,SUP-6721-0027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ1 34MM OFST 96MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0127,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ2 37MM OFST 99MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0230,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ3 30MM OFST 102MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0330,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ4 42MM OFST 105MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0435,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,,,
ACCOLADE II SZ5 35MM NECK ANGLE HIP STEM 108MM V40 -,SUP-6721-0535,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ6 35MM OFST 111MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ7 50MM OFST 114MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0737,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ8 51MM OFST 117MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0837,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ9 53MM OFST 120MM ACCOLADE II V40 PRFT PRIM RECON -,SUP-6721-0937,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM SZ10 57MM OFST 123MM ACCOLADE II V40 PRFT PRIM -,SUP-6721-1040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SM 9MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-109,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4186.89,2930.823,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1083.148443,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SM 11MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4186.89,2930.823,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1083.148443,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SM 16MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-116,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4186.89,2930.823,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1083.148443,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ2 16MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1318.95608,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB LRG 9MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-309,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1318.95608,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 11MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-311,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1318.95608,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB LRG 16MM DURACN PS CS LIP ARTC L/R KN DURATION -,SUP-6742-4-316,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5098.4,3568.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1318.95608,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 22X50-52MM D SHL TRIDENT 0DG ECCT UHMWPE CNSTRN -,SUP-690-00-22D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2534.946973,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 22X50-52MM E SHL TRIDENT 0DG ECCT UHMWPE CNSTRN -,SUP-690-00-22E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2534.946973,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 22X54-56MM F SHL TRIDENT 0DG ECCT UHMWPE CNSTRN -,SUP-690-00-28F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2534.946973,9.170825,27238.33344,percent of total billed charges,,,
TRIDENT 0 DG ACETABULAR INSERT SZ H -,SUP-690-00-32H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9798.79,6859.153,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2534.946973,9.170825,27238.33344,percent of total billed charges,,,
TRIDENT ALL POLY CONSTRAINED ACETABULAR INSERT -,SUP-69-2244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10027.4,7019.18,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2594.08838,9.170825,27238.33344,percent of total billed charges,,,
ALL POLY CONSTRAINED INSERT 46MM -,SUP-69-2246,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10027.4,7019.18,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2594.08838,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM UNITRAX 40MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-040,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM UNITRAX 42MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM UNITRAX 43MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM UNITRAX 46MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM UNITRAX 47MM UNIPL PRIM MODULAR ENPROS -,SUP-6942-5-047,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE HIP UNITRAX V40 PRIM MODULAR UNIPL -4MM NK TAPR -,SUP-6942-6-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,203.785751,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE HIP UNITRAX V40 PRIM MODULAR UNIPL +0MML NK TAPR -,SUP-6942-6-065,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,203.785751,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE HIP UNITRAX V40 PRIM MODULAR UNIPL +8MM NK TAPR -,SUP-6942-6-075,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,203.785751,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE HIP UNITRAX C UNIPL -3MM NK C-TAPR -,SUP-6942-7-060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,203.785751,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE HIP UNITRAX C UNIPL +0MML NK C-TAPR -,SUP-6942-7-065,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,203.785751,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE HIP UNITRAX C UNIPL +5MM NK C-TAPR -,SUP-6942-7-075,CDM,C1776,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,203.785751,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE HIP UNITRAX C UNIPL +10MM NK C-TAPR -,SUP-6942-7-085,CDM,C1776,HCPCS,278,RC,,,outpatient,,,810.6,567.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,209.70222,9.170825,27238.33344,percent of total billed charges,,,
STEM HIP HIGH OFFSET INSIGNIA SZ 4 X 36MM X 103MM -,SUP-7000-6604,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,9.170825,27238.33344,percent of total billed charges,,,
SHELL CLUSTERHOLE ACET 46MM C TRIDENT TRITANIUM -,SUP-702-04-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,,,
TRIDENT IITRITANIUM CLUSTERHOLE 48MM D -,SUP-702-04-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,,,
SHELL TRIDENT II TRITANIUM CLUSTERHOLE ACETABULAR 50MM D -,SUP-702-04-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,,,
TRIDENT II TRITANIUM CLUSTERHOLE ACETABULAR SHELL -,SUP-702-04-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,,,
TRIDENT II TRITANIUM CLUSTERHOLE ACET SHELL 54MM -,SUP-702-04-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,,,
TRIDENT II TRITANIUM CLUSTERHOLE ACE SHELL 56MM F -,SUP-702-04-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,,,
TRIDENT II TRITANIUM CLUSTERHOLE ACE SHELL 58MM F -,SUP-702-04-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,,,
TRIDENT II TRITANIUM CLUST ACE SHELL SZ 60MM G -,SUP-702-04-60G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,,,
SHELL CLUSTERHOLE ACET SIZE 62MM G TRIDENT II TRITANIUM -,SUP-702-04-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACET 64MM H TRIDENT II TRIT CLUSTERHOLE -,SUP-702-04-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4562.3,3193.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1180.26701,9.170825,27238.33344,percent of total billed charges,,,
44MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-44B,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,,,
46MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-46C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,,,
48MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1207.71508,9.170825,27238.33344,percent of total billed charges,,,
52MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,,,
54MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,,,
56MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,,,
58MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,,,
60MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-60G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,,,
62MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,,,
64MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,,,
66MM TRIDENT II CLUSTERHOLE HA CUP -,SUP-702-11-66H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,,,
TRIDENT II TRITANIUM MULTIHOLE ACE SHELL 48MM D -,SUP-709-04-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2797.698215,9.170825,27238.33344,percent of total billed charges,,,
SHELL TRIDENT II TITAN MLTHLE ACE SIZE 52MM E -,SUP-709-04-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2797.698215,9.170825,27238.33344,percent of total billed charges,,,
SHELL TRIDENT II TRITANIUM MLTHOLE ACE 54MM E -,SUP-709-04-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2797.698215,9.170825,27238.33344,percent of total billed charges,,,
TRIDENT II TRITANIUM MULTHL SHELL 56MM F -,SUP-709-04-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2797.698215,9.170825,27238.33344,percent of total billed charges,,,
SHELL MULTIHOLE ACETABULAR 62MM X G TRIDENT II TRITANIUM -,SUP-709-04-62G,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2797.698215,9.170825,27238.33344,percent of total billed charges,,,
SHELL TRIDENT II TITANIUM 64MM H MULTIHOLE -,SUP-709-04-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2797.698215,9.170825,27238.33344,percent of total billed charges,,,
SHELL MULTIHOLE ACET SZ 66MM H TRIDENT II TRITANIUM -,SUP-709-04-66H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2797.698215,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACETABULAR 68MM ALPHA I MULTIHOLE TRIDENT II TRITANIUM -,SUP-709-04-68I,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10814.45,7570.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2797.698215,9.170825,27238.33344,percent of total billed charges,,,
COMP ACTB 22X42MM SHL TANDEM AN-ROT BIPLR COCR UHMWPE MAX -,SUP-71322042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2755.51,1928.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,712.850437,9.170825,27238.33344,percent of total billed charges,,,
REF XLPE 36 20 DEG 54-56F -,SUP-7133-3345,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9094.89,6366.423,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2352.848043,9.170825,27238.33344,percent of total billed charges,,,
ACET LINER 36 X 58 R3 20 DEG XLPE -,SUP-71335758,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6230.19,4361.133,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1611.750153,9.170825,27238.33344,percent of total billed charges,,,
COVER SCR HL HIP THRD R3 REFLC STRL -,SUP-71336500,CDM,C1776,HCPCS,278,RC,,,outpatient,,,407.81,285.467,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,105.500447,9.170825,27238.33344,percent of total billed charges,,,
SHELL ACETABULAR 58MM R3 MULTI HOLE -,SUP-71338668,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8734.15,6113.905,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2259.524605,9.170825,27238.33344,percent of total billed charges,,,
OXINIUM HD 12/14 22MM +4 -,SUP-71342204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7011.09,4907.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1813.768983,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM 36MM +0MML NK OXNM 12/14 TAPR STRL -,SUP-71343600,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8339.46,5837.622,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2157.418302,9.170825,27238.33344,percent of total billed charges,,,
GNS II CMT TIB SIZE 2 LEFT -,SUP-71420162,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1185.632448,9.170825,27238.33344,percent of total billed charges,,,
GNS II CMT TIBIAL SIZE 3 LEFT -,SUP-71420164,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1185.632448,9.170825,27238.33344,percent of total billed charges,,,
GNS II CMT TIB SIZE 5 LEFT -,SUP-71420168,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1185.632448,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ3 64/48MM RT KN CMNT GENESIS II NPOR -,SUP-71420182,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4286.44,3000.508,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1108.902028,9.170825,27238.33344,percent of total billed charges,,,
GNS II CMT TIB SIZE 4 RIGHT -,SUP-71420184,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1185.632448,9.170825,27238.33344,percent of total billed charges,,,
GNS II CMT TIB SIZE 6 RIGHT -,SUP-71420188,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1185.632448,9.170825,27238.33344,percent of total billed charges,,,
GNSII CON INS SZ3-4 11MM -,SUP-71420524,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2656.973176,9.170825,27238.33344,percent of total billed charges,,,
INSERT GENESIS II SZ 3-4 13MM -,SUP-71420526,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2656.973176,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3-4 15MM 68-71MM M/L 48-50MM A/P GENESIS II -,SUP-71420528,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2656.973176,9.170825,27238.33344,percent of total billed charges,,,
GNS II CON INS SZ 3-4 18MM -,SUP-71420530,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2656.973176,9.170825,27238.33344,percent of total billed charges,,,
GNS II CON INS SZ5-6 15MM -,SUP-71420542,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,926.27535,9.170825,27238.33344,percent of total billed charges,,,
GNS II RESUR PAT 29MM -,SUP-71420574,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,9.170825,27238.33344,percent of total billed charges,,,
RESURF PAT GEN II 32MM -,SUP-71420576,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 35X9MM THK UHMWPE PEGX3 RSRFC GENESIS II -,SUP-71420578,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,431.941042,9.170825,27238.33344,percent of total billed charges,,,
GNS II RESURF PAT 26MM -,SUP-71420580,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5-6 13MM 74-77MM M/L 52-54MM A/P GENESIS II PS -,SUP-71420834,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2502.77,1751.939,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,647.466599,9.170825,27238.33344,percent of total billed charges,,,
LEGION CON ART INS 9MM SZ 1-2 -,SUP-71420959,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,926.27535,9.170825,27238.33344,percent of total billed charges,,,
INSERT G2 CONST SZ1-2 11MM -,SUP-71420960,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,973.206117,9.170825,27238.33344,percent of total billed charges,,,
INSERT ARTICULAR G2 CONST SIZE 1-2 13MM -,SUP-71420962,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2656.973176,9.170825,27238.33344,percent of total billed charges,,,
COMP FEMORAL SIZE 4 RIGHT LEGI -,SUP-71420964,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,926.27535,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ1-2 18MM 60-64MM M/L 42-45MM A/P GENESIS II -,SUP-71420966,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,926.27535,9.170825,27238.33344,percent of total billed charges,,,
LGN HM ST 3-4 5MM LTMD-RTLA -,SUP-71421142,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6854.06,4797.842,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1773.145322,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ3 LEGION LT KN CNSTRN REVISN OXNM -,SUP-71421163,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7309.809091,9.170825,27238.33344,percent of total billed charges,,,
LGN OX CONSTRAINED FEM 4 LT -,SUP-71421164,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7309.809091,9.170825,27238.33344,percent of total billed charges,,,
LGN OX CONSTRAINED FEM 6 LT -,SUP-71421166,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7309.809091,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT FEMORAL SIZE 4 RIGHT -,SUP-71421174,CDM,C1776,HCPCS,278,RC,,,outpatient,,,29666.87,20766.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7674.819269,9.170825,27238.33344,percent of total billed charges,,,
LEGION OX CONSTRAINED FEM 5 RT -,SUP-71421175,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7309.809091,9.170825,27238.33344,percent of total billed charges,,,
LEGION PS OIN FEM SZ3 RT -,SUP-71421203,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2583.887839,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ4 LEGION RT KN PS OXNM POR -,SUP-71421204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10489.23,7342.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2713.563801,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 LEGION RT KN PS OXNM POR -,SUP-71421205,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2583.887839,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ6 LEGION PS OXIN RIGHT -,SUP-71421206,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2583.887839,9.170825,27238.33344,percent of total billed charges,,,
LEGION PS OXIN FEM SZ4 LT -,SUP-71421214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2583.887839,9.170825,27238.33344,percent of total billed charges,,,
LEGION PS OXIN FEM SZ6 LT -,SUP-71421216,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2583.887839,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 LEGION RT KN CR REVISN OXNM POR -,SUP-71421225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9893.85,6925.695,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2559.538995,9.170825,27238.33344,percent of total billed charges,,,
LEGION CR OXIN FEM SZ6 RT -,SUP-71421226,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2583.887839,9.170825,27238.33344,percent of total billed charges,,,
LEGION NARROW PS OXIN SZ 4N LT -,SUP-71421264,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2583.887839,9.170825,27238.33344,percent of total billed charges,,,
LEGION NARROW PS OXIN SZ 6N LT -,SUP-71421266,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2583.887839,9.170825,27238.33344,percent of total billed charges,,,
LEGION NARROW PS OXIN SZ 5N RT -,SUP-71421275,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2470.3263,9.170825,27238.33344,percent of total billed charges,,,
LEGION NARROW PS OXIN SZ 6N RT -,SUP-71421276,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9574.46,6702.122,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2476.912802,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3-4 13MM GENESIS II PS ARTC L/R KN-HI FLEX OXNM -,SUP-71421510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3539.59,2477.713,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,915.691933,9.170825,27238.33344,percent of total billed charges,,,
GEN II PS HIGH FLEXION ARTICULAR INSERT SZ 5-6 13 -,SUP-71421517,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5975.55,4182.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1545.874785,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT DIST KN SZ3 LEGION 10MM WDG BLCK -,SUP-71421658,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1196.735852,9.170825,27238.33344,percent of total billed charges,,,
WEDGE FEM LGN SCRW DIS SZ4 5MM -,SUP-71421661,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1646.8842,9.170825,27238.33344,percent of total billed charges,,,
LEGION SCREW DIS FEM WDG SZ5 5MM -,SUP-71421664,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6068.92,4248.244,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1570.029604,9.170825,27238.33344,percent of total billed charges,,,
LEGION SCW LWDG S5 5D X 5P -,SUP-71421741,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8891.18,6223.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2300.148266,9.170825,27238.33344,percent of total billed charges,,,
JUNI OX FB FEM SZ 3 LM RL -,SUP-71422343,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2564.746626,9.170825,27238.33344,percent of total billed charges,,,
JUNI OX FB FEM SZ 5 LM RL -,SUP-71422345,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2564.746626,9.170825,27238.33344,percent of total billed charges,,,
JUNI OX FB FEM SZ 7 LM RL -,SUP-71422347,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2564.746626,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT FEMORAL JOURNEY OXINIUM SZ 5 RM LL -,SUP-71422355,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2564.746626,9.170825,27238.33344,percent of total billed charges,,,
LGN RK/HK HEMI SZ 3-4 LL/RM 5MM -,SUP-71423420,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8496.49,5947.543,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2198.041963,9.170825,27238.33344,percent of total billed charges,,,
LGN RK/HK HEMI SZ 3-4 LM/RL 5MM -,SUP-71423432,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8496.49,5947.543,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2198.041963,9.170825,27238.33344,percent of total billed charges,,,
LEGION REVISION TIBIAL BASEPLATE -,SUP-71424001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2922.963342,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE REVISION LONG TIBIA SIZE 2 LT -,SUP-71424002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2922.963342,9.170825,27238.33344,percent of total billed charges,,,
TIBIA BASE LGN REV SIZE 4 LT -,SUP-71424004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2922.963342,9.170825,27238.33344,percent of total billed charges,,,
LGN REV TIBIA BASE SZ 5 LT -,SUP-71424005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2922.963342,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIBIAL SIZE 2 RIGHT -,SUP-71424012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11863.04,8304.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3068.968448,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE TIB SZ3 RT KN LEGION TI REVISN -,SUP-71424013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2922.963342,9.170825,27238.33344,percent of total billed charges,,,
LEGION REV TIBIA BASE SZ 5 RT -,SUP-71424015,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2922.963342,9.170825,27238.33344,percent of total billed charges,,,
STEM PRESSFIT LONG 10MM X 120MM -,SUP-71424023,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1548.071148,9.170825,27238.33344,percent of total billed charges,,,
LGN PRESSFIT STEM 12MM X 120MM -,SUP-71424025,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1624.925744,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 13MM LEGION PRFT REVISN 120MM TI FEM KN -,SUP-71424026,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1548.071148,9.170825,27238.33344,percent of total billed charges,,,
STEM STRAIGHT 14MM X 120MM LEG -,SUP-71424027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1624.925744,9.170825,27238.33344,percent of total billed charges,,,
STEM LGN PRESSFIT 15MM X 120MM -,SUP-71424028,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1624.925744,9.170825,27238.33344,percent of total billed charges,,,
LGN PRESSFIT STEM 16MM X 120MM -,SUP-71424029,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1548.071148,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTENSION LEGION TI PRESSFIT 18MM X 120MM -,SUP-71424031,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6281.12,4396.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1624.925744,9.170825,27238.33344,percent of total billed charges,,,
LGN PRESSFIT STEM 11MM X 160MM -,SUP-71424044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1589.791697,9.170825,27238.33344,percent of total billed charges,,,
STEM LGN PRESSFIT 12MM X 160MM -,SUP-71424045,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1589.791697,9.170825,27238.33344,percent of total billed charges,,,
STEM LGN PRESSFIT 13MM X 160MM -,SUP-71424046,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1589.791697,9.170825,27238.33344,percent of total billed charges,,,
LGN PRESSFIT STEM 15MM X 160MM -,SUP-71424048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1589.791697,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 16MM LEGION PRFT REVISN 160MM TI FEM KN -,SUP-71424049,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6145.31,4301.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1589.791697,9.170825,27238.33344,percent of total billed charges,,,
STEM LGN CEMENT 14MM X 160MM STRT -,SUP-71424206,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6527.27,4569.089,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1688.604749,9.170825,27238.33344,percent of total billed charges,,,
LGN OFFSET COUPLER 2MM -,SUP-71424223,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6132.58,4292.806,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1586.498446,9.170825,27238.33344,percent of total billed charges,,,
LGN OFFSET COUPLER 4MM -,SUP-71424225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6132.58,4292.806,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1586.498446,9.170825,27238.33344,percent of total billed charges,,,
LGN CR HIGH FLEX XLPE SZ 3-4 9MM -,SUP-71453111,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,973.206117,9.170825,27238.33344,percent of total billed charges,,,
INSERT LEGION CR HIGH FLEX XLPE SZ 3-4 -,SUP-71453112,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,926.27535,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3-4 9MM LEGION CR KN XLPE -,SUP-71453146,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.16315,9.170825,27238.33344,percent of total billed charges,,,
LGN PS HIGH FLEX XLPE SZ 1-2 10MM -,SUP-71453171,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,926.27535,9.170825,27238.33344,percent of total billed charges,,,
LGN PS HIGH FLEX XLPE SZ 3-4 12MM -,SUP-71453174,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,926.27535,9.170825,27238.33344,percent of total billed charges,,,
LGN PS HIGH FLEX XLPE SZ 1-2 15MM -,SUP-71453204,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,973.206117,9.170825,27238.33344,percent of total billed charges,,,
LGN PS HIGH FLEX XLPE SZ 3-4 9MM -,SUP-71453211,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,973.206117,9.170825,27238.33344,percent of total billed charges,,,
LEGION PS HIGH FLEX XLPE SZ 3-4 11MM -,SUP-71453212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,926.27535,9.170825,27238.33344,percent of total billed charges,,,
LGN PS HIGH FLEX SLPE SZ 3-4 13MM -,SUP-71453213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,926.27535,9.170825,27238.33344,percent of total billed charges,,,
LEGION PS HIGH FLEX XLPE SZ 3-4 15MM -,SUP-71453214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4308.51,3015.957,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1114.611537,9.170825,27238.33344,percent of total billed charges,,,
LGN PS HIGH FLEX XLPE SZ 5-6 15MM -,SUP-71453224,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,926.27535,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3-4 13MM PS KN LEGION XLPE -,SUP-71453248,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,926.27535,9.170825,27238.33344,percent of total billed charges,,,
LGN XLPE DISHED ISRT SZ 5-6 15MM -,SUP-71453287,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,926.27535,9.170825,27238.33344,percent of total billed charges,,,
JOURNEY PFJ IMPLANT X-SM LT -,SUP-71461010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3650.10178,9.170825,27238.33344,percent of total billed charges,,,
JOURNEY PFJ IMPLANT X-SMALL RIGHT -,SUP-71461011,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12604.89,8823.423,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3260.885043,9.170825,27238.33344,percent of total billed charges,,,
JOURNEY PFJ IMPLANT SM LT -,SUP-71461012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3650.10178,9.170825,27238.33344,percent of total billed charges,,,
JOURNEY PF IMPLANT SM RT -,SUP-71461013,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3650.10178,9.170825,27238.33344,percent of total billed charges,,,
SCREW 5MMX55MM LCK CORT TRIGEN META-NAIL INTNL HX CPTR 4.7MM -,SUP-71642255,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2452.49,1716.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,634.459163,9.170825,27238.33344,percent of total billed charges,,,
UNIPL -,SUP-71701035,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14184.25,9928.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3669.465475,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 38X9MM THK GENESIS II REVISN PS -,SUP-71926225,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,9.170825,27238.33344,percent of total billed charges,,,
GEN II 7.5MM RESUR PAT 26MM -,SUP-71932634,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,431.941042,9.170825,27238.33344,percent of total billed charges,,,
GEN II 7.5MM RESUR PAT 29MM -,SUP-71932635,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3366.62,2356.634,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,870.944594,9.170825,27238.33344,percent of total billed charges,,,
LEGION REV TIB BASE W/JRNY LOCK SZ 5 -,SUP-71933571,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11863.04,8304.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3068.968448,9.170825,27238.33344,percent of total billed charges,,,
CONE TIB LGN ID 18 SHORT -,SUP-71935386,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22278,15594.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5763.3186,9.170825,27238.33344,percent of total billed charges,,,
WEDGE TIB LEGION CONE ID 20 SHORT -,SUP-71935387,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21210.51,14847.357,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5487.158937,9.170825,27238.33344,percent of total billed charges,,,
LEGION TIB CONE ID 22 SHORT -,SUP-71935388,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21210.51,14847.357,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5487.158937,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL CONE LEGION 18 LONG -,SUP-71935393,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22927.78,16049.446,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5931.416686,9.170825,27238.33344,percent of total billed charges,,,
LEGION TIB CONE ID 22 LONG -,SUP-71935395,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21210.51,14847.357,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5487.158937,9.170825,27238.33344,percent of total billed charges,,,
FEM CONE LGN ID 18MM LEFT -,SUP-71935400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22324.41,15627.087,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5775.324867,9.170825,27238.33344,percent of total billed charges,,,
LEGION FEM CONE ID 20MM LEFT -,SUP-71935401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22324.41,15627.087,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5775.324867,9.170825,27238.33344,percent of total billed charges,,,
LEGION FEM CONE ID 22MM LEFT -,SUP-71935402,CDM,C1776,HCPCS,278,RC,,,outpatient,,,22324.41,15627.087,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5775.324867,9.170825,27238.33344,percent of total billed charges,,,
WEDGE FEMORAL LEGION CONE ID 18MM KNEE RIGHT -,SUP-71935407,CDM,C1776,HCPCS,278,RC,,,outpatient,,,23447.6,16413.32,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6065.89412,9.170825,27238.33344,percent of total billed charges,,,
STEM FEMORAL ANTHOLOGY AFIT SO POR PL HA SZ7 -,SUP-71935567,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6009.5,4206.65,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1554.65765,9.170825,27238.33344,percent of total billed charges,,,
SCROPIO-FLEX X3 TIBIAL BEARING INSERT CR SZ11 -,SUP-72-26-1110,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1148.581434,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 36X46-48MM D SHL TRIDENT 0DG NEUT X3 3.9MM PRIM -,SUP-723-00-36D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 36X50-52MM E SHL TRIDENT 0DG NEUT X3 5.9MM PRIM -,SUP-723-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 40X54-56MM G SHL TRIDENT 0DG X3 5.8MM PRIM -,SUP-723-00-40F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
INSERT ACTB 28MM X 54MM RESTOR ADM/MDM X3 48G -,SUP-7236-2-854,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1207.71508,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ7 24X71/47MM 18X27MM SCORP CNSTRN TOTAL -,SUP-72-4-0724,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5828.45,4079.915,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1507.820015,9.170825,27238.33344,percent of total billed charges,,,
PIN NONRIM SPEED 65 STERILE -,SUP-74013480,CDM,C1776,HCPCS,278,RC,,,outpatient,,,128.37,89.859,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,33.209319,9.170825,27238.33344,percent of total billed charges,,,
PIN NONRIM SPEED 80 STERILE -,SUP-74013490,CDM,C1776,HCPCS,278,RC,,,outpatient,,,122.54,85.778,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,31.701098,9.170825,27238.33344,percent of total billed charges,,,
JOURNEY II CR FEM OX NP RT SZ. 4 -,SUP-74021154,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2583.887839,9.170825,27238.33344,percent of total billed charges,,,
COMP JRNY II CR FEM OX NP LT SZ 4 -,SUP-74021164,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2583.887839,9.170825,27238.33344,percent of total billed charges,,,
JRNY II BCS FEMORAL OXIN RT SZ 3 -,SUP-74022113,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9987.97,6991.579,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2583.887839,9.170825,27238.33344,percent of total billed charges,,,
JOURNEY TIBIA BASE NP RT SZ 2 -,SUP-74022212,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1185.632448,9.170825,27238.33344,percent of total billed charges,,,
JOURNEY TIBIA BASE NP RT SZ 3 -,SUP-74022213,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1185.632448,9.170825,27238.33344,percent of total billed charges,,,
JOURNEY TIBA BASE NP RT SZ. 4 -,SUP-74022214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4218.31,2952.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1091.276797,9.170825,27238.33344,percent of total billed charges,,,
JOURNEY TIBIA BASE NP LT SZ3 -,SUP-74022223,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1185.632448,9.170825,27238.33344,percent of total billed charges,,,
JOURNEY BCS PAT RESRF RD 32 MM STD -,SUP-74024832,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2017.9,1412.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,522.03073,9.170825,27238.33344,percent of total billed charges,,,
JOURNEY II CR ISRT XLPE RT SZ 3-4 9MM -,SUP-74025631,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,926.27535,9.170825,27238.33344,percent of total billed charges,,,
JRNY II ISRT XLPE DD LT SZ 3-4 9MM -,SUP-74025741,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,926.27535,9.170825,27238.33344,percent of total billed charges,,,
JRNY II BCS XLPE ART ISRT SZ 1-2 RT 12MM -,SUP-74027214,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,926.27535,9.170825,27238.33344,percent of total billed charges,,,
JRNY II BCS XLPE ART ISRT SZ 5-6 LT 12MM -,SUP-74027264,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3761.91,2633.337,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,973.206117,9.170825,27238.33344,percent of total billed charges,,,
44MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-44B,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,,,
48MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-48D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,,,
50MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-50D,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,,,
52MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-52E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,,,
54MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-54E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,,,
56MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-56F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,,,
58MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-58F,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,,,
64MM TRIDENT II PSL CLUSTERHOLE CUP -,SUP-742-11-64H,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1018.902885,9.170825,27238.33344,percent of total billed charges,,,
POLARCUP XLPE INSERT 43/22 NON-CEM -,SUP-75018942,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4478.01,3134.607,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1158.461187,9.170825,27238.33344,percent of total billed charges,,,
POLARCUP SHELL 43 CEMENTED -,SUP-75100451,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2635.01472,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT DIST KN SZ7 SCORP 5MM WDG BLCK CMNT SPCR TOTAL -,SUP-75-1-0705,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4305.81,3014.067,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1113.913047,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT POST KN SZ7 SCORP 5MM WDG BLCK SPCR TOTAL STABILIZED -,SUP-75-2-0705,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4305.81,3014.067,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1113.913047,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL LEFT MEDIAL SZ 4 NON-POROUS -,SUP-761-1401,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2305.63788,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL LEFT MEDIAL SIZE 6 NON-POROUS -,SUP-761-1601,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2305.63788,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL TRAY LEFT MEDIAL SIZE 3 NON-POROUS -,SUP-762-3100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1427.29964,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL TRAY LEFT MEDIAL SZ 4 NON-POROUS -,SUP-762-4100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1427.29964,9.170825,27238.33344,percent of total billed charges,,,
INSERT TRIDENT X3 ECCENTRIC 0DEG 36MM -,SUP-763-00-36E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT LEFT MEDIAL SZ 4 7MM -,SUP-763-4071,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1207.71508,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ7 66MM M/L 60-62MM A/P SCORP LT KN TOTAL -,SUP-76-4107L,CDM,C1776,HCPCS,278,RC,,,outpatient,,,17711.12,12397.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4581.866744,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL HEAD 12/14 COCR 36MM +3.5 -,SUP-8018-36-03,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,582.776077,9.170825,27238.33344,percent of total billed charges,,,
HEAD 12/14 COCR FRDM 36MM X +6 -,SUP-802403605,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7259.36,5081.552,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1877.996432,9.170825,27238.33344,percent of total billed charges,,,
3.5MM CORT LOCK SCR 48MM NS -,SUP-816135048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,882.25,617.575,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,228.238075,9.170825,27238.33344,percent of total billed charges,,,
SPACER NO PROFILE 16 X 14 X 8MM 7IN STERILE SHORELINE -,SUP-85-0208-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9039.72,6327.804,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2338.575564,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ4 76/51MM L/R KN PFC TI CR MODULAR + NPOR -,SUP-86-0124,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11851.9,8296.33,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3066.08653,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ2 64/43MM L/R KN PFC SIG KLD NPOR -,SUP-86-4180,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1207.71508,9.170825,27238.33344,percent of total billed charges,,,
STEM TAPER SIDMA 13 X 120 CEMENTED -,SUP-86-6498,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,,,
STEM TAPER 13 X 150 -,SUP-86-6499,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 12MM UNIV PFC PRFT MODULAR 75MM CMNT TIB KN -,SUP-86-7412,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,,,
STEM EXTEND 14MM UNIV PFC PRFT MODULAR 75MM CMNT TIB KN -,SUP-86-7414,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,,,
STEM UNIVERSAL FLUTED 75MM X 18MM -,SUP-86-7418,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,,,
STEM UNIVERSAL FLUTED 75MM X 24MM -,SUP-86-7421,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,,,
STEM FLUTED 115 X 16MM -,SUP-86-7430,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,,,
STEM UNIVERSAL FLUTED 115MM X 18MM -,SUP-86-7432,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,,,
STEM UNIVERSAL FLUTED 115MM X 20MM -,SUP-86-7433,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,,,
STEM RADIAL ALIGN TITANIUM 11MM X 0MM -,SUP-90176510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10481.8,7337.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2711.64166,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 28X48-50MM X-ALT 0DG NEUT STD HXLPE 6MM NON- HD F -,SUP-931-28-248,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB 36X52-54MM X-ALT 0DG NEUT STD HXLPE 6MM HD F /FMP -,SUP-932-36-252,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1111.53042,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ2.5 63/59MM SIGMA FB RT KN CR CMNT COCR NPOR -,SUP-96-0018,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7199.14,5039.398,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1862.417518,9.170825,27238.33344,percent of total billed charges,,,
SIGMA TC3 FEM RT SZ2 -,SUP-96-0087,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2497.43806,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL TC3 CEMENTED SIGMA SIZE 5 RIGHT -,SUP-96-0090,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2497.43806,9.170825,27238.33344,percent of total billed charges,,,
FEMORAL TC3 CEMENTED SIGMA SIZE 2.5 RIGHT -,SUP-96-0092,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2497.43806,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 32MM XS UHMWPE PEGX3 PFC SIG OVL DOME -,SUP-96-0100,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 38MM STD UHMWPE PEGX3 PFC SIG OVL DOME -,SUP-96-0102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,,,
COMP PTLR 41MM LRG UHMWPE PEGX3 PFC SIG OVL DOME -,SUP-96-0103,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.935066,9.170825,27238.33344,percent of total billed charges,,,
ADAPTER FEM 5DG PFC SIGMA TC3 KN REVISN CMNT TI -,SUP-96-0781,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8615.53,6030.871,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2228.837611,9.170825,27238.33344,percent of total billed charges,,,
BOLT FEMORAL ADAPTER +2/-2 OFF -,SUP-96-0784,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1623.81,1136.667,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,420.079647,9.170825,27238.33344,percent of total billed charges,,,
DISTAL AUGMENT SIZE 2 4MM RIGHT -,SUP-96-0821,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1080.654575,9.170825,27238.33344,percent of total billed charges,,,
DISTAL AUGMENT SIZE 2 8MM RIGHT -,SUP-96-0823,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1080.654575,9.170825,27238.33344,percent of total billed charges,,,
DISTAL AUGMENT SIZE 2.5 8MM RIGHT -,SUP-96-0843,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1080.654575,9.170825,27238.33344,percent of total billed charges,,,
DISTAL  AUGMENT  COMBO  SIZE 2.5 16MM RIGHT -,SUP-96-0852,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1080.654575,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT FEM SZ4 PFC SIG POST KN WDG/BLCK 4MM COCR -,SUP-96-0886,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1080.654575,9.170825,27238.33344,percent of total billed charges,,,
COMBO PFC SIGMA POST AUG CEMENTED SIZE 5 X 8MM -,SUP-960908,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1080.654575,9.170825,27238.33344,percent of total billed charges,,,
COMBO PFC SIGMA DIST AUG CEMENTED SIZE 6 X 12MM LEFT -,SUP-96-0909,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1080.654575,9.170825,27238.33344,percent of total billed charges,,,
COMBO PFC SIGMA DIST AUG CEMENTED SIZE 6 X 16MM LEFT -,SUP-96-0911,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1080.654575,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5 10MM 74MM/47MM M/L/A/P PFC SIG PS ARTCSURF -,SUP-96-2051,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.16315,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT ROTATING PLTFRM SIZE 3 X 12.5MM -,SUP-96-2132,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.16315,9.170825,27238.33344,percent of total billed charges,,,
TIBAL INSERT ROT PLAT STAB SZ4 12.5MM -,SUP-96-2142,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.16315,9.170825,27238.33344,percent of total billed charges,,,
TIBAL INSERT ROTATING PLATFORM (STAB) 4- 20MM -,SUP-96-2145,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4774.5,3342.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1235.16315,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT ROT PLTFRM TC3 SZ 2 12.5MM -,SUP-96-2322,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT ROTATING PLATFORM SIZE 2 20MM -,SUP-96-2325,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT ROTATING PLATFORM TC3 SZ 12.5 -,SUP-96-2332,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT ROTATING PLTFRM SZ3 30MM -,SUP-96-2348,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL INSERT TC3 RP S4 12.5 -,SUP-96-2352,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL PLATFORM TCS SZ 5 GVF 22.5MM -,SUP-96-2366,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBTRY SZ3 8MM KN PFC SIG UHMWPE CR POST LIP -,SUP-96-2540,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6645.51,4651.857,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1719.193437,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ5 15X89/55MM PFC SIG PS TCMPRTMNTL BEAR ARTC -,SUP-97-0473,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM UNIPL COCR POR -,SUP-98000100400,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12559.22,8791.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3249.070214,9.170825,27238.33344,percent of total billed charges,,,
KT THR PRFT SUMMIT -,SUP-98-0001-006-00,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12559.22,8791.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3249.070214,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB LRG VIVACIT VIT-E XLNK PE CNSTRN F/T/H ARTHPL -,SUP-98000125053,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21605.69,15123.983,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5589.392003,9.170825,27238.33344,percent of total billed charges,,,
KT THR PRIM KINECTIV -,SUP-98000132001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21605.69,15123.983,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5589.392003,9.170825,27238.33344,percent of total billed charges,,,
KT THR PERSONA -,SUP-98-0002-415-20,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21605.69,15123.983,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5589.392003,9.170825,27238.33344,percent of total billed charges,,,
SYS TKR PRIM CONSTRUT -,SUP-98000600000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,20654.23,14457.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5343.249301,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ3 10MM PFC SIG MODULAR CS STAB ANTMC KN POR CTD -,SUP-98-6061,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,,,
LINK NECK SEGMENT WITHOUTH COLLAR 12/14MM 126 DEG 65MM -,SUP-99-0984/30,CDM,C1776,HCPCS,278,RC,,,outpatient,,,19311.31,13517.917,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4995.835897,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE HIP +5MM 12/14 TAPR ASR UNIPL -,SUP-9998-00-315,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1022.29,715.603,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,264.466423,9.170825,27238.33344,percent of total billed charges,,,
SLEEVE HIP +8MM 12/14 TAPR ASR ADPR UNIPL -,SUP-9998-00-318,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,264.166331,9.170825,27238.33344,percent of total billed charges,,,
RADIAL HEAD 22MM -,SUP-ALN-RH1-220,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9803.64,6862.548,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2536.201668,9.170825,27238.33344,percent of total billed charges,,,
HEAD RADIAL 20MM -,SUP-ALN-RHI-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9803.64,6862.548,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2536.201668,9.170825,27238.33344,percent of total billed charges,,,
RADIAL HEAD 24MM -,SUP-ALN-RHI-240,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9803.64,6862.548,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2536.201668,9.170825,27238.33344,percent of total billed charges,,,
STEM 8MM X 0MM -,SUP-ALN-RST-0800,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2513.146324,9.170825,27238.33344,percent of total billed charges,,,
STEM 8MM X 2MM -,SUP-ALN-RST-0802,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2513.146324,9.170825,27238.33344,percent of total billed charges,,,
RADAIL STEM ALIGN 9MM X 0MM -,SUP-ALN-RST-0900,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2513.146324,9.170825,27238.33344,percent of total billed charges,,,
STEM 10MM X 0MM -,SUP-ALN-RST-1000,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2513.146324,9.170825,27238.33344,percent of total billed charges,,,
PACKAGED RADIAL STEM 11MM X 2MM -,SUP-ALN-RST-1102,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9714.52,6800.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2513.146324,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT KN 7DG 8DG XL LRG 9.83 MDL OPN 78-88MM 88-96 MM -,SUP-AR-13400L-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2086.05332,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT KN 11DG 12DG XL LRG 14.13 MDL OPN 78-88MM 88-96 MM -,SUP-AR-13400L-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8063.6,5644.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2086.05332,9.170825,27238.33344,percent of total billed charges,,,
PIP DART PEEK 10 DEGREE 2.5X30MM -,SUP-AR-4154PS-3010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,734.845111,9.170825,27238.33344,percent of total billed charges,,,
IMPLANT PIP 3MM PEEK 30MM 10DG ANG -,SUP-AR-4155PS-3010,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,734.845111,9.170825,27238.33344,percent of total billed charges,,,
SCREW 7X12 PROSTOP ARTHROEREISIS -,SUP-AR-4207-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1641.394586,9.170825,27238.33344,percent of total billed charges,,,
SCREW 8 X 14 MM PROSTOP SFT THRD -,SUP-AR-4208-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6154.44,4308.108,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1592.153628,9.170825,27238.33344,percent of total billed charges,,,
SCREW 9X14 PROSTOP ARTHROEREISIS -,SUP-AR-4209-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1641.394586,9.170825,27238.33344,percent of total billed charges,,,
SCREW 10X14MM PROSTOP SFT THRD CNCL TI F /ARTHROEREISIS -,SUP-AR-4210-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1641.394586,9.170825,27238.33344,percent of total billed charges,,,
SCREW 11X16MM PROSTOP SFT THRD CNCL TI F /ARTHROEREISIS -,SUP-AR-4211-16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1641.394586,9.170825,27238.33344,percent of total billed charges,,,
SCREW 12X16 PROSTOP ARTHROEREISI S -,SUP-AR-4212-16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6344.78,4441.346,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1641.394586,9.170825,27238.33344,percent of total billed charges,,,
"GUIDE WIRE .045"" X 5.91"" -",SUP-AR-8933K,CDM,C1776,HCPCS,278,RC,,,outpatient,,,40.85,28.595,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.567895,9.170825,27238.33344,percent of total billed charges,,,
STEM HUMERAL UNIVERS  SZ 6 -,SUP-AR-9100-06P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13645.28,9551.696,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3530.033936,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 10MM UNIVERS II 148MM SHLDR -,SUP-AR-9100-10P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13645.28,9551.696,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3530.033936,9.170825,27238.33344,percent of total billed charges,,,
GLENOID UNIV BASEPLATE SMALL -,SUP-AR-9120-01,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7278.46,5094.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1882.937602,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 54X23MM UNIVERS II ECCT -,SUP-AR-9154-23P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1921.3649,9.170825,27238.33344,percent of total billed charges,,,
ANATOEMIC PROSTHESIS 17MM -,SUP-AR-9500-170,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,858.348491,9.170825,27238.33344,percent of total billed charges,,,
ANATOEMIC PROSTHESIS 18.5MM -,SUP-AR-9500-185,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,858.348491,9.170825,27238.33344,percent of total billed charges,,,
ANATOEMIC PROSTHESIS 20MM -,SUP-AR-9500-200,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,858.348491,9.170825,27238.33344,percent of total billed charges,,,
ANATOEMIC PROSTHESIS 21.5 MM -,SUP-AR-9500-215,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,858.348491,9.170825,27238.33344,percent of total billed charges,,,
RESTRICTOR CEMENT REV 30MM -,SUP-B000-0300,CDM,C1776,HCPCS,278,RC,,,outpatient,,,583.5,408.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,150.95145,9.170825,27238.33344,percent of total billed charges,,,
REVERSE BODY STANDARD AND REVERSE BODY SCREW -,SUP-BBS-0960-21STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2881.6593,9.170825,27238.33344,percent of total billed charges,,,
TSS PRIMARY PROXIMAL BODY 2.5 08STD -,SUP-BOD-0923-020-08STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1625.890695,9.170825,27238.33344,percent of total billed charges,,,
BODY TSS PRIMARY PROXIMAL 10 LRG -,SUP-BOD-0923-020-10LRG,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1625.890695,9.170825,27238.33344,percent of total billed charges,,,
BODY TSS PRIMARY PROXIMAL 10 STD -,SUP-BOD-0923-020-10STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1625.890695,9.170825,27238.33344,percent of total billed charges,,,
BODY TSS PRIMARY PROXIMAL 2.5 X 12 STD -,SUP-BOD-0923-020-12STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1625.890695,9.170825,27238.33344,percent of total billed charges,,,
BODY HUM LRG 40MM TI PROX GFT TITAN F/MODULAR SHLDR SYS -,SUP-BOD-0923-020-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6836.57,4785.599,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1768.620659,9.170825,27238.33344,percent of total billed charges,,,
BODY TSS PRIMARY PROX 2.5 14 LRG -,SUP-BOD-0923-020-14LRG,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1625.890695,9.170825,27238.33344,percent of total billed charges,,,
TSS PRIMARY PROXIMAL BODY 2.5 14STD -,SUP-BOD-0923-020-14STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1625.890695,9.170825,27238.33344,percent of total billed charges,,,
TSS FRACTURE BODY 2.5 08LRG -,SUP-BOD-0923-021-08LRG,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1625.890695,9.170825,27238.33344,percent of total billed charges,,,
TSS FRACTURE BODY 2.5 08STD -,SUP-BOD-0923-021-08STD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6284.85,4399.395,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1625.890695,9.170825,27238.33344,percent of total billed charges,,,
ULNAR STEM 5.0MM 2CM EXT STEM -,SUP-DRUJ-IS250,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9932.28,6952.596,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2569.480836,9.170825,27238.33344,percent of total billed charges,,,
AEQREVSD FX/ADAPTER LATRLZD HMRL INSRT 36MM 9MM -,SUP-DWD861,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8929.38,6250.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2310.030606,9.170825,27238.33344,percent of total billed charges,,,
AEQUALIS REVERSED FX STEM 11MM X 130MM -,SUP-DWD903,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24223.61,16956.527,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6266.647907,9.170825,27238.33344,percent of total billed charges,,,
TORNIER PERFORM REVERSED STANDARD GLENOSPHERE DIA 36MM -,SUP-DWJ012,CDM,C1776,HCPCS,278,RC,,,outpatient,,,15178.74,10625.118,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3926.740038,9.170825,27238.33344,percent of total billed charges,,,
LINER ACTB SZ23 36MM MAX-ROM RINGLOC +3 HW E1 -,SUP-EP108323,CDM,C1776,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,9.170825,27238.33344,percent of total billed charges,,,
BEARING E1 44-36 STD HMRL -,SUP-EP-115393,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1372.4035,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB 10X71/75MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-EP-183540,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1204.157955,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB 12X71/75MM VANGRD CR POST LIP MODULAR ARTC BEAR -,SUP-EP-183542,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1204.157955,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB 18MMX67MM M/L VANGRD ANT STAB MODULAR ARTC BEAR -,SUP-EP-189048,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1204.157955,9.170825,27238.33344,percent of total billed charges,,,
ACT ARTIC E1 HIP BRG 28X42MM -,SUP-EP-200148,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1191.807617,9.170825,27238.33344,percent of total billed charges,,,
ACT ARTIC E1 HIP BRG 28X44MM -,SUP-EP-200150,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1191.807617,9.170825,27238.33344,percent of total billed charges,,,
ACT ARTIC E1 HIP BRG 28 X 50MM -,SUP-EP-200156,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4606.91,3224.837,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1191.807617,9.170825,27238.33344,percent of total billed charges,,,
IMPLANT TOE JOINT PRIMUS SIZE 40 -,SUP-FGT-40T,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6915.85,4841.095,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1789.130395,9.170825,27238.33344,percent of total billed charges,,,
RSS GLENOID BASEPLATE-S -,SUP-GBP-0961-094-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.807,9.170825,27238.33344,percent of total billed charges,,,
TSS PEGGED GLENOID XS -,SUP-GLN-0920-030-00P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9802.32,6861.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2535.860184,9.170825,27238.33344,percent of total billed charges,,,
GLENOID TSS PEGGED S -,SUP-GLN-0920-030-01P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4010.16,2807.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1037.428392,9.170825,27238.33344,percent of total billed charges,,,
TSS PEGGED GLENOID S -,SUP-GLN-0920-030-01P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9802.32,6861.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2535.860184,9.170825,27238.33344,percent of total billed charges,,,
TSS PEGGED GLENOID -,SUP-GLN-0920-030-02P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9802.32,6861.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2535.860184,9.170825,27238.33344,percent of total billed charges,,,
TSS PEGGED GLENOID L -,SUP-GLN-0920-030-03P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4010.16,2807.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1037.428392,9.170825,27238.33344,percent of total billed charges,,,
GLENDOID S FIN-LOCK -,SUP-GLN-0926-030-01A,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5882.18,4117.526,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1521.719966,9.170825,27238.33344,percent of total billed charges,,,
RSS GLENOSPHERE CONCENTRIC -S 2MM -,SUP-GLS-0961-02C-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.807,9.170825,27238.33344,percent of total billed charges,,,
RSS GLENOSPHERE CONCENTRIC -S 5MM -,SUP-GLS-0961-05C-S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2744.807,9.170825,27238.33344,percent of total billed charges,,,
TSS PEGGED GLENOID XS -,SUP-GN092003000P,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10292.44,7204.708,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2662.654228,9.170825,27238.33344,percent of total billed charges,,,
KEY SURG 26MM F /UHR ACTB HEAD REM -,SUP-HIUHRK26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1195.26,836.682,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,309.213762,9.170825,27238.33344,percent of total billed charges,,,
BASE PLATE ASSEMBLY IJS-E -,SUP-IJS-ELB-BPA,CDM,C1776,HCPCS,278,RC,,,outpatient,,,21316.33,14921.431,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5514.534571,9.170825,27238.33344,percent of total billed charges,,,
STANDARD POLY LINER +0 -,SUP-LNR-0960-00S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1921.3649,9.170825,27238.33344,percent of total billed charges,,,
RSS HXL LINER STANDARD +35 -,SUP-LNR-0960-191-3S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1921.3649,9.170825,27238.33344,percent of total billed charges,,,
RSS HXL LINER STANDARD +65 -,SUP-LNR-0960-191-6S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1921.3649,9.170825,27238.33344,percent of total billed charges,,,
RSS HXL LINER STANDARD +9S -,SUP-LNR-0960-191-9S,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1921.3649,9.170825,27238.33344,percent of total billed charges,,,
RSS HXL LINER STANDARD +OS -,SUP-LNR-0960-191-OS,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1921.3649,9.170825,27238.33344,percent of total billed charges,,,
RSS HXL LINER RETENTIVE +6R -,SUP-LNR-0960-192-6R,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1921.3649,9.170825,27238.33344,percent of total billed charges,,,
SYSTEM GREAT TOE MOVEMENT PROX PHALANX HEMI -,SUP-MGT-890-20PPH,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10627.83,7439.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2749.419621,9.170825,27238.33344,percent of total billed charges,,,
SYS MOVEMENT GREAT TOE SIZE 40 HEMI PROX PHALANX -,SUP-MGT89040PPH,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10627.83,7439.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2749.419621,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM 44X19MM TITAN 2.5 ECCT COCR -,SUP-MHH-0920-010-4419,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6991.01,4893.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1808.574287,9.170825,27238.33344,percent of total billed charges,,,
TSS COCR ECCENTRIC HEAD 2.5 40 X 15MM -,SUP-MHH-0923-010-4015E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1808.563939,9.170825,27238.33344,percent of total billed charges,,,
TSS COCR CONCENTRIC HEAD 2.5 44 X 19MM -,SUP-MHH-0923-010-4419C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1808.563939,9.170825,27238.33344,percent of total billed charges,,,
HEAD TSS COCR ECCENTRIC 2.5 44 X 19MM -,SUP-MHH-0923-010-4419E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1808.563939,9.170825,27238.33344,percent of total billed charges,,,
CONCENTRIC HEAD TSS COCR 2.5 46 X 14MM -,SUP-MHH-0923-010-4614C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1808.563939,9.170825,27238.33344,percent of total billed charges,,,
TSS COCR ECCENTRIC HEAD 2.5 46 X 14MM -,SUP-MHH-0923-010-4614E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1808.563939,9.170825,27238.33344,percent of total billed charges,,,
HEAD CONCENTRIC TSS COCR 2.5 46MM X 17MM -,SUP-MHH-0923-010-4617C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1808.563939,9.170825,27238.33344,percent of total billed charges,,,
HEAD TSS COCR ECCENTRIC 2.5 46 X 17MM -,SUP-MHH-0923-010-4617E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1808.563939,9.170825,27238.33344,percent of total billed charges,,,
TSS COCR CONCENTRIC HEAD 2.5 46 X 20MM -,SUP-MHH-0923-010-4620C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1808.563939,9.170825,27238.33344,percent of total billed charges,,,
TSS COCR CONCENTRIC HEAD 2.5 48 X 18MM -,SUP-MHH-0923-010-4818C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1808.563939,9.170825,27238.33344,percent of total billed charges,,,
HEAD HUM COCR CONC 2.5 X 48 X 21MM TSS -,SUP-MHH-0923-010-4821C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1808.563939,9.170825,27238.33344,percent of total billed charges,,,
HEAD TSS COCR ECCENTRIC 2.5 48 X 21MM -,SUP-MHH-0923-010-4821E,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1808.563939,9.170825,27238.33344,percent of total billed charges,,,
TSS COCR CONCENTRIC HEAD 2.5 50 X 19MM -,SUP-MHH-0923-010-5019C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1808.563939,9.170825,27238.33344,percent of total billed charges,,,
TSS COCR CONCENTRIC HEAD 2.5 50 X 22MM -,SUP-MHH-0923-010-5022C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1808.563939,9.170825,27238.33344,percent of total billed charges,,,
HEAD TSS COCR CONCENTRIC 2.5 52 X 20MM -,SUP-MHH-0923-010-5220C,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6990.97,4893.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1808.563939,9.170825,27238.33344,percent of total billed charges,,,
IMPLANT SZ30 -,SUP-MHT-30,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6017.99,4212.593,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1556.854013,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT LT SIZE 7 FEMORAL CR NONPOROUS COCR -,SUP-ORTHO DEV,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEMORAL 36MM +3 BIOLOX DELTA -,SUP-ORTHO DEV,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,685.619675,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL PS 8MM SIZE 5 VITAMIN E -,SUP-ORTHO DEV,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
STEM PLASMA SPRAY STD SIZE 11 -,SUP-ORTHO DEVELOPMENT,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,9.170825,27238.33344,percent of total billed charges,,,
COMP TIB SZ1 STRIDE LL/RM -,SUP-PFSI-00001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1188.392777,9.170825,27238.33344,percent of total billed charges,,,
COMP TIB SZ2 STRIDE LL/RM -,SUP-PFSI-00003,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1188.392777,9.170825,27238.33344,percent of total billed charges,,,
COMP TIB SZ2 STRIDE RL/LM -,SUP-PFSI-00004,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1188.392777,9.170825,27238.33344,percent of total billed charges,,,
STRIDE TIBIA BASEPLATE SIZE 3 RM/LL -,SUP-PFSI00005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1188.392777,9.170825,27238.33344,percent of total billed charges,,,
COMP TIB SZ3 STRIDE LL/RM -,SUP-PFSI-00005,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1114.391642,9.170825,27238.33344,percent of total billed charges,,,
COMP TIB SZ3 STRIDE RL/LM -,SUP-PFSI-00006,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1188.392777,9.170825,27238.33344,percent of total billed charges,,,
COMP TIBIAL STRIDE SZ 4 RMLL -,SUP-PFSI00007,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1188.392777,9.170825,27238.33344,percent of total billed charges,,,
STRIDE TIBIA BASEPLATE SZ. 4 LM/RL -,SUP-PFSI00008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1188.392777,9.170825,27238.33344,percent of total billed charges,,,
COMP TIB SZ4 STRIDE RL/LM -,SUP-PFSI-00008,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4593.71,3215.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1188.392777,9.170825,27238.33344,percent of total billed charges,,,
COMP TIB SZ5 STRIDE LL/RM -,SUP-PFSI-00009,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5156.46,3609.522,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1333.976202,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL 8MM SIZE A -,SUP-PFSI00021,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,673.463362,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ A 9MM -,SUP-PFSI-00022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,673.463362,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIB SZ B 8MM -,SUP-PFSI00027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,673.463362,9.170825,27238.33344,percent of total billed charges,,,
STRIDE POLY INSERT SZ. B 8MM -,SUP-PFSI00027,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,673.463362,9.170825,27238.33344,percent of total billed charges,,,
STRIDE POLY INSERT TIB SZ-C 8MM -,SUP-PFSI00033,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2603.26,1822.282,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,673.463362,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ1 STRIDE LL/RM -,SUP-PFSI-00052,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2593.49337,9.170825,27238.33344,percent of total billed charges,,,
STRIDE FEMUR SZ. 3 LM/RL -,SUP-PFSI00055,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10492.44,7344.708,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2714.394228,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ3 STRIDE LL/RM -,SUP-PFSI00056,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10492.44,7344.708,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2714.394228,9.170825,27238.33344,percent of total billed charges,,,
STRIDE FEMUR SIZE 4 RM/LL -,SUP-PFSI00058,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10492.44,7344.708,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2714.394228,9.170825,27238.33344,percent of total billed charges,,,
COMP FEM SZ5 STRIDE LL/RM -,SUP-PFSI-00060,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2593.49337,9.170825,27238.33344,percent of total billed charges,,,
COMP COMPREHESIVE MODULAR HYBRID REGNREX SHLDR POST -,SUP-PT-113950,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 9MM LNG REUNION COCR HAP CTD SHLDR -,SUP-R53514509,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1976.26104,9.170825,27238.33344,percent of total billed charges,,,
SPACER KN 46MM FEM MODHD ANTBTC REMEDY -,SUP-RHHDSM,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8093.31,5665.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2093.739297,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM MED MODULAR -,SUP-RHSTMD,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1866.46876,9.170825,27238.33344,percent of total billed charges,,,
HEAD FEM REFLEX HYBRID 32MM +2.5MM NK COCR C-TAPR PRIM LFRIC -,SUP-S1400HH32,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
C-TAPER LFIT INTER HEAD 28MM +2.5 -,SUP-S-1400-HH82,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
C-TAPER HEAD +7.5 OFFSET LFIT SZ. 28MM / +7.5 -,SUP-S-1400-HH84,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,548.49574,9.170825,27238.33344,percent of total billed charges,,,
PEG 4 MOD GLEN SZ 2 -,SUP-SAGL2042,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,617.059001,9.170825,27238.33344,percent of total billed charges,,,
4 PEG MOD GLEN SZ 3 -,SUP-SAGL2043,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,617.059001,9.170825,27238.33344,percent of total billed charges,,,
PEG 4 MOD GLEN SZ 4 -,SUP-SAGL2044,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,617.059001,9.170825,27238.33344,percent of total billed charges,,,
PEG 4 MOD GLEN SZ5 -,SUP-SAGL2045,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,617.059001,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT 4 PEG MOD GLEN LT AUG SZ 2 -,SUP-SAGL2142,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2470.3263,9.170825,27238.33344,percent of total billed charges,,,
4 PEG MOD GLEN LT AUG SZ 3 -,SUP-SAGL2143,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2470.3263,9.170825,27238.33344,percent of total billed charges,,,
PEG 4 MOD GLEN LT AUG SZ 5 -,SUP-SAGL2145,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2470.3263,9.170825,27238.33344,percent of total billed charges,,,
4 PEG MOD GLEN RT AUG SZ 2 -,SUP-SAGL2242,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2470.3263,9.170825,27238.33344,percent of total billed charges,,,
4 PEG MOD GLEN RT AUG SZ 3 -,SUP-SAGL2243,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2470.3263,9.170825,27238.33344,percent of total billed charges,,,
4 PEG MOD GLEN RT AUG SZ 4 -,SUP-SAGL2244,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2470.3263,9.170825,27238.33344,percent of total billed charges,,,
PEG 4 MOD GLEN RT AUG SZ 5 -,SUP-SAGL2245,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9549,6684.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2470.3263,9.170825,27238.33344,percent of total billed charges,,,
MODULAR POST PPS -,SUP-SAGP0001,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,,,
MODULAR POST TM -,SUP-SAGP0002,CDM,C1776,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,342.811131,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 10MM SHLDR -,SUP-SEM092002510,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1641.164343,9.170825,27238.33344,percent of total billed charges,,,
OXINIUM LEGION PS-SPC FEMUR LEFT SIZE 5 -,SUP-SMITH & NE,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9155.58,6408.906,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2368.548546,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 16.7MM PROX 10MM DIST SM 150MM INTSPC HI RELS 25MM -,SUP-SPC0022,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12735.59,8914.913,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3294.697133,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 10.5MM/21.9MM DIA P/D MED/SHRT 156MM INTSPC HI RELS -,SUP-SPC0122,CDM,C1776,HCPCS,278,RC,,,outpatient,,,12364.29,8655.003,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3198.641823,9.170825,27238.33344,percent of total billed charges,,,
SPACER THR CMNT XL 54MM HIP REVISN INTSPC -,SUP-SPC0421,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11101.87,7771.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2872.053769,9.170825,27238.33344,percent of total billed charges,,,
STEM FEM 10.5MM/21.9MM DIA P/D MED LNG 271MM INTSPC HI RELS -,SUP-SPC0422,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3457.99116,9.170825,27238.33344,percent of total billed charges,,,
SPACER THR CMNT LNG STM 60MM HIP REVISN INTSPC -,SUP-SPC0522,CDM,C1776,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3457.99116,9.170825,27238.33344,percent of total billed charges,,,
SMART TOE INTRAMEDULLARY ARTHRODEAL 11MM -,SUP-ST0XS-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6409.29,4486.503,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1658.083323,9.170825,27238.33344,percent of total billed charges,,,
TSS PRESS FIT STEM SZ. O7 -,SUP-STEM-0920-025-07,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1641.164343,9.170825,27238.33344,percent of total billed charges,,,
TSS PRESS FIT STEM SIZE 08 -,SUP-STEM-0920-025-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1641.164343,9.170825,27238.33344,percent of total billed charges,,,
TSS PRESS FIT HUM STEM SIZE 09 -,SUP-STEM-0920-025-09,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1641.164343,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 12MM PRFT TITAN -,SUP-STEM-0920-025-1,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1641.164343,9.170825,27238.33344,percent of total billed charges,,,
TSS PRESS FIT STEM SZ 10 -,SUP-STEM-0920-025-10,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1641.164343,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 11MM PRFT TITAN -,SUP-STEM-0920-025-11,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1641.164343,9.170825,27238.33344,percent of total billed charges,,,
STEM PRESS FIT TSS SZ 12 -,SUP-STEM-0920-025-12,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1641.164343,9.170825,27238.33344,percent of total billed charges,,,
STEM HUM 13MM PRFT TITAN -,SUP-STEM-0920-025-13,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1641.164343,9.170825,27238.33344,percent of total billed charges,,,
TSS PRESS FIT STEM SZ 14 -,SUP-STEM-0920-025-14,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1641.164343,9.170825,27238.33344,percent of total billed charges,,,
STEM PRESS FIT TSS SZ 15 -,SUP-STEM-0920-025-15,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1641.164343,9.170825,27238.33344,percent of total billed charges,,,
TSS PRESS FIT STEM SIZE 16 -,SUP-STEM-0920-025-16,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1641.164343,9.170825,27238.33344,percent of total billed charges,,,
TSS CEMENTED STEM SZ 08 -,SUP-STEM-0950-025-08,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6343.89,4440.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1641.164343,9.170825,27238.33344,percent of total billed charges,,,
INSERT ECCENTRIC CUP 10' X 36MM X3 CODE E TRIDENT -,SUP-STRYKER,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4105.64,2873.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1062.129068,9.170825,27238.33344,percent of total billed charges,,,
WEDGE ACETABULAR AUGMENT 54MM X 56MM X 15MM -,SUP-STRYKER,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2137.886452,9.170825,27238.33344,percent of total billed charges,,,
COMP VRSDL GLNSPR 36MM TI -,SUP-TI-115310,CDM,C1776,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,9.170825,27238.33344,percent of total billed charges,,,
COMP ACTB 26X42MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-42-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,,,
COMP ACTB 26X43MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-43-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,,,
COMP ACTB 26X44MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-44-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,,,
COMP ACTB 26X45MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-45-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,,,
COMP ACTB 26X46MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-46-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,,,
COMP ACTB 26X47MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-47-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,,,
COMP ACTB 26X48MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-48-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,,,
COMP ACTB 26X50MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-50-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,,,
COMP ACTB 26X51MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-51-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,,,
COMP ACTB 26X52MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-52-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,,,
COMP ACTB 26X53MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-53-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,,,
COMP ACTB 26X54MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-54-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,,,
COMP ACTB 26X55MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-55-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,,,
COMP ACTB 26X56MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-56-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,,,
COMP ACTB 26X58MM UNIV UHR PRIM BIPLR BVL LIP 1PC LCK -,SUP-UH1-58-26,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,679.26859,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT FEM DIST 12MM SIZE 4 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1292.255653,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE 3LT REV TIBIA LNG -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,11298.66,7909.062,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2922.963342,9.170825,27238.33344,percent of total billed charges,,,
AUGMENT TIBIAL HALF BLOCK #6 T -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4379.86,3065.902,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1133.069782,9.170825,27238.33344,percent of total billed charges,,,
BASEPLATE MED GLENOID UNIVER -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7278.46,5094.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1882.937602,9.170825,27238.33344,percent of total billed charges,,,
GLENOID REVERS 39 +4 LAT -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2305.63788,9.170825,27238.33344,percent of total billed charges,,,
CONE PROX BODY SIZE 0 60MM TYP -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28694.06,20085.842,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7423.153322,9.170825,27238.33344,percent of total billed charges,,,
CUP PIVOT BIPOLAR 22 X 45MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT LGN OX FEMORAL 5LT C -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,28255.93,19779.151,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7309.809091,9.170825,27238.33344,percent of total billed charges,,,
COMPONENT LT MOD FEM SIZE 3 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18267.96,12787.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4725.921252,9.170825,27238.33344,percent of total billed charges,,,
CONE TIBIAL 31 X 31 X 25MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4841.187624,9.170825,27238.33344,percent of total billed charges,,,
CONE FEMORAL MEDIUM LEFT 30MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,18713.52,13099.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4841.187624,9.170825,27238.33344,percent of total billed charges,,,
CUP UNIVERS REVERS 39 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7575.54,5302.878,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1959.792198,9.170825,27238.33344,percent of total billed charges,,,
GLENOID POLY WITH PEG LG -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,,,
GLENOID POLY WITH PEG SMALL -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,,,
HEAD 40 CER 16/18 TAPER BIOLOXD -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,710.144435,9.170825,27238.33344,percent of total billed charges,,,
HUMERAL HEAD UNIVERS 44/17 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1921.3649,9.170825,27238.33344,percent of total billed charges,,,
INSERT HUMERAL M/39 +3 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4307.66,3015.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1114.391642,9.170825,27238.33344,percent of total billed charges,,,
POSTERIOR FEM AUGMENT 8MM SZ 4 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4995.19,3496.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1292.255653,9.170825,27238.33344,percent of total billed charges,,,
INSERT TIBIAL #5 13MM TS -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,,,
STEM DIST CONICAL 21MM X 155MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,9959.34,6971.538,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2576.481258,9.170825,27238.33344,percent of total billed charges,,,
STEM HIP MODULAR 13MM X 127MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10941.84,7659.288,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2830.654008,9.170825,27238.33344,percent of total billed charges,,,
TRIAL CONE MED 31 X 31 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,2768.92,1938.244,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,716.319604,9.170825,27238.33344,percent of total billed charges,,,
WEDGE ACET AUGMENT 46MM X 15MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8263.96,5784.772,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2137.886452,9.170825,27238.33344,percent of total billed charges,,,
STEM STR DIST 21MM X 150MM TAP -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3826.843033,9.170825,27238.33344,percent of total billed charges,,,
STEM HIP MODULAR 12MM X 127MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10941.84,7659.288,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2830.654008,9.170825,27238.33344,percent of total billed charges,,,
STEM STR DIST 21MM X 90MM TAPE -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,14792.59,10354.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3826.843033,9.170825,27238.33344,percent of total billed charges,,,
STEM UNIVERS SZ10 CAP COATED -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,10546.34,7382.438,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2728.338158,9.170825,27238.33344,percent of total billed charges,,,
TIB TRAY ROTATING REV  SZ 2 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2305.63788,9.170825,27238.33344,percent of total billed charges,,,
TRIAL KNEE INSERT 3X12 PS ORTH -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,241.52232,9.170825,27238.33344,percent of total billed charges,,,
TIBAL INSERT TOTAL STAB SZ.3 9 -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,8842.42,6189.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2287.534054,9.170825,27238.33344,percent of total billed charges,,,
TIBIAL HALF BLOCK #6 5MM -,SUP-UNDEFINED,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4483.07,3138.149,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1159.770209,9.170825,27238.33344,percent of total billed charges,,,
COMPR NANO HMRL PPS 36MM -,SUP-US-115736,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24134.5,16894.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6243.59515,9.170825,27238.33344,percent of total billed charges,,,
COMPR NANO HMRL PPS 38MM -,SUP-US-115738,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24134.5,16894.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6243.59515,9.170825,27238.33344,percent of total billed charges,,,
COMPR NANO HMRL PPS 40MM -,SUP-US-115740,CDM,C1776,HCPCS,278,RC,,,outpatient,,,24134.5,16894.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6243.59515,9.170825,27238.33344,percent of total billed charges,,,
BEARING HUM 44-36MM XL STD RVRS CMPRHNSV ARCM -,SUP-XL115363,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
ARCOM XL 44-36 STD HMRL BRNG -,SUP-XL-115363,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
44MM X 36MM CURV HUMERAL BEARING -,SUP-XL-115364,CDM,C1776,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1173.28211,9.170825,27238.33344,percent of total billed charges,,,
PERSONA FEMUR CEMENTED STD CCR SIZE 7 LEFT -,SUP-ZIMMER,CDM,C1776,HCPCS,278,RC,,,outpatient,,,6684.3,4679.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1729.22841,9.170825,27238.33344,percent of total billed charges,,,
LEAD DEFIB IMPL BIPLR PERMNT PCNG ETAK RELIANCE 59CM 9FR -,SUP-0137,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures,,
ENDOTAK RELIANCE S 64CM REF: 0138 -,SUP-0138,CDM,C1777,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures,,
LEAD PCNG 64CM ETAK RELIANCE SG -,SUP-0181,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures,,
ENDOTAK RELIANCE S 0272 59CM -,SUP-0272-59,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures,,
ENDOTAK RELIANCE S 0273 64CM -,SUP-0273-64,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures,,
LEAD ENDOTAK RELIANCE SINGLE C -,SUP-0292,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures,,
LEAD DEFIB PCNG ETAK RELIANCE 59CM GORE-HYBRID ETFE CTD STRD -,SUP-0292-59,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures,,
LEAD ICD RELIANCE 4-FRONT DEFIB -,SUP-0672-59,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures,,
LEAD DEFIB IMPL LINOX SMRT S 65CM ECRD SIL INSL SGL COIL -,SUP-369818,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures,,
LEAD DEFIB IMPL LINOX SMRT S 60CM ECRD SIL INSL SGL COIL -,SUP-375012,CDM,C1777,HCPCS,278,RC,,,outpatient,,,12976.94,9083.858,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures,,
LEAD PCNG PROTEGO T FX -,SUP-379967,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR PROTEGO S SGL COIL 75CM LD CARD IMPL -,SUP-379968,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR PROTEGO S SGL COIL 60CM LD CARD IMPL -,SUP-379970,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures,,
PLEXA PROMRI DF-1 S DS 65/15 -,SUP-414005,CDM,C1777,HCPCS,278,RC,,,outpatient,,,10734.28,7513.996,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures,,
LEAD DEFIB TRIPLR SPRNT QUATTRO 58CM 8.6FRX12MM SPC RT ECRD -,SUP-6935-58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures,,
LEAD DEFIB TRIPLR SPRNT QUATTRO 75CM 8.6FRX12MM SPC SIL -,SUP-6935M,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures,,
LEAD DEFIB TRIPLR SPRNT QUATTRO 72CM 8.6FRX12MM SPC SIL -,SUP-6935M72,CDM,C1777,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures,,
LEAD DEFIB UNIPL 58CM 7.5FR SUBQ SIL INSL SUT ON ANCHR SLV -,SUP-6996SQ58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures,,
LEAD DEFIB TRUE BIPLR DURATA 60CM 7FR VNTRC OPTIM INSL STRD -,SUP-7122/60,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures,,
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FR VNTRC OPTIM INSL STRD -,SUP-7122/65,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures,,
LEAD DEFIB TRUE BIPLR DURATA 52CM 7FR VNTRC OPTIM INSL SGL. -,SUP-7122Q/52,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures,,
LEAD DEFIB 7FRX58CM DURATA TRUE BIPLR HLCL TIP AV SGL SHOCK. -,SUP-7122Q/58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures,,
LEAD DEFIB 7FRX65CM DURATA TRUE BIPLR HLCL TIP AV SGL SHOCK -,SUP-7122Q/65,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures,,
LEAD DEFIB 8FR INTRO 58CM OPTISURE TRUE BIPLR SGL COIL -,SUP-LDA210Q/58,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures,,
LEAD DEFIB 8FR INTRO 65CM OPTISURE TRUE BIPLR SGL COIL -,SUP-LDA210Q-65,CDM,C1777,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9966.28992,other,Non-Reimbursable Procedures,,
PK LEAD NEURSTM ACC -,SUP-30571SC,CDM,C1778,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures,,
KT LEAD NEURSTM OCTRODE 60CM ACC -,SUP-3186,CDM,C1778,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures,,
OCTRODE -,SUP-3189,CDM,C1778,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures,,
LEAD NEURSTM PENTA 60CM PDL -,SUP-3228,CDM,C1778,HCPCS,278,RC,,,outpatient,,,14480.7,10136.49,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures,,
KT LEAD NEURSTM LMTRD S-8 60CM ACC -,SUP-3286,CDM,C1778,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures,,
KT 8MMX60CM LDX1 REVISN F/MDTRNC DEEP BRN STIM DBS -,SUP-3550-27,CDM,C1778,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures,,
KT EXTENSION NEURSTM 40CM ACC -,SUP-3708140,CDM,C1778,HCPCS,278,RC,,,outpatient,,,3007.62,2105.334,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures,,
KT LEAD NEURSTM PLTNM-IRDM ELCTRD 60CM STD ACC -,SUP-3777-60,CDM,C1778,HCPCS,278,RC,,,outpatient,,,7193.58,5035.506,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures,,
KT LEAD NEURSTM 60CM PERC CMPCT ACC -,SUP-3778-60,CDM,C1778,HCPCS,278,RC,,,outpatient,,,7193.58,5035.506,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures,,
KT LEAD NEURSTM PLTNM-IRDM ELCTRD PU SLVR COR 75CM PERC -,SUP-3778-75,CDM,C1778,HCPCS,278,RC,,,outpatient,,,7193.58,5035.506,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures,,
LEAD PCNG 56CM TIP PISCES QUAD -,SUP-3887-56,CDM,C1778,HCPCS,278,RC,,,outpatient,,,4498.64,3149.048,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures,,
KT LEAD NEURSTM SPEC FLRPLYMR PLTNM-IRDM SIL RBR PLYSTR PU -,SUP-3956530,CDM,C1778,HCPCS,278,RC,,,outpatient,,,17822.4,12475.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures,,
KT LEAD NEURSTM SPEC 65CM SPIN CRD 5-6-5 LD ACC -,SUP-3956565,CDM,C1778,HCPCS,278,RC,,,outpatient,,,17822.4,12475.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures,,
REACTIV8 IMPLANTABLE LEAD 45CM -,SUP-8145,CDM,C1778,HCPCS,278,RC,,,outpatient,,,11127.86,7789.502,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures,,
STIMULATOR NERVE SPRINT ENDURA PNS SYSTEM -,SUP-9244-6001,CDM,C1778,HCPCS,278,RC,,,outpatient,,,18193.7,12735.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures,,
STIMULATOR NERVE SPRINT EXTENSA PNS SYSTEM -,SUP-9288-6002,CDM,C1778,HCPCS,278,RC,,,outpatient,,,30075.3,21052.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures,,
LEAD NEURSTM VECTRIS SURECAN 60CM PERC IMPL -,SUP-977A260,CDM,C1778,HCPCS,278,RC,,,outpatient,,,8347.95,5843.565,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures,,
SYS PROGRAMMER NEURSTM VECTRIS SURSCN 75CM SPIN CRD CMPCT -,SUP-977A275,CDM,C1778,HCPCS,278,RC,,,outpatient,,,8347.95,5843.565,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures,,
SURESCAN MRI -,SUP-977C165,CDM,C1778,HCPCS,278,RC,,,outpatient,,,20681.41,14476.987,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures,,
LEAD SPECIFY SURESCAN MRI LEAD -,SUP-977C265,CDM,C1778,HCPCS,278,RC,,,outpatient,,,20681.41,14476.987,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures,,
SURESCAN 2 X 8 PADDLE LEAD -,SUP-977C290,CDM,C1778,HCPCS,278,RC,,,outpatient,,,20681.41,14476.987,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures,,
LEAD INTERSTIM MICRO 28CM SSMRI TINED -,SUP-978A128,CDM,C1778,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures,,
INTERSTIM MRI LEAD KIT 2.16MM X 28CM -,SUP-978B128,CDM,C1778,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures,,
LEAD NEUROSTIMULATOR INTERSTIM L41 CM TINE SSMRI -,SUP-978B133,CDM,C1778,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures,,
FREEDOM 4A NEUROSTIMULATOR FR4A-TRL-A0 -,SUP-FR4A-TRL-A0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures,,
FREEDOM 4A NEUROSTIMULATOR FR4A-TRL-B0 -,SUP-FR4A-TRL-B0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures,,
FREEDOM-8A TRIAL KIT CH A US -,SUP-FR8A-TRL-A0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures,,
FREEDOM 8A NEUROSTIMULATOR FR8A-TRL-B0 -,SUP-FR8A-TRL-B0,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures,,
KIT INTELLIS TRIAL LEAD 2 -,SUP-INTELTRIAL2,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures,,
BLUE PERC LEAD KIT -,SUP-LEAD1058-70B,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures,,
NEVRO 70CM SURGICAL LEAD KIT -,SUP-LEAD3005-70B,CDM,C1778,HCPCS,278,RC,,,outpatient,,,10396.4,7277.48,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures,,
KT NEURSTM PRGMR PRECISN ACC -,SUP-M365SC550040,CDM,C1778,HCPCS,278,RC,,,outpatient,,,6196.24,4337.368,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures,,
VECTRIS SURESCAN MRI COMPACT LEAD KIT 1 X 8 SC -,SUP-MEDTRONIC INC,CDM,C1778,HCPCS,278,RC,,,outpatient,,,8347.95,5843.565,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures,,
SLIM TIP DRG -,SUP-MN10450-50A,CDM,C1778,HCPCS,278,RC,,,outpatient,,,9331.07,6531.749,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures,,
SLIMTIP DRG 90A -,SUP-MN10450-90A,CDM,C1778,HCPCS,278,RC,,,outpatient,,,9509.36,6656.552,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures,,
KIT NEUROSTIMULATOR TUNNEL TOOL -,SUP-MN15000,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2572.47,1800.729,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures,,
FREEDOM -4A PNS SYSTEM -,SUP-Q4SP-1-US DW,CDM,C1778,HCPCS,278,RC,,,outpatient,,,40705.5,28493.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures,,
FREEDOM -4A PNS SYSTEM -,SUP-Q4SP-2-US,CDM,C1778,HCPCS,278,RC,,,outpatient,,,44406,31084.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures,,
COVEREDGE 32 MRI PADDLE LEAD 50CM -,SUP-SC-8436-50,CDM,C1778,HCPCS,278,RC,,,outpatient,,,29704,20792.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures,,
TRIAL LEAD KIT -,SUP-TLEAD1058-70B,CDM,C1778,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,150.646235,34103.808,other,Non-Reimbursable Procedures,,
LEAD PCNG 9FRX12MM SPC AV + DX PERMNT BIPLR STRD ELUT TND FX -,SUP-1368,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,2035.392,other,Non-Reimbursable Procedures,,
LEAD PCNG 9FRX12MM SPC 52CM AV + DX PERMNT BIPLR STRD ELUT -,SUP-1368/52,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,2035.392,other,Non-Reimbursable Procedures,,
LEAD PCNG 9FRX12MM SPC 58CM AV + DX PERMNT BIPLR STRD ELUT -,SUP-1368/58,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,2035.392,other,Non-Reimbursable Procedures,,
PACING  LEAD TENDRIL STS 2088TC-65 -,SUP-2088TC-65,CDM,C1779,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,2035.392,other,Non-Reimbursable Procedures,,
LEAD PCNG 58CM SOLOX IMPL BIPLR ECRD SGL -PASS PSS FX -,SUP-333900,CDM,C1779,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,2035.392,other,Non-Reimbursable Procedures,,
MESH SURG LRG 5.4X7IN OVL PP EPTFE CMPSX KL NABSB PTCH -,SUP-0010202,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5029.22,3520.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH SURG SM 3.1X4.7IN OVL MONO PP PDS EPTFE VENTRIO PRT -,SUP-0010211,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3818.72,2673.104,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH SURG LRG 5.4X7IN OVL MONO PP PDS EPTFE VENTRIO PRT ABSB -,SUP-0010212,CDM,C1781,HCPCS,278,RC,,,outpatient,,,7123.55,4986.485,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH SURG 4.5IN LRG CIR MONO PP PDS EPTFE VENTRIO PRT ABSB -,SUP-0010214,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4340.04,3038.028,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH SURG MED 4.3X5.5IN OVL MONO PP PDS EPTFE VENTRIO PRT -,SUP-0010215,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5013.01,3509.107,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH SURG 8CM LRG 3.2X3.2IN CIR PP EPTFE VENTRALEX NABSB -,SUP-0010303,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4167.7,2917.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH PERFIX PLUG MED -,SUP-0112760,CDM,C1781,HCPCS,278,RC,,,outpatient,,,984.1,688.87,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH PERFIX PLUG LRG -,SUP-0112770,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1660.12,1162.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH PLUG PERFIX X-LRG -,SUP-0112780,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1159.39,811.573,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH 3DMAX DAVOL LRG LEFT -,SUP-0115311,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH 3DMAX DAVOL X-LRG LEFT -,SUP-0115312,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1187.9,831.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH 3DMAX DAVOL LRG RIGHT -,SUP-0115321,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH 3DMAX DAVOL X-LRG RIGHT -,SUP-0115322,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1187.9,831.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH MOD KUGEL 3.5 X 5 -,SUP-0115816,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH SURG 4X6IN ELLIP MONO PP EPTFE COMPOSIX E /X NABSB -,SUP-0123460,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2954.63,2068.241,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH ATRIUM 1 X 4 - DISC DO NOT USE -,SUP-1000104-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,116.7,81.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH ATRIUM 2 X 4 -  DISC DO NOT USE -,SUP-1000204-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,128.37,89.859,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH ATRIUM 6X6 - DISCONTINUED DO NOT USE -,SUP-1000606-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,163.38,114.366,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH ATRIUM 6 X 6 - DO NOT USE DISCONTINUED -,SUP-1000606-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,163.38,114.366,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH SURG 10X14IN PP KNTD PROLITE NABSB SHT -,SUP-1001014-00,CDM,C1781,HCPCS,278,RC,,,outpatient,,,478.47,334.929,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH ATRIUM PRE SHAPED -,SUP-1010306-02,CDM,C1781,HCPCS,278,RC,,,outpatient,,,192.56,134.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH SURG 20X30CM RECT EPTFE GORE-TEX PTCH -,SUP-1320030020,CDM,C1781,HCPCS,278,RC,,,outpatient,,,18928.87,13250.209,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH SURG 5X10CM EPTFE GORE-TEX PTCH -,SUP-1405010010,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1754.47,1228.129,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH SURG 10X15CM OVL EPTFE GORE-TEX PLG -,SUP-1410015010,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4014.93,2810.451,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
IMPLANT ARTELON 0.3X16CM -,SUP-31052,CDM,C1781,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
IMPLANT ARTELON 0.7X16CM -,SUP-31056,CDM,C1781,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH PROLENE 3D PATCH LRG -,SUP-3DPL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3399.12,2379.384,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH PROLENE 3D PATCH MED -,SUP-3DPM,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3399.12,2379.384,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH RESTORELLE 24CM X 4CM -,SUP-501420,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4419.28,3093.496,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH VENTRALEX ST SM 4.3CM -,SUP-5950007,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2292.25,1604.575,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH VENTRALEX ST MD 6.4CM -,SUP-5950008,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2488.78,1742.146,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH VENTRALEX ST LRG 8.0CM -,SUP-5950009,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3167.55,2217.285,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH SURG 3IN SM CIR MONO PP CO-KNTD VENTRALEX ST ECHO PS -,SUP-5950010,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3765.73,2636.011,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH SURG SM 3.1X4.7IN OVL MONO PP CO-KNTD VENTRALEX ST ECHO -,SUP-5950030,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4634.12,3243.884,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH SURG MED 4.3.X5.5IN OVL MONO PP CO-KNTD VENTRALEX ST -,SUP-5950040,CDM,C1781,HCPCS,278,RC,,,outpatient,,,6128.34,4289.838,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH SURG XL 8.7X10.7IN OVL MONO PP PTFE HYDRGL CO-KNTD -,SUP-5950080,CDM,C1781,HCPCS,278,RC,,,outpatient,,,12018.24,8412.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH SURG 4X6IN ELLIP MONO PP PTFE HYDRGL CO-KNTD -,SUP-5954460,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3720.86,2604.602,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH SURG 15CM MED RND ACCUMESH PSTN -,SUP-AMPPCO15X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3904.18,2732.926,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH SURG 20CM MED RND ACCUMESH PSTN -,SUP-AMPPCO20X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4655.67,3258.969,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH PARIETEX 15CM X 10CM RT -,SUP-AUTO-VTX1510,CDM,C1781,HCPCS,278,RC,,,outpatient,,,465.28,325.696,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH DEXTILE MEDIUM LEFT 13 X 9CM ANATOMICAL -,SUP-DXT1309AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH DEXTILE MEDIUM RIGHT 13 X 9CM ANATOMICAL -,SUP-DXT1309AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,787.73,551.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH DEXTILE LARGE LEFT 15 X 10CM ANATOMICAL -,SUP-DXT1510AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,846.08,592.256,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH DEXTILE LARGE RIGHT 15 X 10CM ANATOMICAL -,SUP-DXT1510AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,846.08,592.256,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH DEXTILE XL LEFT 16 X 12CM ANATOMICAL -,SUP-DXT1612AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH DEXTILE XL RIGHT 16 X 12CM ANATOMICAL -,SUP-DXT1612AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
PATCH BOVINE 0.8 X 8CM -,SUP-E0.8P8,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1160.81,812.567,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
PATCH BOVINE 2.0 X 9CM -,SUP-E2P9,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2008.89,1406.223,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
GORE BIOABSORBABLE SYNTHETIC MESH 7CM X 10CM -,SUP-HH0710,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH LAP PROGRIP 15 X 10 -,SUP-LPG1510,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1664.57,1165.199,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH PROGRIP ANATOM 15x10 L -,SUP-LPG1510AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1878.87,1315.209,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH PROGRIP ANATOM 15x10 R -,SUP-LPG1510AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1878.87,1315.209,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH PROGRIP LAPAROSCOPIC SELF-FIX 16 X 12 -,SUP-LPG1612,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1888.04,1321.628,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH PROGRIP ANATOM 16X12 L -,SUP-LPG1612AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2098.94,1469.258,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH PROGRIP ANATOMICAL RIGHT 16CM X 12CM -,SUP-LPG1612AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2098.94,1469.258,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
UPSYLON TRADITIONAL Y MESH -,SUP-M0068318200,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4180.97,2926.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH PROCEED 6IN X 8IN -,SUP-PCDG1,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4886.8,3420.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH PROCEED 4IN X 6IN -,SUP-PCDN1,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2936.68,2055.676,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
IMPLANT BIO TISS 10X15CM 3D RND PLYSTR PRCN COLL OPN SKRT -,SUP-PCO1510OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2440.67,1708.469,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
IMPLANT PLYSTR PRCN COLL 10X15CM PRTX 1.7MM ABSB 3D RND KNTD -,SUP-PCO1510X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1920.48,1344.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
IMPLANT BIO TISS 15CM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCO15X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2513.71,1759.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
IMPLANT BIO TISS 15X20CM 3D RECT PLYSTR PRCN COLL KNTD PRTX -,SUP-PCO2015OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3387.39,2371.173,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
IMPLANT BIO TISS 15X20CM 3D RND PLYSTR PRCN COLL KNTD PRTX -,SUP-PCO2015X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3237.25,2266.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH PARIETEX HEART SHAPED -,SUP-PCO2H1,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1862.49,1303.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH PARIETEX HORSE SHOE -,SUP-PCO2H3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1999.72,1399.804,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
IMPLANT BIO TISS 20X30CM 3D RECT PLYSTR PRCN COLL KNTD PRTX -,SUP-PCO3020X,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5125.65,3587.955,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
PATCH VENTRAL PARITEX 4.6CM -,SUP-PCO4VP,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1712.49,1198.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
PATCH VENTRAL PARITEX 6.6CM -,SUP-PCO6VP,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2052.19,1436.533,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
IMPLANT BIO TISS 8CM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCO8OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2128.52,1489.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
IMPLANT BIO TISS 8CM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCO8OSX,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2365.35,1655.745,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
PATCH VENTRAL PARITEX 8.6CM -,SUP-PCO8VP,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2635.99,1845.193,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
IMPLANT BIO TISS 50MM 3D RND PLYSTR PRCN COLL KNTD PRTX ABSB -,SUP-PCOPM15H50,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2579.06,1805.342,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH PROLENE HERNIA SYSTEM LARGE -,SUP-PHSL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2038.93,1427.251,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH PROLENE HERNIA SYSTEM MEDIUM -,SUP-PHSM,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2038.93,1427.251,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH PARIENTENE PROGRIP 15CM X 9CM -,SUP-PP1509G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1083.58,758.506,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH PARITENE MACROPOROUS 15 X 10 -,SUP-PPM1510X3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,223.71,156.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH PARITENE MACROPOROUS 15 X 15 -,SUP-PPM1515X3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,259.54,181.678,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH PARIETENE 20 X 20 -,SUP-PPM2020,CDM,C1781,HCPCS,278,RC,,,outpatient,,,301.09,210.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH PARIETENE 30 X 30 -,SUP-PPM3030,CDM,C1781,HCPCS,278,RC,,,outpatient,,,563.14,394.198,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH PARIETENE 45 X 30 -,SUP-PPM4530,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1191.23,833.861,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
DURASORB PTM 0616 6 X 16 -,SUP-PTM 0616,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
DURASORB PTM1 025 10 X 25 -,SUP-PTM1025,CDM,C1781,HCPCS,278,RC,,,outpatient,,,9653.8,6757.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
DURASORB PTM 2025 -,SUP-PTM2025,CDM,C1781,HCPCS,278,RC,,,outpatient,,,20050.2,14035.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH SURG 6X11CM RECT PLYSTR KNTD MERSILN NABSB SHT -,SUP-RMS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,992.11,694.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH SYMBOTEX 25 X 20 0118362 -,SUP-SMY2520OS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,6454.57,4518.199,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH SYMBOTEX VENTRAL 12CM -,SUP-SYM12,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1989.6,1392.72,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH SYMBOTEX VENTRAL 15CM -,SUP-SYM15,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2490.4,1743.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH SYMBOTEX VENTRAL 15CM -,SUP-SYM15,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2571.48,1800.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH SYMBOTEX VENTRAL 15 X 10 NON SKIRTED -,SUP-SYM1510,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1808.74,1266.118,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH SYMBOTEX 15 X 10 -,SUP-SYM1510OS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2418.08,1692.656,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH SYMBOTEX 2012E -,SUP-SYM2012E,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2774.79,1942.353,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH SYMBOTEX 20 X 15 CM -,SUP-SYM2015,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2613.29,1829.303,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH SYMBOTEX 20 X 15 SKIRTED -,SUP-SYM2015OS,CDM,C1781,HCPCS,278,RC,,,outpatient,,,3726.15,2608.305,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH SURG 25X15CM ELLIP MONO PLYSTR COLL SYMBOTEX NABSB -,SUP-SYM2515E,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4592.69,3214.883,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH PARIETENE DS COMPOSITE 25CM X 20CM -,SUP-SYM2520,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4274.74,2992.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH SYMBOTEX 25 X 20 -,SUP-SYM2520,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4118.24,2882.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH SYMBOTEX 30 X 20 -,SUP-SYM3020,CDM,C1781,HCPCS,278,RC,,,outpatient,,,5381.94,3767.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH SYMBOTEX COMPOSITE -,SUP-SYM3728,CDM,C1781,HCPCS,278,RC,,,outpatient,,,6391.04,4473.728,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
Symbotexâ„¢ Composite Mesh- 42 x 32 cm -,SUP-SYM4232,CDM,C1781,HCPCS,278,RC,,,outpatient,,,7515.87,5261.109,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH SYMBOTEX VENTRAL 9CM -,SUP-SYM9,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1450.75,1015.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH SURG 10X15CM PLYSTR KNTD PRTX SHT -,SUP-TECT1510ADPL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,734.63,514.241,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
"MESH PARIETEX ANATOMICAL LEFT 6X4"" -",SUP-TECT1510AL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,648.04,453.628,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
"MESH PARIETEX ANATOMICAL RIGHT 6X4"" -",SUP-TECT1510AR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,648.04,453.628,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH SURG 8X12CM MONO PLYSTR KNTD PRTX PROGRIP PRT -,SUP-TEM1208GL,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1175.76,823.032,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH SURG 8X12CM MONO PLYSTR KNTD PRTX PROGRIP PRT ABSB -,SUP-TEM1208GR,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1175.76,823.032,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH PARIETEX PROGRIP 15cm x 9cm -,SUP-TEM1509G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1083.58,758.506,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH PARIETEX PROGRIP 15 X 15CM -,SUP-TEM1515G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1131.55,792.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH PARIETEX PROGRIP 20X15 -,SUP-TEM2015G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1382.48,967.736,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH PARIETEX PROGRIP 30X15 -,SUP-TEM3015G,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1925.62,1347.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH SURG 30X30CM 3D PLYSTR KNTD PRTX EASEGRIP SHT -,SUP-TET3030,CDM,C1781,HCPCS,278,RC,,,outpatient,,,1054.85,738.395,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH SURG 3X6IN RECT MONO PLGCPRN-25 PP KNTD ULTRAPRO PRT -,SUP-UMR3,CDM,C1781,HCPCS,278,RC,,,outpatient,,,908.96,636.272,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
GRAFT HEMASHIELD 10MM X100CM G -,SUP-UNDEFINED,CDM,C1781,HCPCS,278,RC,,,outpatient,,,2550.8,1785.56,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH VENTRIO XL 10 X 13 -,SUP-UNDEFINED,CDM,C1781,HCPCS,278,RC,,,outpatient,,,8233.36,5763.352,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
MESH VICRYL WOVEN FLAT12IN x 12IN ABSORBABLE HERNIA REPAIR -,SUP-VWML,CDM,C1781,HCPCS,278,RC,,,outpatient,,,4702.1,3291.47,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,15398.5536,other,Non-Reimbursable Procedures,,
STENT DES 2.25X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332220,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,200.09685,4563.1488,percent of total billed charges,,,
STENT DES 2.5X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332250,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,200.09685,4563.1488,percent of total billed charges,,,
STENT DES 3X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332300,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,200.09685,4563.1488,percent of total billed charges,,,
STENT DES 3.5X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332350,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,200.09685,4563.1488,percent of total billed charges,,,
STENT DES 4X32MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902332400,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,200.09685,4563.1488,percent of total billed charges,,,
STENT DES 2.75X38MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902338270,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,200.09685,4563.1488,percent of total billed charges,,,
STENT DES 3.5X38MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902338350,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,200.09685,4563.1488,percent of total billed charges,,,
STENT DES 4X38MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902338400,CDM,C1784,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1537.09192,200.09685,4563.1488,percent of total billed charges,,,
IMPLANT BIO TISS 6.5CM 3D RND PLYSTR PRCN COLL KNTD PRTX -,SUP-PNP6X3,CDM,C1784,HCPCS,278,RC,,,outpatient,,,891.3,623.91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,230.57931,200.09685,4563.1488,percent of total billed charges,,,
PACEMAKER UNIPL BIPLR INSGA I ULTRA 2CHMBR RR 10.8ML 25.4GM -,SUP-1290,CDM,C1785,HCPCS,275,RC,,,outpatient,,,21052.71,14736.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5446.336077,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER UNIPL BIPLR EVIA 2CHMBR 44.5X53MM 6.5MM 12ML 25GM -,SUP-359529,CDM,C1785,HCPCS,275,RC,,,outpatient,,,11220.69,7854.483,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2902.792503,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER UNIPL BIPLR EVIA 2CHMBR RR 44.5X53MM 6.5MM 12ML -,SUP-377848,CDM,C1785,HCPCS,275,RC,,,outpatient,,,14573.53,10201.471,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3770.172211,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER IMPL ENTOVIS PROMRI 2CHMBR IS-1 CONN SR-T ACC -,SUP-404722,CDM,C1785,HCPCS,275,RC,,,outpatient,,,18565,12995.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4802.7655,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER IMPL UNIPL VERITY ADX MS DR 2CHMBR RR 45X52MM 6MM -,SUP-5357M/S,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9332.85,6532.995,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2414.408295,399.86,21372.62592,percent of total billed charges,,,
GENERATOR TEMP PLS 2CHMBR 5392 ACC -,SUP-5392KIT,CDM,C1785,HCPCS,275,RC,,,outpatient,,,27828.94,19480.258,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7199.346778,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER IMPL UNIPL BIPLR VCT DR 2CHMBR RR V- PCNG RDC -,SUP-5810,CDM,C1785,HCPCS,275,RC,,,outpatient,,,13842.06,9689.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3580.940922,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER IMPL UNIPL BIPLR VCT XL DR 2CHMBR RR V- PCNG RDC -,SUP-5816,CDM,C1785,HCPCS,275,RC,,,outpatient,,,13842.06,9689.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3580.940922,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER IMPL UNIPL BIPLR ZPHR 2CHMBR RR 43X44MM 6MM 8.5ML -,SUP-5820,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9332.85,6532.995,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2414.408295,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER IMPL UNIPL BIPLR ZPHR 2CHMBR RR 43X44MM 6MM 8.5ML -,SUP-5820,CDM,C1785,HCPCS,275,RC,,,outpatient,,,22278,15594.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5763.3186,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER IMPL UNIPL BIPLR ZPHR DR 2CHMBR RR 44X52MM 6MM -,SUP-5826,CDM,C1785,HCPCS,275,RC,,,outpatient,,,18565,12995.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4802.7655,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER IMPL SURSCN ADVISA 2CHMBR RR MUL-PRGM IS-1 CONN SR -,SUP-A2DR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16337.2,11436.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4226.43364,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER IMPL UNIPL ADAPTA DR 2CHMBR RR 12ML 21GM IS-1 -,SUP-ADAPTADRK2,CDM,C1785,HCPCS,275,RC,,,outpatient,,,27828.94,19480.258,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7199.346778,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER IMPL BIPLR ADAPT 2CHMBR RR 13.1ML 31.3GM IS-1 CONN -,SUP-ADDRL1,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16567.96,11597.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4286.131252,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER IMPL UNIPL BIPLR ADAPTA 2CHMBR RR 42.9MMX44.7MM -,SUP-ADDRS1,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16567.96,11597.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4286.131252,399.86,21372.62592,percent of total billed charges,,,
GENERATOR 2CHMBR -,SUP-DR2550,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16708.5,11695.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4322.48895,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER ESSENTIO DR DYNMC ADJ TI ACC -,SUP-L101,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9341.91,6539.337,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2416.752117,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER ESSENTIO DR MRI L111 -,SUP-L111,CDM,C1785,HCPCS,275,RC,,,outpatient,,,12460.83,8722.581,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3223.616721,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER IMPL ESSENTIO EL DR 2CHMBR 4.45X5.88X0.75IN 29.1GM -,SUP-L121,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9341.91,6539.337,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2416.752117,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER ACCOLADE DR -REF: L301 -,SUP-L301,CDM,C1785,HCPCS,275,RC,,,outpatient,,,9442.9,6610.03,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2442.87823,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER ACCOLADE MRI DR L311 -,SUP-L311,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10582.05,7407.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2737.576335,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER IMPL UNIPL BIPLR ACCENT DR 2CHMBR RR WRLS TELEM -,SUP-PM2110,CDM,C1785,HCPCS,275,RC,,,outpatient,,,12438.55,8706.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3217.852885,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER ENDURITY 2CHMBR 50X46MM 6MM 10.4ML 19GM IS-1 CONN -,SUP-PM2160,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10470.66,7329.462,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2708.759742,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER IMPL ACCENT DR 2CHMBR RR 52X52MM 6MM 12.8ML 23GM -,SUP-PM2210,CDM,C1785,HCPCS,275,RC,,,outpatient,,,12438.55,8706.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3217.852885,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER IMPL ASSURITY 2CHMBR RR 50X47MM 6MM 10.4ML 20GM -,SUP-PM2240,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10732.43,7512.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2776.479641,399.86,21372.62592,percent of total billed charges,,,
ASSURITY MRI PACEMAKER DR-RF PM2272 -,SUP-PM2272,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10582.05,7407.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2737.576335,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER IMPL BIPLR REVO 2CHMBR RR SURSCN PCNG -,SUP-REVOMRIPEEM,CDM,C1785,HCPCS,275,RC,,,outpatient,,,23622.66,16535.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6111.182142,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER IMPL BIPLR REVO SURSCN 2CHMBR RR 45X51X8MM 12.7ML -,SUP-RVDR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,17439.96,12207.972,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4511.717652,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER ALTRUA 20 DDDR MUL-PRGM 43X49X8MM 29.6GM 12.6ML -,SUP-S202,CDM,C1785,HCPCS,275,RC,,,outpatient,,,17451.1,12215.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4514.59957,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER ALTRUA 20 MUL-PRGM 42X44X8MM 25.4GM 10.8ML IS-1 -,SUP-S203,CDM,C1785,HCPCS,275,RC,,,outpatient,,,14373.02,10061.114,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3718.300274,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER BIPLR ALTRUA 60 2CHMBR RR 42X44MM 8MM 10.8ML -,SUP-S603,CDM,C1785,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4034.32302,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER IMPL UNIPL BIPLR SENSIA 2CHMBR RR -,SUP-SEDR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10396.4,7277.48,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2689.54868,399.86,21372.62592,percent of total billed charges,,,
GENERATOR VERSA DUAL CHAMBER -,SUP-UNDEFINED,CDM,C1785,HCPCS,275,RC,,,outpatient,,,20402.94,14282.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5278.240578,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER ALTRUA 20 DR 2 LD -,SUP-UNDEFINED,CDM,C1785,HCPCS,275,RC,,,outpatient,,,19827.42,13879.194,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5129.353554,399.86,21372.62592,percent of total billed charges,,,
VERSA DR VEDR01 -,SUP-VEDR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,10396.4,7277.48,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2689.54868,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER MRI AZURE XT DR SURESCAN -,SUP-W1DR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,18565,12995.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4802.7655,399.86,21372.62592,percent of total billed charges,,,
Azure S DR MRI Surescan W3DR01 -,SUP-W3DR01,CDM,C1785,HCPCS,275,RC,,,outpatient,,,16708.5,11695.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4322.48895,399.86,21372.62592,percent of total billed charges,,,
PACEMAKER BIPLR INSGA ULTRA SR SGL-CHMBR RR 10ML 23.4GM IS-1 -,SUP-1190,CDM,C1786,HCPCS,275,RC,,,outpatient,,,17451.1,12215.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4514.59957,399.86,46489.17504,percent of total billed charges,,,
PACEMAKER RELAY INTMD UNIPL CARD 5MM -,SUP-293-03,CDM,C1786,HCPCS,275,RC,,,outpatient,,,16151.55,11306.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4178.405985,399.86,46489.17504,percent of total billed charges,,,
PACEMAKER UNIPL BIPLR EVIA SR-T SGL-CHMBR RR 39X53MM 6.5MM -,SUP-359 533,CDM,C1786,HCPCS,275,RC,,,outpatient,,,10983.05,7688.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2841.315035,399.86,46489.17504,percent of total billed charges,,,
PACEMAKER IMPL ENTOVIS SR-T PROMRI SGL-CHMBR ACC -,SUP-404723,CDM,C1786,HCPCS,275,RC,,,outpatient,,,10457.22,7320.054,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2705.282814,399.86,46489.17504,percent of total billed charges,,,
GENERATOR IMPL VERF SGL-CHMBR -,SUP-5156,CDM,C1786,HCPCS,275,RC,,,outpatient,,,11792.49,8254.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3050.717163,399.86,46489.17504,percent of total billed charges,,,
PACEMAKER IMPL UNIPL VERITY ADX MS DR SGL-CHMBR RR 42X52MM -,SUP-5157M/S,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8533.24,5973.268,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2207.549188,399.86,46489.17504,percent of total billed charges,,,
PACEMAKER IMPL UNIPL BIPLR ZPHR SGL-CHMBR RR 41X44MM 6MM 8ML -,SUP-5620,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8533.24,5973.268,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2207.549188,399.86,46489.17504,percent of total billed charges,,,
PACEMAKER IMPL UNIPL BIPLR ZPHR XL SR SGL-CHMBR RR 52X42MM -,SUP-5626,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8533.24,5973.268,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2207.549188,399.86,46489.17504,percent of total billed charges,,,
PACEMAKER IMPL SURSCN ADVISA 1CHMBR IS-1 CONN SR -,SUP-A3SR01,CDM,C1786,HCPCS,275,RC,,,outpatient,,,14852,10396.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3842.2124,399.86,46489.17504,percent of total billed charges,,,
PACEMAKER IMPL UNIPL ADAPTA SR SGL-CHMBR RR 7.5MM 11ML -,SUP-ADSR06,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9952.18,6966.526,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2574.628966,399.86,46489.17504,percent of total billed charges,,,
GENERATOR PCMKR  SR SSIR -,SUP-ICV1122,CDM,C1786,HCPCS,275,RC,,,outpatient,,,12497.96,8748.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3233.222252,399.86,46489.17504,percent of total billed charges,,,
ESSENTIO 4.45X4.81X0.75 CM D 13.2ML TI -,SUP-L100,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8899.67,6229.769,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2302.344629,399.86,46489.17504,percent of total billed charges,,,
PACEMAKER ESSENTIO SR MRI -,SUP-L110,CDM,C1786,HCPCS,275,RC,,,outpatient,,,10901.37,7630.959,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2820.184419,399.86,46489.17504,percent of total billed charges,,,
PACEMAKER ACCOLADE SR -REF: L300 -,SUP-L300,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,399.86,46489.17504,percent of total billed charges,,,
ACCOLADE MRI SR PACEMAKER L310 -,SUP-L310,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,399.86,46489.17504,percent of total billed charges,,,
PACEMAKER LEADLESS SINGLE AVEIR RV REF: LSP112V -,SUP-LSP112V,CDM,C1786,HCPCS,275,RC,,,outpatient,,,37130,25991,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9605.531,399.86,46489.17504,percent of total billed charges,,,
MICRA MDT TRANSCATHER PACING MICRA SYSTEM -,SUP-MC1VR01,CDM,C1786,HCPCS,275,RC,,,outpatient,,,26520.25,18564.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6860.788675,399.86,46489.17504,percent of total billed charges,,,
MICRA AV TRANSCATHETER  MC1AVR1 -,SUP-MICRAAVTCPSYSTEM,CDM,C1786,HCPCS,275,RC,,,outpatient,,,38855.25,27198.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10051.85318,399.86,46489.17504,percent of total billed charges,,,
TRANSCATHETER PACING SYSTEM INC:CAPSULEDELIV CATHINTROD -,SUP-MICRATCPSYSTEM,CDM,C1786,HCPCS,275,RC,,,outpatient,,,26520.25,18564.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6860.788675,399.86,46489.17504,percent of total billed charges,,,
PACEMAKER IMPL UNIPL BIPLR ACCENT SR SGL-CHMBR RR WRLS TELEM -,SUP-PM1110,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9375.33,6562.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2425.397871,399.86,46489.17504,percent of total billed charges,,,
PACEMAKER ENDURITY SGL-CHMBR 50X41X6MM 6MM 19GM 9.7ML IS-1 -,SUP-PM1160,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,399.86,46489.17504,percent of total billed charges,,,
PACEMAKER IMPL UNIPL BIPLR ACCENT SR SGL-CHMBR RR WRLS TELEM -,SUP-PM1210,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9375.33,6562.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2425.397871,399.86,46489.17504,percent of total billed charges,,,
PACEMAKER IMPL ASSURITY SGL-CHMBR RR 50X47MM 6MM 10.4ML 20GM -,SUP-PM1240,CDM,C1786,HCPCS,275,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2250.74174,399.86,46489.17504,percent of total billed charges,,,
ASSURITY MRI PACEMAKER SR-RF -,SUP-PM1272,CDM,C1786,HCPCS,275,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,399.86,46489.17504,percent of total billed charges,,,
PACEMAKER ALTRUA 40 SR SGL-CHMBR RR 42X42X8MM 10ML 23.4GM -,SUP-S401,CDM,C1786,HCPCS,275,RC,,,outpatient,,,12887.82,9021.474,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3334.079034,399.86,46489.17504,percent of total billed charges,,,
SYS ADAPTER PCMKR F/SR -,SUP-UNDEFINED,CDM,C1786,HCPCS,275,RC,,,outpatient,,,23744.64,16621.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6142.738368,399.86,46489.17504,percent of total billed charges,,,
DEFIBRILLATOR VIVA QUAD S CRTN -,SUP-VIVA QUAD S CRT-D,CDM,C1786,HCPCS,275,RC,,,outpatient,,,60532.78,42372.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15659.83019,399.86,46489.17504,percent of total billed charges,,,
Azure S SR NRI SureScan W3SR01 -,SUP-W3SR01,CDM,C1786,HCPCS,275,RC,,,outpatient,,,16708.5,11695.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4322.48895,399.86,46489.17504,percent of total billed charges,,,
GENERATOR PROCLAIM 7 ELITE -,SUP-3662,CDM,C1787,HCPCS,272,RC,,,outpatient,,,40409.46,28286.622,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10453.9273,399.86,28973.58282,percent of total billed charges,,,
PROGRAMMER NEURSTM MYSTIM HNDHLD DVC -,SUP-377-44,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4606.91,3224.837,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1191.807617,399.86,28973.58282,percent of total billed charges,,,
PROGRAMMER NEURSTM MYSTIM 2.2X3.7X1.1IN -,SUP-377-46,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4606.91,3224.837,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1191.807617,399.86,28973.58282,percent of total billed charges,,,
PROGRAMMER NEURSTM IMMG-LN -,SUP-3852,CDM,C1787,HCPCS,272,RC,,,outpatient,,,2517.74,1762.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,651.339338,399.86,28973.58282,percent of total billed charges,,,
PRODIGY 3856 -,SUP-3856,CDM,C1787,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,399.86,28973.58282,percent of total billed charges,,,
PROCLAIM DRG CONTROLLER LEAD -,SUP-7883,CDM,C1787,HCPCS,272,RC,,,outpatient,,,6212.96,4349.072,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1607.292752,399.86,28973.58282,percent of total billed charges,,,
PROGRAMMER PATIENT 97740 -,SUP-97740,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4507.13,3154.991,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1165.994531,399.86,28973.58282,percent of total billed charges,,,
CONTROLLER 97745NT INTELLIS PTM NONTRIAL -,SUP-97745NT,CDM,C1787,HCPCS,272,RC,,,outpatient,,,4507.13,3154.991,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1165.994531,399.86,28973.58282,percent of total billed charges,,,
INTERSTIM KIT COMM W/HANDSET GU US -,SUP-TH90Q01,CDM,C1787,HCPCS,272,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1756.67648,399.86,28973.58282,percent of total billed charges,,,
PORT IMPLINFN NPWR 8FRX1.6MM ID 12.7MM X- PRT ISP PU LF -,SUP-0607540,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1620.15,1134.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures,,
PORT IMPLINFN NPWR 9.5FR CATH X- PRT PLST PRT LF MRI-COND -,SUP-0607675,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2417.77,1692.439,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures,,
PORT POWER LOW PROFILE 8F -,SUP-1708060,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2318.07,1622.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures,,
PORT IMPLINFN PWR INJ 6FR CATH PWR PRT TI LF 1LUM -,SUP-1716000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2242.11,1569.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures,,
PORT IMPLINFN PWR INJ 8FR CATH PWR PRT M R I ISP PU LF 1LUM -,SUP-1808000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2243.33,1570.331,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures,,
PORT POWER 8F #1808000 -,SUP-1808000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2243.33,1570.331,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures,,
PORT INFS 9FR CATH PWR PRT DUO M R I PLST LF LUMX2 -,SUP-1829500,CDM,C1788,HCPCS,278,RC,,,outpatient,,,2559.29,1791.503,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures,,
KT NEEDLE INFS 20GAX1IN POWERLOC PRT ACCESS SAFTY YST NACL -,SUP-2672010,CDM,C1788,HCPCS,278,RC,,,outpatient,,,99.2,69.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures,,
PORT INFS PWR INJ 8FR CATH PWR PRT VUE ISP PU CATH LF -,SUP-5608062,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1261.52,883.064,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures,,
PORT INFS 8FR MRI-SF PWR SLIM -,SUP-5618000,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1261.52,883.064,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures,,
TRY CV LUMX2 9.5FRX60CM GRSHNG LF ACC -,SUP-7726952,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1902.88,1332.016,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures,,
CATH INFS PRT 6.6FR SMRT PRT CT TI /CARBOTHAN/ PU LPRO INJ -,SUP-CT66LTPD,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures,,
CATH INFS PRT 8FR SMRT PRT CT TI/SIL INJ -,SUP-CT75STSD,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures,,
CATH INFS PRT 8FR SMRT PRT CT FLUOROMAX TI/PU INJ -,SUP-CT80STPD,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures,,
CATH INFS PRT 6.6FR MINI SMRT PRT CT TI /CARBOTHAN/ PU INJ -,SUP-H787CT66PTPD0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures,,
SMARTPORT PLASTIC W/VORTEX TECH IF FILLED DETATCHED -,SUP-H787CT80LPPDVI0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures,,
CATH INFS PRT 9.6FR SMRT PRT CT FLUOROMAX TI/SIL INJ -,SUP-H787CT96STSD0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1245.62,871.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures,,
CATH INFS PRT 12/11.4 FR DIA INTRO/CATH VORT LP TI SIL DL -,SUP-H787LVTX52130,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1669.66,1168.762,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures,,
PORT IMPLINFN 8FR INTRO 7.2FR CATH VORT VX TI SIL LF -,SUP-H787P12355K0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1137.83,796.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures,,
PORT VORTEX VASC 9.6 -,SUP-H787P5455K0,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1457.64,1020.348,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures,,
PORT XCELA PLUS POWER INDECTABLE 8F FILLED DETATCHED -,SUP-H965440320,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures,,
PORT INFS 8FR MED DIGNITY -,SUP-MRDP80AMS,CDM,C1788,HCPCS,278,RC,,,outpatient,,,1404.63,983.241,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,22.2704,1965.53472,other,Non-Reimbursable Procedures,,
EXPANDER TISSUE SMOOTH 600CC NATRELLE FULL HT VAR -,SUP-133S-FV-14-T,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BRST 397ML 13.1CM NATRLL 4.2CM PRJCT -,SUP-15-397,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BRST 125ML SIL GEL MOD+ RND 8.9CM MEMORYGEL 2.8CM -,SUP-350-1251BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1080.654575,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BRST SIL GEL MOD+ RND 150CC -,SUP-350-1501BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BRST 175ML SIL GEL MOD+ RND 10CM MEMORYGEL 3.1CM -,SUP-350-1751BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1080.654575,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BRST 200ML SIL GEL MOD+ RND 10.5CM MEMORYGEL 3.2CM -,SUP-350-2001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1080.654575,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BRST 350-420ML SAL MOD+ RND 12.1-11.7CM MENTOR -,SUP-350-2350,CDM,C1789,HCPCS,278,RC,,,outpatient,,,2597.25,1818.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,671.908575,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BRST 250ML SIL GEL HPRO RND 10.5CM MEMORYGEL 4.3CM -,SUP-350-2504BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1148.581434,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BRST 600ML SIL GEL MOD+ RND 15CM MEMORYGEL 4.6CM -,SUP-350-6001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4320.47,3024.329,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1117.705589,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BRST 650ML SIL GEL MOD+ RND 15.4CM MEMORYGEL 4.7CM -,SUP-350-6501BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4320.47,3024.329,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1117.705589,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BRST 650ML SIL GEL HPRO RND 14.4CM MEMORYGEL 5.7CM -,SUP-350-6504BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1148.581434,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BRST 700ML SIL GEL MOD+ RND 15.8CM MEMORYGEL 4.9CM -,SUP-350-7001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4320.47,3024.329,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1117.705589,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BRST 130ML SIL GEL MOD CLASS RND 9.6CM MEMORYGEL -,SUP-350-7130MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BRST 150ML SIL GEL MOD CLASS RND 10.3CM MEMORYGEL -,SUP-350-7150MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BRST SIL GEL MOD+ RND CLSSC 190CC -,SUP-350-7190MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BRST SIL GEL MOD+ RND CLSSC 215CC -,SUP-350-7215MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4201.12,2940.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.829744,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BRST 750ML SIL GEL MOD CLASS RND 16.1CM MEMORYGEL -,SUP-350-7501BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1080.654575,261.9915,4400.1792,percent of total billed charges,,,
BREAST IMPLANT SMOOTH ROUND MODERATE 750CC -,SUP-350-7750MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,261.9915,4400.1792,percent of total billed charges,,,
BREAST IMPLANT SMOOTH ROUND MODERATE 800CC -,SUP-350-7800MC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.02704,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BRST 800ML SIL GEL HPRO RND 16.5CM MEMORYGEL 5.1CM -,SUP-350-8001BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1080.654575,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BRST 800ML SIL GEL HPRO RND 15.5CM MEMORYGEL 6CM -,SUP-350-8004BC,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1148.581434,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BRST 330-350ML SIL SAL BIOCELL PTOTIC SHP NATRLL -,SUP-363LF-330,CDM,C1789,HCPCS,278,RC,,,outpatient,,,3628.24,2539.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,938.625688,261.9915,4400.1792,percent of total billed charges,,,
NATRELLE SALINE FILLED SMOOTH ROUND IMLANTS 640CC -,SUP-68HP-600,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1637.85,1146.495,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,423.711795,261.9915,4400.1792,percent of total billed charges,,,
NATRELLE SMOOTH ROUND SALINE IMPLANTS 68LP-225 -,SUP-68LP-225,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,261.9915,4400.1792,percent of total billed charges,,,
NATRELLE SMOOTH ROUND SALINE IMPLANTS 250CC -,SUP-68LP-250,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,261.9915,4400.1792,percent of total billed charges,,,
NATRELLE SMOOTH ROUND SALINE IMPLANTS 275CC -,SUP-68LP-275,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1590.15,1113.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.371805,261.9915,4400.1792,percent of total billed charges,,,
SIZER IMPLANT NATRELLE INSPIRA 295CC FULL PROFILE -,SUP-MSZ-F295,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,301.9029,261.9915,4400.1792,percent of total billed charges,,,
SIZER NATRELLE INSPIRA 335CC FULL -,SUP-MSZ-F335,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,301.9029,261.9915,4400.1792,percent of total billed charges,,,
SIZER IMPLANT NATRELLE INSPIRA 650CC FULL PROFILE -,SUP-MSZ-F650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,301.9029,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 200CC NATRELLE INSPIRA FULL -,SUP-SCF-200,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 240CC NATRELLE INSPIRA FULL -,SUP-SCF-240,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 265CC NATRELLE INSPIRA FULL -,SUP-SCF-265,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 295CC NATRELLE INSPIRA FULL -,SUP-SCF-295,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 335CC NATRELLE INSPIRA FULL -,SUP-SCF-335,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 345CC NATRELLE INSPIRA FULL -,SUP-SCF-345,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 365CC NATRELLE INSPIRA FULL -,SUP-SCF-365,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 385CC NATRELLE INSPIRA FULL -,SUP-SCF-385,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 415CC NATRELLE INSPIRA FULL -,SUP-SCF-415,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 450CC NATRELLE INSPIRA FULL -,SUP-SCF-450,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 485CC NATRELLE INSPIRA FULL -,SUP-SCF-485,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4787.23,3351.061,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1238.456401,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 520CC NATRELLE INSPIRA FULL -,SUP-SCF-520,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 560CC NATRELLE INSPIRA FULL -,SUP-SCF-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 605CC NATRELLE INSPIRA FULL -,SUP-SCF-605,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5623.3,3936.31,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1454.74771,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 650CC NATRELLE INSPIRA FULL -,SUP-SCF-650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHES GEL 695CC NATRELLE INSPIRA FULL -,SUP-SCF-695,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
NATRELLE INSPIRA COHESIVE IMPLANT 745 -,SUP-SCF-745,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
NATRELLE INSPIRA COHESIVE IMPLANT 770 -,SUP-SCF-770,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST 460CC NATRELLE SMOOTH ROUND -,SUP-SCL-460,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST 490CC SMOOTH COHESIVE LOW PLUS PROFILE -,SUP-SCLP-490,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST 540CC SMOOTH COHESIVE LOW PLUS PROFILE -,SUP-SCLP-540,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST 330CC NATRELLE SMOOTH ROUND -,SUP-SCM-330,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST 360CC NATRELLE SMOOTH ROUND -,SUP-SCM-360,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST 375CC NATRELLE SMOOTH ROUND -,SUP-SCM-375,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SILICONE 375CC NATRELLE INSPIRA STYLE MODERAT -,SUP-SCM-375,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST 405CC NATRELLE SMOOTH ROUND -,SUP-SCM-405,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHES 485CC NATRELLE INSPIRA MODERATE -,SUP-SCM-485,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 560CC NATRELLE INSPIRA MOD -,SUP-SCM-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 600CC NATRELLE INSPIRA MOD -,SUP-SCM-600,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 640CC NAT INSPIRA MOD -,SUP-SCM-640,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHES GEL 685CC NATRELLE INSPIRA MOD -,SUP-SCM-685,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHES GEL 755CC NATRELLE INSPIRA MOD -,SUP-SCM-755,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 340CC NATRELLE INSPIRA FULL -,SUP-SCX-340,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 375CC NATRELLE INSP EXTRA FUL -,SUP-SCX-375,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 525CC NATRELLE INSPIRA FULL -,SUP-SCX-525,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 545CC NATRELLE INSPIRA FULL -,SUP-SCX-545,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST 560CC SMOOTH COHESIVE NATRELLE INSPIRA FULL -,SUP-SCX-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST 580CC SMOOTH COHESIVE NATRELLE INSPIRA FULL -,SUP-SCX-580,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST 615CC SMOOTH COHESIVE NATRELLE INSPIRA FULL -,SUP-SCX-615,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH COHESIVE 650CC NATRELLE INSP EX-FULL -,SUP-SCX-650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
NATRELLE INSPIRA COHESIVE IMPLANT 700 -,SUP-SCX-700,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
NATRELLE INSPIRA COHESIVE IMPLANT 750 -,SUP-SCX-750,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
NATRELLE INSPIRA COHESIVE IMPLANT 800CC -,SUP-SCX-800,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT SMOOTH HIGH PROFILE XTRA 755 CC -,SUP-SHPX755,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5211.63,3648.141,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1348.248681,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT SMOOTH HIGH PROFILE XTRA 790 CC -,SUP-SHPX790,CDM,C1789,HCPCS,278,RC,,,outpatient,,,5211.63,3648.141,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1348.248681,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH FULL 450CC NATRELLE INSPIRA FULL -,SUP-SSF-450,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH FULL 520CC NATRELLE INSPIRA FULL -,SUP-SSF-520,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH FULL 560CC NATRELLE INSPIRA FULL -,SUP-SSF-560,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH FULL 650CC NATRELLE INSPIRA FULL -,SUP-SSF-650,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH FULL 695CC NATRELLE INSPIRA FULL -,SUP-SSF-695,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH FULL 745CC NATRELLE INSPIRA FULL -,SUP-SSF-745,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH SOFT TOUCH 330CC NATRELLE INSPIRA MOD -,SUP-SSM-330,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH SOFT TOUCH 445CC NATRELLE INSPIRA MOD -,SUP-SSM-445,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH SOFT TOUCH 485CC NATRELLE INSPIRA MOD -,SUP-SSM-485,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST SMOOTH SOFT TOUCH 520CC NATRELLE INSPIRA MOD -,SUP-SSM-520,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST EXTRA FULL SOFT TOUCH 750CC -,SUP-SSX-750,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
IMPLANT BREAST EXTRA FULL SOFT TOUCH 800CC -,SUP-SSX-800,CDM,C1789,HCPCS,278,RC,,,outpatient,,,4647.18,3253.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.225466,261.9915,4400.1792,percent of total billed charges,,,
PROSTHESIS PENL CL SPCTR MALE 9.5MMX12CM CNCLBL SNP FIT TIP -,SUP-720054-01,CDM,C1813,HCPCS,278,RC,,,outpatient,,,20421.5,14295.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5283.04205,150.646235,27674.62656,percent of total billed charges,,,
PROSTHESIS PENL CL SPCTR MALE 9.5MMX16CM SIL PE TI SEG -,SUP-720054-02,CDM,C1813,HCPCS,278,RC,,,outpatient,,,21238.36,14866.852,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5494.363732,150.646235,27674.62656,percent of total billed charges,,,
PROSTHESIS PENL AMS SPCTR MALE 12MMX20CM SIL PE TI SEG CYL -,SUP-720074-03,CDM,C1813,HCPCS,278,RC,,,outpatient,,,28358.17,19850.719,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7336.258579,150.646235,27674.62656,percent of total billed charges,,,
PROSTHESIS PENL AMS 700 LGX 100CM SAL FIL INFL MOMNTRY SQZ -,SUP-720185-01,CDM,C1813,HCPCS,278,RC,,,outpatient,,,12122.95,8486.065,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3136.207165,150.646235,27674.62656,percent of total billed charges,,,
AMS 800 PRESSURE REGULATION BALLOON -,SUP-72400024,CDM,C1813,HCPCS,278,RC,,,outpatient,,,12791.29,8953.903,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3309.106723,150.646235,27674.62656,percent of total billed charges,,,
KT PROSTHESIS PENL URIN ARTF SPHNCR IMPL SAL FIL SCRT CYL -,SUP-724000-95,CDM,C1813,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,173.595461,150.646235,27674.62656,percent of total billed charges,,,
PUMP URIN SPHNCR AMS 800 MALE SIL CNCLD FLD-FIL W/O INHBZN -,SUP-724000-98,CDM,C1813,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4034.32302,150.646235,27674.62656,percent of total billed charges,,,
PROSTHESIS PENL AMBICOR 11MM/12.5MM DIA FIL PMP 16CM SAL FIL -,SUP-72401451,CDM,C1813,HCPCS,278,RC,,,outpatient,,,31752.76,22226.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8214.439012,150.646235,27674.62656,percent of total billed charges,,,
AMS AMBICOR PENILE PROTHESIS -,SUP-72401452,CDM,C1813,HCPCS,278,RC,,,outpatient,,,34352.98,24047.086,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8887.115926,150.646235,27674.62656,percent of total billed charges,,,
AMS AMBICOR PENILE PROTHESIS 18CM X 14 MM -,SUP-72401454,CDM,C1813,HCPCS,278,RC,,,outpatient,,,31752.76,22226.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8214.439012,150.646235,27674.62656,percent of total billed charges,,,
RESERVOIR PROS -,SUP-724014-77,CDM,C1813,HCPCS,278,RC,,,outpatient,,,3317.93,2322.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,858.348491,150.646235,27674.62656,percent of total billed charges,,,
PROSTHESIS PENL AMS 700 LGX 65CM SAL FIL INFL MOMNTRY SQZ -,SUP-724041-55,CDM,C1813,HCPCS,278,RC,,,outpatient,,,12122.95,8486.065,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3136.207165,150.646235,27674.62656,percent of total billed charges,,,
PROSTHESIS PENL AMS 700 CX MALE 100ML SAL FIL INFL CYL TIP -,SUP-72404156,CDM,C1813,HCPCS,278,RC,,,outpatient,,,9765.19,6835.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2526.254653,150.646235,27674.62656,percent of total billed charges,,,
PROSTHESIS PENL PMP AMS 700 CX MALE SAL FIL INFL STRL -,SUP-724042-09,CDM,C1813,HCPCS,278,RC,,,outpatient,,,15498.06,10848.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4009.348122,150.646235,27674.62656,percent of total billed charges,,,
18CM 700CX -,SUP-72404232,CDM,C1813,HCPCS,278,RC,,,outpatient,,,25200.41,17640.287,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6519.346067,150.646235,27674.62656,percent of total billed charges,,,
PUMP AMS 700 12MM X 18CM CX MS PENILE -,SUP-72404232-10,CDM,C1813,HCPCS,278,RC,,,outpatient,,,31466.59,22026.613,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8140.406833,150.646235,27674.62656,percent of total billed charges,,,
AMS 700 CX MS PUMP IZ 21CM -,SUP-72404233-12,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26705.28,18693.696,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6908.655936,150.646235,27674.62656,percent of total billed charges,,,
PROSTHESIS PENL AMS 700 LGX 15MM CL INFL PRECNCT W/MS PMP -,SUP-724042-51,CDM,C1813,HCPCS,278,RC,,,outpatient,,,28543.19,19980.233,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7384.123253,150.646235,27674.62656,percent of total billed charges,,,
PROSTHESIS PENL AMS 700 LGX 18CM SAL FIL INFL MOMNTRY SQZ -,SUP-72404252,CDM,C1813,HCPCS,278,RC,,,outpatient,,,36034.67,25224.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9322.169129,150.646235,27674.62656,percent of total billed charges,,,
AMS 700 LGX MS PUMP IZ 21CM X 12MM -,SUP-72404253-12,CDM,C1813,HCPCS,278,RC,,,outpatient,,,32354.71,22648.297,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8370.163477,150.646235,27674.62656,percent of total billed charges,,,
PROSTHESIS PENL AMS 700 CXR 14CM X 9.5MM -,SUP-72404262,CDM,C1813,HCPCS,278,RC,,,outpatient,,,25200.41,17640.287,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6519.346067,150.646235,27674.62656,percent of total billed charges,,,
AMS CXR MS PUMP IZ -,SUP-72404264,CDM,C1813,HCPCS,278,RC,,,outpatient,,,32749.43,22924.601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8472.277541,150.646235,27674.62656,percent of total billed charges,,,
EXTENDER PENL AMS SPCTR 12MM/14MM DIA CL 3CM REAR TIP -,SUP-724043-23,CDM,C1813,HCPCS,278,RC,,,outpatient,,,9913.98,6939.786,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2564.746626,150.646235,27674.62656,percent of total billed charges,,,
IMPLANT PENL RSVR CLPLST 75ML HYDRPHL CTD LKOUT VLV STRL -,SUP-90-9075K-LOC,CDM,C1813,HCPCS,278,RC,,,outpatient,,,5602.08,3921.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1449.258096,150.646235,27674.62656,percent of total billed charges,,,
PROSTHESIS PENL TITAN 16CM HYDRPHL RST CTD CYL 3 PRT REFL -,SUP-90-9916SC,CDM,C1813,HCPCS,278,RC,,,outpatient,,,24505.8,17154.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6339.65046,150.646235,27674.62656,percent of total billed charges,,,
PROSTHESIS PENL STD 18CM BIOFLEX/SIL MALE SCRT CL/PMP ST -,SUP-90-9918SNCOTR,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26752.17,18726.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6920.786379,150.646235,27674.62656,percent of total billed charges,,,
PROSTHESIS PENL STD 20CM BIOFLEX/SIL MALE SCRT CL/PMP ST -,SUP-90-9920SCOTR,CDM,C1813,HCPCS,278,RC,,,outpatient,,,24505.8,17154.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6339.65046,150.646235,27674.62656,percent of total billed charges,,,
KT PROSTHESIS PENL TITAN MALE NRW BS EXTEND ESSAY NDLX1 -,SUP-91-9480SNC,CDM,C1813,HCPCS,278,RC,,,outpatient,,,2507.14,1754.998,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,648.597118,150.646235,27674.62656,percent of total billed charges,,,
PROSTHESIS PENL RSVR TITAN 75ML BIOFLEX SIL INFL SLF-CNTN -,SUP-ER8075,CDM,C1813,HCPCS,278,RC,,,outpatient,,,6938.94,4857.258,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1795.103778,150.646235,27674.62656,percent of total billed charges,,,
ST PROSTHESIS PENL TITAN 18CM BIOFLEX SIL CYL INFL SLF-CNTN -,SUP-ES2918,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26956.38,18869.466,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6973.615506,150.646235,27674.62656,percent of total billed charges,,,
ST PROSTHESIS TITAN 22CM BIOFLEX SIL TCH ZERO DG CL PMP -,SUP-ES2922,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26956.38,18869.466,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6973.615506,150.646235,27674.62656,percent of total billed charges,,,
PROSTHESIS PENL TITAN 18CM 0DG ANG CYL INFL 1-TCH RELS -,SUP-ESR918,CDM,C1813,HCPCS,278,RC,,,outpatient,,,27550.46,19285.322,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7127.304002,150.646235,27674.62656,percent of total billed charges,,,
ST UROLOGICAL PMP/CL TITAN 20CM BIOFLEX SIL 0DG ANG PENL -,SUP-ESR920,CDM,C1813,HCPCS,278,RC,,,outpatient,,,26752.17,18726.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6920.786379,150.646235,27674.62656,percent of total billed charges,,,
AMS AMBICOR 16CM X 14MM -,SUP-UNDEFINED,CDM,C1813,HCPCS,278,RC,,,outpatient,,,30531.59,21372.113,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7898.522333,150.646235,27674.62656,percent of total billed charges,,,
PROSTHESIS PENL 3.5CM INFL SCRT INHBZN CONTINENCE -,SUP-720157-01,CDM,C1815,HCPCS,278,RC,,,outpatient,,,16337.2,11436.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4226.43364,399.86,21443.91168,percent of total billed charges,,,
PUMP CORTIAL 700 PROSTHESIS -,SUP-72404127,CDM,C1815,HCPCS,278,RC,,,outpatient,,,26900.69,18830.483,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6959.208503,399.86,21443.91168,percent of total billed charges,,,
SYS UROLOGICAL AMS 800 4CM CUF BLT W/IZ -,SUP-724041-30,CDM,C1815,HCPCS,278,RC,,,outpatient,,,27921.76,19545.232,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7223.359312,399.86,21443.91168,percent of total billed charges,,,
PROSTHESIS PENL AMS 800 4.5CM SAL FIL CNCLD CYL SCRT INHBZN -,SUP-72404131,CDM,C1815,HCPCS,278,RC,,,outpatient,,,27921.76,19545.232,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7223.359312,399.86,21443.91168,percent of total billed charges,,,
PROSTHESIS PENL AMS 800 5.0CM SAL FIL CNCLD CYL SCRT INHBZN -,SUP-72404132,CDM,C1815,HCPCS,278,RC,,,outpatient,,,26585.08,18609.556,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6877.560196,399.86,21443.91168,percent of total billed charges,,,
PROSTHESIS PENL AMS 800 6.0CM SAL FIL ARTIF URINARY SPHINCTR -,SUP-72404134,CDM,C1815,HCPCS,278,RC,,,outpatient,,,25935.31,18154.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6709.464697,399.86,21443.91168,percent of total billed charges,,,
OCCLUDERS FLO RESTER 1.5 -,SUP-50150,CDM,C1817,HCPCS,278,RC,,,outpatient,,,470.8,329.56,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,121.79596,99.62861,33156.48,percent of total billed charges,,,
OCCLUDERS FLO RESTER 2.5 -,SUP-50250,CDM,C1817,HCPCS,278,RC,,,outpatient,,,470.8,329.56,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,121.79596,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER VASC 2MM BLB 30MM INTNL VES FLO-RST DISP -,SUP-60200,CDM,C1817,HCPCS,278,RC,,,outpatient,,,443.78,310.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,114.805886,99.62861,33156.48,percent of total billed charges,,,
AMPLATZER AMULET 16MM WW REF: 9-ACP2-007-016 -,SUP-9-ACP2-007-016,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10849.6193,99.62861,33156.48,percent of total billed charges,,,
AMPLATZER AMULET 18MM WW REF: 9-ACP2-007-018 -,SUP-9-ACP2-007-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10849.6193,99.62861,33156.48,percent of total billed charges,,,
AMPLATZER AMULET 20 MM WW REF: 9-ACP2-007-020 -,SUP-9-ACP2-007-020,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10849.6193,99.62861,33156.48,percent of total billed charges,,,
AMPLATZER AMULET 22 MM WW REF: 9-ACP2-007-022 -,SUP-9-ACP2-007-022,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10849.6193,99.62861,33156.48,percent of total billed charges,,,
AMPLATZER AMULET 25 MM WW REF: 9-ACP2-010-025 -,SUP-9-ACP2-010-025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10849.6193,99.62861,33156.48,percent of total billed charges,,,
AMPLATZER AMULET 28 MM WW REF: 9-ACP2-010-028 -,SUP-9-ACP2-010-028,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10849.6193,99.62861,33156.48,percent of total billed charges,,,
AMPLATZER AMULET 31 MM WW REF: 9-ACP2-010-031 -,SUP-9-ACP2-010-031,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10849.6193,99.62861,33156.48,percent of total billed charges,,,
AMPLATZER AMULET 34 MM WW REF: 9-ACP2-010-034 -,SUP-9-ACP2-010-034,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10849.6193,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER AMPLATZER SEPTAL 5MM  REF: 9-ASD-005 -,SUP-9-ASD-005,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER AMPLATZER SEPTAL 6MM  REF: 9-ASD-006 -,SUP-9-ASD-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 08MM WST 16MM/20MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-008,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 10MM WST 18MM/22MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-010,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 11MM WST 21MM/25MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-011,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 12MM WST 22MM/26MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-012,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 13MM WST 23MM/27MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-013,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 14MM WST 24MM/28MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-014,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 15MM WST 25MM/29MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-015,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 16MM WST 26MM/30MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-016,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 18MM WST 28MM/32MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 19MM WST 28MM/32MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-019,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 20MM WST 30MM/34MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-020,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 22MM WST 32MM/36MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-022,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 24MM WST 34MM/38MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-024,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 26MM WST 36MM/40MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-026,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 28MM WST 38MM/42MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-028,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 30MM WST 40MM/44MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-030,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 32MM WST 42MM/46MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-032,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 34MM WST 44MM/50MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-034,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 36MM WST 46MM/52MM DIA RT/LA DISC AMPLATZER -,SUP-9-ASD-036,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 18MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 25MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 30MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-030,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER SPT 35MM DISC AMPLATZER NTNL INTRWVN PLYSTR DBL -,SUP-9-ASD-MF-035,CDM,C1817,HCPCS,278,RC,,,outpatient,,,29284.43,20499.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7575.882041,99.62861,33156.48,percent of total billed charges,,,
GRAFT VASC 5MMX12.5MM AMPLATZER OCLR SE FUL CX-SECT CVRGLS -,SUP-9-AVP038-005,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1262.61122,99.62861,33156.48,percent of total billed charges,,,
GRAFT VASC 6X11MM AMPLATZER PLG SE FUL CX-SECT CVRGLS LT ATR -,SUP-9-AVP038-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1262.61122,99.62861,33156.48,percent of total billed charges,,,
GRAFT VASC 7MMX12.5MM AMPLATZER PLG OCLR SE FUL CX-SECT -,SUP-9-AVP038-007,CDM,C1817,HCPCS,278,RC,,,outpatient,,,5177.68,3624.376,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1339.465816,99.62861,33156.48,percent of total billed charges,,,
PLUG VASCULAR AMPLATZER 6MM REF:09-AVP2-006 -,SUP-9-AVP2-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1089.300329,99.62861,33156.48,percent of total billed charges,,,
PLUG VASCULAR AMPLATZER 8 -,SUP-9-AVP2-008,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1089.300329,99.62861,33156.48,percent of total billed charges,,,
PLUG VASCULAR AMPLATZER 10 011 -,SUP-9-AVP2-010,CDM,C1817,HCPCS,278,RC,,,outpatient,,,3971.97,2780.379,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1027.548639,99.62861,33156.48,percent of total billed charges,,,
PLUG VASCULAR AMPLATZER 12 -,SUP-9-AVP2-012,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1089.300329,99.62861,33156.48,percent of total billed charges,,,
PLUG VASCULAR AMPLATZER 16 -,SUP-9-AVP2-016,CDM,C1817,HCPCS,278,RC,,,outpatient,,,3971.97,2780.379,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1027.548639,99.62861,33156.48,percent of total billed charges,,,
PLUG VASCULAR AMPLATZER 18 -,SUP-9-AVP2-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4210.67,2947.469,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1089.300329,99.62861,33156.48,percent of total billed charges,,,
GRAFT VASC 22X6MM AMPLATZER PLG SE MUL-LOBE LT ATR NTNL -,SUP-9-AVP2-022,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER DCT 5MM/4MM DIA DSCND AOR/PA AMPLATZER NTNL INTRWVN -,SUP-9-PDA-003,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2876.857828,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER DCT 6MM/4MM DIA DSCND AOR/PA AMPLATZER NTNL INTRWVN -,SUP-9-PDA-004,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2876.857828,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER DCT 8MM/6MM DIA DSCND AOR/PA AMPLATZER NTNL INTRWVN -,SUP-9-PDA-005,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2876.857828,99.62861,33156.48,percent of total billed charges,,,
10/8 AMPLATZER DUCT OCCLUDER -,SUP-9-PDA-006,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2876.857828,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER VASC DCT 12MM/10MM DIA/DSCND/PULM AOR 7FRX8MM NTNL -,SUP-9-PDA-007,CDM,C1817,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2876.857828,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER DUCT II AMPLATZER 3MMX4MM -,SUP-9-PDA2-03-04,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4924.755485,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER DCT 5MM/4MM DIA WST/DISC AMPLATZER NTNL DBL DISC -,SUP-9-PDA2-05-04,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4924.755485,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER DCT 5MM/6MM DIA WST/DISC AMPLATZER NTNL DBL DISC. -,SUP-9-PDA2-05-06,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4924.755485,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER DUCT II AMPLATZER 6MMX4MM -,SUP-9-PDA2-06-04,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4924.755485,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER DUCT II AMPLATZER 6MMX6MM -,SUP-9-PDA2-06-06,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4924.755485,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER DCT 5MM/11MM DIA WST/DISC AMPLATZER NTNL DBL DISC.. -,SUP-9-PDA2-06-06,CDM,C1817,HCPCS,278,RC,,,outpatient,,,19036.55,13325.585,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4924.755485,99.62861,33156.48,percent of total billed charges,,,
OCCULUDER AMPLATZER PFO 18MM -,SUP-9-PFO-018,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9600.729528,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER AMPLATZER PFO 25MM -,SUP-9-PFO-025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9600.729528,99.62861,33156.48,percent of total billed charges,,,
OCCLUDER AMPLATZER PFO 35MM -,SUP-9-PFO-035,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9600.729528,99.62861,33156.48,percent of total billed charges,,,
AMPLATZER TALISMAN PFO OCCLUDER 8FR 18MM REF:9-PFO-1818 -,SUP-9-PFO-1818,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9600.729528,99.62861,33156.48,percent of total billed charges,,,
AMPLATZER TALISMAN PFO OCCLUDER 25-18MM -,SUP-9-PFO-2518,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9600.729528,99.62861,33156.48,percent of total billed charges,,,
AMPLATZER TALISMAN PFO OCCLUDER 30-25MM -,SUP-9-PFO-3025,CDM,C1817,HCPCS,278,RC,,,outpatient,,,37111.44,25978.008,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9600.729528,99.62861,33156.48,percent of total billed charges,,,
TORQVUE SHEATH 12F 80CM 45X45 REF: 9-TV45X45-12F-080 -,SUP-9-TV45X45-12F-080,CDM,C1817,HCPCS,278,RC,,,outpatient,,,4676.89,3273.823,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1209.911443,99.62861,33156.48,percent of total billed charges,,,
CLOSURE DEVICE WATCHMAN FLEX 27MM -,SUP-M635WU0270,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10849.6193,99.62861,33156.48,percent of total billed charges,,,
SHEATH WATCHMAN 21MM 12FR CLSR 75CM TRNSEPT -,SUP-M635WU21060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10849.6193,99.62861,33156.48,percent of total billed charges,,,
SHEATH WATCHMAN 24MM 12FR CLSR 75CM  TRNSEPT -,SUP-M635WU24060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10849.6193,99.62861,33156.48,percent of total billed charges,,,
SHEATH WATCHMAN 27MM 12FR CLSR 75CM  TRNSEPT -,SUP-M635WU27060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10849.6193,99.62861,33156.48,percent of total billed charges,,,
SHEATH WATCHMAN 30MM 12FR CLSR 75CM TRNSEPT -,SUP-M635WU30060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10849.6193,99.62861,33156.48,percent of total billed charges,,,
SHEATH WATCHMAN 33MM 12FR CLSR 75CM TRANSEPT -,SUP-M635WU33060,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10849.6193,99.62861,33156.48,percent of total billed charges,,,
CLOSURE DEVICE WATCHMAN FLEX 20MM -,SUP-M635WU50200,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10849.6193,99.62861,33156.48,percent of total billed charges,,,
CLOSURE DEVICE WATCHMAN FLEX 31MM -,SUP-M635WU50310,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10849.6193,99.62861,33156.48,percent of total billed charges,,,
CLOSURE DEVICE WATCHMAN FLEX 35MM -,SUP-M635WU50350,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10849.6193,99.62861,33156.48,percent of total billed charges,,,
CLOSURE DEVICE WATCHMAN FLEX PRO 20MM REF:M635WU60200 -,SUP-M635WU60200,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11168.72575,99.62861,33156.48,percent of total billed charges,,,
CLOSURE DEVICE WATCHMAN FLEX PRO 24MM REF:M635WU60240 -,SUP-M635WU60240,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11168.72575,99.62861,33156.48,percent of total billed charges,,,
CLOSURE DEVICE WATCHMAN FLEX PRO 27MM REF:M635WU60270 -,SUP-M635WU60270,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11168.72575,99.62861,33156.48,percent of total billed charges,,,
CLOSURE DEVICE WATCHMAN FLEX PRO 31MM REF:M635WU60310 -,SUP-M635WU60310,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11168.72575,99.62861,33156.48,percent of total billed charges,,,
CLOSURE DEVICE WATCHMAN FLEX PRO 35MM REF:M635WU60350 -,SUP-M635WU60350,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11168.72575,99.62861,33156.48,percent of total billed charges,,,
CLOSURE DEVICE WATCHMAN FLEX PRO 40MM REF:M635WU60400 -,SUP-M635WU60400,CDM,C1817,HCPCS,278,RC,,,outpatient,,,43172.5,30220.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11168.72575,99.62861,33156.48,percent of total billed charges,,,
CLOSURE DEVICE WATCHMAN FLEX 24MM -,SUP-M63WU50240,CDM,C1817,HCPCS,278,RC,,,outpatient,,,41939,29357.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10849.6193,99.62861,33156.48,percent of total billed charges,,,
TULOC LOCALIZATION WIRE 20G X 5CM -,SUP-271660,CDM,C1819,HCPCS,278,RC,,,outpatient,,,200.72,140.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,45.06164,416.02,other,Non-Reimbursable Procedures,,
TULOC LOCALIZATION WIRE 20G X 9CM -,SUP-271661,CDM,C1819,HCPCS,278,RC,,,outpatient,,,200.72,140.504,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,45.06164,416.02,other,Non-Reimbursable Procedures,,
TULOC PREMIUM LOCALIZATION WIRE 20G X 5CM -,SUP-271880,CDM,C1819,HCPCS,278,RC,,,outpatient,,,256.74,179.718,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,45.06164,416.02,other,Non-Reimbursable Procedures,,
TULOC PREMIUM LOCALIZATION WIRE 20G X 9CM -,SUP-271881,CDM,C1819,HCPCS,278,RC,,,outpatient,,,256.74,179.718,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,45.06164,416.02,other,Non-Reimbursable Procedures,,
ETERNA IMPLANTABLE PULSE GENERATOR -,SUP-32400,CDM,C1820,HCPCS,278,RC,,,outpatient,,,45639.5,31947.65,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11806.93865,399.86,41625.59232,percent of total billed charges,,,
PRODIGY 3730 -,SUP-3730,CDM,C1820,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,741.02028,399.86,41625.59232,percent of total billed charges,,,
SYS GENERATOR NEURSTM RSTOR ADVANCED PERC MUL-PRGM RCHG ACC -,SUP-377-13,CDM,C1820,HCPCS,278,RC,,,outpatient,,,31108.87,21776.209,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8047.864669,399.86,41625.59232,percent of total billed charges,,,
NEURSTM IMPL RESTORESENSOR 2.1INX2.1IN PERC SMALLEST -,SUP-377-14,CDM,C1820,HCPCS,278,RC,,,outpatient,,,38238.5,26766.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9892.29995,399.86,41625.59232,percent of total billed charges,,,
PRODIGY MRI -,SUP-3772,CDM,C1820,HCPCS,278,RC,,,outpatient,,,38929.26,27250.482,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10070.99956,399.86,41625.59232,percent of total billed charges,,,
NEURSTM IMPL RESTORESENSOR SURSCN 9X54X54MM SPIN CRD RCHG -,SUP-97714,CDM,C1820,HCPCS,278,RC,,,outpatient,,,38238.5,26766.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9892.29995,399.86,41625.59232,percent of total billed charges,,,
INTERSTIM MICRO MRI RECHARGEABLE NEUROSTIMULATOR -,SUP-97810,CDM,C1820,HCPCS,278,RC,,,outpatient,,,25644.47,17951.129,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6634.224389,399.86,41625.59232,percent of total billed charges,,,
MICROSTIMULATOR INS 97810 RECHARGEABLE -,SUP-97810,CDM,C1820,HCPCS,278,RC,,,outpatient,,,25644.47,17951.129,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6634.224389,399.86,41625.59232,percent of total billed charges,,,
KT GENERATOR NEURSTM PRECISN SPCTR -,SUP-M365SC1110020,CDM,C1820,HCPCS,278,RC,,,outpatient,,,54199.99,37939.993,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,14021.53741,399.86,41625.59232,percent of total billed charges,,,
VERTIFLEX SUPERION IDS-10MM -,SUP-101-9810,CDM,C1821,HCPCS,278,RC,,,outpatient,,,25619.7,17933.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6627.81639,399.86,19675.9296,percent of total billed charges,,,
VERTIFLEX SUPERION IDS-12MM -,SUP-101-9812,CDM,C1821,HCPCS,278,RC,,,outpatient,,,25619.7,17933.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6627.81639,399.86,19675.9296,percent of total billed charges,,,
VERTIFLEX SUPERION IDS -14MM -,SUP-101-9814,CDM,C1821,HCPCS,278,RC,,,outpatient,,,25619.7,17933.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6627.81639,399.86,19675.9296,percent of total billed charges,,,
SPACER CERV 8X27MMX0.016IN ZYSTON -,SUP-14-533108,CDM,C1821,HCPCS,278,RC,,,outpatient,,,12995.5,9096.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3361.93585,399.86,19675.9296,percent of total billed charges,,,
SPACER ANT CERV 19-25MMH FORTIFY OPTMZ FIT TI -,SUP-151.051,CDM,C1821,HCPCS,278,RC,,,outpatient,,,18565,12995.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4802.7655,399.86,19675.9296,percent of total billed charges,,,
SPACER ANT CERV 15X18MM FTPRNT FORTIFY 7DG OPTMZ FIT TI -,SUP-151.334,CDM,C1821,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,617.059001,399.86,19675.9296,percent of total billed charges,,,
SPACER ANT CERV 15X18MM FTPRNT FORTIFY 7DG OPTMZ FIT TI. -,SUP-151.384,CDM,C1821,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,617.059001,399.86,19675.9296,percent of total billed charges,,,
MESH 14MM ROUND 30MM HGT -,SUP-176014030,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11221.61,7855.127,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2903.030507,399.86,19675.9296,percent of total billed charges,,,
MESH SURG 23X27MM DIA 12X14MM OBLNG TRPZD TI HARMS -,SUP-1763-02-012,CDM,C1821,HCPCS,278,RC,,,outpatient,,,14854.78,10398.346,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3842.931586,399.86,19675.9296,percent of total billed charges,,,
RISE SPACER 8 X 22MM- 7-13MM -,SUP-193.001,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4418.54426,399.86,19675.9296,percent of total billed charges,,,
SPACER RISE 8 X 22MM 8-14MM 10 DEG -,SUP-193.021,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4418.54426,399.86,19675.9296,percent of total billed charges,,,
SPACER RISE 10 X 22 7-13 -,SUP-193.101,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4418.54426,399.86,19675.9296,percent of total billed charges,,,
SPACER RISE 10 X 26MM 7-14MM -,SUP-193.102,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4418.54426,399.86,19675.9296,percent of total billed charges,,,
SPACER RISE 10 X 26MM 10-17MM -,SUP-193.112,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4418.54426,399.86,19675.9296,percent of total billed charges,,,
RISE SPACER 10X22MM 8-14MM 10 DEGREES -,SUP-193.121,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4418.54426,399.86,19675.9296,percent of total billed charges,,,
RISE SPACER 10MM X 26MM 8-15MM 10 DEGREES -,SUP-193.122,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4418.54426,399.86,19675.9296,percent of total billed charges,,,
SPACER SPINAL RISE 10MM X 30MM 8-15MM 10 DEG -,SUP-193.123,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4418.54426,399.86,19675.9296,percent of total billed charges,,,
RISE SPACER 10 X 26MM 10-17MM -,SUP-193.142,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4418.54426,399.86,19675.9296,percent of total billed charges,,,
RISER SPACER 10X22MM- 9-15MM -,SUP-193.151,CDM,C1821,HCPCS,278,RC,,,outpatient,,,17079.8,11955.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4418.54426,399.86,19675.9296,percent of total billed charges,,,
NORMANDY 12X14 30MM 10DEGREES -,SUP-250-1214-30-10,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19597.21,13718.047,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5069.798227,399.86,19675.9296,percent of total billed charges,,,
CAGE 12X14 44-76 10 DEGREE -,SUP-250-1214-4410,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19597.21,13718.047,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5069.798227,399.86,19675.9296,percent of total billed charges,,,
SPACER THORLUM VERT 12X26X12MM SUSTAIN-O OBLQ PEEK RDLCNT -,SUP-304.972,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,399.86,19675.9296,percent of total billed charges,,,
SPACER SMALL 12 X 14 ZERO DEG 19MM NIKO CORPECTOMY -,SUP-342.719,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11547.43,8083.201,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2987.320141,399.86,19675.9296,percent of total billed charges,,,
SPACER SPINAL NIKO PEEK 7 D D12 MM SMALL 14X15MM CORPECTOMY -,SUP-342.815,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11547.43,8083.201,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2987.320141,399.86,19675.9296,percent of total billed charges,,,
SEASPINE 7H CAGE -,SUP-AC4-143077,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9901.25,6930.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2561.453375,399.86,19675.9296,percent of total billed charges,,,
SEASPINE CAGE 16X14X6MM 7 DEGREE 3D INTERBODY -,SUP-AC4-264067,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1427.29964,399.86,19675.9296,percent of total billed charges,,,
GENESYS 6H CAGE -,SUP-ACC804-06S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,399.86,19675.9296,percent of total billed charges,,,
CAGE 9 X 26 X 12 6-20 DEGREES -,SUP-ET1-102612,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19678.9,13775.23,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5090.93143,399.86,19675.9296,percent of total billed charges,,,
SEASPINE 9 X 26 0-14 DEGREE LORDOTIC CAGE -,SUP-ET1-142608,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4322.48895,399.86,19675.9296,percent of total billed charges,,,
SEASPINE 10H 17 DEGREE CAGE -,SUP-ET1-172610,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4322.48895,399.86,19675.9296,percent of total billed charges,,,
CAGE EXPANDABLE SEASPINE 10H 9W 30L -,SUP-ET1-173010,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4322.48895,399.86,19675.9296,percent of total billed charges,,,
SEASPINE 10-14MM 8 DEGREE CAGE -,SUP-ET1-382810,CDM,C1821,HCPCS,278,RC,,,outpatient,,,16708.5,11695.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4322.48895,399.86,19675.9296,percent of total billed charges,,,
APACHE SPACER 8MM -,SUP-GAC-08SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1427.29964,399.86,19675.9296,percent of total billed charges,,,
TITANIUM APACHE CAGE 5MM -,SUP-GAC3D-05SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,399.86,19675.9296,percent of total billed charges,,,
TITANIUM APACHE CAGE 6MM -,SUP-GAC3D-06SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,399.86,19675.9296,percent of total billed charges,,,
7MM CAGE APACHE -,SUP-GAC3D-07SL,CDM,C1821,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1482.19578,399.86,19675.9296,percent of total billed charges,,,
CAGE TLIF 7MM X 30MM -,SUP-GP-07-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,399.86,19675.9296,percent of total billed charges,,,
CAGE APACHE PEEK SPACER 8 X 30 -,SUP-GP-08-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,399.86,19675.9296,percent of total billed charges,,,
CAGE 25 STRAIGHT 9MM -,SUP-GP-09,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,399.86,19675.9296,percent of total billed charges,,,
CAGE 9 X 30 -,SUP-GP-09-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,399.86,19675.9296,percent of total billed charges,,,
CAGE 10MM STANDARD PLIF -,SUP-GP-10,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,399.86,19675.9296,percent of total billed charges,,,
CAGE PEEK 30 X 10MM -,SUP-GP-10-30,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,399.86,19675.9296,percent of total billed charges,,,
CAGE APACHE 11MM -,SUP-GP-11,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,399.86,19675.9296,percent of total billed charges,,,
CAGE 8MM BI-CONVEX PLIF -,SUP-GPC2-08,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,399.86,19675.9296,percent of total billed charges,,,
CAGE 9MM CONVEX PLIF -,SUP-GPC2-09,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,399.86,19675.9296,percent of total billed charges,,,
SPACER PEEK 10 X 24 CONVEX -,SUP-GPC2-10,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,399.86,19675.9296,percent of total billed charges,,,
CAGE PEEK APACHE 11MM -,SUP-GPC2-11,CDM,C1821,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2415.43016,399.86,19675.9296,percent of total billed charges,,,
SPINEART LUMBAR POSTERIOR TI CAGE L24 W10.5 H08 12 DEG -,SUP-JUT-PX 24 08-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2635.01472,399.86,19675.9296,percent of total billed charges,,,
JULIET TI PO LUMBAR POSTERIOR TI CAGE L24 W10.5 H10 12DEG -,SUP-JUT-PX 24 10-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2635.01472,399.86,19675.9296,percent of total billed charges,,,
CAGE LUMBAR POSTERIOR TI L24 W10.5 H11 12 DEG -,SUP-JUT-PX 24 11-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2635.01472,399.86,19675.9296,percent of total billed charges,,,
CAGE LUMBAR POSTERIOR TI L24 W10.5 H12 -,SUP-JUT-PX 24 12-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2635.01472,399.86,19675.9296,percent of total billed charges,,,
CAGE TRANSORAMINAL LUMBAR TI L 30 W 10.5 H 14 -,SUP-JUT-T6 30 14-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2635.01472,399.86,19675.9296,percent of total billed charges,,,
TRANSFORMATIONAL LUMBAR TI CAGE L34 W10.5 H12 06 DEG -,SUP-JUT-T6 34 12-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2635.01472,399.86,19675.9296,percent of total billed charges,,,
CAGE CERV 7MM/4.1MM H A/P ROI- C LRDTC -,SUP-MC1443P,CDM,C1821,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1701.78034,399.86,19675.9296,percent of total billed charges,,,
CAGE CERV 10MM/7.1MM H A/P ROI- C LRDTC -,SUP-MC1446P,CDM,C1821,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1701.78034,399.86,19675.9296,percent of total billed charges,,,
PATHLOC LUMBAR INTERBODY FUSION CAGE 12MM 15 DEGREES -,SUP-PT2211-0815S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,19678.9,13775.23,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5090.93143,399.86,19675.9296,percent of total billed charges,,,
SCARLET AL-T SECURED ANTERIOR CAGE SMALL H12 15' -,SUP-SCA-LS 15 12-S,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2881.6593,399.86,19675.9296,percent of total billed charges,,,
CAGE 11MM LUCENT STR -,SUP-UNDEFINED,CDM,C1821,HCPCS,278,RC,,,outpatient,,,11695.95,8187.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3025.742265,399.86,19675.9296,percent of total billed charges,,,
NPG IMPLANT AND CHARGER -,SUP-HFX-D,CDM,C1822,HCPCS,278,RC,,,outpatient,,,60441.5,42309.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,46419.072,other,Non-Reimbursable Procedures,,
KIT BLUE LEAD 90CM WITH 5MM SPACING -,SUP-LEAD1058-90B,CDM,C1822,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,46419.072,other,Non-Reimbursable Procedures,,
IPG KIT -,SUP-NIPG2500,CDM,C1822,HCPCS,278,RC,,,outpatient,,,60441.5,42309.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,46419.072,other,Non-Reimbursable Procedures,,
NEVRO IPG KIT WITH NEW BATTERY -,SUP-NIPG3000,CDM,C1822,HCPCS,278,RC,,,outpatient,,,60441.5,42309.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,46419.072,other,Non-Reimbursable Procedures,,
STENT DES 4X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-10074400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3X15MM XIENCE V RX BE PRMNT 143CM EVEROL CMPLNT -,SUP-1009541-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT 2.8X16MM GRAFTMS RX 143CM SEM-COM HYDRCT -,SUP-1012580-16,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT 4X16MM GRAFTMS RX 143CM SEM-COM HYDRCT -,SUP-1012582-16,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT 4X26MM GRAFTMS RX 143CM SEM-COM HYDRCT -,SUP-1012582-26,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.25X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.25X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.25X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.25X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.25X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.25X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074250-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074275-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074300-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.25X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.25X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.25X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.25X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.25X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.25X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.25X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.25X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074325-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.5X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.5X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.5X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.5X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.5X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.5X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.5X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.5X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074350-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4X8MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4X12MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4X15MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4X18MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4X23MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4X28MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4X33MM XIENCE XPED RX BE PRMNT 145CM EVEROL -,SUP-1074400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4X38MM XIENCE XPED RX BE PRMNT 145CM EVEROL CMPLNT -,SUP-1074400-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.25X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125225-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.25X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.25X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.25X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.25X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.25X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125250-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125275-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125275-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3X15MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125300-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.25X12MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.25X23MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.25X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35644.8,24951.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.25X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.25X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN -,SUP-1125325-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4X8MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4X18MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4X28MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4X33MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4X38MM XIENCE ALP RX BE EVEROL CMPLNT 0.014IN GW -,SUP-1125400-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT 3X19MM JOST GRAFTMS OTW BE 143CM SEM-COM HYDREX CTD -,SUP-12744-19,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT 4X19MM JOST GRAFTMS OTW BE 143CM SEM-COM HYDREX CTD -,SUP-12746-19,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.25X8MM XIENCE SKYPOINT -,SUP-1804225-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.25X12MM XIENCE SKYPOINT -,SUP-1804225-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.25X15MM XIENCE SKYPOINT -,SUP-1804225-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.25X18MM XIENCE SKYPOINT -,SUP-1804225-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.25X23MM XIENCE SKYPOINT -,SUP-1804225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.25X28MM XIENCE SKYPOINT -,SUP-1804225-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.25X33MM XIENCE SKYPOINT -,SUP-1804225-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.25X38MM XIENCE SKYPOINT -,SUP-1804225-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X8MM XIENCE SKYPOINT -,SUP-1804250-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X12MM XIENCE SKYPOINT -,SUP-1804250-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X15MM XIENCE SKYPOINT -,SUP-1804250-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X18MM XIENCE SKYPOINT -,SUP-1804250-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X23MM XIENCE SKYPOINT -,SUP-1804250-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X28MM XIENCE SKYPOINT -,SUP-1804250-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X33MM XIENCE SKYPOINT -,SUP-1804250-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X38MM XIENCE SKYPOINT -,SUP-1804250-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X8MM XIENCE SKYPOINT -,SUP-1804275-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X12MM XIENCE SKYPOINT -,SUP-1804275-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X15MM XIENCE SKYPOINT -,SUP-1804275-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X18MM XIENCE SKYPOINT -,SUP-1804275-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X23MM XIENCE SKYPOINT -,SUP-1804275-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X28MM XIENCE SKYPOINT -,SUP-1804275-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X33MM XIENCE SKYPOINT -,SUP-1804275-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X38MM XIENCE SKYPOINT -,SUP-1804275-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.0X8MM XIENCE SKYPOINT -,SUP-1804300-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.0X12MM XIENCE SKYPOINT -,SUP-1804300-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.0X15MM XIENCE SKYPOINT -,SUP-1804300-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.0X18MM XIENCE SKYPOINT -,SUP-1804300-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.0X23MM XIENCE SKYPOINT -,SUP-1804300-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.0X28MM XIENCE SKYPOINT -,SUP-1804300-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.0X33MM XIENCE SKYPOINT -,SUP-1804300-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.0X38MM XIENCE SKYPOINT -,SUP-1804300-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.25X8MM XIENCE SKYPOINT -,SUP-1804325-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.25X12MM XIENCE SKYPOINT -,SUP-1804325-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.25X15MM XIENCE SKYPOINT -,SUP-1804325-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.25X18MM XIENCE SKYPOINT -,SUP-1804325-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.25X23MM XIENCE SKYPOINT -,SUP-1804325-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.25X28MM XIENCE SKYPOINT -,SUP-1804325-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.25X33MM XIENCE SKYPOINT -,SUP-1804325-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.25X38MM XIENCE SKYPOINT -,SUP-1804325-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.5X8MM XIENCE SKYPOINT -,SUP-1804350-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.5X12MM XIENCE SKYPOINT -,SUP-1804350-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.5X15MM XIENCE SKYPOINT -,SUP-1804350-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.5X18MM XIENCE SKYPOINT -,SUP-1804350-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.5X23MM XIENCE SKYPOINT -,SUP-1804350-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.5X28MM XIENCE SKYPOINT -,SUP-1804350-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.5X33MM XIENCE SKYPOINT -,SUP-1804350-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.5X38MM XIENCE SKYPOINT -,SUP-1804350-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4.0X8MM XIENCE SKYPOINT -,SUP-1804400-08,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4.0X12MM XIENCE SKYPOINT -,SUP-1804400-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4.0X15MM XIENCE SKYPOINT -,SUP-1804400-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4.0X18MM XIENCE SKYPOINT -,SUP-1804400-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4.0X23MM XIENCE SKYPOINT -,SUP-1804400-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4.0X28MM XIENCE SKYPOINT -,SUP-1804400-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4.0X33MM XIENCE SKYPOINT -,SUP-1804400-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4.0X38MM XIENCE SKYPOINT -,SUP-1804400-38,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4.5 X12MM XIENCE SKYPOINT -,SUP-1804450-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4.5 X15MM XIENCE SKYPOINT -,SUP-1804450-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4.5 X18MM XIENCE SKYPOINT -,SUP-1804450-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4.5 X23MM XIENCE SKYPOINT -,SUP-1804450-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4.5 X28MM XIENCE SKYPOINT -,SUP-1804450-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4.5 X33MM XIENCE SKYPOINT -,SUP-1804450-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 5.0 X12MM XIENCE SKYPOINT -,SUP-1804500-12,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 5.0 X15MM XIENCE SKYPOINT -,SUP-1804500-15,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 5.0 X18MM XIENCE SKYPOINT -,SUP-1804500-18,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 5.0 X23MM XIENCE SKYPOINT -,SUP-1804500-23,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 5.0 X28MM XIENCE SKYPOINT -,SUP-1804500-28,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 5.0 X33MM XIENCE SKYPOINT -,SUP-1804500-33,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 30MM PROX 30MM DIST 25-27MM OD AOR 140MM ZENITH TX2 -,SUP-2TEG-2P-30-140-,CDM,C1874,HCPCS,278,RC,,,outpatient,,,29835.9,20885.13,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
DETACHABLE COIL 4MM X 8MM -,SUP-36-152,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT PK PAPYRUS 2.5/15 -,SUP-434887,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT PK PAPYRUS 3.0/15 -,SUP-434888,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT PK PAPYRUS 3.5/15 -,SUP-434889,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT PK PAPYRUS 4.0/15 -,SUP-434890,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT PK PAPYRUS 4.5/15 -,SUP-434891,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT PK PAPYRUS 5.0/15 -,SUP-434892,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT PK PAPYRUS 2.5/20 -,SUP-434893,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT PK PAPYRUS 3.0/20 -,SUP-434894,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT PK PAPYRUS 3.5/20 -,SUP-434895,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT PK PAPYRUS 4.0/20 -,SUP-434896,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT PK PAPYRUS 4.5/20 -,SUP-434897,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT PK PAPYRUS 5.0/20 -,SUP-434898,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT PK PAPYRUS 3.0/26 -,SUP-434899,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT PK PAPYRUS 3.5/26 -,SUP-434900,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT PK PAPYRUS 4.0/26 -,SUP-434901,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT PK PAPYRUS 4.5/26 -,SUP-434902,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT PK PAPYRUS 5.0/26 -,SUP-434903,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
COVERA VASCULAR COVERED STENT 6 x 60 Ref: AVFM06060 -,SUP-AVFM06060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
COVERA VASCULAR COVERED STENT 7 X 80 8F -,SUP-AVFM07080,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
COVERA 8MM X 40MM FLARED -,SUP-AVFM08040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
COVERA 8MM X 60MM FLARED -,SUP-AVFM08060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT VASCULAR COVERA FLARE 8MM X 80MM -,SUP-AVFM08080,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
COVERA STENT GRAFT 10 X 40 -,SUP-AVFM10040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
COVERA VASCULAR COVERED STENT 6 x 40 Ref: AVSM06040 -,SUP-AVSM06040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
COVERA AV STENT GRAFT 8MM X 60MM X 80MM -,SUP-AVSM08060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT COVERA AV GRAFT 8MM X 80MM X 80MM -,SUP-AVSM08080,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT COVERA AV GRAFT 10MM X 60MM 80CM STRAIGHT -,SUP-AVSM10060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
VIABAHN BALLOON EXPANDABLE 7MM X 29MM STENT -,SUP-BXA072902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12468.25,8727.775,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
BALLOON EXPANDABLE ENDOPROSTHESIS VIABAHN 8-11 7FR 29LGTH -,SUP-BXA082902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13199.72,9239.804,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
BALLOON EXPANDABLE ENDOPROSTHESIS VIABAHN 8-11 7FR 39LGTH -,SUP-BXA083902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
BALLOON EXPANDABLE ENDOPROSTHESIS VIABAHN 8-11 7FR 59 LGTH -,SUP-BXA085902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12468.25,8727.775,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT VIABAHN 11MM X 39CM GORE -,SUP-BXA113902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11844.47,8291.129,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
VIABAHN BALLOON EXPANDABLE 1MM X 59MM STENT -,SUP-BXA115902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT VIABAHN VBX BALLOON EXPANDABLE ENDOPROSTHESIS 2 -,SUP-BXAL082901A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
VIABAHN VBX BALLOON EXPANDABLE ENDOPROSTHESIS -,SUP-BXAL082902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT VIABAHN VBX 8MM X 39MM BALLOON EXPANDABLE -,SUP-BXAL083901A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
VIABAHN VBX 8MM X 59MM BALLOON AXPANDABLE STENT -,SUP-BXAL085901A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
VIABAHN VBX BALLOON EXPANDABLE ENDOPROSTHESIS -,SUP-BXAL085902A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10916.22,7641.354,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
EXCLUDER CONFORM AAA EXT ENDO 26MM X 4.5CM 15FR -,SUP-CXA260005,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19511.82,13658.274,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT 3.5X15MM DRIVER OTW BE  143CM 0.014IN GW COMP -,SUP-DRV35015W,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 22X39MM ZENITH FLEX BIFUR MAIN BD EXTEND Z-TRAK -,SUP-ESBE-22-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 24X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-24-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 26X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-26-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 28MM DI 39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK -,SUP-ESBE-28-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 30X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-30-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 32X39MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-32-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 36X50MM ZENITH FLEX MAIN BD EXTEND Z-TRAK INTRO SYS -,SUP-ESBE-36-50-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10550.58,7385.406,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT STENT ENDURANT 23MM -,SUP-ESBF2314C103E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 28/14X103MM ENDURANT IIS BIFUR STNT PRELD PROX -,SUP-ESBF2814C103E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,36592.73,25614.911,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 32/14X103MM ENDURANT IIS BIFUR STNT PRELD PROX -,SUP-ESBF3214C103E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
CONVERTER EV 12MM DIST 24MM PROX 80MM ZENITH FLEX Z-TRAK -,SUP-ESC-24-12-80-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
CONVERTER EV 28MMX12MMX80MM ZENITH FLEX Z-TRAK INTRO SYS -,SUP-ESC-28-12-80ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
CONVERTER EV 32MMX12MMX80MM ZENITH FLEX Z-TRAK INTRO SYS -,SUP-ESC-32-12-80-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
CONVERTER EV 36MMX12MMX82MM ZENITH FLEX Z-TRAK INTRO SYS -,SUP-ESC-36-12-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11432.33,8002.631,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 18X55MM ZENITH AOR -,SUP-ESLE-18-55-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8246.09,5772.263,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
SYS STENT ENDURANT II GRAFT BI -,SUP-ETBF2316C145E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT GRAFT ENDURANT II AORTIC EXTENSION 49E -,SUP-ETCF2323C49E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14726.69,10308.683,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT GRAFT ENDURANT II AO EXT -,SUP-ETCF2828C49E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15079.42,10555.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STEN GRAFT ENDURANT II AORTIC EXT 49E -,SUP-ETCF3232C49E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16783.13,11748.191,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT GRAFT ENDURANTII ILEXT -,SUP-ETEW1313C82E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16402.18,11481.526,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT GRAFT ENDUR II LIMB -,SUP-ETLW1610C156E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT STENT ENDUR II LIMB -,SUP-ETLW1610C199E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,22910.14,16037.098,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT STENT ENDUR IIS LIMB -,SUP-ETLW1610C93E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17372.2,12160.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 16/13X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1613C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17548.57,12283.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 16/13X156MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1613C156E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,24713.73,17299.611,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 16/16X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1616C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,18067.09,12646.963,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 16/16X82MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1616C82E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17280.3,12096.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 16/20X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1620C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,18250.51,12775.357,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 16/20X124MM ENDURANT II BIFUR STNT LMB PRELD PROX -,SUP-ETLW1620C124E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17548.57,12283.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT GRAFT ENDUR II LIMB -,SUP-ETLW1624C156E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,22575.04,15802.528,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT GRAFT CONTRAL ENDURANT -,SUP-ETLW1624C93E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17372.2,12160.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT GRAFT ENDURANT II AUI -,SUP-ETUF2314C102E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 28/14X102MM ENDURANT II BIFUR STNT AOR ILC PRELD -,SUP-ETUF2814C102E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT STENT ENDURANT II 14MM X 36 X102MM -,SUP-ETUF3614C102E,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 7MM 9FR CATH 50MM 120CM TOT 80CM DLV SYS FLAIR FLR -,SUP-FAF07050,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 8MM 9FR CATH 40MM 800CM TOT 80CM DLV SYS FLAIR FLR -,SUP-FAF08040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 7MM 9FR CATH 40MM 120CM TOT 80CM DLV SYS FLAIR STR -,SUP-FAS07040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9995.4,6996.78,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ENPROS 10MM 9FR CATH 40MM FLUENCY+ 117CM TRACHBR SE -,SUP-FTL10040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9825.92,6878.144,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ENPROS 7MM 8FR CATH 60MM FLUENCY+ 80CM TRACHBR SE -,SUP-FTM07060,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10077.08,7053.956,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ENPROS 8MM 9FR CATH 40MM FLUENCY+ 80CM TRACHBR SE -,SUP-FTM08040,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10077.08,7053.956,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ENPROS 12X54MM ZENITH AAA CNTRLAT ILC LEG WVN PLYSTR -,SUP-G12446,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 12MM IPSI LEG DIA 106MM DIST LEG 28MM DIST BD -,SUP-G32500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 30MM PROX 24-26MM OD AOR 94MM PROX BD ZENITH FEN -,SUP-G32533,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
ZENITH FENESTRATED PROXIMAL BODY -,SUP-G32537,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7045.04,4931.528,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT CUST ZFEN-P 2-24-124-R -,SUP-G32540,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 28MM PROX 23-24MM OD AOR 124MM PROX BD ZENITH FEN -,SUP-G32542,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 30MM PROX 24-26MM OD AOR 124MM PROX BD ZENITH FEN -,SUP-G32543,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT ZENITH FEN PROXIMAL BODY - ZFEN-P-2-32-124-R -,SUP-G32544,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 36MM PROX 29-31MM OD AOR 122MM PROX BD ZENITH FEN -,SUP-G32548,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT ZENITH DISTAL BODY - ZFEN-12-28-91 -,SUP-G32554,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 24/12X113MM ZENITH RENU ANCLRY CNVTR H&L-B 1-SHOT -,SUP-G36155,CDM,C1874,HCPCS,278,RC,,,outpatient,,,24186.48,16930.536,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
DRUG ELUTING STENT 80 PTX -,SUP-G38480,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
S ZILVER PTX 6 X 120 X 125 DRU -,SUP-G38482,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9315.54,6520.878,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT PTX 7MM X 40MM -,SUP-G38486,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5487.45,3841.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
DRUG ELUTING STENT 7 - 60 PTX -,SUP-G38487,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6981.34,4886.938,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
DRUG ELUTING STENT 7 - 100 PTX -,SUP-G38489,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ZILVER PTX 7MM X 120MM P -,SUP-G38490,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9315.54,6520.878,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT 8mm x 40mm PTX ZILVER -,SUP-G38495,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5487.45,3841.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ZILVER 8MM X 80MM PTX DRUG ELUTING PERIP -,SUP-G38518,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ZIV6-35-125-8-120-PTX -,SUP-G38532,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9315.54,6520.878,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 20X30MM ZENITH FLEX BIFUR ILC PLG H&L-B 1-SHOT -,SUP-G43055,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7775.01,5442.507,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 36MMX11.3CM ZENITH FLEX AAA BIFUR STNT 20FR DLV SYS -,SUP-G43357,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30491.16,21343.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 36MMX12MMX127MM ZENITH RENU ANCLRY CNVTR H&L-B -,SUP-G43366,CDM,C1874,HCPCS,278,RC,,,outpatient,,,23484.73,16439.311,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
ZENITH TX2 DISSECTION ENDOVASCULAR GRAFT STRAIGHT COMPONENT -,SUP-G47454,CDM,C1874,HCPCS,278,RC,,,outpatient,,,49547.23,34683.061,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
COMPONENT STRAIGHT ENDO GRAFT ZENITH TX2 DISSECTION -,SUP-G47457,CDM,C1874,HCPCS,278,RC,,,outpatient,,,43823.79,30676.653,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
ZENITH FLEX AAA ENDOVASC GRAFT MAIN BODY -,SUP-G48403,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 24MM BD 20-21MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-G48408,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT ZENITH FLEX AAA ENDOVASCULAR BIFURC MAIN BODY -,SUP-G48409,CDM,C1874,HCPCS,278,RC,,,outpatient,,,34530.9,24171.63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
ENDOGRAFT 32-82 ZENITH FLEX -,SUP-G48427,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 36MM BD 29-32MM OD AOR 95MM ZENITH FLEX BIFUR MAIN -,SUP-G48428,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
ZENITH FLEX AAA ENDOVASCULAR GRAFT 20FR -,SUP-G48429,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT ZEINTH 36X95MM ENDOVAS A -,SUP-G48432,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 36MM BD 29-32MM OD AOR 113MM ZENITH FLEX BIFUR MAIN -,SUP-G48433,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 14MM MAIN BD 37MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-G48454,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 22MM MAIN BD 39MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-G48472,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11454.61,8018.227,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 24MM MAIN BD 39MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-G48476,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11454.61,8018.227,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT COLONIC 18MM X 23MM X 12 -,SUP-G51183,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ESOPHAGEAL EVOLUTION FULLY COVERED 20-25-8 -,SUP-G52225,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 38MM PROX 38MM DIST 33-34MM OD AOR 202MM ZENITH TX2 -,SUP-G53435,CDM,C1874,HCPCS,278,RC,,,outpatient,,,29835.9,20885.13,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT ZENITH FLES Z-TRAK AAA ENDOVASC MAIN BODY EXT -,SUP-G55213,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9273.14,6491.198,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
ZENITH FLEX WITH SPIRAL Z ENDOVASCULAR GRAFT -,SUP-G55221,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT ZENITH FLEX LEG 13X56 -,SUP-G55231,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 16MM DIST 56MM ZENITH SPRL-Z CNTRLAT IPSI ILC LEG -,SUP-G55237,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT ZENITH FLEX LEG 16X74 14FR -,SUP-G55238,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT ZENITH FLEX LEG 20MM X 39MM -,SUP-G55240,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 24MM DIST 90MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-G55247,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT ZENITH 22 X 113 -,SUP-G55357,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30944.14,21660.898,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
ZENITH RENU AAA ANCILLARY GRAFT CON 12MM X 28MM X 113MM -,SUP-G55376,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30944.14,21660.898,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
ICAST COVERED STENT- 9MMX38MMX120CM -,SUP-G60511,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9841.79,6889.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
SYNERGY II US MR 2.5X8 -,SUP-H493926008250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
SYNERGY II US MR 2.75X8 -,SUP-H493926008270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
SYNERGY II US MR 3.5X8 -,SUP-H7433926008350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X24MM TAXUS EXPR2 OTW BE PRMNT 135CM PACLIT -,SUP-H7493896824250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8912.4,6238.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.5X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4X8MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902308400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.25X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.5X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4X12MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902312400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X16MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902316250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4X16MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902316400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X20MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902320270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3X20MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902320300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4X20MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902320400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.25X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.5X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4X24MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902324400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.25X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4X28MM ION OTW BE PRMNT 143CM PACLIT THN STRUT -,SUP-H7493902328400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.25X16MM ION MONORAIL RX BE PRMNT 144CM PACLIT -,SUP-H7493902416220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X16MM ION MONORAIL RX BE PRMNT 144CM PACLIT -,SUP-H7493902416270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3X20MM ION MONORAIL RX BE PRMNT 144CM PACLIT THN -,SUP-H7493902420300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3X28MM ION MONORAIL RX BE PRMNT 144CM PACLIT THN -,SUP-H7493902428300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X32MM ION MONORAIL RX BE PRMNT 144CM PACLIT THN -,SUP-H7493902432250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X32MM ION MONORAIL RX BE PRMNT 144CM PACLIT -,SUP-H7493902432270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.25X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.5X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4X8MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911408400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.25X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.5X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4X12MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911412400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.25X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.5X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4X16MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911416400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.25X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.5X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4X20MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911420400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.25X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.5X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4X24MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911424400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.25X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.5X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4X28MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911428400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.25X32MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911432220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X32MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911432250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.5X32MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911432350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.5X38MM PROMUS ELEM+ MR RX BE PRMNT 144CM EVEROL -,SUP-H7493911438350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.25X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SV -,SUP-H7493911608220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911608250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911608270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL WKHRS -,SUP-H7493911608300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4X8MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911608400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.25X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911612250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.5X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911612350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4X12MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911612400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.25X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.5X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911616350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4X16MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911616400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.5X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911620350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4X20MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911620400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.25X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.5X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911624350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4X24MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911624400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.25X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911628250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.5X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911628350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4X28MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911628400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.25X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911632250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.5X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911632350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4X32MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911632400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.5X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL SM -,SUP-H7493911638250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911638270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911638300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3.5X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL -,SUP-H7493911638350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4X38MM PROMUS ELEM+ OTW BE PRMNT 144CM EVEROL LRG -,SUP-H7493911638400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 2.25 X 8 -,SUP-H7493926008220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
SYNERGY II US MR 2.25X8 -,SUP-H7493926008220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 2.50 X 8 -,SUP-H7493926008250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 2.75 X 8 -,SUP-H7493926008270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 3.00 X 8 -,SUP-H7493926008300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
SYNERGY II US MR 3.00X8 -,SUP-H7493926008300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 3.50 X 8 -,SUP-H7493926008350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 4.00 X 8 -,SUP-H7493926008400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
SYNERGY II US MR 4.0X8 -,SUP-H7493926008400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 2.25 X 12 -,SUP-H7493926012220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 2.50 X 12 -,SUP-H7493926012250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 2.75 X 12 -,SUP-H7493926012270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 3.00 X 12 -,SUP-H7493926012300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 3.50 X 12 -,SUP-H7493926012350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 4.00 X 12 -,SUP-H7493926012400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 2.25 X 16 -,SUP-H7493926016220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 2.50 X 16 -,SUP-H7493926016250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 2.75 X 16 -,SUP-H7493926016270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 3.00 X 16 -,SUP-H7493926016300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 3.50 X 16 -,SUP-H7493926016350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 4.00 X 16 -,SUP-H7493926016400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 2.25 X 20 -,SUP-H7493926020220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 2.50 X 20 -,SUP-H7493926020250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 2.50 X 24 -,SUP-H7493926020250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 2.50 X 28 -,SUP-H7493926020250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 2.75 X 20 -,SUP-H7493926020270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 3.00 X 20 -,SUP-H749392602030,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 3.50 X 20 -,SUP-H7493926020350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 4.00 X 20 -,SUP-H7493926020400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 2.25 X 24 -,SUP-H7493926024220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 2.75 X 24 -,SUP-H7493926024270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 3.00 X 24 -,SUP-H7493926024300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 3.50 X 24 -,SUP-H7493926024350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 4.00 X 24 -,SUP-H7493926024400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 2.25 X 28 -,SUP-H7493926028220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 2.75 X 28 -,SUP-H7493926028270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 3.00 X 28 -,SUP-H7493926028300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 3.50 X 28 -,SUP-H7493926028350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 4.00 X 28 -,SUP-H7493926028400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 2.50 X 32 -,SUP-H7493926032250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 2.75 X 32 -,SUP-H7493926032270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 3.00 X 32 -,SUP-H7493926032300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 3.50 X 32 -,SUP-H7493926032350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 4.00 X 32 -,SUP-H7493926032400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 2.25 X 38 -,SUP-H7493926038220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 2.50 X 38 -,SUP-H7493926038250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 2.75 X 38 -,SUP-H7493926038270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 3.00 X 38 -,SUP-H7493926038300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 3.50 X 38 -,SUP-H7493926038350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES MR 4.00 X 38 -,SUP-H7493926038400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 2.25 X 8 -,SUP-H7493926108220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 2.50 X 8 -,SUP-H7493926108250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 2.75 X 8 -,SUP-H7493926108270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 3.00 X 8 -,SUP-H7493926108300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 3.50 X 8 -,SUP-H7493926108350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 4.00 X 8 -,SUP-H7493926108400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 2.25 X 12 -,SUP-H7493926112220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 2.50 X 12 -,SUP-H7493926112250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 2.75 X 12 -,SUP-H7493926112270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 3.00 X 12 -,SUP-H7493926112300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 3.50 X 12 -,SUP-H7493926112350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 4.00 X 12 -,SUP-H7493926112400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 2.25 X 16 -,SUP-H7493926116220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 2.50 X 16 -,SUP-H7493926116250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 2.75 X 16 -,SUP-H7493926116270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 3.00 X 16 -,SUP-H7493926116300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 3.50 X 16 -,SUP-H7493926116350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 4.00 X 16 -,SUP-H7493926116400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 2.25 X 20 -,SUP-H7493926120220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 2.50 X 20 -,SUP-H7493926120250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 2.75 X 20 -,SUP-H7493926120270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 3.00 X 20 -,SUP-H7493926120300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 3.50 X 20 -,SUP-H7493926120350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 4.00 X 20 -,SUP-H7493926120400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 2.25 X 24 -,SUP-H7493926124220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 2.50 X 24 -,SUP-H7493926124250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 2.75 X 24 -,SUP-H7493926124270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 3.00 X 24 -,SUP-H7493926124300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 3.50 X 24 -,SUP-H7493926124350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 4.00 X 24 -,SUP-H7493926124400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 2.25 X 28 -,SUP-H7493926128220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 2.50 X 28 -,SUP-H7493926128250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 2.75 X 28 -,SUP-H7493926128270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 3.00 X 28 -,SUP-H7493926128300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 3.50 X 28 -,SUP-H7493926128350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 4.00 X 28 -,SUP-H7493926128400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 2.25 X 32 -,SUP-H7493926132220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 2.50 X 32 -,SUP-H7493926132250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 2.75 X 32 -,SUP-H7493926132270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 3.00 X 32 -,SUP-H7493926132300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 3.50 X 32 -,SUP-H7493926132350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 4.00 X 32 -,SUP-H7493926132400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 2.25 X 38 -,SUP-H7493926138220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 2.50 X 38 -,SUP-H7493926138250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 2.75 X 38 -,SUP-H7493926138270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 3.00 X 38 -,SUP-H7493926138300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 3.50 X 38 -,SUP-H7493926138350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY DES OTW 4.00 X 38 -,SUP-H7493926138400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
ELUVIA US 6MM X 40MM X 130CM -,SUP-H74939294600410,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
ELUVIA US 6MM X 60MM X 130CM -,SUP-H74939294600610,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
ELUVIA US 6MM X 80MM X 130CM -,SUP-H74939294600810,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
ELUVIA US 6MM X 100MM X 130CM -,SUP-H74939294601010,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
ELUVIA US 6MM X 120MM X 130CM -,SUP-H74939294601210,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10749.14,7524.398,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
ELUVIA US 6X150 130 cm -,SUP-H74939294601510,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13719.54,9603.678,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
ELUVIA 7MM x 40MM x 130CM -,SUP-H74939294700410,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8466.78,5926.746,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
ELUVIA 7MM x 60MM x 130CM -,SUP-H74939294700610,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
ELUVIA DRUG-ELUTING VASCULAR STENT SYSTEM 7MM X 80MM X 130CM -,SUP-H74939294700810,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
ELUVIA 7MM x 100MM x 130CM -,SUP-H74939294701010,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9635.24,6744.668,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
ELUVIA 7MM x 120MM x 130CM -,SUP-H74939294701210,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10749.14,7524.398,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
ELUVIA US 7X150 130 cm -,SUP-H74939294701510,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13719.54,9603.678,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT PROMUS ELITE US MR 4.0 X 8MM -,SUP-H7493941208400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT PROMUS ELITE US MR 4.0 X 12MM -,SUP-H7493941212400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT PROMUS ELITE US MR 2.50 X 32MM -,SUP-H7493941232250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT PROMUS ELITE US MR 3.50 X 32MM -,SUP-H7493941232350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT PROMUS ELITE US MR 3.50 X 38MM -,SUP-H7493941238350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 2.25 X 8 -,SUP-H7493941808220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 2.50 X 8 -,SUP-H7493941808250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 2.75 X 8 -,SUP-H7493941808270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 3.0 X 8 -,SUP-H7493941808300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 3.5 X 8 -,SUP-H7493941808350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 4.0 X 8 -,SUP-H7493941808400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 2.25 X 12 -,SUP-H7493941812220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 2.50 X 12 -,SUP-H7493941812250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 2.75 X 12 -,SUP-H7493941812270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 3.0 X 12 -,SUP-H7493941812300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 3.5 X 12 -,SUP-H7493941812350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 4.0 X 12 -,SUP-H7493941812400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 4.5 X 12 -,SUP-H7493941812450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 5.0 X 12 -,SUP-H7493941812500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 2.25 X 16 -,SUP-H7493941816220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 2.50 X 16 -,SUP-H7493941816250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 2.75 X 16 -,SUP-H7493941816270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 3.0 X 16 -,SUP-H7493941816300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 3.5 X 16 -,SUP-H7493941816350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 4.0 X 16 -,SUP-H7493941816400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 4.5 X 16 -,SUP-H7493941816450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 5.0 X 16 -,SUP-H7493941816500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 2.25 X 20 -,SUP-H7493941820220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 2.50 X 20 -,SUP-H7493941820250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 2.75 X 20 -,SUP-H7493941820270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 3.0 X 20 -,SUP-H7493941820300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 3.5 X 20 -,SUP-H7493941820350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 4.0 X 20 -,SUP-H7493941820400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 4.5 X 20 -,SUP-H7493941820450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 5.0 X 20 -,SUP-H7493941820500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 2.25 X 24 -,SUP-H7493941824220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 2.50 X 24 -,SUP-H7493941824250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 2.75 X 24 -,SUP-H7493941824270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 3.0 X 24 -,SUP-H7493941824300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 3.5 X 24 -,SUP-H7493941824350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 4.0 X 24 -,SUP-H7493941824400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 4.5 X 24 -,SUP-H7493941824450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 5.0 X 24 -,SUP-H7493941824500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 2.25 X 28 -,SUP-H7493941828220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 2.50 X 28 -,SUP-H7493941828250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 2.75 X 28 -,SUP-H7493941828270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 3.0 X 28 -,SUP-H7493941828300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 3.5 X 28 -,SUP-H7493941828350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 4.0 X 28 -,SUP-H7493941828400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 4.5 X 28 -,SUP-H7493941828450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 5.0 X 28 -,SUP-H7493941828500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 2.25 X 32 -,SUP-H7493941832220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 2.50 X 32 -,SUP-H7493941832250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 2.75 X 32 -,SUP-H7493941832270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 3.0 X 32 -,SUP-H7493941832300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 3.5 X 32 -,SUP-H7493941832350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 4.0 X 32 -,SUP-H7493941832400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 4.5 X 32 -,SUP-H7493941832450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 5.0 X 32 -,SUP-H7493941832500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 2.25 X 38 -,SUP-H7493941838220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 2.50 X 38 -,SUP-H7493941838250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 2.75 X 38 -,SUP-H7493941838270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 3.0 X 38 -,SUP-H7493941838300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 3.5 X 38 -,SUP-H7493941838350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR 4.0 X 38 -,SUP-H7493941838400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR US 2.5 X 48MM REF:H7493941848250 -,SUP-H7493941848250,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR US 2.75 X 48MM REF:H7493941848270 -,SUP-H7493941848270,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR US 3 X 48MM REF:H7493941848300 -,SUP-H7493941848300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR US 3.5 X 48MM REF:H7493941848350 -,SUP-H7493941848350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT SYNERGY XD DES MR US 4 X 48MM REF:H7493941848400 -,SUP-H7493941848400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT S MEGATRON DES US MR 3.5 X 16MM REF:H7493942816350 -,SUP-H7493942816350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT S MEGATRON DES US MR 3.5 X 20MM REF:H7493942820350 -,SUP-H7493942820350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT S MEGATRON DES US MR 4 X 20MM REF:H7493942820400 -,SUP-H7493942820400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT S MEGATRON DES US MR 4.5 X 20MM REF:H7493942820450 -,SUP-H7493942820450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT S MEGATRON DES US MR 5 X 20MM REF:H7493942820500 -,SUP-H7493942820500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT S MEGATRON DES US MR 3.5 X 24MM REF:H7493942824350 -,SUP-H7493942824350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT S MEGATRON DES US MR 4 X 24MM REF:H7493942824400 -,SUP-H7493942824400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT S MEGATRON DES US MR 4.5 X 24MM REF:H7493942824450 -,SUP-H7493942824450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT S MEGATRON DES US MR 5 X 24MM REF:H7493942824500 -,SUP-H7493942824500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT S MEGATRON DES US MR 3.5 X 28MM REF:H7493942828350 -,SUP-H7493942828350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT S MEGATRON DES US MR 4.0 X 28MM REF:H7493942828400 -,SUP-H7493942828400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT S MEGATRON DES US MR 4.5 X 28MM REF:H7493942828450 -,SUP-H7493942828450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT S MEGATRON DES US MR 5.0 X 28MM REF:H7493942828500 -,SUP-H7493942828500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT S MEGATRON DES US MR 3.5 X 32MM REF:H7493942832350 -,SUP-H7493942832350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT S MEGATRON DES US MR 4.0 X 32MM REF:H7493942832400 -,SUP-H7493942832400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT S MEGATRON DES US MR 4.5 X 32MM REF:H7493942832450 -,SUP-H7493942832450,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT S MEGATRON DES US MR 5.0 X 32MM REF:H7493942832500 -,SUP-H7493942832500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
SYNERGY II US MR 2.25X12 -,SUP-H749396012220,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT BIL 10X60MM 194CM CATH WALLSTNT SE UNCNTSTR CVR ENPROS -,SUP-H965431100,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7116.04,4981.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT BALLOON EXPANDABLE VASC COVERED -,SUP-LSMU0800737,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT LIFESTREAM 7MM X 58MM BALLOON EXP -,SUP-LSMU0800758,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
LIFESTREAM BALLOON EP VASC COVERED STENT 80CM X 26MM -,SUP-LSMU0800826,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
12MM X 38MM LIFE STREAM -,SUP-LSMU0801238,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT LIFESTREAM 5MM X 26MM -,SUP-LSMU1350526,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
LIFESTREAM 12MM X 38MM X 80CM -,SUP-LSMU1350626,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13923.75,9746.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
FIBERED PLATINUM COIL 2 X 5MM -,SUP-M0013120211,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2243.7,1570.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
FIBERED PLATNUM COIL 4 X 4MM -,SUP-M0013120221,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2243.7,1570.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
DETACHABLE COIL 3MM X 6MM -,SUP-M001361500,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2622.16,1835.512,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
DETACHABLE COIL 6MM X 10MM -,SUP-M001361560,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2093.7,1465.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
PUSHER SURG ARSCP 0.016INX177CM VASC COIL 16 -,SUP-M0014012160,CDM,C1874,HCPCS,278,RC,,,outpatient,,,1036.3,725.41,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ESPH 18MM BD 13MM BD 23MM FLR 15CM POLYFLEX SE SIL LF -,SUP-M00514320,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8623.21,6036.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ESPH 18MM 25/23MM OD P/D FLR 18.5FR CATH 10CM WALLFLX -,SUP-M00516700,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ESPH 18MM 25/23MM OD P/D FLR 12CM WALLFLX SE BRD FLLY -,SUP-M00516710,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
WALLFLEX ESOPHAGEAL FULLY COVERED 18 X 15 -,SUP-M00516720,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ESPH 23MM 28/28MM OD P/D FLR 10CM WALLFLX SE BRD FLLY -,SUP-M00516730,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
WALLFLEX ESOPHAGEAL FULLY COVERED 23 X 10 -,SUP-M00516730,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ESPH 23MM 28/28MM OD P/D FLR 12CM WALLFLX SE BRD FLLY -,SUP-M00516740,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
WALLFLEX ESOPHAGEAL FULLY COVERED 23 X 12 -,SUP-M00516740,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
WALLFLEX ESOPHAGEAL FULLY COVERED 18 X 15 -,SUP-M00516750,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10604.02,7422.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ESPH 18MM 23/23MM OD P/D FLR 10CM WALLFLX SE BRD FLLY -,SUP-M00516900,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9314.91,6520.437,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
WALLFLEX ESOPHAGEAL PARTIALLY COVERED 18 X 10 -,SUP-M00516900,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
WALLFLEX ESOPHAGEAL PARTIALLY COVERED 18 X 12 -,SUP-M00516910,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ESPH 18MM 23/23MM OD P/D FLR 123MM WALLFLX SE BRD FLLY -,SUP-M00516910,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
WALLFLEX PC ESOPH STENT 23/28MM X 105MM -,SUP-M00516930,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
WALLFLEX ESOPHAGEAL PARTIALLY COVERED 23 X 12 -,SUP-M00516940,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10387.49,7271.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT AXIOS ELECTROCAUTERY-ENHANCED 15mm X 10mm -,SUP-M00553650,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17317.43,12122.201,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT CYST GASTROSTOMY AXIOS -,SUP-M00553650,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19659.22,13761.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT AXIOS 10 X 20 EE LO -,SUP-M00553660,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19659.22,13761.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT BIL 10X60MM WALLSTNT RX SE PRT CVR MTL 0.035IN GW COMP -,SUP-M00569710,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7266.24,5086.368,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT WALLFLEX BILIARY FULLY COVERED -,SUP-M00570350,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
S WALLFLEX BILI 10X40 RX COV -,SUP-M00570360,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT BIL 10X60MM WALLFLX RX SE FLLY CVR PLATINOL 0.035IN GW -,SUP-M00570370,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT BIL 10X80MM WALLFLX RX SE FLLY CVR PLATINOL 0.035IN GW -,SUP-M00570380,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9758.77,6831.139,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT PARTIALLY COVERED 8 X 100 -,SUP-M00570730,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9639.76,6747.832,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ULTRAFLEX 8 X 40 25MM TR -,SUP-M00576520,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT TRACHBR 10MM XPND 18FR COMPRESS 30MM ULFLX PRT CVR -,SUP-M00576530,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT RX COVRD 15 X 30 -,SUP-M00576550,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT RX COVRD 25 X 40 -,SUP-M00576560,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT CVRD ULTRAFLEX 14 X 40 -,SUP-M00576580,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT CVRD ULTRAFLEX 14 X 60 -,SUP-M00576590,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT TRACHBR 16MMX40MM ULFLX CVR DIST RELS SIL DIST RELS -,SUP-M00576610,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ULTRAFLEX 16X45 -,SUP-M00576620,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT CVRD ULTRAFLEX 18 X 40 -,SUP-M00576640,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT CVRD ULTRAFLEX 20 X 40 -,SUP-M00576670,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11747.93,8223.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT CVRD ULTRAFLEX 20 X 80 -,SUP-M00576690,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11748.3,8223.81,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ESOPHAGEAL 23 X 150 ENDO -,SUP-MAXX-2315,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9175.53,6422.871,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  2.00 x 08MM -,SUP-ONYXNG20008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  2.00 x 12MM -,SUP-ONYXNG20012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  2.00 x 15MM -,SUP-ONYXNG20015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  2.00 x 18MM -,SUP-ONYXNG20018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2983.75,2088.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  2.00 x 30MM -,SUP-ONYXNG20030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  2.25 x 08MM -,SUP-ONYXNG22508UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  2.25 x 12MM -,SUP-ONYXNG22512UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  2.25 x 15MM -,SUP-ONYXNG22515UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  2.25 x 18MM -,SUP-ONYXNG22518UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  2.25 x 22MM -,SUP-ONYXNG22522UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  2.25 x 26MM -,SUP-ONYXNG22526UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  2.25 x 30MM -,SUP-ONYXNG22530UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  2.25 x 34MM -,SUP-ONYXNG22534UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  2.25 x 38MM -,SUP-ONYXNG22538UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  2.50 x 08MM -,SUP-ONYXNG25008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  2.50 x 12MM -,SUP-ONYXNG25012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  2.50 x 15MM -,SUP-ONYXNG25015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  2.50 x 18MM -,SUP-ONYXNG25018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  2.50 x 22MM -,SUP-ONYXNG25022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  2.50 x 26MM -,SUP-ONYXNG25026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  2.50 x 30MM -,SUP-ONYXNG25030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  2.50 x 34MM -,SUP-ONYXNG25034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  2.50 x 38MM -,SUP-ONYXNG25038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  2.75 x 08MM -,SUP-ONYXNG27508UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  2.75 x 12MM -,SUP-ONYXNG27512UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  2.75 x 15MM -,SUP-ONYXNG27515UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  2.75 x 18MM -,SUP-ONYXNG27518UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  2.75 x 22MM -,SUP-ONYXNG27522UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  2.75 x 26MM -,SUP-ONYXNG27526UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  2.75 x 30MM -,SUP-ONYXNG27530UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  2.75 x 34MM -,SUP-ONYXNG27534UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  2.75 x 38MM -,SUP-ONYXNG27538UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  3.0 x 08MM -,SUP-ONYXNG30008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  3.0 x 12MM -,SUP-ONYXNG30012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  3.0 x 15MM -,SUP-ONYXNG30015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  3.0 x 18MM -,SUP-ONYXNG30018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  3.0 x 22MM -,SUP-ONYXNG30022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  3.0 x 26MM -,SUP-ONYXNG30026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  3.0 x 30MM -,SUP-ONYXNG30030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  3.0 x 34MM -,SUP-ONYXNG30034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  3.0 x 38MM -,SUP-ONYXNG30038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  3.5 x 08MM -,SUP-ONYXNG35008UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  3.5 x 12MM -,SUP-ONYXNG35012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  3.5 x 15MM -,SUP-ONYXNG35015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  3.5 x 18MM -,SUP-ONYXNG35018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  3.5 x 22MM -,SUP-ONYXNG35022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  3.5 x 26MM -,SUP-ONYXNG35026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  3.5 x 30MM -,SUP-ONYXNG35030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  3.5 x 34MM -,SUP-ONYXNG35034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  3.5 x 38MM -,SUP-ONYXNG35038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  4.0 x 12MM -,SUP-ONYXNG40012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  4.0 x 15MM -,SUP-ONYXNG40015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  4.0 x 18MM -,SUP-ONYXNG40018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  4.0 x 22MM -,SUP-ONYXNG40022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  4.0 x 26MM -,SUP-ONYXNG40026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  4.0 x 30MM -,SUP-ONYXNG40030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  4.0 x 34MM -,SUP-ONYXNG40034UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  4.0 x 38MM -,SUP-ONYXNG40038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  4.5 x 12MM -,SUP-ONYXNG45012UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  4.5 x 15MM -,SUP-ONYXNG45015UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  4.5 x 18MM -,SUP-ONYXNG45018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  4.5 x 22MM -,SUP-ONYXNG45022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  4.5 x 26MM -,SUP-ONYXNG45026UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  4.5 x 30MM -,SUP-ONYXNG45030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  5.0 x 18MM -,SUP-ONYXNG50018UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  5.0 x 22MM -,SUP-ONYXNG50022UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ONYX DES  5.0 x 30MM -,SUP-ONYXNG50030UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT BIL 5X18MM 135CM PALMZ GENESIS RX BE TRNSHEP SS -,SUP-PG1850BAX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4882.72,3417.904,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
EXCLUDER AAA ENDO EXTENDER 26MMX3.3CM 16FR -,SUP-PLA260300,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13934.89,9754.423,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 32MM 27-29MM AOR 4.5CM EXCLDR AOR EXTEND LPRO SULS -,SUP-PLA320400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13934.89,9754.423,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
EXCLUDER AAA ENDO EXTENDER 36MM X 4.5CM 18FR -,SUP-PLA360400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13934.89,9754.423,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
EXCLUDER AAA ENDOPROSTHESIS L 16MM X 12MM X 14CM 12F -,SUP-PLC121400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
EXCLUDER CONTRALATERAL LEG 16MM X 14.5MM X 10CM 12F -,SUP-PLC141000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GORE EXCLUDER AAA ENDOPROSTHESIS -,SUP-PLC141200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 13.5-14.5MM 16MM ILC 9.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PLC161000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 13.5-14.5MM 16MM ILC 11.5CM EXCLDR CNTRLAT LEG ILC -,SUP-PLC161200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 13.5-14.5MM 16MM ILC 13.5CM EXCLDR CNTRLAT LEG ILC -,SUP-PLC161400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EXCLUDER AAA ENDO CONTRA LEG 16 X 18 X 9.5CM 12FR -,SUP-PLC181000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
EXCLUDER AAA ENDO CONTRA LEG 16MM X 20MM X 11.5CM 12FR -,SUP-PLC201200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
EXCLUDER AAA ENDO CONTRA LEG 16 X 23 X 12 14FR -,SUP-PLC231200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
EXCLUDER AAA ENDO CONTRA LEG 16MM X 23MM X 14CM 14FR -,SUP-PLC231400,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GORE EXCLUDER AAA CONTRALATERAL LEG 16 X 27 X 100MM -,SUP-PLK271000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,19808.86,13866.202,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GORE VIATORR 10MM X 6CM -,SUP-PTB8106275,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17651.6,12356.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GORE VIATORR 10MM X 7CM -,SUP-PTB8107275,CDM,C1874,HCPCS,278,RC,,,outpatient,,,17651.6,12356.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 10-11MM 12MM ILC 10CM EXCLDR CNTRLAT LEG LPRO SULS -,SUP-PXC121000,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 12-13.5MM 14.5MM ILC 12CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC141200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 13.5-14.5 MM 6MMX11.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC161200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 16.5-18.5 MM 20MMX11.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC201200,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 16.5-18.5 MM 20MMX13.5CM EXCLDR CNTRLAT LEG LPRO -,SUP-PXC201400-L,CDM,C1874,HCPCS,278,RC,,,outpatient,,,15594.6,10916.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 10MMX7CM EXCLDR ILC EXTEND LPRO SULS CNSTRCT SEAL -,SUP-PXL161007,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11510.3,8057.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 12MMX7CM EXCLDR ILC EXTEND LPRO SULS CNSTRCT SEAL -,SUP-PXL161207,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10953.35,7667.345,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 27-29/12-13.5MM 31/14.5MM DIA AOR/ILC 18CM EXCLDR -,SUP-RLT311413,CDM,C1874,HCPCS,278,RC,,,outpatient,,,32100.6,22470.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 2.75X18MM RESOLUT IN RX BE PRMNT 140CM ZOTARO -,SUP-RSINT27518UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30022W,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30026W,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 3X38MM RESOLUT IN RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT30038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT DES 4X38MM RESOLUT IN RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT40038UX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 22MM 18FR SHTH 8.2CM BIFUR -,SUP-TFFB-22-82,CDM,C1874,HCPCS,278,RC,,,outpatient,,,30491.16,21343.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT 22X82 ZENITH ENDOVASC AA -,SUP-TFFB-22-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 22MM BD 18-19MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-22-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT ZENITH 24X82 ENDOVASC -,SUP-TFFB-24-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 26MM BD 22MM AOR 111MM ZENITH FLEX BIFUR MAIN BD -,SUP-TFFB-26-111-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT 26X82 ZEINTH ENDOV AAA -,SUP-TFFB-26-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 26MM BD 22MM AOR 96MM ZENITH FLEX BIFUR MAIN BD -,SUP-TFFB-26-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 28MM BD 23-24MM OD AOR 111MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-28-111-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 28MM BD 23-24MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-28-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 30MM BD 25-26MM OD AOR 11.1CM ZENITH FLEX BIFUR -,SUP-TFFB-30-111,CDM,C1874,HCPCS,278,RC,,,outpatient,,,31404.55,21983.185,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 30MM BD 25-26MM OD AOR 111MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-30-111-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT 30X82 ZEINTH ENDOVASC AB -,SUP-TFFB-30-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV ZENITH FLEX 30MM 20FRX9.6MM BIFUR MAIN BD EXTEND -,SUP-TFFB-30-96,CDM,C1874,HCPCS,278,RC,,,outpatient,,,29150.76,20405.532,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 30MM BD 25-26MM OD AOR 96MM ZENITH FLEX BIFUR MAIN -,SUP-TFFB-30-96-2T,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
COOK GRAFT TFFB-30-96-ZT -,SUP-TFFB-30-96-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ENPROS 12X71MM ZENITH AAA CNTRLAT ILC LEG WVN PLYSTR -,SUP-TFLE-12-71,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ENPROS 14X54MM ZENITH AAA CNTRLAT ILC LEG WVN PLYSTR -,SUP-TFLE-14-54,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 14MM MAIN 56MM LEG ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-TFLE-14-56-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11454.61,8018.227,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 14MM MAIN BD 73MM ZENITH FLEX BIFUR CNTRLAT IPSI -,SUP-TFLE-14-73,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 14X56MM ZENITH FLEX AAA Z-TRAK BIFUR ILC CNTRLAT -,SUP-TFLE-15-56,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ENPROS 18MM 16FR SHTH 54MM ZENITH AAA CNTRLAT ILC LEG -,SUP-TFLE-18-54,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11124.15,7786.905,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT ZENITH FLEX AAA 28X82M -,SUP-TTFB-28-82-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26169.94,18318.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT STENT ENDUR IIS BIF BODY -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,35185.32,24629.724,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GORE VIATORR 10MM X 8CM -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16385.47,11469.829,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
S VIABAHN 7MM X 7CM VIA VAS -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ESOPHAGEAL 21X150 -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,9175.53,6422.871,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT POLYFLEX AIRWAY 16X40 -,SUP-UNDEFINED,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8267.48,5787.236,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
VALIANT THORACIC CAPTIVA STENT GRAFT 26MM X 112MM 22FR -,SUP-VAMF2626C100TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,40668.87,28468.209,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT GRAFT VALIANT CAPTIVA WITH DELIVERY SYSTEM -,SUP-VAMF2828C100TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,40668.5,28467.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ENPROS 5MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART. -,SUP-VBH051002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12063.54,8444.478,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ENPROS 6MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART. -,SUP-VBH061002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12152.65,8506.855,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ENPROS 6MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC_ART. -,SUP-VBH061502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13968.31,9777.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ENPROS 7MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBH071002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12152.65,8506.855,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ENPROS 8MMX10CM 120CM VIABAHN SE LPRO TIP TO HUB DPLY -,SUP-VBH081002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12152.65,8506.855,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ENPROS 9MMX15CM 120CM VIABAHN SE LPRO TIP TO HUB DPLY -,SUP-VBH091502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13968.31,9777.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
S 10MMX 5.0CM VIA VASC 120CM -,SUP-VBH100502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11785.06,8249.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ENPROS 10MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBH101502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14495.55,10146.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GORE VIABAHN ENDOPROSTHESIS- 7MMX5CM 8FR 120CMCATH -,SUP-VBHR070502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12910.1,9037.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ENPROS 8MM 8FR DVC 5CM GORE-HYBRID VIABAHN 120CM NTNL -,SUP-VBHR080502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12910.1,9037.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ENPROS 6MMX5CM 120CM VIABAHN FEM ILC ART TIP TO HUB -,SUP-VBJ060502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11268.96,7888.272,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ENPROS 6MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART. -,SUP-VBJ061502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14347.03,10042.921,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ENPROS 6MMX25CM 120CM GORE-HYBRID VIABAHN SUPRFC FEM -,SUP-VBJ062502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,23555.27,16488.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ENPROS 7MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJ071502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14347.03,10042.921,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ENPROS 8MMX5CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJ080502,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10923.65,7646.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ENPROS 8MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJ081002,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12445.98,8712.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ENPROS 5MM 6FRX5CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR050502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,11669.96,8168.972,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ENPROS 5MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR051002A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12761.58,8933.106,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ENPROS 5MMX15CM VIABAHN 120MM CATH -,SUP-VBJR051502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14885.42,10419.794,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ENPROS 5MM 6FRX25CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR052502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,24297.87,17008.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ENPROS 6MMX5CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR060502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13403.93,9382.751,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ENPROS 6MMX10CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR061002A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ENPROS 6MMX15CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR061502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14224.5,9957.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ENPROS 6MM 6FRX25CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR062502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,23351.06,16345.742,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ENPROS 7MM 7FRX5CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR070502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,12226.91,8558.837,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ENPROS 7MM 7FRX10CM GORE-HYBRID VIABAHN 120CM FEM ILC -,SUP-VBJR071002A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,13366.8,9356.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT ENPROS 7MMX25CM GORE-HYBRID VIABAHN 120CM FEM ILC ART -,SUP-VBJR072502A,CDM,C1874,HCPCS,278,RC,,,outpatient,,,26414.28,18489.996,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
VALIANT NAVION THORACIC STENT GRAFT SYSTEM -,SUP-VNMC2020C94TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
THORACIC STENT GRAFT 94MM 25MM -,SUP-VNMC2525C94TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT GRAFT VALION NAVION THORACIC -,SUP-VNMC4040C55TU,CDM,C1874,HCPCS,278,RC,,,outpatient,,,45627.17,31939.019,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT GORE VIABIL 10MM X 6CM BILIARY -,SUP-VSWVN1006,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT GORE VIABIL 10MM X 8CM BILIARY -,SUP-VSWVN1008,CDM,C1874,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 28MM PROX BD DIA 94MM PROX BD ZENITH FEN INTNL -,SUP-ZFEN-9-2-28-94R,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 12MM IPSI LEG DIA 121MM DIST LEG 28MM DIST BD -,SUP-ZFEN-D-1228121C,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
FENESTRATED DISTAL BODY -,SUP-ZFEN-D-12-2876C,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14592.09,10214.463,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT HUM TIS FEN 26MM ZENITH EV PROX BD LF -,SUP-ZFEN-P-226124-R,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 36MM PROX 29-31MM OD AOR 107MM PROX BD ZENITH FEN -,SUP-ZFEN-P-2-36107R,CDM,C1874,HCPCS,278,RC,,,outpatient,,,28765.22,20135.654,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT VASC DES ZILVER PTX 6X100MM 125CM OTW SE PRELD -,SUP-ZISV6351256100,CDM,C1874,HCPCS,278,RC,,,outpatient,,,8381.86,5867.302,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT VASC DES ZILVER PTX 6X60MM 125CM OTW SE PRELD -,SUP-ZIV6-35-125660,CDM,C1874,HCPCS,278,RC,,,outpatient,,,6981.34,4886.938,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT VASC DES ZILVER PTX 7X100MM 125CM OTW SE PRELD -,SUP-ZIV6351257100PT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7617.98,5332.586,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT VASC DES ZILVER PTX 7X80MM 125CM OTW SE PRELD -,SUP-ZIV635125780PTX,CDM,C1874,HCPCS,278,RC,,,outpatient,,,7617.98,5332.586,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 11MM DIST 56MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-ZSLE-11-56-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,14387.88,10071.516,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 11MM DIST 74MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-ZSLE-11-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT ZENITH FLEX LEG 13X74 -,SUP-ZSLE-13-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT ZENITH AAA LEG 13X90MM -,SUP-ZSLE-13-90-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 16MMX90MM ZENITH SPRL -Z BIFUR CNTRLAT IPSI -,SUP-ZSLE-16-16-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 16MM DIST 39MM ZENITH SPRL -Z CNTRLAT IPSI ILC LEG -,SUP-ZSLE-16-39-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT ZENITH AAA LEG 20X74MM -,SUP-ZSLE-20-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT ZENITH AAA 24 X 56MM LEG -,SUP-ZSLE-24-56-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
GRAFT EV 24MM 16FR ID 6MM INTRO SHTH 74MM ZENITH SPRL -Z -,SUP-ZSLE-24-74-ZT,CDM,C1874,HCPCS,278,RC,,,outpatient,,,16441.16,11508.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,232.64935,38052.27264,other,Non-Reimbursable Procedures,,
STENT 4.5X13MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003381-13,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 4.5X18MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003381-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 4.5X28MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003381-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 5X13MM MULTILNK ULT RX BE PRMNT 143CM MUL-CMPLNT LRG -,SUP-1003382-13,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2X8MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2X12MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2X15MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2X18MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2X23MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2X28MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007821-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.25X8MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.25X12MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.25X15MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.25X18MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.25X23MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.25X28MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007822-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.5X8MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.5X12MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.5X15MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.5X18MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.5X23MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.5X28MM MULTILNK MVI RX BE 143CM THN STRUT SV -,SUP-1007823-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.75X8MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007847-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.75X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007847-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.75X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007847-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3X8MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3X23MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007848-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3.5X8MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3.5X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3.5X23MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3.5X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007849-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 4X12MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007850-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 4X23MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007850-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 4X28MM MULTILNK VIS RX BE PRMNT 143CM WKHRS -,SUP-1007850-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.75X15MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010142-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.75X23MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010142-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3X8MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010143-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3X15MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010143-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VISION OTW 3.5 X 15 -,SUP-1010144-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VISION OTW 3.5 X 23 -,SUP-1010144-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3.5X28MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010144-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 4X18MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010145-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 4X23MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010145-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2X8MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3.5X12MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2X15MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3.5X18MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2X23MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2X28MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010152-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.25X8MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.25X12MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.25X15MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.25X18MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.25X23MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.25X28MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010153-28,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.5X8MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-08,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.5X12MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.5X15MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.5X18MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.5X23MM MULTILNK MVI OTW BE 143CM THN STRUT SV -,SUP-1010154-23,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC ACCULINK 5X20MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011337-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC ACCULINK 5X30MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011337-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC ACCULINK 5X40MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011337-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S RX ACCULINK 7.0MM X 30MM X 132CM -,SUP-1011339-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC ACCULINK 7X40MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011339-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
6-8 mm X 30mm RX ACCULINK STENT -,SUP-1011343-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC ACCULINK 6-8X40MM 132CM RX SE PRMNT 6FR/8FR -,SUP-1011343-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
ACCULINK STENT 7-10 X 40MM -,SUP-1011344-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 4X12MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011487-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 4X18MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011487-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 4.5X15MM 135CM DLV CATH HERCULINK ELITE RX BE -,SUP-1011490-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 5X15MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011493-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 5X18MM 135CM DLV CATH HERCULINK ELITE RX BE PRMNT -,SUP-1011493-18,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR SELF-EXPANDING 6.0MM X 100MM X 80CM -,SUP-1012528-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR SELF-EXPANDING 6.0MM X 20MM X 80CM -,SUP-1012528-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR SELF-EXPANDING 6.0MM X 30MM X 80CM -,SUP-1012528-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR SELF-EXPANDING 6.0MM X 40MM X 80CM -,SUP-1012528-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR SEL-EXPANDING 6.0MM X 60MM X 80CM -,SUP-1012528-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAT SELF-EXPANDING 6.0MM X 80MM X 80CM -,SUP-1012528-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 100MM X 80CM -,SUP-1012529-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 20MM X 80CM -,SUP-1012529-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 30MM X 80CM -,SUP-1012529-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 40MM X 80CM -,SUP-1012529-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 60MM X 80CM -,SUP-1012529-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 80MM X 80CM -,SUP-1012529-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
ABSOLUTE PRO 8 X 100MM X 80CM -,SUP-1012530-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCUALR SELF-EXPANDING 8.0MM X 20MM X 80CM -,SUP-1012530-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR SELF-EXPANDING 8.0MM X 30MM X 80CM -,SUP-1012530-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
ABSOLUTE PRO VASCULAR SELF-EXPANDING STENT SYS 8 X 40 -,SUP-1012530-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
ABSOLUTE PRO 8 X 60MM X 80CM -,SUP-1012530-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
ABSOLUTE PRO 8 X 80MM X 80CM -,SUP-1012530-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR SELF-EXPANDING 9.0MM X 100MM X 80CM -,SUP-1012531-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR SELF-EXPANDING 9.0MM 20MM X 80CM -,SUP-1012531-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR SELF-EXPANDING 9.0MM X 30MM X 80CM -,SUP-1012531-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR SELF-EXPANDING 9.0MM X 40MM X 80CM -,SUP-1012531-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR SELF-EXPANDING 9.0MM X 60MM X 80CM -,SUP-1012531-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR SELF-EXPANDING 9.0MM X 80MM X 80CM -,SUP-1012531-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 100MM X 80CM -,SUP-1012532-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 20MM X 80CM -,SUP-1012532-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 30MM X 80CM -,SUP-1012532-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT ABSOLUTE PRO 10 X 40MM X 80CM -,SUP-1012532-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC ABSOLUTE PRO 10X60CM -,SUP-1012532-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
ABSOLUTE PRO SELF EXPANDING STENT 10MM X 80MM C 80CM -,SUP-1012532-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC ABSOLUTE PRO 6X100MM 135CM OTW SE PRMNT -,SUP-1012534-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC ABSOLUTE PRO 6X40MM 135CM OTW SE PRMNT -,SUP-1012534-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC ABSOLUTE PRO 7.0X100MM 135CM -,SUP-1012535-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 20MM X 135CM -,SUP-1012535-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 30MM X 135CM -,SUP-1012535-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC ABSOLUTE PRO 7X40MM 135CM OTW SE PRMNT -,SUP-1012535-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC ABSOLUTE PRO 7X60MM 135CM OTW SE PRMNT -,SUP-1012535-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR SELF-EXPANDING 7.0MM X 80MM X 135CM -,SUP-1012535-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR SELF-EXPANDING 8.0MM X 100MM X 135CM -,SUP-1012536-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR SELF-EXPANDING 8.0MM X 20MM X 135CM -,SUP-1012536-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR SELF-EXPANDING 8.0MM X 30MM X 135CM -,SUP-1012536-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR SELF-EXPANDING 8.0MM X 40MM X 135CM -,SUP-1012536-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC ABSOLUTE PRO 8.0 X 60MM X 135CM -,SUP-1012536-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR SELF-EXPANDING 9.0MM X 100MM X 135CM -,SUP-1012537-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR SELF-EXPANDED 9.0MM X 40MM X 135CM -,SUP-1012537-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR SELF-EXPANDING 9.0MM X 80MM X 135CM -,SUP-1012537-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 100MM X 135CM -,SUP-1012538-100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 20MM X 135CM -,SUP-1012538-20,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 30MM X 135CM -,SUP-1012538-30,CDM,C1876,HCPCS,278,RC,,,outpatient,,,1272.12,890.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 40MM X 135CM -,SUP-1012538-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 60MM X 135CM -,SUP-1012538-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR SELF-EXPANDING 10.0MM X 80MM X 135CM -,SUP-1012538-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2226.21,1558.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR BALLOON-EXPANDABLE 6.0MM X 16MM X 80CM -,SUP-1012622-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC OMNILINK ELITE 6X19MM 80CM OTW BE PRMNT -,SUP-1012622-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC OMNILINK ELITE 6X29MM 80CM OTW BE PRMNT -,SUP-1012622-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC OMNILINK ELITE 6X39MM 80CM OTW BE PRMNT -,SUP-1012622-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC OMNILINK ELITE 6X59MM 80CM OTW BE PRMNT -,SUP-1012622-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 12MM X 80CM -,SUP-1012623-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 16MM X 80CM -,SUP-1012623-16,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC OMNILINK ELITE 7X19MM 80CM OTW BE PRMNT -,SUP-1012623-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC OMNILINK ELITE 7X29MM 80CM OTW BE PRMNT -,SUP-1012623-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC OMNILINK ELITE 7X39MM 80CM OTW BE PRMNT -,SUP-1012623-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC OMNILINK ELITE 7X59MM 80CM OTW BE PRMNT -,SUP-1012623-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC OMNILINK ELITE 8X19MM 80CM OTW BE PRMNT -,SUP-1012624-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC OMNILINK ELITE 8X29MM 80CM OTW BE PRMNT -,SUP-1012624-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC OMNILINK ELITE 8X39MM 80CM OTW BE PRMNT -,SUP-1012624-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC OMNILINK ELITE 8X59MM 80CM OTW BE PRMNT -,SUP-1012624-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC OMNILINK ELITE 9X19MM 80CM OTW BE PRMNT -,SUP-1012625-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC OMNILINK ELITE 9X29MM 80CM OTW BE PRMNT -,SUP-1012625-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC OMNILINK ELITE 9X39MM 80CM OTW BE PRMNT -,SUP-1012625-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC OMNILINK ELITE 9X59MM 80CM OTW BE PRMNT -,SUP-1012625-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC OMNILINK ELITE 10X19MM 80CM OTW BE PRMNT -,SUP-1012626-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC OMNILINK ELITE 10X29MM 80CM OTW BE PRMNT -,SUP-1012626-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC OMNILINK ELITE 10X39MM 80CM OTW BE PRMNT -,SUP-1012626-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC OMNILINK ELITE 10X59MM 80CM OTW BE PRMNT -,SUP-1012626-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR BALLOON-EXPANDABLE 6.0MM X 16MM X 135 -,SUP-1012629-16,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC OMNILINK ELITE 6X19MM 135CM OTW BE PRMNT -,SUP-1012629-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC OMNILINK ELITE 6X29MM 135CM OTW BE PRMNT -,SUP-1012629-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC OMNILINK ELITE 6X39MM 135CM OTW BE PRMNT -,SUP-1012629-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC OMNILINK ELITE 6X59MM 135CM OTW BE PRMNT -,SUP-1012629-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 12MM X 135CM -,SUP-1012630-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASCULAR BALLOON-EXPANDABLE 7.0MM X 16MM X 135CM -,SUP-1012630-16,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC OMNILINK ELITE 7X19MM 135CM OTW BE PRMNT -,SUP-1012630-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC OMNILINK ELITE 7X29MM 135CM OTW BE PRMNT -,SUP-1012630-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC OMNILINK ELITE 7X39MM 135CM OTW BE PRMNT -,SUP-1012630-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC OMNILINK ELITE 7X59MM 135CM OTW BE PRMNT -,SUP-1012630-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC OMNILINK ELITE 8X19MM 135CM OTW BE PRMNT -,SUP-1012631-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC OMNILINK ELITE 8X29MM 135CM OTW BE PRMNT -,SUP-1012631-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC OMNILINK ELITE 8X39MM 135CM OTW BE PRMNT -,SUP-1012631-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC OMNILINK ELITE 8X59MM 135CM OTW BE PRMNT -,SUP-1012631-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC OMNILINK ELITE 9X19MM 135CM OTW BE PRMNT -,SUP-1012632-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC OMNILINK ELITE 9X29MM 135CM OTW BE PRMNT -,SUP-1012632-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC OMNILINK ELITE 9X39MM 135CM OTW BE PRMNT -,SUP-1012632-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC OMNILINK ELITE 9X59MM 135CM OTW BE PRMNT -,SUP-1012632-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC OMNILINK ELITE 10X19MM 135CM OTW BE PRMNT -,SUP-1012633-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC OMNILINK ELITE 10X29MM 135CM OTW BE PRMNT -,SUP-1012633-29,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC OMNILINK ELITE 10X39MM 135CM OTW BE PRMNT -,SUP-1012633-39,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC OMNILINK ELITE 10X59MM 135CM OTW BE PRMNT -,SUP-1012633-59,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 4X12MM JOST GRAFTMS OTW BE 143CM SEM-COM HYDREX CTD -,SUP-12746-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10164.38,7115.066,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
BIOMIMICS 3-D STENT 5MM X 60MM -,SUP-142122-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
BIOMIMICS 3-D STENT 6MM X 60MM -,SUP-142122-02,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
BIOMIMICS 3-D STENT 7MM X 60MM -,SUP-142122-03,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
BIOMIMICS 3-D STENT 5MM X 80MM -,SUP-142122-05,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
BIOMIMICS 3-D STENT 6MM X 80MM -,SUP-142122-06,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
BIOMIMICS 3-D STENT 7MM X 80MM -,SUP-142122-07,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
BIOMIMICS 3-D STENT 5MM X 100MM -,SUP-142122-09,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
BIOMIMICS 3-D STENT 6MM X 100MM -,SUP-142122-10,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
BIOMIMICS 3-D STENT 7MM X 100MM -,SUP-142122-11,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5305,3713.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
BIOMIMICS 3-D STENT 5MM X 125MM -,SUP-142122-13,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
BIOMIMICS 3-D STENT 6MM X 125MM -,SUP-142122-14,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
BIOMIMICS 3-D STENT 7MM X 125MM -,SUP-142122-15,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
BIOMIMICS 3-D STENT 5MM X 150MM -,SUP-144700-05,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
BIOMIMICS 3-D STENT 6MM X 150MM -,SUP-144700-12,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
BIOMIMICS 3-D STENT 7MM X 150MM -,SUP-144700-19,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S BILIARY LD PMTD 8 X 37 X75 6 -,SUP-38046-84075,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 8X37MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38046-84075,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 9 X 25MM 75CM EXP LD -,SUP-38046-92075,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 10X25MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-12013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 10X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-16013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 6X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-63013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 7X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-38047-76013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 8X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-38047-84013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S BILIARY EXPRESS 8X37X135CM L -,SUP-38047-84013,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
PULSAR 18 - 6 X 40 X 135 -,SUP-390724,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
PULSAR 18 - 6 X 120 X 135 -,SUP-390728,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
PULSAR 18 - 6 X 150 X 135 -,SUP-390729,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2792.79,1954.953,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
PULSAR 18  7X40X135  .018 -,SUP-390734,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC OTW 6 X 120 X 120 -,SUP-39200-06122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC EPIC 6X120MM 120CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-39200-06122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-XPD 7X118X120 -,SUP-39200-07122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC EPIC 7X120MM 163CM/120CM WKG CATH SE MTLC ILC -,SUP-39200-07122,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-XPD 7X79X120 -,SUP-39200-07802,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC EPIC 7X80MM 120CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-39200-07802,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-XPD 9X40X120 -,SUP-39200-09402,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
EPIC STENT 10MM X 40MM X 120CM -,SUP-39200-10402,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
EPIC STENT 10MM X 60MM X 120CM -,SUP-39200-10602,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
EPIC STENT 12MM X 60MM X 120CM -,SUP-39200-12602,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT ENPROS 24MM 11FR CATH 70MM WALLSTNT RP 100CM TOT 75CM -,SUP-40512,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT PULSAR - 18 T3 4/20/135 -,SUP-430477,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT PULSAR - 18 T3 4/40/135 -,SUP-430479,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT PULSAR - 18 T3 4/80/135 -,SUP-430481,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT PULSAR - 18 T3  5/80/135 -,SUP-430491,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT PULSAR - 18 T3 5/120/135 -,SUP-430493,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT PULSAR - 18 T3 5/200/135 -,SUP-430496,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT PULSAR - 18 T3 6/40/135 -,SUP-430499,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT PULSAR - 18 T3 6/80/135 -,SUP-430501,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT PULSAR - 18 T3 6/120/135 -,SUP-430503,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT PULSAR - 18 T3 6/150/135 -,SUP-430504,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT PULSAR - 18 T3 6/200/135 -,SUP-430506,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT PULSAR - 18 T3 7/120/135 -,SUP-430513,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT PULSAR - 18 T3 7/150/135 -,SUP-430514,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
WRENCH SPLTY HX F /CPI -,SUP-6563,CDM,C1876,HCPCS,278,RC,,,outpatient,,,175.05,122.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT URET 6FR 22-32CM INLAY OPTM PLYMR BLND DBL PIGTL TAPR -,SUP-788600,CDM,C1876,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC XACT 7-9X40MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82086-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC XACT 7-9X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82087-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC XACT 9X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82088-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC XACT 9X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82089-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC XACT 6-8X40MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82090-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC XACT 6-8X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82091-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC XACT 8X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82092-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC XACT 8X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82093-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC XACT 7X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82094-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC XACT 7X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82095-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC XACT 10.8MM X 40MM X 136CM -,SUP-82096-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC XACT 10X30MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82098-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC XACT 10X20MM 136CM RX SE PRMNT 6FR/8FR SHTH/GUID -,SUP-82099-01,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9739.98,6817.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
ABRE STENTS 16MM X 80MM -,SUP-AB9U16080090,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6896.5,4827.55,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
ABRE STENTS 18MM X 100MM -,SUP-AB9U18100090,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6896.5,4827.55,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
ABRE STENTS 18MM X 120MM -,SUP-AB9U18120090,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6896.5,4827.55,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
COVERA AV STENT GRAFT 7MM X 60MM X 80MM -,SUP-AVSM07060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10767.7,7537.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC SMART CONT 6X30MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06030ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC SMART CONT 6X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC SMART CONT 6X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC SMART CONT 6X80MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06080ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC SMART CONT 6X100MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06100ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC SMART CONT 6X120MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06120ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC SMART CONT 6X150MM 120CM SE 0.035IN/6FR/8FR -,SUP-C06150ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC SMART CONT 7X30MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07030ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC SMART CONT 7X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC SMART CONT 7X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC SMART CONT 7X80MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07080ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC SMART CONT 7X100MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07100ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC SMART CONT 7X120MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07120ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC SMART CONT 7X150MM 120CM SE 0.035IN/6FR/8FR -,SUP-C07150ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC SMART CONT 8X30MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08030ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC SMART CONT 8X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC SMART CONT 8X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC SMART CONT 8X80MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08080ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC SMART CONT 8X100MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08100ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC SMART CONT 8X120MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08120ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC SMART CONT 8X150MM 120CM SE 0.035IN/6FR/8FR -,SUP-C08150ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC SMART CONT 10X40MM 120CM SE 0.035IN/6FR/8FR -,SUP-C10040ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC SMART CONT 10X60MM 120CM SE 0.035IN/6FR/8FR -,SUP-C10060ML,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3341.8,2339.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 12X40MM 120CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-C12040MB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 12X60MM 120CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-C12060MB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 12X60MM 80CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-C12060SB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 6X100MM 130CM LIFESTENT SE HLCL NTNL 0.035IN GW -,SUP-EX061003CD,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9230.7,6461.49,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC LIFESTENT 6X150MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX061503CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7639.2,5347.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC LIFESTENT 6X170MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX061703CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9336.8,6535.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC LIFESTENT 6X200MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX062003CL,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC LIFESTENT 7X60MM 130CM SE 0.035IN/6FR GW/SHTH -,SUP-EX070603CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
GRAFT EV 8MM 9FR CATH 40MM 120CM TOT 80CM DLV SYS FLAIR STR -,SUP-FAS08040,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11020.18,7714.126,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
COIL MICRONESTER EMBOLIZATION 0.018 X 5CM X 3MM -,SUP-G23520,CDM,C1876,HCPCS,278,RC,,,outpatient,,,851.91,596.337,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 5MM 7FR GUID CATH 30MM 125CM ZILVER 518 OTW SE -,SUP-G31351,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S ZILVER 518 5X40 125CM S-E ZI -,SUP-G31352,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 4X40MM 125CM ZILVER 518 OTW SE PRELD FLXB SLT TUBE -,SUP-G31439,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 8MM 6FRX40MM 80CM SE PRELD MTL NTNL 5FR SHTH MUL -,SUP-G32020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6790.4,4753.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S ZILVER .035 125CM 5 X 60 -,SUP-G32033,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 8X80MM MTL SE 6FRX125CM PRELD DLV SYS NTNL 6FR -,SUP-G36025,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S ZILVER 518 5X80 125CM S-E -,SUP-G36048,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 14X30MM 80CM ZILVER 635 OTW SE PRELD FLXB SLT TUBE -,SUP-G36233,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 12MM 8FR GUID CATH 40MM 125CM ZILVER 635 OTW SE -,SUP-G36239,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
12MM X 8CM ZILVER 635 STENT -,SUP-G36241,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 14MM 8FR GUID CATH 40MM 125CM ZILVER 635 OTW SE -,SUP-G36244,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 14X60MM 125CM ZILVER 635 OTW SE PRELD 0.035IN GW -,SUP-G36245,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 5X20MM 135CM FRMLA 418 BLN-XPD GUID CATH 5/6 FR -,SUP-G42956,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4034.03,2823.821,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 6X24MM 135CM FRMLA 418 OTW BE U STRUT TAPR 0.018IN -,SUP-G42962,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S ZILVER 518 VASC 6X40 125CM S -,SUP-G43771,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S ZILVER518 VASC 6X60 125CM -,SUP-G43772,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S ZILVER 518 VASC 6X80 125CM S -,SUP-G43773,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
7x40x125 ZILVER STENT 0.018 -,SUP-G43776,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC ZILVER 518 7X80MM 125CM OTW SE 0.018IN/5FR -,SUP-G43778,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC ZILVER 518 8X60MM 125CM OTW SE 0.018IN/5FR -,SUP-G43782,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S ZILVER .035 125CM 6 X 60 012 -,SUP-G43822,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S ZILVER .035 125CM 6 X 80 012 -,SUP-G43823,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC ZILVER 635 7X30MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43825,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC ZILVER 635 7X40MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43826,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC ZILVER 635 7X60MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43827,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC ZILVER 635 7X80MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43828,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC ZILVER 635 8X30MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC ZILVER 635 8X40MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43831,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC ZILVER 635 8X60MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43832,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC ZILVER 635 8X80MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43833,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC ZILVER 635 10X40MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43841,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC ZILVER 635 10X60MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43842,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC ZILVER 635 10X80MM 125CM OTW SE PRELD 0.035IN/6FR -,SUP-G43843,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
COIL NESTOR 3 X 5 -,SUP-G47334,CDM,C1876,HCPCS,278,RC,,,outpatient,,,577.61,404.327,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
COIL MICRONESTOR EMBOLIZATION .018 X 7CM X 4MM PLAT -,SUP-G47339,CDM,C1876,HCPCS,278,RC,,,outpatient,,,638.87,447.209,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
ZENITH DISSECTION ENDOVASCULAR STENT -,SUP-G47492,CDM,C1876,HCPCS,278,RC,,,outpatient,,,41924.2,29346.94,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
ZENITH DISSECTION ENDOVASCULAR STENT -,SUP-G47493,CDM,C1876,HCPCS,278,RC,,,outpatient,,,41924.2,29346.94,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT ENDOVASCULAR DISSECTION ZENITH -,SUP-G47496,CDM,C1876,HCPCS,278,RC,,,outpatient,,,37318.31,26122.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT DUODENAL EVOLUTION CONTROL RELEASE 22-27-9 -,SUP-G48026,CDM,C1876,HCPCS,278,RC,,,outpatient,,,8886.94,6220.858,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S ZILVER .035 125CM 5 X 100 -,SUP-G50162,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 7MM 8FR GUID CATH LNG 100MM 125CM ZILVER FLEX 35 -,SUP-G50168,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 7MM 8FR GUID CATH LNG 120MM 125CM ZILVER FLEX 35 -,SUP-G50169,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 7X140MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-G50170,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 8X100MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-G50171,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 8MM 8FR GUID CATH LNG 140MM 125CM ZILVER FLEX 35 -,SUP-G50173,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 10X100MM 80CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-G50177,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
Z STENT BILIARY 8 X 8 -,SUP-G50623,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6153.8,4307.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC FRMLA 418 5X16MM 80CM OTW BE PRMNT -,SUP-G56609,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC FRMLA 418 5X20MM 80CM OTW BE PRMNT -,SUP-G56610,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC FRMLA 418 6X12MM 80CM OTW BE PRMNT -,SUP-G56611,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC FRMLA 418 6X16MM 80CM OTW BE PRMNT -,SUP-G56613,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC FRMLA 418 6X20MM 80CM OTW BE PRMNT -,SUP-G56614,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC FRMLA 418 7X16MM 80CM -,SUP-G56617,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC FRMLA 418 5X12MM 80CM OTW BE PRMNT -,SUP-G56631,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4812.65,3368.855,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC FRMLA 414 5X20MM 80CM RX BE PRMNT 0.014IN/5FR/6FR -,SUP-G56950,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC FRMLA 414 5X16MM 135CM RX BE PRMNT -,SUP-G56958,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
0.14 ZILVER 5MM X 120MM X 135CM -,SUP-G56966,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC FRMLA 414 5X20MM 135CM RX BE PRMNT -,SUP-G56969,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC FRMLA 414 6X12MM 135CM RX BE PRMNT -,SUP-G56970,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC FRMLA 414 6X16MM 135CM RX BE PRMNT -,SUP-G56971,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC FRMLA 414 6X20MM 135CM RX BE PRMNT -,SUP-G56972,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
0.14 ZILVER 7MM X 160MM X 135CM -,SUP-G56974,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC FRMLA 414 7X20MM 135CM RX BE PRMNT -,SUP-G56975,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4392.08,3074.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
US PRE PP-CA-397 P&B BARE METAL STENT ZVT7-35-120-16-60 -,SUP-G57453,CDM,C1876,HCPCS,278,RC,,,outpatient,,,8016.87,5611.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
SYS STENT VASCULAR ZILVER VENA 16MM 100MM 120CM VEIN OTW -,SUP-G57454,CDM,C1876,HCPCS,278,RC,,,outpatient,,,8016.87,5611.809,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
VENOUS WALLSTENT 10X94X75CM -,SUP-H74912044109470,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
VENOUS WALLSTENT 12X60X75CM -,SUP-H74912044126070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
VENOUS WALLSTENT 12X90X75CM -,SUP-H74912044129070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
VENOUS WALLSTENT 14X60X75CM -,SUP-H74912044146070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
VENOUS WALLSTENT 14X90X75CM -,SUP-H74912044149070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
VENOUS WALLSTENT 16X40X75CM -,SUP-H74912044164070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
VENOUS WALLSTENT 16X60X75CM -,SUP-H74912044166070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
VENOUS WALLSTENT 16X90X75CM -,SUP-H74912044169070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
VENOUS WALLSTENT 18X40X75CM -,SUP-H74912044184070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
VENOUS WALLSTENT 18X60X75CM -,SUP-H74912044186070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
VENOUS WALLSTENT 18X90X75CM -,SUP-H74912044189070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
VENOUS WALLSTENT 20X40X75CM -,SUP-H74912044204070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
VENOUS WALLSTENT 20X55X75CM -,SUP-H74912044205570,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
VENOUS WALLSTENT 20X80X75CM -,SUP-H74912044208070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
VICI VENOUS STENT 12MM X60MM X 100CM -,SUP-H74912060100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
VICI VENOUS STENT 14MM X 60MM X 100CM -,SUP-H74914060100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
VICI VENOUS STENT 14MM X 90MM X 100CM -,SUP-H74914090100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
VICI VENOUS STENT 16MM X 60MM X 100CM -,SUP-H74916060100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
VICI VENOUS STENT 16MM X90MM X 100CM -,SUP-H74916090100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 6X14MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937911614150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
FG EXP SD RENAL-BILIARY 7.0mmX15mmX150cm -,SUP-H74937911715150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 4X19MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912419150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 5X19MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912519150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 6X18MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912618150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 7X19MM 150CM EXP SD MONORAIL RX BE PRMNT RNL -,SUP-H74937912719150,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 10X37MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046104070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 10X57MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046106070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S BIL EXPRESS PMTD  6X27X75 -,SUP-H74938046630750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 6X27MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046630750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S BILIARY LD PMTD 6X37X75 6FR -,SUP-H74938046640750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 6X37MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046640750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 6X57MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046660750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S BILI LD PMTD 6 X 57 X 75 EXP -,SUP-H74938046660750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 7X27MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046730750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S BILIARY LD PMTD 7X37X75 40CM -,SUP-H74938046740750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S  BILI LD PMTD 7 X 57 X 75 EX -,SUP-H74938046760750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EXPRESS B-I LD 8 X 27 X 75 P -,SUP-H74938046830750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 8X27MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046830750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
BEACON 8MM X 37MM X 75CM  ILIAC STENT -,SUP-H74938046840750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
8 X 57 X 75CM EXPRESS STENT -,SUP-H74938046860750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S BILI LD PMTD 8 X 57 X 75 EXP -,SUP-H74938046860750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 9X57MM 75CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938046960750,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 10X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047140130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 5X17MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047520130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 5X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047530130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 5X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047540130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 5X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047560130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 6X17MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047620130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 6X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047640130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 6X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047660130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 7X17MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047720130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 7X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047730130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 7X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047740130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
7 X 57MM EXPRESS ILIAC / BILIARY STENT 135CM -,SUP-H74938047760130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 8X27MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047830130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 8X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047860130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 9X25MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047920130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 9X37MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047940130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 9X57MM 135CM EXP LD OTW BE PRMNT ILC ART NC SS -,SUP-H74938047960130,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3X16MM VERIFLEX OTW BE PRMNT LO XING THN STRUT HYDRCT -,SUP-H7493893516300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3294.06,2305.842,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-XPD 6X100X120 -,SUP-H74939200061020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-XPD 6X19X120 -,SUP-H74939200062020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-XPD 6X29X120 -,SUP-H74939200063020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-XPD 6X40X120 -,SUP-H74939200064020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-XPD 6X51X120 -,SUP-H74939200065020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-XPD 6X61X120 -,SUP-H74939200066020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-XPD 6X71X120 -,SUP-H74939200067020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-XPD 6X80X120 -,SUP-H74939200068020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-XPD 7X99X120 -,SUP-H74939200071020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-XPD 7X19X120 -,SUP-H74939200072020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-XPD 7X29X120 -,SUP-H74939200073020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-XPD 7X41X120 -,SUP-H74939200074020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-XPD 7X50X120 -,SUP-H74939200075020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-XPD 7X60X120 -,SUP-H74939200076020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-XPD 7X70X120 -,SUP-H74939200077020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-XPD 8X100X120 -,SUP-H74939200081020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-XPD 8X120X120 -,SUP-H74939200081220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-XPD 8X20X120 -,SUP-H74939200082020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-XPD 8X31X120 -,SUP-H74939200083020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-XPD 8X41X120 -,SUP-H74939200084020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-XPD 8X51X120 -,SUP-H74939200085020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-XPD 8X61X120 -,SUP-H74939200086020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-XPD 8X72X120 -,SUP-H74939200087020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-XPD 8X82X120 -,SUP-H74939200088020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-XPD 9X99X120 -,SUP-H74939200091020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-XPD 9X21X120 -,SUP-H74939200092020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-XPD 9X30X120 -,SUP-H74939200093020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-XPD 9X51X120 -,SUP-H74939200095020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-XPD 9X61X120 -,SUP-H74939200096020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-XPD 9X81X120 -,SUP-H74939200098020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-XPD 10X98X120 -,SUP-H74939200101020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-EXP 10X20X120 -,SUP-H74939200102020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-EXP 10X30X120 -,SUP-H74939200103020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-XPD 10X40X120 -,SUP-H74939200104020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-XPD 10X50X120 -,SUP-H74939200105020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC EPIC 10X60MM 120CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939200106020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-XPD 10X71X120 -,SUP-H74939200107020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4535.3,3174.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-XPD 10X80X120 -,SUP-H74939200108020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-EXP 12X32X120 -,SUP-H74939200123020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-XPD 12X42X120 -,SUP-H74939200124020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-XPD 12X52X120 -,SUP-H74939200125020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5517.2,3862.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S EPIC ILIAC S-XPD 12X61X120 -,SUP-H74939200126020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.2X8MM REBEL MR RX BE -,SUP-H7493927408220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.5X8MM REBEL MR RX BE -,SUP-H7493927408250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.75X8MM REBEL MR RX BE -,SUP-H7493927408270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3X8MM REBEL MR RX BE -,SUP-H7493927408300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3.5X8MM REBEL MR RX BE -,SUP-H7493927408350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 4X8MM REBEL MR RX BE -,SUP-H7493927408400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.25X12MM REBEL MR RX BE -,SUP-H7493927412220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.5X12MM REBEL MR RX BE -,SUP-H7493927412250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.75X12MM REBEL MR RX BE -,SUP-H7493927412270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3X12MM REBEL MR RX BE -,SUP-H7493927412300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3.5X12MM REBEL MR RX BE -,SUP-H7493927412350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 4X12MM REBEL MR RX BE -,SUP-H7493927412400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 4.5X12MM REBEL MR RX BE -,SUP-H7493927412450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.25X16MM REBEL MR RX BE -,SUP-H7493927416220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.5X16MM REBEL MR RX BE -,SUP-H7493927416250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.75X16MM REBEL MR RX BE -,SUP-H7493927416270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3X16MM REBEL MR RX BE -,SUP-H7493927416300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3.5X16MM REBEL MR RX BE -,SUP-H7493927416350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 4X16MM REBEL MR RX BE -,SUP-H7493927416400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 4.5X16MM REBEL MR RX BE -,SUP-H7493927416450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.25X20MM REBEL MR RX BE -,SUP-H7493927420220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.5X20MM REBEL MR RX BE -,SUP-H7493927420250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.75X20MM REBEL MR RX BE -,SUP-H7493927420270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3X20MM REBEL MR RX BE -,SUP-H7493927420300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3.5X20MM REBEL MR RX BE -,SUP-H7493927420350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 4X20MM REBEL MR RX BE -,SUP-H7493927420400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 4.5X20MM REBEL MR RX BE -,SUP-H7493927420450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.25X24MM REBEL MR RX BE -,SUP-H7493927424220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.5X24MM REBEL MR RX BE -,SUP-H7493927424250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.75X24MM REBEL MR RX BE -,SUP-H7493927424270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3X24MM REBEL MR RX BE -,SUP-H7493927424300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3.5X24MM REBEL MR RX BE -,SUP-H7493927424350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 4X24MM REBEL MR RX BE -,SUP-H7493927424400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 4.5X24MM REBEL MR RX BE -,SUP-H7493927424450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.25X28MM REBEL MR RX BE -,SUP-H7493927428220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.5X28MM REBEL MR RX BE -,SUP-H7493927428250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.75X28MM REBEL MR RX BE -,SUP-H7493927428270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3X28MM REBEL MR RX BE -,SUP-H7493927428300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3.5X28MM REBEL MR RX BE -,SUP-H7493927428350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 4X28MM REBEL MR RX BE -,SUP-H7493927428400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 4.5X28MM REBEL MR RX BE -,SUP-H7493927428450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.75X32MM REBEL MR RX BE -,SUP-H7493927432270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3X32MM REBEL MR RX BE -,SUP-H7493927432300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3.5X32MM REBEL MR RX BE -,SUP-H7493927432350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 4X32MM REBEL MR RX BE -,SUP-H7493927432400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 4.5X32MM REBEL MR RX BE -,SUP-H7493927432450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.25X8MM REBEL OTW BE -,SUP-H7493927508220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.5X8MM REBEL OTW BE -,SUP-H7493927508250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.75X8MM REBEL OTW BE -,SUP-H7493927508270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3X8MM REBEL OTW BE -,SUP-H7493927508300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3.5X8MM REBEL OTW BE -,SUP-H7493927508350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 4X8MM REBEL OTW BE -,SUP-H7493927508400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.25X12MM REBEL OTW BE -,SUP-H7493927512220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.5X12MM REBEL OTW BE -,SUP-H7493927512250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.75X12MM REBEL OTW BE -,SUP-H7493927512270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3X12MM REBEL OTW BE -,SUP-H7493927512300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3.5X12MM REBEL OTW BE -,SUP-H7493927512350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 4X12MM REBEL OTW BE -,SUP-H7493927512400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 4.5X12MM REBEL OTW BE -,SUP-H7493927512450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.25X16MM REBEL OTW BE -,SUP-H7493927516220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.5X16MM REBEL OTW BE -,SUP-H7493927516250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.75X16MM REBEL OTW BE -,SUP-H7493927516270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3X16MM REBEL OTW BE -,SUP-H7493927516300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3.5X16MM REBEL OTW BE -,SUP-H7493927516350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 4X16MM REBEL OTW BE -,SUP-H7493927516400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 4.5X16MM REBEL OTW BE -,SUP-H7493927516450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.25X20MM REBEL OTW BE -,SUP-H7493927520220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.5X20MM REBEL OTW BE -,SUP-H7493927520250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.75X20MM REBEL OTW BE -,SUP-H7493927520270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3X20MM REBEL OTW BE -,SUP-H7493927520300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3.5X20MM REBEL OTW BE -,SUP-H7493927520350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 4X20MM REBEL OTW BE -,SUP-H7493927520400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 4.5X20MM REBEL OTW BE -,SUP-H7493927520450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.25X24MM REBEL OTW BE -,SUP-H7493927524220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.5X24MM REBEL OTW BE -,SUP-H7493927524250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.75X24MM REBEL OTW BE -,SUP-H7493927524270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3X24MM REBEL OTW BE -,SUP-H7493927524300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3.5X24MM REBEL OTW BE -,SUP-H7493927524350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 4X24MM REBEL OTW BE -,SUP-H7493927524400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 4.5X24MM REBEL OTW BE -,SUP-H7493927524450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.25X28MM REBEL OTW BE -,SUP-H7493927528220,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.5X28MM REBEL OTW BE -,SUP-H7493927528250,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.75X28MM REBEL OTW BE -,SUP-H7493927528270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3X28MM REBEL OTW BE -,SUP-H7493927528300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3.5X28MM REBEL OTW BE -,SUP-H7493927528350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 4X28MM REBEL OTW BE -,SUP-H7493927528400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 4.5X28MM REBEL OTW BE -,SUP-H7493927528450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 2.75X32MM REBEL OTW BE -,SUP-H7493927532270,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3X32MM REBEL OTW BE -,SUP-H7493927532300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3.5X32MM REBEL OTW BE -,SUP-H7493927532350,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 4X32MM REBEL OTW BE -,SUP-H7493927532400,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 4.5X32MM REBEL OTW BE -,SUP-H7493927532450,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC INNOVA 5X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293050230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC INNOVA 5X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC INNOVA 5X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC INNOVA 5X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC INNOVA 5X180MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293051830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC INNOVA 5X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293052030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9018.5,6312.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC INNOVA 5X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293054030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC INNOVA 5X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293056030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC INNOVA 5X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293058030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC INNOVA 6X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293060230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC INNOVA 6X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC INNOVA 6X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC INNOVA 6X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC INNOVA 6X180MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293061830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC INNOVA 6X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293062030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC INNOVA 6X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293064030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC INNOVA 6X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293066030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC INNOVA 6X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293068030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC INNOVA 7X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293070230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC INNOVA 7X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293071030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC INNOVA 7X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293071230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC INNOVA 7X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293071530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC INNOVA 7X180X130 SE ILC -,SUP-H74939293071830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC INNOVA 7X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293072030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC INNOVA 7X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293074030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC INNOVA 7X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293076030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC INNOVA 7X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293078030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC INNOVA 8X20MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293080230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC INNOVA 8X100MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293081030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC INNOVA 8X120MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293081230,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC INNOVA 8X150MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293081530,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2840.53,1988.371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC INNOVA 8X180X130 SE ILC -,SUP-H74939293081830,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC INNOVA 8X200MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293082030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,11120.44,7784.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC INNOVA 8X40MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293084030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC INNOVA 8X60MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293086030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC INNOVA 8X80MM 130CM OTW SE 0.035IN/6FR GW/SHTH -,SUP-H74939293088030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT ENPROS 22MM 10FR CATH 45MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965404510,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT ENPROS 22MM 10FR CATH 70MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965404520,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT ENPROS 24MM 11FR CATH 35MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965405100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT ENPROS 24MM 11FR CATH 45MM WALLSTNT RP 100CM TOT 75CM -,SUP-H965405110,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3938.55,2756.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
WALLSTENT 24X70 X 75CM/11F UNI PLUS 1 -,SUP-H965405120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 2.25X8MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22508UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 2.25X8MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 2.25X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22512UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 2.25X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 2.25X14MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22514UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 2.25X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22518UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 2.25X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 2.25X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22522UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 2.25X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 2.25X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT22526UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 2.25X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT22526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 2.5X8MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25008UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 2.5X8MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25008W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 2.5X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 2.5X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 2.5X14MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25014UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS #1 27IN INTGRTY MO-4 DTCH 140CM MONO GUT TAPR PNT -,SUP-INT25014W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 2.5X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 2.5X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 2.5X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 2.5X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 2.5X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 2.5X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT25026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 2.75X8MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27508UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 2.75X8MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 2.75X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27512UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 2.75X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 2.75X14MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27514UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 2.75X14MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27514W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 2.75X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27518UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 2.75X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 2.75X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27522UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 2.75X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 2.75X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT27526UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 2.75X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-INT27526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 3X9MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30009UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 3X9MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 3X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 3X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 3X15MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30015UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 3X15MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 3X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 3X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 3X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 3X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 3X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 3X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 3X30MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT30030UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 3X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT30030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 3.5X9MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35009UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 3.5X9MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 3.5X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 3.5X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 3.5X15MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35015UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 3.5X15MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 3.5X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 3.5X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 3.5X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 3.5X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 3.5X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 3.5X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 3.5X30MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35030UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 3.5X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT35030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 4X9MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40009UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 4X9MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 4X12MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40012UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 4X12MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 4X15MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40015UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 4X15MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 4X18MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40018UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 4X18MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 4X22MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40022UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 4X22MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 4X26MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40026UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 4X26MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 4X30MM INTGRTY RX BE PRMNT 140CM ZOTARO SEM-COM LO -,SUP-INT40030UX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 4X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-INT40030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT LIFESTREAM 7MM X 26MM X 80MM -,SUP-LSMU0800726,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT ENPROS 8MM 6FR CATH 80MM WALLSTNT RP 100CM TOT 75CM -,SUP-M001711300,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7320.9,5124.63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT ESPH 18MM BD 23MMX7CM ULFLX NON- CVR FLR END MTL LF -,SUP-M00514070,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT DUOD 22MMX6CM WALLFLX 230CM DLV SYS TTS/ OTW NTNL FLR -,SUP-M00565010,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT WALLFLEX DUODENAL 22 X 60 -,SUP-M00565010,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT DUOD 22MMX9CM WALLFLX 230CM NON- CVR NTNL LF -,SUP-M00565020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT WALLFLEX DUODENAL 22 X 90 -,SUP-M00565020,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT WALLFLEX DUODENAL 22 X 120 -,SUP-M00565030,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT WALLFLEX COLONIC 25 X 60 -,SUP-M00565040,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT WALLFLEX COLONIC 25 X 90 -,SUP-M00565050,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT WALLFLEX COLONIC 25 X 120 -,SUP-M00565060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT WALLFLEX COLONIC 22 X 60 -,SUP-M00565100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT WALLFLEX COLONIC 22 X 90 -,SUP-M00565110,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT WALLFLEX COLONIC 22 X 120 -,SUP-M00565120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,9697.02,6787.914,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT ENPROS 10FR 20X60MM WALLSTNT 135CM HRP -,SUP-M00565620,CDM,C1876,HCPCS,278,RC,,,outpatient,,,116.7,81.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT COLN 22MM BD 10FR CATH 6CM WALLSTNT 135CM CATH 160CM -,SUP-M00565640,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7434.26,5203.982,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 10X80MM WALLSTNT RX SE UNCVR MTL 0.035IN GW COMP -,SUP-M00569660,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6340.15,4438.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 8X80MM WALLFLX RX SE UNCVR PLATINOL 0.035IN GW -,SUP-M00570620,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 8X100MM WALLFLX RX SE NON- CVR PLATINOL 0.035IN GW -,SUP-M00570630,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 10X60MM WALLFLX RX SE NON- CVR PLATINOL 0.035IN GW -,SUP-M00570640,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
CATH GUID 6FRX68CM ACUITY BREAK-AWAY COR CS-IC 130 -,SUP-M00570650,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
WALLFLEX BILIARY RX UNCOVERED 10 X 80 -,SUP-M00570650,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
WALLFLEX RX UNCOVERED BILIARY STENT 10MM X 100MM -,SUP-M00570660,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
WALLFLEX BILIARY RX UNCOVERED 10 X 40 -,SUP-M00570890,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7438.2,5206.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 14X60MM 120CM SMART CONT SE TRNSHEP MICRO MRKR SEG -,SUP-N1460BB,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT PULSAR - 18 T3 5/40/135 -,SUP-NO MANUFACTURE IN DICTIONARY,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 10X30MM PALMZ XL BE UNMT TRNSHEP CLSD CELLFLEX SEG -,SUP-P3110,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 5X15MM 135CM PALMZ BLU RX BE TRNSHEP COCR 0.014IN -,SUP-PB1550BAX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4882.72,3417.904,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 5X15MM 135CM PALMZ BLU OTW BE TRNSHEP COCR 0.018IN -,SUP-PB1550BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 6X18MM 80CM PALMZ BLU OTW BE TRNSHEP COCR 0.014IN -,SUP-PB1860BSS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 6X18MM 135CM PALMZ BLU OTW BE TRNSHEP COCR 0.018IN -,SUP-PB1860BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 6X24MM 135CM PALMZ BLU OTW BE TRNSHEP COCR 0.018IN -,SUP-PB2460BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4215.44,2950.808,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 6X18MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG1860BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 6X18MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG1860BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 9X19MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG1990BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 6X24MM 135CM PALMZ GENESIS RX BE TRNSHEP SS -,SUP-PG2460BAX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4948.93,3464.251,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 6X24MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2460BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 8X24MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG2480BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 10X29MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2910BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 5X29MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG2950BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 5X30MM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW COMP -,SUP-PG2950BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 6X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2960BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 7X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG2970BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 7X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN. -,SUP-PG2970BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 8X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN. -,SUP-PG2980BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 8X29MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN- -,SUP-PG2980BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4177.25,2924.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 10X39MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3910BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 6X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3960BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 7X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3970BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 8X29MM 135CM PALMZ_GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3980BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 8X39MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG3980BSX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 7X59MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG5970BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 7X59MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG5970BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 8X59MM 135CM PALMZ GENESIS BE TRNSHEP SS 0.035IN -,SUP-PG5980BPX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 6X79MM 80CM PALMZ GENESIS BE TRNSHEP SS 0.035IN GW -,SUP-PG7960BPS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,3823.97,2676.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 6X20MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506020120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 6X40MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 6X60MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 6X80MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506080120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 6X100MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506100120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 6X120MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506120120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 6X150MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506150120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 6X200MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3506200120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,12141.51,8499.057,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 7X20MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507020120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 7X40MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 7X60MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 7X80MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507080120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 7X120MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507120120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 7X150MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3507150120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 8X40MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3508040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 8X60MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3508060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 8X80MM 120CM EVERFLX SE SUPRFC FEM/PROX POPLT ART -,SUP-PRB3508080120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC EVERFLX 10X120MM 120CM SE 3-WV PEAK DSGN PRECISN -,SUP-PRB3508100120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 12X120MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT -,SUP-PRB3508120120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 8X150MM 120CM EVERFLX SE SUPRFC FEM PROX POPLT ART -,SUP-PRB3508150120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 7X37MM 135CM VISI-PRO BE MNT SS 0.035IN/6FR -,SUP-PXB350737135,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 8X27MM 135CM VISI-PRO BE MNT SS 0.035IN/6FR -,SUP-PXB350827135,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 8X37MM 135CM VISI-PRO BE MNT SS 0.035IN/6FR -,SUP-PXB350837135,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT DES 2.25X8MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT DES 2.25X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT DES 2.25X14MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22514W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT DES 2.25X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT DES 2.25X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT DES 2.25X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BMS 2.25X30MM INTGRTY OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT22530W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT DES 2.5X8MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25008W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT DES 2.5X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT DES 2.5X14MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25014W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT DES 2.5X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT DES 2.5X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT DES 2.5X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT DES 2.5X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT25030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT DES 2.75X8MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27508W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT DES 2.75X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27512W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT DES 2.75X14MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27514W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT DES 2.75X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27518W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT DES 2.75X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27522W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT DES 2.75X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27526W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT DES 2.75X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT27530W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT DES 3X9MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT30009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT DES 3X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT DES 3X15MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT DES 3X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT DES 3X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT30030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT DES 3.5X9MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT DES 3.5X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT DES 3.5X15MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT DES 3.5X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT DES 3.5X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT DES 3.5X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT DES 3.5X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT35030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT DES 4X9MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO SEM-COM -,SUP-RSINT40009W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT DES 4X12MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40012W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT DES 4X15MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40015W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT DES 4X18MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40018W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT DES 4X22MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40022W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT DES 4X26MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40026W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT DES 4X30MM RESOLUT IN OTW BE PRMNT 140CM ZOTARO -,SUP-RSINT40030W,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 4MM 6FR CATH 60MM 120CM SUPERA TRNSHEP -,SUP-S-04-060-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 5MM 6FR CATH 40MM 120CM SUPERA TRNSHEP -,SUP-S-05-040-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 5MM 6FR CATH 80MM 120CM SUPERA TRNSHEP -,SUP-S-05-080-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6599.42,4619.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 5MM 6FR CATH 100MM 120CM SUPERA TRNSHEP -,SUP-S-05-100-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6599.42,4619.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 6MM 6FR CATH 40MM 120CM SUPERA TRNSHEP -,SUP-S-06-040-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,7617.98,5332.586,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 7MM 6FR CATH 60MM 120CM SUPERA TRNSHEP -,SUP-S-07-060-120-6F,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6578.2,4604.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 8X100MM 120CM SUPERA TRNSHEP -,SUP-S-08-100-120-G3,CDM,C1876,HCPCS,278,RC,,,outpatient,,,6599.42,4619.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT PERIPHERAL 4.5MM X 20MM X 120CM  6F -,SUP-S-45-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT PERIPHERAL 4.5MM X 30MM X 120CM  6F -,SUP-S-45-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC SUPERA 4.5X40MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-45-040-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC SUPERA 4.5X60MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-45-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT PERIPHERAL 4.5MM X 80MM X 120CM  6F -,SUP-S-45-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT PERIPHERAL 4.5MM X 100MM X 120CM  6F -,SUP-S-45-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC SUPERA 4.5X120MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-45-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT PERIPHERAL 5MM X 20MM X 120CM  6F -,SUP-S-50-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT PERIPHERAL 5MM X 30MM X 120CM  6F -,SUP-S-50-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC SUPERA 5 X 60MM 120 -,SUP-S-50-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT  VASC SUPERA 5 X 80MM x 120 -,SUP-S-50-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
5MM X 100MM X 120CM SUPERA STENT -,SUP-S-50-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
5MM x 120MM x 120CM SUPERA STENT -,SUP-S-50-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC SUPERA 5.5X40MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-040-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC SUPERA 5.5X60MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC SUPERA 5.5X80MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
SUPERA PERIPHERAL STENT SYSTEM 5.5MM X 100MM X 120CM -,SUP-S-55-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5495.98,3847.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC SUPERA 5.5X120MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC SUPERA 5.5X150MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-55-150-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT PERIPHERAL 6MM X 30MM X 120CM  6F -,SUP-S-60-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT SUPERA 6.0MM X 80 X 120CM -,SUP-S-60-080-120-P,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5920.38,4144.266,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT SUPERA 6MM X 80 X 120CM -,SUP-S-60-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S SUPERA 6.0MM X 100 X 120CM -,SUP-S-60-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S SUPERA 6.0MM X 120 X 120CM -,SUP-S-60-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S SUPERA 6.0MM X 150 X 120CM -,SUP-S-60-150-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT PERIPHERAL  6.5MM X 20MM X 120CM 6F -,SUP-S-65-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT PERIPHERAL 6.5MM X 30MM X 120CM  6F -,SUP-S-65-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC SUPERA 6.5X40MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-040-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC SUPERA 6.5X60MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-060-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC SUPERA 6.5X80MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-080-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC SUPERA 6.5X100MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-100-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC SUPERA 6.5X120MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-120-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC SUPERA 6.5X150MM 120CM RX 6FR SHTH COMPAT PERIPH -,SUP-S-65-150-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT PERIPHERAL 7.0MM X 020MM X 120CM  6F -,SUP-S-70-020-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT PERIPHERAL 7.0MM X 030MM X 120CM  6F -,SUP-S-70-030-120-P6,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 10X40MM 120CM PROTEGE GPS OTW SE PRMNT OPN LATTICE -,SUP-SERB651040120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 10X60MM 120CM PROTEGE GPS OTW SE PRMNT OPN LATTICE -,SUP-SERB651060120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 12X20MM 120CM PROTEGE GPS OTW SE PRMNT OPN LATTICE -,SUP-SERB651220120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
7MM X 30MM TCAR STENT ENROUTE -,SUP-SR-0730-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
7MM X 40MM STENT TCAR ENROUTE -,SUP-SR-0740-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
8MM X 30MM STENT TCAR ENROUTE -,SUP-SR-0830-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
8MM X 40MM STENT TCAR ENROUTE -,SUP-SR-0840-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
9MM X 30MM STENT TCAR ENROUTE -,SUP-SR-0930-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
9MM X 40MM STENT TCAR ENROUTE -,SUP-SR-0940-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
ENROUTE TANSCAROTID STENT SYSTEM SR-1030-CS -,SUP-SR-1030-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
ENROUTE TANSCAROTID STENT -,SUP-SR-1040-CS,CDM,C1876,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC MISAGO 6MM X120MM X 200CM RX R -,SUP-SXR06120R,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC MISAGO 6X150MM 135CM SELF EXPANDING -,SUP-SXR06150R,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
GRAFT EV 14X40 ILC -,SUP-UNDEFINED,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S BILI EXPRESS 5X15X150 -,SUP-UNDEFINED,CDM,C1876,HCPCS,278,RC,,,outpatient,,,2721.18,1904.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 5X18 GENESIS AVIATOR -,SUP-UNDEFINED,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
VENOUS 8F 10mm x 80 mm 120cm CATHETER LENGTH -,SUP-VENUM10080,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
VENOVO VENOUS STENT 12MM X 60MM -,SUP-VENUM12060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
16MM x 60MM x 80CM VENOVO STENT -,SUP-VENUM16060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
VENOUS STENT 14MM x 100MM 120CM CATHETER LENGTH -,SUP-VENUM16080,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
VENOVO VENOUS STENT 18MM X 100MM X 80CM -,SUP-VENUM18100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
VENOUS STENT SYSTEM 18X 120MM 80CM CATH LENGTH -,SUP-VENUM18120,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
VENOVO 10FR 20MM X 60MM- 80CM CATHETER LENGTH -,SUP-VENUM20060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5941.6,4159.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 4MMX6CM 125CM ZILVER 518 OTW SE PRELD SLT TUBE -,SUP-ZIB5-125-4.0-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 4MMX8CM 125CM ZILVER 518 OTW SE PRELD SLT TUBE -,SUP-ZIB5-125-4.0-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S ZILVER 518 5X60 125CM S-E -,SUP-ZIB5-125-5.0-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 12MM 8FR GUID CATH 60MM 125CM ZILVER 635 OTW SE -,SUP-ZIB6-125-12.060,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S ZILVER .035 120CM 5 X 40 -,SUP-ZIB6-125-5.0-40,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S ZILVER .035 125CM 5 X 80 -,SUP-ZIB6-125-5.0-80,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 6X100MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-ZIB6-35-1256100,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT BIL 6X140MM 125CM ZILVER FLEX 35 OTW SE PRELD FLXB SLT -,SUP-ZIB6-35-1256140,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT ZILVER 6MM X 60MM X 125MM -,SUP-ZIV5-18-125-6-60,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC ZILVER 518 8X40MM 125CM OTW SE 0.018IN/5FR -,SUP-ZIV5-18-125-840,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC ZILVER 518 8X80MM 125CM OTW SE 0.018IN/5FR -,SUP-ZIV5-18-125-880,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5271.01,3689.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
S ZILVER 6 X 30 -,SUP-ZIV6-35-125-630,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT ZILVER 6 X 40 -,SUP-ZIV6-35-125-640,CDM,C1876,HCPCS,278,RC,,,outpatient,,,4332.36,3032.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT VASC DES ZILVER PTX 6X40MM 125CM OTW SE PRELD -,SUP-ZIV635125640PTX,CDM,C1876,HCPCS,278,RC,,,outpatient,,,5487.45,3841.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,32197.7856,other,Non-Reimbursable Procedures,,
STENT 3.5X18MM MULTILNK VIS OTW BE PRMNT 143CM WKHRS -,SUP-1010144-18,CDM,C1877,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,198.065125,7007.6928,other,Non-Reimbursable Procedures,,
CATH GUID 7FR AL 0.75 SH 100CM -,SUP-G782AL75,CDM,C1877,HCPCS,278,RC,,,outpatient,,,882.25,617.575,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,198.065125,7007.6928,other,Non-Reimbursable Procedures,,
STENT ESPH 18MM 23/23MM OD P/D FLR 153MM WALLFLX SE BRD FLLY -,SUP-M00516920,CDM,C1877,HCPCS,278,RC,,,outpatient,,,9124.6,6387.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,198.065125,7007.6928,other,Non-Reimbursable Procedures,,
PALMAZ UNMOUNTED STENT DIA 1 -,SUP-P4010,CDM,C1877,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,198.065125,7007.6928,other,Non-Reimbursable Procedures,,
STENT BIL 10X59MM PALMZ GENESIS BE UNMT TRNSHEP SS 0.035IN -,SUP-PG5910B,CDM,C1877,HCPCS,278,RC,,,outpatient,,,3986.29,2790.403,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,198.065125,7007.6928,other,Non-Reimbursable Procedures,,
IMPLANT VOCAL CRD PST PROLARYN PLUS 1ML SYR -,SUP-8044M0K5,CDM,C1878,HCPCS,278,RC,,,outpatient,,,3246.32,2272.424,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,2621.49888,other,Non-Reimbursable Procedures,,
IMPLANT VOCAL CORD PROLARYN GEL 1CC NEEDLE -,SUP-8602M0K5,CDM,C1878,HCPCS,278,RC,,,outpatient,,,3413.41,2389.387,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,2621.49888,other,Non-Reimbursable Procedures,,
IMPLANT THYRPL MONT SZ9 SIL EAR FEM STRL -,SUP-MTF.09,CDM,C1878,HCPCS,278,RC,,,outpatient,,,1828.67,1280.069,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,2621.49888,other,Non-Reimbursable Procedures,,
KIT THYROPLASTY MALE -,SUP-MT-SPM,CDM,C1878,HCPCS,278,RC,,,outpatient,,,3308.38,2315.866,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,2621.49888,other,Non-Reimbursable Procedures,,
FILTER VASC BIRDS NEST 40MMX40CM SS VC MRKR -,SUP-178242,CDM,C1880,HCPCS,278,RC,,,outpatient,,,9467.05,6626.935,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.22547,6153.5825,other,Non-Reimbursable Procedures,,
FILTER EMBL PROT OPTEASE 6FR ID 8FR INTRO SHTH 55CM SLF CNTR -,SUP-466-F220A,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3189.03,2232.321,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.22547,6153.5825,other,Non-Reimbursable Procedures,,
FILTER OPTEASE FEMORAL 55CM -,SUP-466-F230AF,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3189.03,2232.321,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.22547,6153.5825,other,Non-Reimbursable Procedures,,
FILTER VASC BIRD S NEST 40MM 11FR CATH 12FR INTRO 75CM SS VC -,SUP-BNF-75-PB,CDM,C1880,HCPCS,278,RC,,,outpatient,,,9467.05,6626.935,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.22547,6153.5825,other,Non-Reimbursable Procedures,,
FILTER EMBL NAVALIGN CELECT 30X48MM FEM VC -,SUP-G03767,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.22547,6153.5825,other,Non-Reimbursable Procedures,,
FILTER CELECT VENA CAVA UNI -,SUP-G34505,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4773.95,3341.765,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.22547,6153.5825,other,Non-Reimbursable Procedures,,
VENA CAVA FILTER FEMORAL & JUG -,SUP-G34505,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4773.95,3341.765,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.22547,6153.5825,other,Non-Reimbursable Procedures,,
FILTER EMBL CELECT 30MM 7FR INTRO SHTH 48MM UNISET VC -,SUP-G52915,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4668.4,3267.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.22547,6153.5825,other,Non-Reimbursable Procedures,,
FILTER EMBL GUNTHER TULIP 30X50MM FEM VC -,SUP-G52917,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3819.15,2673.405,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.22547,6153.5825,other,Non-Reimbursable Procedures,,
FILTER VASC NAVALIGN CELECT 30MM 7FR CATH UNIV 49MM UNISET -,SUP-IGTCFS651UNICEL,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4773.95,3341.765,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.22547,6153.5825,other,Non-Reimbursable Procedures,,
FILTER VASC GUNTHER TULIP 30MM 8.5FR INTRO SHTH 50MM PRELD -,SUP-IGTCFS-65-FEM,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.22547,6153.5825,other,Non-Reimbursable Procedures,,
FILTER VASC GUNTHER TULIP 30MM 8.5FR INTRO SHTH 50MM- -,SUP-IGTCFS-65-UNI,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.22547,6153.5825,other,Non-Reimbursable Procedures,,
FILTER VENA CAVA TULIP UNI GUNTHER -,SUP-IGTCFS-65-UNI,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3819.15,2673.405,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.22547,6153.5825,other,Non-Reimbursable Procedures,,
FILTER GREENFIELD JUG -,SUP-M001503000,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4249.67,2974.769,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.22547,6153.5825,other,Non-Reimbursable Procedures,,
FILTER GREENFIELD FEM -,SUP-M001503010,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4249.67,2974.769,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.22547,6153.5825,other,Non-Reimbursable Procedures,,
DILATOR VASC 18GA GW 0.038IN DILATOR 8/10/12 FR DIA SYR -,SUP-M001503500,CDM,C1880,HCPCS,278,RC,,,outpatient,,,776.06,543.242,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.22547,6153.5825,other,Non-Reimbursable Procedures,,
FILTER VASC MERIDIAN NTNL VC -,SUP-MD800F,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.22547,6153.5825,other,Non-Reimbursable Procedures,,
FILTER VASC MERIDIAN NTNL SBCLVN VC -,SUP-MD800J,CDM,C1880,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.22547,6153.5825,other,Non-Reimbursable Procedures,,
FILTER OPTEASE JUGULAR 90CM -,SUP-UNDEFINED,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.22547,6153.5825,other,Non-Reimbursable Procedures,,
FILTER OPTEASE JUGULAR 55CM -,SUP-UNDEFINED,CDM,C1880,HCPCS,278,RC,,,outpatient,,,3189.03,2232.321,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,174.22547,6153.5825,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR PRMT RF DF-1 2CHMBR 50X81MM 14MM 43ML 82GM -,SUP-3207-36,CDM,C1882,HCPCS,275,RC,,,outpatient,,,59022.98,41316.086,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR LUMAX 540 HF-T DF-1 IS-1 CONN 3 CHMBR RR. -,SUP-360347,CDM,C1882,HCPCS,275,RC,,,outpatient,,,38238.5,26766.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR LUMAX 740 HF-T BIVEN PCNG CARD IMPL W/HOME -,SUP-365608,CDM,C1882,HCPCS,275,RC,,,outpatient,,,40705.5,28493.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR ILESTO HF-T DF-1 BIVEN PCNG RDC HI ENRG CARD -,SUP-383547,CDM,C1882,HCPCS,275,RC,,,outpatient,,,40705.5,28493.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR ILESTO HF-T DF-4 BIVEN PCNG HI ENRG CARD IMPL -,SUP-383549,CDM,C1882,HCPCS,275,RC,,,outpatient,,,32036.46,22425.522,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR LUMAX 740 HF-T CARD IMPL W/HOME MNTR MBL -,SUP-393803,CDM,C1882,HCPCS,275,RC,,,outpatient,,,39472,27630.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
DEFIB HI ENRG BIVEN CARD IMPL TI -,SUP-401662,CDM,C1882,HCPCS,275,RC,,,outpatient,,,34503.46,24152.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR PRMT + DF-4 RR V- PCNG RDC 50X75MM 14MM 42ML -,SUP-CD3211-36Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR UNIFY IS-1 CONN 40X79MM 14MM 36ML 78GM CARD -,SUP-CD3231-40,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR UNIFY QUADRA DF-4 IS-4 IS-1 CONN 41X75MM 14MM -,SUP-CD3249-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43251.44,30276.008,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR UNIFY ASSURA DF-1 IS-1 DF-4 BIVEN PCNG 40X79MM -,SUP-CD3257-40,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR UNIFY ASSURA DF-4 TELEM 2CHMBR 40X73MM 14MM -,SUP-CD3257-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35364.45,24755.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR QUADRA ASSURA DF-1 BIVEN PCNG 41X83MM 14MM -,SUP-CD3265-40,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43251.44,30276.008,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR QUADRA ASSURA DF-4 IS-4 IS-1 CONN BIVEN PCNG -,SUP-CD3265-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43251.44,30276.008,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR UNIFY ASSURA CARD IMPL PARYLENE CTD -,SUP-CD3357-40C,CDM,C1882,HCPCS,275,RC,,,outpatient,,,29974.05,20981.835,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
UNIFY ASSURA NXGEN CRT-D 40 MEDIGUIDE -,SUP-CD3357-40C,CDM,C1882,HCPCS,275,RC,,,outpatient,,,47726.58,33408.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR UNIFY ASSURA DF-4 CARD IMPL PARYLENE CTD CD -,SUP-CD3357-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,29974.05,20981.835,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
CRT-D 40 QUADRA ASSURA -,SUP-CD3365-40C CELL,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35225.31,24657.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR QUADRA ASSURA DF-4 SGL/2CHMBR 41X75MM 14MM -,SUP-CD3365-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35225.31,24657.717,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
CRT-D QUADRA ASSURA MP CD3369-40C -,SUP-CD3369-40C,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
CRT-D QUADRA ASSURA MP DFR CON -,SUP-CD3369-40Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
ENTRANT CRT-D CDHFA300Q -,SUP-CDHFA300Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35771.5,25040.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
ENTRANT HF CRT-D DF1 CONNECTOR REF: CDHFA300T -,SUP-CDHFA300T,CDM,C1882,HCPCS,275,RC,,,outpatient,,,35771.5,25040.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
GALLANT CRT-D CDHFA500Q -,SUP-CDHFA500Q,CDM,C1882,HCPCS,275,RC,,,outpatient,,,38238.5,26766.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
GALLANT HF CRT-D DF1 CONNECTOR REF: CDHFA500T -,SUP-CDHFA500T,CDM,C1882,HCPCS,275,RC,,,outpatient,,,38238.5,26766.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR INOGEN MUL PRGM OPTN EXTEND LNGVT VR -,SUP-D141,CDM,C1882,HCPCS,275,RC,,,outpatient,,,28370.5,19859.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR CONSULTA DF-1 IS-1 CONN WRLS TELEM 2CHMBR RR -,SUP-D224TRK,CDM,C1882,HCPCS,275,RC,,,outpatient,,,48626.05,34038.235,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR PROTECTA DF-4 CARD IMPL -,SUP-D334TRM,CDM,C1882,HCPCS,275,RC,,,outpatient,,,39911.13,27937.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
EVERA MRI MRT XT DR DDMB1D4 -,SUP-DDMB1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,37251.7,26076.19,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
VIVA CARD IMPL -,SUP-DTBA1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50599.65,35419.755,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR VIVA XT IS-1 DF-1 ADPTVCRT PHYCRV SMRTSHCK -,SUP-DTBA1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50599.65,35419.755,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR VIVA S DF-4 IS-1 CONN SGL-CHMBR CARD IMPL -,SUP-DTBB1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,42839.46,29987.622,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR VIVA S DF-4 IS-1 CONN SGL-CHMBR CARD IMPL. -,SUP-DTBB1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,42839.46,29987.622,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
DEFIB  VIVA QUAD S CRT-D DF-1 IS-4 CONN CARD IMPL -,SUP-DTBB1Q1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,43172.5,30220.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR VIVA QUAD S DF-4 IS-4 CONN CARD IMPL -,SUP-DTBB1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,42839.46,29987.622,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
CLARIA MRI CRT-D DTMA1D1 -,SUP-DTMA1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49006.96,34304.872,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
CLARIA MRI CRT-D MODEL DTMA1D1 -,SUP-DTMA1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49006.96,34304.872,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
CLARIA MRI CRT-D DTMA1D4 -,SUP-DTMA1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49006.96,34304.872,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
CLARIA MRI QUAD CRT-D Model DTMA1QQ -,SUP-DTMA1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50326.8,35228.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
CLARIA MRI QUAD CRT-D DTMA1QQ -,SUP-DTMA1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50326.8,35228.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
AMPLIA MRI CRT-D DTMB1D1 -,SUP-DTMB1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,47773.46,33441.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
CRTD DTMB1D1 AMPLIA MRI US DF1 -,SUP-DTMB1D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,47773.46,33441.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
AMPLIA CRT-D MRI DEVICE -,SUP-DTMB1D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,54249.33,37974.531,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
AMPLIA MRI QUAD CRT-D SURESCAN DTMB1Q1 -,SUP-DTMB1Q1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
AMPLIA MRI QUAD CRT-D -,SUP-DTMB1Q1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
AMPLIA CRT-D DTMB 1 QQ -,SUP-DTMB1QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
ICD COBALT HF CRT-D MRI SURESCAN REF: DTPB2D1 -,SUP-DTPB2D1,CDM,C1882,HCPCS,275,RC,,,outpatient,,,48237.25,33766.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
COBALT HF QUAD CRTD REF: DTPB2QQ -,SUP-DTPB2QQ,CDM,C1882,HCPCS,275,RC,,,outpatient,,,52793.8,36955.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
CROME MRI CRTD REF: DTPC2D4 -,SUP-DTPC2D4,CDM,C1882,HCPCS,275,RC,,,outpatient,,,50240.46,35168.322,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
CRT-D MOMENTUM IS1 DF4 G124 -,SUP-G124,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
CRT-D MOMENTUM IS1 DF1 G125 -,SUP-G125,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
CRT-D MOMENTUM LV-1 G126 -,SUP-G126,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
CRT-D MOMENTUM X4 IS4-DF1 G138 -,SUP-G138,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
PACEMAKER INOGEN CARD -,SUP-G140,CDM,C1882,HCPCS,275,RC,,,outpatient,,,39225.3,27457.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR INOGEN CARD -,SUP-G141,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR INOGEN DF-1 SGL-CHMBR 5.37CMX8.08CMX0.99CM D -,SUP-G146,CDM,C1882,HCPCS,275,RC,,,outpatient,,,41692.3,29184.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
DEFIBRILLATOR INOGEN DF-4 5.37CMX8.08CMX0.99CM D 32ML CARD -,SUP-G148,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
DYNAGEN CRT-D MODEL G150 -,SUP-G150,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
DYNAGEN CRT-D G-154 DEFIBRILLATOR -,SUP-G154,CDM,C1882,HCPCS,275,RC,,,outpatient,,,31910.65,22337.455,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
CRT-D DYNAGEN X4 G156 -,SUP-G156,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33218.16,23252.712,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
CRT-D VIGILANT X4 IS4 DF4 MRI CONDITIONAL -,SUP-G247,CDM,C1882,HCPCS,275,RC,,,outpatient,,,33304.5,23313.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
COMPIA CRT-D MRI QUAD -,SUP-UNDEFINED,CDM,C1882,HCPCS,275,RC,,,outpatient,,,49093.3,34365.31,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,45329.64864,other,Non-Reimbursable Procedures,,
ANCHOR LD C IN 94IN LF ACC -,SUP-1194,CDM,C1883,HCPCS,278,RC,,,outpatient,,,437.63,306.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3519.77472,other,Non-Reimbursable Procedures,,
KIT EXTENSION INTERSTIM 10CM S  - DISCONTINUED DO NOT USE -,SUP-3095-10,CDM,C1883,HCPCS,278,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3519.77472,other,Non-Reimbursable Procedures,,
KIT REVISION INTERSTIM -,SUP-3550-05,CDM,C1883,HCPCS,278,RC,,,outpatient,,,1079.48,755.636,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3519.77472,other,Non-Reimbursable Procedures,,
KT EXTENSION NEURSTM INTSTM 60CM PERC MRI-COND INSL MULI- -,SUP-3708160,CDM,C1883,HCPCS,278,RC,,,outpatient,,,3007.62,2105.334,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3519.77472,other,Non-Reimbursable Procedures,,
LEAD ADPTR -,SUP-5866,CDM,C1883,HCPCS,278,RC,,,outpatient,,,1325.13,927.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3519.77472,other,Non-Reimbursable Procedures,,
CABLE PCNG -,SUP-5867AS,CDM,C1883,HCPCS,278,RC,,,outpatient,,,116.7,81.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3519.77472,other,Non-Reimbursable Procedures,,
EXTENDER LD UNIPL -,SUP-6981M,CDM,C1883,HCPCS,278,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3519.77472,other,Non-Reimbursable Procedures,,
EXTENDER LD BIPLR MRI-COND -,SUP-6984M,CDM,C1883,HCPCS,278,RC,,,outpatient,,,1079.48,755.636,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3519.77472,other,Non-Reimbursable Procedures,,
ADAPTER NEURSTM 27.4CM SPIN CRD 2X4 PCKT -,SUP-740-02,CDM,C1883,HCPCS,278,RC,,,outpatient,,,4583.04,3208.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,26.19915,3519.77472,other,Non-Reimbursable Procedures,,
FILTER EMBL PROT EMBOSHIELD NAV6 5MMX190CM WIRE UNCNTSTR -,SUP-22437-19,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,5331.24633,other,Non-Reimbursable Procedures,,
FILTER EMBL PROT EMBOSHIELD NAV6 7.2MMSMX190CM WIRE UNCNTSTR -,SUP-22438-19,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,5331.24633,other,Non-Reimbursable Procedures,,
FILTER EMBL PROT FLTWR EZ 3.2FRX190CM WIRE NTNL LOOP CRTD -,SUP-H749201001900,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6875.28,4812.696,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,5331.24633,other,Non-Reimbursable Procedures,,
FILTER EMBL PROT FLTWR EZ 3.2FRX300CM WIRE NTNL LOOP CRTD -,SUP-H749201003000,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7078.99,4955.293,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,5331.24633,other,Non-Reimbursable Procedures,,
EMBOLIC PROT FLTWR EZ 0.042IN 0.014 DIA GW 110U FLTR 190CM -,SUP-H749390711900,CDM,C1884,HCPCS,272,RC,,,outpatient,,,7435.49,5204.843,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,5331.24633,other,Non-Reimbursable Procedures,,
FILTERWIRE EMBL EZ 2.25MM 3.5MMX300CM FEM VC -,SUP-H74939071300,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6457.03,4519.921,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,5331.24633,other,Non-Reimbursable Procedures,,
DEVICE EMBL PROT SPIDERFX 3MM FLTR BSKT 0.014IN GW 0.066IN -,SUP-SPD2US030320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,5331.24633,other,Non-Reimbursable Procedures,,
DEVICE EMBL PROT SPIDERFX 4MM FLTR BSKT 0.014IN GW 0.066IN -,SUP-SPD2US040320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,5331.24633,other,Non-Reimbursable Procedures,,
SPIDER FX 5MM 320 .014 EMBOLIC -,SUP-SPD2US050320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,5331.24633,other,Non-Reimbursable Procedures,,
SPIDER FX 6MM 320 .014 EMBOLIC -,SUP-SPD2US060320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,5331.24633,other,Non-Reimbursable Procedures,,
DEVICE EMBL PROT SPIDERFX 7MM FLTR BSKT 0.014IN GW 0.066IN -,SUP-SPD2US070320,CDM,C1884,HCPCS,272,RC,,,outpatient,,,6588.05,4611.635,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,5331.24633,other,Non-Reimbursable Procedures,,
CATHETER LASER CORONARY ATHETECTOMY 0.9X80 ELACX-80 -,SUP-110-004,CDM,C1885,HCPCS,272,RC,,,outpatient,,,10588.78,7412.146,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7592.15526,other,Non-Reimbursable Procedures,,
CATHETER 1.4MM ELCA CORONARY LASER ATHE -,SUP-114-009,CDM,C1885,HCPCS,272,RC,,,outpatient,,,10588.78,7412.146,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7592.15526,other,Non-Reimbursable Procedures,,
C 1.7M .018IN OTW TURBO ELITE -,SUP-417-152,CDM,C1885,HCPCS,272,RC,,,outpatient,,,9653.8,6757.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7592.15526,other,Non-Reimbursable Procedures,,
CATH ABLT 4MM 90DG 160CM BARRX ULTRA LNG LF -,SUP-90-9200,CDM,C1886,HCPCS,272,RC,,,outpatient,,,9419.88,6593.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7607.37,other,Non-Reimbursable Procedures,,
CATHETER BRONCHIAL THERMOPLAST -,SUP-M005ATS25010,CDM,C1886,HCPCS,272,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7607.37,other,Non-Reimbursable Procedures,,
CATH SHEATH RITESITE C315H40,SUP-,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
GUIDE 8F MARK 1 AL 2 -,SUP-34358-20,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
GUIDE 8F MARK 1 IM -,SUP-34358-26,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
LEAD PCNG 6.6FR 7FR INTRO 53CM TILDA HELIX ELECTRICALLY -,SUP-382889,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
LEAD PCNG 6.6FR 7FR INTRO 60CM TILDA HELIX ELECTRICALLY -,SUP-382895,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATHETER GUIDE 6FR X 85CM INTERNAL MAMMARY -,SUP-38969-122/H749389691220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 5FR IL-3.5 HEARTRAIL III NO SH COR SS FLTWR PTFE -,SUP-40-5370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 5FR IKARI RT 2 HEARTRAIL III NO SH COR SS FLTWR -,SUP-40-5382,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 6FR ID 0.081IN IL-3.5 100CM HEARTRAIL III LRG LUM -,SUP-40-6370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 6FR ID 0.081IN IL-4.5 100CM HEARTRAIL III LRG LUM -,SUP-40-6375,CDM,C1887,HCPCS,272,RC,,,outpatient,,,408.45,285.915,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
MICRO GUIDE CATH NHANCER RX REF: 451669 -,SUP-451669,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATHETER GUIDE -,SUP-490107,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH DX 0.039/0.026IN DIA P/D 45DG ANG TAPR 135CM QCK-CX -,SUP-518-032,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH DX 0.044/0.030IN DIA P/D 15MM SPC 45DG ANG TAPR 90CM -,SUP-518-033,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
C QUICKCROSS .018 150CM -,SUP-518-035,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH DX 0.063/0.050IN DIA P/D 15MM SPC 45DG ANG TAPR 90CM -,SUP-518-036,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
C QUICKCROSS .035 135CM -,SUP-518-037,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
C QUICKCROSS .035 150CM -,SUP-518-038,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
C 0.014-150CM QUICK CROSS -,SUP-518-065,CDM,C1887,HCPCS,272,RC,,,outpatient,,,974.45,682.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH DX 0.052/0.059IN DIA P/D 15MM SPC 45DG ANG TAPR 135CM -,SUP-518-081,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
C QUICK CROSS SEL .035 150CM -,SUP-518-083,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
C QUICK CROSS SEL .014 150 -,SUP-518-087,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
C QUICK CROSS SEL .018 150 -,SUP-518-093,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH DX 3FR ID 1.9FRX140CM TWN PASS RX LPRO LUMX2 COR PERIPH -,SUP-5200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2003.59,1402.513,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATHETER SUPERCROSS 45 ANGLED 0.014 X 130CM -,SUP-5302,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
SUPERCROSS 90 ANGLED TIP CATH -,SUP-5305,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2279.22,1595.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
MICRO GUIDE CATH SUPERCROSS 120 ANGLED TIP REF: 5306 -,SUP-5306,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2472.93,1731.051,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH ANG INFINITI 5FR JR4 REF: 534521T -,SUP-534521T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH ANG 5FR 145 PIGTL 110CM INFINITI REF: 534-552S -,SUP-534552S,CDM,C1887,HCPCS,272,RC,,,outpatient,,,43.47,30.429,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH ANG 5FR IMA CRV 100CM INFIN SLCT 3 STG BRD NBRD PROX -,SUP-534-560T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH ANG INFINITI 6FR JL4 REF: 534620T -,SUP-534620T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH ANG INFINITI 6FR JR4 REF: 534-621T -,SUP-534-621T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH ANG INFINITI 6FR AR MOD REF: 534648T -,SUP-534648T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH ANG INFINITI 6FR RCB REF: 534670T -,SUP-534670T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH ANG INFINITI 6FR LCB REF: 534672T -,SUP-534672T,CDM,C1887,HCPCS,272,RC,,,outpatient,,,45.63,31.941,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
SHEATH GUID 5FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-54-54501,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH DX 6FR 145DG PIGTL 110CM LANGSTON BRD LUMX2 LO XING -,SUP-5540,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1088.81,762.167,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.056IN 5FRX100CM 2.5MM VISTA BRITE TIP SS PTFE -,SUP-556-002-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.056IN 5FR JL3.5 100CM VISTA BRITE TIP BRD -,SUP-556-002-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.056IN 5FR LT COR EBU 3.5 100CM 2.5MM VISTA BRITE -,SUP-556-054-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.056IN 5FR  XBLAD 3.5 LBT 100CM 2.5MM VISTA -,SUP-556-060-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.056IN 5FR BARB 100CM VISTA BRITE TIP BRD MUL-SEG -,SUP-556-174-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,214.44,150.108,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATHETER 6FRX150CM TRAPLINER REF:5566 -,SUP-5566,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3652.11,2556.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATHETER 7FRX150CM TRAPLINER REF:5567 -,SUP-5567,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3652.11,2556.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH DX 6FRX150CM GUIDELINER V2 RX COAX PERIPH -,SUP-5571,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2183.81,1528.667,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH DX 7FRX150CM GUIDELINER V2 RX COAX PERIPH -,SUP-5572,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2183.81,1528.667,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH DX 8FRX150CM GUIDELINER V2 RX COAX PERIPH -,SUP-5573,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2173.21,1521.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
TURNPIKE GOLD 135CM MICRO CATH -,SUP-5621,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3294.06,2305.842,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
TURNPIKE LP 135 ON MICRO CATHETER -,SUP-5638,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3771.46,2640.022,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
TURNPIKE LP 150CM MICRO CATH -,SUP-5639,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2931.24,2051.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATHETER TURNPIKE SPIRAL 135CM -,SUP-5640,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3771.46,2640.022,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.018IN 3.5FR SHFT 70CM 8MM VENTURE OTW CS PED -,SUP-5822,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3146.07,2202.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.088IN 8FR JL4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-588-823,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.088IN 8FR LT COR EBU3 100CM 2.5MM VISTA BRITE -,SUP-588-829,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.088IN 8FR JR4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-588-830,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.088IN 8FR JL3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-588-851,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID VISTA 8FR XB 3.5 -,SUP-588-882,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.088IN 8FR LT COR EBU 4 100CM 2.5MM VISTA BRIT -,SUP-588-894,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH DX 0.054IN 6FRX100CM 2CM PERFORM ULTMT 2 -,SUP-610038ULT2,CDM,C1887,HCPCS,272,RC,,,outpatient,,,140.74,98.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 130DG CRV ATTAIN SELECT COR STR 5.5FR INR CATH -,SUP-6248DEL,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATHETER ATTAIN SELECT REF: 6248V-130 -,SUP-6248V-130,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1284.84,899.388,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH 6248V-90 ATTAIN SELECT II -,SUP-6248V-90,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1284.84,899.388,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATHETER  CRDM Adaptor 6250V-EH -,SUP-6250V-EH,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATHETER ATTAIN COMMAND REF: 6250V-MPR -,SUP-6250V-MPR,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.96MM/MIN 2.4MM/MAX MPX COR 50CM ATTAIN COMMAND -,SUP-6250VMPX,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1471.42,1029.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.07IN 6FR JL3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-002-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.07IN 6FR JL4 100CM VISTA BRITE TIP BRD -,SUP-670-004-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.07IN 6FR JL4 SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-005-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.07IN 6FR JL4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-014-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.07IN 6FR AL1 100CM .75MM SH VISTA BRITE TIP -,SUP-67003500,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.07IN 6FR ALC1 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-036-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.07IN 6FR ALC2 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-040-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.07IN 6FR  XB3 100CM 1.8MM VISTA BRITE TIP -,SUP-670-052-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.07IN 6FR XB 3 SH 100CM VISTA BRITE TIP -,SUP-670-053-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUIDING 6FR XB 3.5 VISTA -,SUP-670-054-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUIDING 6FR XB 3.5 VISTA LBT -,SUP-670-054-0L,CDM,C1887,HCPCS,272,RC,,,outpatient,,,253.82,177.674,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.07IN 6FR LT COR EBU3.5 SH 100CM 2.5MM VISTA -,SUP-670-055-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.07IN 6FR XB4 100CM 2.5MM VISTA BRITE TIP -,SUP-670-056-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.07IN 6FR XB4.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-67005800,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.07IN 6FR XBLAD 3.5 100CM  VISTA BRITE -,SUP-670-060-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.07IN 6FR XBLAD 4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-062-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 6FR XBLAD 4.5 100CM VISTA BRITE TIP -,SUP-67006400,CDM,C1887,HCPCS,272,RC,,,outpatient,,,198.39,138.873,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.07IN 6FR XBLAD 3 100CM VISTA BRITE TIP -,SUP-670-066-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.07IN 6FR JR3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-080-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.07IN 6FR JR4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-67008200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.07IN 6FR JR4 55CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-082-55,CDM,C1887,HCPCS,272,RC,,,outpatient,,,355.35,248.745,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.07IN 6FR JR4 SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-083-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.07IN 6FR ARC1 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-67011000,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.07IN 6FR XBRCA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-126-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.07IN 6FR JEAN- FJL 100CM 2.5MM VISTA BRITE TIP -,SUP-670-166-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 6FR JFL LT REF: 670-166-00 -,SUP-670-166-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.07IN 6FR BARB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-174-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.07IN 6FR LCB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-180-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.07IN 6FR LCB 90CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-180-90,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.07IN 6FR RCB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-182-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.07IN 6FR RCB 90CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-182-90,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.07IN 6FR IMA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-190-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.07IN 6FR VERT 55CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-190-55,CDM,C1887,HCPCS,272,RC,,,outpatient,,,355.35,248.745,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.07IN 6FR IM SH REF: 670-191-00 -,SUP-670-191-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 6FR IM VB-1 100CM VISTA BRITE TIP -,SUP-67019200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,198.39,138.873,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.07IN 6FR RNL CRV 55CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-212-55,CDM,C1887,HCPCS,272,RC,,,outpatient,,,355.35,248.745,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.07IN 6FR HS 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-278-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.07IN 6FR HS SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-670-279-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.078IN 7FR JL4 100CM 2.5MM VISTA BRITE TIP BD -,SUP-778-004-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATHETER GUIDING 7FR JL 5 SH JUDKINS -,SUP-77800900,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUIDE 7FR AL2 REF: 778704000 -,SUP-77804000,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.078IN 7FR LT EBU LAD 3 100CM 2.5MM VISTA BRITE -,SUP-778-052-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.078IN 7FR XB 3.5 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-054-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUIDING  7FR XB3.5 SH VIS -,SUP-778-055-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.078IN 7FR XB4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-056-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.078IN 7FR LT EBU LAD 4.5 100CM 2.5MM VISTA BRITE -,SUP-778-058-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUIDING 7FR XBLAD 3.5 100CM 2.5MM VISTA -,SUP-778-060-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.078IN 7FR LT COR EBU LAD 4 100CM 2.5MM VISTA -,SUP-778-062-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.078IN 7FR JR4 100CM 2.5MM VISTA BRITE BRD -,SUP-778-082-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.078IN 7FR JR4 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-083-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.078IN 7FR ARC1 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-110-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.078IN 7FR ARC2 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-112-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.078IN 7FR RCB 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-182-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.078IN 7FR IMA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-190-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.078IN 7FR MPA-1 COR 100CM 2.5MM VISTA BRITE TIP -,SUP-778-270-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.078IN 7FR HS 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-278-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.078IN 7FR HS SH 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-778-279-00,CDM,C1887,HCPCS,272,RC,,,outpatient,,,208.31,145.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH BLN OCCULSION 2.1FRX135CM ASAHI TORNUS SUPP CHRNC OTW -,SUP-82380-01,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH DX 2.6FRX135CM ASAHI TORNUS SUPP OTW THRD COR SS -,SUP-82381-01,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3795.33,2656.731,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATHETER CENTER POINT REF:9181 -,SUP-9181,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATHETER CENTER POINT REF:9182 -,SUP-9182,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATHETER CENTER POINT REF:9183 -,SUP-9183,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATHETER CENTER POINT REF:9184 -,SUP-9184,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH SHEATH RITESITE C315H2002 -,SUP-C315H2002,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH SHEATH RITESITE C315H4002 -,SUP-C315H4002,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH SHEATH C315HIS02 -,SUP-C315HIS02,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
HIS SHEATH DELIVERY SYSTEM C315HIS02 -,SUP-C315HIS02,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH SHEATH RITESITE C315J02 -,SUP-C315J02,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH SHEATH RITESITE C315S1002 -,SUP-C315S1002,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH SHEATH RITESITE C315S402 -,SUP-C315S402,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH SHEATH RITESITE C315S502 -,SUP-C315S502,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1865.78,1306.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH ELCSURG 7FRX100CM RF FLXB CLSR FST -,SUP-CF7-7-100,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1802.17,1261.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
GLIDECATH MG1 4F 125CM  LONG -,SUP-CG440,CDM,C1887,HCPCS,272,RC,,,outpatient,,,295.54,206.878,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
GLIDECATH MG2 4F 135CM  LONG -,SUP-CG441,CDM,C1887,HCPCS,272,RC,,,outpatient,,,295.54,206.878,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH ABLT CLSR FST 65CM PROC KT MIS-7F11 INTRO -,SUP-CPK6511,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1908.18,1335.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH ABLT CLSR FST 73CM PROC KT MIS-7F11 INTRO -,SUP-CPK8511,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1908.18,1335.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
ASAHI CARAVEL MICROCATHETER 150 CM -,SUP-CRV150-19P,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATHETER CORSAIR PRO XS 150CM REF: CSR150-21S -,SUP-CSR150-21S,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATHETER CORSAIR PRO 150CM CSR150-26P ASAHI -,SUP-CSR150-26P,CDM,C1887,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
"CATHETER CXI SUPPORT 4.OFR X 135CM STR TIP .035"" MAX GUIDEWR -",SUP-CXI-4.0-35-135-P-NS-O,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATHETER CPS LOCATOR 3D- SMALL REF:DS2C100-42 -,SUP-DS2C100-42,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATHETER CPS LOCATOR 3D- MEDIUM REF:DS2C200-42 -,SUP-DS2C200-42,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATHETER CPS LOCATOR 3D- LAGE REF:DS2C300-42 -,SUP-DS2C300-42,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATHETER AGILIS HISPRO DS3H010-38 -,SUP-DS3H010-38,CDM,C1887,HCPCS,272,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATHETER AGILIS HISPRO DS3H010-38  BUNDLE -,SUP-DS3H010-38,CDM,C1887,HCPCS,272,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH ANG 0.056IN 6FR AR1 100CM DXTERITY REF: DXT6AR10 -,SUP-DXT6AR10,CDM,C1887,HCPCS,272,RC,,,outpatient,,,9.92,6.944,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
RING TRANS-JUG ACCESS SET WITH 10fr -,SUP-G06541,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2542.11,1779.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
TRANSJUGLAR LIVER ACCESS SET R -,SUP-G06929,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2558.82,1791.174,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
BEACON TIP 5.0 FR ANGIOGRAPHIC CATHETER - C2 -,SUP-G08442,CDM,C1887,HCPCS,272,RC,,,outpatient,,,151.7,106.19,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATHETER RIM 5FR X 100CM -,SUP-G12870,CDM,C1887,HCPCS,272,RC,,,outpatient,,,758.49,530.943,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH DX 2.6FR STR 65CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G18367,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1051.93,736.351,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATHETER CXI SUPPORT -,SUP-G18368,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1051.93,736.351,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CXI-2.3-14-65-0 -,SUP-G18369,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH CXI 2.3FR X 65CM X 014 SU -,SUP-G18370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH CXI 2.3FR X 90CM X 014 SU -,SUP-G18371,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CXI-2.3-14-90-ANG -,SUP-G18372,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CXI-2.3-14-150-ANG -,SUP-G18376,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH DX 2.6FR ANG 150CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G50003,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH DX 2.6FR STR 90CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G50004,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH DX 3FR/1.9FR P/D STR 135CM CROSSCATH SUPP LUMX1 PERIPH -,SUP-G51573,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH DX 4.8FR/3.7FR P/D STR 90CM CROSSCATH SUPP LUMX1 PERIPH -,SUP-G51580,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH DX 4.8FR/3.7FR P/D STR 135CM CROSSCATH SUPP LUMX1 -,SUP-G51581,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH DX 3.4FR/2.2FR P/D STR 135CM CROSSCATH SUPP LUMX1 -,SUP-G51583,CDM,C1887,HCPCS,272,RC,,,outpatient,,,886.86,620.802,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH DX 4FR DAV 135CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G52543,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
C NAVICROSS ANG 150CM .035 -,SUP-G52545,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH DX 4FR DAV 150CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G52545,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATHETER CXI SUPPORT 4FR X 90CM STR TIP .035 MAX GUIDEWRE -,SUP-G52546,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH DX 4FR DAV 90CM CXI SUPP BRD PERIPH HYDRCT -,SUP-G52547,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1113.05,779.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH ANG 90CM NAVICROSS -,SUP-G52547,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.07IN 7FR XBRCA 100CM 2.5MM VISTA BRITE TIP BRD -,SUP-G778126,CDM,C1887,HCPCS,272,RC,,,outpatient,,,882.25,617.575,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID RELIEVA FLEX SIN S-0 SFT DIST TIP ENDO -,SUP-GC000RF,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1961.19,1372.833,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID RELIEVA FLEX SIN F-70 C SFT DIST TIP ENDO -,SUP-GC070CRF,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1961.19,1372.833,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID RELIEVA FLEX SIN M-110 SFT DIST TIP ENDO -,SUP-GC110RF,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1961.19,1372.833,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH ANGIO IMPULSE 5FR FL3.5 REF:H74916391212 -,SUP-H74916391212,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATHETER 5FR FL4 IMPULSE REF:H74916391222 -,SUP-H74916391222,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH ANGIO IMPULSE 5FR AR1 REF:H74916391842 -,SUP-H74916391842,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH ANG 0.045IN 5FR AL1 100CM IMPULSE REF:H74916391962 -,SUP-H74916391962,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATHETER 5FR AL2 IMPULSE REF:H74916391982 -,SUP-H74916391982,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
ANGIO CATH PIG 6F IMPULSE -,SUP-H74916599412,CDM,C1887,HCPCS,272,RC,,,outpatient,,,87.53,61.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.070IN 6FR AL3 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934356210,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATHETER GUIDING 6FR Mach 1 AL .75 -,SUP-H74934356220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 6FR MACH 1 ML 3.5 REF: H749343565370 -,SUP-H749343565370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.081IN 7FR FL3 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934357050,CDM,C1887,HCPCS,272,RC,,,outpatient,,,306.51,214.557,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.081IN 7FR FL3.5 100CM MACH1 4X2 RND BRD LRG LUM -,SUP-H74934357060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 7FR IM 85CM MACH1 -,SUP-H749343571220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 7FR AL.75 100CM MACH1 REF:H74934357220 -,SUP-H74934357220,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.081IN 7FR RCB 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934357240,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.081IN 7FR Q- TY CRV 4 100CM MACH1 4X2 RND BRD -,SUP-H749343572940,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.070IN 7FR Q4.5 MACH 1 -,SUP-H749343572950,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.081IN 7FR MP1 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934357380,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUIDE 7FR MP2 REF: H74934357390 -,SUP-H74934357390,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.081IN 7FR FR3.5 SH 100CM MACH1 2X2 RND BRD -,SUP-H74934357470,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.081IN 7FR FL4.5 100CM MACH1 2X2 RND BRD LRG LUM -,SUP-H74934357540,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.081IN 7FR CNTRLAT 3 100CM MACH1 2X2 RND BRD LRG -,SUP-H749343575730,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.081IN 7FR CLS 3.5 100CM MACH1 4X2 RND BRD LRG -,SUP-H749343575740,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.081IN 7FR VL3 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934357710,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.081IN 7FR VL3.5 100CM MACH1 4X2 RND BRD LRG LUM -,SUP-H74934357720,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.081IN 7FR FR4 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934357920,CDM,C1887,HCPCS,272,RC,,,outpatient,,,306.51,214.557,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.091IN 8FR FR3.5 100CM MACH1 2X2 RND BRD SD HOL -,SUP-H74934358010,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.091IN 8FR FR4 100CM MACH1 4X2 RND BRD LRG LUM NO -,SUP-H74934358020,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.091IN 8FR FL3.5 100CM MACH1 4X2 RND BRD LRG LUM -,SUP-H74934358060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.091IN 8FR FL4.5 100CM MACH1 2X2 RND BRD LRG LUM -,SUP-H74934358080,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID MACH1 8FR AL.75 SH  90CM - H749343581920 -,SUP-H749343581920,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.091IN 8FR LCB 100CM MACH1 2X2 RND BRD LRG LUM NO -,SUP-H74934358250,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.091IN 8FR FR4 100CM MACH1 4X2 RND BRD LRG LUM SH -,SUP-H74934358480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.070IN 6FR FR3.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969010,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.070IN 6FR FR4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969020,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.07IN 6FR FL3 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969050,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.07IN 6FR FL3.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.07IN 6FR FL4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969070,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.070IN 6FR FL4.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969080,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.070IN 6FR FEM HS 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H749389691410,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.070IN 6FR AR2 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969180,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.070IN 6FR AL1 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969190,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.070IN 6FR AL2 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969200,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.07IN 6FR FRC BYPS 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H74938969240,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.070IN 6FR LCB RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969250,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.070IN 6FR IMA RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969260,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.070IN 6FR FL4 ST RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H74938969290,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.070IN 6FR Q3.5 -,SUP-H749389692930,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.070IN 6FR Q4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389692940,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.070IN 6FR Q4.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389692950,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.07IN 6FR MP1 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969380,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.070IN 6FR FEM MP 2 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H74938969390,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.070IN 6FR HS RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H74938969410,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.070IN 6FR IMA 90CM RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389694460,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.070IN 6FR RC 4 SC RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389694480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.070IN 6FR RC 3.5 SC RUNWAY 2X2 RND BRD LRG LUM -,SUP-H74938969460,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.070IN 6FR FR3.5 RUNWAY 2X2 RND BRD LRG LUM SH -,SUP-H74938969470,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.070IN 6FR FR4 RUNWAY 2X2 RND BRD LRG LUM SH FEM -,SUP-H74938969480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.070IN 6FR ART3 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389694960,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.070IN 6FR ART3.5 RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389694980,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.070IN 6FR ART3.5 RUNWAY 2X2 RND BRD LRG LUM SH -,SUP-H749389694990,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.070IN 6FR ART4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389695000,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.070IN 6FR FL 3.5 SH RUNWAY 2X2 RND BRD LRG -,SUP-H74938969520,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.070IN 6FR MUTA LT 3 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695360,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.070IN 6FR MUTA LT 3.5 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.070IN 6FR MUTA LT 4 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695380,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.070IN 6FR MUTA LT 4.5 RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389695390,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.07IN 6FR FEM CLS 3 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H749389695730,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.070IN 6FR CLS 3.5 RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H749389695740,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.070IN 6FR CLS 4 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389695750,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.070IN 6FR CLS 3.5 RUNWAY 2X2 RND BRD LRG LUM SH -,SUP-H749389695780,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUIDE RUNWAY 6F CLS4 SH -,SUP-H749389695790,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.070IN 6FR KRT HZNT 3H RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389696480,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.081IN 7FR VL3.5 RUNWAY 2X2 RND BRD LRG LUM NO SH -,SUP-H749389696620,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.070IN 6FR FEM JL5 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H749389696640,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.07IN 6FR FEM AL1 100CM RUNWAY 2X2 RND BRD LRG -,SUP-H74938969680,CDM,C1887,HCPCS,272,RC,,,outpatient,,,288.83,202.181,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.070IN 6FR VL3 RUNWAY -,SUP-H74938969710,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.070IN 6FR FL BK -UP 4 100CM RUNWAY 2X2 RND BRD -,SUP-H749389697160,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.070IN 6FR FR4 ST RUNWAY 2X2 RND BRD LRG LUM NO -,SUP-H74938969920,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.070IN 6FR MP1 125CM RUNWAY 2X2 RND BRD LRG LUM -,SUP-H749389699530,CDM,C1887,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
MICRO GUIDE CATH MAMBA FLEX 135 REF: H7493928713540 -,SUP-H7493928713540,CDM,C1887,HCPCS,272,RC,,,outpatient,,,5071.58,3550.106,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
STINGRAY LP BALLOON 3.2FR -,SUP-H749393120SR0,CDM,C1887,HCPCS,272,RC,,,outpatient,,,6490.48,4543.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
GUIDE EXTENSION CATHETER GUIDEZILLA II 6F -,SUP-H7493933515060,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
GUIDE EXTENSION CATHETER GUIDEZILLA II 6F LONG -,SUP-H74939335150610,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
GUIDE EXTENSION CATHETER GUIDEZILLA II 7F -,SUP-H7493933515070,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
GUIDE EXTENSION CATHETER GUIDEZILLA II 8F -,SUP-H7493933515080,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1987.69,1391.383,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH PTCA 135CM CROSSBOSS STINGRAY F/COR CTO -,SUP-H749M1000A0,CDM,C1887,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH ANG 4FR STR 65CM RADIFOCUS GLIDECATH DBL BRD SM-PRFL -,SUP-H787117140155,CDM,C1887,HCPCS,272,RC,,,outpatient,,,388.61,272.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
4FR GLIDECATH LONG 100CM STRAIGHT -,SUP-H787117140225,CDM,C1887,HCPCS,272,RC,,,outpatient,,,295.54,206.878,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH ANG 5FR ANG TAPR 65CM RADIFOCUS GLIDECATH SGL-BRD LRG -,SUP-H787117221045,CDM,C1887,HCPCS,272,RC,,,outpatient,,,388.61,272.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH ANG 5FR STR TAPR 65CM RADIFOCUS GLIDECATH SGL-BRD LRG -,SUP-H787117315025,CDM,C1887,HCPCS,272,RC,,,outpatient,,,388.61,272.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH ANG 4FR JB3 TIP 100CM TORCONNB ADVANTG BEACN BRD PERIPH -,SUP-HNBR4.0-35-100-P-NS-JB3,CDM,C1887,HCPCS,272,RC,,,outpatient,,,227.57,159.299,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.071IN 5FR EBU3.5 100CM LAUNCHR BRD LRG LUM DIST -,SUP-LA5EBU35,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 6FR 3D RIGHT LAUNCHR REF: LA63DRIGHT -,SUP-LA63DRIGHT,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.071IN 6FR AL1 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6AL10,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 6FR AL75 100CM LAUNCHR REF: LA6AL75 -,SUP-LA6AL75,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.071IN 6FR AR1 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6AR10,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.071IN 6FR BU LT EBU 3 100CM LAUNCHR BRD LRG LUM -,SUP-LA6EBU30,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.071IN 6FR BU LT EBU 3.5 100CM LAUNCHR BRD LRG -,SUP-LA6EBU35,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.071IN 6FR BU LT EBU 3.75 100CM LAUNCHR BRD LRG -,SUP-LA6EBU375,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.071IN 6FR BU LT EBU 4 100CM LAUNCHR BRD LRG LUM -,SUP-LA6EBU40,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.071IN 6FR EBU 4.5 100CM LAUNCHR -,SUP-LA6EBU45,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.071IN 6FR BYPS IMA 90CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6IMAD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.071IN 6FR STD JR4 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA6JR40,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 7FR 3D RIGHT LAUNCHR REF: LA73DRIGHT -,SUP-LA73DRIGHT,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUIDE 7 FR AL.75 SH D REF: LA7AL75SHD -,SUP-LA7AL75SHD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.081IN 7FR COR EBU3.5 100CM LAUNCHR BRD LRG LUM -,SUP-LA7EBU35,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.081IN 7FR COR EBU4 100CM LAUNCHR BRD LRG LUM -,SUP-LA7EBU40,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.081IN 7FR EBU4.5 100CM LAUNCHR BRD LRG LUM FLXB -,SUP-LA7EBU45,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 7FR JR4 90CM LAUNCHR -,SUP-LA7JR40D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,256.74,179.718,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
GUIDE 8F AL 1.0 SH 90CM -,SUP-LA8AL10D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
GUIDE 8F AL 2.0 90CM MICR CATH -,SUP-LA8AL20D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
GUIDE 8F AL .75 90CM CATH -,SUP-LA8AL75D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
GUIDE 8F EBU 3.5 90CM -,SUP-LA8EBU35D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
GUIDE 8F EBU 3.5 SH 90CM -,SUP-LA8EBU35D SHD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
GUIDE 8F EBU 4.0 90CM -,SUP-LA8EBU40D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
GUIDE 8F JL 4.0 90CM -,SUP-LA8JL40D,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
GUIDE 8F JL 4.0 SH 90CM -,SUP-LA8JL40D SHD,CDM,C1887,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 105CM 20CM -,SUP-M001181250,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2497.81,1748.467,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D C 1 130CM 20CM -,SUP-M001181310,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2497.81,1748.467,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 150CM 20CM STC-18 -,SUP-M001181370,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2497.81,1748.467,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 130CM 20CM -,SUP-M001182520,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1981.8,1387.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
MICROCATH INTVN 0.027IN 3FR/2.8FR P/D STR 150CM 20CM -,SUP-M001182530,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2297.77,1608.439,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
C RENEGADE HI-FLO MICROCATH -,SUP-M001183030,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2589.9,1812.93,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
MICROCATH INTVN 0.021IN SWAN 130CM DIREXION HI-FLO -,SUP-M001195300,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3221.16,2254.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH MICRO DREXION HI FLO J TO -,SUP-M001195470,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2566.03,1796.221,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.081IN 7FR LIMA 55CM MACH1 4X2 RND BRD LRG LUM -,SUP-M001197620,CDM,C1887,HCPCS,272,RC,,,outpatient,,,560.22,392.154,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH GUID 0.091IN 8FR LIMA 55CM MACH1 RND BRD LRG LUM PERIPH -,SUP-M001198620,CDM,C1887,HCPCS,272,RC,,,outpatient,,,560.22,392.154,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH ANG 4FR PIGTL 65CM IMAGER II SLCT FLSH BRD TRQ TUNG -,SUP-M001315091,CDM,C1887,HCPCS,272,RC,,,outpatient,,,58.24,40.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH ANG 4FR PIGTL 90CM IMAGER II FLSH BRD TRQ MED-GLD CTD -,SUP-M001315111,CDM,C1887,HCPCS,272,RC,,,outpatient,,,58.24,40.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH ANG 4FR CNTRLAT 2 CRV 65CM IMAGER II SLCT BRD TRQ SDE -,SUP-M001316581,CDM,C1887,HCPCS,272,RC,,,outpatient,,,58.24,40.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
MICRO GUIDE CATH FINECROSS M3 2.5 Fr 130 CM REF: M3-1430 -,SUP-M3-1430,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
MICRO GUIDE CATH FINECROSS M3 2.5 Fr 150 CM REF: M3-1450 -,SUP-M3-1450,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
PROGREAT 2.0 70 DEGREE ANGLE  150CM -,SUP-MC*PC2015ZRA,CDM,C1887,HCPCS,272,RC,,,outpatient,,,3652.11,2556.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
PROGREAT COAXIAL MICROCATHETER2.4 FR  150CM   DEGREE ANGLE -,SUP-MC*PE24151YV,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2673.44,1871.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
PROGREAT COAXIAL 2.8 FR  150CM   RO MARKER BAND -,SUP-MC*PE28151YV,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2673.44,1871.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
PROGREAT 2.4  70 DEGREE ANGLE  150CM -,SUP-MC*PV2415ZRA,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2061.89,1443.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
PROGREAT MICROCATHETER 2.4x150CM -,SUP-MCPV2415Y,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1749.17,1224.419,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATHETER NAVICROSS 018 65CM ANGLED STAINLESS STEEL -,SUP-NC18651,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATHETER NAVICROSS 018 90CM ANGLED STAINLESS STEEL -,SUP-NC18901,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
C NAVICROSS 135CM .035 STR T -,SUP-NC35130,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
C NAVICROSS 135CM .035 ANGLE -,SUP-NC35131,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH INTVN 12MM TIP STR TAPR 150CM NAVICROSS SUPP DBL BRD -,SUP-NC35150,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATHETER SUPPORT NAVICROSS 0.035 150CM ANGLED -,SUP-NC35151,CDM,C1887,HCPCS,272,RC,,,outpatient,,,997.79,698.453,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
SHEATH GUID 6FRX90CM PINNACLE -,SUP-RSC03,CDM,C1887,HCPCS,272,RC,,,outpatient,,,743.96,520.772,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
SHEATH GUID 6FRX90CM PINNCL DSTNTN VASC STR CRV GOLD COIL. -,SUP-RSC05,CDM,C1887,HCPCS,272,RC,,,outpatient,,,743.96,520.772,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
SHEATH GUID 6FRX90CM PINNCL DSTNTN VASC MP CRV GOLD COIL -,SUP-RSC07,CDM,C1887,HCPCS,272,RC,,,outpatient,,,743.96,520.772,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
SHEATH GUID 6FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL- -,SUP-RSR01,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
SHEATH GUID 7FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-RSR04,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
SHEATH GUID 7FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-RSR04,CDM,C1887,HCPCS,272,RC,,,outpatient,,,609.76,426.832,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
TIP GUIDE CATH RELIEVA SPIN SPND SIN S-0 SHP TIP BLN WND ORT -,SUP-RSS0,CDM,C1887,HCPCS,272,RC,,,outpatient,,,1696.16,1187.312,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH DX TAPR 65CM TRAILBLAZER SUPP HYDRCT -,SUP-SC035065,CDM,C1887,HCPCS,272,RC,,,outpatient,,,816.9,571.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATHETER GUIDING 6FR X 125 JL 5 JUDKINS -,SUP-SM7361,CDM,C1887,HCPCS,272,RC,,,outpatient,,,882.25,617.575,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
SHEATH 6.5 FR X 55CM X 17MM -,SUP-TG0655517,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2745.05,1921.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH SHEATH RITESITE C315G -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH SHEATH RITESITE C315J01 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH SHEATH RITESITE C315S10 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH SHEATH RITESITE C315S5 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH SHEATH RITESITE C315H20 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH SHEATH RITESITE C315H2001 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH SHEATH RITESITE C315H4001 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH SHEATH RITESITE C315J -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH SHEATH RITESITE C315S4 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH SHEATH RITESITE C315S401 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH SHEATH RITESITE C315H40 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH SHEATH RITESITE C315S1001 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH SHEATH RITESITE C315S501 -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
COIL MICRO RENEGADE STR FIBER -,SUP-UNDEFINED,CDM,C1887,HCPCS,272,RC,,,outpatient,,,2297.77,1608.439,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH OCL 0.97MM 6FR SHTH 110CM WILDCAT FLSH OTW 2MM XING -,SUP-W400,CDM,C1887,HCPCS,272,RC,,,outpatient,,,6769.18,4738.426,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
CATH OCL 0.43MM 5FR SHTH 150CM KITTYCAT 2 OTW 1.7MM XING -,SUP-W550,CDM,C1887,HCPCS,272,RC,,,outpatient,,,6769.18,4738.426,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.22704,7607.37,other,Non-Reimbursable Procedures,,
TUBE PEG 20FR PONSKY NBR NON BALLOON REPLACEMENT -,SUP-000700,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1250.92,875.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
TUBE JJUNO 16FRX108IN PVC/PLST 15ML BLN LUMX2 -,SUP-0042510,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1602.34,1121.638,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
TUBE GASTROSTOMY 14 FR -,SUP-0100-14LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
TUBE GASTROSTOMY FEEDING 16 FR -,SUP-010016LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,220.33,154.231,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
TUBE GASTROSTOMY 16FR -,SUP-0100-16LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
TUBE GASTROSTOMY FEEDING 18FR -,SUP-0100-18,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
MIC GASTROSTOMY TUBE 20 FR -,SUP-0100-20,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
TUBE GASTROSTOMY FEEDING 20 FR -,SUP-0100-20,CDM,C1889,HCPCS,278,RC,,,outpatient,,,45.16,31.612,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
TUBE GASTROSTOMY FEEDING 22 FR -,SUP-0100-22,CDM,C1889,HCPCS,278,RC,,,outpatient,,,225.87,158.109,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
MIC GASTROSTOMY TUBE 24 FR -,SUP-0100-24,CDM,C1889,HCPCS,278,RC,,,outpatient,,,43.52,30.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
TUBE GASTROSTOMY 26 FR -,SUP-0100-26,CDM,C1889,HCPCS,278,RC,,,outpatient,,,217.59,152.313,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
TUBE JJUNO 12FR SIL MI C SECUR-LOK XTRN RETEN RNG -,SUP-0200-12LV,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
TUBE JJUNO 14FR SIL 7-10ML BLN MI C SECUR-LOK XTRN RETEN RNG -,SUP-0200-14,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
TUBE FEEDING JEJUNAL 16F -,SUP-0200-16,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
TUBE JJUNO 18FR SIL 7-10ML BLN MIC-KEY SECUR-LOK XTRN RETEN -,SUP-0200-18,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
TUBE JEJUNOSTOMY 22FR MIC SECUR-LOK SILICONE -,SUP-0200-22,CDM,C1889,HCPCS,278,RC,,,outpatient,,,795.37,556.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
TUBE JJUNO 22FRX45CM SIL 7-10ML BLN MIC-KEY LPRO -,SUP-0250-22,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1221.18,854.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
TUBE MIC JEJUNOSTOMY 14FR / DR. GLEESON -,SUP-0301-14,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1113.49,779.443,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
TUBE NG 6FR SALEM SMP 60CM VYGON -,SUP-1340.06,CDM,C1889,HCPCS,278,RC,,,outpatient,,,79.12,55.384,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
CONNECTOR CATHETER NYLON STRAIGHT 1.5 X 1.0 X 1.9 -,SUP-45103,CDM,C1889,HCPCS,278,RC,,,outpatient,,,481.1,336.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
CONNECTOR CSF CATH STRAIGHT 3 WAY IMP 2 X 1.5 X 1.8 X 1.0 -,SUP-45105,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1359.53,951.671,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
AZUR 18D SYSTEM 4MM X 5CM -,SUP-45-480405,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3570.95,2499.665,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
AZUR CX 35D 4MM X 7C3 DETACHABLE -,SUP-45-750407,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
AZUR CX .035 5MM X 11CM DETACH -,SUP-45-750511,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
AZUR CX DETACH 035 6MMX17CM -,SUP-45-750617,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
AZUR CK DETACHABLE 035 8MM X 12CM -,SUP-45-750812,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
AZUR CX DETACH 035 8MMX24CM -,SUP-45-750824,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
AZUR CX DETACH 035 10MMX19CM -,SUP-45-751019,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
AZUR CX 35 DETACH 13MMX24CM CX COIL -,SUP-45-751324,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
AZUR CX 35D 16MM X 32 CM -,SUP-45-751632,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
AZUR CX 35D 20MM X 39 CM -,SUP-45-752039,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4634.45,3244.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
AZUR CX DETACHABLE 018 6MM X 20CM -,SUP-45-780620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
AZUR CX DETACHABLE 018 7MM X 24CM -,SUP-45-780724,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
AZUR CX DETACHABLE 018 8MM X 28CM -,SUP-45-780828,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
COIL EMBOLIZATION POD 0.020IN 4MM 30CM FULLY DETACHABLE RESH -,SUP-90178538,CDM,C1889,HCPCS,278,RC,,,outpatient,,,8190.92,5733.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
KIT INTRO GASTROSTOMY FEED -,SUP-98432,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1149.84,804.888,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
SENTINEL CEREBRAL PROTECTION SYSTEM REF: CMS15-10C-US -,SUP-CMS15-10C-US,CDM,C1889,HCPCS,278,RC,,,outpatient,,,14852,10396.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
COIL EMBOLIZATION NESTER MICROCOIL PLATINUM L3 CM OD2 MM . -,SUP-G47331,CDM,C1889,HCPCS,278,RC,,,outpatient,,,577.61,404.327,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
14X14 NESTER COIL 0.035 -,SUP-G47347,CDM,C1889,HCPCS,278,RC,,,outpatient,,,705.98,494.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
CATH COOK AIRWAY EXCHANGE 14FR 83CM. -,SUP-G57622,CDM,C1889,HCPCS,278,RC,,,outpatient,,,374.02,261.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
SPACER BONE CERVICAL LOR 6MM -,SUP-LGAL906,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
SPACER BONE CERVICAL LOR 7MM -,SUP-LGAL907,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
SPACER BONE CERVICAL LOR 8MM -,SUP-LGAL908,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
SPACER BONE CERVICAL PAR 6MM -,SUP-LGAP906-P,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
SPACER BONE CERVICAL PAR 7MM -,SUP-LGAP907-P,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
SPACER BONE CERVICAL PAR 8MM -,SUP-LGAP908-P,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
CATHETER DELIVERY AVEIR REF:LSCD111 -,SUP-LSCD111,CDM,C1889,HCPCS,278,RC,,,outpatient,,,7427,5198.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
BASKET SPECIMEN RETRIEVAL ZERO TIP 0.8MM 12MM ENDOSCOPIC -,SUP-M00513200,CDM,C1889,HCPCS,278,RC,,,outpatient,,,1398.8,979.16,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
PROBE BILIARY EHL -,SUP-M00546620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,2273.91,1591.737,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
TUBE PEG 16FR ENDOVIVE LPRO PUL LF -,SUP-M00582060,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
TUBE PEG 18FR ENDOVIVE LPRO PUL LF -,SUP-M00582070,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
KIT BALLOON REPLACEMENT STRAIGHT BOLSTER 20FR -,SUP-M00582080,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
KT TUBE PEG 24FR ENDOVIVE LPRO PUL LF -,SUP-M00582090,CDM,C1889,HCPCS,278,RC,,,outpatient,,,167.64,117.348,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
KIT BALLOON REPLACEMENT RIGHT ANGLE BOLSTER 20FR -,SUP-M00582150,CDM,C1889,HCPCS,278,RC,,,outpatient,,,192.44,134.708,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
TUBE PEG 24FR 3ML BLN SIL ENDOVIVE RT ANG LF -,SUP-M00582160,CDM,C1889,HCPCS,278,RC,,,outpatient,,,192.44,134.708,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
WATCHMAN FXD CURVE ACCESS SYSTEM SGL US REF: M635TU80010 -,SUP-M635TU80010,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
WATCHMAN FXD CURVE ACCESS SYSTEM DBL US REF: M635TU80020 -,SUP-M635TU80020,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
TUBE PEG 14FR 5ML BALLON TRITON LTX -,SUP-PEG-14-BRT-TR1,CDM,C1889,HCPCS,278,RC,,,outpatient,,,233.4,163.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
COIL EMBL 3MMX5CM RUBY MICRO CMPLX STD FRM FLLY DTCH RSHEATH -,SUP-RBY2C0305,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
COIL EMBL 3MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0320,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4769.23,3338.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
COIL EMBL 4MMX10CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0410,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
COIL EMBL 4MMX15CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0415,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
COIL EMBL 4MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0420,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
COIL EMBL 4MMX35CM RUBY CMPLX STD FRM FLLY DTCH RSHEATH -,SUP-RBY2C0435,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
COIL EMBL 5MMX12CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0512,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
COIL EMBL 5MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0520,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
COIL EMBL 5MMX30CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0530,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
COIL EMBL 6MMX20CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4769.23,3338.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
COIL EMBL 6MMX30CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0630,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
COIL EMBL 7MMX25CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0725,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
COIL EMBL 8MMX25CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0825,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
COIL EMBL 8MMX40CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0840,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
COIL EMBL 9MMX30CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C0930,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
COIL EMBL 10MMX35CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1035,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
COIL EMBL 12MMX40CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1240,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
COIL EMBL 12MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1260,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
COIL EMBL 14MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1460,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
COIL EMBL 16MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1660,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
COIL EMBL 18MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C1857,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
COIL EMBL 20MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C2060,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
COIL EMBL 24MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C2457,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
COIL EMBL 28MMX60CM RUBY MICRO CMPLX STD FRM FLLY -,SUP-RBY2C2860,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
COIL EMBL 32MMX60CM RUBY MICRO CMPLX STD FRM FLLY DTCH -,SUP-RBY2C3260,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
RUBYCOIL 36MM X 60MM STANDARD -,SUP-RBY2C3660,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
RUBYCOIL 40MM X 60MM STANDARD -,SUP-RBY2C4060,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
COIL EMBL 2MMX4CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH PLTNM -,SUP-RBY4C0204,CDM,C1889,HCPCS,278,RC,,,outpatient,,,3814.43,2670.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
COIL EMBL 3MMX5CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH PLTNM -,SUP-RBY4C0305,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
COIL EMBL 3MMX15CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0315,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
COIL EMBL 4MMX6CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH PLTNM -,SUP-RBY4C0406,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
COIL EMBL 4MMX15CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0415,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
COIL EMBL 6MMX20CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0620,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
COIL EMBL 6MMX30CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0630,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
COIL EMBL 8MMX35CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0835,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
COIL EMBL 8MMX60CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C0860,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5512.96,3859.072,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
COIL EMBL 16MMX50CM RUBY CMPLX SFT FIL FLLY DTCH RSHEATH -,SUP-RBY4C1650,CDM,C1889,HCPCS,278,RC,,,outpatient,,,5899.16,4129.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
RUBY COIL LP- 1 MM x 5 CM PERIPHERAL EMBOLIZATION COILS -,SUP-RBYLP0105,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
RUBY COIL LP- 2 MM x 10 CM PERIPHERAL EMBOLIZATION COILS -,SUP-RBYLP0210,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4625.96,3238.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
RUBY COIL LP- 3 MM x 4 CM PERIPHERAL EMBOLIZATION COILS -,SUP-RBYLP0304,CDM,C1889,HCPCS,278,RC,,,outpatient,,,4726.26,3308.382,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
PENUMBRA RUBY POD 6MM X 50CM -,SUP-RBYPOD6,CDM,C1889,HCPCS,278,RC,,,outpatient,,,8190.92,5733.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
SPACE OAR VUE HYDROGEL -,SUP-SV-2101,CDM,C1889,HCPCS,278,RC,,,outpatient,,,12791.29,8953.903,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.77024,11406.336,other,Non-Reimbursable Procedures,,
INTRO SHTH 6FRX14CM J SHP TIP 12ML SYR DI-LOK DILATOR 18GA -,SUP-405104,CDM,C1892,HCPCS,272,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.121935,3080.6622,other,Non-Reimbursable Procedures,,
INTRO SHTH 7FRX14CM 0.038INX50CM JTP GW 18GA XTW NDL 12ML -,SUP-405108,CDM,C1892,HCPCS,272,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.121935,3080.6622,other,Non-Reimbursable Procedures,,
KT 12FR 18GAX14CM 0.38INX50CM GW CV 3MM JTP PEEL-AWAY -,SUP-405120,CDM,C1892,HCPCS,272,RC,,,outpatient,,,186.72,130.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.121935,3080.6622,other,Non-Reimbursable Procedures,,
INTRO SHTH 10.5FRX14CM 0.038INX50CM JTP GW 18GA XTW NDL 12ML -,SUP-405122,CDM,C1892,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.121935,3080.6622,other,Non-Reimbursable Procedures,,
INTRO SHTH 8T-TW FR DIA 14CM 0.038INX50CM JTP GW 18GA XTW -,SUP-405129,CDM,C1892,HCPCS,272,RC,,,outpatient,,,245.07,171.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.121935,3080.6622,other,Non-Reimbursable Procedures,,
INTRO SHTH 8FRX14CM J SHP TIP 12ML SYR DI-LOK DILATOR 18GA -,SUP-405145,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.121935,3080.6622,other,Non-Reimbursable Procedures,,
INTRO LD 9FR PEEL-AWAY SHTH SGL-CHMBR -,SUP-405147,CDM,C1892,HCPCS,272,RC,,,outpatient,,,320.93,224.651,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.121935,3080.6622,other,Non-Reimbursable Procedures,,
INTRO SHTH 8FRX14CM 0.038IN GW DI- LOCK DILATOR -,SUP-405412,CDM,C1892,HCPCS,272,RC,,,outpatient,,,90.56,63.392,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.121935,3080.6622,other,Non-Reimbursable Procedures,,
INTRO SHTH 9FRX14CM 0.038IN GW DI- LOCK DILATOR -,SUP-405416,CDM,C1892,HCPCS,272,RC,,,outpatient,,,89.63,62.741,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.121935,3080.6622,other,Non-Reimbursable Procedures,,
TRANSDC TRANSTHORACIC BTRY PK VIEWMATE -,SUP-405422,CDM,C1892,HCPCS,272,RC,,,outpatient,,,175.05,122.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.121935,3080.6622,other,Non-Reimbursable Procedures,,
INTRO SHTH 11FRX14CM 0.038INX50CM JTP GW 18GA XTW NDL 12ML -,SUP-405424,CDM,C1892,HCPCS,272,RC,,,outpatient,,,175.05,122.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.121935,3080.6622,other,Non-Reimbursable Procedures,,
INTRO VASC 8FR SUPER SHTH INFS SDPRT -,SUP-CLS-1008,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.121935,3080.6622,other,Non-Reimbursable Procedures,,
INTRO VASC 8.5FR SUPER SHTH INFS SDPRT -,SUP-CLS-1008.5,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.121935,3080.6622,other,Non-Reimbursable Procedures,,
INTRO VASC 10.5FR SUPER SHTH INFS SDPRT -,SUP-CLS-1010.5,CDM,C1892,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.121935,3080.6622,other,Non-Reimbursable Procedures,,
INTRO VASC 8FR LNG SUPER SHTH INFS SDPRT -,SUP-CLS-2508,CDM,C1892,HCPCS,272,RC,,,outpatient,,,301.67,211.169,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.121935,3080.6622,other,Non-Reimbursable Procedures,,
CPS DIRECT MEDI GUIDE ENABLED OUT CATH  RIGHT -,SUP-DS2M044,CDM,C1892,HCPCS,272,RC,,,outpatient,,,4296.6,3007.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.121935,3080.6622,other,Non-Reimbursable Procedures,,
SET INTRODUCER PEEL-AWAY SAFE-T-J -,SUP-G04496,CDM,C1892,HCPCS,272,RC,,,outpatient,,,397.66,278.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.121935,3080.6622,other,Non-Reimbursable Procedures,,
SHEATH SAFE PRELUDE 6F 13CM LN -,SUP-PLS-1006,CDM,C1892,HCPCS,272,RC,,,outpatient,,,274.25,191.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.121935,3080.6622,other,Non-Reimbursable Procedures,,
INTRODUCER MERIT PRELUDE 9F 25CM -,SUP-PLS-2509,CDM,C1892,HCPCS,272,RC,,,outpatient,,,301.67,211.169,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.121935,3080.6622,other,Non-Reimbursable Procedures,,
INTRODUCER 9FR OPTISEAL -,SUP-UNDEFINED,CDM,C1892,HCPCS,272,RC,,,outpatient,,,379.28,265.496,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.121935,3080.6622,other,Non-Reimbursable Procedures,,
CATH GUID 7FR COR -,SUP-358735,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2448.83,1714.181,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,165.054645,2224.9227,other,Non-Reimbursable Procedures,,
INTRO  SL1  CURVE - SJM 8.5FRX 63CM -,SUP-406849,CDM,C1893,HCPCS,272,RC,,,outpatient,,,892.76,624.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,165.054645,2224.9227,other,Non-Reimbursable Procedures,,
INTRO GUID 8.5FRX60CM FAST-CATH SWARTZ TRNSEPT SAFL CRV -,SUP-406868,CDM,C1893,HCPCS,272,RC,,,outpatient,,,898.59,629.013,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,165.054645,2224.9227,other,Non-Reimbursable Procedures,,
INTRO GUID 8FRX60CM FAST-CATH SWARTZ TRNSEPT SAFL CRV -,SUP-406871,CDM,C1893,HCPCS,272,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,165.054645,2224.9227,other,Non-Reimbursable Procedures,,
INTRO GUID 8FRX60CM FAST-CATH SWARTZ TRNSEPT SEPT CRV -,SUP-406885,CDM,C1893,HCPCS,272,RC,,,outpatient,,,904.43,633.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,165.054645,2224.9227,other,Non-Reimbursable Procedures,,
INTRO SEPT CURVE-SJM  8.5FRX60CM -,SUP-406894,CDM,C1893,HCPCS,272,RC,,,outpatient,,,898.59,629.013,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,165.054645,2224.9227,other,Non-Reimbursable Procedures,,
INTRO  RAMP  CURVE - SJM 8.5FRX 63CM -,SUP-406965,CDM,C1893,HCPCS,272,RC,,,outpatient,,,735.21,514.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,165.054645,2224.9227,other,Non-Reimbursable Procedures,,
SHEATH GUIDE LAMP 45 407363 -,SUP-407363,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1015.29,710.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,165.054645,2224.9227,other,Non-Reimbursable Procedures,,
INTRODUCER CATHETER BRITE TIP RADIANZ GUIDING 6FR 110CM -,SUP-687280110,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1363.55,954.485,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,165.054645,2224.9227,other,Non-Reimbursable Procedures,,
INTRODUCER CATHETER BRITE TIP RADIANZ GUIDING 6FR 135CM -,SUP-687280135,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1363.55,954.485,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,165.054645,2224.9227,other,Non-Reimbursable Procedures,,
TRANSSEPTAL ACCESS STYSTEM ACQCROSS QX AG 71 CM REF: 900301 -,SUP-900301,CDM,C1893,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,165.054645,2224.9227,other,Non-Reimbursable Procedures,,
TRANSSEPTAL ACCESS STYSTEM ACQCROSS QX - FC 65CM REF: 900304 -,SUP-900304,CDM,C1893,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,165.054645,2224.9227,other,Non-Reimbursable Procedures,,
TRANSSEPTAL ACCESS STYSTEM ACQCROSS  WT 75CM REF: 900308 -,SUP-900308,CDM,C1893,HCPCS,272,RC,,,outpatient,,,3103.1,2172.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,165.054645,2224.9227,other,Non-Reimbursable Procedures,,
FLEXCATH CROSS FCC 65CM 10FR REF:900310 -,SUP-900310,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,165.054645,2224.9227,other,Non-Reimbursable Procedures,,
FLEXCATH CROSS FCC 65CM 12FR REF:900311 -,SUP-900311,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,165.054645,2224.9227,other,Non-Reimbursable Procedures,,
CATHETER CPS LOCATOR 3D- LAGE EXTRA LONG REF:DS2C300-45 -,SUP-DS2C300-45,CDM,C1893,HCPCS,272,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,165.054645,2224.9227,other,Non-Reimbursable Procedures,,
SHEATH GUID WORLEY RNL TLSCP GUIDE -,SUP-LVI7556207RE,CDM,C1893,HCPCS,272,RC,,,outpatient,,,2464.73,1725.311,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,165.054645,2224.9227,other,Non-Reimbursable Procedures,,
TORFLEX TRANSSEPTAL GUIDING SH -,SUP-TF85-32-63-45,CDM,C1893,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,165.054645,2224.9227,other,Non-Reimbursable Procedures,,
DILATOR VESSEL 5 FR 35 -,SUP-040037A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,23.34,16.338,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
MICINTRO VASC 4.5FRX50CM MICRO EZ FNL DSGN SMTH DILATOR PTFE -,SUP-0928945,CDM,C1894,HCPCS,272,RC,,,outpatient,,,205.74,144.018,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
MICINTRO VASC 5FRX50CM MICRO EZ FNL DSGN SMTH DILATOR PTFE -,SUP-0928950,CDM,C1894,HCPCS,272,RC,,,outpatient,,,213.56,149.492,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
MICINTRO VASC 6FRX50CM MICRO EZ SMTH DILATOR PTFE 7CM A BVL -,SUP-0928960,CDM,C1894,HCPCS,272,RC,,,outpatient,,,189.64,132.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH INTRO 6FRX10CM PINNCL TIF TIP PERIPH 0.038INX45CM SS -,SUP-10-2032,CDM,C1894,HCPCS,272,RC,,,outpatient,,,72.94,51.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO INFS 7FR PEEL-AWAY -,SUP-120089,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.83,253.281,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH INTRO 5FRX10CM GLIDESHEATH RADL STR GOLD COIL MRKR -,SUP-20 -1050,CDM,C1894,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH INTRO 6FRX10CM GLIDESHEATH RADL STR GOLD COIL MRKR -,SUP-20 -1060,CDM,C1894,HCPCS,272,RC,,,outpatient,,,338.43,236.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
S COOK 7FR X 6CM -,SUP-242381,CDM,C1894,HCPCS,272,RC,,,outpatient,,,170.73,119.511,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH INTRO 5FRX10CM GLIDESHEATH RADL STR CRV GOLD COIL -,SUP-30-1050,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.48,364.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH INTRO 6FRX10CM GLIDESHEATH RADL STR CRV GOLD COIL -,SUP-30-1060,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.48,364.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH INTRO 6FRX10CM GLIDESHEATH RADL  STR CRV GOLD COIL -,SUP-30-1065,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.48,364.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH GUID 0.110IN 8FRX62CM PREFACE MP ST TAPR PRFL -,SUP-301803MS,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO CATH 4FRX3.2CM INTRSYT-N PERC SHLD -,SUP-384011,CDM,C1894,HCPCS,272,RC,,,outpatient,,,234.57,164.199,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO CATH 1.9FRX1.9CM INTRSYT-N PERC SHLD -,SUP-384021,CDM,C1894,HCPCS,272,RC,,,outpatient,,,280.08,196.056,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
FORTRESS SHEATH 5FR x 45CM -,SUP-386591,CDM,C1894,HCPCS,272,RC,,,outpatient,,,102.7,71.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
FORTRESS SHEALTH 5FRx45CM -,SUP-386591,CDM,C1894,HCPCS,272,RC,,,outpatient,,,102.7,71.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
S BRITE TIP 10FR 11CM  RB -,SUP-401-011M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 10FRX11CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-011M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH BRITE TIP 4F 11CM -,SUP-401411M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH 5FR 11CM BRITE TIP -,SUP-401511M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH 5FR BRITE TIP 23CM -,SUP-401-523M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 5FRX55CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-555M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 6FRX5.5CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401605M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 6FRX5.5CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-605M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH 6FR 11CM BRITE TIP -,SUP-401-611M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 6FRX5.5CM X 23CM CANN BRT TIP PERC TAPR SMTH -,SUP-401-623M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH 6F 23CM BRITE TIP -,SUP-401-623M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 6FRX55CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-655M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH 7 FR 11CM BRITE TIP -,SUP-401-711M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH 7FR X 23CM BRITE TIP -,SUP-401-723M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 7FRX45CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-745M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH 8FR 11CM BRITE TIP -,SUP-401-811M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
S BRITE TIP 8FR 23CM RB -,SUP-401-823M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 8FRX45CM CANN BRT TIP PERC TAPR SMTH TRANS SIL -,SUP-401-845M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
S BRITE TIP 9FR X 11CM RB -,SUP-401-911M,CDM,C1894,HCPCS,272,RC,,,outpatient,,,64.19,44.933,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHTH INTRO 11FR X 11CM CANN BRT -,SUP-402611X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,43.18,30.226,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 6FR STD L 11CM REF: 402656X -,SUP-402656X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,43.18,30.226,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 2MM ANCURE -,SUP-40320,CDM,C1894,HCPCS,272,RC,,,outpatient,,,962.78,673.946,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
HEMOSTASIS INTRODUCER FAST CATH 10FRX30CM REF: 406180 -,SUP-406180,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.77,253.239,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
HEMOSTASIS INTRODUCER FAST CATH 14FRX30CM REF: 406188 -,SUP-406188,CDM,C1894,HCPCS,272,RC,,,outpatient,,,385.11,269.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
FAST CATH DUO SHEATH 12F  12CM -,SUP-406301,CDM,C1894,HCPCS,272,RC,,,outpatient,,,140.04,98.028,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 7FRX12CM FAST-CATH CATH-LOCK PERC JTP STR SNP -,SUP-406702,CDM,C1894,HCPCS,272,RC,,,outpatient,,,62.26,43.582,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 8FRX12CM FAST-CATH CATH-LOCK PERC JTP STR SNP -,SUP-406706,CDM,C1894,HCPCS,272,RC,,,outpatient,,,105.03,73.521,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 4FRX12CM FAST-CATH CATH-LOCK PERC JTP STR SNP -,SUP-406709,CDM,C1894,HCPCS,272,RC,,,outpatient,,,105.03,73.521,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 8FRX60CM FAST-CATH TRNSEPT MLNS CRV SNP LOCK -,SUP-406805,CDM,C1894,HCPCS,272,RC,,,outpatient,,,501.81,351.267,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SR0 CURVE-SJM -,SUP-406853,CDM,C1894,HCPCS,272,RC,,,outpatient,,,898.59,629.013,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH AGILIS MED-REPROC  8.5X 71CM -,SUP-408310,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2473.84,1731.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 4FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-604X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 6FR MI D L 23CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-606D,CDM,C1894,HCPCS,272,RC,,,outpatient,,,93.36,65.352,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 7FR MI D L 23CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-607T,CDM,C1894,HCPCS,272,RC,,,outpatient,,,93.36,65.352,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH INTRODUCER AVANTI 7FR X 11 CM -,SUP-504-607X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 8FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-608X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 9FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-609X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 10FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504610X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 11FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-611X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 5MS FR DIA MI D L 23CM CANN AVANTI + PERC TAPR SS -,SUP-504-655T,CDM,C1894,HCPCS,272,RC,,,outpatient,,,103.57,72.499,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 5MS DIA STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-655X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 5MS DIA STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-655X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 6MS FR DIA MI D L 23CM CANN AVANTI + PERC TAPR SS -,SUP-504-656T,CDM,C1894,HCPCS,272,RC,,,outpatient,,,93.36,65.352,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 6FR STD L 11CM CANN AVANTI  PERC TAPR SS W/O -,SUP-504-656X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 6FR STD L 11CM CANN AVANTI + PERC TAPR SS W/O -,SUP-504-656X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
MONITORING SHEATH 7 FR INTRO -,SUP-504-657X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 8MS DIA STD L 11CM CANN AVANTI PERC TAPR SS W/O -,SUP-504-658X,CDM,C1894,HCPCS,272,RC,,,outpatient,,,36.47,25.529,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
TIGHTRAIL MINI 11FR 545-011 -,SUP-540-011,CDM,C1894,HCPCS,272,RC,,,outpatient,,,7193.58,5035.506,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
TIGHTRAIL MINI  9FR 545-009 -,SUP-545-009,CDM,C1894,HCPCS,272,RC,,,outpatient,,,7193.58,5035.506,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
TIGHTRAIL LONG  9FR 545-509 -,SUP-545-509,CDM,C1894,HCPCS,272,RC,,,outpatient,,,10121.94,7085.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
TIGHTRAIL LONG 11FR 545-511 -,SUP-545-511,CDM,C1894,HCPCS,272,RC,,,outpatient,,,10121.94,7085.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
TIGHTRAIL LONG 13FR 545-513 -,SUP-545-513,CDM,C1894,HCPCS,272,RC,,,outpatient,,,10121.94,7085.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH GUID 8FRX45CM PINNCL DSTNTN VASC STR CRV GOLD COIL -,SUP-54-84501,CDM,C1894,HCPCS,272,RC,,,outpatient,,,609.76,426.832,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
GLIDESHEATH SLENDER 6FR X 10CM X .021CM SS GLIDEWIRE -,SUP-60-1060,CDM,C1894,HCPCS,272,RC,,,outpatient,,,353.02,247.114,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
GLIDESHEATH SLENDER A KIT 0.025 GW 6FR 10CM -,SUP-60-1065,CDM,C1894,HCPCS,272,RC,,,outpatient,,,619.97,433.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
GLIDESHEATH SLENDER A KIT 0.025 GW 7FR 10CM -,SUP-60-1075,CDM,C1894,HCPCS,272,RC,,,outpatient,,,619.97,433.979,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 7FRX11CM INPUT PS PERC 0.038IN GW COMP VES -,SUP-700-11,CDM,C1894,HCPCS,272,RC,,,outpatient,,,56.02,39.214,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRODUCER SET 11 FR - DISCONTINUED DO NOT USE -,SUP-7097,CDM,C1894,HCPCS,272,RC,,,outpatient,,,320.93,224.651,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
GLIDESHEATH SLENDER SS KIT 0.025 GW 6FR 10CM -,SUP-80-1065,CDM,C1894,HCPCS,272,RC,,,outpatient,,,353.02,247.114,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
GLIDESHEATH SLENDER SS KIT 0.025 GW 7FR 10CM -,SUP-80-1075,CDM,C1894,HCPCS,272,RC,,,outpatient,,,353.02,247.114,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
AMPLATZER DELIVERY SHEATH TORQVUE 2 5FR REF: 9-TV2-05F120 -,SUP-90176109,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
AMPLATZER DELIVERY SHEATH TORQVUE 2 6FR REF: 9-TV2-06F120 -,SUP-9-TV2-06F120,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4143.83,2900.681,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
TORQVUE SHEATH 14F 80CM 45X45 REF: 9-TV45X45-14F-080 -,SUP-9-TV45X45-14F-080,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4676.89,3273.823,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
OBTURATOR VASC 8FR SHRT -,SUP-AO-09000,CDM,C1894,HCPCS,272,RC,,,outpatient,,,13.65,9.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
CATH PA 7FR X 110CM SWAN-GNZ LUMX4 PLYMR BLND -,SUP-C146F7,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2531.31,1771.917,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRODUCER SHEATH 8.5FR CATH-GARD PERC ARROW KIT -,SUP-CDC-09803-1A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,430.62,301.434,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
9FR. PERC SHEATH INTRO KIT -,SUP-CDC-09903-1A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,418.37,292.859,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 10FRX35CM SUPER ARROW-FLEX PERC SNP-LOCK MIN -,SUP-CL-07035,CDM,C1894,HCPCS,272,RC,,,outpatient,,,547.82,383.474,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 5FR SHTH 4.375IN SHTH 0.035-0.038IN GW HEMSTS VLV -,SUP-CL-07511,CDM,C1894,HCPCS,272,RC,,,outpatient,,,182.55,127.785,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 6FRX24CM SUPER ARROW-FLEX PERC 0.038IN GW COMP -,SUP-CL-07624,CDM,C1894,HCPCS,272,RC,,,outpatient,,,431.79,302.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 6FRX45CM SUPER ARROW-FLEX PERC ANTMIC SURF PU -,SUP-CL-07645,CDM,C1894,HCPCS,272,RC,,,outpatient,,,553.38,387.366,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 7FRX24CM SUPER ARROW-FLEX PERC INTGR HEMSTS -,SUP-CL-07724,CDM,C1894,HCPCS,272,RC,,,outpatient,,,379.08,265.356,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 7FRX45CM SUPER ARROW-FLEX PERC ANTMIC SURF PU -,SUP-CL-07745,CDM,C1894,HCPCS,272,RC,,,outpatient,,,520.82,364.574,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH CLASSICSHEATH 6FR STD 13CM CRV GRN CAP -,SUP-CLS-1006,CDM,C1894,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO VASC 7FR SAFESHEATH INFS SDPRT -,SUP-CLS-1007,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.77,253.239,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO VASC 10FR SUPER SHTH INFS SDPRT -,SUP-CLS-1010,CDM,C1894,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 5FRX11CM SUPER ARROW-FLEX PERC 0.035IN GW COMP -,SUP-CP-07511,CDM,C1894,HCPCS,272,RC,,,outpatient,,,148.79,104.153,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
DRYSEAL FLEX INTRODUCER SHEATH - 1233 -,SUP-DSF1233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3695.08,2586.556,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH INTRO 12FRX28CM DRYSEAL HYDRCT -,SUP-DSF1233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3695.08,2586.556,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH DRYSEAL INTRODUCER -,SUP-DSF1245,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4821.18,3374.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
DRYSEAL FLEX INTRODUCER SHEATH 14FR REF: DSF1433 -,SUP-DSF1433,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3819.2,2673.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
GORE INTRODUCER SHEATH 16 -,SUP-DSF1633,CDM,C1894,HCPCS,272,RC,,,outpatient,,,3695.08,2586.556,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
DRYSEAL SHEATH--16 FR X 65CM -,SUP-DSF1665,CDM,C1894,HCPCS,272,RC,,,outpatient,,,5780.33,4046.231,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
GORE INTRODUCER SHEATH 18 -,SUP-DSF1833,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
22FR X 33CM DRYSEAL SHEATH -,SUP-DSF2233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
GORE DRY SEAL SHEATH 22F X 33CM -,SUP-DSF2233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
22FR X 65CM DRYSEAL SHEATH -,SUP-DSF2265,CDM,C1894,HCPCS,272,RC,,,outpatient,,,5780.33,4046.231,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
GORE DRY SEAL SHEATH 26F X 33CM -,SUP-DSF2633,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH INTRO 18FRX28CM DRYSEAL HYDRCT -,SUP-DSL1828,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4430.74,3101.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
URETHRAL ACCESS SHTH 9.5FR ID AQ HYDRCT TAPR LUMX1 DILATOR -,SUP-FUS-095045,CDM,C1894,HCPCS,272,RC,,,outpatient,,,774.6,542.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
URETHRAL ACCESS SHTH 14FRX28CM AQ HYDRCT FLEXOR TAPR LUMX1 -,SUP-FUS-120028,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
URETHRAL ACCESS SHTH 12FR ID HYDRCT LUMX1 DILATOR -,SUP-FUS-120035,CDM,C1894,HCPCS,272,RC,,,outpatient,,,762.34,533.638,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
URETHRAL ACCESS SHTH 12FRX45CM HYDRCT TAPR LUMX1 DILATOR -,SUP-FUS-120045,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
DILATOR VASCULAR 16FR 20CM REF G01212 -,SUP-G01212,CDM,C1894,HCPCS,272,RC,,,outpatient,,,49.54,34.678,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH MICROPUN TRANSTLS TIP 0.018INX40CM GW PEDAL -,SUP-G02972,CDM,C1894,HCPCS,272,RC,,,outpatient,,,349.52,244.664,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 16FRX30CM PEEL-AWAY 0.038IN GW COMP -,SUP-G02997,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO CATH 22FRX13CM PEEL-AWAY LNG COONS TAPR STR 0.038IN GW -,SUP-G04096,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.57,194.299,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 18FRX15.5CM PEEL-AWAY LNG COONS TAPR STR 20CM VES -,SUP-G06444,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 20FRX13CM PEEL-AWAY PERC STR 20CM VES DILATOR W/O -,SUP-G06445,CDM,C1894,HCPCS,272,RC,,,outpatient,,,273.6,191.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 24FRX13CM PEEL-AWAY PERC STR 20CM VES DILATOR W/O -,SUP-G06446,CDM,C1894,HCPCS,272,RC,,,outpatient,,,273.6,191.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 12FRX15.5CM PEEL-AWAY PERC STR 0.038IN GW COMP -,SUP-G06492,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 14FRX15.5CM PEEL-AWAY PERC STR 0.038IN GW COMP -,SUP-G06496,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SET INTRODUCER PEEL-AWAY .038IN 15.5CM 15FR -,SUP-G06497,CDM,C1894,HCPCS,272,RC,,,outpatient,,,282.59,197.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
RING TRANS-JUG ACCESS SET WITH 9Fr -,SUP-G06541,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2759.32,1931.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 4MM 12FRX13CM PERFORM JTP 0.038IN GW COMP -,SUP-G07369,CDM,C1894,HCPCS,272,RC,,,outpatient,,,293.56,205.492,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 2.9MM 8FRX13CM FLEXOR 0.038IN GW SM CHECK-FLO VLV -,SUP-G07856,CDM,C1894,HCPCS,272,RC,,,outpatient,,,243.44,170.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH CHECKFLO PERFORMA 10FRX30CM -,SUP-G08686,CDM,C1894,HCPCS,272,RC,,,outpatient,,,419.77,293.839,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRODUCER CHECK-FLO PERFORMER 12FR 30CM -,SUP-G08956,CDM,C1894,HCPCS,272,RC,,,outpatient,,,419.77,293.839,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRODUCER CHECK-FLO PERFORMER 14FR 30CM -,SUP-G08957,CDM,C1894,HCPCS,272,RC,,,outpatient,,,419.77,293.839,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
CHECK FLOW PERFORMER INTRODUCER 16FR 70CM REF:G09582 -,SUP-G09582,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRODUCER CHECK-FLO PERFORMER 16FR 30CM -,SUP-G09691,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SET INTRODUCER CHECK-FLO EXTRA LARGE 18FR 40CM -,SUP-G10626,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH GUID 2.2MM 6FRX45CM FLEXOR CHECK-FLO BLKN UP/ OVR -,SUP-G10634,CDM,C1894,HCPCS,272,RC,,,outpatient,,,313.51,219.457,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
S COOK 6FR X 6CM -,SUP-G10675,CDM,C1894,HCPCS,272,RC,,,outpatient,,,170.73,119.511,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SET INTRODUCER CATHETER NEFF 4/6FR -,SUP-G10797,CDM,C1894,HCPCS,272,RC,,,outpatient,,,513.42,359.394,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 5FRX9CM PEEL-AWAY MICROPUNCTURE DENNY MOD LCK -,SUP-G11566,CDM,C1894,HCPCS,272,RC,,,outpatient,,,465.11,325.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 6FRX9CM PEEL-AWAY PERC DENNY MOD 0.018IN GW COMP -,SUP-G11568,CDM,C1894,HCPCS,272,RC,,,outpatient,,,465.11,325.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 8FRX9CM PEEL-AWAY PERC DENNY MOD 0.038IN GW COMP -,SUP-G11570,CDM,C1894,HCPCS,272,RC,,,outpatient,,,375.77,263.039,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
VALVE CHECK-FLO 7F 55C RAABE K -,SUP-G11633,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH RAABE FLEXOR 7FR X 90CM -,SUP-G11634,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH GUID 7FRX70CM FLEXOR CHECK-FLO RAABE MOD STR 0.038IN -,SUP-G11635,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH GUID 6FRX70CM FLEXOR CHECK-FLO RAABE MOD STR 0.038IN -,SUP-G11636,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH GUID 2.9MM 8FRX70CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G11637,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH GUID 2.2MM 6FRX55CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G11638,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH 6FR STRAIGHT FLEXOR -,SUP-G11638,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
CHECK FLOW PERFORMER INTRODUCER 18FR X 30CM -,SUP-G11672,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
VALVE CHECK-FLO 8F 55C RAABE K -,SUP-G12242,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH 6FR 90CM RAABE KCFW-6.0 -,SUP-G12266,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH GUID 3.2MM 9FRX70CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G12606,CDM,C1894,HCPCS,272,RC,,,outpatient,,,361.19,252.833,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRODUCER CHECK-FLO PERFORMER 22FR 25CM -,SUP-G12831,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2364.02,1654.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH GUID 2.5MM 7FRX90CM FLEXOR SHTL SFT TIP HYDRCT -,SUP-G12835,CDM,C1894,HCPCS,272,RC,,,outpatient,,,611.39,427.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH GUID 1.9MM 5FRX55CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G13009,CDM,C1894,HCPCS,272,RC,,,outpatient,,,268.41,187.887,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH GUID 1.9MM 5FRX90CM FLEXOR CHECK-FLO RAABE MOD STR -,SUP-G13069,CDM,C1894,HCPCS,272,RC,,,outpatient,,,348.58,244.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 5FRX70CM FLEXOR CHECK-FLO RAABE MOD STR 0.038IN -,SUP-G13091,CDM,C1894,HCPCS,272,RC,,,outpatient,,,268.41,187.887,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH 6FR. 80CM -,SUP-G13539,CDM,C1894,HCPCS,272,RC,,,outpatient,,,611.39,427.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
URETHRAL ACCESS SHTH 9.5FR ID HYDRCT TAPR LUMX1 DILATOR -,SUP-G19174,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
URETHRAL ACCESS SHTH 9.5FRX28CM AQ HYDRCT FLEXOR TAPR LUMX1 -,SUP-G19176,CDM,C1894,HCPCS,272,RC,,,outpatient,,,961.49,673.043,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH 20F X 25CM COOK -,SUP-G28999,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2364.02,1654.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 12FRX24CM PEEL-AWAY PERC CRV 0.038IN GW COMP 34CM -,SUP-G29839,CDM,C1894,HCPCS,272,RC,,,outpatient,,,689.99,482.993,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 14FRX24CM PEEL-AWAY CRV 0.038IN GW COMP 18GA 12ML -,SUP-G29840,CDM,C1894,HCPCS,272,RC,,,outpatient,,,689.99,482.993,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH GUID 2.5MM 7FRX45CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29885,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
5Fr. 45cm ANSEL SHEATH WITH ANGLE KCFW-5.0-18/38/45-RB-ANL1- -,SUP-G29981,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH GUID 1.9MM 5FRX45CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29981,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH GUID 1.9MM 5FRX90MM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29988,CDM,C1894,HCPCS,272,RC,,,outpatient,,,586.83,410.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH 6F ANSEL 90CM FLEXOR KC -,SUP-G29989,CDM,C1894,HCPCS,272,RC,,,outpatient,,,586.83,410.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH GUID 2.2MM 6FRX55MM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G29996,CDM,C1894,HCPCS,272,RC,,,outpatient,,,420.18,294.126,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH GUID 2.2MM 6FRX55MM FLEXOR CHECK-FLO ANSEL MOD RNL -,SUP-G29997,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHUTTLE SELECT GUIDE SHEATH KS -,SUP-G31138,CDM,C1894,HCPCS,272,RC,,,outpatient,,,617.11,431.977,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH CHECKFLOW 3.4MM 10FRX40CM FLEXOR -,SUP-G32233,CDM,C1894,HCPCS,272,RC,,,outpatient,,,385.81,270.067,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH GUID 4.1MM 12FRX40CM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-G32373,CDM,C1894,HCPCS,272,RC,,,outpatient,,,444.22,310.954,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SET MICROPUNCTURE 5.0F 10CM -,SUP-G36333,CDM,C1894,HCPCS,272,RC,,,outpatient,,,159.7,111.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH GUID 3.2MM 9FRX55CM FLEXOR CHECK-FLO RAABE MOD -,SUP-G36393,CDM,C1894,HCPCS,272,RC,,,outpatient,,,277.45,194.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
MICRO PUNCTURE  5FR X 10CM  0.018INX40CM -,SUP-G43870,CDM,C1894,HCPCS,272,RC,,,outpatient,,,191.21,133.847,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH 5F ANSEL 45CM ANLO -,SUP-G44153,CDM,C1894,HCPCS,272,RC,,,outpatient,,,300.62,210.434,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH 6F ANSEL 45CM -,SUP-G44154,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH MICROPUNCTURE TRANSTLS TIP 0.018INX40CM PLTNM TIP -,SUP-G47942,CDM,C1894,HCPCS,272,RC,,,outpatient,,,190.1,133.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
MICROPUNCTURE STIFF 4F NIT -,SUP-G48003,CDM,C1894,HCPCS,272,RC,,,outpatient,,,281.36,196.952,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
MICROPUNCTURE TRANSITIONLESS STIFFENED CANNULA ACCESS SET -,SUP-G48005,CDM,C1894,HCPCS,272,RC,,,outpatient,,,281.36,196.952,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
WIRE FOR  MICROPUNCTURE 0.018 IN X 40 CM PLTNM TIP -,SUP-G48007,CDM,C1894,HCPCS,272,RC,,,outpatient,,,281.36,196.952,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH GUID 1.5MM 4FRX45MM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-G48186,CDM,C1894,HCPCS,272,RC,,,outpatient,,,312.06,218.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH 4F ANSEL 90CM -,SUP-G48188,CDM,C1894,HCPCS,272,RC,,,outpatient,,,620.26,434.182,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH 5F 90 RB ANSEL KCF-5.0- -,SUP-G48189,CDM,C1894,HCPCS,272,RC,,,outpatient,,,620.26,434.182,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH 7F X 55CM ANSEL 1 -,SUP-G49043,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH GUID 2.9MM 8FRX45CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G49100,CDM,C1894,HCPCS,272,RC,,,outpatient,,,356.11,249.277,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH GUID 3.2MM 9FRX45MM FLEXOR CHECK-FLO ANSEL MOD ANL1 -,SUP-G49102,CDM,C1894,HCPCS,272,RC,,,outpatient,,,356.11,249.277,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH GUID 6FRX70CM FLEXOR 0.038IN GW COMP HYDRCT -,SUP-G56221,CDM,C1894,HCPCS,272,RC,,,outpatient,,,452.45,316.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH GUIDING 7FR x 70CM STRAIGHT -,SUP-G56222,CDM,C1894,HCPCS,272,RC,,,outpatient,,,452.45,316.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH GUID 2.2MM 6FRX70CM FLEXOR CHECK-FLO ANSEL MOD MP -,SUP-G56226,CDM,C1894,HCPCS,272,RC,,,outpatient,,,452.45,316.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH GUID 1.9MM 5FRX55CM FLEXOR CHECK-FLO ANSEL MOD STR. -,SUP-G56230,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH GUID 1.9MM 5FRX55CM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-G56235,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH 6F X 55 ANSEL 1 -,SUP-G56236,CDM,C1894,HCPCS,272,RC,,,outpatient,,,391.35,273.945,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH FLEXOR PARALLEL 9.5CM x 28CM - URETERAL -,SUP-G56429,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1012.66,708.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH FLEXOR PARALLEL 9.5FR x 45CM URETERAL -,SUP-G56431,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1012.66,708.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SET MICROPUNCTURE INTRODUCER 21G -,SUP-G84006,CDM,C1894,HCPCS,272,RC,,,outpatient,,,252.07,176.449,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH GUIDING DESTINATION SLENDER 105CM 6FR STRAIGHT -,SUP-GS-R6ST1C10W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1599.43,1119.601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SYS SHEATH RTRVL 4FR BNTP EMBL PROT FLTWR EZ -,SUP-H749501001500,CDM,C1894,HCPCS,272,RC,,,outpatient,,,595.17,416.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
COAXIAL MICROINTRODUCER KIT 4FR -,SUP-H965457531,CDM,C1894,HCPCS,272,RC,,,outpatient,,,175.05,122.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO PERC 6FR SHTH INTROFLEX -,SUP-I500-F6,CDM,C1894,HCPCS,272,RC,,,outpatient,,,288.25,201.775,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 9FR STD INTROFLEX PERC W/O LIDOCN -,SUP-I505BF9C,CDM,C1894,HCPCS,272,RC,,,outpatient,,,243.32,170.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 5FRX10CM MICROPUNCTURE STF CANN COAX CATH PR -,SUP-JCD5.01810.0MPI,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.06,81.242,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
10fr 0.035 Flexer Guiding Sheath -,SUP-KCFW-10.0-35-RB-RTPS-100,CDM,C1894,HCPCS,272,RC,,,outpatient,,,641.79,449.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 2.2MM 6FRX30CM FLEXOR CHECK-FLO ANSEL MOD STR -,SUP-KCFW6.0-38-30RB,CDM,C1894,HCPCS,272,RC,,,outpatient,,,268.35,187.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO CATH 6FRX13CM SHTH FLEXOR NTPR 0.038IN GW VES DILATOR -,SUP-KCFW-6.0-38-RB,CDM,C1894,HCPCS,272,RC,,,outpatient,,,243.44,170.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO 4.5FRX5CM MICRO-ACCESS TEARAWAY 0.018INX4.CM MRK NTNL -,SUP-KIT-010-03,CDM,C1894,HCPCS,272,RC,,,outpatient,,,204.23,142.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
CATHETER RETRIEVAL AVEIR REF:LSCR111 -,SUP-LSCR111,CDM,C1894,HCPCS,272,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
LOADING SYSTEM ENVEO R  LS-MDT2-2629-US -,SUP-LS-MDT2-2629-US,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2067.2,1447.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
CATHETER INTRODUCER AVEIR 30CM REF:LSN25301 -,SUP-LSN25301,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 21GA ACCUSTICK II STF CANN -,SUP-M001207020,CDM,C1894,HCPCS,272,RC,,,outpatient,,,416.39,291.473,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH INTRO 8.5FRX60CM HEARTSPAN TRNSEPT 55DG CRV TAPR -,SUP-M0045660550,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1108.65,776.055,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH URET 11/13FRX36CM NAVIGATOR -,SUP-M0062502021,CDM,C1894,HCPCS,272,RC,,,outpatient,,,567.91,397.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH NAVIGATOR HD 11/13 X 28 -,SUP-M0062502210,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH NAVIGATOR HD 11 13 36 -,SUP-M0062502220,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH NAVIGATOR HD 11 13 46 -,SUP-M0062502230,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH NAVIGATOR HD 12 14 36 -,SUP-M0062502250,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH NAVIGATOR 12F/14F X 46CM -,SUP-M0062502260,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
ST DILATOR URETH 8-30FR OD 35CM 30CM SHTH TFLN-CT TAPR GRAD -,SUP-M0062601000,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1208.3,845.81,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
ST DILATOR URETH SHTH 8FR/10FR 70CM/35CM L PTFE TAPR LF -,SUP-M0062601200,CDM,C1894,HCPCS,272,RC,,,outpatient,,,280.31,196.217,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
URETHRAL ACCESS SHTH 34FR TAPR -,SUP-M0062601600,CDM,C1894,HCPCS,272,RC,,,outpatient,,,344.5,241.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
MICRO PUNCTURE 4FR X 10 CM NTNL 0.018X 40 -,SUP-MAK401NPD,CDM,C1894,HCPCS,272,RC,,,outpatient,,,91.84,64.288,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
MICRO PUNCTURE  5FR X 10CM  0.018INX40CM - MAK501N -,SUP-MAK501N,CDM,C1894,HCPCS,272,RC,,,outpatient,,,151.42,105.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
MICRA INTRO SHEATH HYDRO COAT -,SUP-MI2355A,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
MICINTRO SHTH 7FRX7CM VENEFIT ECHGNC TIP 21GA -,SUP-MIS7F07,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
MICRO INTRO SHEATH 7F 11CM -,SUP-MIS-7F11,CDM,C1894,HCPCS,272,RC,,,outpatient,,,116.7,81.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH MICROPUNCTURE TRANSTLS TIP 0.018INX40CM PLTNM TIP -,SUP-MPIS-401-NT,CDM,C1894,HCPCS,272,RC,,,outpatient,,,190.1,133.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 4FR MICROPUNCTURE TRANSTLS TIP 0.018INX40CM PLTNM -,SUP-MPIS401PEDNTSST,CDM,C1894,HCPCS,272,RC,,,outpatient,,,197.05,137.935,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 5FRX10CM MICROPUNCTURE TRANSTLS TIP 0.018INX40CM -,SUP-MPIS-501-NT,CDM,C1894,HCPCS,272,RC,,,outpatient,,,191.21,133.847,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO ORTHO 4FR MICRO-STK NTNL WIRE -,SUP-MR190421,CDM,C1894,HCPCS,272,RC,,,outpatient,,,105.03,73.521,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 18FRX85CM PERFORM 0.038IN GW 97CM VES DILATOR -,SUP-RCFW18.0P3885RB,CDM,C1894,HCPCS,272,RC,,,outpatient,,,693.2,485.24,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 2.6MM 8FRX63CM PERFORM MLNS CRV 0.038IN GW COMP -,SUP-RCFW8.0-38-63,CDM,C1894,HCPCS,272,RC,,,outpatient,,,433.42,303.394,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH INTRO 6FRX10CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB602,CDM,C1894,HCPCS,272,RC,,,outpatient,,,152.29,106.603,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH INTRO 7FR X 10CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB702,CDM,C1894,HCPCS,272,RC,,,outpatient,,,152.29,106.603,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH INTRO 8FRX25CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB803,CDM,C1894,HCPCS,272,RC,,,outpatient,,,193.72,135.604,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH INTRO 9FRX10CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB902,CDM,C1894,HCPCS,272,RC,,,outpatient,,,152.29,106.603,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH INTRO 9FRX25CM PINNCL R/O II PERIPH GOLD COIL MRKR -,SUP-RSB903,CDM,C1894,HCPCS,272,RC,,,outpatient,,,193.72,135.604,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH INTRO 5FRX10CM PINNCL PERIPH STR CRV 0.035IN GW COMP -,SUP-RSS501,CDM,C1894,HCPCS,272,RC,,,outpatient,,,63.43,44.401,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH 8FR 10CM PINNACLE -,SUP-RSS802,CDM,C1894,HCPCS,272,RC,,,outpatient,,,60.68,42.476,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH 9FR 10CM PINNACLE -,SUP-RSS901,CDM,C1894,HCPCS,272,RC,,,outpatient,,,63.43,44.401,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 14FRX28CM SENTRANT 0.035IN GW HYDRCT -,SUP-SENSH1428W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1108.65,776.055,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
INTRO SHTH 16FRX28CM SENTRANT 0.035IN GW COMP HYDRCT -,SUP-SENSH1628W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1123.71,786.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH 18FR MEDTRONIC -,SUP-SENSH1828W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1123.71,786.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH 20FR X 28CM MEDTRONIC -,SUP-SENSH2028W,CDM,C1894,HCPCS,272,RC,,,outpatient,,,1258.87,881.209,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
MICRO PUNCTURE  5FR X 10CM  0.018INX40CM STIFF- S-MAK501N -,SUP-S-MAK501N,CDM,C1894,HCPCS,272,RC,,,outpatient,,,210.06,147.042,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH NAVIGATOR 12F/14F X 28CM -,SUP-STRYKER INSTRUMENTS,CDM,C1894,HCPCS,272,RC,,,outpatient,,,683.28,478.296,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
9.5F SAFESHEATH PEEL AWAY HEMO -,SUP-UNDEFINED,CDM,C1894,HCPCS,272,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SHEATH INTRO 6FR BRT TIP -,SUP-UNDEFINED,CDM,C1894,HCPCS,272,RC,,,outpatient,,,122.54,85.778,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
CATAPULT US 5F 15CM STRAIGHT 5PK -,SUP-US-35015-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,519.32,363.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
CATAPULT US 5F 45CM STRAIGHT 5PK -,SUP-US-35045-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,636.02,445.214,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
CATAPULT US 5F 60CM STRAIGHT 5PK -,SUP-US-35060-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,694.37,486.059,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
CATAPULT US 5F 90CM STRAIGHT 5PK -,SUP-US-35090-F-ST-H,CDM,C1894,HCPCS,272,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
TRANSEPTAL ACCESS SET VERSACROSS REF: VXSK0032 -,SUP-VXSK0032,CDM,C1894,HCPCS,272,RC,,,outpatient,,,4630.78,3241.546,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
SET INTRODUCER CHECK-FLO EXTRA LARGE 20FR 40CM -,SUP-XVCFW-20.0-35-40,CDM,C1894,HCPCS,272,RC,,,outpatient,,,2364.02,1654.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.064425,7986.663,other,Non-Reimbursable Procedures,,
LEAD DEFIB IMPL BIPLR PERMNT PCNG ETAK RELIANCE 59CM 8FR -,SUP-0157,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures,,
LEAD DEFIB ETAK RELIANCE 59CM -,SUP-0275-59,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures,,
LEAD DEFIB ETAK RELIANCE 64CM -,SUP-0276-64,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures,,
LEAD DEFIB ENDOTAK RELIANCE G 64CM -,SUP-0286,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures,,
LEAD DEFIB PCNG ETAK RELIANCE 64CM GORE-HYBRID ETFE CTD STRD -,SUP-0293-64,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10470.66,7329.462,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures,,
LEAD DEFIB IMPL BIPLR ETAK RELIANCE 4- SITE 59CM RT ECRD -,SUP-0295,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures,,
LEAD DEFIB IMPL BIPLR ETAK RELIANCE 4- SITE 64CM RT ECRD -,SUP-0296,CDM,C1895,HCPCS,278,RC,,,outpatient,,,10155.06,7108.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures,,
LEAD RELIANCE 4-FRONT 0673 64 CM -,SUP-0673-64,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures,,
LEAD DEFIB BIPLR PERMNT PCNG KENTROX SL 65CM 7.8FRX180MM SPC -,SUP-350054,CDM,C1895,HCPCS,278,RC,,,outpatient,,,14265.35,9985.745,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures,,
LEAD DEFIB IMPL LINOX SMRT SD 65CM 18CM ECRD SIL INSL DL -,SUP-359067,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9991.68,6994.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures,,
LEAD PCNG 60MM LINOX SD IMPL BIPLR RV STRD ELUT ACT -,SUP-363303,CDM,C1895,HCPCS,278,RC,,,outpatient,,,14265.35,9985.745,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures,,
LEAD DEFIB TRIPLR SPRNT QUATTRO 65CM 8.6FRX12MM SPC RT ECRD -,SUP-6935-65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures,,
LEAD DEFIB 8.6FRX12MM SPC 55CM SPRNT QUATTRO TRIPLR STRD -,SUP-6935M55,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures,,
LEAD DEFIB TRIPLR SPRNT QUATTRO 62CM 8.6FRX12MM SPC SIL -,SUP-6935M62,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures,,
LEAD PCNG 8.6FRX12MM SPC 58CM SPRNT QUATTRO PERMNT QDPL -,SUP-6947-58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures,,
LEAD PCNG 8.6FRX12MM SPC 65CM SPRNT QUATTRO PERMNT QDPL -,SUP-6947-65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures,,
LEAD DEFIB QDPL SPRNT QUATTRO 55CM 8.6FRX12MM SPC RT ECRD -,SUP-6947M55,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures,,
LEAD DEFIB QDPL SPRNT QUATTRO 62CM 8.6FRX12MM SPC RT ECRD -,SUP-6947M62,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures,,
LEAD DEFIB QDPL SPRNT QUATTRO 72CM 8.6FRX12MM SPC RT ECRD -,SUP-6947M72,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11881.6,8317.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures,,
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FRX170MM SPC VNTRC OPTIM -,SUP-7120/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures,,
LEAD DEFIB TRUE BIPLR DURATA 52CM 7FRX170MM SPC VNTRC OPTIM -,SUP-7120Q/52,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures,,
LEAD DEFIB TRUE BIPLR DURATA 58CM 7FR VNTRC OPTIM INSL SGL -,SUP-7120Q/58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures,,
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FR VNTRC OPTIM INSL SGL -,SUP-7120Q/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures,,
LEAD DEFIBRILLATOR DURATA OPTIM L21 CM OD7 FR 2 COIL -,SUP-7121,CDM,C1895,HCPCS,278,RC,,,outpatient,,,11031.32,7721.924,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures,,
LEAD DEFIB TRUE BIPLR DURATA 65CM 7FRX210MM SPC VNTRC OPTIM -,SUP-7121/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures,,
LEAD DEFIB TRUE BIPLR DURATA 52CM 7FR VNTRC OPTIM INSL SGL -,SUP-7121Q/52,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures,,
LEAD DEFIB DURATA IMPL -,SUP-7131,CDM,C1895,HCPCS,278,RC,,,outpatient,,,17543.93,12280.751,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures,,
LEAD DEFIB TRUE BIPLR DURATA 58CM 17CM-TO-PROX COIL 7FR -,SUP-7170Q/58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures,,
LEAD DEFIB TRUE BIPLR DURATA 58CM 21CM-TO-PROX COIL 7FR -,SUP-7171Q/58,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9973.4,6981.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures,,
LEAD DEFIB 8FR INTRO 65CM OPTISURE TRUE BIPLR XTD-RETRAC -,SUP-LDA230Q/65,CDM,C1895,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,13473.73824,other,Non-Reimbursable Procedures,,
ELECTRODE DEFIB 12FR DIST TIP 9FR COIL 45CM Q-TRAK TRIPLR -,SUP-3400,CDM,C1896,HCPCS,278,RC,,,outpatient,,,14852,10396.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,11406.336,other,Non-Reimbursable Procedures,,
ELECTRODE DEFIB 12FR DIST TIP 45CM EMBLEM TRIPLR SUBQ DIST -,SUP-3401,CDM,C1896,HCPCS,278,RC,,,outpatient,,,14852,10396.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,11406.336,other,Non-Reimbursable Procedures,,
EMBLEM S-ICD LEAD 3501-45CM -,SUP-3501-45,CDM,C1896,HCPCS,278,RC,,,outpatient,,,14109.4,9876.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,11406.336,other,Non-Reimbursable Procedures,,
LEAD EPICARDIAC 5071 -,SUP-5071,CDM,C1896,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,11406.336,other,Non-Reimbursable Procedures,,
LEAD PCNG 58CM TRANSVENE IMPL UNIPL ECRD CS SVC -,SUP-6937A58,CDM,C1896,HCPCS,278,RC,,,outpatient,,,4774,3341.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,11406.336,other,Non-Reimbursable Procedures,,
OPTISURE DEFIBRILLATION LEAD DF1 SINGLE COIL LDA210-65 -,SUP-LDA210-65,CDM,C1896,HCPCS,278,RC,,,outpatient,,,9839.45,6887.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,11406.336,other,Non-Reimbursable Procedures,,
KT LEAD NEURSTM OCTRODE 60CM PERC ACC -,SUP-3086ANS,CDM,C1897,HCPCS,278,RC,,,outpatient,,,2864.4,2005.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,196.493625,28414.1568,other,Non-Reimbursable Procedures,,
KT LEAD NEURSTM 60CM PERC ACC 6MM -,SUP-3873-60,CDM,C1897,HCPCS,278,RC,,,outpatient,,,3580.5,2506.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,196.493625,28414.1568,other,Non-Reimbursable Procedures,,
KT LEAD NEURSTM 60CM PERC SUBCOMPACT ACC -,SUP-3875-60,CDM,C1897,HCPCS,278,RC,,,outpatient,,,3461.15,2422.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,196.493625,28414.1568,other,Non-Reimbursable Procedures,,
REACTIV8 IMPLANTABLE PULSE GENERATOR -,SUP-5100,CDM,C1897,HCPCS,278,RC,,,outpatient,,,36997.6,25898.32,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,196.493625,28414.1568,other,Non-Reimbursable Procedures,,
KT IT REVISN INTFC TRANSP STRN RLF SLVX2 NS RLR F/SULS PMP -,SUP-8578,CDM,C1897,HCPCS,278,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,196.493625,28414.1568,other,Non-Reimbursable Procedures,,
LEAD NEURSTM VECTRIS SURSCN 60CM PERC SPIN CRD MRI-COND -,SUP-977D260,CDM,C1897,HCPCS,278,RC,,,outpatient,,,3809.65,2666.755,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,196.493625,28414.1568,other,Non-Reimbursable Procedures,,
SLIM TIP DRG TRIAL LEAD KIT -,SUP-MN10350-50A,CDM,C1897,HCPCS,278,RC,,,outpatient,,,4874.15,3411.905,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,196.493625,28414.1568,other,Non-Reimbursable Procedures,,
SLIP TIP DRG -,SUP-MN10350-90A,CDM,C1897,HCPCS,278,RC,,,outpatient,,,4909.5,3436.65,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,196.493625,28414.1568,other,Non-Reimbursable Procedures,,
STIMWAVE NEUROSTIMULATOR RECEIVER KIT -,SUP-STQ4-RCV-A0,CDM,C1897,HCPCS,278,RC,,,outpatient,,,32936.92,23055.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,196.493625,28414.1568,other,Non-Reimbursable Procedures,,
PNS PERMANENT TINED RECEIVER KIT CHANNEL B -,SUP-STQ4-RCV-B0,CDM,C1897,HCPCS,278,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,196.493625,28414.1568,other,Non-Reimbursable Procedures,,
LEAD NRV STIM 50CM F/TRL -,SUP-UNDEFINED,CDM,C1897,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,196.493625,28414.1568,other,Non-Reimbursable Procedures,,
LEAD PCNG 8FR INTRO 58CM TENDRIL DX PERMNT BIPLR AV -,SUP-1388TC/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 1642T X 46 -,SUP-1642T/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 7FR INTRO 10MM SPC 52CM ISFLX PERMNT BIPLR STR AV -,SUP-1646T/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 1646T-58 ISFLX PERMNT BIPLR_STR AV -,SUP-1646T/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 46CM TENDRIL -,SUP-1688TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
TENDRIL SDX 1688TC/46 -,SUP-1688TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD TENDRIL 1688 TC/58 -,SUP-1688TC-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 6FR INTRO 10MM SPC 52CM TENDRILL SDX PERMNT BIPLR -,SUP-1788TC/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 6FR INTRO 10MM SPC 58CM TENDRILL SDX PERMNT BIPLR -,SUP-1788TC/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 7FR INTRO 10MM SPC 46CM TENDRILL ST PERMNT BIPLR -,SUP-1882TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 7FR INTRO 10MM SPC 52CM TENDRILL ST PERMNT BIPLR -,SUP-1882TC/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 6FR INTRO 10MM SPC 46CM TENDRILL ST PERMNT BIPLR -,SUP-1888TC/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 6FR INTRO 10MM SPC 52CM TENDRILL ST PERMNT BIPLR -,SUP-1888TC/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 6FR INTRO 10MM SPC 58CM TENDRILL ST PERMNT BIPLR -,SUP-1888TC/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1908.29,1335.803,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD ISOFLEX OPTIM J 1944-46CM -,SUP-1944/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 7FR INTRO 10MM SPC 52CM ISFLX PERMNT BIPLR J-SHP -,SUP-1944/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG ISOFLEX 1948-52 ISFLX PERMNT BIPLR STR AV. -,SUP-1948/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 7FR INTRO 10MM SPC 58CM ISFLX PERMNT BIPLR STR AV -,SUP-1948/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD OPINSENSE  MODEL 1999-52 -,SUP-1999/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD CATH DELIVERED 3830 69CM,SUP-2,CDM,C1898,HCPCS,275,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 6FRX46CM TENDRIL STS IMPL BIPLR RAV ACT SCR IN FX -,SUP-2088TC-46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 6FRX52CM TENDRIL STS IMPL BIPLR RAV ACT SCR IN FX -,SUP-2088TC-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 6FRX58CM TENDRIL STS IMPL BIPLR RAV ACT SCR IN FX -,SUP-2088TC-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 6.6FRX15MM SPC 60CM SELOX ST 60 PERMNT IMPL BIPLR -,SUP-346367,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 6.6FRX15MM SPC 53CM SELOX JT 53 PERMNT IMPL BIPLR -,SUP-346368,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 6.6FRX10MM SPC 45CM SETROX DX PERMNT IMPL BIPLR -,SUP-350973,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 7FRX10MM SPC 53CM SETROX DX PERMNT IMPL BIPLR HLCL -,SUP-350974,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 6.6FRX10MM SPC 60CM SETROX DX PERMNT IMPL BIPLR -,SUP-350975,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2040.69,1428.483,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 6.6FR 7FR INTRO 53CM TILDA STR PSS FX -,SUP-382872,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD CATH DELIVERED 3830 69 CM -,SUP-383069,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 52CM SELUTE PICOTIP COMPLIANCE PRACTITIONERS -,SUP-4064,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 5.7FRX10MM SPC 35CM CAP NOV PERMNT BIPLR AV STRD -,SUP-4076-35,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2570.74,1799.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PPM 45CM CAPSURE FIX NOVUS 4076-45 -,SUP-4076-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 5.7FRX10MM SPC 45CM CAP NOV IMPL BIPLR AV STRD -,SUP-4076-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 5.3FRX9MM SPC 52CM CPSR SP NOVUS PERMNT BIPLR AV -,SUP-4092-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 5.3FRX9MM SPC 58CM CPSR SP NOVUS PERMNT BIPLR AV -,SUP-4092-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 6.7FRX10MM SPC 53CM DEXTRUS PERMNT BIPLR HLCL TIP -,SUP-4136-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 6.7FRX10MM SPC 60CM DEXTRUS PERMNT BIPLR HLCL TIP -,SUP-4137,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2252.71,1576.897,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 5.7FRX16MM SPC 58CM FNLN STRX PERMNT BIPLR STR -,SUP-4457,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 1.7X16MM SPC_45CM FINELINE II EZ STEROX PERMNT -,SUP-4469,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 1.7X16MM SPC 45CM FINELINE II EZ STEROX PERMNT -,SUP-4469-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 1.7X16MM SPC 52CM FINELINE II EZ STEROX PERMNT -,SUP-4470-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 1.7X16MM SPC 58CM FINELINE II EZ STEROX PERMNT -,SUP-4471,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 5.7FRX45CM FNLN STRX AJ PERMNT BIPLR JTP RA ECRD -,SUP-4479,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 5.7FRX52CM FNLN STRX AJ PERMNT BIPLR JTP RA ECRD -,SUP-4480-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 5.3FRX9MM SPC 45CM CPSR SP NOVUS PERMNT BIPLR JTP -,SUP-4592-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 5.3FR CPSR SP NOVUS J-SHP ATR BIPLR -,SUP-4592-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD MEDTRONIC CAPSURE VDD-2 5038S-52 -,SUP-5038S-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD MEDTRONIC CAPSURE VDD-2 5038S-58 -,SUP-5038S-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2385.23,1669.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG EPCRD -,SUP-5071-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2673.44,1871.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PPM 45CM CAPSUREFIX SURSCN NOVUS 5076-45 -,SUP-5076-45,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 6.2FRX10MM SPC 52CM CAPSUREFIX SURSCN NOVUS IMPL -,SUP-5076-52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 6.2FR X10MM SPC 58CM CAPSUREFIX SURSCN NOVUS IMPL -,SUP-5076-58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 6.2FRX10MM SPC 65CM CAPSUREFIX SURSCN NOVUS IMPL -,SUP-5076-65,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 7FRX45CM CPSR FX MRI BIPLR STR AV ACT SCR IN FX -,SUP-5086MRI-45CM,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 7FRX52CM CPSR FX MRI BIPLR STR AV ACT SCR IN FX -,SUP-5086MRI-52CM,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 7FRX58CM CAPSUREFIX BIPLR STR AV ACT SCR IN FX -,SUP-5086MRI-58CM,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 35MM MYOPORE IMPL BIPLR EPCRD AV STRD ELUT ACT SCR -,SUP-511211,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD MYOPORE BIPOLAR 511211 -,SUP-511211,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 54CM MYOPORE IMPL BIPLR EPCRD AV STRD ELUT ACT SCR -,SUP-511212,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 7.2FRX53CM CAPSUREFIX PERMNT BIPLR J-SHP TIP ATR -,SUP-5568-53,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
BIPOLAR TEMPORARY MYOCARDIAL PACING LEAD -,SUP-6495F,CDM,C1898,HCPCS,278,RC,,,outpatient,,,408.45,285.915,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
OIL MNRL F/EZ INS STYL -,SUP-6529,CDM,C1898,HCPCS,278,RC,,,outpatient,,,175.05,122.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD INGEVITY MRI 7731 52 CM P -,SUP-7731,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD INGEVITY MRI 7732-59 ( PASSIVE ) -,SUP-7732,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD INGEVITY MRI 7732 59 -,SUP-7732-59,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
INGEVITY MRI  MODEL 7735-45 -,SUP-7735,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD INGEVITY MRI 7736-52 ( PASSIVE J ) -,SUP-7736,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD INGEVITY MRI 7740 -,SUP-7740,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD INGEVITY MRI 7741 52CM -,SUP-7741,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD INGEVITY MRI 7742 59CM -,SUP-7742,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
INGEVITY + 7840-45cm -,SUP-7840,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
INGEVITY + 7841/52 -,SUP-7841/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
INGEVITY + 7842/59 LEAD -,SUP-7842/59,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1855.18,1298.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG ELAFIX ATR -,SUP-ELAFIX P2 752,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2549.32,1784.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 7FRX52CM BIPLR ECRD THN TND -,SUP-ELAPASSP752,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 7FRX58CM BIPLR ECRD THN TND -,SUP-ELAPASSP758,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2549.32,1784.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 7FRX52CM BIPLR J-SHP ECRD THN TND -,SUP-ELAPASSPJ752,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2120.2,1484.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
TENDRIL MRI LEAD 46CM -,SUP-LPA1200M/46,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
TENDRIL MRI LEAD- 52CM -,SUP-LPA1200M/52,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
TENDRIL MRI LEAD- 58CM -,SUP-LPA1200M/58,CDM,C1898,HCPCS,278,RC,,,outpatient,,,1818.07,1272.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD CATH DELIVERED 3830 59CM -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD CATH DELIVERED 3830 74CM -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD CATH DELIVERED 3830 49CM -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2332.22,1632.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD GENTR -,SUP-UNDEFINED,CDM,C1898,HCPCS,278,RC,,,outpatient,,,2650.25,1855.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,39.298725,2053.20192,other,Non-Reimbursable Procedures,,
LEAD PCNG 7FR INTRO 20MM SPC 86CM QUICKFLEX PERMNT BIPLR -,SUP-1156T/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,12252.9,8577.03,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures,,
LEAD PCNG 5FRX20MM SPC 75CM QUICKFLEX U BIPLR STYP CRV LH -,SUP-1258T/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures,,
LEAD PCNG 5FRX20MM SPC 86CM QUICKFLEX U BIPLR STYP CRV LH -,SUP-1258T/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures,,
LEAD PCNG 5FRX20MM SPC 92CM QUICKFLEX U BIPLR STYP CRV LH -,SUP-1258T/92,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5984.04,4188.828,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures,,
Lead Quartet 1456/75Q LV Lead -,SUP-1456/75Q,CDM,C1900,HCPCS,278,RC,,,outpatient,,,8445.56,5911.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures,,
LEAD QUARTET 1456Q/86 LV LEAD -,SUP-1456/86Q,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures,,
QUARTET LEAD DOUBLE BEND- 75 CM MODEL 1457Q/75 -,SUP-1457Q/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures,,
QUARTET LEAD DOUBLE BEND-86CM MODEL 1457Q/86 -,SUP-1457Q/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures,,
LEAD PCNG 7FR INTRO 75CMX16MM QRTT CRT STYP CRV LH LPRO -,SUP-1458Q/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures,,
LEAD PCNG 7FR INTRO 86CMX16MM QRTT CRT STYP CRV LH LPRO -,SUP-1458Q/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures,,
LEAD QUARTET 75 WIDE SPACING -,SUP-1458QL/75,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures,,
LEAD QUARTET 1458QL 86 WIDE SPACING -,SUP-1458QL/86,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures,,
LEAD PCNG 5.4FRX18MM SPC 77CM COROX PERMNT IMPL BIPLR HMSPHR -,SUP-355148,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5228.61,3660.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures,,
LEAD SENTUS OTW QP L-75 -,SUP-386835,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures,,
LEAD SENTUS OTW QP S-75 -,SUP-400719,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures,,
LV LEAD SENTUS OTW QP L 75/49 -,SUP-408718,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures,,
LV LEAD SENTUS OTW QP L 85/49 -,SUP-408719,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures,,
LEAD PCNG 5FRX88CM ATTAIN PERMNT UNIPL CANTED LT VNTRC OTW -,SUP-4195-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10025.1,7017.57,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures,,
LEAD PCNG 4FRX21MM SPC 88CM ATTAIN PERMNT BIPLR ANG LT VNTRC -,SUP-4196-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures,,
LEAD PCNG 5.3FRX21MM SPC 88CM ATTAIN ABILITY + IMPL BIPLR -,SUP-4296-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures,,
LEAD ATTAIN PERFORMA LV REF:429878 -,SUP-429878,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10270.48,7189.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures,,
LEAD PCNG 5.3FRX21MM SPC 78CM ATTAIN PERFORM QDPL DBL CRV LT -,SUP-4298-78,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10210.75,7147.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures,,
LEAD ATTAIN PERFORM 4298-88 CM QDPL DBL CRV LT -,SUP-4298-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures,,
LEAD ATTAIN PERFORMA QUAD LV  88 -,SUP-439888,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures,,
LEAD PCNG 6FRX11MM SPC 80CM EASYTRAK 2 IMPL UNIPL BIPLR LT -,SUP-4542,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5585.1,3909.57,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures,,
LEAD PCNG 6FRX11MM SPC 90CM EASYTRAK 2 IMPL UNIPL BIPLR LT -,SUP-4543,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5585.1,3909.57,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures,,
LEAD PCNG 6FRX11MM SPC 90CM EASYTRAK 3 IMPL UNIPL BIPLR LT -,SUP-4549,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5585.1,3909.57,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures,,
LEAD PCNG 4.5FRX90CM ACUITY IMPL UNIPL LT ECRD VNTRC SPRL FX -,SUP-4592,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures,,
LEAD ATTAIN PERFORMA LV 4598-78 -,SUP-4598-78,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures,,
LEAD ATTAIN PERFORMA LV 4598-88 -,SUP-4598-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10185.6,7129.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures,,
LEAD ACUITY X4 86CM STRAIGHT -,SUP-4671,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures,,
LEAD ACUITY X4 95CM STRAIGHT -,SUP-4672-95,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures,,
LV LEAD ACUTIY SPIRAL S MODEL 4674-86 -,SUP-4674,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures,,
LEAD ACUITY X4 95CM SPIRAL S -,SUP-4675-95,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures,,
LEAD ACUITY X4 86CM SPIRAL L -,SUP-4677,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures,,
LEAD ACUITY X4 95CM SPIRAL L -,SUP-4678-95,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5092.8,3564.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures,,
LEAD ATTAIN STABILITY QUAD MRI SURESCAN LV LEAD REF:4798-88 -,SUP-4798-88,CDM,C1900,HCPCS,278,RC,,,outpatient,,,10247.88,7173.516,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures,,
LV LEAD SENTUS OTW QP S 75/49 MODEL 406081 -,SUP-706081,CDM,C1900,HCPCS,278,RC,,,outpatient,,,7851.4,5495.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures,,
LEAD COROX OTW-L 85-BP -,SUP-UNDEFINED,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5228.61,3660.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures,,
LEAD COROX OTW-L 75-BP -,SUP-UNDEFINED,CDM,C1900,HCPCS,278,RC,,,outpatient,,,5228.61,3660.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,9410.2272,other,Non-Reimbursable Procedures,,
PROBE PERC SPIN 17GAX6IN -,SUP-0407-250-000,CDM,C2614,HCPCS,270,RC,,,outpatient,,,8309.75,5816.825,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6381.888,other,Non-Reimbursable Procedures,,
SIR-SPHERES Y-90 RESIN MICROSPHERES -,SUP-SIR-Y001,CDM,C2616,HCPCS,278,RC,,,outpatient,,,44393.67,31075.569,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11484.64243,399.86,42246.08608,percent of total billed charges,,,
STENT BLDR 14F/7FRX24CM RETROMAX + PERCUFLEX HYDRPLS CTD -,SUP-145-148,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1085.19,759.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT 6FR OPEN END -,SUP-160205,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT URET 8FRX80CM PERCUFLEX STR OPEN TIP -,SUP-160215,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
URINARY STENT 7FR CLOSED TIP -,SUP-160230,CDM,C2617,HCPCS,278,RC,,,outpatient,,,535.8,375.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT PANC 7FR PSHR CATH 5CM FREEMN -ALIPERT FLEX-STNT -,SUP-6521,CDM,C2617,HCPCS,278,RC,,,outpatient,,,320.93,224.651,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT PANC 7FRX9CM FREEMN FLX-STNT SGL PIGTL DBL XTRN FLNG -,SUP-6575,CDM,C2617,HCPCS,278,RC,,,outpatient,,,268.41,187.887,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT URET 4.7FRX26CM INLAY DBL PIGTL TAPR -,SUP-778426,CDM,C2617,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT BIL 10FRX5CM COTTON-LEUNG CRV TAPR PE -,SUP-CLSO 10-5,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT BIL 7FRX7CM COTTON-LEUNG CRV TAPR PE P/D FLP -,SUP-CLSO 7-7,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT BILIARY ZIMMON 8FR 12CM 0.035IN GW 3.2MM -,SUP-G21404,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT BIL 10FRX7CM COTTON-LEUNG CRV TAPR PE -,SUP-G21469,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT BIL 10FRX8CM COTTON-LEUNG CRV TAPR PE P/D FLP -,SUP-G21472,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT BIL 10FRX10CM COTTON-LEUNG CRV TAPR PE P/D FLP -,SUP-G21807,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT BILIARY ZIMMON 10-5 -,SUP-G21975,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT PANC 5FRX5CM ZIMMON SPRL SH PE PIGTL TAPR FLP LF MRI -,SUP-G22980,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT PANC 3FRX4CM ZIMMON SPRL SH PE PIGTL TAPR OPTN DCT FLP -,SUP-G24566,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT PANC 5FRX9CM GEENEN SPRL SH SOF-FLEX OFST PROX FLP LF -,SUP-G49666,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT PANC 5FR 7CM GEENEN SOF-FLEX NO INTERNAL FLAP -,SUP-G49670,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT PANC 5FR 9CM GEENEN SOF-FLEX NO INTERNAL FLAP -,SUP-G49671,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT BIL 7FRX5CM COMPASS BDS DBL PIGTL TAPR PLST 0.035IN GW -,SUP-G55519,CDM,C2617,HCPCS,278,RC,,,outpatient,,,414.29,290.003,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT PANC 5FR 3CM GEENEN SOF-FLEX NO INTERNAL FLAP -,SUP-GPSOS-SF-5-3,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT PANC 5FR 5CM GEENEN SOF-FLEX NO INTERNAL PLAP -,SUP-GPSOS-SF-5-5,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT URET 8FRX22CM PERCUFLEX DBL PIGTL FLXB STF -,SUP-M001245500,CDM,C2617,HCPCS,278,RC,,,outpatient,,,826.41,578.487,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT URET 6FRX22CM PERCUFLEX DBL PIGTL -,SUP-M001245730,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT URET 6FRX24CM PERCUFLEX DBL PIGTL -,SUP-M001245740,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT URET 6FRX26CM PERCUFLEX DBL PIGTL -,SUP-M001245750,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT URET 6FRX28CM PERCUFLEX DBL PIGTL -,SUP-M001245760,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1129.71,790.797,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT URET 8FRX26CM FLEXIMA DBL PIGTL -,SUP-M001274030,CDM,C2617,HCPCS,278,RC,,,outpatient,,,697.87,488.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT ADVANIX 7FR X 3CM DOUBLE PIGTAIL -,SUP-M00532160,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
ADVANIX DOUBLE PIGTAIL 7FR X 5CM -,SUP-M00532180,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
ADVANIX DOUBLE PIGTAIL 7FR X 7CM -,SUP-M00532190,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
ADVANIX DOUBLE PIGTAIL 7FR X 10CM -,SUP-M00532210,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
ADVANIX DOUBLE PIGTAIL 10FR X 5CM -,SUP-M00532260,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT BIL 10FRX5CM ADVANIX RX SGL DBL PIGTL PLST 4.2MM WKG -,SUP-M00532260,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
ADVANIX DOUBLE PIGTAIL 10FR X 7CM -,SUP-M00532270,CDM,C2617,HCPCS,278,RC,,,outpatient,,,330.44,231.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT BIL 10FRX15CM WALLSTNT DUOD BND PERCUFLEX -,SUP-M00533700,CDM,C2617,HCPCS,278,RC,,,outpatient,,,290.87,203.609,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT URET 8FRX22CM PERCUFLEX DBL PIGTL PSTNR -,SUP-M0061453800,CDM,C2617,HCPCS,278,RC,,,outpatient,,,441.13,308.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
SCISSORS SURG KAYE CRV 7.5IN SERR DSCT V. MUELLER LF -,SUP-M0061552310,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT URET 6FRX24CM POLARIS LOOP PERCUFLEX -,SUP-M0061552320,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT URET 6FRX26CM POLARIS LOOP PERCUFLEX -,SUP-M0061552330,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT URET 6FRX28CM POLARIS LOOP PERCUFLEX -,SUP-M0061552340,CDM,C2617,HCPCS,278,RC,,,outpatient,,,885.17,619.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT URET 8FRX26CM POLARIS LOOP PERCUFLEX -,SUP-M0061552530,CDM,C2617,HCPCS,278,RC,,,outpatient,,,836.51,585.557,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT URET 7FRX80CM PERCUFLEX STR LF -,SUP-M006160210,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1071.6,750.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT PERC PLUS 4.8 X 24 -,SUP-M0061752520,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT PERC PLUS 4.8 X 26 -,SUP-M0061752530,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT PERC PLUS 4.8 X 28 -,SUP-M0061752540,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT PERCUFLEX PLUS 6 X 22 -,SUP-M0061752610,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT PERCUFLEX PLUS 6 X 24 -,SUP-M0061752620,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT PERCUFLEX PLUS 6 X 26 -,SUP-M0061752630,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT PERCUFLEX PLUS 6 X 28 -,SUP-M0061752640,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT PERCUFLEX PLUS 6 X 30 -,SUP-M0061752650,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT PERCUFLEX PLUS 7FR X 24CM -,SUP-M0061752720,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT PERCUFLEX PLUS 7FR X 26CM -,SUP-M0061752730,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT PERCUFLEX PLUS 8 X 26 -,SUP-M0061752830,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT PERCUFLEX PLUS 8 X 28 NO -,SUP-M0061752840,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT URET 8FRX30CM PERCUFLEX DBL PIGTL TAPR -,SUP-M0061752850,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT URET 4.8FR 22-30CM CONTR VL PERCUFLEX DBL PIGTL TAPR -,SUP-M0061801550,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT URET 6FR 22-30CM CONTR VL PERCUFLEX DBL PIGTL TAPR -,SUP-M0061801560,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT URET CONTOUR 6 X 22 -,SUP-M0061802210,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT URET CONTOUR 6 X 28 -,SUP-M0061802240,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT URET 8FRX28CM PERCUFLEX TAPR LF -,SUP-M00618022440,CDM,C2617,HCPCS,278,RC,,,outpatient,,,665.19,465.633,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT URET CONTOUR 8 X 24 -,SUP-M0061802420,CDM,C2617,HCPCS,278,RC,,,outpatient,,,628.6,440.02,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT URET 6FRX22CM NTNL/PTFE DBL PIGTL -,SUP-M006190131090,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1073.17,751.219,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT URET 6FRX24CM NTNL/PTFE DBL PIGTL -,SUP-M006190132090,CDM,C2617,HCPCS,278,RC,,,outpatient,,,1073.17,751.219,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT URET 6FRX22CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921310,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT URET 6FRX24CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921320,CDM,C2617,HCPCS,278,RC,,,outpatient,,,791.28,553.896,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT URET 6FRX26CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921330,CDM,C2617,HCPCS,278,RC,,,outpatient,,,791.28,553.896,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT URET 6FRX28CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921340,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT URET 8FRX22CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921510,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT URET 8FRX26CM POLARIS ULTRA PERCUFLEX DBL PIGTL TAPR -,SUP-M0061921530,CDM,C2617,HCPCS,278,RC,,,outpatient,,,837.32,586.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT PANC 5FRX5CM ZIMMON SPRL SH PE PIGTL TAPR OPTN DCT FLP -,SUP-SPSOF-5-5,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT BIL 7FRX10CM ZIMMON DBL PIGTL TAPR PE -,SUP-ZSO-7-10,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
STENT BIL 7FRX7CM ZIMMON DBL PIGTL TAPR PE -,SUP-ZSO-7-7,CDM,C2617,HCPCS,278,RC,,,outpatient,,,350.1,245.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,734.3115,other,Non-Reimbursable Procedures,,
PROBE CRYOSPHERE 11IN -,SUP-CRYOS,CDM,C2618,HCPCS,272,RC,,,outpatient,,,10397.8,7278.46,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7607.37,other,Non-Reimbursable Procedures,,
PROBE CRYOSPHERE 18IN -,SUP-CRYOS-L,CDM,C2618,HCPCS,272,RC,,,outpatient,,,9468.15,6627.705,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7607.37,other,Non-Reimbursable Procedures,,
ICEROD 1.5C X 90 NEEDLE -,SUP-FPRPR3533,CDM,C2618,HCPCS,272,RC,,,outpatient,,,8042.38,5629.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7607.37,other,Non-Reimbursable Procedures,,
NEEDLE ICEROD CX 90 VL -,SUP-FPRPR3533,CDM,C2618,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7607.37,other,Non-Reimbursable Procedures,,
NEEDLE ICEPEARL  2.1C X 90 -,SUP-FPRPR3601,CDM,C2618,HCPCS,272,RC,,,outpatient,,,8042.38,5629.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7607.37,other,Non-Reimbursable Procedures,,
NEEDLE ICEFORCE 2.1 X 90 -,SUP-FPRPR3602,CDM,C2618,HCPCS,272,RC,,,outpatient,,,10610,7427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7607.37,other,Non-Reimbursable Procedures,,
PACEMAKER IMPL BIPLR ADAPTA VDD SGL-CHMBR RR 11.1ML 23.6GM -,SUP-ADVDD01,CDM,C2619,HCPCS,275,RC,,,outpatient,,,16567.96,11597.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4286.131252,399.86,12724.19328,percent of total billed charges,,,
PACEMAKER IMPL EVIA HF-T TRI CHMBR 14ML 27GM IS-1 CONN -,SUP-377208,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25991,18193.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6723.8717,399.86,24381.0432,percent of total billed charges,,,
PACEMAKER IMPL SYNCRA 15ML 26GM DR -,SUP-C2TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5763.3186,399.86,24381.0432,percent of total billed charges,,,
PACEMAKER IMPL CONSULTA CRT-P SGL-CHMBR 15ML 26GM IS-1 CONN -,SUP-C4TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5763.3186,399.86,24381.0432,percent of total billed charges,,,
PACEMAKER IMPL ANTHEM 2CHMBR RR 52X58MM 6MM 13.7ML 25GM IS-1 -,SUP-PM3210,CDM,C2621,HCPCS,275,RC,,,outpatient,,,19897.97,13928.579,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5147.604839,399.86,24381.0432,percent of total billed charges,,,
PACEMAKER IMPL ALLURE RF 59X55MM 6MM 14ML 24GM IS-1 CONN -,SUP-PM3222,CDM,C2621,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4034.32302,399.86,24381.0432,percent of total billed charges,,,
PACEMAKER IMPL QDPL ALLURE QUADRA RF 2CHMBR RR 59X56MM 6MM -,SUP-PM3242,CDM,C2621,HCPCS,275,RC,,,outpatient,,,20792.8,14554.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5379.09736,399.86,24381.0432,percent of total billed charges,,,
CRT-PACER QUADRA ALLURE MP  RF -,SUP-PM3262,CDM,C2621,HCPCS,275,RC,,,outpatient,,,21813.88,15269.716,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5643.250756,399.86,24381.0432,percent of total billed charges,,,
QUADRA ALLURE MP MRI PM3562 -,SUP-PM3562,CDM,C2621,HCPCS,275,RC,,,outpatient,,,20792.8,14554.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5379.09736,399.86,24381.0432,percent of total billed charges,,,
PACEMAKER ALTRUA 60 49MMX43X8MM 12.1ML TI -,SUP-S606 DR EL,CDM,C2621,HCPCS,275,RC,,,outpatient,,,18193.7,12735.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4706.71019,399.86,24381.0432,percent of total billed charges,,,
VALITUDE CRT-P U125 -,SUP-U125,CDM,C2621,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4034.32302,399.86,24381.0432,percent of total billed charges,,,
CRT-P VALITUDE MODEL - U128 -,SUP-U128,CDM,C2621,HCPCS,275,RC,,,outpatient,,,15594.6,10916.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4034.32302,399.86,24381.0432,percent of total billed charges,,,
VISIONIST CRT-P MODEL U226 BI-V PACEMAKER -,SUP-U226,CDM,C2621,HCPCS,275,RC,,,outpatient,,,27736.11,19415.277,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7175.331657,399.86,24381.0432,percent of total billed charges,,,
CRT-P VISIONIST X4 - U228 -,SUP-U228,CDM,C2621,HCPCS,275,RC,,,outpatient,,,20313.82,14219.674,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5255.185234,399.86,24381.0432,percent of total billed charges,,,
PACEMAKER IMPL INVIVE CRT-PS SMARTDELAY ALGORITHM RPM -,SUP-V172,CDM,C2621,HCPCS,275,RC,,,outpatient,,,31746.15,22222.305,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8212.729005,399.86,24381.0432,percent of total billed charges,,,
PACEMAKER INTUA CARD -,SUP-V272,CDM,C2621,HCPCS,275,RC,,,outpatient,,,28590.1,20013.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7396.25887,399.86,24381.0432,percent of total billed charges,,,
PACEMAKER PERCEPTA CRT-P MRI W1TR01 -,SUP-W1TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25991,18193.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6723.8717,399.86,24381.0432,percent of total billed charges,,,
SOLARA CRT-P MRI W1TR03 -,SUP-W1TR03,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5763.3186,399.86,24381.0432,percent of total billed charges,,,
PACEMAKER PERCEPTA QUAD CRT-P MRI W4TR01 -,SUP-W4TR01,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25991,18193.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6723.8717,399.86,24381.0432,percent of total billed charges,,,
PACEMAKER SERENA QUAD CRT-P MRI W4TR02 -,SUP-W4TR02,CDM,C2621,HCPCS,275,RC,,,outpatient,,,25248.4,17673.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6531.76108,399.86,24381.0432,percent of total billed charges,,,
SOLARA QUAD CRT-P MRI W4TR03 -,SUP-W4TR03,CDM,C2621,HCPCS,275,RC,,,outpatient,,,22278,15594.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5763.3186,399.86,24381.0432,percent of total billed charges,,,
PROSTHESIS PENL CNCLBL 14MMX16CM ANG RGD CONN MIN SPR BK -,SUP-720056-02,CDM,C2622,HCPCS,278,RC,,,outpatient,,,24383.27,17068.289,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6307.951949,399.86,23086.3872,percent of total billed charges,,,
IMPLANT PENL CL 12MMX12CM SIL PE TI SEG MALE CNCLBL SNP FIT -,SUP-720074-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,20421.5,14295.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5283.04205,399.86,23086.3872,percent of total billed charges,,,
PROSTHESIS TACTRA 9.5MM X 14CM-23CM MALLEABLE -,SUP-720080-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,30060.4,21042.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7776.62548,399.86,23086.3872,percent of total billed charges,,,
TACTRA 11CM MALLEABLE PROSTHESIS -,SUP-720081-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,30060.4,21042.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7776.62548,399.86,23086.3872,percent of total billed charges,,,
TACTRA 13MM X 18CM-27CM MALLEABLE PROSTHESIS -,SUP-720082-01,CDM,C2622,HCPCS,278,RC,,,outpatient,,,28358.17,19850.719,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7336.258579,399.86,23086.3872,percent of total billed charges,,,
IMPLANT PENL DURA 11 10MMX14CM CL HX WRNCH STRL -,SUP-720093-10,CDM,C2622,HCPCS,278,RC,,,outpatient,,,15579.75,10905.825,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4030.481325,399.86,23086.3872,percent of total billed charges,,,
TIP PROS DURA II 10MMX1CM UNIV PENL STRL -,SUP-720093-12,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,622.543441,399.86,23086.3872,percent of total billed charges,,,
TIP PROS DURA II 10MMX5CM PROX PENL STRL -,SUP-720093-16,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,622.543441,399.86,23086.3872,percent of total billed charges,,,
TIP PROS DURA II 10MMX4CM DIST PENL STRL -,SUP-720093-23,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,622.543441,399.86,23086.3872,percent of total billed charges,,,
TIP PROS DURA II 10MMX2CM UNIV PENL STRL -,SUP-720093-60,CDM,C2622,HCPCS,278,RC,,,outpatient,,,2406.43,1684.501,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,622.543441,399.86,23086.3872,percent of total billed charges,,,
KT PROSTHESIS PENL 11MMX25CM MALE CYL MLBL TRMBL ADPR W/TAIL -,SUP-91-9511SC,CDM,C2622,HCPCS,278,RC,,,outpatient,,,20291.55,14204.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5249.423985,399.86,23086.3872,percent of total billed charges,,,
BARD BALLOON LUTONIX .035 4.0 X 150MM -,SUP-BSLX3513041505F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8912.4,6238.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
CATH PTCA 6MMX130CM LUTONIX 60MM DRG CTD 0.035IN GW COMP -,SUP-BSLX351306605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
LUTONIX BALLOON 6MM X 80MM -,SUP-BSLX351306805F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,7214.8,5050.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
RANGER DCB OTW  4.0MM x 40MM x 135CM -,SUP-H74939419400410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
RANGER GLOBAL DCB OTW 4.0 X 80MM 135CM -,SUP-H74939419400810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
RANGER GLOBAL DCB OTW 4.0 X 100MM 135CM -,SUP-H74939419401010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
RANGER GLOBAL DCB OTW 4.0 X 150MM 150CM -,SUP-H74939419401510,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
RANGER GLOBAL DCB OTW 4.0 X 200MM 150CM -,SUP-H74939419402010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
RANGER GLOBAL DCB OTW 4.0 X 200MM 150CM -,SUP-H74939419500410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
RANGER GLOBAL DCB OTW 5.0 X 60MM 135CM -,SUP-H74939419500610,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
CATH BALLOON RANGER GLOBAL 5.0 X 80MM X 135CM GLOBAL DCB OTW -,SUP-H74939419500810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
RANGER GLOBAL DCB OTW 5.0 X 100MM 135CM -,SUP-H74939419501010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
RANGER GLOBAL DCB OTW 5.0 X 120MM 150CM -,SUP-H74939419501210,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5708.18,3995.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
RANGER GLOBAL DCB OTW 5.0 X 150MM 150CM -,SUP-H74939419501510,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
RANGER DCB OTW 5.0MM x 200MM x 150CM -,SUP-H74939419502010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
RANGER GLOBAL DCB OTW 5.0 X 200MM 90CM -,SUP-H74939419502090,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
RANGER GLOBAL DCB OTW 6.0 X 40MM 135CM -,SUP-H74939419600410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
RANGER GLOBAL DCB OTW 6.0 X 60MM 135CM -,SUP-H74939419600610,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
CATH BALLOON RANGER GLOBAL 6.0 X 80MM X 135CM GLOBAL DCB OTW -,SUP-H74939419600810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
RANGER GLOBAL DCB OTW 6.0 X 100MM 135CM -,SUP-H74939419601010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
RANGER GLOBAL DCB OTW 6.0 X 200MM 150CM -,SUP-H74939419602010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
RANGER GLOBAL DCB OTW 7.0 X 40MM 135CM -,SUP-H74939419700410,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
RANGER GLOBAL DCB OTW 7.0 X 60MM 135CM -,SUP-H74939419700610,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
RANGER GLOBAL DCB OTW 7.0 X 80MM 135CM -,SUP-H74939419700810,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
RANGER GLOBAL DCB OTW 7.0 X 100MM 135CM -,SUP-H74939419701010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5283.78,3698.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
RANGER GLOBAL DCB OTW 7.0 X 150MM 150CM -,SUP-H74939419701510,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6556.98,4589.886,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
RANGER GLOBAL DCB OTW 7.0 X 200MM 150CM -,SUP-H74939419702010,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8254.58,5778.206,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
LUTONIX 018 6 X 80MM -,SUP-LX181306805F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
CATH PTCA 4MMX130CM LUTONIX 40MM DRG CTD 0.035IN GW COMP -,SUP-LX351304405F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
CATH PTCA 4MMX130CM LUTONIX 60MM DRG CTD 0.035IN GW COMP -,SUP-LX351304605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
CATH PTCA 5MMX130CM LUTONIX 100MM DRG CTD 0.035IN GW COMP -,SUP-LX3513051005F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
CATH PTCA 5X150MM LUTONIX 130CM -,SUP-LX3513051505F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
CATH PTCA 5MMX130CM LUTONIX 60MM DRG CTD 0.035IN GW COMP -,SUP-LX351305605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
B LUTONIX 6MM X 100MM X 130 -,SUP-LX3513061005F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
CATH PTCA 6X150MM LUTONIX 130CM -,SUP-LX3513061505F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
LUTONIX BALLOON -,SUP-LX3513062205F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,8700.2,6090.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
CATH PTCA LUTONIX 0.035 X 6.0MM X 130CM 6FR DRG CTD GW GROUP -,SUP-LX351306605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
CATH PTCA 6MMX130CM LUTONIX 80MM DRG CTD 0.035IN GW COMP -,SUP-LX351306805F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
LUTONIX BALLOON 7MM X 100MM X 130M -,SUP-LX3513071005F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
S LUTONIX 7 X 40 X 130 -,SUP-LX351307405F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
S LUTONIX 7 X 60 X 130 -,SUP-LX351307605F,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
BALLOON LUTONIX .035 X 10MM X 40MM -,SUP-LX35751040V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
BALLOON LUTONIX .035 X 10MM X 60MM -,SUP-LX35751060V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
LUTONIX 12MM X 40MMX 75CM -,SUP-LX35751240V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,6896.5,4827.55,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
BALLOON LUTONIX .035  4.0MM X 40MM -,SUP-LX3575440V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
CATH LUTONIX BALLOON DILATATION 6MM 75CM 40MM PACLITAXEL LF -,SUP-LX3575640V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
CATH LUTONIX BALLOON DILATATION 6MM 75CM 60MM PACLITAXEL LF -,SUP-LX3575660V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
LUTONIX DCB BALLOON 6 X 80 X 75 -,SUP-LX3575680V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
BALLOON LUTONIX .035  7.0MM X 40MM -,SUP-LX3575740V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
BALLOON LUTONIX .035  4 X 60 X 75 -,SUP-LX3575760V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
BALLOON LUTONIX .035 X 8MM X 40MM X 75CM -,SUP-LX3575840V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
BALLOON LUTONIX  .035 8 X 60 X 75 -,SUP-LX3575860V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
BALLOON LUTONIX .035 9.0MM X 40MM X 75CM -,SUP-LX3575940V,CDM,C2623,HCPCS,272,RC,,,outpatient,,,5729.4,4010.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,6390.1908,other,Non-Reimbursable Procedures,,
STENT NEPHURET 8.5FRX22CM ULTRATHANE COPE DBL PIGTL BND -,SUP-240735,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT NEPHURET 8.5FRX24CM ULTRATHANE COPE DBL PIGTL BND -,SUP-240736,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT NEPHURET 8.5FRX28 CM ULTRATHANE COPE DBL PIGTL BND -,SUP-244806,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT URET 4.7FRX24CM INLAY DBL PIGTL TAPR -,SUP-778424,CDM,C2625,HCPCS,278,RC,,,outpatient,,,396.78,277.746,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
8FR X 22 BARD OPTIMA INLAY URETERAL STENT -,SUP-778822,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
8FR X 24 BARD OPTIMA INLAY URETERAL STENT -,SUP-778824,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
8FR X 26 BARD OPTIMA INLAY URETERAL STENT -,SUP-778826,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
8FR X 28 BARD OPTIMA INLAY URETERAL STENT -,SUP-778828,CDM,C2625,HCPCS,278,RC,,,outpatient,,,525.15,367.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT URETERAL INLAY 6F 20 OPT -,SUP-788620,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT URETERAL INLAY 6F 22 OPT -,SUP-788622,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT URETERAL INLAY 6F 24 -,SUP-788624,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT URETERAL INLAY 6F 26 -,SUP-788626,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT URETERAL INLAY 6F 28 -,SUP-788628,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT URETERAL INLAY 6F 30 -,SUP-788630,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
BARD OPTIMA INLAY STENT 7 X 24 -,SUP-788724,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
BARD OPTIMA INLAY STENT 7 X 26 -,SUP-788726,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
BARD OPTIMA INLAY STENT 7 X 28 -,SUP-788728,CDM,C2625,HCPCS,278,RC,,,outpatient,,,641.85,449.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT BIL 7FRX5CM COTTON-LEUNG CRV TAPR PE P/D FLP PSH CATH -,SUP-CLBS-7-5,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT FANELLI BILIARY -,SUP-G13699,CDM,C2625,HCPCS,278,RC,,,outpatient,,,2999.5,2099.65,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT URET 7FRX75CM BNDR RT SOF-FLEX -,SUP-G14779,CDM,C2625,HCPCS,278,RC,,,outpatient,,,446.79,312.753,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT URET 7FRX75CM BNDR PTFE -,SUP-G14780,CDM,C2625,HCPCS,278,RC,,,outpatient,,,451.1,315.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT BILIARY DOUBLE PIGTAIL 7 X 7 -,SUP-G21396,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT BILIARY DOUBLE PIGTAIL 7 X 9 -,SUP-G21398,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT GEENAN PANCREATIC 7X7 -,SUP-G21479,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT GEENAN PANCREATIC 7X9 -,SUP-G21480,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT SET ZIMMON BILIARY 7-12 -,SUP-G21526,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT ZIMON BILIARY 7 X 15 -,SUP-G21529,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT ZIMMON DBL PIGTAIL 10X4 -,SUP-G21781,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT BIL 10MMX5CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN -,SUP-G25379,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT BIL 10MMX7CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN -,SUP-G25380,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT BIL 7MMX5CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN GW -,SUP-G25656,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT BIL 7MMX7CM OASIS COTTON-LEUNG PRELD 1 ACTN 0.035IN GW -,SUP-G25657,CDM,C2625,HCPCS,278,RC,,,outpatient,,,671.03,469.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT SOLUS DOUBLE PIGTAIL 10FR 3CM -,SUP-G25670,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT SOLUS DBL PIGTAIL 10 X 4 -,SUP-G25671,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT SOLUS DBL PIGTAIL 10 X 5 -,SUP-G25672,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT SOLUS DOUBLE PIGTAIL 10FR 1CM -,SUP-G26829,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT DBLE PIGTAIL 10F 1CM -,SUP-G26829,CDM,C2625,HCPCS,278,RC,,,outpatient,,,647.69,453.383,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT NEPHURET 10.2FRX22CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48162,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT NEPHURET 8.5FRX24CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48176,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT NEPHURET 8.5FRX26CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48180,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT NEPHURET 8.5FRX26CM ULTRATHANE COPE DBL PIGTL BND -,SUP-G48180,CDM,C2625,HCPCS,278,RC,,,outpatient,,,790.58,553.406,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
COMPASS BDS BILIARY STENT 7FR 15CM -,SUP-G58990,CDM,C2625,HCPCS,278,RC,,,outpatient,,,408.45,285.915,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT PANC 3FRX4CM GEENEN 170CM/320CM PSH/GUID CATH SPRL SH -,SUP-GEPD3-4,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
TUBE LRNCMY JCKSN SZ8 12MMX7CM OSDE V. MUELLER CRV MIRR FNSH -,SUP-GEPD3-5,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
CATH DRN 10FR NAVIFLEX RX -,SUP-M00533580,CDM,C2625,HCPCS,278,RC,,,outpatient,,,512.08,358.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT ADVANIX RX 7FR X 5CM PRELOADED -,SUP-M00534200,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT ADVANIX RX 7FR X 7CM PRELOADED -,SUP-M00534210,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT ADVANIX RX 7FR X 9CM PRELOADED -,SUP-M00534220,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT BIL 2.3MMX9CM ADVANIX RX PRELD DUOD BND PLST 3.2MM WKG -,SUP-M00534220,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT ADVANIX RX 7FR X 12CM PRELOADED -,SUP-M00534230,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT ADVANIX RX 10FR X 5CM PRELOADED -,SUP-M00534320,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT ADVANIX RX 10FR X 5CM PRELOADED -,SUP-M00534330,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT BIL 10FRX9CM ADVANIX RX PRELD DUOD BND PLST 4.2MM WKG -,SUP-M00534340,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT ADVANIX RX 10FR X 9CM PRELOADED -,SUP-M00534340,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT ADVANIX RX 10FR X 12CM PRELOADED -,SUP-M00534350,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT BIL 10FRX12CM ADVANIX RX PRELD DUOD BND PLST 4.2MM WKG -,SUP-M00534350,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT ADVANIX RX 10FR X 15CM -,SUP-M00534360,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT BIL 10FRX15CM ADVANIX RX PRELD DUOD BND PLST 4.2MM WKG -,SUP-M00534360,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT BIL 8.5FRX7CM ADVANIX RX PRELD CTR BND PLST 3.2MM WKG -,SUP-M00534630,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT BIL 8.5FRX9CM ADVANIX RX PRELD CTR BND PLST 3.2MM WKG -,SUP-M00534640,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT BIL 10FRX7CM ADVANIX RX PRELD CTR BND PLST 4.2MM WKG -,SUP-M00534690,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT BIL 10FRX12CM ADVANIX RX PRELD CTR BND PLST 4.2MM WKG -,SUP-M00534710,CDM,C2625,HCPCS,278,RC,,,outpatient,,,803.65,562.555,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT ADVANTIX 5X3 PANCREATIC NO LEADING BARB SINGLE PIGTAIL -,SUP-M00537390,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT ADVANTIX 5 X 4 PANCREATIC - NO LEADING BARB -,SUP-M00537400,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT ADVANTIX 5X5 PANCREATIC NO LEADING BARB SINGLE PIGTAIL -,SUP-M00537410,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT ADVANTIX 5 X 3 PANCREATIC -LEADING BARB -,SUP-M00537430,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT ADVANTIX 5 X 4 PANCREATIC -LEADING BARB -,SUP-M00537440,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT ADVANTIX 5X3 PANCREATIC NO LEADING BARB STRAIGHT -,SUP-M00537500,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT ADVANTIX 5X5 PANCREATIC NO LEADING BARB STRAIGHT -,SUP-M00537520,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT KIT PANCREATIC 5FR X 3CM -,SUP-M00537540,CDM,C2625,HCPCS,278,RC,,,outpatient,,,1033.15,723.205,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
STENT BIL 7FRX4CM ZIMMON DBL PIGTL TAPR PE 170CM PSH CATH -,SUP-ZEBD-7-4,CDM,C2625,HCPCS,278,RC,,,outpatient,,,741.05,518.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,89.07711,1949.675,other,Non-Reimbursable Procedures,,
PAIN CONTROL DEVICE BEELINE -,SUP-UNDEFINED,CDM,C2626,HCPCS,278,RC,,,outpatient,,,758.55,530.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,196.236885,170.294475,582.5664,percent of total billed charges,,,
HC Cath Stamey Suprapubic 14,PX-27200045,CDM,C2627,HCPCS,272,RC,,,outpatient,,,306,214.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,24.890315,416.02,other,Non-Reimbursable Procedures,,
ST SUPRAPUBIC 12FRX25CM CONN TUBEX1/NDL OBTURATORX1/ 1W -,SUP-G14313,CDM,C2627,HCPCS,272,RC,,,outpatient,,,357.1,249.97,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,24.890315,416.02,other,Non-Reimbursable Procedures,,
CATHETER MALECOT DRAINAGE 14FR 30CM -,SUP-G55824,CDM,C2627,HCPCS,272,RC,,,outpatient,,,307.21,215.047,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,24.890315,416.02,other,Non-Reimbursable Procedures,,
LAWRENCE SUPRA-FOLEY 16F -,SUP-SF-S16-851,CDM,C2627,HCPCS,272,RC,,,outpatient,,,110.87,77.609,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,24.890315,416.02,other,Non-Reimbursable Procedures,,
OCCULSION BALLOON CATH 90CM BR -,SUP-590-001,CDM,C2628,HCPCS,272,RC,,,outpatient,,,4415.95,3091.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,23.64434,10635.57648,other,Non-Reimbursable Procedures,,
CATH OCL 6FRX10MM BLN ATTAIN COR -,SUP-6215,CDM,C2628,HCPCS,272,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,23.64434,10635.57648,other,Non-Reimbursable Procedures,,
CATHETER PRUITT OCCLUSION 3F 7MM 27CM -,SUP-E2103-36,CDM,C2628,HCPCS,272,RC,,,outpatient,,,1743.86,1220.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,23.64434,10635.57648,other,Non-Reimbursable Procedures,,
CATH ANG 5FR SHTH 135CM 3.75X20X1.5MM BLN ENTEER PERIPH -,SUP-ENB37520135,CDM,C2628,HCPCS,272,RC,,,outpatient,,,10273.24,7191.268,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,23.64434,10635.57648,other,Non-Reimbursable Procedures,,
CATHETER OCCLUSION ER-REBOA PLUS -,SUP-ER7232PLUS,CDM,C2628,HCPCS,272,RC,,,outpatient,,,14833.44,10383.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,23.64434,10635.57648,other,Non-Reimbursable Procedures,,
CATH HSG 5FRX30CM SIL 1ML BLN/SYR OPN TIP MRI-COND STRL SUD -,SUP-G17147,CDM,C2628,HCPCS,272,RC,,,outpatient,,,171.9,120.33,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,23.64434,10635.57648,other,Non-Reimbursable Procedures,,
B CODA-2-10.0-35-140-46 -,SUP-G23773,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2702.08,1891.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,23.64434,10635.57648,other,Non-Reimbursable Procedures,,
CODA BALLOON 46MM -,SUP-G23773,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2702.08,1891.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,23.64434,10635.57648,other,Non-Reimbursable Procedures,,
CATH URET 6.2FRX26CM LF W/HSG/SHG MLBL STYL -,SUP-J-UHSG-062026,CDM,C2628,HCPCS,272,RC,,,outpatient,,,105.32,73.724,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,23.64434,10635.57648,other,Non-Reimbursable Procedures,,
KIT CATHETER REBOA CONVENIENCE -,SUP-KT1835C,CDM,C2628,HCPCS,272,RC,,,outpatient,,,1192.61,834.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,23.64434,10635.57648,other,Non-Reimbursable Procedures,,
CATHETER BALLOON MOLDING OCCLUSION 10MM X 37MM 10FR -,SUP-MOB37,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2740.28,1918.196,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,23.64434,10635.57648,other,Non-Reimbursable Procedures,,
CATH OUTBACK RE-ENTRY 120CM -,SUP-OTB59120A,CDM,C2628,HCPCS,272,RC,,,outpatient,,,8021.16,5614.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,23.64434,10635.57648,other,Non-Reimbursable Procedures,,
Q50X STENT GRAFT BALLOON CATHETER -,SUP-Q50-100-X,CDM,C2628,HCPCS,272,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,23.64434,10635.57648,other,Non-Reimbursable Procedures,,
CATH GUID 8FR 10-46MM INFL 100CM RELIANT PU 12FR SHTH -,SUP-REL46,CDM,C2628,HCPCS,272,RC,,,outpatient,,,2500.25,1750.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,23.64434,10635.57648,other,Non-Reimbursable Procedures,,
MICRO INTRO KIT 21G 4FR 7CM TCAR - MULT'S OF 10EA -,SUP-SR-4F21G7D-MP,CDM,C2628,HCPCS,272,RC,,,outpatient,,,1167,816.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,23.64434,10635.57648,other,Non-Reimbursable Procedures,,
HSG CATHETER -,SUP-UNDEFINED,CDM,C2628,HCPCS,272,RC,,,outpatient,,,207.35,145.145,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,23.64434,10635.57648,other,Non-Reimbursable Procedures,,
CATH ABLT THRP COOL PATH MED CURL 7FR 2-5-2MM SPC 110CM QDPL -,SUP-A088047,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures,,
CATH ABLT THRP COOL PATH LRG CURL 7FR 2-5-2MM SPC 110CM QDPL -,SUP-A088049,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures,,
CATH ABLT SAFIRE BLU MED SWP DIST REACH CRV 7FR 2-5-2MM SPC -,SUP-A088106,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures,,
CATH ABLT SAFIRE BLU MED CURL DIST REACH CRV 7FR 2-5-2MM SPC -,SUP-A088107,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures,,
CATH ABLT SAFIRE BLU LRG SWP 7FR 2-5-2MM SPC LRG SWP 110CM -,SUP-A088108,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures,,
CATH ABLT SAFIRE BLU MED CURL DIST REACH CRV 7FR HGH TRQ -,SUP-A402871,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures,,
CATH ABLT SAFIRE BLU LRG CURL DIST REACH CRV HGH TRQ SHFT -,SUP-A402872,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures,,
CATH ABLT SAFIRE BLU MED CURL CRV EP DUO -,SUP-A700455,CDM,C2630,HCPCS,272,RC,,,outpatient,,,6366,4456.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures,,
CATH ABLT TACTICATH SE BI-D DF -,SUP-A-TCSE-DF,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10440.96,7308.672,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures,,
CATH ABLT TACTI SE BI-D FJ -,SUP-A-TCSE-FJ,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10440.96,7308.672,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures,,
CATH ABLT TACTIFLEX SE BID DF REF: A-TFSE-DF -,SUP-A-TFSE-DF,CDM,C2630,HCPCS,272,RC,,,outpatient,,,14387.88,10071.516,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures,,
CATH ABLT TACTIFLEX SE BID FJ REF: A-TFSE-FJ -,SUP-A-TFSE-FJ,CDM,C2630,HCPCS,272,RC,,,outpatient,,,14387.88,10071.516,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures,,
CATH ABLT THERMOCOOL SF F-J CRV 8FR 2-5-2MM SPC 115CM BIDIR -,SUP-BDI35FJRT,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7957.5,5570.25,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures,,
CATH ABLT THERMOCOOL SF B- CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131601,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures,,
CATH ABLT THERMOCOOL SF D-CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131602,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures,,
CATH ABLT THERMOCOOL SF F-CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131603,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures,,
CATH ABLT THERMOCOOL SF J-CRV 8FR 2-5-2MM ELCTRD SPC 115CM -,SUP-D131604,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7108.7,4976.09,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures,,
CATH ABLT THERMOCOOL SF CARTO XP F-TY CRV STEER UNI- DRCT -,SUP-D131803,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures,,
CATH ABLT THERMOCOOL SF CARTO XP J CRV STEER UNI- DRCT HTORQ -,SUP-D131804,CDM,C2630,HCPCS,272,RC,,,outpatient,,,10953.35,7667.345,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures,,
CATH ABLT CHILLI II STD CRV 7.5FRX2.5MM SPC 4MM TIP 110CM -,SUP-M00490310,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7151.14,5005.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures,,
CATH ABLT THRMCPL CRV 7.5FR LRG 110CM 2.5/2.5MM SPC -,SUP-M0049031K20,CDM,C2630,HCPCS,272,RC,,,outpatient,,,7151.14,5005.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures,,
CATH ABLT TACTICATH 65 MM -,SUP-PN-004 065,CDM,C2630,HCPCS,272,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures,,
CATH ABLT TACTICATH 75MM -,SUP-PN-004075,CDM,C2630,HCPCS,272,RC,,,outpatient,,,11139,7797.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,10316.10996,other,Non-Reimbursable Procedures,,
DEVICE SUTCAP 12MM OPN ACCESS -,SUP-M0068311251,CDM,C2631,HCPCS,272,RC,,,outpatient,,,2073.95,1451.765,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,536.530865,399.86,1487.02215,percent of total billed charges,,,
HC Mra- W/Dye- Upper Extremity,PX-61000005,CDM,C8934,CPT,610,RC,,,outpatient,,,2034,1423.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,1724.0184,other,Non-Reimbursable Procedures,,
HC Mra- W/O Dye- Upper Extr,PX-61000006,CDM,C8935,CPT,610,RC,,,outpatient,,,1745,1221.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,267.439885,1479.062,other,Non-Reimbursable Procedures,,
HC Mra- W/O&W/Dye- Upper Extr,PX-61000007,CDM,C8936,CPT,610,RC,,,outpatient,,,3036,2125.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,2573.3136,other,Non-Reimbursable Procedures,,
HC Cad Breast MRI,PX-61000089,CDM,C8937,HCPCS,610,RC,,,outpatient,,,344,240.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,77.228,836,other,Non-Reimbursable Procedures,,
BUPIVACAINE-MELOXICAM ER 400-12 MG/14ML IJ SOLN,RX-155306,CDM,C9088,HCPCS,636,RC,47426-0301-02,NDC,outpatient,14,ML,1200.46,840.322,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.71,921.95328,other,Non-Reimbursable Procedures,,
PANTOPRAZOLE SODIUM 40 MG IV SOLR,RX-26226,CDM,C9113,HCPCS,636,RC,00008-0923-51,NDC,outpatient,1,UN,8.55,5.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.211885,1.69273,416.02,percent of total billed charges,,,
PANTOPRAZOLE SODIUM 40 MG IV SOLR,RX-26226,CDM,C9113,HCPCS,636,RC,55150-0202-00,NDC,outpatient,1,UN,7.54,5.278,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.950598,1.69273,416.02,percent of total billed charges,,,
PANTOPRAZOLE SODIUM 40 MG IV SOLR,RX-26226,CDM,C9113,HCPCS,636,RC,00008-0923-60,NDC,outpatient,1,UN,8.55,5.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.211885,1.69273,416.02,percent of total billed charges,,,
PANTOPRAZOLE SODIUM 40 MG IV SOLR,RX-26226,CDM,C9113,HCPCS,636,RC,55150-0202-10,NDC,outpatient,1,UN,7.54,5.278,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.950598,1.69273,416.02,percent of total billed charges,,,
PANTOPRAZOLE SODIUM 40 MG IV SOLR,RX-26226,CDM,C9113,HCPCS,636,RC,00008-0923-55,NDC,outpatient,1,UN,8.55,5.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.211885,1.69273,416.02,percent of total billed charges,,,
COCAINE HCL 4 % EX SOLN,RX-1792,CDM,C9143,HCPCS,636,RC,70839-0362-04,NDC,outpatient,4,ML,1089.63,762.741,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,281.887281,1.4,836.83584,percent of total billed charges,,,
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-01,NDC,outpatient,50,ML,360.88,252.616,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.39,416.02,other,Non-Reimbursable Procedures,,
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-10,NDC,outpatient,50,ML,344.88,241.416,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,,,,3.39,416.02,other,Non-Reimbursable Procedures,,
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-10,NDC,outpatient,50,ML,360.88,252.616,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.39,416.02,other,Non-Reimbursable Procedures,,
CLEVIDIPINE BUTYRATE 0.5 MG/ML IV EMUL WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4081068,CDM,C9248,HCPCS,636,RC,10122-0610-01,NDC,outpatient,50,ML,344.88,241.416,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,,,,3.39,416.02,other,Non-Reimbursable Procedures,,
LACOSAMIDE 200 MG/20ML IV SOLN,RX-96972,CDM,C9254,HCPCS,636,RC,72603-0140-02,NDC,outpatient,20,ML,100.4,70.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.31,416.02,other,Non-Reimbursable Procedures,,
LACOSAMIDE 200 MG/20ML IV SOLN,RX-96972,CDM,C9254,HCPCS,636,RC,00131-1810-67,NDC,outpatient,20,ML,278.22,194.754,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.31,416.02,other,Non-Reimbursable Procedures,,
LACOSAMIDE 200 MG/20ML IV SOLN,RX-96972,CDM,C9254,HCPCS,636,RC,72603-0140-01,NDC,outpatient,20,ML,100.4,70.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.31,416.02,other,Non-Reimbursable Procedures,,
BUPIVACAINE LIPOSOME 1.3 % IJ SUSP,RX-112781,CDM,C9290,HCPCS,636,RC,65250-0266-09,NDC,outpatient,20,ML,1495.03,1046.521,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.36,1148.18304,other,Non-Reimbursable Procedures,,
BUPIVACAINE LIPOSOME 1.3 % IJ SUSP,RX-112781,CDM,C9290,HCPCS,636,RC,65250-0266-20,NDC,outpatient,20,ML,1495.03,1046.521,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.36,1148.18304,other,Non-Reimbursable Procedures,,
CAP NERVE AXOGEN 2MM X 15MM -,SUP-AGT215,CDM,C9353,HCPCS,278,RC,,,outpatient,,,6688.54,4681.978,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,5136.79872,other,Non-Reimbursable Procedures,,
CAP NERVE AXOGEN 3MM X 15MM -,SUP-AGT315,CDM,C9353,HCPCS,278,RC,,,outpatient,,,6688.54,4681.978,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,5136.79872,other,Non-Reimbursable Procedures,,
CAP NERVE AXOGEN 4 X 15 -,SUP-AGT415,CDM,C9353,HCPCS,278,RC,,,outpatient,,,6688.54,4681.978,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,5136.79872,other,Non-Reimbursable Procedures,,
NEUROMATRIX 6.0MM DIAMETER 2.5CM LENGTH -,SUP-CNC6025,CDM,C9355,HCPCS,278,RC,,,outpatient,,,5756.22,4029.354,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,182.24,5164.04736,other,Non-Reimbursable Procedures,,
NEUROFLEX NERVE 4MM X 2.5CM -,SUP-CNCF4025,CDM,C9355,HCPCS,278,RC,,,outpatient,,,6724.02,4706.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,182.24,5164.04736,other,Non-Reimbursable Procedures,,
NEUROFLEX NERVE 6MM X 2.5CM -,SUP-CNCF6025,CDM,C9355,HCPCS,278,RC,,,outpatient,,,6724.02,4706.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,182.24,5164.04736,other,Non-Reimbursable Procedures,,
MESH SURGIMEND 5X6CM 1.0MM -,SUP-606-001-002,CDM,C9358,HCPCS,636,RC,,,outpatient,,,2525.06,1767.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,24858.15552,other,Non-Reimbursable Procedures,,
MESH SURGIMEND 5X6CM 1.0MM - C -,SUP-606-001-002,CDM,C9358,HCPCS,636,RC,,,outpatient,,,2525.06,1767.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,24858.15552,other,Non-Reimbursable Procedures,,
MESH SURGIMEND BOVINE 10 X 15CM -,SUP-606-001-006,CDM,C9358,HCPCS,636,RC,,,outpatient,,,9819.33,6873.531,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,24858.15552,other,Non-Reimbursable Procedures,,
IMPLANT NDNTR COLL 4X7CM SRGMND RECT -,SUP-606-001-013,CDM,C9358,HCPCS,636,RC,,,outpatient,,,2616.64,1831.648,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,24858.15552,other,Non-Reimbursable Procedures,,
SURGIMEND PRS 10CM X 20CM RECT -,SUP-606-004-102,CDM,C9358,HCPCS,636,RC,,,outpatient,,,16238.36,11366.852,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,24858.15552,other,Non-Reimbursable Procedures,,
MESH SURGIMEND 8CM X 16CM SEMI OVAL FENESTRAED -,SUP-606-004-103,CDM,C9358,HCPCS,636,RC,,,outpatient,,,10392.54,7274.778,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,24858.15552,other,Non-Reimbursable Procedures,,
GRAFT FTL BVN NDNTR COLL MATRIX 20X30CM SRGMND 2MM SHT RECT -,SUP-606-200-017,CDM,C9358,HCPCS,636,RC,,,outpatient,,,27546.57,19282.599,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,24858.15552,other,Non-Reimbursable Procedures,,
MESH SURGIMEND 3.0 13 X 25CM -,SUP-606-300-009,CDM,C9358,HCPCS,636,RC,,,outpatient,,,26387.33,18471.131,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,24858.15552,other,Non-Reimbursable Procedures,,
MESH SURGIMEND 20 X 30 X 3MM -,SUP-606-300-017,CDM,C9358,HCPCS,636,RC,,,outpatient,,,32367.39,22657.173,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,24858.15552,other,Non-Reimbursable Procedures,,
GENTRIX SURGICAL MATRIX HIATAL 7.5 X 6CM -,SUP-HIAT0706,CDM,C9358,HCPCS,636,RC,,,outpatient,,,4704.78,3293.346,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,24858.15552,other,Non-Reimbursable Procedures,,
MESH SURGIMEND 3.0 10 X 15CM -,SUP-603-300-006,CDM,C9360,HCPCS,636,RC,,,outpatient,,,12178.79,8525.153,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,41430.25152,other,Non-Reimbursable Procedures,,
MESH SURGIMEND 10 X 15CM 2.0 -,SUP-606-200-006,CDM,C9360,HCPCS,636,RC,,,outpatient,,,10364.84,7255.388,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,41430.25152,other,Non-Reimbursable Procedures,,
IMPLANT NDNTR COLL 13X20CM SRGMND RECT -,SUP-606-200-009,CDM,C9360,HCPCS,636,RC,,,outpatient,,,22457.19,15720.033,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,41430.25152,other,Non-Reimbursable Procedures,,
MESH SURGIMEND 25X40 X 3.0MM -,SUP-606-300-016,CDM,C9360,HCPCS,636,RC,,,outpatient,,,53945.64,37761.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,41430.25152,other,Non-Reimbursable Procedures,,
NEUROMEND12MM X 2.5CM -,SUP-CNW12025,CDM,C9361,HCPCS,636,RC,,,outpatient,,,6724.07,4706.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,177.26,5164.08576,other,Non-Reimbursable Procedures,,
NEUROMEND 4MM X 2.25CM -,SUP-CNW4025,CDM,C9361,HCPCS,636,RC,,,outpatient,,,6464.93,4525.451,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,177.26,5164.08576,other,Non-Reimbursable Procedures,,
IMPLANT BIO TISS 3X8CM 3D HYDR PRCN COLL MATRIX PERMACOL SHT -,SUP-P100308,CDM,C9364,HCPCS,636,RC,,,outpatient,,,2987.95,2091.565,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,18.39,18739.8144,other,Non-Reimbursable Procedures,,
MESH PERMACOL 5X10CM 1.0MM -,SUP-P100510,CDM,C9364,HCPCS,636,RC,,,outpatient,,,4648.41,3253.887,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,18.39,18739.8144,other,Non-Reimbursable Procedures,,
IMPLANT BIO TISS 10X10CM 3D HYDR PRCN DERM COLL PERMACOL SHT -,SUP-P101010,CDM,C9364,HCPCS,636,RC,,,outpatient,,,9294.36,6506.052,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,18.39,18739.8144,other,Non-Reimbursable Procedures,,
IMPLANT BIO TISS 15X20CM 3D HYDR PRCN COLL MATRIX PERMACOL -,SUP-P151520,CDM,C9364,HCPCS,636,RC,,,outpatient,,,24400.8,17080.56,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,18.39,18739.8144,other,Non-Reimbursable Procedures,,
SARILUMAB 200 MG/1.14ML SC SOAJ,RX-143091,CDM,C9399,HCPCS,636,RC,00024-5922-01,NDC,outpatient,1.14,ML,5813.71,4069.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1504.006777,399.86,4927.700596,percent of total billed charges,,,
CANGRELOR TETRASODIUM 50 MG IV SOLR,RX-131579,CDM,C9460,HCPCS,636,RC,10122-0620-01,NDC,outpatient,1,UN,2428.93,1700.251,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,18.2,1865.41824,other,Non-Reimbursable Procedures,,
CANGRELOR TETRASODIUM 50 MG IV SOLR,RX-131579,CDM,C9460,HCPCS,636,RC,10122-0620-10,NDC,outpatient,1,UN,2428.93,1700.251,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,18.2,1865.41824,other,Non-Reimbursable Procedures,,
HC Perc Drug-El Cor Stent Sing,PX-48100003,CDM,C9600,CPT,481,RC,,,outpatient,,,32584,22808.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8429.4808,399.86,25024.512,percent of total billed charges,,,
HC Perc Drug-El Cor Stent Bran,PX-48100004,CDM,C9601,CPT,481,RC,,,outpatient,,,33887,23720.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,26025.216,other,Non-Reimbursable Procedures,,
HC Perc D-E Cor Stent Ather S,PX-48100005,CDM,C9602,CPT,481,RC,,,outpatient,,,33887,23720.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8766.5669,399.86,26793.51305,percent of total billed charges,,,
HC Perc D-E Cor Revasc T Cabg S,PX-48100007,CDM,C9604,CPT,481,RC,,,outpatient,,,33887,23720.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8766.5669,399.86,26025.216,percent of total billed charges,,,
HC Perc D-E Cor Revasc T Cabg B,PX-48100008,CDM,C9605,CPT,481,RC,,,outpatient,,,33887,23720.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8766.5669,399.86,26025.216,percent of total billed charges,,,
HC Perc D-E Cor Revasc Chro Sin,PX-48100010,CDM,C9607,CPT,481,RC,,,outpatient,,,33887,23720.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8766.5669,399.86,26793.51305,percent of total billed charges,,,
HC Perc D-E Cor Revasc Chro Add,PX-48100011,CDM,C9608,CPT,481,RC,,,outpatient,,,33887,23720.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8766.5669,399.86,26025.216,percent of total billed charges,,,
HC Admin Influenza Virus Vac,PX-77100001,CDM,G0008,CPT,771,RC,,,outpatient,,,193,135.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,49.9291,19.95,416.02,percent of total billed charges,,,
HC Immuniz-Admin-Each Addl,PX-77100005,CDM,G0008,CPT,771,RC,,,outpatient,,,215,150.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,55.6205,19.95,416.02,percent of total billed charges,,,
HC Admin Pneumococcal Vaccine,PX-77100002,CDM,G0009,CPT,771,RC,,,outpatient,,,193,135.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,49.9291,19.95,416.02,percent of total billed charges,,,
HC Immuniz-Admin-Each Addl,PX-77100006,CDM,G0009,CPT,771,RC,,,outpatient,,,215,150.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,55.6205,19.95,416.02,percent of total billed charges,,,
HC Admin Hepatitis B Vaccine,PX-77100003,CDM,G0010,CPT,771,RC,,,outpatient,,,193,135.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,49.9291,19.95,416.02,percent of total billed charges,,,
HC Immuniz-Admin-Each Addl,PX-77100007,CDM,G0010,CPT,771,RC,,,outpatient,,,215,150.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,55.6205,19.95,416.02,percent of total billed charges,,,
HC Inject for Sacroiliac Joint,PX-36900022,CDM,G0259,CPT,369,RC,,,outpatient,,,827,578.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,213.9449,185.6615,1592,percent of total billed charges,,,
HC Inj for Sacroiliac Jt Anesth,PX-36900023,CDM,G0260,CPT,369,RC,,,outpatient,,,1722,1205.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,445.4814,386.589,2141,percent of total billed charges,,,
HC Occlusive Device in Vein Art,PX-48100001,CDM,G0269,CPT,481,RC,,,outpatient,,,202,141.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,45.349,1592,other,Non-Reimbursable Procedures,,
HC Iliac Art Angio-Cardiac Cath,PX-32000003,CDM,G0278,CPT,320,RC,,,outpatient,,,113,79.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,25.3685,416.02,other,Non-Reimbursable Procedures,,
HC Elec Stim Other Than Wound,PX-42000003,CDM,G0283,CPT,420,RC,,,outpatient,,,123,86.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,31.8201,12.01,416.02,percent of total billed charges,,,
HC Observation Time,PX-76200003,CDM,G0378,CPT,762,RC,,,outpatient,,,101,70.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,26.1287,22.6745,6652,percent of total billed charges,,,
HC Observation Carve-Out,PX-76200004,CDM,G0378,CPT,762,RC,,,outpatient,,,101,70.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,26.1287,22.6745,6652,percent of total billed charges,,,
HC Direct Refer Hospital Observ,PX-76200001,CDM,G0379,CPT,762,RC,,,outpatient,,,1442,1009.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,373.0454,104.83,6652,percent of total billed charges,,,
HC PR Trauma Respons W/Hosp Criti,PX-68200001,CDM,G0390,HCPCS,682,RC,,,outpatient,,,10370,7259,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7964.16,other,Non-Reimbursable Procedures,,
HC Full Trauma,PX-68200002,CDM,G0390,HCPCS,682,RC,,,outpatient,,,10370,7259,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7964.16,other,Non-Reimbursable Procedures,,
HC Partial Trauma,PX-68200003,CDM,G0390,HCPCS,682,RC,,,outpatient,,,7029,4920.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,7964.16,other,Non-Reimbursable Procedures,,
HC Mod Sedat Endo Service >5yrs,PX-37000025,CDM,G0500,HCPCS,370,RC,,,outpatient,,,240,168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,53.88,416.02,other,Non-Reimbursable Procedures,,
HC Inter Devc Remote 30d,PX-48000092,CDM,G2066,HCPCS,480,RC,,,outpatient,,,118,82.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,30.5266,26.491,416.02,percent of total billed charges,,,
ABATACEPT 250 MG IV SOLR,RX-70287,CDM,J0129,HCPCS,636,RC,00003-2187-13,NDC,outpatient,1,UN,3823.57,2676.499,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,989.157559,43.27,2936.50176,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0131,HCPCS,636,RC,67457-0940-10,NDC,outpatient,100,ML,44.93,31.451,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.623391,0.04,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0131,HCPCS,636,RC,36000-0306-60,NDC,outpatient,100,ML,53.83,37.681,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.925821,0.04,416.02,percent of total billed charges,,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0131,HCPCS,636,RC,67457-0940-10,NDC,outpatient,100,ML,44.93,31.451,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.623391,0.04,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0131,HCPCS,636,RC,67457-0940-10,NDC,outpatient,100,ML,44.93,31.451,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.623391,0.04,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0131,HCPCS,636,RC,36000-0306-60,NDC,outpatient,100,ML,53.83,37.681,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.925821,0.04,416.02,percent of total billed charges,,,
ACETYLCYSTEINE 200 MG/ML IV SOLN,RX-38303,CDM,J0132,HCPCS,636,RC,00574-0805-00,NDC,outpatient,30,ML,278.49,194.943,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,72.045363,0.57,416.02,percent of total billed charges,,,
ACETYLCYSTEINE 200 MG/ML IV SOLN,RX-38303,CDM,J0132,HCPCS,636,RC,00574-0805-30,NDC,outpatient,30,ML,278.49,194.943,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,72.045363,0.57,416.02,percent of total billed charges,,,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,55150-0155-20,NDC,outpatient,20,ML,19.14,13.398,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.951518,0.02,416.02,percent of total billed charges,,,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-09,NDC,outpatient,20,ML,18.52,12.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.791124,0.02,416.02,percent of total billed charges,,,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-20,NDC,outpatient,20,ML,18.52,12.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.791124,0.02,416.02,percent of total billed charges,,,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-10,NDC,outpatient,10,ML,8.9,6.23,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.30243,0.02,416.02,percent of total billed charges,,,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,55150-0154-10,NDC,outpatient,10,ML,11.47,8.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.967289,0.02,416.02,percent of total billed charges,,,
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,RX-23128,CDM,J0133,HCPCS,636,RC,63323-0325-03,NDC,outpatient,10,ML,8.9,6.23,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.30243,0.02,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,40.48,28.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.472176,0.04,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,24.48,17.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,6.332976,0.04,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,40.48,28.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.472176,0.04,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,24.48,17.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,6.332976,0.04,416.02,percent of total billed charges,,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,40.48,28.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.472176,0.04,416.02,percent of total billed charges,,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,24.48,17.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,6.332976,0.04,416.02,percent of total billed charges,,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,40.48,28.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.472176,0.04,416.02,percent of total billed charges,,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,24.48,17.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,6.332976,0.04,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,40.48,28.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.472176,0.04,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-00,NDC,outpatient,100,ML,24.48,17.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,6.332976,0.04,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,40.48,28.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.472176,0.04,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0134,HCPCS,636,RC,63323-0434-41,NDC,outpatient,100,ML,24.48,17.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,6.332976,0.04,416.02,percent of total billed charges,,,
ADALIMUMAB 40 MG/0.8ML SC PSKT,RX-129739,CDM,J0135,HCPCS,636,RC,00074-3799-02,NDC,outpatient,1,UN,9266.62,6486.634,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2397.274594,336.23,7116.76416,percent of total billed charges,,,
ADALIMUMAB 40 MG/0.8ML SC PNKT,RX-129742,CDM,J0135,HCPCS,636,RC,00074-4339-02,NDC,outpatient,1,UN,9266.62,6486.634,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2397.274594,336.23,7116.76416,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,23.59,16.513,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,6.102733,0.05,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,39.59,27.713,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.241933,0.05,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0136,HCPCS,636,RC,00264-4100-95,NDC,outpatient,100,ML,39.59,27.713,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.241933,0.05,416.02,percent of total billed charges,,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,23.59,16.513,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,6.102733,0.05,416.02,percent of total billed charges,,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,39.59,27.713,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.241933,0.05,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,23.59,16.513,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,6.102733,0.05,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0136,HCPCS,636,RC,00264-4100-95,NDC,outpatient,100,ML,39.59,27.713,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.241933,0.05,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0136,HCPCS,636,RC,00264-4100-90,NDC,outpatient,100,ML,39.59,27.713,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.241933,0.05,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,34.69,24.283,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.974303,0.05,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IV SOLN,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,34.69,24.283,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.974303,0.05,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,18.69,13.083,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,4.835103,0.05,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-108021,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,18.69,13.083,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,4.835103,0.05,416.02,percent of total billed charges,,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,34.69,24.283,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.974303,0.05,416.02,percent of total billed charges,,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,18.69,13.083,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,4.835103,0.05,416.02,percent of total billed charges,,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,34.69,24.283,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.974303,0.05,416.02,percent of total billed charges,,,
ACETAMINOPHEN IV PEDI SYRINGE 10 MG/ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080985,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,18.69,13.083,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,4.835103,0.05,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,34.69,24.283,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.974303,0.05,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-10,NDC,outpatient,100,ML,18.69,13.083,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,4.835103,0.05,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,34.69,24.283,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.974303,0.05,416.02,percent of total billed charges,,,
ACETAMINOPHEN 10 MG/ML IVPB IN VIA-FLEX BAG|DISCARDED DRUG NOT ADMINISTERED,RX-4080986,CDM,J0137,HCPCS,636,RC,00143-9386-01,NDC,outpatient,100,ML,18.69,13.083,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,4.835103,0.05,416.02,percent of total billed charges,,,
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,RX-15330,CDM,J0153,HCPCS,636,RC,55150-0193-01,NDC,outpatient,30,ML,91.83,64.281,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,23.756421,0.4,631.24992,percent of total billed charges,,,
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,RX-15330,CDM,J0153,HCPCS,636,RC,16714-0997-01,NDC,outpatient,30,ML,109.72,76.804,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,28.384564,0.4,631.24992,percent of total billed charges,,,
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,RX-15330,CDM,J0153,HCPCS,636,RC,67457-0857-30,NDC,outpatient,30,ML,821.94,575.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,212.635878,0.4,631.24992,percent of total billed charges,,,
ADENOSINE 6 MG/2ML IV SOLN,RX-38703,CDM,J0153,HCPCS,636,RC,67457-0855-02,NDC,outpatient,2,ML,24.68,17.276,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.384716,0.4,631.24992,percent of total billed charges,,,
ADENOSINE 6 MG/2ML IV SOLN,RX-38703,CDM,J0153,HCPCS,636,RC,67457-0855-00,NDC,outpatient,2,ML,24.68,17.276,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.384716,0.4,631.24992,percent of total billed charges,,,
EPINEPHRINE 0.15 MG/0.3ML IJ SOAJ,RX-124855,CDM,J0171,HCPCS,636,RC,49502-0101-01,NDC,outpatient,1,UN,616.75,431.725,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,159.553225,0.73,960.94464,percent of total billed charges,,,
EPINEPHRINE 0.15 MG/0.3ML IJ SOAJ,RX-124855,CDM,J0171,HCPCS,636,RC,49502-0101-02,NDC,outpatient,1,UN,616.75,431.725,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,159.553225,0.73,960.94464,percent of total billed charges,,,
EPINEPHRINE 0.15 MG/0.3ML IJ SOAJ,RX-124855,CDM,J0171,HCPCS,636,RC,49502-0501-02,NDC,outpatient,1,UN,1251.23,875.861,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,323.693201,0.73,960.94464,percent of total billed charges,,,
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,00115-1694-30,NDC,outpatient,1,UN,506.88,354.816,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,131.129856,0.73,960.94464,percent of total billed charges,,,
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,49502-0500-02,NDC,outpatient,1,UN,1251.23,875.861,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,323.693201,0.73,960.94464,percent of total billed charges,,,
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,00115-1694-49,NDC,outpatient,1,UN,506.88,354.816,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,131.129856,0.73,960.94464,percent of total billed charges,,,
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,49502-0102-01,NDC,outpatient,1,UN,616.75,431.725,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,159.553225,0.73,960.94464,percent of total billed charges,,,
EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ,RX-124857,CDM,J0171,HCPCS,636,RC,49502-0102-02,NDC,outpatient,1,UN,616.75,431.725,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,159.553225,0.73,960.94464,percent of total billed charges,,,
EPINEPHRINE INFUSION PREMIX 1 MG IN 250 ML,RX-4080061,CDM,J0171,HCPCS,636,RC,99999-0001-65,NDC,outpatient,250,ML,83.79,58.653,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,21.676473,0.73,960.94464,percent of total billed charges,,,
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER,RX-4080099,CDM,J0171,HCPCS,636,RC,42023-0159-25,NDC,outpatient,1,ML,57.57,40.299,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,14.893359,0.73,960.94464,percent of total billed charges,,,
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER,RX-4080099,CDM,J0171,HCPCS,636,RC,42023-0159-01,NDC,outpatient,1,ML,57.57,40.299,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,14.893359,0.73,960.94464,percent of total billed charges,,,
EPINEPHRINE HCL 0.1 MG/ML IJ WRAPPER,RX-4080103,CDM,J0171,HCPCS,636,RC,76329-3318-01,NDC,outpatient,10,ML,42.5,29.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.99475,0.73,960.94464,percent of total billed charges,,,
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER FOR CODE NARRATOR,RX-4081384,CDM,J0171,HCPCS,636,RC,42023-0159-01,NDC,outpatient,1,ML,57.57,40.299,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,14.893359,0.73,960.94464,percent of total billed charges,,,
EPINEPHRINE HCL 1 MG/ML IJ WRAPPER FOR CODE NARRATOR,RX-4081384,CDM,J0171,HCPCS,636,RC,42023-0159-25,NDC,outpatient,1,ML,57.57,40.299,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,14.893359,0.73,960.94464,percent of total billed charges,,,
EPINEPHRINE PF 1 MG/ML IJ SOLN,RX-140555,CDM,J0173,HCPCS,636,RC,54288-0103-01,NDC,outpatient,1,ML,35.98,25.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.308026,1.61,416.02,percent of total billed charges,,,
EPINEPHRINE PF 1 MG/ML IJ SOLN,RX-140555,CDM,J0173,HCPCS,636,RC,54288-0103-10,NDC,outpatient,1,ML,35.98,25.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.308026,1.61,416.02,percent of total billed charges,,,
AGALSIDASE BETA 35 MG IV SOLR,RX-35775,CDM,J0180,HCPCS,636,RC,58468-0040-01,NDC,outpatient,1,UN,20575.06,14402.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5322.768022,215.38,15801.64608,percent of total billed charges,,,
AGALSIDASE BETA 5 MG IV SOLR,RX-38494,CDM,J0180,HCPCS,636,RC,58468-0041-01,NDC,outpatient,1,UN,2938.8,2057.16,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,760.26756,215.38,15801.64608,percent of total billed charges,,,
ALGLUCOSIDASE ALFA 50 MG IV SOLR,RX-76353,CDM,J0221,HCPCS,636,RC,58468-0160-01,NDC,outpatient,1,UN,2661.83,1863.281,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,688.615421,194.92,2044.28544,percent of total billed charges,,,
REMDESIVIR 100 MG IV SOLR,RX-150611,CDM,J0248,HCPCS,636,RC,61958-2901-02,NDC,outpatient,1,UN,1654.57,1158.199,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,428.037259,5.51,1270.70976,percent of total billed charges,,,
ALPHA1-PROTEINASE INHIBITOR 1000 MG/20ML IV SOLN,RX-141646,CDM,J0256,HCPCS,636,RC,13533-0705-11,NDC,outpatient,1,UN,1462.8,1023.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,378.42636,4.88,1606.272,percent of total billed charges,,,
ALPHA1-PROTEINASE INHIBITOR 1000 MG/20ML IV SOLN,RX-141646,CDM,J0256,HCPCS,636,RC,13533-0705-01,NDC,outpatient,1,UN,1462.8,1023.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,378.42636,4.88,1606.272,percent of total billed charges,,,
ZEMAIRA 1000 MG IV SOLR,RX-36564,CDM,J0256,HCPCS,636,RC,00053-7201-02,NDC,outpatient,1,UN,2091.5,1464.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,541.07105,4.88,1606.272,percent of total billed charges,,,
ALPROSTADIL 500 MCG/ML IJ SOLN,RX-9001,CDM,J0270,HCPCS,636,RC,00009-3169-06,NDC,outpatient,1,ML,564.52,395.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,146.041324,2.98,4260,percent of total billed charges,,,
ALPROSTADIL 500 MCG/ML IJ SOLN,RX-9001,CDM,J0270,HCPCS,636,RC,00009-3169-01,NDC,outpatient,1,ML,564.52,395.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,146.041324,2.98,4260,percent of total billed charges,,,
AMIKACIN SULFATE 500 MG/2ML IJ SOLN,RX-108131,CDM,J0278,HCPCS,636,RC,23155-0290-31,NDC,outpatient,2,ML,17.6,12.32,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.55312,0.77,416.02,percent of total billed charges,,,
AMIKACIN SULFATE 500 MG/2ML IJ SOLN,RX-108131,CDM,J0278,HCPCS,636,RC,23155-0290-41,NDC,outpatient,2,ML,17.6,12.32,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.55312,0.77,416.02,percent of total billed charges,,,
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5922-16,NDC,outpatient,20,ML,38.54,26.978,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.970298,4.51,416.02,percent of total billed charges,,,
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5921-16,NDC,outpatient,10,ML,61.06,42.742,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15.796222,4.51,416.02,percent of total billed charges,,,
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5922-01,NDC,outpatient,20,ML,38.54,26.978,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.970298,4.51,416.02,percent of total billed charges,,,
AMINOPHYLLINE 25 MG/ML IV SOLN,RX-407,CDM,J0280,HCPCS,636,RC,00409-5921-01,NDC,outpatient,10,ML,61.06,42.742,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15.796222,4.51,416.02,percent of total billed charges,,,
AMIODARONE HCL IN DEXTROSE 900-5 MG/500ML-% IV SOLN,RX-135815,CDM,J0282,HCPCS,636,RC,70092-1005-38,NDC,outpatient,500,ML,218.97,153.279,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,56.647539,0.46,416.02,percent of total billed charges,,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-01,NDC,outpatient,3,ML,9.41,6.587,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.434367,0.46,416.02,percent of total billed charges,,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,67457-0153-03,NDC,outpatient,3,ML,16.55,11.585,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.281485,0.46,416.02,percent of total billed charges,,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,67457-0153-18,NDC,outpatient,18,ML,55.43,38.801,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,14.339741,0.46,416.02,percent of total billed charges,,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-09,NDC,outpatient,9,ML,22.43,15.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.802641,0.46,416.02,percent of total billed charges,,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,67457-0153-00,NDC,outpatient,3,ML,16.55,11.585,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.281485,0.46,416.02,percent of total billed charges,,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,00143-9875-25,NDC,outpatient,3,ML,3.58,2.506,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.926146,0.46,416.02,percent of total billed charges,,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-02,NDC,outpatient,9,ML,22.43,15.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.802641,0.46,416.02,percent of total billed charges,,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,00143-9875-01,NDC,outpatient,3,ML,3.58,2.506,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.926146,0.46,416.02,percent of total billed charges,,,
AMIODARONE HCL 150 MG/3ML IV WRAPPER,RX-4080147,CDM,J0282,HCPCS,636,RC,63323-0616-03,NDC,outpatient,3,ML,9.41,6.587,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.434367,0.46,416.02,percent of total billed charges,,,
AMPHOTERICIN B 50 MG IV SOLR,RX-464,CDM,J0285,HCPCS,636,RC,39822-1055-05,NDC,outpatient,1,UN,155.22,108.654,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,40.155414,34.84689,416.02,percent of total billed charges,,,
AMPHOTERICIN B LIPID 5 MG/ML IV SUSP,RX-22981,CDM,J0287,HCPCS,636,RC,57665-0101-41,NDC,outpatient,20,ML,431.74,302.218,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,111.691138,11.13,416.02,percent of total billed charges,,,
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,RX-21900,CDM,J0289,HCPCS,636,RC,00469-3051-30,NDC,outpatient,1,UN,1268.66,888.062,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,328.202342,23.33,974.33088,percent of total billed charges,,,
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,RX-21900,CDM,J0289,HCPCS,636,RC,62756-0233-01,NDC,outpatient,1,UN,328.95,230.265,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,85.099365,23.33,974.33088,percent of total billed charges,,,
AMPICILLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080940,CDM,J0290,HCPCS,636,RC,25021-0136-10,NDC,outpatient,1,UN,10.62,7.434,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.747394,0.78,416.02,percent of total billed charges,,,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,65219-0016-01,NDC,outpatient,1,UN,5.52,3.864,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.428024,0.78,416.02,percent of total billed charges,,,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,00781-3407-95,NDC,outpatient,1,UN,4.29,3.003,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.109823,0.78,416.02,percent of total billed charges,,,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,67850-0024-00,NDC,outpatient,1,UN,8.62,6.034,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.229994,0.78,416.02,percent of total billed charges,,,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,67850-0024-10,NDC,outpatient,1,UN,8.62,6.034,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.229994,0.78,416.02,percent of total billed charges,,,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,65219-0016-10,NDC,outpatient,1,UN,5.52,3.864,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.428024,0.78,416.02,percent of total billed charges,,,
AMPICILLIN SODIUM 500 MG IV SOLR (100 MG/ML),RX-4081479,CDM,J0290,HCPCS,636,RC,00781-3407-78,NDC,outpatient,1,UN,4.29,3.003,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.109823,0.78,416.02,percent of total billed charges,,,
AMPICILLIN SODIUM 1 G IJ SOLR,RX-469,CDM,J0290,HCPCS,636,RC,25021-0136-10,NDC,outpatient,1,UN,10.62,7.434,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.747394,0.78,416.02,percent of total billed charges,,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,25021-0137-20,NDC,outpatient,1,UN,16.54,11.578,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.278898,0.78,416.02,percent of total billed charges,,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,55150-0114-20,NDC,outpatient,1,UN,13.5,9.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.49245,0.78,416.02,percent of total billed charges,,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,65219-0020-23,NDC,outpatient,1,UN,32.57,22.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.425859,0.78,416.02,percent of total billed charges,,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,72485-0422-10,NDC,outpatient,1,UN,18.51,12.957,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.788537,0.78,416.02,percent of total billed charges,,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,44567-0103-10,NDC,outpatient,1,UN,45.23,31.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.701001,0.78,416.02,percent of total billed charges,,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,65219-0020-03,NDC,outpatient,1,UN,32.57,22.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.425859,0.78,416.02,percent of total billed charges,,,
AMPICILLIN SODIUM 2 G IJ SOLR,RX-472,CDM,J0290,HCPCS,636,RC,72485-0422-01,NDC,outpatient,1,UN,18.51,12.957,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.788537,0.78,416.02,percent of total billed charges,,,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,00781-3407-78,NDC,outpatient,1,UN,4.29,3.003,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.109823,0.78,416.02,percent of total billed charges,,,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,65219-0016-01,NDC,outpatient,1,UN,5.52,3.864,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.428024,0.78,416.02,percent of total billed charges,,,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,67850-0024-00,NDC,outpatient,1,UN,8.62,6.034,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.229994,0.78,416.02,percent of total billed charges,,,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,67850-0024-10,NDC,outpatient,1,UN,8.62,6.034,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.229994,0.78,416.02,percent of total billed charges,,,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,00781-3407-95,NDC,outpatient,1,UN,4.29,3.003,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.109823,0.78,416.02,percent of total billed charges,,,
AMPICILLIN SODIUM 500 MG IJ SOLR,RX-474,CDM,J0290,HCPCS,636,RC,65219-0016-10,NDC,outpatient,1,UN,5.52,3.864,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.428024,0.78,416.02,percent of total billed charges,,,
AMPICILLIN-SULBACTAM SODIUM 15 (10-5) G IV SOLR,RX-105616,CDM,J0295,HCPCS,636,RC,00049-0024-28,NDC,outpatient,1,UN,84.11,58.877,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,21.759257,1.600685,416.02,percent of total billed charges,,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IV SOLR,RX-27283,CDM,J0295,HCPCS,636,RC,00409-2987-03,NDC,outpatient,1,UN,24.87,17.409,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.433869,1.600685,416.02,percent of total billed charges,,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IV SOLR,RX-27283,CDM,J0295,HCPCS,636,RC,00409-2987-23,NDC,outpatient,1,UN,24.87,17.409,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.433869,1.600685,416.02,percent of total billed charges,,,
AMPICILLIN-SULBACTAM 3 G 100 ML ADD-VANTAGE BAG,RX-400006,CDM,J0295,HCPCS,636,RC,99999-0003-15,NDC,outpatient,100,ML,43.51,30.457,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.256037,1.600685,416.02,percent of total billed charges,,,
AMPICILLIN-SULBACTAM 3 G 100 ML IVPB BATCHED,RX-4081206,CDM,J0295,HCPCS,636,RC,99999-0003-29,NDC,outpatient,100,ML,29.73,20.811,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.691151,1.600685,416.02,percent of total billed charges,,,
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR,RX-9083,CDM,J0295,HCPCS,636,RC,71288-0031-20,NDC,outpatient,1,UN,21.1,14.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.45857,1.600685,416.02,percent of total billed charges,,,
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR,RX-9083,CDM,J0295,HCPCS,636,RC,55150-0116-20,NDC,outpatient,1,UN,7.13,4.991,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.844531,1.600685,416.02,percent of total billed charges,,,
AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR,RX-9083,CDM,J0295,HCPCS,636,RC,71288-0031-21,NDC,outpatient,1,UN,21.1,14.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.45857,1.600685,416.02,percent of total billed charges,,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,25021-0143-30,NDC,outpatient,1,UN,36.19,25.333,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.362353,1.600685,416.02,percent of total billed charges,,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,71288-0032-21,NDC,outpatient,1,UN,33.6,23.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.69232,1.600685,416.02,percent of total billed charges,,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,72485-0417-10,NDC,outpatient,1,UN,18.05,12.635,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.669535,1.600685,416.02,percent of total billed charges,,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,55150-0117-10,NDC,outpatient,1,UN,13.78,9.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.564886,1.600685,416.02,percent of total billed charges,,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,55150-0117-20,NDC,outpatient,1,UN,13.78,9.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.564886,1.600685,416.02,percent of total billed charges,,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,70594-0082-01,NDC,outpatient,1,UN,37.01,25.907,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.574487,1.600685,416.02,percent of total billed charges,,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,71288-0032-20,NDC,outpatient,1,UN,33.6,23.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.69232,1.600685,416.02,percent of total billed charges,,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,55150-0117-01,NDC,outpatient,1,UN,13.78,9.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.564886,1.600685,416.02,percent of total billed charges,,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,70594-0082-02,NDC,outpatient,1,UN,37.01,25.907,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.574487,1.600685,416.02,percent of total billed charges,,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,00641-6117-01,NDC,outpatient,1,UN,28.2,19.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.29534,1.600685,416.02,percent of total billed charges,,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,00641-6117-10,NDC,outpatient,1,UN,28.2,19.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.29534,1.600685,416.02,percent of total billed charges,,,
AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR,RX-9084,CDM,J0295,HCPCS,636,RC,72485-0417-01,NDC,outpatient,1,UN,18.05,12.635,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.669535,1.600685,416.02,percent of total billed charges,,,
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,70004-0908-09,NDC,outpatient,5,ML,95.5,66.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,24.70585,0.82,416.02,percent of total billed charges,,,
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,70092-1086-44,NDC,outpatient,5,ML,84.42,59.094,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,21.839454,0.82,416.02,percent of total billed charges,,,
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,69374-0920-05,NDC,outpatient,5,ML,14.14,9.898,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.658018,0.82,416.02,percent of total billed charges,,,
SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN,RX-7536,CDM,J0330,HCPCS,636,RC,70004-0910-09,NDC,outpatient,5,ML,31.6,22.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.17492,0.82,416.02,percent of total billed charges,,,
ANIDULAFUNGIN 100 MG IV SOLR,RX-88093,CDM,J0348,HCPCS,636,RC,00049-0116-28,NDC,outpatient,1,UN,139.38,97.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,36.057606,0.46,416.02,percent of total billed charges,,,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,00641-6231-01,NDC,outpatient,1,ML,12.17,8.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.148379,2.732165,416.02,percent of total billed charges,,,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,00641-6231-25,NDC,outpatient,1,ML,12.17,8.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.148379,2.732165,416.02,percent of total billed charges,,,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,55150-0400-01,NDC,outpatient,1,ML,14.72,10.304,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.808064,2.732165,416.02,percent of total billed charges,,,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,63323-0614-00,NDC,outpatient,1,ML,14.49,10.143,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.748563,2.732165,416.02,percent of total billed charges,,,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,55150-0400-25,NDC,outpatient,1,ML,14.72,10.304,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.808064,2.732165,416.02,percent of total billed charges,,,
HYDRALAZINE HCL 20 MG/ML IJ SOLN,RX-3697,CDM,J0360,HCPCS,636,RC,63323-0614-01,NDC,outpatient,1,ML,14.49,10.143,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.748563,2.732165,416.02,percent of total billed charges,,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,00069-3150-83,NDC,outpatient,1,UN,24.39,17.073,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.309693,1.834165,416.02,percent of total billed charges,,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70436-0019-82,NDC,outpatient,1,UN,12.13,8.491,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.138031,1.834165,416.02,percent of total billed charges,,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70860-0100-10,NDC,outpatient,1,UN,13.9,9.73,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.59593,1.834165,416.02,percent of total billed charges,,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,00069-3150-84,NDC,outpatient,1,UN,24.39,17.073,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.309693,1.834165,416.02,percent of total billed charges,,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,63323-0398-10,NDC,outpatient,1,UN,8.17,5.719,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.113579,1.834165,416.02,percent of total billed charges,,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70095-0025-01,NDC,outpatient,1,UN,8.79,6.153,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.273973,1.834165,416.02,percent of total billed charges,,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,55150-0174-10,NDC,outpatient,1,UN,9.22,6.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.385214,1.834165,416.02,percent of total billed charges,,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,63323-0398-01,NDC,outpatient,1,UN,8.17,5.719,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.113579,1.834165,416.02,percent of total billed charges,,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70095-0025-02,NDC,outpatient,1,UN,8.79,6.153,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.273973,1.834165,416.02,percent of total billed charges,,,
AZITHROMYCIN 500 MG IV SOLR,RX-21063,CDM,J0456,HCPCS,636,RC,70860-0100-41,NDC,outpatient,1,UN,13.9,9.73,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.59593,1.834165,416.02,percent of total billed charges,,,
AZITHROMYCIN 500 MG IN 250 ML NS PREMIX,RX-4080917,CDM,J0456,HCPCS,636,RC,99999-0001-37,NDC,outpatient,255,ML,46.12,32.284,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.931244,1.834165,416.02,percent of total billed charges,,,
AZTREONAM 1 G IJ SOLR 100 MG/ML,RX-4081004,CDM,J0457,HCPCS,636,RC,00003-2560-16,NDC,outpatient,1,UN,122.23,85.561,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,31.620901,1.97,416.02,percent of total billed charges,,,
AZTREONAM 1 G IJ SOLR 100 MG/ML,RX-4081004,CDM,J0457,HCPCS,636,RC,00409-0829-11,NDC,outpatient,1,UN,98.69,69.083,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,25.531103,1.97,416.02,percent of total billed charges,,,
AZTREONAM 1 G IJ SOLR 100 MG/ML,RX-4081004,CDM,J0457,HCPCS,636,RC,00409-0829-01,NDC,outpatient,1,UN,98.69,69.083,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,25.531103,1.97,416.02,percent of total billed charges,,,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,00409-0830-01,NDC,outpatient,1,UN,201.48,141.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,52.122876,1.97,416.02,percent of total billed charges,,,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,00409-0830-11,NDC,outpatient,1,UN,201.48,141.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,52.122876,1.97,416.02,percent of total billed charges,,,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,63323-0402-01,NDC,outpatient,1,UN,201.48,141.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,52.122876,1.97,416.02,percent of total billed charges,,,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,63323-0402-20,NDC,outpatient,1,UN,201.48,141.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,52.122876,1.97,416.02,percent of total billed charges,,,
AZTREONAM 2 G IJ SOLR 100 MG/ML,RX-4081467,CDM,J0457,HCPCS,636,RC,00003-2570-16,NDC,outpatient,1,UN,244.45,171.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,63.239215,1.97,416.02,percent of total billed charges,,,
AZTREONAM 1 G IJ SOLR,RX-9185,CDM,J0457,HCPCS,636,RC,00409-0829-01,NDC,outpatient,1,UN,98.69,69.083,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,25.531103,1.97,416.02,percent of total billed charges,,,
AZTREONAM 1 G IJ SOLR,RX-9185,CDM,J0457,HCPCS,636,RC,00003-2560-16,NDC,outpatient,1,UN,122.23,85.561,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,31.620901,1.97,416.02,percent of total billed charges,,,
AZTREONAM 1 G IJ SOLR,RX-9185,CDM,J0457,HCPCS,636,RC,00409-0829-11,NDC,outpatient,1,UN,98.69,69.083,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,25.531103,1.97,416.02,percent of total billed charges,,,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,00409-0830-01,NDC,outpatient,1,UN,201.48,141.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,52.122876,1.97,416.02,percent of total billed charges,,,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,63323-0402-20,NDC,outpatient,1,UN,201.48,141.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,52.122876,1.97,416.02,percent of total billed charges,,,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,00409-0830-11,NDC,outpatient,1,UN,201.48,141.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,52.122876,1.97,416.02,percent of total billed charges,,,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,00003-2570-16,NDC,outpatient,1,UN,244.45,171.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,63.239215,1.97,416.02,percent of total billed charges,,,
AZTREONAM 2 G IJ SOLR,RX-9186,CDM,J0457,HCPCS,636,RC,63323-0402-01,NDC,outpatient,1,UN,201.48,141.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,52.122876,1.97,416.02,percent of total billed charges,,,
ATROPINE SULFATE 0.1 MG/ML IJ SOLN WRAPPER,RX-4080930,CDM,J0461,HCPCS,636,RC,76329-3340-01,NDC,outpatient,10,ML,42.72,29.904,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.051664,0.09,416.02,percent of total billed charges,,,
ATROPINE SULFATE 0.4 MG/ML IJ SOLN WRAPPER,RX-4080931,CDM,J0461,HCPCS,636,RC,00517-1004-01,NDC,outpatient,1,ML,19.31,13.517,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.995497,0.09,416.02,percent of total billed charges,,,
ATROPINE SULFATE 0.4 MG/ML IJ SOLN WRAPPER,RX-4080931,CDM,J0461,HCPCS,636,RC,00517-1004-25,NDC,outpatient,1,ML,19.31,13.517,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.995497,0.09,416.02,percent of total billed charges,,,
ATROPINE SULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4081335,CDM,J0461,HCPCS,636,RC,00517-1001-01,NDC,outpatient,1,ML,30.76,21.532,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.957612,0.09,416.02,percent of total billed charges,,,
ATROPINE SULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4081335,CDM,J0461,HCPCS,636,RC,00517-1001-25,NDC,outpatient,1,ML,30.76,21.532,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.957612,0.09,416.02,percent of total billed charges,,,
ATROPINE SULFATE 0.25 MG/5ML IJ SOSY,RX-729,CDM,J0461,HCPCS,636,RC,00409-9630-15,NDC,outpatient,5,ML,87.58,61.306,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,22.656946,0.09,416.02,percent of total billed charges,,,
ATROPINE SULFATE 0.25 MG/5ML IJ SOSY,RX-729,CDM,J0461,HCPCS,636,RC,00409-9630-05,NDC,outpatient,5,ML,87.58,61.306,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,22.656946,0.09,416.02,percent of total billed charges,,,
BACLOFEN 10000 MCG/20ML IT WRAPPER,RX-4081072,CDM,J0475,HCPCS,636,RC,66794-0155-01,NDC,outpatient,20,ML,794.33,556.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,205.493171,174.58,1359.95136,percent of total billed charges,,,
BACLOFEN 20000 MCG/20ML IT WRAPPER,RX-4081073,CDM,J0475,HCPCS,636,RC,66794-0156-02,NDC,outpatient,20,ML,1497.87,1048.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,387.498969,174.58,1359.95136,percent of total billed charges,,,
BACLOFEN 40000 MCG/20ML IT WRAPPER,RX-4081074,CDM,J0475,HCPCS,636,RC,66794-0157-02,NDC,outpatient,20,ML,1770.77,1239.539,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,458.098199,174.58,1359.95136,percent of total billed charges,,,
BACLOFEN 50 MCG/ML IT SOSY,RX-107798,CDM,J0476,HCPCS,636,RC,66794-0151-01,NDC,outpatient,1,ML,326.81,228.767,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,84.545747,40.38,416.02,percent of total billed charges,,,
BELIMUMAB 120 MG IV SOLR,RX-108842,CDM,J0490,HCPCS,636,RC,49401-0101-01,NDC,outpatient,1,UN,1753.47,1227.429,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,453.622689,50.93,4488.66816,percent of total billed charges,,,
BELIMUMAB 400 MG IV SOLR,RX-108843,CDM,J0490,HCPCS,636,RC,49401-0102-01,NDC,outpatient,1,UN,5844.62,4091.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1512.003194,50.93,4488.66816,percent of total billed charges,,,
DICYCLOMINE HCL 10 MG/ML IM SOLN,RX-2417,CDM,J0500,HCPCS,636,RC,14789-0010-07,NDC,outpatient,2,ML,41.12,28.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.637744,9.23144,416.02,percent of total billed charges,,,
DICYCLOMINE HCL 10 MG/ML IM SOLN,RX-2417,CDM,J0500,HCPCS,636,RC,14789-0010-02,NDC,outpatient,2,ML,41.12,28.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.637744,9.23144,416.02,percent of total billed charges,,,
DICYCLOMINE HCL 10 MG/ML IM SOLN,RX-2417,CDM,J0500,HCPCS,636,RC,58914-0080-52,NDC,outpatient,2,ML,345.64,241.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,89.417068,9.23144,416.02,percent of total billed charges,,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9729-05,NDC,outpatient,2,ML,114.01,79.807,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,29.494387,16.21,416.02,percent of total billed charges,,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9233-05,NDC,outpatient,2,ML,97.73,68.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,25.282751,16.21,416.02,percent of total billed charges,,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9729-01,NDC,outpatient,2,ML,114.01,79.807,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,29.494387,16.21,416.02,percent of total billed charges,,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,68382-0860-02,NDC,outpatient,2,ML,102.98,72.086,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,26.640926,16.21,416.02,percent of total billed charges,,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,00143-9233-01,NDC,outpatient,2,ML,97.73,68.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,25.282751,16.21,416.02,percent of total billed charges,,,
BENZTROPINE MESYLATE 1 MG/ML IJ SOLN,RX-9259,CDM,J0515,HCPCS,636,RC,68382-0860-10,NDC,outpatient,2,ML,102.98,72.086,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,26.640926,16.21,416.02,percent of total billed charges,,,
PENICILLIN G BENZATHINE & PROC 1200000 UNIT/2ML IM SUSP,RX-108051,CDM,J0558,HCPCS,636,RC,60793-0600-10,NDC,outpatient,2,ML,908.68,636.076,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,235.075516,15.67,697.86624,percent of total billed charges,,,
PENICILLIN G BENZATHINE & PROC 1200000 UNIT/2ML IM SUSP,RX-108051,CDM,J0558,HCPCS,636,RC,60793-0600-02,NDC,outpatient,2,ML,908.68,636.076,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,235.075516,15.67,697.86624,percent of total billed charges,,,
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SUSY,RX-158171,CDM,J0561,HCPCS,636,RC,60793-0700-01,NDC,outpatient,1,ML,595.58,416.906,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,154.076546,20.17,1623.552,percent of total billed charges,,,
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SUSY,RX-158171,CDM,J0561,HCPCS,636,RC,60793-0700-10,NDC,outpatient,1,ML,595.58,416.906,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,154.076546,20.17,1623.552,percent of total billed charges,,,
PENICILLIN G BENZATHINE 1200000 UNIT/2ML IM SUSY,RX-158172,CDM,J0561,HCPCS,636,RC,60793-0701-02,NDC,outpatient,2,ML,1139.95,797.965,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,294.905065,20.17,1623.552,percent of total billed charges,,,
PENICILLIN G BENZATHINE 1200000 UNIT/2ML IM SUSY,RX-158172,CDM,J0561,HCPCS,636,RC,60793-0701-10,NDC,outpatient,2,ML,1139.95,797.965,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,294.905065,20.17,1623.552,percent of total billed charges,,,
PENICILLIN G BENZATHINE 2400000 UNIT/4ML IM SUSY,RX-162947,CDM,J0561,HCPCS,636,RC,60793-0702-04,NDC,outpatient,4,ML,2114,1479.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,546.8918,20.17,1623.552,percent of total billed charges,,,
PENICILLIN G BENZATHINE 2400000 UNIT/4ML IM SUSY,RX-162947,CDM,J0561,HCPCS,636,RC,60793-0702-10,NDC,outpatient,4,ML,2114,1479.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,546.8918,20.17,1623.552,percent of total billed charges,,,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,16729-0275-03,NDC,outpatient,1,UN,294.51,206.157,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,76.189737,0.17,416.02,percent of total billed charges,,,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,16729-0275-67,NDC,outpatient,1,UN,294.51,206.157,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,76.189737,0.17,416.02,percent of total billed charges,,,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,55150-0210-10,NDC,outpatient,1,UN,189.45,132.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,49.010715,0.17,416.02,percent of total billed charges,,,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,00781-3158-95,NDC,outpatient,1,UN,308.39,215.873,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,79.780493,0.17,416.02,percent of total billed charges,,,
BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR,RX-142407,CDM,J0583,HCPCS,636,RC,00781-3158-94,NDC,outpatient,1,UN,308.39,215.873,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,79.780493,0.17,416.02,percent of total billed charges,,,
ONABOTULINUMTOXINA 100 UNITS IJ SOLR,RX-100610,CDM,J0585,HCPCS,636,RC,00023-1145-01,NDC,outpatient,1,UN,1749.84,1224.888,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,452.683608,6.15,1343.87712,percent of total billed charges,,,
BUPRENORPHINE HCL 0.3 MG/ML IJ SOLN,RX-9320,CDM,J0592,HCPCS,636,RC,42023-0179-05,NDC,outpatient,1,ML,53.16,37.212,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.752492,4.03,416.02,percent of total billed charges,,,
BUPRENORPHINE HCL 0.3 MG/ML IJ SOLN,RX-9320,CDM,J0592,HCPCS,636,RC,42023-0179-01,NDC,outpatient,1,ML,53.16,37.212,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.752492,4.03,416.02,percent of total billed charges,,,
BUTORPHANOL TARTRATE 2 MG/ML IJ SOLN,RX-9334,CDM,J0595,HCPCS,636,RC,00409-1626-01,NDC,outpatient,1,ML,29.94,20.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.745478,4.06,416.02,percent of total billed charges,,,
BUTORPHANOL TARTRATE 2 MG/ML IJ SOLN,RX-9334,CDM,J0595,HCPCS,636,RC,00409-1626-21,NDC,outpatient,1,ML,29.94,20.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.745478,4.06,416.02,percent of total billed charges,,,
EDETATE CALCIUM DISODIUM 1 GM/5ML IJ SOLN,RX-108094,CDM,J0600,HCPCS,250,RC,64980-0588-05,NDC,outpatient,5,ML,16465.83,11526.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4259.710221,60.43,12645.75744,percent of total billed charges,,,
EDETATE CALCIUM DISODIUM 1 GM/5ML IJ SOLN,RX-108094,CDM,J0600,HCPCS,250,RC,64980-0588-51,NDC,outpatient,5,ML,16465.83,11526.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4259.710221,60.43,12645.75744,percent of total billed charges,,,
CALCIUM GLUCONATE 10 % IV SOLN,RX-1312,CDM,J0612,HCPCS,636,RC,63323-0360-01,NDC,outpatient,10,ML,36.54,25.578,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.452898,0.04,416.02,percent of total billed charges,,,
CALCIUM GLUCONATE 10 % IV SOLN,RX-1312,CDM,J0612,HCPCS,636,RC,63323-0360-19,NDC,outpatient,10,ML,36.54,25.578,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.452898,0.04,416.02,percent of total billed charges,,,
CALCIUM GLUCONATE-NACL 1-0.8 GM/100ML-% IV SOLN,RX-156703,CDM,J0613,HCPCS,636,RC,44567-0622-24,NDC,outpatient,100,ML,37.38,26.166,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.670206,0.08,416.02,percent of total billed charges,,,
CALCIUM GLUCONATE-NACL 1-0.8 GM/100ML-% IV SOLN,RX-156703,CDM,J0613,HCPCS,636,RC,44567-0622-01,NDC,outpatient,100,ML,37.38,26.166,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.670206,0.08,416.02,percent of total billed charges,,,
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-24,NDC,outpatient,100,ML,53.38,37.366,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.809406,0.08,416.02,percent of total billed charges,,,
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-01,NDC,outpatient,100,ML,53.38,37.366,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.809406,0.08,416.02,percent of total billed charges,,,
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-01,NDC,outpatient,100,ML,37.38,26.166,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,9.670206,0.08,416.02,percent of total billed charges,,,
CALCIUM GLUCONATE 1 G PREMIX IN SODIUM CHLORIDE 100 ML|DISCARDED DRUG NOT ADMINISTERED,RX-4080568,CDM,J0613,HCPCS,636,RC,44567-0622-24,NDC,outpatient,100,ML,37.38,26.166,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,9.670206,0.08,416.02,percent of total billed charges,,,
CALCITONIN (SALMON) 200 UNIT/ML IJ SOLN,RX-9347,CDM,J0630,HCPCS,636,RC,67457-0675-02,NDC,outpatient,2,ML,2806.57,1964.599,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,726.059659,399.86,2155.44576,percent of total billed charges,,,
CALCITONIN (SALMON) 200 UNIT/ML IJ SOLN,RX-9347,CDM,J0630,HCPCS,636,RC,42023-0205-01,NDC,outpatient,2,ML,2193.21,1535.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,567.383427,399.86,2155.44576,percent of total billed charges,,,
LEUCOVORIN CALCIUM IM INJECTION,RX-4080923,CDM,J0640,HCPCS,636,RC,25021-0813-10,NDC,outpatient,50,ME,16.97,11.879,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.390139,2.68951,416.02,percent of total billed charges,,,
LEUCOVORIN CALCIUM 350 MG IJ SOLR,RX-4393,CDM,J0640,HCPCS,636,RC,00143-9552-01,NDC,outpatient,1,UN,106.72,74.704,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,27.608464,2.68951,416.02,percent of total billed charges,,,
LEUCOVORIN CALCIUM 50 MG IJ SOLR,RX-4394,CDM,J0640,HCPCS,636,RC,25021-0813-10,NDC,outpatient,50,ME,11.98,8.386,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.099226,2.68951,416.02,percent of total billed charges,,,
LEVOTHYROXINE SODIUM 100 MCG IV SOLR,RX-113060,CDM,J0651,HCPCS,250,RC,63323-0649-07,NDC,outpatient,1,UN,279.46,195.622,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,72.296302,4.2921885,416.02,percent of total billed charges,,,
LEVOTHYROXINE SODIUM 100 MCG IV SOLR,RX-113060,CDM,J0651,HCPCS,250,RC,63323-0885-10,NDC,outpatient,5,ML,293.44,205.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,75.912928,4.2921885,416.02,percent of total billed charges,,,
LEVOTHYROXINE SODIUM 100 MCG IV SOLR,RX-113060,CDM,J0651,HCPCS,250,RC,63323-0885-12,NDC,outpatient,5,ML,293.44,205.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,75.912928,4.2921885,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1559-19,NDC,outpatient,30,ML,19.59,13.713,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.067933,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,55150-0167-10,NDC,outpatient,10,ML,10.85,7.595,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.806895,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00143-9330-10,NDC,outpatient,10,ML,7.82,5.474,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.023034,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-18,NDC,outpatient,10,ML,8.79,6.153,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.273973,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,63323-0464-17,NDC,outpatient,10,ML,6.48,4.536,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.676376,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00143-9330-01,NDC,outpatient,10,ML,7.82,5.474,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.023034,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-01,NDC,outpatient,10,ML,8.79,6.153,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.273973,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1559-30,NDC,outpatient,30,ML,19.59,13.713,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.067933,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,55150-0168-30,NDC,outpatient,30,ML,11.11,7.777,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.874157,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,63323-0464-01,NDC,outpatient,10,ML,6.48,4.536,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.676376,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-02,NDC,outpatient,30,ML,8.79,6.153,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.273973,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.25 % IJ SOLN,RX-105639,CDM,J0665,HCPCS,636,RC,00409-1159-19,NDC,outpatient,30,ML,8.79,6.153,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.273973,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,63323-0466-01,NDC,outpatient,30,ML,9.57,6.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.475759,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,55150-0170-30,NDC,outpatient,30,ML,12.34,8.638,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.192358,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,63323-0466-37,NDC,outpatient,30,ML,9.57,6.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.475759,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1162-02,NDC,outpatient,30,ML,9.72,6.804,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.514564,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1560-19,NDC,outpatient,30,ML,17.89,12.523,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.628143,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1162-01,NDC,outpatient,10,ML,10.08,7.056,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.607696,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.5 % IJ SOLN,RX-105640,CDM,J0665,HCPCS,636,RC,00409-1560-18,NDC,outpatient,10,ML,19.43,13.601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.026541,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,00409-1165-02,NDC,outpatient,30,ML,16.97,11.879,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.390139,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,00409-1165-19,NDC,outpatient,30,ML,16.97,11.879,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.390139,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,63323-0472-01,NDC,outpatient,30,ML,12.8,8.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.31136,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL (PF) 0.75 % IJ SOLN,RX-122185,CDM,J0665,HCPCS,636,RC,63323-0472-37,NDC,outpatient,30,ML,12.8,8.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.31136,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL 0.25 % IJ SOLN,RX-1222,CDM,J0665,HCPCS,636,RC,63323-0465-57,NDC,outpatient,5,ML,5.5,3.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.42285,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL 0.25 % IJ SOLN,RX-1222,CDM,J0665,HCPCS,636,RC,63323-0465-01,NDC,outpatient,5,ML,5.5,3.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.42285,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL 0.5 % IJ SOLN,RX-1223,CDM,J0665,HCPCS,636,RC,00409-1163-18,NDC,outpatient,5,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE HCL 0.5 % IJ SOLN,RX-1223,CDM,J0665,HCPCS,636,RC,00409-1163-01,NDC,outpatient,5,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE IN DEXTROSE 0.75-8.25 % IT SOLN,RX-9316,CDM,J0665,HCPCS,636,RC,00409-1761-18,NDC,outpatient,2,ML,20.36,14.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.267132,0.01,416.02,percent of total billed charges,,,
BUPIVACAINE IN DEXTROSE 0.75-8.25 % IT SOLN,RX-9316,CDM,J0665,HCPCS,636,RC,00409-1761-10,NDC,outpatient,2,ML,20.36,14.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.267132,0.01,416.02,percent of total billed charges,,,
MEPIVACAINE HCL (PF) 2 % IJ SOLN,RX-105638,CDM,J0670,HCPCS,636,RC,63323-0294-01,NDC,outpatient,20,ML,27.95,19.565,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.230665,3.08,416.02,percent of total billed charges,,,
MEPIVACAINE HCL (PF) 2 % IJ SOLN,RX-105638,CDM,J0670,HCPCS,636,RC,63323-0294-27,NDC,outpatient,20,ML,27.95,19.565,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.230665,3.08,416.02,percent of total billed charges,,,
CEFAZOLIN IVPB 2 G IN 100 ML D4W PREMIX|DISCARDED DRUG NOT ADMINISTERED,RX-4080727,CDM,J0689,HCPCS,636,RC,00338-3508-41,NDC,outpatient,100,ML,26.74,18.718,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,6.917638,1.22,416.02,percent of total billed charges,,,
CEFAZOLIN IVPB 2 G IN 100 ML D4W PREMIX,RX-4080727,CDM,J0689,HCPCS,636,RC,00338-3508-41,NDC,outpatient,100,ML,42.74,29.918,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.056838,1.22,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,00143-9924-90,NDC,outpatient,1,UN,5.85,4.095,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.513395,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,25021-0101-10,NDC,outpatient,1,UN,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,60505-6142-00,NDC,outpatient,1,UN,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,60505-6142-05,NDC,outpatient,1,UN,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 1 G IJ SOLR,RX-1445,CDM,J0690,HCPCS,636,RC,44567-0707-25,NDC,outpatient,1,UN,7.84,5.488,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.028208,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 10 G IJ SOLR,RX-1446,CDM,J0690,HCPCS,636,RC,00143-9983-91,NDC,outpatient,1,UN,40.9,28.63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.58083,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 10 G IJ SOLR,RX-1446,CDM,J0690,HCPCS,636,RC,00143-9983-03,NDC,outpatient,1,UN,40.9,28.63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.58083,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 500 MG IJ SOLR,RX-1448,CDM,J0690,HCPCS,636,RC,44567-0706-25,NDC,outpatient,1,UN,4.28,2.996,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.107236,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 2 G IJ SOLR,RX-158156,CDM,J0690,HCPCS,636,RC,60505-6231-05,NDC,outpatient,1,UN,18.74,13.118,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.848038,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 2 G IJ SOLR,RX-158156,CDM,J0690,HCPCS,636,RC,60505-6231-00,NDC,outpatient,1,UN,18.74,13.118,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.848038,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 1 G IV SOLR ADD-VANTAGE,RX-27297,CDM,J0690,HCPCS,636,RC,00409-2585-11,NDC,outpatient,1,UN,12.17,8.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.148379,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 1 G IV SOLR ADD-VANTAGE,RX-27297,CDM,J0690,HCPCS,636,RC,00409-2585-01,NDC,outpatient,1,UN,12.17,8.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.148379,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,00143-9924-90,NDC,outpatient,1,UN,5.85,4.095,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.513395,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,25021-0101-10,NDC,outpatient,1,UN,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,60505-6142-00,NDC,outpatient,1,UN,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,60505-6142-05,NDC,outpatient,1,UN,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080941,CDM,J0690,HCPCS,636,RC,44567-0707-25,NDC,outpatient,1,UN,7.84,5.488,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.028208,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,44567-0707-25,NDC,outpatient,1,UN,7.84,5.488,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.028208,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,60505-6142-00,NDC,outpatient,1,UN,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,60505-6142-05,NDC,outpatient,1,UN,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,00143-9924-90,NDC,outpatient,1,UN,5.85,4.095,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.513395,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 1 G IJ SOLR 1000 MG/5 ML,RX-4080993,CDM,J0690,HCPCS,636,RC,25021-0101-10,NDC,outpatient,1,UN,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.74534,416.02,percent of total billed charges,,,
CEFAZOLIN SODIUM 1 G 100 ML ADD-VANTAGE BAG,RX-4081138,CDM,J0690,HCPCS,636,RC,99999-0003-01,NDC,outpatient,100,ML,32.9,23.03,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.51123,0.74534,416.02,percent of total billed charges,,,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,00409-9566-01,NDC,outpatient,1,UN,16.63,11.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.302181,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,44567-0240-10,NDC,outpatient,1,UN,23.44,16.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.063928,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,60505-6146-04,NDC,outpatient,1,UN,12,8.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.1044,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,00409-9566-10,NDC,outpatient,1,UN,16.63,11.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.302181,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,25021-0121-20,NDC,outpatient,1,UN,17.97,12.579,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.648839,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 1 G IJ SOLR,RX-16369,CDM,J0692,HCPCS,636,RC,60505-6146-00,NDC,outpatient,1,UN,12,8.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.1044,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,00409-9735-01,NDC,outpatient,1,UN,25.5,17.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.59685,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,25021-0122-50,NDC,outpatient,1,UN,32.22,22.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.335314,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,70594-0090-01,NDC,outpatient,1,UN,40.3,28.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.42561,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,00409-9735-10,NDC,outpatient,1,UN,25.5,17.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.59685,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,44567-0241-10,NDC,outpatient,1,UN,40.3,28.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.42561,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,60505-6246-00,NDC,outpatient,1,UN,19.47,13.629,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.036889,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,60505-6246-04,NDC,outpatient,1,UN,19.47,13.629,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.036889,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 2 G IV SOLR,RX-27311,CDM,J0692,HCPCS,636,RC,70594-0090-02,NDC,outpatient,1,UN,40.3,28.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.42561,1.22,416.02,percent of total billed charges,,,
CEFEPIME IVPB 1 G IN 100 ML NS COMPOUNDED,RX-4080828,CDM,J0692,HCPCS,636,RC,99999-0001-09,NDC,outpatient,100,ML,48.93,34.251,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.658191,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,00409-9735-01,NDC,outpatient,1,UN,25.5,17.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.59685,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,00409-9735-10,NDC,outpatient,1,UN,25.5,17.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.59685,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,44567-0241-10,NDC,outpatient,1,UN,40.3,28.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.42561,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,60505-6147-04,NDC,outpatient,1,UN,19.47,13.629,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.036889,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,60505-6147-00,NDC,outpatient,1,UN,34.31,24.017,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.875997,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,70594-0090-01,NDC,outpatient,1,UN,40.3,28.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.42561,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 2 G IJ SOLR 2000 MG/12.5 ML,RX-4080972,CDM,J0692,HCPCS,636,RC,70594-0090-02,NDC,outpatient,1,UN,40.3,28.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.42561,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,60505-6146-00,NDC,outpatient,1,UN,12,8.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.1044,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,00409-9566-10,NDC,outpatient,1,UN,16.63,11.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.302181,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,60505-6146-04,NDC,outpatient,1,UN,12,8.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.1044,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,00409-9566-01,NDC,outpatient,1,UN,16.63,11.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.302181,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,25021-0121-20,NDC,outpatient,1,UN,17.97,12.579,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.648839,1.22,416.02,percent of total billed charges,,,
CEFEPIME HCL 1 G IJ SOLR 1000 MG/11.3 ML,RX-4081003,CDM,J0692,HCPCS,636,RC,44567-0240-10,NDC,outpatient,1,UN,23.44,16.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.063928,1.22,416.02,percent of total billed charges,,,
CEFOXITIN SODIUM-DEXTROSE 2-2.2 GM-%(50ML) IV SOLR,RX-144407,CDM,J0694,HCPCS,636,RC,00264-3125-11,NDC,outpatient,1,UN,147.33,103.131,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,38.114271,3.679555,416.02,percent of total billed charges,,,
CEFOXITIN IVPB 2 G IN 100 ML NS COMPOUNDED,RX-4080864,CDM,J0694,HCPCS,636,RC,99999-0001-16,NDC,outpatient,100,ML,46.14,32.298,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.936418,3.679555,416.02,percent of total billed charges,,,
CEFOXITIN SODIUM 1 G IV SOLR 1000 MG/10.5 ML,RX-4080998,CDM,J0694,HCPCS,636,RC,44567-0245-25,NDC,outpatient,1,UN,40.92,28.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.586004,3.679555,416.02,percent of total billed charges,,,
CEFOXITIN SODIUM 1 G IV SOLR 1000 MG/10.5 ML,RX-4080998,CDM,J0694,HCPCS,636,RC,25021-0109-10,NDC,outpatient,1,UN,16.39,11.473,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.240093,3.679555,416.02,percent of total billed charges,,,
CEFOXITIN SODIUM 2 G IV SOLR 2000 MG/11.1 ML,RX-4081009,CDM,J0694,HCPCS,636,RC,44567-0246-25,NDC,outpatient,1,UN,82.04,57.428,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,21.223748,3.679555,416.02,percent of total billed charges,,,
CEFOXITIN SODIUM 2 G IV SOLR 2000 MG/11.1 ML,RX-4081009,CDM,J0694,HCPCS,636,RC,25021-0110-20,NDC,outpatient,1,UN,30.34,21.238,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.848958,3.679555,416.02,percent of total billed charges,,,
CEFOXITIN SODIUM 1 G IV SOLR,RX-9461,CDM,J0694,HCPCS,636,RC,25021-0109-10,NDC,outpatient,1,UN,16.39,11.473,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.240093,3.679555,416.02,percent of total billed charges,,,
CEFOXITIN SODIUM 1 G IV SOLR,RX-9461,CDM,J0694,HCPCS,636,RC,44567-0245-25,NDC,outpatient,1,UN,40.92,28.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.586004,3.679555,416.02,percent of total billed charges,,,
CEFOXITIN SODIUM 2 G IV SOLR,RX-9463,CDM,J0694,HCPCS,636,RC,25021-0110-20,NDC,outpatient,1,UN,30.34,21.238,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.848958,3.679555,416.02,percent of total billed charges,,,
CEFOXITIN SODIUM 2 G IV SOLR,RX-9463,CDM,J0694,HCPCS,636,RC,44567-0246-25,NDC,outpatient,1,UN,82.04,57.428,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,21.223748,3.679555,416.02,percent of total billed charges,,,
CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G IV SOLR,RX-129169,CDM,J0695,HCPCS,636,RC,67919-0030-01,NDC,outpatient,1,UN,652.32,456.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,168.755184,7.54,500.98176,percent of total billed charges,,,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00143-9857-01,NDC,outpatient,1,UN,5.23,3.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.353001,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00143-9857-25,NDC,outpatient,1,UN,5.23,3.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.353001,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00781-3208-95,NDC,outpatient,1,UN,17.99,12.593,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.654013,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,00781-3208-85,NDC,outpatient,1,UN,17.99,12.593,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.654013,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,25021-0106-10,NDC,outpatient,1,UN,9.22,6.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.385214,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 1 G IJ SOLR 100 MG/ML,RX-4080991,CDM,J0696,HCPCS,636,RC,44567-0701-25,NDC,outpatient,1,UN,4.75,3.325,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.228825,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00781-3209-95,NDC,outpatient,1,UN,11.14,7.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.881918,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,25021-0107-20,NDC,outpatient,1,UN,18.72,13.104,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.842864,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,44567-0702-25,NDC,outpatient,1,UN,9.03,6.321,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.336061,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00143-9856-01,NDC,outpatient,1,UN,9.12,6.384,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.359344,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00143-9856-25,NDC,outpatient,1,UN,9.12,6.384,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.359344,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 2 G IJ SOLR 100 MG/ML,RX-4080992,CDM,J0696,HCPCS,636,RC,00781-3209-90,NDC,outpatient,1,UN,11.14,7.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.881918,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00781-3208-85,NDC,outpatient,1,UN,17.99,12.593,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.654013,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00143-9857-25,NDC,outpatient,1,UN,5.23,3.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.353001,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00781-3208-95,NDC,outpatient,1,UN,17.99,12.593,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.654013,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00143-9857-01,NDC,outpatient,1,UN,5.23,3.661,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.353001,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00409-7332-01,NDC,outpatient,1,UN,6.94,4.858,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.795378,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,44567-0701-25,NDC,outpatient,1,UN,4.75,3.325,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.228825,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,00409-7332-11,NDC,outpatient,1,UN,6.94,4.858,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.795378,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 1 G IJ SOLR,RX-9487,CDM,J0696,HCPCS,636,RC,25021-0106-10,NDC,outpatient,1,UN,9.22,6.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.385214,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00143-9856-01,NDC,outpatient,1,UN,9.12,6.384,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.359344,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,44567-0702-25,NDC,outpatient,1,UN,9.03,6.321,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.336061,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00143-9856-25,NDC,outpatient,1,UN,9.12,6.384,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.359344,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00781-3209-90,NDC,outpatient,1,UN,11.14,7.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.881918,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,00781-3209-95,NDC,outpatient,1,UN,11.14,7.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.881918,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 2 G IJ SOLR,RX-9488,CDM,J0696,HCPCS,636,RC,25021-0107-20,NDC,outpatient,1,UN,18.72,13.104,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.842864,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00143-9859-01,NDC,outpatient,1,UN,4.32,3.024,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.117584,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00409-7337-11,NDC,outpatient,1,UN,3.47,2.429,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.897689,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00143-9859-25,NDC,outpatient,1,UN,4.32,3.024,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.117584,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00409-7337-01,NDC,outpatient,1,UN,3.47,2.429,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.897689,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00781-3206-85,NDC,outpatient,1,UN,6.33,4.431,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.637571,0.44,416.02,percent of total billed charges,,,
CEFTRIAXONE SODIUM 250 MG IJ SOLR,RX-9489,CDM,J0696,HCPCS,636,RC,00781-3206-95,NDC,outpatient,1,UN,6.33,4.431,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.637571,0.44,416.02,percent of total billed charges,,,
CEFUROXIME SODIUM 750 MG IJ SOLR,RX-1465,CDM,J0697,HCPCS,636,RC,00143-9979-90,NDC,outpatient,1,UN,12.5,8.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.23375,1.88,416.02,percent of total billed charges,,,
CEFUROXIME SODIUM 750 MG IJ SOLR,RX-1465,CDM,J0697,HCPCS,636,RC,25021-0118-10,NDC,outpatient,1,UN,9.6,6.72,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.48352,1.88,416.02,percent of total billed charges,,,
CEFUROXIME SODIUM 750 MG IJ SOLR,RX-1465,CDM,J0697,HCPCS,636,RC,00143-9979-22,NDC,outpatient,1,UN,12.5,8.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.23375,1.88,416.02,percent of total billed charges,,,
CEFUROXIME SODIUM 1.5 G IV SOLR,RX-27299,CDM,J0697,HCPCS,636,RC,00143-9977-22,NDC,outpatient,1,UN,21.64,15.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.598268,1.88,416.02,percent of total billed charges,,,
CEFUROXIME SODIUM 1.5 G IV SOLR,RX-27299,CDM,J0697,HCPCS,636,RC,00143-9977-90,NDC,outpatient,1,UN,21.64,15.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.598268,1.88,416.02,percent of total billed charges,,,
CEFUROXIME SODIUM 750 MG IJ SOLR 750 MG/8.3 ML,RX-4080994,CDM,J0697,HCPCS,636,RC,25021-0118-10,NDC,outpatient,1,UN,9.6,6.72,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.48352,1.88,416.02,percent of total billed charges,,,
CEFUROXIME SODIUM 750 MG IJ SOLR 750 MG/8.3 ML,RX-4080994,CDM,J0697,HCPCS,636,RC,00143-9979-90,NDC,outpatient,1,UN,12.5,8.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.23375,1.88,416.02,percent of total billed charges,,,
CEFUROXIME SODIUM 750 MG IJ SOLR 750 MG/8.3 ML,RX-4080994,CDM,J0697,HCPCS,636,RC,00143-9979-22,NDC,outpatient,1,UN,12.5,8.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.23375,1.88,416.02,percent of total billed charges,,,
CEFUROXIME SODIUM 1.5 G IJ SOLR IN 16 ML,RX-4081008,CDM,J0697,HCPCS,636,RC,00143-9977-90,NDC,outpatient,1,UN,21.64,15.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.598268,1.88,416.02,percent of total billed charges,,,
CEFUROXIME SODIUM 1.5 G IJ SOLR IN 16 ML,RX-4081008,CDM,J0697,HCPCS,636,RC,00143-9977-22,NDC,outpatient,1,UN,21.64,15.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.598268,1.88,416.02,percent of total billed charges,,,
BETAMETHASONE SOD PHOS & ACET 6 (3-3) MG/ML IJ SUSP,RX-9266,CDM,J0702,HCPCS,636,RC,78206-0118-01,NDC,outpatient,5,ML,170.75,119.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,44.173025,6.96,416.02,percent of total billed charges,,,
BETAMETHASONE SOD PHOS & ACET 6 (3-3) MG/ML IJ SUSP,RX-9266,CDM,J0702,HCPCS,636,RC,00517-0720-01,NDC,outpatient,5,ML,143.92,100.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,37.232104,6.96,416.02,percent of total billed charges,,,
CAFFEINE CITRATE 60 MG/3ML IV SOLN,RX-109034,CDM,J0706,HCPCS,636,RC,51754-0500-01,NDC,outpatient,3,ML,26.75,18.725,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.920225,1.65,416.02,percent of total billed charges,,,
CEFTAROLINE FOSAMIL 400 MG IV SOLR,RX-107670,CDM,J0712,HCPCS,636,RC,00456-0400-10,NDC,outpatient,1,UN,806.58,564.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,208.662246,3.89,619.45344,percent of total billed charges,,,
CEFTAROLINE FOSAMIL 400 MG IV SOLR,RX-107670,CDM,J0712,HCPCS,636,RC,00456-0400-01,NDC,outpatient,1,UN,806.58,564.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,208.662246,3.89,619.45344,percent of total billed charges,,,
CEFTAROLINE FOSAMIL 600 MG IV SOLR,RX-107671,CDM,J0712,HCPCS,636,RC,00456-0600-10,NDC,outpatient,1,UN,806.58,564.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,208.662246,3.89,619.45344,percent of total billed charges,,,
CEFTAROLINE FOSAMIL 600 MG IV SOLR,RX-107671,CDM,J0712,HCPCS,636,RC,00456-0600-01,NDC,outpatient,1,UN,806.58,564.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,208.662246,3.89,619.45344,percent of total billed charges,,,
CEFTAZIDIME 2 G IV SOLR,RX-27291,CDM,J0713,HCPCS,636,RC,25021-0128-50,NDC,outpatient,1,UN,37.01,25.907,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.574487,1.66,416.02,percent of total billed charges,,,
CEFTAZIDIME 2 G IV SOLR,RX-27291,CDM,J0713,HCPCS,636,RC,44567-0236-10,NDC,outpatient,1,UN,23.52,16.464,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.084624,1.66,416.02,percent of total billed charges,,,
CEFTAZIDIME 1 MG/ML IJ SOLR,RX-4080666,CDM,J0713,HCPCS,636,RC,00409-5082-16,NDC,outpatient,1,UN,14.25,9.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.686475,1.66,416.02,percent of total billed charges,,,
CEFTAZIDIME 1 G IJ SOLR 1000 MG/10.8 ML,RX-4081001,CDM,J0713,HCPCS,636,RC,00409-5082-16,NDC,outpatient,1,UN,14.25,9.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.686475,1.66,416.02,percent of total billed charges,,,
CEFTAZIDIME 2 G IJ SOLR 2000 MG/11.5 ML,RX-4081002,CDM,J0713,HCPCS,636,RC,25021-0128-50,NDC,outpatient,1,UN,37.01,25.907,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.574487,1.66,416.02,percent of total billed charges,,,
CEFTAZIDIME 1 G IJ SOLR,RX-9474,CDM,J0713,HCPCS,636,RC,00409-5082-16,NDC,outpatient,1,UN,14.25,9.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.686475,1.66,416.02,percent of total billed charges,,,
CEFTAZIDIME 1 G IJ SOLR,RX-9474,CDM,J0713,HCPCS,636,RC,00409-5082-11,NDC,outpatient,1,UN,14.25,9.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.686475,1.66,416.02,percent of total billed charges,,,
CEFTAZIDIME 1 G IJ SOLR,RX-9474,CDM,J0713,HCPCS,636,RC,44567-0235-25,NDC,outpatient,1,UN,13.87,9.709,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.588169,1.66,416.02,percent of total billed charges,,,
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G IV SOLR,RX-130403,CDM,J0714,HCPCS,636,RC,00456-2700-10,NDC,outpatient,1,UN,1625.76,1138.032,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,420.584112,92.48,1248.58368,percent of total billed charges,,,
CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G IV SOLR,RX-130403,CDM,J0714,HCPCS,636,RC,00456-2700-01,NDC,outpatient,1,UN,1625.76,1138.032,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,420.584112,92.48,1248.58368,percent of total billed charges,,,
CLONIDINE HCL (ANALGESIA) 100 MCG/ML EP SOLN,RX-19333,CDM,J0735,HCPCS,636,RC,67457-0218-10,NDC,outpatient,10,ML,45.22,31.654,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.698414,10.15189,416.02,percent of total billed charges,,,
CLONIDINE HCL (ANALGESIA) 500 MCG/ML EP SOLN,RX-27113,CDM,J0735,HCPCS,636,RC,39822-2010-01,NDC,outpatient,10,ML,402.95,282.065,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,104.243165,10.15189,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE 150 MG/ML IJ WRAPPER,RX-4080195,CDM,J0736,HCPCS,636,RC,00009-0775-26,NDC,outpatient,4,ML,13.99,9.793,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.619213,1.61,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE 150 MG/ML IJ WRAPPER,RX-4080195,CDM,J0736,HCPCS,636,RC,00009-0775-20,NDC,outpatient,4,ML,13.99,9.793,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.619213,1.61,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0736,HCPCS,636,RC,00781-3288-09,NDC,outpatient,50,ML,48.27,33.789,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.487449,1.61,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0736,HCPCS,636,RC,00781-3288-91,NDC,outpatient,50,ML,48.27,33.789,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.487449,1.61,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-09,NDC,outpatient,50,ML,64.73,45.311,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.745651,1.61,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-91,NDC,outpatient,50,ML,64.73,45.311,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.745651,1.61,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-91,NDC,outpatient,50,ML,48.73,34.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,12.606451,1.61,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0736,HCPCS,636,RC,00781-3289-09,NDC,outpatient,50,ML,48.73,34.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,12.606451,1.61,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0737,HCPCS,636,RC,00338-3410-50,NDC,outpatient,50,ML,30.91,21.637,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.996417,2.59,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE IN D5W 300 MG/50ML IV SOLN,RX-9625,CDM,J0737,HCPCS,636,RC,00338-3410-24,NDC,outpatient,50,ML,30.91,21.637,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.996417,2.59,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-50,NDC,outpatient,50,ML,34.25,23.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.860475,2.59,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-24,NDC,outpatient,50,ML,34.25,23.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.860475,2.59,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-24,NDC,outpatient,50,ML,18.25,12.775,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,4.721275,2.59,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-24,NDC,outpatient,50,ML,18.25,12.775,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,4.721275,2.59,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-50,NDC,outpatient,50,ML,34.25,23.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.860475,2.59,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-24,NDC,outpatient,50,ML,34.25,23.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.860475,2.59,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3612-50,NDC,outpatient,50,ML,18.25,12.775,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,4.721275,2.59,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9626,CDM,J0737,HCPCS,636,RC,00338-3616-50,NDC,outpatient,50,ML,18.25,12.775,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,4.721275,2.59,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-24,NDC,outpatient,50,ML,22.7,15.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,5.87249,2.59,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-50,NDC,outpatient,50,ML,22.7,15.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,5.87249,2.59,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-24,NDC,outpatient,50,ML,38.7,27.09,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.01169,2.59,416.02,percent of total billed charges,,,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN,RX-9627,CDM,J0737,HCPCS,636,RC,00338-3814-50,NDC,outpatient,50,ML,38.7,27.09,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.01169,2.59,416.02,percent of total billed charges,,,
IMIPENEM-CILASTATIN 250 MG IV SOLR,RX-9602,CDM,J0743,HCPCS,636,RC,63323-0349-25,NDC,outpatient,1,UN,25.58,17.906,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.617546,5.74271,416.02,percent of total billed charges,,,
IMIPENEM-CILASTATIN 500 MG IV SOLR,RX-9603,CDM,J0743,HCPCS,636,RC,63323-0322-01,NDC,outpatient,1,UN,43.92,30.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.362104,5.74271,416.02,percent of total billed charges,,,
IMIPENEM-CILASTATIN 500 MG IV SOLR,RX-9603,CDM,J0743,HCPCS,636,RC,63323-0322-25,NDC,outpatient,1,UN,43.92,30.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.362104,5.74271,416.02,percent of total billed charges,,,
CIPROFLOXACIN IN D5W 200 MG/100ML IV SOLN,RX-108130,CDM,J0744,HCPCS,636,RC,00409-2300-24,NDC,outpatient,100,ML,26.8,18.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.93316,1.86,416.02,percent of total billed charges,,,
CIPROFLOXACIN IN D5W 200 MG/100ML IV SOLN,RX-108130,CDM,J0744,HCPCS,636,RC,00409-2300-01,NDC,outpatient,100,ML,26.8,18.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.93316,1.86,416.02,percent of total billed charges,,,
CIPROFLOXACIN IN D5W 400 MG/200ML IV SOLN,RX-108132,CDM,J0744,HCPCS,636,RC,25021-0114-87,NDC,outpatient,200,ML,42.7,29.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.04649,1.86,416.02,percent of total billed charges,,,
COLISTIMETHATE SODIUM (CBA) 150 MG IJ SOLR,RX-142413,CDM,J0770,HCPCS,636,RC,70594-0023-04,NDC,outpatient,1,UN,46.34,32.438,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.988158,10.40333,416.02,percent of total billed charges,,,
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,00713-0351-02,NDC,outpatient,2,ML,13.73,9.611,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.551951,3.01,416.02,percent of total billed charges,,,
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,00713-0351-25,NDC,outpatient,2,ML,13.73,9.611,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.551951,3.01,416.02,percent of total billed charges,,,
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,14789-0700-07,NDC,outpatient,2,ML,14.97,10.479,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.872739,3.01,416.02,percent of total billed charges,,,
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,00713-0351-09,NDC,outpatient,2,ML,15.66,10.962,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.051242,3.01,416.02,percent of total billed charges,,,
PROCHLORPERAZINE EDISYLATE 5 MG/ML IJ SOLN WRAPPER,RX-4081176,CDM,J0780,HCPCS,636,RC,14789-0700-02,NDC,outpatient,2,ML,14.97,10.479,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.872739,3.01,416.02,percent of total billed charges,,,
COSYNTROPIN 0.25 MG IJ SOLR,RX-9686,CDM,J0834,HCPCS,636,RC,00548-5900-00,NDC,outpatient,1,UN,74.02,51.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,19.148974,16.61749,416.02,percent of total billed charges,,,
COSYNTROPIN 0.25 MG IJ SOLR,RX-9686,CDM,J0834,HCPCS,636,RC,00781-3440-71,NDC,outpatient,1,UN,356.89,249.823,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,92.327443,16.61749,416.02,percent of total billed charges,,,
COSYNTROPIN 0.25 MG IJ SOLR,RX-9686,CDM,J0834,HCPCS,636,RC,00781-3440-95,NDC,outpatient,1,UN,356.89,249.823,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,92.327443,16.61749,416.02,percent of total billed charges,,,
DAPTOMYCIN 500 MG IV SOLR,RX-36989,CDM,J0873,HCPCS,636,RC,70594-0034-01,NDC,outpatient,1,UN,65.78,46.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,17.017286,0.04,416.02,percent of total billed charges,,,
DALBAVANCIN HCL 500 MG IV SOLR,RX-125774,CDM,J0875,HCPCS,636,RC,57970-0100-01,NDC,outpatient,1,UN,2550.24,1785.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,659.747088,14.7,4668.927562,percent of total billed charges,,,
DAPTOMYCIN 350 MG IV SOLR,RX-143414,CDM,J0878,HCPCS,636,RC,16729-0434-05,NDC,outpatient,1,UN,201.5,141.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,52.12805,0.03,416.02,percent of total billed charges,,,
DAPTOMYCIN 350 MG IV SOLR,RX-143414,CDM,J0878,HCPCS,636,RC,16729-0434-45,NDC,outpatient,1,UN,201.59,141.113,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,52.151333,0.03,416.02,percent of total billed charges,,,
DAPTOMYCIN 500 MG IV SOLR,RX-36989,CDM,J0878,HCPCS,636,RC,00143-9378-01,NDC,outpatient,1,UN,57.59,40.313,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,14.898533,0.03,416.02,percent of total billed charges,,,
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0883,HCPCS,636,RC,25021-0414-50,NDC,outpatient,50,ML,333.29,233.303,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,86.222123,1.35,1059.84,percent of total billed charges,,,
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0883,HCPCS,636,RC,00143-9559-01,NDC,outpatient,50,ML,438.53,306.971,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,113.447711,1.35,1059.84,percent of total billed charges,,,
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0883,HCPCS,636,RC,16729-0430-43,NDC,outpatient,50,ML,358.65,251.055,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,92.782755,1.35,1059.84,percent of total billed charges,,,
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0883,HCPCS,636,RC,00143-9559-01,NDC,outpatient,50,ML,422.53,295.771,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,109.308511,1.35,1059.84,percent of total billed charges,,,
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0883,HCPCS,636,RC,16729-0430-43,NDC,outpatient,50,ML,342.65,239.855,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,88.643555,1.35,1059.84,percent of total billed charges,,,
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0883,HCPCS,636,RC,25021-0414-50,NDC,outpatient,50,ML,317.29,222.103,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,82.082923,1.35,1059.84,percent of total billed charges,,,
ARGATROBAN 250 MG/2.5ML IV SOLN,RX-28947,CDM,J0883,HCPCS,636,RC,00143-9674-01,NDC,outpatient,2.5,ML,1380,966,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,357.006,1.35,1059.84,percent of total billed charges,,,
ARGATROBAN 250 MG/2.5ML IV SOLN,RX-28947,CDM,J0883,HCPCS,636,RC,00409-1140-01,NDC,outpatient,2.5,ML,226.15,158.305,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,58.505005,1.35,1059.84,percent of total billed charges,,,
ARGATROBAN 250 MG/2.5ML IV SOLN,RX-28947,CDM,J0883,HCPCS,636,RC,63323-0526-03,NDC,outpatient,2.5,ML,1328.82,930.174,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,343.765734,1.35,1059.84,percent of total billed charges,,,
EPOETIN ALFA 10000 UNIT/ML IJ SOLN,RX-9938,CDM,J0885,HCPCS,636,RC,59676-0310-00,NDC,outpatient,1,ML,622.94,436.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,161.154578,6.88,478.41792,percent of total billed charges,,,
EPOETIN ALFA 10000 UNIT/ML IJ SOLN,RX-9938,CDM,J0885,HCPCS,636,RC,59676-0310-01,NDC,outpatient,1,ML,622.94,436.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,161.154578,6.88,478.41792,percent of total billed charges,,,
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,55513-0148-01,NDC,outpatient,1,ML,283.41,198.387,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,73.318167,6.88,478.41792,percent of total billed charges,,,
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,55513-0148-10,NDC,outpatient,1,ML,283.41,198.387,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,73.318167,6.88,478.41792,percent of total billed charges,,,
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,59676-0304-01,NDC,outpatient,1,ML,456.83,319.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,118.181921,6.88,478.41792,percent of total billed charges,,,
EPOETIN ALFA 4000 UNIT/ML IJ SOLN,RX-9941,CDM,J0885,HCPCS,636,RC,59676-0304-00,NDC,outpatient,1,ML,456.83,319.781,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,118.181921,6.88,478.41792,percent of total billed charges,,,
ARGATROBAN 50 MG/50ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-111477,CDM,J0891,HCPCS,636,RC,16729-0430-11,NDC,outpatient,50,ML,342.65,239.855,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,88.643555,0.46,416.02,percent of total billed charges,,,
ARGATROBAN 50 MG/50ML IV SOLN,RX-111477,CDM,J0891,HCPCS,636,RC,16729-0430-11,NDC,outpatient,50,ML,358.65,251.055,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,92.782755,0.46,416.02,percent of total billed charges,,,
DECITABINE 50 MG IV SOLR,RX-76364,CDM,J0894,HCPCS,636,RC,16729-0224-05,NDC,outpatient,1,UN,335.38,234.766,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,86.762806,1.63,416.02,percent of total billed charges,,,
DEFEROXAMINE MESYLATE 500 MG IJ SOLR,RX-9723,CDM,J0895,HCPCS,636,RC,60505-6236-00,NDC,outpatient,1,UN,46.34,32.438,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.988158,6.78,416.02,percent of total billed charges,,,
DEFEROXAMINE MESYLATE 500 MG IJ SOLR,RX-9723,CDM,J0895,HCPCS,636,RC,60505-6236-06,NDC,outpatient,1,UN,46.34,32.438,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.988158,6.78,416.02,percent of total billed charges,,,
DENOSUMAB 120 MG/1.7ML SC SOLN,RX-106804,CDM,J0897,HCPCS,636,RC,55513-0730-01,NDC,outpatient,1.7,ML,8861.12,6202.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2292.371744,24.19,6805.34016,percent of total billed charges,,,
DENOSUMAB 60 MG/ML SC SOSY,RX-146195,CDM,J0897,HCPCS,636,RC,55513-0710-01,NDC,outpatient,1,ML,4649.31,3254.517,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1202.776497,24.19,6805.34016,percent of total billed charges,,,
METHYLPREDNISOLONE ACETATE 40 MG/ML IJ SUSP,RX-4995,CDM,J1030,HCPCS,636,RC,00009-3073-03,NDC,outpatient,1,ML,22.62,15.834,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.851794,5.07819,416.02,percent of total billed charges,,,
METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP,RX-4996,CDM,J1040,HCPCS,636,RC,70121-1574-01,NDC,outpatient,1,ML,25.95,18.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.713265,5.82353,416.02,percent of total billed charges,,,
METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP,RX-4996,CDM,J1040,HCPCS,636,RC,70121-1574-05,NDC,outpatient,1,ML,25.94,18.158,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.710678,5.82353,416.02,percent of total billed charges,,,
METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP,RX-4996,CDM,J1040,HCPCS,636,RC,00009-3475-03,NDC,outpatient,1,ML,34.96,24.472,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.044152,5.82353,416.02,percent of total billed charges,,,
TESTOSTERONE CYPIONATE 200 MG/ML IM SOLN,RX-7784,CDM,J1071,HCPCS,636,RC,00009-0417-01,NDC,outpatient,1,ML,41.92,29.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.844704,0.03,416.02,percent of total billed charges,,,
DEXAMETHASONE SOD PHOSPHATE PF 10 MG/ML IJ SOLN,RX-116345,CDM,J1100,HCPCS,636,RC,99999-0003-18,NDC,outpatient,1,ML,8.17,5.719,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.113579,0.11,416.02,percent of total billed charges,,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,63323-0165-01,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.11,416.02,percent of total billed charges,,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,00641-6145-01,NDC,outpatient,1,ML,4.14,2.898,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.071018,0.11,416.02,percent of total billed charges,,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,55150-0237-01,NDC,outpatient,1,ML,4.01,2.807,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.037387,0.11,416.02,percent of total billed charges,,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,67457-0423-00,NDC,outpatient,1,ML,3.69,2.583,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.954603,0.11,416.02,percent of total billed charges,,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,00641-6145-25,NDC,outpatient,1,ML,4.14,2.898,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.071018,0.11,416.02,percent of total billed charges,,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,63323-0165-02,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.11,416.02,percent of total billed charges,,,
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ WRAPPER,RX-4080098,CDM,J1100,HCPCS,636,RC,67457-0423-12,NDC,outpatient,1,ML,3.69,2.583,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.954603,0.11,416.02,percent of total billed charges,,,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,00641-0367-25,NDC,outpatient,1,ML,6.11,4.277,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.580657,0.11,416.02,percent of total billed charges,,,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,63323-0506-01,NDC,outpatient,1,ML,6.99,4.893,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.808313,0.11,416.02,percent of total billed charges,,,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,70069-0021-01,NDC,outpatient,1,ML,8.17,5.719,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.113579,0.11,416.02,percent of total billed charges,,,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,70069-0021-25,NDC,outpatient,1,ML,8.17,5.719,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.113579,0.11,416.02,percent of total billed charges,,,
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ WRAPPER,RX-4080102,CDM,J1100,HCPCS,636,RC,00641-0367-21,NDC,outpatient,1,ML,6.11,4.277,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.580657,0.11,416.02,percent of total billed charges,,,
DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN,RX-9859,CDM,J1110,HCPCS,636,RC,81284-0411-10,NDC,outpatient,1,ML,179.49,125.643,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,46.434063,40.295505,416.02,percent of total billed charges,,,
DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN,RX-9859,CDM,J1110,HCPCS,636,RC,81284-0411-00,NDC,outpatient,1,ML,179.49,125.643,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,46.434063,40.295505,416.02,percent of total billed charges,,,
DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN,RX-9859,CDM,J1110,HCPCS,636,RC,81284-0411-05,NDC,outpatient,1,ML,220.97,154.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,57.164939,40.295505,416.02,percent of total billed charges,,,
ACETAZOLAMIDE SODIUM 500 MG IJ SOLR,RX-114,CDM,J1120,HCPCS,636,RC,23155-0313-31,NDC,outpatient,1,UN,45.84,32.088,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.858808,10.29108,416.02,percent of total billed charges,,,
ACETAZOLAMIDE SODIUM 500 MG IJ SOLR,RX-114,CDM,J1120,HCPCS,636,RC,67457-0853-50,NDC,outpatient,1,UN,164.43,115.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,42.538041,10.29108,416.02,percent of total billed charges,,,
ACETAZOLAMIDE SODIUM 500 MG IJ SOLR,RX-114,CDM,J1120,HCPCS,636,RC,00143-9503-01,NDC,outpatient,1,UN,178.94,125.258,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,46.291778,10.29108,416.02,percent of total billed charges,,,
DIGOXIN 0.25 MG/ML IJ SOLN,RX-2442,CDM,J1160,HCPCS,636,RC,00641-1410-35,NDC,outpatient,2,ML,14.62,10.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.782194,3.28219,416.02,percent of total billed charges,,,
DIGOXIN 0.25 MG/ML IJ SOLN,RX-2442,CDM,J1160,HCPCS,636,RC,00641-1410-31,NDC,outpatient,2,ML,14.62,10.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.782194,3.28219,416.02,percent of total billed charges,,,
DIGOXIN 0.1 MG/ML IJ SOLN,RX-9853,CDM,J1160,HCPCS,636,RC,70515-0263-10,NDC,outpatient,1,ML,449.39,314.573,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,116.257193,3.28219,416.02,percent of total billed charges,,,
DIGOXIN IMMUNE FAB 40 MG IV SOLR,RX-31432,CDM,J1162,HCPCS,636,RC,50633-0120-11,NDC,outpatient,1,UN,12197.8,8538.46,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3155.57086,399.86,9367.9104,percent of total billed charges,,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,00641-0493-25,NDC,outpatient,2,ML,5.82,4.074,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.505634,0.44,416.02,percent of total billed charges,,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-10,NDC,outpatient,2,ML,10.45,7.315,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.703415,0.44,416.02,percent of total billed charges,,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-02,NDC,outpatient,2,ML,10.45,7.315,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.703415,0.44,416.02,percent of total billed charges,,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-05,NDC,outpatient,5,ML,10.7,7.49,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.76809,0.44,416.02,percent of total billed charges,,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,42192-0614-30,NDC,outpatient,5,ML,10.7,7.49,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.76809,0.44,416.02,percent of total billed charges,,,
PHENYTOIN SODIUM 50 MG/ML IJ SOLN,RX-6256,CDM,J1165,HCPCS,636,RC,00641-0493-21,NDC,outpatient,2,ML,5.82,4.074,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.505634,0.44,416.02,percent of total billed charges,,,
HYDROMORPHONE HCL PF 10 MG/ML IJ SOLN,RX-116809,CDM,J1170,HCPCS,636,RC,00703-0113-03,NDC,outpatient,10,ML,44.91,31.437,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.618217,2.507665,416.02,percent of total billed charges,,,
HYDROMORPHONE HCL PF 10 MG/ML IJ SOLN,RX-116809,CDM,J1170,HCPCS,636,RC,00409-2634-25,NDC,outpatient,10,ML,71.61,50.127,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,18.525507,2.507665,416.02,percent of total billed charges,,,
HYDROMORPHONE HCL PF 10 MG/ML IJ SOLN,RX-116809,CDM,J1170,HCPCS,636,RC,00703-0113-01,NDC,outpatient,10,ML,44.91,31.437,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.618217,2.507665,416.02,percent of total billed charges,,,
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,00409-1283-03,NDC,outpatient,1,ML,11.43,8.001,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.956941,2.507665,416.02,percent of total billed charges,,,
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,00409-1283-31,NDC,outpatient,1,ML,11.43,8.001,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.956941,2.507665,416.02,percent of total billed charges,,,
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,76045-0009-11,NDC,outpatient,1,ML,11.73,8.211,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.034551,2.507665,416.02,percent of total billed charges,,,
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,76045-0009-01,NDC,outpatient,1,ML,11.73,8.211,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.034551,2.507665,416.02,percent of total billed charges,,,
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,76045-0009-96,NDC,outpatient,0.5,ML,12.4,8.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.20788,2.507665,416.02,percent of total billed charges,,,
HYDROMORPHONE HCL 1 MG/ML IJ SOLN,RX-3757,CDM,J1170,HCPCS,636,RC,76045-0009-06,NDC,outpatient,0.5,ML,12.4,8.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.20788,2.507665,416.02,percent of total billed charges,,,
HYDROMORPHONE HCL 2 MG/ML IJ SOLN,RX-3758,CDM,J1170,HCPCS,636,RC,00641-6151-01,NDC,outpatient,1,ML,11.17,7.819,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.889679,2.507665,416.02,percent of total billed charges,,,
HYDROMORPHONE HCL 2 MG/ML IJ SOLN,RX-3758,CDM,J1170,HCPCS,636,RC,00641-6151-25,NDC,outpatient,1,ML,11.17,7.819,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.889679,2.507665,416.02,percent of total billed charges,,,
CONC DILAUDID 10 MG/ML PCA,RX-4080160,CDM,J1170,HCPCS,636,RC,99999-0000-95,NDC,outpatient,50,ML,267.65,187.355,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,69.241055,2.507665,416.02,percent of total billed charges,,,
DEXRAZOXANE HCL 500 MG IV SOLR,RX-146172,CDM,J1190,HCPCS,636,RC,51991-0942-98,NDC,outpatient,1,UN,575.66,402.962,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,148.923242,87.49,442.10688,percent of total billed charges,,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,00641-0376-21,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.74534,416.02,percent of total billed charges,,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-00,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.74534,416.02,percent of total billed charges,,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-16,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.74534,416.02,percent of total billed charges,,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-01,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.74534,416.02,percent of total billed charges,,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,63323-0664-41,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.74534,416.02,percent of total billed charges,,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,00641-0376-25,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.74534,416.02,percent of total billed charges,,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,72485-0101-01,NDC,outpatient,1,ML,4.75,3.325,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.228825,0.74534,416.02,percent of total billed charges,,,
DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN,RX-2508,CDM,J1200,HCPCS,636,RC,72485-0101-25,NDC,outpatient,1,ML,4.75,3.325,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.228825,0.74534,416.02,percent of total billed charges,,,
CHLOROTHIAZIDE SODIUM 500 MG IV SOLR,RX-9526,CDM,J1205,HCPCS,636,RC,25021-0305-20,NDC,outpatient,1,UN,139.6,97.72,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,36.11452,31.3402,416.02,percent of total billed charges,,,
DIMETHYL SULFOXIDE 50 % IS SOLN,RX-9873,CDM,J1212,HCPCS,636,RC,67457-0177-50,NDC,outpatient,50,ML,1852.55,1296.785,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,479.254685,399.86,1422.7584,percent of total billed charges,,,
METHADONE HCL 10 MG/ML IJ SOLN,RX-10546,CDM,J1230,HCPCS,636,RC,99999-0000-89,NDC,outpatient,1,ML,43.49,30.443,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.250863,9.763505,945.2928,percent of total billed charges,,,
METHADONE HCL 10 MG/ML IJ SOLN,RX-10546,CDM,J1230,HCPCS,636,RC,67457-0217-20,NDC,outpatient,20,ML,869.71,608.797,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,224.993977,9.763505,945.2928,percent of total billed charges,,,
METHADONE 10 MG/ML PCA,RX-4080162,CDM,J1230,HCPCS,636,RC,99999-0000-13,NDC,outpatient,50,ML,1230.85,861.595,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,318.420895,9.763505,945.2928,percent of total billed charges,,,
METHADONE 1 MG/ML IV INFUSION PREMIX,RX-4080178,CDM,J1230,HCPCS,636,RC,99999-0000-27,NDC,outpatient,200,ML,874.19,611.933,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,226.152953,9.763505,945.2928,percent of total billed charges,,,
DIPYRIDAMOLE 5 MG/ML IV SOLN,RX-9891,CDM,J1245,HCPCS,636,RC,00641-2569-41,NDC,outpatient,10,ML,75.79,53.053,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,19.606873,3.78,416.02,percent of total billed charges,,,
DIPYRIDAMOLE 5 MG/ML IV SOLN,RX-9891,CDM,J1245,HCPCS,636,RC,00641-2569-44,NDC,outpatient,10,ML,75.79,53.053,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,19.606873,3.78,416.02,percent of total billed charges,,,
DOBUTAMINE-DEXTROSE 1-5 MG/ML-% IV SOLN,RX-18314,CDM,J1250,HCPCS,636,RC,00409-2346-32,NDC,outpatient,250,ML,52.72,36.904,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.638664,4.15774,416.02,percent of total billed charges,,,
DOBUTAMINE-DEXTROSE 1-5 MG/ML-% IV SOLN,RX-18314,CDM,J1250,HCPCS,636,RC,00338-1073-02,NDC,outpatient,250,ML,38.25,26.775,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.895275,4.15774,416.02,percent of total billed charges,,,
DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN,RX-18315,CDM,J1250,HCPCS,636,RC,00409-2347-31,NDC,outpatient,250,ML,72.74,50.918,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,18.817838,4.15774,416.02,percent of total billed charges,,,
DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN,RX-18315,CDM,J1250,HCPCS,636,RC,00409-2347-32,NDC,outpatient,250,ML,72.74,50.918,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,18.817838,4.15774,416.02,percent of total billed charges,,,
DOBUTAMINE-DEXTROSE 2-5 MG/ML-% IV SOLN,RX-18315,CDM,J1250,HCPCS,636,RC,00338-1075-02,NDC,outpatient,250,ML,52.72,36.904,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.638664,4.15774,416.02,percent of total billed charges,,,
DOBUTAMINE 50 MG IN D5W 50 ML SYRINGE FROM PREMIX BAG (NEO/PED),RX-4081532,CDM,J1250,HCPCS,636,RC,99999-0004-34,NDC,outpatient,50,ML,24.49,17.143,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.335563,4.15774,416.02,percent of total billed charges,,,
DOBUTAMINE HCL 250 MG/20ML IV SOLN,RX-77318,CDM,J1250,HCPCS,636,RC,00143-9141-01,NDC,outpatient,20,ML,18.52,12.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.791124,4.15774,416.02,percent of total billed charges,,,
DOBUTAMINE HCL 250 MG/20ML IV SOLN,RX-77318,CDM,J1250,HCPCS,636,RC,00409-2344-01,NDC,outpatient,20,ML,27.59,19.313,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.137533,4.15774,416.02,percent of total billed charges,,,
DOBUTAMINE HCL 250 MG/20ML IV SOLN,RX-77318,CDM,J1250,HCPCS,636,RC,00143-9141-10,NDC,outpatient,20,ML,18.52,12.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.791124,4.15774,416.02,percent of total billed charges,,,
DOPAMINE-DEXTROSE 0.8-5 MG/ML-% IV SOLN,RX-14844,CDM,J1265,HCPCS,636,RC,00338-1005-02,NDC,outpatient,250,ML,41.59,29.113,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.759333,0.7,416.02,percent of total billed charges,,,
DOPAMINE-DEXTROSE 1.6-5 MG/ML-% IV SOLN,RX-14845,CDM,J1265,HCPCS,636,RC,00338-1007-02,NDC,outpatient,250,ML,48.27,33.789,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.487449,0.7,416.02,percent of total billed charges,,,
DOPAMINE-DEXTROSE 1.6-5 MG/ML-% IV SOLN,RX-14845,CDM,J1265,HCPCS,636,RC,00409-7809-22,NDC,outpatient,250,ML,50.49,35.343,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.061763,0.7,416.02,percent of total billed charges,,,
DOPAMINE-DEXTROSE 1.6-5 MG/ML-% IV SOLN,RX-14845,CDM,J1265,HCPCS,636,RC,00409-7809-11,NDC,outpatient,250,ML,50.49,35.343,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.061763,0.7,416.02,percent of total billed charges,,,
DOPAMINE HCL 40 MG/ML IV SOLN,RX-2595,CDM,J1265,HCPCS,636,RC,00409-9104-21,NDC,outpatient,10,ML,13.16,9.212,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.404492,0.7,416.02,percent of total billed charges,,,
DOPAMINE HCL 40 MG/ML IV SOLN,RX-2595,CDM,J1265,HCPCS,636,RC,00409-9104-20,NDC,outpatient,10,ML,13.16,9.212,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.404492,0.7,416.02,percent of total billed charges,,,
DOPAMINE 40 MG IN D5W 50 ML SYRINGE FROM PREMIX BAG (NEO/PED),RX-4081531,CDM,J1265,HCPCS,636,RC,99999-0004-33,NDC,outpatient,50,ML,21.92,15.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.670704,0.7,416.02,percent of total billed charges,,,
ECULIZUMAB 300 MG/30ML IV SOLN,RX-81696,CDM,J1300,HCPCS,636,RC,25682-0001-01,NDC,outpatient,30,ML,18003.46,12602.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4657.495102,224.63,13826.65728,percent of total billed charges,,,
VELETRI 1.5 MG IV SOLR,RX-106514,CDM,J1325,HCPCS,636,RC,66215-0402-01,NDC,outpatient,1,UN,260.55,182.385,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,67.404285,15.86,416.02,percent of total billed charges,,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00409-3510-21,NDC,outpatient,1,UN,135.69,94.983,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,35.103003,10.42,416.02,percent of total billed charges,,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,60505-6196-00,NDC,outpatient,1,UN,127.17,89.019,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,32.898879,10.42,416.02,percent of total billed charges,,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00143-9398-01,NDC,outpatient,1,UN,100.74,70.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,26.061438,10.42,416.02,percent of total billed charges,,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,16714-0889-10,NDC,outpatient,1,UN,129.15,90.405,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,33.411105,10.42,416.02,percent of total billed charges,,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00143-9398-10,NDC,outpatient,1,UN,100.74,70.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,26.061438,10.42,416.02,percent of total billed charges,,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,00409-3510-22,NDC,outpatient,1,UN,135.69,94.983,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,35.103003,10.42,416.02,percent of total billed charges,,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,16714-0889-01,NDC,outpatient,1,UN,129.15,90.405,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,33.411105,10.42,416.02,percent of total billed charges,,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,42023-0221-01,NDC,outpatient,1,UN,95.49,66.843,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,24.703263,10.42,416.02,percent of total billed charges,,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,42023-0221-10,NDC,outpatient,1,UN,95.49,66.843,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,24.703263,10.42,416.02,percent of total billed charges,,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,55150-0282-20,NDC,outpatient,1,UN,111.68,78.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,28.891616,10.42,416.02,percent of total billed charges,,,
ERTAPENEM SODIUM 1 G IJ SOLR,RX-31922,CDM,J1335,HCPCS,636,RC,60505-6196-04,NDC,outpatient,1,UN,127.17,89.019,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,32.898879,10.42,416.02,percent of total billed charges,,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00409-3510-22,NDC,outpatient,1,UN,135.69,94.983,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,35.103003,10.42,416.02,percent of total billed charges,,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,60505-6196-04,NDC,outpatient,1,UN,127.17,89.019,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,32.898879,10.42,416.02,percent of total billed charges,,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00143-9398-10,NDC,outpatient,1,UN,100.74,70.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,26.061438,10.42,416.02,percent of total billed charges,,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,16714-0889-10,NDC,outpatient,1,UN,129.15,90.405,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,33.411105,10.42,416.02,percent of total billed charges,,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,42023-0221-01,NDC,outpatient,1,UN,95.49,66.843,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,24.703263,10.42,416.02,percent of total billed charges,,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00409-3510-21,NDC,outpatient,1,UN,135.69,94.983,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,35.103003,10.42,416.02,percent of total billed charges,,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,16714-0889-01,NDC,outpatient,1,UN,129.15,90.405,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,33.411105,10.42,416.02,percent of total billed charges,,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,42023-0221-10,NDC,outpatient,1,UN,95.49,66.843,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,24.703263,10.42,416.02,percent of total billed charges,,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,55150-0282-20,NDC,outpatient,1,UN,111.68,78.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,28.891616,10.42,416.02,percent of total billed charges,,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,00143-9398-01,NDC,outpatient,1,UN,100.74,70.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,26.061438,10.42,416.02,percent of total billed charges,,,
ERTAPENEM 1 G IJ SOLR 100 MG/ML,RX-4080999,CDM,J1335,HCPCS,636,RC,60505-6196-00,NDC,outpatient,1,UN,127.17,89.019,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,32.898879,10.42,416.02,percent of total billed charges,,,
ERYTHROMYCIN LACTOBIONATE 500 MG IV SOLR,RX-2903,CDM,J1364,HCPCS,636,RC,00409-6482-11,NDC,outpatient,1,UN,236.03,165.221,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,61.060961,52.988735,416.02,percent of total billed charges,,,
ERYTHROMYCIN LACTOBIONATE 500 MG IV SOLR,RX-2903,CDM,J1364,HCPCS,636,RC,00409-6482-01,NDC,outpatient,1,UN,236.03,165.221,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,61.060961,52.988735,416.02,percent of total billed charges,,,
ESTROGENS CONJUGATED 25 MG IJ SOLR,RX-9972,CDM,J1410,HCPCS,636,RC,00046-0749-05,NDC,outpatient,1,UN,1513.36,1059.352,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,391.506232,339.74932,1162.26048,percent of total billed charges,,,
FERRIC CARBOXYMALTOSE 750 MG/15ML IV SOLN,RX-122648,CDM,J1439,HCPCS,636,RC,00517-0650-01,NDC,outpatient,15,ML,2478.29,1734.803,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,641.133623,1.1,1903.32672,percent of total billed charges,,,
FLUCONAZOLE IN SODIUM CHLORIDE 200-0.9 MG/100ML-% IV SOLN,RX-10049,CDM,J1450,HCPCS,636,RC,25021-0184-82,NDC,outpatient,100,ML,36.03,25.221,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.320961,2.61,416.02,percent of total billed charges,,,
FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN,RX-10050,CDM,J1450,HCPCS,636,RC,00409-4688-12,NDC,outpatient,200,ML,35.54,24.878,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.194198,2.61,416.02,percent of total billed charges,,,
FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN,RX-10050,CDM,J1450,HCPCS,636,RC,00409-4688-16,NDC,outpatient,200,ML,35.54,24.878,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.194198,2.61,416.02,percent of total billed charges,,,
FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN,RX-10050,CDM,J1450,HCPCS,636,RC,69784-0003-06,NDC,outpatient,200,ML,35.58,24.906,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.204546,2.61,416.02,percent of total billed charges,,,
FLUCONAZOLE IVPB,RX-4080630,CDM,J1450,HCPCS,636,RC,99999-0001-23,NDC,outpatient,50,ML,23.46,16.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.069102,2.61,416.02,percent of total billed charges,,,
FOMEPIZOLE 1 GM/ML IV SOLN,RX-22185,CDM,J1451,HCPCS,636,RC,70710-1478-01,NDC,outpatient,1.5,ML,2014.79,1410.353,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,521.226173,7.3781655,1590,percent of total billed charges,,,
FOMEPIZOLE 1 GM/ML IV SOLN,RX-22185,CDM,J1451,HCPCS,636,RC,67457-0211-02,NDC,outpatient,1.5,ML,1680.9,1176.63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,434.84883,7.3781655,1590,percent of total billed charges,,,
FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR,RX-106783,CDM,J1453,HCPCS,636,RC,00006-3061-00,NDC,outpatient,1,UN,1375.94,963.158,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,355.955678,0.14,1056.72192,percent of total billed charges,,,
FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR,RX-106783,CDM,J1453,HCPCS,636,RC,00006-3061-01,NDC,outpatient,1,UN,1375.94,963.158,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,355.955678,0.14,1056.72192,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0437-10,NDC,outpatient,100,ML,2692.38,1884.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,696.518706,47.99,8270.99136,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0438-20,NDC,outpatient,200,ML,5384.76,3769.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1393.037412,47.99,8270.99136,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0439-40,NDC,outpatient,400,ML,10769.52,7538.664,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2786.074824,47.99,8270.99136,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0436-90,NDC,outpatient,100,ML,2692.38,1884.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,696.518706,47.99,8270.99136,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0439-93,NDC,outpatient,400,ML,10769.52,7538.664,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2786.074824,47.99,8270.99136,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0437-91,NDC,outpatient,100,ML,2692.38,1884.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,696.518706,47.99,8270.99136,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) PRIVIGEN 10 % IV SOLN,RX-4080092,CDM,J1459,HCPCS,636,RC,44206-0436-05,NDC,outpatient,100,ML,2692.38,1884.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,696.518706,47.99,8270.99136,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) IM INJ,RX-15342,CDM,J1460,HCPCS,636,RC,13533-0335-04,NDC,outpatient,2,ML,422.8,295.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,109.37836,48.47,416.02,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) IM INJ,RX-15342,CDM,J1460,HCPCS,636,RC,13533-0335-40,NDC,outpatient,2,ML,422.8,295.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,109.37836,48.47,416.02,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-41,NDC,outpatient,400,ML,8399.24,5879.468,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2172.883388,48.81,6450.61632,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-71,NDC,outpatient,100,ML,2099.81,1469.867,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,543.220847,48.81,6450.61632,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-20,NDC,outpatient,100,ML,2099.81,1469.867,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,543.220847,48.81,6450.61632,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-25,NDC,outpatient,200,ML,4199.62,2939.734,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.441694,48.81,6450.61632,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-72,NDC,outpatient,100,ML,2099.81,1469.867,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,543.220847,48.81,6450.61632,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-21,NDC,outpatient,100,ML,2099.81,1469.867,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,543.220847,48.81,6450.61632,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-24,NDC,outpatient,200,ML,4199.62,2939.734,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1086.441694,48.81,6450.61632,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMUNEX-C 10 % IV SOLN,RX-4080221,CDM,J1561,HCPCS,636,RC,13533-0800-40,NDC,outpatient,400,ML,8399.24,5879.468,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2172.883388,48.81,6450.61632,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD S/D  5 % IGA <=2.2,RX-4080223,CDM,J1566,HCPCS,636,RC,00944-2620-03,NDC,outpatient,5,GR,934.5,654.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,241.75515,77.77,1531.4,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD S/D  5 % IGA <= 1,RX-4080224,CDM,J1566,HCPCS,636,RC,00944-2656-03,NDC,outpatient,5,GR,577.48,404.236,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,149.394076,77.77,1531.4,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD S/D  5 % IGA <= 1,RX-4080224,CDM,J1566,HCPCS,636,RC,00944-2658-04,NDC,outpatient,10,GR,1154.96,808.472,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,298.788152,77.77,1531.4,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) OCTAGAM 5 % IV SOLN,RX-4080225,CDM,J1568,HCPCS,636,RC,68209-0843-03,NDC,outpatient,200,ML,1884.53,1319.171,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,487.527911,44.12,1447.31904,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) OCTAGAM 5 % IV SOLN,RX-4080225,CDM,J1568,HCPCS,636,RC,68209-0843-04,NDC,outpatient,200,ML,1884.53,1319.171,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,487.527911,44.12,1447.31904,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-03,NDC,outpatient,100,ML,2726.33,1908.431,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,705.301571,46.03,6281.46432,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-06,NDC,outpatient,200,ML,5452.66,3816.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1410.603142,46.03,6281.46432,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-09,NDC,outpatient,100,ML,2726.33,1908.431,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,705.301571,46.03,6281.46432,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-10,NDC,outpatient,100,ML,2726.33,1908.431,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,705.301571,46.03,6281.46432,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-13,NDC,outpatient,300,ML,8178.99,5725.293,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2115.904713,46.03,6281.46432,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-05,NDC,outpatient,100,ML,2726.33,1908.431,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,705.301571,46.03,6281.46432,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-08,NDC,outpatient,100,ML,2726.33,1908.431,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,705.301571,46.03,6281.46432,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-11,NDC,outpatient,100,ML,2726.33,1908.431,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,705.301571,46.03,6281.46432,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-12,NDC,outpatient,200,ML,5452.66,3816.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1410.603142,46.03,6281.46432,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-04,NDC,outpatient,100,ML,2726.33,1908.431,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,705.301571,46.03,6281.46432,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-02,NDC,outpatient,100,ML,2726.33,1908.431,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,705.301571,46.03,6281.46432,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) GAMMAGARD 10 % IV SOLN,RX-4080222,CDM,J1569,HCPCS,636,RC,00944-2700-07,NDC,outpatient,300,ML,8178.99,5725.293,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2115.904713,46.03,6281.46432,percent of total billed charges,,,
GANCICLOVIR SODIUM 500 MG IV SOLR,RX-10101,CDM,J1570,HCPCS,636,RC,70436-0089-55,NDC,outpatient,1,UN,165.87,116.109,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,42.910569,36.41,416.02,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-00,NDC,outpatient,400,ML,4250.4,2975.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1099.57848,48.52,3264.3072,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-08,NDC,outpatient,200,ML,2125.2,1487.64,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,549.78924,48.52,3264.3072,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-05,NDC,outpatient,400,ML,4250.4,2975.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1099.57848,48.52,3264.3072,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-03,NDC,outpatient,200,ML,2125.2,1487.64,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,549.78924,48.52,3264.3072,percent of total billed charges,,,
IMMUNE GLOBULIN (HUMAN) FLEBOGAMMA 5 % DIF IV SOLN,RX-4080226,CDM,J1572,HCPCS,636,RC,61953-0004-04,NDC,outpatient,200,ML,2125.2,1487.64,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,549.78924,48.52,3264.3072,percent of total billed charges,,,
GENTAMICIN 80 MG IN NS 50 ML IV SOLN PREMIX,RX-15911,CDM,J1580,HCPCS,636,RC,99999-0002-93,NDC,outpatient,50,ML,25.25,17.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.532175,1.23924,416.02,percent of total billed charges,,,
GENTAMICIN 80 MG IN NS 50 ML IV SOLN PREMIX,RX-15911,CDM,J1580,HCPCS,636,RC,00338-0509-41,NDC,outpatient,50,ML,25,17.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.4675,1.23924,416.02,percent of total billed charges,,,
GENTAMICIN SULFATE 10 MG/ML IJ SOLN,RX-3425,CDM,J1580,HCPCS,636,RC,63323-0173-01,NDC,outpatient,2,ML,9.88,6.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.555956,1.23924,416.02,percent of total billed charges,,,
GENTAMICIN SULFATE 10 MG/ML IJ SOLN,RX-3425,CDM,J1580,HCPCS,636,RC,63323-0173-02,NDC,outpatient,2,ML,9.88,6.916,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.555956,1.23924,416.02,percent of total billed charges,,,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-02,NDC,outpatient,2,ML,5.52,3.864,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.428024,1.23924,416.02,percent of total billed charges,,,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-03,NDC,outpatient,20,ML,102.62,71.834,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,26.547794,1.23924,416.02,percent of total billed charges,,,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,00409-1207-13,NDC,outpatient,2,ML,12.55,8.785,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.246685,1.23924,416.02,percent of total billed charges,,,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,00409-1207-03,NDC,outpatient,2,ML,12.55,8.785,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.246685,1.23924,416.02,percent of total billed charges,,,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-20,NDC,outpatient,20,ML,102.62,71.834,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,26.547794,1.23924,416.02,percent of total billed charges,,,
GENTAMICIN SULFATE 40 MG/ML IJ SOLN,RX-3426,CDM,J1580,HCPCS,636,RC,63323-0010-01,NDC,outpatient,2,ML,5.52,3.864,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.428024,1.23924,416.02,percent of total billed charges,,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,00143-9682-25,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.51,416.02,percent of total billed charges,,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,00517-4601-25,NDC,outpatient,1,ML,7.56,5.292,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.955772,0.51,416.02,percent of total billed charges,,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,70121-1394-05,NDC,outpatient,1,ML,17.13,11.991,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.431531,0.51,416.02,percent of total billed charges,,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,00143-9682-01,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.51,416.02,percent of total billed charges,,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,70121-1394-01,NDC,outpatient,1,ML,17.13,11.991,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.431531,0.51,416.02,percent of total billed charges,,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,71288-0414-03,NDC,outpatient,1,ML,4.37,3.059,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.130519,0.51,416.02,percent of total billed charges,,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,16714-0536-01,NDC,outpatient,1,ML,5.69,3.983,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.472003,0.51,416.02,percent of total billed charges,,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,16714-0536-25,NDC,outpatient,1,ML,5.69,3.983,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.472003,0.51,416.02,percent of total billed charges,,,
GLYCOPYRROLATE 0.2 MG/ML IJ SOLN WRAPPER,RX-4080553,CDM,J1596,HCPCS,636,RC,71288-0414-01,NDC,outpatient,1,ML,4.37,3.059,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.130519,0.51,416.02,percent of total billed charges,,,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00597-0053-01,NDC,outpatient,1,UN,403.75,282.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,104.450125,90.641875,579.456,percent of total billed charges,,,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00597-0053-45,NDC,outpatient,1,UN,403.75,282.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,104.450125,90.641875,579.456,percent of total billed charges,,,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00548-5850-00,NDC,outpatient,1,UN,754.5,528.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,195.18915,90.641875,579.456,percent of total billed charges,,,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1610,HCPCS,636,RC,00597-0260-10,NDC,outpatient,1,UN,403.75,282.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,104.450125,90.641875,579.456,percent of total billed charges,,,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1611,HCPCS,636,RC,63323-0596-11,NDC,outpatient,1,UN,610.61,427.427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,157.964807,101.41,468.94848,percent of total billed charges,,,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1611,HCPCS,636,RC,63323-0596-13,NDC,outpatient,1,UN,610.61,427.427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,157.964807,101.41,468.94848,percent of total billed charges,,,
GLUCAGON HCL (RDNA) 1 MG IJ SOLR WRAPPER,RX-4080638,CDM,J1611,HCPCS,636,RC,63323-0593-03,NDC,outpatient,1,UN,610.59,427.413,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,157.959633,101.41,468.94848,percent of total billed charges,,,
GRANISETRON HCL 1 MG/ML IV SOLN,RX-12552,CDM,J1626,HCPCS,636,RC,00143-9744-01,NDC,outpatient,1,ML,11.46,8.022,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.964702,0.28,416.02,percent of total billed charges,,,
GRANISETRON HCL 1 MG/ML IV SOLN,RX-12552,CDM,J1626,HCPCS,636,RC,00143-9744-10,NDC,outpatient,1,ML,11.46,8.022,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.964702,0.28,416.02,percent of total billed charges,,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,00143-9501-25,NDC,outpatient,1,ML,7.22,5.054,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.867814,0.74534,416.02,percent of total billed charges,,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,76045-0737-10,NDC,outpatient,1,ML,15.64,10.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.046068,0.74534,416.02,percent of total billed charges,,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,67457-0426-00,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.74534,416.02,percent of total billed charges,,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,76045-0737-01,NDC,outpatient,1,ML,15.64,10.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.046068,0.74534,416.02,percent of total billed charges,,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,00143-9501-01,NDC,outpatient,1,ML,7.22,5.054,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.867814,0.74534,416.02,percent of total billed charges,,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,63323-0474-00,NDC,outpatient,1,ML,3.76,2.632,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.972712,0.74534,416.02,percent of total billed charges,,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,63323-0474-01,NDC,outpatient,1,ML,3.76,2.632,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.972712,0.74534,416.02,percent of total billed charges,,,
HALOPERIDOL LACTATE 5 MG/ML IJ SOLN,RX-3584,CDM,J1630,HCPCS,636,RC,67457-0426-12,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.74534,416.02,percent of total billed charges,,,
HEPARIN LOCK FLUSH 100 UNIT/ML IV SOLN WRAPPER,RX-4080200,CDM,J1642,HCPCS,636,RC,08290-3064-24,NDC,outpatient,5,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.02,416.02,other,Non-Reimbursable Procedures,,
HEPARIN LOCK FLUSH 100 UNIT/ML IV SOLN WRAPPER,RX-4080200,CDM,J1642,HCPCS,636,RC,64253-0333-35,NDC,outpatient,5,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.02,416.02,other,Non-Reimbursable Procedures,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,25021-0400-01,NDC,outpatient,1,ML,5.04,3.528,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.303848,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,25021-0400-10,NDC,outpatient,10,ML,16.81,11.767,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.348747,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-15,NDC,outpatient,10,ML,18.71,13.097,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.840277,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0920-11,NDC,outpatient,1,ML,3.83,2.681,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.990821,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,00409-2720-31,NDC,outpatient,10,ML,15.99,11.193,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.136613,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0276-01,NDC,outpatient,2,ML,21.8,15.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.63966,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0385-10,NDC,outpatient,10,ML,19.64,13.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.080868,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,71288-0400-03,NDC,outpatient,2,ML,19.86,13.902,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.137782,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-05,NDC,outpatient,10,ML,18.71,13.097,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.840277,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0920-25,NDC,outpatient,1,ML,3.83,2.681,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.990821,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0931-14,NDC,outpatient,10,ML,10.28,7.196,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.659436,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63739-0931-28,NDC,outpatient,10,ML,10.28,7.196,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.659436,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0372-99,NDC,outpatient,1,ML,13.11,9.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.391557,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0385-99,NDC,outpatient,10,ML,19.64,13.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.080868,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,00409-2720-02,NDC,outpatient,10,ML,15.99,11.193,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.136613,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0276-02,NDC,outpatient,2,ML,21.8,15.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.63966,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-33,NDC,outpatient,30,ML,21.77,15.239,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.631899,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,63323-0540-36,NDC,outpatient,30,ML,21.77,15.239,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.631899,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,67457-0372-12,NDC,outpatient,1,ML,13.11,9.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.391557,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN,RX-10176,CDM,J1644,HCPCS,636,RC,71288-0400-02,NDC,outpatient,2,ML,19.86,13.902,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.137782,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 20000 UNIT/ML IJ SOLN,RX-10178,CDM,J1644,HCPCS,636,RC,63739-0986-11,NDC,outpatient,1,ML,33.86,23.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.759582,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 20000 UNIT/ML IJ SOLN,RX-10178,CDM,J1644,HCPCS,636,RC,63739-0986-25,NDC,outpatient,1,ML,33.86,23.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.759582,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,00409-2723-31,NDC,outpatient,1,ML,3.99,2.793,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.032213,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,00409-2723-02,NDC,outpatient,1,ML,3.99,2.793,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.032213,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,63739-0953-11,NDC,outpatient,1,ML,6.36,4.452,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.645332,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,63739-0953-25,NDC,outpatient,1,ML,6.36,4.452,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.645332,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,71288-0403-01,NDC,outpatient,1,ML,3.33,2.331,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.861471,0.22,416.02,percent of total billed charges,,,
HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN,RX-10181,CDM,J1644,HCPCS,636,RC,71288-0403-02,NDC,outpatient,1,ML,3.33,2.331,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.861471,0.22,416.02,percent of total billed charges,,,
HEPARIN (PORCINE) IN NACL 25000-0.45 UT/250ML-% IV SOLN,RX-135728,CDM,J1644,HCPCS,636,RC,00409-7650-52,NDC,outpatient,250,ML,63.84,44.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.515408,0.22,416.02,percent of total billed charges,,,
HEPARIN (PORCINE) IN NACL 25000-0.45 UT/250ML-% IV SOLN,RX-135728,CDM,J1644,HCPCS,636,RC,00409-7650-62,NDC,outpatient,250,ML,63.84,44.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.515408,0.22,416.02,percent of total billed charges,,,
HEPARIN SOD (PORCINE) IN D5W 100 UNIT/ML IV SOLN,RX-24329,CDM,J1644,HCPCS,636,RC,63323-0523-01,NDC,outpatient,250,ML,44.93,31.451,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.623391,0.22,416.02,percent of total billed charges,,,
HEPARIN SOD (PORCINE) IN D5W 100 UNIT/ML IV SOLN,RX-24329,CDM,J1644,HCPCS,636,RC,00264-9587-20,NDC,outpatient,250,ML,77.19,54.033,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,19.969053,0.22,416.02,percent of total billed charges,,,
HEPARIN SOD (PORCINE) IN D5W 100 UNIT/ML IV SOLN,RX-24329,CDM,J1644,HCPCS,636,RC,63323-0523-74,NDC,outpatient,250,ML,44.93,31.451,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.623391,0.22,416.02,percent of total billed charges,,,
HEPARIN SOD (PORCINE) PREMIX 30000 UNITS IN 1L NS,RX-4080227,CDM,J1644,HCPCS,636,RC,70092-1281-08,NDC,outpatient,1000,ML,120.09,84.063,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,31.067283,0.22,416.02,percent of total billed charges,,,
HEPARIN SOD (PORCINE) PREMIX 30000 UNITS IN 1L NS,RX-4080227,CDM,J1644,HCPCS,636,RC,99999-0921-33,NDC,outpatient,1000,ML,91.43,64.001,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,23.652941,0.22,416.02,percent of total billed charges,,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00264-9872-10,NDC,outpatient,500,ML,33.8,23.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.74406,0.22,416.02,percent of total billed charges,,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,99999-0001-71,NDC,outpatient,500,ML,22,15.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.6914,0.22,416.02,percent of total billed charges,,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00338-0424-18,NDC,outpatient,500,ML,28.85,20.195,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.463495,0.22,416.02,percent of total billed charges,,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-1005-01,NDC,outpatient,500,ML,33.99,23.793,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.793213,0.22,416.02,percent of total billed charges,,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-1005-20,NDC,outpatient,500,ML,33.99,23.793,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.793213,0.22,416.02,percent of total billed charges,,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-7620-03,NDC,outpatient,500,ML,33.99,23.793,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.793213,0.22,416.02,percent of total billed charges,,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,63323-0519-02,NDC,outpatient,500,ML,31.42,21.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.128354,0.22,416.02,percent of total billed charges,,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,00409-7620-13,NDC,outpatient,500,ML,33.99,23.793,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.793213,0.22,416.02,percent of total billed charges,,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,63323-0519-77,NDC,outpatient,500,ML,31.42,21.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.128354,0.22,416.02,percent of total billed charges,,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,99999-0001-81,NDC,outpatient,1000,ML,22.86,16.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.913882,0.22,416.02,percent of total billed charges,,,
HEPARIN (PORCINE) IN NACL 2-0.9 UNIT/ML-% IJ SOLN WRAPPER,RX-4081178,CDM,J1644,HCPCS,636,RC,99999-0002-94,NDC,outpatient,5,ML,16.13,11.291,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.172831,0.22,416.02,percent of total billed charges,,,
HEPARIN (PORCINE) IN NACL 25000-0.9 UT/250ML-% IV SOLN,RX-4081544,CDM,J1644,HCPCS,636,RC,99999-0003-32,NDC,outpatient,250,ML,30.4,21.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.86448,0.22,416.02,percent of total billed charges,,,
HEPARIN (PORCINE) IN NACL 25000-0.9 UT/250ML-% IV SOLN,RX-4081544,CDM,J1644,HCPCS,636,RC,99999-0003-31,NDC,outpatient,250,ML,42.73,29.911,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.054251,0.22,416.02,percent of total billed charges,,,
ENOXAPARIN SODIUM 30 MG/0.3ML IJ SOSY,RX-158184,CDM,J1650,HCPCS,636,RC,00548-5601-00,NDC,outpatient,0.3,ML,20.03,14.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.181761,0.57,416.02,percent of total billed charges,,,
ENOXAPARIN SODIUM 40 MG/0.4ML IJ SOSY,RX-158185,CDM,J1650,HCPCS,636,RC,00548-5602-00,NDC,outpatient,0.4,ML,26.7,18.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.90729,0.57,416.02,percent of total billed charges,,,
ENOXAPARIN SODIUM 60 MG/0.6ML IJ SOSY,RX-158186,CDM,J1650,HCPCS,636,RC,00548-5603-00,NDC,outpatient,0.6,ML,40.05,28.035,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.360935,0.57,416.02,percent of total billed charges,,,
ENOXAPARIN SODIUM 80 MG/0.8ML IJ SOSY,RX-158187,CDM,J1650,HCPCS,636,RC,00548-5604-00,NDC,outpatient,0.8,ML,53.4,37.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.81458,0.57,416.02,percent of total billed charges,,,
ENOXAPARIN SODIUM 100 MG/ML IJ SOSY,RX-158188,CDM,J1650,HCPCS,636,RC,00548-5605-00,NDC,outpatient,1,ML,66.75,46.725,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,17.268225,0.57,416.02,percent of total billed charges,,,
ENOXAPARIN SODIUM 120 MG/0.8ML IJ SOSY,RX-158189,CDM,J1650,HCPCS,636,RC,00548-5606-00,NDC,outpatient,0.8,ML,80.1,56.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,20.72187,0.57,416.02,percent of total billed charges,,,
ENOXAPARIN SODIUM 150 MG/ML IJ SOSY,RX-158190,CDM,J1650,HCPCS,636,RC,00548-5607-00,NDC,outpatient,1,ML,100.13,70.091,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,25.903631,0.57,416.02,percent of total billed charges,,,
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,67457-0583-00,NDC,outpatient,0.4,ML,146.14,102.298,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,37.806418,0.92,416.02,percent of total billed charges,,,
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,55150-0231-00,NDC,outpatient,0.4,ML,58.52,40.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15.139124,0.92,416.02,percent of total billed charges,,,
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,55150-0231-10,NDC,outpatient,0.4,ML,58.52,40.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15.139124,0.92,416.02,percent of total billed charges,,,
FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN,RX-108027,CDM,J1652,HCPCS,636,RC,67457-0583-04,NDC,outpatient,0.4,ML,146.14,102.298,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,37.806418,0.92,416.02,percent of total billed charges,,,
FONDAPARINUX SODIUM 7.5 MG/0.6ML SC SOLN,RX-108028,CDM,J1652,HCPCS,636,RC,55111-0680-10,NDC,outpatient,0.6,ML,45.65,31.955,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.809655,0.92,416.02,percent of total billed charges,,,
FONDAPARINUX SODIUM 7.5 MG/0.6ML SC SOLN,RX-108028,CDM,J1652,HCPCS,636,RC,55111-0680-11,NDC,outpatient,0.6,ML,45.65,31.955,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.809655,0.92,416.02,percent of total billed charges,,,
FONDAPARINUX SODIUM 10 MG/0.8ML SC SOLN,RX-108029,CDM,J1652,HCPCS,636,RC,67457-0585-08,NDC,outpatient,0.8,ML,146.14,102.298,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,37.806418,0.92,416.02,percent of total billed charges,,,
FONDAPARINUX SODIUM 10 MG/0.8ML SC SOLN,RX-108029,CDM,J1652,HCPCS,636,RC,67457-0585-00,NDC,outpatient,0.8,ML,146.14,102.298,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,37.806418,0.92,416.02,percent of total billed charges,,,
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55150-0230-00,NDC,outpatient,0.5,ML,20.75,14.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.368025,0.92,416.02,percent of total billed charges,,,
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55111-0678-11,NDC,outpatient,0.5,ML,21,14.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.4327,0.92,416.02,percent of total billed charges,,,
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55150-0230-10,NDC,outpatient,0.5,ML,20.75,14.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.368025,0.92,416.02,percent of total billed charges,,,
FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN,RX-32215,CDM,J1652,HCPCS,636,RC,55111-0678-10,NDC,outpatient,0.5,ML,21,14.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.4327,0.92,416.02,percent of total billed charges,,,
TETANUS IMMUNE GLOBULIN 250 UNIT/ML IM SOSY,RX-156399,CDM,J1670,HCPCS,636,RC,13533-0634-02,NDC,outpatient,1,ML,1484.53,1039.171,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,384.047911,333.276985,1140.11904,percent of total billed charges,,,
TETANUS IMMUNE GLOBULIN 250 UNIT/ML IM SOSY,RX-156399,CDM,J1670,HCPCS,636,RC,13533-0634-20,NDC,outpatient,1,ML,1484.53,1039.171,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,384.047911,333.276985,1140.11904,percent of total billed charges,,,
HYDROCORTISONE SOD SUC (PF) 250 MG IJ SOLR,RX-160127,CDM,J1720,HCPCS,636,RC,00009-0013-05,NDC,outpatient,1,UN,153.4,107.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,39.68458,13.56878,416.02,percent of total billed charges,,,
HYDROCORTISONE SOD SUC (PF) 500 MG IJ SOLR,RX-160129,CDM,J1720,HCPCS,636,RC,00009-0016-12,NDC,outpatient,1,UN,308.7,216.09,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,79.86069,13.56878,416.02,percent of total billed charges,,,
HYDROCORTISONE NA SUCCINATE PF 100 MG IJ WRAPPER,RX-4080176,CDM,J1720,HCPCS,636,RC,00009-0825-01,NDC,outpatient,1,UN,60.44,42.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15.635828,13.56878,416.02,percent of total billed charges,,,
HYDROCORTISONE NA SUCCINATE PF 100 MG IJ WRAPPER,RX-4080176,CDM,J1720,HCPCS,636,RC,00009-0011-04,NDC,outpatient,1,UN,83.69,58.583,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,21.650603,13.56878,416.02,percent of total billed charges,,,
IBANDRONATE SODIUM 3 MG/3ML IV SOLN,RX-110306,CDM,J1740,HCPCS,636,RC,60505-6097-00,NDC,outpatient,3,ML,291.8,204.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,75.48866,27.14,416.02,percent of total billed charges,,,
IBUTILIDE FUMARATE 1 MG/10ML IV SOLN,RX-100740,CDM,J1742,HCPCS,636,RC,00009-3794-01,NDC,outpatient,10,ML,380.26,266.182,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,98.373262,85.36837,416.02,percent of total billed charges,,,
INFLIXIMAB 100 MG IV SOLR,RX-23796,CDM,J1745,HCPCS,636,RC,57894-0030-01,NDC,outpatient,1,UN,3124.93,2187.451,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,808.419391,32.22,2399.94624,percent of total billed charges,,,
IRON DEXTRAN 50 MG/ML IJ SOLN,RX-3990,CDM,J1750,HCPCS,636,RC,00023-6082-01,NDC,outpatient,2,ML,145.94,102.158,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,37.754678,17.18,416.02,percent of total billed charges,,,
IRON DEXTRAN 50 MG/ML IJ SOLN,RX-3990,CDM,J1750,HCPCS,636,RC,00023-6082-10,NDC,outpatient,2,ML,145.94,102.158,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,37.754678,17.18,416.02,percent of total billed charges,,,
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2310-05,NDC,outpatient,10,ML,278.93,195.251,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,72.159191,0.21,416.02,percent of total billed charges,,,
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2340-01,NDC,outpatient,5,ML,137.29,96.103,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,35.516923,0.21,416.02,percent of total billed charges,,,
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2310-01,NDC,outpatient,10,ML,278.93,195.251,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,72.159191,0.21,416.02,percent of total billed charges,,,
IRON SUCROSE 20 MG/ML IV SOLN,RX-29132,CDM,J1756,HCPCS,636,RC,00517-2340-10,NDC,outpatient,5,ML,131.72,92.204,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,34.075964,0.21,416.02,percent of total billed charges,,,
DROPERIDOL 2.5 MG/ML IJ SOLN,RX-2654,CDM,J1790,HCPCS,636,RC,00517-9702-25,NDC,outpatient,2,ML,31.33,21.931,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.105071,3.83,416.02,percent of total billed charges,,,
DROPERIDOL 2.5 MG/ML IJ SOLN,RX-2654,CDM,J1790,HCPCS,636,RC,00517-9702-01,NDC,outpatient,2,ML,31.33,21.931,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.105071,3.83,416.02,percent of total billed charges,,,
PROPRANOLOL HCL 1 MG/ML IV SOLN,RX-29335,CDM,J1800,HCPCS,636,RC,63323-0604-00,NDC,outpatient,1,ML,8.17,5.719,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.113579,1.834165,416.02,percent of total billed charges,,,
PROPRANOLOL HCL 1 MG/ML IV SOLN,RX-29335,CDM,J1800,HCPCS,636,RC,63323-0604-01,NDC,outpatient,1,ML,8.17,5.719,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.113579,1.834165,416.02,percent of total billed charges,,,
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-29805,CDM,J1805,HCPCS,636,RC,25021-0308-84,NDC,outpatient,250,ML,320.4,224.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,82.88748,0.19,416.02,percent of total billed charges,,,
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-29805,CDM,J1805,HCPCS,636,RC,67457-0657-25,NDC,outpatient,250,ML,410.52,287.364,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,106.201524,0.19,416.02,percent of total billed charges,,,
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN,RX-29805,CDM,J1805,HCPCS,636,RC,67457-0657-25,NDC,outpatient,250,ML,426.52,298.564,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,110.340724,0.19,416.02,percent of total billed charges,,,
ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN,RX-29805,CDM,J1805,HCPCS,636,RC,25021-0308-84,NDC,outpatient,250,ML,336.4,235.48,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,87.02668,0.19,416.02,percent of total billed charges,,,
ESMOLOL HCL 100 MG/10ML IV SOLN,RX-82085,CDM,J1805,HCPCS,636,RC,67457-0182-10,NDC,outpatient,10,ML,17.12,11.984,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.428944,0.19,416.02,percent of total billed charges,,,
ESMOLOL HCL 100 MG/10ML IV SOLN,RX-82085,CDM,J1805,HCPCS,636,RC,67457-0182-00,NDC,outpatient,10,ML,17.12,11.984,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.428944,0.19,416.02,percent of total billed charges,,,
ESMOLOL HCL 100 MG/10ML IV SOLN,RX-82085,CDM,J1805,HCPCS,636,RC,55150-0194-10,NDC,outpatient,10,ML,10.39,7.273,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.687893,0.19,416.02,percent of total billed charges,,,
ESMOLOL HCL 2500 MG/250ML IV SOLN,RX-142051,CDM,J1806,HCPCS,636,RC,44567-0811-10,NDC,outpatient,250,ML,430.97,301.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,111.491939,0.36,416.02,percent of total billed charges,,,
ESMOLOL HCL 2500 MG/250ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-142051,CDM,J1806,HCPCS,636,RC,44567-0811-10,NDC,outpatient,250,ML,414.97,290.479,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,107.352739,0.36,416.02,percent of total billed charges,,,
INTERFERON BETA-1B 0.3 MG SC KIT,RX-124318,CDM,J1830,HCPCS,636,RC,50419-0524-01,NDC,outpatient,1,UN,1865.02,1305.514,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,482.480674,114.43,1432.33536,percent of total billed charges,,,
INTERFERON BETA-1B 0.3 MG SC KIT,RX-124318,CDM,J1830,HCPCS,636,RC,50419-0524-35,NDC,outpatient,1,UN,1865.02,1305.514,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,482.480674,114.43,1432.33536,percent of total billed charges,,,
ISAVUCONAZONIUM SULFATE 372 MG IV SOLR,RX-130407,CDM,J1833,HCPCS,636,RC,00469-0420-01,NDC,outpatient,1,UN,1572.32,1100.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,406.759184,1,1207.54176,percent of total billed charges,,,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-24,NDC,outpatient,100,ML,24.23,16.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.268301,0.02,416.02,percent of total billed charges,,,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,00338-1055-48,NDC,outpatient,100,ML,5.14,3.598,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,1.329718,0.02,416.02,percent of total billed charges,,,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-24,NDC,outpatient,100,ML,8.23,5.761,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,2.129101,0.02,416.02,percent of total billed charges,,,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,00338-1055-48,NDC,outpatient,100,ML,21.14,14.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.468918,0.02,416.02,percent of total billed charges,,,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-01,NDC,outpatient,100,ML,24.23,16.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.268301,0.02,416.02,percent of total billed charges,,,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,00409-0152-01,NDC,outpatient,100,ML,8.23,5.761,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,2.129101,0.02,416.02,percent of total billed charges,,,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,47335-0993-01,NDC,outpatient,100,ML,23.2,16.24,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.00184,0.02,416.02,percent of total billed charges,,,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,25021-0131-82,NDC,outpatient,100,ML,9.77,6.839,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,2.527499,0.02,416.02,percent of total billed charges,,,
METRONIDAZOLE 500 MG/100ML IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-158235,CDM,J1836,HCPCS,636,RC,47335-0993-01,NDC,outpatient,100,ML,7.2,5.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,1.86264,0.02,416.02,percent of total billed charges,,,
METRONIDAZOLE 500 MG/100ML IV SOLN,RX-158235,CDM,J1836,HCPCS,636,RC,25021-0131-82,NDC,outpatient,100,ML,25.77,18.039,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.666699,0.02,416.02,percent of total billed charges,,,
METRONIDAZOLE IN NACL IVPB,RX-4080369,CDM,J1836,HCPCS,636,RC,99999-0001-74,NDC,outpatient,50,ML,20.37,14.259,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.269719,0.02,416.02,percent of total billed charges,,,
METRONIDAZOLE IV SYRINGE (PEDIATRIC),RX-40840043,CDM,J1836,HCPCS,636,RC,99999-0001-74,NDC,outpatient,50,ML,20.37,14.259,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.269719,0.02,416.02,percent of total billed charges,,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,62332-0600-01,NDC,outpatient,1,ML,9.77,6.839,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.527499,0.55,416.02,percent of total billed charges,,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,72266-0118-25,NDC,outpatient,1,ML,4.8,3.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.24176,0.55,416.02,percent of total billed charges,,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,00409-3795-01,NDC,outpatient,1,ML,18.43,12.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.767841,0.55,416.02,percent of total billed charges,,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,63323-0162-00,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.55,416.02,percent of total billed charges,,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,00338-0072-25,NDC,outpatient,1,ML,3.57,2.499,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.923559,0.55,416.02,percent of total billed charges,,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,00409-3795-19,NDC,outpatient,1,ML,18.43,12.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.767841,0.55,416.02,percent of total billed charges,,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,62332-0600-25,NDC,outpatient,1,ML,9.77,6.839,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.527499,0.55,416.02,percent of total billed charges,,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,63323-0162-01,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.55,416.02,percent of total billed charges,,,
KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN,RX-22473,CDM,J1885,HCPCS,636,RC,72266-0118-01,NDC,outpatient,1,ML,4.8,3.36,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.24176,0.55,416.02,percent of total billed charges,,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,72266-0102-01,NDC,outpatient,20,ML,12.14,8.498,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.140618,0.24,416.02,percent of total billed charges,,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,00409-2339-24,NDC,outpatient,4,ML,35.3,24.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.13211,0.24,416.02,percent of total billed charges,,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,25021-0317-20,NDC,outpatient,20,ML,9.98,6.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.581826,0.24,416.02,percent of total billed charges,,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,36000-0320-01,NDC,outpatient,4,ML,16.17,11.319,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.183179,0.24,416.02,percent of total billed charges,,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,36000-0320-10,NDC,outpatient,4,ML,16.17,11.319,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.183179,0.24,416.02,percent of total billed charges,,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,00409-2267-54,NDC,outpatient,40,ML,40.77,28.539,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.547199,0.24,416.02,percent of total billed charges,,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1920,HCPCS,636,RC,00409-2339-34,NDC,outpatient,4,ML,35.3,24.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.13211,0.24,416.02,percent of total billed charges,,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1921,HCPCS,636,RC,00143-9622-01,NDC,outpatient,20,ML,8.85,6.195,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.289495,1.24,416.02,percent of total billed charges,,,
LABETALOL HCL 5 MG/ML IV SOLN,RX-10372,CDM,J1921,HCPCS,636,RC,00143-9623-01,NDC,outpatient,40,ML,18.87,13.209,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.881669,1.24,416.02,percent of total billed charges,,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0570-04,NDC,outpatient,4,ML,8.04,5.628,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.079948,0.62,416.02,percent of total billed charges,,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0572-01,NDC,outpatient,10,ML,8.64,6.048,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.235168,0.62,416.02,percent of total billed charges,,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6007-01,NDC,outpatient,10,ML,15.42,10.794,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.989154,0.62,416.02,percent of total billed charges,,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6007-10,NDC,outpatient,10,ML,15.42,10.794,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.989154,0.62,416.02,percent of total billed charges,,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6008-10,NDC,outpatient,4,ML,14.21,9.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.676127,0.62,416.02,percent of total billed charges,,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0570-01,NDC,outpatient,4,ML,8.04,5.628,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.079948,0.62,416.02,percent of total billed charges,,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,65219-0572-10,NDC,outpatient,10,ML,8.64,6.048,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.235168,0.62,416.02,percent of total billed charges,,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,72205-0101-01,NDC,outpatient,4,ML,12.36,8.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.197532,0.62,416.02,percent of total billed charges,,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,72205-0101-07,NDC,outpatient,4,ML,12.36,8.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.197532,0.62,416.02,percent of total billed charges,,,
BUMETANIDE 0.25 MG/ML IJ SOLN,RX-9308,CDM,J1939,HCPCS,636,RC,00641-6008-01,NDC,outpatient,4,ML,14.21,9.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.676127,0.62,416.02,percent of total billed charges,,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,00409-6102-04,NDC,outpatient,4,ML,9.24,6.468,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.390388,0.4,416.02,percent of total billed charges,,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,00409-6102-18,NDC,outpatient,4,ML,9.24,6.468,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.390388,0.4,416.02,percent of total billed charges,,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-32,NDC,outpatient,4,ML,4.75,3.325,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.228825,0.4,416.02,percent of total billed charges,,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-33,NDC,outpatient,10,ML,7.2,5.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.86264,0.4,416.02,percent of total billed charges,,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-44,NDC,outpatient,10,ML,7.2,5.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.86264,0.4,416.02,percent of total billed charges,,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,63323-0280-26,NDC,outpatient,4,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.4,416.02,percent of total billed charges,,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,70860-0302-04,NDC,outpatient,4,ML,4.94,3.458,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.277978,0.4,416.02,percent of total billed charges,,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,71288-0203-05,NDC,outpatient,4,ML,3.66,2.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.946842,0.4,416.02,percent of total billed charges,,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,72603-0251-01,NDC,outpatient,4,ML,3.79,2.653,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.980473,0.4,416.02,percent of total billed charges,,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,72603-0251-25,NDC,outpatient,4,ML,3.79,2.653,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.980473,0.4,416.02,percent of total billed charges,,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,23155-0473-42,NDC,outpatient,4,ML,4.75,3.325,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.228825,0.4,416.02,percent of total billed charges,,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,25021-0311-10,NDC,outpatient,10,ML,7.25,5.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.875575,0.4,416.02,percent of total billed charges,,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,63323-0280-04,NDC,outpatient,4,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.4,416.02,percent of total billed charges,,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,36000-0283-25,NDC,outpatient,4,ML,5.41,3.787,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.399567,0.4,416.02,percent of total billed charges,,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,36000-0284-25,NDC,outpatient,10,ML,8.33,5.831,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.154971,0.4,416.02,percent of total billed charges,,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,63323-0280-03,NDC,outpatient,4,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.4,416.02,percent of total billed charges,,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,70860-0302-42,NDC,outpatient,4,ML,4.94,3.458,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.277978,0.4,416.02,percent of total billed charges,,,
FUROSEMIDE 10 MG/ML IJ SOLN,RX-3291,CDM,J1940,HCPCS,636,RC,71288-0203-04,NDC,outpatient,4,ML,3.66,2.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.946842,0.4,416.02,percent of total billed charges,,,
LEUPROLIDE ACETATE 3.75 MG IM KIT,RX-13691,CDM,J1950,HCPCS,636,RC,00074-3641-03,NDC,outpatient,1,UN,4758.7,3331.09,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1231.07569,399.86,10964.15232,percent of total billed charges,,,
LEUPROLIDE ACETATE (3 MONTH) 11.25 MG IM KIT,RX-21044,CDM,J1950,HCPCS,636,RC,00074-3663-03,NDC,outpatient,1,UN,14276.24,9993.368,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3693.263288,399.86,10964.15232,percent of total billed charges,,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,67457-0265-00,NDC,outpatient,100,ML,64.06,44.842,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.572322,0.06,416.02,percent of total billed charges,,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,70860-0603-82,NDC,outpatient,100,ML,63.62,44.534,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.458494,0.06,416.02,percent of total billed charges,,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,14789-0220-08,NDC,outpatient,100,ML,48.49,33.943,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.544363,0.06,416.02,percent of total billed charges,,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,14789-0220-10,NDC,outpatient,100,ML,48.49,33.943,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.544363,0.06,416.02,percent of total billed charges,,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,43598-0636-10,NDC,outpatient,100,ML,87.65,61.355,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,22.675055,0.06,416.02,percent of total billed charges,,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,43598-0636-52,NDC,outpatient,100,ML,87.65,61.355,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,22.675055,0.06,416.02,percent of total billed charges,,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,44567-0502-01,NDC,outpatient,100,ML,49.38,34.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.774606,0.06,416.02,percent of total billed charges,,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,70860-0603-41,NDC,outpatient,100,ML,63.62,44.534,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.458494,0.06,416.02,percent of total billed charges,,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,00264-1009-90,NDC,outpatient,100,ML,43.15,30.205,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.162905,0.06,416.02,percent of total billed charges,,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,44567-0502-10,NDC,outpatient,100,ML,49.38,34.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.774606,0.06,416.02,percent of total billed charges,,,
LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN,RX-113476,CDM,J1953,HCPCS,636,RC,67457-0265-10,NDC,outpatient,100,ML,64.06,44.842,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.572322,0.06,416.02,percent of total billed charges,,,
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,70860-0604-82,NDC,outpatient,100,ML,79.64,55.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,20.602868,0.06,416.02,percent of total billed charges,,,
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,70860-0604-41,NDC,outpatient,100,ML,79.64,55.748,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,20.602868,0.06,416.02,percent of total billed charges,,,
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,44567-0503-01,NDC,outpatient,100,ML,60.06,42.042,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15.537522,0.06,416.02,percent of total billed charges,,,
LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN,RX-113477,CDM,J1953,HCPCS,636,RC,44567-0503-10,NDC,outpatient,100,ML,60.06,42.042,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15.537522,0.06,416.02,percent of total billed charges,,,
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,00409-1886-22,NDC,outpatient,5,ML,6.38,4.466,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.650506,0.06,416.02,percent of total billed charges,,,
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,00409-1886-02,NDC,outpatient,5,ML,6.38,4.466,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.650506,0.06,416.02,percent of total billed charges,,,
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,55150-0177-05,NDC,outpatient,5,ML,5.07,3.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.311609,0.06,416.02,percent of total billed charges,,,
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,67457-0790-05,NDC,outpatient,5,ML,10.7,7.49,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.76809,0.06,416.02,percent of total billed charges,,,
LEVETIRACETAM 500 MG/5ML IV SOLN,RX-77195,CDM,J1953,HCPCS,636,RC,67457-0790-00,NDC,outpatient,5,ML,10.7,7.49,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.76809,0.06,416.02,percent of total billed charges,,,
LEVOFLOXACIN IN D5W 250 MG/50ML IV SOLN,RX-108118,CDM,J1956,HCPCS,636,RC,25021-0132-81,NDC,outpatient,50,ML,25.26,17.682,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.534762,0.92,416.02,percent of total billed charges,,,
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00143-9721-24,NDC,outpatient,100,ML,25.77,18.039,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.666699,0.92,416.02,percent of total billed charges,,,
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00409-0528-23,NDC,outpatient,100,ML,28.85,20.195,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.463495,0.92,416.02,percent of total billed charges,,,
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00143-9721-01,NDC,outpatient,100,ML,25.77,18.039,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.666699,0.92,416.02,percent of total billed charges,,,
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,00409-0528-25,NDC,outpatient,100,ML,28.85,20.195,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.463495,0.92,416.02,percent of total billed charges,,,
LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN,RX-108119,CDM,J1956,HCPCS,636,RC,25021-0132-82,NDC,outpatient,100,ML,26.28,18.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.798636,0.92,416.02,percent of total billed charges,,,
LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN,RX-108120,CDM,J1956,HCPCS,636,RC,00409-0528-31,NDC,outpatient,150,ML,32.2,22.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.33014,0.92,416.02,percent of total billed charges,,,
LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN,RX-108120,CDM,J1956,HCPCS,636,RC,25021-0132-83,NDC,outpatient,150,ML,33.74,23.618,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.728538,0.92,416.02,percent of total billed charges,,,
LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN,RX-108120,CDM,J1956,HCPCS,636,RC,00409-0528-35,NDC,outpatient,150,ML,32.2,22.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.33014,0.92,416.02,percent of total billed charges,,,
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,25021-0132-81,NDC,outpatient,50,ML,25.26,17.682,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.534762,0.92,416.02,percent of total billed charges,,,
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,36000-0046-24,NDC,outpatient,50,ML,26.54,18.578,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.865898,0.92,416.02,percent of total billed charges,,,
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,63323-0355-50,NDC,outpatient,50,ML,45.6,31.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.79672,0.92,416.02,percent of total billed charges,,,
LEVOFLOXACIN 5 MG/ML PEDI SYRINGE,RX-4080081,CDM,J1956,HCPCS,636,RC,00143-9722-24,NDC,outpatient,50,ML,23.97,16.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.201039,0.92,416.02,percent of total billed charges,,,
LIDOCAINE IN D5W 4-5 MG/ML-% IV SOLN,RX-14868,CDM,J2001,HCPCS,636,RC,00338-0409-03,NDC,outpatient,500,ML,42.7,29.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.02,416.02,other,Non-Reimbursable Procedures,,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,00781-3433-95,NDC,outpatient,300,ML,100.11,70.077,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,25.898457,3.08,416.02,percent of total billed charges,,,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,55150-0242-51,NDC,outpatient,300,ML,53.38,37.366,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.809406,3.08,416.02,percent of total billed charges,,,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,00781-3433-46,NDC,outpatient,300,ML,100.11,70.077,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,25.898457,3.08,416.02,percent of total billed charges,,,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,57664-0683-57,NDC,outpatient,300,ML,46.71,32.697,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.083877,3.08,416.02,percent of total billed charges,,,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,63323-0713-03,NDC,outpatient,300,ML,49.38,34.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.774606,3.08,416.02,percent of total billed charges,,,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,57664-0683-31,NDC,outpatient,300,ML,46.71,32.697,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.083877,3.08,416.02,percent of total billed charges,,,
LINEZOLID SYRINGE 2 MG/ML (PEDI/NEO),RX-4080083,CDM,J2020,HCPCS,636,RC,63323-0713-13,NDC,outpatient,300,ML,49.38,34.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.774606,3.08,416.02,percent of total billed charges,,,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,00781-3433-46,NDC,outpatient,300,ML,100.11,70.077,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,25.898457,3.08,416.02,percent of total billed charges,,,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,57664-0683-31,NDC,outpatient,300,ML,46.71,32.697,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.083877,3.08,416.02,percent of total billed charges,,,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,00781-3433-95,NDC,outpatient,300,ML,100.11,70.077,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,25.898457,3.08,416.02,percent of total billed charges,,,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,55150-0242-51,NDC,outpatient,300,ML,53.38,37.366,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.809406,3.08,416.02,percent of total billed charges,,,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,57664-0683-57,NDC,outpatient,300,ML,46.71,32.697,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.083877,3.08,416.02,percent of total billed charges,,,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,63323-0713-03,NDC,outpatient,300,ML,49.38,34.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.774606,3.08,416.02,percent of total billed charges,,,
LINEZOLID 2 MG/ML IV SOLN WRAPPER,RX-4080790,CDM,J2020,HCPCS,636,RC,63323-0713-13,NDC,outpatient,300,ML,49.38,34.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.774606,3.08,416.02,percent of total billed charges,,,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00409-1985-30,NDC,outpatient,1,ML,16.06,11.242,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.154722,0.85,416.02,percent of total billed charges,,,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6207-25,NDC,outpatient,1,ML,5.04,3.528,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.303848,0.85,416.02,percent of total billed charges,,,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6044-01,NDC,outpatient,1,ML,4.94,3.458,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.277978,0.85,416.02,percent of total billed charges,,,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6044-25,NDC,outpatient,1,ML,4.94,3.458,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.277978,0.85,416.02,percent of total billed charges,,,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00409-1985-03,NDC,outpatient,1,ML,16.06,11.242,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.154722,0.85,416.02,percent of total billed charges,,,
LORAZEPAM 2 MG/ML IJ SOLN,RX-10467,CDM,J2060,HCPCS,636,RC,00641-6207-01,NDC,outpatient,1,ML,5.04,3.528,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.303848,0.85,416.02,percent of total billed charges,,,
LORAZEPAM INFUSION PREMIX,RX-4080084,CDM,J2060,HCPCS,636,RC,SH408-0084-01,NDC,outpatient,100,ML,126.59,88.613,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,32.748833,0.85,416.02,percent of total billed charges,,,
MANNITOL 25 % IV SOLN,RX-4750,CDM,J2150,HCPCS,636,RC,00409-4031-01,NDC,outpatient,50,ML,10.28,7.196,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.659436,2.30786,416.02,percent of total billed charges,,,
MANNITOL 25 % IV SOLN,RX-4750,CDM,J2150,HCPCS,636,RC,00409-4031-16,NDC,outpatient,50,ML,10.28,7.196,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.659436,2.30786,416.02,percent of total billed charges,,,
MEPERIDINE 10 MG/ML PCA,RX-400415,CDM,J2175,HCPCS,636,RC,99999-0000-09,NDC,outpatient,50,ML,59.93,41.951,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15.503891,2.386435,416.02,percent of total billed charges,,,
MEPERIDINE HCL 25 MG/ML IJ SOLN,RX-4903,CDM,J2175,HCPCS,636,RC,00641-6052-25,NDC,outpatient,1,ML,10.63,7.441,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.749981,2.386435,416.02,percent of total billed charges,,,
MEPERIDINE HCL 25 MG/ML IJ SOLN,RX-4903,CDM,J2175,HCPCS,636,RC,00641-6052-01,NDC,outpatient,1,ML,10.63,7.441,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.749981,2.386435,416.02,percent of total billed charges,,,
MEPERIDINE HCL 50 MG/ML IJ SOLN,RX-4904,CDM,J2175,HCPCS,636,RC,00641-6053-25,NDC,outpatient,1,ML,11.08,7.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.866396,2.386435,416.02,percent of total billed charges,,,
MEPERIDINE HCL 50 MG/ML IJ SOLN,RX-4904,CDM,J2175,HCPCS,636,RC,00641-6053-01,NDC,outpatient,1,ML,11.08,7.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.866396,2.386435,416.02,percent of total billed charges,,,
MEPOLIZUMAB 100 MG SC SOLR,RX-131231,CDM,J2182,HCPCS,636,RC,00173-0881-01,NDC,outpatient,1,UN,8145.21,5701.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2107.165827,29.75,6255.52128,percent of total billed charges,,,
MEROPENEM 500 MG IV SOLR,RX-17379,CDM,J2185,HCPCS,636,RC,63323-0507-01,NDC,outpatient,1,UN,14.25,9.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.686475,0.35,416.02,percent of total billed charges,,,
MEROPENEM 500 MG IV SOLR,RX-17379,CDM,J2185,HCPCS,636,RC,63323-0507-20,NDC,outpatient,1,UN,14.25,9.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.686475,0.35,416.02,percent of total billed charges,,,
MEROPENEM 500 MG IV SOLR,RX-17379,CDM,J2185,HCPCS,636,RC,55150-0207-20,NDC,outpatient,1,UN,7.45,5.215,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.927315,0.35,416.02,percent of total billed charges,,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00409-1391-22,NDC,outpatient,1,UN,20.02,14.014,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.179174,0.35,416.02,percent of total billed charges,,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00781-3098-95,NDC,outpatient,1,UN,48.95,34.265,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.663365,0.35,416.02,percent of total billed charges,,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,70121-1453-01,NDC,outpatient,1,UN,45.95,32.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.887265,0.35,416.02,percent of total billed charges,,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,70121-1453-07,NDC,outpatient,1,UN,45.95,32.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.887265,0.35,416.02,percent of total billed charges,,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00781-3098-94,NDC,outpatient,1,UN,48.95,34.265,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.663365,0.35,416.02,percent of total billed charges,,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,00409-1391-21,NDC,outpatient,1,UN,20.02,14.014,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.179174,0.35,416.02,percent of total billed charges,,,
MEROPENEM 1 G IV SOLR,RX-17380,CDM,J2185,HCPCS,636,RC,55150-0208-30,NDC,outpatient,1,UN,17.23,12.061,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.457401,0.35,416.02,percent of total billed charges,,,
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,51991-0144-17,NDC,outpatient,1,ML,67.64,47.348,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,17.498468,15.18518,416.02,percent of total billed charges,,,
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,00517-0740-01,NDC,outpatient,1,ML,89.19,62.433,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,23.073453,15.18518,416.02,percent of total billed charges,,,
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,00517-0740-20,NDC,outpatient,1,ML,89.19,62.433,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,23.073453,15.18518,416.02,percent of total billed charges,,,
METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN,RX-10571,CDM,J2210,HCPCS,636,RC,51991-0144-99,NDC,outpatient,1,ML,67.64,47.348,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,17.498468,15.18518,416.02,percent of total billed charges,,,
METHYLNALTREXONE BROMIDE 12 MG/0.6ML SC SOLN,RX-91651,CDM,J2212,HCPCS,636,RC,65649-0551-02,NDC,outpatient,0.6,ML,659.14,461.398,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,170.519518,1.07677,506.21952,percent of total billed charges,,,
MICAFUNGIN SODIUM 50 MG IV SOLR,RX-41144,CDM,J2248,HCPCS,636,RC,70710-1724-06,NDC,outpatient,1,UN,160.37,112.259,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,41.487719,0.29,590.53056,percent of total billed charges,,,
MICAFUNGIN SODIUM 50 MG IV SOLR,RX-41144,CDM,J2248,HCPCS,636,RC,00469-3250-10,NDC,outpatient,1,UN,384.44,269.108,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,99.454628,0.29,590.53056,percent of total billed charges,,,
MICAFUNGIN SODIUM 50 MG IV SOLR,RX-41144,CDM,J2248,HCPCS,636,RC,70710-1724-01,NDC,outpatient,1,UN,160.37,112.259,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,41.487719,0.29,590.53056,percent of total billed charges,,,
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,00469-3211-10,NDC,outpatient,1,UN,768.92,538.244,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,198.919604,0.29,590.53056,percent of total billed charges,,,
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,25021-0191-10,NDC,outpatient,1,UN,136.09,95.263,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,35.206483,0.29,590.53056,percent of total billed charges,,,
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,70710-1725-01,NDC,outpatient,1,UN,320.73,224.511,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,82.972851,0.29,590.53056,percent of total billed charges,,,
MICAFUNGIN SODIUM 100 MG IV SOLR,RX-77685,CDM,J2248,HCPCS,636,RC,70710-1725-06,NDC,outpatient,1,UN,320.73,224.511,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,82.972851,0.29,590.53056,percent of total billed charges,,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,23155-0600-31,NDC,outpatient,2,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.13,416.02,percent of total billed charges,,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,00409-2305-16,NDC,outpatient,2,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.13,416.02,percent of total billed charges,,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,00409-2305-17,NDC,outpatient,2,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.13,416.02,percent of total billed charges,,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,23155-0600-41,NDC,outpatient,2,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.13,416.02,percent of total billed charges,,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-12,NDC,outpatient,2,ML,6.08,4.256,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.572896,0.13,416.02,percent of total billed charges,,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-15,NDC,outpatient,2,ML,6.08,4.256,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.572896,0.13,416.02,percent of total billed charges,,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-18,NDC,outpatient,5,ML,13.45,9.415,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.479515,0.13,416.02,percent of total billed charges,,,
MIDAZOLAM HCL 1 MG/ML IJ WRAPPER,RX-4080031,CDM,J2250,HCPCS,636,RC,63323-0411-25,NDC,outpatient,5,ML,13.45,9.415,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.479515,0.13,416.02,percent of total billed charges,,,
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2250,HCPCS,636,RC,70004-0411-59,NDC,outpatient,100,ML,159.16,111.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,41.174692,0.13,416.02,percent of total billed charges,,,
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2250,HCPCS,636,RC,99999-0001-46,NDC,outpatient,100,ML,75.72,53.004,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,19.588764,0.13,416.02,percent of total billed charges,,,
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00409-2308-01,NDC,outpatient,1,ML,3.95,2.765,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.021865,0.13,416.02,percent of total billed charges,,,
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00641-6060-01,NDC,outpatient,10,ML,8.07,5.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.087709,0.13,416.02,percent of total billed charges,,,
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00409-2308-21,NDC,outpatient,1,ML,3.95,2.765,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.021865,0.13,416.02,percent of total billed charges,,,
MIDAZOLAM HCL 5 MG/ML IJ WRAPPER,RX-4080182,CDM,J2250,HCPCS,636,RC,00641-6060-10,NDC,outpatient,10,ML,8.07,5.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.087709,0.13,416.02,percent of total billed charges,,,
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2251,HCPCS,636,RC,44567-0611-01,NDC,outpatient,100,ML,77.41,54.187,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,20.025967,0.18,416.02,percent of total billed charges,,,
MIDAZOLAM INFUSION 100 MG/100 ML PREMIX,RX-4080093,CDM,J2251,HCPCS,636,RC,44567-0611-10,NDC,outpatient,100,ML,77.41,54.187,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,20.025967,0.18,416.02,percent of total billed charges,,,
MILRINONE IN DEXTROSE 20 MG/100ML IV SOLN,RX-122186,CDM,J2260,HCPCS,636,RC,00143-9719-01,NDC,outpatient,100,ML,44.93,31.451,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.623391,1.41,416.02,percent of total billed charges,,,
MILRINONE IN DEXTROSE 20 MG/100ML IV SOLN,RX-122186,CDM,J2260,HCPCS,636,RC,00143-9719-10,NDC,outpatient,100,ML,44.93,31.451,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.623391,1.41,416.02,percent of total billed charges,,,
MILRINONE IN DEXTROSE 20 MG/100ML IV SOLN,RX-122186,CDM,J2260,HCPCS,636,RC,25021-0313-82,NDC,outpatient,100,ML,50.27,35.189,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.004849,1.41,416.02,percent of total billed charges,,,
MILRINONE LACTATE 10 MG/10ML IV SOLN,RX-122188,CDM,J2260,HCPCS,636,RC,00143-9710-10,NDC,outpatient,10,ML,16.45,11.515,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.255615,1.41,416.02,percent of total billed charges,,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00409-1891-03,NDC,outpatient,1,ML,9.04,6.328,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.338648,2.02948,416.02,percent of total billed charges,,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00641-6125-01,NDC,outpatient,1,ML,10.46,7.322,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.706002,2.02948,416.02,percent of total billed charges,,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00641-6125-25,NDC,outpatient,1,ML,10.46,7.322,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.706002,2.02948,416.02,percent of total billed charges,,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2270,HCPCS,636,RC,00409-1891-01,NDC,outpatient,1,ML,9.04,6.328,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.338648,2.02948,416.02,percent of total billed charges,,,
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2270,HCPCS,636,RC,00641-6127-25,NDC,outpatient,1,ML,10.68,7.476,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.762916,2.02948,416.02,percent of total billed charges,,,
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2270,HCPCS,636,RC,00641-6127-01,NDC,outpatient,1,ML,10.68,7.476,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.762916,2.02948,416.02,percent of total billed charges,,,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2270,HCPCS,636,RC,00409-1890-01,NDC,outpatient,1,ML,9.93,6.951,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.568891,2.02948,416.02,percent of total billed charges,,,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2270,HCPCS,636,RC,52533-0161-45,NDC,outpatient,1,ML,33.38,23.366,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.635406,2.02948,416.02,percent of total billed charges,,,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2270,HCPCS,636,RC,00409-1890-03,NDC,outpatient,1,ML,9.93,6.951,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.568891,2.02948,416.02,percent of total billed charges,,,
MORPHINE SULFATE 50 MG/ML IV SOLN,RX-27393,CDM,J2270,HCPCS,636,RC,00409-1134-05,NDC,outpatient,50,ML,115.7,80.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,29.93159,2.02948,416.02,percent of total billed charges,,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2272,HCPCS,636,RC,63323-0454-01,NDC,outpatient,1,ML,8.51,5.957,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.201537,1.816205,416.02,percent of total billed charges,,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2272,HCPCS,636,RC,63323-0454-00,NDC,outpatient,1,ML,8.51,5.957,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.201537,1.816205,416.02,percent of total billed charges,,,
MORPHINE SULFATE (PF) 4 MG/ML IV SOLN,RX-117338,CDM,J2272,HCPCS,636,RC,76045-0005-10,NDC,outpatient,1,ML,8.79,6.153,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.273973,1.816205,416.02,percent of total billed charges,,,
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2272,HCPCS,636,RC,63323-0451-01,NDC,outpatient,1,ML,9.36,6.552,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.421432,1.816205,416.02,percent of total billed charges,,,
MORPHINE SULFATE (PF) 10 MG/ML IV SOLN,RX-117340,CDM,J2272,HCPCS,636,RC,63323-0451-00,NDC,outpatient,1,ML,9.36,6.552,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.421432,1.816205,416.02,percent of total billed charges,,,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2272,HCPCS,636,RC,63323-0452-01,NDC,outpatient,1,ML,8.27,5.789,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.139449,1.816205,416.02,percent of total billed charges,,,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2272,HCPCS,636,RC,76045-0004-10,NDC,outpatient,1,ML,8.09,5.663,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.092883,1.816205,416.02,percent of total billed charges,,,
MORPHINE SULFATE (PF) 2 MG/ML IV SOLN,RX-119146,CDM,J2272,HCPCS,636,RC,63323-0452-00,NDC,outpatient,1,ML,8.27,5.789,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.139449,1.816205,416.02,percent of total billed charges,,,
MORPHINE SULFATE (PF) 1 MG/ML IJ SOLN,RX-15852,CDM,J2274,HCPCS,636,RC,00641-6019-10,NDC,outpatient,10,ML,82.11,57.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,21.241857,10.46,1022.48448,percent of total billed charges,,,
MORPHINE SULFATE (PF) 1 MG/ML IJ SOLN,RX-15852,CDM,J2274,HCPCS,636,RC,00641-6019-01,NDC,outpatient,10,ML,82.11,57.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,21.241857,10.46,1022.48448,percent of total billed charges,,,
MORPHINE SULF MICROINFUSION PF 200 MG/20ML (10 MG/ML) IJ SOLN,RX-77009,CDM,J2274,HCPCS,636,RC,00641-6039-01,NDC,outpatient,20,ML,695.45,486.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,179.912915,10.46,1022.48448,percent of total billed charges,,,
MORPHINE SULF MICROINFUSION PF 500 MG/20ML (25 MG/ML) IJ SOLN,RX-77010,CDM,J2274,HCPCS,636,RC,00641-6040-01,NDC,outpatient,20,ML,1331.36,931.952,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,344.422832,10.46,1022.48448,percent of total billed charges,,,
NALBUPHINE HCL 10 MG/ML IJ SOLN,RX-5339,CDM,J2300,HCPCS,636,RC,00409-1463-01,NDC,outpatient,1,ML,17.79,12.453,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.602273,2.72,416.02,percent of total billed charges,,,
NALBUPHINE HCL 10 MG/ML IJ SOLN,RX-5339,CDM,J2300,HCPCS,636,RC,00409-1463-71,NDC,outpatient,1,ML,17.79,12.453,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.602273,2.72,416.02,percent of total billed charges,,,
NITROGLYCERIN IN D5W 400-5 MCG/ML-% IV SOLN,RX-14895,CDM,J2305,HCPCS,636,RC,00338-1051-02,NDC,outpatient,250,ML,62.73,43.911,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.228251,1.3,416.02,percent of total billed charges,,,
NITROGLYCERIN IN D5W 400-5 MCG/ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-14895,CDM,J2305,HCPCS,636,RC,00338-1051-02,NDC,outpatient,250,ML,46.73,32.711,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,12.089051,1.3,416.02,percent of total billed charges,,,
NITROGLYCERIN IN D5W 100-5 MCG/ML-% IV SOLN,RX-15858,CDM,J2305,HCPCS,636,RC,00338-1047-02,NDC,outpatient,250,ML,56.05,39.235,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,14.500135,1.3,416.02,percent of total billed charges,,,
NITROGLYCERIN IN D5W 100-5 MCG/ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-15858,CDM,J2305,HCPCS,636,RC,00338-1047-02,NDC,outpatient,250,ML,40.05,28.035,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,10.360935,1.3,416.02,percent of total billed charges,,,
NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN,RX-15859,CDM,J2305,HCPCS,636,RC,00338-1049-02,NDC,outpatient,250,ML,58.28,40.796,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15.077036,1.3,416.02,percent of total billed charges,,,
NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN,RX-15859,CDM,J2305,HCPCS,636,RC,99999-0004-40,NDC,outpatient,250,ML,45.49,31.843,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.768263,1.3,416.02,percent of total billed charges,,,
NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-15859,CDM,J2305,HCPCS,636,RC,00338-1049-02,NDC,outpatient,250,ML,42.28,29.596,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,10.937836,1.3,416.02,percent of total billed charges,,,
NITROGLYCERIN 5 MG/ML IV SOLN,RX-5599,CDM,J2305,HCPCS,636,RC,00517-4810-01,NDC,outpatient,10,ML,51.4,35.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.29718,1.3,416.02,percent of total billed charges,,,
NITROGLYCERIN 5 MG/ML IV SOLN,RX-5599,CDM,J2305,HCPCS,636,RC,00517-4810-25,NDC,outpatient,10,ML,51.4,35.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.29718,1.3,416.02,percent of total billed charges,,,
NALOXONE HCL 2 MG/2ML IJ SOSY,RX-136113,CDM,J2310,HCPCS,636,RC,76329-3369-01,NDC,outpatient,2,ML,42.08,29.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.886096,3.03075,416.02,percent of total billed charges,,,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,00409-1215-01,NDC,outpatient,1,ML,63.16,44.212,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.339492,3.03075,416.02,percent of total billed charges,,,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,36000-0308-10,NDC,outpatient,1,ML,13.5,9.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.49245,3.03075,416.02,percent of total billed charges,,,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,67457-0292-02,NDC,outpatient,1,ML,15.44,10.808,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.994328,3.03075,416.02,percent of total billed charges,,,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,36000-0308-01,NDC,outpatient,1,ML,13.5,9.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.49245,3.03075,416.02,percent of total billed charges,,,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,67457-0292-00,NDC,outpatient,1,ML,15.44,10.808,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.994328,3.03075,416.02,percent of total billed charges,,,
NALOXONE HCL 0.4 MG/ML IJ SOLN,RX-5373,CDM,J2310,HCPCS,636,RC,00409-1215-21,NDC,outpatient,1,ML,63.16,44.212,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.339492,3.03075,416.02,percent of total billed charges,,,
OCTREOTIDE ACETATE 50 MCG/ML IJ SOLN,RX-91278,CDM,J2354,HCPCS,636,RC,67457-0239-00,NDC,outpatient,1,ML,17.58,12.306,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.547946,0.86,416.02,percent of total billed charges,,,
OCTREOTIDE ACETATE 50 MCG/ML IJ SOLN,RX-91278,CDM,J2354,HCPCS,636,RC,67457-0239-01,NDC,outpatient,1,ML,17.58,12.306,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.547946,0.86,416.02,percent of total billed charges,,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,00641-6175-01,NDC,outpatient,1,ML,7.84,5.488,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.028208,0.86,416.02,percent of total billed charges,,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,23155-0688-31,NDC,outpatient,1,ML,11.88,8.316,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.073356,0.86,416.02,percent of total billed charges,,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,63323-0376-01,NDC,outpatient,1,ML,11.92,8.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.083704,0.86,416.02,percent of total billed charges,,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,23155-0688-41,NDC,outpatient,1,ML,11.88,8.316,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.073356,0.86,416.02,percent of total billed charges,,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,00641-6175-10,NDC,outpatient,1,ML,7.84,5.488,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.028208,0.86,416.02,percent of total billed charges,,,
OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN,RX-91279,CDM,J2354,HCPCS,636,RC,63323-0376-00,NDC,outpatient,1,ML,11.92,8.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.083704,0.86,416.02,percent of total billed charges,,,
OCTREOTIDE ACETATE 200 MCG/ML IJ SOLN,RX-91280,CDM,J2354,HCPCS,636,RC,00641-6177-01,NDC,outpatient,0.5,ML,25.17,17.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.511479,0.86,416.02,percent of total billed charges,,,
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,00641-6176-10,NDC,outpatient,1,ML,46.52,32.564,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.034724,0.86,416.02,percent of total billed charges,,,
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,00641-6176-01,NDC,outpatient,1,ML,46.52,32.564,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.034724,0.86,416.02,percent of total billed charges,,,
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,63323-0377-00,NDC,outpatient,1,ML,41.91,29.337,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.842117,0.86,416.02,percent of total billed charges,,,
OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN,RX-91281,CDM,J2354,HCPCS,636,RC,63323-0377-01,NDC,outpatient,1,ML,41.91,29.337,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.842117,0.86,416.02,percent of total billed charges,,,
OMALIZUMAB 150 MG/ML SC SOSY,RX-144954,CDM,J2357,HCPCS,636,RC,50242-0215-01,NDC,outpatient,1,ML,3822.49,2675.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.878163,38.29,2935.67232,percent of total billed charges,,,
OMALIZUMAB 75 MG/0.5ML SC SOSY,RX-144955,CDM,J2357,HCPCS,636,RC,50242-0214-01,NDC,outpatient,0.5,ML,1911.25,1337.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,494.440375,38.29,2935.67232,percent of total billed charges,,,
OMALIZUMAB 150 MG SC SOLR,RX-36151,CDM,J2357,HCPCS,636,RC,50242-0040-62,NDC,outpatient,1,UN,3822.49,2675.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,988.878163,38.29,2935.67232,percent of total billed charges,,,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00781-3159-72,NDC,outpatient,1,UN,62.44,43.708,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.153228,0.92,416.02,percent of total billed charges,,,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00002-7597-01,NDC,outpatient,1,UN,206.8,144.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,53.49916,0.92,416.02,percent of total billed charges,,,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00517-0955-01,NDC,outpatient,1,UN,115.66,80.962,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,29.921242,0.92,416.02,percent of total billed charges,,,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,00781-9105-72,NDC,outpatient,1,UN,62.44,43.708,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.153228,0.92,416.02,percent of total billed charges,,,
OLANZAPINE 10 MG IM SOLR,RX-38263,CDM,J2359,HCPCS,636,RC,55150-0308-01,NDC,outpatient,1,UN,77.39,54.173,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,20.020793,0.92,416.02,percent of total billed charges,,,
ORPHENADRINE CITRATE 30 MG/ML IJ SOLN,RX-5886,CDM,J2360,HCPCS,636,RC,00641-6182-01,NDC,outpatient,2,ML,19.23,13.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.974801,4.317135,416.02,percent of total billed charges,,,
ORPHENADRINE CITRATE 30 MG/ML IJ SOLN,RX-5886,CDM,J2360,HCPCS,636,RC,00641-6182-10,NDC,outpatient,2,ML,19.23,13.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.974801,4.317135,416.02,percent of total billed charges,,,
PHENYLEPHRINE HCL 100 MCG/ML SYRINGE,RX-4080501,CDM,J2371,HCPCS,636,RC,70004-0810-11,NDC,outpatient,5,ML,23.81,16.667,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.159647,0.01,416.02,percent of total billed charges,,,
PHENYLEPHRINE HCL 100 MCG/ML SYRINGE,RX-4080501,CDM,J2371,HCPCS,636,RC,70004-0810-12,NDC,outpatient,10,ML,25.28,17.696,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.539936,0.01,416.02,percent of total billed charges,,,
PHENYLEPHRINE HCL 100 MCG/ML SYRINGE,RX-4080501,CDM,J2371,HCPCS,636,RC,70092-1046-46,NDC,outpatient,10,ML,24.79,17.353,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.413173,0.01,416.02,percent of total billed charges,,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,00781-3422-71,NDC,outpatient,1,ML,12.34,8.638,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.192358,0.01,416.02,percent of total billed charges,,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1577-01,NDC,outpatient,1,ML,9.89,6.923,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.558543,0.01,416.02,percent of total billed charges,,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1577-05,NDC,outpatient,1,ML,9.89,6.923,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.558543,0.01,416.02,percent of total billed charges,,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1578-01,NDC,outpatient,5,ML,19.7,13.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.09639,0.01,416.02,percent of total billed charges,,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70121-1578-07,NDC,outpatient,5,ML,19.7,13.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.09639,0.01,416.02,percent of total billed charges,,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70069-0801-25,NDC,outpatient,1,ML,6.49,4.543,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.678963,0.01,416.02,percent of total billed charges,,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,00781-3422-92,NDC,outpatient,1,ML,12.34,8.638,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.192358,0.01,416.02,percent of total billed charges,,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,70069-0801-01,NDC,outpatient,1,ML,6.49,4.543,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.678963,0.01,416.02,percent of total billed charges,,,
PHENYLEPHRINE HCL 10 MG/ML IJ SOLN WRAPPER,RX-4080699,CDM,J2371,HCPCS,636,RC,25021-0315-01,NDC,outpatient,1,ML,3.42,2.394,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.884754,0.01,416.02,percent of total billed charges,,,
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,63323-0477-01,NDC,outpatient,20,ML,78.86,55.202,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,20.401082,0.03,416.02,percent of total billed charges,,,
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,00143-9209-10,NDC,outpatient,20,ML,51.18,35.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.240266,0.03,416.02,percent of total billed charges,,,
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,63323-0477-27,NDC,outpatient,20,ML,78.86,55.202,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,20.401082,0.03,416.02,percent of total billed charges,,,
CHLOROPROCAINE HCL (PF) 2 % IJ SOLN,RX-136106,CDM,J2401,HCPCS,636,RC,00143-9209-01,NDC,outpatient,20,ML,51.18,35.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.240266,0.03,416.02,percent of total billed charges,,,
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,63323-0478-01,NDC,outpatient,20,ML,82.77,57.939,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,21.412599,0.03,416.02,percent of total billed charges,,,
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,00143-9210-01,NDC,outpatient,20,ML,54.03,37.821,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.977561,0.03,416.02,percent of total billed charges,,,
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,00143-9210-10,NDC,outpatient,20,ML,54.03,37.821,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.977561,0.03,416.02,percent of total billed charges,,,
CHLOROPROCAINE HCL (PF) 3 % IJ SOLN,RX-136107,CDM,J2401,HCPCS,636,RC,63323-0478-27,NDC,outpatient,20,ML,82.77,57.939,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,21.412599,0.03,416.02,percent of total billed charges,,,
NICARDIPINE HCL 2.5 MG/ML IV SOLN,RX-12370,CDM,J2404,HCPCS,636,RC,00143-9689-01,NDC,outpatient,10,ML,41.12,28.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.637744,0.54,416.02,percent of total billed charges,,,
NICARDIPINE HCL 2.5 MG/ML IV SOLN,RX-12370,CDM,J2404,HCPCS,636,RC,00143-9689-10,NDC,outpatient,10,ML,41.12,28.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.637744,0.54,416.02,percent of total billed charges,,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00409-4755-03,NDC,outpatient,2,ML,6.09,4.263,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.575483,0.09,416.02,percent of total billed charges,,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,23155-0547-31,NDC,outpatient,2,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.09,416.02,percent of total billed charges,,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,23155-0549-31,NDC,outpatient,20,ML,18.1,12.67,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.68247,0.09,416.02,percent of total billed charges,,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,60505-6130-00,NDC,outpatient,2,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.09,416.02,percent of total billed charges,,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,60505-6130-05,NDC,outpatient,2,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.09,416.02,percent of total billed charges,,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00641-6078-01,NDC,outpatient,2,ML,3.61,2.527,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.933907,0.09,416.02,percent of total billed charges,,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00641-6078-25,NDC,outpatient,2,ML,3.61,2.527,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.933907,0.09,416.02,percent of total billed charges,,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,23155-0547-42,NDC,outpatient,2,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.09,416.02,percent of total billed charges,,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,00409-4755-18,NDC,outpatient,2,ML,6.09,4.263,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.575483,0.09,416.02,percent of total billed charges,,,
ONDANSETRON HCL 2 MG/ML IJ SOLN WRAPPER,RX-4080204,CDM,J2405,HCPCS,636,RC,36000-0012-25,NDC,outpatient,2,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.09,416.02,percent of total billed charges,,,
PAMIDRONATE DISODIUM 30 MG/10ML IV SOLN,RX-32589,CDM,J2430,HCPCS,636,RC,61703-0324-18,NDC,outpatient,10,ML,46.42,32.494,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.008854,8.263845,416.02,percent of total billed charges,,,
PAMIDRONATE DISODIUM 30 MG/10ML IV SOLN,RX-32589,CDM,J2430,HCPCS,636,RC,67457-0430-10,NDC,outpatient,10,ML,36.81,25.767,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.522747,8.263845,416.02,percent of total billed charges,,,
PALONOSETRON HCL 0.25 MG/5ML IV SOLN,RX-36591,CDM,J2469,HCPCS,636,RC,55111-0694-07,NDC,outpatient,5,ML,25.1,17.57,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.49337,0.62,416.02,percent of total billed charges,,,
PALONOSETRON HCL 0.25 MG/5ML IV SOLN,RX-36591,CDM,J2469,HCPCS,636,RC,60505-6193-01,NDC,outpatient,5,ML,13.32,9.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.445884,0.62,416.02,percent of total billed charges,,,
PARICALCITOL 5 MCG/ML IV SOLN,RX-22960,CDM,J2501,HCPCS,636,RC,00074-1658-01,NDC,outpatient,1,ML,40.71,28.497,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.531677,0.5,416.02,percent of total billed charges,,,
PEGLOTICASE 8 MG/ML IV SOLN,RX-107664,CDM,J2507,HCPCS,636,RC,75987-0080-10,NDC,outpatient,1,ML,59467.57,41627.299,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15384.26036,399.86,45671.09376,percent of total billed charges,,,
PENICILLIN G POT IN DEXTROSE 60000 UNIT/ML IV WRAPPER,RX-4080111,CDM,J2540,HCPCS,636,RC,00338-1025-41,NDC,outpatient,50,ML,55.67,38.969,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,14.401829,1.01,416.02,percent of total billed charges,,,
PENICILLIN G POTASSIUM 5000000 UNITS IJ SOLR,RX-6086,CDM,J2540,HCPCS,636,RC,44567-0311-10,NDC,outpatient,1,UN,17.93,12.551,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.638491,1.01,416.02,percent of total billed charges,,,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,55150-0121-50,NDC,outpatient,1,UN,18.43,12.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.767841,1.1,416.02,percent of total billed charges,,,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,00781-3114-91,NDC,outpatient,1,UN,30.55,21.385,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.903285,1.1,416.02,percent of total billed charges,,,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,44567-0803-10,NDC,outpatient,1,UN,27.96,19.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.233252,1.1,416.02,percent of total billed charges,,,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,72485-0404-10,NDC,outpatient,1,UN,18.51,12.957,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.788537,1.1,416.02,percent of total billed charges,,,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,00781-3114-95,NDC,outpatient,1,UN,30.55,21.385,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.903285,1.1,416.02,percent of total billed charges,,,
PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR,RX-18302,CDM,J2543,HCPCS,636,RC,72485-0404-01,NDC,outpatient,1,UN,18.51,12.957,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.788537,1.1,416.02,percent of total billed charges,,,
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,60505-6157-00,NDC,outpatient,1,UN,9.79,6.853,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.532673,1.1,416.02,percent of total billed charges,,,
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,64679-0056-02,NDC,outpatient,1,UN,13.78,9.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.564886,1.1,416.02,percent of total billed charges,,,
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,55150-0120-30,NDC,outpatient,1,UN,12.91,9.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.339817,1.1,416.02,percent of total billed charges,,,
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,60505-6157-04,NDC,outpatient,1,UN,9.79,6.853,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.532673,1.1,416.02,percent of total billed charges,,,
PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR,RX-18303,CDM,J2543,HCPCS,636,RC,64679-0056-01,NDC,outpatient,1,UN,13.78,9.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.564886,1.1,416.02,percent of total billed charges,,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00409-3383-02,NDC,outpatient,1,UN,25.13,17.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.501131,1.1,416.02,percent of total billed charges,,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00781-3110-90,NDC,outpatient,1,UN,17.66,12.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.568642,1.1,416.02,percent of total billed charges,,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00781-3110-95,NDC,outpatient,1,UN,17.66,12.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.568642,1.1,416.02,percent of total billed charges,,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,60505-6156-04,NDC,outpatient,1,UN,7.94,5.558,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.054078,1.1,416.02,percent of total billed charges,,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,44567-0801-10,NDC,outpatient,1,UN,14.21,9.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.676127,1.1,416.02,percent of total billed charges,,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,55150-0119-30,NDC,outpatient,1,UN,8.76,6.132,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.266212,1.1,416.02,percent of total billed charges,,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,60505-6156-00,NDC,outpatient,1,UN,7.94,5.558,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.054078,1.1,416.02,percent of total billed charges,,,
PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR,RX-18304,CDM,J2543,HCPCS,636,RC,00409-3383-11,NDC,outpatient,1,UN,25.13,17.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.501131,1.1,416.02,percent of total billed charges,,,
PROMETHAZINE HCL 25 MG/ML IJ SOLN,RX-6618,CDM,J2550,HCPCS,636,RC,00641-1495-35,NDC,outpatient,1,ML,7.75,5.425,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.004925,1.739875,416.02,percent of total billed charges,,,
PROMETHAZINE HCL 25 MG/ML IJ SOLN,RX-6618,CDM,J2550,HCPCS,636,RC,00641-1495-31,NDC,outpatient,1,ML,7.75,5.425,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.004925,1.739875,416.02,percent of total billed charges,,,
PHENOBARBITAL SODIUM 130 MG/ML IJ SOLN,RX-6221,CDM,J2560,HCPCS,636,RC,00641-0477-21,NDC,outpatient,1,ML,155.87,109.109,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,40.323569,13.89655,416.02,percent of total billed charges,,,
PHENOBARBITAL SODIUM 130 MG/ML IJ SOLN,RX-6221,CDM,J2560,HCPCS,636,RC,00641-0477-25,NDC,outpatient,1,ML,155.87,109.109,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,40.323569,13.89655,416.02,percent of total billed charges,,,
PHENOBARBITAL SODIUM 65 MG/ML IJ SOLN,RX-6224,CDM,J2560,HCPCS,636,RC,00641-0476-21,NDC,outpatient,1,ML,61.9,43.33,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.01353,13.89655,416.02,percent of total billed charges,,,
PHENOBARBITAL SODIUM 65 MG/ML IJ SOLN,RX-6224,CDM,J2560,HCPCS,636,RC,00641-0476-25,NDC,outpatient,1,ML,61.9,43.33,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.01353,13.89655,416.02,percent of total billed charges,,,
OXYTOCIN 10 UNIT/ML IJ SOLN,RX-5944,CDM,J2590,HCPCS,636,RC,63323-0012-06,NDC,outpatient,0.3,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.74534,416.02,percent of total billed charges,,,
OXYTOCIN 10 UNIT/ML IJ SOLN,RX-5944,CDM,J2590,HCPCS,636,RC,63323-0012-10,NDC,outpatient,0.3,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.74534,416.02,percent of total billed charges,,,
OXYTOCIN 10 UNIT/ML IJ SOLN,RX-5944,CDM,J2590,HCPCS,636,RC,42023-0116-25,NDC,outpatient,1,ML,7.42,5.194,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.919554,0.74534,416.02,percent of total billed charges,,,
DESMOPRESSIN ACETATE 4 MCG/ML IJ SOLN WRAPPER,RX-4081353,CDM,J2597,HCPCS,636,RC,69918-0899-01,NDC,outpatient,1,ML,91.9,64.33,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,23.77453,5.42,416.02,percent of total billed charges,,,
DESMOPRESSIN ACETATE 4 MCG/ML IJ SOLN WRAPPER,RX-4081353,CDM,J2597,HCPCS,636,RC,69918-0899-10,NDC,outpatient,1,ML,91.9,64.33,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,23.77453,5.42,416.02,percent of total billed charges,,,
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-01,NDC,outpatient,100,ML,534.45,374.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,138.262215,1.62,422.7456,percent of total billed charges,,,
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-10,NDC,outpatient,100,ML,534.45,374.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,138.262215,1.62,422.7456,percent of total billed charges,,,
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-01,NDC,outpatient,100,ML,550.45,385.315,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,142.401415,1.62,422.7456,percent of total billed charges,,,
VASOPRESSIN-DEXTROSE 40-5 UT/100ML-% IV SOLN,RX-168771,CDM,J2598,HCPCS,636,RC,42023-0219-10,NDC,outpatient,100,ML,550.45,385.315,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,142.401415,1.62,422.7456,percent of total billed charges,,,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42367-0570-87,NDC,outpatient,0.25,ML,175.83,123.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,45.487221,1.62,422.7456,percent of total billed charges,,,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42023-0164-01,NDC,outpatient,1,ML,50.82,35.574,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.147134,1.62,422.7456,percent of total billed charges,,,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,55150-0370-01,NDC,outpatient,0.25,ML,21.94,15.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.675878,1.62,422.7456,percent of total billed charges,,,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42367-0570-22,NDC,outpatient,0.25,ML,175.83,123.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,45.487221,1.62,422.7456,percent of total billed charges,,,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,55150-0370-25,NDC,outpatient,0.25,ML,21.94,15.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.675878,1.62,422.7456,percent of total billed charges,,,
VASOPRESSIN 20 UNIT/ML IJ SOLN WRAPPER,RX-4080639,CDM,J2598,HCPCS,636,RC,42023-0164-25,NDC,outpatient,1,ML,50.82,35.574,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.147134,1.62,422.7456,percent of total billed charges,,,
FLUPHENAZINE HCL 2.5 MG/ML IJ SOLN,RX-3216,CDM,J2679,HCPCS,636,RC,63323-0281-10,NDC,outpatient,0.5,ML,19.62,13.734,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.075694,4.40469,416.02,percent of total billed charges,,,
FLUPHENAZINE DECANOATE 25 MG/ML IJ SOLN,RX-3215,CDM,J2680,HCPCS,636,RC,63323-0272-05,NDC,outpatient,0.5,ML,32.89,23.023,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.508643,4.586535,416.02,percent of total billed charges,,,
FLUPHENAZINE DECANOATE 25 MG/ML IJ SOLN,RX-3215,CDM,J2680,HCPCS,636,RC,42023-0129-01,NDC,outpatient,0.5,ML,20.43,14.301,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.285241,4.586535,416.02,percent of total billed charges,,,
PROCAINAMIDE HCL 100 MG/ML IJ SOLN,RX-6562,CDM,J2690,HCPCS,636,RC,00409-1902-11,NDC,outpatient,1,ML,24.43,17.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.320041,5.484535,1082.90304,percent of total billed charges,,,
PROCAINAMIDE HCL 100 MG/ML IJ SOLN,RX-6562,CDM,J2690,HCPCS,636,RC,00409-1902-01,NDC,outpatient,1,ML,24.43,17.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.320041,5.484535,1082.90304,percent of total billed charges,,,
PROCAINAMIDE HCL 500 MG/ML IJ SOLN,RX-6563,CDM,J2690,HCPCS,636,RC,14789-0900-07,NDC,outpatient,2,ML,1410.03,987.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,364.774761,5.484535,1082.90304,percent of total billed charges,,,
PROCAINAMIDE HCL 500 MG/ML IJ SOLN,RX-6563,CDM,J2690,HCPCS,636,RC,14789-0900-02,NDC,outpatient,2,ML,1410.03,987.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,364.774761,5.484535,1082.90304,percent of total billed charges,,,
OXACILLIN SODIUM 10 G IV SOLR,RX-150085,CDM,J2700,HCPCS,636,RC,63323-0811-00,NDC,outpatient,1,UN,137.38,96.166,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,35.540206,0.87,416.02,percent of total billed charges,,,
OXACILLIN SODIUM 10 G IV SOLR,RX-150085,CDM,J2700,HCPCS,636,RC,25021-0163-99,NDC,outpatient,1,UN,489.5,342.65,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,126.63365,0.87,416.02,percent of total billed charges,,,
OXACILLIN SODIUM 10 G IV SOLR,RX-150085,CDM,J2700,HCPCS,636,RC,55150-0129-99,NDC,outpatient,1,UN,150.46,105.322,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,38.924002,0.87,416.02,percent of total billed charges,,,
OXACILLIN SODIUM 1 G IJ SOLR,RX-5924,CDM,J2700,HCPCS,636,RC,64679-0698-02,NDC,outpatient,1,UN,20.97,14.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.424939,0.87,416.02,percent of total billed charges,,,
OXACILLIN SODIUM 1 G IJ SOLR,RX-5924,CDM,J2700,HCPCS,636,RC,55150-0127-15,NDC,outpatient,1,UN,19.11,13.377,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.943757,0.87,416.02,percent of total billed charges,,,
OXACILLIN SODIUM 1 G IJ SOLR,RX-5924,CDM,J2700,HCPCS,636,RC,64679-0698-01,NDC,outpatient,1,UN,20.97,14.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.424939,0.87,416.02,percent of total billed charges,,,
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,63323-0812-01,NDC,outpatient,1,UN,25.17,17.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.511479,0.87,416.02,percent of total billed charges,,,
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,64679-0699-01,NDC,outpatient,1,UN,38.24,26.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.892688,0.87,416.02,percent of total billed charges,,,
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,64679-0699-02,NDC,outpatient,1,UN,38.24,26.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.892688,0.87,416.02,percent of total billed charges,,,
OXACILLIN SODIUM 2 G IJ SOLR,RX-5926,CDM,J2700,HCPCS,636,RC,63323-0812-20,NDC,outpatient,1,UN,25.17,17.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.511479,0.87,416.02,percent of total billed charges,,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0209-01,NDC,outpatient,20,ML,9.98,6.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-24,NDC,outpatient,100,ML,36.94,25.858,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-54,NDC,outpatient,100,ML,36.94,25.858,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0690-01,NDC,outpatient,100,ML,32.93,23.051,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,25021-0608-20,NDC,outpatient,20,ML,10.49,7.343,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,43598-0548-21,NDC,outpatient,50,ML,20.47,14.329,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0209-10,NDC,outpatient,20,ML,9.98,6.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0248-01,NDC,outpatient,100,ML,43.17,30.219,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0248-10,NDC,outpatient,100,ML,43.17,30.219,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0528-10,NDC,outpatient,20,ML,9.98,6.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0977-20,NDC,outpatient,50,ML,18.69,13.083,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,63323-0269-22,NDC,outpatient,20,ML,9.57,6.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,63323-0269-29,NDC,outpatient,20,ML,9.57,6.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-33,NDC,outpatient,50,ML,18.47,12.929,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0528-01,NDC,outpatient,20,ML,8.95,6.265,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,25021-0608-51,NDC,outpatient,100,ML,57.41,40.187,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,43598-0548-50,NDC,outpatient,50,ML,20.47,14.329,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0234-01,NDC,outpatient,50,ML,21.59,15.113,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00069-0234-20,NDC,outpatient,50,ML,21.59,15.113,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,00409-4699-53,NDC,outpatient,50,ML,18.47,12.929,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0690-10,NDC,outpatient,100,ML,32.93,23.051,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,16714-0977-01,NDC,outpatient,50,ML,18.69,13.083,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures,,
PROPOFOL 10 MG/ML IV EMUL WRAPPER,RX-4080130,CDM,J2704,HCPCS,636,RC,25021-0608-50,NDC,outpatient,50,ML,28.71,20.097,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-33,NDC,outpatient,50,ML,34.47,24.129,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,25021-0608-50,NDC,outpatient,50,ML,44.71,31.297,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,43598-0548-50,NDC,outpatient,50,ML,36.47,25.529,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-54,NDC,outpatient,100,ML,52.94,37.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0690-01,NDC,outpatient,100,ML,48.93,34.251,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,25021-0608-51,NDC,outpatient,100,ML,73.41,51.387,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0234-01,NDC,outpatient,50,ML,37.59,26.313,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0234-20,NDC,outpatient,50,ML,37.59,26.313,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0248-01,NDC,outpatient,100,ML,59.17,41.419,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00069-0248-10,NDC,outpatient,100,ML,59.17,41.419,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-24,NDC,outpatient,100,ML,52.94,37.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,00409-4699-53,NDC,outpatient,50,ML,34.47,24.129,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0690-10,NDC,outpatient,100,ML,48.93,34.251,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0977-01,NDC,outpatient,50,ML,34.69,24.283,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,16714-0977-20,NDC,outpatient,50,ML,34.69,24.283,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures,,
PROPOFOL INFUSION 10 MG/ML,RX-40840026,CDM,J2704,HCPCS,636,RC,43598-0548-21,NDC,outpatient,50,ML,36.47,25.529,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.09,416.02,other,Non-Reimbursable Procedures,,
NEOSTIGMINE METHYLSULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4080613,CDM,J2710,HCPCS,636,RC,70121-1479-01,NDC,outpatient,10,ML,34.98,24.486,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.049326,0.43,416.02,percent of total billed charges,,,
NEOSTIGMINE METHYLSULFATE 1 MG/ML IJ SOLN WRAPPER,RX-4080613,CDM,J2710,HCPCS,636,RC,70121-1479-07,NDC,outpatient,10,ML,34.98,24.486,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.049326,0.43,416.02,percent of total billed charges,,,
PROTAMINE SULFATE 10 MG/ML IV SOLN,RX-6677,CDM,J2720,HCPCS,636,RC,63323-0229-05,NDC,outpatient,5,ML,44.82,31.374,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.594934,0.95,416.02,percent of total billed charges,,,
PROTAMINE SULFATE 10 MG/ML IV SOLN,RX-6677,CDM,J2720,HCPCS,636,RC,63323-0229-30,NDC,outpatient,25,ML,134.62,94.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,34.826194,0.95,416.02,percent of total billed charges,,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00703-4502-04,NDC,outpatient,2,ML,17.23,12.061,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.457401,0.92943,416.02,percent of total billed charges,,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-3414-01,NDC,outpatient,2,ML,4.14,2.898,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.071018,0.92943,416.02,percent of total billed charges,,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00703-4502-01,NDC,outpatient,2,ML,17.23,12.061,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.457401,0.92943,416.02,percent of total billed charges,,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-5255-25,NDC,outpatient,2,ML,4.14,2.898,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.071018,0.92943,416.02,percent of total billed charges,,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-3414-18,NDC,outpatient,2,ML,4.14,2.898,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.071018,0.92943,416.02,percent of total billed charges,,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,00409-5255-02,NDC,outpatient,2,ML,4.14,2.898,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.071018,0.92943,416.02,percent of total billed charges,,,
METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN,RX-5002,CDM,J2765,HCPCS,636,RC,76045-0101-20,NDC,outpatient,2,ML,9.08,6.356,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.348996,0.92943,416.02,percent of total billed charges,,,
QUINUPRISTIN-DALFOPRISTIN 500 MG IV SOLR,RX-26335,CDM,J2770,HCPCS,636,RC,61570-0260-01,NDC,outpatient,1,UN,1916.14,1341.298,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,495.705418,7.136465,1471.59552,percent of total billed charges,,,
QUINUPRISTIN-DALFOPRISTIN 500 MG IV SOLR,RX-26335,CDM,J2770,HCPCS,636,RC,61570-0260-10,NDC,outpatient,1,UN,1916.14,1341.298,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,495.705418,7.136465,1471.59552,percent of total billed charges,,,
RASBURICASE 1.5 MG IV SOLR,RX-33591,CDM,J2783,HCPCS,636,RC,00024-5150-10,NDC,outpatient,1,UN,3073.12,2151.184,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,795.016144,357.36,11800.75008,percent of total billed charges,,,
RASBURICASE 7.5 MG IV SOLR,RX-76868,CDM,J2783,HCPCS,636,RC,00024-5151-75,NDC,outpatient,1,UN,15365.56,10755.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3975.070372,357.36,11800.75008,percent of total billed charges,,,
REGADENOSON 0.4 MG/5ML IV SOLN,RX-91408,CDM,J2785,HCPCS,636,RC,00469-6501-89,NDC,outpatient,5,ML,593.55,415.485,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,153.551385,2.88,455.8464,percent of total billed charges,,,
REGADENOSON 0.4 MG/5ML IV SOLN,RX-91408,CDM,J2785,HCPCS,636,RC,71288-0201-85,NDC,outpatient,5,ML,30.71,21.497,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.944677,2.88,455.8464,percent of total billed charges,,,
REGADENOSON 0.4 MG/5ML IV SOLN,RX-91408,CDM,J2785,HCPCS,636,RC,67457-0994-05,NDC,outpatient,5,ML,26.97,18.879,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.977139,2.88,455.8464,percent of total billed charges,,,
RHO D IMMUNE GLOBULIN 5000 UNIT/4.4ML IJ SOLN,RX-70574,CDM,J2792,HCPCS,636,RC,70257-0310-04,NDC,outpatient,4.4,ML,3912.94,2739.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1012.277578,33.71,3005.13792,percent of total billed charges,,,
RHO D IMMUNE GLOBULIN 5000 UNIT/4.4ML IJ SOLN,RX-70574,CDM,J2792,HCPCS,636,RC,70257-0310-51,NDC,outpatient,4.4,ML,3912.94,2739.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1012.277578,33.71,3005.13792,percent of total billed charges,,,
RISPERIDONE MICROSPHERES ER 37.5 MG IM SRER,RX-148032,CDM,J2794,HCPCS,636,RC,50458-0307-11,NDC,outpatient,1,UN,2304,1612.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,596.0448,10.7,2359.38048,percent of total billed charges,,,
RISPERIDONE MICROSPHERES ER 50 MG IM SRER,RX-148033,CDM,J2794,HCPCS,636,RC,50458-0308-11,NDC,outpatient,1,UN,3072.11,2150.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,794.754857,10.7,2359.38048,percent of total billed charges,,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-11,NDC,outpatient,30,ML,20.56,14.392,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.318872,0.06,416.02,percent of total billed charges,,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-20,NDC,outpatient,20,ML,59.55,41.685,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15.405585,0.06,416.02,percent of total billed charges,,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,70069-0064-01,NDC,outpatient,30,ML,20.21,14.147,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.228327,0.06,416.02,percent of total billed charges,,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,55150-0198-30,NDC,outpatient,30,ML,20.21,14.147,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.228327,0.06,416.02,percent of total billed charges,,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-01,NDC,outpatient,20,ML,59.55,41.685,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15.405585,0.06,416.02,percent of total billed charges,,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,63323-0286-35,NDC,outpatient,30,ML,20.56,14.392,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.318872,0.06,416.02,percent of total billed charges,,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,43066-0023-01,NDC,outpatient,30,ML,15.73,11.011,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.069351,0.06,416.02,percent of total billed charges,,,
ROPIVACAINE HCL 5 MG/ML IJ SOLN,RX-18195,CDM,J2795,HCPCS,636,RC,43066-0023-10,NDC,outpatient,30,ML,15.73,11.011,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.069351,0.06,416.02,percent of total billed charges,,,
ROMIPLOSTIM 125 MCG SC SOLR,RX-148858,CDM,J2796,HCPCS,636,RC,55513-0223-01,NDC,outpatient,1,UN,3455.52,2418.864,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,893.943024,95.47,5307.61728,percent of total billed charges,,,
ROMIPLOSTIM 250 MCG SC SOLR,RX-93566,CDM,J2796,HCPCS,636,RC,55513-0221-01,NDC,outpatient,1,UN,6910.96,4837.672,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1787.865352,95.47,5307.61728,percent of total billed charges,,,
SILTUXIMAB 100 MG IV SOLR,RX-125552,CDM,J2860,HCPCS,636,RC,73090-0420-01,NDC,outpatient,1,UN,4143.92,2900.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1072.032104,139.22,12730.14528,percent of total billed charges,,,
SILTUXIMAB 400 MG IV SOLR,RX-125553,CDM,J2860,HCPCS,636,RC,73090-0421-01,NDC,outpatient,1,UN,16575.71,11602.997,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4288.136177,139.22,12730.14528,percent of total billed charges,,,
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00024-2792-10,NDC,outpatient,5,ML,35.83,25.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.269221,2.12,416.02,percent of total billed charges,,,
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00024-2792-01,NDC,outpatient,5,ML,35.83,25.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.269221,2.12,416.02,percent of total billed charges,,,
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00143-9570-01,NDC,outpatient,5,ML,61.68,43.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15.956616,2.12,416.02,percent of total billed charges,,,
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,RX-24932,CDM,J2916,HCPCS,636,RC,00143-9570-10,NDC,outpatient,5,ML,61.68,43.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15.956616,2.12,416.02,percent of total billed charges,,,
METHYLPREDNISOLONE SODIUM SUCC 40 MG IJ SOLR,RX-10580,CDM,J2920,HCPCS,636,RC,00009-0039-28,NDC,outpatient,1,UN,20.03,14.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.181761,4.24,416.02,percent of total billed charges,,,
METHYLPREDNISOLONE SODIUM SUCC 40 MG IJ SOLR,RX-10580,CDM,J2920,HCPCS,636,RC,00009-0039-30,NDC,outpatient,1,UN,20.03,14.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.181761,4.24,416.02,percent of total billed charges,,,
METHYLPREDNISOLONE SODIUM SUCC 1000 MG IJ SOLR,RX-10577,CDM,J2930,HCPCS,636,RC,00009-0698-01,NDC,outpatient,1,UN,79.04,55.328,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,20.447648,5.73,565.07136,percent of total billed charges,,,
METHYLPREDNISOLONE SODIUM SUCC 125 MG IJ SOLR,RX-10578,CDM,J2930,HCPCS,636,RC,00009-0047-22,NDC,outpatient,1,UN,31.87,22.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.244769,5.73,565.07136,percent of total billed charges,,,
METHYLPREDNISOLONE SODIUM SUCC 125 MG IJ SOLR,RX-10578,CDM,J2930,HCPCS,636,RC,00009-0047-25,NDC,outpatient,1,UN,31.87,22.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.244769,5.73,565.07136,percent of total billed charges,,,
METHYLPREDNISOLONE SODIUM SUCC 2000 MG IJ SOLR,RX-10579,CDM,J2930,HCPCS,636,RC,00009-0850-01,NDC,outpatient,1,UN,735.77,515.039,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,190.343699,5.73,565.07136,percent of total billed charges,,,
METHYLPREDNISOLONE SODIUM SUCC 500 MG IJ SOLR,RX-10581,CDM,J2930,HCPCS,636,RC,00009-0758-01,NDC,outpatient,1,UN,87,60.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,22.5069,5.73,565.07136,percent of total billed charges,,,
METHYLPREDNISOLONE SODIUM SUCC 1000 MG IJ ACT-O-VIAL,RX-4081056,CDM,J2930,HCPCS,636,RC,00009-0018-20,NDC,outpatient,1,UN,235.14,164.598,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,60.830718,5.73,565.07136,percent of total billed charges,,,
METHYLPREDNISOLONE SODIUM SUCC 500 MG IJ ACT-O-VIAL,RX-4081057,CDM,J2930,HCPCS,636,RC,00009-0003-02,NDC,outpatient,1,UN,180.85,126.595,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,46.785895,5.73,565.07136,percent of total billed charges,,,
ALTEPLASE 2 MG IJ SOLR,RX-31310,CDM,J2997,HCPCS,636,RC,50242-0041-64,NDC,outpatient,1,UN,725.13,507.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,187.591131,89.15,17236.24704,percent of total billed charges,,,
ALTEPLASE 2 MG IJ SOLR,RX-31310,CDM,J2997,HCPCS,636,RC,99999-0000-50,NDC,outpatient,2,ML,723.71,506.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,187.223777,89.15,17236.24704,percent of total billed charges,,,
ALTEPLASE 100 MG IV SOLR,RX-9002,CDM,J2997,HCPCS,636,RC,50242-0085-27,NDC,outpatient,1,UN,22443.03,15710.121,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5806.011861,89.15,17236.24704,percent of total billed charges,,,
ALTEPLASE 50 MG IV SOLR,RX-9003,CDM,J2997,HCPCS,636,RC,50242-0044-13,NDC,outpatient,1,UN,11221.53,7855.071,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2903.009811,89.15,17236.24704,percent of total billed charges,,,
STREPTOMYCIN SULFATE 1 G IM SOLR,RX-7508,CDM,J3000,HCPCS,636,RC,39822-0706-02,NDC,outpatient,1,UN,186.61,130.627,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,48.276007,31.57,416.02,percent of total billed charges,,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-41,NDC,outpatient,50,ML,40.05,28.035,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.360935,0.84,416.02,percent of total billed charges,,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-61,NDC,outpatient,50,ML,40.05,28.035,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.360935,0.84,416.02,percent of total billed charges,,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00641-6027-01,NDC,outpatient,2,ML,6.08,4.256,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.572896,0.84,416.02,percent of total billed charges,,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-12,NDC,outpatient,2,ML,7.42,5.194,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.919554,0.84,416.02,percent of total billed charges,,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-22,NDC,outpatient,2,ML,7.31,5.117,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.891097,0.84,416.02,percent of total billed charges,,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00641-6027-25,NDC,outpatient,2,ML,6.08,4.256,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.572896,0.84,416.02,percent of total billed charges,,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-13,NDC,outpatient,5,ML,9.41,6.587,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.434367,0.84,416.02,percent of total billed charges,,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,00409-9094-12,NDC,outpatient,2,ML,7.31,5.117,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.891097,0.84,416.02,percent of total billed charges,,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-02,NDC,outpatient,2,ML,7.42,5.194,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.919554,0.84,416.02,percent of total billed charges,,,
FENTANYL CITRATE (PF) 0.05 MG/ML IJ SOLN WRAPPER,RX-4080787,CDM,J3010,HCPCS,636,RC,63323-0806-05,NDC,outpatient,5,ML,9.41,6.587,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.434367,0.84,416.02,percent of total billed charges,,,
TENECTEPLASE 50 MG IV KIT,RX-28530,CDM,J3101,HCPCS,636,RC,50242-0120-47,NDC,outpatient,1,UN,19380.84,13566.588,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5013.823308,152.7,14884.48512,percent of total billed charges,,,
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,63323-0665-01,NDC,outpatient,1,ML,6.42,4.494,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.660854,1.358225,416.02,percent of total billed charges,,,
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,00143-9746-10,NDC,outpatient,1,ML,6.05,4.235,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.565135,1.358225,416.02,percent of total billed charges,,,
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,00143-9746-01,NDC,outpatient,1,ML,6.05,4.235,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.565135,1.358225,416.02,percent of total billed charges,,,
TERBUTALINE SULFATE 1 MG/ML IJ SOLN,RX-11507,CDM,J3105,HCPCS,636,RC,63323-0665-00,NDC,outpatient,1,ML,6.42,4.494,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.660854,1.358225,416.02,percent of total billed charges,,,
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,55150-0318-01,NDC,outpatient,1,ML,65.18,45.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.862066,14.63291,416.02,percent of total billed charges,,,
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,55150-0318-25,NDC,outpatient,1,ML,65.18,45.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.862066,14.63291,416.02,percent of total billed charges,,,
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,00641-1398-35,NDC,outpatient,2,ML,108.05,75.635,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,27.952535,14.63291,416.02,percent of total billed charges,,,
CHLORPROMAZINE HCL 25 MG/ML IJ SOLN WRAPPER,RX-4080720,CDM,J3230,HCPCS,636,RC,00641-1398-31,NDC,outpatient,2,ML,108.05,75.635,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,27.952535,14.63291,416.02,percent of total billed charges,,,
THYROTROPIN ALFA 0.9 MG IM SOLR,RX-156409,CDM,J3240,HCPCS,636,RC,58468-0030-02,NDC,outpatient,1,UN,5457.19,3820.033,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1411.775053,399.86,4191.12192,percent of total billed charges,,,
TIGECYCLINE 50 MG IV SOLR,RX-41652,CDM,J3243,HCPCS,636,RC,55150-0228-10,NDC,outpatient,1,UN,119.66,83.762,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,30.956042,0.52,416.02,percent of total billed charges,,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-01,NDC,outpatient,100,ML,301.69,211.183,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,78.047203,3.83,567.65184,percent of total billed charges,,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-02,NDC,outpatient,250,ML,723.13,506.191,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,187.073731,3.83,567.65184,percent of total billed charges,,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-03,NDC,outpatient,100,ML,198.47,138.929,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,51.344189,3.83,567.65184,percent of total billed charges,,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0430-01,NDC,outpatient,250,ML,513.98,359.786,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,132.966626,3.83,567.65184,percent of total billed charges,,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-03,NDC,outpatient,100,ML,214.47,150.129,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,55.483389,3.83,567.65184,percent of total billed charges,,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0429-01,NDC,outpatient,100,ML,235.39,164.773,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,60.895393,3.83,567.65184,percent of total billed charges,,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0430-01,NDC,outpatient,250,ML,529.98,370.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,137.105826,3.83,567.65184,percent of total billed charges,,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-01,NDC,outpatient,100,ML,285.69,199.983,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,73.908003,3.83,567.65184,percent of total billed charges,,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080866,CDM,J3246,HCPCS,636,RC,55150-0429-01,NDC,outpatient,100,ML,219.39,153.573,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,56.756193,3.83,567.65184,percent of total billed charges,,,
TIROFIBAN HCL IN NACL 0.9% 50 MCG/ML IV SOLN WRAPPER,RX-4080866,CDM,J3246,HCPCS,636,RC,25208-0002-02,NDC,outpatient,250,ML,739.13,517.391,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,191.212931,3.83,567.65184,percent of total billed charges,,,
TRIMETHOBENZAMIDE HCL 100 MG/ML IM SOLN,RX-8178,CDM,J3250,HCPCS,636,RC,42023-0119-25,NDC,outpatient,2,ML,199.22,139.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,51.538214,44.72489,416.02,percent of total billed charges,,,
TOBRAMYCIN SULFATE 1.2 G IJ SOLR,RX-11565,CDM,J3260,HCPCS,636,RC,39822-0412-01,NDC,outpatient,1,UN,217.92,152.544,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,56.375904,0.882285,416.02,percent of total billed charges,,,
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,67457-0473-00,NDC,outpatient,2,ML,3.93,2.751,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.016691,0.882285,416.02,percent of total billed charges,,,
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,00409-3578-01,NDC,outpatient,2,ML,13.74,9.618,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.554538,0.882285,416.02,percent of total billed charges,,,
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,00409-3578-11,NDC,outpatient,2,ML,13.74,9.618,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.554538,0.882285,416.02,percent of total billed charges,,,
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,63323-0306-02,NDC,outpatient,2,ML,16.01,11.207,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.141787,0.882285,416.02,percent of total billed charges,,,
TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN,RX-39918,CDM,J3260,HCPCS,636,RC,67457-0473-22,NDC,outpatient,2,ML,3.93,2.751,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.016691,0.882285,416.02,percent of total billed charges,,,
TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN,RX-97790,CDM,J3260,HCPCS,636,RC,67457-0428-30,NDC,outpatient,30,ML,45.26,31.682,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.708762,0.882285,416.02,percent of total billed charges,,,
TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN,RX-97790,CDM,J3260,HCPCS,636,RC,63323-0306-30,NDC,outpatient,30,ML,60.48,42.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15.646176,0.882285,416.02,percent of total billed charges,,,
TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN,RX-97790,CDM,J3260,HCPCS,636,RC,67457-0428-00,NDC,outpatient,30,ML,45.26,31.682,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.708762,0.882285,416.02,percent of total billed charges,,,
TOCILIZUMAB 20 MG/ML IV WRAPPER,RX-4080174,CDM,J3262,HCPCS,636,RC,50242-0135-01,NDC,outpatient,4,ML,1422.05,995.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,367.884335,5.91,5460.64128,percent of total billed charges,,,
TOCILIZUMAB 20 MG/ML IV WRAPPER,RX-4080174,CDM,J3262,HCPCS,636,RC,50242-0137-01,NDC,outpatient,20,ML,7110.21,4977.147,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1839.411327,5.91,5460.64128,percent of total billed charges,,,
TOCILIZUMAB 20 MG/ML IV WRAPPER,RX-4080174,CDM,J3262,HCPCS,636,RC,50242-0136-01,NDC,outpatient,10,ML,3555.08,2488.556,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,919.699196,5.91,5460.64128,percent of total billed charges,,,
TRIAMCINOLONE ACETONIDE 10 MG/ML IJ SUSP,RX-11584,CDM,J3301,HCPCS,636,RC,00003-0494-20,NDC,outpatient,5,ML,49.71,34.797,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.859977,0.9,416.02,percent of total billed charges,,,
TRIAMCINOLONE ACETONIDE 40 MG/ML IJ SUSP,RX-8120,CDM,J3301,HCPCS,636,RC,00003-0293-05,NDC,outpatient,1,ML,38.5,26.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.95995,0.9,416.02,percent of total billed charges,,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,69339-0136-03,NDC,outpatient,2,ML,63.74,44.618,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.489538,5.25,416.02,percent of total billed charges,,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,76045-0204-20,NDC,outpatient,2,ML,59.63,41.741,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15.426281,5.25,416.02,percent of total billed charges,,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00409-1273-03,NDC,outpatient,2,ML,106.04,74.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,27.432548,5.25,416.02,percent of total billed charges,,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,69339-0136-34,NDC,outpatient,2,ML,63.74,44.618,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.489538,5.25,416.02,percent of total billed charges,,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,76045-0204-00,NDC,outpatient,2,ML,59.63,41.741,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15.426281,5.25,416.02,percent of total billed charges,,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00409-1273-32,NDC,outpatient,2,ML,106.04,74.228,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,27.432548,5.25,416.02,percent of total billed charges,,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00641-6244-01,NDC,outpatient,2,ML,60.45,42.315,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15.638415,5.25,416.02,percent of total billed charges,,,
DIAZEPAM 5 MG/ML IJ SOLN,RX-2401,CDM,J3360,HCPCS,636,RC,00641-6244-10,NDC,outpatient,2,ML,60.45,42.315,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15.638415,5.25,416.02,percent of total billed charges,,,
VANCOMYCIN HCL IN DEXTROSE 750 MG/150ML IV SOLN,RX-108740,CDM,J3370,HCPCS,636,RC,00338-3580-48,NDC,outpatient,150,ML,49.93,34.951,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.916891,2.16,672.6528,percent of total billed charges,,,
VANCOMYCIN HCL IN DEXTROSE 750 MG/150ML IV SOLN,RX-108740,CDM,J3370,HCPCS,636,RC,99999-0000-88,NDC,outpatient,150,ML,35.17,24.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.098479,2.16,672.6528,percent of total billed charges,,,
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,25021-0158-99,NDC,outpatient,10,GR,205.59,143.913,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,53.186133,2.16,672.6528,percent of total billed charges,,,
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,67457-0342-10,NDC,outpatient,10,GR,875.85,613.095,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,226.582395,2.16,672.6528,percent of total billed charges,,,
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,70594-0048-01,NDC,outpatient,10,GR,267,186.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,69.0729,2.16,672.6528,percent of total billed charges,,,
VANCOMYCIN HCL 10 G IV SOLR,RX-11627,CDM,J3370,HCPCS,636,RC,63323-0314-61,NDC,outpatient,10,GR,107.34,75.138,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,27.768858,2.16,672.6528,percent of total billed charges,,,
VANCOMYCIN HCL IN DEXTROSE 500 MG/100ML IV SOLN,RX-11632,CDM,J3370,HCPCS,636,RC,00338-3551-48,NDC,outpatient,100,ML,52.94,37.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.695578,2.16,672.6528,percent of total billed charges,,,
VANCOMYCIN HCL IN NACL 750-0.9 MG/150ML-% IV SOLN,RX-134904,CDM,J3370,HCPCS,636,RC,00338-3582-01,NDC,outpatient,150,ML,73.41,51.387,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,18.991167,2.16,672.6528,percent of total billed charges,,,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,00143-9357-10,NDC,outpatient,1,UN,12.35,8.645,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.194945,2.16,672.6528,percent of total billed charges,,,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,16714-0309-01,NDC,outpatient,1,UN,11.19,7.833,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.894853,2.16,672.6528,percent of total billed charges,,,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,16714-0309-10,NDC,outpatient,1,UN,11.19,7.833,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.894853,2.16,672.6528,percent of total billed charges,,,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,67457-0340-01,NDC,outpatient,1,UN,16.63,11.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.302181,2.16,672.6528,percent of total billed charges,,,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,00143-9357-01,NDC,outpatient,1,UN,12.35,8.645,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.194945,2.16,672.6528,percent of total billed charges,,,
VANCOMYCIN HCL 1 G IV SOLR,RX-144289,CDM,J3370,HCPCS,636,RC,67457-0340-00,NDC,outpatient,1,UN,16.63,11.641,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.302181,2.16,672.6528,percent of total billed charges,,,
VANCOMYCIN HCL 5 G IV SOLR,RX-144290,CDM,J3370,HCPCS,636,RC,00409-6509-01,NDC,outpatient,5,GR,364.64,255.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,94.332368,2.16,672.6528,percent of total billed charges,,,
VANCOMYCIN HCL 5 G IV SOLR,RX-144290,CDM,J3370,HCPCS,636,RC,25021-0157-99,NDC,outpatient,5,GR,81.22,56.854,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,21.011614,2.16,672.6528,percent of total billed charges,,,
VANCOMYCIN HCL 5 G IV SOLR,RX-144290,CDM,J3370,HCPCS,636,RC,67457-0341-05,NDC,outpatient,5,GR,361.57,253.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,93.538159,2.16,672.6528,percent of total billed charges,,,
VANCOMYCIN HCL 1.5 G IV SOLR,RX-145320,CDM,J3370,HCPCS,636,RC,00409-3515-11,NDC,outpatient,1,UN,51.81,36.267,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.403247,2.16,672.6528,percent of total billed charges,,,
VANCOMYCIN HCL 1.5 G IV SOLR,RX-145320,CDM,J3370,HCPCS,636,RC,00409-3515-01,NDC,outpatient,1,UN,51.81,36.267,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.403247,2.16,672.6528,percent of total billed charges,,,
VANCOMYCIN HCL 500 MG IV SOLR,RX-8443,CDM,J3370,HCPCS,636,RC,72611-0761-01,NDC,outpatient,1,UN,15.42,10.794,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.989154,2.16,672.6528,percent of total billed charges,,,
VANCOMYCIN HCL 500 MG IV SOLR,RX-8443,CDM,J3370,HCPCS,636,RC,72611-0761-10,NDC,outpatient,1,UN,15.42,10.794,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.989154,2.16,672.6528,percent of total billed charges,,,
VANCOMYCIN HCL IN DEXTROSE 1 GM/200ML IV SOLN,RX-92895,CDM,J3370,HCPCS,636,RC,00338-3552-48,NDC,outpatient,200,ML,52.27,36.589,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.522249,2.16,672.6528,percent of total billed charges,,,
VEDOLIZUMAB 300 MG IV SOLR,RX-125757,CDM,J3380,HCPCS,636,RC,64764-0300-20,NDC,outpatient,1,UN,23919.77,16743.839,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6188.044499,22.26,18370.38336,percent of total billed charges,,,
HYDROXYZINE HCL 50 MG/ML IM SOLN,RX-3770,CDM,J3410,HCPCS,636,RC,00517-5601-25,NDC,outpatient,1,ML,82.29,57.603,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,21.288423,12.41,416.02,percent of total billed charges,,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,55150-0273-01,NDC,outpatient,0.5,ML,4.61,3.227,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.192607,0.88453,416.02,percent of total billed charges,,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,67457-0196-02,NDC,outpatient,0.5,ML,3.94,2.758,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.019278,0.88453,416.02,percent of total billed charges,,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,00641-6228-25,NDC,outpatient,0.5,ML,4.75,3.325,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.228825,0.88453,416.02,percent of total billed charges,,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,25021-0500-02,NDC,outpatient,0.5,ML,4.68,3.276,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.210716,0.88453,416.02,percent of total billed charges,,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,55150-0273-25,NDC,outpatient,0.5,ML,4.61,3.227,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.192607,0.88453,416.02,percent of total billed charges,,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,67457-0196-00,NDC,outpatient,0.5,ML,3.94,2.758,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.019278,0.88453,416.02,percent of total billed charges,,,
THIAMINE HCL 100 MG/ML IJ SOLN,RX-7876,CDM,J3411,HCPCS,636,RC,00641-6228-01,NDC,outpatient,0.5,ML,4.75,3.325,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.228825,0.88453,416.02,percent of total billed charges,,,
PYRIDOXINE HCL 100 MG/ML IJ SOLN,RX-6744,CDM,J3415,HCPCS,636,RC,63323-0180-00,NDC,outpatient,0.5,ML,20.17,14.119,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.217979,4.528165,416.02,percent of total billed charges,,,
PYRIDOXINE HCL 100 MG/ML IJ SOLN,RX-6744,CDM,J3415,HCPCS,636,RC,63323-0180-01,NDC,outpatient,0.5,ML,20.17,14.119,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.217979,4.528165,416.02,percent of total billed charges,,,
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,63323-0044-01,NDC,outpatient,1,ML,6.18,4.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.598766,1.15,416.02,percent of total billed charges,,,
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,63323-0044-00,NDC,outpatient,1,ML,6.18,4.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.598766,1.15,416.02,percent of total billed charges,,,
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,00143-9621-01,NDC,outpatient,1,ML,10.83,7.581,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.801721,1.15,416.02,percent of total billed charges,,,
CYANOCOBALAMIN 1000 MCG/ML IJ SOLN,RX-2007,CDM,J3420,HCPCS,636,RC,00143-9621-25,NDC,outpatient,1,ML,10.83,7.581,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.801721,1.15,416.02,percent of total billed charges,,,
HYDROXOCOBALAMIN 5 G IV SOLR,RX-111437,CDM,J3424,HCPCS,250,RC,50633-0310-11,NDC,outpatient,1,UN,2471.2,1729.84,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,639.29944,5.69,1897.8816,percent of total billed charges,,,
PHYTONADIONE 1 MG/0.5ML IJ SOLN WRAPPER,RX-4080206,CDM,J3430,HCPCS,636,RC,76329-1240-01,NDC,outpatient,0.5,ML,98.15,68.705,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,25.391405,2.51,416.02,percent of total billed charges,,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,69097-0708-31,NDC,outpatient,1,ML,82.7,57.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,21.39449,2.51,416.02,percent of total billed charges,,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,00409-9158-31,NDC,outpatient,1,ML,85.53,59.871,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,22.126611,2.51,416.02,percent of total billed charges,,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,43598-0405-16,NDC,outpatient,1,ML,78.97,55.279,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,20.429539,2.51,416.02,percent of total billed charges,,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,00409-9158-01,NDC,outpatient,1,ML,85.53,59.871,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,22.126611,2.51,416.02,percent of total billed charges,,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,00409-9158-50,NDC,outpatient,1,ML,85.53,59.871,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,22.126611,2.51,416.02,percent of total billed charges,,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,43598-0405-11,NDC,outpatient,1,ML,78.97,55.279,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,20.429539,2.51,416.02,percent of total billed charges,,,
VITAMIN K1 10 MG/ML IJ SOLN,RX-8718,CDM,J3430,HCPCS,636,RC,69097-0708-96,NDC,outpatient,1,ML,82.7,57.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,21.39449,2.51,416.02,percent of total billed charges,,,
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,00049-3190-28,NDC,outpatient,1,UN,59.15,41.405,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15.302105,0.78,416.02,percent of total billed charges,,,
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,70436-0029-80,NDC,outpatient,1,UN,78.41,54.887,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,20.284667,0.78,416.02,percent of total billed charges,,,
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,00781-3416-94,NDC,outpatient,1,UN,325.92,228.144,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,84.315504,0.78,416.02,percent of total billed charges,,,
VORICONAZOLE 200 MG IV SOLR,RX-33010,CDM,J3465,HCPCS,636,RC,39822-1077-01,NDC,outpatient,1,UN,89.45,62.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,23.140715,0.78,416.02,percent of total billed charges,,,
HYALURONIDASE HUMAN 15 UNIT/ML INJECTION SYRINGE,RX-4081350,CDM,J3473,HCPCS,636,RC,99999-0004-00,NDC,outpatient,1,ML,164.85,115.395,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,42.646695,0.36,416.02,percent of total billed charges,,,
HYALURONIDASE HUMAN 150 UNIT/ML IJ SOLN,RX-76338,CDM,J3473,HCPCS,636,RC,18657-0117-04,NDC,outpatient,1,ML,164.85,115.395,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,42.646695,0.36,416.02,percent of total billed charges,,,
HYALURONIDASE HUMAN 150 UNIT/ML IJ SOLN,RX-76338,CDM,J3473,HCPCS,636,RC,18657-0117-01,NDC,outpatient,1,ML,164.85,115.395,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,42.646695,0.36,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00264-4400-54,NDC,outpatient,100,ML,30.4,21.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.86448,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,63323-0108-01,NDC,outpatient,100,ML,26.28,18.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.798636,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,67457-0567-00,NDC,outpatient,100,ML,30.4,21.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.86448,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00409-6727-11,NDC,outpatient,100,ML,46.71,32.697,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.083877,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,63323-0108-00,NDC,outpatient,100,ML,26.28,18.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.798636,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00338-1709-40,NDC,outpatient,100,ML,22.17,15.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.735379,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 1 G IN 100 ML D5W IV SOLN PREMIX,RX-138347,CDM,J3475,HCPCS,636,RC,00409-6727-23,NDC,outpatient,100,ML,46.71,32.697,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.083877,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,00409-6729-24,NDC,outpatient,50,ML,36.31,25.417,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.393397,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,44567-0420-24,NDC,outpatient,50,ML,43.82,30.674,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.336234,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,67457-0553-00,NDC,outpatient,50,ML,33.74,23.618,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.728538,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,25021-0612-81,NDC,outpatient,50,ML,24.74,17.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.400238,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,63323-0106-05,NDC,outpatient,50,ML,32.45,22.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.394815,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,00409-6729-11,NDC,outpatient,50,ML,36.31,25.417,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.393397,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,00338-1708-40,NDC,outpatient,50,ML,28.6,20.02,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.39882,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,44567-0420-00,NDC,outpatient,50,ML,43.82,30.674,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.336234,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,47335-0992-01,NDC,outpatient,50,ML,28.85,20.195,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.463495,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 2 G IN 50 ML PREMIX,RX-4080085,CDM,J3475,HCPCS,636,RC,63323-0106-02,NDC,outpatient,50,ML,32.45,22.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.394815,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 40 MG/ML SOLN WRAPPER,RX-4080721,CDM,J3475,HCPCS,636,RC,00409-2050-01,NDC,outpatient,500,ML,38.25,26.775,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.895275,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 40 MG/ML SOLN WRAPPER,RX-4080721,CDM,J3475,HCPCS,636,RC,00409-2050-20,NDC,outpatient,500,ML,38.25,26.775,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.895275,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 40 MG/ML SOLN WRAPPER,RX-4080721,CDM,J3475,HCPCS,636,RC,63323-0106-15,NDC,outpatient,500,ML,33.99,23.793,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.793213,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-03,NDC,outpatient,2,ML,5.46,3.822,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.412502,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-11,NDC,outpatient,10,ML,6.53,4.571,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.689311,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0642-50,NDC,outpatient,2,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-01,NDC,outpatient,2,ML,5.46,3.822,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.412502,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0064-04,NDC,outpatient,10,ML,6.53,4.571,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.689311,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,63323-0642-02,NDC,outpatient,50,ML,55.41,38.787,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,14.334567,0.47,416.02,percent of total billed charges,,,
MAGNESIUM SULFATE 50 % IJ SOLN,RX-4720,CDM,J3475,HCPCS,636,RC,99999-0002-95,NDC,outpatient,2,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.858884,0.47,416.02,percent of total billed charges,,,
POTASSIUM CHLORIDE 10 MEQ/100ML IV SOLN,RX-11074,CDM,J3480,HCPCS,636,RC,00338-0709-48,NDC,outpatient,100,ML,26.8,18.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.93316,0.1,416.02,percent of total billed charges,,,
POTASSIUM CHLORIDE 10 MEQ/100ML IV SOLN,RX-11074,CDM,J3480,HCPCS,636,RC,00990-7074-26,NDC,outpatient,100,ML,36.92,25.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.551204,0.1,416.02,percent of total billed charges,,,
POTASSIUM CHLORIDE 20 MEQ/100ML IV SOLN,RX-11076,CDM,J3480,HCPCS,636,RC,00990-7075-26,NDC,outpatient,100,ML,37.81,26.467,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.781447,0.1,416.02,percent of total billed charges,,,
POTASSIUM CHLORIDE 20 MEQ/100ML IV SOLN,RX-11076,CDM,J3480,HCPCS,636,RC,00338-0705-48,NDC,outpatient,100,ML,26.8,18.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.93316,0.1,416.02,percent of total billed charges,,,
POTASSIUM CHLORIDE 20 MEQ/50ML IV SOLN,RX-11077,CDM,J3480,HCPCS,636,RC,00338-0703-41,NDC,outpatient,50,ML,26.28,18.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.798636,0.1,416.02,percent of total billed charges,,,
POTASSIUM CHLORIDE 20 MEQ/50ML IV SOLN,RX-11077,CDM,J3480,HCPCS,636,RC,00990-7077-14,NDC,outpatient,50,ML,37.59,26.313,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.724533,0.1,416.02,percent of total billed charges,,,
POTASSIUM CHLORIDE IN NACL 20-0.9 MEQ/L-% IV SOLN,RX-11081,CDM,J3480,HCPCS,636,RC,00338-0691-04,NDC,outpatient,1000,ML,26.28,18.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.798636,0.1,416.02,percent of total billed charges,,,
POTASSIUM CHLORIDE IN NACL 40-0.9 MEQ/L-% IV SOLN,RX-11082,CDM,J3480,HCPCS,636,RC,00338-0695-04,NDC,outpatient,1000,ML,31.42,21.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.128354,0.1,416.02,percent of total billed charges,,,
KCL IN NACL 0.9% 10 MEQ/100ML IV SOLN,RX-166975,CDM,J3480,HCPCS,636,RC,99999-0001-77,NDC,outpatient,100,ML,26.28,18.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.798636,0.1,416.02,percent of total billed charges,,,
POTASSIUM CHLORIDE IN NACL 20-0.45 MEQ/L-% IV SOLN,RX-36046,CDM,J3480,HCPCS,636,RC,00338-0704-34,NDC,outpatient,1000,ML,26.28,18.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.798636,0.1,416.02,percent of total billed charges,,,
POTASSIUM CHLORIDE IN NACL 20 MEQ/50ML IV SOLN,RX-4081006,CDM,J3480,HCPCS,636,RC,99999-0001-79,NDC,outpatient,50,ML,31.17,21.819,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.063679,0.1,416.02,percent of total billed charges,,,
POTASSIUM CHLORIDE IN NACL 20 MEQ/100ML IV SOLN,RX-4081007,CDM,J3480,HCPCS,636,RC,99999-0001-78,NDC,outpatient,100,ML,30.91,21.637,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.996417,0.1,416.02,percent of total billed charges,,,
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN,RX-6429,CDM,J3480,HCPCS,636,RC,63323-0965-20,NDC,outpatient,20,ML,6.48,4.536,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.676376,0.1,416.02,percent of total billed charges,,,
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN,RX-6429,CDM,J3480,HCPCS,636,RC,63323-0965-02,NDC,outpatient,20,ML,6.48,4.536,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.676376,0.1,416.02,percent of total billed charges,,,
POTASSIUM CL IN DEXTROSE 5% 20 MEQ/L IV SOLN,RX-9791,CDM,J3480,HCPCS,636,RC,00338-0683-04,NDC,outpatient,1000,ML,31.42,21.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.128354,0.1,416.02,percent of total billed charges,,,
KCL IN DEXTROSE-NACL 20-5-0.9 MEQ/L-%-% IV SOLN,RX-9795,CDM,J3480,HCPCS,636,RC,00264-7652-00,NDC,outpatient,1000,ML,38.25,26.775,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,9.895275,0.1,416.02,percent of total billed charges,,,
KCL IN DEXTROSE-NACL 20-5-0.9 MEQ/L-%-% IV SOLN,RX-9795,CDM,J3480,HCPCS,636,RC,00338-0803-04,NDC,outpatient,1000,ML,26.28,18.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.798636,0.1,416.02,percent of total billed charges,,,
KCL IN DEXTROSE-NACL 10-5-0.45 MEQ/L-%-% IV SOLN,RX-9799,CDM,J3480,HCPCS,636,RC,00338-0669-04,NDC,outpatient,1000,ML,31.42,21.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.128354,0.1,416.02,percent of total billed charges,,,
KCL IN DEXTROSE-NACL 10-5-0.45 MEQ/L-%-% IV SOLN,RX-9799,CDM,J3480,HCPCS,636,RC,00990-7993-09,NDC,outpatient,1000,ML,47.15,33.005,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.197705,0.1,416.02,percent of total billed charges,,,
KCL IN DEXTROSE-NACL 20-5-0.2 MEQ/L-%-% IV SOLN,RX-9800,CDM,J3480,HCPCS,636,RC,00264-7645-00,NDC,outpatient,1000,ML,47.15,33.005,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.197705,0.1,416.02,percent of total billed charges,,,
KCL IN DEXTROSE-NACL 20-5-0.2 MEQ/L-%-% IV SOLN,RX-9800,CDM,J3480,HCPCS,636,RC,00338-0663-04,NDC,outpatient,1000,ML,31.42,21.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.128354,0.1,416.02,percent of total billed charges,,,
KCL IN DEXTROSE-NACL 20-5-0.45 MEQ/L-%-% IV SOLN,RX-9801,CDM,J3480,HCPCS,636,RC,00338-0671-04,NDC,outpatient,1000,ML,26.28,18.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.798636,0.1,416.02,percent of total billed charges,,,
KCL IN DEXTROSE-NACL 40-5-0.45 MEQ/L-%-% IV SOLN,RX-9807,CDM,J3480,HCPCS,636,RC,00338-0675-04,NDC,outpatient,1000,ML,31.42,21.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.128354,0.1,416.02,percent of total billed charges,,,
ZIDOVUDINE 10 MG/ML IV SOLN,RX-11691,CDM,J3485,HCPCS,636,RC,49702-0213-01,NDC,outpatient,20,ML,126.03,88.221,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,32.603961,1.51,416.02,percent of total billed charges,,,
ZIDOVUDINE 10 MG/ML IV SOLN,RX-11691,CDM,J3485,HCPCS,636,RC,49702-0213-26,NDC,outpatient,20,ML,126.03,88.221,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,32.603961,1.51,416.02,percent of total billed charges,,,
ZIPRASIDONE MESYLATE 20 MG IM SOLR,RX-33175,CDM,J3486,HCPCS,636,RC,00049-3920-20,NDC,outpatient,1,UN,264.92,185.444,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,68.534804,7.43,416.02,percent of total billed charges,,,
ZIPRASIDONE MESYLATE 20 MG IM SOLR,RX-33175,CDM,J3486,HCPCS,636,RC,00049-3920-83,NDC,outpatient,1,UN,264.92,185.444,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,68.534804,7.43,416.02,percent of total billed charges,,,
ZOLEDRONIC ACID 4 MG/5ML IV CONC,RX-35640,CDM,J3489,HCPCS,636,RC,67457-0390-54,NDC,outpatient,5,ML,30.53,21.371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.898111,6.47,416.02,percent of total billed charges,,,
ZOLEDRONIC ACID 5 MG/100ML IV SOLN,RX-81434,CDM,J3489,HCPCS,636,RC,67457-0619-10,NDC,outpatient,100,ML,182.43,127.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,47.194641,6.47,416.02,percent of total billed charges,,,
ZOLEDRONIC ACID 5 MG/100ML IV SOLN,RX-81434,CDM,J3489,HCPCS,636,RC,55111-0688-52,NDC,outpatient,100,ML,126.81,88.767,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,32.805747,6.47,416.02,percent of total billed charges,,,
IDARUCIZUMAB 2.5 GM/50ML IV SOLN,RX-132721,CDM,J3590,HCPCS,636,RC,00597-0197-05,NDC,outpatient,100,ML,13473.22,9431.254,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3485.522014,399.86,10347.43296,percent of total billed charges,,,
SODIUM CHLORIDE 0.45 % IV SOLN,RX-7318,CDM,J7030,HCPCS,250,RC,00338-0043-04,NDC,outpatient,1000,ML,26.28,18.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.798636,2.54,416.02,percent of total billed charges,,,
SODIUM CHLORIDE 0.45 % IV SOLN,RX-7318,CDM,J7030,HCPCS,250,RC,00338-0043-03,NDC,outpatient,500,ML,23.71,16.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.133777,2.54,416.02,percent of total billed charges,,,
DEXTROSE-SODIUM CHLORIDE 5-0.9 % IV SOLN,RX-9815,CDM,J7042,HCPCS,636,RC,00338-0089-04,NDC,outpatient,1000,ML,26.28,18.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.798636,1.14,416.02,percent of total billed charges,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-11,NDC,outpatient,50,ML,22.43,15.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.802641,1.81,416.02,percent of total billed charges,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-38,NDC,outpatient,100,ML,22.17,15.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.735379,1.81,416.02,percent of total billed charges,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-41,NDC,outpatient,50,ML,22.94,16.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.934578,1.81,416.02,percent of total billed charges,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00409-7100-04,NDC,outpatient,250,ML,30.14,21.098,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.797218,1.81,416.02,percent of total billed charges,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-02,NDC,outpatient,250,ML,22.43,15.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.802641,1.81,416.02,percent of total billed charges,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-48,NDC,outpatient,100,ML,22.69,15.883,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.869903,1.81,416.02,percent of total billed charges,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,63323-0624-74,NDC,outpatient,250,ML,25,17.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.4675,1.81,416.02,percent of total billed charges,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-03,NDC,outpatient,500,ML,23.71,16.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.133777,1.81,416.02,percent of total billed charges,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00338-0017-31,NDC,outpatient,50,ML,22.43,15.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.802641,1.81,416.02,percent of total billed charges,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,00409-7100-02,NDC,outpatient,250,ML,30.14,21.098,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.797218,1.81,416.02,percent of total billed charges,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7060,HCPCS,636,RC,63323-0624-04,NDC,outpatient,250,ML,25,17.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.4675,1.81,416.02,percent of total billed charges,,,
DEXTROSE 5 % IV PVC FREE SOLN,RX-4080550,CDM,J7060,HCPCS,636,RC,00264-7510-10,NDC,outpatient,500,ML,33.99,23.793,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.793213,1.81,416.02,percent of total billed charges,,,
DEXTROSE 5 % IV PVC FREE SOLN,RX-4080550,CDM,J7060,HCPCS,636,RC,00338-6346-03,NDC,outpatient,500,ML,42.7,29.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.04649,1.81,416.02,percent of total billed charges,,,
DEXTROSE 5 % IV SOLN,RX-2364,CDM,J7070,HCPCS,636,RC,00338-0017-04,NDC,outpatient,1000,ML,21.14,14.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.468918,3.62,416.02,percent of total billed charges,,,
DEXTRAN 40 IN D5W 10 % IV SOLN,RX-9759,CDM,J7100,HCPCS,636,RC,00409-7418-13,NDC,outpatient,500,ML,116.13,81.291,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,30.042831,19.23,416.02,percent of total billed charges,,,
DEXTRAN 40 IN D5W 10 % IV SOLN,RX-9759,CDM,J7100,HCPCS,636,RC,00409-7418-03,NDC,outpatient,500,ML,116.13,81.291,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,30.042831,19.23,416.02,percent of total billed charges,,,
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00264-7750-20,NDC,outpatient,250,ML,33.8,23.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.74406,2.39,416.02,percent of total billed charges,,,
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00338-0117-03,NDC,outpatient,500,ML,23.71,16.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.133777,2.39,416.02,percent of total billed charges,,,
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00338-0117-02,NDC,outpatient,250,ML,22.43,15.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.802641,2.39,416.02,percent of total billed charges,,,
LACTATED RINGERS IV SOLN,RX-4318,CDM,J7120,HCPCS,636,RC,00338-0117-04,NDC,outpatient,1000,ML,26.28,18.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.798636,2.39,416.02,percent of total billed charges,,,
DEXTROSE IN LACTATED RINGERS 5 % IV SOLN,RX-9788,CDM,J7121,HCPCS,636,RC,00338-0125-04,NDC,outpatient,1000,ML,26.28,18.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.798636,5.89986,416.02,percent of total billed charges,,,
PROTHROMBIN COMPLEX CONC HUMAN 500 UNITS IV KIT,RX-122122,CDM,J7168,HCPCS,636,RC,63833-0386-02,NDC,outpatient,1,UN,3022.2,2115.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,781.84314,2.568211,4642.0992,percent of total billed charges,,,
PROTHROMBIN COMPLEX CONC HUMAN 1000 UNITS IV KIT,RX-125272,CDM,J7168,HCPCS,636,RC,63833-0387-02,NDC,outpatient,1,UN,6044.4,4231.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1563.68628,2.568211,4642.0992,percent of total billed charges,,,
ANTIHEMOPHILIC FACTOR-VWF 500-500 UNITS IV KIT,RX-134441,CDM,J7183,HCPCS,636,RC,68982-0182-01,NDC,outpatient,1,UN,1449,1014.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,374.8563,1.26,2225.664,percent of total billed charges,,,
ANTIHEMOPHILIC FACTOR-VWF 1000-1000 UNITS IV KIT,RX-134442,CDM,J7183,HCPCS,636,RC,68982-0182-02,NDC,outpatient,1,UN,2898,2028.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,749.7126,1.26,2225.664,percent of total billed charges,,,
ANTIHEMOPHILIC FACTOR-VWF 250-600 UNITS IV SOLR,RX-70404,CDM,J7187,HCPCS,636,RC,63833-0625-01,NDC,outpatient,1,UN,1821.6,1275.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,471.24792,1.23,3240,percent of total billed charges,,,
ANTIHEMOPHILIC FACTOR-VWF 250-600 UNITS IV SOLR,RX-70404,CDM,J7187,HCPCS,636,RC,63833-0615-02,NDC,outpatient,1,UN,1821.6,1275.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,471.24792,1.23,3240,percent of total billed charges,,,
ANTIHEMOPHILIC FACTOR-VWF 500-1200 UNITS IV SOLR,RX-70405,CDM,J7187,HCPCS,636,RC,63833-0626-01,NDC,outpatient,1,UN,3643.2,2550.24,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,942.49584,1.23,3240,percent of total billed charges,,,
ANTIHEMOPHILIC FACTOR-VWF 500-1200 UNITS IV SOLR,RX-70405,CDM,J7187,HCPCS,636,RC,63833-0616-02,NDC,outpatient,1,UN,3643.2,2550.24,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,942.49584,1.23,3240,percent of total billed charges,,,
ANTIHEMOPHILIC FACTOR-VWF 1000-2400 UNITS IV SOLR,RX-70406,CDM,J7187,HCPCS,636,RC,63833-0617-02,NDC,outpatient,1,UN,3036,2125.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,785.4132,1.23,3240,percent of total billed charges,,,
ANTIHEMOPHILIC FACTOR-VWF 1000-2400 UNITS IV SOLR,RX-70406,CDM,J7187,HCPCS,636,RC,63833-0627-01,NDC,outpatient,1,UN,3036,2125.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,785.4132,1.23,3240,percent of total billed charges,,,
COAGULATION FACTOR VIIA RECOMB 1 MG IV SOLR,RX-92853,CDM,J7189,HCPCS,636,RC,00169-7201-01,NDC,outpatient,1,UN,6342.76,4439.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1640.872012,2.13,24356.18304,percent of total billed charges,,,
COAGULATION FACTOR VIIA RECOMB 1 MG IV SOLR,RX-92853,CDM,J7189,HCPCS,636,RC,00169-7211-11,NDC,outpatient,1,UN,6342.76,4439.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1640.872012,2.13,24356.18304,percent of total billed charges,,,
COAGULATION FACTOR VIIA RECOMB 2 MG IV SOLR,RX-92854,CDM,J7189,HCPCS,636,RC,00169-7212-11,NDC,outpatient,1,UN,12685.52,8879.864,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3281.744024,2.13,24356.18304,percent of total billed charges,,,
COAGULATION FACTOR VIIA RECOMB 2 MG IV SOLR,RX-92854,CDM,J7189,HCPCS,636,RC,00169-7202-01,NDC,outpatient,1,UN,12685.52,8879.864,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3281.744024,2.13,24356.18304,percent of total billed charges,,,
COAGULATION FACTOR VIIA RECOMB 5 MG IV SOLR,RX-92855,CDM,J7189,HCPCS,636,RC,00169-7205-01,NDC,outpatient,1,UN,31713.78,22199.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8204.354886,2.13,24356.18304,percent of total billed charges,,,
ANTIHEMOPHILIC FACTOR VIII RAHF-PFM 500 UNITS IV SOLR,RX-76366,CDM,J7192,HCPCS,636,RC,00944-3052-02,NDC,outpatient,1,UN,1863,1304.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,481.9581,1.25,2861.568,percent of total billed charges,,,
ANTIHEMOPHILIC FACTOR VIII RAHF-PFM 1000 UNITS IV SOLR,RX-76367,CDM,J7192,HCPCS,636,RC,00944-3053-02,NDC,outpatient,1,UN,3726,2608.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,963.9162,1.25,2861.568,percent of total billed charges,,,
ANTITHROMBIN III (HUMAN) 500 UNITS IV SOLR,RX-9116,CDM,J7197,HCPCS,636,RC,13533-0606-12,NDC,outpatient,1,UN,4954.2,3467.94,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1281.65154,3.35,3804.8256,percent of total billed charges,,,
ANTITHROMBIN III (HUMAN) 500 UNITS IV SOLR,RX-9116,CDM,J7197,HCPCS,636,RC,13533-0602-50,NDC,outpatient,1,UN,4954.2,3467.94,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1281.65154,3.35,3804.8256,percent of total billed charges,,,
ANTIINHIBITOR COAGULANT CMPLX 2500 UNITS IV SOLR,RX-146201,CDM,J7198,HCPCS,636,RC,64193-0425-02,NDC,outpatient,1,UN,13869,9708.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3587.9103,1.94,10651.392,percent of total billed charges,,,
SODIUM HYALURONATE (VISCOSUP) 25 MG/2.5ML IX SOSY,RX-127543,CDM,J7321,HCPCS,636,RC,89130-4444-01,NDC,outpatient,2.5,ML,1023.91,716.737,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,264.885517,73.22,786.36288,percent of total billed charges,,,
AZATHIOPRINE 50 MG ORAL TABS,RX-9183,CDM,J7500,HCPCS,259,RC,68084-0229-11,NDC,outpatient,1,UN,2.39,1.673,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.618293,0.536555,416.02,percent of total billed charges,,,
AZATHIOPRINE 50 MG ORAL TABS,RX-9183,CDM,J7500,HCPCS,259,RC,68084-0229-01,NDC,outpatient,1,UN,2.39,1.673,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.618293,0.536555,416.02,percent of total billed charges,,,
CYCLOSPORINE 50 MG/ML IV SOLN,RX-9705,CDM,J7516,HCPCS,636,RC,00574-0866-10,NDC,outpatient,5,ML,142.85,99.995,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,36.955295,15.32,416.02,percent of total billed charges,,,
MYCOPHENOLATE MOFETIL HCL 500 MG IV SOLR,RX-23968,CDM,J7519,HCPCS,636,RC,71288-0803-20,NDC,outpatient,1,UN,89.27,62.489,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,23.094149,0.52,416.02,percent of total billed charges,,,
MYCOPHENOLATE MOFETIL HCL 500 MG IV SOLR,RX-23968,CDM,J7519,HCPCS,636,RC,00004-0298-09,NDC,outpatient,1,UN,298.3,208.81,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,77.17021,0.52,416.02,percent of total billed charges,,,
METHACHOLINE CHLORIDE 100 MG IN SOLR,RX-27032,CDM,J7674,HCPCS,636,RC,64281-0100-06,NDC,outpatient,1,UN,341.28,238.896,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.86,416.02,other,Non-Reimbursable Procedures,,
METHACHOLINE CHLORIDE 100 MG IN SOLR,RX-27032,CDM,J7674,HCPCS,636,RC,64281-0100-00,NDC,outpatient,1,UN,341.28,238.896,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.86,416.02,other,Non-Reimbursable Procedures,,
ETOPOSIDE 50 MG ORAL CAPS,RX-10001,CDM,J8560,HCPCS,636,RC,00378-3266-32,NDC,outpatient,1,UN,309.74,216.818,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,80.129738,69.53663,416.02,percent of total billed charges,,,
ETOPOSIDE 50 MG ORAL CAPS,RX-10001,CDM,J8560,HCPCS,636,RC,00378-3266-94,NDC,outpatient,1,UN,309.74,216.818,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,80.129738,69.53663,416.02,percent of total billed charges,,,
MERCAPTOPURINE 50 MG ORAL TABS,RX-10531,CDM,J8999,HCPCS,259,RC,00054-4581-11,NDC,outpatient,1,UN,14.11,9.877,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3.650257,0.370425,416.02,percent of total billed charges,,,
MERCAPTOPURINE 50 MG ORAL TABS,RX-10531,CDM,J8999,HCPCS,259,RC,00378-3547-52,NDC,outpatient,1,UN,4.39,3.073,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.135693,0.370425,416.02,percent of total billed charges,,,
BICALUTAMIDE 50 MG ORAL TABS,RX-15746,CDM,J8999,HCPCS,259,RC,16729-0023-10,NDC,outpatient,1,UN,2.86,2.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.739882,0.370425,416.02,percent of total billed charges,,,
ANASTROZOLE 1 MG ORAL TABS,RX-16205,CDM,J8999,HCPCS,259,RC,60687-0112-11,NDC,outpatient,1,UN,3.22,2.254,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.833014,0.370425,416.02,percent of total billed charges,,,
ANASTROZOLE 1 MG ORAL TABS,RX-16205,CDM,J8999,HCPCS,259,RC,60687-0112-21,NDC,outpatient,1,UN,3.22,2.254,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.833014,0.370425,416.02,percent of total billed charges,,,
MEGESTROL ACETATE 40 MG ORAL TABS,RX-4871,CDM,J8999,HCPCS,259,RC,64380-0159-01,NDC,outpatient,1,UN,1.65,1.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.426855,0.370425,416.02,percent of total billed charges,,,
MEGESTROL ACETATE 400 MG/10ML ORAL SUSP,RX-76824,CDM,J8999,HCPCS,259,RC,00121-0945-10,NDC,outpatient,10,ML,15.58,10.906,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.030546,0.370425,416.02,percent of total billed charges,,,
MEGESTROL ACETATE 400 MG/10ML ORAL SUSP,RX-76824,CDM,J8999,HCPCS,259,RC,99999-0003-95,NDC,outpatient,10,ML,8.73,6.111,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.258451,0.370425,416.02,percent of total billed charges,,,
MEGESTROL ACETATE 400 MG/10ML ORAL SUSP,RX-76824,CDM,J8999,HCPCS,259,RC,00121-0945-40,NDC,outpatient,10,ML,15.58,10.906,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.030546,0.370425,416.02,percent of total billed charges,,,
TAMOXIFEN CITRATE 10 MG ORAL TABS,RX-7711,CDM,J8999,HCPCS,259,RC,63739-0143-10,NDC,outpatient,1,UN,1.98,1.386,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.512226,0.370425,416.02,percent of total billed charges,,,
DOXORUBICIN HCL 2 MG/ML IV PUSH SOLN,RX-2616,CDM,J9000,HCPCS,636,RC,00069-3031-20,NDC,outpatient,10,ML,34.71,24.297,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.979477,2.5,525.12,percent of total billed charges,,,
DOXORUBICIN HCL 2 MG/ML IV PUSH SOLN,RX-2616,CDM,J9000,HCPCS,636,RC,00069-3030-20,NDC,outpatient,5,ML,19.68,13.776,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.091216,2.5,525.12,percent of total billed charges,,,
DOXORUBICIN HCL 2 MG/ML IV PUSH SOLN,RX-2616,CDM,J9000,HCPCS,636,RC,00069-3032-20,NDC,outpatient,25,ML,44.02,30.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.387974,2.5,525.12,percent of total billed charges,,,
DOXORUBICIN HCL 10 MG IV SOLR,RX-2617,CDM,J9000,HCPCS,636,RC,00143-9092-01,NDC,outpatient,1,UN,143.64,100.548,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,37.159668,2.5,525.12,percent of total billed charges,,,
DOXORUBICIN HCL 50 MG IV SOLR,RX-2619,CDM,J9000,HCPCS,636,RC,00143-9277-01,NDC,outpatient,1,UN,683.75,478.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,176.886125,2.5,525.12,percent of total billed charges,,,
ARSENIC TRIOXIDE 12 MG/6ML IV SOLN,RX-141420,CDM,J9017,HCPCS,636,RC,63459-0601-06,NDC,outpatient,6,ML,3082.97,2158.079,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,797.564339,7.2,2367.72096,percent of total billed charges,,,
ARSENIC TRIOXIDE 12 MG/6ML IV SOLN,RX-141420,CDM,J9017,HCPCS,636,RC,63459-0601-11,NDC,outpatient,6,ML,3082.97,2158.079,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,797.564339,7.2,2367.72096,percent of total billed charges,,,
AZACITIDINE 100 MG IJ SUSR,RX-78420,CDM,J9025,HCPCS,636,RC,43598-0305-62,NDC,outpatient,1,UN,83.86,58.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,21.694582,0.32,416.02,percent of total billed charges,,,
AZACITIDINE 100 MG IJ SUSR,RX-78420,CDM,J9025,HCPCS,636,RC,63323-0771-39,NDC,outpatient,1,UN,117.36,82.152,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,30.361032,0.32,416.02,percent of total billed charges,,,
BENDAMUSTINE HCL 5 MG/ML IV SOLR WRAPPER,RX-4080211,CDM,J9033,HCPCS,636,RC,63459-0390-08,NDC,outpatient,5,ML,889.43,622.601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,230.095541,5.43,2152.77312,percent of total billed charges,,,
BENDAMUSTINE HCL 5 MG/ML IV SOLR WRAPPER,RX-4080211,CDM,J9033,HCPCS,636,RC,63459-0391-20,NDC,outpatient,20,ML,2803.09,1962.163,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,725.159383,5.43,2152.77312,percent of total billed charges,,,
BENDAMUSTINE HCL 100 MG/4ML IV SOLN,RX-133070,CDM,J9034,HCPCS,636,RC,63459-0348-04,NDC,outpatient,4,ML,5078.48,3554.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1313.802776,12.95,3900.27264,percent of total billed charges,,,
BEVACIZUMAB 25 MG/ML IV WRAPPER,RX-4080193,CDM,J9035,HCPCS,636,RC,50242-0060-01,NDC,outpatient,4,ML,2279.25,1595.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,589.641975,72.7,7001.856,percent of total billed charges,,,
BEVACIZUMAB 25 MG/ML IV WRAPPER,RX-4080193,CDM,J9035,HCPCS,636,RC,50242-0061-01,NDC,outpatient,16,ML,9117,6381.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2358.5679,72.7,7001.856,percent of total billed charges,,,
BLEOMYCIN SULFATE 30 UNITS IJ SOLR,RX-17012,CDM,J9040,HCPCS,636,RC,63323-0137-20,NDC,outpatient,1,UN,120.16,84.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,31.085392,14.931495,416.02,percent of total billed charges,,,
BLEOMYCIN SULFATE 15 UNITS IJ SOLR *TEST DOSE*,RX-9289,CDM,J9040,HCPCS,636,RC,16714-0886-01,NDC,outpatient,1,UN,66.51,46.557,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,17.206137,14.931495,416.02,percent of total billed charges,,,
BORTEZOMIB 3.5 MG IJ SOLR,RX-123070,CDM,J9041,HCPCS,636,RC,00143-9098-01,NDC,outpatient,1,UN,58.7,41.09,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,15.18569,1.57,905.322979,percent of total billed charges,,,
BORTEZOMIB 3.5 MG IJ SOLR,RX-123070,CDM,J9041,HCPCS,636,RC,10019-0991-01,NDC,outpatient,1,UN,147.6,103.32,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,38.18412,1.57,905.322979,percent of total billed charges,,,
BRENTUXIMAB VEDOTIN 50 MG IV SOLR,RX-111348,CDM,J9042,HCPCS,636,RC,51144-0050-01,NDC,outpatient,1,UN,32323.72,22626.604,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8362.146364,221.96,24824.61696,percent of total billed charges,,,
CABAZITAXEL 60 MG/1.5ML IV SOLN,RX-105644,CDM,J9043,HCPCS,636,RC,00024-5824-11,NDC,outpatient,6,ML,39665.77,27766.039,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10261.5347,206.03,30463.31136,percent of total billed charges,,,
CARBOPLATIN 10 MG/ML IV SOLN WRAPPER,RX-4080212,CDM,J9045,HCPCS,636,RC,00703-4248-01,NDC,outpatient,45,ML,63.71,44.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.481777,2.41,416.02,percent of total billed charges,,,
CARBOPLATIN 10 MG/ML IV SOLN WRAPPER,RX-4080212,CDM,J9045,HCPCS,636,RC,61703-0339-50,NDC,outpatient,45,ML,157.96,110.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,40.864252,2.41,416.02,percent of total billed charges,,,
CARFILZOMIB 60 MG IV SOLR,RX-117047,CDM,J9047,HCPCS,636,RC,76075-0101-01,NDC,outpatient,1,UN,8945.66,6261.962,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2314.242242,47.04,6870.26688,percent of total billed charges,,,
CETUXIMAB 200 MG/100ML IV SOLN,RX-108072,CDM,J9055,HCPCS,636,RC,66733-0958-23,NDC,outpatient,100,ML,4373.8,3061.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1131.50206,72.08,3359.0784,percent of total billed charges,,,
CETUXIMAB 100 MG/50ML IV SOLN,RX-37989,CDM,J9055,HCPCS,636,RC,66733-0948-23,NDC,outpatient,50,ML,2186.9,1530.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,565.75103,72.08,3359.0784,percent of total billed charges,,,
CISPLATIN 1 MG/ML IV WRAPPER,RX-4080194,CDM,J9060,HCPCS,636,RC,00703-5748-11,NDC,outpatient,100,ML,67.89,47.523,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,17.563143,2.37,416.02,percent of total billed charges,,,
CLADRIBINE 1 MG/ML IV SOLN WRAPPER,RX-4080791,CDM,J9065,HCPCS,636,RC,63323-0140-10,NDC,outpatient,10,ML,347.72,243.404,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,89.955164,14.25,416.02,percent of total billed charges,,,
CYCLOPHOSPHAMIDE 1 G IJ SOLR,RX-38270,CDM,J9070,HCPCS,636,RC,00781-3244-94,NDC,outpatient,1,UN,1602.63,1121.841,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,414.600381,17.09,1230.81984,percent of total billed charges,,,
CYCLOPHOSPHAMIDE 500 MG IJ SOLR,RX-38271,CDM,J9070,HCPCS,636,RC,00781-3233-94,NDC,outpatient,1,UN,1017.09,711.963,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,263.121183,17.09,1230.81984,percent of total billed charges,,,
CYCLOPHOSPHAMIDE 2 G IJ SOLR,RX-38280,CDM,J9070,HCPCS,636,RC,10019-0957-01,NDC,outpatient,1,UN,1524.13,1066.891,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,394.292431,17.09,1230.81984,percent of total billed charges,,,
CYTARABINE (PF) 100 MG/ML IJ SOLN,RX-20156,CDM,J9100,HCPCS,636,RC,61703-0319-22,NDC,outpatient,20,ML,53.29,37.303,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.786123,0.77,416.02,percent of total billed charges,,,
CYTARABINE (PF) 100 MG/ML IJ SOLN,RX-20156,CDM,J9100,HCPCS,636,RC,63323-0120-20,NDC,outpatient,20,ML,40.95,28.665,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,10.593765,0.77,416.02,percent of total billed charges,,,
CYTARABINE (PF) 20 MG/ML IJ SOLN,RX-96982,CDM,J9100,HCPCS,636,RC,61703-0303-46,NDC,outpatient,50,ML,62.44,43.708,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.153228,0.77,416.02,percent of total billed charges,,,
CYTARABINE (PF) 20 MG/ML IJ SOLN,RX-96982,CDM,J9100,HCPCS,636,RC,61703-0305-38,NDC,outpatient,5,ML,16.81,11.767,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.348747,0.77,416.02,percent of total billed charges,,,
CYTARABINE (PF) 20 MG/ML IJ SOLN,RX-96982,CDM,J9100,HCPCS,636,RC,61703-0305-58,NDC,outpatient,5,ML,16.81,11.767,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.348747,0.77,416.02,percent of total billed charges,,,
CYTARABINE 20 MG/ML IJ SOLN,RX-9709,CDM,J9100,HCPCS,636,RC,61703-0304-36,NDC,outpatient,25,ML,34.67,24.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.969129,0.77,416.02,percent of total billed charges,,,
DACARBAZINE 200 MG IV SOLR,RX-2091,CDM,J9130,HCPCS,636,RC,00143-9245-01,NDC,outpatient,1,UN,16.44,11.508,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.253028,3.69078,416.02,percent of total billed charges,,,
DACARBAZINE 200 MG IV SOLR,RX-2091,CDM,J9130,HCPCS,636,RC,00143-9245-10,NDC,outpatient,1,UN,16.44,11.508,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.253028,3.69078,416.02,percent of total billed charges,,,
DEGARELIX ACETATE(240 MG DOSE) 120 MG/VIAL SC SOLR,RX-150086,CDM,J9155,HCPCS,636,RC,55566-8403-01,NDC,outpatient,1,UN,1744.22,1220.954,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,451.229714,4.18,1339.56096,percent of total billed charges,,,
DEGARELIX ACETATE 80 MG SC SOLR,RX-96986,CDM,J9155,HCPCS,636,RC,55566-8303-01,NDC,outpatient,1,UN,1117.94,782.558,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,289.211078,4.18,1339.56096,percent of total billed charges,,,
DOCETAXEL 20 MG/ML IV CONC WRAPPER,RX-4080197,CDM,J9171,HCPCS,636,RC,16729-0267-65,NDC,outpatient,8,ML,615.8,431.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,159.30746,0.79,1115.136,percent of total billed charges,,,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,00409-0201-02,NDC,outpatient,2,ML,45.67,31.969,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.814829,0.79,1115.136,percent of total billed charges,,,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,43066-0006-01,NDC,outpatient,8,ML,120.55,84.385,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,31.186285,0.79,1115.136,percent of total billed charges,,,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,66758-0050-02,NDC,outpatient,8,ML,726,508.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,187.8162,0.79,1115.136,percent of total billed charges,,,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,00409-0201-20,NDC,outpatient,16,ML,345.35,241.745,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,89.342045,0.79,1115.136,percent of total billed charges,,,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,66758-0050-01,NDC,outpatient,2,ML,181.5,127.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,46.95405,0.79,1115.136,percent of total billed charges,,,
DOCETAXEL 10 MG/ML IV WRAPPER,RX-4080198,CDM,J9171,HCPCS,636,RC,66758-0050-03,NDC,outpatient,16,ML,1452,1016.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,375.6324,0.79,1115.136,percent of total billed charges,,,
EPIRUBICIN HCL 2 MG/ML IV SOLN WRAPPER,RX-4080365,CDM,J9178,HCPCS,636,RC,00009-5091-01,NDC,outpatient,25,ML,112.35,78.645,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,29.064945,1.34,416.02,percent of total billed charges,,,
ERIBULIN MESYLATE 1 MG/2ML IV PUSH SOLN,RX-106773,CDM,J9179,HCPCS,636,RC,62856-0389-01,NDC,outpatient,2,ML,4032.6,2822.82,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1043.23362,128.78,3097.0368,percent of total billed charges,,,
ETOPOSIDE 100 MG/5ML IV SOLN,RX-124543,CDM,J9181,HCPCS,636,RC,16729-0114-08,NDC,outpatient,25,ML,169.25,118.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,43.784975,0.7,416.02,percent of total billed charges,,,
ETOPOSIDE 100 MG/5ML IV SOLN,RX-124543,CDM,J9181,HCPCS,636,RC,16729-0114-31,NDC,outpatient,5,ML,33.84,23.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.754408,0.7,416.02,percent of total billed charges,,,
FLUDARABINE PHOSPHATE 25 MG/ML IV WRAPPER,RX-4080526,CDM,J9185,HCPCS,636,RC,25021-0242-02,NDC,outpatient,2,ML,278.39,194.873,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,72.019493,62.498555,604.75,percent of total billed charges,,,
FLUOROURACIL 50 MG/ML IV SOLN WRAPPER,RX-4080199,CDM,J9190,HCPCS,636,RC,16729-0276-11,NDC,outpatient,50,ML,99.65,69.755,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,25.779455,1.83,416.02,percent of total billed charges,,,
FLUOROURACIL 500 MG/10ML IV PUSH SOLN,RX-82200,CDM,J9190,HCPCS,636,RC,63323-0117-00,NDC,outpatient,10,ML,8.43,5.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.180841,1.83,416.02,percent of total billed charges,,,
FLUOROURACIL 500 MG/10ML IV PUSH SOLN,RX-82200,CDM,J9190,HCPCS,636,RC,63323-0117-10,NDC,outpatient,10,ML,8.43,5.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2.180841,1.83,416.02,percent of total billed charges,,,
GEMCITABINE HCL 200 MG/5.26ML IV SOLN,RX-112786,CDM,J9201,HCPCS,636,RC,00409-0183-01,NDC,outpatient,5.26,ML,31.43,22.001,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,8.130941,2.79,416.02,percent of total billed charges,,,
GEMCITABINE HCL 1 GM/26.3ML IV SOLN,RX-112787,CDM,J9201,HCPCS,636,RC,00409-0181-01,NDC,outpatient,26.3,ML,133.66,93.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,34.577842,2.79,416.02,percent of total billed charges,,,
GEMCITABINE HCL 200 MG IV SOLR,RX-17121,CDM,J9201,HCPCS,636,RC,25021-0234-10,NDC,outpatient,1,UN,27.81,19.467,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.194447,2.79,416.02,percent of total billed charges,,,
GEMCITABINE HCL 1 G IV SOLR,RX-17122,CDM,J9201,HCPCS,636,RC,16714-0930-01,NDC,outpatient,1,UN,63.54,44.478,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,16.437798,2.79,416.02,percent of total billed charges,,,
GOSERELIN ACETATE 3.6 MG SC IMPL,RX-10137,CDM,J9202,HCPCS,636,RC,70720-0950-36,NDC,outpatient,1,UN,2706.82,1894.774,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,700.254334,399.86,5828.5824,percent of total billed charges,,,
GOSERELIN ACETATE 10.8 MG SC IMPL,RX-16254,CDM,J9202,HCPCS,636,RC,70720-0951-30,NDC,outpatient,1,UN,7589.3,5312.51,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1963.35191,399.86,5828.5824,percent of total billed charges,,,
IRINOTECAN HCL 20 MG/ML IV SOLN WRAPPER,RX-4080202,CDM,J9206,HCPCS,636,RC,61703-0349-09,NDC,outpatient,5,ML,56.89,39.823,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,14.717443,2.5,416.02,percent of total billed charges,,,
IRINOTECAN HCL 20 MG/ML IV SOLN WRAPPER,RX-4080202,CDM,J9206,HCPCS,636,RC,60505-6128-01,NDC,outpatient,5,ML,26.29,18.403,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6.801223,2.5,416.02,percent of total billed charges,,,
IRINOTECAN HCL 20 MG/ML IV SOLN WRAPPER,RX-4080202,CDM,J9206,HCPCS,636,RC,61703-0349-16,NDC,outpatient,2,ML,43.49,30.443,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.250863,2.5,416.02,percent of total billed charges,,,
IXABEPILONE 15 MG IV SOLR,RX-88652,CDM,J9207,HCPCS,636,RC,70020-1910-01,NDC,outpatient,1,UN,5537.91,3876.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1432.657317,122.55,12759.31392,percent of total billed charges,,,
IXABEPILONE 45 MG IV SOLR,RX-88653,CDM,J9207,HCPCS,636,RC,70020-1911-01,NDC,outpatient,1,UN,16613.69,11629.583,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4297.961603,122.55,12759.31392,percent of total billed charges,,,
IFOSFAMIDE 1 G IV SOLR,RX-10248,CDM,J9208,HCPCS,636,RC,10019-0925-82,NDC,outpatient,1,UN,94.35,66.045,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,24.408345,21.181575,416.02,percent of total billed charges,,,
IFOSFAMIDE 1 G IV SOLR,RX-10248,CDM,J9208,HCPCS,636,RC,10019-0925-01,NDC,outpatient,1,UN,94.35,66.045,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,24.408345,21.181575,416.02,percent of total billed charges,,,
IFOSFAMIDE 3 G IV SOLR,RX-10249,CDM,J9208,HCPCS,636,RC,00338-3993-01,NDC,outpatient,1,UN,350.95,245.665,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,90.790765,21.181575,416.02,percent of total billed charges,,,
IFOSFAMIDE 3 G IV SOLR,RX-10249,CDM,J9208,HCPCS,636,RC,10019-0926-02,NDC,outpatient,1,UN,288.44,201.908,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,74.619428,21.181575,416.02,percent of total billed charges,,,
IFOSFAMIDE 3 G IV SOLR,RX-10249,CDM,J9208,HCPCS,636,RC,10019-0926-16,NDC,outpatient,1,UN,288.44,201.908,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,74.619428,21.181575,416.02,percent of total billed charges,,,
MESNA 100 MG/ML IV SOLN,RX-10537,CDM,J9209,HCPCS,636,RC,00338-1305-01,NDC,outpatient,10,ML,28.36,19.852,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,7.336732,1.67,416.02,percent of total billed charges,,,
MESNA 100 MG/ML IV SOLN,RX-10537,CDM,J9209,HCPCS,636,RC,63323-0733-11,NDC,outpatient,10,ML,222.31,155.617,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,57.511597,1.67,416.02,percent of total billed charges,,,
IDARUBICIN HCL 1 MG/ML IV SOLN WRAPPER,RX-4080583,CDM,J9211,HCPCS,636,RC,00013-2576-91,NDC,outpatient,5,ML,121.76,85.232,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,31.499312,27.33512,416.02,percent of total billed charges,,,
LEUPROLIDE ACETATE 7.5 MG IM KIT,RX-10392,CDM,J9217,HCPCS,636,RC,00074-3642-03,NDC,outpatient,1,UN,5670.76,3969.532,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1467.025612,165.86,17420.48256,percent of total billed charges,,,
LEUPROLIDE ACETATE (3 MONTH) 22.5 MG IM KIT,RX-21045,CDM,J9217,HCPCS,636,RC,00074-3346-03,NDC,outpatient,1,UN,17012.14,11908.498,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4401.040618,165.86,17420.48256,percent of total billed charges,,,
LEUPROLIDE ACETATE (4 MONTH) 30 MG IM KIT,RX-21108,CDM,J9217,HCPCS,636,RC,00074-3683-03,NDC,outpatient,1,UN,22682.92,15878.044,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5868.071404,165.86,17420.48256,percent of total billed charges,,,
LEUPROLIDE ACETATE (4 MONTH) 30 MG SC KIT,RX-35236,CDM,J9217,HCPCS,636,RC,62935-0303-30,NDC,outpatient,1,UN,1549.29,1084.503,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,400.801323,165.86,17420.48256,percent of total billed charges,,,
IPILIMUMAB 5 MG/ML IV SOLN WRAPPER,RX-4080201,CDM,J9228,HCPCS,636,RC,00003-2327-11,NDC,outpatient,10,ML,24402.93,17082.051,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6313.037991,167.93,74965.60128,percent of total billed charges,,,
IPILIMUMAB 5 MG/ML IV SOLN WRAPPER,RX-4080201,CDM,J9228,HCPCS,636,RC,00003-2328-22,NDC,outpatient,40,ML,97611.46,68328.022,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,25252.0847,167.93,74965.60128,percent of total billed charges,,,
METHOTREXATE SODIUM 25 MG/ML IJ SOLN WRAPPER,RX-4080788,CDM,J9250,HCPCS,636,RC,61703-0350-38,NDC,outpatient,0.5,ML,3.4,2.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.87958,0.27,416.02,percent of total billed charges,,,
METHOTREXATE SODIUM 25 MG/ML IJ SOLN WRAPPER,RX-4080788,CDM,J9250,HCPCS,636,RC,61703-0350-37,NDC,outpatient,0.5,ML,3.4,2.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.87958,0.27,416.02,percent of total billed charges,,,
METHOTREXATE SODIUM (PF) 25 MG/ML IJ SOLN WRAPPER,RX-4080789,CDM,J9260,HCPCS,636,RC,00143-9519-01,NDC,outpatient,2,ML,6.58,4.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.702246,1.47721,416.02,percent of total billed charges,,,
METHOTREXATE SODIUM (PF) 25 MG/ML IJ SOLN WRAPPER,RX-4080789,CDM,J9260,HCPCS,636,RC,00143-9519-10,NDC,outpatient,2,ML,6.58,4.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1.702246,1.47721,416.02,percent of total billed charges,,,
NELARABINE 5 MG/ML IV SOLN,RX-70267,CDM,J9261,HCPCS,636,RC,00078-0683-61,NDC,outpatient,50,ML,2241.96,1569.372,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,579.995052,72.53,1721.82528,percent of total billed charges,,,
OXALIPLATIN 5 MG/ML IV SOLR WRAPPER,RX-4080205,CDM,J9263,HCPCS,636,RC,00703-3986-01,NDC,outpatient,20,ML,216.64,151.648,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,56.044768,0.06,416.02,percent of total billed charges,,,
OXALIPLATIN 5 MG/ML IV SOLR WRAPPER,RX-4080205,CDM,J9263,HCPCS,636,RC,67457-0469-10,NDC,outpatient,10,ML,50.32,35.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,13.017784,0.06,416.02,percent of total billed charges,,,
PACLITAXEL PROTEIN-BOUND PART 100 MG IV SUSR,RX-40475,CDM,J9264,HCPCS,636,RC,68817-0134-50,NDC,outpatient,1,UN,4383.41,3068.387,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1133.988167,12.06,3366.45888,percent of total billed charges,,,
PACLITAXEL 6 MG/ML IV CONC WRAPPER,RX-4080637,CDM,J9267,HCPCS,636,RC,61703-0342-50,NDC,outpatient,50,ML,238.31,166.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,61.650797,0.1,416.02,percent of total billed charges,,,
PACLITAXEL 6 MG/ML IV CONC WRAPPER,RX-4080637,CDM,J9267,HCPCS,636,RC,63323-0763-50,NDC,outpatient,50,ML,433.61,303.527,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,112.174907,0.1,416.02,percent of total billed charges,,,
PENTOSTATIN 10 MG IV SOLR,RX-10910,CDM,J9268,HCPCS,636,RC,00409-0801-01,NDC,outpatient,1,UN,6377.89,4464.523,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1649.960143,399.86,4898.21952,percent of total billed charges,,,
PEMBROLIZUMAB 25 MG/ML IV SOLN WRAPPER,RX-4080564,CDM,J9271,HCPCS,636,RC,00006-3026-02,NDC,outpatient,4,ML,16212.43,11348.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4194.155641,54.81,12451.14624,percent of total billed charges,,,
MITOMYCIN 20 MG IV SOLR,RX-10630,CDM,J9280,HCPCS,636,RC,16729-0108-11,NDC,outpatient,1,UN,505.56,353.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,130.788372,42.51,2565.35808,percent of total billed charges,,,
MITOMYCIN 40 MG IV SOLR,RX-10631,CDM,J9280,HCPCS,636,RC,00143-9280-01,NDC,outpatient,1,UN,3340.31,2338.217,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,864.138197,42.51,2565.35808,percent of total billed charges,,,
MITOMYCIN 40 MG IV SOLR,RX-10631,CDM,J9280,HCPCS,636,RC,16729-0116-38,NDC,outpatient,1,UN,3340.2,2338.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,864.10974,42.51,2565.35808,percent of total billed charges,,,
MITOMYCIN 5 MG IV SOLR,RX-10632,CDM,J9280,HCPCS,636,RC,16729-0115-05,NDC,outpatient,1,UN,734.35,514.045,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,189.976345,42.51,2565.35808,percent of total billed charges,,,
MITOXANTRONE HCL 20 MG/10ML IV CONC,RX-93748,CDM,J9293,HCPCS,636,RC,61703-0343-18,NDC,outpatient,10,ML,279.99,195.993,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,72.433413,29.06,416.02,percent of total billed charges,,,
NIVOLUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080562,CDM,J9299,HCPCS,636,RC,00003-3772-11,NDC,outpatient,4,ML,3567.83,2497.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,922.997621,30.46,16440.55296,percent of total billed charges,,,
NIVOLUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080562,CDM,J9299,HCPCS,636,RC,00003-3774-12,NDC,outpatient,10,ML,8919.54,6243.678,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2307.484998,30.46,16440.55296,percent of total billed charges,,,
NIVOLUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080562,CDM,J9299,HCPCS,636,RC,00003-3734-13,NDC,outpatient,24,ML,21406.97,14984.879,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5537.983139,30.46,16440.55296,percent of total billed charges,,,
OBINUTUZUMAB 1000 MG/40ML IV SOLN,RX-124650,CDM,J9301,HCPCS,636,RC,50242-0070-01,NDC,outpatient,40,ML,23571.67,16500.169,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,6097.991029,70.55,18103.04256,percent of total billed charges,,,
PANITUMUMAB 20 MG/ML IV SOLN WRAPPER,RX-4080216,CDM,J9303,HCPCS,636,RC,55513-0956-01,NDC,outpatient,20,ML,18284.9,12799.43,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4730.30363,149.71,14042.8032,percent of total billed charges,,,
PANITUMUMAB 20 MG/ML IV SOLN WRAPPER,RX-4080216,CDM,J9303,HCPCS,636,RC,55513-0954-01,NDC,outpatient,5,ML,4571.26,3199.882,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1182.584962,149.71,14042.8032,percent of total billed charges,,,
PEMETREXED DISODIUM 500 MG IV SOLR,RX-37894,CDM,J9305,HCPCS,636,RC,00002-7623-01,NDC,outpatient,1,UN,11216.1,7851.27,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2901.60507,4.18,8613.9648,percent of total billed charges,,,
PEMETREXED DISODIUM 100 MG IV SOLR,RX-89350,CDM,J9305,HCPCS,636,RC,00002-7640-01,NDC,outpatient,1,UN,2243.22,1570.254,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,580.321014,4.18,8613.9648,percent of total billed charges,,,
PERTUZUMAB 420 MG/14ML IV SOLN,RX-116596,CDM,J9306,HCPCS,636,RC,50242-0145-01,NDC,outpatient,14,ML,18666.61,13066.627,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4829.052007,15.37,14335.95648,percent of total billed charges,,,
PRALATREXATE 20 MG/ML IV SOLN WRAPPER,RX-4080207,CDM,J9307,HCPCS,636,RC,72893-0003-01,NDC,outpatient,1,ML,20371.07,14259.749,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5269.995809,356.51,15644.98176,percent of total billed charges,,,
RAMUCIRUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080567,CDM,J9308,HCPCS,636,RC,00002-7669-01,NDC,outpatient,10,ML,4084.74,2859.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1056.722238,68.87,15685.39392,percent of total billed charges,,,
RAMUCIRUMAB 10 MG/ML IV SOLN WRAPPER,RX-4080567,CDM,J9308,HCPCS,636,RC,00002-7678-01,NDC,outpatient,50,ML,20423.69,14296.583,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5283.608603,68.87,15685.39392,percent of total billed charges,,,
RITUXIMAB 10 MG/ML IV SOLN WRAPPER,RX-4080719,CDM,J9312,HCPCS,636,RC,50242-0053-06,NDC,outpatient,50,ML,13435.14,9404.598,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,3475.670718,77.31,10318.18752,percent of total billed charges,,,
RITUXIMAB 10 MG/ML IV SOLN WRAPPER,RX-4080719,CDM,J9312,HCPCS,636,RC,50242-0051-21,NDC,outpatient,10,ML,2687.03,1880.921,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,695.134661,77.31,10318.18752,percent of total billed charges,,,
STREPTOZOCIN 1 G IV SOLR,RX-11436,CDM,J9320,HCPCS,636,RC,00703-4636-01,NDC,outpatient,1,UN,1171.99,820.393,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,303.193813,223.44,900.08832,percent of total billed charges,,,
TEMSIROLIMUS 25 MG/ML IV SOLN,RX-82228,CDM,J9330,HCPCS,636,RC,00008-1179-01,NDC,outpatient,2.5,ML,5549.29,3884.503,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1435.601323,32.21,4261.85472,percent of total billed charges,,,
TOPOTECAN HCL 1 MG/ML IV SOLN WRAPPER,RX-4080561,CDM,J9351,HCPCS,636,RC,16729-0151-31,NDC,outpatient,1,UN,263.29,184.303,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,68.113123,0.5,416.02,percent of total billed charges,,,
ADO-TRASTUZUMAB EMTANSINE 100 MG IV SOLR,RX-120086,CDM,J9354,HCPCS,636,RC,50242-0088-01,NDC,outpatient,1,UN,11130.41,7791.287,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2879.437067,38.33,13677.02016,percent of total billed charges,,,
ADO-TRASTUZUMAB EMTANSINE 160 MG IV SOLR,RX-120087,CDM,J9354,HCPCS,636,RC,50242-0087-01,NDC,outpatient,1,UN,17808.62,12466.034,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4607.089994,38.33,13677.02016,percent of total billed charges,,,
TRASTUZUMAB 21 MG/ML IV SOLR WRAPPER,RX-4080954,CDM,J9355,HCPCS,636,RC,50242-0132-01,NDC,outpatient,150,ME,4754.01,3327.807,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1229.862387,77.94,3651.07968,percent of total billed charges,,,
TRASTUZUMAB 21 MG/ML IV SOLR WRAPPER|DISCARDED DRUG NOT ADMINISTERED,RX-4080954,CDM,J9355,HCPCS,636,RC,50242-0132-01,NDC,outpatient,150,ME,4456.89,3119.823,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,1152.997443,77.94,3651.07968,percent of total billed charges,,,
VINBLASTINE SULFATE 1 MG/ML IV SOLN IV PUSH,RX-8594,CDM,J9360,HCPCS,636,RC,63323-0278-10,NDC,outpatient,10,ML,173.56,121.492,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,44.899972,3.95,416.02,percent of total billed charges,,,
VINCRISTINE SULFATE 1 MG/ML IV SOLN,RX-8597,CDM,J9370,HCPCS,636,RC,61703-0309-16,NDC,outpatient,2,ML,46.03,32.221,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,11.907961,7.49,416.02,percent of total billed charges,,,
VINCRISTINE SULFATE 1 MG/ML IV SOLN,RX-8597,CDM,J9370,HCPCS,636,RC,61703-0309-06,NDC,outpatient,2,ML,92.35,64.645,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,23.890945,7.49,416.02,percent of total billed charges,,,
VINORELBINE TARTRATE 10 MG/ML IV SOLN WRAPPER,RX-4080209,CDM,J9390,HCPCS,636,RC,25021-0204-05,NDC,outpatient,5,ML,163.03,114.121,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,42.175861,7.59,416.02,percent of total billed charges,,,
FULVESTRANT 250 MG/5ML IM SOSY,RX-160451,CDM,J9394,HCPCS,636,RC,63323-0715-01,NDC,outpatient,10,ML,518.07,362.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,134.024709,1.65,1060,percent of total billed charges,,,
FULVESTRANT 250 MG/5ML IM SOSY,RX-160451,CDM,J9394,HCPCS,636,RC,63323-0715-05,NDC,outpatient,10,ML,518.07,362.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,134.024709,1.65,1060,percent of total billed charges,,,
COLLAR CERV FOAM LARGE -,SUP-00273900400,CDM,L0120,HCPCS,274,RC,,,outpatient,,,175.05,122.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.41367,416.02,other,Non-Reimbursable Procedures,,
COLLAR SM 20.5INX3.5IN SFT DENS BRTHBL STCKNT CVR FOAM/CTTN -,SUP-1018-02,CDM,L0120,HCPCS,274,RC,,,outpatient,,,22.99,16.093,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.41367,416.02,other,Non-Reimbursable Procedures,,
COLLAR CERVICAL STAT MEDIUM -,SUP-1018-03,CDM,L0120,HCPCS,274,RC,,,outpatient,,,19.66,13.762,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.41367,416.02,other,Non-Reimbursable Procedures,,
CERVICAL COLLAR XL SOFT 22x3.5 -,SUP-1050-24,CDM,L0120,HCPCS,274,RC,,,outpatient,,,23.75,16.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.41367,416.02,other,Non-Reimbursable Procedures,,
COLLAR PHILADELPHIA CERVICAL SM TRACH 2PC 4.25IN X 10-13IN -,SUP-1044-11,CDM,L0172,HCPCS,274,RC,,,outpatient,,,126.85,88.795,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.10504,416.02,other,Non-Reimbursable Procedures,,
COLLAR PHILADELPHIA CERVICAL MD TRACH 2PC 4.25IN X 13-16IN -,SUP-1044-12,CDM,L0172,HCPCS,274,RC,,,outpatient,,,126.85,88.795,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.10504,416.02,other,Non-Reimbursable Procedures,,
COLLAR PHILADELPHIA CERVICAL LRG TRACH 2PC 4.25IN X 16-19IN -,SUP-1044-13,CDM,L0172,HCPCS,274,RC,,,outpatient,,,126.85,88.795,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.10504,416.02,other,Non-Reimbursable Procedures,,
COLLAR CERVICAL RIGID MED TRACH 2PC 3.25IN X 13-16IN -,SUP-1113MPP,CDM,L0172,HCPCS,274,RC,,,outpatient,,,53.92,37.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.10504,416.02,other,Non-Reimbursable Procedures,,
COLLAR CERVICAL RIGID SM TRACH 2PC 3.25IN X 10-13IN -,SUP-1113SPP,CDM,L0172,HCPCS,274,RC,,,outpatient,,,53.92,37.744,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.10504,416.02,other,Non-Reimbursable Procedures,,
COLLAR PHILADELPHIA SM 3.25IN 10-13 IN -,SUP-79-83133,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.23,46.361,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.10504,416.02,other,Non-Reimbursable Procedures,,
COLLAR PHILADELPHIA MD 3.25IN x 13-16 IN -,SUP-79-83135,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.23,46.361,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.10504,416.02,other,Non-Reimbursable Procedures,,
COLLAR PHILADELPHIA LG 3.25IN x 16-19IN -,SUP-79-83137,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.23,46.361,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.10504,416.02,other,Non-Reimbursable Procedures,,
COLLAR PHILADELPHIA SM 4.25IN x 10-13IN -,SUP-79-83143,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.46,46.522,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.10504,416.02,other,Non-Reimbursable Procedures,,
COLLAR PHILADELPHIA LG 4.25IN x 16-19IN -,SUP-79-83147,CDM,L0172,HCPCS,274,RC,,,outpatient,,,66.46,46.522,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.10504,416.02,other,Non-Reimbursable Procedures,,
KNEE SUPPORT- HINGED PULL UP- MEDIUM -,SUP-NE7711-73,CDM,L1820,HCPCS,274,RC,,,outpatient,,,136.07,95.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,29.06826,416.02,other,Non-Reimbursable Procedures,,
KNEE SUPPORT HINGED PULL UP- LRG -,SUP-NE7711-74,CDM,L1820,HCPCS,274,RC,,,outpatient,,,129.48,90.636,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,29.06826,416.02,other,Non-Reimbursable Procedures,,
SUPPORT KNEE HINGED PULL UP LARGE -,SUP-NE7711-74,CDM,L1820,HCPCS,274,RC,,,outpatient,,,136.13,95.291,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,29.06826,416.02,other,Non-Reimbursable Procedures,,
KNEE SUPPORT HINGED PULL UP X-LRG -,SUP-NE7711-75,CDM,L1820,HCPCS,274,RC,,,outpatient,,,136.07,95.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,29.06826,416.02,other,Non-Reimbursable Procedures,,
SUPPORT KNEE HINGED PULL UP X-LARGE -,SUP-NE7711-75,CDM,L1820,HCPCS,274,RC,,,outpatient,,,129.48,90.636,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,29.06826,416.02,other,Non-Reimbursable Procedures,,
BRACE KNEE ENHANCED TROM - DONJOY -,SUP-11-9114-9,CDM,L1832,HCPCS,274,RC,,,outpatient,,,544.99,381.493,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,110.03643,1222.676,other,Non-Reimbursable Procedures,,
KNEE BRACE HINGED TROM DONJOY -,SUP-11-9114-9,CDM,L1832,HCPCS,274,RC,,,outpatient,,,544.99,381.493,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,110.03643,1222.676,other,Non-Reimbursable Procedures,,
BRACE KN POSTOP 18-26IN FIT UPTO 34IN THG 6IN ABV MI D PTLR -,SUP-75-7500-000,CDM,L1832,HCPCS,274,RC,,,outpatient,,,490.14,343.098,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,110.03643,1222.676,other,Non-Reimbursable Procedures,,
ANKLE BRACE SPORTS ORTHOSIS LACE UP BOA SMALL -,SUP-AB3000-12,CDM,L1902,HCPCS,274,RC,,,outpatient,,,105.56,73.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,23.579235,416.02,other,Non-Reimbursable Procedures,,
ANKLE BRACE SPORTS ORTHOSIS LACE UP BOA MEDIUM -,SUP-AB3000-14,CDM,L1902,HCPCS,274,RC,,,outpatient,,,105.03,73.521,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,23.579235,416.02,other,Non-Reimbursable Procedures,,
BRACE ANKLE SPORTS ORTHOSIS LACE UP BOA LARGE -,SUP-AB3000-16,CDM,L1902,HCPCS,274,RC,,,outpatient,,,105.56,73.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,23.579235,416.02,other,Non-Reimbursable Procedures,,
BRACE ANKLE- SPORTS ORTHOSIS LACE UP BOA- XL -,SUP-AB3000-18,CDM,L1902,HCPCS,274,RC,,,outpatient,,,111.45,78.015,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,23.579235,416.02,other,Non-Reimbursable Procedures,,
SPLINT ORTHO LT ANKL/FT LRG SZ8-10 PLST CLSD HL MLD HK/LOP -,SUP-A508LL,CDM,L1930,HCPCS,274,RC,,,outpatient,,,180.48,126.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,34.77954,420.504,other,Non-Reimbursable Procedures,,
SPLINT ORTHO LT ANKL/FT MED SZ8-10 PLST CLSD HL MLD HK/LOP -,SUP-A508LM,CDM,L1930,HCPCS,274,RC,,,outpatient,,,179.78,125.846,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,34.77954,420.504,other,Non-Reimbursable Procedures,,
SPLINT ORTHO RT ANKL/FT LRG SZ8-10 MALE PLST CLSD HL MLD -,SUP-A508RL,CDM,L1930,HCPCS,274,RC,,,outpatient,,,180.48,126.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,34.77954,420.504,other,Non-Reimbursable Procedures,,
SPLINT ORTHO RT ANKL/FT LRG SZ8-10 PLST CLSD HL MLD HK/LOP -,SUP-A508RM,CDM,L1930,HCPCS,274,RC,,,outpatient,,,175.28,122.696,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,34.77954,420.504,other,Non-Reimbursable Procedures,,
SPLINT ORTHO RT ANKL/FT SM SZ3-6 FEM PLST CLSD HL MLD HK/LOP -,SUP-A508RS,CDM,L1930,HCPCS,274,RC,,,outpatient,,,226.22,158.354,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,34.77954,420.504,other,Non-Reimbursable Procedures,,
AFO FOR FOOT AND ANKLE -,SUP-XEE64330,CDM,L1930,HCPCS,274,RC,,,outpatient,,,154.92,108.444,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,34.77954,420.504,other,Non-Reimbursable Procedures,,
AFO FOR FOOT AND ANKLE -,SUP-XEE64331,CDM,L1930,HCPCS,274,RC,,,outpatient,,,154.92,108.444,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,34.77954,420.504,other,Non-Reimbursable Procedures,,
SYS FOOT OTHTC SM PEGASSIST DARCO -,SUP-PW1,CDM,L3002,HCPCS,274,RC,,,outpatient,,,73.46,51.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,19.004102,16.49177,416.02,percent of total billed charges,,,
SYS FOOT OTHTC MED PEGASSIST DARCO -,SUP-PW2,CDM,L3002,HCPCS,274,RC,,,outpatient,,,73.46,51.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,19.004102,16.49177,416.02,percent of total billed charges,,,
SYS FOOT OTHTC XL PEGASSIST DARCO -,SUP-PW4,CDM,L3002,HCPCS,274,RC,,,outpatient,,,73.46,51.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,19.004102,16.49177,416.02,percent of total billed charges,,,
SHOE POSTOP SZ5-6.5 SM MALE RT/LT LACE-UP CLSR -,SUP-2020-01,CDM,L3260,HCPCS,274,RC,,,outpatient,,,31.86,22.302,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures,,
SHOE POSTOP SZ7-8.5 MED MALE RT/LT LACE-UP CLSR -,SUP-2020-02,CDM,L3260,HCPCS,274,RC,,,outpatient,,,31.86,22.302,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures,,
SHOE POSTOP SZ9-11 LRG MALE RT/LT LACE-UP CLSR -,SUP-2020-03,CDM,L3260,HCPCS,274,RC,,,outpatient,,,31.86,22.302,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures,,
SHOE POSTOP SZ4-6 SM FEM RT/LT LACE-UP CLSR -,SUP-2021-01,CDM,L3260,HCPCS,274,RC,,,outpatient,,,30.87,21.609,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures,,
SHOE POSTOP SZ6.5-8 MED FEM RT/LT LACE-UP CLSR -,SUP-2021-02,CDM,L3260,HCPCS,274,RC,,,outpatient,,,30.87,21.609,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures,,
SHOE POSTOP SZ8.5-10 LRG L/R ANKL OPN TOE CLSD HL CNVS RBR -,SUP-2021-03,CDM,L3260,HCPCS,274,RC,,,outpatient,,,30.87,21.609,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures,,
BOOT CAST SM 4.5X8.5IN CNVS FT RCKR SOLE NSLIP HK/LOP CLSR -,SUP-2035-02,CDM,L3260,HCPCS,274,RC,,,outpatient,,,27.25,19.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures,,
CAST SHOE MED CANVAS ROCKER -,SUP-2035-03,CDM,L3260,HCPCS,274,RC,,,outpatient,,,27.6,19.32,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures,,
SHOE CAST LRG 5.25X11.5IN CNVS FT RCKR SOLE NSLIP HK/LOP -,SUP-2035-04,CDM,L3260,HCPCS,274,RC,,,outpatient,,,27.25,19.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures,,
SURGICAL SHOE MENS XL -,SUP-5701024,CDM,L3260,HCPCS,274,RC,,,outpatient,,,39.56,27.692,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures,,
SHOE ORTHO ANKL SM SZ7.5-10 MSH CLSD HL CLSD TOE HK/LOP STRP -,SUP-92732502,CDM,L3260,HCPCS,274,RC,,,outpatient,,,221.73,155.211,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures,,
SHOE ORTHO ANKL MED SZ8.5-10 MALE MSH CLSD HL CLSD TOE -,SUP-92732503,CDM,L3260,HCPCS,274,RC,,,outpatient,,,214.44,150.108,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures,,
SHOE ORTHO ANKL LRG SZ10.5-12 MSH CLSD HL CLSD TOE HK/LOP -,SUP-92732504,CDM,L3260,HCPCS,274,RC,,,outpatient,,,214.44,150.108,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures,,
SHOE CAST SZ6-8 MALE SZ7.5-10 FEM SM FT DARCO HEELWEDGE -,SUP-92732602,CDM,L3260,HCPCS,274,RC,,,outpatient,,,116.41,81.487,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures,,
SHOE CAST SZ8.5-10 MALE 10.5-13 FEM MED FT DARCO HEELWEDGE -,SUP-92732603,CDM,L3260,HCPCS,274,RC,,,outpatient,,,124.52,87.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures,,
SHOE POST-OP NYLON RUBBER HOOK/LOOP MALE SMALL -,SUP-A152305,CDM,L3260,HCPCS,274,RC,,,outpatient,,,20.66,14.462,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures,,
POST OP SHOE NYLON RUBBER HOOK/LOOP MALE LRG -,SUP-A152307,CDM,L3260,HCPCS,274,RC,,,outpatient,,,22.29,15.603,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures,,
SHOE POSTOP MENS SM SIZES 6-8 MEDSURG -,SUP-MQM1B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures,,
SHOE POSTOP MENS MED SIZES 8.5-10 MEDSURG -,SUP-MQM2B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures,,
SHOE POSTOP MENS LG SIZES 10.5-12 MEDSURG -,SUP-MQM3B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures,,
SHOE POSTOP MENS XL SIZES 12.5-14 MEDSURG -,SUP-MQM4B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures,,
SHOE POSTOP WOMENS SM SIZES 4-6 MEDSURG -,SUP-MQW1B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures,,
SHOE POSTOP WOMENS MED SIZES 6.5- 8 MEDSURG -,SUP-MQW2B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures,,
SHOE POSTOP SZ6.5-8 FEM MED MEDSURG OPN TOE CLSD HL RCKR BTM -,SUP-MQW2B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,110.4,77.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures,,
SHOE POSTOP WOMENS LG SIZES  8.5 -10 MEDSURG -,SUP-MQW3B,CDM,L3260,HCPCS,274,RC,,,outpatient,,,62.56,43.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures,,
SHOE DARCO SURGICAL MENS SMALL -,SUP-MSM1N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,28.47,19.929,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures,,
SHOES DARCO MENS MEDIUM -,SUP-MSM2N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,47.21,33.047,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures,,
SHOES DARCO MENS LARGE -,SUP-MSM3N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,48.55,33.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures,,
SHOES DARCO WOMENS SMALL -,SUP-MSW1N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,48.55,33.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures,,
SHOES DARCO WOMENS MEDIUM -,SUP-MSW2N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,28.47,19.929,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures,,
SHOES DARCO WOMENS LARGE -,SUP-MSW3N,CDM,L3260,HCPCS,274,RC,,,outpatient,,,45.63,31.941,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures,,
BOOT CAST REG FT PD WVN TCC-EZ -,SUP-TCC21100,CDM,L3260,HCPCS,274,RC,,,outpatient,,,393.57,275.499,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures,,
BOOT CAST LRG FT PD WVN TCC-EZ -,SUP-TCC21114,CDM,L3260,HCPCS,274,RC,,,outpatient,,,444.34,311.038,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures,,
BOOT CAST LRG FT CHARCOT PD WVN TCC-EZ -,SUP-TCC21116,CDM,L3260,HCPCS,274,RC,,,outpatient,,,538.28,376.796,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures,,
SYS CAST 3IN FT CHARCOT PD WVN W/REGULARX2 BT TCC-EZ -,SUP-TCC23000,CDM,L3260,HCPCS,274,RC,,,outpatient,,,627.97,439.579,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures,,
SYS CAST SZ4 IN FT PD WVN W/2 REG BT TCC-EZ -,SUP-TCC24000,CDM,L3260,HCPCS,274,RC,,,outpatient,,,627.97,439.579,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,4.63817,482.28096,other,Non-Reimbursable Procedures,,
IMMOBILIZER SHLDR LRG ELAS HUM CUF RB WRP -,SUP-00078300300,CDM,L3670,HCPCS,274,RC,,,outpatient,,,291.75,204.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.81201,416.02,other,Non-Reimbursable Procedures,,
IMMOBILIZER SHLDR LRG ELAS HUM CUF CONTR RB WRP -,SUP-00078400300,CDM,L3670,HCPCS,274,RC,,,outpatient,,,233.4,163.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.81201,416.02,other,Non-Reimbursable Procedures,,
IMMOBILIZER SHLDR SMALL ULTRASLING III BLACK -,SUP-11-0449-2,CDM,L3670,HCPCS,274,RC,,,outpatient,,,305.46,213.822,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.81201,416.02,other,Non-Reimbursable Procedures,,
IMMOBILIZER SHLDR MED ULTRASLING III BLACK -,SUP-11-0449-3,CDM,L3670,HCPCS,274,RC,,,outpatient,,,305.46,213.822,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.81201,416.02,other,Non-Reimbursable Procedures,,
SUPPORT RT SHLDR SM 11IN MSH FBRC ULSNG ER HUM CUF 15DEG -,SUP-11-1343-2-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.81201,416.02,other,Non-Reimbursable Procedures,,
SUPPORT LT SHLDR ARM SM UPTO 11IN MSH FBRC ULSNG ER BRTHBL -,SUP-11-1344-2-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.81201,416.02,other,Non-Reimbursable Procedures,,
SUPPORT LT SHLDR ARM LRG ABV 13IN MSH FBRC ULSNG ER BRTHBL -,SUP-11-1344-4-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.81201,416.02,other,Non-Reimbursable Procedures,,
SUPPORT RT SHLDR SM 11IN MSH FBRC ULSNG ER HUM CUF 30DEG -,SUP-11-1345-2,CDM,L3670,HCPCS,274,RC,,,outpatient,,,371.22,259.854,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.81201,416.02,other,Non-Reimbursable Procedures,,
SUPPORT RT SHLDR LRG 13-15IN MSH FBRC ULSNG ER HUM 30DEG -,SUP-11-1345-4-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.81201,416.02,other,Non-Reimbursable Procedures,,
SUPPORT LT SHLDR LRG 13-15IN MSH FBRC ULSNG ER BRTHBL HUM -,SUP-11-1346-4-06000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,353.54,247.478,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.81201,416.02,other,Non-Reimbursable Procedures,,
IMMOBILIZER SHLDR SLING MED 7IN X 17IN -,SUP-11630006,CDM,L3670,HCPCS,274,RC,,,outpatient,,,243.14,170.198,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.81201,416.02,other,Non-Reimbursable Procedures,,
IMMOBILIZER SHLDR SLING LRG 7IN X 18IN -,SUP-11630007,CDM,L3670,HCPCS,274,RC,,,outpatient,,,243.14,170.198,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.81201,416.02,other,Non-Reimbursable Procedures,,
IIMMOBILIZER SHOULDER VELPEAU M -,SUP-23-1872,CDM,L3670,HCPCS,274,RC,,,outpatient,,,29.7,20.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.81201,416.02,other,Non-Reimbursable Procedures,,
IMMOBILIZER SHOULDER VELPEAU L -,SUP-23-1873-000,CDM,L3670,HCPCS,274,RC,,,outpatient,,,29.7,20.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.81201,416.02,other,Non-Reimbursable Procedures,,
IMMOBILIZER SHLDR SM PD WRST/HUM CUF SHLDR/WST STRP -,SUP-667110,CDM,L3670,HCPCS,274,RC,,,outpatient,,,343.1,240.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.81201,416.02,other,Non-Reimbursable Procedures,,
IMMOBILIZER RT/LT SHLDR XS CTTN CLTH 6X12.5IN PCH CLSD/OPN -,SUP-9002-01,CDM,L3670,HCPCS,274,RC,,,outpatient,,,29.12,20.384,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.81201,416.02,other,Non-Reimbursable Procedures,,
IMMOBILIZER SHOULDER UNIVERSAL -,SUP-9013-00,CDM,L3670,HCPCS,274,RC,,,outpatient,,,56.25,39.375,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.81201,416.02,other,Non-Reimbursable Procedures,,
SHOULDER IMMOBILIZER W/FOAM SMALL -,SUP-A111015,CDM,L3670,HCPCS,274,RC,,,outpatient,,,19.02,13.314,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.81201,416.02,other,Non-Reimbursable Procedures,,
SHOULDER IMMOBILIZER W/FOAM WAIST STRAP M -,SUP-A111016,CDM,L3670,HCPCS,274,RC,,,outpatient,,,19.02,13.314,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.81201,416.02,other,Non-Reimbursable Procedures,,
IMMOBILIZER SHLDR X-LRG 9IN X 22.5IN -,SUP-A111018,CDM,L3670,HCPCS,274,RC,,,outpatient,,,16.98,11.886,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.81201,416.02,other,Non-Reimbursable Procedures,,
IMMOBILIZER SHOULDER VELP XLG -,SUP-TX9023-04,CDM,L3670,HCPCS,274,RC,,,outpatient,,,31.1,21.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.81201,416.02,other,Non-Reimbursable Procedures,,
SPLINT RT HND SM 6.5-7.25IN ALIFLEECE LINER THRMPLST DLX FIG -,SUP-5183,CDM,L3807,HCPCS,274,RC,,,outpatient,,,286.27,200.389,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,31.76675,416.02,other,Non-Reimbursable Procedures,,
SPLINT RT HND LRG 8.25-9.25IN ALIFLEECE LINER THRMPLST DLX -,SUP-5187,CDM,L3807,HCPCS,274,RC,,,outpatient,,,284.4,199.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,31.76675,416.02,other,Non-Reimbursable Procedures,,
SPLINT LT SM RST -,SUP-5812,CDM,L3807,HCPCS,274,RC,,,outpatient,,,273.08,191.156,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,31.76675,416.02,other,Non-Reimbursable Procedures,,
SPLINT WRST MED POLY FOAM CCKUP -,SUP-A1601P,CDM,L3807,HCPCS,274,RC,,,outpatient,,,141.5,99.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,31.76675,416.02,other,Non-Reimbursable Procedures,,
EXTERNAL FIX DIGIT WIDGET -,SUP-DWD-232,CDM,L3921,HCPCS,274,RC,,,outpatient,,,7002.6,4901.82,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,335.72,5377.9968,other,Non-Reimbursable Procedures,,
SPLINT THUMB SPICA RIGHT MED/LRG 3.5IN - 4.25IN -,SUP-340M/LR,CDM,L3924,HCPCS,274,RC,,,outpatient,,,68.27,47.789,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,17.661449,15.326615,416.02,percent of total billed charges,,,
THUMB SPLINT COMFORT COOL CMC LT MEDIUM -,SUP-348ML,CDM,L3924,HCPCS,274,RC,,,outpatient,,,92.66,64.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,23.971142,15.326615,416.02,percent of total billed charges,,,
THUMB SPLINT COMFORT COOL CMC RT MEDIUM -,SUP-348MR,CDM,L3924,HCPCS,274,RC,,,outpatient,,,92.66,64.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,23.971142,15.326615,416.02,percent of total billed charges,,,
LMB SPRING PIP EXTENSION ASSIST -,SUP-704103,CDM,L3925,HCPCS,274,RC,,,outpatient,,,89.16,62.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,17.225885,416.02,other,Non-Reimbursable Procedures,,
SPLINT FINGER EXTENSION LMB SPRING SIZE A -,SUP-704200,CDM,L3925,HCPCS,274,RC,,,outpatient,,,76.73,53.711,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,17.225885,416.02,other,Non-Reimbursable Procedures,,
SPLINT FINGER EXTENSION SPRING LMB SIZE C -,SUP-704202,CDM,L3925,HCPCS,274,RC,,,outpatient,,,76.79,53.753,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,17.225885,416.02,other,Non-Reimbursable Procedures,,
BOOT WALKER LRG AIRCAST SZ10-13 MALE SZ11-15 FEM PED -,SUP-01EF-L,CDM,L4361,HCPCS,274,RC,,,outpatient,,,269.52,188.664,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,69.724824,50.613525,568.638,percent of total billed charges,,,
BOOT WALKER MED AIRCAST SZ7-10 MALE SZ8-11 FEM -,SUP-01EF-M,CDM,L4361,HCPCS,274,RC,,,outpatient,,,269.52,188.664,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,69.724824,50.613525,568.638,percent of total billed charges,,,
BOOT WALKER SM AIRCAST SZ4-7 MALE SZ5-8 FEM -,SUP-01F-S,CDM,L4361,HCPCS,274,RC,,,outpatient,,,263.86,184.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,68.260582,50.613525,568.638,percent of total billed charges,,,
BOOT WALKER XL AIRCAST SZ 13+ MALE SZ 15+ FEM -,SUP-01F-XL,CDM,L4361,HCPCS,274,RC,,,outpatient,,,263.86,184.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,68.260582,50.613525,568.638,percent of total billed charges,,,
BOOT WALKER LRG SHELL 10-13M/11-15F -,SUP-1175LPP,CDM,L4361,HCPCS,274,RC,,,outpatient,,,225.45,157.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,58.323915,50.613525,568.638,percent of total billed charges,,,
WALKER FULL SHELL 2 SHORT- SMALL -,SUP-15500047,CDM,L4361,HCPCS,274,RC,,,outpatient,,,274.6,192.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,71.03902,50.613525,568.638,percent of total billed charges,,,
WALKER- FULL SHELL 2 SHORT- MEDIUM -,SUP-15500048,CDM,L4361,HCPCS,274,RC,,,outpatient,,,249.74,174.818,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,64.607738,50.613525,568.638,percent of total billed charges,,,
WALKER FULL SHELL 2 SHORT LARGE -,SUP-1550049,CDM,L4361,HCPCS,274,RC,,,outpatient,,,234.33,164.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,60.621171,50.613525,568.638,percent of total billed charges,,,
BOOT ORTHO FT MED/L FLEECE LINER OPN TOE SEMI- FLXB SHL -,SUP-6963,CDM,L4394,HCPCS,274,RC,,,outpatient,,,127.09,88.963,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,20.61,416.02,other,Non-Reimbursable Procedures,,
VALVE SPK 15X23MM PASSY-MUIR WHITE -,SUP-PMV 005,CDM,L8501,HCPCS,274,RC,,,outpatient,,,429.46,300.622,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,52.37136,418.655068,other,Non-Reimbursable Procedures,,
VALVE SPK PASSY-MUIR PMV 15X22MM LPRO REUS FLEX AQUA -,SUP-PMV 007,CDM,L8501,HCPCS,274,RC,,,outpatient,,,493.93,345.751,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,52.37136,418.655068,other,Non-Reimbursable Procedures,,
VALVE SPK/SWALW IN G 15X23MM PASSY-MUIR PMV 1W  CLEAR -,SUP-PMV 2000,CDM,L8501,HCPCS,274,RC,,,outpatient,,,429.46,300.622,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,52.37136,418.655068,other,Non-Reimbursable Procedures,,
VALVE PASSY MUIR PURPLE SPEAK SWALLOW IN G 15X23MM PMV -,SUP-PMV 2001,CDM,L8501,HCPCS,274,RC,,,outpatient,,,429.46,300.622,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,52.37136,418.655068,other,Non-Reimbursable Procedures,,
VALVE SPK SHILEY 0.66MM MINI STRL MONOKA PHONATE W/O O2 PRT -,SUP-SSV,CDM,L8501,HCPCS,274,RC,,,outpatient,,,233.28,163.296,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,52.37136,418.655068,other,Non-Reimbursable Procedures,,
PROSTHESIS VOCAL CRD BLOM-SINGER CLASSIC 20FRX8MM INDWL STRL -,SUP-IN 2008-SO,CDM,L8509,HCPCS,274,RC,,,outpatient,,,1378.13,964.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,125.65,1058.40384,other,Non-Reimbursable Procedures,,
PROSTHESIS VOCAL CRD BLOM-SINGER 20FRX14MM INDWL STRL -,SUP-IN2014-SO,CDM,L8509,HCPCS,274,RC,,,outpatient,,,1378.13,964.691,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,125.65,1058.40384,other,Non-Reimbursable Procedures,,
IMPLANT BRST 600ML SIL GEL HPRO RND 14CM MEMORYGEL 5.6CM -,SUP-350-6004BC,CDM,L8600,HCPCS,278,RC,,,outpatient,,,4439.82,3107.874,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,3409.78176,other,Non-Reimbursable Procedures,,
BULKAMID URETHRAL BULKING SYSTEM -,SUP-50050,CDM,L8606,HCPCS,278,RC,,,outpatient,,,4880.6,3416.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,252.25,3748.3008,other,Non-Reimbursable Procedures,,
COAPTITE SYRINGE 1ML -,SUP-M0068903000,CDM,L8606,HCPCS,278,RC,,,outpatient,,,1975.44,1382.808,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,252.25,3748.3008,other,Non-Reimbursable Procedures,,
SPHERE EYE 18MM -,SUP-14254,CDM,L8610,HCPCS,278,RC,,,outpatient,,,315.09,220.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,70.737705,686.06,other,Non-Reimbursable Procedures,,
IMPLANT OSS PRT WIET 1.14MM SHFT 3.25MMX5MM OFF-CTR HAP FLEX -,SUP-0516,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2625.7,1837.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures,,
PROSTHESIS OSS PRT 4X5MM CTR HAP FLEX TI MLBL -,SUP-0550,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2565.44,1795.808,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures,,
MNP TOTAL TITANIUM .2 X 3.00MM -,SUP-1004434,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures,,
MNP TOTAL TITANIUM .2 X 3.5MM -,SUP-1004436,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2517.74,1762.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures,,
OMEGA CONNECTOR 1.5MM X 8MMX0.5 -,SUP-1004930,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1219.12,853.384,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures,,
PROSTHESIS OSS ASTN PLAS-PR MOD PORP 3MM FLNG DIA 1MM SHFT -,SUP-14-0063,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1300.05,910.035,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures,,
PISTON OTO SCHKNT 0.8MMX4.25MM WIRE LOOP FLPLS SS -,SUP-14-0105,CDM,L8613,HCPCS,278,RC,,,outpatient,,,628.66,440.062,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures,,
LOOP WIRE HOUSE TYPE .12 X 4.0 -,SUP-140184,CDM,L8613,HCPCS,278,RC,,,outpatient,,,268.41,187.887,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures,,
LOOP WIRE HOUSE TYPE .12 X 4.25 -,SUP-140184,CDM,L8613,HCPCS,278,RC,,,outpatient,,,346.6,242.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures,,
PISTON OTO RCHRD 0.6MMX3.50MM RBN LOOP FLPLS PLTNM -,SUP-14-0781,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures,,
PISTON OTO RCHRD 0.6X4MM RBN LOOP FLPLS PLTNM -,SUP-14-0783,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures,,
PISTON OTO RCHRD 0.6MMX4.25MM RBN LOOP FLPLS PLTNM -,SUP-14-0784,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures,,
PISTON OTO RCHRD 0.8X4MM RBN LOOP FLPLS PLTNM -,SUP-14-0792,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1024.74,717.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures,,
PISTON OTO RCHRD 0.8MMX4.5MM RBN LOOP FLPLS PLTNM -,SUP-14-0794,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1014.59,710.213,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures,,
PLATE OSS MED 10MM POR HAP ATTIC DFCT -,SUP-14-0863,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1063.14,744.198,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures,,
PLATE OSS 14MM LRG POR HAP ATTIC DFCT -,SUP-14-0864,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1072.41,750.687,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures,,
PROSTHESIS OSS APLBM SM 2X2MM 1MM CANN HAP INCSTP -,SUP-14-0956,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2182.32,1527.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures,,
PROSTHESIS OSS PRT GLDNBRG 1.5MM 1.14MM FLLY CANN HAP EAR -,SUP-14-0963,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2038.36,1426.852,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures,,
PROSTHESIS OSS APLBM 2.5X3MM HAP INCUS -,SUP-14-0973,CDM,L8613,HCPCS,278,RC,,,outpatient,,,2205.54,1543.878,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures,,
PROSTHESIS OSS RCHRD 0.4MM PSTN 1MM WELL 4.50MM CUP PED -,SUP-142152,CDM,L8613,HCPCS,278,RC,,,outpatient,,,761.58,533.106,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures,,
Eclipse Flat Ribbon Piston .6MM X 4.50MM -,SUP-472-450,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1863.34,1304.338,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures,,
Eclipse Flat Ribbon Piston .6MM X 4.75MM -,SUP-472-475,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1863.34,1304.338,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures,,
Eclipse Flat Ribbon Piston .6MM X 5.00MM -,SUP-472-500,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1863.34,1304.338,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures,,
PROSTHESIS OSS UM TORP 2X10MM CTR TI ADJ -,SUP-7014-1044,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1852.68,1296.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures,,
PROSTHESIS OSS UM TORP 2X5MM CTR TI ADJ -,SUP-7014-1046,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1852.68,1296.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures,,
PISTON OSS SMRT 0.6X4MM WIRE LOOP FLPLS NTNL STPS ADLT -,SUP-70145926,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1601.92,1121.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures,,
PISTON OSS SMRT 0.6MMX4.25MM WIRE LOOP FLPLS NTNL STPS ADLT -,SUP-70145927,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1601.92,1121.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures,,
PISTON OSS SMRT 0.6MMX4.50MM WIRE LOOP FLPLS NTNL STPS ADLT -,SUP-70145928,CDM,L8613,HCPCS,278,RC,,,outpatient,,,1601.92,1121.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures,,
DISTANCE PLATES REPLACEMENT 0.1 /0.2 /0.3 -,SUP-8000140,CDM,L8613,HCPCS,278,RC,,,outpatient,,,723.54,506.478,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,60.258045,2016.5376,other,Non-Reimbursable Procedures,,
JOINT FINGER SWANSON 1 MCP FLEXIBLE STERILE W/O GROMMETS SIL -,SUP-4700001,CDM,L8630,HCPCS,278,RC,,,outpatient,,,4602.62,3221.834,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,3534.81216,other,Non-Reimbursable Procedures,,
IMPLANT PIP MCP SZ4 SWNSN SIL -,SUP-G470-0004,CDM,L8630,HCPCS,278,RC,,,outpatient,,,4413.76,3089.632,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,3534.81216,other,Non-Reimbursable Procedures,,
PROSTHESIS PENL TOROSA LRG SAL FIL CYL INFL PRECNCT SCRT -,SUP-450-1329,CDM,L8699,HCPCS,278,RC,,,outpatient,,,8471.02,5929.714,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2191.452874,163.74581,6505.74336,percent of total billed charges,,,
PROSTHESIS TSTCLR 2.9CMX4.5IN -,SUP-96-450-1329,CDM,L8699,HCPCS,278,RC,,,outpatient,,,7002.6,4901.82,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1811.57262,163.74581,6505.74336,percent of total billed charges,,,
LEAD ANCHOR KIT -,SUP-ACCK5300,CDM,L8699,HCPCS,278,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,188.690606,163.74581,6505.74336,percent of total billed charges,,,
WEIGHT EYELID THN 0.6MM PLTNM 0.6GM SPHRCL CRV TAPR EDGE RND -,SUP-LL 6006,CDM,L8699,HCPCS,278,RC,,,outpatient,,,1749.17,1224.419,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,452.510279,163.74581,6505.74336,percent of total billed charges,,,
UROLIFT ATC IMPLANT CARTRIDGE -,SUP-UL2ATC-C,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4986.7,3490.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1290.05929,163.74581,6505.74336,percent of total billed charges,,,
IMPLANT CARTRIDGE UROLIFT -,SUP-UL2-C,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4350.1,3045.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1125.37087,163.74581,6505.74336,percent of total billed charges,,,
IMPLANT UROLOGICAL UROLIFT 2 CARTRIDGE -,SUP-UL2-C,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1204.157955,163.74581,6505.74336,percent of total billed charges,,,
KIT HANDLE UROLIFT DELIVERY HANDLE IMPLANT CARTRIDGE -,SUP-UL2-CHK,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1204.157955,163.74581,6505.74336,percent of total billed charges,,,
IMPLANT HANDLE CARTRIDGE UROLIFT -,SUP-UL2-CHK,CDM,L8699,HCPCS,278,RC,,,outpatient,,,4654.65,3258.255,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1204.157955,163.74581,6505.74336,percent of total billed charges,,,
HC Bebtelovimab Injection,PX-26000018,CDM,M0222,HCPCS,260,RC,,,outpatient,,,1455,1018.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,366.2,,,366.2,326.6475,1117.44,fee schedule,,,
HC Cryoprecipitate Each Unit,PX-39000006,CDM,P9012,CPT,390,RC,,,outpatient,,,1227,858.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,317.4249,49.4,942.336,percent of total billed charges,,,
HC RBC Leukocytes Reduced,PX-39000007,CDM,P9016,CPT,390,RC,,,outpatient,,,551,385.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,142.5437,123.6995,423.168,percent of total billed charges,,,
HC Plasma 1 Donor Frz W/in 8 Hr,PX-39000008,CDM,P9017,CPT,390,RC,,,outpatient,,,379,265.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,98.0473,71.53,416.02,percent of total billed charges,,,
HC Red Blood Cells Unit,PX-39000009,CDM,P9021,CPT,390,RC,,,outpatient,,,471,329.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,121.8477,105.7395,416.02,percent of total billed charges,,,
HC Washed Red Blood Cells Unit,PX-39000010,CDM,P9022,CPT,390,RC,,,outpatient,,,1028,719.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,265.9436,163,871.3328,percent of total billed charges,,,
HC Platelets Leukocytes Reduced,PX-39000011,CDM,P9031,CPT,390,RC,,,outpatient,,,1397,977.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,361.4039,136.61,1072.896,percent of total billed charges,,,
HC Platelets Leukoreduced Irrad,PX-39000012,CDM,P9033,CPT,390,RC,,,outpatient,,,1633,1143.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,422.4571,163,1384.1308,percent of total billed charges,,,
HC Platelet Pheres Leukoreduced,PX-39000013,CDM,P9035,CPT,390,RC,,,outpatient,,,1233,863.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,318.9771,163,1119.53,percent of total billed charges,,,
HC Plate Pheres Leukoredu Irrad,PX-39000014,CDM,P9037,CPT,390,RC,,,outpatient,,,1624,1136.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,420.1288,163,1476.21,percent of total billed charges,,,
HC RBC Deglycerolized,PX-39000015,CDM,P9039,CPT,390,RC,,,outpatient,,,2586,1810.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,668.9982,163,2191.8936,percent of total billed charges,,,
HC RBC Leukoreduced Irradiated,PX-39000016,CDM,P9040,CPT,390,RC,,,outpatient,,,636,445.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,164.5332,142.782,598.2,percent of total billed charges,,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,76125-0790-25,NDC,outpatient,250,ML,171.75,120.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,44.431725,25.321355,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,68516-5214-03,NDC,outpatient,250,ML,168.42,117.894,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,43.570254,25.321355,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 5 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8982,CDM,P9045,HCPCS,636,RC,68982-0623-03,NDC,outpatient,500,ML,347.1,242.97,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,89.79477,25.321355,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,00944-0495-05,NDC,outpatient,250,ML,112.79,78.953,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,29.178773,25.321355,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,44206-0310-25,NDC,outpatient,250,ML,199.57,139.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,51.628759,25.321355,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,44206-0310-90,NDC,outpatient,250,ML,199.57,139.699,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,51.628759,25.321355,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,00944-0495-06,NDC,outpatient,250,ML,112.79,78.953,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,29.178773,25.321355,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,68516-5214-01,NDC,outpatient,250,ML,168.42,117.894,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,43.570254,25.321355,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,68982-0623-03,NDC,outpatient,500,ML,363.1,254.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,93.93397,25.321355,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 5 % IV SOLN,RX-8982,CDM,P9045,HCPCS,636,RC,76125-0790-26,NDC,outpatient,250,ML,171.75,120.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,44.431725,25.321355,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-01,NDC,outpatient,50,ML,209.58,146.706,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,54.218346,7.294005,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-04,NDC,outpatient,100,ML,48.49,33.943,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.544363,7.294005,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-02,NDC,outpatient,100,ML,320.83,224.581,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,82.998721,7.294005,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-03,NDC,outpatient,50,ML,168.42,117.894,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,43.570254,7.294005,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-04,NDC,outpatient,100,ML,32.49,22.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,8.405163,7.294005,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-08,NDC,outpatient,100,ML,414.3,290.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,107.17941,7.294005,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,64208-2512-07,NDC,outpatient,100,ML,309.7,216.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,80.11939,7.294005,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-01,NDC,outpatient,50,ML,168.42,117.894,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,43.570254,7.294005,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-04,NDC,outpatient,100,ML,320.83,224.581,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,82.998721,7.294005,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-08,NDC,outpatient,100,ML,430.3,301.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,111.31861,7.294005,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-00,NDC,outpatient,100,ML,293.7,205.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,75.98019,7.294005,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-02,NDC,outpatient,100,ML,304.83,213.381,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,78.859521,7.294005,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-04,NDC,outpatient,100,ML,304.83,213.381,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,78.859521,7.294005,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-02,NDC,outpatient,100,ML,48.49,33.943,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,12.544363,7.294005,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-03,NDC,outpatient,50,ML,209.58,146.706,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,54.218346,7.294005,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 25 % IV SOLN,RX-8981,CDM,P9047,HCPCS,636,RC,68516-5216-00,NDC,outpatient,100,ML,309.7,216.79,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,80.11939,7.294005,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,00944-0493-02,NDC,outpatient,100,ML,32.49,22.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,8.405163,7.294005,416.02,percent of total billed charges,,,
ALBUMIN HUMAN 25 % IV SOLN|DISCARDED DRUG NOT ADMINISTERED,RX-8981,CDM,P9047,HCPCS,636,RC,64208-2512-07,NDC,outpatient,100,ML,293.7,205.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],JW,,25.87,,75.98019,7.294005,416.02,percent of total billed charges,,,
HC Platelets- Hla-M- L/R- Unit,PX-39000026,CDM,P9052,HCPCS,390,RC,,,outpatient,,,1807,1264.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,467.4709,163,1698,percent of total billed charges,,,
HC RBC- Frz/Deg/Wsh- L/R- Irrad,PX-39000023,CDM,P9057,CPT,390,RC,,,outpatient,,,2062,1443.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,533.4394,163,1747.7512,percent of total billed charges,,,
HC RBC- L/R- Cmv-Neg- Irrad,PX-39000024,CDM,P9058,CPT,390,RC,,,outpatient,,,1235,864.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,319.4945,163,1046.786,percent of total billed charges,,,
HC Plasma- Frz Between 8-24hour,PX-39000025,CDM,P9059,CPT,390,RC,,,outpatient,,,222,155.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,57.4314,49.839,416.02,percent of total billed charges,,,
HC Platelets- Pheresis- Pathogen-Reduced- Each Unit,PX-39000028,CDM,P9073,HCPCS,390,RC,,,outpatient,,,1626,1138.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,420.6462,163,1265.41,percent of total billed charges,,,
HC Pathogen Test for Platelets,PX-30000897,CDM,P9100,HCPCS,300,RC,,,outpatient,,,89,62.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,23.0243,19.9805,416.02,percent of total billed charges,,,
FERUMOXYTOL 510 MG/17ML IV SOLN,RX-98312,CDM,Q0138,HCPCS,636,RC,59338-0775-01,NDC,outpatient,17,ML,945.71,661.997,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,244.655177,0.34,726.30528,percent of total billed charges,,,
ONDANSETRON HCL 4 MG ORAL TABS,RX-10778,CDM,Q0162,HCPCS,259,RC,00904-6551-61,NDC,outpatient,1,UN,1.57,1.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.406159,0.01,416.02,percent of total billed charges,,,
ONDANSETRON 4 MG ORAL TBDP,RX-27697,CDM,Q0162,HCPCS,259,RC,68462-0157-13,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.256113,0.01,416.02,percent of total billed charges,,,
ONDANSETRON 4 MG ORAL TBDP,RX-27697,CDM,Q0162,HCPCS,259,RC,68462-0157-40,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.256113,0.01,416.02,percent of total billed charges,,,
ONDANSETRON 4 MG ORAL TBDP,RX-27697,CDM,Q0162,HCPCS,259,RC,65862-0390-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.256113,0.01,416.02,percent of total billed charges,,,
PROCHLORPERAZINE MALEATE 5 MG ORAL TABS,RX-6583,CDM,Q0164,HCPCS,259,RC,50268-0684-15,NDC,outpatient,1,UN,3.56,2.492,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.920972,0.35,416.02,percent of total billed charges,,,
PROCHLORPERAZINE MALEATE 5 MG ORAL TABS,RX-6583,CDM,Q0164,HCPCS,259,RC,50268-0684-11,NDC,outpatient,1,UN,3.56,2.492,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.920972,0.35,416.02,percent of total billed charges,,,
DRONABINOL 2.5 MG ORAL CAPS,RX-9904,CDM,Q0167,HCPCS,259,RC,60687-0375-11,NDC,outpatient,1,UN,18.82,13.174,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.868734,0.73,416.02,percent of total billed charges,,,
DRONABINOL 2.5 MG ORAL CAPS,RX-9904,CDM,Q0167,HCPCS,259,RC,60687-0375-21,NDC,outpatient,1,UN,18.82,13.174,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,4.868734,0.73,416.02,percent of total billed charges,,,
PROMETHAZINE HCL 25 MG ORAL TABS,RX-6622,CDM,Q0169,HCPCS,259,RC,00904-7304-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.256113,0.09,416.02,percent of total billed charges,,,
PROMETHAZINE HCL 25 MG ORAL TABS,RX-6622,CDM,Q0169,HCPCS,259,RC,68382-0041-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,0.256113,0.09,416.02,percent of total billed charges,,,
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,00069-6001-10,NDC,outpatient,10,ML,77.92,54.544,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,20.157904,2.55,416.02,percent of total billed charges,,,
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,63323-0403-02,NDC,outpatient,2,ML,19.75,13.825,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.109325,2.55,416.02,percent of total billed charges,,,
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,63323-0403-01,NDC,outpatient,2,ML,19.75,13.825,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,5.109325,2.55,416.02,percent of total billed charges,,,
FOSPHENYTOIN SODIUM 50 MG PE/ML IJ WRAPPER,RX-4080134,CDM,Q2009,HCPCS,636,RC,00069-6001-21,NDC,outpatient,10,ML,77.92,54.544,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,20.157904,2.55,416.02,percent of total billed charges,,,
DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ,RX-27431,CDM,Q2050,HCPCS,636,RC,47335-0050-40,NDC,outpatient,25,ML,1589.76,1112.832,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,411.270912,87.98,1653.428703,percent of total billed charges,,,
DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ,RX-27431,CDM,Q2050,HCPCS,636,RC,00338-0067-01,NDC,outpatient,25,ML,1408.44,985.908,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,364.363428,87.98,1653.428703,percent of total billed charges,,,
HC Telehealth Originating Site Facility Fee,PX-78000001,CDM,Q3014,HCPCS,780,RC,,,outpatient,,,373,261.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,83.7385,416.02,other,Non-Reimbursable Procedures,,
IMPLANT TY I COLL 1X1IN DURAMATRIX-ONLAY -,SUP-CDSLM11,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,1553.95,1087.765,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,348.861775,3862.93248,other,Non-Reimbursable Procedures,,
DURAMATRIX SUTURABLE 2 X 2 -,SUP-DMS22,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,2490.5,1743.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,348.861775,3862.93248,other,Non-Reimbursable Procedures,,
DURAMATRIX SUTURABLE  3x3 -,SUP-DMS33,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,4042.29,2829.603,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,348.861775,3862.93248,other,Non-Reimbursable Procedures,,
DURAMATRIX SUTURABLE 4 X 5 -,SUP-DMS45,CDM,Q4100,HCPCS,278,RC,,,outpatient,,,5029.86,3520.902,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,348.861775,3862.93248,other,Non-Reimbursable Procedures,,
HC Skin Apligraf,PX-63600004,CDM,Q4101,HCPCS,636,RC,,,outpatient,,,8745,6121.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,30.42,6716.16,other,Non-Reimbursable Procedures,,
HC Matrix Wound Oasis by Sq Cm,PX-63600006,CDM,Q4102,HCPCS,636,RC,,,outpatient,,,65,45.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.25,659.42016,other,Non-Reimbursable Procedures,,
DRESSING WND 3 X 3.5CM OASIS WND MATRIX -,SUP-8213-1000-33,CDM,Q4102,CPT,278,RC,,,outpatient,,,858.62,601.034,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,12.25,659.42016,other,Non-Reimbursable Procedures,,
INTEGRA BILAYER MATRIX WOUND DRESSING 4 x 5 -,SUP-BMW4051,CDM,Q4104,HCPCS,278,RC,,,outpatient,,,24698.88,17289.216,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.96,24594.91584,other,Non-Reimbursable Procedures,,
MATRIX MESHED BILAYER 2X2 INTE -,SUP-MWM2021,CDM,Q4104,HCPCS,278,RC,,,outpatient,,,20440.07,14308.049,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.96,24594.91584,other,Non-Reimbursable Procedures,,
MATRIX MESH BILAYER 4 X 5 -,SUP-MWM4051,CDM,Q4104,HCPCS,278,RC,,,outpatient,,,32024.63,22417.241,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,48.96,24594.91584,other,Non-Reimbursable Procedures,,
HC Primatrix Mesh by Sq Cm,PX-63600008,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,186,130.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.757,4074.24,other,Non-Reimbursable Procedures,,
PRIMATRIX 0.2 x 26.5 ROPE 3 UNITS/BOX -,SUP-607-001-009,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,2157.3,1510.11,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.757,4074.24,other,Non-Reimbursable Procedures,,
PRIMATRIX 2X2 MESHED -,SUP-607-005-220,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,2364.02,1654.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.757,4074.24,other,Non-Reimbursable Procedures,,
PRIMATRIX 3X3 MESHED -,SUP-607-005-330,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,2506.35,1754.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.757,4074.24,other,Non-Reimbursable Procedures,,
PRIMATRIX 4 X 4CM  MESH -,SUP-607-005-440,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,3074.46,2152.122,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.757,4074.24,other,Non-Reimbursable Procedures,,
PRIMATRIX 6 X 6 MESH -,SUP-607-005-660,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,5305,3713.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.757,4074.24,other,Non-Reimbursable Procedures,,
PRIMATRIX 4X4 AG -,SUP-UNDEFINED,CDM,Q4110,HCPCS,636,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,41.757,4074.24,other,Non-Reimbursable Procedures,,
ALLODERM LARGE THK1.04-2.28 MM THICK L12 CM X W4 CM 48CM2 -,SUP-102050,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,5700.37,3990.259,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,31.11,14996.48256,other,Non-Reimbursable Procedures,,
ALLODERM LARGE THK2-2.8 MM THICK L12CM X W6CM 72CM2 -,SUP-151972,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,4655.67,3258.969,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,31.11,14996.48256,other,Non-Reimbursable Procedures,,
GRAFT SOFT TISSUE AXIS TUTOPLAST DERMIS 12CM X 8CM ALLODERM -,SUP-939812,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,10961.89,7673.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,31.11,14996.48256,other,Non-Reimbursable Procedures,,
ALLODERM CONTOUR LARGE PERF L21.5 CM X W10 230.05CM2 -,SUP-CL1519P,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,19526.67,13668.669,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,31.11,14996.48256,other,Non-Reimbursable Procedures,,
ALLODERM CONTOUR MED PERF THICK 19.3 CM X 9.6 CM 185.28CM2 -,SUP-CM1519P,CDM,Q4116,HCPCS,278,RC,,,outpatient,,,15267.86,10687.502,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,31.11,14996.48256,other,Non-Reimbursable Procedures,,
ACELL MICROMATRIX POWDER 200MG -,SUP-MM0200,CDM,Q4118,HCPCS,278,RC,,,outpatient,,,2929.8,2050.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.5,8051.0208,other,Non-Reimbursable Procedures,,
ACELL MICRO MATRIX 500 MG -,SUP-MM0500,CDM,Q4118,HCPCS,278,RC,,,outpatient,,,5728.55,4009.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.5,8051.0208,other,Non-Reimbursable Procedures,,
ACELL MICRO MATRIX 1000 MG -,SUP-MM1000,CDM,Q4118,HCPCS,278,RC,,,outpatient,,,10483.1,7338.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,2.5,8051.0208,other,Non-Reimbursable Procedures,,
SURGICLOSE MICRO 38CM2 -,SUP-50205P04D0D,CDM,Q4121,HCPCS,636,RC,,,outpatient,,,8488,5941.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2195.8456,46.98,6518.784,percent of total billed charges,,,
HC Matrix Wound Oasis Ultra by Sq Cm,PX-63600010,CDM,Q4124,HCPCS,636,RC,,,outpatient,,,61,42.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.16,4034.304,other,Non-Reimbursable Procedures,,
HC Matrix Oasis Ultra 7 X 10,PX-63600014,CDM,Q4124,HCPCS,636,RC,,,outpatient,,,5253,3677.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.16,4034.304,other,Non-Reimbursable Procedures,,
GRAFT ARTHROFLEX DERMIS THK1.5MM 35MM X 35MM 12.25CM2 -,SUP-AFLEX100,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,7779.25,5445.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,209.5932,10851.38688,other,Non-Reimbursable Procedures,,
DERMIS DECELLULARIZED 35MM X 35MM X 2.0MM 12.25SQCM -,SUP-AFLEX200,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,11781.35,8246.945,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,209.5932,10851.38688,other,Non-Reimbursable Procedures,,
ARTHROFLEX 40MM X 70MM X 3.0 DERMIS DECELLULARIZED 28SQCM -,SUP-AFLEX301,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,14129.41,9890.587,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,209.5932,10851.38688,other,Non-Reimbursable Procedures,,
ARTHROFLEX 25 X 30 X 1MM 7.5SQCM -,SUP-AFLEX403,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,933.6,653.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,209.5932,10851.38688,other,Non-Reimbursable Procedures,,
CONNECT PRE-SUTURED TENDON-ZORC 4.5 x 160MM -,SUP-FCON,CDM,Q4125,HCPCS,278,RC,,,outpatient,,,5187.44,3631.208,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,209.5932,10851.38688,other,Non-Reimbursable Procedures,,
SURGICLOSE 7 X 10CM- 70SQCM -,SUP-50205N03D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,16121.85,11285.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.06,20434.45248,other,Non-Reimbursable Procedures,,
SURGICLOSE 6 X 8 MESHED 2:1 UP TO 86CM2 -,SUP-50205N18D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,10804.83,7563.381,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.06,20434.45248,other,Non-Reimbursable Procedures,,
SURGICLOSE MESHED 2:1 4X6 CM- 24SQCM -,SUP-50205N20D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,6934.7,4854.29,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.06,20434.45248,other,Non-Reimbursable Procedures,,
SURGICLOSE MESHED 7 X 20 -,SUP-50205N21D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,26607.36,18625.152,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.06,20434.45248,other,Non-Reimbursable Procedures,,
SURGICLOSE MICRO 95 CM2 -,SUP-50205P31D0D,CDM,Q4158,HCPCS,278,RC,,,outpatient,,,15965.9,11176.13,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,3.06,20434.45248,other,Non-Reimbursable Procedures,,
ACELL WOUND/BURN MATRIX 2 LAYER -,SUP-BMM0710,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,4509.25,3156.475,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,18.9,9453.0048,other,Non-Reimbursable Procedures,,
CYTAL BURN MATRIX -,SUP-BMM1015,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,8116.65,5681.655,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,18.9,9453.0048,other,Non-Reimbursable Procedures,,
CYTAL WOUND MATRIX 1 LAYER 3 X 7CM -,SUP-WS0307,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,853.08,597.156,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,18.9,9453.0048,other,Non-Reimbursable Procedures,,
MATRIX WOUND ACELL GENTRIX 5M X 5CM 25CM2 3 LAYERS -,SUP-WSR0505,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,4118.77,2883.139,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,18.9,9453.0048,other,Non-Reimbursable Procedures,,
WOUND MATRIX CYTEL 3 LAYER 7 X 10CM -,SUP-WSR0710,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,8206.84,5744.788,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,18.9,9453.0048,other,Non-Reimbursable Procedures,,
WOUND MATRIX 3 LAYER 10 X 15CM -,SUP-WSR1015,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,12308.6,8616.02,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,18.9,9453.0048,other,Non-Reimbursable Procedures,,
ACELL WOUND MATRIX 6-LAYER MESH -,SUP-WSX0505,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,4869.99,3408.993,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,18.9,9453.0048,other,Non-Reimbursable Procedures,,
CYTAL WOUND MATRIX 6 LAYER 7 X 10CM -,SUP-WSX0710,CDM,Q4166,HCPCS,278,RC,,,outpatient,,,9562.83,6693.981,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,18.9,9453.0048,other,Non-Reimbursable Procedures,,
HC Epifix- per Square Centimeter,PX-63600024,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,501,350.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,112.4745,3643.99872,other,Non-Reimbursable Procedures,,
EPIFIX DISK 14MM -,SUP-GS-5140,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,1746.51,1222.557,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,112.4745,3643.99872,other,Non-Reimbursable Procedures,,
EPIFIX DISK 18MM -,SUP-GS-5180,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,3733.27,2613.289,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,112.4745,3643.99872,other,Non-Reimbursable Procedures,,
EPIFIX 2 X 2 CM -,SUP-GS-5220,CDM,Q4186,HCPCS,636,RC,,,outpatient,,,4744.79,3321.353,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,112.4745,3643.99872,other,Non-Reimbursable Procedures,,
PURAPLY AM 2CMX2CM -,SUP-00000000000000000000000000000,CDM,Q4196,HCPCS,636,RC,,,outpatient,,,4057.9,2840.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1049.77873,102.28,3422.3616,percent of total billed charges,,,
PURAPLY AM 2CMX4CM -,SUP-PURAPLYAM-COM 2X4,CDM,Q4196,HCPCS,636,RC,,,outpatient,,,4456.2,3119.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1152.81894,102.28,3422.3616,percent of total billed charges,,,
FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY,RX-132201,CDM,Q5101,HCPCS,636,RC,61314-0318-10,NDC,outpatient,0.5,ML,603.14,422.198,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,156.032318,0.18,741.12768,percent of total billed charges,,,
FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY,RX-132201,CDM,Q5101,HCPCS,636,RC,61314-0318-01,NDC,outpatient,0.5,ML,603.11,422.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,156.024557,0.18,741.12768,percent of total billed charges,,,
FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY,RX-132201,CDM,Q5101,HCPCS,636,RC,61314-0318-05,NDC,outpatient,0.5,ML,603.14,422.198,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,156.032318,0.18,741.12768,percent of total billed charges,,,
FILGRASTIM-SNDZ 480 MCG/0.8ML IJ SOSY,RX-132202,CDM,Q5101,HCPCS,636,RC,61314-0326-10,NDC,outpatient,0.8,ML,965.01,675.507,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,249.648087,0.18,741.12768,percent of total billed charges,,,
FILGRASTIM-SNDZ 480 MCG/0.8ML IJ SOSY,RX-132202,CDM,Q5101,HCPCS,636,RC,61314-0326-05,NDC,outpatient,0.8,ML,965.01,675.507,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,249.648087,0.18,741.12768,percent of total billed charges,,,
INFLIXIMAB-DYYB 100 MG IV SOLR,RX-136637,CDM,Q5103,HCPCS,636,RC,00069-0809-01,NDC,outpatient,1,UN,1389.66,972.762,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,359.505042,13.62,1653.428703,percent of total billed charges,,,
INFLIXIMAB-ABDA 100 MG IV SOLR,RX-139995,CDM,Q5104,HCPCS,636,RC,00006-4305-01,NDC,outpatient,1,UN,1902.38,1331.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,492.145706,27.18,1653.428703,percent of total billed charges,,,
INFLIXIMAB-ABDA 100 MG IV SOLR,RX-139995,CDM,Q5104,HCPCS,636,RC,00006-4305-02,NDC,outpatient,1,UN,1902.38,1331.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,492.145706,27.18,1653.428703,percent of total billed charges,,,
EPOETIN ALFA-EPBX 2000 UNIT/ML IJ SOLN,RX-143174,CDM,Q5106,HCPCS,636,RC,00069-1305-10,NDC,outpatient,1,ML,79.46,55.622,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,20.556302,7.5,416.02,percent of total billed charges,,,
EPOETIN ALFA-EPBX 2000 UNIT/ML IJ SOLN,RX-143174,CDM,Q5106,HCPCS,636,RC,00069-1305-01,NDC,outpatient,1,ML,79.46,55.622,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,20.556302,7.5,416.02,percent of total billed charges,,,
EPOETIN ALFA-EPBX 3000 UNIT/ML IJ SOLN,RX-143175,CDM,Q5106,HCPCS,636,RC,00069-1306-01,NDC,outpatient,1,ML,119.19,83.433,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,30.834453,7.5,416.02,percent of total billed charges,,,
EPOETIN ALFA-EPBX 3000 UNIT/ML IJ SOLN,RX-143175,CDM,Q5106,HCPCS,636,RC,00069-1306-10,NDC,outpatient,1,ML,119.19,83.433,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,30.834453,7.5,416.02,percent of total billed charges,,,
EPOETIN ALFA-EPBX 4000 UNIT/ML IJ SOLN,RX-143176,CDM,Q5106,HCPCS,636,RC,00069-1307-10,NDC,outpatient,1,ML,158.92,111.244,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,41.112604,7.5,416.02,percent of total billed charges,,,
EPOETIN ALFA-EPBX 4000 UNIT/ML IJ SOLN,RX-143176,CDM,Q5106,HCPCS,636,RC,00069-1307-01,NDC,outpatient,1,ML,158.92,111.244,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,41.112604,7.5,416.02,percent of total billed charges,,,
EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN,RX-143177,CDM,Q5106,HCPCS,636,RC,00069-1308-01,NDC,outpatient,1,ML,377.7,264.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,97.71099,7.5,416.02,percent of total billed charges,,,
EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN,RX-143177,CDM,Q5106,HCPCS,636,RC,00069-1308-10,NDC,outpatient,1,ML,377.7,264.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,97.71099,7.5,416.02,percent of total billed charges,,,
EPOETIN ALFA-EPBX 40000 UNIT/ML IJ SOLN,RX-143178,CDM,Q5106,HCPCS,636,RC,00069-1309-01,NDC,outpatient,0.05,ML,75.54,52.878,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,19.542198,7.5,416.02,percent of total billed charges,,,
EPOETIN ALFA-EPBX 40000 UNIT/ML IJ SOLN,RX-143178,CDM,Q5106,HCPCS,636,RC,00069-1309-04,NDC,outpatient,0.05,ML,75.54,52.878,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,19.542198,7.5,416.02,percent of total billed charges,,,
RITUXIMAB-ABBS 10 MG/ML IV SOLN WRAPPER,RX-4081244,CDM,Q5115,HCPCS,636,RC,63459-0103-10,NDC,outpatient,10,ML,1691.22,1183.854,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,437.518614,33.59,7269.974281,percent of total billed charges,,,
RITUXIMAB-ABBS 10 MG/ML IV SOLN WRAPPER,RX-4081244,CDM,Q5115,HCPCS,636,RC,63459-0104-50,NDC,outpatient,50,ML,6662.37,4663.659,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1723.555119,33.59,7269.974281,percent of total billed charges,,,
INFLIXIMAB-AXXQ 100 MG IV SOLR,RX-150921,CDM,Q5121,HCPCS,636,RC,55513-0670-01,NDC,outpatient,1,UN,2071.48,1450.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,535.891876,21.29,1590.89664,percent of total billed charges,,,
MEDIA CONTR PRFLTRN LPD MICSPHR INJ SUSP VL DEFINITY -,SUP-DE16,CDM,Q9957,CPT,636,RC,,,outpatient,,,554.33,388.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,40.92,438.4896,other,Non-Reimbursable Procedures,,
DEFINITY DE-4 -,SUP-DE4,CDM,Q9957,CPT,636,RC,,,outpatient,,,570.95,399.665,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,40.92,438.4896,other,Non-Reimbursable Procedures,,
DIATRIZOATE MEGLUMINE & SODIUM 66-10 % ORAL SOLN,RX-9828,CDM,Q9963,HCPCS,636,RC,00270-0445-40,NDC,outpatient,7.5,ML,3.71,2.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.22,416.02,other,Non-Reimbursable Procedures,,
IOHEXOL 180 MG/ML IJ SOLN,RX-10319,CDM,Q9965,HCPCS,636,RC,00407-1411-10,NDC,outpatient,3,ML,16.35,11.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.56,416.02,other,Non-Reimbursable Procedures,,
IOHEXOL 180 MG/ML IJ SOLN,RX-10319,CDM,Q9965,HCPCS,636,RC,99999-0004-10,NDC,outpatient,3,ML,16.35,11.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,1.56,416.02,other,Non-Reimbursable Procedures,,
IOPAMIDOL 41 % IJ SOLN,RX-10325,CDM,Q9966,HCPCS,636,RC,00270-1411-11,NDC,outpatient,10,ML,98.1,68.67,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.38,416.02,other,Non-Reimbursable Procedures,,
IOHEXOL 240 MG/ML IJ SOLN,RX-119843,CDM,Q9966,HCPCS,636,RC,00407-1412-33,NDC,outpatient,10,ML,32.7,22.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.38,416.02,other,Non-Reimbursable Procedures,,
IOHEXOL 240 MG/ML IJ SOLN,RX-119843,CDM,Q9966,HCPCS,636,RC,99999-0004-07,NDC,outpatient,10,ML,32.7,22.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.38,416.02,other,Non-Reimbursable Procedures,,
IOHEXOL 240 MG/ML IJ SOLN,RX-119843,CDM,Q9966,HCPCS,636,RC,00407-1412-30,NDC,outpatient,10,ML,32.7,22.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.38,416.02,other,Non-Reimbursable Procedures,,
IOPAMIDOL 61 % IJ SOLN,RX-10327,CDM,Q9967,HCPCS,636,RC,00270-1412-15,NDC,outpatient,15,ML,81.75,57.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.14,416.02,other,Non-Reimbursable Procedures,,
IOPAMIDOL 76 % IV SOLN,RX-10328,CDM,Q9967,HCPCS,636,RC,00270-1316-35,NDC,outpatient,50,ML,272.5,190.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.14,416.02,other,Non-Reimbursable Procedures,,
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-10,NDC,outpatient,5,ML,10.9,7.63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.14,416.02,other,Non-Reimbursable Procedures,,
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-58,NDC,outpatient,5,ML,10.9,7.63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.14,416.02,other,Non-Reimbursable Procedures,,
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-59,NDC,outpatient,5,ML,10.9,7.63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.14,416.02,other,Non-Reimbursable Procedures,,
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-61,NDC,outpatient,5,ML,10.9,7.63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.14,416.02,other,Non-Reimbursable Procedures,,
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,00407-1413-63,NDC,outpatient,5,ML,10.9,7.63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.14,416.02,other,Non-Reimbursable Procedures,,
IOHEXOL 300 MG/ML IJ SOLN,RX-119842,CDM,Q9967,HCPCS,636,RC,99999-0004-09,NDC,outpatient,5,ML,10.9,7.63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.14,416.02,other,Non-Reimbursable Procedures,,
IOPAMIDOL 61 % IV SOLN,RX-27737,CDM,Q9967,HCPCS,636,RC,00270-1315-25,NDC,outpatient,30,ML,163.5,114.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.14,416.02,other,Non-Reimbursable Procedures,,
IOVERSOL 68 % IJ SOLN,RX-39700,CDM,Q9967,HCPCS,636,RC,00019-1323-02,NDC,outpatient,20,ML,109,76.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.14,416.02,other,Non-Reimbursable Procedures,,
ISOSULFAN BLUE 1 % SC SOLN,RX-10358,CDM,Q9968,HCPCS,636,RC,67457-0220-05,NDC,outpatient,5,ML,2840.8,1988.56,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.53,2181.7344,other,Non-Reimbursable Procedures,,
ISOSULFAN BLUE 1 % SC SOLN,RX-10358,CDM,Q9968,HCPCS,636,RC,67457-0220-00,NDC,outpatient,5,ML,2840.8,1988.56,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,9.53,2181.7344,other,Non-Reimbursable Procedures,,
ACETAMINOPHEN 160 MG/5ML ORAL SOLN,RX-100,CDM,S5000,HCPCS,259,RC,81033-0002-30,NDC,outpatient,650,ME,11.57,8.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACETAMINOPHEN 160 MG/5ML ORAL SOLN,RX-100,CDM,S5000,HCPCS,259,RC,00121-1971-21,NDC,outpatient,650,ME,11.57,8.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACETAMINOPHEN 160 MG/5ML ORAL SOLN,RX-100,CDM,S5000,HCPCS,259,RC,00121-1971-00,NDC,outpatient,650,ME,11.57,8.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACETAMINOPHEN 160 MG/5ML ORAL SOLN,RX-100,CDM,S5000,HCPCS,259,RC,81033-0002-20,NDC,outpatient,650,ME,11.57,8.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FAMOTIDINE 40 MG/5ML ORAL SUSR,RX-10010,CDM,S5000,HCPCS,259,RC,99999-0004-18,NDC,outpatient,2.5,ML,4.86,3.402,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FAMOTIDINE 40 MG/5ML ORAL SUSR,RX-10010,CDM,S5000,HCPCS,259,RC,70954-0316-10,NDC,outpatient,50,ML,117.71,82.397,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FAMOTIDINE 20 MG ORAL TABS,RX-10011,CDM,S5000,HCPCS,259,RC,00904-7193-06,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FAMOTIDINE 20 MG ORAL TABS,RX-10011,CDM,S5000,HCPCS,259,RC,63739-0645-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FAMOTIDINE 20 MG ORAL TABS,RX-10011,CDM,S5000,HCPCS,259,RC,50268-0299-15,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FAMOTIDINE 20 MG ORAL TABS,RX-10011,CDM,S5000,HCPCS,259,RC,50268-0299-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FAMOTIDINE 20 MG ORAL TABS,RX-10011,CDM,S5000,HCPCS,259,RC,62332-0001-31,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FELBAMATE 600 MG ORAL TABS,RX-10025,CDM,S5000,HCPCS,259,RC,72578-0057-16,NDC,outpatient,1,UN,5.99,4.193,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FINASTERIDE 5 MG ORAL TABS,RX-10037,CDM,S5000,HCPCS,259,RC,00904-6830-06,NDC,outpatient,1,UN,1.66,1.162,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FINASTERIDE 5 MG ORAL TABS,RX-10037,CDM,S5000,HCPCS,259,RC,60687-0428-01,NDC,outpatient,1,UN,2.29,1.603,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FINASTERIDE 5 MG ORAL TABS,RX-10037,CDM,S5000,HCPCS,259,RC,60687-0428-11,NDC,outpatient,1,UN,2.29,1.603,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FINASTERIDE 5 MG ORAL TABS,RX-10037,CDM,S5000,HCPCS,259,RC,00904-6830-61,NDC,outpatient,1,UN,2.18,1.526,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLECAINIDE ACETATE 100 MG ORAL TABS,RX-10041,CDM,S5000,HCPCS,259,RC,00054-0011-21,NDC,outpatient,1,UN,2.98,2.086,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLECAINIDE ACETATE 100 MG ORAL TABS,RX-10041,CDM,S5000,HCPCS,259,RC,50268-0321-11,NDC,outpatient,1,UN,2.86,2.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLECAINIDE ACETATE 100 MG ORAL TABS,RX-10041,CDM,S5000,HCPCS,259,RC,50268-0321-15,NDC,outpatient,1,UN,2.86,2.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLECAINIDE ACETATE 50 MG ORAL TABS,RX-10043,CDM,S5000,HCPCS,259,RC,50268-0320-15,NDC,outpatient,1,UN,3.66,2.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLECAINIDE ACETATE 50 MG ORAL TABS,RX-10043,CDM,S5000,HCPCS,259,RC,00054-0010-20,NDC,outpatient,1,UN,2.45,1.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLECAINIDE ACETATE 50 MG ORAL TABS,RX-10043,CDM,S5000,HCPCS,259,RC,50268-0320-11,NDC,outpatient,1,UN,3.66,2.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLUCONAZOLE 100 MG ORAL TABS,RX-10044,CDM,S5000,HCPCS,259,RC,68084-0728-11,NDC,outpatient,1,UN,4.94,3.458,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLUCONAZOLE 100 MG ORAL TABS,RX-10044,CDM,S5000,HCPCS,259,RC,00904-6500-61,NDC,outpatient,1,UN,4.03,2.821,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLUCONAZOLE 100 MG ORAL TABS,RX-10044,CDM,S5000,HCPCS,259,RC,68084-0728-01,NDC,outpatient,1,UN,4.94,3.458,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLUCONAZOLE 200 MG ORAL TABS,RX-10045,CDM,S5000,HCPCS,259,RC,00904-6501-61,NDC,outpatient,1,UN,6.68,4.676,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VITAMIN D2 (ERGOCALCIFEROL) 1.25 MG (50000 UNITS) ORAL CAPS,RX-100493,CDM,S5000,HCPCS,259,RC,50268-0297-11,NDC,outpatient,1,UN,3.93,2.751,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VITAMIN D2 (ERGOCALCIFEROL) 1.25 MG (50000 UNITS) ORAL CAPS,RX-100493,CDM,S5000,HCPCS,259,RC,50268-0297-15,NDC,outpatient,1,UN,3.93,2.751,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VITAMIN D2 (ERGOCALCIFEROL) 1.25 MG (50000 UNITS) ORAL CAPS,RX-100493,CDM,S5000,HCPCS,259,RC,64380-0737-06,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLUCYTOSINE 500 MG ORAL CAPS,RX-10052,CDM,S5000,HCPCS,259,RC,42794-0010-08,NDC,outpatient,1,UN,233.01,163.107,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLUDROCORTISONE ACETATE 0.1 MG ORAL TABS,RX-10054,CDM,S5000,HCPCS,259,RC,00115-7033-01,NDC,outpatient,1,UN,2.43,1.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLUDROCORTISONE ACETATE 0.1 MG ORAL TABS,RX-10054,CDM,S5000,HCPCS,259,RC,50268-0330-11,NDC,outpatient,1,UN,2.26,1.582,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLUDROCORTISONE ACETATE 0.1 MG ORAL TABS,RX-10054,CDM,S5000,HCPCS,259,RC,50268-0330-15,NDC,outpatient,1,UN,2.26,1.582,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLUOROURACIL 5 % EX CREA,RX-10065,CDM,S5000,HCPCS,259,RC,16729-0542-35,NDC,outpatient,40,GR,458.18,320.726,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLUOROURACIL 5 % EX CREA,RX-10065,CDM,S5000,HCPCS,259,RC,51672-4118-06,NDC,outpatient,40,GR,108.41,75.887,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLUOXETINE HCL 10 MG ORAL CAPS,RX-10069,CDM,S5000,HCPCS,259,RC,16714-0720-02,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLUOXETINE HCL 20 MG ORAL CAPS,RX-10070,CDM,S5000,HCPCS,259,RC,00904-7346-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLURBIPROFEN SODIUM 0.03 % OP SOLN,RX-10080,CDM,S5000,HCPCS,259,RC,69292-0722-25,NDC,outpatient,2.5,ML,140.89,98.623,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLUVOXAMINE MALEATE 50 MG ORAL TABS,RX-10085,CDM,S5000,HCPCS,259,RC,60505-0165-01,NDC,outpatient,1,UN,1.63,1.141,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FOSINOPRIL SODIUM 10 MG ORAL TABS,RX-10094,CDM,S5000,HCPCS,259,RC,69097-0856-05,NDC,outpatient,1,UN,1.76,1.232,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RITONAVIR 100 MG ORAL TABS,RX-100995,CDM,S5000,HCPCS,259,RC,00074-2340-30,NDC,outpatient,1,UN,37.01,25.907,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GLIPIZIDE 5 MG ORAL TABS,RX-10117,CDM,S5000,HCPCS,259,RC,60505-0141-00,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GLIPIZIDE 5 MG ORAL TABS,RX-10117,CDM,S5000,HCPCS,259,RC,00904-6637-61,NDC,outpatient,1,UN,1.21,0.847,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GLYBURIDE 2.5 MG ORAL TABS,RX-10126,CDM,S5000,HCPCS,259,RC,00093-8343-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GLYCOPYRROLATE 1 MG ORAL TABS,RX-10130,CDM,S5000,HCPCS,259,RC,23155-0606-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GUANFACINE HCL 1 MG ORAL TABS,RX-10149,CDM,S5000,HCPCS,259,RC,68094-0065-59,NDC,outpatient,1,UN,8.9,6.23,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GUANFACINE HCL 1 MG ORAL TABS,RX-10149,CDM,S5000,HCPCS,259,RC,68094-0065-62,NDC,outpatient,1,UN,8.9,6.23,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACETAMINOPHEN 500 MG ORAL TABS,RX-102,CDM,S5000,HCPCS,259,RC,00904-6730-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROCORTISONE 5 MG ORAL TABS,RX-10209,CDM,S5000,HCPCS,259,RC,59762-0073-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROCORTISONE 5 MG ORAL TABS,RX-10209,CDM,S5000,HCPCS,259,RC,64380-0970-25,NDC,outpatient,1,UN,1.23,0.861,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROCORTISONE 100 MG/60ML RE ENEM,RX-10210,CDM,S5000,HCPCS,259,RC,62559-0138-11,NDC,outpatient,60,ML,88.11,61.677,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROCORTISONE 100 MG/60ML RE ENEM,RX-10210,CDM,S5000,HCPCS,259,RC,62559-0138-07,NDC,outpatient,60,ML,88.11,61.677,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROCORTISONE MICRONIZED POWD,RX-10217,CDM,S5000,HCPCS,259,RC,51552-0020-05,NDC,outpatient,100,GR,1580.42,1106.294,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROXYCHLOROQUINE SULFATE 200 MG ORAL TABS,RX-10235,CDM,S5000,HCPCS,259,RC,68084-0269-11,NDC,outpatient,1,UN,4.87,3.409,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROXYCHLOROQUINE SULFATE 200 MG ORAL TABS,RX-10235,CDM,S5000,HCPCS,259,RC,00904-7046-61,NDC,outpatient,1,UN,3.27,2.289,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROXYCHLOROQUINE SULFATE 200 MG ORAL TABS,RX-10235,CDM,S5000,HCPCS,259,RC,68084-0269-01,NDC,outpatient,1,UN,4.87,3.409,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROXYUREA 500 MG ORAL CAPS,RX-10236,CDM,S5000,HCPCS,259,RC,68084-0284-01,NDC,outpatient,1,UN,3.02,2.114,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROXYUREA 500 MG ORAL CAPS,RX-10236,CDM,S5000,HCPCS,259,RC,68084-0284-11,NDC,outpatient,1,UN,3.02,2.114,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,59651-0032-47,NDC,outpatient,473,ML,67.36,47.152,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,68094-0494-61,NDC,outpatient,5,ML,2.54,1.778,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,00121-0914-05,NDC,outpatient,5,ML,2.5,1.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,51672-2130-08,NDC,outpatient,120,ML,11.22,7.854,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,68094-0494-62,NDC,outpatient,5,ML,2.59,1.813,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,99999-0004-24,NDC,outpatient,5,ML,1.37,0.959,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,00121-0914-00,NDC,outpatient,5,ML,2.5,1.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,59651-0032-05,NDC,outpatient,5,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IBUPROFEN 100 MG/5ML ORAL SUSP,RX-10246,CDM,S5000,HCPCS,259,RC,68094-0494-59,NDC,outpatient,5,ML,2.54,1.778,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
INDIGOTINDISULFONATE SODIUM 8 MG/ML IJ SOLN,RX-10265,CDM,S5000,HCPCS,250,RC,81284-0315-00,NDC,outpatient,5,ML,1398.02,978.614,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
INDIGOTINDISULFONATE SODIUM 8 MG/ML IJ SOLN,RX-10265,CDM,S5000,HCPCS,250,RC,81284-0315-05,NDC,outpatient,5,ML,1398.02,978.614,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
INDOCYANINE GREEN 25 MG IV SOLR,RX-10266,CDM,S5000,HCPCS,250,RC,70100-0424-01,NDC,outpatient,1,UN,501.97,351.379,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
INDOCYANINE GREEN 25 MG IV SOLR,RX-10266,CDM,S5000,HCPCS,250,RC,70100-0424-02,NDC,outpatient,1,UN,501.97,351.379,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
INDOMETHACIN SODIUM 1 MG IV SOLR,RX-10267,CDM,S5000,HCPCS,250,RC,63323-0659-03,NDC,outpatient,1,UN,1192.43,834.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
INSULIN NPH (HUMAN) (ISOPHANE) 100 UNIT/ML SC SUSP,RX-10284,CDM,S5000,HCPCS,259,RC,00002-8315-01,NDC,outpatient,10,ML,61.5,43.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
INSULIN REGULAR HUMAN 100 UNIT/ML IJ SOLN,RX-10289,CDM,S5000,HCPCS,259,RC,00002-8215-01,NDC,outpatient,10,ML,61.5,43.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACETAMINOPHEN 120 MG RE SUPP,RX-103,CDM,S5000,HCPCS,259,RC,45802-0732-30,NDC,outpatient,1,UN,1.69,1.183,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BETAMETHASONE VALERATE 0.1 % EX CREA,RX-1031,CDM,S5000,HCPCS,259,RC,00472-0370-15,NDC,outpatient,15,GR,93.12,65.184,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BETAMETHASONE VALERATE 0.1 % EX CREA,RX-1031,CDM,S5000,HCPCS,259,RC,00713-0326-15,NDC,outpatient,15,GR,50.4,35.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BETAMETHASONE VALERATE 0.1 % EX LOTN,RX-1032,CDM,S5000,HCPCS,259,RC,00168-0041-60,NDC,outpatient,60,ML,267,186.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ISOSORBIDE MONONITRATE 20 MG ORAL TABS,RX-10357,CDM,S5000,HCPCS,259,RC,00228-2620-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ISRADIPINE 5 MG ORAL CAPS,RX-10363,CDM,S5000,HCPCS,259,RC,16252-0540-01,NDC,outpatient,1,UN,8.59,6.013,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ITRACONAZOLE 100 MG ORAL CAPS,RX-10364,CDM,S5000,HCPCS,259,RC,16714-0743-02,NDC,outpatient,1,UN,5.65,3.955,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
KETOCONAZOLE 2 % EX CREA,RX-10368,CDM,S5000,HCPCS,259,RC,00168-0099-15,NDC,outpatient,15,GR,22.57,15.799,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
KETOROLAC TROMETHAMINE 10 MG ORAL TABS,RX-10371,CDM,S5000,HCPCS,259,RC,70710-1710-01,NDC,outpatient,1,UN,3.63,2.541,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
KETOROLAC TROMETHAMINE 10 MG ORAL TABS,RX-10371,CDM,S5000,HCPCS,259,RC,00093-0314-01,NDC,outpatient,1,UN,4.33,3.031,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LABETALOL HCL 100 MG ORAL TABS,RX-10373,CDM,S5000,HCPCS,259,RC,60687-0439-11,NDC,outpatient,1,UN,1.32,0.924,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LABETALOL HCL 100 MG ORAL TABS,RX-10373,CDM,S5000,HCPCS,259,RC,60687-0439-01,NDC,outpatient,1,UN,1.32,0.924,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LABETALOL HCL 200 MG ORAL TABS,RX-10374,CDM,S5000,HCPCS,259,RC,60687-0450-11,NDC,outpatient,1,UN,1.81,1.267,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LABETALOL HCL 200 MG ORAL TABS,RX-10374,CDM,S5000,HCPCS,259,RC,60687-0450-01,NDC,outpatient,1,UN,1.81,1.267,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMMONIUM LACTATE 12 % EX LOTN,RX-10380,CDM,S5000,HCPCS,259,RC,63044-0484-09,NDC,outpatient,225,GR,29.04,20.328,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMMONIUM LACTATE 12 % EX LOTN,RX-10380,CDM,S5000,HCPCS,259,RC,00904-5984-26,NDC,outpatient,226,GR,13.08,9.156,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMMONIUM LACTATE 12 % EX LOTN,RX-10380,CDM,S5000,HCPCS,259,RC,16864-0000-18,NDC,outpatient,225,GR,41.06,28.742,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMMONIUM LACTATE 12 % EX LOTN,RX-10380,CDM,S5000,HCPCS,259,RC,30781-7098-79,NDC,outpatient,225,GR,41.06,28.742,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMMONIUM LACTATE 12 % EX LOTN,RX-10380,CDM,S5000,HCPCS,259,RC,51672-1300-05,NDC,outpatient,225,GR,61.08,42.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TAMSULOSIN HCL 0.4 MG ORAL CAPS,RX-103890,CDM,S5000,HCPCS,259,RC,57237-0014-01,NDC,outpatient,1,UN,1.24,0.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TAMSULOSIN HCL 0.4 MG ORAL CAPS,RX-103890,CDM,S5000,HCPCS,259,RC,63739-0567-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TAMSULOSIN HCL 0.4 MG ORAL CAPS,RX-103890,CDM,S5000,HCPCS,259,RC,68084-0299-01,NDC,outpatient,1,UN,1.04,0.728,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TAMSULOSIN HCL 0.4 MG ORAL CAPS,RX-103890,CDM,S5000,HCPCS,259,RC,72603-0115-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TAMSULOSIN HCL 0.4 MG ORAL CAPS,RX-103890,CDM,S5000,HCPCS,259,RC,68084-0299-11,NDC,outpatient,1,UN,1.04,0.728,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACETAMINOPHEN 325 MG RE SUPP,RX-104,CDM,S5000,HCPCS,259,RC,51672-2116-02,NDC,outpatient,1,UN,2.7,1.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACETAMINOPHEN 325 MG RE SUPP,RX-104,CDM,S5000,HCPCS,259,RC,51672-2116-04,NDC,outpatient,1,UN,1.99,1.393,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVOTHYROXINE SODIUM 88 MCG ORAL TABS,RX-10403,CDM,S5000,HCPCS,259,RC,42292-0038-01,NDC,outpatient,1,UN,2.39,1.673,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVOTHYROXINE SODIUM 88 MCG ORAL TABS,RX-10403,CDM,S5000,HCPCS,259,RC,60687-0486-11,NDC,outpatient,1,UN,2.07,1.449,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVOTHYROXINE SODIUM 88 MCG ORAL TABS,RX-10403,CDM,S5000,HCPCS,259,RC,42292-0038-20,NDC,outpatient,1,UN,2.39,1.673,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVOTHYROXINE SODIUM 88 MCG ORAL TABS,RX-10403,CDM,S5000,HCPCS,259,RC,60687-0486-01,NDC,outpatient,1,UN,2.07,1.449,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVOTHYROXINE SODIUM 112 MCG ORAL TABS,RX-10404,CDM,S5000,HCPCS,259,RC,69238-1835-01,NDC,outpatient,1,UN,1.64,1.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVOTHYROXINE SODIUM 112 MCG ORAL TABS,RX-10404,CDM,S5000,HCPCS,259,RC,42292-0039-01,NDC,outpatient,1,UN,2.79,1.953,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVOTHYROXINE SODIUM 112 MCG ORAL TABS,RX-10404,CDM,S5000,HCPCS,259,RC,42292-0039-20,NDC,outpatient,1,UN,2.79,1.953,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVOTHYROXINE SODIUM 137 MCG ORAL TABS,RX-10405,CDM,S5000,HCPCS,259,RC,00074-3727-90,NDC,outpatient,1,UN,6.49,4.543,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVOTHYROXINE SODIUM 137 MCG ORAL TABS,RX-10405,CDM,S5000,HCPCS,259,RC,00378-1823-77,NDC,outpatient,1,UN,2.29,1.603,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVOTHYROXINE SODIUM 137 MCG ORAL TABS,RX-10405,CDM,S5000,HCPCS,259,RC,00527-3287-46,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVOTHYROXINE SODIUM 175 MCG ORAL TABS,RX-10406,CDM,S5000,HCPCS,259,RC,42292-0040-01,NDC,outpatient,1,UN,3.47,2.429,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVOTHYROXINE SODIUM 175 MCG ORAL TABS,RX-10406,CDM,S5000,HCPCS,259,RC,42292-0040-20,NDC,outpatient,1,UN,3.47,2.429,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00409-4279-02,NDC,outpatient,30,ML,13.42,9.394,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00409-4279-16,NDC,outpatient,30,ML,13.42,9.394,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-04,NDC,outpatient,2,ML,4.85,3.395,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-97,NDC,outpatient,10,ML,24.48,17.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00143-9595-01,NDC,outpatient,5,ML,7.61,5.327,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00409-4713-26,NDC,outpatient,5,ML,4.55,3.185,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,55150-0159-74,NDC,outpatient,5,ML,3.68,2.576,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00143-9595-25,NDC,outpatient,5,ML,7.61,5.327,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00409-4713-02,NDC,outpatient,5,ML,4.55,3.185,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-08,NDC,outpatient,10,ML,24.48,17.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-09,NDC,outpatient,5,ML,6.46,4.522,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-27,NDC,outpatient,2,ML,4.85,3.395,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,63323-0492-57,NDC,outpatient,5,ML,6.46,4.522,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,00409-4713-12,NDC,outpatient,5,ML,4.55,3.185,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL (PF) 1 % IJ SOLN,RX-104207,CDM,S5000,HCPCS,250,RC,55150-0163-30,NDC,outpatient,30,ML,6.17,4.319,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00143-9594-01,NDC,outpatient,5,ML,7.61,5.327,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-2066-05,NDC,outpatient,5,ML,11.34,7.938,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-4282-12,NDC,outpatient,10,ML,10.34,7.238,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,55150-0165-05,NDC,outpatient,5,ML,4.63,3.241,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0495-27,NDC,outpatient,2,ML,8.69,6.083,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00143-9594-25,NDC,outpatient,5,ML,7.61,5.327,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-4282-01,NDC,outpatient,2,ML,4.57,3.199,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-4282-11,NDC,outpatient,2,ML,4.57,3.199,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0495-07,NDC,outpatient,5,ML,6.46,4.522,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0496-97,NDC,outpatient,10,ML,28.48,19.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-2066-10,NDC,outpatient,5,ML,11.34,7.938,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-4282-02,NDC,outpatient,10,ML,10.34,7.238,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,55150-0164-02,NDC,outpatient,2,ML,4.16,2.912,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0495-04,NDC,outpatient,5,ML,6.46,4.522,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0496-03,NDC,outpatient,10,ML,28.48,19.936,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,00409-4282-25,NDC,outpatient,2,ML,4.57,3.199,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL (PF) 2 % IJ SOLN,RX-104208,CDM,S5000,HCPCS,250,RC,63323-0495-09,NDC,outpatient,2,ML,8.69,6.083,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE-EPINEPHRINE 0.5 %-1:200000 IJ SOLN,RX-10426,CDM,S5000,HCPCS,250,RC,00409-3177-01,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE-EPINEPHRINE 0.5 %-1:200000 IJ SOLN,RX-10426,CDM,S5000,HCPCS,250,RC,63323-0481-57,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE-EPINEPHRINE 0.5 %-1:200000 IJ SOLN,RX-10426,CDM,S5000,HCPCS,250,RC,63323-0481-01,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE-EPINEPHRINE 0.5 %-1:200000 IJ SOLN,RX-10426,CDM,S5000,HCPCS,250,RC,00409-3177-16,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,00409-3178-16,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,00409-3178-17,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,63323-0482-03,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,00409-3178-01,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,63323-0482-01,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,63323-0482-27,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,00409-3178-02,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN,RX-10427,CDM,S5000,HCPCS,250,RC,63323-0482-17,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE-EPINEPHRINE 1.5 %-1:200000 IJ SOLN,RX-10429,CDM,S5000,HCPCS,250,RC,63323-0488-07,NDC,outpatient,30,ML,30.31,21.217,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE-EPINEPHRINE 1.5 %-1:200000 IJ SOLN,RX-10429,CDM,S5000,HCPCS,250,RC,63323-0488-37,NDC,outpatient,30,ML,30.31,21.217,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BETHANECHOL CHLORIDE 10 MG ORAL TABS,RX-1043,CDM,S5000,HCPCS,259,RC,00832-0511-01,NDC,outpatient,1,UN,1.83,1.281,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BETHANECHOL CHLORIDE 10 MG ORAL TABS,RX-1043,CDM,S5000,HCPCS,259,RC,00832-0511-89,NDC,outpatient,1,UN,1.83,1.281,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN,RX-10430,CDM,S5000,HCPCS,250,RC,00409-3182-01,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN,RX-10430,CDM,S5000,HCPCS,250,RC,63323-0483-27,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN,RX-10430,CDM,S5000,HCPCS,250,RC,00409-3182-11,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN,RX-10430,CDM,S5000,HCPCS,250,RC,63323-0483-03,NDC,outpatient,1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN,RX-10431,CDM,S5000,HCPCS,250,RC,00409-3183-01,NDC,outpatient,20,ML,16.35,11.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN,RX-10431,CDM,S5000,HCPCS,250,RC,63323-0489-02,NDC,outpatient,20,ML,30.18,21.126,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN,RX-10431,CDM,S5000,HCPCS,250,RC,63323-0489-17,NDC,outpatient,10,ML,19.13,13.391,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN,RX-10431,CDM,S5000,HCPCS,250,RC,00409-3183-11,NDC,outpatient,20,ML,16.35,11.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN,RX-10431,CDM,S5000,HCPCS,250,RC,63323-0489-27,NDC,outpatient,20,ML,30.18,21.126,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BETHANECHOL CHLORIDE 25 MG ORAL TABS,RX-1044,CDM,S5000,HCPCS,259,RC,00832-0512-01,NDC,outpatient,1,UN,2.51,1.757,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BETHANECHOL CHLORIDE 25 MG ORAL TABS,RX-1044,CDM,S5000,HCPCS,259,RC,00832-0512-89,NDC,outpatient,1,UN,2.51,1.757,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIOTHYRONINE SODIUM 10 MCG/ML IV SOLN,RX-10442,CDM,S5000,HCPCS,250,RC,39822-0151-01,NDC,outpatient,1,ML,1739.29,1217.503,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIOTHYRONINE SODIUM 5 MCG ORAL TABS,RX-10443,CDM,S5000,HCPCS,259,RC,00093-2179-01,NDC,outpatient,1,UN,2.45,1.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIOTHYRONINE SODIUM 5 MCG ORAL TABS,RX-10443,CDM,S5000,HCPCS,259,RC,68382-0582-01,NDC,outpatient,1,UN,2.45,1.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LISINOPRIL 10 MG ORAL TABS,RX-10449,CDM,S5000,HCPCS,259,RC,00904-6798-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LISINOPRIL 10 MG ORAL TABS,RX-10449,CDM,S5000,HCPCS,259,RC,68180-0980-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LISINOPRIL 10 MG ORAL TABS,RX-10449,CDM,S5000,HCPCS,259,RC,68180-0980-03,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LISINOPRIL 5 MG ORAL TABS,RX-10451,CDM,S5000,HCPCS,259,RC,00904-6797-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LITHIUM CARBONATE ER 300 MG ORAL TBCR,RX-10454,CDM,S5000,HCPCS,259,RC,68084-0640-01,NDC,outpatient,1,UN,1.52,1.064,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LITHIUM CARBONATE ER 300 MG ORAL TBCR,RX-10454,CDM,S5000,HCPCS,259,RC,68084-0640-11,NDC,outpatient,1,UN,1.52,1.064,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LITHIUM CARBONATE ER 450 MG ORAL TBCR,RX-10455,CDM,S5000,HCPCS,259,RC,68462-0224-01,NDC,outpatient,1,UN,1,0.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LITHIUM CARBONATE ER 450 MG ORAL TBCR,RX-10455,CDM,S5000,HCPCS,259,RC,68084-0655-01,NDC,outpatient,1,UN,2.55,1.785,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LITHIUM CARBONATE ER 450 MG ORAL TBCR,RX-10455,CDM,S5000,HCPCS,259,RC,68084-0655-11,NDC,outpatient,1,UN,2.55,1.785,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRANEXAMIC ACID 650 MG ORAL TABS,RX-104576,CDM,S5000,HCPCS,259,RC,50268-0772-13,NDC,outpatient,1,UN,11.87,8.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRANEXAMIC ACID 650 MG ORAL TABS,RX-104576,CDM,S5000,HCPCS,259,RC,62559-0265-30,NDC,outpatient,1,UN,10.97,7.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRANEXAMIC ACID 650 MG ORAL TABS,RX-104576,CDM,S5000,HCPCS,259,RC,69918-0301-30,NDC,outpatient,1,UN,6.2,4.34,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRANEXAMIC ACID 650 MG ORAL TABS,RX-104576,CDM,S5000,HCPCS,259,RC,50268-0772-11,NDC,outpatient,1,UN,11.87,8.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RIFAXIMIN 550 MG ORAL TABS,RX-104604,CDM,S5000,HCPCS,259,RC,65649-0303-03,NDC,outpatient,1,UN,223.91,156.737,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RIFAXIMIN 550 MG ORAL TABS,RX-104604,CDM,S5000,HCPCS,259,RC,65649-0303-02,NDC,outpatient,1,UN,223.91,156.737,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LORATADINE 10 MG ORAL TABS,RX-10466,CDM,S5000,HCPCS,259,RC,51079-0246-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LORATADINE 10 MG ORAL TABS,RX-10466,CDM,S5000,HCPCS,259,RC,00904-6852-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LORATADINE 10 MG ORAL TABS,RX-10466,CDM,S5000,HCPCS,259,RC,51079-0246-20,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SIROLIMUS 0.5 MG ORAL TABS,RX-104764,CDM,S5000,HCPCS,259,RC,59762-1001-01,NDC,outpatient,1,UN,20.25,14.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SIROLIMUS 0.5 MG ORAL TABS,RX-104764,CDM,S5000,HCPCS,259,RC,68382-0520-01,NDC,outpatient,1,UN,18.05,12.635,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MAFENIDE ACETATE 85 MG/GM EX CREA,RX-10478,CDM,S5000,HCPCS,259,RC,16571-0723-60,NDC,outpatient,56.7,GR,282.85,197.995,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CAFFEINE CITRATE 60 MG/3ML ORAL SOLN,RX-104787,CDM,S5000,HCPCS,259,RC,25021-0602-03,NDC,outpatient,3,ML,26.44,18.508,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CAFFEINE CITRATE 60 MG/3ML ORAL SOLN,RX-104787,CDM,S5000,HCPCS,259,RC,63323-0406-03,NDC,outpatient,3,ML,31.83,22.281,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CAFFEINE CITRATE 60 MG/3ML ORAL SOLN,RX-104787,CDM,S5000,HCPCS,259,RC,51754-0501-03,NDC,outpatient,3,ML,27.32,19.124,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CAFFEINE CITRATE 60 MG/3ML ORAL SOLN,RX-104787,CDM,S5000,HCPCS,259,RC,63323-0406-01,NDC,outpatient,3,ML,31.83,22.281,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MAGNESIUM OXIDE 140 MG ORAL CAPS,RX-10490,CDM,S5000,HCPCS,259,RC,60569-0495-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACETAMINOPHEN 650 MG RE SUPP,RX-105,CDM,S5000,HCPCS,259,RC,45802-0730-33,NDC,outpatient,1,UN,1.05,0.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACETAMINOPHEN 650 MG RE SUPP,RX-105,CDM,S5000,HCPCS,259,RC,45802-0730-30,NDC,outpatient,1,UN,1.95,1.365,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MEDIUM CHAIN TRIGLYCERIDES ORAL OIL,RX-10518,CDM,S5000,HCPCS,259,RC,41679-0365-03,NDC,outpatient,946,ML,46.31,32.417,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MEDIUM CHAIN TRIGLYCERIDES ORAL OIL,RX-10518,CDM,S5000,HCPCS,259,RC,99999-0003-04,NDC,outpatient,1,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MEDIUM CHAIN TRIGLYCERIDES ORAL OIL,RX-10518,CDM,S5000,HCPCS,259,RC,41679-0365-13,NDC,outpatient,946,ML,46.31,32.417,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MEDIUM CHAIN TRIGLYCERIDES ORAL OIL,RX-10518,CDM,S5000,HCPCS,259,RC,99999-0003-05,NDC,outpatient,15,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MESALAMINE ER 250 MG ORAL CPCR,RX-10533,CDM,S5000,HCPCS,259,RC,54092-0189-81,NDC,outpatient,1,UN,12.49,8.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BROMOCRIPTINE MESYLATE 0.8 MG ORAL TABS,RX-105409,CDM,S5000,HCPCS,259,RC,68012-0258-20,NDC,outpatient,1,UN,23.23,16.261,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METFORMIN HCL 500 MG ORAL TABS,RX-10544,CDM,S5000,HCPCS,259,RC,00904-7162-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METFORMIN HCL 500 MG ORAL TABS,RX-10544,CDM,S5000,HCPCS,259,RC,60687-0155-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METFORMIN HCL 500 MG ORAL TABS,RX-10544,CDM,S5000,HCPCS,259,RC,60687-0155-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LACOSAMIDE 10 MG/ML ORAL SOLN,RX-105482,CDM,S5000,HCPCS,259,RC,99999-0001-42,NDC,outpatient,20,ML,187.97,131.579,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LACOSAMIDE 10 MG/ML ORAL SOLN,RX-105482,CDM,S5000,HCPCS,259,RC,00131-5410-72,NDC,outpatient,5,ML,47,32.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METHENAMINE HIPPURATE 1 G ORAL TABS,RX-10549,CDM,S5000,HCPCS,259,RC,60687-0694-11,NDC,outpatient,1,UN,7.92,5.544,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METHENAMINE HIPPURATE 1 G ORAL TABS,RX-10549,CDM,S5000,HCPCS,259,RC,60687-0694-21,NDC,outpatient,1,UN,7.92,5.544,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METHIMAZOLE 5 MG ORAL TABS,RX-10553,CDM,S5000,HCPCS,259,RC,23155-0070-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METHIMAZOLE 5 MG ORAL TABS,RX-10553,CDM,S5000,HCPCS,259,RC,60687-0669-11,NDC,outpatient,1,UN,2.25,1.575,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METHIMAZOLE 5 MG ORAL TABS,RX-10553,CDM,S5000,HCPCS,259,RC,60687-0669-01,NDC,outpatient,1,UN,2.25,1.575,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-9042-01,NDC,outpatient,10,ML,18.15,12.705,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,63323-0468-02,NDC,outpatient,30,ML,28.84,20.188,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-1746-10,NDC,outpatient,10,ML,17.38,12.166,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-1746-71,NDC,outpatient,30,ML,36.85,25.795,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-9042-11,NDC,outpatient,10,ML,18.15,12.705,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,63323-0468-17,NDC,outpatient,10,ML,18.16,12.712,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-1746-70,NDC,outpatient,10,ML,17.38,12.166,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,63323-0468-01,NDC,outpatient,10,ML,18.16,12.712,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,63323-0468-37,NDC,outpatient,30,ML,28.84,20.188,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN,RX-105633,CDM,S5000,HCPCS,250,RC,00409-1746-30,NDC,outpatient,30,ML,36.85,25.795,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,00409-9045-11,NDC,outpatient,10,ML,11.21,7.847,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-31,NDC,outpatient,30,ML,25.5,17.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-37,NDC,outpatient,30,ML,30.98,21.686,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,00409-9045-17,NDC,outpatient,30,ML,11.88,8.316,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-01,NDC,outpatient,30,ML,30.98,21.686,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-02,NDC,outpatient,30,ML,25.5,17.85,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-04,NDC,outpatient,10,ML,18.61,13.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,63323-0462-17,NDC,outpatient,10,ML,18.61,13.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,00409-9045-01,NDC,outpatient,10,ML,11.21,7.847,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPIVACAINE-EPINEPHRINE (PF) 0.5% -1:200000 IJ SOLN,RX-105634,CDM,S5000,HCPCS,250,RC,00409-9045-16,NDC,outpatient,30,ML,11.88,8.316,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METHYLERGONOVINE MALEATE 0.2 MG ORAL TABS,RX-10572,CDM,S5000,HCPCS,259,RC,69238-1605-02,NDC,outpatient,1,UN,78.51,54.957,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METHYLERGONOVINE MALEATE 0.2 MG ORAL TABS,RX-10572,CDM,S5000,HCPCS,259,RC,60687-0813-11,NDC,outpatient,1,UN,190.6,133.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METHYLERGONOVINE MALEATE 0.2 MG ORAL TABS,RX-10572,CDM,S5000,HCPCS,259,RC,60687-0813-94,NDC,outpatient,1,UN,190.6,133.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METHYLERGONOVINE MALEATE 0.2 MG ORAL TABS,RX-10572,CDM,S5000,HCPCS,259,RC,69238-1605-08,NDC,outpatient,1,UN,71.96,50.372,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METOLAZONE 2.5 MG ORAL TABS,RX-10587,CDM,S5000,HCPCS,259,RC,51079-0023-01,NDC,outpatient,1,UN,11.25,7.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METOLAZONE 2.5 MG ORAL TABS,RX-10587,CDM,S5000,HCPCS,259,RC,51079-0023-20,NDC,outpatient,1,UN,11.25,7.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METOLAZONE 5 MG ORAL TABS,RX-10588,CDM,S5000,HCPCS,259,RC,51079-0024-01,NDC,outpatient,1,UN,12.79,8.953,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METOLAZONE 5 MG ORAL TABS,RX-10588,CDM,S5000,HCPCS,259,RC,51079-0024-20,NDC,outpatient,1,UN,12.79,8.953,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METRONIDAZOLE 0.75 % VA GEL,RX-10592,CDM,S5000,HCPCS,259,RC,16714-0557-01,NDC,outpatient,70,GR,66.67,46.669,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MEXILETINE HCL 150 MG ORAL CAPS,RX-10595,CDM,S5000,HCPCS,259,RC,62559-0820-01,NDC,outpatient,1,UN,1.38,0.966,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MEXILETINE HCL 150 MG ORAL CAPS,RX-10595,CDM,S5000,HCPCS,259,RC,00093-8739-01,NDC,outpatient,1,UN,2.26,1.582,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MEXILETINE HCL 150 MG ORAL CAPS,RX-10595,CDM,S5000,HCPCS,259,RC,50742-0239-01,NDC,outpatient,1,UN,1.39,0.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MEXILETINE HCL 200 MG ORAL CAPS,RX-10596,CDM,S5000,HCPCS,259,RC,00093-8740-01,NDC,outpatient,1,UN,3.1,2.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MICONAZOLE NITRATE 2 % EX POWD,RX-10599,CDM,S5000,HCPCS,259,RC,53329-0169-79,NDC,outpatient,85,GR,16.27,11.389,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MICONAZOLE NITRATE 2 % EX POWD,RX-10599,CDM,S5000,HCPCS,259,RC,11701-0038-16,NDC,outpatient,85,GR,25.73,18.011,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MICROFIBRILLAR COLL HEMOSTAT EX PADS,RX-10605,CDM,S5000,HCPCS,259,RC,53276-1010-08,NDC,outpatient,1,UN,496.85,347.795,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MICROFIBRILLAR COLL HEMOSTAT EX POWD,RX-10606,CDM,S5000,HCPCS,250,RC,53276-1010-02,NDC,outpatient,1,GR,993.69,695.583,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ULIPRISTAL ACETATE 30 MG ORAL TABS,RX-106079,CDM,S5000,HCPCS,259,RC,73302-0456-01,NDC,outpatient,1,UN,159.36,111.552,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MIDODRINE HCL 2.5 MG ORAL TABS,RX-10609,CDM,S5000,HCPCS,259,RC,00245-0211-11,NDC,outpatient,1,UN,1.99,1.393,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MIDODRINE HCL 2.5 MG ORAL TABS,RX-10609,CDM,S5000,HCPCS,259,RC,00378-1901-01,NDC,outpatient,1,UN,2.12,1.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,51079-0453-01,NDC,outpatient,1,UN,1.17,0.819,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,00245-0212-01,NDC,outpatient,1,UN,2.4,1.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,00245-0212-89,NDC,outpatient,1,UN,2.4,1.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,51079-0453-20,NDC,outpatient,1,UN,1.17,0.819,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,00904-6818-61,NDC,outpatient,1,UN,2.24,1.568,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MIDODRINE HCL 5 MG ORAL TABS,RX-10610,CDM,S5000,HCPCS,259,RC,63739-0145-10,NDC,outpatient,1,UN,1.05,0.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NEOMYCIN-POLYMYXIN-DEXAMETH 3.5-10000-0.1 OP SUSP,RX-106248,CDM,S5000,HCPCS,259,RC,24208-0830-60,NDC,outpatient,5,ML,59.63,41.741,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NEOMYCIN-POLYMYXIN-DEXAMETH 3.5-10000-0.1 OP OINT,RX-106249,CDM,S5000,HCPCS,259,RC,61314-0631-36,NDC,outpatient,3.5,GR,69.78,48.846,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MISOPROSTOL 100 MCG ORAL TABS,RX-10628,CDM,S5000,HCPCS,259,RC,59762-5007-01,NDC,outpatient,1,UN,2.08,1.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MISOPROSTOL 100 MCG ORAL TABS,RX-10628,CDM,S5000,HCPCS,259,RC,60687-0735-11,NDC,outpatient,1,UN,9.27,6.489,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MISOPROSTOL 100 MCG ORAL TABS,RX-10628,CDM,S5000,HCPCS,259,RC,00025-1451-34,NDC,outpatient,1,UN,17.24,12.068,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MISOPROSTOL 100 MCG ORAL TABS,RX-10628,CDM,S5000,HCPCS,259,RC,60687-0735-01,NDC,outpatient,1,UN,9.27,6.489,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MISOPROSTOL 200 MCG ORAL TABS,RX-10629,CDM,S5000,HCPCS,259,RC,60687-0746-11,NDC,outpatient,1,UN,7.19,5.033,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MISOPROSTOL 200 MCG ORAL TABS,RX-10629,CDM,S5000,HCPCS,259,RC,60687-0746-01,NDC,outpatient,1,UN,7.19,5.033,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL (PF) 0.5 % IJ SOLN,RX-106363,CDM,S5000,HCPCS,250,RC,00409-4278-01,NDC,outpatient,50,ML,10.28,7.196,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL (PF) 0.5 % IJ SOLN,RX-106363,CDM,S5000,HCPCS,250,RC,00409-4278-16,NDC,outpatient,50,ML,10.28,7.196,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DABIGATRAN ETEXILATE MESYLATE 75 MG ORAL CAPS,RX-106490,CDM,S5000,HCPCS,259,RC,00597-0355-56,NDC,outpatient,1,UN,12.92,9.044,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DABIGATRAN ETEXILATE MESYLATE 75 MG ORAL CAPS,RX-106490,CDM,S5000,HCPCS,259,RC,00597-0355-61,NDC,outpatient,1,UN,12.92,9.044,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DABIGATRAN ETEXILATE MESYLATE 150 MG ORAL CAPS,RX-106491,CDM,S5000,HCPCS,259,RC,00597-0360-82,NDC,outpatient,1,UN,12.92,9.044,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DABIGATRAN ETEXILATE MESYLATE 150 MG ORAL CAPS,RX-106491,CDM,S5000,HCPCS,259,RC,00597-0360-55,NDC,outpatient,1,UN,12.92,9.044,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MORPHINE SULFATE (CONCENTRATE) 20 MG/ML ORAL SOLN,RX-10655,CDM,S5000,HCPCS,259,RC,99999-0002-18,NDC,outpatient,1,ML,2.33,1.631,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MORPHINE SULFATE (CONCENTRATE) 20 MG/ML ORAL SOLN,RX-10655,CDM,S5000,HCPCS,259,RC,00406-8003-30,NDC,outpatient,0.25,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MUPIROCIN 2 % EX OINT,RX-10674,CDM,S5000,HCPCS,259,RC,68462-0180-22,NDC,outpatient,22,GR,18.61,13.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MUPIROCIN 2 % EX OINT,RX-10674,CDM,S5000,HCPCS,259,RC,45802-0112-22,NDC,outpatient,22,GR,13.61,9.527,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MUPIROCIN 2 % EX OINT,RX-10674,CDM,S5000,HCPCS,259,RC,51672-1312-00,NDC,outpatient,22,GR,11.07,7.749,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NABUMETONE 500 MG ORAL TABS,RX-10676,CDM,S5000,HCPCS,259,RC,60687-0630-21,NDC,outpatient,1,UN,3.85,2.695,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NABUMETONE 500 MG ORAL TABS,RX-10676,CDM,S5000,HCPCS,259,RC,00591-3670-01,NDC,outpatient,1,UN,1.2,0.84,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NABUMETONE 500 MG ORAL TABS,RX-10676,CDM,S5000,HCPCS,259,RC,60687-0630-11,NDC,outpatient,1,UN,3.85,2.695,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NALTREXONE HCL 50 MG ORAL TABS,RX-10685,CDM,S5000,HCPCS,259,RC,00904-7036-04,NDC,outpatient,1,UN,7.95,5.565,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NALTREXONE HCL 50 MG ORAL TABS,RX-10685,CDM,S5000,HCPCS,259,RC,68084-0291-21,NDC,outpatient,1,UN,8.68,6.076,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NALTREXONE HCL 50 MG ORAL TABS,RX-10685,CDM,S5000,HCPCS,259,RC,00406-1170-03,NDC,outpatient,1,UN,4.49,3.143,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NALTREXONE HCL 50 MG ORAL TABS,RX-10685,CDM,S5000,HCPCS,259,RC,68084-0291-11,NDC,outpatient,1,UN,8.68,6.076,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NICARDIPINE HCL 20 MG ORAL CAPS,RX-10712,CDM,S5000,HCPCS,259,RC,68462-0120-90,NDC,outpatient,1,UN,18.98,13.286,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NICARDIPINE HCL 20 MG ORAL CAPS,RX-10712,CDM,S5000,HCPCS,259,RC,62559-0205-90,NDC,outpatient,1,UN,35.49,24.843,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NICARDIPINE HCL 30 MG ORAL CAPS,RX-10713,CDM,S5000,HCPCS,259,RC,68462-0121-90,NDC,outpatient,1,UN,27.58,19.306,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NICARDIPINE HCL 30 MG ORAL CAPS,RX-10713,CDM,S5000,HCPCS,259,RC,42806-0502-09,NDC,outpatient,1,UN,24.73,17.311,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NICOTINE POLACRILEX 2 MG MT GUM,RX-10717,CDM,S5000,HCPCS,259,RC,00536-1362-23,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NICOTINE POLACRILEX 2 MG MT GUM,RX-10717,CDM,S5000,HCPCS,259,RC,00536-3029-23,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NICOTINE POLACRILEX 4 MG MT GUM,RX-10718,CDM,S5000,HCPCS,259,RC,00135-0242-08,NDC,outpatient,1,UN,2.37,1.659,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NICOTINE POLACRILEX 4 MG MT GUM,RX-10718,CDM,S5000,HCPCS,259,RC,00536-1372-23,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NIMODIPINE 30 MG ORAL CAPS,RX-10722,CDM,S5000,HCPCS,259,RC,23155-0512-11,NDC,outpatient,1,UN,5.11,3.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NIMODIPINE 30 MG ORAL CAPS,RX-10722,CDM,S5000,HCPCS,259,RC,23155-0512-00,NDC,outpatient,1,UN,5.11,3.577,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,50268-0625-15,NDC,outpatient,1,UN,7.34,5.138,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,16714-0439-01,NDC,outpatient,1,UN,7.17,5.019,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,50268-0625-11,NDC,outpatient,1,UN,7.34,5.138,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,00904-7137-61,NDC,outpatient,1,UN,6.96,4.872,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,60687-0633-01,NDC,outpatient,1,UN,9.67,6.769,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NITROFURANTOIN MONOHYD MACRO 100 MG ORAL CAPS,RX-10724,CDM,S5000,HCPCS,259,RC,60687-0633-11,NDC,outpatient,1,UN,9.67,6.769,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPRENORPHINE 5 MCG/HR TD PTWK,RX-107660,CDM,S5000,HCPCS,259,RC,42858-0750-40,NDC,outpatient,1,UN,220.77,154.539,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPRENORPHINE 5 MCG/HR TD PTWK,RX-107660,CDM,S5000,HCPCS,259,RC,50742-0372-04,NDC,outpatient,1,UN,146.92,102.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPRENORPHINE 5 MCG/HR TD PTWK,RX-107660,CDM,S5000,HCPCS,259,RC,50742-0372-01,NDC,outpatient,1,UN,146.92,102.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPRENORPHINE 10 MCG/HR TD PTWK,RX-107661,CDM,S5000,HCPCS,259,RC,00093-3657-40,NDC,outpatient,1,UN,232.52,162.764,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPRENORPHINE 10 MCG/HR TD PTWK,RX-107661,CDM,S5000,HCPCS,259,RC,00093-3657-21,NDC,outpatient,1,UN,232.52,162.764,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OLSALAZINE SODIUM 250 MG ORAL CAPS,RX-10773,CDM,S5000,HCPCS,259,RC,00037-6860-10,NDC,outpatient,1,UN,61.39,42.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VALPROIC ACID 250 MG/5ML ORAL SOLN,RX-107838,CDM,S5000,HCPCS,259,RC,00121-4675-00,NDC,outpatient,5,ML,4.92,3.444,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VALPROIC ACID 250 MG/5ML ORAL SOLN,RX-107838,CDM,S5000,HCPCS,259,RC,00121-4675-40,NDC,outpatient,5,ML,7.15,5.005,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VALPROIC ACID 250 MG/5ML ORAL SOLN,RX-107838,CDM,S5000,HCPCS,259,RC,00121-4675-05,NDC,outpatient,5,ML,7.15,5.005,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VALPROIC ACID 250 MG/5ML ORAL SOLN,RX-107838,CDM,S5000,HCPCS,259,RC,99999-0001-41,NDC,outpatient,5,ML,2.27,1.589,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BISACODYL 5 MG ORAL TBEC,RX-1079,CDM,S5000,HCPCS,259,RC,00904-6407-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BISACODYL 10 MG RE SUPP,RX-1080,CDM,S5000,HCPCS,259,RC,00574-7050-12,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BISACODYL 10 MG RE SUPP,RX-1080,CDM,S5000,HCPCS,259,RC,58980-0415-50,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BISACODYL 10 MG RE SUPP,RX-1080,CDM,S5000,HCPCS,259,RC,81421-0021-03,NDC,outpatient,1,UN,3.38,2.366,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BISACODYL 10 MG RE SUPP,RX-1080,CDM,S5000,HCPCS,259,RC,00574-7050-50,NDC,outpatient,1,UN,1.02,0.714,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BISACODYL 10 MG RE SUPP,RX-1080,CDM,S5000,HCPCS,259,RC,58980-0415-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TESTOSTERONE 25 MG/2.5GM (1%) TD GEL,RX-108038,CDM,S5000,HCPCS,259,RC,64380-0151-02,NDC,outpatient,2.5,GR,13.58,9.506,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TESTOSTERONE 25 MG/2.5GM (1%) TD GEL,RX-108038,CDM,S5000,HCPCS,259,RC,64380-0151-01,NDC,outpatient,2.5,GR,13.58,9.506,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TESTOSTERONE 50 MG/5GM (1%) TD GEL,RX-108039,CDM,S5000,HCPCS,259,RC,00591-3524-30,NDC,outpatient,5,GR,13.67,9.569,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TESTOSTERONE 50 MG/5GM (1%) TD GEL,RX-108039,CDM,S5000,HCPCS,259,RC,00591-3524-26,NDC,outpatient,5,GR,13.67,9.569,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXYCODONE HCL 100 MG/5ML ORAL CONC,RX-10812,CDM,S5000,HCPCS,259,RC,00406-8557-30,NDC,outpatient,30,ML,133.24,93.268,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXYCODONE HCL 100 MG/5ML ORAL CONC,RX-10812,CDM,S5000,HCPCS,259,RC,99999-0002-27,NDC,outpatient,1,ML,7.21,5.047,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXYCODONE HCL 5 MG/5ML ORAL SOLN,RX-10813,CDM,S5000,HCPCS,259,RC,64950-0354-55,NDC,outpatient,5,ML,8.79,6.153,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXYCODONE HCL 5 MG/5ML ORAL SOLN,RX-10813,CDM,S5000,HCPCS,259,RC,64950-0354-05,NDC,outpatient,5,ML,8.79,6.153,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,00406-0552-23,NDC,outpatient,1,UN,1.17,0.819,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,10702-0018-50,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,68084-0354-11,NDC,outpatient,1,UN,1.65,1.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,00904-6966-61,NDC,outpatient,1,UN,1.01,0.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,00406-0552-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,00406-0552-62,NDC,outpatient,1,UN,1.17,0.819,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,42858-0001-10,NDC,outpatient,1,UN,1,0.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXYCODONE HCL 5 MG ORAL TABS,RX-10814,CDM,S5000,HCPCS,259,RC,68084-0354-01,NDC,outpatient,1,UN,1.65,1.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PAROXETINE HCL 20 MG ORAL TABS,RX-10855,CDM,S5000,HCPCS,259,RC,63739-0963-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BISMUTH SUBCARBONATE POWD,RX-1086,CDM,S5000,HCPCS,259,RC,62991-2844-02,NDC,outpatient,100,GR,276.06,193.242,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BISMUTH SUBSALICYLATE 262 MG/15ML ORAL SUSP,RX-1090,CDM,S5000,HCPCS,259,RC,99999-0001-91,NDC,outpatient,30,ML,2.01,1.407,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BISMUTH SUBSALICYLATE 262 MG/15ML ORAL SUSP,RX-1090,CDM,S5000,HCPCS,259,RC,37000-0475-08,NDC,outpatient,10,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PERMETHRIN 5 % EX CREA,RX-10917,CDM,S5000,HCPCS,259,RC,00472-0242-60,NDC,outpatient,60,GR,76.37,53.459,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,00310-0095-30,NDC,outpatient,1,UN,54.75,38.325,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,31722-0623-90,NDC,outpatient,1,UN,7.15,5.005,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,42571-0259-30,NDC,outpatient,1,UN,4.47,3.129,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,00378-1905-77,NDC,outpatient,1,UN,17.44,12.208,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,60687-0786-11,NDC,outpatient,1,UN,7.84,5.488,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ROFLUMILAST 500 MCG ORAL TABS,RX-109401,CDM,S5000,HCPCS,259,RC,60687-0786-21,NDC,outpatient,1,UN,7.84,5.488,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PHENOXYBENZAMINE HCL 10 MG ORAL CAPS,RX-10945,CDM,S5000,HCPCS,259,RC,66993-0066-02,NDC,outpatient,1,UN,73.53,51.471,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PHENTOLAMINE MESYLATE 5 MG IJ SOLR,RX-10947,CDM,S5000,HCPCS,259,RC,00143-9564-01,NDC,outpatient,1,UN,1208.89,846.223,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PHENTOLAMINE MESYLATE 5 MG IJ SOLR,RX-10947,CDM,S5000,HCPCS,259,RC,00143-9564-10,NDC,outpatient,1,UN,1233.54,863.478,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LINAGLIPTIN 5 MG ORAL TABS,RX-109773,CDM,S5000,HCPCS,259,RC,00597-0140-61,NDC,outpatient,1,UN,56.14,39.298,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RILPIVIRINE HCL 25 MG ORAL TABS,RX-109909,CDM,S5000,HCPCS,259,RC,59676-0278-01,NDC,outpatient,1,UN,209.04,146.328,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PHENYTOIN 50 MG ORAL CHEW,RX-11018,CDM,S5000,HCPCS,259,RC,60687-0156-25,NDC,outpatient,1,UN,4.05,2.835,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PHENYTOIN 50 MG ORAL CHEW,RX-11018,CDM,S5000,HCPCS,259,RC,00904-7199-07,NDC,outpatient,1,UN,3.73,2.611,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PHENYTOIN 50 MG ORAL CHEW,RX-11018,CDM,S5000,HCPCS,259,RC,60687-0156-95,NDC,outpatient,1,UN,4.05,2.835,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PHENYTOIN SODIUM EXTENDED 30 MG ORAL CAPS,RX-11019,CDM,S5000,HCPCS,259,RC,00071-3740-66,NDC,outpatient,1,UN,5.97,4.179,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PHYTONADIONE 5 MG ORAL TABS,RX-11024,CDM,S5000,HCPCS,259,RC,60687-0381-94,NDC,outpatient,1,UN,227.6,159.32,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PHYTONADIONE 5 MG ORAL TABS,RX-11024,CDM,S5000,HCPCS,259,RC,60687-0381-11,NDC,outpatient,1,UN,227.6,159.32,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RIVAROXABAN 10 MG ORAL TABS,RX-110250,CDM,S5000,HCPCS,259,RC,50458-0580-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RIVAROXABAN 10 MG ORAL TABS,RX-110250,CDM,S5000,HCPCS,259,RC,50458-0580-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FIDAXOMICIN 200 MG ORAL TABS,RX-110360,CDM,S5000,HCPCS,259,RC,52015-0080-01,NDC,outpatient,1,UN,501.77,351.239,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TICAGRELOR 90 MG ORAL TABS,RX-110427,CDM,S5000,HCPCS,259,RC,00186-0777-39,NDC,outpatient,1,UN,30.77,21.539,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CALCIUM POLYCARBOPHIL 625 MG ORAL TABS,RX-11046,CDM,S5000,HCPCS,259,RC,00536-4306-05,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CALCIUM POLYCARBOPHIL 625 MG ORAL TABS,RX-11046,CDM,S5000,HCPCS,259,RC,00904-2500-91,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POLYSACCHARIDE IRON COMPLEX 150 MG ORAL CAPS,RX-11050,CDM,S5000,HCPCS,259,RC,00904-5395-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POTASSIUM CITRATE ER 10 MEQ (1080 MG) ORAL TBCR,RX-11083,CDM,S5000,HCPCS,259,RC,68084-0850-33,NDC,outpatient,1,UN,8.47,5.929,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POTASSIUM CITRATE ER 10 MEQ (1080 MG) ORAL TBCR,RX-11083,CDM,S5000,HCPCS,259,RC,00178-0610-01,NDC,outpatient,1,UN,7.92,5.544,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POTASSIUM CITRATE ER 10 MEQ (1080 MG) ORAL TBCR,RX-11083,CDM,S5000,HCPCS,259,RC,68084-0850-32,NDC,outpatient,1,UN,8.47,5.929,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OSELTAMIVIR PHOSPHATE 6 MG/ML ORAL SUSR,RX-110998,CDM,S5000,HCPCS,259,RC,00004-0822-05,NDC,outpatient,60,ML,624.52,437.164,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OSELTAMIVIR PHOSPHATE 6 MG/ML ORAL SUSR,RX-110998,CDM,S5000,HCPCS,259,RC,99999-0000-41,NDC,outpatient,5,ML,52.63,36.841,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OSELTAMIVIR PHOSPHATE 6 MG/ML ORAL SUSR,RX-110998,CDM,S5000,HCPCS,259,RC,27241-0139-09,NDC,outpatient,60,ML,35.52,24.864,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OSELTAMIVIR PHOSPHATE 6 MG/ML ORAL SUSR,RX-110998,CDM,S5000,HCPCS,259,RC,68180-0678-01,NDC,outpatient,60,ML,26.7,18.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PRAVASTATIN SODIUM 10 MG ORAL TABS,RX-11110,CDM,S5000,HCPCS,259,RC,00904-5891-61,NDC,outpatient,1,UN,1.35,0.945,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PRAVASTATIN SODIUM 20 MG ORAL TABS,RX-11111,CDM,S5000,HCPCS,259,RC,00904-5892-61,NDC,outpatient,1,UN,2.3,1.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PRAVASTATIN SODIUM 20 MG ORAL TABS,RX-11111,CDM,S5000,HCPCS,259,RC,51079-0458-01,NDC,outpatient,1,UN,2.39,1.673,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PRAVASTATIN SODIUM 20 MG ORAL TABS,RX-11111,CDM,S5000,HCPCS,259,RC,51079-0458-20,NDC,outpatient,1,UN,2.39,1.673,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PRIMIDONE 50 MG ORAL TABS,RX-11129,CDM,S5000,HCPCS,259,RC,68084-0202-01,NDC,outpatient,1,UN,2.64,1.848,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PRIMIDONE 50 MG ORAL TABS,RX-11129,CDM,S5000,HCPCS,259,RC,68084-0202-11,NDC,outpatient,1,UN,2.64,1.848,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PROCHLORPERAZINE 25 MG RE SUPP,RX-11138,CDM,S5000,HCPCS,259,RC,00574-7226-12,NDC,outpatient,1,UN,26.18,18.326,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PROMETHAZINE HCL 12.5 MG RE SUPP,RX-11143,CDM,S5000,HCPCS,259,RC,00713-0536-12,NDC,outpatient,1,UN,43.38,30.366,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PROMETHAZINE HCL 12.5 MG RE SUPP,RX-11143,CDM,S5000,HCPCS,259,RC,00713-0536-06,NDC,outpatient,1,UN,43.38,30.366,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PROMETHAZINE HCL 25 MG RE SUPP,RX-11144,CDM,S5000,HCPCS,259,RC,00713-0526-12,NDC,outpatient,1,UN,43.38,30.366,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PROPAFENONE HCL 150 MG ORAL TABS,RX-11146,CDM,S5000,HCPCS,259,RC,00591-0582-01,NDC,outpatient,1,UN,1.95,1.365,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PROPAFENONE HCL 225 MG ORAL TABS,RX-11147,CDM,S5000,HCPCS,259,RC,00591-0583-01,NDC,outpatient,1,UN,1.32,0.924,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PYRIDOSTIGMINE BROMIDE 60 MG ORAL TABS,RX-11239,CDM,S5000,HCPCS,259,RC,00904-6622-61,NDC,outpatient,1,UN,3.64,2.548,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PYRIDOSTIGMINE BROMIDE 60 MG ORAL TABS,RX-11239,CDM,S5000,HCPCS,259,RC,68382-0659-06,NDC,outpatient,1,UN,1.59,1.113,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PYRIDOSTIGMINE BROMIDE ER 180 MG ORAL TBCR,RX-11240,CDM,S5000,HCPCS,259,RC,47781-0335-30,NDC,outpatient,1,UN,71.76,50.232,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PYRIMETHAMINE 25 MG ORAL TABS,RX-11246,CDM,S5000,HCPCS,259,RC,43598-0672-01,NDC,outpatient,1,UN,1019.51,713.657,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POLIDOCANOL 1 % IV SOLN,RX-112481,CDM,S5000,HCPCS,250,RC,67850-0141-00,NDC,outpatient,2,ML,92.93,65.051,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POLIDOCANOL 1 % IV SOLN,RX-112481,CDM,S5000,HCPCS,250,RC,67850-0141-05,NDC,outpatient,2,ML,92.93,65.051,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RAMIPRIL 1.25 MG ORAL CAPS,RX-11258,CDM,S5000,HCPCS,259,RC,68382-0144-06,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RAMIPRIL 5 MG ORAL CAPS,RX-11261,CDM,S5000,HCPCS,259,RC,57237-0224-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RAMIPRIL 5 MG ORAL CAPS,RX-11261,CDM,S5000,HCPCS,259,RC,68382-0146-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLOBAZAM 10 MG ORAL TABS,RX-112703,CDM,S5000,HCPCS,259,RC,60687-0423-21,NDC,outpatient,1,UN,9.33,6.531,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLOBAZAM 10 MG ORAL TABS,RX-112703,CDM,S5000,HCPCS,259,RC,60687-0423-11,NDC,outpatient,1,UN,9.33,6.531,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLOBAZAM 10 MG ORAL TABS,RX-112703,CDM,S5000,HCPCS,259,RC,68180-0157-01,NDC,outpatient,1,UN,2.47,1.729,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RIVAROXABAN 15 MG ORAL TABS,RX-112834,CDM,S5000,HCPCS,259,RC,50458-0578-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RIVAROXABAN 15 MG ORAL TABS,RX-112834,CDM,S5000,HCPCS,259,RC,50458-0578-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RIBAVIRIN 200 MG ORAL CAPS,RX-11286,CDM,S5000,HCPCS,259,RC,65862-0290-84,NDC,outpatient,1,UN,5.94,4.158,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RIFABUTIN 150 MG ORAL CAPS,RX-11290,CDM,S5000,HCPCS,259,RC,59762-1350-01,NDC,outpatient,1,UN,47.58,33.306,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RIFAMPIN 600 MG IV SOLR,RX-11291,CDM,S5000,HCPCS,250,RC,67457-0445-60,NDC,outpatient,1,UN,242,169.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RIFAMPIN 600 MG IV SOLR,RX-11291,CDM,S5000,HCPCS,250,RC,00068-0597-01,NDC,outpatient,1,UN,360.5,252.35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RIFAMPIN 600 MG IV SOLR,RX-11291,CDM,S5000,HCPCS,250,RC,63323-0351-20,NDC,outpatient,1,UN,246.71,172.697,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RIFAMPIN 150 MG ORAL CAPS,RX-11292,CDM,S5000,HCPCS,259,RC,60687-0575-11,NDC,outpatient,1,UN,10.17,7.119,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RIFAMPIN 150 MG ORAL CAPS,RX-11292,CDM,S5000,HCPCS,259,RC,60687-0575-21,NDC,outpatient,1,UN,10.17,7.119,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RIFAMPIN 300 MG ORAL CAPS,RX-11293,CDM,S5000,HCPCS,259,RC,60687-0586-01,NDC,outpatient,1,UN,6.25,4.375,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RIFAMPIN 300 MG ORAL CAPS,RX-11293,CDM,S5000,HCPCS,259,RC,60687-0586-11,NDC,outpatient,1,UN,6.25,4.375,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACETAZOLAMIDE 250 MG ORAL TABS,RX-113,CDM,S5000,HCPCS,259,RC,60687-0619-01,NDC,outpatient,1,UN,9.15,6.405,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACETAZOLAMIDE 250 MG ORAL TABS,RX-113,CDM,S5000,HCPCS,259,RC,60687-0619-11,NDC,outpatient,1,UN,9.15,6.405,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RACEPINEPHRINE HCL 2.25 % IN NEBU,RX-113082,CDM,S5000,HCPCS,259,RC,00487-5901-99,NDC,outpatient,1,UN,5.79,4.053,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FIRST-OMEPRAZOLE 2 MG/ML ORAL SUSP,RX-113272,CDM,S5000,HCPCS,259,RC,99999-9003-64,NDC,outpatient,5,ML,27.75,19.425,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FIRST-OMEPRAZOLE 2 MG/ML ORAL SUSP,RX-113272,CDM,S5000,HCPCS,259,RC,65628-0070-03,NDC,outpatient,5,ML,27.75,19.425,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,00904-6925-61,NDC,outpatient,1,UN,1.38,0.966,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,60687-0242-11,NDC,outpatient,1,UN,1.35,0.945,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,16714-0612-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,68180-0352-09,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,76282-0213-18,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,16714-0612-04,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SERTRALINE HCL 50 MG ORAL TABS,RX-11351,CDM,S5000,HCPCS,259,RC,60687-0242-01,NDC,outpatient,1,UN,1.35,0.945,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LURASIDONE HCL 20 MG ORAL TABS,RX-113587,CDM,S5000,HCPCS,259,RC,16729-0346-10,NDC,outpatient,1,UN,5,3.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LURASIDONE HCL 20 MG ORAL TABS,RX-113587,CDM,S5000,HCPCS,259,RC,63402-0302-30,NDC,outpatient,1,UN,165.29,115.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LURASIDONE HCL 20 MG ORAL TABS,RX-113587,CDM,S5000,HCPCS,259,RC,67877-0638-30,NDC,outpatient,1,UN,1.86,1.302,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SILVER NITRATE-POT NITRATE 75-25 % EX MISC,RX-11359,CDM,S5000,HCPCS,259,RC,12870-0001-01,NDC,outpatient,10,UN,28.31,19.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SOD CITRATE-CITRIC ACID 500-334 MG/5ML ORAL SOLN,RX-11394,CDM,S5000,HCPCS,259,RC,00121-1190-00,NDC,outpatient,30,ML,19.63,13.741,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SOD CITRATE-CITRIC ACID 500-334 MG/5ML ORAL SOLN,RX-11394,CDM,S5000,HCPCS,259,RC,00121-1190-30,NDC,outpatient,30,ML,19.63,13.741,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE 0.9 % IR SOLN,RX-11403,CDM,S5000,HCPCS,250,RC,00338-0048-04,NDC,outpatient,1000,ML,15.82,11.074,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE 0.9 % IR SOLN,RX-11403,CDM,S5000,HCPCS,250,RC,00338-0048-03,NDC,outpatient,500,ML,11.87,8.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE (HYPERTONIC) 2 % OP SOLN,RX-11404,CDM,S5000,HCPCS,259,RC,24208-0276-15,NDC,outpatient,15,ML,65.35,45.745,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SOTALOL HCL 80 MG ORAL TABS,RX-11421,CDM,S5000,HCPCS,259,RC,68084-0654-11,NDC,outpatient,1,UN,4.36,3.052,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SOTALOL HCL 80 MG ORAL TABS,RX-11421,CDM,S5000,HCPCS,259,RC,68084-0654-01,NDC,outpatient,1,UN,4.36,3.052,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,00093-2210-01,NDC,outpatient,1,UN,1.34,0.938,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,51079-0753-20,NDC,outpatient,1,UN,1.48,1.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,59762-0401-05,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,29033-0003-05,NDC,outpatient,1,UN,1.06,0.742,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,62135-0436-90,NDC,outpatient,1,UN,16.45,11.515,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SUCRALFATE 1 G ORAL TABS,RX-11442,CDM,S5000,HCPCS,259,RC,51079-0753-01,NDC,outpatient,1,UN,1.48,1.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TERBUTALINE SULFATE 2.5 MG ORAL TABS,RX-11508,CDM,S5000,HCPCS,259,RC,62559-0721-01,NDC,outpatient,1,UN,4.45,3.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TERBUTALINE SULFATE 2.5 MG ORAL TABS,RX-11508,CDM,S5000,HCPCS,259,RC,00527-1318-01,NDC,outpatient,1,UN,19.38,13.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TETRACAINE HCL 1 % IJ SOLN,RX-11517,CDM,S5000,HCPCS,250,RC,54288-0127-10,NDC,outpatient,2,ML,164.48,115.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TETRACAINE HCL 1 % IJ SOLN,RX-11517,CDM,S5000,HCPCS,250,RC,54288-0127-01,NDC,outpatient,2,ML,164.48,115.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
THROMBIN 20000 UNITS EX KIT,RX-11544,CDM,S5000,HCPCS,250,RC,60793-0217-21,NDC,outpatient,1,UN,883.55,618.485,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
THROMBIN 20000 UNITS EX KIT,RX-11544,CDM,S5000,HCPCS,250,RC,60793-0217-22,NDC,outpatient,1,UN,883.55,618.485,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
THROMBIN 5000 UNITS EX SOLR,RX-11548,CDM,S5000,HCPCS,250,RC,60793-0215-05,NDC,outpatient,1,UN,195.76,137.032,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TIMOLOL MALEATE 0.25 % OP SOLN,RX-11561,CDM,S5000,HCPCS,259,RC,64980-0513-05,NDC,outpatient,5,ML,10.28,7.196,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TIMOLOL MALEATE 0.25 % OP SOLN,RX-11561,CDM,S5000,HCPCS,259,RC,60758-0802-05,NDC,outpatient,5,ML,11.17,7.819,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TIMOLOL MALEATE 0.5 % OP SOLN,RX-11562,CDM,S5000,HCPCS,259,RC,64980-0514-05,NDC,outpatient,5,ML,21.94,15.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TIMOLOL MALEATE 0.5 % OP SOLN,RX-11562,CDM,S5000,HCPCS,259,RC,60758-0801-05,NDC,outpatient,5,ML,22.48,15.736,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OP OINT,RX-11566,CDM,S5000,HCPCS,259,RC,00078-0876-01,NDC,outpatient,3.5,GR,1115.32,780.724,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OP SUSP,RX-11567,CDM,S5000,HCPCS,259,RC,24208-0295-25,NDC,outpatient,2.5,ML,173.64,121.548,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRIAMTERENE 50 MG ORAL CAPS,RX-11588,CDM,S5000,HCPCS,259,RC,59212-0002-01,NDC,outpatient,1,UN,60.49,42.343,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRIAMTERENE 50 MG ORAL CAPS,RX-11588,CDM,S5000,HCPCS,259,RC,66993-0831-02,NDC,outpatient,1,UN,36.58,25.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRIFLURIDINE 1 % OP SOLN,RX-11595,CDM,S5000,HCPCS,259,RC,61314-0044-75,NDC,outpatient,7.5,ML,948.02,663.614,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POLYMYXIN B-TRIMETHOPRIM 10000-0.1 UNIT/ML-% OP SOLN,RX-11596,CDM,S5000,HCPCS,259,RC,61314-0628-10,NDC,outpatient,10,ML,43.88,30.716,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POLYMYXIN B-TRIMETHOPRIM 10000-0.1 UNIT/ML-% OP SOLN,RX-11596,CDM,S5000,HCPCS,259,RC,24208-0315-10,NDC,outpatient,10,ML,47.84,33.488,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG ORAL TABS,RX-11599,CDM,S5000,HCPCS,259,RC,00904-2725-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
URSODIOL 300 MG ORAL CAPS,RX-11624,CDM,S5000,HCPCS,259,RC,60687-0100-01,NDC,outpatient,1,UN,15.37,10.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
URSODIOL 300 MG ORAL CAPS,RX-11624,CDM,S5000,HCPCS,259,RC,60687-0100-11,NDC,outpatient,1,UN,15.37,10.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VECURONIUM BROMIDE 10 MG IV SOLR,RX-11634,CDM,S5000,HCPCS,250,RC,55150-0235-01,NDC,outpatient,1,UN,11.52,8.064,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VECURONIUM BROMIDE 10 MG IV SOLR,RX-11634,CDM,S5000,HCPCS,250,RC,55150-0235-10,NDC,outpatient,1,UN,11.52,8.064,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VECURONIUM BROMIDE 20 MG IV SOLR,RX-11635,CDM,S5000,HCPCS,250,RC,00143-9232-10,NDC,outpatient,1,UN,41.49,29.043,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VECURONIUM BROMIDE 20 MG IV SOLR,RX-11635,CDM,S5000,HCPCS,250,RC,00143-9232-01,NDC,outpatient,1,UN,41.49,29.043,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
WARFARIN SODIUM 1 MG ORAL TABS,RX-11664,CDM,S5000,HCPCS,259,RC,00832-1211-89,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
WARFARIN SODIUM 1 MG ORAL TABS,RX-11664,CDM,S5000,HCPCS,259,RC,00832-1211-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IPRATROPIUM-ALBUTEROL 20-100 MCG/ACT IN AERS,RX-116728,CDM,S5000,HCPCS,259,RC,00597-0024-02,NDC,outpatient,4,GR,2012.08,1408.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ZIDOVUDINE 100 MG ORAL CAPS,RX-11692,CDM,S5000,HCPCS,259,RC,65862-0107-01,NDC,outpatient,1,UN,6.23,4.361,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ZIDOVUDINE 10 MG/ML ORAL SYRP,RX-11693,CDM,S5000,HCPCS,259,RC,,,outpatient,5,ML,3.1,2.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ZOLPIDEM TARTRATE 5 MG ORAL TABS,RX-11701,CDM,S5000,HCPCS,259,RC,00904-6082-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LINACLOTIDE 145 MCG ORAL CAPS,RX-117352,CDM,S5000,HCPCS,259,RC,00456-1201-30,NDC,outpatient,1,UN,74.11,51.877,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RIVASTIGMINE 13.3 MG/24HR TD PT24,RX-117356,CDM,S5000,HCPCS,259,RC,70710-1198-01,NDC,outpatient,1,UN,8.83,6.181,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RIVASTIGMINE 13.3 MG/24HR TD PT24,RX-117356,CDM,S5000,HCPCS,259,RC,00378-9072-16,NDC,outpatient,1,UN,6.86,4.802,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RIVASTIGMINE 13.3 MG/24HR TD PT24,RX-117356,CDM,S5000,HCPCS,259,RC,00378-9072-93,NDC,outpatient,1,UN,6.86,4.802,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RIVASTIGMINE 13.3 MG/24HR TD PT24,RX-117356,CDM,S5000,HCPCS,259,RC,70710-1198-07,NDC,outpatient,1,UN,8.83,6.181,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MORPHINE SULFATE ER 30 MG ORAL TBCR,RX-119007,CDM,S5000,HCPCS,259,RC,00406-8330-01,NDC,outpatient,1,UN,1.46,1.022,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MORPHINE SULFATE ER 30 MG ORAL TBCR,RX-119007,CDM,S5000,HCPCS,259,RC,00406-8330-62,NDC,outpatient,1,UN,4.35,3.045,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MORPHINE SULFATE ER 30 MG ORAL TBCR,RX-119007,CDM,S5000,HCPCS,259,RC,00406-8330-23,NDC,outpatient,1,UN,4.35,3.045,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MORPHINE SULFATE ER 30 MG ORAL TBCR,RX-119007,CDM,S5000,HCPCS,259,RC,00904-6558-61,NDC,outpatient,1,UN,5.15,3.605,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
APIXABAN 2.5 MG ORAL TABS,RX-119040,CDM,S5000,HCPCS,259,RC,00003-0893-21,NDC,outpatient,1,UN,6.17,4.319,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
APIXABAN 2.5 MG ORAL TABS,RX-119040,CDM,S5000,HCPCS,259,RC,00003-0893-31,NDC,outpatient,1,UN,6.17,4.319,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,00703-2056-03,NDC,outpatient,10,ML,102.35,71.645,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,70069-0161-01,NDC,outpatient,10,ML,30.13,21.091,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,70069-0161-10,NDC,outpatient,10,ML,30.13,21.091,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,71288-0714-11,NDC,outpatient,10,ML,30.26,21.182,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,71288-0714-10,NDC,outpatient,10,ML,30.26,21.182,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN,RX-119150,CDM,S5000,HCPCS,250,RC,00703-2056-01,NDC,outpatient,10,ML,102.35,71.645,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MORPHINE SULFATE ER 15 MG ORAL TBCR,RX-119246,CDM,S5000,HCPCS,259,RC,00228-4270-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MORPHINE SULFATE ER 15 MG ORAL TBCR,RX-119246,CDM,S5000,HCPCS,259,RC,00406-8315-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MORPHINE SULFATE ER 15 MG ORAL TBCR,RX-119246,CDM,S5000,HCPCS,259,RC,00406-8315-23,NDC,outpatient,1,UN,2.2,1.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MORPHINE SULFATE ER 15 MG ORAL TBCR,RX-119246,CDM,S5000,HCPCS,259,RC,63304-0450-01,NDC,outpatient,1,UN,1.05,0.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MORPHINE SULFATE ER 15 MG ORAL TBCR,RX-119246,CDM,S5000,HCPCS,259,RC,00406-8315-62,NDC,outpatient,1,UN,2.2,1.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MORPHINE SULFATE ER 100 MG ORAL TBCR,RX-119248,CDM,S5000,HCPCS,259,RC,00406-8390-23,NDC,outpatient,1,UN,12.34,8.638,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MORPHINE SULFATE ER 100 MG ORAL TBCR,RX-119248,CDM,S5000,HCPCS,259,RC,00406-8390-62,NDC,outpatient,1,UN,12.34,8.638,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
INFUVITE ADULT IV INJ,RX-119571,CDM,S5000,HCPCS,250,RC,54643-5649-01,NDC,outpatient,10,ML,39.65,27.755,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
INFUVITE ADULT IV INJ,RX-119571,CDM,S5000,HCPCS,250,RC,54643-5650-02,NDC,outpatient,10,ML,3.96,2.772,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
INFUVITE ADULT IV INJ,RX-119571,CDM,S5000,HCPCS,250,RC,54643-5650-09,NDC,outpatient,10,ML,3.96,2.772,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
INFUVITE ADULT IV INJ,RX-119571,CDM,S5000,HCPCS,250,RC,54643-5650-28,NDC,outpatient,10,ML,3.96,2.772,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
APIXABAN 5 MG ORAL TABS,RX-119614,CDM,S5000,HCPCS,259,RC,00003-0894-31,NDC,outpatient,1,UN,6.17,4.319,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MESALAMINE 400 MG ORAL CPDR,RX-119913,CDM,S5000,HCPCS,259,RC,60687-0556-32,NDC,outpatient,1,UN,23.14,16.198,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MESALAMINE 400 MG ORAL CPDR,RX-119913,CDM,S5000,HCPCS,259,RC,00023-5853-18,NDC,outpatient,1,UN,15.96,11.172,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MESALAMINE 400 MG ORAL CPDR,RX-119913,CDM,S5000,HCPCS,259,RC,59762-0117-01,NDC,outpatient,1,UN,10.4,7.28,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MESALAMINE 400 MG ORAL CPDR,RX-119913,CDM,S5000,HCPCS,259,RC,60687-0556-33,NDC,outpatient,1,UN,23.14,16.198,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MECLIZINE HCL 12.5 MG ORAL TABS,RX-12024,CDM,S5000,HCPCS,259,RC,60687-0775-11,NDC,outpatient,1,UN,1.73,1.211,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MECLIZINE HCL 12.5 MG ORAL TABS,RX-12024,CDM,S5000,HCPCS,259,RC,60687-0775-01,NDC,outpatient,1,UN,1.73,1.211,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
THEOPHYLLINE ER 300 MG ORAL TB12,RX-12098,CDM,S5000,HCPCS,259,RC,68462-0721-01,NDC,outpatient,1,UN,5.92,4.144,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
THEOPHYLLINE ER 300 MG ORAL TB12,RX-12098,CDM,S5000,HCPCS,259,RC,62332-0025-31,NDC,outpatient,1,UN,11.73,8.211,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MEMANTINE HCL ER 14 MG ORAL CP24,RX-121474,CDM,S5000,HCPCS,259,RC,00456-3414-33,NDC,outpatient,1,UN,7.56,5.292,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MEMANTINE HCL ER 21 MG ORAL CP24,RX-121475,CDM,S5000,HCPCS,259,RC,00456-3421-33,NDC,outpatient,1,UN,7.56,5.292,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MEMANTINE HCL ER 28 MG ORAL CP24,RX-121476,CDM,S5000,HCPCS,259,RC,00456-3428-33,NDC,outpatient,1,UN,63.71,44.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOXYLAMINE-PYRIDOXINE 10-10 MG ORAL TBEC,RX-121504,CDM,S5000,HCPCS,259,RC,55494-0100-10,NDC,outpatient,1,UN,13.41,9.387,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOXYLAMINE-PYRIDOXINE 10-10 MG ORAL TBEC,RX-121504,CDM,S5000,HCPCS,259,RC,70505-0100-10,NDC,outpatient,1,UN,13.18,9.226,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
QUINIDINE GLUCONATE ER 324 MG ORAL TBCR,RX-12197,CDM,S5000,HCPCS,259,RC,53489-0141-01,NDC,outpatient,1,UN,24.15,16.905,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VENLAFAXINE HCL 25 MG ORAL TABS,RX-12203,CDM,S5000,HCPCS,259,RC,68084-0896-25,NDC,outpatient,1,UN,3.98,2.786,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VENLAFAXINE HCL 25 MG ORAL TABS,RX-12203,CDM,S5000,HCPCS,259,RC,68084-0896-95,NDC,outpatient,1,UN,3.98,2.786,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VENLAFAXINE HCL 75 MG ORAL TABS,RX-12206,CDM,S5000,HCPCS,259,RC,57664-0395-88,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VENLAFAXINE HCL 75 MG ORAL TABS,RX-12206,CDM,S5000,HCPCS,259,RC,68084-0856-01,NDC,outpatient,1,UN,3.02,2.114,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VENLAFAXINE HCL 75 MG ORAL TABS,RX-12206,CDM,S5000,HCPCS,259,RC,68084-0856-11,NDC,outpatient,1,UN,3.02,2.114,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VENLAFAXINE HCL 37.5 MG ORAL TABS,RX-12207,CDM,S5000,HCPCS,259,RC,68084-0844-11,NDC,outpatient,1,UN,2.34,1.638,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VENLAFAXINE HCL 37.5 MG ORAL TABS,RX-12207,CDM,S5000,HCPCS,259,RC,68084-0844-01,NDC,outpatient,1,UN,2.34,1.638,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DORNASE ALFA 2.5 MG/2.5ML IN SOLN,RX-12211,CDM,S5000,HCPCS,259,RC,50242-0100-40,NDC,outpatient,2.5,ML,560.63,392.441,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DORNASE ALFA 2.5 MG/2.5ML IN SOLN,RX-12211,CDM,S5000,HCPCS,259,RC,50242-0100-39,NDC,outpatient,2.5,ML,560.63,392.441,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IRON-VITAMIN C 65-125 MG ORAL TABS,RX-122332,CDM,S5000,HCPCS,259,RC,63736-0123-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXYCODONE HCL ER 10 MG ORAL T12A,RX-122363,CDM,S5000,HCPCS,259,RC,59011-0410-20,NDC,outpatient,1,UN,22.52,15.764,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXYCODONE HCL ER 20 MG ORAL T12A,RX-122366,CDM,S5000,HCPCS,259,RC,59011-0420-20,NDC,outpatient,1,UN,41.94,29.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXYCODONE HCL ER 20 MG ORAL T12A,RX-122366,CDM,S5000,HCPCS,259,RC,59011-0420-10,NDC,outpatient,1,UN,40.9,28.63,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXYCODONE HCL ER 40 MG ORAL T12A,RX-122368,CDM,S5000,HCPCS,259,RC,59011-0440-20,NDC,outpatient,1,UN,71.8,50.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOLUTEGRAVIR SODIUM 50 MG ORAL TABS,RX-122784,CDM,S5000,HCPCS,259,RC,49702-0228-13,NDC,outpatient,1,UN,324.81,227.367,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LURASIDONE HCL 60 MG ORAL TABS,RX-122968,CDM,S5000,HCPCS,259,RC,65162-0082-03,NDC,outpatient,1,UN,1.48,1.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LURASIDONE HCL 60 MG ORAL TABS,RX-122968,CDM,S5000,HCPCS,259,RC,16729-0348-10,NDC,outpatient,1,UN,5,3.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,99999-0002-60,NDC,outpatient,3,ML,9.75,6.825,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,00517-7604-01,NDC,outpatient,4,ML,26.92,18.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,63323-0690-30,NDC,outpatient,30,ML,25.77,18.039,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,00409-3308-03,NDC,outpatient,30,ML,57.68,40.376,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,63323-0694-04,NDC,outpatient,4,ML,17.02,11.914,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,99999-0002-61,NDC,outpatient,3,ML,9.75,6.825,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,00409-3308-11,NDC,outpatient,30,ML,57.68,40.376,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,00517-7604-25,NDC,outpatient,4,ML,26.92,18.844,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,63323-0690-22,NDC,outpatient,30,ML,25.77,18.039,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACETYLCYSTEINE 20 % IN SOLN,RX-123,CDM,S5000,HCPCS,259,RC,63323-0694-22,NDC,outpatient,4,ML,17.02,11.914,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,70860-0605-03,NDC,outpatient,2,ML,9.94,6.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,71288-0505-03,NDC,outpatient,2,ML,11.79,8.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,70860-0605-41,NDC,outpatient,2,ML,9.94,6.958,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,66794-0230-02,NDC,outpatient,2,ML,21.6,15.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,66794-0230-42,NDC,outpatient,2,ML,21.6,15.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN,RX-123049,CDM,S5000,HCPCS,250,RC,71288-0505-02,NDC,outpatient,2,ML,11.79,8.253,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CETIRIZINE HCL 5 MG/5ML ORAL SOLN,RX-124298,CDM,S5000,HCPCS,259,RC,99999-0004-13,NDC,outpatient,5,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CETIRIZINE HCL 5 MG/5ML ORAL SOLN,RX-124298,CDM,S5000,HCPCS,259,RC,51672-4070-08,NDC,outpatient,2.5,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TOBRAMYCIN 0.3 % OP SOLN,RX-124312,CDM,S5000,HCPCS,259,RC,70069-0131-01,NDC,outpatient,5,ML,22.25,15.575,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TOBRAMYCIN 0.3 % OP SOLN,RX-124312,CDM,S5000,HCPCS,259,RC,61314-0643-05,NDC,outpatient,5,ML,42.15,29.505,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
EXENATIDE 5 MCG/0.02ML SC SOPN,RX-124738,CDM,S5000,HCPCS,259,RC,00310-6512-01,NDC,outpatient,1.2,ML,2102.55,1471.785,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
EXENATIDE 10 MCG/0.04ML SC SOPN,RX-124739,CDM,S5000,HCPCS,259,RC,00310-6524-01,NDC,outpatient,2.4,ML,2102.55,1471.785,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIRAGLUTIDE 18 MG/3ML SC SOPN,RX-124740,CDM,S5000,HCPCS,250,RC,00169-4060-12,NDC,outpatient,3,ML,1117.4,782.18,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIRAGLUTIDE 18 MG/3ML SC SOPN,RX-124740,CDM,S5000,HCPCS,250,RC,00169-4060-13,NDC,outpatient,3,ML,1117.41,782.187,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ESTRADIOL 0.5 MG ORAL TABS,RX-12491,CDM,S5000,HCPCS,259,RC,00555-0899-02,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ESTRADIOL 0.5 MG ORAL TABS,RX-12491,CDM,S5000,HCPCS,259,RC,42806-0087-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TOBRAMYCIN 0.3 % OP OINT,RX-125351,CDM,S5000,HCPCS,259,RC,00078-0813-01,NDC,outpatient,3.5,GR,1047.63,733.341,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DIPHENHYDRAMINE HCL 12.5 MG/5ML ORAL LIQD,RX-12556,CDM,S5000,HCPCS,259,RC,00904-6985-20,NDC,outpatient,2.5,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,00487-9801-01,NDC,outpatient,2.5,ML,1.51,1.057,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,00487-9801-60,NDC,outpatient,2.5,ML,1.12,0.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,00378-7970-93,NDC,outpatient,2.5,ML,1.02,0.714,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,60687-0394-83,NDC,outpatient,2.5,ML,1.05,0.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,76204-0100-01,NDC,outpatient,2.5,ML,1.24,0.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IPRATROPIUM BROMIDE 0.02 % IN SOLN,RX-12580,CDM,S5000,HCPCS,259,RC,60687-0394-79,NDC,outpatient,2.5,ML,1.05,0.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PHENYLEPHRINE-COCOA BUTTER 0.25-88.44 % RE SUPP,RX-125849,CDM,S5000,HCPCS,259,RC,00536-1186-12,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CAFFEINE 200 MG ORAL TABS,RX-1259,CDM,S5000,HCPCS,259,RC,46017-0018-40,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DANTROLENE SODIUM 250 MG IV SUSR,RX-126042,CDM,S5000,HCPCS,250,RC,42367-0540-32,NDC,outpatient,1,UN,5868.29,4107.803,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
EMPAGLIFLOZIN 10 MG ORAL TABS,RX-126076,CDM,S5000,HCPCS,259,RC,00597-0152-30,NDC,outpatient,1,UN,55.29,38.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
EMPAGLIFLOZIN 10 MG ORAL TABS,RX-126076,CDM,S5000,HCPCS,259,RC,00597-0152-37,NDC,outpatient,1,UN,55.29,38.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
EMPAGLIFLOZIN 25 MG ORAL TABS,RX-126078,CDM,S5000,HCPCS,259,RC,00597-0153-37,NDC,outpatient,1,UN,55.29,38.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML IJ SOLN,RX-1262,CDM,S5000,HCPCS,250,RC,00517-2502-01,NDC,outpatient,2,ML,107.33,75.131,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CAFFEINE-SODIUM BENZOATE 125-125 MG/ML IJ SOLN,RX-1262,CDM,S5000,HCPCS,250,RC,00517-2502-10,NDC,outpatient,2,ML,107.33,75.131,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TERBINAFINE HCL 250 MG ORAL TABS,RX-12724,CDM,S5000,HCPCS,259,RC,65862-0079-30,NDC,outpatient,1,UN,1.29,0.903,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRIAMTERENE-HCTZ 37.5-25 MG ORAL CAPS,RX-12729,CDM,S5000,HCPCS,259,RC,00781-2074-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FAMOTIDINE IN NACL 20-0.9 MG/50ML-% IV SOLN,RX-12735,CDM,S5000,HCPCS,250,RC,00338-5197-41,NDC,outpatient,50,ML,24.23,16.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML ORAL ELIX,RX-127530,CDM,S5000,HCPCS,259,RC,75826-0127-04,NDC,outpatient,5,ML,13.49,9.443,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML ORAL ELIX,RX-127530,CDM,S5000,HCPCS,259,RC,75826-0128-05,NDC,outpatient,5,ML,45.71,31.997,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML ORAL ELIX,RX-127530,CDM,S5000,HCPCS,259,RC,99999-0002-29,NDC,outpatient,5,ML,70.67,49.469,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML ORAL ELIX,RX-127530,CDM,S5000,HCPCS,259,RC,75826-0128-04,NDC,outpatient,5,ML,45.71,31.997,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PB-HYOSCY-ATROPINE-SCOPOLAMINE 16.2 MG/5ML ORAL ELIX,RX-127530,CDM,S5000,HCPCS,259,RC,75826-0127-05,NDC,outpatient,5,ML,13.49,9.443,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPRENORPHINE 7.5 MCG/HR TD PTWK,RX-127562,CDM,S5000,HCPCS,259,RC,42858-0353-40,NDC,outpatient,1,UN,309.07,216.349,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PILOCARPINE HCL 5 MG ORAL TABS,RX-12803,CDM,S5000,HCPCS,259,RC,68084-0928-25,NDC,outpatient,1,UN,10.51,7.357,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PILOCARPINE HCL 5 MG ORAL TABS,RX-12803,CDM,S5000,HCPCS,259,RC,00527-1313-01,NDC,outpatient,1,UN,4.2,2.94,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PILOCARPINE HCL 5 MG ORAL TABS,RX-12803,CDM,S5000,HCPCS,259,RC,68084-0928-95,NDC,outpatient,1,UN,10.51,7.357,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TIOTROPIUM BROMIDE MONOHYDRATE 2.5 MCG/ACT IN AERS,RX-128423,CDM,S5000,HCPCS,259,RC,00597-0100-51,NDC,outpatient,4,GR,308.39,215.873,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PENTOSAN POLYSULFATE SODIUM 100 MG ORAL CAPS,RX-12912,CDM,S5000,HCPCS,259,RC,50458-0098-01,NDC,outpatient,1,UN,46.46,32.522,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TACROLIMUS 1 MG ORAL CAPS,RX-12933,CDM,S5000,HCPCS,259,RC,00904-7097-61,NDC,outpatient,1,UN,4.43,3.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TACROLIMUS 1 MG ORAL CAPS,RX-12933,CDM,S5000,HCPCS,259,RC,51079-0818-20,NDC,outpatient,1,UN,4.95,3.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TACROLIMUS 1 MG ORAL CAPS,RX-12933,CDM,S5000,HCPCS,259,RC,51079-0818-01,NDC,outpatient,1,UN,4.95,3.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOMEBORO EX PACK,RX-129475,CDM,S5000,HCPCS,259,RC,57074-0001-77,NDC,outpatient,1,UN,2.6,1.82,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DARUNAVIR-COBICISTAT 800-150 MG ORAL TABS,RX-129730,CDM,S5000,HCPCS,259,RC,59676-0575-30,NDC,outpatient,1,UN,354.92,248.444,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PYRIDOSTIGMINE BROMIDE 10 MG/2ML IV SOLN,RX-129741,CDM,S5000,HCPCS,250,RC,00781-3040-72,NDC,outpatient,2,ML,130.52,91.364,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PYRIDOSTIGMINE BROMIDE 10 MG/2ML IV SOLN,RX-129741,CDM,S5000,HCPCS,250,RC,00781-3040-95,NDC,outpatient,2,ML,130.52,91.364,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SCOPOLAMINE 1 MG/3DAYS TD PT72,RX-129902,CDM,S5000,HCPCS,259,RC,10019-0553-90,NDC,outpatient,1,UN,23.54,16.478,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SCOPOLAMINE 1 MG/3DAYS TD PT72,RX-129902,CDM,S5000,HCPCS,259,RC,50742-0505-01,NDC,outpatient,1,UN,42.28,29.596,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SCOPOLAMINE 1 MG/3DAYS TD PT72,RX-129902,CDM,S5000,HCPCS,259,RC,50742-0505-24,NDC,outpatient,1,UN,23.2,16.24,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SCOPOLAMINE 1 MG/3DAYS TD PT72,RX-129902,CDM,S5000,HCPCS,259,RC,10019-0553-04,NDC,outpatient,1,UN,23.54,16.478,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,00143-9318-10,NDC,outpatient,4,ML,15.67,10.969,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,67457-0852-04,NDC,outpatient,4,ML,24.37,17.059,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,00143-9318-01,NDC,outpatient,4,ML,15.67,10.969,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,00409-3375-14,NDC,outpatient,4,ML,23.45,16.415,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,67457-0852-00,NDC,outpatient,4,ML,24.37,17.059,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,70121-1576-01,NDC,outpatient,4,ML,19.72,13.804,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,00409-3375-04,NDC,outpatient,4,ML,23.45,16.415,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,25021-0316-04,NDC,outpatient,4,ML,19.53,13.671,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,RX-130074,CDM,S5000,HCPCS,250,RC,70121-1576-07,NDC,outpatient,4,ML,19.72,13.804,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CALCIUM CARBONATE 600 MG ORAL TABS,RX-1302,CDM,S5000,HCPCS,259,RC,20555-0005-00,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CALCIUM CARBONATE 600 MG ORAL TABS,RX-1302,CDM,S5000,HCPCS,259,RC,00904-3232-92,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE 4 % EX PTCH,RX-130376,CDM,S5000,HCPCS,259,RC,00536-1202-07,NDC,outpatient,1,UN,3.11,2.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE 4 % EX PTCH,RX-130376,CDM,S5000,HCPCS,259,RC,70512-0812-30,NDC,outpatient,1,UN,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE 4 % EX PTCH,RX-130376,CDM,S5000,HCPCS,259,RC,41167-0058-40,NDC,outpatient,1,UN,6.13,4.291,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DESVENLAFAXINE SUCCINATE ER 25 MG ORAL TB24,RX-130484,CDM,S5000,HCPCS,259,RC,59762-1210-03,NDC,outpatient,1,UN,2.76,1.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DESVENLAFAXINE SUCCINATE ER 25 MG ORAL TB24,RX-130484,CDM,S5000,HCPCS,259,RC,68180-0604-06,NDC,outpatient,1,UN,2.56,1.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CALCIUM CHLORIDE 10 % IV SOLN,RX-1306,CDM,S5000,HCPCS,250,RC,00409-1631-10,NDC,outpatient,10,ML,41.92,29.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CALCIUM CHLORIDE 10 % IV SOLN,RX-1306,CDM,S5000,HCPCS,250,RC,00409-4928-11,NDC,outpatient,10,ML,55.67,38.969,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CALCIUM CHLORIDE 10 % IV SOLN,RX-1306,CDM,S5000,HCPCS,250,RC,76329-3304-01,NDC,outpatient,10,ML,39.08,27.356,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CALCIUM CHLORIDE 10 % IV SOLN,RX-1306,CDM,S5000,HCPCS,250,RC,00409-4928-34,NDC,outpatient,10,ML,55.67,38.969,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CALCIUM CHLORIDE 10 % IV SOLN,RX-1306,CDM,S5000,HCPCS,250,RC,00409-1631-40,NDC,outpatient,10,ML,41.92,29.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VERAPAMIL HCL ER 240 MG ORAL TBCR,RX-13073,CDM,S5000,HCPCS,259,RC,60687-0515-01,NDC,outpatient,1,UN,5.2,3.64,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VERAPAMIL HCL ER 240 MG ORAL TBCR,RX-13073,CDM,S5000,HCPCS,259,RC,60687-0515-11,NDC,outpatient,1,UN,5.2,3.64,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VERAPAMIL HCL ER 240 MG ORAL TBCR,RX-13073,CDM,S5000,HCPCS,259,RC,68462-0260-01,NDC,outpatient,1,UN,1.48,1.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TIOTROPIUM BROMIDE-OLODATEROL 2.5-2.5 MCG/ACT IN AERS,RX-131078,CDM,S5000,HCPCS,259,RC,00597-0155-70,NDC,outpatient,4,GR,308.39,215.873,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VITAMIN D3 10 MCG (400 UNIT) ORAL TABS,RX-13108,CDM,S5000,HCPCS,259,RC,00904-5823-60,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VITAMIN D3 10 MCG (400 UNIT) ORAL TABS,RX-13108,CDM,S5000,HCPCS,259,RC,50268-0863-15,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VITAMIN D3 10 MCG (400 UNIT) ORAL TABS,RX-13108,CDM,S5000,HCPCS,259,RC,50268-0863-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ELVITEG-COBIC-EMTRICIT-TENOFAF 150-150-200-10 MG ORAL TABS,RX-131233,CDM,S5000,HCPCS,259,RC,61958-1901-01,NDC,outpatient,1,UN,572.84,400.988,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VALACYCLOVIR HCL 500 MG ORAL TABS,RX-13133,CDM,S5000,HCPCS,259,RC,00904-6565-61,NDC,outpatient,1,UN,4.32,3.024,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VALACYCLOVIR HCL 500 MG ORAL TABS,RX-13133,CDM,S5000,HCPCS,259,RC,63739-0077-10,NDC,outpatient,1,UN,4,2.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VALACYCLOVIR HCL 500 MG ORAL TABS,RX-13133,CDM,S5000,HCPCS,259,RC,68084-0215-11,NDC,outpatient,1,UN,4.3,3.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VALACYCLOVIR HCL 500 MG ORAL TABS,RX-13133,CDM,S5000,HCPCS,259,RC,68084-0215-01,NDC,outpatient,1,UN,4.3,3.01,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SACUBITRIL-VALSARTAN 24-26 MG ORAL TABS,RX-131630,CDM,S5000,HCPCS,259,RC,00078-0659-20,NDC,outpatient,1,UN,46.68,32.676,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SACUBITRIL-VALSARTAN 49-51 MG ORAL TABS,RX-131631,CDM,S5000,HCPCS,259,RC,00078-0777-20,NDC,outpatient,1,UN,46.68,32.676,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SACUBITRIL-VALSARTAN 97-103 MG ORAL TABS,RX-131632,CDM,S5000,HCPCS,259,RC,00078-0696-20,NDC,outpatient,1,UN,46.68,32.676,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMINOCAPROIC ACID 0.25 GM/ML ORAL SOLN,RX-131645,CDM,S5000,HCPCS,259,RC,99999-0001-90,NDC,outpatient,5,ML,202.39,141.673,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VERAPAMIL HCL ER 120 MG ORAL TBCR,RX-13184,CDM,S5000,HCPCS,259,RC,68462-0292-01,NDC,outpatient,1,UN,1.05,0.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPIVACAINE-EPINEPHRINE (PF) 0.75% -1:200000 IJ SOLN,RX-132205,CDM,S5000,HCPCS,250,RC,63323-0460-37,NDC,outpatient,30,ML,34.71,24.297,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TICAGRELOR 60 MG ORAL TABS,RX-132286,CDM,S5000,HCPCS,259,RC,00186-0776-60,NDC,outpatient,1,UN,30.77,21.539,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
KETAMINE HCL 10 MG/ML IN NS IV SYRINGE,RX-132334,CDM,S5000,HCPCS,250,RC,70092-9119-44,NDC,outpatient,5,ML,27.82,19.474,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
KETAMINE HCL 10 MG/ML IN NS IV SYRINGE,RX-132334,CDM,S5000,HCPCS,250,RC,70004-0430-09,NDC,outpatient,5,ML,28.93,20.251,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
KETAMINE HCL 10 MG/ML IN NS IV SYRINGE,RX-132334,CDM,S5000,HCPCS,250,RC,69374-0982-55,NDC,outpatient,5,ML,26.7,18.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
KETAMINE HCL 10 MG/ML IN NS IV SYRINGE,RX-132334,CDM,S5000,HCPCS,250,RC,70092-1119-44,NDC,outpatient,5,ML,20.39,14.273,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CALCIUM ACETATE (PHOS BINDER) 667 MG ORAL CAPS,RX-132734,CDM,S5000,HCPCS,259,RC,00904-7119-06,NDC,outpatient,1,UN,3.29,2.303,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CALCIUM ACETATE (PHOS BINDER) 667 MG ORAL CAPS,RX-132734,CDM,S5000,HCPCS,259,RC,68084-0479-01,NDC,outpatient,1,UN,5.45,3.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CALCIUM ACETATE (PHOS BINDER) 667 MG ORAL CAPS,RX-132734,CDM,S5000,HCPCS,259,RC,68084-0479-11,NDC,outpatient,1,UN,5.45,3.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPRENORPHINE HCL 75 MCG BU FILM,RX-132950,CDM,S5000,HCPCS,259,RC,59385-0021-01,NDC,outpatient,1,UN,29.34,20.538,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPRENORPHINE HCL 75 MCG BU FILM,RX-132950,CDM,S5000,HCPCS,259,RC,59385-0021-60,NDC,outpatient,1,UN,29.34,20.538,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPRENORPHINE HCL 300 MCG BU FILM,RX-132952,CDM,S5000,HCPCS,259,RC,59385-0023-60,NDC,outpatient,1,UN,46.07,32.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPRENORPHINE HCL 300 MCG BU FILM,RX-132952,CDM,S5000,HCPCS,259,RC,59385-0023-01,NDC,outpatient,1,UN,46.07,32.249,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPRENORPHINE HCL 750 MCG BU FILM,RX-132955,CDM,S5000,HCPCS,259,RC,59385-0026-01,NDC,outpatient,1,UN,70.24,49.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPRENORPHINE HCL 750 MCG BU FILM,RX-132955,CDM,S5000,HCPCS,259,RC,59385-0026-60,NDC,outpatient,1,UN,70.24,49.168,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPRENORPHINE HCL 900 MCG BU FILM,RX-132956,CDM,S5000,HCPCS,259,RC,59385-0027-01,NDC,outpatient,1,UN,72.31,50.617,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPRENORPHINE HCL 900 MCG BU FILM,RX-132956,CDM,S5000,HCPCS,259,RC,59385-0027-60,NDC,outpatient,1,UN,72.31,50.617,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NALOXONE HCL 4 MG/0.1ML NA LIQD,RX-132964,CDM,S5000,HCPCS,259,RC,00093-2165-19,NDC,outpatient,1,UN,146.88,102.816,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NALOXONE HCL 4 MG/0.1ML NA LIQD,RX-132964,CDM,S5000,HCPCS,259,RC,00093-2165-68,NDC,outpatient,1,UN,146.88,102.816,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PRENATAL VITAMIN PLUS LOW IRON 27-1 MG ORAL TABS,RX-133380,CDM,S5000,HCPCS,259,RC,39328-0106-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FAMCICLOVIR 500 MG ORAL TABS,RX-13358,CDM,S5000,HCPCS,259,RC,60505-3247-03,NDC,outpatient,1,UN,1.93,1.351,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRANEXAMIC ACID 1000 MG/10ML IV SOLN,RX-133831,CDM,S5000,HCPCS,250,RC,39822-1000-01,NDC,outpatient,10,ML,23.86,16.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRANEXAMIC ACID 1000 MG/10ML IV SOLN,RX-133831,CDM,S5000,HCPCS,250,RC,81284-0611-00,NDC,outpatient,10,ML,24.48,17.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRANEXAMIC ACID 1000 MG/10ML IV SOLN,RX-133831,CDM,S5000,HCPCS,250,RC,72485-0510-10,NDC,outpatient,10,ML,14.6,10.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRANEXAMIC ACID 1000 MG/10ML IV SOLN,RX-133831,CDM,S5000,HCPCS,250,RC,81284-0611-10,NDC,outpatient,10,ML,24.48,17.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRANEXAMIC ACID 1000 MG/10ML IV SOLN,RX-133831,CDM,S5000,HCPCS,250,RC,72485-0510-01,NDC,outpatient,10,ML,14.6,10.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
INSULIN REGULAR HUMAN (CONC) 500 UNIT/ML SC SOPN,RX-134373,CDM,S5000,HCPCS,259,RC,00002-8824-01,NDC,outpatient,3,ML,1168.7,818.09,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
INSULIN REGULAR HUMAN (CONC) 500 UNIT/ML SC SOPN,RX-134373,CDM,S5000,HCPCS,259,RC,00002-8824-27,NDC,outpatient,3,ML,1168.7,818.09,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
EMTRICITABINE-TENOFOVIR AF 200-25 MG ORAL TABS,RX-134420,CDM,S5000,HCPCS,259,RC,61958-2002-01,NDC,outpatient,1,UN,316.88,221.816,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DILTIAZEM HCL-DEXTROSE 125-5 MG/125ML-% IV SOLN,RX-134429,CDM,S5000,HCPCS,250,RC,70092-1007-36,NDC,outpatient,125,ML,77.9,54.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DILTIAZEM HCL-DEXTROSE 125-5 MG/125ML-% IV SOLN,RX-134429,CDM,S5000,HCPCS,250,RC,70092-1575-36,NDC,outpatient,125,ML,81.02,56.714,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DILTIAZEM HCL-DEXTROSE 125-5 MG/125ML-% IV SOLN,RX-134429,CDM,S5000,HCPCS,250,RC,70004-0540-35,NDC,outpatient,125,ML,123.38,86.366,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PSYLLIUM 400 MG ORAL CAPS,RX-134482,CDM,S5000,HCPCS,259,RC,37000-0405-14,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CARBAMAZEPINE 100 MG ORAL CHEW,RX-1355,CDM,S5000,HCPCS,259,RC,00904-3854-61,NDC,outpatient,1,UN,1.65,1.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CARBAMAZEPINE 100 MG ORAL CHEW,RX-1355,CDM,S5000,HCPCS,259,RC,60687-0479-01,NDC,outpatient,1,UN,1.69,1.183,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CARBAMAZEPINE 100 MG ORAL CHEW,RX-1355,CDM,S5000,HCPCS,259,RC,60687-0479-11,NDC,outpatient,1,UN,1.69,1.183,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CARBAMAZEPINE 100 MG/5ML ORAL SUSP,RX-1356,CDM,S5000,HCPCS,259,RC,99999-0001-92,NDC,outpatient,10,ML,6.06,4.242,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METHYLENE BLUE (ANTIDOTE) 50 MG/10ML IV SOLN,RX-135699,CDM,S5000,HCPCS,250,RC,00517-0374-01,NDC,outpatient,10,ML,411.18,287.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METHYLENE BLUE (ANTIDOTE) 50 MG/10ML IV SOLN,RX-135699,CDM,S5000,HCPCS,250,RC,00517-0374-05,NDC,outpatient,10,ML,411.18,287.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CARBAMAZEPINE 200 MG ORAL TABS,RX-1357,CDM,S5000,HCPCS,259,RC,00904-6172-61,NDC,outpatient,1,UN,2.42,1.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE-SODIUM BICARBONATE 1-8.4 % IJ SOSY,RX-135806,CDM,S5000,HCPCS,250,RC,70092-1443-43,NDC,outpatient,1,ML,22.08,15.456,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE-SODIUM BICARBONATE 1-8.4 % IJ SOSY,RX-135806,CDM,S5000,HCPCS,250,RC,99999-0003-11,NDC,outpatient,1.1,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE-SODIUM BICARBONATE 1-8.4 % IJ SOSY,RX-135806,CDM,S5000,HCPCS,250,RC,70004-0725-05,NDC,outpatient,1,ML,19.02,13.314,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VANCOMYCIN HCL IN NACL 0.9 % 1500 MG/250ML IV SOLN,RX-135845,CDM,S5000,HCPCS,250,RC,70004-0924-59,NDC,outpatient,280,ML,189.24,132.468,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VANCOMYCIN HCL IN NACL 0.9 % 1500 MG/250ML IV SOLN,RX-135845,CDM,S5000,HCPCS,250,RC,99999-0001-84,NDC,outpatient,280,ML,33.42,23.394,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VANCOMYCIN HCL IN NACL 0.9 % 1500 MG/250ML IV SOLN,RX-135845,CDM,S5000,HCPCS,250,RC,70092-9056-05,NDC,outpatient,280,ML,121.34,84.938,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CARBAMIDE PEROXIDE 6.5 % OT SOLN,RX-1359,CDM,S5000,HCPCS,259,RC,00904-6627-35,NDC,outpatient,15,ML,6.35,4.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CARBAMIDE PEROXIDE 6.5 % OT SOLN,RX-1359,CDM,S5000,HCPCS,259,RC,78112-0736-21,NDC,outpatient,15,ML,17.89,12.523,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CARBAMIDE PEROXIDE 6.5 % OT SOLN,RX-1359,CDM,S5000,HCPCS,259,RC,78112-0736-23,NDC,outpatient,15,ML,15.56,10.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METHOTREXATE SODIUM 2.5 MG ORAL TABS,RX-13594,CDM,S5000,HCPCS,259,RC,00054-8550-25,NDC,outpatient,1,UN,5.49,3.843,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METHOTREXATE SODIUM 2.5 MG ORAL TABS,RX-13594,CDM,S5000,HCPCS,259,RC,50268-0527-15,NDC,outpatient,1,UN,5.12,3.584,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METHOTREXATE SODIUM 2.5 MG ORAL TABS,RX-13594,CDM,S5000,HCPCS,259,RC,50268-0527-11,NDC,outpatient,1,UN,5.12,3.584,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DEXMEDETOMIDINE HCL 1000 MCG/10ML IV SOLN,RX-136367,CDM,S5000,HCPCS,250,RC,44567-0601-04,NDC,outpatient,10,ML,205.59,143.913,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MICONAZOLE NITRATE 2 % EX OINT,RX-13651,CDM,S5000,HCPCS,259,RC,53329-0172-10,NDC,outpatient,71,GR,15.17,10.619,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MICONAZOLE NITRATE 2 % EX OINT,RX-13651,CDM,S5000,HCPCS,259,RC,11701-0067-23,NDC,outpatient,57,GR,25.88,18.116,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VANCOMYCIN HCL IN NACL 0.9 % 1250 MG/250ML IV SOLN,RX-136649,CDM,S5000,HCPCS,250,RC,70092-9054-05,NDC,outpatient,275,ML,111.55,78.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VANCOMYCIN HCL IN NACL 0.9 % 1250 MG/250ML IV SOLN,RX-136649,CDM,S5000,HCPCS,250,RC,71506-0015-58,NDC,outpatient,275,ML,93.39,65.373,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VANCOMYCIN HCL IN NACL 0.9 % 1250 MG/250ML IV SOLN,RX-136649,CDM,S5000,HCPCS,250,RC,70004-0923-59,NDC,outpatient,275,ML,170.02,119.014,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VANCOMYCIN HCL IN NACL 0.9 % 1250 MG/250ML IV SOLN,RX-136649,CDM,S5000,HCPCS,250,RC,99999-0001-85,NDC,outpatient,275,ML,59.61,41.727,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GUAIFENESIN 100 MG/5ML ORAL LIQD,RX-13748,CDM,S5000,HCPCS,259,RC,00121-2232-00,NDC,outpatient,15,ML,6.68,4.676,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GUAIFENESIN 100 MG/5ML ORAL LIQD,RX-13748,CDM,S5000,HCPCS,259,RC,00121-2232-15,NDC,outpatient,15,ML,6.68,4.676,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DILTIAZEM HCL-SODIUM CHLORIDE 125-0.9 MG/125ML-% IV SOLN,RX-137908,CDM,S5000,HCPCS,250,RC,76154-0818-05,NDC,outpatient,125,ML,82.75,57.925,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DILTIAZEM HCL-SODIUM CHLORIDE 125-0.9 MG/125ML-% IV SOLN,RX-137908,CDM,S5000,HCPCS,250,RC,99999-0003-40,NDC,outpatient,125,ML,51.6,36.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXYTOCIN-SODIUM CHLORIDE 30-0.9 UT/500ML-% IV SOLN,RX-137935,CDM,S5000,HCPCS,250,RC,70092-1068-07,NDC,outpatient,500,ML,106.3,74.41,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXYTOCIN-SODIUM CHLORIDE 30-0.9 UT/500ML-% IV SOLN,RX-137935,CDM,S5000,HCPCS,250,RC,70092-1552-07,NDC,outpatient,500,ML,97.53,68.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LINACLOTIDE 72 MCG ORAL CAPS,RX-138008,CDM,S5000,HCPCS,259,RC,00456-1203-30,NDC,outpatient,1,UN,74.11,51.877,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BACITRACIN ZINC 500 UNIT/GM EX OINT,RX-13818,CDM,S5000,HCPCS,259,RC,57896-0145-14,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BACITRACIN ZINC 500 UNIT/GM EX OINT,RX-13818,CDM,S5000,HCPCS,259,RC,00536-1263-28,NDC,outpatient,28,GR,4.99,3.493,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BACITRACIN ZINC 500 UNIT/GM EX OINT,RX-13818,CDM,S5000,HCPCS,259,RC,58980-0011-10,NDC,outpatient,28.35,GR,10.1,7.07,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VANCOMYCIN HCL IN NACL 2-0.9 GM/500ML-% IV SOLN,RX-138299,CDM,S5000,HCPCS,250,RC,99999-0002-01,NDC,outpatient,540,ML,36.84,25.788,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VANCOMYCIN HCL IN NACL 2-0.9 GM/500ML-% IV SOLN,RX-138299,CDM,S5000,HCPCS,250,RC,71506-0019-59,NDC,outpatient,540,ML,128.46,89.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VANCOMYCIN HCL IN NACL 1.75-0.9 GM/500ML-% IV SOLN,RX-138322,CDM,S5000,HCPCS,250,RC,99999-0002-00,NDC,outpatient,535,ML,35.39,24.773,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VANCOMYCIN HCL IN NACL 1.75-0.9 GM/500ML-% IV SOLN,RX-138322,CDM,S5000,HCPCS,250,RC,71506-0017-59,NDC,outpatient,535,ML,119.16,83.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BENZOCAINE 20 % MT AERO,RX-138339,CDM,S5000,HCPCS,259,RC,00283-0679-02,NDC,outpatient,57,GR,120.74,84.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PORACTANT ALFA 120 MG/1.5ML INTRATRACHEA SUSP,RX-138354,CDM,S5000,HCPCS,250,RC,10122-0510-01,NDC,outpatient,1.5,ML,1807.78,1265.446,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PORACTANT ALFA 240 MG/3ML INTRATRACHEA SUSP,RX-138355,CDM,S5000,HCPCS,250,RC,10122-0510-03,NDC,outpatient,3,ML,2153.49,1507.443,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
COLESTIPOL HCL 1 G ORAL TABS,RX-13884,CDM,S5000,HCPCS,259,RC,00115-5211-16,NDC,outpatient,1,UN,4.6,3.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
COLESTIPOL HCL 1 G ORAL TABS,RX-13884,CDM,S5000,HCPCS,259,RC,60687-0715-11,NDC,outpatient,1,UN,12.93,9.051,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
COLESTIPOL HCL 1 G ORAL TABS,RX-13884,CDM,S5000,HCPCS,259,RC,00009-0450-03,NDC,outpatient,1,UN,9.24,6.468,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
COLESTIPOL HCL 1 G ORAL TABS,RX-13884,CDM,S5000,HCPCS,259,RC,59762-0450-01,NDC,outpatient,1,UN,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
COLESTIPOL HCL 1 G ORAL TABS,RX-13884,CDM,S5000,HCPCS,259,RC,60687-0715-21,NDC,outpatient,1,UN,12.93,9.051,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MORPHINE SULFATE 100 MG IN NACL 0.9 % 100 ML IV PREMIX,RX-138903,CDM,S5000,HCPCS,250,RC,70092-1130-36,NDC,outpatient,100,ML,83.73,58.611,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MORPHINE SULFATE 100 MG IN NACL 0.9 % 100 ML IV PREMIX,RX-138903,CDM,S5000,HCPCS,250,RC,70092-1380-36,NDC,outpatient,100,ML,69.27,48.489,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MORPHINE SULFATE 100 MG IN NACL 0.9 % 100 ML IV PREMIX,RX-138903,CDM,S5000,HCPCS,250,RC,99999-0003-24,NDC,outpatient,100,ML,48.85,34.195,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DAPAGLIFLOZIN PROPANEDIOL 5 MG ORAL TABS,RX-138997,CDM,S5000,HCPCS,259,RC,00310-6205-30,NDC,outpatient,1,UN,54.15,37.905,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DAPAGLIFLOZIN PROPANEDIOL 5 MG ORAL TABS,RX-138997,CDM,S5000,HCPCS,259,RC,66993-0456-30,NDC,outpatient,1,UN,54.61,38.227,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DAPAGLIFLOZIN PROPANEDIOL 10 MG ORAL TABS,RX-138998,CDM,S5000,HCPCS,259,RC,66993-0457-30,NDC,outpatient,1,UN,57.77,40.439,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DAPAGLIFLOZIN PROPANEDIOL 10 MG ORAL TABS,RX-138998,CDM,S5000,HCPCS,259,RC,00310-6210-39,NDC,outpatient,1,UN,54.15,37.905,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OCUVITE-LUTEIN ORAL TABS,RX-139063,CDM,S5000,HCPCS,259,RC,00536-5090-08,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OCUVITE-LUTEIN ORAL TABS,RX-139063,CDM,S5000,HCPCS,259,RC,24208-0387-62,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SARILUMAB 200 MG/1.14ML SC SOSY,RX-139347,CDM,S5000,HCPCS,250,RC,00024-5910-00,NDC,outpatient,1.14,ML,5813.71,4069.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SARILUMAB 200 MG/1.14ML SC SOSY,RX-139347,CDM,S5000,HCPCS,250,RC,00024-5910-01,NDC,outpatient,1.14,ML,5813.71,4069.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CARISOPRODOL 350 MG ORAL TABS,RX-1395,CDM,S5000,HCPCS,259,RC,50228-0109-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LAMOTRIGINE 25 MG ORAL TABS,RX-13981,CDM,S5000,HCPCS,259,RC,00904-7007-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LAMOTRIGINE 25 MG ORAL TABS,RX-13981,CDM,S5000,HCPCS,259,RC,51672-4130-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LAMOTRIGINE 25 MG ORAL TABS,RX-13981,CDM,S5000,HCPCS,259,RC,68084-0318-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LAMOTRIGINE 25 MG ORAL TABS,RX-13981,CDM,S5000,HCPCS,259,RC,68084-0318-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LAMOTRIGINE 100 MG ORAL TABS,RX-13982,CDM,S5000,HCPCS,259,RC,68084-0319-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LAMOTRIGINE 100 MG ORAL TABS,RX-13982,CDM,S5000,HCPCS,259,RC,00904-7008-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LAMOTRIGINE 100 MG ORAL TABS,RX-13982,CDM,S5000,HCPCS,259,RC,51672-4131-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LAMOTRIGINE 100 MG ORAL TABS,RX-13982,CDM,S5000,HCPCS,259,RC,68084-0319-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CALCIUM CARBONATE ANTACID 1250 MG/5ML ORAL SUSP,RX-140541,CDM,S5000,HCPCS,259,RC,00121-4766-05,NDC,outpatient,5,ML,9.19,6.433,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DILTIAZEM HCL ER 60 MG ORAL CP12,RX-14100,CDM,S5000,HCPCS,259,RC,51079-0924-01,NDC,outpatient,1,UN,13.61,9.527,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DILTIAZEM HCL ER 60 MG ORAL CP12,RX-14100,CDM,S5000,HCPCS,259,RC,51079-0924-20,NDC,outpatient,1,UN,13.61,9.527,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DILTIAZEM HCL ER 90 MG ORAL CP12,RX-14101,CDM,S5000,HCPCS,259,RC,51079-0925-01,NDC,outpatient,1,UN,16,11.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DILTIAZEM HCL ER 90 MG ORAL CP12,RX-14101,CDM,S5000,HCPCS,259,RC,51079-0925-20,NDC,outpatient,1,UN,16,11.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
KETOCONAZOLE 2 % EX SHAM,RX-14132,CDM,S5000,HCPCS,259,RC,45802-0465-64,NDC,outpatient,120,ML,53.4,37.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BECLOMETHASONE DIPROP HFA 40 MCG/ACT IN AERB,RX-141345,CDM,S5000,HCPCS,259,RC,59310-0302-40,NDC,outpatient,10.6,GR,878.5,614.95,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BECLOMETHASONE DIPROP HFA 80 MCG/ACT IN AERB,RX-141346,CDM,S5000,HCPCS,259,RC,59310-0304-80,NDC,outpatient,10.6,GR,1176.28,823.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BICTEGRAVIR-EMTRICITAB-TENOFOV 50-200-25 MG ORAL TABS,RX-142007,CDM,S5000,HCPCS,259,RC,61958-2501-01,NDC,outpatient,1,UN,572.84,400.988,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLUCONAZOLE 40 MG/ML ORAL SUSR,RX-14233,CDM,S5000,HCPCS,259,RC,99999-0002-78,NDC,outpatient,5,ML,12.62,8.834,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLUCONAZOLE 40 MG/ML ORAL SUSR,RX-14233,CDM,S5000,HCPCS,259,RC,59762-5030-01,NDC,outpatient,35,ML,84.73,59.311,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLUCONAZOLE 40 MG/ML ORAL SUSR,RX-14233,CDM,S5000,HCPCS,259,RC,16714-0696-01,NDC,outpatient,35,ML,43.77,30.639,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MAGNESIUM CHLORIDE 64 MG ORAL TBEC,RX-142395,CDM,S5000,HCPCS,259,RC,10006-0700-13,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MAGNESIUM CHLORIDE 64 MG ORAL TBEC,RX-142395,CDM,S5000,HCPCS,259,RC,68585-0005-75,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MAGNESIUM CHLORIDE 64 MG ORAL TBEC,RX-142395,CDM,S5000,HCPCS,259,RC,57896-0635-06,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POTASSIUM IODIDE (EXPECTORANT) 1 GM/ML ORAL SOLN,RX-142406,CDM,S5000,HCPCS,259,RC,71740-0112-30,NDC,outpatient,0.25,ML,14.74,10.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POTASSIUM IODIDE (EXPECTORANT) 1 GM/ML ORAL SOLN,RX-142406,CDM,S5000,HCPCS,259,RC,99999-0003-49,NDC,outpatient,1,ML,58.94,41.258,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DARUN-COBIC-EMTRICIT-TENOFAF 800-150-200-10 MG ORAL TABS,RX-143657,CDM,S5000,HCPCS,259,RC,59676-0800-30,NDC,outpatient,1,UN,678.69,475.083,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PIMAVANSERIN TARTRATE 34 MG ORAL CAPS,RX-143683,CDM,S5000,HCPCS,259,RC,63090-0340-30,NDC,outpatient,1,UN,740.93,518.651,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM ZIRCONIUM CYCLOSILICATE 10 G ORAL PACK,RX-143885,CDM,S5000,HCPCS,259,RC,00310-1110-01,NDC,outpatient,1,UN,69.73,48.811,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM ZIRCONIUM CYCLOSILICATE 10 G ORAL PACK,RX-143885,CDM,S5000,HCPCS,259,RC,00310-1110-39,NDC,outpatient,1,UN,69.73,48.811,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLONIDINE 0.1 MG/24HR TD PTWK,RX-144285,CDM,S5000,HCPCS,259,RC,52817-0610-04,NDC,outpatient,1,UN,36.6,25.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLONIDINE 0.1 MG/24HR TD PTWK,RX-144285,CDM,S5000,HCPCS,259,RC,00378-0871-16,NDC,outpatient,1,UN,58.96,41.272,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLONIDINE 0.1 MG/24HR TD PTWK,RX-144285,CDM,S5000,HCPCS,259,RC,00378-0871-99,NDC,outpatient,1,UN,58.96,41.272,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLONIDINE 0.2 MG/24HR TD PTWK,RX-144286,CDM,S5000,HCPCS,259,RC,00591-3509-04,NDC,outpatient,1,UN,89.34,62.538,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLONIDINE 0.2 MG/24HR TD PTWK,RX-144286,CDM,S5000,HCPCS,259,RC,51862-0454-01,NDC,outpatient,1,UN,43.76,30.632,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLONIDINE 0.2 MG/24HR TD PTWK,RX-144286,CDM,S5000,HCPCS,259,RC,00591-3509-54,NDC,outpatient,1,UN,89.34,62.538,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLONIDINE 0.2 MG/24HR TD PTWK,RX-144286,CDM,S5000,HCPCS,259,RC,51862-0454-04,NDC,outpatient,1,UN,43.76,30.632,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLONIDINE 0.2 MG/24HR TD PTWK,RX-144286,CDM,S5000,HCPCS,259,RC,82089-0102-34,NDC,outpatient,1,UN,502.38,351.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLONIDINE 0.3 MG/24HR TD PTWK,RX-144287,CDM,S5000,HCPCS,259,RC,00591-3510-04,NDC,outpatient,1,UN,122.13,85.491,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLONIDINE 0.3 MG/24HR TD PTWK,RX-144287,CDM,S5000,HCPCS,259,RC,00591-3510-54,NDC,outpatient,1,UN,122.13,85.491,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RIVAROXABAN 2.5 MG ORAL TABS,RX-144544,CDM,S5000,HCPCS,259,RC,50458-0577-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RIVAROXABAN 2.5 MG ORAL TABS,RX-144544,CDM,S5000,HCPCS,259,RC,50458-0577-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DORZOLAMIDE HCL 2 % OP SOLN,RX-14471,CDM,S5000,HCPCS,259,RC,42571-0141-26,NDC,outpatient,10,ML,151.26,105.882,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DORZOLAMIDE HCL 2 % OP SOLN,RX-14471,CDM,S5000,HCPCS,259,RC,24208-0485-10,NDC,outpatient,10,ML,36.09,25.263,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DORZOLAMIDE HCL 2 % OP SOLN,RX-14471,CDM,S5000,HCPCS,259,RC,61314-0019-10,NDC,outpatient,10,ML,71.78,50.246,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
REVEFENACIN 175 MCG/3ML IN SOLN,RX-145104,CDM,S5000,HCPCS,259,RC,49502-0806-93,NDC,outpatient,3,ML,93.63,65.541,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
REVEFENACIN 175 MCG/3ML IN SOLN,RX-145104,CDM,S5000,HCPCS,259,RC,49502-0806-32,NDC,outpatient,3,ML,93.63,65.541,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TERAZOSIN HCL 1 MG ORAL CAPS,RX-14550,CDM,S5000,HCPCS,259,RC,50268-0764-15,NDC,outpatient,1,UN,2.5,1.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TERAZOSIN HCL 1 MG ORAL CAPS,RX-14550,CDM,S5000,HCPCS,259,RC,50268-0764-11,NDC,outpatient,1,UN,2.5,1.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TERAZOSIN HCL 5 MG ORAL CAPS,RX-14553,CDM,S5000,HCPCS,259,RC,50268-0766-11,NDC,outpatient,1,UN,2.67,1.869,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TERAZOSIN HCL 5 MG ORAL CAPS,RX-14553,CDM,S5000,HCPCS,259,RC,50268-0766-15,NDC,outpatient,1,UN,2.67,1.869,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ABLYSINOL IA SOLN,RX-145979,CDM,S5000,HCPCS,250,RC,54288-0105-02,NDC,outpatient,5,ML,2091.2,1463.84,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ABLYSINOL IA SOLN,RX-145979,CDM,S5000,HCPCS,250,RC,54288-0105-15,NDC,outpatient,5,ML,2091.2,1463.84,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PYRIDOSTIGMINE BROMIDE 60 MG/5ML ORAL SOLN,RX-146239,CDM,S5000,HCPCS,259,RC,69238-1731-02,NDC,outpatient,473,ML,2201.68,1541.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PYRIDOSTIGMINE BROMIDE 60 MG/5ML ORAL SOLN,RX-146239,CDM,S5000,HCPCS,259,RC,99999-0002-40,NDC,outpatient,5,ML,47,32.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VERAPAMIL HCL ER 180 MG ORAL TBCR,RX-14626,CDM,S5000,HCPCS,259,RC,75834-0158-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
INDOMETHACIN ER 75 MG ORAL CPCR,RX-14628,CDM,S5000,HCPCS,259,RC,68084-0411-11,NDC,outpatient,1,UN,9.29,6.503,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
INDOMETHACIN ER 75 MG ORAL CPCR,RX-14628,CDM,S5000,HCPCS,259,RC,68084-0411-21,NDC,outpatient,1,UN,9.29,6.503,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRAMADOL HCL 50 MG ORAL TABS,RX-14632,CDM,S5000,HCPCS,259,RC,00904-7179-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRAMADOL HCL 50 MG ORAL TABS,RX-14632,CDM,S5000,HCPCS,259,RC,29300-0355-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRAMADOL HCL 50 MG ORAL TABS,RX-14632,CDM,S5000,HCPCS,259,RC,60687-0795-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRAMADOL HCL 50 MG ORAL TABS,RX-14632,CDM,S5000,HCPCS,259,RC,00093-0058-05,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRAMADOL HCL 50 MG ORAL TABS,RX-14632,CDM,S5000,HCPCS,259,RC,60687-0795-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACETIC ACID 5 % SOLN,RX-14702,CDM,S5000,HCPCS,259,RC,99999-0000-92,NDC,outpatient,60,ML,12.55,8.785,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METFORMIN HCL 850 MG ORAL TABS,RX-14719,CDM,S5000,HCPCS,259,RC,00904-7163-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METFORMIN HCL 850 MG ORAL TABS,RX-14719,CDM,S5000,HCPCS,259,RC,60687-0143-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METFORMIN HCL 850 MG ORAL TABS,RX-14719,CDM,S5000,HCPCS,259,RC,60687-0143-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GLYBURIDE MICRONIZED 1.5 MG ORAL TABS,RX-14777,CDM,S5000,HCPCS,259,RC,00093-8034-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
INSULIN REGULAR(HUMAN) IN NACL 100-0.9 UT/100ML-% IV SOLN,RX-147794,CDM,S5000,HCPCS,250,RC,00338-0126-12,NDC,outpatient,100,ML,98.33,68.831,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRANEXAMIC ACID-NACL 1000-0.7 MG/100ML-% IV SOLN,RX-147865,CDM,S5000,HCPCS,250,RC,51754-0108-03,NDC,outpatient,100,ML,46.71,32.697,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRANEXAMIC ACID-NACL 1000-0.7 MG/100ML-% IV SOLN,RX-147865,CDM,S5000,HCPCS,250,RC,51754-0108-01,NDC,outpatient,100,ML,46.71,32.697,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DORZOLAMIDE HCL-TIMOLOL MAL PF 2-0.5 % OP SOLN,RX-147878,CDM,S5000,HCPCS,259,RC,82584-0604-30,NDC,outpatient,1,UN,14.17,9.919,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DORZOLAMIDE HCL-TIMOLOL MAL PF 2-0.5 % OP SOLN,RX-147878,CDM,S5000,HCPCS,259,RC,82584-0604-01,NDC,outpatient,1,UN,14.17,9.919,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TIZANIDINE HCL 2 MG ORAL TABS,RX-14792,CDM,S5000,HCPCS,259,RC,50268-0759-11,NDC,outpatient,1,UN,2.93,2.051,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TIZANIDINE HCL 2 MG ORAL TABS,RX-14792,CDM,S5000,HCPCS,259,RC,50268-0759-15,NDC,outpatient,1,UN,2.93,2.051,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TIZANIDINE HCL 4 MG ORAL TABS,RX-14793,CDM,S5000,HCPCS,259,RC,00904-6418-61,NDC,outpatient,1,UN,1.85,1.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LANSOPRAZOLE 30 MG ORAL TBDD,RX-148035,CDM,S5000,HCPCS,259,RC,00378-6982-88,NDC,outpatient,1,UN,22.99,16.093,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LANSOPRAZOLE 30 MG ORAL TBDD,RX-148035,CDM,S5000,HCPCS,259,RC,68382-0772-30,NDC,outpatient,1,UN,20.73,14.511,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LANSOPRAZOLE 30 MG ORAL TBDD,RX-148035,CDM,S5000,HCPCS,259,RC,68382-0772-77,NDC,outpatient,1,UN,20.73,14.511,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LANSOPRAZOLE 30 MG ORAL TBDD,RX-148035,CDM,S5000,HCPCS,259,RC,00378-6982-32,NDC,outpatient,1,UN,22.99,16.093,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LANSOPRAZOLE 30 MG ORAL TBDD,RX-148035,CDM,S5000,HCPCS,259,RC,64764-0544-11,NDC,outpatient,1,UN,56.9,39.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LOSARTAN POTASSIUM 25 MG ORAL TABS,RX-14823,CDM,S5000,HCPCS,259,RC,68084-0346-11,NDC,outpatient,1,UN,1.75,1.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LOSARTAN POTASSIUM 25 MG ORAL TABS,RX-14823,CDM,S5000,HCPCS,259,RC,68084-0346-01,NDC,outpatient,1,UN,1.75,1.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LOSARTAN POTASSIUM 50 MG ORAL TABS,RX-14824,CDM,S5000,HCPCS,259,RC,50268-0505-11,NDC,outpatient,1,UN,1.24,0.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LOSARTAN POTASSIUM 50 MG ORAL TABS,RX-14824,CDM,S5000,HCPCS,259,RC,00904-7048-61,NDC,outpatient,1,UN,1.68,1.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LOSARTAN POTASSIUM 50 MG ORAL TABS,RX-14824,CDM,S5000,HCPCS,259,RC,31722-0701-30,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LOSARTAN POTASSIUM 50 MG ORAL TABS,RX-14824,CDM,S5000,HCPCS,259,RC,31722-0701-90,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LOSARTAN POTASSIUM 50 MG ORAL TABS,RX-14824,CDM,S5000,HCPCS,259,RC,50268-0505-15,NDC,outpatient,1,UN,1.24,0.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FOSFOMYCIN TROMETHAMINE 3 G ORAL PACK,RX-14825,CDM,S5000,HCPCS,259,RC,70700-0268-99,NDC,outpatient,1,UN,214.58,150.206,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FOSFOMYCIN TROMETHAMINE 3 G ORAL PACK,RX-14825,CDM,S5000,HCPCS,259,RC,69097-0579-67,NDC,outpatient,1,UN,204.35,143.045,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FOSFOMYCIN TROMETHAMINE 3 G ORAL PACK,RX-14825,CDM,S5000,HCPCS,259,RC,70700-0268-94,NDC,outpatient,1,UN,214.58,150.206,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ATOVAQUONE 750 MG/5ML ORAL SUSP,RX-14953,CDM,S5000,HCPCS,259,RC,70748-0299-01,NDC,outpatient,210,ML,615.84,431.088,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ATOVAQUONE 750 MG/5ML ORAL SUSP,RX-14953,CDM,S5000,HCPCS,259,RC,99999-0004-54,NDC,outpatient,5,ML,14.67,10.269,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BACTERIOSTATIC WATER(BENZ ALC) IJ SOLN,RX-14979,CDM,S5000,HCPCS,250,RC,00409-3977-01,NDC,outpatient,30,ML,8.02,5.614,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BACTERIOSTATIC WATER(BENZ ALC) IJ SOLN,RX-14979,CDM,S5000,HCPCS,250,RC,00409-3977-03,NDC,outpatient,30,ML,8.02,5.614,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MOEXIPRIL HCL 7.5 MG ORAL TABS,RX-15025,CDM,S5000,HCPCS,259,RC,68462-0209-01,NDC,outpatient,1,UN,3.46,2.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VITAMIN A 3 MG (10000 UT) ORAL CAPS,RX-150260,CDM,S5000,HCPCS,259,RC,40093-0140-03,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VITAMIN A 3 MG (10000 UT) ORAL CAPS,RX-150260,CDM,S5000,HCPCS,259,RC,00904-2085-60,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VITAMIN A 3 MG (10000 UT) ORAL CAPS,RX-150260,CDM,S5000,HCPCS,259,RC,40093-0101-44,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROCORT-PRAMOXINE (PERIANAL) 2.5-1 % EX CREA,RX-150325,CDM,S5000,HCPCS,259,RC,45802-0472-64,NDC,outpatient,30,GR,583,408.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACETIC ACID 3 % SOLN,RX-15091,CDM,S5000,HCPCS,259,RC,51552-0051-06,NDC,outpatient,500,ML,97.9,68.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACETIC ACID 3 % SOLN,RX-15091,CDM,S5000,HCPCS,259,RC,99999-0001-49,NDC,outpatient,60,ML,11.75,8.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LOPERAMIDE HCL 1 MG/7.5ML ORAL SOLN,RX-150997,CDM,S5000,HCPCS,259,RC,68094-0129-59,NDC,outpatient,15,ML,10.55,7.385,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LOPERAMIDE HCL 1 MG/7.5ML ORAL SOLN,RX-150997,CDM,S5000,HCPCS,259,RC,68094-0129-62,NDC,outpatient,15,ML,10.55,7.385,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MYCOPHENOLATE MOFETIL 250 MG ORAL CAPS,RX-15113,CDM,S5000,HCPCS,259,RC,51079-0721-01,NDC,outpatient,1,UN,2.18,1.526,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MYCOPHENOLATE MOFETIL 250 MG ORAL CAPS,RX-15113,CDM,S5000,HCPCS,259,RC,51079-0721-20,NDC,outpatient,1,UN,2.18,1.526,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MYCOPHENOLATE MOFETIL 250 MG ORAL CAPS,RX-15113,CDM,S5000,HCPCS,259,RC,60687-0494-11,NDC,outpatient,1,UN,2.25,1.575,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MYCOPHENOLATE MOFETIL 250 MG ORAL CAPS,RX-15113,CDM,S5000,HCPCS,259,RC,60687-0494-01,NDC,outpatient,1,UN,2.25,1.575,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POLY-VI-SOL/IRON 11 MG/ML ORAL SOLN,RX-151638,CDM,S5000,HCPCS,259,RC,00087-0405-01,NDC,outpatient,0.5,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POLY-VI-SOL/IRON 11 MG/ML ORAL SOLN,RX-151638,CDM,S5000,HCPCS,259,RC,99999-0001-69,NDC,outpatient,0.5,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TACROLIMUS ER 1 MG ORAL TB24,RX-151676,CDM,S5000,HCPCS,259,RC,68992-3010-03,NDC,outpatient,1,UN,3.04,2.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TACROLIMUS ER 0.75 MG ORAL TB24,RX-151678,CDM,S5000,HCPCS,259,RC,68992-3075-03,NDC,outpatient,1,UN,2.28,1.596,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TACROLIMUS ER 4 MG ORAL TB24,RX-151679,CDM,S5000,HCPCS,259,RC,68992-3040-03,NDC,outpatient,1,UN,12.17,8.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SENNOSIDES 8.8 MG/5ML ORAL SYRP,RX-15168,CDM,S5000,HCPCS,259,RC,00536-1266-59,NDC,outpatient,10,ML,1.5,1.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SENNOSIDES 8.8 MG/5ML ORAL SYRP,RX-15168,CDM,S5000,HCPCS,259,RC,99999-0002-42,NDC,outpatient,10,ML,1.6,1.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SENNOSIDES 8.8 MG/5ML ORAL SYRP,RX-15168,CDM,S5000,HCPCS,259,RC,57896-0472-10,NDC,outpatient,10,ML,1.39,0.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SENNOSIDES 8.8 MG/5ML ORAL SYRP,RX-15168,CDM,S5000,HCPCS,259,RC,57896-0472-08,NDC,outpatient,5,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SENNOSIDES 8.8 MG/5ML ORAL SYRP,RX-15168,CDM,S5000,HCPCS,259,RC,00536-1266-10,NDC,outpatient,10,ML,1.5,1.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRACE MINERALS CU-MN-SE-ZN 300-55-60-3000 MCG/ML IV SOLN,RX-151858,CDM,S5000,HCPCS,250,RC,00517-9305-01,NDC,outpatient,1,ML,93.05,65.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRACE MINERALS CU-MN-SE-ZN 300-55-60-3000 MCG/ML IV SOLN,RX-151858,CDM,S5000,HCPCS,250,RC,00517-9305-25,NDC,outpatient,1,ML,93.05,65.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METHACHOLINE CHLORIDE IN KIT,RX-151916,CDM,S5000,HCPCS,259,RC,69374-0542-06,NDC,outpatient,18,ML,600.75,420.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DICLOFENAC SODIUM 1 % EX GEL,RX-152701,CDM,S5000,HCPCS,259,RC,00536-1294-97,NDC,outpatient,100,GR,33.38,23.366,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DICLOFENAC SODIUM 1 % EX GEL,RX-152701,CDM,S5000,HCPCS,259,RC,43598-0977-10,NDC,outpatient,100,GR,59.19,41.433,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DICLOFENAC SODIUM 1 % EX GEL,RX-152701,CDM,S5000,HCPCS,259,RC,69097-0524-44,NDC,outpatient,100,GR,59.63,41.741,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SUMATRIPTAN SUCCINATE 25 MG ORAL TABS,RX-15327,CDM,S5000,HCPCS,259,RC,65862-0146-36,NDC,outpatient,1,UN,1.72,1.204,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DICLOFENAC SODIUM 50 MG ORAL TBEC,RX-15340,CDM,S5000,HCPCS,259,RC,60687-0606-11,NDC,outpatient,1,UN,2.07,1.449,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DICLOFENAC SODIUM 50 MG ORAL TBEC,RX-15340,CDM,S5000,HCPCS,259,RC,16571-0202-10,NDC,outpatient,1,UN,1.23,0.861,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DICLOFENAC SODIUM 50 MG ORAL TBEC,RX-15340,CDM,S5000,HCPCS,259,RC,61442-0102-01,NDC,outpatient,1,UN,1.24,0.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DICLOFENAC SODIUM 50 MG ORAL TBEC,RX-15340,CDM,S5000,HCPCS,259,RC,00228-2550-11,NDC,outpatient,1,UN,1.63,1.141,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DICLOFENAC SODIUM 50 MG ORAL TBEC,RX-15340,CDM,S5000,HCPCS,259,RC,60687-0606-01,NDC,outpatient,1,UN,2.07,1.449,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DICLOFENAC SODIUM 75 MG ORAL TBEC,RX-15341,CDM,S5000,HCPCS,259,RC,16571-0201-06,NDC,outpatient,1,UN,1.46,1.022,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AYR SALINE NASAL NA GEL,RX-15372,CDM,S5000,HCPCS,259,RC,00225-0525-47,NDC,outpatient,14.1,GR,10.92,7.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AYR SALINE NASAL NA GEL,RX-15372,CDM,S5000,HCPCS,259,RC,05928-0000-99,NDC,outpatient,28.4,GR,22.75,15.925,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RIMANTADINE HCL 100 MG ORAL TABS,RX-15440,CDM,S5000,HCPCS,259,RC,00115-1911-01,NDC,outpatient,1,UN,10.21,7.147,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CHERRY ORAL SYRP,RX-1562,CDM,S5000,HCPCS,259,RC,00395-2662-16,NDC,outpatient,473,ML,78.58,55.006,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FAT EMULSION PLANT BASED (SOY) 20 % IV EMUL,RX-156372,CDM,S5000,HCPCS,250,RC,00338-0519-09,NDC,outpatient,250,ML,59.39,41.573,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FAT EMULSION PLANT BASED (SOY) 20 % IV EMUL,RX-156372,CDM,S5000,HCPCS,250,RC,00338-0519-13,NDC,outpatient,500,ML,73.85,51.695,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMANTADINE HCL 50 MG/5ML ORAL SOLN,RX-156382,CDM,S5000,HCPCS,259,RC,00121-0646-10,NDC,outpatient,10,ML,13.67,9.569,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALENDRONATE SODIUM 10 MG ORAL TABS,RX-15661,CDM,S5000,HCPCS,259,RC,16714-0631-01,NDC,outpatient,1,UN,1.72,1.204,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM THIOSULFATE 250 MG/ML IV SOLN,RX-156724,CDM,S5000,HCPCS,250,RC,60267-0705-50,NDC,outpatient,50,ML,431.65,302.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PRISMASOL BGK 0/2.5 32-2.5 MEQ/L EC SOLN,RX-156740,CDM,S5000,HCPCS,250,RC,24571-0108-06,NDC,outpatient,5000,ML,294.88,206.416,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PRISMASOL BGK 4/2.5 32-4-2.5 MEQ/L EC SOLN,RX-156741,CDM,S5000,HCPCS,250,RC,24571-0105-06,NDC,outpatient,5000,ML,294.88,206.416,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PRISMASOL BGK 2/0 32-2 MEQ/L EC SOLN,RX-156742,CDM,S5000,HCPCS,250,RC,24571-0102-06,NDC,outpatient,5000,ML,294.88,206.416,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PRISMASOL BGK 2/3.5 32-2-3.5 MEQ/L EC SOLN,RX-156743,CDM,S5000,HCPCS,250,RC,24571-0103-06,NDC,outpatient,5000,ML,325.06,227.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SOTALOL HCL 120 MG ORAL TABS,RX-15723,CDM,S5000,HCPCS,259,RC,60505-0159-00,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SOTALOL HCL 120 MG ORAL TABS,RX-15723,CDM,S5000,HCPCS,259,RC,00093-1060-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CALCITONIN (SALMON) 200 UNIT/ACT NA SOLN,RX-15738,CDM,S5000,HCPCS,259,RC,49884-0161-11,NDC,outpatient,3.7,ML,207.33,145.131,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CALCITONIN (SALMON) 200 UNIT/ACT NA SOLN,RX-15738,CDM,S5000,HCPCS,259,RC,60505-0823-06,NDC,outpatient,3.7,ML,230.15,161.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CARVEDILOL 6.25 MG ORAL TABS,RX-15747,CDM,S5000,HCPCS,259,RC,00904-6301-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CARVEDILOL 12.5 MG ORAL TABS,RX-15749,CDM,S5000,HCPCS,259,RC,00904-6302-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CARVEDILOL 12.5 MG ORAL TABS,RX-15749,CDM,S5000,HCPCS,259,RC,68382-0094-05,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AZITHROMYCIN 200 MG/5ML ORAL SUSR,RX-15797,CDM,S5000,HCPCS,259,RC,99999-0002-81,NDC,outpatient,6.25,ML,21.03,14.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AZITHROMYCIN 200 MG/5ML ORAL SUSR,RX-15797,CDM,S5000,HCPCS,259,RC,00093-2026-23,NDC,outpatient,18.75,ML,62.17,43.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AZITHROMYCIN 200 MG/5ML ORAL SUSR,RX-15797,CDM,S5000,HCPCS,259,RC,59762-3120-01,NDC,outpatient,18.75,ML,76.85,53.795,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DARUNAVIR 800 MG ORAL TABS,RX-158170,CDM,S5000,HCPCS,259,RC,59676-0566-30,NDC,outpatient,1,UN,310.53,217.371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
INSULIN LISPRO 100 UNIT/ML IJ SOLN,RX-158181,CDM,S5000,HCPCS,259,RC,00002-7533-01,NDC,outpatient,3,ML,80.06,56.042,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
INSULIN LISPRO 100 UNIT/ML IJ SOLN,RX-158181,CDM,S5000,HCPCS,259,RC,00024-5924-10,NDC,outpatient,10,ML,322.63,225.841,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
INSULIN LISPRO 100 UNIT/ML IJ SOLN,RX-158181,CDM,S5000,HCPCS,259,RC,00024-5926-05,NDC,outpatient,3,ML,50.03,35.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LAMIVUDINE 150 MG ORAL TABS,RX-15880,CDM,S5000,HCPCS,259,RC,00904-6583-04,NDC,outpatient,1,UN,21.27,14.889,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LAMIVUDINE 150 MG ORAL TABS,RX-15880,CDM,S5000,HCPCS,259,RC,64380-0710-03,NDC,outpatient,1,UN,2.38,1.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LAMIVUDINE 10 MG/ML ORAL SOLN,RX-15881,CDM,S5000,HCPCS,259,RC,54838-0566-70,NDC,outpatient,15,ML,23.1,16.17,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACARBOSE 50 MG ORAL TABS,RX-15895,CDM,S5000,HCPCS,259,RC,64380-0759-06,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DAKINS (1/2 STRENGTH) 0.25 % EX SOLN,RX-15950,CDM,S5000,HCPCS,259,RC,00436-0936-16,NDC,outpatient,473,ML,52.63,36.841,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NIRMATRELVIR&RITONAVIR 150/100 10 X 150 MG & 10 X 100MG ORAL TBPK,RX-159847,CDM,S5000,HCPCS,259,RC,00069-5317-02,NDC,outpatient,1,UN,571.55,400.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NIRMATRELVIR&RITONAVIR 150/100 10 X 150 MG & 10 X 100MG ORAL TBPK,RX-159847,CDM,S5000,HCPCS,259,RC,00069-5317-20,NDC,outpatient,1,UN,3544.84,2481.388,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NIRMATRELVIR&RITONAVIR 300/100 20 X 150 MG & 10 X 100MG ORAL TBPK,RX-159848,CDM,S5000,HCPCS,259,RC,00069-5321-03,NDC,outpatient,1,UN,571.55,400.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NIRMATRELVIR&RITONAVIR 300/100 20 X 150 MG & 10 X 100MG ORAL TBPK,RX-159848,CDM,S5000,HCPCS,259,RC,00069-5321-30,NDC,outpatient,1,UN,3544.84,2481.388,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METHADONE HCL 10 MG/ML ORAL CONC,RX-15996,CDM,S5000,HCPCS,259,RC,99999-0002-10,NDC,outpatient,10,ML,27.28,19.096,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METHADONE HCL 10 MG/ML ORAL CONC,RX-15996,CDM,S5000,HCPCS,259,RC,00406-0527-10,NDC,outpatient,0.5,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ESTROGENS CONJUGATED 0.625 MG/GM VA CREA,RX-160113,CDM,S5000,HCPCS,259,RC,00046-0872-21,NDC,outpatient,30,GR,1850.58,1295.406,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CALCIPOTRIENE 0.005 % EX CREA,RX-16034,CDM,S5000,HCPCS,259,RC,16714-0763-01,NDC,outpatient,60,GR,327.35,229.145,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GLUCOSE 4 G ORAL CHEW,RX-16050,CDM,S5000,HCPCS,259,RC,56151-1610-11,NDC,outpatient,1,UN,3.58,2.506,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GLUCOSE 4 G ORAL CHEW,RX-16050,CDM,S5000,HCPCS,259,RC,56151-1610-51,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GLUCOSE 4 G ORAL CHEW,RX-16050,CDM,S5000,HCPCS,259,RC,80681-0100-00,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DESMOPRESSIN ACETATE 0.2 MG ORAL TABS,RX-16053,CDM,S5000,HCPCS,259,RC,60687-0732-11,NDC,outpatient,1,UN,7.9,5.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DESMOPRESSIN ACETATE 0.2 MG ORAL TABS,RX-16053,CDM,S5000,HCPCS,259,RC,23155-0490-01,NDC,outpatient,1,UN,1.27,0.889,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DESMOPRESSIN ACETATE 0.2 MG ORAL TABS,RX-16053,CDM,S5000,HCPCS,259,RC,60687-0732-21,NDC,outpatient,1,UN,7.9,5.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METHYLENE BLUE 1 % IV SOLN,RX-160649,CDM,S5000,HCPCS,250,RC,54288-0147-01,NDC,outpatient,10,ML,616.77,431.739,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACTIDOSE WITH SORBITOL 25 GM/120ML ORAL SUSP,RX-160655,CDM,S5000,HCPCS,259,RC,00574-0520-74,NDC,outpatient,120,ML,51.8,36.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACTIDOSE WITH SORBITOL 25 GM/120ML ORAL SUSP,RX-160655,CDM,S5000,HCPCS,259,RC,66689-0203-04,NDC,outpatient,120,ML,73.16,51.212,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IPRATROPIUM BROMIDE 0.03 % NA SOLN,RX-16070,CDM,S5000,HCPCS,259,RC,24208-0398-30,NDC,outpatient,30,ML,45.66,31.962,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IPRATROPIUM BROMIDE 0.03 % NA SOLN,RX-16070,CDM,S5000,HCPCS,259,RC,00054-0045-44,NDC,outpatient,30,ML,160.2,112.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CALCIUM CARB-CHOLECALCIFEROL 600-5 MG-MCG ORAL TABS,RX-160700,CDM,S5000,HCPCS,259,RC,80681-0138-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IPRATROPIUM BROMIDE 0.06 % NA SOLN,RX-16071,CDM,S5000,HCPCS,259,RC,00054-0046-41,NDC,outpatient,15,ML,147.99,103.593,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IPRATROPIUM BROMIDE 0.06 % NA SOLN,RX-16071,CDM,S5000,HCPCS,259,RC,60505-0827-01,NDC,outpatient,15,ML,69.49,48.643,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FAMCICLOVIR 250 MG ORAL TABS,RX-16081,CDM,S5000,HCPCS,259,RC,60505-3246-03,NDC,outpatient,1,UN,1.06,0.742,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CALCIUM CITRATE-VITAMIN D 200-6.25 MG-MCG ORAL TABS,RX-160846,CDM,S5000,HCPCS,259,RC,00536-3223-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CALCIUM CITRATE-VITAMIN D 200-6.25 MG-MCG ORAL TABS,RX-160846,CDM,S5000,HCPCS,259,RC,16500-0535-02,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CALCIUM CITRATE-VITAMIN D 200-6.25 MG-MCG ORAL TABS,RX-160846,CDM,S5000,HCPCS,259,RC,16500-0535-03,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RILUZOLE 50 MG ORAL TABS,RX-16124,CDM,S5000,HCPCS,259,RC,67877-0286-60,NDC,outpatient,1,UN,2.96,2.072,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CALCITRIOL 1 MCG/ML ORAL SOLN,RX-16218,CDM,S5000,HCPCS,259,RC,99999-0002-71,NDC,outpatient,1,ML,19.3,13.51,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CALCITRIOL 1 MCG/ML ORAL SOLN,RX-16218,CDM,S5000,HCPCS,259,RC,63304-0241-59,NDC,outpatient,1,ML,19.3,13.51,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CALCITRIOL 1 MCG/ML ORAL SOLN,RX-16218,CDM,S5000,HCPCS,259,RC,00054-3120-41,NDC,outpatient,1,ML,24.45,17.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CHLORDIAZEPOXIDE HCL 25 MG ORAL CAPS,RX-1623,CDM,S5000,HCPCS,259,RC,51079-0141-20,NDC,outpatient,1,UN,2.52,1.764,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CHLORDIAZEPOXIDE HCL 25 MG ORAL CAPS,RX-1623,CDM,S5000,HCPCS,259,RC,00555-0159-02,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CHLORDIAZEPOXIDE HCL 25 MG ORAL CAPS,RX-1623,CDM,S5000,HCPCS,259,RC,51079-0141-01,NDC,outpatient,1,UN,2.52,1.764,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CHLORDIAZEPOXIDE HCL 5 MG ORAL CAPS,RX-1624,CDM,S5000,HCPCS,259,RC,51079-0374-01,NDC,outpatient,1,UN,2.65,1.855,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CHLORDIAZEPOXIDE HCL 5 MG ORAL CAPS,RX-1624,CDM,S5000,HCPCS,259,RC,51079-0374-20,NDC,outpatient,1,UN,2.65,1.855,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
EUCERIN ORIGINAL HEALING EX CREA,RX-162713,CDM,S5000,HCPCS,259,RC,72140-0038-68,NDC,outpatient,57,GR,20.04,14.028,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GLIMEPIRIDE 2 MG ORAL TABS,RX-16356,CDM,S5000,HCPCS,259,RC,68084-0326-01,NDC,outpatient,1,UN,2.06,1.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GLIMEPIRIDE 2 MG ORAL TABS,RX-16356,CDM,S5000,HCPCS,259,RC,68084-0326-11,NDC,outpatient,1,UN,2.06,1.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GLIMEPIRIDE 2 MG ORAL TABS,RX-16356,CDM,S5000,HCPCS,259,RC,55111-0321-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CHLORPHENIRAMINE MALEATE 4 MG ORAL TABS,RX-1645,CDM,S5000,HCPCS,259,RC,00904-0012-59,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CHLORPHENIRAMINE MALEATE 4 MG ORAL TABS,RX-1645,CDM,S5000,HCPCS,259,RC,00904-0012-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PHENYLEPH-SHARK LIV OIL-MO-PET 0.25-3-14-71.9 % RE OINT,RX-16462,CDM,S5000,HCPCS,259,RC,00573-2871-93,NDC,outpatient,28,GR,25.8,18.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CHLORPROMAZINE HCL 10 MG ORAL TABS,RX-1653,CDM,S5000,HCPCS,259,RC,00904-7129-61,NDC,outpatient,1,UN,10.41,7.287,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CHLORPROMAZINE HCL 10 MG ORAL TABS,RX-1653,CDM,S5000,HCPCS,259,RC,50268-0162-15,NDC,outpatient,1,UN,4.66,3.262,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CHLORPROMAZINE HCL 10 MG ORAL TABS,RX-1653,CDM,S5000,HCPCS,259,RC,50268-0162-11,NDC,outpatient,1,UN,4.66,3.262,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CHLORPROMAZINE HCL 100 MG ORAL TABS,RX-1654,CDM,S5000,HCPCS,259,RC,69238-1060-01,NDC,outpatient,1,UN,6.98,4.886,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CHLORPROMAZINE HCL 100 MG ORAL TABS,RX-1654,CDM,S5000,HCPCS,259,RC,00904-7132-61,NDC,outpatient,1,UN,20.86,14.602,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CHLORPROMAZINE HCL 25 MG ORAL TABS,RX-1656,CDM,S5000,HCPCS,259,RC,50268-0163-15,NDC,outpatient,1,UN,7.19,5.033,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CHLORPROMAZINE HCL 25 MG ORAL TABS,RX-1656,CDM,S5000,HCPCS,259,RC,69238-1056-01,NDC,outpatient,1,UN,2.88,2.016,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CHLORPROMAZINE HCL 25 MG ORAL TABS,RX-1656,CDM,S5000,HCPCS,259,RC,50268-0163-11,NDC,outpatient,1,UN,7.19,5.033,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
KETOTIFEN FUMARATE 0.035 % OP SOLN,RX-165824,CDM,S5000,HCPCS,259,RC,00536-1252-40,NDC,outpatient,5,ML,30.09,21.063,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
KETOTIFEN FUMARATE 0.035 % OP SOLN,RX-165824,CDM,S5000,HCPCS,259,RC,72485-0617-10,NDC,outpatient,5,ML,28.93,20.251,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
KETOTIFEN FUMARATE 0.035 % OP SOLN,RX-165824,CDM,S5000,HCPCS,259,RC,00065-4011-05,NDC,outpatient,5,ML,42.77,29.939,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CHLORTHALIDONE 25 MG ORAL TABS,RX-1661,CDM,S5000,HCPCS,259,RC,51079-0058-01,NDC,outpatient,1,UN,7.86,5.502,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CHLORTHALIDONE 25 MG ORAL TABS,RX-1661,CDM,S5000,HCPCS,259,RC,51079-0058-20,NDC,outpatient,1,UN,7.86,5.502,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PAROXETINE HCL 10 MG ORAL TABS,RX-16632,CDM,S5000,HCPCS,259,RC,68084-0044-01,NDC,outpatient,1,UN,2.56,1.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PAROXETINE HCL 10 MG ORAL TABS,RX-16632,CDM,S5000,HCPCS,259,RC,68084-0044-11,NDC,outpatient,1,UN,2.56,1.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PAROXETINE HCL 10 MG ORAL TABS,RX-16632,CDM,S5000,HCPCS,259,RC,63739-0888-10,NDC,outpatient,1,UN,2.7,1.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FERROUS SULFATE ER 45 MG ORAL TBCR,RX-167735,CDM,S5000,HCPCS,259,RC,10006-0730-13,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACD FORMULA A 0.73-2.45-2.2 GM/100ML VI SOLN,RX-16825,CDM,S5000,HCPCS,250,RC,00942-0641-04,NDC,outpatient,1000,ML,60.15,42.105,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,20555-0036-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,68094-0110-59,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,50268-0524-15,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,77333-0516-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,50268-0524-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,68094-0110-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MELATONIN 3 MG ORAL TABS,RX-16830,CDM,S5000,HCPCS,259,RC,77333-0516-25,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYOSCYAMINE SULFATE ER 0.375 MG ORAL TB12,RX-17010,CDM,S5000,HCPCS,259,RC,51525-0115-01,NDC,outpatient,1,UN,1.16,0.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRANDOLAPRIL 1 MG ORAL TABS,RX-17017,CDM,S5000,HCPCS,259,RC,68180-0566-01,NDC,outpatient,1,UN,2.46,1.722,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SELEGILINE HCL 5 MG ORAL CAPS,RX-17280,CDM,S5000,HCPCS,259,RC,60505-0055-01,NDC,outpatient,1,UN,2.47,1.729,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DERMAPHOR EX OINT,RX-17369,CDM,S5000,HCPCS,259,RC,72140-0452-31,NDC,outpatient,50,GR,20.25,14.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DERMAPHOR EX OINT,RX-17369,CDM,S5000,HCPCS,259,RC,61924-0184-04,NDC,outpatient,106,GR,13.68,9.576,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DERMAPHOR EX OINT,RX-17369,CDM,S5000,HCPCS,259,RC,72140-0031-47,NDC,outpatient,396,GR,61.68,43.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RISPERIDONE 1 MG/ML ORAL SOLN,RX-17377,CDM,S5000,HCPCS,259,RC,65162-0673-84,NDC,outpatient,0.25,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RISPERIDONE 1 MG/ML ORAL SOLN,RX-17377,CDM,S5000,HCPCS,259,RC,27808-0002-01,NDC,outpatient,0.25,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RISPERIDONE 1 MG/ML ORAL SOLN,RX-17377,CDM,S5000,HCPCS,259,RC,99999-0003-81,NDC,outpatient,1,ML,4.12,2.884,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AZITHROMYCIN 600 MG ORAL TABS,RX-17387,CDM,S5000,HCPCS,259,RC,62332-0253-30,NDC,outpatient,1,UN,1.72,1.204,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLINDAMYCIN HCL 150 MG ORAL CAPS,RX-1740,CDM,S5000,HCPCS,259,RC,00904-5959-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NEVIRAPINE 200 MG ORAL TABS,RX-17403,CDM,S5000,HCPCS,259,RC,31722-0505-60,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLINDAMYCIN PHOSPHATE 1 % EX SOLN,RX-1742,CDM,S5000,HCPCS,259,RC,45802-0562-02,NDC,outpatient,60,ML,48.6,34.02,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLINDAMYCIN PHOSPHATE 1 % EX SOLN,RX-1742,CDM,S5000,HCPCS,259,RC,00168-0201-60,NDC,outpatient,60,ML,139.11,97.377,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MIRTAZAPINE 15 MG ORAL TABS,RX-17466,CDM,S5000,HCPCS,259,RC,51079-0086-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MIRTAZAPINE 15 MG ORAL TABS,RX-17466,CDM,S5000,HCPCS,259,RC,00904-6519-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MIRTAZAPINE 15 MG ORAL TABS,RX-17466,CDM,S5000,HCPCS,259,RC,51079-0086-20,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CANDIDA ALBICANS SKN TST ANTGN ID SOLN,RX-17524,CDM,S5000,HCPCS,250,RC,59584-0138-01,NDC,outpatient,0.1,ML,121.71,85.197,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLONIDINE HCL 0.1 MG ORAL TABS,RX-1755,CDM,S5000,HCPCS,259,RC,60687-0113-01,NDC,outpatient,1,UN,1.25,0.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLONIDINE HCL 0.1 MG ORAL TABS,RX-1755,CDM,S5000,HCPCS,259,RC,60687-0113-11,NDC,outpatient,1,UN,1.25,0.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLORAZEPATE DIPOTASSIUM 3.75 MG ORAL TABS,RX-1759,CDM,S5000,HCPCS,259,RC,13107-0319-01,NDC,outpatient,1,UN,4.43,3.101,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLOTRIMAZOLE 1 % EX CREA,RX-1767,CDM,S5000,HCPCS,259,RC,45802-0434-11,NDC,outpatient,30,GR,10.42,7.294,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLOTRIMAZOLE 1 % EX CREA,RX-1767,CDM,S5000,HCPCS,259,RC,51672-2002-02,NDC,outpatient,30,GR,6.01,4.207,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLOTRIMAZOLE 1 % EX SOLN,RX-1768,CDM,S5000,HCPCS,259,RC,51672-1260-03,NDC,outpatient,30,ML,97.86,68.502,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLOTRIMAZOLE 1 % VA CREA,RX-1769,CDM,S5000,HCPCS,259,RC,51672-2003-06,NDC,outpatient,45,GR,11.82,8.274,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS,RX-17837,CDM,S5000,HCPCS,259,RC,66993-0019-68,NDC,outpatient,18,GR,146.67,102.669,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS,RX-17837,CDM,S5000,HCPCS,259,RC,00093-3174-31,NDC,outpatient,8.5,GR,117.83,82.481,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS,RX-17837,CDM,S5000,HCPCS,259,RC,00173-0682-24,NDC,outpatient,8,GR,92.49,64.743,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BRIMONIDINE TARTRATE 0.2 % OP SOLN,RX-17881,CDM,S5000,HCPCS,259,RC,61314-0143-05,NDC,outpatient,5,ML,13.04,9.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BRIMONIDINE TARTRATE 0.2 % OP SOLN,RX-17881,CDM,S5000,HCPCS,259,RC,24208-0411-05,NDC,outpatient,5,ML,61.95,43.365,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BRIMONIDINE TARTRATE 0.2 % OP SOLN,RX-17881,CDM,S5000,HCPCS,259,RC,71921-0185-05,NDC,outpatient,5,ML,41.12,28.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BRIMONIDINE TARTRATE 0.2 % OP SOLN,RX-17881,CDM,S5000,HCPCS,259,RC,70069-0231-01,NDC,outpatient,5,ML,7.26,5.082,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
B COMPLEX ORAL CAPS,RX-17882,CDM,S5000,HCPCS,259,RC,54629-0560-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OLANZAPINE 5 MG ORAL TABS,RX-17936,CDM,S5000,HCPCS,259,RC,00904-6377-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DEXAMETHASONE 1 MG/ML ORAL CONC,RX-17946,CDM,S5000,HCPCS,259,RC,00054-3176-44,NDC,outpatient,30,ML,90.92,63.644,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ZAFIRLUKAST 20 MG ORAL TABS,RX-17960,CDM,S5000,HCPCS,259,RC,68084-0059-21,NDC,outpatient,1,UN,10.83,7.581,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ZAFIRLUKAST 20 MG ORAL TABS,RX-17960,CDM,S5000,HCPCS,259,RC,68084-0059-11,NDC,outpatient,1,UN,10.83,7.581,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMMONIUM LACTATE 12 % EX CREA,RX-17997,CDM,S5000,HCPCS,259,RC,45802-0513-77,NDC,outpatient,140,GR,35.52,24.864,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CODEINE SULFATE 15 MG ORAL TABS,RX-1801,CDM,S5000,HCPCS,259,RC,00054-0243-24,NDC,outpatient,1,UN,2.94,2.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SENNA 8.6 MG ORAL TABS,RX-18138,CDM,S5000,HCPCS,259,RC,00904-7252-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
COLCHICINE 0.6 MG ORAL TABS,RX-1821,CDM,S5000,HCPCS,259,RC,42292-0054-01,NDC,outpatient,1,UN,13.56,9.492,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
COLCHICINE 0.6 MG ORAL TABS,RX-1821,CDM,S5000,HCPCS,259,RC,65162-0710-09,NDC,outpatient,1,UN,2.83,1.981,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
COLCHICINE 0.6 MG ORAL TABS,RX-1821,CDM,S5000,HCPCS,259,RC,42292-0054-03,NDC,outpatient,1,UN,13.56,9.492,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BISOPROLOL FUMARATE 5 MG ORAL TABS,RX-18288,CDM,S5000,HCPCS,259,RC,29300-0126-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BISOPROLOL-HYDROCHLOROTHIAZIDE 10-6.25 MG ORAL TABS,RX-18289,CDM,S5000,HCPCS,259,RC,10135-0742-30,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BISOPROLOL-HYDROCHLOROTHIAZIDE 10-6.25 MG ORAL TABS,RX-18289,CDM,S5000,HCPCS,259,RC,29300-0189-01,NDC,outpatient,1,UN,2.16,1.512,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BISOPROLOL-HYDROCHLOROTHIAZIDE 5-6.25 MG ORAL TABS,RX-18290,CDM,S5000,HCPCS,259,RC,29300-0188-01,NDC,outpatient,1,UN,2.18,1.526,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BISOPROLOL-HYDROCHLOROTHIAZIDE 2.5-6.25 MG ORAL TABS,RX-18291,CDM,S5000,HCPCS,259,RC,29300-0187-01,NDC,outpatient,1,UN,2.03,1.421,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BISOPROLOL-HYDROCHLOROTHIAZIDE 2.5-6.25 MG ORAL TABS,RX-18291,CDM,S5000,HCPCS,259,RC,68462-0878-30,NDC,outpatient,1,UN,1.61,1.127,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TORSEMIDE 10 MG ORAL TABS,RX-18292,CDM,S5000,HCPCS,259,RC,50268-0755-15,NDC,outpatient,1,UN,1.14,0.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TORSEMIDE 10 MG ORAL TABS,RX-18292,CDM,S5000,HCPCS,259,RC,50268-0755-11,NDC,outpatient,1,UN,1.14,0.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,00054-0077-25,NDC,outpatient,1,UN,1.1,0.77,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,50268-0756-11,NDC,outpatient,1,UN,1.5,1.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,00054-0077-29,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,50268-0756-15,NDC,outpatient,1,UN,1.5,1.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,68084-0539-01,NDC,outpatient,1,UN,1.28,0.896,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TORSEMIDE 20 MG ORAL TABS,RX-18293,CDM,S5000,HCPCS,259,RC,68084-0539-11,NDC,outpatient,1,UN,1.28,0.896,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TORSEMIDE 100 MG ORAL TABS,RX-18294,CDM,S5000,HCPCS,259,RC,50268-0757-15,NDC,outpatient,1,UN,1.64,1.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TORSEMIDE 100 MG ORAL TABS,RX-18294,CDM,S5000,HCPCS,259,RC,31722-0532-01,NDC,outpatient,1,UN,2.32,1.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TORSEMIDE 100 MG ORAL TABS,RX-18294,CDM,S5000,HCPCS,259,RC,50268-0757-11,NDC,outpatient,1,UN,1.64,1.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GABAPENTIN 400 MG ORAL CAPS,RX-18307,CDM,S5000,HCPCS,259,RC,00904-6667-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GABAPENTIN 400 MG ORAL CAPS,RX-18307,CDM,S5000,HCPCS,259,RC,63739-0904-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,60687-0591-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,45963-0556-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,60687-0591-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,63739-0903-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,00904-6666-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GABAPENTIN 300 MG ORAL CAPS,RX-18308,CDM,S5000,HCPCS,259,RC,16714-0662-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GABAPENTIN 100 MG ORAL CAPS,RX-18309,CDM,S5000,HCPCS,259,RC,60687-0580-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GABAPENTIN 100 MG ORAL CAPS,RX-18309,CDM,S5000,HCPCS,259,RC,60687-0580-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GABAPENTIN 100 MG ORAL CAPS,RX-18309,CDM,S5000,HCPCS,259,RC,63739-0902-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GABAPENTIN 100 MG ORAL CAPS,RX-18309,CDM,S5000,HCPCS,259,RC,00904-6665-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RISPERIDONE 2 MG ORAL TABS,RX-18311,CDM,S5000,HCPCS,259,RC,00904-7363-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RISPERIDONE 1 MG ORAL TABS,RX-18313,CDM,S5000,HCPCS,259,RC,00904-7362-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RISPERIDONE 1 MG ORAL TABS,RX-18313,CDM,S5000,HCPCS,259,RC,42291-0910-60,NDC,outpatient,1,UN,11.7,8.19,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPROPION HCL ER (SR) 100 MG ORAL TB12,RX-18385,CDM,S5000,HCPCS,259,RC,68084-0697-11,NDC,outpatient,1,UN,2.72,1.904,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPROPION HCL ER (SR) 100 MG ORAL TB12,RX-18385,CDM,S5000,HCPCS,259,RC,68084-0697-01,NDC,outpatient,1,UN,2.72,1.904,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPROPION HCL ER (SR) 150 MG ORAL TB12,RX-18386,CDM,S5000,HCPCS,259,RC,68084-0708-25,NDC,outpatient,1,UN,2.27,1.589,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPROPION HCL ER (SR) 150 MG ORAL TB12,RX-18386,CDM,S5000,HCPCS,259,RC,68084-0708-95,NDC,outpatient,1,UN,2.27,1.589,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
REMIFENTANIL HCL 1 MG IV SOLR,RX-18398,CDM,S5000,HCPCS,250,RC,00143-9391-01,NDC,outpatient,1,UN,164.07,114.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
REMIFENTANIL HCL 1 MG IV SOLR,RX-18398,CDM,S5000,HCPCS,250,RC,63323-0723-03,NDC,outpatient,1,UN,164.48,115.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
REMIFENTANIL HCL 1 MG IV SOLR,RX-18398,CDM,S5000,HCPCS,250,RC,00143-9391-10,NDC,outpatient,1,UN,164.07,114.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
REMIFENTANIL HCL 1 MG IV SOLR,RX-18398,CDM,S5000,HCPCS,250,RC,63323-0723-01,NDC,outpatient,1,UN,164.48,115.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CARVEDILOL 3.125 MG ORAL TABS,RX-18551,CDM,S5000,HCPCS,259,RC,00904-6300-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LATANOPROST 0.005 % OP SOLN,RX-18621,CDM,S5000,HCPCS,259,RC,24208-0463-25,NDC,outpatient,2.5,ML,46.77,32.739,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LATANOPROST 0.005 % OP SOLN,RX-18621,CDM,S5000,HCPCS,259,RC,59762-0333-02,NDC,outpatient,2.5,ML,18.92,13.244,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LATANOPROST 0.005 % OP SOLN,RX-18621,CDM,S5000,HCPCS,259,RC,61314-0547-01,NDC,outpatient,2.5,ML,19.1,13.37,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LATANOPROST 0.005 % OP SOLN,RX-18621,CDM,S5000,HCPCS,259,RC,70069-0421-01,NDC,outpatient,2.5,ML,19.9,13.93,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DONEPEZIL HCL 5 MG ORAL TABS,RX-18786,CDM,S5000,HCPCS,259,RC,00904-6477-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NITROPRUSSIDE SODIUM 25 MG/ML IV SOLN,RX-18908,CDM,S5000,HCPCS,250,RC,43598-0587-23,NDC,outpatient,2,ML,87.58,61.306,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NITROPRUSSIDE SODIUM 25 MG/ML IV SOLN,RX-18908,CDM,S5000,HCPCS,250,RC,67457-0839-02,NDC,outpatient,2,ML,53.45,37.415,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NITROPRUSSIDE SODIUM 25 MG/ML IV SOLN,RX-18908,CDM,S5000,HCPCS,250,RC,72485-0105-01,NDC,outpatient,2,ML,69.91,48.937,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVOFLOXACIN 250 MG ORAL TABS,RX-18918,CDM,S5000,HCPCS,259,RC,00904-6351-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVOFLOXACIN 500 MG ORAL TABS,RX-18919,CDM,S5000,HCPCS,259,RC,00904-6352-61,NDC,outpatient,1,UN,1.04,0.728,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TOPIRAMATE 25 MG ORAL TABS,RX-18920,CDM,S5000,HCPCS,259,RC,68084-0342-11,NDC,outpatient,1,UN,1.38,0.966,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TOPIRAMATE 25 MG ORAL TABS,RX-18920,CDM,S5000,HCPCS,259,RC,68084-0342-01,NDC,outpatient,1,UN,1.38,0.966,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TOPIRAMATE 100 MG ORAL TABS,RX-18922,CDM,S5000,HCPCS,259,RC,68084-0344-01,NDC,outpatient,1,UN,2.19,1.533,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TOPIRAMATE 100 MG ORAL TABS,RX-18922,CDM,S5000,HCPCS,259,RC,68084-0344-11,NDC,outpatient,1,UN,2.19,1.533,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ATORVASTATIN CALCIUM 10 MG ORAL TABS,RX-19176,CDM,S5000,HCPCS,259,RC,00904-6290-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ATORVASTATIN CALCIUM 20 MG ORAL TABS,RX-19178,CDM,S5000,HCPCS,259,RC,00904-6291-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AZELASTINE HCL 0.1 % NA SOLN,RX-19179,CDM,S5000,HCPCS,259,RC,60505-0833-05,NDC,outpatient,30,ML,24.97,17.479,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CABERGOLINE 0.5 MG ORAL TABS,RX-19226,CDM,S5000,HCPCS,259,RC,59762-1005-01,NDC,outpatient,1,UN,22.17,15.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CABERGOLINE 0.5 MG ORAL TABS,RX-19226,CDM,S5000,HCPCS,259,RC,23155-0823-73,NDC,outpatient,1,UN,8.36,5.852,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CABERGOLINE 0.5 MG ORAL TABS,RX-19226,CDM,S5000,HCPCS,259,RC,50742-0118-08,NDC,outpatient,1,UN,13.91,9.737,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PHENYLEPHRINE HCL 10 % OP SOLN,RX-19636,CDM,S5000,HCPCS,259,RC,70756-0614-30,NDC,outpatient,5,ML,178,124.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BENZOCAINE 20 % MT GEL,RX-19691,CDM,S5000,HCPCS,259,RC,10310-0566-20,NDC,outpatient,11.9,GR,20.34,14.238,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CARBACHOL 0.01 % IO SOLN,RX-19704,CDM,S5000,HCPCS,259,RC,00065-0023-15,NDC,outpatient,1.5,ML,66,46.2,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DIAZOXIDE 50 MG/ML ORAL SUSP,RX-19713,CDM,S5000,HCPCS,259,RC,00254-1010-19,NDC,outpatient,30,ML,1132.89,793.023,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DIAZOXIDE 50 MG/ML ORAL SUSP,RX-19713,CDM,S5000,HCPCS,259,RC,99999-0003-50,NDC,outpatient,1,ML,37.77,26.439,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DICLOFENAC SODIUM 0.1 % OP SOLN,RX-19714,CDM,S5000,HCPCS,259,RC,61314-0014-25,NDC,outpatient,2.5,ML,39.79,27.853,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DICLOFENAC SODIUM 0.1 % OP SOLN,RX-19714,CDM,S5000,HCPCS,259,RC,24208-0457-05,NDC,outpatient,5,ML,46.46,32.522,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLUOROMETHOLONE 0.25 % OP SUSP,RX-19722,CDM,S5000,HCPCS,259,RC,11980-0228-05,NDC,outpatient,5,ML,692.51,484.757,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP,RX-19736,CDM,S5000,HCPCS,250,RC,00009-0746-30,NDC,outpatient,1,ML,216.41,151.487,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP,RX-19736,CDM,S5000,HCPCS,250,RC,00548-5400-00,NDC,outpatient,1,ML,75.65,52.955,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METHYLCELLULOSE (LAXATIVE) 500 MG ORAL TABS,RX-19740,CDM,S5000,HCPCS,259,RC,00135-0199-02,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METHYLCELLULOSE (LAXATIVE) 500 MG ORAL TABS,RX-19740,CDM,S5000,HCPCS,259,RC,49348-0541-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OFLOXACIN 0.3 % OP SOLN,RX-19746,CDM,S5000,HCPCS,259,RC,60505-0560-00,NDC,outpatient,5,ML,32.22,22.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OFLOXACIN 0.3 % OP SOLN,RX-19746,CDM,S5000,HCPCS,259,RC,64980-0515-05,NDC,outpatient,5,ML,58.61,41.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POVIDONE-IODINE 5 % OP SOLN,RX-19791,CDM,S5000,HCPCS,259,RC,00065-0411-30,NDC,outpatient,30,ML,45.26,31.682,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NEOMYCIN-POLYMYXIN-PRAMOXINE 1 % EX CREA,RX-19880,CDM,S5000,HCPCS,259,RC,12547-0407-40,NDC,outpatient,14.2,GR,19.03,13.321,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SERTRALINE HCL 25 MG ORAL TABS,RX-19882,CDM,S5000,HCPCS,259,RC,60687-0231-11,NDC,outpatient,1,UN,1.26,0.882,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SERTRALINE HCL 25 MG ORAL TABS,RX-19882,CDM,S5000,HCPCS,259,RC,60687-0231-01,NDC,outpatient,1,UN,1.26,0.882,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NELFINAVIR MESYLATE 250 MG ORAL TABS,RX-20032,CDM,S5000,HCPCS,259,RC,63010-0010-30,NDC,outpatient,1,UN,17.47,12.229,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MESNA 400 MG ORAL TABS,RX-20077,CDM,S5000,HCPCS,259,RC,67108-3565-09,NDC,outpatient,1,UN,287.17,201.019,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CYANOCOBALAMIN 100 MCG ORAL TABS,RX-2008,CDM,S5000,HCPCS,259,RC,50268-0852-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CYANOCOBALAMIN 100 MCG ORAL TABS,RX-2008,CDM,S5000,HCPCS,259,RC,50268-0852-15,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CYCLOBENZAPRINE HCL 10 MG ORAL TABS,RX-2017,CDM,S5000,HCPCS,259,RC,60687-0558-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CYCLOBENZAPRINE HCL 10 MG ORAL TABS,RX-2017,CDM,S5000,HCPCS,259,RC,60687-0558-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CYCLOPENTOLATE HCL 1 % OP SOLN,RX-2025,CDM,S5000,HCPCS,259,RC,24208-0735-01,NDC,outpatient,2,ML,47.31,33.117,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CYCLOPENTOLATE HCL 1 % OP SOLN,RX-2025,CDM,S5000,HCPCS,259,RC,24208-0735-06,NDC,outpatient,15,ML,121.82,85.274,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CYPROHEPTADINE HCL 4 MG ORAL TABS,RX-2033,CDM,S5000,HCPCS,259,RC,50268-0189-11,NDC,outpatient,1,UN,2.94,2.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CYPROHEPTADINE HCL 4 MG ORAL TABS,RX-2033,CDM,S5000,HCPCS,259,RC,50268-0189-15,NDC,outpatient,1,UN,2.94,2.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CYSTEINE HCL 50 MG/ML IV SOLN,RX-2034,CDM,S5000,HCPCS,250,RC,51754-1007-01,NDC,outpatient,10,ML,375.94,263.158,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CYSTEINE HCL 50 MG/ML IV SOLN,RX-2034,CDM,S5000,HCPCS,250,RC,51754-1007-03,NDC,outpatient,10,ML,375.94,263.158,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ANAGRELIDE HCL 0.5 MG ORAL CAPS,RX-20446,CDM,S5000,HCPCS,259,RC,00172-5241-60,NDC,outpatient,1,UN,3.43,2.401,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ANAGRELIDE HCL 0.5 MG ORAL CAPS,RX-20446,CDM,S5000,HCPCS,259,RC,13668-0453-01,NDC,outpatient,1,UN,2.97,2.079,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,00143-9506-10,NDC,outpatient,10,ML,25.46,17.822,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,55150-0221-10,NDC,outpatient,10,ML,12.44,8.708,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,00143-9507-01,NDC,outpatient,20,ML,27.51,19.257,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,00143-9507-10,NDC,outpatient,20,ML,27.51,19.257,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,00143-9506-01,NDC,outpatient,10,ML,25.46,17.822,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,72266-0146-01,NDC,outpatient,10,ML,13.73,9.611,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ETOMIDATE 2 MG/ML IV SOLN,RX-20472,CDM,S5000,HCPCS,250,RC,72266-0146-10,NDC,outpatient,10,ML,13.73,9.611,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MELOXICAM 7.5 MG ORAL TABS,RX-20566,CDM,S5000,HCPCS,259,RC,50268-0525-15,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MELOXICAM 7.5 MG ORAL TABS,RX-20566,CDM,S5000,HCPCS,259,RC,50268-0525-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PYRETHRINS-PIPERONYL BUTOXIDE 0.33-4 % EX LIQD,RX-20781,CDM,S5000,HCPCS,259,RC,49348-0443-34,NDC,outpatient,118,ML,21.53,15.071,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MIGLITOL 25 MG ORAL TABS,RX-20799,CDM,S5000,HCPCS,259,RC,69367-0303-01,NDC,outpatient,1,UN,7.35,5.145,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,00143-9785-10,NDC,outpatient,5,ML,20.56,14.392,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,63323-0494-05,NDC,outpatient,5,ML,9.31,6.517,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,70860-0784-05,NDC,outpatient,5,ML,10.16,7.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,70860-0784-41,NDC,outpatient,5,ML,10.16,7.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,00143-9785-01,NDC,outpatient,5,ML,20.56,14.392,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VALPROATE SODIUM 100 MG/ML IV SOLN,RX-20887,CDM,S5000,HCPCS,250,RC,63323-0494-01,NDC,outpatient,5,ML,9.31,6.517,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AZITHROMYCIN 250 MG ORAL TABS,RX-20943,CDM,S5000,HCPCS,259,RC,60687-0742-01,NDC,outpatient,1,UN,3.5,2.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AZITHROMYCIN 250 MG ORAL TABS,RX-20943,CDM,S5000,HCPCS,259,RC,60687-0742-11,NDC,outpatient,1,UN,3.5,2.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AZITHROMYCIN 250 MG ORAL TABS,RX-20943,CDM,S5000,HCPCS,259,RC,65862-0641-63,NDC,outpatient,1,UN,1.45,1.015,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVOCARNITINE 200 MG/ML IV SOLN,RX-20954,CDM,S5000,HCPCS,250,RC,54482-0147-01,NDC,outpatient,5,ML,99.51,69.657,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVOCARNITINE 200 MG/ML IV SOLN,RX-20954,CDM,S5000,HCPCS,250,RC,00143-9852-01,NDC,outpatient,5,ML,94.7,66.29,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVOCARNITINE 200 MG/ML IV SOLN,RX-20954,CDM,S5000,HCPCS,250,RC,00143-9852-10,NDC,outpatient,5,ML,94.7,66.29,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OLANZAPINE 2.5 MG ORAL TABS,RX-21057,CDM,S5000,HCPCS,259,RC,00904-6283-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXCARBAZEPINE 300 MG ORAL TABS,RX-21061,CDM,S5000,HCPCS,259,RC,60687-0722-01,NDC,outpatient,1,UN,2.53,1.771,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXCARBAZEPINE 300 MG ORAL TABS,RX-21061,CDM,S5000,HCPCS,259,RC,60687-0722-11,NDC,outpatient,1,UN,2.53,1.771,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXCARBAZEPINE 300 MG ORAL TABS,RX-21061,CDM,S5000,HCPCS,259,RC,62756-0184-88,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CITALOPRAM HYDROBROMIDE 20 MG ORAL TABS,RX-21062,CDM,S5000,HCPCS,259,RC,00904-6085-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMPHETAMINE-DEXTROAMPHETAMINE 5 MG ORAL TABS,RX-21284,CDM,S5000,HCPCS,259,RC,42806-0339-01,NDC,outpatient,1,UN,1.83,1.281,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PRAMIPEXOLE DIHYDROCHLORIDE 1 MG ORAL TABS,RX-21288,CDM,S5000,HCPCS,259,RC,60687-0592-11,NDC,outpatient,1,UN,3.34,2.338,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PRAMIPEXOLE DIHYDROCHLORIDE 1 MG ORAL TABS,RX-21288,CDM,S5000,HCPCS,259,RC,60687-0592-21,NDC,outpatient,1,UN,3.34,2.338,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PRAMIPEXOLE DIHYDROCHLORIDE 1.5 MG ORAL TABS,RX-21289,CDM,S5000,HCPCS,259,RC,68462-0334-90,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PRAMIPEXOLE DIHYDROCHLORIDE 0.25 MG ORAL TABS,RX-21290,CDM,S5000,HCPCS,259,RC,00904-6704-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PENTOXIFYLLINE ER 400 MG ORAL TBCR,RX-21300,CDM,S5000,HCPCS,259,RC,00904-5448-61,NDC,outpatient,1,UN,1.11,0.777,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PENTOXIFYLLINE ER 400 MG ORAL TBCR,RX-21300,CDM,S5000,HCPCS,259,RC,60505-0033-06,NDC,outpatient,1,UN,2.18,1.526,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DAPSONE 100 MG ORAL TABS,RX-2131,CDM,S5000,HCPCS,259,RC,70954-0136-10,NDC,outpatient,1,UN,5.05,3.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DAPSONE 25 MG ORAL TABS,RX-2132,CDM,S5000,HCPCS,259,RC,70954-0135-10,NDC,outpatient,1,UN,4.35,3.045,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LETROZOLE 2.5 MG ORAL TABS,RX-21509,CDM,S5000,HCPCS,259,RC,00078-0249-15,NDC,outpatient,1,UN,108.93,76.251,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LETROZOLE 2.5 MG ORAL TABS,RX-21509,CDM,S5000,HCPCS,259,RC,59651-0180-30,NDC,outpatient,1,UN,1.55,1.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CARMUSTINE IN POLIFEPROSAN 7.7 MG IL WAFR,RX-21672,CDM,S5000,HCPCS,250,RC,24338-0050-08,NDC,outpatient,8,UN,110831.48,77582.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ROPINIROLE HCL 0.25 MG ORAL TABS,RX-21688,CDM,S5000,HCPCS,259,RC,00904-6373-61,NDC,outpatient,1,UN,1.51,1.057,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ROPINIROLE HCL 1 MG ORAL TABS,RX-21689,CDM,S5000,HCPCS,259,RC,00904-6374-61,NDC,outpatient,1,UN,1.76,1.232,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ROPINIROLE HCL 2 MG ORAL TABS,RX-21690,CDM,S5000,HCPCS,259,RC,50268-0744-15,NDC,outpatient,1,UN,2.46,1.722,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ROPINIROLE HCL 2 MG ORAL TABS,RX-21690,CDM,S5000,HCPCS,259,RC,50268-0744-11,NDC,outpatient,1,UN,2.46,1.722,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
QUETIAPINE FUMARATE 25 MG ORAL TABS,RX-21823,CDM,S5000,HCPCS,259,RC,60687-0327-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
QUETIAPINE FUMARATE 25 MG ORAL TABS,RX-21823,CDM,S5000,HCPCS,259,RC,60687-0327-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
QUETIAPINE FUMARATE 25 MG ORAL TABS,RX-21823,CDM,S5000,HCPCS,259,RC,00904-6638-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
QUETIAPINE FUMARATE 100 MG ORAL TABS,RX-21824,CDM,S5000,HCPCS,259,RC,00904-6640-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TIAGABINE HCL 4 MG ORAL TABS,RX-21827,CDM,S5000,HCPCS,259,RC,62756-0224-83,NDC,outpatient,1,UN,16.11,11.277,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IRBESARTAN 150 MG ORAL TABS,RX-21848,CDM,S5000,HCPCS,259,RC,31722-0730-90,NDC,outpatient,1,UN,1.91,1.337,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IRBESARTAN 150 MG ORAL TABS,RX-21848,CDM,S5000,HCPCS,259,RC,33342-0048-10,NDC,outpatient,1,UN,1.15,0.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLOPIDOGREL BISULFATE 75 MG ORAL TABS,RX-22142,CDM,S5000,HCPCS,259,RC,00904-6294-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RALOXIFENE HCL 60 MG ORAL TABS,RX-22143,CDM,S5000,HCPCS,259,RC,60687-0266-21,NDC,outpatient,1,UN,23.4,16.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RALOXIFENE HCL 60 MG ORAL TABS,RX-22143,CDM,S5000,HCPCS,259,RC,60687-0266-11,NDC,outpatient,1,UN,23.4,16.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DILTIAZEM HCL 100 MG IV SOLR,RX-22156,CDM,S5000,HCPCS,250,RC,00409-4350-03,NDC,outpatient,1,UN,40.12,28.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DILTIAZEM HCL 100 MG IV SOLR,RX-22156,CDM,S5000,HCPCS,250,RC,00409-4350-13,NDC,outpatient,1,UN,40.12,28.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TOBRAMYCIN 300 MG/5ML IN NEBU,RX-22240,CDM,S5000,HCPCS,259,RC,68180-0962-04,NDC,outpatient,5,ML,27.71,19.397,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TOBRAMYCIN 300 MG/5ML IN NEBU,RX-22240,CDM,S5000,HCPCS,259,RC,70756-0604-44,NDC,outpatient,5,ML,19.47,13.629,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TOBRAMYCIN 300 MG/5ML IN NEBU,RX-22240,CDM,S5000,HCPCS,259,RC,70756-0604-56,NDC,outpatient,5,ML,19.47,13.629,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TOBRAMYCIN 300 MG/5ML IN NEBU,RX-22240,CDM,S5000,HCPCS,259,RC,68180-0962-56,NDC,outpatient,5,ML,27.71,19.397,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MUPIROCIN CALCIUM 2 % EX CREA,RX-22251,CDM,S5000,HCPCS,259,RC,51672-1370-01,NDC,outpatient,15,GR,62.62,43.834,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MUPIROCIN CALCIUM 2 % EX CREA,RX-22251,CDM,S5000,HCPCS,259,RC,68462-0564-17,NDC,outpatient,15,GR,861.28,602.896,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OFLOXACIN 0.3 % OT SOLN,RX-22257,CDM,S5000,HCPCS,259,RC,70756-0609-15,NDC,outpatient,5,ML,31.29,21.903,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OFLOXACIN 0.3 % OT SOLN,RX-22257,CDM,S5000,HCPCS,259,RC,24208-0410-05,NDC,outpatient,5,ML,214.49,150.143,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LACTASE 3000 UNITS ORAL TABS,RX-22469,CDM,S5000,HCPCS,259,RC,77333-0430-25,NDC,outpatient,1,UN,1.55,1.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LACTASE 3000 UNITS ORAL TABS,RX-22469,CDM,S5000,HCPCS,259,RC,00904-5224-52,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LACTASE 3000 UNITS ORAL TABS,RX-22469,CDM,S5000,HCPCS,259,RC,77333-0430-50,NDC,outpatient,1,UN,1.55,1.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MONTELUKAST SODIUM 10 MG ORAL TABS,RX-22509,CDM,S5000,HCPCS,259,RC,00904-6808-06,NDC,outpatient,1,UN,1.19,0.833,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MONTELUKAST SODIUM 10 MG ORAL TABS,RX-22509,CDM,S5000,HCPCS,259,RC,00904-6808-61,NDC,outpatient,1,UN,1.44,1.008,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MONTELUKAST SODIUM 5 MG ORAL CHEW,RX-22510,CDM,S5000,HCPCS,259,RC,50268-0574-11,NDC,outpatient,1,UN,2.8,1.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MONTELUKAST SODIUM 5 MG ORAL CHEW,RX-22510,CDM,S5000,HCPCS,259,RC,50268-0574-15,NDC,outpatient,1,UN,2.8,1.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML ORAL SUSP,RX-22560,CDM,S5000,HCPCS,259,RC,00121-0853-40,NDC,outpatient,20,ML,60.61,42.427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML ORAL SUSP,RX-22560,CDM,S5000,HCPCS,259,RC,99999-0002-45,NDC,outpatient,20,ML,22.52,15.764,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML ORAL SUSP,RX-22560,CDM,S5000,HCPCS,259,RC,00121-0853-20,NDC,outpatient,20,ML,60.61,42.427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
REPAGLINIDE 2 MG ORAL TABS,RX-22585,CDM,S5000,HCPCS,259,RC,65862-0672-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
REPAGLINIDE 1 MG ORAL TABS,RX-22586,CDM,S5000,HCPCS,259,RC,65862-0671-01,NDC,outpatient,1,UN,1.06,0.742,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POTASSIUM CITRATE-CITRIC ACID 1100-334 MG/5ML ORAL SOLN,RX-22646,CDM,S5000,HCPCS,259,RC,99999-0002-34,NDC,outpatient,15,ML,3.14,2.198,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POTASSIUM CITRATE-CITRIC ACID 1100-334 MG/5ML ORAL SOLN,RX-22646,CDM,S5000,HCPCS,259,RC,60258-0003-16,NDC,outpatient,10,ML,5.88,4.116,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POTASSIUM CITRATE-CITRIC ACID 1100-334 MG/5ML ORAL SOLN,RX-22646,CDM,S5000,HCPCS,259,RC,00121-0676-16,NDC,outpatient,15,ML,3.61,2.527,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
URSODIOL 250 MG ORAL TABS,RX-22660,CDM,S5000,HCPCS,259,RC,00904-6890-04,NDC,outpatient,1,UN,10.99,7.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
URSODIOL 250 MG ORAL TABS,RX-22660,CDM,S5000,HCPCS,259,RC,60687-0527-11,NDC,outpatient,1,UN,6.99,4.893,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
URSODIOL 250 MG ORAL TABS,RX-22660,CDM,S5000,HCPCS,259,RC,60687-0527-21,NDC,outpatient,1,UN,6.99,4.893,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
URSODIOL 250 MG ORAL TABS,RX-22660,CDM,S5000,HCPCS,259,RC,68462-0473-01,NDC,outpatient,1,UN,2.31,1.617,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DESIPRAMINE HCL 25 MG ORAL TABS,RX-2286,CDM,S5000,HCPCS,259,RC,50742-0113-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PAROXETINE HCL 10 MG/5ML ORAL SUSP,RX-22959,CDM,S5000,HCPCS,259,RC,99999-0001-34,NDC,outpatient,10,ML,72.98,51.086,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PAROXETINE HCL 10 MG/5ML ORAL SUSP,RX-22959,CDM,S5000,HCPCS,259,RC,70954-0319-10,NDC,outpatient,5,ML,32.69,22.883,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN,RX-22982,CDM,S5000,HCPCS,259,RC,24208-0486-10,NDC,outpatient,10,ML,45.62,31.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN,RX-22982,CDM,S5000,HCPCS,259,RC,65862-0946-01,NDC,outpatient,10,ML,89,62.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN,RX-22982,CDM,S5000,HCPCS,259,RC,71921-0226-10,NDC,outpatient,10,ML,45.39,31.773,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN,RX-22982,CDM,S5000,HCPCS,259,RC,82584-0605-10,NDC,outpatient,10,ML,996.05,697.235,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DORZOLAMIDE HCL-TIMOLOL MAL 2-0.5 % OP SOLN,RX-22982,CDM,S5000,HCPCS,259,RC,70069-0051-01,NDC,outpatient,10,ML,38.99,27.293,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMOXICILLIN-POT CLAVULANATE 250-125 MG ORAL TABS,RX-22992,CDM,S5000,HCPCS,259,RC,42571-0160-30,NDC,outpatient,1,UN,9.65,6.755,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMOXICILLIN-POT CLAVULANATE 250-125 MG ORAL TABS,RX-22992,CDM,S5000,HCPCS,259,RC,00781-1874-31,NDC,outpatient,1,UN,6.58,4.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CAPECITABINE 500 MG ORAL TABS,RX-22994,CDM,S5000,HCPCS,259,RC,00004-1101-50,NDC,outpatient,1,UN,195.05,136.535,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CAPECITABINE 500 MG ORAL TABS,RX-22994,CDM,S5000,HCPCS,259,RC,16729-0073-29,NDC,outpatient,1,UN,1.65,1.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RISEDRONATE SODIUM 30 MG ORAL TABS,RX-23015,CDM,S5000,HCPCS,259,RC,00093-3100-56,NDC,outpatient,1,UN,220.55,154.385,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CAMPHOR-MENTHOL 0.5-0.5 % EX LOTN,RX-23063,CDM,S5000,HCPCS,259,RC,00536-1268-12,NDC,outpatient,222,ML,16.8,11.76,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CAMPHOR-MENTHOL 0.5-0.5 % EX LOTN,RX-23063,CDM,S5000,HCPCS,259,RC,46122-0573-10,NDC,outpatient,222,ML,11.13,7.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLINISOL SF 15 % IV SOLN,RX-23068,CDM,S5000,HCPCS,250,RC,00338-0502-06,NDC,outpatient,2000,ML,211.8,148.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLINIMIX E/DEXTROSE (5/15) 5 % IV SOLN,RX-23165,CDM,S5000,HCPCS,250,RC,00338-1123-04,NDC,outpatient,2000,ML,211.8,148.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLINIMIX E/DEXTROSE (5/15) 5 % IV SOLN,RX-23165,CDM,S5000,HCPCS,250,RC,00338-1147-03,NDC,outpatient,1000,ML,122.8,85.96,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DEXAMETHASONE 0.5 MG ORAL TABS,RX-2322,CDM,S5000,HCPCS,259,RC,00054-8179-25,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CANDESARTAN CILEXETIL 4 MG ORAL TABS,RX-23229,CDM,S5000,HCPCS,259,RC,33342-0114-07,NDC,outpatient,1,UN,5.64,3.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CANDESARTAN CILEXETIL 4 MG ORAL TABS,RX-23229,CDM,S5000,HCPCS,259,RC,62332-0341-90,NDC,outpatient,1,UN,4.08,2.856,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CANDESARTAN CILEXETIL 16 MG ORAL TABS,RX-23231,CDM,S5000,HCPCS,259,RC,33342-0116-07,NDC,outpatient,1,UN,4.6,3.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DEXAMETHASONE 1 MG ORAL TABS,RX-2324,CDM,S5000,HCPCS,259,RC,00054-8174-25,NDC,outpatient,1,UN,1.46,1.022,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DEXAMETHASONE 4 MG ORAL TABS,RX-2327,CDM,S5000,HCPCS,259,RC,00054-8175-25,NDC,outpatient,1,UN,4.2,2.94,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DEXAMETHASONE 4 MG ORAL TABS,RX-2327,CDM,S5000,HCPCS,259,RC,66993-0730-51,NDC,outpatient,1,UN,4.47,3.129,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DEXAMETHASONE 4 MG ORAL TABS,RX-2327,CDM,S5000,HCPCS,259,RC,66993-0730-80,NDC,outpatient,1,UN,4.47,3.129,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DEXAMETHASONE 6 MG ORAL TABS,RX-2328,CDM,S5000,HCPCS,259,RC,00054-8183-25,NDC,outpatient,1,UN,6.68,4.676,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DEXAMETHASONE SODIUM PHOSPHATE 0.1 % OP SOLN,RX-2335,CDM,S5000,HCPCS,259,RC,24208-0720-02,NDC,outpatient,5,ML,228.82,160.174,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE 4 % EX CREA,RX-23461,CDM,S5000,HCPCS,259,RC,00496-0882-05,NDC,outpatient,5,GR,12.51,8.757,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE 4 % EX CREA,RX-23461,CDM,S5000,HCPCS,259,RC,00496-0882-06,NDC,outpatient,5,GR,12.51,8.757,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE 4 % EX CREA,RX-23461,CDM,S5000,HCPCS,259,RC,39328-0024-30,NDC,outpatient,30,GR,40.32,28.224,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DEXTROSE 10 % IV SOLN,RX-2357,CDM,S5000,HCPCS,250,RC,00338-0023-02,NDC,outpatient,250,ML,25,17.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DEXTROSE 10 % IV SOLN,RX-2357,CDM,S5000,HCPCS,250,RC,00338-0023-04,NDC,outpatient,1000,ML,26.28,18.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DEXTROSE 20 % IV SOLN,RX-2359,CDM,S5000,HCPCS,250,RC,00990-7935-19,NDC,outpatient,500,ML,62.73,43.911,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DEXTROSE 250 MG/ML IV SOLN,RX-2361,CDM,S5000,HCPCS,250,RC,00409-1775-10,NDC,outpatient,10,ML,57.77,40.439,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-4902-34,NDC,outpatient,50,ML,59.41,41.587,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-6648-16,NDC,outpatient,50,ML,19.02,13.314,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-7517-66,NDC,outpatient,50,ML,58.08,40.656,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,76329-3302-01,NDC,outpatient,50,ML,66.31,46.417,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-6648-02,NDC,outpatient,50,ML,19.02,13.314,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-7517-16,NDC,outpatient,50,ML,31.82,22.274,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,00409-4902-64,NDC,outpatient,50,ML,59.41,41.587,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,69374-0953-50,NDC,outpatient,50,ML,66.75,46.725,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DEXTROSE 50 % IV SOLN,RX-2365,CDM,S5000,HCPCS,250,RC,69623-0201-39,NDC,outpatient,50,ML,93.45,65.415,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
EFAVIRENZ 200 MG ORAL CAPS,RX-23900,CDM,S5000,HCPCS,259,RC,64980-0407-09,NDC,outpatient,1,UN,33.64,23.548,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DIAZEPAM 2 MG ORAL TABS,RX-2404,CDM,S5000,HCPCS,259,RC,51079-0284-20,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DIAZEPAM 2 MG ORAL TABS,RX-2404,CDM,S5000,HCPCS,259,RC,00172-3925-60,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DIAZEPAM 2 MG ORAL TABS,RX-2404,CDM,S5000,HCPCS,259,RC,51079-0284-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DIAZEPAM 5 MG ORAL TABS,RX-2405,CDM,S5000,HCPCS,259,RC,51079-0285-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DIAZEPAM 5 MG ORAL TABS,RX-2405,CDM,S5000,HCPCS,259,RC,51079-0285-20,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MICONAZOLE NITRATE 4 % VA CREA,RX-24050,CDM,S5000,HCPCS,259,RC,63736-0442-01,NDC,outpatient,15,GR,44.73,31.311,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DICLOXACILLIN SODIUM 250 MG ORAL CAPS,RX-2414,CDM,S5000,HCPCS,259,RC,00093-3123-01,NDC,outpatient,1,UN,2.5,1.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DICLOXACILLIN SODIUM 250 MG ORAL CAPS,RX-2414,CDM,S5000,HCPCS,259,RC,59651-0565-01,NDC,outpatient,1,UN,2.33,1.631,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MIDAZOLAM HCL 2 MG/ML ORAL SYRP,RX-24176,CDM,S5000,HCPCS,259,RC,68094-0764-59,NDC,outpatient,5,ML,21.65,15.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MIDAZOLAM HCL 2 MG/ML ORAL SYRP,RX-24176,CDM,S5000,HCPCS,259,RC,68094-0764-62,NDC,outpatient,5,ML,21.65,15.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DICYCLOMINE HCL 10 MG ORAL CAPS,RX-2418,CDM,S5000,HCPCS,259,RC,60687-0369-11,NDC,outpatient,1,UN,1.75,1.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DICYCLOMINE HCL 10 MG ORAL CAPS,RX-2418,CDM,S5000,HCPCS,259,RC,60687-0369-01,NDC,outpatient,1,UN,1.75,1.225,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DICYCLOMINE HCL 20 MG ORAL TABS,RX-2420,CDM,S5000,HCPCS,259,RC,60687-0380-11,NDC,outpatient,1,UN,1.8,1.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DICYCLOMINE HCL 20 MG ORAL TABS,RX-2420,CDM,S5000,HCPCS,259,RC,60687-0380-01,NDC,outpatient,1,UN,1.8,1.26,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG ORAL TABS,RX-24216,CDM,S5000,HCPCS,259,RC,00536-1248-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG ORAL TABS,RX-24216,CDM,S5000,HCPCS,259,RC,60687-0622-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG ORAL TABS,RX-24216,CDM,S5000,HCPCS,259,RC,60687-0622-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG ORAL TABS,RX-24216,CDM,S5000,HCPCS,259,RC,63739-0432-02,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ISOSORBIDE MONONITRATE ER 60 MG ORAL TAB,RX-24268,CDM,S5000,HCPCS,259,RC,00904-6450-61,NDC,outpatient,1,UN,1.31,0.917,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TELMISARTAN 40 MG ORAL TABS,RX-24335,CDM,S5000,HCPCS,259,RC,00597-0040-37,NDC,outpatient,1,UN,19.23,13.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROCORTISONE-ACETIC ACID 1-2 % OT SOLN,RX-24385,CDM,S5000,HCPCS,259,RC,51672-3007-01,NDC,outpatient,10,ML,303.14,212.198,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ABACAVIR SULFATE 300 MG ORAL TABS,RX-24438,CDM,S5000,HCPCS,259,RC,00378-4105-91,NDC,outpatient,1,UN,13.01,9.107,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ABACAVIR SULFATE 300 MG ORAL TABS,RX-24438,CDM,S5000,HCPCS,259,RC,68084-0021-11,NDC,outpatient,1,UN,26.71,18.697,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ABACAVIR SULFATE 300 MG ORAL TABS,RX-24438,CDM,S5000,HCPCS,259,RC,68084-0021-21,NDC,outpatient,1,UN,26.71,18.697,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DIGOXIN 125 MCG ORAL TABS,RX-2444,CDM,S5000,HCPCS,259,RC,00904-5921-61,NDC,outpatient,1,UN,3.14,2.198,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXYBUTYNIN CHLORIDE ER 5 MG ORAL TB24,RX-24470,CDM,S5000,HCPCS,259,RC,00904-6570-04,NDC,outpatient,1,UN,7.7,5.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXYBUTYNIN CHLORIDE ER 5 MG ORAL TB24,RX-24470,CDM,S5000,HCPCS,259,RC,68084-0480-01,NDC,outpatient,1,UN,4.79,3.353,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXYBUTYNIN CHLORIDE ER 5 MG ORAL TB24,RX-24470,CDM,S5000,HCPCS,259,RC,68084-0480-11,NDC,outpatient,1,UN,4.79,3.353,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXYBUTYNIN CHLORIDE ER 5 MG ORAL TB24,RX-24470,CDM,S5000,HCPCS,259,RC,63739-0548-33,NDC,outpatient,1,UN,5.24,3.668,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXYBUTYNIN CHLORIDE ER 5 MG ORAL TB24,RX-24470,CDM,S5000,HCPCS,259,RC,00904-6570-61,NDC,outpatient,1,UN,5.08,3.556,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CILOSTAZOL 100 MG ORAL TABS,RX-24474,CDM,S5000,HCPCS,259,RC,50268-0177-11,NDC,outpatient,1,UN,3.18,2.226,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CILOSTAZOL 100 MG ORAL TABS,RX-24474,CDM,S5000,HCPCS,259,RC,50268-0177-15,NDC,outpatient,1,UN,3.18,2.226,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CELECOXIB 100 MG ORAL CAPS,RX-24500,CDM,S5000,HCPCS,259,RC,60687-0436-11,NDC,outpatient,1,UN,3.16,2.212,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CELECOXIB 100 MG ORAL CAPS,RX-24500,CDM,S5000,HCPCS,259,RC,00904-6502-61,NDC,outpatient,1,UN,3.56,2.492,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CELECOXIB 100 MG ORAL CAPS,RX-24500,CDM,S5000,HCPCS,259,RC,60687-0436-01,NDC,outpatient,1,UN,3.16,2.212,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CELECOXIB 200 MG ORAL CAPS,RX-24501,CDM,S5000,HCPCS,259,RC,00904-6503-61,NDC,outpatient,1,UN,5.49,3.843,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CELECOXIB 200 MG ORAL CAPS,RX-24501,CDM,S5000,HCPCS,259,RC,60505-3849-01,NDC,outpatient,1,UN,2.67,1.869,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ISOSORBIDE MONONITRATE ER 30 MG ORAL TB24,RX-24521,CDM,S5000,HCPCS,259,RC,00904-6449-61,NDC,outpatient,1,UN,1.08,0.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MODAFINIL 100 MG ORAL TABS,RX-24702,CDM,S5000,HCPCS,259,RC,00904-6791-04,NDC,outpatient,1,UN,21.38,14.966,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MODAFINIL 100 MG ORAL TABS,RX-24702,CDM,S5000,HCPCS,259,RC,50268-0570-12,NDC,outpatient,1,UN,25.83,18.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MODAFINIL 100 MG ORAL TABS,RX-24702,CDM,S5000,HCPCS,259,RC,50268-0570-11,NDC,outpatient,1,UN,25.83,18.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MODAFINIL 100 MG ORAL TABS,RX-24702,CDM,S5000,HCPCS,259,RC,68084-0621-11,NDC,outpatient,1,UN,21.38,14.966,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MODAFINIL 100 MG ORAL TABS,RX-24702,CDM,S5000,HCPCS,259,RC,68084-0621-21,NDC,outpatient,1,UN,21.38,14.966,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BELLADONNA ALKALOIDS-OPIUM 16.2-60 MG RE SUPP,RX-24731,CDM,S5000,HCPCS,259,RC,00574-7040-12,NDC,outpatient,1,UN,104.53,73.171,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DILTIAZEM HCL 30 MG ORAL TABS,RX-2475,CDM,S5000,HCPCS,259,RC,00093-0318-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DILTIAZEM HCL 30 MG ORAL TABS,RX-2475,CDM,S5000,HCPCS,259,RC,60687-0717-11,NDC,outpatient,1,UN,1.81,1.267,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DILTIAZEM HCL 30 MG ORAL TABS,RX-2475,CDM,S5000,HCPCS,259,RC,60687-0717-01,NDC,outpatient,1,UN,1.81,1.267,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DIMENHYDRINATE 50 MG ORAL TABS,RX-2485,CDM,S5000,HCPCS,259,RC,00904-2051-59,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TACROLIMUS 0.5 MG ORAL CAPS,RX-24914,CDM,S5000,HCPCS,259,RC,00904-6623-61,NDC,outpatient,1,UN,2.82,1.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU,RX-24915,CDM,S5000,HCPCS,259,RC,00093-4146-45,NDC,outpatient,3,ML,7.12,4.984,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU,RX-24915,CDM,S5000,HCPCS,259,RC,76204-0800-11,NDC,outpatient,3,ML,5.32,3.724,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU,RX-24915,CDM,S5000,HCPCS,259,RC,00093-4146-56,NDC,outpatient,3,ML,7.12,4.984,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU,RX-24915,CDM,S5000,HCPCS,259,RC,76204-0800-01,NDC,outpatient,3,ML,5.32,3.724,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVALBUTEROL HCL 1.25 MG/3ML IN NEBU,RX-24916,CDM,S5000,HCPCS,259,RC,76204-0900-01,NDC,outpatient,3,ML,5.47,3.829,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVALBUTEROL HCL 1.25 MG/3ML IN NEBU,RX-24916,CDM,S5000,HCPCS,259,RC,76204-0900-11,NDC,outpatient,3,ML,5.47,3.829,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,00378-8270-55,NDC,outpatient,3,ML,1.22,0.854,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,76204-0200-60,NDC,outpatient,3,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,00378-8270-31,NDC,outpatient,3,ML,1.22,0.854,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,47335-0703-49,NDC,outpatient,3,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,47335-0703-52,NDC,outpatient,3,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,60687-0395-79,NDC,outpatient,3,ML,1.02,0.714,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,00487-9501-01,NDC,outpatient,3,ML,1.41,0.987,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,47335-0703-48,NDC,outpatient,3,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,76204-0200-01,NDC,outpatient,3,ML,1.18,0.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU,RX-250,CDM,S5000,HCPCS,259,RC,60687-0395-83,NDC,outpatient,3,ML,1.02,0.714,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL SUSR,RX-25005,CDM,S5000,HCPCS,259,RC,66689-0307-08,NDC,outpatient,160,ML,1111.44,778.008,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MYCOPHENOLATE MOFETIL 200 MG/ML ORAL SUSR,RX-25005,CDM,S5000,HCPCS,259,RC,99999-0002-21,NDC,outpatient,2.5,ML,69.2,48.44,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DIPHENHYDRAMINE HCL 25 MG ORAL CAPS,RX-2509,CDM,S5000,HCPCS,259,RC,00904-7237-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DIPHENHYDRAMINE HCL 12.5 MG/5ML ORAL SOLN,RX-2511,CDM,S5000,HCPCS,259,RC,00121-0489-00,NDC,outpatient,5,ML,15.4,10.78,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DIPHENHYDRAMINE HCL 12.5 MG/5ML ORAL SOLN,RX-2511,CDM,S5000,HCPCS,259,RC,00121-0489-05,NDC,outpatient,5,ML,15.4,10.78,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CIPROFLOXACIN HCL 250 MG ORAL TABS,RX-25118,CDM,S5000,HCPCS,259,RC,65862-0076-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CIPROFLOXACIN HCL 250 MG ORAL TABS,RX-25118,CDM,S5000,HCPCS,259,RC,62135-0308-01,NDC,outpatient,1,UN,12.1,8.47,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CIPROFLOXACIN HCL 250 MG ORAL TABS,RX-25118,CDM,S5000,HCPCS,259,RC,00143-9927-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DIPHENOXYLATE-ATROPINE 2.5-0.025 MG ORAL TABS,RX-2516,CDM,S5000,HCPCS,259,RC,00406-1236-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DIPHENOXYLATE-ATROPINE 2.5-0.025 MG ORAL TABS,RX-2516,CDM,S5000,HCPCS,259,RC,69315-0910-01,NDC,outpatient,1,UN,2.4,1.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALBUTEROL SULFATE 2 MG/5ML ORAL SYRP,RX-252,CDM,S5000,HCPCS,259,RC,70752-0102-12,NDC,outpatient,5,ML,1.91,1.337,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALBUTEROL SULFATE 2 MG/5ML ORAL SYRP,RX-252,CDM,S5000,HCPCS,259,RC,99999-0003-98,NDC,outpatient,5,ML,1.34,0.938,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALBUTEROL SULFATE 2 MG/5ML ORAL SYRP,RX-252,CDM,S5000,HCPCS,259,RC,00472-0825-16,NDC,outpatient,5,ML,1.24,0.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DIPYRIDAMOLE 25 MG ORAL TABS,RX-2528,CDM,S5000,HCPCS,259,RC,64980-0133-01,NDC,outpatient,1,UN,5.27,3.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALBUTEROL SULFATE 2 MG ORAL TABS,RX-253,CDM,S5000,HCPCS,259,RC,68084-0949-25,NDC,outpatient,1,UN,27.72,19.404,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALBUTEROL SULFATE 2 MG ORAL TABS,RX-253,CDM,S5000,HCPCS,259,RC,68084-0949-95,NDC,outpatient,1,UN,27.72,19.404,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DISOPYRAMIDE PHOSPHATE 100 MG ORAL CAPS,RX-2535,CDM,S5000,HCPCS,259,RC,00093-3127-01,NDC,outpatient,1,UN,5.28,3.696,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DISULFIRAM 250 MG ORAL TABS,RX-2540,CDM,S5000,HCPCS,259,RC,47781-0607-30,NDC,outpatient,1,UN,7.69,5.383,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POLYETHYLENE GLYCOL 3350 17 G ORAL PACK,RX-25424,CDM,S5000,HCPCS,259,RC,62559-0157-10,NDC,outpatient,1,UN,3.43,2.401,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POLYETHYLENE GLYCOL 3350 17 G ORAL PACK,RX-25424,CDM,S5000,HCPCS,259,RC,00904-6931-81,NDC,outpatient,1,UN,3.67,2.569,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POLYETHYLENE GLYCOL 3350 17 G ORAL PACK,RX-25424,CDM,S5000,HCPCS,259,RC,00904-6931-86,NDC,outpatient,1,UN,3.67,2.569,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POLYETHYLENE GLYCOL 3350 17 G ORAL PACK,RX-25424,CDM,S5000,HCPCS,259,RC,62559-0157-17,NDC,outpatient,1,UN,3.43,2.401,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DIVALPROEX SODIUM 125 MG ORAL TBEC,RX-2551,CDM,S5000,HCPCS,259,RC,60687-0211-21,NDC,outpatient,1,UN,3.46,2.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DIVALPROEX SODIUM 125 MG ORAL TBEC,RX-2551,CDM,S5000,HCPCS,259,RC,60687-0211-11,NDC,outpatient,1,UN,3.46,2.422,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RISPERIDONE 0.25 MG ORAL TABS,RX-25519,CDM,S5000,HCPCS,259,RC,68084-0270-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RISPERIDONE 0.25 MG ORAL TABS,RX-25519,CDM,S5000,HCPCS,259,RC,68084-0270-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RISPERIDONE 0.25 MG ORAL TABS,RX-25519,CDM,S5000,HCPCS,259,RC,68382-0112-14,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DIVALPROEX SODIUM 250 MG ORAL TBEC,RX-2552,CDM,S5000,HCPCS,259,RC,68084-0776-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DIVALPROEX SODIUM 250 MG ORAL TBEC,RX-2552,CDM,S5000,HCPCS,259,RC,68084-0776-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RISPERIDONE 0.5 MG ORAL TABS,RX-25520,CDM,S5000,HCPCS,259,RC,00904-7361-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PIOGLITAZONE HCL 15 MG ORAL TABS,RX-25528,CDM,S5000,HCPCS,259,RC,60687-0391-11,NDC,outpatient,1,UN,3.42,2.394,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PIOGLITAZONE HCL 15 MG ORAL TABS,RX-25528,CDM,S5000,HCPCS,259,RC,60687-0391-01,NDC,outpatient,1,UN,3.42,2.394,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DIVALPROEX SODIUM 500 MG ORAL TBEC,RX-2553,CDM,S5000,HCPCS,259,RC,68084-0782-61,NDC,outpatient,1,UN,1.16,0.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DIVALPROEX SODIUM 500 MG ORAL TBEC,RX-2553,CDM,S5000,HCPCS,259,RC,68084-0782-11,NDC,outpatient,1,UN,1.16,0.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DIVALPROEX SODIUM 500 MG ORAL TBEC,RX-2553,CDM,S5000,HCPCS,259,RC,00904-6861-90,NDC,outpatient,1,UN,1.2,0.84,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOCUSATE SODIUM 100 MG ORAL CAPS,RX-2566,CDM,S5000,HCPCS,259,RC,00904-7280-60,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOCUSATE SODIUM 100 MG ORAL CAPS,RX-2566,CDM,S5000,HCPCS,259,RC,00904-7183-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOCUSATE SODIUM 100 MG ORAL CAPS,RX-2566,CDM,S5000,HCPCS,259,RC,00904-7280-80,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IVERMECTIN 3 MG ORAL TABS,RX-25820,CDM,S5000,HCPCS,259,RC,42799-0806-01,NDC,outpatient,1,UN,14.59,10.213,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IVERMECTIN 3 MG ORAL TABS,RX-25820,CDM,S5000,HCPCS,259,RC,00006-0032-20,NDC,outpatient,1,UN,19.14,13.398,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOXEPIN HCL 10 MG ORAL CAPS,RX-2608,CDM,S5000,HCPCS,259,RC,00904-7052-61,NDC,outpatient,1,UN,2.19,1.533,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOXEPIN HCL 10 MG ORAL CAPS,RX-2608,CDM,S5000,HCPCS,259,RC,51079-0436-20,NDC,outpatient,1,UN,2.53,1.771,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOXEPIN HCL 10 MG ORAL CAPS,RX-2608,CDM,S5000,HCPCS,259,RC,51079-0436-01,NDC,outpatient,1,UN,2.53,1.771,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOXEPIN HCL 100 MG ORAL CAPS,RX-2609,CDM,S5000,HCPCS,259,RC,51079-0651-20,NDC,outpatient,1,UN,6.84,4.788,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOXEPIN HCL 100 MG ORAL CAPS,RX-2609,CDM,S5000,HCPCS,259,RC,00378-6410-01,NDC,outpatient,1,UN,5.48,3.836,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOXEPIN HCL 100 MG ORAL CAPS,RX-2609,CDM,S5000,HCPCS,259,RC,51079-0651-01,NDC,outpatient,1,UN,6.84,4.788,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOXEPIN HCL 25 MG ORAL CAPS,RX-2611,CDM,S5000,HCPCS,259,RC,00378-3125-01,NDC,outpatient,1,UN,2.29,1.603,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOXEPIN HCL 25 MG ORAL CAPS,RX-2611,CDM,S5000,HCPCS,259,RC,51079-0437-01,NDC,outpatient,1,UN,2.89,2.023,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOXEPIN HCL 25 MG ORAL CAPS,RX-2611,CDM,S5000,HCPCS,259,RC,51079-0437-20,NDC,outpatient,1,UN,2.89,2.023,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MUSCLE RUB 10-15 % EX CREA,RX-26210,CDM,S5000,HCPCS,259,RC,00536-1101-45,NDC,outpatient,85,GR,10.6,7.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MUSCLE RUB 10-15 % EX CREA,RX-26210,CDM,S5000,HCPCS,259,RC,00536-1349-57,NDC,outpatient,85,GR,9.08,6.356,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MUSCLE RUB 10-15 % EX CREA,RX-26210,CDM,S5000,HCPCS,259,RC,57896-0116-03,NDC,outpatient,85,GR,10.97,7.679,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,63323-0130-11,NDC,outpatient,1,UN,45.64,31.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,68382-0910-10,NDC,outpatient,1,UN,107.52,75.264,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,00143-9381-10,NDC,outpatient,1,UN,49.76,34.832,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,67457-0437-10,NDC,outpatient,1,UN,68.55,47.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,68382-0910-01,NDC,outpatient,1,UN,107.52,75.264,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,00143-9381-01,NDC,outpatient,1,UN,49.76,34.832,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,67457-0437-00,NDC,outpatient,1,UN,68.55,47.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOXYCYCLINE HYCLATE 100 MG IV SOLR,RX-2622,CDM,S5000,HCPCS,250,RC,63323-0130-02,NDC,outpatient,1,UN,45.64,31.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PANTOPRAZOLE SODIUM 40 MG ORAL TBEC,RX-26225,CDM,S5000,HCPCS,259,RC,00904-6474-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PANTOPRAZOLE SODIUM 40 MG ORAL TBEC,RX-26225,CDM,S5000,HCPCS,259,RC,51079-0051-20,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PANTOPRAZOLE SODIUM 40 MG ORAL TBEC,RX-26225,CDM,S5000,HCPCS,259,RC,35573-0428-51,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PANTOPRAZOLE SODIUM 40 MG ORAL TBEC,RX-26225,CDM,S5000,HCPCS,259,RC,51079-0051-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PANTOPRAZOLE SODIUM 40 MG ORAL TBEC,RX-26225,CDM,S5000,HCPCS,259,RC,35573-0428-80,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOXYCYCLINE HYCLATE 100 MG ORAL TABS,RX-2625,CDM,S5000,HCPCS,259,RC,00904-0430-06,NDC,outpatient,1,UN,5.29,3.703,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOXYCYCLINE HYCLATE 100 MG ORAL TABS,RX-2625,CDM,S5000,HCPCS,259,RC,00143-2112-50,NDC,outpatient,1,UN,1.07,0.749,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOXYCYCLINE HYCLATE 100 MG ORAL TABS,RX-2625,CDM,S5000,HCPCS,259,RC,62584-0693-21,NDC,outpatient,1,UN,4.84,3.388,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOXYCYCLINE HYCLATE 100 MG ORAL TABS,RX-2625,CDM,S5000,HCPCS,259,RC,62584-0693-11,NDC,outpatient,1,UN,4.84,3.388,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CARBIDOPA-LEVODOPA ER 50-200 MG ORAL TBCR,RX-26371,CDM,S5000,HCPCS,259,RC,68084-0282-11,NDC,outpatient,1,UN,4.16,2.912,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CARBIDOPA-LEVODOPA ER 50-200 MG ORAL TBCR,RX-26371,CDM,S5000,HCPCS,259,RC,68084-0282-01,NDC,outpatient,1,UN,4.16,2.912,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAPS,RX-26546,CDM,S5000,HCPCS,259,RC,31722-0632-31,NDC,outpatient,1,UN,4.28,2.996,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAPS,RX-26546,CDM,S5000,HCPCS,259,RC,64380-0799-01,NDC,outpatient,1,UN,8.24,5.768,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ENTACAPONE 200 MG ORAL TABS,RX-26547,CDM,S5000,HCPCS,259,RC,27241-0049-10,NDC,outpatient,1,UN,2.4,1.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ENTACAPONE 200 MG ORAL TABS,RX-26547,CDM,S5000,HCPCS,259,RC,60687-0188-11,NDC,outpatient,1,UN,18.43,12.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ENTACAPONE 200 MG ORAL TABS,RX-26547,CDM,S5000,HCPCS,259,RC,60687-0188-21,NDC,outpatient,1,UN,18.43,12.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
EXEMESTANE 25 MG ORAL TABS,RX-26551,CDM,S5000,HCPCS,259,RC,59762-2858-01,NDC,outpatient,1,UN,6.65,4.655,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVETIRACETAM 500 MG ORAL TABS,RX-26817,CDM,S5000,HCPCS,259,RC,65862-0246-08,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVETIRACETAM 500 MG ORAL TABS,RX-26817,CDM,S5000,HCPCS,259,RC,00904-7124-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MOXIFLOXACIN HCL 400 MG ORAL TABS,RX-26854,CDM,S5000,HCPCS,259,RC,65862-0603-30,NDC,outpatient,1,UN,13.67,9.569,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOFETILIDE 125 MCG ORAL CAPS,RX-26965,CDM,S5000,HCPCS,259,RC,16729-0490-12,NDC,outpatient,1,UN,6.58,4.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOFETILIDE 125 MCG ORAL CAPS,RX-26965,CDM,S5000,HCPCS,259,RC,69452-0131-17,NDC,outpatient,1,UN,2.23,1.561,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOFETILIDE 125 MCG ORAL CAPS,RX-26965,CDM,S5000,HCPCS,259,RC,72205-0039-60,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOFETILIDE 250 MCG ORAL CAPS,RX-26966,CDM,S5000,HCPCS,259,RC,69452-0132-17,NDC,outpatient,1,UN,2.23,1.561,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOFETILIDE 250 MCG ORAL CAPS,RX-26966,CDM,S5000,HCPCS,259,RC,00904-6682-08,NDC,outpatient,1,UN,13.18,9.226,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOFETILIDE 250 MCG ORAL CAPS,RX-26966,CDM,S5000,HCPCS,259,RC,42291-0412-60,NDC,outpatient,1,UN,1.48,1.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOFETILIDE 500 MCG ORAL CAPS,RX-26967,CDM,S5000,HCPCS,259,RC,00904-6683-08,NDC,outpatient,1,UN,13.31,9.317,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOFETILIDE 500 MCG ORAL CAPS,RX-26967,CDM,S5000,HCPCS,259,RC,42291-0413-60,NDC,outpatient,1,UN,1.4,0.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TERBINAFINE HCL 1 % EX CREA,RX-27023,CDM,S5000,HCPCS,259,RC,51672-2080-01,NDC,outpatient,15,GR,24.57,17.199,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREDNISOLONE ACETATE 0.12 % OP SUSP,RX-27038,CDM,S5000,HCPCS,259,RC,11980-0174-05,NDC,outpatient,5,ML,659.54,461.678,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXCARBAZEPINE 150 MG ORAL TABS,RX-27049,CDM,S5000,HCPCS,259,RC,60687-0711-11,NDC,outpatient,1,UN,1.81,1.267,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXCARBAZEPINE 150 MG ORAL TABS,RX-27049,CDM,S5000,HCPCS,259,RC,60687-0711-01,NDC,outpatient,1,UN,1.81,1.267,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CHARCOAL ACTIVATED ORAL LIQD,RX-27099,CDM,S5000,HCPCS,259,RC,66689-0202-04,NDC,outpatient,120,ML,82.77,57.939,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RISEDRONATE SODIUM 5 MG ORAL TABS,RX-27112,CDM,S5000,HCPCS,259,RC,33342-0107-07,NDC,outpatient,1,UN,11.13,7.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NIACIN ER (ANTIHYPERLIPIDEMIC) 500 MG ORAL TBCR,RX-27181,CDM,S5000,HCPCS,259,RC,47335-0539-81,NDC,outpatient,1,UN,1.02,0.714,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NIACIN ER (ANTIHYPERLIPIDEMIC) 500 MG ORAL TBCR,RX-27181,CDM,S5000,HCPCS,259,RC,59651-0018-90,NDC,outpatient,1,UN,1.7,1.19,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MAGNESIUM SULFATE (LAXATIVE) ORAL GRAN,RX-27322,CDM,S5000,HCPCS,259,RC,70677-0038-01,NDC,outpatient,454,GR,8.09,5.663,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MAGNESIUM SULFATE (LAXATIVE) ORAL GRAN,RX-27322,CDM,S5000,HCPCS,259,RC,49580-0394-04,NDC,outpatient,1814,GR,16.15,11.305,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MAGNESIUM SULFATE (LAXATIVE) ORAL GRAN,RX-27322,CDM,S5000,HCPCS,259,RC,70677-1210-01,NDC,outpatient,454,GR,8.09,5.663,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MINERAL OIL LIGHT OIL,RX-27386,CDM,S5000,HCPCS,259,RC,63323-0254-10,NDC,outpatient,10,ML,39.03,27.321,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MINERAL OIL LIGHT OIL,RX-27386,CDM,S5000,HCPCS,259,RC,63323-0254-02,NDC,outpatient,2,ML,34.38,24.066,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
THEOPHYLLINE ER 100 MG ORAL CP24,RX-27418,CDM,S5000,HCPCS,259,RC,52244-0100-10,NDC,outpatient,1,UN,14.48,10.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PENTAMIDINE ISETHIONATE 300 MG IJ SOLR,RX-27430,CDM,S5000,HCPCS,250,RC,63323-0113-10,NDC,outpatient,1,UN,686.14,480.298,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DINOPROSTONE 10 MG VA INST,RX-27467,CDM,S5000,HCPCS,259,RC,55566-2800-01,NDC,outpatient,1,UN,2100.63,1470.441,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NITROGLYCERIN 0.1 MG/HR TD PT24,RX-27471,CDM,S5000,HCPCS,259,RC,00378-9102-93,NDC,outpatient,1,UN,2.47,1.729,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NITROGLYCERIN 0.1 MG/HR TD PT24,RX-27471,CDM,S5000,HCPCS,259,RC,00378-9102-16,NDC,outpatient,1,UN,2.47,1.729,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NITROGLYCERIN 0.2 MG/HR TD PT24,RX-27472,CDM,S5000,HCPCS,259,RC,00378-9104-16,NDC,outpatient,1,UN,2.2,1.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NITROGLYCERIN 0.2 MG/HR TD PT24,RX-27472,CDM,S5000,HCPCS,259,RC,00378-9104-93,NDC,outpatient,1,UN,2.2,1.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NITROGLYCERIN 0.3 MG/HR TD PT24,RX-27473,CDM,S5000,HCPCS,259,RC,50742-0515-01,NDC,outpatient,1,UN,217.89,152.523,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NITROGLYCERIN 0.3 MG/HR TD PT24,RX-27473,CDM,S5000,HCPCS,259,RC,50742-0515-30,NDC,outpatient,1,UN,217.89,152.523,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NITROGLYCERIN 0.4 MG/HR TD PT24,RX-27474,CDM,S5000,HCPCS,259,RC,43598-0894-30,NDC,outpatient,1,UN,9.32,6.524,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NITROGLYCERIN 0.4 MG/HR TD PT24,RX-27474,CDM,S5000,HCPCS,259,RC,00378-9112-93,NDC,outpatient,1,UN,2.77,1.939,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NITROGLYCERIN 0.4 MG/HR TD PT24,RX-27474,CDM,S5000,HCPCS,259,RC,00378-9112-16,NDC,outpatient,1,UN,2.77,1.939,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NITROGLYCERIN 0.6 MG/HR TD PT24,RX-27475,CDM,S5000,HCPCS,259,RC,00378-9116-16,NDC,outpatient,1,UN,3.17,2.219,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NITROGLYCERIN 0.6 MG/HR TD PT24,RX-27475,CDM,S5000,HCPCS,259,RC,00378-9116-93,NDC,outpatient,1,UN,3.17,2.219,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FELODIPINE ER 2.5 MG ORAL TB24,RX-27489,CDM,S5000,HCPCS,259,RC,13668-0132-01,NDC,outpatient,1,UN,1.96,1.372,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FELODIPINE ER 2.5 MG ORAL TB24,RX-27489,CDM,S5000,HCPCS,259,RC,00603-3581-21,NDC,outpatient,1,UN,1.73,1.211,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FELODIPINE ER 2.5 MG ORAL TB24,RX-27489,CDM,S5000,HCPCS,259,RC,68462-0233-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DM-GUAIFENESIN ER 30-600 MG ORAL TB12,RX-27543,CDM,S5000,HCPCS,259,RC,00536-1161-37,NDC,outpatient,1,UN,1.77,1.239,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DM-GUAIFENESIN ER 30-600 MG ORAL TB12,RX-27543,CDM,S5000,HCPCS,259,RC,63824-0056-34,NDC,outpatient,1,UN,1.93,1.351,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DIVALPROEX SODIUM 125 MG ORAL CSDR,RX-27631,CDM,S5000,HCPCS,259,RC,68084-0313-11,NDC,outpatient,1,UN,3.24,2.268,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DIVALPROEX SODIUM 125 MG ORAL CSDR,RX-27631,CDM,S5000,HCPCS,259,RC,68084-0313-01,NDC,outpatient,1,UN,3.24,2.268,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DIVALPROEX SODIUM 125 MG ORAL CSDR,RX-27631,CDM,S5000,HCPCS,259,RC,68382-0106-01,NDC,outpatient,1,UN,1.55,1.085,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CARBAMAZEPINE ER 200 MG ORAL CP12,RX-27632,CDM,S5000,HCPCS,259,RC,50268-0171-11,NDC,outpatient,1,UN,7.06,4.942,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CARBAMAZEPINE ER 200 MG ORAL CP12,RX-27632,CDM,S5000,HCPCS,259,RC,50268-0171-13,NDC,outpatient,1,UN,7.06,4.942,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CARBAMAZEPINE ER 300 MG ORAL CP12,RX-27633,CDM,S5000,HCPCS,259,RC,66993-0409-32,NDC,outpatient,1,UN,5.66,3.962,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CARBAMAZEPINE ER 100 MG ORAL TB12,RX-27634,CDM,S5000,HCPCS,259,RC,51672-4123-01,NDC,outpatient,1,UN,1.04,0.728,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CARBAMAZEPINE ER 400 MG ORAL TB12,RX-27636,CDM,S5000,HCPCS,259,RC,51672-4125-01,NDC,outpatient,1,UN,2.24,1.568,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ASPIRIN-DIPYRIDAMOLE ER 25-200 MG ORAL CP12,RX-27644,CDM,S5000,HCPCS,259,RC,49884-0007-02,NDC,outpatient,1,UN,22.19,15.533,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ASPIRIN-DIPYRIDAMOLE ER 25-200 MG ORAL CP12,RX-27644,CDM,S5000,HCPCS,259,RC,68462-0405-60,NDC,outpatient,1,UN,2.36,1.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NIFEDIPINE ER OSMOTIC RELEASE 60 MG ORAL TB24,RX-27659,CDM,S5000,HCPCS,259,RC,68084-0598-01,NDC,outpatient,1,UN,8.9,6.23,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NIFEDIPINE ER OSMOTIC RELEASE 60 MG ORAL TB24,RX-27659,CDM,S5000,HCPCS,259,RC,68084-0598-11,NDC,outpatient,1,UN,8.9,6.23,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NIFEDIPINE ER OSMOTIC RELEASE 90 MG ORAL TB24,RX-27660,CDM,S5000,HCPCS,259,RC,62175-0262-37,NDC,outpatient,1,UN,9.51,6.657,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NIFEDIPINE ER OSMOTIC RELEASE 90 MG ORAL TB24,RX-27660,CDM,S5000,HCPCS,259,RC,68084-0603-11,NDC,outpatient,1,UN,11.24,7.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NIFEDIPINE ER OSMOTIC RELEASE 90 MG ORAL TB24,RX-27660,CDM,S5000,HCPCS,259,RC,68084-0603-21,NDC,outpatient,1,UN,11.24,7.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLUORESCEIN SODIUM 1 MG OP STRP,RX-27663,CDM,S5000,HCPCS,259,RC,17238-0900-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TROLAMINE SALICYLATE 10 % EX CREA,RX-27680,CDM,S5000,HCPCS,259,RC,41167-0057-24,NDC,outpatient,141,GR,30.75,21.525,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DESMOPRESSIN ACE SPRAY REFRIG 0.01 % NA SOLN,RX-27770,CDM,S5000,HCPCS,259,RC,24208-0342-05,NDC,outpatient,5,ML,655.13,458.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ZONISAMIDE 100 MG ORAL CAPS,RX-27780,CDM,S5000,HCPCS,259,RC,50268-0816-11,NDC,outpatient,1,UN,2.24,1.568,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ZONISAMIDE 100 MG ORAL CAPS,RX-27780,CDM,S5000,HCPCS,259,RC,50268-0816-15,NDC,outpatient,1,UN,2.24,1.568,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-03,NDC,outpatient,500,ML,23.71,16.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-04,NDC,outpatient,1000,ML,21.14,14.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-41,NDC,outpatient,50,ML,22.94,16.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-48,NDC,outpatient,100,ML,22.69,15.883,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,,,outpatient,500,ML,21.14,14.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00264-1800-32,NDC,outpatient,100,ML,28.85,20.195,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-02,NDC,outpatient,250,ML,22.43,15.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-31,NDC,outpatient,50,ML,22.43,15.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-9543-02,NDC,outpatient,250,ML,25,17.5,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-9543-04,NDC,outpatient,500,ML,26.7,18.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00409-7101-67,NDC,outpatient,100,ML,25.77,18.039,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00487-4301-10,NDC,outpatient,100,ML,28.85,20.195,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE 0.9 % IV SOLN,RX-27838,CDM,S5000,HCPCS,250,RC,00338-0049-38,NDC,outpatient,100,ML,22.17,15.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VENLAFAXINE HCL ER 37.5 MG ORAL CP24,RX-27857,CDM,S5000,HCPCS,259,RC,68084-0698-11,NDC,outpatient,1,UN,2.07,1.449,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VENLAFAXINE HCL ER 37.5 MG ORAL CP24,RX-27857,CDM,S5000,HCPCS,259,RC,68084-0698-01,NDC,outpatient,1,UN,2.07,1.449,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VENLAFAXINE HCL ER 75 MG ORAL CP24,RX-27858,CDM,S5000,HCPCS,259,RC,68084-0709-01,NDC,outpatient,1,UN,2.26,1.582,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VENLAFAXINE HCL ER 75 MG ORAL CP24,RX-27858,CDM,S5000,HCPCS,259,RC,68084-0709-11,NDC,outpatient,1,UN,2.26,1.582,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VENLAFAXINE HCL ER 75 MG ORAL CP24,RX-27858,CDM,S5000,HCPCS,259,RC,00904-7077-61,NDC,outpatient,1,UN,1.54,1.078,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NICOTINE 7 MG/24HR TD PT24,RX-27860,CDM,S5000,HCPCS,259,RC,43598-0446-74,NDC,outpatient,1,UN,4.78,3.346,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NICOTINE 14 MG/24HR TD PT24,RX-27862,CDM,S5000,HCPCS,259,RC,43598-0447-74,NDC,outpatient,1,UN,5.28,3.696,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NICOTINE 21 MG/24HR TD PT24,RX-27863,CDM,S5000,HCPCS,259,RC,00536-5896-88,NDC,outpatient,1,UN,7.5,5.25,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NICOTINE 21 MG/24HR TD PT24,RX-27863,CDM,S5000,HCPCS,259,RC,43598-0448-28,NDC,outpatient,1,UN,5.25,3.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NICOTINE 21 MG/24HR TD PT24,RX-27863,CDM,S5000,HCPCS,259,RC,43598-0448-74,NDC,outpatient,1,UN,4.94,3.458,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NICOTINE 21 MG/24HR TD PT24,RX-27863,CDM,S5000,HCPCS,259,RC,00536-5896-33,NDC,outpatient,1,UN,7.5,5.25,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE VISCOUS HCL 2 % MT SOLN,RX-27898,CDM,S5000,HCPCS,259,RC,62135-0712-42,NDC,outpatient,5,ML,20.16,14.112,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE VISCOUS HCL 2 % MT SOLN,RX-27898,CDM,S5000,HCPCS,259,RC,99999-0002-05,NDC,outpatient,15,ML,60.48,42.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE VISCOUS HCL 2 % MT SOLN,RX-27898,CDM,S5000,HCPCS,259,RC,00054-3500-49,NDC,outpatient,5,ML,2.23,1.561,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE VISCOUS HCL 2 % MT SOLN,RX-27898,CDM,S5000,HCPCS,259,RC,72888-0125-26,NDC,outpatient,5,ML,2.5,1.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FENTANYL 25 MCG/HR TD PT72,RX-27905,CDM,S5000,HCPCS,259,RC,47781-0424-47,NDC,outpatient,1,UN,17.49,12.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FENTANYL 25 MCG/HR TD PT72,RX-27905,CDM,S5000,HCPCS,259,RC,47781-0424-11,NDC,outpatient,1,UN,17.49,12.243,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FENTANYL 50 MCG/HR TD PT72,RX-27906,CDM,S5000,HCPCS,259,RC,00378-9122-98,NDC,outpatient,1,UN,37.78,26.446,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FENTANYL 50 MCG/HR TD PT72,RX-27906,CDM,S5000,HCPCS,259,RC,47781-0426-11,NDC,outpatient,1,UN,25.49,17.843,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FENTANYL 50 MCG/HR TD PT72,RX-27906,CDM,S5000,HCPCS,259,RC,47781-0426-47,NDC,outpatient,1,UN,25.49,17.843,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FENTANYL 50 MCG/HR TD PT72,RX-27906,CDM,S5000,HCPCS,259,RC,00378-9122-16,NDC,outpatient,1,UN,37.78,26.446,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FENTANYL 75 MCG/HR TD PT72,RX-27907,CDM,S5000,HCPCS,259,RC,47781-0427-11,NDC,outpatient,1,UN,37.66,26.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FENTANYL 75 MCG/HR TD PT72,RX-27907,CDM,S5000,HCPCS,259,RC,47781-0427-47,NDC,outpatient,1,UN,37.66,26.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FENTANYL 100 MCG/HR TD PT72,RX-27908,CDM,S5000,HCPCS,259,RC,00378-9124-16,NDC,outpatient,1,UN,93.74,65.618,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FENTANYL 100 MCG/HR TD PT72,RX-27908,CDM,S5000,HCPCS,259,RC,00378-9124-98,NDC,outpatient,1,UN,93.74,65.618,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
EMPTY STERILIZED CONTAINER,RX-2795,CDM,S5000,HCPCS,250,RC,63323-0001-30,NDC,outpatient,1,UN,4.71,3.297,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
EMPTY STERILIZED CONTAINER,RX-2795,CDM,S5000,HCPCS,250,RC,63323-0001-10,NDC,outpatient,1,UN,3.99,2.793,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM POLYSTYRENE SULFONATE 15 GM/60ML ORAL SUSP,RX-27999,CDM,S5000,HCPCS,259,RC,46287-0006-60,NDC,outpatient,60,ML,91.85,64.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SERTRALINE HCL 20 MG/ML ORAL CONC,RX-28011,CDM,S5000,HCPCS,259,RC,16714-0601-02,NDC,outpatient,2.5,ML,10.37,7.259,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SERTRALINE HCL 20 MG/ML ORAL CONC,RX-28011,CDM,S5000,HCPCS,259,RC,99999-0003-51,NDC,outpatient,2.5,ML,10.37,7.259,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FE FUMARATE-B12-VIT C-FA-IFC ORAL CAPS,RX-28030,CDM,S5000,HCPCS,259,RC,51991-0635-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BENZOCAINE-MENTHOL 20-0.5 % EX AERO,RX-28048,CDM,S5000,HCPCS,259,RC,16864-0680-01,NDC,outpatient,78,GR,22.91,16.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BENZOCAINE-MENTHOL 20-0.5 % EX AERO,RX-28048,CDM,S5000,HCPCS,259,RC,16864-0680-02,NDC,outpatient,56,GR,17.7,12.39,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ASPIRIN BUF(CACARB-MGCARB-MGO) 325 MG ORAL TABS,RX-28122,CDM,S5000,HCPCS,259,RC,00904-2015-59,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,00093-5245-19,NDC,outpatient,1,UN,2.89,2.023,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,00093-5245-65,NDC,outpatient,1,UN,2.89,2.023,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,33342-0083-07,NDC,outpatient,1,UN,3.81,2.667,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,55111-0262-81,NDC,outpatient,1,UN,3.06,2.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,55111-0262-79,NDC,outpatient,1,UN,3.06,2.142,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OLANZAPINE 5 MG ORAL TBDP,RX-28159,CDM,S5000,HCPCS,259,RC,60505-3275-00,NDC,outpatient,1,UN,1.9,1.33,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OLANZAPINE 10 MG ORAL TBDP,RX-28160,CDM,S5000,HCPCS,259,RC,49884-0321-52,NDC,outpatient,1,UN,2.45,1.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OLANZAPINE 10 MG ORAL TBDP,RX-28160,CDM,S5000,HCPCS,259,RC,49884-0321-55,NDC,outpatient,1,UN,2.45,1.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LINEZOLID 600 MG ORAL TABS,RX-28224,CDM,S5000,HCPCS,259,RC,67877-0419-33,NDC,outpatient,1,UN,7.42,5.194,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LINEZOLID 600 MG ORAL TABS,RX-28224,CDM,S5000,HCPCS,259,RC,67877-0419-84,NDC,outpatient,1,UN,7.42,5.194,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LINEZOLID 600 MG ORAL TABS,RX-28224,CDM,S5000,HCPCS,259,RC,00904-6553-04,NDC,outpatient,1,UN,7.73,5.411,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LINEZOLID 100 MG/5ML ORAL SUSR,RX-28225,CDM,S5000,HCPCS,259,RC,59762-1308-04,NDC,outpatient,150,ML,1694.12,1185.884,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LINEZOLID 100 MG/5ML ORAL SUSR,RX-28225,CDM,S5000,HCPCS,259,RC,99999-0002-85,NDC,outpatient,30,ML,340.43,238.301,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PENTAMIDINE ISETHIONATE 300 MG IN SOLR,RX-28235,CDM,S5000,HCPCS,259,RC,63323-0877-15,NDC,outpatient,1,UN,686.24,480.368,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RIVASTIGMINE TARTRATE 1.5 MG ORAL CAPS,RX-28278,CDM,S5000,HCPCS,259,RC,00904-7107-61,NDC,outpatient,1,UN,10.27,7.189,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RIVASTIGMINE TARTRATE 3 MG ORAL CAPS,RX-28279,CDM,S5000,HCPCS,259,RC,55111-0353-60,NDC,outpatient,1,UN,2.6,1.82,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
INSULIN GLARGINE 100 UNIT/ML SC SOLN,RX-28282,CDM,S5000,HCPCS,259,RC,00088-2220-33,NDC,outpatient,10,ML,252.19,176.533,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
COLESEVELAM HCL 625 MG ORAL TABS,RX-28372,CDM,S5000,HCPCS,259,RC,60687-0385-25,NDC,outpatient,1,UN,13.08,9.156,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
COLESEVELAM HCL 625 MG ORAL TABS,RX-28372,CDM,S5000,HCPCS,259,RC,60687-0385-95,NDC,outpatient,1,UN,13.08,9.156,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROCODONE-ACETAMINOPHEN 10-325 MG ORAL TABS,RX-28384,CDM,S5000,HCPCS,259,RC,00406-0125-62,NDC,outpatient,1,UN,2,1.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROCODONE-ACETAMINOPHEN 10-325 MG ORAL TABS,RX-28384,CDM,S5000,HCPCS,259,RC,00406-0125-23,NDC,outpatient,1,UN,2,1.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ESTRADIOL 0.05 MG/24HR TD PTWK,RX-28408,CDM,S5000,HCPCS,259,RC,00378-3350-99,NDC,outpatient,1,UN,65.95,46.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ESTRADIOL 0.05 MG/24HR TD PTWK,RX-28408,CDM,S5000,HCPCS,259,RC,00378-3350-16,NDC,outpatient,1,UN,65.95,46.165,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ESTRADIOL 0.1 MG/24HR TD PTWK,RX-28409,CDM,S5000,HCPCS,259,RC,00378-3352-99,NDC,outpatient,1,UN,65.26,45.682,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ESTRADIOL 0.1 MG/24HR TD PTWK,RX-28409,CDM,S5000,HCPCS,259,RC,00378-3352-16,NDC,outpatient,1,UN,65.26,45.682,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NIFEDIPINE ER OSMOTIC RELEASE 30 MG ORAL TB24,RX-28643,CDM,S5000,HCPCS,259,RC,68084-0597-11,NDC,outpatient,1,UN,5.37,3.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NIFEDIPINE ER OSMOTIC RELEASE 30 MG ORAL TB24,RX-28643,CDM,S5000,HCPCS,259,RC,68084-0597-01,NDC,outpatient,1,UN,5.37,3.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METHYLPHENIDATE HCL ER (OSM) 18 MG ORAL TBCR,RX-28750,CDM,S5000,HCPCS,259,RC,13811-0706-10,NDC,outpatient,1,UN,3.22,2.254,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METHYLPHENIDATE HCL ER (OSM) 18 MG ORAL TBCR,RX-28750,CDM,S5000,HCPCS,259,RC,50458-0585-01,NDC,outpatient,1,UN,53.04,37.128,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUDESONIDE 0.25 MG/2ML IN SUSP,RX-28774,CDM,S5000,HCPCS,259,RC,00186-1988-04,NDC,outpatient,2,ML,35.8,25.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUDESONIDE 0.25 MG/2ML IN SUSP,RX-28774,CDM,S5000,HCPCS,259,RC,00487-9601-01,NDC,outpatient,2,ML,17.76,12.432,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,68180-0984-05,NDC,outpatient,2,ML,5.21,3.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,69097-0319-87,NDC,outpatient,2,ML,8.61,6.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,69097-0319-53,NDC,outpatient,2,ML,12.55,8.785,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,00093-6816-45,NDC,outpatient,2,ML,39.45,27.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,00093-6816-73,NDC,outpatient,2,ML,39.45,27.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,47335-0632-49,NDC,outpatient,1,ML,6.14,4.298,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,69097-0319-32,NDC,outpatient,2,ML,12.55,8.785,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,00487-9701-01,NDC,outpatient,2,ML,14.93,10.451,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,68180-0984-30,NDC,outpatient,2,ML,5.21,3.647,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUDESONIDE 0.5 MG/2ML IN SUSP,RX-28775,CDM,S5000,HCPCS,259,RC,69097-0319-86,NDC,outpatient,2,ML,8.61,6.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,00168-0053-16,NDC,outpatient,453.6,GR,58.59,41.013,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,00168-0053-21,NDC,outpatient,28.35,GR,7.2,5.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,38779-3068-00,NDC,outpatient,30,GR,75.03,52.521,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,00521-2311-00,NDC,outpatient,52.5,GR,7.25,5.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,00521-2335-00,NDC,outpatient,390,GR,19.1,13.37,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,08080-4302-01,NDC,outpatient,30,ML,5.88,4.116,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
WHITE PETROLATUM EX GEL,RX-28809,CDM,S5000,HCPCS,259,RC,53329-0993-04,NDC,outpatient,113,GR,5.26,3.682,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SUSP,RX-28810,CDM,S5000,HCPCS,259,RC,24208-0635-62,NDC,outpatient,10,ML,221.08,154.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SUSP,RX-28810,CDM,S5000,HCPCS,259,RC,61314-0645-11,NDC,outpatient,10,ML,217.88,152.516,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GLYCERIN LIQD,RX-28815,CDM,S5000,HCPCS,259,RC,00395-1031-96,NDC,outpatient,177,ML,23.63,16.541,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MAGNESIUM HYDROXIDE 400 MG/5ML ORAL SUSP,RX-28836,CDM,S5000,HCPCS,259,RC,00121-0431-30,NDC,outpatient,30,ML,4.14,2.898,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CYCLOSPORINE MODIFIED 25 MG ORAL CAPS,RX-28842,CDM,S5000,HCPCS,259,RC,00093-9018-19,NDC,outpatient,1,UN,1.84,1.288,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CYCLOSPORINE MODIFIED 25 MG ORAL CAPS,RX-28842,CDM,S5000,HCPCS,259,RC,00093-9018-65,NDC,outpatient,1,UN,1.84,1.288,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CYCLOSPORINE MODIFIED 100 MG ORAL CAPS,RX-28843,CDM,S5000,HCPCS,259,RC,00078-0248-61,NDC,outpatient,1,UN,46.19,32.333,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CYCLOSPORINE MODIFIED 100 MG ORAL CAPS,RX-28843,CDM,S5000,HCPCS,259,RC,00078-0248-15,NDC,outpatient,1,UN,46.19,32.333,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CYCLOSPORINE MODIFIED 100 MG/ML ORAL SOLN,RX-28844,CDM,S5000,HCPCS,259,RC,00172-7313-20,NDC,outpatient,50,ML,396.5,277.55,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ERYTHROMYCIN 2 % EX SOLN,RX-2887,CDM,S5000,HCPCS,259,RC,45802-0038-46,NDC,outpatient,60,ML,71.56,50.092,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ERYTHROMYCIN 5 MG/GM OP OINT,RX-2888,CDM,S5000,HCPCS,259,RC,00574-4024-11,NDC,outpatient,1,GR,31.37,21.959,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ERYTHROMYCIN 5 MG/GM OP OINT,RX-2888,CDM,S5000,HCPCS,259,RC,00574-4024-50,NDC,outpatient,1,GR,31.37,21.959,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ERYTHROMYCIN 5 MG/GM OP OINT,RX-2888,CDM,S5000,HCPCS,259,RC,48102-0057-11,NDC,outpatient,1,GR,40.3,28.21,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ERYTHROMYCIN 5 MG/GM OP OINT,RX-2888,CDM,S5000,HCPCS,259,RC,24208-0910-19,NDC,outpatient,1,GR,31.03,21.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,68084-0975-11,NDC,outpatient,1,UN,4.25,2.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,68094-0005-59,NDC,outpatient,1,UN,2.33,1.631,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,68084-0975-01,NDC,outpatient,1,UN,4.25,2.975,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,00406-8515-23,NDC,outpatient,1,UN,2.43,1.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,00406-8515-62,NDC,outpatient,1,UN,2.43,1.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXYCODONE HCL 15 MG ORAL TABS,RX-28899,CDM,S5000,HCPCS,259,RC,68094-0005-61,NDC,outpatient,1,UN,2.33,1.631,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ERYTHROMYCIN BASE 250 MG ORAL TBEC,RX-2891,CDM,S5000,HCPCS,259,RC,13668-0586-30,NDC,outpatient,1,UN,21.71,15.197,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ERYTHROMYCIN BASE 250 MG ORAL TBEC,RX-2891,CDM,S5000,HCPCS,259,RC,24338-0122-03,NDC,outpatient,1,UN,24.57,17.199,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NA HYALUR & NA CHOND-NA HYALUR 0.4-0.35 ML IO KIT,RX-28916,CDM,S5000,HCPCS,250,RC,08065-1831-35,NDC,outpatient,0.75,ML,867.31,607.117,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVOFLOXACIN 750 MG ORAL TABS,RX-28964,CDM,S5000,HCPCS,259,RC,00904-6353-61,NDC,outpatient,1,UN,2.17,1.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5ML ORAL SUSR,RX-2899,CDM,S5000,HCPCS,259,RC,24338-0134-02,NDC,outpatient,100,ML,1005.7,703.99,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5ML ORAL SUSR,RX-2899,CDM,S5000,HCPCS,259,RC,99999-0002-77,NDC,outpatient,5,ML,50.87,35.609,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5ML ORAL SUSR,RX-2899,CDM,S5000,HCPCS,259,RC,75834-0295-01,NDC,outpatient,100,ML,494.4,346.08,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METFORMIN HCL ER 500 MG ORAL TB24,RX-28995,CDM,S5000,HCPCS,259,RC,51224-0007-50,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METFORMIN HCL ER 500 MG ORAL TB24,RX-28995,CDM,S5000,HCPCS,259,RC,70010-0491-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALENDRONATE SODIUM 70 MG ORAL TABS,RX-29048,CDM,S5000,HCPCS,259,RC,16714-0633-01,NDC,outpatient,1,UN,2.67,1.869,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALENDRONATE SODIUM 35 MG ORAL TABS,RX-29072,CDM,S5000,HCPCS,259,RC,16714-0632-01,NDC,outpatient,1,UN,5.43,3.801,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,65162-0698-90,NDC,outpatient,473,ML,168.39,117.873,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,99999-0003-42,NDC,outpatient,6,ML,2.43,1.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,59762-5050-06,NDC,outpatient,6,ML,2.26,1.582,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,59762-5050-07,NDC,outpatient,470,ML,154.78,108.346,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,65162-0698-06,NDC,outpatient,6,ML,2.47,1.729,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,42192-0608-06,NDC,outpatient,6,ML,15.62,10.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,42192-0608-16,NDC,outpatient,470,ML,144.32,101.024,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GABAPENTIN 300 MG/6ML ORAL SOLN,RX-29169,CDM,S5000,HCPCS,259,RC,42192-0608-40,NDC,outpatient,6,ML,15.62,10.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DILTIAZEM HCL ER COATED BEADS 120 MG ORAL CP24,RX-29270,CDM,S5000,HCPCS,259,RC,50742-0248-30,NDC,outpatient,1,UN,1.44,1.008,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DILTIAZEM HCL ER COATED BEADS 120 MG ORAL CP24,RX-29270,CDM,S5000,HCPCS,259,RC,50742-0248-90,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DILTIAZEM HCL ER COATED BEADS 120 MG ORAL CP24,RX-29270,CDM,S5000,HCPCS,259,RC,60687-0195-01,NDC,outpatient,1,UN,1.87,1.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DILTIAZEM HCL ER COATED BEADS 120 MG ORAL CP24,RX-29270,CDM,S5000,HCPCS,259,RC,60687-0195-11,NDC,outpatient,1,UN,1.87,1.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DILTIAZEM HCL ER COATED BEADS 120 MG ORAL CP24,RX-29270,CDM,S5000,HCPCS,259,RC,68682-0993-98,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DILTIAZEM HCL ER COATED BEADS 180 MG ORAL CP24,RX-29272,CDM,S5000,HCPCS,259,RC,00904-7218-61,NDC,outpatient,1,UN,1.28,0.896,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DILTIAZEM HCL ER COATED BEADS 180 MG ORAL CP24,RX-29272,CDM,S5000,HCPCS,259,RC,62037-0598-90,NDC,outpatient,1,UN,2.27,1.589,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DILTIAZEM HCL ER COATED BEADS 180 MG ORAL CP24,RX-29272,CDM,S5000,HCPCS,259,RC,60687-0206-01,NDC,outpatient,1,UN,1.65,1.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DILTIAZEM HCL ER COATED BEADS 180 MG ORAL CP24,RX-29272,CDM,S5000,HCPCS,259,RC,60687-0206-11,NDC,outpatient,1,UN,1.65,1.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DILTIAZEM HCL ER COATED BEADS 240 MG ORAL CP24,RX-29274,CDM,S5000,HCPCS,259,RC,00904-7219-61,NDC,outpatient,1,UN,1.59,1.113,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DILTIAZEM HCL ER COATED BEADS 240 MG ORAL CP24,RX-29274,CDM,S5000,HCPCS,259,RC,60687-0217-01,NDC,outpatient,1,UN,2.46,1.722,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DILTIAZEM HCL ER COATED BEADS 240 MG ORAL CP24,RX-29274,CDM,S5000,HCPCS,259,RC,60687-0217-11,NDC,outpatient,1,UN,2.46,1.722,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DILTIAZEM HCL ER COATED BEADS 300 MG ORAL CP24,RX-29276,CDM,S5000,HCPCS,259,RC,24979-0029-07,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DILTIAZEM HCL ER COATED BEADS 300 MG ORAL CP24,RX-29276,CDM,S5000,HCPCS,259,RC,60687-0228-01,NDC,outpatient,1,UN,6.23,4.361,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DILTIAZEM HCL ER COATED BEADS 300 MG ORAL CP24,RX-29276,CDM,S5000,HCPCS,259,RC,60687-0228-11,NDC,outpatient,1,UN,6.23,4.361,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOCOSANOL 10 % EX CREA,RX-29287,CDM,S5000,HCPCS,259,RC,00135-0300-01,NDC,outpatient,2,GR,72.76,50.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,00054-0079-28,NDC,outpatient,1,UN,1.72,1.204,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,50268-0102-11,NDC,outpatient,1,UN,5.8,4.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,50268-0102-13,NDC,outpatient,1,UN,5.8,4.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,60505-2575-07,NDC,outpatient,1,UN,1.09,0.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,65649-0101-02,NDC,outpatient,1,UN,26.86,18.802,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BALSALAZIDE DISODIUM 750 MG ORAL CAPS,RX-29299,CDM,S5000,HCPCS,259,RC,72789-0149-69,NDC,outpatient,1,UN,1.89,1.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % EX CREA,RX-29424,CDM,S5000,HCPCS,259,RC,00168-0258-15,NDC,outpatient,15,GR,71.29,49.903,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % EX CREA,RX-29424,CDM,S5000,HCPCS,259,RC,16714-0496-01,NDC,outpatient,15,GR,55.61,38.927,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NATEGLINIDE 60 MG ORAL TABS,RX-29437,CDM,S5000,HCPCS,259,RC,60687-0673-11,NDC,outpatient,1,UN,7.98,5.586,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NATEGLINIDE 60 MG ORAL TABS,RX-29437,CDM,S5000,HCPCS,259,RC,60687-0673-21,NDC,outpatient,1,UN,7.98,5.586,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MIRTAZAPINE 15 MG ORAL TBDP,RX-29531,CDM,S5000,HCPCS,259,RC,65862-0021-06,NDC,outpatient,1,UN,1.96,1.372,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ZIPRASIDONE HCL 20 MG ORAL CAPS,RX-29778,CDM,S5000,HCPCS,259,RC,00904-6269-08,NDC,outpatient,1,UN,11.99,8.393,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ZIPRASIDONE HCL 60 MG ORAL CAPS,RX-29780,CDM,S5000,HCPCS,259,RC,68084-0105-11,NDC,outpatient,1,UN,7.81,5.467,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ZIPRASIDONE HCL 60 MG ORAL CAPS,RX-29780,CDM,S5000,HCPCS,259,RC,50268-0813-11,NDC,outpatient,1,UN,7.96,5.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ZIPRASIDONE HCL 60 MG ORAL CAPS,RX-29780,CDM,S5000,HCPCS,259,RC,68084-0105-09,NDC,outpatient,1,UN,7.81,5.467,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ZIPRASIDONE HCL 60 MG ORAL CAPS,RX-29780,CDM,S5000,HCPCS,259,RC,50268-0813-12,NDC,outpatient,1,UN,7.96,5.572,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ZIPRASIDONE HCL 80 MG ORAL CAPS,RX-29781,CDM,S5000,HCPCS,259,RC,00781-2168-60,NDC,outpatient,1,UN,1.24,0.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ZIPRASIDONE HCL 80 MG ORAL CAPS,RX-29781,CDM,S5000,HCPCS,259,RC,68084-0106-09,NDC,outpatient,1,UN,7.81,5.467,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ZIPRASIDONE HCL 80 MG ORAL CAPS,RX-29781,CDM,S5000,HCPCS,259,RC,68084-0106-11,NDC,outpatient,1,UN,7.81,5.467,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GALANTAMINE HYDROBROMIDE 4 MG ORAL TABS,RX-29806,CDM,S5000,HCPCS,259,RC,68084-0729-21,NDC,outpatient,1,UN,14.03,9.821,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GALANTAMINE HYDROBROMIDE 4 MG ORAL TABS,RX-29806,CDM,S5000,HCPCS,259,RC,68084-0729-11,NDC,outpatient,1,UN,14.03,9.821,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GALANTAMINE HYDROBROMIDE 4 MG ORAL TABS,RX-29806,CDM,S5000,HCPCS,259,RC,70436-0004-06,NDC,outpatient,1,UN,1.21,0.847,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,00904-6322-61,NDC,outpatient,1,UN,2.19,1.533,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,00904-6322-06,NDC,outpatient,1,UN,1.21,0.847,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,50742-0615-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,45963-0709-11,NDC,outpatient,1,UN,1.28,0.896,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,51079-0169-01,NDC,outpatient,1,UN,2.11,1.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METOPROLOL SUCCINATE ER 25 MG ORAL TAB,RX-29858,CDM,S5000,HCPCS,259,RC,51079-0169-20,NDC,outpatient,1,UN,2.11,1.477,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
EYE STREAM OP SOLN,RX-2999,CDM,S5000,HCPCS,259,RC,00065-0530-01,NDC,outpatient,30,ML,81.97,57.379,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METOPROLOL SUCCINATE ER 50 MG ORAL TAB,RX-30070,CDM,S5000,HCPCS,259,RC,51079-0170-01,NDC,outpatient,1,UN,1.9,1.33,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METOPROLOL SUCCINATE ER 50 MG ORAL TAB,RX-30070,CDM,S5000,HCPCS,259,RC,68382-0565-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METOPROLOL SUCCINATE ER 50 MG ORAL TAB,RX-30070,CDM,S5000,HCPCS,259,RC,00904-6323-61,NDC,outpatient,1,UN,2.29,1.603,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METOPROLOL SUCCINATE ER 50 MG ORAL TAB,RX-30070,CDM,S5000,HCPCS,259,RC,50742-0616-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METOPROLOL SUCCINATE ER 50 MG ORAL TAB,RX-30070,CDM,S5000,HCPCS,259,RC,51079-0170-20,NDC,outpatient,1,UN,1.9,1.33,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,00904-6324-61,NDC,outpatient,1,UN,2.66,1.862,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,50268-0542-15,NDC,outpatient,1,UN,2.35,1.645,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,60687-0413-11,NDC,outpatient,1,UN,3.08,2.156,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,51079-0171-03,NDC,outpatient,1,UN,5.81,4.067,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,60687-0413-01,NDC,outpatient,1,UN,3.08,2.156,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,51079-0171-01,NDC,outpatient,1,UN,5.81,4.067,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METOPROLOL SUCCINATE ER 100 MG ORAL TAB,RX-30071,CDM,S5000,HCPCS,259,RC,50268-0542-11,NDC,outpatient,1,UN,2.35,1.645,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VALGANCICLOVIR HCL 450 MG ORAL TABS,RX-30148,CDM,S5000,HCPCS,259,RC,68084-0965-25,NDC,outpatient,1,UN,121.31,84.917,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VALGANCICLOVIR HCL 450 MG ORAL TABS,RX-30148,CDM,S5000,HCPCS,259,RC,68084-0965-95,NDC,outpatient,1,UN,121.31,84.917,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VALGANCICLOVIR HCL 450 MG ORAL TABS,RX-30148,CDM,S5000,HCPCS,259,RC,63739-0357-33,NDC,outpatient,1,UN,93.6,65.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CITALOPRAM HYDROBROMIDE 10 MG ORAL TABS,RX-30264,CDM,S5000,HCPCS,259,RC,00904-6084-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXCARBAZEPINE 300 MG/5ML ORAL SUSP,RX-30479,CDM,S5000,HCPCS,259,RC,68094-0123-59,NDC,outpatient,5,ML,23.66,16.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXCARBAZEPINE 300 MG/5ML ORAL SUSP,RX-30479,CDM,S5000,HCPCS,259,RC,99999-0002-25,NDC,outpatient,5,ML,33.09,23.163,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXCARBAZEPINE 300 MG/5ML ORAL SUSP,RX-30479,CDM,S5000,HCPCS,259,RC,00078-0357-52,NDC,outpatient,5,ML,39.3,27.51,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXCARBAZEPINE 300 MG/5ML ORAL SUSP,RX-30479,CDM,S5000,HCPCS,259,RC,68094-0123-62,NDC,outpatient,5,ML,23.66,16.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MELATONIN 5 MG SL SUBL,RX-30511,CDM,S5000,HCPCS,259,RC,54629-0615-00,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FERROUS SULFATE 325 (65 FE) MG ORAL TABS,RX-3074,CDM,S5000,HCPCS,259,RC,00904-7591-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FERROUS SULFATE 325 (65 FE) MG ORAL TABS,RX-3074,CDM,S5000,HCPCS,259,RC,20555-0021-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FERROUS SULFATE 325 (65 FE) MG ORAL TABS,RX-3074,CDM,S5000,HCPCS,259,RC,00904-7590-60,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,16714-0576-02,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,60687-0677-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,51079-0205-20,NDC,outpatient,1,UN,1.23,0.861,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,60687-0677-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,51079-0205-01,NDC,outpatient,1,UN,1.23,0.861,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,55111-0729-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALLOPURINOL 100 MG ORAL TABS,RX-310,CDM,S5000,HCPCS,259,RC,00904-7041-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALLOPURINOL 300 MG ORAL TABS,RX-311,CDM,S5000,HCPCS,259,RC,51079-0206-20,NDC,outpatient,1,UN,1.68,1.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALLOPURINOL 300 MG ORAL TABS,RX-311,CDM,S5000,HCPCS,259,RC,00904-6572-61,NDC,outpatient,1,UN,1.71,1.197,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALLOPURINOL 300 MG ORAL TABS,RX-311,CDM,S5000,HCPCS,259,RC,51079-0206-01,NDC,outpatient,1,UN,1.68,1.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FISH OIL 1000 MG ORAL CAPS,RX-3113,CDM,S5000,HCPCS,259,RC,77333-0308-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FISH OIL 1000 MG ORAL CAPS,RX-3113,CDM,S5000,HCPCS,259,RC,77333-0308-25,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMOXICILLIN-POT CLAVULANATE 600-42.9 MG/5ML ORAL SUSR,RX-31177,CDM,S5000,HCPCS,259,RC,00143-9853-75,NDC,outpatient,75,ML,63.42,44.394,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMOXICILLIN-POT CLAVULANATE 600-42.9 MG/5ML ORAL SUSR,RX-31177,CDM,S5000,HCPCS,259,RC,99999-0002-82,NDC,outpatient,5,ML,8.55,5.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VALSARTAN 160 MG ORAL TABS,RX-31210,CDM,S5000,HCPCS,259,RC,31722-0153-90,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VALSARTAN 160 MG ORAL TABS,RX-31210,CDM,S5000,HCPCS,259,RC,60687-0634-01,NDC,outpatient,1,UN,4.62,3.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VALSARTAN 160 MG ORAL TABS,RX-31210,CDM,S5000,HCPCS,259,RC,60687-0634-11,NDC,outpatient,1,UN,4.62,3.234,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VALSARTAN 160 MG ORAL TABS,RX-31210,CDM,S5000,HCPCS,259,RC,33342-0064-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUDESONIDE 3 MG ORAL CPEP,RX-31576,CDM,S5000,HCPCS,259,RC,65162-0778-10,NDC,outpatient,1,UN,2.47,1.729,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUDESONIDE 3 MG ORAL CPEP,RX-31576,CDM,S5000,HCPCS,259,RC,00574-9855-10,NDC,outpatient,1,UN,2.52,1.764,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALBUTEROL SULFATE 0.63 MG/3ML IN NEBU,RX-31577,CDM,S5000,HCPCS,259,RC,76204-0010-55,NDC,outpatient,3,ML,1.98,1.386,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALBUTEROL SULFATE 0.63 MG/3ML IN NEBU,RX-31577,CDM,S5000,HCPCS,259,RC,00487-0301-01,NDC,outpatient,3,ML,2.43,1.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALBUTEROL SULFATE 1.25 MG/3ML IN NEBU,RX-31578,CDM,S5000,HCPCS,259,RC,00487-9904-01,NDC,outpatient,3,ML,2.43,1.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALBUTEROL SULFATE 1.25 MG/3ML IN NEBU,RX-31578,CDM,S5000,HCPCS,259,RC,00487-9904-25,NDC,outpatient,3,ML,2.43,1.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMPHETAMINE-DEXTROAMPHET ER 10 MG ORAL CP24,RX-31587,CDM,S5000,HCPCS,259,RC,00228-3059-11,NDC,outpatient,1,UN,12.55,8.785,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMPHETAMINE-DEXTROAMPHET ER 10 MG ORAL CP24,RX-31587,CDM,S5000,HCPCS,259,RC,64850-0511-01,NDC,outpatient,1,UN,2,1.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMPHETAMINE-DEXTROAMPHET ER 10 MG ORAL CP24,RX-31587,CDM,S5000,HCPCS,259,RC,70010-0030-01,NDC,outpatient,1,UN,3.45,2.415,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
UREA 40 % EX LOTN,RX-31683,CDM,S5000,HCPCS,259,RC,54295-0312-18,NDC,outpatient,226.8,GR,419.86,293.902,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
UREA 40 % EX LOTN,RX-31683,CDM,S5000,HCPCS,259,RC,81542-0201-08,NDC,outpatient,226.8,GR,454.17,317.919,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TENOFOVIR DISOPROXIL FUMARATE 300 MG ORAL TABS,RX-31684,CDM,S5000,HCPCS,259,RC,61958-0401-01,NDC,outpatient,1,UN,180.36,126.252,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLUOCINONIDE 0.05 % EX CREA,RX-3187,CDM,S5000,HCPCS,259,RC,00093-0262-15,NDC,outpatient,15,GR,162.14,113.498,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLUOCINONIDE 0.05 % EX CREA,RX-3187,CDM,S5000,HCPCS,259,RC,51672-1386-01,NDC,outpatient,15,GR,35.32,24.724,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLUOCINONIDE 0.05 % EX OINT,RX-3189,CDM,S5000,HCPCS,259,RC,51672-1264-01,NDC,outpatient,15,GR,55.01,38.507,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLUOCINONIDE 0.05 % EX SOLN,RX-3190,CDM,S5000,HCPCS,259,RC,51672-1273-02,NDC,outpatient,20,ML,137.87,96.509,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLUOROMETHOLONE 0.1 % OP SUSP,RX-3208,CDM,S5000,HCPCS,259,RC,60758-0880-05,NDC,outpatient,5,ML,308.83,216.181,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLUPHENAZINE HCL 1 MG ORAL TABS,RX-3218,CDM,S5000,HCPCS,259,RC,00527-1788-01,NDC,outpatient,1,UN,6.6,4.62,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLUPHENAZINE HCL 2.5 MG ORAL TABS,RX-3220,CDM,S5000,HCPCS,259,RC,70954-0274-10,NDC,outpatient,1,UN,2.47,1.729,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLUPHENAZINE HCL 2.5 MG ORAL TABS,RX-3220,CDM,S5000,HCPCS,259,RC,00527-1789-01,NDC,outpatient,1,UN,10.2,7.14,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLUPHENAZINE HCL 5 MG ORAL TABS,RX-3221,CDM,S5000,HCPCS,259,RC,00527-1790-01,NDC,outpatient,1,UN,13.8,9.66,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLUPHENAZINE HCL 5 MG ORAL TABS,RX-3221,CDM,S5000,HCPCS,259,RC,69238-1680-01,NDC,outpatient,1,UN,6.45,4.515,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FOLIC ACID 5 MG/ML IJ SOLN,RX-3232,CDM,S5000,HCPCS,250,RC,39822-1100-01,NDC,outpatient,0.2,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FOLIC ACID 5 MG/ML IJ SOLN,RX-3232,CDM,S5000,HCPCS,250,RC,63323-0184-10,NDC,outpatient,0.2,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FOLIC ACID 1 MG ORAL TABS,RX-3233,CDM,S5000,HCPCS,259,RC,00904-7224-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FOLIC ACID 1 MG ORAL TABS,RX-3233,CDM,S5000,HCPCS,259,RC,60687-0681-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FOLIC ACID 1 MG ORAL TABS,RX-3233,CDM,S5000,HCPCS,259,RC,60687-0681-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALPRAZOLAM 0.25 MG ORAL TABS,RX-324,CDM,S5000,HCPCS,259,RC,00781-1061-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALPRAZOLAM 0.25 MG ORAL TABS,RX-324,CDM,S5000,HCPCS,259,RC,65862-0676-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALPRAZOLAM 0.5 MG ORAL TABS,RX-325,CDM,S5000,HCPCS,259,RC,00781-1077-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PAROXETINE HCL ER 12.5 MG ORAL TB24,RX-32631,CDM,S5000,HCPCS,259,RC,62175-0470-32,NDC,outpatient,1,UN,4.97,3.479,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METHYLPHENIDATE HCL ER (OSM) 27 MG ORAL TBCR,RX-32654,CDM,S5000,HCPCS,259,RC,13811-0707-10,NDC,outpatient,1,UN,3.33,2.331,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OLMESARTAN MEDOXOMIL 20 MG ORAL TABS,RX-32762,CDM,S5000,HCPCS,259,RC,68462-0437-30,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OLMESARTAN MEDOXOMIL 20 MG ORAL TABS,RX-32762,CDM,S5000,HCPCS,259,RC,00713-0861-30,NDC,outpatient,1,UN,39.98,27.986,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OLMESARTAN MEDOXOMIL 20 MG ORAL TABS,RX-32762,CDM,S5000,HCPCS,259,RC,33342-0179-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RISEDRONATE SODIUM 35 MG ORAL TABS,RX-32895,CDM,S5000,HCPCS,259,RC,33342-0109-50,NDC,outpatient,1,UN,18.52,12.964,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FUROSEMIDE 10 MG/ML ORAL SOLN,RX-3292,CDM,S5000,HCPCS,259,RC,68094-0756-59,NDC,outpatient,4,ML,7.04,4.928,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FUROSEMIDE 10 MG/ML ORAL SOLN,RX-3292,CDM,S5000,HCPCS,259,RC,68094-0756-62,NDC,outpatient,4,ML,7.04,4.928,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FUROSEMIDE 8 MG/ML ORAL SOLN,RX-3293,CDM,S5000,HCPCS,259,RC,68094-0867-59,NDC,outpatient,5,ML,7.04,4.928,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FUROSEMIDE 8 MG/ML ORAL SOLN,RX-3293,CDM,S5000,HCPCS,259,RC,68094-0867-62,NDC,outpatient,5,ML,7.04,4.928,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FUROSEMIDE 20 MG ORAL TABS,RX-3294,CDM,S5000,HCPCS,259,RC,00904-7177-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FUROSEMIDE 20 MG ORAL TABS,RX-3294,CDM,S5000,HCPCS,259,RC,00054-8297-25,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FUROSEMIDE 40 MG ORAL TABS,RX-3295,CDM,S5000,HCPCS,259,RC,51079-0073-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FUROSEMIDE 40 MG ORAL TABS,RX-3295,CDM,S5000,HCPCS,259,RC,51079-0073-20,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FUROSEMIDE 80 MG ORAL TABS,RX-3296,CDM,S5000,HCPCS,259,RC,51079-0527-20,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FUROSEMIDE 80 MG ORAL TABS,RX-3296,CDM,S5000,HCPCS,259,RC,51079-0527-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FUROSEMIDE 80 MG ORAL TABS,RX-3296,CDM,S5000,HCPCS,259,RC,00054-8301-25,NDC,outpatient,1,UN,2.07,1.449,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMPHETAMINE-DEXTROAMPHET ER 5 MG ORAL CP24,RX-33005,CDM,S5000,HCPCS,259,RC,54092-0381-01,NDC,outpatient,1,UN,29.29,20.503,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VORICONAZOLE 200 MG ORAL TABS,RX-33009,CDM,S5000,HCPCS,259,RC,00904-7024-04,NDC,outpatient,1,UN,43.81,30.667,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMOXICILLIN-POT CLAVULANATE 500-125 MG ORAL TABS,RX-33227,CDM,S5000,HCPCS,259,RC,00781-1831-01,NDC,outpatient,1,UN,1.59,1.113,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMOXICILLIN-POT CLAVULANATE 875-125 MG ORAL TABS,RX-33228,CDM,S5000,HCPCS,259,RC,00143-9249-20,NDC,outpatient,1,UN,5.26,3.682,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMOXICILLIN-POT CLAVULANATE 875-125 MG ORAL TABS,RX-33228,CDM,S5000,HCPCS,259,RC,65862-0503-01,NDC,outpatient,1,UN,2.34,1.638,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMOXICILLIN-POT CLAVULANATE 875-125 MG ORAL TABS,RX-33228,CDM,S5000,HCPCS,259,RC,65862-0503-20,NDC,outpatient,1,UN,1.87,1.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMOXICILLIN-POT CLAVULANATE 875-125 MG ORAL TABS,RX-33228,CDM,S5000,HCPCS,259,RC,42571-0162-01,NDC,outpatient,1,UN,2.67,1.869,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ESCITALOPRAM OXALATE 10 MG ORAL TABS,RX-33512,CDM,S5000,HCPCS,259,RC,68084-0617-01,NDC,outpatient,1,UN,1.04,0.728,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ESCITALOPRAM OXALATE 10 MG ORAL TABS,RX-33512,CDM,S5000,HCPCS,259,RC,00904-6426-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ESCITALOPRAM OXALATE 10 MG ORAL TABS,RX-33512,CDM,S5000,HCPCS,259,RC,68084-0617-11,NDC,outpatient,1,UN,1.04,0.728,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VALSARTAN 40 MG ORAL TABS,RX-33541,CDM,S5000,HCPCS,259,RC,31722-0151-30,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VALSARTAN 40 MG ORAL TABS,RX-33541,CDM,S5000,HCPCS,259,RC,60687-0612-11,NDC,outpatient,1,UN,3.18,2.226,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VALSARTAN 40 MG ORAL TABS,RX-33541,CDM,S5000,HCPCS,259,RC,60687-0612-21,NDC,outpatient,1,UN,3.18,2.226,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GEMFIBROZIL 600 MG ORAL TABS,RX-3378,CDM,S5000,HCPCS,259,RC,60687-0224-01,NDC,outpatient,1,UN,1.15,0.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GEMFIBROZIL 600 MG ORAL TABS,RX-3378,CDM,S5000,HCPCS,259,RC,60687-0224-11,NDC,outpatient,1,UN,1.15,0.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METAXALONE 800 MG ORAL TABS,RX-33963,CDM,S5000,HCPCS,259,RC,00527-1435-01,NDC,outpatient,1,UN,2.54,1.778,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DUTASTERIDE 0.5 MG ORAL CAPS,RX-34089,CDM,S5000,HCPCS,259,RC,42806-0549-09,NDC,outpatient,1,UN,1.7,1.19,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
EZETIMIBE 10 MG ORAL TABS,RX-34153,CDM,S5000,HCPCS,259,RC,60687-0373-11,NDC,outpatient,1,UN,18.75,13.125,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
EZETIMIBE 10 MG ORAL TABS,RX-34153,CDM,S5000,HCPCS,259,RC,51660-0200-90,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
EZETIMIBE 10 MG ORAL TABS,RX-34153,CDM,S5000,HCPCS,259,RC,60687-0373-21,NDC,outpatient,1,UN,18.75,13.125,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
EZETIMIBE 10 MG ORAL TABS,RX-34153,CDM,S5000,HCPCS,259,RC,00904-7103-04,NDC,outpatient,1,UN,18.36,12.852,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GENTAMICIN SULFATE 0.1 % EX CREA,RX-3423,CDM,S5000,HCPCS,259,RC,45802-0056-35,NDC,outpatient,15,GR,170.02,119.014,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GENTAMICIN SULFATE 0.1 % EX OINT,RX-3424,CDM,S5000,HCPCS,259,RC,45802-0046-35,NDC,outpatient,15,GR,132.44,92.708,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GENTAMICIN SULFATE 0.3 % OP SOLN,RX-3428,CDM,S5000,HCPCS,259,RC,24208-0580-60,NDC,outpatient,5,ML,23.41,16.387,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GENTAMICIN SULFATE 0.3 % OP SOLN,RX-3428,CDM,S5000,HCPCS,259,RC,61314-0633-05,NDC,outpatient,5,ML,21.99,15.393,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ARIPIPRAZOLE 10 MG ORAL TABS,RX-34369,CDM,S5000,HCPCS,259,RC,60687-0179-01,NDC,outpatient,1,UN,22.5,15.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ARIPIPRAZOLE 10 MG ORAL TABS,RX-34369,CDM,S5000,HCPCS,259,RC,60687-0179-11,NDC,outpatient,1,UN,22.5,15.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ARIPIPRAZOLE 15 MG ORAL TABS,RX-34370,CDM,S5000,HCPCS,259,RC,63739-0078-33,NDC,outpatient,1,UN,22.38,15.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ARIPIPRAZOLE 15 MG ORAL TABS,RX-34370,CDM,S5000,HCPCS,259,RC,27241-0054-03,NDC,outpatient,1,UN,2.88,2.016,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ARIPIPRAZOLE 15 MG ORAL TABS,RX-34370,CDM,S5000,HCPCS,259,RC,60687-0191-11,NDC,outpatient,1,UN,27.24,19.068,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ARIPIPRAZOLE 15 MG ORAL TABS,RX-34370,CDM,S5000,HCPCS,259,RC,60687-0191-21,NDC,outpatient,1,UN,27.24,19.068,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DIVALPROEX SODIUM ER 250 MG ORAL TB24,RX-34418,CDM,S5000,HCPCS,259,RC,68084-0310-01,NDC,outpatient,1,UN,2.75,1.925,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DIVALPROEX SODIUM ER 250 MG ORAL TB24,RX-34418,CDM,S5000,HCPCS,259,RC,68084-0310-11,NDC,outpatient,1,UN,2.75,1.925,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ATOMOXETINE HCL 10 MG ORAL CAPS,RX-34444,CDM,S5000,HCPCS,259,RC,31722-0714-30,NDC,outpatient,1,UN,8.16,5.712,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ATOMOXETINE HCL 10 MG ORAL CAPS,RX-34444,CDM,S5000,HCPCS,259,RC,35573-0415-30,NDC,outpatient,1,UN,14,9.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ATOMOXETINE HCL 10 MG ORAL CAPS,RX-34444,CDM,S5000,HCPCS,259,RC,68462-0265-30,NDC,outpatient,1,UN,4.5,3.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ATOMOXETINE HCL 10 MG ORAL CAPS,RX-34444,CDM,S5000,HCPCS,259,RC,55111-0519-30,NDC,outpatient,1,UN,7.25,5.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ATOMOXETINE HCL 25 MG ORAL CAPS,RX-34446,CDM,S5000,HCPCS,259,RC,16714-0757-01,NDC,outpatient,1,UN,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ATOMOXETINE HCL 25 MG ORAL CAPS,RX-34446,CDM,S5000,HCPCS,259,RC,64980-0375-03,NDC,outpatient,1,UN,7.25,5.075,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ATOMOXETINE HCL 40 MG ORAL CAPS,RX-34447,CDM,S5000,HCPCS,259,RC,68462-0268-30,NDC,outpatient,1,UN,2.91,2.037,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ATOMOXETINE HCL 40 MG ORAL CAPS,RX-34447,CDM,S5000,HCPCS,259,RC,00093-3545-56,NDC,outpatient,1,UN,17.9,12.53,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ATOMOXETINE HCL 40 MG ORAL CAPS,RX-34447,CDM,S5000,HCPCS,259,RC,60687-0326-95,NDC,outpatient,1,UN,14.68,10.276,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ATOMOXETINE HCL 40 MG ORAL CAPS,RX-34447,CDM,S5000,HCPCS,259,RC,60687-0326-25,NDC,outpatient,1,UN,14.68,10.276,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROCODONE-ACETAMINOPHEN 5-325 MG ORAL TABS,RX-34505,CDM,S5000,HCPCS,259,RC,00406-0123-23,NDC,outpatient,1,UN,1.5,1.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROCODONE-ACETAMINOPHEN 5-325 MG ORAL TABS,RX-34505,CDM,S5000,HCPCS,259,RC,00406-0123-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROCODONE-ACETAMINOPHEN 5-325 MG ORAL TABS,RX-34505,CDM,S5000,HCPCS,259,RC,00406-0123-62,NDC,outpatient,1,UN,1.5,1.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPRENORPHINE HCL 2 MG SL SUBL,RX-34711,CDM,S5000,HCPCS,259,RC,60687-0481-21,NDC,outpatient,1,UN,6.96,4.872,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPRENORPHINE HCL 2 MG SL SUBL,RX-34711,CDM,S5000,HCPCS,259,RC,60687-0481-11,NDC,outpatient,1,UN,6.96,4.872,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPRENORPHINE HCL 8 MG SL SUBL,RX-34712,CDM,S5000,HCPCS,259,RC,42858-0502-03,NDC,outpatient,1,UN,2.47,1.729,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPRENORPHINE HCL 8 MG SL SUBL,RX-34712,CDM,S5000,HCPCS,259,RC,60687-0492-11,NDC,outpatient,1,UN,11.98,8.386,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPRENORPHINE HCL 8 MG SL SUBL,RX-34712,CDM,S5000,HCPCS,259,RC,60687-0492-21,NDC,outpatient,1,UN,11.98,8.386,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPRENORPHINE HCL-NALOXONE HCL 2-0.5 MG SL SUBL,RX-34713,CDM,S5000,HCPCS,259,RC,00054-0188-13,NDC,outpatient,1,UN,2.47,1.729,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPRENORPHINE HCL-NALOXONE HCL 2-0.5 MG SL SUBL,RX-34713,CDM,S5000,HCPCS,259,RC,65162-0416-03,NDC,outpatient,1,UN,2.45,1.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPRENORPHINE HCL-NALOXONE HCL 8-2 MG SL SUBL,RX-34714,CDM,S5000,HCPCS,259,RC,50268-0145-11,NDC,outpatient,1,UN,14.96,10.472,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPRENORPHINE HCL-NALOXONE HCL 8-2 MG SL SUBL,RX-34714,CDM,S5000,HCPCS,259,RC,50268-0145-15,NDC,outpatient,1,UN,14.96,10.472,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPRENORPHINE HCL-NALOXONE HCL 8-2 MG SL SUBL,RX-34714,CDM,S5000,HCPCS,259,RC,42858-0602-03,NDC,outpatient,1,UN,27,18.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SOLN,RX-34814,CDM,S5000,HCPCS,259,RC,61314-0646-10,NDC,outpatient,10,ML,188.28,131.796,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SOLN,RX-34814,CDM,S5000,HCPCS,259,RC,24208-0631-10,NDC,outpatient,10,ML,205.06,143.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ROSUVASTATIN CALCIUM 10 MG ORAL TABS,RX-35134,CDM,S5000,HCPCS,259,RC,60687-0245-11,NDC,outpatient,1,UN,4.01,2.807,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ROSUVASTATIN CALCIUM 10 MG ORAL TABS,RX-35134,CDM,S5000,HCPCS,259,RC,00904-6779-61,NDC,outpatient,1,UN,3.97,2.779,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ROSUVASTATIN CALCIUM 10 MG ORAL TABS,RX-35134,CDM,S5000,HCPCS,259,RC,60687-0245-01,NDC,outpatient,1,UN,4.01,2.807,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,16714-0990-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,50268-0710-11,NDC,outpatient,1,UN,2.29,1.603,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,60687-0256-01,NDC,outpatient,1,UN,5.36,3.752,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,60687-0256-11,NDC,outpatient,1,UN,5.36,3.752,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,00904-6780-61,NDC,outpatient,1,UN,3.57,2.499,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ROSUVASTATIN CALCIUM 20 MG ORAL TABS,RX-35135,CDM,S5000,HCPCS,259,RC,50268-0710-15,NDC,outpatient,1,UN,2.29,1.603,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CYCLOSPORINE 0.05 % OP EMUL,RX-35209,CDM,S5000,HCPCS,259,RC,00023-9163-30,NDC,outpatient,1,UN,44.22,30.954,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALUMINUM HYDROXIDE GEL 320 MG/5ML ORAL SUSP,RX-353,CDM,S5000,HCPCS,259,RC,99999-0002-48,NDC,outpatient,30,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALUMINUM HYDROXIDE GEL 320 MG/5ML ORAL SUSP,RX-353,CDM,S5000,HCPCS,259,RC,00536-0091-85,NDC,outpatient,5,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GRISEOFULVIN ULTRAMICROSIZE 250 MG ORAL TABS,RX-3536,CDM,S5000,HCPCS,259,RC,00115-1725-01,NDC,outpatient,1,UN,20.98,14.686,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXYBUTYNIN 3.9 MG/24HR TD PTTW,RX-35495,CDM,S5000,HCPCS,259,RC,00023-6153-08,NDC,outpatient,1,UN,349.43,244.601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXYBUTYNIN 3.9 MG/24HR TD PTTW,RX-35495,CDM,S5000,HCPCS,259,RC,00023-9637-08,NDC,outpatient,1,UN,10.21,7.147,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXYBUTYNIN 3.9 MG/24HR TD PTTW,RX-35495,CDM,S5000,HCPCS,259,RC,00023-6153-01,NDC,outpatient,1,UN,349.43,244.601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXYBUTYNIN 3.9 MG/24HR TD PTTW,RX-35495,CDM,S5000,HCPCS,259,RC,00023-9637-01,NDC,outpatient,1,UN,10.21,7.147,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RISPERIDONE 0.5 MG ORAL TBDP,RX-35686,CDM,S5000,HCPCS,259,RC,49884-0311-52,NDC,outpatient,1,UN,2.41,1.687,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RISPERIDONE 0.5 MG ORAL TBDP,RX-35686,CDM,S5000,HCPCS,259,RC,49884-0311-55,NDC,outpatient,1,UN,2.41,1.687,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RISPERIDONE 1 MG ORAL TBDP,RX-35687,CDM,S5000,HCPCS,259,RC,49884-0315-55,NDC,outpatient,1,UN,2.77,1.939,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RISPERIDONE 1 MG ORAL TBDP,RX-35687,CDM,S5000,HCPCS,259,RC,49884-0315-52,NDC,outpatient,1,UN,2.77,1.939,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MOXIFLOXACIN HCL 0.5 % OP SOLN,RX-35699,CDM,S5000,HCPCS,259,RC,72266-0158-01,NDC,outpatient,3,ML,45.03,31.521,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MOXIFLOXACIN HCL 0.5 % OP SOLN,RX-35699,CDM,S5000,HCPCS,259,RC,00832-1410-03,NDC,outpatient,3,ML,113.88,79.716,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METFORMIN HCL ER 750 MG ORAL TB24,RX-35771,CDM,S5000,HCPCS,259,RC,67877-0414-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METFORMIN HCL ER 750 MG ORAL TB24,RX-35771,CDM,S5000,HCPCS,259,RC,70010-0492-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METFORMIN HCL ER 750 MG ORAL TB24,RX-35771,CDM,S5000,HCPCS,259,RC,62756-0143-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HALOPERIDOL 0.5 MG ORAL TABS,RX-3578,CDM,S5000,HCPCS,259,RC,51079-0733-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HALOPERIDOL 0.5 MG ORAL TABS,RX-3578,CDM,S5000,HCPCS,259,RC,51079-0733-20,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HALOPERIDOL 2 MG ORAL TABS,RX-3581,CDM,S5000,HCPCS,259,RC,00832-1530-11,NDC,outpatient,1,UN,1.81,1.267,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HALOPERIDOL 2 MG ORAL TABS,RX-3581,CDM,S5000,HCPCS,259,RC,00378-0214-01,NDC,outpatient,1,UN,2.45,1.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HALOPERIDOL 5 MG ORAL TABS,RX-3583,CDM,S5000,HCPCS,259,RC,51079-0736-20,NDC,outpatient,1,UN,1.41,0.987,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HALOPERIDOL 5 MG ORAL TABS,RX-3583,CDM,S5000,HCPCS,259,RC,51079-0736-01,NDC,outpatient,1,UN,1.41,0.987,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONC,RX-3585,CDM,S5000,HCPCS,259,RC,54838-0501-15,NDC,outpatient,0.5,ML,2.5,1.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HALOPERIDOL LACTATE 2 MG/ML ORAL CONC,RX-3585,CDM,S5000,HCPCS,259,RC,99999-0003-09,NDC,outpatient,0.5,ML,2.5,1.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POTASSIUM CHLORIDE CRYS ER 10 MEQ ORAL TBCR,RX-35942,CDM,S5000,HCPCS,259,RC,00245-5317-89,NDC,outpatient,1,UN,1.08,0.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POTASSIUM CHLORIDE CRYS ER 10 MEQ ORAL TBCR,RX-35942,CDM,S5000,HCPCS,259,RC,00245-5317-01,NDC,outpatient,1,UN,1.08,0.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POTASSIUM CHLORIDE CRYS ER 10 MEQ ORAL TBCR,RX-35942,CDM,S5000,HCPCS,259,RC,63739-0972-10,NDC,outpatient,1,UN,1.14,0.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POTASSIUM CHLORIDE CRYS ER 20 MEQ ORAL TBCR,RX-35943,CDM,S5000,HCPCS,259,RC,00245-5319-01,NDC,outpatient,1,UN,1.25,0.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POTASSIUM CHLORIDE CRYS ER 20 MEQ ORAL TBCR,RX-35943,CDM,S5000,HCPCS,259,RC,00832-5325-11,NDC,outpatient,1,UN,1.25,0.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POTASSIUM CHLORIDE CRYS ER 20 MEQ ORAL TBCR,RX-35943,CDM,S5000,HCPCS,259,RC,00245-5319-89,NDC,outpatient,1,UN,1.25,0.875,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ATAZANAVIR SULFATE 150 MG ORAL CAPS,RX-36149,CDM,S5000,HCPCS,259,RC,42385-0920-60,NDC,outpatient,1,UN,11.33,7.931,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ATAZANAVIR SULFATE 200 MG ORAL CAPS,RX-36150,CDM,S5000,HCPCS,259,RC,65862-0712-60,NDC,outpatient,1,UN,13.22,9.254,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREMASOL 10 % IV SOLN,RX-36160,CDM,S5000,HCPCS,250,RC,00338-1130-03,NDC,outpatient,500,ML,98.33,68.831,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
EMTRICITABINE 200 MG ORAL CAPS,RX-36252,CDM,S5000,HCPCS,259,RC,61958-0601-01,NDC,outpatient,1,UN,77.2,54.04,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMANTADINE HCL 100 MG ORAL CAPS,RX-364,CDM,S5000,HCPCS,259,RC,50268-0069-11,NDC,outpatient,1,UN,4.75,3.325,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMANTADINE HCL 100 MG ORAL CAPS,RX-364,CDM,S5000,HCPCS,259,RC,50268-0069-15,NDC,outpatient,1,UN,4.75,3.325,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ARIPIPRAZOLE 5 MG ORAL TABS,RX-36438,CDM,S5000,HCPCS,259,RC,60687-0168-01,NDC,outpatient,1,UN,15.64,10.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ARIPIPRAZOLE 5 MG ORAL TABS,RX-36438,CDM,S5000,HCPCS,259,RC,60687-0168-11,NDC,outpatient,1,UN,15.64,10.948,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % OT SUSP,RX-36576,CDM,S5000,HCPCS,259,RC,16714-0628-01,NDC,outpatient,7.5,ML,422.83,295.981,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % OT SUSP,RX-36576,CDM,S5000,HCPCS,259,RC,43598-0326-75,NDC,outpatient,7.5,ML,438.69,307.083,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % OT SUSP,RX-36576,CDM,S5000,HCPCS,259,RC,62756-0427-90,NDC,outpatient,7.5,ML,336.96,235.872,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVETIRACETAM 100 MG/ML ORAL SOLN,RX-36590,CDM,S5000,HCPCS,259,RC,00121-4799-40,NDC,outpatient,5,ML,9.93,6.951,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVETIRACETAM 100 MG/ML ORAL SOLN,RX-36590,CDM,S5000,HCPCS,259,RC,60687-0249-67,NDC,outpatient,5,ML,12.02,8.414,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVETIRACETAM 100 MG/ML ORAL SOLN,RX-36590,CDM,S5000,HCPCS,259,RC,00121-4799-05,NDC,outpatient,5,ML,9.93,6.951,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVETIRACETAM 100 MG/ML ORAL SOLN,RX-36590,CDM,S5000,HCPCS,259,RC,60687-0249-40,NDC,outpatient,5,ML,12.02,8.414,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ROSUVASTATIN CALCIUM 5 MG ORAL TABS,RX-36612,CDM,S5000,HCPCS,259,RC,00904-6778-61,NDC,outpatient,1,UN,2.9,2.03,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
KETOROLAC TROMETHAMINE 0.4 % OP SOLN,RX-36631,CDM,S5000,HCPCS,259,RC,60758-0773-05,NDC,outpatient,5,ML,248.94,174.258,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPROPION HCL ER (XL) 150 MG ORAL TB24,RX-36775,CDM,S5000,HCPCS,259,RC,00904-7084-04,NDC,outpatient,1,UN,5.27,3.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPROPION HCL ER (XL) 150 MG ORAL TB24,RX-36775,CDM,S5000,HCPCS,259,RC,00904-7084-61,NDC,outpatient,1,UN,6.35,4.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPROPION HCL ER (XL) 150 MG ORAL TB24,RX-36775,CDM,S5000,HCPCS,259,RC,16729-0443-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOCUSATE SODIUM 50 MG/5ML ORAL LIQD,RX-36962,CDM,S5000,HCPCS,259,RC,00121-1870-10,NDC,outpatient,10,ML,6.46,4.522,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOCUSATE SODIUM 50 MG/5ML ORAL LIQD,RX-36962,CDM,S5000,HCPCS,259,RC,63739-0976-01,NDC,outpatient,10,ML,3.61,2.527,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOCUSATE SODIUM 50 MG/5ML ORAL LIQD,RX-36962,CDM,S5000,HCPCS,259,RC,63739-0976-10,NDC,outpatient,10,ML,3.61,2.527,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOCUSATE SODIUM 50 MG/5ML ORAL LIQD,RX-36962,CDM,S5000,HCPCS,259,RC,00121-1870-00,NDC,outpatient,10,ML,6.46,4.522,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOCUSATE SODIUM 50 MG/5ML ORAL LIQD,RX-36962,CDM,S5000,HCPCS,259,RC,99999-0001-96,NDC,outpatient,10,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
THEOPHYLLINE ER 400 MG ORAL TB24,RX-36973,CDM,S5000,HCPCS,259,RC,42858-0701-01,NDC,outpatient,1,UN,3.89,2.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
THEOPHYLLINE ER 400 MG ORAL TB24,RX-36973,CDM,S5000,HCPCS,259,RC,29033-0001-01,NDC,outpatient,1,UN,5.44,3.808,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PHENOL 1.4 % MT LIQD,RX-36976,CDM,S5000,HCPCS,259,RC,49348-0991-36,NDC,outpatient,177,ML,7.88,5.516,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PHENOL 1.4 % MT LIQD,RX-36976,CDM,S5000,HCPCS,259,RC,78112-0011-03,NDC,outpatient,177,ML,17.33,12.131,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PHENOL 1.4 % MT LIQD,RX-36976,CDM,S5000,HCPCS,259,RC,00904-6305-21,NDC,outpatient,177,ML,7.09,4.963,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDRALAZINE HCL 10 MG ORAL TABS,RX-3698,CDM,S5000,HCPCS,259,RC,51079-0074-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDRALAZINE HCL 10 MG ORAL TABS,RX-3698,CDM,S5000,HCPCS,259,RC,51079-0074-20,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALFUZOSIN HCL ER 10 MG ORAL TB24,RX-36982,CDM,S5000,HCPCS,259,RC,57237-0114-90,NDC,outpatient,1,UN,2,1.4,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALFUZOSIN HCL ER 10 MG ORAL TB24,RX-36982,CDM,S5000,HCPCS,259,RC,29300-0155-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
EPLERENONE 25 MG ORAL TABS,RX-36983,CDM,S5000,HCPCS,259,RC,60687-0451-11,NDC,outpatient,1,UN,18.55,12.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
EPLERENONE 25 MG ORAL TABS,RX-36983,CDM,S5000,HCPCS,259,RC,60687-0451-21,NDC,outpatient,1,UN,18.55,12.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
EPLERENONE 25 MG ORAL TABS,RX-36983,CDM,S5000,HCPCS,259,RC,51991-0877-33,NDC,outpatient,1,UN,1.68,1.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
EPLERENONE 25 MG ORAL TABS,RX-36983,CDM,S5000,HCPCS,259,RC,59762-1710-02,NDC,outpatient,1,UN,5.59,3.913,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ZONISAMIDE 25 MG ORAL CAPS,RX-36987,CDM,S5000,HCPCS,259,RC,68462-0128-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,31722-0520-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,63739-0327-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,23155-0833-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,51079-0075-01,NDC,outpatient,1,UN,1.14,0.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,51079-0075-20,NDC,outpatient,1,UN,1.14,0.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,60687-0822-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDRALAZINE HCL 25 MG ORAL TABS,RX-3700,CDM,S5000,HCPCS,259,RC,60687-0822-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
THERA M PLUS ORAL TABS,RX-37053,CDM,S5000,HCPCS,259,RC,57896-0621-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
THERA M PLUS ORAL TABS,RX-37053,CDM,S5000,HCPCS,259,RC,00536-3445-08,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,00591-3870-44,NDC,outpatient,1,UN,1.42,0.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,00904-6505-61,NDC,outpatient,1,UN,1.34,0.938,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,60687-0173-11,NDC,outpatient,1,UN,2.01,1.407,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,00591-3870-45,NDC,outpatient,1,UN,1.42,0.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,60687-0173-57,NDC,outpatient,1,UN,2.01,1.407,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MEMANTINE HCL 5 MG ORAL TABS,RX-37170,CDM,S5000,HCPCS,259,RC,00832-1112-60,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROCHLOROTHIAZIDE 25 MG ORAL TABS,RX-3720,CDM,S5000,HCPCS,259,RC,60687-0593-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROCHLOROTHIAZIDE 25 MG ORAL TABS,RX-3720,CDM,S5000,HCPCS,259,RC,60687-0593-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROCORTISONE 1 % EX CREA,RX-3726,CDM,S5000,HCPCS,259,RC,00536-1277-80,NDC,outpatient,28,GR,5.24,3.668,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROCORTISONE 1 % EX CREA,RX-3726,CDM,S5000,HCPCS,259,RC,49348-0521-72,NDC,outpatient,28.4,GR,6.32,4.424,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROCORTISONE 1 % EX LOTN,RX-3728,CDM,S5000,HCPCS,259,RC,00394-0859-32,NDC,outpatient,114,ML,22.83,15.981,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROCORTISONE 1 % EX LOTN,RX-3728,CDM,S5000,HCPCS,259,RC,00096-0732-04,NDC,outpatient,120,ML,56.61,39.627,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROCORTISONE 1 % EX OINT,RX-3731,CDM,S5000,HCPCS,259,RC,00168-0020-31,NDC,outpatient,28.35,GR,18.05,12.635,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROCORTISONE 10 MG ORAL TABS,RX-3733,CDM,S5000,HCPCS,259,RC,60687-0582-01,NDC,outpatient,1,UN,6.08,4.256,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROCORTISONE 10 MG ORAL TABS,RX-3733,CDM,S5000,HCPCS,259,RC,59762-0074-01,NDC,outpatient,1,UN,1.14,0.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROCORTISONE 10 MG ORAL TABS,RX-3733,CDM,S5000,HCPCS,259,RC,60687-0582-11,NDC,outpatient,1,UN,6.08,4.256,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROCORTISONE ACETATE 25 MG RE SUPP,RX-3738,CDM,S5000,HCPCS,259,RC,00574-7090-12,NDC,outpatient,1,UN,5.54,3.878,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROCORTISONE ACETATE 25 MG RE SUPP,RX-3738,CDM,S5000,HCPCS,259,RC,10135-0751-12,NDC,outpatient,1,UN,7.8,5.46,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,00245-0036-60,NDC,outpatient,1,UN,3.71,2.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,42806-0270-95,NDC,outpatient,1,UN,3.48,2.436,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,42806-0270-98,NDC,outpatient,1,UN,3.48,2.436,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,49884-0466-65,NDC,outpatient,1,UN,2.84,1.988,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,00245-0036-89,NDC,outpatient,1,UN,3.71,2.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CHOLESTYRAMINE LIGHT 4 G ORAL PACK,RX-37482,CDM,S5000,HCPCS,259,RC,49884-0466-63,NDC,outpatient,1,UN,2.84,1.988,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CARBAMAZEPINE ER 100 MG ORAL CP12,RX-37567,CDM,S5000,HCPCS,259,RC,50268-0170-13,NDC,outpatient,1,UN,7.06,4.942,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CARBAMAZEPINE ER 100 MG ORAL CP12,RX-37567,CDM,S5000,HCPCS,259,RC,50268-0170-11,NDC,outpatient,1,UN,7.06,4.942,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BSS IO SOLN,RX-37579,CDM,S5000,HCPCS,259,RC,00065-0795-15,NDC,outpatient,15,ML,24.7,17.29,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROMORPHONE HCL 2 MG ORAL TABS,RX-3760,CDM,S5000,HCPCS,259,RC,00406-3243-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROMORPHONE HCL 2 MG ORAL TABS,RX-3760,CDM,S5000,HCPCS,259,RC,42858-0301-01,NDC,outpatient,1,UN,1.14,0.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROMORPHONE HCL 2 MG ORAL TABS,RX-3760,CDM,S5000,HCPCS,259,RC,60687-0579-01,NDC,outpatient,1,UN,1.27,0.889,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROMORPHONE HCL 2 MG ORAL TABS,RX-3760,CDM,S5000,HCPCS,259,RC,60687-0579-11,NDC,outpatient,1,UN,1.27,0.889,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROMORPHONE HCL 2 MG ORAL TABS,RX-3760,CDM,S5000,HCPCS,259,RC,42858-0301-25,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROMORPHONE HCL 4 MG ORAL TABS,RX-3761,CDM,S5000,HCPCS,259,RC,60687-0590-11,NDC,outpatient,1,UN,1.06,0.742,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROMORPHONE HCL 4 MG ORAL TABS,RX-3761,CDM,S5000,HCPCS,259,RC,00406-3244-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROMORPHONE HCL 4 MG ORAL TABS,RX-3761,CDM,S5000,HCPCS,259,RC,42858-0234-01,NDC,outpatient,1,UN,17.03,11.921,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROMORPHONE HCL 4 MG ORAL TABS,RX-3761,CDM,S5000,HCPCS,259,RC,60687-0590-01,NDC,outpatient,1,UN,1.06,0.742,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METOPROLOL TARTRATE 25 MG ORAL TABS,RX-37637,CDM,S5000,HCPCS,259,RC,00378-0018-05,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METOPROLOL TARTRATE 25 MG ORAL TABS,RX-37637,CDM,S5000,HCPCS,259,RC,51079-0255-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METOPROLOL TARTRATE 25 MG ORAL TABS,RX-37637,CDM,S5000,HCPCS,259,RC,62584-0265-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METOPROLOL TARTRATE 25 MG ORAL TABS,RX-37637,CDM,S5000,HCPCS,259,RC,51079-0255-20,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METOPROLOL TARTRATE 25 MG ORAL TABS,RX-37637,CDM,S5000,HCPCS,259,RC,62584-0265-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLINDAMYCIN PALMITATE HCL 75 MG/5ML ORAL SOLR,RX-37642,CDM,S5000,HCPCS,259,RC,23155-0603-51,NDC,outpatient,100,ML,170.44,119.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLINDAMYCIN PALMITATE HCL 75 MG/5ML ORAL SOLR,RX-37642,CDM,S5000,HCPCS,259,RC,59762-0016-01,NDC,outpatient,100,ML,170.44,119.308,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLINDAMYCIN PALMITATE HCL 75 MG/5ML ORAL SOLR,RX-37642,CDM,S5000,HCPCS,259,RC,99999-0002-90,NDC,outpatient,10,ML,18.43,12.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GLIPIZIDE ER 2.5 MG ORAL TB24,RX-37648,CDM,S5000,HCPCS,259,RC,60687-0768-11,NDC,outpatient,1,UN,4.6,3.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GLIPIZIDE ER 2.5 MG ORAL TB24,RX-37648,CDM,S5000,HCPCS,259,RC,60687-0768-21,NDC,outpatient,1,UN,4.6,3.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GLIPIZIDE ER 5 MG ORAL TB24,RX-37649,CDM,S5000,HCPCS,259,RC,68084-0111-01,NDC,outpatient,1,UN,2.4,1.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GLIPIZIDE ER 5 MG ORAL TB24,RX-37649,CDM,S5000,HCPCS,259,RC,68084-0111-11,NDC,outpatient,1,UN,2.4,1.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GUAIFENESIN ER 600 MG ORAL TB12,RX-37651,CDM,S5000,HCPCS,259,RC,68084-0572-01,NDC,outpatient,1,UN,2.76,1.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GUAIFENESIN ER 600 MG ORAL TB12,RX-37651,CDM,S5000,HCPCS,259,RC,63824-0008-50,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GUAIFENESIN ER 600 MG ORAL TB12,RX-37651,CDM,S5000,HCPCS,259,RC,68084-0572-11,NDC,outpatient,1,UN,2.76,1.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GUAIFENESIN ER 600 MG ORAL TB12,RX-37651,CDM,S5000,HCPCS,259,RC,00904-6718-39,NDC,outpatient,1,UN,2.32,1.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROXYZINE HCL 10 MG/5ML ORAL SYRP,RX-3771,CDM,S5000,HCPCS,259,RC,54838-0502-80,NDC,outpatient,5,ML,2.88,2.016,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROXYZINE HCL 10 MG/5ML ORAL SYRP,RX-3771,CDM,S5000,HCPCS,259,RC,99999-0002-50,NDC,outpatient,5,ML,1.16,0.812,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROXYZINE HCL 10 MG/5ML ORAL SYRP,RX-3771,CDM,S5000,HCPCS,259,RC,62135-0750-47,NDC,outpatient,5,ML,21.74,15.218,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROXYZINE HCL 10 MG ORAL TABS,RX-3772,CDM,S5000,HCPCS,259,RC,63739-0483-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROXYZINE HCL 25 MG ORAL TABS,RX-3774,CDM,S5000,HCPCS,259,RC,63739-0486-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROXYZINE HCL 25 MG ORAL TABS,RX-3774,CDM,S5000,HCPCS,259,RC,60687-0675-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROXYZINE HCL 25 MG ORAL TABS,RX-3774,CDM,S5000,HCPCS,259,RC,00904-6617-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROXYZINE HCL 25 MG ORAL TABS,RX-3774,CDM,S5000,HCPCS,259,RC,60687-0675-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TALC 5 G PL SUSR,RX-37812,CDM,S5000,HCPCS,259,RC,63256-0200-05,NDC,outpatient,1,UN,458.35,320.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CINACALCET HCL 30 MG ORAL TABS,RX-38100,CDM,S5000,HCPCS,259,RC,55513-0073-30,NDC,outpatient,1,UN,75.45,52.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CINACALCET HCL 30 MG ORAL TABS,RX-38100,CDM,S5000,HCPCS,259,RC,00904-7067-04,NDC,outpatient,1,UN,76.53,53.571,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CINACALCET HCL 30 MG ORAL TABS,RX-38100,CDM,S5000,HCPCS,259,RC,60687-0525-21,NDC,outpatient,1,UN,64.87,45.409,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CINACALCET HCL 30 MG ORAL TABS,RX-38100,CDM,S5000,HCPCS,259,RC,70436-0007-04,NDC,outpatient,1,UN,1.94,1.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CINACALCET HCL 30 MG ORAL TABS,RX-38100,CDM,S5000,HCPCS,259,RC,60687-0525-11,NDC,outpatient,1,UN,64.87,45.409,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ORPHENADRINE CITRATE ER 100 MG ORAL TB12,RX-38213,CDM,S5000,HCPCS,259,RC,43386-0480-24,NDC,outpatient,1,UN,2.27,1.589,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PROPRANOLOL HCL ER 60 MG ORAL CP24,RX-38224,CDM,S5000,HCPCS,259,RC,62559-0530-01,NDC,outpatient,1,UN,2.1,1.47,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PROPRANOLOL HCL ER 60 MG ORAL CP24,RX-38224,CDM,S5000,HCPCS,259,RC,00228-2778-11,NDC,outpatient,1,UN,6.75,4.725,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PROPRANOLOL HCL ER 60 MG ORAL CP24,RX-38224,CDM,S5000,HCPCS,259,RC,42291-0522-01,NDC,outpatient,1,UN,1.68,1.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PROPRANOLOL HCL ER 80 MG ORAL CP24,RX-38225,CDM,S5000,HCPCS,259,RC,00228-2779-11,NDC,outpatient,1,UN,8.57,5.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PROPRANOLOL HCL ER 80 MG ORAL CP24,RX-38225,CDM,S5000,HCPCS,259,RC,00527-4117-37,NDC,outpatient,1,UN,1.14,0.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PROPRANOLOL HCL ER 120 MG ORAL CP24,RX-38226,CDM,S5000,HCPCS,259,RC,42291-0524-01,NDC,outpatient,1,UN,2.42,1.694,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PROPRANOLOL HCL ER 120 MG ORAL CP24,RX-38226,CDM,S5000,HCPCS,259,RC,00228-2780-11,NDC,outpatient,1,UN,10.29,7.203,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LACTULOSE 10 GM/15ML ORAL SOLN,RX-38245,CDM,S5000,HCPCS,259,RC,00121-1154-00,NDC,outpatient,30,ML,4.94,3.458,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LACTULOSE 10 GM/15ML ORAL SOLN,RX-38245,CDM,S5000,HCPCS,259,RC,45963-0439-65,NDC,outpatient,15,ML,1.01,0.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LACTULOSE 10 GM/15ML ORAL SOLN,RX-38245,CDM,S5000,HCPCS,259,RC,00121-1154-30,NDC,outpatient,30,ML,4.94,3.458,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LACTULOSE 10 GM/15ML ORAL SOLN,RX-38245,CDM,S5000,HCPCS,259,RC,45963-0439-30,NDC,outpatient,30,ML,2.01,1.407,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LACTULOSE 10 GM/15ML ORAL SOLN,RX-38245,CDM,S5000,HCPCS,259,RC,99999-0001-83,NDC,outpatient,30,ML,2.16,1.512,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CETIRIZINE HCL 5 MG ORAL CHEW,RX-38402,CDM,S5000,HCPCS,259,RC,00781-5283-64,NDC,outpatient,1,UN,12.96,9.072,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CETIRIZINE HCL 5 MG ORAL CHEW,RX-38402,CDM,S5000,HCPCS,259,RC,00781-5283-06,NDC,outpatient,1,UN,12.96,9.072,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IBUPROFEN 200 MG ORAL TABS,RX-3841,CDM,S5000,HCPCS,259,RC,00904-7914-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,60687-0446-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,60687-0446-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,67877-0319-05,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,00904-5853-60,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,67877-0319-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IBUPROFEN 400 MG ORAL TABS,RX-3843,CDM,S5000,HCPCS,259,RC,00904-5853-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IBUPROFEN 600 MG ORAL TABS,RX-3844,CDM,S5000,HCPCS,259,RC,00904-5854-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
INFUVITE PEDIATRIC IV SOLN,RX-38445,CDM,S5000,HCPCS,250,RC,54643-5646-01,NDC,outpatient,4,ML,53.96,37.772,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
INFUVITE PEDIATRIC IV SOLN,RX-38445,CDM,S5000,HCPCS,250,RC,54643-5646-09,NDC,outpatient,1,ML,15.58,10.906,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IBUPROFEN 800 MG ORAL TABS,RX-3845,CDM,S5000,HCPCS,259,RC,00904-5855-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLUOXETINE HCL 20 MG/5ML ORAL SOLN,RX-38488,CDM,S5000,HCPCS,259,RC,00121-4721-05,NDC,outpatient,5,ML,14.38,10.066,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IMIPRAMINE HCL 10 MG ORAL TABS,RX-3860,CDM,S5000,HCPCS,259,RC,69584-0425-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IMIPRAMINE HCL 25 MG ORAL TABS,RX-3861,CDM,S5000,HCPCS,259,RC,69584-0426-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NEOMYCIN-BACITRACIN ZN-POLYMYX 5-400-10000 OP OINT,RX-38701,CDM,S5000,HCPCS,259,RC,24208-0780-55,NDC,outpatient,3.5,GR,57.59,40.313,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
INDAPAMIDE 2.5 MG ORAL TABS,RX-3879,CDM,S5000,HCPCS,259,RC,62559-0511-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
INDAPAMIDE 2.5 MG ORAL TABS,RX-3879,CDM,S5000,HCPCS,259,RC,00228-2571-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SELENIUM SULFIDE 1 % EX SHAM,RX-38961,CDM,S5000,HCPCS,259,RC,00536-1995-53,NDC,outpatient,207,ML,9.22,6.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PEG 3350-KCL-NABCB-NACL-NASULF 240 G ORAL SOLR,RX-38965,CDM,S5000,HCPCS,259,RC,43386-0060-19,NDC,outpatient,4000,ML,53.4,37.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
INDOMETHACIN 25 MG ORAL CAPS,RX-3897,CDM,S5000,HCPCS,259,RC,50268-0430-15,NDC,outpatient,1,UN,1.4,0.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
INDOMETHACIN 25 MG ORAL CAPS,RX-3897,CDM,S5000,HCPCS,259,RC,50268-0430-11,NDC,outpatient,1,UN,1.4,0.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
INDOMETHACIN 50 MG RE SUPP,RX-3901,CDM,S5000,HCPCS,259,RC,69344-0102-33,NDC,outpatient,1,UN,1095.8,767.06,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RIFAXIMIN 200 MG ORAL TABS,RX-39063,CDM,S5000,HCPCS,259,RC,65649-0301-03,NDC,outpatient,1,UN,43.55,30.485,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMILORIDE HCL 5 MG ORAL TABS,RX-391,CDM,S5000,HCPCS,259,RC,00574-0292-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NYSTATIN 100000 UNIT/GM EX POWD,RX-39136,CDM,S5000,HCPCS,259,RC,68382-0370-01,NDC,outpatient,15,GR,31.18,21.826,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NYSTATIN 100000 UNIT/GM EX POWD,RX-39136,CDM,S5000,HCPCS,259,RC,16714-0769-01,NDC,outpatient,15,GR,25.04,17.528,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NYSTATIN 100000 UNIT/GM EX POWD,RX-39136,CDM,S5000,HCPCS,259,RC,69315-0306-15,NDC,outpatient,15,GR,24.5,17.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NYSTATIN 100000 UNIT/GM EX POWD,RX-39136,CDM,S5000,HCPCS,259,RC,00832-0465-15,NDC,outpatient,15,GR,37.52,26.264,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NYSTATIN 100000 UNIT/GM EX POWD,RX-39136,CDM,S5000,HCPCS,259,RC,68308-0152-15,NDC,outpatient,15,GR,27.84,19.488,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
EMTRICITABINE-TENOFOVIR DF 200-300 MG ORAL TABS,RX-39255,CDM,S5000,HCPCS,259,RC,61958-0701-01,NDC,outpatient,1,UN,265.08,185.556,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DULOXETINE HCL 20 MG ORAL CPEP,RX-39275,CDM,S5000,HCPCS,259,RC,60687-0723-11,NDC,outpatient,1,UN,3.39,2.373,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DULOXETINE HCL 20 MG ORAL CPEP,RX-39275,CDM,S5000,HCPCS,259,RC,00904-7043-04,NDC,outpatient,1,UN,3.3,2.31,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DULOXETINE HCL 20 MG ORAL CPEP,RX-39275,CDM,S5000,HCPCS,259,RC,60687-0723-21,NDC,outpatient,1,UN,3.39,2.373,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DULOXETINE HCL 30 MG ORAL CPEP,RX-39276,CDM,S5000,HCPCS,259,RC,57237-0018-90,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DULOXETINE HCL 30 MG ORAL CPEP,RX-39276,CDM,S5000,HCPCS,259,RC,60687-0734-01,NDC,outpatient,1,UN,3.41,2.387,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DULOXETINE HCL 30 MG ORAL CPEP,RX-39276,CDM,S5000,HCPCS,259,RC,60687-0734-11,NDC,outpatient,1,UN,3.41,2.387,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DULOXETINE HCL 30 MG ORAL CPEP,RX-39276,CDM,S5000,HCPCS,259,RC,00904-7044-61,NDC,outpatient,1,UN,3.08,2.156,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVALBUTEROL HCL 1.25 MG/0.5ML IN NEBU,RX-39278,CDM,S5000,HCPCS,259,RC,00378-6993-93,NDC,outpatient,1,UN,20.14,14.098,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVALBUTEROL HCL 1.25 MG/0.5ML IN NEBU,RX-39278,CDM,S5000,HCPCS,259,RC,00378-6993-31,NDC,outpatient,1,UN,20.14,14.098,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CEFDINIR 250 MG/5ML ORAL SUSR,RX-39522,CDM,S5000,HCPCS,259,RC,99999-0002-80,NDC,outpatient,6,ML,3.93,2.751,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CEFDINIR 250 MG/5ML ORAL SUSR,RX-39522,CDM,S5000,HCPCS,259,RC,65862-0219-60,NDC,outpatient,60,ML,88.92,62.244,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CEFDINIR 250 MG/5ML ORAL SUSR,RX-39522,CDM,S5000,HCPCS,259,RC,68180-0723-04,NDC,outpatient,60,ML,87.31,61.117,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MESALAMINE ER 500 MG ORAL CPCR,RX-39575,CDM,S5000,HCPCS,259,RC,54092-0191-12,NDC,outpatient,1,UN,24.97,17.479,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IODINE STRONG 5 % ORAL SOLN,RX-3961,CDM,S5000,HCPCS,259,RC,48433-0230-15,NDC,outpatient,14,ML,132.64,92.848,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IODINE STRONG 5 % ORAL SOLN,RX-3961,CDM,S5000,HCPCS,259,RC,51552-0019-44,NDC,outpatient,14,ML,5.44,3.808,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACAMPROSATE CALCIUM 333 MG ORAL TBEC,RX-39720,CDM,S5000,HCPCS,259,RC,60687-0121-25,NDC,outpatient,1,UN,6.9,4.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACAMPROSATE CALCIUM 333 MG ORAL TBEC,RX-39720,CDM,S5000,HCPCS,259,RC,60687-0121-95,NDC,outpatient,1,UN,6.9,4.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLUMAZENIL 0.5 MG/5ML IV SOLN,RX-39744,CDM,S5000,HCPCS,250,RC,36000-0148-01,NDC,outpatient,5,ML,12.98,9.086,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLUMAZENIL 0.5 MG/5ML IV SOLN,RX-39744,CDM,S5000,HCPCS,250,RC,00143-9784-10,NDC,outpatient,5,ML,13.42,9.394,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLUMAZENIL 0.5 MG/5ML IV SOLN,RX-39744,CDM,S5000,HCPCS,250,RC,00143-9784-01,NDC,outpatient,5,ML,13.42,9.394,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLUMAZENIL 0.5 MG/5ML IV SOLN,RX-39744,CDM,S5000,HCPCS,250,RC,36000-0148-10,NDC,outpatient,5,ML,12.98,9.086,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLUMAZENIL 0.5 MG/5ML IV SOLN,RX-39744,CDM,S5000,HCPCS,250,RC,63323-0424-05,NDC,outpatient,5,ML,15.68,10.976,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVOFLOXACIN 25 MG/ML ORAL SOLN,RX-39970,CDM,S5000,HCPCS,259,RC,00527-1948-68,NDC,outpatient,10,ML,85.98,60.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVOFLOXACIN 25 MG/ML ORAL SOLN,RX-39970,CDM,S5000,HCPCS,259,RC,99999-0002-53,NDC,outpatient,10,ML,37.07,25.949,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LANTHANUM CARBONATE 500 MG ORAL CHEW,RX-39975,CDM,S5000,HCPCS,259,RC,54092-0252-45,NDC,outpatient,1,UN,49.37,34.559,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LANTHANUM CARBONATE 500 MG ORAL CHEW,RX-39975,CDM,S5000,HCPCS,259,RC,54092-0252-90,NDC,outpatient,1,UN,49.37,34.559,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LANTHANUM CARBONATE 500 MG ORAL CHEW,RX-39975,CDM,S5000,HCPCS,259,RC,68180-0819-42,NDC,outpatient,1,UN,24.73,17.311,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LANTHANUM CARBONATE 500 MG ORAL CHEW,RX-39975,CDM,S5000,HCPCS,259,RC,68180-0819-52,NDC,outpatient,1,UN,24.73,17.311,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FENOFIBRATE 48 MG ORAL TABS,RX-40009,CDM,S5000,HCPCS,259,RC,51079-0599-20,NDC,outpatient,1,UN,4.01,2.807,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FENOFIBRATE 48 MG ORAL TABS,RX-40009,CDM,S5000,HCPCS,259,RC,51079-0599-01,NDC,outpatient,1,UN,4.01,2.807,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FENOFIBRATE 145 MG ORAL TABS,RX-40010,CDM,S5000,HCPCS,259,RC,51079-0608-20,NDC,outpatient,1,UN,10.74,7.518,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FENOFIBRATE 145 MG ORAL TABS,RX-40010,CDM,S5000,HCPCS,259,RC,60687-0629-21,NDC,outpatient,1,UN,4.19,2.933,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MAGIC MOUTHWASH ORAL SUSPENSION *HOSPITAL USE ONLY*,RX-400477,CDM,S5000,HCPCS,259,RC,65628-0050-01,NDC,outpatient,10,ML,19.54,13.678,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MAGIC MOUTHWASH ORAL SUSPENSION *HOSPITAL USE ONLY*,RX-400477,CDM,S5000,HCPCS,259,RC,65628-0050-04,NDC,outpatient,5,ML,14,9.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MAGIC MOUTHWASH ORAL SUSPENSION *HOSPITAL USE ONLY*,RX-400477,CDM,S5000,HCPCS,259,RC,99999-0000-61,NDC,outpatient,180,ML,12.46,8.722,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MAGIC MOUTHWASH ORAL SUSPENSION *HOSPITAL USE ONLY*,RX-400477,CDM,S5000,HCPCS,259,RC,99999-0000-82,NDC,outpatient,10,ML,19.54,13.678,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RIFAMPIN 10 MG/ML ORAL SUSPENSION,RX-400484,CDM,S5000,HCPCS,259,RC,99999-0001-44,NDC,outpatient,120,ML,34,23.8,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METOPROLOL TARTRATE 12.5 MG ORAL SPLIT TABLET,RX-400503,CDM,S5000,HCPCS,259,RC,,,outpatient,12.5,ME,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METOPROLOL TARTRATE 12.5 MG ORAL SPLIT TABLET,RX-400503,CDM,S5000,HCPCS,259,RC,SH040-0403-01,NDC,outpatient,12.5,ME,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METOPROLOL TARTRATE 12.5 MG ORAL SPLIT TABLET,RX-400503,CDM,S5000,HCPCS,259,RC,99999-0002-12,NDC,outpatient,12.5,ME,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CEFAZOLIN EYE DROPS 50 MG/ML 20 ML BOTTLE,RX-400598,CDM,S5000,HCPCS,259,RC,SH408-0378-01,NDC,outpatient,20,ML,18.41,12.887,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MISOPROSTOL 25 MCG ORAL SPLIT TABS,RX-400620,CDM,S5000,HCPCS,259,RC,SH040-0620-01,NDC,outpatient,1,UN,1.69,1.183,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MISOPROSTOL 25 MCG ORAL SPLIT TABS,RX-400620,CDM,S5000,HCPCS,259,RC,,,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ISONIAZID 100 MG ORAL TABS,RX-4026,CDM,S5000,HCPCS,259,RC,00555-0066-02,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMINOCAPROIC ACID 250 MG/ML IV SOLN,RX-403,CDM,S5000,HCPCS,250,RC,00517-9120-25,NDC,outpatient,4,ML,8,5.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMINOCAPROIC ACID 250 MG/ML IV SOLN,RX-403,CDM,S5000,HCPCS,250,RC,00409-4346-16,NDC,outpatient,20,ML,18.34,12.838,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMINOCAPROIC ACID 250 MG/ML IV SOLN,RX-403,CDM,S5000,HCPCS,250,RC,00409-4346-73,NDC,outpatient,20,ML,18.34,12.838,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMINOCAPROIC ACID 250 MG/ML IV SOLN,RX-403,CDM,S5000,HCPCS,250,RC,00517-9120-01,NDC,outpatient,4,ML,8,5.6,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN,RX-4034,CDM,S5000,HCPCS,250,RC,14789-0015-07,NDC,outpatient,5,ML,1453.64,1017.548,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN,RX-4034,CDM,S5000,HCPCS,250,RC,14789-0015-05,NDC,outpatient,5,ML,1453.64,1017.548,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN,RX-4034,CDM,S5000,HCPCS,250,RC,00548-9502-00,NDC,outpatient,5,ML,246.51,172.557,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MESALAMINE 1000 MG RE SUPP,RX-40369,CDM,S5000,HCPCS,259,RC,59762-0118-03,NDC,outpatient,1,UN,22.5,15.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MESALAMINE 1000 MG RE SUPP,RX-40369,CDM,S5000,HCPCS,259,RC,69918-0560-30,NDC,outpatient,1,UN,7.56,5.292,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SOLIFENACIN SUCCINATE 5 MG ORAL TABS,RX-40392,CDM,S5000,HCPCS,259,RC,51248-0150-01,NDC,outpatient,1,UN,52.84,36.988,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CYANOCOBALAMIN 500 MCG SL SUBL,RX-40518,CDM,S5000,HCPCS,259,RC,00743-1203-59,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CYANOCOBALAMIN 500 MCG SL SUBL,RX-40518,CDM,S5000,HCPCS,259,RC,74312-0035-95,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ISOSORBIDE DINITRATE 10 MG ORAL TABS,RX-4064,CDM,S5000,HCPCS,259,RC,68084-0082-01,NDC,outpatient,1,UN,2.67,1.869,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ISOSORBIDE DINITRATE 10 MG ORAL TABS,RX-4064,CDM,S5000,HCPCS,259,RC,68084-0082-11,NDC,outpatient,1,UN,2.67,1.869,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ISOSORBIDE DINITRATE 20 MG ORAL TABS,RX-4065,CDM,S5000,HCPCS,259,RC,00904-6620-61,NDC,outpatient,1,UN,2.27,1.589,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE 0.9 % IV PVC FREE SOLN,RX-4080010,CDM,S5000,HCPCS,250,RC,00264-1800-32,NDC,outpatient,100,ML,28.85,20.195,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE 0.9 % IV PVC FREE SOLN,RX-4080010,CDM,S5000,HCPCS,250,RC,00264-7800-10,NDC,outpatient,500,ML,31.42,21.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE 0.9 % IV PVC FREE SOLN,RX-4080010,CDM,S5000,HCPCS,250,RC,00264-7800-20,NDC,outpatient,250,ML,30.14,21.098,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROMORPHONE 100 MG/100 ML INFUSION,RX-4080055,CDM,S5000,HCPCS,250,RC,99999-0000-26,NDC,outpatient,100,ML,168.65,118.055,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DILTIAZEM ADDVANTAGE INFUSION IN NS,RX-4080056,CDM,S5000,HCPCS,250,RC,99999-0000-00,NDC,outpatient,100,ML,54.5,38.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FENTANYL INFUSION PREMIX 10 MCG/ML 250 ML,RX-4080065,CDM,S5000,HCPCS,250,RC,70092-1093-37,NDC,outpatient,250,ML,130.86,91.602,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FENTANYL INFUSION PREMIX 10 MCG/ML 250 ML,RX-4080065,CDM,S5000,HCPCS,250,RC,70004-0229-40,NDC,outpatient,250,ML,277.66,194.362,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FENTANYL INFUSION PREMIX 10 MCG/ML 250 ML,RX-4080065,CDM,S5000,HCPCS,250,RC,99999-0001-54,NDC,outpatient,250,ML,37.36,26.152,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FENTANYL INFUSION PREMIX 10 MCG/ML 250 ML,RX-4080065,CDM,S5000,HCPCS,250,RC,70004-0202-40,NDC,outpatient,250,ML,236.1,165.27,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
KETAMINE INFUSION 500 MG IN 250 ML INFUSION,RX-4080078,CDM,S5000,HCPCS,250,RC,70004-0442-40,NDC,outpatient,250,ML,112.79,78.953,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
KETAMINE INFUSION 500 MG IN 250 ML INFUSION,RX-4080078,CDM,S5000,HCPCS,250,RC,99999-9990-03,NDC,outpatient,250,ML,37.81,26.467,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MORPHINE INFUSION 250 MG IN D5W 250 ML PREMIX,RX-4080096,CDM,S5000,HCPCS,250,RC,99999-0001-61,NDC,outpatient,250,ML,35.02,24.514,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FAMOTIDINE 10 MG/ML IJ WRAPPER,RX-4080100,CDM,S5000,HCPCS,250,RC,00641-6022-01,NDC,outpatient,2,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FAMOTIDINE 10 MG/ML IJ WRAPPER,RX-4080100,CDM,S5000,HCPCS,250,RC,00641-6022-25,NDC,outpatient,2,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FAMOTIDINE 10 MG/ML IJ WRAPPER,RX-4080100,CDM,S5000,HCPCS,250,RC,67457-0433-22,NDC,outpatient,2,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FAMOTIDINE 10 MG/ML IJ WRAPPER,RX-4080100,CDM,S5000,HCPCS,250,RC,67457-0433-00,NDC,outpatient,2,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ARTIFICIAL TEARS EYE SOLN WRAPPER,RX-4080101,CDM,S5000,HCPCS,259,RC,57896-0181-05,NDC,outpatient,15,ML,5.55,3.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ARTIFICIAL TEARS EYE SOLN WRAPPER,RX-4080101,CDM,S5000,HCPCS,259,RC,00065-0426-36,NDC,outpatient,15,ML,27.17,19.019,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NAFCILLIN SODIUM 1 G IJ WRAPPER,RX-4080106,CDM,S5000,HCPCS,250,RC,63323-0327-10,NDC,outpatient,1,UN,15.49,10.843,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NAFCILLIN SODIUM 2 G IJ WRAPPER,RX-4080107,CDM,S5000,HCPCS,250,RC,44567-0222-10,NDC,outpatient,1,UN,90.46,63.322,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NAFCILLIN SODIUM 2 G IJ WRAPPER,RX-4080107,CDM,S5000,HCPCS,250,RC,63323-0328-20,NDC,outpatient,1,UN,24.64,17.248,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NAFCILLIN SODIUM 2 G IJ WRAPPER,RX-4080107,CDM,S5000,HCPCS,250,RC,55150-0123-15,NDC,outpatient,1,UN,30.45,21.315,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NOREPINEPHRINE PREMIX 4 MG IN 250 ML NS,RX-4080110,CDM,S5000,HCPCS,250,RC,70004-0781-40,NDC,outpatient,250,ML,123.78,86.646,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NOREPINEPHRINE PREMIX 4 MG IN 250 ML NS,RX-4080110,CDM,S5000,HCPCS,250,RC,70092-1650-05,NDC,outpatient,250,ML,102.2,71.54,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NOREPINEPHRINE PREMIX 4 MG IN 250 ML NS,RX-4080110,CDM,S5000,HCPCS,250,RC,71266-5020-02,NDC,outpatient,250,ML,112.97,79.079,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PHENYLEPHRINE IV PREMIX 40 MG IN 250 ML NS,RX-4080112,CDM,S5000,HCPCS,250,RC,42852-0838-25,NDC,outpatient,250,ML,158.85,111.195,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PHENYLEPHRINE IV PREMIX 40 MG IN 250 ML NS,RX-4080112,CDM,S5000,HCPCS,250,RC,70092-9170-05,NDC,outpatient,250,ML,146.26,102.382,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PHENYLEPHRINE IV PREMIX 40 MG IN 250 ML NS,RX-4080112,CDM,S5000,HCPCS,250,RC,70004-0812-40,NDC,outpatient,250,ML,93.12,65.184,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PHENYLEPHRINE IV PREMIX 10 MG IN 250 ML NS,RX-4080113,CDM,S5000,HCPCS,250,RC,70004-0811-40,NDC,outpatient,250,ML,109.23,76.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PHENYLEPHRINE IV PREMIX 10 MG IN 250 ML NS,RX-4080113,CDM,S5000,HCPCS,250,RC,71506-0010-58,NDC,outpatient,250,ML,88.76,62.132,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VANCOMYCIN HCL IN DEXTROSE 1250 MG/250 ML IV SOLN,RX-4080122,CDM,S5000,HCPCS,250,RC,99999-0000-46,NDC,outpatient,275,ML,64.38,45.066,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VANCOMYCIN HCL IN DEXTROSE 1500 MG/250 ML IV SOLN,RX-4080123,CDM,S5000,HCPCS,250,RC,99999-0000-47,NDC,outpatient,280,ML,80.8,56.56,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CARDIOPLEGIA SOLN HIGH POTASSIUM 4:1 INDUCTION,RX-4080154,CDM,S5000,HCPCS,250,RC,72196-0101-01,NDC,outpatient,500,ML,673.36,471.352,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CARDIOPLEGIA SOLN LOW POTASSION 4:1 REPERFUSATE,RX-4080155,CDM,S5000,HCPCS,250,RC,71285-0007-01,NDC,outpatient,238.75,ML,1537.64,1076.348,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CARDIOPLEGIA SOLN LOW POTASSIUM 4:1 MAINTENANCE,RX-4080156,CDM,S5000,HCPCS,250,RC,72196-0104-01,NDC,outpatient,1000,ML,1042.09,729.463,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CONCENTRATED DILAUDID 1 MG/ML PCA,RX-4080157,CDM,S5000,HCPCS,250,RC,70004-0303-62,NDC,outpatient,50,ML,212.25,148.575,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DILAUDID 0.2 MG/ML PCA (HYDROMORPHONE),RX-4080159,CDM,S5000,HCPCS,250,RC,70004-0300-62,NDC,outpatient,50,ML,69.63,48.741,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PRISMASATE K 0/CA 3.5 CRRT SOLUTION,RX-4080163,CDM,S5000,HCPCS,250,RC,00000-1053-53,NDC,outpatient,5000,ML,188.44,131.908,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FENTANYL 2 MCG/ML WITH BUPIVACAINE 0.125 % EPIDURAL,RX-4080168,CDM,S5000,HCPCS,250,RC,99999-0001-52,NDC,outpatient,100,ML,30.84,21.588,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FENTANYL 2 MCG/ML WITH BUPIVACAINE 0.125 % EPIDURAL,RX-4080168,CDM,S5000,HCPCS,250,RC,70004-0231-64,NDC,outpatient,100,ML,109.23,76.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FENTANYL 2 MCG/ML WITH BUPIVACAINE 0.125 % EPIDURAL,RX-4080168,CDM,S5000,HCPCS,250,RC,70092-1202-75,NDC,outpatient,100,ML,258.44,180.908,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FENTANYL 2 MCG/ML WITH BUPIVACAINE 0.125 % EPIDURAL,RX-4080168,CDM,S5000,HCPCS,250,RC,70092-9202-75,NDC,outpatient,100,ML,251.94,176.358,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FENTANYL 5 MCG/ML WITH BUPIVACAINE 0.075 % EPIDURAL,RX-4080169,CDM,S5000,HCPCS,250,RC,99999-0001-55,NDC,outpatient,100,ML,34.55,24.185,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FENTANYL 3 MCG/ML WITH BUPIVACAINE 0.075 % EPIDURAL,RX-4080170,CDM,S5000,HCPCS,250,RC,99999-0000-03,NDC,outpatient,100,ML,67.18,47.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FENTANYL CITRATE (PF) 0.05 MG/ML NASAL SOLUTION,RX-4080181,CDM,S5000,HCPCS,259,RC,00409-9094-22,NDC,outpatient,2,ML,6.33,4.431,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FENTANYL CITRATE (PF) 0.05 MG/ML NASAL SOLUTION,RX-4080181,CDM,S5000,HCPCS,259,RC,00409-9094-12,NDC,outpatient,2,ML,6.33,4.431,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MIDAZOLAM HCL 5 MG/ML NASAL SOLUTION,RX-4080183,CDM,S5000,HCPCS,250,RC,00409-2308-01,NDC,outpatient,1,ML,3.42,2.394,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MIDAZOLAM HCL 5 MG/ML NASAL SOLUTION,RX-4080183,CDM,S5000,HCPCS,250,RC,00409-2308-21,NDC,outpatient,1,ML,3.42,2.394,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NICARDIPINE HCL IN NACL 1 MG/10 ML IV SYRINGE,RX-4080192,CDM,S5000,HCPCS,250,RC,70004-0756-12,NDC,outpatient,10,ML,39.83,27.881,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NICARDIPINE HCL IN NACL 1 MG/10 ML IV SYRINGE,RX-4080192,CDM,S5000,HCPCS,250,RC,99999-0001-50,NDC,outpatient,10,ML,10.7,7.49,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DILTIAZEM HCL 5 MG/ML IV WRAPPER,RX-4080196,CDM,S5000,HCPCS,250,RC,00641-6014-01,NDC,outpatient,10,ML,22.61,15.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DILTIAZEM HCL 5 MG/ML IV WRAPPER,RX-4080196,CDM,S5000,HCPCS,250,RC,00641-6014-10,NDC,outpatient,10,ML,22.61,15.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DILTIAZEM HCL 5 MG/ML IV WRAPPER,RX-4080196,CDM,S5000,HCPCS,250,RC,00641-6013-01,NDC,outpatient,5,ML,14.35,10.045,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DILTIAZEM HCL 5 MG/ML IV WRAPPER,RX-4080196,CDM,S5000,HCPCS,250,RC,00641-6013-10,NDC,outpatient,5,ML,14.35,10.045,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NIFEDIPINE-LIDOCAINE 0.3%-1.5% OINT,RX-408020,CDM,S5000,HCPCS,259,RC,00000-0000-03,NDC,outpatient,30,GR,333.75,233.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METOPROLOL TARTRATE 1 MG/ML IV SOLN WRAPPER,RX-4080203,CDM,S5000,HCPCS,250,RC,00409-1778-15,NDC,outpatient,5,ML,3.47,2.429,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METOPROLOL TARTRATE 1 MG/ML IV SOLN WRAPPER,RX-4080203,CDM,S5000,HCPCS,250,RC,00409-1778-05,NDC,outpatient,5,ML,3.47,2.429,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DIBUCAINE 1 % EX OINT WRAPPER,RX-4080210,CDM,S5000,HCPCS,259,RC,71399-2829-01,NDC,outpatient,28,GR,14.21,9.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DIBUCAINE 1 % EX OINT WRAPPER,RX-4080210,CDM,S5000,HCPCS,259,RC,00536-1211-95,NDC,outpatient,28,GR,13.84,9.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
COCOA BUTTER STICK,RX-4080278,CDM,S5000,HCPCS,259,RC,07570-7011-00,NDC,outpatient,30,ML,4.41,3.087,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CAPSAICIN 0.025 % EX CREAM WRAPPER,RX-4080289,CDM,S5000,HCPCS,259,RC,00536-2525-25,NDC,outpatient,60,GR,10.95,7.665,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE-PRILOCAINE 2.5-2.5 % EX CREAM WRAPPER,RX-4080290,CDM,S5000,HCPCS,259,RC,62332-0582-04,NDC,outpatient,5,GR,24.68,17.276,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE-PRILOCAINE 2.5-2.5 % EX CREAM WRAPPER,RX-4080290,CDM,S5000,HCPCS,259,RC,00168-0357-55,NDC,outpatient,5,GR,29.95,20.965,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE-PRILOCAINE 2.5-2.5 % EX CREAM WRAPPER,RX-4080290,CDM,S5000,HCPCS,259,RC,62332-0582-31,NDC,outpatient,30,GR,87.18,61.026,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NITROGLYCERIN IN D5W 2000 MCG/20 ML IV SYRINGE,RX-4080358,CDM,S5000,HCPCS,250,RC,SH408-0358-01,NDC,outpatient,20,ML,3.71,2.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NITROGLYCERIN IN D5W 2000 MCG/20 ML IV SYRINGE,RX-4080358,CDM,S5000,HCPCS,250,RC,99999-0000-54,NDC,outpatient,20,ML,3.71,2.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MULTIVITAMIN CHILDRENS ORAL CHEW WRAPPER,RX-4080360,CDM,S5000,HCPCS,259,RC,80681-0049-00,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMPHOTERICIN B EYE DROPS 0.2 MG/ML 10 ML BOTTLE,RX-4080376,CDM,S5000,HCPCS,259,RC,SH408-0376-01,NDC,outpatient,10,ML,61.86,43.302,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ASPIRIN 1 MG/ML ORAL SUSPENSION 81 ML FOR ASA DESENSITIZATION,RX-4080380,CDM,S5000,HCPCS,259,RC,SH408-0380-01,NDC,outpatient,81,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CEFTAZIDIME EYE DROPS 22.5 MG/ML SYRINGE,RX-4080386,CDM,S5000,HCPCS,259,RC,99999-0000-32,NDC,outpatient,1,ML,37.46,26.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLINDAMYCIN MOUTH WASH 3 MG/ML,RX-4080388,CDM,S5000,HCPCS,259,RC,99999-0000-33,NDC,outpatient,250,ML,10.02,7.014,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDO 4%-EPI 0.05%-TETRACAINE 0.5% (LET) GEL 3 ML,RX-4080408,CDM,S5000,HCPCS,259,RC,69623-0801-14,NDC,outpatient,3,ML,35.6,24.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDO 4%-EPI 0.05%-TETRACAINE 0.5% (LET) GEL 3 ML,RX-4080408,CDM,S5000,HCPCS,259,RC,70092-1135-44,NDC,outpatient,3,ML,49.22,34.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDO 4%-EPI 0.05%-TETRACAINE 0.5% (LET) GEL 3 ML,RX-4080408,CDM,S5000,HCPCS,259,RC,88888-0926-28,NDC,outpatient,3,ML,22.25,15.575,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDO 4%-EPI 0.05%-TETRACAINE 0.5% (LET) GEL 3 ML,RX-4080408,CDM,S5000,HCPCS,259,RC,99999-0003-19,NDC,outpatient,3,ML,14.57,10.199,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MAG SULFATE-GLYCERIN-WATER ENEMA 180 ML,RX-4080412,CDM,S5000,HCPCS,259,RC,00000-0000-02,NDC,outpatient,180,ML,28.04,19.628,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METOPROLOL TARTRATE ORAL SUSPENSION 1 MG/ML,RX-4080416,CDM,S5000,HCPCS,259,RC,99999-0003-46,NDC,outpatient,12.5,ML,1.93,1.351,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,00121-0759-08,NDC,outpatient,237,ML,159.26,111.482,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,62135-0250-37,NDC,outpatient,240,ML,1184.42,829.094,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,69238-2122-20,NDC,outpatient,20,ML,14.96,10.472,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,00121-0759-20,NDC,outpatient,20,ML,13.44,9.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,42799-0815-01,NDC,outpatient,237,ML,151.87,106.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,99999-0002-35,NDC,outpatient,20,ML,13.44,9.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,99999-0002-36,NDC,outpatient,5,ML,2.94,2.058,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,00121-0885-16,NDC,outpatient,480,ML,1149.17,804.419,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML SOLN WRAPPER,RX-4080418,CDM,S5000,HCPCS,259,RC,62135-0250-20,NDC,outpatient,20,ML,98.71,69.097,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MORPHINE 0.4 MG/ML 1 ML NEONATAL ORAL SYRINGE,RX-4080423,CDM,S5000,HCPCS,259,RC,SH408-0423-01,NDC,outpatient,1,ML,1.09,0.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MORPHINE 0.4 MG/ML 1 ML NEONATAL ORAL SYRINGE,RX-4080423,CDM,S5000,HCPCS,259,RC,99999-0001-12,NDC,outpatient,1,ML,1.09,0.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE 1 MEQ/ML 1 ML ORAL SYRINGE,RX-4080424,CDM,S5000,HCPCS,259,RC,99999-0001-25,NDC,outpatient,1,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE-MINERAL OIL-GLYCERIN ENEMA,RX-4080430,CDM,S5000,HCPCS,259,RC,SH408-0430-01,NDC,outpatient,135,ML,9.22,6.454,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POTASSIUM CHLORIDE 2 MEQ/1.5 ML ORAL SYRINGE,RX-4080432,CDM,S5000,HCPCS,259,RC,99999-0001-26,NDC,outpatient,1.5,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POTASSIUM CHLORIDE 2 MEQ/1.5 ML ORAL SYRINGE,RX-4080432,CDM,S5000,HCPCS,259,RC,,,outpatient,1.5,ML,1.92,1.344,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SPIRONOLACTONE 6 MG/3 ML ORAL SYRINGE,RX-4080435,CDM,S5000,HCPCS,259,RC,99999-0000-28,NDC,outpatient,3,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CEFAZOLIN IVPB 2 G IN 100 ML NS PREMIX,RX-4080437,CDM,S5000,HCPCS,250,RC,99999-0000-45,NDC,outpatient,100,ML,47.78,33.446,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VANCOMYCIN INTRACAMERAL INJECTION 10 MG/ML,RX-4080449,CDM,S5000,HCPCS,259,RC,SH408-0449-01,NDC,outpatient,2,ML,22.21,15.547,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VANCOMYCIN INTRACAMERAL INJECTION 10 MG/ML,RX-4080449,CDM,S5000,HCPCS,259,RC,SH408-0450-01,NDC,outpatient,0.1,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VANCOMYCIN EYE SOLUTION 25 MG/ML,RX-4080451,CDM,S5000,HCPCS,259,RC,SH408-0451-01,NDC,outpatient,20,ML,54.07,37.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VANCOMYCIN EYE SOLUTION 50 MG/ML ,RX-4080452,CDM,S5000,HCPCS,259,RC,SH408-0452-01,NDC,outpatient,20,ML,54.07,37.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
WARFARIN SODIUM 0.5 MG ORAL SPLIT TABS,RX-4080479,CDM,S5000,HCPCS,259,RC,51672-4027-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
WARFARIN SODIUM 0.5 MG ORAL SPLIT TABS,RX-4080479,CDM,S5000,HCPCS,259,RC,76282-0327-01,NDC,outpatient,1,UN,1.15,0.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
WARFARIN SODIUM 0.5 MG ORAL SPLIT TABS,RX-4080479,CDM,S5000,HCPCS,259,RC,99999-0002-46,NDC,outpatient,0.5,ME,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
WARFARIN SODIUM 1.25 MG ORAL SPLIT TABS,RX-4080485,CDM,S5000,HCPCS,259,RC,51672-4029-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
WARFARIN SODIUM 1.25 MG ORAL SPLIT TABS,RX-4080485,CDM,S5000,HCPCS,259,RC,99999-0002-47,NDC,outpatient,1.25,ME,4.53,3.171,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,69374-0315-25,NDC,outpatient,250,ML,118.35,82.845,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,69374-0533-25,NDC,outpatient,250,ML,140.6,98.42,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,70004-0775-40,NDC,outpatient,250,ML,320.83,224.581,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,81298-9658-01,NDC,outpatient,250,ML,261.87,183.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,70004-0785-40,NDC,outpatient,250,ML,301.03,210.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,70092-1652-05,NDC,outpatient,250,ML,216.97,151.879,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,81298-9658-03,NDC,outpatient,250,ML,261.87,183.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NOREPINEPHRINE PREMIX 16 MG IN 250 ML NS,RX-4080499,CDM,S5000,HCPCS,250,RC,70092-1468-05,NDC,outpatient,250,ML,192.22,134.554,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
THIAMINE HCL 100 MG ORAL TABS WRAPPER,RX-4080502,CDM,S5000,HCPCS,259,RC,00904-7191-06,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
THIAMINE HCL 100 MG ORAL TABS WRAPPER,RX-4080502,CDM,S5000,HCPCS,259,RC,77333-0934-25,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
THIAMINE HCL 100 MG ORAL TABS WRAPPER,RX-4080502,CDM,S5000,HCPCS,259,RC,48433-0108-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
THIAMINE HCL 100 MG ORAL TABS WRAPPER,RX-4080502,CDM,S5000,HCPCS,259,RC,77333-0934-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NEOSTIGMINE METHYLSULFATE 1 MG/ML SYRINGE,RX-4080506,CDM,S5000,HCPCS,250,RC,69374-0932-03,NDC,outpatient,3,ML,45.62,31.934,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NEOSTIGMINE METHYLSULFATE 1 MG/ML SYRINGE,RX-4080506,CDM,S5000,HCPCS,250,RC,70092-1084-44,NDC,outpatient,5,ML,61.01,42.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NEOSTIGMINE METHYLSULFATE 1 MG/ML SYRINGE,RX-4080506,CDM,S5000,HCPCS,250,RC,76045-0383-13,NDC,outpatient,3,ML,51.74,36.218,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NEOSTIGMINE METHYLSULFATE 1 MG/ML SYRINGE,RX-4080506,CDM,S5000,HCPCS,250,RC,76045-0383-30,NDC,outpatient,3,ML,51.74,36.218,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NEOSTIGMINE METHYLSULFATE 1 MG/ML SYRINGE,RX-4080506,CDM,S5000,HCPCS,250,RC,70004-0750-09,NDC,outpatient,5,ML,78.06,54.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FERROUS GLUCONATE 324 MG ORAL TABS WRAPPER,RX-4080542,CDM,S5000,HCPCS,259,RC,00574-0508-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FERROUS GLUCONATE 324 MG ORAL TABS WRAPPER,RX-4080542,CDM,S5000,HCPCS,259,RC,20555-0019-00,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ARTIFICIAL TEARS OP OINT WRAPPER,RX-4080546,CDM,S5000,HCPCS,259,RC,00065-0518-01,NDC,outpatient,3.5,GR,29.43,20.601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ARTIFICIAL TEARS OP OINT WRAPPER,RX-4080546,CDM,S5000,HCPCS,259,RC,10119-0022-39,NDC,outpatient,3.5,GR,30.17,21.119,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE 1 % FOR PLEURODESIS,RX-4080551,CDM,S5000,HCPCS,250,RC,99999-0003-43,NDC,outpatient,50,ML,13.37,9.359,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POTASSIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080554,CDM,S5000,HCPCS,250,RC,00409-7295-01,NDC,outpatient,15,ML,59.41,41.587,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POTASSIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080554,CDM,S5000,HCPCS,250,RC,65219-0052-29,NDC,outpatient,5,ML,93.68,65.576,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POTASSIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080554,CDM,S5000,HCPCS,250,RC,00409-7295-11,NDC,outpatient,15,ML,59.41,41.587,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POTASSIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080554,CDM,S5000,HCPCS,250,RC,65219-0052-09,NDC,outpatient,5,ML,93.68,65.576,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,00409-4888-10,NDC,outpatient,10,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,00409-4888-02,NDC,outpatient,10,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,63323-0186-01,NDC,outpatient,10,ML,3.71,2.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,00409-4888-12,NDC,outpatient,10,ML,9.82,6.874,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,63323-0186-10,NDC,outpatient,10,ML,3.71,2.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE 0.9 % IJ SOLN WRAPPER,RX-4080555,CDM,S5000,HCPCS,250,RC,00409-4888-01,NDC,outpatient,10,ML,9.82,6.874,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MENTHOL-ZINC OXIDE 0.44-20.625 % EX OINT WRAPPER,RX-4080556,CDM,S5000,HCPCS,259,RC,00799-0001-04,NDC,outpatient,113,GR,20.12,14.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MENTHOL-ZINC OXIDE 0.44-20.625 % EX OINT WRAPPER,RX-4080556,CDM,S5000,HCPCS,259,RC,10135-0701-04,NDC,outpatient,113,GR,13.58,9.506,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DILTIAZEM 100 MG ADDVANTAGE INFUSION IN D5W 100 ML,RX-4080558,CDM,S5000,HCPCS,250,RC,99999-0000-01,NDC,outpatient,100,ML,48.09,33.663,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HIV POST EXPOSURE KIT,RX-4080559,CDM,S5000,HCPCS,259,RC,SH408-0559-01,NDC,outpatient,1,UN,1178.97,825.279,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPIVACAINE 0.125 % IN 100 ML NS NERVE BLOCK CASSETTE,RX-4080570,CDM,S5000,HCPCS,250,RC,61553-0829-48,NDC,outpatient,100,ML,76.93,53.851,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FENTANYL 3 MCG/ML WITH BUPIVACAINE 0.125 % EPIDURAL,RX-4080589,CDM,S5000,HCPCS,250,RC,99999-0000-04,NDC,outpatient,100,ML,79.95,55.965,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VEIN GRAFT SOLUTION,RX-4080591,CDM,S5000,HCPCS,250,RC,99999-0000-07,NDC,outpatient,505.67,ML,73.5,51.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLECAINIDE ACETATE 20 MG/ML ORAL SUSP,RX-4080607,CDM,S5000,HCPCS,259,RC,99999-0003-52,NDC,outpatient,2.5,ML,2.45,1.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYOSCYAMINE SULFATE 0.125 MG SL SUBL WRAPPER,RX-4080632,CDM,S5000,HCPCS,259,RC,42192-0338-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MESALAMINE 4 G RE ENEM WRAPPER,RX-4080640,CDM,S5000,HCPCS,259,RC,45802-0098-51,NDC,outpatient,60,ML,33.11,23.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MESALAMINE 4 G RE ENEM WRAPPER,RX-4080640,CDM,S5000,HCPCS,259,RC,45802-0098-46,NDC,outpatient,60,ML,33.11,23.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MESALAMINE 4 G RE ENEM WRAPPER,RX-4080640,CDM,S5000,HCPCS,259,RC,45802-0923-41,NDC,outpatient,60,ML,80.91,56.637,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MAGNESIUM OXIDE 400 MG ORAL TABS WRAPPER,RX-4080641,CDM,S5000,HCPCS,259,RC,64980-0339-90,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MAGNESIUM OXIDE 400 MG ORAL TABS WRAPPER,RX-4080641,CDM,S5000,HCPCS,259,RC,64980-0339-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MAGNESIUM OXIDE 400 MG ORAL TABS WRAPPER,RX-4080641,CDM,S5000,HCPCS,259,RC,10006-0700-28,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MAGNESIUM GLUCONATE 500 MG ORAL TABS WRAPPER,RX-4080642,CDM,S5000,HCPCS,259,RC,60258-0172-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GI COCKTAIL SUSPENSION,RX-4080647,CDM,S5000,HCPCS,259,RC,99999-0000-39,NDC,outpatient,55,ML,82.33,57.631,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CARDIOPLEGIA SOLN DEL NIDO,RX-4080676,CDM,S5000,HCPCS,250,RC,99999-0004-39,NDC,outpatient,1052.8,ML,113.01,79.107,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
EPINEPHRINE PF 10 MCG/ML 10 ML SYRINGE,RX-4080700,CDM,S5000,HCPCS,250,RC,70092-1512-46,NDC,outpatient,10,ML,20.96,14.672,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
EPINEPHRINE PF 10 MCG/ML 10 ML SYRINGE,RX-4080700,CDM,S5000,HCPCS,250,RC,70092-1617-46,NDC,outpatient,10,ML,31.42,21.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE 0.9 % IV SOLN MINI-BAG 100 ML,RX-4080711,CDM,S5000,HCPCS,250,RC,00338-0553-18,NDC,outpatient,100,ML,29.37,20.559,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HYDROCORTISONE ORAL SUSPENSION 2.5 MG/ML COMPOUNDED PRODUCT,RX-4080716,CDM,S5000,HCPCS,259,RC,99999-0000-80,NDC,outpatient,1,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLUDROCORTISONE ACETATE SUSP 0.2 MG/ML,RX-4080718,CDM,S5000,HCPCS,259,RC,99999-0000-81,NDC,outpatient,1,ML,4.96,3.472,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ZINC OXIDE 40 % (BOUDREAUX'S) PASTE,RX-4080754,CDM,S5000,HCPCS,259,RC,74300-0000-71,NDC,outpatient,113,GR,26.15,18.305,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ZINC OXIDE 40 % (BOUDREAUX'S) PASTE,RX-4080754,CDM,S5000,HCPCS,259,RC,62103-0323-02,NDC,outpatient,57,GR,14.72,10.304,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NALOXONE INHALATION KIT - HOSPITAL USE ONLY,RX-4080774,CDM,S5000,HCPCS,259,RC,99999-0000-90,NDC,outpatient,1,UN,110.81,77.567,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CISATRACURIUM BESYLATE 10 MG/ML IV SOLN WRAPPER,RX-4080786,CDM,S5000,HCPCS,250,RC,00409-1103-01,NDC,outpatient,20,ML,230.78,161.546,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CISATRACURIUM BESYLATE 10 MG/ML IV SOLN WRAPPER,RX-4080786,CDM,S5000,HCPCS,250,RC,00409-1103-11,NDC,outpatient,20,ML,230.78,161.546,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CEFAZOLIN IVPB 3 G IN 100 ML NS PREMIX,RX-4080801,CDM,S5000,HCPCS,250,RC,99999-0001-10,NDC,outpatient,130,ML,33.43,23.401,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PERICAPSULAR MIXTURE INJECTION,RX-4080804,CDM,S5000,HCPCS,250,RC,70092-1433-50,NDC,outpatient,50,ML,216.36,151.452,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PERICAPSULAR MIXTURE INJECTION,RX-4080804,CDM,S5000,HCPCS,250,RC,99999-0000-98,NDC,outpatient,50,ML,59.06,41.342,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRANEXAMIC ACID 5 % MOUTHWASH ORAL SUSPENSION,RX-4080811,CDM,S5000,HCPCS,259,RC,99999-0001-06,NDC,outpatient,169,ML,77.47,54.229,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP *DYE FREE*,RX-4080831,CDM,S5000,HCPCS,259,RC,00045-0166-04,NDC,outpatient,120,ML,28.31,19.817,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP *DYE FREE*,RX-4080831,CDM,S5000,HCPCS,259,RC,50580-0170-05,NDC,outpatient,5,ML,1.37,0.959,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP *DYE FREE*,RX-4080831,CDM,S5000,HCPCS,259,RC,99999-0001-17,NDC,outpatient,5,ML,1.37,0.959,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BABY BUTT BALM,RX-4080852,CDM,S5000,HCPCS,259,RC,99999-0001-13,NDC,outpatient,118.7,GR,70.96,49.672,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACETAZOLAMIDE 25 MG/ML SUSPENSION,RX-4080874,CDM,S5000,HCPCS,259,RC,99999-0001-21,NDC,outpatient,5,ML,10.93,7.651,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,99999-0002-20,NDC,outpatient,15,ML,2.01,1.407,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,00005-4344-62,NDC,outpatient,15,ML,2.09,1.463,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,00573-0513-30,NDC,outpatient,15,ML,2.32,1.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,68094-0120-59,NDC,outpatient,15,ML,7.68,5.376,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,69618-0008-58,NDC,outpatient,15,ML,2.55,1.785,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,00573-0513-15,NDC,outpatient,15,ML,2.32,1.624,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MULTIVITAMIN-MINERAL-IRON ORAL LIQUID WRAPPER,RX-4080909,CDM,S5000,HCPCS,259,RC,68094-0120-61,NDC,outpatient,15,ML,7.68,5.376,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FERRIC SUBSULFATE SOLN WRAPPER,RX-4080921,CDM,S5000,HCPCS,250,RC,38779-1284-08,NDC,outpatient,8,ML,2.35,1.645,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FERRIC SUBSULFATE SOLN WRAPPER,RX-4080921,CDM,S5000,HCPCS,250,RC,10481-0112-02,NDC,outpatient,8,ML,9.33,6.531,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FERRIC SUBSULFATE SOLN WRAPPER,RX-4080921,CDM,S5000,HCPCS,250,RC,10481-0112-08,NDC,outpatient,8,ML,47.67,33.369,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FERRIC SUBSULFATE SOLN WRAPPER,RX-4080921,CDM,S5000,HCPCS,250,RC,49452-3081-02,NDC,outpatient,8,ML,2.35,1.645,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080937,CDM,S5000,HCPCS,250,RC,63323-0170-05,NDC,outpatient,5,ML,35.56,24.892,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080937,CDM,S5000,HCPCS,250,RC,63323-0881-01,NDC,outpatient,15,ML,169.35,118.545,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080937,CDM,S5000,HCPCS,250,RC,63323-0881-16,NDC,outpatient,15,ML,169.35,118.545,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080937,CDM,S5000,HCPCS,250,RC,63323-0884-01,NDC,outpatient,5,ML,79.73,55.811,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM PHOSPHATE 3 MMOLE/ML IV SOLN WRAPPER,RX-4080937,CDM,S5000,HCPCS,250,RC,63323-0884-06,NDC,outpatient,5,ML,79.73,55.811,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,43066-0007-10,NDC,outpatient,5,ML,8.46,5.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,63323-0426-05,NDC,outpatient,5,ML,7.05,4.935,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,67457-0228-02,NDC,outpatient,5,ML,6.84,4.788,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,39822-4200-05,NDC,outpatient,10,ML,22.61,15.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,39822-4200-06,NDC,outpatient,10,ML,22.61,15.827,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,63323-0426-02,NDC,outpatient,5,ML,7.05,4.935,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,72611-0756-01,NDC,outpatient,5,ML,24.17,16.919,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,72611-0756-10,NDC,outpatient,5,ML,24.17,16.919,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,00143-9250-01,NDC,outpatient,5,ML,10.46,7.322,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,25021-0662-05,NDC,outpatient,5,ML,11.88,8.316,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,55150-0225-05,NDC,outpatient,5,ML,9.23,6.461,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,00143-9250-10,NDC,outpatient,5,ML,10.46,7.322,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,55150-0226-10,NDC,outpatient,10,ML,18.46,12.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ROCURONIUM BROMIDE 10 MG/ML IV SOLN WRAPPER,RX-4080961,CDM,S5000,HCPCS,250,RC,66794-0228-41,NDC,outpatient,5,ML,6.84,4.788,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMIODARONE ORAL SUSPENSION 40 MG/ML,RX-4080970,CDM,S5000,HCPCS,259,RC,99999-0001-63,NDC,outpatient,10,ML,2.04,1.428,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MORPHINE SULFATE 100 MG/100 ML IN D5W PF PREMIX,RX-4081012,CDM,S5000,HCPCS,250,RC,99999-0000-99,NDC,outpatient,100,ML,312.37,218.659,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
EPHEDRINE SULFATE 5 MG/ML IJ WRAPPER,RX-4081019,CDM,S5000,HCPCS,250,RC,14789-0250-10,NDC,outpatient,10,ML,61.68,43.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
EPHEDRINE SULFATE 5 MG/ML IJ WRAPPER,RX-4081019,CDM,S5000,HCPCS,250,RC,14789-0250-07,NDC,outpatient,10,ML,61.68,43.176,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
EPHEDRINE SULFATE 5 MG/ML IJ WRAPPER,RX-4081019,CDM,S5000,HCPCS,250,RC,42023-0243-01,NDC,outpatient,10,ML,42.55,29.785,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
INSULIN REGULAR 1 UNIT/ML INFUSION PREMIX,RX-4081020,CDM,S5000,HCPCS,250,RC,00338-0126-12,NDC,outpatient,100,ML,98.33,68.831,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
INSULIN REGULAR 1 UNIT/ML INFUSION PREMIX,RX-4081020,CDM,S5000,HCPCS,250,RC,99999-0000-87,NDC,outpatient,100,ML,34.01,23.807,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DILTIAZEM 100 MG IN 100 ML NS BATCHED INFUSION,RX-4081050,CDM,S5000,HCPCS,250,RC,99999-0002-64,NDC,outpatient,100,ML,56.68,39.676,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
URSODIOL 50 MG/ML ORAL SUSPENSION,RX-4081064,CDM,S5000,HCPCS,259,RC,99999-0002-69,NDC,outpatient,1,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPRENORPHINE-NALOXONE (SUBOXONE) SL FILM 8 MG-2 MG KIT,RX-4081171,CDM,S5000,HCPCS,259,RC,99999-0003-16,NDC,outpatient,1,UN,142.33,99.631,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,00409-1323-05,NDC,outpatient,5,ML,19.63,13.741,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,00409-1323-15,NDC,outpatient,5,ML,19.63,13.741,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,00409-4903-11,NDC,outpatient,5,ML,17.92,12.544,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,00409-4903-34,NDC,outpatient,5,ML,17.92,12.544,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,76329-3390-01,NDC,outpatient,5,ML,27.15,19.005,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL (CARDIAC) 20 MG/ML IV SOLN WRAPPER,RX-4081175,CDM,S5000,HCPCS,250,RC,63323-0208-05,NDC,outpatient,5,ML,7.41,5.187,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRANEXAMIC ACID 100 MG/ML FOR INHALATION,RX-4081187,CDM,S5000,HCPCS,250,RC,72485-0510-01,NDC,outpatient,10,ML,12.64,8.848,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRANEXAMIC ACID 100 MG/ML FOR INHALATION,RX-4081187,CDM,S5000,HCPCS,250,RC,81284-0611-00,NDC,outpatient,10,ML,24.48,17.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRANEXAMIC ACID 100 MG/ML FOR INHALATION,RX-4081187,CDM,S5000,HCPCS,250,RC,81284-0611-10,NDC,outpatient,10,ML,24.48,17.136,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRANEXAMIC ACID 100 MG/ML FOR INHALATION,RX-4081187,CDM,S5000,HCPCS,250,RC,39822-1000-01,NDC,outpatient,10,ML,23.86,16.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRANEXAMIC ACID 100 MG/ML FOR INHALATION,RX-4081187,CDM,S5000,HCPCS,250,RC,72485-0510-10,NDC,outpatient,10,ML,12.64,8.848,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MORPHINE SULFATE 100 MG/100 ML IN NS PF PREMIX,RX-4081195,CDM,S5000,HCPCS,250,RC,99999-0003-26,NDC,outpatient,100,ML,312.37,218.659,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PANTOPRAZOLE 80 MG/100 ML INFUSION PREMIX,RX-4081208,CDM,S5000,HCPCS,250,RC,99999-0000-77,NDC,outpatient,100,ML,36.56,25.592,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NICARDIPINE HCL 40 MG IN NACL 200 ML IV SOLN WRAPPER,RX-4081293,CDM,S5000,HCPCS,250,RC,00143-9633-10,NDC,outpatient,200,ML,242.06,169.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NICARDIPINE HCL 40 MG IN NACL 200 ML IV SOLN WRAPPER,RX-4081293,CDM,S5000,HCPCS,250,RC,00143-9633-01,NDC,outpatient,200,ML,242.06,169.442,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE 3 % IV ONCE,RX-4081432,CDM,S5000,HCPCS,250,RC,99999-0003-86,NDC,outpatient,100,ML,18.06,12.642,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FAMOTIDINE IN NACL 20-0.9 MG/10 ML-% IV SOSY,RX-4081444,CDM,S5000,HCPCS,250,RC,99999-0003-96,NDC,outpatient,5,ML,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM HYALURONATE 10 MG/ML IO SOLN WRAPPER,RX-4081458,CDM,S5000,HCPCS,250,RC,05047-4508-38,NDC,outpatient,0.4,ML,397.92,278.544,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV *BATCHED*,RX-4081542,CDM,S5000,HCPCS,250,RC,99999-0004-35,NDC,outpatient,50,ML,157.29,110.103,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NALOXONE HCL 4 MG/0.1ML NA LIQD FOR CODE NARRATOR,RX-4081549,CDM,S5000,HCPCS,259,RC,00093-2165-19,NDC,outpatient,1,UN,146.88,102.816,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NALOXONE HCL 4 MG/0.1ML NA LIQD FOR CODE NARRATOR,RX-4081549,CDM,S5000,HCPCS,259,RC,00093-2165-68,NDC,outpatient,1,UN,146.88,102.816,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MORPHINE SULFATE 1 MG/ML 100 ML PCA,RX-4081551,CDM,S5000,HCPCS,250,RC,99999-0004-53,NDC,outpatient,100,ML,48.85,34.195,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MORPHINE SULFATE 1 MG/ML 100 ML PCA,RX-4081551,CDM,S5000,HCPCS,250,RC,70092-1518-75,NDC,outpatient,100,ML,209.09,146.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PRASUGREL HCL 10 MG TABS - OMNICELL CATH LAB USE ONLY,RX-4081602,CDM,S5000,HCPCS,259,RC,00378-5186-93,NDC,outpatient,0.5,UN,4.12,2.884,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PRASUGREL HCL 10 MG TABS - OMNICELL CATH LAB USE ONLY,RX-4081602,CDM,S5000,HCPCS,259,RC,65162-0002-03,NDC,outpatient,0.5,UN,2.9,2.03,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PRASUGREL HCL 10 MG TABS - OMNICELL CATH LAB USE ONLY,RX-4081602,CDM,S5000,HCPCS,259,RC,65862-0830-30,NDC,outpatient,0.5,UN,1,0.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METHADONE 10 MG TABLET DISCHARGE KIT,RX-4081610,CDM,S5000,HCPCS,259,RC,99999-0004-50,NDC,outpatient,1,UN,6.15,4.305,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PRISMASATE K 4/CA 2.5 CRRT SOLUTION,RX-40840045,CDM,S5000,HCPCS,250,RC,SH408-4045-01,NDC,outpatient,5000,ML,188.44,131.908,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PRISMASATE K 2/CA 0 CRRT SOLUTION,RX-40840046,CDM,S5000,HCPCS,250,RC,SH408-4046-01,NDC,outpatient,5000,ML,188.44,131.908,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BENZOCAINE-MENTHOL 6-10 MG MT LOZG,RX-41085,CDM,S5000,HCPCS,259,RC,78112-0011-06,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BENZOCAINE-MENTHOL 6-10 MG MT LOZG,RX-41085,CDM,S5000,HCPCS,259,RC,78112-0012-66,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GALANTAMINE HYDROBROMIDE ER 8 MG ORAL CP24,RX-41138,CDM,S5000,HCPCS,259,RC,63629-2364-01,NDC,outpatient,1,UN,6.03,4.221,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GALANTAMINE HYDROBROMIDE ER 8 MG ORAL CP24,RX-41138,CDM,S5000,HCPCS,259,RC,47335-0835-83,NDC,outpatient,1,UN,5.27,3.689,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IPRATROPIUM BROMIDE HFA 17 MCG/ACT IN AERS,RX-41142,CDM,S5000,HCPCS,259,RC,00597-0087-17,NDC,outpatient,12.9,GR,1940.98,1358.686,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ENTECAVIR 0.5 MG ORAL TABS,RX-41147,CDM,S5000,HCPCS,259,RC,00003-1611-12,NDC,outpatient,1,UN,197.48,138.236,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ENTECAVIR 1 MG ORAL TABS,RX-41148,CDM,S5000,HCPCS,259,RC,65862-0842-30,NDC,outpatient,1,UN,8.95,6.265,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FENTANYL 12 MCG/HR TD PT72,RX-41382,CDM,S5000,HCPCS,259,RC,00378-9119-98,NDC,outpatient,1,UN,50.62,35.434,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FENTANYL 12 MCG/HR TD PT72,RX-41382,CDM,S5000,HCPCS,259,RC,47781-0423-47,NDC,outpatient,1,UN,21.37,14.959,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FENTANYL 12 MCG/HR TD PT72,RX-41382,CDM,S5000,HCPCS,259,RC,00378-9119-16,NDC,outpatient,1,UN,50.62,35.434,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FENTANYL 12 MCG/HR TD PT72,RX-41382,CDM,S5000,HCPCS,259,RC,47781-0423-11,NDC,outpatient,1,UN,21.37,14.959,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PARICALCITOL 1 MCG ORAL CAPS,RX-41497,CDM,S5000,HCPCS,259,RC,49483-0687-03,NDC,outpatient,1,UN,4.45,3.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PARICALCITOL 1 MCG ORAL CAPS,RX-41497,CDM,S5000,HCPCS,259,RC,65862-0936-30,NDC,outpatient,1,UN,5.24,3.668,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVOCARNITINE 1 GM/10ML ORAL SOLN,RX-41623,CDM,S5000,HCPCS,259,RC,99999-0002-52,NDC,outpatient,10,ML,6.37,4.459,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVOCARNITINE 1 GM/10ML ORAL SOLN,RX-41623,CDM,S5000,HCPCS,259,RC,52817-0830-04,NDC,outpatient,1,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM TETRADECYL SULFATE 3 % IV SOLN,RX-41793,CDM,S5000,HCPCS,250,RC,24201-0201-01,NDC,outpatient,0.5,ML,58.03,40.621,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM TETRADECYL SULFATE 3 % IV SOLN,RX-41793,CDM,S5000,HCPCS,250,RC,67457-0163-02,NDC,outpatient,0.5,ML,64.31,45.017,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM TETRADECYL SULFATE 3 % IV SOLN,RX-41793,CDM,S5000,HCPCS,250,RC,24201-0201-05,NDC,outpatient,0.5,ML,58.03,40.621,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM TETRADECYL SULFATE 3 % IV SOLN,RX-41793,CDM,S5000,HCPCS,250,RC,67457-0163-00,NDC,outpatient,0.5,ML,58.19,40.733,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OMEGA-3-ACID ETHYL ESTERS 1 G ORAL CAPS,RX-41822,CDM,S5000,HCPCS,259,RC,64380-0761-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE 5 % EX OINT,RX-41831,CDM,S5000,HCPCS,259,RC,64380-0789-32,NDC,outpatient,35.44,GR,61.67,43.169,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE 5 % EX OINT,RX-41831,CDM,S5000,HCPCS,259,RC,65162-0918-38,NDC,outpatient,35.44,GR,50,35,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SILDENAFIL CITRATE 20 MG ORAL TABS,RX-41832,CDM,S5000,HCPCS,259,RC,63739-0072-33,NDC,outpatient,1,UN,2.21,1.547,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SILDENAFIL CITRATE 20 MG ORAL TABS,RX-41832,CDM,S5000,HCPCS,259,RC,00904-6671-04,NDC,outpatient,1,UN,2.21,1.547,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METRONIDAZOLE 1 % EX GEL,RX-41899,CDM,S5000,HCPCS,259,RC,51672-4215-03,NDC,outpatient,60,GR,258.99,181.293,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AVEENO SOOTHING BATH TREATMENT EX PACK,RX-41904,CDM,S5000,HCPCS,259,RC,08137-0036-40,NDC,outpatient,1,UN,2.74,1.918,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RAMELTEON 8 MG ORAL TABS,RX-42064,CDM,S5000,HCPCS,259,RC,50268-0708-11,NDC,outpatient,1,UN,11.47,8.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RAMELTEON 8 MG ORAL TABS,RX-42064,CDM,S5000,HCPCS,259,RC,50268-0708-15,NDC,outpatient,1,UN,11.47,8.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RAMELTEON 8 MG ORAL TABS,RX-42064,CDM,S5000,HCPCS,259,RC,70010-0028-03,NDC,outpatient,1,UN,6.31,4.417,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DICYCLOMINE HCL 10 MG/5ML ORAL SOLN,RX-42119,CDM,S5000,HCPCS,259,RC,00054-0622-63,NDC,outpatient,5,ML,3.5,2.45,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DICYCLOMINE HCL 10 MG/5ML ORAL SOLN,RX-42119,CDM,S5000,HCPCS,259,RC,99999-0003-12,NDC,outpatient,5,ML,5.06,3.542,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREGABALIN 25 MG ORAL CAPS,RX-42162,CDM,S5000,HCPCS,259,RC,60687-0473-01,NDC,outpatient,1,UN,1.96,1.372,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREGABALIN 25 MG ORAL CAPS,RX-42162,CDM,S5000,HCPCS,259,RC,50228-0350-90,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREGABALIN 25 MG ORAL CAPS,RX-42162,CDM,S5000,HCPCS,259,RC,60687-0473-11,NDC,outpatient,1,UN,1.96,1.372,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREGABALIN 50 MG ORAL CAPS,RX-42163,CDM,S5000,HCPCS,259,RC,72205-0012-90,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREGABALIN 50 MG ORAL CAPS,RX-42163,CDM,S5000,HCPCS,259,RC,00071-1013-41,NDC,outpatient,1,UN,45.77,32.039,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREGABALIN 50 MG ORAL CAPS,RX-42163,CDM,S5000,HCPCS,259,RC,00904-6992-61,NDC,outpatient,1,UN,2.3,1.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREGABALIN 75 MG ORAL CAPS,RX-42164,CDM,S5000,HCPCS,259,RC,00071-1014-41,NDC,outpatient,1,UN,45.77,32.039,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREGABALIN 75 MG ORAL CAPS,RX-42164,CDM,S5000,HCPCS,259,RC,60687-0495-01,NDC,outpatient,1,UN,1.87,1.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREGABALIN 75 MG ORAL CAPS,RX-42164,CDM,S5000,HCPCS,259,RC,62332-0121-90,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREGABALIN 75 MG ORAL CAPS,RX-42164,CDM,S5000,HCPCS,259,RC,00904-7000-61,NDC,outpatient,1,UN,2.47,1.729,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREGABALIN 75 MG ORAL CAPS,RX-42164,CDM,S5000,HCPCS,259,RC,60687-0495-11,NDC,outpatient,1,UN,1.87,1.309,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREGABALIN 100 MG ORAL CAPS,RX-42165,CDM,S5000,HCPCS,259,RC,00904-7001-61,NDC,outpatient,1,UN,2.38,1.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREGABALIN 100 MG ORAL CAPS,RX-42165,CDM,S5000,HCPCS,259,RC,69238-1313-09,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREGABALIN 100 MG ORAL CAPS,RX-42165,CDM,S5000,HCPCS,259,RC,62332-0122-90,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREGABALIN 150 MG ORAL CAPS,RX-42166,CDM,S5000,HCPCS,259,RC,00904-7002-61,NDC,outpatient,1,UN,2.56,1.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREGABALIN 150 MG ORAL CAPS,RX-42166,CDM,S5000,HCPCS,259,RC,00071-1016-41,NDC,outpatient,1,UN,45.77,32.039,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
KETAMINE HCL 10 MG/ML IJ SOLN,RX-4236,CDM,S5000,HCPCS,250,RC,42023-0113-10,NDC,outpatient,20,ML,41.57,29.099,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
KETAMINE HCL 100 MG/ML IJ SOLN,RX-4237,CDM,S5000,HCPCS,250,RC,42023-0115-10,NDC,outpatient,5,ML,53.45,37.415,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
KETAMINE HCL 50 MG/ML IJ SOLN,RX-4238,CDM,S5000,HCPCS,250,RC,00143-9508-01,NDC,outpatient,10,ML,23.23,16.261,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
KETAMINE HCL 50 MG/ML IJ SOLN,RX-4238,CDM,S5000,HCPCS,250,RC,00143-9508-10,NDC,outpatient,10,ML,23.23,16.261,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMITRIPTYLINE HCL 10 MG ORAL TABS,RX-432,CDM,S5000,HCPCS,259,RC,70756-0201-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMITRIPTYLINE HCL 10 MG ORAL TABS,RX-432,CDM,S5000,HCPCS,259,RC,50268-0037-11,NDC,outpatient,1,UN,1.35,0.945,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMITRIPTYLINE HCL 10 MG ORAL TABS,RX-432,CDM,S5000,HCPCS,259,RC,50268-0037-15,NDC,outpatient,1,UN,1.35,0.945,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMITRIPTYLINE HCL 25 MG ORAL TABS,RX-435,CDM,S5000,HCPCS,259,RC,60687-0433-01,NDC,outpatient,1,UN,1.4,0.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMITRIPTYLINE HCL 25 MG ORAL TABS,RX-435,CDM,S5000,HCPCS,259,RC,00781-1487-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMITRIPTYLINE HCL 25 MG ORAL TABS,RX-435,CDM,S5000,HCPCS,259,RC,60687-0433-11,NDC,outpatient,1,UN,1.4,0.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DIGOXIN 0.05 MG/ML ORAL SOLN,RX-43556,CDM,S5000,HCPCS,259,RC,00054-0057-46,NDC,outpatient,60,ML,612.5,428.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DIGOXIN 0.05 MG/ML ORAL SOLN,RX-43556,CDM,S5000,HCPCS,259,RC,99999-0004-03,NDC,outpatient,2.5,ML,25.53,17.871,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMITRIPTYLINE HCL 50 MG ORAL TABS,RX-436,CDM,S5000,HCPCS,259,RC,60687-0444-11,NDC,outpatient,1,UN,1.83,1.281,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMITRIPTYLINE HCL 50 MG ORAL TABS,RX-436,CDM,S5000,HCPCS,259,RC,60687-0444-01,NDC,outpatient,1,UN,1.83,1.281,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL 4 % MT SOLN,RX-43717,CDM,S5000,HCPCS,259,RC,76329-6300-05,NDC,outpatient,4,ML,116.7,81.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMMONIA AROMATIC IN INHA,RX-439,CDM,S5000,HCPCS,259,RC,67777-0251-01,NDC,outpatient,1,UN,1.04,0.728,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEUCOVORIN CALCIUM 5 MG ORAL TABS,RX-4398,CDM,S5000,HCPCS,259,RC,00054-8496-19,NDC,outpatient,1,UN,7.46,5.222,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEUCOVORIN CALCIUM 5 MG ORAL TABS,RX-4398,CDM,S5000,HCPCS,259,RC,00555-0484-02,NDC,outpatient,1,UN,5.35,3.745,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVOTHYROXINE SODIUM 25 MCG ORAL TABS,RX-4420,CDM,S5000,HCPCS,259,RC,51079-0444-01,NDC,outpatient,1,UN,2.38,1.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVOTHYROXINE SODIUM 25 MCG ORAL TABS,RX-4420,CDM,S5000,HCPCS,259,RC,60687-0453-11,NDC,outpatient,1,UN,1.54,1.078,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVOTHYROXINE SODIUM 25 MCG ORAL TABS,RX-4420,CDM,S5000,HCPCS,259,RC,51079-0444-20,NDC,outpatient,1,UN,2.38,1.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVOTHYROXINE SODIUM 25 MCG ORAL TABS,RX-4420,CDM,S5000,HCPCS,259,RC,60687-0453-01,NDC,outpatient,1,UN,1.54,1.078,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVOTHYROXINE SODIUM 50 MCG ORAL TABS,RX-4421,CDM,S5000,HCPCS,259,RC,51079-0440-01,NDC,outpatient,1,UN,2.52,1.764,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVOTHYROXINE SODIUM 50 MCG ORAL TABS,RX-4421,CDM,S5000,HCPCS,259,RC,60687-0464-01,NDC,outpatient,1,UN,1.67,1.169,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVOTHYROXINE SODIUM 50 MCG ORAL TABS,RX-4421,CDM,S5000,HCPCS,259,RC,60687-0464-11,NDC,outpatient,1,UN,1.67,1.169,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVOTHYROXINE SODIUM 50 MCG ORAL TABS,RX-4421,CDM,S5000,HCPCS,259,RC,00074-4552-11,NDC,outpatient,1,UN,6.49,4.543,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVOTHYROXINE SODIUM 50 MCG ORAL TABS,RX-4421,CDM,S5000,HCPCS,259,RC,51079-0440-20,NDC,outpatient,1,UN,2.52,1.764,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVOTHYROXINE SODIUM 75 MCG ORAL TABS,RX-4422,CDM,S5000,HCPCS,259,RC,51079-0441-20,NDC,outpatient,1,UN,2.6,1.82,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVOTHYROXINE SODIUM 75 MCG ORAL TABS,RX-4422,CDM,S5000,HCPCS,259,RC,60687-0475-01,NDC,outpatient,1,UN,2.04,1.428,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVOTHYROXINE SODIUM 75 MCG ORAL TABS,RX-4422,CDM,S5000,HCPCS,259,RC,51079-0441-01,NDC,outpatient,1,UN,2.6,1.82,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVOTHYROXINE SODIUM 75 MCG ORAL TABS,RX-4422,CDM,S5000,HCPCS,259,RC,60687-0475-11,NDC,outpatient,1,UN,2.04,1.428,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVOTHYROXINE SODIUM 100 MCG ORAL TABS,RX-4423,CDM,S5000,HCPCS,259,RC,51079-0442-01,NDC,outpatient,1,UN,2.67,1.869,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVOTHYROXINE SODIUM 100 MCG ORAL TABS,RX-4423,CDM,S5000,HCPCS,259,RC,51079-0442-20,NDC,outpatient,1,UN,2.67,1.869,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVOTHYROXINE SODIUM 100 MCG ORAL TABS,RX-4423,CDM,S5000,HCPCS,259,RC,00074-6624-11,NDC,outpatient,1,UN,6.49,4.543,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVOTHYROXINE SODIUM 125 MCG ORAL TABS,RX-4424,CDM,S5000,HCPCS,259,RC,51079-0443-01,NDC,outpatient,1,UN,3.14,2.198,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVOTHYROXINE SODIUM 125 MCG ORAL TABS,RX-4424,CDM,S5000,HCPCS,259,RC,51079-0443-20,NDC,outpatient,1,UN,3.14,2.198,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVOTHYROXINE SODIUM 150 MCG ORAL TABS,RX-4425,CDM,S5000,HCPCS,259,RC,60687-0530-01,NDC,outpatient,1,UN,2.51,1.757,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVOTHYROXINE SODIUM 150 MCG ORAL TABS,RX-4425,CDM,S5000,HCPCS,259,RC,00074-7069-11,NDC,outpatient,1,UN,6.49,4.543,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL 4 % EX SOLN,RX-4450,CDM,S5000,HCPCS,259,RC,00527-6004-80,NDC,outpatient,50,ML,75.88,53.116,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL 4 % EX SOLN,RX-4450,CDM,S5000,HCPCS,259,RC,60432-0465-51,NDC,outpatient,50,ML,131.72,92.204,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL 4 % EX SOLN,RX-4450,CDM,S5000,HCPCS,259,RC,00054-3505-47,NDC,outpatient,50,ML,107.03,74.921,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL 0.5 % IJ SOLN,RX-4451,CDM,S5000,HCPCS,250,RC,63323-0484-57,NDC,outpatient,50,ML,22.7,15.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL 1 % IJ SOLN,RX-4452,CDM,S5000,HCPCS,250,RC,00409-4276-02,NDC,outpatient,50,ML,8.23,5.761,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL 1 % IJ SOLN,RX-4452,CDM,S5000,HCPCS,250,RC,00409-4276-16,NDC,outpatient,20,ML,4.63,3.241,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL 1 % IJ SOLN,RX-4452,CDM,S5000,HCPCS,250,RC,00409-4276-17,NDC,outpatient,50,ML,8.23,5.761,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL 1 % IJ SOLN,RX-4452,CDM,S5000,HCPCS,250,RC,00409-4276-01,NDC,outpatient,20,ML,4.63,3.241,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,55150-0254-10,NDC,outpatient,10,ML,3.76,2.632,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,55150-0255-20,NDC,outpatient,20,ML,4.22,2.954,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0486-17,NDC,outpatient,10,ML,16.35,11.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0202-01,NDC,outpatient,2,ML,11.73,8.211,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0486-02,NDC,outpatient,20,ML,18.2,12.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0486-26,NDC,outpatient,20,ML,8.02,5.614,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,00409-4277-01,NDC,outpatient,20,ML,5.14,3.598,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,00409-4277-16,NDC,outpatient,20,ML,5.14,3.598,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0202-02,NDC,outpatient,2,ML,11.73,8.211,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0486-01,NDC,outpatient,10,ML,16.35,11.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIDOCAINE HCL 2 % IJ SOLN,RX-4454,CDM,S5000,HCPCS,250,RC,63323-0486-27,NDC,outpatient,20,ML,18.2,12.74,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMOXICILLIN 250 MG ORAL CAPS,RX-450,CDM,S5000,HCPCS,259,RC,16714-0298-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMOXICILLIN 250 MG ORAL CAPS,RX-450,CDM,S5000,HCPCS,259,RC,65862-0016-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIOTHYRONINE SODIUM 25 MCG ORAL TABS,RX-4504,CDM,S5000,HCPCS,259,RC,51862-0321-01,NDC,outpatient,1,UN,3.45,2.415,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIOTHYRONINE SODIUM 25 MCG ORAL TABS,RX-4504,CDM,S5000,HCPCS,259,RC,00093-2178-01,NDC,outpatient,1,UN,3.21,2.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LIOTHYRONINE SODIUM 25 MCG ORAL TABS,RX-4504,CDM,S5000,HCPCS,259,RC,59762-1207-01,NDC,outpatient,1,UN,3.28,2.296,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMOXICILLIN 500 MG ORAL CAPS,RX-451,CDM,S5000,HCPCS,259,RC,16714-0299-03,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LITHIUM CARBONATE 150 MG ORAL CAPS,RX-4528,CDM,S5000,HCPCS,259,RC,00054-8526-25,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LITHIUM CARBONATE 300 MG ORAL CAPS,RX-4529,CDM,S5000,HCPCS,259,RC,00054-8527-25,NDC,outpatient,1,UN,1.04,0.728,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LITHIUM CARBONATE 300 MG ORAL CAPS,RX-4529,CDM,S5000,HCPCS,259,RC,31722-0545-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMOXICILLIN 250 MG/5ML ORAL SUSR,RX-454,CDM,S5000,HCPCS,259,RC,00093-4155-79,NDC,outpatient,80,ML,14.6,10.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMOXICILLIN 250 MG/5ML ORAL SUSR,RX-454,CDM,S5000,HCPCS,259,RC,00143-9889-15,NDC,outpatient,150,ML,20.7,14.49,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMOXICILLIN 250 MG/5ML ORAL SUSR,RX-454,CDM,S5000,HCPCS,259,RC,99999-0002-83,NDC,outpatient,10,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LOPERAMIDE HCL 2 MG ORAL CAPS,RX-4560,CDM,S5000,HCPCS,259,RC,51079-0690-20,NDC,outpatient,1,UN,3,2.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LOPERAMIDE HCL 2 MG ORAL CAPS,RX-4560,CDM,S5000,HCPCS,259,RC,51079-0690-01,NDC,outpatient,1,UN,3,2.1,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LOPERAMIDE HCL 2 MG ORAL CAPS,RX-4560,CDM,S5000,HCPCS,259,RC,60687-0229-01,NDC,outpatient,1,UN,2.63,1.841,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LOPERAMIDE HCL 2 MG ORAL CAPS,RX-4560,CDM,S5000,HCPCS,259,RC,60687-0229-11,NDC,outpatient,1,UN,2.63,1.841,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LORAZEPAM 2 MG/ML ORAL CONC,RX-4571,CDM,S5000,HCPCS,259,RC,00121-0770-01,NDC,outpatient,30,ML,33.11,23.177,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LORAZEPAM 2 MG/ML ORAL CONC,RX-4571,CDM,S5000,HCPCS,259,RC,00054-3532-44,NDC,outpatient,30,ML,100.26,70.182,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LORAZEPAM 2 MG/ML ORAL CONC,RX-4571,CDM,S5000,HCPCS,259,RC,99999-0001-38,NDC,outpatient,1,ML,3.55,2.485,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LORAZEPAM 0.5 MG ORAL TABS,RX-4572,CDM,S5000,HCPCS,259,RC,00093-3425-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LORAZEPAM 0.5 MG ORAL TABS,RX-4572,CDM,S5000,HCPCS,259,RC,00904-6007-60,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LORAZEPAM 0.5 MG ORAL TABS,RX-4572,CDM,S5000,HCPCS,259,RC,13107-0083-05,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LORAZEPAM 0.5 MG ORAL TABS,RX-4572,CDM,S5000,HCPCS,259,RC,00904-6007-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LORAZEPAM 0.5 MG ORAL TABS,RX-4572,CDM,S5000,HCPCS,259,RC,69315-0904-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LORAZEPAM 1 MG ORAL TABS,RX-4573,CDM,S5000,HCPCS,259,RC,00904-6008-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LORAZEPAM 1 MG ORAL TABS,RX-4573,CDM,S5000,HCPCS,259,RC,69315-0905-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LORAZEPAM 1 MG ORAL TABS,RX-4573,CDM,S5000,HCPCS,259,RC,00093-3426-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LORAZEPAM 1 MG ORAL TABS,RX-4573,CDM,S5000,HCPCS,259,RC,69315-0905-05,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LOXAPINE SUCCINATE 25 MG ORAL CAPS,RX-4600,CDM,S5000,HCPCS,259,RC,00591-0371-01,NDC,outpatient,1,UN,2.33,1.631,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LOXAPINE SUCCINATE 5 MG ORAL CAPS,RX-4601,CDM,S5000,HCPCS,259,RC,00591-0369-01,NDC,outpatient,1,UN,1.31,0.917,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MAGNESIUM CITRATE 1.745 GM/30ML ORAL SOLN,RX-4711,CDM,S5000,HCPCS,259,RC,70677-1111-01,NDC,outpatient,296,ML,7.91,5.537,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MANNITOL 20 % IV SOLN,RX-4749,CDM,S5000,HCPCS,250,RC,00338-0357-02,NDC,outpatient,250,ML,79.42,55.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MANNITOL 20 % IV SOLN,RX-4749,CDM,S5000,HCPCS,250,RC,00990-7715-13,NDC,outpatient,500,ML,93.88,65.716,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MANNITOL 20 % IV SOLN,RX-4749,CDM,S5000,HCPCS,250,RC,00338-0357-03,NDC,outpatient,500,ML,80.53,56.371,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MANNITOL 20 % IV SOLN,RX-4749,CDM,S5000,HCPCS,250,RC,00990-7715-03,NDC,outpatient,500,ML,93.88,65.716,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MEDROXYPROGESTERONE ACETATE 10 MG ORAL TABS,RX-4854,CDM,S5000,HCPCS,259,RC,00555-0779-02,NDC,outpatient,1,UN,1.07,0.749,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MEDROXYPROGESTERONE ACETATE 2.5 MG ORAL TABS,RX-4855,CDM,S5000,HCPCS,259,RC,00555-0872-02,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METHADONE HCL 10 MG ORAL TABS,RX-4953,CDM,S5000,HCPCS,259,RC,00406-5771-23,NDC,outpatient,1,UN,1.39,0.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METHADONE HCL 10 MG ORAL TABS,RX-4953,CDM,S5000,HCPCS,259,RC,00406-5771-62,NDC,outpatient,1,UN,1.39,0.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METHADONE HCL 10 MG ORAL TABS,RX-4953,CDM,S5000,HCPCS,259,RC,00054-0710-20,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METHADONE HCL 5 MG ORAL TABS,RX-4954,CDM,S5000,HCPCS,259,RC,00406-5755-23,NDC,outpatient,1,UN,1.17,0.819,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METHADONE HCL 5 MG ORAL TABS,RX-4954,CDM,S5000,HCPCS,259,RC,00406-5755-62,NDC,outpatient,1,UN,1.17,0.819,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METHAZOLAMIDE 50 MG ORAL TABS,RX-4962,CDM,S5000,HCPCS,259,RC,00574-0791-01,NDC,outpatient,1,UN,6.49,4.543,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METHOCARBAMOL 500 MG ORAL TABS,RX-4971,CDM,S5000,HCPCS,259,RC,00904-7057-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METHOCARBAMOL 500 MG ORAL TABS,RX-4971,CDM,S5000,HCPCS,259,RC,31722-0533-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METHOCARBAMOL 500 MG ORAL TABS,RX-4971,CDM,S5000,HCPCS,259,RC,76385-0123-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METHYLPHENIDATE HCL 10 MG ORAL TABS,RX-4986,CDM,S5000,HCPCS,259,RC,68084-0823-11,NDC,outpatient,1,UN,5.13,3.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METHYLPHENIDATE HCL 10 MG ORAL TABS,RX-4986,CDM,S5000,HCPCS,259,RC,68084-0823-21,NDC,outpatient,1,UN,5.13,3.591,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METHYLPHENIDATE HCL 10 MG ORAL TABS,RX-4986,CDM,S5000,HCPCS,259,RC,00406-1144-01,NDC,outpatient,1,UN,1.43,1.001,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METHYLPREDNISOLONE 16 MG ORAL TABS,RX-4992,CDM,S5000,HCPCS,259,RC,59762-0050-01,NDC,outpatient,1,UN,8.54,5.978,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METHYLPREDNISOLONE 4 MG ORAL TABS,RX-4993,CDM,S5000,HCPCS,259,RC,00904-6914-61,NDC,outpatient,1,UN,4.37,3.059,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METHYLPREDNISOLONE 4 MG ORAL TABS,RX-4993,CDM,S5000,HCPCS,259,RC,68084-0149-01,NDC,outpatient,1,UN,4.95,3.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METHYLPREDNISOLONE 4 MG ORAL TABS,RX-4993,CDM,S5000,HCPCS,259,RC,68084-0149-11,NDC,outpatient,1,UN,4.95,3.465,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METOCLOPRAMIDE HCL 10 MG ORAL TABS,RX-5005,CDM,S5000,HCPCS,259,RC,60687-0631-01,NDC,outpatient,1,UN,2.56,1.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METOCLOPRAMIDE HCL 10 MG ORAL TABS,RX-5005,CDM,S5000,HCPCS,259,RC,60687-0631-11,NDC,outpatient,1,UN,2.56,1.792,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METOPROLOL TARTRATE 50 MG ORAL TABS,RX-5009,CDM,S5000,HCPCS,259,RC,51079-0801-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METOPROLOL TARTRATE 50 MG ORAL TABS,RX-5009,CDM,S5000,HCPCS,259,RC,51079-0801-20,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METOPROLOL TARTRATE 50 MG ORAL TABS,RX-5009,CDM,S5000,HCPCS,259,RC,62584-0266-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METOPROLOL TARTRATE 50 MG ORAL TABS,RX-5009,CDM,S5000,HCPCS,259,RC,62584-0266-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METRONIDAZOLE 250 MG ORAL TABS,RX-5015,CDM,S5000,HCPCS,259,RC,00904-7156-61,NDC,outpatient,1,UN,1.09,0.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METRONIDAZOLE 500 MG ORAL TABS,RX-5016,CDM,S5000,HCPCS,259,RC,60687-0550-11,NDC,outpatient,1,UN,2.17,1.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METRONIDAZOLE 500 MG ORAL TABS,RX-5016,CDM,S5000,HCPCS,259,RC,29300-0227-01,NDC,outpatient,1,UN,1.76,1.232,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METRONIDAZOLE 500 MG ORAL TABS,RX-5016,CDM,S5000,HCPCS,259,RC,60687-0550-01,NDC,outpatient,1,UN,2.17,1.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MICONAZOLE NITRATE 2 % EX CREA,RX-5039,CDM,S5000,HCPCS,259,RC,61269-0735-14,NDC,outpatient,14,GR,7.54,5.278,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MINERAL OIL ORAL OIL,RX-5086,CDM,S5000,HCPCS,259,RC,99999-0002-15,NDC,outpatient,30,ML,1.39,0.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MINERAL OIL ORAL OIL,RX-5086,CDM,S5000,HCPCS,259,RC,48433-0202-30,NDC,outpatient,30,ML,5.08,3.556,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MINOCYCLINE HCL 50 MG ORAL CAPS,RX-5111,CDM,S5000,HCPCS,259,RC,00591-5694-60,NDC,outpatient,1,UN,1.26,0.882,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MINOXIDIL 10 MG ORAL TABS,RX-5114,CDM,S5000,HCPCS,259,RC,68084-0205-11,NDC,outpatient,1,UN,2.48,1.736,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MINOXIDIL 10 MG ORAL TABS,RX-5114,CDM,S5000,HCPCS,259,RC,68084-0205-01,NDC,outpatient,1,UN,2.48,1.736,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MINOXIDIL 2.5 MG ORAL TABS,RX-5115,CDM,S5000,HCPCS,259,RC,00591-5642-01,NDC,outpatient,1,UN,1.01,0.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MINOXIDIL 2.5 MG ORAL TABS,RX-5115,CDM,S5000,HCPCS,259,RC,68084-0204-11,NDC,outpatient,1,UN,2.25,1.575,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MINOXIDIL 2.5 MG ORAL TABS,RX-5115,CDM,S5000,HCPCS,259,RC,68084-0204-01,NDC,outpatient,1,UN,2.25,1.575,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,00121-0904-05,NDC,outpatient,5,ML,4.01,2.807,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,68094-0001-59,NDC,outpatient,5,ML,4.7,3.29,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,99999-0002-19,NDC,outpatient,5,ML,2.14,1.498,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,00054-0237-49,NDC,outpatient,100,ML,37.38,26.166,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,68094-0001-62,NDC,outpatient,5,ML,4.7,3.29,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MORPHINE SULFATE 10 MG/5ML ORAL SOLN,RX-5176,CDM,S5000,HCPCS,259,RC,00121-0904-94,NDC,outpatient,5,ML,4.01,2.807,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MORPHINE SULFATE 15 MG ORAL TABS,RX-5178,CDM,S5000,HCPCS,259,RC,00054-0235-24,NDC,outpatient,1,UN,3.2,2.24,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MORPHINE SULFATE 15 MG ORAL TABS,RX-5178,CDM,S5000,HCPCS,259,RC,00054-0235-25,NDC,outpatient,1,UN,2.1,1.47,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MORPHINE SULFATE 10 MG RE SUPP,RX-5180,CDM,S5000,HCPCS,259,RC,00574-7112-12,NDC,outpatient,1,UN,19.66,13.762,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NADOLOL 20 MG ORAL TABS,RX-5330,CDM,S5000,HCPCS,259,RC,60687-0302-95,NDC,outpatient,1,UN,11.38,7.966,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NADOLOL 20 MG ORAL TABS,RX-5330,CDM,S5000,HCPCS,259,RC,60687-0302-25,NDC,outpatient,1,UN,11.38,7.966,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NADOLOL 40 MG ORAL TABS,RX-5331,CDM,S5000,HCPCS,259,RC,00904-7071-07,NDC,outpatient,1,UN,9.11,6.377,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NADOLOL 40 MG ORAL TABS,RX-5331,CDM,S5000,HCPCS,259,RC,69097-0868-07,NDC,outpatient,1,UN,1.13,0.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NAPROXEN 250 MG ORAL TABS,RX-5391,CDM,S5000,HCPCS,259,RC,50268-0594-15,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NAPROXEN 250 MG ORAL TABS,RX-5391,CDM,S5000,HCPCS,259,RC,65162-0188-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NAPROXEN 250 MG ORAL TABS,RX-5391,CDM,S5000,HCPCS,259,RC,50268-0594-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NAPROXEN 375 MG ORAL TABS,RX-5392,CDM,S5000,HCPCS,259,RC,50268-0595-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NAPROXEN 375 MG ORAL TABS,RX-5392,CDM,S5000,HCPCS,259,RC,65162-0189-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NAPROXEN 375 MG ORAL TABS,RX-5392,CDM,S5000,HCPCS,259,RC,50268-0595-15,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NAPROXEN 500 MG ORAL TABS,RX-5393,CDM,S5000,HCPCS,259,RC,65862-0522-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NAPROXEN 500 MG ORAL TABS,RX-5393,CDM,S5000,HCPCS,259,RC,65162-0190-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NAPROXEN 500 MG ORAL TABS,RX-5393,CDM,S5000,HCPCS,259,RC,63739-0403-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NEOMYCIN SULFATE 500 MG ORAL TABS,RX-5472,CDM,S5000,HCPCS,259,RC,39822-0310-05,NDC,outpatient,1,UN,3.09,2.163,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NEOMYCIN SULFATE 500 MG ORAL TABS,RX-5472,CDM,S5000,HCPCS,259,RC,39822-0310-07,NDC,outpatient,1,UN,3.09,2.163,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NEOMYCIN-POLYMYXIN-GRAMICIDIN 1.75-10000-.025 OP SOLN,RX-5474,CDM,S5000,HCPCS,259,RC,24208-0790-62,NDC,outpatient,10,ML,150.86,105.602,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NIACIN 100 MG ORAL TABS,RX-5539,CDM,S5000,HCPCS,259,RC,80681-0057-00,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NIFEDIPINE 10 MG ORAL CAPS,RX-5558,CDM,S5000,HCPCS,259,RC,23155-0194-01,NDC,outpatient,1,UN,1.98,1.386,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NITROFURANTOIN MACROCRYSTAL 50 MG ORAL CAPS,RX-5595,CDM,S5000,HCPCS,259,RC,57664-0232-88,NDC,outpatient,1,UN,3.41,2.387,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NITROGLYCERIN 0.3 MG SL SUBL,RX-5603,CDM,S5000,HCPCS,259,RC,68462-0638-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NITROGLYCERIN 0.3 MG SL SUBL,RX-5603,CDM,S5000,HCPCS,259,RC,72888-0138-01,NDC,outpatient,1,UN,1.43,1.001,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NITROGLYCERIN 0.3 MG SL SUBL,RX-5603,CDM,S5000,HCPCS,259,RC,00071-0417-24,NDC,outpatient,1,UN,3.05,2.135,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NITROGLYCERIN 0.4 MG SL SUBL,RX-5604,CDM,S5000,HCPCS,259,RC,43598-0436-35,NDC,outpatient,0.75,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NITROGLYCERIN 0.4 MG SL SUBL,RX-5604,CDM,S5000,HCPCS,259,RC,68462-0639-25,NDC,outpatient,0.75,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NITROGLYCERIN 0.4 MG SL SUBL,RX-5604,CDM,S5000,HCPCS,259,RC,68462-0639-45,NDC,outpatient,0.75,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NITROGLYCERIN 0.4 MG SL SUBL,RX-5604,CDM,S5000,HCPCS,259,RC,43598-0436-11,NDC,outpatient,0.75,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NITROGLYCERIN 2 % TD OINT,RX-5606,CDM,S5000,HCPCS,259,RC,00281-0326-08,NDC,outpatient,1,GR,9.96,6.972,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NORTRIPTYLINE HCL 25 MG ORAL CAPS,RX-5675,CDM,S5000,HCPCS,259,RC,60687-0293-01,NDC,outpatient,1,UN,1.89,1.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NORTRIPTYLINE HCL 25 MG ORAL CAPS,RX-5675,CDM,S5000,HCPCS,259,RC,60687-0293-11,NDC,outpatient,1,UN,1.89,1.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NYSTATIN 100000 UNIT/GM EX CREA,RX-5749,CDM,S5000,HCPCS,259,RC,00713-0678-15,NDC,outpatient,15,GR,53.4,37.38,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NYSTATIN 100000 UNIT/GM EX CREA,RX-5749,CDM,S5000,HCPCS,259,RC,45802-0059-35,NDC,outpatient,15,GR,17.03,11.921,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NYSTATIN 100000 UNIT/GM EX CREA,RX-5749,CDM,S5000,HCPCS,259,RC,51672-1289-01,NDC,outpatient,15,GR,18.83,13.181,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NYSTATIN 100000 UNIT/GM EX OINT,RX-5750,CDM,S5000,HCPCS,259,RC,45802-0048-35,NDC,outpatient,15,GR,13.29,9.303,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NYSTATIN 100000 UNIT/GM EX OINT,RX-5750,CDM,S5000,HCPCS,259,RC,00472-0166-15,NDC,outpatient,15,GR,61.35,42.945,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,63739-0160-70,NDC,outpatient,5,ML,2.63,1.841,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,99999-0003-91,NDC,outpatient,5,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,00121-0868-05,NDC,outpatient,5,ML,4.74,3.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,00121-1045-16,NDC,outpatient,5,ML,4.21,2.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,63739-0160-10,NDC,outpatient,5,ML,2.63,1.841,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NYSTATIN 100000 UNIT/ML MT SUSP,RX-5751,CDM,S5000,HCPCS,259,RC,00121-0868-00,NDC,outpatient,5,ML,4.74,3.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NYSTATIN-TRIAMCINOLONE 100000-0.1 UNIT/GM-% EX CREA,RX-5754,CDM,S5000,HCPCS,259,RC,51672-1263-01,NDC,outpatient,15,GR,15.02,10.514,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NYSTATIN-TRIAMCINOLONE 100000-0.1 UNIT/GM-% EX OINT,RX-5755,CDM,S5000,HCPCS,259,RC,51672-1272-01,NDC,outpatient,15,GR,22.37,15.659,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ORA-PLUS ORAL LIQD,RX-5851,CDM,S5000,HCPCS,259,RC,00574-0303-16,NDC,outpatient,473,ML,130.96,91.672,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ORA-SWEET SF ORAL SYRP,RX-5853,CDM,S5000,HCPCS,259,RC,00574-0302-16,NDC,outpatient,473,ML,130.96,91.672,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXAZEPAM 10 MG ORAL CAPS,RX-5930,CDM,S5000,HCPCS,259,RC,62584-0812-11,NDC,outpatient,1,UN,8.63,6.041,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXAZEPAM 10 MG ORAL CAPS,RX-5930,CDM,S5000,HCPCS,259,RC,62584-0812-01,NDC,outpatient,1,UN,8.63,6.041,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXAZEPAM 10 MG ORAL CAPS,RX-5930,CDM,S5000,HCPCS,259,RC,00228-2067-10,NDC,outpatient,1,UN,3.24,2.268,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXAZEPAM 15 MG ORAL CAPS,RX-5931,CDM,S5000,HCPCS,259,RC,62584-0813-11,NDC,outpatient,1,UN,9.09,6.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXAZEPAM 15 MG ORAL CAPS,RX-5931,CDM,S5000,HCPCS,259,RC,62584-0813-01,NDC,outpatient,1,UN,9.09,6.363,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXYBUTYNIN CHLORIDE 5 MG ORAL TABS,RX-5938,CDM,S5000,HCPCS,259,RC,60687-0670-11,NDC,outpatient,1,UN,1.85,1.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXYBUTYNIN CHLORIDE 5 MG ORAL TABS,RX-5938,CDM,S5000,HCPCS,259,RC,60687-0670-01,NDC,outpatient,1,UN,1.85,1.295,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXYBUTYNIN CHLORIDE 5 MG ORAL TABS,RX-5938,CDM,S5000,HCPCS,259,RC,00904-7027-61,NDC,outpatient,1,UN,1.69,1.183,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXYCODONE-ACETAMINOPHEN 5-325 MG ORAL TABS,RX-5940,CDM,S5000,HCPCS,259,RC,00406-0512-62,NDC,outpatient,1,UN,1.65,1.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OXYCODONE-ACETAMINOPHEN 5-325 MG ORAL TABS,RX-5940,CDM,S5000,HCPCS,259,RC,00406-0512-23,NDC,outpatient,1,UN,1.65,1.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PAPAVERINE HCL 30 MG/ML IJ SOLN,RX-6030,CDM,S5000,HCPCS,250,RC,14789-0121-05,NDC,outpatient,2,ML,78.96,55.272,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PAPAVERINE HCL 30 MG/ML IJ SOLN,RX-6030,CDM,S5000,HCPCS,250,RC,54288-0142-01,NDC,outpatient,2,ML,69.91,48.937,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PAPAVERINE HCL 30 MG/ML IJ SOLN,RX-6030,CDM,S5000,HCPCS,250,RC,54288-0142-10,NDC,outpatient,2,ML,69.91,48.937,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PAPAVERINE HCL 30 MG/ML IJ SOLN,RX-6030,CDM,S5000,HCPCS,250,RC,00517-4002-25,NDC,outpatient,2,ML,103.84,72.688,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PAPAVERINE HCL 30 MG/ML IJ SOLN,RX-6030,CDM,S5000,HCPCS,250,RC,14789-0121-07,NDC,outpatient,2,ML,78.96,55.272,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PENICILLIN G SODIUM 5000000 UNITS IJ SOLR,RX-6087,CDM,S5000,HCPCS,250,RC,00781-6153-94,NDC,outpatient,1,UN,142.02,99.414,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PENICILLIN G SODIUM 5000000 UNITS IJ SOLR,RX-6087,CDM,S5000,HCPCS,250,RC,00781-6153-95,NDC,outpatient,1,UN,142.02,99.414,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PENICILLIN V POTASSIUM 250 MG/5ML ORAL SOLR,RX-6091,CDM,S5000,HCPCS,259,RC,99999-0002-88,NDC,outpatient,10,ML,2.67,1.869,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PENICILLIN V POTASSIUM 250 MG/5ML ORAL SOLR,RX-6091,CDM,S5000,HCPCS,259,RC,00093-4127-73,NDC,outpatient,100,ML,26.7,18.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PENICILLIN V POTASSIUM 250 MG ORAL TABS,RX-6092,CDM,S5000,HCPCS,259,RC,57237-0040-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PENICILLIN V POTASSIUM 500 MG ORAL TABS,RX-6093,CDM,S5000,HCPCS,259,RC,00143-9836-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PENICILLIN V POTASSIUM 500 MG ORAL TABS,RX-6093,CDM,S5000,HCPCS,259,RC,00093-1174-01,NDC,outpatient,1,UN,1.67,1.169,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PERPHENAZINE 2 MG ORAL TABS,RX-6157,CDM,S5000,HCPCS,259,RC,00904-6599-61,NDC,outpatient,1,UN,2.75,1.925,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PERPHENAZINE 8 MG ORAL TABS,RX-6159,CDM,S5000,HCPCS,259,RC,00904-6601-61,NDC,outpatient,1,UN,5.02,3.514,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PHENAZOPYRIDINE HCL 100 MG ORAL TABS,RX-6193,CDM,S5000,HCPCS,259,RC,65162-0681-10,NDC,outpatient,1,UN,1.61,1.127,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,00121-0942-05,NDC,outpatient,5,ML,7.01,4.907,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,54932-0501-81,NDC,outpatient,473,ML,75.78,53.046,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,13517-0107-16,NDC,outpatient,473,ML,307.31,215.117,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,00121-0942-50,NDC,outpatient,5,ML,7.01,4.907,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,99999-0002-30,NDC,outpatient,5,ML,2.5,1.75,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PHENOBARBITAL 20 MG/5ML ORAL ELIX,RX-6212,CDM,S5000,HCPCS,259,RC,16571-0675-16,NDC,outpatient,473,ML,82.09,57.463,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PHENOBARBITAL 32.4 MG ORAL TABS,RX-6217,CDM,S5000,HCPCS,259,RC,16571-0673-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PHENOBARBITAL 32.4 MG ORAL TABS,RX-6217,CDM,S5000,HCPCS,259,RC,00904-6575-61,NDC,outpatient,1,UN,1.34,0.938,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PHENYLEPHRINE HCL 0.25 % NA SOLN,RX-6243,CDM,S5000,HCPCS,259,RC,00225-0800-47,NDC,outpatient,15,ML,13.42,9.394,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PHENYLEPHRINE HCL 0.5 % NA SOLN,RX-6244,CDM,S5000,HCPCS,259,RC,00225-0805-47,NDC,outpatient,15,ML,13.42,9.394,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PHENYLEPHRINE HCL 1 % NA SOLN,RX-6245,CDM,S5000,HCPCS,259,RC,00225-0810-47,NDC,outpatient,15,ML,15.09,10.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PHENYLEPHRINE HCL 2.5 % OP SOLN,RX-6246,CDM,S5000,HCPCS,259,RC,70756-0629-25,NDC,outpatient,2,ML,146.94,102.858,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PHENYTOIN 125 MG/5ML ORAL SUSP,RX-6255,CDM,S5000,HCPCS,259,RC,60687-0275-62,NDC,outpatient,4,ML,13.48,9.436,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PHENYTOIN 125 MG/5ML ORAL SUSP,RX-6255,CDM,S5000,HCPCS,259,RC,60687-0275-66,NDC,outpatient,4,ML,13.48,9.436,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAPS,RX-6257,CDM,S5000,HCPCS,259,RC,57664-0808-88,NDC,outpatient,1,UN,1.19,0.833,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAPS,RX-6257,CDM,S5000,HCPCS,259,RC,65862-0692-01,NDC,outpatient,1,UN,1.74,1.218,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PILOCARPINE HCL 1 % OP SOLN,RX-6279,CDM,S5000,HCPCS,259,RC,61314-0203-15,NDC,outpatient,15,ML,342.03,239.421,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PILOCARPINE HCL 2 % OP SOLN,RX-6280,CDM,S5000,HCPCS,259,RC,61314-0204-15,NDC,outpatient,15,ML,351.44,246.008,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PILOCARPINE HCL 2 % OP SOLN,RX-6280,CDM,S5000,HCPCS,259,RC,70069-0191-01,NDC,outpatient,15,ML,140.98,98.686,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PILOCARPINE HCL 4 % OP SOLN,RX-6282,CDM,S5000,HCPCS,259,RC,61314-0206-15,NDC,outpatient,15,ML,326.81,228.767,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PIROXICAM 10 MG ORAL CAPS,RX-6310,CDM,S5000,HCPCS,259,RC,42571-0176-01,NDC,outpatient,1,UN,3.12,2.184,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POLY-VI-SOL ORAL SOLN,RX-6374,CDM,S5000,HCPCS,259,RC,00087-0402-03,NDC,outpatient,1,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POLY-VI-SOL ORAL SOLN,RX-6374,CDM,S5000,HCPCS,259,RC,99999-0001-68,NDC,outpatient,1,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POLYMYXIN B SULFATE 500000 UNITS IJ SOLR,RX-6393,CDM,S5000,HCPCS,250,RC,55150-0234-10,NDC,outpatient,1,UN,16.13,11.291,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POTASSIUM ACETATE 2 MEQ/ML IV SOLN,RX-6420,CDM,S5000,HCPCS,250,RC,00409-8183-01,NDC,outpatient,20,ML,16.35,11.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POTASSIUM ACETATE 2 MEQ/ML IV SOLN,RX-6420,CDM,S5000,HCPCS,250,RC,00409-8183-11,NDC,outpatient,20,ML,16.35,11.445,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POTASSIUM ACETATE 2 MEQ/ML IV SOLN,RX-6420,CDM,S5000,HCPCS,250,RC,51754-2001-04,NDC,outpatient,20,ML,18.07,12.649,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POVIDONE-IODINE 10 % EX SOLN,RX-6458,CDM,S5000,HCPCS,259,RC,52380-1905-00,NDC,outpatient,59,ML,4.73,3.311,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PRAZOSIN HCL 1 MG ORAL CAPS,RX-6468,CDM,S5000,HCPCS,259,RC,51079-0630-01,NDC,outpatient,1,UN,6.21,4.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PRAZOSIN HCL 1 MG ORAL CAPS,RX-6468,CDM,S5000,HCPCS,259,RC,51079-0630-20,NDC,outpatient,1,UN,6.21,4.347,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PRAZOSIN HCL 1 MG ORAL CAPS,RX-6468,CDM,S5000,HCPCS,259,RC,68084-0996-01,NDC,outpatient,1,UN,5.34,3.738,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PRAZOSIN HCL 1 MG ORAL CAPS,RX-6468,CDM,S5000,HCPCS,259,RC,68084-0996-11,NDC,outpatient,1,UN,5.34,3.738,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PRAZOSIN HCL 5 MG ORAL CAPS,RX-6470,CDM,S5000,HCPCS,259,RC,51079-0632-01,NDC,outpatient,1,UN,14.76,10.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PRAZOSIN HCL 5 MG ORAL CAPS,RX-6470,CDM,S5000,HCPCS,259,RC,51079-0632-20,NDC,outpatient,1,UN,14.76,10.332,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREDNISOLONE ACETATE 1 % OP SUSP,RX-6487,CDM,S5000,HCPCS,259,RC,11980-0180-05,NDC,outpatient,5,ML,534.23,373.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREDNISOLONE ACETATE 1 % OP SUSP,RX-6487,CDM,S5000,HCPCS,259,RC,60758-0119-05,NDC,outpatient,5,ML,106.58,74.606,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREDNISOLONE ACETATE 1 % OP SUSP,RX-6487,CDM,S5000,HCPCS,259,RC,61314-0637-05,NDC,outpatient,5,ML,113.48,79.436,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREDNISONE 1 MG ORAL TABS,RX-6493,CDM,S5000,HCPCS,259,RC,00054-4741-25,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREDNISONE 1 MG ORAL TABS,RX-6493,CDM,S5000,HCPCS,259,RC,00054-8739-25,NDC,outpatient,1,UN,1.06,0.742,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREDNISONE 1 MG ORAL TABS,RX-6493,CDM,S5000,HCPCS,259,RC,59651-0484-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREDNISONE 10 MG ORAL TABS,RX-6494,CDM,S5000,HCPCS,259,RC,00054-0017-20,NDC,outpatient,1,UN,1.02,0.714,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREDNISONE 10 MG ORAL TABS,RX-6494,CDM,S5000,HCPCS,259,RC,60687-0134-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREDNISONE 10 MG ORAL TABS,RX-6494,CDM,S5000,HCPCS,259,RC,00904-6923-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREDNISONE 10 MG ORAL TABS,RX-6494,CDM,S5000,HCPCS,259,RC,00603-5338-21,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREDNISONE 10 MG ORAL TABS,RX-6494,CDM,S5000,HCPCS,259,RC,60687-0134-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREDNISONE 2.5 MG ORAL TABS,RX-6495,CDM,S5000,HCPCS,259,RC,00054-8740-25,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREDNISONE 2.5 MG ORAL TABS,RX-6495,CDM,S5000,HCPCS,259,RC,00054-4742-25,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,00054-0018-20,NDC,outpatient,1,UN,1.09,0.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,59746-0175-06,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,64380-0785-07,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,60687-0145-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,00904-7127-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREDNISONE 20 MG ORAL TABS,RX-6496,CDM,S5000,HCPCS,259,RC,60687-0145-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREDNISONE 5 MG ORAL TABS,RX-6497,CDM,S5000,HCPCS,259,RC,60687-0122-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREDNISONE 5 MG ORAL TABS,RX-6497,CDM,S5000,HCPCS,259,RC,00054-8724-25,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREDNISONE 5 MG ORAL TABS,RX-6497,CDM,S5000,HCPCS,259,RC,60687-0122-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREDNISONE 50 MG ORAL TABS,RX-6498,CDM,S5000,HCPCS,259,RC,59651-0489-01,NDC,outpatient,1,UN,1.61,1.127,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREDNISONE 50 MG ORAL TABS,RX-6498,CDM,S5000,HCPCS,259,RC,00054-0019-20,NDC,outpatient,1,UN,1.23,0.861,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREDNISONE 50 MG ORAL TABS,RX-6498,CDM,S5000,HCPCS,259,RC,00054-0019-25,NDC,outpatient,1,UN,1.08,0.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PREDNISONE 50 MG ORAL TABS,RX-6498,CDM,S5000,HCPCS,259,RC,10135-0779-01,NDC,outpatient,1,UN,1.24,0.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ASCORBIC ACID 500 MG/ML IJ SOLN,RX-654,CDM,S5000,HCPCS,250,RC,67157-0101-51,NDC,outpatient,50,ML,1099.15,769.405,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PRIMIDONE 250 MG ORAL TABS,RX-6544,CDM,S5000,HCPCS,259,RC,50268-0687-15,NDC,outpatient,1,UN,2.53,1.771,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PRIMIDONE 250 MG ORAL TABS,RX-6544,CDM,S5000,HCPCS,259,RC,50268-0687-11,NDC,outpatient,1,UN,2.53,1.771,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PROBENECID 500 MG ORAL TABS,RX-6561,CDM,S5000,HCPCS,259,RC,00591-5347-01,NDC,outpatient,1,UN,2.65,1.855,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PROMETHAZINE-CODEINE 6.25-10 MG/5ML ORAL SYRP,RX-6627,CDM,S5000,HCPCS,259,RC,27808-0065-02,NDC,outpatient,2.5,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PROMETHAZINE-CODEINE 6.25-10 MG/5ML ORAL SYRP,RX-6627,CDM,S5000,HCPCS,259,RC,99999-0002-39,NDC,outpatient,5,ML,1.21,0.847,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ASCORBIC ACID 500 MG ORAL TABS,RX-664,CDM,S5000,HCPCS,259,RC,00904-0523-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ASCORBIC ACID 500 MG ORAL TABS,RX-664,CDM,S5000,HCPCS,259,RC,00904-0523-60,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PROPARACAINE HCL 0.5 % OP SOLN,RX-6644,CDM,S5000,HCPCS,259,RC,24208-0730-06,NDC,outpatient,15,ML,110.61,77.427,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PROPARACAINE HCL 0.5 % OP SOLN,RX-6644,CDM,S5000,HCPCS,259,RC,61314-0016-01,NDC,outpatient,15,ML,111.21,77.847,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PROPRANOLOL HCL 20 MG/5ML ORAL SOLN,RX-6654,CDM,S5000,HCPCS,259,RC,00121-0908-05,NDC,outpatient,5,ML,10.08,7.056,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PROPRANOLOL HCL 20 MG/5ML ORAL SOLN,RX-6654,CDM,S5000,HCPCS,259,RC,00054-3727-63,NDC,outpatient,500,ML,209.15,146.405,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PROPRANOLOL HCL 20 MG/5ML ORAL SOLN,RX-6654,CDM,S5000,HCPCS,259,RC,00121-0908-40,NDC,outpatient,5,ML,10.08,7.056,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PROPRANOLOL HCL 10 MG ORAL TABS,RX-6656,CDM,S5000,HCPCS,259,RC,60687-0587-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PROPRANOLOL HCL 10 MG ORAL TABS,RX-6656,CDM,S5000,HCPCS,259,RC,60687-0587-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PROPRANOLOL HCL 10 MG ORAL TABS,RX-6656,CDM,S5000,HCPCS,259,RC,69238-2077-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PROPRANOLOL HCL 10 MG ORAL TABS,RX-6656,CDM,S5000,HCPCS,259,RC,00378-0182-01,NDC,outpatient,1,UN,1.22,0.854,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PROPRANOLOL HCL 40 MG ORAL TABS,RX-6658,CDM,S5000,HCPCS,259,RC,60687-0609-11,NDC,outpatient,1,UN,2.26,1.582,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PROPRANOLOL HCL 40 MG ORAL TABS,RX-6658,CDM,S5000,HCPCS,259,RC,00603-5484-21,NDC,outpatient,1,UN,1.21,0.847,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PROPRANOLOL HCL 40 MG ORAL TABS,RX-6658,CDM,S5000,HCPCS,259,RC,60687-0609-01,NDC,outpatient,1,UN,2.26,1.582,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PROPYLTHIOURACIL 50 MG ORAL TABS,RX-6662,CDM,S5000,HCPCS,259,RC,67253-0651-10,NDC,outpatient,1,UN,2.63,1.841,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PROPYLTHIOURACIL 50 MG ORAL TABS,RX-6662,CDM,S5000,HCPCS,259,RC,00228-2348-10,NDC,outpatient,1,UN,3.18,2.226,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PSEUDOEPHEDRINE HCL 30 MG ORAL TABS,RX-6714,CDM,S5000,HCPCS,259,RC,00904-5053-59,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PSEUDOEPHEDRINE HCL 30 MG ORAL TABS,RX-6714,CDM,S5000,HCPCS,259,RC,00904-6990-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PYRAZINAMIDE 500 MG ORAL TABS,RX-6738,CDM,S5000,HCPCS,259,RC,70954-0484-10,NDC,outpatient,1,UN,17.43,12.201,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PYRAZINAMIDE 500 MG ORAL TABS,RX-6738,CDM,S5000,HCPCS,259,RC,10135-0735-60,NDC,outpatient,1,UN,15.09,10.563,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PYRAZINAMIDE 500 MG ORAL TABS,RX-6738,CDM,S5000,HCPCS,259,RC,33342-0447-11,NDC,outpatient,1,UN,19.28,13.496,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PYRIDOXINE HCL 50 MG ORAL TABS,RX-6748,CDM,S5000,HCPCS,259,RC,50268-0858-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PYRIDOXINE HCL 50 MG ORAL TABS,RX-6748,CDM,S5000,HCPCS,259,RC,50268-0858-15,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PYRIDOXINE HCL 50 MG ORAL TABS,RX-6748,CDM,S5000,HCPCS,259,RC,77333-0940-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PYRIDOXINE HCL 50 MG ORAL TABS,RX-6748,CDM,S5000,HCPCS,259,RC,77333-0940-25,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
QUININE SULFATE 324 MG ORAL CAPS,RX-6781,CDM,S5000,HCPCS,259,RC,50742-0238-30,NDC,outpatient,1,UN,2.82,1.974,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ASPIRIN 81 MG ORAL CHEW,RX-680,CDM,S5000,HCPCS,259,RC,63739-0434-02,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ASPIRIN 81 MG ORAL CHEW,RX-680,CDM,S5000,HCPCS,259,RC,66553-0002-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ASPIRIN 81 MG ORAL CHEW,RX-680,CDM,S5000,HCPCS,259,RC,00904-6794-30,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ASPIRIN 81 MG ORAL CHEW,RX-680,CDM,S5000,HCPCS,259,RC,00904-6794-80,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ASPIRIN 325 MG ORAL TABS,RX-681,CDM,S5000,HCPCS,259,RC,66553-0001-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ASPIRIN 325 MG ORAL TABS,RX-681,CDM,S5000,HCPCS,259,RC,57896-0901-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ASPIRIN 325 MG ORAL TBEC,RX-685,CDM,S5000,HCPCS,259,RC,57896-0921-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ASPIRIN 81 MG ORAL TBEC,RX-688,CDM,S5000,HCPCS,259,RC,00904-6783-70,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ASPIRIN 81 MG ORAL TBEC,RX-688,CDM,S5000,HCPCS,259,RC,00536-1234-41,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ASPIRIN 81 MG ORAL TBEC,RX-688,CDM,S5000,HCPCS,259,RC,63739-0212-02,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ASPIRIN 300 MG RE SUPP,RX-693,CDM,S5000,HCPCS,259,RC,00574-7034-12,NDC,outpatient,1,UN,4.58,3.206,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
INSULIN DETEMIR 100 UNIT/ML SC SOLN,RX-70261,CDM,S5000,HCPCS,259,RC,00169-3687-12,NDC,outpatient,10,ML,388.27,271.789,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PACK,RX-70284,CDM,S5000,HCPCS,259,RC,60258-0006-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PACK,RX-70284,CDM,S5000,HCPCS,259,RC,71351-0010-01,NDC,outpatient,1,UN,1.65,1.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PACK,RX-70284,CDM,S5000,HCPCS,259,RC,71351-0010-99,NDC,outpatient,1,UN,1.65,1.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PACK,RX-70284,CDM,S5000,HCPCS,259,RC,60258-0006-15,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SALINE NASAL SPRAY 0.65 % NA SOLN,RX-7030,CDM,S5000,HCPCS,259,RC,00904-3865-75,NDC,outpatient,44,ML,3.33,2.331,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SALINE NASAL SPRAY 0.65 % NA SOLN,RX-7030,CDM,S5000,HCPCS,259,RC,49348-0356-25,NDC,outpatient,44,ML,5.88,4.116,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRAMADOL HCL ER 200 MG ORAL TB24,RX-70353,CDM,S5000,HCPCS,259,RC,68180-0698-06,NDC,outpatient,1,UN,19.84,13.888,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RANOLAZINE ER 500 MG ORAL TB12,RX-70434,CDM,S5000,HCPCS,259,RC,50268-0722-11,NDC,outpatient,1,UN,5.07,3.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RANOLAZINE ER 500 MG ORAL TB12,RX-70434,CDM,S5000,HCPCS,259,RC,50268-0722-15,NDC,outpatient,1,UN,5.07,3.549,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RANOLAZINE ER 500 MG ORAL TB12,RX-70434,CDM,S5000,HCPCS,259,RC,68462-0319-60,NDC,outpatient,1,UN,1.05,0.735,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RANOLAZINE ER 500 MG ORAL TB12,RX-70434,CDM,S5000,HCPCS,259,RC,60687-0549-11,NDC,outpatient,1,UN,5.08,3.556,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RANOLAZINE ER 500 MG ORAL TB12,RX-70434,CDM,S5000,HCPCS,259,RC,60687-0549-21,NDC,outpatient,1,UN,5.08,3.556,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LUBIPROSTONE 24 MCG ORAL CAPS,RX-70472,CDM,S5000,HCPCS,259,RC,00254-3029-02,NDC,outpatient,1,UN,4.45,3.115,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLUTICASONE PROPIONATE 50 MCG/ACT NA SUSP,RX-70536,CDM,S5000,HCPCS,259,RC,00536-1183-99,NDC,outpatient,9.9,ML,45.6,31.92,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FLUTICASONE PROPIONATE 50 MCG/ACT NA SUSP,RX-70536,CDM,S5000,HCPCS,259,RC,00054-3270-99,NDC,outpatient,16,GR,32.12,22.484,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
INSULIN LISPRO PROT & LISPRO (75-25) 100 UNIT/ML SC SUSP,RX-70693,CDM,S5000,HCPCS,259,RC,00002-7511-01,NDC,outpatient,10,ML,211.82,148.274,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ATENOLOL 25 MG ORAL TABS,RX-717,CDM,S5000,HCPCS,259,RC,51079-0759-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ATENOLOL 25 MG ORAL TABS,RX-717,CDM,S5000,HCPCS,259,RC,51079-0759-20,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ATENOLOL 50 MG ORAL TABS,RX-718,CDM,S5000,HCPCS,259,RC,51079-0684-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ATENOLOL 50 MG ORAL TABS,RX-718,CDM,S5000,HCPCS,259,RC,51079-0684-20,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SILVER SULFADIAZINE 1 % EX CREA,RX-7224,CDM,S5000,HCPCS,259,RC,43598-0210-50,NDC,outpatient,50,GR,55.18,38.626,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SILVER SULFADIAZINE 1 % EX CREA,RX-7224,CDM,S5000,HCPCS,259,RC,61570-0131-55,NDC,outpatient,50,GR,30.49,21.343,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SILVER SULFADIAZINE 1 % EX CREA,RX-7224,CDM,S5000,HCPCS,259,RC,43598-0210-40,NDC,outpatient,400,GR,153.08,107.156,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SIMETHICONE 80 MG ORAL CHEW,RX-7227,CDM,S5000,HCPCS,259,RC,77333-0812-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SIMETHICONE 80 MG ORAL CHEW,RX-7227,CDM,S5000,HCPCS,259,RC,49348-0188-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SIMETHICONE 80 MG ORAL CHEW,RX-7227,CDM,S5000,HCPCS,259,RC,77333-0812-25,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SIMETHICONE 80 MG ORAL CHEW,RX-7227,CDM,S5000,HCPCS,259,RC,00904-7206-60,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SIMETHICONE 80 MG ORAL CHEW,RX-7227,CDM,S5000,HCPCS,259,RC,69618-0033-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SIMETHICONE 40 MG/0.6ML ORAL SUSP,RX-7228,CDM,S5000,HCPCS,259,RC,00536-1303-75,NDC,outpatient,0.3,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SIMETHICONE 40 MG/0.6ML ORAL SUSP,RX-7228,CDM,S5000,HCPCS,259,RC,49348-0740-27,NDC,outpatient,0.6,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SIMETHICONE 40 MG/0.6ML ORAL SUSP,RX-7228,CDM,S5000,HCPCS,259,RC,99999-0003-45,NDC,outpatient,0.6,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM ACETATE 2 MEQ/ML IV SOLN,RX-7301,CDM,S5000,HCPCS,250,RC,00409-7299-73,NDC,outpatient,20,ML,14.91,10.437,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM ACETATE 2 MEQ/ML IV SOLN,RX-7301,CDM,S5000,HCPCS,250,RC,00409-7299-83,NDC,outpatient,20,ML,14.91,10.437,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM ACETATE 4 MEQ/ML IV SOLN,RX-7302,CDM,S5000,HCPCS,250,RC,63323-0032-00,NDC,outpatient,100,ML,36.05,25.235,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM ACETATE 4 MEQ/ML IV SOLN,RX-7302,CDM,S5000,HCPCS,250,RC,63323-0032-04,NDC,outpatient,100,ML,36.05,25.235,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM BICARBONATE 4.2 % IV SOLN,RX-7306,CDM,S5000,HCPCS,250,RC,00409-5555-02,NDC,outpatient,5,ML,19.45,13.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM BICARBONATE 4.2 % IV SOLN,RX-7306,CDM,S5000,HCPCS,250,RC,00409-5534-14,NDC,outpatient,10,ML,57.94,40.558,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM BICARBONATE 4.2 % IV SOLN,RX-7306,CDM,S5000,HCPCS,250,RC,00409-5534-24,NDC,outpatient,10,ML,57.94,40.558,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM BICARBONATE 4.2 % IV SOLN,RX-7306,CDM,S5000,HCPCS,250,RC,00409-5555-12,NDC,outpatient,5,ML,19.45,13.615,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM BICARBONATE 4.2 % IV SOLN,RX-7306,CDM,S5000,HCPCS,250,RC,63323-0083-05,NDC,outpatient,5,ML,33.6,23.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM BICARBONATE 7.5 % IV SOLN,RX-7308,CDM,S5000,HCPCS,250,RC,00409-4916-14,NDC,outpatient,50,ML,85.67,59.969,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM BICARBONATE 7.5 % IV SOLN,RX-7308,CDM,S5000,HCPCS,250,RC,00409-4916-24,NDC,outpatient,50,ML,85.67,59.969,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-4900-24,NDC,outpatient,10,ML,71.78,50.246,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-6625-14,NDC,outpatient,50,ML,35.83,25.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-6637-14,NDC,outpatient,50,ML,54.74,38.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-6637-24,NDC,outpatient,50,ML,54.74,38.318,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,51754-5001-04,NDC,outpatient,50,ML,22.7,15.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,63323-0089-50,NDC,outpatient,50,ML,24.7,17.29,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-6625-22,NDC,outpatient,50,ML,35.83,25.081,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,76329-3352-01,NDC,outpatient,50,ML,66.31,46.417,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,00409-4900-14,NDC,outpatient,10,ML,71.78,50.246,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,51754-5001-01,NDC,outpatient,50,ML,22.7,15.89,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM BICARBONATE 8.4 % IV SOLN,RX-7309,CDM,S5000,HCPCS,250,RC,69374-0214-50,NDC,outpatient,50,ML,48.95,34.265,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM BICARBONATE 650 MG ORAL TABS,RX-7313,CDM,S5000,HCPCS,259,RC,66553-0008-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE 3 % IV SOLN,RX-7321,CDM,S5000,HCPCS,250,RC,99999-0004-11,NDC,outpatient,250,ML,21.14,14.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE 3 % IV SOLN,RX-7321,CDM,S5000,HCPCS,250,RC,00338-0054-03,NDC,outpatient,500,ML,26.28,18.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE 4 MEQ/ML IV SOLN,RX-7322,CDM,S5000,HCPCS,250,RC,63323-0095-61,NDC,outpatient,100,ML,55.63,38.941,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE 4 MEQ/ML IV SOLN,RX-7322,CDM,S5000,HCPCS,250,RC,63323-0095-02,NDC,outpatient,100,ML,55.63,38.941,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE 0.9 % IN NEBU,RX-7325,CDM,S5000,HCPCS,259,RC,00487-9301-03,NDC,outpatient,3,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE 0.9 % IN NEBU,RX-7325,CDM,S5000,HCPCS,259,RC,00487-9301-33,NDC,outpatient,3,ML,1.13,0.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE 0.9 % IN NEBU,RX-7325,CDM,S5000,HCPCS,259,RC,76204-0300-03,NDC,outpatient,3,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE 3 % IN NEBU,RX-7327,CDM,S5000,HCPCS,259,RC,50190-0142-63,NDC,outpatient,4,ML,2.6,1.82,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE 3 % IN NEBU,RX-7327,CDM,S5000,HCPCS,259,RC,00487-9003-30,NDC,outpatient,4,ML,2.44,1.708,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE 1 G ORAL TABS,RX-7328,CDM,S5000,HCPCS,259,RC,00223-1760-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE 1 G ORAL TABS,RX-7328,CDM,S5000,HCPCS,259,RC,77333-0835-25,NDC,outpatient,1,UN,1.03,0.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE 1 G ORAL TABS,RX-7328,CDM,S5000,HCPCS,259,RC,77333-0835-10,NDC,outpatient,1,UN,1.03,0.721,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE (HYPERTONIC) 5 % OP OINT,RX-7331,CDM,S5000,HCPCS,259,RC,24208-0385-55,NDC,outpatient,3.5,GR,68.8,48.16,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE (HYPERTONIC) 5 % OP SOLN,RX-7332,CDM,S5000,HCPCS,259,RC,00536-1254-94,NDC,outpatient,15,ML,15.76,11.032,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM HYPOCHLORITE 5 % SOLN,RX-7343,CDM,S5000,HCPCS,259,RC,SH000-4343-01,NDC,outpatient,4000,ML,17.8,12.46,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM POLYSTYRENE SULFONATE ORAL POWD,RX-7356,CDM,S5000,HCPCS,259,RC,11534-0166-15,NDC,outpatient,15,GR,55.61,38.927,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SULFACETAMIDE SODIUM 10 % OP SOLN,RX-7359,CDM,S5000,HCPCS,259,RC,24208-0670-04,NDC,outpatient,15,ML,213.67,149.569,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ATROPINE SULFATE 1 % OP SOLN,RX-736,CDM,S5000,HCPCS,259,RC,60219-1749-03,NDC,outpatient,5,ML,103.02,72.114,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SPIRONOLACTONE 25 MG ORAL TABS,RX-7437,CDM,S5000,HCPCS,259,RC,63629-1061-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SPIRONOLACTONE 25 MG ORAL TABS,RX-7437,CDM,S5000,HCPCS,259,RC,00904-6927-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SPIRONOLACTONE 25 MG ORAL TABS,RX-7437,CDM,S5000,HCPCS,259,RC,51079-0103-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SPIRONOLACTONE 25 MG ORAL TABS,RX-7437,CDM,S5000,HCPCS,259,RC,51079-0103-20,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-24,NDC,outpatient,50,ML,8.74,6.118,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-50,NDC,outpatient,50,ML,8.74,6.118,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,63323-0185-10,NDC,outpatient,10,ML,4.07,2.849,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-17,NDC,outpatient,10,ML,3.6,2.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-25,NDC,outpatient,100,ML,13.88,9.716,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00641-6147-01,NDC,outpatient,10,ML,4.79,3.353,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00641-6147-25,NDC,outpatient,10,ML,4.79,3.353,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-10,NDC,outpatient,10,ML,3.6,2.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00409-4887-99,NDC,outpatient,100,ML,13.88,9.716,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,63323-0185-20,NDC,outpatient,20,ML,7,4.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
STERILE WATER FOR INJECTION IJ SOLN,RX-7484,CDM,S5000,HCPCS,250,RC,00641-6147-10,NDC,outpatient,10,ML,4.22,2.954,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
STERILE WATER FOR IRRIGATION IR SOLN,RX-7485,CDM,S5000,HCPCS,250,RC,00338-0003-47,NDC,outpatient,3000,ML,26.7,18.69,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
STERILE WATER FOR IRRIGATION IR SOLN,RX-7485,CDM,S5000,HCPCS,250,RC,00338-0004-04,NDC,outpatient,1000,ML,8.9,6.23,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
STOMAHESIVE PASTE PSTE,RX-7493,CDM,S5000,HCPCS,259,RC,68455-0106-90,NDC,outpatient,56.7,GR,38.61,27.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SULFADIAZINE 500 MG ORAL TABS,RX-7554,CDM,S5000,HCPCS,259,RC,42806-0757-60,NDC,outpatient,1,UN,65.91,46.137,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN,RX-7556,CDM,S5000,HCPCS,250,RC,70069-0362-10,NDC,outpatient,10,ML,27.51,19.257,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN,RX-7556,CDM,S5000,HCPCS,250,RC,00703-9514-01,NDC,outpatient,10,ML,28.26,19.782,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN,RX-7556,CDM,S5000,HCPCS,250,RC,00703-9514-03,NDC,outpatient,10,ML,28.26,19.782,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN,RX-7556,CDM,S5000,HCPCS,250,RC,70069-0362-01,NDC,outpatient,10,ML,27.51,19.257,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG ORAL TABS,RX-7557,CDM,S5000,HCPCS,259,RC,50268-0728-15,NDC,outpatient,1,UN,1.12,0.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG ORAL TABS,RX-7557,CDM,S5000,HCPCS,259,RC,60687-0603-11,NDC,outpatient,1,UN,1.41,0.987,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG ORAL TABS,RX-7557,CDM,S5000,HCPCS,259,RC,50268-0728-11,NDC,outpatient,1,UN,1.12,0.784,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG ORAL TABS,RX-7557,CDM,S5000,HCPCS,259,RC,60687-0603-65,NDC,outpatient,1,UN,1.41,0.987,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SULFASALAZINE 500 MG ORAL TABS,RX-7562,CDM,S5000,HCPCS,259,RC,59762-5000-05,NDC,outpatient,1,UN,1.02,0.714,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SULFASALAZINE 500 MG ORAL TBEC,RX-7563,CDM,S5000,HCPCS,259,RC,59762-0104-05,NDC,outpatient,1,UN,1.47,1.029,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SULFASALAZINE 500 MG ORAL TBEC,RX-7563,CDM,S5000,HCPCS,259,RC,00013-0102-50,NDC,outpatient,1,UN,8.65,6.055,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VARENICLINE TARTRATE 0.5 MG ORAL TABS,RX-76444,CDM,S5000,HCPCS,259,RC,49884-0155-76,NDC,outpatient,1,UN,6.79,4.753,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VARENICLINE TARTRATE 1 MG ORAL TABS,RX-76445,CDM,S5000,HCPCS,259,RC,60687-0648-11,NDC,outpatient,1,UN,43.68,30.576,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VARENICLINE TARTRATE 1 MG ORAL TABS,RX-76445,CDM,S5000,HCPCS,259,RC,60687-0648-21,NDC,outpatient,1,UN,43.68,30.576,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACETYLCHOLINE CHLORIDE 20 MG IO SOLR,RX-76641,CDM,S5000,HCPCS,259,RC,24208-0539-20,NDC,outpatient,1,UN,349.11,244.377,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DAKINS (1/4 STRENGTH) 0.125 % EX SOLN,RX-76724,CDM,S5000,HCPCS,259,RC,00436-0672-16,NDC,outpatient,473,ML,52.63,36.841,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DAKINS (1/4 STRENGTH) 0.125 % EX SOLN,RX-76724,CDM,S5000,HCPCS,259,RC,39328-0064-12,NDC,outpatient,473,ML,44.21,30.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,00121-4948-15,NDC,outpatient,15,ML,19.43,13.601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,00121-4948-40,NDC,outpatient,15,ML,19.43,13.601,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,00121-0948-16,NDC,outpatient,7.5,ML,2.05,1.435,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,63739-0724-01,NDC,outpatient,15,ML,8.75,6.125,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,63739-0724-50,NDC,outpatient,15,ML,8.75,6.125,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
POTASSIUM CHLORIDE 20 MEQ/15ML (10%) ORAL SOLN,RX-76913,CDM,S5000,HCPCS,259,RC,00121-0948-15,NDC,outpatient,15,ML,3.54,2.478,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VITAMIN D3 25 MCG (1000 UT) ORAL TABS,RX-76997,CDM,S5000,HCPCS,259,RC,20555-0033-00,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TANNIC ACID POWD,RX-7715,CDM,S5000,HCPCS,259,RC,,,outpatient,20,GR,9.26,6.482,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SELENIUM 40 MCG/ML IV SOLN,RX-77308,CDM,S5000,HCPCS,250,RC,69784-0840-01,NDC,outpatient,10,ML,230.25,161.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SELENIUM 40 MCG/ML IV SOLN,RX-77308,CDM,S5000,HCPCS,250,RC,69784-0840-05,NDC,outpatient,10,ML,230.25,161.175,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SITAGLIPTIN PHOSPHATE 25 MG ORAL TABS,RX-77615,CDM,S5000,HCPCS,259,RC,00006-0221-28,NDC,outpatient,1,UN,78.54,54.978,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SITAGLIPTIN PHOSPHATE 25 MG ORAL TABS,RX-77615,CDM,S5000,HCPCS,259,RC,00006-0221-01,NDC,outpatient,1,UN,78.54,54.978,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SITAGLIPTIN PHOSPHATE 100 MG ORAL TABS,RX-77617,CDM,S5000,HCPCS,259,RC,00006-0277-01,NDC,outpatient,1,UN,78.54,54.978,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SITAGLIPTIN PHOSPHATE 100 MG ORAL TABS,RX-77617,CDM,S5000,HCPCS,259,RC,00006-0277-31,NDC,outpatient,1,UN,78.53,54.971,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SITAGLIPTIN PHOSPHATE 100 MG ORAL TABS,RX-77617,CDM,S5000,HCPCS,259,RC,00006-0277-28,NDC,outpatient,1,UN,78.54,54.978,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METOCLOPRAMIDE HCL 10 MG/10ML ORAL SOLN,RX-77710,CDM,S5000,HCPCS,259,RC,00121-1576-10,NDC,outpatient,10,ML,13.35,9.345,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
METOCLOPRAMIDE HCL 10 MG/10ML ORAL SOLN,RX-77710,CDM,S5000,HCPCS,259,RC,99999-0001-27,NDC,outpatient,1,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TETRACAINE HCL 0.5 % OP SOLN,RX-7795,CDM,S5000,HCPCS,259,RC,68682-0920-64,NDC,outpatient,15,ML,325.88,228.116,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TETRACAINE HCL 0.5 % OP SOLN,RX-7795,CDM,S5000,HCPCS,259,RC,00065-0741-14,NDC,outpatient,4,ML,54.08,37.856,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TETRACYCLINE HCL 250 MG ORAL CAPS,RX-7796,CDM,S5000,HCPCS,259,RC,23155-0766-01,NDC,outpatient,1,UN,2.97,2.079,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
THEOPHYLLINE 80 MG/15ML ORAL ELIX,RX-7820,CDM,S5000,HCPCS,259,RC,00121-4820-15,NDC,outpatient,15,ML,35.25,24.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
THEOPHYLLINE 80 MG/15ML ORAL ELIX,RX-7820,CDM,S5000,HCPCS,259,RC,00121-4820-40,NDC,outpatient,15,ML,35.25,24.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
THEOPHYLLINE 80 MG/15ML ORAL ELIX,RX-7820,CDM,S5000,HCPCS,259,RC,60687-0258-44,NDC,outpatient,15,ML,40.12,28.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
THEOPHYLLINE 80 MG/15ML ORAL ELIX,RX-7820,CDM,S5000,HCPCS,259,RC,60687-0258-71,NDC,outpatient,15,ML,40.12,28.084,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
THERA ORAL TABS,RX-7825,CDM,S5000,HCPCS,259,RC,00904-0539-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
THERA-DERM EX LOTN,RX-7831,CDM,S5000,HCPCS,259,RC,00904-4299-09,NDC,outpatient,236,ML,8.41,5.887,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MESALAMINE 1.2 G ORAL TBEC,RX-78310,CDM,S5000,HCPCS,259,RC,00527-3012-48,NDC,outpatient,1,UN,7.61,5.327,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CALAMINE 8-8 % EX LOTN,RX-78879,CDM,S5000,HCPCS,259,RC,49348-0011-34,NDC,outpatient,177,ML,6.31,4.417,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CALAMINE 8-8 % EX LOTN,RX-78879,CDM,S5000,HCPCS,259,RC,00395-0413-96,NDC,outpatient,177,ML,11.82,8.274,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CALAMINE 8-8 % EX LOTN,RX-78879,CDM,S5000,HCPCS,259,RC,00904-2533-21,NDC,outpatient,177,ML,5.52,3.864,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GUAIFENESIN-CODEINE 100-10 MG/5ML ORAL SOLN,RX-79088,CDM,S5000,HCPCS,259,RC,00121-1775-05,NDC,outpatient,5,ML,11.06,7.742,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GUAIFENESIN-CODEINE 100-10 MG/5ML ORAL SOLN,RX-79088,CDM,S5000,HCPCS,259,RC,00121-1775-40,NDC,outpatient,5,ML,11.06,7.742,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GUAIFENESIN-CODEINE 100-10 MG/5ML ORAL SOLN,RX-79088,CDM,S5000,HCPCS,259,RC,99999-0002-04,NDC,outpatient,5,ML,1.78,1.246,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
THYROID 30 MG ORAL TABS,RX-7944,CDM,S5000,HCPCS,259,RC,62559-0741-01,NDC,outpatient,1,UN,2.88,2.016,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TOLNAFTATE 1 % EX CREA,RX-8020,CDM,S5000,HCPCS,259,RC,00904-0722-36,NDC,outpatient,14.18,GR,4.36,3.052,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TOLNAFTATE 1 % EX CREA,RX-8020,CDM,S5000,HCPCS,259,RC,49348-0155-29,NDC,outpatient,15,GR,8.88,6.216,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TOLNAFTATE 1 % EX POWD,RX-8021,CDM,S5000,HCPCS,259,RC,00536-1329-26,NDC,outpatient,45,GR,7.41,5.187,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRAZODONE HCL 150 MG ORAL TABS,RX-8084,CDM,S5000,HCPCS,259,RC,50268-0776-15,NDC,outpatient,1,UN,1.77,1.239,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRAZODONE HCL 150 MG ORAL TABS,RX-8084,CDM,S5000,HCPCS,259,RC,68382-0807-01,NDC,outpatient,1,UN,1.31,0.917,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRAZODONE HCL 150 MG ORAL TABS,RX-8084,CDM,S5000,HCPCS,259,RC,50268-0776-11,NDC,outpatient,1,UN,1.77,1.239,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,42291-0868-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,50111-0560-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,42291-0868-90,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,68382-0805-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,00904-6868-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRAZODONE HCL 50 MG ORAL TABS,RX-8085,CDM,S5000,HCPCS,259,RC,60505-2653-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRIAMCINOLONE ACETONIDE 0.025 % EX CREA,RX-8112,CDM,S5000,HCPCS,259,RC,00168-0003-80,NDC,outpatient,80,GR,21.72,15.204,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRIAMCINOLONE ACETONIDE 0.1 % EX CREA,RX-8113,CDM,S5000,HCPCS,259,RC,45802-0064-36,NDC,outpatient,80,GR,11.04,7.728,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRIAMCINOLONE ACETONIDE 0.1 % EX CREA,RX-8113,CDM,S5000,HCPCS,259,RC,67877-0251-80,NDC,outpatient,80,GR,39.16,27.412,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRIAMCINOLONE ACETONIDE 0.5 % EX CREA,RX-8114,CDM,S5000,HCPCS,259,RC,45802-0065-35,NDC,outpatient,15,GR,20.23,14.161,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRIAMCINOLONE ACETONIDE 0.025 % EX LOTN,RX-8115,CDM,S5000,HCPCS,259,RC,70752-0129-05,NDC,outpatient,60,ML,126.03,88.221,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRIAMCINOLONE ACETONIDE 0.1 % EX LOTN,RX-8116,CDM,S5000,HCPCS,259,RC,60432-0561-61,NDC,outpatient,60,ML,66.75,46.725,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRIAMCINOLONE ACETONIDE 0.1 % EX LOTN,RX-8116,CDM,S5000,HCPCS,259,RC,00713-0676-53,NDC,outpatient,60,ML,73.43,51.401,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRIAMCINOLONE ACETONIDE 0.025 % EX OINT,RX-8117,CDM,S5000,HCPCS,259,RC,00168-0005-80,NDC,outpatient,80,GR,21.01,14.707,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRIAMCINOLONE ACETONIDE 0.1 % EX OINT,RX-8118,CDM,S5000,HCPCS,259,RC,00168-0006-80,NDC,outpatient,80,GR,22.79,15.953,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRIAMCINOLONE ACETONIDE 0.1 % EX OINT,RX-8118,CDM,S5000,HCPCS,259,RC,00713-0228-80,NDC,outpatient,80,GR,37.03,25.921,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRIAMCINOLONE ACETONIDE 0.1 % EX OINT,RX-8118,CDM,S5000,HCPCS,259,RC,45802-0055-36,NDC,outpatient,80,GR,19.58,13.706,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRIAMCINOLONE ACETONIDE 0.1 % EX OINT,RX-8118,CDM,S5000,HCPCS,259,RC,51672-1284-08,NDC,outpatient,80,GR,43.44,30.408,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRIAMCINOLONE ACETONIDE 0.5 % EX OINT,RX-8119,CDM,S5000,HCPCS,259,RC,33342-0332-15,NDC,outpatient,15,GR,28.77,20.139,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRIAMCINOLONE ACETONIDE 0.1 % MT PSTE,RX-8121,CDM,S5000,HCPCS,259,RC,64980-0320-05,NDC,outpatient,5,GR,139.78,97.846,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DIVALPROEX SODIUM ER 500 MG ORAL TB24,RX-81426,CDM,S5000,HCPCS,259,RC,00904-7182-45,NDC,outpatient,1,UN,11.3,7.91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUDESONIDE-FORMOTEROL FUMARATE 80-4.5 MCG/ACT IN AERO,RX-81453,CDM,S5000,HCPCS,259,RC,00310-7372-20,NDC,outpatient,10.2,GR,973.53,681.471,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUDESONIDE-FORMOTEROL FUMARATE 80-4.5 MCG/ACT IN AERO,RX-81453,CDM,S5000,HCPCS,259,RC,00186-0372-28,NDC,outpatient,6.9,GR,250.86,175.602,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUDESONIDE-FORMOTEROL FUMARATE 160-4.5 MCG/ACT IN AERO,RX-81454,CDM,S5000,HCPCS,259,RC,00186-0370-28,NDC,outpatient,6,GR,250.85,175.595,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUDESONIDE-FORMOTEROL FUMARATE 160-4.5 MCG/ACT IN AERO,RX-81454,CDM,S5000,HCPCS,259,RC,00310-7370-20,NDC,outpatient,10.2,GR,1011.48,708.036,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRIFLUOPERAZINE HCL 1 MG ORAL TABS,RX-8161,CDM,S5000,HCPCS,259,RC,00781-8028-01,NDC,outpatient,1,UN,2.52,1.764,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRIFLUOPERAZINE HCL 5 MG ORAL TABS,RX-8164,CDM,S5000,HCPCS,259,RC,00781-8034-01,NDC,outpatient,1,UN,4.68,3.276,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRIHEXYPHENIDYL HCL 2 MG ORAL TABS,RX-8166,CDM,S5000,HCPCS,259,RC,00591-5335-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRIHEXYPHENIDYL HCL 2 MG ORAL TABS,RX-8166,CDM,S5000,HCPCS,259,RC,69452-0241-20,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TRIHEXYPHENIDYL HCL 5 MG ORAL TABS,RX-8167,CDM,S5000,HCPCS,259,RC,70954-0211-10,NDC,outpatient,1,UN,1.15,0.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CEFIXIME 200 MG/5ML ORAL SUSR,RX-81816,CDM,S5000,HCPCS,259,RC,68180-0407-03,NDC,outpatient,6.25,ML,50.07,35.049,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CEFIXIME 200 MG/5ML ORAL SUSR,RX-81816,CDM,S5000,HCPCS,259,RC,99999-0002-91,NDC,outpatient,6.25,ML,120.07,84.049,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GLUCOSE 40 % ORAL GEL,RX-81823,CDM,S5000,HCPCS,259,RC,00574-0070-30,NDC,outpatient,37.5,GR,12.35,8.645,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GLUCOSE 40 % ORAL GEL,RX-81823,CDM,S5000,HCPCS,259,RC,19962-0627-63,NDC,outpatient,31,GR,6.68,4.676,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GLUCOSE 40 % ORAL GEL,RX-81823,CDM,S5000,HCPCS,259,RC,19962-0626-53,NDC,outpatient,31,GR,6.68,4.676,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GLUCOSE 40 % ORAL GEL,RX-81823,CDM,S5000,HCPCS,259,RC,00574-0069-15,NDC,outpatient,37.5,GR,12.35,8.645,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GLUCOSE 40 % ORAL GEL,RX-81823,CDM,S5000,HCPCS,259,RC,00574-0069-30,NDC,outpatient,37.5,GR,12.35,8.645,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE 7 % IN NEBU,RX-82134,CDM,S5000,HCPCS,259,RC,50190-0141-23,NDC,outpatient,4,ML,2.6,1.82,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE 7 % IN NEBU,RX-82134,CDM,S5000,HCPCS,259,RC,83490-0207-60,NDC,outpatient,4,ML,3.01,2.107,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SODIUM CHLORIDE 7 % IN NEBU,RX-82134,CDM,S5000,HCPCS,259,RC,83490-0307-60,NDC,outpatient,4,ML,1.2,0.84,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
THROMBI-GEL 40 EX PADS,RX-82259,CDM,S5000,HCPCS,259,RC,60793-0908-04,NDC,outpatient,1,UN,254.02,177.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TROPICAMIDE 1 % OP SOLN,RX-8250,CDM,S5000,HCPCS,259,RC,70069-0121-01,NDC,outpatient,15,ML,25.3,17.71,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RIVASTIGMINE 4.6 MG/24HR TD PT24,RX-82504,CDM,S5000,HCPCS,259,RC,00078-0501-15,NDC,outpatient,1,UN,93.94,65.758,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RIVASTIGMINE 4.6 MG/24HR TD PT24,RX-82504,CDM,S5000,HCPCS,259,RC,00078-0501-61,NDC,outpatient,1,UN,93.94,65.758,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RIVASTIGMINE 9.5 MG/24HR TD PT24,RX-82505,CDM,S5000,HCPCS,259,RC,47781-0305-03,NDC,outpatient,1,UN,24.46,17.122,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RIVASTIGMINE 9.5 MG/24HR TD PT24,RX-82505,CDM,S5000,HCPCS,259,RC,47781-0305-11,NDC,outpatient,1,UN,24.46,17.122,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TUBERCULIN PPD 5 UNIT/0.1ML ID SOLN,RX-8259,CDM,S5000,HCPCS,250,RC,49281-0752-21,NDC,outpatient,0.1,ML,35.98,25.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TUBERCULIN PPD 5 UNIT/0.1ML ID SOLN,RX-8259,CDM,S5000,HCPCS,250,RC,49281-0752-78,NDC,outpatient,0.1,ML,35.98,25.186,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
UNNA-FLEX ELASTIC UNNA BOOT EX MISC,RX-8371,CDM,S5000,HCPCS,250,RC,68455-0107-63,NDC,outpatient,1,UN,44.16,30.912,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VALPROIC ACID 250 MG ORAL CAPS,RX-8429,CDM,S5000,HCPCS,259,RC,00832-0310-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VALPROIC ACID 250 MG ORAL CAPS,RX-8429,CDM,S5000,HCPCS,259,RC,00591-4012-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VALPROIC ACID 250 MG ORAL CAPS,RX-8429,CDM,S5000,HCPCS,259,RC,69452-0150-20,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BACITRA-NEOMYCIN-POLYMYXIN-HC 1 % OP OINT,RX-849,CDM,S5000,HCPCS,259,RC,24208-0785-55,NDC,outpatient,3.5,GR,70.76,49.532,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VERAPAMIL HCL 2.5 MG/ML IV SOLN,RX-8527,CDM,S5000,HCPCS,250,RC,51754-0203-02,NDC,outpatient,2,ML,15.45,10.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VERAPAMIL HCL 2.5 MG/ML IV SOLN,RX-8527,CDM,S5000,HCPCS,250,RC,51754-0203-04,NDC,outpatient,2,ML,15.45,10.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VERAPAMIL HCL 2.5 MG/ML IV SOLN,RX-8527,CDM,S5000,HCPCS,250,RC,70710-1643-07,NDC,outpatient,2,ML,44.5,31.15,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VERAPAMIL HCL 2.5 MG/ML IV SOLN,RX-8527,CDM,S5000,HCPCS,250,RC,51754-0203-01,NDC,outpatient,2,ML,15.45,10.815,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VERAPAMIL HCL 120 MG ORAL TABS,RX-8528,CDM,S5000,HCPCS,259,RC,23155-0486-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VERAPAMIL HCL 40 MG ORAL TABS,RX-8529,CDM,S5000,HCPCS,259,RC,23155-0059-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VERAPAMIL HCL 80 MG ORAL TABS,RX-8530,CDM,S5000,HCPCS,259,RC,23155-0026-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BACITRACIN-NEOMYCIN-POLYMYXIN 400-3.5-5000 EX OINT,RX-854,CDM,S5000,HCPCS,259,RC,49348-0029-72,NDC,outpatient,30,GR,11.49,8.043,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BACITRACIN-NEOMYCIN-POLYMYXIN 400-3.5-5000 EX OINT,RX-854,CDM,S5000,HCPCS,259,RC,70677-0013-01,NDC,outpatient,28.4,GR,10.49,7.343,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BACITRACIN-POLYMYXIN B 500-10000 UNIT/GM EX OINT,RX-855,CDM,S5000,HCPCS,259,RC,00501-3798-05,NDC,outpatient,14.2,GR,20.67,14.469,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BACITRACIN-POLYMYXIN B 500-10000 UNIT/GM OP OINT,RX-856,CDM,S5000,HCPCS,259,RC,24208-0555-55,NDC,outpatient,3.5,GR,22.88,16.016,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BACLOFEN 10 MG ORAL TABS,RX-860,CDM,S5000,HCPCS,259,RC,00904-6475-61,NDC,outpatient,1,UN,1.6,1.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BACLOFEN 10 MG ORAL TABS,RX-860,CDM,S5000,HCPCS,259,RC,00527-1330-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BACLOFEN 10 MG ORAL TABS,RX-860,CDM,S5000,HCPCS,259,RC,63739-0479-10,NDC,outpatient,1,UN,1.74,1.218,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VITAMIN C 250 MG ORAL TABS,RX-8679,CDM,S5000,HCPCS,259,RC,50268-0860-15,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VITAMIN C 250 MG ORAL TABS,RX-8679,CDM,S5000,HCPCS,259,RC,50268-0860-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VITAMIN E 100 UNITS ORAL CAPS,RX-8698,CDM,S5000,HCPCS,259,RC,80681-0134-00,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VITAMIN E 400 UNITS ORAL CAPS,RX-8701,CDM,S5000,HCPCS,259,RC,77333-0951-25,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VITAMIN E 400 UNITS ORAL CAPS,RX-8701,CDM,S5000,HCPCS,259,RC,77333-0951-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VITAMIN E 400 UNITS ORAL CAPS,RX-8701,CDM,S5000,HCPCS,259,RC,00536-1352-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VITAMINS A & D EX OINT,RX-8723,CDM,S5000,HCPCS,259,RC,57896-0110-05,NDC,outpatient,5,GR,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
VITAMINS A & D EX OINT,RX-8723,CDM,S5000,HCPCS,259,RC,57896-0110-14,NDC,outpatient,5,GR,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
WARFARIN SODIUM 2 MG ORAL TABS,RX-8749,CDM,S5000,HCPCS,259,RC,62584-0984-11,NDC,outpatient,1,UN,1.22,0.854,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
WARFARIN SODIUM 2 MG ORAL TABS,RX-8749,CDM,S5000,HCPCS,259,RC,62584-0984-01,NDC,outpatient,1,UN,1.22,0.854,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
WARFARIN SODIUM 2.5 MG ORAL TABS,RX-8750,CDM,S5000,HCPCS,259,RC,00832-1213-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
WARFARIN SODIUM 2.5 MG ORAL TABS,RX-8750,CDM,S5000,HCPCS,259,RC,00832-1213-89,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
WARFARIN SODIUM 2.5 MG ORAL TABS,RX-8750,CDM,S5000,HCPCS,259,RC,68084-0027-01,NDC,outpatient,1,UN,1.29,0.903,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
WARFARIN SODIUM 2.5 MG ORAL TABS,RX-8750,CDM,S5000,HCPCS,259,RC,68084-0027-11,NDC,outpatient,1,UN,1.29,0.903,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
WARFARIN SODIUM 5 MG ORAL TABS,RX-8751,CDM,S5000,HCPCS,259,RC,00832-1216-89,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
WARFARIN SODIUM 5 MG ORAL TABS,RX-8751,CDM,S5000,HCPCS,259,RC,00832-1216-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
WARFARIN SODIUM 7.5 MG ORAL TABS,RX-8752,CDM,S5000,HCPCS,259,RC,00832-1218-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
WARFARIN SODIUM 7.5 MG ORAL TABS,RX-8752,CDM,S5000,HCPCS,259,RC,00832-1218-89,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
THROMBIN 5000 UNITS EX KIT,RX-87798,CDM,S5000,HCPCS,250,RC,60793-0705-05,NDC,outpatient,1,UN,217.65,152.355,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
THROMBIN 5000 UNITS EX KIT,RX-87798,CDM,S5000,HCPCS,250,RC,60793-0205-05,NDC,outpatient,1,UN,228.51,159.957,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CALCIUM GLUCONATE (ANTIDOTE) 2.5 % EX GEL,RX-87801,CDM,S5000,HCPCS,259,RC,35181-7303-32,NDC,outpatient,25,GR,146.52,102.564,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BRIMONIDINE TARTRATE-TIMOLOL 0.2-0.5 % OP SOLN,RX-87834,CDM,S5000,HCPCS,259,RC,82182-0455-05,NDC,outpatient,5,ML,356.54,249.578,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BRIMONIDINE TARTRATE-TIMOLOL 0.2-0.5 % OP SOLN,RX-87834,CDM,S5000,HCPCS,259,RC,00023-9211-05,NDC,outpatient,5,ML,838.92,587.244,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DIAZEPAM 2.5 MG RE GEL,RX-87865,CDM,S5000,HCPCS,259,RC,68682-0650-20,NDC,outpatient,1,UN,430.63,301.441,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DIAZEPAM 10 MG RE GEL,RX-87867,CDM,S5000,HCPCS,259,RC,68682-0652-20,NDC,outpatient,1,UN,622.96,436.072,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DIAZEPAM 20 MG RE GEL,RX-87869,CDM,S5000,HCPCS,259,RC,68682-0655-20,NDC,outpatient,1,UN,601.24,420.868,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,00378-1631-93,NDC,outpatient,2,ML,38.15,26.705,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,62332-0655-01,NDC,outpatient,2,ML,18.21,12.747,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,62332-0655-60,NDC,outpatient,2,ML,18.21,12.747,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,70756-0608-44,NDC,outpatient,2,ML,11.64,8.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,70756-0608-60,NDC,outpatient,2,ML,11.64,8.148,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,00093-4061-06,NDC,outpatient,2,ML,64.19,44.933,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,00093-4061-19,NDC,outpatient,2,ML,64.19,44.933,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,00378-1631-32,NDC,outpatient,2,ML,38.15,26.705,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FORMOTEROL FUMARATE 20 MCG/2ML IN NEBU,RX-88225,CDM,S5000,HCPCS,259,RC,49502-0605-61,NDC,outpatient,2,ML,20.29,14.203,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RALTEGRAVIR POTASSIUM 400 MG ORAL TABS,RX-88608,CDM,S5000,HCPCS,259,RC,00006-0227-61,NDC,outpatient,1,UN,143.66,100.562,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ZINC CHLORIDE 1 MG/ML IV SOLN,RX-8865,CDM,S5000,HCPCS,250,RC,00409-4090-01,NDC,outpatient,10,ML,63.68,44.576,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ZINC CHLORIDE 1 MG/ML IV SOLN,RX-8865,CDM,S5000,HCPCS,250,RC,00409-4090-11,NDC,outpatient,10,ML,63.68,44.576,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAPS,RX-88704,CDM,S5000,HCPCS,259,RC,00004-0802-85,NDC,outpatient,1,UN,57.3,40.11,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAPS,RX-88704,CDM,S5000,HCPCS,259,RC,31722-0630-31,NDC,outpatient,1,UN,3.93,2.751,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OSELTAMIVIR PHOSPHATE 45 MG ORAL CAPS,RX-88705,CDM,S5000,HCPCS,259,RC,00004-0801-85,NDC,outpatient,1,UN,57.3,40.11,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ZINC OXIDE 20 % EX OINT,RX-8874,CDM,S5000,HCPCS,259,RC,00536-1316-98,NDC,outpatient,454,GR,22.23,15.561,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ZINC OXIDE 20 % EX OINT,RX-8874,CDM,S5000,HCPCS,259,RC,75834-0170-01,NDC,outpatient,28.4,GR,13.53,9.471,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ZINC SULFATE 1 MG/ML IV SOLN,RX-8878,CDM,S5000,HCPCS,250,RC,00517-6101-01,NDC,outpatient,10,ML,75.92,53.144,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ZINC SULFATE 1 MG/ML IV SOLN,RX-8878,CDM,S5000,HCPCS,250,RC,00517-6101-25,NDC,outpatient,10,ML,75.92,53.144,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ZINC SULFATE 5 MG/ML IV SOLN,RX-8879,CDM,S5000,HCPCS,250,RC,00517-8005-01,NDC,outpatient,5,ML,189.8,132.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ZINC SULFATE 5 MG/ML IV SOLN,RX-8879,CDM,S5000,HCPCS,250,RC,00517-8005-25,NDC,outpatient,5,ML,189.8,132.86,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ZINC SULFATE 220 (50 ZN) MG ORAL CAPS,RX-8880,CDM,S5000,HCPCS,259,RC,77333-0983-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ZINC SULFATE 220 (50 ZN) MG ORAL CAPS,RX-8880,CDM,S5000,HCPCS,259,RC,77333-0983-25,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SEVELAMER CARBONATE 800 MG ORAL TABS,RX-89201,CDM,S5000,HCPCS,259,RC,00904-6707-82,NDC,outpatient,1,UN,11.14,7.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SEVELAMER CARBONATE 800 MG ORAL TABS,RX-89201,CDM,S5000,HCPCS,259,RC,68094-0034-64,NDC,outpatient,1,UN,6.38,4.466,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SEVELAMER CARBONATE 800 MG ORAL TABS,RX-89201,CDM,S5000,HCPCS,259,RC,68094-0034-59,NDC,outpatient,1,UN,6.38,4.466,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
NEBIVOLOL HCL 5 MG ORAL TABS,RX-89284,CDM,S5000,HCPCS,259,RC,00904-7189-04,NDC,outpatient,1,UN,7.99,5.593,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLOPIDOGREL BISULFATE 300 MG ORAL TABS,RX-89346,CDM,S5000,HCPCS,259,RC,00904-6467-07,NDC,outpatient,1,UN,32.67,22.869,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLOPIDOGREL BISULFATE 300 MG ORAL TABS,RX-89346,CDM,S5000,HCPCS,259,RC,00904-6467-10,NDC,outpatient,1,UN,22.14,15.498,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACEBUTOLOL HCL 200 MG ORAL CAPS,RX-8939,CDM,S5000,HCPCS,259,RC,50268-0050-15,NDC,outpatient,1,UN,5.16,3.612,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACEBUTOLOL HCL 200 MG ORAL CAPS,RX-8939,CDM,S5000,HCPCS,259,RC,50268-0050-11,NDC,outpatient,1,UN,5.16,3.612,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ZINC OXIDE 11.3 % EX CREA,RX-89412,CDM,S5000,HCPCS,259,RC,30103-0040-00,NDC,outpatient,60,GR,12.55,8.785,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ZINC OXIDE 11.3 % EX CREA,RX-89412,CDM,S5000,HCPCS,259,RC,57074-0001-86,NDC,outpatient,60,GR,9.35,6.545,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,00121-1781-00,NDC,outpatient,5,ML,4.72,3.304,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,68094-0231-61,NDC,outpatient,5,ML,2.67,1.869,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,00121-1781-05,NDC,outpatient,5,ML,4.72,3.304,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,68094-0231-62,NDC,outpatient,5,ML,2.76,1.932,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,68094-0231-59,NDC,outpatient,5,ML,2.67,1.869,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACETAMINOPHEN 160 MG/5ML ORAL SUSP,RX-8943,CDM,S5000,HCPCS,259,RC,99999-0004-23,NDC,outpatient,5,ML,2.67,1.869,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ETRAVIRINE 100 MG ORAL TABS,RX-89432,CDM,S5000,HCPCS,259,RC,59676-0570-01,NDC,outpatient,1,UN,53.89,37.723,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ETRAVIRINE 100 MG ORAL TABS,RX-89432,CDM,S5000,HCPCS,259,RC,60219-1721-07,NDC,outpatient,1,UN,36.43,25.501,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACETAMINOPHEN-CODEINE 300-30 MG ORAL TABS,RX-8949,CDM,S5000,HCPCS,259,RC,00406-0484-23,NDC,outpatient,1,UN,1.51,1.057,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACETAMINOPHEN-CODEINE 300-30 MG ORAL TABS,RX-8949,CDM,S5000,HCPCS,259,RC,00406-0484-62,NDC,outpatient,1,UN,1.51,1.057,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
THROMBIN (RECOMBINANT) 5000 UNITS EX SOLR,RX-89570,CDM,S5000,HCPCS,250,RC,00338-0322-01,NDC,outpatient,1,UN,281.38,196.966,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUTALBITAL-APAP-CAFFEINE 50-325-40 MG ORAL TABS,RX-8958,CDM,S5000,HCPCS,259,RC,00904-6938-06,NDC,outpatient,1,UN,4.29,3.003,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUTALBITAL-APAP-CAFFEINE 50-325-40 MG ORAL TABS,RX-8958,CDM,S5000,HCPCS,259,RC,10702-0253-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUTALBITAL-APAP-CAFFEINE 50-325-40 MG ORAL TABS,RX-8958,CDM,S5000,HCPCS,259,RC,60687-0672-11,NDC,outpatient,1,UN,4.66,3.262,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUTALBITAL-APAP-CAFFEINE 50-325-40 MG ORAL TABS,RX-8958,CDM,S5000,HCPCS,259,RC,00527-1695-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUTALBITAL-APAP-CAFFEINE 50-325-40 MG ORAL TABS,RX-8958,CDM,S5000,HCPCS,259,RC,60687-0672-65,NDC,outpatient,1,UN,4.66,3.262,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACETIC ACID 0.25 % IR SOLN,RX-8963,CDM,S5000,HCPCS,250,RC,00338-0656-04,NDC,outpatient,1000,ML,13.35,9.345,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACYCLOVIR 5 % EX CREA,RX-8967,CDM,S5000,HCPCS,259,RC,45802-0044-75,NDC,outpatient,5,GR,210.13,147.091,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACYCLOVIR 5 % EX CREA,RX-8967,CDM,S5000,HCPCS,259,RC,00187-0994-45,NDC,outpatient,5,GR,822.36,575.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACYCLOVIR 200 MG ORAL CAPS,RX-8969,CDM,S5000,HCPCS,259,RC,60505-0042-06,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACYCLOVIR 200 MG ORAL CAPS,RX-8969,CDM,S5000,HCPCS,259,RC,00904-5789-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACYCLOVIR 200 MG/5ML ORAL SUSP,RX-8970,CDM,S5000,HCPCS,259,RC,00472-0082-16,NDC,outpatient,473,ML,1582.85,1107.995,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACYCLOVIR 200 MG/5ML ORAL SUSP,RX-8970,CDM,S5000,HCPCS,259,RC,99999-0004-02,NDC,outpatient,5,ML,4.94,3.458,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACYCLOVIR 200 MG/5ML ORAL SUSP,RX-8970,CDM,S5000,HCPCS,259,RC,31722-0681-47,NDC,outpatient,473,ML,244.17,170.919,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACYCLOVIR 800 MG ORAL TABS,RX-8972,CDM,S5000,HCPCS,259,RC,68084-0109-01,NDC,outpatient,1,UN,3.08,2.156,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ACYCLOVIR 800 MG ORAL TABS,RX-8972,CDM,S5000,HCPCS,259,RC,68084-0109-11,NDC,outpatient,1,UN,3.08,2.156,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,00904-7325-62,NDC,outpatient,30,ML,11.09,7.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,70677-1063-01,NDC,outpatient,10,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,57896-0629-12,NDC,outpatient,10,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,00121-1761-30,NDC,outpatient,30,ML,7.21,5.047,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,00904-7325-73,NDC,outpatient,30,ML,11.09,7.763,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,70677-1063-30,NDC,outpatient,30,ML,1.7,1.19,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML ORAL SUSP,RX-9009,CDM,S5000,HCPCS,259,RC,99999-0002-58,NDC,outpatient,30,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMINOCAPROIC ACID 500 MG ORAL TABS,RX-9063,CDM,S5000,HCPCS,259,RC,69680-0115-30,NDC,outpatient,1,UN,26.56,18.592,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMIODARONE HCL 200 MG ORAL TABS,RX-9066,CDM,S5000,HCPCS,259,RC,00904-6993-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMIODARONE HCL 200 MG ORAL TABS,RX-9066,CDM,S5000,HCPCS,259,RC,00245-0147-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMIODARONE HCL 200 MG ORAL TABS,RX-9066,CDM,S5000,HCPCS,259,RC,00245-0147-89,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMIODARONE HCL 200 MG ORAL TABS,RX-9066,CDM,S5000,HCPCS,259,RC,63739-0051-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMLODIPINE BESYLATE 2.5 MG ORAL TABS,RX-9070,CDM,S5000,HCPCS,259,RC,00904-6369-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMLODIPINE BESYLATE 5 MG ORAL TABS,RX-9071,CDM,S5000,HCPCS,259,RC,00904-6370-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMLODIPINE BESYLATE 5 MG ORAL TABS,RX-9071,CDM,S5000,HCPCS,259,RC,68382-0122-16,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TABS,RX-9081,CDM,S5000,HCPCS,259,RC,42806-0341-01,NDC,outpatient,1,UN,1.52,1.064,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TABS,RX-9081,CDM,S5000,HCPCS,259,RC,64850-0502-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DESVENLAFAXINE SUCCINATE ER 50 MG ORAL TB24,RX-91073,CDM,S5000,HCPCS,259,RC,00591-3659-30,NDC,outpatient,1,UN,2.77,1.939,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DESVENLAFAXINE SUCCINATE ER 50 MG ORAL TB24,RX-91073,CDM,S5000,HCPCS,259,RC,00008-1211-14,NDC,outpatient,1,UN,5.76,4.032,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DESVENLAFAXINE SUCCINATE ER 50 MG ORAL TB24,RX-91073,CDM,S5000,HCPCS,259,RC,51991-0311-90,NDC,outpatient,1,UN,2.38,1.666,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ROPINIROLE HCL ER 2 MG ORAL TB24,RX-92015,CDM,S5000,HCPCS,259,RC,55111-0659-30,NDC,outpatient,1,UN,2.69,1.883,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BENAZEPRIL HCL 10 MG ORAL TABS,RX-9220,CDM,S5000,HCPCS,259,RC,50268-0110-15,NDC,outpatient,1,UN,2.09,1.463,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BENAZEPRIL HCL 10 MG ORAL TABS,RX-9220,CDM,S5000,HCPCS,259,RC,50268-0110-11,NDC,outpatient,1,UN,2.09,1.463,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BETAXOLOL HCL 0.5 % OP SOLN,RX-9268,CDM,S5000,HCPCS,259,RC,61314-0245-01,NDC,outpatient,5,ML,147.74,103.418,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BETAXOLOL HCL 10 MG ORAL TABS,RX-9269,CDM,S5000,HCPCS,259,RC,10135-0623-01,NDC,outpatient,1,UN,2.28,1.596,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BETAXOLOL HCL 10 MG ORAL TABS,RX-9269,CDM,S5000,HCPCS,259,RC,10702-0013-01,NDC,outpatient,1,UN,1.58,1.106,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
MOUTH KOTE MT SOLN,RX-92764,CDM,S5000,HCPCS,259,RC,50930-0098-02,NDC,outpatient,59,ML,21.53,15.071,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BROMOCRIPTINE MESYLATE 2.5 MG ORAL TABS,RX-9297,CDM,S5000,HCPCS,259,RC,00574-0106-03,NDC,outpatient,1,UN,3.28,2.296,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUMETANIDE 0.5 MG ORAL TABS,RX-9309,CDM,S5000,HCPCS,259,RC,50268-0130-15,NDC,outpatient,1,UN,5.55,3.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUMETANIDE 0.5 MG ORAL TABS,RX-9309,CDM,S5000,HCPCS,259,RC,42799-0119-01,NDC,outpatient,1,UN,1.43,1.001,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUMETANIDE 0.5 MG ORAL TABS,RX-9309,CDM,S5000,HCPCS,259,RC,50268-0130-11,NDC,outpatient,1,UN,5.55,3.885,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,00185-0129-05,NDC,outpatient,1,UN,1.38,0.966,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,50268-0131-15,NDC,outpatient,1,UN,3.09,2.163,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,60687-0384-01,NDC,outpatient,1,UN,3.38,2.366,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,69238-1490-01,NDC,outpatient,1,UN,1.61,1.127,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,00185-0129-01,NDC,outpatient,1,UN,1.65,1.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,50268-0131-11,NDC,outpatient,1,UN,3.09,2.163,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUMETANIDE 1 MG ORAL TABS,RX-9310,CDM,S5000,HCPCS,259,RC,60687-0384-11,NDC,outpatient,1,UN,3.38,2.366,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 IJ SOLN,RX-9318,CDM,S5000,HCPCS,250,RC,63323-0463-57,NDC,outpatient,50,ML,49.4,34.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPIVACAINE-EPINEPHRINE 0.5% -1:200000 IJ SOLN,RX-9318,CDM,S5000,HCPCS,250,RC,63323-0463-01,NDC,outpatient,50,ML,49.4,34.58,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPROPION HCL 100 MG ORAL TABS,RX-9321,CDM,S5000,HCPCS,259,RC,00904-6636-61,NDC,outpatient,1,UN,4.6,3.22,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPROPION HCL 75 MG ORAL TABS,RX-9322,CDM,S5000,HCPCS,259,RC,50268-0142-15,NDC,outpatient,1,UN,2.99,2.093,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPROPION HCL 75 MG ORAL TABS,RX-9322,CDM,S5000,HCPCS,259,RC,50268-0142-11,NDC,outpatient,1,UN,2.99,2.093,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPROPION HCL 75 MG ORAL TABS,RX-9322,CDM,S5000,HCPCS,259,RC,60687-0340-11,NDC,outpatient,1,UN,3.85,2.695,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUPROPION HCL 75 MG ORAL TABS,RX-9322,CDM,S5000,HCPCS,259,RC,60687-0340-01,NDC,outpatient,1,UN,3.85,2.695,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUSPIRONE HCL 5 MG ORAL TABS,RX-9324,CDM,S5000,HCPCS,259,RC,00093-0053-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUSPIRONE HCL 5 MG ORAL TABS,RX-9324,CDM,S5000,HCPCS,259,RC,51079-0985-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUSPIRONE HCL 5 MG ORAL TABS,RX-9324,CDM,S5000,HCPCS,259,RC,51079-0985-20,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BUSPIRONE HCL 5 MG ORAL TABS,RX-9324,CDM,S5000,HCPCS,259,RC,00904-7122-61,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CALCITRIOL 0.25 MCG ORAL CAPS,RX-9350,CDM,S5000,HCPCS,259,RC,69452-0207-20,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CALCITRIOL 0.25 MCG ORAL CAPS,RX-9350,CDM,S5000,HCPCS,259,RC,23155-0662-01,NDC,outpatient,1,UN,1.4,0.98,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CALCIUM CARBONATE ANTACID 500 MG ORAL CHEW,RX-9385,CDM,S5000,HCPCS,259,RC,68084-0988-32,NDC,outpatient,1,UN,2.86,2.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CALCIUM CARBONATE ANTACID 500 MG ORAL CHEW,RX-9385,CDM,S5000,HCPCS,259,RC,66553-0004-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CALCIUM CARBONATE ANTACID 500 MG ORAL CHEW,RX-9385,CDM,S5000,HCPCS,259,RC,00904-6412-92,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CALCIUM CARBONATE ANTACID 500 MG ORAL CHEW,RX-9385,CDM,S5000,HCPCS,259,RC,68084-0988-33,NDC,outpatient,1,UN,2.86,2.002,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SORBITOL 70 % SOLN,RX-93927,CDM,S5000,HCPCS,259,RC,46287-0500-30,NDC,outpatient,30,ML,9.48,6.636,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00378-9671-30,NDC,outpatient,3,ML,2.4,1.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00378-9671-60,NDC,outpatient,3,ML,2.4,1.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00487-0201-03,NDC,outpatient,3,ML,1.13,0.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,76204-0600-01,NDC,outpatient,3,ML,1.22,0.854,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00487-0201-01,NDC,outpatient,3,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,47335-0756-48,NDC,outpatient,3,ML,1.42,0.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00378-9671-31,NDC,outpatient,3,ML,2.4,1.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,00378-9671-93,NDC,outpatient,3,ML,2.4,1.68,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN,RX-93931,CDM,S5000,HCPCS,259,RC,47335-0756-49,NDC,outpatient,3,ML,1.42,0.994,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CAPTOPRIL 12.5 MG ORAL TABS,RX-9401,CDM,S5000,HCPCS,259,RC,00904-7105-61,NDC,outpatient,1,UN,6.29,4.403,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CAPTOPRIL 25 MG ORAL TABS,RX-9402,CDM,S5000,HCPCS,259,RC,00904-7106-61,NDC,outpatient,1,UN,5.2,3.64,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CARBIDOPA-LEVODOPA 10-100 MG ORAL TABS,RX-9406,CDM,S5000,HCPCS,259,RC,00093-9701-01,NDC,outpatient,1,UN,1.15,0.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CARBIDOPA-LEVODOPA 25-100 MG ORAL TABS,RX-9407,CDM,S5000,HCPCS,259,RC,00093-9702-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CARBIDOPA-LEVODOPA 25-100 MG ORAL TABS,RX-9407,CDM,S5000,HCPCS,259,RC,60687-0661-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CARBIDOPA-LEVODOPA 25-100 MG ORAL TABS,RX-9407,CDM,S5000,HCPCS,259,RC,60687-0661-11,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN,RX-9413,CDM,S5000,HCPCS,250,RC,00009-0856-05,NDC,outpatient,1,ML,319.49,223.643,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN,RX-9413,CDM,S5000,HCPCS,250,RC,00009-0856-08,NDC,outpatient,1,ML,319.49,223.643,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BENZOCAINE-MENTHOL 15-3.6 MG MT LOZG,RX-94141,CDM,S5000,HCPCS,259,RC,00904-6255-49,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RENO CAPS 1 MG ORAL CAPS,RX-94178,CDM,S5000,HCPCS,259,RC,60258-0162-01,NDC,outpatient,1,UN,2.43,1.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
RENO CAPS 1 MG ORAL CAPS,RX-94178,CDM,S5000,HCPCS,259,RC,63044-0622-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CEFACLOR 250 MG ORAL CAPS,RX-9430,CDM,S5000,HCPCS,259,RC,61442-0171-30,NDC,outpatient,1,UN,8.1,5.67,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CEFADROXIL 500 MG ORAL CAPS,RX-9436,CDM,S5000,HCPCS,259,RC,16714-0388-01,NDC,outpatient,1,UN,1.08,0.756,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CEFADROXIL 500 MG ORAL CAPS,RX-9436,CDM,S5000,HCPCS,259,RC,65862-0085-50,NDC,outpatient,1,UN,2.45,1.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CEFADROXIL 500 MG ORAL CAPS,RX-9436,CDM,S5000,HCPCS,259,RC,68180-0180-01,NDC,outpatient,1,UN,2.36,1.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CEFADROXIL 500 MG ORAL CAPS,RX-9436,CDM,S5000,HCPCS,259,RC,68180-0180-08,NDC,outpatient,1,UN,2.65,1.855,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CEFPODOXIME PROXETIL 200 MG ORAL TABS,RX-9469,CDM,S5000,HCPCS,259,RC,00781-5439-20,NDC,outpatient,1,UN,12.33,8.631,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CEFPODOXIME PROXETIL 200 MG ORAL TABS,RX-9469,CDM,S5000,HCPCS,259,RC,65862-0096-20,NDC,outpatient,1,UN,14.53,10.171,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CEFUROXIME AXETIL 250 MG ORAL TABS,RX-9495,CDM,S5000,HCPCS,259,RC,65862-0699-60,NDC,outpatient,1,UN,2.34,1.638,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CEFUROXIME AXETIL 250 MG ORAL TABS,RX-9495,CDM,S5000,HCPCS,259,RC,16714-0400-02,NDC,outpatient,1,UN,3.64,2.548,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CEFUROXIME AXETIL 250 MG ORAL TABS,RX-9495,CDM,S5000,HCPCS,259,RC,67877-0215-60,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CEPHALEXIN 250 MG ORAL CAPS,RX-9499,CDM,S5000,HCPCS,259,RC,50268-0151-15,NDC,outpatient,1,UN,1.49,1.043,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CEPHALEXIN 250 MG ORAL CAPS,RX-9499,CDM,S5000,HCPCS,259,RC,60687-0152-01,NDC,outpatient,1,UN,1.3,0.91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CEPHALEXIN 250 MG ORAL CAPS,RX-9499,CDM,S5000,HCPCS,259,RC,50268-0151-11,NDC,outpatient,1,UN,1.49,1.043,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CEPHALEXIN 250 MG ORAL CAPS,RX-9499,CDM,S5000,HCPCS,259,RC,60687-0152-11,NDC,outpatient,1,UN,1.3,0.91,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CEPHALEXIN 250 MG ORAL CAPS,RX-9499,CDM,S5000,HCPCS,259,RC,67877-0220-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CHLORHEXIDINE GLUCONATE 0.12 % MT SOLN,RX-9516,CDM,S5000,HCPCS,259,RC,69339-0138-19,NDC,outpatient,15,ML,6.15,4.305,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CHLORHEXIDINE GLUCONATE 0.12 % MT SOLN,RX-9516,CDM,S5000,HCPCS,259,RC,69339-0138-15,NDC,outpatient,15,ML,6.55,4.585,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CHLOROTHIAZIDE 250 MG/5ML ORAL SUSP,RX-9525,CDM,S5000,HCPCS,259,RC,,,outpatient,1,ML,1.39,0.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CHLOROTHIAZIDE 250 MG/5ML ORAL SUSP,RX-9525,CDM,S5000,HCPCS,259,RC,,,outpatient,5,ML,5.99,4.193,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FERROUS SULFATE 75 (15 FE) MG/ML ORAL SOLN,RX-95693,CDM,S5000,HCPCS,259,RC,54838-0011-50,NDC,outpatient,50,ML,14.02,9.814,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
FERROUS SULFATE 75 (15 FE) MG/ML ORAL SOLN,RX-95693,CDM,S5000,HCPCS,259,RC,99999-0003-94,NDC,outpatient,1,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CIPROFLOXACIN HCL 0.3 % OP SOLN,RX-9610,CDM,S5000,HCPCS,259,RC,61314-0656-05,NDC,outpatient,5,ML,15.4,10.78,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CIPROFLOXACIN HCL 0.3 % OP SOLN,RX-9610,CDM,S5000,HCPCS,259,RC,69315-0308-05,NDC,outpatient,5,ML,62.3,43.61,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLARITHROMYCIN 250 MG ORAL TABS,RX-9616,CDM,S5000,HCPCS,259,RC,00527-1931-06,NDC,outpatient,1,UN,1.14,0.798,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLARITHROMYCIN 250 MG ORAL TABS,RX-9616,CDM,S5000,HCPCS,259,RC,65862-0225-60,NDC,outpatient,1,UN,1.39,0.973,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLINDAMYCIN PHOSPHATE 1 % EX GEL,RX-9623,CDM,S5000,HCPCS,259,RC,59762-3743-01,NDC,outpatient,30,GR,208.26,145.782,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLINDAMYCIN PHOSPHATE 1 % EX GEL,RX-9623,CDM,S5000,HCPCS,259,RC,00168-0202-30,NDC,outpatient,30,GR,207.33,145.131,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLOBETASOL PROPIONATE 0.05 % EX CREA,RX-9630,CDM,S5000,HCPCS,259,RC,69238-1532-05,NDC,outpatient,15,GR,19.83,13.881,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLOBETASOL PROPIONATE 0.05 % EX CREA,RX-9630,CDM,S5000,HCPCS,259,RC,51672-1258-02,NDC,outpatient,30,GR,31.11,21.777,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLOBETASOL PROPIONATE 0.05 % EX OINT,RX-9631,CDM,S5000,HCPCS,259,RC,21922-0017-05,NDC,outpatient,30,GR,42.19,29.533,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLOBETASOL PROPIONATE 0.05 % EX OINT,RX-9631,CDM,S5000,HCPCS,259,RC,51672-1259-02,NDC,outpatient,30,GR,43.53,30.471,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLOMIPRAMINE HCL 25 MG ORAL CAPS,RX-9635,CDM,S5000,HCPCS,259,RC,68084-0790-25,NDC,outpatient,1,UN,36.81,25.767,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLOMIPRAMINE HCL 25 MG ORAL CAPS,RX-9635,CDM,S5000,HCPCS,259,RC,68084-0790-95,NDC,outpatient,1,UN,36.81,25.767,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLONAZEPAM 0.5 MG ORAL TABS,RX-9637,CDM,S5000,HCPCS,259,RC,60687-0544-01,NDC,outpatient,1,UN,1.65,1.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLONAZEPAM 0.5 MG ORAL TABS,RX-9637,CDM,S5000,HCPCS,259,RC,60687-0544-11,NDC,outpatient,1,UN,1.65,1.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLONAZEPAM 1 MG ORAL TABS,RX-9638,CDM,S5000,HCPCS,259,RC,43547-0407-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLONAZEPAM 1 MG ORAL TABS,RX-9638,CDM,S5000,HCPCS,259,RC,60687-0555-01,NDC,outpatient,1,UN,1.65,1.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLONAZEPAM 1 MG ORAL TABS,RX-9638,CDM,S5000,HCPCS,259,RC,16729-0137-00,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLONAZEPAM 1 MG ORAL TABS,RX-9638,CDM,S5000,HCPCS,259,RC,60687-0555-11,NDC,outpatient,1,UN,1.65,1.155,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLOTRIMAZOLE 10 MG MT TROC,RX-9644,CDM,S5000,HCPCS,259,RC,00054-4146-22,NDC,outpatient,1,UN,1.41,0.987,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLOTRIMAZOLE 10 MG MT TROC,RX-9644,CDM,S5000,HCPCS,259,RC,00574-0107-70,NDC,outpatient,1,UN,1.34,0.938,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLOZAPINE 100 MG ORAL TABS,RX-9647,CDM,S5000,HCPCS,259,RC,60687-0415-01,NDC,outpatient,1,UN,2.55,1.785,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLOZAPINE 100 MG ORAL TABS,RX-9647,CDM,S5000,HCPCS,259,RC,51079-0922-01,NDC,outpatient,1,UN,4.21,2.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLOZAPINE 100 MG ORAL TABS,RX-9647,CDM,S5000,HCPCS,259,RC,60687-0415-11,NDC,outpatient,1,UN,2.55,1.785,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLOZAPINE 100 MG ORAL TABS,RX-9647,CDM,S5000,HCPCS,259,RC,51079-0922-20,NDC,outpatient,1,UN,4.21,2.947,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLOZAPINE 25 MG ORAL TABS,RX-9648,CDM,S5000,HCPCS,259,RC,51079-0921-01,NDC,outpatient,1,UN,2.14,1.498,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CLOZAPINE 25 MG ORAL TABS,RX-9648,CDM,S5000,HCPCS,259,RC,51079-0921-20,NDC,outpatient,1,UN,2.14,1.498,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
COLLAGENASE 250 UNIT/GM EX OINT,RX-9682,CDM,S5000,HCPCS,259,RC,50484-0010-30,NDC,outpatient,30,GR,1218.46,852.922,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CROMOLYN SODIUM 4 % OP SOLN,RX-9691,CDM,S5000,HCPCS,259,RC,61314-0237-10,NDC,outpatient,10,ML,27.77,19.439,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LACOSAMIDE 50 MG ORAL TABS,RX-96968,CDM,S5000,HCPCS,259,RC,00131-2477-60,NDC,outpatient,1,UN,53.28,37.296,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LACOSAMIDE 50 MG ORAL TABS,RX-96968,CDM,S5000,HCPCS,259,RC,00131-2477-35,NDC,outpatient,1,UN,48.43,33.901,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LACOSAMIDE 50 MG ORAL TABS,RX-96968,CDM,S5000,HCPCS,259,RC,68462-0678-60,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LACOSAMIDE 100 MG ORAL TABS,RX-96969,CDM,S5000,HCPCS,259,RC,00131-2478-60,NDC,outpatient,1,UN,83.29,58.303,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LACOSAMIDE 100 MG ORAL TABS,RX-96969,CDM,S5000,HCPCS,259,RC,51991-0349-06,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LACOSAMIDE 100 MG ORAL TABS,RX-96969,CDM,S5000,HCPCS,259,RC,60687-0687-11,NDC,outpatient,1,UN,5.37,3.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LACOSAMIDE 100 MG ORAL TABS,RX-96969,CDM,S5000,HCPCS,259,RC,31722-0813-60,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LACOSAMIDE 100 MG ORAL TABS,RX-96969,CDM,S5000,HCPCS,259,RC,60687-0687-57,NDC,outpatient,1,UN,5.37,3.759,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CYCLOPENTOLATE HCL 2 % OP SOLN,RX-9700,CDM,S5000,HCPCS,259,RC,00065-0397-02,NDC,outpatient,2,ML,180.67,126.469,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % OP SOLN,RX-9701,CDM,S5000,HCPCS,259,RC,00065-0359-02,NDC,outpatient,2,ML,144.23,100.961,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CYCLOSPORINE 100 MG ORAL CAPS,RX-9706,CDM,S5000,HCPCS,259,RC,00078-0241-15,NDC,outpatient,1,UN,74.28,51.996,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CYCLOSPORINE 100 MG ORAL CAPS,RX-9706,CDM,S5000,HCPCS,259,RC,00078-0241-61,NDC,outpatient,1,UN,74.28,51.996,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CYCLOSPORINE 100 MG ORAL CAPS,RX-9706,CDM,S5000,HCPCS,259,RC,60505-0134-00,NDC,outpatient,1,UN,46.97,32.879,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CYCLOSPORINE 25 MG ORAL CAPS,RX-9707,CDM,S5000,HCPCS,259,RC,00078-0240-61,NDC,outpatient,1,UN,18.61,13.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CYCLOSPORINE 25 MG ORAL CAPS,RX-9707,CDM,S5000,HCPCS,259,RC,68084-0879-95,NDC,outpatient,1,UN,18.44,12.908,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CYCLOSPORINE 25 MG ORAL CAPS,RX-9707,CDM,S5000,HCPCS,259,RC,00078-0240-15,NDC,outpatient,1,UN,18.61,13.027,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
CYCLOSPORINE 25 MG ORAL CAPS,RX-9707,CDM,S5000,HCPCS,259,RC,68084-0879-25,NDC,outpatient,1,UN,18.44,12.908,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DANTROLENE SODIUM 20 MG IV SOLR,RX-9716,CDM,S5000,HCPCS,250,RC,42023-0123-06,NDC,outpatient,1,UN,288.51,201.957,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DANTROLENE SODIUM 25 MG ORAL CAPS,RX-9718,CDM,S5000,HCPCS,259,RC,00904-7211-04,NDC,outpatient,1,UN,4.53,3.171,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DANTROLENE SODIUM 25 MG ORAL CAPS,RX-9718,CDM,S5000,HCPCS,259,RC,00115-4411-01,NDC,outpatient,1,UN,2.65,1.855,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SUMATRIPTAN SUCCINATE 6 MG/0.5ML SC SOLN,RX-97343,CDM,S5000,HCPCS,250,RC,55150-0173-01,NDC,outpatient,0.5,ML,17.69,12.383,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
SUMATRIPTAN SUCCINATE 6 MG/0.5ML SC SOLN,RX-97343,CDM,S5000,HCPCS,250,RC,63323-0273-01,NDC,outpatient,0.5,ML,24.66,17.262,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PROMETHAZINE HCL 6.25 MG/5ML ORAL SOLN,RX-97609,CDM,S5000,HCPCS,259,RC,99999-0002-38,NDC,outpatient,10,ML,1.5,1.05,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PROMETHAZINE HCL 6.25 MG/5ML ORAL SOLN,RX-97609,CDM,S5000,HCPCS,259,RC,60432-0608-16,NDC,outpatient,10,ML,3.48,2.436,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,00121-1276-00,NDC,outpatient,10,ML,7.53,5.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,49348-0861-10,NDC,outpatient,10,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,61787-0513-04,NDC,outpatient,118,ML,17.33,12.131,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,00904-7135-72,NDC,outpatient,10,ML,6.5,4.55,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,49348-0861-34,NDC,outpatient,118,ML,8.93,6.251,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,61787-0513-10,NDC,outpatient,10,ML,1.7,1.19,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,00121-1276-10,NDC,outpatient,10,ML,7.53,5.271,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5ML ORAL LIQD,RX-9774,CDM,S5000,HCPCS,259,RC,99999-0001-87,NDC,outpatient,10,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
TOLVAPTAN 15 MG ORAL TABS,RX-97893,CDM,S5000,HCPCS,259,RC,59148-0020-50,NDC,outpatient,1,UN,1428.57,999.999,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PANCRELIPASE (LIP-PROT-AMYL) 6000-19000 UNITS ORAL CPEP,RX-98034,CDM,S5000,HCPCS,259,RC,00032-0046-70,NDC,outpatient,1,UN,8.55,5.985,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PANCRELIPASE (LIP-PROT-AMYL) 24000-76000 UNITS ORAL CPEP,RX-98036,CDM,S5000,HCPCS,259,RC,00032-1224-01,NDC,outpatient,1,UN,33.86,23.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PANCRELIPASE (LIP-PROT-AMYL) 24000-76000 UNITS ORAL CPEP,RX-98036,CDM,S5000,HCPCS,259,RC,00032-2636-01,NDC,outpatient,1,UN,33.86,23.702,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DEXTROSE-SODIUM CHLORIDE 10-0.45 % IV SOLN,RX-9809,CDM,S5000,HCPCS,250,RC,00264-7622-00,NDC,outpatient,1000,ML,51.6,36.12,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DEXTROSE-SODIUM CHLORIDE 5-0.2 % IV SOLN,RX-9812,CDM,S5000,HCPCS,250,RC,00338-0077-04,NDC,outpatient,1000,ML,26.28,18.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DEXTROSE-SODIUM CHLORIDE 5-0.33 % IV SOLN,RX-9813,CDM,S5000,HCPCS,250,RC,00264-7614-10,NDC,outpatient,500,ML,40.48,28.336,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DEXTROSE-SODIUM CHLORIDE 5-0.45 % IV SOLN,RX-9814,CDM,S5000,HCPCS,250,RC,00338-0085-03,NDC,outpatient,500,ML,23.71,16.597,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DEXTROSE-SODIUM CHLORIDE 5-0.45 % IV SOLN,RX-9814,CDM,S5000,HCPCS,250,RC,00338-0085-04,NDC,outpatient,1000,ML,26.28,18.396,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DRONEDARONE HCL 400 MG ORAL TABS,RX-98329,CDM,S5000,HCPCS,259,RC,00024-4142-60,NDC,outpatient,1,UN,53.6,37.52,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PRASUGREL HCL 5 MG ORAL TABS,RX-98372,CDM,S5000,HCPCS,259,RC,60505-4642-03,NDC,outpatient,1,UN,1.06,0.742,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PRASUGREL HCL 10 MG ORAL TABS,RX-98373,CDM,S5000,HCPCS,259,RC,00378-5186-93,NDC,outpatient,1,UN,4.12,2.884,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PRASUGREL HCL 10 MG ORAL TABS,RX-98373,CDM,S5000,HCPCS,259,RC,65862-0830-30,NDC,outpatient,1,UN,1,0.7,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
PRASUGREL HCL 10 MG ORAL TABS,RX-98373,CDM,S5000,HCPCS,259,RC,65162-0002-03,NDC,outpatient,1,UN,2.9,2.03,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BENZOIN COMPOUND EX TINC,RX-987,CDM,S5000,HCPCS,259,RC,00395-0243-92,NDC,outpatient,1,ML,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DINOPROSTONE 0.5 MG/3GM VA GEL,RX-9874,CDM,S5000,HCPCS,259,RC,00009-3359-01,NDC,outpatient,3,GR,1932.45,1352.715,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BENZONATATE 100 MG ORAL CAPS,RX-988,CDM,S5000,HCPCS,259,RC,00904-7153-61,NDC,outpatient,1,UN,1.32,0.924,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BENZONATATE 100 MG ORAL CAPS,RX-988,CDM,S5000,HCPCS,259,RC,64380-0712-06,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BENZONATATE 100 MG ORAL CAPS,RX-988,CDM,S5000,HCPCS,259,RC,69452-0143-20,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BENZONATATE 100 MG ORAL CAPS,RX-988,CDM,S5000,HCPCS,259,RC,42806-0714-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOXAZOSIN MESYLATE 1 MG ORAL TABS,RX-9894,CDM,S5000,HCPCS,259,RC,68084-0836-25,NDC,outpatient,1,UN,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOXAZOSIN MESYLATE 1 MG ORAL TABS,RX-9894,CDM,S5000,HCPCS,259,RC,00904-5522-61,NDC,outpatient,1,UN,2.36,1.652,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOXAZOSIN MESYLATE 1 MG ORAL TABS,RX-9894,CDM,S5000,HCPCS,259,RC,68084-0836-95,NDC,outpatient,1,UN,3.32,2.324,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOXAZOSIN MESYLATE 4 MG ORAL TABS,RX-9896,CDM,S5000,HCPCS,259,RC,60505-0095-00,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOXAZOSIN MESYLATE 4 MG ORAL TABS,RX-9896,CDM,S5000,HCPCS,259,RC,00904-5524-61,NDC,outpatient,1,UN,2.28,1.596,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOXAZOSIN MESYLATE 4 MG ORAL TABS,RX-9896,CDM,S5000,HCPCS,259,RC,16729-0213-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOXYCYCLINE MONOHYDRATE 25 MG/5ML ORAL SUSR,RX-9902,CDM,S5000,HCPCS,259,RC,99999-0002-89,NDC,outpatient,20,ML,27.06,18.942,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
DOXYCYCLINE MONOHYDRATE 25 MG/5ML ORAL SUSR,RX-9902,CDM,S5000,HCPCS,259,RC,68180-0657-01,NDC,outpatient,20,ML,27.06,18.942,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ECONAZOLE NITRATE 1 % EX CREA,RX-9915,CDM,S5000,HCPCS,259,RC,51672-1303-01,NDC,outpatient,15,GR,32.65,22.855,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ENALAPRIL MALEATE 10 MG ORAL TABS,RX-9924,CDM,S5000,HCPCS,259,RC,23155-0772-01,NDC,outpatient,1,UN,1.15,0.805,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ENALAPRIL MALEATE 10 MG ORAL TABS,RX-9924,CDM,S5000,HCPCS,259,RC,43547-0547-10,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ENALAPRIL MALEATE 2.5 MG ORAL TABS,RX-9925,CDM,S5000,HCPCS,259,RC,16714-0442-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ENALAPRILAT 1.25 MG/ML IV INJ,RX-9929,CDM,S5000,HCPCS,250,RC,00143-9786-01,NDC,outpatient,2,ML,34.39,24.073,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ENALAPRILAT 1.25 MG/ML IV INJ,RX-9929,CDM,S5000,HCPCS,250,RC,00143-9786-10,NDC,outpatient,2,ML,34.39,24.073,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OPIUM 10 MG/ML (1%) ORAL TINC,RX-99405,CDM,S5000,HCPCS,259,RC,99999-0002-24,NDC,outpatient,0.6,ML,13.98,9.786,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
OPIUM 10 MG/ML (1%) ORAL TINC,RX-99405,CDM,S5000,HCPCS,259,RC,42799-0217-01,NDC,outpatient,0.6,ML,13.98,9.786,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GLYCERIN (LAXATIVE) 1 G RE SUPP,RX-99417,CDM,S5000,HCPCS,259,RC,58980-0409-12,NDC,outpatient,1,UN,2.17,1.519,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVONORGESTREL 1.5 MG ORAL TABS,RX-99445,CDM,S5000,HCPCS,259,RC,69536-0146-19,NDC,outpatient,1,UN,133.73,93.611,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
LEVONORGESTREL 1.5 MG ORAL TABS,RX-99445,CDM,S5000,HCPCS,259,RC,69536-0162-88,NDC,outpatient,1,UN,133.64,93.548,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ESTROGENS CONJUGATED 0.3 MG ORAL TABS,RX-9973,CDM,S5000,HCPCS,259,RC,00046-1100-81,NDC,outpatient,1,UN,28.4,19.88,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ETHACRYNATE SODIUM 50 MG IV SOLR,RX-9979,CDM,S5000,HCPCS,250,RC,42023-0157-01,NDC,outpatient,1,UN,1563.3,1094.31,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ETHACRYNATE SODIUM 50 MG IV SOLR,RX-9979,CDM,S5000,HCPCS,250,RC,67457-0297-50,NDC,outpatient,1,UN,2098.98,1469.286,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BENZTROPINE MESYLATE 0.5 MG ORAL TABS,RX-998,CDM,S5000,HCPCS,259,RC,68084-0381-01,NDC,outpatient,1,UN,1.82,1.274,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BENZTROPINE MESYLATE 0.5 MG ORAL TABS,RX-998,CDM,S5000,HCPCS,259,RC,68084-0381-11,NDC,outpatient,1,UN,1.82,1.274,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ETHACRYNIC ACID 25 MG ORAL TABS,RX-9980,CDM,S5000,HCPCS,259,RC,69238-1126-01,NDC,outpatient,1,UN,8.7,6.09,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ETHAMBUTOL HCL 400 MG ORAL TABS,RX-9983,CDM,S5000,HCPCS,259,RC,68850-0012-02,NDC,outpatient,1,UN,3.21,2.247,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GUANFACINE HCL ER 1 MG ORAL TB24,RX-99835,CDM,S5000,HCPCS,259,RC,60505-3927-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GUANFACINE HCL ER 1 MG ORAL TB24,RX-99835,CDM,S5000,HCPCS,259,RC,24979-0533-01,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
GUANFACINE HCL ER 2 MG ORAL TB24,RX-99836,CDM,S5000,HCPCS,259,RC,62332-0746-31,NDC,outpatient,1,UN,0.99,0.693,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ETHOSUXIMIDE 250 MG ORAL CAPS,RX-9989,CDM,S5000,HCPCS,259,RC,23155-0532-01,NDC,outpatient,1,UN,5.34,3.738,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ETHOSUXIMIDE 250 MG ORAL CAPS,RX-9989,CDM,S5000,HCPCS,259,RC,64380-0878-06,NDC,outpatient,1,UN,1.63,1.141,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BENZTROPINE MESYLATE 1 MG ORAL TABS,RX-999,CDM,S5000,HCPCS,259,RC,68084-0388-01,NDC,outpatient,1,UN,1.62,1.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
BENZTROPINE MESYLATE 1 MG ORAL TABS,RX-999,CDM,S5000,HCPCS,259,RC,68084-0388-11,NDC,outpatient,1,UN,1.62,1.134,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ETODOLAC 200 MG ORAL CAPS,RX-9997,CDM,S5000,HCPCS,259,RC,60505-0039-01,NDC,outpatient,1,UN,1.83,1.281,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ETODOLAC 200 MG ORAL CAPS,RX-9997,CDM,S5000,HCPCS,259,RC,62559-0250-01,NDC,outpatient,1,UN,1.72,1.204,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
ETODOLAC 300 MG ORAL CAPS,RX-9998,CDM,S5000,HCPCS,259,RC,62559-0251-01,NDC,outpatient,1,UN,2.43,1.701,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,0.222255,85118.57664,other,Non-Reimbursable Procedures,,
HC Crisis Intervention Mental Health Services- per Diem,PX-90000001,CDM,S9485,HCPCS,900,RC,,,outpatient,,,1627,1138.9,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,420.9049,365.2615,1249.536,percent of total billed charges,,,
HC Full Trauma No Notification,PX-45000633,CDM,TR450,LOCAL,450,RC,,,outpatient,,,10370,7259,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,2682.719,399.86,9291.52,percent of total billed charges,,,
HC Partial Trauma No Notification,PX-45000634,CDM,TR450,LOCAL,450,RC,,,outpatient,,,7029,4920.3,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,1818.4023,399.86,9291.52,percent of total billed charges,,,
IOL 16D 5.5X12.5MM PMMA AC CNVXPLN ACRYSOF MTA3U0 -,SUP-MTA3U0.160,CDM,V2630,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,188.690606,129.686915,921.62304,percent of total billed charges,,,
IOL 9.5D 5.5MMX12.5MM AC CNVXPLN -,SUP-MTA3UO.095,CDM,V2630,HCPCS,276,RC,,,outpatient,,,577.67,404.369,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,149.443229,129.686915,921.62304,percent of total billed charges,,,
IOL 10.5D 5.5MMX12.5MM AC CNVXPLN -,SUP-MTA3UO.105,CDM,V2630,HCPCS,276,RC,,,outpatient,,,577.67,404.369,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,149.443229,129.686915,921.62304,percent of total billed charges,,,
IOL 20D 5.5MMX12.5MM AC CNVXPLN -,SUP-MTA3UO.200,CDM,V2630,HCPCS,276,RC,,,outpatient,,,1200.03,840.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,310.447761,129.686915,921.62304,percent of total billed charges,,,
IOL 22D 5.5X13MM AC CNVXPLN -,SUP-MTA4UO.220,CDM,V2630,HCPCS,276,RC,,,outpatient,,,1200.03,840.021,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,310.447761,129.686915,921.62304,percent of total billed charges,,,
IOL 12.5D 5.5MMX13.5MM AC CNVXPLN -,SUP-MTA5U0.125,CDM,V2630,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,188.690606,129.686915,921.62304,percent of total billed charges,,,
IOL 10.5D X 13.5OP AC CNVXPLN -,SUP-MTA5UO.105,CDM,V2630,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,188.690606,129.686915,921.62304,percent of total billed charges,,,
IOL 8.5D PC -,SUP-AR40MN085,CDM,V2632,HCPCS,276,RC,,,outpatient,,,1021.13,714.791,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 23D 6X13MM CLARIFLEX CLRFLXC 3PC PC BICNVX SIL BLU COR -,SUP-CLRFLXC.230,CDM,V2632,HCPCS,276,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 26.5D CLARIFLEX PC -,SUP-CLRFLXC.265,CDM,V2632,HCPCS,276,RC,,,outpatient,,,612.68,428.876,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 16.5D 6X13MM ACRYSF MA60AC 3PC PC BICNVX BLU ACRYLT -,SUP-MA60AC.165,CDM,V2632,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL +1D 6X13MM ACRYSF MA60MA MULPC PC MNSCS BLU ACRYLT -,SUP-MA60MA.010,CDM,V2632,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 3D 6X13MM ACRYSF MA60MA MULPC PC MNSCS BLU ACRYLT -,SUP-MA60MA.030,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL -4D 6X13MM ACRYSF XPD SRS MULPC PC BICNVX BLU ACRYLT -,SUP-MA60MA-4.0,CDM,V2632,HCPCS,276,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
LENS I/O X.010 NEGATIVE D -,SUP-MA60MAN010,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 4D 6X13MM ACRYSF XPD SRS MULPC PC BICNVX BLU ACRYLT -,SUP-MA60MAN040,CDM,V2632,HCPCS,276,RC,,,outpatient,,,729.38,510.566,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
LENS I/O MN60AC X 8.0 -,SUP-MN60AC.080,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 28D 6X13MM ACRYSF MN60AC MULPC PC BICNVX NAT YEL ACRYLT -,SUP-MN60AC.280,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 2.0 DIA 6X13MM ACRYSF XPD SRS MULPC PC MNSCS NAT -,SUP-MN60MA.020,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 3D 6X13MM ACRYSF XPD SRS MULPC PC MNSCS NAT -,SUP-MN60MA.030,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
LENS IOL 5.0D MN60MA 6X13MM ACRYSF MULPC PC MNSCS BLU ACRYLT -,SUP-MN60MA.050,CDM,V2632,HCPCS,276,RC,,,outpatient,,,875.25,612.675,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 9D 6X13MM ACRYSF SA60AT 1-PC PC BICNVX CLR ACRYLT -,SUP-SA60AT.090,CDM,V2632,HCPCS,276,RC,,,outpatient,,,781.89,547.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 30D 6X13MM ACRYSF 1-PC PC BICNVX NAT ANT ASYM -,SUP-SN60AT.300,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 31D 6X13MM 31  ACRYSF SA60AT 1-PC PC BICNVX CLR ACRYLT -,SUP-SN60AT.310,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 34D 6X13MM ACRYSF SA60AT 1-PC PC BICNVX CLR ACRYLT -,SUP-SN60AT.340,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 6.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.065,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 7D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.070,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 9D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.090,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 9.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.095,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 10D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.100,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 10.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.105,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 11D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.110,CDM,V2632,HCPCS,276,RC,,,outpatient,,,781.89,547.323,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 11.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.115,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 12D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.120,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 13D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.130,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 13.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.135,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 14D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.140,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 14.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.145,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 16D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.160,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 16.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.165,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 17D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.170,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 17.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.175,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 18D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.180,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 19D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.190,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 20D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.200,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 21D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.210,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 21.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.215,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 22D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.220,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 22.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.225,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 23D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.230,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 24D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.240,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 24.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.245,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 25D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.250,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 26D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.260,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 26.5D 6X13MM ACRYSF SN60WF 1-PC PC BICNVX NAT ACRYLT -,SUP-SN60WF.265,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 19D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.190,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 20D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.200,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 20.5D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.205,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 21D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.210,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 21.5D 6X13MM ACRYSF RESTOR SN6AD1 1-PC PC SYM BICNVX -,SUP-SN6AD1.215,CDM,V2632,HCPCS,276,RC,,,outpatient,,,4272.73,2990.911,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
LENS I/O MA60MA x 1.0 -,SUP-UNDEFINED,CDM,V2632,HCPCS,276,RC,,,outpatient,,,869.42,608.594,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
IOL 24.5D 6X13MM TECNIS ZA9003 3PC PC BICNVX HYDRPHB ACRL -,SUP-ZA9003.245,CDM,V2632,HCPCS,276,RC,,,outpatient,,,816.9,571.83,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,137.54666,3281.45664,other,Non-Reimbursable Procedures,,
LENS ACRYSOF TORIC IQ  SN6AT3 X 9.5D -,SUP-SN6AT3.095,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,,,
IOL TORIC LENS  SN6AT3  12.0 -,SUP-SN6AT3.120,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,,,
IOL 15.5D 6X13MM ACRYSF SN6AT3 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT3.155,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,,,
IOL 16.0D  6X13MM ACRYSF  SN6AT3 -,SUP-SN6AT3.160,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,,,
IOL 17.0D  6X13MM ACRYSF  SN6AT3 -,SUP-SN6AT3.170,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,,,
IOL 18.0 D 6X13MM ACRYSF SN6AT3 -,SUP-SN6AT3.180,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,,,
IOL 19.5D 6X13MM ACRYSF SN6AT3 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT3.195,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,,,
IOL 24D 6X13MM ACRYSF  SN6 -,SUP-SN6AT3.240,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,,,
IOL 13.5D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.135,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,,,
IOL 19D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.190,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,,,
IOL 19.5D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.195,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,,,
IOL 21D 6X13MM ACRYSF SN6AT4 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT4.210,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,,,
IOL 16D 6X13MM ACRYSF SN6AT5 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT5.160,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,,,
LENS ACRYSOF IQ  SN6AT5.180 -,SUP-SN6AT5.180,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,,,
IOL 21D 6X13MM ACRYSF SN6AT5 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT5.210,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,,,
IOL 23D 6X13MM ACRYSF SN6AT5 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT5.230,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,,,
IOL 11D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT6.110,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,,,
IOL 13.5D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT -,SUP-SN6AT6.135,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,,,
IOL 14D 6X13MM  ACRYSF  SN6AT6 -,SUP-SN6AT6.140,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,,,
IOL LENS SN6AT6 X 18.0 D -,SUP-SN6AT6.180,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,,,
IOL 20D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT6.200,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,,,
IOL 20.5D 6X13MM ACRYSF SN6AT6 1-PC PC SYM BICNVX ACRYLT -,SUP-SN6AT6.205,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2093.7,1465.59,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,541.64019,399.86,2223.8905,percent of total billed charges,,,
IOL TORIC LENS 23.5 DIOPTER -,SUP-SN6AT6.235,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,,,
IOL 22D 6X13MM ACRYSF SN6AT6 1-PC PC BICNVX ACRYLT MTHCRYLT -,SUP-SN6AT6U220,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,,,
IOL 20D 6X13MM  ACRYSF -,SUP-SN6AT7.200,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,,,
IOL 23.5D  6X13MM  ACRYSF   SN6AT7 -,SUP-SN6AT7.235,CDM,V2787,HCPCS,276,RC,,,outpatient,,,2623.75,1836.625,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,25.87,,678.764125,399.86,2223.8905,percent of total billed charges,,,
AMNIOGRAFT AMNIO MEMBR HUM TIS FRZN 3.5X3.5CM SZ-C -,SUP-AG-3535,CDM,V2790,HCPCS,278,RC,,,outpatient,,,4272.73,2990.911,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,3992.7552,other,Non-Reimbursable Procedures,,
GRAFT HUM TIS 3.5X3.5CM SZ-C AMNIOGRFT AMNIO MEMBR 50-100U -,SUP-AG-3535F,CDM,V2790,HCPCS,278,RC,,,outpatient,,,5198.9,3639.23,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],,,,,,399.86,3992.7552,other,Non-Reimbursable Procedures,,
Bilateral procedure,,,,,,,,,,,,,,BLUE CHIP MEDICARE MANAGED CARE [1010303],BLUE CHIP MEDICARE MANAGED CARE [101030301],50,,150,,,,,,150% payment adjustment for the item or service to which the modifier is appended.,,
HC Semi-Private Unit,PX-12100001,CDM,12100001,LOCAL,121,RC,,,inpatient,,,1577,1103.9,CIGNA [1000112],CIGNA [100011201],,,,,,525.9295,1261.6,,,,
HC Med/Surg Stepdown,PX-12100003,CDM,12100003,LOCAL,121,RC,,,inpatient,,,2423,1696.1,CIGNA [1000112],CIGNA [100011201],,,,,,808.0705,1938.4,,,,
HC Maternity Unit,PX-12200001,CDM,12200001,LOCAL,122,RC,,,inpatient,,,2193,1535.1,CIGNA [1000112],CIGNA [100011201],,,,,,731.3655,1754.4,,,,
HC Pediatric Semi-Private Unit,PX-12300001,CDM,12300001,LOCAL,123,RC,,,inpatient,,,3323,2326.1,CIGNA [1000112],CIGNA [100011201],,,,,,1108.2205,2658.4,,,,
HC S.E. Rehab Semi-Private Unit,PX-12800001,CDM,12800001,LOCAL,128,RC,,,inpatient,,,1783,1248.1,CIGNA [1000112],CIGNA [100011201],,,,,,594.6305,2483,,,,
HC Nursery,PX-17000001,CDM,17000001,LOCAL,170,RC,,,inpatient,,,1333,933.1,CIGNA [1000112],CIGNA [100011201],,,,,,444.5555,1066.4,,,,
HC Nursery Boarder,PX-17900001,CDM,17900001,LOCAL,179,RC,,,inpatient,,,1195,836.5,CIGNA [1000112],CIGNA [100011201],,,,,,398.5325,956,,,,
HC Icu/Ccu Unit,PX-20000001,CDM,20000001,LOCAL,200,RC,,,inpatient,,,4009,2806.3,CIGNA [1000112],CIGNA [100011201],,,,,,1337.0015,3207.2,,,,
HC Icu Surgical Unit,PX-20100001,CDM,20100001,LOCAL,201,RC,,,inpatient,,,3646,2552.2,CIGNA [1000112],CIGNA [100011201],,,,,,1215.941,2916.8,,,,
HC Telemetry Unit,PX-20600001,CDM,20600001,LOCAL,206,RC,,,inpatient,,,2015,1410.5,CIGNA [1000112],CIGNA [100011201],,,,,,672.0025,1612,,,,
HC Trauma,PX-20800001,CDM,20800001,LOCAL,208,RC,,,inpatient,,,4810,3367,CIGNA [1000112],CIGNA [100011201],,,,,,1604.135,3848,,,,
HC Onc. Vad Kit,PX-27000020,CDM,27000020,LOCAL,270,RC,,,inpatient,,,90,63,CIGNA [1000112],CIGNA [100011201],,,,,,20.205,72,,,,
HC Imed Pump for Lvl II,PX-27000021,CDM,27000021,LOCAL,270,RC,,,inpatient,,,118,82.6,CIGNA [1000112],CIGNA [100011201],,,,,,26.491,94.4,,,,
HC Imed Pump,PX-27000022,CDM,27000022,LOCAL,270,RC,,,inpatient,,,113,79.1,CIGNA [1000112],CIGNA [100011201],,,,,,25.3685,90.4,,,,
HC Local Anesth Supplies,PX-27000023,CDM,27000023,LOCAL,270,RC,,,inpatient,,,80,56,CIGNA [1000112],CIGNA [100011201],,,,,,17.96,64,,,,
HC Periop O2,PX-27000044,CDM,27000044,LOCAL,270,RC,,,inpatient,,,79,55.3,CIGNA [1000112],CIGNA [100011201],,,,,,17.7355,63.2,,,,
HC Bone Bx Kit,PX-27000050,CDM,27000050,LOCAL,270,RC,,,inpatient,,,267,186.9,CIGNA [1000112],CIGNA [100011201],,,,,,59.9415,213.6,,,,
HC Kit Portex Nerve Block,PX-27000051,CDM,27000051,LOCAL,270,RC,,,inpatient,,,90,63,CIGNA [1000112],CIGNA [100011201],,,,,,20.205,72,,,,
HC Cannister Vac W/O Gel Ats,PX-27000052,CDM,27000052,LOCAL,270,RC,,,inpatient,,,282,197.4,CIGNA [1000112],CIGNA [100011201],,,,,,63.309,225.6,,,,
HC Dressing Kci Small 5/Cs,PX-27000053,CDM,27000053,LOCAL,270,RC,,,inpatient,,,268,187.6,CIGNA [1000112],CIGNA [100011201],,,,,,60.166,214.4,,,,
HC Cannister W/Gel Ats,PX-27000054,CDM,27000054,LOCAL,270,RC,,,inpatient,,,283,198.1,CIGNA [1000112],CIGNA [100011201],,,,,,63.5335,226.4,,,,
HC Compression Stocking A6530,PX-27000055,CDM,27000055,LOCAL,270,RC,,,inpatient,,,285,199.5,CIGNA [1000112],CIGNA [100011201],,,,,,63.9825,228,,,,
HC Custom Molded Insert,PX-27000056,CDM,27000056,LOCAL,270,RC,,,inpatient,,,287,200.9,CIGNA [1000112],CIGNA [100011201],,,,,,64.4315,229.6,,,,
HC Dressing Kci Medium 10/Cs,PX-27000057,CDM,27000057,LOCAL,270,RC,,,inpatient,,,307,214.9,CIGNA [1000112],CIGNA [100011201],,,,,,68.9215,245.6,,,,
HC Surgical Boot/Shoe L3260,PX-27000058,CDM,27000058,LOCAL,270,RC,,,inpatient,,,423,296.1,CIGNA [1000112],CIGNA [100011201],,,,,,94.9635,338.4,,,,
HC Vaccum Assisted Closure Pump,PX-27000059,CDM,27000059,LOCAL,270,RC,,,inpatient,,,438,306.6,CIGNA [1000112],CIGNA [100011201],,,,,,98.331,350.4,,,,
HC Ortho Wedge Shoe,PX-27000060,CDM,27000060,LOCAL,270,RC,,,inpatient,,,529,370.3,CIGNA [1000112],CIGNA [100011201],,,,,,118.7605,423.2,,,,
HC Foot Pressure Support A9283,PX-27000061,CDM,27000061,LOCAL,270,RC,,,inpatient,,,529,370.3,CIGNA [1000112],CIGNA [100011201],,,,,,118.7605,423.2,,,,
HC Sensor Nicom,PX-27000062,CDM,27000062,LOCAL,270,RC,,,inpatient,,,816,571.2,CIGNA [1000112],CIGNA [100011201],,,,,,183.192,652.8,,,,
HC 6 Channel Pneumogram,PX-27000063,CDM,27000063,LOCAL,270,RC,,,inpatient,,,3884,2718.8,CIGNA [1000112],CIGNA [100011201],,,,,,871.958,3107.2,,,,
HC Pneumogram 4-Channel,PX-27000064,CDM,27000064,LOCAL,270,RC,,,inpatient,,,4891,3423.7,CIGNA [1000112],CIGNA [100011201],,,,,,1098.0295,3912.8,,,,
HC Pad Artic Gel Large,PX-27000065,CDM,27000065,LOCAL,270,RC,,,inpatient,,,5242,3669.4,CIGNA [1000112],CIGNA [100011201],,,,,,1176.829,4193.6,,,,
HC Pneumogram 6- Channel,PX-27000066,CDM,27000066,LOCAL,270,RC,,,inpatient,,,5466,3826.2,CIGNA [1000112],CIGNA [100011201],,,,,,1227.117,4372.8,,,,
HC Therapy Polar Cooler,PX-27000068,CDM,27000068,LOCAL,270,RC,,,inpatient,,,667,466.9,CIGNA [1000112],CIGNA [100011201],,,,,,149.7415,533.6,,,,
HC Liner Foam Permanently Med,PX-27000069,CDM,27000069,LOCAL,270,RC,,,inpatient,,,353,247.1,CIGNA [1000112],CIGNA [100011201],,,,,,79.2485,282.4,,,,
HC Dressing Kci Vac Small,PX-27000070,CDM,27000070,LOCAL,270,RC,,,inpatient,,,327,228.9,CIGNA [1000112],CIGNA [100011201],,,,,,73.4115,261.6,,,,
HC Dressing Kci Vac Large,PX-27000071,CDM,27000071,LOCAL,270,RC,,,inpatient,,,390,273,CIGNA [1000112],CIGNA [100011201],,,,,,87.555,312,,,,
HC Developmental Aides,PX-27000072,CDM,27000072,LOCAL,270,RC,,,inpatient,,,707,494.9,CIGNA [1000112],CIGNA [100011201],,,,,,158.7215,565.6,,,,
"HC Ez Reacher 30"" Suction",PX-27100004,CDM,27100004,LOCAL,271,RC,,,inpatient,,,144,100.8,CIGNA [1000112],CIGNA [100011201],,,,,,32.328,122.0544,,,,
HC Support Bra Ez-on Med 958,PX-27100005,CDM,27100005,LOCAL,271,RC,,,inpatient,,,262,183.4,CIGNA [1000112],CIGNA [100011201],,,,,,58.819,222.0712,,,,
HC Support Bra Ez-on Lrg 958,PX-27100006,CDM,27100006,LOCAL,271,RC,,,inpatient,,,272,190.4,CIGNA [1000112],CIGNA [100011201],,,,,,61.064,230.5472,,,,
HC Support Bra Ez-on X-Lrg 958,PX-27100007,CDM,27100007,LOCAL,271,RC,,,inpatient,,,306,214.2,CIGNA [1000112],CIGNA [100011201],,,,,,68.697,259.3656,,,,
HC Support Bra Ez-on Queen,PX-27100008,CDM,27100008,LOCAL,271,RC,,,inpatient,,,377,263.9,CIGNA [1000112],CIGNA [100011201],,,,,,84.6365,319.5452,,,,
HC Bra Ez-on Super Queen,PX-27100009,CDM,27100009,LOCAL,271,RC,,,inpatient,,,471,329.7,CIGNA [1000112],CIGNA [100011201],,,,,,105.7395,399.2196,,,,
HC Gradient Com Stocking,PX-27100010,CDM,27100010,LOCAL,271,RC,,,inpatient,,,490,343,CIGNA [1000112],CIGNA [100011201],,,,,,110.005,415.324,,,,
HC Kit Flexi Seal Fecal,PX-27100011,CDM,27100011,LOCAL,271,RC,,,inpatient,,,939,657.3,CIGNA [1000112],CIGNA [100011201],,,,,,210.8055,795.8964,,,,
HC Port Power Loc Access Kit,PX-27200054,CDM,27200054,LOCAL,272,RC,,,inpatient,,,88,61.6,CIGNA [1000112],CIGNA [100011201],,,,,,19.756,74.5888,,,,
HC Dressing Kci Vac White Lg,PX-27200055,CDM,27200055,LOCAL,272,RC,,,inpatient,,,95,66.5,CIGNA [1000112],CIGNA [100011201],,,,,,21.3275,80.522,,,,
HC Sheath Brite Tip 11cm,PX-27200056,CDM,27200056,LOCAL,272,RC,,,inpatient,,,108,75.6,CIGNA [1000112],CIGNA [100011201],,,,,,24.246,91.5408,,,,
HC Kit Refill Syncromed Sys. Pain,PX-27200057,CDM,27200057,LOCAL,272,RC,,,inpatient,,,128,89.6,CIGNA [1000112],CIGNA [100011201],,,,,,28.736,108.4928,,,,
HC Sock Fracture,PX-27200058,CDM,27200058,LOCAL,272,RC,,,inpatient,,,193,135.1,CIGNA [1000112],CIGNA [100011201],,,,,,43.3285,163.5868,,,,
HC Tube Gastrostomy Replacement,PX-27200059,CDM,27200059,LOCAL,272,RC,,,inpatient,,,195,136.5,CIGNA [1000112],CIGNA [100011201],,,,,,43.7775,165.282,,,,
HC Mod of Depth Shoe,PX-27200060,CDM,27200060,LOCAL,272,RC,,,inpatient,,,225,157.5,CIGNA [1000112],CIGNA [100011201],,,,,,50.5125,190.71,,,,
HC Catheter Broncho 39l,PX-27200061,CDM,27200061,LOCAL,272,RC,,,inpatient,,,349,244.3,CIGNA [1000112],CIGNA [100011201],,,,,,78.3505,295.8124,,,,
HC Catheter Bronch 35 Left 95892,PX-27200062,CDM,27200062,LOCAL,272,RC,,,inpatient,,,349,244.3,CIGNA [1000112],CIGNA [100011201],,,,,,78.3505,295.8124,,,,
HC Endo-Bronch Tube 37fr Left,PX-27200063,CDM,27200063,LOCAL,272,RC,,,inpatient,,,349,244.3,CIGNA [1000112],CIGNA [100011201],,,,,,78.3505,295.8124,,,,
HC Tube Endo Bronch #35 Left,PX-27200064,CDM,27200064,LOCAL,272,RC,,,inpatient,,,349,244.3,CIGNA [1000112],CIGNA [100011201],,,,,,78.3505,295.8124,,,,
HC Endo Bronch Tube #39,PX-27200065,CDM,27200065,LOCAL,272,RC,,,inpatient,,,349,244.3,CIGNA [1000112],CIGNA [100011201],,,,,,78.3505,295.8124,,,,
HC Catheter Broncho 41l,PX-27200066,CDM,27200066,LOCAL,272,RC,,,inpatient,,,349,244.3,CIGNA [1000112],CIGNA [100011201],,,,,,78.3505,295.8124,,,,
HC Kit Arterial Line Arrow,PX-27200067,CDM,27200067,LOCAL,272,RC,,,inpatient,,,349,244.3,CIGNA [1000112],CIGNA [100011201],,,,,,78.3505,295.8124,,,,
HC Cassette Kci Veralink,PX-27200068,CDM,27200068,LOCAL,272,RC,,,inpatient,,,357,249.9,CIGNA [1000112],CIGNA [100011201],,,,,,80.1465,302.5932,,,,
HC Shiley Trach Tube 6lpc,PX-27200069,CDM,27200069,LOCAL,272,RC,,,inpatient,,,357,249.9,CIGNA [1000112],CIGNA [100011201],,,,,,80.1465,302.5932,,,,
HC Tube Trach Shiley 8lpc,PX-27200070,CDM,27200070,LOCAL,272,RC,,,inpatient,,,357,249.9,CIGNA [1000112],CIGNA [100011201],,,,,,80.1465,302.5932,,,,
HC Catheter Single 4fr Bard,PX-27200071,CDM,27200071,LOCAL,272,RC,,,inpatient,,,374,261.8,CIGNA [1000112],CIGNA [100011201],,,,,,83.963,317.0024,,,,
HC Bivona #7 Trach Uncuffed,PX-27200072,CDM,27200072,LOCAL,272,RC,,,inpatient,,,396,277.2,CIGNA [1000112],CIGNA [100011201],,,,,,88.902,335.6496,,,,
HC Retractor C Section Large,PX-27200073,CDM,27200073,LOCAL,272,RC,,,inpatient,,,402,281.4,CIGNA [1000112],CIGNA [100011201],,,,,,90.249,340.7352,,,,
HC Midline 4fr Bd#384308,PX-27200074,CDM,27200074,LOCAL,272,RC,,,inpatient,,,409,286.3,CIGNA [1000112],CIGNA [100011201],,,,,,91.8205,346.6684,,,,
HC Transducer Triple W/Vamp Pls,PX-27200075,CDM,27200075,LOCAL,272,RC,,,inpatient,,,418,292.6,CIGNA [1000112],CIGNA [100011201],,,,,,93.841,354.2968,,,,
HC B Pleurx Drainage Kit,PX-27200076,CDM,27200076,LOCAL,272,RC,,,inpatient,,,417,291.9,CIGNA [1000112],CIGNA [100011201],,,,,,93.6165,353.4492,,,,
HC Catheter Swan Ganz J Pacing,PX-27200078,CDM,27200078,LOCAL,272,RC,,,inpatient,,,446,312.2,CIGNA [1000112],CIGNA [100011201],,,,,,100.127,378.0296,,,,
HC Tube Trach Distal Xlt 5.0,PX-27200079,CDM,27200079,LOCAL,272,RC,,,inpatient,,,451,315.7,CIGNA [1000112],CIGNA [100011201],,,,,,101.2495,382.2676,,,,
HC Tube Trach Distal Xlt 6.0,PX-27200080,CDM,27200080,LOCAL,272,RC,,,inpatient,,,466,326.2,CIGNA [1000112],CIGNA [100011201],,,,,,104.617,394.9816,,,,
HC Tube Trach 8 Cuff Non X Long,PX-27200081,CDM,27200081,LOCAL,272,RC,,,inpatient,,,466,326.2,CIGNA [1000112],CIGNA [100011201],,,,,,104.617,394.9816,,,,
HC Sling Sam Pelvic Medium,PX-27200082,CDM,27200082,LOCAL,272,RC,,,inpatient,,,470,329,CIGNA [1000112],CIGNA [100011201],,,,,,105.515,398.372,,,,
HC Set Tube Kaci Veratrac Duo,PX-27200083,CDM,27200083,LOCAL,272,RC,,,inpatient,,,488,341.6,CIGNA [1000112],CIGNA [100011201],,,,,,109.556,413.6288,,,,
HC Retractor C Section Xlarge,PX-27200084,CDM,27200084,LOCAL,272,RC,,,inpatient,,,516,361.2,CIGNA [1000112],CIGNA [100011201],,,,,,115.842,437.3616,,,,
HC Kit Mini 4fr Single Lumen,PX-27200085,CDM,27200085,LOCAL,272,RC,,,inpatient,,,519,363.3,CIGNA [1000112],CIGNA [100011201],,,,,,116.5155,439.9044,,,,
HC Trach Bivona Tis 6id,PX-27200086,CDM,27200086,LOCAL,272,RC,,,inpatient,,,523,366.1,CIGNA [1000112],CIGNA [100011201],,,,,,117.4135,443.2948,,,,
HC Pack C Section Custom Disp,PX-27200087,CDM,27200087,LOCAL,272,RC,,,inpatient,,,541,378.7,CIGNA [1000112],CIGNA [100011201],,,,,,121.4545,458.5516,,,,
HC Trach Bivona Tts 8mm,PX-27200088,CDM,27200088,LOCAL,272,RC,,,inpatient,,,541,378.7,CIGNA [1000112],CIGNA [100011201],,,,,,121.4545,458.5516,,,,
HC Trach Bivona 7.5 X 10,PX-27200089,CDM,27200089,LOCAL,272,RC,,,inpatient,,,556,389.2,CIGNA [1000112],CIGNA [100011201],,,,,,124.822,471.2656,,,,
HC Tube Feeding Mic Key 14f 1.7,PX-27200091,CDM,27200091,LOCAL,272,RC,,,inpatient,,,674,471.8,CIGNA [1000112],CIGNA [100011201],,,,,,151.313,571.2824,,,,
HC Kit Mic-Key G Feeding 16-3.5,PX-27200092,CDM,27200092,LOCAL,272,RC,,,inpatient,,,694,485.8,CIGNA [1000112],CIGNA [100011201],,,,,,155.803,588.2344,,,,
HC Kit Mic-Key G Feeding 24-3.5,PX-27200093,CDM,27200093,LOCAL,272,RC,,,inpatient,,,694,485.8,CIGNA [1000112],CIGNA [100011201],,,,,,155.803,588.2344,,,,
HC Mic Key G Tube 20fr 3.5cm,PX-27200094,CDM,27200094,LOCAL,272,RC,,,inpatient,,,694,485.8,CIGNA [1000112],CIGNA [100011201],,,,,,155.803,588.2344,,,,
HC Device Support Foot,PX-27200095,CDM,27200095,LOCAL,272,RC,,,inpatient,,,703,492.1,CIGNA [1000112],CIGNA [100011201],,,,,,157.8235,595.8628,,,,
HC Catheter 4 Fr Mid Line,PX-27200096,CDM,27200096,LOCAL,272,RC,,,inpatient,,,719,503.3,CIGNA [1000112],CIGNA [100011201],,,,,,161.4155,609.4244,,,,
HC Tcc Size 3,PX-27200097,CDM,27200097,LOCAL,272,RC,,,inpatient,,,722,505.4,CIGNA [1000112],CIGNA [100011201],,,,,,162.089,611.9672,,,,
HC Femostop Gold Compress Sys,PX-27200098,CDM,27200098,LOCAL,272,RC,,,inpatient,,,731,511.7,CIGNA [1000112],CIGNA [100011201],,,,,,164.1095,619.5956,,,,
HC Dot Poly Midline 4fr Sl Full,PX-27200099,CDM,27200099,LOCAL,272,RC,,,inpatient,,,765,535.5,CIGNA [1000112],CIGNA [100011201],,,,,,171.7425,648.414,,,,
HC Powerwand 5fr 10cm,PX-27200100,CDM,27200100,LOCAL,272,RC,,,inpatient,,,776,543.2,CIGNA [1000112],CIGNA [100011201],,,,,,174.212,657.7376,,,,
HC Powerwand Single Sterile 5fr,PX-27200101,CDM,27200101,LOCAL,272,RC,,,inpatient,,,776,543.2,CIGNA [1000112],CIGNA [100011201],,,,,,174.212,657.7376,,,,
HC Needle Intraosseous Pd 15g,PX-27200102,CDM,27200102,LOCAL,272,RC,,,inpatient,,,845,591.5,CIGNA [1000112],CIGNA [100011201],,,,,,189.7025,716.222,,,,
HC Needle Intraosseous Ad 15g,PX-27200103,CDM,27200103,LOCAL,272,RC,,,inpatient,,,845,591.5,CIGNA [1000112],CIGNA [100011201],,,,,,189.7025,716.222,,,,
HC Needle Intraosseous,PX-27200104,CDM,27200104,LOCAL,272,RC,,,inpatient,,,845,591.5,CIGNA [1000112],CIGNA [100011201],,,,,,189.7025,716.222,,,,
HC Kit Triple Lumen Cath 7 X 6,PX-27200105,CDM,27200105,LOCAL,272,RC,,,inpatient,,,895,626.5,CIGNA [1000112],CIGNA [100011201],,,,,,200.9275,758.602,,,,
HC Multi Lumen Cvc Kit Toh Cust,PX-27200106,CDM,27200106,LOCAL,272,RC,,,inpatient,,,895,626.5,CIGNA [1000112],CIGNA [100011201],,,,,,200.9275,758.602,,,,
HC Pad Zoll Aed Cprd Access Kit,PX-27200107,CDM,27200107,LOCAL,272,RC,,,inpatient,,,827,578.9,CIGNA [1000112],CIGNA [100011201],,,,,,185.6615,700.9652,,,,
HC Kit Flexi Seal Fecal,PX-27200108,CDM,27200108,LOCAL,272,RC,,,inpatient,,,939,657.3,CIGNA [1000112],CIGNA [100011201],,,,,,210.8055,795.8964,,,,
HC Powerwand Quick Kit 5fr,PX-27200109,CDM,27200109,LOCAL,272,RC,,,inpatient,,,979,685.3,CIGNA [1000112],CIGNA [100011201],,,,,,219.7855,829.8004,,,,
HC Mahurkar Dual Lumen Subclav Ca,PX-27200110,CDM,27200110,LOCAL,272,RC,,,inpatient,,,1581,1106.7,CIGNA [1000112],CIGNA [100011201],,,,,,354.9345,1340.0556,,,,
HC Catheter With Curved Extension,PX-27200111,CDM,27200111,LOCAL,272,RC,,,inpatient,,,1581,1106.7,CIGNA [1000112],CIGNA [100011201],,,,,,354.9345,1340.0556,,,,
HC Set Cath Cricothyroidotomy,PX-27200112,CDM,27200112,LOCAL,272,RC,,,inpatient,,,1136,795.2,CIGNA [1000112],CIGNA [100011201],,,,,,255.032,962.8736,,,,
HC Rusch Quick Trac Small 2.0,PX-27200113,CDM,27200113,LOCAL,272,RC,,,inpatient,,,1269,888.3,CIGNA [1000112],CIGNA [100011201],,,,,,284.8905,1075.6044,,,,
HC Set Prism Prewarm M100'2,PX-27200114,CDM,27200114,LOCAL,272,RC,,,inpatient,,,1319,923.3,CIGNA [1000112],CIGNA [100011201],,,,,,296.1155,1117.9844,,,,
HC Set Prismaflex M100's,PX-27200115,CDM,27200115,LOCAL,272,RC,,,inpatient,,,1399,979.3,CIGNA [1000112],CIGNA [100011201],,,,,,314.0755,1185.7924,,,,
HC Bakri Postpartum Balloon,PX-27200116,CDM,27200116,LOCAL,272,RC,,,inpatient,,,1408,985.6,CIGNA [1000112],CIGNA [100011201],,,,,,316.096,1193.4208,,,,
HC Flo Trac Sensor Mhd6,PX-27200117,CDM,27200117,LOCAL,272,RC,,,inpatient,,,2027,1418.9,CIGNA [1000112],CIGNA [100011201],,,,,,455.0615,1718.0852,,,,
HC Pad Universal Artic Gel,PX-27200118,CDM,27200118,LOCAL,272,RC,,,inpatient,,,2219,1553.3,CIGNA [1000112],CIGNA [100011201],,,,,,498.1655,1880.8244,,,,
HC Cath Presep 8.5 Oximetry,PX-27200119,CDM,27200119,LOCAL,272,RC,,,inpatient,,,2602,1821.4,CIGNA [1000112],CIGNA [100011201],,,,,,584.149,2205.4552,,,,
HC Set Cricothyrotomy Cath,PX-27200120,CDM,27200120,LOCAL,272,RC,,,inpatient,,,2943,2060.1,CIGNA [1000112],CIGNA [100011201],,,,,,660.7035,2494.4868,,,,
HC Pad Artic Gel Small,PX-27200121,CDM,27200121,LOCAL,272,RC,,,inpatient,,,5565,3895.5,CIGNA [1000112],CIGNA [100011201],,,,,,1249.3425,4716.894,,,,
HC Pad Gel Artic Medium,PX-27200122,CDM,27200122,LOCAL,272,RC,,,inpatient,,,5512,3858.4,CIGNA [1000112],CIGNA [100011201],,,,,,1237.444,4671.9712,,,,
HC Rhino G2 Blue,PX-27200123,CDM,27200123,LOCAL,272,RC,,,inpatient,,,4120,2884,CIGNA [1000112],CIGNA [100011201],,,,,,924.94,3492.112,,,,
HC Pad Artic Gel Lrg,PX-27200124,CDM,27200124,LOCAL,272,RC,,,inpatient,,,5512,3858.4,CIGNA [1000112],CIGNA [100011201],,,,,,1237.444,4671.9712,,,,
HC Bag External Drainage Collect,PX-27200125,CDM,27200125,LOCAL,272,RC,,,inpatient,,,1349,944.3,CIGNA [1000112],CIGNA [100011201],,,,,,302.8505,1143.4124,,,,
HC Catheter Thoracic 28fr,PX-27200126,CDM,27200126,LOCAL,272,RC,,,inpatient,,,39,27.3,CIGNA [1000112],CIGNA [100011201],,,,,,8.7555,33.0564,,,,
HC Tube Endo Bronch Left 37,PX-27200127,CDM,27200127,LOCAL,272,RC,,,inpatient,,,349,244.3,CIGNA [1000112],CIGNA [100011201],,,,,,78.3505,295.8124,,,,
HC Electrode Temporary Pacing 6,PX-27200128,CDM,27200128,LOCAL,272,RC,,,inpatient,,,1238,866.6,CIGNA [1000112],CIGNA [100011201],,,,,,277.931,1049.3288,,,,
HC Set Pneumothorax,PX-27200129,CDM,27200129,LOCAL,272,RC,,,inpatient,,,1113,779.1,CIGNA [1000112],CIGNA [100011201],,,,,,249.8685,943.3788,,,,
HC System External Drainage III,PX-27200130,CDM,27200130,LOCAL,272,RC,,,inpatient,,,1887,1320.9,CIGNA [1000112],CIGNA [100011201],,,,,,423.6315,1599.4212,,,,
HC Electrode Temporary Pacing 5,PX-27200131,CDM,27200131,LOCAL,272,RC,,,inpatient,,,1097,767.9,CIGNA [1000112],CIGNA [100011201],,,,,,246.2765,929.8172,,,,
HC Tray Tru Close Thoracic Vent,PX-27200132,CDM,27200132,LOCAL,272,RC,,,inpatient,,,1504,1052.8,CIGNA [1000112],CIGNA [100011201],,,,,,337.648,1274.7904,,,,
HC Tube Trach Flex Laser 6.0 Mm,PX-27200133,CDM,27200133,LOCAL,272,RC,,,inpatient,,,319,223.3,CIGNA [1000112],CIGNA [100011201],,,,,,71.6155,270.3844,,,,
HC Pack Cesarean Custom,PX-27200134,CDM,27200134,LOCAL,272,RC,,,inpatient,,,462,323.4,CIGNA [1000112],CIGNA [100011201],,,,,,103.719,391.5912,,,,
HC Hemostat Instat 1gm,PX-27200135,CDM,27200135,LOCAL,272,RC,,,inpatient,,,1077,753.9,CIGNA [1000112],CIGNA [100011201],,,,,,241.7865,912.8652,,,,
HC Tube Trach Distal Xlt 7.0,PX-27200136,CDM,27200136,LOCAL,272,RC,,,inpatient,,,486,340.2,CIGNA [1000112],CIGNA [100011201],,,,,,109.107,411.9336,,,,
HC Surgicel 2 X 14 #1951,PX-27200137,CDM,27200137,LOCAL,272,RC,,,inpatient,,,447,312.9,CIGNA [1000112],CIGNA [100011201],,,,,,100.3515,378.8772,,,,
HC Ligator Saeed Sx Shoot,PX-27200138,CDM,27200138,LOCAL,272,RC,,,inpatient,,,1332,932.4,CIGNA [1000112],CIGNA [100011201],,,,,,299.034,1129.0032,,,,
HC Cath Swan Ganz 7.5 Vip Port,PX-27200139,CDM,27200139,LOCAL,272,RC,,,inpatient,,,297,207.9,CIGNA [1000112],CIGNA [100011201],,,,,,66.6765,251.7372,,,,
HC Cath Multilumen Access,PX-27200140,CDM,27200140,LOCAL,272,RC,,,inpatient,,,537,375.9,CIGNA [1000112],CIGNA [100011201],,,,,,120.5565,455.1612,,,,
HC Trach Bivona Tts 7mm,PX-27200141,CDM,27200141,LOCAL,272,RC,,,inpatient,,,565,395.5,CIGNA [1000112],CIGNA [100011201],,,,,,126.8425,478.894,,,,
HC Kit Pleurx Drainage W Bottle,PX-27200142,CDM,27200142,LOCAL,272,RC,,,inpatient,,,417,291.9,CIGNA [1000112],CIGNA [100011201],,,,,,93.6165,353.4492,,,,
HC Retractor Wound Alexis Lrg,PX-27200143,CDM,27200143,LOCAL,272,RC,,,inpatient,,,412,288.4,CIGNA [1000112],CIGNA [100011201],,,,,,92.494,349.2112,,,,
HC Unit Cold Therapy Deroyal,PX-27200144,CDM,27200144,LOCAL,272,RC,,,inpatient,,,691,483.7,CIGNA [1000112],CIGNA [100011201],,,,,,155.1295,585.6916,,,,
HC Dressing Kci Vac Silver Med,PX-27200145,CDM,27200145,LOCAL,272,RC,,,inpatient,,,506,354.2,CIGNA [1000112],CIGNA [100011201],,,,,,113.597,428.8856,,,,
HC Kit Midline Cath 20ga X 20cm,PX-27200146,CDM,27200146,LOCAL,272,RC,,,inpatient,,,424,296.8,CIGNA [1000112],CIGNA [100011201],,,,,,95.188,359.3824,,,,
HC Cath Mahurkar 3 Lumen 12x20,PX-27200147,CDM,27200147,LOCAL,272,RC,,,inpatient,,,594,415.8,CIGNA [1000112],CIGNA [100011201],,,,,,133.353,503.4744,,,,
HC Retractor Alexis Wound Xlg,PX-27200148,CDM,27200148,LOCAL,272,RC,,,inpatient,,,529,370.3,CIGNA [1000112],CIGNA [100011201],,,,,,118.7605,448.3804,,,,
HC Surgiflo Hemostatic Matrix,PX-27200149,CDM,27200149,LOCAL,272,RC,,,inpatient,,,906,634.2,CIGNA [1000112],CIGNA [100011201],,,,,,203.397,767.9256,,,,
HC Kit Monitoring Press Abviser,PX-27200150,CDM,27200150,LOCAL,272,RC,,,inpatient,,,648,453.6,CIGNA [1000112],CIGNA [100011201],,,,,,145.476,549.2448,,,,
HC Tray Fuhrman Pleural Drain,PX-27200151,CDM,27200151,LOCAL,272,RC,,,inpatient,,,990,693,CIGNA [1000112],CIGNA [100011201],,,,,,222.255,839.124,,,,
HC Kit Cath Triple Lumen 20cm,PX-27200152,CDM,27200152,LOCAL,272,RC,,,inpatient,,,865,605.5,CIGNA [1000112],CIGNA [100011201],,,,,,194.1925,733.174,,,,
HC Dressing Kci Simplace Med,PX-27200153,CDM,27200153,LOCAL,272,RC,,,inpatient,,,433,303.1,CIGNA [1000112],CIGNA [100011201],,,,,,97.2085,367.0108,,,,
HC Tube Non Balloon Replace Peg,PX-27200154,CDM,27200154,LOCAL,272,RC,,,inpatient,,,394,275.8,CIGNA [1000112],CIGNA [100011201],,,,,,88.453,333.9544,,,,
HC Cath 12fr Hp Triple Lumen,PX-27200155,CDM,27200155,LOCAL,272,RC,,,inpatient,,,606,424.2,CIGNA [1000112],CIGNA [100011201],,,,,,136.047,513.6456,,,,
HC Cath Pneumothorax Ak01500,PX-27200156,CDM,27200156,LOCAL,272,RC,,,inpatient,,,700,490,CIGNA [1000112],CIGNA [100011201],,,,,,157.15,593.32,,,,
HC Kit Cranial Access 826614,PX-27200158,CDM,27200158,LOCAL,272,RC,,,inpatient,,,2205,1543.5,CIGNA [1000112],CIGNA [100011201],,,,,,495.0225,1868.958,,,,
"HC Sensor Flotrac W Vamp 60""",PX-27200159,CDM,27200159,LOCAL,272,RC,,,inpatient,,,1336,935.2,CIGNA [1000112],CIGNA [100011201],,,,,,299.932,1132.3936,,,,
HC Trach Lg 4.0 Quick Rusch,PX-27200160,CDM,27200160,LOCAL,272,RC,,,inpatient,,,1094,765.8,CIGNA [1000112],CIGNA [100011201],,,,,,245.603,927.2744,,,,
HC Tray Pericardiocentesis Stra,PX-27200161,CDM,27200161,LOCAL,272,RC,,,inpatient,,,1188,831.6,CIGNA [1000112],CIGNA [100011201],,,,,,266.706,1006.9488,,,,
HC Trocar Endo Ethicon 12 512sd,PX-27200162,CDM,27200162,LOCAL,272,RC,,,inpatient,,,1154,807.8,CIGNA [1000112],CIGNA [100011201],,,,,,259.073,978.1304,,,,
HC Tube Laryngectomy 12mm Metal,PX-27200163,CDM,27200163,LOCAL,272,RC,,,inpatient,,,1154,807.8,CIGNA [1000112],CIGNA [100011201],,,,,,259.073,978.1304,,,,
HC Tray Midline CT 4f 20cm Single,PX-27200164,CDM,27200164,LOCAL,272,RC,,,inpatient,,,785,549.5,CIGNA [1000112],CIGNA [100011201],,,,,,176.2325,665.366,,,,
HC Tray Midline CT 5f 20cm Dual,PX-27200165,CDM,27200165,LOCAL,272,RC,,,inpatient,,,779,545.3,CIGNA [1000112],CIGNA [100011201],,,,,,174.8855,660.2804,,,,
HC Mahurkar Triple Lumen Cath Tray #16,PX-27200166,CDM,27200166,LOCAL,272,RC,,,inpatient,,,1191,833.7,CIGNA [1000112],CIGNA [100011201],,,,,,267.3795,1009.4916,,,,
HC Mahurkar Triple Lumen Cath Tray #20,PX-27200167,CDM,27200167,LOCAL,272,RC,,,inpatient,,,983,688.1,CIGNA [1000112],CIGNA [100011201],,,,,,220.6835,833.1908,,,,
HC Compartment Pressure Monitoring Kit,PX-27200168,CDM,27200168,LOCAL,272,RC,,,inpatient,,,457,319.9,CIGNA [1000112],CIGNA [100011201],,,,,,102.5965,387.3532,,,,
HC Kit Perc Sheath Introducer 8.5,PX-27200169,CDM,27200169,LOCAL,272,RC,,,inpatient,,,471,329.7,CIGNA [1000112],CIGNA [100011201],,,,,,105.7395,399.2196,,,,
HC Cath Arrow Cvc Kit Latex Free,PX-27200170,CDM,27200170,LOCAL,272,RC,,,inpatient,,,465,325.5,CIGNA [1000112],CIGNA [100011201],,,,,,104.3925,394.134,,,,
HC Electrode Temporary Pacing 4,PX-27200171,CDM,27200171,LOCAL,272,RC,,,inpatient,,,823,576.1,CIGNA [1000112],CIGNA [100011201],,,,,,184.7635,697.5748,,,,
HC Catheter Bipolar Pacing 5,PX-27200172,CDM,27200172,LOCAL,272,RC,,,inpatient,,,619,433.3,CIGNA [1000112],CIGNA [100011201],,,,,,138.9655,524.6644,,,,
HC Set Emergency Pneumothorax,PX-27200173,CDM,27200173,LOCAL,272,RC,,,inpatient,,,795,556.5,CIGNA [1000112],CIGNA [100011201],,,,,,178.4775,673.842,,,,
HC Kit Pneumothorax,PX-27200174,CDM,27200174,LOCAL,272,RC,,,inpatient,,,722,505.4,CIGNA [1000112],CIGNA [100011201],,,,,,162.089,611.9672,,,,
HC Impella Purge Cassette,PX-27200175,CDM,27200175,LOCAL,272,RC,,,inpatient,,,245,171.5,CIGNA [1000112],CIGNA [100011201],,,,,,55.0025,207.662,,,,
HC Tray Midline CT 4f 20cm Singl,PX-27200176,CDM,27200176,LOCAL,272,RC,,,inpatient,,,954,667.8,CIGNA [1000112],CIGNA [100011201],,,,,,214.173,808.6104,,,,
HC Tray Midline CT 5f 20cm Dual F,PX-27200177,CDM,27200177,LOCAL,272,RC,,,inpatient,,,1154,807.8,CIGNA [1000112],CIGNA [100011201],,,,,,259.073,978.1304,,,,
HC Kit Microez Mst Nitinol 4.5 7c,PX-27200178,CDM,27200178,LOCAL,272,RC,,,inpatient,,,497,347.9,CIGNA [1000112],CIGNA [100011201],,,,,,111.5765,421.2572,,,,
HC Kit Microez Mst 5f Nsx,PX-27200179,CDM,27200179,LOCAL,272,RC,,,inpatient,,,251,175.7,CIGNA [1000112],CIGNA [100011201],,,,,,56.3495,212.7476,,,,
HC Electrode One Step Cpr Adult,PX-27200180,CDM,27200180,LOCAL,272,RC,,,inpatient,,,408,285.6,CIGNA [1000112],CIGNA [100011201],,,,,,91.596,345.8208,,,,
HC Electrode One Step Pediatric,PX-27200181,CDM,27200181,LOCAL,272,RC,,,inpatient,,,447,312.9,CIGNA [1000112],CIGNA [100011201],,,,,,100.3515,378.8772,,,,
HC Ambu® Ascopetm 4 Broncho Large (5.8/2.8),PX-27200196,CDM,27200196,LOCAL,272,RC,,,inpatient,,,359,251.3,CIGNA [1000112],CIGNA [100011201],,,,,,80.5955,304.2884,,,,
HC Ambu® Ascopetm 4 Broncho Regular (5.0/2.2),PX-27200197,CDM,27200197,LOCAL,272,RC,,,inpatient,,,312,218.4,CIGNA [1000112],CIGNA [100011201],,,,,,70.044,264.4512,,,,
HC Ambu® Ascopetm 4 Broncho Slim (3.8/1.2),PX-27200198,CDM,27200198,LOCAL,272,RC,,,inpatient,,,312,218.4,CIGNA [1000112],CIGNA [100011201],,,,,,70.044,264.4512,,,,
HC Tray Pneumothorax Turkel 9 Cm Sys,PX-27200199,CDM,27200199,LOCAL,272,RC,,,inpatient,,,622,435.4,CIGNA [1000112],CIGNA [100011201],,,,,,139.639,527.2072,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400003,CDM,27400003,LOCAL,274,RC,,,inpatient,,,552,386.4,CIGNA [1000112],CIGNA [100011201],,,,,,123.924,467.8752,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400005,CDM,27400005,LOCAL,274,RC,,,inpatient,,,1221,854.7,CIGNA [1000112],CIGNA [100011201],,,,,,274.1145,1034.9196,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400008,CDM,27400008,LOCAL,274,RC,,,inpatient,,,3772,2640.4,CIGNA [1000112],CIGNA [100011201],,,,,,846.814,3197.1472,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400012,CDM,27400012,LOCAL,274,RC,,,inpatient,,,1954,1367.8,CIGNA [1000112],CIGNA [100011201],,,,,,438.673,1656.2104,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400015,CDM,27400015,LOCAL,274,RC,,,inpatient,,,3806,2664.2,CIGNA [1000112],CIGNA [100011201],,,,,,854.447,3225.9656,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400030,CDM,27400030,LOCAL,274,RC,,,inpatient,,,661,462.7,CIGNA [1000112],CIGNA [100011201],,,,,,148.3945,560.2636,,,,
HC Brace Knee Enhanced Trom,PX-27400038,CDM,27400038,LOCAL,274,RC,,,inpatient,,,570,399,CIGNA [1000112],CIGNA [100011201],,,,,,127.965,483.132,,,,
HC Brace Enhanced Trom Donjoy,PX-27400039,CDM,27400039,LOCAL,274,RC,,,inpatient,,,570,399,CIGNA [1000112],CIGNA [100011201],,,,,,127.965,483.132,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400047,CDM,27400047,LOCAL,274,RC,,,inpatient,,,3385,2369.5,CIGNA [1000112],CIGNA [100011201],,,,,,759.9325,2869.126,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400050,CDM,27400050,LOCAL,274,RC,,,inpatient,,,3185,2229.5,CIGNA [1000112],CIGNA [100011201],,,,,,715.0325,2699.606,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400107,CDM,27400107,LOCAL,274,RC,,,inpatient,,,380,266,CIGNA [1000112],CIGNA [100011201],,,,,,85.31,322.088,,,,
HC Medical/Surgical Supplies: Prosthetic/Orthotic Devices,PX-27400117,CDM,27400117,LOCAL,274,RC,,,inpatient,,,779,545.3,CIGNA [1000112],CIGNA [100011201],,,,,,174.8855,660.2804,,,,
HC Add. to Lower Extremity L2210,PX-27400184,CDM,27400184,LOCAL,274,RC,,,inpatient,,,330,231,CIGNA [1000112],CIGNA [100011201],,,,,,74.085,279.708,,,,
HC Lift Elevation Heel & Sole,PX-27400185,CDM,27400185,LOCAL,274,RC,,,inpatient,,,382,267.4,CIGNA [1000112],CIGNA [100011201],,,,,,85.759,323.7832,,,,
HC Add. Lower Extremity Orthosis,PX-27400186,CDM,27400186,LOCAL,274,RC,,,inpatient,,,448,313.6,CIGNA [1000112],CIGNA [100011201],,,,,,100.576,379.7248,,,,
HC Depth Shoe A5500,PX-27400187,CDM,27400187,LOCAL,274,RC,,,inpatient,,,473,331.1,CIGNA [1000112],CIGNA [100011201],,,,,,106.1885,400.9148,,,,
HC Compression Stocking A6533,PX-27400188,CDM,27400188,LOCAL,274,RC,,,inpatient,,,502,351.4,CIGNA [1000112],CIGNA [100011201],,,,,,112.699,425.4952,,,,
HC Collar L0172,PX-27400189,CDM,27400189,LOCAL,274,RC,,,inpatient,,,658,460.6,CIGNA [1000112],CIGNA [100011201],,,,,,147.721,557.7208,,,,
HC Ko Elastic Knee Joint L1820,PX-27400190,CDM,27400190,LOCAL,274,RC,,,inpatient,,,661,462.7,CIGNA [1000112],CIGNA [100011201],,,,,,148.3945,560.2636,,,,
HC Procedure Ortho Shoe/L3649,PX-27400191,CDM,27400191,LOCAL,274,RC,,,inpatient,,,703,492.1,CIGNA [1000112],CIGNA [100011201],,,,,,157.8235,595.8628,,,,
HC Air Cast Boot L4386,PX-27400192,CDM,27400192,LOCAL,274,RC,,,inpatient,,,745,521.5,CIGNA [1000112],CIGNA [100011201],,,,,,167.2525,631.462,,,,
HC Static Afa L4396,PX-27400193,CDM,27400193,LOCAL,274,RC,,,inpatient,,,785,549.5,CIGNA [1000112],CIGNA [100011201],,,,,,176.2325,665.366,,,,
HC Brace Tlso,PX-27400194,CDM,27400194,LOCAL,274,RC,,,inpatient,,,901,630.7,CIGNA [1000112],CIGNA [100011201],,,,,,202.2745,763.6876,,,,
HC Lumbar Corsette L0450,PX-27400195,CDM,27400195,LOCAL,274,RC,,,inpatient,,,915,640.5,CIGNA [1000112],CIGNA [100011201],,,,,,205.4175,775.554,,,,
HC Brace Warm and Form,PX-27400196,CDM,27400196,LOCAL,274,RC,,,inpatient,,,1117,781.9,CIGNA [1000112],CIGNA [100011201],,,,,,250.7665,946.7692,,,,
HC Afo L1940,PX-27400197,CDM,27400197,LOCAL,274,RC,,,inpatient,,,2560,1792,CIGNA [1000112],CIGNA [100011201],,,,,,574.72,2169.856,,,,
HC Ankle Foot Orthosis L1940,PX-27400198,CDM,27400198,LOCAL,274,RC,,,inpatient,,,2560,1792,CIGNA [1000112],CIGNA [100011201],,,,,,574.72,2169.856,,,,
HC POS OP Knee Brace L1832,PX-27400199,CDM,27400199,LOCAL,274,RC,,,inpatient,,,2974,2081.8,CIGNA [1000112],CIGNA [100011201],,,,,,667.663,2520.7624,,,,
HC Afo Plastic L1960,PX-27400200,CDM,27400200,LOCAL,274,RC,,,inpatient,,,3011,2107.7,CIGNA [1000112],CIGNA [100011201],,,,,,675.9695,2552.1236,,,,
HC Ankle/Foot Orthosis Afo,PX-27400201,CDM,27400201,LOCAL,274,RC,,,inpatient,,,3011,2107.7,CIGNA [1000112],CIGNA [100011201],,,,,,675.9695,2552.1236,,,,
HC Left Afo Brace/Atlantic Pros,PX-27400202,CDM,27400202,LOCAL,274,RC,,,inpatient,,,3165,2215.5,CIGNA [1000112],CIGNA [100011201],,,,,,710.5425,2682.654,,,,
HC Afo L1932,PX-27400203,CDM,27400203,LOCAL,274,RC,,,inpatient,,,3418,2392.6,CIGNA [1000112],CIGNA [100011201],,,,,,767.341,2897.0968,,,,
HC Ankle Foot Orthosis L1970,PX-27400204,CDM,27400204,LOCAL,274,RC,,,inpatient,,,3462,2423.4,CIGNA [1000112],CIGNA [100011201],,,,,,777.219,2934.3912,,,,
HC Back Brace Tlso Lo486,PX-27400205,CDM,27400205,LOCAL,274,RC,,,inpatient,,,6597,4617.9,CIGNA [1000112],CIGNA [100011201],,,,,,1481.0265,5591.6172,,,,
HC Cervical Collar L0172,PX-27400206,CDM,27400206,LOCAL,274,RC,,,inpatient,,,658,460.6,CIGNA [1000112],CIGNA [100011201],,,,,,147.721,557.7208,,,,
HC Philly Collar No Extension,PX-27400207,CDM,27400207,LOCAL,274,RC,,,inpatient,,,658,460.6,CIGNA [1000112],CIGNA [100011201],,,,,,147.721,557.7208,,,,
HC Cervical Collar 2/Piece L0174,PX-27400208,CDM,27400208,LOCAL,274,RC,,,inpatient,,,1232,862.4,CIGNA [1000112],CIGNA [100011201],,,,,,276.584,1044.2432,,,,
HC Lumbar Orthosis L0627,PX-27400209,CDM,27400209,LOCAL,274,RC,,,inpatient,,,1750,1225,CIGNA [1000112],CIGNA [100011201],,,,,,392.875,1483.3,,,,
HC Lso Sagoro Rigid Frame L0631,PX-27400210,CDM,27400210,LOCAL,274,RC,,,inpatient,,,3933,2753.1,CIGNA [1000112],CIGNA [100011201],,,,,,882.9585,3333.6108,,,,
HC Lso Sagittal Coronal L0637,PX-27400211,CDM,27400211,LOCAL,274,RC,,,inpatient,,,4114,2879.8,CIGNA [1000112],CIGNA [100011201],,,,,,923.593,3487.0264,,,,
HC Hip Abduction Orthosis L1686,PX-27400212,CDM,27400212,LOCAL,274,RC,,,inpatient,,,4461,3122.7,CIGNA [1000112],CIGNA [100011201],,,,,,1001.4945,3781.1436,,,,
HC Knee Orthosis L1830,PX-27400213,CDM,27400213,LOCAL,274,RC,,,inpatient,,,466,326.2,CIGNA [1000112],CIGNA [100011201],,,,,,104.617,394.9816,,,,
HC Knee Orthosis L1832,PX-27400214,CDM,27400214,LOCAL,274,RC,,,inpatient,,,2974,2081.8,CIGNA [1000112],CIGNA [100011201],,,,,,667.663,2520.7624,,,,
HC Knee Orthosis L1832,PX-27400215,CDM,27400215,LOCAL,274,RC,,,inpatient,,,2974,2081.8,CIGNA [1000112],CIGNA [100011201],,,,,,667.663,2520.7624,,,,
HC Knee Osthosis L1832,PX-27400216,CDM,27400216,LOCAL,274,RC,,,inpatient,,,2974,2081.8,CIGNA [1000112],CIGNA [100011201],,,,,,667.663,2520.7624,,,,
HC Afo L1930,PX-27400217,CDM,27400217,LOCAL,274,RC,,,inpatient,,,1062,743.4,CIGNA [1000112],CIGNA [100011201],,,,,,238.419,900.1512,,,,
HC Adj. Dorsal Splint L1930,PX-27400218,CDM,27400218,LOCAL,274,RC,,,inpatient,,,1062,743.4,CIGNA [1000112],CIGNA [100011201],,,,,,238.419,900.1512,,,,
HC L'nard Boot L1930,PX-27400219,CDM,27400219,LOCAL,274,RC,,,inpatient,,,1062,743.4,CIGNA [1000112],CIGNA [100011201],,,,,,238.419,900.1512,,,,
HC Hip Adj Ext L2624,PX-27400220,CDM,27400220,LOCAL,274,RC,,,inpatient,,,1445,1011.5,CIGNA [1000112],CIGNA [100011201],,,,,,324.4025,1224.782,,,,
HC Bk Soft Interface L2820,PX-27400221,CDM,27400221,LOCAL,274,RC,,,inpatient,,,448,313.6,CIGNA [1000112],CIGNA [100011201],,,,,,100.576,379.7248,,,,
HC Lift Elevation L3332,PX-27400222,CDM,27400222,LOCAL,274,RC,,,inpatient,,,347,242.9,CIGNA [1000112],CIGNA [100011201],,,,,,77.9015,294.1172,,,,
HC Wrist Hand/Finger Ortho L3807,PX-27400223,CDM,27400223,LOCAL,274,RC,,,inpatient,,,1065,745.5,CIGNA [1000112],CIGNA [100011201],,,,,,239.0925,902.694,,,,
HC Wrist Cockup Nonmolded L3908,PX-27400224,CDM,27400224,LOCAL,274,RC,,,inpatient,,,353,247.1,CIGNA [1000112],CIGNA [100011201],,,,,,79.2485,299.2028,,,,
HC Orthosis Upper Limb Hum. Frac,PX-27400225,CDM,27400225,LOCAL,274,RC,,,inpatient,,,1413,989.1,CIGNA [1000112],CIGNA [100011201],,,,,,317.2185,1197.6588,,,,
HC Walking Boot L4360,PX-27400226,CDM,27400226,LOCAL,274,RC,,,inpatient,,,1290,903,CIGNA [1000112],CIGNA [100011201],,,,,,289.605,1093.404,,,,
HC Walking Boot Prefab L4360,PX-27400227,CDM,27400227,LOCAL,274,RC,,,inpatient,,,1290,903,CIGNA [1000112],CIGNA [100011201],,,,,,289.605,1093.404,,,,
HC Walking Boot L4360,PX-27400228,CDM,27400228,LOCAL,274,RC,,,inpatient,,,2135,1494.5,CIGNA [1000112],CIGNA [100011201],,,,,,479.3075,1809.626,,,,
HC Cam Walker L4386,PX-27400229,CDM,27400229,LOCAL,274,RC,,,inpatient,,,745,521.5,CIGNA [1000112],CIGNA [100011201],,,,,,167.2525,631.462,,,,
HC Bk Stump Shrinker L8440,PX-27400230,CDM,27400230,LOCAL,274,RC,,,inpatient,,,262,183.4,CIGNA [1000112],CIGNA [100011201],,,,,,58.819,222.0712,,,,
HC Stump Shrinker L8440,PX-27400231,CDM,27400231,LOCAL,274,RC,,,inpatient,,,262,183.4,CIGNA [1000112],CIGNA [100011201],,,,,,58.819,222.0712,,,,
HC Liner Foam Permanently Lg,PX-27400232,CDM,27400232,LOCAL,274,RC,,,inpatient,,,353,247.1,CIGNA [1000112],CIGNA [100011201],,,,,,79.2485,299.2028,,,,
HC Kit Electrode Pacing,PX-27500027,CDM,27500027,LOCAL,275,RC,,,inpatient,,,1286,900.2,CIGNA [1000112],CIGNA [100011201],,,,,,288.707,1090.0136,,,,
HC Medical/Surgical Supplies: Other Implants,PX-27800095,CDM,27800095,LOCAL,278,RC,,,inpatient,,,649,454.3,CIGNA [1000112],CIGNA [100011201],,,,,,145.7005,550.0924,,,,
HC Leg Post Rigid Brace/Sc Ortho,PX-27800096,CDM,27800096,LOCAL,278,RC,,,inpatient,,,758,530.6,CIGNA [1000112],CIGNA [100011201],,,,,,170.171,642.4808,,,,
HC Kit Picc 4fr per-Q Poly Cath,PX-27800097,CDM,27800097,LOCAL,278,RC,,,inpatient,,,1063,744.1,CIGNA [1000112],CIGNA [100011201],,,,,,238.6435,900.9988,,,,
HC Floseal Matrix Hemostatic,PX-27800098,CDM,27800098,LOCAL,278,RC,,,inpatient,,,1093,765.1,CIGNA [1000112],CIGNA [100011201],,,,,,245.3785,926.4268,,,,
HC Kit Picc 5fr per-Q Poly Cath,PX-27800099,CDM,27800099,LOCAL,278,RC,,,inpatient,,,1217,851.9,CIGNA [1000112],CIGNA [100011201],,,,,,273.2165,1031.5292,,,,
HC Tray Power Picc Dual 5f,PX-27800100,CDM,27800100,LOCAL,278,RC,,,inpatient,,,1355,948.5,CIGNA [1000112],CIGNA [100011201],,,,,,304.1975,1148.498,,,,
HC Tray Power Picc Single 4f,PX-27800101,CDM,27800101,LOCAL,278,RC,,,inpatient,,,1398,978.6,CIGNA [1000112],CIGNA [100011201],,,,,,313.851,1184.9448,,,,
HC Tray Power Picc Triple 5fr,PX-27800102,CDM,27800102,LOCAL,278,RC,,,inpatient,,,1474,1031.8,CIGNA [1000112],CIGNA [100011201],,,,,,330.913,1249.3624,,,,
HC Tray Power Picc Triple 6f,PX-27800103,CDM,27800103,LOCAL,278,RC,,,inpatient,,,1499,1049.3,CIGNA [1000112],CIGNA [100011201],,,,,,336.5255,1270.5524,,,,
HC Sepafilm/5x6,PX-27800104,CDM,27800104,LOCAL,278,RC,,,inpatient,,,1773,1241.1,CIGNA [1000112],CIGNA [100011201],,,,,,398.0385,1502.7948,,,,
HC 3cg Power Picc Max 4fr Sl,PX-27800105,CDM,27800105,LOCAL,278,RC,,,inpatient,,,1585,1109.5,CIGNA [1000112],CIGNA [100011201],,,,,,355.8325,1343.446,,,,
HC 3cg Power Picc Max 5fr Dl,PX-27800106,CDM,27800106,LOCAL,278,RC,,,inpatient,,,1636,1145.2,CIGNA [1000112],CIGNA [100011201],,,,,,367.282,1386.6736,,,,
HC 3cg Power Picc Max 6fr Tl,PX-27800107,CDM,27800107,LOCAL,278,RC,,,inpatient,,,1749,1224.3,CIGNA [1000112],CIGNA [100011201],,,,,,392.6505,1482.4524,,,,
HC Valve Passy Muir Aqua,PX-27800108,CDM,27800108,LOCAL,278,RC,,,inpatient,,,474,331.8,CIGNA [1000112],CIGNA [100011201],,,,,,106.413,401.7624,,,,
HC Passy Muir Valve - Clear,PX-27800113,CDM,27800113,LOCAL,278,RC,,,inpatient,,,474,331.8,CIGNA [1000112],CIGNA [100011201],,,,,,106.413,401.7624,,,,
HC Valve Passy Muir Purple,PX-27800114,CDM,27800114,LOCAL,278,RC,,,inpatient,,,474,331.8,CIGNA [1000112],CIGNA [100011201],,,,,,106.413,401.7624,,,,
HC Liner Foam Permanently X-Lg,PX-27800115,CDM,27800115,LOCAL,278,RC,,,inpatient,,,328,229.6,CIGNA [1000112],CIGNA [100011201],,,,,,73.636,278.0128,,,,
HC Tube Trach Proximal Xlt 7.0,PX-27800117,CDM,27800117,LOCAL,278,RC,,,inpatient,,,486,340.2,CIGNA [1000112],CIGNA [100011201],,,,,,109.107,411.9336,,,,
HC Barrier Seprafilm 3x5in,PX-27800118,CDM,27800118,LOCAL,278,RC,,,inpatient,,,1773,1241.1,CIGNA [1000112],CIGNA [100011201],,,,,,398.0385,1502.7948,,,,
HC Tube Feeding Low Profile 20f,PX-27800119,CDM,27800119,LOCAL,278,RC,,,inpatient,,,694,485.8,CIGNA [1000112],CIGNA [100011201],,,,,,155.803,588.2344,,,,
HC Valve Speaking White #005,PX-27800121,CDM,27800121,LOCAL,278,RC,,,inpatient,,,474,331.8,CIGNA [1000112],CIGNA [100011201],,,,,,106.413,401.7624,,,,
HC Tray Percu Introducer 8.5fr,PX-27800122,CDM,27800122,LOCAL,278,RC,,,inpatient,,,475,332.5,CIGNA [1000112],CIGNA [100011201],,,,,,106.6375,402.61,,,,
HC Basket Zerotip Airway Retriv,PX-27800125,CDM,27800125,LOCAL,278,RC,,,inpatient,,,1710,1197,CIGNA [1000112],CIGNA [100011201],,,,,,383.895,1449.396,,,,
HC Indwelling Prosthesis 20fr 8mm,PX-27800126,CDM,27800126,LOCAL,278,RC,,,inpatient,,,1327,928.9,CIGNA [1000112],CIGNA [100011201],,,,,,297.9115,1124.7652,,,,
HC Indwelling Prosthesis 2.0,PX-27800127,CDM,27800127,LOCAL,278,RC,,,inpatient,,,1327,928.9,CIGNA [1000112],CIGNA [100011201],,,,,,297.9115,1124.7652,,,,
HC Prosthesis Blom - 8mm,PX-27800128,CDM,27800128,LOCAL,278,RC,,,inpatient,,,1300,910,CIGNA [1000112],CIGNA [100011201],,,,,,291.85,1101.88,,,,
HC Drug Collection,PX-30000005,CDM,30000005,LOCAL,300,RC,,,inpatient,,,32,22.4,CIGNA [1000112],CIGNA [100011201],,,,,,7.184,27.1232,,,,
HC Cardiac Mnr Thoracic Prcd,PX-36000003,CDM,36000003,LOCAL,360,RC,,,inpatient,,,142,99.4,CIGNA [1000112],CIGNA [100011201],,,,,,31.879,120.3592,,,,
HC Non-Pump Open Heart Other,PX-36000004,CDM,36000004,LOCAL,360,RC,,,inpatient,,,157,109.9,CIGNA [1000112],CIGNA [100011201],,,,,,35.2465,133.0732,,,,
HC Pump Procedure,PX-36000005,CDM,36000005,LOCAL,360,RC,,,inpatient,,,152,106.4,CIGNA [1000112],CIGNA [100011201],,,,,,34.124,128.8352,,,,
HC Non Pump Procedure,PX-36000006,CDM,36000006,LOCAL,360,RC,,,inpatient,,,208,145.6,CIGNA [1000112],CIGNA [100011201],,,,,,46.696,176.3008,,,,
HC Sub Minor Proc,PX-36000014,CDM,36000014,LOCAL,360,RC,,,inpatient,,,60,42,CIGNA [1000112],CIGNA [100011201],,,,,,13.47,50.856,,,,
HC Pain Mgmt Proc,PX-36000015,CDM,36000015,LOCAL,360,RC,,,inpatient,,,75,52.5,CIGNA [1000112],CIGNA [100011201],,,,,,16.8375,63.57,,,,
HC Endoscopy,PX-36000016,CDM,36000016,LOCAL,360,RC,,,inpatient,,,60,42,CIGNA [1000112],CIGNA [100011201],,,,,,13.47,50.856,,,,
HC Minor Proc,PX-36000017,CDM,36000017,LOCAL,360,RC,,,inpatient,,,75,52.5,CIGNA [1000112],CIGNA [100011201],,,,,,16.8375,63.57,,,,
HC Major Proc,PX-36000019,CDM,36000019,LOCAL,360,RC,,,inpatient,,,99,69.3,CIGNA [1000112],CIGNA [100011201],,,,,,22.2255,83.9124,,,,
HC Intensive Major Procedure,PX-36000020,CDM,36000020,LOCAL,360,RC,,,inpatient,,,140,98,CIGNA [1000112],CIGNA [100011201],,,,,,31.43,118.664,,,,
HC Ercp,PX-36000021,CDM,36000021,LOCAL,360,RC,,,inpatient,,,138,96.6,CIGNA [1000112],CIGNA [100011201],,,,,,30.981,116.9688,,,,
HC Cardiac Maj Thoracic Prcd,PX-36000022,CDM,36000022,LOCAL,360,RC,,,inpatient,,,159,111.3,CIGNA [1000112],CIGNA [100011201],,,,,,35.6955,134.7684,,,,
HC Anesthesia Block,PX-37000001,CDM,37000001,LOCAL,370,RC,,,inpatient,,,700,490,CIGNA [1000112],CIGNA [100011201],,,,,,157.15,593.32,,,,
HC Anesthesia Spinal,PX-37000002,CDM,37000002,LOCAL,370,RC,,,inpatient,,,850,595,CIGNA [1000112],CIGNA [100011201],,,,,,190.825,720.46,,,,
HC Anesthesia General Minor,PX-37000003,CDM,37000003,LOCAL,370,RC,,,inpatient,,,1662,1163.4,CIGNA [1000112],CIGNA [100011201],,,,,,373.119,1408.7112,,,,
HC Anesthesia Epidural,PX-37000004,CDM,37000004,LOCAL,370,RC,,,inpatient,,,950,665,CIGNA [1000112],CIGNA [100011201],,,,,,213.275,805.22,,,,
HC Anesthesia General Major,PX-37000005,CDM,37000005,LOCAL,370,RC,,,inpatient,,,2924,2046.8,CIGNA [1000112],CIGNA [100011201],,,,,,656.438,2478.3824,,,,
HC Anesthesia Gen/Epi,PX-37000006,CDM,37000006,LOCAL,370,RC,,,inpatient,,,1200,840,CIGNA [1000112],CIGNA [100011201],,,,,,269.4,1017.12,,,,
HC Anesthesia General Intensive,PX-37000007,CDM,37000007,LOCAL,370,RC,,,inpatient,,,4262,2983.4,CIGNA [1000112],CIGNA [100011201],,,,,,956.819,3612.4712,,,,
HC Anesthesia General Cvs Bypass Pump,PX-37000008,CDM,37000008,LOCAL,370,RC,,,inpatient,,,9166,6416.2,CIGNA [1000112],CIGNA [100011201],,,,,,2057.767,7769.1016,,,,
HC Anesthesia Mac,PX-37000009,CDM,37000009,LOCAL,370,RC,,,inpatient,,,1200,840,CIGNA [1000112],CIGNA [100011201],,,,,,269.4,1017.12,,,,
HC Endo Level I,PX-49000001,CDM,49000001,LOCAL,490,RC,,,inpatient,,,3749,2624.3,CIGNA [1000112],CIGNA [100011201],,,,,,841.6505,3177.6524,,,,
HC Endo Level II,PX-49000002,CDM,49000002,LOCAL,490,RC,,,inpatient,,,5356,3749.2,CIGNA [1000112],CIGNA [100011201],,,,,,1202.422,4539.7456,,,,
HC Endo Level III,PX-49000003,CDM,49000003,LOCAL,490,RC,,,inpatient,,,9641,6748.7,CIGNA [1000112],CIGNA [100011201],,,,,,2164.4045,8171.7116,,,,
HC Recovery Room,PX-71000001,CDM,71000001,LOCAL,710,RC,,,inpatient,,,25,17.5,CIGNA [1000112],CIGNA [100011201],,,,,,5.6125,21.19,,,,
HC Second Stage Recovery per Minute,PX-71000002,CDM,71000002,LOCAL,710,RC,,,inpatient,,,22,15.4,CIGNA [1000112],CIGNA [100011201],,,,,,4.939,18.6472,,,,
HC Recovery - Sub Minor Proc,PX-71000003,CDM,71000003,LOCAL,710,RC,,,inpatient,,,23,16.1,CIGNA [1000112],CIGNA [100011201],,,,,,5.1635,19.4948,,,,
HC Recovery Rm - Minor Procedure,PX-71000004,CDM,71000004,LOCAL,710,RC,,,inpatient,,,28,19.6,CIGNA [1000112],CIGNA [100011201],,,,,,6.286,23.7328,,,,
HC Recovery Rm,PX-71000005,CDM,71000005,LOCAL,710,RC,,,inpatient,,,29,20.3,CIGNA [1000112],CIGNA [100011201],,,,,,6.5105,24.5804,,,,
HC Recovery Rm - Major Procedure,PX-71000006,CDM,71000006,LOCAL,710,RC,,,inpatient,,,33,23.1,CIGNA [1000112],CIGNA [100011201],,,,,,7.4085,27.9708,,,,
HC Recovery Rm - Intensive Major,PX-71000007,CDM,71000007,LOCAL,710,RC,,,inpatient,,,38,26.6,CIGNA [1000112],CIGNA [100011201],,,,,,8.531,32.2088,,,,
HC Extended Recovery Overnight,PX-71000009,CDM,71000009,LOCAL,710,RC,,,inpatient,,,1500,1050,CIGNA [1000112],CIGNA [100011201],,,,,,336.75,1271.4,,,,
HC Observation Nursing Time,PX-76200006,CDM,76200006,LOCAL,762,RC,,,inpatient,,,101,70.7,CIGNA [1000112],CIGNA [100011201],,,,,,22.6745,6652,,,,
HC Tandem Dialysis,PX-80100001,CDM,80100001,LOCAL,801,RC,,,inpatient,,,1142,799.4,CIGNA [1000112],CIGNA [100011201],,,,,,256.379,967.9592,,,,
HC Single Dialysis,PX-80100002,CDM,80100002,LOCAL,801,RC,,,inpatient,,,1142,799.4,CIGNA [1000112],CIGNA [100011201],,,,,,256.379,967.9592,,,,
HC Unscheduled/Emergent Dialysis,PX-80100003,CDM,80100003,LOCAL,801,RC,,,inpatient,,,1142,799.4,CIGNA [1000112],CIGNA [100011201],,,,,,256.379,967.9592,,,,
HC Weekend/Holiday Dialysis,PX-80100004,CDM,80100004,LOCAL,801,RC,,,inpatient,,,1142,799.4,CIGNA [1000112],CIGNA [100011201],,,,,,256.379,967.9592,,,,
HC Capd per:Exchange,PX-80300001,CDM,80300001,LOCAL,803,RC,,,inpatient,,,569,398.3,CIGNA [1000112],CIGNA [100011201],,,,,,127.7405,482.2844,,,,
HC Ccpd ER,PX-80400001,CDM,80400001,LOCAL,804,RC,,,inpatient,,,569,398.3,CIGNA [1000112],CIGNA [100011201],,,,,,127.7405,482.2844,,,,
HC Ccpd,PX-80400002,CDM,80400002,LOCAL,804,RC,,,inpatient,,,1142,799.4,CIGNA [1000112],CIGNA [100011201],,,,,,256.379,967.9592,,,,
HC Dietary Services per 15 Mins,PX-99000006,CDM,99000006,LOCAL,990,RC,,,inpatient,,,29,20.3,CIGNA [1000112],CIGNA [100011201],,,,,,6.5105,24.5804,,,,
HC Hearing Aid Batteries,PX-99000034,CDM,99000034,LOCAL,479,RC,,,inpatient,,,7,4.9,CIGNA [1000112],CIGNA [100011201],,,,,,1.5715,163,,,,
HC Hearing Aid Tune Up,PX-99000037,CDM,99000037,LOCAL,479,RC,,,inpatient,,,43,30.1,CIGNA [1000112],CIGNA [100011201],,,,,,9.6535,163,,,,
HC Hearing Aid Fit,PX-99000038,CDM,99000038,LOCAL,479,RC,,,inpatient,,,171,119.7,CIGNA [1000112],CIGNA [100011201],,,,,,38.3895,163,,,,
HC Full Trauma No Notification,PX-45000633,CDM,TR450,LOCAL,450,RC,,,inpatient,,,10370,7259,CIGNA [1000112],CIGNA [100011201],,,,,,399.86,9291.52,,,,
HC Partial Trauma No Notification,PX-45000634,CDM,TR450,LOCAL,450,RC,,,inpatient,,,7029,4920.3,CIGNA [1000112],CIGNA [100011201],,,,,,399.86,6297.984,,,,
Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face- Mouth And Neck With Major O.R. Procedures,3,MS-DRG,,,,,,,inpatient,,,404600.26,283220.182,CIGNA [1000112],CIGNA [100011201],,,68,,275128.1768,7771.48,434261.5728,percent of total billed charges,,,
Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face- Mouth And Neck Without Major O.R. Procedures,4,MS-DRG,,,,,,,inpatient,,,379341.67,265539.169,CIGNA [1000112],CIGNA [100011201],,,68,,257952.3356,7771.48,303473.336,percent of total billed charges,,,
Tracheostomy For Face- Mouth And Neck Diagnoses Or Laryngectomy With McC,11,MS-DRG,,,,,,,inpatient,,,57485.95,40240.165,CIGNA [1000112],CIGNA [100011201],,,68,,39090.446,7771.48,109336.4384,percent of total billed charges,,,
Tracheostomy For Face- Mouth And Neck Diagnoses Or Laryngectomy With Cc,12,MS-DRG,,,,,,,inpatient,,,82266.47,57586.529,CIGNA [1000112],CIGNA [100011201],,,68,,55941.1996,7771.48,83151.2976,percent of total billed charges,,,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With McC Or Chemotherapy Implant Or Epilepsy With Neurostimulator,23,MS-DRG,,,,,,,inpatient,,,82526.76,57768.732,CIGNA [1000112],CIGNA [100011201],,,68,,56118.1968,7771.48,115600.0408,percent of total billed charges,,,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without McC,24,MS-DRG,,,,,,,inpatient,,,54359.41,38051.587,CIGNA [1000112],CIGNA [100011201],,,68,,36964.3988,7771.48,77031.5696,percent of total billed charges,,,
Craniotomy And Endovascular Intracranial Procedures With McC,25,MS-DRG,,,,,,,inpatient,,,91861.46,64303.022,CIGNA [1000112],CIGNA [100011201],,,68,,62465.7928,7771.48,90620.608,percent of total billed charges,,,
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,,,inpatient,,,74058,51840.6,CIGNA [1000112],CIGNA [100011201],,,68,,50359.44,7771.48,61975.4176,percent of total billed charges,,,
Craniotomy And Endovascular Intracranial Procedures Without Cc/McC,27,MS-DRG,,,,,,,inpatient,,,61484.65,43039.255,CIGNA [1000112],CIGNA [100011201],,,68,,41809.562,7771.48,50003.4464,percent of total billed charges,,,
Spinal Procedures With McC,28,MS-DRG,,,,,,,inpatient,,,148126.56,103688.592,CIGNA [1000112],CIGNA [100011201],,,68,,100726.0608,7771.48,123186.8824,percent of total billed charges,,,
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,inpatient,,,74991.36,52493.952,CIGNA [1000112],CIGNA [100011201],,,68,,50994.1248,7771.48,68016.116,percent of total billed charges,,,
Spinal Procedures Without Cc/McC,30,MS-DRG,,,,,,,inpatient,,,28580.9,20006.63,CIGNA [1000112],CIGNA [100011201],,,68,,19435.012,7771.48,45091.4528,percent of total billed charges,,,
Ventricular Shunt Procedures With McC,31,MS-DRG,,,,,,,inpatient,,,61588.79,43112.153,CIGNA [1000112],CIGNA [100011201],,,68,,41880.3772,7771.48,84912.2392,percent of total billed charges,,,
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,,,inpatient,,,117340.84,82138.588,CIGNA [1000112],CIGNA [100011201],,,68,,79791.7712,7771.48,93872.672,percent of total billed charges,,,
Ventricular Shunt Procedures Without Cc/McC,33,MS-DRG,,,,,,,inpatient,,,50092.67,35064.869,CIGNA [1000112],CIGNA [100011201],,,68,,34063.0156,7771.48,40074.136,percent of total billed charges,,,
Carotid Artery Stent Procedures With McC,34,MS-DRG,,,,,,,inpatient,,,80412.35,56288.645,CIGNA [1000112],CIGNA [100011201],,,68,,54680.398,7771.48,78796.564,percent of total billed charges,,,
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,inpatient,,,59060.84,41342.588,CIGNA [1000112],CIGNA [100011201],,,68,,40161.3712,7771.48,47248.672,percent of total billed charges,,,
Carotid Artery Stent Procedures Without Cc/McC,36,MS-DRG,,,,,,,inpatient,,,55590.26,38913.182,CIGNA [1000112],CIGNA [100011201],,,68,,37801.3768,7771.48,44472.208,percent of total billed charges,,,
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,inpatient,,,47239.38,33067.566,CIGNA [1000112],CIGNA [100011201],,,68,,32122.7784,7771.48,37791.504,percent of total billed charges,,,
Extracranial Procedures Without Cc/McC,39,MS-DRG,,,,,,,inpatient,,,40302.61,28211.827,CIGNA [1000112],CIGNA [100011201],,,68,,27405.7748,7771.48,32242.088,percent of total billed charges,,,
Peripheral- Cranial Nerve And Other Nervous System Procedures With McC,40,MS-DRG,,,,,,,inpatient,,,42423.5,29696.45,CIGNA [1000112],CIGNA [100011201],,,68,,28847.98,7771.48,76431.7552,percent of total billed charges,,,
Peripheral- Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator,41,MS-DRG,,,,,,,inpatient,,,29478.8,20635.16,CIGNA [1000112],CIGNA [100011201],,,68,,20045.584,7771.48,45768.2704,percent of total billed charges,,,
Peripheral- Cranial Nerve And Other Nervous System Procedures Without Cc/McC,42,MS-DRG,,,,,,,inpatient,,,40958.56,28670.992,CIGNA [1000112],CIGNA [100011201],,,68,,27851.8208,7771.48,35613.98,percent of total billed charges,,,
Spinal Disorders And Injuries With Cc/McC,52,MS-DRG,,,,,,,inpatient,,,14188.67,9932.069,CIGNA [1000112],CIGNA [100011201],,,68,,9648.2956,4731.921445,40779.2736,percent of total billed charges,,,
Spinal Disorders And Injuries Without Cc/McC,53,MS-DRG,,,,,,,inpatient,,,42918.11,30042.677,CIGNA [1000112],CIGNA [100011201],,,68,,29184.3148,7771.48,34334.488,percent of total billed charges,,,
Nervous System Neoplasms With McC,54,MS-DRG,,,,,,,inpatient,,,16507.92,11555.544,CIGNA [1000112],CIGNA [100011201],,,68,,11225.3856,5505.39132,30377.7624,percent of total billed charges,,,
Nervous System Neoplasms Without McC,55,MS-DRG,,,,,,,inpatient,,,15148.1,10603.67,CIGNA [1000112],CIGNA [100011201],,,68,,10300.708,5051.89135,22105.9976,percent of total billed charges,,,
Degenerative Nervous System Disorders With McC,56,MS-DRG,,,,,,,inpatient,,,32807.03,22964.921,CIGNA [1000112],CIGNA [100011201],,,68,,22308.7804,7771.48,50741.056,percent of total billed charges,,,
Degenerative Nervous System Disorders Without McC,57,MS-DRG,,,,,,,inpatient,,,21955.44,15368.808,CIGNA [1000112],CIGNA [100011201],,,68,,14929.6992,7322.13924,27046.3608,percent of total billed charges,,,
Multiple Sclerosis And Cerebellar Ataxia With McC,58,MS-DRG,,,,,,,inpatient,,,18732.22,13112.554,CIGNA [1000112],CIGNA [100011201],,,68,,12737.9096,6247.19537,37401.2648,percent of total billed charges,,,
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,inpatient,,,30559.84,21391.888,CIGNA [1000112],CIGNA [100011201],,,68,,20780.6912,7771.48,24793.004,percent of total billed charges,,,
Multiple Sclerosis And Cerebellar Ataxia Without Cc/McC,60,MS-DRG,,,,,,,inpatient,,,18686.21,13080.347,CIGNA [1000112],CIGNA [100011201],,,68,,12706.6228,6231.851035,18083.5936,percent of total billed charges,,,
Ischemic Stroke- Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With McC,61,MS-DRG,,,,,,,inpatient,,,81185.85,56830.095,CIGNA [1000112],CIGNA [100011201],,,68,,55206.378,7771.48,64948.68,percent of total billed charges,,,
Ischemic Stroke- Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc,62,MS-DRG,,,,,,,inpatient,,,55465.6,38825.92,CIGNA [1000112],CIGNA [100011201],,,68,,37716.608,7771.48,44372.48,percent of total billed charges,,,
Ischemic Stroke- Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/McC,63,MS-DRG,,,,,,,inpatient,,,65826.61,46078.627,CIGNA [1000112],CIGNA [100011201],,,68,,44762.0948,7771.48,52661.288,percent of total billed charges,,,
Intracranial Hemorrhage Or Cerebral Infarction With McC,64,MS-DRG,,,,,,,inpatient,,,31988.78,22392.146,CIGNA [1000112],CIGNA [100011201],,,68,,21752.3704,7771.48,40307.1224,percent of total billed charges,,,
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,inpatient,,,20095.65,14066.955,CIGNA [1000112],CIGNA [100011201],,,68,,13665.042,6701.899275,20608.488,percent of total billed charges,,,
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/McC,66,MS-DRG,,,,,,,inpatient,,,17438.35,12206.845,CIGNA [1000112],CIGNA [100011201],,,68,,11858.078,5143.64,13950.68,percent of total billed charges,,,
Nonspecific Cva And Precerebral Occlusion Without Infarction With McC,67,MS-DRG,,,,,,,inpatient,,,38053.25,26637.275,CIGNA [1000112],CIGNA [100011201],,,68,,25876.21,7771.48,30442.6,percent of total billed charges,,,
Nonspecific Cva And Precerebral Occlusion Without Infarction Without McC,68,MS-DRG,,,,,,,inpatient,,,27888.66,19522.062,CIGNA [1000112],CIGNA [100011201],,,68,,18964.2888,6429.37,22310.928,percent of total billed charges,,,
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,inpatient,,,17825.05,12477.535,CIGNA [1000112],CIGNA [100011201],,,68,,12121.034,5687.74,16215.2528,percent of total billed charges,,,
Nonspecific Cerebrovascular Disorders With McC,70,MS-DRG,,,,,,,inpatient,,,36237.19,25366.033,CIGNA [1000112],CIGNA [100011201],,,68,,24641.2892,7771.48,35233.0168,percent of total billed charges,,,
Nonspecific Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,inpatient,,,26346.94,18442.858,CIGNA [1000112],CIGNA [100011201],,,68,,17915.9192,7313.53,21354.2032,percent of total billed charges,,,
Cranial And Peripheral Nerve Disorders With McC,73,MS-DRG,,,,,,,inpatient,,,24367.12,17056.984,CIGNA [1000112],CIGNA [100011201],,,68,,16569.6416,7771.48,31318.012,percent of total billed charges,,,
Cranial And Peripheral Nerve Disorders Without McC,74,MS-DRG,,,,,,,inpatient,,,24431.87,17102.309,CIGNA [1000112],CIGNA [100011201],,,68,,16613.6716,7368.52,21123.1936,percent of total billed charges,,,
Viral Meningitis With Cc/McC,75,MS-DRG,,,,,,,inpatient,,,38318.52,26822.964,CIGNA [1000112],CIGNA [100011201],,,68,,26056.5936,7771.48,34902.7136,percent of total billed charges,,,
Viral Meningitis Without Cc/McC,76,MS-DRG,,,,,,,inpatient,,,18360.72,12852.504,CIGNA [1000112],CIGNA [100011201],,,68,,12485.2896,6123.30012,18580.0616,percent of total billed charges,,,
Hypertensive Encephalopathy With McC,77,MS-DRG,,,,,,,inpatient,,,24086.79,16860.753,CIGNA [1000112],CIGNA [100011201],,,68,,16379.0172,7771.48,31332.1968,percent of total billed charges,,,
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,,,inpatient,,,18407.7,12885.39,CIGNA [1000112],CIGNA [100011201],,,68,,12517.236,6138.96795,20219.4192,percent of total billed charges,,,
Nontraumatic Stupor And Coma With McC,80,MS-DRG,,,,,,,inpatient,,,17643.44,12350.408,CIGNA [1000112],CIGNA [100011201],,,68,,11997.5392,5884.08724,40280.7792,percent of total billed charges,,,
Traumatic Stupor And Coma >1 Hour With McC,82,MS-DRG,,,,,,,inpatient,,,45789.39,32052.573,CIGNA [1000112],CIGNA [100011201],,,68,,31136.7852,7771.48,47014.5064,percent of total billed charges,,,
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,inpatient,,,24521.38,17164.966,CIGNA [1000112],CIGNA [100011201],,,68,,16674.5384,7771.48,28173.0392,percent of total billed charges,,,
Traumatic Stupor And Coma >1 Hour Without Cc/McC,84,MS-DRG,,,,,,,inpatient,,,12382.21,8667.547,CIGNA [1000112],CIGNA [100011201],,,68,,8419.9028,4129.467035,19372.384,percent of total billed charges,,,
Traumatic Stupor And Coma <1 Hour With McC,85,MS-DRG,,,,,,,inpatient,,,44820.5,31374.35,CIGNA [1000112],CIGNA [100011201],,,68,,30477.94,7771.48,45916.1976,percent of total billed charges,,,
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,inpatient,,,22755.94,15929.158,CIGNA [1000112],CIGNA [100011201],,,68,,15474.0392,7589.10599,26578.2624,percent of total billed charges,,,
Traumatic Stupor And Coma <1 Hour Without Cc/McC,87,MS-DRG,,,,,,,inpatient,,,19756.53,13829.571,CIGNA [1000112],CIGNA [100011201],,,68,,13434.4404,6241.25,17913.376,percent of total billed charges,,,
Concussion With McC,88,MS-DRG,,,,,,,inpatient,,,61939.59,43357.713,CIGNA [1000112],CIGNA [100011201],,,68,,42118.9212,7771.48,49551.672,percent of total billed charges,,,
Concussion With Cc,89,MS-DRG,,,,,,,inpatient,,,38694.98,27086.486,CIGNA [1000112],CIGNA [100011201],,,68,,26312.5864,7678.2,30955.984,percent of total billed charges,,,
Other Disorders Of Nervous System With McC,91,MS-DRG,,,,,,,inpatient,,,27946.92,19562.844,CIGNA [1000112],CIGNA [100011201],,,68,,19003.9056,7771.48,36937.2192,percent of total billed charges,,,
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,inpatient,,,23877.59,16714.313,CIGNA [1000112],CIGNA [100011201],,,68,,16236.7612,7134.82,21455.5232,percent of total billed charges,,,
Other Disorders Of Nervous System Without Cc/McC,93,MS-DRG,,,,,,,inpatient,,,19087.94,13361.558,CIGNA [1000112],CIGNA [100011201],,,68,,12979.7992,5653.01,15994.3752,percent of total billed charges,,,
Bacterial And Tuberculous Infections Of Nervous System With McC,94,MS-DRG,,,,,,,inpatient,,,86655,60658.5,CIGNA [1000112],CIGNA [100011201],,,68,,58925.4,7771.48,73931.1776,percent of total billed charges,,,
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,,,inpatient,,,61521.3,43064.91,CIGNA [1000112],CIGNA [100011201],,,68,,41834.484,7771.48,49217.04,percent of total billed charges,,,
Bacterial And Tuberculous Infections Of Nervous System Without Cc/McC,96,MS-DRG,,,,,,,inpatient,,,33095.5,23166.85,CIGNA [1000112],CIGNA [100011201],,,68,,22504.94,7771.48,48572.808,percent of total billed charges,,,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With McC,97,MS-DRG,,,,,,,inpatient,,,90065.06,63045.542,CIGNA [1000112],CIGNA [100011201],,,68,,61244.2408,7771.48,72642.3872,percent of total billed charges,,,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,inpatient,,,23740.04,16618.028,CIGNA [1000112],CIGNA [100011201],,,68,,16143.2272,7771.48,43954.6424,percent of total billed charges,,,
Seizures With McC,100,MS-DRG,,,,,,,inpatient,,,22104.14,15472.898,CIGNA [1000112],CIGNA [100011201],,,68,,15030.8152,7371.73069,40228.0928,percent of total billed charges,,,
Seizures Without McC,101,MS-DRG,,,,,,,inpatient,,,15944.38,11161.066,CIGNA [1000112],CIGNA [100011201],,,68,,10842.1784,5317.45073,18675.3024,percent of total billed charges,,,
Headaches With McC,102,MS-DRG,,,,,,,inpatient,,,25624.62,17937.234,CIGNA [1000112],CIGNA [100011201],,,68,,17424.7416,7771.48,23494.0816,percent of total billed charges,,,
Headaches Without McC,103,MS-DRG,,,,,,,inpatient,,,20277.76,14194.432,CIGNA [1000112],CIGNA [100011201],,,68,,13788.8768,5992.35,17228.4528,percent of total billed charges,,,
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,,,inpatient,,,26970.92,18879.644,CIGNA [1000112],CIGNA [100011201],,,68,,18340.2256,7771.48,31022.1576,percent of total billed charges,,,
Neurological Eye Disorders,123,MS-DRG,,,,,,,inpatient,,,18842.87,13190.009,CIGNA [1000112],CIGNA [100011201],,,68,,12813.1516,5537.24,16276.0448,percent of total billed charges,,,
Sinus And Mastoid Procedures With Cc/McC,135,MS-DRG,,,,,,,inpatient,,,60852.06,42596.442,CIGNA [1000112],CIGNA [100011201],,,68,,41379.4008,7771.48,48854.4776,percent of total billed charges,,,
Mouth Procedures Without Cc/McC,138,MS-DRG,,,,,,,inpatient,,,12689.7,8882.79,CIGNA [1000112],CIGNA [100011201],,,68,,8628.996,4232.01495,16484.764,percent of total billed charges,,,
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,inpatient,,,50999.49,35699.643,CIGNA [1000112],CIGNA [100011201],,,68,,34679.6532,7771.48,43533.1512,percent of total billed charges,,,
Major Head And Neck Procedures Without Cc/McC,142,MS-DRG,,,,,,,inpatient,,,31036.34,21725.438,CIGNA [1000112],CIGNA [100011201],,,68,,21104.7112,7771.48,31861.0872,percent of total billed charges,,,
Other Ear- Nose- Mouth And Throat O.R. Procedures With McC,143,MS-DRG,,,,,,,inpatient,,,146130.64,102291.448,CIGNA [1000112],CIGNA [100011201],,,68,,99368.8352,7771.48,116904.512,percent of total billed charges,,,
Other Ear- Nose- Mouth And Throat O.R. Procedures With Cc,144,MS-DRG,,,,,,,inpatient,,,29177.65,20424.355,CIGNA [1000112],CIGNA [100011201],,,68,,19840.802,7771.48,35595.7424,percent of total billed charges,,,
Ear- Nose- Mouth And Throat Malignancy With Cc,147,MS-DRG,,,,,,,inpatient,,,20455.22,14318.654,CIGNA [1000112],CIGNA [100011201],,,68,,13909.5496,6821.81587,25222.6008,percent of total billed charges,,,
Ear- Nose- Mouth And Throat Malignancy Without Cc/McC,148,MS-DRG,,,,,,,inpatient,,,18282.89,12798.023,CIGNA [1000112],CIGNA [100011201],,,68,,12432.3652,5689.187157,16225.3848,percent of total billed charges,,,
Dysequilibrium,149,MS-DRG,,,,,,,inpatient,,,21458.09,15020.663,CIGNA [1000112],CIGNA [100011201],,,68,,14591.5012,5321.63,17166.472,percent of total billed charges,,,
Epistaxis With McC,150,MS-DRG,,,,,,,inpatient,,,36459.7,25521.79,CIGNA [1000112],CIGNA [100011201],,,68,,24792.596,7771.48,29167.76,percent of total billed charges,,,
Epistaxis Without McC,151,MS-DRG,,,,,,,inpatient,,,17762.28,12433.596,CIGNA [1000112],CIGNA [100011201],,,68,,12078.3504,5332.48243,15360.112,percent of total billed charges,,,
Otitis Media And Uri With McC,152,MS-DRG,,,,,,,inpatient,,,22895.06,16026.542,CIGNA [1000112],CIGNA [100011201],,,68,,15568.6408,7635.50251,22993.5608,percent of total billed charges,,,
Otitis Media And Uri Without McC,153,MS-DRG,,,,,,,inpatient,,,11257.92,7880.544,CIGNA [1000112],CIGNA [100011201],,,68,,7655.3856,3754.51632,14421.8888,percent of total billed charges,,,
Other Ear- Nose- Mouth And Throat Diagnoses With McC,154,MS-DRG,,,,,,,inpatient,,,33108.79,23176.153,CIGNA [1000112],CIGNA [100011201],,,68,,22513.9772,7771.48,32953.3168,percent of total billed charges,,,
Other Ear- Nose- Mouth And Throat Diagnoses With Cc,155,MS-DRG,,,,,,,inpatient,,,14149.33,9904.531,CIGNA [1000112],CIGNA [100011201],,,68,,9621.5444,4718.801555,18918.4704,percent of total billed charges,,,
Other Ear- Nose- Mouth And Throat Diagnoses Without Cc/McC,156,MS-DRG,,,,,,,inpatient,,,3168.14,2217.698,CIGNA [1000112],CIGNA [100011201],,,68,,2154.3352,1056.57469,13625.5136,percent of total billed charges,,,
Dental And Oral Diseases With McC,157,MS-DRG,,,,,,,inpatient,,,25823.75,18076.625,CIGNA [1000112],CIGNA [100011201],,,68,,17560.15,7771.48,33180.2736,percent of total billed charges,,,
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,inpatient,,,17794.61,12456.227,CIGNA [1000112],CIGNA [100011201],,,68,,12100.3348,5934.502435,19058.292,percent of total billed charges,,,
Dental And Oral Diseases Without Cc/McC,159,MS-DRG,,,,,,,inpatient,,,15217,10651.9,CIGNA [1000112],CIGNA [100011201],,,68,,10347.56,4744.97,13366.1344,percent of total billed charges,,,
Major Chest Procedures With McC,163,MS-DRG,,,,,,,inpatient,,,128830.68,90181.476,CIGNA [1000112],CIGNA [100011201],,,68,,87604.8624,7771.48,103064.544,percent of total billed charges,,,
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,inpatient,,,83811.85,58668.295,CIGNA [1000112],CIGNA [100011201],,,68,,56992.058,7771.48,67049.48,percent of total billed charges,,,
Major Chest Procedures Without Cc/McC,165,MS-DRG,,,,,,,inpatient,,,63087.07,44160.949,CIGNA [1000112],CIGNA [100011201],,,68,,42899.2076,7771.48,50469.656,percent of total billed charges,,,
Other Respiratory System O.R. Procedures With McC,166,MS-DRG,,,,,,,inpatient,,,68518.66,47963.062,CIGNA [1000112],CIGNA [100011201],,,68,,46592.6888,7771.48,78036.664,percent of total billed charges,,,
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,inpatient,,,50504.64,35353.248,CIGNA [1000112],CIGNA [100011201],,,68,,34343.1552,7771.48,40403.712,percent of total billed charges,,,
Other Respiratory System O.R. Procedures Without Cc/McC,168,MS-DRG,,,,,,,inpatient,,,36816.23,25771.361,CIGNA [1000112],CIGNA [100011201],,,68,,25035.0364,7771.48,29452.984,percent of total billed charges,,,
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,inpatient,,,76600.57,53620.399,CIGNA [1000112],CIGNA [100011201],,,68,,52088.3876,7771.48,62178.0576,percent of total billed charges,,,
Pulmonary Embolism With McC Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,inpatient,,,27323.68,19126.576,CIGNA [1000112],CIGNA [100011201],,,68,,18580.1024,7771.48,28554.0024,percent of total billed charges,,,
Pulmonary Embolism Without McC,176,MS-DRG,,,,,,,inpatient,,,16280.09,11396.063,CIGNA [1000112],CIGNA [100011201],,,68,,11070.4612,5429.410015,16505.028,percent of total billed charges,,,
Respiratory Infections And Inflammations With McC,177,MS-DRG,,,,,,,inpatient,,,30316.04,21221.228,CIGNA [1000112],CIGNA [100011201],,,68,,20614.9072,7771.48,32756.756,percent of total billed charges,,,
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,inpatient,,,21346.77,14942.739,CIGNA [1000112],CIGNA [100011201],,,68,,14515.8036,7119.147795,20103.9144,percent of total billed charges,,,
Respiratory Infections And Inflammations Without Cc/McC,179,MS-DRG,,,,,,,inpatient,,,20533.98,14373.786,CIGNA [1000112],CIGNA [100011201],,,68,,13963.1064,6302.75,16427.184,percent of total billed charges,,,
Respiratory Neoplasms With McC,180,MS-DRG,,,,,,,inpatient,,,24678.76,17275.132,CIGNA [1000112],CIGNA [100011201],,,68,,16781.5568,7771.48,35415.3928,percent of total billed charges,,,
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,inpatient,,,15915.05,11140.535,CIGNA [1000112],CIGNA [100011201],,,68,,10822.234,5307.669175,22497.0928,percent of total billed charges,,,
Major Chest Trauma With McC,183,MS-DRG,,,,,,,inpatient,,,30366.68,21256.676,CIGNA [1000112],CIGNA [100011201],,,68,,20649.3424,7771.48,32163.0208,percent of total billed charges,,,
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,inpatient,,,23252.15,16276.505,CIGNA [1000112],CIGNA [100011201],,,68,,15811.462,7520.46,21641.952,percent of total billed charges,,,
Major Chest Trauma Without Cc/McC,185,MS-DRG,,,,,,,inpatient,,,26254.04,18377.828,CIGNA [1000112],CIGNA [100011201],,,68,,17852.7472,5597.297704,21003.232,percent of total billed charges,,,
Pleural Effusion With McC,186,MS-DRG,,,,,,,inpatient,,,23322.86,16326.002,CIGNA [1000112],CIGNA [100011201],,,68,,15859.5448,7771.48,32017.12,percent of total billed charges,,,
Pleural Effusion With Cc,187,MS-DRG,,,,,,,inpatient,,,25224.41,17657.087,CIGNA [1000112],CIGNA [100011201],,,68,,17152.5988,7468.37,20343.0296,percent of total billed charges,,,
Pleural Effusion Without Cc/McC,188,MS-DRG,,,,,,,inpatient,,,14227.72,9959.404,CIGNA [1000112],CIGNA [100011201],,,68,,9674.8496,4744.94462,14875.8024,percent of total billed charges,,,
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,inpatient,,,23597.45,16518.215,CIGNA [1000112],CIGNA [100011201],,,68,,16046.266,7771.48,25076.7,percent of total billed charges,,,
Chronic Obstructive Pulmonary Disease With McC,190,MS-DRG,,,,,,,inpatient,,,20380.17,14266.119,CIGNA [1000112],CIGNA [100011201],,,68,,13858.5156,6796.786695,22762.5512,percent of total billed charges,,,
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,inpatient,,,18415.04,12890.528,CIGNA [1000112],CIGNA [100011201],,,68,,12522.2272,6141.41584,17408.8024,percent of total billed charges,,,
Chronic Obstructive Pulmonary Disease Without Cc/McC,192,MS-DRG,,,,,,,inpatient,,,15021,10514.7,CIGNA [1000112],CIGNA [100011201],,,68,,10214.28,5009.5035,13114.8608,percent of total billed charges,,,
Simple Pneumonia And Pleurisy With McC,193,MS-DRG,,,,,,,inpatient,,,24854.58,17398.206,CIGNA [1000112],CIGNA [100011201],,,68,,16901.1144,7771.48,26703.8992,percent of total billed charges,,,
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,inpatient,,,16852.25,11796.575,CIGNA [1000112],CIGNA [100011201],,,68,,11459.53,5620.225375,16616.48,percent of total billed charges,,,
Simple Pneumonia And Pleurisy Without Cc/McC,195,MS-DRG,,,,,,,inpatient,,,11327.34,7929.138,CIGNA [1000112],CIGNA [100011201],,,68,,7702.5912,3777.66789,12620.4192,percent of total billed charges,,,
Interstitial Lung Disease With McC,196,MS-DRG,,,,,,,inpatient,,,25824.88,18077.416,CIGNA [1000112],CIGNA [100011201],,,68,,17560.9184,7771.48,38181.4288,percent of total billed charges,,,
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,inpatient,,,14747.43,10323.201,CIGNA [1000112],CIGNA [100011201],,,68,,10028.2524,4918.267905,20059.3336,percent of total billed charges,,,
Interstitial Lung Disease Without Cc/McC,198,MS-DRG,,,,,,,inpatient,,,102750.94,71925.658,CIGNA [1000112],CIGNA [100011201],,,68,,69870.6392,5370.829997,82200.752,percent of total billed charges,,,
Pneumothorax With McC,199,MS-DRG,,,,,,,inpatient,,,30942.21,21659.547,CIGNA [1000112],CIGNA [100011201],,,68,,21040.7028,7771.48,35770.0128,percent of total billed charges,,,
Pneumothorax With Cc,200,MS-DRG,,,,,,,inpatient,,,23899.07,16729.349,CIGNA [1000112],CIGNA [100011201],,,68,,16251.3676,7771.48,22440.3536,percent of total billed charges,,,
Pneumothorax Without Cc/McC,201,MS-DRG,,,,,,,inpatient,,,14142.03,9899.421,CIGNA [1000112],CIGNA [100011201],,,68,,9616.5804,4716.367005,13716.7016,percent of total billed charges,,,
Bronchitis And Asthma With Cc/McC,202,MS-DRG,,,,,,,inpatient,,,14008.78,9806.146,CIGNA [1000112],CIGNA [100011201],,,68,,9525.9704,4671.92813,19589.2088,percent of total billed charges,,,
Bronchitis And Asthma Without Cc/McC,203,MS-DRG,,,,,,,inpatient,,,8434.66,5904.262,CIGNA [1000112],CIGNA [100011201],,,68,,5735.5688,2812.95911,14109.8232,percent of total billed charges,,,
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,inpatient,,,19382.31,13567.617,CIGNA [1000112],CIGNA [100011201],,,68,,13179.9708,5734.05,16432.0776,percent of total billed charges,,,
Other Respiratory System Diagnoses With McC,205,MS-DRG,,,,,,,inpatient,,,29471.66,20630.162,CIGNA [1000112],CIGNA [100011201],,,68,,20040.7288,7771.48,38252.3528,percent of total billed charges,,,
Other Respiratory System Diagnoses Without McC,206,MS-DRG,,,,,,,inpatient,,,18289.13,12802.391,CIGNA [1000112],CIGNA [100011201],,,68,,12436.6084,6099.424855,18355.1312,percent of total billed charges,,,
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,inpatient,,,153413.76,107389.632,CIGNA [1000112],CIGNA [100011201],,,68,,104321.3568,7771.48,131061.4728,percent of total billed charges,,,
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,inpatient,,,60056.19,42039.333,CIGNA [1000112],CIGNA [100011201],,,68,,40838.2092,7771.48,54390.6024,percent of total billed charges,,,
Other Heart Assist System Implant,215,MS-DRG,,,,,,,inpatient,,,163000.7,114100.49,CIGNA [1000112],CIGNA [100011201],,,68,,110840.476,7771.48,214680.8688,percent of total billed charges,,,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/McC,218,MS-DRG,,,,,,,inpatient,,,144438.6,101107.02,CIGNA [1000112],CIGNA [100011201],,,68,,98218.248,7771.48,120552.5624,percent of total billed charges,,,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/McC,221,MS-DRG,,,,,,,inpatient,,,282573.82,197801.674,CIGNA [1000112],CIGNA [100011201],,,68,,192150.1976,7771.48,226059.056,percent of total billed charges,,,
Other Cardiothoracic Procedures With McC,228,MS-DRG,,,,,,,inpatient,,,215439.26,150807.482,CIGNA [1000112],CIGNA [100011201],,,68,,146498.6968,7771.48,172351.408,percent of total billed charges,,,
Coronary Bypass With Cardiac Catheterization Or Open Ablation With McC,233,MS-DRG,,,,,,,inpatient,,,335724.2,235006.94,CIGNA [1000112],CIGNA [100011201],,,68,,228292.456,7771.48,268579.36,percent of total billed charges,,,
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without McC,234,MS-DRG,,,,,,,inpatient,,,168474.77,117932.339,CIGNA [1000112],CIGNA [100011201],,,68,,114562.8436,7771.48,134779.816,percent of total billed charges,,,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With McC,239,MS-DRG,,,,,,,inpatient,,,57370.89,40159.623,CIGNA [1000112],CIGNA [100011201],,,68,,39012.2052,7771.48,102059.636,percent of total billed charges,,,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,inpatient,,,51903.54,36332.478,CIGNA [1000112],CIGNA [100011201],,,68,,35294.4072,7771.48,59008.768,percent of total billed charges,,,
Permanent Cardiac Pacemaker Implant With McC,242,MS-DRG,,,,,,,inpatient,,,86942.73,60859.911,CIGNA [1000112],CIGNA [100011201],,,68,,59121.0564,7771.48,69554.184,percent of total billed charges,,,
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,inpatient,,,65531.01,45871.707,CIGNA [1000112],CIGNA [100011201],,,68,,44561.0868,7771.48,52424.808,percent of total billed charges,,,
Permanent Cardiac Pacemaker Implant Without Cc/McC,244,MS-DRG,,,,,,,inpatient,,,63411.07,44387.749,CIGNA [1000112],CIGNA [100011201],,,68,,43119.5276,7771.48,50728.856,percent of total billed charges,,,
Aicd Generator Procedures,245,MS-DRG,,,,,,,inpatient,,,15907.12,11134.984,CIGNA [1000112],CIGNA [100011201],,,68,,10816.8416,5305.02452,99020.036,percent of total billed charges,,,
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without McC,251,MS-DRG,,,,,,,inpatient,,,55424.98,38797.486,CIGNA [1000112],CIGNA [100011201],,,68,,37688.9864,7771.48,44339.984,percent of total billed charges,,,
Other Vascular Procedures With McC,252,MS-DRG,,,,,,,inpatient,,,85181.97,59627.379,CIGNA [1000112],CIGNA [100011201],,,68,,57923.7396,7771.48,69509.5728,percent of total billed charges,,,
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,inpatient,,,82797.33,57958.131,CIGNA [1000112],CIGNA [100011201],,,68,,56302.1844,7771.48,66237.864,percent of total billed charges,,,
Other Vascular Procedures Without Cc/McC,254,MS-DRG,,,,,,,inpatient,,,61488.65,43042.055,CIGNA [1000112],CIGNA [100011201],,,68,,41812.282,7771.48,49190.92,percent of total billed charges,,,
Upper Limb And Toe Amputation For Circulatory System Disorders With McC,255,MS-DRG,,,,,,,inpatient,,,163135.56,114194.892,CIGNA [1000112],CIGNA [100011201],,,68,,110932.1808,7771.48,130508.448,percent of total billed charges,,,
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,inpatient,,,13744.76,9621.332,CIGNA [1000112],CIGNA [100011201],,,68,,9346.4368,4583.87746,34319.1104,percent of total billed charges,,,
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/McC,257,MS-DRG,,,,,,,inpatient,,,13802.75,9661.925,CIGNA [1000112],CIGNA [100011201],,,68,,9385.87,4603.217125,18073.4616,percent of total billed charges,,,
Cardiac Pacemaker Device Replacement Without McC,259,MS-DRG,,,,,,,inpatient,,,51584.98,36109.486,CIGNA [1000112],CIGNA [100011201],,,68,,35077.7864,7771.48,41267.984,percent of total billed charges,,,
Cardiac Pacemaker Revision Except Device Replacement With McC,260,MS-DRG,,,,,,,inpatient,,,218275.68,152792.976,CIGNA [1000112],CIGNA [100011201],,,68,,148427.4624,7771.48,174620.544,percent of total billed charges,,,
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,inpatient,,,57651.04,40355.728,CIGNA [1000112],CIGNA [100011201],,,68,,39202.7072,7771.48,46120.832,percent of total billed charges,,,
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,inpatient,,,28475.53,19932.871,CIGNA [1000112],CIGNA [100011201],,,68,,19363.3604,7771.48,70820.6536,percent of total billed charges,,,
Aortic And Heart Assist Procedures Except Pulsation Balloon With McC,268,MS-DRG,,,,,,,inpatient,,,101907.56,71335.292,CIGNA [1000112],CIGNA [100011201],,,68,,69297.1408,7771.48,135104.1408,percent of total billed charges,,,
Aortic And Heart Assist Procedures Except Pulsation Balloon Without McC,269,MS-DRG,,,,,,,inpatient,,,145888.49,102121.943,CIGNA [1000112],CIGNA [100011201],,,68,,99204.1732,7771.48,116710.792,percent of total billed charges,,,
Other Major Cardiovascular Procedures With McC,270,MS-DRG,,,,,,,inpatient,,,185659.89,129961.923,CIGNA [1000112],CIGNA [100011201],,,68,,126248.7252,7771.48,148527.912,percent of total billed charges,,,
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,inpatient,,,127626.27,89338.389,CIGNA [1000112],CIGNA [100011201],,,68,,86785.8636,7771.48,102101.016,percent of total billed charges,,,
Other Major Cardiovascular Procedures Without Cc/McC,272,MS-DRG,,,,,,,inpatient,,,104134.1,72893.87,CIGNA [1000112],CIGNA [100011201],,,68,,70811.188,7771.48,83307.28,percent of total billed charges,,,
Percutaneous And Other Intracardiac Procedures Without McC,274,MS-DRG,,,,,,,inpatient,,,98959.28,69271.496,CIGNA [1000112],CIGNA [100011201],,,68,,67292.3104,7771.48,79167.424,percent of total billed charges,,,
Cardiac Defibrillator Implant With Cardiac Catheterization And McC,275,MS-DRG,,,,,,,inpatient,,,167450.04,117215.028,CIGNA [1000112],CIGNA [100011201],,,68,,113866.0272,7771.48,143195.556,percent of total billed charges,,,
Cardiac Defibrillator Implant Without McC,277,MS-DRG,,,,,,,inpatient,,,278318.05,194822.635,CIGNA [1000112],CIGNA [100011201],,,68,,189256.274,7771.48,222654.44,percent of total billed charges,,,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With McC,278,MS-DRG,,,,,,,inpatient,,,130044.83,91031.381,CIGNA [1000112],CIGNA [100011201],,,68,,88430.4844,7771.48,104035.864,percent of total billed charges,,,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without McC,279,MS-DRG,,,,,,,inpatient,,,135336.66,94735.662,CIGNA [1000112],CIGNA [100011201],,,68,,92028.9288,7771.48,108269.328,percent of total billed charges,,,
Acute Myocardial Infarction- Discharged Alive With McC,280,MS-DRG,,,,,,,inpatient,,,31571.18,22099.826,CIGNA [1000112],CIGNA [100011201],,,68,,21468.4024,7771.48,33263.356,percent of total billed charges,,,
Acute Myocardial Infarction- Discharged Alive With Cc,281,MS-DRG,,,,,,,inpatient,,,22298.62,15609.034,CIGNA [1000112],CIGNA [100011201],,,68,,15163.0616,6744.11,18679.3552,percent of total billed charges,,,
Acute Myocardial Infarction- Discharged Alive Without Cc/McC,282,MS-DRG,,,,,,,inpatient,,,15726.17,11008.319,CIGNA [1000112],CIGNA [100011201],,,68,,10693.7956,5244.677695,14693.4264,percent of total billed charges,,,
Acute Myocardial Infarction- Expired With McC,283,MS-DRG,,,,,,,inpatient,,,47695.81,33387.067,CIGNA [1000112],CIGNA [100011201],,,68,,32433.1508,7771.48,39624.2256,percent of total billed charges,,,
Acute Myocardial Infarction- Expired With Cc,284,MS-DRG,,,,,,,inpatient,,,30935.67,21654.969,CIGNA [1000112],CIGNA [100011201],,,68,,21036.2556,5312.22,24748.536,percent of total billed charges,,,
Circulatory Disorders Except Ami- With Cardiac Catheterization With McC,286,MS-DRG,,,,,,,inpatient,,,48769.97,34138.979,CIGNA [1000112],CIGNA [100011201],,,68,,33163.5796,7771.48,44850.3112,percent of total billed charges,,,
Circulatory Disorders Except Ami- With Cardiac Catheterization Without McC,287,MS-DRG,,,,,,,inpatient,,,33854.25,23697.975,CIGNA [1000112],CIGNA [100011201],,,68,,23020.89,7771.48,27083.4,percent of total billed charges,,,
Acute And Subacute Endocarditis With McC,288,MS-DRG,,,,,,,inpatient,,,36276.49,25393.543,CIGNA [1000112],CIGNA [100011201],,,68,,24668.0132,7771.48,55347.0632,percent of total billed charges,,,
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,inpatient,,,34648,24253.6,CIGNA [1000112],CIGNA [100011201],,,68,,23560.64,7771.48,31948.2224,percent of total billed charges,,,
Heart Failure And Shock With McC,291,MS-DRG,,,,,,,inpatient,,,22051.33,15435.931,CIGNA [1000112],CIGNA [100011201],,,68,,14994.9044,7354.118555,26442.4936,percent of total billed charges,,,
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,inpatient,,,17435.09,12204.563,CIGNA [1000112],CIGNA [100011201],,,68,,11855.8612,5814.602515,17453.3832,percent of total billed charges,,,
Cardiac Arrest- Unexplained With McC,296,MS-DRG,,,,,,,inpatient,,,34260.06,23982.042,CIGNA [1000112],CIGNA [100011201],,,68,,23296.8408,7771.48,33198.5112,percent of total billed charges,,,
Peripheral Vascular Disorders With McC,299,MS-DRG,,,,,,,inpatient,,,30642.24,21449.568,CIGNA [1000112],CIGNA [100011201],,,68,,20836.7232,7771.48,32781.0728,percent of total billed charges,,,
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,inpatient,,,19909.9,13936.93,CIGNA [1000112],CIGNA [100011201],,,68,,13538.732,6639.95165,21692.612,percent of total billed charges,,,
Peripheral Vascular Disorders Without Cc/McC,301,MS-DRG,,,,,,,inpatient,,,15022.69,10515.883,CIGNA [1000112],CIGNA [100011201],,,68,,10215.4292,5010.067115,14454.3112,percent of total billed charges,,,
Atherosclerosis With McC,302,MS-DRG,,,,,,,inpatient,,,19965.6,13975.92,CIGNA [1000112],CIGNA [100011201],,,68,,13576.608,6658.5276,23571.0848,percent of total billed charges,,,
Atherosclerosis Without McC,303,MS-DRG,,,,,,,inpatient,,,16291.73,11404.211,CIGNA [1000112],CIGNA [100011201],,,68,,11078.3764,4894.02,13625.5136,percent of total billed charges,,,
Hypertension With McC,304,MS-DRG,,,,,,,inpatient,,,26689.62,18682.734,CIGNA [1000112],CIGNA [100011201],,,68,,18148.9416,7771.48,23806.1472,percent of total billed charges,,,
Hypertension Without McC,305,MS-DRG,,,,,,,inpatient,,,17122.11,11985.477,CIGNA [1000112],CIGNA [100011201],,,68,,11643.0348,5343.34,15212.1848,percent of total billed charges,,,
Cardiac Congenital And Valvular Disorders With McC,306,MS-DRG,,,,,,,inpatient,,,18809.29,13166.503,CIGNA [1000112],CIGNA [100011201],,,68,,12790.3172,6272.898215,30343.3136,percent of total billed charges,,,
Cardiac Congenital And Valvular Disorders Without McC,307,MS-DRG,,,,,,,inpatient,,,16249.07,11374.349,CIGNA [1000112],CIGNA [100011201],,,68,,11049.3676,5419.064845,18770.5432,percent of total billed charges,,,
Cardiac Arrhythmia And Conduction Disorders With McC,308,MS-DRG,,,,,,,inpatient,,,21486.31,15040.417,CIGNA [1000112],CIGNA [100011201],,,68,,14610.6908,7165.684385,24438.384,percent of total billed charges,,,
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,inpatient,,,15843.59,11090.513,CIGNA [1000112],CIGNA [100011201],,,68,,10773.6412,5283.837265,14981.1752,percent of total billed charges,,,
Cardiac Arrhythmia And Conduction Disorders Without Cc/McC,310,MS-DRG,,,,,,,inpatient,,,13559.61,9491.727,CIGNA [1000112],CIGNA [100011201],,,68,,9220.5348,4040.24,11337.708,percent of total billed charges,,,
Angina Pectoris,311,MS-DRG,,,,,,,inpatient,,,18298.95,12809.265,CIGNA [1000112],CIGNA [100011201],,,68,,12443.286,5043.07,14639.16,percent of total billed charges,,,
Syncope And Collapse,312,MS-DRG,,,,,,,inpatient,,,18654.24,13057.968,CIGNA [1000112],CIGNA [100011201],,,68,,12684.8832,6057.47,17656.0232,percent of total billed charges,,,
Chest Pain,313,MS-DRG,,,,,,,inpatient,,,18746.43,13122.501,CIGNA [1000112],CIGNA [100011201],,,68,,12747.5724,5215.27,14997.144,percent of total billed charges,,,
Other Circulatory System Diagnoses With McC,314,MS-DRG,,,,,,,inpatient,,,33351.93,23346.351,CIGNA [1000112],CIGNA [100011201],,,68,,22679.3124,7771.48,43636.4976,percent of total billed charges,,,
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,inpatient,,,17192.63,12034.841,CIGNA [1000112],CIGNA [100011201],,,68,,11690.9884,5733.742105,19500.0472,percent of total billed charges,,,
Other Circulatory System Diagnoses Without Cc/McC,316,MS-DRG,,,,,,,inpatient,,,16812.59,11768.813,CIGNA [1000112],CIGNA [100011201],,,68,,11432.5612,5422.92,13832.2064,percent of total billed charges,,,
Percutaneous Cardiovascular Procedures With Intraluminal Device With McC Or 4+ Arteries/Intraluminal Devices,321,MS-DRG,,,,,,,inpatient,,,107897.8,75528.46,CIGNA [1000112],CIGNA [100011201],,,68,,73370.504,7771.48,86318.24,percent of total billed charges,,,
Percutaneous Cardiovascular Procedures With Intraluminal Device Without McC,322,MS-DRG,,,,,,,inpatient,,,85234.32,59664.024,CIGNA [1000112],CIGNA [100011201],,,68,,57959.3376,7771.48,68187.456,percent of total billed charges,,,
Coronary Intravascular Lithotripsy With Intraluminal Device With McC,323,MS-DRG,,,,,,,inpatient,,,110878.49,77614.943,CIGNA [1000112],CIGNA [100011201],,,68,,75397.3732,7771.48,88702.792,percent of total billed charges,,,
Coronary Intravascular Lithotripsy With Intraluminal Device Without McC,324,MS-DRG,,,,,,,inpatient,,,99829.51,69880.657,CIGNA [1000112],CIGNA [100011201],,,68,,67884.0668,7771.48,79863.608,percent of total billed charges,,,
Stomach- Esophageal And Duodenal Procedures With McC,326,MS-DRG,,,,,,,inpatient,,,70344.55,49241.185,CIGNA [1000112],CIGNA [100011201],,,68,,47834.294,7771.48,102914.7768,percent of total billed charges,,,
Stomach- Esophageal And Duodenal Procedures With Cc,327,MS-DRG,,,,,,,inpatient,,,76692.68,53684.876,CIGNA [1000112],CIGNA [100011201],,,68,,52151.0224,7771.48,61354.144,percent of total billed charges,,,
Stomach- Esophageal And Duodenal Procedures Without Cc/McC,328,MS-DRG,,,,,,,inpatient,,,58306.69,40814.683,CIGNA [1000112],CIGNA [100011201],,,68,,39648.5492,7771.48,46645.352,percent of total billed charges,,,
Major Small And Large Bowel Procedures With McC,329,MS-DRG,,,,,,,inpatient,,,92091.01,64463.707,CIGNA [1000112],CIGNA [100011201],,,68,,62621.8868,7771.48,93046.2088,percent of total billed charges,,,
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,inpatient,,,66292.87,46405.009,CIGNA [1000112],CIGNA [100011201],,,68,,45079.1516,7771.48,53034.296,percent of total billed charges,,,
Major Small And Large Bowel Procedures Without Cc/McC,331,MS-DRG,,,,,,,inpatient,,,44944.36,31461.052,CIGNA [1000112],CIGNA [100011201],,,68,,30562.1648,7771.48,35955.488,percent of total billed charges,,,
Rectal Resection With McC,332,MS-DRG,,,,,,,inpatient,,,65516.56,45861.592,CIGNA [1000112],CIGNA [100011201],,,68,,44551.2608,7771.48,70285.684,percent of total billed charges,,,
Rectal Resection With Cc,333,MS-DRG,,,,,,,inpatient,,,51060.47,35742.329,CIGNA [1000112],CIGNA [100011201],,,68,,34721.1196,7771.48,43063.0264,percent of total billed charges,,,
Peritoneal Adhesiolysis With McC,335,MS-DRG,,,,,,,inpatient,,,76073.75,53251.625,CIGNA [1000112],CIGNA [100011201],,,68,,51730.15,7771.48,73434.7096,percent of total billed charges,,,
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,inpatient,,,39391.39,27573.973,CIGNA [1000112],CIGNA [100011201],,,68,,26786.1452,7771.48,42805.6736,percent of total billed charges,,,
Peritoneal Adhesiolysis Without Cc/McC,337,MS-DRG,,,,,,,inpatient,,,43856.45,30699.515,CIGNA [1000112],CIGNA [100011201],,,68,,29822.386,7771.48,35085.16,percent of total billed charges,,,
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,inpatient,,,22777.13,15943.991,CIGNA [1000112],CIGNA [100011201],,,68,,15488.4484,7596.172855,30177.1488,percent of total billed charges,,,
Minor Small And Large Bowel Procedures Without Cc/McC,346,MS-DRG,,,,,,,inpatient,,,25360.83,17752.581,CIGNA [1000112],CIGNA [100011201],,,68,,17245.3644,7771.48,25232.7328,percent of total billed charges,,,
Anal And Stomal Procedures With McC,347,MS-DRG,,,,,,,inpatient,,,33046.94,23132.858,CIGNA [1000112],CIGNA [100011201],,,68,,22471.9192,7771.48,47956.7824,percent of total billed charges,,,
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,inpatient,,,21678.05,15174.635,CIGNA [1000112],CIGNA [100011201],,,68,,14741.074,7229.629675,25508.3232,percent of total billed charges,,,
Anal And Stomal Procedures Without Cc/McC,349,MS-DRG,,,,,,,inpatient,,,20851.83,14596.281,CIGNA [1000112],CIGNA [100011201],,,68,,14179.2444,6954.085305,17850.5576,percent of total billed charges,,,
Inguinal And Femoral Hernia Procedures With McC,350,MS-DRG,,,,,,,inpatient,,,123839.74,86687.818,CIGNA [1000112],CIGNA [100011201],,,68,,84211.0232,7771.48,99071.792,percent of total billed charges,,,
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,inpatient,,,41444.06,29010.842,CIGNA [1000112],CIGNA [100011201],,,68,,28181.9608,7771.48,33155.248,percent of total billed charges,,,
Inguinal And Femoral Hernia Procedures Without Cc/McC,352,MS-DRG,,,,,,,inpatient,,,27314.17,19119.919,CIGNA [1000112],CIGNA [100011201],,,68,,18573.6356,7771.48,22341.06,percent of total billed charges,,,
Hernia Procedures Except Inguinal And Femoral With McC,353,MS-DRG,,,,,,,inpatient,,,60356.38,42249.466,CIGNA [1000112],CIGNA [100011201],,,68,,41042.3384,7771.48,59430.2592,percent of total billed charges,,,
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,inpatient,,,30185.36,21129.752,CIGNA [1000112],CIGNA [100011201],,,68,,20526.0448,7771.48,34471.0904,percent of total billed charges,,,
Hernia Procedures Except Inguinal And Femoral Without Cc/McC,355,MS-DRG,,,,,,,inpatient,,,34745.89,24322.123,CIGNA [1000112],CIGNA [100011201],,,68,,23627.2052,7771.48,27796.712,percent of total billed charges,,,
Other Digestive System O.R. Procedures With McC,356,MS-DRG,,,,,,,inpatient,,,122041.99,85429.393,CIGNA [1000112],CIGNA [100011201],,,68,,82988.5532,7771.48,97633.592,percent of total billed charges,,,
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,inpatient,,,40025.14,28017.598,CIGNA [1000112],CIGNA [100011201],,,68,,27217.0952,7771.48,45632.5016,percent of total billed charges,,,
Other Digestive System O.R. Procedures Without Cc/McC,358,MS-DRG,,,,,,,inpatient,,,22899.78,16029.846,CIGNA [1000112],CIGNA [100011201],,,68,,15571.8504,7637.07663,27457.72,percent of total billed charges,,,
Major Esophageal Disorders With McC,368,MS-DRG,,,,,,,inpatient,,,52357.14,36649.998,CIGNA [1000112],CIGNA [100011201],,,68,,35602.8552,7771.48,41885.712,percent of total billed charges,,,
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,inpatient,,,25013.89,17509.723,CIGNA [1000112],CIGNA [100011201],,,68,,17009.4452,7771.48,20620.6464,percent of total billed charges,,,
Major Gastrointestinal Disorders And Peritoneal Infections With McC,371,MS-DRG,,,,,,,inpatient,,,31663.98,22164.786,CIGNA [1000112],CIGNA [100011201],,,68,,21531.5064,7771.48,35427.5512,percent of total billed charges,,,
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,inpatient,,,22657.22,15860.054,CIGNA [1000112],CIGNA [100011201],,,68,,15406.9096,7435.09,20857.7352,percent of total billed charges,,,
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/McC,373,MS-DRG,,,,,,,inpatient,,,16862.96,11804.072,CIGNA [1000112],CIGNA [100011201],,,68,,11466.8128,5379.51,14697.4792,percent of total billed charges,,,
Digestive Malignancy With McC,374,MS-DRG,,,,,,,inpatient,,,35452.33,24816.631,CIGNA [1000112],CIGNA [100011201],,,68,,24107.5844,7771.48,42787.436,percent of total billed charges,,,
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,inpatient,,,28899.99,20229.993,CIGNA [1000112],CIGNA [100011201],,,68,,19651.9932,7771.48,24898.3768,percent of total billed charges,,,
Digestive Malignancy Without Cc/McC,376,MS-DRG,,,,,,,inpatient,,,13461.5,9423.05,CIGNA [1000112],CIGNA [100011201],,,68,,9153.82,4489.41025,17891.0856,percent of total billed charges,,,
Gastrointestinal Hemorrhage With McC,377,MS-DRG,,,,,,,inpatient,,,36368.06,25457.642,CIGNA [1000112],CIGNA [100011201],,,68,,24730.2808,7771.48,36841.9784,percent of total billed charges,,,
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,inpatient,,,26039.38,18227.566,CIGNA [1000112],CIGNA [100011201],,,68,,17706.7784,7186.19,20831.504,percent of total billed charges,,,
Gastrointestinal Hemorrhage Without Cc/McC,379,MS-DRG,,,,,,,inpatient,,,12685.62,8879.934,CIGNA [1000112],CIGNA [100011201],,,68,,8626.2216,4230.65427,12900.0624,percent of total billed charges,,,
Complicated Peptic Ulcer With McC,380,MS-DRG,,,,,,,inpatient,,,33309.68,23316.776,CIGNA [1000112],CIGNA [100011201],,,68,,22650.5824,7771.48,38994.0152,percent of total billed charges,,,
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,inpatient,,,25551.79,17886.253,CIGNA [1000112],CIGNA [100011201],,,68,,17375.2172,7667.34,22069.5224,percent of total billed charges,,,
Uncomplicated Peptic Ulcer With McC,383,MS-DRG,,,,,,,inpatient,,,17337.01,12135.907,CIGNA [1000112],CIGNA [100011201],,,68,,11789.1668,5781.892835,25617.7488,percent of total billed charges,,,
Uncomplicated Peptic Ulcer Without McC,384,MS-DRG,,,,,,,inpatient,,,17367.77,12157.439,CIGNA [1000112],CIGNA [100011201],,,68,,11810.0836,5792.151295,17621.5744,percent of total billed charges,,,
Inflammatory Bowel Disease With McC,385,MS-DRG,,,,,,,inpatient,,,26393.7,18475.59,CIGNA [1000112],CIGNA [100011201],,,68,,17947.716,7771.48,32922.9208,percent of total billed charges,,,
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,inpatient,,,16705.38,11693.766,CIGNA [1000112],CIGNA [100011201],,,68,,11359.6584,5571.24423,20109.9936,percent of total billed charges,,,
Inflammatory Bowel Disease Without Cc/McC,387,MS-DRG,,,,,,,inpatient,,,12511.84,8758.288,CIGNA [1000112],CIGNA [100011201],,,68,,8508.0512,4172.69864,13582.9592,percent of total billed charges,,,
Gastrointestinal Obstruction With McC,388,MS-DRG,,,,,,,inpatient,,,25855.59,18098.913,CIGNA [1000112],CIGNA [100011201],,,68,,17581.8012,7771.48,29788.08,percent of total billed charges,,,
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,inpatient,,,16977.78,11884.446,CIGNA [1000112],CIGNA [100011201],,,68,,11544.8904,5662.08963,16245.6488,percent of total billed charges,,,
Gastrointestinal Obstruction Without Cc/McC,390,MS-DRG,,,,,,,inpatient,,,12959.35,9071.545,CIGNA [1000112],CIGNA [100011201],,,68,,8812.358,4215.34,11086.4344,percent of total billed charges,,,
Esophagitis- Gastroenteritis And Miscellaneous Digestive Disorders With McC,391,MS-DRG,,,,,,,inpatient,,,20838.16,14586.712,CIGNA [1000112],CIGNA [100011201],,,68,,14169.9488,6949.52636,26037.2136,percent of total billed charges,,,
Esophagitis- Gastroenteritis And Miscellaneous Digestive Disorders Without McC,392,MS-DRG,,,,,,,inpatient,,,16987.8,11891.46,CIGNA [1000112],CIGNA [100011201],,,68,,11551.704,5530.73,15811.9992,percent of total billed charges,,,
Other Digestive System Diagnoses With McC,393,MS-DRG,,,,,,,inpatient,,,37534.54,26274.178,CIGNA [1000112],CIGNA [100011201],,,68,,25523.4872,7771.48,33555.1576,percent of total billed charges,,,
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,inpatient,,,23011.57,16108.099,CIGNA [1000112],CIGNA [100011201],,,68,,15647.8676,6791.14,19074.5032,percent of total billed charges,,,
Other Digestive System Diagnoses Without Cc/McC,395,MS-DRG,,,,,,,inpatient,,,17300.89,12110.623,CIGNA [1000112],CIGNA [100011201],,,68,,11764.6052,4700.83,13840.712,percent of total billed charges,,,
Appendix Procedures With McC,397,MS-DRG,,,,,,,inpatient,,,61991.24,43393.868,CIGNA [1000112],CIGNA [100011201],,,68,,42154.0432,7771.48,50206.0864,percent of total billed charges,,,
Appendix Procedures With Cc,398,MS-DRG,,,,,,,inpatient,,,56760.43,39732.301,CIGNA [1000112],CIGNA [100011201],,,68,,38597.0924,7771.48,45408.344,percent of total billed charges,,,
Appendix Procedures Without Cc/McC,399,MS-DRG,,,,,,,inpatient,,,27586.47,19310.529,CIGNA [1000112],CIGNA [100011201],,,68,,18758.7996,7771.48,22778.7624,percent of total billed charges,,,
Pancreas- Liver And Shunt Procedures With McC,405,MS-DRG,,,,,,,inpatient,,,46019.16,32213.412,CIGNA [1000112],CIGNA [100011201],,,68,,31293.0288,7771.48,110001.0976,percent of total billed charges,,,
Pancreas- Liver And Shunt Procedures With Cc,406,MS-DRG,,,,,,,inpatient,,,55926.32,39148.424,CIGNA [1000112],CIGNA [100011201],,,68,,38029.8976,7771.48,56905.3648,percent of total billed charges,,,
Pancreas- Liver And Shunt Procedures Without Cc/McC,407,MS-DRG,,,,,,,inpatient,,,51764.06,36234.842,CIGNA [1000112],CIGNA [100011201],,,68,,35199.5608,7771.48,43275.7984,percent of total billed charges,,,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,inpatient,,,23884.65,16719.255,CIGNA [1000112],CIGNA [100011201],,,68,,16241.562,7771.48,42479.4232,percent of total billed charges,,,
Laparoscopic Cholecystectomy Without C.D.E. With McC,417,MS-DRG,,,,,,,inpatient,,,63968.01,44777.607,CIGNA [1000112],CIGNA [100011201],,,68,,43498.2468,7771.48,51174.408,percent of total billed charges,,,
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,inpatient,,,44129.12,30890.384,CIGNA [1000112],CIGNA [100011201],,,68,,30007.8016,7771.48,35303.296,percent of total billed charges,,,
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/McC,419,MS-DRG,,,,,,,inpatient,,,36100.79,25270.553,CIGNA [1000112],CIGNA [100011201],,,68,,24548.5372,7771.48,28880.632,percent of total billed charges,,,
Hepatobiliary Diagnostic Procedures With McC,420,MS-DRG,,,,,,,inpatient,,,75254.61,52678.227,CIGNA [1000112],CIGNA [100011201],,,68,,51173.1348,7771.48,71515.7088,percent of total billed charges,,,
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,,,inpatient,,,37061.98,25943.386,CIGNA [1000112],CIGNA [100011201],,,68,,25202.1464,7771.48,33182.3,percent of total billed charges,,,
Hepatobiliary Diagnostic Procedures Without Cc/McC,422,MS-DRG,,,,,,,inpatient,,,34064.62,23845.234,CIGNA [1000112],CIGNA [100011201],,,68,,23163.9416,7771.48,29773.8952,percent of total billed charges,,,
Other Hepatobiliary Or Pancreas O.R. Procedures With McC,423,MS-DRG,,,,,,,inpatient,,,81747.41,57223.187,CIGNA [1000112],CIGNA [100011201],,,68,,55588.2388,7771.48,82415.7144,percent of total billed charges,,,
Cirrhosis And Alcoholic Hepatitis With McC,432,MS-DRG,,,,,,,inpatient,,,29574.59,20702.213,CIGNA [1000112],CIGNA [100011201],,,68,,20110.7212,7771.48,39699.2024,percent of total billed charges,,,
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,inpatient,,,21623.94,15136.758,CIGNA [1000112],CIGNA [100011201],,,68,,14704.2792,7211.58399,21676.4008,percent of total billed charges,,,
Cirrhosis And Alcoholic Hepatitis Without Cc/McC,434,MS-DRG,,,,,,,inpatient,,,14349.7,10044.79,CIGNA [1000112],CIGNA [100011201],,,68,,9757.796,4483.05,14111.8496,percent of total billed charges,,,
Malignancy Of Hepatobiliary System Or Pancreas With McC,435,MS-DRG,,,,,,,inpatient,,,41847.14,29292.998,CIGNA [1000112],CIGNA [100011201],,,68,,28456.0552,7771.48,36971.668,percent of total billed charges,,,
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,inpatient,,,20489.14,14342.398,CIGNA [1000112],CIGNA [100011201],,,68,,13932.6152,6833.12819,22849.6864,percent of total billed charges,,,
Disorders Of Pancreas Except Malignancy With McC,438,MS-DRG,,,,,,,inpatient,,,28902.5,20231.75,CIGNA [1000112],CIGNA [100011201],,,68,,19653.7,7771.48,33715.2432,percent of total billed charges,,,
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,inpatient,,,16481.74,11537.218,CIGNA [1000112],CIGNA [100011201],,,68,,11207.5832,5496.66029,17431.0928,percent of total billed charges,,,
Disorders Of Pancreas Except Malignancy Without Cc/McC,440,MS-DRG,,,,,,,inpatient,,,15295.1,10706.57,CIGNA [1000112],CIGNA [100011201],,,68,,10400.668,4383.92,12464.3864,percent of total billed charges,,,
Disorders Of Liver Except Malignancy- Cirrhosis Or Alcoholic Hepatitis With McC,441,MS-DRG,,,,,,,inpatient,,,34043.85,23830.695,CIGNA [1000112],CIGNA [100011201],,,68,,23149.818,7771.48,38305.0392,percent of total billed charges,,,
Disorders Of Liver Except Malignancy- Cirrhosis Or Alcoholic Hepatitis With Cc,442,MS-DRG,,,,,,,inpatient,,,21274.77,14892.339,CIGNA [1000112],CIGNA [100011201],,,68,,14466.8436,6740.49,19579.0768,percent of total billed charges,,,
Disorders Of Liver Except Malignancy- Cirrhosis Or Alcoholic Hepatitis Without Cc/McC,443,MS-DRG,,,,,,,inpatient,,,11297.88,7908.516,CIGNA [1000112],CIGNA [100011201],,,68,,7682.5584,3767.84298,14237.4864,percent of total billed charges,,,
Disorders Of The Biliary Tract With McC,444,MS-DRG,,,,,,,inpatient,,,39694.28,27785.996,CIGNA [1000112],CIGNA [100011201],,,68,,26992.1104,7771.48,34134.708,percent of total billed charges,,,
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,inpatient,,,32558.38,22790.866,CIGNA [1000112],CIGNA [100011201],,,68,,22139.6984,7771.48,26046.704,percent of total billed charges,,,
Disorders Of The Biliary Tract Without Cc/McC,446,MS-DRG,,,,,,,inpatient,,,33146.93,23202.851,CIGNA [1000112],CIGNA [100011201],,,68,,22539.9124,5905.53,26517.544,percent of total billed charges,,,
Combined Anterior And Posterior Spinal Fusion With McC,453,MS-DRG,,,,,,,inpatient,,,126551.26,88585.882,CIGNA [1000112],CIGNA [100011201],,,68,,86054.8568,7771.48,101241.008,percent of total billed charges,,,
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,,,inpatient,,,108469.17,75928.419,CIGNA [1000112],CIGNA [100011201],,,68,,73759.0356,7771.48,86775.336,percent of total billed charges,,,
Combined Anterior And Posterior Spinal Fusion Without Cc/McC,455,MS-DRG,,,,,,,inpatient,,,115580.93,80906.651,CIGNA [1000112],CIGNA [100011201],,,68,,78595.0324,7771.48,92464.744,percent of total billed charges,,,
Spinal Fusion Except Cervical With Spinal Curvature- Malignancy- Infection Or Extensive Fusions With Cc,457,MS-DRG,,,,,,,inpatient,,,143333.97,100333.779,CIGNA [1000112],CIGNA [100011201],,,68,,97467.0996,7771.48,116295.096,percent of total billed charges,,,
Spinal Fusion Except Cervical With McC,459,MS-DRG,,,,,,,inpatient,,,98009.72,68606.804,CIGNA [1000112],CIGNA [100011201],,,68,,66646.6096,7771.48,78407.776,percent of total billed charges,,,
Spinal Fusion Except Cervical Without McC,460,MS-DRG,,,,,,,inpatient,,,99867.86,69907.502,CIGNA [1000112],CIGNA [100011201],,,68,,67910.1448,7771.48,79894.288,percent of total billed charges,,,
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With McC,461,MS-DRG,,,,,,,inpatient,,,327456.17,229219.319,CIGNA [1000112],CIGNA [100011201],,,68,,222670.1956,7771.48,261964.936,percent of total billed charges,,,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With McC,463,MS-DRG,,,,,,,inpatient,,,128878.42,90214.894,CIGNA [1000112],CIGNA [100011201],,,68,,87637.3256,7771.48,109439.7848,percent of total billed charges,,,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With Cc,464,MS-DRG,,,,,,,inpatient,,,40970.26,28679.182,CIGNA [1000112],CIGNA [100011201],,,68,,27859.7768,7771.48,59750.4304,percent of total billed charges,,,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Without Cc/McC,465,MS-DRG,,,,,,,inpatient,,,35885.97,25120.179,CIGNA [1000112],CIGNA [100011201],,,68,,24402.4596,7771.48,35176.2776,percent of total billed charges,,,
Revision Of Hip Or Knee Replacement With McC,466,MS-DRG,,,,,,,inpatient,,,84828.36,59379.852,CIGNA [1000112],CIGNA [100011201],,,68,,57683.2848,7771.48,103230.8952,percent of total billed charges,,,
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,inpatient,,,72170.88,50519.616,CIGNA [1000112],CIGNA [100011201],,,68,,49076.1984,7771.48,69402.1736,percent of total billed charges,,,
Revision Of Hip Or Knee Replacement Without Cc/McC,468,MS-DRG,,,,,,,inpatient,,,88973.4,62281.38,CIGNA [1000112],CIGNA [100011201],,,68,,60501.912,7771.48,71178.72,percent of total billed charges,,,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With McC Or Total Ankle Replacement,469,MS-DRG,,,,,,,inpatient,,,112079.98,78455.986,CIGNA [1000112],CIGNA [100011201],,,68,,76214.3864,7771.48,89663.984,percent of total billed charges,,,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without McC,470,MS-DRG,,,,,,,inpatient,,,49135.63,34394.941,CIGNA [1000112],CIGNA [100011201],,,68,,33412.2284,7771.48,39308.504,percent of total billed charges,,,
Cervical Spinal Fusion With McC,471,MS-DRG,,,,,,,inpatient,,,68213.66,47749.562,CIGNA [1000112],CIGNA [100011201],,,68,,46385.2888,7771.48,98422.248,percent of total billed charges,,,
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,inpatient,,,62194.58,43536.206,CIGNA [1000112],CIGNA [100011201],,,68,,42292.3144,7771.48,58704.808,percent of total billed charges,,,
Cervical Spinal Fusion Without Cc/McC,473,MS-DRG,,,,,,,inpatient,,,60389.67,42272.769,CIGNA [1000112],CIGNA [100011201],,,68,,41064.9756,7771.48,48311.736,percent of total billed charges,,,
Amputation For Musculoskeletal System And Connective Tissue Disorders With McC,474,MS-DRG,,,,,,,inpatient,,,118369.6,82858.72,CIGNA [1000112],CIGNA [100011201],,,68,,80491.328,7771.48,94695.68,percent of total billed charges,,,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,inpatient,,,42743.34,29920.338,CIGNA [1000112],CIGNA [100011201],,,68,,29065.4712,7771.48,43711.4744,percent of total billed charges,,,
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/McC,476,MS-DRG,,,,,,,inpatient,,,10865.65,7605.955,CIGNA [1000112],CIGNA [100011201],,,68,,7388.642,3623.694275,23567.032,percent of total billed charges,,,
Biopsies Of Musculoskeletal System And Connective Tissue With McC,477,MS-DRG,,,,,,,inpatient,,,79298.26,55508.782,CIGNA [1000112],CIGNA [100011201],,,68,,53922.8168,7771.48,69683.8432,percent of total billed charges,,,
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,inpatient,,,43683.25,30578.275,CIGNA [1000112],CIGNA [100011201],,,68,,29704.61,7771.48,47385.3376,percent of total billed charges,,,
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/McC,479,MS-DRG,,,,,,,inpatient,,,48180.79,33726.553,CIGNA [1000112],CIGNA [100011201],,,68,,32762.9372,7771.48,38544.632,percent of total billed charges,,,
Hip And Femur Procedures Except Major Joint With McC,480,MS-DRG,,,,,,,inpatient,,,63845.68,44691.976,CIGNA [1000112],CIGNA [100011201],,,68,,43415.0624,7771.48,59596.424,percent of total billed charges,,,
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,inpatient,,,51147.69,35803.383,CIGNA [1000112],CIGNA [100011201],,,68,,34780.4292,7771.48,42045.7736,percent of total billed charges,,,
Hip And Femur Procedures Except Major Joint Without Cc/McC,482,MS-DRG,,,,,,,inpatient,,,37492.92,26245.044,CIGNA [1000112],CIGNA [100011201],,,68,,25495.1856,7771.48,32146.8096,percent of total billed charges,,,
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,inpatient,,,82685.37,57879.759,CIGNA [1000112],CIGNA [100011201],,,68,,56226.0516,7771.48,66148.296,percent of total billed charges,,,
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,inpatient,,,54953.11,38467.177,CIGNA [1000112],CIGNA [100011201],,,68,,37368.1148,7771.48,43962.488,percent of total billed charges,,,
Knee Procedures With Principal Diagnosis Of Infection Without Cc/McC,487,MS-DRG,,,,,,,inpatient,,,28558.04,19990.628,CIGNA [1000112],CIGNA [100011201],,,68,,19419.4672,7771.48,32019.1464,percent of total billed charges,,,
Knee Procedures Without Principal Diagnosis Of Infection With Cc/McC,488,MS-DRG,,,,,,,inpatient,,,29907.22,20935.054,CIGNA [1000112],CIGNA [100011201],,,68,,20336.9096,7771.48,39824.8392,percent of total billed charges,,,
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/McC,489,MS-DRG,,,,,,,inpatient,,,28726.07,20108.249,CIGNA [1000112],CIGNA [100011201],,,68,,19533.7276,7771.48,25098.9904,percent of total billed charges,,,
Lower Extremity And Humerus Procedures Except Hip- Foot And Femur With McC,492,MS-DRG,,,,,,,inpatient,,,73476.69,51433.683,CIGNA [1000112],CIGNA [100011201],,,68,,49964.1492,7771.48,71957.464,percent of total billed charges,,,
Lower Extremity And Humerus Procedures Except Hip- Foot And Femur With Cc,493,MS-DRG,,,,,,,inpatient,,,59232.47,41462.729,CIGNA [1000112],CIGNA [100011201],,,68,,40278.0796,7771.48,48653.864,percent of total billed charges,,,
Lower Extremity And Humerus Procedures Except Hip- Foot And Femur Without Cc/McC,494,MS-DRG,,,,,,,inpatient,,,55024.26,38516.982,CIGNA [1000112],CIGNA [100011201],,,68,,37416.4968,7771.48,44019.408,percent of total billed charges,,,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/McC,497,MS-DRG,,,,,,,inpatient,,,25582.79,17907.953,CIGNA [1000112],CIGNA [100011201],,,68,,17396.2972,7771.48,27214.552,percent of total billed charges,,,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/McC,498,MS-DRG,,,,,,,inpatient,,,53889.53,37722.671,CIGNA [1000112],CIGNA [100011201],,,68,,36644.8804,7771.48,51160.5208,percent of total billed charges,,,
Soft Tissue Procedures With McC,500,MS-DRG,,,,,,,inpatient,,,39746.36,27822.452,CIGNA [1000112],CIGNA [100011201],,,68,,27027.5248,7771.48,64206.484,percent of total billed charges,,,
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,inpatient,,,35413.37,24789.359,CIGNA [1000112],CIGNA [100011201],,,68,,24081.0916,7771.48,36169.2136,percent of total billed charges,,,
Soft Tissue Procedures Without Cc/McC,502,MS-DRG,,,,,,,inpatient,,,46820.44,32774.308,CIGNA [1000112],CIGNA [100011201],,,68,,31837.8992,7771.48,37456.352,percent of total billed charges,,,
Foot Procedures With McC,503,MS-DRG,,,,,,,inpatient,,,139085.96,97360.172,CIGNA [1000112],CIGNA [100011201],,,68,,94578.4528,7771.48,111268.768,percent of total billed charges,,,
Foot Procedures With Cc,504,MS-DRG,,,,,,,inpatient,,,58509.52,40956.664,CIGNA [1000112],CIGNA [100011201],,,68,,39786.4736,7771.48,46807.616,percent of total billed charges,,,
Foot Procedures Without Cc/McC,505,MS-DRG,,,,,,,inpatient,,,18215.65,12750.955,CIGNA [1000112],CIGNA [100011201],,,68,,12386.642,6074.919275,35575.4784,percent of total billed charges,,,
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,inpatient,,,34935.4,24454.78,CIGNA [1000112],CIGNA [100011201],,,68,,23756.072,7771.48,30375.736,percent of total billed charges,,,
Major Shoulder Or Elbow Joint Procedures With Cc/McC,507,MS-DRG,,,,,,,inpatient,,,46308.19,32415.733,CIGNA [1000112],CIGNA [100011201],,,68,,31489.5692,7771.48,39273.6584,percent of total billed charges,,,
Major Shoulder Or Elbow Joint Procedures Without Cc/McC,508,MS-DRG,,,,,,,inpatient,,,21924.51,15347.157,CIGNA [1000112],CIGNA [100011201],,,68,,14908.6668,7311.824085,26152.7184,percent of total billed charges,,,
Arthroscopy,509,MS-DRG,,,,,,,inpatient,,,27294.99,19106.493,CIGNA [1000112],CIGNA [100011201],,,68,,18560.5932,7771.48,35593.716,percent of total billed charges,,,
Shoulder- Elbow Or Forearm Procedures- Except Major Joint Procedures With McC,510,MS-DRG,,,,,,,inpatient,,,62572,43800.4,CIGNA [1000112],CIGNA [100011201],,,68,,42548.96,7771.48,57914.512,percent of total billed charges,,,
Shoulder- Elbow Or Forearm Procedures- Except Major Joint Procedures With Cc,511,MS-DRG,,,,,,,inpatient,,,55415.55,38790.885,CIGNA [1000112],CIGNA [100011201],,,68,,37682.574,7771.48,44332.44,percent of total billed charges,,,
Shoulder- Elbow Or Forearm Procedures- Except Major Joint Procedures Without Cc/McC,512,MS-DRG,,,,,,,inpatient,,,47238.2,33066.74,CIGNA [1000112],CIGNA [100011201],,,68,,32121.976,7771.48,37790.56,percent of total billed charges,,,
Hand Or Wrist Procedures- Except Major Thumb Or Joint Procedures With Cc/McC,513,MS-DRG,,,,,,,inpatient,,,43600.38,30520.266,CIGNA [1000112],CIGNA [100011201],,,68,,29648.2584,7771.48,34880.304,percent of total billed charges,,,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With McC,515,MS-DRG,,,,,,,inpatient,,,49277.7,34494.39,CIGNA [1000112],CIGNA [100011201],,,68,,33508.836,7771.48,62660.3408,percent of total billed charges,,,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,inpatient,,,53176.69,37223.683,CIGNA [1000112],CIGNA [100011201],,,68,,36160.1492,7771.48,42541.352,percent of total billed charges,,,
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/McC,517,MS-DRG,,,,,,,inpatient,,,52111.68,36478.176,CIGNA [1000112],CIGNA [100011201],,,68,,35435.9424,7771.48,41689.344,percent of total billed charges,,,
Back And Neck Procedures Except Spinal Fusion With McC Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,inpatient,,,37618.21,26332.747,CIGNA [1000112],CIGNA [100011201],,,68,,25580.3828,7771.48,72622.1232,percent of total billed charges,,,
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,inpatient,,,45454.66,31818.262,CIGNA [1000112],CIGNA [100011201],,,68,,30909.1688,7771.48,39954.5288,percent of total billed charges,,,
Back And Neck Procedures Except Spinal Fusion Without Cc/McC,520,MS-DRG,,,,,,,inpatient,,,30414.64,21290.248,CIGNA [1000112],CIGNA [100011201],,,68,,20681.9552,7771.48,29040.3384,percent of total billed charges,,,
Hip Replacement With Principal Diagnosis Of Hip Fracture With McC,521,MS-DRG,,,,,,,inpatient,,,66299.82,46409.874,CIGNA [1000112],CIGNA [100011201],,,68,,45083.8776,7771.48,59061.4544,percent of total billed charges,,,
Hip Replacement With Principal Diagnosis Of Hip Fracture Without McC,522,MS-DRG,,,,,,,inpatient,,,59172.56,41420.792,CIGNA [1000112],CIGNA [100011201],,,68,,40237.3408,7771.48,47338.048,percent of total billed charges,,,
Fractures Of Femur With McC,533,MS-DRG,,,,,,,inpatient,,,15534.08,10873.856,CIGNA [1000112],CIGNA [100011201],,,68,,10563.1744,5180.61568,30898.5472,percent of total billed charges,,,
Fractures Of Femur Without McC,534,MS-DRG,,,,,,,inpatient,,,23461.3,16422.91,CIGNA [1000112],CIGNA [100011201],,,68,,15953.684,5705.828554,18769.04,percent of total billed charges,,,
Fractures Of Hip And Pelvis With McC,535,MS-DRG,,,,,,,inpatient,,,19899.42,13929.594,CIGNA [1000112],CIGNA [100011201],,,68,,13531.6056,6636.45657,26949.0936,percent of total billed charges,,,
Fractures Of Hip And Pelvis Without McC,536,MS-DRG,,,,,,,inpatient,,,17540.07,12278.049,CIGNA [1000112],CIGNA [100011201],,,68,,11927.2476,5582.83,16432.0776,percent of total billed charges,,,
Sprains- Strains- And Dislocations Of Hip- Pelvis And Thigh With Cc/McC,537,MS-DRG,,,,,,,inpatient,,,18243.05,12770.135,CIGNA [1000112],CIGNA [100011201],,,68,,12405.274,6084.057175,18620.5896,percent of total billed charges,,,
Sprains- Strains- And Dislocations Of Hip- Pelvis And Thigh Without Cc/McC,538,MS-DRG,,,,,,,inpatient,,,12750.59,8925.413,CIGNA [1000112],CIGNA [100011201],,,68,,8670.4012,4252.321765,13607.276,percent of total billed charges,,,
Osteomyelitis With McC,539,MS-DRG,,,,,,,inpatient,,,15126.14,10588.298,CIGNA [1000112],CIGNA [100011201],,,68,,10285.7752,5044.56769,40987.9928,percent of total billed charges,,,
Osteomyelitis With Cc,540,MS-DRG,,,,,,,inpatient,,,18734.75,13114.325,CIGNA [1000112],CIGNA [100011201],,,68,,12739.63,6248.039125,26229.7216,percent of total billed charges,,,
Osteomyelitis Without Cc/McC,541,MS-DRG,,,,,,,inpatient,,,13958.41,9770.887,CIGNA [1000112],CIGNA [100011201],,,68,,9491.7188,4655.129735,17726.9472,percent of total billed charges,,,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With McC,542,MS-DRG,,,,,,,inpatient,,,18971.85,13280.295,CIGNA [1000112],CIGNA [100011201],,,68,,12900.858,6327.111975,37790.3336,percent of total billed charges,,,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,inpatient,,,20157.83,14110.481,CIGNA [1000112],CIGNA [100011201],,,68,,13707.3244,6722.636305,21496.0512,percent of total billed charges,,,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/McC,544,MS-DRG,,,,,,,inpatient,,,15770.25,11039.175,CIGNA [1000112],CIGNA [100011201],,,68,,10723.77,5259.378375,15313.5048,percent of total billed charges,,,
Connective Tissue Disorders With McC,545,MS-DRG,,,,,,,inpatient,,,29219.27,20453.489,CIGNA [1000112],CIGNA [100011201],,,68,,19869.1036,7771.48,51201.0488,percent of total billed charges,,,
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,inpatient,,,19656.15,13759.305,CIGNA [1000112],CIGNA [100011201],,,68,,13366.182,6555.326025,23459.6328,percent of total billed charges,,,
Connective Tissue Disorders Without Cc/McC,547,MS-DRG,,,,,,,inpatient,,,8610.08,6027.056,CIGNA [1000112],CIGNA [100011201],,,68,,5854.8544,2871.46168,15120.9968,percent of total billed charges,,,
Septic Arthritis With Cc,549,MS-DRG,,,,,,,inpatient,,,46061.25,32242.875,CIGNA [1000112],CIGNA [100011201],,,68,,31321.65,7771.48,36849,percent of total billed charges,,,
Medical Back Problems With McC,551,MS-DRG,,,,,,,inpatient,,,27883.52,19518.464,CIGNA [1000112],CIGNA [100011201],,,68,,18960.7936,7771.48,34576.4632,percent of total billed charges,,,
Medical Back Problems Without McC,552,MS-DRG,,,,,,,inpatient,,,22361.84,15653.288,CIGNA [1000112],CIGNA [100011201],,,68,,15206.0512,6815.74,19530.4432,percent of total billed charges,,,
Bone Diseases And Arthropathies With McC,553,MS-DRG,,,,,,,inpatient,,,13901.34,9730.938,CIGNA [1000112],CIGNA [100011201],,,68,,9452.9112,4636.09689,26470.8632,percent of total billed charges,,,
Bone Diseases And Arthropathies Without McC,554,MS-DRG,,,,,,,inpatient,,,18962.8,13273.96,CIGNA [1000112],CIGNA [100011201],,,68,,12894.704,5718.85,16912.3344,percent of total billed charges,,,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without McC,556,MS-DRG,,,,,,,inpatient,,,20178.82,14125.174,CIGNA [1000112],CIGNA [100011201],,,68,,13721.5976,5833.89,16545.556,percent of total billed charges,,,
Tendonitis- Myositis And Bursitis With McC,557,MS-DRG,,,,,,,inpatient,,,32769.21,22938.447,CIGNA [1000112],CIGNA [100011201],,,68,,22283.0628,7771.48,31403.1208,percent of total billed charges,,,
Tendonitis- Myositis And Bursitis Without McC,558,MS-DRG,,,,,,,inpatient,,,15272.59,10690.813,CIGNA [1000112],CIGNA [100011201],,,68,,10385.3612,5093.408765,17504.0432,percent of total billed charges,,,
Aftercare- Musculoskeletal System And Connective Tissue With McC,559,MS-DRG,,,,,,,inpatient,,,16267.53,11387.271,CIGNA [1000112],CIGNA [100011201],,,68,,11061.9204,5425.221255,37612.0104,percent of total billed charges,,,
Aftercare- Musculoskeletal System And Connective Tissue With Cc,560,MS-DRG,,,,,,,inpatient,,,15449.56,10814.692,CIGNA [1000112],CIGNA [100011201],,,68,,10505.7008,5152.42826,23076.6432,percent of total billed charges,,,
Aftercare- Musculoskeletal System And Connective Tissue Without Cc/McC,561,MS-DRG,,,,,,,inpatient,,,9300.65,6510.455,CIGNA [1000112],CIGNA [100011201],,,68,,6324.442,3101.766775,16567.8464,percent of total billed charges,,,
Fracture- Sprain- Strain And Dislocation Except Femur- Hip- Pelvis And Thigh With McC,562,MS-DRG,,,,,,,inpatient,,,32385.67,22669.969,CIGNA [1000112],CIGNA [100011201],,,68,,22022.2556,7771.48,29660.4168,percent of total billed charges,,,
Fracture- Sprain- Strain And Dislocation Except Femur- Hip- Pelvis And Thigh Without McC,563,MS-DRG,,,,,,,inpatient,,,24167.6,16917.32,CIGNA [1000112],CIGNA [100011201],,,68,,16433.968,6300.58,19334.08,percent of total billed charges,,,
Other Musculoskeletal System And Connective Tissue Diagnoses With McC,564,MS-DRG,,,,,,,inpatient,,,25802.93,18062.051,CIGNA [1000112],CIGNA [100011201],,,68,,17545.9924,7771.48,31798.2688,percent of total billed charges,,,
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,inpatient,,,22006.13,15404.291,CIGNA [1000112],CIGNA [100011201],,,68,,14964.1684,7280.97,20661.1744,percent of total billed charges,,,
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/McC,566,MS-DRG,,,,,,,inpatient,,,6764.1,4734.87,CIGNA [1000112],CIGNA [100011201],,,68,,4599.588,2255.82735,15157.472,percent of total billed charges,,,
Skin Debridement With McC,570,MS-DRG,,,,,,,inpatient,,,33594.41,23516.087,CIGNA [1000112],CIGNA [100011201],,,68,,22844.1988,7771.48,61002.7456,percent of total billed charges,,,
Skin Debridement With Cc,571,MS-DRG,,,,,,,inpatient,,,26173.08,18321.156,CIGNA [1000112],CIGNA [100011201],,,68,,17797.6944,7771.48,33938.1472,percent of total billed charges,,,
Skin Graft For Skin Ulcer Or Cellulitis With McC,573,MS-DRG,,,,,,,inpatient,,,229287.37,160501.159,CIGNA [1000112],CIGNA [100011201],,,68,,155915.4116,7771.48,183429.896,percent of total billed charges,,,
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,inpatient,,,76990.64,53893.448,CIGNA [1000112],CIGNA [100011201],,,68,,52353.6352,7771.48,70208.6808,percent of total billed charges,,,
Other Skin- Subcutaneous Tissue And Breast Procedures With McC,579,MS-DRG,,,,,,,inpatient,,,44370,31059,CIGNA [1000112],CIGNA [100011201],,,68,,30171.6,7771.48,66042.4024,percent of total billed charges,,,
Other Skin- Subcutaneous Tissue And Breast Procedures With Cc,580,MS-DRG,,,,,,,inpatient,,,32530.15,22771.105,CIGNA [1000112],CIGNA [100011201],,,68,,22120.502,7771.48,35926.0456,percent of total billed charges,,,
Other Skin- Subcutaneous Tissue And Breast Procedures Without Cc/McC,581,MS-DRG,,,,,,,inpatient,,,34001.93,23801.351,CIGNA [1000112],CIGNA [100011201],,,68,,23121.3124,7771.48,29161.9224,percent of total billed charges,,,
Mastectomy For Malignancy Without Cc/McC,583,MS-DRG,,,,,,,inpatient,,,26986.11,18890.277,CIGNA [1000112],CIGNA [100011201],,,68,,18350.5548,7771.48,33283.62,percent of total billed charges,,,
Breast Biopsy- Local Excision And Other Breast Procedures With Cc/McC,584,MS-DRG,,,,,,,inpatient,,,15783.7,11048.59,CIGNA [1000112],CIGNA [100011201],,,68,,10732.916,5263.86395,41486.4872,percent of total billed charges,,,
Skin Ulcers With McC,592,MS-DRG,,,,,,,inpatient,,,11607.65,8125.355,CIGNA [1000112],CIGNA [100011201],,,68,,7893.202,3871.151275,41666.8368,percent of total billed charges,,,
Skin Ulcers With Cc,593,MS-DRG,,,,,,,inpatient,,,11196.69,7837.683,CIGNA [1000112],CIGNA [100011201],,,68,,7613.7492,3734.096115,24774.7664,percent of total billed charges,,,
Skin Ulcers Without Cc/McC,594,MS-DRG,,,,,,,inpatient,,,9029.64,6320.748,CIGNA [1000112],CIGNA [100011201],,,68,,6140.1552,3011.38494,17196.0304,percent of total billed charges,,,
Major Skin Disorders With McC,595,MS-DRG,,,,,,,inpatient,,,27847.46,19493.222,CIGNA [1000112],CIGNA [100011201],,,68,,18936.2728,7771.48,42858.36,percent of total billed charges,,,
Major Skin Disorders Without McC,596,MS-DRG,,,,,,,inpatient,,,30386.11,21270.277,CIGNA [1000112],CIGNA [100011201],,,68,,20662.5548,7157.25,24308.888,percent of total billed charges,,,
Malignant Breast Disorders With McC,597,MS-DRG,,,,,,,inpatient,,,49956.04,34969.228,CIGNA [1000112],CIGNA [100011201],,,68,,33970.1072,7771.48,39964.832,percent of total billed charges,,,
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,inpatient,,,27430.15,19201.105,CIGNA [1000112],CIGNA [100011201],,,68,,18652.502,7771.48,21944.12,percent of total billed charges,,,
Non-Malignant Breast Disorders With Cc/McC,600,MS-DRG,,,,,,,inpatient,,,13956.43,9769.501,CIGNA [1000112],CIGNA [100011201],,,68,,9490.3724,4654.469405,19396.7008,percent of total billed charges,,,
Non-Malignant Breast Disorders Without Cc/McC,601,MS-DRG,,,,,,,inpatient,,,9383.02,6568.114,CIGNA [1000112],CIGNA [100011201],,,68,,6380.4536,3129.23717,12148.268,percent of total billed charges,,,
Cellulitis With McC,602,MS-DRG,,,,,,,inpatient,,,27986.19,19590.333,CIGNA [1000112],CIGNA [100011201],,,68,,19030.6092,7771.48,29775.9216,percent of total billed charges,,,
Cellulitis Without McC,603,MS-DRG,,,,,,,inpatient,,,16886.67,11820.669,CIGNA [1000112],CIGNA [100011201],,,68,,11482.9356,5631.704445,17850.5576,percent of total billed charges,,,
Trauma To The Skin- Subcutaneous Tissue And Breast With McC,604,MS-DRG,,,,,,,inpatient,,,38556.84,26989.788,CIGNA [1000112],CIGNA [100011201],,,68,,26218.6512,7771.48,30845.472,percent of total billed charges,,,
Trauma To The Skin- Subcutaneous Tissue And Breast Without McC,605,MS-DRG,,,,,,,inpatient,,,21359.36,14951.552,CIGNA [1000112],CIGNA [100011201],,,68,,14524.3648,6578.42,18717.8568,percent of total billed charges,,,
Minor Skin Disorders With McC,606,MS-DRG,,,,,,,inpatient,,,6185.67,4329.969,CIGNA [1000112],CIGNA [100011201],,,68,,4206.2556,2062.920945,32627.0664,percent of total billed charges,,,
Minor Skin Disorders Without McC,607,MS-DRG,,,,,,,inpatient,,,19860.65,13902.455,CIGNA [1000112],CIGNA [100011201],,,68,,13505.242,5973.54,17514.1752,percent of total billed charges,,,
Adrenal And Pituitary Procedures With Cc/McC,614,MS-DRG,,,,,,,inpatient,,,37769.13,26438.391,CIGNA [1000112],CIGNA [100011201],,,68,,25683.0084,7771.48,46177.6032,percent of total billed charges,,,
Adrenal And Pituitary Procedures Without Cc/McC,615,MS-DRG,,,,,,,inpatient,,,58015.91,40611.137,CIGNA [1000112],CIGNA [100011201],,,68,,39450.8188,7771.48,46412.728,percent of total billed charges,,,
Amputation Of Lower Limb For Endocrine- Nutritional And Metabolic Disorders With McC,616,MS-DRG,,,,,,,inpatient,,,66449.27,46514.489,CIGNA [1000112],CIGNA [100011201],,,68,,45185.5036,7771.48,78318.3336,percent of total billed charges,,,
Amputation Of Lower Limb For Endocrine- Nutritional And Metabolic Disorders With Cc,617,MS-DRG,,,,,,,inpatient,,,29882.58,20917.806,CIGNA [1000112],CIGNA [100011201],,,68,,20320.1544,7771.48,39154.1008,percent of total billed charges,,,
Amputation Of Lower Limb For Endocrine- Nutritional And Metabolic Disorders Without Cc/McC,618,MS-DRG,,,,,,,inpatient,,,10245.69,7171.983,CIGNA [1000112],CIGNA [100011201],,,68,,6967.0692,3416.937615,25228.68,percent of total billed charges,,,
Skin Grafts And Wound Debridement For Endocrine- Nutritional And Metabolic Disorders With McC,622,MS-DRG,,,,,,,inpatient,,,103303.17,72312.219,CIGNA [1000112],CIGNA [100011201],,,68,,70246.1556,7771.48,82642.536,percent of total billed charges,,,
Skin Grafts And Wound Debridement For Endocrine- Nutritional And Metabolic Disorders With Cc,623,MS-DRG,,,,,,,inpatient,,,20666.05,14466.235,CIGNA [1000112],CIGNA [100011201],,,68,,14052.914,6892.127675,38785.296,percent of total billed charges,,,
Thyroid- Parathyroid And Thyroglossal Procedures With Cc,626,MS-DRG,,,,,,,inpatient,,,27302.86,19112.002,CIGNA [1000112],CIGNA [100011201],,,68,,18565.9448,7771.48,30582.4288,percent of total billed charges,,,
Thyroid- Parathyroid And Thyroglossal Procedures Without Cc/McC,627,MS-DRG,,,,,,,inpatient,,,31328.53,21929.971,CIGNA [1000112],CIGNA [100011201],,,68,,21303.4004,7771.48,25670.4352,percent of total billed charges,,,
Other Endocrine- Nutritional And Metabolic O.R. Procedures With McC,628,MS-DRG,,,,,,,inpatient,,,48752.32,34126.624,CIGNA [1000112],CIGNA [100011201],,,68,,33151.5776,7771.48,79967.8232,percent of total billed charges,,,
Other Endocrine- Nutritional And Metabolic O.R. Procedures With Cc,629,MS-DRG,,,,,,,inpatient,,,41481.26,29036.882,CIGNA [1000112],CIGNA [100011201],,,68,,28207.2568,7771.48,45596.0264,percent of total billed charges,,,
Diabetes With McC,637,MS-DRG,,,,,,,inpatient,,,33585.6,23509.92,CIGNA [1000112],CIGNA [100011201],,,68,,22838.208,7771.48,29510.4632,percent of total billed charges,,,
Diabetes With Cc,638,MS-DRG,,,,,,,inpatient,,,16607.1,11624.97,CIGNA [1000112],CIGNA [100011201],,,68,,11292.828,5538.46785,18586.1408,percent of total billed charges,,,
Diabetes Without Cc/McC,639,MS-DRG,,,,,,,inpatient,,,15715.82,11001.074,CIGNA [1000112],CIGNA [100011201],,,68,,10686.7576,4408.52,12697.4224,percent of total billed charges,,,
Miscellaneous Disorders Of Nutrition- Metabolism- Fluids And Electrolytes With McC,640,MS-DRG,,,,,,,inpatient,,,19706.61,13794.627,CIGNA [1000112],CIGNA [100011201],,,68,,13400.4948,6572.154435,26912.6184,percent of total billed charges,,,
Miscellaneous Disorders Of Nutrition- Metabolism- Fluids And Electrolytes Without McC,641,MS-DRG,,,,,,,inpatient,,,15211.2,10647.84,CIGNA [1000112],CIGNA [100011201],,,68,,10343.616,5072.9352,15836.316,percent of total billed charges,,,
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,inpatient,,,44600.9,31220.63,CIGNA [1000112],CIGNA [100011201],,,68,,30328.612,7771.48,35680.72,percent of total billed charges,,,
Endocrine Disorders With McC,643,MS-DRG,,,,,,,inpatient,,,24319.36,17023.552,CIGNA [1000112],CIGNA [100011201],,,68,,16537.1648,7771.48,33583.5272,percent of total billed charges,,,
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,inpatient,,,18127.98,12689.586,CIGNA [1000112],CIGNA [100011201],,,68,,12327.0264,6045.68133,20942.844,percent of total billed charges,,,
Endocrine Disorders Without Cc/McC,645,MS-DRG,,,,,,,inpatient,,,13087.48,9161.236,CIGNA [1000112],CIGNA [100011201],,,68,,8899.4864,4364.67458,15785.656,percent of total billed charges,,,
Major Bladder Procedures With McC,653,MS-DRG,,,,,,,inpatient,,,74103.71,51872.597,CIGNA [1000112],CIGNA [100011201],,,68,,50390.5228,7771.48,112955.5888,percent of total billed charges,,,
Major Bladder Procedures With Cc,654,MS-DRG,,,,,,,inpatient,,,32847.58,22993.306,CIGNA [1000112],CIGNA [100011201],,,68,,22336.3544,7771.48,57182.9816,percent of total billed charges,,,
Kidney And Ureter Procedures For Neoplasm With McC,656,MS-DRG,,,,,,,inpatient,,,74882.24,52417.568,CIGNA [1000112],CIGNA [100011201],,,68,,50919.9232,7771.48,66014.0328,percent of total billed charges,,,
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,inpatient,,,35825.52,25077.864,CIGNA [1000112],CIGNA [100011201],,,68,,24361.3536,7771.48,37042.592,percent of total billed charges,,,
Kidney And Ureter Procedures For Neoplasm Without Cc/McC,658,MS-DRG,,,,,,,inpatient,,,45531.4,31871.98,CIGNA [1000112],CIGNA [100011201],,,68,,30961.352,7771.48,36425.12,percent of total billed charges,,,
Kidney And Ureter Procedures For Non-Neoplasm With McC,659,MS-DRG,,,,,,,inpatient,,,43577.66,30504.362,CIGNA [1000112],CIGNA [100011201],,,68,,29632.8088,7771.48,52366.2288,percent of total billed charges,,,
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,inpatient,,,27744.56,19421.192,CIGNA [1000112],CIGNA [100011201],,,68,,18866.3008,7771.48,27151.7336,percent of total billed charges,,,
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/McC,661,MS-DRG,,,,,,,inpatient,,,23214.29,16250.003,CIGNA [1000112],CIGNA [100011201],,,68,,15785.7172,7701.35,20803.0224,percent of total billed charges,,,
Minor Bladder Procedures With McC,662,MS-DRG,,,,,,,inpatient,,,26200.57,18340.399,CIGNA [1000112],CIGNA [100011201],,,68,,17816.3876,7771.48,63211.5216,percent of total billed charges,,,
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,inpatient,,,51470.37,36029.259,CIGNA [1000112],CIGNA [100011201],,,68,,34999.8516,7771.48,41176.296,percent of total billed charges,,,
Minor Bladder Procedures Without Cc/McC,664,MS-DRG,,,,,,,inpatient,,,21663.46,15164.422,CIGNA [1000112],CIGNA [100011201],,,68,,14731.1528,7224.76391,21881.0672,percent of total billed charges,,,
Prostatectomy With McC,665,MS-DRG,,,,,,,inpatient,,,440302,308211.4,CIGNA [1000112],CIGNA [100011201],,,68,,299405.36,7771.48,352241.6,percent of total billed charges,,,
Prostatectomy With Cc,666,MS-DRG,,,,,,,inpatient,,,21861.75,15303.225,CIGNA [1000112],CIGNA [100011201],,,68,,14865.99,7290.893625,33378.8608,percent of total billed charges,,,
Prostatectomy Without Cc/McC,667,MS-DRG,,,,,,,inpatient,,,16201.02,11340.714,CIGNA [1000112],CIGNA [100011201],,,68,,11016.6936,5403.04017,20825.3128,percent of total billed charges,,,
Transurethral Procedures With McC,668,MS-DRG,,,,,,,inpatient,,,48931.22,34251.854,CIGNA [1000112],CIGNA [100011201],,,68,,33273.2296,7771.48,59091.8504,percent of total billed charges,,,
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,inpatient,,,33035.66,23124.962,CIGNA [1000112],CIGNA [100011201],,,68,,22464.2488,7771.48,31358.54,percent of total billed charges,,,
Transurethral Procedures Without Cc/McC,670,MS-DRG,,,,,,,inpatient,,,33732.79,23612.953,CIGNA [1000112],CIGNA [100011201],,,68,,22938.2972,7065.36,26986.232,percent of total billed charges,,,
Other Kidney And Urinary Tract Procedures With McC,673,MS-DRG,,,,,,,inpatient,,,60478,42334.6,CIGNA [1000112],CIGNA [100011201],,,68,,41125.04,7771.48,84906.16,percent of total billed charges,,,
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,inpatient,,,73440.29,51408.203,CIGNA [1000112],CIGNA [100011201],,,68,,49939.3972,7771.48,58752.232,percent of total billed charges,,,
Renal Failure With McC,682,MS-DRG,,,,,,,inpatient,,,25189.25,17632.475,CIGNA [1000112],CIGNA [100011201],,,68,,17128.69,7771.48,30436.528,percent of total billed charges,,,
Renal Failure With Cc,683,MS-DRG,,,,,,,inpatient,,,17753.72,12427.604,CIGNA [1000112],CIGNA [100011201],,,68,,12072.5296,5920.86562,18012.6696,percent of total billed charges,,,
Renal Failure Without Cc/McC,684,MS-DRG,,,,,,,inpatient,,,9135.38,6394.766,CIGNA [1000112],CIGNA [100011201],,,68,,6212.0584,3046.64923,12310.38,percent of total billed charges,,,
Kidney And Urinary Tract Neoplasms With McC,686,MS-DRG,,,,,,,inpatient,,,27497.1,19247.97,CIGNA [1000112],CIGNA [100011201],,,68,,18698.028,7771.48,38209.7984,percent of total billed charges,,,
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,inpatient,,,25492.34,17844.638,CIGNA [1000112],CIGNA [100011201],,,68,,17334.7912,7581.24,21329.8864,percent of total billed charges,,,
Kidney And Urinary Tract Infections With McC,689,MS-DRG,,,,,,,inpatient,,,20757.97,14530.579,CIGNA [1000112],CIGNA [100011201],,,68,,14115.4196,6922.782995,23716.9856,percent of total billed charges,,,
Kidney And Urinary Tract Infections Without McC,690,MS-DRG,,,,,,,inpatient,,,16632.65,11642.855,CIGNA [1000112],CIGNA [100011201],,,68,,11310.202,5546.988775,16263.8864,percent of total billed charges,,,
Urinary Stones With McC,693,MS-DRG,,,,,,,inpatient,,,4007.39,2805.173,CIGNA [1000112],CIGNA [100011201],,,68,,2725.0252,1336.464565,29794.1592,percent of total billed charges,,,
Urinary Stones Without McC,694,MS-DRG,,,,,,,inpatient,,,15019.62,10513.734,CIGNA [1000112],CIGNA [100011201],,,68,,10213.3416,5009.04327,15834.2896,percent of total billed charges,,,
Kidney And Urinary Tract Signs And Symptoms With McC,695,MS-DRG,,,,,,,inpatient,,,29850.37,20895.259,CIGNA [1000112],CIGNA [100011201],,,68,,20298.2516,7771.48,23880.296,percent of total billed charges,,,
Kidney And Urinary Tract Signs And Symptoms Without McC,696,MS-DRG,,,,,,,inpatient,,,12055.26,8438.682,CIGNA [1000112],CIGNA [100011201],,,68,,8197.5768,4020.42921,14016.6088,percent of total billed charges,,,
Other Kidney And Urinary Tract Diagnoses With McC,698,MS-DRG,,,,,,,inpatient,,,25421.96,17795.372,CIGNA [1000112],CIGNA [100011201],,,68,,17286.9328,7771.48,34061.7576,percent of total billed charges,,,
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,inpatient,,,18359.1,12851.37,CIGNA [1000112],CIGNA [100011201],,,68,,12484.188,6122.75985,20665.2272,percent of total billed charges,,,
Other Kidney And Urinary Tract Diagnoses Without Cc/McC,700,MS-DRG,,,,,,,inpatient,,,8380.95,5866.665,CIGNA [1000112],CIGNA [100011201],,,68,,5699.046,2795.046825,14065.2424,percent of total billed charges,,,
Major Male Pelvic Procedures Without Cc/McC,708,MS-DRG,,,,,,,inpatient,,,55574.17,38901.919,CIGNA [1000112],CIGNA [100011201],,,68,,37790.4356,7771.48,44459.336,percent of total billed charges,,,
Penis Procedures With Cc/McC,709,MS-DRG,,,,,,,inpatient,,,18738.26,13116.782,CIGNA [1000112],CIGNA [100011201],,,68,,12742.0168,6249.20971,45533.208,percent of total billed charges,,,
Transurethral Prostatectomy With Cc/McC,713,MS-DRG,,,,,,,inpatient,,,28299.1,19809.37,CIGNA [1000112],CIGNA [100011201],,,68,,19243.388,7771.48,29299.7176,percent of total billed charges,,,
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/McC,717,MS-DRG,,,,,,,inpatient,,,29999.37,20999.559,CIGNA [1000112],CIGNA [100011201],,,68,,20399.5716,7771.48,37597.8256,percent of total billed charges,,,
Malignancy- Male Reproductive System With Cc,723,MS-DRG,,,,,,,inpatient,,,3972.81,2780.967,CIGNA [1000112],CIGNA [100011201],,,68,,2701.5108,1324.932135,22754.4456,percent of total billed charges,,,
Benign Prostatic Hypertrophy Without McC,726,MS-DRG,,,,,,,inpatient,,,40258.34,28180.838,CIGNA [1000112],CIGNA [100011201],,,68,,27375.6712,5378.07,32206.672,percent of total billed charges,,,
Inflammation Of The Male Reproductive System With McC,727,MS-DRG,,,,,,,inpatient,,,22656.48,15859.536,CIGNA [1000112],CIGNA [100011201],,,68,,15406.4064,7555.93608,29773.8952,percent of total billed charges,,,
Inflammation Of The Male Reproductive System Without McC,728,MS-DRG,,,,,,,inpatient,,,13639.47,9547.629,CIGNA [1000112],CIGNA [100011201],,,68,,9274.8396,4548.763245,16557.7144,percent of total billed charges,,,
Other Male Reproductive System Diagnoses With Cc/McC,729,MS-DRG,,,,,,,inpatient,,,16117.99,11282.593,CIGNA [1000112],CIGNA [100011201],,,68,,10960.2332,5375.349665,22306.6112,percent of total billed charges,,,
Other Male Reproductive System Diagnoses Without Cc/McC,730,MS-DRG,,,,,,,inpatient,,,5959.58,4171.706,CIGNA [1000112],CIGNA [100011201],,,68,,4052.5144,1987.51993,12298.2216,percent of total billed charges,,,
Uterine And Adnexa Procedures For Non-Malignancy With Cc/McC,742,MS-DRG,,,,,,,inpatient,,,28503.79,19952.653,CIGNA [1000112],CIGNA [100011201],,,68,,19382.5772,7771.48,37014.2224,percent of total billed charges,,,
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/McC,743,MS-DRG,,,,,,,inpatient,,,26776.68,18743.676,CIGNA [1000112],CIGNA [100011201],,,68,,18208.1424,7771.48,24288.4304,percent of total billed charges,,,
D&C- Conization- Laparoscopy And Tubal Interruption With Cc/McC,744,MS-DRG,,,,,,,inpatient,,,42207.27,29545.089,CIGNA [1000112],CIGNA [100011201],,,68,,28700.9436,7771.48,39593.8296,percent of total billed charges,,,
D&C- Conization- Laparoscopy And Tubal Interruption Without Cc/McC,745,MS-DRG,,,,,,,inpatient,,,41300.62,28910.434,CIGNA [1000112],CIGNA [100011201],,,68,,28084.4216,7771.48,33040.496,percent of total billed charges,,,
Vagina- Cervix And Vulva Procedures With Cc/McC,746,MS-DRG,,,,,,,inpatient,,,54026.22,37818.354,CIGNA [1000112],CIGNA [100011201],,,68,,36737.8296,7771.48,43220.976,percent of total billed charges,,,
Vagina- Cervix And Vulva Procedures Without Cc/McC,747,MS-DRG,,,,,,,inpatient,,,14150.78,9905.546,CIGNA [1000112],CIGNA [100011201],,,68,,9622.5304,4719.28513,19354.1464,percent of total billed charges,,,
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,,,inpatient,,,71661.69,50163.183,CIGNA [1000112],CIGNA [100011201],,,68,,48729.9492,7771.48,57329.352,percent of total billed charges,,,
Other Female Reproductive System O.R. Procedures With Cc/McC,749,MS-DRG,,,,,,,inpatient,,,40397.2,28278.04,CIGNA [1000112],CIGNA [100011201],,,68,,27470.096,7771.48,52451.3376,percent of total billed charges,,,
Malignancy- Female Reproductive System With McC,754,MS-DRG,,,,,,,inpatient,,,31179.58,21825.706,CIGNA [1000112],CIGNA [100011201],,,68,,21202.1144,7771.48,36661.6288,percent of total billed charges,,,
Malignancy- Female Reproductive System With Cc,755,MS-DRG,,,,,,,inpatient,,,7660.86,5362.602,CIGNA [1000112],CIGNA [100011201],,,68,,5209.3848,2554.89681,22495.0664,percent of total billed charges,,,
Malignancy- Female Reproductive System Without Cc/McC,756,MS-DRG,,,,,,,inpatient,,,11168.92,7818.244,CIGNA [1000112],CIGNA [100011201],,,68,,7594.8656,3724.83482,19350.0936,percent of total billed charges,,,
Infections- Female Reproductive System With Cc,758,MS-DRG,,,,,,,inpatient,,,20130.99,14091.693,CIGNA [1000112],CIGNA [100011201],,,68,,13689.0732,6713.685165,20655.0952,percent of total billed charges,,,
Infections- Female Reproductive System Without Cc/McC,759,MS-DRG,,,,,,,inpatient,,,18187.49,12731.243,CIGNA [1000112],CIGNA [100011201],,,68,,12367.4932,4943.22,14549.992,percent of total billed charges,,,
Menstrual And Other Female Reproductive System Disorders With Cc/McC,760,MS-DRG,,,,,,,inpatient,,,19375.46,13562.822,CIGNA [1000112],CIGNA [100011201],,,68,,13175.3128,6461.71591,19970.172,percent of total billed charges,,,
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,inpatient,,,14024.34,9817.038,CIGNA [1000112],CIGNA [100011201],,,68,,9536.5512,4677.11739,22215.4232,percent of total billed charges,,,
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,inpatient,,,9265.92,6486.144,CIGNA [1000112],CIGNA [100011201],,,68,,6300.8256,3090.18432,28156.828,percent of total billed charges,,,
Abortion With D&C- Aspiration Curettage Or Hysterotomy,770,MS-DRG,,,,,,,inpatient,,,25214.53,17650.171,CIGNA [1000112],CIGNA [100011201],,,68,,17145.8804,6425.75,21802.0376,percent of total billed charges,,,
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,inpatient,,,8836.34,6185.438,CIGNA [1000112],CIGNA [100011201],,,68,,6008.7112,2946.91939,14456.3376,percent of total billed charges,,,
Cesarean Section With Sterilization With McC,783,MS-DRG,,,,,,,inpatient,,,17734.56,12414.192,CIGNA [1000112],CIGNA [100011201],,,68,,12059.5008,5914.47576,37326.288,percent of total billed charges,,,
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,inpatient,,,18719.59,13103.713,CIGNA [1000112],CIGNA [100011201],,,68,,12729.3212,6242.983265,21945.912,percent of total billed charges,,,
Cesarean Section With Sterilization Without Cc/McC,785,MS-DRG,,,,,,,inpatient,,,17648.18,12353.726,CIGNA [1000112],CIGNA [100011201],,,68,,12000.7624,5885.66803,17728.9736,percent of total billed charges,,,
Cesarean Section Without Sterilization With McC,786,MS-DRG,,,,,,,inpatient,,,21072.73,14750.911,CIGNA [1000112],CIGNA [100011201],,,68,,14329.4564,7027.755455,32742.5712,percent of total billed charges,,,
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,inpatient,,,18455.52,12918.864,CIGNA [1000112],CIGNA [100011201],,,68,,12549.7536,6154.91592,21516.3152,percent of total billed charges,,,
Cesarean Section Without Sterilization Without Cc/McC,788,MS-DRG,,,,,,,inpatient,,,17822.26,12475.582,CIGNA [1000112],CIGNA [100011201],,,68,,12119.1368,5943.72371,18338.92,percent of total billed charges,,,
Neonates- Died Or Transferred To Another Acute Care Facility,789,MS-DRG,,,,,,,inpatient,,,6500.45,4550.315,CIGNA [1000112],CIGNA [100011201],,,68,,4420.306,2167.900075,36529.9128,percent of total billed charges,,,
Extreme Immaturity Or Respiratory Distress Syndrome- Neonate,790,MS-DRG,,,,,,,inpatient,,,71335.38,49934.766,CIGNA [1000112],CIGNA [100011201],,,68,,48508.0584,7771.48,120469.48,percent of total billed charges,,,
Prematurity With Major Problems,791,MS-DRG,,,,,,,inpatient,,,39411.64,27588.148,CIGNA [1000112],CIGNA [100011201],,,68,,26799.9152,7771.48,82273.8664,percent of total billed charges,,,
Prematurity Without Major Problems,792,MS-DRG,,,,,,,inpatient,,,10975.85,7683.095,CIGNA [1000112],CIGNA [100011201],,,68,,7463.578,3660.445975,49642.7472,percent of total billed charges,,,
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,inpatient,,,8093.71,5665.597,CIGNA [1000112],CIGNA [100011201],,,68,,5503.7228,2699.252285,84513.0384,percent of total billed charges,,,
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,inpatient,,,5349.51,3744.657,CIGNA [1000112],CIGNA [100011201],,,68,,3637.6668,1784.061585,29913.7168,percent of total billed charges,,,
Normal Newborn,795,MS-DRG,,,,,,,inpatient,,,4927.51,3449.257,CIGNA [1000112],CIGNA [100011201],,,68,,3350.7068,1378.34,7947.23,percent of total billed charges,,,
Vaginal Delivery With Sterilization And/Or D&C With McC,796,MS-DRG,,,,,,,inpatient,,,17976.19,12583.333,CIGNA [1000112],CIGNA [100011201],,,68,,12223.8092,5995.059365,25869.0224,percent of total billed charges,,,
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,inpatient,,,23001.33,16100.931,CIGNA [1000112],CIGNA [100011201],,,68,,15640.9044,6655.835261,19619.6048,percent of total billed charges,,,
Vaginal Delivery With Sterilization And/Or D&C Without Cc/McC,798,MS-DRG,,,,,,,inpatient,,,14819.75,10373.825,CIGNA [1000112],CIGNA [100011201],,,68,,10077.43,4942.386625,19619.6048,percent of total billed charges,,,
Splenic Procedures With McC,799,MS-DRG,,,,,,,inpatient,,,81427.43,56999.201,CIGNA [1000112],CIGNA [100011201],,,68,,55370.6524,7771.48,96345.188,percent of total billed charges,,,
Splenic Procedures Without Cc/McC,801,MS-DRG,,,,,,,inpatient,,,60652.11,42456.477,CIGNA [1000112],CIGNA [100011201],,,68,,41243.4348,7771.48,48521.688,percent of total billed charges,,,
Other O.R. Procedures Of The Blood And Blood Forming Organs With McC,802,MS-DRG,,,,,,,inpatient,,,94944.09,66460.863,CIGNA [1000112],CIGNA [100011201],,,68,,64561.9812,7771.48,75955.272,percent of total billed charges,,,
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/McC,804,MS-DRG,,,,,,,inpatient,,,22075,15452.5,CIGNA [1000112],CIGNA [100011201],,,68,,15011,7362.0125,22401.852,percent of total billed charges,,,
Vaginal Delivery Without Sterilization Or D&C With McC,805,MS-DRG,,,,,,,inpatient,,,13956.78,9769.746,CIGNA [1000112],CIGNA [100011201],,,68,,9490.6104,4654.58613,20221.4456,percent of total billed charges,,,
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,inpatient,,,13483.61,9438.527,CIGNA [1000112],CIGNA [100011201],,,68,,9168.8548,4496.783935,14661.004,percent of total billed charges,,,
Vaginal Delivery Without Sterilization Or D&C Without Cc/McC,807,MS-DRG,,,,,,,inpatient,,,13157.23,9210.061,CIGNA [1000112],CIGNA [100011201],,,68,,8946.9164,4387.936205,12912.2208,percent of total billed charges,,,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With McC,808,MS-DRG,,,,,,,inpatient,,,31882.27,22317.589,CIGNA [1000112],CIGNA [100011201],,,68,,21679.9436,7771.48,46412.6656,percent of total billed charges,,,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With Cc,809,MS-DRG,,,,,,,inpatient,,,26642.66,18649.862,CIGNA [1000112],CIGNA [100011201],,,68,,18117.0088,7771.48,25096.964,percent of total billed charges,,,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders Without Cc/McC,810,MS-DRG,,,,,,,inpatient,,,85706.42,59994.494,CIGNA [1000112],CIGNA [100011201],,,68,,58280.3656,6951.04,68565.136,percent of total billed charges,,,
Red Blood Cell Disorders With McC,811,MS-DRG,,,,,,,inpatient,,,33080.94,23156.658,CIGNA [1000112],CIGNA [100011201],,,68,,22495.0392,7771.48,28507.3952,percent of total billed charges,,,
Red Blood Cell Disorders Without McC,812,MS-DRG,,,,,,,inpatient,,,21914.25,15339.975,CIGNA [1000112],CIGNA [100011201],,,68,,14901.69,6364.97,18701.6456,percent of total billed charges,,,
Coagulation Disorders,813,MS-DRG,,,,,,,inpatient,,,31592.62,22114.834,CIGNA [1000112],CIGNA [100011201],,,68,,21482.9816,7771.48,31366.6456,percent of total billed charges,,,
Reticuloendothelial And Immunity Disorders With McC,814,MS-DRG,,,,,,,inpatient,,,15313.53,10719.471,CIGNA [1000112],CIGNA [100011201],,,68,,10413.2004,5107.062255,42357.8392,percent of total billed charges,,,
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,inpatient,,,14949.63,10464.741,CIGNA [1000112],CIGNA [100011201],,,68,,10165.7484,4985.701605,20590.2504,percent of total billed charges,,,
Other Antepartum Diagnoses With O.R. Procedures With McC,817,MS-DRG,,,,,,,inpatient,,,35079.77,24555.839,CIGNA [1000112],CIGNA [100011201],,,68,,23854.2436,7771.48,51371.2664,percent of total billed charges,,,
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,inpatient,,,56068.99,39248.293,CIGNA [1000112],CIGNA [100011201],,,68,,38126.9132,7771.48,44855.192,percent of total billed charges,,,
Other Antepartum Diagnoses With O.R. Procedures Without Cc/McC,819,MS-DRG,,,,,,,inpatient,,,15513.53,10859.471,CIGNA [1000112],CIGNA [100011201],,,68,,10549.2004,5173.762255,16545.556,percent of total billed charges,,,
Lymphoma And Leukemia With Major O.R. Procedures With McC,820,MS-DRG,,,,,,,inpatient,,,86514.51,60560.157,CIGNA [1000112],CIGNA [100011201],,,68,,58829.8668,7771.48,117974.9816,percent of total billed charges,,,
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,inpatient,,,70253.02,49177.114,CIGNA [1000112],CIGNA [100011201],,,68,,47772.0536,7771.48,56202.416,percent of total billed charges,,,
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/McC,822,MS-DRG,,,,,,,inpatient,,,27823.59,19476.513,CIGNA [1000112],CIGNA [100011201],,,68,,18920.0412,7771.48,23173.9104,percent of total billed charges,,,
Lymphoma And Non-Acute Leukemia With Other Procedures With McC,823,MS-DRG,,,,,,,inpatient,,,49236.57,34465.599,CIGNA [1000112],CIGNA [100011201],,,68,,33480.8676,7771.48,94819.3088,percent of total billed charges,,,
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/McC,825,MS-DRG,,,,,,,inpatient,,,56788.87,39752.209,CIGNA [1000112],CIGNA [100011201],,,68,,38616.4316,7771.48,45431.096,percent of total billed charges,,,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With McC,826,MS-DRG,,,,,,,inpatient,,,115032.85,80522.995,CIGNA [1000112],CIGNA [100011201],,,68,,78222.338,7771.48,96764.6528,percent of total billed charges,,,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without Cc/McC,828,MS-DRG,,,,,,,inpatient,,,37373.35,26161.345,CIGNA [1000112],CIGNA [100011201],,,68,,25413.878,7771.48,32479.1392,percent of total billed charges,,,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/McC,829,MS-DRG,,,,,,,inpatient,,,26899.5,18829.65,CIGNA [1000112],CIGNA [100011201],,,68,,18291.66,7771.48,62486.0704,percent of total billed charges,,,
Other Antepartum Diagnoses Without O.R. Procedures With McC,831,MS-DRG,,,,,,,inpatient,,,8108.51,5675.957,CIGNA [1000112],CIGNA [100011201],,,68,,5513.7868,2704.188085,23321.8376,percent of total billed charges,,,
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,inpatient,,,9811.14,6867.798,CIGNA [1000112],CIGNA [100011201],,,68,,6671.5752,3272.01519,15143.2872,percent of total billed charges,,,
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/McC,833,MS-DRG,,,,,,,inpatient,,,8494.15,5945.905,CIGNA [1000112],CIGNA [100011201],,,68,,5776.022,2832.799025,10533.2272,percent of total billed charges,,,
Acute Leukemia Without Major O.R. Procedures With McC,834,MS-DRG,,,,,,,inpatient,,,33540.42,23478.294,CIGNA [1000112],CIGNA [100011201],,,68,,22807.4856,7771.48,111997.1016,percent of total billed charges,,,
Acute Leukemia Without Major O.R. Procedures With Cc,835,MS-DRG,,,,,,,inpatient,,,15922.85,11145.995,CIGNA [1000112],CIGNA [100011201],,,68,,10827.538,5310.270475,43279.8512,percent of total billed charges,,,
Lymphoma And Non-Acute Leukemia With McC,840,MS-DRG,,,,,,,inpatient,,,35119.86,24583.902,CIGNA [1000112],CIGNA [100011201],,,68,,23881.5048,7771.48,64630.0016,percent of total billed charges,,,
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,inpatient,,,17465.46,12225.822,CIGNA [1000112],CIGNA [100011201],,,68,,11876.5128,5824.73091,31771.9256,percent of total billed charges,,,
Lymphoma And Non-Acute Leukemia Without Cc/McC,842,MS-DRG,,,,,,,inpatient,,,22518.92,15763.244,CIGNA [1000112],CIGNA [100011201],,,68,,15312.8656,7510.05982,21313.6752,percent of total billed charges,,,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With McC,843,MS-DRG,,,,,,,inpatient,,,21080.37,14756.259,CIGNA [1000112],CIGNA [100011201],,,68,,14334.6516,7030.303395,38361.7784,percent of total billed charges,,,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,inpatient,,,11557.79,8090.453,CIGNA [1000112],CIGNA [100011201],,,68,,7859.2972,3854.522965,24217.5064,percent of total billed charges,,,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/McC,845,MS-DRG,,,,,,,inpatient,,,13919.38,9743.566,CIGNA [1000112],CIGNA [100011201],,,68,,9465.1784,4642.11323,16954.8888,percent of total billed charges,,,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With McC,846,MS-DRG,,,,,,,inpatient,,,22506.34,15754.438,CIGNA [1000112],CIGNA [100011201],,,68,,15304.3112,7505.86439,51746.1504,percent of total billed charges,,,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,inpatient,,,14849.65,10394.755,CIGNA [1000112],CIGNA [100011201],,,68,,10097.762,4952.358275,25747.4384,percent of total billed charges,,,
Infectious And Parasitic Diseases With O.R. Procedures With McC,853,MS-DRG,,,,,,,inpatient,,,91139.43,63797.601,CIGNA [1000112],CIGNA [100011201],,,68,,61974.8124,7771.48,101350.396,percent of total billed charges,,,
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,inpatient,,,41334.13,28933.891,CIGNA [1000112],CIGNA [100011201],,,68,,28107.2084,7771.48,40491.5248,percent of total billed charges,,,
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/McC,855,MS-DRG,,,,,,,inpatient,,,41292.75,28904.925,CIGNA [1000112],CIGNA [100011201],,,68,,28079.07,7771.48,33034.2,percent of total billed charges,,,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With McC,856,MS-DRG,,,,,,,inpatient,,,65177.47,45624.229,CIGNA [1000112],CIGNA [100011201],,,68,,44320.6796,7771.48,91416.9832,percent of total billed charges,,,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,inpatient,,,33908.27,23735.789,CIGNA [1000112],CIGNA [100011201],,,68,,23057.6236,7771.48,44153.2296,percent of total billed charges,,,
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/McC,858,MS-DRG,,,,,,,inpatient,,,18266.15,12786.305,CIGNA [1000112],CIGNA [100011201],,,68,,12420.982,6091.761025,26108.1376,percent of total billed charges,,,
Postoperative And Post-Traumatic Infections With McC,862,MS-DRG,,,,,,,inpatient,,,32409.02,22686.314,CIGNA [1000112],CIGNA [100011201],,,68,,22038.1336,7771.48,37257.3904,percent of total billed charges,,,
Postoperative And Post-Traumatic Infections Without McC,863,MS-DRG,,,,,,,inpatient,,,26972.96,18881.072,CIGNA [1000112],CIGNA [100011201],,,68,,18341.6128,7071.87,21578.368,percent of total billed charges,,,
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,inpatient,,,18759.94,13131.958,CIGNA [1000112],CIGNA [100011201],,,68,,12756.7592,6256.43999,18195.0456,percent of total billed charges,,,
Viral Illness With McC,865,MS-DRG,,,,,,,inpatient,,,22475.35,15732.745,CIGNA [1000112],CIGNA [100011201],,,68,,15283.238,7495.529225,29907.6376,percent of total billed charges,,,
Viral Illness Without McC,866,MS-DRG,,,,,,,inpatient,,,13589.18,9512.426,CIGNA [1000112],CIGNA [100011201],,,68,,9240.6424,4531.99153,17927.5608,percent of total billed charges,,,
Other Infectious And Parasitic Diseases Diagnoses With McC,867,MS-DRG,,,,,,,inpatient,,,29124.07,20386.849,CIGNA [1000112],CIGNA [100011201],,,68,,19804.3676,7771.48,43450.0688,percent of total billed charges,,,
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,inpatient,,,22783.92,15948.744,CIGNA [1000112],CIGNA [100011201],,,68,,15493.0656,7598.43732,21277.2,percent of total billed charges,,,
Other Infectious And Parasitic Diseases Diagnoses Without Cc/McC,869,MS-DRG,,,,,,,inpatient,,,6491.58,4544.106,CIGNA [1000112],CIGNA [100011201],,,68,,4414.2744,2164.94193,14579.948,percent of total billed charges,,,
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,inpatient,,,165811.55,116068.085,CIGNA [1000112],CIGNA [100011201],,,68,,112751.854,7771.48,140966.516,percent of total billed charges,,,
Septicemia Or Severe Sepsis Without Mv >96 Hours With McC,871,MS-DRG,,,,,,,inpatient,,,32860.99,23002.693,CIGNA [1000112],CIGNA [100011201],,,68,,22345.4732,7771.48,39764.0472,percent of total billed charges,,,
Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC,872,MS-DRG,,,,,,,inpatient,,,22133.41,15493.387,CIGNA [1000112],CIGNA [100011201],,,68,,15050.7188,7381.492235,20892.184,percent of total billed charges,,,
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,,,inpatient,,,167914.64,117540.248,CIGNA [1000112],CIGNA [100011201],,,68,,114181.9552,7771.48,134331.712,percent of total billed charges,,,
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,inpatient,,,22889.31,16022.517,CIGNA [1000112],CIGNA [100011201],,,68,,15564.7308,6248.48,19425.0704,percent of total billed charges,,,
Depressive Neuroses,881,MS-DRG,,,,,,,inpatient,,,44762.95,31334.065,CIGNA [1000112],CIGNA [100011201],,,68,,30438.806,5798.441546,35810.36,percent of total billed charges,,,
Neuroses Except Depressive,882,MS-DRG,,,,,,,inpatient,,,10863.25,7604.275,CIGNA [1000112],CIGNA [100011201],,,68,,7387.01,3622.893875,19491.9416,percent of total billed charges,,,
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,inpatient,,,35747.4,25023.18,CIGNA [1000112],CIGNA [100011201],,,68,,24308.232,7771.48,33842.9064,percent of total billed charges,,,
Psychoses,885,MS-DRG,,,,,,,inpatient,,,20082.8,14057.96,CIGNA [1000112],CIGNA [100011201],,,68,,13656.304,6697.6138,28562.108,percent of total billed charges,,,
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,inpatient,,,10508,7355.6,CIGNA [1000112],CIGNA [100011201],,,68,,7145.44,3504.418,36402.2496,percent of total billed charges,,,
Alcohol- Drug Abuse Or Dependence- Left Ama,894,MS-DRG,,,,,,,inpatient,,,15836.23,11085.361,CIGNA [1000112],CIGNA [100011201],,,68,,10768.6364,3961.38,12668.984,percent of total billed charges,,,
Alcohol- Drug Abuse Or Dependence Without Rehabilitation Therapy With McC,896,MS-DRG,,,,,,,inpatient,,,35553.78,24887.646,CIGNA [1000112],CIGNA [100011201],,,68,,24176.5704,7771.48,36086.1312,percent of total billed charges,,,
Alcohol- Drug Abuse Or Dependence Without Rehabilitation Therapy Without McC,897,MS-DRG,,,,,,,inpatient,,,18541.81,12979.267,CIGNA [1000112],CIGNA [100011201],,,68,,12608.4308,5972.81,17876.9008,percent of total billed charges,,,
Wound Debridements For Injuries With McC,901,MS-DRG,,,,,,,inpatient,,,46387.19,32471.033,CIGNA [1000112],CIGNA [100011201],,,68,,31543.2892,7771.48,89773.5728,percent of total billed charges,,,
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,inpatient,,,59864.86,41905.402,CIGNA [1000112],CIGNA [100011201],,,68,,40708.1048,7771.48,47891.888,percent of total billed charges,,,
Wound Debridements For Injuries Without Cc/McC,903,MS-DRG,,,,,,,inpatient,,,13693.85,9585.695,CIGNA [1000112],CIGNA [100011201],,,68,,9311.818,4566.898975,24701.816,percent of total billed charges,,,
Skin Grafts For Injuries With Cc/McC,904,MS-DRG,,,,,,,inpatient,,,114417.1,80091.97,CIGNA [1000112],CIGNA [100011201],,,68,,77803.628,7771.48,91533.68,percent of total billed charges,,,
Hand Procedures For Injuries,906,MS-DRG,,,,,,,inpatient,,,51389.12,35972.384,CIGNA [1000112],CIGNA [100011201],,,68,,34944.6016,7771.48,44224.1536,percent of total billed charges,,,
Other O.R. Procedures For Injuries With McC,907,MS-DRG,,,,,,,inpatient,,,48914.02,34239.814,CIGNA [1000112],CIGNA [100011201],,,68,,33261.5336,7771.48,80721.644,percent of total billed charges,,,
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,inpatient,,,44494.39,31146.073,CIGNA [1000112],CIGNA [100011201],,,68,,30256.1852,7771.48,40872.488,percent of total billed charges,,,
Other O.R. Procedures For Injuries Without Cc/McC,909,MS-DRG,,,,,,,inpatient,,,14125.93,9888.151,CIGNA [1000112],CIGNA [100011201],,,68,,9605.6324,4710.997655,25698.8048,percent of total billed charges,,,
Traumatic Injury With McC,913,MS-DRG,,,,,,,inpatient,,,57017.38,39912.166,CIGNA [1000112],CIGNA [100011201],,,68,,38771.8184,7771.48,45613.904,percent of total billed charges,,,
Traumatic Injury Without McC,914,MS-DRG,,,,,,,inpatient,,,28970.93,20279.651,CIGNA [1000112],CIGNA [100011201],,,68,,19700.2324,6429.37,23176.744,percent of total billed charges,,,
Allergic Reactions With McC,915,MS-DRG,,,,,,,inpatient,,,42664.44,29865.108,CIGNA [1000112],CIGNA [100011201],,,68,,29011.8192,7771.48,35214.7792,percent of total billed charges,,,
Allergic Reactions Without McC,916,MS-DRG,,,,,,,inpatient,,,12818.09,8972.663,CIGNA [1000112],CIGNA [100011201],,,68,,8716.3012,4274.833015,13455.296,percent of total billed charges,,,
Poisoning And Toxic Effects Of Drugs With McC,917,MS-DRG,,,,,,,inpatient,,,41573.69,29101.583,CIGNA [1000112],CIGNA [100011201],,,68,,28270.1092,7771.48,33258.952,percent of total billed charges,,,
Poisoning And Toxic Effects Of Drugs Without McC,918,MS-DRG,,,,,,,inpatient,,,19845.67,13891.969,CIGNA [1000112],CIGNA [100011201],,,68,,13495.0556,5723.92,17921.4816,percent of total billed charges,,,
Complications Of Treatment With McC,919,MS-DRG,,,,,,,inpatient,,,48229.35,33760.545,CIGNA [1000112],CIGNA [100011201],,,68,,32795.958,7771.48,38583.48,percent of total billed charges,,,
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,inpatient,,,20650.21,14455.147,CIGNA [1000112],CIGNA [100011201],,,68,,14042.1428,6886.845035,20584.1712,percent of total billed charges,,,
Complications Of Treatment Without Cc/McC,921,MS-DRG,,,,,,,inpatient,,,18737.44,13116.208,CIGNA [1000112],CIGNA [100011201],,,68,,12741.4592,5002.55,14989.952,percent of total billed charges,,,
Other Injury- Poisoning And Toxic Effect Diagnoses With McC,922,MS-DRG,,,,,,,inpatient,,,42436.37,29705.459,CIGNA [1000112],CIGNA [100011201],,,68,,28856.7316,7771.48,34229.9488,percent of total billed charges,,,
Other Injury- Poisoning And Toxic Effect Diagnoses Without McC,923,MS-DRG,,,,,,,inpatient,,,18119.88,12683.916,CIGNA [1000112],CIGNA [100011201],,,68,,12321.5184,6042.97998,20665.2272,percent of total billed charges,,,
Non-Extensive Burns,935,MS-DRG,,,,,,,inpatient,,,6946.99,4862.893,CIGNA [1000112],CIGNA [100011201],,,68,,4723.9532,2316.821165,44505.8232,percent of total billed charges,,,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,inpatient,,,22686.24,15880.368,CIGNA [1000112],CIGNA [100011201],,,68,,15426.6432,7565.86104,42783.3832,percent of total billed charges,,,
Signs And Symptoms With McC,947,MS-DRG,,,,,,,inpatient,,,29399.47,20579.629,CIGNA [1000112],CIGNA [100011201],,,68,,19991.6396,7771.48,26061.5304,percent of total billed charges,,,
Signs And Symptoms Without McC,948,MS-DRG,,,,,,,inpatient,,,16042.18,11229.526,CIGNA [1000112],CIGNA [100011201],,,68,,10908.6824,5350.06703,16099.748,percent of total billed charges,,,
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,inpatient,,,5109.91,3576.937,CIGNA [1000112],CIGNA [100011201],,,68,,3474.7388,1704.154985,11487.6616,percent of total billed charges,,,
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,,,inpatient,,,149455.54,104618.878,CIGNA [1000112],CIGNA [100011201],,,68,,101629.7672,7771.48,138360.5656,percent of total billed charges,,,
Limb Reattachment- Hip And Femur Procedures For Multiple Significant Trauma,956,MS-DRG,,,,,,,inpatient,,,64530.82,45171.574,CIGNA [1000112],CIGNA [100011201],,,68,,43880.9576,7771.48,77453.0608,percent of total billed charges,,,
Other O.R. Procedures For Multiple Significant Trauma With McC,957,MS-DRG,,,,,,,inpatient,,,104697.23,73288.061,CIGNA [1000112],CIGNA [100011201],,,68,,71194.1164,7771.48,151244.4168,percent of total billed charges,,,
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,inpatient,,,68495.96,47947.172,CIGNA [1000112],CIGNA [100011201],,,68,,46577.2528,7771.48,83274.908,percent of total billed charges,,,
Other Multiple Significant Trauma With McC,963,MS-DRG,,,,,,,inpatient,,,43017.73,30112.411,CIGNA [1000112],CIGNA [100011201],,,68,,29252.0564,7771.48,55049.1824,percent of total billed charges,,,
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,inpatient,,,32958.94,23071.258,CIGNA [1000112],CIGNA [100011201],,,68,,22412.0792,7771.48,30400.0528,percent of total billed charges,,,
Hiv With Major Related Condition With McC,974,MS-DRG,,,,,,,inpatient,,,42445.87,29712.109,CIGNA [1000112],CIGNA [100011201],,,68,,28863.1916,7771.48,60508.304,percent of total billed charges,,,
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,,,inpatient,,,19415.36,13590.752,CIGNA [1000112],CIGNA [100011201],,,68,,13202.4448,6475.02256,28801.2232,percent of total billed charges,,,
Hiv With Major Related Condition Without Cc/McC,976,MS-DRG,,,,,,,inpatient,,,36673.45,25671.415,CIGNA [1000112],CIGNA [100011201],,,68,,24937.946,6867.108649,29338.76,percent of total billed charges,,,
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,inpatient,,,53209.61,37246.727,CIGNA [1000112],CIGNA [100011201],,,68,,36182.5348,7771.48,42567.688,percent of total billed charges,,,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC,981,MS-DRG,,,,,,,inpatient,,,96543.58,67580.506,CIGNA [1000112],CIGNA [100011201],,,68,,65649.6344,7771.48,96341.1352,percent of total billed charges,,,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,inpatient,,,54470.12,38129.084,CIGNA [1000112],CIGNA [100011201],,,68,,37039.6816,7771.48,49616.404,percent of total billed charges,,,
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/McC,983,MS-DRG,,,,,,,inpatient,,,18703.75,13092.625,CIGNA [1000112],CIGNA [100011201],,,68,,12718.55,6237.700625,33802.3784,percent of total billed charges,,,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With McC,987,MS-DRG,,,,,,,inpatient,,,51141.58,35799.106,CIGNA [1000112],CIGNA [100011201],,,68,,34776.2744,7771.48,70984.792,percent of total billed charges,,,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,inpatient,,,31104,21772.8,CIGNA [1000112],CIGNA [100011201],,,68,,21150.72,7771.48,34773.024,percent of total billed charges,,,
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,,,inpatient,,,13700.33,9590.231,CIGNA [1000112],CIGNA [100011201],,,68,,9316.2244,4569.060055,10960.264,percent of total billed charges,,,
Ungroupable,999,MS-DRG,,,,,,,inpatient,,,28509.33,19956.531,CIGNA [1000112],CIGNA [100011201],,,68,,19386.3444,7771.48,22807.464,percent of total billed charges,,,
HC Fine Needle Aspiration Bx W/O Img Gdn Ea Addl,PX-36900722,CDM,10004,CPT,369,RC,,,outpatient,,,79,55.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,49.612,17.7355,1592,percent of total billed charges,,,
HC Fine Needle Aspiration Bx W/US Gdn 1st Lesion,PX-36900723,CDM,10005,CPT,369,RC,,,outpatient,,,2116,1481.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,1328.848,399.86,2141,percent of total billed charges,,,
HC Fine Needle Aspiration Bx W/US Gdn Ea Addl,PX-36900724,CDM,10006,CPT,369,RC,,,outpatient,,,258,180.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,162.024,57.921,1592,percent of total billed charges,,,
HC Fine Needle Aspiration W/O Imaging Guidance,PX-36900674,CDM,10021,CPT,369,RC,,,outpatient,,,871,609.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,546.988,195.5395,1592,percent of total billed charges,,,
HC Image-Guided Catheter Fluid Collection Drainage,PX-36900043,CDM,10030,CPT,369,RC,,,outpatient,,,692,484.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,434.576,155.354,2141,percent of total billed charges,,,
HC Plcmt of Soft Tissue Loc Device(S)- Perc- First Lesion,PX-36900637,CDM,10035,CPT,369,RC,,,outpatient,,,1860,1302,CIGNA [1000112],CIGNA [100011201],,,62.8,,1168.08,291.227805,2141,percent of total billed charges,,,
HC Plmt Sft Tiss Loclzj Dev Perq Each Addl Lesion,PX-36900889,CDM,10036,CPT,369,RC,,,outpatient,,,130,91,CIGNA [1000112],CIGNA [100011201],,,62.8,,81.64,29.185,1592,percent of total billed charges,,,
HC Drain Skin Abscess Simple,PX-36900044,CDM,10060,CPT,369,RC,,,outpatient,,,922,645.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,579.016,206.989,1592,percent of total billed charges,,,
HC Drain Skin Abscess Complic,PX-36900045,CDM,10061,CPT,369,RC,,,outpatient,,,922,645.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,579.016,206.989,1592,percent of total billed charges,,,
HC Drainage of Hematoma/Fluid,PX-36900048,CDM,10140,CPT,369,RC,,,outpatient,,,4838,3386.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,3038.264,399.86,3715.584,percent of total billed charges,,,
HC Puncture Drainage of Lesion,PX-36100003,CDM,10160,CPT,361,RC,,,outpatient,,,916,641.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,575.248,205.642,1592,percent of total billed charges,,,
HC Puncture Drainage of Lesion,PX-36900049,CDM,10160,CPT,369,RC,,,outpatient,,,916,641.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,575.248,205.642,1592,percent of total billed charges,,,
HC Complex Drainage- Wound,PX-36900050,CDM,10180,CPT,369,RC,,,outpatient,,,8640,6048,CIGNA [1000112],CIGNA [100011201],,,62.8,,5425.92,399.86,6635.52,percent of total billed charges,,,
HC Debridement- Infected Skin- Up to 10% Bsa,PX-36900606,CDM,11000,CPT,369,RC,,,outpatient,,,1174,821.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,737.272,263.563,1592,percent of total billed charges,,,
HC Debridement- Infected Skin- Ea Add 10% Bsa,PX-36900607,CDM,11001,CPT,369,RC,,,outpatient,,,53,37.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,33.284,11.8985,1592,percent of total billed charges,,,
HC Debride Necrotic Skin/ Tissue- Genit & Perinm,PX-36900608,CDM,11004,CPT,369,RC,,,outpatient,,,2036,1425.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,1278.608,399.86,2998,percent of total billed charges,,,
HC Dbrdmt Skn Subq T/M/F Necro Infctj Abdl Wall,PX-36900876,CDM,11005,CPT,369,RC,,,outpatient,,,2001,1400.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,1256.628,399.86,2998,percent of total billed charges,,,
HC Dbrdmt Skn Subq T/M/F Necro Infctj Gent/Abdl,PX-36900877,CDM,11006,CPT,369,RC,,,outpatient,,,1815,1270.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,1139.82,399.86,2998,percent of total billed charges,,,
HC Removal Prosthetic Matrl Abdl Wall for Infection,PX-36900878,CDM,11008,CPT,369,RC,,,outpatient,,,706,494.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,443.368,158.497,3914,percent of total billed charges,,,
HC Dbrdmt W/Rmvl Fm Fx&/Dislc Skin&Subq Tissus,PX-36900743,CDM,11010,CPT,369,RC,,,outpatient,,,2113,1479.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,1326.964,399.86,2141,percent of total billed charges,,,
HC Dbrdmt W/Rmvl Fm Fx&/Dislc Skn Subq T/M/F Musc,PX-36900773,CDM,11011,CPT,369,RC,,,outpatient,,,2197,1537.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,1379.716,399.86,2141,percent of total billed charges,,,
HC Dbrdmt Fx&/Dislc Subq T/M/F Bone,PX-36900744,CDM,11012,CPT,369,RC,,,outpatient,,,9022,6315.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,5665.816,399.86,6928.896,percent of total billed charges,,,
HC Debridement- Skin- Sub-Q Tissue-=<20 Sq Cm,PX-36900052,CDM,11042,CPT,369,RC,,,outpatient,,,1018,712.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,639.304,228.541,1592,percent of total billed charges,,,
HC Debridement- Skin- Sub-Q Tissue-Muscle-=<20 Sq Cm,PX-36900053,CDM,11043,CPT,369,RC,,,outpatient,,,1065,745.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,668.82,239.0925,1592,percent of total billed charges,,,
HC Debridement- Skin- Sub-Q Tissue-Muscle-Bone-=<20 Sq Cm,PX-36900054,CDM,11044,CPT,369,RC,,,outpatient,,,2829,1980.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,1776.612,399.86,2477.315575,percent of total billed charges,,,
HC Debridement- Skin- Sub-Q Tissue-Each Add 20 Sq Cm,PX-36900055,CDM,11045,CPT,369,RC,,,outpatient,,,1203,842.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,755.484,270.0735,1592,percent of total billed charges,,,
HC Debridement- Skin- Sub-Q Tissue-Muscle-Each Add 20 Sq Cm,PX-36900056,CDM,11046,CPT,369,RC,,,outpatient,,,1203,842.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,755.484,270.0735,1592,percent of total billed charges,,,
HC Debridement- Skin- Sub-Q Tissue-Muscle-Bone-Each Add 20 Sq Cm,PX-36900057,CDM,11047,CPT,369,RC,,,outpatient,,,1910,1337,CIGNA [1000112],CIGNA [100011201],,,62.8,,1199.48,399.86,1592,percent of total billed charges,,,
HC Trim Nail(S),PX-36900064,CDM,11719,CPT,369,RC,,,outpatient,,,347,242.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,217.916,62.19,1592,percent of total billed charges,,,
HC Debridement of Nail(S)- 1-5,PX-36900065,CDM,11720,CPT,369,RC,,,outpatient,,,347,242.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,217.916,66.75974,1592,percent of total billed charges,,,
HC Debridement Nail Any Method 6/>,PX-36900791,CDM,11721,CPT,369,RC,,,outpatient,,,212,148.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,133.136,47.594,1592,percent of total billed charges,,,
HC Removal of Nail Plate,PX-36900067,CDM,11730,CPT,369,RC,,,outpatient,,,431,301.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,270.668,96.7595,1592,percent of total billed charges,,,
HC Avulsion Nail Plate Partial/Comp Simple Ea Addl,PX-36900831,CDM,11732,CPT,369,RC,,,outpatient,,,139,97.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,87.292,31.2055,1592,percent of total billed charges,,,
HC Evacuation Subungual Hematoma,PX-36900832,CDM,11740,CPT,369,RC,,,outpatient,,,159,111.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,99.852,35.6955,1592,percent of total billed charges,,,
HC Removal of Nail Bed,PX-36900069,CDM,11750,CPT,369,RC,,,outpatient,,,1914,1339.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,1201.992,399.86,1592,percent of total billed charges,,,
HC Biopsy Nail Unit Separate Procedure,PX-36900763,CDM,11755,CPT,369,RC,,,outpatient,,,2197,1537.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,1379.716,399.86,2141,percent of total billed charges,,,
HC Repair Nail Bed,PX-36900833,CDM,11760,CPT,369,RC,,,outpatient,,,909,636.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,570.852,113.876282,1592,percent of total billed charges,,,
HC Wedge Excision Skin Nail Fold,PX-36900834,CDM,11765,CPT,369,RC,,,outpatient,,,1377,963.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,864.756,156.65,1592,percent of total billed charges,,,
HC Resuperf Wnd Body <2.5cm,PX-36900070,CDM,12001,CPT,369,RC,,,outpatient,,,505,353.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,317.14,113.3725,1592,percent of total billed charges,,,
HC Resup Npterf Wnd Body 2.6-7.5 Cm,PX-36900071,CDM,12002,CPT,369,RC,,,outpatient,,,505,353.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,317.14,113.3725,1592,percent of total billed charges,,,
HC Resuperf Wnd Body 7.6-12.5 Cm,PX-36900072,CDM,12004,CPT,369,RC,,,outpatient,,,445,311.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,279.46,99.9025,1592,percent of total billed charges,,,
HC Resuperf Wnd Body 12.6-20 Cm,PX-36900839,CDM,12005,CPT,369,RC,,,outpatient,,,513,359.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,322.164,115.1685,1592,percent of total billed charges,,,
HC Resuperf Wnd Body 20.1-30 Cm,PX-36900840,CDM,12006,CPT,369,RC,,,outpatient,,,648,453.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,406.944,145.476,1592,percent of total billed charges,,,
HC Resuperf Wnd Body >30 Cm,PX-36900841,CDM,12007,CPT,369,RC,,,outpatient,,,425,297.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,266.9,95.4125,1592,percent of total billed charges,,,
HC Simple Repair F/E/E/N/L/M 2.5cm/<,PX-36900758,CDM,12011,CPT,369,RC,,,outpatient,,,329,230.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,206.612,73.8605,1592,percent of total billed charges,,,
HC Resuperf Wnd Face 2.6-5 Cm,PX-36900842,CDM,12013,CPT,369,RC,,,outpatient,,,400,280,CIGNA [1000112],CIGNA [100011201],,,62.8,,251.2,89.8,1592,percent of total billed charges,,,
HC Resuperf Wnd Face 5.1-7.5 Cm,PX-36900843,CDM,12014,CPT,369,RC,,,outpatient,,,479,335.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,300.812,107.5355,1592,percent of total billed charges,,,
HC Resuperf Wnd Face 7.6-12.5 Cm,PX-36900844,CDM,12015,CPT,369,RC,,,outpatient,,,633,443.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,397.524,142.1085,1592,percent of total billed charges,,,
HC Resuperf Wnd Face 12.6-20 Cm,PX-36900845,CDM,12016,CPT,369,RC,,,outpatient,,,779,545.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,489.212,174.8855,1592,percent of total billed charges,,,
HC Simple Repair Suprfcl Wnds F/E/E/N/L/Mucs Membrnes;20.1-30.0 Cm,PX-36900846,CDM,12017,CPT,369,RC,,,outpatient,,,555,388.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,348.54,124.5975,1592,percent of total billed charges,,,
HC Simple Repair Suprfcl Wnds F/E/E/N/L/Mucs Membrnes;Over 30.0 Cm,PX-36900847,CDM,12018,CPT,369,RC,,,outpatient,,,448,313.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,281.344,100.576,1592,percent of total billed charges,,,
HC Closure Superf Wnd Dehis Simple,PX-36900848,CDM,12020,CPT,369,RC,,,outpatient,,,1377,963.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,864.756,309.1365,1592,percent of total billed charges,,,
HC Closure Superf Wnd Dehis W Packing,PX-36900849,CDM,12021,CPT,369,RC,,,outpatient,,,809,566.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,508.052,181.6205,1592,percent of total billed charges,,,
HC Repair Intermediate S/a/T/E 2.5 Cm/<,PX-36900757,CDM,12031,CPT,369,RC,,,outpatient,,,891,623.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,559.548,200.0295,1592,percent of total billed charges,,,
HC Layr Clos Wnd Trunk-Arm-Leg 2.6-7.5 Cm,PX-36900850,CDM,12032,CPT,369,RC,,,outpatient,,,505,353.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,317.14,113.3725,1592,percent of total billed charges,,,
HC Layr Clos Wnd Trunk-Arm-Leg 7.6-12.5 Cm,PX-36900851,CDM,12034,CPT,369,RC,,,outpatient,,,685,479.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,430.18,153.7825,1592,percent of total billed charges,,,
HC Layr Clos Wnd Trunk-Arm-Leg 12.6-20 Cm,PX-36900852,CDM,12035,CPT,369,RC,,,outpatient,,,685,479.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,430.18,153.7825,1592,percent of total billed charges,,,
HC Layr Clos Wnd Trunk-Arm-Leg 20.1-30 Cm,PX-36900853,CDM,12036,CPT,369,RC,,,outpatient,,,649,454.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,407.572,145.7005,1592,percent of total billed charges,,,
HC Layr Clos Wnd Trunk-Arm-Leg >30 Cm,PX-36900854,CDM,12037,CPT,369,RC,,,outpatient,,,4504,3152.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,2828.512,399.86,3459.072,percent of total billed charges,,,
HC Repair Intermediate N/H/F/Xtrnl Gent 2.5cm/<,PX-36900756,CDM,12041,CPT,369,RC,,,outpatient,,,634,443.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,398.152,142.333,1592,percent of total billed charges,,,
HC Repair Intermediate Neck/Hand/Feet/Xtrnl Gent 2.6-7.5 Cm,PX-36900806,CDM,12042,CPT,369,RC,,,outpatient,,,633,443.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,397.524,142.1085,1592,percent of total billed charges,,,
HC Layr Clos Wnd Rest Body 7.6-12.5 Cm,PX-36900855,CDM,12044,CPT,369,RC,,,outpatient,,,623,436.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,391.244,139.8635,1592,percent of total billed charges,,,
HC Layr Clos Wnd Rest Body 12.6-20 Cm,PX-36900856,CDM,12045,CPT,369,RC,,,outpatient,,,627,438.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,393.756,140.7615,1592,percent of total billed charges,,,
HC Layr Clos Wnd Rest Body 20.1-30 Cm,PX-36900857,CDM,12046,CPT,369,RC,,,outpatient,,,1056,739.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,663.168,237.072,2141,percent of total billed charges,,,
HC Repair Intermediate N/H/F/Xtrnl Gent >30.0 Cm,PX-36900858,CDM,12047,CPT,369,RC,,,outpatient,,,5238,3666.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,3289.464,399.86,4022.784,percent of total billed charges,,,
HC Repair Intermediate F/E/E/N/L&/Muc 2.5 Cm/<,PX-36900755,CDM,12051,CPT,369,RC,,,outpatient,,,891,623.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,559.548,200.0295,1592,percent of total billed charges,,,
HC Layr Clos Wnd Face-Facial 2.5-5 Cm,PX-36900859,CDM,12052,CPT,369,RC,,,outpatient,,,596,417.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,374.288,133.802,1592,percent of total billed charges,,,
HC Layr Clos Wnd Face-Facial 5.1-7.5 Cm,PX-36900860,CDM,12053,CPT,369,RC,,,outpatient,,,663,464.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,416.364,148.8435,1592,percent of total billed charges,,,
HC Layr Clos Wnd Face-Facial 7.6-12.5 Cm,PX-36900861,CDM,12054,CPT,369,RC,,,outpatient,,,652,456.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,409.456,146.374,1592,percent of total billed charges,,,
HC Layr Clos Wnd Face-Facial 12.6-20 Cm,PX-36900862,CDM,12055,CPT,369,RC,,,outpatient,,,749,524.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,470.372,168.1505,1592,percent of total billed charges,,,
HC Layr Clos Wnd Face-Facial 20.1-30 Cm,PX-36900863,CDM,12056,CPT,369,RC,,,outpatient,,,1419,993.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,891.132,318.5655,1592,percent of total billed charges,,,
HC Repair Intermediate F/E/E/N/L&/Muc >30.0 Cm,PX-36900864,CDM,12057,CPT,369,RC,,,outpatient,,,1132,792.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,710.896,254.134,1592,percent of total billed charges,,,
HC Repair Complex Trunk 1.1-2.5 Cm,PX-36900788,CDM,13100,CPT,369,RC,,,outpatient,,,1831,1281.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,1149.868,399.86,1592,percent of total billed charges,,,
HC Recmpl Wnd Trunk 2.6-7.5 Cm,PX-36900865,CDM,13101,CPT,369,RC,,,outpatient,,,1090,763,CIGNA [1000112],CIGNA [100011201],,,62.8,,684.52,244.705,1592,percent of total billed charges,,,
HC Rep-Skin-Trunk-Cmplx-+5 Cm/<,PX-36900866,CDM,13102,CPT,369,RC,,,outpatient,,,250,175,CIGNA [1000112],CIGNA [100011201],,,62.8,,157,56.125,1592,percent of total billed charges,,,
HC Repair Complex Scalp/Arm/Leg 1.1-2.5 Cm,PX-36900754,CDM,13120,CPT,369,RC,,,outpatient,,,1761,1232.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,1105.908,395.3445,1592,percent of total billed charges,,,
HC Recmpl Wnd Scalp-Extr 2.6-7.5 Cm,PX-36900867,CDM,13121,CPT,369,RC,,,outpatient,,,735,514.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,461.58,165.0075,1592,percent of total billed charges,,,
HC Rep-Skin-Scalp/Extrem+5 Cm/<,PX-36900868,CDM,13122,CPT,369,RC,,,outpatient,,,305,213.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,191.54,68.4725,1592,percent of total billed charges,,,
HC Repair Complex F/C/C/M/N/Ax/G/H/F 1.1-2.5 Cm,PX-36900753,CDM,13131,CPT,369,RC,,,outpatient,,,1145,801.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,719.06,257.0525,1592,percent of total billed charges,,,
HC Recmpl Wnd Head-Fac-Hand 2.6-7.5 Cm,PX-36900869,CDM,13132,CPT,369,RC,,,outpatient,,,723,506.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,454.044,162.3135,1592,percent of total billed charges,,,
HC Repr-Face-Genital-Hand-Ft+5 Cmcm/<,PX-36900870,CDM,13133,CPT,369,RC,,,outpatient,,,578,404.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,362.984,129.761,1592,percent of total billed charges,,,
HC Repair Complex Eyelid/Nose/Ear/Lip 1.1-2.5 Cm,PX-36900752,CDM,13151,CPT,369,RC,,,outpatient,,,1761,1232.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,1105.908,395.3445,1592,percent of total billed charges,,,
HC Recmpl Wnd Lid-Nos-Ear 2.5-7.5 Cm,PX-36900871,CDM,13152,CPT,369,RC,,,outpatient,,,743,520.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,466.604,166.8035,1592,percent of total billed charges,,,
HC Repr-Eyelid-Nose-Ear-Lip+5 Cm,PX-36900872,CDM,13153,CPT,369,RC,,,outpatient,,,462,323.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,290.136,103.719,1592,percent of total billed charges,,,
HC Secd Clos Surg Wnd Exten/Complic,PX-36900873,CDM,13160,CPT,369,RC,,,outpatient,,,4504,3152.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,2828.512,399.86,3459.072,percent of total billed charges,,,
HC Dressing Change Under Anesthesia,PX-36900774,CDM,15852,CPT,369,RC,,,outpatient,,,1831,1281.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,1149.868,108.7,1592,percent of total billed charges,,,
HC Exc Coccyx/Ulcer W Suture,PX-36900598,CDM,15920,CPT,369,RC,,,outpatient,,,3425,2397.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,2150.9,399.86,4341.777195,percent of total billed charges,,,
HC Exc Sacr Press Ulc W Pri Suture,PX-36900599,CDM,15931,CPT,369,RC,,,outpatient,,,7558,5290.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4746.424,399.86,5804.544,percent of total billed charges,,,
HC Exc Sacr Press Ulc W Flap Clos,PX-36900600,CDM,15934,CPT,369,RC,,,outpatient,,,9536,6675.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,5988.608,399.86,7323.648,percent of total billed charges,,,
HC Exc Sacr Press Ulc W Musc Flap Clo,PX-36900601,CDM,15936,CPT,369,RC,,,outpatient,,,5831,4081.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,3661.868,399.86,4478.208,percent of total billed charges,,,
HC Exc Isch Pres Ulc W Prim Clos,PX-36900602,CDM,15940,CPT,369,RC,,,outpatient,,,7558,5290.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4746.424,399.86,5804.544,percent of total billed charges,,,
HC Exc Isch Pres Ulc W Flap Clos,PX-36900603,CDM,15944,CPT,369,RC,,,outpatient,,,5831,4081.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,3661.868,399.86,5481.863562,percent of total billed charges,,,
HC Exc Isch Pres Ulc Bone Myocut Flap,PX-36900604,CDM,15946,CPT,369,RC,,,outpatient,,,9536,6675.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,5988.608,399.86,7323.648,percent of total billed charges,,,
HC Exc Troc Pres Ulc W Prim Clos,PX-36900605,CDM,15950,CPT,369,RC,,,outpatient,,,7558,5290.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4746.424,399.86,5804.544,percent of total billed charges,,,
HC Initial Tx 1st Degree Burn Local Tx,PX-36900591,CDM,16000,CPT,369,RC,,,outpatient,,,393,275.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,246.804,88.2285,1592,percent of total billed charges,,,
HC Dress/Debrid Small Burn No Anes,PX-36900090,CDM,16020,CPT,369,RC,,,outpatient,,,812,568.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,509.936,182.294,1592,percent of total billed charges,,,
HC Dress/Debrid Med Burn No Anesth,PX-36900091,CDM,16025,CPT,369,RC,,,outpatient,,,812,568.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,509.936,182.294,1592,percent of total billed charges,,,
HC Dress/Debrid Large Burn No Anesth,PX-36900092,CDM,16030,CPT,369,RC,,,outpatient,,,845,591.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,530.66,189.7025,1592,percent of total billed charges,,,
HC Escharotomy Each Additional Incision,PX-36900883,CDM,16036,CPT,369,RC,,,outpatient,,,670,469,CIGNA [1000112],CIGNA [100011201],,,62.8,,420.76,150.415,2998,percent of total billed charges,,,
HC Destruc Cut/Vasc 10-50 Sqcm,PX-36900094,CDM,17107,CPT,369,RC,,,outpatient,,,1763,1234.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,1107.164,395.7935,1592,percent of total billed charges,,,
HC Punc/Aspir Breast Cyst,PX-36900096,CDM,19000,CPT,369,RC,,,outpatient,,,1637,1145.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,1028.036,367.5065,2141,percent of total billed charges,,,
HC Puct/Aspir Breast Cyst-Each Addn,PX-36900097,CDM,19001,CPT,369,RC,,,outpatient,,,60,42,CIGNA [1000112],CIGNA [100011201],,,62.8,,37.68,13.47,1592,percent of total billed charges,,,
HC Bx Breast W Device 1st Lesion Stereotactic Guide,PX-36900099,CDM,19081,CPT,369,RC,,,outpatient,,,4317,3021.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,2711.076,399.86,3315.456,percent of total billed charges,,,
HC Bx Breast W Device Addl Lesion Stereotact Guide,PX-36900100,CDM,19082,CPT,369,RC,,,outpatient,,,3998,2798.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,2510.744,399.86,3070.464,percent of total billed charges,,,
HC Bx Breast W Device 1st Lesion Ultrasound Guide,PX-36900101,CDM,19083,CPT,369,RC,,,outpatient,,,3271,2289.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,2054.188,399.86,2998,percent of total billed charges,,,
HC Bx Breast W Device Addl Lesion Ultrasound Guide,PX-36900102,CDM,19084,CPT,369,RC,,,outpatient,,,2336,1635.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,1467.008,399.86,1794.048,percent of total billed charges,,,
HC Bx Breast W Device 1st Lesion Magnetic Res Guide,PX-36900103,CDM,19085,CPT,369,RC,,,outpatient,,,5120,3584,CIGNA [1000112],CIGNA [100011201],,,62.8,,3215.36,399.86,3932.16,percent of total billed charges,,,
HC Bx Breast W Device Addl Lesion Magnet Res Guide,PX-36900104,CDM,19086,CPT,369,RC,,,outpatient,,,2232,1562.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,1401.696,399.86,1714.176,percent of total billed charges,,,
HC Perq Device Placemt Breast Loc 1st Les W Guidnce,PX-36900106,CDM,19281,CPT,369,RC,,,outpatient,,,915,640.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,574.62,108.7,2998,percent of total billed charges,,,
HC Perq Device Placemt Breast Loc Ea Les W Guidnce,PX-36900107,CDM,19282,CPT,369,RC,,,outpatient,,,880,616,CIGNA [1000112],CIGNA [100011201],,,62.8,,552.64,197.56,1592,percent of total billed charges,,,
HC Perq Breast Loc Device Placemt 1st Strtctc Guid,PX-36900108,CDM,19283,CPT,369,RC,,,outpatient,,,2116,1481.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,1328.848,108.7,2141,percent of total billed charges,,,
HC Perq Breast Loc Device Placemt Ea Lesion Strtctc,PX-36900109,CDM,19284,CPT,369,RC,,,outpatient,,,84,58.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,52.752,18.858,1592,percent of total billed charges,,,
HC Perq Breast Loc Device Placemt 1st Lesio US Imag,PX-36900110,CDM,19285,CPT,369,RC,,,outpatient,,,1175,822.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,737.9,108.7,2141,percent of total billed charges,,,
HC Perq Breast Loc Device Placemt Each Les US Image,PX-36900111,CDM,19286,CPT,369,RC,,,outpatient,,,274,191.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,172.072,61.513,1592,percent of total billed charges,,,
HC Perq Breast Loc Device Placemt 1st Lesio MR Guid,PX-36900112,CDM,19287,CPT,369,RC,,,outpatient,,,2116,1481.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,1328.848,108.7,2141,percent of total billed charges,,,
HC Place Postop Breast Cath for Rad,PX-36900114,CDM,19296,CPT,369,RC,,,outpatient,,,14045,9831.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,8820.26,399.86,14403.82399,percent of total billed charges,,,
HC Muscle Biopsy,PX-36900115,CDM,20200,CPT,369,RC,,,outpatient,,,3700,2590,CIGNA [1000112],CIGNA [100011201],,,62.8,,2323.6,399.86,2998,percent of total billed charges,,,
HC Biopsy Muscle Deep,PX-36900764,CDM,20205,CPT,369,RC,,,outpatient,,,9022,6315.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,5665.816,399.86,6928.896,percent of total billed charges,,,
HC Needle Biopsy-Muscle,PX-36900116,CDM,20206,CPT,369,RC,,,outpatient,,,3700,2590,CIGNA [1000112],CIGNA [100011201],,,62.8,,2323.6,399.86,2998,percent of total billed charges,,,
HC Bone Biopsy-Trocar/Needle Superf,PX-36900117,CDM,20220,CPT,369,RC,,,outpatient,,,3847,2692.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,2415.916,399.86,2954.496,percent of total billed charges,,,
HC Bone Biopsy-Trocar/Needle Deep,PX-36900118,CDM,20225,CPT,369,RC,,,outpatient,,,3700,2590,CIGNA [1000112],CIGNA [100011201],,,62.8,,2323.6,399.86,2998,percent of total billed charges,,,
HC Biopsy Bone Open Superficial,PX-36900770,CDM,20240,CPT,369,RC,,,outpatient,,,9022,6315.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,5665.816,399.86,6928.896,percent of total billed charges,,,
HC Biopsy Bone Open Deep,PX-36900769,CDM,20245,CPT,369,RC,,,outpatient,,,9022,6315.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,5665.816,399.86,6928.896,percent of total billed charges,,,
HC Inject Sinus Tract for Dx W Xray,PX-36900120,CDM,20501,CPT,369,RC,,,outpatient,,,1451,1015.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,911.228,235.074116,1592,percent of total billed charges,,,
HC Removal Foreign Body Muscle/Tendon Sheath Simple,PX-36900749,CDM,20520,CPT,369,RC,,,outpatient,,,5218,3652.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,3276.904,399.86,4007.424,percent of total billed charges,,,
HC Rmvl Foreign Body Muscle/Tendon Sheath Deep/Comp,PX-36900748,CDM,20525,CPT,369,RC,,,outpatient,,,5793,4055.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,3638.004,399.86,4449.024,percent of total billed charges,,,
HC Injection of Tendon Sheath,PX-36900693,CDM,20550,CPT,369,RC,,,outpatient,,,823,576.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,516.844,184.7635,1592,percent of total billed charges,,,
HC Injection Single Tendon Origin/Insertion,PX-36900793,CDM,20551,CPT,369,RC,,,outpatient,,,903,632.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,567.084,202.7235,1592,percent of total billed charges,,,
HC Inject Trigger Point- 1 or 2,PX-36900123,CDM,20552,CPT,369,RC,,,outpatient,,,658,460.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,413.224,147.721,1592,percent of total billed charges,,,
HC Drain/Inject Small Joint/Bursa,PX-36100004,CDM,20600,CPT,361,RC,,,outpatient,,,714,499.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,448.392,160.293,1592,percent of total billed charges,,,
HC Drain/Inject Small Joint/Bursa,PX-36900125,CDM,20600,CPT,369,RC,,,outpatient,,,714,499.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,448.392,160.293,1592,percent of total billed charges,,,
HC Arthrocnt Aspir&/Inj Small Jt/Bursaw/US Rec Rprt,PX-36900787,CDM,20604,CPT,369,RC,,,outpatient,,,938,656.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,589.064,210.581,1592,percent of total billed charges,,,
HC Drain/Inject Intermediate Joint/Bursa,PX-36100005,CDM,20605,CPT,361,RC,,,outpatient,,,753,527.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,472.884,169.0485,1592,percent of total billed charges,,,
HC Drain/Inject Intermediate Joint/Bursa,PX-36900126,CDM,20605,CPT,369,RC,,,outpatient,,,753,527.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,472.884,169.0485,1592,percent of total billed charges,,,
HC Arthrocentesis Aspir&/Inj Interm Jt/Burs W/US,PX-36100030,CDM,20606,CPT,361,RC,,,outpatient,,,1844,1290.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,1158.032,399.86,2141,percent of total billed charges,,,
HC Drain/Inject Large Joint/Bursa,PX-36100006,CDM,20610,CPT,361,RC,,,outpatient,,,658,460.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,413.224,147.721,1592,percent of total billed charges,,,
HC Drain/Inject Large Joint/Bursa,PX-36900127,CDM,20610,CPT,369,RC,,,outpatient,,,658,460.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,413.224,147.721,1592,percent of total billed charges,,,
HC Arthrocentesis Aspir&/Inj Major Jt/Bursa W/US,PX-36100031,CDM,20611,CPT,361,RC,,,outpatient,,,784,548.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,492.352,176.008,1592,percent of total billed charges,,,
HC Ablate- Bone Tumor(S) Perq,PX-36900128,CDM,20982,CPT,369,RC,,,outpatient,,,16473,11531.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,10345.044,399.86,20110.10933,percent of total billed charges,,,
HC Biopsy Soft Tissue Neck/Chest,PX-36900130,CDM,21550,CPT,369,RC,,,outpatient,,,4796,3357.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,3011.888,399.86,3683.328,percent of total billed charges,,,
HC Vertebroplasty Each Addl Cervicothor/Lumbosacral,PX-36900134,CDM,22512,CPT,369,RC,,,outpatient,,,1695,1186.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,1064.46,380.5275,1592,percent of total billed charges,,,
HC Biopsy Soft Tissue Shoulder Superficial,PX-36900138,CDM,23065,CPT,369,RC,,,outpatient,,,2502,1751.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,1571.256,399.86,2477.315575,percent of total billed charges,,,
HC Inj Proc Shoulder Arthrography/CT/MRI,PX-36900139,CDM,23350,CPT,369,RC,,,outpatient,,,1114,779.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,699.592,235.074116,1592,percent of total billed charges,,,
HC Clsd Tx Shoulder Dislc W/Manipulation W/O Anes,PX-36900581,CDM,23650,CPT,369,RC,,,outpatient,,,735,514.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,461.58,165.0075,1592,percent of total billed charges,,,
HC Clsd Tx Shoulder Dislc W/Manipulation Req Anes,PX-36900582,CDM,23655,CPT,369,RC,,,outpatient,,,3604,2522.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,2263.312,399.86,2998,percent of total billed charges,,,
HC I&D Upper Arm/Elbow Deep Abscess/Hematoma,PX-36900784,CDM,23930,CPT,369,RC,,,outpatient,,,5218,3652.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,3276.904,399.86,4341.777195,percent of total billed charges,,,
HC Incision&Drainage Upper Arm/Elbow Bursa,PX-36900751,CDM,23931,CPT,369,RC,,,outpatient,,,3342,2339.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,2098.776,399.86,2998,percent of total billed charges,,,
HC Biopsy Soft Tissue Upper Arm/Elbow Superficial,PX-36900768,CDM,24065,CPT,369,RC,,,outpatient,,,5218,3652.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,3276.904,399.86,4007.424,percent of total billed charges,,,
HC Biopsy Soft Tissue Upper Arm/Elbow Area Deep,PX-36900767,CDM,24066,CPT,369,RC,,,outpatient,,,9022,6315.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,5665.816,399.86,6928.896,percent of total billed charges,,,
HC Injection for Elbow Arthrogram,PX-36900143,CDM,24220,CPT,369,RC,,,outpatient,,,1224,856.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,768.672,274.788,1592,percent of total billed charges,,,
HC I&D Forearm&/Wrist Deep Abscess/Hematoma,PX-36900782,CDM,25028,CPT,369,RC,,,outpatient,,,9952,6966.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,6249.856,399.86,7643.136,percent of total billed charges,,,
HC Incision & Drainage Forearm&/Wrist Bursa,PX-36900783,CDM,25031,CPT,369,RC,,,outpatient,,,4983,3488.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,3129.324,399.86,3826.944,percent of total billed charges,,,
HC Incision Deep Bone Cortex Forearm&/Wrist,PX-36900785,CDM,25035,CPT,369,RC,,,outpatient,,,21621,15134.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,13577.988,399.86,16604.928,percent of total billed charges,,,
HC Arthrt Rdcrpl/Midcarpl Jt W/Expl Drg/Rmvl FB,PX-36900778,CDM,25040,CPT,369,RC,,,outpatient,,,9952,6966.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,6249.856,399.86,7643.136,percent of total billed charges,,,
HC Biopsy Soft Tissue Forearm&/Wrist Superficial,PX-36900766,CDM,25065,CPT,369,RC,,,outpatient,,,5218,3652.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,3276.904,399.86,4007.424,percent of total billed charges,,,
HC Biopsy Soft Tissue Forearm&/Wrist Deep,PX-36900765,CDM,25066,CPT,369,RC,,,outpatient,,,9022,6315.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,5665.816,399.86,6928.896,percent of total billed charges,,,
HC Injection for Wrist Arthrogram,PX-36900149,CDM,25246,CPT,369,RC,,,outpatient,,,1660,1162,CIGNA [1000112],CIGNA [100011201],,,62.8,,1042.48,235.074116,1592,percent of total billed charges,,,
HC Cltx Dstl Rdl Fx/Epiphysl Sep W/Manj When Perf,PX-36900792,CDM,25605,CPT,369,RC,,,outpatient,,,2563,1794.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,1609.564,399.86,2455.793921,percent of total billed charges,,,
HC Drainage Finger Abscess Complicated,PX-36900750,CDM,26011,CPT,369,RC,,,outpatient,,,2563,1794.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,1609.564,399.86,2998,percent of total billed charges,,,
HC Drainage Tendon Sheath Digit&/Palm Each,PX-36900781,CDM,26020,CPT,369,RC,,,outpatient,,,9952,6966.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,6249.856,399.86,7643.136,percent of total billed charges,,,
HC Drainage of Palmar Bursa Single Bursa,PX-36900780,CDM,26025,CPT,369,RC,,,outpatient,,,9952,6966.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,6249.856,399.86,7643.136,percent of total billed charges,,,
HC Drainage of Palmar Bursa Multiple Bursa,PX-36900779,CDM,26030,CPT,369,RC,,,outpatient,,,9952,6966.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,6249.856,399.86,7643.136,percent of total billed charges,,,
HC Incision Bone Cortex Hand/Finger,PX-36900786,CDM,26034,CPT,369,RC,,,outpatient,,,4983,3488.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,3129.324,399.86,3826.944,percent of total billed charges,,,
HC Arthrt Expl Drg/Rmvl Loose/FB Carp/Mtcrpl Jt,PX-36900775,CDM,26070,CPT,369,RC,,,outpatient,,,4983,3488.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,3129.324,399.86,3826.944,percent of total billed charges,,,
HC Arthrt Expl Drg/Rmvl Loose/FB Mtcarphlngl Jt Ea,PX-36900777,CDM,26075,CPT,369,RC,,,outpatient,,,9952,6966.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,6249.856,399.86,7643.136,percent of total billed charges,,,
HC Arthrt Expl Drg/Rmvl Loose/FB Iphal Jt Ea,PX-36900776,CDM,26080,CPT,369,RC,,,outpatient,,,4983,3488.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,3129.324,399.86,3826.944,percent of total billed charges,,,
HC Bx Soft Tissues-Pelv/Hip-Superficl,PX-36900160,CDM,27040,CPT,369,RC,,,outpatient,,,3700,2590,CIGNA [1000112],CIGNA [100011201],,,62.8,,2323.6,399.86,2841.6,percent of total billed charges,,,
HC Bx Soft Tissues-Pelv/Hip-Deep,PX-36900161,CDM,27041,CPT,369,RC,,,outpatient,,,3700,2590,CIGNA [1000112],CIGNA [100011201],,,62.8,,2323.6,399.86,2841.6,percent of total billed charges,,,
HC Injection Hip Arthrogram,PX-36900162,CDM,27093,CPT,369,RC,,,outpatient,,,1589,1112.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,997.892,235.074116,1592,percent of total billed charges,,,
HC Closed Rx Prox/Neck Femur Fx-Manip,PX-36900886,CDM,27232,CPT,369,RC,,,outpatient,,,3499,2449.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,2197.372,399.86,2998,percent of total billed charges,,,
HC Cltx Hip Dislocation Traumatic W/O Anesthesia,PX-36900583,CDM,27250,CPT,369,RC,,,outpatient,,,902,631.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,566.456,202.499,1592,percent of total billed charges,,,
HC Cltx Hip Dislocation Traumatic Req Anesthesia,PX-36900584,CDM,27252,CPT,369,RC,,,outpatient,,,2848,1993.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,1788.544,399.86,2455.793921,percent of total billed charges,,,
HC Cltx Post Hip Arthrp Dislc W/O Anes,PX-36900585,CDM,27265,CPT,369,RC,,,outpatient,,,671,469.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,421.388,150.6395,1592,percent of total billed charges,,,
HC Cltx Post Hip Arthrp Dislc Req Anes,PX-36900586,CDM,27266,CPT,369,RC,,,outpatient,,,2045,1431.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,1284.26,399.86,2998,percent of total billed charges,,,
HC Unlisted Procedure Pelvis/Hip Joint,PX-36900700,CDM,27299,CPT,369,RC,,,outpatient,,,715,500.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,449.02,160.5175,1592,percent of total billed charges,,,
HC I&D Deep Absc Bursa/Hematoma Thigh/Knee Region,PX-36900814,CDM,27301,CPT,369,RC,,,outpatient,,,7663,5364.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,4812.364,399.86,5885.184,percent of total billed charges,,,
HC Injection Knee Arthrography,PX-36900731,CDM,27369,CPT,369,RC,,,outpatient,,,1446,1012.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,908.088,324.627,1592,percent of total billed charges,,,
HC Injection for Ankle Arthrogram,PX-36900167,CDM,27648,CPT,369,RC,,,outpatient,,,834,583.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,523.752,187.233,1592,percent of total billed charges,,,
HC Closed Tx Bimalleolar Ankle Fracture W/Manj,PX-36900880,CDM,27810,CPT,369,RC,,,outpatient,,,3663,2564.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,2300.364,292.65,2813.184,percent of total billed charges,,,
HC Application Cast Shoulder Hand Long Arm,PX-36900741,CDM,29065,CPT,369,RC,,,outpatient,,,664,464.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,416.992,149.068,1592,percent of total billed charges,,,
HC Application Cast Elbow Finger Short Arm,PX-36900739,CDM,29075,CPT,369,RC,,,outpatient,,,893,625.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,560.804,200.4785,1592,percent of total billed charges,,,
HC Application Cast Hand & Lower Forearm Gauntlet,PX-36900740,CDM,29085,CPT,369,RC,,,outpatient,,,491,343.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,308.348,110.2295,1592,percent of total billed charges,,,
HC Application Cast Finger,PX-36900771,CDM,29086,CPT,369,RC,,,outpatient,,,511,357.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,320.908,114.7195,1592,percent of total billed charges,,,
HC Application Long Arm Splint Shoulder Hand,PX-36900759,CDM,29105,CPT,369,RC,,,outpatient,,,453,317.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,284.484,101.6985,1592,percent of total billed charges,,,
HC Application Short Arm Splint Forearm-Hand Static,PX-36900576,CDM,29125,CPT,369,RC,,,outpatient,,,354,247.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,222.312,79.473,1592,percent of total billed charges,,,
HC Application Short Arm Splint Dynamic,PX-36900577,CDM,29126,CPT,369,RC,,,outpatient,,,354,247.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,222.312,79.473,1592,percent of total billed charges,,,
HC Application Finger Splint Static,PX-36900579,CDM,29130,CPT,369,RC,,,outpatient,,,221,154.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,138.788,49.6145,1592,percent of total billed charges,,,
HC Application Finger Splint Dynamic,PX-36900580,CDM,29131,CPT,369,RC,,,outpatient,,,218,152.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,136.904,48.941,1592,percent of total billed charges,,,
HC Strapping Shoulder,PX-36900761,CDM,29240,CPT,369,RC,,,outpatient,,,405,283.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,254.34,90.9225,1592,percent of total billed charges,,,
HC Strapping Elbow/Wrist,PX-36900760,CDM,29260,CPT,369,RC,,,outpatient,,,122,85.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,76.616,27.389,1592,percent of total billed charges,,,
HC Strapping Hand/Finger,PX-36900790,CDM,29280,CPT,369,RC,,,outpatient,,,122,85.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,76.616,27.389,1592,percent of total billed charges,,,
HC Application Short Leg Cast Below Knee-Toe,PX-36900818,CDM,29405,CPT,369,RC,,,outpatient,,,699,489.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,438.972,156.9255,1592,percent of total billed charges,,,
HC Application Long Leg Splint Thigh Ankle/Toes,PX-36900737,CDM,29505,CPT,369,RC,,,outpatient,,,554,387.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,347.912,124.373,1592,percent of total billed charges,,,
HC Application Short Leg Splint Calf Foot,PX-36900578,CDM,29515,CPT,369,RC,,,outpatient,,,354,247.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,222.312,79.473,1592,percent of total billed charges,,,
HC Ctrl Nosebleed-Anter-Simple,PX-36900181,CDM,30901,CPT,369,RC,,,outpatient,,,347,242.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,217.916,77.9015,1592,percent of total billed charges,,,
HC PR Control Nasal Hemorrhage Anterior Simple,PX-96000041,CDM,30901,CPT,960,RC,,,outpatient,,,347,242.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,217.916,77.9015,1592,percent of total billed charges,,,
HC Control Nasal Hemorrhage Anterior Complex,PX-36900745,CDM,30903,CPT,369,RC,,,outpatient,,,289,202.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,181.492,64.8805,1592,percent of total billed charges,,,
HC PR Control Nasal Hemorrhage Anterior Complex,PX-96000042,CDM,30903,CPT,960,RC,,,outpatient,,,289,202.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,181.492,64.8805,1592,percent of total billed charges,,,
HC Ctrl Nsl Hemrrg Pst Nasal Packs&/Cautery 1st,PX-36900746,CDM,30905,CPT,369,RC,,,outpatient,,,486,340.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,305.208,109.107,1592,percent of total billed charges,,,
HC Ctrl Nsl Hemrrg Pst Nasal Packs&/Cautery Subsq,PX-36900747,CDM,30906,CPT,369,RC,,,outpatient,,,510,357,CIGNA [1000112],CIGNA [100011201],,,62.8,,320.28,114.495,1592,percent of total billed charges,,,
HC Insert Emergency Endotrach Airway,PX-36100007,CDM,31500,CPT,361,RC,,,outpatient,,,544,380.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,341.632,122.128,1592,percent of total billed charges,,,
HC Insert Emergency Endotrach Airway,PX-36900182,CDM,31500,CPT,369,RC,,,outpatient,,,544,380.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,341.632,122.128,1592,percent of total billed charges,,,
HC PR Intubation Endotracheal Emergency Procedure,PX-96000038,CDM,31500,CPT,960,RC,,,outpatient,,,544,380.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,341.632,122.128,1592,percent of total billed charges,,,
HC Trach Tube Change,PX-36900183,CDM,31502,CPT,369,RC,,,outpatient,,,615,430.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,386.22,138.0675,1592,percent of total billed charges,,,
HC Laryngoscopy-Flex Fiber-Diagnostic,PX-36900185,CDM,31575,CPT,369,RC,,,outpatient,,,371,259.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,232.988,83.2895,1592,percent of total billed charges,,,
HC Bronchoscopy-Diagnostic,PX-36900187,CDM,31622,CPT,369,RC,,,outpatient,,,3151,2205.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,1978.828,399.86,2998,percent of total billed charges,,,
HC Bronchoscopy-Diagnostic W Brush,PX-36900188,CDM,31623,CPT,369,RC,,,outpatient,,,3150,2205,CIGNA [1000112],CIGNA [100011201],,,62.8,,1978.2,399.86,2998,percent of total billed charges,,,
HC Brnchsc W/Brncl Alveolar Lavage,PX-36900896,CDM,31624,CPT,369,RC,,,outpatient,,,3935,2754.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,2471.18,399.86,3022.08,percent of total billed charges,,,
HC Bronchoscopy-Biopsy,PX-36900189,CDM,31625,CPT,369,RC,,,outpatient,,,3271,2289.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,2054.188,399.86,2998,percent of total billed charges,,,
HC Needle Biopsy Pleura,PX-36900190,CDM,32400,CPT,369,RC,,,outpatient,,,3700,2590,CIGNA [1000112],CIGNA [100011201],,,62.8,,2323.6,399.86,2998,percent of total billed charges,,,
HC Core Needle Bx Lung/Mediastinum Perq W/Img,PX-36900808,CDM,32408,CPT,369,RC,,,outpatient,,,4594,3215.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,2885.032,399.86,3528.192,percent of total billed charges,,,
HC Insertion Indwelling Tunneled Pleural Catheter,PX-36900192,CDM,32550,CPT,369,RC,,,outpatient,,,8367,5856.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,5254.476,399.86,6425.856,percent of total billed charges,,,
HC Tube Thoracostomy Includes Water Seal,PX-36100008,CDM,32551,CPT,361,RC,,,outpatient,,,1951,1365.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,1225.228,399.86,2447.133941,percent of total billed charges,,,
HC Tube Thoracostomy Includes Water Seal,PX-36900193,CDM,32551,CPT,369,RC,,,outpatient,,,1951,1365.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,1225.228,399.86,2447.133941,percent of total billed charges,,,
HC Tube Thoracostomy Includes Water Seal,PX-36900573,CDM,32551,CPT,369,RC,,,outpatient,,,1951,1365.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,1225.228,399.86,2447.133941,percent of total billed charges,,,
HC PR Tube Thoracostomy Includes Water Seal,PX-96000039,CDM,32551,CPT,960,RC,,,outpatient,,,1951,1365.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,1225.228,399.86,2447.133941,percent of total billed charges,,,
HC Removal of Indwelling Tunneled Pleural Catheter With Cuff,PX-36900194,CDM,32552,CPT,369,RC,,,outpatient,,,2265,1585.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,1422.42,399.86,2141,percent of total billed charges,,,
HC Perc Place Intra-Thoracic Interstit Rad Therapy Guide- 1/Mult,PX-36900195,CDM,32553,CPT,369,RC,,,outpatient,,,4198,2938.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,2636.344,399.86,3224.064,percent of total billed charges,,,
HC Thoracentesis Needle/Cath Pleura W/O Imaging,PX-36900196,CDM,32554,CPT,369,RC,,,outpatient,,,1874,1311.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,1176.872,399.86,2141,percent of total billed charges,,,
HC Thoracentesis Needle/Cath Pleura W/Imaging,PX-36100001,CDM,32555,CPT,361,RC,,,outpatient,,,1636,1145.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,1027.408,367.282,2141,percent of total billed charges,,,
HC Thoracentesis Needle/Cath Pleura W/Imaging,PX-36900197,CDM,32555,CPT,369,RC,,,outpatient,,,1636,1145.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,1027.408,367.282,2141,percent of total billed charges,,,
HC Perq Drainage Pleura Insert Cath W/O Imaging,PX-36900742,CDM,32556,CPT,369,RC,,,outpatient,,,2896,2027.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,1818.688,399.86,2998,percent of total billed charges,,,
HC Perq Drainage Pleura Insert Cath W/Imaging,PX-36900198,CDM,32557,CPT,369,RC,,,outpatient,,,1882,1317.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,1181.896,399.86,2447.133941,percent of total billed charges,,,
HC PR Instlj via Chest Tube/Cath Agent for Pleurodesis,PX-96000040,CDM,32560,CPT,960,RC,,,outpatient,,,2265,1585.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,1422.42,399.86,1739.52,percent of total billed charges,,,
HC Instlj via Ch Tube/Cath Agent Fbrnlysis 1st Day,PX-36900826,CDM,32561,CPT,369,RC,,,outpatient,,,1421,994.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,892.388,319.0145,2141,percent of total billed charges,,,
HC Instlj Ch Tube/Cath Agent Fbrnlysis Sbsq Day,PX-36900827,CDM,32562,CPT,369,RC,,,outpatient,,,1421,994.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,892.388,319.0145,2141,percent of total billed charges,,,
HC Pericardiocentesis W/Img Guidance When Performed,PX-36100034,CDM,33016,CPT,361,RC,,,outpatient,,,5537,3875.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,3477.236,399.86,4252.416,percent of total billed charges,,,
HC Pericardiocentesis W/Img Guidance When Performed,PX-36900797,CDM,33016,CPT,369,RC,,,outpatient,,,5537,3875.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,3477.236,399.86,4252.416,percent of total billed charges,,,
HC Inser Hart Pacer Xvenous Atrial,PX-36900204,CDM,33206,CPT,369,RC,,,outpatient,,,27344,19140.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,17172.032,399.86,21000.192,percent of total billed charges,,,
HC Inser Hart Pacer Xvenous Ventr,PX-36900205,CDM,33207,CPT,369,RC,,,outpatient,,,36767,25736.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,23089.676,399.86,28237.056,percent of total billed charges,,,
HC Inser Hart Pacer Xvenous Atr/Ventr,PX-36900206,CDM,33208,CPT,369,RC,,,outpatient,,,27344,19140.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,17172.032,399.86,21000.192,percent of total billed charges,,,
HC Inser Heart Temp Pacer One Chmbr,PX-36900207,CDM,33210,CPT,369,RC,,,outpatient,,,21456,15019.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,13474.368,399.86,16478.208,percent of total billed charges,,,
HC Insert Pulse Gener One Chmbr,PX-36900209,CDM,33212,CPT,369,RC,,,outpatient,,,21456,15019.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,13474.368,399.86,16478.208,percent of total billed charges,,,
HC Insert Pulse Gener Dual Chmbr,PX-36900210,CDM,33213,CPT,369,RC,,,outpatient,,,27344,19140.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,17172.032,399.86,21000.192,percent of total billed charges,,,
HC Upgrade of Pacemaker System,PX-36900211,CDM,33214,CPT,369,RC,,,outpatient,,,27344,19140.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,17172.032,399.86,21000.192,percent of total billed charges,,,
HC Reposition Transvenous Electrode,PX-36900212,CDM,33215,CPT,369,RC,,,outpatient,,,4029,2820.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,2530.212,399.86,4870.452937,percent of total billed charges,,,
HC Revise Electrode-Pacing-Dual,PX-36900215,CDM,33217,CPT,369,RC,,,outpatient,,,21456,15019.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,13474.368,399.86,16478.208,percent of total billed charges,,,
HC Reeletrode-Pacing-Single,PX-36900216,CDM,33218,CPT,369,RC,,,outpatient,,,9056,6339.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,5687.168,399.86,6955.008,percent of total billed charges,,,
HC Reelectrode-Pacing-Dual,PX-36900217,CDM,33220,CPT,369,RC,,,outpatient,,,9056,6339.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,5687.168,399.86,6955.008,percent of total billed charges,,,
HC Ins Pacemaker Pulse Gen Only W/Exist Mult Leads,PX-36900218,CDM,33221,CPT,369,RC,,,outpatient,,,48979,34285.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,30758.812,399.86,37615.872,percent of total billed charges,,,
HC Relocation of Skin Pocket for Pacemaker,PX-36900219,CDM,33222,CPT,369,RC,,,outpatient,,,4504,3152.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,2828.512,399.86,3459.072,percent of total billed charges,,,
HC Relocate Skin Pocket Cardioverter-Defibrillator,PX-36900220,CDM,33223,CPT,369,RC,,,outpatient,,,2716,1901.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,1705.648,399.86,2998,percent of total billed charges,,,
HC Insrt Pacing Elect-W/Attach Prev Device,PX-36900221,CDM,33224,CPT,369,RC,,,outpatient,,,27344,19140.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,17172.032,399.86,21000.192,percent of total billed charges,,,
HC Insj Eltrd Car Ven Sys Tm Insj Cvdfb/Pm Pls Gen,PX-36900222,CDM,33225,CPT,369,RC,,,outpatient,,,7571,5299.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,4754.588,399.86,6364,percent of total billed charges,,,
HC Reposit Prev Implanted Cardiac Electrode,PX-36900223,CDM,33226,CPT,369,RC,,,outpatient,,,3644,2550.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,2288.432,399.86,4870.452937,percent of total billed charges,,,
HC Remvl Perm Pm Plse Gen W/Repl Plse Gen Sngl Lead,PX-36900224,CDM,33227,CPT,369,RC,,,outpatient,,,17786,12450.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,11169.608,399.86,13659.648,percent of total billed charges,,,
HC Remvl Perm Pm Pls Gen W/Repl Plse Gen 2 Lead Sys,PX-36900225,CDM,33228,CPT,369,RC,,,outpatient,,,19652,13756.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,12341.456,399.86,16316.30039,percent of total billed charges,,,
HC Remvl Perm Pm Pls Gen W/Repl Plse Gen Mult Lead,PX-36900226,CDM,33229,CPT,369,RC,,,outpatient,,,22582,15807.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,14181.496,399.86,29773.2518,percent of total billed charges,,,
HC Ins Pacng Cvdfb Pls Gen Only W/Exist Dual Leads,PX-36900227,CDM,33230,CPT,369,RC,,,outpatient,,,67496,47247.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,42387.488,399.86,51836.928,percent of total billed charges,,,
HC Ins Pacng Cvdfb Pls Gen Only W/Exist Multi Leads,PX-36900228,CDM,33231,CPT,369,RC,,,outpatient,,,64998,45498.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,40818.744,399.86,50269.54813,percent of total billed charges,,,
HC Remv Perm Pacer Generator,PX-36900229,CDM,33233,CPT,369,RC,,,outpatient,,,21456,15019.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,13474.368,399.86,16478.208,percent of total billed charges,,,
HC Remv Transven Pacer Electrode-1 Lead,PX-36900230,CDM,33234,CPT,369,RC,,,outpatient,,,9056,6339.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,5687.168,399.86,6955.008,percent of total billed charges,,,
HC Remv Transven Pacer Electrode-2 Lead,PX-36900231,CDM,33235,CPT,369,RC,,,outpatient,,,9056,6339.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,5687.168,399.86,6955.008,percent of total billed charges,,,
HC Rmv Pulse Generator-Sngl/Dual,PX-36900233,CDM,33241,CPT,369,RC,,,outpatient,,,9028,6319.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,5669.584,399.86,6933.504,percent of total billed charges,,,
HC Rmv Pacer/Electrd-Transven Extrct,PX-36900234,CDM,33244,CPT,369,RC,,,outpatient,,,9056,6339.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,5687.168,399.86,6955.008,percent of total billed charges,,,
HC Insert Electrd Leads/Repostion,PX-36900235,CDM,33249,CPT,369,RC,,,outpatient,,,86384,60468.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,54249.152,399.86,66342.912,percent of total billed charges,,,
HC Rem Pac Cvdfb Plse Gen &Repl Plse Gen Sngl Lead,PX-36900236,CDM,33262,CPT,369,RC,,,outpatient,,,63006,44104.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,39567.768,399.86,48388.608,percent of total billed charges,,,
HC Rem Pac Cvdfb Plse Gen &Repl Plse Gen Dual Lead,PX-36900237,CDM,33263,CPT,369,RC,,,outpatient,,,65752,46026.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,41292.256,399.86,50497.536,percent of total billed charges,,,
HC Rem Pac Cvdfb Pls Gen &Repl Plse Gen Multi Lead,PX-36900238,CDM,33264,CPT,369,RC,,,outpatient,,,65752,46026.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,41292.256,399.86,50497.536,percent of total billed charges,,,
HC Replace Aortic Valve Perq Femoral Artry Approach,PX-36900544,CDM,33361,CPT,369,RC,,,outpatient,,,27728,19409.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,17413.184,399.86,21295.104,percent of total billed charges,,,
HC Replace Aortic Valve Openfemoral Artery Approach,PX-36900545,CDM,33362,CPT,369,RC,,,outpatient,,,29393,20575.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,18458.804,399.86,24913.5068,percent of total billed charges,,,
HC Replace Aortic Valve Open Axillry Artry Approach,PX-36900546,CDM,33363,CPT,369,RC,,,outpatient,,,27728,19409.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,17413.184,399.86,21295.104,percent of total billed charges,,,
HC Replace Aortic Valve Open Iliac Artery Approach,PX-36900547,CDM,33364,CPT,369,RC,,,outpatient,,,29393,20575.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,18458.804,399.86,22573.824,percent of total billed charges,,,
HC Replace Aortic Valve Open Transaortic Approach,PX-36900548,CDM,33365,CPT,369,RC,,,outpatient,,,29393,20575.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,18458.804,399.86,22573.824,percent of total billed charges,,,
HC Transcatheter Transapical Replacemt Aortic Valve,PX-36900549,CDM,33366,CPT,369,RC,,,outpatient,,,29393,20575.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,18458.804,399.86,24913.5068,percent of total billed charges,,,
HC Replace Aortic Valve W/Byp Prq Art/Venous Apprch,PX-36900550,CDM,33367,CPT,369,RC,,,outpatient,,,27728,19409.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,17413.184,399.86,23502.2528,percent of total billed charges,,,
HC Replace Aortic Valve W/Byp Open Art/Venous Aprch,PX-36900551,CDM,33368,CPT,369,RC,,,outpatient,,,29393,20575.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,18458.804,399.86,24913.5068,percent of total billed charges,,,
HC Replace Aorta Valve W/Byp Cntrl Art/Venous Aprch,PX-36900552,CDM,33369,CPT,369,RC,,,outpatient,,,29393,20575.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,18458.804,399.86,24913.5068,percent of total billed charges,,,
HC Endovasc Taa Reincl Subcl,PX-36900241,CDM,33880,CPT,369,RC,,,outpatient,,,6951,4865.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,4365.228,399.86,5338.368,percent of total billed charges,,,
HC Endovasc Taa Rew/O Subcl,PX-36900242,CDM,33881,CPT,369,RC,,,outpatient,,,5970,4179,CIGNA [1000112],CIGNA [100011201],,,62.8,,3749.16,399.86,4584.96,percent of total billed charges,,,
HC Insert Endovasc Prosth- Taa,PX-36900243,CDM,33883,CPT,369,RC,,,outpatient,,,4420,3094,CIGNA [1000112],CIGNA [100011201],,,62.8,,2775.76,399.86,3746.392,percent of total billed charges,,,
HC Endovasc Prosth- Taa- Ea Add,PX-36900244,CDM,33884,CPT,369,RC,,,outpatient,,,1649,1154.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,1035.572,370.2005,2998,percent of total billed charges,,,
HC Endovasc Dist Extens Taa Prosth- Delayed,PX-36900245,CDM,33886,CPT,369,RC,,,outpatient,,,3820,2674,CIGNA [1000112],CIGNA [100011201],,,62.8,,2398.96,399.86,3237.832,percent of total billed charges,,,
HC Car-Car Bypass Grft W/ Endovas Taa Repair,PX-36900247,CDM,33891,CPT,369,RC,,,outpatient,,,4194,2935.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,2633.832,399.86,3220.992,percent of total billed charges,,,
HC Remove Pul Art Emboli No Bypass,PX-36900248,CDM,33915,CPT,369,RC,,,outpatient,,,1800,1260,CIGNA [1000112],CIGNA [100011201],,,62.8,,1130.4,399.86,2998,percent of total billed charges,,,
HC Insert Intra-Aortic Balloon Asst Device,PX-36900249,CDM,33967,CPT,369,RC,,,outpatient,,,2513,1759.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,1578.164,399.86,6913,percent of total billed charges,,,
HC Rmv Aortic Balloon Device,PX-36900250,CDM,33968,CPT,369,RC,,,outpatient,,,139,97.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,87.292,31.2055,6913,percent of total billed charges,,,
HC Insj Perq Vad W/Rs&I L Hrt Arterial Access Only,PX-36900251,CDM,33990,CPT,369,RC,,,outpatient,,,4109,2876.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,2580.452,399.86,3155.712,percent of total billed charges,,,
HC Removal Perq Left Hrt Vad Artl/Artl&Ven Sep Insj,PX-36900252,CDM,33992,CPT,369,RC,,,outpatient,,,4188,2931.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,2630.064,399.86,3549.7488,percent of total billed charges,,,
HC Repositioning Perq R/L Vad W/Img Gdn Sep Insj,PX-36900253,CDM,33993,CPT,369,RC,,,outpatient,,,4188,2931.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,2630.064,399.86,3549.7488,percent of total billed charges,,,
HC Insj Perq Vad W/Rs&I R Heart Venous Access Only,PX-36900809,CDM,33995,CPT,369,RC,,,outpatient,,,4109,2876.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,2580.452,399.86,3155.712,percent of total billed charges,,,
HC Removal Perq R Heart Vad Venous Cannula Sep Insj,PX-36900810,CDM,33997,CPT,369,RC,,,outpatient,,,4188,2931.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,2630.064,293.5896,3216.384,percent of total billed charges,,,
HC Cardiac Surg Procedure Unlist,PX-36900254,CDM,33999,CPT,369,RC,,,outpatient,,,1770,1239,CIGNA [1000112],CIGNA [100011201],,,62.8,,1111.56,397.365,2141,percent of total billed charges,,,
HC Cardiac Surg Procedure Unlist,PX-36900635,CDM,33999,CPT,369,RC,,,outpatient,,,1770,1239,CIGNA [1000112],CIGNA [100011201],,,62.8,,1111.56,397.365,2141,percent of total billed charges,,,
HC Remv Art Clot Axill-Brach-Arm Incis,PX-36900255,CDM,34101,CPT,369,RC,,,outpatient,,,12541,8778.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,7875.748,399.86,9631.488,percent of total billed charges,,,
HC Remv Art Clot Arm-Arm Incis,PX-36900256,CDM,34111,CPT,369,RC,,,outpatient,,,12541,8778.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,7875.748,399.86,9631.488,percent of total billed charges,,,
HC Remv Art Clot Iliac-Pop-Leg Incis,PX-36900257,CDM,34201,CPT,369,RC,,,outpatient,,,12541,8778.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,7875.748,399.86,9631.488,percent of total billed charges,,,
HC Remv Art Clot Low Leg-Leg Incis,PX-36900258,CDM,34203,CPT,369,RC,,,outpatient,,,12541,8778.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,7875.748,399.86,9631.488,percent of total billed charges,,,
HC Aaa Repair-Iliac Artery Occlsn Device,PX-36900264,CDM,34808,CPT,369,RC,,,outpatient,,,152,106.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,95.456,34.124,2998,percent of total billed charges,,,
HC Aaa Repr-Expose Femoral Art-Groin Incis,PX-36900265,CDM,34812,CPT,369,RC,,,outpatient,,,238,166.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,149.464,53.431,2998,percent of total billed charges,,,
HC Aaa Repair- Femoral-Femoral Graft,PX-36900266,CDM,34813,CPT,369,RC,,,outpatient,,,167,116.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,104.876,37.4915,2998,percent of total billed charges,,,
HC Aaa Repr-Expose Iliac Art-Abd Incis- Unilat,PX-36900267,CDM,34820,CPT,369,RC,,,outpatient,,,337,235.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,211.636,75.6565,2998,percent of total billed charges,,,
HC Open Iliac Art Exp W/Conduit-Unilat,PX-36900270,CDM,34833,CPT,369,RC,,,outpatient,,,447,312.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,280.716,100.3515,2998,percent of total billed charges,,,
HC Open Brach Art Exp-Endovas Pros-Unilat,PX-36900271,CDM,34834,CPT,369,RC,,,outpatient,,,218,152.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,136.904,48.941,2998,percent of total billed charges,,,
HC Thrombectomy a-V Graft- Exc Hemodialysis,PX-36900278,CDM,35875,CPT,369,RC,,,outpatient,,,12541,8778.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,7875.748,399.86,9631.488,percent of total billed charges,,,
HC Place Needle in Vein,PX-36900279,CDM,36000,CPT,369,RC,,,outpatient,,,343,240.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,215.404,77.0035,1592,percent of total billed charges,,,
HC Injection Rx Extremity Pseudoaneurysm,PX-36900280,CDM,36002,CPT,369,RC,,,outpatient,,,775,542.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,486.7,173.9875,2141,percent of total billed charges,,,
HC Injection Proc-Extremity-Venography,PX-36900281,CDM,36005,CPT,369,RC,,,outpatient,,,258,180.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,162.024,57.921,1592,percent of total billed charges,,,
HC Place Cath in Vein-Svc-Ivc,PX-36900282,CDM,36010,CPT,369,RC,,,outpatient,,,541,378.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,339.748,121.4545,1592,percent of total billed charges,,,
HC Place Cath in Vein-Select,PX-36900283,CDM,36011,CPT,369,RC,,,outpatient,,,773,541.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,485.444,173.5385,1592,percent of total billed charges,,,
HC Place Cath in Vein-Subselect,PX-36900284,CDM,36012,CPT,369,RC,,,outpatient,,,909,636.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,570.852,204.0705,1592,percent of total billed charges,,,
HC Place Cath in Rt Hrt-Main Pulm Art,PX-36900285,CDM,36013,CPT,369,RC,,,outpatient,,,8331,5831.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,5231.868,399.86,6398.208,percent of total billed charges,,,
HC Place Cath in Lt/Rt Pulm Art,PX-36900286,CDM,36014,CPT,369,RC,,,outpatient,,,721,504.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,452.788,161.8645,1592,percent of total billed charges,,,
HC Place Cath in Subsegmt Pulm Art,PX-36900287,CDM,36015,CPT,369,RC,,,outpatient,,,1662,1163.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,1043.736,373.119,1592,percent of total billed charges,,,
HC Place Cath Carot/Vert Art,PX-36900288,CDM,36100,CPT,369,RC,,,outpatient,,,628,439.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,394.384,140.986,1592,percent of total billed charges,,,
HC Place Cath Extrem Artery,PX-36900290,CDM,36140,CPT,369,RC,,,outpatient,,,340,238,CIGNA [1000112],CIGNA [100011201],,,62.8,,213.52,76.33,1592,percent of total billed charges,,,
HC Place Cath Aorta via Translumbar,PX-36900293,CDM,36160,CPT,369,RC,,,outpatient,,,2609,1826.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,1638.452,399.86,2003.712,percent of total billed charges,,,
HC Place Cath Aorta,PX-36900294,CDM,36200,CPT,369,RC,,,outpatient,,,721,504.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,452.788,161.8645,1592,percent of total billed charges,,,
HC Place Cath Selective Art-Neck,PX-36900295,CDM,36215,CPT,369,RC,,,outpatient,,,1030,721,CIGNA [1000112],CIGNA [100011201],,,62.8,,646.84,231.235,1592,percent of total billed charges,,,
HC Place Cath Subselect Art-Neck,PX-36900296,CDM,36216,CPT,369,RC,,,outpatient,,,568,397.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,356.704,127.516,1592,percent of total billed charges,,,
HC Place Cath Subsubselect Art-Neck,PX-36900297,CDM,36217,CPT,369,RC,,,outpatient,,,1545,1081.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,970.26,346.8525,1592,percent of total billed charges,,,
HC Place Cath Addn Subselec Art-Neck,PX-36900298,CDM,36218,CPT,369,RC,,,outpatient,,,109,76.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,68.452,24.4705,1592,percent of total billed charges,,,
HC Nonslctv Cath Thor Aorta Angio Intr/Xtrcranl Art,PX-36900299,CDM,36221,CPT,369,RC,,,outpatient,,,9691,6783.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,6085.948,399.86,7442.688,percent of total billed charges,,,
HC Slctv Cath Carotid/Innom Art Angio Xtrcranl Art,PX-36900300,CDM,36222,CPT,369,RC,,,outpatient,,,9691,6783.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,6085.948,399.86,7442.688,percent of total billed charges,,,
HC Slctv Cath Carotid/Innom Art Angio Intrcranl Art,PX-36900301,CDM,36223,CPT,369,RC,,,outpatient,,,9141,6398.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,5740.548,399.86,8396.844904,percent of total billed charges,,,
HC Slctv Cath Intrnl Carotid Art Angio Intrcrnl Art,PX-36900302,CDM,36224,CPT,369,RC,,,outpatient,,,15847,11092.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,9951.916,399.86,12170.496,percent of total billed charges,,,
HC Slctv Cath Subclavian Art Angio Vertebral Artery,PX-36900303,CDM,36225,CPT,369,RC,,,outpatient,,,9141,6398.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,5740.548,399.86,7020.288,percent of total billed charges,,,
HC Slctv Cath Vertebral Art Angio Vertebral Artery,PX-36900304,CDM,36226,CPT,369,RC,,,outpatient,,,15847,11092.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,9951.916,399.86,12170.496,percent of total billed charges,,,
HC Slctv Cath Xtrnl Carotid Angio Xtrnl Carotd Circ,PX-36900305,CDM,36227,CPT,369,RC,,,outpatient,,,515,360.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,323.42,115.6175,1592,percent of total billed charges,,,
HC Slctv Cath Intrcrnl Brnch Angio Intrl Carot/Vert,PX-36900306,CDM,36228,CPT,369,RC,,,outpatient,,,612,428.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,384.336,137.394,1592,percent of total billed charges,,,
HC Place Cath Select Art-Abd/Pel,PX-36900307,CDM,36245,CPT,369,RC,,,outpatient,,,1107,774.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,695.196,248.5215,1592,percent of total billed charges,,,
HC Place Cath Subselect Art-Abd/Pel,PX-36900308,CDM,36246,CPT,369,RC,,,outpatient,,,1236,865.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,776.208,277.482,1592,percent of total billed charges,,,
HC Place Cath Subsubselect Art-Abd/Pel,PX-36900309,CDM,36247,CPT,369,RC,,,outpatient,,,1442,1009.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,905.576,323.729,1592,percent of total billed charges,,,
HC Place Cath Addn Subsel Art-Abd/Pel,PX-36900310,CDM,36248,CPT,369,RC,,,outpatient,,,258,180.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,162.024,57.921,1592,percent of total billed charges,,,
HC Slctv Cath 1stord W/WO Art Punct/Fluoro/S&I Uni,PX-36900311,CDM,36251,CPT,369,RC,,,outpatient,,,9430,6601,CIGNA [1000112],CIGNA [100011201],,,62.8,,5922.04,399.86,7242.24,percent of total billed charges,,,
HC Slctv Cath 1stord W/WO Art Punct/Fluor/S&I Bilat,PX-36900312,CDM,36252,CPT,369,RC,,,outpatient,,,9430,6601,CIGNA [1000112],CIGNA [100011201],,,62.8,,5922.04,399.86,7242.24,percent of total billed charges,,,
HC Supslctv Cath 2nd+Ord Renl&Acces Artery/S&I Uni,PX-36900313,CDM,36253,CPT,369,RC,,,outpatient,,,9430,6601,CIGNA [1000112],CIGNA [100011201],,,62.8,,5922.04,399.86,8396.844904,percent of total billed charges,,,
HC Supslctv Cath 2nd+Ord Renl&Acces Arter/S&I Bilat,PX-36900314,CDM,36254,CPT,369,RC,,,outpatient,,,9430,6601,CIGNA [1000112],CIGNA [100011201],,,62.8,,5922.04,399.86,7242.24,percent of total billed charges,,,
Vnpnxr <3 Years Phys/Qhp Skill Other Vein,PX-36900875,CDM,36406,CPT,369,RC,,,outpatient,,,24,16.8,CIGNA [1000112],CIGNA [100011201],,,,,,5.388,416.02,other,Venipuncture and Blood Draw No Pay,,
HC Blood Transfusion Service,PX-39100001,CDM,36430,CPT,391,RC,,,outpatient,,,923,646.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,579.644,207.2135,1592,percent of total billed charges,,,
HC Injection; Spider Veins-Limb/Trunk,PX-36900315,CDM,36468,CPT,369,RC,,,outpatient,,,909,636.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,570.852,156.65,1592,percent of total billed charges,,,
HC Injection Therapy Vein-One Vein,PX-36900316,CDM,36470,CPT,369,RC,,,outpatient,,,909,636.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,570.852,204.0705,1592,percent of total billed charges,,,
HC Injection Therapy Vein-Mult Veins,PX-36900317,CDM,36471,CPT,369,RC,,,outpatient,,,383,268.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,240.524,85.9835,1592,percent of total billed charges,,,
HC Endovenous Rf- 1st Vein,PX-36900318,CDM,36475,CPT,369,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,6623.08,percent of total billed charges,,,
HC Endovenous Rf- Vein Add-On,PX-36900319,CDM,36476,CPT,369,RC,,,outpatient,,,1797,1257.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,1128.516,399.86,1592,percent of total billed charges,,,
HC Endovenous Laser- 1st Vein,PX-36900320,CDM,36478,CPT,369,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,5781.504,percent of total billed charges,,,
HC Endovenous Laser Vein Addon,PX-36900321,CDM,36479,CPT,369,RC,,,outpatient,,,1797,1257.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,1128.516,399.86,1592,percent of total billed charges,,,
HC Percut Portal Vein Cath,PX-36900322,CDM,36481,CPT,369,RC,,,outpatient,,,915,640.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,574.62,205.4175,1592,percent of total billed charges,,,
HC Venous Select Sampling W Cath,PX-36900323,CDM,36500,CPT,369,RC,,,outpatient,,,412,288.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,258.736,92.494,1592,percent of total billed charges,,,
HC Cathj Umbilical Vein Dx/Ther Nb,PX-36900588,CDM,36510,CPT,369,RC,,,outpatient,,,773,541.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,485.444,173.5385,1592,percent of total billed charges,,,
HC Ther Apheresis-Platelets,PX-36900553,CDM,36513,CPT,369,RC,,,outpatient,,,1337,935.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,839.636,300.1565,2081.64,percent of total billed charges,,,
HC Ther Apheresis-Plasma Pheresis,PX-36900324,CDM,36514,CPT,369,RC,,,outpatient,,,4919,3443.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,3089.132,399.86,3777.792,percent of total billed charges,,,
HC Insert Non-Tunnel Cv Cath < 5 Y/O,PX-36100009,CDM,36555,CPT,361,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,5781.504,percent of total billed charges,,,
HC Insert Non-Tunnel Cv Cath < 5 Y/O,PX-36900325,CDM,36555,CPT,369,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,5781.504,percent of total billed charges,,,
HC Insert Non-Tunnel Cv Cath,PX-36100010,CDM,36556,CPT,361,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,6012.672,percent of total billed charges,,,
HC Insert Non-Tunnel Cv Cath,PX-36900326,CDM,36556,CPT,369,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,6012.672,percent of total billed charges,,,
HC PR Insj Non-Tunneled Central Venous Cath Age 5 Yr/>,PX-96000046,CDM,36556,CPT,960,RC,,,outpatient,,,7829,5480.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,4916.612,399.86,6012.672,percent of total billed charges,,,
HC Insert Tunneled Cv Cath W/O Port or Pump < 5 Y/O,PX-36100011,CDM,36557,CPT,361,RC,,,outpatient,,,12541,8778.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,7875.748,399.86,9631.488,percent of total billed charges,,,
HC Insert Tunneled Cv Cath W/O Port or Pump < 5 Y/O,PX-36900327,CDM,36557,CPT,369,RC,,,outpatient,,,12541,8778.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,7875.748,399.86,9631.488,percent of total billed charges,,,
HC Insert Tunneled Cv Cath W/O Port or Pump,PX-36100012,CDM,36558,CPT,361,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,5781.504,percent of total billed charges,,,
HC Insert Tunneled Cv Cath W/O Port or Pump,PX-36900328,CDM,36558,CPT,369,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,5781.504,percent of total billed charges,,,
HC Insert Tunneled Cv Cath With Port <5 Y/O,PX-36100013,CDM,36560,CPT,361,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,5781.504,percent of total billed charges,,,
HC Insert Tunneled Cv Cath With Port <5 Y/O,PX-36900329,CDM,36560,CPT,369,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,5781.504,percent of total billed charges,,,
HC Insert Tunneled Cv Cath With Port,PX-36100014,CDM,36561,CPT,361,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,5781.504,percent of total billed charges,,,
HC Insert Tunneled Cv Cath With Port,PX-36900330,CDM,36561,CPT,369,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,5781.504,percent of total billed charges,,,
HC Insert Tunneled Cv Cath With Pump,PX-36100015,CDM,36563,CPT,361,RC,,,outpatient,,,12541,8778.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,7875.748,399.86,9631.488,percent of total billed charges,,,
HC Insert Tunneled Cv Cath With Pump,PX-36900331,CDM,36563,CPT,369,RC,,,outpatient,,,12541,8778.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,7875.748,399.86,9631.488,percent of total billed charges,,,
HC Insert Tunneled Cv Cath W 2 Access Sites- W/O Pump or Port,PX-36900332,CDM,36565,CPT,369,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,5781.504,percent of total billed charges,,,
HC Insert Tunneled Cv Cath W 2 Access Sites- W/ Pump or Port,PX-36900333,CDM,36566,CPT,369,RC,,,outpatient,,,12541,8778.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,7875.748,399.86,9631.488,percent of total billed charges,,,
HC Insert Picc W/O Sub-Q Port <5 Y/O,PX-36900334,CDM,36568,CPT,369,RC,,,outpatient,,,3698,2588.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,2322.344,399.86,2840.064,percent of total billed charges,,,
HC Insert Picc W/O Sub-Q Port,PX-36900335,CDM,36569,CPT,369,RC,,,outpatient,,,3698,2588.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,2322.344,399.86,2953.728,percent of total billed charges,,,
HC PR Insj Prph Cvc W/O Subq Port/Pmp Age 5 Yr/>,PX-96000047,CDM,36569,CPT,960,RC,,,outpatient,,,3846,2692.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,2415.288,399.86,2953.728,percent of total billed charges,,,
HC Insert Picc W/ Sub-Q Port <5 Y/O,PX-36900336,CDM,36570,CPT,369,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,5781.504,percent of total billed charges,,,
HC Insert Picc W/ Sub-Q Port,PX-36900337,CDM,36571,CPT,369,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,5781.504,percent of total billed charges,,,
HC Repair Cv Cath W/O Subq Port or Pump,PX-36900338,CDM,36575,CPT,369,RC,,,outpatient,,,1421,994.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,892.388,319.0145,2141,percent of total billed charges,,,
HC Repair Cv Cath W Subq Port or Pump,PX-36900339,CDM,36576,CPT,369,RC,,,outpatient,,,3698,2588.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,2322.344,399.86,2840.064,percent of total billed charges,,,
HC Replace Cv Cath- Catheter Only W Subq Pump or Port,PX-36900340,CDM,36578,CPT,369,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,5781.504,percent of total billed charges,,,
HC Replace Cv Cath- Complete- Non-Tunneled- W/O Subq Port or Pump,PX-36900341,CDM,36580,CPT,369,RC,,,outpatient,,,3698,2588.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,2322.344,399.86,2840.064,percent of total billed charges,,,
HC Replace Cv Cath- Complete- Tunneled- W/O Subq Port or Pump,PX-36900342,CDM,36581,CPT,369,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,5781.504,percent of total billed charges,,,
HC Replace Cv Cath- Complete- Non-Tunneled- W Subq Port or Pump,PX-36900343,CDM,36582,CPT,369,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,5781.504,percent of total billed charges,,,
HC Replace Cv Cath- Complete- Tunneled- W Subq Port or Pump,PX-36900344,CDM,36583,CPT,369,RC,,,outpatient,,,12541,8778.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,7875.748,399.86,9631.488,percent of total billed charges,,,
HC Replace Picc W/O Port or Pump,PX-36900345,CDM,36584,CPT,369,RC,,,outpatient,,,3698,2588.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,2322.344,399.86,2840.064,percent of total billed charges,,,
HC Replace Picc W Port or Pump,PX-36900346,CDM,36585,CPT,369,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,5781.504,percent of total billed charges,,,
HC Removal Tunneled Cv Cath W/O Subq Port or Pump,PX-36900347,CDM,36589,CPT,369,RC,,,outpatient,,,1421,994.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,892.388,319.0145,2141,percent of total billed charges,,,
HC Removal Tunneled Cv Cath W Subq Port or Pump,PX-36900348,CDM,36590,CPT,369,RC,,,outpatient,,,3698,2588.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,2322.344,399.86,2998,percent of total billed charges,,,
HC Collect Blood From Implant Venous Access Device,PX-76100001,CDM,36591,CPT,761,RC,,,outpatient,,,160,112,CIGNA [1000112],CIGNA [100011201],,,,,,35.92,1592,other,Venipuncture and Blood Draw No Pay,,
HC Collect Blood From Catheter Venous Nos,PX-36900349,CDM,36592,CPT,369,RC,,,outpatient,,,125,87.5,CIGNA [1000112],CIGNA [100011201],,,,,,28.0625,1592,other,Venipuncture and Blood Draw No Pay,,
HC Declot of Cent Venous Catheter,PX-36900350,CDM,36593,CPT,369,RC,,,outpatient,,,806,564.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,506.168,180.947,1592,percent of total billed charges,,,
HC Mech Remov Pericath Obstr Cv Dev via Ven Access,PX-36900351,CDM,36595,CPT,369,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,5781.504,percent of total billed charges,,,
HC Mech Remov Intralum Obstr Cv Dev Thru Lumen,PX-36900352,CDM,36596,CPT,369,RC,,,outpatient,,,3698,2588.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,2322.344,399.86,2840.064,percent of total billed charges,,,
HC Reposition Venous Catheter,PX-36900353,CDM,36597,CPT,369,RC,,,outpatient,,,3698,2588.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,2322.344,399.86,2840.064,percent of total billed charges,,,
HC Contrast Inj Cent Ven Cath- Inc Flouro,PX-36900354,CDM,36598,CPT,369,RC,,,outpatient,,,406,284.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,254.968,91.147,1592,percent of total billed charges,,,
HC Withdrawal of Arterial Blood,PX-36900355,CDM,36600,CPT,369,RC,,,outpatient,,,297,207.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,186.516,66.6765,1592,percent of total billed charges,,,
HC Insert Cath-Art-Percut-Shortterm,PX-36900356,CDM,36620,CPT,369,RC,,,outpatient,,,309,216.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,194.052,69.3705,1592,percent of total billed charges,,,
HC Catheterization Umbilical Newborn Art Dx/Therapy,PX-36900836,CDM,36660,CPT,369,RC,,,outpatient,,,10702,7491.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,6720.856,399.86,9071.0152,percent of total billed charges,,,
HC Placement Needle Intraosseous Infusion,PX-36900592,CDM,36680,CPT,369,RC,,,outpatient,,,568,397.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,356.704,127.516,1592,percent of total billed charges,,,
HC PR Placement Needle Intraosseous Infusion,PX-96000050,CDM,36680,CPT,960,RC,,,outpatient,,,568,397.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,356.704,127.516,1592,percent of total billed charges,,,
HC Insert Cannula-Vein-Vein,PX-36900358,CDM,36800,CPT,369,RC,,,outpatient,,,12541,8778.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,7875.748,399.86,9631.488,percent of total billed charges,,,
HC Revise Av Fistula-W/O Thrombectomy,PX-36900359,CDM,36832,CPT,369,RC,,,outpatient,,,12541,8778.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,7875.748,399.86,9631.488,percent of total billed charges,,,
HC Insert Transven Intrahep Portosys Shunt,PX-36900361,CDM,37182,CPT,369,RC,,,outpatient,,,4120,2884,CIGNA [1000112],CIGNA [100011201],,,62.8,,2587.36,399.86,5756,percent of total billed charges,,,
HC Revis Transven Intrahep Portosys Shunt,PX-36900362,CDM,37183,CPT,369,RC,,,outpatient,,,13035,9124.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,8185.98,399.86,18955.84,percent of total billed charges,,,
HC Prim Perc Mech Thrombectomy- Arterial,PX-36900363,CDM,37184,CPT,369,RC,,,outpatient,,,26415,18490.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,16588.62,399.86,26793.51305,percent of total billed charges,,,
HC Prim Perc Mech Thrombectomy- Arterial Ea Add,PX-36900364,CDM,37185,CPT,369,RC,,,outpatient,,,824,576.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,517.472,184.988,4800.911611,percent of total billed charges,,,
HC Sec Perc Mech Thrombect- Arterial- W Other Proc,PX-36900365,CDM,37186,CPT,369,RC,,,outpatient,,,1236,865.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,776.208,277.482,8164.18419,percent of total billed charges,,,
HC Percut Mech Thrombectomy- Venous,PX-36900366,CDM,37187,CPT,369,RC,,,outpatient,,,26415,18490.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,16588.62,399.86,20286.72,percent of total billed charges,,,
HC Percut Mech Thrombectomy- Venous- Repeat,PX-36900367,CDM,37188,CPT,369,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,6788.57,percent of total billed charges,,,
HC Ins Intrvas Vc Filtr W/WO Vas Acs Vsl Selxn Rs&I,PX-36900368,CDM,37191,CPT,369,RC,,,outpatient,,,14030,9821,CIGNA [1000112],CIGNA [100011201],,,62.8,,8810.84,399.86,10775.04,percent of total billed charges,,,
HC Repsng Intrvas Vc Filtr W/WO Acs Vsl Selxn Rs&I,PX-36900369,CDM,37192,CPT,369,RC,,,outpatient,,,9628,6739.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,6046.384,399.86,7394.304,percent of total billed charges,,,
HC Rtrvl Intrvas Vc Filtr W/WO Acs Vsl Selxn Rs&I,PX-36900370,CDM,37193,CPT,369,RC,,,outpatient,,,9998,6998.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,6278.744,399.86,7678.464,percent of total billed charges,,,
HC Thrombolysis Cerebral IV Infusion,PX-36900762,CDM,37195,CPT,369,RC,,,outpatient,,,613,429.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,384.964,137.6185,1592,percent of total billed charges,,,
HC Prq Transcatheter Rtrvl Intrvas FB With Imaging,PX-36900371,CDM,37197,CPT,369,RC,,,outpatient,,,8825,6177.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,5542.1,399.86,6777.6,percent of total billed charges,,,
HC Transcatheter Biopsy,PX-36900372,CDM,37200,CPT,369,RC,,,outpatient,,,12541,8778.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,7875.748,399.86,9631.488,percent of total billed charges,,,
HC Thrombolysis Arterial Infusion W/Imaging Init Tx,PX-36900374,CDM,37211,CPT,369,RC,,,outpatient,,,12541,8778.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,7875.748,399.86,9631.488,percent of total billed charges,,,
HC Thrombolysis Venous Infusion W/Imaging Init Tx,PX-36900375,CDM,37212,CPT,369,RC,,,outpatient,,,3239,2267.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,2034.092,399.86,4870.452937,percent of total billed charges,,,
HC Thrombolysis Art/Venous Infsn W/Image Subsq Tx,PX-36900376,CDM,37213,CPT,369,RC,,,outpatient,,,7224,5056.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,4536.672,399.86,5548.032,percent of total billed charges,,,
HC Cessation Thrombolytic Thrpy W/Catheter Removal,PX-36900377,CDM,37214,CPT,369,RC,,,outpatient,,,7224,5056.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,4536.672,399.86,5548.032,percent of total billed charges,,,
HC Transcath Stent- Cca W/Eps,PX-36900378,CDM,37215,CPT,369,RC,,,outpatient,,,553,387.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,347.284,124.1485,2998,percent of total billed charges,,,
HC Revascularize Iliac Artery-Angioplasty- Initial Vessel,PX-36900379,CDM,37220,CPT,369,RC,,,outpatient,,,15994,11195.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,10044.232,399.86,12283.392,percent of total billed charges,,,
HC Revascularize Iliac Artery-Angioplasty/Stent- Initial Vessel,PX-36900380,CDM,37221,CPT,369,RC,,,outpatient,,,16597,11617.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,10422.916,399.86,18955.84,percent of total billed charges,,,
HC Revascularize Iliac Artery-Angioplasty- Ea Add Vessel,PX-36900381,CDM,37222,CPT,369,RC,,,outpatient,,,15818,11072.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,9933.704,399.86,12148.224,percent of total billed charges,,,
HC Revascularize Iliac Artery-Angioplasty/Stent- Ea Add Vessel,PX-36900382,CDM,37223,CPT,369,RC,,,outpatient,,,16216,11351.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,10183.648,399.86,12453.888,percent of total billed charges,,,
HC Revascularize Fem/Pop Artery-Angioplasty,PX-36900383,CDM,37224,CPT,369,RC,,,outpatient,,,16599,11619.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,10424.172,399.86,12748.032,percent of total billed charges,,,
HC Revascularize Fem/Pop Artery-Angioplasty/Atherectomy,PX-36900384,CDM,37225,CPT,369,RC,,,outpatient,,,34070,23849,CIGNA [1000112],CIGNA [100011201],,,62.8,,21395.96,399.86,26793.51305,percent of total billed charges,,,
HC Revascularize Fem/Pop Artery-Angioplasty/Stent,PX-36900385,CDM,37226,CPT,369,RC,,,outpatient,,,32579,22805.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,20459.612,399.86,25020.672,percent of total billed charges,,,
HC Revascularize Fem/Pop Artery-Angioplasty/Stent/Atherectomy,PX-36900386,CDM,37227,CPT,369,RC,,,outpatient,,,59005,41303.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,37055.14,399.86,45315.84,percent of total billed charges,,,
HC Revascularize Tibial/Peron Artery-Angioplasty Initial,PX-36900387,CDM,37228,CPT,369,RC,,,outpatient,,,15999,11199.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,10047.372,399.86,16809.6787,percent of total billed charges,,,
HC Revascularize Tibial/Peron Artery-Angioplasty/Atherectomy Initial,PX-36900388,CDM,37229,CPT,369,RC,,,outpatient,,,34866,24406.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,21895.848,399.86,26793.51305,percent of total billed charges,,,
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent Initial,PX-36900389,CDM,37230,CPT,369,RC,,,outpatient,,,34070,23849,CIGNA [1000112],CIGNA [100011201],,,62.8,,21395.96,399.86,26793.51305,percent of total billed charges,,,
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent/Atherectomy Init,PX-36900390,CDM,37231,CPT,369,RC,,,outpatient,,,58146,40702.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,36515.688,399.86,44656.128,percent of total billed charges,,,
HC Revascularize Tibial/Peron Artery-Angioplasty Ea Add,PX-36900391,CDM,37232,CPT,369,RC,,,outpatient,,,16052,11236.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,10080.656,399.86,12327.936,percent of total billed charges,,,
HC Revascularize Tibial/Peron Artery-Angioplasty/Atherectomy Ea Add,PX-36900392,CDM,37233,CPT,369,RC,,,outpatient,,,33576,23503.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,21085.728,399.86,25786.368,percent of total billed charges,,,
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent Ea Add,PX-36900393,CDM,37234,CPT,369,RC,,,outpatient,,,16052,11236.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,10080.656,399.86,12327.936,percent of total billed charges,,,
HC Revascularize Tibial/Peron Artery-Angioplasty/Stent/Atherectomy Ea Add,PX-36900394,CDM,37235,CPT,369,RC,,,outpatient,,,15818,11072.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,9933.704,399.86,12148.224,percent of total billed charges,,,
HC Open/Perq Placement Intravascular Stent Initial,PX-36900395,CDM,37236,CPT,369,RC,,,outpatient,,,26415,18490.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,16588.62,399.86,20286.72,percent of total billed charges,,,
HC Open/Perq Placement Intravascular Stent Ea Addl,PX-36900396,CDM,37237,CPT,369,RC,,,outpatient,,,3978,2784.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,2498.184,399.86,4532,percent of total billed charges,,,
HC Open/Perq Placement Intravascular Stent Same 1st,PX-36900397,CDM,37238,CPT,369,RC,,,outpatient,,,26415,18490.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,16588.62,399.86,20286.72,percent of total billed charges,,,
HC Open/Perq Placemt Intravasc Stent Same Ea Addl,PX-36900398,CDM,37239,CPT,369,RC,,,outpatient,,,3978,2784.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,2498.184,399.86,4532,percent of total billed charges,,,
HC Vascular Embolization or Occlusion Venous Rs&I,PX-36900399,CDM,37241,CPT,369,RC,,,outpatient,,,26415,18490.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,16588.62,399.86,20286.72,percent of total billed charges,,,
HC Vascular Embolization or Occlusion Arterial Rs&I,PX-36900400,CDM,37242,CPT,369,RC,,,outpatient,,,26415,18490.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,16588.62,399.86,26793.51305,percent of total billed charges,,,
HC Vascular Embolize/Occlude Organ Tumor Infarct,PX-36900401,CDM,37243,CPT,369,RC,,,outpatient,,,26415,18490.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,16588.62,399.86,20286.72,percent of total billed charges,,,
HC Vascular Embolization or Occlusion Hemorrhage,PX-36100016,CDM,37244,CPT,361,RC,,,outpatient,,,26415,18490.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,16588.62,399.86,20286.72,percent of total billed charges,,,
HC Vascular Embolization or Occlusion Hemorrhage,PX-36900402,CDM,37244,CPT,369,RC,,,outpatient,,,26415,18490.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,16588.62,399.86,20286.72,percent of total billed charges,,,
HC Temporal Artery Ligatn or Bx,PX-36900554,CDM,37609,CPT,369,RC,,,outpatient,,,4643,3250.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,2915.804,399.86,3565.824,percent of total billed charges,,,
HC Phleb Veins - Extrem - to 20,PX-36900405,CDM,37765,CPT,369,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,5781.504,percent of total billed charges,,,
HC Phleb Veins - Extrem 20+,PX-36900406,CDM,37766,CPT,369,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,5781.504,percent of total billed charges,,,
HC Injection for Spleen X-Ray,PX-36900408,CDM,38200,CPT,369,RC,,,outpatient,,,381,266.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,239.268,85.5345,1592,percent of total billed charges,,,
HC Bone Marrow; Aspiration Only,PX-36100017,CDM,38220,CPT,361,RC,,,outpatient,,,1973,1381.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,1239.044,399.86,2477.315575,percent of total billed charges,,,
HC Bone Marrow; Aspiration Only,PX-36900409,CDM,38220,CPT,369,RC,,,outpatient,,,1973,1381.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,1239.044,399.86,2477.315575,percent of total billed charges,,,
HC Bone Marrow Bx- Needle/Trocar,PX-36100018,CDM,38221,CPT,361,RC,,,outpatient,,,1972,1380.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,1238.416,399.86,2477.315575,percent of total billed charges,,,
HC Bone Marrow Bx- Needle/Trocar,PX-36900410,CDM,38221,CPT,369,RC,,,outpatient,,,1972,1380.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,1238.416,399.86,2477.315575,percent of total billed charges,,,
HC Dx Bone Marrow Bx & Aspir,PX-36100032,CDM,38222,CPT,361,RC,,,outpatient,,,4653,3257.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,2922.084,399.86,4341.777195,percent of total billed charges,,,
HC Dx Bone Marrow Bx & Aspir,PX-36900703,CDM,38222,CPT,369,RC,,,outpatient,,,4653,3257.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,2922.084,399.86,4341.777195,percent of total billed charges,,,
HC Needle Biopsy- Lymph Node(S),PX-36900411,CDM,38505,CPT,369,RC,,,outpatient,,,1973,1381.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,1239.044,399.86,2998,percent of total billed charges,,,
HC Injection for Lymphatic Xray,PX-36900412,CDM,38790,CPT,369,RC,,,outpatient,,,500,350,CIGNA [1000112],CIGNA [100011201],,,62.8,,314,112.25,1592,percent of total billed charges,,,
HC Identify Sentinel Node,PX-36900413,CDM,38792,CPT,369,RC,,,outpatient,,,540,378,CIGNA [1000112],CIGNA [100011201],,,62.8,,339.12,121.23,1592,percent of total billed charges,,,
HC Biopsy of Floor of Mouth,PX-36900555,CDM,41108,CPT,369,RC,,,outpatient,,,2598,1818.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,1631.544,399.86,2477.315575,percent of total billed charges,,,
HC Biopsy Salivary Gland-Needle,PX-36900414,CDM,42400,CPT,369,RC,,,outpatient,,,1637,1145.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,1028.036,367.5065,2141,percent of total billed charges,,,
HC Injection for Salivary X-Ray,PX-36900415,CDM,42550,CPT,369,RC,,,outpatient,,,424,296.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,266.272,95.188,1592,percent of total billed charges,,,
HC Dilation/Cath of Salivary Duct,PX-36900416,CDM,42660,CPT,369,RC,,,outpatient,,,533,373.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,334.724,119.6585,1592,percent of total billed charges,,,
HC Inc/Drain Peritonsil Abscess,PX-36900812,CDM,42700,CPT,369,RC,,,outpatient,,,685,479.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,430.18,153.7825,1592,percent of total billed charges,,,
HC Placement Ng/Og Tube by Physician,PX-36900423,CDM,43752,CPT,369,RC,,,outpatient,,,325,227.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,204.1,72.9625,1592,percent of total billed charges,,,
HC PR Naso/Oro-Gastric Tube Plmt Req Phys&Fluor Gdnce,PX-96000043,CDM,43752,CPT,960,RC,,,outpatient,,,325,227.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,204.1,72.9625,1592,percent of total billed charges,,,
HC Gastric Intubatj & Aspiraj W/Phys Skill/Lavage,PX-36900575,CDM,43753,CPT,369,RC,,,outpatient,,,579,405.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,363.612,129.9855,1592,percent of total billed charges,,,
HC Reposition Gastric Feeding Tube Thru Duodenum,PX-36900425,CDM,43761,CPT,369,RC,,,outpatient,,,496,347.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,311.488,111.352,1592,percent of total billed charges,,,
HC Perq Replacement Gtube Not Req Revj Gstrst Trc,PX-36100033,CDM,43762,CPT,361,RC,,,outpatient,,,879,615.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,552.012,197.3355,1592,percent of total billed charges,,,
HC Perq Replacement Gtube Not Req Revj Gstrst Trc,PX-36900727,CDM,43762,CPT,369,RC,,,outpatient,,,879,615.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,552.012,197.3355,1592,percent of total billed charges,,,
HC Intro Long GI Tube,PX-36900427,CDM,44500,CPT,369,RC,,,outpatient,,,1673,1171.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,1050.644,375.5885,2998,percent of total billed charges,,,
HC Drainage of Pelvic Abscess,PX-36900428,CDM,45000,CPT,369,RC,,,outpatient,,,2727,1908.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,1712.556,399.86,4005.9,percent of total billed charges,,,
HC Drainage of Deep Rectal Abscess,PX-36900429,CDM,45020,CPT,369,RC,,,outpatient,,,6425,4497.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,4034.9,399.86,4934.4,percent of total billed charges,,,
HC I&D Ischiorectal&/Perirectal Abscess Spx,PX-36900738,CDM,46040,CPT,369,RC,,,outpatient,,,3716,2601.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,2333.648,399.86,2998,percent of total billed charges,,,
HC Needle Biopsy Liver,PX-36900430,CDM,47000,CPT,369,RC,,,outpatient,,,3700,2590,CIGNA [1000112],CIGNA [100011201],,,62.8,,2323.6,399.86,2998,percent of total billed charges,,,
HC Needle Biopsy Liver-W Othr Proc,PX-36900431,CDM,47001,CPT,369,RC,,,outpatient,,,972,680.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,610.416,218.214,1592,percent of total billed charges,,,
HC Ablat-Open-1+ Liver Tumor(S)-Percut Rf,PX-36900433,CDM,47382,CPT,369,RC,,,outpatient,,,13307,9314.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,8356.796,399.86,10219.776,percent of total billed charges,,,
HC Cholecystostomy-Percutaneous- Complete,PX-36900434,CDM,47490,CPT,369,RC,,,outpatient,,,8367,5856.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,5254.476,399.86,6425.856,percent of total billed charges,,,
HC Biliary Endoscopy Percut-Dil Strict,PX-36900443,CDM,47555,CPT,369,RC,,,outpatient,,,8367,5856.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,5254.476,399.86,6425.856,percent of total billed charges,,,
HC Biliary Endoscopy Percut-Dil+Stent,PX-36900444,CDM,47556,CPT,369,RC,,,outpatient,,,13307,9314.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,8356.796,399.86,15728.70471,percent of total billed charges,,,
HC Needle Biopsy of Pancreas,PX-36900446,CDM,48102,CPT,369,RC,,,outpatient,,,3700,2590,CIGNA [1000112],CIGNA [100011201],,,62.8,,2323.6,399.86,2998,percent of total billed charges,,,
HC Anast Panc Cyst-Bowel-Direct,PX-36900447,CDM,48520,CPT,369,RC,,,outpatient,,,1740,1218,CIGNA [1000112],CIGNA [100011201],,,62.8,,1092.72,390.63,2998,percent of total billed charges,,,
HC Exploratory Laparotomy Celiotomy W/WO Biopsy Spx,PX-36900881,CDM,49000,CPT,369,RC,,,outpatient,,,8564,5994.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,5378.192,399.86,6577.152,percent of total billed charges,,,
HC Reopening Recent Laparotomy,PX-36900882,CDM,49002,CPT,369,RC,,,outpatient,,,8564,5994.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,5378.192,399.86,6577.152,percent of total billed charges,,,
HC Abdom Paracentesis Dx/Ther W/O Imaging Guidance,PX-36900448,CDM,49082,CPT,369,RC,,,outpatient,,,925,647.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,580.9,207.6625,2998,percent of total billed charges,,,
HC Abdom Paracentesis Dx/Ther W Imaging Guidance,PX-36100002,CDM,49083,CPT,361,RC,,,outpatient,,,1635,1144.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,1026.78,367.0575,2998,percent of total billed charges,,,
HC Abdom Paracentesis Dx/Ther W Imaging Guidance,PX-36900449,CDM,49083,CPT,369,RC,,,outpatient,,,1635,1144.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,1026.78,367.0575,2998,percent of total billed charges,,,
HC Percut Biopsy- Abdominal Mass,PX-36900450,CDM,49180,CPT,369,RC,,,outpatient,,,3700,2590,CIGNA [1000112],CIGNA [100011201],,,62.8,,2323.6,399.86,2998,percent of total billed charges,,,
HC Remove Peritoneal Foreign Body,PX-36900451,CDM,49402,CPT,369,RC,,,outpatient,,,8367,5856.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,5254.476,399.86,6425.856,percent of total billed charges,,,
HC Image-Guide Fluid Collxn Drainage Cath Visc Perq,PX-36900452,CDM,49405,CPT,369,RC,,,outpatient,,,2870,2009,CIGNA [1000112],CIGNA [100011201],,,62.8,,1802.36,399.86,2998,percent of total billed charges,,,
HC Img-Guide Fluid Collxn Drainag Cath Periton Perq,PX-36900453,CDM,49406,CPT,369,RC,,,outpatient,,,2647,1852.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,1662.316,399.86,2998,percent of total billed charges,,,
HC Insertion Tunnel Intraperitoneal Cath W Image Guidance,PX-36900455,CDM,49418,CPT,369,RC,,,outpatient,,,7964,5574.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,5001.392,399.86,6116.352,percent of total billed charges,,,
HC Removal Tunneled Intraperitoneal Catheter,PX-36900456,CDM,49422,CPT,369,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,4727.584,399.86,5781.504,percent of total billed charges,,,
HC Drainage Catheter Exchange,PX-36900457,CDM,49423,CPT,369,RC,,,outpatient,,,4271,2989.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,2682.188,399.86,3280.128,percent of total billed charges,,,
HC Contrast Inj-Abscess/Cyst via Cath Tube,PX-36900458,CDM,49424,CPT,369,RC,,,outpatient,,,491,343.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,308.348,110.2295,1592,percent of total billed charges,,,
HC Insert Gastrostomy Tube Percutaneous,PX-36900460,CDM,49440,CPT,369,RC,,,outpatient,,,4271,2989.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,2682.188,399.86,3280.128,percent of total billed charges,,,
HC Convert Gastrostomy-Gastro-Jejunostomy Tube Percutaneous,PX-36900461,CDM,49446,CPT,369,RC,,,outpatient,,,4271,2989.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,2682.188,399.86,3280.128,percent of total billed charges,,,
HC Replace Gastrostomy/Cecostomy Tube Percutaneous,PX-36100019,CDM,49450,CPT,361,RC,,,outpatient,,,1644,1150.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,1032.432,369.078,2998,percent of total billed charges,,,
HC Replace Gastrostomy/Cecostomy Tube Percutaneous,PX-36900462,CDM,49450,CPT,369,RC,,,outpatient,,,1644,1150.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,1032.432,369.078,2998,percent of total billed charges,,,
HC Replace Duodenostomy/Jejunostomy Tube Percutaneous,PX-36100020,CDM,49451,CPT,361,RC,,,outpatient,,,1692,1184.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,1062.576,379.854,2998,percent of total billed charges,,,
HC Replace Duodenostomy/Jejunostomy Tube Percutaneous,PX-36900463,CDM,49451,CPT,369,RC,,,outpatient,,,1692,1184.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,1062.576,379.854,2998,percent of total billed charges,,,
HC Replacement Gastro-Jejunostomy Tube Percutaneous,PX-36100021,CDM,49452,CPT,361,RC,,,outpatient,,,2617,1831.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,1643.476,399.86,2998,percent of total billed charges,,,
HC Replacement Gastro-Jejunostomy Tube Percutaneous,PX-36900464,CDM,49452,CPT,369,RC,,,outpatient,,,2617,1831.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,1643.476,399.86,2998,percent of total billed charges,,,
HC Obstructive Material Removal From GI Tube,PX-36900465,CDM,49460,CPT,369,RC,,,outpatient,,,2128,1489.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,1336.384,399.86,2998,percent of total billed charges,,,
HC Contrast Injection Percutaneouos Radiologic Eval GI Tube,PX-36900466,CDM,49465,CPT,369,RC,,,outpatient,,,606,424.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,380.568,136.047,1592,percent of total billed charges,,,
CEPHALEXIN 250 MG/5ML ORAL SUSR,RX-9502,CDM,50000,HCPCS,259,RC,68180-0441-01,NDC,outpatient,100,ML,50.29,35.203,CIGNA [1000112],CIGNA [100011201],,,62.8,,31.58212,1.160665,416.02,percent of total billed charges,,,
CEPHALEXIN 250 MG/5ML ORAL SUSR,RX-9502,CDM,50000,HCPCS,259,RC,99999-0002-84,NDC,outpatient,10,ML,5.17,3.619,CIGNA [1000112],CIGNA [100011201],,,62.8,,3.24676,1.160665,416.02,percent of total billed charges,,,
HC Biopsy of Kidney-Percutaneous,PX-36900467,CDM,50200,CPT,369,RC,,,outpatient,,,3700,2590,CIGNA [1000112],CIGNA [100011201],,,62.8,,2323.6,399.86,2998,percent of total billed charges,,,
HC Change Ureter Stent- Percut,PX-36900468,CDM,50382,CPT,369,RC,,,outpatient,,,4709,3296.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,2957.252,399.86,4179.83,percent of total billed charges,,,
HC Remove Ureter Stent- Percut,PX-36900469,CDM,50384,CPT,369,RC,,,outpatient,,,4709,3296.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,2957.252,399.86,3616.512,percent of total billed charges,,,
HC Change Ext Transneph Ureter Stent W/ Fluoro,PX-36900470,CDM,50387,CPT,369,RC,,,outpatient,,,4709,3296.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,2957.252,399.86,3616.512,percent of total billed charges,,,
HC Remove Renal Tube W/Fluoro,PX-36900471,CDM,50389,CPT,369,RC,,,outpatient,,,1513,1059.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,950.164,339.6685,2141,percent of total billed charges,,,
HC Percut Drain/Inject Renal Cyst,PX-36900472,CDM,50390,CPT,369,RC,,,outpatient,,,726,508.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,455.928,162.987,2141,percent of total billed charges,,,
HC Instll Rx Agnt Into Rnal Tub,PX-36900473,CDM,50391,CPT,369,RC,,,outpatient,,,533,373.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,334.724,119.6585,1592,percent of total billed charges,,,
HC Measure Kidney Pressure Thru Tube,PX-36900478,CDM,50396,CPT,369,RC,,,outpatient,,,1513,1059.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,950.164,334.48,2141,percent of total billed charges,,,
HC Plmt Nephrostomy Cath Prq New Access Rs&I,PX-36900659,CDM,50432,CPT,369,RC,,,outpatient,,,5502,3851.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,3455.256,399.86,4225.536,percent of total billed charges,,,
HC Renal Endoscopy-Remv FB/Stone,PX-36900480,CDM,50561,CPT,369,RC,,,outpatient,,,11603,8122.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,7286.684,399.86,8911.104,percent of total billed charges,,,
HC Perc Radiofreq Ablate Renal Tumor,PX-36900481,CDM,50592,CPT,369,RC,,,outpatient,,,13307,9314.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,8356.796,399.86,10219.776,percent of total billed charges,,,
HC Inject Indwell Cath-Ureter X-Ray,PX-36900482,CDM,50684,CPT,369,RC,,,outpatient,,,374,261.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,234.872,83.963,1592,percent of total billed charges,,,
HC Change of Ureterostomy Tube via Ileal Conduit,PX-36900483,CDM,50688,CPT,369,RC,,,outpatient,,,4709,3296.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,2957.252,399.86,3616.512,percent of total billed charges,,,
HC Inject Retrograde/Conduit X-Ray,PX-36900484,CDM,50690,CPT,369,RC,,,outpatient,,,533,373.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,334.724,119.6585,1592,percent of total billed charges,,,
HC Ureter Endoscopy Thru Ureterostomy W Biopsy,PX-36900485,CDM,50955,CPT,369,RC,,,outpatient,,,11603,8122.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,7286.684,399.86,8911.104,percent of total billed charges,,,
HC Ureter Endoscopy Thru Ureterostomy Remv FB or Calculus,PX-36900486,CDM,50961,CPT,369,RC,,,outpatient,,,11603,8122.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,7286.684,399.86,8911.104,percent of total billed charges,,,
HC Aspiration Bladder Needle,PX-36100022,CDM,51100,CPT,361,RC,,,outpatient,,,699,489.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,438.972,156.9255,1592,percent of total billed charges,,,
HC Aspiration Bladder Needle,PX-36900488,CDM,51100,CPT,369,RC,,,outpatient,,,699,489.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,438.972,156.9255,1592,percent of total billed charges,,,
HC Aspiration Bladder Trocar/Intracatheter,PX-36100023,CDM,51101,CPT,361,RC,,,outpatient,,,2419,1693.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,1519.132,179.53,2998,percent of total billed charges,,,
HC Aspiration Bladder Trocar/Intracatheter,PX-36900489,CDM,51101,CPT,369,RC,,,outpatient,,,2419,1693.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,1519.132,179.53,2998,percent of total billed charges,,,
HC Aspiration Bladder Insert Suprapubic Catheter,PX-36100024,CDM,51102,CPT,361,RC,,,outpatient,,,4709,3296.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,2957.252,399.86,3616.512,percent of total billed charges,,,
HC Aspiration Bladder Insert Suprapubic Catheter,PX-36900490,CDM,51102,CPT,369,RC,,,outpatient,,,4709,3296.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,2957.252,399.86,3616.512,percent of total billed charges,,,
HC Injection for Bladder X-Ray,PX-36900491,CDM,51600,CPT,369,RC,,,outpatient,,,1455,1018.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,913.74,235.074116,1592,percent of total billed charges,,,
HC Inject for Retrograde Urethocysto,PX-36900492,CDM,51610,CPT,369,RC,,,outpatient,,,976,683.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,612.928,219.112,1592,percent of total billed charges,,,
HC Bldr Irrigation Smpl Lavage &/Instlj,PX-36900732,CDM,51700,CPT,369,RC,,,outpatient,,,879,615.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,552.012,197.3355,1592,percent of total billed charges,,,
HC Insert-Non-Indwelling Bladder Catheter,PX-36900494,CDM,51701,CPT,369,RC,,,outpatient,,,389,272.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,244.292,87.3305,1592,percent of total billed charges,,,
HC Insert-Temp Indwelling Blad Cath-Simple,PX-36900495,CDM,51702,CPT,369,RC,,,outpatient,,,391,273.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,245.548,87.7795,1592,percent of total billed charges,,,
HC Insert-Temp Indwelling Blad Cath-Comp,PX-36900496,CDM,51703,CPT,369,RC,,,outpatient,,,354,247.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,222.312,79.473,1592,percent of total billed charges,,,
HC Change of Bladder Tube-Simple,PX-36900497,CDM,51705,CPT,369,RC,,,outpatient,,,456,319.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,286.368,102.372,1592,percent of total billed charges,,,
HC Emg Stds Anal/Urtl Sphnctr Oth/Thn Ndl,PX-36900667,CDM,51784,CPT,369,RC,,,outpatient,,,475,332.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,298.3,106.6375,1592,percent of total billed charges,,,
HC Meas Post-Voiding Residual Urine&/Bladder Cap,PX-36900733,CDM,51798,CPT,369,RC,,,outpatient,,,212,148.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,133.136,47.594,1592,percent of total billed charges,,,
HC Cysto/Ureteroscopy-Tx Ureter Strict,PX-36900500,CDM,52344,CPT,369,RC,,,outpatient,,,8086,5660.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,5078.008,399.86,6210.048,percent of total billed charges,,,
HC Circumcision Age >28 Days,PX-36900772,CDM,54161,CPT,369,RC,,,outpatient,,,6599,4619.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,4144.172,399.86,5068.032,percent of total billed charges,,,
HC Irrigation Corpora Cavernosa Priapism,PX-36900736,CDM,54220,CPT,369,RC,,,outpatient,,,591,413.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,371.148,120.28264,1592,percent of total billed charges,,,
HC Biopsy of Prostate-Needle/Punch,PX-36900501,CDM,55700,CPT,369,RC,,,outpatient,,,4709,3296.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,2957.252,399.86,3616.512,percent of total billed charges,,,
HC I&D of Vulva/Perineum Abscess,PX-36900502,CDM,56405,CPT,369,RC,,,outpatient,,,829,580.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,520.612,186.1105,1592,percent of total billed charges,,,
HC PR Colporrhaphy- Suture Vaginal Injury- Non-OB,PX-36900795,CDM,57200,CPT,369,RC,,,outpatient,,,5013,3509.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,3148.164,399.86,4777.053449,percent of total billed charges,,,
HC Cath/Inject Hysterosalpingogram,PX-36900505,CDM,58340,CPT,369,RC,,,outpatient,,,1092,764.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,685.776,235.074116,1592,percent of total billed charges,,,
HC Reopen Fallopian Tube-Transcerv Cath,PX-36900506,CDM,58345,CPT,369,RC,,,outpatient,,,6900,4830,CIGNA [1000112],CIGNA [100011201],,,62.8,,4333.2,399.86,5299.2,percent of total billed charges,,,
HC Fetal Non-Stress Test,PX-92000003,CDM,59025,CPT,920,RC,,,outpatient,,,490,343,CIGNA [1000112],CIGNA [100011201],,,62.8,,307.72,110.005,416.02,percent of total billed charges,,,
HC PR Vaginal Delivery Only,PX-96000044,CDM,59409,CPT,960,RC,,,outpatient,,,3062,2143.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,1922.936,399.86,4777.053449,percent of total billed charges,,,
HC PR Delivery Placenta Separate Procedure,PX-96000045,CDM,59414,CPT,960,RC,,,outpatient,,,7176,5023.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,4506.528,399.86,5511.168,percent of total billed charges,,,
HC Biopsy of Thyroid-Percut,PX-36900512,CDM,60100,CPT,369,RC,,,outpatient,,,1514,1059.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,950.792,339.893,2141,percent of total billed charges,,,
HC Endocrine Surgery Proc Unlisted,PX-36900513,CDM,60699,CPT,369,RC,,,outpatient,,,6035,4224.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,3789.98,399.86,11413.04,percent of total billed charges,,,
HC Brain Shunt Tube/Reserv Injectn,PX-36900514,CDM,61070,CPT,369,RC,,,outpatient,,,1885,1319.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,1183.78,399.86,2141,percent of total billed charges,,,
HC Endovasc Temp Balloon Occlus-Head/Nck,PX-36900515,CDM,61623,CPT,369,RC,,,outpatient,,,26415,18490.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,16588.62,399.86,20286.72,percent of total billed charges,,,
HC Perm Occlusion/Embolization-Percut-Cns,PX-36900516,CDM,61624,CPT,369,RC,,,outpatient,,,533,373.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,334.724,119.6585,5756,percent of total billed charges,,,
HC Percut Cath Occlusn Non Cns Lesn,PX-36900517,CDM,61626,CPT,369,RC,,,outpatient,,,26415,18490.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,16588.62,399.86,20286.72,percent of total billed charges,,,
HC Percut Aspiration Vertebral Disc,PX-36900518,CDM,62267,CPT,369,RC,,,outpatient,,,1637,1145.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,1028.036,367.5065,2141,percent of total billed charges,,,
HC Spinal Puncture-Lumbar-Diagnostic,PX-36100025,CDM,62270,CPT,361,RC,,,outpatient,,,915,640.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,574.62,205.4175,2141,percent of total billed charges,,,
HC Spinal Puncture-Lumbar-Diagnostic,PX-36900519,CDM,62270,CPT,369,RC,,,outpatient,,,915,640.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,574.62,205.4175,2141,percent of total billed charges,,,
HC PR Spinal Puncture Lumbar Diagnostic,PX-96000051,CDM,62270,CPT,960,RC,,,outpatient,,,915,640.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,574.62,205.4175,2141,percent of total billed charges,,,
HC Spinal Puncture-Therapeutic Drainage,PX-36100026,CDM,62272,CPT,361,RC,,,outpatient,,,1256,879.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,788.768,281.972,2141,percent of total billed charges,,,
HC Spinal Puncture-Therapeutic Drainage,PX-36900520,CDM,62272,CPT,369,RC,,,outpatient,,,1256,879.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,788.768,281.972,2141,percent of total billed charges,,,
HC Inj-Lumb Epidur-Blood/Clot Patch,PX-36900521,CDM,62273,CPT,369,RC,,,outpatient,,,915,640.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,574.62,205.4175,2141,percent of total billed charges,,,
HC Inject-Myelography &/or CT Scan-Spinal,PX-36900522,CDM,62284,CPT,369,RC,,,outpatient,,,1312,918.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,823.936,294.544,1592,percent of total billed charges,,,
HC Diskectomy-Percutaneous Lumbar,PX-36900523,CDM,62287,CPT,369,RC,,,outpatient,,,6304,4412.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,3958.912,399.86,6224.0876,percent of total billed charges,,,
HC Inject Diskogram-Lumbar-Ea Level,PX-36900524,CDM,62290,CPT,369,RC,,,outpatient,,,1256,879.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,788.768,281.972,1592,percent of total billed charges,,,
HC Inj-Cerv/Thorac-for Diskography,PX-36900525,CDM,62291,CPT,369,RC,,,outpatient,,,1107,774.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,695.196,248.5215,1592,percent of total billed charges,,,
HC Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/O Img Gdn,PX-36900884,CDM,62322,CPT,369,RC,,,outpatient,,,2586,1810.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,1624.008,399.86,2141,percent of total billed charges,,,
HC Elec Anlys Implt Ithcl/Edrl Pmp W/Repr Phys/Qhp,PX-36900526,CDM,62370,CPT,369,RC,,,outpatient,,,821,574.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,515.588,155.844464,1592,percent of total billed charges,,,
HC Inject Nerv Blck-Trigeminal,PX-36900609,CDM,64400,CPT,369,RC,,,outpatient,,,891,623.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,559.548,200.0295,1592,percent of total billed charges,,,
HC Inject Nerv Blck-Great Occiptl,PX-36900611,CDM,64405,CPT,369,RC,,,outpatient,,,1634,1143.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,1026.152,323.2601,1592,percent of total billed charges,,,
HC Inject Nerv Blck-Vagus Nerve,PX-36900612,CDM,64408,CPT,369,RC,,,outpatient,,,877,613.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,550.756,196.8865,1592,percent of total billed charges,,,
HC Inj-Anes Agent-Brachial Plexus-Single,PX-36900616,CDM,64415,CPT,369,RC,,,outpatient,,,1544,1080.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,969.632,346.628,2141,percent of total billed charges,,,
HC Inj-Anes Agent-Brachial Plexus-Cont Inf,PX-36900617,CDM,64416,CPT,369,RC,,,outpatient,,,2785,1949.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,1748.98,399.86,2141,percent of total billed charges,,,
HC Inject Nerv Blck-Axillary Nerv,PX-36900618,CDM,64417,CPT,369,RC,,,outpatient,,,1544,1080.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,969.632,346.628,2141,percent of total billed charges,,,
HC Inject Nerv Blck-Suprascap N.,PX-36900619,CDM,64418,CPT,369,RC,,,outpatient,,,1544,1080.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,969.632,346.628,2141,percent of total billed charges,,,
HC Inject Nerv Blck-Intercostal-One,PX-36900620,CDM,64420,CPT,369,RC,,,outpatient,,,1382,967.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,867.896,310.259,2141,percent of total billed charges,,,
HC Inject Nerv Blck-Intercost-Multpl,PX-36900621,CDM,64421,CPT,369,RC,,,outpatient,,,2785,1949.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,1748.98,399.86,2141,percent of total billed charges,,,
HC Inject Nerv Blck-Ilioingu/Iliohyp,PX-36900622,CDM,64425,CPT,369,RC,,,outpatient,,,1544,1080.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,969.632,346.628,2141,percent of total billed charges,,,
HC Inject Nerv Blck-Pudendal,PX-36100029,CDM,64430,CPT,361,RC,,,outpatient,,,2785,1949.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,1748.98,399.86,2141,percent of total billed charges,,,
HC Inject Nerv Blck-Pudendal,PX-36900623,CDM,64430,CPT,369,RC,,,outpatient,,,2785,1949.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,1748.98,399.86,2141,percent of total billed charges,,,
HC Inject Nerv Blck-Paracervical,PX-36900624,CDM,64435,CPT,369,RC,,,outpatient,,,1544,1080.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,969.632,346.628,2141,percent of total billed charges,,,
HC Inj-Anes Agent-Sciatic Nerve-Single,PX-36900625,CDM,64445,CPT,369,RC,,,outpatient,,,2785,1949.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,1748.98,399.86,2141,percent of total billed charges,,,
HC Inj-Anes Agent-Sciatic Nerve-Cont Inf,PX-36900626,CDM,64446,CPT,369,RC,,,outpatient,,,2785,1949.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,1748.98,399.86,2141,percent of total billed charges,,,
HC Inj-Anes Agent-Femoral Nerve-Single,PX-36900627,CDM,64447,CPT,369,RC,,,outpatient,,,1544,1080.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,969.632,346.628,2141,percent of total billed charges,,,
HC Inj-Anes Agent-Femoral Nerve-Cont Inf,PX-36900628,CDM,64448,CPT,369,RC,,,outpatient,,,6090,4263,CIGNA [1000112],CIGNA [100011201],,,62.8,,3824.52,399.86,4677.12,percent of total billed charges,,,
HC N Block Inj- Lumbar Plexus,PX-36900629,CDM,64449,CPT,369,RC,,,outpatient,,,2785,1949.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,1748.98,399.86,2141,percent of total billed charges,,,
HC Inject Nerv Blck-Othr Periph Nerv,PX-36900630,CDM,64450,CPT,369,RC,,,outpatient,,,1634,1143.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,1026.152,366.833,2141,percent of total billed charges,,,
HC Njx Aa&/Strd Plantar Common Digital Nerves,PX-36900835,CDM,64455,CPT,369,RC,,,outpatient,,,825,577.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,518.1,185.2125,1592,percent of total billed charges,,,
HC Inject Anes/Steroid Foramen Cerv/Thoracic W Img Guide -1 Level,PX-36900631,CDM,64479,CPT,369,RC,,,outpatient,,,2785,1949.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,1748.98,399.86,2141,percent of total billed charges,,,
HC Inject Anes/Steroid Foramen Cerv/Thoracic W Img Guide -Ea Add Level,PX-36900632,CDM,64480,CPT,369,RC,,,outpatient,,,230,161,CIGNA [1000112],CIGNA [100011201],,,62.8,,144.44,51.635,1592,percent of total billed charges,,,
HC Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level,PX-36100027,CDM,64483,CPT,361,RC,,,outpatient,,,1693,1185.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,1063.204,380.0785,2141,percent of total billed charges,,,
HC Njx Aa&/Strd Tfrml Epi Lumbar/Sacral 1 Level,PX-36900531,CDM,64483,CPT,369,RC,,,outpatient,,,1693,1185.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,1063.204,380.0785,2141,percent of total billed charges,,,
HC Njx Aa&/Strd Tfrml Epi Lumbar/Sacral Ea Addl,PX-36900532,CDM,64484,CPT,369,RC,,,outpatient,,,416,291.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,261.248,93.392,1592,percent of total billed charges,,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- 1st Level,PX-36100028,CDM,64490,CPT,361,RC,,,outpatient,,,1693,1185.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,1063.204,380.0785,2141,percent of total billed charges,,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- 1st Level,PX-36900533,CDM,64490,CPT,369,RC,,,outpatient,,,1693,1185.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,1063.204,380.0785,2141,percent of total billed charges,,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- 2nd Level,PX-36900633,CDM,64491,CPT,369,RC,,,outpatient,,,221,154.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,138.788,49.6145,1592,percent of total billed charges,,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Cerv/Thorac- Add Level,PX-36900634,CDM,64492,CPT,369,RC,,,outpatient,,,224,156.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,140.672,50.288,1592,percent of total billed charges,,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Lumbar/Sac- 1st Level,PX-36900536,CDM,64493,CPT,369,RC,,,outpatient,,,1693,1185.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,1063.204,380.0785,2141,percent of total billed charges,,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Lumbar/Sac- 2nd Level,PX-36900537,CDM,64494,CPT,369,RC,,,outpatient,,,1693,1185.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,1063.204,380.0785,1592,percent of total billed charges,,,
HC Inj Dx/Ther Agnt Paravert Facet Joint-Img Guide-Lumbar/Sac- Add Level,PX-36900538,CDM,64495,CPT,369,RC,,,outpatient,,,54,37.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,33.912,12.123,1592,percent of total billed charges,,,
HC Inject Nerv Blck-Celiac Plexus,PX-36900539,CDM,64530,CPT,369,RC,,,outpatient,,,2165,1515.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,1359.62,399.86,2141,percent of total billed charges,,,
HC Unlisted Procedure Nervous System,PX-36100035,CDM,64999,CPT,361,RC,,,outpatient,,,687,480.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,431.436,154.2315,1592,percent of total billed charges,,,
HC Unlisted Procedure Nervous System,PX-36900829,CDM,64999,CPT,369,RC,,,outpatient,,,687,480.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,431.436,154.2315,1592,percent of total billed charges,,,
HC Removal Impacted Cerumen Using Irrigation/Lavage- Unilateral,PX-36900636,CDM,69209,CPT,369,RC,,,outpatient,,,205,143.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,128.74,46.0225,1592,percent of total billed charges,,,
HC Removal Impacted Cerumen Instrumentation Unilat,PX-36900540,CDM,69210,CPT,369,RC,,,outpatient,,,305,213.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,191.54,66.75974,1592,percent of total billed charges,,,
HC X-Ray Eye for Foreign Body,PX-32000004,CDM,70030,CPT,320,RC,,,outpatient,,,271,189.7,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,60.8395,416.02,fee schedule,,,
HC X-Ray Jaw <4 Vw,PX-32000005,CDM,70100,CPT,320,RC,,,outpatient,,,595,416.5,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,71.24,456.96,fee schedule,,,
HC X-Ray Jaw 4+ Vw,PX-32000006,CDM,70110,CPT,320,RC,,,outpatient,,,489,342.3,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,76.026473,416.02,fee schedule,,,
HC X-Ray Mastoids <3 Vw,PX-32000007,CDM,70120,CPT,320,RC,,,outpatient,,,384,268.8,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,86.208,416.02,fee schedule,,,
HC X-Ray Mastoids 3+ Vw,PX-32000008,CDM,70130,CPT,320,RC,,,outpatient,,,295,206.5,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,66.2275,416.02,fee schedule,,,
HC X-Ray Facial Bones <3 Vw,PX-32000009,CDM,70140,CPT,320,RC,,,outpatient,,,336,235.2,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,71.24,416.02,fee schedule,,,
HC X-Ray Facial Bones 3+ Vw,PX-32000010,CDM,70150,CPT,320,RC,,,outpatient,,,252,176.4,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,56.574,416.02,fee schedule,,,
HC X-Ray Nasal Bones,PX-32000011,CDM,70160,CPT,320,RC,,,outpatient,,,319,223.3,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,71.24,416.02,fee schedule,,,
HC X-Ray Orbits,PX-32000012,CDM,70200,CPT,320,RC,,,outpatient,,,328,229.6,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,73.636,416.02,fee schedule,,,
HC X-Ray Sinuses <3 Vw,PX-32000013,CDM,70210,CPT,320,RC,,,outpatient,,,328,229.6,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,71.24,416.02,fee schedule,,,
HC X-Ray Sinuses 3+ Vw,PX-32000014,CDM,70220,CPT,320,RC,,,outpatient,,,444,310.8,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,71.24,416.02,fee schedule,,,
HC X-Ray Exam Sella,PX-32000015,CDM,70240,CPT,320,RC,,,outpatient,,,262,183.4,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,58.819,416.02,fee schedule,,,
HC X-Ray Skull <4 Vw,PX-32000016,CDM,70250,CPT,320,RC,,,outpatient,,,352,246.4,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,76.026473,416.02,fee schedule,,,
HC X-Ray Skull 4+ Vw,PX-32000017,CDM,70260,CPT,320,RC,,,outpatient,,,419,293.3,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,76.026473,416.02,fee schedule,,,
HC X-Ray Teeth Single,PX-32000018,CDM,70300,CPT,320,RC,,,outpatient,,,241,168.7,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,54.1045,416.02,fee schedule,,,
HC X-Ray Tmj Unilat,PX-32000019,CDM,70328,CPT,320,RC,,,outpatient,,,241,168.7,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,54.1045,416.02,fee schedule,,,
HC X-Ray Tmj Bilat,PX-32000020,CDM,70330,CPT,320,RC,,,outpatient,,,716,501.2,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,71.24,549.888,fee schedule,,,
HC MRI- Tmj,PX-61000008,CDM,70336,CPT,610,RC,,,outpatient,,,2588,1811.6,CIGNA [1000112],CIGNA [100011201],,836,,,836,267.439885,1987.584,case rate,,,
HC Panoramic X-Ray of Jaws,PX-32000022,CDM,70355,CPT,320,RC,,,outpatient,,,241,168.7,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,54.1045,416.02,fee schedule,,,
HC X-Ray Neck Soft Tissue,PX-32000023,CDM,70360,CPT,320,RC,,,outpatient,,,232,162.4,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,52.084,416.02,fee schedule,,,
HC X-Ray Salivary Gland,PX-32000025,CDM,70380,CPT,320,RC,,,outpatient,,,262,183.4,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,58.819,416.02,fee schedule,,,
HC X-Ray Sialogram,PX-32000026,CDM,70390,CPT,320,RC,,,outpatient,,,537,375.9,CIGNA [1000112],CIGNA [100011201],,646.6965,,,646.6965,120.5565,646.6965,fee schedule,,,
HC CT Scan-Head/Brain-W/O Contrast Matl,PX-35000002,CDM,70450,CPT,350,RC,,,outpatient,,,1070,749,CIGNA [1000112],CIGNA [100011201],,575,,,575,89.81,821.76,case rate,,,
HC CT Scan Head Contrast,PX-35000003,CDM,70460,CPT,350,RC,,,outpatient,,,1333,933.1,CIGNA [1000112],CIGNA [100011201],,575,,,575,124.33,1023.744,case rate,,,
CT Head/Brain W/O & W/Contrast Material,PX-35000004,CDM,70470,CPT,350,RC,,,outpatient,,,1615,1130.5,CIGNA [1000112],CIGNA [100011201],,575,,,575,153.75,1240.32,case rate,,,
HC CT Scan-Orbit/Sella/Post Fossa/Ear-W/O,PX-35000005,CDM,70480,CPT,350,RC,,,outpatient,,,657,459.9,CIGNA [1000112],CIGNA [100011201],,575,,,575,96.160741,575,case rate,,,
HC CT Scan Skull Contrast,PX-35000006,CDM,70481,CPT,350,RC,,,outpatient,,,774,541.8,CIGNA [1000112],CIGNA [100011201],,575,,,575,173.763,667.43,case rate,,,
CT Orbit Sella/Post Fossa/Ear W/O & W/Contr Matr,PX-35000007,CDM,70482,CPT,350,RC,,,outpatient,,,1619,1133.3,CIGNA [1000112],CIGNA [100011201],,575,,,575,200.53123,1243.392,case rate,,,
HC CT Scan-Maxillofacial Area-W/O Contrast,PX-35000008,CDM,70486,CPT,350,RC,,,outpatient,,,1200,840,CIGNA [1000112],CIGNA [100011201],,575,,,575,96.160741,921.6,case rate,,,
HC CT Scan- Face/Jaw Contrast,PX-35000009,CDM,70487,CPT,350,RC,,,outpatient,,,1321,924.7,CIGNA [1000112],CIGNA [100011201],,575,,,575,200.53123,1014.528,case rate,,,
CT Maxillofacial W/O & W/Contrast Material,PX-35000010,CDM,70488,CPT,350,RC,,,outpatient,,,1158,810.6,CIGNA [1000112],CIGNA [100011201],,575,,,575,200.53123,889.344,case rate,,,
HC CT Scan-Soft Tissue Neck-W/O Contrast,PX-35000011,CDM,70490,CPT,350,RC,,,outpatient,,,514,359.8,CIGNA [1000112],CIGNA [100011201],,575,,,575,96.160741,575,case rate,,,
HC CT Neck Tissue Contrast,PX-35000012,CDM,70491,CPT,350,RC,,,outpatient,,,1482,1037.4,CIGNA [1000112],CIGNA [100011201],,575,,,575,194.55,1138.176,case rate,,,
CT Soft Tissue Neck W/O & W/Contrast Material,PX-35000014,CDM,70492,CPT,350,RC,,,outpatient,,,1755,1228.5,CIGNA [1000112],CIGNA [100011201],,575,,,575,200.53123,1347.84,case rate,,,
CT Angiography Head W/Contrast/Noncontrast,PX-35000013,CDM,70496,CPT,350,RC,,,outpatient,,,1330,931,CIGNA [1000112],CIGNA [100011201],,575,,,575,200.53123,1021.44,case rate,,,
CT Angiography Neck W/Contrast/Noncontrast,PX-35000015,CDM,70498,CPT,350,RC,,,outpatient,,,1157,809.9,CIGNA [1000112],CIGNA [100011201],,575,,,575,200.53123,888.576,case rate,,,
HC MRI- Face- Neck,PX-61000009,CDM,70540,CPT,610,RC,,,outpatient,,,5081,3556.7,CIGNA [1000112],CIGNA [100011201],,836,,,836,237.688956,3902.208,case rate,,,
HC MRI- Face- Neck W/Contrast,PX-61000010,CDM,70542,CPT,610,RC,,,outpatient,,,2710,1897,CIGNA [1000112],CIGNA [100011201],,836,,,836,365.99,2081.28,case rate,,,
MRI Orbit Face & Neck W/O & W/Contrast Matrl,PX-61000011,CDM,70543,CPT,610,RC,,,outpatient,,,1692,1184.4,CIGNA [1000112],CIGNA [100011201],,836,,,836,379.854,1299.456,case rate,,,
HC MR Angio- Head,PX-61000012,CDM,70544,CPT,610,RC,,,outpatient,,,2279,1595.3,CIGNA [1000112],CIGNA [100011201],,836,,,836,267.439885,1750.272,case rate,,,
HC MR Angio- Head W/Contrast,PX-61000013,CDM,70545,CPT,610,RC,,,outpatient,,,2279,1595.3,CIGNA [1000112],CIGNA [100011201],,836,,,836,374.62,1750.272,case rate,,,
Mra Head W/O & W/Contrast Material,PX-61000014,CDM,70546,CPT,610,RC,,,outpatient,,,2279,1595.3,CIGNA [1000112],CIGNA [100011201],,836,,,836,301.425681,1750.272,case rate,,,
HC MR Angio- Neck,PX-61000015,CDM,70547,CPT,610,RC,,,outpatient,,,2182,1527.4,CIGNA [1000112],CIGNA [100011201],,836,,,836,267.439885,1675.776,case rate,,,
HC MR Angio- Neck W/Contrast,PX-61000016,CDM,70548,CPT,610,RC,,,outpatient,,,2469,1728.3,CIGNA [1000112],CIGNA [100011201],,836,,,836,399.86,1896.192,case rate,,,
Mra Neck W/O &W/Contrast Material,PX-61000017,CDM,70549,CPT,610,RC,,,outpatient,,,2534,1773.8,CIGNA [1000112],CIGNA [100011201],,836,,,836,301.425681,1946.112,case rate,,,
HC MRI Brain,PX-61000018,CDM,70551,CPT,610,RC,,,outpatient,,,2090,1463,CIGNA [1000112],CIGNA [100011201],,836,,,836,188.66,1605.12,case rate,,,
HC MRI Brain Contrast,PX-61000019,CDM,70552,CPT,610,RC,,,outpatient,,,5255,3678.5,CIGNA [1000112],CIGNA [100011201],,836,,,836,268.7,4035.84,case rate,,,
MRI Brain Brain Stem W/O W/Contrast Material,PX-61000020,CDM,70553,CPT,610,RC,,,outpatient,,,2668,1867.6,CIGNA [1000112],CIGNA [100011201],,836,,,836,307.14,2049.024,case rate,,,
HC X-Ray Exam Chest 1 View,PX-32000245,CDM,71045,CPT,320,RC,,,outpatient,,,214,149.8,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,48.043,416.02,fee schedule,,,
HC X-Ray Exam Chest 2 Views,PX-32000246,CDM,71046,CPT,320,RC,,,outpatient,,,232,162.4,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,52.084,416.02,fee schedule,,,
HC X-Ray Exam Chest 3 Views,PX-32000247,CDM,71047,CPT,320,RC,,,outpatient,,,245,171.5,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,55.0025,416.02,fee schedule,,,
HC X-Ray Exam Chest 4+ Views,PX-32000248,CDM,71048,CPT,320,RC,,,outpatient,,,410,287,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,76.026473,416.02,fee schedule,,,
HC X-Ray Ribs- Chest 3+ Vw,PX-32000036,CDM,71101,CPT,320,RC,,,outpatient,,,484,338.8,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,76.026473,416.02,fee schedule,,,
HC X-Ray Ribs- Chest 4+ Vw,PX-32000038,CDM,71111,CPT,320,RC,,,outpatient,,,562,393.4,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,76.026473,431.616,fee schedule,,,
HC X-Ray Sternum 2+ Vw,PX-32000039,CDM,71120,CPT,320,RC,,,outpatient,,,358,250.6,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,71.24,416.02,fee schedule,,,
HC X-Ray Sterno-Clavicluar Jt,PX-32000040,CDM,71130,CPT,320,RC,,,outpatient,,,250,175,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,56.125,416.02,fee schedule,,,
HC Diagnostic Computed Tomography Thorax W/O Cntrst,PX-35000016,CDM,71250,CPT,350,RC,,,outpatient,,,1388,971.6,CIGNA [1000112],CIGNA [100011201],,575,,,575,96.160741,1065.984,case rate,,,
HC Diagnostic Computed Tomography Thorax W/Contrast,PX-35000017,CDM,71260,CPT,350,RC,,,outpatient,,,1624,1136.8,CIGNA [1000112],CIGNA [100011201],,575,,,575,195.34,1247.232,case rate,,,
HC Diagnostic Computed Tomography Thorax C-/C+,PX-35000018,CDM,71270,CPT,350,RC,,,outpatient,,,1982,1387.4,CIGNA [1000112],CIGNA [100011201],,575,,,575,200.53123,1522.176,case rate,,,
HC Computed Tomography Thorax Lw Dose Lng Ca Scr C-,PX-35000070,CDM,71271,CPT,350,RC,,,outpatient,,,264,184.8,CIGNA [1000112],CIGNA [100011201],,575,,,575,59.268,575,case rate,,,
CT Angiography Chest W/Contrast/Noncontrast,PX-35000019,CDM,71275,CPT,350,RC,,,outpatient,,,1592,1114.4,CIGNA [1000112],CIGNA [100011201],,575,,,575,200.53123,1222.656,case rate,,,
HC MRI- Chest,PX-61000023,CDM,71550,CPT,610,RC,,,outpatient,,,1979,1385.3,CIGNA [1000112],CIGNA [100011201],,836,,,836,237.688956,1519.872,case rate,,,
HC MRI- Chest- W/Contrast,PX-61000024,CDM,71551,CPT,610,RC,,,outpatient,,,3128,2189.6,CIGNA [1000112],CIGNA [100011201],,836,,,836,399.86,2402.304,case rate,,,
MRI Chest W/O & W/Contrast Material,PX-61000025,CDM,71552,CPT,610,RC,,,outpatient,,,1547,1082.9,CIGNA [1000112],CIGNA [100011201],,836,,,836,347.3015,1288.93,case rate,,,
HC MR Angio Chest (Mra) W/Contrast,PX-61000026,CDM,71555,CPT,610,RC,,,outpatient,,,2367,1656.9,CIGNA [1000112],CIGNA [100011201],,836,,,836,301.425681,1817.856,case rate,,,
HC MR Angio Chest (Mra) Without Contrast,PX-61000071,CDM,71555,CPT,610,RC,,,outpatient,,,2367,1656.9,CIGNA [1000112],CIGNA [100011201],,836,,,836,301.425681,1817.856,case rate,,,
HC MR Angio Chest (Mra) W/Without Contrast,PX-61000072,CDM,71555,CPT,610,RC,,,outpatient,,,2367,1656.9,CIGNA [1000112],CIGNA [100011201],,836,,,836,301.425681,1817.856,case rate,,,
HC X-Ray Spine One View,PX-32000042,CDM,72020,CPT,320,RC,,,outpatient,,,251,175.7,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,56.3495,416.02,fee schedule,,,
HC Radex Spine Cervical 2 or 3 Views,PX-32000043,CDM,72040,CPT,320,RC,,,outpatient,,,296,207.2,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,66.452,416.02,fee schedule,,,
HC Radex Spine Cervical 4 or 5 Views,PX-32000044,CDM,72050,CPT,320,RC,,,outpatient,,,300,210,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,67.35,416.02,fee schedule,,,
HC Radex Spine Cervical 6 or More Views,PX-32000045,CDM,72052,CPT,320,RC,,,outpatient,,,300,210,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,67.35,416.02,fee schedule,,,
HC X-Ray Thoracic Spine 2 Vw,PX-32000046,CDM,72070,CPT,320,RC,,,outpatient,,,252,176.4,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,56.574,416.02,fee schedule,,,
HC X-Ray Thoracic Spine+Swim 3 Vw,PX-32000047,CDM,72072,CPT,320,RC,,,outpatient,,,283,198.1,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,63.5335,416.02,fee schedule,,,
HC X-Ray Thoracic Spine 4 Vw,PX-32000048,CDM,72074,CPT,320,RC,,,outpatient,,,306,214.2,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,68.697,416.02,fee schedule,,,
HC X-Ray Thor-Lumb Sp 2 Vw,PX-32000049,CDM,72080,CPT,320,RC,,,outpatient,,,357,249.9,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,71.24,416.02,fee schedule,,,
HC X-Ray Exam Entire Spi 1 Vw,PX-32000233,CDM,72081,CPT,320,RC,,,outpatient,,,241,168.7,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,54.1045,416.02,fee schedule,,,
HC X-Ray Exam Entire Spi 2/3 Vw,PX-32000234,CDM,72082,CPT,320,RC,,,outpatient,,,385,269.5,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,86.4325,416.02,fee schedule,,,
HC X-Ray Exam Entire Spi 4/5 Vw,PX-32000235,CDM,72083,CPT,320,RC,,,outpatient,,,757,529.9,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,119.991125,581.376,fee schedule,,,
HC X-Ray Exam Entire Spi 6/> Vw,PX-32000236,CDM,72084,CPT,320,RC,,,outpatient,,,757,529.9,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,76.026473,581.376,fee schedule,,,
HC X-Ray Lumbar Spine 2/3 Vw,PX-32000051,CDM,72100,CPT,320,RC,,,outpatient,,,235,164.5,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,52.7575,416.02,fee schedule,,,
HC X-Ray Lumbar Spine 4 Vw,PX-32000052,CDM,72110,CPT,320,RC,,,outpatient,,,323,226.1,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,72.5135,416.02,fee schedule,,,
HC X-Ray Lumbar Spine 6+ Vw,PX-32000053,CDM,72114,CPT,320,RC,,,outpatient,,,602,421.4,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,76.026473,462.336,fee schedule,,,
HC X-Ray Lumbar Spine Flex/Exten,PX-32000232,CDM,72120,CPT,320,RC,,,outpatient,,,411,287.7,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,92.2695,416.02,fee schedule,,,
HC CT Scan-Cervical Spine-W/O Contrast,PX-35000020,CDM,72125,CPT,350,RC,,,outpatient,,,1359,951.3,CIGNA [1000112],CIGNA [100011201],,575,,,575,96.160741,1043.712,case rate,,,
HC CT Scan Cerv Spine Contrast,PX-35000021,CDM,72126,CPT,350,RC,,,outpatient,,,1556,1089.2,CIGNA [1000112],CIGNA [100011201],,575,,,575,196.52,1195.008,case rate,,,
CT Cervical Spine W/O &W/Contrast Material,PX-35000022,CDM,72127,CPT,350,RC,,,outpatient,,,2239,1567.3,CIGNA [1000112],CIGNA [100011201],,575,,,575,200.53123,1719.552,case rate,,,
HC CT Scan-Thoracic Spine-W/O Contrast,PX-35000023,CDM,72128,CPT,350,RC,,,outpatient,,,909,636.3,CIGNA [1000112],CIGNA [100011201],,575,,,575,96.160741,698.112,case rate,,,
HC CT Scan Dorsal Sp Contrast,PX-35000024,CDM,72129,CPT,350,RC,,,outpatient,,,1037,725.9,CIGNA [1000112],CIGNA [100011201],,575,,,575,196.52,796.416,case rate,,,
CT Thoracic Spine W/O & W/Contrast Material,PX-35000025,CDM,72130,CPT,350,RC,,,outpatient,,,2219,1553.3,CIGNA [1000112],CIGNA [100011201],,575,,,575,200.53123,1704.192,case rate,,,
HC CT Scan-Lumbar Spine-W/O Contrast,PX-35000026,CDM,72131,CPT,350,RC,,,outpatient,,,688,481.6,CIGNA [1000112],CIGNA [100011201],,575,,,575,96.160741,575,case rate,,,
HC CT Scan Lumbar Sp Contrast,PX-35000027,CDM,72132,CPT,350,RC,,,outpatient,,,1427,998.9,CIGNA [1000112],CIGNA [100011201],,575,,,575,195.73,1095.936,case rate,,,
CT Lumbar Spine W/O & W/Contrast Material,PX-35000028,CDM,72133,CPT,350,RC,,,outpatient,,,1377,963.9,CIGNA [1000112],CIGNA [100011201],,575,,,575,200.53123,1057.536,case rate,,,
HC MRI- Cerv Spine,PX-61000027,CDM,72141,CPT,610,RC,,,outpatient,,,2115,1480.5,CIGNA [1000112],CIGNA [100011201],,836,,,836,185.92,1624.32,case rate,,,
HC MRI- Cerv Spine Contrast,PX-61000028,CDM,72142,CPT,610,RC,,,outpatient,,,3043,2130.1,CIGNA [1000112],CIGNA [100011201],,836,,,836,270.27,2337.024,case rate,,,
HC MRI- Dorsal Spine,PX-61000029,CDM,72146,CPT,610,RC,,,outpatient,,,2222,1555.4,CIGNA [1000112],CIGNA [100011201],,836,,,836,185.92,1706.496,case rate,,,
HC MRI- Dorsal Spine Contrast,PX-61000030,CDM,72147,CPT,610,RC,,,outpatient,,,2843,1990.1,CIGNA [1000112],CIGNA [100011201],,836,,,836,266.73,2183.424,case rate,,,
HC MRI- Lumbar Spine,PX-61000031,CDM,72148,CPT,610,RC,,,outpatient,,,2651,1855.7,CIGNA [1000112],CIGNA [100011201],,836,,,836,185.92,2035.968,case rate,,,
HC MRI- Lumbar Spine Contrast,PX-61000032,CDM,72149,CPT,610,RC,,,outpatient,,,2645,1851.5,CIGNA [1000112],CIGNA [100011201],,836,,,836,265.17,2031.36,case rate,,,
MRI Spinal Canal Cervical W/O & W/Contr Matrl,PX-61000033,CDM,72156,CPT,610,RC,,,outpatient,,,3124,2186.8,CIGNA [1000112],CIGNA [100011201],,836,,,836,307.53,2399.232,case rate,,,
MRI Spinal Canal Thoracic W/O & W/Contr Matrl,PX-61000034,CDM,72157,CPT,610,RC,,,outpatient,,,2833,1983.1,CIGNA [1000112],CIGNA [100011201],,836,,,836,307.93,2175.744,case rate,,,
MRI Spinal Canal Lumbar W/O & W/Contr Matrl,PX-61000035,CDM,72158,CPT,610,RC,,,outpatient,,,3181,2226.7,CIGNA [1000112],CIGNA [100011201],,836,,,836,305.58,2443.008,case rate,,,
HC X-Ray Pelvis 1/2 Vw,PX-32000054,CDM,72170,CPT,320,RC,,,outpatient,,,287,200.9,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,64.4315,416.02,fee schedule,,,
CT Angiography Pelvis W/Contrast/Noncontrast,PX-35000029,CDM,72191,CPT,350,RC,,,outpatient,,,1269,888.3,CIGNA [1000112],CIGNA [100011201],,575,,,575,200.53123,974.592,case rate,,,
HC CT Scan-Pelvis-W/O Contrast,PX-35000030,CDM,72192,CPT,350,RC,,,outpatient,,,1368,957.6,CIGNA [1000112],CIGNA [100011201],,575,,,575,96.160741,1050.624,case rate,,,
HC CT Scan of Pelvis Contrast,PX-35000031,CDM,72193,CPT,350,RC,,,outpatient,,,1561,1092.7,CIGNA [1000112],CIGNA [100011201],,575,,,575,195.33,1198.848,case rate,,,
CT Pelvis W/O & W/Contrast Material,PX-35000032,CDM,72194,CPT,350,RC,,,outpatient,,,1902,1331.4,CIGNA [1000112],CIGNA [100011201],,575,,,575,200.53123,1460.736,case rate,,,
HC MRI- Pelvis- W/O Contrast,PX-61000036,CDM,72195,CPT,610,RC,,,outpatient,,,2241,1568.7,CIGNA [1000112],CIGNA [100011201],,836,,,836,237.688956,1721.088,case rate,,,
HC MRI- Pelvis W/Contrast,PX-61000037,CDM,72196,CPT,610,RC,,,outpatient,,,2850,1995,CIGNA [1000112],CIGNA [100011201],,836,,,836,372.27,2188.8,case rate,,,
MRI Pelvis W/O & W/Contrast Material,PX-61000038,CDM,72197,CPT,610,RC,,,outpatient,,,2753,1927.1,CIGNA [1000112],CIGNA [100011201],,836,,,836,399.547552,2114.304,case rate,,,
HC MR Angio Pelvis(Mra) W/Contrast,PX-61000039,CDM,72198,CPT,610,RC,,,outpatient,,,2908,2035.6,CIGNA [1000112],CIGNA [100011201],,836,,,836,399.86,2233.344,case rate,,,
HC MR Angio Pelvis(Mra) Without Contrast,PX-61000073,CDM,72198,CPT,610,RC,,,outpatient,,,2710,1897,CIGNA [1000112],CIGNA [100011201],,836,,,836,399.86,2233.344,case rate,,,
HC MR Angio Pelvis(Mra) W/Without Contrast,PX-61000074,CDM,72198,CPT,610,RC,,,outpatient,,,1826,1278.2,CIGNA [1000112],CIGNA [100011201],,836,,,836,399.86,2233.344,case rate,,,
HC X-Ray Sacroiliac Jts 3+ Vw,PX-32000056,CDM,72202,CPT,320,RC,,,outpatient,,,443,310.1,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,76.026473,416.02,fee schedule,,,
HC X-Ray Sacrum/Coccyx 2+ Vw,PX-32000057,CDM,72220,CPT,320,RC,,,outpatient,,,336,235.2,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,71.24,416.02,fee schedule,,,
HC Myelography Cerv Spine,PX-32000058,CDM,72240,CPT,320,RC,,,outpatient,,,1478,1034.6,CIGNA [1000112],CIGNA [100011201],,2051.3855,,,2051.3855,331.811,2051.3855,fee schedule,,,
HC Myelography Thorax Spine,PX-32000059,CDM,72255,CPT,320,RC,,,outpatient,,,1823,1276.1,CIGNA [1000112],CIGNA [100011201],,2051.3855,,,2051.3855,399.86,2051.3855,fee schedule,,,
HC Myelography Lumbar Spine,PX-32000060,CDM,72265,CPT,320,RC,,,outpatient,,,1760,1232,CIGNA [1000112],CIGNA [100011201],,2051.3855,,,2051.3855,395.12,2051.3855,fee schedule,,,
HC Myelography of Entire Spine,PX-32000061,CDM,72270,CPT,320,RC,,,outpatient,,,1823,1276.1,CIGNA [1000112],CIGNA [100011201],,2051.3855,,,2051.3855,399.86,2051.3855,fee schedule,,,
HC X-Ray-C/T-Disk-Superv/Interpret,PX-32000062,CDM,72285,CPT,320,RC,,,outpatient,,,4306,3014.2,CIGNA [1000112],CIGNA [100011201],,4977.9345,,,4977.9345,399.86,4977.9345,fee schedule,,,
HC Discography Lumbar Spine,PX-32000064,CDM,72295,CPT,320,RC,,,outpatient,,,4306,3014.2,CIGNA [1000112],CIGNA [100011201],,4977.9345,,,4977.9345,399.86,4977.9345,fee schedule,,,
HC X-Ray Clavicle,PX-32000065,CDM,73000,CPT,320,RC,,,outpatient,,,170,119,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,38.165,416.02,fee schedule,,,
HC X-Ray Scapula,PX-32000066,CDM,73010,CPT,320,RC,,,outpatient,,,306,214.2,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,68.697,416.02,fee schedule,,,
HC X-Ray Shoulder 1 Vw,PX-32000067,CDM,73020,CPT,320,RC,,,outpatient,,,256,179.2,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,57.472,416.02,fee schedule,,,
HC X-Ray Shoulder 2+ Vw,PX-32000068,CDM,73030,CPT,320,RC,,,outpatient,,,139,97.3,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,31.2055,416.02,fee schedule,,,
HC Arthrogram of Shoulder,PX-32000069,CDM,73040,CPT,320,RC,,,outpatient,,,1690,1183,CIGNA [1000112],CIGNA [100011201],,1020.2995,,,1020.2995,379.405,1297.92,fee schedule,,,
HC X-Ray Ac Jts,PX-32000070,CDM,73050,CPT,320,RC,,,outpatient,,,323,226.1,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,71.24,416.02,fee schedule,,,
HC X-Ray Humerus,PX-32000071,CDM,73060,CPT,320,RC,,,outpatient,,,178,124.6,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,39.961,416.02,fee schedule,,,
HC X-Ray Elbow 2 Vw,PX-32000072,CDM,73070,CPT,320,RC,,,outpatient,,,171,119.7,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,38.3895,416.02,fee schedule,,,
HC X-Ray Elbow 3+ Vw,PX-32000073,CDM,73080,CPT,320,RC,,,outpatient,,,129,90.3,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,28.9605,416.02,fee schedule,,,
HC Arthrogram of Elbow,PX-32000074,CDM,73085,CPT,320,RC,,,outpatient,,,1331,931.7,CIGNA [1000112],CIGNA [100011201],,1020.2995,,,1020.2995,298.8095,1022.208,fee schedule,,,
HC X-Ray Forearm 2 Vw,PX-32000075,CDM,73090,CPT,320,RC,,,outpatient,,,225,157.5,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,50.5125,416.02,fee schedule,,,
HC X-Ray Arm- Infant,PX-32000076,CDM,73092,CPT,320,RC,,,outpatient,,,368,257.6,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,76.026473,416.02,fee schedule,,,
HC X-Ray Wrist 2 Vw,PX-32000077,CDM,73100,CPT,320,RC,,,outpatient,,,190,133,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,42.655,416.02,fee schedule,,,
HC X-Ray Wrist 3+ Vw,PX-32000078,CDM,73110,CPT,320,RC,,,outpatient,,,241,168.7,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,54.1045,416.02,fee schedule,,,
HC Arthrogram of Wrist,PX-32000079,CDM,73115,CPT,320,RC,,,outpatient,,,1722,1205.4,CIGNA [1000112],CIGNA [100011201],,1020.2995,,,1020.2995,237.819698,1322.496,fee schedule,,,
HC X-Ray Hand 2 Vw,PX-32000080,CDM,73120,CPT,320,RC,,,outpatient,,,306,214.2,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,68.697,416.02,fee schedule,,,
HC X-Ray Hand 3+ Vw,PX-32000081,CDM,73130,CPT,320,RC,,,outpatient,,,236,165.2,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,52.982,416.02,fee schedule,,,
HC X-Ray Exam of Finger(S),PX-32000082,CDM,73140,CPT,320,RC,,,outpatient,,,129,90.3,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,28.9605,416.02,fee schedule,,,
HC CT Scan-Upper Extremity-W/O Contrast,PX-35000034,CDM,73200,CPT,350,RC,,,outpatient,,,959,671.3,CIGNA [1000112],CIGNA [100011201],,575,,,575,96.160741,736.512,case rate,,,
HC CT Scan of Arm Contrast,PX-35000035,CDM,73201,CPT,350,RC,,,outpatient,,,1388,971.6,CIGNA [1000112],CIGNA [100011201],,575,,,575,193.37,1065.984,case rate,,,
CT Upper Extremity W/O & W/Contrast Material,PX-35000036,CDM,73202,CPT,350,RC,,,outpatient,,,1961,1372.7,CIGNA [1000112],CIGNA [100011201],,575,,,575,200.53123,1506.048,case rate,,,
CT Angiography Upper Extremity,PX-35000037,CDM,73206,CPT,350,RC,,,outpatient,,,1345,941.5,CIGNA [1000112],CIGNA [100011201],,575,,,575,200.53123,1032.96,case rate,,,
HC MRI- Upper Extremity W/O Contrast,PX-61000040,CDM,73218,CPT,610,RC,,,outpatient,,,2888,2021.6,CIGNA [1000112],CIGNA [100011201],,836,,,836,237.688956,2217.984,case rate,,,
HC MRI- Upper Extremity W/Contrast,PX-61000041,CDM,73219,CPT,610,RC,,,outpatient,,,2936,2055.2,CIGNA [1000112],CIGNA [100011201],,836,,,836,371.09,2254.848,case rate,,,
HC MRI Ext Upp No Jnt W-W/O,PX-61000042,CDM,73220,CPT,610,RC,,,outpatient,,,3144,2200.8,CIGNA [1000112],CIGNA [100011201],,836,,,836,399.547552,2414.592,case rate,,,
MRI Any Jt Upper Extremity W/O Contrast Matrl,PX-61000043,CDM,73221,CPT,610,RC,,,outpatient,,,3039,2127.3,CIGNA [1000112],CIGNA [100011201],,836,,,836,204.76,2333.952,case rate,,,
HC MRI- Joint Upper Extrem W/Contrast,PX-61000044,CDM,73222,CPT,610,RC,,,outpatient,,,3144,2200.8,CIGNA [1000112],CIGNA [100011201],,836,,,836,340.49,2414.592,case rate,,,
MRI Any Jt Upper Extremity W/O & W/Contr Matrl,PX-61000045,CDM,73223,CPT,610,RC,,,outpatient,,,3060,2142,CIGNA [1000112],CIGNA [100011201],,836,,,836,399.547552,2350.08,case rate,,,
HC X-Ray Exam Hip Uni 1 View,PX-32000237,CDM,73501,CPT,320,RC,,,outpatient,,,222,155.4,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,49.839,416.02,fee schedule,,,
HC X-Ray Exam Hip Uni 2-3 Views,PX-32000238,CDM,73502,CPT,320,RC,,,outpatient,,,222,155.4,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,49.839,416.02,fee schedule,,,
HC X-Ray Exam Hip Uni 4/> Views,PX-32000239,CDM,73503,CPT,320,RC,,,outpatient,,,385,269.5,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,86.4325,416.02,fee schedule,,,
HC X-Ray Exam Hips Bi 2 Views,PX-32000240,CDM,73521,CPT,320,RC,,,outpatient,,,385,269.5,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,86.4325,416.02,fee schedule,,,
HC X-Ray Exam Hips Bi 5/> Views,PX-32000242,CDM,73523,CPT,320,RC,,,outpatient,,,757,529.9,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,76.026473,581.376,fee schedule,,,
HC Arthrogram of Hip,PX-32000086,CDM,73525,CPT,320,RC,,,outpatient,,,1616,1131.2,CIGNA [1000112],CIGNA [100011201],,1020.2995,,,1020.2995,237.819698,1241.088,fee schedule,,,
HC X-Ray Exam of Femur 1,PX-32000243,CDM,73551,CPT,320,RC,,,outpatient,,,213,149.1,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,47.8185,416.02,fee schedule,,,
HC X-Ray Exam of Femur 2/>,PX-32000244,CDM,73552,CPT,320,RC,,,outpatient,,,241,168.7,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,54.1045,416.02,fee schedule,,,
HC X-Ray Knee 1 or 2 View,PX-32000090,CDM,73560,CPT,320,RC,,,outpatient,,,213,149.1,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,47.8185,416.02,fee schedule,,,
HC X-Ray Knee 3 View,PX-32000091,CDM,73562,CPT,320,RC,,,outpatient,,,232,162.4,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,52.084,416.02,fee schedule,,,
HC X-Ray Knee 4+ View,PX-32000092,CDM,73564,CPT,320,RC,,,outpatient,,,260,182,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,58.37,416.02,fee schedule,,,
HC X-Ray Knee Bilat Standing,PX-32000093,CDM,73565,CPT,320,RC,,,outpatient,,,394,275.8,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,71.24,416.02,fee schedule,,,
HC Arthrogram of Knee Joint,PX-32000094,CDM,73580,CPT,320,RC,,,outpatient,,,1704,1192.8,CIGNA [1000112],CIGNA [100011201],,1020.2995,,,1020.2995,382.548,1308.672,fee schedule,,,
HC X-Ray Tib + Fib- 2vw,PX-32000095,CDM,73590,CPT,320,RC,,,outpatient,,,199,139.3,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,44.6755,416.02,fee schedule,,,
HC X-Ray Leg- Infant,PX-32000096,CDM,73592,CPT,320,RC,,,outpatient,,,231,161.7,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,51.8595,416.02,fee schedule,,,
HC X-Ray Ankle 2 Vw,PX-32000097,CDM,73600,CPT,320,RC,,,outpatient,,,137,95.9,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,30.7565,416.02,fee schedule,,,
HC X-Ray Ankle 3+ Vw,PX-32000098,CDM,73610,CPT,320,RC,,,outpatient,,,130,91,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,29.185,416.02,fee schedule,,,
HC Arthrogram of Ankle,PX-32000099,CDM,73615,CPT,320,RC,,,outpatient,,,1221,854.7,CIGNA [1000112],CIGNA [100011201],,1020.2995,,,1020.2995,237.819698,1020.2995,fee schedule,,,
HC X-Ray Foot 2 Vw,PX-32000100,CDM,73620,CPT,320,RC,,,outpatient,,,158,110.6,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,35.471,416.02,fee schedule,,,
HC X-Ray Foot 3+ Vw,PX-32000101,CDM,73630,CPT,320,RC,,,outpatient,,,164,114.8,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,36.818,416.02,fee schedule,,,
HC X-Ray Heel,PX-32000102,CDM,73650,CPT,320,RC,,,outpatient,,,234,163.8,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,52.533,416.02,fee schedule,,,
HC X-Ray Toe(S),PX-32000103,CDM,73660,CPT,320,RC,,,outpatient,,,192,134.4,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,43.104,416.02,fee schedule,,,
HC CT Scan-Lower Extremity-W/O Contrast,PX-35000038,CDM,73700,CPT,350,RC,,,outpatient,,,968,677.6,CIGNA [1000112],CIGNA [100011201],,575,,,575,96.160741,743.424,case rate,,,
HC CT Scan of Leg Contrast,PX-35000039,CDM,73701,CPT,350,RC,,,outpatient,,,987,690.9,CIGNA [1000112],CIGNA [100011201],,575,,,575,196.51,758.016,case rate,,,
CT Lower Extremity W/O & W/Contrast Matrl,PX-35000040,CDM,73702,CPT,350,RC,,,outpatient,,,1903,1332.1,CIGNA [1000112],CIGNA [100011201],,575,,,575,200.53123,1461.504,case rate,,,
CT Angiography Lower Extremity,PX-35000041,CDM,73706,CPT,350,RC,,,outpatient,,,1176,823.2,CIGNA [1000112],CIGNA [100011201],,575,,,575,200.53123,903.168,case rate,,,
HC MRI- Lower Extrem,PX-61000046,CDM,73718,CPT,610,RC,,,outpatient,,,2836,1985.2,CIGNA [1000112],CIGNA [100011201],,836,,,836,237.688956,2178.048,case rate,,,
HC MRI- Lower Extrem W/Contrast,PX-61000047,CDM,73719,CPT,610,RC,,,outpatient,,,2396,1677.2,CIGNA [1000112],CIGNA [100011201],,836,,,836,372.66,1840.128,case rate,,,
HC MRI- Lower Extr- W/O Contrast F/U by Contrast,PX-61000048,CDM,73720,CPT,610,RC,,,outpatient,,,3060,2142,CIGNA [1000112],CIGNA [100011201],,836,,,836,399.547552,2350.08,case rate,,,
HC MRI Lower Extrem Jt- W/O Contrast,PX-61000049,CDM,73721,CPT,610,RC,,,outpatient,,,3008,2105.6,CIGNA [1000112],CIGNA [100011201],,836,,,836,205.15,2310.144,case rate,,,
HC MRI- Joint of Leg W/Contrast,PX-61000050,CDM,73722,CPT,610,RC,,,outpatient,,,3018,2112.6,CIGNA [1000112],CIGNA [100011201],,836,,,836,345.98,2317.824,case rate,,,
MRI Any Jt Lower Extrem W/O & W/Contrast Matrl,PX-61000051,CDM,73723,CPT,610,RC,,,outpatient,,,3098,2168.6,CIGNA [1000112],CIGNA [100011201],,836,,,836,399.547552,2379.264,case rate,,,
HC MR Angio Lower Extrem (Mra) W/Contrast,PX-61000052,CDM,73725,CPT,610,RC,,,outpatient,,,2710,1897,CIGNA [1000112],CIGNA [100011201],,836,,,836,399.86,2290.176,case rate,,,
HC MR Angio Lower Extrem (Mra) Without Contrast,PX-61000075,CDM,73725,CPT,610,RC,,,outpatient,,,2710,1897,CIGNA [1000112],CIGNA [100011201],,836,,,836,399.86,2290.176,case rate,,,
HC MR Angio Lower Extrem (Mra) W/Without Contrast,PX-61000076,CDM,73725,CPT,610,RC,,,outpatient,,,2982,2087.4,CIGNA [1000112],CIGNA [100011201],,836,,,836,399.86,2290.176,case rate,,,
HC X-Ray Exam Abdomen 1 View,PX-32000249,CDM,74018,CPT,320,RC,,,outpatient,,,232,162.4,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,52.084,416.02,fee schedule,,,
HC X-Ray Exam Abdomen 2 Views,PX-32000250,CDM,74019,CPT,320,RC,,,outpatient,,,443,310.1,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,76.026473,416.02,fee schedule,,,
HC X-Ray Exam Abdomen 3+ Views,PX-32000251,CDM,74021,CPT,320,RC,,,outpatient,,,410,287,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,92.045,416.02,fee schedule,,,
HC CT Scan-Abdomen-W/O Contrast,PX-35000042,CDM,74150,CPT,350,RC,,,outpatient,,,1449,1014.3,CIGNA [1000112],CIGNA [100011201],,575,,,575,96.160741,1112.832,case rate,,,
HC CT Scan of Abdomen Contrast,PX-35000043,CDM,74160,CPT,350,RC,,,outpatient,,,1586,1110.2,CIGNA [1000112],CIGNA [100011201],,575,,,575,194.55,1218.048,case rate,,,
CT Abdomen W/O & W/Contrast Material,PX-35000044,CDM,74170,CPT,350,RC,,,outpatient,,,2058,1440.6,CIGNA [1000112],CIGNA [100011201],,575,,,575,200.53123,1580.544,case rate,,,
HC CT Angio Abd&Plvis Cntrst Mtrl W/WO Cntrst Imges,PX-35000045,CDM,74174,CPT,350,RC,,,outpatient,,,2581,1806.7,CIGNA [1000112],CIGNA [100011201],,575,,,575,329.339098,1982.208,case rate,,,
CT Angiography Abdomen W/Contrast/Noncontrast,PX-35000046,CDM,74175,CPT,350,RC,,,outpatient,,,1355,948.5,CIGNA [1000112],CIGNA [100011201],,575,,,575,200.53123,1040.64,case rate,,,
HC CT Scan-Abdoment and Pelvis-W/O Contrast,PX-35000047,CDM,74176,CPT,350,RC,,,outpatient,,,1368,957.6,CIGNA [1000112],CIGNA [100011201],,575,,,575,142.38,1050.624,case rate,,,
HC CT Scan-Abdoment and Pelvis-W Contrast,PX-35000048,CDM,74177,CPT,350,RC,,,outpatient,,,1971,1379.7,CIGNA [1000112],CIGNA [100011201],,575,,,575,204.61123,1513.728,case rate,,,
CT Abdomen & Pelvis W/O Contrst 1/> Body Re,PX-35000049,CDM,74178,CPT,350,RC,,,outpatient,,,2122,1485.4,CIGNA [1000112],CIGNA [100011201],,575,,,575,204.61123,1629.696,case rate,,,
HC MRI- Abdomen (MRI),PX-61000053,CDM,74181,CPT,610,RC,,,outpatient,,,2357,1649.9,CIGNA [1000112],CIGNA [100011201],,836,,,836,237.688956,1810.176,case rate,,,
HC MRI- Abdomen W/Contrast,PX-61000054,CDM,74182,CPT,610,RC,,,outpatient,,,5081,3556.7,CIGNA [1000112],CIGNA [100011201],,836,,,836,399.547552,3902.208,case rate,,,
MRI Abdomen W/O & W/Contrast Material,PX-61000055,CDM,74183,CPT,610,RC,,,outpatient,,,2698,1888.6,CIGNA [1000112],CIGNA [100011201],,836,,,836,399.547552,2072.064,case rate,,,
HC MR Angio Abdomen (Mra) W/Contrast,PX-61000056,CDM,74185,CPT,610,RC,,,outpatient,,,2446,1712.2,CIGNA [1000112],CIGNA [100011201],,836,,,836,301.425681,1878.528,case rate,,,
HC MR Angio Abdomen (Mra) Without Contrast,PX-61000077,CDM,74185,CPT,610,RC,,,outpatient,,,2446,1712.2,CIGNA [1000112],CIGNA [100011201],,836,,,836,301.425681,1878.528,case rate,,,
HC MR Angio Abdomen (Mra) W/Without Contrast,PX-61000078,CDM,74185,CPT,610,RC,,,outpatient,,,2446,1712.2,CIGNA [1000112],CIGNA [100011201],,836,,,836,301.425681,1878.528,case rate,,,
HC Esophagram,PX-32000107,CDM,74220,CPT,320,RC,,,outpatient,,,981,686.7,CIGNA [1000112],CIGNA [100011201],,499.422,,,499.422,76.026473,753.408,fee schedule,,,
HC Swallowing Fcn-W/Cine &/or Video,PX-32000108,CDM,74230,CPT,320,RC,,,outpatient,,,874,611.8,CIGNA [1000112],CIGNA [100011201],,499.422,,,499.422,128.66,671.232,fee schedule,,,
HC Remove Esophagus Obstruction,PX-32000109,CDM,74235,CPT,320,RC,,,outpatient,,,1157,809.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,726.596,259.7465,888.576,percent of total billed charges,,,
HC Xray Upper GI Tract,PX-32000110,CDM,74240,CPT,320,RC,,,outpatient,,,916,641.2,CIGNA [1000112],CIGNA [100011201],,499.422,,,499.422,200.53123,703.488,fee schedule,,,
HC Xray Upper GI Air Contrast,PX-32000113,CDM,74246,CPT,320,RC,,,outpatient,,,865,605.5,CIGNA [1000112],CIGNA [100011201],,499.422,,,499.422,194.1925,664.32,fee schedule,,,
HC X-Ray-Small Bowel-W/Mult Serial Films,PX-32000116,CDM,74250,CPT,320,RC,,,outpatient,,,2949,2064.3,CIGNA [1000112],CIGNA [100011201],,499.422,,,499.422,128.66,2264.832,fee schedule,,,
HC X-Ray Small Bowel Enteroclysis,PX-32000117,CDM,74251,CPT,320,RC,,,outpatient,,,1182,827.4,CIGNA [1000112],CIGNA [100011201],,499.422,,,499.422,183.14,907.776,fee schedule,,,
HC X-Ray Colon Contrast,PX-32000118,CDM,74270,CPT,320,RC,,,outpatient,,,1071,749.7,CIGNA [1000112],CIGNA [100011201],,499.422,,,499.422,200.53123,822.528,fee schedule,,,
HC X-Ray Colon Air Contrast,PX-32000119,CDM,74280,CPT,320,RC,,,outpatient,,,1758,1230.6,CIGNA [1000112],CIGNA [100011201],,499.422,,,499.422,200.53123,1350.144,fee schedule,,,
HC X-Ray Oper Cholangiogram,PX-32000123,CDM,74300,CPT,320,RC,,,outpatient,,,1336,935.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,839.008,145.12362,1026.048,percent of total billed charges,,,
HC X-Ray Oper Cholangio Addnl Set,PX-32000124,CDM,74301,CPT,320,RC,,,outpatient,,,289,202.3,CIGNA [1000112],CIGNA [100011201],,,62.8,,181.492,64.8805,416.02,percent of total billed charges,,,
HC X-Ray Bile/Pancreas Endoscopy,PX-32000129,CDM,74330,CPT,320,RC,,,outpatient,,,1038,726.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,651.864,145.12362,797.184,percent of total billed charges,,,
HC X-Ray Introductn GI Tube,PX-32000130,CDM,74340,CPT,320,RC,,,outpatient,,,872,610.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,547.616,195.08,669.696,percent of total billed charges,,,
HC X-Ray Guide Enteroclysis Tube,PX-32000131,CDM,74355,CPT,320,RC,,,outpatient,,,2913,2039.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,1829.364,260.23,2237.184,percent of total billed charges,,,
HC X-Ray Guide- GI Dilation,PX-32000132,CDM,74360,CPT,320,RC,,,outpatient,,,631,441.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,396.268,141.6595,484.608,percent of total billed charges,,,
HC Percut Transhepat Dilat-Bile Duct Strict,PX-32000133,CDM,74363,CPT,320,RC,,,outpatient,,,2462,1723.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,1546.136,399.86,1890.816,percent of total billed charges,,,
HC X-Ray IV Pyelogram (Ivp),PX-32000134,CDM,74400,CPT,320,RC,,,outpatient,,,599,419.3,CIGNA [1000112],CIGNA [100011201],,499.422,,,499.422,134.4755,499.422,fee schedule,,,
HC X-Ray IV Pyelogram+Tomography,PX-32000136,CDM,74415,CPT,320,RC,,,outpatient,,,2078,1454.6,CIGNA [1000112],CIGNA [100011201],,499.422,,,499.422,200.53123,1595.904,fee schedule,,,
HC X-Ray Retrograde Pyelogram,PX-32000137,CDM,74420,CPT,320,RC,,,outpatient,,,1189,832.3,CIGNA [1000112],CIGNA [100011201],,1020.2995,,,1020.2995,237.819698,1020.2995,fee schedule,,,
HC Antegrade Urography Radiological Supvj & Interpj,PX-32000138,CDM,74425,CPT,320,RC,,,outpatient,,,2829,1980.3,CIGNA [1000112],CIGNA [100011201],,1020.2995,,,1020.2995,399.86,2172.672,fee schedule,,,
HC X-Ray Cystogram- Min 3 View,PX-32000139,CDM,74430,CPT,320,RC,,,outpatient,,,1189,832.3,CIGNA [1000112],CIGNA [100011201],,1020.2995,,,1020.2995,237.819698,1020.2995,fee schedule,,,
HC X-Ray Urethrocystogram,PX-32000140,CDM,74450,CPT,320,RC,,,outpatient,,,762,533.4,CIGNA [1000112],CIGNA [100011201],,646.6965,,,646.6965,171.069,646.6965,fee schedule,,,
HC X-Ray Urethrocystogram+Voiding,PX-32000141,CDM,74455,CPT,320,RC,,,outpatient,,,762,533.4,CIGNA [1000112],CIGNA [100011201],,646.6965,,,646.6965,171.069,646.6965,fee schedule,,,
HC X-Ray Renal Cyst Xlumbar+Contrst,PX-32000142,CDM,74470,CPT,320,RC,,,outpatient,,,542,379.4,CIGNA [1000112],CIGNA [100011201],,1393.3385,,,1393.3385,121.679,1393.3385,fee schedule,,,
HC X-Ray Guide- Gu Dilation,PX-32000145,CDM,74485,CPT,320,RC,,,outpatient,,,3417,2391.9,CIGNA [1000112],CIGNA [100011201],,5136.771,,,5136.771,399.86,5136.771,fee schedule,,,
HC X-Ray Hysterosalpingogram,PX-32000146,CDM,74740,CPT,320,RC,,,outpatient,,,1695,1186.5,CIGNA [1000112],CIGNA [100011201],,646.6965,,,646.6965,237.819698,1301.76,fee schedule,,,
HC X-Ray Xcerv Cath Fallopian Tube,PX-32000147,CDM,74742,CPT,320,RC,,,outpatient,,,1270,889,CIGNA [1000112],CIGNA [100011201],,,62.8,,797.56,285.115,975.36,percent of total billed charges,,,
HC Cardiac MRI Morphology & Function W/O Contrast,PX-61000057,CDM,75557,CPT,610,RC,,,outpatient,,,2222,1555.4,CIGNA [1000112],CIGNA [100011201],,836,,,836,88.902,1706.496,case rate,,,
HC PR Cardiac MRI Morphology & Function W/O Contrast,PX-97200020,CDM,75557,CPT,972,RC,,,outpatient,,,396,277.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,248.688,88.902,1706.496,percent of total billed charges,,,
HC Cardiac MRI W/W/O Contrast & Further Seq,PX-61000059,CDM,75561,CPT,610,RC,,,outpatient,,,2644,1850.8,CIGNA [1000112],CIGNA [100011201],,836,,,836,102.5965,2030.592,case rate,,,
HC PR Cardiac MRI W/W/O Contrast & Further Seq,PX-97200021,CDM,75561,CPT,972,RC,,,outpatient,,,457,319.9,CIGNA [1000112],CIGNA [100011201],,,62.8,,286.996,102.5965,2030.592,percent of total billed charges,,,
HC Cardiac MRI for Velocity Flow Mapping,PX-61000061,CDM,75565,CPT,610,RC,,,outpatient,,,222,155.4,CIGNA [1000112],CIGNA [100011201],,836,,,836,9.2045,836,case rate,,,
HC PR Cardiac MRI for Velocity Flow Mapping,PX-97200022,CDM,75565,CPT,972,RC,,,outpatient,,,41,28.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,25.748,9.2045,836,percent of total billed charges,,,
HC CT Heart W/O Contrast Quant Eval Coronary Calcium,PX-35000052,CDM,75571,CPT,350,RC,,,outpatient,,,264,184.8,CIGNA [1000112],CIGNA [100011201],,575,,,575,19.0825,575,case rate,,,
HC PR CT Heart W/O Contrast Quant Eval Coronary Calcium,PX-97200023,CDM,75571,CPT,972,RC,,,outpatient,,,85,59.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,53.38,19.0825,575,percent of total billed charges,,,
HC CT Heart Contrast Eval Cardiac Struct/Morph,PX-35000053,CDM,75572,CPT,350,RC,,,outpatient,,,872,610.4,CIGNA [1000112],CIGNA [100011201],,575,,,575,58.819,669.696,case rate,,,
HC PR CT Heart Contrast Eval Cardiac Struct/Morph,PX-97200024,CDM,75572,CPT,972,RC,,,outpatient,,,262,183.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,164.536,58.819,669.696,percent of total billed charges,,,
HC CT Heart Contrast Eval Cardiac Struct/Morph- Congen Heart Disease,PX-35000054,CDM,75573,CPT,350,RC,,,outpatient,,,1016,711.2,CIGNA [1000112],CIGNA [100011201],,575,,,575,58.819,780.288,case rate,,,
HC PR CT Heart Contrast Eval Cardiac Struct/Morph- Congen Heart Disease,PX-97200025,CDM,75573,CPT,972,RC,,,outpatient,,,262,183.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,164.536,58.819,780.288,percent of total billed charges,,,
HC CT Angio Hrt Cornry Art/Bypass Grfts Contrst 3d Post,PX-35000055,CDM,75574,CPT,350,RC,,,outpatient,,,1073,751.1,CIGNA [1000112],CIGNA [100011201],,575,,,575,57.921,824.064,case rate,,,
HC PR CT Angio Hrt Cornry Art/Bypass Grfts Contrst 3d Post,PX-97200026,CDM,75574,CPT,972,RC,,,outpatient,,,258,180.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,162.024,57.921,824.064,percent of total billed charges,,,
HC N-Invas Est C Ffr Augmnt Sw Alys Cta I&R Phy/Qhp,PX-48000097,CDM,75580,CPT,480,RC,,,outpatient,,,2856,1999.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,1793.568,399.86,2536.61118,percent of total billed charges,,,
HC Angio Aortogram Thoracic,PX-32000148,CDM,75600,CPT,320,RC,,,outpatient,,,3155,2208.5,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,,,
HC Angio Aortogram Thor Serial,PX-32000149,CDM,75605,CPT,320,RC,,,outpatient,,,12541,8778.7,CIGNA [1000112],CIGNA [100011201],,14233.715,,,14233.715,399.86,14233.715,fee schedule,,,
HC Angio Aortogram Abd Serial,PX-32000150,CDM,75625,CPT,320,RC,,,outpatient,,,5654,3957.8,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,,,
HC Angio Aortobifemoral W Cath,PX-32000151,CDM,75630,CPT,320,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,,,
Cta Abdl Aorta&Bi Iliofem W/Contrast&Postp,PX-35000056,CDM,75635,CPT,350,RC,,,outpatient,,,1721,1204.7,CIGNA [1000112],CIGNA [100011201],,575,,,575,200.53123,1321.728,case rate,,,
HC Angio Spinal Selectv,PX-32000153,CDM,75705,CPT,320,RC,,,outpatient,,,11403,7982.1,CIGNA [1000112],CIGNA [100011201],,14233.715,,,14233.715,399.86,14233.715,fee schedule,,,
HC Angio Extremity Unilat,PX-32000154,CDM,75710,CPT,320,RC,,,outpatient,,,6489,4542.3,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,,,
HC Angio Extermity Bilat,PX-32000155,CDM,75716,CPT,320,RC,,,outpatient,,,7162,5013.4,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,,,
HC Angio Visceral Selectv/Subselec,PX-32000156,CDM,75726,CPT,320,RC,,,outpatient,,,9831,6881.7,CIGNA [1000112],CIGNA [100011201],,14233.715,,,14233.715,399.86,14233.715,fee schedule,,,
HC Angio Adrenal Unilat Select,PX-32000157,CDM,75731,CPT,320,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,,,
HC Angio Adrenal Bilat Select,PX-32000158,CDM,75733,CPT,320,RC,,,outpatient,,,6665,4665.5,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,,,
HC Angio Pelvis,PX-32000159,CDM,75736,CPT,320,RC,,,outpatient,,,11403,7982.1,CIGNA [1000112],CIGNA [100011201],,14233.715,,,14233.715,399.86,14233.715,fee schedule,,,
HC Angio Pulmon Unilat Select,PX-32000160,CDM,75741,CPT,320,RC,,,outpatient,,,6665,4665.5,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,,,
HC Angio Pulmon Bilat Select,PX-32000161,CDM,75743,CPT,320,RC,,,outpatient,,,7162,5013.4,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,,,
HC Angio Pulmon Bilat Nonselec,PX-32000162,CDM,75746,CPT,320,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,,,
HC Angio Intern Mammary,PX-32000163,CDM,75756,CPT,320,RC,,,outpatient,,,6665,4665.5,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,,,
HC Angio Ea Addnl Selectv Vessel,PX-32000164,CDM,75774,CPT,320,RC,,,outpatient,,,3538,2476.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,2221.864,399.86,2717.184,percent of total billed charges,,,
HC Nonvascular Shuntogram,PX-32000166,CDM,75809,CPT,320,RC,,,outpatient,,,411,287.7,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,92.2695,416.02,fee schedule,,,
HC Venogram Splenoportogram,PX-32000167,CDM,75810,CPT,320,RC,,,outpatient,,,7698,5388.6,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,,,
HC Venogram Extrem Unilat,PX-32000168,CDM,75820,CPT,320,RC,,,outpatient,,,3212,2248.4,CIGNA [1000112],CIGNA [100011201],,4120.349,,,4120.349,399.86,4120.349,fee schedule,,,
HC Venogram Extrem Bilat,PX-32000169,CDM,75822,CPT,320,RC,,,outpatient,,,2940,2058,CIGNA [1000112],CIGNA [100011201],,4120.349,,,4120.349,399.86,4120.349,fee schedule,,,
HC Venogram Infer Vena Cava,PX-32000170,CDM,75825,CPT,320,RC,,,outpatient,,,5987,4190.9,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,,,
HC Venogram Super Vena Cava,PX-32000171,CDM,75827,CPT,320,RC,,,outpatient,,,2874,2011.8,CIGNA [1000112],CIGNA [100011201],,4120.349,,,4120.349,399.86,4120.349,fee schedule,,,
HC Venogram Renal Unilat,PX-32000172,CDM,75831,CPT,320,RC,,,outpatient,,,6489,4542.3,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,,,
HC Venogram Renal Bilat,PX-32000173,CDM,75833,CPT,320,RC,,,outpatient,,,6665,4665.5,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,,,
HC Venogram Adrenal Unilat,PX-32000174,CDM,75840,CPT,320,RC,,,outpatient,,,7698,5388.6,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,,,
HC Venogram Adrenal Bilat,PX-32000175,CDM,75842,CPT,320,RC,,,outpatient,,,11403,7982.1,CIGNA [1000112],CIGNA [100011201],,14233.715,,,14233.715,399.86,14233.715,fee schedule,,,
HC Venogram Sinus/Jugular,PX-32000176,CDM,75860,CPT,320,RC,,,outpatient,,,6665,4665.5,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,,,
HC Venogram Super Sag Sinus,PX-32000177,CDM,75870,CPT,320,RC,,,outpatient,,,4428,3099.6,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,,,
HC Venogram Epidural,PX-32000178,CDM,75872,CPT,320,RC,,,outpatient,,,4428,3099.6,CIGNA [1000112],CIGNA [100011201],,1602.0655,,,1602.0655,399.86,3400.704,fee schedule,,,
HC Venogram Orbital,PX-32000179,CDM,75880,CPT,320,RC,,,outpatient,,,1638,1146.6,CIGNA [1000112],CIGNA [100011201],,1602.0655,,,1602.0655,367.731,1602.0655,fee schedule,,,
HC Percut Xhepatic Porto+Dynamic,PX-32000180,CDM,75885,CPT,320,RC,,,outpatient,,,7698,5388.6,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,,,
HC Percut Xhepatic Portogram,PX-32000181,CDM,75887,CPT,320,RC,,,outpatient,,,7528,5269.6,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,,,
HC Venogram Hepatic W Hemodynamics,PX-32000182,CDM,75889,CPT,320,RC,,,outpatient,,,5272,3690.4,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,,,
HC Venogram Hepatic,PX-32000183,CDM,75891,CPT,320,RC,,,outpatient,,,6665,4665.5,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,399.86,8249.769,fee schedule,,,
HC Venous Sampling by Catheter,PX-32000184,CDM,75893,CPT,320,RC,,,outpatient,,,11403,7982.1,CIGNA [1000112],CIGNA [100011201],,14233.715,,,14233.715,399.86,14233.715,fee schedule,,,
HC Transcatheter Rx Embolizatn,PX-32000185,CDM,75894,CPT,320,RC,,,outpatient,,,2536,1775.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,1592.608,145.12362,1947.648,percent of total billed charges,,,
HC Angrph Cath F-Up Std Tcat Other Than Thrombylsis,PX-32000187,CDM,75898,CPT,320,RC,,,outpatient,,,3747,2622.9,CIGNA [1000112],CIGNA [100011201],,8249.769,,,8249.769,260.23,8249.769,fee schedule,,,
HC Remove-Obst Matl-Cva Dev via Sep Ven Acc,PX-32000188,CDM,75901,CPT,320,RC,,,outpatient,,,4773,3341.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,2997.444,260.23,3665.664,percent of total billed charges,,,
HC Remove-Obst Matl-Cva Device via Lumen,PX-32000189,CDM,75902,CPT,320,RC,,,outpatient,,,471,329.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,295.788,105.7395,416.02,percent of total billed charges,,,
HC Endovasc Repair Thor Aorta Incl Subclavian,PX-32000195,CDM,75956,CPT,320,RC,,,outpatient,,,1446,1012.2,CIGNA [1000112],CIGNA [100011201],,,62.8,,908.088,324.627,1110.528,percent of total billed charges,,,
HC Endovasc Repair Thor Aorta Excl Subclavian,PX-32000196,CDM,75957,CPT,320,RC,,,outpatient,,,1312,918.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,823.936,294.544,1007.616,percent of total billed charges,,,
HC Proximal Extens Durng Endovasc Rethor Aorta,PX-32000197,CDM,75958,CPT,320,RC,,,outpatient,,,845,591.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,530.66,189.7025,648.96,percent of total billed charges,,,
HC Delayed Prox Extens Endovasc Rethor Aorta,PX-32000198,CDM,75959,CPT,320,RC,,,outpatient,,,744,520.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,467.232,167.028,571.392,percent of total billed charges,,,
HC Vascular Biopsy,PX-32000203,CDM,75970,CPT,320,RC,,,outpatient,,,2918,2042.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,1832.504,145.12362,2241.024,percent of total billed charges,,,
HC Change Percut Tube/Drain Cath W Contrast Monit,PX-32000207,CDM,75984,CPT,320,RC,,,outpatient,,,2885,2019.5,CIGNA [1000112],CIGNA [100011201],,,62.8,,1811.78,145.12362,2215.68,percent of total billed charges,,,
HC Rad Guided-Percut Drainage-W/Cath Place,PX-32000208,CDM,75989,CPT,320,RC,,,outpatient,,,888,621.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,557.664,145.12362,681.984,percent of total billed charges,,,
HC Rad Guided-Percut Drainage-W/Cath Place,PX-35000057,CDM,75989,CPT,350,RC,,,outpatient,,,888,621.6,CIGNA [1000112],CIGNA [100011201],,575,,,575,145.12362,681.984,case rate,,,
HC Fluoroscopy Spx Up to 1 Hour Phys/Qhp Time,PX-32000209,CDM,76000,CPT,320,RC,,,outpatient,,,997,697.9,CIGNA [1000112],CIGNA [100011201],,646.6965,,,646.6965,195.08,765.696,fee schedule,,,
HC X-Ray Nose-Rectum Child F.B.,PX-32000210,CDM,76010,CPT,320,RC,,,outpatient,,,340,238,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,71.24,416.02,fee schedule,,,
HC X-Ray Fistula-Abscess-Sinus Tract,PX-32000211,CDM,76080,CPT,320,RC,,,outpatient,,,1950,1365,CIGNA [1000112],CIGNA [100011201],,1393.3385,,,1393.3385,237.819698,1497.6,fee schedule,,,
HC X-Ray Exam- Breast Specimen,PX-32000212,CDM,76098,CPT,320,RC,,,outpatient,,,984,688.8,CIGNA [1000112],CIGNA [100011201],,1393.3385,,,1393.3385,220.908,1393.3385,fee schedule,,,
HC Cine/Videoradiology-Exc Where Spec Incl,PX-32000214,CDM,76120,CPT,320,RC,,,outpatient,,,382,267.4,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,85.759,416.02,fee schedule,,,
HC 3d Rendering W/Interp & Postprocess Supervision,PX-35000058,CDM,76376,CPT,350,RC,,,outpatient,,,352,246.4,CIGNA [1000112],CIGNA [100011201],,575,,,575,79.024,836,case rate,,,
HC 3d Rendering W/Interp & Postprocess Supervision,PX-40200003,CDM,76376,CPT,402,RC,,,outpatient,,,352,246.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,221.056,79.024,836,percent of total billed charges,,,
HC 3d Rendering W/Interp & Postprocess Supervision,PX-61000062,CDM,76376,CPT,610,RC,,,outpatient,,,352,246.4,CIGNA [1000112],CIGNA [100011201],,836,,,836,79.024,836,case rate,,,
HC 3d Rendering W/Interp&Postproc Diff Work Station,PX-35000059,CDM,76377,CPT,350,RC,,,outpatient,,,422,295.4,CIGNA [1000112],CIGNA [100011201],,575,,,575,94.739,836,case rate,,,
HC 3d Rendering W/Interp&Postproc Diff Work Station,PX-40200004,CDM,76377,CPT,402,RC,,,outpatient,,,422,295.4,CIGNA [1000112],CIGNA [100011201],,,62.8,,265.016,94.739,836,percent of total billed charges,,,
HC 3d Rendering W/Interp&Postproc Diff Work Station,PX-61000063,CDM,76377,CPT,610,RC,,,outpatient,,,422,295.4,CIGNA [1000112],CIGNA [100011201],,836,,,836,94.739,836,case rate,,,
HC CT Scan-Limited/Localized F/U Study,PX-35000060,CDM,76380,CPT,350,RC,,,outpatient,,,928,649.6,CIGNA [1000112],CIGNA [100011201],,575,,,575,71.24,712.704,case rate,,,
HC MRI Spectroscopy,PX-61000064,CDM,76390,CPT,610,RC,,,outpatient,,,2218,1552.6,CIGNA [1000112],CIGNA [100011201],,836,,,836,81.08,1703.424,case rate,,,
HC Magnetic Resonance Elastography,PX-61000090,CDM,76391,CPT,610,RC,,,outpatient,,,842,589.4,CIGNA [1000112],CIGNA [100011201],,836,,,836,189.029,836,case rate,,,
HC Unlisted CT Procedure,PX-35000061,CDM,76497,CPT,350,RC,,,outpatient,,,229,160.3,CIGNA [1000112],CIGNA [100011201],,575,,,575,51.4105,575,case rate,,,
HC US- Head- Real Time,PX-40200005,CDM,76506,CPT,402,RC,,,outpatient,,,433,303.1,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,97.2085,416.02,fee schedule,,,
HC US- Head/Neck Tissues-Real Time,PX-40200006,CDM,76536,CPT,402,RC,,,outpatient,,,444,310.8,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,99.678,416.02,fee schedule,,,
HC US- Chest-Real Time,PX-40200007,CDM,76604,CPT,402,RC,,,outpatient,,,417,291.9,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,93.6165,416.02,fee schedule,,,
HC US Breast Uni Real Time With Image Complete,PX-40200056,CDM,76641,CPT,402,RC,,,outpatient,,,385,269.5,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,86.4325,416.02,fee schedule,,,
HC US Breast Uni Real Time With Image Limited,PX-40200055,CDM,76642,CPT,402,RC,,,outpatient,,,353,247.1,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,71.24,416.02,fee schedule,,,
HC US- Abdom-B-Scan &/or Real Time-Complete,PX-40200009,CDM,76700,CPT,402,RC,,,outpatient,,,461,322.7,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,103.4945,416.02,fee schedule,,,
HC US- Abdomen Limited,PX-40200010,CDM,76705,CPT,402,RC,,,outpatient,,,341,238.7,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,76.5545,416.02,fee schedule,,,
HC Ultrasound Exam Aaa Screen,PX-40200002,CDM,76706,CPT,402,RC,,,outpatient,,,261,182.7,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,58.5945,416.02,fee schedule,,,
HC US-Retroperit- B-Scan/Real Time-Complete,PX-40200011,CDM,76770,CPT,402,RC,,,outpatient,,,368,257.6,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,82.616,416.02,fee schedule,,,
HC US- Retroperitnl Abd- Ltd,PX-40200012,CDM,76775,CPT,402,RC,,,outpatient,,,345,241.5,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,77.4525,416.02,fee schedule,,,
HC US- Spinal Canal & Contents,PX-40200014,CDM,76800,CPT,402,RC,,,outpatient,,,595,416.5,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,119.991125,456.96,fee schedule,,,
HC US- OB < 14 Wks- Single Fetus,PX-40200015,CDM,76801,CPT,402,RC,,,outpatient,,,289,202.3,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,64.8805,416.02,fee schedule,,,
HC US- OB < 14 Wks- Add'l Fetus,PX-40200016,CDM,76802,CPT,402,RC,,,outpatient,,,224,156.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,140.672,50.288,416.02,percent of total billed charges,,,
HC US- OB >/= 14 Wks- Sngl Fetus,PX-40200017,CDM,76805,CPT,402,RC,,,outpatient,,,421,294.7,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,94.5145,416.02,fee schedule,,,
HC US- OB >/= 14 Wks- Addl Fetus,PX-40200018,CDM,76810,CPT,402,RC,,,outpatient,,,713,499.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,447.764,157.086513,547.584,percent of total billed charges,,,
HC US-Preg Uter-Fet & Mat-+ Detl Fet Exm,PX-40200019,CDM,76811,CPT,402,RC,,,outpatient,,,725,507.5,CIGNA [1000112],CIGNA [100011201],,646.6965,,,646.6965,162.7625,646.6965,fee schedule,,,
HC US-Preg Uter-Fet & Mat-+ Detl Fet-Addl,PX-40200020,CDM,76812,CPT,402,RC,,,outpatient,,,240,168,CIGNA [1000112],CIGNA [100011201],,,62.8,,150.72,53.88,416.02,percent of total billed charges,,,
HC US-Pregnant Uterus-Limited- 1/> Fetuses,PX-40200021,CDM,76815,CPT,402,RC,,,outpatient,,,303,212.1,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,68.0235,416.02,fee schedule,,,
HC US-Pregnant Uterus-F/U-Transabd App,PX-40200022,CDM,76816,CPT,402,RC,,,outpatient,,,600,420,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,119.991125,460.8,fee schedule,,,
HC US-Pregnant Uterus-Transvaginal,PX-40200023,CDM,76817,CPT,402,RC,,,outpatient,,,355,248.5,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,79.6975,416.02,fee schedule,,,
HC Fetal Biophysical Profile,PX-40200024,CDM,76818,CPT,402,RC,,,outpatient,,,439,307.3,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,98.5555,416.02,fee schedule,,,
HC Fetal Biophys Prof-W/O Nst,PX-40200025,CDM,76819,CPT,402,RC,,,outpatient,,,358,250.6,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,80.371,416.02,fee schedule,,,
HC Doppler Fetal Umbilical Artery,PX-40200026,CDM,76820,CPT,402,RC,,,outpatient,,,290,203,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,65.105,416.02,fee schedule,,,
HC US-Pregnant Uterus-Limited- 1/> Fetuses,PX-40200028,CDM,76827,CPT,402,RC,,,outpatient,,,578,404.6,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,119.991125,443.904,fee schedule,,,
HC Sono Fetal Hrt Doppl F/U,PX-40200029,CDM,76828,CPT,402,RC,,,outpatient,,,146,102.2,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,32.777,416.02,fee schedule,,,
HC Echography-Transvaginal,PX-40200030,CDM,76830,CPT,402,RC,,,outpatient,,,365,255.5,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,81.9425,416.02,fee schedule,,,
HC Sono Exam- Hysterosonography,PX-40200031,CDM,76831,CPT,402,RC,,,outpatient,,,1006,704.2,CIGNA [1000112],CIGNA [100011201],,646.6965,,,646.6965,199.512292,772.608,fee schedule,,,
HC Echo-Pelvic (Nonobstetric),PX-40200032,CDM,76856,CPT,402,RC,,,outpatient,,,361,252.7,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,81.0445,416.02,fee schedule,,,
HC Sono Pelvis Limited,PX-40200033,CDM,76857,CPT,402,RC,,,outpatient,,,332,232.4,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,74.534,416.02,fee schedule,,,
HC Echo-Scrotum & Contents,PX-40200034,CDM,76870,CPT,402,RC,,,outpatient,,,457,319.9,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,102.5965,416.02,fee schedule,,,
HC Echo-Transrectal,PX-40200035,CDM,76872,CPT,402,RC,,,outpatient,,,401,280.7,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,90.0245,416.02,fee schedule,,,
HC Echo-Transrectal-Prostate Vol,PX-40200036,CDM,76873,CPT,402,RC,,,outpatient,,,273,191.1,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,61.2885,416.02,fee schedule,,,
HC US-Extremity-Nonvascular-Real-Time Image-Complete,PX-40200037,CDM,76881,CPT,402,RC,,,outpatient,,,400,280,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,89.8,416.02,fee schedule,,,
HC US-Extremity-Nonvascular-Real-Time Image-Limited,PX-40200038,CDM,76882,CPT,402,RC,,,outpatient,,,253,177.1,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,56.7985,416.02,fee schedule,,,
HC US Inft Hips R-T Img Dynamic Req Phys/Qhp Manj,PX-40200039,CDM,76885,CPT,402,RC,,,outpatient,,,412,288.4,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,71.24,416.02,fee schedule,,,
HC US Inft Hips R-T Img Lmtd Static Phys/Qhp Manj,PX-40200040,CDM,76886,CPT,402,RC,,,outpatient,,,412,288.4,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,71.24,416.02,fee schedule,,,
HC US Guid-Comp Repair-Pseudo-Aneur/Av Fist,PX-40200041,CDM,76936,CPT,402,RC,,,outpatient,,,681,476.7,CIGNA [1000112],CIGNA [100011201],,775.5705,,,775.5705,152.8845,775.5705,fee schedule,,,
HC US Guide- Vascular Access,PX-40200042,CDM,76937,CPT,402,RC,,,outpatient,,,251,175.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,157.628,56.3495,416.02,percent of total billed charges,,,
HC US Guide- Tissue Ablation,PX-40200043,CDM,76940,CPT,402,RC,,,outpatient,,,460,322,CIGNA [1000112],CIGNA [100011201],,,62.8,,288.88,103.27,416.02,percent of total billed charges,,,
HC Sono Guide Needle Biopsy,PX-40200044,CDM,76942,CPT,402,RC,,,outpatient,,,868,607.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,545.104,166.37,666.624,percent of total billed charges,,,
HC Sono Guide Amniocentesis,PX-40200045,CDM,76946,CPT,402,RC,,,outpatient,,,354,247.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,222.312,79.473,416.02,percent of total billed charges,,,
HC US Guid-Comp Repair-Pseudo-Aneur/Av Fist,PX-40200048,CDM,76998,CPT,402,RC,,,outpatient,,,604,422.8,CIGNA [1000112],CIGNA [100011201],,,62.8,,379.312,135.598,463.872,percent of total billed charges,,,
HC Fluoroguide Cntrl Ven Access-Place-Replace-Remove,PX-32000217,CDM,77001,CPT,320,RC,,,outpatient,,,521,364.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,327.188,116.9645,416.02,percent of total billed charges,,,
HC Fluoroscopic Guidance Needle Placement,PX-32000218,CDM,77002,CPT,320,RC,,,outpatient,,,318,222.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,199.704,71.391,416.02,percent of total billed charges,,,
HC Fluorscopic Guidance Spinal Injection,PX-32000219,CDM,77003,CPT,320,RC,,,outpatient,,,518,362.6,CIGNA [1000112],CIGNA [100011201],,,62.8,,325.304,116.291,416.02,percent of total billed charges,,,
HC CT Guidance Stereotactic Localization,PX-35000062,CDM,77011,CPT,350,RC,,,outpatient,,,1801,1260.7,CIGNA [1000112],CIGNA [100011201],,575,,,575,399.86,1383.168,case rate,,,
HC CT Guidance Needle Placement,PX-35000063,CDM,77012,CPT,350,RC,,,outpatient,,,1747,1222.9,CIGNA [1000112],CIGNA [100011201],,575,,,575,63.344499,1341.696,case rate,,,
HC CT Guidance Tissue Ablation,PX-35000064,CDM,77013,CPT,350,RC,,,outpatient,,,1755,1228.5,CIGNA [1000112],CIGNA [100011201],,575,,,575,63.344499,1347.84,case rate,,,
HC CT Guidance Placement Rad Therapy Fields,PX-35000065,CDM,77014,CPT,350,RC,,,outpatient,,,623,436.1,CIGNA [1000112],CIGNA [100011201],,575,,,575,139.8635,575,case rate,,,
HC MRI Guidance Needle Placement,PX-61000066,CDM,77021,CPT,610,RC,,,outpatient,,,3092,2164.4,CIGNA [1000112],CIGNA [100011201],,836,,,836,399.86,2374.656,case rate,,,
HC MRI Breast Without Contrast Material Unilateral,PX-61000083,CDM,77046,CPT,610,RC,,,outpatient,,,842,589.4,CIGNA [1000112],CIGNA [100011201],,836,,,836,189.029,836,case rate,,,
HC MRI Breast Without Contrast Material Bilateral,PX-61000086,CDM,77047,CPT,610,RC,,,outpatient,,,842,589.4,CIGNA [1000112],CIGNA [100011201],,836,,,836,189.029,836,case rate,,,
HC MRI Breast With Contrast W/Cad Unilateral,PX-61000084,CDM,77048,CPT,610,RC,,,outpatient,,,2118,1482.6,CIGNA [1000112],CIGNA [100011201],,836,,,836,399.547552,1936.896,case rate,,,
HC MRI Breast W/Out&With Contrast W/Cad Unilateral,PX-61000085,CDM,77048,CPT,610,RC,,,outpatient,,,2522,1765.4,CIGNA [1000112],CIGNA [100011201],,836,,,836,399.547552,1936.896,case rate,,,
HC MRI Breast With Contrast W/Cad Bilateral,PX-61000087,CDM,77049,CPT,610,RC,,,outpatient,,,2788,1951.6,CIGNA [1000112],CIGNA [100011201],,836,,,836,399.547552,2548.224,case rate,,,
HC MRI Breast W/Out&With Contrast W/Cad Bilateral,PX-61000088,CDM,77049,CPT,610,RC,,,outpatient,,,3318,2322.6,CIGNA [1000112],CIGNA [100011201],,836,,,836,399.547552,2548.224,case rate,,,
HC Digital Breast Tomosynthesis Unilateral,PX-40100006,CDM,77061,CPT,401,RC,,,outpatient,,,321,224.7,CIGNA [1000112],CIGNA [100011201],,250.1105,,,250.1105,72.0645,416.02,fee schedule,,,
HC Digital Breast Tomosynthesis Bilateral,PX-40100007,CDM,77062,CPT,401,RC,,,outpatient,,,393,275.1,CIGNA [1000112],CIGNA [100011201],,318.9185,,,318.9185,88.2285,416.02,fee schedule,,,
HC Screening Digital Breast Tomosynthesis Bi,PX-40300004,CDM,77063,CPT,403,RC,,,outpatient,,,202,141.4,CIGNA [1000112],CIGNA [100011201],,68.808,,,68.808,22.99364,416.02,fee schedule,,,
HC Dx Mammo Incl Cad Uni,PX-40100008,CDM,77065,CPT,401,RC,,,outpatient,,,393,275.1,CIGNA [1000112],CIGNA [100011201],,250.1105,,,250.1105,88.2285,416.02,fee schedule,,,
HC Dx Mammo Incl Cad Bi,PX-40100009,CDM,77066,CPT,401,RC,,,outpatient,,,466,326.2,CIGNA [1000112],CIGNA [100011201],,318.9185,,,318.9185,90.800319,416.02,fee schedule,,,
HC Scr Mammo Bi Incl Cad,PX-40300005,CDM,77067,CPT,403,RC,,,outpatient,,,466,326.2,CIGNA [1000112],CIGNA [100011201],,264.4455,,,264.4455,90.800319,416.02,fee schedule,,,
HC Manual Appl Stress Pfrmd Phys/Qhp Joint Films,PX-32000222,CDM,77071,CPT,320,RC,,,outpatient,,,262,183.4,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,58.819,416.02,fee schedule,,,
HC X-Rays for Bone Age,PX-32000223,CDM,77072,CPT,320,RC,,,outpatient,,,218,152.6,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,48.941,416.02,fee schedule,,,
HC X-Rays- Bone Length Studies,PX-32000224,CDM,77073,CPT,320,RC,,,outpatient,,,502,351.4,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,76.026473,416.02,fee schedule,,,
HC X-Rays- Bone Survey- Limited,PX-32000225,CDM,77074,CPT,320,RC,,,outpatient,,,502,351.4,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,112.699,416.02,fee schedule,,,
HC X-Rays- Bone Survey Complete,PX-32000226,CDM,77075,CPT,320,RC,,,outpatient,,,502,351.4,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,112.699,416.02,fee schedule,,,
HC X-Rays- Bone Survey- Infant,PX-32000227,CDM,77076,CPT,320,RC,,,outpatient,,,502,351.4,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,76.026473,416.02,fee schedule,,,
HC Dexa-Bone Density- 1 + Site- Axial Skeleton,PX-32000228,CDM,77080,CPT,320,RC,,,outpatient,,,575,402.5,CIGNA [1000112],CIGNA [100011201],,295.9825,,,295.9825,119.991125,441.6,fee schedule,,,
HC Dexa-Bone Density- 1 + Site- Appendiculr Skeltn,PX-32000229,CDM,77081,CPT,320,RC,,,outpatient,,,114,79.8,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,25.593,416.02,fee schedule,,,
HC MRI- Bone Marrow,PX-61000070,CDM,77084,CPT,610,RC,,,outpatient,,,2406,1684.2,CIGNA [1000112],CIGNA [100011201],,836,,,836,267.439885,1847.808,case rate,,,
HC Tbs Techl Prep&Transmis Data Alys Pfrmd Elsewhr,PX-32000262,CDM,77090,CPT,320,RC,,,outpatient,,,248,173.6,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,55.676,416.02,fee schedule,,,
HC Tbs Technical Calculation Only,PX-32000263,CDM,77091,CPT,320,RC,,,outpatient,,,248,173.6,CIGNA [1000112],CIGNA [100011201],,240.593,,,240.593,55.676,416.02,fee schedule,,,
HC Thyroid Uptake Single/Multiple Quant Measurement,PX-34100001,CDM,78012,CPT,341,RC,,,outpatient,,,935,654.5,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,209.9075,1076.394,fee schedule,,,
HC Thyroid Imaging With Vascular Flow,PX-34100002,CDM,78013,CPT,341,RC,,,outpatient,,,633,443.1,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,142.1085,1076.394,fee schedule,,,
HC Thyroid Uptake W/Blood Flow Sngle/Mult Quan Meas,PX-34100003,CDM,78014,CPT,341,RC,,,outpatient,,,982,687.4,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,220.459,1076.394,fee schedule,,,
HC Thyroid Met Imaging Body,PX-34100005,CDM,78018,CPT,341,RC,,,outpatient,,,1049,734.3,CIGNA [1000112],CIGNA [100011201],,1397.122,,,1397.122,235.5005,1397.122,fee schedule,,,
HC Thyroid Met Uptake,PX-34100006,CDM,78020,CPT,341,RC,,,outpatient,,,171,119.7,CIGNA [1000112],CIGNA [100011201],,,62.8,,107.388,38.3895,416.02,percent of total billed charges,,,
HC Parathyroid Planar Imaging,PX-34100007,CDM,78070,CPT,341,RC,,,outpatient,,,1575,1102.5,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,353.5875,1209.6,fee schedule,,,
HC Parathyroid Planar Imaging W/WO Subtraction,PX-34100008,CDM,78071,CPT,341,RC,,,outpatient,,,1357,949.9,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,304.6465,1076.394,fee schedule,,,
HC Parathyroid Imaging W/Tomographic Spect & CT,PX-34100009,CDM,78072,CPT,341,RC,,,outpatient,,,1898,1328.6,CIGNA [1000112],CIGNA [100011201],,1397.122,,,1397.122,358.69,1457.664,fee schedule,,,
HC Adrenal Nuclear Imaging,PX-34100010,CDM,78075,CPT,341,RC,,,outpatient,,,2974,2081.8,CIGNA [1000112],CIGNA [100011201],,3675.6585,,,3675.6585,399.86,3675.6585,fee schedule,,,
HC Bone Marrow Imaging- Ltd,PX-34100011,CDM,78102,CPT,341,RC,,,outpatient,,,1403,982.1,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,314.9735,1077.504,fee schedule,,,
HC Bone Marrow Imaging- Mult,PX-34100012,CDM,78103,CPT,341,RC,,,outpatient,,,1403,982.1,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,314.9735,1077.504,fee schedule,,,
HC Bone Marrow Imaging- Body,PX-34100013,CDM,78104,CPT,341,RC,,,outpatient,,,659,461.3,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,147.9455,1076.394,fee schedule,,,
HC Spleen Imaging,PX-34100015,CDM,78185,CPT,341,RC,,,outpatient,,,971,679.7,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,217.9895,1076.394,fee schedule,,,
HC Lymphatics & Lymph Glands Imaging,PX-34100016,CDM,78195,CPT,341,RC,,,outpatient,,,1071,749.7,CIGNA [1000112],CIGNA [100011201],,1397.122,,,1397.122,240.4395,1397.122,fee schedule,,,
HC Liver Imaging,PX-34100017,CDM,78201,CPT,341,RC,,,outpatient,,,2228,1559.6,CIGNA [1000112],CIGNA [100011201],,1397.122,,,1397.122,399.86,2239.93036,fee schedule,,,
HC Liver and Spleen Imaging,PX-34100021,CDM,78215,CPT,341,RC,,,outpatient,,,1205,843.5,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,270.5225,1076.394,fee schedule,,,
HC Hepatobiliary Syst Imaging Including Gallbladder,PX-34100023,CDM,78226,CPT,341,RC,,,outpatient,,,1384,968.8,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,310.708,1076.394,fee schedule,,,
HC Hepatobil Syst Imag Inc Gb W/Pharma Intervenj,PX-34100024,CDM,78227,CPT,341,RC,,,outpatient,,,1384,968.8,CIGNA [1000112],CIGNA [100011201],,1397.122,,,1397.122,310.708,1397.122,fee schedule,,,
HC Serial Salivary Imaging,PX-34100025,CDM,78231,CPT,341,RC,,,outpatient,,,788,551.6,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,176.906,1076.394,fee schedule,,,
HC Gastroesophageal Reflux Exam,PX-34100027,CDM,78262,CPT,341,RC,,,outpatient,,,1043,730.1,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,234.1535,1076.394,fee schedule,,,
HC Gastric Emptying Study,PX-34100028,CDM,78264,CPT,341,RC,,,outpatient,,,838,586.6,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,188.131,1076.394,fee schedule,,,
HC Acute GI Blood Loss Imaging,PX-34100031,CDM,78278,CPT,341,RC,,,outpatient,,,2079,1455.3,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,399.86,1596.672,fee schedule,,,
HC Bowel Imaging,PX-34100032,CDM,78290,CPT,341,RC,,,outpatient,,,893,625.1,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,200.4785,1076.394,fee schedule,,,
HC Leveen/Shunt Patency Exam,PX-34100033,CDM,78291,CPT,341,RC,,,outpatient,,,954,667.8,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,214.173,1076.394,fee schedule,,,
HC Bone Imaging- Limited Area,PX-34100034,CDM,78300,CPT,341,RC,,,outpatient,,,962,673.4,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,215.969,1076.394,fee schedule,,,
HC Bone Imaging- Multiple Areas,PX-34100035,CDM,78305,CPT,341,RC,,,outpatient,,,1098,768.6,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,246.501,1076.394,fee schedule,,,
HC Bone Imaging- Whole Body,PX-34100036,CDM,78306,CPT,341,RC,,,outpatient,,,893,625.1,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,200.4785,1076.394,fee schedule,,,
HC Bone Imaging- 3 Phase,PX-34100037,CDM,78315,CPT,341,RC,,,outpatient,,,956,669.2,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,214.622,1076.394,fee schedule,,,
HC Myocardial Spect Single Study at Rest or Stress,PX-34100040,CDM,78451,CPT,341,RC,,,outpatient,,,4510,3157,CIGNA [1000112],CIGNA [100011201],,3675.6585,,,3675.6585,399.86,3675.6585,fee schedule,,,
HC Myocardial Spect Multiple Studies,PX-34100041,CDM,78452,CPT,341,RC,,,outpatient,,,4510,3157,CIGNA [1000112],CIGNA [100011201],,3675.6585,,,3675.6585,399.86,3675.6585,fee schedule,,,
HC Myocardial Perfusion Planar 1 Study Rest/Stress,PX-34100042,CDM,78453,CPT,341,RC,,,outpatient,,,3900,2730,CIGNA [1000112],CIGNA [100011201],,3675.6585,,,3675.6585,399.86,3675.6585,fee schedule,,,
HC Myocardial Perfusion Planar Multiple Studies,PX-34100043,CDM,78454,CPT,341,RC,,,outpatient,,,3900,2730,CIGNA [1000112],CIGNA [100011201],,3675.6585,,,3675.6585,399.86,3675.6585,fee schedule,,,
HC Gated Heart- Planar Single,PX-34100048,CDM,78472,CPT,341,RC,,,outpatient,,,1586,1110.2,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,356.057,1218.048,fee schedule,,,
HC Heart Image- Spect,PX-34100050,CDM,78494,CPT,341,RC,,,outpatient,,,1671,1169.7,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,375.1395,1283.328,fee schedule,,,
HC Pulmonary Ventilation Imaging,PX-34100052,CDM,78579,CPT,341,RC,,,outpatient,,,767,536.9,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,172.1915,1076.394,fee schedule,,,
HC Lung Perfusion Imaging,PX-34100053,CDM,78580,CPT,341,RC,,,outpatient,,,640,448,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,143.68,1076.394,fee schedule,,,
HC Pulmonary Ventilation & Perfusion Imaging,PX-34100054,CDM,78582,CPT,341,RC,,,outpatient,,,946,662.2,CIGNA [1000112],CIGNA [100011201],,1397.122,,,1397.122,212.377,1397.122,fee schedule,,,
HC Quant Differential Pulm Perfusion W/WO Imaging,PX-34100055,CDM,78597,CPT,341,RC,,,outpatient,,,902,631.4,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,202.499,1076.394,fee schedule,,,
HC Quant Diff Pulm Prfusion & Ventlaj W/WO Imaging,PX-34100056,CDM,78598,CPT,341,RC,,,outpatient,,,1499,1049.3,CIGNA [1000112],CIGNA [100011201],,1397.122,,,1397.122,336.5255,1397.122,fee schedule,,,
HC Brain Imaging < 4 Static Views W Vascular Flow,PX-34100058,CDM,78601,CPT,341,RC,,,outpatient,,,2704,1892.8,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,399.86,2076.672,fee schedule,,,
HC Brain Imaging Min 4 Static Views W Vascular Flow,PX-34100059,CDM,78606,CPT,341,RC,,,outpatient,,,1589,1112.3,CIGNA [1000112],CIGNA [100011201],,1397.122,,,1397.122,356.7305,1397.122,fee schedule,,,
HC Brain Imaging Pet Metabolic,PX-40400003,CDM,78608,CPT,404,RC,,,outpatient,,,4890,3423,CIGNA [1000112],CIGNA [100011201],,1913,,,1913,399.86,3755.52,case rate,,,
HC CSF Fluid Scan Cisternography,PX-34100061,CDM,78630,CPT,341,RC,,,outpatient,,,2570,1799,CIGNA [1000112],CIGNA [100011201],,1397.122,,,1397.122,399.86,1973.76,fee schedule,,,
HC CSF Shunt Evaluation,PX-34100062,CDM,78645,CPT,341,RC,,,outpatient,,,916,641.2,CIGNA [1000112],CIGNA [100011201],,1397.122,,,1397.122,205.642,1397.122,fee schedule,,,
HC CSF Leakage Detection & Localization,PX-34100063,CDM,78650,CPT,341,RC,,,outpatient,,,3215,2250.5,CIGNA [1000112],CIGNA [100011201],,3675.6585,,,3675.6585,399.86,3675.6585,fee schedule,,,
HC Renal Imaging- Static,PX-34100064,CDM,78700,CPT,341,RC,,,outpatient,,,1292,904.4,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,290.054,1076.394,fee schedule,,,
HC Renal Flow/Funct Imaging,PX-34100065,CDM,78707,CPT,341,RC,,,outpatient,,,1210,847,CIGNA [1000112],CIGNA [100011201],,1397.122,,,1397.122,271.645,1397.122,fee schedule,,,
HC Renal Flow/Funct Image-Pharm Rx,PX-34100066,CDM,78708,CPT,341,RC,,,outpatient,,,899,629.3,CIGNA [1000112],CIGNA [100011201],,1397.122,,,1397.122,201.8255,1397.122,fee schedule,,,
HC Testicular Imaging & Flow,PX-34100069,CDM,78761,CPT,341,RC,,,outpatient,,,845,591.5,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,189.7025,1076.394,fee schedule,,,
HC Tumor Imaging- Limited Area,PX-34100070,CDM,78800,CPT,341,RC,,,outpatient,,,867,606.9,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,194.6415,1076.394,fee schedule,,,
HC Tumor Imaging- Whole Body- Single Day,PX-34100072,CDM,78802,CPT,341,RC,,,outpatient,,,3124,2186.8,CIGNA [1000112],CIGNA [100011201],,3675.6585,,,3675.6585,399.86,3675.6585,fee schedule,,,
HC Tumor Imaging Spect,PX-34100073,CDM,78803,CPT,341,RC,,,outpatient,,,2419,1693.3,CIGNA [1000112],CIGNA [100011201],,3675.6585,,,3675.6585,399.86,3675.6585,fee schedule,,,
HC Tumor Imaging- Whole Body- 2 or More Days,PX-34100074,CDM,78804,CPT,341,RC,,,outpatient,,,2916,2041.2,CIGNA [1000112],CIGNA [100011201],,3675.6585,,,3675.6585,399.86,3675.6585,fee schedule,,,
HC Inject Radiopharm Non-Imaging Localization- IV,PX-34100080,CDM,78808,CPT,341,RC,,,outpatient,,,1227,858.9,CIGNA [1000112],CIGNA [100011201],,1076.394,,,1076.394,275.4615,1076.394,fee schedule,,,
HC Pet Imaging CT for Attenuation Limited Area,PX-40400004,CDM,78814,CPT,404,RC,,,outpatient,,,5186,3630.2,CIGNA [1000112],CIGNA [100011201],,1913,,,1913,399.86,3982.848,case rate,,,
HC Pet Imaging CT Attenuation Skull Base Mid-Thigh,PX-40400005,CDM,78815,CPT,404,RC,,,outpatient,,,6904,4832.8,CIGNA [1000112],CIGNA [100011201],,1913,,,1913,399.86,5302.272,case rate,,,
HC Pet Imaging for CT Attenuation Whole Body,PX-40400006,CDM,78816,CPT,404,RC,,,outpatient,,,7705,5393.5,CIGNA [1000112],CIGNA [100011201],,1913,,,1913,399.86,5917.44,case rate,,,
HC Rp Loclzj Tum Spect W/CT 1 Area 1 Day Imaging,PX-34100081,CDM,78830,CPT,341,RC,,,outpatient,,,4318,3022.6,CIGNA [1000112],CIGNA [100011201],,3675.6585,,,3675.6585,399.86,3675.6585,fee schedule,,,
HC Rp Loclzj Tum Spect 2 Area 1d Img/1 Area Img>2+D,PX-34100082,CDM,78831,CPT,341,RC,,,outpatient,,,4318,3022.6,CIGNA [1000112],CIGNA [100011201],,3675.6585,,,3675.6585,399.86,3675.6585,fee schedule,,,
HC Rp Loclzj Tum Spect CT 2area 1d Img/1 AR Img>2+D,PX-34100083,CDM,78832,CPT,341,RC,,,outpatient,,,4899,3429.3,CIGNA [1000112],CIGNA [100011201],,4124.5085,,,4124.5085,399.86,4124.5085,fee schedule,,,
HC Radiopharmaceutical Quantification Meas 1 Area,PX-34100084,CDM,78835,CPT,341,RC,,,outpatient,,,203,142.1,CIGNA [1000112],CIGNA [100011201],,,62.8,,127.484,45.5735,416.02,percent of total billed charges,,,
HC Nuclear Therapy- Oral,PX-34200001,CDM,79005,CPT,342,RC,,,outpatient,,,782,547.4,CIGNA [1000112],CIGNA [100011201],,691.5815,,,691.5815,175.559,691.5815,fee schedule,,,
HC Urinalysis- Auto- W/O Scope,PX-30000067,CDM,81003,CPT,300,RC,,,outpatient,,,32,22.4,CIGNA [1000112],CIGNA [100011201],,5.11,,,5.11,2.29,24.576,fee schedule,,,
HC Urine Pregnancy Test,PX-30000713,CDM,81025,CPT,300,RC,,,outpatient,,,28,19.6,CIGNA [1000112],CIGNA [100011201],,19.6,,,19.6,6.286,21.504,fee schedule,,,
HC Molecular Pathology Procedure Level 4,PX-30000097,CDM,81403,CPT,300,RC,,,outpatient,,,716,501.2,CIGNA [1000112],CIGNA [100011201],,421.33,,,421.33,160.742,549.888,fee schedule,,,
HC Blood Occult-by Peroxid- Feces- 1-3 Simult- Non Ca Screen,PX-30000715,CDM,82272,CPT,300,RC,,,outpatient,,,24,16.8,CIGNA [1000112],CIGNA [100011201],,9.632,,,9.632,3.33,18.432,fee schedule,,,
HC Glucose Blood Test,PX-30000221,CDM,82962,CPT,300,RC,,,outpatient,,,45,31.5,CIGNA [1000112],CIGNA [100011201],,7.462,,,7.462,2.4,34.56,fee schedule,,,
HC Bone Marrow-Smear Interpretation,PX-31000012,CDM,85097,CPT,310,RC,,,outpatient,,,1038,726.6,CIGNA [1000112],CIGNA [100011201],,108.71,,,108.71,39.73,1313.895373,fee schedule,,,
HC Coagulation Time- Activated,PX-30000417,CDM,85347,CPT,300,RC,,,outpatient,,,80,56,CIGNA [1000112],CIGNA [100011201],,9.73,,,9.73,4.35,61.44,fee schedule,,,
HC Hgb/Rbcs Fetal Fetomaternal Hemrrg Rosette,PX-30000732,CDM,85461,CPT,300,RC,,,outpatient,,,32,22.4,CIGNA [1000112],CIGNA [100011201],,21.28,,,21.28,6.78,24.576,fee schedule,,,
HC Sickling RBC Reduction,PX-30000730,CDM,85660,CPT,300,RC,,,outpatient,,,25,17.5,CIGNA [1000112],CIGNA [100011201],,12.53,,,12.53,5.6125,19.2,fee schedule,,,
HC Platelet Antibodies,PX-30000453,CDM,86022,CPT,300,RC,,,outpatient,,,128,89.6,CIGNA [1000112],CIGNA [100011201],,41.79,,,41.79,18.77,98.304,fee schedule,,,
HC Cold Agglutinin Screen,PX-30000465,CDM,86156,CPT,300,RC,,,outpatient,,,158,110.6,CIGNA [1000112],CIGNA [100011201],,18.382,,,18.382,6.51,121.344,fee schedule,,,
HC Cold Agglutinin- Titer,PX-30000466,CDM,86157,CPT,300,RC,,,outpatient,,,29,20.3,CIGNA [1000112],CIGNA [100011201],,18.34,,,18.34,6.5105,24.43,fee schedule,,,
HC Leukocyte Phagocytosis,PX-30000866,CDM,86344,CPT,300,RC,,,outpatient,,,33,23.1,CIGNA [1000112],CIGNA [100011201],,23.632,,,23.632,7.4085,25.344,fee schedule,,,
HC Cmv Antibody,PX-30000526,CDM,86644,CPT,300,RC,,,outpatient,,,155,108.5,CIGNA [1000112],CIGNA [100011201],,32.732,,,32.732,14.71,119.04,fee schedule,,,
HC Hla Typing- a-B-or C /Single,PX-30000582,CDM,86812,CPT,300,RC,,,outpatient,,,252,176.4,CIGNA [1000112],CIGNA [100011201],,58.73,,,58.73,26.37,193.536,fee schedule,,,
HC Hla Typing Dr/Dq Single Antigen,PX-30000731,CDM,86816,CPT,300,RC,,,outpatient,,,124,86.8,CIGNA [1000112],CIGNA [100011201],,68.642,,,68.642,27.838,95.232,fee schedule,,,
HC Hla Typing- Dr/Dq-Multi Antgn,PX-30000584,CDM,86817,CPT,300,RC,,,outpatient,,,287,200.9,CIGNA [1000112],CIGNA [100011201],,241.472,,,241.472,64.4315,241.472,fee schedule,,,
HC RBC Antibody Screen,PX-30000585,CDM,86850,CPT,300,RC,,,outpatient,,,99,69.3,CIGNA [1000112],CIGNA [100011201],,22.232,,,22.232,6.25,92.88556,fee schedule,,,
HC RBC Antibody Elution,PX-30000586,CDM,86860,CPT,300,RC,,,outpatient,,,358,250.6,CIGNA [1000112],CIGNA [100011201],,2.072,,,2.072,2.072,274.944,fee schedule,,,
HC RBC Antibody Identification,PX-30000587,CDM,86870,CPT,300,RC,,,outpatient,,,501,350.7,CIGNA [1000112],CIGNA [100011201],,2.842,,,2.842,2.842,549.235176,fee schedule,,,
HC Antihuman Globulin Dir Ea Antiserum,PX-30000588,CDM,86880,CPT,300,RC,,,outpatient,,,117,81.9,CIGNA [1000112],CIGNA [100011201],,12.25,,,12.25,5.5,93.463636,fee schedule,,,
HC Antihuman Globulin Indir Qual Ea Reagent Cell,PX-30000589,CDM,86885,CPT,300,RC,,,outpatient,,,357,249.9,CIGNA [1000112],CIGNA [100011201],,13.02,,,13.02,5.85,274.176,fee schedule,,,
HC Antihuman Globulin Indirect Ea Antibody Titer,PX-30000590,CDM,86886,CPT,300,RC,,,outpatient,,,357,249.9,CIGNA [1000112],CIGNA [100011201],,11.802,,,11.802,5.29,274.176,fee schedule,,,
HC Blood Typing- Abo,PX-30000592,CDM,86900,CPT,300,RC,,,outpatient,,,208,145.6,CIGNA [1000112],CIGNA [100011201],,6.79,,,6.79,3.05,195.186327,fee schedule,,,
HC Blood Typing- Rh (D),PX-30000593,CDM,86901,CPT,300,RC,,,outpatient,,,85,59.5,CIGNA [1000112],CIGNA [100011201],,6.79,,,6.79,3.05,65.28,fee schedule,,,
HC Blood Type Antigen Donor Reagent Serum- Ea Antigen,PX-30000594,CDM,86902,CPT,300,RC,,,outpatient,,,628,439.6,CIGNA [1000112],CIGNA [100011201],,14.462,,,14.462,3.91,549.235176,fee schedule,,,
HC Blood Typing Antigen Screen Patient Serum/Unit,PX-30000718,CDM,86904,CPT,300,RC,,,outpatient,,,311,217.7,CIGNA [1000112],CIGNA [100011201],,37.17,,,37.17,9.71,238.848,fee schedule,,,
HC Blood Typing- RBC Antigens,PX-30000595,CDM,86905,CPT,300,RC,,,outpatient,,,628,439.6,CIGNA [1000112],CIGNA [100011201],,8.722,,,8.722,3.91,549.235176,fee schedule,,,
HC Blood Typing Serologic Rh Phenotyping Complete,PX-30000719,CDM,86906,CPT,300,RC,,,outpatient,,,284,198.8,CIGNA [1000112],CIGNA [100011201],,17.64,,,17.64,7.91,218.112,fee schedule,,,
HC Compatibility Test-Spin Tech,PX-30000596,CDM,86920,CPT,300,RC,,,outpatient,,,355,248.5,CIGNA [1000112],CIGNA [100011201],,2.31,,,2.31,2.31,272.64,fee schedule,,,
HC Compatibilit